Neonatal Transfusion Recommendations at RCH

  • The following recommendations apply to neonates at the Royal Children's Hospital

    Transfusion of blood products to neonates should comply with hospital procedures in regard to pretransfusion testingblood administration and management and reporting of adverse effects

    Transfusion of red cell products

    Red blood cells

    Red cells may be required for neonatal transfusion for surgery or resuscitation when large volumes are required.

    Indications for transfusion in the neonate

    Haemoglobin thresholds vary depending on neonatal age and oxygen requirement at time of transfusion. The values listed below outline haemoglobin thresholds in neonates taking into consideration age and oxygen requirements:

                                                                         Hb (g/L)
     Postnatal week No respiratory supportRespiratory support 
     1 100 - 120 g/L110 - 130 g/L
     2 85 - 110 g/L100 - 125 g/L
     >3 70 - 100 g/L 85 - 110 g/L

    • Other factors may impact these thresholds such as: anticipated blood loss (e.g. haemolysis, phlebotomy or surgery)
    • quality of nutrition
    • severity of illness
    • site of sampling – Hb measured on blood samples obtained from a large artery or from veins tends to be lower than that from free-flowing capillary samples.

    In all cases, a haemoglobin result from an FBE is preferable to a blood gas haemoglobin. 

    Red Cell Requirements

    • Group O and Rhesus compatible with infant's group. If infant group identical red cells are used, these must be compatible with any circulating maternal antibody.
    • Leucocyte depleted. All red cell products are leucocyte depleted by the Blood Service.
    • Irradiated at time of blood issue
    • Administer using the Baxter Neonatal Set or McGaw 'in-line blood filter IV set' for leucocyte depleted products
    • Commence transfusion within 30 minutes of product receipt and complete transfusion within 4 hours of spiking pack.

    *Note: If an infant is undergoing massive or rapid transfusion, the use of older red cell units may be associated with hyperkalaemia. If this clinical circumstance is anticipated request red cells which are <= 5 days old at the time of crossmatch. 


    In neonates typical transfusion dose is 10–20mL/kg (where the upper end of the range applies to severe anaemia, expected ongoing risk factors or concurrent bleeding).

                                                                                          Estimated Hb (g/L) after transfusion
    Current Hb (g/L) Transfusion of 10mL/kg Transfusion of 15mL/kg Transfusion of 20 mL/kg 
    Very preterm neonate with estimated blood volume 100 mL/kg     
     7091 102 112 
     80101 112 122 
     90111 122 132 
    Term neonate with estimated blood volume 80 mL/kg
    7096 109 123 
     80106 119 133 
     90116 129 143 

    Red blood cells for exchange transfusion

    Exchange transfusion is generally carried out for hyperbilirubinaemia and/or anaemia, usually due to haemolytic disease of the newborn (HDN) or prematurity.

    The Blood Service produces a red cell product specifically for neonatal exchange transfusion.  This red cell product has the following specifications:

    • Group O
      • CMV Negative
      • Fresh (<= 5 days)
      • Known haematocrit  (<0.6)
      • RhD negative
      • Kell negative
    • Leucocyte depleted
    • Irradiated at time of blood issue
    • Commence transfusion within 30 minutes of product receipt and complete transfusion within 4 hours of spiking pack.

    Whole Blood

    Whole blood is no longer available from the blood service


    Pedipaks should be used for all red cell top-up transfusions in infants. Pedipaks are available as a stock item in group O Positive and O Negative. They are CMV negative and leucocyte depleted. One blood donation is split into four equal volumes (approximately 50ml). The use of pedipaks enables us to minimise patient exposure to multiple donors.   


    Pedipaks should be requested at the time of blood request. Please indicate volume of transfusion.

    Pedipak specifications

    • Available in O Positive and O Negative
    • CMV Negative
    • Leucocyte depleted
    • Irradiated at time of blood issue 
    • Administer via the Baxter Neonatal Set
    • Commence transfusion within 30 minutes of product receipt and complete transfusion within 4 hours of spiking pack.

    Neonatal extended expiry (ASBT protocol)

    The neonatal extended expiry (ASBT protocol) enables us to omit repeated blood group antibody screening prior to transfusion for infants during the first 4 months of life. This protocol recognises that the development of antibodies to red cell antigens is very uncommon in the first 4 months of life. The protocol reduces the requirement for repeated sampling of blood.

    Which patients are eligible?

    Any infant less than 4 months of age who is likely to require more than one transfusion.

    The laboratory will make an assessment of suitability according to established criteria;

    • Less than 4 months
    • Pretransfusion ABO and Rh(D) group performed
    • DAT negative
    • No atypical red cell antibodies detected
    • One continuous admission

    If accepted, the laboratory will issue a report indicating that a further sample will not be required for any further blood group and antibody screens until a date when the baby is 4 months from birth.

    If an infant is discharged and readmitted, they must requalify for neonatal extended expiry protocol.

    Who is excluded?

    Any infants with a positive DAT and/or significant maternal red cell antibody shall be excluded.

    How to request the neonatal extended expiryl?

    Order neonatal extended expiry in EMR.

    Indicate any previous transfusion history, in particular intrauterine transfusion, or transfusion outside RCH. Indicate transferring hospital.

    How to order blood for patients with an approved neonatal extended expiry order?

