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Rao RB. Biomarkers of Brain Dysfunction in Perinatal Iron Deficiency. Nutrients 2024; 16:1092. [PMID: 38613125 PMCID: PMC11013337 DOI: 10.3390/nu16071092] [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] [Received: 02/13/2024] [Revised: 03/28/2024] [Accepted: 04/04/2024] [Indexed: 04/14/2024] Open
Abstract
Iron deficiency in the fetal and neonatal period (perinatal iron deficiency) bodes poorly for neurodevelopment. Given its common occurrence and the negative impact on brain development, a screening and treatment strategy that is focused on optimizing brain development in perinatal iron deficiency is necessary. Pediatric societies currently recommend a universal iron supplementation strategy for full-term and preterm infants that does not consider individual variation in body iron status and thus could lead to undertreatment or overtreatment. Moreover, the focus is on hematological normalcy and not optimal brain development. Several serum iron indices and hematological parameters in the perinatal period are associated with a risk of abnormal neurodevelopment, suggesting their potential use as biomarkers for screening and monitoring treatment in infants at risk for perinatal iron deficiency. A biomarker-based screening and treatment strategy that is focused on optimizing brain development will likely improve outcomes in perinatal iron deficiency.
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Affiliation(s)
- Raghavendra B. Rao
- Division of Neonatology, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN 55455, USA;
- Masonic Institute for the Developing Brain, Minneapolis, MN 55414, USA
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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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Iron Homeostasis Disruption and Oxidative Stress in Preterm Newborns. Nutrients 2020; 12:nu12061554. [PMID: 32471148 PMCID: PMC7352191 DOI: 10.3390/nu12061554] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/24/2020] [Accepted: 05/25/2020] [Indexed: 02/06/2023] Open
Abstract
Iron is an essential micronutrient for early development, being involved in several cellular processes and playing a significant role in neurodevelopment. Prematurity may impact on iron homeostasis in different ways. On the one hand, more than half of preterm infants develop iron deficiency (ID)/ID anemia (IDA), due to the shorter duration of pregnancy, early postnatal growth, insufficient erythropoiesis, and phlebotomy losses. On the other hand, the sickest patients are exposed to erythrocytes transfusions, increasing the risk of iron overload under conditions of impaired antioxidant capacity. Prevention of iron shortage through placental transfusion, blood-sparing practices for laboratory assessments, and iron supplementation is the first frontier in the management of anemia in preterm infants. The American Academy of Pediatrics recommends the administration of 2 mg/kg/day of oral elemental iron to human milk-fed preterm infants from one month of age to prevent ID. To date, there is no consensus on the type of iron preparations, dosages, or starting time of administration to meet optimal cost-efficacy and safety measures. We will identify the main determinants of iron homeostasis in premature infants, elaborate on iron-mediated redox unbalance, and highlight areas for further research to tailor the management of iron metabolism.
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Karg E, Kovács L, Ignácz F, Varga E, Hocsi M, Szűts P, Kemény L, Bereczki C, Oláh J. Phototherapy-induced blistering reaction and eruptive melanocytic nevi in a child with transient neonatal porphyrinemia. Pediatr Dermatol 2018; 35:e272-e275. [PMID: 29962053 DOI: 10.1111/pde.13569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Neonatal blue-light phototherapy induced a blistering reaction followed by eruption of melanocytic nevi on the exposed skin surface of a child with transient neonatal porphyrinemia. New nevi are still developing 4 years after the triggering event. The role of phototoxicity-induced epidermal injury, that of porphyrins and the influence of neonatal blue-light therapy, in this unique phenomenon are discussed.
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Affiliation(s)
- Eszter Karg
- Department of Pediatrics, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - László Kovács
- Department of Dermatology, Erzsébet Hospital, Hódmezővásárhely, Hungary
| | - Ferenc Ignácz
- Department of Optics and Quantum Electronics, University of Szeged, Szeged, Hungary
| | - Erika Varga
- Department of Dermatology and Allergology, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Mária Hocsi
- Department of Pediatrics, Erzsébet Hospital, Hódmezővásárhely, Hungary
| | - Péter Szűts
- Department of Pediatrics, Erzsébet Hospital, Hódmezővásárhely, Hungary
| | - Lajos Kemény
- Department of Dermatology and Allergology, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Csaba Bereczki
- Department of Pediatrics, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Judit Oláh
- Department of Dermatology and Allergology, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
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Lynch S, Pfeiffer CM, Georgieff MK, Brittenham G, Fairweather-Tait S, Hurrell RF, McArdle HJ, Raiten DJ. Biomarkers of Nutrition for Development (BOND)-Iron Review. J Nutr 2018; 148:1001S-1067S. [PMID: 29878148 PMCID: PMC6297556 DOI: 10.1093/jn/nxx036] [Citation(s) in RCA: 172] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 05/27/2017] [Accepted: 11/07/2017] [Indexed: 12/20/2022] Open
Abstract
This is the fifth in the series of reviews developed as part of the Biomarkers of Nutrition for Development (BOND) program. The BOND Iron Expert Panel (I-EP) reviewed the extant knowledge regarding iron biology, public health implications, and the relative usefulness of currently available biomarkers of iron status from deficiency to overload. Approaches to assessing intake, including bioavailability, are also covered. The report also covers technical and laboratory considerations for the use of available biomarkers of iron status, and concludes with a description of research priorities along with a brief discussion of new biomarkers with potential for use across the spectrum of activities related to the study of iron in human health.The I-EP concluded that current iron biomarkers are reliable for accurately assessing many aspects of iron nutrition. However, a clear distinction is made between the relative strengths of biomarkers to assess hematological consequences of iron deficiency versus other putative functional outcomes, particularly the relationship between maternal and fetal iron status during pregnancy, birth outcomes, and infant cognitive, motor and emotional development. The I-EP also highlighted the importance of considering the confounding effects of inflammation and infection on the interpretation of iron biomarker results, as well as the impact of life stage. Finally, alternative approaches to the evaluation of the risk for nutritional iron overload at the population level are presented, because the currently designated upper limits for the biomarker generally employed (serum ferritin) may not differentiate between true iron overload and the effects of subclinical inflammation.
