Salwa Hindawi

Dr Salwa HindawiMSc, FRCPath, CTM

Medical Director of Blood Transfusion ServicesKAUH, Jeddah

Makah 28th April2008

Blood Transfusion In Neonates and Children

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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

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Consider:

1. Child will live long enough to get a long term complication of blood transfusion

2. children has special need

3.Lack of evidence for many transfusion practice in children ,depending on adult experience and clinical judgment.

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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.

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Pretransfusion testing in Infants less than 4 month of ageMaternal sample:ABO & RhD group & Antibody screen.

Infant samples:ABO & RhD group & Direct antiglobulin test (DAT).Antibody screen (if maternal sample unavailable) .

If no atypical Antibody in maternal & infant serum & DAT on infant red cell is negative, Cross matching is unnecessary .

After 4 month Compatibility testing is required as for adults.

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cross matching within 1st 4 month of age

Compatibility testing is required only under the following conditions:

1. unexpected antibody is detected in the infant's or mother's serum;

2. the infant has a positive direct antiglobulin test result; or

3. the infant is to receive RBC transfusion incompatible with the mother's serum

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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 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.

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strategies to reduce donor exposure orRBC 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

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using appropriately collected and stored multipack RBC units

using appropriately screened and handled RBCs from regular or designated donors; and

collecting and transfusing umbilical cord

blood (autologous blood transfusion).

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PRBCs SpecificationRBCs administered should be as fresh as

possible

group O, or group specific

hemoglobin S negative

CMV-seronegative or leukoreduced

irradiated as indicated.

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Guidelines for Transfusion of RBCs in Patients Less than 4 Months of Age:

1 .Hemoglobin <7 g/dL with low reticulocyte count and symptoms of anemia

2 .Hemoglobin <10 g/dL with an infant

On <35% hood O2

On O2 by nasal cannulaOn continuous positive airway pressure (CPAP)/intermittent mandatory ventilation (IMV) with mechanical ventilation with mean airway pressure <6 cm H2OSignificant apnea or bradycardiaSignificant tachycardia or tachypneaLow weight gain

3 .Hemoglobin <12 g/dL with an infant

On >35% hood O2

On CPAP/IMV with mean airway pressure 6 to 8 cm H2O

4 .Hemoglobin <15 g/dL with an infant

On extracorporeal membrane oxygenation (ECMO)Congenital cyanotic heart disease

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Guidelines for Transfusion of RBCs in Patients More than 4 Months of Age*

1 .Intraoperative blood loss of15% total blood volume (TBV)

2 .Hemoglobin <8 g/dL

In Perioperative period, with symptoms of anemiaIn chemotherapy or radiotherapyIn chronic congenital or acquired symptomatic anemiaIn emergency surgical procedures with expected blood loss in patient with significant preoperative anemiaIn preoperative anemia when other corrective therapy is not available

3 .Acute blood loss with hypovolemia not responsive to other therapy

4 .Hemoglobin <13 g/dL with

Severe pulmonary diseaseECMO

5 .Chronic transfusion programs for disorders of red cellProduction such as: thalassemia major and Diamond-Blackfan syndrome

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Guidelines for Platelet Transfusion in Neonates:

1 .Platelet count <20-30,000/ L in neonate with failure of platelet production

2 .Platelet count <50,000/L in stable premature infant

With active bleedingInvasive procedure with failure of platelet production

3 .Platelet count <100,000/L in sick premature infant

With active bleedingInvasive procedure in patient with disseminated intravascular coagulation

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Guidelines for Platelet Transfusion in Older Children:

• Platelet count 5000 to 10,000/L with failure of platelet production

• Maintain platelet count ≥ 100,000/L for central nervous system (CNS) bleeding or planned CNS surgery.

• Maintain platelet count ≥ 50,000/L if actively bleeding or undergoing major surgery.

• Prophylactic transfusion for patients with platelet counts between 5 to 10,000/L.

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Guidelines for the Transfusion of Fresh Frozen Plasma

1 .Replacement therapy

When specific factor concentrates are not available, including but not limited to Factors II, V, X, and XI, protein C or SPT >1.5 and /or PTT >1.5.During therapeutic plasma exchange when FFP is indicated (plasma from which the cryoprecipitate has been removed may be beneficial in thrombotic thrombocytopenic purpura not responsive to conventional plasma exchange)

2 .Reversal of warfarin in an emergency situation, such as before an invasive procedure with active bleeding.

