Pediatrics 2008;122:375-391.

Here is another article, also dealing with newborns with anemia of prematurity. The dosing regimen in these babies was well tolerated and could be a helpful guide in the treatment of a 4-month-old surgical patient.

Pediatrics 1994;93:918-923

Recombinant Human Erythropoietin in the Treatment of the Anemia of Prematurity: Results of a Double-Blind, Placebo-Controlled Study

Meyer MP, et al.
Department of Paediatrics and Child Health and the ‡Department of Haematology and the Leukaemia Centre, University of Cape Town and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa.

ABSTRACT. Objective. To assess the efficacy of recombinant human erythropoietin (rHuEpo) in the treatment of the anemia of prematurity.
Methodology. A double-blind, placebo-controlled study was conducted on 80 preterm infants (<32 weeks; postnatal age, 2 to 8 weeks; central hematocrit <35%). Patients were randomly assigned to receive subcutaneous rHuEpo (Eprex, 600 U/kg per week) or an equivalent volume of placebo, for up to 6 weeks. All patients received supplements of vitamin E (25 IU) and iron (3 mg/kg per day). The iron supplement was increased if declining serum ferritin measurements were noted.
Results. Treatment and placebo groups did not differ significantly with respect to mean gestational age, birth weight, hematocrit, or reticulocyte count at study entry. Fewer transfusions were administered to those receiving erythropoietin (7 compared with 21; P = .002). Compared with the placebo group, the infants receiving rHuEpo had a higher mean hematocrit (32.3 ± 4% vs 29.3 ± 6.2%; P = .014) and absolute reticulocyte count (223 ± 73 vs 124.9 ± 73 x 109/L; P < .001) at the end of the study. The mean neutrophil count was not significantly reduced at study exit (P = .8), nor at any other period during the trial in the rHuEpo group. Intercurrent events (mostly infections) were not increased in the treatment group, although there was one case of sudden infant death syndrome at age 4 months.
Conclusions. Using a dose of rHuEpo of 600 U/kg per week, this study has shown a clear reduction in the requirement for blood transfusion in preterm infants.

A six month old patient of mine is going to Columbus next week for ASD repair by this same doctor.

The newly raised concerns about overdoing the EPO make it's elective pre-op use even more challenging -- kind of like throwing a long bomb pass into the end zone. The ball has to be thrown with just the right trajectory and force, while the receiver (the patient) has to kind of cooperate and make just the right amount of progress.

If the ball is overthrown, that is too much EPO is given, or too many doses, the hematocrit could rise into the range where clots are more likely to form. For surgery this time of year, that could happen if, for instance, a flu or rsv infection occurred a few days before surgery, or something else unexpected.

I think giving 600 units per kg weekly (start the prior auth process with the third party at least two weeks beforehand) beginning one month pre-op would be reasonable in most situations (no pre-existing anemia). Give maybe 5mg/ kg day of supplemental iron, maybe an extra 200 mg extra vit C for an infant, 500 ug folate.

Figure that the hematocrit will do nothing for the first week, then start rising. Check it weekly. Back off on the last dose if it looks like the hematocrit will exceed 50. Remember, it will keep rising for at least a week after the last dose.