Historical Perspectives: Perinatal Profiles: Geoffrey S. Dawes: A Neonatologist's Appreciation Roderic H.

Phibbs NeoReviews 2007;8;e365-e367

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://neoreviews.aappublications.org/cgi/content/full/neoreviews;8/9/e365

NeoReviews is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 2000. NeoReviews is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2007 by the American Academy of Pediatrics. All rights reserved. Online ISSN: 1526-9906.

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historical perspectives

Perinatal Profiles: Geoffrey S. Dawes: A Neonatologist’s Appreciation
Roderic H. Phibbs, MD*

Introduction
When neonatology was emerging as a clinical discipline in the late 1950s and early 1960s, it had the advantage of a strong foundation of basic research in fetal and neonatal physiology. In particular, the new clinical enterprise (it was not yet a subspecialty) focused on cardiorespiratory pathophysiology. This foundation came from a few distinguished research laboratories studying fetal and neonatal physiology and the processes of the transition from fetal to neonatal life. The preeminent laboratory in the field was the Nuffield Institute for Medical Research at Oxford, directed by Geoffrey S. Dawes. Geoffrey Dawes became the director of the Institute in 1948. He received his medical degree in 1943, and in the following 5 years, he gained recognition as a prominent investigator in pharmacology and physiology. The very short interval between receiving his degree and being named director of an important research institute indicates how quickly the academic leadership recognized his exceptional qualities. As the new director, Dawes set the primary focus of research for the Nuffield Institute as developmental physiology. In this role, the Nuffield became the successor to the path of research started by Sir Joseph Barcroft at Cambridge early in the twentieth century. Dawes and his co-

The Underpinnings of Neonatal/Perinatal Medicine
Author Disclosure Dr Phibbs did not disclose any financial relationships relevant to this article.

investigators concentrated particularly on the preparations for and mechanisms of adaptation to extrauterine life. A central focus of the research was the adaptive mechanisms in the circulatory and respiratory systems, including placental function, establishment of lung function, and changes in the pulmonary and systemic circulations. Although most of the work examined cardiorespiratory physiology and its neurohumoral regulation, researchers also studied fetal growth and metabolism, and their studies included the responses to stresses such as hypoxia and hemorrhage. One of the hallmarks of the research of this highly productive group was the elegance of their experimental designs.

Responses to Stress
The clinical implications of this work were self-evident. What happened when the adaptive mechanisms for extrauterine life failed? What were the responses to stresses such as asphyxia? Beginning in 1958, Dawes and his associates had an ideal opportunity to expand this line of research. The United States National Institutes of Health were supporting studies on the mechanisms of brain injury in the fetus and newborn being performed in a primate laboratory in Puerto Rico, and various groups of investigators were invited to participate in the different aspects of the research. Dawes and the Nuffield team were among those invited to collaborate and made several extended visits over the next few years to conduct research with other investigators, particularly Stanley James and Karlis Adamsons. They made exNeoReviews Vol.8 No.9 September 2007 e365

*Department of Pediatrics and Cardiovascular Research Institute, University of California, San Francisco, Calif.

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Fetal Physiology
During the formative era of “modern” neonatology, ie, neonatal care based on cardiopulmonary pathophysiology in the mid to late 1950s and early 1960s, many conferences dealt with the general topic of how to deploy a system of physiology-based care for newborns. Dawes was highly sought after for such conferences as much for his insightful, probing commentary on the work of others as for presentation of his own research. A good example of these times was the Ross Conference “Adaptations to Extrauterine Life,” held in Vancouver in November 1958. The Session Chairs were Dawes and McCance from Cambridge, and Harvard’s Clement Smith, the author of the text Physiology of the Newborn Infant, which was required reading for budding neonatologists. Mildred Stahlman, L. Stanley James, Thomas Oliver, Sidney Segal, and Jim Sutherland were among the attendees who were emerging as some of the early leaders in neonatology. In this program, Dawes’ presentation was effects of anoxia on newborn animals. The proceedings of the conference reflect the interests and intellectual energy of the formative years of neonatology. The program ended with a roundtable discussion on clinical applications in which McCance commented on “euthermia versus hypothermia” and Smith commented on “the effects of placental transfusion,” both subjects of research publications in 2006 and 2007. In 1967, Julius Comroe, the director of at the Cardiovascular Research Institute at the University of California, San Francisco (UCSF), invited Geoffrey Dawes to take a sabbatical at the Institute to write the book on fetal physiology. Dawes accepted and came to San Francisco for the latter half of 1967. Comroe provided Dawes with editorial staff, a

Figure. The paradigm of the progression of cardiorespiratory changes during asphyxia.

Reprinted with permission from Dawes GS. Fetal and Neonatal Physiology. Chicago, Ill: Yearbook Medical Publishers, Inc; 1968.

tensive observations of the sequences of responses to progressive asphyxia. The resulting studies brought forth the paradigm of the progression of cardiorespiratory changes during asphyxia. The Figure from Dawes’ book that illustrates this paradigm has been reproduced both in its original form and with minor modifications in many clinical textbooks, usually as the starting point for a discussion of fetal asphyxia. (For exe366 NeoReviews Vol.8 No.9 September 2007

ample, see Figures 1.6 and 1.7 on page 1–7 of the Fourth Edition the American Academy of Pediatrics Textbook of Neonatal Resuscitation). They also started to study the responses to various components of resuscitation. For example, they demonstrated that when heart failure is due to acute asphyxia, correction of acidosis by an infusion of alkali quickly restores normal myocardial contractility.

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medical illustrator, and an editorial advisory committee of physiologists who met with him weekly to critique his most recent chapter. Dawes clearly wanted the text to appeal to clinicians as well as physiologists, meeting frequently with Bill Tooley, the head of neonatology at UCSF, to discuss his strategy for upcoming chapters and regularly attending the weekly neonatal/perinatal clinical conferences, where he was an imposing presence. The product of the sabbatical was the superbly written and beautifully illustrated Fetal and Neonatal Physiology, published by Year Book Medical Publishers, Inc, in 1968. Although not a clinical text in the strict sense, most of the book is highly relevant to the practice of clinical neonatology. It quickly became required reading for serious students of neonatology. It remains highly relevant today and is so well written and illustrated that it probably still should be required reading for neonatologists in training. The original home for the Nuffield Institute for Medical Research was in an abandoned astronomical observatory in central Oxford. The building was designed by Christopher Wren, the great 17th century architect who designed many of the important buildings built after the great fire of London. However, this fine building of historic interest was not well suited for experimental physiology. When a new hospital of Obstetrics and Neonatal Pediatrics was built at Headington on the outskirts of Oxford, the Nuffield Institute moved into a large new facility immediately adjacent the clinical buildings, which was symbolic of Dawes’ close ties to clinical perinatology and neonatology. There was continuous exchange between the buildings, and Dawes regularly at-

tended and participated actively in the weekly perinatal/neonatal clinical conferences. The proximity of the clinical units facilitated the Institute’s close collaboration with obstetricians and pediatricians. When Dawes began using the chronic in utero fetal lamb preparation, he noticed that fetal lambs made intermittent respiratory movements that occurred during rapid eye movement sleep. Moving to the human, his obstetrically trained research fellows could detect fetal breathing movements by ultrasonography that also were intermittent. These observations spawned a burst of clinical research in many centers as perinatologists studied the effects of various maternal states on fetal breathing. In time, fetal breathing movements became part of the biophysical profile of fetal well-being. As Dawes became familiar with the clinical methods of assessing fetal well-being, he was unhappy with the way fetal heart rate tracings were used to detect a fetus in distress because the system depended on expert recognition of particular patterns. He accumulated a very large database of digitized human fetal heart rate tracings and, with his strong background in mathematics, launched on a large-scale analysis. Ultimately, he developed a program that would allow automated detection of fetal distress. An instrument company produced a microprocessor that used his method to detect troublesome patterns of the fetal heart rate.

Developing Leaders
Another major contribution of Dawes was the development of leaders in academic neonatology and perinatology. There were three types of researchers at the Nuffield. The first were what might be considered the permanent scientists, some of

whom stayed on for many years and others of whom were there for several years, then moved to other academic positions, usually in physiology. The second group was the research fellows in training. Some of these were predoctorate, but in later years, many were postdoctorate pediatricians and obstetricians. The attraction of the Nuffield for physicians headed for careers in academic neonatology and perinatology were obvious, so talented young clinicians flocked to the Institute. They later filled many university faculty positions in neonatology and perinatology, particularly in the United Kingdom, Canada, the United States, Australia, and New Zealand. The third group of investigators was the established academicians, usually in perinatology, neonatology, or physiology, who spent a sabbatical leave (generally 6 months to 1 year) working in the Institute before returning to their home medical schools. The investigators who passed through the Nuffield became a sort of informal network that continued to communicate and often collaborate in research. Many of Geoffery Dawes’ long list of awards are related to neonatology and perinatology. Some of these include Fellow, Royal Collage of Obstetricians and Gynaecologists, the American Academy of Pediatrics, and American Collage of Obstetricians and Gynecologicts; the Apgar Award from the American Academy of Pediatrics; and the James Spence Award from the British Pediatric Association. Geoffrey Dawes stepped down as the director of the Nuffield Institute in 1985 and died in 1996. A more complete appreciation of him by Sir Graham Liggins appeared in Biographical Memoirs of Fellows of the Royal Society 1998.

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Historical Perspectives: Perinatal Profiles: Geoffrey S. Dawes: A Neonatologist's Appreciation Roderic H. Phibbs NeoReviews 2007;8;e365-e367

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Developmental Defects in Neutrophils from Preterm Infants Sharat Chandra, Hillary Haines, Colin Michie and Akhil Maheshwari NeoReviews 2007;8;e368-e376

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://neoreviews.aappublications.org/cgi/content/full/neoreviews;8/9/e368

NeoReviews is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 2000. NeoReviews is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2007 by the American Academy of Pediatrics. All rights reserved. Online ISSN: 1526-9906.

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Article

hematology

Developmental Defects in Neutrophils from Preterm Infants
Sharat Chandra, MD, MRCPCH,* Hillary Haines, MD,† Colin Michie, FRCPCH, Akhil Maheshwari, MD†§

Objectives

After completing this article, readers should be able to:

1. Define key neutrophil functions and involved mechanisms. 2. Identify developmental defects in preterm neutrophils. 3. Describe the effect on neutrophils of clinical interventions, such as the use of recombinant myeloid growth factors and drugs commonly used in the neonatal intensive care unit.

Author Disclosure Drs Chandra, Haines, Michie, and Maheshwari did not disclose any financial relationships relevant to this article.

Abstract
Neutrophil development starts in the early second trimester in the human fetus and continues through the rest of the gestation. Preterm birth can interrupt the maturation of fetal neutrophils and place the preterm neonate at risk of life-threatening infections. Various developmental defects have been identified in preterm neutrophils, such as in the ability of circulating neutrophils to cross the endothelial barrier and abnormalities in chemotaxis, respiratory burst, and degranulation. The availability of recombinant human myeloid growth factors has renewed interest in understanding the mechanisms and natural history of such defects. In this article, we review various aspects of the developmental immaturity of preterm neutrophils.

Introduction
Neutrophils are the first-line defenders against bacterial and fungal pathogens. In the human fetus, neutrophil development starts at a relatively late stage (10 to 14 weeks’ gestation), when hematopoietic progenitor cells in the bone marrow begin to differentiate into neutrophil precursors. (1)(2) Functional maturation of neutrophils continues through the rest of the gestation, and interruptions in this process due to preterm birth can place the preterm neonate at risk of life-threatening infections.

Neutrophil Kinetics
Bone marrow neutrophils are broadly classified into early precursors that have a capacity for four to five cell divisions and the later, postmitotic stages that are in the process of differentiation (Fig. 1). Studies in adults show that the neutrophil proliferating pool (NPP) contains about 2 109 cells/kg body weight, and the neutrophil storage pool (NSP) contains about 6 109 cells/kg body weight. (1) The NPP and NSP together contain nearly 90% of all neutrophils in the body. The remaining 10% (0.6 109 cells/kg body weight) are distributed equally free in circulation or emarginated to the vascular endothelium in microcirculatory channels. During acute inflammation, neutrophils are released initially from the NSP, and once these stores are exhausted, progressively immature cells are mobilized (the “left” shift of sepsis). Circulating neutrophils persist in the bloodstream for 6 to 8 hours and subsequently for a few hours to several days in tissues.

Developmental Defects
In the mid-gestation fetus and preterm infant, the NSP is very small and can be exhausted readily during sepsis. (1) The NPP also is smaller, about one-tenth the size (per kilogram
*Department of Pediatrics, University of South Alabama, Mobile, Ala. † Department of Pediatrics, University of Alabama at Birmingham, Ala. ‡ Department of Paediatrics, Ealing Hospital, NHS Trust, London, United Kingdom. § Department of Cell Biology, University of Alabama at Birmingham, Ala. e368 NeoReviews Vol.8 No.9 September 2007

