Whose specimen for Neonatal Work-Up

[Brenda K Hutson]

Everywhere I have worked (until now), we have approached Neonatal Work-Ups as follows:

1. Perform initial Type and Screen on heelstick from infant

2. Check for Anti-A,B in baby if mom Group O and baby non-group O.

3. If Antibody Screen Positive, can use mom's plasma/serum for Antibody ID (rather than exsanguinating the baby).

In my current job, they don't even ask for a specimen on the baby (or say, well, they did a Type and Coombs on the Cord); they do everything with the mom's specimen. I think that:

1. Important to know infant's ABO/Rh (and never transfuse based on Cord results)

2. Need to see what is going on in baby; not just what you might find in mom (that may or may not be affecting the baby)

Your thoughts and/or experience??

Thanks,

Brenda Hutson, CLS(ASCP)SBB

[JOANBALONE]

Hi Brenda,

I think only ABO/Rh is required on a pretransfusion specimen, reverse type not required. (Can a cord blood be considered a pretransfusion sample??? Not sure about that.)

Testing for passive A,B is not routinely required.

Mom or baby's specimen may be used to screen/identify unexpected antibodies.

JB

[Auntie-D]

We do the group on the cord blood and confirm that the blood is foetal with sodium hydroxide. We would never do an antibody screen on a neonate unless there was a requirement for blood/products and then we would crossmatch/screen against the maternal sample.

Have you seen how traumatic a heel stick is? Why put a newborn (and the mother) through that distress unnecessarily?

Edit - we don't do a reverse group, only a forward with A, B and AB, 2 D's, control and a dct

[tricore]

We do not use cord blood for transfusion purposes. We have the test codes set so the ABO/Rh from the cord blood does not go into the baby's permanent BB file. Therefore heel stick must be done for the type and screen. Antibody work up, if necessary, is done on Mom's specimen.

[Auntie-D]

Therefore heel stick must be done for the type and screen.

Why are you performing a screen on a neonatal sample - you are just identifying maternal antibodies?

Also why have you deemed that a cord blood is unsuitable for a group?

[tricore]

We don't do an antibody screen on a neonate unless they need a transfusion. We do not use cord bloods because we have seen too many mislabeled. That said, I personally don't think they should be used to determine Rh type of baby for RHIG for mom. I have a few examples: received a cord blood labeled with a name that did not match the requisition, when I inquired, the mother whose name on the tube had gone home undelivered. Then there was the time I received one cord blood from a set of twins. I was told that there was one placenta! Did heel sticks, one was an A, the other was an O.

[kate murphy]

We use the cord spec for ABO/Rh, DAT of the baby. Cords are collected on every baby, but we only test those from Rh neg moms, moms with antibodies or if the clinical condition of the baby warrants it. Most mom/baby ABO incompatibilities do not adversely affect the neonate.

If you're have a problem with mislabeled cords, you should address that with your Quality department rather than keep sticking the babies.

All babies get O Neg rbc, we only crossmatch with mom if she has an antibody. Otherwise, no crossmatch. Dedicate 1 donor unit to 1 baby to reduce donor exposure.

[tricore]

As I said, It is my personal opinion, the babies all get stuck anyway for PKU, etc. It only takes a drop or two to do the ABO/Rh. The incidents I described took place in different institutions in different cities. Quality departments were non existant at that time. If mom has an antibody, crossmatches are done with mom's plasma. We do electronic crossmatch otherwise. Have always done one donor one baby.

[Liz]

I agree with Michele and Joan. The newborn gets stuck once for Blood group and after that if the sample is not enough we can work on the mom's serum for the abs as written by one of the agencies, cannot remember where.

[Auntie-D]

I agree with Michele and Joan. The newborn gets stuck once for Blood group and after that if the sample is not enough we can work on the mom's serum for the abs as written by one of the agencies, cannot remember where.

But why stick the baby if there isn't any need. It is a really traumatic procedure even to get a couple of drops out of a heel stick - why do it when you can get cord blood?

[Liz]

Basically to prevent any mishaps as mentioned in Michele's post and because anyhow they get drawn for routine neonatal screening.

[Brenda K Hutson]

No reverse type on Neonatal Specimen (usually say until 4 mos). Would never transfuse based on Cord Blood Testing; always require a heelstick (unless Nurse gets blood from a line).

Thanks!

