You made it! On this page, you will find things to keep in mind when delivering an ISO baby. If you haven't already, it is helpful to keep a notebook and write down all your questions (and the doctor's answers) about birth and the hospital's processes. Also, make sure they will have antigen negative blood ready for baby. If you've got anti-Kell, baby needs Kell negative blood. If he needs a transfusion, you don't want to wait several hours and risk brain damage while they find blood. Don't forget to pop over to the Info page for some printables to help you keep track of all the test results.

After Birth Complications

Anemia

Jaundice

Bronze Baby Syndrome

Kernicterus

BIND

Neutropenia

Thrombocytopenia

 

After Birth Complications

Anemia

What is it?

Anemia is when the baby does not have enough blood. If the baby is too anemic, a blood transfusion is needed.


How is it found?

You can find out if baby is anemic by blood draws to check the hemoglobin or hematocrit level.


Selected Normal Pediatric Laboratory Values – Hemoglobin (24)

Age
 Females (g/dL)
 Males (g/dL)
Newborn
  12.7 - 18.3
  14.7 - 18.6
  10.4 - 12.4
  10.3 - 12.4
Selected Normal Pediatric Laboratory Values - Hematocrit (24)
Age
 Females (%)
 Males (%)
Newborn
 37.4 - 55.9
 43.4 - 56.1
 6 months - 2 years
 31.2 - 37.2
 30.9 - 37.0

What is the treatment?

The treatment for anemia is a transfusion. Depending on what symptoms baby is showing, some doctors will choose to delay transfusion to give the baby time to make more of his own blood cells. Transfusions are done through an IV into the arm, umbilical cord, or head. While this may be distressing for mom to watch, it is easier on the baby.


IRON IS NOT AN ACCEPTABLE TREATMENT FOR AN ISO BABY (47). The anemia faced by an iso baby is caused by red blood cell destruction, not iron deficiency. Many iso babies have normal or even high levels of iron and can be easily overdosed and killed from supplements. Your baby should never be given iron supplements without having his ferritin levels checked. Normal Ferritin levels are 25-200 ng/mL (46).


What is the best outcome?

After treatment, many babies begin doing much better. ISO babies are at risk of developing late onset anemia from 3 – 12 weeks old, so it is important to have your baby's hemoglobin levels checked until they are at least 12 weeks old. Some babies need checked longer, especially if they have had IUTs. In this case, you may be assigned a neonatologist, or hematologist who will follow your baby closely.


What is the worst outcome?

Untreated anemia can be fatal. Even with treatment, it is still possible for the baby to die.

Jaundice

What is it?

Jaundice is the buildup of bilirubin in the bloodstream. It can occur from a variety of causes, but the red blood cell destruction from iso can be very severe.


How is it found?

You can find out if baby is jaundice by blood draws to check the bilirubin level.


Bilirubin tends to peak around days 4-6 with ISO babies. One thing to watch out for, is rebounding jaundice. ISO babies tend to have a decrease in bilirubin when on lights, but rapidly increase when the lights are removed. This can occur up to 3-4 days after removal from lights, so keep checking the bilirubin levels even after treatment has ended.


What is the treatment?

The treatment for jaundice is phototherapy and possibly a transfusion. Depending on what symptoms baby is showing, some doctors will choose to delay transfusion to give the baby time to take care of things himself. Transfusions are done through an IV into the arm, umbilical cord, or head. While this may be distressing for mom to watch, it is easier on the baby.


Note: Iso jaundice is not the same as breastfeeding jaundice. Breastfeeding will not make your iso baby's jaundice worse. There is no formula doctors can feed the baby to reduce jaundice.


Conversely, if the baby is breastfeeding well and appears healthy and vigorous, this can be reassuring. The mother may have breastfed previous babies who also developed significant jaundice. If so, she may be one of the approximately 20-40% of women who have above-average levels of beta-glucuronidase in their breast milk, which potentiates and prolongs hyperbilirubinemia in their breastfed babies. (37)


In the presence of Rh isoimmunization, a cord bilirubin level of more than 5 mg/dL or a rate of rise in serum bilirubin of more than 0.5-1 mg/dL/h is predictive of the ultimate need for exchange transfusion. (37)

Parenteral administration of immunoglobulin G (IVIG) has been shown in controlled clinical trials to reduce the need for exchange transfusion in both Rh and ABO immune-mediated hemolytic disease. Its mechanism of action is not entirely clear.

