Late-onset neutropenia in very low birth weight infants

The European Guidelines on Diagnosis and Management of Neutropenia in Adults and Children: A Consensus Between the European Hematology Association and the EuNet-INNOCHRON COST Action

Neutropenia, as an isolated blood cell deficiency, is a feature of a wide spectrum of acquired or congenital, benign or premalignant disorders with a predisposition to develop myelodysplastic neoplasms/acute myeloid leukemia that may arise at any age. In recent years, advances in diagnostic methodologies, particularly in the field of genomics, have revealed novel genes and mechanisms responsible for etiology and disease evolution and opened new perspectives for tailored treatment. Despite the research and diagnostic advances in the field, real world evidence, arising from international neutropenia patient registries and scientific networks, has shown that the diagnosis and management of neutropenic patients is mostly based on the physicians' experience and local practices. Therefore, experts participating in the European Network for the Innovative Diagnosis and Treatment of Chronic Neutropenias have collaborated under the auspices of the European Hematology Association to produce recommendations for the diagnosis and management of patients across the whole spectrum of chronic neutropenias. In the present article, we describe evidence- and consensus-based guidelines for the definition and classification, diagnosis, and follow-up of patients with chronic neutropenias including special entities such as pregnancy and the neonatal period. We particularly emphasize the importance of combining the clinical findings with classical and novel laboratory testing, and advanced germline and/or somatic mutational analyses, for the characterization, risk stratification, and monitoring of the entire spectrum of neutropenia patients. We believe that the wide clinical use of these practical recommendations will be particularly beneficial for patients, families, and treating physicians.

Characterization of Neutropenia in Preterm Neonates Following Administration of Darbepoetin Alfa

OBJECTIVE

This study is to evaluate the effects of darbepoetin alfa (darbe) on neutrophil count in preterm neonates treated for anemia of prematurity.

METHODS

This was a retrospective chart review comparing the absolute neutrophil counts (ANCs) of neonates administered 2 doses of subcutaneous darbe 10 mcg/kg to that of a randomly selected comparator group of neonates not administered the drug. Neonates <34 weeks gestational age, gestational age between 23w1d and 33w4d, born between July 2016 and June 2019, were included in the study.

RESULTS

The ANCs of 45 darbe-treated neonates compared with those of 45 randomly selected comparator control neonates revealed no difference in the rate of occurrence of neutropenia (ANC ≤1000/μL) between the darbe-treated neonates (26.7%) and comparator neonates (24.4%) (p > 0.99). There was also no difference in the rate of occurrence of severe neutropenia (ANC ≤500/μL) between the darbe-treated neonates (11.1%) and comparator neonates (6.7%) (p = 0.70). Darbepoetin alfa did not lead to differences in rates of resolution of neutropenia or severe neutropenia.

CONCLUSIONS

Short-term administration of darbe did not affect the ANCs of preterm neonates treated for anemia of prematurity. There was no difference in the rates of occurrence of neutropenia, severe neutropenia, or resolution of either between the darbe-treated neonates and comparator neonates.

Clinical and Laboratory Findings of Nosocomial Sepsis in Extremely Low Birth Weight Infants According to Causative Organisms

BACKGROUND

nosocomial sepsis remains a significant source of morbidity and mortality in extremely low birth weight (ELBW) infants. Early and accurate diagnosis is very important, but it is difficult due to the similarities in clinical manifestation between the causative microorganisms. We tried to identify the differences between causative microorganisms in clinical and laboratory findings and to help choose antibiotics, when sepsis was suspected in ELBW infants.

METHODS

a retrospective study was conducted on preterm infants, born at less than 28 weeks of gestation, with a birth weight of less than 1000 g between January 2009 and December 2019. Clinical and laboratory findings of suspected sepsis, after the first 72 h of life, were assessed. We classified them into four groups according to blood culture results (gram positive, gram negative, fungal, and negative culture groups) and compared them.

RESULTS

a total of 158 patients were included after using the exclusion criteria, with 45 (29%) in the gram positive group, 35 (22%) in the gram negative group, 27 (17%) in the fungal group, and 51 (32%) in the negative culture group. There were no significant differences in mean gestational age, birth weight, and neonatal morbidities, except for the age of onset, which was earlier in the fungal group than other groups. White blood cell (WBC) counts were the highest in the gram negative group and the lowest in the fungal group. The mean platelet counts were the lowest in the fungal group. C-reactive protein (CRP) levels were the highest in the gram negative group, while glucose was the highest in the fungal group.

CONCLUSIONS

in conclusion, we showed that there are some differences in laboratory findings, according to causative microorganisms in the nosocomial sepsis of ELBW infants. Increased WBC and CRP were associated with gram negative infection, while decreased platelet and glucose level were associated with fungal infection. These data may be helpful for choosing empirical antibiotics when sepsis is suspected.

Fecal HBD-2 and Claudin-3 may be potential biomarkers to predict the deterioration of necrotizing enterocolitis: A prospective study

BACKGROUND AND PURPOSE

Necrotizing enterocolitis (NEC) is a critical gastrointestinal disease. We aim to explore the value of fecal human β-defensin 2 (HBD-2), Claudin-3, high-mobility group box-1 protein (HMGB-1), and resistin-like molecule β (Relmβ) as well as some laboratory metrics to predict the deterioration of NEC.

