- Email: [email protected]
Role of G-CSF GM-CSF in the management of infections in preterm newborns: an update
Early Human Development 90S2 (2014) S15–S17
Contents lists available at ScienceDirect
Early Human Development j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / e a r l h u m d ev
Review
Role of G-CSF and GM-CSF in the management of infections in preterm newborns: an update Elio Castagnola*, Carlo Dufour Istituto Giannina Gaslini, Genoa, Italy
article info
summary
Keywords: G-CSF GM-CSF Neutropenia Neonate Sepsis Growth factor
Neutropenia (definable as an absolute granulocyte count <1,000/mL in neonates) is a relatively frequent condition in small for gestational age and/or low birth weight neonates. Colony stimulating factors (CSF), namely granulocyte- (G-CSF) and granulocyte–macrophage- (GM-CSF) CSF, have been proposed for prophylaxis and therapy of severe infections in this condition. Available data do not support the use of these substances for prophylaxis of infections in the presence of neutropenia. On the contrary, there might be space for their use, mainly for G-CSF, in case of severe infectious complications in severely neutropenic neonates (absolute polymorphonuclear neutrophil count <500/mL) and/or in the presence of specific hematological diseases causing neutropenia. © 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction/Background Neutropenia identifies a condition of reduced absolute polymorphonuclear neutrophil (PMN) count that in the normal neonate can be defined as an absolute PMN count <1000/mL [1], even though there have been reports that in the first two weeks of life normal values may be down to <500/mL. Neutropenia is a relatively frequent finding in the neonatal intensive care unit, especially during the first week of life and particularly in preterm (≤34 weeks of gestational age), small for gestational age (SGA, weight <10th percentile for gestational age) and/or very low birth weight (VLBW, <1500 g) neonates [2]. Its presence, perhaps independently from its duration, has been associated in various ways with development of early or late infections in these patient populations [2,3]. Neonatal neutropenia can be due to decreased production of neutrophils, increased neutrophil destruction, excessive neutrophil margination, or combinations of these three mechanisms [4]. Hematologic diseases like severe congenital neutropenia (SCN) may be detectable at birth because of very low PMN count (<200/mL) and/or severe infections (skin, umbilicus, lung, sepsis), while other congenital bone marrow failure syndromes are rarely fully identifiable at birth, and suspicion can rise based on family history or on the combination of mono-, bi-, tri-lineage cytopenia with small size for gestational age and/or somatic malformations [1]. * Corresponding author. Elio Castagnola, Infectious Diseases Unit, Istituto Giannina Gaslini, Largo G. Gaslini, 5, 16147 Genova, Italy. Tel.: +39 010 5636 2428; fax: +39 010 376 34 36. E-mail address: [email protected] (E. Castagnola). 0378-3782/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved.
Recombinant human granulocyte colony-stimulating factor (rG-CSF) is available for clinical use in two forms: lenograstim, a glycosylated protein indistinguishable from native G-CSF, and filgrastim, a non-glycosylated version that slightly differs from the other also in the peptide chain; in vivo these are of equivalent effectiveness. There are two recombinant versions of GM-CSF: molgramostim, which is not glycosylated and differs from the native compound by one amino acid, and sargramostim, which differs from the native form by one amino acid and glycosylation. Studies of functional activity of stimulated neutrophils in neonates and mothers at high risk of infection and in normal adults [5] showed that G-CSF and GM-CSF significantly delayed neutrophil apoptosis at least in normal adults. This effect was only visible in normal neonates and only after stimulation with G-CSF. In neonates at risk for sepsis neither G-CSF nor GM-CSF reduced neutrophil apoptosis, differently from normal neonates whose neutrophil function was increased by both growth factors. Finally, rhG-CSF, even though it increased the absolute neutrophil count to normal values in neutropenic neonates, did not completely recover neutrophil function to that of normal controls [6]. In view of these considerations it is a plausible hypothesis that the administration of G-CSF and GM-CSF to neutropenic neonates could increase the number and improve the function of PMN, reducing the risk or improving the prognosis of neutropenic neonates with severe infectious complications.