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Affiliation(s)
| | - Christine M Pfeiffer
- National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Michael K Georgieff
- Division of Neonatology, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, MN
| | - Gary Brittenham
- Division of Pediatric Hematology, Oncology and Stem Cell Transplant, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY
| | - Susan Fairweather-Tait
- Department of Nutrition, Norwich Medical School, Norwich Research Park, University of East Anglia, Norwich NR4 7JT, UK
| | - Richard F Hurrell
- Institute of Food, Nutrition and Health, Swiss Federal Institute of Technology, Zurich, Switzerland
| | - Harry J McArdle
- Rowett Institute of Nutrition and Health, University of Aberdeen, Aberdeen AB21 9SB, UK
| | - Daniel J Raiten
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH)
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German K, Vu PT, Grelli KN, Denton C, Lee G, Juul SE. Zinc Protoporphyrin-to-Heme Ratio and Ferritin as Measures of Iron Sufficiency in the Neonatal Intensive Care Unit. J Pediatr 2018; 194:47-53. [PMID: 29212619 DOI: 10.1016/j.jpeds.2017.10.041] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 09/15/2017] [Accepted: 10/16/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate ferritin and zinc protoporphyrin-to-heme (ZnPP/H) ratios as biomarkers of iron status in neonates, determine how specific clinical events affected these measures, and assess how iron status changed during hospitalization. STUDY DESIGN We performed a retrospective study of all infants with paired ferritin and ZnPP/H measurements between October 2014 and May 2016. Concordance of these measurements, effects of sepsis, red blood cell transfusion, erythropoietin treatment, and iron supplementation were assessed. Iron status was measured over time. RESULTS A total of 228 patients (mean birth weight 1.3 kg, median gestational age 29 weeks) were evaluated. Mean log ZnPP/H values in infants with and without sepsis were not significantly different (4.98 µmol/mol vs 4.97 µmol/mol, adjusted P = .103), whereas log-transformed ferritin values increased significantly during infection (5.23 ng/mL vs 4.04 ng/mL, adjusted P < .001). Ferritin also increased more significantly than ZnPP/H following red blood cell transfusion (ferritin: mean 5.03 ng/mL vs 4.0 ng/mL, P < .001; ZnPP/H: mean 4.85 µmol/mol vs 4.98 µmol/mol, P < .001). The mean iron supplementations at 30, 60, and 90 days were 5.4, 6.9, and 7.4 mg/kg/day, respectively. Ferritin values decreased with advancing postnatal age (adjusted P < .001), with 66% of ferritin values less than 76 ng/mL. Treatment with erythropoietin increased ZnPP/H, but not ferritin levels. CONCLUSIONS Ferritin is more significantly affected by inflammatory events such as sepsis and transfusion than ZnPP/H, thus, ZnPP/H may be a more reliable marker of iron status in this population. Infants showed worsening iron sufficiency over time despite supplementation above American Academy of Pediatrics guidelines.
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Affiliation(s)
- Kendell German
- Department of Neonatology, University of Washington, Seattle, WA.
| | - Phuong T Vu
- Department of Biostatistics, University of Washington, Seattle, WA
| | | | - Christopher Denton
- Department of Pediatrics, Children's Hospital of Los Angeles, Los Angeles, CA
| | - Gina Lee
- Department of Neonatology, University of Washington, Seattle, WA
| | - Sandra E Juul
- Department of Neonatology, University of Washington, Seattle, WA
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7
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Dao DT, Anez-Bustillos L, Cho BS, Li Z, Puder M, Gura KM. Assessment of Micronutrient Status in Critically Ill Children: Challenges and Opportunities. Nutrients 2017; 9:nu9111185. [PMID: 29143766 PMCID: PMC5707657 DOI: 10.3390/nu9111185] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 10/19/2017] [Accepted: 10/20/2017] [Indexed: 02/06/2023] Open
Abstract
Micronutrients refer to a group of organic vitamins and inorganic trace elements that serve many functions in metabolism. Assessment of micronutrient status in critically ill children is challenging due to many complicating factors, such as evolving metabolic demands, immature organ function, and varying methods of feeding that affect nutritional dietary intake. Determination of micronutrient status, especially in children, usually relies on a combination of biomarkers, with only a few having been established as a gold standard. Almost all micronutrients display a decrease in their serum levels in critically ill children, resulting in an increased risk of deficiency in this setting. While vitamin D deficiency is a well-known phenomenon in critical illness and can predict a higher need for intensive care, serum concentrations of many trace elements such as iron, zinc, and selenium decrease as a result of tissue redistribution in response to systemic inflammation. Despite a decrease in their levels, supplementation of micronutrients during times of severe illness has not demonstrated clear benefits in either survival advantage or reduction of adverse outcomes. For many micronutrients, the lack of large and randomized studies remains a major hindrance to critically evaluating their status and clinical significance.
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Affiliation(s)
- Duy T Dao
- Department of Surgery and Vascular Biology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Lorenzo Anez-Bustillos
- Department of Surgery and Vascular Biology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Bennet S Cho
- Department of Surgery and Vascular Biology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Zhilling Li
- Department of Pharmacy, Shanghai Children's Hospital, Shanghai Jiao Tong University, 355 Luding Road, Shanghai 200062, China.
| | - Mark Puder
- Department of Surgery and Vascular Biology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Kathleen M Gura
- Department of Pharmacy and the Division of Gastroenterology and Nutrition, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
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Zinc protoporphyrin/heme ratio as parameter of iron status in moderately preterm infants: natural course and associations in the first 4 months. J Perinatol 2017; 37:690-694. [PMID: 28181998 DOI: 10.1038/jp.2017.3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 01/06/2017] [Accepted: 01/12/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To determine the natural course of zinc protoporphyrin/heme ratio (ZnPP/H) and its role in the detection of iron deficiency (ID) and iron-deficiency anemia (IDA) in the first 4 months of life in moderately preterm infants. STUDY DESIGN ZnPP/H was measured at 1 week, 6 weeks and 4 months postnatal age in a prospective cohort of 161 Dutch infants born at a gestational age of 32+0 to 36+6 weeks who did not receive an erythrocyte transfusion or iron supplementation. RESULTS ZnPP/H levels decreased in the first 6 weeks and increased thereafter. At 4 months postnatal age, ZnPP/H was higher in the 11 (8.5%) infants with IDA (mean (s.d.): 260.8 (16.1)) but not in the 27 (21.3%) infants with ID (mean (s.d.): 177.0 (15.1)) compared with normal infants (mean (s.d.): 157.3 (12.5)). CONCLUSION In moderately preterm infants, ZnPP/H can be of additional value to detect infants at risk for IDA due to iron-deficient erythropoiesis at 4 months of age.
