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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

    Preterm neonates will commonly receive small, top up transfusions of 10 – 20ml/kg to treat anaemia of prematurity.

    Neonates may also receive large volume transfusions; for example, exchange transfusion for the treatment of haemolytic disease of the newborn and cardiopulmonary bypass pump priming for cardiac surgery and extra-corporeal life support (ECLS). 

    Indications for transfusion in preterm neonate

    Haemoglobin (Hb) thresholds vary depending on neonatal post-natal age, oxygen requirements and respiratory support.  

    The values listed below outline Hb thresholds in preterm neonates taking into consideration age and oxygen requirements:

                                                                                                          Hb (g/L)

     Postnatal week


                                               No respiratory support

                                           Respiratory support 

     1                                                 100 - 120 g/L                                          110 - 130 g/L
     2                                                   85 - 110 g/L                                          100 - 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 general, a Hb result from an FBE is preferable to a blood gas Hb. 

    Red Cell Requirements

      • Group O and Rhesus compatible with the infant's blood group
      • Red cell antigen negative for any maternal alloantibodies in the instance of haemolytic disease of the fetus/newborn (HDN)
      • Irradiated at time of blood issue
      • CMV negative
      • Administer using the Baxter Neonatal Set or an 'in-line blood filter set'
      • Commence transfusion within 30 minutes of product receipt and complete transfusion within 4 hours of spiking pack.

      *Note: If an infant is undergoing a large-volume transfusion (exchange transfusion or ECLS), the use of older red cell units may be associated with hyperkalaemia. Request red cells which are 5 days old.


      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     

       70 g/L                                          91 g/L                                 102 g/L                                     112 g/L
       80 g/L                                         101 g/L                                 112 g/L                                     122 g/L
       90 g/L                                         111 g/L                                 122 g/L                                     132 g/L

      Term neonate with estimated blood volume 80 mL/kg

       70 g/L                                         96 g/L                                  109 g/L                                     123 g/L
       80 g/L                                         106 g/L                                  119 g/L                                     133 g/L
       90 g/L                                        116 g/L                                  129 g/L                                     143 g/L

      Red blood cells for exchange transfusion

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

      The Australian Red Cross 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 old)
        • Known haematocrit  (<0.6)
        • RhD negative
        • Kell negative
        • Irradiated at time of blood issue
        • Red cell antigen negative for any maternal alloantibodies

      Commence transfusion within 30 minutes of product receipt and complete transfusion within 4 hours of spiking pack.


      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
      • 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.

      Transfusion of platelets

      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.


      Platelet count (x10^9/L)

                                                                    Clinical situation to trigger platelet transfusion in neonates

      <25 - 30

      Stable term or preterm infant with asymptomatic thrombocytopenia and no bleeding

      30 - 50

      Sick preterm infant with thrombocytopenia


      Term or preterm infant with symptomatic thrombocytopenia and minor bleeding, coagulopathy or prior to surgery.


      Term or preterm infant with symptomatic thrombocytopenia and major bleeding or requiring major surgery (e.g. neurosurgery)


      • Avoid giving excess volume to neonates
      • Order 5 – 10 ml/kg (up to one pedipak)
      • 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.
      • Usual dose is 10-20 ml/kg
      • 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.

      Transfusion of Cryoprecipitate

      • Average volume 20-30ml.
      • Usual dose is 5-10 ml/kg
      • 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.

      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 preformed
          • DAT negative
          • No red cell antibodies detected

          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 expiry?

          Order neonatal extended expiry in EMR.

          Indicate any previous transfusion history, in particular intrauterine transfusion, or transfusion outside RCH and indicate the 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.


          The Australian and New Zealand Society of Blood Transfusion, Guidelines for Transfusion and Immunohaematology Laboratory Practice, November 2016 provides guidance on the use of CMV seronegative blood components. Their guidance is that CMV seronegative cellular blood components should be used in intrauterine transfusions and neonates (up to 28 days post expected date of delivery). 

          When CMV seronegative products are not available, leucocyte depleted products are an acceptable alternative..



          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)

          Occasionally severe haemolytic transfusion reactions have been reported in neonates or infants receiving red blood cell or FFP transfusions containing anti-T antibodies. The T-antigen may be exposed on the neonatal RBC surface by neuraminidase-producing bacteria such as Clostridium species and are often in association with necrotising enterocolitis (NEC). T activation may be detected in the laboratory by a lectin test, however, this test is no longer available. 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. All non-essential transfusions of FFP and platelets should be avoided. 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: the request form should indicate the type of specimen i.e. maternal or cord sample

          Forward samples to the laboratory immediately for processing.