Download PDF
Semin Thromb Hemost 2003; 29(5): 515-528
DOI: 10.1055/s-2003-44558
Copyright © 2003 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

Polycythemia and Hyperviscosity in the Newborn

Ted S. Rosenkrantz
  • Professor and Head, Division of Neonatology, Department of Pediatrics, University of Connecticut, Farmington, Connecticut
Further Information

Publication History

Publication Date:
21 November 2003 (online)

    Permissions and Reprints

ABSTRACT

Research from the past 15 to 20 years has led to a comprehensive understanding of the etiology and effects of polycythemia and hyperviscosity in the newborn. Polycythemia and hyperviscosity are generally a result of a poor intrauterine environment or hypoxic complications during labor and delivery. Changes in blood viscosity are a direct result of changes in hematocrit because the plasma viscosity in the newborn is virtually always normal. Polycythemia and hyperviscosity are associated with decreases in blood flow to the brain, heart, lung, intestines, and carcass. Renal blood flow is not affected, but renal plasma flow is diminished, resulting in a lower glomerular filtration rate (GFR). The elevated hemoglobin and hematocrit are associated with an increase in the arterial oxygen content. It is the increase in arterial oxygen content, not the hyperviscosity, that is directly responsible for the decreased blood flow in the brain and heart as well as cardiac output. As a result, brain and cardiac oxygenation is normal. Decreased pulmonary blood flow appears to be the result of hyperviscosity and can result in system hypoxia. This can be corrected by a partial exchange transfusion to lower the hematocrit and viscosity. This will also improve renal function by increasing plasma flow. Because the abnormalities in brain function are due to a primary hypoxia event and not reduced cerebral blood flow, a partial exchange transfusion will not improve short-term or long-term abnormalities in neurological functioning.

