Trial-related blood sampling and red blood cell transfusions in preterm infants

AIM

To determine if trial-related blood sampling increases the risk of later red blood cell (RBC) transfusion in very preterm infants, we compared the volume of clinical- and trial-related blood samples, in a specific trial and correlated to subsequent RBC transfusion.

METHODS

For 193 very preterm infants, participating in the FortiColos trial (NCT03537365), trial-related blood volume drawn was in accordance with ethical considerations established by the European Commission. Medical records were reviewed to assess the number and accumulated volume (mL/kg) of blood samples (both clinical- and trial-related). Data were compared with the need of RBC transfusions during the first 28 days of life.

RESULTS

Mean (SD) gestational age and birth weight was 28 ± 1 weeks and 1168 ± 301 g. In total, 11% of total blood volume was drawn for sampling (8.1 ± 5.1 mL/kg) and trial-related sampling accounted for 1.6 ± 0.6 mL/kg. Trial-related blood sampling had no impact on RBC transfusion (p = 0.9).

CONCLUSION

Clinical blood sampling in very preterm infants is associated with blood loss and subsequent need for RBC transfusions. In a specific trial requiring blood samples, we found no additional burden of trial-related blood sampling. The study suggests that trial-related sampling is safe if European criteria are followed.

Erythrocyte transfusions are associated with retinopathy of prematurity in extremely low gestational age newborns

AIM

Retinopathy of prematurity (ROP) is a major morbidity in preterm infants causing visual impairment including blindness. Prevention and timely treatment are critical. We investigated the potential role of red blood cell (RBC) transfusions as risk factor for ROP development.

METHODS

Retrospective cohort study of data from 68 tertiary level neonatal intensive care units in Germany. Preterm infants born at 22 + 0 to 28 + 6 weeks of gestation between January 2009 and December 2021 were enrolled.

RESULTS

We included n = 12 565 infants. Prevalence of any ROP was 49.2% with most infants being diagnosed with stage 1 (21.5%) and 2 disease (17.2%). ROP stage 3 was present in 10.2%, stage 4 in 0.3%, and ROP requiring treatment in 6.6%. Infants with ROP had significantly more frequently a history of RBC transfusions. Adjusting for confounders, RBC transfusions were associated with increased odds of ROP (OR 1.4, p < 0.001), ROP progression (OR 2.1, p < 0.01) and ROP requiring treatment (OR 3.6, p < 0.001). Restrictive transfusion approaches correlated with decreased (OR 0.7, p < 0.001), liberal regimes with increased odds (OR 1.2, p = 0.001).

CONCLUSION

The present study confirmed an association of RBC transfusions and ROP. Our findings emphasise the need for anaemia prevention and critical re-evaluation of transfusion practices in preterm infants.

Red Blood Cell Transfusion Thresholds for Anemia of Prematurity

Anemia of prematurity affects the majority of preterm infants, particularly extremely low birthweight infants. Anemia of prematurity arises from both innate and iatrogenic causes and results in more than 80% of extremely preterm infants receiving red blood cell transfusions during the first month after birth. Multiple randomized controlled trials were conducted to evaluate the effect of using lower versus higher transfusion thresholds based on hemoglobin levels. These trials showed no difference in the primary outcome of neurodevelopmental impairment at 2 years of age between lower and higher thresholds. However, some uncertainties about transfusion thresholds remain. This review elaborates the following: 1) the etiology, prevention, and treatment of anemia of prematurity with a focus on red blood cell transfusions, 2) the history of randomized controlled trials on the treatment of anemia of prematurity, and 3) limitations of the evidence and remaining questions about thresholds for red blood cell transfusions in preterm infants.

Perinatal outcome of pregnancy complicated by twin anemia-polycythemia sequence: systematic review and meta-analysis

OBJECTIVE

To report the perinatal outcome of monochorionic diamniotic (MCDA) twin pregnancies complicated by twin anemia-polycythemia sequence (TAPS), according to the type of TAPS (spontaneous or postlaser) and the management option adopted.

METHODS

MEDLINE, EMBASE and The Cochrane Library databases were searched for studies reporting on the outcome of twin pregnancies complicated by TAPS. Inclusion criteria were non-anomalous MCDA twin pregnancies with a diagnosis of TAPS. The primary outcome was perinatal mortality; secondary outcomes were neonatal morbidity and preterm birth (PTB). The outcomes were stratified according to the type of TAPS (spontaneous or following laser treatment for twin-twin transfusion syndrome) and the management option adopted (expectant, laser surgery, intrauterine transfusion (IUT) or selective reduction (SR)). Random-effects meta-analysis of proportions was used to analyze the data.

RESULTS

Perinatal outcome was assessed according to whether TAPS occurred spontaneously or after laser treatment in 506 pregnancies (38 studies). Intrauterine death (IUD) occurred in 5.2% (95% CI, 3.6-7.1%) of twins with spontaneous TAPS and in 10.2% (95% CI, 7.4-13.3%) of those with postlaser TAPS, while the corresponding rates of neonatal death were 4.0% (95% CI, 2.6-5.7%) and 9.2% (95% CI, 6.6-12.3%), respectively. Severe neonatal morbidity occurred in 29.3% (95% CI, 25.6-33.1%) of twins after spontaneous TAPS and in 33.3% (95% CI, 17.4-51.8%) after postlaser TAPS, while the corresponding rates of severe neurological morbidity were 4.0% (95% CI, 3.5-5.7%) and 11.1% (95% CI, 6.2-17.2%), respectively. PTB complicated 86.3% (95% CI, 77.2-93.3%) of pregnancies with spontaneous TAPS and all cases with postlaser TAPS (100% (95% CI, 84.3-100%)). Iatrogenic PTB was more frequent than spontaneous PTB in both groups. Perinatal outcome was assessed according to the management option adopted in 417 pregnancies (21 studies). IUD occurred in 9.8% (95% CI, 4.3-17.1%) of twins managed expectantly and in 13.1% (95% CI, 9.2-17.6%), 12.1% (95% CI, 7.7-17.3%) and 7.6% (95% CI, 1.3-18.5%) of those treated with laser surgery, IUT and SR, respectively. Severe neonatal morbidity affected 27.3% (95% CI, 13.6-43.6%) of twins in the expectant-management group, 28.7% (95% CI, 22.7-35.1%) of those in the laser-surgery group, 38.2% (95% CI, 18.3-60.5%) of those in the IUT group and 23.3% (95% CI, 10.5-39.2%) of those in the SR group. PTB complicated 80.4% (95% CI, 59.8-94.8%), 73.4% (95% CI, 48.1-92.3%), 100% (95% CI, 76.5-100%) and 100% (95% CI, 39.8-100%) of pregnancies after expectant management, laser surgery, IUT and SR, respectively.

CONCLUSIONS

The present meta-analysis provides pooled estimates of the risks of perinatal mortality, neonatal morbidity and PTB in twin pregnancies complicated by TAPS, stratified by the type of TAPS and the management option adopted. Although a direct comparison could not be performed, the results from this systematic review suggest that spontaneous TAPS may have a better prognosis than postlaser TAPS. No differences in terms of mortality and morbidity were observed when comparing different management options for TAPS, although these findings should be interpreted with caution in view of the limitations of the included studies. Individualized prenatal management, taking into account the severity of TAPS and gestational age, is currently the recommended strategy. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Association of Blood Donor Sex and Age With Outcomes in Very Low-Birth-Weight Infants Receiving Blood Transfusion

IMPORTANCE

There are conflicting data on the association between blood donor characteristics and outcomes among patients receiving transfusions.

OBJECTIVE

To evaluate the association of blood donor sex and age with mortality or serious morbidity in very low-birth-weight (VLBW) infants receiving blood transfusions.

