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Relationship of Early Anemia with Neurodevelopment and Brain Injury in Very Low Birth Weight Preterm Infants-A Prospective Cohort Study. Nutrients 2022; 14:nu14224931. [PMID: 36432616 PMCID: PMC9695480 DOI: 10.3390/nu14224931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/08/2022] [Accepted: 11/17/2022] [Indexed: 11/23/2022] Open
Abstract
Anemia is associated with neurodevelopmental delays and brain injury in infants and toddlers, but whether early anemia has a similar effect in neonatal preterm infants is largely unknown. Thus, this study aimed to determine the relationship of early anemia with neurodevelopment and brain injury in very-low-birth-weight (VLBW) preterm infants within the neonatal period. A prospective cohort study including 110 VLBW preterm infants was conducted in Southern China from 2016 to 2018. All participants were followed from birth to 1 month corrected age. Early anemia is defined as hemoglobin of ≤145 g/L within the first week after birth. The non-anemic group (control group, N = 55) was 1:1 matched with the early anemia group (N = 55) according to birth weight and gestational age. Neurodevelopment at 1 month corrected age and brain injury within 1 month corrected age were measured by neonatal behavioral neurological assessments (NBNA) and cranial ultrasound, respectively. Compared to the control group, the early anemia group had a lower score in behavioral ability in the NBNA test [11 (10-12) vs. 10 (9.5-11), p = 0.033]. Early anemia was negatively associated with the NBNA total score (β= -0.680, 95% CI: -1.300, -0.059), especially with the behavioral ability score (β= -0.504, 95% CI: -0.941, -0.067) after adjusting for the confounders. However, no association between early anemia and brain injury was observed. In conclusion, in VLBW preterm infants, early anemia is negatively correlated with neurodevelopment, especially with behavioral ability.
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Transfusions and neurodevelopmental outcomes in extremely low gestation neonates enrolled in the PENUT Trial: a randomized clinical trial. Pediatr Res 2021; 90:109-116. [PMID: 33432157 PMCID: PMC7797706 DOI: 10.1038/s41390-020-01273-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/19/2020] [Accepted: 10/02/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Outcomes of extremely low gestational age neonates (ELGANs) may be adversely impacted by packed red blood cell (pRBC) transfusions. We investigated the impact of transfusions on neurodevelopmental outcome in the Preterm Erythropoietin (Epo) Neuroprotection (PENUT) Trial population. METHODS This is a post hoc analysis of 936 infants 24-0/6 to 27-6/7 weeks' gestation enrolled in the PENUT Trial. Epo 1000 U/kg or placebo was given every 48 h × 6 doses, followed by 400 U/kg or sham injections 3 times a week through 32 weeks postmenstrual age. Six hundred and twenty-eight (315 placebo, 313 Epo) survived and were assessed at 2 years of age. We evaluated associations between BSID-III scores and the number and volume of pRBC transfusions. RESULTS Each transfusion was associated with a decrease in mean cognitive score of 0.96 (95% CI of [-1.34, -0.57]), a decrease in mean motor score of 1.51 (-1.91, -1.12), and a decrease in mean language score of 1.10 (-1.54, -0.66). Significant negative associations between BSID-III score and transfusion volume and donor exposure were observed in the placebo group but not in the Epo group. CONCLUSIONS Transfusions in ELGANs were associated with worse outcomes. We speculate that strategies to minimize the need for transfusions may improve outcomes. IMPACT Transfusion number, volume, and donor exposure in the neonatal period are associated with worse neurodevelopmental (ND) outcome at 2 years of age, as assessed by the Bayley Infant Scales of Development, Third Edition (BSID-III). The impact of neonatal packed red blood cell transfusions on the neurodevelopmental outcome of preterm infants is unknown. We speculate that strategies to minimize the need for transfusions may improve neurodevelopmental outcomes.
