[Recombinant human erythropoietin in premature infants. Evaluation of a one year experience]

[Pediatric preparations of blood products]

The transfusion in pediatrics may require specific preparations to adapt to the various characteristics from preterm neonates to big child: weight, immaturity, immune system, blood volume, long and short-term prognosis, and to meet the needs of pathologies related to the perinatal period. The knowledge of the process for preparation, conservation and administration of these particular products shall permit a transfusion in safe conditions by supporting the prescribers in a personalized blood management.

Respective effects of phlebotomy losses and erythropoietin treatment on the need for blood transfusion in very premature infants

BACKGROUND

The benefit to risk ratio of the treatment with erythropoietin (EPO) as a means of limiting the number of transfusions in very preterm infants during hospitalization, seems to be modest since the adoption of restrictive transfusion criteria and of policy limiting phlebotomy losses. We therefore aim to evaluate the factors associated with the number of late blood transfusion in very preterm infants in a unit where the routine use of EPO has been discontinued.

METHODS

A comparative "before-after" study was carried out in premature infants born before 32 weeks postmenstrual age (PMA), over a period of one year before (EPO group) and one year after (non-EPO group) the discontinuation of EPO therapy.

RESULTS

A total of 48 infants were included in the study (EPO = 21; non-EPO = 27). The number of infants transfused after the 15 day of life (D15) and the number of transfusions per infant after D15 were not significantly different between the two groups. In a multivariate analysis, the gestational age and the volume of blood drawn off during the first month of life significantly influenced the need for transfusions after the 15th day of life, independently of the treatment with EPO. The hemoglobin levels measured at different times of hospitalization (median postnatal age: 16, 33 and 67 days) were not significantly different between the two groups.

CONCLUSIONS

Our study shows that the discontinuation of EPO did not change the number of late transfusions. Even when a policy limiting phlebotomy losses is used, blood loss is an important and independent risk factor for late transfusion of very preterm infants.

Red blood cell transfusions in newborn infants: Revised guidelines

In general, health care professionals taking care of high risk infants in neonatal intensive care units have become more restrictive in their use of red blood cell transfusion over the past 10 years. The present statement is intended for those caring for high risk newborn infants (preterm to one month of age). The objectives of this statement are to provide guidelines to reduce the incidence of anemia in preterm and term infants, to identify strategies to decrease the need for red blood cell transfusions and to limit donor exposure in this population. Recommendations for red blood cell transfusions are included.

Érythropoïétine chez le nouveau-né : efficacité comparée des voies d’administration sous-cutanée et intraveineuse

OBJECTIVE

Our aim was to compare the effectiveness of a one-month treatment with recombinant human erythropoietine (rHuEpo) according to the administration route.

METHODS

Retrospective study based on the data collection from medical files of 64 preterm infant hospitalized in the "institut de puériculture et de périnatalogie" (Paris) between January 13th, 2002 and April 13th, 2002. The first group (N =33) was treated by subcutaneous rHuEpo 750 IU/kg per week, in three injections by week, for one month. The second group (N =15) was treated by continuous infusion of rHuEpo in total parenteral nutrition 1050 IU/kg per week (30% augmentation to compensate the amount absorbed by the filter). The third group (N =16) received 750 IU/kg per week of rHuEpo in three direct intravenous injections. The effectiveness of rHuEpo was evaluated by the absolute reticulocyte count, the level of hemoglobin and the incidence of blood transfusion (multiple logistic analysis of variant and regression).

RESULTS

The absolute reticulocyte count and hemoglobin level were significantly reduced after one month of treatment by continuous infusion of rHuEpo in total parenteral nutrition and direct intravenous injections compared with a one-month treatment by subcutaneous rHuEpo. Hemoglobine level were at 8.8 and 9.6 g/dl vs 10.3 g/dl (P =0.02) and absolute reticulocyte count at 123,000/mm3 and 190,000/mm3 vs 216,000/mm3 (p =0.001). The number of transfused infants was significantly increased with utilization of continuous (40%) and direct intravenous (75%) compared with those treated by subcutaneous route (21.2%) while the ferritin level and phlebotomy losses were not significantly different in the three groups. The number of blood transfusion was significantly linked to phlebotomy losses and administration route of rHuEpo.

CONCLUSION

Our study tends to demonstrate that rHuEpo administered subcutaneously reduces significantly the number of transfusion in contrary to intravenous routes. Waiting for pilot study and new molecules, we recommend subcutaneous administration of rHuEpo to preterm infants 250 IU/kg three times weekly in the treatment of anemia of prematurity.

