1. 18 AABB News | MARCH 2016
By Marian Mostovy
AABB CONTRIBUTING WRITER

2. The Magazine for Transfusion and Cellular Therapies Professionals 19
Between ten and 20 percent of whole blood
donors in the United States are younger than age 20.
The majority of these donations occur at high school
and college blood drives. In addition, the American Red
Cross (ARC), which provides 40 percent of the nation’s
blood supply, collects 14 percent of blood donations from
donors between the ages of 16 and 18.
While blood donation is generally safe, the youngest
donors are at an increased risk for physical and psycho-
logical reactions following donation. Most of these
complications are minor, including lightheadedness,
dizziness and sweating. But the number of young
donors who experience a reaction is double that
of older donors, even when controlling for other
variables such as first-time donation.1
Also, in the
small number of cases when donors faint, injuries
occur at a significantly higher rate among donors
younger than age 23.2
Minor reactions, often called vasovagal or
pre-fainting symptoms, usually resolve quickly.
But donors who experience such reactions are
less apt to donate again, especially if they are
first-time donors. “You are only allowed to begin
donating when you are 16 years old with parental
permission — or 17 years old in some places —
so there is a disproportionate number of first time
donors in this age group,” said Tom Watkins, DO,
PhD, chief medical officer of the MEDIC Regional
Blood Center in Knoxville, Tennessee. “Donors
are self-selecting, so if they’ve had a bad reaction,
they probably aren’t going to come back again.”
The results of studies back this logic. The
likelihood that a donor will return to make a
repeat donation decreases with the severity of
their reactions. When a donation goes smoothly,
a donor is more likely to make additional
donations in the future. More than 60 percent of
whole blood donations come from repeat donors.
“Young donors are the growing part of the
donor population,” said Anne Lassinger, director
of clinical education and training for The Institute for
Transfusion Medicine (ITxM). “They are the future of our
industry. If we don’t emphasize how important donating
is from the beginning, we are not going to keep them as
lifelong donors.”
As AABB and blood centers became aware of the
heightened risks for young donors, they began focusing
on ways to increase safety. In 2008, an AABB task force
recommended that blood centers adopt approaches to help
reduce reactions and injuries related to them. The recom-
mendations, based on clinical studies and observations,
include raising the blood volume criteria, hydration and
distraction.3
Blood centers are continuing to implement
policies and procedures to enhance young donors’ safety
and satisfaction as the body of research in this area grows.
SAFETY for
ENSURING
YOUNGER
BL D
DONORS

3. 20 AABB News | MARCH 2016
Positive Results
Blood Systems, Inc. (BSI), a non-profit that collects
about 1 million units of blood per year in 15 states,
implemented several interventions to reduce reactions
in young whole blood donors in 2008. An analysis of 12
months of data showed positive results compared with
a 12-month period prior to the interventions. Overall
reaction rates — which included mild, moderate and
severe reactions — decreased by 24 percent; the fainting
rate decreased by 22 percent.4
“We identified that blood donors with low blood
volume had greater reaction rates than donors with large
blood volume,” said Hany Kamel, MD, corporate medical
director and vice president of BSI. “We changed our
policy accordingly, so that a young person with blood
volume of less than 3.5 liters is deferred.”
BSI developed blood volume tables based on height,
weight and gender for donors younger than age 23. The
guidelines prevent people from donating more than 15
percent of their blood volume, the limit set by AABB and
the Council of Europe.2
BSI introduced other interventions to decrease the risk
of reactions in young donors. “We encouraged donors
to drink 16 ounces of water during or after donation, and
instructed them to do muscle tension exercises while they
were in the chair,” explained Kamel.
Water is thought to reduce reactions because the
volume in the stomach signals the body to send more
blood there, similar to when one eats, and thereby to the
central nervous system.
Applied muscle tension, or AMT, is a technique where
donors tighten large muscles in their arms and legs
in short bursts that is thought to help reduce the risk
of fainting. BSI donors were asked to tighten their leg
muscles for 5 seconds, relax for them 5 seconds, for
as long as they felt comfortable doing so through the
donation.
The American Red Cross implemented similar
interventions for donors between the ages of 16 and
18 — including blood volume limits, hydration and AMT
— in 35 regional blood centers during a two-year period.
Reactions were reduced by 18-33 percent following the
implementation of these interventions. One striking effect
was a 14 percent reduction in fainting among 16-year-old
females.1
The Fear Factor
Donors’ fears of the risks associated with blood dona-
tion are of particular concern in younger donors. “If the
kids come in extremely nervous about the process, they
are very much set up to have a reaction,” said Watkins,
whose organization collects blood at high schools and
colleges in eastern Tennessee. “There is also sympathetic
fainting, which is real. If one donor faints, it sometimes
triggers three or four others to faint.”
Fear is more common in high school donors than other
donors. In one study, 44 percent of high school donors
said they were afraid of the blood donation process. In
comparison, the fear rate in the general population is 15
percent.2
Donors’ fears of the risks associated with
blood donation are of particular concern in
younger donors.“If the kids come in extremely
nervous about the process,they are very much
set up to have a reaction,”saidWatkins.

