ENDOGENOUS CLEARANCE RATE AND SYNTHESIS OF ALPHAFOETOPROTEIN DURING AND AFTER BLOOD EXCHANGE TRANSFUSION IN HYPERBILIRUBINAEMIC NEWBORNS

Abstract. Teppo, A.-M. and Simell, O. (Department of Paediatrics, University of Helsinki, Helsinki, Finland). Endogenous clearance rate and synthesis of alphafoetoprotein during and after blood exchange transfusion in hyperbilirubinaemic newborns. Acta Paediatr Scand, 69: 491, 1980. —Plasma alphafoetoprotein (AFP) concentration was monitored in 22 hyperbilirubinaemic infants during blood exchange transfusion at the age of 0–4 days, in order to determine the endogenous clearance rate and demonstrate possible postnatal synthesis of AFP. The rapid fall in plasma AFP during the transfusion to 19±4% (mean ±1 S.D.) was followed by an increase to 81±15% of the initial concentration; only a 68% rise was expected after the establishment of a new equilibrium between the intra- and extravascular pools of AFP. Repeated transfusions in the same individuals gave similar findings. In two infants the total amount of AFP in these pools increased by 4.0–7.4 mg after the transfusions. The results could be accounted for by postnatal AFP synthesis. Because of the diffusion of AFP from the extravascular compartment to the intravascular pool the actual turnover rate of AFP could not be measured. The estimated magnitude of endogenous turnover rate of AFP, 0.02–0.09 min^-1, gave a mean half-life of about 20 min, which is distinctly shorter than that of AFP in plasma (3–5 days); this could be due to either continuous synthesis of AFP or transfer of presynthesized AFP from the liver cells to extracellular pool. We postulate that either the synthesis or the turnover rate of AFP is controlled by the plasma AFP concentration via a negative feedback mechanism.     

BLOOD TRANSFUSION: A POSSIBLE RISK FACTOR IN RETROLENTAL FIBROPLASIA

ABSTRACT. Clark, C, Gibbs, J. A. H., Maniello, R., Outerbridge, E. W., and Aranda, J. V. (Department of Newborn Medicine, McGill University, Montreal Children's Hospital Research Institute, Montreal, Quebec, Canada). Blood transfusion: A possible risk factor in retrolental Fibroplasia. Acta Paediatr Scand, 70:535,.–The effect of blood transfusion on the occurrence of RLF was evaluated in 58 infants who weighed less than 1 001 g at birth (Group I) and 70 oxygen treated infants of various birth weights (Group 11). Although there was no significant difference between Group 1 infants with or without exchange transfusion as to birth weight, gestational age, duration of oxygen therapy, peak Po₂'s, or multiple births, there was a significantly increased incidence of pre-retrolental fibroplasia in transfused over non-transfused Group II infants. When Group II infants were stratified for prematurity and oxygen duration, this difference persisted in those not already at risk for RLF. This increased incidence of retinopathy in transfused infants suggests that blood transfusion may be a risk factor in the pathogenesis of RLF.     

DEFIBRINATION SYNDROME IN A NEWBORN, AND ITS TREATMENT WITH EXCHANGE TRANSFUSION

A male infant was born asphyxiated, but after few minutes of artificial respiration, spontaneous breathing was established. During the next few hours he developed a severe bleeding tendency with signs of intracranial hemorrhage. In the palms of the hands and soles of the feet there were symmetrical large ecchymoses with a sharp border to normal skin. Coagulation studies showed the characteristics of a defibrination syndrome. He was treated with one exchange transfusion of heparinised blood, and corticosteroids for one week. After the exchange transfusion a rapid and marked improvement was noted. He was followed up during his first year of life, and the development has been quite normal. No permanent disabilities have been found. It is possible that asphyxia was the trigger mechanism for the defibrination syndrome in this case. Early recognition of the acute defibrination syndrome and immediate start of therapy may be lifesaving.     

