I don’t know why I didn’t think of this, but it is sort of obvious, it just takes someone to think about it and then do it. We need to reduce blood draws in preterm infants, the blood we take for lab tests is one of the major causes of needing a blood transfusion. So whatever we can do to reduce blood draws is likely to be a benefit.
One way to do this is to find another source of blood, by which I mean the palcenta. On admission to the NICU we often draw a complete blood count, blood cultures, a cross-match, a glucose and occasionally other test. The inimitable Robert Christensen published a preliminary study recently (Christensen RD, Lambert DK, Baer VL, Montgomery DP, Barney CK, Coulter DM, et al. Postponing or eliminating red blood cell transfusions of very low birth weight neonates by obtaining all baseline laboratory blood tests from otherwise discarded fetal blood in the placenta. Transfusion. 2011;51(2):253-8. http://onlinelibrary.wiley.com/doi/10.1111/j.1537-2995.2010.02827.x/pdf) examining whether obtaining this blood from the placenta instead would improve the hemoglobin level of the baby, and therefore decrease blood transfusions. It may be common sense, but the results were quite interesting.
Now this wasn’t a formal randomized trial, rather a case-control study, so we should be raher skeptical about the results, and when you see the actual paper, the controls had more blood taken every day of the first week of life, not just on day one, so they were different in some way other than just the initial blood sampling. However Dr Christensen and colleagues did show that there was an increase in hemoglobin over the first 18 hours of life in the babies with admission bloods taken from the placenta, and a decrease in those who had an average of about 6 Ml more blood taken from the baby than the placenta sampling group. This difference I think is quite likely due to the different admission blood sampling.
They also showed fewer early blood transfusions and fewer intraventricular hemorrhages in the placenta sampling group. Now as I said this was not an RCT so these results are no more than interesting and probably worth pursuing with a larger study; but they are consistent with another observational study by Dr Christensen and his group which also suggested that there is a link between blood transfusion and IVH, specifically with whether a grade 1 hemorrhage might progress to a larger hemorrhage. (Baer VL, Lambert DK, Henry E, Snow GL, Christensen RD: Red blood cell transfusion of preterm neonates with a grade 1 intraventricular hemorrhage is associated with extension to a grade 3 or 4 hemorrhage. Transfusion 2011, 51(9):1933-1939. http://onlinelibrary.wiley.com/doi/10.1111/j.1537-2995.2011.03081.x/pdf)
Also importantly this group did not use delayed cord clamping, or umbilical cord stripping, which also have beneficial effects on hemoglobin levels, and perhaps on other outcomes as well. More on that another time.