Management of massive bleeding in newborns relies largely on data from older patients, with limited evidence specific to this population to guide care, according to a narrative review recently published in Transfusion.
A multicenter study cited in the review reported that 25% of neonates admitted to intensive care experienced bleeding, with 11% classified as major or severe.
Massive bleeding in newborns is typically defined as the need for large-volume transfusion relative to body weight and can result from a range of causes, including placental complications, surgical procedures, birth-related trauma and conditions such as fetal and neonatal alloimmune thrombocytopenia (FNAIT). Early recognition can be challenging, particularly when blood loss is not immediately visible.
Most guidelines for newborns are based on recommendations developed for older children and adults, which can lead to differences in care between institutions.
Newborns respond differently to blood loss than older patients, meaning adult-based guidelines may not be appropriate. Their lower blood volume and immature coagulation systems increase the risk of rapid deterioration.
Learn more about FNAIT testing and diagnosis
During severe bleeding, problems with clotting can worsen due to low body temperature, acid buildup, and dilution of clotting factors. A drop of just one degree in body temperature can reduce the blood’s ability to clot by about 10%, making temperature control an important part of management.
While studies in stable preterm infants suggest fewer red blood cell transfusions may be safe, it is unclear if this approach applies during severe bleeding. The optimal timing for platelet or fibrinogen transfusions in newborns with active bleeding also remains unclear.
“Much remains unknown about the management of massive transfusion in newborns,” the authors noted.
Emerging tools such as viscoelastic testing may help guide transfusion decisions by providing rapid, real-time assessment of clot formation and breakdown. However, standardized reference ranges for neonates are still lacking.
The authors emphasize that early use of massive transfusion protocols and coordinated care are critical, even with limited evidence, and that more research is needed to improve transfusion strategies in newborns with life-threatening bleeding, including conditions such as fetal and neonatal alloimmune thrombocytopenia (FNAIT).
Sign up here to get the latest news, perspectives and information about FNAIT sent directly to your inbox. Registration is free and only takes a minute.
