Anemia of Prematurity - Portal Neonatal

and equilibrium between the intravascular and extravascular spaces, having to repeat the
procedure at least once is not uncommon. Using O negative blood rather than the baby's
blood type is important because not all circulating antibodies may be removed. Packed
RBCs resuspended in fresh frozen plasma must be used for this procedure.
o Risks
� This procedure carries both inherent risks and iatrogenic ones and should be carefully
performed. The reported overall mortality rate is about 3:1000; the risk of significant
morbidity has been reported at about 5:100. In very ill babies, the risks are higher.
One series of 25 ill infants reported a mortality rate of 20%.
� Transfusing with banked blood products carries a risk of infection. Currently, the risk
of infection with known pathogens is exceedingly small. However, a risk of infection
with pathogens that have not yet been discovered (ie, most recently hepatitis C)
continues.
� During the procedure, continually monitor for attendant physiologic aberrations, such
as hypoglycemia, thrombocytopenia, hyperkalemia (particularly if the banked blood is
older than 5 d), and hypocalcemia (if ethylenediamine tetra-acetic acid [EDTA]
preservative is used in the banked blood).
� Mechanical issues can contribute to the overall mortality and morbidity of the
procedure. The need for central access, catheter- and infusion-related problems, and
human error during infusion are all areas that can pose potentially significant risk.
� Since the advent of phototherapy and obstetric treatment of Rh disease, the need for
exchange transfusion has diminished.
o Indicated bilirubin levels
� As mentioned above, no clear-cut level of bilirubin exists above which encephalopathy
is assured and below which neurologic safety exists. Birthweight, gestational age, and
chronologic age are all important, as are a baby's systemic condition, fluid and
nutritional status, acid-base status, and the presence or absence of known pathology.
In 1994, the American Academy of Pediatrics (AAP) published practice parameters for
the management of hyperbilirubinemia in the healthy term infant. In this document, the
AAP recommended exchange transfusion for serum bilirubin levels greater than 20-25
mg/dL, depending on the chronologic age of the infant. Some have criticized these
parameters as being too aggressive.
� Studies have reported neurologically normal outcomes in healthy term infants with
histories of serum bilirubin levels as high as 46 mg/dL. However, the recent
resurgence in kernicterus has been reported to occur exclusively in near-term infants
with serum bilirubin levels greater than 30 mg/dL. The level at which to intervene is a
clinical question that remains to be answered. The procedure should be highly
considered in babies with significant risk factors predisposing for kernicterus (eg,
sepsis, acidosis, hemolytic disease) if the bilirubin level has approached the 20- to 25mg/dL
range.
• Agar: Enteral administration of agar has been tried in an attempt to decrease the
enterohepatic recirculation of conjugated bilirubin. It has not proved to be clinically useful and
may cause intestinal obstruction.
• Sn-mesoporphyrin: Experimental therapy with Sn-mesoporphyrin inhibits bilirubin production
by interfering with heme-oxygenase, an essential enzyme in the catabolic pathway of
hemoglobin. This therapy is in clinical trials but has not been approved for use by the Food
and Drug Administration (FDA).
Consultations: Obtaining input from a pediatric neurologist during the acute presentation of bilirubin
encephalopathy may be useful. However, the history and clinical presentation may make the diagnosis
apparent. In the chronic phase, involving neurodevelopmental specialists in the care and evaluation of
the infant is important. Developmental potential can be maximized by early identification of and
intervention for neurologic deficits.
If the patient develops hydrocephalus, consultation with a neurosurgeon is recommended.