Brenda

Hi Brenda,

I think only ABO/Rh is required on a pretransfusion specimen, reverse type not required. (Can a cord blood be considered a pretransfusion sample??? Not sure about that.)

Testing for passive A,B is not routinely required.

Mom or baby's specimen may be used to screen/identify unexpected antibodies.

JB

[Brenda K Hutson]

The "reason" (in my mind) is that just because there is an antibody in the maternal circulation, does not necessarily mean it is in the baby (mom could have it from a previous pregnancy or transfusion (snd yes, I have both seen, and performed neonatal heelsticks).

Brenda

We do the group on the cord blood and confirm that the blood is foetal with sodium hydroxide. We would never do an antibody screen on a neonate unless there was a requirement for blood/products and then we would crossmatch/screen against the maternal sample.

Have you seen how traumatic a heel stick is? Why put a newborn (and the mother) through that distress unnecessarily?

Edit - we don't do a reverse group, only a forward with A, B and AB, 2 D's, control and a dct

[Brenda K Hutson]

I have worked in 5 other Hospitals (prior to current one); 3 of them large, major Medical Centers; other 2 mid-size (400 beds). Everywhere I have worked (and everything I have read) states that one should NEVER use any Cord Blood Testing for transfusion purposes! Why? Having been in Management positions in several of my jobs and thus receiving all of the Error Reports (whatever your Institution calls them); performing Audits, etc., I can tell you that by far, the worst place for labeling errors of specimens occurs in L&D! And we are not talking occassional errors. What I think frequently occurs is that the MD obtains the cord specimen; hands off the unlabeled tube; the Nurse takes the tube "somewhere" and puts "a" label on it; it is then passed off to someone else (usually outside of L&D) to put some Infant identification on the specimen. It is frightening the # and type of errors that come out of there (makes you wonder how many people go home with their own babies!...Ha Ha..just kidding).

So while there may be mixed feelings on testing a specimen from the baby (though that is also something I have done everywhere else I have worked; until now), I feel very strongly about the Cord Specimen issue.

Brenda

Why are you performing a screen on a neonatal sample - you are just identifying maternal antibodies?

Also why have you deemed that a cord blood is unsuitable for a group?

[kate murphy]

But if you are crossmatching for the baby with mom's serum/plasma, wouldn't you match all her antibodies? otherwise, you'd have incompatible crossmatches. Could be that for an antibody of low titer, all antibody is bound to baby's rbc and the antibody screen on baby's venipuncture is neg. You may only recover this antibody from a baby's eluate. And you need a quantity of rbc to do that - which you'd have with a cord sample. I would advocate not bleeding the baby, use mom's blood whenever possible and match all mom's antibodies.

The "reason" (in my mind) is that just because there is an antibody in the maternal circulation, does not necessarily mean it is in the baby (mom could have it from a previous pregnancy or transfusion (snd yes, I have both seen, and performed neonatal heelsticks).

Brenda

[Brenda K Hutson]

And having tried to work with Quality and "get" L&D to label Cords correctly, in my experience, has never gone anywhere either.

As far as whether or not to use Cord Blood test results for Rhogam....I had never really thought of that in comparison to stating they cannot be used for "transfusion" purposes. I guess my rationale then in using the Rh Type of the Cord (even after my strong reply about Cord labeling errors) would be that it would not hurt the mom to get unnecessary Rhogam (excpect financially). But that being said, it does bring up the point; what if the error is the other direction; that the baby is really Rh POS (so the mom should get Rhogam), but a mislabeled Cord is received and types as Rh NEG? Something to think about....maybe.

Also, just as an aside; not all places give group O only to babies. Many large Medical Centers also stock O POS, A POS, A NEG and maybe even group B. You might also get non-group O if you accept parent Directed Donors for babies (they can have very strong feelings about their baby getting blood from anyone than them; provided their type is compatible of course).

Brenda Hutson

As I said, It is my personal opinion, the babies all get stuck anyway for PKU, etc. It only takes a drop or two to do the ABO/Rh. The incidents I described took place in different institutions in different cities. Quality departments were non existant at that time. If mom has an antibody, crossmatches are done with mom's plasma. We do electronic crossmatch otherwise. Have always done one donor one baby.

[Auntie-D]

The "reason" (in my mind) is that just because there is an antibody in the maternal circulation, does not necessarily mean it is in the baby (mom could have it from a previous pregnancy or transfusion (snd yes, I have both seen, and performed neonatal heelsticks).

