A Management Guideline to Reduce the Frequency of Blood Transfusion in Very-Low-Birth-Weight Infants

Abstract

Very-low-birth-weight (VLBW) infants often require blood transfusions for anemia. Studies have investigated the preventative effect of delayed cord clamping, high-dose iron, and costly recombinant erythropoietin. As part of our unit clinical governance framework to improving patient care, we audited the effect of a preventative management guideline that combines delayed cord clamping for 30 seconds with early protein intake and early oral iron supplementation (6 mg/kg from days 7 to 10 of life, if milk feeds 60 mL/kg/d) combined with a restrictive transfusion policy in infants < 32 weeks' gestation and < 1500 g birth weight. Data on blood transfusions in VLBW infants during the first 6 weeks of life collected before the start of the new regimen (period I) were compared with data in consecutively born VLBW infants after the introduction of the management guideline (period II). Age (in days) when milk feeds and oral iron supplements were introduced was recorded. Statistical analysis used Wilcoxon signed-rank test. VLBW infants in period I ( N = 18, median birth weight 1001 g [727; 1158]) received a median of four transfusions (0.75; 9) compared with 1.5 (0.75; 5, P = 0.01) VLBW infant transfusions in period II ( N = 22, median birth weight 967 g [792; 1131]). Milk feeds of 60 mL/kg/d were achieved on median day 12 (6; to 16), and iron was introduced on median day 38 (21; to 44) in period I compared with milk feeds on day 9 (7; 15, P = 0.05) and oral iron on day 16 (11; 21, P < 0001) in period II. The combination of a 30-second delay in cord clamping, early protein and iron, and a change of transfusion thresholds reduced the number of blood transfusions by half.

Pharmacodynamically optimized erythropoietin treatment combined with phlebotomy reduction predicted to eliminate blood transfusions in selected preterm infants

“…The current study supports the work of Rabe et al (12) in showing that a combination of therapeutic interventions can reduce RBCTx to a greater extent in preterm infants than individual interventions. As expected, a greater proportion of infants with BW 1.0–1.5 kg were predicted to avoid RBCTx compared to infants with BW <1.0 kg.…”

“…Although these three strategies for reducing RBCTxs in preterm infants have all shown promise by our group (8, 10) and others (7, 12), application of a combination of these strategies has greater potential for reducing RBCTxs than any of these alone. We thus hypothesized that RBCTx can be eliminated in a significant proportion of preterm infants by optimizing Epo dosing in combination with reductions in laboratory phlebotomy loss.…”

Research Opportunities to Improve Neonatal Red Blood Cell Transfusion

“…While these approaches are feasible for most NICUs and have been demonstrated to be effective, they can be improved upon by basic and clinical research focused on: 1) implementation studies of delayed cord clamping and milking that address barriers and latent risk across various health delivery systems; 2) defining necessary and unnecessary laboratory testing and frequency for the population of infants cared for in the NICU; 3) continued innovation and improvement in micro- and nano-instrumentation; and 4) education of caregivers on optimal application of non-pharmacological approaches to reducing laboratory phlebotomy blood loss. Moreover, when several approaches are combined, an even greater cumulative effect can be achieved in reducing neonatal RBC transfusions [63]. …”

Nonpharmacological, Blood Conservation Techniques for Preventing Neonatal Anemia—Effective and Promising Strategies for Reducing Transfusion

“…In 2009, Rabe et al 37 evaluated the effect of a multipronged approach to decreasing RBC transfusions in VLBW infants. The components of this approach included delaying cord clamping for ≥30 seconds, increasing early protein intake, beginning early oral iron supplementation, and instituting restrictive transfusion guidelines.…”

“…80 Consistent with the well-established fact that adequate protein intake is needed for optimal body growth, the protein-supplemented VLBW group also demonstrated greater weight gain: 1490 versus 633 g during the 6-week study period. In successful multipronged treatment-prevention strategy for minimizing neonatal anemia and reducing RBC transfusions by Rabe et al, 37 these investigators included enhanced protein intake beginning immediately after birth.…”