Editor’s Note: Dr. Eli Cahan (he/him) is the editor emeritus of the Section on Pediatric Trainees (SOPT) feature in Pediatrics and an investigative journalist who covers child welfare. He is also a resident at The Boston Combined Residency Program.
-Rachel Y. Moon, MD, Associate Editor, Digital Media, Pediatrics
Four ounces means different things to different people.
To the parent of an infant, it’s the amount of milk per feed. To a baker, it’s the amount of butter in cookie dough. To a TSA agent, it’s more liquid than is allowable in a carry-on bag. And to an extremely premature infant, it’s their total blood volume—meaning the amount of blood circulating through their entire body.
As healthcare providers, we tend to think about total blood volume only when circumstances are dire: for instance, during severe trauma involving multiple wounds. Given their reduced blood volume reserve, blood loss from daily, routine blood draws can add up quickly for premature infants.
Increasingly, there’s been a movement, especially in pediatrics, to preserve blood—meaning fewer blood draws and fewer transfusions—when possible. The movement is in part due to:
- National blood product shortages that intensified during the pandemic
- More evidence about the neurodevelopmental consequences of pain and distress related to blood draws
- Growing efforts to reduce childhood blood loss to minimize transfusion-related side effects
For neonates, due to higher-still risks of transfusions, including cardiogenic shock due to the impact of too much volume on an immature heart, reducing preventable blood loss has proven a key focus area. For example, delayed cord clamping, which has become standard of care in non-emergency births, has been associated with a 49% reduction in perinatal mortality.
Despite the push for blood preservation, routine blood draws remain common.
In the past decade, blood test ordering volume rose 5% annually, in part because electronic medical records make it easier to order tests. The average pediatric cancer patient has 4 tests sent daily, and tests are frequently reordered daily on patients in the pediatric intensive care unit, even when previous values have been normal. Even though only 5% blood loss creates a risk of adverse events, the average blood draw is around 0.5cc—meaning that, for the extremely premature infant, 3 days of “routine” tests are enough to place them at dangerous levels of blood loss.
This is the context in which Dr. Megha Sharma and colleagues, as described in their article being early released this week in Pediatrics (10.1542/peds.2024-065921), developed a quality improvement initiative to reduce iatrogenic blood loss in premature newborns. The University of Arkansas team undertook a comprehensive package of efforts including:
- Increased provider awareness through education and feedback
- Revised order sets to de-automate blood draws
- Ongoing “blood lost-and-cost” analysis, so staff were aware of the amount of blood loss and costs of each blood test
In total, the authors studied over 350 infants. They observed a 12% reduction in blood loss and almost $300,000 in cost savings—around $1,700 per patient—in the post-implementation group.
It is worth noting that the authors did not study the clinical outcomes of patients in the post-intervention group. “Research is also needed to understand the short- and long-term unintended negative consequences of de-implementation,” the team wrote, “and to develop and test approaches to mitigate or prevent their occurrence.”
Nonetheless, this article represents an important contribution. I encourage you to read the article and view the accompanying video abstract.