KEYWORDS

Polycythemia - hyperviscosity - newborn - hypoxia - hematocrit - blood flow

REFERENCES

  • 1 Wood J L. Plethora in the newborn infant associated with cyanosis and convulsions.  J Pediatr . 1952;  54 143-151
    PubMedSearch in Google Scholar
  • 2 Michael A F, Mauer A M. Maternal-fetal transfusion as a cause of plethora in the neonatal period.  Pediatrics . 1961;  28 458-461
    PubMedSearch in Google Scholar
  • 3 Minkowski A. Acute cardiac failure in connection with neonatal polycythemia (in monovular twins and single newborn infants).  Biol Neonate . 1962;  4 61-74
    PubMedSearch in Google Scholar
  • 4 Danks D M, Stevens L H. Neonatal respiratory distress with a high hematocrit.  Lancet . 1964;  2 499-500
    PubMedSearch in Google Scholar
  • 5 Gross G P, Hathaway W E, McGaughey H R. Hyperviscosity in the neonate.  J Pediatr . 1973;  82 1004-1012
    CrossrefPubMedSearch in Google Scholar
  • 6 Ramamurthy R S, Brans Y W. Neonatal polycythemia. I. Criteria for diagnosis and treatment.  Pediatrics . 1981;  68 168-174
    PubMedSearch in Google Scholar
  • 7 Oh W, Lind J. Venous and capillary hematocrit in newborn infants and placental transfusion.  Acta Paediatr Scand . 1966;  55 38-40
    PubMedSearch in Google Scholar
  • 8 Wirth F H, Goldberg K E, Lubchenco L O. Neonatal hyperviscosity. I. Incidence.  Pediatrics . 1979;  63 833-836
    PubMedSearch in Google Scholar
  • 9 Stevens K, Wirth F H. Incidence of neonatal hyperviscosity at sea level.  J Pediatr . 1980;  97 118-119
    PubMedSearch in Google Scholar
  • 10 Brooks G I, Backes C R. Hyperviscosity secondary to polycythemia in the appropriate for gestational age neonate.  J Am Osteopath Assoc . 1981;  80 415-418
    PubMedSearch in Google Scholar
  • 11 Reisner S H, Mor N, Levy Y, Merlob P. Incidence of neonatal polycythemia.  Isr J Med Sci . 1983;  19 848-849
    PubMedSearch in Google Scholar
  • 12 Oh W, Oh M A, Lind J. Renal function and blood volume in newborn infants related to placental transfusion.  Acta Paediatr Scand . 1966;  56 197-210
    PubMedSearch in Google Scholar
  • 13 Oh W, Blankenship W, Lind J. Further study of neonatal blood volume in relation to placental transfusion.  Ann Paediatr . 1996;  207 147-159
    PubMedSearch in Google Scholar
  • 14 Yao A C, Moinian M, Lind J. Distribution of blood between infants and placenta after birth.  Lancet . 1969;  2 871-873
    PubMedSearch in Google Scholar
  • 15 Linderkamp O. Placental transfusion: determinants and effects.  Clin Perinatol . 1981;  9 559-592
    PubMedSearch in Google Scholar
  • 16 Shohat M, Teisner S H, Mimoini F, Merlob P. Neonatal polycythemia. II. Definition related to time of sampling.  Pediatrics . 1984;  73 11-13
    PubMedSearch in Google Scholar
  • 17 Poiseuille J LM. Recherches experimentales sur le mouvement des liquides dans les tubes de tres petits diametres.  C R Acad Sci . 1840;  11 961-1041
    PubMedSearch in Google Scholar
  • 18 van der Elst W C, Malan A F, de van Heese H. Blood viscosity in modern medicine.  S Afr Med J . 1977;  52 526-528
    PubMedSearch in Google Scholar
  • 19 Wells R E, Penton R, Merrill E W. Measurements of viscosity of biologic fluids by core plate viscometer.  J Lab Clin Med . 1961;  57 646-656
    PubMedSearch in Google Scholar
  • 20 Wells R E, Merrill E W. Influence of flow properties of blood upon viscosity-hematocrit relationships.  J Clin Invest . 1961;  41 1591-1598
    PubMedSearch in Google Scholar
  • 21 Dintenfass L. Blood viscosity, internal fluidity of the red cell, dynamic coagulation and the critical capillary radius as factors in the physiology and pathology of circulation and microcirculation.  Med J Aust . 1968;  1 688-696
    PubMedSearch in Google Scholar
