A Tale of Two Hospitals: The Evolution of Phototherapy Treatment for Neonatal Jaundice

Abstract

* Abbreviations: Rh — : Rhesus factor TSB — : total serum bilirubin Phototherapy was developed in the late 1950s and is today considered the mainstay of managing neonatal jaundice. Yet prominent academic leaders continued to promote the older approach of exchange transfusion well into the 1970s, despite the considerable risks involved. This article explores why phototherapy took so long to be embraced, and how pediatric residents were caught in the middle of the controversy.—Jeffrey P. Baker, MD, PhDSection Editor, Historical Perspectives The chief rationale of treating newborn jaundice is the prevention of kernicterus, a devastating and often fatal outcome attributed to bilirubin’s effects on the basal ganglia. Infants so affected commonly develop a characteristic choreoathetoid form of cerebral palsy accompanied by severe intellectual disability.1 In the mid-20th century, pediatric researchers scored a breakthrough by demonstrating the efficacy of exchange transfusion in preventing this devastating syndrome. The majority of infants thus treated were Rhesus factor positive (Rh+) children born to Rh– mothers exposed to the Rh factor during a previous pregnancy. Maternal antibodies to neonatal red blood cells caused extensive hemolysis, causing the total bilirubin level to rise rapidly and overwhelm the liver’s ability to process and excrete it. Exchange transfusion, rarely performed today, was a challenging procedure that might keep physicians up all night, patiently withdrawing the infant’s blood through an umbilical venous catheter in small increments by syringe and replacing them with an equal volume of donor blood. The procedure was technically difficult and fraught with the possibility of a fatal electrolyte or fluid imbalance.2 In the late 1950s, phototherapy emerged as another potential treatment of jaundice. In 1956 at Rochford General Hospital in Essex, England, Sister J. Ward noted that sunshine decreased neonatal jaundice. Meanwhile, hospital biochemists noted erroneously low bilirubin levels in samples sitting in sunlight before processing.3 Soon afterward came the first evidence … Address correspondence to Elliott Mark Weiss, MD, 550 First Ave #NBV 8S4-11, Department of Pediatrics, NYU School of Medicine, New York NY 10016. E-mail: elliottmweiss{at}gmail.com