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Bolat F, Dursun M, Sarıaydın M. Packed Red Blood Cell Transfusion as a Predictor of Moderate-Severe Bronchopulmonary Dysplasia: A Comparative Cohort Study of Very Preterm Infants. Am J Perinatol 2024; 41:e1499-e1507. [PMID: 36898407 DOI: 10.1055/a-2051-8245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
OBJECTIVE Bronchopulmonary dysplasia (BPD) is a leading cause of morbidity and mortality in neonatal intensive care units. Our aim was to evaluate association between packed red blood cell transfusion and the development of BPD in very preterm infants. STUDY DESIGN This retrospective study of very preterm infants (mean gestational age: 27.1 ± 2.4 weeks, birth weight: 970 ± 271 g) was conducted at Biruni University (Turkey) between July 2016 and December 2020. RESULTS BPD developed in 107 of the 246 enrolled neonates, including 47 (43.9%), 27 (25.3%), and 33 (30.8%) diagnosed with mild, moderate, and severe BPD, respectively. A total of 728 transfusions were administered. The increased number (4 transfusions [2-7] vs. 1 [1-3], p = 0.001) and volume of transfusions (75 mL/kg volume [40-130] vs. 20 [15-43], p = 0.001) were significantly higher in infants with BPD compared to those without BPD. The transfusion volume cut-off for the prediction of BPD by receiver operating characteristic curve analysis was 42 mL/kg (sensitivity 73.6%; specificity 75%; area under the receiver-operating characteristic curve: 0.82). In multivariate analysis, multiple transfusions and larger transfusion volume were independent risk factors for moderate-severe BPD. CONCLUSION The increased number and volume of transfusions were associated with BPD in very preterm infants. A packed red blood cell transfusion volume ≥42 mL/kg was a statistically significant predictor of the development of BPD at a postmenstrual age of 36 weeks. KEY POINTS · Transfusions were found to be an important risk factor for BPD development in very premature infants.. · Number and volume of transfusion were associated with the severity of BPD.. · Optimal cut point volume of transfusion for prediction of BPD was 42 mL/kg body weight..
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Affiliation(s)
- Fatih Bolat
- Division of Neonatology, Department of Pediatrics, Istinye University Faculty of Medicine, Istanbul, Turkey
| | - Mesut Dursun
- Division of Neonatology, Department of Pediatrics, Biruni University Faculty of Medicine, Istanbul, Turkey
| | - Mehmet Sarıaydın
- Division of Neonatology, Department of Pediatrics, Biruni University Faculty of Medicine, Istanbul, Turkey
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Luban NLC. They are not just small adults. Transfusion 2024; 64:929-932. [PMID: 38577963 DOI: 10.1111/trf.17782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 03/06/2024] [Indexed: 04/06/2024]
Affiliation(s)
- Naomi L C Luban
- Children's National Research Institute, Washington, DC, USA
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Salas AA, Gunn E, Carlo WA, Bell EF, Das A, Josephson CD, Patel RM, Tan S, Kirpalani H. Timing of Red Blood Cell Transfusions and Occurrence of Necrotizing Enterocolitis: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2024; 7:e249643. [PMID: 38700862 PMCID: PMC11069076 DOI: 10.1001/jamanetworkopen.2024.9643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 03/05/2024] [Indexed: 05/06/2024] Open
Abstract
Importance Observational studies often report that anemia and red blood cell (RBC) transfusions are associated with a higher risk of necrotizing enterocolitis (NEC) among extremely low-birthweight (ELBW) infants. Objective To evaluate whether there is a temporal association between 72-hour hazard periods of exposure to RBC transfusions and NEC among ELBW infants randomized to either higher or lower hemoglobin transfusion thresholds. Design, Setting, and Participants This post hoc secondary analysis of 1690 ELBW infants who survived to postnatal day 10 enrolled in the Transfusion of Prematures (TOP) randomized multicenter trial between December 1, 2012, and April 12, 2017, was performed between June 2021 and July 2023. Exposures First, the distribution of RBC transfusions and the occurrence of NEC up to postnatal day 60 were examined. Second, 72-hour posttransfusion periods were categorized as hazard periods and the pretransfusion periods of variable duration as control periods. Then, the risk of NEC in posttransfusion hazard periods was compared with that in pretransfusion control periods, stratifying the risk based on randomization group (higher or lower hemoglobin transfusion threshold group). Main Outcomes and Measures The primary outcome was incidence of NEC stage 2 or 3. Secondary outcomes included the incidence rates of NEC within five 10-day intervals, taking into account the number of days at risk. Results Of 1824 ELBW infants randomized during the TOP trial, 1690 were included in the present analysis (mean [SD] gestational age, 26.0 [1.5] weeks; 899 infants [53.2%] were female). After categorizing 4947 hazard periods and 5813 control periods, we identified 133 NEC cases. Fifty-nine of these cases (44.4%) occurred during hazard periods. Baseline and clinical characteristics of infants with NEC during hazard periods did not differ from those of infants with NEC during control periods. The risk of NEC was 11.9 per 1000 posttransfusion hazard periods and 12.7 per 1000 control periods (adjusted risk ratio, 0.95; 95% CI, 0.68-1.32; P = .74). This risk did not differ significantly between randomization groups, but the incidence rate of NEC per 1000 days peaked between postnatal days 20 and 29 in the lower hemoglobin transfusion threshold group. Conclusions and Relevance The findings of this post hoc analysis suggest that, among ELBW infants with the hemoglobin ranges occurring in the TOP trial, exposure to RBC transfusions was not temporally associated with a higher risk of NEC during 72-hour posttransfusion hazard periods. Given that the incidence rate of NEC peaked between postnatal days 20 and 29 among infants with lower hemoglobin values, a more in-depth examination of this at-risk period using larger data sets is warranted. Trial Registration ClinicalTrials.gov Identifier: NCT01702805.
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Affiliation(s)
- Ariel A. Salas
- Department of Pediatrics, University of Alabama at Birmingham
| | - Elizabeth Gunn
- Department of Pediatrics, University of Alabama at Birmingham
| | | | | | - Abhik Das
- Statistical and Environmental Sciences Unit, RTI International, Washington, DC
| | - Cassandra D. Josephson
- Cancer and Blood Disorders Institute and Blood Bank/Transfusion Medicine, Johns Hopkins All Children’s Hospital, St Petersburg, Florida
- Department of Oncology, John Hopkins University School of Medicine, Baltimore, Maryland
| | - Ravi M. Patel
- Department of Pediatrics, Emory University, Atlanta, Georgia
| | - Sylvia Tan
- Statistical and Environmental Sciences Unit, RTI International, Washington, DC
| | - Haresh Kirpalani
- Department of Pediatrics, University of Pennsylvania, Philadelphia
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Heeger LE, Koster MIJ, Caram-Deelder C, Bekker V, van der Bom JG, Lopriore E. Umbilical Cord Blood as an Alternative to Neonatal Blood for Complete Blood Count: A Comparison Study. J Pediatr 2024; 271:114059. [PMID: 38636783 DOI: 10.1016/j.jpeds.2024.114059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 04/08/2024] [Accepted: 04/14/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVE To assess concordance between umbilical cord blood (UCB) and neonatal blood (NB) laboratory test results at birth. STUDY DESIGN This retrospective study considered very preterm neonates (<32 weeks' gestational age) admitted to a tertiary neonatal intensive care unit from 2012 to 2023. Inclusion criteria required neonates with a complete blood count measured in both UCB and NB drawn within 2 hours after birth. Median hemoglobin (Hb) and hematocrit (Hct) concentrations were compared between UCB (venous samples) and NB (venous, arterial, or capillary samples). RESULTS A total of 432 neonates with paired UCB and NB values were included in the study. Hb concentration in UCB was 14.7 g/dL (IQR 13.5-16.1 g/dL) compared with 14.8 g/dL (IQR 12.6-19.3 g/dL) in venous NB samples, 13.9 g/dL (IQR 12.9-15.3 g/dL) in arterial NB and 18.7 g/dL (IQR 16.6-20.8 g/dL) in capillary NB. The regression equation showed a correction factor of 1.08 for converting Hb values from UCB to venous NB. Median Hct concentration in UCB was 0.45 L/L (IQR: 0.41-0.49 L/L) compared with 0.48 L/L (IQR 0.43-0.54 L/L) in venous NB, 0.42 L/L (IQR 0.38-0.45 L/L) in arterial NB and 0.57 L/L, (IQR 0.51-0.63 L/L) in capillary NB. CONCLUSIONS Hb and Hct concentrations measured in UCB are similar to those measured in venous blood in very preterm infants and are valid alternatives for NB tests at birth. Hb and Hct concentrations in arterial and capillary NB are respectively lower and higher compared with UCB measurements.
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Affiliation(s)
- Lisanne E Heeger
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands; Sanquin Blood Supply Foundation, Clinical Center for Transfusion Research, Amsterdam, The Netherlands
| | - Myrthe I J Koster
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Camila Caram-Deelder
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Vincent Bekker
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Johanna G van der Bom
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands.
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Zheng L, Gu X, Zhao P, Yang T, Zhang Q, Jiang S, Cao Y, Lee SK, Zhou W, Wang J. Characteristics of red blood cell transfusion among very preterm infants in China. Vox Sang 2024. [PMID: 38622920 DOI: 10.1111/vox.13622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 03/03/2024] [Accepted: 03/10/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND AND OBJECTIVES National-level data on the incidence of red blood cell (RBC) transfusions and outcomes among very preterm infants (VPIs) are lacking in China. This study aims to describe the use and variation of RBC transfusion among VPIs in China. MATERIALS AND METHODS This cohort study was conducted among 70 tertiary hospitals participating in the Chinese Neonatal Network (CHNN) from 2019 to 2020 across China. All VPIs admitted to the CHNN neonatal intensive care units (NICUs) were included. RESULTS A total of 13,447 VPIs were enrolled, of whom 7026 (52.2%) received ≥1 RBC transfusions. The mean number of transfusions per infant was 2 (interquartile range [IQR] 1-4 times) and the median age at first transfusion was 15 days (IQR 3-27 days). The transfusion rate was higher in critically ill infants compared with non-critically ill infants (70.5% vs. 39.3%). The transfusion rate varied widely (13.5%-95.0%) between different NICUs. The prevalence of death, severe intra-ventricular haemorrhage, necrotizing enterocolitis (NEC) or spontaneous intestinal perforation (SIP), sepsis, bronchopulmonary dysplasia (BPD), severe retinopathy of prematurity (ROP) and cystic periventricular leukomalacia (cPVL) was significantly higher in the transfused group. Among non-critically ill infants, RBC transfusion was independently associated with BPD, severe ROP and cPVL. CONCLUSION Our study, providing the first baseline data on RBC transfusions among VPIs in China, shows an alarmingly high RBC transfusion rate with significant site variations. There is an urgent need for national guidelines on RBC transfusions for VPIs in China.
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Affiliation(s)
- Lu Zheng
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Xinyue Gu
- NHC Key Laboratory of Neonatal Diseases, Fudan University, Children's Hospital of Fudan University, Shanghai, China
| | - Pu Zhao
- Department of Neonatology, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Tongling Yang
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Qin Zhang
- Department of Neonatology, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Siyuan Jiang
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
- NHC Key Laboratory of Neonatal Diseases, Fudan University, Children's Hospital of Fudan University, Shanghai, China
| | - Yun Cao
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
- NHC Key Laboratory of Neonatal Diseases, Fudan University, Children's Hospital of Fudan University, Shanghai, China
| | - Shoo K Lee
- Department of Pediatrics, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Wenhao Zhou
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
- NHC Key Laboratory of Neonatal Diseases, Fudan University, Children's Hospital of Fudan University, Shanghai, China
| | - Jin Wang
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
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Balasubramanian H, Bhanushali M, Tripathi V, Srinivasan L, Sakharkar S, Pillai A, Kabra NS. Effect of minimization of early blood sampling losses among extremely premature neonates- A randomized clinical trial. J Pediatr 2024:114002. [PMID: 38447757 DOI: 10.1016/j.jpeds.2024.114002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 02/08/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024]
Abstract
OBJECTIVE To evaluate the effect of blood sampling stewardship on transfusion requirements among infants born extremely preterm. STUDY DESIGN In this single-center, randomized controlled trial, infants born at <28 weeks of gestation and birth weight of <1000 g were randomized at 24 hours of age to two different blood sampling approaches: restricted sampling versus conventional sampling. The stewardship intervention in the restricted sampling group included targeted reduction in blood sampling volume and frequency and point of care testing methods in the first six weeks after birth. Both groups received early recombinant erythropoietin from day three of age. Primary outcome was the rate of early red blood cell (RBC) transfusions in the first six postnatal weeks. RESULTS A total of 102 infants (mean gestational age: 26 weeks; birth weight: 756 g) were enrolled. Fidelity to the sampling protocol was achieved in 95% of the infants. Sampling losses in the first six weeks were significantly lower in the restricted sampling group (16.8 ml/kg vs 23.6 ml/kg, P<0.001). The restricted sampling group had a significantly lower rate of early postnatal RBC transfusion (41% versus 73%, RR: 0.56 [0.39-0.81], P=0.001). The hazard of needing a transfusion during NICU stay was reduced by 55% by restricted sampling. Mortality and neonatal morbidities were similar between the two groups. CONCLUSION Minimization of blood sampling losses by approximately one third in the first six weeks after birth leads to substantial reduction in the early RBC transfusion rate in infants born extremely preterm who weighed <1000 g at birth. TRIAL REGISTRATION http://www.ctri.nic.in (CTRI/2020/01/022964).
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Affiliation(s)
| | | | | | | | | | - Anish Pillai
- Surya Children's Hospital, Mumbai, Maharashtra, India
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Lakshminrusimha S, Abman SH. Oxygen Targets in Neonatal Pulmonary Hypertension: Individualized, "Precision-Medicine" Approach. Clin Perinatol 2024; 51:77-94. [PMID: 38325948 PMCID: PMC10857735 DOI: 10.1016/j.clp.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
Oxygen is a specific pulmonary vasodilator. Hypoxemia causes pulmonary vasoconstriction, and normoxia leads to pulmonary vasodilation. However, hyperoxia does not enhance pulmonary vasodilation but causes oxidative stress. There are no clinical trials evaluating optimal oxygen saturation or Pao2 in pulmonary hypertension. Data from translational studies and case series suggest that oxygen saturation of 90% to 97% or Pao2 between 50 and 80 mm Hg is associated with the lowest pulmonary vascular resistance.
