Early Hyperbilirubinemia in Neonates with Down Syndrome.

OBJECTIVE: To compare total serum bilirubin (TSB) levels, phototherapy usage, and hospital readmission for jaundice among neonates with Down syndrome vs controls. STUDY DESIGN: A retrospective cohort study using 15 years of multihospital data. We created control reference intervals (5th, median, and 95th percentiles) for initial TSB values hourly during the first days after birth, and determined the proportion of neonates with Down syndrome whose TSB exceeded the 95th percentile control interval. We determined the proportion with an initial TSB exceeding the upper control reference interval, the highest TSB recorded, the percentage of neonates receiving phototherapy, and the rate of hospital readmission for jaundice treatment. RESULTS: We compared 357 neonates with Down syndrome with 377 368 controls. Compared with controls, those with Down syndrome had 4.7 times the risk (95% CI, 3.9-5.7; P < .0001) of an initial TSB exceeding the 95th percentile control interval (23.5% vs 5.0%), 8.9 times (95% CI, 8.1-9.8; P < .0001) the phototherapy usage (62.2% vs 7.0%), and 3.6 times (95% CI, 1.6-8.2; P = .0075) the readmission rate for jaundice (17.4 vs 4.8 per 1000 live births). CONCLUSIONS: Neonates with Down syndrome have a substantial risk of early hyperbilirubinemia. The American Academy of Pediatrics currently advises obtaining an early screening complete blood count from neonates with Down syndrome. We submit that assessing their TSB is also advisable.

Screening umbilical cord blood for congenital Iron deficiency.

OBJECTIVES: Small for gestational age infants (SGA), infants of diabetic mothers (IDM), and very low birth weight infants (VLBW) are at risk for congenital iron deficiency. We evaluated the iron status of SGA, IDM, and VLBW neonates at birth and sought mechanistic explanations in those with iron deficiency. METHODS: This was a prospective study. If congenital iron deficiency was present, maternal iron studies were obtained. When neonates were two weeks old, their iron status was reevaluated. RESULTS: Sixteen of 180 neonates screened were iron deficient at birth. The Body Mass Index of the 16 mothers was high. These mothers often had mild iron deficiency and measurable hepcidin levels. Two weeks after birth, neonates had improved iron measurements. CONCLUSIONS: Among SGA, IDM, and VLBW neonates, maternal obesity is a risk factor for congenital iron deficiency. We speculate that elevated hepcidin levels in obese pregnant women impede iron absorption and interfere with transplacental iron transfer.

Bilirubin levels and phototherapy use before and after neonatal red blood cell transfusions.

BACKGROUND: Our previous retrospective study suggested that red blood cell (RBC) transfusion of preterm neonates can be associated with an increase in bilirubin, but this has not been tested prospectively. STUDY DESIGN AND METHODS: We studied neonates before and after RBC transfusions, recording serial bilirubin levels and whether they qualified for phototherapy. Because lysed RBCs release plasma-free hemoglobin (Hb), a precursor to bilirubin, we also measured plasma free Hb and bilirubin from the donor blood. RESULTS: We studied 50 transfusions given to 39 neonates. Gestation ages of transfused neonates, at birth, were 26 (24-29) weeks (median [interquartile range]); birthweights were 750 (620-1070) g. The study transfusion was given on Day of Life 9.9 (3.4-19.2). In 20% (10/50) phototherapy was being administered at the beginning of and during the transfusion. In these patients neither the 4- to 6- nor the 24- to 36-hour-posttransfusion bilirubin levels were significantly higher than before transfusion. However, in 30% of the others (12/40) phototherapy was started (or restarted) after the transfusion and 15% had a posttransfusion bilirubin increase of at least 2.5 mg/dL. These neonates received donor blood with a higher plasma-free Hb (p < 0.05). CONCLUSIONS: Neonates commonly qualify for phototherapy after transfusion. A minority (15% in this series) have a posttransfusion bilirubin increase of at least 2.5 mg/dL. We speculate that neonates qualifying for a RBC transfusion, who are judged to be at high risk for bilirubin-induced neurotoxicity, might benefit from checking their serum bilirubin level after the transfusion and providing donor blood with low plasma-free Hb levels.

