1
|
Kitsommart R, Limrungsikul A, Tongsawang N, Thamwiriyakul N, Deesomchok A, Pithakton N, Paes B. Impact of level of neonatal care on phlebotomy and blood transfusion in extremely low birthweight infants: a prospective, multicenter, observational study. Front Pediatr 2023; 11:1238402. [PMID: 37724088 PMCID: PMC10505442 DOI: 10.3389/fped.2023.1238402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 08/21/2023] [Indexed: 09/20/2023] Open
Abstract
Objectives To explore the level of neonatal care on cumulative phlebotomy loss (cPL) and red cell transfusions in extremely low birthweight [ELBW; birthweight (BW) <1,000 g] infants, up to 40 weeks post-conceptual age (PCA). The secondary objective was to determine the associations between cPL and number of transfusions and between transfusions and hospital outcomes. Methods A prospective, comparative, observational study was conducted in two level IV and two level III neonatal intensive care units (NICUs) in Thailand. Daily cPL volume and number of blood tests were recorded. Descriptive data are reported as frequency and percentage for categorical variables and median [25th percentile (P25), 75th percentile (P75)] for continuous data according to the data distribution. A p-value <0.05 was considered statistically significant. Results 210 ELBW infants were included; 99 and 111 were admitted to level IV and level III NICUs, respectively. Birth weight of level IV infants was lower 780.0 [660.0, 875.0] vs. 865.0 [723.0, 930.0] g; p < 0.001]. Initial group hematocrits were similar (43.1% vs. 44.0%, p = 0.47). cPL for each infant was 28.1 [16.5, 46.4] ml. Level IV infants had more tests (n = 89 [54, 195] vs. 59 [37, 88], p < 0.001). Counterintuitively, there was a lower cPL trend in level IV infants, but this was insignificant (19.6 [12.3, 52.3] vs. 28.9 [19.3, 45.3] ml; p = 0.06). The number of transfusions in both NICUs was similar 4 [2, 6], with a strong correlation between cPL and number of transfusions (r = 0.79, p < 0.001). Transfusions were significantly associated with bronchopulmonary dysplasia [BPD; adjusted RR (95% CI): 2.6 (1.2, 5.3), p = 0.01]. Conclusions Level IV NICUs conducted more blood tests in ELBW infants without a difference in cPL, and number of transfusions. Cumulative PL correlated with number of transfusions and was associated with BPD risk. Minimizing cPL by point-of-care tests and restrictive transfusion criteria, may reduce need for transfusion.
Collapse
Affiliation(s)
- Ratchada Kitsommart
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Anchalee Limrungsikul
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Numtip Tongsawang
- Department of Pediatric Nursing, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Areeya Deesomchok
- Department of Pediatrics, Buddhachinaraj Hospital, Phitsanulok, Thailand
| | - Nuttanan Pithakton
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Bosco Paes
- Department of Pediatrics (Neonatal Division), McMaster University, Hamilton, ON, Canada
| |
Collapse
|
2
|
Stark MJ, Collins CT, Andersen CC, Crawford TM, Sullivan TR, Bednarz J, Morton R, Marks DC, Dieng M, Owen LS, Opie G, Travadi J, Tan K, Morris S. Study protocol of the WashT Trial: transfusion with washed versus unwashed red blood cells to reduce morbidity and mortality in infants born less than 28 weeks' gestation - a multicentre, blinded, parallel group, randomised controlled trial. BMJ Open 2023; 13:e070272. [PMID: 37487676 PMCID: PMC10373745 DOI: 10.1136/bmjopen-2022-070272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/26/2023] Open
Abstract
INTRODUCTION Many extremely preterm newborns develop anaemia requiring a transfusion, with most receiving three to five transfusions during their admission. While transfusions save lives, the potential for transfusion-related adverse outcomes is an area of growing concern. Transfusion is an independent predictor of death and is associated with increased morbidity, length of hospital stay, risk of infection and immune modulation. The underlying mechanisms include adverse pro-inflammatory and immunosuppressive responses. Evidence supports an association between transfusion of washed red cells and fewer post-transfusion complications potentially through removal of chemokines, lipids, microaggregates and other biological response modifiers. However, the clinical and cost-effectiveness of washed cells have not been determined. METHODS AND ANALYSIS This is a multicentre, randomised, double-blinded trial of washed versus unwashed red cells. Infants <28 weeks' gestation requiring a transfusion will be enrolled. Transfusion approaches will be standardised within each study centre and will occur as soon as possible with a recommended fixed transfusion volume of 15 mL/kg whenever the haemoglobin is equal to or falls below a predefined restrictive threshold, or when clinically indicated. The primary outcome is a composite of mortality and/or major morbidity to first discharge home, defined as one or more of the following: physiologically defined bronchopulmonary dysplasia; unilateral or bilateral retinopathy of prematurity grade >2, and; necrotising enterocolitis stage ≥2. To detect a 10% absolute reduction in the composite outcome from 69% with unwashed red blood cell (RBCs) to 59% with washed RBCs with 90% power, requires a sample size of 1124 infants (562 per group). Analyses will be performed on an intention-to-treat basis with a prespecified statistical analysis plan. A cost-effectiveness analysis will also be undertaken. ETHICS AND DISSEMINATION Ethics approval has been obtained from the Women's and Children's Health Network Human Research Ethics Committee (HREC/12/WCHN/55). The study findings will be disseminated through peer-reviewed articles and conferences. TRIAL REGISTRATION NUMBER ACTRN12613000237785 Australian New Zealand Clinical Trials Registry.
Collapse
Affiliation(s)
- Michael J Stark
- Department of Neonatal Medicine, The Women's and Children's Hospital Adelaide, Adelaide, South Australia, Australia
- Robinson Research Institute, The University of Adelaide, North Adelaide, South Australia, Australia
- SAHMRI Women and Kids Theme, South Australian Health and Medical Research Institute, North Adelaide, South Australia, Australia
| | - Carmel T Collins
- SAHMRI Women and Kids Theme, South Australian Health and Medical Research Institute, North Adelaide, South Australia, Australia
| | - Chad C Andersen
- Department of Neonatal Medicine, The Women's and Children's Hospital Adelaide, Adelaide, South Australia, Australia
- Robinson Research Institute, The University of Adelaide, North Adelaide, South Australia, Australia
| | - Tara M Crawford
- Department of Neonatal Medicine, The Women's and Children's Hospital Adelaide, Adelaide, South Australia, Australia
- Robinson Research Institute, The University of Adelaide, North Adelaide, South Australia, Australia
- SAHMRI Women and Kids Theme, South Australian Health and Medical Research Institute, North Adelaide, South Australia, Australia
| | - Thomas R Sullivan
- SAHMRI Women and Kids Theme, South Australian Health and Medical Research Institute, North Adelaide, South Australia, Australia
- School of Public Health, The University of Adelaide, Adelaide, South Australia, Australia
| | - Jana Bednarz
- SAHMRI Women and Kids Theme, South Australian Health and Medical Research Institute, North Adelaide, South Australia, Australia
- School of Public Health, The University of Adelaide, Adelaide, South Australia, Australia
| | - Rachael Morton
- National Health and Medical Research Council (NHMRC) Clinical Trials Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Denese C Marks
- Research and Development, Australian Red Cross Lifeblood New South Wales and Australian Capital Territory, Teams, New South Wales, Australia
| | - Mbathio Dieng
- National Health and Medical Research Council (NHMRC) Clinical Trials Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Louise S Owen
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, Victoria, Australia
- Critical Care and Neurosciences Division, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Gillian Opie
- Department of Obstetrics & Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
- Neonatal Services, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Javeed Travadi
- Department of Paediatrics, Royal Darwin Hospital, Casuarina, Northern Territory, Australia
| | - Kenneth Tan
- Monah Newborn, Monash Children's Hospital, Clayton, Victoria, Australia
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Scott Morris
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- Department of Neonatal Medicine, Flinders Medical Centre, Bedford Park, South Australia, Australia
| |
Collapse
|
3
|
Tang L, Zhu TT, Zhao J. Association between red blood cell transfusion and bronchopulmonary dysplasia: a systematic review and meta-analysis. Front Pediatr 2023; 11:1095889. [PMID: 37325359 PMCID: PMC10266411 DOI: 10.3389/fped.2023.1095889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 04/21/2023] [Indexed: 06/17/2023] Open
Abstract
Background We aimed to determine the association between red blood cell transfusions (RBCT) and bronchopulmonary dysplasia (BPD) in neonates. Methods A systematic review and meta-analysis were conducted using data obtained from literature search of PubMed, Embase, and Web of Science from their inception till May 1, 2022. Two reviewers independently selected potentially relevant studies, and after data extraction, they assessed the methodological quality of the included studies using the Newcastle-Ottawa scale. Data were pooled using random-effects models in Review Manager 5.3. Subgroup-analysis was performed based on the number of transfusions and adjusted results. Results Of the 1,011 identified records, 21 total case-control, cross-sectional, and cohort studies were selected, which included a total of 6,567 healthy controls and 1,476 patients with BPD. The pooled unadjusted odds ratio ([OR], 4.01; 95% confidence interval [CI] 2.31-6.97) and adjusted OR (5.11; 95% CI 3.11-8.4) showed significant association between RBCT and BPD. A substantial heterogeneity was noted, which could be due to different variables controlled for in each study. The subgroup analysis showed that heterogeneity may be partially explained by the extent of transfusion. Conclusion The association between BPD and RBCT remains unclear based on the current data due to the substantial heterogeneity among the results. Well-designed studies are still needed in the future.
