Andrea Loui

Hematologic effects of maternal antiretroviral therapy and transmission prophylaxis in HIV-1-exposed uninfected newborn infants.

Objective:A prospective observational study to investigate hematologic alterations during the first 3 months of life in HIV-exposed uninfected infants subjected to antiretroviral medication before and after birth. Methods:Two hundred twenty-one consecutive uninfected infants born to HIV-positive mothers on antiretroviral medication during pregnancy were included. Perinatal transmission prophylaxis comprised zidovudine (ZDV) administered intravenously intrapartum and 10 days after birth. Blood counts and differentials were determined at birth and at 2, 4, 6, and 12 weeks of age, and hematologic toxicity was graded according to pediatric toxicity scales. Data were analyzed according to the kind of prenatal medication (ZDV alone or with another nucleoside reverse transcriptase inhibitor [NRTI] vs. highly active antiretroviral therapy [HAART]). Results:Median hemoglobin was significantly lower in HAART-exposed newborns from birth (P = 0.004) until day 28. During follow-up, 119 (53.8%) infants had anemia grade 2 or higher on at least 1 occasion; 16 (7.2%) received red blood cell transfusion at 23 (range: 1-56) days of age. Neutropenia grade 2 or higher occurred in 106 (48.0%) infants at least once; 8 infants had staphylococcal infections, and 2 infections were severe. After adjustment for possible confounders (prematurity, birth weight, ethnicity, gender, duration of maternal antiretroviral therapy, maternal Centers for Disease Control and Prevention stage, and maternal illicit drug use), HAART exposure was the only independent risk factor for anemia (odds ratio [OR] = 2.22, 95% confidence interval [CI]: 1.06 to 4.64; P = 0.034) and neutropenia (OR = 2.15, CI: 1.02 to 4.55; P = 0.045). Conclusions:Antiretroviral transmission prophylaxis is associated with significant anemia and neutropenia in HIV-uninfected infants during the first 3 months of life. Anemia was more profound in HAART-exposed infants.

Immature platelet fraction as novel laboratory parameter predicting the course of neonatal thrombocytopenia

Thrombocytopenia occurs in up to 30% of neonates admitted to neonatal intensive care units (NICUs). In preterm neonates, severe thrombocytopenia is associated with increased risk of intracerebral bleeding. Thus, diagnosis of thrombocytopenia often leads to repeated subsequent analysis of blood cell counts and transfusion of platelets. However, no evidence has been provided that current practice for platelet transfusion prevents bleeding complications and improves clinical outcome. A rapid automated method to assess reticulated platelets, the immature platelet fraction (IPF), is available (Briggs et al, 2000). The aim of this study was to investigate the diagnostic value of IPF as a marker for megakaryopoietic activity in neonates. All 612 neonates admitted to our NICUs over a 6-month period were included in the study. Written parental consent and organisational approval were obtained. During the first postnatal week, blood samples were obtained as clinically indicated. To generate reference values for the IPF, patients were divided in two groups: The control group (n = 456) always displayed normal platelet counts (150–450 · 10/l). In the thrombocytopenic group (n = 156), platelet counts dropped below 150 · 10/l at least once. Blood samples obtained after platelet transfusion were excluded from analysis. Platelet counts were optically measured with the automated analyser XE-2100 (Sysmex, Kobe, Japan) equipped with the software xe-ipf-master. Determination of IPF is based on fluorescence flow cytometry using a nucleic acid specific dye that stains RNA in erythrocytic and platelet reticulocytes. The computed algorithm discriminates mature and immature platelet populations applying a preset gate (fluorescent intensity = RNA-content; forward scatter = cell volume). The IPF is normally expressed as a percentage of the platelet count to indicate the rate of platelet production; additionally, absolute values may be used to differentiate between insufficient platelet production and increased consumption as cause of thrombocytopenia. Regression analysis was used to calculate the correlation between platelet counts and IPF. Student’s t-test was applied to compare group means. Statistical analysis was performed using the software statgraphics (Manugistics Inc., Rockville, MD, USA). A P-value < 0Æ05 was considered to indicate statistical significance. In 1045 out of 1339 blood specimens IPF was routinely determined in addition to platelet counts. Four hundred and fifty-six patients (838 specimens) were assigned to the control group, 25Æ5% of patients (n = 156; 501 specimens) to the thrombocytopenic group. The mean [standard deviation (SD)] birth weight in the control group was significantly higher than in the thrombocytopenic group [2717 g, (SD ± 849) vs. 2188 g, (SD ± 105), P < 0Æ001]; this also refers to mean gestational age [36Æ3 weeks, (SD ± 3Æ7) vs. 34Æ2 weeks, (SD ± 5Æ0), P < 0Æ001]. In controls, the mean IPF value was 4Æ3% [95% confidence interval (CI) 0Æ7–7Æ9%] during the first postnatal week. In the thrombocytopenic group, the mean IPF (SD) during the first postnatal week was always significantly higher than in the control group [e.g. day 1: IPF 8Æ7% (9Æ3) vs. 4Æ53% (1Æ8); P < 0Æ001; Fig 1). 36% of thrombocytopenic neonates displayed an IPF above 7Æ9%. We found no significant correlation between gestational age and IPF. Using simultaneous IPF and platelet measurements of both groups, a significant negative correlation between IPF and platelet counts was found with an exponential decay (r = )0Æ62, P < 0Æ001). Increasing platelet counts were anticipated by an increased IPF, reflecting enhanced platelet production (Fig 1). According to the study aim, we analysed whether the platelet counts on the following day were somehow predicted by means of previous IPF values. In patients whose blood samples were analysed on two subsequent days, the difference in platelet counts was plotted against the corresponding IPF value (Fig 2). In this scatter plot, specimens (n = 398) were divided in to four quadrants according to IPF (>8%, which is outside CI > 95% of controls) and difference in platelet counts (severe

