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The [[pathogenesis]] of [[anemia of prematurity]] is multifactorial. [[Anemia of prematurity]] is the result of a combination of decreased [[erythropoietin]] production, increased [[erythropoietin]] [[metabolism]], deficient [[iron]] stores, decreased [[RBC]] lifespan, and blood loss during [[phlebotomy]].<ref name="pmid6502312">{{cite journal| author=Stockman JA, Graeber JE, Clark DA, McClellan K, Garcia JF, Kavey RE| title=Anemia of prematurity: determinants of the erythropoietin response. | journal=J Pediatr | year= 1984 | volume= 105 | issue= 5 | pages= 786-92 | pmid=6502312 | doi=10.1016/s0022-3476(84)80308-x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6502312 }} </ref><ref name="pmid20817366">{{cite journal| author=Strauss RG| title=Anaemia of prematurity: pathophysiology and treatment. | journal=Blood Rev | year= 2010 | volume= 24 | issue= 6 | pages= 221-5 | pmid=20817366 | doi=10.1016/j.blre.2010.08.001 | pmc=2981681 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20817366 }} </ref> | The [[pathogenesis]] of [[anemia of prematurity]] is multifactorial. [[Anemia of prematurity]] is the result of a combination of decreased [[erythropoietin]] production, increased [[erythropoietin]] [[metabolism]], deficient [[iron]] stores, decreased [[RBC]] lifespan, and blood loss during [[phlebotomy]].<ref name="pmid6502312">{{cite journal| author=Stockman JA, Graeber JE, Clark DA, McClellan K, Garcia JF, Kavey RE| title=Anemia of prematurity: determinants of the erythropoietin response. | journal=J Pediatr | year= 1984 | volume= 105 | issue= 5 | pages= 786-92 | pmid=6502312 | doi=10.1016/s0022-3476(84)80308-x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6502312 }} </ref><ref name="pmid20817366">{{cite journal| author=Strauss RG| title=Anaemia of prematurity: pathophysiology and treatment. | journal=Blood Rev | year= 2010 | volume= 24 | issue= 6 | pages= 221-5 | pmid=20817366 | doi=10.1016/j.blre.2010.08.001 | pmc=2981681 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20817366 }} </ref> | ||
===Physiological anemia in newborns=== | ===Physiological anemia in newborns=== | ||
Normally, all the [[newborns]] experience a fall in the [[haemoglobin]] concentration during the first few weeks of life. Healthy, [[ | Normally, all the [[newborns]] experience a fall in the [[haemoglobin]] concentration during the first few weeks of life. Healthy, [[full-term]] [[infants]] usually develop [[anemia]] around 10-12 weeks of life after birth. [[Hemoglobin]] concentration never falls below 10 g/dl in healthy [[infants]]. [[Physiological anemia]] is well tolerated and does not require any therapy.<ref name="pmid20817366">{{cite journal| author=Strauss RG| title=Anaemia of prematurity: pathophysiology and treatment. | journal=Blood Rev | year= 2010 | volume= 24 | issue= 6 | pages= 221-5 | pmid=20817366 | doi=10.1016/j.blre.2010.08.001 | pmc=2981681 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20817366 }} </ref> | ||
*After birth, an [[embryo]] transitions from a [[hypoxic]] state in-utero to an [[infant]] in a relatively hyperoxic environment | *After birth, an [[embryo]] transitions from a [[hypoxic]] state [[in-utero]] to an [[infant]] in a relatively hyperoxic environment | ||
*This transition leads to an increase in [[blood oxygen]] and [[tissue oxygen]] concentration in [[newborns]] | *This transition leads to an increase in [[blood oxygen]] and [[tissue oxygen]] concentration in [[newborns]] | ||
*Increased [[oxygen]] concentration inhibits [[erythropoietin]] production and eventually stops [[erythropoiesis]] | *Increased [[oxygen]] concentration inhibits [[erythropoietin]] production and eventually stops [[erythropoiesis]] | ||
*Due to the rapid growth and disproportionate RBC production, [[hemoglobin]] levels fall gradually in infants | *Due to the rapid growth and disproportionate [[RBC production]], [[hemoglobin]] levels fall gradually in infants | ||
*The drop in [[hemoglobin]] concentration continues until the [[tissue hypoxia]] develops which usually takes around 6-12weeks after birth | *The drop in [[hemoglobin]] concentration continues until the [[tissue hypoxia]] develops which usually takes around 6-12weeks after birth | ||
*[[Tissue hypoxia]] activates the [[oxygen sensors]] present in the [[kidney]] and [[liver]] to stimulate the [[erythropoietin]] and [[red blood cells]] production | *[[Tissue hypoxia]] activates the [[oxygen sensors]] present in the [[kidney]] and [[liver]] to stimulate the [[erythropoietin]] and [[red blood cells]] (RBC) production | ||
*[[Fullterm newborns]] have enough iron stores for [[erythropoiesis]] until 20 weeks of life | *[[Fullterm newborns]] have enough iron stores for [[erythropoiesis]] until 20 weeks of life | ||
*Infants have a shorter [[RBC]] lifespan and increased [[ | *Infants have a shorter [[RBC]] lifespan and increased [[erythropoietin]] [[metabolism]] when compared to adults<ref name="pmid8847295">{{cite journal| author=Widness JA, Veng-Pedersen P, Peters C, Pereira LM, Schmidt RL, Lowe LS| title=Erythropoietin pharmacokinetics in premature infants: developmental, nonlinearity, and treatment effects. | journal=J Appl Physiol (1985) | year= 1996 | volume= 80 | issue= 1 | pages= 140-8 | pmid=8847295 | doi=10.1152/jappl.1996.80.1.140 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8847295 }} </ref> | ||
