Polycythemia of the Newborn Treatment & Management
- Author: Karen J Lessaris, MD; Chief Editor: Ted Rosenkrantz, MD more...
Therapy in newborns with polycythemia is based on both the measured central venous hematocrit (Hct) level and the presence or absence of symptoms. Carefully monitor vital signs and bilirubin, glucose, and electrolyte levels as needed in newborns with polycythemia.
Treatment of polycythemia with partial exchange transfusion (PET) remains controversial. Regarding treatment with partial exchange, the Committee of the Fetus and Newborn of the American Academy of Pediatrics states, "The accepted treatment of polycythemia is partial exchange transfusion (PET)." The group also acknowledges that no evidence suggests that exchange transfusion affects the long-term outcome.[9, 10]
Treatment for asymptomatic patients
In asymptomatic patients with a Hct level of 65-75%, perform cardiorespiratory monitoring and monitoring of Hct and glucose levels every 6-12 hours, and observe the patient for symptoms. Continue this monitoring for at least 24 hours or until the Hct level declines.
In asymptomatic patients with a Hct level of more than 75% on repeated measurements, consider PET.
Treatment for symptomatic patients
In symptomatic patients with a Hct level of 60-65%, consider alternative explanations for the symptoms. Although polycythemia and hyperviscosity may be the etiology of the symptoms, other causes for the symptoms must be excluded.
In symptomatic patients with a Hct level more than 65% with symptoms attributable to polycythemia and hyperviscosity, consider PET or observation with intravenous fluids for added hydration. Proceed to PET if symptoms worsen.
Perform PET using an umbilical venous catheter to reduce the central Hct level to 50-55%.
The total blood volume to be exchanged is determined as follows: [blood volume(patient's Hct – desired Hct)]/(patient's Hct), where blood volume = the patient's weight in kilograms multiplied by 90 mL/kg.
Normal saline is the replacement fluid of choice for exchange transfusions because it is effective and inexpensive. As alternatives, Plasmanate, 5% albumin, or fresh frozen plasma can be used. However, none of these is more effective than normal saline. In addition, both 5% albumin and fresh frozen plasma are blood products, and certain religious beliefs prohibit their use. Lastly, these colloid products have been associated with complications such as necrotizing enterocolitis (NEC).
Sterile technique is required.
An exchange transfusion can be performed in 3 ways, depending on the type of vascular access that is available. Regardless of the method used, aliquots should not exceed approximately 5 mL/kg delivered or removed over 2-3 minutes.
If only a single umbilical venous catheter is in place, use a push-pull technique. With this technique, the withdrawal of blood is alternated with the administration of replacement fluid through the single catheter. Do not remove more than 5 mL/kg in any single withdrawal.
If both umbilical venous and arterial catheters are in place, withdraw blood from the arterial catheter while administering the replacement fluid through the venous catheter.
If a venous or arterial umbilical catheter and a peripheral venous catheter are in place, the former can be used for blood withdrawal, whereas the latter is used to simultaneously and continuously infuse the replacement fluid.
Feedings may cautiously be introduced hours after completing the PET.
Perform routine newborn follow-up care.
Jeevasankar M, Agarwal R, Paul VK, et al. Polycythemia in the newborn. Indian J Pediatr. January 2008. 75(1):68-73.
Mimouni FB, Merlob P, Dollberg S, Mandel D. Neonatal polycythaemia: critical review and a consensus statement of the Israeli Neonatology Association. Acta Paediatr. 2011 Oct. 100(10):1290-6. [Medline].
Vlug RD, Lopriore E, Janssen M, et al. Thrombocytopenia in neonates with polycythemia: incidence, risk factors and clinical outcome. Expert Rev Hematol. 2015 Feb. 8 (1):123-9. [Medline].
Rincon D, Foguet A, Rojas M, et al. [Time of cord clamping and neonatal complications, a prospective study]. An Pediatr (Barc). 2014 Sep. 81(3):142-8. [Medline].
