Transport of neonates with severe jaundice on phototherapy: Implications for regional areas.

Abstract

A recent article by the Victorian Paediatric Infant Perinatal Emergency Retrieval Service1 showed that phototherapy is feasible and safe during transport of neonates with severe unconjugated jaundice and may reduce the requirement for exchange transfusion. Interestingly, logistic regression analysis in that study showed that intravenous immunoglobulin (IVIG) did not emerge as independently associated with exchange transfusion. This raises two discussion points. The first is, how can regional areas improve the early identification of neonates who are at risk of severe jaundice at birth so as to instigate early intensive phototherapy and reduce the chances of exchange transfusion? Second, is there a role for IVIG in infants with severe jaundice awaiting retrieval? I think regional centres need to consider making umbilical cord bilirubin measurement routine in babies with Rhesus-negative mothers or other risk factors to enable early intensive phototherapy. By using available normograms, infants with high cord bilirubin values can receive intensive phototherapy even within 1 h after birth. The 2011 randomised controlled trial (RCT) quoted by the authors suggested that IVIG was ineffective in preventing exchange transfusion in Rhesus isoimmunisation. I would like to point out that the numbers in that RCT were small (80 infants), intensive prophylactic phototherapy was started immediately after birth, thereby reducing the risk of severe jaundice, and most of the infants had received intrauterine transfusions (IUTs). In regional Australia, it is unlikely to be the case that neonates requiring transport would have received prophylactic phototherapy immediately after birth nor would such patients have received IUT. Patients who are identified in pregnancy to be at very high risk or who would have received IUT are likely to be found in tertiary centres under Maternal Fetal Medicine units. The American Academy of Pediatrics 2004 guidelines recommended the administration of IVIG in isoimmune haemolytic disease, but there has been mixed evidence from systematic reviews. A 2002 Cochrane review2 and another systematic review of RCTs3 found a significant reduction in the need for an exchange transfusion with the use of IVIG. One later systematic review4 showed that the efficacy of IVIG was inconclusive in Rhesus isoimmunisation. Studies that had a low risk of bias showed no benefit, while studies with high risk of bias showed benefit. I think it is positive news for infants in regional areas that phototherapy is feasible and safe during transport. While the evidence for IVIG is inconclusive, I think regional hospitals in consultation with neonatologists still need to consider using IVIG prior to transport if it is available together with early intensive phototherapy,especially in cases where significant delays in transport are likely to occur and serum bilirubin is rapidly rising towards exchange levels. IVIG will be particularly useful in selected cases where parents are likely to object to exchange transfusion for religious reasons such as Jehovah's Witnesses or out of fear for adverse effects of exchange transfusion. Larger well-designed RCTs are obviously needed to determine the efficacy of IVIG in severe unconjugated jaundice. None declared.