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ARTICLE:
Gregory L. Jackson, William D. Engle, Dorothy M. Sendelbach, Debra A. Vedro, Sue Josey, Jodi Vinson, Carol Bryant, Gary Hahn, and Charles R. Rosenfeld
Are Complete Blood Cell Counts Useful in the Evaluation of Asymptomatic Neonates Exposed to Suspected Chorioamnionitis?
Pediatrics 2004; 113: 1173-1180 [Abstract] [Full text] [PDF]
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[Read P3R] Labor and stress at delivery are confounders in the evaluation of neonatal sepsis
Eleanor J Molloy, Kelly Nigro, Linda Sandhaus, R. William G. Watson, Michelle C Walsh   (28 May 2004)

Labor and stress at delivery are confounders in the evaluation of neonatal sepsis 28 May 2004
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Eleanor J Molloy,
Neonatology Fellow
Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA,
Kelly Nigro, Linda Sandhaus, R. William G. Watson, Michelle C Walsh

Send letter to journal:
Re: Labor and stress at delivery are confounders in the evaluation of neonatal sepsis

elesean{at}hotmail.com Eleanor J Molloy, et al.

Dear Sir or Madam,

We wish to congratulate Jackson JL and co-authors on their extensive study on the use of neutrophil counts in the management of infants with maternal chorioamnionitis. These infants present a daily clinical conundrum for the neonatologist in the absence of clear evidence-based guidelines. We are particularly interested in the mode of delivery of these infants as neutrophil counts are higher in infants born following vaginal delivery compared with elective caesarean section with no labour (1-4). Higher band counts have also been described (4). In addition, several studies indicate that neonatal neutrophil function is activated by labor (5-7). Did the authors analyse the effect of labour on the neutrophil counts especially within an hour of birth? In this study, was the immature to mature granulocyte (IT) ratio higher in infants delivered vaginally or by emergency Caesarean section following labour compared with those born by elective caesarean section with no labour? It would be interesting to see if the duration of labour influenced the usefulness of the IT ratio in symptomatic infants. Infants with low Apgars have higher immature neutrophils types as shown in the umbilical cord blood transplant literature (8). Did infants with low Apgars or cord pH have a deranged IT ratio and if so, did it normalise in the asymptomatic infants in their serial CBCs? In addition what was the effect of either stress at birth or labor on the serial values of CBCs in asymptomatic compared with symptomatic infants? The influence of stress at birth may be important when interpreting the IT ratio especially in conjunction with serial CRP measurements to aid in clinical decision- making. The exclusion of infants requiring neonatal intensive care may artificially reduce the number of term or near-term symptomatic infants exposed to maternal chorioamnionitis. It would be interesting to evaluate serial CBCs in this group of infants. Currently, a combination of routine tests including CBC, CRP in conjunction with the complete clinical assessment and placental pathology remain the commonest diagnostic tools in the diagnosis of early onset neonatal sepsis in term or near-term infants (9). Several promising diagnostic tests for neonatal sepsis are in development such as Interleukin -6 and 10, granulocyte colony stimulating factor levels, procalcitonin and CD11b (10). However these remain non- specific markers of inflammation or infection and additionally are expensive and cumbersome at present. Studies combining these indices in to a sepsis scoring system could potentially aid in this difficult diagnosis.

References: 1. Chirico G, Gasparoni A, Ciardelli L, Martinotti L, Rondini G. Leukocyte counts in relation to the method of delivery during the first five days of life. Biol Neonate. 1999;75(5):294-9. 2. Thilaganathan B, Meher-Homji N, Nicolaides KH. Labor: an immunologically beneficial process for the neonate. Am J Obstet Gynecol. 1994 ;171(5):1271-2 3. Herson VC, Block C, Eisenfeld LI, Maderazo E, Krause PJ. Effect of labor and delivery on neonatal polymorphonuclear leukocyte number and function. Am J Perinatol. 1992 ;9(4):285-8 4. Hasan R, Inoue S, Banerjee A. Higher white blood cell counts and band forms in newborns delivered vaginally compared with those delivered by cesarean section. Am J Clin Pathol. 1993;100(2):116-8 5. Gessler P, Dahinden C. Increased respiratory burst and increased expression of complement receptor-3 (CD11b/CD18) and of IL-8 receptor-A in neutrophil granulocytes from newborns after vaginal delivery. Biol Neonate. 2003;83(2):107-12. 6. Weinschenk NP, Farina A, Bianchi DW. Neonatal neutrophil activation is a function of labor length in preterm infants. Pediatr Res. 1998 ;44(6):942-5 7. Molloy EJ, O'Neill AJ, Grantham JJ, Sheridan-Pereira M, Fitzpatrick JM, Webb DW, Watson RW. Labor Promotes Neonatal Neutrophil Survival and Lipopolysaccharide Responsiveness. Pediatr Res 2004, DOI: 10.1203/01.PDR.0000130473.30874.B6 8. Aufderhaar U, Holzgreve W, Danzer E, Tichelli A, Troeger C, Surbek DV The impact of intrapartum factors on umbilical cord blood stem cell banking. J Perinat Med. 2003;31(4):317-22. 9. Berger C, Uehlinger J, Ghelfi D, Blau N, Fanconi S. Comparison of C- reactive protein and white blood cell count with differential in neonates at risk for septicaemia. Eur J Pediatr. 1995 ;154(2):138-44 10. Ng PC. Diagnostic markers of infection in neonates. Arch Dis Child Fetal Neonatal Ed 2004;89:F229-F235.