Pattern of Blood Transfusion in the Special Care Baby Unit of Benue State University Teaching Hospital in Makurdi North-Central Nigeria

ABSTRACT


INTRODUCTION
lood transfusion is a lifesaving procedure in which whole blood or parts of blood are introduced into a patient's bloodstream intravenously.¹ It is an \10 Ochoga et al., Pattern of Blood Transfusion in the Special Care Baby Unit for patients over 60 years of age, however in low income countries, up to 54% of transfusions are for children under the age of 5-years.² The need for blood transfusion in neonates may occur due to physiological 3 or pathological causes. Globally a cohort study undertaken in a neonatal intensive care unit reported a 4 5 transfusion rate of 13.4%. In Nigeria Pam S et al from Jos north-central Nigeria reported a prevalence of 16.7% as compared to 27.9% by Ogunlesi TA from 6 South west Nigeria. There is an enormous need for blood transfusion in the newborn particularly due to the reduced marrow 7 activity in the new born period. Moreover preterm infants require transfusions for several reasons such as lower hemoglobin levels at birth, low levels of erythropoietin in addition to a hyporegenerative bone 8 marrow with attendant anaemia of prematurity. Repeated blood sampling of infants requiring frequent monitoring is another common cause of anemia among 9 hospitalized infants. The major causes of neonatal morbidity and mortality that require hospital admission such as prematurity, neonatal infections and neonatal jaundice require blood transfusion in their management with either top up transfusions or in form of exchange blood transfusion leading to the high rates of transfusions among 10 newborns. Despite several efforts there still remains some controversy about the threshold for transfusion in newborns and the lack of a well developed transfusion service. The rate of blood transfusion is still very high among neonates in Nigeria with the major indications being severe anaemia, anaemia of prematurity, neonatal 3 jaundice, neonatal sepsis, bleeding disorders. Since blood transfusion is associated with potential risks and adverse effects, it is therefore pertinent to ensure that it is given only when it is indicated. Despite significant improvement brought to blood testing and handling, there remain both infectious and non-infectious risks 11 associated with allogenic blood transfusions. While there are reports of the pattern of blood transfusion in other centres, there is a paucity of local data on the patterns of blood transfusion in our locality. A total of 1142 neonates were admitted over the study period. Of these 126 (11.0%) were transfused with one blood product or the other. Table 1 shows the sociodemographic characteristics of mothers. The mean age of mothers was 27.33±4.55 years. The majority (40.5%) of mothers were aged 23-27 years. The mean gestational age was 35.48±3.95 weeks. Over half (52.4%) of mothers delivered at a gestational age between 36-40 weeks. The majority (81.7%) of the mothers had a singleton delivery. A greater percentage (79.4%) of the mothers had vaginal delivery. As shown in table 2, the median age of the neonates was 3.0 days at admission. The majority of the neonates were aged 1-5 days. Nearly two-third (61.1%) of the babies were males, while 38.9% were females with a male to female ratio of 1.57:1.The mean weight of the neonates was 2.23±0.82 kg. Above half of the babies (55.6%) were low birth weights. The majority of the neonates (46.9%) had blood group O+, followed by (30.6%) blood group B.   (Table 4). As shown in Table 5,majority of the neonates (88.9%) were discharged, while 7.9% discharged against medical advice (DAMA) and 4% died. About half of the neonates (42.9%) had 1-10 day's duration of hospital stay. Table 6 showed the association of age, gestational age, birth weight and duration of hospital stay. There was no statistically significant association between all the variables and the outcome variables.

DISCUSSION
This study showed that most transfusions in our SCBU involved the use of sedimented red blood cells and whole blood as we lack facilities to administer other blood products. The commonest indication for transfusion was severe neonatal jaundice. This is 5,6,12,13 similar to the experience of some other centres. The prevalence of blood transfusion was 11.0% in the present study and similar to 11.7% reported by Joel- 12 Medewase VI et al in Southwest Nigeria. However a higher prevalence of blood transfusion was reported by 5 Pam et al from Jos North central Nigeria 16.5%, Ayede 13 6 et al 27.9% and Ogunlesi et al 30.8% both from South Western Nigeria. The reason for the high prevalence in the other study sites could be because they have a comparatively larger population of subjects (e.g preterms) who often require transfusion.
14 However Jalo et al in North Eastern Nigeria reported a prevalence of 3.5%, which is lower than the finding in our centre. Their finding could be attributable to a lower proportion of neonates susceptible to transfusion in their study. Our study has demonstrated that Preterms still constitute a significant proportion of the transfused neonates, therefore there is need to promote programmes and policies that prevent prematurity. From the present study, males were more frequently transfused with blood when compared with the females. Similar patterns were reported from other 6,12,15. centres within Nigeria.
However there is no readily available explanation for this male preponderance. In the present study low birth weight (55.6%) and preterm (42.9%) neonates were frequently transfused and this is similar to patterns reported by earlier  5,6,13,16,17 researchers.
Moreover preterm infants require transfusions for several reasons such as lower haemoglobin levels at birth, low levels of erythropoietin in addition to a hyporegenerative bone marrow with attendant anaemia of prematurity. Repeated blood sampling of infants requiring frequent monitoring is another common cause of anaemia 9 among hospitalized infants. The indications for transfusion in the present study were anaemia of prematurity, sepsis and severe neonatal jaundice (NNJ) which are reflections of the 10,18 national neonatal burden.
Jaundice and anaemia were the commonest indication for blood transfusion 12 similar to that reported by Joel-Medewase VI et al bulk of exchange blood transfusions(EBTs). This is to say that NNJ contributes significantly to the requirements of blood transfusion in the neonatal period. Some of the babies who had EBT in the present study had anaemia requiring a top up transfusion. This maybe as a result of ongoing hemolysis from the primary cause of jaundice such as blood group incompatibilities. Other causes such as bacterial infection resulting from umbilical cannulation and poor mixing of blood used for the procedure may cause sedimentation of cells leading to anaemia. Apart from adequate mixing of blood during EBT, there is little that can be done to stop post-EBT anaemia, especially when there is on going hemolysis. More than half of the babies in our study had several transfusions ,unlike 5 29% reported from Jos, Nigeria. The outcome in the present study was good as 88.9% of the neonates were discharged.
The transfusion rate in our SCBU was low when compared to most of the studies. The major indications for transfusion were anaemia and severe hyperbilirubinaemia. EBT was the main type of CONCLUSION transfusion among the neonates in this study. There is need to promote measures that prevent indications for EBT and employ other less problematic modalities for treatment of severe hyperbilirubinemia e.g intensive phototherapy and the use of tin protoporphrin.We Suggest preventive measures against development of conditions that lead to need for transfusion. These includes adequate ANC, prevention of neonatal sepsis, developing capacities of SCBU staff to be able to provide non transfusion therapy where indicated, and implementation of National Newborn Care Policies

Limitation
The retrospective nature of this study limited the exploration of other factors (e. g parental/socio cultural perception about blood transfusion) associated with neonatal blood transfusion. The present study has identified risk factors for neonatal blood transfusion in our practice and the need to obviate them. The study underscores the need to implement measures against the incidence of prematurity and neonatal jaundice in our environment of practice.