PLACENTAL TRANSFUSION IN INFANTS OF DIABETIC MOTHERS ELUCIDATED BY PLACENTAL RESIDUAL BLOOD VOLUME

The influence of the method of delivery and the clamping technique on the placental transfusion is investigated by measurement of the placental residual blood volume in 58 infants of diabetic mothers and in 65 infants of nondiabetic mothers. It is shown that infants of diabetic mothers delivered vaginally compared with infants of diabetic mothers delivered by caesarean section, have a larger placental residual blood volume, if early clamping is employed. This relation suggests that also in infants of diabetic mothers, a temporary deposition of the distribution of the foeto-placental blood volume between the infant and the placenta occurs during vaginal delivery, because of the impaired venous backflow to the infant. The difference in the placental residual blood volume is more pronounced for infants of diabetic mothers than for infants of non-diabetic mothers. Further, it is shown that the placental residual blood volume is significant larger in infants of diabetic mothers but only after vaginal delivery with early clamping, compared with the same group of infants of non-diabetic mothers.     

ARTERIALIZATION OF CAPILLARY BLOOD: HISTAMINE IONTOPHORESIS IN ENDOTOXIN SHOCK

Values of pO₂ obtained from capillary blood by histamine iontophoresis were compared with arterial values both before and after the induction of endotoxin shock in the experimental animal. Capillary blood pO₂ levels were found to compare favourably with arterial blood levels in both circumstances. It is suggested that arterialisation of capillary blood by histamine iontophoresis could be used to determine pO₂ levels in the acutely ill child when arterial blood is not readily available.     

THE ACID-BASE AND ELECTROLYTE PATTERN IN THE ERYTHROBLASTOTIC INFANT AND ITS RELATIONSHIP TO VARIOUS PARAMETERS DURING EXCHANGE TRANSFUSION

The effect of exchange transfusion in the electrolyte and acid-base balance has been studied in 37 newborn infants undergoing the procedure because of hyperbilirubinemia. Particular interest was focused on possible relationships between induced changes and various pertinent parameters such as infant and donor blood characteristics and rate and volume of the exchange. A statistically highly significant decrease in pH and plasma bicarbonate was noted together with a decrease of the potassium level. Changes in other electrolytes were inconsistent. There was a highly significant correlation between rate of exchange and acid-base disturbance as well as between induced potassium decrease and the total volume of the procedure. There was no demonstrable increase of the susceptibility to induced changes among the low-weight infants. A recovery period of 20 minutes was usually sufficient to allow for the control of the metabolic derangement and in some instances an alkalotic overshoot was encountered as related to the preoperative control value. The potassium level continued to fall during the recovery period. The technical aspects of the procedure are discussed against the reported findings.     

TREATMENT OF SEPTICAEMIA IN THE NEWBORN INFANT: CHOICE OF INITIAL ANTIMICROBIAL DRUGS AND THE ROLE OF EXCHANGE TRANSFUSION1

Abstract. The therapeutic success of antibiotics used at the beginning of treatment and the effect of exchange transfusion in cases of septicaemia were tested in 22 newborn infants. The clinical course of these patients was compared with the outcome of 11 newborn infants who received antibiotic treatment without exchange transfusion. The following results were obtained: 1) All 6 patients initially receiving antibiotics, which were ineffective in vitro, died. In this group of patients the incidence of septic organ involvements (meningitis, ventriculitis, peritonitis) was significantly increased, 2) Following exchange transfusion, an impressive clinical improvement was consistently observed. 3) In patients who had initially received effective antibiotics and exchange transfusion, the lethality was significantly lower than in patients without exchange transfusion. 4) Our bacteriological findings show that continuous monitoring of cultures from blood, CSF and stool is necessary to choose the most effective antibiotic in the prevailing nosocomical circumstances.     

