PERSONAL PRACTICE

A practical guide to red their admission raising the possibility that some may be avoid-
able. Given the finite supply of red cell donors in the UK clini-

blood cell transfusion in cians must judiciously transfuse red cells and other blood
products in order to avoid wasteful use of such a valuable

children resource.
Leaning on local and national guidance is key to haemovigi-
lance but may leave you unclear about the rationale behind
Craig Stewart transfusion practice. This article aims to guide you through the
Patrick Davies why, when and how of red cell transfusion in paediatrics. Armed
with this information you may better understand how to treat
Harish Vyas your individual patient and anticipate potential complications.

Red blood cell physiology

Abstract
Red cell transfusion is common in paediatric practice and indicated in Red blood cells, or erythrocytes, make up around 45% of whole
haemorrhagic shock, anaemia and certain inherited haematological blood and 99% of its cellular components, with the remainder
diseases. As with other blood products there are risks associated consisting of white blood cells and platelets. Circulating blood
with their administration and improper use. Extensive guidance is volumes vary with age but as a guide are approximately 90ml/kg
available in the UK in order to maintain adequate haemovigilance for term infants under 3 months, 80ml/kg for older infants and
and safe transfusion practice. This article summarises the rationale children and 70ml/kg for adolescents. For simplicity a figure of
behind red cell transfusion and offers a practical guide to clinical de- 80ml/kg could be applied across all ages. Red cells consist of the
cision making in the acute hospital setting. oxygen carrying proteins haemoglobin made up as four protein
subunits and a central haem moiety (an iron containing mole-
Keywords anaemia; blood transfusion; haematology; haemorrhage;
cule). Haemoglobin acts as a store for oxygen feeding the dis-
red blood cell
solved oxygen that is available to the tissues.
Normal haemoglobin (Hb) values vary with age as well as
sex, race and ethnicity. From birth to three months of age infants
Introduction
develop a physiological anaemia with high Hb levels of >140 g/L
Allogenic red blood cell transfusions are a part of everyday in health term infants at birth which drop to a nadir of around
practice across the paediatric specialities in the acute hospital 110 g/L at six to nine weeks of age. For older children the mean
setting and can be lifesaving when used appropriately. The most Hb sits at around 130 g/L. The World Health Organisation define
commonly transfused groups are children on paediatric or anaemia as Hb values below 115 g/L in children and severe
neonatal intensive care units (PICU/NICUs), those undergoing anaemia if less than 80 g/L.
cardiac surgery, transfusion-dependent children with inherited It makes sense therefore that the transfusion of red blood cells
conditions and those requiring intensive chemotherapy for ma- increases overall circulating blood volume and to an extent
lignant disease. Comprehensive safe transfusion guidance in the systemic oxygenation. However this does not necessarily trans-
UK is provided by the Joint United Kingdom Blood Transfusion late to improved oxygen delivery, particularly to peripheral
and Tissue Transplantation Services Professional Advisory vascular beds. Additionally the affinity haemoglobin has for ox-
Committee (JPAC; see the Handbook of Transfusion Medicine, ygen is determined by factors associated with tissue activity. As
5th edition and the Guidelines for the Blood Transfusion Services described by oxygen-haemoglobin dissociation curve increased
in the UK, 8th edition), NHS Blood and Transfusion and National body temperature, acidosis, hypercarbia and increase DPG (2,3-
Institute for Health and Care Excellence (NICE) guidance (Blood diphosphoglycerate - a by-product of glycolysis) cause oxygen
Transfusion, 2015; ng24). These national guidelines alongside to dissociate from haemoglobin at a higher pO2 than normal. This
local hospital based policies reflect the inherent risks and com- means that in active tissues oxygen can be delivered more
plications of transfusing blood products. readily.
Recent studies suggest that a significant percentage of paedi-
atric transfusion recipients receive only one transfusion during Pre-transfusion testing and safe transfusion practice
Blood transfusion is a complex, high risk, multi-step procedure
that relies on collaborative team working and strict adherence to
Craig Stewart MRCPCH BMBS BSc (Hons), Paediatric Critical Care Unit, well described procedures in order to minimise errors and
Nottingham Children’s Hospital, Nottingham, UK. Conflicts of adverse outcomes.
interest: none declared. Following blood donation, in addition to blood grouping and
Patrick Davies MRCPCH BMBS, Paediatric Critical Care Unit, antibody screening, the following mandatory tests are performed:
Nottingham Children’s Hospital, Nottingham, UK. Conflicts of
Hepatitis B e HBsAg
interest: none declared.
Human immunodeficiency virus e anti-HIV 1 and 2 and HIV
NAT (nucleic acid testing)
Harish Vyas DM FRCPCH FRCP, Honorary Consultant PICU and
Respiratory Medicine, NUH Nottingham and Emeritus Honorary
Hepatitis C e anti-HCV and HCV NAT
Professor, University of Nottingham, School of Medicine,
Human T-cell lymphotropic virus e anti-HTLV I and II
Nottingham, UK. Conflicts of interest: none declared.
Syphilis e syphilis antibodies

