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Neonatal alloimmune neutropenia (NAIN) is caused by maternal alloimmunisation to fetal human neutrophil antigens (HNAs). This study investigated maternal HNA/HLA alloantibodies involved with NAIN and identified the frequency of NAIN in Brazilian neonates. Neonatal neutropenia (neutrophil count < 1.5 × 109 /L) was investigated in samples from 10,000 unselected neonates, resulting in 88 neutropenic newborns (NBs) and their 83 mothers. Genotyping was performed by PCR-SSP (HNA-1/-4) and PCR-RFLP (HNA-3/-5). Serologic studies were performed by GAT (granulocyte agglutination test), Flow-WIFT (white blood cells immunofluorescence test) and LABScreen-Multi-HNA-Kit (OneLambda®) (LSM). Neonatal neutropenia was identified in 88/10,000 (0·9%) NBs. Genotyping revealed 60·2% maternal-fetal HNA incompatibilities (31·8% for HNA-1; 14·8% for HNA-3; 15·9% for HNA-4; 21·6% for HNA-5). Serologic studies revealed 37·3% of mothers with positive results with at least one technique. The detected anti-HNA specificities were confirmed in eight positive cases related to HNA-1/-3 systems. In cases with maternal-fetal HNA-4/-5 incompatibility, no specific neutrophil alloantibodies were found but anti-HLA I/II were present. Anti-HNA-2 was not identified. This is a large Brazilian study which involved the investigation of antibodies against all five HNA systems in neutropenia cases and showed a frequency of NAIN in 8/10,000 neonates. Among the HNA antibodies identified, we highlight the anti-HNA-1d and anti-HNA-3b, antibodies unusual in alloimmunised women, and rarely related to NAIN cases.

Background Numerous studies have examined the association between ABO blood groups and adult disease states, but very few have studied the neonatal population. The objective of this study was to determine the relationship between AB blood group and the occurrence of common neonatal disorders such as neutropenia at birth, sepsis, respiratory distress syndrome (RDS), intraventricular hemorrhage (IVH), retinopathy of prematurity (ROP), and patent ductus arteriosus (PDA) compared to all other blood groups. Methods We performed a retrospective review on 3,981 infants born at 22 0/7 to 42 6/7 weeks' gestational age and compared the relative risk of neonatal diseases in infants with AB blood group to that of infants with all other blood groups (A, B, and O). Results When compared to all other blood groups, AB infants demonstrated an increased risk for developing negative clinical outcomes. AB blood group was significantly associated with a 14-89% increased risk of neutropenia at birth, sepsis, RDS, and ROP. Risks for IVH and PDA were not significant. Conclusion We hypothesize that the phenotypic expression of A and B antigens, rather than the antigens themselves, in the AB group may reveal an enhanced susceptibility to injury at the endothelial level resulting in an increased risk for disease development.

Neonatal immune neutropenia is observed in rare cases in newborns from mothers with idiopathic or autoimmune neutropenia, secondary to passive transfer of maternal granulocyte auto-antibodies. We performed a literature review and report four supplementary cases from the French registry of neutropenia. Only 14 cases (11 mothers, 14 newborns) have been reported. Granulocyte aggregation (GAT) and granulocyte indirect immunofluorescence test (GIFT) are the recommended laboratory procedures for antibody detection. Monoclonal antibody-specific immobilization of granulocyte antigens (MAIGA)-confirmed antibody specificity. Antibody detection in newborns is not generally possible owing to extreme neutropenia. In half of the cases autoantibodies against neutrophils (AAN) were positive in maternal sera (7 out of 11). In some newborns tested, IgG+ AAN were also positive, with disappearance in parallel of spontaneous neutrophil count improvement. No correlation between maternal type of AAN and titer and neonatal neutropenia can be established. Neutropenia resolved spontaneously between 2 weeks and 4 months. Infections in newborns were observed in 43% of cases, with no deaths reported. Granulocyte colony-stimulating factor (G-CSF) was administered to some newborns (5 out of 14) in the case of infections. Low-dose G-CSF administered to childbearing women during pregnancy could be proposed to prevent neutropenia in newborns. From the few cases reported so far it is impossible to draw any conclusions regarding frequency, risk factors, and outcome, but the overall prognosis for newborns seems good. Because it can be associated with potentially severe neonatal infections, autoimmune neutropenia in childbearing mothers should be closely monitored in collaboration with gynecologists and pediatricians.

Data on the use of Granulocyte colony-stimulating factor (G-CSF) in pregnant cancer patients are scarce. The International Network of Cancer, Infertility and Pregnancy (INCIP) reviewed data of pregnant patients treated with chemotherapy and G-CSF, and their offspring. Among 2083 registered patients, 42 pregnant patients received G-CSF for the following indications: recent chemotherapy induced febrile neutropenia (5, 12%), dose dense chemotherapy (28, 67%), poly chemotherapy (7, 17%), or prevention of neutropenia at delivery (2, 5%). Among 24 women receiving dose dense chemotherapy, three (13%) patients recovered from asymptomatic neutropenia within 5 days. One patient developed pancytopenia following polychemotherapy after which the pregnancy was complicated by chorioamnionitis and intrauterine death. Nineteen singleton livebirths (49%) were born preterm. Sixteen neonates (41%) were admitted to the Neonatal Intensive care Unit (NICU). No neonatal neutropenia occurred. Two neonates had congenital malformations. Out of 21 children in follow-up, there were four children with a motor development delay and two premature infants had a delay in cognitive development. In conclusion, the rate of maternal and neonatal complications are similar to those described in (pregnant) women treated with chemotherapy. Due to small numbers and limited follow-up, rare or delayed effects among offspring exposed to G-CSF in utero cannot be ruled out yet.