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E. Castagnola, C. Dufour / Early Human Development 90S2 (2014) S15–S17
2. Use of G-CSF or GM-CSF in neutropenic neonates for preventing infectious complications A systematic Cochrane review performed in 2003 that evaluated effectiveness of CSF for the prevention of neonatal severe infections identified a total of 359 neonates enrolled in 3 studies and showed absence of effect of these molecules in reducing mortality [7]. However, as the authors of the review clearly stated, the identification of sepsis as the primary outcome of prophylaxis studies was hampered by inadequately stringent definitions of systemic infection and many studies were represented by small case series or randomized clinical trials with very low power [7]. More recently the role of CSF in neonatal neutropenia has been evaluated in two large, multicenter, randomized, clinical trials. In the first one, doubleblind, placebo-controlled, a total of 200 SGA neonates with a total PMN count <1500/mL were randomized to receive intravenous rG-CSF (10 mg/kg q24h) for 3 days or placebo [8]. No difference was observed in infection-free survival at 4 weeks after treatment, even though a transient effect was observed at 2 weeks especially in the most immature neonates. In the second one, single-blind, a total of 280 preterm SGA (<31 weeks of gestational age) neonates received GM-CSF (10 mg/kg q24h) subcutaneously for 5 days or standard management [9]. In spite of an increase in PMN count in the first days of life in neonates receiving GM-CSF, there was no significant difference in sepsis-free survival. Moreover, a meta-analysis of studies of GM-CSF administration for preventing neonatal infections showed no effect of this intervention on all-cause mortality at 28 days from start of treatment [9]. Interestingly, an analysis of general health outcomes performed 2 years after the study showed that neonates treated with GM-CSF had a marginally increased incidence of cough (relative risk [RR] 1.7, 95% confidence interval [CI] 1.1, 2.6) and signs of chronic respiratory disease (Harrison’s sulcus; RR 2.0, 95% CI 1.0, 3.9) [10], though this was not reflected in bronchodilator use or need for hospitalization for respiratory disease. 3. Use of G-CSF or GM-CSF for the treatment of neonatal sepsis Another possible strategy for the use of CSF is their administration to improve outcome in established systemic infection, especially when complicated by a low neutrophil count. Doses of 10 mg/kg/day of G-CSF have been administered intravenously for 3–14 days [11,12] or subcutaneously for 1 or 3 days [13] for this purpose. These treatments were safe, but no effect on survival was observed. A systematic review of 7 studies (all small with the largest including 60 patients), enrolling a total of 257 infants with suspected systemic bacterial infection, and including the aforementioned trials, showed that there was no evidence that the addition of G-CSF or GM-CSF to antibiotic therapy in preterm infants with suspected systemic infection improved 14-day survival. However, a subgroup analysis of 97 neonates with neutropenia (defined in the review by an absolute PMN count <1700/mL) at onset of clinical septic syndrome showed a significant reduction in mortality at 14 days (RR 0.34, 95% CI 0.12, 0.92; risk reduction −0.18, 95% CI −0.33, −0.03), with a number needed to treat (NNT) of 6 patients (95% CI 3, 33) [7]. More recently in a randomized single-blind, non placebo-controlled study, 40 preterm (<37 weeks) neonates weighing <2000 g, with sepsis and an absolute PMN count <5000/mL, received intravenous rhG-CSF at 10 mg/kg/day for 5 days or standard therapy [14]. Neonates treated with G-CSF had decreased overall mortality