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Affiliation(s)
- Satyan Lakshminrusimha
- Department of Pediatrics, University of California, UC Davis Children's Hospital, 2516 Stockton Boulevard, Sacramento, CA 95817, USA.
| | - Steven H Abman
- Department of Pediatrics, The Pediatric Heart Lung Center, University of Colorado Anschutz Medical Campus, Mail Stop B395, 13123 East 16th Avenue, Aurora, CO 80045, USA
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8
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Bahr TM, Snow GL, Christensen TR, Davenport P, Henry E, Tweddell SM, Ilstrup SJ, Yoder BA, Ohls RK, Sola-Visner MC, Christensen RD. Can Red Blood Cell and Platelet Transfusions Have a Pathogenic Role in Bronchopulmonary Dysplasia? J Pediatr 2024; 265:113836. [PMID: 37992802 DOI: 10.1016/j.jpeds.2023.113836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 11/08/2023] [Accepted: 11/15/2023] [Indexed: 11/24/2023]
Abstract
OBJECTIVE To evaluate whether transfusions in infants born preterm contribute to the pathogenesis of bronchopulmonary dysplasia (BPD). STUDY DESIGN We conducted a multihospital, retrospective study seeking associations between red blood cell or platelet transfusions and BPD. We tabulated all transfusions administered from January 2018 through December 2022 to infants born ≤29 weeks or <1000 g until 36 weeks postmenstrual age and compared those with BPD grade. We performed a sensitivity analysis to assess the possibility of a causal relationship. We then determined whether each transfusion was compliant with restrictive guidelines, and we estimated effects fewer transfusions might have on future BPD incidence. RESULTS Eighty-four infants did not develop BPD and 595 did; 352 developed grade 1 (mild), 193 grade 2 (moderate), and 50 grade 3 (severe). Transfusions were given at <36 weeks to 7% of those who did not develop BPD, 46% who did, and 98% who developed severe BPD. For every transfusion the odds of developing BPD increased by a factor of 2.27 (95% CI, 1.59-3.68; P < .001). Sensitivity analyses suggested that transfusions might contribute to BPD. Fifty-seven percent of red blood cell transfusions and 68% of platelet transfusions were noncompliant with new restrictive guidelines. Modeling predicted that complying with restrictive guidelines could reduce the transfusion rate by 20%-30% and the moderate to severe BPD rate by ∼4%-6%. CONCLUSIONS Transfusions were associated with BPD incidence and severity. Lowering transfusion rates to comply with current restrictive guidelines might result in a small but meaningful reduction in BPD rates.
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Affiliation(s)
- Timothy M Bahr
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT; Department of Neonatology, Intermountain Health, Murray, UT.
| | | | - Thomas R Christensen
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Patricia Davenport
- Division of Newborn Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Erick Henry
- Department of Neonatology, Intermountain Health, Murray, UT
| | - Sarah M Tweddell
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Sarah J Ilstrup
- Transfusion Services and Department of Pathology, Intermountain Health, Murray, UT
| | - Bradley A Yoder
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Robin K Ohls
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Martha C Sola-Visner
- Division of Newborn Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Robert D Christensen
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT; Department of Neonatology, Intermountain Health, Murray, UT
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Valete COS, Angelica Luiz Ferreira E, Montenegro CP, Pilati MCA, Rodrigues Wilde MOD, Witkowski SM. Frequency of red blood cell transfusions in preterm neonates in Brazil: A systematic review and meta-analysis. Vox Sang 2024; 119:8-15. [PMID: 37920102 DOI: 10.1111/vox.13553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/11/2023] [Accepted: 10/08/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Red blood cell transfusions are frequent in preterm neonates. The proportion of preterm neonates transfused in Brazil remains unknown. We systematically reviewed the literature to estimate the frequency of red blood cell transfusions in preterm neonates in Brazil. MATERIALS AND METHODS The LILACS, EMBASE, Cochrane, SciELO, MEDLINE (PubMed), Web of Science, Scopus, BDTD and 27 national university institutional databases were searched for studies that analysed red blood cell transfusion in preterm neonates in Brazil without period restriction. The Preferred Reporting Items in Systematic Reviews and Meta-Analyses guidelines were followed, and the GRADE methodology was applied. A random-effects model along with the restricted maximum likelihood method was used, and the Freeman-Tukey transformed proportion was used to estimate effect size. RESULTS Nine studies, representing 6548 preterm neonates, were included in the qualitative and quantitative analyses. The mean gestational age ranged from 26.0 to 31.6 weeks. Most of the studies were from the Southeast region. The pooled estimated frequency of red blood cell transfusions was 58.0% (95% confidence interval = 52.0%-64.0%, p < 0.001) with low certainty. There was statistically significant heterogeneity among studies (I2 = 92.5%, p < 0.001). CONCLUSION In this current meta-analysis of the evidence available, which included moderate and extremely preterm neonates, the observed frequency of red blood cell transfusions in preterm neonates in Brazil was 58.0% and this estimate can help health programming. Some Brazilian regions were not included in this study, and further research is needed to provide a more representative overview of Brazil.
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Affiliation(s)
| | | | - Carolina Perez Montenegro
- Medicine Department (DMed), Federal University of São Carlos (UFSCar), São Carlos, São Paulo, Brazil
| | - Maria Clara Alves Pilati
- Medicine Department (DMed), Federal University of São Carlos (UFSCar), São Carlos, São Paulo, Brazil
| | | | - Sandra Mara Witkowski
- Department of Pediatrics, University of Vale do Itajaí, Itajaí, Santa Catarina, Brazil
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Culbreath K, Keefe G, Nes E, Edwards EM, Knell J, Morrow KA, Soll RF, Jaksic T, Horbar JD, Modi BP. Association between neurodevelopmental outcomes and concomitant presence of NEC and IVH in extremely low birth weight infants. J Perinatol 2024; 44:108-115. [PMID: 37735208 DOI: 10.1038/s41372-023-01780-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 08/31/2023] [Accepted: 09/12/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVE To quantify the association between necrotizing enterocolitis (NEC) and neurodevelopmental disability (NDI) in extremely low birth weight (ELBW) infants with intraventricular hemorrhage (IVH). STUDY DESIGN ELBW survivors born 2011-2017 and evaluated at 16-26 months corrected age in the Vermont Oxford Network (VON) ELBW Follow-Up Project were included. Logistic regression determined the adjusted relative risk (aRR) of severe NDI in medical or surgical NEC compared to no NEC, stratified by severity of IVH. RESULTS Follow-up evaluation occurred in 5870 ELBW survivors. Compared to no NEC, medical NEC had no impact on NDI, regardless of IVH status. Surgical NEC increased risk of NDI in patients with no IVH (aRR 1.69; 95% CI 1.36-2.09), mild IVH (aRR 1.36;0.97-1.92), and severe IVH (aRR 1.35;1.13-1.60). CONCLUSIONS ELBW infants with surgical NEC carry increased risk of neurodevelopmental disability within each IVH severity stratum. These data describe the additive insult of surgical NEC and IVH on neurodevelopment, informing prognostic discussions and highlighting the need for preventative interventions.
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Affiliation(s)
- Katherine Culbreath
- Boston Children's Hospital, Department of Surgery and Center for Advanced Intestinal Rehabilitation, Boston, MA, USA
| | - Gregory Keefe
- Boston Children's Hospital, Department of Surgery and Center for Advanced Intestinal Rehabilitation, Boston, MA, USA
| | - Emily Nes
- Boston Children's Hospital, Department of Surgery and Center for Advanced Intestinal Rehabilitation, Boston, MA, USA
| | | | - Jamie Knell
- Boston Children's Hospital, Department of Surgery and Center for Advanced Intestinal Rehabilitation, Boston, MA, USA
| | | | | | - Tom Jaksic
- Boston Children's Hospital, Department of Surgery and Center for Advanced Intestinal Rehabilitation, Boston, MA, USA
| | | | - Biren P Modi
- Boston Children's Hospital, Department of Surgery and Center for Advanced Intestinal Rehabilitation, Boston, MA, USA.
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Moore CM, Lorusso A, Morgan L, Brazil S, Croxon H, Waters A, Farrelly A, Hervig T, Curley A. Safety and feasibility of platelet transfusion through long catheters in the neonatal intensive care unit: an in vitro study. Arch Dis Child Fetal Neonatal Ed 2023; 109:70-73. [PMID: 37433587 PMCID: PMC10803993 DOI: 10.1136/archdischild-2023-325632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 06/30/2023] [Indexed: 07/13/2023]
Abstract
OBJECTIVE To assess the safety and feasibility of platelet transfusion through small-bore long lines used in the neonatal intensive care unit (NICU), including double-lumen umbilical venous catheters (UVCs) and 24 G and 28 G peripherally inserted central catheters (PICCs). DESIGN Prospective in vitro controlled study. SETTING Blood transfusion service laboratory. METHODS In vitro platelet transfusions were set up as per NICU practice. Transfusion line pressure was monitored. Post-transfusion swirling, presence of aggregates, pH analysis and automated cell count in vitro activation response by flow cytometry assessing CD62P expression were assessed. MAIN OUTCOME MEASURES All transfusions completed successfully. The rate of infusion was reduced in 5 of 16 transfusions through 28 G lines due to 'pressure high' alarms. There was no difference in swirling values or transfusion aggregate formation, CD62P expression levels, platelet count, platelet distribution width, mean platelet volume, plateletcrit or platelet to large cell ratio across transfusions post-transfusion. CONCLUSIONS This study showed that in vitro platelet transfusion performed through 24 G and 28 G neonatal PICC lines and double-lumen UVCs is non-inferior to 24 G short cannulas, using outcome measures of platelet clumping, platelet activation and line occlusion. This suggests that where available these lines can be used if necessary for platelet transfusion.
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Affiliation(s)
- Carmel Maria Moore
- School of Medicine, University College Dublin, Dublin, Ireland
- Neonatology, National Maternity Hospital, Dublin, Ireland
| | - Alice Lorusso
- National Blood Centre, Irish Blood Transfusion Service, Dublin, Ireland
| | - Liam Morgan
- National Blood Centre, Irish Blood Transfusion Service, Dublin, Ireland
| | - Sinead Brazil
- National Blood Centre, Irish Blood Transfusion Service, Dublin, Ireland
| | - Harry Croxon
- National Blood Centre, Irish Blood Transfusion Service, Dublin, Ireland
| | - Allison Waters
- National Blood Centre, Irish Blood Transfusion Service, Dublin, Ireland
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
| | - Aileen Farrelly
- National Blood Centre, Irish Blood Transfusion Service, Dublin, Ireland
| | - Tor Hervig
- National Blood Centre, Irish Blood Transfusion Service, Dublin, Ireland
| | - Anna Curley
- School of Medicine, University College Dublin, Dublin, Ireland
- Neonatology, National Maternity Hospital, Dublin, Ireland
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12
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Ma T, Sun Y, Wang Q, Liu F, Hua K, Wang L, Song A, Wang W, Xie X, Yang J, Li X. Retrospective cohort study of neonatal blood transfusion in China. BMC Pediatr 2023; 23:621. [PMID: 38066456 PMCID: PMC10709978 DOI: 10.1186/s12887-023-04225-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/02/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Blood transfusion therapy is extremely important for certain neonatal diseases, but the threshold for neonatal blood transfusion is not the same in different countries. Until now, clinical studies to determine the suitable threshold for newborns in China are lacking. Therefore, it is of high importance to establish a multi-center cohort study to explore appropriate transfusion thresholds for newborns in China. METHODS This retrospective cohort study investigated neonatal blood transfusion therapy administered from January 1, 2017 to June 30, 2018, with the aim of evaluating the effect of restricted and nonrestricted blood transfusion on neonatal health. The subjects were enrolled in 46 hospitals in China. A total of 5669 neonatal cases were included in the study. Clinical diagnosis and transfusion treatment of these neonates were collected and the data were retrospectively analyzed. The neonates were followed up 1 week and 1 month after leaving the hospital. The newborns' and their mothers' data were collected containing 280 variables in the database. The primary outcome of the study was mortality, and the secondary outcomes were complications, hospital stays, NICU hospital stays and hospital costs. RESULTS Results from the < 1500 g group showed that there was a higher mortality rate in the restricted transfusion group (11.41%) when compared with the non-restricted transfusion group (5.12%) (P = 0.000). Among the secondary outcomes, the restricted transfusion group had fewer costs. Results from the 1500-2500 g group showed that the mortality rates of the restricted and non-restricted transfusion groups were 3.53% and 4.71%, respectively, however there was no statistical significance between the two groups (P = 0.345). Among the secondary outcomes, the restricted transfusion group had fewer hospital stays, NICU hospital stays and hospital costs. The incidence of necrotizing enterocolitis was lower in the restricted transfusion group (OR, 2.626; 95% confidence interval [CI], 1.445 to 4.773; P = 0.003). The results from the ≥ 2500 g restricted transfusion group suggested that the mortality rate of (3.02%) was significantly lower than that of non-restricted transfusion group (9.55%) (P = 0.000). Among the secondary outcomes, the restricted transfusion group had fewer hospital stays and hospital costs. The incidence of retinopathy of prematurity was lower in the restricted transfusion group (OR, 4.624; 95% confidence interval [CI], 2.32 to 9.216; P = 0.000). CONCLUSIONS Current transfusion protocols for newborns weighing less than 1500 g may be inappropriate and lead to higher mortality. The current transfusion threshold performed better for the other two weight groups.
