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 INTRAVENOUS IMMUNE GLOBIN (IVIG) ADMINISTRATION IN NEONATES:

Patient population:

Neonates with isoimmune hemolytic disease of the newborn due to Rh or ABO incompatibility. Although data are limited, IVIG may be helpful in other types of Rh hemolytic disease such as anti-C and anti-E. It may be considered for non-isoimmune causes of hemolytic anemia such as G6PD deficiency.

Other indications for IVIG in neonates include immune thrombocytopenia and overwhelming sepsis.

Criteria for Use in Isoimmune Hemolytic Disease:

In Rh or ABO hemolytic disease, if the total serum bilirubin is rising despite intensive phototherapy or the total serum bilirubin level is within 2 to 3 mg/dL (34-51 μmol/L) of the exchange level.

Suggest guidelines from Hammerman 2000

Total Serum Billirubin (TSB) Levels for IVIG Administration in Term Healthy ABO-incompatible Coombs-positive Neonates.

AGE	TSB level despite 4 hours of phototherapy
<12 hours	204 mcmol/L (12 mg/dL)
12-24 hours	272 mcmol/L (16 mg/dL)
25-72 hours	306 mcmol/dL (18/dL)

 Additional Criteria: Hb<130 g/L

Consider administration as early as possible when active hemolytic disease of newborn is diagnosed and exchange transfusion is a possibility.

Intravenous gammaglobulin has been shown to reduce the need for exchange transfusion, repeat exchange transfusions, the duration of hospital stay, and phototherapy in Rh and ABO hemolytic disease. The mechanism of action appears to be related to blockage of Fc receptors in the neonatal reticuloendothelial system.

Contraindications

Neonates with IgA deficiency or hypogammaglobunemia (with IgA antibodies in the patient's serum)-risk of hypersensitivity or anaphylactic reactions .

Dosage and Administration:

Use Gamunex (10% Immune Globulin Intravenous (Human)), a ready-to-use sterile solution of human immune protein for intravenous administration.

Dose of 0.5 g-1.0 g/kg IVIG should be infused over 2 hours. If necessary, the dose can be repeated in 12 hours.

Sample Calculation

Gamunex is supplied in 2.5 g and 5g vials. To minimize wastage, choose the nearest vial size according to the patient's weight to administer within the range of 0.5-1.0 g/kg.

For 3 kg infant:

Dose of IVIG= 3kg x 1.0 g/kg= 3g (round to 2.5 g)

10% Solution has 1.0 g in 10 mL or 2.5 g in 25 mL

Infuse at 1.5 mL/hr (0.5 mL/kg/hr) x 30 minutes 

If tolerated, increase  to 12 mL/hr (4 mL/kg/hr) to infuse total volume approximately 2-2.5 hours.

For Gamunex, the maximum allowed rate of infusion is 8.4 mL/kg/hr

Spring Season Heading Off

 Nepal is, undoubtedly , a naturally country that enjoys pleasant weather round the year. Its geographical diversity has divided the Seasons in Nepal into five weather zones-tropical, temperate zone, cold zone, sub artic zone and the artic zone.

The country enjoys different seasons of spring, summer, monsoons, autumn, and winter. However, the spring and autumn season offer the ideal time to visit the country when it is neither too hot, nor too cold.

Spring season in Nepal:

Spring season in Nepal continues from March till May. It also offers the best time to visit the beautiful country of Nepal. In this particular season, the country attracts large number  of tourists. The months of March-April are considered the second best season for marketing, the best time being October-November.

Summer In Nepal:

The month of June heralds arrival of summers which lasts till August. During the summer months, the average temperature lingers around 28 C. However, the terai and hilly areas experience much higher temperature due to scorching sun.

Monsoon in Nepal:

Nepal receives monsoons from June that continues till September, with 2,500 millimeters of rain every year. After monsoons, starts the dry season from October till November which offers enjoyable weather, as countryside gets lush green after the rains.

Autumn in Nepal:

As the natives get a little relief from scorching summers and heavy rains, then comes autumn which lasts from September to November. This is certainly the best time to visit Nepal, as the surrounds get clear by summer monsoons. During autumn months, the weather remains pleasant, not much affected by cold. 

Winter season in Nepal:

Nepal enjoys winter season during December-February . The temperature reaches almost the freezing point during these months, while hilly regions experience rough weather and heavy snowfall.

Locally, seasons in Nepal is also categorized into 6 divides. Each lasting 2 months.