Red Blood cell transfusion in paediatrics. How and when to transfuse anaemic patients in paediatrics. Looking at specific conditions.

1. Red blood cell
transfusion
rationale in
paediatrics
Dr T van Niekerk

2. Topic Outline
• INTRODUCTION
• PREVALENCE OF PEDIATRIC RED BLOOD CELL TRANSFUSION
• GENERAL PRINCIPLES
• Rationale for transfusion
• Restrictive versus liberal strategy
• Factors in clinical decision-making
• SPECIFIC CLINICAL SCENARIOS
• Neonates
• Critical illness
• Surgery
• Malignancy
• Chronic kidney disease
• Chronic anemias

3. volume and iron
overload
Transmit
infection
Transfusion
reactions
Immunologic
consequences
Lifesaving

4. PREVALENCE OF PEDIATRIC RED BLOOD CELL TRANSFUSION
• 1 to 3 percent of hospitalized children receive RBC transfusions
• In a study analysing data on >1,000,000 non-neonatal paediatric
admissions from the 2016 Kid's Inpatient Database, RBC transfusions
were administered in 2.6 percent.
• RBC transfusion was more common in elective admissions compared
with nonelective.
• RBC transfusion correlated with severity of illness, hospital length of
stay, and risk of mortality.

5. GENERAL PRINCIPLES: Rationale for
transfusion
• ensuring sufficient circulating RBCs to prevent or reduce morbidity and
mortality while avoiding unnecessary transfusions.
• The principal rationale behind RBC transfusion is to provide sufficient cells
to prevent or reverse tissue hypoxia due to limited oxygen delivery. T
• here are limited data on the Hgb level required for sufficient tissue
oxygenation in healthy children,
• data from animal studies and clinical observations of children with chronic
haemolytic anemia suggest that Hb of approximately 6.7 g/dL can be well
tolerated
• The risk of mortality and other adverse outcomes increases with Hgb levels
<5 g/dL (hematocrit <15 percent).

6. Restrictive versus liberal strategy
• a restrictive transfusion strategy is sufficient rather than a liberal
transfusion strategy.
• For hemodynamically stable hospitalized paediatric patients,
including hemodynamically stable children with critical illness, we
recommend a restrictive RBC transfusion strategy (ie, Hgb of 7 g/dL as
the transfusion threshold) rather than more liberal transfusion
strategies.
• Transfusion at higher Hgb levels may be appropriate in certain
conditions such as acute blood loss from trauma or surgery, cyanotic
congenital heart disease (CHD), malignancy, and chronic anaemias
(eg, sickle cell disease, thalassemia).

7. Factors in clinical decision-making
• Degree of anemia (Hgb level)
• Acuity of anemia
• Degree of symptoms
• Cardiopulmonary stability
• Ongoing blood loss
• Underlying conditions

8. Degree of anaemia (Hgb level)
• "transfusion trigger": an absolute Hgb value below which the patient needs RBC
transfusion.
• Do not use the Hgb alone
• clinical setting (eg, acute or chronic) and physiologic status of the patient.
• The physiologic response to anaemia in children is different from adults.
• In critically ill children who are stable an Hgb threshold of 7 g/dL has been used
to decrease transfusion requirements without increasing adverse outcomes
• Hgb levels <5 to 6 g/dL or haematocrit <15 to 18 percent- RBC transfusion is
warranted for severe anaemia
• Hgb concentrations >10 g/dL (haematocrit >30 percent) - Transfusion is generally
not indicated in children with
• 6 and 10 g/dL (haematocrit 18 to 30 percent) -the decision to transfuse is
dependent upon the clinical situation.

9. Acuity of anaemia
• Chronically anaemic children often tolerate Hgb concentrations as low
as 6 to 7 g/dL (haematocrit 18 to 21 percent) because they are able to
maintain adequate intravascular volume and tissue oxygenation.
• Patients with an acute loss of blood and hypovolemia may require
transfusion, depending on the extent of blood loss.