ADRENOCORTICOTROPHIN AND GLUCOCORTICOID RESPONSE TO EXCHANGE TRANSFUSION

Abstract. Plasma adrenocorticotrophin (ACTH) and glucocorticoid concentrations were measured during and for 3 hours after exchange transfusion in four groups of infants. Transfusions with ACD blood via the umbilical artery were performed on 10 infants of 35–40 weeks gestation and 11 infants of 27 to 33 weeks gestation. Ten transfusions via the umbilical vein were performed with ACD blood and 9 with heparin blood on infants of 32 to 41 weeks gestation. In all four types of transfusion there was a significant washing out of ACTH and glucocorticoids from the baby. An associated rise of plasma ACTH and glucocorticoid levels indicated increased secretion in the larger infants transfused with ACD blood via the umbilical artery. Equivocal results were obtained in the other groups. After all types of transfusion plasma glucocorticoid levels remained relatively constant for one hour and then doubled in the second and third hour. The results suggest that ( a ) exchange transfusion via the umbilical artery is more stressful than that via the umbilical vein, ( b ) the glucocorticoid response of premature infants to exchange transfusion is similar to that of mature infants, ( c ) an unspecified stimulus, which is not solely hypoglycaemia nor the metabolic reaction to a citrate load, results in a rise in plasma glucocorticoid levels 2–3 hours after all types of transfusion.     

EFFECT OF PHOTOTHERAPY AND EXCHANGE TRANSFUSION ON PRIMARY BILE ACIDS IN THE SERUM OF HYPERBILIRUBINAEMIC NEWBORNS

ABSTRACT. Serum primary bile acid (cholic (CA) and chenodeoxycholic (CDCA) acid) concentrations were measured in 14 preterm and 11 full-term hyperbilirubinaemic newborns at the beginning and end of, and 24 and 72 hours following phototherapy. Only in the preterm newborns with gestational ages of 35-38 weeks there was a significant decrease of mean serum bile acid concentrations which could be shown 72 hours after the beginning of phototherapy. It can be hypothesized that the decrease was a result of a direct effect of light on the excretory liver function. Serum CA and CDCA concentrations were also measured in 5 hyperbilirubinaemic newborns at the beginning and end, and 24, 48 and 72 hours after the end of exchange transfusion. Exchange transfusion caused a clear immediate decrease in the mean serum primary bile acid concentrations. However, on day 2 after exchange transfusion the mean serum concentration of CA was about 150% and that of CDCA about 110% of the initial values. The most hyperbilirubinaemic newborns had extremely high primary bile acid serum concentrations before therapy. As bile acids compete with bilirubin for albumin binding it should be considered whether high bile acids in the serum of hyperbilirubinaemic newborns presuppose exchange transfusions.     

A DOUBLE BLIND STUDY OF THE EFFECT OF PHENOBARBITONE ON NEONATAL HYPERBILIRUBINAEMIA AND FREQUENCY OF EXCHANGE TRANSFUSION

In a double blind study the effect of phenobarbitone on neonatal hyperbilirubinaemia and the frequency of exchange transfusion was investigated. Newborn infants admitted were randomly assigned to one of two groups. The treated group comprised 56 and the control group 60 infants. Either placebo solution or phenobarbitone was injected i.m. at 8 hourly intervals for a total of 10 injections. The single dose varied between 1 mg and 5 mg according to weight. One exchange transfusion had to be performed in the treated and 11 in the control group. This difference is statistically significant. Serumbilirubin concentrations from the 4th day on were significantly lower in the treated infants than in controls.     

