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The evaluation of polycythemic newborns: Efficacy of partial exchange

transfusion

Article  in  The journal of maternal-fetal & neonatal medicine: the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies,
the International Society of Perinatal Obstetricians · December 2011
DOI: 10.3109/14767058.2010.550350 · Source: PubMed

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 The Journal of Maternal-Fetal and Neonatal Medicine, December 2011; 24(12): 1492–1497
Ó 2011 Informa UK, Ltd.
ISSN 1476-7058 print/ISSN 1476-4954 online
DOI: 10.3109/14767058.2010.550350

The evaluation of polycythemic newborns: efficacy of partial exchange

transfusion

SINAN USLU1, HAMUS OZDEMIR2, ALI BULBUL1, SERDAR COMERT1, EMRAH CAN1, &
ASIYE NUHOGLU1
1
Division of Neonatology, Department of Pediatrics, Sisli Etfal Children Hospital, Istanbul, Turkey and 2Division of Neonatology,
Department of Pediatrics, Diyarbakir Children Hospital, Diyarbakir, Turkey
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Dr. Sinan Uslu on 11/09/11

Abstract
Objectives. To evaluate the clinical characteristics and risk factors of symptomatic and asymptomatic polycythemic neonates
performed partial exchange transfusion (PET) and to determine the time of resolution of symptoms and effect of PET on short-
term morbidity.
Methods. This prospective cohort study was conducted with symptomatic (hematocrit; Hct 465% plus a clinical symptom) and
asymptomatic (Hct level 470% without any symptoms) neonates who underwent PET due to polycythemia.
Results. Among the patients performed PET, 43 (69.3%) were symptomatic and 19 (30.7%) asymptomatic. Persistent pulmonary
hypertension and minor problems like hypoglycemia, hypocalcemia, hyperbilirubinemia, and thrombocytopenia improved in all
patients within 24 h, 2.5 + 1.0, 3.1 + 1.4, 56.2 + 16.9, and 53.5 + 10.5 h, respectively, after PET (in except one symptomatic
neonate with hypoglycemia). In symptomatic group, in three patients with suspected necrotizing enterocolitis (NEC) prior to PET
For personal use only.

stage IIa NEC developed. No other clinical and ultrasonographic findings were observed after PET.
Conclusions. Early morbidities, due to polycythemia may be reversed with PET within a short time. PET did not increase or cause
any complications except NEC. The issue that either NEC was a sign of polycythemia or a complication of PET could not be
definitely outlined.

Keywords: Newborn, partial exchange transfusion, polycythemia

Introduction morbidity (such as necrotizing enterocolitis (NEC)) itself [6–8].

Polycythemia is defined as increased total red blood cell mass
(central venous hematocrit (Hct) 465% or venous hemoglo-
bin 422 g/dl in a neonate), may cause serious morbidity in
newborns if not diagnosed and treated efficiently [1]. Incidence
is reported as 1.5–4% among all live births [2]. The main
causative mechanism of the clinical findings is the hypervisc-
osity which occurs due to diminished perfusion developing
secondary to resistance to blood flow. A linear relation is found
between hyperviscosity and Hct values 465% [3]. As viscosity
increase, the tissue oxygenation is disrupted due to diminished
microcirculation and if this condition is not treated may lead to
morbidity. Otherwise, some clinicians noted that the elevated
hemoglobin and Hct are associated with an increase in the
arterial oxygen content. It is the increase in arterial oxygen
content, not the hyperviscosity, that is, directly responsible for
the decreased blood flow in the brain and heart as well as
cardiac output [4].
A partial exchange transfusion (PET) is the only specific
therapy for prevention of possible morbidities [5]. However
there are many reports stating that PET may be a cause of
A long-term follow-up meta-analysis study has not shown any
potential beneficial effects of PET for prevention of neurolo-
gical sequelae [9,10]. Although there are data to indicate that
the long-term outcomes are not improved in infants receiving
this intervention, it is an effective method for lowering the Hct,
alleviating viscosity by returning cerebral blood flow velocity to
normal, and reversing or improving associated clinical findings
[11]. Therefore, there are some controversies about perform-
ing PET in polycythemic newborns.
The aim of the study is to evaluate the symptomatic and
asymptomatic polycythemic neonates performed PET and, to
determine the time of resolution of symptoms and effect of
PET on short-term morbidity.
Material and methods
Study design
The study was conducted in the neonatal intensive care unit
(NICU) of Diyarbakir Children Hospital, between 1 February
2007 and 30 April 2008. Our hospital’s NICU is a referral

