Intravenous immunoglobulin in isoimmune haemolytic disease of newborn: an updated systematic review and meta-analysis

Does strengths of a positive direct antiglobulin test predicts the need for phototherapy and duration of phototherapy? - a single center, retrospective study

BACKGROUND

Use of Direct Antiglobulin test (DAT) in management of neonatal hyperbilirubinemia is conflicting.

OBJECTIVE

whether strength of positive DAT predicts the need for phototherapy, duration of phototherapy and need for major interventions.

METHODS

We retrospectively collected data on all DAT positive neonates with birth gestational age ≥32 weeks over six years (2014-2019). Data regarding blood group, DAT and clinical details were obtained from a hospital database. We also collected data on serial hemoglobin and other relevant laboratory parameters. We also collected data on infants receiving major interventions such as exchange transfusion, in-utero transfusion, immunoglobulins, and postnatal transfusion for the duration of the study period. All of these infants were electronically followed up for a period of 6 weeks. This study was approved by institutional audit authority. All the statistics were performed using SPSS software.

RESULTS

Out of 1285 DAT tests performed, only 91 infants were positive (7%), and 78 DAT positive infants were available for analysis. There were 54 infants with DAT (1+), 15 infants with DAT (2+), 7 infants with DAT (3+) and 2 infants with DAT (4+). There was no significant statistical difference in terms of need for phototherapy, duration of phototherapy, need for major interventions and hemoglobin levels at different time points between the groups (DAT 1+ Vs DAT ≥2+; DAT ≤2+ Vs DAT >2). A Total of 10 infants received major intervention, with one infant receiving all three interventions (DAT 3+ with significant maternal antibodies), 2 additional infants (both DAT1+) received exchange transfusion, 6 additional infants received immunoglobulin (2 infants: DAT 2+; 4 infants: DAT 1+) and one additional infant (DAT 1+) with significant maternal antibodies received a postnatal transfusion.

CONCLUSION

Strength of a DAT did not predict the need for phototherapy, duration of phototherapy, and the need for major hemolysis related intervention in the first 6 weeks of life.

History and current standard of postnatal management in hemolytic disease of the fetus and newborn

Since the discovery of the Rh blood group system in 1940, a greater understanding of hemolytic disease of the fetus and newborn (HDFN) was gained. In the years thereafter, researchers and clinicians came to the current understanding that fetal and neonatal red blood cells (RBC) are hemolyzed by maternal alloantibodies directed against RBC antigens potentially leading to severe disease. Preventative measures, such as Rhesus(D) immunoprophylaxis (RhIG), have greatly decreased the prevalence of Rh(D)-mediated HDFN, although a gap between high-income countries and middle- to low-income countries was created largely due to a lack in availability and high costs of RhIG. Other important developments in the past decades have improved the identification, monitoring, and care of pregnancies, fetuses, and neonates with HDFN. Prenatally, fetal anemia may occur and intrauterine transfusions may be needed. Postnatally, pediatricians should be aware of the (antenatally determined) risk of hemolysis in RBC alloimmunization and should provide treatment for hyperbilirubinemia in the early phase and monitor for anemia in the late phase of the disease. Through this review, we aim to provide an overview of important historic events and to provide hands-on guidelines for the delivery and postnatal management of neonates with HDFN. Secondarily, we aim to describe recent scientific findings and evidence gaps.

CONCLUSION

 Multiple developments have improved the identification, monitoring, and care of pregnancies and neonates with HDFN throughout the centuries. Pediatricians should be aware of the (antenatally determined) risk of hemolysis in RBC alloimmunization and should provide treatment for hyperbilirubinemia in the early phase and monitor for late anemia in the late phase of the disease. Future studies should be set in an international setting and ultimately aim to eradicate HDFN on a global scale.

WHAT IS KNOWN

• Developments have led to a greater understanding of the pathophysiology, an improved serological identification and monitoring of at-risk cases and the current pre- and postnatal treatment.

WHAT IS NEW

• This review provides the pediatrician with hands-on guidelines for the delivery and postnatal management of neonates with HDFN. • Future studies should be set in an international setting with the ultimate aim of eradicating HDFN.

Immunoglobulin for hemolytic jaundice in Japan: A retrospective survey

BACKGROUND

Intravenous immunoglobulin G (IVIG) is used to treat blood-type incompatibility hemolytic disease of newborns (BTHDN). Although IVIG's efficacy for treating BTHDN has been challenged, as an updated systematic review suggests, IVIG could significantly reduce exchange transfusions. We conducted a mail-in questionnaire survey to ascertain actual use of IVIG for BTHDN in Japan.

