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As it is clearly stated in the review by Gottstein and Cooke,1 we consider it unethical to withhold or delay high dose intravenous immunglobulin (IVIG) treatment in infants with haemolytic disease of the newborn. Since the study we did in 1995,2 we have treated 129 patients with Coomb’s positive haemolytic disease of the newborn, with the same method and had to resort to exchange transfusions only in three cases. On the other hand, late anaemia is a frequent problem in these cases, necessitating multiple blood transfusions, with well known complications.
The authors suggest that multiple doses of IVIG may reduce late anaemia. However, our observation in a limited number of cases is that, even multiple doses of IVIG are ineffective in preventing late anaemia. In an earlier unpublished study, we had shown that the erythropoietin levels were low in these infants. Therefore, we had conducted a double blind, randomised pilot study to investigate the effects of recombinant erythropoietin (rHEPO) in these patients.3 In this study, rHEPO was administered at a dose of 200 units/kg, subcutaneously, three times a week, starting at the 14th day of life and lasting for six weeks. This protocol reduced the number of erythrocyte transfusions significantly. With the impetus of this pilot study, we have used the same protocol for the subsequent 103 patients and the mean number of transfusions in this group was 1.5, with the majority of patients (55%) not needing any transfusions at all. There were no complications, including changes in neutrophil or platelet counts, and haemorrhagic or infectious complications. The administration of rHEPO to patients with haemolytic disease of the newborn, who had received IVIG early in life, not only decreases the infants’ exposure to multiple blood donors, but also diminishes the need for hospitalisation and hence the cost that is involved. Therefore, rHEPO treatment is a suitable alternative to erythrocyte transfusions in these infants.