(Received 17 October 2010; revised 28 November 2010; accepted 20 December 2010)

Correspondence: Sinan Uslu, M.D., Specialist in Neonatology, Division of Neonatology, Department of Pediatrics, Sisli Etfal Children Hospital,
Halaskargazi Cad. Sisli, 34360, Istanbul, Turkey and Darusafaka mah. Acelya sok. Yonca sit. 1B blok D:9 34460, Istinye, Istanbul, Turkey.
Fax: þ90-212-234-11-21. GSM: þ90-532-737-00-15. E-mail: sinanuslumd@hotmail.com
 Partial exchange transfusion in polychytemic newborns
unit, giving medical support to a region with approximately
200,000 births per year. Since the hospital does not have an
obstetrics clinic, all the hospitalized neonates are transferred
from other hospitals. Written and verbal informed consent
was taken from parents during hospitalization and before any
drug treatment or invasive procedure according to the
guidelines of Turkish Neonatology Society. Every neonate’s
gestational age is determined by using New Ballard Scoring
System and term neonates are evaluated for fetal malnutrition
using Clinical Assessment of Nutritional Status (CANS)
scoring system.
From all the neonates who were referred to NICU, a
capillary Hct sample was obtained. A central venous Hct
sample was collected if capillary Hct level was 465%. All the
neonates were hospitalized if the central venous Hct level
was 465%. From all hospitalized patients, blood samples
were collected for complete blood count, biochemical tests,
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Dr. Sinan Uslu on 11/09/11
hemoculture, and C-reactive protein. Chest X-ray, cranial,
and abdominal US were performed. Electrocardiography
(ECG) and echocardiography (ECHO) were done if neces-
sary. The neonates who did not have any pathological disease
except polycythemia were included in this study.
The indications and the procedure of PET
The current standard neonatal practice for performing a PET
is a symptomatic newborn with a Hct level of 65% or more or
an asymptomatic newborn with a Hct level of 70% or more
[9]. In this study, PET was performed according to the
following criteria:
For personal use only.
1. Symptomatic neonates with a Hct 465%
(a) Feeding problems (feeding intolerance and poor
sucking): vomiting, residuals more than 30% of the
last feeding or absent of sucking reflex in 2 h of
admissions.
(b) Cyanosis: not related to any congenital heart disease
or pulmonary pathology by using chest X-ray, ECG,
and ECHO.
(c) Respiratory distress: no any primary lung and
cardiac disease.
(d) Hypoglycemia: persistence of blood glucose levels
below 35 mg/dl.
2. Asymptomatic neonates with Hct level 470%
Definition of the patient population: Symptomatic group;
the neonates with a Hct level 465% and who met at least one
of the PET criteria. Asymptomatic group; the neonates with a
Hct level 470% and who did not have any symptoms
including the PET criteria (poor sucking, feeding intolerance,
cyanosis, respiratory distress, and hypoglycemia).
Selected both group of infants were treated with PET using
0.9% NaCl. PET was performed with umbilical vein catheter
under sterile conditions. The exchange volume in milliliters
was calculated by the following standard formula (PET
volume ¼ blood volume (ml/kg) 6 [(observed Hct – desired
Hct (55)/observed Hct].
Data collection
The demographic features (birth weight, gestational week,
type of delivery, gender, fetal malnutrition, hospitalization
time, history of home delivery, maternal age, and history of
antenatal care) were documented. Maternal diseases like
diabetes mellitus, cardiac, respiratory, or renal diseases were
defined as chronic disorders. Transcranial and abdominal
1493
ultrasonographic (US) and Doppler examinations were
performed before and within 24–72 h after PET. Blood
samples for whole blood count, electrolytes, renal, and hepatic
function tests were collected before and 2, 6, 12, 24, 36, 48,
and 72 h after the procedure. After PET, the feeding was
initiated every 2 h with control of residue and, tachypnea,
irritability, lethargy, and cyanosis were screened every hour.
Morbidity and improvement definition
Metabolic problems [such as hypoglycemia (plasma glucose
level 535 mg/dl) [10] and hypocalcemia (serum total Ca
concentration 58 mg/dl in term infants or 57 mg/dl in
preterm infants) [12]], hyperbilirubinemia (defined by Amer-
ican Academy of Pediatrics recommendation) [13], thrombo-
cytopenia (5100,000/mm3) [10], respiratory distress, poor
sucking, feeding intolerance, cyanosis, irritability, and lethargy
which did not need to be treated after PET were accepted as
minor problems. Metabolic problems and thrombocytopenia
which need treatment in addition to PET, intracranial
hemorrhage (ICH), renal vein thrombosis (RVT), adrenal
hematoma, NEC (defined according to Bell criteria) [14] and
persistent pulmonary hypertension (PPH) (increased pulmon-
ary vascular resistance, right-to-left shunting, and severe
hypoxemia without evidence of congenital heart disease
diagnosed by ECHO) were accepted as major problems.
Improvement of problems were defined by the following
criteria; hypoglycemia: plasma glucose level 450 mg/dl,
hypocalcemia: serum total Ca concentration 48 mg/dl in
term infants or 47 mg/dl in preterm infants, hyperbilirubine-
mia: improvement was defined according to recommendation
of American Academy of Pediatrics, thrombocytope-
nia: 4100,000/mm3.
Statistical analysis
The symptomatic and asymptomatic patients were compared
regarding minor and major problems before or after PET.
Statistical package for social sciences (SPSS) for Windows
11.5 was used for the statistical analysis of data. Chi-square
test, Mann–Whitney U and Spearman’s correlation test were
used and p 5 0.05 was accepted as significant.
Results
During the study period, 3428 patients were hospitalized in
the NICU. The neonates with a Hct between 65% and 70%
and without any symptoms (n ¼ 15) were managed by
enhancing the fluid intake and repeating the Hct measure-
ment every 4–6 h. Since these patients did not need PET and
they were discharged, they were not included in the study.
Sixty-two (1.8%) neonates who met the inclusion criteria and
underwent PET comprised the study group. Of the 62
patients, 43 (69.3%) were in symptomatic group, whereas
19 (30.7%) were in asymptomatic group. The demographic
clinical features were shown in Table I and maternal risk
factors in Table II. In the asymptomatic patients the mean Hct
level before PET was found to be higher (p ¼ 0.03).
Symptomatic neonates were admitted to the hospital later
than the asymptomatic group (p ¼ 0.04). The median Hct
level in symptomatic patients with a major problem (n ¼ 12)
was found to be 73.5% (range: 71–82%). The other
demographic features were not different between the two
groups (Tables I and II).
The referral reasons of the neonates at the time of
admission were as follows: in symptomatic patients; feeding
 1494 S. Uslu et al.

