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Satrom KM, Farouk ZL, Slusher TM. Management challenges in the treatment of severe hyperbilirubinemia in low- and middle-income countries: Encouraging advancements, remaining gaps, and future opportunities. Front Pediatr 2023; 11:1001141. [PMID: 36861070 PMCID: PMC9969105 DOI: 10.3389/fped.2023.1001141] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 01/17/2023] [Indexed: 02/15/2023] Open
Abstract
Neonatal jaundice (NJ) is common in newborn infants. Severe NJ (SNJ) has potentially negative neurological sequelae that are largely preventable in high resource settings if timely diagnosis and treatment are provided. Advancements in NJ care in low- and middle-income countries (LMIC) have been made over recent years, especially with respect to an emphasis on parental education about the disease and technological advancements for improved diagnosis and treatment. Challenges remain, however, due to lack of routine screening for SNJ risk factors, fragmented medical infrastructure, and lack of culturally appropriate and regionally specific treatment guidelines. This article highlights both encouraging advancements in NJ care as well as remaining gaps. Opportunities are identified for future work in eliminating the gaps in NJ care and preventing death and disability related to SNJ around the globe.
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Affiliation(s)
- Katherine M Satrom
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis, MN, United States
| | - Zubaida L Farouk
- Department of Pediatrics, Aminu Kano Teaching Hospital, Kano, Nigeria.,Centre for Infectious Diseases Research, Bayero University, Kano, Nigeria
| | - Tina M Slusher
- Department of Pediatrics, Global Health Program, Critical Care Division, University of Minnesota, Minneapolis, MN, United States.,Department of Pediatrics, Hennepin Healthcare, Minneapolis, MN, United States
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2
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Cornet MC, Kemper AR, Maisels MJ, Watchko J, Newman TB. Neonatal hyperbilirubinemia and bilirubin neurotoxicity: what can be learned from the database analysis? Pediatr Res 2022; 92:1204. [PMID: 35136201 DOI: 10.1038/s41390-022-01973-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/30/2021] [Accepted: 01/23/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Marie-Coralie Cornet
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA.
| | - Alex R Kemper
- Division of Primary Care Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - M Jeffrey Maisels
- Department of Pediatrics, Oakland University William Beaumont School of Medicine, Beaumont Children's Hospital, Royal Oak, MI, USA
| | - Jon Watchko
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Thomas B Newman
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA.,Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, USA
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3
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Models of bilirubin neurological damage: lessons learned and new challenges. Pediatr Res 2022:10.1038/s41390-022-02351-x. [PMID: 36302856 DOI: 10.1038/s41390-022-02351-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 09/26/2022] [Accepted: 10/03/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Jaundice (icterus) is the visible manifestation of the accumulation of bilirubin in the tissue and is indicative of potential toxicity to the brain. Since its very first description more than 2000 years ago, many efforts have been undertaken to understand the molecular determinants of bilirubin toxicity to neuronal cells to reduce the risk of neurological sequelae through the use of available chemicals and in vitro, ex vivo, in vivo, and clinical models. Although several studies have been performed, important questions remain unanswered, such as the reasons for regional sensitivity and the interplay with brain development. The number of new molecular effects identified has increased further, which has added even more complexity to the understanding of the condition. As new research challenges emerged, so does the need to establish solid models of prematurity. METHODS This review critically summarizes the key mechanisms of severe neonatal hyperbilirubinemia and the use of the available models and technologies for translational research. IMPACT We critically review the conceptual dogmas and models used for studying bilirubin-induced neurotoxicity. We point out the pitfalls and translational gaps, and suggest new clinical research challenges. We hope to inform researchers on the pro and cons of the models used, and to help direct their experimental focus in a most translational research.
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Chen YY, Chen WL. Serum Bilirubin and Sperm Quality in Adult Population. TOXICS 2022; 10:toxics10060295. [PMID: 35736904 PMCID: PMC9227271 DOI: 10.3390/toxics10060295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/20/2022] [Accepted: 05/26/2022] [Indexed: 02/04/2023]
Abstract
The neurotoxicity of bilirubin has been extensively reported in numerous studies. However, the association between bilirubin and male fertility has not yet been studied. The main goal of this study was to investigate the association between serum total bilirubin and sperm quality in an adult population. In this cross-sectional study, 9057 participants who attended the MJ health examination (2010–2016) were enrolled. Sperm specimens were collected by masturbation, and sperm quality was analyzed in accordance with the WHO criteria. Serum total bilirubin levels were measured by an automatic biochemical profile analyzer. Thereafter, the associations between serum total bilirubin and sperm quality were determined by a multivariable linear regression. Serum total bilirubin was inversely associated with sperm concentration and normal morphology with β values of −13.82 (95% CI: −26.99, −0.64) and −18.38 (95% CI: −30.46, −6.29) after adjusting for covariables. The highest levels of serum total bilirubin were significantly associated with sperm concentration and normal morphology with β values of −14.15 (95% CI: −28.36, 0.06) and −21.15 (95% CI: −33.99, −8.30). Our study highlighted the potential impact of serum bilirubin on sperm quality in a male population. Additional longitudinal research is necessary to explore these findings and underlying mechanisms.
