Archives of Disease in Childhood 1994; 70: F182-F187

Effect of fresh frozen plasma and gammaglobulinon humoral immunity in neonatal sepsis

B A Acunas, M Peakman, G Liossis, E T Davies, B Bakoleas, C Costalos, H R Gamsu,D Vergani

AbstractFresh frozen plasma and intravenousimmunoglobulin are used as prophylaxisagainst, and for the treatment of, neonatalinfection. It is assumed that any beneficialeffect is mediated through the humoralimmune factors contained in eachpreparation. The effect of fresh frozenplasma and intravenous immunoglobulinon humoral immune markers (immuno-globulins and IgG subclasses, com-plement components and activationproducts, and C reactive protein) wasinvestigated over a 24 hour period aftertheir randomised administration to 67infants with suspected infection. Thirtyinfants without suspicion ofinfection werestudied as controls. Compared withcontrol infants, infants with suspectedinfection had increased concentrations ofC reactive protein, reduced concentra-tions of fibronectin, and increased con-centrations of the complement activationmarker C3d, but similar concentrations ofIgG, IgG subclasses, IgA, and IgM. Afterintravenous immunoglobulin treatment(500 mg/kg) concentrations of total IgGand all IgG subclasses increased, as didIgA and complement component C4.Concentrations of C reactive proteindecreased after intravenous immuno-globulin treatment and were significantlylower than baseline after 24 hours. In con-trast, no change in IgG or IgG subclassconcentrations occurred after fresh frozenplasma administration. At 24 hours afterfresh frozen plasma administration, con-centrations of IgA, IgM, and C4 weresignificantly higher than baseline andserum IgA was significantly higher than ininfants tested 24 hours after intravenousimmunoglobulin treatment. These resultsconfirm the rational basis for intravenousimmunoglobulin treatment but questionthe value of fresh frozen plasma, particu-larly in the light of its attendant problemsas an untreated blood product.(Arch Dis Child 1994; 70: F182-F187)

Numerous humoral deficiencies in term andpremature neonates seem to be crucial con-tributory factors to the increased susceptibilityto infection seen at this age. These include lowconcentrations of IgG in preterm infants dueto lack of placental transfer,1 2 deficiency ofpathogen specific IgG such as antibody to

group B streptococci,3 deficiency of IgGsubclasses,4 decreased concentrations of cir-culating complement factors,5 and decreasedconcentrations of circulating fibronectin.6 Inthe last decade various studies have beenundertaken in an attempt to show an enhance-ment of the neonatal host defence mechanismby the use of granulocyte transfusions,7therapeutic exchange transfusions, and intra-venous immunoglobulins. Among theseimmunotherapeutic strategies, intravenousimmunoglobulin has been widely usedprophylactically, especially in very low birth-weight neonates given single or repeated dosesand as an adjunctive treatment in patientswith sepsis; this treatment has been shownto result in improved survival.8-14 In addition,fresh frozen plasma is widely used as aputative source of immunoglobulins andcomplement factors to provide an adjunctivetreatment in the management of neonatalsepsis.'5 There have been no studies todetermine whether fresh frozen plasma hasany effect on components of the neonatalimmune system, however. The aim of thisstudy was to determine the effect of freshfrozen plasma on the major components ofneonatal humoral immunity such asimmunoglobulins, complement factors, andfibronectin, and to compare these with theeffect if intravenous immunoglobulin on thesame factors.

Subjects and methodsSUBJECTSBetween February 1991 and March 1993 twoneonatal centres participated in this study; theneonatal unit of the general hospital in Piraeus,Greece and the Children Nationwide RegionalNeonatal Centre of King's College Hospital,London. Newborn infants with 'possible' or'probable' infection who fulfilled theclinical/laboratory criteria for these diagnosesas described previously'6 were enrolled.Neonates with severe congenital malforma-tions, viral embryopathy, and those in whomdeath was considered inevitable wereexcluded. Previous treatment of the motherwith antibiotics did not exclude entry of infantsinto the study. Infants were enrolled into thestudy when they had their first suspectedepisode of infection. After written informedconsent was obtained from their parents, theinfants were randomly assigned to receiveeither fresh frozen plasma or intravenousimmunoglobulin using a sealed envelope

Department ofImmunology andChildren NationwideRegional NeonatalCentre of King'sCollege Hospital,LondonB A AcunasM PeakmanE T DaviesH R GamsuD Vergani

