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Neonatal Anemia. Kirsten E. Crowley, MD June 2005. Definitions. Anemia: Central venous hemoglobin < 13 g/dL or capillary hemoglobin < 14.5 g/dL in infant > 34 weeks and 0-28 days old Average value for central venous hemoglobin at birth for > 34 weeks GA is 17 g/dL

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neonatal anemia

Neonatal Anemia

Kirsten E. Crowley, MD

June 2005

definitions
Definitions
  • Anemia: Central venous hemoglobin < 13 g/dL or capillary hemoglobin < 14.5 g/dL in infant > 34 weeks and 0-28 days old
  • Average value for central venous hemoglobin at birth for > 34 weeks GA is 17 g/dL
  • Reticulocyte count in cord blood 3-7%
  • Average mean corpuscular volume 107 fL
physiologic anemia of infancy
Physiologic anemia of infancy
  • In healthy term infants, hemoglobin levels begin to decline around the third week of life
  • Reach a nadir of 11 g/dL at 8-12 weeks
differences in premature infants
Differences in premature infants
  • At birth they have slightly lower hemoglobin levels, and higher MCV and retic counts
  • The nadir is lower and is reached sooner
    • Average nadir is 7-9 g/dL and is reached at 4-8 weeks of age
    • Related to a combination of decreased RBC mass at birth, increased iatrogenic losses from lab draws, shorter RBC life span, inadequate erythropoietin production, and rapid body growth
pathophysiology
Pathophysiology
  • Anemia in the newborn results from three processes
    • Loss of RBCs: hemorrhagic anemia
      • Most common cause
    • Increased destruction: hemolytic anemia
    • Underproduction of RBCs: hypoplastic anemia
hemorrhagic anemia
Hemorrhagic anemia
  • Antepartum period (1/1000 live births)
    • Loss of placental integrity
      • Abruption, previa, traumatic amniocentesis
    • Anomalies of the umbilical cord or placental vessels
      • Velamentous insertion of the cord in twins, communicating vessels, cord hematoma, entanglement of the cord
    • Twin-twin transfusion syndrome
      • Only in monozygotic multiple births
      • 13-33% of twin pregnancies have TTTS
      • Difference in hemoglobin usually > 5 g/dL
      • Congestive heart disease common in anemic twin and hyperviscosity common in plethoric twin
hemorrhagic anemia7
Hemorrhagic anemia
  • Intrapartum period
    • Fetomaternal hemorrhage (30-50% of pregnancies)
      • Increased risk with preeclampsia-eclampsia, need for instrumentation, and c-section
    • C-section: anemia increased in emergency c-section
    • Traumatic rupture of the cord
    • Failure of placental transfusion due to cord occlusion (nuchal or prolapsed cord)
    • Obstetric trauma causing occult visceral or intracranial hemorrhage
hemorrhagic anemia8
Hemorrhagic anemia
  • Neonatal period
    • Enclosed hemorrhage: suggests obstetric trauma or severe perinatal distress
      • Caput succedaneum, cephalhematoma, intracranial hemorrhage, visceral hemorrhage
    • Defects in hemostasis
      • Congenital coagulation factor deficiency
      • Consumption coagulopathy: DIC, sepsis
      • Vitamin K dependent factor deficiency
        • Failure to give vit K causes bleeding at 3-4 days of age
      • Thrombocytopenia: immune, or congenital with absent radii
    • Iatrogenic blood loss due to blood draws
hemolytic anemia
Hemolytic anemia
  • Immune hemolysis: Rh incompatibility or autoimmune hemolysis
  • Nonimmune: sepsis, TORCH infection
  • Congenital erythrocyte defect
    • G6PD, thalassemia, unstable hemoglobins, membrane defects (hereditary spherocytosis, elliptocytosis)
  • Systemic diseases: galactosemia, osteopetrosis
  • Nutritional deficiency: vitamin E presents later
hypoplastic anemia
Hypoplastic anemia
  • Congenital
    • Diamond-Blackfan syndrome, congenital leukemia, sideroblastic anemia
  • Acquired
    • Infection: Rubella and syphilis are the most common
    • Aplastic crisis, aplastic anemia
clinical presentation
Clinical presentation
  • Determine the following factors
    • Age at presentation
    • Associated clinical features
    • Hemodynamic status of the infant
    • Presence or absence of comensatory reticulocytosis
presentation of hemorrhagic anemia
Presentation of hemorrhagic anemia
