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The Clinical Use of Blood - Handbook (WHO; 2002; 222 pages)

Introduction
The appropriate use of blood and blood products
Replacement fluids
Blood products
Clinical transfusion procedures
Adverse effects of transfusion
Clinical decisions on transfusion
General medicine
Obstetrics
Paediatrics & neonatology
Key points
Paediatric anaemia
Transfusion in special clinical situations
Printable version
Bleeding and clotting disorders
Export document as HTML file Thrombocytopenia
Help
Neonatal transfusion
Export document as PDF file
Surgery & anaesthesia
Acute surgery & trauma
Burns
Glossary
Back cover

Paediatric anaemia

Paediatric anaemia is defined as a reduction of haemoglobin concentration or red cell blood volume below the normal values for healthy
children. Normal haemoglobin/haematocrit values differ according to the child’s age.

Age Haemoglobin concentration (g/dl)

Cord blood (term) ± 16.5 g/dl

Neonate: Day 1 ± 18.0 g/dl

1 month ± 14.0 g/dl

3 months ± 11.0 g/dl

6 months-6 years ± 12.0 g/dl

7-13 years ± 13.0 g/dl

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 > 14 years Same as adults, by sex

Causes

Very young children are at particular risk of severe anaemia. The majority of paediatric transfusions are given to children under three years
of age. This is due to a combination of the following factors occurring during a rapid growth phase when blood volume is expanding:

• Iron-poor weaning diets

• Recurrent or chronic infection
• Haemolytic episodes in malarious areas.

A severely anaemic child with other illness (e.g. acute infection), has a high risk of mortality. As well as treating the anaemia, it is
essential to look for and treat other conditions: e.g. diarrhoeal disease, pneumonia and malaria.

Prevention

The most effective and cost-effective means of preventing anaemia-associated mortality and the use of blood transfusion is to prevent
severe anaemia by:

• Early detection of anaemia

• Effective treatment and prophylaxis of the underlying causes of anaemia
• Clinical monitoring of children with mild and moderate anaemia.

CAUSES OF PAEDIATRIC ANAEMIA

Decreased production of normal red blood cells

• Nutritional deficiencies due to insufficient intake or absorption (iron, B12, folate)

• HIV infection
• Chronic disease or inflammation
• Lead poisoning
• Chronic renal disease
• Neoplastic diseases (leukaemia, neoplasms invading bone marrow)

Increased destruction of red blood cells

• Malaria
• Haemoglobinopathies (sickle cell disease, thalassaemia)
• G6PD deficiency
• Rh D or ABO incompatibility in the newborn
• Autoimmune disorders
• Spherocytosis

Loss of red blood cells

• Hookworm infection
• Acute trauma
• Surgery
• Repeated diagnostic blood sampling

Clinical assessment

Clinical assessment of the degree of anaemia should be supported by a reliable determination of haemoglobin or haematocrit.

Prompt recognition and treatment of malaria (see pp. 95-97) and any associated complications can be life-saving since death can
occur within 48 hours.

Management of compensated anaemia

In children, as in adults, the body’s mechanisms to compensate for chronic anaemia often means that very low haemoglobin levels can be
tolerated with few or no symptoms, provided anaemia develops slowly over weeks or months.

A child with well-compensated anaemia may have:

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 • Raised respiratory rate
• Increased heart rate

But will be:

• Alert
• Able to drink or breastfeed
• Normal, quiet breathing, with abdominal movement
• Minimal chest movement

Management of decompensated anaemia

Many factors can precipitate decompensation in an anaemic child and lead to life-threatening hypoxia of tissues and organs.

Causes of decompensation

1 Increased demand for oxygen:

• Infection
• Pain
• Fever
• Exercise

2 Further reduction in oxygen supply

• Acute blood loss

• Pneumonia

Early signs of decompensation

• Laboured, rapid breathing with intercostal, subcostal and suprasternal retraction/recession (respiratory distress)

• Increased use of abdominal muscles for breathing

• Flaring of nostrils

• Difficulty with feeding

Signs of acute decompensation

• Forced expiration (‘grunting’)/respiratory distress

• Mental status changes
• Diminished peripheral pulses
• Congestive cardiac failure
• Hepatomegaly
• Poor peripheral perfusion (capillary refill greater than 2 seconds)

Supportive treatment

Immediate supportive treatment is needed if the child is severely anaemic with:

• Respiratory distress
• Difficulty in feeding
• Congestive cardiac failure
• Mental status changes.

A child with these clinical signs needs urgent treatment as there is a high risk of death due to insufficient oxygen carrying-
capacity.