METHODS

Infants diagnosed with NEC at Stage II were enrolled in our study. Those who progressed to Stage III were included in the Stage III group and the rest were included in the Stage II group. Clinical data and laboratory metrics of the infants were collected. Fecal samples of HBD2, HMGB-1, Claudin-3, and Relmβ collected during their enrollment were determined by using enzyme-linked immunosorbent assay (ELISA) kits. Student's t-test, the Mann-Whitney U test, the chi-square test, receiver operating characteristic (ROC), and logistic regression analysis were performed.

RESULTS

Sixty infants diagnosed with NEC at Stage II were enrolled in our study, with 27 in the Stage III group (n = 27) and 33 in the Stage II group (n = 33). Although many of these NEC cases were late preterm and term infants, the infants in the Stage III group had a lower gestational age (P < 0.05). The incidence of gestational diabetes mellitus, peritonitis, intestinal adhesion, and sepsis was higher and more infants in the Stage III group underwent surgeries (P < 0.05). The levels of HBD-2 and Claudin-3 were higher and neutrophil count was lower in the Stage III group than in the Stage II Group, and the area under the curve (AUC) was 0.754, 0,755, and 0.666, respectively (P < 0.05). HBD-2 ≥ 1649.02 ng/g and Claudin-3 ≥ 2488.71 pg/g were included in the multivariate stepwise logistic regression analysis (P < 0.05), and the AUC of the model was 0.805 (95% CI: 0.688-0.922).

CONCLUSION

Fecal HBD-2 and Claudin-3 may be potential biomarkers to predict the deterioration of NEC from Stage II to Stage III.

[Risk factors for neutropenia of late newborns]

OBJECTIVE

To study the risk factors and treatment for neutropenia of late newborns (NLN).

METHODS

Related clinical data were collected from the preterm infants and critically ill neonates who were admitted to the neonatal intensive care unit from July 2019 to January 2020. A total of 46 newborns with a blood absolute neutrophil count (ANC) of < 1.5×10⁹/L for two consecutive times at weeks 2-4 after birth were enrolled as the NLN group. A total of 92 late newborns with a blood ANC of ≥ 1.5×10⁹/L, matched at a ratio of 1:2, were enrolled as the control group. Possible risk factors associated with NLN and the treatment process were recorded. A logistic regression analysis was performed to identify the risk factors for NLN.

RESULTS

Among the 46 neonates in the NLN group, 29 had a gestational age of < 32 weeks, 14 had a gestational age of 32-37 weeks, and 3 had a gestational age of > 37 weeks. There was no significant difference between the two groups in the incidence rates of gestational hypertension, premature rupture of membranes > 18 hours and intrauterine distress, 5-minute Apgar score, the duration of positive pressure ventilation, the incidence rate of early-onset sepsis, and the type of initially used antibiotics (P > 0.05). Compared with the control group, the NLN group had a higher incidence rate of late-onset sepsis and a longer duration of antibiotic use (P < 0.05). Late-onset sepsis and prolonged duration of antibiotic use were independent risk factors for NLN (P < 0.05). With the presence of late-onset sepsis, the risk of NLN was increased by 1.537 times in neonates, and the risk of NLN was increased by 76.9% for every 3-day increase in the duration of antibiotic use. The mean age at the diagnosis of NLN was (21±6) days for the 46 neonates in the NLN group. Thirteen neonates with NLN were administered with recombinant human granulocyte colony-stimulating factor (G-CSF, 10 μg/kg) once or twice. O the 13 neonates, 6 had an ANC of < 0.5×10⁹/L and 7 had a gestational age of < 32 weeks or severe disease conditions. After treatment the ANC returned to > 1.0×10⁹/L in the 13 neonates. No drug-related adverse reactions were found. After the diagnosis of NLN, 2 neonates developed sepsis, and the remaining 44 neonates did not develop any common purulent infections.

CONCLUSIONS

The risk of NLN increases with the presence of late-onset sepsis and the increase in the duration of antibiotic use. NLN is generally a benign process. G-CSF appears to be safe and effective for NLN with severe disease conditions or severe reduction in ANC.

Effects of milk feeding strategies on short- and long-term productivity of Holstein heifers

Research investigating the effects of feeding raw or pasteurized nonsaleable milk (NSM) on heifers' performance beyond the period of supplementation is limited. This study aimed to examine the effects of type of milk [NSM or milk replacer (MR)] and pasteurization of NSM on preweaning and first-lactation performance of heifers born with low (<36.3 kg) or normal birth weight (≥36.3 kg). Holstein heifers (n = 154) were sequentially assigned to 1 of 3 treatments: MR, pasteurized NSM, or raw NSM. Heifers assigned to raw NSM were fed raw colostrum, whereas heifers assigned to MR and pasteurized NSM were fed pasteurized colostrum. The low birth weight heifers were fed 1.4 L at each feeding until they reached 36.3 kg body weight, whereas normal birth weight heifers were fed 1.9 L at each feeding. A grain mix starter was offered throughout the study. Heifers were weaned ≥42 d old if consuming at least 0.9 kg/d of starter for 3 consecutive days. Data were analyzed with the MIXED procedure of SAS (SAS Institute Inc., Cary, NC), and the basic model included milk treatments, birth weight group, and treatment × birth weight group. The low birth weight heifers fed raw colostrum and NSM versus pasteurized colostrum and NSM had lower serum protein concentrations. Heifers fed MR versus NSM had or tended to have greater concentrations of hematocrit, red blood cells, and eosinophils but lesser concentrations of platelets, although some of those responses were temporary. Pasteurization tended to increase blood lymphocyte concentrations. Heifers with normal birth weight had greater concentrations of blood neutrophils, lymphocytes, and monocytes, compared with low birth weight heifers. For the first 42 d of life, low birth weight heifers fed pasteurized versus raw NSM had greater weight gain, grain intake, and feed efficiency and were weaned earlier (hazard ratio for weaning by 56 d: 2.90). These pasteurization effects for low birth weight heifers tended to be sustained through 24 wk of age, indicated by greater weight gain and hip height growth. In their first lactation, low birth weight heifers produced less mature-equivalent (MEq) protein and tended to produce less MEq milk and fat than normal birth weight heifers. However, the negative effects of low birth weight on MEq milk and fat yield was only evident in heifers fed raw NSM, whereas the performance of low birth weight heifers was similar to that of normal birth weight when fed MR or pasteurized NSM. These findings confirm that calf management practices influence future performance; in this case, failing to pasteurize milk and colostrum for low birth weight heifers had effects that remained apparent for more than 2 years.

