LearnTransfusion Series

Topic Teaching: Blood Product Support and Transfusion Practices in Very Low Birth Weight Infants: More than meets the eye

April 7, 2020 | 12:00PM to 1:00PM (EDT)


Presented by:

Cassandra D. Josephson, MD
Professor, Pathology and Pediatrics, Emory University School of Medicine
Director of Clinical Research, Center for Transfusion and Cellular Therapies
Children's Healthcare of Atlanta Blood, Tissue, and Apheresis Services, Atlanta, GA


1.    Discuss the physiologic (hematologic and immunologic) difference between very low birth weight infants and term neonates.
2.    Present data on blood product utilization and transfusion practices in this vulnerable population.
3.    RCTs and other studies for RBCs, Platelets and Plasma in this population.
4.    Pathogen reduced products and the future for these patients.


1.    Ghirardello S, Dusi E, Cortinovis I, Villa S, Fumagalli M, Agosti M, Milani S, Mosca F. Effects of Red Blood Cell Transfusions on the Risk of Developing Complications or Death: An Observational Study of a Cohort of Very Low Birth Weight Infants. Am J Perinatol.   2017;34(1):88-95. Epub 2016/06/02. doi: 10.1055/s-0036-1584300. PubMed PMID: 27249797.
2.    Keir AK, Yang J, Harrison A, Pelausa E, Shah PS, Canadian Neonatal N. Temporal changes in blood product usage in preterm neonates born at less than 30 weeks' gestation in Canada. Transfusion. 2015;55(6):1340-6. doi: https://dx.doi.org/10.1111/trf.12998.
3.    Wang YC, Chan OW, Chiang MC, Yang PH, Chu SM, Hsu JF, Fu RH, Lien R. Red Blood Cell Transfusion and Clinical Outcomes in Extremely Low Birth Weight Preterm Infants. Pediatr Neonatol. 2017;58(3):216-22. Epub 2016/08/16. doi: 10.1016/j.pedneo.2016.03.009. PubMed PMID: 27514234.
4.    Josephson CD, Wesolowski A, Bao G, Sola-Visner MC, Dudell G, Castillejo MI, Shaz BH, Easley KA, Hillyer CD, Maheshwari A. Do red cell transfusions increase the risk of necrotizing enterocolitis in premature infants? J Pediatr. 2010;157(6):972-8 e1-3. Epub 2010/07/24. doi: S0022-3476(10)00482-8 [pii]10.1016/j.jpeds.2010.05.054. PubMed PMID: 20650470.
5.    Marin T, Strickland OL. Transfusion-related necrotizing enterocolitis: a conceptual framework. Advances in neonatal care : official journal of the National Association of Neonatal Nurses. 2013;13(3):166-74. doi: 10.1097/ANC.0b013e318285f901. PubMed PMID: 23722487.
6.    Mohamed A, Shah PS. Transfusion associated necrotizing enterocolitis: a meta-analysis of observational data. Pediatrics. 2012;129(3):529-40. Epub 2012/02/22. doi: peds.2011-2872 [pii]10.1542/peds.2011-2872. PubMed PMID: 22351894.
7.    Sharma R, Kraemer DF, Torrazza RM, Mai V, Neu J, Shuster JJ, Hudak ML. Packed red blood cell transfusion is not associated with increased risk of necrotizing enterocolitis in premature infants. Journal of perinatology : official journal of the California Perinatal Association. 2014;34(11):858-62. doi: https://dx.doi.org/10.1038/jp.2014.59.
8.    Garg P, Pinotti R, Lal CV, Salas AA. Transfusion-associated necrotizing enterocolitis in preterm infants: an updated meta-analysis of observational data. J Perinat Med. 2018;46(6):677-85. Epub 2017/11/28. doi: 10.1515/jpm-2017-0162. PubMed PMID: 29176013.
9.    Hay S, Zupancic JA, Flannery DD, Kirpalani H, Dukhovny D. Should we believe in transfusion-associated enterocolitis? Applying a GRADE to the literature. Semin Perinatol. 2017;41(1):80-91. Epub 2016/11/22. doi: 10.1053/j.semperi.2016.09.021. PubMed PMID: 27866662.
10.   Patel RM, Knezevic A, Shenvi N, Hinkes M, Keene S, Roback JD, Easley KA, Josephson CD. Association of Red Blood Cell Transfusion, Anemia, and Necrotizing Enterocolitis in Very Low-Birth-Weight Infants. JAMA. 2016;315(9):889-97. doi: https://dx.doi.org/10.1001/jama.2016.1204.
