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Pediatrics and Neonatology (2014) xx, 1e3

Available online at www.sciencedirect.com

ScienceDirect
journal homepage: http://www.pediatr-neonatol.com

BRIEF COMMUNICATION

Comparison of Risk for Early Onset Sepsis

in Small-for-Gestational-Age Neonates and
Appropriate-for-Gestational-Age Neonates
Based on Lower Levels of White Blood Cell,
Neutrophil, and Platelet Counts
Nora Hofer a,*, Silvia Edlinger a, Bernhard Resch a,b
a
Research Unit for Neonatal Infectious Diseases and Epidemiology, Medical University of Graz,
Graz, Austria
b
Division of Neonatology, Department of Pediatrics and Adolescent Medicine,
Medical University of Graz, Graz, Austria

Received Jun 5, 2013; received in revised form Nov 5, 2013; accepted Dec 6, 2013

Intrauterine growth restriction and its postnatal equivalent, that is, small for gestational age (SGA) at birth, are
known to be risk factors for adverse neonatal outcomes.1
Like other organs, bone marrow is dependent on oxygen
and nutritional supply and some reports suggest that SGA
neonates are at an increased risk for lower levels of white
blood cell (WBC) and neutrophil counts during the first few
days after birth.2e4 However, evidence is scarce and the
clinical importance of these differences is unclear. The aim
of this study was to analyze WBC, neutrophil, and platelet
counts during the first 3 days of life and compare the
risk for early onset sepsis in SGA and appropriate-forgestational-age (AGA) neonates.
We used a preexisting database, which contained laboratory and clinical information from all neonates who were
hospitalized in our neonatal intensive care unit within the
first 24 hours of life during the 5-year-period from 2004 to
2008. We excluded neonates for whom no complete blood
count was determined during the first 3 days of life as well

* Corresponding author. Department of Pediatrics and Adolescent

Medicine, Medical University of Graz, Auenbruggerplatz 34/2, A-8036
Graz, Austria.
E-mail address: nora.hofer@medunigraz.at (N. Hofer).

as neonates with incomplete clinical information. The study

was approved by the local ethics committee. We analyzed
1110 WBCs, 865 neutrophils, and 1104 platelets counts
obtained from 501 preterm and 236 term neonates in the
first 3 days of life. Sixty of the 501 preterm neonates (12%)
and 39 of the 236 term neonates (17%) were SGA (birth
weight <10 percentile, as defined by Voigt et al5).
The SGA neonates had lower median WBC (11.1  103/mL
vs. 13.8  103/mL, p < 0.001), lower median neutrophil
counts (7.3  103/mL vs. 9.5  103/mL, p Z 0.001), and
lower median platelet counts (194  103/mL vs. 225  103/
mL, p < 0.001) in the first 3 days of life compared with AGA
neonates. The same was true when analyzing values separately for preterm (WBC: 9.0  103/mL vs. 12.5  103/mL,
p < 0.001; neutrophil count: 5.3  103/mL vs. 8.3  103/mL,
p < 0.001; platelet count: 167  103/mL vs. 218  103/mL,
p < 0.001) and term neonates (WBC: 16.7  103/mL vs.
18.3  103/mL, p Z 0.007; neutrophil count: 10.8  103/mL
vs. 13.7  103/mL, p Z 0.024; platelet count: 214  103/mL
vs. 239  103/mL, p Z 0.047). The count distribution in the
first 3 days is shown in Fig. 1.
Among the preterm neonates, 25 and 103 patients (5.0%
and 20.6%, respectively) had culture-proven and clinical
early onset neonatal sepsis, and among the term neonates

http://dx.doi.org/10.1016/j.pedneo.2013.12.006
1875-9572/Copyright 2014, Taiwan Pediatric Association. Published by Elsevier Taiwan LLC. All rights reserved.