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Affiliation(s)
- Yuan-Yuei Chen
- Department of Pathology, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei 114, Taiwan;
- Department of Pathology, Tri-Service General Hospital Songshan Branch, School of Medicine, National Defense Medical Center, Taipei 114, Taiwan
| | - Wei-Liang Chen
- Division of Family Medicine, Department of Family and Community Medicine, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei 114, Taiwan
- Division of Geriatric Medicine, Department of Family and Community Medicine, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei 114, Taiwan
- Department of Biochemistry, National Defense Medical Center, Taipei,114, Taiwan
- Correspondence: ; Tel.: +886-2-87923311 (ext. 16567); Fax: +886-2-87927057
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Zheng H, Lin J, Lin Q, Zheng W. Magnetic Resonance Image of Neonatal Acute Bilirubin Encephalopathy: A Diffusion Kurtosis Imaging Study. Front Neurol 2021; 12:645534. [PMID: 34512498 PMCID: PMC8425508 DOI: 10.3389/fneur.2021.645534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 07/16/2021] [Indexed: 01/31/2023] Open
Abstract
Background and Objective: The abnormal T1-weighted imaging of MRI can be used to characterize neonatal acute bilirubin encephalopathy (ABE) in newborns, but has limited use in evaluating the severity and prognosis of ABE. This study aims to assess the value of diffusion kurtosis imaging (DKI) in detecting ABE and understanding its pathogenesis. Method: Seventy-six newborns with hyperbilirubinemia were grouped into three groups (mild group, moderate group, and severe group) based on serum bilirubin levels. All the patients underwent conventional MRI and DKI serial, as well as 40 healthy full-term infants (control group). The regions of interest (ROIs) were the bilateral globus pallidus, dorsal thalamus, frontal lobe, auditory radiation, superior temporal gyrus, substantia nigra, hippocampus, putamen, and inferior olivary nucleus. The values of mean diffusivity (MD), axial kurtosis (AK), radial kurtosis (RK), and mean kurtosis (MK), and fractional anisotropy (FA), radial diffusivity (RD), and axis diffusivity (AD) of the ROIs were evaluated. All newborns were followed up and evaluated using the Denver Development Screening Test (DDST). According to the follow-up results, the patients were divided into the normal group, the suspicious abnormal group, and the abnormal group. Result: Compared with the control group, significant differences were observed with the increased MK of dorsal thalamus, AD of globus pallidus in the moderate group, and increased RD, MK, AK, and RK value of globus pallidus, dorsal thalamus, auditory radiation, superior temporal gyrus, and hippocampus in the severe group. The peak value of total serum bilirubin was moderately correlated with the MK of globus pallidus, dorsal thalamus, and auditory radiation and was positively correlated with the other kurtosis value. Out of 76 patients, 40 finished the DDST, and only 9 patients showed an abnormality. Compared with the normal group, the AK value of inferior olivary nucleus showed significant differences (p < 0.05) in the suspicious abnormal group, and the MK of globus pallidus, temporal gyrus, and auditory radiation; RK of globus pallidus, dorsal thalamus, and auditory radiation; and MD of globus pallidus showed significant differences (p < 0.05) in the abnormal group. Conclusion: DKI can reflect the subtle structural changes of neonatal ABE, and MK is a sensitive indicator to indicate the severity of brain damage.
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Affiliation(s)
- Hongyi Zheng
- Department of Radiology, The Second Affiliated Hospital, Medical College of Shantou University, Shantou, China
| | - Jiefen Lin
- Department of Radiology, The Second Affiliated Hospital, Medical College of Shantou University, Shantou, China
| | - Qihuan Lin
- Department of Radiology, The Second Affiliated Hospital, Medical College of Shantou University, Shantou, China
| | - Wenbin Zheng
- Department of Radiology, The Second Affiliated Hospital, Medical College of Shantou University, Shantou, China
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6
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Abstract
This article attempts to highlight contemporary issues relating to term neonatal hyperbilirubinemia and to focus attention on controversial issues and concepts with the potential to effect change in clinical approach. On the one hand, the focus is bilirubin neurotoxicity, which is now known to encompass a wide, diverse spectrum of features. The various aspects of this spectrum are outlined and defined. On the other hand, bilirubin also possesses antioxidant properties. As such, mild hyperbilirubinemia is suggested as actually offering the neonate some protective advantage.