Neonatal Unit of theGeneral Hospital,Piraeus, GreeceG LiossisB BakoleasC Costalos

Correspondence to:Dr Mark Peakman, King'sCollege School of Medicineand Dentistry, BessemerRoad, London SE5 9PJ.Accepted 16 December 1993

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Table 1 Demographic data for infants treated with fresh frozen plasma (FFP) and intra-venous immunoglobulin (IVIG), and infants in the control group

FFP group IVIG group Control group(n=34) (n=33) (n=30)

Mean (SEM) gestational age (weeks)Mean (SEM) birth weight (g)Male (%)Mean (SEM) postnatal age (days)Premature (%/o)Possible infection (/)Probable infection (%)Proved infection (%)Mean (SEM) leucocyte count (X 109/1)Mean (SEM) neutrophil count (x 109/1)Mean (SEM) platelet count (x 109A/)No of deaths

34 (4 82)1990 (880)*

619 1 (10-3)7041581513-36 (7 20)7-47 (4 69)

345 (443)3

35-21 (4-41)2410 (980)

757-4 (7*7)

5145543013-46 (7-78)831 (547)

278 (142)3

35-63 (3-19)2050 (680)

5310-2 (10-6)60

11-13 (5-16)8-64 (5-72)

318 (146)None

tube, and umbilicus, and similarly cultureswere made ofbody fluids (blood, cerebrospinalfluid, urine, and gastric aspirate). Blood wasalso taken for haemoglobin concentration,leucocyte and platelet counts, and leucocytedifferential. Infection was considered proved ifblood or cerebrospinal fluid cultures werepositive or cultures from urine or from morethan two swab sites were 3+ positive (definedas heavy confluent growth after overnightculture) with a pure growth of a singleorganism.

*p<0.05 compared with IVIG group.

method within one to six hours of the develop-ment of clinical signs of infection. In an

attempt to provide an equal distribution ofpremature (<37 weeks' gestation) and terminfants (>37 weeks' gestation), two sets ofsealed envelopes were used (one for preterm,one for term infants). A group of infants with-out suspicion of infection and matched for age,birth weight, and gestational age was con-

currently enrolled as the control group. It wasconsidered unethical to include a placebogroup when neonatal infection was suspected.The study was approved by the research ethicscommittee of Camberwell Health Authority,London and the ethical committee of PiraeusGeneral Hospital.

Fresh frozen plasma compatible with theblood group of the infant to be transfused was

supplied from the appropriate blood bank andhad been screened serologically for hepatitis B,cytomegalovirus, and HIV. The intravenousimmunoglobulin used in this study (Sando-globulin, from Sandoz Pharmaceuticals manu-

factured by the Central Laboratory, Swiss RedCross, Berne, Switzerland) was lyophilisedhuman normal immunoglobulin (3 g/100 mlvial with 5% sucrose). Three lots ofSandoglobulin (lot numbers 032623120,23652370, 23652000) were used in the study.Fresh frozen plasma (15 ml/kg body weight) or

Sandoglobulin (500 mg/kg body weight) was

infused through a peripheral intravenouscatheter, avoiding mixing with other solutionsor drugs. The infusion rate was 0-02ml/kg/minute initially and thereafter this wasincreased every 15 minutes to a maximuminfusion rate of 0-15 ml/kg/minute. Before theinfusion of fresh frozen plasma patients withsuspected necrotising enterocolitis were

screened with a specific agglutination testusing peanut lectin derived from Arachishypogea to detect T cell activation.17 None ofthe infants studied was positive on testing forT antigen activation. During the infusion, vitalsigns (heart rate, respiratory rate, bodytemperature, and blood pressure) were closelymonitored as well as signs of adverse reactionssuch as flushing, fever, emesis, restlessness,and irritability.

