Dr Salwa Hindawi

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Blood Transfusion In Neonates and Children

• Dr Salwa Hindawi
• MSc, FRCPath, CTM
• Medical Director of Blood Transfusion Services
• KAUH, Jeddah
• 
  
• 
  Makah 28th
  April2008

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Introduction

• Blood Transfusion is not without hazards
• you should weigh the risk against benefit
• use of right products to the right patient at
  the right time

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Consider
1. Child will live long enough to get a long term
complication of blood transfusion 2. children
has special need 3.Lack of evidence for many
transfusion practice in children ,depending on
adult experience and clinical judgment.
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• use of clinical guidelines may provide the
  following
• improvements in outcomes.
• improvements in medical practice.
• decision support tools for practitioners.
• points of reference for medical orientation and
• education.
• criteria for self-evaluation.

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Pretransfusion testing in Infants less than 4
month of age

• Maternal sample
• ABO RhD group Antibody screen.
• Infant samples
• ABO RhD group Direct antiglobulin test (DAT).
• Antibody screen (if maternal sample unavailable).
  
• If no atypical Antibody in maternal infant
  serum DAT on infant red cell is negative, Cross
  matching is unnecessary.
• After 4 month Compatibility testing is required
  as for adults.

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cross matching within 1st 4 month of age

• Compatibility testing is required only under the
  following conditions
• 1. unexpected antibody is detected in the
  infant's or mother's serum
• 2. the infant has a positive direct antiglobulin
  test result or
• 3. the infant is to receive RBC transfusion
  incompatible with the mother's serum

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• For infants with ABO hemolytic disease of the
  newborn, only group O RBCs should be transfused
  until compatibility tests are nonreactive with
  ABO-specific units.
• For plasma and platelet transfusions, infants
  should receive ABO-specific components whenever
  possible, to avoid transfusing plasma antibody
  incompatible with the infant's red cell antigens.

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strategies to reduce donor exposure orRBC
transfusions

• delayed clamping of the umbilical cord
• restricting blood sampling
• using recombinant human erythropoietin to
  stimulate erythropoiesis
• using iron supplementation or vitamins to
  minimize the severity of anemia

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• using appropriately collected and stored
  multipack RBC units
• using appropriately screened and handled RBCs
  from regular or designated donors and
• collecting and transfusing umbilical cord blood
  (autologous blood transfusion).

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PRBCs Specification

• RBCs administered should be as fresh as possible
• group O, or group specific
• hemoglobin S negative
• CMV-seronegative or leukoreduced
• irradiated as indicated.

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Guidelines for Transfusion of RBCs in Patients Less than 4 Months of Age
1. Hemoglobin lt7 g/dL with low reticulocyte count and symptoms of anemia
2. Hemoglobin lt10 g/dL with an infant
On lt35 hood O2 On O2 by nasal cannula On continuous positive airway pressure (CPAP)/intermittent mandatory ventilation (IMV) with mechanical ventilation with mean airway pressure lt6 cm H2O Significant apnea or bradycardia Significant tachycardia or tachypnea Low weight gain
3. Hemoglobin lt12 g/dL with an infant
On gt35 hood O2 On CPAP/IMV with mean airway pressure ?6 to 8 cm H2O
4. Hemoglobin lt15 g/dL with an infant
On extracorporeal membrane oxygenation (ECMO) Congenital cyanotic heart disease
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Guidelines for Transfusion of RBCs in Patients More than 4 Months of Age
1. Intraoperative blood loss of15 total blood volume (TBV)
2. Hemoglobin lt8 g/dL
In Perioperative period, with symptoms of anemia In chemotherapy or radiotherapy In chronic congenital or acquired symptomatic anemia In emergency surgical procedures with expected blood loss in patient with significant preoperative anemia In preoperative anemia when other corrective therapy is not available
3. Acute blood loss with hypovolemia not responsive to other therapy
4. Hemoglobin lt13 g/dL with
Severe pulmonary disease ECMO
5. Chronic transfusion programs for disorders of red cell Production such as thalassemia major and Diamond-Blackfan syndrome
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Guidelines for Platelet Transfusion in Neonates
1. Platelet count lt20-30,000/ L in neonate with failure of platelet production
2. Platelet count lt50,000/L in stable premature infant
With active bleeding Invasive procedure with failure of platelet production
3. Platelet count lt100,000/L in sick premature infant
With active bleeding Invasive procedure in patient with disseminated intravascular coagulation
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Guidelines for Platelet Transfusion in Older Children
Platelet count 5000 to 10,000/L with failure of platelet production Maintain platelet count 100,000/L for central nervous system (CNS) bleeding or planned CNS surgery.
Maintain platelet count 50,000/L if actively bleeding or undergoing major surgery.
Prophylactic transfusion for patients with platelet counts between 5 to 10,000/L.
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Guidelines for the Transfusion of Fresh Frozen Plasma
1. Replacement therapy
When specific factor concentrates are not available, including but not limited to Factors II, V, X, and XI, protein C or S PT gt1.5 and /or PTT gt1.5. During therapeutic plasma exchange when FFP is indicated (plasma from which the cryoprecipitate has been removed may be beneficial in thrombotic thrombocytopenic purpura not responsive to conventional plasma exchange)
2. Reversal of warfarin in an emergency situation, such as before an invasive procedure with active bleeding.
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Guidelines for the Use of Cryoprecipitate
1. Hypofibrinogenemia or dysfibrinogenemia with active bleeding or undergoing an invasive procedure
2. Factor XIII deficiency with active bleeding or undergoing an invasive procedure
3. For bleeding episodes in small children with hemophilia A (note that previously untreated children should receive recombinant Factor VIII)
4. von Willebrand disease when DDAVP is contraindicated or not available, and when virus- inactivated plasma-derived Factor VIII concentrate, which contains vWF, is not available
- Active bleeding - Before an invasive procedure
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Guidelines for Granulocyte Transfusion in Children 1. Neonates and children with neutropenia or granulocyte dysfunction with bacterial sepsis and lack of responsiveness to standard therapy.
2. Neutropenic neonates and children with fungal disease not responsive to standard therapy.
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Requirements for Granulocyte Products Intended for Children Ensure ABO compatibility Ensure that they are crossmatch compatible Irradiate Transfuse as soon as possible Use standard blood filter Do not use leukocyte reduction filter Administer within 4 to 6 hours of collection Do not administer with amphotericin separate administration by as much time as practical Use HLA-matched components in alloimmunized patients Infuse over 1 to 2 hours Use CMV-seronegative units if recipient is CMV seronegative
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ABO Selection of Blood Components
Patient ABO Type RBCs, Platelets Plasma   Cryoprecipitate
O O  O, A, B, AB
A A,O A,AB
B B,O B,AB
AB AB,A,B,O AB
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Administration of blood components