SINGLE INJECTION POLYFRUCTOSAN CLEARANCE IN NORMAL and ASPHYXIATED NEONATES

Abstract. Svenningsen, N. VV. (Department of Paediatrics, University Hospital, Lund, Sweden). Single injection polyfructosan clearance in normal and asphyxiated neonates. Acta Paediatr Scand, 64:87, 1975.–The postnatal development of the glomerular filtration rate in 36 neonates has been evaluated by the single injection polyfructosan clearance method (GFR_pfr) by studies performed at 0–1, 2–4 and 5–7 weeks of postnatal age. During the first weeks of life there is a rapid postnatal increase of GFR_pfr of almost the same magnitude in term and preterm healthy infants. Thus the postnatal development of glomerular filtration rate is more closely related to extra-uterine excretory needs than to the maturatinal stage and gestational age at birth. In the asphyxiated neonates studied the GFR_pfr was significantly lowered in the immediate postasphyxial stage while the infants were still hypoxemic. However the postnatal rise of GFR_Pfr in the time period following the postasphyxial stage was of the same order as in the non-asphyxiated healthy neonates.     

THE INFLUENCE OF THE PLACENTAL TRANSFUSION ON THE CAPILLARY BLOOD GAS AND ACID-BASE BALANCE IN THE NEWBORN INFANT

Of 77 normal newborns, 42 were clamped early while 35 were clamped late. Using capillary blood from an unwarmed heel, the hema-tocrit and the acid-base balance of the two groups were compared. During the first day of life the hematocrit of late-clamped newborns was fairly constant and higher than that of early-clamped babies, the latter showing a definite fall 2–24 hours after birth. Regarding the acid-base balance, no difference was found between the two groups of newborns except when measurements were performed 3–5 hours after birth. At this time actual pH and standard bicarbonate were lower in late-clamped babies than in early-clamped, while P_CO2 was identical. On the basis of the hematocrit findings it is proposed that the placental transfusion, by creating oedema of the interstitial space, may contribute to the well known discrepancy between the acid-base status of the capillary and the arterial blood of the newborn.     

PERINATAL ACIDOSIS AND PLACENTAL TRANSFUSION1

Umbilical artery pH and residual placental blood volume (RPBV) were determined for 75 full-term newborn infants born by vaginal delivery. For 39 infants of multiparous mothers (IMM), there was a significant relationship between fetal acidosis and reduced RPBV. For 36 infants of primiparous mothers (IPM) a significant relationship was not present. Results of an earlier study suggested that perinatal acidosis was associated with reduced RPBV. The present study confirms this association for IMM's. The reason for the lack of a clearcut effect in IPMs is unknown.     

ELEVATED EXHALED CARBON MONOXIDE CONCENTRATION IN HEMOGLOBINOPATHIES AND ITS RELATION TO RED BLOOD CELL TRANSFUSION THERAPY

In this study, the authors examined a possible role of measurements of end-tidal carbon monoxide (CO), corrected for inhaled CO (ETCOc), as a noninvasive screening tool for hemoglobinopathies and as an indicator for when transfusions would be required in patients receiving chronic transfusions. ETCOc measurements were obtained in subjects with sickle cell disease (n = 18), thalassemia (n = 21), and healthy controls (n = 62). ETCOc values less than 3 parts per million (ppm) yielded a positive predictive value of 93% and negative predictive value of 94% in identifying hemoglobinopathies. Subsequently, 7 subjects with thalassemia had laboratory parameters and ETCOc measured over 2 transfusion cycles. ETCOc values were 4.90 ± 0.32 ppm (mean ± SD), with 89% of values being above normal (≥3 ppm). Pretransfusion ETCOc levels significantly correlated with pretransfusion reticulocyte count (r = .96, P <.001), but not with pretransfusion hemoglobin (r = .44, P = .16) or pretransfusion soluble transferrin receptors (sTfR, r = .52, P = .10). In conclusion, we found that patients with hemoglobinopathies have ETCOc values above the range for healthy controls and ETCOc measurements can be used as an adjunct to hemoglobin measurements to determine the proper timing of transfusions.     