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Affiliation(s)
- Ting Ma
- Department of Transfusion Medicine, Shaanxi Provincial People's Hospital, 256 Youyi West Road, Xi'an, 710068, China
| | - Yang Sun
- Department of Data Center, Shaanxi Provincial People's Hospital, Xi'an, 710068, China
| | - Qiushi Wang
- Department of Transfusion Medicine, Shengjing Hospital of China Medical University, Shenyang, 110004, China
| | - Fenghua Liu
- Department of Transfusion Medicine, The Fisrt Affiliated Hospital of Harbin Medical University, Harbin, 150000, China
| | - Kai Hua
- College of Life Sciences, Northwest University, Xi'an, 710068, China
| | - Liqin Wang
- Department of Transfusion Medicine, Shaanxi Provincial People's Hospital, 256 Youyi West Road, Xi'an, 710068, China
| | - Aowei Song
- Department of Transfusion Medicine, Shaanxi Provincial People's Hospital, 256 Youyi West Road, Xi'an, 710068, China
| | - Wenhua Wang
- Department of Transfusion Medicine, Shaanxi Provincial People's Hospital, 256 Youyi West Road, Xi'an, 710068, China
| | - Xinxin Xie
- Department of Transfusion Medicine, Shaanxi Provincial People's Hospital, 256 Youyi West Road, Xi'an, 710068, China
| | - Jiangcun Yang
- Department of Transfusion Medicine, Shaanxi Provincial People's Hospital, 256 Youyi West Road, Xi'an, 710068, China.
| | - Xiling Li
- Department of Transfusion Medicine, Children's Hospital Of ShanXi, Xinmin North Street, 13, Xinghualing District, Taiyuan, 030013, China.
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13
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Andersen CC, Stark MJ, Kirpalani HM. Thresholds for Red Blood Cell Transfusion in Preterm Infants: Evidence to Practice. Clin Perinatol 2023; 50:763-774. [PMID: 37866846 DOI: 10.1016/j.clp.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
Rapid blood loss with circulatory shock is dangerous for the preterm infant as cardiac output and oxygen-carrying capacity are simultaneously imperilled. This requires prompt restoration of circulating blood volume with emergency transfusion. It is recommended that clinicians use both clinical and laboratory responses to guide transfusion requirements in this situation. For preterm infants with anemia of prematurity, it is recommended that clinicians use a restrictive algorithm from one of two recently published clinical trials. Transfusion outside these algorithms in very preterm infants is not evidence-based and is actively discouraged.
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Affiliation(s)
- Chad C Andersen
- Department of Perinatal Medicine, Women's and Children's Hospital and Robinson Research Institute, University of Adelaide, South Australia.
| | - Michael J Stark
- Department of Perinatal Medicine, Women's and Children's Hospital and Robinson Research Institute, University of Adelaide, South Australia
| | - Haresh M Kirpalani
- Children's Hospital of Philadelphia at University Pennsylvania, Philadelphia, USA; McMaster University, Hamilton, Ontario, Canada
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14
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Dantes G, Keene S. Transfusion in Neonatal Extracorporeal Membrane Oxygenation: A Best Practice Review. Clin Perinatol 2023; 50:839-852. [PMID: 37866851 DOI: 10.1016/j.clp.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
Extracorporeal Membrane Oxygenation (ECMO) is an important tool for managing critically ill neonates. Bleeding and thrombotic complications are common and significant. An understanding of ECMO physiology, its interactions with the unique neonatal hemostatic pathways, and appreciation for the distinctive risks and benefits of neonatal transfusion as it applies to ECMO are required. Currently, there is variability regarding transfusion practices, related to changing norms and a lack of high-quality literature and trials. This review provides an analysis of the neonatal ECMO transfusion literature and summarizes available best practice guidelines.
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Affiliation(s)
- Goeto Dantes
- Department of Surgery, Emory University, Children's Healthcare of Atlanta, Atlanta, GA, USA; Emory University School of Medicine, Emory University, Atlanta, GA, USA.
| | - Sarah Keene
- Emory University School of Medicine, Emory University, Atlanta, GA, USA; Department of Neonatology, Emory University, Children's Healthcare of Atlanta, Atlanta, GA, USA; Emory + Children's Pediatric Institute, Atlanta, GA, USA
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15
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Salem A, Patel RM. Blood Donor Sex and Outcomes in Transfused Infants. Clin Perinatol 2023; 50:805-820. [PMID: 37866849 PMCID: PMC10688602 DOI: 10.1016/j.clp.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
Red blood cell transfusion is common in neonatal intensive care. Multiple trials have evaluated different thresholds for when to administer red blood cell transfusion. In contrast, there has been less focus on studies of the characteristics of red blood cells transfused into neonates. In this review, the authors summarize the emerging literature on the potential impact of the sex of blood donors on outcomes in transfused neonates using a systematic search strategy. The authors review the uncertainty generated from studies with conflicting findings and discuss considerations regarding the impact of blood donor sex and other characteristics on neonatal outcomes.
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Affiliation(s)
- Anand Salem
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, 2015 Uppergate Drive Northeast, Atlanta, GA 30322, USA
| | - Ravi Mangal Patel
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, 2015 Uppergate Drive Northeast, Atlanta, GA 30322, USA.
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16
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Chapman M, Keir A. Patient Blood Management in Neonates. Clin Perinatol 2023; 50:869-879. [PMID: 37866853 DOI: 10.1016/j.clp.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
Patient blood management (PBM) is an evidence-based care package to improve patient outcomes by optimizing a patient's blood, minimizing blood loss, and the effective management and, when appropriate, the tolerance of anemia. It is relatively well-developed in adult medicine and remains in its infancy in neonatology. This review explores why evidence-based guidelines are insufficient, discusses the variations in neonatal transfusion practice and why this matters, and provides the key updates in neonatal transfusion practice. The authors give examples of a successful neonatal PBM program and single-center projects.
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Affiliation(s)
- Michelle Chapman
- Department of Perinatal Medicine, Women's and Children's Hospital, 72 King William Road, North Adelaide, South Australia 5006, Australia
| | - Amy Keir
- Department of Perinatal Medicine, Women's and Children's Hospital, 72 King William Road, North Adelaide, South Australia 5006, Australia; Women's and Children's Hospital, North Adelaide and Clinical Associate Professor, Adelaide Medical School, University of Adelaide, South Australia, Australia.
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17
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Lyle ANJ, Shaikh H, Oslin E, Gray MM, Weiss EM. Race and Ethnicity of Infants Enrolled in Neonatal Clinical Trials: A Systematic Review. JAMA Netw Open 2023; 6:e2348882. [PMID: 38127349 PMCID: PMC10739112 DOI: 10.1001/jamanetworkopen.2023.48882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/08/2023] [Indexed: 12/23/2023] Open
Abstract
Importance Representativeness of populations within neonatal clinical trials is crucial to moving the field forward. Although racial and ethnic disparities in research inclusion are well documented in other fields, they are poorly described within neonatology. Objective To describe the race and ethnicity of infants included in a sample of recent US neonatal clinical trials and the variability in this reporting. Evidence Review A systematic search of US neonatal clinical trials entered into Cochrane CENTRAL 2017 to 2021 was conducted. Two individuals performed inclusion determination, data extraction, and quality assessment independently with discrepancies adjudicated by consensus. Findings Of 120 studies with 14 479 participants that met the inclusion criteria, 75 (62.5%) included any participant race or ethnicity data. In the studies that reported race and ethnicity, the median (IQR) percentage of participants of each background were 0% (0%-1%) Asian, 26% (9%-42%) Black, 3% (0%-12%) Hispanic, 0% (0%-0%) Indigenous (eg, Alaska Native, American Indian, and Native Hawaiian), 0% (0%-0%) multiple races, 57% (30%-68%) White, and 7% (1%-21%) other race or ethnicity. Asian, Black, Hispanic, and Indigenous participants were underrepresented, while White participants were overrepresented compared with a reference sample of the US clinical neonatal intensive care unit (NICU) population from the Vermont Oxford Network. Many participants were labeled as other race or ethnicity without adequate description. There was substantial variability in terms and methods of reporting race and ethnicity data. Geographic representation was heavily skewed toward the Northeast, with nearly one-quarter of states unrepresented. Conclusions and Relevance These findings suggest that neonatal research may perpetuate inequities by underrepresenting Asian, Black, Hispanic, and Indigenous neonates in clinical trials. Studies varied in documentation of race and ethnicity, and there was regional variation in the sites included. Based on these findings, funders and clinical trialists are advised to consider a 3-point targeted approach to address these issues: prioritize identifying ways to increase diversity in neonatal clinical trial participation, agree on a standardized method to report race and ethnicity among neonatal clinical trial participants, and prioritize the inclusion of participants from all regions of the US in neonatal clinical trials.
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Affiliation(s)
- Allison N J Lyle
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Henna Shaikh
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Ellie Oslin
- Treuman Katz Center for Pediatric Bioethics and Palliative Care, Seattle Children's Research Institute, Seattle, Washington
| | - Megan M Gray
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Elliott Mark Weiss
- Department of Pediatrics, University of Washington School of Medicine, Seattle
- Treuman Katz Center for Pediatric Bioethics and Palliative Care, Seattle Children's Research Institute, Seattle, Washington
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18
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Glaser K, Härtel C, Dammann O, Herting E, Andres O, Speer CP, Göpel W, Stahl A. Erythrocyte transfusions are associated with retinopathy of prematurity in extremely low gestational age newborns. Acta Paediatr 2023; 112:2507-2515. [PMID: 37667535 DOI: 10.1111/apa.16965] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/20/2023] [Accepted: 08/24/2023] [Indexed: 09/06/2023]
Abstract
AIM Retinopathy of prematurity (ROP) is a major morbidity in preterm infants causing visual impairment including blindness. Prevention and timely treatment are critical. We investigated the potential role of red blood cell (RBC) transfusions as risk factor for ROP development. METHODS Retrospective cohort study of data from 68 tertiary level neonatal intensive care units in Germany. Preterm infants born at 22 + 0 to 28 + 6 weeks of gestation between January 2009 and December 2021 were enrolled. RESULTS We included n = 12 565 infants. Prevalence of any ROP was 49.2% with most infants being diagnosed with stage 1 (21.5%) and 2 disease (17.2%). ROP stage 3 was present in 10.2%, stage 4 in 0.3%, and ROP requiring treatment in 6.6%. Infants with ROP had significantly more frequently a history of RBC transfusions. Adjusting for confounders, RBC transfusions were associated with increased odds of ROP (OR 1.4, p < 0.001), ROP progression (OR 2.1, p < 0.01) and ROP requiring treatment (OR 3.6, p < 0.001). Restrictive transfusion approaches correlated with decreased (OR 0.7, p < 0.001), liberal regimes with increased odds (OR 1.2, p = 0.001). CONCLUSION The present study confirmed an association of RBC transfusions and ROP. Our findings emphasise the need for anaemia prevention and critical re-evaluation of transfusion practices in preterm infants.
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Affiliation(s)
- Kirsten Glaser
- Division of Neonatology, Department of Women's and Children's Health, University of Leipzig Medical Center, Leipzig, Germany
| | - Christoph Härtel
- Department of Pediatrics, University Hospital of Würzburg, Würzburg, Germany
| | - Olaf Dammann
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Egbert Herting
- Department of Pediatrics, University Hospital of Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Oliver Andres
- Department of Pediatrics, University Hospital of Würzburg, Würzburg, Germany
| | - Christian P Speer
- Department of Pediatrics, University Hospital of Würzburg, Würzburg, Germany
| | - Wolfgang Göpel
- Department of Pediatrics, University Hospital of Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Andreas Stahl
- Department of Ophthalmology, University Medicine Greifswald, Greifswald, Germany
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19
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Patel RM, Keir A. Understanding the WHEN, WHAT, and WHY of Neonatal Transfusion Medicine. Clin Perinatol 2023; 50:xix-xxi. [PMID: 37866856 DOI: 10.1016/j.clp.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Affiliation(s)
- Ravi Mangal Patel
- Emory University School of Medicine and Children's Healthcare of Atlanta, 2015 Uppergate Drive NE, Atlanta, GA 30322, USA.
| | - Amy Keir
- South Australia Health and Medical Research Institute, 72 King William Road, North Adelaide, SA 5006, Australia.
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20
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Moore CM, O'Sullivan S, Curley AE. Parents' understanding and experiences of blood component transfusion in the neonatal intensive care unit: A qualitative study. Acta Paediatr 2023; 112:2493-2502. [PMID: 37615240 DOI: 10.1111/apa.16952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/03/2023] [Accepted: 08/15/2023] [Indexed: 08/25/2023]
Abstract
AIM Blood component transfusion is a common intervention in the neonatal intensive care unit (NICU). Parents consent on their babies' behalf. This study aimed to explore parents' understandings and experiences of consenting and the subsequent blood transfusion. METHODS A "low inference" qualitative descriptive semi-structured interview approach was utilised. Grounded theory was employed. Parents described their memories of babies' transfusions, their responses to the consent process and assessed the written information they were given. RESULTS A purposive sample of 17 parents whose babies required blood transfusion in the NICU participated. Parents talked about their initial fears of transfusion, later replaced by confidence in the process and results of transfusion and trust in the healthcare professional team. The main themes elicited by the interviews were parents' expectations and outcomes of transfusion, parents' prior and current opinions of transfusion, parents trust in healthcare professionals and how parents would like to receive information about transfusions in the NICU. CONCLUSION Parents in our study trust information from the healthcare professionals caring for their baby and would like more specific information about how blood transfusion will impact their baby, in a variety of means. Parents felt that blood transfusions were beneficial for their babies.
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Affiliation(s)
- Carmel Maria Moore
- School of Medicine, University College Dublin, Dublin 4, Ireland
- Neonatology, National Maternity Hospital, Dublin 2, Ireland
| | - Sara O'Sullivan
- School of Sociology, University College Dublin, Dublin 4, Ireland
| | - Anna E Curley
- School of Medicine, University College Dublin, Dublin 4, Ireland
- Neonatology, National Maternity Hospital, Dublin 2, Ireland
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21
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Bailey SM, Mally PV. Near-Infrared Spectroscopy to Guide and Understand Effects of Red Blood Cell Transfusion. Clin Perinatol 2023; 50:895-910. [PMID: 37866855 DOI: 10.1016/j.clp.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
This review is a summary of available evidence regarding the use of near-infrared spectroscopy (NIRS) to help better guide and understand the effects of red blood cell (RBC) transfusion in neonatal patients. We review recent literature demonstrating the changes that take place in regional tissue oxygen saturation (rSO2) resulting from RBC transfusion. We also discuss in detail if any correlation exists between rSO2 and hemoglobin values in neonates. Finally, we review studies that have evaluated the use of NIRS as a transfusion guide during neonatal intensive care.