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Beard J, deRegnier RA, Shaw MD, Rao R, Georgieff M. Diagnosis of Iron Deficiency in Infants. Lab Med 2015. [DOI: 10.1309/7kj11rx758uklxxm] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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10
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Iron supplementation in premature infants using the zinc protoporphyrin to heme ratio: short- and long-term outcomes. J Perinatol 2013; 33:712-6. [PMID: 23599120 DOI: 10.1038/jp.2013.40] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 03/13/2013] [Accepted: 03/18/2013] [Indexed: 01/27/2023]
Abstract
OBJECTIVE The objective of this study was to determine the effect of incrementally higher doses of iron on the zinc protoporphyrin to heme ratio (ZnPP/H) and serum ferritin, and developmental outcomes in premature infants at risk for iron deficiency. STUDY DESIGN Infants eligible for this prospective, randomized blinded trial were between 27 and 30 completed weeks of gestation, older than 1 week of age and tolerating 100 ml kg(-1) per day of enteral feedings. The control group was treated with 2.2 mg kg(-1) per day of ferrous sulfate and the treatment group was treated with 3 to 12 mg kg(-1) per day based on the ZnPP/H. Infants had follow-up with Bayley exams at 6 and 24 months corrected age. Statistical evaluation included Student's t-tests and Fisher's exact test. RESULT Eighty-one infants were enrolled (40 control, 41 treatment). The average total iron dose for the control group was 2.2 mg kg(-1) per day and for the treatment group was 10.4 mg kg(-1) per day (P<0.05). The ZnPP/H was not different between the two groups. The ferritin at the end of the study was decreased in the control group but remained stable in the treatment group (control initial 202±109 ng ml(-1), final 168±141 ng ml(-1) (P<0.05); treatment initial 187±131 ng ml(-1), final 176±118 ng ml(-1)). At 24 months, infants with psychomotor development index <85 occurred in 25% of the subjects in the control group and in 7% of subjects in the treatment group in a post hoc analysis (odds ratio, 4.2; 95% confidence interval, 0.7 to 43, P=0.07). CONCLUSION The ZnPP/H may not be a reliable marker of iron status when used in a short period of time during iron supplementation. Infants treated with a lower dose of ferrous sulfate had a decreasing serum ferritin and a trend toward increased motor delays at 24 months.
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Brabin L, Brabin BJ, Gies S. Influence of iron status on risk of maternal or neonatal infection and on neonatal mortality with an emphasis on developing countries. Nutr Rev 2013; 71:528-40. [PMID: 23865798 PMCID: PMC3721428 DOI: 10.1111/nure.12049] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Infection is a major cause of neonatal death in developing countries. This review investigates whether host iron status affects the risk of maternal and/or neonatal infection, potentially contributing to neonatal death, and summarizes the iron acquisition mechanisms described for pathogens causing stillbirth, preterm birth, and congenital infection. In vitro evidence shows that iron availability influences the severity and chronicity of infections that cause these negative outcomes of pregnancy. In vivo evidence is lacking, as relevant studies of maternal iron supplementation have not assessed the effect of iron status on the risk of maternal and/or neonatal infection. Reducing iron-deficiency anemia among women is beneficial and should improve the iron stores of babies; moreover, there is evidence that iron status in young children predicts the risk of malaria and, possibly, the risk of invasive bacterial diseases. Caution with maternal iron supplementation is indicated in iron-replete women who may be at high risk of exposure to infection, although distinguishing between iron-replete and iron-deficient women is currently difficult in developing countries, where a point-of-care test is needed. Further research is indicated to investigate the risk of infection relative to iron status in mothers and babies in order to avoid iron intervention strategies that may result in detrimental birth outcomes in some groups of women.
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Affiliation(s)
- Loretta Brabin
- Academic Unit of Obstetrics & Gynaecology, University of Manchester, Manchester, UK.
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Abstract
OBJECTIVE To review causes of anemia in preterm infants and to suggest potential preventive measures. METHODS Data for this review is obtained from review of the literature. RESULTS An approach to investigating and treating causes of neonatal anemia is outlined. CONCLUSIONS Clinical practices can significantly impact anemia in premature infants. Delayed cord clamping, decreasing phlebotomy loss and optimizing nutritional support are practices that may decrease the severity of anemia, thereby decreasing the need for transfusions or erythropoietin treatment.
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Affiliation(s)
- Sandra Juul
- Department of Pediatrics, Division of Neonatology, University of Washington, Seattle, WA 98195-6320, USA.
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13
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Cheng CF, Zerzan JC, Johnson DB, Juul SE. Zinc protoporphyrin-to-heme ratios in high-risk and preterm infants. J Pediatr 2012; 161:81-7.e1. [PMID: 22306048 DOI: 10.1016/j.jpeds.2011.12.048] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Revised: 11/16/2011] [Accepted: 12/29/2011] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To refine the reference range for the zinc protoporphyrin-to-heme ratio (ZnPP/H) of preterm infants, we assessed the impact of maternal risk factors on ZnPP/H and evaluated the impact of changes in iron supplementation on iron status. STUDY DESIGN The reference range for neonatal ZnPP/H was refined using prospective data from 31 reference infants ≤ 35 weeks' postmenstrual age (PMA) plus retrospective data from 51 infants <30 weeks' PMA, and 59 infants 30-40 weeks' PMA. Cord blood and first week of life values were compared when both were available. The impact of maternal risk factors was assessed by examining prospectively collected ZnPP/H from 48 high-risk infants. The effect of changing iron supplementation guidelines was evaluated by retrospective chart review of serial ZnPP/H from 194 infants. RESULTS Cord ZnPP/H was lower at 30-35 weeks' gestation than at 24-26 weeks' gestation (P = .01). Cord ZnPP/H values from insulin-dependent diabetic mothers were elevated compared with reference values. Changing the iron supplementation protocol was not associated with improved ZnPP/H measurements. CONCLUSIONS Cord blood and postnatal reference ranges for ZnPP/H are defined. Iron balance depends on a complex interaction of prenatal and postnatal factors.