  • Acute hemorrhagic anemia
    • Pallor without jaundice or cyanosis and unrelieved by oxygen
    • Tachypnea or gasping respirations
    • Decreased perfusion progressing to hypovolemic shock
      • Decreased central venous pressure
    • Normocytic or normochromic RBC indices
    • Reticulocytosis within 2-3 days of event
presentation of hemorrhagic anemia13
Presentation of hemorrhagic anemia
  • Chronic
    • Pallor without jaundice or cyanosis and unrelieved by oxygen
    • Minimal signs of respiratory distress
    • Central venous pressure normal
    • Microcytic or hypochromic RBC indices
    • Compensatory reticulocytosis
    • Enlarge liver d/t extramedullary erythropoiesis
    • Hydrops fetalis or stillbirth may occur
presentation of hemolytic anemia
Presentation of hemolytic anemia
  • Jaundice is usually the first symptom
  • Compensatory reticulocytosis
  • Pallor presents after 48 hours of age
  • Unconjugated hyperbilirubinemia of > 10-12 mg/dL
  • Tachypnea and hepatosplenomegaly may be present
presentation of hypoplastic anemia
Presentation of hypoplastic anemia
  • Uncommon
  • Presents after 48 hours of age
  • Absence of jaundice
  • Reticulocytopenia
presentation of other forms
Presentation of other forms
  • Twin-twin transfusion
    • Growth failure in the anemic twin, often > 20%
  • Occult internal hemorrhage
    • Intracranial: bulging anterior fontanelle and neurologic signs (altered mental status, apnea, seizures)
    • Visceral hemorrhage: most often liver is damaged and leads to abdominal mass
    • Pulmonary hemorrhage: radiographic opacification of a hemithorax with bloody tracheal secretions
diagnosis
Diagnosis
  • Initial studies
    • Hemoglobin
    • RBC indices
      • Microcytic or hypochromic suggest fetomaternal or twin-twin hemorrhage, or a-thalassemia
      • Normocytic or normochromic suggest acute hemorrhage, systemic disease, intrinsic RBC defect, or hypoplastic anemia
    • Reticulocyte count
      • elevation suggests antecedent hemorrhage or hemolytic anemia while low count is seen with hypoplastic anemia
diagnosis18
Diagnosis
  • Initial studies continued
    • Blood smear looking for
      • spherocytes (ABO incompatibility or hereditary spherocytosis)
      • elliptocytes (hereditary elliptocytosis)
      • pyknocytes (G6PD)
      • schistocytes (consumption coagulopathy)
    • Direct Coombs test: positive in isoimmune or autoimmune hemolysis
other diagnostic studies
Other diagnostic studies
  • Blood type and Rh in isoimmune hemolysis
  • Kleihauer-Betke test on maternal blood looking for fetomaternal hemorrhage
  • CXR for pulmonary hemorrhage
  • Bone marrow aspiration for congenital hypoplastic or aplastic anemia
  • TORCH: bone films, IgM levels, serologies, urine for CMV
  • DIC panel, platelets looking for consumption
  • Occult hemorrhage: placental exam, cranial or abdominal ultrasound
  • Intrinsic RBC defects: enzyme studies, globin chain ratios, membrane studies
management
Management
  • Simple replacement transfusion
    • Indications:
      • acute hemorrhage
        • Use 10-15 ml/kg O, RH- packed RBCs or blood cross-matched to mom and adjust hct to 50%
        • Give via low UVC or central UVC if time permits
        • Draw diagnostic studies before transfusion
      • ongoing deficit replacement
      • maintenance of effective oxygen-carrying capacity
        • Hct < 35% in severe cardiopulmonary disease
        • Hct < 30% in mild-moderate cardiopulmonary disease, apnea, symptomatic anemia, need for surgery
        • Hct < 21%
management21
Management
  • Exchange transfusion
    • Indications
      • Chronic hemolytic anemia or hemorrhagic anemia with increased central venous pressure
      • Severe isoimmune hemolytic anemia
      • Consumption coagulopathy
  • Nutritional replacement: iron, folate, vitamin E
prophylactic management
Prophylactic management
  • Erythropoietin
    • Increased erythropoiesis without significant side effects
    • Decreases need for late transfusions
    • Will not compensate for anemia due to labs
      • Need to have restrictive policy for blood sampling and micromethods in the lab
  • Nutritional supplementation: iron, folate, vitamin E