78  Transfusion

78.1 Introduction

Blood transfusion is a critical, lifesaving intervention in paediatric practice. In sub-Saharan Africa, including Ghana, transfusion plays a vital role in the management of severe anaemia, neonatal conditions, trauma, malignancies, and surgical emergencies. However, transfusion also carries significant risks such as transfusion reactions, infections, circulatory overload, and alloimmunization.

Paediatric transfusion differs from adult transfusion in several key ways: children’s blood volumes are smaller, immune systems are less mature, and many transfusion indications arise from conditions unique to childhood (e.g., severe malaria anaemia, haemoglobinopathies). Therefore, understanding transfusion principles tailored to paediatrics is essential for safe and effective care.

This chapter provides a comprehensive review of paediatric transfusion medicine—including physiology, indications, product selection, dosing, safety, and Ghana-specific considerations. It is intended for medical students, residents, and practising paediatricians preparing for ward work and examinations.

78.2 Physiology of Blood and Components in Children

Children have different blood volumes and haematological characteristics compared with adults.

78.2.1 Blood Volume by Age

Age Group	Approximate Blood Volume
Preterm neonate	90–100 mL/kg
Term neonate	80–90 mL/kg
Infant (1–12 months)	75–80 mL/kg
Child	70–75 mL/kg
Adolescent	65–70 mL/kg

The smaller the blood volume, the greater the physiological impact of even minor blood loss. A loss of 20 mL of blood is negligible in an adult but clinically relevant in a neonate.

78.2.2 Developmental Haematology

• Neonatal haemoglobin is predominantly fetal haemoglobin (HbF), with high oxygen affinity.
• Physiological anaemia occurs at 6–12 weeks due to decline in erythropoietin.
• Iron stores deplete early in life, making infants more vulnerable to iron deficiency.
• Immune system immaturity increases susceptibility to transfusion-transmitted pathogens and alloimmunization.

78.3 Indications for Paediatric Transfusion

Transfusion decisions must balance expected benefits against risks. Indications can be grouped into:

1. Red Cell Transfusion
2. Platelet Transfusion
3. Plasma (FFP) Transfusion
4. Cryoprecipitate Transfusion
5. Whole Blood (rare, selected contexts)

78.3.1 Indications for Red Cell Transfusion

78.3.1.1 Acute Severe Anaemia

Common causes in Ghana:

• Severe malaria
• Sickle cell disease crises
• Acute haemolysis (G6PD deficiency)
• Acute bleeding (trauma, obstetric haemorrhage in adolescents)
• Severe sepsis

Thresholds for transfusion (common paediatric practice):

• Hb < 4 g/dL — transfuse immediately.
• Hb 4–6 g/dL — transfuse if symptomatic (shock, respiratory distress, heart failure).
• Hb 6–10 g/dL — consider only in special situations such as:
  • ongoing blood loss
    
  • cardiopulmonary disease
    
  • severe infection with compromised oxygen delivery
    
• Hb > 10 g/dL — rarely indicated.

78.3.1.2 Chronic Anaemia

Conditions:

• Thalassemia major
  
• Sickle cell disease (selected indications; not routine)
  
• Bone marrow failure syndromes
  
• Chronic renal disease

Transfusions are individualized, often part of long-term management.

78.3.1.3 Perioperative Transfusion

Indications:

• Anticipated significant blood loss
• Preoperative correction of Hb < 8 g/dL in major surgery
• Intraoperative haemodynamic instability due to blood loss

78.3.1.4 Neonatal Transfusion Indications

• Symptomatic anaemia
  
• Anaemia of prematurity with severe cardiorespiratory compromise
  
• Significant iatrogenic blood loss in NICUs
  
• Exchange transfusion for severe jaundice (RBC + plasma)

78.4 Blood Components and Their Uses

Modern transfusion practice prefers component therapy rather than whole blood.

78.4.1 Packed Red Blood Cells (PRBCs)

• Indicated for anaemia with reduced oxygen-carrying capacity.
• Haematocrit: 50–70%.

78.4.2 Whole Blood

• Used in Ghana in select situations such as severe acute haemorrhage in resource-constrained facilities.
• Haematocrit ~40%.
• Higher risk of volume overload.

