Variation in Neonatal Transfusion Practice

Abstract

Objective: To estimate the incidence of blood product transfusion, including red blood cells, platelets, and plasma, and characterize pretransfusion hematologic values for infants during their initial hospitalization after birth.

Study design: Retrospective cohort study using data from 7 geographically diverse US academic and community hospitals that participated in the National Heart Lung and Blood Institute Recipient Epidemiology and Donor Evaluation Study-III (REDS-III) from 2013 to 2016. Pretransfusion hematologic values were evaluated closest to each transfusion and no more than 24 hours beforehand.

Results: Data from 60 243 infants were evaluated. The incidence of any transfusion differed by gestational age (P < .0001), with 80% (95% CI 76%-84%) transfused at <27 weeks of gestation (n = 329) and 0.5% (95% CI 0.5%-0.6%) transfused at ≥37 weeks of gestation (n = 53 919). The median pretransfusion hemoglobin was 11.2 g/dL (10th-90th percentile 8.8-14.1) for the entire cohort, ranging from 10.5 g/dL (8.8-12.3) for infants born extremely preterm at <27 weeks of gestation to 13.0 g/dL (10.5-15.5) for infants born at term. The median pretransfusion platelet count (×10⁹/L) was 71 (10th-90th percentile 26-135) for the entire cohort, and was >45 for all gestational age groups examined. The median pretransfusion international normalized ratio for the entire cohort was 1.7 (10th-90th percentile 1.2-2.8).

Conclusions: There is wide variability in pretransfusion hemoglobin, platelet count, and international normalized ratio values for neonatal transfusions. Our findings suggest that a large proportion of neonatal transfusions in the US are administered at thresholds greater than supported by the best-available evidence and highlight an opportunity for improved patient blood management.

Keywords: blood; infant; plasma; platelet; preterm; red blood cell.

Figure 1.. Pre-transfusion hematologic values, stratified by gestational age.

Density plots show the distribution of pre-transfusion hematologic values for hemoglobin (g/dL), platelet count (× 10⁹/L) and INR (P<0.001 for testing for differences in median value by gestational age strata using Kruskal-Wallis test for each hematologic parameter).

Figure 2.. Pre-transfusion hematologic values, stratified by diagnoses.

Density plot shows the distribution of pre-transfusion hematologic values for hemoglobin (g/dL), platelet count (× 10⁹/L) and INR. Due to the skewed distribution of platelet data, the density estimation curves span negative values. P <0.0001 for test for difference in median values among groups using Kruskal-Wallis test. Abbreviations: NEC, necrotizing enterocolitis; CLD, chronic lung disease; BPD, bronchopulmonary dysplasia; IVH, intraventricular hemorrhage; ROP, retinopathy of prematurity; HDFN, hemolytic disease of the fetus and newborn; MAS, meconium aspiration syndrome; HIE, hypoxic-ischemic encephalopathy; CDH, congenital diaphragmatic hernia; ECMO, extracorporeal membrane oxygenation; PPHN, persistent pulmonary hypertension of the newborn; CHD, congenital heart disease.