PAEDIATRICS AND CHILD HEALTH 30:3 108 Ó 2019 Elsevier Ltd. All rights reserved.
 PERSONAL PRACTICE

Additional tests, performed in special circumstances, include: CMV-negative blood

Malarial antibodies Cytomegalovirus (CMV) is a common herpes virus that causes

West Nile Virus antibodies asymptomatic infection or mild feverish illness in healthy

Trypanosoma cruzi antibodies immunocompetent children. The virus persists in blood mono-
Once blood is processed and tested it can be refrigerated and cytes in up to 60% of adults, including blood donors, who are
stored for up to 42 days. lifelong carriers of the virus, meaning that CMV positivity in
transfused blood is very common. CMV infection can cause se-
Label samples carefully and get them checked before vere, occasionally fatal infection in neonates and immunocom-
sending to the laboratory promised children and so ‘CMV negative’ blood is only
At the point of requesting red cells for transfusion strict sample recommended for the following patient groups:
labelling policies are in place in order to minimise the risk of
Intrauterine transfusion
administering the wrong blood into patients. Blood transfusion
Neonates up to 28 days post expected date of delivery
services have a ‘zero tolerance’ policy with incorrectly labelled
Allogenic haematopoietic stem cell transplant recipients
samples so ensure that requests are second checked to mitigate
During pregnancy (to protect the fetus)
this risk. Other than in the emergency setting, where O D-nega- NB. Organ transplant patients do not require CMV negative
tive blood is used, red cell transfusions should be fully cross- blood.
matched and only compatible products given.
Irradiated blood
Gain consent and document Following variant CreutzfeldteJakob disease (vCJD) risk-
Prior to administering red cells clinicians should obtain ‘valid reduction measures introduced in 1999 donor blood has uni-
consent’ which must be documented in the clinical records. versally undergone leucodepletion. This process involves
Signed consent is not typically mandatory but may be a local filtering the blood to remove white cells. Despite this certain
requirement. Information leaflets for parents and children are patient groups require irradiated blood products in order to
available from the UK Transfusion Service. Where emergency prevent donor white blood cells replicating and mounting and
treatment is necessary seeking consent must not delay or prevent immune response manifested as transfusion-associated graft-
transfusion and information must be given to the family retro- versus host disease (TA-GvHD). Irradiated blood products are
spectively. Although rare in paediatric practice it is important to treated with either gamma or x-rays. Indications for irradiated
be aware of management strategies in the case of parents or their blood include:
child refusing transfusion of blood components and products for
Haemato-oncology patients - depending upon the disease
religious or cultural reasons. For example Jehovah’s Witnesses and type of immunosuppressive drugs and biologicals - ex-
will not accept transfusions of whole blood or its major de- amples include:
rivatives. Such a family may wish to involve the hospital liaison
Acute leukaemia if receiving donations from first or sec-
committee to give support in these circumstances. These can be ond degree relatives
very challenging clinical encounters and so local advice should
Hodgkin’s lymphoma
be sought. Crucially one must respect the family’s wishes and
7 days before stem cell harvest
work with them to find an agreeable solution. In the emergency
Those treated with purine analogues and certain mono-
situation the legal position is that in the unconscious patient clonal antibody therapy
whose wishes regarding blood transfusions may be unknown, We recommend that you consult with local policies as they
the doctor caring for the patient is expected to act on the basis of may vary from the above.
what is known of the patient’s wishes, what is clinically neces-
sary, and what is in the best interests of the patient. When to transfuse: transfusion thresholds