METHODS

The survey, conducted in 2014, included infants born between January 1, 2009, and December 31, 2013. Questionnaires were sent to the heads of neonatal intensive care units (NICUs) at perinatal centers of the Japan Neonatologist Association.

RESULTS

A total of 195 centers (64.6%) responded to the questionnaire. During the study period, 170 centers (87.2%) reported incidences of BTHDN. Among these centers, there were 1726 diagnosed cases of BTHDN in neonates. Of these cases, 419 infants were treated with IVIG in 127 centers, representing approximately 74.7% of all centers. After the exclusion of cases with missing data and those where consent for data usage was not obtained, a total 916 infants were included in this study. Of these, 219 (23.9%) were treated with IVIG after phototherapy, and 187 (20.4%) of these infants did not require further blood exchange transfusion. The IVIG dosages ranged from 40 to 1200 mg/kg/dose, but the majority were between 500 and 1000 mg/kg/dose, with a median of 800 mg/kg/dose. About 20% of the infants treated with IVIG showed late-onset anemia and required treatment. Adverse events were reported in less than 1% of infants.

CONCLUSIONS

For the treatment of BTHDN, IVIG administration was widely used in NICUs in Japan without severe adverse events.

[Interpretation of "International guidelines regarding the role of IVIG in the management of Rh- and ABO-mediated haemolytic disease of the newborn"]

International guidelines regarding the role of intravenous immunoglobulin (IVIG) in the management of Rh- and ABO-mediated haemolytic disease of the newborn was drafted by an international panel of experts in the fields of hematology, neonatology, and blood transfusion and was published in British Journal of Haematology on March 16, 2022. The guidelines summarize the evidence-based practice of IVIG in Rh- and ABO-mediated haemolytic disease of the newborn and propose related recommendations. The guidelines recommend that IVIG should not be applied as a routine treatment regimen for Rh- and ABO-mediated haemolytic disease of the newborn in order to reduce exchange transfusion (ET), and the best time to apply IVIG remains unclear in the situations where hyperbilirubinaemia is severe (approaching or exceeding the ET threshold) or ET cannot be implemented. These guidelines are formulated with rigorous methods, but with the lower quality of evidence.

Hemolytic Disease of the Newborn: A Community Hospitalist Perspective

Hemolytic disease of the newborn is commonly diagnosed and managed by pediatric and newborn hospitalists. Severe cases, however, pose unique challenges for community hospitals without higher level neonatal intensive care units. This case highlights the challenges faced by pediatric hospitalists in the community and suggests a focused approach to management.

International guidelines regarding the role of IVIG in the management of Rh- and ABO-mediated haemolytic disease of the newborn

Haemolytic disease of the newborn (HDN) can be associated with significant morbidity. Prompt treatment with intensive phototherapy (PT) and exchange transfusions (ETs) can dramatically improve outcomes. ET is invasive and associated with risks. Intravenous immunoglobulin (IVIG) may be an alternative therapy to prevent use of ET. An international panel of experts was convened to develop evidence-based recommendations regarding the effectiveness and safety of IVIG to reduce the need for ETs, improve neurocognitive outcomes, reduce bilirubin level, reduce the frequency of red blood cell (RBC) transfusions and severity of anaemia, and/or reduce duration of hospitalization for neonates with Rh or ABO-mediated HDN. We used a systematic approach to search and review the literature and then develop recommendations from published data. These recommendations conclude that IVIG should not be routinely used to treat Rh or ABO antibody-mediated HDN. In situations where hyperbilirubinaemia is severe (and ET is imminent), or when ET is not readily available, the role of IVIG is unclear. High-quality studies are urgently needed to assess the optimal use of IVIG in patients with HDN.

Is intravenous immunoglobulin a risk factor for necrotizing enterocolitis in neonates with haemolytic disease of the newborn? A retrospective cohort study

BACKGROUND AND OBJECTIVES

To assess whether the use of intravenous immunoglobulin (IVIG) in late-preterm and term newborns with haemolytic disease of the newborn (HDN) is associated with an increased risk of necrotizing enterocolitis (NEC).