Administration in hyperbilirubinemia resulting from isoimmune hemolytic disease that is unresponsive to phototherapy and/or is approaching exchange level has been recommended by the AAP in its 2004 revised clinical practice guideline.

Note: If IVIG was used, it can affect vaccines. No live virus vaccines for at least 7-12 months after last infusion. My dr said Ivig blocks antibodies from attaching to the cells, so any made by the body in response to the vaccine wouldn't stay, and the shots would need to be started over again. See the section on IVIG for more information.


What is the best outcome?

With proper care and treatment, baby will remove the destroyed blood cells from their system and the bilirubin levels will drop. Treated properly, there are usually no long term problems from bilirubin.


What is the worst outcome?

Untreated jaundice can cause brain damage, Kernicterus, Cerebral Palsy, BIND, and more. Jaundice can ultimately lead to death.


 

All of the babies below are jaundiced. They have varying degrees. For some it is easy to tell that they are yellow, but others are more difficult. If you look closely around the eyes and nose you should see it on most of the babies.

  • Note the yellow around the eyes.
    Note the yellow around the eyes.

Bronze Baby Syndrome

What is it?

Bilirubin in the blood is found in two forms: conjugated (direct) and unconjugated (indirect). Conjugated bilirubin has already been bound and is ready to be excreted by the body. In bronze baby syndrome, there is a build up of conjugated bilirubin that can’t get out of the body fast enough. This causes the baby to turn green, gray, bronze, or black.


How is it found?

A visual check of the baby and a blood test showing the conjugated bilirubin will confirm bronze baby syndrome.


Bilirubin tends to peak around days 4-6 with ISO babies. One thing to watch out for, is rebounding jaundice. ISO babies tend to have a decrease in bilirubin when on lights, but rapidly increase when the lights are removed. This can occur up to 3-4 days after removal from lights, so keep checking the bilirubin levels even after treatment has ended.


What is the treatment?

Treatment options include exchange transfusion, and IVIG. In some cases the removal of lights will help. Lights are there to help bind the bilirubin and get it ready to move out of the body. In bronze baby syndrome, the bilirubin is already bound, it just can’t get out of the body fast enough. Removing lights MUST be weighed carefully against baby’s trend and rate of rise, whether or not bili has peaked, and if there’s been significant rebound with light withdrawal. The presence of conjugated bilirubin and bronze baby syndrome does not mean that you should not continue phototherapy49, especially if baby is still near the exchange threshold.


Bilirubin tends to peak around days 4-6 with ISO babies. One thing to watch out for, is rebounding jaundice. ISO babies tend to have a decrease in bilirubin when on lights, but rapidly increase when the lights are removed. This can occur up to 3-4 days after removal from lights, so keep checking the bilirubin levels even after treatment has ended.


What is the best outcome?

Bronze baby syndrome is not harmful and will gradually resolve over a few weeks.


What is the worst outcome?

While bronze baby syndrome itself is not harmful, it can be a sign of other bilirubin issues such as kernicterus and bilirubin needs to be monitored closely.

Kernicterus

What is it?

Kernicterus is bilirubin staining on the baby's brain. It can cause several neurological problems.

Immune hemolytic disease, most often Rh isoimmunization (erythroblastosis fetalis), is the easiest way to get kernicterus (37).


How is it found?

Hematologic laboratory evaluation is the cornerstone of evaluation of the baby with hyperbilirubinemia. Although jaundice can be appreciated clinically, observation alone is not a reliable method to assess the severity or estimate risk factors for the infant.37 Your baby must be blood tested.


When assessing possible kernicterus, remember that a history of risk for hemolytic disease can be an important clue to a neonate's increased risk of pathologic hyperbilirubinemia, particularly Rh antigen incompatibility between mother and baby (37).

Note: Male infants have consistently higher levels of serum bilirubin than do female infants. Among infants reported in the US kernicterus registry, 67% of the patients were male (37).


Theoretically, most cases of kernicterus may be completely prevented by initiation of phototherapy in every baby shortly after birth. Therefore, this devastating neurologic disease could be prevented most of the time. As such, a significant component of medicolegal liability is introduced into the management of hyperbilirubinemia. Clinical reports of kernicterus in the absence of profound hyperbilirubinemia, coupled with the lack of definitive standards of care for the initiation of phototherapy, further complicate this exposure. As with all medical care, conformity with published clinical guidelines, rationale for departure from accepted clinical norms, and good documentation are the best defenses.