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7
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Kristensen L, Lai ABK, Ebbesen F, Donneborg ML. A greater awareness of children with glucose-6-phosphate dehydrogenase deficiency is imperative in western countries. Acta Paediatr 2021; 110:1935-1941. [PMID: 33560519 DOI: 10.1111/apa.15803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 01/07/2021] [Accepted: 02/08/2021] [Indexed: 11/30/2022]
Abstract
AIM This national retrospective Danish study described the characteristics of children diagnosed with glucose-6-phosphate dehydrogenase (G6PD) deficiency, an inherited X-linked recessive disorder that often affects children of Middle Eastern descent. METHODS We studied children born between 1 January 2000 and 31 December 2017 and diagnosed with G6PD deficiency. They were identified from the Danish National Hospital Discharge Register and the Danish Database of Extreme Neonatal Hyperbilirubinaemia. RESULTS There were 113 children diagnosed with G6PD deficiency, 67% were of Middle Eastern descent and they were frequently diagnosed before the onset of symptoms, based on known heredity. Of the 67 infants born in Denmark, 10% had extreme neonatal hyperbilirubinaemia and one developed kernicterus spectrum disorder, as did one child born in the Middle East. Most (61%) of the 33 children with jaundice received phototherapy, 12% had exchange transfusions and 18% received whole blood transfusions. After the neonatal period, 23% of the cohort had blood transfusions and 4% needed intensive care for acute haemolytic anaemia. The incidence of G6PD deficiency appeared to be severely underestimated. CONCLUSION Many families from countries where G6PD deficiency is endemic move to Denmark and other Western countries. Greater awareness is essential to avoid chronic and potentially lethal, consequences.
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Affiliation(s)
| | | | - Finn Ebbesen
- Department of Paediatrics Aalborg University Hospital Aalborg Denmark
- Department of Clinical Medicine Aalborg University Aalborg Denmark
| | - Mette L. Donneborg
- Department of Paediatrics The North Denmark Region Hospital Hjørring Denmark
- Department of Clinical Medicine Aalborg University Aalborg Denmark
- Centre for Clinical Research The North Denmark Regional Hospital Hjørring Denmark
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8
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Siddappa AM, Prekker FL, Slusher TM. Improving Effectiveness of Phototherapy in an Academic Center: A Quality Improvement Project. Glob Pediatr Health 2020; 7:2333794X20969275. [PMID: 33195747 PMCID: PMC7605035 DOI: 10.1177/2333794x20969275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 09/02/2020] [Accepted: 09/30/2020] [Indexed: 11/16/2022] Open
Abstract
Neonatal hyperbilirubinemia is a common cause of delayed discharge and readmissions in our institution. As previously published, the irradiance our phototherapy (PT) units provided was below the irradiance recommended by the AAP for intensive phototherapy (>30 µW/cm2/nm). We measured irradiance delivered by our PT units (Drager 4000) using a standardized footprint grid. By varying number of blue and white fluorescent PT lights, height of PT unit above the neonate and type of bed used (open bassinet versus isolette), we determined the optimal PT arrangement needed to deliver intensive PT (30 µW/cm2/nm). We then developed a standardized, multidisciplinary protocol specifying light arrangement and distance required needed to achieve the desired irradiance level. We were able to show improved irradiance following above changes. Onsite measurement of irradiance provided by local phototherapy units and development of a multidisciplinary, standardized protocol are necessary to assure delivery of recommended levels PT for neonates with hyperbilirubinemia.
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Affiliation(s)
- Ashajyothi M Siddappa
- Hennepin Healthcare, Minneapolis, MN, USA.,University of Minnesota, Minnesota, MN, USA
| | - Frances L Prekker
- Hennepin Healthcare, Minneapolis, MN, USA.,University of Minnesota, Minnesota, MN, USA
| | - Tina M Slusher
- Hennepin Healthcare, Minneapolis, MN, USA.,University of Minnesota, Minnesota, MN, USA
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9
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Hansen TWR, Wong RJ, Stevenson DK. Molecular Physiology and Pathophysiology of Bilirubin Handling by the Blood, Liver, Intestine, and Brain in the Newborn. Physiol Rev 2020; 100:1291-1346. [PMID: 32401177 DOI: 10.1152/physrev.00004.2019] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Bilirubin is the end product of heme catabolism formed during a process that involves oxidation-reduction reactions and conserves iron body stores. Unconjugated hyperbilirubinemia is common in newborn infants, but rare later in life. The basic physiology of bilirubin metabolism, such as production, transport, and excretion, has been well described. However, in the neonate, numerous variables related to nutrition, ethnicity, and genetic variants at several metabolic steps may be superimposed on the normal physiological hyperbilirubinemia that occurs in the first week of life and results in bilirubin levels that may be toxic to the brain. Bilirubin exists in several isomeric forms that differ in their polarities and is considered a physiologically important antioxidant. Here we review the chemistry of the bilirubin molecule and its metabolism in the body with a particular focus on the processes that impact the newborn infant, and how differences relative to older children and adults contribute to the risk of developing both acute and long-term neurological sequelae in the newborn infant. The final section deals with the interplay between the brain and bilirubin and its entry, clearance, and accumulation. We conclude with a discussion of the current state of knowledge regarding the mechanism(s) of bilirubin neurotoxicity.
