Audit to evaluate clinical practice variation in the management of newborns with positive direct antiglobulin test (DAT)
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Authors
Azadi, B
Narayanan, U
Kurup, U
Issue Date
2021
Type
Scientific Paper
Language
Keywords
Research Subject Categories::MEDICINE::Dermatology and venerology,clinical genetics, internal medicine::Internal medicine::Paediatric medicine
Alternative Title
Abstract
Abstract
Background Haemolytic Disease of Newborn (HDN) caused by Rhesus or ABO incompatibility can cause severe haemolysis, jaundice and anaemia in infants. The direct antiglobulin test (DAT) is the test of choice in this clinical context. However, most infants with positive DAT are asymptomatic, while some may present with jaundice with or without anaemia. Subsequent neonatal anaemia may be either of early (<1 week postnatally) or late onset (≥2 weeks postnatally).Folic acid supplementation in neonates with a positive DAT may reduce the incidence of late onset anaemia. Before considering managing infants with positive DAT, it is important to consider the low sensitivity and specificity of the test. Therefore, both clinical features and laboratory results should be used to diagnose HDN. Objectives To audit our current practice in the management of DAT positive infants to support/refute presence of unwarranted variation. Methods Retrospective review of the clinical profile of all infants who had a positive DAT result over a 1 year period (2019). Results 43 infants had positive DAT results in the study period. 17 (40%) were asymptomatic, 21 (49%) had mild jaundice with no anaemia and 5 (11%) had haemolytic disease of newborn (HDN).There was unwarranted variation in folic acid treatment initiation, duration of therapy and follow up. These were not necessarily based on the clinical symptoms or risk of anaemia. Of those asymptomatic (N=17), 13 were DAT+ (3 received treatment up to 3mo and follow-up). 3 were DAT 2+ and 1 had DAT 4+ (0 received either treatment or follow-up). · Of those with mild jaundice (N=21), 17 had DAT+ (12 received treatment for 6w-4mo and follow-up; 5 did not receive treatment or follow-up). 2 had DAT 2+ (both received treatment, 6w-3mo and follow-up). 1 had DAT 3+ and 1 had DAT 4+ (both received 3mo treatment and follow-up). · Of those with HDN (N=5), 2 had DAT 2+ (1 did not receive treatment and 1 had no clear documentation on whether treatment/follow-up offered), 2 had DAT 3+ and 1 had DAT 4+ (all received 4w treatment and were offered follow-up). Conclusions Our audit showed unwarranted variation in the management of newborns with DAT positive results. Folic acid prescriptions had no relationship to clinical symptomatology or DAT severity and the duration of treatment/follow up (6 week to 3 months) was inconsistent. Any potential benefit was offset by significant increases in healthcare costs and adverse patient experience.Our audit highlighted a clear and unwarranted variation. DAT should only be requested where there is a high index of clinical suspicion and if positive, folic acid therapy and monitoring for late-onset anaemia should be reserved for those select groups. A new guideline is being developed to standardise management of DAT positive infants.
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Citation
Azadi, B., Narayanan, U., Kurup, U. (2021) Audit to evaluate clinical practice variation in the management of newborns with positive direct antiglobulin test (DAT). Archives of Disease in Childhood. 106(Suppl 1): A280. DOI: http://dx.doi.org/10.1136/archdischild-2021-rcpch.486