Outcomes after implementing restrictive blood transfusion criteria in extremely premature infants

Epidemiology, risk factors, clinical presentation and complications of late-onset neonatal sepsis among preterm neonates in Cyprus: a prospective case-control study

BACKGROUND

Late-onset neonatal sepsis (LOS) is common in preterm neonates, with increasing incidence in recent years. In the present study, we examined the epidemiology, clinical presentation, and complications of LOS in Cyprus and quantified possible risk factors for the development of this condition.

METHODS

The study subjects were preterm neonates admitted in the Neonatal Intensive Care Unit (NICU) of Archbishop Makarios III Hospital, the only neonatal tertiary centre in Cyprus. A prospective, case-control study was designed, and carried out between April 2017-October 2018. Depending on blood culture results, preterm neonates were classified as "Confirmed LOS": positive blood culture - microorganism isolated and LOS symptoms, "Unconfirmed LOS": negative blood culture and LOS symptoms, and "Controls" group: negative blood culture and absence of LOS symptoms. Comparisons between the 3 groups were performed and the associations between demographic, clinical and treatment characteristics with the likelihood of LOS were assessed using univariate and multivariate logistic regression.

RESULTS

A total of 350 preterm neonates were included in the study and the incidence of LOS was 41.1%. 79 (22.6%) and 65 (18.6%) neonates were classified as "Confirmed LOS", and "unconfirmed LOS" cases respectively while 206 (58.9%) served as controls. The rate of confirmed LOS ranged from 12.2% in moderate to late preterm neonates to 78.6% in extremely preterm neonates. In the multivariate model, we demonstrated an independent association between LOS and duration of hospitalization (OR: 1.06, 95%CI: 1.01-1.10), duration of ventilation (OR: 1.23, 95%CI: 1.07-1.43) and necrotising enterocolitis (OR: 3.41, 95%CI: 1.13-10.25).

CONCLUSIONS

The present study highlights the epidemiology of LOS in preterm neonates in Cyprus and its association with the duration of ventilation and hospitalization as well as with necrotizing enterocolitis. Establishment of protocols for the prevention of nosocomial infections during hospitalization in the NICUs and mechanical ventilation of preterm neonates is recommended.

Retrospective cohort study of neonatal blood transfusion in China

BACKGROUND

Blood transfusion therapy is extremely important for certain neonatal diseases, but the threshold for neonatal blood transfusion is not the same in different countries. Until now, clinical studies to determine the suitable threshold for newborns in China are lacking. Therefore, it is of high importance to establish a multi-center cohort study to explore appropriate transfusion thresholds for newborns in China.

METHODS

This retrospective cohort study investigated neonatal blood transfusion therapy administered from January 1, 2017 to June 30, 2018, with the aim of evaluating the effect of restricted and nonrestricted blood transfusion on neonatal health. The subjects were enrolled in 46 hospitals in China. A total of 5669 neonatal cases were included in the study. Clinical diagnosis and transfusion treatment of these neonates were collected and the data were retrospectively analyzed. The neonates were followed up 1 week and 1 month after leaving the hospital. The newborns' and their mothers' data were collected containing 280 variables in the database. The primary outcome of the study was mortality, and the secondary outcomes were complications, hospital stays, NICU hospital stays and hospital costs.

RESULTS

Results from the < 1500 g group showed that there was a higher mortality rate in the restricted transfusion group (11.41%) when compared with the non-restricted transfusion group (5.12%) (P = 0.000). Among the secondary outcomes, the restricted transfusion group had fewer costs. Results from the 1500-2500 g group showed that the mortality rates of the restricted and non-restricted transfusion groups were 3.53% and 4.71%, respectively, however there was no statistical significance between the two groups (P = 0.345). Among the secondary outcomes, the restricted transfusion group had fewer hospital stays, NICU hospital stays and hospital costs. The incidence of necrotizing enterocolitis was lower in the restricted transfusion group (OR, 2.626; 95% confidence interval [CI], 1.445 to 4.773; P = 0.003). The results from the ≥ 2500 g restricted transfusion group suggested that the mortality rate of (3.02%) was significantly lower than that of non-restricted transfusion group (9.55%) (P = 0.000). Among the secondary outcomes, the restricted transfusion group had fewer hospital stays and hospital costs. The incidence of retinopathy of prematurity was lower in the restricted transfusion group (OR, 4.624; 95% confidence interval [CI], 2.32 to 9.216; P = 0.000).

CONCLUSIONS

Current transfusion protocols for newborns weighing less than 1500 g may be inappropriate and lead to higher mortality. The current transfusion threshold performed better for the other two weight groups.

