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To the Editor:

Like nearly all previous authors, Morgan et al report that patients with transfusion-related acute gut injury (TRAGI) are of lower birth weight and gestational age and develop disease later in life compared with patients without TRAGI. They also report that most cases of necrotizing enterocolitis occur at approximately 31 weeks postconceptual age, a recent age clustering recognition that raises some additional questions about gut maturation and angiogenesis.

Their data provide an important contribution to the emerging literature on TRAGI because it represents a large multihospital cohort. Although other authors reporting on TRAGI have used various guidelines for packed red blood cell (PRBC) transfusion, including differences in storage media, volume transfused, and age of stored blood, they provided little commentary on blood group typing.¹, ², ³, ⁴, ⁵ Thus, the question of whether non–group-specific PRBC transfusion plays a role in the development of TRAGI has not been thoroughly investigated to date. It is reassuring to know that there is no association with the development of necrotizing enterocolitis, and that this etiologic mechanism can be excluded.

The authors also found a lower overall rate of TRAGI (8.3%) compared with similar reports of 25%-56%.¹, ², ³, ⁴, ⁵ There are at least 2 possible explanations for this finding. Clinicians have failed to reach a consensus on an appropriate threshold to initiate PRBC transfusion in very low birth weight infants⁶ and on whether to withhold feedings during PRBC transfusion. Several authors found a significant association between anemia and the development of TRAGI, whereas others claimed improvement from withholding feedings during transfusion; unfortunately, none of these studies are randomized or prospective.¹, ³, ⁵, ⁷ A limitation of the study of Morgan et al is that the authors did not provide information on these 2 controversial elements of decision making for their 3 study groups.

We appreciate the comments from Morgan et al and are pleased to have the opportunity to highlight several important issues. Given the incomplete information on this topic, we have established a registry to gather clinical information and to identify clinicians interested in a future clinical trial: www.tragiregistry.com.

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References 

1. Mally P, Golombek S, Mishra R, Nigam S, Mohandas K, Depalhma H, et al. Association of necrotizing enterocolitis with elective packed red blood cell transfusions in stable, growing, premature neonates. Am J Perinatol. 2006;23:451–458
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2. Christensen R, Lambert D, Henry E, Wiedmeier S, Snow G, Baer V, et al. Is “transfusion-associated necrotizing enterocolitis” an authentic pathogenic entity?. Transfusion. 2009;50:1106–1112
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3. El-Dib M, Narang S, Lee E, Massaro AN, Aly H. Red blood cell transfusion, feeding and necrotizing enterocolitis in preterm infants. J Perinatol. 2011;31:183–187
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4. Paul DA, Mackley A, Novitsky A, Zhao Y, Brooks A, Locke RG. Increased odds of necrotizing enterocolitis after transfusion of red blood cells in premature infants. Pediatrics. 2011;127:635–641
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5. Singh R, Visintainer PF, Frantz ID, Shah BL, Meyer KM, Favila SA, et al. Association of necrotizing enterocolitis with anemia and packed red blood cell transfusions in preterm infants. J Perinatol. 2011;31:176–182
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6. Strauss RG. Anaemia of prematurity: pathophysiology and treatment. Blood Rev. 2010;24:221–225
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7. Perciaccante JV, Young TE. Necrotizing enterocolitis associated with packed red blood cell transfusions in premature neonates. E-PAS2008:5839.8. Abstract presented at 2008 PAS meeting.
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