Early anemia and neonatal morbidity in extremely low birth-weight preterm infants

[Clinical practice guidelines for the diagnosis and treatment of anemia of prematurity (2025)]

Anemia of prematurity (AOP) is a multifactorial condition associated with congenital iron deficiency, low erythropoietin levels, a short lifespan of red blood cells, and iatrogenic blood loss. AOP is a common complication in premature infants that can adversely affect growth, development, and long-term neurocognitive outcomes. To standardize the diagnosis and treatment of AOP, the Neonatal Clinical Practice Guidelines Expert Committee and the Neonatal Evidence-Based Medicine Group of the Commission of Neonatal Medicine of the Cross-Strait Medical and Health Exchange Association, along with the Editorial Office of the Chinese Journal of Contemporary Pediatrics, have developed the "Clinical practice guidelines for the diagnosis and treatment of anemia of prematurity (2025)", based on the World Health Organization's handbook for guideline development and the formulation/revision principles of Chinese clinical practice guidelines. This guideline addresses eight clinical issues related to AOP, including risk factors, early identification, etiological diagnosis, diagnostic criteria, early prevention, transfusion therapy, strategies to improve prognosis, and post-discharge follow-up. It presents 29 recommendations formed from current evidence and expert consensus, aiming to provide guidance and decision-making support for healthcare professionals in the diagnosis and treatment of AOP.

Fetal Hemoglobin as a Predictive Biomarker for Retinopathy of Prematurity: A Prospective Multicenter Cohort Study in Portugal

Background/Objectives: Retinopathy of prematurity (ROP) is a leading cause of vision impairment in preterm infants, with its pathogenesis linked to oxygen exposure. Red blood cell (RBC) transfusions, commonly performed in neonatal intensive care units (NICUs), reduce fetal hemoglobin (HbF) fraction, altering oxygen dynamics and potentially contributing to ROP. We aimed to investigate the relationship between RBC transfusions, HbF percentage, and ROP, evaluating HbF as a potential predictive biomarker. Methods: A multicenter, prospective study was conducted across eight Portuguese NICUs, involving infants born at <32 weeks gestational age (GA) or <1500 g. ROP staging followed the International Classification of ROP (ICROP2). Clinical data were collected during hospitalization, and HbF fractions were measured from blood samples in the first four weeks of life using standardized methods. Infants were stratified by ROP presence and treatment requirement. Statistical analysis was performed using SPSS 28.0, with p < 0.05. Results: Eighty-two infants (mean GA: 28.1 ± 2.1 weeks, birth weight: 1055.8 ± 258.3 g) were included. Among them, 29 (35.4%) presented ROP and 4 (4.9%) required treatment. Infants with ROP had more RBC transfusions and lower HbF percentages than those without ROP (p < 0.05). Lower HbF was associated with more RBC transfusions (p < 0.001). Kaplan-Meier survival curves showed a higher ROP risk in infants with reduced HbF (p < 0.05). Conclusions: Low HbF percentage in the first four weeks of life may increase ROP risk in preterm infants. HbF could serve as a biomarker for ROP prediction. Interventions preserving HbF may reduce ROP risk. Further studies are needed to validate HbF as a biomarker and refine prevention strategies.

Effect of Allium spices (garlic and onion) on the bioaccessibility of iron from Moringa oleifera leaves

The aim of this study was to investigate the effect of garlic and onion, two Allium spices rich in sulfur compounds, on the bioaccessibility of iron from Moringa oleifera leaves. We first quantified anti-nutritional factors in various cooked mixtures of Moringa oleifera leaves and spices, with increasing level of incorporation of garlic or onion. We then assessed the iron bioaccessibility of the various mixtures using a simulated in vitro digestion method. Finally, we studied the speciation of bioaccessible iron. Total phenols contents ranging from 801.44 to 903.07 and from 869.78 to 990.72 mg/100 g of dry matter in garlic and onion mixtures, respectively, increased (p < .05) with the level of incorporation of spices. Phytates contents followed the same tendency with values ranging from 1.84 to 2.12 and from 1.75 to 2.02 mg/100 g of dry matter in garlic and onion mixtures, respectively. Although the presence of garlic and onion significantly reduced (p < .05) the total iron content of the mixtures (11.56-11.96 mg/100 g of dry matter), we noticed that bioaccessible iron was significantly higher (p < .05) in spiced mixtures (36.35%-48.40%) compared to the control (23.28%), with the greatest amount found in the mixture containing 10 g of onion. The predominant specie of bioaccessible iron was organic iron, whose amounts in the spiced mixtures (0.59-0.69 mg/L) were all significantly higher (p < .05) than in the control (0.32 mg/L). Globally, the presence of spices produced no significant variation (p > .05) in amounts of ferrous iron, the major inorganic specie of bioaccessible iron. The use of garlic and onion as ingredients could help improving the iron status of populations consuming iron-rich leafy vegetables.

