Number Of Exchange Transfusions Research Articles

The Effect of Tunnel versus Conventional Phototherapy on the T Lymphocytes in Full Term Neonates with Hyperbilirubinemia

Background Neonatal jaundice is one of the most common conditions. Phototherapy has been accepted as the standard treatment for neonatal jaundice and the decline in the number of exchange transfusions in recent years is, at least in part, likely a direct reflection of the effectiveness of phototherapy at treating hyperbilirubinemia. However, this treatment modality also has some complications. One possible harmful consequence is potential immunotoxic effects by affection of lymphocytes subtypes which can affect the immune system functions in infants. Aim of the Work current study was performed to compare the effect of both conventional and tunnel phototherapy on lymphocytes subsets in term neonates (≥37weeks) with unconjugated hyperbilirubinemia. Patients and Methods The present study was conducted on 60 term neonates (≥37weeks) 40 of them with unconjugated hyperbilirubinemia admitted to NICUs in Ain-Shams University hospital during the period from January 2019 to July 2019. They were randomly assigned to 3 groups: 20 patients were exposed to conventional phototherapy and 20 patients were exposed to tunnel phototherapy and the other 20 healthy full term were assigned as control group. Total serum bilirubin (TSB), direct serum bilirubin (DSB), CBC, CD4 and CD8 percentages and absolute count were measured before and 48 h after phototherapy in the phototherapy groups. Baseline lab was done in the control group at once. Results significant decrease in total and direct bilirubin post-phototherapy in both phototherapy groups proved that tunnel phototherapy is as effective as conventional phototherapy as both provided rapid decrease in bilirubin levels. As regards the effect of phototherapy on lymphocytic count, we found that lymphocytic count significantly decreased post-phototherapy in both phototherapy groups. As regards the effect of phototherapy on CD4+ and CD8+ percentages, we found that CD4+ % significantly decreased postphototherapy in conventional phototherapy group. Moreover, when we measured CD4+ and CD8+ absolute counts, we found that CD4+ and CD8+ absolute counts significantly decreased post-phototherapy in both phototherapy groups. In the view of the effect of phototherapy on CD4/CD8 ratio, we found that the ratio significantly increased in tunnel phototherapy group. Conclusion Conventional and tunnel phototherapy which are used in the treatment of neonatal hyperbilirubinemia, affects the function of the immune system in newborns via alterations in CD4+ and CD8+ absolute counts.

Periodic change of body position under phototherapy in term and preterm neonates with hyperbilirubinaemia.