MANAGEMENT OF SEVERE DECOMPENSATED ANAEMIA

1 Position the child and airway to improve ventilation: e.g. sitting up.

2 Give high concentrations of oxygen to improve oxygenation.

3 Take blood sample for crossmatching, haemoglobin estimation and other relevant tests.

4 Control temperature or fever to reduce oxygen demands:

• Cool by tepid sponging

• Give antipyretics: e.g. paracetamol.

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 5 Treat volume overload and cardiac failure with diuretics: e.g. frusemide, 2 mg/kg by mouth or 1 mg/kg intravenously to a maximum
dose of 20 mg/24 hours.

The dose may need to be repeated if signs of cardiac failure persist.

6 Treat acute bacterial infection or malaria.

REASSESSMENT

1 Reassess before giving blood as children often stabilize with diuretics, positioning and oxygen.

2 Clinically assess the need for increased oxygen-carrying capacity.

3 Check haemoglobin concentration to determine severity of anaemia.

Severely anaemic children are, contrary to common belief, rarely in congestive heart failure, and dyspnoea is due to acidosis. The sicker
the child, the more rapidly transfusion needs to be started.

Transfusion

The decision to transfuse should not be based on the haemoglobin level alone, but also on a careful assessment of the child’s
clinical condition.

Both laboratory and clinical assessment are essential. A child with moderate anaemia and pneumonia may have more need of increased
oxygen-carrying capacity than one with a lower haemoglobin who is clinically stable.

If the child is stable, is monitored closely and is treated effectively for other conditions, such as acute infection, oxygenation may improve
without the need for transfusion.

INDICATIONS FOR TRANSFUSION

1 Haemoglobin concentration of 4 g/dl or less (or haematocrit 12%), whatever the clinical condition of the patient.

2 Haemoglobin concentration of 4-6 g/dl (or haematocrit 13-18%) if any the following clinical features are present:

• Clinical features of hypoxia:

- Acidosis (usually causes dyspnoea)

- Impaired consciousness

• Hyperparasitaemia (>20%).

The procedure for paediatric transfusion is shown on p. 142.

Special equipment for paediatric and neonatal transfusion

Never re-use an adult unit of blood for a second paediatric patient because of the risk of bacteria entering the pack during the
first transfusion and proliferating while the blood is out of the refrigerator.

• Where possible, use paediatric blood packs which enable repeat transfusions to be given to the same patient from a
single donation unit. This reduces the risk of infection

• Infants and children require small volumes of fluid and can easily suffer circulatory overload if the infusion is not well-
controlled. If possible, use an infusion device that makes it easy to control the rate and volume of infusion.

TRANSFUSION PROCEDURE

1 If transfusion is needed, give sufficient blood to make the child clinically stable.

2 5 ml/kg of red cells or 10 ml/kg whole blood are usually sufficient to relieve acute shortage of oxygen carrying-capacity. This will

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 increase haemoglobin concentration by approximately 2-3 g/dl unless there is continued bleeding or haemolysis.

3 A red cell transfusion is preferable to whole blood for a patient at risk of circulatory overload, which may precipitate or worsen cardiac
failure. 5 ml/kg of red cells gives the same oxygen-carrying capacity as 10 ml/kg of whole blood and contains less plasma protein and
fluid to overload the circulation.

4 Where possible, use a paediatric blood pack and a device to control the rate and volume of transfusion and

5 Although rapid fluid infusion increases the risk of volume overload and cardiac failure, give the first 5 ml/kg of red cells to relieve the
acute signs of tissue hypoxia. Subsequent transfusion should be given slowly: e.g. 5 ml/kg of red cells over 1 hour.

6 Give frusemide 1 mg/kg by mouth or 0.5 mg/kg by slow IV injection to a maximum dose of 20 mg/kg if patient is likely to develop
cardiac failure and pulmonary oedema. Do not inject it into the blood pack.

7 Monitor during transfusion for signs of:

• Cardiac failure
• Fever
• Respiratory distress
• Tachypnoea
• Hypotension
• Acute transfusion reactions
• Shock
• Haemolysis (jaundice, hepatosplenomegaly)
• Bleeding due to DIC.

8 Re-evaluate the patient’s haemoglobin or haematocrit and clinical condition after transfusion.

9 If the patient is still anaemic with clinical signs of hypoxia or a critically low haemoglobin level, give a second transfusion of 5-10 ml/kg
of red cells or 10-15 ml/kg of whole blood.

10 Continue treatment of anaemia to help haematological recovery.

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