Clinical Practice Guideline for Red Blood Cell Transfusion Thresholds in Very Preterm Neonates

The clinical practice guideline for red blood cell transfusion thresholds in very preterm neonates was published in the journal JAMA Network Open. A systematic review of six randomised clinical trials comprising of 3,483 participants (mean [SD] age range, 25.9-29.8 [1.5-3.0] weeks) that compared high versus low haemoglobin-based or haematocrit-based transfusion thresholds was reviewed. Recommendations were developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Evidence summaries were also generated for the two PICO questions which focused on short-term outcomes and longer-term outcomes.   

In preterm neonates with less than 30 weeks’ gestational age (GA), the authors recommended a restrictive red cell transfusion strategy (conditional recommendation, with moderate certainty of evidence). Amongst the trials reviewed, the ranges for higher versus lower haemoglobin threshold study arms were similar, however, thresholds differed by the severity of illness. At postnatal weeks 1, 2, and 3 or more, for neonates on respiratory support, the authors recommended hemoglobin thresholds of 110, 100, and 90 g/L, respectively; for neonates with no or minimal respiratory support, the recommended thresholds were 100, 85, and 70 g/L, respectively.    

Regarding short-term outcomes, data from 5 trials found that a low threshold compared with a high threshold had little or no correlation with survival at any time point (risk difference [RD], −0.1% [95% CI, −2.3% to 2.4%]; relative risk [RR], 0.99 [95% CI, 0.84-1.17]). For death or neurodevelopmental impairment at 2 years’ corrected age, there was little or no difference between low and high thresholds (based on data from 3 trials; RD, 0.5% [95% CI, −2.0% to 3.8%]; RR, 1.01 [95%CI, 0.93-1.09], acknowledging that studies of school-aged children are ongoing. The subgroup analyses also revealed no compelling evidence of any subgroup differences when all-cause mortality was assessed by birth weight (<1000 g vs >1000 g), GA (<28 weeks vs ≥28 weeks), sex (male vs female), and transfusion volume (<20 mL/kg vs ≥20 mL/kg).    

Whilst this guideline has some limitations, including definitions of critical illness between trials, the use of a restrictive transfusion strategy in preterm neonates with less than 30 weeks’ gestational age was recommended. These recommendations may not apply to every patient, such as those with acute or severe illness. 

Reference

Deschmann E et al. Clinical Practice Guideline for Red Blood Cell Transfusion Thresholds in Very Preterm Neonates. JAMA Network Open 2024: 7(6): e2417431. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2820028