Thrombocytopenia in late preterm and term neonates after perinatal asphyxia.

BACKGROUND: A recent NHLBI conference concluded that platelet (PLT) transfusions of neonates must become more evidence based. One neonatal disorder for which transfusions are given is a poorly defined entity, the "thrombocytopenia of perinatal asphyxia." To expand the evidence base for this entity, we performed a multicentered, retrospective analysis of neonates with perinatal asphyxia. STUDY DESIGN AND METHODS: We analyzed records of term and late preterm neonates with perinatal asphyxia defined by a cord blood pH of not more than 6.99 and/or base deficit of at least 16 mmol/L. From these we identified neonates with at least two PLT counts of fewer than 150 × 10(9) /L in the first week of life and described the severity, nadir, and duration of the thrombocytopenia. RESULTS: Thrombocytopenia occurred in 31% (117/375) of neonates with asphyxia versus 5% of matched nonasphyxiated controls admitted to a neonatal intensive care unit (p < 0.0001). Twenty-one of the 117 asphyxiated neonates were excluded from the remaining analysis due to disseminated intravascular coagulation or extracorporeal membrane oxygenation. Nadir PLT counts of the remaining 96 were on Day 3 (75 × 10(9) /L; 90% confidence interval, 35.7 × 10(9) -128.6 × 10(9) /L) and normalized by Days 19 to 21. PLT counts after asphyxia roughly correlated inversely with elevated nucleated red blood cell count (NRBC) counts at birth. Thirty of the 96 received at least one PLT transfusion, all given prophylactically, none for bleeding. CONCLUSIONS: We maintain that the thrombocytopenia of perinatal asphyxia is an authentic entity. Its association with elevated NRBC counts suggests that hypoxia is involved in the pathogenesis. Because PLT counts are only moderately low, the condition is transient, and bleeding problems seem rare, we speculate that PLT transfusions should not be needed for most neonates with this condition.

Reference intervals for common coagulation tests of preterm infants (CME).

BACKGROUND: Fresh-frozen plasma (FFP) is sometimes administered to nonbleeding preterm neonates who are judged to be at risk for bleeding because they have abnormal coagulation tests. The benefits/risks of this practice are not well defined. One limitation to progress is lack of reference intervals for the common coagulation tests, thus limiting precision about whether coagulation tests are indeed abnormal. STUDY DESIGN AND METHODS: In a sequential observational study, fetal blood was drawn at preterm birth (≤ 34 weeks) from the umbilical vein near the placenta. Fibrinogen, prothrombin time, activated partial thromboplastin time, D-dimer, platelet (PLT) count, and mean PLT volume were measured. Reference intervals were constructed using 5th and 95th percentile values. Associations were then sought between abnormal coagulation values at birth and bleeding problems identified during the first week. RESULTS: Coagulation tests were drawn at 175 preterm deliveries and the results were organized into reference intervals by gestational age. No abnormal coagulation value, either alone or in combination, predicted hemorrhage (intraventricular, gastrointestinal, or pulmonary) during the first week. However, fibrinogen exceeding the 95th percentile was associated with evidence of in utero infection/inflammation (correlations with elevated C-reactive protein, p<0.01, and elevated immature to total neutrophil ratio, p<0.001). CONCLUSIONS: Abnormal coagulation values at preterm birth do not predict bleeding during the first week. This suggests to us that bleeding in the days after preterm birth is not generally the result of in utero coagulopathy. These findings bring into question the value of coagulation screening of nonbleeding preterm infants and prophylactic FFP administration to those with abnormal values.

Association, among very-low-birthweight neonates, between red blood cell transfusions in the week after birth and severe intraventricular hemorrhage.