Phototherapy is the mainstay of treatment of neonatal hyperbilirubinaemia. Periodic change in position of the neonate under phototherapy (from supine to prone or lateral positions) may improve the efficiency of phototherapy by hastening the access of phototherapy light to bilirubin deposited in different parts of the skin and subcutaneous tissue. To evaluate the effects of periodic change of body position during phototherapy as compared to no prescribed change in body position, on serum total bilirubin level and duration of treatment in neonates with unconjugated hyperbilirubinaemia during the first 28 days of life. Secondary objectives of the review included evaluation of the efficacy of periodic change of body position on the need for or number of exchange transfusions, incidence of bilirubin-induced neurological damage (BIND), side effects of phototherapy, and sudden infant death syndrome (SIDS). We used the standard search strategy of Cochrane Neonatal to run comprehensive searches in the Cochrane Central Register of Controlled Trials (CENTRAL; 2021, Issue 3) in the Cochrane Library and Ovid MEDLINE and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions on 5 March 2021. We also searched clinical trials databases and the reference lists of included studies and relevant reviews for randomised controlled trials (RCTs) and quasi-RCTs. We included RCTs and quasi-RCTs if they enrolled neonates (term and preterm) of either gender with unconjugated hyperbilirubinaemia requiring phototherapy and compared periodic change of the body position of the infant under phototherapy with no prescribed change in body position. Two review authors independently assessed trial quality and extracted data, consulting with a third review author in the case of disagreement. We used standard Cochrane methodological procedures, including assessing the risk of bias of included studies. We used the GRADE approach to assess the certainty of evidence. Primary outcomes were the duration of phototherapy and rate of fall of serum bilirubin at 24 hours. Secondary outcomes included the need for exchange transfusion, number of exchange transfusions, incidence of BIND, and SIDS. We included five studies (343 neonates) with an overall high risk of bias in the review. The body position under phototherapy was changed every two hours or every two-and-a-half hours in two studies each, and every three hours in one study. Three of the five studiesincluded healthy term neonates, whilst the other two studies also included preterm neonates (≥ 33 weeks' gestation); however, separate data about review outcomes in preterm neonates were not available. Periodic change in body position may lead tolittle or no difference in the duration of phototherapy (mean difference (MD) 1.71 hours, 95% confidence interval (CI) -3.17 to 6.59 hours; I² = 58%; 4 studies, 231 participants; low certainty evidence). Only one study reported the rate of fall of serum total bilirubin at 24 hours of starting the phototherapy. Periodic change in body position may lead tolittle or no difference in the rateof fall of serum total bilirubin at 24 hours(MD0.02 mg/dL/h, 95% CI -0.02 to 0.06 mg/dL/h; 1 study, 100 participants; low certainty evidence). We downgraded the certainty of evidence to low due to risk of bias and imprecision. None of the included studies reported the need for or number of exchange transfusions, incidence of BIND, or SIDS. Lack of separate data precluded subgroup analysis. The available evidence is insufficient to determine the effects of periodic change of body position compared with no prescribed change of body position under phototherapy. There is low certainty evidence that there may be little or no difference in the duration of phototherapy andrate of fall in bilirubin at 24 hours of starting phototherapy between periodic change in body position and no prescribed change of body position under phototherapy in term and preterm neonates. None of the included studies reported the effect of change of position on the need for or number of exchange transfusions, incidence of BIND, or SIDS. One study is awaitingclassification and could not be included in the review. Further studies are needed to evaluate theeffectof periodic change in body position under phototherapy, especially in neonates with haemolytic hyperbilirubinaemia and in very preterm neonates. The results of this systematic review apply mainly to neonates born at late-preterm or term gestation receiving phototherapy for non-haemolytic hyperbilirubinaemia.

Characteristics and outcomes of patients with sickle cell disease admitted to pediatric intensive care: A retrospective review

INTRODUCTION: Sickle cell disease (SCD) is autosomal recessive disorder common in the Kingdom of Saudi Arabia (KSA). This is first study in KSA, and middle-east revealing characteristics of pediatric SCD patients admitted to pediatric intensive care unit (PICU). METHODS: Retrospective review of SCD patients admitted to PICU over 6-years-period (2013–2019). Data collected using patient's files and PICU book. Descriptive analysis and percentages presented in tabulated and graphical form. RESULTS: Fifty-eight patients admitted 93 times to PICU, (4.5% of total PICU admission). Most admissions were from station and emergency room (38, 33 admissions respectively). Admissions categorized into emergency and elective (59, 34 admissions respectively). Average length of stay was 1.9 days. Acute chest syndrome (ACS) (n = 28) represented 30% of admissions, followed by cerebrovascular accident (CVA) (18.2%). Five patients (5.37%) admitted for other neurological causes. Twenty-five (26.8%) admitted electively for stroke prevention, 9 (9.6%) admitted postoperatively. Considerable number of exchange transfusion in 65 (69.8%) admissions. Three needed inotropes, five invasive ventilation. Thirteen/58 (22.4%) had previous stroke, 20 (34.4%) had previous ACS, whereas significant number (n = 37, 63.8%) had frequent vaso-occlusive crisis. Mean white blood cell was 18.37 × 103/μl (emergency group), and 10.4 × 103/μl (elective group). Mean hemoglobin 7.8 g/dl and 9.67 g/dl in emergency and elective groups, respectively. Seventy percent of patients prescribed hydroxyurea and 27% of patients were on regular transfusion. Mortality rate of SCD in PICU was low (n = 2, 3.4%). CONCLUSION: PICU is one of the essential components of comprehensive health-care services for patients with SCD. Cooperation between intensivists, hematologists, and other health-care providers in addition to the early referral of critically ill SCD patients to PICU leads to better disease outcomes.

Immunoglobulin for alloimmune hemolytic disease in neonates.