Most transfusion incidents are avoidable In the acute hospital setting decision making around when to
The UK Serious Hazards of Transfusion (SHOT) data revealed transfuse can be difficult particularly given the known associated
that the majority of transfusion incidents are preventable and risks and complications. Broadly speaking red cell transfusion
nearly always caused by human error. JPAC recommend triggers fall into two groups - haemorrhage shock and anaemia.
following the ‘transfusion ten commandments’ in order to ensure
safe transfusion practice. Haemorrhagic shock
In essence they start by asking ‘is blood transfusion necessary WHO define clinically significant bleeding according to adult
in this patient?’ followed by ensuring that the ‘right blood’ is grades which have been pragmatically modified for paediatric
given to the ‘right patient’ at the ‘right time’ in the ‘right place’ practice. There is little direct evidence to guide practice in chil-
(see JPAC, Handbook of Transfusion Medicine, 5th edition for dren. Massive blood loss is defined as either 80ml/kg (i.e. entire
full details). circulating volume) in 24 hours or 40ml/kg in 3 hours. Practi-
cally speaking however accurate measurement of blood loss is
When ‘special requirements’ are indicated very difficult and so evidence or suspicion of serious haemor-
rhage with accompanied haemodynamic changes expected with
When requesting red cells one must consider if ‘special re- hypovolaemia are the usual triggers. Blood loss may be obvious
quirements’ are indicated for their patient. These include CMV as in trauma but may also be occult, caused by surgery or other
negative and irradiated products. procedures.

PAEDIATRICS AND CHILD HEALTH 30:3 109 Ó 2019 Elsevier Ltd. All rights reserved.
 PERSONAL PRACTICE

Non-infectious transfusion reactions

Description and mechanism Onset Severity Treatment

Acute haemolytic transfusion From ABO incompatibility Sudden Life threatening Aggressive fluid replacement
reaction (AHTR) leading to rapid onset and diuresis
haemolysis, release of
inflammatory cytokines,
circulatory shock, acute
renal failure and
coagulopathy
Delayed AHTR Haemolysis of transfused More than 24 hours after Moderate - falling Hb Supportive
cells in patient already transfusion - up to 14 days; concentration, jaundice and
‘alloimmunised’ to a red cell need to confirm diagnosis fever to Haemoglobinuria
antigen by blood transfusion with laboratory and acute renal failure
or pregnancy; most common investigations
are Kidd and Rh antigen
Febrile non-HTR More common with platelets Within 2 hours - must be a Mild Slowing or temporarily
- release of cytokines from diagnosis of exclusion stopping infusion,
leucocytes, fever  rigors, antipyretics - if symptoms
myalgia and nausea in worsen stop and consider
absence of other symptoms haemolytic or bacterial
reaction
Allergic reactions More common with platelets Sudden, may occur in IgA- Can be mild to life Antihistamines if mild, if
and FFP (as plasma rich), deficient individuals threatening angio-oedema severe stop infusion,
range from mild urticaria to or anaphylaxis resuscitation measures as
life threatening anaphylaxis. per APLS guidance, early IM
Following British Society for Adrenaline
Haematology guideline
investigations
Transfusion-associated lung 1:150,000 units transfused; Within 2e6 hours - fever, Life threatening Supportive oxygen therapy,
injury (TRALI) Donor blood antibodies rigors, breathlessness, may include mechanical
react with patient’s cough, hypotension, chest X- ventilation
neutrophils, monocytes and ray - bilateral nodular
pulmonary endothelium, shadowing
particularly if multiple
donors
Transfusion-associated Acute or worsening Within 6 hours, high risk in Life threatening Supplementary oxygen and
circulatory overload (TACO) pulmonary oedema due to those with underlying diuretics  mechanical
volume excess cardiovascular disease ventilation
Hypotensive reactions Isolated fall in systolic blood Within 1 hour Most transient, can progress Stop infusion, nurse patient
pressure of >30 mmHg, no to shock or organ flat with leg elevation
evidence of allergic reaction dysfunction
or haemorrhage
Transfusion-associated graft- Rare; viable lymphocytes in 7e14 days (up to 30 days) Almost always fatal Preventative strategy -
versus-host disease (Ta- donated blood engraft in standard leucodepletion as
GvHD) patient and mount immune well as irradiating red cells
response against recipients
cells of different HLA type,
typically patients with
immunodeficiency or
undergoing chemotherapy

