Minimizing blood loss and the need for transfusions in very premature infants

The diagnostic value of salivary C-reactive protein in neonatal infections: a meta-analysis

PURPOSE

C-reactive protein (CRP), as an acute phase protein, is a sensitive indicator of neonatal bacterial infection. Some recent studies have shown that there is a correlation between CRP levels in serum and saliva, and using saliva to detect CRP levels is expected to be an ideal and non-invasive method to predict neonatal infection. The purpose of this Meta-analysis was to evaluate the diagnostic value of salivary CRP for neonatal infection.

METHODS

We searched PubMed, Embase, Web of Science, and Scopus databases in October 2023 and included observational studies that examined salivary CRP in newborns with bacterial infections. Data was extracted regarding the methodology, participant characteristics, and outcome measures.

RESULTS

Nine articles were included, with a total of 696 newborns. Salivary CRP levels are significantly higher in neonates with infections compared to non-infected group (SMD = 0.58, 95%CI [0.40-0.76], P < 0.001). The accuracy for salivary CRP to predict serum CRP abnormality is high (sensitivity 86%, specificity 88%, area under the curve = 0.94).

CONCLUSIONS

Our meta-analysis suggested that salivary CRP can be used as an alternative biomarker to serum CRP for detecting neonatal infection.

Transfusion strategies for neonates: current perspectives

Background

Blood transfusion intervention has been proven to be a crucial therapeutic aid for preterm infants with serious morbidities such as sepsis, intraventricular hemorrhage, and cardiopulmonary insufficiencies. However, blood transfusion practices have also been shown to cause significant adverse outcomes, which may negate the therapeutic effect of the intervention. To address the varying policies regarding the administration of blood products, healthcare professionals have adopted a consensus-based approach. The absence of a standard protocol has resulted in conflicting outcomes in previous clinical studies.

Objective

This study aimed to evaluate the effectiveness of blood transfusion practices in preterm infants by analyzing past clinical research and identifying the current trends that have emerged as a result of recent trials.

Results

Recent trials have demonstrated comparable trends in mortality rates and other primary outcomes, including retinopathy of prematurity, intraventricular hemorrhage, bronchopulmonary dysplasia, and brain injury, following transfusion of blood products in both groups. Nevertheless, employing restrictive thresholds rather than adopting a liberal approach can reduce these outcomes.

Conclusion

The current literature does not provide clear support for either technique as opposing and contradictory results are evident. However, there is a slight inclination toward the restrictive transfusion threshold due to recent trials, which warrants further in-depth investigation into this issue.

Hyperbilirubinemia screening and treatment in neonates born prior to 35 weeks of gestation

BACKGROUND

Guidelines on when to screen for neonatal hyperbilirubinemia apply to infants born at 35 weeks or later of gestation. It is unknown whether infants born earlier would benefit from similar guidelines. Our objective was to examine hyperbilirubinemia screening and phototherapy prescription among early preterm infants during the first 6 days of life.

METHODS

We reviewed the charts of 193 infants born prior to 35 weeks of gestation who were admitted to a tertiary care NICU in Southeastern Ontario in 2018-2019. Information on total serum bilirubin (TSB) measurements over each 12-hour interval during the first six days of life and the treatment decision (no treatment, initiate, continue, or stop phototherapy) was extracted. We also examined what proportion of infants were prescribed phototherapy during each 12-hour interval.

RESULTS

Of 1006 TSB measurements performed over the first 6 days of life, 605 were done to determine whether phototherapy should be initiated. Treatment was prescribed in 275 instances (45%). A higher proportion of infants born prior to 28 weeks of gestation required phototherapy in the first 12 hours of life (37%) compared to those born at 28-32 weeks (20%) and 33-34 weeks (5.7%).

CONCLUSIONS

Our results suggest that TSB measurements are often poorly timed to detect treatment need in infants born prior to 35 weeks of gestation. This unnecessarily increases the risk of complications from phlebotomy and is an ineffective use of health care resources. There is a need to develop guidelines to optimize hyperbilirubinemia screening among early preterm infants.