Exchange transfusion and phototherapy have traditionally been used to treat jaundice and avoid the associated neurological complications. Because of the risks and burdens of exchange transfusion, intravenous immunoglobulin (IVIg) has been suggested as an alternative therapy for alloimmune hemolytic disease of the newborn (HDN) to reduce the need for exchange transfusion. To assess the effect and complications of IVIg in newborn infants with alloimmune HDN on the need for and number of exchange transfusions. We performed electronic searches of CENTRAL, PubMed, Embase (Ovid), Web of Science, CINAHL (EBSCOhost), Academic Search Premier, and the trial registers ClinicalTrials.gov and controlled-trials.com in May 2017. We also searched reference lists of included and excluded trials and relevant reviews for further relevant studies. We considered all randomized and quasi-randomized controlled trials of IVIg in the treatment of alloimmune HDN. Trials must have used predefined criteria for the use of IVIg and exchange transfusion therapy to be included. We used the standard methods of Cochrane and its Neonatal Review Group. We assessed studies for inclusion and two review authors independently assessed quality and extracted data. We discussed any differences of opinion to reach consensus. We contacted investigators for additional or missing information. We calculated risk ratio (RR), risk difference (RD) and number needed to treat for an additional beneficial outcome (NNTB) for categorical outcomes. We calculated mean difference (MD) for continuous variables. We used GRADE criteria to assess the risk of bias for major outcomes and to summarize the level of evidence. Nine studies with 658 infants fulfilled the inclusion criteria. Term and preterm infants with Rh or ABO (or both) incompatibility were included. The use of exchange transfusion decreased significantly in the immunoglobulin treated group (typical RR 0.35, 95% CI 0.25 to 0.49; typical RD -0.22, 95% CI -0.27 to -0.16; NNTB 5). The mean number of exchange transfusions per infant was also significantly lower in the immunoglobulin treated group (MD -0.34, 95% CI -0.50 to -0.17). However, sensitivity analysis by risk of bias showed that in the only two studies in which the treatment was masked by use of a placebo and outcome assessment was blinded, the results differed; there was no difference in the need for exchange transfusions (RR 0.98, 95% CI 0.48 to 1.98) or number of exchange transfusions (MD -0.04, 95% CI -0.18 to 0.10). Two studies assessed long-term outcomes and found no cases of kernicterus, deafness or cerebral palsy. Although overall results show a significant reduction in the need for exchange transfusion in infants treated with IVIg, the applicability of the results is limited because of low to very low quality of evidence. Furthermore, the two studies at lowest risk of bias show no benefit of IVIg in reducing the need for and number of exchange transfusions. Based on these results, we have insufficient confidence in the effect estimate for benefit of IVIg to make even a weak recommendation for the use of IVIg for the treatment of alloimmune HDN. Further studies are needed before the use of IVIg for the treatment of alloimmune HDN can be recommended, and should include blinding of the intervention by use of a placebo as well as sufficient sample size to assess the potential for serious adverse effects.

THREE HUNDRED SIXTY DEGREE PHOTOTHERAPY VERSUS CONVENTIONAL PHOTOTHERAPY IN NEONATAL INDIRECT HYPERBILIRUBINEMIA

Background
 Phototherapy is the mainstay of treatment of hyperbilirubinemia. The efficacy of phototherapy depended on the light spectrum (wavelength), intensity of and type of the light and surface area of the infant exposed to phototherapy and distance of the light from the baby. A measure of the efficacy of phototherapy is the rate of decline in total serum bilirubin per hour and the dramatic reduction in the number of exchange transfusions being performed.
 Objectives
 To determine the efficacy of increasing surface area of phototherapy (360◦) compared with conventional single surface fluorescent phototherapy.
 Patients and Methods
 A prospective study was done for 214 neonates, who were admitted to neonatal care unit at Raprin teaching hospital in a period of 6 months from the first of January till the thirty of July 2013. Neonates were presented with significant indirect hyperbilirubinemia that needed phototherapy, less than two weeks of age were included in this study. According to the level of total serum bilirubin and availability of highly intensive phototherapy the cases were divided in to two groups.
 Results
 The mean starting TSB in group I was 15.03±2.53 mg/dl while in group II 19.65±3.34 mg/dl and the percentage of decline after 12 hour in group I was 19.17±13.08%, while in group II was 39.37±10.31% , and it was statistically significant (p<0.001). The decline rate after 12 hour ,regarding group I was 0.23 ± 0.21 mg/dl/hr, while in group II was 0.50 ± 0.33 mg/dl/hr which was statistically significant (p<0.001). There was a significant decline in the number of exchange transfusion in 2013 when the highly intensive 360 degree phototherapy started to be used.
 Conclusion
 Increasing surface area of exposure increase the rate of reducing of the serum bilirubin, and decreases rate of exchange transfusion as well.