Role of Early Onset Neutropenia in Development of Candidemia in Premature Infants

BACKGROUND

The aim of the study was to assess the effect of early-onset neutropenia (EON) on the development of candidemia in premature infants and evaluate other risk factors.

MATERIALS AND METHODS

This prospective study was carried out in a neonatal intensive care unit of Cairo University Hospital. Fifty neutropenic premature infants were matched to 50 non-neutropenics. Subjects were then regrouped into candidemics and non-candidemics to study other risk factors such as central venous catheters, mechanical ventilation, parenteral nutrition, drugs as corticosteroids and others. Candidemia was assessed by Bactec and then seminested polymerase chain reaction for culture negatives.

RESULTS

Candidemia developed in 28 neutropenic preterms and in 8 non-neutropenics (odds ratio  = 6.68, 95% confidence interval = 2.61-17.1, p <0.001). Risk factors for invasive fungal infection in univariate analysis included bacterial septicemia, mechanical ventilation, parenteral nutrition and steroid therapy. Independent predictors of candidemia in multivariate regression analysis included EON, mechanical ventilation and steroid therapy.

CONCLUSION

EON is an independent risk factor for candidemia in premature infants.

Is umbilical cord milking always an advantage?

OBJECTIVE

The role of cord milking as an alternative to delayed cord clamping is an area that requires more research. Purpose of this clinical trial was to investigate the impact of umbilical cord milking on the absolute neutrophil counts (ANCs) and the neutropenia frequency of preterm infants.

METHODS

Fifty-eight pregnant women were randomly assigned to one of the umbilical cord milking and control groups. A total of 54 preterm infants (gestational age ≤ 32 weeks) were enrolled into the study. The umbilical cords of 25 infants were clamped immediately after birth, and in 29 infants, umbilical cord milking was performed first.

RESULTS

The ANCs were statistically significantly lower in the cord milking group compared with the control group on days 1, 3 and 7. The frequency of neutropenia was higher in the cord milking group compared with the control group.

CONCLUSION

In our study, ANCs were lower in the cord milking group and the frequency of neutropenia was higher. Umbilical cord milking plays a role on the ANCs of preterm infants.

Influences of the microbiome on the early origins of allergic asthma

During and immediately after birth, neonates are exposed to an environment laden with bacteria, a stark contrast to the sterile environment of the womb. Over the ensuing weeks and months, environmental microbial communities colonize their new host, and subsequent host-microbial cross-talk provides key developmental signals for the host's immune system. Emerging data from epidemiological and cellular research studies suggest that the nature of this cross-talk might be an underlying factor for the development, maintenance, and exacerbation of chronic lung diseases, such as asthma and chronic obstructive pulmonary disease. This review describes recent findings concerning the bacterial microbiota in the airways and places these data within the context of epidemiological and experimental studies that allude to the functional significance of host-microbial cross-talk in pulmonary inflammation.

Late-onset neutropenia: defining limits of neutrophil count in very low birth weight infants

OBJECTIVE

To evaluate the incidence, onset, duration, characteristics and importance of late-onset neutropenia (defined as absolute neutrophil count<1500 μl(-1) at 3 weeks of age or later) in a group of very low birth weight (VLBW) infants.

STUDY DESIGN

Routine complete blood cell counts (CBCs) obtained from VLBW infants over a period of 7 years were gathered retrospectively, including those of newborns with weekly CBCs taken over a duration of at least 3 weeks. Data were obtained from between January 2003 and December 2009.

RESULT

CBCs of 399 newborns were included. Values were obtained from birth to 36 weeks of postnatal age. Late-onset neutropenia was observed in 259 cases (65%). Neutropenic infants had a mean of 0.5 weeks lower gestational age. Late-onset neutropenia was more frequent in children with intraventricular hemorrhage but not in patients who received erythropoietin. The median age of neutropenia onset was 7 weeks in extremely low birth weight infants and 6 weeks in VLBW infants. The fifth percentile of neutrophils between weeks 3 and 4 was 1280 μl(-1) and between weeks 13 and 15 was 500 μl(-1). The average duration was 2 weeks with normalized values after 18 weeks.

CONCLUSION

A neutrophil count <1500 μl(-1) after the third week of life is frequently observed in VLBW infants and should not be used as a lower reference limit. The fifth percentile varies according to postnatal age from around 1300 μl(-1) in week 4 of life, decreasing to a nadir of 500 μl(-1) between 3 and 4 months of age. Values normalize in the first year of life.

Granulocyte Colony-stimulating Factor for Preterms with Sepsis and Neutropenia: A Randomized Controlled Trial

Background:

Bacterial sepsis is one of the major causes of mortality in newborn infants. Mortality increases when sepsis is associated with neutropenia.