11.   Maheshwari A, Patel RM, Christensen RD. Anemia, red blood cell transfusions, and necrotizing enterocolitis. Semin Pediatr Surg. 2018;27(1):47-51. Epub 2017/12/26. doi: 10.1053/j.sempedsurg.2017.11.009. PubMed PMID: 29275817.
12.  Curley A, Stanworth SJ, Willoughby K, Fustolo-Gunnink SF, Venkatesh V, Hudson C, Deary A, Hodge R, Hopkins V, Lopez Santamaria B, Mora A, Llewelyn C, D'Amore A, Khan R, Onland W, Lopriore E, Fijnvandraat K, New H, Clarke P, Watts T. Randomized Trial of Platelet-Transfusion Thresholds in Neonates. N Engl J Med. 2019;380(3):242-51. Epub 2018/11/06. doi: 10.1056/NEJMoa1807320. PubMed PMID: 30387697.
13.   Fustolo-Gunnink SF, Fijnvandraat K, van Klaveren D, Stanworth S, Curley AE, Onland W, Steyerberg EW, de Kort E, d'Haens E, Hulzebos C, Huisman EJ, de Boode WP, Lopriore E, van der Bom JG. Preterm neonates benefit from low prophylactic platelet transfusion threshold despite varying risk of bleeding or death. Blood. 2019. Epub 2019/11/08. doi: 10.1182/blood.2019000899. PubMed PMID: 31697817.
14.   Patel RM, Josephson CD, Shenvi N, Maheshwari A, Easley KA, Stowell S, Sola-Visner M, Ferrer-Marin F. Platelet transfusions and mortality in necrotizing enterocolitis. Transfusion. 2019;59(3):981-8. Epub 2019/01/01. doi: 10.1111/trf.15112. PubMed PMID: 30597571; PMCID: PMC6402966.
15.   Guillen U, Cummings JJ, Bell EF, Hosono S, Frantz AR, Maier RF, Whyte RK, Boyle E, Vento M, Widness JA, Kirpalani H. International survey of transfusion practices for extremely premature infants. Semin Perinatol. 2012;36(4):244-7. Epub 2012/07/24. doi: 10.1053/j.semperi.2012.04.004. PubMed PMID: 22818544; PMCID: PMC3579510.
16.   Kirpalani H, Whyte RK, Andersen C, Asztalos EV, Heddle N, Blajchman MA, Peliowski A, Rios A, LaCorte M, Connelly R, Barrington K, Roberts RS. The Premature Infants in Need of Transfusion (PINT) study: a randomized, controlled trial of a restrictive (low) versus liberal (high) transfusion threshold for extremely low birth weight infants. J Pediatr. 2006;149(3):301-7. Epub 2006/08/31. doi: S0022-3476(06)00444-6 [pii]10.1016/j.jpeds.2006.05.011. PubMed PMID: 16939737.
17.   Bell EF, Strauss RG, Widness JA, Mahoney LT, Mock DM, Seward VJ, Cress GA, Johnson KJ, Kromer IJ, Zimmerman MB. Randomized trial of liberal versus restrictive guidelines for red blood cell transfusion in preterm infants. Pediatrics. 2005;115(6):1685-91. Epub 2005/06/03. doi: 115/6/1685 [pii] 10.1542/peds.2004-1884. PubMed PMID: 15930233; PMCID: 2866196.
18.   Qadri SM, Chen D, Schubert P, Devine DV, Sheffield WP. Early gamma-irradiation and subsequent storage of red cells in SAG-M additive solution potentiate energy imbalance, microvesiculation and susceptibility to stress-induced apoptotic cell death. Vox Sang. 2017;112(5):480-3. Epub 2017/04/06. doi: 10.1111/vox.12518. PubMed PMID: 28378415.
19.   de Korte D, Thibault L, Handke W, Harm SK, Morrison A, Fitzpatrick A, Marks DC, Yi QL, Acker JP. Timing of gamma irradiation and blood donor sex influences in vitro characteristics of red blood cells. Transfusion. 2018;58(4):917-26. Epub 2018/01/18. doi: 10.1111/trf.14481. PubMed PMID: 29341199.
20.   Saito-Benz M, Murphy WG, Tzeng YC, Atkinson G, Berry MJ. Storage after gamma irradiation affects in vivo oxygen delivery capacity of transfused red blood cells in preterm infants. Transfusion. 2018;58(9):2108-12. Epub 2018/08/31. doi: 10.1111/trf.14764. PubMed PMID: 30160773.