Prophylactic Versus Therapeutic Phototherapy in Very Low Birth Weight Infants

Background: Preterm and very low birth weight (VLBW) infants are at great risk of hyperbilirubinemia and bilirubin-associated brain damage. Objectives: The aim of this study was to compare the efficacy of prophylactic versus therapeutic phototherapy in VLBW infants. Patients and Methods: Fifty VLBW infants were randomly assigned to receive either phototherapy from the first day of life regardless of their serum bilirubin level for up to five days (prophylactic group) or phototherapy when their bilirubin level reached half the exchange transfusion level (therapeutic group). All data, including gestational age, gender, birth weight, serum bilirubin level on the first day, peak serum bilirubin concentration, the age at which the peak serum bilirubin level was reached, duration of phototherapy, and the number of exchange transfusions, were studied and analyzed. Results: The mean bilirubin level on the first day in both groups exhibited no significant difference. The peak serum bilirubin was 7.7 ± 1.4 and 8.5 ± 2.1 mg/dL in the prophylactic and therapeutic group, respectively, and there was no significant difference in the age at which the peak serum bilirubin levels were reached in both groups (2.4 ± 1.2 vs. 2.1 ± 1 days in the prophylactic and the therapeutic group, respectively). The mean duration of phototherapy in the prophylactic group was 84 ± 43 hours, while for the therapeutic group it was 72 ± 39 hours, and hence the difference was not significant. The need for an exchange transfusion was lower in the prophylactic group compared to the therapeutic group (33% vs. 7%), although the difference was not statistically meaningful (P < 0.112). Conclusions: According to our study, phototherapy should not be used as prophylactic therapy for all VLBW infants, but rather it should be individualized in order to maintain low bilirubin levels.

PO-0326 Comprehensive Analysis Of Exchange Transfusions Performed Over A 6yr Period In A Tertiary Neonatal Intensive Care Unit: Abstract PO-0326 Table 1

<h3>Introduction</h3> In the 1940’s, exchange transfusion (ExT) was introduced to help decrease the morbidity and mortality associated with haemolytic disease of the newborn (HDN) and prevent kernicterus. ExT was subsequently applied to other causes of neonatal hyperbiliribinaemia, severe neonatal anaemia from a variety of causes, some non-immune hydrops cases, Neonatal metabolic conditions such as hyperammonaemia, severe hyperkalaemia and neonatal haemochromatosis. In the 1970’s when ExT was exclusively used for the management of HDN, Lucey <i><i>et al</i>,</i> predicted a decrease in frequency of this procedure for HDN in future. Complications were estimated to increase due to the lack or decreased frequency of ExT with time. <h3>Objectives</h3> To determine. Number of ET done over a 6 yr period. Patients demographics, time of ExT, Indications. Number of Babies who have had Inutero ExT. Maternal details: Blood group, antibodies. The level of bilirubin at which transfusion took place. Prior treatment pre-ExT: In-utero Tx, Intravenous Immunoglobulin (IVIG) use; use of albumin infusion. The ExT-related complications: Any complication not present prior to the ET which occurred within 48 hrs after the ET: Defined as follows- platelet count &lt;150, hypocalaemia, ionised Calcium &lt;0.8, fits, raised INR. <h3>Methods</h3> Setting: Level 3 NICU. Retrospective notes review of patients who underwent ExT. January 2008–March 2014 (6.25 yrs). Exclusion criteria: Those for which notes were not obtained. <h3>Results</h3> Total admissions to the NICU over the period = 5,000. Number of exchange transfusions done= 15 in 14 patients. 0.3% of admissions over the period. Table of cases. Total number of request made to the Blood transfusion department for blood product for exchange. <h3>Conclusion</h3> Average ExT/yr in a Level 3 NICU = 2.4/yr. ExT is currently being used for a variety of causes. There were no complications related to the procedure itself. Complications post-ExT were all biochemical (hypocalcaemia- in 13 cases) or haematologic (low platelets 13 cases) Use of IVIG: Given pre-Ext to all ABO, Rh cases except 2 and to the Non-immune hydrops secondary to Parvovirus. 1st documented case of ExT use in hyperbilirubinaemia secondary to accidental Hyperlipidaemia from TPN-Lipid infusion and Haemolysis with Anaemia post-Octenisan wash treatment for MRSA-colonisation treatment in a preterm baby.