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that have a glutamate-leucinearginine (ELR) tripeptide sequence (such as interleukin-8 [IL-8/ CXCL8]) have neutrophil-specific chemotactic activity. (12) In inflamed areas, transient interruptions in the flow of marginating neutrophils cause them to roll on the vascular endothelial surface. This process is mediated through a process of repetitive binding and release of the selectin ligands (Lselectin on neutrophils, E- and P-selectin on endothelium) from their sialomucin receptors called Figure 1. Neutrophils differentiate in the bone marrow through a series of well-defined addressins. The term “selectin” is stages, which can be grouped broadly into the neutrophil proliferating pool (NPP) and the derived from a key lectin domain neutrophil storage pool (NSP). In the preterm infant, the size of the NSP is very small and that interacts selectively with can be depleted easily during sepsis. oligosaccharide receptors bearing sialylated carbohydrate moieties. L-selectin is expressed constitutively on neutrophils and is shed after cellular activation. of body weight) seen in adults. (3) In extremely preterm (13) In contrast, E- and P-selectin appear on endothelial neonates, the total neutrophil mass (estimated indirectly cells during inflammation and represent the “reserve” by measuring plasma concentrations of soluble CD16, capacity for neutrophil recruitment that is deployed durwhich is shed from the neutrophil surface) is about one ing a microbial insult. (14) fifth of that seen in adults. (4) Rolling neutrophils slow down and attach to endothelium through the binding of beta2-integrins to variEffect of Common Clinical Interventions ous receptors on endothelial cells. (15) These beta2- or Recombinant granulocyte colony-stimulating factor (Gleukocyte integrins are heterodimeric molecules that CSF), granulocyte macrophage colony-stimulating facmediate cell-cell and cell-matrix interactions. Neutrotor (GM-CSF), and corticosteroids can release neutrophils display three integrins that have an identical 95phils from the NSP. (5)(6)(7) Epinephrine can release kDa beta2-chain (CD18): leukocyte function-associated emarginated neutrophils rapidly into circulation for antigen-1 (LFA-1, alphaLbeta2, CD11a/CD18), Mac-1 about 30 to 45 minutes. (8) A mild demarginating (alphaMbeta2, CD11b/CD18), and p150,95 (alphaX response also has been reported in preterm infants after beta2, CD11c/CD18). These integrins bind to endothered cell transfusions. (9) lial receptors such as the intercellular adhesion molecule-1 (ICAM-1) and ICAM-2. LFA-1 binds to Recruitment of Circulating Neutrophils to both ICAM-1 and ICAM-2; Mac-1 and p150,95 bind Sites of Inflammation exclusively to ICAM-1. ICAM-3 is expressed on hemaCirculating neutrophils leave the intravascular comparttopoietic cells and does not participate in leukocytement to enter the tissues in three major steps: marginendothelial interactions. Integrin activation requires ation and rolling on vascular endothelium, attachment to chemokines such as IL-8 (produced by activated endothe endothelial cells, and transendothelial migration thelium), which increase the number and avidity of (Fig. 2). (10)(11) Leukocyte traffic is directed preferenbeta2-integrins and cause rearrangement of the cytotially to inflamed areas through regional changes in skeleton. (16) ICAM-2 is expressed constitutively on vascular flow and along concentration gradients of endothelial cells and may act as the initial ligand for humoral chemoattractants such as chemokines, bacterial neutrophil integrins. ICAM-1, like E-selectin, is upreguproducts (such as formyl-met-leu-phe [f-MLP]), comlated during inflammation. (17) plement fragments (C5a), and leukotrienes (LTB4). Transendothelial migration (TEM) of activated neuAmong chemokines, members of the CXC subfamily trophils involves the platelet-endothelial cell adhesion
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preterm and term neonates. Mac-1 expression is about 10% of adult levels at 27 weeks’ gestation, increases to 45% at 36 weeks’ gestation, is 57% at term, and reaches adult values in early childhood. (23) Although most studies are in agreement on lower Mac-1 expression on neonatal neutrophils, there is one report of normal Mac-1 in neonates, and the authors cautioned that neutrophil isolation techniques can influence Mac-1 exFigure 2. Schematic representation of recruitment of circulating neutrophils to inflamed pression. (24) tissues. Neutrophils adhere transiently to inflamed endothelium to roll on its surface, slow TEM of neutrophils is affected down and attach to the endothelium, become activated, and migrate through the by their deformability. Although endothelium into the tissues. initial studies reported conflicting data, deformability of mature restmolecule (PECAM1, CD31), the integrin-associated ing neutrophils appears to be similar in healthy preterm protein (IAP, CD47), and a number of other junctional neonates, term neonates, and adults. (25) However, the molecules. (18) TEM is a rapidly occurring process that release of immature neutrophils from the NSP during is completed in less than 2 minutes after leukocytesepsis is associated with an overall reduction in neutroendothelial contact is established and may occur either phil deformability. (26) through transcellular diapedesis or via active migration of neutrophils through “pores” at tricellular endothelial Effect of Common Clinical Interventions junctions. G-CSF increases the expression of beta2-integrins, but lowers L-selectin expression on neonatal neutrophils Developmental Defects (both term and preterm). (27) In contrast, early dexaCompared with neutrophils from adults, neutrophils methasone administration decreases beta2-integrin exfrom both term and preterm neonates adhere poorly to pression on neutrophils. (28) the endothelium. Neonatal neutrophils have lower selectin and beta2-integrin expression. L-selectin expression is Chemotaxis lower at birth than in adults and decreases further during Once outside the blood vessel, neutrophils migrate along the first 24 to 72 hours after birth. (19) Neonatal concentration gradients of various chemoattractants “stress,” as in perinatal asphyxia, may reduce further such as IL-8 (and other ELR CXC chemokines), L-selectin expression on neutrophils. (20) In addition, f-MLP, and C5a. (12) These chemotactic stimuli bind to neonatal neutrophils have defective shedding of high-affinity G-protein-coupled receptors on the leukoL-selectin. (19) The combination of lower expression cyte surface, and minute spatial gradients in chemoatand impaired shedding of L-selectin reduces the fretractant concentrations can cause the receptors to be quency of neutrophil rolling events, which are a ratedistributed asymmetrically toward the migrating neutrolimiting step in tissue recruitment of neutrophils. Charphil pseudopodium. Cellular movement involves a numacteristics of preterm vascular endothelium, such as lower ber of intracellular signaling pathways and cytoskeletal P-selectin expression, contribute further to defects in proteins. A chemoattractant hierarchy has been reported neutrophil recruitment. (21) wherein bacterial products are preferred over host cheNeonatal neutrophils have lower expression of Macmokines. (29) 1(CD18/CD11b), one of the beta2-integrins, which correlates with lower neutrophil-endothelial adherence Developmental Defects and transmigration. (22) Neutrophils from both preNeutrophils from both term and preterm neonates have term and term infants are unable to upregulate Mac-1 an impaired chemotactic response. Neutrophils from expression following stimulation by bacterial products. newborns migrate at about half the speed traveled by The absolute Mac-1 content per neutrophil is lower in adult cells. (30)(31) Although neutrophils from term
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infants achieve normal chemotactic function by 2 weeks after birth, such postnatal neutrophil maturation begins 2 to 3 weeks after birth in immature preterm infants and proceeds very slowly. (32) Neutrophils from preterm infants born at 34 to 36 weeks’ gestation achieve normal chemotaxis by 40 to 42 weeks postconceptional age (PCA). In more immature preterm infants ( 34 wk), neutrophil chemotaxis improves with time but remains impaired compared with adults, even at 42 weeks PCA. (33) The presence of various clinical confounders makes it difficult to separate the effects of clinical stress from the effects of prematurity on neutrophil function. Gramnegative sepsis may depress neutrophil chemotaxis; superficial infections are associated with enhanced chemotaxis. (34)(35) Neonatal neutrophils bind various chemoattractants normally. However, chemoattractant-induced membrane depolarization, calcium transport, and sugar uptake are relatively less efficient. Neonatal neutrophils show an incremental chemotactic response to increasing chemokine concentrations, but these responses remain lower than in adult neutrophils. (36) The chemotactic defect in neonatal neutrophils may be multifactorial, affected by factors such as a larger, poorly motile neutrophil subpopulation; impaired calcium mobilization; and aberrations in intracellular signaling pathways such as nuclear factor-kappa-B activation. (37)(38) Lower Mac-1 expression also can impede chemotaxis due to impaired neutrophil interaction with the extracellular matrix. (37)(39)

Effect of Common Clinical Interventions
In preterm infants, intrapartum exposure to magnesium sulfate reduces both neutrophil chemotaxis and random motility. (40) Theophylline concentrations in the high therapeutic range (84 mcmol/L or 15 mcg/mL) cause dose-dependent reductions in neutrophil chemotaxis. Cells from preterm infants are particularly sensitive to this effect. In contrast, theophylline concentrations in the low therapeutic range (28 mcmol/L or 5 mcg/mL) increase neutrophil activity. (41) Indomethacin also has an adverse effect on neutrophil chemotaxis, which is more pronounced in preterm infants. (42) Both G-CSF and GM-CSF increase neutrophil chemotactic responsiveness to other chemoattractants. (43)

fuses with a lysosome for killing of internalized microorganisms and terminal degradation of the cargo. (44) Phagocytosis is more efficient when the target is opsonized by specific immunoglobulin G (IgG) or complement factors. IgG promotes phagocytosis by neutralizing bacterial inhibitors of phagocytosis such as the capsular polysaccharide and by activating the classic pathway of complement that provides the opsonic C3 fragments. Opsonins also convert the relatively hydrophilic microbial surface to be more hydrophobic and, therefore, more readily ingested. Neutrophils express receptors for IgG (Fcgamma receptors I-III, or CD16, CD32, CD64), C3b (CR1), and iC3b (CR3). In some instances, microorganisms may be ingested without opsonization through lectin-carbohydrate (lectins on bacterial fimbriae interact with neutrophil glycoproteins), proteinprotein (proteins such as filamentous hemagglutinin that express the arg-glyasp or RGD amino acid sequence bind to integrins), and hydrophobic-protein (bacterial glycolipids and neutrophil integrins) interactions. (44)(45) The interaction of IgG or complement receptors on the neutrophil surface with the opsonized particle trigger cytoskeletal rearrangements to enclose the opsonized particle within a phagosome. Phagocytosis is most efficient when organisms are coated with both IgG and C3, which allows cooperative interaction of cognate receptors for both the opsonins. As mentioned previously, neutrophils express integrin receptors for matrix proteins with the RGD tripeptide motif (such as fibronectin, laminin, and collagen) and ingest C3-coated particles more efficiently when adherent to surfaces coated with these RGD-bearing proteins. (44)(46)(47)

Developmental Defects
Neutrophils from preterm neonates have a developmental defect in phagocytosis that corrects by late third trimester or term gestation (to become comparable to adult neutrophils). (31) Preterm neutrophils ingest particles more slowly and ingest fewer bacteria (such as Escherichia coli). The lack of opsonic activity is an important consideration because preterm infants often have lower concentrations of specific antibodies. Adult neutrophils lose their phagocytic efficiency if suspended in serum of preterm infants. (48) Similarly, neutrophils of preterm neonates significantly increase their phagocytic function following exposure to adult serum or therapeutic Ig preparations. (48)(49)(50) Compared with term neonates and adults, preterm neutrophils have a lower expression of CD16 (Fcgamma-RIII) and CD32 (Fc-gamma-RII), the two most abundant neutrophil IgG receptors. In “stressed” preNeoReviews Vol.8 No.9 September 2007 e371

Phagocytosis
Phagocytosis is a specific form of endocytosis directed at engulfing solid particles into an internal phagosome. This internalized phagosome “matures” through interactions with the endosomal compartment and eventually

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term neonates who have severe respiratory distress syndrome or sepsis, CD16 expression may be even lower. (51) Whereas CD16 expression normally increases to adult levels over the first 3 weeks after birth, CD32 deficiency does not correct with time. CD32 is the high-affinity receptor for IgG2 (important against encapsulated bacteria), and CD32 deficiency may represent an important immune defect in preterm neonates. (52) Unlike CD16 and CD32, CD64 expression on neonatal neutrophils (both preterm and term) may be higher than on neutrophils from adults. (53). CD64 is not affected by neonatal “stress,” as in respiratory distress and or prolonged rupture of membranes, and emerging data suggest that CD64 might be a useful early marker for bacterial infections. (54)

Effect of Common Clinical Interventions
G-CSF and GM-CSF both activate neutrophil phagocytosis. The benefits of intravenous immunoglobulin (IVIG) as a source of opsonic activity remain uncertain. (48)(50)(55) A major limitation may be in the formulation of current IVIG preparations, which may not have adequate concentrations of antibodies against neonatal pathogens. (56)

mechanisms, such as low pH (as low as 6.0), defensins, bactericidal/permeability-increasing protein (BPI), lactoferrin, lysozyme, and a variety of cationic proteins. Defensins are broad-spectrum antimicrobial peptides that have activity against gram-positive and gramnegative bacteria, fungi, and enveloped viruses. (60) BPI binds lipopolysaccharide (LPS) and blocks its effects, can damage the outer membrane of gram-negative bacteria, and has some opsonic activity. (61) Lactoferrin, an iron chelator, is bacteriostatic as it deprives bacteria of the iron required for growth. Lactoferrin also is involved in neutrophil degranulation, oxygen radical production, and granulocytopoiesis. Lysozyme hydrolyzes a glycoside bond in the bacterial cell wall peptidoglycan. Primary granules also contain other cationic antibacterial proteins such as azurocidin, indolicin, and cathelicidins. (44)(62)

Developmental Defects
Although preterm neutrophils have a higher oxygen consumption and normal/elevated release of superoxide and H2O2, the overall respiratory burst is depressed. This deficiency is more marked in preterm infants who have a high severity of sickness. (31)(63)(64) Neutrophil oxidative burst remains impaired in preterm infants despite opsonization with IgG and complement. (65) Perinatal events can influence the respiratory burst in neonatal neutrophils. Labor and vaginal delivery activate the generation of free oxygen radicals in neonatal neutrophils. In contrast, perinatal distress can suppress the neutrophil respiratory burst. Cytokines such as interferons and tumor necrosis factor (TNF)-alpha as well as LPS can prime neutrophils for an accelerated respiratory burst in vitro, but prolonged exposure to these agents (during sepsis) can dampen their effect. Reduced respiratory burst activity in preterm infants correlates with impaired intracellular killing of Staphylococcus aureus or E coli. Whereas bacterial killing by neutrophils from term neonates consistently has been found to be normal, killing of staphylococci was impaired in preterm neonates whose birthweights were less than 2,000 g. (66) The postnatal maturation of the respiratory burst response varies according to gestational age. During the first postnatal week, infants born at 24 to 28 weeks’ gestation have a lower respiratory burst than those born at 29 to 35 weeks’ gestation. The differences between preterm infants born at different gestational ages disappear in about 2 months, but overall, neutrophils from preterm infants continue to have a weaker oxidative burst than neutrophils from adults. The postnatal maturation

Killing
The phagolysosome provides an enclosed space in which an ingested microbe is exposed to high concentrations of toxic substances, while limiting the exposure of the phagocyte and other cells to these potentially injurious agents. (44) The major killing mechanism in neutrophils involves the generation of highly reactive free oxygen radicals in a “respiratory burst.” An NADPH-dependent respiratory burst oxidase localized on the cell membrane (and, therefore, the phagosome membrane) reduces molecular oxygen (O2) to superoxide anion (O 2 ). (57) Subsequent generation of hydrogen peroxide (H2O2) and the hydroxyl radical (OH ) (formed in the presence of iron) also contributes to the microbicidal capacity of neutrophils. (58) Such oxygen-dependent bactericidal mechanisms can be divided broadly into myeloperoxidase (MPO)independent (such as H2O2) and MPO-dependent (MPO catalyzes reactions between H2O2 and halides to form highly reactive products). (59) H2O2 is a weak bactericidal agent per se, but the MPO-H2O2-halide system increases its efficacy by nearly 50-fold. The bactericidal effects of free oxygen radicals are due to oxidizing effects on various components of the bacterial cell wall. (58) Neutrophils also have elaborate nonoxidative killing
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such as cathepsins, proteinase-3, and elastase; and antimicrobial proteins such as defensins and the BPI. These granules release their contents into the phagolysosomes and are involved in intracellular killing. The specific granules contain antibacterial agents such as lactoferrin and lysozyme, receptors for complement components, and bacterial products such as f-MLP. Specific granules fuse with the cell membrane to release their contents by exocytosis and bring functionally important membrane proteins such as integrins, cytochromeb558, and receptors for chemotactic agents and opsonins to the cell surface. Specific granules play an important role in extracellular killing. (74)
Figure 3. Neutrophils have two major types of intracellular granules: azurophilic (or primary) and specific (or secondary).

Developmental Defects

of the respiratory burst may not be seen at all in sick preterm infants receiving intensive care. (67) Preterm neutrophils respond poorly to LPS due to lower expression of the LPS receptor (CD14) and the adhesion molecule CD11b and secretion of neutrophil elastase. (68) In addition, CD14-independent upregulation of CD11b in response to TNF-alpha and bacterial products such as f-MLP is impaired. Such hyporesponsiveness to LPS may predispose the preterm neonate further to gram-negative sepsis.

Neutrophils from term neonates have granule contents and degranulation responses similar to those from adults. (75) However, neutrophils from preterm infants have a lower capacity to release BPI, elastase, and lactoferrin than neutrophils from adults and term infants. (31)(76)

Effect of Common Clinical Interventions
Whereas G-CSF activates mature neutrophils without degranulation of primary granules, (77) GM-CSF induces degranulation and exocytosis of granule contents. (78) Anti-inflammatory agents such as corticosteroids and indomethacin inhibit the degranulation of secondary granules. (79)

Effect of Common Clinical Interventions
In “stressed” preterm infants receiving intensive care, recombinant GM-CSF can boost the neutrophil respiratory burst to levels seen in term neonates. (69) Similarly, G-CSF can enhance the neutrophil respiratory burst response in septic preterm infants. (70)(71) In adults, hypertonic saline may enhance host response to bacterial challenge by augmenting superoxide formation in neutrophils. (72) Intracellular killing also may be augmented by fluoroquinolones such as ciprofloxacin, which have a potent intraphagosomal bactericidal activity against both gram-positive and gram-negative bacteria. (73)

Cytokine Production
Emerging data show that neutrophils can synthesize cytokines in response to a variety of inflammatory stimuli. The expression profiles of neutrophil-derived cytokines are similar with those of monocytes and macrophages, including TNF-alpha, IL-1-beta, both CC and CXC chemokines (eg, IL-8, interferon-inducible protein 10, and macrophage inflammatory protein-1-alpha), and angiogenic factors such as vascular endothelial growth factor. There is no information on cytokine production by neonatal neutrophils.