  • 22 Linderkamp O, Versmold H IT, Riegel K P, Betke K. Contributions of red cells and plasma to blood viscosity in preterm and full-term infants and adults.  Pediatrics . 1984;  74 45-51
    PubMedSearch in Google Scholar
  • 23 Burton A C. Role of geometry, of size and shape, in the microcirculation.  Fed Proc . 1966;  25 1753-1760
    PubMedSearch in Google Scholar
  • 24 Bergqvist G. Viscosity of the blood in the newborn infants.  Acta Paediatr Scand . 1974;  63 858-864
    PubMedSearch in Google Scholar
  • 25 Wells R. Syndromes of hyperviscosity.  N Engl J Med . 1970;  283 183-186
    PubMedSearch in Google Scholar
  • 26 Somer T, Ditzel J. Clinical and rheological studies in a patient with hyperviscosity syndrome due to Waldenstrom's macroglobulinemia.  Bibl Haematol . 1981;  47 242-246
    PubMedSearch in Google Scholar
  • 27 Charm S E, Kurland G S. Blood Flow and Microcirculation.  New York: Wiley; 1974
    Search in Google Scholar
  • 28 Smith C M, Prasler W J, Tukey D P. et al . Fetal red cells are more deformable than adult red cells (Abst).  Blood . 1981;  58 35a
    PubMedSearch in Google Scholar
  • 29 Linderkamp O, Wu P YK, Meiselman H J. Deformability of density separated red blood cells in normal newborn infants and adults.  Pediatr Res . 1982;  16 964-968
    PubMedSearch in Google Scholar
  • 30 Lichtman M A. Cellular deformability during maturation of the myeloblast.  N Engl J Med . 1970;  283 943-948
    PubMedSearch in Google Scholar
  • 31 Lichtman M A. Rheology of leukocytes, leukocyte suspensions, and blood in leukemia.  J Clin Invest . 1973;  52 350-358
    PubMedSearch in Google Scholar
  • 32 Miller M E. Developmental maturation of human neutrophil motility and its relationship to membrane deformability. In: Bellanti JA, Dayton DH, eds. The Phagocytic Cell in Host Resistance New York: Raven Press 1975: 295
    Search in Google Scholar
  • 33 Rand P W, Austin W H, Lacombe E, Barker N. pH and blood viscosity.  J Appl Physiol . 1968;  25 550-559
    PubMedSearch in Google Scholar
  • 34 Fahraeus R, Lindqvist T. The viscosity of the blood in narrow capillary tubes.  Am J Physiol . 1931;  96 562-568
    PubMedSearch in Google Scholar
  • 35 Nowicki P, Oh W, Yao A, Hansen N B, Stonestreet S S. Effect of polycythemia on gastrointestinal blood flow and oxygenation in piglets.  Am J Physiol . 1984;  247 G220-G225
    PubMedSearch in Google Scholar
  • 36 LeBlanc M H, Kotagal V R, Kleinman L I. Physiological effects of hypervolemic polycythemia in newborn dogs.  J Appl Physiol . 1982;  53 865-872
    PubMedSearch in Google Scholar
  • 37 Surjadhana A, Rouleau J, Boerboom L, Hoffman J IE. Myocardial blood flow and its distribution in anesthetized polycythemic dogs.  Circ Res . 1978;  43 619-631
    PubMedSearch in Google Scholar
  • 38 Brashear R E. Effects of acute plasma for blood exchange in experimental polycythemia.  Respiration . 1980;  40 297-306
    PubMedSearch in Google Scholar
  • 39 Rosenkrantz T S, Oh W. Cerebral blood flow velocity in infants with polycythemia and hyperviscosity: Effects of partial exchange transfusion with Plamanate.  J Pediatr . 1982;  101 94-98
    PubMedSearch in Google Scholar
  • 40 Fouron J C, Hebert F. The circulatory effects of hematocrit variations in normovolemic newborn lambs.  J Pediatr . 1973;  82 995-1003
    PubMedSearch in Google Scholar
  • 41 Gatti R A, Muister A J, Cole R B, Paul M H. Neonatal polycythemia with transient cyanosis and cardiorespiratory abnormalities.  J Pediatr . 1966;  69 1063-1072
    PubMedSearch in Google Scholar
  • 42 Kotagal V R, Keenan W J, Reuter J H. et al . Regional blood flow in polycythemia and hypervolemia (Abst).  Pediatr Res . 1977;  11 394A
    PubMedSearch in Google Scholar
  • 43 Swetnam S M, Yabek S M, Alverson D C. Hemodynamic consequences of neonatal polycythemia.  J Pediatr . 1987;  110 443-447