===Pathological Anemia of Prematurity=== | ===Pathological Anemia of Prematurity=== | ||
In [[preterm]] [[infants]], multiple [[physiological factors]] exaggerate and combine to result in [[pathological anemia]]. [[Hemoglobin]] levels drop rapidly to less than 10 g/dl around 4-6 weeks after birth. [[Infants]] with 1-1.5 kg of [[birthweight]] have [[hemoglobin]] levels around 8 g/dl, whereas [[infants]] with [[birthweight]] less than 1 kg have [[hemoglobin]] levels around 7 g/dl or less. The profound decrease in [[hemoglobin]] levels in [[premature infants]] produce abnormal [[signs]] and [[symptoms]] and require a [[blood transfusion]]. <ref name="pmid20817366">{{cite journal| author=Strauss RG| title=Anaemia of prematurity: pathophysiology and treatment. | journal=Blood Rev | year= 2010 | volume= 24 | issue= 6 | pages= 221-5 | pmid=20817366 | doi=10.1016/j.blre.2010.08.001 | pmc=2981681 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20817366 }} </ref> | In [[preterm]] [[infants]], multiple [[physiological factors]] exaggerate and combine to result in [[pathological anemia]]. [[Hemoglobin]] levels drop rapidly to less than 10 g/dl around 4-6 weeks after birth. [[Infants]] with 1-1.5 kg of [[birthweight]] have [[hemoglobin]] levels around 8 g/dl, whereas [[infants]] with [[birthweight]] less than 1 kg have [[hemoglobin]] levels around 7 g/dl or less. The profound decrease in [[hemoglobin]] levels in [[premature infants]] produce abnormal [[signs]] and [[symptoms]] and require a [[blood transfusion]]. <ref name="pmid20817366">{{cite journal| author=Strauss RG| title=Anaemia of prematurity: pathophysiology and treatment. | journal=Blood Rev | year= 2010 | volume= 24 | issue= 6 | pages= 221-5 | pmid=20817366 | doi=10.1016/j.blre.2010.08.001 | pmc=2981681 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20817366 }} </ref> | ||
*[[ | *A greater proportion of [[fetal erythropoiesis]] and [[iron transport]] from [[mother]] to [[infants] occur during the [[third trimester]]. So, [[infants]] born [[prematurely]] have deficient [[iron stores]] required for the [[red blood cells production]] | ||
*[[Blood loss]] during [[phlebotomy]] is the major contributor of [[anemia of prematurity]] | *[[Blood loss]] during [[phlebotomy]] is the major contributor of [[anemia of prematurity]] | ||
*Majority of [[preterm infants]] are [[sick]] and [[critically ill]] that require frequent [[blood sampling]] for various [[laboratory investigations]] needed for their [[clinical monitoring]]. The average amount of [[blood loss]] during [[sampling]] ranges from 0.8-3.1 ml/kg/day, a significant amount that requires replacement | *Majority of [[preterm]] [[infants]] are [[sick]] and [[critically ill]] that require frequent [[blood sampling]] for various [[laboratory investigations]] needed for their [[clinical monitoring]]. The average amount of [[blood loss]] during [[sampling]] ranges from 0.8-3.1 ml/kg/day, a significant amount that requires replacement | ||
*[[Preterm infants]] are at increased risk of [[nosocomial infections]] that lead to [[oxidative hemolysis]] | *[[Preterm]] [[infants]] are at increased risk of [[nosocomial infections]] that lead to [[oxidative hemolysis]] | ||
*In [[premature infants]], [[liver]] is the major site of [[erythropoiesis]]. [[Liver]] [[EPO]] is less sensitive to anemia and tissue hypoxia<ref name="pmid9787158">{{cite journal| author=Dame C, Fahnenstich H, Freitag P, Hofmann D, Abdul-Nour T, Bartmann P | display-authors=etal| title=Erythropoietin mRNA expression in human fetal and neonatal tissue. | journal=Blood | year= 1998 | volume= 92 | issue= 9 | pages= 3218-25 | pmid=9787158 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9787158 }} </ref> | *In [[premature infants]], [[liver]] is the major site of [[erythropoiesis]]. [[Liver]] [[EPO]] is less sensitive to anemia and tissue hypoxia<ref name="pmid9787158">{{cite journal| author=Dame C, Fahnenstich H, Freitag P, Hofmann D, Abdul-Nour T, Bartmann P | display-authors=etal| title=Erythropoietin mRNA expression in human fetal and neonatal tissue. | journal=Blood | year= 1998 | volume= 92 | issue= 9 | pages= 3218-25 | pmid=9787158 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9787158 }} </ref> | ||
*[[Preterm infants]] have deficient [[Vitamin E]], [[Vitamin B12]], [[Folic acid]] stores required for [[red blood cells]] production | *[[Preterm infants]] have deficient [[Vitamin E]], [[Vitamin B12]], [[Folic acid]] stores required for [[red blood cells]] production | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Asra Firdous, M.B.B.S.[2]
Overview
Anemia of prematurity is multifactorial in origin. Phlebotomy is the major contributing factor. Other important factors are decreased erythropoietin production, increased erythropoietin metabolism, deficient iron stores, and decreased RBC lifespan.