Materials and Methods:

We conducted a prospective, randomized, double-blind, placebo-controlled trial of recombinant human granulocyte colony-stimulating factor on preterm neonates (gestational age (GA) <34 weeks) with sepsis and absolute neutrophil count (ANC) of <1500 cells/mm³. Mortality, duration of Neonatal Intensive Care Unit (NICU) stay, hematological parameters (ANC, platelet count, and total leukocyte count) were compared between the two groups. The GCSF group (n=39) received GCSF intravenously in a single daily dose of 10 μg/kg/day in a 5% dextrose solution over 20-40 min for three consecutive days, while the control group (n=39) received placebo of an equivalent volume of 5% dextrose.

Results:

Baseline demographic profile among the two groups was comparable. Mortality rate in the GCSF group was significantly lower than in the control group (10% vs. 35%; P<0.05). By day 3 of treatment, ANC in the GCSF group was significantly higher (3521±327) compared to 2094±460 in the control group, with P value being <0.05. Duration of NICU stay also decreased significantly in the GCSF group.

Conclusion:

The administration of GCSF in preterms with septicemia and neutropenia resulted in lower mortality rates. Further studies are required to confirm our results and establish this adjunctive therapy in neonatal sepsis.

Use of the complete blood cell count in late-onset neonatal sepsis

BACKGROUND

Late-onset sepsis is an important cause of morbidity and mortality in infants. Diagnosis of late-onset sepsis can be challenging. The complete blood cell count and differential have been previously evaluated as diagnostic tools for late-onset sepsis in small, single-center reports.

OBJECTIVE

We evaluated the diagnostic accuracy of the complete blood cell count and differential in late-onset sepsis in a large multicenter population.

STUDY DESIGN

Using a cohort of all infants with cultures and complete blood cell count data from a large administrative database, we calculated odds ratios for infection, as well as sensitivity, specificity, positive and negative predictive values and likelihood ratios for various commonly used cut-off values.

RESULTS

High and low white blood cell counts, high absolute neutrophil counts, high immature-to-total neutrophil ratios and low platelet counts were associated with late-onset sepsis. Associations were weaker with increasing postnatal age at the time of the culture. Specificity was highest for white blood cell counts <1000/mm and >50,000/mm (>99%). Positive likelihood ratios were highest for white blood cell counts <1000/mm (4.1) and platelet counts <50,000/mm (3.5).

CONCLUSION

No complete blood cell count index possessed adequate sensitivity to reliably rule out late-onset sepsis in this population.

Neonatal neutropenia: what diagnostic evaluation is needed and when is treatment recommended?

Neutropenia is a relatively frequent finding in the neonatal intensive care unit, particularly in very low birth weight neonates during the first week of life. Healthy term and preterm neonates have blood neutrophil counts within the same basic range as adults, but their neutrophil function, and their neutrophil kinetics during infection, differ considerably from those of adults. Neutrophil function of neonates, particularly preterm neonates, is less robust than that of adults and might also contribute to the increase in propensity to infection. In premature infants, early-onset neutropenia is correlated with sepsis, maternal hypertension, intrauterine growth restriction, severe asphyxia, and periventricular haemorrhage, and might be associated with an increase in the incidence of early-onset sepsis, nosocomial infection, and Candida colonisation. Some varieties of neutropenia in the NICU are very common and others are extremely rare. The most common causes of neutropenia in the NICU have an underlying cause that is often evident, and require little diagnostic evaluation. Unlike, persistent neutropenia should prompt evaluation even if it is of moderate severity. The laboratory tests to consider are those that provide a specific diagnosis. The first tests that should be ordered are a blood film, a complete blood count on the mother, and, if her blood neutrophil concentration is normal, maternal neutrophil antigen typing and an anti-neutrophil antibody screen. A bone marrow biopsy can be useful in cases with prolonged, unusual, or refractory neutropenia. Various treatments have been proposed as means of enhancing neutrophil production and function in preterm infants. Both recombinant granulocyte stimulating factor and recombinant granulocyte macrophage-colony-stimulating factor have been tried with variable success. Intravenous immunoglobulin, corticosteroids, granulocyte transfusions, and gamma interferon did not show a clear adequate beneficial role for the therapy of neonatal neutropenia.

Neonatal autoimmune diseases: a critical review

Neonatal autoimmune diseases are distinctly rare. Most neonatal autoimmune diseases result from the transplacental transfer of maternal antibodies directed against fetal or neonatal antigens in various tissues. In neonatal lupus, the heart seems to be particularly susceptible. Primary autoimmunity in newborns, with the exception of familial autoinflammatory diseases, is virtually non-existent. The pathophysiologic basis for the development of neonatal autoimmunity is not entirely clear, but differences in the neonatal immune system compared with the adult immune system, as well as unique characteristics of target antigens in the newborn period may be important factors. Neonatal lupus is the most common presentation of autoimmunity in the newborn. But the characteristics defining neonatal lupus are not well defined and the presentation of neonatal lupus differs from that of classical lupus. Other neonatal autoimmune diseases involving the interaction between maternal antibodies and fetal/neonatal antigens include neonatal anti-phospholipid syndrome, Behcet's disease, neonatal autoimmune thyroid disease, neonatal polymyositis and dermatomyositis, neonatal scleroderma and neonatal type I diabetes mellitus. While autoantibodies have been detected in patients with neonatal autoimmune disease, the pathogenic role of autoantibodies has not been well defined. Other mechanisms may play a role in the development of neonatal autoimmunity, including fetal/maternal microchimerism and aberrant apoptosis of fetal cells. The autoinflammatory syndromes are a completely different category, but are also included in discussion of neonatal autoimmune diseases. The autoinflammatory syndromes include the cryopyrin associated periodic syndromes (CAPS) - familial cold autoinflammatory syndrome (FCAS), neonatal onset multisystem inflammatory disease (NOMID) and Muckle-Wells syndrome, which all share a common pathophysiologic mechanism.