Modifiable Risk Factors and Preventative Strategies for Severe Retinopathy of Prematurity

Severe ROP is characterized by the development of retinal fibrovascular proliferation that may progress to retinal detachment. The purpose of this report is to review five of the most common and well-studied perinatal and neonatal modifiable risk factors for the development of severe ROP. Hyperoxemia, hypoxia, and associated prolonged respiratory support are linked to the development of severe ROP. While there is a well-established association between clinical maternal chorioamnionitis and severe ROP, there is greater variability between histologic chorioamnionitis and severe ROP. Neonatal sepsis, including both bacterial and fungal subtypes, are independent predictors of severe ROP in preterm infants. Although there is limited evidence related to platelet transfusions, the risk of severe ROP increases with the number and volume of red blood cell transfusions. Poor postnatal weight gain within the first six weeks of life is also strongly tied to the development of severe ROP. We also discuss preventative strategies that may reduce the risk of severe ROP. Limited evidence-based studies exist regarding the protective effects of caffeine, human milk, and vitamins A and E.

Packed red blood cell transfusion in preterm infants

Premature infants commonly receive adult packed red blood cells (pRBCs) during their hospital stay. As adult erythrocytes differ substantially from those of preterm infants, transfusion of adult pRBCs into preterm infants can be considered inappropriate for the physiology of a preterm infant. An absence of standardisation of transfusion protocols makes it difficult to compare and interpret pertinent clinical data, as reflected by unclear associations between pRBC transfusion and complications related to prematurity, such as bronchopulmonary dysplasia, neurodevelopmental impairment, retinopathy of prematurity, or necrotising enterocolitis. The difficulty in interpreting clinical data is further increased by differences in study designs that either overestimate pRBC-associated complications of prematurity or have not yet been designed to directly link pRBC transfusions to their respective complications. Thus, neonatal transfusion practice has become an ongoing difficulty, in which differences in transfusion guidelines hinder the ability to generate comparable clinical data, and heterogeneity in clinical data prevents the implementation of standardised transfusion protocols. To overcome these issues, novel approaches with biochemical-clinical translational designs could enable clinicians to gather causal evidence instead of circumstantial correlation.

The Outcome of Blood Transfusions in Conservative and Surgical Necrotizing Enterocolitis and Spontaneous Intestinal Perforation

INTRODUCTION

 In necrotizing enterocolitis (NEC), blood transfusions (BTs) are a disputed factor concerning the etiology and the outcome. We assessed retrospectively the effects of preonset BT on the outcome of NEC and spontaneous intestinal perforation (SIP).

MATERIALS AND METHODS

 With ethical consent, we reviewed the hospital records of 113 neonates from 2002 to 2019 with surgical NEC (NECs) (n = 57), conservatively treated NEC (NECc) (n = 20), and SIP (n = 36). The onset was defined as the day of surgery (NECs and SIP) or diagnosis (NECc). The effects of preonset BT (total, beyond 48 hours, and within 48 hours) were compared with the effects of birth weight (BW), gestational age (GA), intracerebral hemorrhage, respiratory distress syndrome, septicemia, and patent ductus arteriosus. Main outcome measure was 2-week mortality, and secondary measures were small intestinal loss and days on parenteral nutrition (PN).

RESULTS

 Overall mortality (8.9%) was predicted independently by BT total and BT beyond 48 hours, risk ratio (RR) = 1.1 to 1.2 (95% confidence interval [CI] = 1.0-1.4), p = 0.01 to 0.02, and BW and GA, RR = 0.7 to 1.0 (95% CI = 0.5-1.0), p = 0.02 to 0.04. Mortality in NECs (12%) was predicted by BT total and BT beyond 48 hours only, RR = 1.1 to 1.2 (95% CI = 1.0-1.5), p = 0.03 to 0.04. BT within 48 hours of onset did not predict mortality. No factors were related with secondary outcome measures or with mortality in patients with SIP or NECc.

CONCLUSION

 In NECs, preoperative BT and BT given more than 48 hours before surgery were correlated with slightly increased 2-week mortality but not with small intestinal loss or duration of PN.

Risk factors for necrotizing enterocolitis in neonates: A meta-analysis

OBJECTIVE

The objective is to identify the risk factors for necrotizing enterocolitis (NEC) in neonates by a meta-analysis, and to provide a reference for the prevention of NEC.

METHODS

The databases, including Chinese Biomedical Literature Datebase, China National Knowledge Infrastructure, Wanfang database, and Weipu Periodical database, PubMed, Web of Science, Embase, Cochrane Library, were searched for studies on the risk factors for NEC in neonates. The meta-analysis was carried out with the aid of Stata software.