Collapse
Affiliation(s)
- Li Tang
- Department of Pediatrics Hematology and Oncology Nursing, West China Second University Hospital, Sichuan University, Chengdu, China
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, China
| | - Ting Ting Zhu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, China
| | - Jing Zhao
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, China
| |
Collapse
|
4
|
Fu X, Zhao X, Weng A, Zhang Q. Comparative efficacy and safety of restrictive versus liberal transfusion thresholds in anemic preterm infants: a meta-analysis of 12 randomized controlled trials. Ann Hematol 2023; 102:283-297. [PMID: 36542102 PMCID: PMC9889497 DOI: 10.1007/s00277-022-05072-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022]
Abstract
The comparative efficacy and safety of restrictive with liberal transfusion thresholds remain controversial in anemic preterm infants. This meta-analysis aimed to compare the efficacy and safety of these two transfusion thresholds for anemic preterm infants. We searched PubMed, Embase, Cochrane Library, and China National Knowledge Infrastructure (CNKI) for relevant randomized controlled trials (RCTs) comparing restrictive with liberal transfusion thresholds in anemic preterm infants through April 30, 2022. Two independent investigators screened literature, extracted data, and appraised the methodological quality of eligible studies. Meta-analysis was conducted using RevMan version 5.3.5. Twelve RCTs with 4380 preterm infants were included. Liberal transfusion threshold significantly increased the level of hemoglobin after transfusion (mean difference (MD): -10.03; 95% confidence interval (CI): -15.98 to -4.08; p=0.001; I2=94%) and hematocrit (MD: -3.62; 95%CI: -6.78 to -0.46; p=0.02; I2=80%) compared with restrictive transfusion. Infants' age at first transfusion in restrictive transfusion group was higher than that of infants in liberal transfusion group (MD: 5.08; 95%CI: 2.27 to7.89; p=0.004; I2=54%); however, restrictive transfusion was associated with more time on supplemental oxygen (MD: 3.56; 95%CI: 1.93 to 5.18; p<0.001; I2=62%) and ventilator or CPAP (MD: 3.31; 95%CI: 1.42 to 5.20; p=0.006; I2=75%). For the remaining outcomes, two transfusion strategies were comparable. Furthermore, a series of sensitivity analyses confirmed the robustness of the level of hemoglobin after transfusion, age at first transfusion, time on ventilator or CPAP, and safety outcomes. Evidence with substantial heterogeneity indicates that liberal and restrictive transfusion thresholds are effective and safe blood cell transfusion strategies in anemic preterm infants, but the liberal strategy may be more effective in shortening the length of necessary respiratory support.
Collapse
Affiliation(s)
- Xiaoling Fu
- Department of Blood Transfusion, Hainan Women and Children's Medical Center, Haikou, 570000, Hainan Province, China.
| | - Xingdan Zhao
- Department of Blood Transfusion, Hainan Women and Children's Medical Center, Haikou, 570000, Hainan Province, China
| | - Aihan Weng
- Department of Blood Transfusion, Hainan Women and Children's Medical Center, Haikou, 570000, Hainan Province, China
| | - Qian Zhang
- Department of Blood Transfusion, Hainan Women and Children's Medical Center, Haikou, 570000, Hainan Province, China
| |
Collapse
|
5
|
Garcia MR, Comstock BA, Patel RM, Tolia VN, Josephson CD, Georgieff MK, Rao R, Monsell SE, Juul SE, Ahmad KA. Iron supplementation and the risk of bronchopulmonary dysplasia in extremely low gestational age newborns. Pediatr Res 2023; 93:701-707. [PMID: 35725917 PMCID: PMC9763546 DOI: 10.1038/s41390-022-02160-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 04/26/2022] [Accepted: 05/22/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND The aim of this study was to determine the relationship between iron exposure and the development of bronchopulmonary dysplasia (BPD). METHODS A secondary analysis of the PENUT Trial dataset was conducted. The primary outcome was BPD at 36 weeks gestational age and primary exposures of interest were cumulative iron exposures in the first 28 days and through 36 weeks' gestation. Descriptive statistics were calculated for study cohort characteristics with analysis adjusted for the factors used to stratify randomization. RESULTS Of the 941 patients, 821 (87.2%) survived to BPD evaluation at 36 weeks, with 332 (40.4%) diagnosed with BPD. The median cohort gestational age was 26 weeks and birth weight 810 g. In the first 28 days, 76% of infants received enteral iron and 55% parenteral iron. The median supplemental cumulative enteral and parenteral iron intakes at 28 days were 58.5 and 3.1 mg/kg, respectively, and through 36 weeks' 235.8 and 3.56 mg/kg, respectively. We found lower volume of red blood cell transfusions in the first 28 days after birth and higher enteral iron exposure in the first 28 days after birth to be associated with lower rates of BPD. CONCLUSIONS We find no support for an increased risk of BPD with iron supplementation. TRIAL REGISTRATION NUMBER NCT01378273. https://clinicaltrials.gov/ct2/show/NCT01378273 IMPACT: Prior studies and biologic plausibility raise the possibility that iron administration could contribute to the pathophysiology of oxidant-induced lung injury and thus bronchopulmonary dysplasia in preterm infants. For 24-27-week premature infants, this study finds no association between total cumulative enteral iron supplementation at either 28-day or 36-week postmenstrual age and the risk for developing bronchopulmonary dysplasia.
