Journal of Clinical Neuroscience xxx (2014) xxxxxx

Contents lists available at ScienceDirect

Journal of Clinical Neuroscience

journal homepage: www.elsevier.com/locate/jocn

Review

Neuroprotection with erythropoietin in preterm and/or low birth weight

infants
Jie Zhang, Qiuxia Wang, Hong Xiang, Yue Xin, Ming Chang, Hongyan Lu
Department of Pediatrics, The Afliated Hospital of Jiangsu University, 438 Jiefang Road, Zhenjiang 212001, Jiangsu Province, PR China

a r t i c l e

i n f o

Article history:
Received 5 July 2013
Accepted 27 October 2013
Available online xxxx
Keywords:
Brain injury
Erythropoietin
Low birth weight infants
Neonates
Neurodevelopmental outcome

a b s t r a c t
Neonatal brain injury caused by extreme prematurity remains a great challenge for prevention. Erythropoietin (EPO) has shown neuroprotective effects in a series of neonatal experimental models and recent
clinical trials of premature infants. In this meta-analysis of seven clinical trials, EPO was associated with a
highly reproducible reduction in the risk of neurodevelopmental disability in preterm infants. However,
there was no difference in the risk for morbidity, cerebral palsy, visual decit, severe hearing decit, necrotizing enterocolitis, intracranial hemorrhage and patent ductus arteriosus. The use of EPO, to some
extent, is associated with reduction in neurodevelopmental disability in preterm infants. More double
blind randomized controlled trials are needed to establish the best therapeutic approach for neuroprotection in preterm infants.
2014 Elsevier Ltd. All rights reserved.

1. Introduction
Preterm birth rates have been reported to range from 5% to 7%
of live births in some developed countries, but are estimated to be
substantially higher in developing countries [1]. These gures appear to be rising [2]. Children who are born prematurely have a
high risk of neurodevelopmental delay [3,4]. Neurodevelopmental
impairment (neurosensory abnormality including cerebral palsy,
deafness, blindness, and/or Mental Developmental Index score of
<70) is present in 36% to 48% of survivors [5,6]. These decits impart a signicant burden to the children, their families, and society.
Given the high incidence of survival with neurodevelopmental sequelae, physicians have been searching for effective strategies to
prevent or minimize the long-term consequences of neonatal brain
injury of prematurity.
Erythropoietin (EPO), which was originally identied for its role
in erythropoiesis, has been used to treat a number of anemic states,
including early and late anemia of prematurity [7,8]. Surprisingly,
neuroprotection with EPO has also been documented in spinal cord
injury, traumatic brain injury, ischemic stroke, and perinatal
asphyxia [9].
Successful pilot studies suggested that EPO was both feasible
and broadly safe in neonates, supporting further randomized trials.
The primary objective of this systematic review was to evaluate

the efcacy and safety of EPO used for neuronal development protection, including results from recent trials.

2. Methods
2.1. Studies
For this review, both randomized and quasi-randomized (for
example, randomization based on day, date, or hospital number)
clinical trials of EPO used for neuronal development protection
were included. Cohort studies, retrospective studies, case series,
case reports, letters to editors that did not contain primary data,
editorials, review articles and commentaries were not included,
but were explored to identify potential new studies. Multiple
reports of primary studies were reviewed to identify all relevant
outcomes for this article.
2.2. Participants
Preterm (<37 weeks) and/or low birth weight (<2500 g) neonates were considered eligible for inclusion.
2.3. Intervention

Corresponding author. Tel.: +86 511 8508 2260.

E-mail address: lhy5154@163.com (H. Lu).

Studies that investigated EPO treatment versus placebo or no

intervention were eligible for inclusion.

http://dx.doi.org/10.1016/j.jocn.2013.10.040
0967-5868/ 2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Zhang J et al. Neuroprotection with erythropoietin in preterm and/or low birth weight infants. J Clin Neurosci (2014),
http://dx.doi.org/10.1016/j.jocn.2013.10.040