Clofibrate in combination with phototherapy for unconjugated neonatal hyperbilirubinaemia

There are many pathological conditions leading to an elevated unconjugated bilirubin level (hyperbilirubinaemia) in neonates. Currently the standard therapies for unconjugated hyperbilirubinaemia include phototherapy and exchange transfusion. In addition to phototherapy, clofibrate has been studied as a treatment for hyperbilirubinaemia in several countries. To determine the efficacy and safety of clofibrate in combination with phototherapy versus phototherapy alone in unconjugated neonatal hyperbilirubinaemia. Randomised controlled trials were identified by searching MEDLINE (1950 to April 2012) before being translated for use in The Cochrane Library, EMBASE 1980 to April 2012 and CINAHL databases. All searches were re-run on 2 April 2012. We included trials where neonates with hyperbilirubinaemia received either clofibrate in combination with phototherapy or phototherapy alone or placebo in combination with phototherapy. Data were extracted and analysed independently by two review authors (MG and HM). Treatment effects on the following outcomes were determined: mean change in bilirubin levels, mean duration of treatment with phototherapy, number of exchange transfusions needed, adverse effects of clofibrate, bilirubin encephalopathy and neonatal mortality. Study authors were contacted for additional information. Studies were analysed for methodological quality in a 'Risk of bias' table. Fifteen studies (two including preterm neonates and 13 including term neonates) were included in this review. All but one of the included studies were conducted in Iran. For preterm neonates, there was a significantly lower bilirubin level in the 100 mg/kg clofibrate group compared to the control group with a mean difference of -1.37 mg/dL (95% CI -2.19 mg/dL to -0.55 mg/dL) (-23 µmol/L; 95% CI -36 µmol/L to -9 µmol/L) after 48 hours. For the term neonates, there were significantly lower bilirubin levels in the clofibrate group compared to the control group after both 24 and 48 hours of treatment with a weighted mean difference of -2.14 mg/dL (95% CI -2.53 mg/dL to -1.75 mg/dL) (-37 µmol/L; 95% CI -43 µmol/L to -30 µmol/L] and -1.82 mg/dL (95% CI -2.25 mg/dL to -1.38 mg/dL) (-31 µmol/L; 95% CI -38 µmol/L to -24 µmol/L), respectively.There was a significantly lower duration of phototherapy in the clofibrate group compared to the control group for both preterm and term neonates with a weighted mean difference of -23.82 hours (95% CI -30.46 hours to -17.18 hours) and -25.40 hours (95% CI -28.94 hours to -21.86 hours), respectively.None of the studies reported on bilirubin encephalopathy rates, neonatal mortality rates, or the levels of parental or staff satisfactions with the interventions. There are insufficient data from different countries on the use of clofibrate in combination with phototherapy for hyperbilirubinaemia to make recommendations for practice. There is a need for larger trials to determine how effective clofibrate is in reducing the need for, and duration of, phototherapy in term and preterm infants with hyperbilirubinaemia.

1299 Are we Undertreating Hyperbilirubinemia in Preterm Infants?

AimTo compare serum bilirubin level for exchange transfusion in pre-term infants (< 32 weeks) against standard guidelines.MethodologyRetrospective audit. Preterm infants (< 32 weeks) and Birth weight < 1500 gms included....

Intravenous immunoglobulin to treat neonatal alloimmune haemolytic disease

Objective: To compare the efficacy of intravenous immunoglobulin (IVIg) and exchange transfusion (EXT) on rhesus haemolytic disease of the newborn (Rh-HDN) and evaluate treatment-related side effects. Methods: Retrospective chart review of two cohorts of newborns with Rh-HDN, treated with (Group 2) or without (Group 1) IVIg. Length of phototherapy, number of EXT, IVIg infusions, intrauterine and top-up red blood cells transfusions, need and permanence of umbilical venous catheter, and length of hospital stay, as well as treatment-related adverse events, were evaluated. Results: Charts of 88 newborns were reviewed (34 in Group 1, 54 in Group 2). Infants in Group 2 received a significantly lower number of EXT, had a lower risk of neurological impairment and needed an umbilical venous catheter for shorter, but required longer phototherapy, longer length of hospital stay, and more top-up transfusions. EXT was associated with a high number of adverse events. Two newborns treated with IVIg developed necrotizing enterocolitis (NEC). Conclusions: IVIg appear as an effective alternative to EXT, reducing the risk of neurological impairment and complications related to EXT. However, side effects of IVIg treatment (higher need of top-up transfusions and longer hospital stay) should be taken into account and the risk of NEC should be carefully monitored during treatment.

