Purpose and Goal: CEARP #1088

  • Describe the pathophysiology of anemia of prematurity.
  • Identify specific approaches for the prevention and treatment of anemia of prematurity.

None of the planners, faculty or content specialists has any conflict of interest or will be presenting any off-label product use. This presentation has no commercial support or sponsorship, nor is it co-sponsored.

Requirements for Successful Completion

  • Successfully complete the post-test.
  • Complete the evaluation form.


  • October 2013 - October 2015

Learning Objectives

  • Describe the pathophysiology of anemia of prematurity.
  • Describe the signs and symptoms of anemia of prematurity.
  • Identify at least two approaches for the prevention and treatment of anemia of prematurity.


  • Anemia has been defined as a hemoglobin or hematocrit level at least two standard deviations from the mean for age.
  • Anemia of prematurity has been defined as a low reticulocyte count and a poor response to erythropoietin.


  • All infants experience a decline in circulating red blood cells after birth.
  • Increased tissue oxygenation → decreased erythropoietin production.
  • The lowest red blood cell levels occur at 2 weeks of age.
  • The lowest hematocrit levels occur around 4-8 weeks of age.
  • Retciuloctye counts are important at this time.
    • Reticulocyte counts measure the rate of red blood cell production.
    • Retciulocytes exist in blood for 2 days before becoming mature red blood cells.
  • Normal reticulocyte counts at birth:
    • Term infants: 3-6%
    • Preterm infants: 8-10%
  • Normal reticulocyte counts at 4-8 weeks of age:
    • Dependent on gestational age, chronological age and health status

Contributing Factors

  • Decreased red blood cell count at birth
  • Shorter red blood cell lifespan
  • Increased iatrogenic loss from lab draws
  • Abrupt decline in reticulocyte count after birth
  • Inadequate erythropoietin production
  • Poor iron stores and poor ability to build stores
  • Rapid growth → hemodilution

Signs and Symptoms

  • Tachycardia
  • Tachypnea
  • Lethargy
  • Paleness
  • Apnea
  • Bradycardia
  • Poor feeding
  • Poor growth
  • Elevated lactic acid

Prevention and Treatment


  • Reducing blood loss
  • Supplemental iron
  • Supplemental vitamin E
  • Administration of erythropoietin


  • Packed red blood cell transfusion

The Importance of Iron

  • Fetal iron stores accumulate in the third trimester.
  • Premature infants have poor iron stores.
  • Premature infants have a poor ability to build stores from feeds.
  • Iron is a major part of hemoglobin and is essential for red blood cell production.
  • Without adequate iron intake → increased susceptibility to anemia


  1. Meyers, P. and Huffstetler, A. 2013. National Association of Neonatal Nurses: Anemia of Prematurity: To Transfuse or Not to Transfuse  
  2. Salsbury, D. 2001. Anemia of Prematurity. Neonatal Network 29 (5), p 13-20.
  3. NeoReviews  
  4. UpToDate  

Test and Evaluation

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