Management Of Neonatal Hyperbilirubinemia Research Articles

The impact of phototherapy in the management of neonatal hyperbilirubinemia: comparison of historical cohorts

To quantitatively assess the impact of phototherapy (PT) in the prevention of kernicterus we calculated the rate of exchange transfusion (ET) in two large historical cohorts of Greek neonates (birthweight > or = 2.5 kg), one before (period I: 1957-61) and one after (period II: 1980-92) the introduction of PT. Overall, the introduction of PT was associated with a reduction of the rate of ET from 0.43% in period I to 0.05% in period II. The reduction was observed in all etiological categories but was more marked in the ABO-incompatible group. With an estimated rate of kernicterus without treatment of 0.085% (excluding rhesus hemolytic disease of the newborn and prematurity) we estimated that 4.2 and 0.36 infants were treated by ET for each spared kernicterus in periods I and II, respectively. Finally, in period II 185 infants were treated with PT or PT and ET for each spared kernicterus.

The management of neonatal hyperbilirubinemia-Part I.

The management of neonatal hyperbilirubinemia-Part I.

Too Long for Too Little

In 1974, the National Institute of Child Health and Human Development initiated a six-institution collaborative study to evaluate phototherapy as a therapeutic modality for the management of neonatal hyperbilirubinemia. The first phase of the study was completed in 1976; the results of this work were published in 1985. Too long to wait. The study was undertaken primarily, we are told, to answer two important questions: (1) "Is phototherapy effective in preventing brain injury from hyperbilirubinemia, when employed to lower serum bilirubin levels?" and (2) "Is phototherapy as effective as exchange transfusion at predetermined serum bilirubin levels for preventing brain damage from neonatal hyperbilirubinemia?" The answers to these questions are not provided in the published report.

Neonatal and Infant Mortality in Relation to Phototherapy

Of all the parameters for assessing the effectiveness and safety of phototherapy in the management of neonatal hyperbilirubinemia, none is as unambiguous as death. Although death rates are definitive, any relationship to the treatment modality or lack thereof may be confounded by other events. No prior data suggest the possibility of either enhanced or reduced mortality in infants treated with phototherapy.34,50 The groups were allocated randomly and the care given the two groups was the same, with the exception that one group received phototherapy. It was stipulated that research protocol requirements were at no time to take precedence over the medical care needs of the infant. RESULTS Seventy-two (10.7%) of the 672 newborns entered into the phototherapy group and 62 (9.3%) of the 667 newborns in the control group died during the first year of life. During the period prior to discharge from the nurseries, there were 68 (10.1%) deaths in the phototherapy group and 51 (7.6%) in the control group. All of the deaths except one in each group were in newborns who weighed less than 2,000 g at birth. These differences, as well as deaths in the first seven or 28 days of life, were not significantly different (X2 with Yates correction) when P < .05 was taken to be the upper level of significance (Table 1). DEATHS BY BIRTH WEIGHT SUBGROUPS The number of newborns entered into each study group and the deaths prior to discharge from the hospital for the birth weight groups 1,000 g or less and 1,001 to 1,999 g are indicated in Table 2.

Efficacy of Phototherapy in Prevention and Management of Neonatal Hyperbilirubinemia

This report concerns the efficacy of phototherapy in preventing hyperbilirubinemia in infants with birth weight less than 2,000 g and in controlling already established hyperbilirubinemia in infants weighing more than 2,000 g in the National Institute of Child Health and Human Development (NICHHD, also called NICHD) phototherapy study initiated in 1974. The details of the protocol have been reported by Bryla.18 STUDY POPULATION The study included 1,339 infants from the six participating institutions: 672 were randomly assigned to the phototherapy group and 667 to the control group. As described previously, these infants were studied according to specific protocols in three birth weight groups.18 In infants weighing less than 2,000 g at birth (group A), the efficacy of phototherapy begun at 24 ± 12 hours of age in preventing hyperbilirubinemia was examined. In the other two birth weight groups infants with birth weight 2,000 to 2,499 g [group B] and infants with birth weight 2,500 g or more [group C], the effect of phototherapy on already-established hyperbilirubinemia was examined. MODE OF USE OF PHOTOTHERAPY Phototherapy using Westinghouse daylight fluorescent bulbs in an Air Shields unit was administered continuously. Duration of phototherapy was 96 hours for all treated infants. In each study group, an attempt was made to apply phototherapy in a manner that mimicked common usage, except that control subjects were used. Further, because no infant was to be exposed to bilirubin levels considered "unsafe," maximum bilirubin levels were established for each weight group and exchange transfusions were performed in both phototherapy-treated and control infants when these levels were reached.

