• Acute blood loss with haemodynamic compromise or ≥10% blood volume loss (e.g. significant feto-maternal transfusion, pulmonary haemorrhage or subgaleal haemorrhage)
  • in emergency, use Group O RhD negative blood
  • transfuse 10 mL/kg over 30 min 
  • further transfusion based on haemoglobin (Hb)
• Top-up blood transfusion, if Hb below threshold levels quoted in the following situations 

Adapted from British Committee for Standards in Haematology recommendations

* e.g. poor weight gain or significant apnoeas
† <4% or count <100 x 10⁹ g/L

Communication

• If clinical condition permits before transfusion, inform parents that baby will receive blood transfusion 
  • document discussion
• If parents refuse transfusion (e.g. Jehovah’s Witness) follow local policy

Crossmatch

• For top-up transfusions in well baby, arrange with blood bank during normal working hours
• Crossmatch against maternal serum (or neonatal serum if maternal serum not available) for first 4 months 
• For first transfusion, send samples of baby’s and mother's blood 

Direct Coombs testing

• Laboratory will perform direct Coombs test (DCT) on maternal serum for any atypical antibodies
• If maternal DCT negative, blood issued will be crossmatched once against maternal serum. No further maternal blood samples are necessary for repeat top-up transfusions
• If maternal DCT positive, crossmatching of donor red blood cells against maternal serum is required every time

Multiple transfusions

• In babies <29 weeks who may need multiple transfusions, use paediatric satellite packs (‘paedipacks’) from 1 donor (if available) to reduce multiple donor exposure

When to use irradiated blood

• Irradiated blood must always be given for those:
  • who have received intra-uterine transfusion 
  • with suspected or proven immunodeficiency 
  • receiving blood from a first- or second-degree relative, or an HLA-selected donor 

When to use CMV-seronegative blood

• As CMV seronegativity cannot be guaranteed in untested blood, use only CMV-seronegative blood for neonatal transfusions
  • blood products in use in the UK are leucodepleted to <5 x 10⁶ leucocytes/unit at point of manufacture

Special considerations

Iron supplements

• Premature babies receiving breast milk - commence oral iron supplementation at aged 28 days (see Nutrition and enteral feeding guideline)

Withholding feeds during transfusion

• Some units withhold enteral feeds during transfusion whilst others continue – there is insufficient evidence for clear recommendation

Babies with necrotising enterocolitis (NEC)

• Transfuse using red cells in sodium chloride 0.9%, adenine, glucose and mannitol (SAG-M), preferably, as it is relatively plasma-free. This may not be available in all units 
• Any unexpected haemolysis associated with transfusion in a baby with NEC should be investigated for T-cell activation in consultation with local haematology department and with close involvement of consultant neonatologist

Exchange transfusion

• See Exchange transfusion guideline

Volume of transfusion

• Give 15 mL/kg of red cell transfusion for babies who are not actively bleeding irrespective of pre-transfusion Hb
• Give 20 mL/kg of red cell transfusion in case of massive haemorrhage (see Massive haemorrhage guideline)

Rate of administration

• Administer blood at 15 mL/kg over 3–4 hr 
• Increase rate in presence of active haemorrhage with shock (see Massive haemorrhage and Subgaleal haemorrhage guidelines)
• Via peripheral venous or umbilical venous line (not via long line/arterial line)

Use of furosemide

• Routine use not recommended
• Consider soon after blood transfusion for babies:
  • with chronic lung disease 
  • with haemodynamically significant PDA
  • in heart failure
  • with oedema or fluid overload

• Clearly document indication for transfusion and consent in the notes
• Ensure positive identification of baby using accessible identification 
• Ensure blood transfusion volume and rate is prescribed in appropriate infusion chart 
• Observations, including:
  • continuous ECG 
  • SpO₂
  • hourly temperature and BP (recorded before, during and after transfusion)
• Appropriate labelling of syringes to ensure compliance with current best practice
• Unless clinically urgent, avoid transfusion out-of-hours 
• To reduce need for blood transfusion, minimise blood sampling in babies (micro-techniques, non-invasive monitoring) and avoid unnecessary testing
• Delay cord clamping in accordance with the resuscitation council guidelines (see Resuscitation guideline)
• Ensure donor exposure is minimised by using satellite packs from same donor
• After transfusion, record benefit (or lack thereof)
• Document pre- and post-transfusion Hb levels

Hazards of transfusion

• Most important are:
  • infections – bacterial/viral
  • hypocalcaemia
  • volume overload
  • citrate toxicity
  • rebound hypoglycaemia (following high glucose levels in additive solutions)
  • thrombocytopenia after exchange transfusion