Degranulation
Neutrophils contain two major types of granules (Fig. 3) (62): “azurophilic” granules (stain positive with the azure A dye) and “specific” granules (do not stain with azure A). Azurophilic granules contain MPO; proteolytic enzymes

Resolution of the Inflammatory Response
Neutrophils also assist in the clearance of apoptotic neutrophils or other cellular debris at sites of inflammation.
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Thus, neutrophils may contribute to resolution of inflammation, acting as a back-up system in situations when the macrophage clearance system is insufficient or overwhelmed. (80) The scavenger function of neutrophils has not been studied in the neonate.

17. Kellersch B, Kolanus W. Membrane-proximal signaling events in
beta-2 integrin activation. Results Probl Cell Differ. 2006;43:245–257

18. Wagner JG, Roth RA. Neutrophil migration mechanisms, with
an emphasis on the pulmonary vasculature. Pharmacol Rev. 2000; 52:349 –374 19. Kim SK, Keeney SE, Alpard SK, Schmalstieg FC. Comparison of L-selectin and CD11b on neutrophils of adults and neonates during the first month of life. Pediatr Res. 2003;53:132–136 20. Hashimoto M, Nishida A, Minakami H, et al. Decreased expression of L-selectin on peripheral blood polymorphonuclear leukocytes in neonates with severe asphyxia. Biol Neonate. 2002;81:95–98 21. Lorant DE, Li W, Tabatabaei N, Garver MK, Albertine KH. P-selectin expression by endothelial cells is decreased in neonatal rats and human premature infants. Blood. 1999;94:600 – 609 22. Reddy RK, Xia Y, Hanikyrova M, Ross GD. A mixed population of immature and mature leucocytes in umbilical cord blood results in a reduced expression and function of CR3 (CD11b/ CD18). Clin Exp Immunol. 1998;114:462– 467 23. McEvoy LT, Zakem-Cloud H, Tosi MF. Total cell content of CR3 (CD11b/CD18) and LFA-1 (CD11a/CD18) in neonatal neutrophils: relationship to gestational age. Blood. 1996;87:3929 –3933 24. Falconer AE, Carr R, Edwards SW. Neutrophils from preterm neonates and adults show similar cell surface receptor expression: analysis using a whole blood assay. Biol Neonate. 1995;67:26 –33 25. Ruef P, Bohler T, Linderkamp O. Deformability and volume of neonatal and adult leukocytes. Pediatr Res. 1991;29:128 –132 26. Linderkamp O, Ruef P, Brenner B, Gulbins E, Lang F. Passive deformability of mature, immature, and active neutrophils in healthy and septicemic neonates. Pediatr Res. 1998;44:946 –950 27. Ohls RK, Bellis YM, Dupree JC, Sklar LC. Effects of granulocyte colony-stimulating factor on neutrophil adhesive molecules in neonates. J Pediatr Hematol Oncol. 2001;23:506 –510 28. Nupponen I, Repo H, Kari A, Pohjavuori M, Andersson S. Early dexamethasone decreases expression of activation markers on neutrophils and monocytes in preterm infants. Acta Paediatr. 2002;91: 1200 –1207 29. Heit B, Tavener S, Raharjo E, Kubes P. An intracellular signaling hierarchy determines direction of migration in opposing chemotactic gradients. J Cell Biol. 2002;159:91–102 30. Carr R, Pumford D, Davies JM. Neutrophil chemotaxis and adhesion in preterm babies. Arch Dis Child. 1992;67:813– 817 31. Bektas S, Goetze B, Speer CP. Decreased adherence, chemotaxis and phagocytic activities of neutrophils from preterm neonates. Acta Paediatr Scand. 1990;79:1031–1038 32. Sacchi F, Rondini G, Mingrat G, et al. Different maturation of neutrophil chemotaxis in term and preterm newborn infants. J Pediatr. 1982;101:273–274 33. Eisenfeld L, Krause PJ, Herson V, et al. Longitudinal study of neutrophil adherence and motility. J Pediatr. 1990;117:926 –929 34. Turkmen M, Satar M, Atici A. Neutrophil chemotaxis and random migration in preterm and term infants with sepsis. Am J Perinatol. 2000;17:107–112 35. Laurenti F, Ferro R, Marzetti G, Rossini M, Bucci G. Neutrophil chemotaxis in preterm infants with infections. J Pediatr. 1980; 96:468 – 470 36. Fox SE, Lu W, Maheshwari A, Christensen RD, Calhoun DA. The effects and comparative differences of neutrophil specific chemokines on neutrophil chemotaxis of the neonate. Cytokine. 2005; 29:135–140 37. Weinberger B, Laskin DL, Mariano TM, et al. Mechanisms

Antibody-dependent Cellular Cytotoxicity
Neutrophils participate in viral and tumor surveillance and have a rapid cytotoxic activity against virus-infected and tumor cells opsonized by specific Igs. (81) Neutrophil antibody-dependent cellular cytotoxicity has not been studied in the neonate.

References
1. Maheshwari A, Christensen RD. Developmental granulocytopoiesis. In: Polin RA, Fox WW, Abman SH, eds. Fetal and Neonatal Physiology. Vol. 2. 3rd ed. Philadelphia, Pa: WB Saunders Company; 2004:1388 –1395 2. Slayton WB, Li Y, Calhoun DA, et al. The first-appearance of neutrophils in the human fetal bone marrow cavity. Early Hum Dev. 1998;53:129 –144 3. Engle WA, Schreiner RL, Baehner RL. Neonatal white blood cell disorders. Semin Perinatol. 1983;7:184 –200 4. Carr R, Huizinga TW. Low soluble FcRIII receptor demonstrates reduced neutrophil reserves in preterm neonates. Arch Dis Child Fetal Neonatal Ed. 2000;83:F160 5. Cairo MS. Review of G-CSF and GM-CSF. Effects on neonatal neutrophil kinetics. Am J Pediatr Hematol Oncol. 1989;11:238 –244 6. Calhoun DA, Christensen RD. Human developmental biology of granulocyte colony-stimulating factor. Clin Perinatol. 2000;27: 559 –576 7. Calhoun DA, Christensen RD. Recent advances in the pathogenesis and treatment of nonimmune neutropenias in the neonate. Curr Opin Hematol. 1998;5:37– 41 8. Christensen RD, Rothstein G. Pitfalls in the interpretation of leukocyte counts of newborn infants. Am J Clin Pathol. 1979;72: 608 – 611 9. Wright IM, Skinner AM. Post-transfusion white cell count in the sick preterm neonate. J Paediatr Child Health. 2001;37:44 – 46 10. McIntyre TM, Prescott SM, Weyrich AS, Zimmerman GA. Cell-cell interactions: leukocyte-endothelial interactions. Curr Opin Hematol. 2003;10:150 –158 11. Panes J, Granger DN. Leukocyte-endothelial cell interactions: implications for the pathogenesis and treatment of gastrointestinal disease. Dig Dis. 1994;12:232–241 12. Bagorda A, Mihaylov VA, Parent CA. Chemotaxis: moving forward and holding on to the past. Thromb Haemost. 2006;95:12–21 13. Rosen SD. Ligands for L-selectin: homing, inflammation, and beyond. Annu Rev Immunol. 2004;22:129 –156 14. Rosen SD, Bertozzi CR. The selectins and their ligands. Curr Opin Cell Biol. 1994;6:663– 673 15. Edwards SW. Cell signalling by integrins and immunoglobulin receptors in primed neutrophils. Trends Biochem Sci. 1995;20: 362–367 16. Luscinskas FW, Kiely JM, Ding H, et al. In vitro inhibitory effect of IL-8 and other chemoattractants on neutrophil-endothelial adhesive interactions. J Immunol. 1992;149:2163–2171
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underlying reduced responsiveness of neonatal neutrophils to distinct chemoattractants. J Leukoc Biol. 2001;70:969 –976 38. Krause PJ, Kreutzer DL, Eisenfeld L, et al. Characterization of nonmotile neutrophil subpopulations in neonates and adults. Pediatr Res. 1989;25:519 –524 39. Jones DH, Schmalstieg FC, Dempsey K, et al. Subcellular distribution and mobilization of MAC-1 (CD11b/CD18) in neonatal neutrophils. Blood. 1990;75:488 – 498 40. Mehta R, Petrova A. Intrapartum magnesium sulfate exposure attenuates neutrophil function in preterm neonates. Biol Neonate. 2006;89:99 –103 41. Mehta R, Weinberger B, Usmani SS, Wapnir RA, Harper RG. Theophylline alters neutrophil function in preterm infants. Biol Neonate. 2002;81:176 –181 42. Kamran S, Usmani SS, Wapnir RA, Mehta R, Harper RG. In vitro effect of indomethacin on polymorphonuclear leukocyte function in preterm infants. Pediatr Res. 1993;33:32–35 43. Parravicini E, van de Ven C, Anderson L, Cairo MS. Myeloid hematopoietic growth factors and their role in prevention and/or treatment of neonatal sepsis. Transfus Med Rev. 2002;16:11–24 44. Segal AW. How neutrophils kill microbes. Annu Rev Immunol. 2005;197–223 45. Ofek I, Goldhar J, Keisari Y, Sharon N. Nonopsonic phagocytosis of microorganisms. Annu Rev Microbiol. 1995;49:239 –276 46. Carreno MP, Gresham HD, Brown EJ. Isolation of leukocyte response integrin: a novel RGD-binding protein involved in regulation of phagocytic function. Clin Immunol Immunopathol. 1993;69:43–51 47. Ruoslahti E. Fibronectin and its receptors. Annu Rev Biochem. 1988;57:375– 413 48. Etzioni A, Obedeanu N, Blazer S, Benderly A, Merzbach D. Effect of an intravenous gammaglobulin preparation on the opsonophagocytic activity of preterm serum against coagulasenegative staphylococci. Acta Paediatr Scand. 1990;79:156 –161 49. Dossett JH, Williams RC, Jr, Quie PG. Studies on interaction of bacteria, serum factors and polymorphonuclear leukocytes in mothers and newborns. Pediatrics. 1969;44:49 –57 50. Bialek R, Bartmann P. Is there an effect of immunoglobulins and G-CSF on neutrophil phagocytic activity in preterm infants? Infection. 1998;26:375–378 51. Payne NR, Fleit HB. Extremely low birth weight infants have lower Fc gamma RIII (CD 16) plasma levels and their PMN produce less Fc gamma RIII compared to adults. Biol Neonate. 1996;69:235–242 52. Payne NR, Frestedt J, Hunkeler N, Gehrz R. Cell-surface expression of immunoglobulin G receptors on the polymorphonuclear leukocytes and monocytes of extremely premature infants. Pediatr Res. 1993;33:452– 457 53. Fjaertoft G, Hakansson L, Foucard T, Ewald U, Venge P. CD64 (Fcgamma receptor I) cell surface expression on maturing neutrophils from preterm and term newborn infants. Acta Paediatr. 2005;94:295–302 54. Fjaertoft G, Hakansson L, Ewald U, Foucard T, Venge P. Neutrophils from term and preterm newborn infants express the high affinity Fcgamma-receptor I (CD64) during bacterial infections. Pediatr Res. 1999;45:871– 876 55. Christensen RD, Brown MS, Hall DC, Lassiter HA, Hill HR. Effect on neutrophil kinetics and serum opsonic capacity of intravenous administration of immune globulin to neonates with clinical signs of early-onset sepsis. J Pediatr. 1991;118:606 – 614 56. Ohlsson A, Lacy JB. Intravenous immunoglobulin for suspected or subsequently proven infection in neonates. Cochrane Database Syst Rev. 2004:CD001239

57. Quinn MT, Gauss KA. Structure and regulation of the neutrophil respiratory burst oxidase: comparison with nonphagocyte oxidases. J Leukoc Biol. 2004;76:760 –781 58. Clark RA. Activation of the neutrophil respiratory burst oxidase. J Infect Dis. 1999;179(suppl 2):S309 –317 59. Klebanoff SJ. Myeloperoxidase: friend and foe. J Leukoc Biol. 2005;77:598 – 625 60. Lehrer RI. Multispecific myeloid defensins. Curr Opin Hematol. 2007;14:16 –21 61. Elsbach P, Weiss J. Role of the bactericidal/permeabilityincreasing protein in host defence. Curr Opin Immunol. 1998;10: 45– 49 62. Moraes TJ, Zurawska JH, Downey GP. Neutrophil granule contents in the pathogenesis of lung injury. Curr Opin Hematol. 2006;13: 21–27 63. Drossou V, Kanakoudi F, Tzimouli V, et al. Impact of prematurity, stress and sepsis on the neutrophil respiratory burst activity of neonates. Biol Neonate. 1997;72:201–209 64. Komatsu H, Tsukimori K, Hata K, Satoh S, Nakano H. The characterization of superoxide production of human neonatal neutrophil. Early Hum Dev. 2001;65:11–19 65. Bjorkqvist M, Jurstrand M, Bodin L, Fredlund H, Schollin J. Defective neutrophil oxidative burst in preterm newborns on exposure to coagulase-negative staphylococci. Pediatr Res. 2004;55:966 –971 66. Gahr M, Blanke R, Speer CP. Polymorphonuclear leukocyte function in term and preterm newborn infants. Biol Neonate. 1985;48: 15–20 67. Strunk T, Temming P, Gembruch U, Reiss I, Bucsky P, Schultz C. Differential maturation of the innate immune response in human fetuses. Pediatr Res. 2004;56:219 –226 68. Henneke P, Osmers I, Bauer K, Lamping N, Versmold HT, Schumann RR. Impaired CD14-dependent and independent response of polymorphonuclear leukocytes in preterm infants. J Perinat Med. 2003;31:176 –183 69. Jaswon MS, Jones HM, Linch DC. The effects of recombinant human granulocyte-macrophage colony stimulating factor on the neutrophil respiratory burst in the term and preterm infant when studied in whole blood. Pediatr Res. 1994;36:623– 627 70. Ahmad M, Fleit HB, Golightly MG, La Gamma EF. In vivo effect of recombinant human granulocyte colony-stimulating factor on phagocytic function and oxidative burst activity in septic neutropenic neonates. Biol Neonate. 2004;86:48 –54 71. Wolach B, Gavrieli R, Pomeranz A. Effect of granulocyte and granulocyte macrophage colony stimulating factors (G-CSF and GM-CSF) on neonatal neutrophil functions. Pediatr Res. 2000;48:369–373 72. Shields CJ, O’Sullivan AW, Wang JH, Winter DC, Kirwan WO, Redmond HP. Hypertonic saline enhances host response to bacterial challenge by augmenting receptor-independent neutrophil intracellular superoxide formation. Ann Surg. 2003;238:249 –257 73. Peman J, Canton E, Hernandez MT, Gobernado M. Intraphagocytic killing of gram-positive bacteria by ciprofloxacin. J Antimicrob Chemother. 1994;34:965–974 74. Borregaard N, Cowland JB. Granules of the human neutrophilic polymorphonuclear leukocyte. Blood. 1997;89:3503–3521 75. Ambruso DR, Bentwood B, Henson PM, Johnston RB Jr. Oxidative metabolism of cord blood neutrophils: relationship to content and degranulation of cytoplasmic granules. Pediatr Res. 1984;18:1148 –1153 76. Nupponen I, Turunen R, Nevalainen T, et al. Extracellular release of bactericidal/permeability-increasing protein in newborn infants. Pediatr Res. 2002;51:670 – 674
NeoReviews Vol.8 No.9 September 2007 e375

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77. Kondo S, Okamura S, Ohhara N, Niho Y. Direct action of
human granulocyte colony-stimulating factor on mature human neutrophils: flow-cytometric analysis. Res Commun Chem Pathol Pharmacol. 1990;67:249 –257 78. Fabian I, Kletter Y, Mor S, et al. Activation of human eosinophil and neutrophil functions by haematopoietic growth factors: comparisons of IL-1, IL-3, IL-5 and GM-CSF. Br J Haematol. 1992;80:137–143

79. Davies J, Sheppard K, Fletcher J. Inhibition of human neutrophil
secondary granule discharge by antiinflammatory agents. Inflammation. 1984;8:343–351 80. Rydell-Tormanen K, Uller L, Erjefalt JS. Neutrophil cannibalism–a back up when the macrophage clearance system is insufficient. Respir Res. 2006;7:143 81. Jaeschke H, Smith CW. Mechanisms of neutrophil-induced parenchymal cell injury. J Leukoc Biol. 1997;61:647– 653

NeoReviews Quiz
1. Circulating neutrophils leave the intravascular compartment to enter the tissues in three major steps: margination and rolling on vascular endothelium, attachment to endothelial cells, and transendothelial migration. Several molecules play key roles in each of these processes. Of the following, the molecule most involved in transendothelial migration is: A. B. C. D. E. Endothelial intercellular adhesion molecule-1. Leukocyte function-associated antigen-1. L-selectin ligand on neutrophils. Platelet-endothelial cell adhesion molecule. P-selectin ligand on endothelium.

