Prediction of transfusions in extremely low-birthweight infants in the erythropoietin era

BACKGROUND: The purpose of the present paper was to detect the clinical factors most predictive of red blood cell (RBC) transfusion in extremely low-birthweight (ELBW) infants in the recombinant human erythropoietin era. METHODS: Between 1995 and 2000, 66 ELBW infants were admitted to a level III neonatal intensive care unit. Fifty-four of 66 infants were eligible for enrollment in the present study. Infants were treated with erythropoietin 200 IU/kg per dose s.c. twice a week with 4-6 mg/kg per day iron supplement. RESULTS: The mean gestational age and birthweight were 26.5 +/- 2.1 weeks and 776 +/- 134 g, respectively. Ten of 54 ELBW infants (18.5%) died during the first 21 days. Eight of 10 dead infants (80.0%) and 27 of 44 surviving infants (61.4%) received one or more RBC transfusions. The overall requirement for RBC transfusions in the surviving infants was 3.0 +/- 3.2 per infant/hospital course (range: 0-9) . There were significant differences in gestational weeks, birthweight, initial hemoglobin value, 5 min Apgar score, phlebotomy loss, phlebotomy loss/birthweight, duration of mechanical ventilation, duration of oxygen supplement, and incidence of both intraventricular hemorrhage and chronic lung disease between the transfused and non-transfused group. The predictive variables, initial hemoglobin level (odds ratio [OR] 2.61; 1 g/dL), birthweight (OR 3.00; 100 g), and gestational week (OR 1.89; 1 week), were found to be most predictive for transfusion on logistic regression analysis. CONCLUSION: ELBW infants are still the population at greatest risk for repeated blood transfusions after introduction of erythropoietin treatment. If labor develops, it is often impossible to extend the pregnancy period, therefore efforts should be made to increase hemoglobin level at birth.     

Stepping up versus standard doses of erythropoietin in preterm infants: a randomized controlled trial

In this study, it is hypothesized that a planned increase in the dose of recombinant human erythropoietin (rh-EPO) can prevent transfusion in very low birth weight infants. Two different regimens of rh-EPO were administrated, one consisting in increasing dosage up to 5000 U/kg/wk, according to the individual reticulocytes response, and the second in a standard therapy of 1250 U/kg/wk. Fifty-one infants participated. Despite a significant higher reticulocytosis, the study was prematurely terminated due to the results of an interim analysis showing that transfusion was not avoided by increasing the rh-EPO. No significant differences were found between the two regimens concerning transfusion rate, volume transfused, gain in weight, and adverse effects. Progressive titration of rh-EPO to improve the biological response does not leave premature infants free of transfusion.     

早产儿贫血现状及防治研究进展

随着现代医疗技术水平的不断提高,早产儿存活率也在不断提高,但早产儿贫血目前仍是早产儿营养管理上的常见问题之一。防治早产儿贫血的主要方法有不同途径的补充铁剂、红细胞输注及合理使用重组人红细胞生成素等,但上述防治方法各有利弊。文章就早产儿贫血的现状及防治方面进展进行论述。     

呵护早产儿从母乳喂养开始

母乳喂养是降低新生儿死亡率的重要干预手段之一,对早产儿尤其如此。早产母乳中的成分与足月母乳不同,其营养价值和生物学功能更适合早产儿的需求。在NICU积极推进母乳喂养能降低早产相关疾病的发生率,改善神经行为发育,降低成年慢性非传染性疾病的发病风险。对低出生体质量早产儿,强化母乳喂养是最佳的喂养方式,能优化蛋白质摄入,促进早产儿体格增长和骨骼矿化。应当以积极的支持策略来保证早产儿母乳喂养的顺利实施。     

Polycythemia in an infant secondary to granulocyte transfusions

Granulocyte transfusions may be useful for neutropenic pediatric patients with refractory bacterial or fungal infections. Many potential adverse sequelae associated with granulocyte transfusions are well recognized, including febrile reactions, fluid overload, alloimmunization, and lung injury. Other potential adverse sequelae, however, are less well known. This case report describes an infant with familial hemophagocytic lymphohistiocytosis who developed polycythemia (hemoglobin 10-17.6 g/dl) following four daily transfusions of 20 ml/kg of apheresis collected, steroid stimulated donor granulocytes. Expanded knowledge of potential risks of transfused granulocytes will allow for rapid recognition of transfusion-related complications, should they occur.     