Background: Recombinant human IGF-1/binding protein-3 (rhIGF-1/BP-3) is currently tested as a therapy in preterm infants but possible effects on the gut, including necrotizing enterocolitis (NEC), have not been tested. The aim of this study was to evaluate if rhIGF-1/BP-3 supplementation in the first days after birth negatively affects clinical variables like growth, physical activity, blood chemistry and hematology and gut maturation (e.g., intestinal permeability, morphology, enzyme activities, cytokine levels, enterocyte proliferation, NEC lesions), using NEC-sensitive preterm pigs as a model for preterm infants.Methods: Preterm pigs were given twice daily subcutaneous injections of rhIGF-1/BP-3 or vehicle. Blood was collected for IGF-1 measurements and gut tissue for NEC evaluation and biochemical analyses on day 5.Results: Baseline circulating IGF-1 levels were low in preterm pigs compared with near-term pigs reared by their mother (40 ng/mL). rhIGF-1/BP-3 treatment reduced the incidence of severe NEC lesions (7/24 vs.16/24, p = 0.01) and overall NEC severity (1.8 ± 0.2 vs. 2.6 ± 0.3, p < 0.05, with most lesions occurring in colon). In the small intestine, villi length (405 ± 25 vs. 345 ± 33 μm) and activities of the brush border peptidases aminopeptidase N and dipeptidylpeptidase IV were increased in rhIGF-1/BP-3 treated pigs, relative to control pigs (+31–44%, both p < 0.05). The treatment had no effects on body weight, blood chemistry or hematology, except for an increase in blood leucocyte and neutrophil counts (p < 0.05, i.e., reduced neonatal neutropenia). Likewise, rhIGF-1/BP-3 treatment did not affect intestinal tissue cytokine levels (IL-1β, IL-6, IL-8, TNFα,), enterocyte proliferation, goblet cell density, permeability or bacterial translocation to the bone marrow.Conclusion: Supplemental rhIGF-1/BP-3 did not negatively affect any of the measured variables of clinical status or gut maturation in preterm pigs. Longer-term safety and efficacy of exogenous rhIGF-1/BP-3 to support maturation of the gut and other critical organs in preterm newborns remain to be investigated in both pigs and infants.

Introduction: Neonatal neutropenia is often secondary to sepsis, low birth weight, pregnancy-induced maternal hypertension, and other conditions. Case Report: We report a case of asymptomatic isoimmune neutropenia in a pair of preterm twins. Genotyping confirmed that the mother was negative for HNA-1a, 1b, and 1c, consistent with an FcγRIIIb deficiency. The father was 1(a+b+c–) and the neonates were 1(a–b+c–). A strongly positive result was observed in the granulocyte immunofluorescence test against paternal neutrophils (IgG antibodies). IgG anti-CD16b isoantibodies were detected in the mother’s breast milk. Neutropenia resolved after 28 days without requiring any specific treatments. Discussion: Even though neonatal alloimmune neutropenia (NAN) is usually benign and self-limiting, some patients pre­sent with delayed separation of the umbilical cord, mild skin infections, omphalitis, or severe infections like pneumonia, sepsis, and meningitis. Thus, it is important to rule out NAN in case of neonatal neutropenia.

Summary Neutropenia, usually defined as a blood neutrophil count

Neutropenia is a self-resolving condition in many newborn infants. However, the formation and the role of the neutrophils are considered to be slightly different in the premature infants. The neutrophils act as a vital component in the innate immunity so the neonatal neutropenia in premature infants must be identified promptly and treated depending on the risk factors, especially of the clinical infections. Neutropenia in premature infants has various causes, such as maternal and pre-natal conditions, congenital syndromes, immune-mediated processes, nosocomial infections and idiopathic. However, not all neutropenia in the premature infants is clinically relevant and often does not add to the danger of infection. In this review article, we will discuss the development of neutrophils, the causes of neonatal neutropenia, and the relationships of neutropenia with premature infants and some viable management of neutropenia in premature infants.

Neonatal alloimmune thrombocytopenia (NAIT) is the most common cause of severe perinatal thrombocytopenia, results from feto-maternal platelet antigen incompatibility leading to the production of maternal antibodies and destruction of fetal platelets during pregnancy. Correlation between anti-HLA alloantibodies and neonatal neutropenia is extremely rare, in part because of reduced expression of leukocyte HLAs in neonates. Because both platelets and neutrophils exhibit HLAs, it is possible for HLA antibodies to cause both neonatal alloimune neutropenia and Neonatal alloimmune thrombocytopenia. Combined alloimune cytopenias are rare. We report a case of Neonatal alloimmune thrombocytopenia associated with neutropenia alloimune. Received: 30/09/2017 - Accepted: 18/10/2017

Background Human neutrophil antigens (HNA) are able to provoke allo- and autoimmune antibodies which lead to reactions like autoimmune and neonatal neutropenia. However, until now no data about HNA genotype distribution in Syrian population exists. The aim of this study was to determine the HNA allele frequencies in the largest group asking for asylum in Germany since 2015. Allele frequencies were compared to data from German blood donors. Therefore, we calculated the risk of alloimmunization and associated transfusion reactions, as well as the risk of developing neonatal neutropenia for newborns of mixed race couples. Methods We isolated DNA from blood samples of 100 Syrian volunteers and typed them for HNA-1, -3, -4, and -5 by using a commercial polymerase chain reaction kit with sequence-specific primers (SSP-PCR). Then, we compared the HNA genotype distribution with data from Germans and different populations from literature. Results In Syrian population the gene frequencies for HNA-1a, HNA-1b, and HNA-1c were 0.375, 0.580, and 0.040, for HNA-3a and -3b 0.742 and 0.258, for HNA-4a and -4b 0.860 and 0.140, and for HNA-5a and -5bw 0.660 and 0.340, respectively. No statistically significant differences between Syrian and German gene frequencies were found. Conclusions This study is the first to report HNA gene frequencies in Syrian population. There is no significant difference of HNA genotype frequencies compared to the German population. Therefore, no elevated alloimmunization risks in transfusion of blood and blood components and in pregnancy of mixed race couples exist.