MATERIALS AND METHODS

A retrospective cohort study was conducted in a tertiary centre. Infants with HDN during early neonatal period (<7 days) who were of ≥34 weeks' gestation and born between January 2019 and October 2021 were included. Propensity score, interaction as well as univariate and multiple logistic regression analyses were employed.

RESULTS

One-thousand two-hundred and fifty-nine infants with HDN were enrolled, of whom 192 (15.3%) received IVIG. NEC was diagnosed in 29 (2.3%) patients with 5 (2.6%) in the IVIG group and 24 (2.2%) in the non-IVIG group. No significant association between IVIG administration and confirmed NEC was observed using univariate analysis (p > 0.05). The possible predictors of NEC, as assessed by multivariate analysis, were caesarean delivery, haemoglobin on admission <130 g/L and patent ductus arteriosus (PDA). There was no interactive effect of IVIG against NEC for prematurity, low birth weight, caesarean delivery, haemoglobin on admission <130 g/L and PDA.

CONCLUSIONS

In late-preterm and term infants with HDN, there was no evidence that the early use of IVIG led to the development of NEC.

Different Types of Minor Blood Group Incompatibility Causing Haemolytic Disease of Neonates in one of the National Children's Medical Centre in China

Purpose

To review the neonatal cases with different types of minor blood group incompatible haemolytic diseases in China, and to improve the clinical understanding and management.

Materials and Methods

Seven cases from January, 1st, 2013 to December 31st, 2019 were searched out and reviewed retrospectively. All clinical data and laboratory findings were collected.

Results

There were totally seven cases enrolled including three cases of MNS, three of Diego, and one of Kidd combined with Rh, anti-RhE incompatibility. Among the seven cases, two had intrauterine transfusion, two underwent exchange transfusion, five received intravenous immune globulin, five cases developed anaemia, and three of them had transfusion. But among them, only four were found to have positive antibody screening and three were confirmed HDN with antibody types antenatally.

Conclusion

The clinical presentation is diverse. Antibody screening followed by the technique of peak systolic velocity in the fetal middle cerebral artery (MCA-PSV) helps to filter out the severe cases.

Exchange transfusion for hemolytic hyperbilirubinemia: could some be averted by emergent administration of an inhibitor of bilirubin production?

OBJECTIVES

The objective of this study is to explore the hypothetical number of neonates where an exchange transfusion (ET) could be prevented by emergency administration of an inhibitor of bilirubin production.

STUDY DESIGN

We identified all neonates who received an ET in our NICUs during the past 12 years. We reviewed the indications for ET and recorded the time between ordering and beginning the exchange.

RESULTS

Forty-six neonates underwent ET, 37 (80.4%) for hemolytic hyperbilirubinemia (36.9 ± 2.9 weeks gestation and 2.5 ± 2.1 days old at ET). The mean delay period was 7.5 ± 3.5 h. Nine (19.6%) had ET not involving bilirubin.

CONCLUSIONS

A trial testing compounds that can inhibit bilirubin production would have about three eligible neonates/years in our system. Since our births are 1% of national, up to 300 neonates/years might qualify for such a study.

Hemolysis due to Alpha-Hemolytic Enterococcus Urinary Infection: A Rare Cause of Early and Severe Unconjugated Hyperbilirubinemia in a Neonate

The reason for reporting this case is to remind that some microorganisms may cause hemolysis leading to early and severe hyperbilirubinemia by secreting hemolysin in cases; where bilirubin levels cannot be successfully decreased despite effective phototherapy, intravenous immunoglobulin, and even exchange transfusion, or in cases of increased rebound bilirubin (although urinary tract infection is associated with increased conjugated bilirubin fraction and prolonged jaundice). The most common causes of hemolysis are ABO/Rh incompatibility and enzyme deficiencies such as glucose-6-phosphate dehydrogenase (G6PDH), pyruvate kinase (PK), and galactose-1-phosphate uridyltransferase (GALT). Our patient was a male infant, weighing 3,160 g, at 38 + 4 gestational week; he was referred to our unit with total bilirubin level of 14.7 mg/dL recorded at the postnatal 20th hour and was initiated treatment with intensive phototherapy and prepared for exchange transfusion. The G6PD, PK, and GALT enzyme levels studied at the postnatal 96th hour and reducing substances in urine were detected to be normal/negative, whereas complete urinalysis revealed pyuria (7 leukocytes per each high power field). α-hemolysis-producing 105 colony-forming unit/mL Enterobacter cloacae grew on blood agar in the urine culture. As reported in our case, hemolysin-secreting α and β-hemolytic bacteria can lead to severe and early hemolysis and unconjugated hyperbilirubinemia, as in blood type incompatibility and enzyme deficiencies.