2. Chemotaxis represents migration of neutrophils outside of blood vessels along concentration gradients of various chemoattractants. Several common clinical interventions can influence the neutrophil chemotactic response in neonates. Of the following, the intervention most likely to increase neutrophil chemotaxis in neonates is: A. B. C. D. E. Dexamethasone treatment for chronic lung disease. Granulocyte colony-stimulating factor administration for leukopenia. Indomethacin treatment for patent ductus arteriosus. Intrapartum exposure to magnesium sulfate. Theophylline administration in high therapeutic range.

3. Phagocytosis represents engulfment of microorganisms or other target particles by neutrophils into an internal phagosome. The internalized phagosome fuses with a lysosome, which causes terminal degradation of the internalized target. Phagocytosis is most efficient when the target is opsonized by specific immunoglobulin G or complement factors. Of the following, the opsonin that is expressed in higher concentrations in neonatal neutrophils relative to adult neutrophils is: A. B. C. D. E. CD CD CD CD CD 11b. 16. 18. 32. 64.

4. Neutrophils contain two major types of granules: “azurophilic” granules that stain positive with azure A dye and “specific” granules that do not stain positive with azure A dye. These granules play an important role in intracellular killing of microorganisms by neutrophils. Of the following, the constituent of the “specific” neutrophil granules most critical for host defense is: A. B. C. D. E. Antibacterial lactoferrin. Antimicrobial defensin. Bactericidal permeability-increasing protein. Myeloperoxidase. Proteolytic cathepsin.

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Developmental Defects in Neutrophils from Preterm Infants Sharat Chandra, Hillary Haines, Colin Michie and Akhil Maheshwari NeoReviews 2007;8;e368-e376

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Transfusions in the Preterm Infant Robin K. Ohls NeoReviews 2007;8;e377-e386

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://neoreviews.aappublications.org/cgi/content/full/neoreviews;8/9/e377

NeoReviews is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 2000. NeoReviews is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2007 by the American Academy of Pediatrics. All rights reserved. Online ISSN: 1526-9906.

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Article

hematology

Transfusions in the Preterm Infant
Robin K. Ohls, MD*

Objectives

After completing this article, readers should be able to:

Author Disclosure Dr Ohls did not disclose any financial relationships relevant to this article.

1. Characterize physiologic oxygen delivery in neonates. 2. Review findings of studies of high and low transfusion thresholds in neonates. 3. Describe strategies to decrease red cell transfusions in neonates.

Abstract
Preterm infants in the neonatal intensive care unit receive a greater number of red cell transfusions than any other hospitalized patient group. During the first weeks after birth, when blood draws are frequent and phlebotomy losses are high, approximately 50% of extremely low birthweight (ELBW) infants receive their first transfusion. (1) By the end of hospitalization, approximately 85% of ELBW infants have received at least one transfusion. (2)(3)(4) Although the numbers of transfusions administered to preterm infants remains significant, they have decreased over the last 20 years, primarily due to the institution of restrictive transfusion guidelines in conjunction with the study of erythropoietin administration to preterm infants. (5)(6) This article reviews the need for administering red cell transfusions, summarizes studies evaluating the efficacy of restrictive transfusion guidelines, and provides strategies to decrease red cell transfusions in neonates, including instituting neonatal transfusion guidelines.

Administering Red Cell Transfusions: Oxygen Delivery and Consumption
The primary purpose of a red cell transfusion is to provide an immediate increase in oxygen delivery to the tissues. (7) Oxygen delivery (DO2) can be quantified as the product of cardiac output (CO) and arterial oxygen content (CaO2): CO (dL/min) CaO2 (mL/dL) DO2 (mL/min) Arterial oxygen content is determined by the hemoglobin concentration, the arterial oxygen saturation (%), the oxygen-carrying capacity of hemoglobin (Hgb) (mL/g g/dL Hgb), and the solubility of oxygen in the blood (in mL/dL): CaO2 (SaO2 1.34 [Hgb]) (0.0031 PaO2) Improving cardiac output, oxygen saturation, or hemoglobin concentration increases the amount of oxygen supplied to tissues. If both oxygen saturation and cardiac output are maximized, the only way to deliver more oxygen to tissues is to increase the hemoglobin concentration. Such an increase is achieved by increasing the red cell mass, either through a red cell transfusion or the administration of red cell growth factors. The ratio of oxygen consumption to oxygen delivery is known as the oxygen extraction ratio and generally ranges from 0.15 to 0.33, which means that the body consumes 15% to 33% of the oxygen delivered. As the oxygen extraction ratio reaches or exceeds 0.40, organ and cellular function can begin to decline. (8) In young, healthy, conscious adults, the critical threshold below which oxygen consumption equals oxygen delivery occurs at less than 7.3 mL/kg per minute of oxygen. (9)(10) Any further decrease in oxygen delivery results in a decrease in oxygen consumption and tissue hypoxia. Neonates have a leftward-shifted oxygen-hemoglobin dissociation curve due to fetal
*Professor of Pediatrics, Director, Neonatal-Perinatal Fellowship Program, Children’s Hospital of New Mexico, Pediatrics/Division of Neonatology, University of New Mexico, Albuquerque, NM. NeoReviews Vol.8 No.9 September 2007 e377

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hemoglobin and decreased concentrations of 2,3diphosphoglycerate. In addition, preterm infants experience increased demands of accelerated growth. Despite these added burdens, neonates have a great ability to compensate for a gradual decrease in hemoglobin and may be able to deliver an adequate amount of oxygen to tissues. (11)(12)(13) For example, newborns whose hemoglobin concentrations are less than 4 g/dL (40 g/L) because of chronic severe fetomaternal hemorrhage can appear adequately compensated for this value of hemoglobin, as indicated by a normal heart rate, normal perfusion, and no acidosis. (14) Anemia occurs when the red cell mass is not adequate to meet the oxygen demands of the tissues, and the current treatment for anemia is a red cell transfusion. Studies evaluating administration of artificial oxygen carriers are ongoing, but have not yet included neonates. (15) Presently, the only method to increase hemoglobin acutely and significantly is by red cell transfusion. The difficulty comes in distinguishing a neonate who has anemia and requires immediate treatment from a neonate who has a low hematocrit. Although the risk of transmission of known infectious agents such as hepatitis B and C virus and human immunodeficiency virus (HIV) is relatively low in the blood supplied to United States hospitals, the risk of infectious agents newly identified in transfused blood such as Trypanosoma cruzi, West Nile virus, Plasmodium sp, and parvovirus B19, remains to be determined. (16)(17)(18) The decision to transfuse, therefore, should be taken with deliberation, and caregivers should be consistent in obtaining consent prior to a transfusion and documenting benefit in the neonate following a transfusion.

groups (18.7% restrictive versus 23.3% liberal), although mortality rates were significantly lower in the restrictive group among patients who were less acutely ill (8.7% versus 16.1%) and patients younger than 55 years of age. The mortality rate during hospitalization was lower in the restrictive group (22.2% versus 28.1%, P 0.05). The authors concluded that a restrictive strategy of red cell transfusion was at least as effective as a liberal transfusion strategy and possibly superior. Subsequent studies have noted similar findings (20)(21) and resulted in the development of more conservative transfusion guidelines for adult intensive care unit (ICU) patients.

Pediatric Studies
Few studies have been performed in the pediatric population. Pediatric intensivists have relied on adult ICU study results, and caregivers have been cautious about implementing more restrictive transfusion guidelines. In one retrospective analysis, children admitted to pediatric intensive care units (PICUs) who had hemoglobin values of 9 g/dL (90 g/L) or less were evaluated. (22) Of 240 children enrolled, 131 were transfused and 109 were not. Transfusions were associated with increased days of oxygen use, mechanical ventilation, vasopressor infusion, PICU stay, and hospital stay. The authors concluded that red cell transfusions were associated with increased use of resources in critically ill children. A prospective study to determine the incidence of red cell transfusions in critically ill children was performed in Canadian centers. (23) Among 985 children, at least one transfusion was given in 139 cases (14%). The most common reasons for transfusions were: hemoglobin value less than 9.5 g/dL (95 g/L), cardiac disease, increased illness severity, and multiple organ dysfunction. A multicenter study recently performed in Canadian PICUs evaluated the efficacy of restrictive versus liberal transfusion guidelines in critically ill pediatric patients. (24) Investigators enrolled 637 stable, critically ill children who had hemoglobin concentrations less than 9.5 g/dL (95 g/L) within 7 days of PICU admission. Patients enrolled in the restrictive transfusion group (320 patients) were transfused if their hemoglobin decreased below 7 g/dL (70 g/L), and those enrolled in the liberal strategy group (317 patients) were transfused if their hemoglobin decreased below 9.5 g/dL (95 g/L). Hemoglobin concentrations were maintained more than 2 g/dL (20 g/L) lower in the restrictive strategy group, and those patients received 44% fewer transfusions. Only 7 patients (2%) in the liberal strategy group were not transfused compared with 174 patients (54%) in the

Studies Evaluating the Efficacy of Transfusion Guidelines
Increasingly restrictive transfusion guidelines have been evaluated over the past 2 decades. The ability of critically ill patients to adapt to lower hemoglobin values recently has been investigated, and studies in adults, children, and neonates have sought to determine the safety and efficacy of transfusion guidelines.

Adult Studies
The results of studies evaluating transfusion guidelines in critically ill adults have changed transfusion practices significantly over the last decade. (19)(20)(21) The most noteworthy of these, known as the Transfusion Requirements in Critical Care (TRICC) trial, randomized 838 critically ill adults to a restrictive or liberal transfusion strategy. (19) The 30-day mortality was similar between
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restrictive strategy group. Multiorgan system failure occurred in a similar percentage of patients (12%) in both groups, and mortality was identical. The authors concluded that a transfusion threshold of 7 g/dL (70 g/L) can be used in stable pediatric intensive care patients without increasing adverse outcomes. Despite these studies, the optimal hemoglobin concentrations and transfusion thresholds remain to be determined in pediatric intensive care patients, especially those who have cyanotic heart disease. A marked variability still exists among pediatric intensivists in terms of both hemoglobin thresholds for transfusions and the volume of transfusions ordered. (25) Similar to other types of patients and age ranges tested, further study is required in pediatric patients to determine a definitive marker for transfusion need.

Table 1.

Red Cell Transfusion Guidelines From the United States Recombinant Human Erythropoietin Trial (26)

Do not transfuse for blood out alone Do not transfuse for low hematocrit (Hct) alone Transfuse at Hct <35% (0.35) for infants who are:
● ●

Receiving >35% oxygen Receiving continuous positive airway pressure or mechanical ventilation with mean airway pressure of 6 to 8 cm H2O Receiving any supplemental oxygen Receiving continuous positive airway pressure or mechanical ventilation with mean airway pressure <6 cm H2O Having significant episodes of apnea and bradycardia (>9 episodes in 12 h or 2 episodes in 24 h requiring bagging while receiving therapeutic doses of methylxanthines) Experiencing heart rates >180 beats/min or respiratory rates >80 breaths/min for 24 h Experiencing weight gain <10 g/d over at least 4 days while receiving 100 kcal/kg per day Undergoing surgery Asymptomatic, with absolute reticulocyte count <100 103/mcL (100 109/L)

Transfuse at Hct <30% (0.30) for infants who are:
● ●

Neonatal Studies
Twenty to thirty years ago, standard transfusion practices in the neonatal intensive care unit (NICU) involved maintaining the hematocrits of infants at or above 40%, and the volume of blood removed through phlebotomy was replaced when losses reached 10 mL/kg. Transfusion practices began to change in many units in the United States following the publication of a randomized trial of recombinant human erythropoietin (Epo) therapy in preterm infants who had anemia of prematurity. (26) The study investigators created guidelines for the restrictive use of red cell transfusions for preterm infants that still are used in many NICUs today (Table 1). As a result of this and other studies, the number of transfusions given to neonates in the United States, especially extremely low-birthweight (ELBW) infants, decreased from an average of 10 per hospitalization to 4 per hospitalization. (5) Decreases in transfusions administered to preterm infants also occurred in many countries throughout Europe. (6) The average number of transfusions given to similarly sized infants decreased to three per infant during an entire hospitalization. The lower number of transfusions administered to European ELBW infants likely was due to decreased phlebotomy losses. In multicenter studies employing restrictive transfusion guidelines and recording phlebotomy losses, preterm infants in the United States averaged 80 mL/kg in phlebotomy losses compared with 40 mL/kg for infants in Europe and South America. (2)(3)(4) Because of their incredibly small blood volumes, there always will be a direct correlation between blood removed for phlebotomy and blood transfused in critically ill ELBW infants. (26) The American Academy of Pediatrics has begun to

● ● ●

Transfuse at Hct <20% (0.20) for infants who are:

develop neonatal transfusion guidelines. Other countries, such as Canada, published guidelines in the 1990s. In 2002, in response to a significant upswing in the number of patients infected with HIV and hepatitis C via blood transfusions, (27) the Canadian Paediatric Society revised their transfusion guidelines to an even greater restrictive level (summarized in Table 2). (28) Three randomized studies evaluated the impact of restrictive transfusion guidelines in preterm infants. The first, performed by Bifano and colleagues and published in abstract form, (29)(30) evaluated ELBW infants weighing 650 to 1,000 g who were randomized from 1 to 36 weeks postmenstrual age (PMA) to a “high” hematocrit strategy (hematocrit maintained at 32% [0.32]) or a “low” hematocrit strategy (hematocrit maintained at 30% [0.30]). Hematocrits were maintained in the designated range with transfusions and Epo in the high group, and with transfusions alone in the low
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Canadian Paediatric Society Recommendations for Red Cell Transfusions (28)
Table 2.