Collapse
Affiliation(s)
- Melissa R Garcia
- San Antonio Uniformed Services Health Education Consortium, San Antonio, TX, USA
| | | | - Ravi M Patel
- Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Veeral N Tolia
- Pediatrix Medical Group, Dallas, TX, USA
- Baylor University Medical Center, Dallas, TX, USA
| | - Cassandra D Josephson
- Emory University School of Medicine and Center for Transfusion and Cellular Therapies, Atlanta, GA, USA
| | | | | | | | | | - Kaashif A Ahmad
- San Antonio Uniformed Services Health Education Consortium, San Antonio, TX, USA.
- Pediatrix Medical Group, San Antonio, TX, USA.
- Baylor College of Medicine, San Antonio, TX, USA.
- Pediatrix and Obstetrix Specialists of Houston, Houston, TX, USA.
- Methodist Children's Hospital, San Antonio, TX, USA.
| |
Collapse
|
6
|
Li J, Zhang J, Hao Q, Chen H, Cheng X. Erythropoietin for preventing bronchopulmonary dysplasia in preterm infants: A systematic review and meta-analysis. Pediatr Pulmonol 2022; 57:1051-1063. [PMID: 35043596 DOI: 10.1002/ppul.25837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 01/15/2022] [Accepted: 01/17/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Recombinant erythropoietin (rEPO) has erythropoiesis and anti-inflammatory properties that might help reduce lung injury in preterm infants. OBJECTIVE To conduct a systematic review and meta-analysis to evaluate the possible role of rEPO in altering the risk of bronchopulmonary dysplasia (BPD). METHODS PubMed, EMBASE, Web of Science, and the Cochrane Library databases were searched to identify randomized controlled trials (RCTs) that evaluated the effects of rEPO for the prevention of BPD in preterm infants. RESULTS Fourteen studies (3199 infants) were included. Our results could not demonstrate a significant effect of rEPO on the incidence of BPD36 (risk ratio [RR]: 0.97, 95% confidence interval [CI]: 0.87-1.09, p = 0.63, I2 = 0, 12 RCTs, high-quality evidence), BPD28 (RR: 1.28, 95% CI: 0.91-1.79, p = 0.15, I2 = 17%, three RCTs, low-quality evidence) and oxygen dependence days. The test for subgroup analysis by administration route of rEPO showed similar outcomes above. Some of the included trials reported a significant effect of intravenous rEPO on reduction of sepsis (RR: 0.82, 95% CI: 0.70-0.96, p = 0.01, I2 = 0, high-quality evidence) and any stage necrotizing enterocolitis (NEC) (RR: 0.75, 95% CI: 0.59-0.94, p = 0.01, I2 = 0, moderate-quality evidence). The incidence of mortality and stage II or higher NEC was comparable in rEPO and control infants. CONCLUSION Our results suggest that rEPO does not affect the risk of developing BPD in preterm infants. Adequately powered RCTs are required to further confirm these findings.
Collapse
Affiliation(s)
- Jing Li
- Department of Neonatology, The First Affiliated Hospital of Zheng Zhou University, Zhengzhou, China
| | - Jing Zhang
- Department of Neonatology, The First Affiliated Hospital of Zheng Zhou University, Zhengzhou, China
| | - Qingfei Hao
- Department of Neonatology, The First Affiliated Hospital of Zheng Zhou University, Zhengzhou, China
| | - Haoming Chen
- Department of Neonatology, The First Affiliated Hospital of Zheng Zhou University, Zhengzhou, China
| | - Xiuyong Cheng
- Department of Neonatology, The First Affiliated Hospital of Zheng Zhou University, Zhengzhou, China
| |
Collapse
|
7
|
Crawford TM, Andersen CC, Hodyl NA, Robertson SA, Stark MJ. Effect of washed versus unwashed red blood cells on transfusion-related immune responses in preterm newborns. Clin Transl Immunology 2022; 11:e1377. [PMID: 35284073 PMCID: PMC8907378 DOI: 10.1002/cti2.1377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 01/04/2022] [Accepted: 02/04/2022] [Indexed: 12/22/2022] Open
Abstract
Objectives Transfusion with washed packed red blood cells (PRBCs) may be associated with reduced transfusion‐related pro‐inflammatory cytokine production. This may be because of alterations in recipient immune responses. Methods This randomised trial evaluated the effect of transfusion with washed compared with unwashed PRBCs on pro‐inflammatory cytokines and endothelial activation in 154 preterm newborns born before 29 weeks’ gestation. Changes in plasma cytokines and measures of endothelial activation in recipient blood were analysed after each of the first three transfusions. Results By the third transfusion, infants receiving unwashed blood had an increase in IL‐17A (P = 0.04) and TNF (P = 0.007), whereas infants receiving washed blood had reductions in IL‐17A (P = 0.013), TNF (P = 0.048), IL‐6 (P = 0.001), IL‐8 (P = 0.037), IL‐12 (P = 0.001) and IFN‐γ (P = 0.001). The magnitude of the post‐transfusion increase in cytokines did not change between the first and third transfusions in the unwashed group but decreased in the washed group for IL‐12 (P = 0.001), IL‐17A (P = 0.01) and TNF (P = 0.03), with the difference between the groups reaching significance by the third transfusion (P < 0.001 for each cytokine). Conclusion The pro‐inflammatory immune response to transfusion in preterm infants can be modified when PRBCs are washed prior to transfusion. Further studies are required to determine whether the use of washed PRBCs for neonatal transfusion translates into reduced morbidity and mortality.
Collapse
Affiliation(s)
- Tara M Crawford
- The Women's and Children's Hospital Adelaide SA Australia.,The Robinson Research Institute The University of Adelaide Adelaide SA Australia
| | - Chad C Andersen
- The Women's and Children's Hospital Adelaide SA Australia.,The Robinson Research Institute The University of Adelaide Adelaide SA Australia
| | - Nicolette A Hodyl
- The Robinson Research Institute The University of Adelaide Adelaide SA Australia
| | - Sarah A Robertson
- The Robinson Research Institute The University of Adelaide Adelaide SA Australia
| | - Michael J Stark
- The Women's and Children's Hospital Adelaide SA Australia.,The Robinson Research Institute The University of Adelaide Adelaide SA Australia
| |
Collapse
|
8
|
Wang P, Wang X, Deng H, Li L, Chong W, Hai Y, Zhang Y. Restrictive versus liberal transfusion thresholds in very low birth weight infants: A systematic review with meta-analysis. PLoS One 2021; 16:e0256810. [PMID: 34460843 PMCID: PMC8405031 DOI: 10.1371/journal.pone.0256810] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 08/17/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND To assess the efficacy and safety of restrictive versus liberal red blood cell transfusion thresholds in very low birth weight infants. METHODS We searched MEDLINE, EMBASE, and Cochrane database without any language restrictions. The last search was conducted in August 15, 2020. All randomized controlled trials comparing the use of restrictive versus liberal red blood cell transfusion thresholds in very low birth weight (VLBW) infants were selected. Pooled risk ratio (RR) for dichotomous variable with 95% confidence intervals were assessed by a random-effects model. The primary outcome was all-cause mortality. RESULTS Overall, this meta-analysis included 6 randomized controlled trials comprising 3,483 participants. Restrictive transfusion does not increase the risk of all-cause mortality (RR, 0.99; 95% CI, 0.84 to 1.17; I2 = 0%; high-quality evidence), and does not increase the composite outcome of death or neurodevelopmental impairment (RR, 1.01, 95% CI, 0.93-1.09; I2 = 7%; high-quality evidence) or other serious adverse events. Results were similar in subgroup analyses of all-cause mortality by weight of infants, gestational age, male infants, and transfusion volume. CONCLUSIONS In very low birth weight infants, a restrictive threshold for red blood cell transfusion was not associated with increased risk of all-cause mortality, in either short term or long term.