Leonie van den Broek,1 Jutte van der Werff-ten Bosch,2 Pieter-Jan Cortoos,3 Susanne van Steijn,1 Machiel van den Akker1,21Departmentof Pediatrics, Queen Paola Children’s Hospital, Antwerp, Belgium; 2Department of Pediatric Hematology Oncology, UZ Brussel, Brussels, Belgium; 3Pharmacy, UZ Brussel, Brussels, Belgium Abstract: Neonatal neutropenia is regularly seen with variable etiology. We describe a breastfed infant with maternal medication use as a probable cause of neonatal neutropenia. An 8 days old exclusively breastfed female infant of Arab-Berber descent was referred to our hospital because of an infection of the umbilicus. Complete blood count showed a picture of severe isolated neutropenia. After initiating intravenous antibiotic treatment, the infection quickly resolved, but the isolated neutropenia persisted. Bone marrow aspiration indicated severe congenital neutropenia. The mother was known to have Crohn’s disease, treated with methylprednisolone and adalimumab up to 3 months before delivery, and latent tuberculosis, for which she used isoniazid postnatally. Breast-feeding was terminated and filgrastim was started, with an increase of the neutrophilic count. After several weeks, filgrastim could be terminated. Bone marrow and complete blood count were repeated and were completely normal. This case report describes a very young breastfed female infant with severe neutropenia, causing an infection, in which maternal adalimumab use could not be excluded as a possible cause. Maternal isoniazid use is highly unlikely. Keywords: congenital neutropenia, neonate, breast-feeding, adalimumab, isoniazid

While immunoglobulin biologicals are increasingly used during pregnancy, there have been concerns on the immune function and vaccination of infants born to mothers taking immunoglobulin biologicals. In addition to the detection of biologicals in cord blood, cases of severe neonatal neutropenia and fatal dissemination of Bacillus Calmette-Guérin (BCG) have been reported. With increasing number of infants exposed to immunoglobulin biologicals in utero, there is a need to address the challenges in vaccinating these infants. This review summarizes the available evidence to discuss the issues of immunoglobulin biological exposure in utero, neonatal immune function, long-term immune development, and the challenges and strategies of vaccinating newborns and infants who were born to mothers taking biologicals during pregnancy.

Placental insufficiency is an important contributor to the intra utero growth restriction (IUGR). Increasing severity of placental insufficiency results in fetal adaptation (diving reflex) leading to preferential blood circulation to the brain and increased comprise of the intestines and the kidneys. Antenatal Doppler abnormalities including absent or reversal of end-diastolic flow (AREDF) in the umbilical artery in IUGR fetus is a reflection of greater severity of utero placental insufficiency and more compromised intestine. Prolonged exposure to fetal hypoxia and ischemia could result in altered development of motor, secretory, mucosal functions and after birth the intestine is more susceptible to stasis, abnormal colonization, and bacterial invasion (1). Post-natal physiological flow studies report persistent mesenteric artery flow abnormalities lasting for almost a week in IUGR infants with AREDF (2,3). Pregnancy induced hypertension in association with IUGR and neonatal neutropenia could further increase the risk of early infections in these neonates. Thus these high risk preterm infants are at risk for early necrotizing enterocolitis (NEC) [odds ratio (OR) =2.13; 95% CI: 1.49–3.03] due to ischemia of mesenteric vascular bed emanating from redistribution of blood flow to vital organs in the fetus (1). IUGR and also AREDF are thus independent risk factors for NEC when adjusted for gestational age at birth.

Aim: The aim of this study was to provide an overview of foetal/neonatal alloimmune neutropenia (FNAIN), together with advice on the clinical management. Methods: Neutrophil serology in the Netherlands is centralised at Sanquin Diagnostic Services. We examined FNAIN cases between January 1, 1991, and July 1, 2013, to determine the number of cases diagnosed, the relationship with human neutrophil antigen (HNA) antibody, the clinical presentation and therapeutic interventions. Results: We identified 35 FNAIN cases. The detected HNA antibodies were as follows: antiHNA-1a (n = 7), anti-HNA-1b (n = 12), anti-HNA-1c (n = 2), anti-HNA-2 (n = 8), antiHNA-3a (n = 1), anti-HNA-5a (n = 1) and anti-FccRIIIb (n = 4). No infections were diagnosed in 14 neonates, and the other 21 neonates suffered from omphalitis (n = 6), urinary tract infection (n = 1), candida mucositis (n = 1), fever of unknown origin (n = 6) and sepsis (n = 7, 20%). Parity, gestational age, birthweight, neutrophil counts and antibody specificity were not significantly different for cases with, and without, infections. All the infected children were treated with antibiotics. No children died. Conclusion: More than half (21) of the 35 cases of FNAIN presented with infections and most implicated were HNA-1a, HNA-1b and HNA-2. Treatment with antibiotics seemed adequate. A neonatal neutropenia workflow model for use in neonatal intensive care units is presented.

A 42-year-old gravida 5 para 3 woman delivered a male newborn at 36 weeks of gestation. She had no significant medical problems and her previous pregnancies led to healthy newborns. The current pregnancy was uneventful and the baby appeared healthy (body weight, 3190 g; Apgar score, 8/10/10). On the second day of life jaundice appeared. Laboratory tests revealed hyperbilirubinemia (total bilirubin 21.5 mg/dL; reference interval

The main purpose of this article was to report the incidence of neonatal neutropenia or leukopenia after chemotherapy exposure during pregnancy according to the time elapsed between treatment during pregnancy and birth.A single study reports 33% of infants exposed to chemotherapy within the last month of pregnancy are born with neutropenia, which can place the newborn at risk for nosocomial infections. On the basis of this report, chemotherapy is typically stopped by 34 weeks of pregnancy to avoid maternal or neonatal myelosuppression at delivery. Such a pause in treatment may affect maternal health. Determining the true incidence of neutropenia after chemotherapy in relation to the time of this lapse in treatment is important to support this practice.Complete blood counts are collected for newborn whose mothers were treated for cancer during pregnancy and enrolled in the Cancer and Pregnancy Registry. Neutropenia was defined as absolute neutrophil count1000 mm3 and leukopenia was defined as white blood cells5000 cells/μL. Incidence of neutropenia was calculated according to the time elapsed from last chemotherapy treatment until birth. Fisher's exact test is used to determine if neutropenia or leukopenia is related to the time elapsed between chemotherapy during pregnancy and newborn birth. A Bayesian analysis evaluated the occurrence of neutropenia and leukopenia according to the number of days between the initiation of chemotherapy and birth.A total of 135 infants exposed to chemotherapy in utero with a complete blood count collected at birth were identified from the database. Only 7.3% and 2.9% of infants were born with neutropenia or leukopenia, respectively. The highest incidence of newborn neutropenia occurred in infants delivered 22 to 28 days after chemotherapy.The incidence of neutropenia peaks when chemotherapy is given 22 to 28 days before birth, while leukopenia is highest if delivery is7 days from chemotherapy.

