Neonatal transfusion practice: undesired variation or personalised medicine?

In their article, ‘Red blood cell transfusions in neonatal intensive care units: a nationwide observational cohort study’, authors Heeger et al highlight the critical topic of variation in neonatal red blood cell (RBC) transfusion practices and adherence to guidelines.

Heeger and colleagues demonstrate that despite introducing a national RBC transfusion guideline in the Netherlands in 2019, 46.5% of transfusions for neonates <32 weeks gestation occurred above the recommended thresholds at that time. They found significant variation among neonatal intensive care units, with transfusions above thresholds ranging from 15% to 71% and increasing with postnatal age, with most transfusions above recommended thresholds occurring after the third postnatal week. When the authors adjusted for case-mix using sample weights, including gestational age, variation in transfusion rates between centres persisted. Introducing a guideline alone does not mean it will be strictly adhered to, and this study nicely characterises practices in relation to national guidance. In this commentary, we discuss potential reasons for the study findings within the context of guidelines and clinical variation.