Collapse
Affiliation(s)
- Peng Wang
- Affiliated Hospital & Clinical Medical College of Chengdu University, Chengdu, Sichuan, China
| | - Xing Wang
- Affiliated Hospital & Clinical Medical College of Chengdu University, Chengdu, Sichuan, China
| | - Haidong Deng
- West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Linjie Li
- Affiliated Hospital & Clinical Medical College of Chengdu University, Chengdu, Sichuan, China
| | - Weelic Chong
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - Yang Hai
- Zucker School of Medicine at Hofstra/Northwell, New York, New York, United States of America
| | - Yu Zhang
- Affiliated Hospital & Clinical Medical College of Chengdu University, Chengdu, Sichuan, China
- West China Hospital, Sichuan University, Chengdu, Sichuan, China
- * E-mail:
| |
Collapse
|
9
|
Hoyos AB, Vasquez-Hoyos P. 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. J Perinatol 2021; 41:1403-1411. [PMID: 33568772 DOI: 10.1038/s41372-021-00945-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 11/11/2020] [Accepted: 01/19/2021] [Indexed: 01/31/2023]
Abstract
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.
Collapse
Affiliation(s)
- Angela B Hoyos
- Division of Neonatology, Clínica del Country, Bogota, DC, Colombia. .,Universidad El Bosque, Bogota, Colombia.
| | - Pablo Vasquez-Hoyos
- Sociedad de Cirugía Hospital de San José, Bogota, Colombia.,Department of Pediatrics, Universidad Nacional de Colombia, Bogota, Colombia.,Department of Pediatrics, Fundación Universitaria de Ciencias de la Salud, Bogota, Colombia
| |
Collapse
|
10
|
Juul SE, Vu PT, Comstock BA, Wadhawan R, Mayock DE, Courtney SE, Robinson T, Ahmad KA, Bendel-Stenzel E, Baserga M, LaGamma EF, Downey LC, O’Shea M, Rao R, Fahim N, Lampland A, Frantz ID, Khan J, Weiss M, Gilmore MM, Ohls R, Srinivasan N, Perez JE, McKay V, Heagerty PJ. Effect of High-Dose Erythropoietin on Blood Transfusions in Extremely Low Gestational Age Neonates: Post Hoc Analysis of a Randomized Clinical Trial. JAMA Pediatr 2020; 174:933-943. [PMID: 32804205 PMCID: PMC7432302 DOI: 10.1001/jamapediatrics.2020.2271] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
IMPORTANCE Extremely preterm infants are among the populations receiving the highest levels of transfusions. Erythropoietin has not been recommended for premature infants because most studies have not demonstrated a decrease in donor exposure. OBJECTIVES To determine whether high-dose erythropoietin given within 24 hours of birth through postmenstrual age of 32 completed weeks will decrease the need for blood transfusions. DESIGN, SETTING, AND PARTICIPANTS The Preterm Erythropoietin Neuroprotection Trial (PENUT) is a randomized, double-masked clinical trial with participants enrolled at 19 sites consisting of 30 neonatal intensive care units across the United States. Participants were born at a gestational age of 24 weeks (0-6 days) to 27 weeks (6-7 days). Exclusion criteria included conditions known to affect neurodevelopmental outcomes. Of 3266 patients screened, 2325 were excluded, and 941 were enrolled and randomized to erythropoietin (n = 477) or placebo (n = 464). Data were collected from December 12, 2013, to February 25, 2019, and analyzed from March 1 to June 15, 2019. INTERVENTIONS In this post hoc analysis, erythropoietin, 1000 U/kg, or placebo was given every 48 hours for 6 doses, followed by 400 U/kg or sham injections 3 times a week through postmenstrual age of 32 weeks. MAIN OUTCOMES AND MEASURES Need for transfusion, transfusion numbers and volume, number of donor exposures, and lowest daily hematocrit level are presented herein. RESULTS A total of 936 patients (488 male [52.1%]) were included in the analysis, with a mean (SD) gestational age of 25.6 (1.2) weeks and mean (SD) birth weight of 799 (189) g. Erythropoietin treatment (vs placebo) decreased the number of transfusions (unadjusted mean [SD], 3.5 [4.0] vs 5.2 [4.4]), with a relative rate (RR) of 0.66 (95% CI, 0.59-0.75); the cumulative transfused volume (mean [SD], 47.6 [60.4] vs 76.3 [68.2] mL), with a mean difference of -25.7 (95% CI, 18.1-33.3) mL; and donor exposure (mean [SD], 1.6 [1.7] vs 2.4 [2.0]), with an RR of 0.67 (95% CI, 0.58-0.77). Despite fewer transfusions, erythropoietin-treated infants tended to have higher hematocrit levels than placebo-treated infants, most noticeable at gestational week 33 in infants with a gestational age of 27 weeks (mean [SD] hematocrit level in erythropoietin-treated vs placebo-treated cohorts, 36.9% [5.5%] vs 30.4% [4.6%] (P < .001). Of 936 infants, 160 (17.1%) remained transfusion free at the end of 12 postnatal weeks, including 43 in the placebo group and 117 in the erythropoietin group (P < .001). CONCLUSIONS AND RELEVANCE These findings suggest that high-dose erythropoietin as used in the PENUT protocol was effective in reducing transfusion needs in this population of extremely preterm infants. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01378273.