Table 1

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 PERSONAL PRACTICE

The clinical priorities are early recognition of significant

Transfusion-transmitted infections bleeding and instigation of resuscitation and control of ongoing
Bacteria-associated Mild pyrexia to rapidly lethal septic shock; bleeding. In trauma this may be damage control resuscitation
sepsis rare, more common with platelets (as stored (e.g. applying tourniquets or pelvic splints) prior to definitive
at higher temperature); sudden onset; if highly surgical repair or interventional radiology. With ongoing
pathogenic bacteria then can be life bleeding early activation of the local hospital massive haemor-
threatening acute severe reaction; treatment rhage protocol will result in rapid provision of O D-negative or
includes broad-spectrum antibiotics, group specific red cells. As per the Acute Paediatric Life Support
haemodynamic support. guidelines initial red cell transfusions should be given as 5ml/kg
Syphilis Donations all screened. No reported cases of aliquots of warmed packed red cells. All transfused blood prod-
transmission since surveillance began in 1996. ucts should be prescribed in ml/kg for children weighing less
Hepatitis A, B, C & E Hepatitis A and E are spread by the faeco-oral than 50kg.
route (usually contaminated food and water) Following red cell transfusion one should anticipate and treat
and transmission by blood transfusion is very coagulopathy and thrombocytopenia. A ratio of at least 1 Fresh
rare. Blood is not screened for either virus. Frozen Plasma (FFP):2 red cells: 1 platelets is recommended. In
Hepatitis B and C are transmitted by infectious addition to blood products the RCPCH recommend that Tra-
blood and bodily fluids with the former nexamic acid (TXA; 15mg/kg over 10 minutes followed by 2mg/
remaining the most common viral transfusion- kg/hr) should be given as an antifibrinolytic agent until bleeding
transmitted infection - with <1 in 1.2 million is controlled. This advice followed the publication of the CRASH-
donations for HBV and <1 in 28 million for HCV. 2 trial published in 2010 which demonstrated reduced mortality
Cytomegalovirus (CMV) Common virus that causes asymptomatic in adult trauma. Finally in order to optimise cardiac function,
infection or mild glandular-fever like illness in perfusion and oxygenation clinicians must aim to avoid acidosis,
most healthy patients. 50e60% of UK adults in hypothermia, hypocalcaemia and hyperkalaemia.
the UK are lifelong carriers. Can cause severe,
Anaemia
sometime fatal, infection in fetuses, neonates
Decision making is often based pragmatically on Hb levels which
and immuncompromised patients (see - when
is a surrogate marker for clinical transfusion need. Anaemia may
‘special requirements’ are indicated - above).
be caused by one of three broad mechanisms; reduced red cell
Human Transmission was common during the 1980’s
production, increased red cell destruction or blood loss (as
immunodeficiency epidemic but with modern donor selection and
detailed above). Reduced production is typically as a result of
virus (HIV) 1 & 2 HIV RNA screening it is now rare in the UK - <
inhibition or inefficient stimulation of haemotopoesis (by
1 in 7 million donation.
proinflammatory cytokines for example) and inadequate supply
Human T-cell HTLV I associated with 1e4% lifetime risk of
of vitamin B12 or iron. Increased destruction may be caused by
lymphotropic developing adult T-cell leukaemia/lymphoma;
haemolysis or reduced red cell life span (e.g. phagocytosis or
virus types I and II clinical significance of HTLV II is unknown.
splenic removal from the circulation).
Both virtually eliminated by leucodepletion of
Evidence over the last 20 years has consistently demonstrated
blood products in UK.
that a more restrictive use of red cells is at least equivalent to or
Human Transmission is very rare. The virus is resistant
maybe even superior to maintaining high Hb levels using liberal
parvovirus B19 to routine solvent detergent treatment.
administration of donor blood. The exception to this is in the
Infection is typically asymptomatic without
context of extreme anaemia (Hb < 50 g/L) where English et al.
any chronic carrier state.
showed a significantly increased risk of mortality in malarial
West Nile virus Transmission is very rare as donors returning
children in Kenya. The first of three landmark papers over the
from effected areas are deferred from
last two decades was the Transfusion Requirement in Critical
donation for 28 days.
Care (TRICC) trial published in 1999 which showed that using a
Dengue/Zika/CHIKV UK practice is to delay donation for a minimum
transfusion threshold 70 g/L reduced the number of transfusions
of 6 months for individuals returning from
received by euvolaemic, non-haemorrhaging critical ill adults
tropical virus risk endemic areas.
without worsening outcomes. Subsequently the TRIPICU
Malaria Very rare in UK despite increasing
(Transfusion strategies for patients in paediatric intensive care
international travel.
units) randomised trial by Lacroix et al., in 2007 similarly
Chagas Serious multi-system disease endemic in
showed that a restrictive Hb transfusion trigger of 70 g/L was as
Central and South America. No reported cases
safe as a liberal Hb trigger of 95 g/l and was associated with
of transmission in the UK.
reduced blood use. Furthermore the development of multi-organ
Variant Four cases of transfusion-transmitted infection
dysfunction syndrome was not significantly difference between
CreutzfeldteJakob reported prior to the risk reduction measures
the two groups. It remains unclear however if this can be
disease (vCJD) introduced in 1999. These included
extrapolated to unstable patients. They stated that a higher
leucodepletion of all blood components.
threshold should be considered if the child has symptomatic
Currently there is no practical screening test
anaemia or impaired cardiorespiratory function.
for blood donors.
The most recent comprehensive guidance was published in
Table 2 the British Journal of Haematology in 2016. The guidelines on

