Evidence-based advances in transfusion practice in neonatal intensive care units.

BACKGROUND Transfusions to neonates convey both benefits and risks, and evidence is needed to guide wise use. Such evidence is accumulating, but more information is needed to generate sound evidence-based practices. OBJECTIVE We sought to analyze published information on nine aspects of transfusion practice in neonatal intensive care units. METHODS We assigned 'categories of evidence' and 'recommendations' using the format of the United States Preventive Services Task Force of the Agency for Healthcare Research and Quality. RESULTS The nine practices studied were: (1) delayed clamping or milking of the umbilical cord at preterm delivery - recommended, high/substantial A; (2) drawing the initial blood tests from cord/placental blood from very low birth weight (VLBW, <1,500 g) infants at delivery - recommended, moderate/moderate B; (3) limiting phlebotomy losses of VLBW infants - recommended, moderate/substantial B; (4) selected use of erythropoiesis-stimulating agents to prevent transfusions - recommended, moderate/moderate-moderate/small B, C; (5) using platelet mass, rather than platelet count, in platelet transfusion decisions - recommended, moderate/small C; (6) permitting the platelet count to fall to <20,000/µl in 'stable' neonates before transfusing platelets - recommended, low/small I; (8) permitting the platelet count to fall to <50,000/µl in 'unstable' neonates before transfusing platelets - recommended, moderate/small C, and (9) not performing routine coagulation test screening on every VLBW infant - recommended, moderate/small C. CONCLUSIONS We view these recommendations as dynamic, to be revised as additional evidence becomes available. We predict this list will expand as new studies provide more information to guide best transfusion practices.