    PubMedSearch in Google Scholar
  • 44 Murphy Jr J D, Reller M D, Meyer R A, Kaplan S. Effects of neonatal polycythemia and partial exchange transfusion on cardiac function: an echocardiographic study.  Pediatrics . 1985;  76 909-913
    PubMedSearch in Google Scholar
  • 45 Boehm G, Delitzsch A K, Senger H. et al . Postnatal development of liver and exocrine pancreas in polycythemic newborn infants.  J Pediatr Gastroenterol Nutr . 1992;  15 310-314
    PubMedSearch in Google Scholar
  • 46 Kotagal V R, Kleinman L I. Effect of acute polycythemia on newborn renal hemodynamics and function.  Pediatr Res . 1982;  16 148-151
    PubMedSearch in Google Scholar
  • 47 Bergqvist G, Zetterman R. Blood viscosity and peripheral circulation in newborn infants.  Acta Paediatr Scand . 1974;  63 865-868
    PubMedSearch in Google Scholar
  • 48 Linderkamp O, Strohhacker I, Versmold H T. et al . Peripheral circulation in the newborn: interaction of peripheral blood flow, blood pressure, blood volume and blood viscosity.  Eur J Pediatr . 1978;  129 73-81
    CrossrefPubMedSearch in Google Scholar
  • 49 Gustafsson L, Applegren L, Myrvold H E. The effect of polycythemia on blood flow in working and non-working skeletal muscle.  Acta Physiol Scand . 1980;  109 143-148
    PubMedSearch in Google Scholar
  • 50 Waffarn F, Cole C D, Huxtable R F. Effects of polycythemia and hyperviscosity on cutaneous blood flow and transcutaneous pO2 and pCO2 in neonate.  Pediatrics . 1984;  74 389-394
    PubMedSearch in Google Scholar
  • 51 Jones M D, Traystman R J, Simmons M A, Molteni R A. Effects of changes in arterial O2 content on cerebral blood flow in the lamb.  Am J Physiol . 1981;  240 H209-H215
    PubMedSearch in Google Scholar
  • 52 Rosenkrantz T S, Stonestreet B S, Hansen N B. et al . Cerebral blood flow in the newborn lamb with polycythemia and hyperviscosity.  J Pediatr . 1984;  104 276-280
    CrossrefPubMedSearch in Google Scholar
  • 53 Goldstein M, Stonestreet B S, Brann, B S, Oh W. Cerebral cortical blood flow and oxygen metabolism in normocythemic hyperviscous newborn piglets.  Pediatr Res . 1988;  24 486-489
    PubMedSearch in Google Scholar
  • 54 Rosenkrantz T S, Philipps A F. Cerebral metabolism in the newborn lamb with polycythemia.  Pediatr Res . 1985;  23 329-333
    PubMedSearch in Google Scholar
  • 55 Tenenbaum D G, Piasecki G J, Oh W, Rosenkrantz T S, Jackson B T. Fetal polycythemia and hyperviscosity: effect in umbilical blood flow and fetal oxygen consumption.  Am J Obstet Gynecol . 1983;  147 48-51
    PubMedSearch in Google Scholar
  • 56 Saigal S, Usher R H. Symptomatic neonatal plethora.  Biol Neonate . 1977;  32 62-72
    PubMedSearch in Google Scholar
  • 57 Sacks M O. Occurrence of anemia and polycythemia in phenotypically dissimilar single ovum human twins.  Pediatrics . 1959;  24 604-608
    PubMedSearch in Google Scholar
  • 58 Schwartz J L, Maniscalco W M, Lane A T, Currao W J. Twin transfusion syndrome causing cutaneous erythropoiesis.  Pediatrics . 1984;  74 527-529
    PubMedSearch in Google Scholar
  • 59 Philip A GS, Yee A B, Rosy M. et al . Placental transfusion as an intrauterine phenomenon in deliveries complicated by fetal distress.  BMJ . 1969;  2 11-13
    PubMedSearch in Google Scholar
  • 60 Flod N E, Ackerman B D. Perinatal asphyxia and residual placental blood volume.  Acta Paediatr Scand . 1971;  60 433-436
    PubMedSearch in Google Scholar
  • 61 Yao A C, Lind J. Effect of gravity on placental transfusion.  Lancet . 1969;  2 505-506
    PubMedSearch in Google Scholar
  • 62 Oh W, Omori K, Emmanouilides G C, Phelps D I. Placenta to lamb fetus transfusion in utero during acute hypoxia.  Am J Obstet Gynecol . 1975;  122 316-321
    PubMedSearch in Google Scholar