All infants with suspected infection (possibleor probable) were screened microbiologicallyusing microscopy and culture examination ofswabs taken from the ear, nose, endotracheal

DEMOGRAPHIC DATASeventy seven infants with suspected infectionwere initially randomised into the study. Tenof these were excluded because of previoustreatment with fresh frozen plasma or becausethey received fresh frozen plasma during thesampling period after having been transfusedwith intravenous immunoglobulin. Thirtyinfants without suspicion of infection wereenrolled as the control group. Table 1 givesthe demographic and laboratory/clinical dataon these infants and on the 67 with suspectedinfection. There was no significant differencein the fresh frozen plasma, intravenousimmunoglobulin, and control groups withrespect to gestational age, postnatal age, andsex (table 1). There was, however, a smalldifference in birthweight between the freshfrozen plasma and intravenous immuno-globulin groups (p=004). The treated groupshad a similar distribution of possible orprobable infection. Twenty five patients (15(44%) of the 34 fresh frozen plasma recipientsand 10 (30%) of the 33 intravenous immuno-globulin recipients) had proved infection.Nine infants were infected with Escherichia coli(five fresh frozen plasma, four intravenousimmunoglobulin), five with Staphylococcus epi-dermidis (three fresh frozen plasma, two intra-venous immunoglobulin), four withStaphylococcus aureus (four fresh frozenplasma, one intravenous immunoglobulin),three with Lancefield group B streptococcus(two fresh frozen plasma, one intravenousimmunoglobulin), two with enterobacter (onefresh frozen plasma, one intravenous immuno-globulin), one with citrobacter (fresh frozenplasma), and one with Kiebsiella pneumoniae(intravenous immunoglobulin). Four of theseinfants were diagnosed as having proved infec-tion on the basis of 3+ positive superficialswabs. One receiving fresh frozen plasma hada pure growth of Lancefield group B strepto-coccus from the nose, ear, umbilicus, gastricaspirate samples, and a maternal high vaginalswab was 3+ positive for the same organism.In the other three infants (all receivingintravenous immunoglobulin), 3+ positivecultures with pure growth of E coli, citro-bacter, and Lancefield group B streptococcuswere obtained from the nose, ear, umbilicus,and gastric aspirate samples. In two ofthese infants cord blood samples were alsoculture positive, and in the other infantendotracheal tube secretions were culturepositive.

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Table 2 Effect offresh frozen plasma (FFP) and intravenous immunoglobulin (IVIG) infusions on plasma concentra-tions of complement factors, fibronectin, and C reactive protein. Values are median (range)

C3d C3 C4 Fibronectin C reactiveGroup (AU/i) (gil) (gil) (mg/i) protein (mg/i)

FFP groupBaseline 615 (40-4100) 0-64 (0-31-1-25) 0-16 (0 04-050) 156 (68-447)t 11-4 (06-280)tAfter 12 hours 555 (40-7040) 0-68 (0-11-1-16) 0-18 (0-03-0-35) 135 (75-542) 17-1 (06-246)After 24 hours 712 (40-5080) 0 73 (0-33-1-28) 0-26 (0-07-1-08)§ ND 19 1 (0 6-249)

IVIG groupBaseline 625 (44-8000)* 0 76 (0-35-1-23)t 0-17 (0-07-0-39) 148 (92-273)t 24-1 (06-253)tAfter 12 hours 357 (680-5200) 0 72 (0 35-1 32) 0 17 (0-06-0 38) 201 (20-497) 9-0 (0-6-128)§After24 hours 532 (78-6640) 0-78 (0-40-1-31) 0 19 (0 09-0 90)§ ND 7-2 (06-88 6)¶

Normal infants 291 )10-3220) 0-60 (0-23-1-08) 0-18 (0 05-0 42) 218 (114-148) 0 7 (0 60-10-2)

ND=Not done; AU/i=arbitrary units/I.*p<0-01 v normal infants; tp<0-0005 v normal infants; tp<000001 v normal infants; §p<005 v baseline; ¶p<0O01 v baseline.

No differences were observed between freshfrozen plasma and intravenous immuno-globulin recipients with respect to initialleucocyte, neutrophil, and platelet counts(table 1). There were three deaths in the freshfrozen plasma treated group: one from group Bstreptococcal septicaemia, severe respiratorydistress syndrome, and grade IV intraventricu-lar haemorrhage two days after enrolment intothe study; one from S aureus septicaemia, alsotwo days after enrolment; and the thirddied 30 days after enrolment due to severebronchopulmonary dysplasia. Similarly, therewere three deaths in the intravenous immuno-globulin treated group: one from enterobactersepticaemia on day 9; one from ventricularseptal defect and congestive heart failure onday 10; and one from candida septicaemiaafter two months. No adverse effects wereobserved with either treatment during or afterinfusion.