Intravenous immunoglobulin G in the treatment of ABO hemolytic disease of the newborn during the early neonatal period at a tertiary academic hospital: a retrospective study

OBJECTIVE

To evaluate the efficacy and safety of intravenous immunoglobulin G (IVIG) in infants with ABO hemolytic disease of the newborn (HDN).

METHODS

Infants with moderate-to-severe ABO HDN during early neonatal period (<7 days) at our hospital in 2017 were included in this retrospective study. Patients treated with IVIG and phototherapy were classified as the IVIG group, and those who only received phototherapy were classified as the phototherapy only group.

RESULTS

Forty-six patients were classified into the IVIG group and 68 other patients were classified into the phototherapy only group. There was no significant difference in duration of phototherapy, hospitalization periods, needs for exchange transfusion, transfusions, and incidence of bilirubin-induced neurological sequelae between these two groups (P = 0.20, 0.27, 0.65, 0.47, 0.78, respectively).

CONCLUSION

It seems unnecessary to expose neonates to IVIG in moderate-to-severe ABO HDN when the available data show no appreciable benefits.

Rh Alloimmunisation: Current Updates in Antenatal and Postnatal Management

In spite of advances in medical science, Rh alloimmunisation remains one of the leading causes of preventable neuro-morbidities and significant neonatal hyperbilirubinemia in lower-middle income countries. Despite availability of effective antenatal preventive strategy (Anti-D), its uptake in antenatal period is low due to ignorance. Further, once diagnosed, there is lack of adequate antenatal follow up in health care facility. Some of these cases even remain undiagnosed in antenatal period only to present as a case of severe hyperbilirubinemia and kernicterus in late neonatal period. Thus, there is an urgent need for creating awareness and educating health care professionals for early detection and timely management in both antenatal and postnatal period. Following two doses of anti-D prophylaxis (one in antenatal period and one in immediate postnatal period) the incidence of Rh alloimmunisation can reduce to <1%. It is recommended to follow all Rh alloimmunised pregnancies antenatally with serial indirect Coombs test titre (till critical titre is reached) followed by serial Doppler velocimetry of middle cerebral artery in a perinatal centre where facility for intrauterine transfusion as well as advanced neonatal care is available. Postnatal management of these infants comprises of confirmation of diagnosis, aggressive phototherapy and in selective cases, double volume exchange transfusion. With appropriate antenatal and postnatal management, the prognosis of Rh alloimmunised pregnancy remains favourable and long term outcome of Rh alloimmunised infants remain comparable with their normal counterparts.

Intravenous Immune Globulin Uses in the Fetus and Neonate: A Review

Intravenous immune globulin (IVIG) is made after processing plasma from healthy donors. It is composed mainly of pooled immunoglobulin and has clinical evidence-based applications in adult and pediatric populations. Recently, several clinical applications have been proposed for managing conditions in the neonatal population, such as hemolytic disease of the newborn, treatment, and prophylaxis for sepsis in high-risk neonates, enterovirus parvovirus and COVID-19 related neonatal infections, fetal and neonatal immune-induced thrombocytopenia, neonatal hemochromatosis, neonatal Kawasaki disease, and some types of immunodeficiency. The dosing, mechanism of action, effectiveness, side effects, and adverse reactions of IVIG have been relatively well studied in adults but are not well described in the neonatal population. This review aims to provide the most recent evidence and consensus guidelines about the use of IVIG in the fetus and neonate.

Neonatal Indirect Hyperbilirubinemia

Neonatal indirect hyperbilirubinemia (IHB) is caused by an imbalance in bilirubin production and elimination. Approximately 60% of term and 80% of preterm infants develop jaundice in the first week of age. This review seeks to provide the reader with a thorough understanding of the physiology of bilirubin, etiology of IHB, and management of severe IHB. Phototherapy and exchange transfusion remain the mainstays of treatment for severe IHB. Noninvasive screening tools, innovative treatments, and a better understanding of how prematurity and genetics contribute to severe IHB have improved our understanding of IHB and may help eliminate the hazards associated with severe IHB, including kernicterus spectrum disorder.

