Blood transfusion in neonates carries risks and should only be done when benefits outweigh risks. Special considerations for neonates include their small size, immature immune systems, and unique hemoglobin and erythropoiesis characteristics. Clinical guidelines can help standardize best practices to improve outcomes. Strategies to reduce transfusions include delayed cord clamping and restrictive blood sampling. Proper blood component specification, testing, and product selection are crucial to ensure safety.

1. Blood Transfusion In Neonates
Dr. Souhila Bait
Laboratory Medicine Resident

2. 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

3. Consider:
 infants will live long enough to get a long term
complication of blood transfusion.
 neonate has special need :
small size
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•
•
•
•
•
O2 affinity of fetal hemoglobin
Immature immune system
Presence of maternal alloantibodies
Shortened red cell survival
Decreased erythropoiesis
Cardiovascular adaptive capacity

4. 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.

5. Strategies to reduce donor exposure or RBC 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.
 Using appropriately collected and stored multipack RBC
units.
 Collecting and transfusing umbilical cord blood (autologous
blood transfusion).

6. Blood and blood component Specification
 RBCs administered should be as fresh as possible: components
for transfusion in utero or to children under 1 year of age must be
prepared from blood donated by donors who have given at least one
previous donation within the past 2 years, which was negative for all
mandatory microbiological marker.
 Leuco-depleted: All components other than granulocytes should be
leucocyte depleted (not more than 5 x106 leucocytes per unit) at the
time of manufacture.
 Leukocyte depletion is important in neonatal transfusion. It helps in
preventing non-hemolytic febrile transfusion reactions (NHFTR), HLA
allo-immunization, transmission of leukotropic viruses (CMV, EBV and
HTLV-1), and replacement of CMV negative blood components.
 Methods of leuco-depletion include the following:
a. Centrifugation and removal of buffy coat (pre-storage).
b. Use of leukocyte filters (pre or post storage).
c. Washing of RBCs with saline.
d. Freezing and thawing of red cells

7. 
irradiated: inactivation of donor T cells to prevent the risk of
transfusion related graft versus host disease(GVHD).

It is essential to irradiate all red cell and platelet components(with the
exception of frozen red cells) for:
1.
2.
3.
4.
5.

Intrauterine transfusion (IUT).
Exchange transfusion (ET) of red cells after IUT.
Top-up transfusion after IUT.
When the donation is from a first- or second-degree relative or a
human leucocyte antigen (HLA)-selected donor.
When the child has proven or suspected immunodeficiency.
cytomegalovirus (CMV) seronegative: or leuco-depleted to
<5x106 /unit has a significant reduction in risk of CMV transmission.

8. Pre-transfusion testing in Infants less than 4 month of age
 mother’s sample should be tested for blood group and for any
atypical red cell antibodies. if the maternel blood is unavailable the
neonatal plasma should be screened to exclude atypical antibodies;
the serum may contain passively transferred maternal antibodies
 ABO compatibility:
 Though ABO antigens may be expressed weakly on neonatal
erythrocytes, neonate’s serum may contain transplacentally
acquired maternal IgG anti-A/or anti-B
 Cross-matching should be carried out with the maternal serum. in
cases where maternal serum is not available, infant serum can be
used; however this is not encouraged.
 Blood for transfusion should be of newborn’s ABO and
Rh group, it should be compatible with any ABO or
atypical red cell antibody present in the maternal serum.

9. Infant
Transfused
Blood
prbc/whole
blood
O(anti A and anti B)
A
(anti B)
B
(anti A)
O
O
O
W/PRbc
A(Ag A)
O (antiA and anti B)
A (anti B)
B (antiA)
AB (0 Ab)
O
A
O
A
PRbc
W/PRbc
PRbc
W/PRbc
B(Ag B)
O(antiA and anti B)
A (anti B)
B (antiA)
AB (0 Ab)
O
O
B
B
PRbc
PRbc
W/PRbc
W/PRbc
A
B
AB
A/B/O
W/PRbc
W/PRbc
W/PRbc
PRbc
O(o Ag)
AB(Ag A +Ag B)
Mom
A (anti B)
B (antiA)
AB (0 Ab)
AB (0 Ab)

10.  If the mother’s and the babies blood groups are the same, transfuse blood
of baby’s ABO group.
 In case mother’s and babies blood group is not compatible, use group O.
 Stable neonates do not require RBC transfusion, regardless of their blood
hemoglobin level, unless they exhibit clinical problems attributable to
anemia.
 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 HDN due to anti-D ,use group O RhD negative blood.
.

11. Suggested transfusion thresholds for infants under 4 months of age
Transfusion of red blood cells
Anaemia in the first 24hrs
Hb 12 g/dl (Hct: 0.36)
Cumulative blood loss in 1 week in a
neonate requiring intensive care
10% blood volume
Neonate receiving intensive care
Hb 12 g/dl
Acute blood loss
10% blood volume
Chronic oxygen dependency
Hb 11 g/dl
Late anaemia, stable infant
Hb 7 g/dl

12.  Neonates may require multiple transfusions, increasing
the risk of infectious disease transmission, through multiple
donor exposures and allo-immunization.
 To reduce exposure to multiple donors, the most important
approach is the use of multipack collection systems so that
multiple RBC transfusions from the same random or
designated donor can be given to the same baby over an
extended period of time.

13. Measures to reduce multiple blood transfusions in preterm infants
 In preterm and sick neonates, needing multiple
transfusions, aliquots from a single donor can be given as
sequential transfusions.
 This is done practically by reserving a bag of fresh PRBC
for up to 7 days for a newborn and withdrawing small
amounts required repeatedly from that bag under laminar
flow using a sterile connecting device, into a fresh blood
bag.