Brenda

I don't understand... If the mother has an IgG antibody, it will be present in the baby's circulation, regardless of when the mother got it (provided the maternal titre is high enough).

[jill]

We do a type on screen on neonates for possible transfusion. We transfuse type specific blood so we also

carry the Baby's plasma to the AHG phase when mom is grp O and baby is grp A, B, or A,B to check for presence of isohemagglutinin.

If present we give grp O. The type and screen sample is good for the lenght of stay the infant is in house which can go up

to 4 months as an expiration.

A DAT must me performed if a previous cord sample was never done. If the screen is positive due to an alloantibody we try and identify it in the neonate's sample. If QNS, we use mom's plasma for ID and x-match.

[Likewine99]

I worked in a pediatric BB for a while and did the same as jill. Our adult hospitals modeled their ped transfusions after us but they rarely did a ped tx.

I agree w/you on the L&D labeling thing. I've heard it explained off to "well you have no idea how hectic it gets in the delivery room".

I'd say stick with a spec from the baby, esp if you have inhouse phleb. Your chances for correct labeling go up immensley when the lab does the draws.

[Liz]

5.16 Special Considerations for Neonates

5.16.1 An initial pretransfusion sample shall be tested to determine ABO group and Rh type. For ABO, only anti-A and anti-B reagents are required. The Rh type shall be determined as in Standard 5.13.2. The serum or plasma of either the neonate or the mother may be used to perform the test for unexpected antibodies as in Standard 5.13.3.

5.16.1.1

Repeat ABO grouping and Rh typing may be omitted for the remainder of the neonate’s hospital admission or until the neonate reaches the age of 4 months, whichever is sooner.

Neonate's blood for forward blood group. Mom can be used for unexpected Abs.

[Mabel Adams]

I think I have heard that children's hospitals usually do screens on the babies and give type-specific blood but many smaller or adult hospitals give only group O blood to neonates and do screens on the moms. Partly the KISS principle. Also children's hospitals may not have the mom present because the baby was shipped in from another hospital.

We almost never give blood to babies whose moms have antibodies--just little preemies (probably that we drew too much blood from for lab testing).

[janet]

There is a standard in Canada that states cord samples cannot be used for typing in transfusion cases. Some techs argue that we trust that type for giving the mom RhIG

[Brenda K Hutson]

Actually, you can either give crossmatched blood, or, give Antigen Negative. I personally would still want to have a picture of what is actually going on in the baby (i.e. Type and Coombs on heelstick); then if necessary, perform Antibody ID on mom's specimen.

Brenda

But if you are crossmatching for the baby with mom's serum/plasma, wouldn't you match all her antibodies? otherwise, you'd have incompatible crossmatches. Could be that for an antibody of low titer, all antibody is bound to baby's rbc and the antibody screen on baby's venipuncture is neg. You may only recover this antibody from a baby's eluate. And you need a quantity of rbc to do that - which you'd have with a cord sample. I would advocate not bleeding the baby, use mom's blood whenever possible and match all mom's antibodies.

[Brenda K Hutson]

Yep, can be...just trying to see what everyone else out there does. I guess I don't agree that the picture of the mom's serum will automatically be that of the baby (though I don't think you will miss anything by testing mom). And again, I would perform the antibody ID on the mom's serum; would just like to get a complete picture of the baby first (by Type and Screen plus DAT; when/if HDN suspected). But that is just me.

Brenda

5.16 Special Considerations for Neonates

5.16.1 An initial pretransfusion sample shall be tested to determine ABO group and Rh type. For ABO, only anti-A and anti-B reagents are required. The Rh type shall be determined as in Standard 5.13.2. The serum or plasma of either the neonate or the mother may be used to perform the test for unexpected antibodies as in Standard 5.13.3.

5.16.1.1

Repeat ABO grouping and Rh typing may be omitted for the remainder of the neonate’s hospital admission or until the neonate reaches the age of 4 months, whichever is sooner.

Neonate's blood for forward blood group. Mom can be used for unexpected Abs.

[AMcCord]

We follow a protocol a lot like Jill, except the antibody ID would be performed on mom's sample or the cord blood sample. We crossmatch with baby or mom, depending on how much sample we have available from baby. Itty bitty premies, we would go with mom's sample except for the front type. Most of our sick babies have lines or a venipuncture is performed, rather than a heelstick. We transfuse babies rarely. Most of them are transferred before it gets to that point, for other reasons.