MEASUREMENT OF COMPONENTS OF HUMORALIMMUNITYSpecimens of 1 ml blood in 10 mmol EDTAand samples from the fresh frozen plasma to betransfused into the infants were collectedimmediately before the administration of eitherfresh frozen plasma or intravenous immuno-globulin and from the control group fromwhom blood was being taken for managementpurposes. A 1 ml blood sample from thetreated infants was also drawn into EDTAat 12 and 24 hours after treatment. Plasmawas separated by centrifugation and storedat -700C. Immunoglobulin classes Aand M, intact complement components C3and C4, C reactive protein, and fibronectinwere measured by nephelometry accordingto the manufacturer's instructions (BehringDiagnostics, Hounslow, Middlesex). TotalIgG and IgG subclasses were measured bynephelometry using kits supplied by TheBinding Site, Birmingham.

All assays were carried out by investigatorswho were unaware of the clinical details.Insufficient plasma was available for all teststo be performed at each time point thereforeIgG subclasses, total IgG, and fibronectinwere measured only on the first (preinfusion)and second (at 12 hours after infusion)samples.

Concentrations of the complement activa-tion product C3d were determined by an

enzyme linked immunosorbent assay (ELISA)using a commercial source of unlabelled andperoxidase labelled antibody to C3d (Dako,High Wycombe) as previously described.18

STATISTICAL ANALYSISComparability of the demographic data of thefresh frozen plasma, intravenous immuno-globulin treated, and control groups onenrolment was assessed using Student's t test.The distribution of concentrations ofimmuno-globulins, C3, C4, C reactive protein, fibro-nectin, and C3d did not fit the hypothesis ofnormality as assessed by the Kolmogorov-Smirnov goodness of fit test. Values weretherefore expressed as medians (range) andcomparisons between groups were performedusing the Mann-Whitney U test. Changes inanalytes after treatment at 12 and 24 hourswere compared using the Wilcoxon signedrank test for matched pairs. All analyseswere performed using the Statistical Packagefor the Social Sciences (SPSS-X) of theUniversity of London Computer CentreAmdahl 5980/300. A two tailed p value lessthen 0 05 was considered to indicate asignificant difference.

ResultsCONCENTRATION OF MARKERS OF HUMORALIMMUNITY AT ENTRYSamples from the fresh frozen plasma andintravenous immunoglobulin treatment groupstaken at the time of the study showed that con-centrations of C reactive protein were signifi-cantly higher (p<00001 for the two groups)and concentrations of fibronectin significantlylower (p<0 005) than in the control group(table 2). In the intravenous immunoglobulintreated group, concentrations of C3 and C3dwere significantly increased compared withcontrol subjects (p<0005 and p<001).Concentrations of IgG and its subclasses, IgA,IgM, and C4 were similar in the treated andcontrol groups. Levels of all parameters weresimilar in the two treatment groups.

CHANGES IN MARKERS OF HUMORAL IMMUNITYAFTER FRESH FROZEN PLASMA TREATMENTA significant increase in concentrations of IgMand IgA was seen 12 hours after fresh frozenplasma treatment (p<0005 and p<0 01)

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Table 3 Effect offresh frozen plasma (FFP) and intravenous immunoglobulin (IVIG) infusions on plasma concentrations of immunoglobulins. Valuesare median (range)

IgG, IgG2 IgG3 IgG4 Total IgG IgM IgAGroup (g/l) (gil) (g/l) (gil) (g/l) (gil) (g/l)

FFP groupBaseline 3-85 (1-58-8-46) 1-31 (0-54-437) 0-35 (0-18-0-75) 0-23 (0-08-0-91) 6-13 (2-94-11-40) 0-14 (0-09-0-96) 0-07 (0-07-1-52)After 12 hours 3-73 (1-91-11-10)** 1-32 (0-70-2-81)** 0-35 (0-08-0-72)11 0-22 (0-09-0-94)1 6-38 (3-17-11-40)** 0-22 (0-09-0-61)t 0-17 (0-07-0 60)4After 24 hours ND ND ND ND ND 0-26 (0-10-0-83)t 0-16 (0-07-0 44)4

IVIG groupBaseline 4-04 (2 09-9 34) 1-23 (0-643-45) 0-32 (0-12-0-82) 0-18 (0-07-0-81) 6-04 (2-66-13-70) 0-16 (0-09-1-12) 0 07 (0 07-0 55)After 12 hours 6-63 (3-81-11-10)§ 2-55 (1-834-18)§ 0-52 (0-21-1-24)§ 0-32 (0-140-33)§ 10-80 (6-57-16-80)§ 0-17 (0-09-1-14) 0-08 (0-07-0-51)tAfter 24 hours ND ND ND ND ND 0-20 (0-09-1-12) 0 07 (007-0 49)*tt

