Transfusion recommendations in neonatal patients are less defined by evidence-based guidelines than those in older children and adults.
When making the decision to transfuse a neonate, clinicians should consider physiologic differences of this age group, gestational and postnatal age, congenital disorders, and maternal factors.
Anemia and thrombocytopenia are highly prevalent in preterm neonates, and the risks versus benefits of transfusion must be weighed carefully in this vulnerable population.
Although a critical therapy in the management of hospitalized pediatric patients, , transfusion of red blood cells (RBCs), platelets, and fresh frozen plasma (FFP) in neonatal patients has not been well characterized in the literature, with few studies describing the indications and recommendations for transfusion in this unique patient population. Anemia and thrombocytopenia are highly prevalent, especially in preterm neonates, with most premature infants in neonatal intensive care units (NICUs) requiring at least 1 transfusion in the first week of life. ,
Physiologic differences between neonates and older infants and children must be taken into account when considering transfusion of blood products. The neonatal period encompasses the first 4 weeks after birth (<28 days old) and includes both full-term (>39 weeks of gestation) as well as premature infants (any neonate born before 37 completed weeks of gestation). Most preterm infants requiring transfusion are very low birth weight (VLBW), weighing less than 1500 g, and extremely low birth weight (ELBW), weighing less than 1000 g. When evaluating neonates with anemia, thrombocytopenia, bleeding, or coagulopathy, clinicians should consider gestational and postnatal age, congenital disorders, maternal factors, and transplacental antibody transfer. In addition, neonates have smaller blood volumes relative to larger children or adults, so potentially toxic exposures or antibodies present in transfused products may be more likely to result in clinically relevant consequences. ,
Unlike in the more well-studied adult population, guidelines for transfusion in neonates varies greatly worldwide and between institutions. More recently, a growing body of research has focused on delineating neonatal transfusion specifics. This review of the existing literature summarizes current evidence-based neonatal transfusion guidelines and highlights areas of current ongoing research and those in need of future studies.
Fetal and neonatal hematopoiesis
When making the decision to transfuse during the neonatal period, it is important to understand fetal and neonatal hematopoiesis. Hemoglobin concentration increases progressively throughout gestation and peaks after birth. Full-term neonates have hemoglobin values of 16 to 17 g/dL at term, which may increase by 1 to 2 g/dL because of placental transfusion at birth and may vary depending on timing of cord clamping. There is a gradual decline in hemoglobin concentration to a nadir of 11 to 12 g/dL at 8 weeks, termed physiologic anemia. Erythropoiesis then accelerates, followed by an increase in hemoglobin level.