Neonatal exchange transfusion in a transitioning healthcare system: a 23-year national trends analysis from Serbia

Neonatal hyperbilirubinemia remains a common neonatal condition. While Rh immunoprophylaxis and phototherapy have dramatically reduced exchange transfusion (ET) use in high-income countries, ET remains essential in selected cases, particularly in transitioning healthcare systems. Comprehensive data from Southeast Europe are limited.

To evaluate 23-year trends in neonatal ET use, indications, and outcomes at a Serbian tertiary referral center.

This retrospective cohort study (2001-2023) included all neonates undergoing ET at the University Clinical Center of Serbia. Data were collected from medical, transfusion, and laboratory records. Primary outcome was ET rate trend; secondary outcomes included indications and complications.

Among 145,702 deliveries, 243 ETs were performed in 206 neonates. ET rates declined significantly from 6.4 to 0 per 1000 deliveries (p < 0.001), mirroring trends observed in high-income countries. Hemolytic disease of the newborn accounted for 67 % of cases, primarily due to anti-D alloimmunization (65.9 %), a profile characteristic of settings with Rh prophylaxis gaps. Non-immune indications included anemia (36.7 %), infections (28.3 %), and other causes (35.0 %). Most procedures were double-volume ET (61.3 %). No ET-related mortality occurred; complications were transient. RhD-negative mothers showed high sensitization rates (82.1 %).

The significant decline in ET rates in Serbia reflects successful perinatal care improvements, yet the persistent burden of anti-D alloimmunization underscores challenges shared with many transitioning health systems. Strengthening Rh immunoprophylaxis programs and expanding access to bilirubin monitoring are essential public health strategies to further reduce ET need in similar healthcare settings worldwide.