PAEDIATRICS AND CHILD HEALTH 30:3 111 Ó 2019 Elsevier Ltd. All rights reserved.
 PERSONAL PRACTICE

transfusion for fetuses, neonates and older children similarly Currently transfusion guidelines differ from the recom-
recommends the use of a Hb threshold of 70 g/L in stable non- mendations described in larger clinical trials. Transfusion
cyanotic patients. For unstable patients or symptomatic volumes for non-bleeding infants and children, excluding
anaemia a higher threshold may be considered. The Premature those on chronic transfusion programmes, should generally be
Infants in Need of Transfusion (PINT) trial in 2006 demonstrated calculated to take the post-transfusion Hb to no more than 20
similar findings amongst neonates. It is reasonable to conclude g/L above the transfusion threshold. In children over 50kg (as
that in haemodynamically stable, acyanotic children a trans- in adults) NICE recommend transfusion of a single unit of red
fusion threshold of 70 g/L should be adopted. cells in non-bleeding patients. For children under 50kg there is
Another group of patients who may require more frequent red no current evidence based ideal Hb, a target of Hb is 120 g/L is
cell transfusions are children with haematological disease such reasonable, but should not exceed 140 g/L. Volume transfused
as beta thalassaemia major or sickle cell disease. Children with should be minimised for infants and children taking into ac-
sickle cell disease require transfusions to maintain levels of HbS count the likelihood of requiring subsequent transfusions and
<30% and as secondary prevention of recurrent strokes and in should not exceed 20ml/kg for top-up transfusions.
young children with recurrent chest syndrome for example. Typical transfusion volumes are calculated using the equa-
Children with rare inherited causes of anaemia including unsta- tion.
ble haemoglobins and Diamond Blackfan anaemia also require
regular transfusions.