J. Zhang et al. / Journal of Clinical Neuroscience xxx (2014) xxxxxx

2.4. Outcomes
The outcomes for this review were mortality, neurodevelopmental disability among survivors, cerebral palsy, cognitive
(Mental Developmental Index <70) delay, psychomotor (Psychomotor Developmental Index <70) delay, visual decit, severe hearing decit, necrotizing enterocolitis, intracranial hemorrhage, and
patent ductus arteriosus.
2.5. Literature search
The Cochrane Central Register of Controlled Trials (CENTRAL
The Cochrane Library 2012, Issue 2) was searched to identify relevant randomized and quasi-randomized controlled trials. MEDLINE
was searched for relevant articles published from 1966 to November 2012 using the following Medical Subject Headings (MeSH)
terms or text words: (exp Erythropoietin/OR erythropoietin:.mp.
OR rhuepo.mp.) AND (neurodevelopment/OR neuroprotection/OR
neurobehavioral development/OR neurological development/OR
neural development) AND (infant, newborn/OR infant, low birth
weight/OR infant, very low birth weight/OR infant, premature/OR
exp Infant, Premature, Diseases) OR (neonate: OR prematur: OR
newborn:).mp. OR newborn infant [age limit]AND (clinical trial.pt.
OR Randomized Controlled Trials/OR random: OR rct OR rcts) OR
(blind OR blinded OR placebo:).mp. OR (review.pt. OR review, academic.pt.) AND human. EMBASE was queried from 1980 to November 2005 and CINAHL from 1982 to November 2012 using the
following MeSH terms or text words: Erythropoietin/OR erythropoietin: OR epo OR epogen OR epoetin: OR (rhuepo).mp. AND
(neurodevelopment/OR
neuroprotection/OR
neurobehavioral
development/OR neurological development/OR neural development) AND exp Infant, Premature, Diseases/OR infant, newborn/
OR infant, low birth weight/OR infant, very low birth weight/OR infant, premature/OR (neonate: OR newborn: OR prematur:).mp. OR
newborn infant. In addition the bibliographies were manually
searched. No language restrictions were applied. Abstracts published from the Pediatric Academic Societies Meetings and the
European Society of Pediatric Research Meetings (published in
Pediatric Research) were hand searched from 1980 to April 2012.
2.6. Data extraction
All abstracts and published studies identied as potentially relevant by the literature search were assessed for inclusion by two
review authors. Each author extracted data separately on a data
extraction form. The information was then compared and differences were resolved by consensus. One review author (A.O.) entered data into RevMan 5.1 Software (Cochrane Collaboration,
Oxford, UK) and the other (S.A.) cross-checked the printout against
his own data extraction forms and any errors were corrected. For
the studies identied in abstract form, the primary author was contacted to obtain further information.
2.7. Quality assessment
The quality of included trials was evaluated independently by
the review authors using the following criteria: blinding of randomization, blinding of intervention, blinding of outcome measure
assessment, and completeness of follow-up.
2.8. Data analysis
Data on efcacy were collected from studies that reported
childhood outcomes. A typical effect size was calculated and reported as pooled relative risk (RR) and number needed to treat to
benet or harm as appropriate with 95% condence interval.

Studies were weighted in all meta-analyses according to inverse

of variance of the outcomes of interest in individual studies. All
analyses (xed effects model) were performed using Revman 5.1
software. The v2 test was applied to detect between-study heterogeneity and I2 values were calculated to assess statistical heterogeneity. Statistical corrections were not employed to adjust for
multiple analyses.
3. Results
Twenty-one reports were evaluated for eligibility. Five retrospective studies, four case series, and ve prospective cohort studies were excluded. Eight reports of seven clinical trials were
selected for inclusion in this review.
3.1. Clinical heterogeneity assessment among included studies
A total of 523 patients were randomized in the included trials. A
detailed description of the studies included is given in Table 1
[1017].
3.2. Primary outcome: Neurodevelopmental disability in childhood
Data on this primary outcome were reported in four studies.
There was a signicant reduction in the risk of neurodevelopmental disability in infants who received EPO compared to controls
(four studies, 297 participants, over effect Z = 2.01 [p < 0.05];
pooled RR = 0.77; test of heterogeneity p = 0.5 and I2 = 0%) (Fig. 1).
3.3. Effectiveness outcomes
There was no difference in the risk of morbidity, cerebral palsy,
Mental Developmental Index <70, Psychomotor Developmental Index <70, visual decit, severe hearing decit, necrotizing enterocolitis, intracranial hemorrhage or patent ductus arteriosus between
infants who received EPO and controls (Fig. 2).
4. Discussion
Preterm infants are at a high risk for brain injury and subsequent neurodevelopmental problems. This meta-analysis of seven
eligible trials in infants conrms that EPO was associated with a reduced risk of the overall outcome of neurodevelopmental disability
in infancy. There was no difference in the risk of morbidity, cerebral palsy, visual decit, severe hearing decit, necrotizing enterocolitis, intracranial hemorrhage and patent ductus arteriosus.
EPO is a 34 kD glycoprotein with four carbohydrate residues,
and was originally puried in the 1970s [18]. The brain effects of
EPO are proposed to involve a heteromeric receptor comprising
the classical erythropoietin receptor (EPOR). Most neurons are
likely to express high levels of EPOR [19]. Binding of exogenous
or endogenous EPO with EPOR leads to conformational changes
in EPOR protein and the signaling protein. Activation of EPO signaling pathways can inhibit the process of neurotoxicity, apoptosis,
inammation, cerebral edema and white matter injury while
increasing neural regeneration including neurovascular remodeling, neural stem cell proliferation and neurite outgrowth [2026].
EPO has been shown to have benecial effects in the central and
peripheral nervous system, observed in multiple settings [2729].
Neonatal recombinant human EPO administration in a novel,
clinically relevant paradigm initiated 4 days after a global prenatal
hypoxic-ischemic insult in rats rescued neural cells, and
induced lasting histological and functional improvement in adult
rats [24]. Administration of a single dose of EPO directly after an
acute hypoxic event has protective effects against subsequent

