serum albuin and oedema

Archives of Disease in Childhood, 1986, 61, 657-660

Serum albumin concentrations and oedema in thenewbornP H T CARTLIDGE AND N RUTTERDepartment of Neonatal Medicine and Surgery, City Hospital, Nottingham

SUMMARY Serum albumin concentration was measured in 195 infants of 25 to 42 weeks'gestation during the neonatal period. Concentrations were significantly lower in preterm infants,rising from a mean of 19 g/l at 26 weeks to 31 g/l at term. There was a 15% increase in albuminconcentrations in the first three weeks of life. Oedema in the early and late neonatal period wascommon in preterm infants but correlated poorly with hypoalbuminaemia. Measurement ofserum albumin concentrations in preterm infants either routinely or because of oedema is notclinically useful.

Subcutaneous oedema is common in the newborn,particularly in the preterm infant, and typicallyinvolves the dorsum of the hands and feet. It is seenas a normal finding in the first few days of life,' butif it is more extensive or occurs later in the newbornperiod it may prompt investigation. Because of therelation between colloid oncotic pressure and serumalbumin concentrations,2 the latter are commonlymeasured and even 'treated' if found to be low.Normal concentrations of serum albumin, however,are not well defined in the newborn. The aim of thisstudy was to determine the normal range of serumalbumin concentrations in newborn infants andexamine the influence of gestation and age on theseconcentrations. We also wished to correlate concen-trations of albumin with the presence and severity ofsubcutaneous oedema.

Methods

All infants admitted to Nottingham City HospitalNeonatal Unit between March and September 1985were studied. The infants were locally born ortransferred from other hospitals and included almostall infants below 35 weeks' gestation regardless ofthe presence of complications of prematurity. In-fants from 35 weeks to term who were admitted forsurgery, who required observation for transienttachypnoea or treatment for infection, or who hadsuffered appreciable birth asphyxia or traumaformed a selected group. Gestational age wasdetermined from the mother's menstrual history,antenatal ultrasound examination, and neonatalassessment by external and neurological criteria.tMeasurement of serum albumin concentrations

and assessment of subcutaneous oedema werecarried out within 48 hours of birth (usually within24 hours) and then at weekly intervals if the infantremained in the neonatal unit. Albumin wasmeasured by the bromocresol purple dye bindingmethod on serum obtained from capillary (heelprick), venous, or arterial blood, which was beingtaken for clinical purposes. If capillary blood wasused the first drop was wiped away to remove anyinterstitial fluid that might contaminate the sample.Subcutaneous oedema was measured at five sites:dorsum of one hand and foot, shin, sternum, andsacrum, using an arbitrary analogue scoring system(Table (a)). The score at each of the five sites wasthen summed to produce an overall oedema grade(Table (b)).Table The assessment ofoedema. The sum oftheoedema score atfive sites: dorsum ofone hand andfoot,skin, sternum, and sacrum produces an overall grade ofoedemaTable (a)

Oedema score

O No oedema1 Minimal oedema2 Obvious oedema3 Pitting oedema more than 1 mm deep*

*Measured with a depth gauge.

Table (b)Total score Grade of oedema

O No oedema1-4 Mild oedema5 or more Moderate oedemaOedema at all sites Generalised oedema

657

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Gestational age (weeks)Fig. 1 Concentrations ofserum albumin during the early neonatal period in infants of25 to 42 weeks' gestation. The meanand the 90% probability limits are shown.Generolised * : I I I I

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Fig. 2 Relation between the degree ofoedema in the early neonatal period and gestational age.

658 Cartlidge and Rutter

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Fig. 3 Correlation between the degree ofoedema and serum albumin concentration in infants with gestational age 25 to42 weeks and age rangefrom 1 day to 27 weeks. There were significant differences between grades 0 and 1 (p7 days) oedema were consideredseparately. In infants over 7 days old with a serumalbumin concentration below the 90% probabilitylimits only three out of 17 (18%) had moderate orgeneralised oedema. In comparison, of infants whohad a serum albumin concentration within the 90%probability limits, 19 out of 123 (15%) had moderateor generalised oedema. There is no significantdifference between these groups.There was no relation between the nutritional

state of the infant and serum albumin concentrationseither at birth or 3 weeks of age. There was norelation between fluid or sodium intake andoedema. Two infants with trisomy 18 had pro-nounced generalised oedema with normal serumalbumin concentrations.

