Subscribe to RSS
DOI: 10.1055/s-0028-1103024
A Management Guideline to Reduce the Frequency of Blood Transfusion in Very-Low-Birth-Weight Infants
Publication History
Publication Date:
15 December 2008 (online)
![](https://www.thieme-connect.de/media/ajp/200903/lookinside/thumbnails/10.1055-s-0028-1103024-1.jpg)
ABSTRACT
Very-low-birth-weight (VLBW) infants often require blood transfusions for anemia. Studies have investigated the preventative effect of delayed cord clamping, high-dose iron, and costly recombinant erythropoietin. As part of our unit clinical governance framework to improving patient care, we audited the effect of a preventative management guideline that combines delayed cord clamping for 30 seconds with early protein intake and early oral iron supplementation (6 mg/kg from days 7 to 10 of life, if milk feeds 60 mL/kg/d) combined with a restrictive transfusion policy in infants < 32 weeks' gestation and < 1500 g birth weight. Data on blood transfusions in VLBW infants during the first 6 weeks of life collected before the start of the new regimen (period I) were compared with data in consecutively born VLBW infants after the introduction of the management guideline (period II). Age (in days) when milk feeds and oral iron supplements were introduced was recorded. Statistical analysis used Wilcoxon signed-rank test. VLBW infants in period I (n = 18, median birth weight 1001 g [727; 1158]) received a median of four transfusions (0.75; 9) compared with 1.5 (0.75; 5, p = 0.01) VLBW infant transfusions in period II (n = 22, median birth weight 967 g [792; 1131]). Milk feeds of 60 mL/kg/d were achieved on median day 12 (6; to 16), and iron was introduced on median day 38 (21; to 44) in period I compared with milk feeds on day 9 (7; 15, p = 0.05) and oral iron on day 16 (11; 21, p < 0001) in period II. The combination of a 30-second delay in cord clamping, early protein and iron, and a change of transfusion thresholds reduced the number of blood transfusions by half.
KEYWORDS
Anemia - transfusion - iron supplementation - cord clamping
REFERENCES
- 1 Ohls R K, Harcum J, Schibler K R, Christensen R D. The effect of erythropoietin on the transfusion requirements of preterm infants weighing 750 grams or less: a randomized, double-blind, placebo-controlled study. J Pediatr. 1997; 131 661-665
- 2 Bolton-Maggs P HB, Murphy M F. Blood transfusion. Arch Dis Child. 2004; 89 4-7
- 3 Murray N A, Roberts I AG. Neonatal transfusion practice. Arch Dis Child Fetal Neonatal Ed. 2004; 89 F101-F107
- 4 Copplestone J A. Changes in blood supplies, regulations, and transfusion practice. BMJ. 2005; 330 268-269
- 5 Brune T, Garritsen H, Witteler R et al.. Autologous placental blood transfusion for the therapy of anaemic neonates. Biol Neonate. 2002; 81 236-243
- 6 Maier R F, Sonntag J, Walka M M et al.. Changing practices of red blood cell transfusions in infants with birth weights less than 1000 g. J Pediatr. 2000; 136 220-224
- 7 National Institute for Clinical Excellence .Principles for Best Practice in Clinical Audit. Oxon, UK; Radcliffe Medical Press 2002
- 8 Rabe H, Reynolds G, Diaz-Rossello J. Early versus delayed umbilical cord clamping in preterm infants. Cochrane Database Syst Rev. 2004 Oct18; (4) CD003248
- 9 Aladangady N, Aitchinson T C, Holland M et al.. Infant's blood volume in a controlled trial of placental transfusion at preterm delivery. Pediatrics. 2006; 117 93-98
- 10 Mercer J S, McGrath M M, Hensman A, Silver H, Oh W. Immediate and delayed cord clamping in infants born between 24 and 32 weeks: a pilot randomized controlled trial. J Perinatol. 2003; 23 466-472
