Neonatal polycythaemia: critical review and a consensus statement of the Israeli Neonatology Association

Embryonic, Fetal, and Neonatal Complications in Infants of Diabetic Mothers: Insights from the Cincinnati Diabetes in Pregnancy Program Project Grant

This study aimed to review how the Cincinnati Diabetes in Pregnancy Program Project Grant (PPG) contributed to the understanding and treatment of neonatal complications in infants of diabetic mothers (IDMs). This is a retrospective review of all PPG work on glycemic control at different pregnancy time points and its association with embryonic, fetal, and neonatal complications, such as congenital malformations (CMs), intrauterine growth restriction, macrosomia, hypoglycemia, respiratory distress syndrome (RDS), asphyxia, and polycythemia. We found that maternal vasculopathy and poor glycemic control during embryogenesis, but not frequency of maternal hypoglycemic episodes or insulin therapy, are independent risk factors for major CMs. A suggestive association of major CMs with maternal Magnesium deficiency was also observed. Poor glycemic control during late embryogenesis and early fetal development was associated with an increased risk of minor CMs. We described a biphasic pattern of fetal growth whereby early growth delay was followed by enhanced fetal growth associated with neonatal macrosomia. Macrosomia was associated with poorer glycemic control in the third trimester and an increased risk of birth trauma. Macrosomia was also correlated with animal-origin insulin concentrations in cord blood, demonstrating that insulin bound to antibodies can cross the placenta and may affect the fetus. We also showed that neonatal hypoglycemia was significantly associated with third-trimester glycemic control, in addition to hyperglycemia occurring during labor. With modern management and adequate prenatal care, IDMs are no longer at increased risk for RDS. Perinatal asphyxia was associated with increased proteinuria appearing in pregnancy, maternal hyperglycemia before delivery, and prematurity. Polycythemia in IDMs is prevalent and correlates with proxy measurements of fetal hypoxemia (nucleated red blood cells at delivery) and poorer glycemic control in late pregnancy. The PPG in its various phases revealed the important role of glycemic control at nearly every stage of pregnancy including labor. KEY POINTS: · Poor glycemic control during embryogenesis is a major risk factor for CMs.. · Magnesium deficiency might contribute to major malformations.. · Macrosomia is associated with poor glycemic control in the third trimester.. · Strict glycemic control reduces fetal and neonatal morbidity in pregnancies with insulin-dependent diabetes mellitus..

Neonatal polycythemia: prevalence, risk factors and predictors of severity

BACKGROUND

Polycythemia is a disorder with several causes and risk factors. The clinical presentation is variable, ranging from asymptomatic newborns to cases with severe physiological changes. The aim of this study was to assess the prevalence, risk factors and predictors of severity of polycythemia in a Portuguese level III Neonatal Intensive Care Unit (NICU).

METHODS

Case-control study of all term newborns with the diagnosis of polycythemia admitted to the NICU of the São João Universitary Hospital Center, Porto, Portugal, from January 1, 1999 to December 31, 2019; and who met one of the following inclusion criteria were eligible for the study: 1) Hct>65% or Hb>22 g/dL; and 2) Hb≥21 g/dL with clinical manifestations of polycythemia.

RESULTS

A total of 53 newborns fulfilled the inclusion criteria and were included in the study, corresponding to a prevalence of 0.57%. Birth outside the hospital was the only risk factor with statistical significance. Of 53 cases, 51 (96.23%) had symptomatic polycythemia. The most frequent symptoms were: hyperbilirubinemia (69.81%), hypoglycemia (52.83%), thrombocytopenia (50.94%), cardiorespiratory (33.96%), and neurological symptoms (33.96%). Of the 53 newborns evaluated, 41 (77.36%) needed treatment. The only risk factors that influenced the hematocrit value were maternal diabetes and fetal growth restriction.