BACKGROUND: Previous reports describe a statistical association, among very-low-birthweight (VLBW, <1500 g) neonates, between red blood cell (RBC) transfusion in the first days after birth and development of severe intraventricular (brain) hemorrhage (IVH). STUDY DESIGN AND METHODS: We hypothesized that after we established a neonatal intensive care unit (NICU) transfusion management program in 2009, a decrease in early (first week after birth) RBC transfusion rate and a decrease in the incidence of severe IVH occurred concomitantly. RESULTS: During a 9-year period 2716 VLBW neonates were admitted to our NICUs. In 2004, 58% of VLBW neonates received one or more RBC transfusions during the first week. After a transfusion compliance program was established in 2009, this rate declined, reaching 25% by 2012. In parallel, the severe IVH rate also declined, from 17% in 2004 to 8% in 2012 (R(2) = 0.73). IVH occurred in 27% of those who received a RBC transfusion during the first week versus less than 2% of those with no early transfusion (p < 0.001). The decrease in IVH rate occurred exclusively among neonates born in an Intermountain Healthcare perinatal center and not among those initially cared for in an "outside" hospital and subsequently transported to an Intermountain NICU. CONCLUSIONS: It remains unclear whether transfusing VLBW neonates during the first days after birth is a proximate cause of IVH. However, the present report is consistent with previous studies showing that successful efforts to reduce early RBC transfusions is associated with a decrease in the incidence of severe IVH.

Association of neonatal red blood cell transfusion with increase in serum bilirubin.

BACKGROUND: It is not clear whether red blood cell (RBC) transfusions typically increase a neonate's total serum bilirubin (TSB) level or if so by how much. STUDY DESIGN AND METHODS: In this retrospective analysis, from 2009 through 2012, we collected TSB measurements before and after transfusions, recording blood types of mothers, neonates, and blood donors and whether phototherapy was used before, during, or after transfusion. RESULTS: Of 7272 neonates admitted during this period, 658 (9%) received 2597 RBC transfusions. TSB levels were drawn before and after 431 transfusions, 255 of which did not have phototherapy at the time the transfusion was administered. The mean increase in TSB was 2.2 mg/dL (95% confidence interval, 1.9-2.5 mg/dL). Seven percent of all transfusions and 12% of transfusions to very-low-birthweight (VLBW) infants (<1500 g) were followed by a TSB increase of at least 5 mg/dL. Transfusions with "universal donor" blood (O-) resulted in a higher TSB increase (p < 0.0001), but the magnitude was clinically insignificant (0.3 mg/dL). Older blood (days since donor draw) did not generate significantly higher posttransfusion TSB levels (p = 0.092). A focused study of the 10 neonates with the highest TSB increases revealed that six were unexplained other than transfusion related. CONCLUSIONS: We describe an association between RBC transfusion and TSB elevation, but we recognize that this does not establish a cause-and-effect relationship. However, the observation that an increase of at least 5 mg/dL occurs after 12% of transfusions to VLBW neonates suggests to us that clinicians will want to evaluate jaundice, or measure bilirubin, on VLBW neonates after transfusion.

Red blood cell transfusion of preterm neonates with a Grade 1 intraventricular hemorrhage is associated with extension to a Grade 3 or 4 hemorrhage.

BACKGROUND: Some preterm infants with a Grade 1 intraventricular hemorrhage (IVH) are subsequently found to have a Grade 3 or 4 IVH, while in others the Grade 1 resolves without extending. STUDY DESIGN AND METHODS: We identified all neonates in our health system in the past 6 years with a Grade 1 IVH and compared those where the hemorrhage extended versus resolved. RESULTS: Grade 1 IVH was identified in 417 neonates; 24 subsequently became a Grade 3, and 22 a Grade 4. These 46 were born earlier, 25 ± 2 weeks versus 30 ± 3 weeks (p = 0.000), with lower birth weight, 811 ± 284 g versus 1432 ± 603 g (p = 0.000); lower 5-minute Apgar scores, 5 ± 2 versus 8 ± 2 (p = 0.000); and slightly lower cord pH, 7.24 ± 0.16 versus 7.28 ± 0.10 (p = 0.009). Older gestational age was the most significant contributor lowering the odds of IVH extension (odds ratio [OR], 0.95; 95% confidence interval [CI], 0.92-0.98). Administering a red blood cell (RBC) transfusion up to and on the day the Grade 1 was detected was the most significant contributor increasing the odds (OR, 2.92; 95% CI, 2.19-3.90) of extension. In both groups (resolving vs. extending) criteria for ordering transfusions were similar as was the proportion of transfusions given out of compliance with guidelines. CONCLUSIONS: An association exists between RBC transfusion and extension of a Grade 1 IVH into a Grade 3 or 4. However, the explanation is unclear and could involve either the reasons transfusion are ordered or the transfusions themselves. Additional studies are needed to discover why neonates are more likely to have IVH extension if transfused.