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Affiliation(s)
- Sean M Bailey
- Division of Neonatology, Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children's Hospital NYU Langone, 317 East 34th Street, Suite 902, New York, NY 10016, USA.
| | - Pradeep V Mally
- Division of Neonatology, Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children's Hospital NYU Langone, 317 East 34th Street, Suite 902, New York, NY 10016, USA
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22
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Gisslen T, Rao R, Georgieff MK. Anemia, Iron Supplementation, and the Brain. Clin Perinatol 2023; 50:853-868. [PMID: 37866852 PMCID: PMC10590989 DOI: 10.1016/j.clp.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
The developing brain is particularly vulnerable to extrinsic environmental events such as anemia and iron deficiency during periods of rapid development. Studies of infants with postnatal iron deficiency and iron deficiency anemia clearly demonstrated negative effects on short-term and long-term brain development and function. Randomized interventional trials studied erythropoiesis-stimulating agents and hemoglobin-based red blood cell transfusion thresholds to determine how they affect preterm infant neurodevelopment. Studies of red blood cell transfusion components are limited in preterm neonates. A biomarker strategy measuring brain iron status and health in the preanemic period is desirable to evaluate treatment options and brain response.
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Affiliation(s)
- Tate Gisslen
- Division of Neonatology, Department of Pediatrics, University of Minnesota Medical School, Academic Office Building, 2450 Riverside Avenue, SAO-401, Minneapolis, MN 55454, USA.
| | - Raghavendra Rao
- Division of Neonatology, Department of Pediatrics, University of Minnesota Medical School, Academic Office Building, 2450 Riverside Avenue, SAO-401, Minneapolis, MN 55454, USA
| | - Michael K Georgieff
- Division of Neonatology, Department of Pediatrics, University of Minnesota Medical School, Academic Office Building, 2450 Riverside Avenue, SAO-401, Minneapolis, MN 55454, USA
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23
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Stark CM, Juul SE. New frontiers in neonatal red blood cell transfusion research. J Perinatol 2023; 43:1349-1356. [PMID: 37667005 DOI: 10.1038/s41372-023-01757-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 08/06/2023] [Accepted: 08/15/2023] [Indexed: 09/06/2023]
Abstract
Red blood cell (RBC) transfusions are common in neonates requiring intensive care. Recent studies have compared restricted versus liberal transfusion guidelines, but limitations exist on evaluations of outcomes in populations that never required a transfusion compared to those receiving any transfusion. Although there are well-established risks associated with RBC transfusions, new data has emerged that suggests additional clinically relevant associations, including adverse neurodevelopmental outcomes, donor sex differences, and inflammation or immunosuppression. Further research is needed to delineate the magnitude of these risks and to further improve the safety of transfusions. The goal of this review is to highlight underappreciated, yet clinically important risks associated with neonatal RBC transfusions and to introduce several areas in which neonates may uniquely benefit from alterations in practice.
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Affiliation(s)
- Christopher M Stark
- Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, MD, USA.
| | - Sandra E Juul
- Institute on Human Development and Disability (IHDD) and the Intellectual and Developmental Disabilities Research Center (IDDRC), Department of Pediatrics, University of Washington, Seattle, WA, USA
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24
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Nakhla D, Kushnir A, Ahmed R, Bhandari V, Hunter K, Nakhla T. Reticulocyte Count: The Forgotten Factor in Transfusion Decisions for Extremely Low Birth Weight Infants. Am J Perinatol 2023; 40:1638-1643. [PMID: 34560784 DOI: 10.1055/a-1653-4585] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Extremely low birth weight (ELBW) infants often receive transfusions of packed red blood cells (PRBCs). Long-term outcomes of infants treated with liberal versus restricted transfusion criteria have been evaluated with conflicting results. Clinicians incorporate a reticulocyte count (RC) in their transfusion decisions. There is a lack of information on reference ranges for RCs in growing ELBW infants and whether infant's chronologic age or corrected gestational age (GA) generates a specific trend in the RCs. Our aim was to evaluate the levels of RCs obtained from ELBW infants over the course of the initial hospitalization. STUDY DESIGN A retrospective chart review of ELBW infants treated in the neonatal intensive care unit (NICU) and had RCs performed. We analyzed the RCs to observe trends based on the chronologic age and corrected GA. RESULTS A total of 738 RCs were analyzed. A positive trend in RCs that reached a peak at 32 to 34 weeks' corrected GA and then experienced a downward trend was observed. CONCLUSION Our report examines a very common hematologic test that is theoretically helpful but is in need of guidelines concerning the appropriate frequency of testing and its utility in making transfusion decisions in ELBW infants. KEY POINTS · RCs should help in making transfusion decisions for ELBW infants.. · No current reference ranges for RC in this population.. · No current reference ranges for RC based on GA and postnatal age..
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Affiliation(s)
- Daniel Nakhla
- Rutgers University, The State University of New Jersey, New Jersey
| | - Alla Kushnir
- Division of Neonatology, Children's Regional Hospital at Cooper University Hospital, Camden, New Jersey
| | - Rafat Ahmed
- Division of Neonatology, Children's Regional Hospital at Cooper University Hospital, Camden, New Jersey
| | - Vineet Bhandari
- Division of Neonatology, Children's Regional Hospital at Cooper University Hospital, Camden, New Jersey
| | - Krystal Hunter
- Division of Neonatology, Children's Regional Hospital at Cooper University Hospital, Camden, New Jersey
| | - Tarek Nakhla
- CHOP Newborn services at Virtua Hospital, Voorhees, New Jersey
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25
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Noroozi-Clever MB, Liao SM, Whitehead HV, Vesoulis ZA. Preterm Infants off Positive Pressure Respiratory Support Have a Higher Incidence of Occult Cerebral Hypoxia. J Pediatr 2023; 262:113648. [PMID: 37517651 PMCID: PMC10822026 DOI: 10.1016/j.jpeds.2023.113648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 07/21/2023] [Accepted: 07/25/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVE To use cerebral near-infrared spectroscopy (NIRS) to quantify occult cerebral hypoxia across respiratory support modes in preterm infants. STUDY DESIGN In this prospective, longitudinal, observational study, infants ≤32 weeks gestation underwent serial pulse oximetry (oxygen saturation [SpO2]) and cerebral NIRS monitoring (4-6 hours per session) following a standardized recording schedule (daily for 2 weeks, every other day for 2 weeks, then weekly until 35 weeks corrected gestational age). Four calculations were made: median cerebral saturation, median cerebral hypoxia burden (proportion of NIRS samples below the hypoxia threshold [<67%]), median systemic saturation, and median systemic hypoxia burden (proportion of SpO2 samples below the desaturation threshold [<85%]). During each recording session, respiratory support mode was noted (room air, low-flow nasal cannula, high-flow nasal cannula, noninvasive positive pressure ventilation, continuous positive airway pressure, and invasive ventilation). RESULTS There were 1013 recording sessions made from 174 infants with a median length of 6.9 hours. Although the systemic (SpO2) hypoxia burden was significantly greater for infants on the highest respiratory support (invasive and noninvasive positive pressure ventilation), the cerebral hypoxia burden was significantly greater during recording sessions made on the lowest respiratory support (8% for room air; 29% for low-flow nasal cannula). CONCLUSIONS Premature infants on the highest levels of respiratory support have less cerebral hypoxia than those on lower respiratory support. These results raise concern about unrecognized cerebral hypoxia during lower acuity periods of neonatal intensive care unit hospitalization and adverse outcomes.
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Affiliation(s)
- Mona B Noroozi-Clever
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Steve M Liao
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Halana V Whitehead
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Zachary A Vesoulis
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO.
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26
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Chock VY, Kirpalani H, Bell EF, Tan S, Hintz SR, Ball MB, Smith E, Das A, Loggins YC, Sood BG, Chalak LF, Wyckoff MH, Kicklighter SD, Kennedy KA, Patel RM, Carlo WA, Johnson KJ, Watterberg KL, Sánchez PJ, Laptook AR, Seabrook RB, Cotten CM, Mancini T, Sokol GM, Ohls RK, Hibbs AM, Poindexter BB, Reynolds AM, DeMauro SB, Chawla S, Baserga M, Walsh MC, Higgins RD, Van Meurs KP. Tissue Oxygenation Changes After Transfusion and Outcomes in Preterm Infants: A Secondary Near-Infrared Spectroscopy Study of the Transfusion of Prematures Randomized Clinical Trial (TOP NIRS). JAMA Netw Open 2023; 6:e2334889. [PMID: 37733345 PMCID: PMC10514737 DOI: 10.1001/jamanetworkopen.2023.34889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 07/18/2023] [Indexed: 09/22/2023] Open
Abstract
Importance Preterm infants with varying degrees of anemia have different tissue oxygen saturation responses to red blood cell (RBC) transfusion, and low cerebral saturation may be associated with adverse outcomes. Objective To determine whether RBC transfusion in preterm infants is associated with increases in cerebral and mesenteric tissue saturation (Csat and Msat, respectively) or decreases in cerebral and mesenteric fractional tissue oxygen extraction (cFTOE and mFTOE, respectively) and whether associations vary based on degree of anemia, and to investigate the association of Csat with death or neurodevelopmental impairment (NDI) at 22 to 26 months corrected age. Design, Setting, and Participants This was a prospective observational secondary study conducted among a subset of infants between August 2015 and April 2017 in the Transfusion of Prematures (TOP) multicenter randomized clinical trial at 16 neonatal intensive care units of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Preterm neonates with gestational age 22 to 28 weeks and birth weight 1000 g or less were randomized to higher or lower hemoglobin thresholds for transfusion. Data were analyzed between October 2020 and May 2022. Interventions Near-infrared spectroscopy monitoring of Csat and Msat. Main Outcomes and Measures Primary outcomes were changes in Csat, Msat, cFTOE, and mFTOE after transfusion between hemoglobin threshold groups, adjusting for age at transfusion, gestational age, birth weight stratum, and center. Secondary outcome at 22 to 26 months was death or NDI defined as cognitive delay (Bayley Scales of Infant and Toddler Development-III score <85), cerebral palsy with Gross Motor Function Classification System level II or greater, or severe vision or hearing impairment. Results A total of 179 infants (45 [44.6%] male) with mean (SD) gestational age 25.9 (1.5) weeks were enrolled, and valid data were captured from 101 infants during 237 transfusion events. Transfusion was associated with a significant increase in mean Csat of 4.8% (95% CI, 2.7%-6.9%) in the lower-hemoglobin threshold group compared to 2.7% (95% CI, 1.2%-4.2%) in the higher-hemoglobin threshold group, while mean Msat increased 6.7% (95% CI, 2.4%-11.0%) vs 5.6% (95% CI, 2.7%-8.5%). Mean cFTOE and mFTOE decreased in both groups to a similar extent. There was no significant change in peripheral oxygen saturation (SpO2) in either group (0.2% vs -0.2%). NDI or death occurred in 36 infants (37%). Number of transfusions with mean pretransfusion Csat less than 50% was associated with NDI or death (odds ratio, 2.41; 95% CI, 1.08-5.41; P = .03). Conclusions and Relevance In this secondary study of the TOP randomized clinical trial, Csat and Msat were increased after transfusion despite no change in SpO2. Lower pretransfusion Csat may be associated with adverse outcomes, supporting further investigation of targeted tissue saturation monitoring in preterm infants with anemia. Trial Registration ClinicalTrials.gov Identifier: NCT01702805.
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Affiliation(s)
- Valerie Y. Chock
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California
| | - Haresh Kirpalani
- Department of Pediatrics, University of Pennsylvania, Philadelphia
| | | | - Sylvia Tan
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | - Susan R. Hintz
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California
| | - M. Bethany Ball
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California
| | - Emily Smith
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | - Abhik Das
- Social, Statistical and Environmental Sciences Unit, RTI International, Rockville, Maryland
| | - Yvonne C. Loggins
- Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Beena G. Sood
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Lina F. Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas
| | - Myra H. Wyckoff
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas
| | - Stephen D. Kicklighter
- Division of Neonatology, Department of Pediatrics, WakeMed Health and Hospitals, Raleigh, North Carolina
| | - Kathleen A. Kennedy
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston
| | - Ravi M. Patel
- Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Waldemar A. Carlo
- Division of Neonatology, University of Alabama at Birmingham, Birmingham
| | | | | | - Pablo J. Sánchez
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus
| | - Abbot R. Laptook
- Department of Pediatrics, Women & Infants Hospital, Brown University, Providence, Rhode Island
| | - Ruth B. Seabrook
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus
| | | | - Toni Mancini
- Department of Pediatrics, University of Pennsylvania, Philadelphia
| | - Gregory M. Sokol
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis
| | - Robin K. Ohls
- University of New Mexico Health Sciences Center, Albuquerque
- Division of Neonatology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Anna Maria Hibbs
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Brenda B. Poindexter
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Anne Marie Reynolds
- Department of Pediatrics, University of Buffalo Women’s and Children’s Hospital of Buffalo, Buffalo, New York
| | - Sara B. DeMauro
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sanjay Chawla
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Mariana Baserga
- Division of Neonatology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Michele C. Walsh
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
- Research and Sponsored Programs, Florida Gulf Coast University, Fort Myers
| | - Krisa P. Van Meurs
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California
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Wei WH, Cho G, Smith M, Morley S. Dissecting the complexity of pediatric blood transfusions and risk of adverse reactions in Aotearoa New Zealand. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2023; 21:428-436. [PMID: 36580030 PMCID: PMC10497383 DOI: 10.2450/2022.0178-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 12/06/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Children have different clinical and physiological drivers for transfusion from adult recipients. However, adverse transfusion reactions (ATRs) in pediatric patients are usually reported using the same criteria as for adults. Broad assessments of pediatric ATRs neglect substantial variation in different developmental stages. MATERIALS AND METHODS This retrospective study included 342,950 patients, ~2.43 million transfusions, and 5,540 ATR reports collated from New Zealand hospitals between 2005 and 2021. Using 16 years as the upper age limit, 138,856 pediatric transfusions and 402 pediatric ATR reports were identified and dissected at three levels: pediatric as a whole, pediatric developmental stage (i.e., neonate, infant, preschool, and school), and chronological age to identify patients at high risk of ATRs. Multivariate logistic regression analysis was followed to quantify risk factors. RESULTS Pediatric recipients had a higher ATR risk than adults (p=6.9-07) but the high risk was associated mainly with children older than 2 years. Neonates and infants accounted for 75.0% of pediatric recipients but had much lower ATR rates than adults. Pediatric transfusion recipients showed a clear male bias prior to age 11 years and then a female bias. However, gender difference in experiencing ATRs was significant only after age 13 years (p=2.3-04). Analyses focusing on the high-risk group revealed allergic reactions being the cause of the elevated risk and identified the main risk factors of number of transfusions (p=4.5-10) and multiple types of components transfused (p=2.0-13). DISCUSSION The identified ATR risk factors signal linkage with the biological drivers for transfusion. Low ATR rates in infancy could also be attributed to use of neonatal components, low transfusions per patient, and less developed immunity. The relative increase in female recipients from age 11 may be associated with increased red blood cell demand following puberty.