RhIg for the prevention Rh immunization and IVIg for the treatment of affected neonates

Rhesus D (RhD) negative pregnant women carrying an RhD positive fetus are at risk of developing anti-D during or after pregnancy. Anti-d-immunoglobulin (RhIg), which is mainly produced from special plasma donated in a few countries for the whole world, is able to prevent an anti-D alloimmunization. Through the introduction of ante- and postnatal anti-d-prophylaxis into clinical routine, the frequency of hemolytic disease of fetus and newborn decreased considerably. Postnatal prophylaxis from the beginning in the 1960s has been applied only to women who delivered an RhD positive newborn. Because the fetal RhD status can be determined with high sensitivity and accuracy from the mother's peripheral blood, targeted antenatal anti-d-prophylaxis is becoming a new standard procedure in more and more countries. Phototherapy and exchange transfusion are still the main pillars for the treatment of RhD hemolytic disease of the newborn. The efficacy of IVIg in the management of these neonates is not conclusive and cannot be recommended until a larger randomized, double-blind, placebo-controlled study is performed.

Efficacy of zinc sulfate on indirect hyperbilirubinemia in premature infants admitted to neonatal intensive care unit: a double-blind, randomized clinical trial

Background

Hyperbilirubinemia is a common neonatal problem. Studies conducted on the effectiveness of zinc salts on serum indirect bilirubin levels in newborns have yielded different results, all calling for further research. This study aimed to determine the effect of oral zinc sulfate on indirect hyperbilirubinemia in preterm infants admitted to the neonatal intensive care unit.

Methods

A randomized double-blind clinical trial was performed in the neonatal intensive care unit of Vali-e-Asr Hospital in Birjand, Iran. The study population comprised neonates aged between 31 and 36 gestational weeks, who required phototherapy in the neonatal intensive care unit. A total of 60 neonates were selected by census and allocated into an experimental group and a control group. In addition to phototherapy, the experimental group received 1 cc/Kg zinc sulfate syrup (containing 5 mg/5 cc zinc sulfate; Merck Company, Germany), and the control group received a placebo syrup (containing 1 cc/kg sucrose). Data were analyzed in SPSS-21 software using the independent t-test, repeated-measures ANOVA, Bonferroni post-hoc test, and Mann-Whitney test. P-values smaller than 0.05 were considered significant.

Results

Bilirubin level changes in the experimental and control groups six hours after intervention were − 1.45 ± 3.23 and − 0.49 ± 0.37 (p = 0.024), respectively. The changes 24 and 48 h after intervention were-3.26 ± 2.78 and − 1.89 ± 1.20 (p = 0.017) in the experimental group and − 4.89 ± 2.76 and − 3.98 ± 2.32 (p = 0.23) in the control group, respectively. There was no significant difference in the phototherapy duration between the two groups (p = 0.24).

Conclusions

The results of this study showed that the use of zinc sulfate syrup in preterm infants with indirect hyperbilirubinemia significantly reduced bilirubin levels within 48 h of treatment.

Trial registration

Trial registration: IRCT, IRCT2015120825439N1. Registered 21 February 2016, http://irct.ir/trial/21277

Severe ABO Hemolytic Disease of the Newborn Requiring Exchange Transfusion

ABO incompatibility (ABOi), the most common cause of hemolytic disease of the newborn (HDN), is nearly always mild and treatable with phototherapy. Reports of ABOi HDN requiring neonatal exchange transfusion are extremely rare since the inception of modern guidelines. Here, a case of ABOi HDN clearly met criteria for exchange transfusion. An O-positive African American mother delivered a B-positive neonate that quickly developed hyperbilirubinemia. The neonatal DAT was positive from anti-B and anti-A,B, and maternal IgG titer was 1024. Double volume exchange transfusion resulted in a favorable outcome. Given early discharge of newborns, further understanding of factors predicting severe disease is needed.

Immunoglobulin for alloimmune hemolytic disease in neonates

BACKGROUND

Exchange transfusion and phototherapy have traditionally been used to treat jaundice and avoid the associated neurological complications. Because of the risks and burdens of exchange transfusion, intravenous immunoglobulin (IVIg) has been suggested as an alternative therapy for alloimmune hemolytic disease of the newborn (HDN) to reduce the need for exchange transfusion.

OBJECTIVES

To assess the effect and complications of IVIg in newborn infants with alloimmune HDN on the need for and number of exchange transfusions.