Collapse
Affiliation(s)
- Sandra E. Juul
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle
| | - Phuong T. Vu
- Department of Biostatistics, University of Washington, Seattle,now with Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington
| | | | - Rajan Wadhawan
- Department of Neonatal-Perinatal Medicine, AdventHealth, Orlando, Florida
| | - Dennis E. Mayock
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle
| | - Sherry E. Courtney
- Division of Neonatology, Department of Pediatrics, University of Arkansas, Little Rock
| | - Tonya Robinson
- Division of Neonatology, Department of Pediatrics, University of Louisville, Louisville, Kentucky
| | - Kaashif A. Ahmad
- Department of Neonatal Medicine, Methodist Children’s Hospital, San Antonio, Texas
| | | | - Mariana Baserga
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City
| | - Edmund F. LaGamma
- Department of Neonatal Medicine, Maria Fareri Children’s Hospital at Westchester, Valhalla, New York
| | - L. Corbin Downey
- Division of Neonatology, Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Michael O’Shea
- Division of Neonatology, Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis
| | - Raghavendra Rao
- Division of Neonatology, Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis
| | - Nancy Fahim
- Division of Neonatology, Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis
| | | | - Ivan D. Frantz
- Division of Neonatology, Department of Pediatrics, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Janine Khan
- Division of Neonatology, Department of Pediatrics, Prentice Women’s Hospital, Chicago, Illinois
| | - Michael Weiss
- Division of Neonatology, Department of Pediatrics, University of Florida, Gainesville
| | - Maureen M. Gilmore
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland
| | - Robin Ohls
- Division of Neonatology, Department of Pediatrics, University of New Mexico, Albuquerque
| | - Nishant Srinivasan
- Department of Pediatrics, Children’s Hospital of the University of Illinois, Chicago
| | - Jorge E. Perez
- Department of Neonatology, South Miami Hospital, South Miami, Florida
| | - Victor McKay
- Department of Neonatology, Johns Hopkins All Children’s Hospital, St. Petersburg, Florida
| | | | | |
Collapse
|
11
|
Crawford TM, Andersen CC, Stark MJ. Effect of repeat transfusion exposure on plasma cytokine and markers of endothelial activation in the extremely preterm neonate. Transfusion 2020; 60:2217-2224. [DOI: 10.1111/trf.15952] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/21/2020] [Accepted: 05/25/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Tara M. Crawford
- The Department of Neonatal Medicine The Women's and Children's Hospital Adelaide Adelaide South Australia Australia
- The Robinson Research Institute, The University of Adelaide Adelaide South Australia Australia
| | - Chad C. Andersen
- The Department of Neonatal Medicine The Women's and Children's Hospital Adelaide Adelaide South Australia Australia
- The Robinson Research Institute, The University of Adelaide Adelaide South Australia Australia
| | - Michael J. Stark
- The Department of Neonatal Medicine The Women's and Children's Hospital Adelaide Adelaide South Australia Australia
- The Robinson Research Institute, The University of Adelaide Adelaide South Australia Australia
| |
Collapse
|
12
|
Sharma A, Xin Y, Chen X, Sood BG. Early prediction of moderate to severe bronchopulmonary dysplasia in extremely premature infants. Pediatr Neonatol 2020; 61:290-299. [PMID: 32217025 DOI: 10.1016/j.pedneo.2019.12.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 11/15/2019] [Accepted: 12/16/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Bronchopulmonary Dysplasia (BPD) is the commonest morbidity in extremely preterm infants (PTIs). Risk factors for BPD have been described in the era before the widespread availability of non-invasive ventilation (NIV) in the delivery room (DR). The objective of this study is to identify risk factors for Moderate/Severe BPD in an era of widespread availability of NIV in the DR. METHODS Detailed antenatal and postnatal data were abstracted for PTIs, 230/7-276/7 weeks GA. Multivariate logistic regression and classification and regression tree analyses (CART) identified predictors for the primary outcome of Moderate/Severe BPD. RESULTS Of 263 eligible infants, 59% had Moderate/Severe BPD. Moderate/Severe BPD was significantly associated with birthweight, gender, DR intubation and surfactant compared to No/Mild BPD. Of infants not intubated in the DR, 40% with No/Mild BPD and 80% with Moderate/Severe BPD received intubation by 48 hours (p < 0.05). Infants with Moderate/Severe BPD received longer duration of oxygen and mechanical (MV). On logistic regression, birthweight, gender, oxygen concentration, cumulative duration of oxygen and MV, surfactant, and blood transfusions predicted Moderate/Severe BPD. Both CART analysis and logistic regression showed duration of oxygen and MV to be the most important predictors for Moderate/Severe BPD. CONCLUSIONS In an era of increasing availability of NIV in the DR, lower birthweight, male gender, surfactant treatment, blood transfusions and respiratory support in the first 2-3 weeks after birth predict Moderate/Severe BPD with high sensitivity and specificity. The majority of these infants received intubation within 48 hours of birth (97%). These data suggest that early failures of NIV represent opportunities for improvement of NIV techniques and of non-invasive surfactant to avoid intubation in the first 48 hours. Furthermore, these risk factors may allow earlier identification of infants most likely to benefit from interventions to prevent or decrease severity of BPD.
Collapse
Affiliation(s)
- Amit Sharma
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Wayne State University, Detroit, MI 48201, USA; Hutzel Women's Hospital, Detroit, MI 48201, USA; Children's Hospital of Michigan, Detroit, MI 48201, USA
| | - Yuemin Xin
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Wayne State University, Detroit, MI 48201, USA
| | - Xinguang Chen
- University of Florida College of Medicine, College of Public Health, USA
| | - Beena G Sood
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Wayne State University, Detroit, MI 48201, USA; Hutzel Women's Hospital, Detroit, MI 48201, USA; Children's Hospital of Michigan, Detroit, MI 48201, USA.
| |
Collapse
|
13
|
Iron Homeostasis Disruption and Oxidative Stress in Preterm Newborns. Nutrients 2020; 12:nu12061554. [PMID: 32471148 PMCID: PMC7352191 DOI: 10.3390/nu12061554] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/24/2020] [Accepted: 05/25/2020] [Indexed: 02/06/2023] Open
Abstract
Iron is an essential micronutrient for early development, being involved in several cellular processes and playing a significant role in neurodevelopment. Prematurity may impact on iron homeostasis in different ways. On the one hand, more than half of preterm infants develop iron deficiency (ID)/ID anemia (IDA), due to the shorter duration of pregnancy, early postnatal growth, insufficient erythropoiesis, and phlebotomy losses. On the other hand, the sickest patients are exposed to erythrocytes transfusions, increasing the risk of iron overload under conditions of impaired antioxidant capacity. Prevention of iron shortage through placental transfusion, blood-sparing practices for laboratory assessments, and iron supplementation is the first frontier in the management of anemia in preterm infants. The American Academy of Pediatrics recommends the administration of 2 mg/kg/day of oral elemental iron to human milk-fed preterm infants from one month of age to prevent ID. To date, there is no consensus on the type of iron preparations, dosages, or starting time of administration to meet optimal cost-efficacy and safety measures. We will identify the main determinants of iron homeostasis in premature infants, elaborate on iron-mediated redox unbalance, and highlight areas for further research to tailor the management of iron metabolism.
Collapse
|
14
|
Hellström W, Forssell L, Morsing E, Sävman K, Ley D. Neonatal clinical blood sampling led to major blood loss and was associated with bronchopulmonary dysplasia. Acta Paediatr 2020; 109:679-687. [PMID: 31505053 PMCID: PMC7155086 DOI: 10.1111/apa.15003] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 09/04/2019] [Accepted: 09/05/2019] [Indexed: 01/23/2023]
Abstract
AIM Studies indicate that reduced foetal haemoglobin levels are related to increased neonatal morbidity rates. This study investigated the relationships between sampling-related blood loss and adult blood transfusions administered during postnatal days 1-14 and the development of severe neonatal morbidities in extremely preterm infants born before 28 weeks of gestation. METHODS The medical files of 149 extremely preterm infants born at two university hospitals in Sweden from 2013 to 2018 were investigated. RESULTS Blood sampling resulted in a 58% depletion of the endogenous blood volume postnatal days 1-14 (median 40.4 mL/kg, interquartile range 23.9-53.3 mL/kg) and correlated with the adult erythrocyte transfusion volume (rS = 0.870, P < .001). Sampling-related blood loss on postnatal days 1-7, adjusted for gestational age at birth and birth weight standard deviation score, was associated with the development of bronchopulmonary dysplasia (BPD) (odds ratio by a 10-unit increase 2.4, 95% confidence interval 1.1-5.4) (P = .03). No associations were found between blood sampling and intraventricular haemorrhage or necrotising enterocolitis in the full statistical model. The largest proportion of sampling-related blood was used for blood gas analyses (48.7%). CONCLUSION Diagnostic blood sampling led to major endogenous blood loss replaced with adult blood components and was associated with the development of BPD.