RESULTS

A total of 52 studies were included, with 48 case-control studies and 4 cohort studies. There were 166,580 neonates in total, with 33,522 neonates in the case group and 133,058 neonates in the control group. The meta-analysis showed that gestational diabetes (OR = 3.62, 95% CI:1.77-7.41), premature rupture of membranes (OR = 3.81, 95% CI:1.16-12.52), low birth weight (OR = 3.00, 95% CI:2.26-3.97), small for gestational age (OR = 1.85, 95% CI:1.15-2.97), septicemia (OR = 4.34, 95% CI:3.06-6.15), blood transfusion (OR = 3.08, 95% CI:2.16-4.38), congenital heart disease (OR = 2.73, 95% CI:1.10-6.78), respiratory distress syndrome (OR = 2.12, 95% CI:1.24-3.63), premature birth (OR = 5.63, 95% CI:2.91-10.92), pneumonia (OR = 4.07, 95% CI:2.84-5.82) were risk factors for NEC in neonates. Breastfeeding (OR = 0.37, 95% CI:0.23-0.59), take probiotics (OR = 0.30, 95% CI:0.22-0.40), prenatal use of glucocorticoids (OR = 0.39, 95% CI:0.30-0.50), Hyperbilirubinemia (OR = 0.28, 95% CI:0.09-0.86) were protective factors for NEC in neonates.

CONCLUSIONS

Gestational diabetes, premature rupture of membranes, low birth weight, small for gestational age, septicemia, blood transfusion, congenital heart disease, respiratory distress syndrome, premature birth, and pneumonia may increase the risk of NEC in neonates. Breastfeeding, taking probiotics, prenatal use of glucocorticoids, and Hyperbilirubinemia may reduce the risk of NEC in neonates.

Impact of early postnatal exposure of red blood cell transfusions on the severity of retinopathy of prematurity

BACKGROUND

Postnatal exposure to red blood cell transfusion (RBCT) in premature infants is an important risk factor for Retinopathy of Prematurity (ROP) progression. We hypothesized that higher number and earlier timing of RBCT are associated with worse ROP severity and result in laser treatment at an earlier postmenstrual age (PMA) in very low birth weight (≤1500 g, VLBW) infants.

METHODS

A retrospective medical record review of 631 VLBW infants over a 5-year period was performed. Demographic features and potential clinical risk factors including number of RBCT, ROP severity, and progression to laser treatment were collected to evaluate predictors of severe ROP. ANCOVA, pairwise post-hoc analyses, and multivariate regression were used to determine associations between frequency and timing of RBCT and ROP severity.

RESULTS

Of the 456 eligible infants, 61 developed severe ROP (13%). There was significant correlation between number of RBCTs and ROP severity, adjusted for gestational age and birthweight (Adjusted R2 = 0.53; p <  0.001). Compared to infants with No/Mild and Type 2 ROP, infants with Type 1 ROP received more RBCTs, with higher number of RBCTs per week during the first month of life (mean RBCT in ROP No/Mild 5.7±0.4 vs Type 2 16.3±1.8 vs Type 1 22.4±1.5, p = 0.042). Laser-treated infants received a higher number of RBCTs than non-treated infants (mean RBCT 22.3 vs. 6.5, p <  0.001) but no correlation was observed between number of RBCTs and PMA at time of laser treatment.

CONCLUSION

Higher number of RBCTs in early postnatal life of VLBW infants was associated with more severe ROP.

Transfusion-associated necrotizing enterocolitis (NEC) in extremely preterm infants: experience of a tertiary neonatal center in UK

OBJECTIVE

To compare the characteristics and short-term outcomes in extremely preterm infants, who developed necrotizing enterocolitis (NEC) following a packed red blood cell transfusion (pRBC) within 48 h (TANEC), with those who developed NEC beyond 48 h (non-TANEC).

SETTING

A single-center retrospective cohort study in a Tertiary neonatal intensive care unit in the UK over a 5-year period.

PATIENTS AND METHODS

Extremely premature infants (23-27 weeks gestation) were selected. TANEC and non-TANEC incidence were calculated from the confirmed NEC group (defined as modified Bell's stage II and beyond). The characteristics and short-term outcomes of infants with TANEC in the first 8 weeks of life were compared to infants with non-TANEC.