Normal infants 3-82 (1-59-8-11) 1-12 (0 40-2 79) 0 55 (0-12-0-95) 0-21 (0-08-0 57) 5 30 (2-25-10-90) 0-22 (0 09-0-53) 0 07 (0 07-0 23)

ND=not done.*p<0 05 v baseline; tp<0-01 v baseline; tp<0 005 v baseline; §p<0-0001 v baseline; Tp<005 v IVIG group; Ilp<0-001 v IVIG group;**p<-000Ol v IVIG group; ttp<0005 v FFP group.

compared with baseline (table 3). At 24 hoursconcentrations of IgM and IgA remainedincreased compared with baseline (p<0001for the two groups) and C4 was significantlyhigher than the pretreatment concentration(p<005). There was no change in the othermarkers of humoral immunity after freshfrozen plasma treatment.

CHANGES IN MARKERS OF HUMORAL IMMUNITYAFTER INTRAVENOUS IMMUNOGLOBULINTREATMENT

A significant increase in total IgG and in allfour IgG subclasses (p<0O0001 for all) andalso in IgA (p<0005) was seen 12 hours afterthe start of intravenous immunoglobulin treat-ment compared with baseline (table 3).Concentrations of total IgG and IgG sub-classes were not measured at 24 hours but con-

centrations of IgA remained significantlyincreased compared with baseline at thistime (p<005). Concentrations of C4 were

increased at 24 hours compared with baseline(p<005). Concentrations of C reactiveprotein did not change in the first 12 hoursafter treatment, but decreased significantlyin the second 12 hours (p<005). At 24 hoursC reactive protein concentrations were

significantly lower than before treatmentstarted (p<0-01). There was no change in theother markers of humoral immunity afterintravenous immunoglobulin.

COMPARISON OF FRESH FROZEN PLASMA AND

INTRAVENOUS IMMUNOGLOBULIN TREATEDGROUPS

At 12 hours after the start of treatment con-

centrations of total IgG and IgG subclasseswere significantly higher in the intravenousimmunoglobulin than in the fresh frozenplasma treated group (p<0-0001 for total IgG,IgG1, and IgG2; P<0001 for IgG3; andp<005 for IgG4) (table 3). At 24 hours afterthe start of treatment, concentrations of IgAwere significantly higher in the fresh frozenplasma than in the intravenous immuno-globulin treated group (p<005).

CHANGES IN MARKERS OF HUMORAL IMMUNITYIN PRETERM INFANTSTo examine whether changes in humoralmarkers after treatment with fresh frozen

plasma or intravenous immunoglobulin weredifferent in more than in less mature infants,treatment groups were divided according togestational age (<35 v -35 weeks). Overall,infants <35 weeks' gestation and those 2,35weeks have similar results to those of the groupas a whole. There were some small differences,however. In the fresh frozen plasma treatedgroup, C4 concentrations were higher at 24hours than at baseline (p<005), but only ininfants <35 weeks' gestation. In addition,though concentrations of IgA did not changewithin the first 12 hours after fresh frozenplasma treatment in infants <35 weeks'gestation, concentrations at 24 hours weresignificantly higher than at baseline (p<0-05).In contrast, in infants 335 weeks' gestation,IgA concentrations increased at 12 hours andremained increased compared with baseline(p<0O005 and p<0 05).

In the intravenous immunoglobulin treatedgroup changes seen in infants <35 weeks'and -35 weeks' gestation were identical toeach other and to those seen in the undividedgroup.

LEVELS OF HUMORAL MARKERS PRESENT INFRESH FROZEN PLASMA AND INTRAVENOUSIMMUNOGLOBULINTable 4 gives the concentrations of IgM, IgA,IgG, IgG subclasses, C reactive protein, C3,C4, C3d, and fibronectin in fresh frozenplasma and intravenous immunoglobulin.

