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Anemia of prematurity: how low is too low?

Journal of Perinatology volume 41, pages 1244–1257 (2021)Cite this article

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Abstract

Anemia of prematurity (AOP) is a common condition with a well-described chronology, nadir hemoglobin levels, and timeline of recovery. However, the underlying pathophysiology and impact of prolonged exposure of the developing infant to low levels of hemoglobin remains unclear. Phlebotomy losses exacerbate the gradual decline of hemoglobin levels which is insidious in presentation, often without any clinical signs. Progressive anemia in preterm infants is associated with poor weight gain, inability to take oral feeds, tachycardia and exacerbation of apneic, and bradycardic events. There remains a lack of consensus on treatment thresholds for RBC transfusion which vary considerably. This review elaborates on the current state of the problem, its implication for the premature infant including association with subphysiologic cerebral tissue oxygenation, necrotizing enterocolitis, and retinopathy of prematurity. It outlines the impact of prophylaxis and treatment of anemia of prematurity and offers suggestions on improving monitoring and management of the condition.

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Fig. 1: Equation depicting oxygen delivery to tissues and the significant role of hemoglobin.
Fig. 2: Iron homeostasis in the neonate: hepcidin regulates iron by degradation of ferroportin (Fpn), a transmembrane glycoprotein receptor present in the duodenal enterocytes and macrophages that transport iron from inside the cell to outside the cell.

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Funding

NIH Grants HL124078 and HL133022 (AM).

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Authors and Affiliations

  1. Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA

    Catherine C. Cibulskis & Amit M. Mathur

  2. Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Akhil Maheshwari

  3. Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO, USA

    Rakesh Rao

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  1. Catherine C. Cibulskis
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  3. Rakesh Rao
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  4. Amit M. Mathur
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CCC performed the literature review and wrote the first draft of the manuscript. RR performed and reviewed the literature and critically edited the review for content. AM coinitiated the concept for the review, performed literature review, and critically reviewed and edited the manuscript for content. AMM initiated the concept for the review, performed literature review, and critically reviewed and edited the manuscript for content.

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Correspondence to Amit M. Mathur.

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Cibulskis, C.C., Maheshwari, A., Rao, R. et al. Anemia of prematurity: how low is too low?. J Perinatol 41, 1244–1257 (2021). https://doi.org/10.1038/s41372-021-00992-0

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  • DOI: https://doi.org/10.1038/s41372-021-00992-0

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