Hemoglobin/Red Cell Distribution width Ratio (HRR): A Novel and Promising Red Cell Parameter in Ductal Closure

BACKGROUND

It is still unclear how effective hematological parameters are in the closure of patent ductus arteriosus (PDA).

OBJECTIVES

The primary aim of our study is to investigate the effect of hemoglobin (HB)-to-red cell distribution width (RDW) ratio (HRR) on the closure of PDA.

METHODS

Premature babies with very low birth weight (VLBW: <1500 g) and <32 gestational weeks were included in the study, and all data were recorded retrospectively. Demographic characteristics, clinical results, red cell parameters, and HRR and their ratios were compared between hemodynamically significant PDA (hsPDA) and non-hsPDA groups. All results were statically analyzed, and P<0.05 was considered statistically significant.

RESULTS

A total of 677 premature babies, 269 in the hsPDA group and 408 in the non-hsPDA group, were included in the study. Hemoglobin (HB), hematocrit (HCT), mean cell volume (MCV), red blood cell (RBC), red cell distribution width (RDW), mean platelet volume (MPV), MCV/RBC ratio, HB/RBC ratio, RDW/RBC ratio, and RDW/MPV ratio were found to be similar between hsPDA and non-hsPDA groups, (p>0.05). HRR was found to be significantly lower in the hsPDA group [median (Quartile 1 (Q1) - Q3) (Q1 - Q3): 0.93 (0.8-1.0)] compared to non-hsPDA [median ( Q1 - Q3): 1.07 (1.0-1.2)] (p<0.001). The AUC for the diagnostic value of HRR in hsPDA was 0.816, and the cutoff value was ≤0.98 (p<0.001, 95% [CI]: 0.785-0.845, sensitivity: 90%, specificity: 92%).

CONCLUSIONS

HRR value was found to be both an effective and powerful parameter in diagnosing hsPDA.

Relationship of Early Anemia with Neurodevelopment and Brain Injury in Very Low Birth Weight Preterm Infants-A Prospective Cohort Study

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.

Severe Anemia at Birth-Incidence and Implications

OBJECTIVE

To identify neonates with severe anemia at birth, defined by a hemoglobin or hematocrit value within the first 6 hours after birth that plotted below the 1st percentile according to gestational age. For each patient, we retrospectively determined whether caregivers recognized the anemia within the first 24 hours after birth and the probable cause and outcome of anemia.

STUDY DESIGN

This was a retrospective cohort analysis of Intermountain Healthcare population-based data from neonates born between January 2011 and December 2020 who had a hemoglobin or hematocrit value measured within the first 6 hours after birth below the 1st percentile lower reference interval (hematocrit ∼35% in near-term/term neonates).

RESULT

Among 299 927 live births, we identified 344 neonates with severe anemia at birth. In 191 of these neonates (55.5%), the anemia was recognized by caregivers during the first 24 hours. Anemia was more likely to be recorded as a problem (85%) if the hemoglobin was ≥2 g/dL below the 1st percentile (P < .001). The lowest hemoglobin values occurred in those in whom hemorrhage was the probable cause (P < .013 vs hemolysis and P < .001 vs hypoproduction, mixed cause, or indeterminant.) Treatment was provided to 39.5%. A retrospective review suggested that mixed mechanisms, particularly hemorrhagic plus hemolytic, occurred more commonly than was recognized at the time of occurrence.

CONCLUSIONS

Severe anemia at birth often went unrecognized on the first day of life. Algorithm-directed retrospective reviews commonly identified causes that were not listed in the medical record. We postulate that earlier recognition and more accurate diagnoses would be facilitated by an electronic medical record-associated hemoglobin/hematocrit gestational age nomogram.

