Pattern of Blood Transfusion in the Neonatal Intensive Care Unit of a Tertiary Hospital in the Niger Delta Region of Nigeria

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Background: Blood transfusion is a common procedure in the neonatal unit of most hospitals. However, it is not completely free from possible complications that can affect the overall outcome of the patient. The transfusion frequency of the neonatal intensive care unit (NICU) of the Delta State University Teaching Hospital (DELSUTH) was perceived to be high. As a result, the study was embarked upon to document the pattern of blood transfusion in the NICU of the DELSUTH.

Aim: To determine the prevalence of neonatal blood transfusion, the indications, the types of blood and blood products transfused, and to document the transfusion reactions in the NICU of the DELSUTH.

Methodology: The study was an analysis of secondary data obtained from NICU transfusion register and the admission register from 1^st of January 2020 to 30^th June 2021. Data extracted included hospital number, age, sex, packed cell volume, indications for blood transfusion, blood groups of neonates, number of transfusions per neonates, types of transfusions, blood and blood products transfused and transfusion reactions documented during the period under review. The data were entered into Excel Spreadsheet and analysis was with IBM SPSS Statistics for Windows 7, version 23

Results:  There were 178 admissions over the study period with 100 (56.2%) males and 78 (43.8%) females. One hundred and seven were born vaginally (60.1%) and 77 (43.3%) neonates were born preterm. There were 99 neonatal transfusions giving a prevalence of 55.6%. The indications for transfusion were anaemia, hyperbilirunaemia and thrombocytopaenia. Whole blood and sedimented blood were the only blood transfused during the period under review. There was no transfusion reaction documented during the period under review.

Conclusion: The prevalence of blood transfusion in the neonatal unit of the DELSUTH was high, nevertheless, no transfusion reaction was recorded. Despite the need for packed red cells and platelets concentrate in the NICU, only whole blood and sedimented blood were transfused. 

Keywords:  Pattern, blood transfusion, neonatal unit, Niger-Delta .

Blood transfusion in the neonatal unit is a frequent procedure and is not uncommon for complications to follow this life saving procedure.^1,2 The demand for blood and blood products is comparatively higher in the neonatal unit when compared to other units in Paediatrics.¹ Blood transfusion among neonates is unique for the following reasons. First, the prenatal transfer of maternal antibodies to the immunologically immature neonates results in unique haematologic compatibility patterns different from those of other groups. Second, immature organ function    exposes the neonate to metabolic complications and to infectious and immunologic complications of blood transfusion. Third, neonates are at high risk of haemodynamic complications because of their small blood volume and the limited capacity to increase blood volume relative to rapid growth.³

The commonest indication for neonatal blood transfusion can vary from one neonatal unit to another. A study carried out in Zaria⁴, in the northwestern part of Nigeria found anaemia to be the commonest indication for neonatal blood transfusion while another study in Sagamu⁵, in the western part of the country found hyperbilirubinaemia to be the commonest indication for neonatal blood transfusion. Literature review reveals that there has been no reported study on the pattern of neonatal blood transfusion in Delta state, a state located in the southern part of Nigeria.

When there is an indication for blood transfusion in NICU in DELSUTH, usually a decision taken by the managing consultant, parents or caregivers are counseled on the need for blood transfusion and the type of transfusion to be done. Once parents verbally consent, the transfusion order is documented with the quantity of blood required, the type of transfusion and the duration of transfusion. Parents are usually advised to donate or get a donor. It is the duty of the laboratory to screen donors, perform grouping and cross matching of patient’s blood and donor’s blood, and collect the blood according to standard procedures or guidelines. While the blood is being transfused to the child usually using a syringe pump, the nurses ensure vital signs are documented every 30 minutes. On completion of the transfusion, the nurses document the transfusion details in a transfusion register.

