From the Guidelines
Intravenous immunoglobulin (IVIG) is indicated for hemolytic disease of the newborn (HDN) when the total serum bilirubin (TSB) level is rising despite intensive phototherapy or is within 2-3 mg/dL of the exchange transfusion level. This recommendation is based on the American Academy of Pediatrics guidelines for the management of hyperbilirubinemia in newborn infants 35 or more weeks of gestation 1. The dose of IVIG recommended is 0.5-1 g/kg over 2 hours, which may be repeated in 12 hours if necessary.
Key Considerations
- IVIG works by blocking Fc receptors on reticuloendothelial cells, reducing the destruction of antibody-coated red blood cells in the newborn's circulation.
- This treatment is particularly useful in Rh and ABO incompatibility cases where maternal antibodies are causing hemolysis of the infant's red blood cells.
- IVIG should be considered early in the management of HDN as it can reduce the need for exchange transfusion, which carries significant risks.
- Close monitoring of bilirubin levels, hemoglobin, and clinical status should continue after IVIG administration, as some infants may still require additional interventions.
Administration and Monitoring
- IVIG should be administered at a dose of 0.5-1 g/kg over 2 hours.
- The infusion may be repeated in 12 hours if necessary, based on the clinical response and bilirubin levels.
- Side effects of IVIG are generally mild but can include fever, chills, and rarely, anaphylaxis, so the infant should be monitored during administration 1.
Clinical Context
- The decision to use IVIG in HDN should be made based on the individual clinical scenario, taking into account the severity of hyperbilirubinemia, the rate of rise of bilirubin levels, and the presence of other risk factors for severe disease.
- The guidelines from the American Academy of Pediatrics provide a framework for decision-making, but clinical judgment is essential in determining the best course of treatment for each infant 1.
From the Research
Indications for IVIG in Hemolytic Disease of the Newborn (HDN)
- IVIG is considered in the management of severe Rh hemolytic disease of the newborn, as it has been shown to decrease the need for exchange transfusion 2.
- The use of IVIG in ABO-mediated HDN is more controversial, with some studies suggesting it may not prevent exchange transfusion or decrease the duration of phototherapy 3.
- IVIG may be considered in situations where hyperbilirubinemia is severe and exchange transfusion is imminent, or when exchange transfusion is not readily available 4.
Timing and Dosage of IVIG
- One study found that administration of IVIG at 12 hours of age was effective in reducing the need for exchange transfusion and decreasing the duration of phototherapy in severe Rh HDN 2.
- The optimal dosage of IVIG is unclear, with studies using varying doses ranging from 0.5 to 1 g/kg 2, 5.
Clinical Outcomes and Safety
- IVIG has been shown to be safe and well-tolerated in neonates with HDN, with few reported adverse effects 2, 6, 5.
- IVIG may reduce the peak total serum bilirubin levels and decrease the need for exchange transfusion, which can be associated with risks and complications 2, 6.
- However, some studies have found that IVIG may not improve clinical outcomes such as re-hospitalization rates or acute bilirubin encephalopathy 3.