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Affiliation(s)
- Carissa F Cheng
- Nutritional Sciences Program, University of Washington, Seattle, WA 98195-6320, USA
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14
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Mukhopadhyay K, Yadav RK, Kishore SS, Garewal G, Jain V, Narang A. Iron status at birth and at 4 weeks in term small-for-gestation infants in comparison with appropriate-for-gestation infants. J Matern Fetal Neonatal Med 2010; 24:886-90. [DOI: 10.3109/14767058.2010.536866] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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15
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Friedman JF, Kurtis JD, Kabyemela ER, Fried M, Duffy PE. The iron trap: iron, malaria and anemia at the mother–child interface. Microbes Infect 2009; 11:460-6. [DOI: 10.1016/j.micinf.2009.02.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2009] [Accepted: 02/20/2009] [Indexed: 11/17/2022]
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16
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Juul SE, McPherson RJ, Bauer LA, Ledbetter KJ, Gleason CA, Mayock DE. A phase I/II trial of high-dose erythropoietin in extremely low birth weight infants: pharmacokinetics and safety. Pediatrics 2008; 122:383-91. [PMID: 18676557 DOI: 10.1542/peds.2007-2711] [Citation(s) in RCA: 137] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES High-dose recombinant erythropoietin is neuroprotective in animal models of neonatal brain injury. Extremely low birth weight infants are at high risk for brain injury and neurodevelopmental problems and might benefit from recombinant erythropoietin. We designed a phase I/II trial to test the safety and determine the pharmacokinetics of high-dose recombinant erythropoietin in extremely low birth weight infants. METHODS In a prospective, dose-escalation, open-label trial, we compared 30 infants who were treated with high-dose recombinant erythropoietin with 30 concurrent control subjects. Eligible infants were <24 hours old, <or=1000 g birth weight, and <or=28 weeks of gestation and had an umbilical artery catheter in place. Each infant received 3 intravenous doses of 500, 1000, or 2500 U/kg at 24-hour intervals beginning on day 1 of age. Blood samples were collected at scheduled intervals to determine recombinant erythropoietin pharmacokinetics. Safety parameters were also evaluated. In the concurrent control group, only clinical data were collected. RESULTS Mean erythropoietin concentrations 30 minutes after recombinant erythropoietin infusion were 5973 +/- 266, 12291 +/- 403, and 34197 +/- 1641 mU/mL after 500, 1000, or 2500 U/kg, respectively. High-dose recombinant erythropoietin followed nonlinear pharmacokinetics as a result of decreasing clearance from the lowest dosage (17.3 mL/hour per kg for 500 U/kg) to the highest dosage (8.2 mL/hour per kg for 2500 U/kg). Steady state was achieved within 24 to 48 hours. Both 1000 and 2500 U/kg recombinant erythropoietin produced peak serum erythropoietin concentrations that were comparable to neuroprotective concentrations that previously were seen in experimental animals. No excess adverse events occurred in the recombinant erythropoietin-treated infants compared with control infants. CONCLUSIONS Early high-dose recombinant erythropoietin is well tolerated by extremely low birth weight infants, causing no excess morbidity or mortality. Recombinant erythropoietin dosages of 1000 and 2500 U/kg achieved neuroprotective serum levels.
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Affiliation(s)
- Sandra E Juul
- Department of Pediatrics, University of Washington, Seattle, Washington 98195, USA.
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17
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Blohowiak SE, Chen ME, Repyak KS, Carlton DP, Georgieff MK, Crenshaw TD, Kling PJ, Kling PJ. Reticulocyte enrichment of zinc protoporphyrin/heme discriminates impaired iron supply during early development. Pediatr Res 2008; 64:63-7. [PMID: 18360311 PMCID: PMC3071474 DOI: 10.1203/pdr.0b013e31817328e5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In infants and children, elevated whole blood zinc protoporphyrin/heme (ZnPP/H) measures iron-deficient (ID) erythropoiesis. Because immature erythrocytes are less dense than mature erythrocytes, we hypothesized that the sensitivity of ZnPP/H is improved if measured in the least dense cells. Blood was collected from control suckling, mildly and severely ID suckling rats. Cord blood was collected after uncomplicated pregnancies (control), diabetic pregnancies (severe ID) and after pregnancies at-risk for iron deficiency (mild ID). ZnPP/H was measured before and after a two-step density centrifugation to obtain the lightest 6.25% of erythrocyte (top fraction). The difference between whole blood and top fraction was defined as DeltaZnPP/H. In rats, although the whole or top ZnPP/H differed by postnatal age, DeltaZnPP/H was greatest after the interval with least body iron accrual. In either rats or humans with mild ID, whole blood ZnPP/H was similar to, but DeltaZnPP/H was greater than controls. In rats and newborn humans, DeltaZnPP/H is more sensitive than whole blood ZnPP/H in identifying conditions associated with impaired erythrocyte iron delivery and may become a useful tool in measuring erythrocyte iron incorporation in early development.
