DO NOT USE FOR CLINICAL PRACTICE
Please use current guidelines available on the UHNM intranet for patient treatment
Please use current guidelines available on the UHNM intranet for patient treatment
Aim to avoid kernicterus and severe anaemia
Keep consultant in charge informed
POSTNATAL MONITORING
Babies at risk
- Those with mothers with known blood group antibodies including:
- D (Rhesus), c, C, s, E, e, Duffy
- Kell: causes bone marrow suppression in addition to haemolysis
Management of babies at risk of haemolysis
- Antenatally: prepare a plan based on antibody titres, middle cerebral artery Dopplers and evidence of hydrops. In severely affected cases, order blood in advance for exchange transfusion
- send cord blood urgently for Hb, blood group, direct Coombs test (DCT), Keilhauer test and serum bilirubin in all babies who have had an in-utero blood transfusion (IUT)
- chase results
- If pale with abnormal cardiorespiratory signs (e.g. tachycardia), admit to NNU
- If baby has positive DCT or had an IUT (regardless of DCT and blood group) discuss with middle grade or consultant
- If cord bloods not available, check baby’s blood immediately for bilirubin, Hb and DCT
- Monitor serum bilirubin, usually at 6-hrly intervals until level is both stable/falling and 2 consecutive values are lower than treatment threshold by at least >50 micromol/L
- Plot bilirubin values on NICE gestational age-specific charts (see below)
- Keep parents informed
- Discuss progress regularly with middle grade or consultant
- Use gestational age-specific charts to determine whether baby needs phototherapy or exchange transfusion
- If baby has negative DCT and did not have IUT, no further action required; baby is not affected
Management of babies with haemolysis diagnosed or suspected postnatally
- Babies with:
- positive DCT, manage as above
- red cell enzyme defect, inform consultant
PHOTOTHERAPY
Indications/treatment thresholds
Refer to NICE jaundice guideline table and treatment charts (https://www.nice.org.uk/guidance/CG98 under 'Tools and resources' then 'CG98 Neonatal Jaundice: treatment threshold graphs')
Prophylactic phototherapy (e.g. from birth) is not beneficial
DO NOT subtract the direct/conjugated bilirubin value from the total
- Inform middle grade when a baby requires phototherapy
Management
- Plot bilirubin values on appropriate gestation NICE treatment chart
- Administer phototherapy (see Jaundice guideline)
- Check bilirubin 6 hr after onset of phototherapy and at least 6-hrly until level is both stable/falling and 2 consecutive values are lower than the treatment threshold by at least >50 micromol/L
INTRAVENOUS IMMUNOGLOBULIN (IVIG)
Always discuss indications with consultant
Indications for IVIG use in isoimmune haemolytic anaemia
Indication | Bilirubin level |
IVIG indication for rapidly rising bilirubin level as recommended by NICE 2010 | Rising at >8.5 micromol/L per hour despite intensive phototherapy [4 light sources used at correct distance (see Table in Jaundiceguideline)] |
Second dose of IVIG | Rising at >8.5 micromol/L per hour despite intensive phototherapy [4 light sources used at correct distance (see Table in Jaundice guideline)] |
Dose and administration
- Complete immunoglobulin request form (this is a red indication for use; please tick relevant box on form)
- 500 mg/kg over 4 hr (see Neonatal Formulary)
EXCHANGE TRANSFUSION
Always discuss indications with consultant
See Exchange transfusion guideline
BEFORE DISCHARGE
- Check discharge Hb, bilirubin and review need for folic acid (see Jaundice guideline for dose)
FOLLOW-UP AND TREATMENT OF LATE ANAEMIA
Babies with weakly positive or 1–2+ DCT
- If baby did not require treatment for jaundice do not give folic acid, no follow-up is needed
- If baby required treatment for jaundice follow guidance below
- If uncertain about the need for follow-up, discuss with consultant
All babies with haemolytic anaemia
- Arrange Hb check and review at aged 2 weeks
- Discuss results urgently with neonatal consultant
- dependent on rate of fall of Hb from discharge Hb, frequency of Hb checks planned (may need to be as often as weekly)
- for babies who had IUT, IVIG or exchange transfusion, follow up with Hb check every 2 weeks initially, and until aged 3 months; thereafter arrange developmental follow-up (see below)
- for all other babies who had >2+ DCT, review with Hb check at 2 and 6 weeks; once Hb stable discharge from follow-up and discontinue folic acid if this has been prescribed
Indication for top-up transfusion for late anaemia
- Symptomatic anaemia
- Hb <75 g/L
Ongoing neurodevelopmental follow-up and hearing test
- Arrange for any baby:
- with definite red cell anomalies
- who has undergone an exchange transfusion
- who has had an IUT
- who required IVIG
- with serum bilirubin at or above exchange transfusion threshold