UNLABELLED Foetal and neonatal alloimmune thrombocytopenia (FNAIT) and neonatal neutropenia caused by maternal autoantibodies against neutrophils are rare disorders. We describe a newborn with severe thrombocytopenia and intracerebral bleeding caused by maternal anti-HPA-3a alloantibodies and mild neutropenia caused by maternal autoantibodies against HNA-1b. This appears to be the first case of simultaneous occurrence of these two conditions. CONCLUSION This case report and review of the literature demonstrate that anti-HPA-3a antibodies can be overlooked by standard assays.

Neutropenia is a relatively frequent finding in the neonatal intensive care unit, particularly in very low birth weight neonates during the first week of life. Healthy term and preterm neonates have blood neutrophil counts within the same basic range as adults, but their neutrophil function, and their neutrophil kinetics during infection, differ considerably from those of adults. Neutrophil function of neonates, particularly preterm neonates, is less robust than that of adults and might also contribute to the increase in propensity to infection. In premature infants, early-onset neutropenia is correlated with sepsis, maternal hypertension, intrauterine growth restriction, severe asphyxia, and periventricular haemorrhage, and might be associated with an increase in the incidence of early-onset sepsis, nosocomial infection, and Candida colonisation. Some varieties of neutropenia in the NICU are very common and others are extremely rare. The most common causes of neutropenia in the NICU have an underlying cause that is often evident, and require little diagnostic evaluation. Unlike, persistent neutropenia should prompt evaluation even if it is of moderate severity. The laboratory tests to consider are those that provide a specific diagnosis. The first tests that should be ordered are a blood film, a complete blood count on the mother, and, if her blood neutrophil concentration is normal, maternal neutrophil antigen typing and an anti-neutrophil antibody screen. A bone marrow biopsy can be useful in cases with prolonged, unusual, or refractory neutropenia. Various treatments have been proposed as means of enhancing neutrophil production and function in preterm infants. Both recombinant granulocyte stimulating factor and recombinant granulocyte macrophage-colony-stimulating factor have been tried with variable success. Intravenous immunoglobulin, corticosteroids, granulocyte transfusions, and gamma interferon did not show a clear adequate beneficial role for the therapy of neonatal neutropenia.

Background: Fear of neutropenia requiring the use of pegfilgrastim has prevented the use of dose dense chemotherapy (dd) during pregnancy. Some physicians/patients may be concerned as well about the ability of the pregnant patient and her neonate to tolerate dose dense chemotherapy during pregnancy. The objective of this study is to compare the outcome of women and their neonates when dose dense chemotherapy is used in pregnancy compared to treatment at least 3 weeks apart. Materials and Methods: A retrospective cohort study of pregnant women receiving chemotherapy for breast cancer were identified from the Cancer and Pregnancy Registry. The timing of chemotherapy in pregnancy was decided by the patient's oncologist in consultation with their patient. Fisher's Exact test comparing patient and neonatal outcome was performed. Results: 109 pregnant women diagnosed with breast cancer participated. Ten women received dose dense (dd) and 99 conventional chemotherapy (cc). The mean gestational age at delivery for dd group was 35.8 (SD 3.1) weeks and 36.3 (SD 2.7) weeks in the cc group, p=.60. Mean birth weight was 2560 (SD 579)grams in the dd group, 2634 (SD 599) grams in the cc group, p=.642]There were no fetuses with growth restriction in the dd group, compared to 7.0% in the cc group, p=1.0. Of the 10 neonates in the dd group, 10% (1/10) experienced transient neutropenia, none did so in the cc group, p=0.09. Neonatal Outcomes GA=gestational age at delivery;IUGR=fetal growth restriction. No significant differences in GA at delivery, Birthweight or neutropenia was found. There was an 10% (1/10) incidence of maternal neutropenia in the dd group, 5.1% in the cc group, p=.45. Maternal mean follow up was 3.5 (2.6) years. The mean time to recurrence was 17.6 months for dd versus 19.7 months in the conventional group, p=0.84. Overall survival in the dd group was 90%, in the cc group, 86%, p=1.0. Maternal Outcomes No significant difference in neutropenia, time to recurrence or survival was found. Discussion: The small number of women receiving dose dense treatment is a limitation of this study. We found that maternal neutropenia, time to recurrence as well as overall survival was comparable between groups. Neonatal birth weight, gestational age at delivery and incidence of neonatal neutropenia was comparable between groups. Dose dense chemotherapy should be considered in pregnant women if the benefits are demonstrated in the nonpregnant population. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-10-21.

Neutropenia is a common hematologic disorder in the newborn intensive care unit, particularly in preterm neonates. Although its cause varies, a significant proportion of the episodes are associated with pregnancy complicated by preeclampsia. In this review, we provide a brief overview of preeclampsia and neonatal neutropenia, with a focus on the neonatal neutropenia associated with maternal preeclampsia. We discuss potential contributory mechanisms to and the natural history of this type of neutropenia, as well as reasonable management strategies in affected neonates.