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Affiliation(s)
- Wen-Hua Wei
- New Zealand Blood Service, Auckland, New Zealand
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
| | - Gavin Cho
- New Zealand Blood Service, Auckland, New Zealand
| | | | - Sarah Morley
- New Zealand Blood Service, Auckland, New Zealand
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28
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Salem A, Patel RM. Red Blood Cell Transfusion, Anemia, Feeding, and the Risk of Necrotizing Enterocolitis. Clin Perinatol 2023; 50:669-681. [PMID: 37536771 DOI: 10.1016/j.clp.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Necrotizing enterocolitis (NEC) is a leading cause of morbidity and mortality in preterm infants. Severe anemia and red blood cell (RBC) transfusion are associated with gut inflammation and injury in preclinical models and observational studies. However, there is uncertainty about the causal role of these factors in the pathogenesis of NEC. Observational studies have shown that withholding feeding during RBC transfusion may reduce the risk of NEC, although confirmatory data from randomized trials are lacking. In this review, we summarize data on feeding during RBC transfusion and its role in NEC and highlight ongoing randomized trials.
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Affiliation(s)
- Anand Salem
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, 2015 Uppergate Drive Northeast, Atlanta, GA 30322, USA
| | - Ravi M Patel
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, 2015 Uppergate Drive Northeast, Atlanta, GA 30322, USA.
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29
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Kitsommart R, Limrungsikul A, Tongsawang N, Thamwiriyakul N, Deesomchok A, Pithakton N, Paes B. Impact of level of neonatal care on phlebotomy and blood transfusion in extremely low birthweight infants: a prospective, multicenter, observational study. Front Pediatr 2023; 11:1238402. [PMID: 37724088 PMCID: PMC10505442 DOI: 10.3389/fped.2023.1238402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 08/21/2023] [Indexed: 09/20/2023] Open
Abstract
Objectives To explore the level of neonatal care on cumulative phlebotomy loss (cPL) and red cell transfusions in extremely low birthweight [ELBW; birthweight (BW) <1,000 g] infants, up to 40 weeks post-conceptual age (PCA). The secondary objective was to determine the associations between cPL and number of transfusions and between transfusions and hospital outcomes. Methods A prospective, comparative, observational study was conducted in two level IV and two level III neonatal intensive care units (NICUs) in Thailand. Daily cPL volume and number of blood tests were recorded. Descriptive data are reported as frequency and percentage for categorical variables and median [25th percentile (P25), 75th percentile (P75)] for continuous data according to the data distribution. A p-value <0.05 was considered statistically significant. Results 210 ELBW infants were included; 99 and 111 were admitted to level IV and level III NICUs, respectively. Birth weight of level IV infants was lower 780.0 [660.0, 875.0] vs. 865.0 [723.0, 930.0] g; p < 0.001]. Initial group hematocrits were similar (43.1% vs. 44.0%, p = 0.47). cPL for each infant was 28.1 [16.5, 46.4] ml. Level IV infants had more tests (n = 89 [54, 195] vs. 59 [37, 88], p < 0.001). Counterintuitively, there was a lower cPL trend in level IV infants, but this was insignificant (19.6 [12.3, 52.3] vs. 28.9 [19.3, 45.3] ml; p = 0.06). The number of transfusions in both NICUs was similar 4 [2, 6], with a strong correlation between cPL and number of transfusions (r = 0.79, p < 0.001). Transfusions were significantly associated with bronchopulmonary dysplasia [BPD; adjusted RR (95% CI): 2.6 (1.2, 5.3), p = 0.01]. Conclusions Level IV NICUs conducted more blood tests in ELBW infants without a difference in cPL, and number of transfusions. Cumulative PL correlated with number of transfusions and was associated with BPD risk. Minimizing cPL by point-of-care tests and restrictive transfusion criteria, may reduce need for transfusion.
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Affiliation(s)
- Ratchada Kitsommart
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Anchalee Limrungsikul
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Numtip Tongsawang
- Department of Pediatric Nursing, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Areeya Deesomchok
- Department of Pediatrics, Buddhachinaraj Hospital, Phitsanulok, Thailand
| | - Nuttanan Pithakton
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Bosco Paes
- Department of Pediatrics (Neonatal Division), McMaster University, Hamilton, ON, Canada
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30
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Moore CM, D'Amore A, Fustolo-Gunnink S, Hudson C, Newton A, Santamaria BL, Deary A, Hodge R, Hopkins V, Mora A, Llewelyn C, Venkatesh V, Khan R, Willoughby K, Onland W, Fijnvandraat K, New HV, Clarke P, Lopriore E, Watts T, Stanworth S, Curley A. Two-year outcomes following a randomised platelet transfusion trial in preterm infants. Arch Dis Child Fetal Neonatal Ed 2023; 108:452-457. [PMID: 36810309 PMCID: PMC10447411 DOI: 10.1136/archdischild-2022-324915] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 02/13/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVE Assess mortality and neurodevelopmental outcomes at 2 years of corrected age in children who participated in the PlaNeT-2/MATISSE (Platelets for Neonatal Transfusion - 2/Management of Thrombocytopenia in Special Subgroup) study, which reported that a higher platelet transfusion threshold was associated with significantly increased mortality or major bleeding compared to a lower one. DESIGN Randomised clinical trial, enrolling from June 2011 to August 2017. Follow-up was complete by January 2020. Caregivers were not blinded; however, outcome assessors were blinded to treatment group. SETTING 43 level II/III/IV neonatal intensive care units (NICUs) across UK, Netherlands and Ireland. PATIENTS 660 infants born at less than 34 weeks' gestation with platelet counts less than 50×109/L. INTERVENTIONS Infants were randomised to undergo a platelet transfusion at platelet count thresholds of 50×109/L (higher threshold group) or 25×109/L (lower threshold group). MAIN OUTCOMES MEASURES Our prespecified long-term follow-up outcome was a composite of death or neurodevelopmental impairment (developmental delay, cerebral palsy, seizure disorder, profound hearing or vision loss) at 2 years of corrected age. RESULTS Follow-up data were available for 601 of 653 (92%) eligible participants. Of the 296 infants assigned to the higher threshold group, 147 (50%) died or survived with neurodevelopmental impairment, as compared with 120 (39%) of 305 infants assigned to the lower threshold group (OR 1.54, 95% CI 1.09 to 2.17, p=0.017). CONCLUSIONS Infants randomised to a higher platelet transfusion threshold of 50×109/L compared with 25×109/L had a higher rate of death or significant neurodevelopmental impairment at a corrected age of 2 years. This further supports evidence of harm caused by high prophylactic platelet transfusion thresholds in preterm infants. TRIAL REGISTRATION NUMBER ISRCTN87736839.
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Affiliation(s)
- Carmel Maria Moore
- School of Medicine, University College Dublin, Dublin, Ireland
- Neonatology, National Maternity Hospital, Dublin, Ireland
| | - Angela D'Amore
- Neonatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Cara Hudson
- Clinical Trials Unit, NHS Blood and Transplant, Bristol, UK
| | - Alice Newton
- Clinical Trials Unit, NHS Blood and Transplant, Bristol, UK
| | | | - Alison Deary
- Clinical Trials Unit, NHS Blood and Transplant, Bristol, UK
| | - Renate Hodge
- Clinical Trials Unit, NHS Blood and Transplant, Bristol, UK
| | | | - Ana Mora
- Clinical Trials Unit, NHS Blood and Transplant, Bristol, UK
| | | | | | - Rizwan Khan
- NICU, University Maternity Hospital Limerick, Limerick, Ireland
| | - Karen Willoughby
- Neonatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Wes Onland
- Neonatology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Karin Fijnvandraat
- Pediatrics, Emma Children's Hospital, Pediatric Hematology, University of Amsterdam, Amsterdam, The Netherlands
| | - Helen V New
- Paediatric Transfusion Medicine, NHS Blood and Transplant, London, UK
| | - Paul Clarke
- Neonatal Intensive Care Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Enrico Lopriore
- Neonatology, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Timothy Watts
- Neonatal Intensive Care Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Simon Stanworth
- National Health Service Blood and Transplant, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Anna Curley
- School of Medicine, University College Dublin, Dublin, Ireland
- Neonatology, National Maternity Hospital, Dublin, Ireland
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31
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Adkins BD, Murfin R, Luu HS, Noland DK. Paediatric clinical decision support: Evaluation of a best practice alert for red blood cell transfusion. Vox Sang 2023; 118:746-752. [PMID: 37431735 DOI: 10.1111/vox.13497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/27/2023] [Accepted: 06/28/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND AND OBJECTIVES Providing red blood cell (RBC) transfusion to paediatric patients with a haemoglobin (Hb) level of <7 g/dL is the current best practice, but it is often difficult to ensure appropriateness of RBC transfusion on a health system level. Electronic health record (EHR) clinical decision support systems have been shown to be effective in encouraging providers to transfuse at appropriate Hb thresholds. We present our experience with an interruptive best practice alert (BPA) at a paediatric healthcare system. MATERIALS AND METHODS An interruptive BPA requiring physician response was implemented in our EHR (Epic Systems Corp., Verona, WI, USA) in 2018 based on Hb thresholds for inpatients. The threshold was initially <8 g/dL and later changed to <7 g/dL in 2019. We assessed total activations, number of RBC transfusions and hospital metrics through 2022 compared to the 2 years prior to implementation. RESULTS The BPA activated 6956 times over 4 years, slightly less than 5/day, and the success rate, with no RBC transfusions within 24 h of order attempt, was 14.5% (1012/6956). There was a downward trend in the number of total RBC transfusions and RBC transfusions per admission after implementation, non-significant (p = 0.41 and p = >0.99). The annual case mix index was similar over the years evaluated. The estimated cost savings based on acquisition costs for RBC units were 213,822 USD or about $51,891 per year. CONCLUSION BPA implementation led to sustained change in RBC transfusion towards best practice, and there were long-term savings in RBC expenditure.
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Affiliation(s)
- Brian D Adkins
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pathology, Children's Health, Dallas, Texas, USA
| | - Roberta Murfin
- Department of Pathology, Children's Health, Dallas, Texas, USA
| | - Hung S Luu
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pathology, Children's Health, Dallas, Texas, USA
| | - Daniel K Noland
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pathology, Children's Health, Dallas, Texas, USA
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32
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Salas AA, Travers CP. The Practice of Enteral Nutrition: Clinical Evidence for Feeding Protocols. Clin Perinatol 2023; 50:607-623. [PMID: 37536767 PMCID: PMC10599301 DOI: 10.1016/j.clp.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Establishing full enteral nutrition in critically ill preterm infants with immature gastrointestinal function is challenging. In this article, we will summarize emerging clinical evidence from randomized clinical trials suggesting the feasibility and efficacy of feeding interventions targeting the early establishment of full enteral nutrition. We will also examine trial outcomes of higher volume feedings after the establishment of full enteral nutrition. Only data from randomized clinical trials will be discussed extensively. Future opportunities for clinical research will also be presented.
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Affiliation(s)
- Ariel A Salas
- Division of Neonatology, Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham, 1700 6th Avenue South Women & Infants Center Suite 9380, Birmingham, AL 35233, USA.
| | - Colm P Travers
- Division of Neonatology, Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham, 1700 6th Avenue South Women & Infants Center Suite 9380, Birmingham, AL 35233, USA
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33
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Zupancic JAF. Economic considerations for resuscitative interventions in the immediate newborn period. Semin Perinatol 2023:151783. [PMID: 37380528 DOI: 10.1016/j.semperi.2023.151783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
We present a systematic scoping review of the literature, which documents that only a very small number of interventions related to delivery room stabilization and resuscitation have been studied for their economic impact. Published analyses are mostly of programmatic interventions such as resuscitation training programs, are mostly in low-resource settings, and are of variable methodological quality. Investigators who are conducting clinical studies of delivery room interventions can address these deficiencies in the literature by engaging with health services researchers to assess economic outcomes alongside those studies. We provide a framework of five questions that clinical researchers may use to decide on when such an ancillary study is indicated, and to provide them with the necessary language to discuss the methodological details of potential evaluations with their health services colleagues. Emphasis should be given to interventions that are targeted to high volumes of patients, are expensive, or are likely to lead to changes in costly chronic outcomes.
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Affiliation(s)
- John A F Zupancic
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA, USA; Division of Newborn Medicine, Harvard Medical School, Boston, MA, USA.
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34
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Wittenmeier E, Komorek Y, Engelhard K. Current hemoglobin thresholds in pediatric anesthesia - guidelines and studies. Curr Opin Anaesthesiol 2023; 36:301-310. [PMID: 36794871 DOI: 10.1097/aco.0000000000001253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
PURPOSE OF REVIEW The use of restrictive transfusion triggers to avoid unnecessary transfusions is one important pillar of Patient Blood Management (PBM). For the safe application of this principle in pediatric patients, anesthesiologists need evidence-based guidelines for hemoglobin (Hb) transfusions thresholds in this specially vulnerable age-group. RECENT FINDINGS This review outlines recent prospective and observational studies examining transfusion thresholds in pediatrics. Recommendations to use transfusion triggers in the perioperative or intensive care setting are summarized. SUMMARY Two high-quality studies confirmed that the use of restrictive transfusion triggers in preterm infants in the intensive care unit (ICU) is reasonable and feasible. Unfortunately, no recent prospective study could be found investigating intraoperative transfusion triggers. Some observational studies showed wide variability in Hb levels before transfusion, a tendency toward restrictive transfusion practices in preterm infants, and liberal transfusion practices in older infants. Although there are comprehensive and useful guidelines for clinical practice in pediatric transfusion, most of them do not cover the intraoperative period in particular because of a lack of high-quality studies. This lack of prospective randomized trials focusing on intraoperative transfusion management remains a major problem for the application of pediatric PBM.