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Affiliation(s)
- Thor W R Hansen
- Division of Paediatric and Adolescent Medicine, Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway; and Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Ronald J Wong
- Division of Paediatric and Adolescent Medicine, Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway; and Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - David K Stevenson
- Division of Paediatric and Adolescent Medicine, Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway; and Department of Pediatrics, Stanford University School of Medicine, Stanford, California
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10
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Kang W, Yuan X, Zhang Y, Song J, Xu F, Liu D, Li R, Xu B, Li W, Cheng Y, Zhu C. Early prediction of adverse outcomes in infants with acute bilirubin encephalopathy. Ann Clin Transl Neurol 2020; 7:1141-1147. [PMID: 32495505 PMCID: PMC7359120 DOI: 10.1002/acn3.51077] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/10/2020] [Accepted: 05/12/2020] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE Acute bilirubin encephalopathy (ABE) remains one of the important causes of neonatal mortality and child disability, early identification, and intervention which could improve outcomes. The purpose of this study was to evaluate early predictors of adverse outcomes in infants with ABE. METHODS Newborns of gestational age ≥ 35 weeks and diagnosed with ABE were included in the study. Bilirubin-induced neurological dysfunction (BIND) score, total serum bilirubin (TSB) peak value, and serum albumin levels were determined. Adverse outcomes were defined as death or survival with auditory dysfunction and/or cerebral palsy. RESULTS Eighty-two infants were eligible for recruitment in the study. The outcome data from 76 ABE infants (92%) were used for analysis, of which 25 infants got adverse outcomes and 51 live a normal life. Univariate analysis for BIND score, TSB peak value, bilirubin-albumin ratio (B/A), albumin level, abnormal AABR, and neonatal sepsis was performed to elucidate the association with adverse outcomes. Bivariate logistic regression analysis showed B/A (OR 10.48, 95%CI: 1.55-70.81, P = 0.02) and BIND score (OR 3.68, 95%CI: 1.39-9.72, P = 0.01) were correlated with adverse outcomes. ROC curve analysis showed that B/A (≥8.9 mg/g), BIND score (≥6) could predict adverse outcomes of ABE separately; B/A in conjunction with BIND score could increase prediction sensitivity to 100%. INTERPRETATION Both B/A and BIND score can be used to predict adverse outcomes of ABE, and the combination of the two parameters can increase prediction sensitivity significantly.
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Affiliation(s)
- Wenqing Kang
- Neonatal Intensive Care Unit, Zhengzhou Key Laboratory of Newborn Disease Research, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, 450018, China
| | - Xiao Yuan
- Henan Key Laboratory of Child Brain Injury, Institute of Neuroscience and Third Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, China
| | - Yaodong Zhang
- Neonatal Intensive Care Unit, Zhengzhou Key Laboratory of Newborn Disease Research, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, 450018, China
| | - Juan Song
- Henan Key Laboratory of Child Brain Injury, Institute of Neuroscience and Third Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, China
| | - Falin Xu
- Henan Key Laboratory of Child Brain Injury, Institute of Neuroscience and Third Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, China
| | - Dapeng Liu
- Neonatal Intensive Care Unit, Zhengzhou Key Laboratory of Newborn Disease Research, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, 450018, China
| | - Rui Li
- Neonatal Intensive Care Unit, Zhengzhou Key Laboratory of Newborn Disease Research, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, 450018, China
| | - Bangli Xu
- Neonatal Intensive Care Unit, Zhengzhou Key Laboratory of Newborn Disease Research, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, 450018, China
| | - Wen Li
- Department of Neonatology, Qilu Hospital of Shandong University, Jinan, China
| | - Yanchao Cheng
- Henan Key Laboratory of Child Brain Injury, Institute of Neuroscience and Third Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, China
| | - Changlian Zhu
- Henan Key Laboratory of Child Brain Injury, Institute of Neuroscience and Third Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, China.,Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg University, Gothenburg, 40530, Sweden
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11
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Watchko JF. TcB, FFR, phototherapy and the persistent occurrence of kernicterus spectrum disorder. J Perinatol 2020; 40:177-179. [PMID: 31911651 DOI: 10.1038/s41372-019-0583-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 12/11/2019] [Accepted: 12/19/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Jon F Watchko
- Division of Newborn Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15213, USA.
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12
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Extreme neonatal hyperbilirubinemia and kernicterus spectrum disorder in Denmark during the years 2000-2015. J Perinatol 2020; 40:194-202. [PMID: 31907395 DOI: 10.1038/s41372-019-0566-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 11/17/2019] [Accepted: 12/17/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine the incidence and etiology of extreme neonatal hyperbilirubinemia, defined as total serum bilirubin (TSB) ≥450 µmol/L, and kernicterus spectrum disorder (KSD) in Denmark between 2000 and 2015. STUDY DESIGN We identified all infants born between 01.01.2000 and 31.12.2015 with TSB ≥450 µmol/L, ratio of conjugated to TSB <0.30, gestational age ≥35 weeks, and postnatal age ≤4 weeks, using Danish hospitals' laboratory databases. RESULT We included 408 infants. The incidence of extreme neonatal hyperbilirubinemia among infants with gestational age ≥35 weeks was 42/100,000 during the study period with a seemingly decreasing incidence between 2005 and 2015. Twelve of the 408 infants developed KSD, (incidence 1.2/100,000) Blood type ABO isohemolytic disease was the most common explanatory etiology. CONCLUSIONS Our study stresses the importance of a systematic approach to neonatal jaundice and ongoing surveillance of extreme neonatal hyperbilirubinemia and KSD.