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Jani P, Lowe K, Hinder M, Galea C, D'Çruz D, Badawi N, Tracy M. Liberal hemoglobin threshold affects cerebral arterial pulsed Doppler and cardiac output, not cerebral tissue oxygenation: a prospective cohort study in anemic preterm infants. Transfusion 2019; 59:3093-3101. [DOI: 10.1111/trf.15452] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 06/15/2019] [Accepted: 06/22/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Pranav Jani
- Westmead Hospital, Department of Neonatology Westmead New South Wales Australia
- The University of Sydney Sydney New South Wales Australia
| | - Krista Lowe
- Westmead Hospital, Department of Neonatology Westmead New South Wales Australia
| | - Murray Hinder
- Westmead Hospital, Department of Neonatology Westmead New South Wales Australia
- The University of Sydney Sydney New South Wales Australia
| | - Claire Galea
- The Children's Hospital at Westmead, Grace Centre for Newborn Care Westmead New South Wales Australia
- The University of Sydney Sydney New South Wales Australia
- Cerebral Palsy Alliance Research Institute Sydney New South Wales Australia
| | - Daphne D'Çruz
- Westmead Hospital, Department of Neonatology Westmead New South Wales Australia
| | - Nadia Badawi
- The Children's Hospital at Westmead, Grace Centre for Newborn Care Westmead New South Wales Australia
- The University of Sydney Sydney New South Wales Australia
- Cerebral Palsy Alliance Research Institute Sydney New South Wales Australia
| | - Mark Tracy
- Westmead Hospital, Department of Neonatology Westmead New South Wales Australia
- The University of Sydney Sydney New South Wales Australia
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Kratimenos P, Christidis P, Kehinde F, Koutroulis I, Santana S, Mossabeb R, Fleishman R. Association between hemoglobin concentrations at discharge from the neonatal intensive care unit with markers of neurodevelopmental outcomes in premature neonates. J Neonatal Perinatal Med 2019; 12:221-230. [PMID: 30829622 DOI: 10.3233/npm-1822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Premature neonates are often subjected to multiple transfusions with red blood cells during their hospitalization in the neonatal intensive care unit (NICU). The hemoglobin threshold for transfusion prior to discharge from the NICU varies significantly among different centers. The aim of the present study is to investigate the association between hemoglobin concentration at discharge with neurodevelopmental outcomes in premature neonates. METHODS Retrospective observation study with regression analysis was performed with follow up assessment in the neuro-developmental outpatient clinic at 30 months of adjusted age. RESULTS Data from 357 neonates born at less than 37 weeks' gestation were analyzed. Sensory and motor neurodevelopment at 30 months of adjusted age, were not associated with the hemoglobin concentration at discharge (p=0.5891 and p=0.4575, respectively). There was no association between the hemoglobin concentration at discharge with fine or gross motor development (p=0.1582 and p=0.3805, respectively). Hemoglobin concentration at discharge was not associated with poor neurodevelopmental outcomes up until 30 months of adjusted age. CONCLUSIONS The data of the present study indicate that the hemoglobin concentration of premature neonates at the time of discharge is not associated with poorer markers of neurodevelopmental outcomes at 30 months of adjusted age. Comorbidities such as BPD and IVH that are present to premature neonates were identified as potential risk factors for certain aspects of the neurodevelopment.
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Affiliation(s)
- Panagiotis Kratimenos
- Drexel University College of Medicine, St. Christopher's Hospital for Children and Temple University Hospital, Philadelphia, PA, USA.,Department of Pediatrics, Division of Neonatology, Children's National Medical Center, George Washington University, School of Medicine and Health Sciences, Washington, DC, USA
| | | | - Folasade Kehinde
- Drexel University College of Medicine, St. Christopher's Hospital for Children and Temple University Hospital, Philadelphia, PA, USA
| | - Ioannis Koutroulis
- Department of Pediatrics, Division of Emergency Medicine, Children's National Medical Center, George Washington University, School of Medicine and Health Sciences, Washington, DC, USA
| | - Stephanie Santana
- Nemours/AI DuPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University, Wilmington, DE, USA
| | - Roschanak Mossabeb
- Drexel University College of Medicine, St. Christopher's Hospital for Children and Temple University Hospital, Philadelphia, PA, USA
| | - Rachel Fleishman
- Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
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Keir AK, New H, Robitaille N, Crighton GL, Wood EM, Stanworth SJ. Approaches to understanding and interpreting the risks of red blood cell transfusion in neonates. Transfus Med 2019; 29:231-238. [DOI: 10.1111/tme.12575] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 12/12/2018] [Accepted: 12/13/2018] [Indexed: 02/01/2023]
Affiliation(s)
- A. K. Keir
- Healthy Mothers, Babies and ChildrenThe South Australian Medical and Research Institute North Adelaide South Australia Australia
- Robinson Research Institute and the Adelaide Medical SchoolThe University of Adelaide Adelaide South Australia Australia
| | - H. New
- NHS Blood and Transplant London UK
- Imperial College London London UK
| | - N. Robitaille
- Division of Hematology–Oncology, Department of PediatricsCHU Sainte‐Justine Montréal Quebec Canada
| | - G. L. Crighton
- Department of HaematologyRoyal Children's Hospital Melbourne Victoria Australia
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive MedicineMonash University Melbourne Victoria Australia
| | - E. M. Wood