- 11 Aggarwal D, Sachdev H PS, Nagpal J, Singh T, Mallika V. Haematological effects of iron supplementation in breast fed term low birth weight infants. Arch Dis Child. 2005; 90 26-29
- 12 Bechensteen A G, Hågå P, Halvorsen S et al.. Erythropoietin, protein and iron supplementation and the prevention of anemia of prematurity. Arch Dis Child. 1993; 69 19-23
- 13 Feelders R A, Kuiper-Kramer E P, van Eijk H G. Structure, function and clinical significance of transferrin receptors. Clin Chem Lab Med. 1999; 3 1-10
- 14 Franz A R, Mihatsch W A, Sanders S, Kron M, Pohlandt F. Prospective randomized trial of early versus late enteral iron supplementation in infants with a birth weight of less than 1301 grams. Pediatrics. 2000; 106 700-706
- 15 Kivivuori S M, Virtanen M, Raivio K O, Viinikka L, Siimes M A. Oral iron is sufficient for erythropoietin treatment of very low birth weight infants. Eur J Pediatr. 1999; 158 147-151
- 16 Ronnholm K A, Siimes M A. Hemoglobin concentration depends on protein intake in small preterm infants fed human milk. Arch Dis Child. 1985; 60 99-104
- 17 Harris R J. Nutrition in the 21st century: what is going wrong?. Arch Dis Child. 2004; 89 154-158
- 18 Kirpalani H, Whyte K, Andersen C et al.. The Premature Infants in Need of Transfusion (PINT) study: a randomized, controlled trial of a restrictive (low) versus liberal (high) transfusion threshold for extremely low birth weight infants. J Pediatr. 2006; 149 301-307
- 19 Ibrahim H M, Krouskop R W, Lewis D F et al.. Placental transfusion: umbilical cord clamping and preterm infants. J Perinatol. 2000; 20 351-354
- 20 Rabe H, Reynolds G, Diaz-Rossello J. A systematic review and meta-analysis of a brief delay in clamping the umbilical cord of preterm infants. Neonatology. 2008; 93 138-144
- 21 Kugelman A, Borenstein-Levin L, Riskin A et al.. Immediate versus delayed umbilical cord clamping in premature neonates born < 35 weeks: a prospective, randomized, controlled study. Am J Perinatol. 2007; 24 307-315
- 22 McDonnell M, Henderson Smart D J. Delayed umbilical cord clamping in preterm infants: a feasibility study. J Paediatr Child Health. 1997; 33 308-310
- 23 Mercer J S, Vohr B R, McGrath M, Padbury J F, Wallach M, Oh W. Delayed cord clamping in very preterm infants reduces the incidence of intraventricular hemorrhage and late onset sepsis: a randomized, controlled trial. Pediatrics. 2006; 117 1235-1242
- 24 Oh W, Carlo W A, Fanaroff A A. Delayed cord clamping in extremely low birth weight infants—a pilot randomized controlled trial. Pediatr Res. 2002; 51 365-366
- 25 Rabe H, Wacker A, Hulskamp G et al.. A randomized controlled trial of delayed cord clamping in very low birth weight preterm infants. Eur J Pediatr. 2000; 159 775-777
- 26 Strauss R G, Mock D M, Johnson K J et al.. A randomized clinical trial comparing immediate versus delayed clamping of the umbilical cord in preterm infants: short-term clinical and laboratory endpoints. Transfusion. 2008; 48 658-665
- 27 Ultee C A, Swart J, van der Deure J, Lasham C, van Baar A L. Delayed cord clamping in preterm infants delivered at 34 to 36 weeks gestation: a randomized controlled trial. Arch Dis Child Fetal Neonatal Ed. 2008; 93 F20-F23
- 28 Hosono S, Mugishima H, Fujita H et al.. Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born less than 29 weeks' gestation: a randomized controlled trial. Arch Dis Child Fetal Neonatal Ed. 2008; 93 F14-F19
- 29 Dewey K G, Chaparro C M. Symposium on “Nutrition in early life: new horizons in a new century.” Session 4: Mineral metabolism and body composition. Iron status in breast-fed infants. Proc Nutr Soc. 2007; 66 412-422
Heike RabeM.D.
Department of Neonatology, Brighton and Sussex University Hospitals NHS Trust
Eastern Road, Brighton BN2 5BE, UK
Email: Heike.Rabe@bsuh.nhs.uk