CONCLUSIONS

The best way to improve the prognosis of polycythemia is to identify the risk factors present throughout pregnancy and make an early diagnosis and treatment. Out-of-hospital births should be avoided. The diagnosis should not be excluded, even if hemoglobin and hematocrit are within normal limits.

Neonatal Polycythemia and Hypoglycemia in Newborns: Are They Related?

OBJECTIVE

This study aimed to test whether neonatal hypoglycemia (NH) is more common in infants with neonatal polycythemia (NP).

STUDY DESIGN

This is a retrospective study based on universal screening of NH and targeted screening for NP. Polycythemia was defined as venous hematocrit ≥ 65%. NH was defined as whole blood glucose (BG) concentration < 48 mg/dL (measured using a "point-of-care" analyzer [Accu-Chek]).

RESULTS

The study population consisted of 119 consecutive term polycythemic infants and 117 controls. There were no significant differences between the two groups in perinatal characteristics, minimal BG concentration, and rate of hypoglycemia. In a stepwise backward multiple regression where NH was the dependent variable, only maternal gestational diabetes mellitus (p = 0.032) and toxemia (p = 0.001) remained significant, whereas NP was insignificant.

CONCLUSION

NH is not more common in NP infants than in non-NP infants. We suggest that the occurrence of NH in infants with NP might be related to the common risk factors of the two morbidities.

Risk factors for readmission for phototherapy due to jaundice in healthy newborns: a retrospective, observational study

BACKGROUND

The guidelines of the American Academy of Pediatrics (AAP) for monitoring neonatal jaundice recommend universal postnatal screening for hyperbilirubinemia within 48 h from discharge. We observed that neonate with low-risk jaundice were more likely to be readmitted to hospital for phototherapy compared to neonate with high-risk jaundice. The aim of this study was to identify additional factors that increase the risk for jaundice-related readmission.

METHODS

This observational case-control study was performed on 100 consecutive neonates with jaundice who were readmitted to hospital for phototherapy treatment and were compared to 100 neonates with jaundice during hospitalization who were not readmitted after discharge. The data retrieved from the medical records of all participants included maternal characteristics, delivery type and noteworthy events, gestational age at delivery, birth weight and weight loss, neonate physical findings, Apgar scores, laboratory findings, length of hospital stay, and administration of phototherapy during hospitalization. The length of time since discharge and readmission for jaundice was also recorded.

RESULTS

The risk of readmission decreased by 48% [odds ratio (OR) =0.52; 95% confidence interval (CI) 0.341-0.801] with every day added to the original hospitalization stay, and by 71% (OR = 0.29; 95% CI 0.091-0.891) if phototherapy had been administered during postnatal hospitalization. In contrast, the risk increased by 28% (OR = 1.28; 95% CI 1.164-1.398) with every elevation by 1% in hematocrit, and by 2.78 time (95% CI 1.213-6.345; p = 0.0156) when the delta in infant weight was > 5% (the difference between birth weight and weight at discharge during the postnatal hospitalization).

CONCLUSIONS

The risk factors for readmission, such as substantial weight loss (> 5% difference between birth and discharge) and elevated hematocrit should be taken into account in the decision to discharge neonate with low-risk jaundice. The AAP guidelines for decreasing readmission rates of neonatal jaundice by postnatal screening for hyperbilirubinemia alone may be more appropriate for neonate with high-risk jaundice.

Infant of diabetic mother: what one needs to know?

The global incidence of diabetes mellitus, including diabetes in pregnant women, is on the rise. Diabetes mellitus in a pregnant woman jeopardizes not only maternal health but can also have significant implications on the child to be born. Therefore, timely diagnosis and strict glycemic control are of utmost importance in achieving a safe outcome for both the mother and fetus. The treating physician should be aware of the complications that can arise due to poor glycemic control during pregnancy. The objective of this article is to discuss the key concerns in a neonate born to diabetic mother, the underlying pathogenesis, and the screening schedule during pregnancy.

