Introduction

The topic of transfusion therapy continues to be heavily researched in both the adult and pediatric populations. Ongoing research continues regarding optimal thresholds for transfusion of blood products, appropriate prophylaxis for venous thromboembolic disease and best practice for treatment of underlying coagulation disorders.

What considerations in blood transfusion and coagulation therapy differ in the child from that of the adult?

The 1999 Transfusion Requirements in Critical Care (TRICC Trial) study is a landmark in adult critical care that supports the institution of restrictive transfusion policies [1]. This study showed a decrease in hospital mortality rate and no difference in thirty day mortality in critically ill patients who had a restrictive transfusion threshold of 7 g/dL. More recent studies have confimred the safety and efficacy of restricted transfusion strategies [2].

Multiple studies have been performed in children to determine the optimal timing and indications for transfusion and have formed the basis for transfusion guidelines at many centers. The 2007 Transfusion Strategies for Patients in Pediatric Intensive Care Units (TRIPICU Study) indicated that a transfusion threshold of 7 g/dL significantly decreased transfusion requirements in pediatric patients without increasing adverse effects [3]. Randomized trials in pediatric burn patients have shown that restrictive transfusion protocols are safe and efficacious in these children as well [4].

Both differences and similarities exist regarding the treatment of anemia, venous thromboembolism, and coagulation disorders among infants, children, and adults. Hemoglobin synthesis and hematopoiesis vary significantly with age as do the underlying causes of anemia, leading to differing transfusion thresholds. Strategies to prevent anemia are also variable. The pre-transfusion preparation of blood components varies between neonates and adults (i.e., exposure to viral antigens) since the immature immune system of the neonate may predispose them to fatal infection.

Developmental hemostasis has been studied to better understand the clotting function of the newborn since the hemostatic system changes over the first years of life. Individual plasma levels of coagulation proteins and the function of the hemostatic system vary with age. For example, children develop venous thromboembolism at a much lower rate than adults, and both the dosing and indications for thromboprophylaxis differ from adult guidelines [5]. To date, no set standard guideline has been published that applies universally to children. Medications offered for the prophylaxis and treatment of thromboembolism also vary due to age-related differences in metabolism and excretion that may require further laboratory monitoring in children. A thorough understanding of the pathophysiology of blood and coagulation disorders is important to be able to deliver care to critically ill neonates and children.

Content in this topic is referenced in SCORE Coagulation overview