UMEM Educational Pearls

Category: Pediatrics

Title: Transfusion guidelines

Keywords: transfusion, anemia, hemoglobin (PubMed Search)

Posted: 4/20/2012 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

Children are at higher risk for complications related to the transfusion of blood products compared with adults. So when should we consider transfusion?


Normal hemoglobin values:

- highest at birth (14 - 24 g/dL),

- decreasing to 8 to 14 g/dL at 3 months,

- increasing to 10 to 14 g/dL at age 6 months to 6 years, 11 to 16 g/dL at age 7 to 12 years, and 11.5 to 18 g/dL in adulthood.

- Although the number of platelets are in the normal range at birth, their function is impaired.


For infants younger than 4 months, thresholds for red blood cell transfusions:

- hemoglobin levels are 12 g/dL for preterm infants or term infants born anemic,

- 11 g/dL for chronic oxygen dependency,

- 12 to 14 g/dL for severe pulmonary disease,

- 7 g/dL for late anemia in a stable infant,

- 12 g/dL for acute blood loss exceeding 10% of estimated blood volume.


For infants older than 4 months, thresholds for red blood cell transfusions:

- hemoglobin levels are 7 g/dL in a stable infant,

- 7 to 8 g/dL in a critically unwell infant or child,

- 8 g/dL in an infant or child with perioperative bleeding,

- 9 g/dL in an infant or child with cyanotic congenital heart disease (increased oxygen demand).

- 9 g/dl in children with thalassemia major (to slow bone marrow stimulation)


For children with sickle cell disease (SCD):

- threshold is 7 to 9 g/dL, or more than 9 g/dL if the child has previously had a stroke.

- perioperatively for major surgery: 9 to 11 g/dL, and sickle hemoglobin should be less than 30%, or less than 20% for thoracic or neurosurgery.


Bottom line:

A threshold of 7 g/dL is indicated for the transfusion of packed red blood cells in most children.




1) Transfusion guidelines in children. Anasethesia and Intensive Care Medicine. 2012;13(1);20–23.

2) Medscape clinical education briefs