Effects and safety of delayed versus early umbilical cord clamping in newborns of HIV-infected mothers

OBJECTIVE

To investigate the effect of a 2 minutes-delayed cord clamp (DCC) versus early cord clamp (ECC) on neonate haemoglobin concentration 24 hours and 1 month after birth, and assess the safety of DCC concerning the risk of HIV infection.

DESIGN

Sixty-four mother-infant peers were enrolled. All mothers were on stable ARV therapy. Viral load, CD4⁺ count and blood haemoglobin (Hb) concentrations 24 hours before delivery were collected from all mothers and their infants.

METHODS

All patients were enrolled at the Department of Paediatrics, AO FBF Sacco Hospital in Milan, and were followed until 18 months after birth. Women with haematological diseases and obstetrical complications were excluded. All of 64 mother and infants couples (32 ECC group and 32 DCC group) completed the study. ECC and DCC are defined as application of umbilical clamp within 30 seconds and 120 seconds after birth, respectively.

RESULTS

Mean birth weight was significantly higher in the DCC compared with ECC group. Mean Hb levels at birth were significantly higher in DCC than in ECC group (p = .05): this difference persisted at 1 month of life. All newborns showed negative viral load.

CONCLUSIONS

DCC 2 minutes after birth is proven to be a safe procedure, particularly beneficial in newborns from HIV mothers. The risk of anemia is significantly decreased at 24 hours after birth and persists at age of 1 month without any increased risk of neonatal jaundice or polycitemia.

Effects of delayed cord clamping on residual placental blood volume, hemoglobin and bilirubin levels in term infants: a randomized controlled trial

OBJECTIVE

The objective of the study was to measure the effects of a 5-min delay (DCC) versus immediate cord clamping (ICC) on residual placental blood volume (RPBV) at birth, and hemoglobin and serum bilirubin at 24 to 48 h of age.

STUDY DESIGN

In this prospective randomized controlled trial, 73 women with term (37 to 41 weeks) singleton fetuses were randomized to DCC (⩾5 min; n=37) or ICC (<20 s; n=36).

RESULTS

Maternal and infant demographics were not different between the groups. Mean cord clamping time was 303±121 (DCC) versus 23±59 (ICC) s (P<0.001) with 10 protocol violations. Cord milking was the proxy for DCC (n=11) when the provider could not wait. Infants randomized to DCC compared with ICC had significantly less RPBV (20.0 versus 30.8 ml kg^-1, P<0.001), higher hemoglobin levels (19.4 versus 17.8 g dl^-1, P=0.002) at 24 to 48 h, with no difference in bilirubin levels.

CONCLUSION

Term infants had early hematological advantage of DCC without increases in hyperbilirubinemia or symptomatic polycythemia.

Can middle cerebral artery peak systolic velocity predict polycythemia in monochorionic-diamniotic twins? Evidence from a prospective cohort study

OBJECTIVE

The antenatal diagnosis of twin anemia-polycythemia sequence (TAPS) in monochorionic-diamniotic (MCDA) twin pregnancies is based on elevated peak systolic velocity in the middle cerebral artery (MCA-PSV) in the donor twin and decreased MCA-PSV in the recipient twin. However, the association between these parameters and polycythemia has not yet been established. The aim of this study was to determine whether MCA-PSV can predict polycythemia in MCDA pregnancies.

METHODS

This was a prospective cohort study of MCDA pregnancies recruited at 14-18 weeks' gestation from a single tertiary care center between January 2011 and June 2014. Fetal MCA Doppler waveforms were recorded every 2 weeks from 18 weeks' gestation until delivery. Only those with an MCA-PSV measurement within 1 week of delivery were included in the analysis. Neonatal hematocrit level was determined in all twins from venous blood obtained within 4 h of delivery. Polycythemia was defined as a hematocrit of > 65%, and anemia as a hematocrit of < 45%. TAPS was diagnosed when an intertwin hemoglobin difference of > 8 g/dL and reticulocyte count ratio of > 1.7 were observed.

