Isolated elevated blood neutrophil concentration at altitude does not require NICU admission if appropriate reference ranges are used

The European Guidelines on Diagnosis and Management of Neutropenia in Adults and Children: A Consensus Between the European Hematology Association and the EuNet-INNOCHRON COST Action

Neutropenia, as an isolated blood cell deficiency, is a feature of a wide spectrum of acquired or congenital, benign or premalignant disorders with a predisposition to develop myelodysplastic neoplasms/acute myeloid leukemia that may arise at any age. In recent years, advances in diagnostic methodologies, particularly in the field of genomics, have revealed novel genes and mechanisms responsible for etiology and disease evolution and opened new perspectives for tailored treatment. Despite the research and diagnostic advances in the field, real world evidence, arising from international neutropenia patient registries and scientific networks, has shown that the diagnosis and management of neutropenic patients is mostly based on the physicians' experience and local practices. Therefore, experts participating in the European Network for the Innovative Diagnosis and Treatment of Chronic Neutropenias have collaborated under the auspices of the European Hematology Association to produce recommendations for the diagnosis and management of patients across the whole spectrum of chronic neutropenias. In the present article, we describe evidence- and consensus-based guidelines for the definition and classification, diagnosis, and follow-up of patients with chronic neutropenias including special entities such as pregnancy and the neonatal period. We particularly emphasize the importance of combining the clinical findings with classical and novel laboratory testing, and advanced germline and/or somatic mutational analyses, for the characterization, risk stratification, and monitoring of the entire spectrum of neutropenia patients. We believe that the wide clinical use of these practical recommendations will be particularly beneficial for patients, families, and treating physicians.

Diagnostic accuracy of complete blood cell count and neutrophil-to-lymphocyte, lymphocyte-to-monocyte, and platelet-to-lymphocyte ratios for neonatal infection

Background

Complete blood cell (CBC) counts and neutrophil-to-lymphocyte (NLR), lymphocyte-to-monocyte (LMR), and platelet-to-lymphocyte ratios (PLR) are simple measurements that are conducted as part of routine diagnostic procedures.

Objective

To determine the diagnostic importance, specificity, and sensitivity of these measurements for the diagnosis of neonatal infections and in discriminating between neonatal sepsis and various other infections.

Methods

We conducted a retrospective study of data from a consecutive series of 232 neonatal patients admitted to Yildirim Beyazit University Yenimahalle Training and Research Hospital in Ankara for 2 years from 2016 to 2018. We included patients with a diagnosis of or clinically suspected infection, and healthy neonates were included as controls. Data included CBC counts, and bacterial culture results, considered the criterion standard for the diagnosis of neonatal sepsis. NLR, LMR, and PLR were calculated. We compared data using independent Student t and Mann-Whitney U tests and determined the sensitivity, specificity, and likelihood ratio (LHOR) of the characteristics for neonatal sepsis using receiver operating characteristic curve analyses.

Results

We included data from 155 neonatal patients with a diagnosis or suspicion of infection and 77 healthy neonates. NLR was significantly higher in neonates with sepsis or fever due to dehydration (P < 0.001) than in neonates with other infections or healthy neonates. LMR was significantly higher in neonates with sepsis or viral infection than in those with other infections or healthy controls (P = 0.003). In neonates with early-onset sepsis (EOS), we found cut-off values of ≥4.79 [area under curve (AUC) 0.845, 95% confidence interval (CI) 0.76-0.93, LHOR 11.6, specificity 98.7%, sensitivity 15%] for NLR, ≥1.24 (AUC 0.295; CI 0.18-0.41, LHOR 1.02, specificity 2.6%, sensitivity 100%) for LMR, and ≥37.72 (AUC 0.268; CI 0.15-0.39, LHOR 0.86, specificity 7.8%, sensitivity 80%) for PLR. We found cut-off values of ≥4.94 (AUC 0.667; CI 0.56-0.77, LHOR 4.16, specificity 98.7%, sensitivity 5.4%) for NLR and ≥10.92 (AUC 0.384; CI 0.26-0.51, LHOR 6.24, specificity 98.7%, sensitivity 8.1%) for LMR in those with late-onset sepsis (LOS).

Conclusions

CBCs, NLR, LMR, and PLR may be useful for the differential diagnosis of EOS and LOS, and neonates with sepsis from those with other infection. NLR may be a useful diagnostic test to identify neonatal patients with septicemia more quickly than other commonly used diagnostic tests such as blood cultures. NLR has high specificity and LHOR, but low sensitivity.

