The persistent challenge of perioperative transfusions and the hidden threat of overtransfusion in pediatric surgery

The administration of allogeneic blood products in the perioperative period remains one of the most challenging therapeutic decisions in pediatric surgery. For the acutely bleeding or severely anemic child, red blood cell (RBC) transfusion is a critical, life-saving intervention. However, it is increasingly recognized that allogeneic blood is not a benign therapeutic fluid; it carries intrinsic risks that can significantly alter a child’s clinical outcome. Despite over a decade of guidelines promoting patient blood management (PBM), and guidelines on transfusion for fetuses, neonates and older children, recent epidemiological evidence suggests that the pediatric surgical community still faces significant hurdles in translating these blood conservation strategies into everyday clinical practice (1-4).

The recent landmark retrospective cohort study by Goobie and Faraoni, analyzing data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) pediatric database, casts a much-needed light on this issue. Spanning an 11-year period from 2012 to 2023 and encompassing over 1.3 million pediatric patients undergoing noncardiac surgery, the findings are both illuminating and alarming (5). Strikingly, the overall incidence of perioperative RBC transfusion was 6.3%. Instead of a progressive decline driven by modern PBM initiatives, the data revealed an upward trajectory over the past decade: transfusion rates rose from a low of 4.7% in 2016 to a peak of 7.0% in 2021, remaining elevated at 6.8% in 2023. The burden of transfusion exposure is disproportionately borne by patients at the extremes of age. Neonates experienced the highest exposure rate at 13.3%, while older children and adolescents (≥12 years) had a rate of 9.6%.

The true value of this important analysis lies not in reaffirming an already recognized association, but in prompting the pediatric perioperative community to confront a more difficult question: what exactly does transfusion represent in these patients? Is it a modifiable driver of adverse outcome, or principally a marker of the profoundly vulnerable child? The study demonstrates a significant, independent association between RBC transfusion and 30-day mortality, which stood at 2.4% in the transfused cohort compared to a mere 0.2% in those who did not receive blood. For vulnerable neonates, the mortality rate associated with blood transfusion climbed to a staggering 14.9%. Transfused children across all age groups experienced significantly higher rates of major complications, including cardiac arrest, septic shock, pneumonia, surgical site infections, and prolonged hospital lengths of stay. It remains unsolved if pediatric transfusion exceeds neonatal since the surgical procedure rate increases with pediatric age (Table 1). However, most guidelines recommend more liberal transfusion triggers with decreasing gestational and postnatal age (6). An additional confounder to the higher transfusion rates observed in neonates under 1 month of age can be the distinct physiology of anemia of prematurity. These infants experience a significantly earlier and more pronounced physiological nadir compared to term infants, which independently elevates transfusion exposure. Given that both transfusion thresholds and baseline mortality rates differ markedly in this specific population, further stratified analysis is urgently required to isolate the true impact of iatrogenic blood loss from underlying neonatal vulnerability. Also, the greater relationship of iatrogenic blood loss to intravascular volume requires frequent blood replacement in extremely low birth weight preterm neonates. Therefore, an additional message from this article might be the current lack of data for transfusion practices in age-specific groups.

Crucially, the relationship between transfusion and adverse outcomes is dose-dependent. As demonstrated in Table 1, the risk of critical morbidities and mortality escalates dramatically with higher volumes of transfused blood. Children receiving massive transfusions (≥60 mL/kg) faced more than a five-fold increased risk of 30-day mortality and a nearly five-fold increased risk of postoperative cardiac arrest. In the interpretation of the correlation it needs to be kept in mind that from an observational cohort analysis like this, causality cannot be inferred.

Due to its retrospective, observational design, the study has several limitations, namely the potential for residual confounding despite multivariable adjustment. To fully contextualize the challenge of residual confounding in this context, it is critical to acknowledge that children do not receive blood products randomly. Rather, transfusion therapy frequently occurs in the setting of significant acute hemorrhage, pre-existing anemia, baseline physiological instability, or unexpected intraoperative complications. Because these underlying clinical factors independently and substantially influence postoperative outcomes, they represent a profound source of confounding by indication that can easily mask the true independent relationship between transfusion practices and clinical outcomes.

The regression results suggest that transfused patients represent a high-risk subgroup with severe baseline frailty—marked by American Society of Anesthesiologists (ASA) status, congenital heart disease, preoperative mechanical ventilation/inotropic support, and surgical complexity. While adjustments were made, propensity score matching or causal inference methods could have better isolated transfusion’s independent effects by reducing baseline imbalance.