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13
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Hansen TWR, Maisels MJ, Ebbesen F, Vreman HJ, Stevenson DK, Wong RJ, Bhutani VK. Sixty years of phototherapy for neonatal jaundice - from serendipitous observation to standardized treatment and rescue for millions. J Perinatol 2020; 40:180-193. [PMID: 31420582 DOI: 10.1038/s41372-019-0439-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 05/04/2019] [Accepted: 05/23/2019] [Indexed: 11/09/2022]
Abstract
A breakthrough discovery 60 years ago by Cremer et al. has since changed the way we treat infants with hyperbilirubinemia and saved the lives of millions from death and disabilities. "Photobiology" has evolved by inquiry of diverse light sources: fluorescent tubes (wavelength range of 400-520 nm; halogen spotlights that emit circular footprints of light; fiberoptic pads/blankets (mostly, 400-550 nm range) that can be placed in direct contact with skin; and the current narrow-band blue light-emitting diode (LED) light (450-470 nm), which overlaps the peak absorption wavelength (458 nm) for bilirubin photoisomerization. Excessive bombardment with photons has raised concerns for oxidative stress in very low birthweight versus term infants treated aggressively with phototherapy. Increased emphasis on prescribing phototherapy as a "drug" that is dosed cautiously and judiciously is needed. In this historical review, we chronicled the basic to the neurotoxic components of severe neonatal hyperbilirubinemia and the use of standardized interventions.
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Affiliation(s)
- Thor Willy Ruud Hansen
- Division of Paediatric and Adolescent Medicine, Department of Neonatal Intensive Care, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - M Jeffrey Maisels
- Department of Pediatrics, Oakland University William Beaumont School of Medicine, Beaumont Children's Hospital, Royal Oak, MI, USA
| | - Finn Ebbesen
- Department of Pediatrics, Aalborg University Hospital, Aalborg, Denmark.,Institute of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Hendrik J Vreman
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - David K Stevenson
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Ronald J Wong
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Vinod K Bhutani
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.
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14
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Shapiro SM, Riordan SM. Review of bilirubin neurotoxicity II: preventing and treating acute bilirubin encephalopathy and kernicterus spectrum disorders. Pediatr Res 2020; 87:332-337. [PMID: 31581172 DOI: 10.1038/s41390-019-0603-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 09/09/2019] [Indexed: 11/09/2022]
Abstract
Previously in Part I of this two-part review, we discussed the current and recent advances in the understanding of the molecular biology and neuropathology of bilirubin neurotoxicity (BNTx). Here in Part II, we summarize current treatment options available to treat the severely jaundiced infants to prevent significant brain damage and improve clinical outcomes. In addition, we review potential novel therapies that are in various stages of research and development. We will emphasize treatments for both prevention and treatment of both acute bilirubin encephalopathy (ABE) and kernicterus spectrum disorders (KSDs), highlighting the treatment of the most disabling neurological sequelae of children with mild-to-severe KSDs whose "rare disease" status often means they are overlooked by the clinical research community at large. As with other secondary dystonias, treatment of the dystonic motor symptoms in kernicterus is the greatest clinical challenge.
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Affiliation(s)
- Steven M Shapiro
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO, USA. .,Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA. .,Department of Pediatrics, University of Kansas Medical Center, Kansas City, KS, USA. .,Department of Pediatrics, University of Missouri-Kansas City, Kansas City, MO, USA.
| | - Sean M Riordan
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO, USA.,Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA.,Department of Pediatrics, University of Missouri-Kansas City, Kansas City, MO, USA
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15
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Yuan X, Song J, Gao L, Cheng Y, Dong H, Zhang R, Liu S, Ding X, Wang Y, Xu F, Zhu C. Early Amplitude-Integrated Electroencephalography Predicts Long-Term Outcomes in Term and Near-Term Newborns With Severe Hyperbilirubinemia. Pediatr Neurol 2019; 98:68-73. [PMID: 31253564 DOI: 10.1016/j.pediatrneurol.2019.04.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 04/15/2019] [Accepted: 04/21/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND We aimed to determine the predictive neurological prognostic value of early amplitude-integrated electroencephalography (aEEG) in term and near-term neonates with severe hyperbilirubinemia compared with cranial magnetic resonance imaging (MRI) and auditory brainstem response (ABR). METHODS Infants of ≥35 weeks of gestation with severe hyperbilirubinemia (total serum bilirubin [TSB] ≥340 μmol/L) or with hyperbilirubinemia (TSB ≥257 μmol/L) in association with bilirubin-induced neurological dysfunction were recruited. All the subjects had an aEEG after being admitted to the neonatal intensive care unit, whereas cranial MRI and ABR were performed when TSB had come down to the normal range. All the infants were followed up to 12 months. RESULTS During the study period, 77 of 83 infants were eligible, of which 71 had severe hyperbilirubinemia and six had hyperbilirubinemia in association with bilirubin-induced neurological dysfunction. Thirty-three infants were diagnosed with acute bilirubin encephalopathy (ABE), two of whom died of ABE, and 62 completed the follow-up, of which 12 infants had adverse outcomes. Sixty-four infants underwent aEEG, 40 infants had cranial MRI, and 39 infants had ABR. Logistic regression and the receiver-operator characteristic curve analysis showed that the ability of severely abnormal aEEG to predict adverse neurological outcomes in severe hyperbilirubinemia was no better than abnormal ABR, with a sensitivity of 35.7% versus 83.3%, a specificity of 92.0% versus 74.1%, a positive predictive value of 55.6% versus 58.8%, and a negative predictive value of 83.6% versus 90.9%. CONCLUSIONS Early aEEG could predict adverse neurodevelopmental outcomes in neonates with severe hyperbilirubinemia, although the sensitivity was lower than ABR.
