pediatrics
Perinatal Anemia
Treatment of Perinatal Anemia
Need for treatment of perinatal anemia varies with degree of anemia and associated medical conditions. Mild anemia in otherwise healthy term and preterm infants generally does not require specific treatment; treatment is directed at the underlying diagnosis. Some patients require transfusion or exchange transfusion of packed RBCs. Transfusion is indicated to treat severe anemia. Infants should be considered for transfusion if symptomatic due to anemia or if a decrease in tissue oxygen delivery is suspected. The decision to transfuse should be based on symptoms, patient age, and degree of illness. Hematocrit alone should not be the deciding factor regarding transfusion because some infants may be asymptomatic with lower levels and others may be symptomatic with higher levels. Guidelines for when to transfuse vary, but one accepted set is described in table Transfusion Guidelines for Infants . Within the first 4 months, before the first transfusion, if not already done, maternal and fetal blood should be tested for both ABO and Rh types determination and to detect the presence of atypical RBC antibodies. Antibody screening should be done on the maternal sample when available, and a DAT should be done on the infant’s RBCs. RBCs for neonatal transfusion must be ABO- and D-compatible with both maternal and neonatal groups and must be indirect antiglobulin test crossmatch–compatible with clinically significant RBC antibodies present in maternal or neonatal plasma. Units that are ABO compatible with both mother and neonate must be used even if the pretransfusion DAT is negative. Typically, group O D-negative RBCs are used for most neonatal top-up and exchange transfusions. If group-specific RBCs are used, which is most common for elective large-volume transfusions, they must be ABO- and D-compatible with both maternal and neonatal groups. Group-identical units should be used when possible for elective large-volume transfusions in infants to minimize the use of group O D-negative RBCs ( Treatment references ). Neonates produce RBC antibodies only rarely, so in cases where the need for transfusion persists, repeat antibody screening is usually not necessary until 4 months of age. Packed RBCs used for transfusion should be filtered (leukocyte depleted), irradiated, and given in aliquots of 10 to 20 mL/kg derived from a single donation; sequential transfusions from the same unit of blood minimize recipient exposure and transfusion complications. Blood from cytomegalovirus-negative donors should be considered for extremely preterm infants. Exchange transfusion in which blood from the neonate is removed in aliquots in sequence with packed RBC transfusion, is indicated for some cases of hemolytic anemia with elevation of serum bilirubin, some cases of severe anemia with heart failure, and cases when infants with chronic blood loss are euvolemic. This procedure decreases plasma antibody titers and bilirubin levels and minimizes fluid overload. An exchange transfusion of a single blood volume (80 to 100 mL/kg, depending on gestational age) removes about 75% of neonatal RBCs, and a double-volume exchange (160 to 200 mL/kg) removes up to 85 to 90% of RBCs and up to 50% of circulating bilirubin ( Treatment references ). Serious adverse effects (eg, thrombocytopenia; necrotizing enterocolitis; hypoglycemia; hypocalcemia; shock, pulmonary edema, or both [caused by shifts in fluid balance]) are common, so the procedure should be done by experienced staff. Guidelines for when to begin exchange transfusion differ and are not evidence based. Recombinant human erythropoietin is not routinely recommended, in part because it has not been shown to reduce transfusion requirements in the first 2 weeks of life. Iron therapy is given to infants who have blood loss (eg, due to hemorrhagic diathesis, gastrointestinal bleeding, frequent phlebotomy). Oral iron supplements are preferred. Parenteral iron may rarely cause anaphylaxis. The American Academy of Pediatrics (AAP) recommends giving breastfed infants a daily liquid iron supplement (1 mg/kg of elemental iron) beginning at 4 months of age until iron-containing solid foods are introduced at about 6 months of age ( Treatment references ). Treatment of more unusual causes of anemia is disorder specific (eg, corticosteroids in Diamond-Blackfan anemia, vitamin B12 for B12 deficiency). 1.New HV, Berryman J, Bolton-Maggs PH, et al: Guidelines on transfusion for fetuses, neonates and older children.Br J Haematol175(5):784–828, 2016. doi: 10.1111/bjh.14233 2.Baker RD, Greer FR, Committee on Nutrition American Academy of Pediatrics: Clinical report—Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0–3 years of age).Pediatrics126(5):1040–1050, 2010. doi: 10.1542/peds.2010-2576 