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive MedicineMonash University Melbourne Victoria Australia
| | - S. J. Stanworth
- NHS Blood and Transplant and Department of HaematologyOxford University Hospitals NHS Foundation Trust Oxford UK
- Radcliffe Department of MedicineUniversity of Oxford Oxford UK
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El-Dib M, Soul JS. Monitoring and management of brain hemodynamics and oxygenation. HANDBOOK OF CLINICAL NEUROLOGY 2019; 162:295-314. [PMID: 31324316 DOI: 10.1016/b978-0-444-64029-1.00014-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
While cardiorespiratory monitoring is standard for newborns in the NICU, monitoring of brain hemodynamics and oxygenation is usually sporadic and targeted to newborns with suspected or confirmed neurologic disorders. This is unfortunate, since critically ill newborns, both preterm and term-born, are at high risk of brain injury and would benefit from improved techniques for continuous monitoring of brain hemodynamics and oxygenation, in addition to monitoring of systemic hemodynamics and oxygenation. Near-infrared spectroscopy (NIRS) and, to a lesser extent, Doppler ultrasound are techniques that have been used in research and increasingly for clinical purposes to measure and monitor brain hemodynamics and oxygenation in newborns. NIRS monitoring can be useful for detection of diverse pathologic conditions that occur frequently in very preterm newborns and in selected populations of term newborns at risk for brain injury related to disturbances of systemic hemodynamics. This chapter reviews the current state of the art with regard to brain-monitoring techniques and the research directed at this important area, and it concludes with suggestions for the use of currently available tools to manage newborns at high risk of neurologic injury from disturbances in brain hemodynamics and oxygenation.
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Affiliation(s)
- Mohamed El-Dib
- Neonatal Neurocritical Care, Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Janet S Soul
- Fetal-Neonatal Neurology Program, Department of Neurology, Boston Children's Hospital, Boston, MA, United States; Department of Neurology, Harvard Medical School, Boston, MA, United States.
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Abstract
PURPOSE OF REVIEW Managing the bleeding pediatric patient perioperatively can be extremely challenging. The primary goals include avoiding hypotension, maintaining adequate tissue perfusion and oxygenation, and maintaining hemostasis. Traditional bleeding management has consisted of transfusion of autologous blood products, however, there is strong evidence that transfusion-related side-effects are associated with increased morbidity and mortality in children. Especially concerning is the increased reported incidence of noninfectious adverse events such as transfusion-related acute lung injury, transfusion-related circulatory overload and transfusion-related immunomodulation. The current approach in perioperative bleeding management of the pediatric patient should focus on the diagnosis and treatment of anemia and coagulopathy with the transfusion of blood products only when clinically indicated and guided by goal-directed strategies. RECENT FINDINGS Current guidelines recommend that a comprehensive multimodal patient blood management strategy is critical in optimizing patient care, avoiding unnecessary transfusion of blood and blood product and limiting transfusion-related side-effects. SUMMARY This article will highlight current guidelines in perioperative bleeding management for our most vulnerable pediatric patients with emphasis on individualized targeted intervention using point-of-care testing and specific coagulation products.
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Clarke-Pounder J, Howlett J, Burnsed J, Donohue PK, Gilmore MM, Aucott SW. Withholding feeding during transfusion: Standardization of practice and nutritional outcomes in premature infants. J Neonatal Perinatal Med 2016; 8:199-205. [PMID: 26485552 DOI: 10.3233/npm-15814113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate the nutritional impact of a feed-holding guideline during transfusion for infants <32 weeks gestation. STUDY DESIGN A pre-/post-interventional study was conducted after introduction of a guideline to hold feeds during transfusion. Demographic variables in addition to nutritional outcomes were collected on all infants admitted within 48 hours of birth with gestational age <32 weeks. Data was collected during a 6 month period pre-intervention and the 6 month period post-intervention. RESULTS There were 145 eligible infants. Mean birth weight and gestational age were similar in both periods. In total, 98 infants received transfusions, and 82 of those had an active feeding order prior to at least one transfusion. Total transfusions per infant and transfusions ordered while an infant had active feeding orders were similar in both periods. Time to full feedings was decreased post-intervention (p < 0.001). Weight at 34 weeks, incidence of second IV placement, additional IV fluid use, and hypoglycemia were similar between groups.Of 593 total transfusions, 207 were ordered while an infant had an active order for enteral nutrition. Pre-intervention, 64% of transfusions had feeds held during transfusion. Post-intervention, 87% of transfusions had feeds held during transfusion. Feeds were held more often (p < 0.001) and for a shorter duration (p = 0.005) in the post-intervention group. CONCLUSION Implementing a guideline standardizing feeding practices during transfusions in premature infants increases standardization of care and results in decreased variability in practice. Adverse nutritional consequences were not found after the introduction of the routine practice of holding feedings during transfusion in preterm infants.
