Red blood cell transfusions were linked to an increased risk of brain injury in very preterm infants, a finding that may also carry implications for conditions like fetal and neonatal alloimmune thrombocytopenia (FNAIT), where transfusions are often part of care and long-term neurologic outcomes are a concern, according to a study published recently in Vox Sanguinis.
In a large retrospective cohort of 12,250 infants born at 32 weeks of gestation or less or weighing under 1500 grams, researchers found that transfusions were independently associated with periventricular leukomalacia, a type of white matter brain injury linked to cerebral palsy and cognitive impairment.
The study included 2,085 infants weighing less than 750 g and 10,165 infants weighing 750 grams or more. Periventricular leukomalacia occurred in 1.8% of infants, while severe retinopathy of prematurity affected 3.6%.
“The current transfusion practice exposes very preterm infants to adult donor erythrocytes that differ fundamentally from neonatal [red blood cells] in size, deformability and hemoglobin composition, resulting in a mismatch between transfused cell properties and the physiological requirements of the immature cerebral microcirculation,” explained the authors of this study.
Read more about causes and risk factors of FNAIT
The risk increased with each transfusion. Among infants weighing less than 750 g, the odds of periventricular leukomalacia rose by 10% per transfusion. In those weighing 750 g or more, the increase was 26% per transfusion. Similar patterns were observed for severe retinopathy of prematurity, though the effect was smaller, with increases of 9% and 15% per transfusion in the two groups.
These findings are particularly important for families dealing with FNAIT, where platelet and sometimes red blood cell transfusions are used to manage bleeding risks in newborns. While transfusions can be lifesaving, this study suggests that repeated exposure to adult donor blood may carry unintended consequences for the developing brain, reinforcing the need to carefully weigh benefits and risks.
Researchers noted that anemia in preterm infants can itself harm the brain by reducing oxygen delivery, and transfusions do improve oxygen levels in the short term. However, adult donor red blood cells differ from newborn cells in size, flexibility and oxygen-binding properties. These differences may disrupt blood flow in the brain’s smallest vessels, potentially contributing to injury over time.
For patients and families, the results do not mean transfusions should be avoided when needed. Instead, they highlight the importance of ongoing research to make transfusions safer. Approaches such as using cord blood products or refining transfusion strategies may help reduce risks. For conditions such as FNAIT, where transfusion decisions are often urgent, these findings underscore the need for continued innovation to protect both survival and long-term neurodevelopment.
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