Recombinant human granulocyte colony-stimulating factor in preterm neonates with sepsis and relative neutropenia: a randomized, single-blind, non-placebo-controlled trial

We performed a prospective, randomized, single-blind, non-placebo-controlled trial on preterm (<37 weeks) neonates (birth weight <2000g) with sepsis and absolute neutrophil counts (ANC) <5000 cells mm(-3) to study the effect of recombinant human granulocyte colony-stimulating factor (rhG-CSF) on all-cause-neonatal mortality and hematological parameters (total leucocyte (TLC, ANC, absolute monocyte and absolute platelet counts). The rhG-CSF group (n = 20) received 10 µg/kg/day of intravenous infusion of rhG-CSF once daily for 5 days along with conventional therapy, and the control group (n = 20) received conventional therapy alone. Hematological parameters on Days 0, 1, 3, 5, 7 and 14 of study entry and all-cause mortality rates at discharge were recorded. Baseline characteristics between the rhG-CSF and control group including mean birth weight (1395 ± 289 vs. 1500 ± 231g), mean gestational age (31.5 ± 2.68 vs. 32.6 ± 2.23 weeks), initial neonatal complaints and maternal characteristics were comparable. Mortality rates were significantly less among the rhG-CSF group (3/20 (15%) vs. 7/20 (35%), p < 0.05). By Day 5 (for TLC) and Day 3 (for ANC) of start of the intervention, rhG-CSF group had significantly higher TLC (8189 ± 1570 vs. 6936 ± 1128 cells mm(-3), p < 0.05) and ANC (4756 ± 1089 vs. 4213 ± 354 cells mm(-3), p < 0.05) compared to controls. ANC levels recovered to levels >5000 cells mm(-3) faster in the rhG-CSF group, with 80% babies having ANC >5000 cells mm(-3) by Day 7 of study entry compared with 35% in the control group (p < 0.05). Preterm neonates with sepsis and neutropenia treated with rhG-CSF adjunctive therapy have decreased all-cause mortality at discharge and a quicker recovery of their total leucocyte and ANC.

The developing immune system - from foetus to toddler

During foetal development, neonatal period and childhood, the immune system is constantly maturing. In the foetus, infection responsiveness is low and associates with spontaneous abortion. During the neonatal period, the infection response shifts towards a more pro-inflammatory response. The immune system of the newborn acquires adaptive features as a result of exposure to microbes.

CONCLUSION

The development of the human immune system is a continuous process where both accelerated and retarded development is deleterious.

Granulocyte colony stimulating factor in neonatal alloimmune neutropenia: a possible association with induced thrombocytopenia

Neonatal alloimmune neutropenia (NAIN) is a rare cause of congenital neutropenia seen in <1% of births. Significant morbidity, usually infections, may result from this disease. The pathophysiology of NAIN, mediated by maternal antibodies crossing the placenta to destroy fetal cells expressing paternal antigens, is similar to that of neonatal alloimmune thrombocytopenia, as well as Rh/ABO hemolytic disease of the newborn. The use of high-dose granulocyte colony stimulating factor in patients with NAIN may cause a reversible thrombocytopenia in some patients.

Eosinophilia in very low birth weight infants

BACKGROUND

Eosinophilia is common in premature infants, though its clinical significance remains unknown. This study investigated the pattern of eosinophilia and related factors in very low birth-weight (VLBW) infants.

METHODS

The medical records of VLBW infants (birth body weight < 1500 g) admitted to the neonatal intensive care unit of a tertiary care center of Cheng Kung University Hospital between January 2005 and June 2007 were analyzed. Complete blood counts (CBC) with differential leukocyte counts were performed weekly. Eosinophilia was defined as an eosinophil count of more than 0.700 x 10(9)/L. The possible related factors were analyzed.

RESULTS

A total of 142 infants were recruited into the study. Those who did not survive after the first 28 days and those with less than four available CBCs were excluded, leaving 107 infants and 828 CBC measurements. Overall, 19.0% of CBCs (157/828) indicated eosinophilia and 69.0% of all infants had at least one instance of eosinophilia during their hospital stay. Eosinophilia mainly occurred in the third week of life (27.1%), with an average peak eosinophil count of 0.520 x 10(9)/L. There were 37.3% of patients with mild eosinophilia (0.700-0.999 x 10(9)/L), 50.7% with moderate eosinophilia (1.000-2.999 x 10(9)/L), and 12% with severe eosinophilia (> or =3.000 x 10(9)/L). The demographic data and perinatal characteristics of infants with and without eosinophilia were comparable. Medical treatments including mechanical ventilation, antibiotic administration, total parenteral nutrition, intravenous catheterization, transfusion, and body weight gains were similar between the two groups. The eosinophil counts in the first week of life were significantly higher in infants with bronchopulmonary dysplasia (p < 0.05). They were also greater in VLBW infants with sepsis at the first, the third, the fourth, the fifth and the seventh weeks (p < 0.05).

CONCLUSION

Eosinophilia is common in VLBW infants and occurs mainly in the third week of life. Higher eosinophil counts were associated with sepsis and family history of atopic eczema. Bronchopulmonary dysplasia was associated with higher eosinophil counts in the first week of life.