78.4.3 Platelets

Indicated for:

• Active bleeding with thrombocytopenia
• Prophylaxis in very low platelet counts (<10 × 10⁹/L)
• Platelet dysfunction (e.g., uremia)

78.4.4 Fresh Frozen Plasma (FFP)

Indications: - Bleeding due to coagulation factor deficiency - DIC - Warfarin reversal in adolescents

Not for:

• Volume expansion
• Simple anaemia

78.4.5 Cryoprecipitate

Contains fibrinogen, von Willebrand factor, factor VIII.

Indications: - Hypofibrinogenemia (<1 g/L) - Disseminated intravascular coagulation - Certain bleeding disorders

78.5 Dosing of Blood Components in Children

Paediatric transfusion doses are weight-based.

78.5.0.1 Red Blood Cells

• Dose: 10–15 mL/kg (PRBC)
• Expected Hb rise: 1–2 g/dL per 10 mL/kg
• Neonates: 10–15 mL/kg over 2–4 hours

78.5.0.2 Whole Blood

• 20 mL/kg (for acute blood loss)

78.5.0.3 Platelets

• Dose: 10–15 mL/kg

or

• 1 unit per 10 kg body weight

Expected rise: 20–40 × 10⁹/L

78.5.0.4 FFP

• 10–15 mL/kg

78.5.0.5 Cryoprecipitate

• 1 unit per 5 kg body weight

or

• 5–10 mL/kg

78.6 Special Considerations in Neonatal Transfusion

Neonates have unique physiology requiring careful approach.

78.6.1 Key Principles

• Use CMV-reduced, irradiated, and fresh (<5 days old) blood where available.
• Avoid potassium accumulation by not using blood stored too long.
• Transfuse slowly: 5 mL/kg/hr unless urgent.

78.6.2 Exchange Transfusion

Indications:

• Severe hyperbilirubinemia
• Haemolytic disease of the newborn

Blood requirements: - Crossmatch with mother’s blood - O-negative, antigen-compatible PRBCs reconstituted with plasma - Haematocrit 40–50%

78.7 Transfusion Decision-Making: Thresholds and Clinical Judgment

In resource-limited settings like Ghana, clinical judgment is especially important.

78.7.1 Clinical Factors Supporting Transfusion:

• Tachycardia
• Respiratory distress
• Signs of cardiac failure
• Lethargy or altered consciousness
• Hypoxia (SpO2 < 92%)
• Shock

78.7.2 Laboratory Red Flags:

• Hb < 4 g/dL (emergency)
• Hb < 6 g/dL with symptoms
• Rising lactate
• Severe thrombocytopenia (<10 × 10⁹/L)

78.7.3 When Not to Transfuse:

• Mild asymptomatic anaemia
• Anaemia that is nutritional and not severe
• Iron deficiency responsive to oral supplementation
• Fever alone without evidence of haemodynamic compromise

78.8 Risks and Complications of Transfusion

Transfusion is not without danger. Vigilance is mandatory.

78.8.1 Acute Transfusion Reactions

• Febrile non-haemolytic reaction
• Allergic reactions (urticaria to anaphylaxis)
• Acute haemolytic reaction (ABO mismatch)
• Transfusion-associated circulatory overload (TACO)
• Transfusion-related acute lung injury (TRALI)

78.8.2 Delayed Reactions

• Delayed haemolytic transfusion reaction
• Transfusion-transmitted infections
• Alloimmunization (especially in sickle cell patients)
• Iron overload (chronic transfusers)

78.8.3 Transfusion-Transmitted Infections (TTIs)

In Ghana, screening is mandatory for:

• HIV
• Hepatitis B
• Hepatitis C
• Syphilis

Malaria transmission risk exists despite screening.

78.8.4 Iron Overload

Occurs in:

• Thalassemia major
• Chronic transfusion protocols
  Management: Iron chelation with deferasirox or deferoxamine.

78.9 Transfusion Safety and Protocols

Safe transfusion practice involves multiple layers of protection.

78.9.1 Pre-Transfusion Steps

• Confirm indication.
• Check baseline vitals.
• Obtain informed consent.
• Crossmatch blood (patient name, age, hospital number).
• Use appropriate component.

78.9.2 Bedside Checks

Always perform the three Rs:

1. Right patient
   
2. Right blood
   
3. Right time

Any mismatch can be fatal.