A critical limitation of the underlying data lies in the management of preoperative anemia. Although median hematocrit values are commented upon, preoperative anemia itself was not formally included as an independent confounder in the main analysis. Given that preoperative anemia is independently associated with both increased transfusion exposure and worse postoperative outcomes in pediatric noncardiac surgery, its omission represents a significant source of residual confounding. Additionally, the reliance on complete-case hematocrit adjustment may not fully capture the true burden of anemia across the broader cohort, underscoring the need for future prospective registries with complete risk-factor capture. Nevertheless, it definitely points to an urgent, ongoing need for the implementation of rigorous, pediatric-specific PBM initiatives. This is particularly critical in the highest transfusion-risk categories identified in the cohort, including neonatal surgery, complex orthopedics, craniofacial reconstruction, and major gastrointestinal surgery, where standardized multi-modal protocols hold the greatest potential to optimize clinical outcomes.

Despite these limitations, the results are nonetheless important, and show that autologous blood transfusion (ABT) is very common and problematic in pediatric patients, especially in view of the wide variation of transfusion practices and outcomes between institutions.

The dose-dependent harm becomes even more alarming when viewed through the lens of a largely unrecognized problem in clinical practice: overtransfusion (OT) (7). Historically, a liberal transfusion approach was often considered a safe default, characterized by an “in doubt, pro blood” attitude. However, recent efforts by the International HIT-OVER Forum emphasize that giving unnecessary blood is an adverse event that directly threatens patient safety. OT is defined as the administration of blood products not covered by guidelines, incorrect component selection, or the provision of inappropriately high doses for a patient’s physiological needs.

The observed outcomes in the Goobie and Faraoni’s study might be attributable to shifts in patient severity/case mix over time. While we acknowledge that confounding factors (e.g., changes in disease severity, clinical practices, or patient demographics) may contribute, studies suggest that OT itself is a significant and independent risk factor for adverse outcomes.

Global literature reviews indicate that the average rate of OT across various patient populations is nearly 47%. In pediatric surgery specifically, an analysis of abdominal procedures revealed an OT rate of 45.3%, frequently identified by postoperative hemoglobin (Hb) levels exceeding 10 g/dL—a clear indicator that a restrictive transfusion threshold was ignored (5,8). While case-mix severity may play a role, the consistent signal across diverse pediatric populations suggests that OT might be a modifiable contributor to poor outcomes. However, unreported intraoperative variables—such as blood loss volume, baseline coagulopathy, transfusion thresholds, and shock management—limit interpretation of associations in pediatric/neonatal surgery. Future prospective studies with granular data on transfusion triggers, patient acuity, and temporal trends would help disentangle these effects.

Contextualizing transfusion decisions and indication is important as the consequences of OT can be severe. Unnecessary blood administration is linked to hypercoagulability, thrombosis, alloimmunization, increased mortality, prolonged hospital stays, and elevated infection rates (9,10). Furthermore, aggressive volume overload through excessive transfusion can lead to transfusion-associated circulatory overload (TACO) and transfusion-associated dyspnea (TAD) (11). However, in the absence of granular, time-resolved data, transfusion may be less the primary driver of postoperative deterioration than a sensitive clinical marker of severe, unmeasured physiological compromise. Prospective trials of restrictive vs. liberal transfusion strategies in critically ill children show that lower transfusion thresholds are safe and can reduce the incidence of OT without increasing adverse events (12-14).

To avoid unnecessary transfusions, the pediatric surgical community must rapidly evolve its approach to hemovigilance. Currently, OT is rarely documented as a transfusion error or adverse event, allowing liberal practices to persist unchecked. The International HIT-OVER Forum strongly recommends standardizing the reporting of OT within hemovigilance systems (see Table 2).

Translational pediatrics is fundamentally about bridging the gap between population-level data and individual patient care. The fact that pediatric blood transfusion rates in North America have trended upward over the last decade indicates that passive knowledge of PBM is insufficient. We must move beyond simply acknowledging the risks of allogeneic blood. It is time to integrate evidence-based PBM protocols into our electronic health records and adopt the HIT-OVER criteria, formally recognizing OT as a reportable adverse event.

Ultimately, advancing pediatric PBM requires a concerted shift toward prospective transfusion research. Future studies must be designed to dynamically integrate real-time patient physiology, hemorrhage severity, precise transfusion timing, and granular blood product exposure. Only by capturing these high-resolution data points can the pediatric perioperative community disentangle confounding factors and precisely define the relationship between specific transfusion practices and clinical outcomes.

The challenge moving forward is not to eliminate transfusion. Rather, it is to better define when transfusion is lifesaving, when it may become excessive, and how clinicians can identify the narrow physiological boundary between the two.

Acknowledgments

Notebooklm was used to produce the Tables 1,2, for text phrasing and optimizing the English language.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Translational Pediatrics. The article has undergone external peer review.

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-0339/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-0339/coif). The authors have no conflicts of interest to declare.

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