Please cite this article in press as: Zhang J et al. Neuroprotection with erythropoietin in preterm and/or low birth weight infants. J Clin Neurosci (2014),
http://dx.doi.org/10.1016/j.jocn.2013.10.040

J. Zhang et al. / Journal of Clinical Neuroscience xxx (2014) xxxxxx

Table 1
Clinical characteristics of participants in the included studies of EPO in preterm and low birth weight infants
Author

EPO/
Control,
n

Inclusion criteria

Exclusion criteria

Intervention criteria

Newton
et al.
[10],
1999

20/20

Birth weight of 61250 g, gestational

age at birth of 633 weeks for the two
pilot studies and <31 weeks for the
multicenter trial

Infants with grade III or IV intracranial

hemorrhage, periventricular leukomalacia, or
major congenital anomalies

Ohls et al.
[11],
2004

87/85

The 10th percentile based on

Alexanders reference intrauterine
growth curves was determined [12]

Not reported

Bierer
et al.
[13],
2006

7/9

Birth weight between 401 and

1000 g, a gestational age at birth of
632 weeks

Fauchere
et al.
[14],
2008

30/15

Gestational age at birth of between

24 weeks and 31 weeks and 6 days

He et al.
[15],
2008
Juul et al.
[16],
2008

22/22

Preterm infants

Major congenital anomaly, positive direct

antiglobulin test, evidence of coagulopathy,
clinical seizures, systolic blood
pressure>100 mmHg, or an absolute neutrophil
count6500/lL
Genetically dened syndromes, congenital
malformations that adversely affect
neurodevelopment, lack of adequate parental
information as a result of emergency cesarean
section, or language barriers
Genetically dened syndromes, hemolysis or
severe infections

The 20 infants enrolled in the rst pilot study

received twice weekly intravenous injections of
100 U/kg of rHuEPO or placebo. The eight infants
in the second pilot study received rHuEPO or
placebo subcutaneously, beginning at 100 U/kg
per day ve times per week. In four control and
three treated infants, the dose was doubled to
200 U/kg per day. A total of 22 infants enrolled at
this center in the multicenter trial received
rHuEPO or placebo subcutaneously at 100 U/kg
per day 5 days a week. All infants received study
medication for 6 weeks maximum
The 87 infants enrolled in the study received an
average of 23 SD10 doses of EPO administrated
over an 8 to 10 week period, of which 53% were
administered intravenously. EPO treated infants
also received an average of 2 SD1 parenteral
iron doses (5 mg/kg) weekly, whereas infants in
the placebo group received an average of 2 SD1
parenteral iron doses (1 mg/kg) weekly
Infants received 400 U/kg EPO or placebo three
times per week

30/30

Birth weight 61000 g, gestational

age at birth of 628 weeks and 6 days

89/57

Birth weight 61000 g

Neubauer
et al.
[17]
2010

Major life-threatening anomalies or

hematopoietic crises such as disseminated
intravascular coagulation, hemolysis as a result of
blood group incompatibilities, or polycythemia
Not reported

Infants were given recombinant human EPO or

NaCl 0.9% intravenously at 3, 12 to 18, and 36 to
42 hours after birth

Infants received intravenous rHuEPO (250 IU/kg,

three times weekly) or placebo for 4 weeks after
postnatal day 7
Infants received three intravenous doses of 500,
1000, or 2500 U/kg at 24 hour intervals beginning
on postnatal day 1
Average cumulative dosage of EPO of 8574 U/kg
(range 175021,500 U/kg) administered over a
68 day (range, 15121 days) period

EPO = erythropoietin, rHuEPO = recombinant human erythropoietin, SD = standard deviation.