Please cite this article in press as: Hofer N, et al., Comparison of Risk for Early Onset Sepsis in Small-for-Gestational-Age Neonates and
Appropriate-for-Gestational-Age Neonates Based on Lower Levels of White Blood Cell, Neutrophil, and Platelet Counts, Pediatrics and
Neonatology (2014), http://dx.doi.org/10.1016/j.pedneo.2013.12.006

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N. Hofer et al

Figure 1 WBC, neutrophil, and platelet counts in (A) preterm and (B) term SGA neonates (gray bars) and AGA neonates (white
bars). Bars represent the interquartile range (25the75th percentile) with median, and lines indicate 5th percentile and 95th
percentile. Statistical analysis was performed using ManneWhitney U test, AGA Z appropriate-for-gestational-age; SGA Z small
for gestational age; WBC Z white blood cell.

the figures were 14 and 50 (5.9% and 21.2%), respectively.

The SGA neonates were not at an increased risk for cultureproven and clinical sepsis (odds ratio was 1.0 for both in
preterm neonates and 1.1 for both in term neonates). In
neonates with culture-proven sepsis, WBC, neutrophil, and
platelet count did not differ between SGA and AGA neonates. In clinical sepsis, preterm SGA neonates had lower
WBC, neutrophil, and platelet counts compared with preterm AGA neonates (WBC: 5.8  103/mL vs. 11.0  103/mL,
p < 0.001; neutrophils: 3.6  103/mL vs. 7.7  103/mL,
p Z 0.023; platelet count: 155  103/mL vs. 205  103/mL,
p Z 0.006), but no differences were found in term
neonates.
We divided neonates in groups of WBC, neutrophil, and
platelet counts within the lower quartile and within the
upper three quartiles (cutoff for WBC 10.0  103/mL, for
neutrophils 5.9  103/mL, and for platelet count 177  103/
mL). When comparing these groups, there was no difference
in risk for culture-proven sepsis between preterm and term
SGA and AGA infants.
The present analysis adds to the growing body of evidence to demonstrate that intrauterine growth restriction
influences WBC, neutrophil, and platelet counts with lower
values in SGA neonates. Few references are found on this
topic and in most analyses the study population is
restricted, by either limits of gestational age and birth
weight, or presence or absence of other conditions (i.e.,
chorioamnionitis, funisitis). In this brief report, we include
a high number of neonates of all gestational ages. Despite
the differences in blood counts between SGA and AGA babies, SGA neonates were not at an increased risk of early
onset neonatal sepsis.

Previous studies revealed conflicting results on the

impact of lower WBC and absolute neutrophil count on
sepsis or mortality.3,6,7 Treatment of neutropenia using
hematopoietic growth factors has been implemented in
certain cases.
Further research on the clinical relevance is needed
prior to when such studies can be put into clinical practice.
In this study, we only analyzed laboratory values determined during the first 3 days of life. The SGA neonates are
known to be at an increased risk for late-onset infection, and
more research is necessary on the immunological aspect in
SGA neonates, which may contribute to an increased risk.
In conclusion, SGA neonates had lower WBC, neutrophil,
and platelet counts compared with their AGA counterparts
during the first 3 days of life. The SGA neonates were not at
an increased risk for early onset neonatal sepsis.

Conflicts of interest
All contributing authors declare no conflicts of interest.

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Please cite this article in press as: Hofer N, et al., Comparison of Risk for Early Onset Sepsis in Small-for-Gestational-Age Neonates and
Appropriate-for-Gestational-Age Neonates Based on Lower Levels of White Blood Cell, Neutrophil, and Platelet Counts, Pediatrics and
Neonatology (2014), http://dx.doi.org/10.1016/j.pedneo.2013.12.006

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Blood counts in SGA neonates

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Please cite this article in press as: Hofer N, et al., Comparison of Risk for Early Onset Sepsis in Small-for-Gestational-Age Neonates and
Appropriate-for-Gestational-Age Neonates Based on Lower Levels of White Blood Cell, Neutrophil, and Platelet Counts, Pediatrics and
Neonatology (2014), http://dx.doi.org/10.1016/j.pedneo.2013.12.006