DESIGN, SETTING, AND PARTICIPANTS

This is a cohort study using data collected from 3 hospitals in Atlanta, Georgia. VLBW infants (≤1500 g) who received red blood cell (RBC) transfusion from exclusively male or female donors were enrolled from January 2010 to February 2014. Infants received follow-up until 90 days, hospital discharge, transfer to a non-study-affiliated hospital, or death. Data analysis was performed from July 2019 to December 2020.

EXPOSURES

Donor sex and mean donor age.

MAIN OUTCOMES AND MEASURES

The primary outcome was a composite outcome of death, necrotizing enterocolitis (Bell stage II or higher), retinopathy of prematurity (stage III or higher), or moderate-to-severe bronchopulmonary dysplasia. Modified Poisson regression, with consideration of covariate interactions, was used to estimate the association between donor sex and age with the primary outcome, with adjustment for the total number of transfusions and birth weight.

RESULTS

In total, 181 infants were evaluated, with a mean (SD) birth weight of 919 (253) g and mean (SD) gestational age of 27.0 (2.2) weeks; 56 infants (31%) received RBC transfusion from exclusively female donors. The mean (SD) donor age was 46.6 (13.7) years. The primary outcome incidence was 21% (12 of 56 infants) among infants receiving RBCs from exclusively female donors, compared with 45% (56 of 125 infants) among those receiving RBCs from exclusively male donors. Significant interactions were detected between female donor and donor age (P for interaction = .005) and between female donor and number of transfusions (P for interaction < .001). For the typical infant, who received a median (interquartile range) of 2 (1-3) transfusions, RBC transfusion from exclusively female donors, compared with male donors, was associated with a lower risk of the primary outcome (relative risk, 0.29; 95% CI, 0.16-0.54). The protective association between RBC transfusions from female donors, compared with male donors, and the primary outcome increased as the donor age increased, but decreased as the number of transfusions increased.

CONCLUSIONS AND RELEVANCE

These findings suggest that RBC transfusion from female donors, particularly older female donors, is associated with a lower risk of death or serious morbidity in VLBW infants receiving transfusion. Larger studies confirming these findings and examining potential mechanisms are warranted.

Association of Bolus Feeding With Splanchnic and Cerebral Oxygen Utilization Efficiency Among Premature Infants With Anemia and After Blood Transfusion

IMPORTANCE

The pathogenesis of transfusion-associated necrotizing enterocolitis remains elusive. Splanchnic hypoperfusion associated with packed red blood cell transfusion (PRBCT) and feeding has been implicated, but studies of splanchnic tissue oxygenation with respect to feeding plus PRBCT are lacking.

OBJECTIVE

To investigate the oxygen utilization efficiency of preterm gut and brain challenged with bolus feeding during anemia and after transfusion using near-infrared spectroscopy.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study conducted from September 1, 2014, to November 30, 2016, at a tertiary neonatal intensive care unit included 25 hemodynamically stable infants with gestational age less than 32 weeks, birth weight less than 1500 g, and postmenstrual age younger than 37 weeks. Data analysis was performed from August 1, 2017, to October 31, 2018.

EXPOSURES

Infants received PRBCT (15 mL/kg for 4 hours) and at least 120 mL/kg daily of second hourly bolus feedings.

MAIN OUTCOMES AND MEASURES

Splanchnic fractional tissue oxygen extraction (FTOEs) and cerebral fractional tissue oxygen extraction (FTOEc) measures were made during 75-minute feeding cycles that comprised a 15-minute preprandial feeding phase (FP0) and 4 contiguous 15-minute postprandial feeding phases (FP1, FP2, FP3, and FP4; each 15 minutes long). The intraindividual comparisons of feeding-related changes were evaluated during the pretransfusion epoch (TE0: 4 hours before onset of transfusion) and 3 TEs after transfusion (TE1: first 8 hours after PRBCT completion; TE2: 9-16 hours after PRBCT completion; and TE3: 17-24 hours after PRBCT completion).

RESULTS

Of 25 enrolled infants (13 [52%] female; median birth weight, 949 g [interquartile range {IQR}, 780-1100 g]; median gestational age, 26.9 weeks [IQR, 25.9-28.6 weeks]; median enrollment weight, 1670 g [IQR, 1357-1937 g]; and median postmenstrual age, 34 weeks [IQR, 32.9-35 weeks]), 1 infant was excluded because of corrupted near-infrared spectroscopy data. No overall association was found between FTOEs and FPs in a multivariable repeated-measures model that accounted for transfusion epochs (primary analysis approach) (FP0: mean estimate, 11.64; 95% CI, 9.55-13.73; FP1: mean estimate, 12.02; 95% CI, 9.92-14.11; FP2: mean estimate, 12.77; 95% CI, 10.68-14.87; FP3: mean estimate, 12.54; 95% CI, 10.45-14.64; FP4: mean estimate, 12.98; 95% CI, 10.89-15.08; P = .16 for the FP association). However exploratory analyses of postprandial changes in FTOEs undertaken for each transfusion epoch separately found evidence of increased postprandial FTOEs during TE1 (mean [SD] FTOEs, 10.55 [5.5] at FP0 vs 13.21 [5.96] at FP4, P = .046). The primary and exploratory analyses found no association between FTOEc and feeding phases, suggesting that cerebral oxygenation may be protected.

CONCLUSIONS AND RELEVANCE

The findings suggest that enteral feeding may be associated with gut ischemia and potentially transfusion-associated necrotizing enterocolitis. The postprandial changes in FTOEs appear to warrant further investigation in larger randomized studies.

The role of recombinant Human erythropoietin in neonatal anemia

AIM

To estimate the blood level of Erythropoietin(EPO) in neonates with anemia of prematurity (APO) and in late hypo-regenerative anemia and to clarify role of EPO in correction of anemia and reducing the number of blood transfusions.

METHODS

This study was carried out on 60 neonates divided into; group I (30 preterm neonates) with AOP received EPO (250 IU/kg/dose subcutaneously 3 times weekly for 4 weeks), compared to group II (30 neonates) with AOP treated only with blood transfusion. CBC parameters and transfusion requirements were followed during therapy. Serum level of EPO was measured by ELISA technique.

RESULTS

By the end of the 4th week of therapy, there was significant increase in group I post r-Hu EPO compared to group II regarding reticulocyte counts (P < 0.001) leading to rise of the Hb (P < 0.001), Hct levels (P < 0.001) with subsequent reduction in the overall number of blood transfusions (P < 0.001).

CONCLUSION

EPO therapy in conjunction with iron, vitamin E and folic acid, stimulated erythropoiesis and significantly reduced the need for blood transfusion in AOP.

Does red blood cell irradiation and/or anemia trigger intestinal injury in premature infants with birth weight ≤ 1250 g? An observational birth cohort study

BACKGROUND

Necrotizing enterocolitis (NEC) is a leading cause of neonatal morbidity and mortality in premature infants. To date, no effective biomarkers exist to predict which premature infants will develop NEC, limiting targeted prevention strategies. Multiple observational studies have reported an association between the exposure to red blood cell (RBC) transfusion and/or anemia and the subsequent development of NEC; however, the underlying physiologic mechanisms of how these factors are independently associated with NEC remain unknown.

METHODS

In this paper, we outline our prospective, multicenter observational cohort study of infants with a birth weight ≤ 1250 g to investigate the associations between RBC transfusion, anemia, intestinal oxygenation and injury that lead to NEC. Our overarching hypothesis is that irradiation of RBC units followed by longer storage perturbs donor RBC metabolism and function, and these derangements are associated with paradoxical microvascular vasoconstriction and intestinal tissue hypoxia increasing the risk for injury and/or NEC in transfused premature infants with already impaired intestinal oxygenation due to significant anemia. To evaluate these associations, we are examining the relationship between prolonged irradiation storage time (pIST), RBC metabolomic profiles, and anemia on intestinal oxygenation non-invasively measured by near-infrared spectroscopy (NIRS), and the development of NEC in transfused premature infants.