and, obviously, a quicker recovery of their total leucocyte and absolute neutrophil count. Data on the efficacy of GM-CSF are even scarcer. A dose of 5 mg/kg q24h was administered to 8 neonates with a post-menstrual age of at least 30 weeks and weighing >1,000 g with a diagnosis of severe infection and neutropenia (defined as an absolute granulocyte count <3000/mL). All patients survived the septic episode [15]. Finally, rG-CSF (5 mg/kg intravenously q12h) was compared to rhGM-CSF (4 mg/kg intravenously q12h) or placebo for the treatment of symptomatic, septic premature neonates in a small study (28 patients enrolled). Neonates receiving rG-CSF had the fastest increase in PMN count (mean values were >1000/mL in all 3 subgroups), but no effect on mortality could be observed [16]. Beyond the possible low power of the therapeutic studies, it is also possible that in these trials the choice of a quite high value of PMN count (frequently >1000/mL) disguised a possible therapeutic effect in neonates with the lowest PMN count. 4. Conclusions Although rhG-CSF and rhGM-CSF appear to have no adverse side effects, their usefulness in treating and preventing sepsis in preterm infants remains unproven. Adequately powered, randomized controlled clinical trials of neutropenic infants are needed to further evaluate efficacy of these agents as adjuncts to antibiotic therapy. With the presently available data probably G-CSF and GM-CSF should no longer be used routinely in neonatal intensive care without further evidence from randomized trials. However there might be space for their use in case of severe infectious complications in severely neutropenic neonates (absolute PMN count <500/mL) and/or in the presence of specific hematological diseases causing neutropenia [1]. Conflict of interest statement The authors have no conflicts of interest to declare. References 1. Fioredda F, Calvillo M, Bonanomi S, Coliva T, Tucci F, Farruggia P, et al. Congenital and acquired neutropenia consensus guidelines on diagnosis from the Neutropenia Committee of the Marrow Failure Syndrome Group of the AIEOP (Associazione Italiana Emato-Oncologia Pediatrica). Pediatr Blood Cancer 2011;57:10–7. 2. Christensen RD, Henry E, Wiedmeier SE, Stoddard RA, Lambert DK. Low blood neutrophil concentrations among extremely low birth weight neonates: data from a multihospital health-care system. J Perinatol 2006;26:682–7. 3. Funke A, Berner R, Traichel B, Schmeisser D, Leititis JU, Niemeyer CM. Frequency, natural course, and outcome of neonatal neutropenia. Pediatrics 2000;106:45–51. 4. Del Vecchio A, Christensen RD. Neonatal neutropenia: what diagnostic evaluation is needed and when is treatment recommended? Early Hum Dev 2012;88(Suppl 2):S19–24. 5. Molloy EJ, O’Neill AJ, Grantham JJ, Sheridan-Pereira M, Fitzpatrick JM, Webb DW, et al. Granulocyte colony-stimulating factor and granulocyte–macrophage colony-stimulating factor have differential effects on neonatal and adult neutrophil survival and function. Pediatr Res 2005;57:806–12. 6. Ahmad M, Fleit HB, Golightly MG, La Gamma EF. In vivo effect of recombinant human granulocyte colony-stimulating factor on phagocytic function and oxidative burst activity in septic neutropenic neonates. Biol Neonate 2004;86:48–54. 7. Carr R, Modi N, Dore C. G-CSF and GM-CSF for treating or preventing neonatal infections. Cochrane Database Syst Rev. 2003;(3):CD003066. 8. Kuhn P, Messer J, Paupe A, Espagne S, Kacet N, Mouchnino G, et al. A multicenter, randomized, placebo-controlled trial of prophylactic recombinant granulocytecolony stimulating factor in preterm neonates with neutropenia. J Pediatr 2009; 155:324–30. 9. Carr R, Brocklehurst P, Dore C, Modi N. Granulocyte–macrophage colony stimulating factor administered as prophylaxis for reduction of sepsis in extremely preterm, small for gestational age neonates (the PROGRAMS trial):
E. Castagnola, C. Dufour / Early Human Development 90S2 (2014) S15–S17
a single-blind, multicentre, randomised controlled trial. Lancet 2009;373: 226–33. 10. Marlow N, Morris T, Brocklehurst P, Carr R, Cowan FM, Patel N, et al. A randomised trial of granulocyte–macrophage colony-stimulating factor for neonatal sepsis: outcomes at 2 years. Arch Dis Child Fetal Neonatal Ed 2013;98:F46–53. 11. Bedford Russell AR, Emmerson AJ, Wilkinson N, Chant T, Sweet DG, Halliday HL, et al. A trial of recombinant human granulocyte colony stimulating factor for the treatment of very low birthweight infants with presumed sepsis and neutropenia. Arch Dis Child Fetal Neonatal Ed 2001;84:F172–6. 12. Miura E, Procianoy RS, Bittar C, Miura CS, Miura MS, Mello C, et al. A randomized, double-masked, placebo-controlled trial of recombinant granulocyte colonystimulating factor administration to preterm infants with the clinical diagnosis of early-onset sepsis. Pediatrics 2001;107:30–5.