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Affiliation(s)
- Eva Wittenmeier
- Department of Anesthesiology, University Medical Centre of the Johannes Gutenberg University Mainz, Germany
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35
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Holzapfel LF, Rysavy MA, Bell EF. Red Blood Cell Transfusion Thresholds for Anemia of Prematurity. Neoreviews 2023; 24:e370-e376. [PMID: 37258497 PMCID: PMC10865726 DOI: 10.1542/neo.24-6-e370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Anemia of prematurity affects the majority of preterm infants, particularly extremely low birthweight infants. Anemia of prematurity arises from both innate and iatrogenic causes and results in more than 80% of extremely preterm infants receiving red blood cell transfusions during the first month after birth. Multiple randomized controlled trials were conducted to evaluate the effect of using lower versus higher transfusion thresholds based on hemoglobin levels. These trials showed no difference in the primary outcome of neurodevelopmental impairment at 2 years of age between lower and higher thresholds. However, some uncertainties about transfusion thresholds remain. This review elaborates the following: 1) the etiology, prevention, and treatment of anemia of prematurity with a focus on red blood cell transfusions, 2) the history of randomized controlled trials on the treatment of anemia of prematurity, and 3) limitations of the evidence and remaining questions about thresholds for red blood cell transfusions in preterm infants.
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Affiliation(s)
- Lindsay F Holzapfel
- McGovern Medical School at University of Texas Health Science Center, Houston, TX
- Children's Memorial Hermann Hospital, Houston, TX
| | - Matthew A Rysavy
- McGovern Medical School at University of Texas Health Science Center, Houston, TX
- Children's Memorial Hermann Hospital, Houston, TX
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36
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Tan GM, Murto K, Downey LA, Wilder MS, Goobie SM. Error traps in Pediatric Patient Blood Management in the Perioperative Period. Paediatr Anaesth 2023. [PMID: 37144721 DOI: 10.1111/pan.14683] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 04/04/2023] [Accepted: 04/12/2023] [Indexed: 05/06/2023]
Abstract
Patient blood management is a patient-centered evidence-based approach to improve patient outcomes by harnessing the patient's own hematopoietic system to optimize blood health while promoting patient safety and empowerment. Perioperative patient blood management is a standard of care in adult medicine, yet it is not commonly accepted in pediatrics. Raising awareness may be the first step in improving perioperative care for the anemic and/or bleeding child. This article highlights five preventable perioperative blood conservation error traps for children. The goal is to provide practical clinical guidance to improve preoperative diagnosis and treatment of anemia, facilitate recognition and treatment of massive hemorrhage, reduce unnecessary allogeneic blood transfusions, and decrease associated complications of anemia and blood component transfusions utilizing a patient/family-centered informed consent and shared decision-making approach.
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Affiliation(s)
- Gee Mei Tan
- Pediatric Anesthesiology Division, Children's Hospital Colorado, University of Colorado, School of Medicine, Aurora, Colorado, USA
| | - Kimmo Murto
- Department of Anesthesiology & Pain Medicine, Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Laura A Downey
- Department of Anesthesiology, Emory University Medical School, Atlanta, Georgia, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Matthew S Wilder
- Pediatric Anesthesiology Division, Children's Hospital Colorado, University of Colorado, School of Medicine, Aurora, Colorado, USA
| | - Susan M Goobie
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Razak A, Patel W, Durrani NUR, Pullattayil AK. Interventions to Reduce Severe Brain Injury Risk in Preterm Neonates: A Systematic Review and Meta-analysis. JAMA Netw Open 2023; 6:e237473. [PMID: 37052920 PMCID: PMC10102877 DOI: 10.1001/jamanetworkopen.2023.7473] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 02/23/2023] [Indexed: 04/14/2023] Open
Abstract
Importance Interventions to reduce severe brain injury risk are the prime focus in neonatal clinical trials. Objective To evaluate multiple perinatal interventions across clinical settings for reducing the risk of severe intraventricular hemorrhage (sIVH) and cystic periventricular leukomalacia (cPVL) in preterm neonates. Data Sources MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases were searched from inception until September 8, 2022, using prespecified search terms and no language restrictions. Study Selection Randomized clinical trials (RCTs) that evaluated perinatal interventions, chosen a priori, and reported 1 or more outcomes (sIVH, cPVL, and severe brain injury) were included. Data Extraction and Synthesis Two co-authors independently extracted the data, assessed the quality of the trials, and evaluated the certainty of the evidence using the Cochrane GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Fixed-effects pairwise meta-analysis was used for data synthesis. Main Outcomes and Measures The 3 prespecified outcomes were sIVH, cPVL, and severe brain injury. Results A total of 221 RCTs that assessed 44 perinatal interventions (6 antenatal, 6 delivery room, and 32 neonatal) were included. Meta-analysis showed with moderate certainty that antenatal corticosteroids were associated with small reduction in sIVH risk (risk ratio [RR], 0.54 [95% CI, 0.35-0.82]; absolute risk difference [ARD], -1% [95% CI, -2% to 0%]; number needed to treat [NNT], 80 [95% CI, 48-232]), whereas indomethacin prophylaxis was associated with moderate reduction in sIVH risk (RR, 0.64 [95% CI, 0.52-0.79]; ARD, -5% [95% CI, -8% to -3%]; NNT, 20 [95% CI, 13-39]). Similarly, the meta-analysis showed with low certainty that volume-targeted ventilation was associated with large reduction in risk of sIVH (RR, 0.51 [95% CI, 0.36-0.72]; ARD, -9% [95% CI, -13% to -5%]; NNT, 11 [95% CI, 7-23]). Additionally, early erythropoiesis-stimulating agents (RR, 0.68 [95% CI, 0.57-0.83]; ARD, -3% [95% CI, -4% to -1%]; NNT, 34 [95% CI, 22-67]) and prophylactic ethamsylate (RR, 0.68 [95% CI, 0.48-0.97]; ARD, -4% [95% CI, -7% to 0%]; NNT, 26 [95% CI, 13-372]) were associated with moderate reduction in sIVH risk (low certainty). The meta-analysis also showed with low certainty that compared with delayed cord clamping, umbilical cord milking was associated with a moderate increase in sIVH risk (RR, 1.82 [95% CI, 1.03-3.21]; ARD, 3% [95% CI, 0%-6%]; NNT, -30 [95% CI, -368 to -16]). Conclusions and Relevance Results of this study suggest that a few interventions, including antenatal corticosteroids and indomethacin prophylaxis, were associated with reduction in sIVH risk (moderate certainty), and volume-targeted ventilation, early erythropoiesis-stimulating agents, and prophylactic ethamsylate were associated with reduction in sIVH risk (low certainty) in preterm neonates. However, clinicians should carefully consider all of the critical factors that may affect applicability in these interventions, including certainty of the evidence, before applying them to clinical practice.
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Affiliation(s)
- Abdul Razak
- Department of Pediatrics, Monash University, Melbourne, Victoria, Australia
- Monash Newborn, Monash Children’s Hospital, Melbourne, Victoria, Australia
- Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Waseemoddin Patel
- Division of Neonatology, Department of Pediatrics, Sidra Medicine, Doha, Qatar
| | - Naveed Ur Rehman Durrani
- Division of Neonatology, Department of Pediatrics, Sidra Medicine, Doha, Qatar
- Department of Pediatrics, Weill Cornell Medicine–Qatar, Doha, Qatar
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38
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Sweet DG, Carnielli VP, Greisen G, Hallman M, Klebermass-Schrehof K, Ozek E, te Pas A, Plavka R, Roehr CC, Saugstad OD, Simeoni U, Speer CP, Vento M, Visser GH, Halliday HL. European Consensus Guidelines on the Management of Respiratory Distress Syndrome: 2022 Update. Neonatology 2023; 120:3-23. [PMID: 36863329 PMCID: PMC10064400 DOI: 10.1159/000528914] [Citation(s) in RCA: 74] [Impact Index Per Article: 74.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/12/2022] [Indexed: 02/17/2023]
Abstract
Respiratory distress syndrome (RDS) care pathways evolve slowly as new evidence emerges. We report the sixth version of "European Guidelines for the Management of RDS" by a panel of experienced European neonatologists and an expert perinatal obstetrician based on available literature up to end of 2022. Optimising outcome for babies with RDS includes prediction of risk of preterm delivery, appropriate maternal transfer to a perinatal centre, and appropriate and timely use of antenatal steroids. Evidence-based lung-protective management includes initiation of non-invasive respiratory support from birth, judicious use of oxygen, early surfactant administration, caffeine therapy, and avoidance of intubation and mechanical ventilation where possible. Methods of ongoing non-invasive respiratory support have been further refined and may help reduce chronic lung disease. As technology for delivering mechanical ventilation improves, the risk of causing lung injury should decrease, although minimising time spent on mechanical ventilation by targeted use of postnatal corticosteroids remains essential. The general care of infants with RDS is also reviewed, including emphasis on appropriate cardiovascular support and judicious use of antibiotics as being important determinants of best outcome. We would like to dedicate this guideline to the memory of Professor Henry Halliday who died on November 12, 2022.These updated guidelines contain evidence from recent Cochrane reviews and medical literature since 2019. Strength of evidence supporting recommendations has been evaluated using the GRADE system. There are changes to some of the previous recommendations as well as some changes to the strength of evidence supporting recommendations that have not changed. This guideline has been endorsed by the European Society for Paediatric Research (ESPR) and the Union of European Neonatal and Perinatal Societies (UENPS).
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Affiliation(s)
- David G. Sweet
- Regional Neonatal Unit, Royal Maternity Hospital, Belfast, UK
| | - Virgilio P. Carnielli
- Department of Neonatology, University Polytechnic Della Marche, University Hospital Ancona, Ancona, Italy
| | - Gorm Greisen
- Department of Neonatology, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Mikko Hallman
- Department of Children and Adolescents, Oulu University Hospital and Medical Research Center, University of Oulu, Oulu, Finland
| | - Katrin Klebermass-Schrehof
- Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Medical University of Vienna, Vienna, Austria
| | - Eren Ozek
- Department of Pediatrics, Marmara University Medical Faculty, Istanbul, Turkey
| | - Arjan te Pas
- Leiden University Medical Centre, Leiden, The Netherlands
| | - Richard Plavka
- Division of Neonatology, Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Faculty of Medicine, Charles University, Prague, Czechia
| | - Charles C. Roehr
- Faculty of Health Sciences, University of Bristol, UK and National Perinatal Epidemiology Unit, Oxford Population Health, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Ola D. Saugstad
- Department of Pediatric Research, Oslo University Hospital Rikshospitalet, University of Oslo, Oslo, Norway
- Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Christian P. Speer
- Department of Pediatrics, University Children's Hospital, Wuerzburg, Germany
| | - Maximo Vento
- Department of Pediatrics and Neonatal Research Unit, Health Research Institute La Fe, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Gerry H.A. Visser
- Department of Obstetrics and Gynecology, University Medical Centre, Utrecht, The Netherlands
| | - Henry L. Halliday
- Department of Child Health, Queen's University Belfast and Royal Maternity Hospital, Belfast, UK
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39
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Garcia MR, Comstock BA, Patel RM, Tolia VN, Josephson CD, Georgieff MK, Rao R, Monsell SE, Juul SE, Ahmad KA. Iron supplementation and the risk of bronchopulmonary dysplasia in extremely low gestational age newborns. Pediatr Res 2023; 93:701-707. [PMID: 35725917 PMCID: PMC9763546 DOI: 10.1038/s41390-022-02160-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 04/26/2022] [Accepted: 05/22/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND The aim of this study was to determine the relationship between iron exposure and the development of bronchopulmonary dysplasia (BPD). METHODS A secondary analysis of the PENUT Trial dataset was conducted. The primary outcome was BPD at 36 weeks gestational age and primary exposures of interest were cumulative iron exposures in the first 28 days and through 36 weeks' gestation. Descriptive statistics were calculated for study cohort characteristics with analysis adjusted for the factors used to stratify randomization. RESULTS Of the 941 patients, 821 (87.2%) survived to BPD evaluation at 36 weeks, with 332 (40.4%) diagnosed with BPD. The median cohort gestational age was 26 weeks and birth weight 810 g. In the first 28 days, 76% of infants received enteral iron and 55% parenteral iron. The median supplemental cumulative enteral and parenteral iron intakes at 28 days were 58.5 and 3.1 mg/kg, respectively, and through 36 weeks' 235.8 and 3.56 mg/kg, respectively. We found lower volume of red blood cell transfusions in the first 28 days after birth and higher enteral iron exposure in the first 28 days after birth to be associated with lower rates of BPD. CONCLUSIONS We find no support for an increased risk of BPD with iron supplementation. TRIAL REGISTRATION NUMBER NCT01378273. https://clinicaltrials.gov/ct2/show/NCT01378273 IMPACT: Prior studies and biologic plausibility raise the possibility that iron administration could contribute to the pathophysiology of oxidant-induced lung injury and thus bronchopulmonary dysplasia in preterm infants. For 24-27-week premature infants, this study finds no association between total cumulative enteral iron supplementation at either 28-day or 36-week postmenstrual age and the risk for developing bronchopulmonary dysplasia.
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Affiliation(s)
- Melissa R Garcia
- San Antonio Uniformed Services Health Education Consortium, San Antonio, TX, USA
| | | | - Ravi M Patel
- Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Veeral N Tolia
- Pediatrix Medical Group, Dallas, TX, USA
- Baylor University Medical Center, Dallas, TX, USA
| | - Cassandra D Josephson
- Emory University School of Medicine and Center for Transfusion and Cellular Therapies, Atlanta, GA, USA
| | | | | | | | | | - Kaashif A Ahmad
- San Antonio Uniformed Services Health Education Consortium, San Antonio, TX, USA.
- Pediatrix Medical Group, San Antonio, TX, USA.
- Baylor College of Medicine, San Antonio, TX, USA.
- Pediatrix and Obstetrix Specialists of Houston, Houston, TX, USA.
- Methodist Children's Hospital, San Antonio, TX, USA.
