Red blood cell transfusion in premature infants leads to worse necrotizing enterocolitis outcomes

Abstract

Background Necrotizing enterocolitis (NEC) is a severe intestinal disease of premature infants with high mortality. Studies suggest a causative relationship between red blood cell (RBC) transfusion and NEC, however, whether RBC transfusion leads to worse outcomes in NEC is unknown. We sought to determine whether RBC transfusion was associated with an increased risk of surgical NEC and mortality. Methods In this retrospective study, 115 patients were enrolled with NEC Bell’s Stage 2A or greater from 2010–2015. Patients were classified based on the timing of RBC transfusion prior to NEC: ≤72 hours, >72 hours, and no transfusion. Variables including gestational age (GA), birth weight (BW), feedings and hematocrit levels were analyzed. Outcomes were surgical intervention for NEC following RBC transfusion and mortality. Results 23 (20%) infants developed NEC ≤ 72 hours after RBC transfusion, 16 (69.6%) required surgery with a mortality rate of 21.7% (n=5). 17 (15%) infants developed NEC > 72 hours after RBC transfusion, 12 (70.6%) required surgery with a mortality rate of 23.5% (n=4). 75 (65%) patients developed NEC without RBC transfusion, 17 (22.7%) required surgery with a mortality rate of 4% (n=3). Lower GA and BW were significantly associated with RBC transfusion and the need for surgical intervention. RBC transfusion ≤72 hours prior to NEC was associated with surgical NEC (pairwise adjusted p<0.001) and mortality (pairwise adjusted p=0.048). However, multivariable logistic regression analysis revealed RBC transfusion is not an independent risk factor for surgical NEC. Conclusions Infants of lower GA and BW were more likely to receive an RBC transfusion prior to NEC, which was significantly associated with surgical intervention and an increasing risk of mortality. Judicious use of transfusions in premature infants may improve NEC outcomes.

Red Blood Cell Transfusion in Preterm Infants: Current Evidence and Controversies

“…In a large retrospective cohort study of 2,311 infants, Paul et al [73] demonstrated that infants who received RBCT had increased adjusted odds (OR = 2.3; 95% CI 1.2–4.2) of developing NEC. Recently retrospective data of 115 infants with NEC demonstrated that RBCT < 72 h before NEC onset was associated with a surgical intervention (pairwise adjusted p < 0.001), but multivariate logistic regression analysis “revealed RBCT is not an independent risk factor for surgical NEC” [74]. …”

Effects of Placental Transfusion by Delayed Cord Clamping or Umbilical Cord Milking versus Immediate Cord Clamping on Neonatal Outcomes in Very Low Birth Weight Neonates

“…The higher concentration of hemoglobin in neonates receiving some form of placental transfusion is a possible explanation for the reduced rate of blood transfusion in the first 72 hours of life in both the UCM and DCC groups when compared to the ICC group. This is important because transfusion of packed RBCs is under scrutiny in the neonatal literature due to concern that there is an association between packed RBC transfusion and morbidities such as necrotizing enterocolitis [5].…”

Necrotising Enterocolitis - epidemiology and imaging

“…171 ➢ Blood transfusion. Transfusion of red blood cells has long been suspected to contribute to the occurrence or severity of NEC, [150][151][152][153][154][155]172 One proposed mechanism is that a sudden increase in blood viscosity would reduce mesenteric blood flow and, in case of simultaneous enteral feeding, cause a relative ischemia. 30 An alternative explanation is an immunologic influence working through mesenteric arterial reactivity and nitric oxide pathways as investigated in premature lambs.…”