Alloimmunization to granulocyte-specific antigens can occur during pregnancy. Maternal IgG can cross the placenta and result in neonatal neutropenia. The clinical course of alloimmune neonatal neutropenia is usually self-limiting with only mild infection. However, in severe cases complicated with bacterial sepsis it is a potentially life-threatening disorder. The effect of intravenous (IV) immunoglobulin, prophylactic antibiotic therapy, and recombinant human granulocyte-colony stimulating factor is variable and may prove useful in some cases. Two cases of alloimmune neonatal neutropenia due to anti HNA-2a alloimmunization in two siblings are reported. The first neonate was administered IV gammaglobulins to increase the blood neutrophil count, at a standard dosage (0.4 g/kg body weight) for 5 days without response. The second neonate did not receive specific therapy for blood neutrophil count increase. Neutropenia persisted for 2 and 6 months, respectively. The choice and efficacy of specific therapy for neutrophil count increase in the management of alloimmune neonatal neutropenia have not yet been fully defined and require additional evaluation in the majority of cases.

Doctor Parviz Lalezari, currently a clinical professor of Medicine and Pathology at Albert Einstein College of Medicine in New York, describes highlights of his research career since 1958. He became the director of the blood bank at Montefiore Hospital in New York City in 1961, director of the Division of Immunohematology until 1996, and then until 2001, was President and chief executive officer of the Bergen Community Regional Blood Center in New Jersey. Doctor Lalezari was born in Iran in 1931, and after graduation from Medical School, he came to the United States in 1956. His initial research was on leukocyte antibodies. After modifying the available antibody detection techniques, he discovered that like hemolytic disease of the newborn and neonatal immune thrombocytopenia, fetal-maternal neutrophil incompatibility can cause neonatal neutropenia. He identified the targets of these antibodies and showed that they were expressed only on peripheral blood neutrophils. Doctor Lalezari also discovered that a common form of neutropenia in early childhood was caused by development of autoantibodies, which surprisingly were directed against the same neutrophil-specific antigens involved in fetal-maternal incompatibility. In 1959, a heparin-neutralizing drug (Polybrene) was introduced to be used after open-heart surgery. Lalezari discovered that Polybrene, a quaternary ammonium polymer, reacted with sialic acid molecules on the red blood cell (RBC) surface, causing the RBCs to aggregate. Later, realizing that the repelling forces generated by the RBC surface membrane charges were responsible for failure of the small IgG antibody molecules to agglutinate the RBCs, he used Polybrene to neutralize the RBC surface negative charge to allow the IgG antibody molecules to induce hemagglutination. This became The Polybrene test, which is to be used in RBC antibody detection.

Neonatal lupus erythematosus (NLE) is a rare autoimmune disorder associated with transplacental migration of maternal autoantibodies against SS-A (Ro) or SS-B (La) antigens that results in cardiac, hepatic, cutaneous, and hematologic manifestations. Although NLE-associated neutropenia is considered transient and benign, neutropenia caused by severe congenital neutropenia (SCN) is life-threatening. Diagnosing a complicated picture of neonatal neutropenia can be challenging because there are many overlapping features between the acquired and inherited etiologies. This article highlights this diagnostic challenge with a case of delayed diagnosis of SCN due to an initial diagnosis of concurrent NLE. Secondary to SCN refractory to granulocyte colony-stimulating factor, our patient underwent a matched sibling cord blood transplant. Posttransplant, the patient developed recurrence of NLE symptoms, representing the first case of maternally transferred autoantibodies causing symptoms in a cord blood recipient. This novel finding prompted a review of the standards for collecting, processing, and storing of cord blood donations. This article also discusses the importance of physician familiarity with the differences and similarities between publicly and privately banked cord blood donations to adequately counsel expectant parents.

After completing this article, readers should be able to: 1. Define neutropenia for preterm and term neonates and the neutrophil concentrations that place infants at risk of developing infection. 2. List the most common causes of neonatal neutropenia. 3. Describe important factors in the evaluation of a neutropenic neonate. 4. Delineate the roles of recombinant granulocyte-colony-stimulating factor and granulocyte macrophage-colony-stimulating factor in the treatment of neonatal neutropenia. Neutropenia was described initially in 1902, but it was not reported as a problem in newborns until the late 1930s. (1)(2) Neutropenia now is recognized relatively commonly among ill neonates, affecting up to 8% of all patients in neonatal intensive care units (NICUs). (3)(4)(5)(6) Of the nearly 400,000 neonates admitted annually to NICUs in the United States, perhaps as many as 32,000 annually have neonatal neutropenia. The incidence of neonatal neutropenia is higher among preterm infants than among term infants, with estimates ranging between 6% and 58%, depending on the definition of neutropenia. (7) Often the neutropenia is transient and does not appear to convey a survival disadvantage. However, in some neonates, it is prolonged and severe, constituting a serious deficiency in antimicrobial defense. This article examines a general approach to the neutropenic neonate and some of the causes and treatments for this group of conditions. The diagnosis of neutropenia is based on a low blood neutrophil concentration. The blood neutrophil count can be calculated readily from a routine complete blood count as follows: ![Formula][1] The percent neutrophils generally is considered the sum of the segmented neutrophils, band neutrophils, and metamyelocytes. Several investigators have provided normal expected ranges for blood neutrophil concentrations among neonates. The definition of neutropenia, the lower limit of normal for blood neutrophil concentrations, has been reported variously as 1,500/mcL, (8) 1,800/mcL, (9) and 1,100/mcL. (10) … [1]: /embed/tex-math-1.gif

BACKGROUND: Passively acquired neonatal neutro-penia is an infrequently reported complication of maternal autoimmune neutropenia (AIN). Two affected siblings are described. The firstborn developed Citrobacter meningitis and was permanently disabled. The second was success-fully managed with pre- and postnatal injections of recom-binant human granulocyte colony-stimulating factor (rHuG–CSF). STUDY DESIGN AND METHODS: Neutrophil-specific antibodies were evaluated by flow cytometry (FC), monoclonal antibody immobilization of granulocyte antigens, and granulocyte agglutination assays. RESULTS: A neutrophil-reactive antibody was detected by FC in samples of the mother's serum spanning a 4-year time frame. This antibody reacted with neutrophils from the mother, father, and their first infant and with 18 of 20 target neutrophils tested. In serologic studies, it was shown that the antibody was not specific for the commonly recognized neutrophil-specific alloantigens HNA-1a (NA1), HNA-1b (NA2), HNA-1c (SH), HNA-2a (NB1), or HNA-3a (5b). CONCLUSION: Severe neonatal neutropenia in the two siblings appears to have been caused by placental transfer of a maternal neutrophil-reactive autoantibody of undetermined specificity. Neutrophil counts should be evaluated in infants born to mothers with chronic neutropenia of possible autoimmune origin so that neutropenic infants can be carefully monitored and antibiotics and/or rHuG–CSF administered if indicated.