SEARCH METHODS

We performed electronic searches of CENTRAL, PubMed, Embase (Ovid), Web of Science, CINAHL (EBSCOhost), Academic Search Premier, and the trial registers ClinicalTrials.gov and controlled-trials.com in May 2017. We also searched reference lists of included and excluded trials and relevant reviews for further relevant studies.

SELECTION CRITERIA

We considered all randomized and quasi-randomized controlled trials of IVIg in the treatment of alloimmune HDN. Trials must have used predefined criteria for the use of IVIg and exchange transfusion therapy to be included.

DATA COLLECTION AND ANALYSIS

We used the standard methods of Cochrane and its Neonatal Review Group. We assessed studies for inclusion and two review authors independently assessed quality and extracted data. We discussed any differences of opinion to reach consensus. We contacted investigators for additional or missing information. We calculated risk ratio (RR), risk difference (RD) and number needed to treat for an additional beneficial outcome (NNTB) for categorical outcomes. We calculated mean difference (MD) for continuous variables. We used GRADE criteria to assess the risk of bias for major outcomes and to summarize the level of evidence.

MAIN RESULTS

Nine studies with 658 infants fulfilled the inclusion criteria. Term and preterm infants with Rh or ABO (or both) incompatibility were included. The use of exchange transfusion decreased significantly in the immunoglobulin treated group (typical RR 0.35, 95% CI 0.25 to 0.49; typical RD -0.22, 95% CI -0.27 to -0.16; NNTB 5). The mean number of exchange transfusions per infant was also significantly lower in the immunoglobulin treated group (MD -0.34, 95% CI -0.50 to -0.17). However, sensitivity analysis by risk of bias showed that in the only two studies in which the treatment was masked by use of a placebo and outcome assessment was blinded, the results differed; there was no difference in the need for exchange transfusions (RR 0.98, 95% CI 0.48 to 1.98) or number of exchange transfusions (MD -0.04, 95% CI -0.18 to 0.10). Two studies assessed long-term outcomes and found no cases of kernicterus, deafness or cerebral palsy.

AUTHORS' CONCLUSIONS

Although overall results show a significant reduction in the need for exchange transfusion in infants treated with IVIg, the applicability of the results is limited because of low to very low quality of evidence. Furthermore, the two studies at lowest risk of bias show no benefit of IVIg in reducing the need for and number of exchange transfusions. Based on these results, we have insufficient confidence in the effect estimate for benefit of IVIg to make even a weak recommendation for the use of IVIg for the treatment of alloimmune HDN. Further studies are needed before the use of IVIg for the treatment of alloimmune HDN can be recommended, and should include blinding of the intervention by use of a placebo as well as sufficient sample size to assess the potential for serious adverse effects.

Intravenous immunoglobulin in the management of a rare cause of hemolytic disease of the newborn: Anti-SARA antibodies

Hemolytic disease of newborn (HDN) is a condition that develops in a fetus, when the IgG molecules produced by the mother pass through the placenta and attack the fetal red blood cells. HDN can occur due to Rh and ABO incompatibilities between the mother and the fetus as well as due to other allo-immune antibodies belonging to Kell (K and k), Duffy (Fya), Kidd (Jka and Jkb), and MNS (M, N, S, and s) systems. Role of intravenous immunoglobulin in management of HDN is not clear.SARA red blood cell antigen, first discovered in 1990 is a low frequency antigen. We report, a multiparous female whose pregnancy was complicated by HDN due to anti-SARA antibodies requiring both exchange transfusion and intravenous immunoglobulin. The response was sustained after intravenous immunoglobulin (IVIG) rather than after exchange transfusion.

Use of intravenous immunoglobulin in neonates at a tertiary academic hospital: a retrospective 11-year study

BACKGROUND

Intravenous immunoglobulin (IVIG) is used to treat a variety of diseases in the neonatal intensive care unit (NICU). Although audits have reported on the spectrum of IVIG use in adults, the indications and utilization in neonates has not been investigated. The objectives of this study were to describe the usage pattern of and indications for IVIG in a tertiary care NICU.

STUDY DESIGN AND METHODS

A retrospective chart review was performed of all neonates who received IVIG in the NICU from January 2003 to December 2013. Data collected included patient demographic features, antenatal maternal details, neonatal laboratory results, treatment details, adverse events, and patient outcome.

