#151: Baby, Now We Got Good Blood! Pediatric Transfusion Medicine

September 3, 2025 | By Sam Masur

Audio

Summary:

Ever wonder why a Type & Screen expires after 72 hours? Join Dr. Rida Hasan (pediatric hematologist and transfusion medicine specialist) as we dive into pediatric transfusion medicine. From massive transfusion protocols to blood product modifications to keeping kids safe from TACOs, this episode is a cell-ebration of pediatric transfusions!

Transfusion Medicine Pearls

1. Up to approximately 25-30 kg, pediatric blood products require weight-based dosing. 
2. Leukoreduced, irradiated, or other specialized blood products are indicated in certain populations to minimize risk of transfusion reactions.
3. If in doubt, call your local blood bank attending about patients with more complicated transfusion histories.
4. Donating blood is a great way to give back to your community and your patients!

Transfusion Medicine Notes 

Pre-transfusion labs

A Type and Screen tests two things. It tests the patient’s blood type (for example, AB+ or O-), which takes about 10 minutes. It also screens for the presence of red cell allo-antibodies against minor red cell antigens (for example, antibodies against Kell or Duffy antigens), which takes about an hour.

A Type and Cross now typically happens automatically when you order packed red blood cells. This order tells the blood bank to prepare a unit of blood cells specifically for a certain patient. It can happen almost immediately for patients with a negative screen, but may take much longer for patients with a more complicated transfusion history and multiple allo-antibodies (i.e. a positive screen). If the patient’s screen is positive, the blood bank must mix the patient’s plasma with the prepared unit of blood to make sure they are compatible. 

Why do I have to order a new Type and Screen every 3 days?

Most hospitals require a new Type and Screen every 72 hours. This frequency is required to monitor for development of new allo-antibodies, especially in patients who are pregnant and/or actively receiving transfusions. 

Sometimes blood banks will do an extended type and screen for healthy outpatients who aren’t receiving transfusions. These extended type and screen tests are valid for longer than 72 hours.

Massive transfusion protocols

Massive transfusion protocols are used to communicate with the blood bank to prepare a larger amount of blood for a patient with acute blood loss. It also communicates to the blood bank that blood is needed quickly, which may not allow for the full cross-matching process. 

Massive transfusion protocols also typically include packed red blood cells, platelets, and either plasma or cryoprecipitate in a specific ratio. Administering multiple blood products prevents coagulopathy. 

Blood products

Packed red blood cells

Indication: anemia (often hemoglobin < 7) or active bleeding

Dose: 10-15 mL/kg up until 30 kg, 1 unit for more than 30 kg

Response: 1-2 mg/dL increase in hemoglobin per dose

Administration notes: 

• Sometimes pRBCs are administered in slower or small aliquots for chronically anemic patients to avoid transfusion-associated circulatory overload (TACO).

Platelets

Indication: thrombocytopenia

Dose: 5-10 mL/kg up until 25-30 kg, 1 unit for more than 25-30 kg

Response: 30,000-50,000 rise in platelet count per dose

Administration notes: 

• Platelets do need to be ABO-compatible, but the risk of a transfusion reaction is much lower than for red blood cells. 

Fun fact: Platelets used to be called “six-packs” because one unit of platelets was made up of pooled platelets from six different donors. Now that most blood donation centers use apheresis instead of spinning down whole blood, most units of platelets come from a single donor. 

Plasma

Indication: coagulopathy

Contents: coagulation factors, antibodies

Dose: 10-15 mg/kg up to 30 kg, 1 unit for more than 30 kg

Response: 10-15% increase in coagulation factors

Administration notes: 

• Because of the logarithmic relationship between coagulation factor levels and INR, plasma administration cannot lower INR below approximately 1.5. 
• There are slight differences between different plasma products (i.e. fresh frozen plasma) but they are interchangeable for most clinical situations. 
• Plasma is not the best product for patients who just need one specific coagulation factor (i.e. hemophilia).