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Affiliation(s)
- Xiao Yuan
- Henan Key Laboratory of Child Brain Injury, Third Affiliated Hospital and Institute of Neuroscience, Zhengzhou University, Zhengzhou, China; Henan Key Laboratory of Child Brain Injury, Department of Neonatology, Third Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Juan Song
- Henan Key Laboratory of Child Brain Injury, Third Affiliated Hospital and Institute of Neuroscience, Zhengzhou University, Zhengzhou, China; Henan Key Laboratory of Child Brain Injury, Department of Neonatology, Third Affiliated Hospital, Zhengzhou University, Zhengzhou, China.
| | - Liang Gao
- Henan Key Laboratory of Child Brain Injury, Department of Neonatology, Third Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Yanchao Cheng
- Henan Key Laboratory of Child Brain Injury, Department of Neonatology, Third Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Huimin Dong
- Henan Key Laboratory of Child Brain Injury, Third Affiliated Hospital and Institute of Neuroscience, Zhengzhou University, Zhengzhou, China
| | - Ruili Zhang
- Henan Key Laboratory of Child Brain Injury, Third Affiliated Hospital and Institute of Neuroscience, Zhengzhou University, Zhengzhou, China
| | - Shasha Liu
- Henan Key Laboratory of Child Brain Injury, Third Affiliated Hospital and Institute of Neuroscience, Zhengzhou University, Zhengzhou, China
| | - Xue Ding
- Henan Key Laboratory of Child Brain Injury, Third Affiliated Hospital and Institute of Neuroscience, Zhengzhou University, Zhengzhou, China
| | - Yong Wang
- Henan Key Laboratory of Child Brain Injury, Third Affiliated Hospital and Institute of Neuroscience, Zhengzhou University, Zhengzhou, China
| | - Falin Xu
- Henan Key Laboratory of Child Brain Injury, Third Affiliated Hospital and Institute of Neuroscience, Zhengzhou University, Zhengzhou, China; Henan Key Laboratory of Child Brain Injury, Department of Neonatology, Third Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Changlian Zhu
- Henan Key Laboratory of Child Brain Injury, Third Affiliated Hospital and Institute of Neuroscience, Zhengzhou University, Zhengzhou, China; Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.
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Çoban A, Türkmen MK, Gürsoy T. Turkish Neonatal Society guideline to the approach, follow-up, and treatment of neonatal jaundice. TURK PEDIATRI ARSIVI 2018; 53:S172-S179. [PMID: 31236030 PMCID: PMC6568284 DOI: 10.5152/turkpediatriars.2018.01816] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Jaundice is one of the most common problems in the newborn. It is generally accepted as a physiologic condition; most cases are benign and transient. However, in a small portion of jaundiced newborn infants, serum bilirubin concentrations increase to a level at which irreversible brain damage can occur. The timely diagnosis and management of severe hyperbilirubinemia is essential to prevent acute bilirubin encephalopathy and kernicterus. Kernicterus still occurs although it is almost always preventable. The focus of this guideline is to reduce the incidence of severe hyperbilirubinemia and bilirubin encephalopathy. Therefore, a system-based approach using the recommendations of this guideline should be implemented in all birthing facilities and continued in ambulatory care of the newborn infants.
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Affiliation(s)
- Asuman Çoban
- Division of Neonatology, Department of Pediatrics, İstanbul University, İstanbul Faculty of Medicine, İstanbul, Turkey
| | - Münevver Kaynak Türkmen
- Division of Neonatology, Department of Pediatrics, Adnan Menderes University, Faculty of Medicine, Aydın, Turkey
| | - Tuğba Gürsoy
- Department of Pediatrics, Koç University, Faculty of Medicine, İstanbul, Turkey
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Watchko JF. Emergency release uncross-matched packed red blood cells for immediate double volume exchange transfusion in neonates with intermediate to advanced acute bilirubin encephalopathy: timely but insufficient? J Perinatol 2018; 38:947-953. [PMID: 29997396 DOI: 10.1038/s41372-018-0168-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 06/14/2018] [Accepted: 06/18/2018] [Indexed: 11/09/2022]
Abstract
Given the urgency of double volume exchange transfusion (ExT) in an infant with intermediate to advanced stages of acute bilirubin encephalopathy (ABE), it has been suggested that emergency release uncross-matched packed red blood cells (ER-PRBC) be used. The efficacy of an ExT in removing bilirubin from the brain, however, is a direct function of the mass of albumin exchanged. The very low albumin content of ER-PRBC may fail to be neuroprotective. Predicted changes in total serum bilirubin (TSB), serum albumin, the bilirubin/albumin (B/A) ratio, plasma volume (PV), and bilirubin equilibration from the extravascular space during ER-PRBC ExT are described. ExT using ER-PRBC is efficacious in lowering the TSB. However, this result is falsely reassuring as significant concurrent serum albumin loss, resultant hypoalbuminemia, contraction of PV, limited bilirubin clearance from the extravascular space, and sustained B/A ratio elevations above recommended ExT treatment thresholds suggest that bilirubin neurotoxicity will continue.