PLACENTAL TRANSFUSION IN THE PREMATURE INFANT WITH OBSERVATION ON CLINICAL COURSE AND OUTCOME

Blood volume was measured in 73 truly premature and 10 “small for date” term infants following early or late cord clamping at birth. Forty-five normal full term infants from a previous study were included for comparison. The results demonstrated that placental transfusion occurred if cord clamping was delayed. The amount of placental transfusion in terms of red cell volume per kg b.w. in the premature infants under 2001 g was less compared to that of both normal full term infants and premature infants above 2001 g. The clinical course showed high incidence and mortality from respiratory distress in premature infants under 2001 g. An interesting observation was the apparently higher mortality resulting from idiopathic respiratory distress syndrome in the late-clamped group weighing under 2001 g.     

LEUKOCYTE TRANSFUSION IN SEVERE NEONATAL VARICELLA

ABSTRACT. A female neonate with severe varicella is reported. She was treated with THF and a leukocyte transfusion from her reconvalescent mother. This procedure seems to have been a turning point, after which she recovered fully. There were no untoward effects from this treatment.     

EFFECT OF EXCHANGE TRANSFUSION ON SERUM RESERVE ALBUMIN FOR BINDING OF BILIRUBIN AND INDEX OF SERUM BILIRUBIN TOXICITY

ABSTRACT. Ebbesen F. (Department of Neonatology, Rigshospitalet, Copenhagen, Denmark). Effect of exchange transfusion on serum reserve albumin for binding of bilirubin and index of serum bilirubin toxicity. Acta Paediatr Scand, 70:643,.–Seventeen newborn infants, who received their first exchange transfusion due to hyperbilirubinaemia and/or rhesus haemolytic disease, were studied. The exchange transfusions were performed with fresh, citrated blood. During the exchange transfusion a marked increase in the serum reserve albumin concentration for binding of bilirubin measured by the [^,4C]-MADDS method was observed, followed by a smaller decrease after the transfusion. Plasma pH increased both during and after the exchange transfusion. During the exchange transfusion a drastic fall in index of serum bilirubin toxicity was observed, followed by a smaller increase after the transfusion. Citrate was not found to interfere in the binding of bilirubin to albumin. The results are in agreement with the clinical finding that an exchange transfusion performed with fresh, citrated blood effectively reduces the risk of bilirubin encephalopathy. The ratio in serum of binding albumin, i.e. bilirubin plus reserve albumin, to total albumin failed to be increased by the exchange transfusion, and a decrease occurred after the transfusion. These findings indicate the presence in infant serum of non-binding albumin. Donor albumin with intact binding potential is partly transformed into the non-binding variety in the course of one hour after the transfusion. In the most severely rhesus sensitized infant a drastic decline of the serum albumin binding capacity was seen during the first day of life.     

HEMOGLOBIN, HEMATOCRIT AND RED BLOOD CELL COUNT IN "CAPILLARY" (SKIN-PRICK) BLOOD COMPARED TO VENOUS BLOOD IN CHILDREN

Hb, Htc and RBC in “capillary” (skin-prick) and venous blood have been compared in 30 children and in 30 adults (15 males and 15 females). “Capillary” blood was obtained from a 3 mm deep puncture in the finger with a “Medipoint” blood lancet. Higher mean values were found in venous blood, particularly in the children.     

PERINATAL ASPHYXIA AND RESIDUAL PLACENTAL BLOOD VOLUME

The present data suggest that perinatal asphyxia may result in a transfer of blood, in utero, from placenta to fetus. The data contain no suggestion that asphyxia causes pooling of fetal blood in the placenta.     

BLOOD PRESSURE IN SWEDISH SCHOOL CHILDREN

ABSTRACT, Systolic and diastolic blood pressure were measured in 1642 Swedish school children aged 12, 14, or 16 years. They represented 71% of all children in these age groups in the municipality where the investigation was done. The blood pressure was measured with an automatic, oscillometric blood pressure monitor. The systolic blood pressure increased significantly with age in both sexes. Boys aged 14 or 16 years had significantly higher systolic blood pressure than girls of the same ages.