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Affiliation(s)
- Sharon E. Blohowiak
- University of Wisconsin - Madison, Department of Pediatrics, Division of Neonatology
| | - Melinda E. Chen
- University of Wisconsin - Madison, Department of Pediatrics, Division of Neonatology
| | - Kristin S. Repyak
- University of Wisconsin - Madison, Department of Pediatrics, Division of Neonatology
| | - David P. Carlton
- University of Wisconsin - Madison, Department of Pediatrics, Division of Neonatology
| | - Michael K. Georgieff
- University of Minnesota, Center for Neurobehavioral Development and Department of Pediatrics
| | | | - Pamela J. Kling
- University of Wisconsin - Madison, Department of Pediatrics, Division of Neonatology
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van Rheenen PF, de Moor LTT, Eschbach S, Brabin BJ. A cohort study of haemoglobin and zinc protoporphyrin levels in term Zambian infants: effects of iron stores at birth, complementary food and placental malaria. Eur J Clin Nutr 2007; 62:1379-87. [PMID: 17671442 DOI: 10.1038/sj.ejcn.1602862] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To examine zinc-protoporphyrin (ZPP) and haemoglobin levels, and to determine predictors of iron deficiency anaemia (IDA) in Zambian infants. SUBJECTS AND METHODS Ninety-one women and their normal birth weight (NBW) infants were followed bi-monthly during the first 6 months of life, and iron status, food intake, malaria parasitaemia and growth were monitored. At 4 months, the infants were divided into two groups, and the data were analysed according to whether or not they were exclusively breastfed. RESULTS Almost two-third of infants were born with low iron stores as defined by ZPP levels, and this proportion increased with age. Over 50% had developed IDA by 6 months. Exclusive breastfeeding at 4 months could be a protective factor for IDA (odds ratio (OR): 0.2; 95% confidence interval (CI): 0.0-1.1). Exclusively breastfed infants had higher haemoglobin values at 4 and 6 months (mean difference 0.6; 95% CI: 0.1-1.2 g/dl and mean difference 0.9; 95% CI: 0.2-1.7 g/dl, respectively), compared with infants with early complementary feeding. In univariate analysis, past or chronic placental malaria appeared to be a predictor of IDA at 4 and 6 months, but the significance was lost in multivariate analysis. CONCLUSIONS Zambian NBW infants are born with low iron stores and have a high risk to develop IDA in the first 6 months of life. Continuation of exclusive breastfeeding after 4 months is associated with a reduction of anaemia. The effect of placental malaria infection on increased risk of infant IDA could not be proven.
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Affiliation(s)
- P F van Rheenen
- Paediatric Gastroenterology, Department of Paediatrics, University Medical Centre, Groningen, The Netherlands.
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van Rheenen P, de Moor L, Eschbach S, de Grooth H, Brabin B. Delayed cord clamping and haemoglobin levels in infancy: a randomised controlled trial in term babies. Trop Med Int Health 2007; 12:603-16. [PMID: 17445128 DOI: 10.1111/j.1365-3156.2007.01835.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES This study was carried out to assess whether delaying umbilical cord clamping is effective in improving the haematological status of term infants living in a malaria-endemic area, and whether this is associated with complications in infants and mothers. METHODS We randomly assigned women delivering term babies in Mpongwe Mission Hospital, Zambia, to delayed cord clamping (DCC, n = 46) or immediate cord clamping (controls, n = 45) and followed their infants on a bi-monthly basis until the age of 6 months. We compared the haemoglobin (Hb) change from cord values and the proportion of anaemic infants. Secondary outcomes related to infant and maternal safety. RESULTS Throughout the observation period infant Hb levels in both groups declined, but more rapidly in controls than in the DCC group [difference in Hb change from baseline at 4 months 1.1 g/dl, 95% confidence interval (CI) 0.2; 2.1]. By 6 months, this difference had disappeared (0.0 g/dl, 95% CI -0.9; 0.8). The odds ratio for iron deficiency anaemia in the DCC group at 4 months was 0.3 (95% CI 0.1; 1.0), but no differences were found between the groups at 6 months. No adverse events were seen in infants and mothers. CONCLUSION Our findings indicate that DCC could help improve the haematological status of term infants living in a malaria-endemic region at 4 months of age. However, the beneficial haematological effect disappeared by 6 months. This simple, free and safe delivery procedure might offer a strategy to reduce early infant anaemia risk, when other interventions are not yet feasible.
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Affiliation(s)
- Patrick van Rheenen
- Department of Paediatrics, Paediatric Gastroenterology, University Medical Centre, Groningen, The Netherlands.
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Siddappa AM, Rao R, Long JD, Widness JA, Georgieff MK. The assessment of newborn iron stores at birth: a review of the literature and standards for ferritin concentrations. Neonatology 2007; 92:73-82. [PMID: 17361090 PMCID: PMC2863301 DOI: 10.1159/000100805] [Citation(s) in RCA: 189] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Serum ferritin measurements are used in clinical populations to estimate total body iron stores and the risk of subsequent iron deficiency or overload. The lack of normative newborn serum ferritin concentration data between 23 and 41 weeks has led to difficulty in establishing the incidence and degree of abnormal iron status in the neonatal period. OBJECTIVES The primary objective of this review was to summarize the maternal and gestational factors that determine ferritin concentrations in full-term and pre-term newborn infants and to generate comprehensive reference values. The secondary objective was to assess serum ferritin concentrations in newborn infants at risk for abnormal fetal iron metabolism, including maternal diabetes mellitus, intrauterine growth restriction and maternal smoking during pregnancy. METHODS Serum ferritin and gestational age data at birth from 457 low-risk pre-term and term infants of 23-41 weeks gestation obtained from 35 published studies reviewed from a period of 25 years and from recently collected data from our centers were assessed by regression analysis. Slopes and intercepts of the high-risk groups were compared with the standard curve. RESULTS Umbilical cord serum ferritin concentrations increased with advancing gestational age, from a mean of 63 mug/l at 23 weeks to 171 mug/l at 41 weeks gestation (p < 0.001). The infants of diabetic mothers had a lower intercept than the control infants (p < 0.001). CONCLUSIONS Iron deficiency and overload have been implicated in neurodevelopmental impairments. Normative cord serum ferritin data may permit a more precise assessment of infants who are at risk for abnormal iron status at birth.