Effect of beginning recombinant erythropoietin treatment within the first week of life, among very-low-birth-weight neonates, on "early" and "late" erythrocyte transfusions: a meta-analysis

OBJECTIVES

Erythrocyte transfusions to neonates can be categorized as "early" if given during the first 3 weeks of life and "late" if given thereafter. We used a meta-analysis to determine whether recombinant erythropoietin (rEpo) administration to very-low-birth-weight (VLBW, <1500 g) neonates, beginning in the first week of life, reduces either "early" or "late" transfusions.

STUDY DESIGN AND METHODS

Studies that used a randomized, placebo-controlled, double-masked design were deemed acceptable. We identified 12 acceptable, relevant, clinical trials. Additional data not provided in the publications were obtained from two of the authors.

RESULTS

The acceptable studies involved an aggregate of 561 rEpo and 529 placebo recipients. If rEpo was begun in the first week of life, the summary odds ratio (OR) for receiving any transfusion ("early" or "late") was 0.52, 95% confidence interval (CI): 0.34 to 0.79 (p=0.001). The OR for receiving an "early" transfusion was 0.54 (95% CI: 0.25 to 1.15; p=0.055), and the OR for receiving a "late" transfusion was 0.56 (95% CI: 0.37 to 0.83; p=0.036). Heterogeneity among studies was too great to estimate the effect of rEpo on the number of transfusions received or the volume of blood transfused (p<0.001 for the Q-test statistic). Subgroup analysis suggested that when rEpo is begun in the first week of life, neonates 1000 to 1500 g and >29 weeks are more likely to completely avoid transfusion than are extremely low-birth-weight (ELBW, <1000 g) neonates. No dose-response relationship was apparent between rEpo dose or iron dose and transfusion. No difference was apparent depending on whether the rEpo was given subcutaneously vs intravenously.

CONCLUSION

If rEpo is begun in the first week of life, a moderate reduction can be expected (p=0.001) in the proportion of VLBW neonates transfused. Reduction is less significant in "early" transfusion (p=0.055) than in "late" transfusion (p=0.036). Such treatment is not likely to eliminate transfusions among ELBW neonates completely.

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.

[Recombinant human erythropoietin: analysis of a policy of treatment in an hospital based population of very-low-birthweight infants]

AIM OF THE STUDY

To evaluate a policy of treatment with human recombinant erythropoietin (rhEPO) and to describe factors related to red blood cell transfusions (RBCTs) in treated neonates.

STUDY

Prospective, observative study.

PATIENTS AND METHODS

One-hundred and sixty-five neonates with gestational age (GA) < 30 weeks and/or birthweight < 1000g admitted between may 1998 and october 1999. Ninety were excluded (congenital malformations n = 6, deaths n = 16, referral to a general hospital before discharge n = 67, ECMO n = 1). Data about the characteristics of the population, the severity of the neonatal period, hemoglobin at birth, blood loses, treatment with rhEPO, number of red blood cells transfusions (RBCTs) and donors were recorded in all infants.

RESULTS

Thirty-eight in seventy-five (51%) neonates received 112 blood transfusions. Eighty-eight were prescribed after day 15. In most of the cases (n = 68), RBCTs were done according to the protocol. In 20 cases (23%) infants were transfused during a late-onset infection. No difference was observed between the non-transfused (group I) and the transfused neonates (group II) with regards to the drug administration: first dose on day 3 +/- 2, number of injections (17 +/- 4 vs 18 +/- 1, ns). The start of oral supplementation with iron was late (12j +/- 8 vs 19j +/- 10, ns). Infants in group II had a lower birthweight (850 +/- 240 vs 1050 +/- 160 g, p < 0,01) for a similar GA (28 +/- 1SA vs 28 +/- 2SA, ns) in association with an increased number of small for date babies (p = 0.03). Antenatal steroïds administration (89 vs 74%, ns), administration of surfactant (59 vs 81%, ns) were similar in the two groups. The Clinical Risk Index for Babies was higher in group II: 5 +/- 3 vs 2 +/- 1 (p < 0,001) as was the duration of oxygen delivery (53 +/- 44 vs 14 +/- 20 days, p < 0,01) and postnatal administration of corticosteroïds ( 38% vs 3%, p < 0.01).

CONCLUSION

The quality of iron administration, RBCTs and the limitation of donors could be improved in our population. Transfusions among neonates born before 30 weeks and/or with a birthweight of less than 1000 g and treated with rhEPO are associated with intrauterine malnutrition and a worse clinical condition on admission. Early identification of at risk neonates could improve prevention of RBCTs and the efficacy of rhEPO administration to preterm infants.