Érythropoïétine chez le nouveau-né : efficacité comparée des voies d’administration sous-cutanée et intraveineuse

Are high cumulative doses of erythropoietin neuroprotective in preterm infants? A two year follow-up report

Background

Preterm infants are at risk for neurodevelopmental sequelae even in absence of major cerebral lesions. The hypothesis that Human Recombinant Erythropoietin (rEpo) could improve the neurodevelopmental outcome in risk neonates has raised the highest interest in recent years.

Methods

A group of preterm neonates born at a gestational age ≤ 30 weeks and free from major cerebral lesions or major visual impairment, were included in the study if they had a complete neurologic evaluation for at least 24 months of postmenstrual age. They were assigned to group I in the case they had been treated with rEpo or group II if untreated. The aim was to evaluate whether rEpo, given at the high cumulative doses utilized for hematologic purposes, is able to improve the neurodevelopmental outcome in preterm infants born at a gestational age ≤ 30 weeks. A group of 104 preterm neonates were studied: 59 neonates who received rEpo for 6.9 ± 2.4 weeks at a median cumulative dose of 6300 UI/Kg (6337 ± 2434 UI/Kg), starting at a median age of 4 days and 45 neonates who were born in the period preceding the routine use of rEpo. The neurodevelopmental quotient at 24 month postmenstrual age was assessed utilizing the Griffiths’ Mental Developmental Scales.

Results

Our results failed to show any difference in the Developmental Quotient at 24 month. Bronchopulmonary dysplasia, minor intraventricular hemorrhages and blood transfusions were the clinical features significantly related to the Developmental Quotient.

Conclusions

Our results do not support the hypothesis that rEpo, administered with the schedule utilized for hematologic purposes, improve the neurodevelopmental outcome of preterm neonates, at least those preterm infants free from major impairments.

How to administrate erythropoietin, intravenous or subcutaneous?

AIM

To determine whether adding recombinant erythropoietin to the intravenous (IV) solution and administering it as a 24-h continuous infusion would result in an erythropoietic effect not inferior to that seen with subcutaneous (SC) administration.

METHODS

Infants weighing ≤1500 grams and ≤32 weeks of gestational age were randomly assigned at 72 h of life to receive erythropoietin (300 units/kg, 3 times a week until 36 complete weeks of postmenstrual age or discharge), either subcutaneously [erythropoietin subcutaneous (ESC) group] or added to IV fluids [erythropoietin intravenous (EIV) group].

RESULTS

One hundred infants were randomized (50 in the EIV group and 50 in the ESC group). The incidence of transfusions was comparable in the two groups, similar in baseline characteristics and haematologic values at study entry. Phlebotomy losses did not differ between groups, and at the end of the study, there were no differences in reticulocyte counts, transferrin saturation and ferritin. No differences in the incidence of side effects were observed.

CONCLUSIONS

In preterm infants, continuous intravenous administration of erythropoietin was not inferior to SC dosing.

[Assessment of erythropoietin treatment in preterm newborns older than 30 weeks of gestation]

BACKGROUND

Human recombinant erythropoietin (rhEPO) has shown a benefit in reducing the number of transfusions in very-low-birth-weight infants. However, no study has reported benefits in older preterms (i.e., 30-32 weeks of gestation [WG]). This study aimed to evaluate the benefit of rhEPO between 30 and 32 WG.

METHODS

Two groups of preterms between 30 and 32 WG were compared in a retrospective study: period 1 with rhEPO (January 2005 to October 2006) and period 2 without rhEPO (November 2006 to May 2007). Newborns with intra-uterine growth retardation, rhesus isoimmunization or surgical procedures were excluded. The main criterion was the number of blood transfusions; the second criterion was hemoglobin at 2, 4 and 6 weeks of life. Morbidity was evaluated on necrotizing enterocolitis, intraventricular hemorrhage (IVH) and periventricular leukomalacia.

RESULTS

Fifty-nine newborns receiving rhEPO and 19 not receiving rhEPO (controls) were included. The two groups were similar for birth weight (p=0.06) and hemoglobin at birth (p=0.41). Only one child (rhEPO group) needed a transfusion. Hemoglobin at 2 weeks (p=0.74), 4 weeks (p=0.13) and 6 weeks (p=0.35) were not statistically different. There was no difference between the 2 groups for necrotizing enterocolitis, IVH or periventricular leukomalacia.

CONCLUSION

This study did not find any benefit using rhEPO in 30 to 32 WG preterm infants in terms of the number of transfusions or hemoglobin levels.

Erythropoietin and prematurity--where do we stand?

Erythropoietin (EPO) treatment for anemia of prematurity is still controversial. Large multicentric trials demonstrate that administration of EPO+Fe cannot prevent early transfusions, particularly in very low birth weight newborns and in infants with severe neonatal diseases, but may have some beneficial effect to prevent late transfusions. Current treatment of anemia of prematurity should be multifactorial trying to minimize all causes that reduce erthrocytic mass (phlebotomies, use of noninvasive procedures) and promoting all factors that increase it (placental transfusion, adequate nutrition support). To evaluate the real impact of EPO treatment it is mandatory to follow similar transfusion protocols for preterm infants in all the studies. The aim of EPO+Fe administration should be to avoid new late transfusions in very low birth weight preterm infants or to prevent the first transfusion after the second week of life in less immature premature with the objective of reducing the number of donors rather than the number of transfusions. We have limited the use of EPO+Fe to infants <30 weeks gestational age and birth weight <or=1250 g as well as to infants weighing 1250-1500 g with initial severe disease. The comparison of outcomes before (28 months period with EPO+Fe treatment to all premature <or=32 weeks gestational age) and after 20 months of implementation of the new protocol showed a significant decrease in EPO+Fe treatment candidates (40.3% vs. 85.9%, P<0.001) without changes in the percentage of transfusions in both periods. Therefore if EPO treatment is to be given it should be limited to preterm infants with a birth weight <1000 g or those of 1000-1250 g associated with risk factors for blood transfusion. It should be started at 3-7 days of life at doses of 250 U/kg subcutaneously, three times a week, for 4-6 weeks depending on gestational age with oral iron 2-12 mg/kg/day to keep ferritin levels greater than 100 ng/mL.