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Affiliation(s)
- Ashajyothi M. Siddappa
- Division of Neonatology, Hennepin County Medical Center, and Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, Minn
| | - Raghavendra Rao
- Division of Neonatology, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, Minn
| | - Jeffrey D. Long
- Department of Educational Psychology, College of Education and Human Development, University of Minnesota, Minneapolis, Minn
| | - John A. Widness
- Division of Neonatology, Department of Pediatrics, University of Iowa School of Medicine, Iowa City, Iowa, USA
| | - Michael K. Georgieff
- Division of Neonatology, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, Minn
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Abstract
Both iron deficiency and iron excess during the fetal and neonatal period bode poorly for developing organ systems. Maternal conditions such as iron deficiency, diabetes mellitus, hypertension and smoking, and preterm birth are the common causes of perinatal iron deficiency. Long-term neurodevelopmental impairments and predisposition to future iron deficiency that are prevalent in infants with perinatal iron deficiency require early diagnosis, optimal treatment and adequate follow-up of infants at risk for the condition. However, due to the potential for oxidant-mediated tissue injury, iron overload should be avoided in the perinatal period, especially in preterm infants.
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Affiliation(s)
- Raghavendra Rao
- Division of Neonatology, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA.
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Abstract
BACKGROUND Zinc protoporphyrin/heme (ZnPP/H) ratios are indicators of incomplete erythrocyte iron delivery. ZnPP/H is more sensitive than measures of iron stores, such as plasma ferritin, in identifying early pre-anemic iron-deficient erythropoiesis. Cord ZnPP/H ratios are elevated in conditions associated with fetal hypoxia, such as diabetes mellitus during pregnancy. In chronic fetal hypoxemia, erythrocyte and hemoglobin syntheses are accelerated and iron is incorporated into erythrocytes. Cord ZnPP/H ratios are correlated with fetal size after diabetic pregnancy. Because fetal size is a surrogate for diabetes control, it is unclear whether glycemic control in diabetes mellitus or fetal size was the major determinant of ZnPP/H ratios and disturbed erythrocyte iron delivery. OBJECTIVE Our goal was to examine whether ZnPP/H ratios were elevated or were associated with growth in large-for-gestation newborns born to mothers without the diagnosis of diabetes mellitus. METHODS In cord blood samples from large and appropriately grown healthy newborns, we measured ZnPP/H and indices of erythropoiesis and iron status. Analyses included simple linear regression, Fisher's exact, and unpaired t testing. RESULTS In the absence of diabetes mellitus, ZnPP/H in 25 large and 24 appropriately grown healthy newborns was similar, and the ratios were within the limits of previously reported normal cord ZnPP/H. Ratios were not correlated with plasma ferritin levels. In large newborns, but not appropriately grown newborns, ZnPP/H ratios were positively correlated with fetal growth (p < 0.03) and estimates of body hemoglobin (p <0.04). CONCLUSIONS Despite 33% greater body hemoglobin mass observed in healthy large, compared to appropriately grown newborns, mean ZnPP/H was normal. Iron incorporation into erythrocytes in large newborns appears adequate. Because the association of ZnPP/H with size and estimated body hemoglobin was observed only in large newborns, factors determining ZnPP/H may differ between large and appropriately grown newborns.
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Affiliation(s)
- Kelsey J Kleven
- Department of Pediatrics, University of Wisconsin, Madison, Wisc 53715, USA
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Lesser KB, Schoel SB, Kling PJ. Elevated zinc protoporphyrin/heme ratios in umbilical cord blood after diabetic pregnancy. J Perinatol 2006; 26:671-6. [PMID: 17024142 DOI: 10.1038/sj.jp.7211600] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Offspring of diabetes patients may suffer from tissue iron deficiency. Erythrocyte zinc protoporphyrin/heme (ZnPP/H) ratios measure impaired iron status. The aim of the study was to examine whether cord ZnPP/H ratios were associated with pregnancy glycemic control. METHODS ZnPP/H was measured in cord blood from 31 pregnancies with insulin-treated diabetes (diabetes group) and compared to population normal values. Maternal glycemic control was assessed by daily glucose log, glycosylated hemoglobin and birth weight. RESULTS Median cord ZnPP/H was higher in the diabetes group than the population normal values (106 (65.2 to 146.8) microM/M vs 68.2 (37.6 to 98.8) micro/M, P < 0.0001). Ratios were directly correlated to surrogates of control (glycosylated hemoglobin, P = 0.05, and birth weight, P < 0.04). Cord ZnPP/H ratios from pregnancies with pre-existing and gestational diabetes were similar. CONCLUSION Because cord ZnPP/H was higher in large offspring of diabetic pregnancy, it might identify greater iron utilization for fetal erythropoiesis.
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Affiliation(s)
- K B Lesser
- Department of Obstetrics, The University of Arizona Health Sciences Center, Tucson, AZ, USA
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Haiden N, Schwindt J, Cardona F, Berger A, Klebermass K, Wald M, Kohlhauser-Vollmuth C, Jilma B, Pollak A. Effects of a combined therapy of erythropoietin, iron, folate, and vitamin B12 on the transfusion requirements of extremely low birth weight infants. Pediatrics 2006; 118:2004-13. [PMID: 17079573 DOI: 10.1542/peds.2006-1113] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Erythropoietin is frequently administered to premature infants to stimulate erythropoiesis. The primary goal of erythropoietin therapy is to reduce transfusions, but the efficacy of erythropoietin has not been convincingly demonstrated in this regard. The aim of this trial was to investigate whether combined administration of vitamin B12, folic acid, iron, and erythropoietin could decrease transfusion requirements in extremely low birth weight infants. PATIENTS AND METHODS In a randomized, controlled trial, extremely low birth weight infants with a birth weight < or = 800 g and a gestational age < or = 32 weeks were randomly assigned to a group receiving combination treatment or a control arm. RESULTS The treatment increased levels of folate in red blood cells, vitamin B12, ferritin, transferrin receptor levels in plasma, and reticulocyte counts. The proportion of infants requiring no transfusions was lower in the treatment group (38%) as compared with controls (5%). The treatment group and the need for mechanical ventilation were independent predictors of the number of transfusions in multiple regression analysis. Cox regression analysis indicated that combined therapy resulted in a 79% risk reduction for any transfusion. CONCLUSION Combined treatment with erythropoietin, intravenous iron, folate, and vitamin B12 during the first weeks reduces the need for transfusion in extremely low birth weight infants.
