Hematology; blood and platelet transfusions

Kirpalani H, Bell EF, Hintz SR, Tan S, Schmidt B, Chaudhary AS, et al. Higher or Lower Hemoglobin Transfusion Thresholds for Preterm Infants. N Engl J Med. 2020;383(27):2639-51.

Study performed partly because of potential long term impacts found in the PINT trial (below). 1,800 ELBW babies randomized to higher or lower transfusion threshold. No advantage found of earlier transfusion in either short or long term outcomes. There was absolutely no sign of any difference in Bayley scores. The low transfusion thresholds were safe, and led to fewer babies being transfused.

Kirpalani H, Whyte RK, Andersen C, Asztalos EV, Heddle N, Blajchman MA, et al. 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.

Comparison of two different transfusion threshold algorithms in 450 ELBW infants, enrolled at <48 h of age. No impact of more restrictive transfusions on any primary or secondary outcome, but many fewer transfusions in the restricted group.

Whyte RK, Kirpalani H, Asztalos EV, Andersen C, Blajchman M, Heddle N, et al. Neurodevelopmental outcome of extremely low birth weight infants randomly assigned to restrictive or liberal hemoglobin thresholds for blood transfusion. Pediatrics. 2009;123(1):207-13.

This was a report of the longer term outcomes of the PINT trial, no differences were found in the planned analysis. A post-hoc analysis (always a dangerous thing to do) suggested that there was maybe an advantage in cognitive scores to the liberal transfusion group.

Franz AR, et al. Effects of Liberal vs Restrictive Transfusion Thresholds on Survival and Neurocognitive Outcomes in Extremely Low-Birth-Weight Infants: The ETTNO Randomized Clinical Trial. JAMA. 2020;324(6):560–70.

This European trial of different transfusion thresholds randomized 1000 infants <1000g at <72 hours of age. 40% of the low threshold group avoided transfusion, compared to 20% of the high threshold babies. The primary outcome was survival to 2 years without disability. There were no differences in outcome between the groups. Either in the parts of the primary outcome or in NEC, BPD or RoP.

Platelets

Curley A, Stanworth SJ, Willoughby K, Fustolo-Gunnink SF, Venkatesh V, Hudson C, et al. Randomized Trial of Platelet-Transfusion Thresholds in Neonates. N Engl J Med. 2019;380(3):242-51..

Comparison of platelet transfusions at a threshold of either 50,000 or 25,000 in newborns not actively bleeding. No advantage of transfusing sooner, in fact there was more bleeding in the group who were transfused sooner. There were few very preterm babies in the first 48 hours of life, so little confidence for the impact on IVH, but no evidence of any benefit.