The frequency of blood transfusion was perceived to be high in the NICU of DELSUTH. Therefore, a study was embarked upon to determine the pattern of blood transfusion in the NICU of DELSUTH over an 18 month period so as to document the frequency, indications, types of neonatal transfusion and the incidents of transfusion reaction.

Methods

The study was a review of neonatal blood transfusion cases in DELSUTH from 1^st January 2020 to 30^th June 2021. The DELSUTH is a tertiary hospital in the oil rich Niger Delta region of Delta State. It serves as a referral centre to the primary and secondary health facilities in Delta state, parts of Edo and Bayelsa State. It’s NICU has a capacity to admit about 20 neonates at a time. The NICU has 3 mechanical ventilators, piped oxygen, 2 radiant warmers, 4 incubators, Arterial Blood Gas analyzer, syringe pumps and infusion pumps. The facility is manned by two neonatologists, 2 senior registrars and 4 junior registrars and 4 nurses.

 Analysis of secondary data obtained from NICU transfusion register and admission register was conducted. Data extracted included hospital number, age, sex, mode of delivery and place of delivery. Other data collected included packed cell volume, indications for blood transfusion, blood groups of neonates, number of transfusions per neonate, types of transfusion, blood and blood products transfused and the transfusion reactions documented during the period under review.

The data were entered into Excel Spreadsheet and analysis was with IBM SPSS Statistics for Windows 7, version 23

There were 178 admissions during the period under review with 100 (56.2%) males, 77 (43.3%) premature neonates and 71 (39.9%) neonates delivered via caesarean section. There were 34 (19.1%) cases of sepsis, 28 (15.7%) of asphyxia, 21 (11.8%) cases of surgical emergencies and 77 (43.3%) of premature neonates with respiratory distress syndrome (RDS) and suspected sepsis. 

Ninety-nine (55. 6%) of the 178 admitted cases required blood transfusion. Of the 99 neonates requiring blood transfusion, 41 (41.4%) were males and 58 (58. 6%) were females. The age range of neonates transfused was 1-32 days with a median age of 6 days; the mean PCV was 31 ± 7% and blood transfusion frequency ranged from 1 -4 sessions with a mean of 1.2 ± 0.6.

Out of the 99 transfused neonates, 23 (23.2) had neonatal jaundice (NNJ), 22 (22.2) had neonatal sepsis, 20 (20.2) had RDS with NNS as shown in table I.

Table I: Clinical Diagnosis of transfused neonates

There were 64 (64.6%) O positive neonates, 17 (17.2%) A positive neonates, 11 (11.1%) B positive neonates and only 3 (3.0%) AB positive neonates as seen in table II. Also, there were only 4 (4.0%) cases of Rhesus negative neonates as seen in table II.

Table II: Blood group of transfused neonates           

There were 58 (58.6%) direct transfusion and 41 (41.4%) exchange blood transfusion (EBT) during the period under review as shown in table III.

Table III: Type of transfusion and indications

Fourteen neonates had multiple transfusion among which 7 (50.0%) were preterm neonates; 4 (28.6%) were neonates with neonatal jaundice (NNJ); 2 (14.3%) were neonates with neonatal sepsis (NNS) and 1 (7.1%) was in a neonate with birth asphyxia. The result shows that multiple transfusion was not significantly associated with preterm neonates.

The prevalence of blood transfusion in the present study was higher than the reported prevalence of 34.9% in Zaria⁴, in the north-western part of Nigeria and 27.9% in Sagamu⁵ in the western part of the country. The high prevalence may be due to the high number of premature infants in the present study which accounted for about 77 (43.3%) of the studied population. Anaemia of prematurity is a major contributor to anaemia in preterm neonates and it is caused by premature birth occurring before placental iron transport and fetal erythropoiesis are complete, by phlebotomy blood losses, by low plasma level of erythropoietin, by rapid growth and need for commensurate red cell volume/mass and by disorders causing red blood cell losses due to bleeding and /or haemolysis.⁶