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Affiliation(s)
- Nadja Haiden
- Department of Pediatrics, Division of Neonatology and Intensive Care, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria.
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Miller SM, McPherson RJ, Juul SE. Iron sulfate supplementation decreases zinc protoporphyrin to heme ratio in premature infants. J Pediatr 2006; 148:44-8. [PMID: 16423596 DOI: 10.1016/j.jpeds.2005.08.052] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2005] [Revised: 07/22/2005] [Accepted: 08/15/2005] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To test the utility of zinc protoporphyrin to heme ratio (ZnPP/H) as an indicator of iron status in premature infants and to evaluate the effect of oral iron supplements on oxidative injury. We hypothesized that iron sulfate supplementation would decrease the ZnPP/H in preterm infants. STUDY DESIGN Infants eligible for this prospective study were: hospitalized, 24 to 32 weeks of gestation, 7 to 60 days old, feeding > or = 70 mL/kg/d, with a ZnPP/H > or = the mean for age. Iron dose was determined by the ZnPP/H. Iron status and oxidative injury were evaluated at study entry and completion. Concurrent control subjects met entry criteria but were not enrolled and were not treated with iron during the study interval. Statistical evaluation included repeated measures analysis of variance and Z-score conversions. RESULTS Entry ZnPP/H of iron-treated subjects (n = 16) and control subjects (n = 16) were not different. The ZnPP/H of iron-treated infants was lower at study end (P < .05) but did not change in control infants. Iron treatment (3 to 12 mg/kg/day) was not associated with changes in conventional measures of iron status nor in measures of oxidative injury. CONCLUSIONS Iron sulfate supplementation (3-12 mg/kg/d) decreases ZnPP/H, is tolerated, and is not associated with increased oxidative injury.
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Affiliation(s)
- Susan M Miller
- Department of Pediatrics, University of Washington, Seattle, WA 98195, USA
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Kling PJ. The zinc protoporphyrin/heme ratio in premature infants: has it found its place? J Pediatr 2006; 148:8-10. [PMID: 16423590 PMCID: PMC1532929 DOI: 10.1016/j.jpeds.2005.09.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2005] [Accepted: 09/26/2005] [Indexed: 10/25/2022]
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Lott DG, Zimmerman MB, Labbé RF, Kling PJ, Widness JA. Erythrocyte zinc protoporphyrin is elevated with prematurity and fetal hypoxemia. Pediatrics 2005; 116:414-22. [PMID: 16061597 DOI: 10.1542/peds.2004-1601] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To examine the utility of red blood cell (RBC) zinc protoporphyrin/heme ratio (ZnPP/H) as an indicator of fetal iron status, because unfavorable neurodevelopmental outcomes have been associated with poor iron status at birth, as indicated by low serum ferritin, and because few reliable indicators of fetal and early neonatal iron status exist. METHODS Consecutively studied preterm and term fetuses at delivery included the following groups: (1) control nonhypoxic, (2) fetuses with intrauterine growth retardation (IUGR), and (3) fetuses of insulin-treated mothers (FDM). We hypothesized (1) that rapid growth velocity associated with an accelerated erythropoiesis among normal fetuses will lead to reduced iron delivery to a rapidly expanding RBC mass and higher umbilical cord blood RBC ZnPP/H and (2) that fetuses that are exposed to pathologic hypoxemia will experience an additional increase in erythropoiesis and higher cord ZnPP/H. ZnPP/H was determined on saline-washed cord blood erythrocytes by hematofluorometry and was examined for its relationship with clinical factors and cord blood laboratory measurements indicative of tissue oxygenation (plasma erythropoietin [EPO] and reticulocyte count) and iron status (plasma ferritin and erythrocyte indices). Statistical testing included 1-way analysis of variance, 2-way analysis of variance with covariates, simple linear regression, and multiple regression analysis. RESULTS Among control group subjects, gestational age at birth was inversely correlated with RBC ZnPP/H and reticulocyte count and positively correlated with ferritin and EPO. Relative to control subjects, IUGR and FDM fetuses at specified gestational age groupings had higher ZnPP/H, lower plasma ferritin, and higher plasma EPO. Statistical modeling of the relationship between ZnPP/H and plasma ferritin among all study groups demonstrated significant impacts of gestational age, plasma EPO, maternal hypertension, and maternal smoking. CONCLUSIONS The inverse association of fetal ZnPP/H with gestational age at birth among control subjects is attributable to erythropoietic stimulation likely as a result of increasing growth velocity at the earliest gestational ages. The relatively higher ZnPP/H observed among fetuses in the IUGR and FDM groups likely is attributable to increased erythropoietic activity secondary to pathologic hypoxemia. Decreased placental iron transfer may also have limited iron availability and contributed to elevated ZnPP/H in the IUGR group. These data support the concept that increased erythropoietic activity and/or limited iron transport may place infants of diabetic mothers and infants with growth retardation at risk for developing systemic iron deficiency later in infancy and in early childhood.
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Affiliation(s)
- David G Lott
- Department of Pediatrics, College of Medicine, University of Iowa, Iowa City, Iowa, USA
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28
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Georgieff MK, Innis SM. Controversial nutrients that potentially affect preterm neurodevelopment: essential fatty acids and iron. Pediatr Res 2005; 57:99R-103R. [PMID: 15817493 DOI: 10.1203/01.pdr.0000160542.69840.0f] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Abstract
PURPOSE OF REVIEW To evaluate the safety and efficacy of metalloporphyrins for the treatment of neonatal hyperbilirubinemia. RECENT FINDING Since the 1980s and 1990s, there have been no publications on trials to determine the efficacy of metalloporphyrins in the treatment of neonatal jaundice. In the past year, a single case report was presented on the compassionate use of tin mesoporphyrin in a very low birth weight infant with intrauterine growth retardation who did not respond to phototherapy. Subcutaneous administration of a single dose of tin mesoporphyrin at 46 hours of life was associated with a greater than 25% reduction in serum bilirubin. This further supports existing evidence that tin mesoporphyrin is efficacious in lowering bilirubin production. In the laboratory, most metalloporphyrins were shown to induce heme oxygenase, and in addition, metalloporphyrins modulate cardiac cell function in vitro. These observations suggest that the therapeutic benefits may be obviated if such considerations hold true in humans. SUMMARY Recent case reports and previous evidence from larger clinical trials conducted in Greece and Argentina in the 1980s and 1990s demonstrate that tin mesoporphyrin is useful in the treatment of neonatal jaundice. Its long-term safety is not well understood but will be important to determine, before its widespread or prophylactic use in neonates with hyperbilirubinemia can be recommended.