  • 63 Humbert J R, Abelson H, Hathaway W E, Battaglia F C. Polycythemia in small for gestational age infants.  J Pediatr . 1969;  75 812-819
    PubMedSearch in Google Scholar
  • 64 Widness J A, Garcia J A, Oh W, Schwartz R. Cord serum erythropoietin values and disappearance rates after birth in polycythemic newborns (Abst).  Pediatr Res . 1982;  16 218A
    PubMedSearch in Google Scholar
  • 65 Philipps A F, Dubin J W, Matty P J, Raye J R. Arterial hypoxemia and hyperinsulinemia in the chronically hyperglycemic fetal lamb.  Pediatr Res . 1982;  16 653-658
    PubMedSearch in Google Scholar
  • 66 Rosenkrantz T S, Oh W. Neonatal polycythemia and hyperviscosity. In: Milunsky A, Friedman EA, Gluck L, eds. Advances in Perinatal Medicine, Vol 5. New York: Plenum Medical Book Co. 1986: 93-123
    Search in Google Scholar
  • 67 Hakanson D O, Oh W. Hyperviscosity in the small-for-gestational age infant.  Biol Neonate . 1980;  37 109-112
    PubMedSearch in Google Scholar
  • 68 Rawlings J S, Pettet G, Wiswell T E, Clapper J. Estimated blood volumes in polycythemic neonates as a function of birth weight.  J Pediatr . 1982;  101 594-599
    PubMedSearch in Google Scholar
  • 69 Brans Y W, Shannon D L, Ramamurthy R S. Neonatal polycythemia. II. Plasma, blood and red cell volume estimates in relation to hematocrit levels and quality of intrauterine growth.  Pediatrics . 1981;  68 175-182
    PubMedSearch in Google Scholar
  • 70 Thorton C J, Shannon D L, Hunter M A, Ramamurthy R S, Brans Y W. Body water estimates in neonatal polycythemia.  J Pediatr . 1983;  102 113-117
    PubMedSearch in Google Scholar
  • 71 Oh W, Wallgren G, Hanson J S, Lind J. The effects of placental transfusion on respiratory mechanics of normal term newborn infants.  Pediatrics . 1967;  40 6-12
    PubMedSearch in Google Scholar
  • 72 Scott F, Evans N. Distal gangrene in a polycythemic recipient fetus in twin-twin transfusion.  Obstet Gynecol . 1995;  86 677-679
    CrossrefPubMedSearch in Google Scholar
  • 73 Malan A F, de van Heese H. The management of polycythemia in the newborn infant.  Early Hum Dev . 1980;  4 393-403
    CrossrefPubMedSearch in Google Scholar
  • 74 Host A, Ulrich M. Late prognosis in untreated neonatal polycythemia with minor or no symptoms.  Acta Paediatr Scand . 1982;  71 629-633
    PubMedSearch in Google Scholar
  • 75 Leake R D, Thanopoulos B, Nieberg R. Hyperviscosity syndrome associated with necrotizing enterocolitis.  Am J Dis Child . 1975;  129 1192-1194
    PubMedSearch in Google Scholar
  • 76 Hakanson D O, Oh W. Necrotizing enterocolitis and hyperviscosity in the newborn infant.  J Pediatr . 1977;  90 458-461
    PubMedSearch in Google Scholar
  • 77 LeBlanc M H, D'Cruz C, Pate K. Necrotizing enterocolitis can be caused by polycythemic hyperviscosity in the newborn dog.  J Pediatr . 1984;  105 804-809
    PubMedSearch in Google Scholar
  • 78 Black V D, Rumack C M, Lubchenco L O, Koops B L. Gastrointestinal injury in polycythemic term infants.  Pediatrics . 1985;  76 225-231
    PubMedSearch in Google Scholar
  • 79 Herson V C, Raye J R, Rowe J C, Philipps A F. Acute renal failure associated with polycythemia in a neonate.  J Pediatr . 1982;  100 137-139
    PubMedSearch in Google Scholar
  • 80 Leake R D, Chan G M, Zakauddin S. et al . Glucose perturbation in experimental hyperviscosity.  Pediatr Res . 1980;  14 1320-1323
    PubMedSearch in Google Scholar
  • 81 Creswell J S, Warburton D, Susa J B. et al . Hyperviscosity in the newborn lamb produces perturbation in glucose homeostasis.  Pediatrics . 1981;  15 1348-1350
    PubMedSearch in Google Scholar
  • 82 Rosenkrantz T S, Philipps A F, Knox I. et al . Regulation of cerebral glucose metabolism in normal and polycythemic newborns.  J Cereb Blood Flow Metab . 1992;  12 856-865
