Comparison of a restricted transfusion schedule with erythropoietin therapy versus a restricted transfusion schedule alone in very low birth weight premature infants.

OBJECTIVE: Erythropoietin (EPO) is commonly used in very low birth weight neonates to minimize blood transfusions during hospitalization. Data are limited comparing the use of EPO along with a restricted transfusion schedule versus a restricted transfusion schedule alone. We compared the effects of a restricted transfusion schedule with EPO versus a restricted transfusion schedule alone during two consecutive 6-month periods.

METHODS: In period I, infants born at <30 weeks gestational age (GA) or <1,500 g birth weight (BW) were treated prophylactically for six weeks with EPO 1,000 U/kg/wk in three divided doses and blood transfusions were given using a restricted transfusion schedule. This was the called the EPO Group. In period II, a restricted transfusion schedule was utilized, but EPO was not administered. This constituted the No EPO Group. No other changes in clinical practice were introduced in either period.

RESULTS: There were 30 neonates in the EPO Group and 20 in the No EPO Group. There were no significant differences in sex, race, mean birth weight (1,074 +/- 283 versus 965 +/- 330 g), mean gestational age (28.9 +/- 2.96 versus 27.8 +/- 2.86 wks), 5 minute Apgar score (7.8 +/- 1.2 versus 7.6 +/- 1.1), or mean hematocrit (48.2% +/- 6.05 versus 48.6% +/- 6.31) at admission. There were no significant differences in the total number of transfusions between the two periods. In the EPO Group, 8/30 patients received 27 transfusions. Six transfusions violated guidelines based on hematocrit level. EPO was discontinued in three infants secondary to treatment-related neutropenia. There were two deaths unassociated with EPO treatment. Excluding deaths, 6 patients received 16 transfusions. In the No EPO Group, 8/20 patients received 13 transfusions. Two transfusions violated guidelines based on hematocrit. There were three deaths and one patient transfer. Excluding these four patients, 6 infants received 11 transfusions (P < or = 1.) Among survivors, there were no significant differences in mean total length of stay (49.3 +/- 22.7 versus 53.2 +/- 26.4 d), mean discharge weight (2,144 +/- 405 versus 2,358 +/- 458 g), or average weight gain/d (20.7 +/- 5.44 versus 22.6 +/- 6.81 g), between the two groups respectively, nor were there significant differences when all babies were included in the analysis. There was a significant difference in mean hematocrit at discharge, respectively, (38.3% +/- 6.84 versus 31.4% +/- 6.26; P = 0.003) in survivors.

CONCLUSIONS: A restricted transfusion schedule without EPO use was associated with lower mean hematocrit at discharge, but not with an increased frequency of transfusions, nor significant differences in length of stay, discharge weight, or average daily weight gain. A restricted transfusion schedule alone avoided side effects and costs associated with EPO. Indications for transfusion and what constitutes appropriate levels of hemoglobin still require clinical investigation, including long-term clinical outcomes.