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

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')

• 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

Indications for IVIG use in isoimmune haemolytic anaemia

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)

See Exchange transfusion guideline

• Check discharge Hb, bilirubin and review need for folic acid (see Jaundice guideline for dose)

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