Collapse
Affiliation(s)
- William Hellström
- Department of Paediatrics Institute of Clinical Sciences Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
| | - Linnéa Forssell
- Department of Clinical Sciences Lund Paediatrics Lund University Skåne University Hospital Lund Sweden
| | - Eva Morsing
- Department of Clinical Sciences Lund Paediatrics Lund University Skåne University Hospital Lund Sweden
| | - Karin Sävman
- Department of Paediatrics Institute of Clinical Sciences Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Region Västra Götaland Department of Neonatology The Queen Silvia Children's Hospital Sahlgrenska University Hospital Gothenburg Sweden
| | - David Ley
- Department of Clinical Sciences Lund Paediatrics Lund University Skåne University Hospital Lund Sweden
| |
Collapse
|
15
|
Lee EY, Kim SS, Park GY, Lee SH. Effect of red blood cell transfusion on short-term outcomes in very low birth weight infants. Clin Exp Pediatr 2020; 63:56-62. [PMID: 32024329 PMCID: PMC7029666 DOI: 10.3345/kjp.2019.00990] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 11/08/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Red blood cell (RBC) transfusion improves cardiorespiratory status of preterm infants by increasing circulating hemoglobin, improving tissue oxygenation, and reducing cardiac output. However, RBC transfusion itself has also been suggested to negatively affect short-term outcomes such as intraventricular hemorrhage (IVH), bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP), and necrotizing enterocolitis (NEC) in premature infants. PURPOSE This study aimed to analyze the relationship between RBC transfusion and short-term outcomes in very low birth weight (VLBW) infants (birth weight, <1,500 g). METHODS We retrospectively reviewed the medical records of VLBW infants admitted to the Soonchunhyang University Bucheon Hospital between October 2010 and December 2017. Infants who died during hospitalization were excluded. The infants were divided into 2 groups according to RBC transfusion status. We investigated the relationship between RBC transfusion and short-term outcomes including BPD, ROP, NEC, and IVH. RESULTS Of the 250 enrolled VLBW infants, 109 (43.6%) underwent transfusion. Univariate analysis revealed that all shortterm outcomes except early-onset sepsis and patent ductus arteriosus were associated with RBC transfusion. In multivariate analysis adjusted for gestational age, birth weight and Apgar score at 1 minute, RBC transfusion was significantly correlated with BPD (odds ratio [OR], 5.42; P<0.001) and NEC (OR, 3.40; P= 0.009). CONCLUSION RBC transfusion is significantly associated with adverse clinical outcomes such as NEC and BPD in VLBW infants. Careful consideration of the patient's clinical condition and appropriate guidelines is required before administration of RBC transfusions.
Collapse
Affiliation(s)
- Eui Young Lee
- Department of Pediatrics, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Sung Shin Kim
- Department of Pediatrics, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Ga Young Park
- Department of Pediatrics, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Sun Hyang Lee
- Department of Pediatrics, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| |
Collapse
|
16
|
Patel RM, Knezevic A, Yang J, Shenvi N, Hinkes M, Roback JD, Easley KA, Josephson CD. Enteral iron supplementation, red blood cell transfusion, and risk of bronchopulmonary dysplasia in very-low-birth-weight infants. Transfusion 2019; 59:1675-1682. [PMID: 30801736 DOI: 10.1111/trf.15216] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 11/29/2018] [Accepted: 01/08/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Enteral iron supplementation and RBC transfusions are routinely administered to very-low-birth-weight (VLBW) infants, although the potential risks of these exposures have not been adequately quantified. This study evaluated the association between the cumulative dose of enteral iron supplementation, total volume of RBCs transfused, and risk of bronchopulmonary dysplasia (BPD) in VLBW infants. STUDY DESIGN AND METHODS Retrospective, multicenter observational cohort study in Atlanta, Georgia. Cumulative supplemental enteral iron exposure and total volume of RBCs transfused were measured until the age at assessment of BPD. Multivariable generalized linear models were used to control for confounding, and the reliability of the factors was assessed in 1000 bootstrap models. RESULTS A total of 598 VLBW infants were studied. In multivariable analyses, a greater cumulative dose of supplemental enteral iron exposure was associated with an increased risk of BPD (adjusted relative risk per 50-mg increase, 1.07; 95% confidence interval [CI], 1.02-1.11; p = 0.002). Similarly, a greater volume of RBCs transfused was associated with a higher risk of BPD (adjusted relative risk per 20-mL increase, 1.05; 95% CI, 1.02-1.07; p < 0.001). Both factors were reliably associated with BPD (>50%). Volume of RBCs transfused was similar to gestational age in reliability as a risk factor for BPD (present in 100% of models) and was more reliable than mechanical ventilation at 1 week of age. CONCLUSION The cumulative dose of supplemental enteral iron exposure and total volume of RBC transfusion are both independently associated with an increased risk of BPD in VLBW infants.
Collapse
Affiliation(s)
- Ravi Mangal Patel
- Division of Neonatology, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Andrea Knezevic
- Biostatistics and Bioinformatics, Rollins School of Public Health, Atlanta, Georgia.,Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jing Yang
- Biostatistics and Bioinformatics, Rollins School of Public Health, Atlanta, Georgia.,Biostatistics and Research Decision Sciences, Merck & Co., Inc., Kenilworth, New Jersey
| | - Neeta Shenvi
- Biostatistics and Bioinformatics, Rollins School of Public Health, Atlanta, Georgia
| | | | - John D Roback
- Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, Georgia
| | - Kirk A Easley
- Biostatistics and Bioinformatics, Rollins School of Public Health, Atlanta, Georgia
| | - Cassandra D Josephson
- Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, Georgia.,Division of Hematology and Oncology, Aflac Cancer and Blood Disorders Center, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| |
Collapse
|
17
|
Hwang JS, Rehan VK. Recent Advances in Bronchopulmonary Dysplasia: Pathophysiology, Prevention, and Treatment. Lung 2018; 196:129-138. [PMID: 29374791 DOI: 10.1007/s00408-018-0084-z] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 01/04/2018] [Indexed: 12/16/2022]
Abstract
Bronchopulmonary dysplasia (BPD) is potentially one of the most devastating conditions in premature infants with longstanding consequences involving multiple organ systems including adverse effects on pulmonary function and neurodevelopmental outcome. Here we review recent studies in the field to summarize the progress made in understanding in the pathophysiology, prognosis, prevention, and treatment of BPD in the last decade. The work reviewed includes the progress in understanding its pathobiology, genomic studies, ventilatory strategies, outcomes, and therapeutic interventions. We expect that this review will help guide clinicians to treat premature infants at risk for BPD better and lead researchers to initiate further studies in the field.
Collapse
Affiliation(s)
- Jung S Hwang
- Department of Pediatrics, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, 1124 West Carson Street, Torrance, CA, 90502, USA
| | - Virender K Rehan
- Department of Pediatrics, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, 1124 West Carson Street, Torrance, CA, 90502, USA.
| |
Collapse
|
18
|
Howarth C, Banerjee J, Aladangady N. Red Blood Cell Transfusion in Preterm Infants: Current Evidence and Controversies. Neonatology 2018; 114:7-16. [PMID: 29550819 DOI: 10.1159/000486584] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 01/04/2018] [Indexed: 01/21/2023]
Abstract
The current evidence regarding the indication, advantages and risks of red blood cell transfusion (RBCT) for preterm infants is discussed. This is an important area in Neonatology to be examined given that 90% of extremely low birth weight infants receive RBCT and many controversies remain regarding when to transfuse and the risks of RBCT. The various treatment thresholds and guidelines used are presented and we compare the short-term clinical benefits of liberal and restrictive RBCT in preterm infants; the majority of these are equivocal and sadly long-term outcome data is limited. The latest evidence on how anaemia and blood transfusion affect organ perfusion in preterm infants is presented. This is important when trying to establish the optimal trigger threshold for RBCT in preterm infants, especially because the knowledge about the adaptive physiological responses to anaemia in very low birth weight infants and the effects of RBCT at various levels of anaemia is also inadequate. Further research into the physiological adaptive response to anaemia of varying degrees and to RBCT at different levels of anaemia in preterm infants of different gestational and post-natal ages is needed before we can conclusively guide the optimal timing and trigger thresholds for RBCT in preterm infants.