21.   MohanKumar K, Namachivayam K, Song T, Jake Cha B, Slate A, Hendrickson JE, Pan H, Wickline SA, Oh JY, Patel RP, He L, Torres BA, Maheshwari A. A murine neonatal model of necrotizing enterocolitis caused by anemia and red blood cell transfusions. Nat Commun. 2019;10(1):3494. Epub 2019/08/04. doi: 10.1038/s41467-019-11199-5. PubMed PMID: 31375667; PMCID: PMC6677753.
22.   Goel R, Josephson CD (co-first author),  Patel EU, Petersen MR,  Makhani S, Frank SM, Ness P, Bloch E,  Gehrie EH, Lokhandwala PM, Nellis MM, Karam O, Shaz BH, Patel RM, Tobian AR.  Perioperative Transfusions and Venous Thromboembolism.  Pediatrics 2020 (in press).
23.   Patel RM, Josephson C. Neonatal and pediatric platelet transfusions: current concepts and controversies.  Curr Opin Hematol. 2019 Nov;26(6):466-472. PMID: 31503020.
24.   Delaney M, Mayock D, Knezevic A, Easley K, Kleine E, Patel RM, Norby-Slycord C, Josephson CD.  Neonatal CMV Infection:  A pilot comparative effectiveness study of transfusion safety using leukoreduced only transfusion strategy. Transfusion 2016;56(8):1945-50.
25.   Sparger K, Assmann S, Granger S, Miller J, Winston A, Christensen R, Josephson  CD,   Stowell SR,  Widness J,  Saxonhouse M, Sola-Visner M.  Platelet Transfusion Practices Among Very Low Birth Weight (VLBW) Infants:  A Multicenter Retrospective Cohort Study. JAMA Pediatr 2016;170(7):687-94.
26.   Fergusson DA, Hébert P, Hogan DL, LeBel L, Rouvinez-Bouali N, Smyth JA, Sankaran K, Tinmouth A, Blajchman MA, Kovacs L, Lachance C, Lee S, Walker CR, Hutton B, Ducharme R, Balchin K, Ramsay T, Ford JC, Kakadekar A, Ramesh K, Shapiro S.Effect of fresh red blood cell transfusions on clinical outcomes in premature, very low-birth-weight infants: the ARIPI randomized trial.  JAMA. 2012 Oct 10;308(14):1443-51.
27.   Higgins RD, Patel RM, Josephson CD.  Preoperative Anemia and Neonates.  JAMA Pediatr 2016;170(9):835-6.
28.   Josephson CD, Caliendo AM, Patel RM, Hillyer CD, Hinkes M, Knezevic A, Shenvi N, Easley KA, Roback JD.  Blood transfusion and breast milk transmission of cytomegalovirus in very low birth weight infants.  JAMA Pediatr 2014; 168:1054-62.
29.   Goel R, Josephson CD.  Recent advances in transfusions in neonates/infants. F1000Res. 2018 May 18;7. pii: F1000 Faculty Rev-609. doi: 10.12688/f1000research.13979.1. eCollection 2018. Review. PMID: 29904575.
30.   Keir AK, Karam O, Hodyl N, Stark M,  Liley, Shah P, Stanworth; International, multicentre, observational study of fluid bolus therapy in neonates.  NeoBolus Study Group:  J Paediatr Child Health. 2019 Jun;55(6):632-639. doi: 10.1111/jpc.14260. Epub 2018 Oct 16.


Note: The session is a self-approved group learning activity (Section 1) as defined by the Maintenance of Certification program of The Royal College of Physicians and Surgeons of Canada.

To register for the LearnTransfusion series, send an email to learn.transfusion@blood.ca with  “Weekly Transfusion Medicine Seminars” in the subject line. Include your name and complete e-mail address in the body of the e-mail, and confirm that you would like to register for the LearnTransfusion series. You will then receive weekly email notifications of upcoming series events with details on how to join the webinars (e.g., call-in number and a link to register for the webinar).

The LearnTransfusion series is the seminar component of the Areas of Focused Competency (AFC)-Diploma Program in Transfusion Medicine. The series, organized by Canadian Blood Services is also open to all practitioners in the field of Transfusion Medicine. Through a series of regular webinars, trainees and practitioners are exposed to various scientific, technical and clinical aspects of transfusion medicine.