Implementing a program to improve compliance with neonatal intensive care unit transfusion guidelines was accompanied by a reduction in transfusion rate: a pre-post analysis within a multihospital health care system.

BACKGROUND: We previously reported that in the year 2006, approximately 35% of the transfusions administered in the Intermountain Healthcare neonatal intensive care units (NICU) were noncompliant with our transfusion guidelines. In January 2009 we instituted an electronic NICU transfusion ordering and monitoring system as part of a new program to improve compliance with transfusion guidelines. STUDY DESIGN AND METHODS: In the four largest NICUs of Intermountain Healthcare, we performed a pre-post analysis of compliance with transfusion guidelines and transfusion usage. RESULTS: After beginning the new transfusion compliance program all four NICUs had an increase in compliance from 65% to 90%. Accompanying the improved compliance, all four NICUs had a reduction in transfusions administered. Specifically, compared with 2007 and 2008, there were 984 fewer NICU transfusions given in 2009. This included 554 fewer red blood cell (RBC) transfusions, 174 fewer platelet transfusions, and 256 fewer frozen plasma infusions. We calculate that in 2009, a total of 200 NICU patients who in previous years would have received one or more transfusions instead received none. Applying specific Intermountain Healthcare billing data to the observed transfusion reductions, this new program resulted in an annual decrease of $780,074 in blood bank charges (blood administration charges were not included). During the 3-year period, January 2007 through December 2009, we detected no change in NICU demographics, major morbidities, length of hospital stay, or mortality rate. CONCLUSION: Implementing a systemwide NICU program to improve compliance with already-established transfusion guidelines increased compliance from 65% to 90%. Improved compliance with transfusion guidelines was accompanied by a significant reduction in transfusions given, with no increase in NICU length of stay or mortality rate.

Among very-low-birth-weight neonates is red blood cell transfusion an independent risk factor for subsequently developing a severe intraventricular hemorrhage?

BACKGROUND: A severe intraventricular hemorrhage (IVH) in a preterm neonate can result in life-long disabilities or death. Pathogenic mechanisms responsible for IVH are incompletely understood. We postulated that if the timing of a severe IVH could be approximated by serial ultrasound, potentially relevant antecedents could be identified. STUDY DESIGN AND METHODS: We retrospectively identified all very-low-birth-weight (VLBW) neonates in our health system, over a 5-year period, with an initial head ultrasound showing no hemorrhage but a subsequent ultrasound showing a Grade 3 or 4. Controls that did not develop an IVH were matched with cases using demographic features and degree of illness measures. RESULTS: Fifty-four cases were matched (1:2) with controls. No differences were found between cases and controls in initial pH, sepsis, ventilation, coagulation studies, or proportion with severe thrombocytopenia. However, during the period when the head ultrasound was normal, cases were more likely to have had a red blood cell (RBC) transfusion (p < 0.001). In 94% of the cases the sequence was 1) no IVH, 2) RBC transfusion, and 3) severe IVH. With the use of logistic regression, each subsequent RBC transfusion during the first week was determined to double the risk of a severe IVH (each transfusion increases relative risk, 2.02; 95% confidence interval, 1.54-3.33). Sensitivity analysis indicated a high likelihood that RBC transfusion, independent of hemoglobin level or other factors, increases the risk of developing a severe IVH. CONCLUSION: These findings suggest a new hypothesis. Namely, RBC transfusions given before the development of an IVH are an independent risk factor for developing a severe IVH.

Postponing or eliminating red blood cell transfusions of very low birth weight neonates by obtaining all baseline laboratory blood tests from otherwise discarded fetal blood in the placenta.