DISCUSSION

Our study will address a critical scientific gap as to whether transfused RBC characteristics, such as irradiation and metabolism, impair intestinal function and/or microvascular circulation. Given the multifactorial etiology of NEC, preventative efforts will be more successful if clinicians understand the underlying pathophysiologic mechanisms and modifiable risk factors influencing the disease.

TRIAL REGISTRATION

Our study is registered in ClinicalTrials.gov Identifier: NCT02741648 .

Immunoglobulin for alloimmune hemolytic disease in neonates

BACKGROUND

Exchange transfusion and phototherapy have traditionally been used to treat jaundice and avoid the associated neurological complications. Because of the risks and burdens of exchange transfusion, intravenous immunoglobulin (IVIg) has been suggested as an alternative therapy for alloimmune hemolytic disease of the newborn (HDN) to reduce the need for exchange transfusion.

OBJECTIVES

To assess the effect and complications of IVIg in newborn infants with alloimmune HDN on the need for and number of exchange transfusions.

SEARCH METHODS

We performed electronic searches of CENTRAL, PubMed, Embase (Ovid), Web of Science, CINAHL (EBSCOhost), Academic Search Premier, and the trial registers ClinicalTrials.gov and controlled-trials.com in May 2017. We also searched reference lists of included and excluded trials and relevant reviews for further relevant studies.

SELECTION CRITERIA

We considered all randomized and quasi-randomized controlled trials of IVIg in the treatment of alloimmune HDN. Trials must have used predefined criteria for the use of IVIg and exchange transfusion therapy to be included.

DATA COLLECTION AND ANALYSIS

We used the standard methods of Cochrane and its Neonatal Review Group. We assessed studies for inclusion and two review authors independently assessed quality and extracted data. We discussed any differences of opinion to reach consensus. We contacted investigators for additional or missing information. We calculated risk ratio (RR), risk difference (RD) and number needed to treat for an additional beneficial outcome (NNTB) for categorical outcomes. We calculated mean difference (MD) for continuous variables. We used GRADE criteria to assess the risk of bias for major outcomes and to summarize the level of evidence.

MAIN RESULTS

Nine studies with 658 infants fulfilled the inclusion criteria. Term and preterm infants with Rh or ABO (or both) incompatibility were included. The use of exchange transfusion decreased significantly in the immunoglobulin treated group (typical RR 0.35, 95% CI 0.25 to 0.49; typical RD -0.22, 95% CI -0.27 to -0.16; NNTB 5). The mean number of exchange transfusions per infant was also significantly lower in the immunoglobulin treated group (MD -0.34, 95% CI -0.50 to -0.17). However, sensitivity analysis by risk of bias showed that in the only two studies in which the treatment was masked by use of a placebo and outcome assessment was blinded, the results differed; there was no difference in the need for exchange transfusions (RR 0.98, 95% CI 0.48 to 1.98) or number of exchange transfusions (MD -0.04, 95% CI -0.18 to 0.10). Two studies assessed long-term outcomes and found no cases of kernicterus, deafness or cerebral palsy.

AUTHORS' CONCLUSIONS

Although overall results show a significant reduction in the need for exchange transfusion in infants treated with IVIg, the applicability of the results is limited because of low to very low quality of evidence. Furthermore, the two studies at lowest risk of bias show no benefit of IVIg in reducing the need for and number of exchange transfusions. Based on these results, we have insufficient confidence in the effect estimate for benefit of IVIg to make even a weak recommendation for the use of IVIg for the treatment of alloimmune HDN. Further studies are needed before the use of IVIg for the treatment of alloimmune HDN can be recommended, and should include blinding of the intervention by use of a placebo as well as sufficient sample size to assess the potential for serious adverse effects.

Iron homeostasis after blood transfusion in stable preterm infants - an observational study

AIM

To evaluate the short-term effects of blood transfusion on iron status [hemoglobin, ferritin, soluble transferrin receptor (sTfR), and reticulocyte count], hepcidin, and erythropoietin in stable preterm infants.

METHOD

Sixty-three preterm infants treated with red blood cell transfusions (RBCTs) were included. Venous blood samples were collected before and within 24 h after each transfusion.

RESULTS

Hemoglobin concentration increased after RBCT (7.2±1.2 g/dL vs. 13.7±2.3 g/dL, P=0.02), as well as ferritin [131 (63-110.4) ng/mL vs. 211 (125.7-299.2) ng/mL, P=0.05); reticulocyte count decreased. sTfR did not change. Hepcidin serum levels increased from 37.5 (21.3-84.7) ng/mL to 72.6 (31.3-126.2) ng/mL, (P=0.04) and erythropoietin decreased (48±19 pg/mL vs. 29±17 pg/mL, P=0.06) after RBCT. A positive linear correlation was found (R2=0.76, P=0.0001) between hepcidin and ferritin levels of post-minus-pre RBCT. Hepcidin levels increased significantly in preterm infants who received RBCT after 1 month of age compared to those who received RBCT at <1 month (P=0.03). No correlation was found between gestational age, weight appropriate for age, or length of blood storage and hepcidin levels.

CONCLUSION

Preterm infants can control iron levels by regulating hepcidin and decreasing erythropoietin. This ability varies with postnatal age.

[Infantile pyknocytosis: A cause of noenatal hemolytic anemia. Is recombinant erythropoietin an alternative to transfusion?]

Infantile pyknocytosis is a neonatal hemolytic disorder which causes anemia and icterus and is characterized by the presence of an increased number of distorted red blood cells called pyknocytes. Resolution spontaneously occurs in the first semester of life. It has been generally described as a rare entity, with an occasional family history. We report seven cases of infantile pyknocytosis observed in our hospital in 3 years. Most of the infants presented with hemolytic icterus and profound anemia that was reaching its peak by the 3rd week of life. Three neonates received one to three red blood cell transfusions, according to former recommendations. However, the following four received a treatment with recombinant erythropoietin administered subcutaneously. Only one of these four cases required a transfusion. All of them were free of hematological disease 2-3 months after completion of treatment. Infantile pyknocytosis is a recognized cause of neonatal hemolytic anemia, which requires careful examination of red cell morphology on a peripheral blood smear. The cause of this transient disorder remains unknown. Our observations show that recombinant erythropoietin therapy is effective in treating infantile pyknocytosis and increases the reticulocyte response, thus improving the hemoglobin level.

Anemia in the Neonate: The Differential Diagnosis and Treatment

Anemia is a common problem in the neonatal period. Presenting symptoms may suggest numerous possible diagnoses ranging from anemia seen as a normal part of development to anemia due to critical pathology. An illustrative case is presented to highlight the appropriate evaluation of the neonate with significant anemia. Several important features of the evaluation of neonatal anemia are highlighted. The constellation of signs and symptoms that occur in conjunction with the anemia are critical for the evaluation. The evaluation should be performed in a step-wise process that starts by eliminating common causes of anemia. Manual review of the peripheral blood smear with a hematologist can be helpful.

[THE FETAL MIDDLE CEREBRAL ARTERY PEAK SYSTOLIC VELOCITY AS A PEDICTOR OF FETAL ANEMIA IN RH-ALLOIMMUNIZED PREGNANCY]

Rh-isoimmunization is a pathological condition in which the fetal red blood cells of a Rh (+) fetus are destroyed by the isoantibodies of a Rh (-) woman sensitized in a previous event. Despite of the wide spread implementation of anti D-gammaglobolin prophylaxis this is still the most common cause for fetal anemia. Recently, sonographic measurement of the fetal middle cerebral artery peak systolic velocity (MCA-PSV) has been shown to be an accurate non-invasive test to predict low fetal hemoglobin levels. We present a case report of Rh-alloimmunized pregnancy with moderate fetal anemia, followed-up by weekly MCA-PSV measurements.