Awan Z, Abouzaid AA, Elbahaie HM, Al Amoudi SM, Andarawi M, F Shehata S. The Prevalence of Isolated Neutropenia at High Altitude in Southern Saudi Arabia: Does Altitude Affect Leucocyte Count?

INTRODUCTION

Isolated neutropenia is a common problem in hematology practice. Benign ethnic neutropenia (BEN) is the common form of neutropenia worldwide and it affects mainly African and Middle Eastern ethnicities. Most cases of isolated mild and moderate neutropenia are benign and associated with no clinical significance. The aim of this study was to estimate the prevalence of isolated neutropenia at high-altitude southern Saudi Arabia.

METHODS

A large dataset of complete blood counts (CBCs) was analyzed for walk-in patients of both genders, of age ranges from 12 to 60 years doing blood tests at a commercial lab for high altitude - 2,270 meters above sea level - (HA) group, and from sea level SL group. Abnormal biochemical or CBC results were excluded before analysis.

RESULTS

For HA group, 3123 CBCs were analyzed and for SL group 18,427 CBCs were analyzed. The prevalence of mild neutropenia, defined as absolute neutrophil count (ANC) in the range of 1.0-.5× 109/L, was 12.4% (n=399) versus 5.6% (n=1025), while moderate neutropenia, defined as ANC of 0.5-1 × 109/L, was present 6% (n=191) versus 1.45% (n=269) in the high altitude and sea level groups, respectively. Severe neutropenia, defined as neutrophil count less than 0.5-1 × 109/L, was rare in both groups.

CONCLUSION

Isolated neutropenia is common in Saudis living at high altitude. While benign ethnic neutropenia (BEN) is thought to be the major contributing factor to this high prevalence, other factors including environmental factors and altitude are possible contributing factors along with underlying ethnic neutropenia.

Medicinal Uses of Hematopoietic Growth Factors in Neonatal Medicine

This review focuses on certain hematopoietic growth factors that are used as medications in clinical neonatology. It is important to note at the chapter onset that although all of the pharmacological agents mentioned in this review have been approved by the US Food and Drug administration for use in humans, none have been granted a specific FDA indication for neonates. Thus, in a sense, all of the agents mentioned in this chapter could be considered experimental, when used in neonates. However, a great many of the pharmacological agents utilized routinely in neonatology practice do not have a specific FDA indication for this population of patients. Consequently, many of the agents reviewed in this chapter are considered by some practitioners to be nonexperimental and are used when they judge such use to be "best practice" for the disorders under treatment.The medicinal uses of the agents in this chapter vary considerably, between geographic locations, and sometimes even within an institutions. "Consistent approaches" aimed at using these agents in uniform ways in the practice of neonatology are encouraged. Indeed some healthcare systems, and some individual NICUs, have developed written guidelines for using these agents within the practice group. Some such guidelines are provided in this review. It should be noted that these guidelines, or "consistent approaches," must be viewed as dynamic and changing, requiring adjustment and refinement as additional evidence accrues.

Potential biomarkers for effective screening of neonatal sepsis infections: An overview

Neonatal sepsis, a clinical disorder developed by bacterial blood stream infections (BSI) in neonates, is one of the serious global public health problems that must be addressed. More than one million of the estimated global newborn deaths per year are occurred due to severe infections. The genesis of the infection is divided into early-onset sepsis (EOS) and late-onset sepsis (LOS) of the disease. The clinical complications of neonatal sepsis may be associated with bronchopulmonary dysplasia, ductus arteriosus and necrotizing enterocolitis. The clinical diagnosis and treatment of neonatal sepsis is highly complicated. Over the past few years distinct biomarkers have been identified. Most widely used biomarkers are C-reactive protein, Procalcitonin (PCT) and Serum amyloid A (SAA). Until recently, many potential biomarkers including Cell Surface antigens and Bacterial surface antigens and genetic biomarkers are being investigated. Protein biomarkers, cytokines and chemokines are getting much interest for identification of neonatal sepsis infection.

Evaluation of altitude-appropriate reference ranges for neutrophils in diagnosis of sepsis in very low birth weight infants: A multicenter retrospective study

Background

The circulating neutrophil count was commonly believed to be influenced by altitude. At present, neutrophil reference ranges (RRs) for very low birth weight (VLBW) neonates are only available from the sea level and from high altitude. This study aimed to construct RRs for neutrophils in VLBW infants in an intermediate-altitude area and assess its usefulness in evaluation for sepsis.

