Postnatal hemolytic disease management varies significantly worldwide, consensus needed
Click Here to Manage Email Alerts
Key takeaways:
- Practice patterns vary widely for management of hemolytic disease of the fetus and newborn (HDFN).
- Researchers are calling for standardized guidelines to manage neonates with HDFN.
Postnatal treatment approaches to hemolytic disease of the fetus and newborn vary significantly worldwide, highlighting the need for better practice agreements to improve care, according to results of a cohort study.
“Studies to quantify the effect of different clinical policies have been challenging, owing to the disease’s rarity,” Derek P. de Winter, MD, a doctoral student in the department of pediatrics and the division of neonatology at Willem-Alexander Children’s Hospital at the Leiden University Medical Center in the Netherlands, told Healio. “In this study, we established a positive clinical association of delivery at term gestation on the exchange transfusion frequency and likelihood of adverse neonatal outcome in affected neonates.”
International practices
De Winter and colleagues conducted an international, retrospective cohort study with 1,855 neonates (median gestational age at delivery, 36.4 weeks) with hemolytic disease of the fetus and newborn (HDFN) born between 2006 and 2021 at 31 expert centers in 22 countries. Researchers evaluated postnatal HDFN management and outcomes variations internationally as part of an effort to improve care.
The findings were published in JAMA Network Open.
Primary outcomes were exchange transfusion frequency, IV immunoglobulin administration, erythropoiesis-stimulating agent administration, red blood cell transfusions and the association between gestational age at delivery with exchange transfusion frequency and risk factors for adverse neonatal outcomes.
Overall, 54.8% of neonates received any form of antenatal treatment and 78% had anti-D antibodies.
Less than one-quarter of neonates (23.5%) received exchange transfusions with wide variation among centers in proportions of frequency from 0% to 78%. Nearly one-quarter of neonates (24.6%) received IV immunoglobulin with even wider variation of 0% to 100%.
Researchers observed an association between higher gestational age at delivery and reduced exchange transfusion frequency for neonates with intrauterine transfusion from about 38.2% at 34 weeks’ gestation to 16.8% after 37 weeks’ gestation. In addition, a weekly increase in gestational age at delivery was associated with a 43.3% reduction in adverse neonatal outcome likelihood (P < .001).
“Contrary to the standard clinical approach of inducing delivery before 37 weeks’ gestation, we provide further evidence to support a policy of delivery at term gestation,” de Winter told Healio.
Neonates who received exchange transfusions had an increased likelihood of experiencing unfavorable outcomes compared with those who did not (OR = 1.55; 95% CI, 1.1-2.18; P = .01).
“We demonstrated high variability in many aspects of the postnatal management of HDFN. Expert consensus studies are needed to establish expert-based clinical guidance and limit variability between centers,” de Winter told Healio. “Future research should aim to consolidate data through an international, prospective registry to uncover additional opportunities for enhancing care and standardizing practices.”
International consensus needed
In an accompanying editorial published in JAMA Network Open, Tina M. Slusher, MD, professor in the department of pediatric critical care medicine at the University of Minnesota and the department of pediatrics at Hennepin Healthcare, and colleagues noted that the findings “paint a picture” of some international confusion on optimal hemolytic disease management.
“This study highlights the need for continued systematic study of postnatal HDFN management, even if the data are better generalized to high-income countries,” the authors wrote. “We argue that high-income countries should bear a large proportion of the costs for studying expensive treatments such as IV immunoglobulin and erythrocyte-stimulating agents but should partner with low- and middle-income countries with a high burden of this disease to conduct even more impactful studies.”
Slusher and colleagues noted researchers should carefully study less-invasive treatments, including optimized delivery timing, adding blood or blood products without removing any blood, follow-up for late anemia, and follow-up for infants and children who had HDFN as neonates, to better inform guidelines for the management of neonates with HDFN.
“Only then will we be able to objectively determine the best evidence-based treatment for HDFN globally standing on the shoulders of the pioneers and giants in this field,” Slusher wrote.
For more information:
Derek P. de Winter, MD, can be reached at d.p.de_winter@lumc.nl.