Neonatal end‐of‐life practice in a German perinatal centre

Aim: To investigate the end‐of‐life practice in a large perinatal centre in Germany.

Nutrition of Very low birth weight infants fed human milk with or without supplemental trace elements: A randomized controlled trial

Background: Very low birth weight infants (<1500 g) have high nutritional needs. Deficiencies of minerals, trace elements (especially zinc) may develop as a result of rapid growth, low body stores and low content of these substances in human milk We hypothesized that fortification of human milk might prevent deficiencies. Methods: Prospective, randomized trial to evaluate mineral, trace element, thyroid status and growth of infants fed human milk fortified with different amounts of calcium, phosphorus and protein, with (BMF) or without (FM 85) trace elements. Sixty-two infants, 1000 to 1499 g birth weight, were randomized. Minerals and trace elements in serum, red blood cells and human milk and alkaline phosphatase activity, TSH, T4 and FT4 in serum were measured once until the fifth day and at 3 and 6 weeks of life. Clinical course and anthropometric measurements were recorded. Results: Intake of zinc, copper, manganese, calcium, phosphorus and magnesium was higher in the BMF group (P < 0.001). Serum zinc concentrations <0.49 mg/L occurred in 12% of the FM 85 group and 7% of the BMF group at 6 weeks (not significant). Median alkaline phosphatase activity was 436/379 IU/L in the FM 85/BMF group at 6 weeks (P < 0.01). The FM 85 group showed a higher weight gain (P < 0.05), possibly because of higher caloric (P < 0.01) and protein intake (P < 0.05) at 3 weeks. Conclusions: Zinc deficiency was rare. Elevated intake of calcium, phosphorus and zinc was associated with lower serum alkaline phosphatase activity but did not influence serum zinc concentration.

Nutritional zinc balance in extremely low-birth-weight infants.