DiscussionSupplementation of the circulating proteins ofneonates prophylactically or after the diagnosis

Table 4 Humoral immune markers in fresh frozen plasmaand intravenous immunoglobulin. Values are median(range)

Freah frozen Intravenousplasma immunoglobulin

IgG, (g/l) 5s66 (3-90-7-94) 18 10IgG2 (g/l) 2 63 (1-46-513) 8 90IgG3 (g/l) 0 53 (0-32-1 28) 1 20IgG4 (g/l) 0-44 (0-14-0-88) 0-70Total IgG (g/l) 9 22 (6 91-12 20) 29 01IgM (gll) 0-83 (0 31-1 96) 0 02IgA (g/1) 1 24 (0.07-3 19) 0 66C3d (AU/1) 330 (84-3260) NDC3 (g/l) 0-08 (0-04-1 21) NDC4 (g/l) 0 22 (0 14-0 48) NDFibronectin (mg/I) 423 (88-817) ND

ND=not done.

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of suspected infection is carried out with theaim of enhancing humoral immunity. Thereare two main sources of humoral immunecomponents in current use: fresh frozenplasma and immunoglobulin. Few studies,however, have addressed the question of theefficacy of intravenous immunoglobulin inproviding humoral immune components, andnone the role of fresh frozen plasma. In thisstudy we showed that intravenous immuno-globulin treatment increases circulating con-centrations of all IgG subclasses, as well asincreasing IgA and complement C4 concentra-tions. C reactive protein, a marker of infectionin neonates, decreased in the immunoglobulintreated group. In contrast, the administrationof fresh frozen plasma had no effect on IgGantibody levels, but resulted in increasedconcentrations of circulating IgA, IgM, andC4. These results confirm the rational basis forintravenous immunoglobulin treatment butquestion the value of fresh frozen plasma,particularly in light of its attendant problems asan untreated blood product.

Efficient phagocytosis and killing of patho-genic organisms by neutrophils only occursafter antibody, complement, and fibronectinproteins are deposited on the surface ofbacteria.19 In this respect, neonatal hostdefences provide inadequate host protectionbecause concentrations of these opsonins arelow.1 3-6 Fresh frozen plasma contains thelabile as well as the stable components ofthe coagulation, fibrinolytic, and complementsystems, and humoral components of im-munity such as immunoglobulins and fibro-nectin.20 Fresh frozen plasma should thereforebe effective in supplementing humoralmechanisms of neonatal host defence. Thisstudy did not show a beneficial effect of freshfrozen plasma on humoral immunity inneonates, however, other than increasing theconcentrations of IgA, IgM, and C4. Thesignificance of increasing circulating IgA isquestionable as IgA functions predominantlyas secreted antibody at mucosal surfaces.Infusion of intravenous immunoglobulincaused a significant increase in total IgG andall its subclasses. This confirms a previousreport by Christensen et al,10 which also didnot show any effect of intravenous immuno-globulin on C3 24 hours after infusion.

Baseline plasma concentrations of C3d andC reactive protein were significantly higher inpatients with suspected infection than in thecontrol group in our study, confirming our pre-vious report.16 C reactive protein is an opsoninand acts as an acute phase reactant, concentra-tions increasing during inflammatory episodes.C3d, on the other hand, is a breakdownproduct of C3 and is presumably generated inthese infants as a result of complementactivation occurring on the bacterial surface. Creactive protein concentrations decreased afterintravenous immunoglobulin, possibly as aresult of confinement of the bacterial infectionand limitation of the release of cytokines whichprovoke the release of acute phase reactants.No changes in C3d and C reactive protein wereseen after treatment with fresh frozen plasma.

Most of our patients with suspectedinfection had low plasma concentrations offibronectin, which acts as a negative acutephase reactant during infection.6 Fibronectinconcentrations did not change after infusionwith either fresh frozen plasma or immuno-globulin, in contrast with the study of Caliouliet al.21

Comparing the concentrations of humoralimmune components in fresh frozen plasmaand immunoglobulin, it is apparent that thehigher IgG content in the latter is responsiblefor the significant increase in total IgG and itssubclasses. To achieve the concentrations ofIgG provided by immunoglobulin, an infusionof 30-50 ml/kg of fresh frozen plasma would berequired, an unacceptable volume in theseinfants.

