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I'm the supervisor at a children's hospital in Central California and here are our indications for the transfusion of RBCs: Neonates: Term and near term neonates and infants < 4 months of age* Hgb/Hct < 7g/dl / 21% Stable anemia with no clinical manifestations Hgb/Hct < 10 g/dl / 30% Moderate cardiopulmonary disease Major surgery Increased oxygen (FiO2) requirement <35%, on CPAP lower setting Significant apnea or bradycardia, tachycardia or tachypnea Low weight gain Hgb/Hct <12 g/dl / 35% Fi02 requirement greater than 35%, on CPAP higher setting Recovering from major surgery Severe traumatic brain injury Significant deterioration of cardiorespiratory status Hgb/Hct < 15 g/dl / 45% FiO2 requirement > 35% Severe cardiopulmonary disease or congenital heart disease On extracorporeal membrane oxygenation (ECMO) *No clear transfusion RBC threshold guideline for low birth weight neonates (BW <1500gm) is available. Randomized clinical trial (Transfusion of Prematures) was started in 2013 and is ongoing. Pediatric patients >4 months old through adult Not bleeding Reasonable in almost all patients if Hgb/Hct < 7 g/dl / 21% Almost never indicated if Hgb/Hct >10 g/dl / 30% unless patient is on ECLS For Hgb between 7-10 g/dl (Hct between 21-30 %): Based on organ dysfunction and ability to handle inadequate oxygenation Respiratory or cardiac failure Chronic disorders of red cell production, severe platelet dysfunction Oncology patients Intra/perioperative conditions or significant bleeding Rapid blood loss exceeding >15% blood volume Intraoperative period as clinically determined by anesthesiology and/or surgeon Immediate postoperative period to restore hemodynamic stability We have built an alert in Epic with our "Prepare RBC" orders (both in mL and in Units) that warns the provider whenever they are placing an RBC order on a patient with a most recent Hgb value > 7 g/dl (or there is no recent Hgb value in the computer on that patient). This alert must be overridden with a reason from this drop down menu (below) in order for the provider to continue placing the order. We can run a report on all transfusions that triggered an Override when the order was placed (that also lists out the trigger value, the override reason, and the patient's problem list) and then the medical director performs an appropriateness review on only those outliers. BPA Overrides: RBC Orders (in mL) and (in Units): Warning if: No Hgb result or Most recent Hgb > 7 g/dl Appropriate criteria: Neonate w/Cardiopulmonary Disease Respiratory or Cardiac Failure ECLS Patient Sickle Cell Patient Thalassemia Patient Active Chemotherapy/Immunosuppressed Patient Hematopoietic Disorder Rapid Blood Loss HOLD for Pre-Op/Procedure Post-Op Hemodynamic Instability Other – specify as Comment

Until there is a definitive answer, it MUST be D Negative, even though the chances are that, at that stage of life, the baby's immune system would not produce an anti-D if D Positive blood was transfused, BUT it could well be that the baby's immune system could be sensitised to the D antigen. ALWAYS ERR ON THE SAFE SIDE.