problems (19/43, 44.2%), tachypnea (14/43, 32.6%), irrit- plethoric appearance (7/19, 36.8%) was observed, and two
ability (4/43, 9.3%), cyanosis (3/43, 7%), jaundice (2/43, patients (2/19, 10.5%) did not have any clinical sign.
4.6%), and lethargy (1/43, 2.3%) were encountered where as The minor and major problems were determined before
in asymptomatic patients; jaundice (10/19, 52.7%) and and after PET and findings were shown in Table III. The
minor problems encountered in the symptomatic group
before PET disappeared in all patients after PET except one
Table I. Characteristics of patients. neonate with hypoglycemia. Glucose infusion (12 mg/kg/
min) was given for 3 days due to hypoglycemia in only one
Symptomatic Asymptomatic neonate who was a small for gestational age (SGA) newborn
patients patients and had fetal malnutrition. During follow-up of this neonate
Characteristics (n ¼ 43) (n ¼ 19) p-value
any other problem was not observed. Bleeding was not
Hct before PET (%)* 71.3 + 4.1 73.4 + 2.1 0.03 observed among the thrombocytopenic neonates. Four patients
Gestation age (week)* 39.4 + 2.3 39.2 + 2.5 0.58 with grade-I ICH were found before PET; in one neonate ICH
Birthweight (g)* 3190.2 + 697.2 3133.7 + 714.7 0.57 was shown to regress while the extent of ICH did not change in
Delivery route, 19 (44.1) 8 (42.1) 0.88 other three of them. The neonates with ICH who were 35–36
Cesarean, n (%)
gestational weeks delivered by prolonged labor. In the
Gender, Male, n (%) 22 (51.1) 11 (57.8) 0.62
symptomatic group, the two patients with adrenal hematoma
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Dr. Sinan Uslu on 11/09/11