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Affiliation(s)
- Jon F Watchko
- Division of Newborn Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15213, USA.
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18
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Extreme neonatal hyperbilirubinemia, acute bilirubin encephalopathy, and kernicterus spectrum disorder in children with galactosemia. Pediatr Res 2018; 84:228-232. [PMID: 29892033 DOI: 10.1038/s41390-018-0066-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 05/10/2018] [Indexed: 11/09/2022]
Abstract
BACKGROUND Galactosemia has not been recognized as a cause of extreme neonatal hyperbilirubinemia, although growing evidence supports this association. METHODS In a retrospective cohort study, we identified children with galactosemia due to GALT deficiency using the Danish Metabolic Laboratory Database. Among these, we identified children with extreme neonatal hyperbilirubinemia or symptoms of ABE. Extreme neonatal hyperbilirubinemia was defined as maximum total serum bilirubin (TSBmax)) level ≥450 µmol/L and a ratio of conjugated serum bilirubin/TSB <0.30. RESULTS We identified 21 children with galactosemia (incidence:1:48,000). Seven children developed extreme neonatal hyperbilirubinemia (median [range] TSBmax level: 491 [456-756] µmol/L), accounting for 1.7% of all extreme neonatal hyperbilirubinemia cases. During the first 10 days of life, hyperbilirubinemia was predominantly of unconjugated type. Four children developed symptoms of intermediate/advanced ABE. One additional child had symptoms of intermediate/advanced ABE without having extreme neonatal hyperbilirubinemia. On follow-up, one child had KSD. CONCLUSIONS Galactosemia is a potential cause of extreme neonatal hyperbilirubinemia, ABE, and KSD. It is crucial that putative galactosemic children are treated aggressively with phototherapy to prevent ABE and KSD. Thus it is important that galactosemia is part of the work up for unconjugated hyperbilirubinemia.
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Neonatal hyperbilirubinaemia: a global perspective. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 2:610-620. [DOI: 10.1016/s2352-4642(18)30139-1] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 04/13/2018] [Accepted: 04/20/2018] [Indexed: 02/07/2023]
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20
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Farouk ZL, Muhammed A, Gambo S, Mukhtar-Yola M, Umar Abdullahi S, Slusher TM. Follow-up of Children with Kernicterus in Kano, Nigeria. J Trop Pediatr 2018; 64:176-182. [PMID: 28605485 DOI: 10.1093/tropej/fmx041] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Acute bilirubin encephalopathy (ABE) is associated with long-term sequelae (kernicterus). It continues to be a significant issue in our region of Nigeria, accounting for much morbidity and mortality. Herein we report the outcome of neonates with ABE seen at our centre. METHODOLOGY We established a surveillance of children who had ABE and returned to follow-up from prospective cases of ABE (2012-2014). ABE was diagnosed based on a bilirubin-induced neurologic dysfunction score of ≥ 1. Kernicterus was subsequently established based on a history of developmental delays, hearing impairments and abnormal physical and neurologic examinations at follow-up age ≥3 months. RESULT Five hundred fifty-one neonates had hyperbilirubinaemia of whom 104 (18.8%) had ABE. Mean transcutaneous bilirubin using the Ingram icterometer was 18.3 mg/dl ± SD 1.9 [(12.5-19.1), total serum bilirubin of 18.1 ± 10.9] (range: 10.3-64 mg/dl). Sixty-five infants returned for follow-up (41 males and 24 females); mean age 9 months (22 days to 17 months). Most (58 of 65; 89.2%) had abnormal neurological findings and 15 (25.9%) had probable kernicterus. CONCLUSION There is a critical need for a National Kernicterus Registry to document all cases of kernicterus and formulate an effective treatment and prevention policy.
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Affiliation(s)
| | | | - Safiya Gambo
- Department of Paediatrics Murtala Muhamed Specialist Hospital, Kano 7002 31, Nigeria
| | | | | | - Tina M Slusher
- Department of Pediatrics, Division of Global Pediatrics University of Minnesota, Minneapolis, MN 55415, USA
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21
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Donneborg ML, Vandborg PK, Hansen BM, Rodrigo-Domingo M, Ebbesen F. Double versus single intensive phototherapy with LEDs in treatment of neonatal hyperbilirubinemia. J Perinatol 2018; 38:154-158. [PMID: 29095431 DOI: 10.1038/jp.2017.167] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 08/23/2017] [Accepted: 09/05/2017] [Indexed: 01/16/2023]
Abstract
OBJECTIVE We investigate whether double phototherapy reduces total serum bilirubin concentration faster than single light during intensive phototherapy with high levels of irradiance using light-emitting diodes. STUDY DESIGN Eighty-three infants with gestational age ⩾33 weeks and uncomplicated hyperbilirubinemia were randomized to either double (n=41) or single phototherapy (n=42) for 24 h. The mean irradiance was 64.8 μW cm-2 nm-1 from above and 39 μW cm-2 nm-1 from below. RESULTS The percentage decreases of total serum bilirubin after 12 h of double vs single phototherapy were (mean (95% confidence interval (CI))) 39% (37 to 42) vs 30% (27 to 32), respectively (P<0.001). After 24 h, the decreases were 58% (56 to 61) vs 47% (44 to 50), respectively (P<0.001). The results were still significant after adjustment for confounding. The only side effect was loose stools. CONCLUSION Even with intensive phototherapy increasing spectral power by increasing the irradiated body surface area, the efficacy of phototherapy is improved.