Improving Care for Children With Sickle Cell Disease/Acute Chest Syndrome

Acute chest syndrome (ACS) is a leading cause of hospitalization and death of children with sickle cell disease (SCD). An evidence-based ACS/SCD guideline was established to standardize care throughout the institution in February 2008. However, by the summer of 2009 use of the guideline was inconsistent, and did not seem to have an impact on length of stay. As a result, an implementation program was developed. This quality-improvement project evaluated the influence of the development and implementation of a clinical practice guideline for children with SCD with ACS or at risk for ACS on clinical outcomes. Clinical outcomes of 139 patients with SCD were evaluated before and after the development of the implementation program. Outcomes included average length of stay, number of exchange transfusions, average cost per SCD admission, and documentation of the clinical respiratory score and pulmonary interventions. Average length of stay decreased from 5.8 days before implementation of the guideline to 4.1 days after implementation (P = .033). No patients required an exchange transfusion. Average cost per SCD admission decreased from $30 359 before guideline implementation to $22 368. Documentation of the clinical respiratory score increased from 31.0% before implementation to 75.5%, which is an improvement of 44.5% (P < .001). Documentation of incentive spirometry and positive expiratory pressure increased from 23.3% before implementation to 50.4%, which is an improvement of 27.1% (P < .001). Implementation of a guideline for children with SCD with ACS or at risk for ACS improved outcomes for patients with SCD.

Intravenous immunoglobulins in rhesus hemolytic disease.

To evaluate the role of intravenous immunoglobulins in Rh hemolytic disease of newborn. The study included all DCT positive Rh isoimmunized babies admitted in the unit from August 2000 to February 2001. Intravenous immunoglobulins in the dose of 500 mg/kg on day 1 and day 2 of life in addition to the standard therapy. Babies who received IVIG were compared with those who did not receive IVIG for the peak bilirubin levels, duration of phototherapy, number of exchange transfusions, discharge PCV and the need for blood transfusions for late anemia till 1 months of age. A total of 34 babies were eligible for the study. 8 babies received IVIG and 26 babies only standard treatment. The mean maximum bilirubin levels were significantly lower in the IVIG group compared to the group who received NO IVIG (16.52 +/- 2.96 Vs 22.72 +/- 8.84, p=0.004). Five babies in the IVIG group (62.5%) and 23 babies in the NO IVIG group required exchange transfusions (88.5%, p=0.014). 12 of the 26 babies in the NO IVIG group required multiple exchange transfusions while none of the babies in IVIG group required more one exchange transfusion (p=0.03). The mean duration of phototherapy was 165 +/- 109 hours in the IVIG group as against 119 +/- 56 hours in the NO IVIG group (p=0.29). Blood transfusion for anemia was more common in the IVIG group (37.5% Vs 11.5% p=0.126) though the packed cell volumes at discharge were similar in both the groups (39.5 +/- 11 Vs 40 +/- 5.1, P=0.92). Intravenous immunoglobulins is effective in decreasing the maximum bilirubin levels and the need for repeated exchange transfusions in Rh hemolytic disease of newborn. There is however an increased need for blood transfusions for late anemia in the babies treated with IVIG.

