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It was interesting to read an excellent review in the January 2004 edition of Archives devoted to the topic of blood transfusion.1 At the same time the issues of haemolytic disease in the newborn (HDN) and alternatives to exchange transfusion (ET), were treated as follows: “A recent systematic review has shown that fewer infants require exchange transfusion for haemolytic disease of the newborn when high dose intravenous immunoglobulin is used”.2 Neonatologists generally applaud the efforts made in an attempt to achieve a “bloodless” solution to the treatment of Rh and/or AB0 HDN in a newborn whose parents are Jehovah’s Witnesses.
In 1999 we published a case of an AB0 incompatible term infant girl born to parents who were Jehovah’s Witnesses.3 The infant was admitted to our neonatal unit with a high serum bilirubin level necessitating ET. The parents signed a request that blood should not be administered under any circumstances. However, they authorised the use of alternative treatments: orally administered D-penicillamine (DPA) (300 mg/kg per day divided into three doses over three days), phototherapy, intravenous fluids, and recombinant human erythropoietin (200 U/kg subcutaneously on every second day for two weeks). Furthermore, we reported the outcome of this infant, who was discharged from the unit in good health following treatment. Her physical growth and motor milestones at 3 years of age revealed no red flags for neurodevelopmental maturation. In addition, the follow up audiometric tests performed on this infant were normal. To our knowledge, this was the first case of an infant who received such a combined alternative (and “bloodless”) treatment for serious AB0 HDN.
As far as the mechanisms of action of DPA in AB0 HDN are concerned, it proved to be a potent inhibitor of haem oxygenase (HO),4 the rate limiting enzyme in haem catabolism to bile pigments, only in neonates. Therefore, this drug can moderate the postnatal formation of plasma bilirubin. The use of DPA in combination with phototherapy seems to be an appropriate combination in diminishing the intensity of hyperbilirubinaemia; because DPA decreases bilirubin production simultaneously, by its antioxidant effects, DPA is able to prevent the possible adverse side effects of phototherapy that have been shown in vitro and most recently in vivo.5
Another possibility in reducing the need for ET in neonates with proven HDN due to Rh and/or AB0 incompatibility, is the use of high dose intravenous immunoglobulin (HDIVIG) as was mentioned by Bolton-Maggs and Murphy.1 Readers will surely recognise that HDIVIG is a blood product, and is consequently unacceptable to Jehovah’s Witness families. Note also that the cost of DPA treatment (about US$2 or €1.5 per patient) is considerably less than HDIVIG.
Although the efficacy of DPA in reducing jaundice was first shown in the 1970s, this drug does not seem to have gained acceptance in the international neonatal community. The lack of “acceptance” of DPA treatment seems sadly parochial to us, because this therapy has been used extensively in Hungary for nearly 30 years. In our own experience, more than 20 000 neonates have been treated without side effects.
The successful use of erythropoietin in the treatment of severe anaemia in a neonate, reported in our paper,3 should also be of considerable practical interest to your readers.