Platelet Transfusion Practices Among Very-Low-Birth-Weight Infants

Abstract

IMPORTANCE Thrombocytopenia and intraventricular hemorrhage (IVH) are common among very-low-birth-weight (VLBW) infants. Survey results suggest that US neonatologists frequently administer platelet transfusions to VLBW infants with mild to moderate thrombocytopenia. OBJECTIVES To characterize platelet transfusion practices in US neonatal intensive care units (NICUs), to determine whether severity of illness influences platelet transfusion decisions, and to examine the association between platelet count (PCT) and the risk for IVH in the first 7 days of life. DESIGN, SETTING, AND PARTICIPANTS This multicenter, retrospective cohort study included 972 VLBW infants treated in 6 US NICUs, with admission dates from January 1, 2006, to December 31, 2007. Data were collected from all infants until NICU discharge or death (last day of data collected, December 4, 2008). Data were entered into the central database, cleaned, and analyzed from May 1, 2009, to February 11, 2016. INTERVENTION Platelet transfusion. MAIN OUTCOMES AND MEASURES Number of platelet transfusions and incidence of IVH. RESULTS Among the 972 VLBW infants (520 [53.5%] male; mean [SD] gestational age, 28.2 [2.9] weeks), 231 received 1002 platelet transfusions (mean [SD], 4.3 [6.0] per infant; range, 1–63 per infant). The pretransfusion PCT was at least 50 000/μL for 653 of 998 transfusions (65.4%) with this information. Two hundred eighty-one transfusions (28.0%) were given during the first 7 days of life. During that period, platelet transfusions were given on 35 of 53 days (66.0%) when the patient had a PCT less than 50 000/μL and on 203 of 436 days (46.6%) when the patient had a PCT of 50 000/μL to 99 000/μL. At least 1 marker of severe illness was present on 198 of 212 patient-days (93.4%) with thrombocytopenia (PCT, <100 000/μL) when a platelet transfusion was given compared with 113 of 190 patient-days (59.5%) with thrombocytopenia when no platelet transfusion was given. Thrombocytopenia was a risk factor for intraventricular hemorrhage during the first 7 days of life (hazard ratio, 2.17; 95% CI, 1.53–3.08; P < .001). However, no correlation was found between severity of thrombocytopenia and risk for IVH. After controlling for significant clinical factors and thrombocytopenia, platelet transfusions did not have a significant effect on the incidence of IVH (hazard ratio, 0.92; 95% CI, 0.49–1.73; P = .80). CONCLUSIONS AND RELEVANCE A large proportion of platelet transfusions were given to VLBW infants with PCT greater than 50 000/μL. Severity of illness influenced transfusion decisions. However, the severity of thrombocytopenia did not correlate with the risk for IVH, and platelet transfusions did not reduce this risk.

Neonatal thrombocytopenia—causes and outcomes following platelet transfusions

“…Specifically, it is important to identify neonates at risk of bleeding who would benefit from PT and to determine whether PT either abrogate or exacerbate common neonatal complications such as sepsis, chronic lung disease, necrotizing enterocolitis (NEC), and retinopathy of prematurity. Among 972 very-low-birthweight (VLBW) infants from a multicenter retrospective cohort study, Sparger et al [5] reported that 231 (24%) had received a total of 1002 PT. A large proportion of PT were given to VLBW infants with platelet counts greater than 50,000/μL.…”

“…Additionally, they found that the severity of illness influenced transfusion decisions. However, the severity of NT did not correlate with the risk of intraventricular hemorrhage (IVH), and in contrast, PT did not reduce the risk of IVH [5]. …”

Platelets in the Newborn

“…Prophylactic platelet transfusion in clinically stable neonates with no active bleeding remains controversial at best [186], consistent with the wide range of national and international clinical practices by neonatologists [177]. In this context, the severity of thrombocytopenia does not correlate with increased risk of intraventricular hemorrhage (IVH), and platelet transfusion for mild to moderate thrombocytopenia does not appear to prevent or reduce the incidence of intracranial hemorrhage [183,187].…”

“…However, there is no agreement regarding prophylactic transfusions when platelets are anywhere between 20,000 and 90,000/μL [184,194,195]. A wide range of thrombocytopenia thresholds are employed, tending to be markedly higher in the United States, between 50,000 and 149,000/µL [187,196,197]. Nonetheless, such trends are based on clinical experience and judgment, rather than on reliable and consistent data.…”

Prophylactic platelet transfusion at higher thresholds was associated with increased risk of death or major bleeding in neonates

“…An international survey conducted across the USA and European countries identified significant variations in platelet-transfusion practices in preterm infants 2. Most of the platelet transfusions in preterm infants are driven by their severity of illness 3. In fact, a large proportion of preterm infants receive platelet transfusions despite the platelet count being more than 50 x10 9 /L 3…”