Research Opportunities to Improve Neonatal Red Blood Cell Transfusion

Abstract

Red blood cell (RBC) transfusion is a common and lifesaving therapy for anemic neonates and infants, particularly among those born prematurely or undergoing surgery. However, evidence-based indications for when to administer RBCs and adverse effects of RBC transfusion on important outcomes including necrotizing enterocolitis, survival, and long-term neurodevelopmental impairment remain uncertain. In addition, blood-banking practices for preterm and term neonates and infants have been largely developed using studies from older children and adults. Use of and refinements in emerging technologies and advances in biomarker discovery and neonatal-specific RBC transfusion databases may allow clinicians to better define and tailor RBC transfusion needs and practices to individual neonates. Decreasing the need for RBC transfusion and developing neonatal-specific approaches in the preparation of donor RBCs have potential for reducing resource utilization and cost, improving outcomes, and assuring blood safety. Finally, large donor-recipient-linked cohort studies can provide data to better understand the balance of the risks and benefits of RBC transfusion in neonates. These studies may also guide the translation of new research into best practices that can rapidly be integrated into routine care. This review highlights key opportunities in transfusion medicine and neonatology for improving the preparation and transfusion of RBCs into neonates and infants. We focus on timely, currently addressable knowledge gaps that can increase the safety and efficacy of preterm and term neonatal and infant RBC transfusion practices.

Keywords: Anemia; Hemoglobin; Infant; Newborn; Prematurity, blood bank.

Figure 1. Variability in the processing of donor RBCs

Some examples of sources of variability in blood banking practices for neonatal RBC transfusion are highlighted. Abbreviations: RBC, red blood cell; CMV, cytomegalovirus.

Figure 2. “Bleeding into the laboratory:” Cumulative phlebotomy loss as a result of laboratory blood testing of neonates

Mean data are shown for 26 ventilated VLBW infants of which 33% of laboratory blood loss was required by laboratory instrumentation for analysis, 59% of blood sampled was discarded as waste, and 8% represents hidden blood loss (e.g. blood left in syringes or on gauze pads, bandages). Reprinted with permission from Transfusion 53:1353–1360, 2013.

Figure 3. Non-pharmacological approaches to reduce laboratory phlebotomy blood loss during the neonatal period

On the top half are six effective approaches to reduce phlebotomy loss, which all begin at birth and extend to various time periods when they are effective. The bottom half illustrates the anticipated relative cumulative reduction in laboratory blood loss if all six interventional approaches are concurrently applied.