RESULTS

Of 162 MCDA pregnancies followed during the study period, 69 had an MCA-PSV measurement within 1 week of delivery and were included in the study. Twenty-five neonates were diagnosed with polycythemia and nine twin pairs met the criteria for TAPS. In a pooled analysis, MCA-PSV was negatively correlated with neonatal hematocrit (P = 0.017, r = -0.215) and was significantly higher in anemic fetuses than in normal controls (1.15 multiples of the median (MoM) vs 1.02 MoM, respectively; P = 0.001). However, MCA-PSV was similar among polycythemic and normal fetuses (0.95 MoM vs 1.02 MoM, respectively; P = 0.47). Intertwin difference in MCA-PSV (delta MCA-PSV) was positively correlated with intertwin hematocrit difference (P = 0.002, r = 0.394). Moreover, twin pregnancies with an intertwin hematocrit difference of > 24% had a significantly greater delta MCA-PSV than did those with an intertwin hematocrit difference of ≤ 24% (delta MCA-PSV, 19 vs 5 cm/s; P < 0.001).

CONCLUSIONS

MCA-PSV is not significantly decreased in polycythemic MCDA twins. However, delta MCA-PSV is associated with a large intertwin difference in hematocrit, and its use may be better than conventional methods for the risk assessment of TAPS. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Review of the correlation between blood flow velocity and polycythemia in the fetus, neonate and adult: appropriate diagnostic levels need to be determined for twin anemia-polycythemia sequence

Twin anemia-polycythemia sequence (TAPS) is recognized increasingly antenatally by the demonstration of an anemic twin and a polycythemic cotwin using the middle cerebral artery peak systolic velocity (MCA-PSV). While the MCA-PSV has been shown to correlate well with anemia in singleton fetuses, the evidence to support its use to diagnose fetal polycythemia appears to be less clear-cut. We aimed to evaluate fetal, neonatal and adult literature used to support the use of MCA-PSV for the diagnosis of polycythemia. Comprehensive literature searches were performed for ultrasound evidence of polycythemia in the human fetus, neonate and adult using key search terms. Only manuscripts in the English language with an abstract were considered for the review, performed in June 2014. Fifteen manuscripts were found for the human fetus, including 38 cases of TAPS. Nine of these defined fetal polycythemia as MCA-PSV < 0.8 multiples of the median (MoM), five used < 1.0 MoM and one used 0.8-1.0 MoM. Only two studies, involving a total of 15 cases, proposed a diagnostic level, acknowledging false-positive and -negative cases, though neither reported sensitivities or specificities. Six neonatal studies (96 neonates) demonstrated evidence of decreased cerebral velocities in polycythemia and a consequent increase with hemodilution. In the adult, five studies (57 polycythemic adults) demonstrated increased flow or velocity with hemodilution. Neither neonatal nor adult studies conclusively defined levels for screening for polycythemia. Despite widespread adoption of a cut-off of < 0.8 MoM in the published literature for the polycythemic fetus in TAPS, this is based upon minimal evidence, with unknown sensitivity and specificity. We recommend caution in excluding TAPS based purely upon the absence of a reduced MCA-PSV.

Determination of whole blood and plasma viscosity in term neonates by flow curve analysis with the LS300 viscometer1