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13. Nayeri F, Soheili H, Kaveh M, Oloomi Yazdi Z, Shariat M, Dalili H. Comparison of two regimens of RhG-CSF in neutropenic neonatal septicemia: a randomized clinical trial. Acta Med Iran 2011;49:575–8. 14. Gathwala G, Walia M, Bala H, Singh S. Recombinant human granulocyte colonystimulating factor in preterm neonates with sepsis and relative neutropenia: a randomized, single-blind, non-placebo-controlled trial. J Trop Pediatr 2012; 58:12–8. 15. Venkateswaran L, Wilimas JA, Dancy R, Wang WC, Korones S, Hayden J, et al. Granulocyte–macrophage colony-stimulating factor in the treatment of neonates with neutropenia and sepsis. Pediatr Hematol Oncol 2000;17:469–73. 16. Ahmad A, Laborada G, Bussel J, Nesin M. Comparison of recombinant granulocyte colony-stimulating factor, recombinant human granulocyte– macrophage colony-stimulating factor and placebo for treatment of septic preterm infacts. Pediatr Infect Dis J 2002;21:1061–5.
Contents lists available at ScienceDirect
Early Human Development j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / e a r l h u m d ev
Review
Role of G-CSF and GM-CSF in the management of infections in preterm newborns: an update Elio Castagnola*, Carlo Dufour Istituto Giannina Gaslini, Genoa, Italy
article info
summary
Keywords: G-CSF GM-CSF Neutropenia Neonate Sepsis Growth factor
Neutropenia (definable as an absolute granulocyte count <1,000/mL in neonates) is a relatively frequent condition in small for gestational age and/or low birth weight neonates. Colony stimulating factors (CSF), namely granulocyte- (G-CSF) and granulocyte–macrophage- (GM-CSF) CSF, have been proposed for prophylaxis and therapy of severe infections in this condition. Available data do not support the use of these substances for prophylaxis of infections in the presence of neutropenia. On the contrary, there might be space for their use, mainly for G-CSF, in case of severe infectious complications in severely neutropenic neonates (absolute polymorphonuclear neutrophil count <500/mL) and/or in the presence of specific hematological diseases causing neutropenia. © 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction/Background Neutropenia identifies a condition of reduced absolute polymorphonuclear neutrophil (PMN) count that in the normal neonate can be defined as an absolute PMN count <1000/mL [1], even though there have been reports that in the first two weeks of life normal values may be down to <500/mL. Neutropenia is a relatively frequent finding in the neonatal intensive care unit, especially during the first week of life and particularly in preterm (≤34 weeks of gestational age), small for gestational age (SGA, weight <10th percentile for gestational age) and/or very low birth weight (VLBW, <1500 g) neonates [2]. Its presence, perhaps independently from its duration, has been associated in various ways with development of early or late infections in these patient populations [2,3]. Neonatal neutropenia can be due to decreased production of neutrophils, increased neutrophil destruction, excessive neutrophil margination, or combinations of these three mechanisms [4]. Hematologic diseases like severe congenital neutropenia (SCN) may be detectable at birth because of very low PMN count (<200/mL) and/or severe infections (skin, umbilicus, lung, sepsis), while other congenital bone marrow failure syndromes are rarely fully identifiable at birth, and suspicion can rise based on family history or on the combination of mono-, bi-, tri-lineage cytopenia with small size for gestational age and/or somatic malformations [1]. * Corresponding author. Elio Castagnola, Infectious Diseases Unit, Istituto Giannina Gaslini, Largo G. Gaslini, 5, 16147 Genova, Italy. Tel.: +39 010 5636 2428; fax: +39 010 376 34 36. E-mail address: [email protected] (E. Castagnola). 0378-3782/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved.