Background Zinc is important for metabolism, cell growth, immunity, and defense against oxygen radicals. Extremely low-birth-weight (< 1000 g) infants have higher nutritional needs, but information on zinc is scarce. The authors performed nutritional balances in 10 infants with birth weights of 500 to 999 g and who were fed with fortified human milk. Methods The authors collected infant feces, urine, and blood and human milk samples during 72 hours at 7 and 12 weeks of age. Zinc concentration was measured by inductively coupled plasma–mass spectrophotometry, atomic emission spectro-photometry, and instrumental neutron activation analysis. Results Mean (SD) intake via human milk was 379 (± 373) &mgr;g · kg−1 · d−1 during both balances. Urinary excretion was high at 7 weeks of age, decreased to half at 12 week, and was negatively correlated (P < 0.01) with weight gain. Mean absorption was slightly positive at 7 weeks of age but zero or negative in most infants at 12 weeks of age. Retention was negative in all infants at both observation periods, except in one infant during the second balance. Clinical zinc deficiency developed in one infant at 12 weeks of age. Conclusions Zinc balances in extremely low-birth-weight infants are highly variable and usually negative. Controlled trials are needed to assess need for and benefits and risks of zinc supplementation.

Calcium, phosphorus and magnesium balance: FM 85 fortification of human milk does not meet mineral needs of extremely low birthweight infants.

Objective: Extremely low birthweight (<1000 g) infants are growing rapidly and their nutritional requirements for calcium, phosphorus, magnesium are high.Design: Prospective, mineral balance.Setting: The study was carried out at the Department of Neonatology, Virchow-Hospital, Charité Berlin and the Department of Molecular Trace Element Research, Hahn-Meitner-Institute Berlin.Subjects: Nineteen infants <1000 g birthweight were admitted, nine infants dropped out and 10 infants (birthweight 730–995 g), fed fortified human milk were included.Intervention: We collected infants urine and feces for 72 h, a sample of human milk and infants blood at 7 and 12 weeks of age. Elements were measured by inductively coupled plasma atomic emission spectrophotometry.Results: Mean (s.d.) mineral concentration in milk was low especially at 12 weeks: calcium 9.88 (±3.58) mmol/l, phosphorus 7.02 (±3.81) mmol/l, magnesium 1.59 (±0.54) mmol/l. Calcium retention was minimal or negative during the study, whereas phosphorus and magnesium balances were positive. Caffeine and diuretics increased mineral excretion. Serum alkaline phosphatase was mostly <800 U/l, and 162 U/l in one infant with zinc deficiency at 12 weeks. Alkaline phosphatase correlated with absorption and retention of phosphorus, and with longitudinal growth.Conclusions: Infants <1000 g have high nutritional needs for calcium, phosphorus and magnesium, which are not met by a human milk fortifier widely used in Europe. Controlled trials are needed to assess requirements, duration and risks of mineral supplementation.

Vascular Endothelial Growth Factor (VEGF) and soluble VEGF receptor 1 (sFlt-1) levels in early and mature human milk from mothers of preterm versus term infants.

Background: Vascular endothelial growth factor (VEGF) and its receptors regulate angiogenesis (formation of blood vessels). The soluble VEGF receptor 1 (sFlt-1) binds VEGF as a potent antagonist. Objective: The objective of this study was to compare VEGF and sFlt-1 levels in milk from mothers of preterm (n = 50) versus term (n = 49) infants in a longitudinal study. Methods: Milk samples were collected on days 3 and 28 of lactation. Vascular endothelial growth factor and sFlt-1 were quantified by sandwich-type enzyme-linked immunosorbent assay. Results: Vascular endothelial growth factor and sFlt-1 were found in high concentrations in early milk (lactation day 3) from mothers of preterm and term infants and were lower in mature milk (lactation day 28). On day 3, median VEGF concentration was lower in preterm than in term milk (37.1 vs 53.9 ng/mL, P < .01). Otherwise, VEGF (day 28) and sFlt-1 (days 3 and 28) did not differ in preterm versus term milk. Conclusions: It was shown for the first time that sFlt-1 is present in human milk. Early human milk contains high concentrations of VEGF and sFlt-1, which decrease over the course of lactation.

Growth of very low birth weight infants after increased amino acid and protein administration.