RESULTS AND INTERPRETATION

Incidence of confirmed NEC was 14% (28/207). On further subgroup analysis of the confirmed NEC cases, 46% (13/28) of infants were identified with TANEC and 54% (15/28) with non-TANEC. The incidence of TANEC did not correlate with the number of antecedent pRBC transfusions or the pre-transfusion median hemoglobin (Hb) levels. There were no significant differences in characteristics between the TANEC and non-TANEC groups. Infants within the TANEC group required more intensive neonatal care support, greater surgical intervention (p-value 0.043) with loss of gut integrity and an increase in number of TPN dependency days (p-value 0.014).

CONCLUSIONS

A significantly worse clinical course and short-term outcome was observed in the TANEC group when compared with the non-TANEC group.

Associations between Red Blood Cell and Platelet Transfusions and Retinopathy of Prematurity

AIM

The aim of this study is to examine possible associations between the transfusion of RBC or platelets (PLTs) and the development of retinopathy of prematurity (ROP) in infants.

METHODS

This retrospective, national, case-control study included all live births in Switzerland between 2013 and 2018. We investigated preterm infants at a gestational age of <28 weeks, who developed higher stage ROP (≥stage 2, n = 178). Each case infant was matched to another of the same sex who did not develop ROP (n = 178, control group).

RESULTS

When compared with the control group, we observed higher numbers of RBC transfusions per infant and higher percentages of infants receiving PLT transfusions in the case group. An adjusted logistic regression analysis revealed that both RBC (odds ratio [OR] 1.081, 95% confidence interval [CI] 1.020-1.146) and PLT transfusions (OR = 2.502, 95% CI 1.566-3.998) numbers were associated with ROP development.

CONCLUSIONS

Multiple RBC and PLT transfusions are associated with higher stage ROP development. Prospective studies are required to determine their potential as risk factors.

Blood Component Transfusion in Tertiary Care Neonatal Intensive Care Unit and Neonatal Intermediate Care Unit: An Audit

Background Neonates admitted in a tertiary neonatal intensive care unit (NICU) require multiple blood transfusions because of extended NICU stay and repeated sampling. The rookie organ systems and miniature blood volumes in the neonate call for regular audits in neonatal blood transfusion practice. Sharing component usage data with the blood bank will prepare them to store components according to demand, thus limiting wastage of components as well as make banks ready to face a shortage in case of ramped up requirements. Objective Auditing neonatal blood transfusion indications and identifying the most commonly used component. Methodology This retrospective cohort study was conducted by the department of pediatrics over 22 months from February 20, 2017, to December 30, 2018. Any preterm and term neonates admitted to the NICU and Neonatal Intermediate Care Unit (NIMC) and receiving any transfusion, i.e., fresh frozen plasma (FFP), red cell concentrate (RCC), platelets, and exchange transfusion were included in our study. We collected data from the medical records of NICU and NIMC admitted patients receiving blood component transfusions from 2011 to 2016. Patients were categorized according to the classification of neonatal conditions by the International Classification of Diseases 11th Revision (ICD-11). There were no exclusion criteria. A descriptive statistical analysis was done, and a Chi-square test was applied. Results Out of 340 neonates, 249 (73.2%) were low birth weight, 139 (40.9%) were small for gestational age (SGA), and 277 (81.5%) neonates required transfusion during the first week of life. The majority of neonates require multiple transfusions. Fourteen(4.12%) neonates required up to 10 transfusions, two neonates required up to 22 transfusions, and 58 neonates required more than five blood transfusions. The majority required transfusion due to neonatal sepsis, Disseminated intravascular coagulopathy, low birth weight, respiratory distress syndrome, and unconjugated hyperbilirubinemia. Thirty-seven point eighty-two percent (37.82%) transfusions were fresh frozen plasma, 31.34% transfusions were red cell concentrate, 28.14% transfusions were platelet concentrate, and 2.70% were whole blood. Out of 340 neonates, 317 survived and were discharged. Conclusion The most commonly transfused component was fresh frozen plasma, the indication was neonatal sepsis, and the group was preterm. Whole blood is still being used and needs to be stopped.

The emerging role of red blood cells in cytokine signalling and modulating immune cells

For many years red blood cells have been described as inert bystanders rather than participants in intercellular signalling, immune function, and inflammatory processes. However, studies are now reporting that red blood cells from healthy individuals regulate immune cell activity and maturation, and red blood cells from disease cohorts are dysfunctional. These cells have now been shown to bind more than 50 cytokines and have been described as a sink for these molecules, and the loss of this activity has been correlated with disease progression. In this review, we summarise what is currently understood about the role of red blood cells in cytokine signalling and in modulating the activity of immune cells. We also discuss the implications of these findings for transfusion medicine and in furthering our understanding of anaemia of chronic inflammation. By bringing these disparate units of work together, we aim to shine a light on an area that requires significantly more investigation.