Examining the Utility of Rapid Salivary C-Reactive Protein as a Predictor for Neonatal Sepsis: An Analytical Cross-Sectional Pilot Study

This study aimed to compare the rapid bedside quantitative assessment of C-reactive protein (CRP) in saliva to serum CRP to predict blood culture-positive sepsis in neonates. The research was carried out over eight months at Fernandez Hospital in India (February 2021-September 2021). The study included 74 randomly selected neonates with clinical symptoms or risk factors of neonatal sepsis requiring blood culture evaluation. SpotSense rapid CRP test was conducted to estimate salivary CRP. In analysis, the area under the curve (AUC) on the receiver operating characteristics (ROC) curve was used. The study population's mean gestational age and median birth weight were 34.1 weeks (SD: ±4.8) and 2370 g (IQR: 1067-3182). The AUC on ROC curve analysis for predicting culture-positive sepsis was 0.72 (95% CI: 0.58 to 0.86, p-value: 0.002) for serum CRP and 0.83 (95% CI: 0.70 to 0.97, p-value: <0.0001) for salivary CRP. The Pearson correlation coefficient between salivary and serum CRP was moderate (r = 0.352, p-value: 0.002). Salivary CRP cut-off scores were comparable to serum CRP in terms of sensitivity, specificity, PPV, NPV, and accuracy in predicting culture-positive sepsis. The rapid bedside assessment of salivary CRP appears to be an easy and promising non-invasive tool in culture-positive sepsis prediction.

Carbon dioxide monitoring in the newborn infant

Carbon dioxide (CO₂ ) monitoring is vital during mechanical ventilation of newborn infants, as morbidity increases when CO₂ levels are inappropriate. Our aim was to review the uses and limitations of such noninvasive monitoring methods. Colorimetry is primarily utilized during resuscitation to determine whether successful intubation has occurred. False negative and positive results can however lead to delays in detecting tracheal versus esophageal intubation. Transcutaneous carbon dioxide sensors have limited use during resuscitation, but can be utilized to provide continuous trend data during on-going ventilation. End-tidal capnography can provide clinicians with quantitative end-tidal CO₂ (EtCO₂ ) values and a continuous real-time capnogram waveform trace. These devices are becoming more widely accepted for use in the neonatal population as the new devices are lightweight with minimal additional dead space. Nevertheless, they have been reported to have variable accuracy when compared to arterial CO₂ measurements, however, divergence of results may be related to disease severity rather than technological limitations. During resuscitation EtCO₂ can be detected by capnography more rapidly than by colorimetry. Furthermore, capnography can be currently utilized in neonatal research settings to determine the physiological dead space and ventilation inhomogeneity, and thus has potential to be beneficial to clinical care. In conclusion, novel modes of noninvasive carbon dioxide monitoring can be safely and reliably utilized in newborn infants during mechanical ventilation. Future randomized trials should aim to address which device provides the most optimal form of monitoring in different clinical contexts.

End-tidal capnography monitoring in infants ventilated on the neonatal intensive care unit

OBJECTIVE

To assess whether end-tidal capnography (EtCO2) monitoring reduced the magnitude of difference in carbon dioxide (CO2) levels and the number of blood gases in ventilated infants.

STUDY DESIGN

A case-control study of a prospective cohort (n = 36) with capnography monitoring and matched historical controls (n = 36).

RESULT

The infants had a median gestational age of 31.6 weeks. A reduction in the highest CO2 level on day 1 after birth was observed after the introduction of EtCO2 monitoring (p = 0.043). There was also a reduction in the magnitude of difference in CO2 levels on days 1 (p = 0.002) and 4 (p = 0.049) after birth. There was no significant difference in the number of blood gases.

CONCLUSION

Continuous end-tidal capnography monitoring in ventilated infants was associated with a reduction in the degree of the magnitude of difference in CO2 levels and highest level of CO2 on the first day after birth.

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

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.

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.

Neonatal red blood cell transfusion

Transfusions are more common in premature infants with approximately 40% of low birth weight infants and up to 90% of extremely low birth weight infants requiring red blood cell transfusion. Although red blood cell transfusion can be life-saving in these preterm infants, it has been associated with higher rates of complications including necrotizing enterocolitis, bronchopulmonary dysplasia, retinopathy of prematurity and possibly abnormal neurodevelopment. The main objective of this review is to assess current red blood cell transfusion practices in the neonatal intensive care unit, to summarize available neonatal transfusion guidelines published in different countries and to emphasize the wide variation in transfusion thresholds that exists for red blood cell transfusion. This review also addresses certain issues specific to red blood cell processing for the neonatal population including storage time, irradiation, cytomegalovirus (CMV) prevention strategies and patient blood management. Future research avenues are proposed to better define optimal transfusion practice in neonatal intensive care units.

Guidelines on Deferred Cord Clamping and Cord Milking: A Systematic Review

CONTEXT

Deferred cord clamping (DCC) saves lives. It reduces extremely preterm infants' mortality by 30%, yet a minority of eligible infants receive it. This may in part be due to lack of awareness or confidence in evidence, or conflicting or vague guidelines.