Collapse
Affiliation(s)
- Claire Howarth
- Homerton University Hospital NHS Foundation Trust, London, United Kingdom
| | | | | |
Collapse
|
19
|
Zhang Z, Huang X, Lu H. Association between red blood cell transfusion and bronchopulmonary dysplasia in preterm infants. Sci Rep 2014; 4:4340. [PMID: 24614152 PMCID: PMC3949297 DOI: 10.1038/srep04340] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Accepted: 02/24/2014] [Indexed: 01/17/2023] Open
Abstract
Anemia and the need for transfusion of packed red blood cells (PRBCs) are common in preterm infants. PRBC transfusion increases the oxygen carrying capacity of hemoglobin and may result in higher rates of organ dysfunction. To determine whether PRBC transfusion in preterm infants is associated with an increased incidence of bronchopulmonary dysplasia (BPD), this retrospective study was performed on neonates with birth weights ≤ 1,500 g or gestational age ≤ 32 weeks admitted from August, 2008 to November, 2013. Infants who received PRBC transfusion before the diagnosis of BPD and those who did not receive PRBC transfusion or received PRBC transfusion after diagnosis of BPD were compared for incidence of BPD and other morbidities. Of 231 preterm infants, 137 received PRBC transfusion before BPD was diagnosed (group 1) and 94 did not (group 2). The incidence of BPD was significantly higher in group 1 than in group 2 (37.2% vs. 2.1%, P < 0.00001). After adjusting for potential risk factors, the adjusted odds ratio for BPD was 9.80 (95% confidence interval, 1.70-56.36; P = 0.01). This study demonstrated an association between PRBC transfusion and BPD in preterm infants. A cautious approach to PRBC transfusion in these infants is warranted.
Collapse
Affiliation(s)
- Zhiqun Zhang
- Division of Neonatology, Department of Pediatrics, Hangzhou First People's Hospital, Zhejiang, China
| | - Xianmei Huang
- Department of Pediatrics, Hangzhou First People's Hospital, Zhejiang, China
| | - Hui Lu
- Division of Neonatology, Department of Pediatrics, Hangzhou First People's Hospital, Zhejiang, China
| |
Collapse
|
20
|
Ibrahim M, Ho SKY, Yeo CL. Restrictive versus liberal red blood cell transfusion thresholds in very low birth weight infants: a systematic review and meta-analysis. J Paediatr Child Health 2014; 50:122-30. [PMID: 24118127 DOI: 10.1111/jpc.12409] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/01/2013] [Indexed: 12/15/2022]
Abstract
AIM A systematic review was conducted to examine the effects of restrictive versus liberal red blood cell (RBC) transfusion thresholds on clinically important outcomes in very low birth weight (VLBW) infants. METHODS Randomised controlled trials (RCTs) of varying RBC transfusion thresholds in VLBW infants were identified by searching MEDLINE, EMBASE, CINAHL, all of the Cochrane Library and other supplementary sources. Selected studies included one of the following outcomes: total number of red blood cell transfusions, donor exposure rate, cranial ultrasonographically diagnosed brain injury, retinopathy of prematurity, bronchopulmonary dysplasia, necrotising enterocolitis or death. Studies to be included were selected by two reviewers who also assessed the risk of bias of each trial. Data extraction and analyses were independently performed by two reviewers. All data were analysed using RevMan 5. RESULTS Six RCTs were identified. One trial did not meet the inclusion criteria, while two had inadequate methodological quality. Pooled analysis of two trials showed that the restrictive transfusion group received a significantly lower mean number of transfusions per infant (mean difference (MD) -1.35, 95% confidence interval (CI) [-2.61, -0.09]) and donor exposure rate (MD -0.54, 95% CI [-0.93, -0.15]). No other statistically significant differences were observed. CONCLUSION Restrictive RBC transfusion thresholds in VLBW infants may be utilised without incurring clinically important increases in the risk of death or major short-term neonatal morbidities.
Collapse
Affiliation(s)
- Masitah Ibrahim
- Department of Neonatal and Developmental Medicine, Singapore General Hospital, Singapore
| | | | | |
Collapse
|
21
|
Abiodun EM, Aisha KG. The association of transfusion status with antioxidant enzymes and malondialdehyde level in Nigerians with sickle cell disease. Asian J Transfus Sci 2014; 8:47-50. [PMID: 24678175 PMCID: PMC3943147 DOI: 10.4103/0973-6247.126692] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Sickle cell disease (SCD) often leads to chronic hemolytic anemia of varying severity, and blood transfusion may be employed in the management of SCD complications. OBJECTIVE The aim of the study was to evaluate the effect of blood transfusion on the activities of some antioxidant enzymes as well as lipid peroxide and to relate transfusion status to these enzymes and malondialdehyde (MDA) in SCD patients. MATERIALS AND METHODS Glutathione peroxidase (GPX), superoxide dismutase, catalase, MDA, and lipoproteins were assayed in 87 SCD and 20 age- and sex-matched subjects with normal hemoglobin. Of the 87 SCD patients, 30 had multiple transfusions, 21 had been transfused once while 36 had not been transfused within the last 3 months. RESULTS Statistically significant decrease in the mean levels of GPX (P = 0.045) and Cu/Zn SOD (P = 0.001) and increased (P = 0.001) MDA were observed in the transfused compared to non-transfused patients. Similarly, significant decrease (P = 0.001) in Cu/Zn SOD and increase (P = 0.01) in MDA were observed in multi transfused compared to those who had been transfused once. Transfusion status correlated (P <0.047) inversely with Cu/Zn SOD and positively with MDA. CONCLUSION Reduced activity levels of serum antioxidant enzymes and increased mean levels of MDA were observed in transfused compared to non-transfused SCD patients and these changes correlated with transfusion status.
Collapse
Affiliation(s)
- Emokpae Mathias Abiodun
- Department of Chemical Pathology, Bayero University Aminu Kano Teaching Hospital, Kano, Nigeria
- Medical Laboratory Science, School of Basic Medical Sciences, College of Medical Sciences, University of Benin, Benin City, Nigeria
| | - Kuliya-Gwarzo Aisha
- Department of Haematology and Blood Transfusion, Bayero University Aminu Kano Teaching Hospital, Kano, Nigeria
| |
Collapse
|
22
|
Abstract
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.
Collapse
Affiliation(s)
- Ga Won Jeon
- Department of Pediatrics, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Jong Beom Sin
- Department of Pediatrics, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| |
Collapse
|
23
|
The effect of maximum storage on iron status, oxidative stress and antioxidant protection in paediatric packed cell units. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2012; 11:419-25. [PMID: 23058860 DOI: 10.2450/2012.0046-12] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 07/09/2012] [Indexed: 01/03/2023]
Abstract
BACKGROUND Premature babies may receive multiple transfusions during the first weeks of their life. Strong associations exist between the receipt of blood transfusions and the development of the major consequences of prematurity such as retinopathy and chronic lung disease. The possible physiological link between the receipt of blood and disease is unclear, but iron-induced oxidative damage and/or bacterial colonisation would promote these conditions. Premature babies are poorly equipped to deal with any increases in iron and oxidative load that they may acquire via blood transfusions. To determine whether there are any relationships between these factors, we studied iron and oxidative status of just expired (i.e. 36 days old) paediatric red blood cell (RBC) packs. MATERIALS AND METHODS Just expired paediatric RBC packs were obtained from the local blood bank. The extracellular medium surrounding the RBC was separated by centrifugation and the following parameters measured: total iron concentration, total iron binding capacity, non-transferrin-bound iron [NTBI], haemoglobin, total and reduced ascorbate, and malondialdehyde concentration. RESULTS The extracellular fluid of the paediatric packs (n =13) was rich in iron, a high percentage of which (36%) was present as potentially toxic NTBI. It was highly redox active with limited antioxidant protection and iron-binding capacity. DISCUSSION The extracellular medium surrounding packed RBC could potentially be toxic if administered to patients with limited iron sequestering and antioxidant capacity, such as premature babies. Further studies are required to determine at what point during storage these changes become potentially harmful so that clinical studies can examine the optimal storage time for blood destined for premature babies.