The major indications for blood transfusion were anaemia, hyperbilirubinaemia and thrombocytopaenia in descending order of importance. Anaemia and hyperbilirubianaemia have been reported by other authors as the main indications for neonatal blood transfusion.^4,5,7 However, 15.0% of neonates were transfused on account of  thrombocytopaenia in the present study. In the study from Sagamu, only 4.4% of neonates had bleeding disorders while in a study in Ogbomosho⁷, bleeding disorder occurred in 3.8% of neonates. It was not stated if these bleeding disorders were due to thrombocytopaenia or from other causes of bleeding; however, bleeding due to thrombocytopaenia was a common finding in premature neonates with sepsis in the present study. Preterm neonates can have thrombocytopaenia from sepsis, placental insufficiency, perinatal asphyxia or congenital infections.⁸

Neonates with hyperbilirubinaemia and thrombocytopaenia were transfused with fresh whole blood, while neonates with anaemia were transfused with sedimented or whole blood. This is because the facility lacked a blood cells separator for separating whole blood into blood products. A similar pattern of blood transfusion has been reported by other authors in Nigeria where whole blood and sedimented blood were given even when other blood products were indicated.^9-11The implication of this practice is that patients are likely to be under-transfused resulting to the need for multiple transfusion, or over-transfused resulting to metabolic complications.

The categories of neonates transfused from the present study showed that premature neonates were the majority of neonates transfused and this has also been reported other authors. ^4,5,8 Also, nearly a quarter of neonates had exchange blood transfusion (EBT) for hyperbilirubinaemia, a proportion which is considered high in modern medicine. Other authors have reported high rates of EBT in neonatal unit of health facilities in Nigeria and have attributed their findings to late presentation of cases and poor phototherapy units.^12,13

Fourteen (14.1%) of neonates from the present study had multiple transfusion and 50% of these multiple transfusion occurred among preterm neonates, though the proportion of preterm neonates who had multiple transfusion was not significantly different from the proportion of term neonates who had multiple transfusion. However, the proportion of neonates that had multiple transfusion in the present study was considerably lower than 29.0% reported in Jos, 56.2% reported in Sagamu and 70.8% reported in Ogbomosho. The wide disparity in the prevalence of multiple transfusion in these studies may be due to different criteria used to determine the need for neonatal blood transfusion. The indications for transfusion in neonates have been well studied; nevertheless, the indications remain somewhat controversial for several reasons. These include: difficulty in determining when a neonate may benefit from transfusion because of the varying haemoglobin levels and types; difficulty in assessing the neonate for clinical indications for transfusion; lack of consensus on definition of significant anaemia symptoms and the possibility that the haemoglobin or haematocrit concentration may not reflect the red blood cell mass in preterm and ill neonates.¹⁴ 

The reason why preterm neonates require multiple transfusions as stated earlier is mainly due to anaemia of prematurity which starts from the 4^th-6^th week of life and resolves between 3-6 months^15,16 Erythropoietin is a recognized therapy in the management of anaemia of prematurity and when effectively used, it reduces the frequency of blood transfusion among preterm neonates. However, due to high cost of this treatment, it is not routinely used in the management of preterm neonates in health facilities in Nigeria.

The commonest ABO Rhesus blood group seen among neonates in the present study was O positive blood group occurring in 64 (64.6%) neonates and this is comparable to 62.6% reported in Calabar in the southern part of Nigeria. The prevalence of Rhesus negativity in the study population was 4.0%, this is also similar to 3.6 % reported in Calabar.¹⁰

No transfusion reaction was recorded during the period under review. This suggest that transfusion reactions are rare in neonates as reported by other authors and this may be due to the immaturity of the immune system of neonates. ^17,18

The prevalence of blood transfusion in the neonatal unit of the DELSUTH was high, nevertheless, no transfusion reaction was recorded. Despite the need for packed red cells and platelets concentrate in the NICU, only whole blood and sedimented blood were transfused. 

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