A colleague in Wisconsin reports that from time to time a baby may be discharged from their hospital following treatment for immune mediated hemolytic disease of the newborn (HDN), only to return unexpectedly days later with a very low hemoglobin and a requirement for one or more transfusions. In an effort to minimize unexpected readmission of neonates due to delayed effects of HDN, the hospital developed an "HDN Directive" (MS Word document) to guide pediatricians to obtain certain lab tests and a Neonatal Consultation for all "at risk" babies. According to the Wisconsin colleague, this HDN Directive keeps more people "in the loop", especially the Neonatal Consult. The HDN Directive also helps to protect HDN babies by:

1. Explaining the need for in-house neonatal consultation for babies at-risk of HDN.
   
   
2. Educating neonatologists about the importance of certain lab tests post-discharge, especially follow up hematocrits.

The Wisconsin colleague would appreciate any feedback from the e-Network Forum.

The following responses have been received.

ADDENDA Dec. 17, 2003

1. A colleague at an academic center in Michigan (whose football team is going to be playing the Editor's football team on New Year's day) has requested clarification of the HDN Directive. According to the inquiring colleague, the HDN Directive is unclear as to which babies are considered at risk. The inquiring colleague adds that if the mother is known to be alloimmunized, then some limited serological testing of the newborn is warranted, and the infant should be monitored for hyperbilrubinemia and anemia, and treated accordingly. Such testing might include an ABO and Rh type (in case transfusion is needed), a DAT with anti-IgG, and Hb/Hct and bilirubin levels.

2. The colleague from Wisconsin who submitted the HDN Directive for review responds to the above query as follows:

According to the HDN Directive, babies at risk for hemolytic anemia will have neonatology consultation and serial lab work. The directive is meant to safeguard babies with known HDN risk by doing the following:

• Include an NICU physician at delivery.
• Include some recommended labs, to be done after delivery, as well as to guide patient follow up by the pediatrician (i.e. weekly HCT, and possibly bilirubin levels)

The Wisconsin colleague adds that the HDN Directive is NOT meant to monitor all newborns, just those at risk of HDN, as defined by their perinatologists. He adds that they have quite a few HDN at-risk babies, that sometimes require PUBS: sometimes babies get the PUBS transfusions, and sometimes they do not, based on the results of Doppler studies, etc. He reports that they have run into more problems when the HDN at-risk babies do NOT get transfused, because everything looks great at delivery, with fairly normal bilirubin levels (full term newborn), but the DAT many times is positive, and sometimes these babies return to their institution needing additional followup care. Their perinatologist defines which babies are "at risk" for HDN and dictates directions for followup care and neonatal consult.

Please submit comments to the e-Network Forum.

Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator