Paediatric Transfusion

In children beyond the neonatal period, transfusion is most often needed for severe anaemia (malaria, sickle cell disease, nutritional and helminth causes), haemorrhage, and cancer or chemotherapy. In malaria endemic areas, severe anaemia is a leading cause of paediatric admission and death, and delay in transfusion kills. Over-transfusion and rapid fluid loading also cause harm, so dose, rate and reassessment must be precise.

Principle. Weight based dosing, a clear indication, careful rate and early reassessment. Treat the cause at the same time.

Risk context. Children with severe anaemia are often volume expanded with high output heart failure, so rapid transfusion can precipitate pulmonary oedema. Rapid crystalloid boluses in non-hypotensive children with severe febrile illness and anaemia have been linked to higher mortality. Children with sepsis, malnutrition and HIV are at higher risk.

Special groups. Severe acute malnutrition (impaired cardiac reserve), sickle cell disease, HIV infection, cancer, congenital heart disease and children with hyperparasitaemia. Blood volume is about 80 mL/kg.

Severe malarial anaemia and severe anaemia in endemic areas.

• Transfuse when haemoglobin is under 4 g/dL (or haematocrit under 12%), whatever the clinical state.

• Transfuse when haemoglobin is 4 to 6 g/dL with any of: respiratory distress or acidotic breathing, shock, impaired consciousness, signs of heart failure, or very high parasitaemia.

• Haemoglobin 6 g/dL or more without these features: treat the cause, with close observation, without transfusion.

Other paediatric thresholds.

• Stable hospitalised child without cardiac disease: haemoglobin under 7 g/dL.

• Cyanotic congenital heart disease and some intensive care states: higher targets as the specialist directs.

• Haematology and oncology: about 7 to 8 g/dL, with symptoms and treatment phase.

• Acute blood loss: by clinical state, not haemoglobin.

Clinical features of decompensation. Deep acidotic breathing, tachycardia, gallop rhythm, enlarged liver, raised jugular venous pressure, crepitations, altered consciousness, cold peripheries and hypotension.

Cause search. Malaria test and treatment, blood film, sickle test, HIV status, stool for hookworm, nutritional assessment, bacterial sepsis and, in older children, haemolysis and marrow failure.

Red flags. Severe malaria with coma, convulsions, hypoglycaemia or shock, severe malnutrition and sickle cell disease with acute chest syndrome.

Dose and rate for severe anaemia.

• Whole blood 20 mL/kg (or red cells 10 mL/kg) over 3 to 4 hours, at about 5 mL/kg/hour.

• In heart failure or severe malnutrition: red cells 10 mL/kg over 3 to 4 hours, give small aliquots, monitor the chest and the liver edge every 30 minutes, and give furosemide 1 mg/kg intravenously only when there are signs of volume overload.

• Reassess after the dose: if haemoglobin is still under 4 g/dL (or under 6 g/dL with distress), repeat 10 mL/kg of red cells.

• Avoid rapid crystalloid boluses in non-hypotensive children. In shock, use cautious boluses (10 to 20 mL/kg) with reassessment, and give blood early.

General paediatric dosing.

• Red cells 10 to 15 mL/kg, with about 4 mL/kg raising haemoglobin by 1 g/dL, at about 5 mL/kg/hour, within 4 hours of leaving controlled storage.

• Whole blood about 6 mL/kg raising haemoglobin by 1 g/dL.

• Platelets 10 to 20 mL/kg, plasma 10 to 20 mL/kg, and cryoprecipitate 5 to 10 mL/kg, never over the adult dose.

• Warm products and use a paediatric set with a filter.

Malaria treatment alongside. Intravenous artesunate 2.4 mg/kg at 0, 12 and 24 hours, then daily (3 mg/kg in children under 20 kg), followed by a full course of an oral artemisinin combination, with dosing by local practice.

Special groups.

• Sickle cell disease: avoid raising haemoglobin over 10 g/dL, and use phenotype matched, sickle negative blood where possible.

• Severe malnutrition: smaller volumes, slower rates and close monitoring.

• Cancer: irradiated, leucodepleted, cytomegalovirus safe products as indicated.

• Consent: obtain it from the parent or guardian, and involve the child by age.

Monitoring. Heart rate, respiratory rate, oxygen saturation, blood pressure, temperature and consciousness before, at 15 minutes, every 30 minutes for the first hour and then hourly. Check haemoglobin after the transfusion and glucose when severe malaria is present.

Complications. Circulatory overload, acute lung injury, febrile and allergic reactions, haemolysis, hypoglycaemia, hyperkalaemia in rapid large volumes and, with repeat transfusion, iron overload.

Referral and escalation. Senior paediatrician for decompensated anaemia, sickle cell crisis, severe malnutrition and poor response. Intensive care for respiratory failure and shock.

Disposition. Treat the cause, give iron when the infection is controlled (about 2 to 4 weeks after recovery, not during acute malaria), treat hookworm and nutritional deficits, and arrange follow up. Post-discharge malaria chemoprevention can reduce readmission where national practice supports it.