BACKGROUND: Safely reducing the proportion of very low birth weight neonates (<1500 g) that receive a red blood cell (RBC) transfusion would be an advance in transfusion practice. STUDY DESIGN AND METHODS: We performed a prospective, single-centered, case-control, feasibility analysis, preparatory to designing a definitive trial. Specifically, we sought to determine whether we could obtain all baseline neonatal intensive care unit blood tests from the placenta, after placental delivery, thereby initially drawing no blood from the neonate. RESULTS: Ten cases where all baseline blood tests were drawn from the placenta, and 10 controls where all tests were drawn from the neonate, were closely matched for birth weight, gestational age, sex, and race. Early cord clamping was used for all 20. Over the first 18 hours the hemoglobin increased in nine cases versus two controls (p = 0.005). During the first 72 hours one case versus five controls qualified for and received an RBC transfusion. In the first week the cases received four transfusions and the controls received 16 (p = 0.02). None of the cases had an intraventricular hemorrhage (IVH) but four of the controls had a Grade 1 and two had a Grade 3 (p = 0.01). CONCLUSION: We speculate that this method is feasible and generally postpones the first RBC transfusion until beyond the period of peak vulnerability to IVH.

Nicotine and metabolites in paired umbilical cord tissue and meconium specimens.

Umbilical cord tissue was studied as a means of detecting prenatal exposure to nicotine. This was accomplished by comparing the presence and concentration of nicotine as well as nicotine metabolites in both umbilical cord tissue and paired meconium samples with maternal smoking histories obtained by self-report. Nicotine and metabolites (cotinine, 3-hydroxycotinine, nornicotine, and anabasine) were detected and quantitated using liquid chromatography-tandem mass spectroscopy. Between June and September 2009, 19 women with a tobacco exposure history (either first- or second-hand tobacco smoke exposure during pregnancy) were consented for the study. A questionnaire was completed to document nicotine exposure during each trimester of pregnancy. All infants were delivered at term (38 weeks or greater) and paired umbilical cord tissue (10-cm segment or greater) and meconium were obtained. Nicotine and 3-hydroxycotinine were most prominent in meconium, whereas cotinine and 3-hydroxycotinine were most prominent in the umbilical cord. Concentrations of all three analytes were generally higher in meconium. Nornicotine was detected only in meconium, at very low concentrations, and anabasine was not detected in either specimen. All analyte concentrations were lowest when the mother stated she quit smoking early in pregnancy or had only second-hand exposure, and detection was poor if exposure was limited to the first or second trimesters. Although different nicotine and metabolite patterns exist in meconium versus umbilical cord tissue, this work indicates that either specimen can be used to detect third-trimester fetal nicotine exposure.

Reconciling markedly discordant values of serum ferritin versus reticulocyte hemoglobin content.

OBJECTIVE: To determine why serum ferritin and reticulocyte hemoglobin (RET-He), drawn to assess neonatal iron sufficiency, sometimes have markedly discordant results. STUDY DESIGN: Retrospective records review of five NICUs over 28 months, identifying all patients with a ferritin and RET-He within 48 h. We examined records of all who had marked discordance (one value >95th % reference interval, the other <5th %). RESULTS: Of 190 paired ferritin and RET-He measurements, 16 (8%) were markedly discordant. Fifteen of the 16 discordant samples involved a high ferritin and a low RET-He. In these, low MCV and high %Micro-R, and low MCH and high %HYPO-He were present. In total, 8 of the 15 had laboratory or clinical evidence of an inflammatory process and five had suspicion of infection documented. CONCLUSIONS: When ferritin and RET-He were discordant, erythrocyte microcytosis and hypochromasia suggested that the RET-He gave the more accurate interpretation; that iron deficiency was likely present.

Exchange transfusion for hemolytic hyperbilirubinemia: could some be averted by emergent administration of an inhibitor of bilirubin production?

OBJECTIVES: The objective of this study is to explore the hypothetical number of neonates where an exchange transfusion (ET) could be prevented by emergency administration of an inhibitor of bilirubin production. STUDY DESIGN: We identified all neonates who received an ET in our NICUs during the past 12 years. We reviewed the indications for ET and recorded the time between ordering and beginning the exchange. RESULTS: Forty-six neonates underwent ET, 37 (80.4%) for hemolytic hyperbilirubinemia (36.9 ± 2.9 weeks gestation and 2.5 ± 2.1 days old at ET). The mean delay period was 7.5 ± 3.5 h. Nine (19.6%) had ET not involving bilirubin. CONCLUSIONS: A trial testing compounds that can inhibit bilirubin production would have about three eligible neonates/years in our system. Since our births are 1% of national, up to 300 neonates/years might qualify for such a study.