Collapse
|
24
|
von Lindern JS, Khodabux CM, Hack KEA, van Haastert IC, Koopman-Esseboom C, van Zwieten PHT, Brand A, Walther FJ. Long-term outcome in relationship to neonatal transfusion volume in extremely premature infants: a comparative cohort study. BMC Pediatr 2011; 11:48. [PMID: 21619675 PMCID: PMC3119036 DOI: 10.1186/1471-2431-11-48] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Accepted: 05/28/2011] [Indexed: 12/18/2022] Open
Abstract
Background In premature born infants red blood cell (RBC) transfusions have been associated with both beneficial and detrimental sequels. Upon RBC transfusion, improvement in cerebral blood flow and oxygenation have been observed, while a more liberal transfusion policy may be associated with a better developmental outcome. The effect of the transfusion volume on long-term outcome is not known. Methods Observational follow-up study of a cohort of extremely premature born infants, treated in 2 neonatal intensive care units using a different transfusion volume (15 ml/kg in Unit A and 20 ml/kg in Unit B). The primary outcome was a composite of post discharge mortality, neuromotor developmental delay, blindness or deafness, evaluated at a mean corrected age (CA) of 24 months related to the transfusion volume/kg bodyweight administered during the postnatal hospital stay. Results Despite the difference in transfusion volume in clinically comparable groups of infants, they received a similar number of transfusions (5.5 ± 3.2 versus 5.5 ± 2.3 respectively in Unit A and B). The total transfused volume in unit A was 79 ± 47 ml/kg and 108 ± 47 ml/kg in unit B (p = 0.02). Total transfused RBC volume per kg bodyweight was not an independent predictor of the composite outcome (p = 0.96, OR 1.0 (CI 0.9-1.1). Conclusion There was no relationship between the composite outcome at 24 months CA and transfusion volume received during the post natal hospital stay. As there was no clinical advantage of the higher transfusion volume, a more restrictive volume will reduce total transfusion volume and donor exposure. Future research on the optimal transfusion volume per event to extreme preterm infants should include larger, prospective studies with a longer follow-up period through to childhood or even adolescence.
Collapse
Affiliation(s)
- Jeannette S von Lindern
- Division of Neonatology J6-S, Department of Pediatrics, Leiden University Medical Center, 2300RC Leiden, the Netherlands.
| | | | | | | | | | | | | | | |
Collapse
|
25
|
Abstract
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.
Collapse
|
26
|
Valieva OA, Strandjord TP, Mayock DE, Juul SE. Effects of transfusions in extremely low birth weight infants: a retrospective study. J Pediatr 2009; 155:331-37.e1. [PMID: 19732577 PMCID: PMC3038786 DOI: 10.1016/j.jpeds.2009.02.026] [Citation(s) in RCA: 126] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2008] [Revised: 10/22/2008] [Accepted: 02/12/2009] [Indexed: 12/18/2022]
Abstract
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.
Collapse
Affiliation(s)
- Olga A Valieva
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA 98195-6320, USA
| | | | | | | |
Collapse
|
27
|
Abstract
The regulation of the availability of micronutrients is particularly critical during periods of rapid growth and differentiation such as the fetal and neonatal stages. Both iron deficiency and excess during the early weeks of life can have severe effects on neurodevelopment that may persist into adulthood and may not be corrected by restoration of normal iron levels. This article provides a succinct overview of our current understanding of the extent to which newborns, particularly premature newborns, are able (or not able) to regulate their iron status according to physiologic need. Postnatal development of factors important to iron homeostasis such as intestinal transport, extracellular transport, cellular uptake and storage, intracellular regulation, and systemic control are examined. Also reviewed are how factors peculiar to the sick and premature neonate can further adversely influence iron homeostasis and exacerbate iron-induced oxidative stress, predispose the infant to bacterial infections, and, thus, compromise his or her clinical situation further. The article concludes with a discussion of the areas of relative ignorance that require urgent investigation to rectify our lack of understanding of iron homeostasis in what is a critical stage of development.
Collapse
Affiliation(s)
- Keith J Collard
- University of Plymouth, School of Health Professions, Peninsula Allied Health Centre, Derriford Road, Plymouth PL6 8BH, United Kingdom.
| |
Collapse
|
28
|
Iron overload following red blood cell transfusion and its impact on disease severity. Biochim Biophys Acta Gen Subj 2008; 1790:694-701. [PMID: 18992790 DOI: 10.1016/j.bbagen.2008.09.010] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2008] [Revised: 09/13/2008] [Accepted: 09/29/2008] [Indexed: 01/19/2023]
Abstract
Transfusion of red blood cells can be a life-saving therapy both for patients with chronic anemias and for those who are critically ill with acute blood loss. However, transfusion has been associated with significant morbidity. Chronic transfusion results in accumulation of excess iron that surpasses the binding capacity of the major iron transport protein, transferrin. The resulting non-transferrin bound iron (NTBI) can catalyze the production of highly reactive oxygen species (ROS) leading to significant and wide spread injury to the liver, heart, and endocrine organs as well as increases in infection. Acute transfusion of red blood cells in critically ill patients likewise has significant effects including increased mortality, prolonged hospital stays, and elevated risk of nosocomial infection. These effects appear to be more profound with increasing age of stored blood. The progressive release of free iron associated with storage time suggests that morbidity following acute transfusion, like that seen in chronic transfusion, may be due in part to elevated levels of NTBI. It is clear that transfusion is necessary in many instances; however, its risks and benefits must be carefully balanced before proceeding to avoid unnecessary iron toxicity.
Collapse
|
29
|
Patole S. Prevention and treatment of necrotising enterocolitis in preterm neonates. Early Hum Dev 2007; 83:635-42. [PMID: 17826009 DOI: 10.1016/j.earlhumdev.2007.07.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2007] [Accepted: 07/30/2007] [Indexed: 01/10/2023]
Abstract
Prevention and treatment of NEC has become an area of priority for research due to the increasing number of preterm survivors at risk, and the significant mortality and morbidity related to the illness. Probiotic supplementation appears to be a promising option for primary prevention of NEC but further large trials are necessary for documenting their safety in terms of sepsis as well as long-term neurodevelopmental outcomes and immune function. As new frontiers including immunomodulating agents like pentoxifylline continue to be explored, the impact of well-established simple strategies like antenatal glucocorticoid therapy, and early and preferential use of breast milk must not be forgotten. Clinical research on manifestations of ileus of prematurity, and feeding in the presence of common risk factors such as IUGR is needed. Safety of minimal enteral feeds in terms of NEC and benefits of standardised feeding regimens need to be confirmed. Association of common clinical practices such as red cell transfusions, H2 receptor blockade, and thickening of feeds with NEC warrants attention. An approach utilising a package of potentially better practices seems to be the most appropriate strategy for the prevention and treatment of NEC.
Collapse
Affiliation(s)
- Sanjay Patole
- Department of Neonatal Paediatrics, KEM Hospital for Women, Perth, Australia.
| |
Collapse
|