4. The Magazine for Transfusion and Cellular Therapies Professionals 21
But fear is not being given enough attention as a
risk factor, according to Bruce Newman, MD, former
medical director of American Red Cross Blood Services of
Southeastern Michigan. “A study by Christopher France
showed that if donors are afraid, they are more than twice
as likely to have a reaction. But donors are not asked if
they are afraid. We can’t deal with the people who are
afraid because we don’t know who they are.”
At the time of donation, Newman recommends asking
donors if they are afraid and, if so, of what: having a
reaction, seeing blood or being fatigued? “We can then
deal with the specific issue, reassure them, and develop a
plan with them,” Newman said. “They can be encouraged
to drink a large glass of water or fruit juice within 20
minutes of the start of the phlebotomy, do muscle tension
toward the end of the phlebotomy, distract themselves, or
engage the staff in conversation.”
Environment, Training and Communication
In addition to blood volume limits, hydration and
distraction, blood centers can reduce the risk of reactions
and make the donation experience better for young
donors in a variety of ways:
• Create a safe environment. “At high school and
college blood drives, we have soft mats around the
collection area and in the wait area where donors
have refreshments,” said Watkins. “The key is to give
donors a soft place to fall if they are going to faint.
An ounce of prevention is worth a pound of cure.”
Also, setting up the collection space so donors can’t
see other each other could help prevent sympathetic
fainting.
• Educate staff. Because reactions are more common
in younger donors, staff need to be trained on how
to provide extra care for this group “It’s important to
understand that younger donors need to be treated
a little differently than older donors,” Lassinger said.
“This generation wants to know the ‘why’ about things,
so explanations about what is going on in the blood
donation process is more important with this group.”
Her team created a staff training video that shows the
donation experience from the viewpoint of a teen.
• Communicate with students and their parents. Good
communication before, during and after donation can
help limit reactions, as well as make the experience
positive. Donors should be encouraged to eat well,
hydrate themselves and get sufficient sleep prior
to donation. BSI makes sure that donors, parents
44% of high school donors said they were afraid
of the blood donation process. In compari-
son, the fear rate in the general population
is 15 percent.
14%
of blood donations, collected
from the American Red Cross,
are from donors between the
ages of 16 and 18. 18-33%By implementing various interventions
for donors between the ages of 16 and 18,
reaction rates were reduced by