RESULTS

Thirty-seven neonates received IVIG over the 11-year period. Twenty-three (67%) were treated for hemolytic disease of the newborn (HDN); 13 treatments were ABO related, six were anti-D related, and four were for clinically significant antibodies. Fourteen (33%) were treated for non-HDN causes, including eight for septic neonates, two for neonates with necrotizing enterocolitis, two for neonates with a clinically significant antibody but without evidence of hemolysis, and two for neonates with glucose 6-phosphate dehydrogenase deficiency. A complete hemolytic workup was not performed consistently before the receipt of IVIG.

CONCLUSIONS

This novel assessment of IVIG use in the NICU revealed the spectrum of disease for which IVIG is ordered. This study also found that key diagnostic tests needed to confirm an immune etiology for idiopathic jaundice are not performed routinely before IVIG receipt. Neonatal transfusion-related databases are needed to carry out pragmatic clinical trials to establish better evidence-based guidelines for IVIG therapy in the NICU.

Delayed cord clamping in red blood cell alloimmunization: safe, effective, and free?

Hemolytic disease of the newborn (HDN), an alloimmune disorder due to maternal and fetal blood type incompatibility, is associated with fetal and neonatal complications related to red blood cell (RBC) hemolysis. After delivery, without placental clearance, neonatal hyperbilirubinemia may develop from ongoing maternal antibody-mediated RBC hemolysis. In cases refractory to intensive phototherapy treatment, exchange transfusions (ET) may be performed to prevent central nervous system damage by reducing circulating bilirubin levels and to replace antibody-coated red blood cells with antigen-negative RBCs. The risks and costs of treating HDN are significant, but appear to be decreased by delayed umbilical cord clamping at birth, a strategy that promotes placental transfusion to the newborn. Compared to immediate cord clamping (ICC), safe and beneficial short-term outcomes have been demonstrated in preterm and term neonates receiving delayed cord clamping (DCC), a practice that may potentially be effective in cases RBC alloimmunization.

Predictors of Repeat Exchange Transfusion for Severe Neonatal Hyperbilirubinemia

OBJECTIVES

To identify the predictors of repeat exchange transfusion among infants with severe hyperbilirubinemia.

DESIGN

Retrospective cross-sectional study.

SETTING

A referral children's hospital in inner-city Lagos, Nigeria.

PATIENTS

Infants who received exchange transfusion for severe hyperbilirubinemia from January 2012 to December 2014.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

The predictors of repeat exchange transfusion were identified among all infants who had at least one exchange transfusion using multivariable logistic regression. A total of 352 infants with mean peak total serum bilirubin of 26.32 ± 7.96 mg/dL received exchange transfusion; of these, 49 (13.9%) with mean peak total serum bilirubin of 32.85 ± 10.54 mg/dL had repeat exchange transfusion. More than two thirds of infants who received exchange transfusion and repeat exchange transfusion were male, and at least one third had ABO incompatibility. No infant had more than two exchange transfusions. The mean age of admission was approximately 5 days (range, 1-14 d). Peak total serum bilirubin greater than or equal to 30 mg/dL (odds ratio, 2.88; 95% CI, 1.46-5.70) and acute bilirubin encephalopathy (odds ratio, 2.37; 95% CI, 1.18-4.77) were predictive of repeat exchange transfusion.

CONCLUSIONS

Acute bilirubin encephalopathy and excessive total serum bilirubin levels at least 30 mg/dL are predictive of repeat exchange transfusion. A risk assessment framework that combines total serum bilirubin levels, acute bilirubin encephalopathy status, and risk factors of neurotoxicity should be considered for the timely detection and monitoring of infants at risk of repeat exchange transfusion.

Neonatal Jaundice in Low- and Middle-Income Countries: Lessons and Future Directions from the 2015 Don Ostrow Trieste Yellow Retreat

Severe neonatal hyperbilirubinemia, defined as total serum bilirubin (TSB) ≥20 mg/dl, is associated with a higher risk of permanent neurological sequelae and death. Jaundice can and should be promptly diagnosed and treated. Reliable methods for TSB assay are not always readily available, particularly in low- and middle-income countries, making the true incidence of severe neonatal jaundice (NNJ) difficult to estimate. To gather a more comprehensive picture, a symposium addressing NNJ worldwide was organized during the 2015 Don Ostrow Trieste Yellow Retreat. Data collected by several researchers in different regions of the world were presented and differences/similarities discussed. This report points out the need for: (1) a coordinated worldwide effort to define the burden and the causes of severe NNJ and its consequences; (2) aggressive educational programs for families and health personnel to facilitate timely care-seeking, and (3) accurate diagnostics and effective phototherapy.