Andersson O, Hellstrom-Westas L, Andersson D, et al. Effect of delayed versus early umbilical cord clamping on neonatal outcomes and iron status at 4 months: a randomised controlled trial. BMJ. 2011 Nov 15. 343:d7157. [Medline]. [Full Text].
Sainz JA, Romero C, García-Mejido J, Soto F, Turmo E. Analysis of middle cerebral artery peak systolic velocity in monochorionic twin pregnancies as a method for identifying spontaneous twin anaemia-polycythaemia sequence. J Matern Fetal Neonatal Med. 2014 Jul. 27 (11):1174-6. [Medline].
Veujoz M, Sananès N, Severac F, et al. Evaluation of prenatal and postnatal diagnostic criteria for twin anemia-polycythemia sequence. Prenat Diagn. 2015 Mar. 35 (3):281-8. [Medline].
Sankar MJ, Agarwal R, Deorari A, Paul VK. Management of polycythemia in neonates. Indian J Pediatr. 2010 Oct. 77(10):1117-21. [Medline].
[Guideline] AAP. American Academy of Pediatrics Committee on Fetus and Newborn: routine evaluation of blood pressure, hematocrit, and glucose in newborns. Pediatrics. 1993 Sep. 92(3):474-6. [Medline].
Morag I, Strauss T, Lubin D, Schushan-Eisen I, Kenet G, Kuint J. Restrictive management of neonatal polycythemia. Am J Perinatol. 2011 Oct. 28(9):677-82. [Medline].
Awonusonu FO, Pauly TH, Hutchison AA. Maternal smoking and partial exchange transfusion for neonatal polycythemia. Am J Perinatol. 2002 Oct. 19(7):349-54. [Medline].
Dempsey EM, Barrington K. Short and long term outcomes following partial exchange transfusion in the polycythaemic newborn: a systematic review. Arch Dis Child Fetal Neonatal Ed. 2006 Jan. 91(1):F2-6. [Medline].
Drew JH, Guaran RL, Grauer S, Hobbs JB. Cord whole blood hyperviscosity: measurement, definition, incidence and clinical features. J Paediatr Child Health. 1991 Dec. 27(6):363-5. [Medline].
Pappas A, Delaney-Black V. Differential diagnosis and management of polycythemia. Pediatr Clin North Am. 2004 Aug. 51(4):1063-86, x-xi. [Medline].
Rosenkrantz TS. Polycythemia and hyperviscosity in the newborn. Semin Thromb Hemost. 2003 Oct. 29(5):515-27. [Medline].
Schimmel MS, Bromiker R, Soll RF. Neonatal polycythemia: is partial exchange transfusion justified?. Clin Perinatol. 2004 Sep. 31(3):545-53, ix-x. [Medline].
Shohat M, Reisner SH, Mimouni F, Merlob P. Neonatal polycythemia: II Definition related to time of sampling. Pediatrics. 1984 Jan. 73(1):11-3. [Medline].
Werner EJ. Neonatal polycythemia and hyperviscosity. Clin Perinatol. 1995 Sep. 22(3):693-710. [Medline].
Wirth FH, Goldberg KE, Lubchenco LO. Neonatal hyperviscosity: I. Incidence. Pediatrics. 1979 Jun. 63(6):833-6. [Medline].
Wong W, Fok TF, Lee CH, et al. Randomised controlled trial: comparison of colloid or crystalloid for partial exchange transfusion for treatment of neonatal polycythaemia. Arch Dis Child Fetal Neonatal Ed. 1997 Sep. 77(2):F115-8. [Medline].
Watchko JF. Common hematologic problems in the newborn nursery. Pediatr Clin North Am. 2015 Apr. 62 (2):509-24. [Medline].
Taniguchi K, Sumie M, Sugibayashi R, Wada S, Matsuoka K, Sago H. Twin anemia-polycythemia sequence after laser surgery for twin-twin transfusion syndrome and maternal morbidity. Fetal Diagn Ther. 2015. 37 (2):148-53. [Medline].