1. Dr Salwa Hindawi MSc, FRCPath, CTM Medical Director of Blood Transfusion Services KAUH, Jeddah Makah 28 th April2008 Blood Transfusion In Neonates and Children

2. Salwa Hindawi 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

3. Salwa Hindawi 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.

4. Salwa Hindawi 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.

5. Salwa Hindawi Pretransfusion testing in Infants less than 4 month of age Maternal 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.

6. Salwa Hindawi 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

7. Salwa Hindawi 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.

8. Salwa Hindawi strategies to reduce donor exposure or RBC 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

9. Salwa Hindawi 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).

10. Salwa Hindawi PRBCs Specification RBCs administered should be as fresh as possible group O, or group specific hemoglobin S negative CMV-seronegative or leukoreduced irradiated as indicated.

11. Salwa Hindawi 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 O 2  On O 2 by nasal cannula  On continuous positive airway pressure (CPAP)/intermittent mandatory ventilation (IMV) with mechanical ventilation with mean airway pressure <6 cm H 2 O  Significant apnea or bradycardia  Significant tachycardia or tachypnea  Low weight gain 3. Hemoglobin <12 g/dL with an infant  On >35% hood O 2  On CPAP/IMV with mean airway pressure 6 to 8 cm H 2 O 4. Hemoglobin <15 g/dL with an infant  On extracorporeal membrane oxygenation (ECMO)  Congenital cyanotic heart disease

12. Salwa Hindawi 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 anemia  In chemotherapy or radiotherapy  In chronic congenital or acquired symptomatic anemia  In emergency surgical procedures with expected blood loss in patient with significant preoperative anemia  In 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 disease  ECMO 5. Chronic transfusion programs for disorders of red cell Production such as: thalassemia major and Diamond-Blackfan syndrome

13. Salwa Hindawi 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 bleeding  Invasive procedure with failure of platelet production 3. Platelet count <100,000/L in sick premature infant  With active bleeding  Invasive procedure in patient with disseminated intravascular coagulation

14. Salwa Hindawi 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.

15. Salwa Hindawi 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 S  PT >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.

16. Salwa Hindawi 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

17. Salwa Hindawi 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.

18. Salwa Hindawi Requirements for Granulocyte Products Intended for Children:  Ensure ABO compatibility  Ensure that they are crossmatch compatible  Irradiate  Transfuse as soon as possible  Use standard blood filter  Do not use leukocyte reduction filter  Administer within 4 to 6 hours of collection  Do not administer with amphotericin; separate administration by as much time as practical  Use HLA-matched components in alloimmunized patients  Infuse over 1 to 2 hours  Use CMV-seronegative units if recipient is CMV seronegative

19. Salwa Hindawi Patient ABO Type RBCs, Platelets Plasma & Cryoprecipitate OO O, A, B, AB AA,OA,AB BB,OB,AB ABAB,A,B,OAB ABO Selection of Blood Components

20. Salwa Hindawi Administration of blood components Pretransfusion : 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.

21. Salwa Hindawi 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

22. Salwa Hindawi 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

23. Salwa Hindawi 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.

24. Salwa Hindawi Leucocytes Reduced Blood Components Leucocytes in the blood components can lead to many complications Universal Leucodepletion verses specific indications.

25. Salwa Hindawi 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:

26. Salwa Hindawi CMV negative blood products: Blood products tested for antibodies to CMV or leukodepleted Indicated to prevent CMV transmission in select populations: 1-Immunodeficient or immunosuppressed patients 2-Neonates 3-Patients w/ hematologic malignancies CMV resides in WBCs (leukodepletion), so screening not necessary for FFP, cryoprecipitate, other plasma products.

27. Salwa Hindawi 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

28. Salwa Hindawi 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

29. Salwa Hindawi 1.premature infants < 1200g birthweight 2. infants with known or suspected congenital immunodeficiency syndromes 3. infants receiving granulocyte transfusions 4. infants receiving directed donor blood component from blood relatives 5. infants receiving HLA-matched or platelet crossmatch-compatible platelets Indications:

30. Salwa Hindawi 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.

31. Salwa Hindawi 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.

32. Salwa Hindawi 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

33. Salwa Hindawi Conclusions Policies, 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.

34. Salwa Hindawi 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 2 nd Edition, 2006. Prenatal and childhood transfusion, Practical Transfusion Medicine 2001.

35. Salwa Hindawi