Although it has been suggested thatintravenous immunoglobulin treatment ismore beneficial in infants of less than 34weeks' gestation and less than 1500 g birthweight,8 9 13 we did not observe any differencein the effects of intravenous immunoglobulinon markers of humoral immunity in verypreterm infants compared with those of oldergestational age. We are aware of only oneprevious study of the effects of fresh frozenplasma on the immune function in neonates.22This study suggested that fresh frozen plasmaenhances neonatal neutrophil motility byproviding complement and fibronectin, facili-tating movement of these cells to sites of infec-tion.22 The study did not include controlsubjects, however, and although the enhance-ment of neutrophil motility was attributed tocomplement factors and fibronectin in thefresh frozen plasma, these components werenot measured. To our knowledge, our study isthe first to show that there are few effects onhumoral immunity after fresh frozen plasmaadministration in neonates, and those changesthat occur are of questionable benefit to thehost.

Despite the paucity of definitive indicationsfor its use, the administration of fresh frozenplasma has increased in recent years.20 2324Although well defined indications exist for theuse of fresh frozen plasma in single or multiplecoagulation deficiencies, indications for manyof its other uses are empirical.20 A study byStrauss et al surveying neonatal transfusionpractices showed that most respondents (77%)transfused fresh frozen plasma appropriately- that is, primarily to treat coagulationdisorders.15 Eight per cent, however, statedthat their most frequent use of fresh frozenplasma was solely to treat sepsis,15 a practicequestioned by the results of this study. The keyopsonins contained in antibody of the IgGclass do not appear to be administered usingfresh frozen plasma. More importantly, freshfrozen plasma, despite donor selection andscreening procedures, still carries the risk ofviral transmission because the process ofpreparation does not eliminate or inactivateviral contaminants.20 This complication isless likely with intravenous immunoglobulinwhich uses ethanol fractionation for viralinactivation. 19

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The results of this study suggest that freshfrozen plasma treatment is less effective thanintravenous immunoglobulin for the provisionof components ofhumoral immunity which areimportant in neonatal infection. The optimumdose, administration time and dosage intervals,potential toxicity, and clinical relevance ofeither treatment remain to be clarified. Inaddition, for the potentially infected neonate,alternative means of achieving improvedimmunity need to be studied. These mightinclude cytokine treatment aimed at increasinggranulocyte production and function, or

fibronectin treatment to foster neutrophiladherence and opsonisation. These methodsmight profitably be combined with immuno-globulin treatment, but not, it seems, withfresh frozen plasma.

1 Gitlin D, Kumate J, Urrusti J, Morales C. The selectivity ofhuman placenta in the transfer of plasma proteins fromthe mother to fetus. Clin Invest 1964; 43: 1938-51.

2 Sidiropoulos D, Herrman U, Morell A, von Muralt G,Barandun S. Transplacental passage of intravenousimmunoglobulin in the last trimester of pregnancy. JfPediatr 1986; 109: 505-8.

3 Baker CJ, Kasper DL. Correlation of maternal antibodydeficiency with susceptibility to neonatal group B strepto-coccal infection. NEnglJMed 1976; 294: 735-6.

4 Einhorn MS, Granoff DM, Nahm MH, Quinn A,Shackelford PG. Concentrations of antibodies in pairedmaternal and inifant sera: relationship to IgG subclasses. JfPediatr 1987; 111: 783-8.

5 Notarengelo LD, Chirico G, Chiara A, et al. Activity of clas-sical and alternative pathways of complement in pretermand small for gestational age infants. Pediatr Res 1984; 18:281-5.

6 Gerdes JS, Yoder MC, Douglas SD, Polin RA. Decreasedplasma fibronectin in neonatal sepsis. Pediatrics 1983; 72:877-81.

7 Cairo MS, Worcester C, Rucker R, et al. Role of circulatingcomplement and polymorphonuclear leucocyte transfu-sion in treatment and outcome in critically ill neonateswith sepsis. _J Pediatr 1987; 110: 935-41.

8 Baker CJ, Rench MA, Noya FJD, Garia-Prats JA. Role ofintravenous immunoglobulin in prevention of late onsetinfection in low birthweight neonates. Rev Infect Dis 1990;12: S463-8.

9 Chirico G, Rondini G, Plebani A, Chiara A, Massa M,Ugazio AG. Intravenous gammaglobulin therapy for pro-phylaxis of infection in high-risk neonates. Jf Pediatr 1987;110: 437-42.

10 Christensen RD, Brown MS, Hall DC, Lassiter HA, HillHR. Effect on neutrophil kinetics and serum opsoniccapacity of intravenous administration of immune globu-lin to neonates with clinical signs of early-onset sepsis. JfPediatr 1991; 118: 606-14.

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