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NICU guideline identifier

Blood products - immunoglobulin IVIG (Newborn Services)

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IVIG immunoglobulin is available for administration to newborns as Intragam P.

Intragam P

  • Contains antibodies to the normal range of infections to which New Zealanders are exposed.
  • Prepared by chromatograph separation of large pools of human plasma and is free from the risk of known viral infections including HIV, Hepatitis B and C.
  • Is for IV use only

Indications

Treatment of Immune Thrombocytopenia (ITP)
IVIG 1g/kg in divided doses over 2 days, i.e, 0.5g/kg/day = 8.3ml/kg given over a 3 hour period each day. Adjustment of both dose and infusion interval is empirical and should be based on the patient's clinical state. Repeat if required to a total dose of 2g/kg
Treatment of Isoimmune Haemolytic Jaundice (as an adjunct to continuous intensified phototherapy)
IVIG 1g/kg (range 0.5-1.5g/kg)over 2-4 hours, can be repeated after 12 hours if required..
Use of IVIG may reduce the need for exchange transfusion in Rhesus and ABO haemolytic disease. Efficacy is not conclusive as studies which have shown a benefit had high risk of bias3
Treatment of NAIT (Neonatal Alloimmune Thrombocytopenia) may be considered if matched platelets are unavailable but response can be delayed by 24-36 hours. Dose 0.4 - 1g/kg/day for 2-5 days can potentially prolong the survival of incompatible platelets4

Prescribing of Intragam P

  • Intragam P is prescribed on the pink blood transfusion/IV fluid chart (CR5541).
  • It is also recorded in patient's multidisciplinary clinical records.
  • Usually given over 1-3 hours.
  • Intragam for neonates comes in 3 grams in a 50ml bottle.

Ordering

After consultation with ARBC Medical Officer, write Blood Products request form with patient's name, number, date of birth, birthweight and present weight. Order on NZBS requisition form (111F01802).

Administration

  1. Informed consent must be obtained - parent signs Agreement to Treatment form (CR0111). There is a patient information leaflet on Intragam P from the Blood Transufsion Service.
  2. Intragam P is for intravenous administration only. It may be infused undiluted. It may also be infused diluted with up to 2 parts of 0.9% saline or 5% glucose.
  3. It may be administered through a standard IV infusion giving set. They must not be infused through a Pall filter (0.22 micron)
  4. Any vial opened should be used promptly
  5. Partially used vials must be discarded
  6. Do not use if solution is turbid
  7. Infusion to be commenced within 15 minutes from leaving Blood Bank (allow this time for it to reach room temperature)
  8. Intragam P may be placed in fridge in Neonatal Unit for short period while intravenous cannula is resited. Do not freeze

Complications/Problems

Adults sometime react to IVIG with fall in blood pressure. Baby should be watched carefully particularly at the start of the infusion.

Most patients have no side effects at all. However the following symptoms may occur: Hypotension, facial flushing or pallor, dyspnoea, non-urticarial skin rash, itching, vomiting. May get delayed adverse reactions to Intragam such as vomiting or rigors. These occur after the infusion has stopped but usually within 24 hours.

Low pH should be considered in sick babies with acid/base problems. Undiluted it is hyperosmolar. Should be given over 1 hour or longer.

If high osmolarity or low pH are a potential problem may be given diluted with equal volumes of 0.9% saline or 5% glucose. Passive acquired antibody can interfere with the response to live vaccines therefore should not normally be given until after three months following a dose of gammaglobulin injection.

Management

  1. If any reaction to Intragam P, it tends to be related to the infusion rate and is most likely to occur in the first hour of infusion.
  2. Stop the infusion temporarily.
  3. Inform Doctor/NS-ANP
  4. Wait until infant has improved clinically (5-10 minutes).
  5. Doctor/NS-ANP orders Intragam P to be recommenced at a slower rate.
  6. All adverse reactions should be reported to the Blood Bank on NZBS Notification and Investigation of Adverse Transfusion form.

See also Blood products - red cell transfusion for more information on the management of adverse reactions. See also management of ITP on the Starship Clinical Guidelines.

References

  1. Neonatal Jaundice. NICE Clinical Guideline 2008. National Institute for Health and Clinical Excellence, 2010
  2. www.medsafe.govt.nz/profs/Datasheet/i/IntragamPinj.pdf
  3. Louis D, More K, Oberoi S, Shah PS. Intravenous immunoglobulin in isoimmune haemolytic disease of newborn: an updated systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2014;99:F325-F331
  4. Peterson JA, McFarland JG, Curtis BR and Aster RH. Neonatal alloimmune thrombocytopenia: pathogenesis, diagnosis and management. Br J Haematol 2013 April;161(1):3-14.

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Document Control

  • Date last published: 14 August 2018
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years