Breast milk warrants consideration as a possible source of immune-associated hemolytic disease of the fetus and newborn (HDFN), according to findings from a case report describing a patient in Chandigarh, India, that was published in Transfusion and Apheresis Science.
The case report describes a 29-year-old female who delivered a male child who weighed 2200 grams at 37 weeks’, one day gestational age. The infant that presented with persistent neonatal anemia and necessitated frequent transfusions.
The cause of HDFN was originally linked to the presence of Rhesus (Rh) D antibodies in the mother’s blood. In fact, both immune and nonimmune causes of HDFN have been recognized today. The immune causes of HDFN are primarily due to antibodies against red blood cell (RBC) antigens, including ABO and Rh antigens. Minor blood group incompatibility also can be associated with hemolysis among infants.
Read more about testing and diagnosis of HDFN
Regarding antibodies against RBC antigens, ABO antibodies are the most frequent cause of HDFN. When the disorder is caused by ABO antibodies, symptoms are typically mild and do not require any treatment in the infant. In contrast, HDFN associated with the anti-D antibody is severe, although the use of Rh immune globulin immunoprophylaxis has led to a significant reduction in the incidence of anti-D–mediated HDFN.
Other alloantibodies can potentially cause HDFN as well, which can vary in levels of severity. The current case presentation depicts a situation in which a specific alloantibody was shown to be the cause of persistent anemia via the mother’s breast milk.
The baby was born by lower segment cesarean section at an outside hospital facility. Although the antenatal period was considered uneventful, while the baby was still hospitalized, he underwent a double-volume exchange transfusion (ET) at 12 hours of life because of hyperbilirubinemia and direct antiglobulin positivity.
Although the baby’s bilirubin concentrations decreased to normal limits on day seven of life, his anemia persisted. Thus, he needed to receive three top-up transfusions at several intervals over a three-week period.
The baby was unable to undergo a complete immunohematologic workup because the hospital lacked the appropriate facilities. Further, in spite of the receipt of top-up transfusions, yellowish discoloration of his skin and lethargy continued to be noted.
Ultimately, at four weeks of age, the infant was referred to the area’s tertiary care center for assessment of his hyperbilirubinemia and anemia. After undergoing laboratory testing, including antibody identification and titration, the presence of anti-c was detected in maternal and neonatal plasma, which supported his prior history of jaundice with hyperbilirubinemia that had necessitated the utilization of phototherapy and ET.
Eventually, the underlying cause of the persistent neonatal anemia was determined to be the passive acquisition of hemolytic alloantibodies—that is, anti-c—via the mother’s breast milk. Once the mother withheld her breast milk, the hemoglobin level of the infant began to improve gradually. Following two weeks of withholding her breast milk, the mother resumed breastfeeding at seven weeks of life, “as breast milk is the most nutritious diet for the neonate.”
The child remained stable and did not require any additional intervention. He is now healthy, receiving solid foods and attaining age-appropriate developmental milestones.
“[The] importance of antenatal screening for [RBC] antibodies is gradually being recognized and adopted in developing countries to minimize the burden of HDFN,” the authors explained. “Breast milk should be considered as a potential source of hemoly[z]ing alloantibodies in newborns and may require evaluation in mothers with alloantibodies in [their] serum,” they concluded.