Red cell transfusions should be considered in neonates in the following specific clinical situations:
● ●

Hypovolemic shock associated with acute blood loss Hematocrit between 30% and 35% (0.30 and 0.35) or hemoglobin between 10 and 12 g/dL (100 and 120 g/L) in extreme illness for which red cell transfusion may improve oxygen delivery to vital organs Hematocrit between 20% and 30% (0.20 and 0.30) or hemoglobin between 6 and 10 g/dL (60 and 100 g/L), and the infant is severely ill and/or receiving mechanical ventilation with compromised oxygen delivery Hematocrit falling below 20% (0.20) or hemoglobin falling below 6 g/dL (60 g/L), with absolute reticulocyte count of 100 to 150 103/mcL (100 to 150 109/L) or less, suggesting low plasma concentration of erythropoietin, with the presence of the following clinical signs: poor weight gain, heart rate >180 beats/min, respiratory distress and increased oxygen needs, and lethargy

group. Statistically significant differences in hematocrit were achieved by week 2 of the study and were maintained through 36 weeks PMA (Figure). There were no differences in baseline characteristics between the two groups, and the average birthweight of all infants enrolled in the study was less than 900 g. At 36 weeks PMA, there was no difference between the 22 infants evaluated in the low hematocrit group and the 21 infants evaluated in the high hematocrit group for weight gain during hospitalization, the number of days spent on a ventilator, or the total number of hospital days. At 1 year of age, both weight gain and head growth were similar for the two groups. In addition, there were no differences in neurodevelopmental impairments between the two groups, including a subgroup of infants whose hematocrits were 22% (0.22) or lower for more than 3 weeks. The investigators concluded that treatments aimed at maintaining hematocrit levels above 32% (0.32) did not demonstrate benefit in ELBW infants and incurred additional cost. Restrictive transfusion policies were not associated with adverse outcomes (Table 3). Bell and colleagues (31) recently published a randomized study on liberal versus restrictive guidelines for red cell transfusion in preterm infants. A total of 100 preterm infants weighing 500 to 1,300 g at birth at a single center
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were randomized to a liberal or restrictive transfusion strategy. Infants received transfusions only when their hematocrit dropped below the assigned value, and transfusion thresholds decreased with improving clinical status. The primary outcome was a difference in the number of transfusions. Secondary outcomes included morbidities associated with prematurity and hospital days. There were no differences in baseline characteristics between the two groups, and average birthweight for all infants enrolled was just less than 1,000 g. Infants randomized to the restrictive strategy received fewer transfusions (an average of two fewer transfusions per patient), but had more episodes of apnea. In addition, infants treated with the restrictive strategy had a greater incidence of intraparenchymal brain hemorrhage or periventricular leukomalacia. Because of this finding, the authors concluded that, although both transfusion programs were well tolerated, the findings of more frequent major adverse head ultrasonographic events in the restrictive transfusion group suggested that such a practice might be harmful to preterm infants. These findings were discussed in a series of letters to the editor following publication of the original study. (32)(33)(34) All of the discussions centered on the conclusions reached by the investigators and the need for further studies to confirm those conclusions. Kirpalani and colleagues (35) recently published the PINT (preterm infant in need of transfusion) study. They sought to determine whether ELBW infants transfused at lower hemoglobin thresholds versus higher thresholds have different rates of survival or morbidity at discharge. This large, multicenter, randomized clinical trial was designed to examine the impact of transfusion strategy on the incidence of a composite outcome of death, retinopathy of prematurity, bronchopulmonary dysplasia, or abnormal brain ultrasonography findings in ELBW infants. A total of 451 infants were randomized to one of two transfusion strategies defined by the hemoglobin thresholds for red cell transfusion. The thresholds varied with age and level of respiratory support required. No baseline differences existed between the 223 infants randomized to the low transfusion threshold and the 228 infants randomized to the high transfusion threshold. The average birthweight of study participants was 770 g. A significant difference in hematocrit values between groups was achieved by the first week of study. The composite primary outcome was similar for both groups: 74% in the low group compared with 70% in the high group (P 0.25). The incidence of brain injury determined by ultrasonography was 12.6% in the low group and 16% in the high group (P 0.53). The authors

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isovolemic hemodilution (the process of removing whole blood and replacing it with an isotonic solution, usually normal saline) on neurocognitive functioning in healthy adults. They determined that the P300 latency period reflected changes in oxygen. Near-infrared spectroscopy also has been evaluated as a tool to identify need for transfusions in preterm infants, (43) but lack of reproducibility in preterm infants remains a significant factor preventing general use of this technique. (44) These studies emphasize the difficulty in determining which infants should receive red cell transfusions, and what signs, symptoms, and laboratory measurements should be used to determine that need.
Figure. Differences in percent hematocrit (Hct) between infants randomized to the high

hematocrit strategy (solid line) and infants randomized to the low hematocrit strategy (dashed line) were achieved by week 2 of the study (*P<0.05), and maintained through 36 weeks postmenstrual age (PMA).

Strategies to Decrease Red Cell Transfusions in Neonates
Indications for Red Cell Transfusions

concluded that maintaining a higher hemoglobin concentration in ELBW infants resulted in more infants receiving transfusions but conferred little evidence of benefit. The infants in the PINT study were of lower gestational age and birthweight than the infants enrolled in the Bell study, yet there was no difference between the two groups in any morbidities. Because the Bell study was published prior to the PINT study, controversy arose regarding the benefits and risks of restrictive transfusion guidelines. Table 3 summarizes the neurologic findings reported in the three randomized studies. A difficulty in interpreting results of transfusion studies in neonates is that such studies measured what infants received, rather than what they actually needed. Neonatal, pediatric, and adult transfusion practices would benefit greatly from studies that generate transfusion guidelines based on need by identifying a useful transfusion marker. Such research remains to be accomplished, but a few investigators have attempted to define parameters, either through direct or indirect oxygen delivery, (8) resolution of signs of anemia, (36)(37)(38) or changes in cardiovascular parameters measured by echocardiography. (39)(40)(41) Work performed by Weiskopf and colleagues (42) evaluated the effects of acute

The indications for red cell transfusions in neonates rely more on the rate of fall in hemoglobin, rather than a specific hemoglobin trigger. Neonates who have significant acute blood loss require immediate volume resuscitation, but may not require a red cell transfusion. Term newborns may tolerate perinatal blood losses up to one third or more of their total blood volume. A neonate likely would benefit from a red cell transfusion if acidosis persists after volume resuscitation and adequate recirculation of the expanded blood volume or if hemorrhage is ongoing. Infants whose hemoglobin values are 10 g/dL (100 g/L) or greater following volume expansion may have adequate oxygen delivery to tissues and simply may require iron supplementation to replace iron stores lost due to the hemorrhage. The volume of red cells to transfuse in a neonate who has known acute hemorrhage can be determined using the following formula: (45) volume of red cells to transfuse desired rise in hematocrit 1.6 weight (kg). Thus, a 2.0-kg infant who has an acute drop in hematocrit at birth to 20% (0.20) would need 80 mL packed red cells to achieve a desired hematocrit of 45% (0.45). Caution should be exercised prior to the acute transfusion of an infant who has a significantly low hematocrit
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Summary of Neurologic Findings for High and Low Hematocrit Strategies
Table 3.

Study Bifano et al (29)(30) (n 50) Intraventricular hemorrhage (n) Any neurodevelopmental insult or growth deficiency (n, %) Bell et al (31) (n 100) Intraventricular hemorrhage (n, %) Periventricular leukomalacia (n, %) Kirpalani et al (35) (n 451) “Ultrasonographic brain injury” (n, %)

Low Hematocrit Strategy (n 22) 0 12 (55%) (n 28) 5 (10%) 4 (14%) (n 175) 22 (12.6%)

High Hematocrit Strategy (n 21) 1 10 (48%) (n 24) 8 (16%) 0 (n 188) 30 (16%)

infant who has a significantly low hematocrit ( 20% [0.20]) in whom an immediate increase in oxygen delivery to tissues is necessary because a significant increase in blood volume may result in the development of congestive heart failure.

Postnatal Changes in Hematocrit

All neonates undergo a natural adaptation to the extrauterine environment that allows them to compensate for a gradual drop in hematocrit. Soon after birth, increased oxygenation results in systemic oxygen delivery at birth; it is vitally important to determine whether the that far exceeds the tissues’ demand for oxygen. Lacking infant experienced an acute or chronic fall in hematocrit. hypoxic stimuli, Epo concentrations fall and erythroInfants who experience twin-to-twin transfusion synpoiesis declines. Hemoglobin concentrations decrease drome or chronic fetomaternal hemorrhage may be comover the first 2 to 3 postnatal months as the infant gains pensated at birth, despite a hematocrit below 30% (0.30). weight, remain stable over the next several weeks as An exchange transfusion should be considered for an erythropoiesis increases, then rise in the fourth to sixth postnatal month in response to an even Table 4. greater Epo stimulus. (46) Term infants tolerate such changes in hemoglobin and hematocrit without ● Review delayed cord clamping with the obstetric team and document the plan consequence, and this period of in the mother’s chart. The infant should be held below the placenta while the decreasing hemoglobin concentracord is intact for 30 to 45 sec. tions is termed “physiologic.” Pre● Monitor and record phlebotomy losses daily. ● Use inline blood sampling or use microsampling devices to decrease the volume term infants experience a decrease need for each laboratory test in hemoglobin to lower values than ● Remove umbilical lines and arterial lines as soon as possible that seen in term infants, and the ● Order laboratory tests judiciously (avoid ordering tests every “x” hours) and decrease is proportional to the dereconsider the need for “standard” or “routine” tests, such as weekly complete gree of prematurity. Hemoglobin blood counts, daily blood gas measurements, or daily chemistry panels ● Determine transfusion guidelines by identifying the lowest hemoglobin or concentrations between 7 and hematocrit value that will be tolerated for clinical scenarios and days of age, 8 g/dL (70 and 80 g/L) occur such as: 1) infant is receiving 100% oxygen, significant ventilator support, and commonly in preterm infants who blood pressure support and has a metabolic acidosis; 2) infant is receiving have not had significant phlebotminimal ventilator support or continuous positive airway pressure; 3) infant is omy losses. receiving enteral feedings and requiring oxygen; 4) infant is receiving full feedings, growing well, and receiving no oxygen support. Consider these Epo concentrations in preterm scenarios if the infant is less than 2 weeks of age, 2 to 4 weeks of age, or infants who have anemia still are greater than 4 weeks of age significantly lower than those ● Initiate erythropoietin treatment during the first day after birth by found in adults, given the degree administering a subcutaneous injection of 400 U/kg or by adding 200 U/kg into of the anemia. (47)(48) This nora protein-containing intravenous solution (such as a 5% dextrose solution with 2% amino acids) to run over 4 to 24 hours mocytic, normochromic anemia, ● Administer parenteral iron, 3 mg/kg once a week or 0.5 mg/kg per day (iron termed the “anemia of prematudextran added to parenteral nutrition or administered intravenously over 4 to rity,” commonly affects infants 6 hours), until the infant tolerates adequate volume feedings, then administer born at 32 weeks’ or less gestation oral iron at 4 to 6 mg/kg per day and is the most common anemia

Guidelines to Reduce Neonatal Transfusions

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Table 5.
● ●

An Example of Transfusion Guidelines

A central hematocrit should be obtained on admission, and no further hematocrits obtained unless specifically ordered. Transfusions generally should be considered only if acute blood loss of >10% associated with symptoms of decreased oxygen delivery occurs or if significant hemorrhage of >20% total blood volume occurs. ● In term and preterm infants, a transfusion should be considered if an immediate need for increased oxygen delivery to tissues is suspected clinically. ● Transfuse 20 mL/kg packed red cells unless the hematocrit is >29% (0.29). A volume of 20 mL/kg also could be used if significant phlebotomy losses are anticipated in smaller infants whose hematocrits are >29% (0.29). The volume may be administered in two 10-mL/kg aliquots. ● For infants receiving erythropoietin, considerations of the above guidelines should be made regarding the rate of decrease in hemoglobin or hematocrit, the infant’s reticulocyte count, the postnatal day of age, the need for supplemental oxygen, and the overall stability of the infant. ● Central measurements of hemoglobin or hematocrit are preferred; alternatively, heel stick measurements may be obtained after warming the heel adequately. An infant meeting the following criteria should not be transfused automatically, but a transfusion should or can be considered for the following: 1) A transfusion should be considered if acute blood loss of >10% associated with symptoms of decreased oxygen delivery occurs or if significant hemorrhage of >20% total blood volume occurs. 2) For infants requiring moderate or significant mechanical ventilation, defined as mean arterial pressure (MAP) >8 cm H2O and FiO2 >0.40 on a conventional ventilator or MAP >14 and FiO2 >0.40 on high-frequency ventilator, transfusions can be considered if the hematocrit is <30% (0.30) (hemoglobin <10 g/dL [100 g/L]). 3) For infants requiring minimal mechanical ventilation, defined as MAP <8 cm H2O and/or FiO2 <0.40 on a conventional ventilator or MAP <14 and/or FiO2 <0.40 on high-frequency ventilator, transfusions can be considered if the hematocrit is <25% (0.25) (hemoglobin <8 g/dL [8 g/L]). 4) For infants receiving supplemental oxygen who do not require mechanical ventilation, transfusions can be considered if the hematocrit is <20% (0.20) (hemoglobin <7 g/dL [70 g/L]), and one or more of the following is present: ● >24 h of tachycardia (heart rate >180 beats/min) or tachypnea (respiratory rate >60 breaths/min) ● A doubling of the oxygen requirement from the previous 48 h ● Lactate >2.5 mEq/L (2.5 mmol/L) or an acute metabolic acidosis (pH <7.20) ● Weight gain <10 g/kg per day over the previous 4 days while receiving >120 kcal/kg per day ● If the infant will undergo major surgery within 72 h 5) For infants who have no symptoms, transfusions can be considered if the hematocrit is <18% (0.18) (hemoglobin <6 g/dL [60 g/L]) associated with an absolute reticulocyte count of <100 103/mcL (100 109/L) (<2%)

seen in the neonatal period. The anemia of prematurity is not specifically responsive to the addition of iron, folate, or vitamin E, although these substrates (as well as vitamin B12) are administered to infants receiving recombinant Epo to maximize erythropoiesis. (4)(49) Some infants may be asymptomatic from their low hematocrit; others demonstrate signs of anemia that are alleviated by transfusion. In preterm infants, determining when to transfuse is not straightforward. (50) When considering a transfusion in a preterm infant who has a low hematocrit that is not due to acute hemorrhage, the clinician should determine initially if the infant needs an immediate increase in oxygen to tissues. If the answer is yes, treatment consists of a transfusion of packed red cells. If there is no evidence that an immediate increase in oxygen delivery is necessary, treatment with red cell growth factors and appropriate substrates might be considered. Because the process of stimulating erythropoiesis requires at least 1 week to affect the reticulocyte count significantly and may not

increase the hemoglobin concentration appreciably during that time, the infant should continue to be observed for signs consistent with anemia.

Cord Blood
Cord blood collection has been studied as a form of “autologous” donation, although most labor and delivery services and corresponding blood banks are not prepared for collection and storage of neonatal cord blood. An alternative to cord blood collection that reduces erythrocyte transfusions is delayed clamping of the umbilical cord. It is possible to promote placental transfer of blood to preterm infants by delaying the clamping of the umbilical cord for 30 seconds. Transfer of 10 to 15 mL/kg body weight can be expected using this method. (51) Mercer and colleagues (52) performed a randomized trial of delayed cord clamping among infants whose birthweights were less than 1,500 g and found lower rates of intraventricular hemorrhage and late-onset sepsis in the infants who underwent delayed cord clampNeoReviews Vol.8 No.9 September 2007 e383

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ing. In other studies, a delay in cord clamping of 30 seconds resulted in improved iron status, (53) fewer transfusions, (54) and an association with improved neurodevelopmental outcomes. (52)

Guidelines to Decrease Transfusions in Neonates
Most (85% to 90%) ELBW infants receive transfusions. However, 10% to 15% never receive a transfusion. This percentage can be increased through the use of such measures as delayed cord clamping, immediate red cell growth factor and iron therapy, judicious laboratory testing using microsampling, and a restrictive transfusion policy. Table 4 offers suggested guidelines to optimize an infant’s chances of remaining transfusion-free. Most importantly, such measures can be identified and a plan created prenatally with the family. In addition, neonatologists can establish a relationship with the family and discuss their NICU transfusion thresholds. An example of transfusion guidelines currently used by several NICUs participating in a study comparing Epo with darbepoetin (a long-acting red cell growth factor) administered to preterm infants is provided in Table 5.

