Anemia of Prematurity

Presentation

• Extreme prematurity and low birth weight
• Gradual onset of pallor
• Tachycardia or flow murmur
• Increased frequency of apnea and bradycardia episodes
• Poor weight gain or increased requirements for respiratory support
• Lethargy or decreased activity

Initial Workup

• Complete Blood Count (CBC) showing normocytic, normochromic anemia with low reticulocyte count
• Calculate blood volume drawn for laboratory testing (iatrogenic loss)
• Assess for signs of overt bleeding or hemolysis (e.g., elevated bilirubin, direct antiglobulin test if indicated)

Management Protocol

• Minimize phlebotomy losses via micro-methods and non-invasive monitoring (e.g., transcutaneous bilirubin, NIRS)
• Provide iron supplementation (typically 2-4 mg/kg/day of elemental iron) once enteral feeds are established > 100 mL/kg/day
• Transfuse packed red blood cells (PRBCs) strictly following unit-specific restrictive transfusion guidelines based on respiratory support and clinical symptoms
• Administer delayed cord clamping (30-60 seconds) at delivery to optimize initial red cell mass (preventative)

Hematology & Transfusion Protocols

• PRBC Transfusion: 10-15 mL/kg administered slowly over 3-4 hours; monitor for volume overload and TACO.
• Platelet Transfusion: 10-15 mL/kg over 30-60 minutes.
• Phototherapy irradiance should check strictly >= 30 µW/cm²/nm at the infant's skin level.
• Monitor for rebound hyperbilirubinemia exactly 12 and 24 hours after discontinuing phototherapy lights.
• Shield eyes meticulously and document position check every hour while under phototherapy.

Standardized Discharge & Follow-Up Criteria

• Adequate weight gain explicitly > 15-30g/day over a continuous 3-5 day period.
• Maintenance of temperature in an open crib with standard clothing for 48 hours.
• Successful completion of the 90-120 minute Infant Car Seat Challenge.
• Caregiver successfully completed CPR training, rooming-in, and independent medication administration.
• Referrals placed for High-Risk Infant Follow-Up Clinic, Early Intervention (PT/OT), and appropriate sub-specialists.

Diagnostic & Management Algorithm

• Neonatal Anemia Transfusion Algorithm: [START] Hgb < threshold -> [DECISION] Respiratory support needed? -> [YES] Transfuse at higher threshold -> [NO] Transfuse at lower threshold -> [ACTION] PRBC 10-15 mL/kg

References

1. Kirpalani H, Whyte RK, Andersen C, et al. a randomized, controlled trial of a restrictive (low) versus liberal (high) transfusion threshold for extremely low birth weight infants. J Pediatr.
2. Whyte RK, Kirpalani H, Asztalos EV, et al. Neurodevelopmental outcome of extremely low birth weight infants randomly assigned to restrictive or liberal hemoglobin thresholds. Pediatrics.