78.9.3 3. Monitoring During Transfusion

Time	Action
Start	Observe for first 15 minutes; vital signs every 15 min
Mid-transfusion	Vitals every 30 min
End	Vitals at completion
Post	Monitor for late reactions

Observe for:

• Fever
  
• Rigors
  
• Rash
  
• Difficulty breathing
  
• Hypotension
  
• Haemoglobinuria

78.9.4 Management of Transfusion Reactions

• Stop transfusion immediately.
• Maintain IV line with saline.
• Check vitals and notify senior/clincians.
• Send blood bag and samples for investigation.
• Treat according to reaction type (antihistamine, adrenaline, oxygen support etc.).

78.10 Transfusion in Special Groups

78.10.1 Children With Severe Malaria

Common in Ghana.

Key points:

• Hb < 6 g/dL with respiratory distress → urgent transfusion.
• Monitor for fluid overload.
• Treat malaria concurrently with artesunate.

78.10.2 Sickle Cell Disease

• Transfuse only for specific indications:
  • Acute chest syndrome
    
  • Stroke
    
  • Severe anaemia
    
  • Preoperative optimization
• Use HbS-negative, matched blood if available.
  
• Avoid unnecessary transfusions to prevent alloimmunization.

78.10.3 Oncology Patients

• Require recurrent transfusions (platelets + RBCs).
• High alloimmunization risk.
• Need irradiated components if receiving chemotherapy causing immunosuppression.

78.11 Blood Banking and Transfusion Services in Ghana

The National Blood Service (NBS) Ghana coordinates:

• Blood donor recruitment
• Testing and processing
• Distribution to health facilities

78.11.1 Challenges:

• Heavy reliance on replacement donors rather than voluntary donors
• Regular shortages necessitating the use of whole blood
• Limited availability of specialized products such as irradiated blood
• Challenges in cold chain maintenance in rural hospitals
• High prevalence of TTIs in general population increasing risk of transfusion-transmitted infections

78.11.2 Strengths:

• National standardized screening procedures
• Expanded donor mobilization programmes
• Increasing availability of PRBCs and FFP in tertiary centres

Improving Ghana’s transfusion services requires enhanced voluntary donation and strengthened hospital transfusion committees.

78.12 Clinical Approach: How to Manage a Child Requiring Transfusion

Step 1: Confirm Indication

Ask: “Will this transfusion save the child’s life or significantly improve outcome?”

Step 2: Evaluate Urgency

• Emergency (Hb < 4 g/dL or shock)
  
• Semi-urgent
  
• Elective

Step 3: Choose the Right Product

• Anaemia → PRBC
  
• Bleeding due to coagulopathy → FFP
  
• Severe thrombocytopenia → Platelets
  
• Hypofibrinogenemia → Cryoprecipitate

Step 4: Calculate Dose

Weight-based dosing.

Step 5: Bedside Safety Checks

Identity, unit number, compatibility.

Step 6: Monitor and Document

Before, during, and after the transfusion.

Step 7: Reassess

A post-transfusion Hb should be checked only when clinically necessary.

78.13 Key Points for Exams and Clinical Practice

• PRBC dose: 10–15 mL/kg raises Hb by 1–2 g/dL.
  
• Whole blood for massive haemorrhage: 20 mL/kg.
  
• Platelets indicated when platelets <10 × 10⁹/L without bleeding.
  
• Never use FFP for nutritional anaemia or volume expansion.
  
• Neonates require fresh, CMV-reduced, irradiated blood.
  
• In Ghana, severe malaria is the leading cause of paediatric transfusion.
  
• Monitor closely for TACO and TRALI.
  
• Document all transfusion reactions and report to hospital transfusion committee.

78.14 Further Reading

1. WHO. Guidelines on the Use of Blood and Blood Products. Geneva: World Health Organization.
   
2. Klein HG, Anstee DJ. Mollison’s Blood Transfusion in Clinical Medicine, 13th ed.
   
3. West African College of Physicians (WACP). Curriculum for Paediatrics.
   
4. National Blood Service, Ghana. Guidelines for Clinical Transfusion Practice.
   
5. Roback JD et al. Technical Manual of the American Association of Blood Banks (AABB), 20th ed.
   
6. Bates I et al. “Transfusion in Sub-Saharan Africa: Challenges and Solutions.” Lancet.