CASE REPORT

A 37-year-old Rh (-) negative gravida 3, para 1, without anti-D gammaglobolin prophylaxis in her previous pregnancies, presented at 27+0 weeks of gestation (w.g.) for a routine third trimester scan. Subsequent ultrasound measurements of MCA-PSV confirmed a progressive increase of the peak systolic velocities from 40 to 80 cm/sec, as well as a gradual rise in the anti-D titers. The evidence of developing fetal anemia necessitated elective Caesarean section performed at 35 wg. The neonate was admitted in the intensive care unit and required resuscitation, one exchange blood transfusion and several courses of phototherapy. The patient was discharged two weeks post partum.

CONCLUSIONS

There is a strong correlation between the high peak systolic velocities in the middle cerebral artery (MCA-PSV) and the low levels of fetal hemoglobin. The high sensitivity and positive predictive value concerning the development of fetal anemia, as well as its good repeatability, makes this non-invasive test a valuable asset in the management of all pregnancies complicated by severe Rh-alloimmunization.

[Autotransfusion of cord blood erythrocytes in newborns with malformations requiring early surgical intervention]

PURPOSE

To evaluate the clinical efficacy of cord blood erythrocytes autotransfiusion for the correction of anemia in the intra-and postoperative periods in infants requiring early surgical correction of congenital malformations.

METHODS

Washed autoemythrocytes from placental umbilical blood were transfused for correction of intra and post-operative anemias. Umbilical blood assembly was carried out after extraction of the child and navel intersection by the occluded mean by a vein puncture distal (placental) end of a navel by the drainage needle which is a part of special transfiusion system. Further blood in the marked containers was pitched in branch of gravitational surgery of blood where its centrifiugal separation on erythrocyte mass and plasma was made. Then concentrated red cells it was put on storage for 21 day in a cooler at temperature 40 °C. Directly ahead of autotransfusion concentrated red cells was exposed to washing out in sterile physiological solution and a filtration through the micromodular filter. Then the marked package with the washed erythrocytes was pitched in branch of surgery of newborns for the purpose offurther anttqtransfusion under indications. The transfusion autoerythrocytes was made according to reacting at the moment of carrying out of work to orders of Ministry of Health of the Russian Federation: to the Order of Ministry of Health of the Russian Federation from November, 25th, 2002 No 363 "About the statement of the Instruction on application of components of blood" and to the Order of Ministry of Health of the Russian Federation from April, 2nd, 2013 N 183n "About the statement of rules of clinical use of donor blood and (or) its components".

RESULTS

Total 122 newborns received an autotransfiusion of washed erythrocytes of placental/umbilical cord blood for the correction of anemia in the department of neonatal surgery in the period from 2005 to 2013. 66 children who are in the first two weeks of life were performed surgical intervention for malformation of the gastrointestinal tract (gastorshizis (22), omphalocele (2). itestinal atresia (10), esophageal atresia or doubling (4)), congenital diaphragmatic hernia (15), space-occupying lesions (teratoma (6) and lymphangioma (3)) and other pathologies (adenomatous lung (1), the sequestration of the lung (2). ovarian cyst (1)). Control group consisted of39 infants operated on for similar malformations , which in the absence of prior communication harvested autologous red blood cells in the first three weeks of life sparkled donor erythrocytes. Inmost cases (57 newborns - 86.4%) of the amount harvested and transfused blood autokonmpo tov was sufficient for the relief ofanemia, despite the fact that the volume of transfused autoeritrotsitnoy mass per kilogram of body weight was almost two times lower than the amount of donor erythrocyte mass used in the comparison group. Additional donor transfusion of red blood cells in the group of children who had autotransfusion, it took nine newborns (13.6%). The main indications for repeated transfusions were clinical and laboratory signs of anemia, persisting after autotransfusion or resulting from repeated operations. After transfusion of washed autoerythrocytes value of clinical and biochemical. blood tests, urinalysis were within the age norm. Post-transfusion reactions in children who have received a transfusion autoerythrocytes not mentioned

CONCLUSION

The use of placental/umbilical cord blood autoe,ythrocyvtes in children requiring early surgical correction of congenital malformations can significantly reduce the need for donor red blood cells. Autologous red blood cells use is a safe and effective alternative to transfusion of donor red blood cells.

Risk factors of transfusion in anemia of very low birth weight infants

PURPOSE

Anemia of prematurity is frequent in preterm infants, for which red blood cell (RBC) transfusion remains the treatment of choice. In this study, we attempted to evaluate the characteristics and risk factors of anemia of prematurity, and suggest ways to reduce anemia and the need for multiple transfusions.

MATERIALS AND METHODS

Preterm infants weighing less than 1500 g (May 2008-May 2009) were divided into two groups depending on whether they received RBC transfusions (transfusion group and non transfusion group). Hemoglobin (Hb) concentration, phlebotomy blood loss, and the amount of RBC transfusion were analyzed. Risk factors of anemia and RBC transfusions were analyzed.

RESULTS

Fifty infants that survived were enrolled in the present study: 39 in the transfusion group and 11 in the non transfusion group. Hb concentrations gradually decreased by eight weeks. In the transfusion group, gestational age and birth weight were smaller, bronchopulmonary dysplasia and sepsis were more frequent, full feeding was delayed, parenteral nutrition and days spent in the hospital were prolonged, and phlebotomy blood loss was greater than that in the non transfusion group.

CONCLUSION

Anemia of prematurity was correlated with increased laboratory blood loss, decreased birth weight, prolonged parenteral nutrition, and delayed body weight gain. Accordingly, reducing laboratory phlebotomy loss and parenteral nutrition, as well as improving body weight gain, may be beneficial to infants with anemia of prematurity.

[Evaluation of the practice of transfusion in the anemia in preterm infants]

The early anemia in preterm infants, usually implies as a remedy, the use of erythrocyte transfusions indicated according to transfusion criteria which are variable from one neonatal center to another.

OBJECTIVE

To evaluate our practice of transfusions concerning the anemia in preterm infants.

METHODS

A descriptive study on 113 preterm infants whose gestational age is < 37 weeks and who were hospitalised in Neonatal Service at the Infants Hospital at Rabat during the year 2006, by recording the gestational age, the weight at birth, the rate of haemoglobin and hematocrit at the first admission of the infant and before his first blood transfusion and finally the clinical and biological indications. In order to analyse the criteria of blood transfusion, we have compared between two groups: a group A of 65 transfused preterm infants and a group B of 48 non-transfused with the test of Chi2 and t Student at threshold of P < 0,005.

RESULTS

The medium gestational age was that of 33 weeks and the medium weight at birth was 1.672 g. 57,5% of preterm infants were transfused. The preterm babies who has received transfusion compared to those who have not, are significantly more preterm, their weight at birth is weak and the time of hospitalisation is longer, having had more nosocomial infections, postnatal bleeding and their haemoglobin and hematocrit rate at birth is lower (P < 0,001). 41,5% of transfused infants had presented clinical signs of anemia and had been transfused one week earlier than asymptomatic infants and had elevated rates of haemoglobin and hematocrit (P < 0,005).

CONCLUSION

The use of blood transfusion is frequent in our context and implies preventive measures to reduce it.

Intrauterine transfusion for parvovirus B19 infection: long-term neurodevelopmental outcome

OBJECTIVE

To evaluate long-term neurodevelopmental outcome of children treated with intrauterine transfusions for fetal anemia because of parvovirus B19 infection.

STUDY DESIGN

Children treated with intrauterine transfusions for fetal anemia because of parvovirus B19 infection underwent standardized age-appropriate neurodevelopmental testing. Main outcome was the incidence of neurodevelopmental impairment.

RESULTS

Twenty-eight children were evaluated at a median age of 5 years (range, 1.5-13 years). Neurodevelopmental impairment was diagnosed in 3 of 28 (11%) children, including 1 child with combined cerebral palsy and severe developmental delay and 2 children with isolated severe developmental delay.

CONCLUSION

Neurodevelopmental impairment in children treated with intrauterine transfusion for parvovirus B19 infection is increased compared with the general population. Large long-term follow-up studies are required to determine potential risk factors.

Fetal anemia of unknown cause--a diagnostic challenge

PURPOSE

To assess the spectrum of underlying diseases in cases of fetal anemia in which the cause was unknown at the time of first and second transfusion or thereafter.