Abstract Aim: To assess the impact of a high enteral protein nutrition strategy in human milk-fed very low birth weight (VLBW) infants (<1500 g) on growth during the first 5 weeks of life. Design: Weight, length and head circumference of VLBW infants were recorded after introduction of a high protein strategy. Results: Forty-three infants (median/interquartile range) of gestational age 27+6 weeks (26+0/29+6), birth weight 984 g (675/1130) were included. Parenteral nutrition was administered for 16 (14/18) days and the nutritional intakes achieved target values 4.3 g/kg/day protein (4.0/4.4); 128 kcal/kg/day energy (119/131). Human milk was fortified with 0.5–2.3 g/kg/day protein powder in addition to a fortifier. Near-intrauterine growth was observed: Weight gain from days 8–35: 17.6 g/kg/day (14.9/20.5); head growth from day 1–35: 0.70 cm/week (0.50/0.80); length growth from day 1–35: 1.0 cm/week (0.8/1.2). The total protein intake was shown to have a significant impact on infant’s weight gain up to the 35th day of life. Conclusion: High protein nutrition enables similar to fetal growth weight gain and head growth of VLBW infants during the first 5 weeks of life. These data support recently published ESPGHAN recommendations.

The Relative Dose Response Test Based on Retinol-Binding Protein 4 Is Not Suitable to Assess Vitamin A Status in Very Low Birth Weight Infants

Background: The relative dose response (RDR) test, which quantifies the increase in serum retinol after vitamin A administration, is a qualitative measure of liver vitamin A stores. Particularly in preterm infants, the feasibility of the RDR test involving blood is critically dependent on small sample volumes. Objectives: This study aimed to assess whether the RDR calculated with retinol-binding protein 4 (RBP4) might be a substitute for the classical retinol-based RDR test for assessing vitamin A status in very preterm infants. Methods: This study included preterm infants with a birth weight below 1,500 g (n = 63, median birth weight 985 g, median gestational age 27.4 weeks) who were treated with 5,000 IU retinyl palmitate intramuscularly 3 times a week for 4 weeks. On day 3 (first vitamin A injection) and day 28 of life (last vitamin A injection), the RDR was calculated and compared using serum retinol and RBP4 concentrations. Results: The concentrations of retinol (p < 0.001) and RBP4 (p < 0.01) increased significantly from day 3 to day 28. On day 3, the median (IQR) retinol-RDR was 27% (8.4-42.5) and the median RBP4-RDR was 8.4% (-3.4 to 27.9), compared to 7.5% (-10.6 to 20.8) and -0.61% (-19.7 to 15.3) on day 28. The results for retinol-RDR and RBP4-RDR revealed no significant correlation. The agreement between retinol-RDR and RBP4-RDR was poor (day 3: Cohens κ = 0.12; day 28: Cohens κ = 0.18). Conclusion: The RDR test based on circulating RBP4 is unlikely to reflect the hepatic vitamin A status in preterm infants.

Characterization of the vitamin A transport in preterm infants after repeated high-dose vitamin A injections.

Background/Objectives:Preterm infants have low vitamin A stores at birth, and parenteral administration of high-dose vitamin A reduces pulmonary morbidity. The aim was to characterize vitamin A transport and status.Subjects/Methods:Prospective study of 69 preterm infants (median birth weight 995 g, gestational age 28 weeks), in which 51 received 5000 IU vitamin A three times per week intramuscular (i.m.) for 4 weeks and 18 infants without i.m. vitamin A served as controls. Serum retinol, retinyl palmitate, total retinol-binding protein 4 (RBP4), retinol-unbound RBP4 (apo-RBP4) and transthyretin concentrations were determined at days 3 (D3) and 28 (D28) of life.Results:D3 retinol concentrations were low for the entire group (382 (285/531) nmol/l; median/interquartile range) and unrelated to gestational age. D28 retinol was unchanged in controls (382 (280/471) nmol/l), but increased in the vitamin A group (596 (480/825) nmol/l; P<0.001). A similar pattern was observed for RBP4. The calculated retinol-to-RBP4 ratio rose in vitamin A infants (D3: 0.81 (0.57/0.94), D28: 0.98 (0.77/1.26); P<0.01) but not in controls. In the vitamin A group, the retinol-to-RBP4 ratio was >1 in 15% of all infants on D3 and in 45% of infants on D28, but was ⩽1 in all, but one, controls on D28.Conclusions:In preterm infants receiving a 4-week course of high-dose i.m. vitamin A, serum retinol concentrations increased by 55%, with molar concentrations of retinol exceeding those of RBP4 in 45% of the infants suggesting transport mechanisms other than RBP4.