Alloimmune neonatal neutropenia (ANN) is a rare but potentially life-threatening disorder of neonates. Demonstration of alloantibodies against granulocyte-specific antigens shared by neonatal and paternal granulocytes in the maternal serum is essential in the diagnosis of ANN. In contrast to granulocyte-specific alloantibodies, the significance of human leucocyte antigen (HLA) class I antibodies for ANN is still a matter of debate. We report on a case of severe isolated and prolonged neutropenia due to anti-HLA B49 alloimmunization only. Immediately after birth, severe, isolated neutropenia was observed and lasted for up to 2 months. Results of serologic testing showed only anti-HLA B49 antibodies in the maternal and neonate's sera. HLA typing showed HLA class I (B49) incompatibility between the mother and the child. Granulocyte-specific antibodies were not detected. Adsorption of the maternal serum with HLA B49-bearing platelets removed serum reactivity with paternal neutrophils. Our results support the idea that certain HLA class I antibodies can induce ANN.

Although anti–tumor necrosis factor (anti-TNF) antibodies are associated with a clear risk of agranulocytosis in adults and are known to cross the placenta, monitoring of the absolute neutrophil count (ANC) in neonates born to mothers receiving these biological agents is not currently recommended. Here, we report on the first case series of 4 newborn patients with severe neutropenia born to mothers treated for ulcerative colitis with infliximab during pregnancy (including the third trimester). The newborns presented with severe neutropenia at birth, which was subsequently complicated by skin infections. The newborns' ANCs returned to the normal range within 8 to 14 weeks, at which time infliximab could not be detected in the blood. Anti-TNF agents probably exert a direct, toxic effect on the bone marrow. Furthermore, the detection of a CD16 autoantibody in 1 mother-newborn pair suggests that infliximab can induce autoimmune neutropenia. Abnormally high levels of the CD16 autoantibody in newborn serum or immaturity of the fetal bone marrow might explain why neutropenia was observed in the child but not in the mother. We recommend the systematic measurement of ANC on cord blood at birth and (in the event of an infection) in the weeks thereafter.

Bacterial sepsis continues to be an important cause of morbidity and mortality in neonates. Neutropenia in the newborn, as a result of decreased bone marrow neutrophil storage pool reserves and myeloid committed progenitor cells, increases the risk of sepsis and is associated with a poor prognosis. The hematopoietic colony-stimulating factors G-CSF (granulocyte colony stimulating factor) and GM-CSF (granulocyte-macrophage colony stimulating factor) increase the number of circulating neutrophil number by stimulating neutrophil precursors proliferation. In a number of clinical trials in very low birthweight neonates and in neonates with preeclampsia-associated neonatal neutropenia, both hematopoietic growth factors significantly increased the circulating absolute neutrophil count. However, no larger study showed that prophylactic G-CSF or GM-CSF treatment resulted in a reduction of infectious complications or in an improved overall survival. Similar results were seen in studies evaluating G-CSF and GM-CSF as intervention therapy in septic neonates. Therefore, experts do not recommend the routine use of the expensive growth factors in preterm and term neonates. However, prospective clinical trials are still needed to evaluate whether specific treatment groups will benefit from the use of G-CSF or GM-CSF. In this regard, efforts must be directed at better defining the endpoints and in particular assigning value to reduction in treatment of possible infectious complications, such as days in hospital, antibiotic usage and costs. In addition, randomized studies are required to evaluate the proper dosage and duration of therapy, which most likely will vary between groups of patients.

Autoimmune neutropenia (AIN) has been reported in infants and children, but not in neonates. AIN is caused by antibodies produced by the patient against their own neutrophils; therefore, it differs from the more common alloimmune neonatal neutropenia and the neonatal neutropenia because of a maternal autoimmune disease in which antineutrophil antibodies of maternal origin cross the placenta. We observed 2 cases of congenital AIN in premature neonates. These are the youngest reported cases, and indicate that AIN can have a prenatal onset. Examination of the bone marrow biopsies revealed an increase in B lymphocytes and myeloperoxidase-positive cells with a maturation arrest at the myelocyte stage. Recombinant human granulocyte colony-stimulating factor effectively treated the neutropenia, as it does in infantile AIN. Ten months after the diagnosis, 1 of the patients still requires recombinant human granulocyte colony-stimulating administration.

Objectives. To determine whether adjunctive therapy with recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF) could reverse sepsis-associated neonatal neutropenia and improve neonatal survival and to assess its safety compared with conventional therapy in a control group. Study Design. This prospective, randomized, controlled trial was performed in 60 infants with neutropenia and clinical signs of sepsis. A subcutaneous injection of rhGM-CSF (5 μg/kg/day) was administered to 30 of the patients for 7 consecutive days. Hematologic parameters (absolute neutrophil, eosinophil, monocyte, lymphocyte counts, and platelet number) and outcome were compared with 30 conventionally treated (control) patients. Results. Twenty-five patients from the GM-CSF-treated group and 24 from the conventionally treated group had early-onset sepsis (≤3 days' postnatal age), and the other 11 patients had late-onset sepsis (>3 days' postnatal age). There was no difference between groups in terms of birth weight; gestational age; gender; maturity; maternal age; and incidence of prolonged rupture of membranes, maternal hypertension, or severity of sepsis. All neonates tolerated GM-CSF well with no adverse reactions. The absolute neutrophil count on day 7 was significantly increased in the GM-CSF-treated group compared with the conventionally treated group: 8088 ± 2822/mm3 versus 2757 ± 823/mm3. The mean platelet count was significantly higher on days 14 in the GM-CSF-treated group compared with conventionally treated group: 266 867 ± 55 102/mm3versus 229 200 ± 52 317/mm3. Hematologic parameters were otherwise similar between groups before treatment and on day 28. Twenty-seven neonates in the rh-GMCSF group and 21 in the control group survived to hospital discharge. The mortality rate in the rhGM-CSF group (10%) was significantly lower than in the conventionally treated group (30%). Conclusion. Treatment with rhGM-CSF is associated with an increase in absolute neutrophil, eosinophil, monocyte, lymphocyte, and platelet counts and decreased mortality in critically ill septic neutropenic neonates. These results suggest that rhGM-CSF may be effective in the treatment of neonatal sepsis with neutropenia, and further randomized trials are needed to confirm its beneficial effects.