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Affiliation(s)
- J Clarke-Pounder
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - J Howlett
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - J Burnsed
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - P K Donohue
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - M M Gilmore
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - S W Aucott
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Nickel RS, Josephson CD. Neonatal Transfusion Medicine: Five Major Unanswered Research Questions for the Twenty-First Century. Clin Perinatol 2015; 42:499-513. [PMID: 26250913 DOI: 10.1016/j.clp.2015.04.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Blood component transfusions are important to the care of preterm neonates; however, their use in clinical practice often is not based on high levels of evidence. Five major questions for neonates are discussed: (1) What is the optimal red blood cell (RBC) transfusion threshold? (2) What is the optimal platelet transfusion threshold? (3) Does the storage age of an RBC unit affect outcomes? (4) Does RBC transfusion contribute to the pathogenesis of necrotizing enterocolitis? and (5) Which new practices should be used to prevent transfusion-transmitted infections? Although definitive answers to these questions do not exist, future research should help answer them.
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Affiliation(s)
- Robert Sheppard Nickel
- Department of Pediatrics, Children's National Health System, The George Washington University School of Medicine and Health Sciences, 111 Michigan Avenue North West, Washington, DC 20010, USA
| | - Cassandra D Josephson
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Children's Healthcare of Atlanta, Emory University, 1405 Clifton Road North East, Atlanta, GA 30322, USA.
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McCoy TE, Conrad AL, Richman LC, Brumbaugh JE, Magnotta VA, Bell EF, Nopoulos PC. The relationship between brain structure and cognition in transfused preterm children at school age. Dev Neuropsychol 2014; 39:226-32. [PMID: 24742312 DOI: 10.1080/87565641.2013.874428] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Examine the relationship between brain structure and cognition in preterm children randomly assigned to a liberal red blood cell (RBC) transfusion strategy as neonates. Intelligence, achievement, and neuropsychological measures were assessed and structural imaging was obtained (n = 26; 38% male). Global brain volumes were related to cognitive outcome. Additionally, females performed lower on verbal fluency; lower performance was related to temporal white matter volume. Findings provide possible evidence of the adverse effect of a liberal RBC transfusion strategy in which females had decreased temporal lobe white matter directly related to poor verbal fluency.
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Affiliation(s)
- Thomasin E McCoy
- a Hope Springs Behavioral Consultants, PLC (Private Practice) , Coralville , Iowa
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Abstract
Red blood cell transfusion is an important and frequent component of neonatal intensive care. The present position statement addresses the methods and indications for red blood cell transfusion of the newborn, based on a review of the current literature. The most frequent indications for blood transfusion in the newborn are the acute treatment of perinatal hemorrhagic shock and the recurrent correction of anemia of prematurity. Perinatal hemorrhagic shock requires immediate treatment with large quantities of red blood cells; the effects of massive transfusion on other blood components must be considered. Some guidelines are now available from clinical trials investigating transfusion in anemia of prematurity; however, considerable uncertainty remains. There is weak evidence that cognitive impairment may be more severe at follow-up in extremely low birth weight infants transfused at lower hemoglobin thresholds; therefore, these thresholds should be maintained by transfusion therapy. Although the risks of transfusion have declined considerably in recent years, they can be minimized further by carefully restricting neonatal blood sampling.
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Whyte RK, Jefferies AL. Les transfusions de culot globulaire aux nouveau-nés. Paediatr Child Health 2014. [DOI: 10.1093/pch/19.4.218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Lindenburg ITM, van Klink JM, Smits-Wintjens VEHJ, van Kamp IL, Oepkes D, Lopriore E. Long-term neurodevelopmental and cardiovascular outcome after intrauterine transfusions for fetal anaemia: a review. Prenat Diagn 2013; 33:815-22. [DOI: 10.1002/pd.4152] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Revised: 03/31/2013] [Accepted: 05/01/2013] [Indexed: 11/08/2022]
Affiliation(s)
| | - Jeanine M. van Klink
- Division of Neonatology, Department of Pediatrics; Leiden University Medical Center; Leiden The Netherlands
| | | | - Inge L. van Kamp
- Department of Obstetrics; Leiden University Medical Center; Leiden The Netherlands
| | - Dick Oepkes
- Department of Obstetrics; Leiden University Medical Center; Leiden The Netherlands
| | - Enrico Lopriore
- Division of Neonatology, Department of Pediatrics; Leiden University Medical Center; Leiden The Netherlands
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