Anemia in Newborn

Anemia developing during the neonatal period (0-28 days of life)

in infants of >34 weeks gestational age

central venous hemoglobin <13 g/dL or

a capillary hemoglobin <14.5 g/dL

ERYTHROID DEVELOPMENT

< 8 weeks : Fetal Yolk Sac

8 weeks : Fetal Liver

24 weeks: Bone marrow

ERYTHROPOIETIN

Stimulates proliferation of erythroid progenitors

Does not cross placenta

EPO concentration increases from 4 mU/ ml at 16 weeks gestation to 40 mU/ ml at 40 weeks

HEMOGLOBIN LEVELS

Gestational Age: Hb directly proportional to GA

18-20 w – 11.5 g/dL

23-25 w – 12.4 g/dL,

26-30 w – 13.4 g/dL,

32- 40w- 17.0 g/dL

Site of Sampling: capillary Hb > venous Hb

Postnatal age

PHYSIOLOGIC ANEMIA OF INFANCY

In Utero: fetal oxygen saturation 45%

EPO levels increase RBC production, Retics 3-7%

At Birth:

Neonatal oxygen saturation increase 95%

EPO level decrease

RBC production decrease, Retics decrease 0 – 1% by day 7

8-12 Weeks :

Hb nadir in term infants – Hb drops to 10 g/ dl

EPO production increase, RBC production increase

PATHOPHYSIOLOGY

Anemia in the newborn infant results from one of the three processes:

Loss of RBCs (Hemorrhagic anemia): most common

Increased destruction of RBCs (Hemolytic anemia)

Underproduction of RBCs (Hypoplastic anemia)

Hemorrhagic anemia

Antepartum period

Loss of placental integrity : abruptio placentae, placenta previa, traumatic amniocentesis

Anomalies of the umbilical cord or placental vessel: velamentous insertion of the umbilical cord, vasa praevia, umbilical cord hematoma.

Twin-twin transfusion: the different in Hb concentration between twin is >5 g/dL

Intrapartum period

Fetomaternal hemorrhage

Cesarean section

Traumatic rupture of the umbilical cord

Failure of placental transfusion: umbilical cord occlusion

Obstetric trauma: intracranial hemorrhage

Neonatal period

Enclosed hemorrhage: caput succedaneum, cephalhematoma, intracranial hemorrhage

Defects in hemostasis: congenital coagulation factor deficiency, thrombocitopenia

Iatrogenic blood loss: loss of 20%

HEMOLYTIC ANEMIA

Immune hemolysis:

Isoimmune hemolytic anemia: Rh incompatibility

Autoimmune hemolytic anemia

Nonimmune hemolysis

Bacterial sepsis

Congenital TORCH

Congenital erythrocyte defect

Metabolic enzyme deficiency: G6PD deficiency, pyruvate kinase deficiency

Thalassemia

Hemoglobinopathy

Membran defect: hereditary spherocytosis, hereditary elliptocytosis

Systemic diseases:

Galactosemia

Osteopetrosis

Nutritional deficiency: Vit E deficiency

HYPOPLASTIC ANEMIA

Congenital disease: Diamond-Blackfan syndrome, congenital leukemia

Acquired disease: infection, aplastic anemia.

Diamond- Blackfan syndrome – pure red cell aplasia

Physiologycal impact

Compensatory Responses

tachycardia

tachypnea

decreased activity

increased erythropoiesis

Physiologycal impact

CONSEQUENCES

cardiac strain

periodic breathing / apnea

increased work of breathing

lethargy, poor feeding

poor growth

anerobic metabolism / lactic acidosis

CLINICAL PRESENTATION

Hemorrhagic anemia

Acute: pallor, tachypnea or gasping respirations, vascular instability.

Chronic: unexplained pallor, minimal sign of respiratory distress, liver enlargement.

Hemolytic anemia: jaundice, pallor, tachypnea, hepatosplenomegaly.

Hypoplastic anemia: presentation after 48 h age, absence of jaundice, reticulocytopenia.

DIAGNOSIS

History: obstetric, neonatal, family

Physical exam: signs of acute blood loss,hemolysis

Lab evaluation:

Hb or Hct

Reticulocyte count

Peripheral blood smear

Coomb’s test, Bilirubin level

Kleihauer – Betke

Bone marrow

Kleihauer – Betke test

TREATMENT

What is the cause of the anemia?

How well is the baby compensating?

How urgently does the anemia need to be corrected?

Risk / benefit analysis of treatment?

Simple replacement transfusion: acute hemorrhagic anemia

–type O, Rh-negative packed RBCs, fresh frozen plasma, dextran

Exchange transfusion: chronic hemolytic anemia, severe isoimmune hemolytic anemia.

Nutritional replacemen: iron, folate, vitamin E.

Packed Red Blood Cell Transfusions

Guidelines controversial and variable

In general:

Replace acute blood loss

Correct anemia that is compromising cardiovascular status or oxygen carrying capacity

Recombinant Human Erythropoietin

Reducing blood transfusions in anemia of prematurity

Over 20 controlled trials published

Modest benefit at best

Conservative transfusion criteria / ¯ phlebotomy loss

Cost effectiveness debated

Need for iron supplementation

IRON SUPPLEMENTATION

Breast fed term babies: 0

Formula fed term babies:

iron fortified formula = 2 mg / kg/ day

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