A multicenter, randomized, placebo-controlled trial of prophylactic recombinant granulocyte-colony stimulating factor in preterm neonates with neutropenia

OBJECTIVE

To test the hypothesis that prophylactic treatment of neutropenic premature neonates with recombinant granulocyte-colony stimulating factor (rG-CSF) would reduce the incidence of nosocomial infections (NIs).

STUDY DESIGN

A total of 25 neonatal intensive care units participated in this multicenter, randomized, double-blind, placebo-controlled trial. Premature infants of gestational age (GA) <or= 32 weeks were included if they had a peripheral blood count showing < 1500 neutrophils/mm(3) for at least 24 hours during the first 3 weeks of life. A total of 200 infants received either rG-CSF (10 microg/kg/day) or placebo for 3 days. Primary outcome was survival free of infection for 4 weeks after treatment, assessed in an intention-to-treat analysis.

RESULTS

A total of 102 infants received rG-CSF (mean GA, 29.2 weeks), and 98 received placebo (mean GA, 29.1 weeks). Survival free of confirmed infection for 4 weeks after treatment was 74/102 in the rG-CSF group and 66/98 in the placebo group (P = .42). However, during 2 weeks, there was a significant difference between groups (86/102 vs 70/98; P = .028).

CONCLUSIONS

In this population, prophylactic rG-CSF did not significantly increase survival free of infection at 4 weeks after treatment. The transient effect observed at 2 weeks in the most immature infants should be evaluated further.

Neonatal Candida spp. infections: an update

Candida-related morbidity and mortality have increased in neonatal intensive care units (NICUs) in the last 20 years. Invasive fungal infections (IFIs) in preterm infants are associated with high severity, high attributable mortality, substantial morbidity and poor outcomes owing to the frequent association with late neurodevelopmental impairment and retinopathy of prematurity in the survivors. Preterm very-low birth weight infants in NICUs have a specific, increased risk for IFIs, mainly because up to 60% of them may become colonized during their first month of life. Prevention of Candida colonization and infection is the key in these settings of unique patients, and solid data have recently been added to the very first promising results obtained in the early 2000’s with administation of fluconazole. In a multicenter randomized trial, this azole caused a striking reduction in the incidences of Candida spp. colonization (from 33 to 9%) and infection (from 13.2 to 3.2%), with no occurrence of significant side-effects and no signs of selective resistance during the 15-month study period. New guidelines incorporating the recent multicenter results are urgently needed.

Low blood neutrophil concentrations among extremely low birth weight neonates: data from a multihospital health-care system

OBJECTIVE

A blood neutrophil concentration < 1000/microl has been reported to occur in about 8% of neonatal intensive care unit (NICU) patients, at some time during their hospital stay. However, the incidence of this finding among extremely low birth weight (ELBW) neonates (< 1000 g birth weight) is not known. Using data from four NICU's in one health-care system, we sought to estimate the incidence, timing, causes, severity and duration of neutrophil counts < 1000/microl among ELBW neonates. We also tabulated the treatments used for this condition and associations with mortality.

METHODS

We performed an historic cohort analysis of all ELBW neonates born during the 36-month period, 1 July 2002 to 30 June 2005, cared for in the four Intermountain Healthcare level III NICU's.

RESULTS

Three hundred and thirty-eight ELBW neonates were the subjects of the analysis. Complete blood cell counts (CBCs) were obtained in all (range, 1 to 123 CBCs/patient). Thirty-eight percent (128/338) had one or more neutrophil counts < 1000/microl. In 57% the low neutrophil count persisted for < 24 h; in 43% it persisted for 1 to 7.5 days. Most of the cases (74%) were detected during the first 3 days of life. Twenty-two percent of cases were not detected until after the first week. Low neutrophil counts were more common among the smallest patients, with a 63% incidence in those < or = 500 g, 44% in those 501 to 600 g and 34% in those 801 to 999 g. When low neutrophil counts were recognized during the first 3 days of life, the patients were typically either small for gestational age (SGA; weight < 10th percentile for gestational age) or born after pregnancy-induced hypertension (PIH) (68%), or had early-onset bacterial infection (6%). When recognized after the first 3 days, the patients typically had necrotizing enterocolitis (31%) or a nosocomial bacterial infection (19%). Alloimmune mechanisms were not tested for in any of the cases. No cause for the low counts was identified among 35% of the neutropenic patients. Intravenous immunoglobulins was administered to 28% of cases, and 100% of these were given according to our written guidelines. Recombinant granulocyte-colony stimulating factor was administered to 13% of cases, and 69% of these were given according to guidelines. Neither the presence of low neutrophil counts nor the severity (lowest recorded count) correlated with mortality rate, except in proven early-onset sepsis.

CONCLUSIONS

We observed low neutrophil counts among ELBW neonates at a rate five times that reported in the general NICU population. Most cases were present in the first days of life and occurred in SGA neonates or those with PIH. In over 1/3, no cause was discovered. We maintain that more consistency is needed in evaluating and treating neutropenia among ELBW neonates.

Can neutrophil responses in very low birth weight infants predict the organisms responsible for late-onset bacterial or fungal sepsis?

OBJECTIVE

To examine neutrophil counts and various neutrophil indices in preterm very low birth weight (VLBW) newborn infants (birth weight <1500 g) with culture-proven late-onset sepsis to determine whether the neutrophil responses could predict the responsible infectious agent.

STUDY DESIGN

Neutrophil parameters were examined during episodes of culture-proven sepsis in a cohort of 1026 VLBW infants, born over a 6-year period and admitted to two different neonatal intensive care units. Revised reference ranges of Mouzinho et al. for circulating neutrophil counts in VLBW infants were used to define the abnormal neutrophil indices.

