Neonatal transfusion variation reflects uncertainty over benefits and risks

There is widespread inconsistency in neonatal transfusion practices, reflecting uncertainty over the evidence for managing anaemia of prematurity, an Australian study shows.

Neonatology clinicians are split over restrictive versus liberal haemoglobin transfusion thresholds for anaemia or prematurity, a survey of 130 members of the Australia and NZ Neonatal Network has revealed

In the survey, which drew responses form about half the neonatology workforce, there was no overall preferred haemoglobin transfusion threshold, with the reported thersholds for premature infants ranging from <60g/L to <120g/L.

When specifically asked about conservative versus liberal haemoglobin thresholds, around 50% of clinicians said they supported a restrictive threshold, 18% supported a liberal threshold and the remainder either had no preference or did not know.

The most commonly cited benefits of blood transfusion for anaemia of prematurity were reduction in respiratory support (32% of respondents) and cardiovascular stability (27%).

However 29% of participants said transfusion offered no tangible benefit and 75% highlighted suppression of endogeneous erythropoiesis as a significant risk of transfusion. Necrotising enterocolitis was reported as a transfusion risk by almost half (48%) of respondents.

And while haemoglobin count was reported as an important criteria for determining transfusion threshold by 91% of neonatologists, other criteria included clinical status (98%), reticulocyte count (83%) and gestational age (86%).

Looking to the future, about half of clinicians believed that assessment of tissue hypoxia by NIRS (near-infrared spectroscopy) may better inform transfusion thresholds.

The survey also revealed that one third of clinicians did not have access to local guidelines on blood transfusion for infants with anaemia of prematurity.

The study authors said the findings reflected the lack of research in the area of anaemia of prematurity, noting most clinicians were guided by evidence from two trials that gave contradictory results on transfusion thresholds.

“In Australasia, the lack of clarity about when to transfuse these infants adds urgency to the need for research into newer clinical adjuncts, such as the degree of tissue hypoxia detected by NIRS to determine timing and efficacy of transfusion for anaemia of prematurity,” they wrote.

“Better consensus is needed to ensure optimal, and equitable treatment for anaemia of prematurity across the Australia and New Zealand Neonatal Network,” they concluded.


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