Recombinant human granulocyte colony-stimulating factor (rG-CSF) is available for clinical use in two forms: lenograstim, a glycosylated protein indistinguishable from native G-CSF, and filgrastim, a non-glycosylated version that slightly differs from the other also in the peptide chain; in vivo these are of equivalent effectiveness. There are two recombinant versions of GM-CSF: molgramostim, which is not glycosylated and differs from the native compound by one amino acid, and sargramostim, which differs from the native form by one amino acid and glycosylation. Studies of functional activity of stimulated neutrophils in neonates and mothers at high risk of infection and in normal adults [5] showed that G-CSF and GM-CSF significantly delayed neutrophil apoptosis at least in normal adults. This effect was only visible in normal neonates and only after stimulation with G-CSF. In neonates at risk for sepsis neither G-CSF nor GM-CSF reduced neutrophil apoptosis, differently from normal neonates whose neutrophil function was increased by both growth factors. Finally, rhG-CSF, even though it increased the absolute neutrophil count to normal values in neutropenic neonates, did not completely recover neutrophil function to that of normal controls [6]. In view of these considerations it is a plausible hypothesis that the administration of G-CSF and GM-CSF to neutropenic neonates could increase the number and improve the function of PMN, reducing the risk or improving the prognosis of neutropenic neonates with severe infectious complications.
S16
E. Castagnola, C. Dufour / Early Human Development 90S2 (2014) S15–S17
2. Use of G-CSF or GM-CSF in neutropenic neonates for preventing infectious complications A systematic Cochrane review performed in 2003 that evaluated effectiveness of CSF for the prevention of neonatal severe infections identified a total of 359 neonates enrolled in 3 studies and showed absence of effect of these molecules in reducing mortality [7]. However, as the authors of the review clearly stated, the identification of sepsis as the primary outcome of prophylaxis studies was hampered by inadequately stringent definitions of systemic infection and many studies were represented by small case series or randomized clinical trials with very low power [7]. More recently the role of CSF in neonatal neutropenia has been evaluated in two large, multicenter, randomized, clinical trials. In the first one, doubleblind, placebo-controlled, a total of 200 SGA neonates with a total PMN count <1500/mL were randomized to receive intravenous rG-CSF (10 mg/kg q24h) for 3 days or placebo [8]. No difference was observed in infection-free survival at 4 weeks after treatment, even though a transient effect was observed at 2 weeks especially in the most immature neonates. In the second one, single-blind, a total of 280 preterm SGA (<31 weeks of gestational age) neonates received GM-CSF (10 mg/kg q24h) subcutaneously for 5 days or standard management [9]. In spite of an increase in PMN count in the first days of life in neonates receiving GM-CSF, there was no significant difference in sepsis-free survival. Moreover, a meta-analysis of studies of GM-CSF administration for preventing neonatal infections showed no effect of this intervention on all-cause mortality at 28 days from start of treatment [9]. Interestingly, an analysis of general health outcomes performed 2 years after the study showed that neonates treated with GM-CSF had a marginally increased incidence of cough (relative risk [RR] 1.7, 95% confidence interval [CI] 1.1, 2.6) and signs of chronic respiratory disease (Harrison’s sulcus; RR 2.0, 95% CI 1.0, 3.9) [10], though this was not reflected in bronchodilator use or need for hospitalization for respiratory disease. 