双胎早产儿神经精神发育水平随访研究

目的 探讨双胎早产儿神经精神发育情况,并分析其危险因素.方法 将2010年6月至2012年6月在昆明医科大学第一附属医院新生儿病房住院的早产几分为2组:双胎早产儿为研究组,单胎早产儿为对照组.对其中88例早产儿在纠正胎龄1岁时行神经精神发育随访,由儿童保健科专人采用贝利婴幼儿发展量表进行测试,其中研究组根据量表正常测试结果分为神经精神发育异常组[智力发展指数(MDI)≤79分]和神经精神发育正常组(MDI ＞79分),并对2组资料进行统计学分析.结果 研究组MDI得分频数分布呈偏态分布,其中59％(27/46例)为神经精神发育异常(MDI≤79分);对照组MDI得分频数分布呈近似正态分布,其中仅12％(5/42例)为神经精神发育异常.1岁时双胎早产儿头围、身长、体质量、MDI、精神运动发展指数(PDI)均低于单胎早产儿,差异均有统计学意义(P均＜0.05).单因素分析中双胎早产儿神经精神发育异常的高危因素有胎龄、出生体质量、母亲育龄、父母亲文化程度、喂养方式、新生儿高胆红素血症、新生儿低血糖症、新生儿脓毒症、感染.多因素Logistic回归分析显示新生儿高胆红素血症是双胎早产儿神经精神发育异常的独立危险因素.结论 同胎龄双胎早产儿的神经精神发育落后于单胎早产儿.新生儿高胆红素血症有可能是导致双胎早产儿神经精神发育异常的高危因素,早期积极处理新生儿高胆红素血症有利于促进双胎早产儿的神经精神发育.     

Transfusion in premature infants impairs production and/or release of red blood cells,white blood cells and platelets

OBJECTIVE: To examine whether red blood cell transfusion in infants with anaemia of prematurity alters peripheral counts of red blood cell precursors, total white blood cells and white cell differential and platelets. METHODOLOGY: In 18 consecutive stable premature infants with anaemia of prematurity, peripheral cell counts were prospectively recorded immediately before transfusion of 20 mL/kg packed red blood cells (given over 6 h), and at 48 h after completion of the transfusion. RESULTS: The median (interquartile range) haematocrit increased from 22.0% (21.3-24.0%) pre-transfusion to 37.0% (36.0-38.0%) post-transfusion (P < 0.001). Red-cell precursors decreased: median (interquartile range) reticulocytes from 3.7% (3.0-7.7%) to 3.7% (2.6-4.1%) (P = 0.03); and median (interquartile range) nucleated red blood cells from 0 G/L (0-0.2 G/L) to 0 G/L (0-0 G/L) (P = 0.03). The mean (SD) platelet count decreased from 420 G/L (154 G/L) to 313 G/L (101 G/L) (P = 0.001). The total white blood cell count and neutrophils did not change significantly; however, median (interquartile range) immature neutrophils decreased from 0.12 G/L (0.06-0.74 G/L) to 0.08 G/L (0.01-0.24 G/L) (P = 0.03). Lymphocytes, eosinophils, basophils and plasma cells remained unchanged. Monocytes increased (P = 0.01). CONCLUSIONS: Forty-eight hours after red blood cell transfusion to premature infants, there is an absolute decrease in red blood cell precursors, immature white blood cells and platelets, probably due to erythropoietin-suppression.     

Pitfalls of gastric intubation in premature infants

Gastric intubation, by oral or nasal route is an essential procedure in the management of premature infants, for gastric aspiration and for feeding. Oesophageal perforation is a rare but important complication of this commonly performed procedure. An illustrative case is presented. Difficulty passing a tube into the stomach is the first clue to the diagnosis. Understanding the evolution of clinical signs and recognizing the radiological changes facilitates an early diagnosis, thereby enabling successful non-operative management.     