Discussion

It has previously been shown that serum albuminconcentrations increase with gestation,3 6 but this isthe first study to provide data on the normal rangeof serum albumin from 26 weeks' gestation to term.

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660 Cartlidge and RutterThere are two possible explanations for the rise. It isknown that small amounts of albumin cross theplacenta.7 This transfer is probably greater towardsterm, as is the case with IgG immunoglobulin.Alternatively, the rise in serum albumin concentra-tions with gestation may be the result of increasedsynthesis by the fetal liver.8 The small postnatal risecould be due to the contraction in extracellularwater that occurs in the early neonatal period.

This study confirms the common finding of sub-cutaneous oedema, particularly in the preterm in-fant, in the early newborn period. Pronounced ormoderate oedema was common in infants below 32weeks' gestation, whereas term infants had no ormild oedema. This is one of the external criteria ofassessment of gestational age used in the Dubowitzscoring system.1 As both oedema and serum albuminconcentration are related to gestational age it is notsurprising that they correlate with each other. Thedegree of correlation is, however, poor, suggestingthat oedema in the newborn is not caused by'hypoalbuminaemia of prematurity'. The latter is anormal not a pathological finding. It is therefore veryunlikely that infusion of albumin would have anyeffect on oedema and this study offers no supportfor its use in preterm infants. Indeed, if given asplasma protein fraction the extra salt load mightincrease the oedema. The incidence of oedema inpreterm infants over 1 week old has not previouslybeen documented. Although much less commonthan in the early neonatal period, oedema waspresent in moderate or pronounced degrees in 20%of infants below 36 weeks' gestation, mainly in thosebelow 32 weeks' gestation. It showed no correlation

with serum albumin concentration and did not seemto be related to sodium and water intake.We conclude that measurement of serum albumin

concentrations in preterm infants, either routinelyor in the presence of oedema, is of little use in theirclinical management.We are grateful to Dr Curnock and Professor Milner for allowingus to study infants under their care and to the junior medical andnursing staff for their help and cooperation. We are indebted to MrSteve Fowler, CMLSO, and his staff in the Department of ClinicalChemistry for performing the albumin measurements.

References'Dubowitz LMS, Dubowitz V, Goldberg C. Clinical assessmentof gestational age in the newborn infant. J Pediatr 1970;77:1-10.

2 Guyton AC. Textbook of medical physiology. 6th ed.Philadelphia: WB Saunders, 1981:366-7.Desmond MM, Sweet LK. Relation of plasma proteins to birthweight, multiple births and edema in the newborn. Pediatrics1949;4:484-9.

4Thom H, McKay E, Gray DWG. Protein concentrations in theumbilical cord plasma of premature and mature infants. Clin Sci1967;33:433-44.

5Hyvannen M, Zeltzer P, Oh W, Stiehm ER. Influence ofgestational age on serum levels of alpha-l-fetoprotein, IgGglobulin, and albumin in newborn infants. J Pediatr1973;82:430-7.

6 Thomas JL, Reichelderfer TE. Premature infants: analysis ofserum during the first seven weeks. Clini Chemn 1968;14:272-80.

7Gitlin D, Kumate J, Urrusti J, Morales C. The selectivity of thehuman placenta in the transfer of plasma proteins from motherto fetus. J Clin Invest 1964;43:1938-51.

8 Dancis J, Braverman N, Lind J. Plasma protein synthesis in thehuman fetus and placenta. J Cliii Invest 1957;36:398-404.

Correspondence to Dr P H T Cartlidge, Department of NeonatalMedicine and Surgery, City Hospital, Hucknall Road, NottinghamNG5 1PB, England.Received 18 April 1986


and oedema in the newborn.Serum albumin concentrations

P H Cartlidge and N Rutter

doi: 10.1136/adc.61.7.6571986 61: 657-660 Arch Dis Child

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serum albuin and oedema

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