• Pretransfusion
• Recipient identification The name and
  identification number on the patients
  identification band must be identical with the
  name and number attached to the unit.
• Unit identification The unit identification
  number on the blood container, the transfusion
  form, and the tag attached to the unit (if not
  the same as the latter) must agree.

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Component Volumes to be Transfused to Children
and Neonates

• Red cell concentrates for exchange
• transfusion
• Term Infant
  80-160mls/kg
• Preterm Infant
  100-200mls/kg
• For top-up transfusion
  10-20mls/kg
• Platelet concentrates
• Children weighing less than 15kg
  10-20mls/kg
• Children weighing more than15kg
  single Apheresis unit
• Fresh Frozen Plasma
  10-20mls/kg
• Cryoprecipitate
  5-10mls/kg

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Infusion flow rates RBC 3-5
mL/kg/hour FFP within 30 minutes, provided the
volume does not exceed 5-10 mL/kg Platelets
within 30 minutes. It is seldom necessary to
reduce the volume of the platelet concentrate if
the dose does not exceed 5-10 mL/kg
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Special Products

• Despite general measures to ensure transfusion
  safety, there still an added risk to infants and
  children with underlying hematological, oncologic
  and immunologic disorders.
• Transfusion reaction may be caused by both
  infectious or non infectious processes.
• Special products are blood components collected,
  processed, and selected specifically to minimize
  these complications.

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Leucocytes Reduced Blood Components

• Leucocytes in the blood components can lead to
  many complications
• Universal Leucodepletion verses specific
  indications.

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Leucodepletion of Blood Components
All neonates and intrautrine transfusion Prevent
ion of Alloimmunization in patients with AML
receiving induction chemotherapy. In patients
with other types of leukemia and in other cancer
patients receiving chemotherapy. Prevention of
Febrile Non Haemolytic Transfusion
Reaction. Replacement of CMV negative blood
components. .
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CMV negative blood products Blood products
tested for antibodies to CMV or
leukodepleted Indicated to prevent CMV
transmission in select populations 1-Immunodefic
ient or immunosuppressed patients 2-Neonates 3-Pat
ients w/ hematologic malignancies CMV resides in
WBCs (leukodepletion), so screening not necessary
for FFP, cryoprecipitate, other plasma products.
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4-In Oncology/BMT patients, CMV titers are
checked If patient is CMV positive, then products
do not have to be CMV negative regardless of
immune status. If patient is CMV negative, he
should receive CMV negative products
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• Irradiation
• -Performed for prevention of transfusion-related
• Graft-versus-Host Disease (GVHD)
• -Irradiation prevents T-cells proliferation
• 25 Gy to blood products effective
• Used for cellular products PRBCs, platelets

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Indications

• premature infants lt 1200g birthweight
• 2. infants with known or suspected congenital
• immunodeficiency syndromes
• 3. infants receiving granulocyte transfusions
• 4. infants receiving directed donor blood
  component from blood relatives
• 5. infants receiving HLA-matched or platelet
• crossmatch-compatible platelets

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6. infants undergoing stem cell transplants (the
stem cell product itself must not be
irradiated) 7. infants undergoing
immunosuppressive therapy, chemotherapy or
radiotherapy 8. infants receiving exchange
transfusions 9. foetuses receiving intrauterine
transfusions 10. infants receiving large volumes
of RBCs in association with ECMO.
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Components negative for Sickle Hemoglobin

• Sickle cell trait
• Hb A 60
• Hb S 40
• Hypoxia and acidosis can lead to sickle crisis.
• Can donate blood.

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AABB Recommendations

• Define patients populations who should receive
  red blood cells known to lack hemoglobin S.
• 1- infants with small blood volume or massive
  transfusion in neonates.
• 2- Sickle cell patients

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Conclusions

• Policies, Procedures and Guidelines for Blood
  Transfusion in Pediatric age group should be in
  place and implemented.
• Training and Education for the hospital staff in
  policies, and guidelines in pediatric age group
  are important issues to be considered.
• The use of special products is a must for
  specific patients in pediatric age group to
  ensure safety.

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References

• Guidelines for Transfusion Therapy of Infants
  from Birth to Four Months of age, New York State
  Council on Human Blood and Transfusion Services,
  Second Edition 2004.
• Pediatric Transfusion, A Physicians handbook
• 2nd Edition, 2006.
• Prenatal and childhood transfusion, Practical
  Transfusion Medicine 2001.

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THANKS