    PubMedSearch in Google Scholar
  • 83 Rivers R PA. Coagulation changes associated with a high haematocrit in the newborn infant.  Acta Paediatr Scand . 1975;  64 449-456
    PubMedSearch in Google Scholar
  • 84 Katz J, Rodriquez E, Mandini G, Branson H E. Normal coagulation findings, thrombocytopenia, and peripheral hemoconcentration in neonatal polycythemia.  J Pediatr . 1982;  101 99-102
    PubMedSearch in Google Scholar
  • 85 Henriksson P. Hyperviscosity of the blood and haemostasis in the newborn infant.  Acta Paediatr Scand . 1979;  68 701-704
    PubMedSearch in Google Scholar
  • 86 Shaikh B S, Erslev A J. Thrombocytopenia in polycythemic mice.  J Lab Clin Med . 1978;  92 765-771
    PubMedSearch in Google Scholar
  • 87 Jackson C W, Smith P J, Edwards C C, Whidden M A. Relationship between packed cell volume, platelets and platelet survival in red blood cell-hypertransfused mice.  J Lab Clin Med . 1979;  94 500-509
    PubMedSearch in Google Scholar
  • 88 Meberg A. Transitory thrombocytopenia in newborn mice after intrauterine hypoxia.  Pediatr Res . 1980;  14 1071-1073
    PubMedSearch in Google Scholar
  • 89 Voorhies T M, Lipper E G, Lee B CP. et al . Occlusive vascular disease in asphyxiated newborn infants.  J Pediatr . 1984;  105 92
    PubMedSearch in Google Scholar
  • 90 Peters M, ten Cate W J, Koo L H, Breederveld C. Persistent antithrombin III deficiency: risk factor for thromboembolic complication in neonates small for gestational age.  J Pediatr . 1984;  105 310-314
    PubMedSearch in Google Scholar
  • 91 Merchant R H, Agarwal M B, Joshi N C, Parekh S R. Neonatal polycythemia-a potentially serious disorder.  Indian J Pediatr . 1983;  50 149-152
    PubMedSearch in Google Scholar
  • 92 Amit M, Camfield P R. Neonatal polycythemia causing multiple cerebral infarcts.  Arch Neurol . 1980;  37 109-110
    PubMedSearch in Google Scholar
  • 93 Goldberg K, Wirth F H, Hathaway W E. et al . Neonatal hyperviscosity. II. Effect of partial plasma exchange transfusion.  Pediatrics . 1982;  69 419-425
    PubMedSearch in Google Scholar
  • 94 Black V D, Lubchenco L D, Luckey D W. et al . Developmental and neurologic sequelae of neonatal hyperviscosity syndrome.  Pediatrics . 1982;  69 426-431
    PubMedSearch in Google Scholar
  • 95 Black V D, Lubchenco L O, Koops B L, Poland R L, Powell D P. Neonatal hyperviscosity: randomized study of effect of partial plasma exchange on long-term outcome.  Pediatrics . 1985;  75 1048-1053
    PubMedSearch in Google Scholar
  • 96 Black V D, Camp B W, Lubchenco L O. et al . Neonatal hyperviscosity is associated with lower achievement and IQ scores at school age (Abst).  Pediatr Res . 1988;  23 442A
    PubMedSearch in Google Scholar
  • 97 Bada H S, Korones S B, Pourcyrous M. et al . Asymptomatic syndrome of polycythemic hyperviscosity: effect of partial plasma exchange transfusion.  J Pediatr . 1992;  120 579-585
    PubMedSearch in Google Scholar
  • 98 Supapannachart S, Siripoonya P, Boonwattanasoontorn W, Kanjanavanit S. Neonatal polycythemia: effects of partial exchange transfusion using fresh frozen plasma, Haemaccel and normal saline.  J Med Assoc Thai . 1999;  82 (suppl 1) S82-S86
    PubMedSearch in Google Scholar
  • 99 Wong W, Fok T F, Lee C H. 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;  77 F115-F118
    CrossrefPubMedSearch in Google Scholar
  • 100 Glader B. Erythrocyte disorders in infancy. In: Schaffer AJ, Avery ME, eds. Diseases of the Newborn Philadelphia: WB Saunders 1977: 625
    Search in Google Scholar
  • 101 American Academy of Pediatrics Committee on Fetus and Newborn. Routine evaluation of blood pressure, hematocrit, and glucose in newborns.  Pediatrics . 1993;  92 474-476
    PubMedSearch in Google Scholar