10. Degree of symptoms
• Most children have symptoms of anaemia at Hgb levels <6 or 7 g/dL
(haematocrit <18 to 21 percent).
• Children with chronic anaemia may not have symptoms at this level
• children with acute blood loss those and underlying medical
conditions may develop symptoms at considerably higher Hgb levels

11. SPECIFIC CLINICAL SCENARIOS
• Neonates
• Critical illness
• Trauma
• Surgery
• Maligancy
• Chronic Kidney Disease
• Chronic Anaemias

12. NEONATES- Specific transfusion issues
• Relative large volumes transfused
• attention to metabolic complications - Ca++, K+, glucose,hypothermia
• Passive transfer of maternal ab (IgG)
• Lack of alloantibodies
• Long life expectancy
• Immature immune system - CMV, GvHD

13. Neonates –RBC transfusion indications
• Restore circulating blood volume
• Increase the 02 carrying capacity
• Exchange transfusion – haemolytic disease of the newborn;
polycythaemia

14. Neonatal RBC trends
• More restrictive use of RBC transfusions over the past decade in
ELBW and VLBW neonates.
• Trend in term babies has not changed
• Aim:
1. Reduce incidence of anemia in term and preterm neonates
2. Reduce need for blood cell transfusions
3. Limit donor exposure in this population thus reducing risks associated with
transfusions

15. Neonates – British guideline for red blood cell
transfusions
Clinical status
• Anaemia in first 24hrs of life
• Neonate receiving Intensive care
• Chronic 02 dependency
• Late anemia, stable pt
• Acute blood loss
Hb conc
<12g/dl
<12g/dl
<11g/dl
<7g/dl
10%TBW

16. CRITICAL ILLNESS
• Unstable – Transfusion is often warranted in unstable anaemic
paediatric patients who have cardiopulmonary compromise.
• Need for transfusion is usually determined by clinical parameters rather than
the patient's Hgb level
• transfusion is rarely indicated if the Hgb level is >10 g/dL (haematocrit >30
percent)

17. Hemodynamically stable
• most critically ill children but hemodynamically stable
• RBC transfusion not be given if the Hgb is ≥7 g/dL (haematocrit ≥21 percent).
• Exceptions to this include children with CHD, acute brain injury, sickle cell
anaemia, oncologic diseases, recent hematopoietic stem cell transplant, and
acute blood loss due to trauma
• A clinical trial randomly assigned 637 critically ill children to either a
restrictive transfusion strategy (Hgb of 7 g/dL as the transfusion
threshold) or a
liberal strategy (Hgb of 9.5 g/dL as the transfusion threshold). The restrictive
strategy decreased transfusion requirements without increasing adverse
outcomes (ie, multiple organ dysfunction syndrome or death).

18. SURGERY
Pre-operative Management
• Patients who are anaemic pre-op are more likely to be transfused
• Unnecessary transfusion can be prevented if FBC checked 4-6 weeks
prior for elective surgery
• Treat Fe deficiency and nutritional deficiency

19. Malignancy.
• Anaemia due to infiltrations, impaired production due to cytokines
and or chemotherapy, nutritional, deficiencies, blood loss.
• Severe fatigue affecting the quality of life
• Allogeneic RC TF useful especially with marrow failure and marrow
infiltration
• Erythropoeitin - conflicting reports on safety - Ca cells may express
EPO receptors

20. MALIGNANCY
• largest groups of patients requiring frequent RBC transfusion
• Children undergoing treatment with cytotoxic chemotherapy
• hematopoietic stem cell transplantation
• One approach is to transfuse at an Hgb level of 6 to 7 g/dL (haematocrit 18 to 21
percent), which, as noted above, is the level at which most children become
symptomatic [
• Some experts suggest an RBC transfusion threshold of Hgb level <8 g/dL
(haematocrit <24 percent) to avoid the development of symptoms, particularly if
ongoing chemotherapy-associated marrow suppression is likely
• Transfusion may also be warranted at higher Hgb levels if there are symptoms
attributable to anaemia.
• Observational data suggest that a restrictive transfusion strategy may reduce
transfusion requirements without increasing adverse outcomes in paediatric
patients undergoing hematopoietic stem cell transplant,