Many hospitals have developed clear documents that outline the standard for evaluation and treatment of hyperbilirubinemia, and some of these risk-management approaches have appeared in the medical literature. That being said, learned minds the world over acknowledge the lack of evidence directing best practice for neonatal hyperbilirubinemia and the complexities that will always demand individualized treatment approaches.


What is the treatment?

 The definitive method of removing bilirubin from the blood is via exchange transfusion. This is currently the indicated approach in the presence of clinical bilirubin-induced neurologic dysfunction (BIND) when the bilirubin level has reached dangerous levels despite preventive efforts. Phototherapy is the most common method aimed at prevention of bilirubin toxicity.

In the presence of Rh isoimmunization, a cord bilirubin level of more than 5 mg/dL or a rate of rise in serum bilirubin of more than 0.5-1 mg/dL/h is predictive of the ultimate need for exchange transfusion.


Parenteral administration of immunoglobulin G (IgG) has been shown in controlled clinical trials to reduce the need for exchange transfusion in both Rh and ABO immune-mediated hemolytic disease. Its mechanism of action is not entirely clear.

Administration in hyperbilirubinemia resulting from isoimmune hemolytic disease that is unresponsive to phototherapy and/or is approaching exchange level has been recommended by the AAP in its 2004 revised clinical practice guideline.

To help ensure that infants may reach their maximum neurodevelopmental potential, referring babies with bilirubin-induced neurologic dysfunction (BIND) to a neurodevelopmental pediatrician skilled in caring for these patients is important. Early identification of and intervention for neurodevelopmental deficits has been shown to positively impact an infant's long-term neurodevelopmental prognosis. (42)


What is the best outcome?
The outcome with Kernicterus varies greatly. Please refer to a Kernicterus source for more information, such as: http://www.kernicterus.org or http://www.pic-k.org or http://emedicine.medscape.com/article/975276-overview


What is the worst outcome?

Kernicterus can kill.

BIND

What is it?

Bilirubin-induced neurologic dysfunction (BIND) is the term applied to the spectrum of neurologic abnormalities associated with hyperbilirubinemia. It can be further divided into characteristic signs and symptoms that appear in the early stages (acute) and those that evolve over a prolonged period (chronic). 37


Please refer to another source for more information, such as: http://www.kernicterus.org or http://www.pic-k.org, or http://emedicine.medscape.com/article/975276-overview

Neutropenia

What is it?

Neutropenia is an abnormally low number of white blood cells. These cells, which are called neutrophils, help the body fight infection. 40


How is it found?

Neutropenia is found through a CBC and differential blood test.


What is the treatment?

In many cases, neutropenia goes away on its own as the bone marrow recovers and begins to produce enough white blood cells.

In rare cases when the neutrophil count is low enough to be life threatening, the following treatments may be recommended:

  • Medicines to stimulate white blood cell production

  • Antibodies from donated blood samples (intravenous immune globulin) (40)

 In severe cases, the granulocyte colony-stimulating factor (G-CSF) has been successfully used to increase the neutrophil counts although resistance to G-CSF has occurred due to anti-HNA-2 isoantibodies (2). On the one hand G-CSF resistance can be the result of reduced neutrophil production in the bone marrow as HNA-2 expression begins very early in myelopoiesis, on the other hand, G-CSF causes increased HNA-2 expression on the neutrophil surface promoting antibody binding and phagocytosis by macrophages. In these cases high doses of intravenous immunoglobulin (IVIG) might be an alternative although ineffective IVIG treatment of NIN has been repeatedly reported. 39


What is the best outcome?
The baby's outlook depends on the cause of the neutropenia. Isoimmune neutropenia will also get better once the mother's antibodies are out of the baby's bloodstream. (40)


What is the worst outcome?

If neutropenia is not caught, even an infection from a small cut can be deadly. However, most infections usually do not cause long-term side effects after the neutropenia goes away or is treated. (40)


Additional Information

If your baby is neutropenic, ask your doctor about waiting to do the rotavirus vaccine.

Thrombocytopenia

What is it?

Thrombocytopenia is an abnormally low number of platelets45. It is especially common after IUTs.


How is it found?

Thrombocytopenia is found through a CBC and differential blood test.


What is the treatment?

In many cases, thrombocytopenia goes away on its own, or an infusion of platelets may be necessary.

What is the best outcome?
The baby's outlook depends on the cause of the thrombocytopenia. Isoimmune thrombocytopenia will also get better once the mother's antibodies are out of the baby's bloodstream. (40)


What is the worst outcome?

If thrombocytopenia is not caught, severe bleeding can occur. Bleeding can even occur in the brain or intestinal tract. (45)