Is "transfusion-associated necrotizing enterocolitis" an authentic pathogenic entity?

BACKGROUND: Necrotizing enterocolitis (NEC) sometimes occurs after a transfusion, but it is unclear whether this is a chance association or cause and effect. STUDY DESIGN AND METHODS: We compared features of neonates that developed surgical NEC within 48 hours after transfusion with others that developed NEC not preceded by transfusion. We assessed the blood used for transfusion and feeding practices among NEC cases and controls. RESULTS: Forty neonates developed surgical NEC after a transfusion and 72 developed NEC unrelated to a transfusion. Those with NEC after transfusion were born at earlier gestation (mean 27 weeks, 90% confidence interval [CI] 26-28 years vs. mean 30, 90% CI 29-31; p < 0.001) and were of lower birth weight (mean 981 g, 90% CI 835-1128 g vs. mean 1371 g, 90% CI 1245-1496; p < 0.001) and developed NEC later during their neonatal intensive care unit course (day of life: mean 23, 90% CI 20-27 vs. mean 16, 90% CI 13-19; p < 0.001). Transfusions were more prevalent among those that developed NEC (p < 0.001). The blood transfused to those that developed NEC was not older, but those who developed NEC had been fed larger volumes of milk in the 24 hours before and during transfusion (p = 0.04) and were more likely to have been fed a bovine product during that period (p = 0.004). CONCLUSION: Approximately one-third of surgical NEC cases in our system occurred after a transfusion. We speculate that a target area for reducing the prevalence of posttransfusion NEC involves feeding practices immediately before and during RBC transfusion.

A low-sodium solution for airway care: results of a multicenter trial.

BACKGROUND: Normal saline is sometimes instilled into the endotracheal tube preparatory to airway suctioning, to assist in removing thick secretions. However, saline can damage the antimicrobial properties of airway secretions. We previously described a low-sodium physiologically based solution for airway care and reported a small (n = 60) randomized trial in neonates, which showed trends toward less ventilator-associated pneumonia (VAP) and less chronic lung disease with the new solution. We now report a multicenter trial of that solution. METHODS: We conducted a before-and-after study with a parallel control group, in 4 level-3 neonatal intensive care units (NICUs). During year 1, all 4 NICUs used saline for airway care. During year 2, one NICU used the test solution exclusively while the other NICUs used saline exclusively. The 2 study outcomes were VAP (cases/1,000 ventilator days) and chronic lung disease, defined 3 ways: supplemental oxygen at 28 days; supplemental oxygen at 36 weeks gestation; and supplemental oxygen on hospital discharge. RESULTS: During the study period 1,116 neonates had endotracheal intubation for respiratory management. Of those, 1,029 received the standard saline for airway suctioning, and the 87 in NICU 4 received the test solution. NICU 4 had a decrease in VAP rate, from 4.2 VAPs/1,000 ventilator days with saline, to 1.6 VAPs/1,000 ventilator days with the test solution (P = .04), and also had the lowest prevalence of chronic lung disease (P < .001 for each definition). CONCLUSIONS: The test solution significantly reduced the VAP and chronic lung disease rates.

Very high users of platelet transfusions in the neonatal intensive care unit.