RESULTS

One hundred sixty-two of 1026 (15.8%) VLBW infants had blood culture-proven late-onset infection. Infections included Gram-positive bacteria (113/162, 70%), Gram-negative bacteria (30/162, 18%) and fungi (19/162, 12%). Of the 162 sepsis episodes, only nine (5.5%) were associated with neutropenia (absolute total neutrophil (ATN) <1100/mm3). Six of the 30 (20%) infants with Gram-negative bacterial sepsis were neutropenic compared to 2.6% infants with Gram-positive bacterial sepsis and none with fungal sepsis (odds ratio: 11; 95% confidence interval: 2.6, 47.3). Neutrophil counts and various neutrophil indices were similar in infants with late-onset Gram-positive bacterial and fungal sepsis; but total white blood cells, and ATN count were significantly lower (P = 0.004 and 0.001, respectively) in infants with late-onset Gram-negative bacterial sepsis.

CONCLUSIONS

In VLBW infants, common organisms causing infection have different effects on neutrophil responses. Occurrence of neutropenia during evaluation of sepsis in sick VLBW infants is more common with Gram-negative bacterial infection.

Stepping up versus standard doses of erythropoietin in preterm infants: a randomized controlled trial

In this study, it is hypothesized that a planned increase in the dose of recombinant human erythropoietin (rh-EPO) can prevent transfusion in very low birth weight infants. Two different regimens of rh-EPO were administrated, one consisting in increasing dosage up to 5000 U/kg/wk, according to the individual reticulocytes response, and the second in a standard therapy of 1250 U/kg/wk. Fifty-one infants participated. Despite a significant higher reticulocytosis, the study was prematurely terminated due to the results of an interim analysis showing that transfusion was not avoided by increasing the rh-EPO. No significant differences were found between the two regimens concerning transfusion rate, volume transfused, gain in weight, and adverse effects. Progressive titration of rh-EPO to improve the biological response does not leave premature infants free of transfusion.

Haematological parameters of HIV-1-uninfected infants born to HIV-1-infected mothers

AIM

To investigate haematological parameters in infants born to HIV-1-infected mothers and exposed to combination antiretroviral therapy (ART) used to prevent mother-to-child transmission (MTCT).

METHODS

A 2-y single-centre follow-up study performed in 109 infants born to HIV-1-positive mothers. Exclusion criteria for the infants were HIV-1 infection, perinatal death, or insufficient information. Haematological parameters of the remainder of 92 infants born to HIV-1-infected mothers and exposed to ART in utero and neonatally were compared with 75 matched non-ART-exposed children.

RESULTS

Transmission rate of HIV-1 was 1.8% and occurred when the mother was not compliant with the treatment. In the HIV-1/ART-exposed children there was a long-lasting reduction in absolute neutrophil counts (ANC) until at least 8 mo of age. According to PACTG toxicity scores, 16 infants were suffering from grade II or more (moderate-to-severe) toxicity of ART on ANC. In a multivariable analysis of maternal and neonatal risk factors, pregnancy duration was correlated with moderate-to-severe toxicity on ANC. There were no clinical implications detected, e.g. increased infections or antibiotic treatment.

CONCLUSION

ART is successful in preventing MTCT, but alterations in haematological parameters may persist for a long period. The clinical implications remain uncertain. This suggestion increases the importance to continue prospective follow-up on the haematological parameters in ART/HIV-exposed children.

Outcome of extremely low birth weight infants with leukemoid reaction

BACKGROUND

Leukemoid reaction (LR) is defined as an absolute neutrophil count (ANC) of >30 x 10(3)/mm(3). No previous study has systemically examined the clinical and prognostic significance of this phenomenon in extremely low birth weight (ELBW) infants.

OBJECTIVE

The purpose of this study was to examine the effect of LR in morbidity, mortality, and long-term developmental outcome in ELBW infants.

METHOD

Infants with gestational age of <or=30 weeks and birth weight <or=1000 g were included in the study (n = 152). The medical records were reviewed for the clinical characteristics and long-term developmental outcome of these infants. Serial complete blood cell count and ANC were calculated on day 1 and weekly thereafter until discharge. LR was defined as an ANC of >30 x 10(3)/mm(3).

RESULTS

LR was detected in 17% of the study infants (26 of 152). ANC increased postnatally in LR (n = 26) and no-LR (n = 126) infants during hospitalization, peaked in the second week of life (43 +/- 3 vs 14 +/- 1 x 10(3)/mm(3)), and remained significantly higher in LR infants during the first 5 weeks of life. LR occurred more frequently during the first 2 weeks of life and lasted for 3 +/- 1 days. There was no significant difference between the LR and no-LR infants in gestational age, birth weight, delivery mode, gender, Apgar scores, or incidence of respiratory distress syndrome, patent ductus arteriosus, necrotizing enterocolitis, intraventricular hemorrhage, and retinopathy of prematurity. LR infants required a significantly longer duration of ventilatory support (36 +/- 4 vs 21 +/- 2 days), longer duration of oxygen requirement (58 +/- 6 vs 40 +/- 3 days), and had a higher incidence of bronchopulmonary dysplasia (BPD) (54% vs 25%) compared with no-LR infants. Furthermore, the length of hospitalization was significantly longer in LR infants (69 +/- 6 vs 54 +/- 3 days). There was no significant difference between the groups in developmental outcome at 2 years of age including receptive/expressive language, fine/gross motor skills, and hearing. Incidence of abnormal neurodevelopment outcome was also similar between LR and no-LR infants.