Growth pattern, n (%)

SGA 9 (20.9) 5 (26.3) 0.73 and one patient with RVT which were detected before PET,
AGA 25 (58.1) 9 (47.3) any additional finding was not observed after PET. The
LGA 9 (20.9) 5 (26.3) neonates with adrenal hematoma were born from primipara
Fetal malnutrition, n (%) 7 (16.2) 3 (15.7) 0.96 mothers by vaginal route with a history of prolonged labor.
Admitted time, n (%) There was no any causative factor in one baby with RVT. Three
524 h 14 (32.5) 12 (63.1) 0.04 patients with feeding intolerance who were accepted as stage Ia
24–48 h 13 (30.2) 5 (26.3) NEC before PET got worse clinically and stage II NEC
448 h 16 (37.3) 2 (10.6) progressively developed after PET. The Hct values of these
Home deliveries, n (%) 8 (18.6) 4 (21) 0.82
neonates were 79%, 80%, and 81% and all of the patients
PET: partial exchange transfusion, Hct: hematocrit, LGA: large for recovered with medical treatment. In two patients presenting
gestational age, SGA: small for gestational age, AGA: appropriate for with tachypnea and Hct values of 74% and 75%, respectively,
gestational age. PPH (pulmonary artery pressure (PAP) of 45 mmHg and 47
For personal use only.

*Values given as mean + SD. mmHg, respectively) was determined by ECHO. After PET

Table II. Maternal risk factors of infants.

Maternal risk factors Symptomatic patients (n ¼ 43) Asymptomatic patients (n ¼ 19) Total (n ¼ 62) p-value
Maternal age (years), n (%)
520 9 (20.9) 4 (21.1) 13 (20.9) 6 (9.7) 0.68
435 4 (9.3) 2 (10.5) 6 (9.7)
No antenatal care, n (%) 11(25.6) 6 (31.5) 17 (27.4) 0.62
Chronic disease, n (%) 15 (34.9) 3 (15.7) 18 (29) 0.12
Smoking, n (%) 8 (18.6) 5 (26.3) 13 (20.9) 0.49

Table III. The minor and major problems before and after partial exchange transfusion.

Symptomatic patients Asymptomatic patients

(n ¼ 43) (n ¼ 19) p-value

Findings* Before PET After PET Before PET After PET Before PET After PET
Minor problems, n (%)
Hypoglycemia 26 (60.5) 1 (2.3) – – – –
Hypocalcemia 7 (16.3) – 4 (21.0) – 0.65 –
Hyperbilirubinemia 17 (39.5) – 8 (42.1) – 0.84 –
Thrombocytopenia 12 (27.9) – 1 (5.3) – 0.04 –
Feeding problems 19 (44.2) – – – – –
Tachypnea 14 (32.6) – – – – –
Irritability and lethargy 5 (11.6) – – – – –
Cyanosis 3 (7) – – – – –
Major problems, n (%)
Intracranial hemorrhage 4 (9.3) 3 (6.9) – – – –
Renal vein thrombosis 1 (2.3) 1 (2.3) – – – –
Adrenal hematoma 2 (4.6) 2 (4.6) – – – –
Persistent pulmonary hypertension 2 (4.6) – – – – –
Necrotizing enterocolitis 3 (6.9) 3 (6.9) – – – –

*A single patient may have more than one finding.