Phototherapy versus photobarb in the management of neonatal hyperbilirubinemia.

Therapeutic efficacy of phototherapy and photobarb (phototherapy plus phenobarbitone) was evaluated in 32 neonates with hyperbilirubinemia. Conventional day light flourescent lamps were used for providing light energy. Mean birth weight and initial mean bilirubin levels were comparable in both the groups. Mean twelve hourly fall of serum bilirubin with photobarb was not significant as compared to phototherapy alone. Similarly, duration of therapy given to deal with comparable levels of bilirubin was not significantly different (P> 0.05).

Phototherapy for Neonatal Hyperbilirubinemia: Efficacy, Mechanism and Toxicity*

Phototherapy is an effective agent for the prevention as well as management of neonatal hyperbilirubinemia of nonhemolytic origin; it is limited in its effectiveness to control hyperbilirubinemia of hemolytic origin. Phototherapy should not be initiated without investigation of the cause of jaundice. Its use should be avoided in the presence of liver disease.

A guide to the use of phototherapy in the management of neonatal hyperbilirubinemia

Nomograms have been designed to provide rational and consistent guidelines for the use of phototherapy in the management of neonatal hyperbilirubinemia. In the management of 195 neonates in the first week of life, phototherapy, given according to these nomograms, was successful, except in some severe cases of Rhesus incompatability, in controlling hyperbilirubinemia in both premature and term neonates. When compared to the more random use before the introduction of the nomograms, phototherapy was reduced significantly without an increase in the requirement for exchange transfusions.

Phototherapy-induced hypocalcemia

THE EFFECTIVENESS of phototherapy in the management of neonatal hyperbilirubinemia has been demonstrated in many controlled clinical trials. '-~ Some controversy exists concerning the safety of phototherapy because of physical and metabolic side effects reported in the treated infants? We report a greater incidence of hypocalcemia in preterm babies submitted to phototherapy. To our knowledge this is the first such reported observation.

Phototherapy for Neonatal Jaundice in Erythrocyte Glucose-6-Phosphate Dehydrogenase-Deficient Infants

The effectiveness of phototherapy in the management of neonatal hyperbilirubinemia in glucose-6-phosphate dehydrogenase (G6PD)-deficient infants was studied. "Prophylactic" phototherapy for six continuous days commencing from the first day of life was effective in preventing a significant rise in bilirubin levels in 12 G6PD-deficient infants in the first three days, during which period a rapid rise was observed in a control group of G6PD-deficient infants. The hemoglobin levels on the first and eighth postnatal days were comparable in both groups. "Therapeutic" phototherapy proved equally effective in reducing bilirubin levels in 24 infants with nonhemolytic hyperbilirubinemia and an equal number of infants with hyperbilirubinemia associated with G6PD deficiency. Phototherapy was efficacious in the prevention or treatment of neonatal hyperbilirubinemia associated with G6PD deficiency; even if its use is prolonged it does not cause hemolysis in such infants.

Controlled clinical trial of phenobarbital (PB) and light for management of neonatal hyperbilirubinemia in a predominant Negro population

Low birth weight infants, less than 24 hrs of age, were randomly assigned to receive either oral PB, 5 mg/kg/day for 5 days, blue light (200–300 footcandles) continuously for 4 days, a combination of PB and light, or no treatment. 90% or more of the infants in each group were Negroes. Infants with a positive Coomb's test were excluded. By the 3rd day, infants receiving Pb, light, and PB and light had significantly lower mean bilirubin concentrations than the controls. Those receiving light had the lowest values. Combining PB with light did not have an additive effect. Bilirubin concentrations of 10 mg% or higher were found in 66% of the controls, 26% of the PB group and in none of the other 2 groups. Mild lethargy occurred in 5 infants receiving PB and mild diarrhea occurred in 2 receiving light. The findings indicate that in Negroes continuous phototherapy is more effective than PB in lowering the serum bilirubin concentration. Results are not improved by combined therapy. PB may be useful when phototherapy is not available.