Common Causes of Neonatal Anaemia

• Preterm delivery before establishment of normal red cell and iron stores in last trimester.
• Blood loss for Laboratory testing.
• Expansion of blood volume with growth.
• Physiological cessation of red cell synthesis in the first 6 weeks after birth.

Although these factors combine to result in the ‘normal’ fall in haemoglobin concentration in the first 6-9 weeks after birth, this is accompanied by improved oxygen unloading capacity as 2,3-DPG levels rise, so that tissue oxygen delivery may improve despite reduced oxygen carrying capacity. Thus the possible benefits of transfusion need to be balanced against the known (and unknown) risks for each individual baby.

Indications for Transfusion

1. Shock due to blood loss.
2. Babies with cardiorespiratory disease.
   Transfuse if haematocrit:
   • <40 if unwell (ventilated, <1000g, ongoing problems)
   • < 35 if moderate lung disease (O₂ requirement > 30%, significant apnoeas and bradycardia)
   • < 30 if mild residual lung disease (CPAP or low rate ventilation in ≤ 30% O₂).
3. Stable growing babies < 6 weeks old.
   • Transfuse if haematocrit < 30 and baby symptomatic (recurrent apnoea and bradycardia, failure of weight gain).
   • Baby for surgery.
4. Stable growing babies > 6 weeks old.
   • Transfuse only if haematocrit < 25 and baby symptomatic. Transfusion at this age will inhibit the normal onset of erythropoiesis and should usually be discussed with a Specialist. Oral iron supplements should be started at 4 weeks of age.

Consent

• Informed consent must be obtained unless the situation is life threatening.
• Consent is documented on a consent form (Agreement to Treatment CR111).
• However, verbal consent by a parent is acceptable provided it is documented in baby’s chart, until written consent is obtained.

Ordering Multipacks

• For infants who are under 1000g and less than 10 days old, or infants who are likely to need multiple transfusions within the first few weeks, order a mulitpack.  This will provide 4 paediatric packs of red cells from a single donor, thereby reducing donor exposure.

Transfusion Volume

• Small babies (<1500g) in the first week of life: 10ml/kg over 2h.
• Larger babies and older babies: 15ml/kg over 2h to maximise haemoglobin rise while minimising numbers of transfusions required. Consider furosemide 1mg/kg half way through the transfusion to minimise volume load.

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References