5. 22 AABB News | MARCH 2016
and staff know there is always a physician available
following donations. ITxM follows up on mild and
moderate reactions, not just severe ones. “The e-mails
and letters send a message that we care about the
donor,” said Lassinger. She notes these donors do not
often respond directly, but they are returning to make
subsequent donations. “Parental involvement is key,”
said Watkins. “Donor services will talk to parents, for
example, if there’s a hematoma, to assure them they
don’t think it will be a more serious issue. We want
them to feel good about the experience; we want them
to feel that we are there to support their child if there
is a reaction.”
• Don’t rush at the end. Most donors who have a
reaction do so at the end of phlebotomy. In addition to
the loss of 500 mL of blood, once donors sit up, several
hundred more milliliters are going to their feet due
to gravity, explained Newman. “We need to ensure
donors feel okay sitting up for a minute before they
get off the bed,” he said. “It’s very important that the
person sits up and is doing well before they walk.”
• Help restore blood volume. BSI encourages donors
to eat salty foods prior to donation and gives out salty
snacks and water after donation to speed the return
of blood. The additional dietary salt prevents off-site
reactions and may be particularly helpful for some
donors.6
• Track and analyze data: As with all safety practices,
good tracking provides information to help pinpoint
areas for improvement. “Our High School Reaction
Team reviews monthly reports on reactions of donors
in the 16-to-18-year age bracket,” said Lassinger. “We
compare that data against our own stats and national
averages to determine where we fall, where we have
seen an uptick in our own reactions overall, and we
compare our sites.”
Iron Deficiency
Collecting double red blood cells through apheresis
could be a strategy for lowering reactions among the
youngest donors because fluid removed during the
process is returned to the donor. However, blood centers
may be wary of this option out of concern about the loss
of iron.
Teens are still growing physically and maturing
cognitively, and their diets are often suboptimal. Some
theorize these factors may make younger donors more
susceptible to iron deficiency compared with adults. In
addition, the effect of iron deficiency might be different in
teens compared with adults. Furthermore, young women
may be menstruating, which is a risk factor for iron
deficiency in all pre-menopausal women.
Iron deficiency has been studied in the adult donor
population for several years, but the iron status of
younger donors is relatively unexplored. “The impact of
iron deficiency without anemia isn’t clear,” said Kamel. “It
may have an effect on cognitive ability in younger people,
since their brains are still developing. There is data in the
literature to support both sides.”
Some attention is beginning to be paid to the question.
For 30 months, BSI screened for iron deficiency with
ferritin testing when donors’ hemoglobin levels were
low but acceptable for donation. The trigger for ferritin
testing was a hemoglobin level between 12.5 and 12.9 g/
dL for females and between 12.5 and 13.4 g/dL for males.
The results of a BSI study examining donations during
a 15-month period show that younger first-time donors
were more likely to have low iron stores than older first-
time donors.7
Among repeat donors, low iron was most
common in donors between ages 16 and 20. Younger
women who are repeat donors had the lowest iron stores
in the donor population.
A study sponsored by the National Heart, Lung, and
Blood Institute is now underway to help establish a basic
understanding of iron stores in young donors. Two REDS-
III program “hubs,” comprised of a blood center and two
or more hospitals, have each enrolled 2,000 donors at
high school blood drives and tested their ferritin. When
the same donors return to donate blood at drives during
the current school year, the ferritin test will be repeated.
“Starting in June, we’ll be able to do an analysis of
high school blood donors based on their presenting ferri-
tin level at the beginning of the year and, for those who
return, we’ll be able to see how that changes,” explained
Alan Mast, MD, senior investigator at the Blood Research
Institute of the BloodCenter of Wisconsin, one of the two
participating hubs. Donors between the ages of 19 and 49,
who make up about 10 percent of the non-students who

6. The Magazine for Transfusion and Cellular Therapies Professionals 23
donate at high school blood drives,
will serve as the control group.
The goal of the study is to docu-
ment “the hemoglobin and iron
status in donors who are 16, 17 or 18,
and determine if it is different from
adult donors,” said Bryan Spencer,
MPH, research scientist for ARC
Massachusetts Region and manager
of the REDS study at the Yale-ARC
Connecticut hub. “In addition, in
young donors for whom we have
more samples to test, we will study
whether the recovery of hemoglobin
and iron between donations is
different compared with adults. It’s
pretty elemental, but there simply
isn’t much on the iron status of
young donors. Researchers have
been looking at these issues for a
number of years, but those studies
have focused on donors age 18 and
older.”
ENDNOTES:
1. Eder AF. Can we improve safety for
young blood donors? ISBT Science
Series 2012; 7:226-229.
2. Newman BH. Management of
Young Blood Donors. Tranfus Med
Hemother 2014; 41:284-295. DOI:
10.1159/000364849.
3. AABB. Association Bulletin #08-04.
Strategies to Reduce Adverse Reactions
and Injuries in Younger Donors. August
28, 2008.
4. Tomasulo P, Kamel H, Bravo M, James
RC, Custer B. Interventions to reduce
the vasovagal reaction rate in young
whole blood donors. Transfusion
2011;51:1511-1521.
5. France CR, France JL, Himawan LK, et
al. How afraid are you of having blood
drawn from your arm? A simple fear
question predicts vasovagal reactions
without causing them among high school
donors. Transfusion 2013; 53: 315–321.
6. Bravo M, Kamel H, Custer B, Tomasulo P.
Factors associated with fainting – before,
during and after whole blood donation.
Vox Sang 2011;101:303-12.
7. Bravo M, Custer B, Tomasulo P, Kamel H.
Age and Gender Relationships Observed
in Routine Ferritin Testing. Poster
presented at AABB Annual Meeting 2014.
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