Outcome predictors for maternal red blood cell alloimmunisation with anti-K and anti-D managed with intrauterine blood transfusion

Red blood cell (RBC) alloimmunisation with anti-D and anti-K comprise the majority of cases of fetal haemolytic disease requiring intrauterine red cell transfusion (IUT). Few studies have investigated which haematological parameters can predict adverse fetal or neonatal outcomes. The aim of the present study was to identify predictors of adverse outcome, including preterm birth, intrauterine fetal demise (IUFD), neonatal death (NND) and/or neonatal transfusion. We reviewed the records of all pregnancies alloimmunised with anti-K and anti-D, requiring IUT over 27 years at a quaternary fetal centre. We reviewed data for 128 pregnancies in 116 women undergoing 425 IUTs. The median gestational age (GA) at first IUT was significantly earlier for anti-K than for anti-D (24·3 vs. 28·7 weeks, P = 0·004). Women with anti-K required more IUTs than women with anti-D (3·84 vs. 3·12 mean IUTs, P = 0·036) and the fetal haemoglobin (Hb) at first IUT was significantly lower (51.0 vs. 70.5 g/l, P = 0·001). The mean estimated daily decrease in Hb did not differ between the two groups. A greater number of IUTs and a slower daily decrease in Hb (g/l/day) between first and second IUTs were predictive of a longer period in utero. Earlier GA at first IUT and a shorter interval from the first IUT until delivery predicted IUFD/NND. Earlier GA and lower Hb at first IUT significantly predicted need for phototherapy and/or blood product use in the neonate. In the anti-K group, a greater number of IUTs was required in women with a higher titre. Furthermore, the higher the titre, the earlier the GA at which an IUT was required in both groups. The rate of fall in fetal Hb between IUTs decreased, as the number of transfusions increased. Our present study identified pregnancies at considerable risk of an unfavourable outcome with anti-D and anti-K RBC alloimmunisation. Identifying such patients can guide pregnancy management, facilitates patient counselling, and can optimise resource use. Prospective studies can also incorporate these characteristics, in addition to laboratory markers, to further identify and improve the outcomes of these pregnancies.

Transfusion prevention using erythropoietin, parenteral sucrose iron, and fewer phlebotomies in infants born at ≤30 weeks gestation at a high altitude center: a 10-year experience

INTRODUCTION

Red blood cell transfusions in infants born at ≤30 weeks gestation are frequent. Erythropoietin therapy reduces transfusions. An increase in hematocrit is an adaptive response at high altitudes but a guaranteed source of iron is necessary for adequate erythropoiesis.

METHODS

A retrospective cohort study was done to compare red blood cell transfusion practices of the 2019 EpicLatino (EPIC) Latin America network database with a single unit at 2650 m above sea level (LOCAL). The data from LOCAL for three time periods were compared over 10 years based on changes in erythropoietin dose and fewer phlebotomies. The number of cases that received transfusions and the total number of transfusions required were compared. Adjustments were made for known risk factors using a multivariate regression analysis.

RESULTS

Two hundred and twenty-one cases in LOCAL and 382 cases from EPIC were included. Overall basic demographic characteristics were similar. In EPIC a significantly higher rate of infection (28% vs. 15%) and outborn (10% vs. 1%) was found, but less necrotizing enterocolitis (9% vs. 15%) and use of prenatal steroids (62% vs. 93%) than LOCAL (p < 0.05). EPIC patients received more transfusions (2.6 ± 3 vs. 0.6 ± 1 times) than LOCAL (p < 0.001) and received them significantly more frequently (61% vs. 25%). Within the LOCAL time periods, no statistically significant differences were found other than the need for transfusions (1st 32%, 2nd 28%, 3rd 9%, p = 0.005) and the average number of transfusions (1st 0.8 ± 1.6, 2nd 0.7 ± 1.3, 3rd 0.1 ± 0.3, p = 0.004). These differences remained significant after multivariate regression analysis and adjusting for risk variables.

CONCLUSION

The combination of erythropoietin, parenteral sucrose iron, fewer phlebotomies during the first 72 h, and delayed umbilical cord clamping seem to reduce red blood cell transfusion needs. This can be extremely important in high altitude units where higher hematocrit is desirable but may also be valuable at sea level.

Neonatal Hemoglobin Levels in Preterm Infants Are Associated with Early Neurological Functioning

BACKGROUND

Neonatal anemia may compromise oxygen transport to the brain. The effects of anemia and cerebral oxygenation on neurological functioning in the early neonatal period are largely unknown.

OBJECTIVE

This study aimed to determine the association between initial hemoglobin levels (Hb) and early neurological functioning in preterm infants by assessing their general movements (GMs).

METHODS

A retrospective analysis of prospectively collected data on preterm infants born before 32 weeks of gestation was conducted. We excluded infants with intraventricular hemorrhage > grade II. On day 8, we assessed infants' GMs, both generally as normal/abnormal and in detail using the general movement optimality score (GMOS). We measured cerebral tissue oxygen saturation (rcSO2) on day 1 using near-infrared spectroscopy.