Summary
Previously, limited knowledge of the pathophysiology of anemia in preterm infants contributed to unfounded and liberal transfusion practices that had uncertain riskbenefit ratios. (1) Over the last 2 decades, researchers have explored an array of strategies to minimize transfusions in the most critically ill patients. Currently, the ideal test or marker for transfusion need does not exist. Studies of the efficacy and outcomes of restrictive transfusion guidelines in adults, children, and neonates should continue.

References
1. Bifano EM, Curran TR. Minimizing donor blood exposure in
the neonatal intensive care unit. Current trends and future prospects. Clin Perinatol. 1995;22:657 2. Maier RF, Obladen M, Muller-Hansen I, et al. Early treatment with erythropoietin beta ameliorates anemia and reduces transfusion requirements in infants with birth weights below 1000 g. J Pediatr. 2002;141:8 3. Donato H, Vain N, Rendo P, et al. Effect of early versus late administration of human recombinant erythropoietin on transfusion requirements in premature infants: results of a randomized, placebo-controlled, multicenter trial. Pediatrics. 2000;105:1066 4. Ohls RK, Ehrenkranz RA, Das A, et al; National Institute of Child Health and Human Development Neonatal Research Network. Neurodevelopmental outcome and growth at 18 to 22
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months’ corrected age in extremely low birth weight infants treated with early erythropoietin and iron. Pediatrics. 2004;114:1287 5. Widness JA, Seward VJ, Kromer IJ, et al. Changing patterns of red blood cell transfusion in very low birth weight infants. J Pediatr. 1996;129:680 6. Maier RF, Sonntag J, Walka MM, et al. Changing practices of red blood cell transfusions in infants with birth weights less than 1000 g. J Pediatr. 2000;136:220 7. Ohls RK. Why, when and how should we provide red cell transfusions to neonates? In: Ohls RK, Yoder M, eds. Questions and Controversies in Neonatology Series: Hematology, Immunology, and Infectious Diseases. Philadelphia, Pa: Elsevier Health Science, in press. 8. Alverson DC. The physiologic impact of anemia in the neonate. Clin Perinatol. 1995;22:609 9. Lieberman JA, Weiskopf RB, Kelley SD, et al. Critical oxygen delivery in conscious humans is less than 7.3 mL O2 kg( 1) min( 1). Anesthesiology. 2000;92:407– 413 10. Madjdpour C, Spahn DR, Weiskopf RB. Anemia and perioperative red blood cell transfusion: a matter of tolerance. Crit Care Med. 2006;34:S102 11. Oski FA, Delivoria-Papadopoulos M. The red cell, 2,3diphosphoglycerate, and tissue oxygen release. J Pediatr. 1970;6: 941–956 12. Delivoria-Papadopoulos M. Postnatal changes in oxygen transport of term, preterm and sick infants: the role of red cell 2,3 diphosphoglycerate in adult hemoglobin. Pediatr Res. 1971;5:235 13. Wimberley PD. Fetal hemoglobin, 2,3-diphosphoglycerate and oxygen transport in the newborn premature infant. Scand J Clin Lab Invest Suppl. 1982;161:1 14. Willis C, Forman CS Jr. Chronic massive fetomaternal hemorrhage: a case report. Obstet Gynecol. 1988;71:459 15. Inayat MS, Bernard AC, Gallicchio VS, et al. Oxygen carriers: a selected review. Transfus Apher Sci. 2006;34:25 16. Pealer LN, Marfin AA, Petersen LR, et al. Transmission of West Nile virus through blood transfusion in the United States in 2002. N Engl J Med. 2003;349:1236 17. Dodd RY. Emerging infections, transfusion safety, and epidemiology. N Engl J Med. 2003;349:1205 18. Alter HJ, Stamer SL, Dodd RY. Emerging infectious diseases that threaten the blood supply. Semin Hematol. 2007;44:32 19. Hebert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999;340: 409 20. Chant C, Wilson G, Friedrich JO. Anemia, transfusion, and phlebotomy practices in critically ill patients with prolonged ICU length of stay: a cohort study. Crit Care. 2006;10:R140 21. Croce MA, Tolley EA, Claridge JA, Fabian TC. Transfusions result in pulmonary morbidity and death after a moderate degree of injury. J Trauma. 2005;59:19 22. Goodman AM, Pollack MM, Patel KM, Luban NLC. Pediatric red blood cell transfusions increase resource use. J Pediatr. 2003; 142:123 23. Armano R, Gauvin F, Ducruet T, et al. Determinants of red blood cell transfusions in a pediatric critical care unit: a prospective, descriptive epidemiological study. Crit Care Med. 2005;33:2637 24. Lacroix J, Hebert PC, Hutchison JS, Hume HA, Tucci M et al. Transfusion strategies for patients in pediatric intensive care units. N Engl J Med. 2007;356:1609 –1619

Downloaded from http://neoreviews.aappublications.org by Alaa Swaify on September 2, 2007

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25. Nahum E, Ben-Ari J, Schonfeld T. Blood transfusion policy
among European pediatric intensive care physicians. J Intensive Care Med. 2004;19:38 26. Shannon KM, Keith JF 3rd, Mentzer WC, et al. Recombinant human erythropoietin stimulates erythropoiesis and reduces erythrocyte transfusions in very low birth weight preterm infants. Pediatrics. 1995;95:1 27. Kondro W. Canadian Red Cross found negligent. Lancet. 1997;350:1154 28. Red blood cell transfusions in newborn infants: revised guidelines. Paediatr Child Health. 2002;7:553 29. Bifano EM. The effect of hematocrit (HCT) level on clinical outcomes in extremely low birthweight (ELBW) infants. Pediatr Res. 2001;49:311A 30. Bifano EM, Bode MM, D’Eugenio DB. Prospective randomized trial of high vs. low hematocrit in extremely low birth weight (ELBW) infants: one year growth and neurodevelopmental outcome. Pediatr Res. 2002;51:325A 31. Bell EF, Strauss RG, Widness JA. Randomized trial of liberal versus restrictive guidelines for red blood cell transfusion in preterm infants. Pediatrics. 2005;115:1685 32. Boedy RF, Mathew OP. Letter to editor: randomized trial of liberal versus restrictive guidelines for red blood cell transfusion in preterm infants. Pediatrics. 2005;116:1048 33. Murray N, Roberts I, Stanworth S. Letter to editor: red blood cell transfusion in neonates. Pediatrics. 2005;116:1609 34. Swamy RS, Embleton ND. Letter to editor: red blood cell transfusions in preterm infants: is there a difference between restrictive and liberal criteria? Pediatrics. 2005;115:257 35. Kirpalani H, Whyte RK, Andersen C. 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 36. Wardle SP, Garr R, Yoxall CW, Weindling AM. A pilot randomised controlled trial of peripheral fractional oxygen extraction to guide blood transfusions in preterm infants. Arch Dis Child Fetal Neonatal Ed. 2002;86:F22 37. Bifano EM, Smith F, Borer J. Relationship between determinants of oxygen delivery and respiratory abnormalities in preterm infants with anemia. J Pediatr. 1992;120:292 38. Izraeli S, Ben-Sira L, Harell D, et al. Lactic acid as a predictor for erythrocyte transfusion in healthy preterm infants with anemia of prematurity. J Pediatr. 1993;122:629 39. Bard H, Fouron JC, Chessex P, Widness JA. Myocardial, erythropoietic, and metabolic adaptations to anemia of prematurity in infants with bronchopulmonary dysplasia. J Pediatr. 1998;132: 630

40. Bohler T, Janecke A, Linderkamp O. Blood transfusion in late
anemia of prematurity: effect on oxygen consumption, heart rate, and weight gain in otherwise healthy infants. Infusionsther Transfusionsmed. 1994;21:376 41. Alkalay AL, Galvis S, Ferry DA, et al. Hemodynamic changes in anemic premature infants: are we allowing the hematocrits to fall too low? Pediatrics. 2003;112:838 42. Weiskopf RB, Toy P, Hopf HW, et al. Acute isovolemic anemia impairs central processing as determined by P300 latency. Clin Neurophysiol. 2005;116:1028 43. Soul JS, Taylor GA, Wypij D, Duplessis AJ, et al. Noninvasive detection of changes in cerebral blood flow by near-infrared spectroscopy in a piglet model of hydrocephalus. Pediatr Res. 2000;48: 445 44. Menke J, Voss U, Moller G, Jorch G. Reproducibility of cerebral near infrared spectroscopy in neonates. Biol Neonate. 2003; 83:6 45. Morris KP, Naqvi N, Davies P, et al. A new formula for blood transfusion volume in the critically ill. Arch Dis Child. 2005;90:724 46. Kling PJ, Schmidt RL, Roberts RA, et al. Serum erythropoietin levels during infancy: associations with erythropoiesis. J Pediatr. 1996;128:791 47. Brown MS, Garcia JF, Phibbs RH, et al. Decreased response of plasma immunoreactive erythropoietin to “available oxygen” in anemia of prematurity. J Pediatr. 1984;105:793 48. Stockman JA, Graeber JE, Clark DA, et al. Anemia of prematurity: determinants of the erythropoietin response. J Pediatr. 1984;105:786 49. Haiden N, Schwindt J, Cardona F, et al. Effects of a combined therapy of erythropoietin, iron, folate, and vitamin B12 on the transfusion requirements of extremely low birth weight infants. Pediatrics. 2006;118:2004 50. Keyes WG, Donohue PK, Spivak JL, et al. Assessing the need for transfusion of premature infants and the role of hematocrit, clinical signs, and erythropoietin level. Pediatrics. 1989;84:412 51. Aladangady N, McHugh S, Aitchison TC, et al. Infant’s blood volume in a controlled trial of placental transfusion at preterm delivery. Pediatrics. 2006;117:93 52. Mercer JS, Vohr BR, McGrath MM, et al. 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 53. Chaparro CM, Neufeld LM, T Alavez G. Effect of timing of umbilical cord clamping on iron status in Mexican infants: a randomized controlled trial. Lancet. 2006;367:1997 54. Philip A. Delayed cord clamping in preterm infants. Pediatrics. 2006;117:1434

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NeoReviews Quiz
5. Preterm infants, especially extremely low-birthweight (ELBW) infants, in the neonatal intensive care unit receive a greater number of red cell transfusions than any other hospitalized patient group. Of the following, the best estimate for the percentage of ELBW infants that receive at least one red cell transfusion by the end of hospitalization is: A. B. C. D. E. 40%. 55%. 70%. 85%. 100%.

6. The primary purpose of a red cell transfusion is to provide an immediate increase in oxygen delivery to the tissues. Oxygen delivery, expressed in milliliters of oxygen per kilogram of bodyweight per minute, can be calculated from cardiac output and arterial oxygen content. The latter can be calculated from hemoglobin concentration, arterial oxygen saturation, and partial pressure of arterial oxygen. Of the following, the critical threshold for oxygen delivery in healthy adults below which tissue hypoxia is likely to ensue is: A. B. C. D. E. 5.0 mL/kg per minute. 7.3 mL/kg per minute. 10.0 mL/kg per minute. 12.3 mL/kg per minute. 15.0 mL/kg per minute.

7. A 2-day old preterm neonate, whose birthweight is 1,950 g, has a sudden onset of pallor. Physical examination reveals marked abdominal distention, enlarged liver, and features of respiratory and cardiac failure. Abdominal ultrasonography reveals multiple hemangiomas in the liver and hemoperitoneum. The infant’s hematocrit is 16% (0.16). A red cell transfusion is ordered with the goal of achieving a desired hematocrit of 40% (0.40). Of the following, the volume of red cells needed for transfusion in this infant is closest to: A. B. C. D. E. 25 mL. 50 mL. 75 mL. 100 mL. 125 mL.

8. A 10-week-old preterm infant, whose birthweight was 840 g, is breathing spontaneously in room air, has two to four episodes of apnea and bradycardia per day that resolve with stimulation, is receiving full enteral feedings by orogastric gavage, and is gaining weight at a rate of 15.6 g/kg per day. The infant’s absolute reticulocyte count is 48 103/mcL (48 109/L). You follow guidelines for restrictive use of red cell transfusions as proposed in the United States Multicenter Epo Study, of one of the earlier randomized trials of erythropoietin treatment in preterm infants. Of the following, the hematocrit threshold for red cell transfusion in this infant is closest to: A. B. C. D. E. 20% 25% 30% 35% 40% (0.20). (0.25). (0.30). (0.35). (0.40)

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Transfusions in the Preterm Infant Robin K. Ohls NeoReviews 2007;8;e377-e386

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Article

respiratory disorders

Magnesium and Perinatal Asphyxia
Clea R. Leone, MD, PhD,* ´ Naila O.E. Barbosa, MD*

Objectives

After completing this article, readers should be able to:

Author Disclosure Drs Leone and Barbosa did not disclose any financial relationships relevant to this article.

1. Describe magnesium metabolism in the newborn. 2. Analyze the role of magnesium in the events that follow an hypoxic-ischemic insult in the newborn. 3. Evaluate the evidence of a potential protective effect of magnesium in newborns after a hypoxic-ischemic event.

Abstract
The pathophysiology of perinatal hypoxic-ischemic insults has been investigated exhaustively to identify the components that must be blocked to reduce neurologic injury in the newborn. Among potential therapeutic strategies for neuroprotection, administration of magnesium has been the object of experimental studies and, recently, clinical trials. This interest is related to the compound’s potential effect of blocking glutamate-controlled N-methyl-D-aspartate (NMDA) receptors and the voltage-dependent calcium channels, preventing the influx of extracellular calcium into the neurons, as well as its action as a membrane stabilizer. To date, results have been variable and are not sufficient to recommend this therapy in newborns who have perinatal asphyxia.