3. Use of G-CSF or GM-CSF for the treatment of neonatal sepsis Another possible strategy for the use of CSF is their administration to improve outcome in established systemic infection, especially when complicated by a low neutrophil count. Doses of 10 mg/kg/day of G-CSF have been administered intravenously for 3–14 days [11,12] or subcutaneously for 1 or 3 days [13] for this purpose. These treatments were safe, but no effect on survival was observed. A systematic review of 7 studies (all small with the largest including 60 patients), enrolling a total of 257 infants with suspected systemic bacterial infection, and including the aforementioned trials, showed that there was no evidence that the addition of G-CSF or GM-CSF to antibiotic therapy in preterm infants with suspected systemic infection improved 14-day survival. However, a subgroup analysis of 97 neonates with neutropenia (defined in the review by an absolute PMN count <1700/mL) at onset of clinical septic syndrome showed a significant reduction in mortality at 14 days (RR 0.34, 95% CI 0.12, 0.92; risk reduction −0.18, 95% CI −0.33, −0.03), with a number needed to treat (NNT) of 6 patients (95% CI 3, 33) [7]. More recently in a randomized single-blind, non placebo-controlled study, 40 preterm (<37 weeks) neonates weighing <2000 g, with sepsis and an absolute PMN count <5000/mL, received intravenous rhG-CSF at 10 mg/kg/day for 5 days or standard therapy [14]. Neonates treated with G-CSF had decreased overall mortality
and, obviously, a quicker recovery of their total leucocyte and absolute neutrophil count. Data on the efficacy of GM-CSF are even scarcer. A dose of 5 mg/kg q24h was administered to 8 neonates with a post-menstrual age of at least 30 weeks and weighing >1,000 g with a diagnosis of severe infection and neutropenia (defined as an absolute granulocyte count <3000/mL). All patients survived the septic episode [15]. Finally, rG-CSF (5 mg/kg intravenously q12h) was compared to rhGM-CSF (4 mg/kg intravenously q12h) or placebo for the treatment of symptomatic, septic premature neonates in a small study (28 patients enrolled). Neonates receiving rG-CSF had the fastest increase in PMN count (mean values were >1000/mL in all 3 subgroups), but no effect on mortality could be observed [16]. Beyond the possible low power of the therapeutic studies, it is also possible that in these trials the choice of a quite high value of PMN count (frequently >1000/mL) disguised a possible therapeutic effect in neonates with the lowest PMN count. 4. Conclusions Although rhG-CSF and rhGM-CSF appear to have no adverse side effects, their usefulness in treating and preventing sepsis in preterm infants remains unproven. Adequately powered, randomized controlled clinical trials of neutropenic infants are needed to further evaluate efficacy of these agents as adjuncts to antibiotic therapy. With the presently available data probably G-CSF and GM-CSF should no longer be used routinely in neonatal intensive care without further evidence from randomized trials. However there might be space for their use in case of severe infectious complications in severely neutropenic neonates (absolute PMN count <500/mL) and/or in the presence of specific hematological diseases causing neutropenia [1]. Conflict of interest statement The authors have no conflicts of interest to declare. References 1. Fioredda F, Calvillo M, Bonanomi S, Coliva T, Tucci F, Farruggia P, et al. Congenital and acquired neutropenia consensus guidelines on diagnosis from the Neutropenia Committee of the Marrow Failure Syndrome Group of the AIEOP (Associazione Italiana Emato-Oncologia Pediatrica). Pediatr Blood Cancer 2011;57:10–7. 