14. Fresh Frozen Plasma
 Fresh frozen plasma should never be used as a simple volume
replacement and it is not clearly superior to crystalloids or colloids in the
management of neonatal hypotension.
 Routine administration to preterm infants to try to prevent peri ventricular
haemorrhage (PVH) has been shown to confer no benefit and should
therefore be avoided.
 Neonates with a significant coagulopathy {e.g. prothrombin time (PT) or
activated partial thromboplastin time (APTT) >1.5 } and significant risk of
bleeding (e.g. preterm and/or intubated, previous PVH) or who are about
to undergo an invasive procedure should receive FFP at a dose of 15
ml/kg.

15.  The only indications for FFP in neonates recommended in the
recent BCSH guidelines are: DIC, vitamin-K-dependent bleeding
and inherited deficiencies of coagulation factors.
 For neonatal transfusions AB Plasma is used (compatible to all blood
groups) , or choose compatible FFP with neonates ABO red cell
antigens (see Table )

16. Platelets Transfusion
Transfusion of platelets
Preterm or term neonate, with bleeding
50 × 109/l
Sick preterm or term infant, not bleeding
30 × 109/l
Stable preterm or term infant, not
bleeding
20 × 109/l
 Term infants are unlikely to bleed if the platelet count is
maintained above 20x109, but in small, preterm babies a higher
threshold is generally recommended, particularly during the first
few days when the risk of PVH is highest or if there is a coexistent coagulopathy.

17. Platelets for neonatal transfusion should be
 ABO identical or compatible RhD identical or compatible.
 Be HPA compatible in infants with allo-immune thrombocytopenia
 Be irradiated if appropriate.
 For platelet and FFP transfusions, plasma compatibility should be
ensured whenever possible.
 Both products contain enough red cell stroma to stimulate Rh
immunization Therefore, RhD- girls for whom only RhD+ products
are available should receive anti-D Ig. The dose should be 50IU/per
unit of FFP(200–300 ml) or per 500 ml of platelets transfused, or
250 IU per adult therapeutic dose of platelets (c. 250–350ml,
whether from a single aphaeresis donation or from a pack derived
from a buffy coat pool from four donations). Components must not
contain other clinically significant red cell antibodies.

18. Cryoprecipitate
 It’s prepared from FFP by thawing at 2-40C.
 Undissolved precipitate is collected by centrifugation
and supernatant plasma is aseptically expressed into a
satellite bag.
 Cryoprecipitate contains about 80 to 100 U of factor
VIII in 10-25 ml of plasma, 300 mg of fibrinogen and
varying amounts of factor XIII. it is stored at
temperature of ≤-200c.
 indications:
 Congenital factor VIII and XIII deficiency.
 von Willebrand disease.
 Afibrinogenemia & dysfibrinogenemia.

19. 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
volume of packed cells(ml)=weight(kg)x desired rise in haemoglobin x 4
 Platelet concentrates:
Children weighing less than 15kg
10-20mls/kg
Children weighing more than15kg
single Apheresis unit/standart pool
Dose: 5-10 ml / kg raise platelet count 75 to 100
109/ l
 Fresh Frozen Plasma
10-20mls/kg
 Cryoprecipitate
5-10mls/kg or 15-30kg= 5 units
> 30 kg= 10 units
It is desirable to give cryoprecipitate only if the neonatal fibrinogen level remains low
despite FFP transfusion.

20. 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.
It has been seen that transfusion with PRBC at a dose of
20ml/kg is well tolerated and results in an overall decrease in
number of transfusions compared to transfusions done at
10ml/kg in preterm an VLBWinfants
In infants and newborn, one unit of PRBC(10ml/kg) increases
Hb by 3g/dl.

21. Choice of ABO group for blood products for administration to children.
ABO group of blood product to be transfused
Patient’s ABO group
Red cells
Platelets
FFP*
First choice
O
O
O
Second choice
–
A
A or B or AB
First choice
A
A
A or AB
Second choice
O**
O**
_
First choice
B
B
B or AB
Second choice
O **
A or O **
_
First choice
AB
AB
AB
Second choice
A, B
A
A
Third choice
O **
O
A
B
AB
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.
*Group
O fresh frozen plasma (FFP) should only be given to patients of group O. Although group AB FFP can be given
to people of any ABO blood group, supplies are usually limited.
**Group
O components which test negatively for ‘high titre’ anti-A and anti-B should be selected.

22. Transfusion exchange
 The main indication for neonatal exchange transfusion is to prevent
neurological complications (kernicterus) caused by a rapidly-rising
unconjugated bilirubin concentration
 If exchange transfusion is needed,must be:
 IAT-cross-match compatible with maternal plasma;
 group O or ABO compatible with maternal and neonatal plasma, RhD
negative or RhD identical with neonate.
 be irradiated and transfused within 24 h of irradiation
 If an ET is required in ABO HDN, this should be with group O red cells
with low titre plasma anti-A and anti-B, or with group O red cells
suspended in AB plasma
 For HDN due to anti-D: use group O Rh D negative
 An exchange transfusion of about two times the neonate’s blood volume
(about 170 ml/kg) is most effective to reduce bilirubin and restore the
haemoglobin level; this can usually be carried out with one unit of whole
blood.
 A unit of whole donor blood will normally have a haematocrit of 37-45%,
which is more than adequate for neonatal needs.

23. Blood film in diagnosing HDN
 Blood film examination is usually diagnostic in DAT



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negative in cases of suspected HDN in ABO,RhD
incompatibility:
Blood film in ABO incompatibility: caracteristically shows
large numbers of spherocytes with little or no increase in
NRBCs.
Blood film in RhD incompatibility:shows few spherocytes
and large number of NRBCs
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 HDN due to anti-D ,use group O RhD negative blood.

24. 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.