Introduction
Magnesium is an important intracellular cation that acts as a cofactor in the cellular bioenergetic process. A possible neuroprotective effect of magnesium has been suggested in hypoxic-ischemic episodes through an antagonistic action at the N-methyl-D-aspartate (NMDA) receptor. (1) Perinatal asphyxia is an important cause of long-term disability. At the cellular level, a hypoxic-ischemic insult initiates a sequence of biochemical events that leads to an accumulation of intracellular calcium. Evidence suggests that stimulation of excitatory amino acid receptors plays a role in the pathogenesis of perinatal hypoxic-ischemic brain injury. Therefore, competitive and noncompetitive NMDA antagonists could be useful as neuroprotective agents. (2) Some animal models have demonstrated that administration of magnesium sulfate has neuroprotective effects against hypoxia-ischemia, but such an effect has not been proved in humans. The primary problems with human studies are the variable doses of magnesium sulfate analyzed, the potential for deleterious effects, and the attempts to provide treatment in time to prevent irreversible damage. (3)

Magnesium Metabolism
Magnesium is essential for a number of cellular functions, including DNA transcription, mitochondrial oxidative phosphorylation, hormone receptor binding, gating of calcium channels, transmembrane ion flux, regulation of adenylate cyclase, muscle contraction, neuronal activity, control of vasomotor tone, cardiac excitability, and neuronal transmitter release. (3)(4) Despite its importance, magnesium homeostasis is poorly understood and has received less attention than other electrolytes. The apparent lack of correlation between serum and
*Department of Pediatrics, School of Medicine, University of Sao Paulo, Brazil. ˜ NeoReviews Vol.8 No.9 September 2007 e387

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tissue magnesium concentrations and the subsequent difficulty in their interpretation contribute to this lack of interest in routine serum magnesium measurements. In humans, less than 1% of total body magnesium is found in the extracellular fluid compartment. It is distributed primarily between bone (65%) and the intracellular components of muscle and soft tissues (34%). Serum magnesium is present in three states: ionized (62%), protein-bound (33%) (primarily to albumin), and in complexes with anions (5%). (3)(5) Serum magnesium concentrations are maintained within a narrow range and are remarkably stable. The homeostatic mechanisms responsible for maintaining such limits seem to be the balance between absorption from the gastrointestinal tract and excretion by the kidney. (6)(7) Gastrointestinal tract absorption appears to depend on the amount of magnesium in the diet. Approximately 40% of the total magnesium consumed is absorbed, mostly from the small intestine. The absorption is primarily by a passive paracellular mechanism that is dependent on solvent drag. (8) The recommended daily intake of magnesium for children and adults is 4 to 5 mg/kg. (9) The major dietary sources of magnesium include nuts, unprocessed cereals, and vegetables. (10) The magnesium concentration in human milk has been determined to be between 25 and 45 mg/L; infant formulas contain about 50 to 96 mg/L. (11) The kidney is the major organ involved in magnesium regulation, although the major regulator of reabsorption is the plasma magnesium concentration. (12) The filtered magnesium load in excess of the amount filtered under normal circumstances usually is excreted. Under conditions of magnesium deprivation, however, there is a complete reabsorption. (4) Approximately 75% of the total plasma magnesium is filtered through the glomerular membrane. In the adult, about 50% to 60% of the filtered magnesium is reabsorbed in the thick ascending loop of Henle and 15% in the proximal tubule. Only 3% to 5% of the filtered magnesium is excreted in the urine under normal conditions. (8) Many drugs, such as amphotericin B, digoxin, gentamicin, and loop diuretics, may increase renal elimination of magnesium by inhibiting reabsorption in the kidneys. (13) Magnesium homeostasis may differ in the neonate compared with the adult. Magnesium reabsorption occurs predominantly in the proximal tubule rather than the loop of Henle in neonates, possibly due to immaturity of the paracellular pathway and the consequent passage of significant amounts of magnesium, sodium, cale388 NeoReviews Vol.8 No.9 September 2007

cium, and water. Another explanation might be the presence of an active transport of magnesium along the proximal tubule that decreases with age. (14)(15) Understanding of the hormonal control of magnesium is incomplete, probably because a specific endocrine control similar to the one that exists for calcium has not yet been identified. Parathyroid hormone (PTH) administration can result in elevated serum magnesium concentrations through increased magnesium reabsorption in the kidney, release from bone, and absorption in the small intestine. Otherwise, chronic hypermagnesemia may impair PTH secretion through a feedback system due to magnesium’s effect as a cofactor of the enzyme adenylate cyclase in parathyroid tissue (8)(13) Vitamin D has been shown to enhance intestinal magnesium absorption, but the effects of calcitonin on the mineral are not known. Steroid hormones, aldosterone, and insulin may decrease magnesium excretion in the kidney. (8)(16) Magnesium is transported actively through the placenta, so cord blood magnesium concentrations are higher than maternal values. The third trimester of gestation is the period of great incorporation, corresponding to about 2 to 3 mg/kg per day. (17) In the neonatal period, some conditions may lead to imbalances of magnesium homeostasis, including intrauterine growth restriction (IUGR). Term newborns who experienced IUGR (birthweight less than the 10th percentile for gestational age and a birthweight ratio less than 0.85) had higher concentrations of ionized magnesium during the first postnatal week compared with term newborns who did not have IUGR in a Brazilian study. (18) These results may indicate a nutritional adaptation of the fetus to the lower availability of magnesium during gestation in the presence of IUGR.

Perinatal Asphyxia
Perinatal hypoxic-ischemic insults and their consequent biochemical events may lead to varying degrees of neuronal injury, including irreversible injury. (19)

Energy Metabolism
Hypoxia-ischemia results in a switch to anaerobic metabolism, with insufficient adenosine 5 -triphosphate (ATP) production, accumulation of lactic acid, and inability to maintain cellular functions. A reduction in ATP synthesis caused by oxygen limitation disrupts ionic equilibrium across membranes. Potassium quickly accumulates in the extracellular space, while sodium and water enter the cell, with the subsequent development of cellular swelling. (20)(21)(22)

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Calcium Homeostasis
Calcium ions accumulate in the cytosol as a consequence of the increased cellular influx into neuronal cells caused by the loss of the membrane potential, leading to the opening of voltage-dependent calcium channels. In addition, during hypoxia, the stimulation of NMDA receptors of the agonist-operated calcium channel by glutamate increases calcium influx into neuronal cells. Calcium also is released from mitochondria that are stimulated by the increase in intracellular sodium and free fatty acids and from the endoplasmic reticulum because of the depletion of ATP. Moreover, calcium efflux across the plasma membrane is decreased by energy failure. (20)(21)(22) The excessive increase in intracellular calcium interferes with many enzymatic reactions, such as activation of phospholipases. Such reactions lead to membrane phospholipid hydrolysis, with the consequent disruption of cellular and organelle membranes, increase in their permeability, and further unfavorable modification in the ionic distribution. Other consequences include alteration of the arachidonic acid cycle, with effects on prostaglandin synthesis, gene expression, and protein synthesis as well as increased production of free radicals. (20)(21)

(20) (23) This is particularly important in the fetal brain because of the larger proportion of NMDA receptors in neurons than in the adult brain, reinforcing the contribution of glutamate-mediated neurotoxicity in this period. (24)

Oxygen Free Radical Production
An intense production of oxygen free radicals during the hypoxic-ischemic process increases the destructive capacity of cellular antioxidants and scavengers. Such free radicals disrupt the cellular membrane, contributing to cell death.

Magnesium and Perinatal Asphyxia
A possible neuroprotective action has been attributed to magnesium in hypoxic-ischemic insults, based on a variety of effects that this cation could have in the pathophysiologic mechanisms present before and after cerebral ischemia. Magnesium may serve as an NMDA receptor antagonist, membrane stabilizer, vasodilator, and anticonvulsive. Magnesium can block the glutamatecontrolled NMDA receptor and the voltage-dependent calcium channels, preventing the influx of extracellular calcium into neurons. (21)(25) Magnesium also prevents persistent membrane depolarization that results from failure of the Na-K-ATP-dependent pump. (23) A hypotensive effect has been proposed by the properties of magnesium as a calcium antagonist. (21) Magnesium also has anticonvulsive properties that may contribute to diminished extension of brain damage. Cerebral ischemia, through the release of excitatory amino acids, is associated with the presence of epileptiform activity, which can disrupt the balance between blood flow and cell metabolism, thereby increasing the area of lesion in the brain. (21) Unfortunately, the results of experimental studies examining such magnesium effects have been variable. (26) (27) A deficiency of magnesium enhanced the susceptibility of hamster hearts to free radical damage, which could be applicable to neurons. (28) In the neonatal rat model, smaller brain lesions were seen after a single dose of magnesium sulfate 15 minutes after an NMDA insult, (29) and the association of magnesium sulfate and free radical inhibitors reduced the neuronal lesion after a hypoxic-ischemic insult in rats. (30) In newborn piglets, however, magnesium sulfate failed to prevent delayed cerebral energy failure after transient hypoxia-ischemia. (27) Moreover, administration of this therapy during a process of asphyxia did not compromise fetus near-term lambs, but also did not reduce cerebral injury. (31) In humans, the results are more controversial, alNeoReviews Vol.8 No.9 September 2007 e389

Excitatory Neurotransmitter Release
Amino acid glutamate is one of the most important excitatory neurotransmitters in the brain. The presence of an NMDA receptor site in the developing brain that involves regions of agonist (glutamate) and antagonist (magnesium) activities may indicate a possible route for protection. (20)(21)(22) During hypoxia-ischemia, glutamate is released from the intracellular compartment linked to the entrance of calcium into cells and their subsequent depolarization. In addition, the sodium-dependent uptake of glutamate by the presynaptic membranes decreases, which maintains an increased extracellular concentration of glutamate and a sustained stimulation of its receptors. (20)(21) Two mechanisms of glutamate-induced neuronal damage have been proposed. One is rapid cell death, which occurs within minutes after induction of the insult and involves an intense influx of sodium, chloride, and water, resulting in cell swelling and lysis. The second, more delayed, mechanism occurs 24 hours after the insult and is dependent on the influx of calcium through NMDA-stimulated calcium channels. The result is an increase in cytosolic calcium concentration that sustains the process by further activating glutamate release and the other damaging mechanisms already mentioned.

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Figure 1. Ionic magnesium concentrations in term newborns who did and did not have perinatal asphyxia during the first postnatal

week. The values in the third and seventh postnatal days were higher in the group that had perinatal asphyxia (*P<0.05). Reprinted with permission from Barbosa NOE, Leone Cr. Rev Paul Pediatr. 2006. (38)

though there are some positive findings. Magnesium sulfate frequently is administered to pregnant women for treatment of pre-eclampsia. Some studies have shown a reduction in the incidence of cerebral palsy in newborns after maternal administration of magnesium sulfate, although others have not shown this effect. (32)(33) Clinical observations suggest a similar potential protective effect in preterm newborns exposed to antenatal magnesium sulfate, in whom the incidence of cerebral palsy was reduced at 3 years of age. (34) However, a logistic regression analysis examining the risk of cerebral palsy in a cohort of newborns who weighed less than 2,000 g and whose mothers had received magnesium sulfate showed no significant effects. (35) Randomized, controlled studies performed in Australia that included preterm newborns born at less than 30 weeks of gestation, who were evaluated at 2 years of age, suggested a smaller frequency of death and cerebral palsy after the use of antenatal magnesium, although the effects were not significant. (36) The duration and severity of a hypoxic-ischemic insult seems to influence the concentration of magnesium in cord blood. For example, magnesium values were lower in umbilical cord blood of infants after severe distress and those who had moderate or severe hypoxic-ischemic
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encephalopathy (HIE). (37) Such decreased magnesium concentrations could be an indicator of more intense neurologic injury. Other authors have suggested an adverse outcome associated with higher concentrations of ionic magnesium at birth. (24) In another study of newborns who had HIE, the mean red cell magnesium content was significantly lower than in healthy newborns. (28) This fact is particularly important because stores of magnesium in red cells usually remain constant throughout gestation. Few studies have examined ionic magnesium in perinatal asphyxia; total magnesium concentration generally has been the reference. We have observed higher concentrations of ionized magnesium in umbilical cord blood of term newborns who had perinatal asphyxia 3 and 7 days after birth in relation to term newborns without perinatal asphyxia (Fig. 1). (38) However, total magnesium concentrations did not differ (Fig. 2). These results were attributed to a renal effect of mild asphyxia, evidenced by the higher lactate and creatinine values observed in the newborns who had asphyxia. In another study of asphyxiated near-term newborns, two different doses of magnesium sulfate were administered within 12 hours of birth. (39) Infants who received 400 mg/kg had a reduction in mean arterial

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Figure 2. Total magnesium concentrations in term newborns who did and did not have perinatal asphyxia during the first postnatal week. There were no differences between the groups. Reprinted with permission from Barbosa NOE, Leone CR. Rev Paul Pediatr. 2006. (38)

blood pressure of about 13% after 1 hour of infusion; those who received 250 mg/kg did not develop hypotension, although they did experience respiratory depression. In contrast, Gathwala and associates (25) documented no effect on heart rate, respiratory rate, oxygen saturation, and mean arterial pressure in term newborns following treatment with magnesium sulfate at doses of 250 mg/kg 30 minutes after birth and 125 mg/kg at 24 and 48 hours after birth. The mean serum concentrations of magnesium measured after different therapeutic schedules have been recognized as regulators of adverse effects, primarily cardiovascular. A range of 1.25 to 2.04 mEq/L (1.25 to 2.04 mmol/L) is expected to be neuroprotective, although symptoms of hypermagnesemia have been reported at serum concentration above 2 mEq/L (2 mmol/L), which is very close to the therapeutic concentration. A recent randomized, controlled study in term newborns who had different grades of HIE documented no effect of 250 mg/kg of magnesium sulfate administered at about 12 hours after birth on the concentrations of glutamine and aspartate in the cerebrospinal fluid at 72 hours after birth. (23) Nevertheless, magnesium use

was associated with an increase in the need for mechanical ventilation and oxygen use. Although no protective effect was shown in this study, earlier use of magnesium after birth might have been more effective if the dose was controlled to avoid undesirable effects on the cardiovascular system. In Japan, a nonrandomized clinical trial was conducted among 30 term newborns who had moderate and severe HIE in four hospitals. (19) The infants received 250 mg/kg of magnesium sulfate over 1 hour within 6 hours of birth, with two additional doses administered at 12 and 24 hours. Dopamine was infused concomitantly. Neither hypotension nor changes in heart rate were observed, although hypotonia occurred and the infants were maintained on mechanical ventilation. There were four neonatal deaths, and at follow-up at 18 months of age, 22 infants (73%) had normal development and 6 infants had cerebral palsy. The calcium-channel and neuromuscular blocking aspects of magnesium suggest that it may have other effects that require control after its administration. Hemodynamic instabilities, such as hypotension, bradycardia,
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delayed intraventricular conduction, and even complete atrial-ventricular block and apnea, have been described.

14. Lelivre-Pegorier M, Merlet-Benichou C, Roinel N, de
Rouffignac C. Developmental pattern of water and electrolyte transport in rat superficial nephrons. Am J Physiol. 1983;245: F15F-21 15. Quamme GA. Renal magnesium handling: new insights in understanding old problems. Kidney Int. 1997;52:1180 –1195 16. Vetter T, Lohse MJ. Magnesium and the parathyroid. Curr Opin Nephrol Hypertens. 2002;11:403– 410 17. Venkataraman PS, Tsang RC. Calcium, magnesium and phosphorus in the nutrition of the newborn. J Am Coll Nutr. 1995;14: 439 – 447 18. Barbosa NOE, Okay TS, Leone CR. Magnesium and intrauterine growth restriction. J Am Coll Nutr. 2005;24:10 –15 19. Ichiba H, Yokoi T, Tamai H, Ueda T, Kim TJ. Neurodevelopmental outcome of infants with birth asphyxia treated with magnesium sulfate. Pediatr Int. 2006;48:70 –75 20. Espinoza MI, Parer JT. Mechanisms of asphyxial brain damage, and possible pharmacological interventions, in the fetus. Am J Obstet Gynecol. 1991;164:1582–1591 21. Berger R, Garnier Y. Pathophysiology of perinatal brain damage. Brain Res Rev. 1999;30:107–134 22. Perlman JM. Intervention strategies for neonatal hypoxicischemic cerebral injury. ClinTher. 2006;28:1353–1365 23. Khashaba MT, Shouman BO, Shaltout AA, et al. Excitatory amino acids and magnesium sulfate in neonatal asphyxia. Brain Dev. 2006;28:375–379 24. Mittendorf R, Pryde PG. An overview of the possible relationship between antenatal pharmacologic magnesium and cerebral palsy. J Perinat Med. 2000;28:286 –293 25. Gathwala G, Khera A, Singh I. Magnesium therapy in birth asphyxia. Indian J Pediatr. 2006;73:209 –212 26. Vannucci RG, Perlman JM. Interventions for perinatal hypoxic-ischemic encephalopathy. Pediatrics. 1997;100:1004 – 1014 27. Penrice J, Amess PN, Punwanis S, et al. Magnesium sulfate after transient hypoxia-ischemia failed to prevent delayed cerebral energy failure in the newborn piglet. Pediatr Res. 1997;41: 443– 447 28. Harrison V, Peat G. Red blood cell magnesium and hypoxicischaemic encephalopaty. Early Hum Dev. 1997;47:287–296 29. McDonald JW, Silverstein FS, Johnson MV. Magnesium reduces N-methyl-D-Aspartate (NMDA)-mediated brain injury in perinatal rats. Neurosci Lett. 1990;109:234 –238 30. Thordstein M, Bagenholm R, Thringer K, Kjillmer I. Scavengers of free oxygen radicals in combination with magnesium ameliorate perinatal hypoxic-ischemic brain damage in the rat. Brain Res. 1993;34:23–26 31. de Haan HH, Gunn AJ, Williams CE, et al. Magnesium sulfate therapy during asphyxia in near-term fetal lambs does not compromise the fetus but does not reduce cerebral injury. Am J Obstet Gynecol. 1997;176:18 –27 32. Kent A, Kecskes Z. Magnesium sulfate for term infants following perinatal asphyxia (protocol). Cochrane Database Syst Rev. 2003;2:CD004494 33. Du Plessis A, Johnston MV. Hypoxic-ischemic brain injury in the newborn, cellular mechanisms and potential strategies for neuroprotection. Clin Perinatol. 1997;24:627– 654 34. Nelson KB, Grether JK. Can magnesium sulfate reduce the risk of cerebral palsy in very low birth weight infants? Pediatrics. 1995; 95:263–269 35. Panneth N, Jelton J, Pinto-Martin J, Susser M, The Neonatal

Conclusion
Among potential reasons for the conflicting clinical results obtained to date are that: 1) the concentration of magnesium needed to act on NMDA receptors has not been reached in some studies, 2) other events may cause neuronal injury, 3) the optimal time to administer magnesium sulfate after an hypoxic-ischemic insult is not yet known, 4) the effective dose of magnesium sulfate has not been determined, and 5) another aspect of damage may be the secondary hypotension caused by magnesium infusion. Some results are promising and reinforce the need for more knowledge about the sequence of events after a hypoxic insult in the newborn, specifically the point to be blocked to prevent neuronal injury and cell death. Similarly, the precise time and safe dose of magnesium need to be determined. Multicenter randomized, controlled studies are needed before an indication for magnesium therapy in newborns who have severe asphyxia can be recommended.

