Transfusion therapy has an important role for pediatric cancer patients. A multicenter retrospective study of 4766 children with cancer demonstrated that 39.3% of the patients were given a transfusion. Red blood cells (RBCs) and platelets were the most commonly transfused components. Patients between 1 to <6 years of age were most likely to be transfused and HSCT, acute myeloid leukemia, and aplastic anemia were most often associated with transfusion.
Anemia occurs due to the suppression or dysfunction of erythropoiesis secondary to the underlying disease, as well as a consequence of bleeding in children with cancer. National audits of pediatric RBC transfusions in the United Kingdom have reported that more than half of pediatric transfusions were given to hematology/oncology patients. The balance between the tolerance to anemia and the need for transfusion may be different from other patients, because of underlying disease, the presence of comorbidities that influence the tolerance to anemia, and complications of multiple previous transfusions. In children with cancer undergoing hematopoietic stem cell transplantation (HSCT) who are at risk for critical illness and hemodynamically stable, suggested Hb value is 7 to 8 g/dL for the threshold of RBC transfusion. RBC transfusions are usually dosed as 10 to 15 mL/kg. However,the decision to transfuse should not be driven by the hemoglobin concentration, the patient's clinical status should also be taken into consideration. Leukoreduction is one of the most common modifications to cellular blood components with universal leukoreduction being accepted increasingly as a standard. Cellular blood components including viable lymphocytes should also need to be irradiated in children with cancer. The gamma irradiation prevents T-lymphocytes from proliferating and reduces the risk of transfusion-associated graft-versus-host disease (TA-GVHD), in patients with significant immunosuppression due to chemotherapy (eg. purine analogs), immunomodulators, radiation, or HSCT patients.
Thrombocytopenia can occur in nearly all children with cancer during their disease course as a result of bone marrow infiltration, chemotherapy, or associated illness, such as sepsis or disseminated intravascular coagulopathy. Platelet transfusions are prescribed to prevent or treat bleeding (referred to as prophylactic or therapeutic transfusions, respectively). In critically ill children with an underlying oncologic diagnosis, 71% of the platelet transfusions were given prophylactically. American Society of Clinical Oncology recommmends for a prophylactic platelet transfusion threshold of 10 × 109/L. However, a scarce data exists to platelet transfusion therapy in pediatric cancer patients with clinically relevant bleeding, fever, hyperleukocytosis, infection, or receiving anticoagulation. Dosing recommendation is 10 to 15 mL/kg of ideal body weight. Leucoreduction and irradiation are also recommended for platelet transfusions in pediatric cancer patients.
Fresh Frozen Plasma (FFP) is transfused to correct multiple coagulation factor deficiencies in patients with active bleeding (therapeutic transfusions) or to prevent bleeding before invasive procedures (prophylactic transfusions). Dosing recommendation is 10 to 20 mL/kg. Patients with cancer may be at risk for abnormalities of hemostasis due to tumor pathology (eg. AML M3) and evolution of the disease as well as treatment effect. Besides, FFP transfusion has significant risk that should be weighed against its perceived benefit.