weightðkgÞ  desired increment in Hb Lg  transfusion factor
Transfusion volume ¼
10

How much to transfuse: the Goldilocks principle The quoted transfusion factor ranges from 3 to 5 but is poorly
evidenced based. Davies et al. carried out a retrospective review
Once a decision has been made to give red cells the next ques-
of 564 transfusions on a paediatric intensive care unit over a 2
tions is what volume should be transfused. Considering that each
year period and proposed a transfusion factor equal to 3/hae-
unit of blood represent a unique donor exposure it is crucial to
matocrit (Hct) level. Give that the UK standard Hct is 0.6 a factor
give just enough and not too much, which may expose a child to
of 5 was recommended. Thus a 10ml/kg transfusion typically
multi donors or indeed be wasteful of such a valuable resource.
gives a Hb increment of 20g/L.
Blood typically comes in two volumes - paediatric packs and
adult units - approximately 50ml and 280ml respectively.
Technical aspects of transfusion
It is recommended that red cell transfusions are kept out of
temperature controlled storage for no more than 4 hours in order
to reduce the risk of bacterial transmission. Practically this
Other potential adverse effects
means that transfusions should be given within this time window
Description but can be given more quickly if clinically indicated. Blood
components must be transfused through a micron filter to
Hyperkalaemia Due to high potassium content of supernatant remove micro-aggregates in order to prevent the accumulation of
of stored red cells and decreased cellular ATP clots in the filter.
production leading to leakage of potassium. Normal maximum infusion rates for top-up transfusion is
Storage lesions Transfusion of red cells stored for more than 2 5ml/kg/hr and so most centres opt to give blood over 3e4 hours.
weeks due to reduced cell function and In the context of acute replacement for hypovolaemia blood can
viability. Resulting in reduced oxygen delivery, be given as a bolus however there is a theoretical risk of re-
electrolyte disturbance and effects on perfusion injury with rapid infusion. It is thought that there is
metabolic state particularly in the critically ill a degree of microvascular injury after transfusion but this has not
patient. been fully characterised.
Cytokine release Transfusion may activate white blood cells and Transfusions should be given in clinical areas where patients
cause release of pro-inflammatory cytokines can be directly observed. Staff administering blood products
leading to microcirculatory effects. must be trained to recognise and treat acute transfusion reactions
Thrombosis Through cytokine mediated vasoconstriction, (see adverse effects of transfusions below). Regular visual
microcirculatory stasis, increased haematocrit monitoring and observations must be carried out prior to and
and haemolysis of stored blood. during transfusions in order to monitor for adverse reactions. It is
Air embolism Risk with any intravenous infusion particularly recommended that minimum observations are carried out pre-
when given rapid blood transfusion. transfusion, at 15 minutes into the transfusion and up to 60
minutes post-transfusion. Patients will typically need to be
Table 3

PAEDIATRICS AND CHILD HEALTH 30:3 112 Ó 2019 Elsevier Ltd. All rights reserved.
 PERSONAL PRACTICE