The effect of recombinant human granulocyte colony-stimulating factor (rhG-CSF) administration at 10 μg/kg/day for 15–30 min over 3 consecutive days in 3 preterm neonates with allo-immune neonatal neutropenia (ANN) is reported. Patients 1 and 2 had antibodies against antigen NA2, while patient 3 had antibodies against NA1. All neonates developed a rapid increase in absolute neutrophil count which reached the normal range within 48 h (from 75–640/mm3 to 2,520–4,700/mm3). However, 23–25 days later, all 3 neonates relapsed into a second phase of severe neutropenia (408–870/mm3). Antibodies against neutrophil antigens were still positive during this period. This second-phase neutropenia persisted for 20–30 days and resolved spontaneously. It may be possible that when rhG-CSF is administered within a short time after birth in neonates with ANN, its effect is exhausted before the concentration of circulating antibodies decreases, with the result that a second phase of neutropenia can be expected.

Objective. Preterm neonates undergoing intensive care have high morbidity from sepsis. These infants also frequently develop neutropenia, and when this is associated with sepsis, mortality is high. This study investigates the potential for granulocyte-macrophage colony-stimulating factor (GM-CSF) to effect a clinically relevant increase in neutrophil number when used prophylactically in high-risk preterm neonates, and assesses its safety in this population. Design. In an open, randomized, controlled study, 75 neonates (25 small for gestational age) Results. Prophylactic GM-CSF therapy completely abolished neutropenia in treated infants, when both well and septic, throughout the period of study. Neutropenia (≤1.7 × 109/L) developed in 16 of 39 control infants. Five control infants experienced an acute decrease in neutrophil count coincident with the onset of sepsis. There was no evidence of hematologic, respiratory, or gastrointestinal toxicity in treated infants. Treated infants had a trend to fewer symptomatic, blood culture positive septic episodes than controls during 2 weeks from study entry (11/36 vs 18/39). Conclusion. Five-day prophylactic GM-CSF completely abolishes postnatal neutropenia and sepsis-induced neutropenia in preterm neonates at high risk of sepsis, and so removes an important risk factor for sepsis and sepsis-related mortality.GM-CSF, preterm neonates, neutropenia, sepsis.

Recombinant haemopoietic growth factors are increasingly used in the treatment and prevention of a variety of inherited and acquired cytopenias in adults and children. In neonatal medicine, most of the available data describe the effects of recombinant granulocyte colony-stimulating factor (G-CSF) and granulocyte-macrophage colony-stimulating factor (GM-CSF) on neutrophil production, and the putative roles of these factors in ameliorating neonatal sepsis. G-CSF induces a dose-dependent increase in blood neutrophils, bone marrow neutrophils and neutrophil progenitors, both in term and preterm babies using doses as low as 5 μg/kg daily. The effects of G-CSF are rapidly reversible, and no serious short- or long-term side-effects have been reported in newborns. However, evidence that G-CSF improves the outcome of neonatal sepsis is not yet available. An alternative approach, administration of G-CSF to pregnant women with an imminent preterm delivery, may result in transplacental passage of G-CSF sufficient to exert a biological effect on the fetus, but further studies are needed to determine whether this reduces the incidence of neonatal sepsis and improves outcome. There has been even less experience of GM-CSF in neonates. In randomized trials, a dose of 10 μg/kg daily has been shown to increase circulating neutrophil and monocyte counts without any evidence of toxicity. While preliminary evidence suggests that GM-CSF may reduce the incidence of nosocomial infections, additional controlled studies of both G-CSF and GM-CSF are needed before their routine use in neonates can be recommended.

The effects of recombinant granulocyte-colony stimulating factor (rhG-CSF) in neonatal neutropenia with presumed sepsis, which has a poor prognosis, were investigated. The study involved 14 neonates with presumed sepsis and neutropenia. Findings were compared with those from 24 historical controls. rhG-CSF (5 micrograms/ kg/day i.v. for 5 days) was administered immediately following diagnosis. Complete blood counts were obtained before and 24, 48, 72, 96 and 120 h after initiation of treatment. Neutrophil storage pool (NSP) was assessed (in 4 patients) before and after treatment. Statistical analysis was performed using one way analysis of variance. Treatment led to an increase in absolute neutrophil count (ANC) levels in 13/14 patients. At the end of treatment, the mean ANC was higher than that of controls (P = 0.007). There was a marked increase in the NSP of between 32% and 65% (P = 0.005). There were two clinical failures, one of whom was considered to have died from his underlying condition. There were no reports of clinical or haematological toxicity during treatment or follow up.