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Affiliation(s)
- Phyllis A Dennery
- Department of Pediatrics, University of Pennsylvania School of Medicine, and Children's Hospital of Philadelphia, Division of Neonatology, Philadelphia, Pennsylvania 19104, USA.
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Abstract
OBJECTIVE To characterize changes in eosinophil counts over time, and to draw comparisons across four gestational age groups with respect to the incidence of, and clinical conditions associated with eosinophilia over the first months of life in a single neonatal intensive care unit (NICU). STUDY DESIGN Weekly complete blood counts (CBCs) were collected from all NICU patients. Eosinophilia was classified as mild, moderate, or severe. Changes in eosinophil counts were examined over time, the incidence of eosinophilia was determined by gestational age group, and clinical correlations sought. RESULTS Eosinophil data from 1652 CBCs were analyzed from 332 infants. Eosinophilia occurred in 148 infants (45%) during their hospitalization. The prevalence, severity, and timing of eosinophilia varied by gestational age, infection, and red blood cell transfusions. CONCLUSIONS The incidence and severity of eosinophilia increased with immaturity, and was temporally associated with infection, necrotizing enterocolitis, and packed red blood cell transfusion.
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Affiliation(s)
- Sandra E Juul
- Department of Pediatrics, University of Washington, Seattle, Washington 98195, USA
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Abstract
OBJECTIVE We sought to identify changes in platelet (PLT) counts over time, and to evaluate the patterns of thrombocytopenia and thrombocytosis in hospitalized infants 23.8 weeks to term gestation. STUDY DESIGN Neonates were divided into four gestational age groups and their PLT counts were retrospectively compared for prevalence of thrombocytopenia, thrombocytosis, and associated conditions. RESULTS Postconceptional age, postnatal age, and sepsis (among other factors) affected PLT counts. When counts from noninfected appropriately grown infants were evaluated, the risk of thrombocytopenia and thrombocytosis were highest in the most preterm infants, and these risks changed with corrected gestational age. PLT counts increased weekly over the first 4 weeks of life for all but the most preterm infants. CONCLUSIONS These data characterize the incidence of thrombocytopenia and thrombocytosis across a wide range of gestational ages and show that, even in noninfected neonates, these conditions are common, and risk decreases with increasing maturity. The age-related changes in PLT patterns may reflect maturation of platelet regulation.
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Affiliation(s)
- Ronald J McPherson
- Department of Pediatrics/Neonatology, University of Washington, Seattle, WA 98195-6320, USA
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Labbé RF, Dewanji A. Iron assessment tests: transferrin receptor vis-à-vis zinc protoporphyrin. Clin Biochem 2004; 37:165-74. [PMID: 14972637 DOI: 10.1016/j.clinbiochem.2003.10.006] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2003] [Accepted: 10/01/2003] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To review and compare the biochemical, analytical, and clinical features of two relatively new tests for assessing iron status and diagnosing iron disorders, namely, the serum transferrin receptor concentration (sTfR) and the erythrocyte zinc protoporphyrin/heme ratio (ZnPP/H). To consider the merits of each test for the diagnosis of iron disorders with emphasis on iron-deficient erythropoiesis, especially in the clinically important preanemia stage of iron depletion. CONCLUSIONS Although the basic biochemical mechanisms underlying the two tests are very different, both of these tests are noteworthy because they are considered to reflect iron status in the bone marrow. The principal advantage to serum transferrin receptor is the lack of a response to anemia of chronic disease (ACD), which affects other iron status indicators, for example, ferritin and transferrin saturation. The principal advantage to erythrocyte zinc protoporphyrin is low cost, but point-of-care testing and simplicity can also be advantages. Both serum transferrin receptor and erythrocyte zinc protoporphyrin have been demonstrated to be useful in a variety of clinical situations. Serum transferrin receptor can be best used in diagnosing iron disorders, especially for patients with pathologies that may affect iron metabolism. Erythrocyte zinc protoporphyrin can be best used as a primary screening test for assessing iron status, especially in patients likely to have uncomplicated iron deficiency. While these applications are primary, both tests are more broadly useful, for example, in monitoring iron therapy.
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Affiliation(s)
- Robert F Labbé
- Department of Laboratory Medicine, University of Washington, Seattle, WA 98104, USA.
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Abstract
OBJECTIVES Human fetuses and neonates ingest erythropoietin (Epo) when they swallow amniotic fluid, colostrum, and human milk. This study was designed to determine whether enterally dosed recombinant Epo (rEpo) stimulates erythropoiesis in preterm neonates. METHODS Preterm infants (<1500 g birth weight) were randomly assigned to receive feedings supplemented with either rEpo (1000 U/kg per day) or placebo for 14 days (n=36). Reticulocyte counts, serum Epo concentrations, hematocrit, and zinc protoporphyrin to heme ratios were measured at baseline and after 7 and 14 days of study drug administration. Transfusion guidelines were followed. Transfusion requirements, medications, feeding tolerance, and clinical diagnoses were documented. RESULTS Enteral rEpo was well tolerated. There were no differences in erythropoietic indexes based on treatment group. Serum Epo concentrations were not different in the treatment versus placebo group, nor were transfusion requirements. CONCLUSIONS Enterally dosed rEpo (1000 U/kg/day) does not significantly influence erythropoiesis or iron utilization when given for a 2-week period, nor does it elevate the serum Epo concentration in preterm or term infants. Oral administration of rEpo is not an effective substitute for parenteral administration.
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Affiliation(s)
- Sandra E Juul
- Department of Pediatrics, Division of Neonatology, University of Washington, Seattle,1 98195, USA.
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