Methods

This was a multicenter retrospective study of 2173 VLBW infants admitted to 20 hospitals in Chongqing in southwest of China with altitude from 1000 to 2600 feet. The RRs for absolute total neutrophils (ATN), absolute total immature neutrophils (ATI), and immature: total neutrophil proportion were constructed based on “normal” neonates (unlikely infection). Values of neutrophil from septic and uninfected neonates were respectively assessed using the revised RRs and the previous Mouzinho’s and Schmutz’s RRs. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were compared using the McNemar’s test or χ² test.

Results

The upper limits for ATN and ATI using the revised RRs were much higher than those using Mouzinho’s RRs, but lower than those using Schmutz’s RRs. The revised RRs and Mouzinho’s RRs had higher sensitivities than Schmutz’s RRs at 73–672 h. The revised RRs had a higher specificity than Mouzinho’s RRs at both 0–72 h and 73–672 h. The NPV for any abnormality in neutrophil values was high at both 0–72 h and 73–672 h irrespective of the RRs used.

Conclusion

Altitude-appropriate RRs for neutrophils is more suitable to guide the diagnosis and management of neonatal sepsis in VLBW infants.

Is umbilical cord milking always an advantage?

OBJECTIVE

The role of cord milking as an alternative to delayed cord clamping is an area that requires more research. Purpose of this clinical trial was to investigate the impact of umbilical cord milking on the absolute neutrophil counts (ANCs) and the neutropenia frequency of preterm infants.

METHODS

Fifty-eight pregnant women were randomly assigned to one of the umbilical cord milking and control groups. A total of 54 preterm infants (gestational age ≤ 32 weeks) were enrolled into the study. The umbilical cords of 25 infants were clamped immediately after birth, and in 29 infants, umbilical cord milking was performed first.

RESULTS

The ANCs were statistically significantly lower in the cord milking group compared with the control group on days 1, 3 and 7. The frequency of neutropenia was higher in the cord milking group compared with the control group.

CONCLUSION

In our study, ANCs were lower in the cord milking group and the frequency of neutropenia was higher. Umbilical cord milking plays a role on the ANCs of preterm infants.

Early-onset neonatal sepsis

Early-onset sepsis remains a common and serious problem for neonates, especially preterm infants. Group B streptococcus (GBS) is the most common etiologic agent, while Escherichia coli is the most common cause of mortality. Current efforts toward maternal intrapartum antimicrobial prophylaxis have significantly reduced the rates of GBS disease but have been associated with increased rates of Gram-negative infections, especially among very-low-birth-weight infants. The diagnosis of neonatal sepsis is based on a combination of clinical presentation; the use of nonspecific markers, including C-reactive protein and procalcitonin (where available); blood cultures; and the use of molecular methods, including PCR. Cytokines, including interleukin 6 (IL-6), interleukin 8 (IL-8), gamma interferon (IFN-γ), and tumor necrosis factor alpha (TNF-α), and cell surface antigens, including soluble intercellular adhesion molecule (sICAM) and CD64, are also being increasingly examined for use as nonspecific screening measures for neonatal sepsis. Viruses, in particular enteroviruses, parechoviruses, and herpes simplex virus (HSV), should be considered in the differential diagnosis. Empirical treatment should be based on local patterns of antimicrobial resistance but typically consists of the use of ampicillin and gentamicin, or ampicillin and cefotaxime if meningitis is suspected, until the etiologic agent has been identified. Current research is focused primarily on development of vaccines against GBS.

Expected erythrocyte, platelet and neutrophil values for term and preterm neonates

Reference ranges are an important guide for properly interpreting the clinical laboratory studies obtained from newborn infants. To judge whether the data contained in a CBC (complete blood count) is "normal," a neonatologist cannot utilize the normal ranges of CBCs constructed by sampling healthy adult volunteers. This is because important developmental differences are present between CBC values from adults vs. neonates. Also, differences in gestational age and post-natal age of neonates result in a need to have separate sets of reference range values for each. Otherwise, much confusion can exist in determining whether the CBC values are lower or higher than they should be. We reasoned that reference ranges constructed from very large databases would be a valuable new tool for neonatologists. To create these, we used the electronic data of Intermountain Healthcare, a multihospital healthcare system in the western USA, focusing on each of the various CBC elements. This presentation will review this process and display some of the novel clinically useful findings resulting from these studies.

Neonatal neutropenia: what diagnostic evaluation is needed and when is treatment recommended?