 Partial exchange transfusion in polychytemic newborns
Table IV. The resolution time of minor problems in both groups after PET.
Symptomatic group (n ¼ 43)
Findings n Time (h)
Hypoglycemia 26 2.5 + 1.0
Hypocalcemia 7 3.4 + 1.5
Hyperbilirubinemia 17 57.9 + 18.6
Thrombocytopenia 12 54.0 + 10.8
Feeding problems 19 9.3 + 4.3
Tachypnea 14 20.5 + 11.3
Irritability or lethargy 5 30.8 + 12.4
Cyanosis 3 1.3 + 0.6
(24 h later), control ECHO showed that the findings of PPH
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Dr. Sinan Uslu on 11/09/11
regressed (PAP 15 mmHg and 12 mmHg, respectively).
In the asymptomatic group, all of the minor problems
diminished after PET and no other additional problems were
seen. No major problems were established in the asympto-
matic group before and after PET. The improvement of mean
time of minor problems in both groups after PET was
presented in Table IV.
Discussion
Neonatal polycythemia is associated with possible short-term
and long-term morbidity in affected newborns. In the
For personal use only.
neonatal period, the only specific treatment to prevent from
severe morbidity of polycythemia is PET [5]. In recent
systematic reviews and meta-analysis, it is reported that
during long-term follow-up, PET did not have a positive
effect on the neurodevelopmental outcome. Therefore,
benefits of PET are unclear [6,10]. This situation raises
questions about the efficacy of PET among health-care
professionals giving neonatal care. In our study, we aimed to
evaluate the medical problems observed before and after PET
and determine the time of resolution of minor problems and
effect of PET on short-term morbidity.
Hakanson and Oh [15] reported that hyperviscosity may be
a factor leading to ischemia in the gastrointestinal tract with
subsequent development of NEC. In the animal experimental
models, it has been shown that polycythemia causes ischemic
bowel necrosis by decreasing blood flow in the gastrointestinal
system [16]. In addition, NEC was found to be related to
polycythemia at a rate of 58% among the neonates with birth
weight 4 2000 g. In one study, polycythemia has been shown
to be an important risk factor for the development of NEC in
the term newborns [17]. On the other hand, it was reported
that NEC developed in neonates who were performed PET
due to polycythemia and the risk increased if the procedure
was done by an umbilical venous catheter [6–8]. But it is not
clear whether polycythemia or PET is the causative factor for
the development of NEC. In our study, NEC progressed to
higher stages in three symptomatic patients after PET. All
these neonates had high Hct levels and feeding intolerance
before PET with NEC (stage Ia). Stage IIa NEC was
determined progressively after PET. Our findings suggest
that PET performed via umbilical vein catheterization in
symptomatic polycythemia may either cause formation of
NEC or worsening of NEC symptoms. For more precise
evaluation, studies with higher number of patients are
required. In our study, feeding problems disappeared after
1495
Asymptomatic group
(n ¼ 19) Both groups (n ¼ 62)
n Time (h) n Time (h)
– – 26 2.5 + 1.0
4 2.5 + 1.0 11 3.1 + 1.4
8 52.5 + 12.7 25 56.2 + 16.9
1 48.0 + 0.0 13 53.5 + 10.5
– – 19 9.3 + 4.3
– – 14 20.5 + 11.3
– – 5 30.8 + 12.4
– – 3 1.3 + 0.6
PET and it has shown that PET is efficient about improve-
ment of the feeding problems.
Polycythemia has been associated with neonatal ischemic
lesions, often complicated by hemorrhage via leading throm-
bosis [18,19]. Increased cerebrovascular resistance and
diminished cerebral blood flow (CBF) velocity, determined
by Doppler studies, have been observed in polycythemic
infants [20,21]. Decreased CBF and oxygen delivery have
been shown in animal experimental studies [22]. In our study,
the patients with ICH were nearterm neonates with a history
of prolonged labor. Therefore, we could not conclude that
polycythemia was the only factor for occurrence of ICH. In
our study the rate of ICH did not increase after PET, it may
signify that PET does not have a negative effect on ICH.
The possible effect of polycythemia (especially thrombus
formation) about the occurrence of RVT is not clear. Whereas
in some studies it has been reported that elevated Hct levels
might cause to decrease renal blood flow owing to the others
they might have no effects on renal blood flow, but renal
plasma flow is diminished, resulting in a lower glomerular
filtration rate [4,23,24]. In our study, RVT was found before
PET in one patient. No etiological factors for formation of
RVT were detected in this patient. It was difficult to tell that
polycythemia was a causative factor for the development of
RVT. Since the extent of RVT did not change after PET, we
have concluded that PET did not have either a positive or
negative effect on RVT.
In both animal and human studies, it has been shown that
polycythemia caused by decreasing pulmonary blood flow and
