Trial Finds No Benefit to Higher Red Cell Transfusions in Preterm Infants

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Neonatology Update

A trial led by our team found that a higher hemoglobin threshold for red blood cell transfusions in anemic, extremely-low-birth-weight newborns does not improve survival or reduce neurodevelopmental impairment by age 2. The study, which is the largest on this topic to date, was recently published in the New England Journal of Medicine.

For the randomized controlled trial, we analyzed 1 824 infants between 22 and 29 weeks of age who weighed less than 1 000 grams at birth. The infants were randomly assigned to 1 of 2 groups:

  • A group that would receive higher red blood cell transfusions
  • A group that would receive lower red blood cell transfusions

We followed both groups until they were about 2 years old and monitored for death or neurodevelopmental impairment, such as cognitive delay, cerebral palsy, and hearing or vision loss.

In comparing the 2 groups, we found no statistically significant difference in outcomes. The higher and lower hemoglobin threshold groups had similar rates of death, neurodevelopmental impairments, and serious adverse events.

The results of this trial support the notion that we can use less blood when transfusing very low-birth-weight babies. Given the potential hazards associated with blood transfusions in an already vulnerable population, these data support the notion that less is more, and we should not be transfusing infants unnecessarily. This also shows how therapies commonly thought of as “standard care” may require further testing to assess their true value.


Kirpalani H, Bell EF, Hintz SR, Tan S, Schmidt B, Chaudhary AS, Johnson KJ, Crawford MM, Newman JE, Vohr BR, Carlo WA, D’Angio CT, Kennedy KA, Ohls RK, Poindexter BB, Schibler K, Whyte RK, Widness JA, Zupancic JAF, Wyckoff MH, Truog WE, Walsh MC, Chock VY, Laptook

AR, Sokol GM, Yoder BA, Patel RM, Cotten CM, Carmen MF, Devaskar U, Chawla S, Seabrook R, Higgins RD, Das A; Eunice Kennedy Shriver NICHD Neonatal Research Network. Higher or lower hemoglobin transfusion thresholds for preterm infants. N Engl J Med. 2020;383(27):2639-2651.

Contributed by: Haresh M. Kirpalani, MD, Professor Emeritus of Neonatology