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40
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Impact of Early Hemoglobin Levels on Neurodevelopment Outcomes of Two-Year-Olds in Very Preterm Children. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020209. [PMID: 36832338 PMCID: PMC9955539 DOI: 10.3390/children10020209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 01/15/2023] [Accepted: 01/17/2023] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To evaluate, in very preterm infants, the hemoglobin (Hb) levels during the first 24 h and the neurodevelopment outcomes at 24 months of corrected age. DESIGN, SETTING, AND PATIENTS We conducted a secondary analysis of the French national prospective and population-based cohort EPIPAGE-2. The eligible study participants were live-born singletons who were born before 32 weeks of gestational age, with early Hb levels who were admitted to the neonatal intensive care unit. MAIN OUTCOME MEASURES The early Hb levels for an outcome survival at 24 months of corrected age without neurodevelopmental impairment were measured. The secondary outcomes were survival at discharge and without severe neonatal morbidity. RESULTS Of the 2158 singletons of <32 weeks with mean early Hb levels of 15.4 (±2.4) g/dL, 1490 of the infants (69%) had a follow-up at two years of age. An early Hb of 15.2 g/dL is the minimum receiving operating characteristic curve at the 24 months risk-free level, but the area under the curve at 0.54 (close to 50%) indicates that this rate was not informative. In logistic regression, no association was found between early Hb levels and outcomes at two years of age (aOR 0.966; 95% CI [0.775-1.204]; p = 0.758) but rather there was a correlation found with severe morbidity (aOR 1.322; 95% CI [1.003-1.743]; p = 0.048). A risk stratification tree showed that male newborns of >26 weeks with Hb of <15.5 g/dL (n = 703) were associated with a poor outcome at 24 months (OR 1.9; CI: [1.5-2.4] p < 0.01). CONCLUSIONS Early low Hb levels are associated with major neonatal morbidities in VP singletons, but not with neurodevelopment outcomes at two years of age, except in male infants of >26 Weeks GA.
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41
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Scrivens A, Reibel NJ, Heeger L, Stanworth S, Lopriore E, New HV, Dame C, Fijnvandraat K, Deschmann E, Aguar M, Brække K, Cardona FS, Cools F, Farrugia R, Ghirardello S, Lozar J, Matasova K, Muehlbacher T, Sankilampi U, Soares H, Szabo M, Szczapa T, Zaharie G, Roehr CC, Fustolo-Gunnink S. Survey of transfusion practices in preterm infants in Europe. Arch Dis Child Fetal Neonatal Ed 2023:archdischild-2022-324619. [PMID: 36653173 DOI: 10.1136/archdischild-2022-324619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 12/10/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Preterm infants commonly receive red blood cell (RBC), platelet and fresh frozen plasma (FFP) transfusions. The aim of this Neonatal Transfusion Network survey was to describe current transfusion practices in Europe and to compare our findings to three recent randomised controlled trials to understand how clinical practice relates to the trial data. METHODS From October to December 2020, we performed an online survey among 597 neonatal intensive care units (NICUs) caring for infants with a gestational age (GA) of <32 weeks in 18 European countries. RESULTS Responses from 343 NICUs (response rate: 57%) are presented and showed substantial variation in clinical practice. For RBC transfusions, 70% of NICUs transfused at thresholds above the restrictive thresholds tested in the recent trials and 22% below the restrictive thresholds. For platelet transfusions, 57% of NICUs transfused at platelet count thresholds above 25×109/L in non-bleeding infants of GA of <28 weeks, while the 25×109/L threshold was associated with a lower risk of harm in a recent trial. FFP transfusions were administered for coagulopathy without active bleeding in 39% and for hypotension in 25% of NICUs. Transfusion volume, duration and rate varied by factors up to several folds between NICUs. CONCLUSIONS Transfusion thresholds and aspects of administration vary widely across European NICUs. In general, transfusion thresholds used tend to be more liberal compared with data from recent trials supporting the use of more restrictive thresholds. Further research is needed to identify the barriers and enablers to incorporation of recent trial findings into neonatal transfusion practice.
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Affiliation(s)
- Alexandra Scrivens
- Newborn Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Lisanne Heeger
- Neonatology, Leiden University Medical Centre, Leiden, The Netherlands.,Sanquin Blood Supply Foundation, Amsterdam, The Netherlands
| | - Simon Stanworth
- Department of Haematology, National Health Service, Blood and Transplant, Oxford University Hopsitals NHS Foundation Trust, Oxford, UK
| | - Enrico Lopriore
- Neonatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Helen V New
- Paediatric Transfusion Medicine, National Health Service, Blood and Transplant, London, UK
| | - Christof Dame
- Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Karin Fijnvandraat
- Sanquin Blood Supply Foundation, Amsterdam, The Netherlands.,Pediatrics, Emma Children's Hospital, Pediatric Hematology, University of Amsterdam, Amsterdam, The Netherlands
| | - Emöke Deschmann
- University Hospital, Stockholm, Karolinska Institute, Stockholm, Sweden
| | - Marta Aguar
- Servicio de Neonatologia, University & Polytechnic Hospital La Fe, Valencia, Spain
| | - Kristin Brække
- Women and Children's division, Department of Neonatal Intensive Care, Ullevål, Oslo University Hospital, Oslo, Norway
| | - Francesco Stefano Cardona
- Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Intensive Care and Pediatric Neurology, Medical University of Vienna, Wien, Austria
| | - Filip Cools
- Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | | | - Stefano Ghirardello
- Neonatal Intensive Care and Neonatology Unit, Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Jana Lozar
- Neonatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Katarina Matasova
- Jessenius Faculty of Medicine in Martin, University Hospital Martin, Martin, Slovakia
| | | | - Ulla Sankilampi
- Department of Pediatrics, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Henrique Soares
- Neonatology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Miklos Szabo
- Division of Neonatology 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Tomasz Szczapa
- II Department of Neonatology, Neonatal Biophysical Monitoring and Cardiopulmonary Therapies Research Unit, Poznan University of Medical Sciences, Poznan, Poland
| | - Gabriela Zaharie
- Neonatology, University of Medicine and Pharmacy Iuliu Hatieganu Cluj, Cluj Napoca, Romania
| | - Charles Christoph Roehr
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Oxford Population Health, Medical Sciences Division, University of Oxford, Oxford, UK .,Women and Children's, Neonatal Intensive Care Unit, Southmead Hospital, North Bristol NHS Trust, Westbury on Trym, Bristol, UK
| | - Suzanne Fustolo-Gunnink
- Sanquin Blood Supply Foundation, Amsterdam, The Netherlands.,Department of Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.,Pediatric Hematology, Amsterdam University Medical Center, Amsterdam, Netherlands
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42
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Fu X, Zhao X, Weng A, Zhang Q. Comparative efficacy and safety of restrictive versus liberal transfusion thresholds in anemic preterm infants: a meta-analysis of 12 randomized controlled trials. Ann Hematol 2023; 102:283-297. [PMID: 36542102 PMCID: PMC9889497 DOI: 10.1007/s00277-022-05072-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022]
Abstract
The comparative efficacy and safety of restrictive with liberal transfusion thresholds remain controversial in anemic preterm infants. This meta-analysis aimed to compare the efficacy and safety of these two transfusion thresholds for anemic preterm infants. We searched PubMed, Embase, Cochrane Library, and China National Knowledge Infrastructure (CNKI) for relevant randomized controlled trials (RCTs) comparing restrictive with liberal transfusion thresholds in anemic preterm infants through April 30, 2022. Two independent investigators screened literature, extracted data, and appraised the methodological quality of eligible studies. Meta-analysis was conducted using RevMan version 5.3.5. Twelve RCTs with 4380 preterm infants were included. Liberal transfusion threshold significantly increased the level of hemoglobin after transfusion (mean difference (MD): -10.03; 95% confidence interval (CI): -15.98 to -4.08; p=0.001; I2=94%) and hematocrit (MD: -3.62; 95%CI: -6.78 to -0.46; p=0.02; I2=80%) compared with restrictive transfusion. Infants' age at first transfusion in restrictive transfusion group was higher than that of infants in liberal transfusion group (MD: 5.08; 95%CI: 2.27 to7.89; p=0.004; I2=54%); however, restrictive transfusion was associated with more time on supplemental oxygen (MD: 3.56; 95%CI: 1.93 to 5.18; p<0.001; I2=62%) and ventilator or CPAP (MD: 3.31; 95%CI: 1.42 to 5.20; p=0.006; I2=75%). For the remaining outcomes, two transfusion strategies were comparable. Furthermore, a series of sensitivity analyses confirmed the robustness of the level of hemoglobin after transfusion, age at first transfusion, time on ventilator or CPAP, and safety outcomes. Evidence with substantial heterogeneity indicates that liberal and restrictive transfusion thresholds are effective and safe blood cell transfusion strategies in anemic preterm infants, but the liberal strategy may be more effective in shortening the length of necessary respiratory support.
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Affiliation(s)
- Xiaoling Fu
- Department of Blood Transfusion, Hainan Women and Children’s Medical Center, Haikou, 570000 Hainan Province China
| | - Xingdan Zhao
- Department of Blood Transfusion, Hainan Women and Children’s Medical Center, Haikou, 570000 Hainan Province China
| | - Aihan Weng
- Department of Blood Transfusion, Hainan Women and Children’s Medical Center, Haikou, 570000 Hainan Province China
| | - Qian Zhang
- Department of Blood Transfusion, Hainan Women and Children’s Medical Center, Haikou, 570000 Hainan Province China
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43
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Odom TL, Eubanks J, Redpath N, Davenport E, Tumin D, Akpan US. Development of necrotizing enterocolitis after blood transfusion in very premature neonates. World J Pediatr 2023; 19:68-75. [PMID: 36227506 DOI: 10.1007/s12519-022-00627-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 09/21/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Prior studies report conflicting evidence on the association between packed red blood cell (PRBC) transfusions and necrotizing enterocolitis (NEC), especially in early weeks of life where transfusions are frequent and spontaneous intestinal perforation can mimic NEC. The primary objective of this study was to evaluate the association between PRBC transfusions and NEC after day of life (DOL) 14 in very premature neonates. METHODS A retrospective cohort analysis of very premature neonates was conducted to investigate association between PRBC transfusions and NEC after DOL 14. Primary endpoints were PRBC transfusions after DOL 14 until the date of NEC diagnosis, discharge, or death. Wilcoxon ranked-sum and Fisher's exact tests, Cox proportional hazards regression, and Kaplan-Meier curves were used to analyze data. RESULTS Of 549 premature neonates, 186 (34%) received transfusions after DOL 14 and nine (2%) developed NEC (median DOL = 38; interquartile range = 32-46). Of the nine with NEC after DOL 14, all were previously transfused (P < 0.001); therefore, hazard of NEC could not be estimated. Post hoc analysis of patients from DOL 10 onward included five additional patients who developed NEC between DOL 10 and DOL 14, and the hazard of NEC increased by a factor of nearly six after PRBC transfusion (hazard ratio = 5.76, 95% confidence interval = 1.02-32.7; P = 0.048). CONCLUSIONS Transfusions were strongly associated with NEC after DOL 14. Prospective studies are needed to determine if restrictive transfusion practices can decrease incidence of NEC after DOL 14.
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Affiliation(s)
- Travis L Odom
- Department of Pediatrics, University of Texas Health Sciences Campus, 7703 Floyd Curl Drive, San Antonio, TX, 78229-3900, USA. .,Department of Pediatrics, Brody School of Medicine at East, Carolina University, Greenville, NC, USA. .,ECU Health Medical Center, Greenville, NC, USA.
| | - Jessica Eubanks
- Department of Pediatrics, Brody School of Medicine at East, Carolina University, Greenville, NC, USA.,ECU Health Medical Center, Greenville, NC, USA
| | - Nusiebeh Redpath
- Department of Pediatrics, Brody School of Medicine at East, Carolina University, Greenville, NC, USA.,ECU Health Medical Center, Greenville, NC, USA
| | - Erica Davenport
- Department of Pediatrics, Brody School of Medicine at East, Carolina University, Greenville, NC, USA.,ECU Health Medical Center, Greenville, NC, USA
| | - Dmitry Tumin
- Department of Pediatrics, Brody School of Medicine at East, Carolina University, Greenville, NC, USA
| | - Uduak S Akpan
- Department of Pediatrics, Brody School of Medicine at East, Carolina University, Greenville, NC, USA
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44
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Red Blood Cell Donor Sex Associated Effects on Morbidity and Mortality in the Extremely Preterm Newborn. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121980. [PMID: 36553422 PMCID: PMC9777093 DOI: 10.3390/children9121980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 12/07/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
Transfusion exposure increases the risk of death in critically ill patients of all ages. This was thought to relate to co-morbidities in the transfusion recipient. However, donor characteristics are increasingly recognised as critical to transfusion recipient outcome with systematic reviews suggesting blood donor sex influences transfusion recipient health. Originally focusing on plasma and platelet transfusions, retrospective studies report greater risks of adverse outcomes such as transfusion related acute lung injury in those receiving products from female donors. There is increasing awareness that exposure to red blood cells (RBCs) poses a similar risk. Recent studies focusing on transfusion related outcomes in extremely preterm newborns report conflicting data on the association between blood donor sex and outcomes. Despite a renewed focus on lower versus higher transfusion thresholds in neonatal clinical practice, this group remain a heavily transfused population, receiving on average 3-5 RBC transfusions during their primary hospital admission. Therefore, evidence supporting a role for better donor selection could have a significant impact on clinical outcomes in this high-risk population. Here, we review the emerging evidence for an association between blood donor sex and clinical outcomes in extremely preterm newborns receiving one or more transfusions.