increasing the pulmonary pressure [25,26]. In cases of PPH
caused by polycythemia and hyperviscosity, it has been
reported that decreasing Hct values might lead to reestablish-
ment of pulmonary blood flow [4]. In our study, PPH totally
diminished in two patients after PET so that it has been
thought PET might be beneficial in treating PPH caused by
polycythemia.
In polycythemia, the mechanism for the development of
thrombocytopenia is still unclear, although it is suggested that
an increase in platelet adhesiveness and a decrease in the
lifespan of platelets play a role in the development of
thrombocytopenia. Among the polycythemic newborns, throm-
bocytopenia is shown to be related with the severity of
symptoms and thought to be a marker of hyperviscosity [27].
Correlatively, in our study, thrombocytopenia was detected
more common in symptomatic group than asymptomatic group
(27.9% versus 5.3% patient). This evidence proved the idea that
thrombocytopenia is related with the severity of symptoms. The
present study does not reveal the cause of thrombocytopenia,
 1496 S. Uslu et al.
although the rapid rise of platelet counts following PET indicate
the presence of reversibly dissociable platelet aggregates or
clumps that form in the smaller vessels that disaggregate and
return to the circulation following procedure.
Hypoglycemia, frequently encountered in the polycythe-
mic infants, may be a consequence of increased glucose
utilization by the increased number of circulating red blood
cells, or decreased glucose production secondary to sluggish
hepatic blood flow [28]. Hypoglycemia except in one
neonate disappeared after PET in our study. In only one
symptomatic patient who was SGA and had fetal malnutri-
tion, hypoglycemia needs to be treated with glucose infusion
(12 mg/kg/min) for 3 days. Hypocalcemia is a frequent
complication (9.9%) of neonatal polycythemia [5,7]. It is
postulated that hypocalcemia is the result of increased levels
of calcitonin gene-related peptide in polycythemic newborns
[29]. But there is no data about the effect of PET on
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Dr. Sinan Uslu on 11/09/11
hypocalcemia associated with polycthemia. In our study, we
showed that PET was effective in treating findings like
hypoglycemia and hypocalcemia encountered among poly-
cythemic patients.
Observational studies suggest that symptoms attributed to
polycythemia do improve after PET [5,9]. But there is no data
about timing of resolution of symptoms. In our study, we
concluded that PET reversed minor problems in polycythemia
within a short time. Because of the lack of control groups, it is
very hard to tell whether the symptoms would have resolved
on their own over a similar time period without PET.
When we evaluated the problems encountered in patients
For personal use only.
with polycythemia, we found that all the problems developed
before PET. Any new major medical problems did not
develop after PET. Therefore, we concluded that major
problems except NEC are not related with the PET
procedure. In our study, we found that major medical
problems developed only in symptomatic patients before
PET. This may show that neonates were brought to the
hospital after the appearance of symptoms. In fact, in our
study we determined that symptomatic neonates admitted to
the hospital later than the asymptomatic ones and this
evidence proved our idea. If the symptoms developed in
patients with polycythemia, this would be a risk factor for the
major problems.
Additionally the median Hct values and ranges of Hct in
polycythemic patients with major symptoms were found to
be 470%. Thus, we may speculate that if these newborns
were screened after birth for polycythemia, they would either
receive treatment or would have undergone PET even if they
were asymptomatic. Maybe, if PET has been performed to
these newborns, major symptoms would not have developed.
Therefore, early diagnosis and treatment of polycythemia
with PET would probably prevent development of major
morbidity.
This study has some important limitations. The long-term
effects of PET were not screened. Another important
limitation was the absence of a control group. Control group
was not composed due to ethical reasons.
As a result, we found that in the symptomatic and
asymptomatic neonates with polycythemia, minor medical
problems diminished within a short time after PET and also
PET did not increase or cause major problems. As a major
medical problem, whether NEC was a sign of polycythemia
or a complication of PET could not be definitely outlined.
Large scale studies are needed for evaluating this con-
troversial issue and the relation of cause to result paradigm.
Declaration of interest: The authors report no conflicts of
interest. The authors alone are responsible for the content and
writing of the paper.
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