Anemia of prematurity medical therapy
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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
PRBC transfusion is the mainstay in the treatment of anemia of prematurity.Treatment of infants with anemia of prematurity depends on the severity of symptoms. Blood transfusion and recombinant erythropoietin therapy are used to treat symptomatic infants
Medical therapy
The optimal therapy for anemia of prematurity depends on the severity of symptoms. Patients with asymptomatic anemia of prematurity require observation and supportive care, whereas symptomatic patients are treated either with blood transfusion or recombinant erythropoietin (EPO) therapy. [1]
Asymptomatic patients
- Patients with no symptoms, stable vital signs, and adequate nutrition require no treatment
- Close monitoring and supportive care are the preferred management in asymptomatic infants with anemia of prematurity
- Measures should be taken to maintain adequate levels of vitamin E, vitamin B12, vitamin B6, and iron
- Regular checking of hematocrit is essential in infants with anemia of prematurity until a steady increase in the hematocrit levels has been achieved
Symptomatic patients
Blood transfusion is the mainstay in the treatment of infants with symptomatic anemia of prematurity. Exogenous recombinant human erythropoietin can also be used.
Erythropoietin
- Recombinant human erythropoietin is used in premature infants to decrease the number of complications associated with transfusion therapy
- The subcutaneous route is the preferred route of administration
- The preferred regimen is 400U/kg/dose through the subcutaneous route (SC) 3 times a week or 200U/kg/dose through intravenous (IV) route daily
- Preterm infants respond well to erythropoietin (EPO) therapy with reticulocytosis
- Supplemental iron and folic acid should be co-administered
- The preferred regimen for iron supplementation is 6-8 mg/kg/day orally or 1 mg/kg IV iron sucrose or iron dextran
- Regular monitoring of serum iron levels should be done using serum ferritin or zinc protoporphyrin to heme ratio, monthly or bimonthly
- Although no adverse effects have been documented in the newborns, erythropoietin therapy is not universally accepted as the standard therapy for infants with anemia of prematurity
- Erythropoietin (EPO) helps in preventing anemia of prematurity in preterm and low birth weight infants
- Alternatively, Darbepoietin alpha can also be used
Blood Transfusion
- Transfusion therapy is the mainstay in the treatment of anemia of prematurity
- Frequency of transfusions depends on the gestational age and severity of symptoms
- A transient decrease in the erythropoiesis and erythropoietin levels occur after the blood transfusion
- PRBC transfusion results in an increase in systemic oxygen transport and decrease in lactic acid levels, cardiac output, and fractional oxygen extraction
- Transfusion guidelines that should be followed in infants with anemia of prematurity are
- 15-20 mg/kg of PRBC transfused over 3-4 hours
- Irradiated, CMV negative, leukocyte depleted, hemoglobin S negative, typed and screened PRBC should be used for transfusion
- If hematocrit is less than 35% in first week after birth and infant is unstable
- If hematocrit is less than 28% in first week after birth or infant is unstable
- If hematocrit is less than 20% after one week of birth
- Significant infectious, hematologic, immunologic, metabolic complications are associated with blood transfusion in infants so standard protocols should be followed
- Complications associated with blood transfusion are
- Allergic reactions
- Infections
- Fluid overload
- Calcium disturbance
- Electrolyte imbalance
- Immune mediated adverse reactions like acute hemolytic reaction, febrile non-hemolytic transfuion reaction, transfusion-related acute lung injury, graft versus host disease, and immunosuppression
- Iron overload
- Transfusion of toxic substances present in the blood like lead, mercury, and plasticizers