Fig. 1. Forest plot of the primary outcome of neurodevelopmental disability in preterm infants who received erythropoietin compared to controls. CI = condence interval,
df = degrees of freedom, EPO = erythropoietin, M-H = Mantel-Haenszel.

susceptibility to seizure. EPO increased latency and reduced duration of seizures in rat pups [30]. In a rat model of postnatal day 10
middle cerebral artery occlusion, rats treated with three doses of
EPO (1 U/g intraperitoneal each) at 0 hours, 24 hours and 7 days
after injury performed better on tests of cognitive function than
rats treated with a single dose and vehicle-treated injured rats at
3 months after injury [31]. Repeated treatment of newborn rats
with high-dose recombinant EPO also improved the development
of hypoxia-exposed newborns and prevented learning impairment
and dopamine neuron loss due to unilateral hypoxic-ischemic

brain injury [32]. EPO may be useful in both the early phase, for
its direct neuroprotective effect by preventing cell death, and the
late phase, by inuencing cell repair, progenitor cell fate, neurogenesis and migration [31]. However, the optimal dosing regimen
to maximize long-term outcomes is not clear.
Although EPO treatment for premature infants with anemia has
a long history and seems to be safe, several issues remaining
regarding its possible potential complications in neonate clinical
application. In a case report study, an extremely premature infant
developed hypertension after EPO treatment for a period of time,

Please cite this article in press as: Zhang J et al. Neuroprotection with erythropoietin in preterm and/or low birth weight infants. J Clin Neurosci (2014),
http://dx.doi.org/10.1016/j.jocn.2013.10.040

J. Zhang et al. / Journal of Clinical Neuroscience xxx (2014) xxxxxx

Fig. 2. Efcacy outcomes in preterm infants who received erythropoietin compared to controls. MDI = Mental Developmental Index, NEC = necrotizing enterocolitis,
PDA = patent ductus arteriosus, PDI = Psychomotor Developmental Index.

and hypertension seemed to improve after EPO was stopped [33].

As a procoagulant, EPO can induce coagulation disorders. Adult patients with polycythemia have increased risk for thromboembolic
phenomena; however, it has been reported that transgenic mice
overexpressing EPO may even be protected against thrombotic
disease by EPO-induced erythrocytosis [34]. In a randomized
controlled trial, extremely low birth weight infants with a birth
weight 6800 g and a gestational age 632 weeks received EPO
during the rst weeks of life. EPO therapy was found to have a
short effect on improving platelet activity and functions without
changing the total platelet count [35]. In one report, recombinant
EPO was found to cause the development of haemangiomas in preterm neonates less than 1000 g after 3 or 4 weeks administration
[36].
This study has some limitations. Randomization and concealment of allocation are of central importance in clinical trials to prevent selection bias, but they do not prevent biases related to the
evaluation, follow-up, or placebo effect. As in other meta-analyses,
publication bias may occur. The treatment strategies applied and
the targeted outcome varied across trials, as did the denitions
of outcomes, trial designs, and duration of follow-up. This is likely
to explain at least some of the observed heterogeneity.

5. Conclusion
The use of EPO is associated with reduction of neurodevelopmental disability in preterm infants to some extent. However it
is still unclear what the proper dose and timing of administration
of EPO should be. Continued assessment of long-term outcomes of
patients enrolled in completed trials should be a key priority to
conrm the long-term safety and efcacy of EPO in treating preterm infants.

Conicts of Interest/Disclosures
The authors declare that they have no nancial or other conicts of interest in relation to this research and its publication.

Acknowledgements
This work was supported by a grant from Jiangsu Provinces
Scientic and Technological Supporting Program (grant number
BL2012058).

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Please cite this article in press as: Zhang J et al. Neuroprotection with erythropoietin in preterm and/or low birth weight infants. J Clin Neurosci (2014),
http://dx.doi.org/10.1016/j.jocn.2013.10.040