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45
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Teofili L, Papacci P, Orlando N, Bianchi M, Pasciuto T, Mozzetta I, Palluzzi F, Giacò L, Giannantonio C, Remaschi G, Santosuosso M, Beccastrini E, Fabbri M, Valentini CG, Bonfini T, Cloclite E, Accorsi P, Dragonetti A, Cresi F, Ansaldi G, Raffaeli G, Villa S, Pucci G, Mondello I, Santodirocco M, Ghirardello S, Vento G. BORN study: a multicenter randomized trial investigating cord blood red blood cell transfusions to reduce the severity of retinopathy of prematurity in extremely low gestational age neonates. Trials 2022; 23:1010. [PMID: 36514106 PMCID: PMC9746198 DOI: 10.1186/s13063-022-06949-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 11/22/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Extremely low gestational age neonates (ELGANs, i.e., neonates born before 28 weeks of gestation) are at high risk of developing retinopathy of prematurity (ROP), with potential long-life visual impairment. Due to concomitant anemia, ELGANs need repeated red blood cell (RBC) transfusions. These produce a progressive replacement of fetal hemoglobin (HbF) by adult hemoglobin (HbA). Furthermore, a close association exists between low levels of HbF and severe ROP, suggesting that a perturbation of the HbF-mediated oxygen release may derange retinal angiogenesis and promote ROP. METHODS/DESIGN BORN (umBilical blOod to tRansfuse preterm Neonates) is a multicenter double-blinded randomized controlled trial in ELGANs, to assess the effect of allogeneic cord blood RBC transfusions (CB-RBCs) on severe ROP development. Recruitment, consent, and randomization take place at 10 neonatology intensive care units (NICUs) of 8 Italian tertiary hospitals. ELGANs with gestational age at birth comprised between 24+0 and 27+6 weeks are randomly allocated into two groups: (1) standard RBC transfusions (adult-RBCs) (control arm) and (2) CB-RBCs (intervention arm). In case of transfusion need, enrolled patients receive transfusions according to the allocation arm, unless an ABO/RhD CB-RBC is unavailable. Nine Italian public CB banks cooperate to make available a suitable amount of CB-RBC units for all participating NICUs. The primary outcome is the incidence of severe ROP (stage 3 or higher) at discharge or 40 weeks of postmenstrual age, which occurs first. DISCUSSION BORN is a groundbreaking trial, pioneering a new transfusion approach dedicated to ELGANs at high risk for severe ROP. In previous non-randomized trials, this transfusion approach was proven feasible and able to prevent the HbF decrease in patients requiring multiple transfusions. Should the BORN trial confirm the efficacy of CB-RBCs in reducing ROP severity, this transfusion strategy would become the preferential blood product to be used in severely preterm neonates. TRIAL REGISTRATION ClinicalTrials.gov NCT05100212. Registered on October 29, 2021.
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Affiliation(s)
- Luciana Teofili
- grid.414603.4Fondazione Policlinico A. Gemelli IRCCS, Largo Gemelli 8, 00168 Rome, Italy ,grid.8142.f0000 0001 0941 3192Università Cattolica del Sacro Cuore, Rome, Italy
| | - Patrizia Papacci
- grid.414603.4Fondazione Policlinico A. Gemelli IRCCS, Largo Gemelli 8, 00168 Rome, Italy ,grid.8142.f0000 0001 0941 3192Università Cattolica del Sacro Cuore, Rome, Italy
| | - Nicoletta Orlando
- grid.414603.4Fondazione Policlinico A. Gemelli IRCCS, Largo Gemelli 8, 00168 Rome, Italy
| | - Maria Bianchi
- grid.414603.4Fondazione Policlinico A. Gemelli IRCCS, Largo Gemelli 8, 00168 Rome, Italy
| | - Tina Pasciuto
- grid.414603.4Fondazione Policlinico A. Gemelli IRCCS, Largo Gemelli 8, 00168 Rome, Italy
| | - Iolanda Mozzetta
- grid.414603.4Fondazione Policlinico A. Gemelli IRCCS, Largo Gemelli 8, 00168 Rome, Italy
| | - Fernando Palluzzi
- grid.414603.4Fondazione Policlinico A. Gemelli IRCCS, Largo Gemelli 8, 00168 Rome, Italy
| | - Luciano Giacò
- grid.414603.4Fondazione Policlinico A. Gemelli IRCCS, Largo Gemelli 8, 00168 Rome, Italy
| | - Carmen Giannantonio
- grid.414603.4Fondazione Policlinico A. Gemelli IRCCS, Largo Gemelli 8, 00168 Rome, Italy
| | - Giulia Remaschi
- grid.24704.350000 0004 1759 9494Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Michela Santosuosso
- grid.24704.350000 0004 1759 9494Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Enrico Beccastrini
- grid.24704.350000 0004 1759 9494Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Marco Fabbri
- grid.144189.10000 0004 1756 8209Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | | | - Tiziana Bonfini
- Azienda Sanitaria Locale-Presidio Ospedaliero di Pescara, Pescara, Italy
| | - Eleonora Cloclite
- Azienda Sanitaria Locale-Presidio Ospedaliero di Pescara, Pescara, Italy
| | - Patrizia Accorsi
- Azienda Sanitaria Locale-Presidio Ospedaliero di Pescara, Pescara, Italy
| | | | - Francesco Cresi
- Città della Salute e della Scienza, Turin, Italy ,grid.7605.40000 0001 2336 6580Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | | | - Genny Raffaeli
- grid.414818.00000 0004 1757 8749Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy ,grid.4708.b0000 0004 1757 2822Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Stefania Villa
- grid.414818.00000 0004 1757 8749Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giulia Pucci
- grid.414504.00000 0000 9051 0784Azienda Ospedaliera Bianchi Melacrino Morelli, Reggio Calabria, Italy
| | - Isabella Mondello
- grid.414504.00000 0000 9051 0784Azienda Ospedaliera Bianchi Melacrino Morelli, Reggio Calabria, Italy
| | - Michele Santodirocco
- grid.413503.00000 0004 1757 9135Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | - Stefano Ghirardello
- grid.419425.f0000 0004 1760 3027Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Giovanni Vento
- grid.414603.4Fondazione Policlinico A. Gemelli IRCCS, Largo Gemelli 8, 00168 Rome, Italy ,grid.8142.f0000 0001 0941 3192Università Cattolica del Sacro Cuore, Rome, Italy
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Abdominal Near Infrared Spectroscopy can be reliably used to measure splanchnic oxygenation changes in preterm infants. J Perinatol 2022:10.1038/s41372-022-01576-2. [PMID: 36496514 DOI: 10.1038/s41372-022-01576-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 11/06/2022] [Accepted: 11/29/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Near-infrared spectroscopy (NIRS) allows assessment of regional tissue oxygen delivery and extraction. There are doubts regarding reliability of gut NIRS measurements. This study assesses reliability of NIRS for monitoring gut oxygenation. STUDY DESIGN Splanchnic tissue haemoglobin index (sTHI), tissue oxygenation index (sTOI) and fractional tissue oxygen extraction (sFTOE) changes during blood transfusion were measured using NIRS and compared to stable control infants. Infants were grouped into 3 chronological age groups: 1-7, 8-28 and ≥29 days of life. RESULTS sTHI, sTOI significantly increased, and sFTOE reduced following blood transfusion in all age group infants (n = 59), with no changes seen in control infants (n = 12). Baseline characteristics including gestational age and feed volumes did not differ between groups. CONCLUSION Gut perfusion measured by NIRS improved in infants who received blood transfusion, a change not seen in the control group, thus suggesting NIRS is a reliable method to measure splanchnic tissue oxygenation.
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Relationship of Early Anemia with Neurodevelopment and Brain Injury in Very Low Birth Weight Preterm Infants-A Prospective Cohort Study. Nutrients 2022; 14:nu14224931. [PMID: 36432616 PMCID: PMC9695480 DOI: 10.3390/nu14224931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/08/2022] [Accepted: 11/17/2022] [Indexed: 11/23/2022] Open
Abstract
Anemia is associated with neurodevelopmental delays and brain injury in infants and toddlers, but whether early anemia has a similar effect in neonatal preterm infants is largely unknown. Thus, this study aimed to determine the relationship of early anemia with neurodevelopment and brain injury in very-low-birth-weight (VLBW) preterm infants within the neonatal period. A prospective cohort study including 110 VLBW preterm infants was conducted in Southern China from 2016 to 2018. All participants were followed from birth to 1 month corrected age. Early anemia is defined as hemoglobin of ≤145 g/L within the first week after birth. The non-anemic group (control group, N = 55) was 1:1 matched with the early anemia group (N = 55) according to birth weight and gestational age. Neurodevelopment at 1 month corrected age and brain injury within 1 month corrected age were measured by neonatal behavioral neurological assessments (NBNA) and cranial ultrasound, respectively. Compared to the control group, the early anemia group had a lower score in behavioral ability in the NBNA test [11 (10-12) vs. 10 (9.5-11), p = 0.033]. Early anemia was negatively associated with the NBNA total score (β= -0.680, 95% CI: -1.300, -0.059), especially with the behavioral ability score (β= -0.504, 95% CI: -0.941, -0.067) after adjusting for the confounders. However, no association between early anemia and brain injury was observed. In conclusion, in VLBW preterm infants, early anemia is negatively correlated with neurodevelopment, especially with behavioral ability.
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Watterberg KL, Carlo WA, Brion LP, Cotten CM, Higgins RD. Overview of the neonatal research network: History, contributions, challenges, and future. Semin Perinatol 2022; 46:151634. [PMID: 35786518 PMCID: PMC10996928 DOI: 10.1016/j.semperi.2022.151634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Neonatal Research Network (NRN) has been a leader in neonatal research since 1986. In this chapter we review its history and achievements in (1) continuing observation of populations, treatments, short and longer-term outcomes, and trends over time; (2) "negative studies" (trials with non-significant primary outcomes) and trials stopped for futility or adverse events, which have influenced practice and subsequent trial design; and, (3) landmark trials that have changed neonatal care. Its consistent framework has enabled the NRN to be a pioneer in conducting longer-term, school-age follow-up. Leveraging its established infrastructure, the NRN has also partnered with other NIH institutes, governmental agencies, and industry to more effectively advance neonatal care. As current examples of its evolution with changing times, the Network has instituted a process to open specific network trials to external institutions and is adding a parent and participant component to future endeavors.
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Affiliation(s)
- Kristi L Watterberg
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM, USA.
| | - Waldemar A Carlo
- Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Luc P Brion
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - C Michael Cotten
- Department of Pediatrics, Duke University School of Medicine, Raleigh, NC, USA
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Mehl SC, Portuondo JI, Pettit RW, Fallon SC, Wesson DE, Massarweh NN, Shah SR, Lopez ME, Vogel AM. Association of red blood cell transfusion volume with postoperative complications and mortality in neonatal surgery. J Pediatr Surg 2022; 57:492-500. [PMID: 35148899 PMCID: PMC9271128 DOI: 10.1016/j.jpedsurg.2021.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/06/2021] [Accepted: 12/30/2021] [Indexed: 10/31/2022]
Abstract
INTRODUCTION Red blood cell transfusion (RBCT) is commonly administered in neonatal surgical care in the absence of clear clinical indications such as active bleeding or anemia. We hypothesized that higher RBCT volumes are associated with worse postoperative outcomes. METHODS Neonates within the National Surgical Quality Improvement Program-Pediatric database who underwent inpatient surgery (2012-2016) were stratified by weight-based RBCT volume: <20cc/kg, 20-40cc/kg, and >40cc/kg. Postoperative complications were categorized as wound, systemic infection, central nervous system (CNS), renal, pulmonary, and cardiovascular. Multivariable logistic regression and cubic spline analysis were used to evaluate the association between RBCT volume, postoperative complications, and 30-day mortality. Sensitivity analysis was conducted by performing propensity score matching. RESULTS Among 9,877 neonates, 1,024 (10%) received RBCTs. Of those who received RBCT, 53% received <20cc/kg, 27% received 20-40cc/kg, and 20% received >40cc/kg. Relative to neonates who were not transfused, RBCT volume was associated with a dose-dependent increase in renal complications, CNS complications, cardiovascular complications, and 30-day mortality. With cubic spline analysis, a lone inflection point for 30-day mortality was identified at a RBCT volume of 30 - 35 cc/kg. After propensity score matching, the dose-dependent relationship was still present for 30-day mortality. CONCLUSION Total RBCT volume is associated with worse postoperative outcomes in neonates with a significant increase in 30-day mortality at a RBCT volume of 30 - 35 cc/kg. Future prospective studies are needed to better understand the association between large RBCT volumes and poor outcomes after neonatal surgery. LEVEL OF EVIDENCE Level IV, Retrospective cohort study.
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Affiliation(s)
- Steven C Mehl
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States, Department of Surgery, Division of Pediatric Surgery, Texas Children’s Hospital, Houston, TX, United States
| | - Jorge I Portuondo
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Rowland W Pettit
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Sara C Fallon
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States, Department of Surgery, Division of Pediatric Surgery, Texas Children’s Hospital, Houston, TX, United States
| | - David E Wesson
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States, Department of Surgery, Division of Pediatric Surgery, Texas Children’s Hospital, Houston, TX, United States
| | - Nader N Massarweh
- Atlanta VA Health Care System, Decatur, GA, United States, Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, GA, United States, Department of Surgery, Morehouse School of Medicine, Atlanta, GA, United States
| | - Sohail R Shah
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States, Department of Surgery, Division of Pediatric Surgery, Texas Children’s Hospital, Houston, TX, United States
| | - Monica E Lopez
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Adam M Vogel
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States; Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX, United States.
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50
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Shukla VV, Rysavy MA, Das A, Tyson JE, Bell EF, Ambalavanan N, Carlo WA. Outcome prediction in newborn infants: Past, present, and future. Semin Perinatol 2022; 46:151641. [PMID: 35850743 PMCID: PMC10969981 DOI: 10.1016/j.semperi.2022.151641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The perinatal and neonatal periods are the periods of considerable organ development and maturation. Perinatal and neonatal illnesses can result in mortality and morbidities that burden families and the healthcare system. Outcome prediction is essential for informing perinatal and intensive care management, prognosis, and post-discharge interventions. The Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NRN) research databases include hospital and neurodevelopment follow-up outcomes of infants with various underlying diseases and conditions receiving intensive care, providing a unique opportunity to assess outcome risk prediction. The NRN has developed outcome risk prediction tools for use in infants with various diseases and conditions that allow data-driven, transparent discussions to inform family-focused communications and clinical management. This review presents the published neonatal outcome risk prediction research from the NRN, their present clinical utility, and possible future directions for advanced individualized risk prediction.
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Affiliation(s)
- Vivek V Shukla
- University of Alabama at Birmingham, Birmingham, AL, USA.
| | | | - Abhik Das
- RTI International, Research Triangle Park, NC, USA
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