Neutropenia is a relatively frequent finding in the neonatal intensive care unit, particularly in very low birth weight neonates during the first week of life. Healthy term and preterm neonates have blood neutrophil counts within the same basic range as adults, but their neutrophil function, and their neutrophil kinetics during infection, differ considerably from those of adults. Neutrophil function of neonates, particularly preterm neonates, is less robust than that of adults and might also contribute to the increase in propensity to infection. In premature infants, early-onset neutropenia is correlated with sepsis, maternal hypertension, intrauterine growth restriction, severe asphyxia, and periventricular haemorrhage, and might be associated with an increase in the incidence of early-onset sepsis, nosocomial infection, and Candida colonisation. Some varieties of neutropenia in the NICU are very common and others are extremely rare. The most common causes of neutropenia in the NICU have an underlying cause that is often evident, and require little diagnostic evaluation. Unlike, persistent neutropenia should prompt evaluation even if it is of moderate severity. The laboratory tests to consider are those that provide a specific diagnosis. The first tests that should be ordered are a blood film, a complete blood count on the mother, and, if her blood neutrophil concentration is normal, maternal neutrophil antigen typing and an anti-neutrophil antibody screen. A bone marrow biopsy can be useful in cases with prolonged, unusual, or refractory neutropenia. Various treatments have been proposed as means of enhancing neutrophil production and function in preterm infants. Both recombinant granulocyte stimulating factor and recombinant granulocyte macrophage-colony-stimulating factor have been tried with variable success. Intravenous immunoglobulin, corticosteroids, granulocyte transfusions, and gamma interferon did not show a clear adequate beneficial role for the therapy of neonatal neutropenia.

Management of neonates with suspected or proven early-onset bacterial sepsis

With improved obstetrical management and evidence-based use of intrapartum antimicrobial therapy, early-onset neonatal sepsis is becoming less frequent. However, early-onset sepsis remains one of the most common causes of neonatal morbidity and mortality in the preterm population. The identification of neonates at risk for early-onset sepsis is frequently based on a constellation of perinatal risk factors that are neither sensitive nor specific. Furthermore, diagnostic tests for neonatal sepsis have a poor positive predictive accuracy. As a result, clinicians often treat well-appearing infants for extended periods of time, even when bacterial cultures are negative. The optimal treatment of infants with suspected early-onset sepsis is broad-spectrum antimicrobial agents (ampicillin and an aminoglycoside). Once a pathogen is identified, antimicrobial therapy should be narrowed (unless synergism is needed). Recent data suggest an association between prolonged empirical treatment of preterm infants (≥5 days) with broad-spectrum antibiotics and higher risks of late onset sepsis, necrotizing enterocolitis, and mortality. To reduce these risks, antimicrobial therapy should be discontinued at 48 hours in clinical situations in which the probability of sepsis is low. The purpose of this clinical report is to provide a practical and, when possible, evidence-based approach to the management of infants with suspected or proven early-onset sepsis.

Reference ranges for blood concentrations of eosinophils and monocytes during the neonatal period defined from over 63 000 records in a multihospital health-care system

OBJECTIVE

Blood concentrations of eosinophils and monocytes are part of the complete blood count. Reference ranges for these concentrations during the neonatal period, established by very large sample sizes and modern methods, are needed for identifying abnormally low or high values.

STUDY DESIGN

We constructed reference ranges for eosinophils per microl and monocytes per microl among neonates of 22 to 42 weeks of gestation, on the day of birth, and also during 28 days after birth. Data were obtained from archived electronic records over an eight and one-half-year period in a multihospital health-care system. In keeping with the reference range concept, values were excluded from neonates with a diagnosis of infection or necrotizing enterocolitis (NEC).

RESULT

Eosinophils and monocytes per microl of blood were electronically retrieved from 96 162 records, of which 63 371 that lacked a diagnosis of infection or NEC were included in this reference range report. The mean value for eosinophils per microl on the day of birth increased linearly between 22 and 42 weeks of gestation, as did the 5 and 95% values. The reference range at 40 weeks was 140 to 1300 microl(-1) (mean 550 microl(-1)). Similarly, the mean value for monocytes increased linearly over this interval, with a reference range at 40 weeks of 300 to 3300 microl(-1) (mean 1400 microl(-1)). Over the first 4 weeks after birth, no appreciable change was observed in 5% limit and mean eosinophil count, with a slight increase in the 95% limit in week 4. A slight increase in monocyte count was observed during the first 2 weeks after birth.

CONCLUSION

The results of this analysis describe reference ranges for blood concentrations of eosinophils and monocytes during the neonatal period. Additional study is needed for determining the relevance of values falling outside the reference range.