MATERIALS AND METHODS

All patients who underwent intrauterine transfusion were identified in the perinatal databases of two tertiary referral centers for prenatal medicine and treatment between 2002 and June 2010.

RESULTS

82 fetuses received intrauterine transfusion in the study period. A total of 356 transfusions were performed in these patients. The causes of fetal anemia in our cohort were alloimmunization (32), parvovirus infection (23), feto-fetal transfusion syndrome (9), sacrococcygeal teratoma (2) and cytomegalovirus infection (1). In the remaining 15 cases, the cause of fetal anemia was unknown at the time of first and second transfusion, and could only be ascertained in the further course of pregnancy, in the postnatal period or was ultimately left in doubt. In all cases markedly elevated peak systolic velocities in the middle cerebral artery accurately predicted fetal anemia. The final diagnosis in these cases was fetomaternal hemorrhage (4), Blackfan-Diamond anemia (1), diffuse neonatal hemangiomatosis with chorangioma (1), kaposi-like hemangioendothelioma (1), elliptocytosis (1), neonatal hemochromatosis (1), mucopolysaccharidosis type VII (1) and in 5 cases the cause of fetal anemia remained unexplained. The latter 5 cases had an uneventful postnatal course and did not require further transfusions in infancy.

CONCLUSION

In cases of fetal anemia with negative indirect Coombs test and TORCH serology, rare causes of anemia have to be considered. Fetal studies should therefore include reticulocyte count, parameters of hemolysis, peripheral blood smear and fetal liver function tests. Maternal studies should involve a search for fetal red cells using flow cytometry rather than Kleihauer-Betke test.

Effect of delayed versus early umbilical cord clamping on neonatal outcomes and iron status at 4 months: a randomised controlled trial

OBJECTIVE

To investigate the effects of delayed umbilical cord clamping, compared with early clamping, on infant iron status at 4 months of age in a European setting.

DESIGN

Randomised controlled trial.

SETTING

Swedish county hospital.

PARTICIPANTS

400 full term infants born after a low risk pregnancy.

INTERVENTION

Infants were randomised to delayed umbilical cord clamping (≥ 180 seconds after delivery) or early clamping (≤ 10 seconds after delivery).

MAIN OUTCOME MEASURES

Haemoglobin and iron status at 4 months of age with the power estimate based on serum ferritin levels. Secondary outcomes included neonatal anaemia, early respiratory symptoms, polycythaemia, and need for phototherapy.

RESULTS

At 4 months of age, infants showed no significant differences in haemoglobin concentration between the groups, but infants subjected to delayed cord clamping had 45% (95% confidence interval 23% to 71%) higher mean ferritin concentration (117 μg/L v 81 μg/L, P < 0.001) and a lower prevalence of iron deficiency (1 (0.6%) v 10 (5.7%), P = 0.01, relative risk reduction 0.90; number needed to treat = 20 (17 to 67)). As for secondary outcomes, the delayed cord clamping group had lower prevalence of neonatal anaemia at 2 days of age (2 (1.2%) v 10 (6.3%), P = 0.02, relative risk reduction 0.80, number needed to treat 20 (15 to 111)). There were no significant differences between groups in postnatal respiratory symptoms, polycythaemia, or hyperbilirubinaemia requiring phototherapy.

CONCLUSIONS

Delayed cord clamping, compared with early clamping, resulted in improved iron status and reduced prevalence of iron deficiency at 4 months of age, and reduced prevalence of neonatal anaemia, without demonstrable adverse effects. As iron deficiency in infants even without anaemia has been associated with impaired development, delayed cord clamping seems to benefit full term infants even in regions with a relatively low prevalence of iron deficiency anaemia. Trial registration Clinical Trials NCT01245296.

[The importance of antenatal immunoprophylaxis for prevention of hemolytic disease of the fetus and newborn]

Hemolytic disease of the fetus and newborn (HDFN) is a consequence of maternal alloimmunization against fetal red blood cell antigens. Alloimmunization against D antigen from Rhesus (Rh) blood group system is particularly important because of its strong immunogenicity. During the last few decades, the introduction of RhD prophylaxis by postpartum administration of anti-D immunoglobulin to RhD negative women, now improved with antenatal prophylaxis, has led to a dramatic decrease in perinatal mortality and morbidity from HDFN. However, severe cases have not disappeared, mostly due to prophylaxis failure. In our case, inappropriate prenatal care during the first pregnancy in an RhD negative mother resulted in primary immunization. In the next pregnancy with an RhD positive child, the mother's secondary immune response was extremely strong and led to early development of severe fetal anemia. The fetus survived thanks to the treatment with intrauterine transfusions (IUT), but they caused suppression of erythropoiesis, which lasted for months after birth. The long lasting, late anemia was treated with repeated postnatal red cell transfusions and recombinant human erythropoietin (rHuEPO). Despite the severity of HDFN in our case, the short-term outcome is good. The boy has normal growth until now, but due to the possibility of an adverse long-term neurodevelopmental outcome, this case requires continuous follow up. It also reminds of the fact that RhD alloimmunization remains an actual problem in daily routine. Antenatal prophylaxis is a crucial step in quality care of those who are at a risk of HDFN.

[Treatment of anaemia of prematurity with SS-R-Hu-erythropoietin and significance of hypoxia-inducible factor]

The main cause of anaemia of prematurity is low erythropoietin levels. A few years ago hypoxia-inducible factor/HIF/gene transcriptor was established, regulating not only the synthesis of erythropoietin /EPO/, but also other growth factors as well as enzymes of anaerobic glycolysis, activated by hypoxia.

OBJECTIVES

The aim of the study is to establish in clinical practice the role of hypoxia, respectively, activated HIF during treatment with erythropoietin by analyzing variations in hematological values; to examine blood lactate levels as an indicator of activated HIF and anaerobic glycolysis with Hb values 110-120 g/l; to analyze the number and impact of red blood cells transfusions on different categories of babies. STUDY DESIGN; The study includes 112 premature infants born before 34 weeks of gestation and below 1400 g. 90 babies, treated with EPO (700-1000 E/kg weekly dose in 2-3 applications, for 2-4 weeks), values of Hb g/l, Ht%, Ret%, Platelets 109/l were followed and compared. Treated babies were divided in two groups: group I--treatment (starting at Hb below 106 g/l, Ht less than 31%); group II--late prophylaxis (starting at Hb > or = 106 g/l, Ht > or = 31%). Blood lactate was examined in 22 non oxygen dependent premature babies without EPO treatment, with Hb 110-120 g/l, Ht 29-32%.

RESULTS

We found that in group II during the first 7-10 days Hb decreases to 105.6 (+/- 9.4) g/l, rising up afterwards to 113.5 (+/-11.0) g/l at day 25-30. Ret reach maximal values at day 15-20 when Hb drops below 110 g/l and Ht below 31%. In group I at day 25-30 of treatment is observed a rise in Hb up to 117.3 (+/-11.3) and of Ht up to 32.7% (+/- 2.6) and no decrease of Hb and Ht values during the first 7-10 days, while Ret rise up to maximal values 6.5% (+/- 3.6) at day 7-10. With Hb levels of 116.4 (+/- 4.6) g/l we found an increase in blood lactate levels up to 2.6 (+/- 0.7) mmol/l as an indicator of relative hypoxia and activated HIF. Mean number of blood transfusions in group I is 3.01(+/- 1.7), versus 2.15 (+/- 1.7) in group II (statistically non-significant). In 29 infants in group II treatment was started at Hb 110-120 g/l and the mean number of red blood cell transfusion is 1.8 (1.5)--statistically significant difference with group I. In 32% from the treated infants we found platelets count rising above 500 x 109/l.

