Of the 14 million units of packed red blood cells administered to 4.8 million patients in the United States every year, approximately 1 percent is administered to pediatric patients. Although a small number when compared to adult transfusions, this still amounts to hundreds of thousands of blood products administered to our smallest and most delicate patient population.
One would imagine that such a widely administered product would be regulated to specific clinical review and oversight; however, red blood cell transfusion has not been subjected to the formal risk/benefit analysis that would be routine for new biological therapeutics. Therefore it begs the question, how safe is blood transfusion therapy in children? What are the alternatives to transfusion therapy? What role does blood volume management play in transfusion exposure?
A recent study looking at the Serious Hazards of Transfusions (SHOT) in pediatric patients was conducted in the United Kingdom which analyzed over 3239 reports of adverse reactions and events associated with blood component transfusion. The study identified the following complications: a) 264 incidents of incorrect blood component transfusion b) 30 acute transfusion reactions and three delayed transfusion reactions, c) 20 cases of transfusion related acute lung injury (TRALI), d) two fatal cases of graft v host disease, and e) two transfusion transmitted infections were documented. This is merely one of many studies demonstrating concerns related to transfusion therapy in children. The article also noted that to date there is no data that exists on the median survival of children who receive transfusion therapy. Perhaps if the scientific community identified the short as well as long term outcomes of transfusion therapy we would better understand the implications and need for use of red cell alternatives to manage anemia and red cell repletion.
There are several pediatric blood management options that have been identified including red cell stimulating factors (Epoetin alfa and Darbepoetin alfa) to increase red cell volume, intravenous iron therapy to treat iron deficiency anemia, and vitamin supplementation (B12/folic acid) to stimulate erythropoiesis. One of the most effective strategies in pediatrics is blood volume management which involves a collaborative approach between lab, phlebotomy, physicians and nurses. The recommendation is to standardize services and establish best practice. One such strategy is to develop pediatric lab volume sampling guidelines to be utilized to minimize volume loss as well as effectively combine and batch related tests. This simple and useful strategy empowers individual clinicians to minimize volume loss and transfusion requirements related to iatrogenic (hospital-induced) blood loss. The key is to preserve pediatric blood volumes, manage anemia, and associated deficiencies and thereby effectively reduce patient exposure to blood products. Although blood product therapy is common in certain pediatric disease states or surgeries, efforts to proactively manage these patients can reduce or eliminate the need for transfusions. Great strides have been made to improve the safety of the blood supply; however, potential long term complications may exist and have not been well studied. Pediatric patients deserve our best care every day and this must include evidence-based blood management practices.
- Slonim A, Joseph J, Turenne W, Sharangpani D, Luban N. Blood Transfusions in children; a multi-institutional analysis of practices and complications. Transfusion Practice 2008;48(1):73-80
- Stainsby D, Jones H, Wells AW, Gibson B, Cohen H. Adverse outcomes of blood transfusion in children: analysis of UK reports to the serious hazards of transfusion scheme. British Journal of Hematology 2008;141:73-79