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Guidelines for the Use of Cryoprecipitate:

1 .Hypofibrinogenemia or dysfibrinogenemia with active bleeding or undergoing an invasive procedure

2 .Factor XIII deficiency with active bleeding or undergoing an invasive procedure

3 .For bleeding episodes in small children with hemophilia A (note that previously untreated children should receive recombinant Factor VIII)

4 .von Willebrand disease when DDAVP is contraindicated or not available, and when virus- inactivated plasma-derived Factor VIII concentrate, which contains vWF, is not available

-Active bleeding- Before an invasive procedure

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Guidelines for Granulocyte Transfusion in Children:

1 .Neonates and children with neutropenia or granulocyte dysfunction with bacterial sepsis and lack of responsiveness to standard therapy.

2 .Neutropenic neonates and children with fungal disease not responsive to standard therapy.

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Requirements for Granulocyte Products Intended for Children:

Ensure ABO compatibility Ensure that they are crossmatch compatibleIrradiateTransfuse as soon as possibleUse standard blood filterDo not use leukocyte reduction filterAdminister within 4 to 6 hours of collectionDo not administer with amphotericin; separate administration by as much time as practicalUse HLA-matched components in alloimmunized patientsInfuse over 1 to 2 hoursUse CMV-seronegative units if recipient is CMV seronegative

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Patient ABO Type RBCs, Platelets Plasma &  Cryoprecipitate

O O O, A, B, AB

AA,OA,AB

BB,OB,AB

ABAB,A,B,OAB

ABO Selection of Blood Components

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Administration of blood componentsPretransfusion:

Recipient identification: The name and identification number on the patient’s identification band must be identical with the name and number attached to the unit .

Unit identification: The unit identification number on the blood container, the transfusion form, and the tag attached to the unit (if not the same as the latter) must agree .

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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

Platelet concentrates:

Children weighing less than 15kg 10-20mls/kg

Children weighing more than15kg single Apheresis unit

Fresh Frozen Plasma 10-20mls/kg Cryoprecipitate 5-10mls/kg

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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

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Special Products:

Despite general measures to ensure transfusion safety, there still an added risk to infants and children with underlying hematological, oncologic and immunologic disorders.

Transfusion reaction may be caused by both infectious or non infectious processes.

Special products are blood components collected, processed, and selected specifically to minimize these complications.

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Leucocytes Reduced Blood Components

Leucocytes in the blood components can lead to many complications

Universal Leucodepletion verses specific indications.

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All neonates and intrautrine transfusion

Prevention of Alloimmunization in patients with AML receiving induction chemotherapy.

In patients with other types of leukemia and in other cancer patients receiving chemotherapy.

Prevention of Febrile Non Haemolytic Transfusion Reaction.

Replacement of CMV negative blood components.

.

Leucodepletion of Blood Components:

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CMV negative blood products:

Blood products tested for antibodies to CMV or leukodepletedIndicated to prevent CMV transmission in select populations:

1-Immunodeficient or immunosuppressed patients2-Neonates

3-Patients w/ hematologic malignanciesCMV resides in WBCs (leukodepletion), so screening not necessary for FFP, cryoprecipitate, other plasma products.

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4-In Oncology/BMT patients, CMV titers are checked If patient is CMV positive, then products do not have to be CMV negative regardless of immune status. If patient is CMV negative, he should receive CMV negative products

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Irradiation:

-Performed for prevention of transfusion-related Graft-versus-Host Disease (GVHD)

-Irradiation prevents T-cells proliferation 25 Gy to blood products effective Used for cellular products: PRBCs, platelets

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1. premature infants < 1200g birthweight

2 .infants with known or suspected congenitalimmunodeficiency syndromes

3. infants receiving granulocyte transfusions

4. infants receiving directed donor blood component from blood relatives

5 .infants receiving HLA-matched or plateletcrossmatch-compatible platelets

Indications:

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6. infants undergoing stem cell transplants (the stem cell product itself must not be irradiated)7. infants undergoing immunosuppressive therapy, chemotherapy or radiotherapy

8. infants receiving exchange transfusions

9. foetuses receiving intrauterine transfusions

10. infants receiving large volumes of RBCs in association with ECMO.

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Components negative for Sickle Hemoglobin

Sickle cell trait:

Hb A = 60%

Hb S = 40%

Hypoxia and acidosis can lead to sickle crisis.

Can donate blood.

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AABB Recommendations

Define patients populations who should receive red blood cells known to lack hemoglobin S.

1- infants with small blood volume or massive transfusion in neonates.

2- Sickle cell patients

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ConclusionsPolicies, 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.

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References:Guidelines for Transfusion Therapy of

Infants from Birth to Four Months of age, New York State Council on Human Blood and Transfusion Services, Second Edition 2004.

Pediatric Transfusion, A Physician’s handbook

2nd Edition, 2006.

Prenatal and childhood transfusion, Practical Transfusion Medicine 2001.

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