Dissecting the complexity of pediatric blood transfusions and risk of adverse reactions in Aotearoa New Zealand

Abstract

Background: Children have different clinical and physiological drivers for transfusion from adult recipients. However, adverse transfusion reactions (ATRs) in pediatric patients are usually reported using the same criteria as for adults. Broad assessments of pediatric ATRs neglect substantial variation in different developmental stages.

Materials and methods: This retrospective study included 342,950 patients, ~2.43 million transfusions, and 5,540 ATR reports collated from New Zealand hospitals between 2005 and 2021. Using 16 years as the upper age limit, 138,856 pediatric transfusions and 402 pediatric ATR reports were identified and dissected at three levels: pediatric as a whole, pediatric developmental stage (i.e., neonate, infant, preschool, and school), and chronological age to identify patients at high risk of ATRs. Multivariate logistic regression analysis was followed to quantify risk factors.

Results: Pediatric recipients had a higher ATR risk than adults (p=6.9^-07) but the high risk was associated mainly with children older than 2 years. Neonates and infants accounted for 75.0% of pediatric recipients but had much lower ATR rates than adults. Pediatric transfusion recipients showed a clear male bias prior to age 11 years and then a female bias. However, gender difference in experiencing ATRs was significant only after age 13 years (p=2.3^-04). Analyses focusing on the high-risk group revealed allergic reactions being the cause of the elevated risk and identified the main risk factors of number of transfusions (p=4.5^-10) and multiple types of components transfused (p=2.0^-13).

Discussion: The identified ATR risk factors signal linkage with the biological drivers for transfusion. Low ATR rates in infancy could also be attributed to use of neonatal components, low transfusions per patient, and less developed immunity. The relative increase in female recipients from age 11 may be associated with increased red blood cell demand following puberty.

Figure 1

Conventional comparisons of pediatric blood transfusions and adverse transfusion reactions (ATR) against adult counterparts (a) Male/Female ratio (top left); (b) Percentage of main ATRs (top right); (c) ATR rate per 10,000 transfusions.

Figure 2

ATR rates by developmental stage and type of component transfused

Figure 3

Dynamic profiles of pediatric transfusions and adverse reactions with age (a) Male/Female ratio (orange) and percentage of newly registered pediatric recipients (blue) (top left); (b) ATR rate per 10,000 transfusions (top right); (c) Rates of allergic reactions and febrile non-hemolytic transfusion reactions per 10,000 transfusions (bottom).

Figure 4

Dynamic profiles of gender differences in number of recipients and average number of transfusions around the gender bias switch point (a) Number of recipients by gender and age, where each column showing the total number while the solid part showing the number of newly registered recipients at the given age (left); (b) Average number of transfusions per recipient at a given age (right).