CONCLUSIONS

LR in ELBW infants is associated with a prolonged need for ventilatory and oxygen support, a higher incidence of BPD, and a tendency for lower mortality. The findings from our study suggest that LR is associated with conditions known to have an excess of proinflammatory cytokines. Additional prospective study is needed to understand the relationship between LR, proinflammatory cytokines, and development of BPD.

Evaluation of neutropenia and neutrophilia in hospitalized preterm infants

OBJECTIVES

To characterize the time course of changes in neutrophil counts, and to draw comparisons across four gestational age groups with respect to incidence of neutropenia and neutrophilia over the first months of life in a single center.

STUDY DESIGN

Weekly complete blood counts (CBC) were collected on all NICU patients. Changes in neutrophil counts over time were examined, the incidence of neutropenia (< or =1100/mm3) and neutrophilia (> or =15,000/mm3 before, and > or =6000/mm3 after 60 hours of life) were determined, and clinical correlations sought.

RESULTS

A total of 2038 CBCs from 347 infants were evaluated. Changes in neonatal neutrophil counts were associated with gestational age, postnatal age, pregnancy-induced hypertension (PIH), and infection, either presumed or documented. Overall, neutropenia occurred 91 times in 50 infants (14% of infants), and the prevalence decreased with maturity and increased with exposure to PIH. In the first week of life, 69% of the neutropenia occurred in infants exposed to PIH. Neutrophilia occurred 579 times in 146 infants (42% of infants), and the prevalence decreased with maturity. Neutrophil deviations from the normal range were often asymptomatic and not associated with recognized clinical conditions.

CONCLUSIONS

The incidence and prevalence of neutrophil abnormalities increased with immaturity, and were more common than previously appreciated in hospitalized preterm infants.

Effect of recombinant granulocyte colony-stimulating factor on blood neutrophil concentrations among patients with "idiopathic neonatal neutropenia": a randomized, placebo-controlled trial

OBJECTIVES

We previously described a severe, prolonged, idiopathic, but self-resolving, variety of neutropenia among preterm neonates. In the present study, we sought to assess the marrow neutrophil reserves of these patients by serially measuring blood neutrophils following the administration of recombinant granulocyte colony-stimulating factor (rG-CSF) or placebo.

STUDY DESIGN

Prospective, randomized trial of rG-CSF vs placebo for infants with "idiopathic neonatal neutropenia".

RESULTS

During 36 consecutive months, 2407 neonates were admitted to the neonatal intensive care unit; 429 weighed less than 1500 g at birth, 14 of these were later diagnosed with "idiopathic neonatal neutropenia"; 10 were enrolled in this trial. The five rG-CSF recipients had an immediate, marked increase in blood neutrophil concentration, indicating adequate rG-CSF-mobilizable marrow neutrophil reserves. This effect persisted to day 5, but counts were not different from those of the five placebo recipients on days 12 and 15.

CONCLUSIONS

Patients with "idiopathic neonatal neutropenia" have a substantial rG-CSF-mobilizable marrow neutrophil reserve. On that basis, we speculate that this variety of neonatal neutropenia does not constitute a significant deficiency in antibacterial defense.

Late-onset neutropenia in very low birthweight infants

AIM

To evaluate the incidence and duration of late-onset neutropenia (defined as an absolute neutrophil count (ANC) <1500 mm(-3) at a postnatal age of >3 wk) in a population of infants with birthweight <2000 g, and to determine whether copper deficiency, a possible cause of both anemia and neutropenia, may be associated with this complication.

METHODS

Complete blood cell count and differential were assessed in 247 low (LBW) and very low birthweight (VLBW) infants who were discharged after 3 wk of life. In neutropenic infants plasma copper and ceruloplasmin levels were also measured.

RESULTS

Late-onset neutropenia was detected in 11 out of 147 VLBW infants (7.5%) and in 7 out of 127 LBW infants (5.5%). A neutrophil count of <1000 mm(-3) was observed in 14 infants (5.1%). A significantly lower gestational age was found in neutropenic infants compared with non-neutropenic infants. In neutropenic infants ANCs were significantly correlated with hemoglobin and hematocrit. In addition, a significant negative correlation was found between neutrophil and reticulocyte counts. Plasma copper concentration was significantly correlated with birthweight. Oral copper sulfate was administered to infants with plasma copper concentration <50 microg dl(-1), and did not seem to affect ANC, hemoglobin, hematocrit or reticulocyte counts.

CONCLUSION

Late-onset neutropenia appears to be a benign condition that is not associated with any particular complication and does not require specific treatment. Reference ranges after the early neonatal period and during the first few months of life in LBW and VLBW infants should probably be set at lower values.

What is the rationale for the use of granulocyte and granulocyte-macrophage colony-stimulating factors in the neonatal intensive care unit?

Neonatal sepsis remains an unsolved major contributor to morbidity and mortality. In the 1980s the promise of augmenting immune function using pooled intravenous gammaglobulin to supplement the exceedingly low levels of immunoglobulin G in premature infants failed to demonstrate a clear advantage. Similarly, cytokine augmentation of cellular function in the 1990s largely appeared to be suffering the same fate. However, both results may arise from a problem in experimental design where the combination of both treatments may be necessary along with specific antibody. For example, in vitro, independently of an array of other humoral and cellular immature immune system issues, opsonization of bacteria is improved in the presence of antibody. The question is whether the same result can be achieved in vivo. No experiments have been reported that directly test this hypothesis.

CONCLUSION

More investigation is needed in this challenging area of neonatal research.