Transfusions for VLBW infants

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Kirpalani et al report a large randomized controlled trial demonstrating that transfusion for low versus high hemoglobin levels had no effect on outcomes. However, fewer infants randomized to the lower transfusion level ever received a transfusion. In an accompanying editorial, Ed Bell contrasts these new results with a smaller trial from Iowa demonstrating fewer brain injuries diagnosed by ultrasound and less apnea in similar infants with hemoglobin levels that were higher than the high transfusion group in the study by Kirpalani et al.

In general, infants have received fewer transfusions than in the past for numerous reasons that include the use of arterial catheter less frequently, more permissive approaches to ventilation resulting in fewer blood gas measurements, and multiple trials indicating little benefit from transfusions to high hemoglobin in all of medicine. The use of polypacks for transfusions has strikingly decreased donor exposures for infant transfusions, and some clinicians use erythropoietin and iron therapy to both decrease transfusions and increase hemoglobin levels. When all is said and done, there are no firm guidelines for transfusion of infants. The trial by Kirpalani et al establishes two transfusion goals that definitively are not different in terms of clinically relevant outcomes.