References
1. Olofsson K, Matthiesen G, Rudnicki M. Whole blood ionized
magnesium in neonatal acidosis and preterm infants: a prospective consecutive study. Acta Paediatr. 2001;90:1398 –1401 2. Engidawork E, Loidl F, Chen Y, et al. Comparison between hypothermia and glutamate antagonism on the immediate outcome of perinatal asphyxia. Exp Brain Res. 2001;138:375–383 3. Fawcett WJ, Haxby EJ, Male DA. Magnesium: physiology and pharmacology. Br J Anaesth. 1999;83:302–320 4. Rude RK. Magnesium metabolism. In: Becker KL, ed. Principles and Practice of Endocrinology and Metabolism. 3rd ed. Philadelphia, Pa: Lippincott; 2001:673– 678 5. Paunier L. Effect of magnesium on phosphorus and calcium metabolism. Monatsschr Kinderheilkd. 1992;140:17–20 6. Tsang RC. Neonatal magnesium disturbances. Am J Dis Child. 1972;124:282–293 7. Elin RJ. Assessment of magnesium status. Clin Chem. 1987;33: 1965–1970 ´ 8. Saris NL, Mervaala E, Karppanen H, Khawaja JA, Lewenstam A. Magnesium. An update on physiological, clinical and analytical aspects. Clin Chim Acta. 2000;294:1–26 9. Geven WB, Monnens LAH, Willems JM. Magnesium metabolism in childhood. Miner Electrolyte Metab. 1993;19:308 –313 10. Reinhart RA. Magnesium metabolism. Arch Intern Med. 1988; 148:2415–2420 11. Sievers E, Schleyerbach U, Schaub Y. Magnesium balance studies in premature and term infants. Eur J Nutr. 2000;39:1– 6 12. Weisinger J, Bellorin-Font E. Magnesium and phosphorus. Lancet. 1998;352:391–396 13. Mclean R. Magnesium and its therapeutic uses: a review. Am J Med. 1994;96:63–76
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Brain Hemorrhage Study Analysis Group. Magnesium sulfate in labor and risk of neonatal brain lesions and cerebral palsy in low birth weight infants. Pediatrics. 1997; 99:e1 36. Crowther CA, Hiler JE, Doyle LW, Haslam RR, Australian Collaborative Trial of Magnesium sulfate. Effect of magnesium sulfate given for neuroprotection before preterm birth: a randomized controlled trial. JAMA. 2005;290:2669 –2676 37. Ilves P, Kiisk M, Soopold T, Talvik T. Serum total magnesium ˜ and ionized calcium concentrations in asphyxiated term newborn

infants with hypoxic-ischaemic encephalopathy. Acta Paediatr. 2000;89:680 – 685 38. Barbosa NOE, Leone CR. Asfixia perinatal e nıveis de magne´ ´ sio em recem-nascidos de termo. Rev Paul Pediatr. 2006;24(1): ´ 6 –13 39. Levene M, Blennow M, Whitelaw A, Hanko E, Fellman V, Hartley R. Acute effects of two different doses of magnesium sulphate in infants with birth asphyxia. Arch Dis Child. 1995;73: 174 –177

NeoReviews Quiz
9. Magnesium, one of the principal cations in the body, plays an important role as a cofactor in many enzymatic reactions and is essential for a number of cellular functions. Of the following, the most accurate statement regarding magnesium metabolism in the newborn is that: A. Cord blood magnesium concentration is higher than maternal magnesium concentration, reflecting active placental transport of magnesium. B. Gastrointestinal absorption of magnesium amounts to 80% of magnesium ingested in the diet. C. Magnesium in the serum is present largely in its protein-bound state, primarily bound to albumin. D. Magnesium reabsorption in the kidney occurs predominantly in the thick ascending limb of the loop of Henle. E. The highest distribution of body magnesium is in the intracellular components of muscle and soft tissues. 10. Perinatal hypoxic-ischemic insults and associated biochemical events result in varying degrees of neuronal injury in the fetus/neonate. Of the following, the most important contributor to hypoxia-ischemiainduced neuronal injury in the fetus is: A. B. C. D. E. Calcium efflux from neuronal cells. Excitatory neurotransmitter glutamate-mediated toxicity. Lactic acid accumulation from anaerobic metabolism. Oxygen free radical-mediated injury during reperfusion. Phospholipase-induced hydrolysis of neuronal cell membranes.

11. Magnesium produces several biochemical effects that may be neuroprotective, which accounts for the interest in this cation as a potential therapeutic strategy for reduction of brain injury following a hypoxic-ischemic insult in the newborn. Of the following, the most likely important mechanism for magnesium-induced neuroprotection is: A. B. C. D. E. Anticonvulsive effect. Cerebral vasodilatation. Neuronal cell membrane stabilization. N-methyl-D-aspartate receptor blockage. Oxygen free radical scavenging.

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Index of Suspicion in the Nursery Katharine Kevill and Richard Auten NeoReviews 2007;8;e394-e397

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NeoReviews is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 2000. NeoReviews is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2007 by the American Academy of Pediatrics. All rights reserved. Online ISSN: 1526-9906.

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index of suspicion in the nursery

Case

Presentation

The reader is encouraged to write possible diagnoses for each case before turning to the discussion. We invite readers to contribute case presentations and discussions. Please inquire first by contacting Dr. Philip at aphilip@stanford.edu.

A 2.6-kg infant was born at 38 weeks’ gestation to a 16-year-old G1P0 woman. The prenatal history included maternal Chlamydia infection. The baby was delivered via emergent cesarian section because of nonreassuring fetal heart tones. His Apgar scores were 7 and 9 at 1 and 5 minutes, respectively. He exhibited tachypnea and hypoxia at birth, with a respiratory rate of 80 to 100 breaths/min, grunting, chest retractions, and coarse breath sounds. Other than a mild systolic ejection murmur, the remainder of the physical examination findings were normal. The baby’s A-a gradient (a measure of the difference in the partial pressure of oxygen in the alveolar spaces and the arterial blood) was elevated, initially 473 mm Hg on 100% FiO2. Chest radiographs showed no signs of acute air space disease for the first several postnatal weeks. Over the next several months, the infant continues to have a respiratory

rate of 60 to 90 breaths/min, with increased work of breathing, gradually requiring increases in supplemental oxygen to achieve an SpO2 in the mid-90s. Chest computed tomography (CT) scan performed at 2 weeks of age showed attenuation of the pulmonary vasculature and hyperinflation of the lungs. Although motion artifact limited the evaluation, the chest CT showed no focal lung opacities and no other anatomic defects. Repeated echocardiography revealed a small patent foramen ovale (left-to-right shunt) and normal ventricular size and function. Multiple therapies are tried without obvious improvement, including inhaled albuterol, systemic dexamethasone, and systemic sildenafil. An aggressive diuretic regimen and supplemental oxygen achieves stable SpO2 and work of breathing. An extensive evaluation is performed to determine the cause of the patient’s persistent respiratory distress. A single test reveals the diagnosis.

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index of suspicion in the nursery

Figure

1. Noncontrast-enhanced, thin-section (highresolution) multidetector CT scan demonstrates abnormalities at several levels in an intubated child (examination performed with inspiratory hold). A. Axial image just below the level of the carina demonstrates scattered increased density of the lung parenchyma (mosaicism) abutting (arrowheads) a more normal area of aeration (A); note also scattered bandlike opacities (arrows). B. Axial image at the level of the mid-heart shows the increased lung density noted previously and several scattered cystic lucencies (arrows); posteromedial opacities are due to atelectasis often seen with intubation. C. Axial image at the lung base demonstrates increased lung density, scattered nodular opacities, posteromedial atelectasis, and irregular septal thickening (arrows).

Case Discussion
Serial chest CT scans performed at 2 and 3 months of age revealed findings consistent with interstitial lung disease (ILD), including worsening ground-glass opacities and septal thickening (Fig. 1). Chronic aspiration was ruled out as a cause when swallow and milk scintigraphy studies revealed no evidence of aspiration, and the upper gastrointestinal tract showed no evidence of a tracheoesophageal fistula. A negative sweat test ruled out cystic fibrosis as a cause for the baby’s chronic respiratory distress. Immunodeficiency was considered as a cause for the worsening ILD, but results of a complete blood count and differential count,

immunoglobulin measurement, and lymphocyte enumeration studies were normal. Multiple blood, urine, and sputum studies failed to identify any viral or bacterial infection. A bronchoscopy performed at 5 weeks of age revealed laryngomalacia, but the magnitude was insufficient to explain a primary cause for the respiratory distress. At 2 months of age, cardiac catheterization was performed to evaluate the possibility of pulmonary artery hypertension. The pulmonary vascular resistance was elevated to 4 Woods units on room air, but normalized to 2 Woods units with administration of 40% oxygen. At 3 months of age, microscopic

examination of a lung biopsy demonstrated findings consistent with pulmonary alveolar proteinosis, including coarsely granular, strongly periodic acid-Schiff stain-positive alveolar exudate; mild thickening of the alveolar septae; and interstitial inflammation (Fig. 2). Genotyping revealed no pathologic mutations in the surfactant protein B or C (SP B and SP C) genes, but did identify three mutations in the ABCA3 gene. The third member of the ATPbinding cassette (ABC) transporter family is believed to play a major role in surfactant synthesis. Although the genetic studies on the patient’s blood could not confirm whether these mutations were on the same or opposite
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index of suspicion in the nursery

dren and fatal lung disease in infants. Abnormal lamellar body formation was observed in infants who had ABCA3 deficiency whose lung biopsies were evaluated by electron microscopy. To date, there is no specific treatment for infants who have ABCA3 deficiency; lung transplant is the only definitive therapy offered. The patient described in this case deteriorated, despite aggressive diuretic therapy and intermittent high-dose steroids. He received a bilateral lung transplant at age 8 months.
Figure 2. Histologic appearance of a lung biopsy obtained at 3 months of age. Staining was with hematoxylin-eosin, 20x magnification. Alveoli are filled by a granular, eosinophilic exudate, with moderate reactive change within thickened alveolar septa.

Lessons for the Clinician
ILD is a potential cause for persistent respiratory distress in term infants who have elevated A-a gradients and diffuse radiographic findings. A systematic approach to the differential diagnosis can be helpful, including assessment of the severity of the lung disease and identification of primary disorders that can predispose to ILD, such as immunodeficiency and aspiration. A lung biopsy often is necessary for definitive diagnosis, with proper attention to lung fixation to allow for electron microscopy. However, ILD due to several types of surfactant dysfunction now is detectable through molecular genetic testing. (Katharine Kevill, MD, Richard Auten, MD, Department of Pediatrics, Duke University, Durham, NC) ACKNOWLEDGMENTS. We thank Donald Frush, MD, Department of Pediatric Radiology at Duke, for the radiographic images.

chromosomes, it was determined that, in view of the clinical course and other supportive laboratory findings, the patient had congenital alveolar proteinosis due to ABCA3 gene mutations.

Pathogenesis/Incidence/ Natural History
Pediatric interstitial lung disease (PILD) describes a heterogenous group of rare disorders characterized by diffuse pulmonary infiltrates that result in tachypnea, crackles, and hypoxemia. The discovery of genetic defects in surfactant function has revealed causes for some cases of PILD that otherwise would have been classified as idiopathic. SP B deficiency initially was described in 1993 as a fatal cause for respiratory distress in a term infant, and SP C deficiency was identified initially in 2001 in an infant whose family history was significant for three generations of ILD. Most recently, ABCA3 deficiency was recognized as a congenital error in surfactant metabolism in a group of infants who had severe neonatal surfactant deficiency.
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Defective surfactant protein processing underlies many cases of pulmonary alveolar proteinosis (PAP), a rare syndrome that has an estimated worldwide prevalence of 3.7 per 1 million. It is characterized pathologically by intra-alveolar filling with surfactant lipoprotein and physiologically by disturbances of pulmonary gas exchange. Fluid returned on bronchoalveolar lavage appears milky and stains positively for periodic acid-Schiff in alveolar macrophages. PAP occurs in three clinically recognized forms: congenital (2% of total cases), secondary (5% to 10% of cases), and idiopathic. Some authors consider genetic defects in surfactant production to be forms of congenital PAP. Hereditary ABCA3 deficiency is an autosomal recessive disorder caused by mutations in the gene encoding member A3 of the ABC family of proteins. The ABC transporters are a large family of transmembrane proteins that transport substrates across biologic membranes. Since its original description, ABCA3 deficiency has been associated with both interstitial lung disease in older chil-

Suggested Reading
Fan L, Langston C. Interstitial lung disease. In: Chernick V, Boat TF, Wilmot RW, Bush A, eds. Kendig’s Disorders of the Respiratory Tract in Children. 7th ed. Philadelphia, Pa: Elsevier; 2006:666 – 675 Nogee LM. Genetic mechanisms of surfac-

Downloaded from http://neoreviews.aappublications.org by Alaa Swaify on September 2, 2007

index of suspicion in the nursery

tant deficiency. Biol Neonate. 2004;85: 314 –318 Presneill JJ, Nakata K, Inoue Y, Seymour JF. Pulmonary alveolar proteinosis. Clin Chest Med. 2004;25:593– 613 De Blic J. Pulmonary alveolar proteinosis in

children. Paediatr Respir Rev. 2004;5: 316 –322 Berclaz P, Trapnell B. Rare childhood lung disorders. In: Chernick V, Boat TF, Wilmot RW, Bush A, eds. Kendig’s Disorders of the Respiratory Tract in Children.

7th ed. Philadelphia, Pa: Elsevier; 2006: 747–761 Prestridge A, Wooldridge J, Deutsch G, et al. Persistent tachypnea and hypoxia in a 3-month-old term infant. J Pediatr. 2006;149:702–706

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NeoReviews Vol.8 No.9 September 2007 e397

Index of Suspicion in the Nursery Katharine Kevill and Richard Auten NeoReviews 2007;8;e394-e397

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