CONCLUSIONS

The presence of hypoxia at low levels of Hb and Ht leads to more rapid activation of erythropoiesis. Nevertheless, these babies need more red blood cell transfusions due to clinical symptoms of hypoxia. Normoxia after red blood cell transfusion leads to decrease of reticulocytes count by 30% and platelets by 35% in spite of treatment. The presence of relative hypoxia with Hb 110-120 g/l u Ht 31-32% is optimal for starting treatment with EPO--levels, low enough for activation of HIF and high enough to avoid blood transfusions.

[Does human recombinant erythropoetin /R-HU-EPO/ treatment for anemia of prematurity have any effect on reducing the number of blood transfusions?]

OBJECTIVES

The aim of the study is to establish the influence of r-hu-EPO treatment for anemia of prematurity on changes in blood count values and the number of inevitable blood transfusions in premature infants.

STUDY DESIGN

The study includes 148 newborn babies--birth weight < or =1400 g, gestational age < or =34 g.w. They were divided in 2 groups: group I--treated with r-hu-EPO 1000 E/kg/week and Fe++ 3-6 mg/kg/day from week 3 after birth; group II--controls, treated only with transfusions of red blood cells. The changes in blood count values (Hb, Ht, Ery, Ret) from day 15-25 until day 60-70 were followed and analyzed, as well as the number of inevitable blood transfusions.

RESULTS

A significant increase in Hb and Ht values was established with r-hu-EPO treated babies. At day 60-70 mean values of Hb are: in r-hu-EPO group 111.1 +/- 11.06 g/l; in control group 99.20 +/- 10.77 g/l (p < 0.001). At the end of the period Ht is 32.02 +/- 3.28% in babies treated with r-hu EPO versus 29.10 +/- 2.87% with controls (p < 0.005). Ret count is significantly higher from day 25-30 in r-hu-EPO group (5.16 +/- 3.23%) versus controls (2.75 +/- 1.33%). Mean number of inevitable blood transfusions in r-hu-EPO treated group is significantly lower (2.06 +/- 1.62) versus controls--3.75 +/- 1.95 (p < 0.001).

CONCLUSION

r-hu EPO treatment has effect on changes in Hb, Ht, Ret and reduces the number of inevitable blood transfusions for anaemia of prematurity.

Effects of transfusions in extremely low birth weight infants: a retrospective study

OBJECTIVES

To determine the risks and benefits associated with the transfusion of packed red blood cells (PRBCs) in extremely low birth weight (ELBW) infants. We hypothesized that when ELBW infants underwent transfusion with the University of Washington Neonatal Intensive Care Unit (NICU) 2006 guidelines, no clinical benefit would be discernible.

STUDY DESIGN

We conducted a retrospective chart review of all ELBW infants admitted to the NICU in 2006. Information on weight gain, apnea, heart rate, and respiratory support was collected for 2 days preceding, the day of, and 3 days after PRBC transfusion. The incidence, timing, and severity of complications of prematurity were documented.

RESULTS

Of the 60 ELBW infants admitted to the NICU in 2006, 78% received PRBC transfusions. Transfusions were not associated with improved weight gain, apnea, or ventilatory/oxygen needs. However, they were associated with increased risk of bronchopulmonary dysplasia, necrotizing enterocolitis, and diuretic use (P < .05). Transfusions correlated with phlebotomy losses, gestational age, and birth weight. No association was found between transfusions and sepsis, retinopathy of prematurity, or erythropoietin use.

CONCLUSIONS

When our 2006 PRBC transfusion guidelines were used, no identifiable clinical benefits were identified, but increased complications of prematurity were noted. New, more restrictive guidelines were developed as a result of this study.

Rhesus haemolytic disease of the newborn: Postnatal management, associated morbidity and long-term outcome

Rhesus haemolytic disease of the newborn can lead to complications such as hyperbilirubinaemia, kernicterus and anaemia. Postnatal management consists mainly of intensive phototherapy, exchange transfusion and blood transfusion. During the last decades, significant progress in prenatal care strategies for patients with Rhesus haemolytic disease has occurred. New prenatal management options have led to a remarkable reduction in perinatal mortality. As a result of the increase in perinatal survival, attention is now shifting towards short-term and long-term morbidity. This review focuses on the management of neonatal and paediatric complications associated with Rhesus haemolytic disease, discusses postnatal treatment options and summarizes the results of studies on short-term and long-term outcome.

Neonatal red cell transfusions

This review discusses RBC transfusion in the neonatal age group and explores how one institution arrived at current common practice. Special considerations such as CMV infectious risk and GVHD are discussed.

[Criteria for diagnosis and therapy of hyporegeneratory anemia in premature newborns below 33 week of gestation and body weight below 1500 grams]

AIM

The aim of the present study is to define criteria for erythropoietin therapy of hyporegeneratory anemia in premature newborns according to hemoglobin (Hb) and hematocrit (Hct) concentration, and reticulocyte count (Ret).

MATERIALS AND METHODS

The prospective study includes two groups of 20 newborns with anemia of prematurity, body weight at birth below 1500 grams and gestation age below 33 gestation week. The newborns in the first group have been treated with beta-erythropoietin for four weeks--750-1000 E/kg weekly dose, divided q48h. Hb, Hct and Ret have been monitored and compared with that of control group newborns. The therapy of newborns in the control group consisted of blood transfusions.

RESULTS

The hematological parameters in the newborns from the first group have been increased permanently after the first week of therapy, with Ret being most sensitive to the therapy. In the second group of newborns, due to blood transfusions, transient increase of Hb and Hct, and decrease of Ret have been observed in next days after the blood transfusions.

CONCLUSIONS

The erythropoietin therapy of hyporegeneratory anemia in preterm newborns leads to rise in Hb, Hct and Ret. The therapy with blood transfusions suppresses erythropoiesis. This leads to decrease in Ret and transient rise in Hb, Hct and erythrocytes. That's why each blood transfusion leads to another one.

Prediction of transfusions in extremely low-birthweight infants in the erythropoietin era

BACKGROUND

The purpose of the present paper was to detect the clinical factors most predictive of red blood cell (RBC) transfusion in extremely low-birthweight (ELBW) infants in the recombinant human erythropoietin era.

METHODS

Between 1995 and 2000, 66 ELBW infants were admitted to a level III neonatal intensive care unit. Fifty-four of 66 infants were eligible for enrollment in the present study. Infants were treated with erythropoietin 200 IU/kg per dose s.c. twice a week with 4-6 mg/kg per day iron supplement.

RESULTS

The mean gestational age and birthweight were 26.5 +/- 2.1 weeks and 776 +/- 134 g, respectively. Ten of 54 ELBW infants (18.5%) died during the first 21 days. Eight of 10 dead infants (80.0%) and 27 of 44 surviving infants (61.4%) received one or more RBC transfusions. The overall requirement for RBC transfusions in the surviving infants was 3.0 +/- 3.2 per infant/hospital course (range: 0-9) . There were significant differences in gestational weeks, birthweight, initial hemoglobin value, 5 min Apgar score, phlebotomy loss, phlebotomy loss/birthweight, duration of mechanical ventilation, duration of oxygen supplement, and incidence of both intraventricular hemorrhage and chronic lung disease between the transfused and non-transfused group. The predictive variables, initial hemoglobin level (odds ratio [OR] 2.61; 1 g/dL), birthweight (OR 3.00; 100 g), and gestational week (OR 1.89; 1 week), were found to be most predictive for transfusion on logistic regression analysis.

CONCLUSION

ELBW infants are still the population at greatest risk for repeated blood transfusions after introduction of erythropoietin treatment. If labor develops, it is often impossible to extend the pregnancy period, therefore efforts should be made to increase hemoglobin level at birth.