41 FOLLOW-UP AT FIVE YEARS OF AGE OF JAUNDICED PREMATURE INFANTS

Very few studies have reported data on the extent to which increased serum levels of bilirubin might be associated with long-term developmental impairment in premature infants. The aim of this investigation was to perform a follow-up at 5 years of age of 30 low-birth-weight infants (range birth weight: 670-1.890 g; range gestational age: 25-33 wKs.) with a clinically significant hyperbilirubinemia (peak total serum bilirubin >11 mg/dl; mean ± S.D.: 15.5 ± 4.2 mg/dl) in the first four days of life. We evaluated the possible relationships between numerous risk factors, related or not to neonatal jaundici and the long-term neuromental outcome. The selected parameters were cross-tabulated and correlated, even combinated with the maximum serum bilirubin level, to the long-term outcome. Twentyfour (80%) of these children had normal neuromotor and mental development. Six subjects were affected by cerebral palsy and one had also a mild intellectual handicap. Only the concurren presence of one or more diseases (x2:6 .8125) and the number of exchange transfusions (x2:4.2500) significantly correlated to the presence of neurological sequelae at five years of age. In conclusion we failed to reveal any significant relations between risk factors, such as the maximum serum bilirubin level or the length of times of bilirubin above 11 mg/dl and of phototherapy exposure, and neuromental outcome at 5 years of age in a group of premature infants.

Executive Summary

A randomized, controlled study of phototherapy for neonatal hyperbilirubinemia was supported by the National Institute of Child Health and Human Development between 1974 to 1976. The study included 672 infants receiving phototherapy and 667 control infants. Phototherapy was effective in preventing hyperbilirubinemia in low-birth-weight infants (&amp;lt;2,000 g) who were placed under daylight fluorescent lights at 24 ± 12 hours of life for 96 hours. In this weight group, the number of exchange transfusions that were required due to hyperbilirubinemia was significantly lower in infants receiving phototherapy (4.1%) than in control infants (24.4%, P &amp;lt; .001). This was true even in infants with hemolysis and may be related to the fact that light treatment was initiated well before the development of hyperbilirubinemia. Phototherapy was effective in controlling hyperbilirubinemia in infants of birth weight 2,000 to 2,499 g when initiated after serum bilirubin concentration had risen above 10 mg/dL (mean 12.3 ± 1.9 mg/dL), as well as in infants with birth weight greater than 2,500 g whose serum bilirubin level had risen above 13 mg/dL (mean 15.7 ± 2.5 mg/dL) and in whom there was no hemolytic disorder. Light therapy instituted at these high levels of serum bilirubin did not effectively control hyperbilirubinemia in these two groups if hemolysis was present. Black infants responded to phototherapy as well as the nonblack infants. Phototherapy was most effective in the first 24 to 48 hours of its use. The pattern of declining efficacy after 48 hours is consistent with the thesis that unstable bilirubin isomers (photobilirubin) formed during the light treatment revert to natural bilirubin in the intestine following hepatic excretion and are reabsorbed via the enterohepatic circulation and contribute again to the bilirubin load to be cleared by the liver.

PHENOBARBITONE IN RHESUS HÆMOLYTIC DISEASE: A Controlled Trial

A controlled trial of the use of phenobarbitone in the management of infants with rhesus hæmolytic disease is reported. Phenobarbitone was given in a dose of approximately 2 mg. per kg. body-weight 8-hourly as soon as the result of the Coombs' test on the cord-blood was known, and was continued until serum-bilirubin levels fell consistently. 30 control infants required 40 exchange transfusions; 30 treated infants required 21 exchange transfusions. This difference is significant at the 2% level. Considering only those infants who were considered to require immediate exchange transfusion at birth by the criteria used in the trial, then 15 control infants required 28 exchange transfusions and 13 treated infants required 19 exchange transfusions. This difference in the number of exchange transfusions per child does not reach clinical significance. If, however, the immediate exchange transfusions at birth are excluded from consideration, the difference between the groups becomes highly significant. 2 babies in the control group died as a direct result of hæmolytic disease or of exchange transfusion. In the treated group there was no neonatal mortality and no morbidity attributable to phenobarbitone. It is concluded that phenobarbitone given to infants affected by rhesus hæmolytic disease from the first few hours of life is of considerable value in reducing the need for exchange transfusion, especially in those mildly affected by rhesus incompatibility.

HEMOLYTIC DISEASE OF THE NEWBORN DUE TO ABO INCOMPATIBILITY: A STUDY OF THE USE OF GROUP O ERYTHROCYTES IN AB PLASMA

Twenty-four infants with hemolytic disease of the newborn due to ABO incompatibility requiring exchange transfusion were treated randomly with either group O blood low in titer for iso-antibodies or washed packed group O erythrocytes resuspended in group AB plasma. No significant differences in survival, sequelae, number of exchange transfusions required or the course of postexchange bilirubin levels was observed. It is concluded that group O cells in AB plasma is not an improvement over conventional group O blood.