Pediatric MHP: Moving away from Cryoprecipitate at The SickKids Hospital

Dr. Caroline Malcolmson outlines how The Hospital for Sick Children has redesigned its pediatric Massive Hemorrhage Protocol (MHP) to reflect the unique physiology, risk profile, and evidence gaps in children. She highlights that pediatric MHPs are rare but carry very high mortality, occur largely outside trauma settings, and require judgment-based activation due to age-dependent blood volumes, misleading hemodynamic stability, developmental hemostasis, and lower thrombin generation. In response, SickKids adopted flexible decision aids rather than rigid criteria, limited escalation through pack-based transfusion, and progressively shifted toward goal-directed, data-driven therapy. Influenced by adult evidence and the FIBRES trial, the center has moved almost entirely away from cryoprecipitate in favor of fibrinogen concentrate due to standardized dosing, rapid availability, and pathogen reduction, with minimal remaining cryoprecipitate use largely confined to the NICU.

With this, Dr. Malcolmson makes a case that evidence reaches patients fastest when it is designed into protocols clinicians can actually use under pressure.