Association of necrotizing enterocolitis with elective packed red blood cell transfusions in stable, growing, premature neonates

The purpose of this study was to determine an association between packed red blood cell (PRBC) transfusions for anemia and necrotizing enterocolitis (NEC) in a subset of stable, growing, premature neonates. As part of a survey of current clinical practices over a 17-month period from June 1999 to October 2000, a chart review was performed to determine the relationship between elective PRBC transfusions and the occurrence of NEC. Demographic data were tabulated and compared between the NEC patients with a prior history of immediate blood transfusion (within 48 hours of onset of symptoms) and those NEC patients without a prior history of immediate blood transfusion. A total of 908 (inborn) neonatal admissions had received 751 PRBC transfusions during the study period; of these, 17 patients (1.8%) had developed radiographic, clinical, or surgical signs of NEC. Six cases of NEC (35%; six of 17 patients) were associated with PRBC transfusions (0.8%; six of 751 transfusions). The transfusion-associated NEC group developed presenting signs within 22 +/- 5 hours (median, 19; range, 12 to 38) of a PRBC transfusion at a mean age of 32 +/- 7 days. In contrast, the non-transfusion-associated NEC group (n = 11) had onset of NEC at a mean age of 12 +/- 7 days ( P < 0.05) after 185 +/- 91 hours (median, 180; range, 96 to 312; P < 0.02] of a transfusion. Prior to the onset of NEC, all of the neonates in the transfusion-associated NEC group were stable, growing, not ventilated, receiving full enteral feedings, and had no other active medical problems except anemia (hematocrit, 24 +/- 3%). In contrast, the nontransfusion NEC group was more often ventilated, was receiving < 50% of fluids by mouth, had lower Apgar scores, and was transfused for an average hematocrit of 37 +/- 7% ( P < 0.05). There was no significant difference in the type, storage, volume, or preservative used between the blood products in the two groups. We identified an unanticipated relationship between late-onset NEC in stable, growing, premature neonates who were transfused electively for anemia of prematurity.

Severe Hemolytic Disease of the Newborn Due to Anti-Cw

BACKGROUND

Pregnancies complicated by Rh isoimmunization have decreased significantly since the widespread use of Rh immune globulin. Uncommon red blood cell antigens have therefore become more clinically evident. We report a case of anti-Cw immunization that resulted in severe fetal anemia that required multiple transfusions.

CASE

A 28-year-old multigravida presented to our service at 18 weeks of gestation with her fourth pregnancy. Her pregnancy was complicated by anti-Cw isoimmunization that resulted in severe fetal anemia requiring in utero fetal blood transfusions.

CONCLUSION

While previous reports recommend only postpartum surveillance when Cw isoimmunization is present, we report a case resulting in severe fetal anemia.

Effects of transfusion in anemia of prematurity

The authors aimed to test the hypothesis that blood transfusions depress hematopoiesis in healthy infants with anemia of prematurity (AOP). They also set out to find markers that predict recovery from AOP. Thirty-nine premature babies underwent weekly and post-transfusion measurements of hemoglobin concentrations, reticulocyte counts (RCC), and erythropoietin levels (EPO). RCC and EPO dropped significantly 7 days after a blood transfusion but had normalized after 14 days. Elevated RCC or EPO levels were not predictive of an increase in hemoglobin. Postnatal HbFg/dL was higher in babies who had received transfusions. The authors conclude that blood transfusions depress erythropoiesis in infants with AOP and stimulate HbF synthesis but this effect is not sustained. Reticulocyte counts and erythropoietin levels are unhelpful in predicting recovery from AOP.

Detection and clinical evaluation of antineutrophil antibodies in neonates who had a blood transfusion or exchange transfusion

BACKGROUND

The aim of this study was to detect and investigate the clinical effects of antineutrophil antibodies in neonates who had received a blood transfusion or exchange transfusion.

METHODS

Venous blood samples were drawn from 34 neonates at pretransfusion (sample 0), immediately after transfusion (sample 1), 2-3 weeks (sample 2) and 8-12 weeks (sample 3) after transfusion. Ten healthy neonates were in the control group. Antineutrophil antibodies were detected using flow cytometric assay.

RESULTS

Antineutrophil antibody was detected in the sera of 20 (58.8%) neonates in the study group. Of these 20 neonates, nine had antineutrophil antibodies in serum samples 0, 1 and 2, which were probably due to the passive transfer of maternal antibodies. Nine neonates had antineutrophil antibodies in serum samples 1 and 2, which were probably due to neutrophil antibodies being present in the donor's blood. In two neonates, antineutrophil antibodies were not detected in samples 0 and 1, but appeared in sample 2, which were probably actively produced by the neonates. All of the antineutrophil antibodies disappeared in the serum samples, except in one neonate. Only one preterm newborn developed neutropenia, which resolved spontaneously in a week. The presence of antineutrophil antibody in transfused neonates was significantly higher than in non-transfused neonates.

CONCLUSIONS

The presence of neutrophil specific antibodies in transfused neonates is not rare and antineutrophil antibodies may be found more often in transfused neonates compared to non-transfused neonates. The clinical significance of those antibodies needs to be assessed since they are transient and their clinical effects are not evident.

Noninvasive monitoring of red blood cell transfusion in very low birthweight infants using diffuse optical spectroscopy

Red blood cell (RBC) transfusion guidelines are designed to maintain adequate tissue oxygenation by increasing blood oxygen-carrying capacity. However, since tissue oxygenation is not measured, RBC transfusion guidelines are mostly subjective. Clinical evidence of oxygen transport/consumption mismatches in infants is often unclear and confounded by multiple factors. Invasive hemoglobin measurements can contribute further to anemia if performed too frequently. Diffuse optical spectroscopy (DOS) is a noninvasive quantitative method to measure the tissue oxy, deoxy, and total hemoglobin concentrations (ctO2Hb, ctHb, ctTHb), as well as mixed arterial-venous tissue hemoglobin saturation (stO2). Our objective is to determine if DOS can assess changes in tissue oxygenation in very low birth weight (VLBW) infants undergoing RBC transfusions. DOS measurements of ctO2Hb and ctHb are performed on 10 VLBW infants before and within 24 h after RBC transfusion. Seven nontransfused infants are studied to evaluate hemodynamic variations independent of RBC transfusion. Tissue near-infrared absorption and scattering values are measured using a four-wavelength (690, 750, 810, and 830 nm) frequency-domain tissue oximeter (OxiplexTS, ISS, Champaign, Illinois). In transfused subjects, DOS demonstrates significant increases in ctO2Hb (48+/-13 versus 74+/-20 microM, p<0.002), ctTHb (87+/-17 versus 107+/-24 microM, p=0.004), and stO2 (54+/-8 versus 68+/-6%, p<0.004) post-transfusion. DOS measurements correlate with mean hemoglobin increases for all infants (r=0.83, p<0.0001). No significant DOS changes occurred in the nontransfused group. Calculations of the differential path length for these transfused subjects show high variability (approximately 20%). DOS may serve as a noninvasive bedside tool to assess tissue oxygenation in infants and provide a functionally based transfusion trigger.

Reduction in red blood cell transfusions among preterm infants: results of a randomized trial with an in-line blood gas and chemistry monitor

BACKGROUND

Critically ill, extremely premature infants develop anemia because of intensive laboratory blood testing and undergo multiple red blood cell (RBC) transfusions in the early weeks of life. To date, researchers have had only limited success in finding ways to reduce transfusions significantly in this patient population.

OBJECTIVE

To reduce RBC transfusions for these infants by using a point-of-care bedside monitor that returns analyzed blood to the patient.

DESIGN, SETTING, AND PATIENTS

This was a prospective, 2-center, randomized, open, controlled, clinical trial with a 1:1 assignment of extremely low birth weight infants (weighing 500-1000 g at birth) to control or monitor groups and analysis with the intention-to-treat approach. Predefined RBC transfusion criteria were applied uniformly in the 2 groups.

INTERVENTIONS

Clinical treatment of study subjects with an in-line, ex vivo, bedside monitor that withdraws blood through an umbilical artery catheter, analyzes blood gases and sodium, potassium, and hematocrit levels, and returns the sample to the patient.

MAIN OUTCOME MEASURES

The total volume and number of RBC transfusions during the first 2 weeks of life and the total volume of blood removed for laboratory testing.