Host defenses in the human neonate are limited by immaturity in phagocytic immunity. Such limitations seem to predispose infected newborns to neutropenia from an exhaustion of the neutrophil reserve. Among the critical defects thus far identified in neonatal phagocytic immunity is a specific reduction in the capacity of mononuclear cells to express granulocyte colony-stimulating factor (G-CSF) after stimulation. However, the safety, pharmacokinetics, and biological efficacy of administration of recombinant human (rh)G-CSF to infected human newborns to compensate for this deficiency is unknown. Forty-two newborn infants (26 to 40 weeks of age) with presumed bacterial sepsis within the first 3 days of life were randomized to receive either placebo or varying doses of rhG-CSF (1.0,5.0, or 10.0 pglkg every 24 hours 136 patients] or 5.0 or 10.0 pglkg every 12 hours [6 patients]) on days 1, 2, and 3. Complete blood counts with differential and platelet counts were obtained at hours 0,2,6,24,48,72, and 96. Circulating G-CSF concentrations were determined at hours 0,2,6, 12, 14, 16, 18,24, and 36. Tibial bone marrow aspirates were obtained after 72 hours for quantification of the bone marrow neutrophil ACTEFUAL SEPSIS occurs in 1 to 10 per 1,000 term infants and is three to four times more common in infants delivered prematurely.'.' The mortality rate for neonates with bacterial sepsis varies between 15% and 75% depending on the virulence of the organism, associated complications, and gestational age.'33 Neutropenia commonly occurs in neonates with sepsis"6 and is associated with increased risk of deah7 The kinetic and molecular explanations for the neutropenia observed in neonates with sepsis have been the subjects of previous investigations. We previously observed quantitative deficiencies in myelopoiesis in the neonatal rat.*-" These deficiencies include a relatively small supply of granulocyte progenitor cells (colony-forming unit granulocyte-macrophage) (Cm-GM), a small neutrophil storage pool (NSP) (polymorphonuclear leukocytes, band neutrophils, and metamyelocytes), and an increased tendency to neutropenia associated with a depleted NSP during experimental sepsis. These observations suggested that new methods of treatment, which induce an increase in the neutrophil supply, might be beneficial for newborn infants with bacterial sepsis. We previously showed that there is far less granulocyte colony-stimulating factor (G-CSF) production by cells of preterm infants than term infant^,""^ and a failure to increase G-CSF mRNA expression after infection in newborn animals.I6 We also observed that administration of a single dose of recombinant human (rh)G-CSF to l-day old newborn rats induced significant neutr~philia,'~**~ whereas administration for 7 days induced neutrophilia and increased the bone marrow neutrophil storage and progenitor pools.'9 Neonatal rats inoculated with lethal doses of group B streptococcus (GBS) and a single pulse of G-CSF had a significantly higher survival rate compared with those treated with antibiotics B storage pool (NSP), neutrophil proliferative pool, granulocyte progenitors, and pluripotent progenitors. Functional activation of neutrophils (C3bi expression) was determined 24 hours after rhG-CSF or placebo administration. Intravenous rhG-CSF was not associated with any recognized acute toxicity. RhG-CSF induced a significant increase in the blood neutrophil concentration 24 hours after the 5 and 10 pglkg doses every 12 and 24 hours and it was sustained as long as 96 hours. A dose-dependent increase in the NSP was seen following rhG-CSF. Neutrophil C3bi expression was rignificantly increased at 24 hours after 10 pglkg every 24-hour dose of rhG-CSF. The half-life of rhG-CSF was 4.4 & 0.4 hours. The rhG-CSF was well tolerated at all gestational ages treated. The rhG-CSF induced a significant increase in the peripheral blood and bone marrow absolute neutrophil concentration and in C3bi expression. Future clinical trials aimed at improving the outcome of overwhelming bacterial sepsis and neutropenia in newborn infants might include the use of rhG-CSF. 0 1994 by The American Society of Hematology.

Antibodies against the human neutrophil antigens (HNA) are able to stimulate transfusion reactions, autoimmune and neonatal neutropenia. The aim of this study was to determine the HNA allele frequencies in the largest ethnic minority group in Germany in comparison with the German population for predicting the risk of alloimmunization and associated transfusion reactions, as well as the risk of developing neonatal neutropenia for the newborn of racial mixed couples. However, there exists no data about HNA genotype distribution in Turkish population. DNA was isolated from blood samples of 119 German and 118 Turkish blood donors and typed them for HNA-1, -3, -4, and -5 by using a commercial polymerase chain reaction kit with sequence-specific primers (SSP-PCR) and compared the HNA genotype distribution of both groups. In German blood donors, the gene frequencies for HNA-1a and HNA-1b were 0.391 and 0.601, for HNA-3a and -3b, 0.744 and 0.256, for HNA-4a and -4b, 0.908 and 0.092, and for HNA-5a and -5bw, 0.731 and 0.269. In Turkish blood donors, we observed 0.420/0.564, 0.737/0.263, 0.881/0.119, and 0.754/0.246 for HNA-1a/1b, -3a/3b, -4a/4b, and -5a/5bw. No statistic significant difference between genotypes in these populations was observed. This study is the first to report HNA gene frequencies in a Turkish population. It showed that there is no difference of HNA genotype in blood donors with Turkish descent in comparison with German blood donors. The alternating transfusion of blood and blood components is no increased risk for developing alloantibodies against HNA antigens. In pregnancy of mixed couples no special screening programs for HNA are necessary.

Autoimmune neutropenia (AIN) can occur during pregnancy. However, neonatal neutropenia occurring in an infant born to a mother with AIN has only rarely been documented. Recently, we have experienced two cases of AIN during pregnancy, both of which caused severe yet transient neonatal neutropenia (< 0.3 x 10(9)/l), probably as a result of transplacental maternal anti-neutrophil autoantibodies. The anti-neutrophil antibodies seemed to be against antigens other than NA1/NA2 because the autoantibodies did not bind to neutrophils of specific NA types selectively in the granulocyte indirect immunofluorescence test. Although AIN is a relatively uncommon disease, neonatal neutropenia caused by maternal AIN may not be quite as rare.

Alloimmunization of a mother against granulocytes causing alloimmune neonatal neutropenia (ANN) in her newborn was found likely to be attributed to previous intradermal injections of paternal lymphocytes. Immunotherapy with leukocytes which was performed for recurrent spontaneous abortions hence provides the possibility of granulocyte alloimmunization and increases the risk of the occurrence of ANN.