2. Christensen RD, Henry E, Wiedmeier SE, Stoddard RA, Lambert DK. Low blood neutrophil concentrations among extremely low birth weight neonates: data from a multihospital health-care system. J Perinatol 2006;26:682–7. 3. Funke A, Berner R, Traichel B, Schmeisser D, Leititis JU, Niemeyer CM. Frequency, natural course, and outcome of neonatal neutropenia. Pediatrics 2000;106:45–51. 4. Del Vecchio A, Christensen RD. Neonatal neutropenia: what diagnostic evaluation is needed and when is treatment recommended? Early Hum Dev 2012;88(Suppl 2):S19–24. 5. Molloy EJ, O’Neill AJ, Grantham JJ, Sheridan-Pereira M, Fitzpatrick JM, Webb DW, et al. Granulocyte colony-stimulating factor and granulocyte–macrophage colony-stimulating factor have differential effects on neonatal and adult neutrophil survival and function. Pediatr Res 2005;57:806–12. 6. Ahmad M, Fleit HB, Golightly MG, La Gamma EF. In vivo effect of recombinant human granulocyte colony-stimulating factor on phagocytic function and oxidative burst activity in septic neutropenic neonates. Biol Neonate 2004;86:48–54. 7. Carr R, Modi N, Dore C. G-CSF and GM-CSF for treating or preventing neonatal infections. Cochrane Database Syst Rev. 2003;(3):CD003066. 8. Kuhn P, Messer J, Paupe A, Espagne S, Kacet N, Mouchnino G, et al. A multicenter, randomized, placebo-controlled trial of prophylactic recombinant granulocytecolony stimulating factor in preterm neonates with neutropenia. J Pediatr 2009; 155:324–30. 9. Carr R, Brocklehurst P, Dore C, Modi N. Granulocyte–macrophage colony stimulating factor administered as prophylaxis for reduction of sepsis in extremely preterm, small for gestational age neonates (the PROGRAMS trial):
E. Castagnola, C. Dufour / Early Human Development 90S2 (2014) S15–S17
a single-blind, multicentre, randomised controlled trial. Lancet 2009;373: 226–33. 10. Marlow N, Morris T, Brocklehurst P, Carr R, Cowan FM, Patel N, et al. A randomised trial of granulocyte–macrophage colony-stimulating factor for neonatal sepsis: outcomes at 2 years. Arch Dis Child Fetal Neonatal Ed 2013;98:F46–53. 11. Bedford Russell AR, Emmerson AJ, Wilkinson N, Chant T, Sweet DG, Halliday HL, et al. A trial of recombinant human granulocyte colony stimulating factor for the treatment of very low birthweight infants with presumed sepsis and neutropenia. Arch Dis Child Fetal Neonatal Ed 2001;84:F172–6. 12. Miura E, Procianoy RS, Bittar C, Miura CS, Miura MS, Mello C, et al. A randomized, double-masked, placebo-controlled trial of recombinant granulocyte colonystimulating factor administration to preterm infants with the clinical diagnosis of early-onset sepsis. Pediatrics 2001;107:30–5.
S17
13. Nayeri F, Soheili H, Kaveh M, Oloomi Yazdi Z, Shariat M, Dalili H. Comparison of two regimens of RhG-CSF in neutropenic neonatal septicemia: a randomized clinical trial. Acta Med Iran 2011;49:575–8. 14. Gathwala G, Walia M, Bala H, Singh S. Recombinant human granulocyte colonystimulating factor in preterm neonates with sepsis and relative neutropenia: a randomized, single-blind, non-placebo-controlled trial. J Trop Pediatr 2012; 58:12–8. 15. Venkateswaran L, Wilimas JA, Dancy R, Wang WC, Korones S, Hayden J, et al. Granulocyte–macrophage colony-stimulating factor in the treatment of neonates with neutropenia and sepsis. Pediatr Hematol Oncol 2000;17:469–73. 16. Ahmad A, Laborada G, Bussel J, Nesin M. Comparison of recombinant granulocyte colony-stimulating factor, recombinant human granulocyte– macrophage colony-stimulating factor and placebo for treatment of septic preterm infacts. Pediatr Infect Dis J 2002;21:1061–5.