Transfusion is performed much less often in older infants and children. The most commonly transfused groups are children on paediatric intensive care units (PICUs), those undergoing cardiac surgery, transfusion-dependent children with inherited conditions such as thalassaemia major, and those following intensive chemotherapy for haematological malignancy or cancer. Transfusion guidelines and blood components for older children are similar to those for adult patients (see appropriate sections of the handbook). Blood transfusion for children with haemoglobinopathies is covered in Chapter 8.
The dose of blood components for infants and children should always be carefully calculated and prescribed in mL, rather than as ‘units’ to prevent errors and avoid potentially dangerous circulatory overload. Dedicated paediatric transfusion charts or care pathways can also reduce dosing and administration errors. It is recommended that:
The TRIPICU randomised controlled trial in stable critically ill children by Lacroix et al. in 2007 found that a restrictive Hb transfusion trigger (70 g/L) was as safe as a liberal Hb trigger (95 g/L) and was associated with reduced blood use. It remains uncertain whether this can be extrapolated to unstable patients.
Expert opinion now generally favours an Hb transfusion trigger of 70 g/L in stable critically ill children, which is the same as the recommendation for adult patients (see Chapter 7). A higher threshold should be considered if the child has symptomatic anaemia or impaired cardiorespiratory function.
There is little high-grade evidence to underpin guidelines for the administration of platelets and FFP in this group. In general, guidelines developed for adult patients are used (see Chapter 7).
Children undergoing treatment for malignancy are generally transfused in a similar manner to adult patients. A red cell transfusion trigger of 70 g/L is appropriate for clinically stable patients without active bleeding. Platelet transfusion guidelines are also similar to those developed for adult practice, although a higher rate of bleeding in children with haematological malignancies has been reported. The 2004 BCSH Transfusion Guidelines for Neonates and Older Children recommend a standard platelet transfusion threshold of 10×109/L in non-infected, clinically stable children. A threshold of 20×109/L is recommended in the presence of severe mucositis, DIC or anticoagulant therapy. Patients with DIC in association with induction therapy for leukaemia and those with extremely high white cell counts may be transfused at 20–40×109/L and a similar level is appropriate for performance of lumbar puncture or insertion of a central venous line.