Determination of shear stresses at given shear rates allow approximation of flow curves by mathematical models and to calculate viscosities of non-Newtonian fluids. In term neonates, the mean arterial blood pressure (MAP) is markedly below that of adults, therefore rheological properties of blood play an important role in maintaining perfusion. Whole blood viscosity was measured in umbilical cord blood taken from 62 term neonates using the LS 300 viscometer. Individual parameters that influence the viscosity of whole blood were measured: red blood cell (RBC) aggregation, plasma viscosity, hematocrit, and RBC deformability. The flow curve of whole blood of neonates was approximated by the method of Ostwald with the highest quality whereas in adults the best approximation was found by the method of Casson. With hematocrits of 0.40, the viscosity of whole blood in newborns approximated by Ostwald (9.84 ± 5.12 mPa·s) was significantly lower than that of adults (15.34 ± 3.01 mPa·s). The aggregation index of the blood of newborns was markedly lower (2.98 ± 2.12) than in adults (14.63 ± 3.50) whereas RBC deformability was higher in neonates. The viscosity of plasma determined by Ostwald revealed a lower exponent (n) in neonates (0.94 ± 022) compared to adults (1.01 ± 0.12) and the viscosity determined by Newton was lower in neonates (1.04 ± 0.16 mPa·s) than in adults (1.19 ± 0.07 mPa·s). The flow curve of neonatal blood which is best approximated by the model of Ostwald emphasizes its important viscous properties necessary for conditions with physiologically low blood pressure.

Common hematologic problems in the newborn nursery

"Common red blood cell disorders encountered in the normal newborn nursery include hemolytic disease of the newborn and resultant hyperbilirubinemia, anemia, and polycythemia. A less frequent clinically relevant hematologic issue in newborns to be covered herein is thrombocytopenia."

Polycythemia in neonatal intensive care unit, risk factors, symptoms, pattern, and management controversy

Background:

Polycythemia (PC) is defined as venous hematocrit (hct) ≥65%. Its incidence is high among certain risk factors (RFs). Its management is controversy.

Aims:

To determine: (1) The incidence of PC in our neonatal intensive care unit (NICU). (2) Most common RF, symptoms, and laboratory abnormalities (LA) associated with PC and their effect on the length of hospital stay (LOS). (3) Whether noninvasive interventions are effective in reducing hct. (4) Hct pattern of PC neonates.

Design:

Retrospective cohort study.

Setting:

NICU at a maternity and children hospital.

Materials and Methods:

Records review of all neonates from March 2011 to August 2013. Inclusions criteria were: (1) Venous hct ≥65%. (2) Neonates born in our institution. (3) Early umbilical cord clamping. (4) Gestational age ≥34 weeks.

Statistical Analysis:

Chi-square and multiple regression analysis.

Results:

One hundred and one PC neonates were eligible. Incidence of PC in our NICU is 14.5%. The most common RF, symptoms, and LA were: Small for gestational age, jaundice and hypoglycemia respectively. Tachypnea (  P - 0.04) and oliguria (P - 0.03) significantly prolonged LOS. Noninvasive interventions or observation could not reduce the hct significantly (P - 0.24). The hcts mean peaked maximally at a mean of 2.8 h of age.

Conclusion:

PC incidence in our NICU is higher than the reported incidence in healthy newborns. Most of the PC neonates were either symptomatic or having LA. Noninvasive interventions or observation were not effective in reducing hct in polycythemic neonates. Hct in both healthy and PC neonates peaked at the same pattern.

Neonatal thrombocytopenia: etiology, management and outcome

Thrombocytopenia is a very common hematological abnormality found in newborns, especially in preterm neonates. Two subgroups can be distinguished: early thrombocytopenia, occurring within the first 72 hours of life, and late thrombocytopenia, occurring after the first 72 hours of life. Early thrombocytopenia is associated with intrauterine growth restriction, whereas late thrombocytopenia is caused mainly by sepsis and necrotizing enterocolitis (NEC). Platelet transfusions are the hallmark of the treatment of neonatal thrombocytopenia. Most of these transfusions are prophylactic, which means they are given in the absence of bleeding. However, the efficacy of these transfusions in preventing bleeding has never been proven. In addition, risks of platelet transfusion seem to be more pronounced in preterm neonates. Because of lack of data, platelet transfusion guidelines differ widely between countries. This review summarizes the current understanding of etiology and management of neonatal thrombocytopenia.