Breath hydrogen excretion in healthy premature infants

Breath hydrogen excretion during the neonatal period was studied on 84 occasions in 44 well premature infants of 27-37 weeks gestational age who all received lactose-containing feeds. Only one of 15 infants studied during the first 24 h excreted hydrogen. Thereafter, the proportion of infants excreting hydrogen increased daily. From day 5 onwards all the infants studied were found to be excreting hydrogen. The concentration and the volume of hydrogen exhaled by infants ranged from 10-230 parts/10(6) and 2.6-107 microL/min, respectively. Breath hydrogen excretion was variable and showed no relationship to birthweight, gestation period, volume of feed or the time of last feed through there was an increase with the age of the infant. Breath hydrogen excretion appears to be a normal phenomenon in premature infants and is probably related to gut colonization with lactose fermenting organisms.     

Minimizing blood loss and the need for transfusions in very premature infants

Reducing blood loss and the need for blood transfusions in extremely preterm infants is part of effective care. Delayed cord clamping is well supported by the evidence and is recommended for infants who do not immediately require resuscitation. Cord milking may be an alternative to delayed cord clamping; however, more research is needed to support its use. In view of concerns regarding the increased risk for cognitive delay, clinicians should avoid using hemoglobin transfusion thresholds lower than those tested in clinical trials. Higher transfusion volumes (15 mL/kg to 20 mL/kg) may decrease exposure to multiple donors. Erythropoietin is not recommended for routine use due to concerns about retinopathy of prematurity. Elemental iron supplementation (2 mg/kg/day to 3 mg/kg/day once full oral feeds are achieved) is recommended to prevent later iron deficiency anemia. Noninvasive monitoring (eg, for carbon dioxide, bilirubin) and point-of-care testing reduce the need for blood sampling. Clinicians should strive to order the minimal amount of blood sampling required for safe patient care, and cluster samplings to avoid unnecessary skin breaks.     

121例早产儿心脏彩色多普勒超声诊断异常结果分析

近年来,出生的早产儿有逐渐增多趋势,随着医学技术的发展,越来越多的早产儿得以存活。为了提高早产儿存活率及生存质量,我院新生儿科应用彩色多普勒超声(彩超)对早产儿进行心脏疾病筛查。现将在我院新生儿病房2003年11月～2005年10月住院的709例早产儿,常规心脏彩超检查中诊断结果异常的121例,报告如下。1资料和方法1.1一般资料709例早产儿中超声诊断结果异常121例(占17.1%),其中男94例,女27例,男∶女为3.48∶1;胎龄(34.4±1.8)周;体重(2224±513)g;检查时日龄(4.38±2.22)d。其中极低体重儿4例,双胎11例,伴尿道下裂、外耳道闭锁、先天愚型…     

Symptomatic zinc deficiency in breast-fed term and premature infants

Two 3-month-old exclusively breast-fed infants, one born at full-term and the other born prematurely, developed symptomatic zinc deficiency manifested by an acrodermatitis enteropathica-like eruption. Inadequate breast milk zinc was demonstrated in both cases. A rapid clinical response followed oral zinc supplementation after which their serum zinc levels returned to normal. The infants remained asymptomatic following cessation of zinc therapy. Reports of similar cases suggest that in a group of infants breast milk does not meet their nutritional zinc requirements. Inadequate breast milk zinc is thought to result from a defect in transfer of zinc from maternal serum to breast milk.     

Endogenous nitric oxide in the upper airways of premature and term infants

Concentrations of endogenous nitric oxide (NO) were measured in premature ( n = 18) and term infants ( n = 7). Nasal gas was aspirated continuously and after timed occlusions, 15 s and 60 s, by a fast-response chemiluminescence analyser. The sampling flow rate was 20 ml min^-1. Typical NO recordings consisted of plateaux and postocclusive peaks. In term infants peak NO concentrations (60 s occlusion) were 2. 71 ± 0. 44 parts per million (ppm) within lOmin after birth, increasing ( p < 0. 05) to 3. 81 ± 0. 25 ppm at 4–7 d postnatally. Peak NO values (15 s occlusion) averaged 1. 22 ± 0. 16 ppm in premature infants (postconcep-tional age 25–37 weeks, body weight 623–2844 g) and the NO concentrations increased significantly with postconceptional age ( p < 0. 05). Nasal excretion rate, estimated from plateau NO concentrations and sampling flow rate, was 0. 10 ± 0. 01 nmol min^-1 kg^-1 in both groups. We conclude that premature and term newborn infants excrete considerable amounts of NO in the upper airways, with hitherto not fully known functions.     