Cryoprecipitate

Indication: DIC or other clinical states with low fibrinogen

Contents: Factor VIII, fibrinogen, and Von Willibrand factor

Dose: 2-5 mL/kg up to 10 kg, 1 unit per 10 kg above 10 kg

Response: 100-150 mg/dL increase in fibrinogen 

Honorable Mention: Four-factor prothrombin concentrate

Indication: warfarin reversal, other situations in which patients will not tolerate high volume of plasma

Contents: Factors II, VI, IX, and X (Vitamin K dependent factors)

Special considerations

Neonates

As blood sits on the shelf, potassium content rises due to hemolysis. Fresher units are less than 7 days old and are preferred for neonates to avoid iatrogenic hyperkalemia.

Neonates also almost always get Type O blood regardless of Type and Screen results because Type and Screen testing is less reliable in the presence of maternal anti-A and anti-B antibodies.

Leukoreduction

Leukoreduced blood is run through a filter to remove white blood cells. It reduces the risk of CMV transmission and the risk of febrile nonhemolytic transfusion reactions. Most blood products in the US are leukoreduced. 

Irradiation

Irradiated units are used for children under 4 months old and immunocompromised patients. Irradiated blood is exposed to gamma radiation to prevent lymphocytes from replicating. This reduces the risk of transfusion-associated graft versus host disease. 

Washing

Washing blood products removes 99% of plasma that’s in the blood product and helps prevent anaphylactic reactions in patients with a history of allergic reactions. 

Blood transfusion tips

Dr. Hasan’s tips for blood product consenting:

Read your institution’s consent form carefully.

Start with the indication for the transfusion. Consider redoing the consent process if the indication changes throughout hospitalization! 

Risks include transfusion reactions and infectious diseases. 

• We mitigate risk of transfusion reactions by monitoring patients closely and stopping the transfusion quickly with any sign of a reaction. 
• We mitigate risk of transfusion-related disease transmission by using a voluntary donor pool, screening donors with a pre-donation questionnaire, and testing donated blood for commonly transmitted infectious diseases (Hepatitis B and C, HIV). 

When to call the blood bank

Call the blood bank attending if you have a patient who:

1. Has received many prior transfusions (i.e. patients with sickle cell disease).
2. Has known allo-antibiodies that may make it more challenging to find an appropriate unit.
3. Will need a large amount of blood in the near future (this helps the blood bank maintain appropriate inventory).

Transfusion reactions

What do I do if someone has a transfusion reaction?

• Stop the transfusion. 
• Stabilize the patient.
• Check to ensure the correct unit was given to the correct patient. 
• Collect a post-transfusion sample from the patient.
• Send the post-transfusion sample and the rest of the unit of blood back to the blood bank for testing. 

Acute hemolytic transfusion reactions happen when blood cells from the incorrect blood type are transfused. Prevent these with careful administrative processes to ensure correct administration at bedside. 

Delayed hemolytic transfusion reactions happen when a patient has allo-antibodies to a minor red blood cell antigen. Prevent these by running a Type and Screen frequently for new allo-antibodies.

Febrile nonhemolytic transfusion reactions happen because of white blood cells and cytokines in blood products. Prevent these with leukoreduction. 

Allergic reactions can happen at any time. Prevent recurrent reactions with washed blood products.

Transfusion-associated circulatory overload happens because of volume overload due to administering a high volume of blood products. Prevent these by avoiding unnecessary transfusions and reducing the volume of the transfusion. 

Transfusion-associated graft versus host disease happens when donor leukocytes reproduce uncontrollably in patients who are severely immunocompromised. Prevent this with irradiation. 

Transfusion-related acute lung injury (TRALI) happens because of an incompatibility in HLA and human neutrophil antibodies. Prevent this by using products only from male or previously-tested female donors.

Goal

Listeners will recognize when and how to safely administer blood products in children, understand key differences between pediatric and adult transfusion practices, and anticipate common complications.

Learning Objectives

1. Describe the indications and dosing for common pediatric blood products, including red blood cells, platelets, plasma, and cryoprecipitate.
2. Differentiate between special product modifications (e.g., leukoreduction, irradiation, washing) and identify which patients require them
3. Recognize and manage common transfusion reactions such as TACO, TRALI, and hemolytic reactions.

Disclosures

Dr. Hasan reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Lidsky H, Hasan R, Chiu C, Masur S. “#151: Baby, Now We Got Good Blood! Pediatric Transfusion Medicine”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/  3rd September, 2025.