    Once an infant is accepted on the neonatal extended expiry, further samples are not required for pretransfusion testing. Blood can be ordered as per regular ordering procedure in EMR.

    Transfusion of platelet products

    The platelet products suitable for neonatal transfusion are single units prepared from whole blood donations or apheresis collections split into small packs for paediatric use. All platelet products prepared in Victoria are leucocyte depleted and irradiated. 

    • Where possible, infants should receive ABO and Rh(D) identical platelets.
    • Avoid giving Rh(D) positive platelets to Rh(D) negative female infants.
    • All platelets are irradiated
    • Product expires 5 days from collection
    • Administer via the Baxter Neonatal Set
    • Commence transfusion within 30 minutes of product receipt and complete transfusion within 4 hours of spiking pack.+


    • Avoid giving excess volume to neonates
    • Order 5 – 10 ml/kg
    • Blood bank will supply the most appropriate unit they have in stock according to the volume ordered and stock available. 

    Transfusion of FFP

    Fresh Frozen Plasma must be compatible with the infants red cell antigens, ie should be group identical or group AB.

    • Paediatric FFP is available in group AB as a stock item.
    • Average volume 60ml.
    • Requires 30 minutes notice for thawing
    • Does not require leucocyte depletion or irradiation
    • Administer via the Baxter Neonatal Set
    • Commence transfusion within 30 minutes of product receipt and complete transfusion within 4 hours of spiking pack.
    • Usually infused in a volume of 10-20ml/kg.

    Transfusion of Cryoprecipitate

    • Cryoprecipitate is available in group O and A
    • Average volume 20-30ml.
    • Requires 30 minutes notice for thawing.
    • Does not require leucocyte depletion or irradiation
    • Administer via the Baxter Neonatal Set
    • Commence transfusion within 30 minutes of product receipt and complete transfusion within 4 hours of spiking pack.
    • Usually infused in a volume of 5ml/kg


    The guidelines of the UK Transfusion Services (2002) state that blood transfused in the first year of life should be cytomegalovirus (CMV) seronegative. Other authorities state that products that have been leucocyte depleted to less than 5 x 106/unit have a significant reduction in the risk of CMV transmission. Transfusion recipients at greatest risk of CMV transmission are fetuses, infants weighing less than 1.5kg, immunodeficient patients and stem cell transplant recipients.
    Some clinicians may prefer CMV seronegative components for patients considered to be particularly susceptible to severe CMV infection (patients with cellular immunodeficiency and stem cell transplant recipients). When CMV seronegative products are not available, leucocyte depleted products are an acceptable alternative. Since 60-70% of the adult population are CMV seropositive, CMV seronegative products may not always be available.



    Cellular blood products may be irradiated to reduce the risk of transfusion-associated graft versus host disease (ta-GVHD).


    All neonates at the Royal Children's Hospital.

    Established clinical guidelines for irradiation of cellular blood products in the fetus and neonate include:

    1. Intrauterine transfusion (IUT)
    2. Exchange transfusion (ET)
    3. Top-up transfusion after IUT
    4. When the donor is a first or second degree relative (directed donation) or HLA matched.
    5. When the infant has proven or suspected immunodeficiency

    The 'universal' irradiation policy at RCH is a practical alternative to selecting appropriate patients, and relies on the fact that RCH has a blood irradiator on site. 


    Cellular products:  Red Blood Cells, Platelets.


    All platelet products used within RCH are irradiated before issue by Australian Red Cross Blood Service (ARCBS).  Irradiation does not alter expiry time for platelet products.

    Red Cell products will be irradiated by the RCH blood bank immediately prior to issue. The irradiation process takes approximately 5 minutes. If there is a need for immediate transfusion for an exsanguinating infant, emergency blood release of non-irradiated blood is available. Do not delay transfusion in this circumstance.

    Irradiation of blood products

    Transfusion Support in Necrotising Enterocolitis (NEC)

    Some infants with NEC and/or sepsis develop T activation of red cells. T activation occurs through the action of bacterial neuraminidases and results in exposure of crypt antigens on the red cell surface. T activation was detected in the laboratory by a lectin test, however, this test is no longer available . Infants with NEC and sepsis can develop haemolysis. There are some reports of transfusion exacerbating haemolysis in these very sick infants. Since all adult plasma contains anti-T which could potentially exacerbate haemolysis, some experts advocate special transfusion support for these infants. Practice in this area is varied because of the lack of definitive studies.

    It is reasonable to avoid plasma exposure by requesting washed red cell products in an infant with significant haemolysis. It is reasonable to avoid using FFP/platelet transfusion unless there is significant coagulopathy/thrombocytopenia in the presence of bleeding and/or need for an invasive procedure. Urgent transfusion should not be delayed while waiting for special blood products.
    Transfusion support should be discussed with the consultant on an individual basis.

    Laboratory specimens and NETS transfers 

    Blood samples (maternal, cord) received with NETS transfers will be accepted by The RCH Core Laboratory when the following criteria are met:

    • The specimen and request form have a minimum of two points of identification:
      1. Firstname and Surname (If first name not yet given, indicate "Baby of" & Surname)
      2. UR or date of birth
    • The two points of identification on the sample and request form are identical
    • The request form is signed by the requesting doctor
    • The request form is signed by the person who collected the sample

    Note that the request form should indicate the type of specimen i.e. maternal or cord sample

    Forward samples to the laboratory immediately where they will be stored appropriately and used as required.