RESULTS

We included 65 infants (median gestational age 29.9 weeks [IQR 28.2-31.0]; median birth weight 1,180 g [IQR 930-1,400]). Median Hb on day 1 was 10.3 mmol/L (range 4.2-13.7). Lower Hb on day 1 was associated with a higher risk of abnormal GMs (OR = 2.3, 95% CI: 1.3-4.1) and poorer GMOSs (B = 0.9, 95% CI: 0.2-1.7). Hemoglobin strongly correlated with rcSO2 (rho = 0.62, p < 0.01). Infants with lower rcSO2 values tended to have a higher risk of abnormal GMs (p = 0.06). After adjusting for confounders, Hb on day 1 explained 44% of the variance of normal/abnormal GMs and rcSO2 explained 17%. Regarding the explained variance of the GMOS, this was 25% and 16%, respectively.

CONCLUSIONS

In preterm infants, low Hb on day 1 is associated with impaired neurological functioning on day 8, which is partly explained by low cerebral oxygenation.

Effect of early prophylactic low-dose recombinant human erythropoietin on retinopathy of prematurity in very preterm infants

BACKGROUND

Very preterm infants are at risk of developing retinopathy of prematurity (ROP). Recombinant human erythropoietin (rhEPO) is routinely used to prevent anemia in preterm infants; however, the effect of rhEPO on ROP development is still controversial. The purpose of this study was to evaluate the effect of early prophylactic low-dose rhEPO administration on ROP development in very preterm infants.

METHODS

A total of 1898 preterm infants born before 32 weeks of gestation were included. Preterm infants received rhEPO (n = 950; 500 U/kg, rhEPO group) or saline (n = 948, control group) intravenously within 72 h of birth and then once every other day for 2 weeks.

RESULTS

The total incidence of ROP was not significantly different between the two groups (10.2% vs. 13.2%, p = 0.055). Further analysis showed that rhEPO group had lower rates of type 2 ROP than the control group (2.2% vs. 4.1%, RR 0.98; 95% CI 0.96-1.00; p = 0.021). Subgroup analysis found that rhEPO treatment significantly decreased the incidence of type 2 ROP in infant boys (1.8% vs. 4.3%, p = 0.021) and in those with a gestational age of 28-29^6/7 weeks (1.1% vs. 4.9%, p = 0.002) and birth weight of 1000-1499 g (1.2% vs. 4.2%, p = 0.002). There was a small increasing tendency for the incidence of ROP in infants with a gestational age of < 28 weeks after rhEPO treatment.

CONCLUSIONS

Repeated low-dose rhEPO administration has no significant influence on the development of ROP; however, it may be effective for type 2 ROP in infant boys or in infants with gestational age > 28 weeks and birth weight > 1500 g. Trial registration The data of this study were retrieved from two clinical studies registered ClinicalTrials.gov (NCT02036073) on January 14, 2014, https://clinicaltrials.gov/ct2/show/NCT02036073 ; and (NCT03919500) on April 18, 2019. https://clinicaltrials.gov/ct2/show/NCT03919500 .

The Thromboelastographic Profile at Birth in Very Preterm Newborns with Patent Ductus Arteriosus

BACKGROUND

The role of hemostasis in the closure of patent ductus arteriosus (PDA) in preterm infants is controversial.

OBJECTIVE

To assess thromboelastography (TEG) at birth in very-low-birth-weight (VLBW) infants affected by PDA.

METHODS

This was an ancillary study of a prospective observational study aimed at defining the TEG profile in healthy VLBW infants in the first month of life. In this analysis, we included neonates of <33 weeks' gestational age (GA) with PDA and compared TEG traces based on (1) spontaneous closure versus the need for pharmacological treatment and (2) treatment response. We collected blood samples in the 1st day of life to perform recalcified native-blood TEG (reaction time, maximum amplitude, and lysis at 30 min [Ly30)]), standard coagulation tests, and a full blood count.

RESULTS

We enrolled 151 infants with a PDA at the first echocardiogram; 111 experienced spontaneous PDA closure while 40 required treatment. Mean GA was 29.7 ± 1.7 and 27.6 ± 2.1 weeks, and birth weight was 1,158 ± 256 and 933 ± 263 g in the 2 groups, respectively (p < 0.001). The hemostatic profile was similar between groups. Median hematocrit (44.6 and 48.7%; p = 0.01) and platelet count (187 and 216 × 103/μL; p = 0.04) were lower in the treated group, although differences lost significance after controlling for GA and illness severity in the multivariate analysis. Responders to PDA treatment (n = 20) had a significantly lower median Ly30 than nonresponders (0 and 0.7%; p = 0.02).

CONCLUSION

TEG at birth does not predict spontaneous PDA closure in preterm newborns. Fibrinolysis is enhanced in nonresponders to PDA treatment; this observation warrants further investigation.