BACKGROUND: In neonatal intensive care unit (NICU) practice, a small percentage of the patients receive a large proportion of the platelet (PLT) transfusions administered. This study sought to better define this very-high-user group. To accomplish this, records of all NICU patients in a multihospital health care system who, during a recent 5(1/2)-year period, received 20 or more PLT transfusions were examined. STUDY DESIGN AND METHODS: Electronic medical record repositories of Intermountain Healthcare neonates with dates of birth from January 1, 2002, through June 30, 2007, who received 20 or more PLT transfusions were identified. The causes of the thrombocytopenia were sought, whether each transfusion given was a treatment for bleeding versus prophylaxis was determined, whether each transfusion was compliant with our transfusion guidelines was judged, and the outcomes were tabulated. RESULTS: During this period, 45 patients received 20 or more PLT transfusions (median, 29; range, 20-79). Medical conditions could be categorized into six diagnoses: 1) extracorporeal membrane oxygenation (ECMO) for congenital diaphragmatic hernia (CDH; n = 13), 2) fungal sepsis (n = 8), 3) ECMO for reasons other than CDH (n = 8), 4) necrotizing enterocolitis (n = 7), 5) bacterial sepsis (n = 7), and 6) congenital hyporegenerative thrombocytopenia (n = 2). Nineteen percent of the transfusions were ordered for oozing, bruising, or bleeding and 81 percent for prophylaxis. Thirty-six percent of transfusions were given in violation of our transfusion guidelines. Forty-nine percent of the high users died, but no deaths were due to hemorrhage. All survivors developed chronic lung disease, and all survivors weighing less than 1250 g at birth developed retinopathy of prematurity. CONCLUSIONS: Almost all patients that received 20 or more PLT transfusions had an acquired, consumptive thrombocytopenia. All could have received fewer transfusions had the guidelines already in place been observed. Eighty-one percent fewer PLT transfusions would have been administered had the paradigm been transfusing only if oozing, bruising, or bleeding was present.

Testing platelet mass versus platelet count to guide platelet transfusions in the neonatal intensive care unit.

BACKGROUND: Platelet (PLT) transfusions can bestow significant benefits but they also carry risks. This study sought a safe means of reducing PLT transfusions to neonatal intensive care unit (NICU) patients with thrombocytopenia by comparing two transfusion guidelines, one based on PLT count and the other on PLT mass (PLT count times mean PLT volume). STUDY DESIGN AND METHODS: Using a prospective, two-centered, before versus after design, PLT transfusion usage and hemorrhagic events were contrasted during a period when PLT count-based transfusion guidelines were in use (Period 1) versus a period when PLT mass-based guidelines were in use (Period 2). RESULTS: No differences were observed between Periods 1 and 2 in NICU admissions, sex, race/ethnicity, percentage of inborn patients, or percentage of patients with a PLT count less than 50 x 10(9) or 51 x 10(9) to 99 x 10(9)/L. In the first period 3.6% of NICU admissions received one or more PLT transfusions. This fell to 1.9% during the second period (p < 0.002). The number of PLT transfusions administered per transfused patient was the same in both periods: 2.0 (1-23) (median [range]) in Period 1 and 2.0 (1-17) in Period 2 (p > 0.40). Significantly fewer PLT transfusions were given in Period 2 for prophylaxis (patient not bleeding; p < 0.001 vs. Period 1). The number given for bleeding did not change between the two periods. In Period 2 no increases were seen in rate of intraventricular hemorrhage (IVH); Grade 3 or 4 IVH; or pulmonary, gastrointestinal, or cutaneous bleeding. CONCLUSIONS: The use of PLT mass-based NICU transfusion guidelines was associated with fewer PLT transfusions and no recognized increase in hemorrhagic problems.

Neonates with suspected microangiopathic disorders: performance of standard manual schistocyte enumeration vs. the automated fragmented red cell count.

OBJECTIVES: To enhance the diagnosis of schistocyte-producing conditions, we compared routine manual schistocyte enumeration with automated fragmented red cell counts (FRCs). STUDY DESIGN: In neonates "suspected" of having sepsis, NEC, or DIC we compared manual schistocyte estimates vs. automated FRC counts. When the two disagreed, we used a "gold standard" from a  ≥ 1000 RBC differential. We also assessed the diagnostic accuracy of the FRC count in diagnosing sepsis, NEC, or DIC. RESULTS: We collected 270 CBCs from 90 neonates. The methods agreed in 63% (95% CI 55%-70%) of the CBCs. Among the 37% where they disagreed, the FRC count was more accurate in 100% (95% CI 88-100%). An elevated FRC count was specific for sepsis, and was sensitive and specific for necrotizing enterocolitis and DIC. CONCLUSIONS: Automated FRC counts have advantages over routine manual evaluation, larger sample size, lower expense, and superior accuracy in diagnosing schistocyte-producing conditions.