RESULTS

The trial was terminated prematurely when one center's NICU changed its standard method of laboratory testing. In the first 2 weeks of life, there was a nonsignificant 17% lower cumulative RBC transfusion volume in the monitor group (n = 46), compared with the control group (n = 47). However, data from the first week only (the period of greater catheter use) demonstrated a significant 33% lower cumulative RBC transfusion volume in the monitor group. Cumulative phlebotomy loss was approximately 25% less in the monitor group throughout the 2-week study period. There was no difference between groups in neonatal mortality, morbidity, and neurodevelopmental outcome rates at 18 to 24 months. This is the first randomized trial documenting that RBC transfusions administered to neonates can by reduced by decreasing laboratory phlebotomy loss.

CONCLUSIONS

As long as an umbilical artery catheter is available for blood sampling with an in-line blood gas and chemistry monitor, significant reductions in neonatal RBC transfusions can be achieved. The patients most likely to benefit from monitor use are the smallest, most critically ill newborns.

Postmortem diagnosis of Diamond-Blackfan anemia

Diamond-Blackfan anemia (DBA) is a rare etiology for congenital anemia, but this diagnosis should be considered when aregenerative hypoplastic anemia occurs in infancy. A term infant girl received a red blood cell transfusion at birth for neonatal anemia (hemoglobin 75 g/L) initially attributed to abruptio placentae. There were no additional investigations. Hemoglobin gradually decreased during the first 4 weeks of life, leading to severe anemia and death despite transfusions. A postmortem diagnosis of DBA was made by extraction of DNA collected on blood filter paper showing a deletion in RPS19 gene. Neonatal anemias should be carefully investigated and close follow-up should be performed during the first months of life, even if there is an obvious hemorrhagic etiology.

Does red blood cell transfusion change the near infra red photoplethysmography signal in infants?

OBJECTIVE

Transfusion practices for neonates are controversial and based on limited scientific information. We examined the use of the plethysmographic volume pulse to assess anemia.

DESIGN

We used near-infrared photoplethysmography (NIRP) to investigate signal strength parameters as area under the curve (AUC) and the first derivate of the amplitude (flux) in anemic infants before and after elective transfusion.

SETTING

Tertiary intensive care unit.

PATIENTS

Thirty-four neonates on day 25+/-15 of life with a pretransfusion hemoglobin level of 8+/-0.9 g/dl. Four infants were excluded for incomplete data.

INTERVENTIONS

Transfusion of 10 ml packed red cells per kilogram body weight

MEASUREMENTS AND RESULTS

The volume pulse signal was obtained with a sensor attached to the sole of the foot. After transfusion we found a significant decrease in number of bradycardia episodes per hour (0.35 vs. 0.16) and episodes of pulse oximeter desaturation less than 85% per hour (1.8 vs. 1.3) and a significant increase in daily weight gain (12+/-7 vs. 20+/-18 g), but neither of the microcirculatory parameters changed significantly (AUC 102+/-38 vs. 101+/-44; flux 435+/-160 vs. 405+/-120).

CONCLUSIONS

Even though infants were transfused at very low levels of hemoglobin with significant clinical effects, microcirculation assessed by NIRP seemed not be affected. Infrared photoplethysmographs present flow not only in the nutritive capillaries but mainly in the subpapillary plexus at a greater depth. This thermoregulatory flow seems not be affected by blood transfusions of anemic infants.

Issues in transfusing preterm infants in the NICU

Decisions regarding whether or not to transfuse preterm infants in the neonatal intensive care unit are often difficult. Although numbers of red blood cell transfusions have decreased in recent years, transfusions are still a common occurrence. For each infant, the advantages of transfusion must be balanced against the consequences and potential risks. This article examines physiologic and iatrogenic causes of anemia in preterm infants, clinical consequences of anemia, the use of transfusions and their risks, and the role of erythropoietin therapy.

Blood transfusion in newborn

Premature infants are among the most frequently transfused groups of patients, usually receiving red cells. The immaturity of the immune system, its lesser ability to cope with a metabolic load and the presence of maternal antibodies, all complicate the picture. Conservation of blood to minimize losses and the need for replacement transfusion is an important strategy that has already been successful in reducing the need for transfusion on neonatal units. The advent of erythropoietin provides another strategy for reducing the need for transfusion. It is unfortunate that the sickest patients who require the most transfusion poorly respond to erythropoietin. Main concern is the long-term consequences of transfusion. Presently the aim is to minimize transfusion risks and give transfusions only when they are indicated.

Efficacy, recovery, and safety of RBCs from autologous placental blood: clinical experience in 52 newborns

BACKGROUND

In the present study, the efficacy, recovery, and safety of RBCs from autologous placental blood (PB-RBCs) were investigated.

STUDY DESIGN AND METHODS

A total of 52 newborns received transfusion with PB-RBCs. The number of newborns requiring no additional allogeneic RBCs was calculated. In 22 of these 52 neonates with a birth weight of 1000 to 2500 g, vital measures were performed during transfusion, and serum potassium levels were measured up to 3 days after transfusion. The results were compared with those of a matched control group given allogeneic RBC transfusions.

RESULTS

All neonates of the study group with a birth weight of less than 1000 g, but only 59 percent those with a birth weight of 1000 to 2500 g and 58 percent of those requiring surgery directly after delivery needed allogeneic transfusions in addition to PB-RBCs. The mean Hb increase after RBC transfusion of 10 mL per kg of body weight was 3 g per dL per kg of body weight in both groups; the Hb decrease was accelerated in the placental blood group (0.32 vs. 0.24 g/dL/day; p < 0.05). There were no intergroup differences in the vital parameters.

CONCLUSION

Our results show no difference in efficacy and safety between PB-RBC transfusion and allogeneic RBC transfusion. According to well-defined criteria, 40 percent of anemic neonates can be supported by autologous placental blood transfusions alone.

Effects of vitamin E supplementation during erythropoietin treatment of the anaemia of prematurity

AIMS

To evaluate the effects of vitamin E supplementation on haemoglobin concentration and the requirement for transfusion in premature infants treated with erythropoietin and iron.

METHODS

Randomised, double blind, placebo controlled trial. Thirty infants </=32 weeks gestation and </=1250 g birth weight, who were defined as stable based on minimal requirements for respiratory support and phlebotomy, and absence of major congenital anomalies were enrolled. All were treated with erythropoietin and iron, and were randomised to receive, in addition, either vitamin E 50 IU/day or placebo for eight weeks or until discharge, whichever came first.

RESULTS

Despite higher vitamin E (alpha-tocopherol) levels in the experimental group in weeks 3 (49.0 v 28.1 micro mol/l) and 8 (66.2 v 38.5 micro mol/l), there were no differences in haemoglobin, reticulocyte count, iron concentration, or transfusion requirement.

CONCLUSIONS

Oral vitamin E supplementation at 50 IU/day does not increase the response of preterm infants to erythropoietin and iron. Vitamin E obtained through standard nutrition may have been sufficient or higher doses may be required.

[Substitutive hemotransfusion in newborns with surgical pathologies]

Transfusion of blood components is not a method of choice at anemia, at the same time, hemotransfusion turns out often vitally indispensable at a pronounced reduction of hemoglobin especially in newborns. Indications for the transfusion of blood components demand that many factors of individual approach should be taken into consideration. Phenotyping of the blood of donor and of patient by using the standard serum methods and gel technology make it possible to avoid transfusion complications.

Profound early-onset neonatal anemia: a case study

B.G. WAS A 38 6/7-WEEK GESTATIONAL age female born to a 29-year-old G2 P0, O+ (antibody negative), rubella immune, RPR nonreactive, GC negative, HepBsAg negative, GBS negative, HIV negative mother. The pregnancy was uncomplicated. The mother had received prenatal care starting in the first trimester. There was no reported history of hydrops fetalis. Thick meconium was noted on artificial rupture of the membranes six hours prior to delivery.