Pathophysiology
The pathogenesis of anemia of prematurity is multifactorial. Anemia of prematurity is the result of a combination of decreased erythropoietin production, increased erythropoietin metabolism, deficient iron stores, decreased RBC lifespan, and blood loss during phlebotomy.[1][2]
Physiological anemia in newborns
Normally, all the newborns experience a fall in the haemoglobin concentration during the first few weeks of life. Healthy, full-term infants usually develop anemia around 10-12 weeks of life after birth. Hemoglobin concentration never falls below 10 g/dl in healthy infants. Physiological anemia is well tolerated and does not require any therapy.[2]
- After birth, an embryo transitions from a hypoxic state in-utero to an infant in a relatively hyperoxic environment
- This transition leads to an increase in blood oxygen and tissue oxygen concentration in newborns
- Increased oxygen concentration inhibits erythropoietin production and eventually stops erythropoiesis
- Due to the rapid growth and disproportionate RBC production, hemoglobin levels fall gradually in infants
- The drop in hemoglobin concentration continues until the tissue hypoxia develops which usually takes around 6-12weeks after birth
- Tissue hypoxia activates the oxygen sensors present in the kidney and liver to stimulate the erythropoietin and red blood cells (RBC) production
- Fullterm newborns have enough iron stores for erythropoiesis until 20 weeks of life
- Infants have a shorter RBC lifespan and increased erythropoietin metabolism when compared to adults[3]
Pathological Anemia of Prematurity
In preterm infants, multiple physiological factors exaggerate and combine to result in pathological anemia. Hemoglobin levels drop rapidly to less than 10 g/dl around 4-6 weeks after birth. Infants with 1-1.5 kg of birthweight have hemoglobin levels around 8 g/dl, whereas infants with birthweight less than 1 kg have hemoglobin levels around 7 g/dl or less. The profound decrease in hemoglobin levels in premature infants produce abnormal signs and symptoms and require a blood transfusion. [2]
- A greater proportion of fetal erythropoiesis and iron transport from mother to [[infants] occur during the third trimester. So, infants born prematurely have deficient iron stores required for the red blood cells production
- Blood loss during phlebotomy is the major contributor of anemia of prematurity
- Majority of preterm infants are sick and critically ill that require frequent blood sampling for various laboratory investigations needed for their clinical monitoring. The average amount of blood loss during sampling ranges from 0.8-3.1 ml/kg/day, a significant amount that requires replacement
- Preterm infants are at increased risk of nosocomial infections that lead to oxidative hemolysis
- In premature infants, liver is the major site of erythropoiesis. Liver EPO is less sensitive to anemia and tissue hypoxia[4]
- Preterm infants have deficient Vitamin E, Vitamin B12, Folic acid stores required for red blood cells production
- A combination of blood loss, decreased erythropoietin production, deficient iron stores, increased erythropoietin metabolism, shortened RBC lifespan contribute to the development of anemia of prematurity
References
- ↑ Stockman JA, Graeber JE, Clark DA, McClellan K, Garcia JF, Kavey RE (1984). "Anemia of prematurity: determinants of the erythropoietin response". J Pediatr. 105 (5): 786–92. doi:10.1016/s0022-3476(84)80308-x. PMID 6502312.
- ↑ 2.0 2.1 2.2 Strauss RG (2010). "Anaemia of prematurity: pathophysiology and treatment". Blood Rev. 24 (6): 221–5. doi:10.1016/j.blre.2010.08.001. PMC 2981681. PMID 20817366.
- ↑ Widness JA, Veng-Pedersen P, Peters C, Pereira LM, Schmidt RL, Lowe LS (1996). "Erythropoietin pharmacokinetics in premature infants: developmental, nonlinearity, and treatment effects". J Appl Physiol (1985). 80 (1): 140–8. doi:10.1152/jappl.1996.80.1.140. PMID 8847295.
- ↑ Dame C, Fahnenstich H, Freitag P, Hofmann D, Abdul-Nour T, Bartmann P; et al. (1998). "Erythropoietin mRNA expression in human fetal and neonatal tissue". Blood. 92 (9): 3218–25. PMID 9787158.