Sue Pace asks for input about a baby who sustained a significant loss of
blood volume from a cord rupture. The loss is evidenced by the baby's low
hemoglobin levels from birth onward, the latest known value at 19 days of
age being 10.0  or 100, depending on the units used.  Hemoglobin values in
babies of that age who have not experienced early clamping of the cord, are
commonly 25 to 50% higher than that.  Imagine how most of us would cope with
the sudden loss of a third of our red blood cells - and we are fully grown,
not in the most rapid period of growth and development in our extrauterine
lives.

If the baby is clinically OK, i.e. growing and thriving, feeding well, and
not showing signs of cardiac stress, and the pediatrician agrees, then I
would feel ok waiting a week or two for a new check, but not longer than
that. Remember, a baby this age is meant to grow, and needs iron to make
more and more erythrocytes.  The other thing going on in a baby this young
is that the fetal erythrocytes, which are much more short-lived, are still
dying off, so the hematocrit and hemoglobin values always drop in the first
few weeks from whatever level they were at birth. The hemoglobin in old
erythrocytes is recycled to a large degree, but having lost a significant
blood volume means that this baby doesn't have the same stores s/he would
have been born with otherwise, and may well need iron from an external
source before the second six months of life.
  
A baby who is anemic enough to be showing clinical signs of it, such as
exhaustion on feeding to the point of not being able to take in enough to
grow on, or an abnormally rapid resting pulse, or any one of a number of
signs of iron deficiency anemia, can not be treated as though it is healthy,
no matter how purely exclusively breastfed it is.  Some places might have
given such a baby a blood transfusion at birth, depending on what local
neonatology culture dictates.  Most places would likely recommend early
supplementation. In the event that the parents prefer to watch and wait, the
only responsible thing to do IMO is to make a careful plan for how best to
do that.  It could be that supplementation could be given intermittently, too.
Rachel Myr
Kristiansand, Norway

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