observed up to 24 hours following blood transfusion for delayed Lacroix J, He bert P, Hutchison J, et al. Transfusion strategies for pa-
reactions. tients in pediatric intensive care units. N Engl J Med 2007; 356:
1609e19. https://doi.org/10.1056/NEJMoa066240.
Adverse effects of transfusion Muszynski J, Guzzetta N, Hall M, et al. Recommendations on RBC
transfusions for critically ill children with nonhemorrhagic shock
Infectious and antigenic transfusion reactions (see Tables 1e3)
from the pediatric critical care transfusion and anemia expertise
are now uncommon (1 in 7000 units transfused) but preventable
initiative. Pediatr Crit Care Med 2018; 19(suppl 1): S121e6.
deaths and significant morbidity still occurs. As mentioned above
New HV, Berryman J, Bolton-Maggs PH, et al. Guidelines on trans-
the Serious Hazards of Transfusion (SHOT) scheme has attrib-
fusion for fetuses, neonates and older children. Br J Haematol
uted most major incidents to human error. Clinicians must
2016; 175: 784e828. https://doi.org/10.1111/bjh.14233.
remain vigilant and aware of potential adverse reactions and act
NICE guideline. Blood transfusion. 2015, https://www.nice.org.uk/
quickly to minimise complications and maintain transfusion
guidance/ng24.
safety.
Norfolk D, ed. Handbook of transfusion medicine. 5th edn. United
Monitoring during transfusion is essential to monitor for
Kingdom Blood Services, 2013. TSO.
symptoms of transfusion reactions. Intravenous chlorphenamine
Roberts I, Shakur H, Coats T, et al. The CRASH-2 trial: a randomised
maleate (piriton) and hydrocortisone may be prescribed in case
controlled trial and economic evaluation of the effects of tranexa-
of a reaction. If a serious transfusion reaction is suspected e stop
mic acid on death, vascular occlusive events and transfusion
the transfusion; assess clinically and start resuscitation if
requirement in bleeding trauma patients. Health Technol Assess
necessary; check that the details on the patient’s ID band and the
2013; 17.
compatibility label of the blood component match; call for
Slonim A, Joseph J, Turenne W, et al. Blood transfusions in children: a
medical assistance and contact the transfusion laboratory. It is
multi-institutional analysis of practices and complications. Trans-
recommended to report all serious adverse transfusion reactions,
fusion 2007; 48: 1 p73e80. https://doi.org/10.1111/j1537-2995.
errors and near-miss incidents.
2007.01484.x.
In most circumstances, stopping the transfusion will be the
Valentine S, Bembea M, Muszynski J, et al. Consensus recommen-
first line of treatment.
dations for RBC transfusion practice in critically ill children from the
pediatric critical care transfusion and anemia expertise initiative.
Conclusions
Pediatr Crit Care Med 2018; 19: 884e98.
Red cell transfusion in paediatrics is common and may be life-
saving but it is not without risk. UK national guidance provides
detailed safety protocols and recommended measures to mitigate
these risks. Clinicians should be aware of the rationale behind its
Practice points
use and an attempt to minimise the requirement for blood
C Comprehensive safe transfusion guidance is provided in the
transfusion should be pursued. A
UK through JPAC (www.transfusionguidelines.org), NHSBT
(www.nhsbt.nhs.uk) and NICE (Blood Transfusion, 2015;
FURTHER READING ng24).
Davies P, Robertson S, Hegde S, et al. Calculating the required C Inappropriate transfusion in medical practice is common
transfusion volume in children. Transfusion 2007; 47: 212e6. and may cause harm.
English M. Life-threatening severe malarial anaemia. Trans R Soc Trop C Red cell transfusion is indicated in haemorrhage shock,
Med Hyg 2000; 94: 585e8. anaemia and certain haematological diseases.
Guidelines for the blood transfusion services in the United Kingdom. C In haemodynamically stable, acyanotic children a trans-
8th edn. TSO, 2013. fusion threshold of 70 g/l should be adopted.
Kirpalani H, Whyte R, Andersen C, et al. The premature infants in need C The majority of transfusion incidents are preventable and
of transfusion (pint) study: a randomized, controlled trial of a nearly always caused by human error.
restrictive (LOW) versus liberal (HIGH) transfusion threshold for C Adverse effects of blood transfusion are related to antigenic
extremely low birth weight infants. J Pediatr 2006; 149: 301e7. e3. and infectious reactions.

PAEDIATRICS AND CHILD HEALTH 30:3 113 Ó 2019 Elsevier Ltd. All rights reserved.