OBJECTIVE

To systematically review clinical practice guidelines and other statements on DCC and cord milking.

DATA SOURCES

Ten academic and guideline databases were searched.

STUDY SELECTION

Clinical practice guidelines and other statements (position statements and consensus statements) providing at least 1 recommendation on DCC or umbilical cord milking among preterm or term infants were included.

DATA EXTRACTION

Data from included statements were extracted by 2 independent reviewers, and discrepancies were resolved through consensus. Guideline quality was appraised with modified Appraisal of Guidelines for Research and Evaluation II and Appraisal of Guidelines for Research and Evaluation Recommendation Excellence tools.

RESULTS

Forty-four statements from 35 organizations were included. All endorsed DCC for uncompromised preterm infants, and 11 cautiously stated that cord milking may be considered when DCC is infeasible. Only half (49%) of the recommendations on the optimal duration of DCC were supported by high-quality evidence. Only 8% of statements cited a mortality benefit of DCC for preterm infants.

LIMITATIONS

Because systematic reviews of guidelines are relatively novel, there are few tools to inform study execution; however, we used the Appraisal of Guidelines for Research and Evaluation II and the Appraisal of Guidelines for Research and Evaluation Recommendation Excellence to assess quality and were methodologically informed by previous systematic reviews of guidelines.

CONCLUSIONS

Statements worldwide clearly encouraged DCC. Their implementability would benefit from noting the preterm mortality benefit of DCC and more granularity.

Iron Homeostasis Disruption and Oxidative Stress in Preterm Newborns

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.

Is placental blood a reliable source for the evaluation of neonatal hemostasis at birth?

BACKGROUND

Phlebotomy is among the main determinants of anemia of prematurity. Blood sparing policies endorsed umbilical cord blood (here called placental) as an alternative source for laboratory testing. Little is known on the suitability of placental blood to evaluate neonatal hemostasis of newborn infants. We aimed to compare the hemostatic profile of paired placental and infant venous blood, by means of prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen, antithrombin, protein C, thromboelastography (TEG) and thrombin generation assay (TGA).

STUDY DESIGN

This was an observational single-center study.

METHODS

We collected at birth venous citrated blood from both placental and infant venous source and performed PT, APTT, fibrinogen, antithrombin, protein C, TEG (reaction time-R; kinetics-K alpha angle-α, maximum amplitude-MA and lysis at 30 minutes-LY30), and TGA (endogenous thrombin potential-ETP).

RESULTS

We enrolled 60 neonates with a median gestational age (range) of 37 weeks (28⁺¹ -41) and birth-weight 2417 g (950-4170). Based on TEG and TGA, placental blood showed a procoagulant imbalance as indicated by lower median R (4.0 vs. 6.1 min; p < 0.001) and K (1.3 vs. 2.2 min; p < 0.001); higher α-angle (69.7 vs. 57.4°; p < 0.001) and ETP (1260 vs. 1078; p = 0.002) than those observed for infant venous blood. PT and APTT did not differ significantly between the two groups.

CONCLUSIONS

While placental and neonatal blood samples are equally suitable to measure the standard coagulation tests PT and APTT, placental blood leads to a procoagulant imbalance when testing is performed with TEG or TGA. These effects should be considered when interpreting results stemming from investigation of neonatal hemostasis.

Mortality and hospital readmissions in the first year of life after intra-uterine and neonatal blood product transfusions: A population data linkage study

AIM

Blood product transfusions are a potentially life-saving therapy for fetal and neonatal anaemia, but there is limited population-based research on outcomes. We aimed to describe mortality, readmission and average hospital stay in the first year of life for infants with or without intra-uterine or neonatal blood product transfusions.

METHODS

Linked birth, hospital and deaths data from New South Wales, Australia (January 2002-June 2014) were used to identify singleton infants (≥23 weeks' gestation, surviving to 29 days; n = 1 089 750) with intra-uterine or neonatal transfusion or no transfusion. Rates of mortality and readmission in the first year (29-365 days) and days in hospital were calculated.

RESULTS

Overall, 68 (0.06/1000) infants had experienced intra-uterine transfusion and 4332 (3.98/1000) neonatal transfusion. Transfusion was more common among those born at earlier gestational ages requiring invasive ventilation. Mortality, readmissions and average days in hospital were higher among transfused than non-transfused infants. Over half of infants with intra-uterine and neonatal transfusion had ≥1 readmission in the first 29-365 days (55.9 and 51.8%, respectively), and around a quarter had ≥2 (20.6 and 28.5%, respectively) compared with 15.3% with ≥1 and 3.5% with ≥2 in the non-transfused group.