21. CHRONIC KIDNEY DISEASE
• Multiple factors - principle cause is EPO deficiency
• EPO has eliminated need for red cell transfusion
• IV Fe supplements also decrease amt of EPO required
• Prospective transplant pts should have as limited an exposure as
possible to prevent alloimmunisation

22. CHRONIC ANAEMIAS - sickle cell disease
• Painful vaso-occlusive crisis
• Precipitating factors: infection, acidosis, dehydration, deoxygenaton, operations,
stasis, extreme exercise, altitude, delivery, cold exposure
• Haemolytic crisis-accompanies painful crisis
• Sequestration crisis:
• Acute chest syndrome
• Hepatic
• Splenic infarcts – rapidly enlarging spleen and decreasing Hb and pain
• Aplastic crisis
• following parvovirus infection or folate deficiency
• Low reticulocyte count, sudden decrease in Hb

23. Sickle cell Disease
• Conservative approach – transfuse only when required
• Pts are adapted to Hb of 6-8 g/dl
• Manage with pain relief, fluids, antibiotics and long-term folate
supplements
• Red cell transfusion not routinely indicated for acute sickle crisis
• Exchange TF may be required for acute chest syndrome, intractable
priapism, prevent recurrence of stroke, red cell, aplasia dt parvo virus
infection , or splenic or hepatic sequestration
• Hb should not be > 10g/dl - raising Hb too much can worsen crisis
causing microvascular damage

24. B- Thalassaemia Major
• Present at age 6-12 months
• Reduced or nonexistent production of B-
globin
• Poor oxygen-carrying capacity of RBCs
• Failure to thrive, poor brain development
• Increased alpha globin production and
precipitation
• RBC precursors are destroyed within the marrow
• Increased splenic destruction of dysfunctional
RBCs
• require transfusion when FTT/ Hb <7
• Chronic TF alleciate anaemia and suppress
EMH
• TF every 3-4 weeks to maintain pre – TF Hb at
9-10g/dl

25. B- Thalassaemia Major
• Regular blood transfusions to maintain Hb >10
• Fe – chelation therapy
• Splenectomy
• Immunisation against Hep B
• Allogenic bone marrow transplantation

26. Autoimmune haemolytic anaemia
• The presence of autoantibodies that bind to the patient's own erythrocytes
• premature red cell destruction due to haemolysis and
• categorized as "warm" or "cold"
• classified as primary (idiopathic) or secondary
• AIHA - often acute onset and severe
• Usually dt viral infection and self-limiting
• Challenge in AlHA is difficulty in obtaining compatible blood
• TIf with least incompatible blood- monitor carefully and transfuse it slowly
• TIf may lead to production of alloAb > increasingly difficult to obtain compatible
blood
• Control immune haemolytic process with immunosuppression - steroids, IVIG,
azathioprine

27. Autoimmune haemolytic anaemia
• No consensus on the threshold for transfusion in AIHA
• Rarely severe and causes cardiovascular compromise (eg, when the
haemoglobin is <5 g/dL).
• Transfusion therapy should not be withheld from a patient with life-
threatening anemia
• Red blood cell (RBC) transfusion (following urgent discussion with blood bank
personnel regarding blood compatibility)
and
• Pharmacotherapy (glucocorticoids in patients with warm AIHA, rutixumab in
patients with cold AIHA)

28. Summary
• Restrictive transfusion practice
• Nutritional anemia tolerate 5g/dl
• Selective indications for hypertransfusions
• Thal Major
• Critical Care - Hb-7g/dI
• BM Failure - Hb- 7g/dl
• Clinical assessment - circulatory and respiratory compromise must
inform decision to TF