10: Effective transfusion in paediatric practice
- The potential risks and benefits must always be considered when making the decision to transfuse children but there is a lack of high-quality research evidence on which to base guidelines.
- SHOT has reported a higher incidence of serious adverse events related to transfusion in children (including identification errors).
- Children transfused in fetal or neonatal life have the longest potential lifespan in which to develop late adverse effects of transfusion.
- Extra safety measures for blood components for fetal, neonatal and infant transfusion include enhanced donor selection and screening for clinically significant blood group antibodies (paediatric antibody tests or ‘PAnTs’).
- Fresh frozen plasma (FFP) and cryoprecipitate for all patients born on or after 1 January 1996 is imported from countries with a low risk of variant Creutzfeldt–Jakob disease (vCJD) and is pathogen-inactivated.
- Transfusion volumes and rates for children should be carefully calculated and prescribed in mL, not component units, to minimise dosing errors and reduce the risk of circulatory overload.
- Intrauterine transfusion of red cells (for haemolytic disease of the fetus and newborn (HDFN)) or platelets (for neonatal alloimmune thrombocytopenia (NAIT)) and neonatal exchange transfusion are complex procedures requiring multidisciplinary input. They should only be performed in specialist units.
- Randomised controlled trials suggest that restrictive Hb transfusion thresholds (similar to current UK guidelines) are safe in clinically stable neonates requiring small volume ‘top-up’ transfusions. However, there is still uncertainty, especially about long-term outcomes, and further research is needed.
- Low platelet counts are common in sick neonates but the relationship of thrombocytopenia to serious bleeding and appropriate triggers for platelet prophylaxis remain uncertain.
- A significant proportion of FFP transfusions in patients in neonatal intensive care units (NICUs) and paediatric intensive care units (PICUs) are given to non-bleeding patients with minor abnormalities in coagulation parameters of uncertain significance.
- A restrictive red cell transfusion policy (threshold 70g/L) is safe for clinically stable children on PICUs.
- Guidelines for the transfusion management of haemato-oncology patients are similar to adult guidelines, although a more liberal platelet prophylaxis policy may be justified.
- Transfusion management of major haemorrhage in children is largely based on experience with adult patients. Age-specific blood components should be used as long as urgent provision of blood is not delayed. Tranexamic acid is now recommended for children with major traumatic haemorrhage.
Paediatric transfusion is a complex area of medicine covering a wide age range from intrauterine life to young adults. The prescriber must balance the risks and benefits of transfusion in each age group and be aware of the indications for special components. However, compared to adult practice there is a relative lack of high-quality research to inform evidence-based guidelines. The UK National Comparative Audit of the Use of Red Cells in Neonates and Children 2010 (http://hospital.blood.co.uk/library/pdf/NCA_red_cells_neonates_children.pdf) showed that 74% of transfused patients received a single red cell component during their admission, suggesting that many transfusions might be avoidable.
The Serious Hazards of Transfusion (SHOT) initiative has reported a higher rate of adverse events in children, including identification errors, especially in the first year of life. Identification errors include confusion of maternal and neonatal samples, problems with multiple births, and failure to apply (or maintain) identification bands. Extra blood component safety measures have been developed for individuals transfused in fetal or neonatal life who have the longest potential lifespan in which to develop late adverse effects of transfusion. Components for fetal, neonatal and infant transfusion are collected from previously tested donors who have given at least one donation in the last two years. These components are screened for clinically significant blood group antibodies (including high-titre anti-A and anti-B) and an indirect antiglobulin test is performed – often known as ‘PAnTs’ (paediatric antibody tests). Fresh frozen plasma (FFP) and cryoprecipitate for all patients born on or after 1 January 1996 is imported from countries with a low risk of vCJD and is pathogen-inactivated (methylene blue or solvent detergent – see Chapter 3).