CONCLUSION

Infants with a history of blood product transfusion, particularly those needing a neonatal transfusion, had higher mortality and more frequent contact with the hospital system in the first year of life than those infants with no history of transfusion.

Implementation of point-of-care testing in a pediatric healthcare setting

Point-of-care testing (POCT) refers to testing performed outside the clinical laboratory near the patient or at the site of patient care. This could be in critical care settings like the intensive care unit (ICU) and emergency department (ED) or primary care settings like physician offices where testing is performed by nonlaboratory personnel. POCT circumvents several steps in central laboratory testing including specimen transportation and processing resulting in faster turnaround times. Provider access to rapid test results at the site of patient care allows for prompt medical decision making which can lead to improved patient outcomes, operational efficiencies, patient satisfaction, and even cost savings in some cases. In addition to providing results rapidly, POCT devices have small specimen volume requirements compared to central laboratory tests making POCT particularly attractive for pediatric healthcare settings. The availability of published reports on the impact of POCT implementation in pediatric care are helpful resources when evaluating the clinical necessity of POCT prior to implementation. Even though several studies have shown advantages to implementing POCT in different pediatric settings, it is important to note that limitations exist that might limit the utilization of certain POCTs in some pediatric populations. So, it is important that these limitations and the analytical performance of a test are considered while keeping the target patient population in mind. Since POCTs are performed by non-laboratory staff who are not trained laboratory personnel, one challenge with POCT is maintaining regulatory compliance and quality assurance. It is therefore important that regulatory and quality assurance programs be put in place prior to implementing POCT in the pediatric hospital. With advances in POCT technology, most POCT devices have the capability to interface to the laboratory information system (LIS) and electronic medical record (EMR). POCT device interfacing allows for improved compliance to regulatory and quality assurance standards. Maintaining a cost efficient POCT program is becoming increasingly important as hospitals and healthcare systems are undergoing consolidation and harmonization. This includes assessing the clinical and operational benefit of POCT before implementation and inventory management to ensure minimal reagent wastage. This review discusses these different considerations when implementing POCT with a focus on the pediatric healthcare setting.

Epidemiology of Necrotizing Enterocolitis: New Considerations Regarding the Influence of Red Blood Cell Transfusions and Anemia

This article summarizes available evidence on the relationship between red blood cell transfusion and anemia, and necrotizing enterocolitis (NEC). We review recent studies that highlight the uncertainty of the effect of red blood cell transfusion on NEC and the potential role of anemia. We also discuss potential pathophysiologic effects of both red blood cell transfusion and anemia and highlight strategies to prevent anemia and red blood cell transfusion. We also discuss ongoing randomized trials that are likely to provide important new evidence to guide red blood cell transfusion practices.

Assessment of haemoglobin measurement by several methods - blood gas analyser, capillary and venous HemoCue® , non-invasive spectrophotometry and laboratory assay - in term and preterm infants

A laboratory haematology analyser is the gold standard for measuring haemoglobin concentration but has disadvantages, especially in neonates. This study compared alternative blood-sparing and non-invasive methods of haemoglobin concentration measurement with the gold standard. Haemoglobin concentrations were measured using a laboratory haematology analyser (reference method), blood gas analyser, HemoCue^® using venous and capillary blood samples and a newly developed non-invasive sensor for neonates < 3 kg. A total of 63 measurements were performed. Body weight (2190 (1820-2520 [967-4450]) g) and haemoglobin concentration (12.3 (10.6-15.2 [8.2-20.5]) g.dl^-1 ) varied widely. Bias/limits of agreement between the alternative methods and reference method were -0.1/-1.2 to 1.0 g.dl^-1 (blood gas analyser), -0.4/-1.8 to 1.1 g.dl^-1 (HemoCue, venous blood), 0.7/-1.9 to 3.2 g.dl^-1 (HemoCue, capillary blood) and -1.2/-4.3 to 2 g.dl^-1 (non-invasive haemoglobin measurement). Perfusion index, body weight and fetal haemoglobin concentration did not affect the accuracy of the alternative measurement methods, and these were successfully applied in term and preterm infants. However, the accuracies of non-invasive haemoglobin measurement and HemoCue of capillary blood especially lacked sufficient agreement with that of the reference method to recommend these methods for clinical decision making.