Effect of hemoglobin on transfusion and neonatal adaptation in extremely low-birthweight infants

Background: The aim of the present paper was to investigate the effect of initial hemoglobin level on red blood cell transfusion and neonatal adaptation in extremely low-birthweight (ELBW) infants.
Methods: Subjects consisted of 54 ELBW infants admitted to level III neonatal intensive care unit between 1995 and 2000, and divided into two groups based on hemoglobin level at birth. High hemoglobin was defined as hemoglobin ≥15.0 g/dL.
Results: There were no significant differences in gestational age and birthweight between the high hemoglobin group ( n  = 28) and low hemoglobin group ( n  = 26). The high hemoglobin group had decreased probability of requiring red blood cell transfusion ( P  < 0.05) and number of red blood cell transfusions ( P  < 0.05). Mortality rate in the low hemoglobin group was significantly higher compared with the high hemoglobin group ( P  = 0.03). In the high hemoglobin group, blood pressures during the first 24 h were significantly higher ( P  < 0.05) and the risk of intraventricular hemorrhage was significantly lower ( P  = 0.04) compared with the low hemoglobin group. The predictive variables, initial hemoglobin level (odds ratio 1.93 [decrease by 1 g/dL]) and intraventricular hemorrhage ≥III (odds ratio 21.76 [positive]) were found to be most predictive for death on logistic regression.
Conclusion: High hemoglobin level at birth is associated with a significantly reduced requirement for red blood cell transfusion and might contribute to stabilization of blood pressure, and thus reduce mortality and the risk of severe intraventricular hemorrhage.     

Current respiratory syncytial virus prevention strategies in high-risk infants

Respiratory syncytial virus (RSV) was initially isolated in 1956. Since then it has become recognized as a major pathogen worldwide. It is a ubiquitous pathogen that produces seasonal epidemics. Primary infection occurs in children before 2 years of age. In older children and adults, RSV usually manifests itself as an upper respiratory tract infection. In immunecompromised patients, those with underlying cardiopulmonary disorders, premature infants, and other vulnerable individuals, RSV infection can produce severe bronchiolitis or pneumonia. In recent years we have observed exciting new information about the prevention of serious RSV infection in high-risk infants including infection control practices, active immunity and passive immunity. Two immunoprophylaxis products (RSV i.v. immune globulin and palivzumab) have been developed for clinical use in the prevention of serious RSV infection. Many other agents including vaccines, super monoclonal antibodies, and antivirals are under development. Although clinicians now have the ability to provide their most vulnerable patients with meaningful prevention strategies, much more needs to be done before we can regard RSV as a preventable disease.     

Intravenous immune globulin reduces the need for exchange transfusions in Rhesus and AB0 incompatibility

Abstract Aim: To conduct a quality control review of a single institution experience with intravenous immune globulin in the treatment of Rhesus and AB0 incompatibility. Methods: Intravenous immune globulin as treatment for Rhesus and AB0 incompatibility was introduced in our hospital in 1998. We performed a chart review of 176 infants with Rhesus or AB0 incompatibility treated in our hospital between 1993 and 2003, divided into a historical control group (1993-1998) and a treatment group (1999-2003). The project was approved through institutional ethics procedures. Results: The use of exchange transfusion as a therapeutic modality was significantly reduced in the cohort treated with intravenous immune globulin (OR 0.11; 95% CI 0.046-0.26, p < 0.001). We found no difference between the intravenous immune globulin group and the infants receiving only exchange transfusion as far as the duration of phototherapy. Infants with Rhesus incompatibility had a higher need for top-up transfusions than those with AB0 incompatibility. Conclusion: This study supports the evidence from previous studies suggesting that intravenous immune globulin significantly reduces the need for exchange transfusion in infants with Rhesus and AB0 incompatibility.