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Affiliation(s)
- M L Donneborg
- Department of Pediatrics, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - P K Vandborg
- Department of Pediatrics, Aalborg University Hospital, Aalborg, Denmark
| | - B M Hansen
- Department of Pediatrics, Herlev Hospital, Copenhagen, Denmark
| | - M Rodrigo-Domingo
- Department of Research, Education and Innovation, Aalborg University Hospital, Aalborg, Denmark
| | - F Ebbesen
- Department of Pediatrics, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Abstract
A pharmacologic view of phototherapy for neonatal jaundice is presented. By considering the photons of therapy light as molecules of a drug, this view connects therapeutic efficacy with photon wavelength, photon dose, dose rate and regimen, efficiency of photon absorption by bilirubin, quantum yields of photoproducts, and their metabolic courses. Based on this view, recommendations to ultimately improve efficacy and safety are presented. Special attention is given to phototherapy regimens for low gestational age, low birthweight infants.
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Affiliation(s)
- Angelo A Lamola
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.
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23
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Abstract
Phototherapy is the main treatment for neonatal hyperbilirubinemia. In acute treatment of extreme hyperbilirubinemia, intensive phototherapy may have a role in 'detoxifying' the bilirubin molecule to more polar photoisomers, which should be less prone to crossing the blood-brain barrier, providing a 'brain-sparing' effect. This article reviews the biology of bilirubin isomers. Although there is evidence supporting the lower toxicity of bilirubin photoisomers, there are studies showing the opposite. There are methodologic weaknesses in most studies and better-designed experiments are needed. In an infant acutely threatened by bilirubin-induced brain damage, intensified phototherapy should be used expediently and aggressively.
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Affiliation(s)
- Thor Willy Ruud Hansen
- Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
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24
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Sherbiny HS, Youssef DM, Sherbini AS, El-Behedy R, Sherief LM. High-intensity light-emitting diode vs fluorescent tubes for intensive phototherapy in neonates. Paediatr Int Child Health 2016; 36:127-33. [PMID: 25844870 DOI: 10.1179/2046905515y.0000000006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Special blue fluorescent tubes are recommended by the American Academy of Pediatrics (AAP) as the most effective light source for lowering serum bilirubin. A high-intensity light-emitting diode ('super LED') could render intensive phototherapy more effective than the above conventional methods. This study compared the efficacy and safety of a high-intensity light-emitting diode bed vs conventional intensive phototherapy with triple fluorescent tube units as a rescue treatment for severe unconjugated neonatal hyperbilirubinaemia. METHOD This was a randomised, prospective trial. Two hundred jaundiced neonates ≥ 35 weeks gestation who met the criteria for intensive phototherapy as per AAP guidelines were randomly assigned to be treated either with triple fluorescent tube units (group 1, n = 100) or a super LED bed (group 2, n = 100). The outcome was the avoidance of exchange transfusion by successful control of hyperbilirubinaemia. RESULTS Statistically significant higher success rates of intensive phototherapy were achieved among neonates treated with super LED (group 2) than in those treated conventionally (group 1) (87% vs 64%, P = 0.003). Significantly higher 'bilirubin decline' rates were reported in both haemolytic and non-haemolytic subgroups treated with the super LED bed compared with a similar sub-population in the conventionally treated group. Comparable numbers of neonates in both groups developed rebound jaundice (8% vs 10% of groups 1 and 2, respectively). Side-effects were mild in both groups, but higher rates of hyperthermia (12% vs 0%, P = 0.03), dehydration (8% vs 2%, P = 0.26) and skin rash (39% vs 1%, P = 0.002) were reported in the fluorescent tubes-treated group compared with the LED group. CONCLUSIONS Super LED is a safe rescue treatment for severe neonatal hyperbilirubinaemia, and its implementation may reduce the need for exchange transfusion.
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Affiliation(s)
| | | | - Ahmad S Sherbini
- b Tropical Medicine, Faculty of Medicine , Zagazig University , , Egypt
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A decision-making tool for exchange transfusions in infants with severe hyperbilirubinemia in resource-limited settings. J Perinatol 2016; 36:338-41. [PMID: 26938921 DOI: 10.1038/jp.2016.25] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 01/18/2016] [Accepted: 01/26/2016] [Indexed: 11/08/2022]
Abstract
Late presentation and ineffective phototherapy account for excessive rates of avoidable exchange transfusions (ETs) in many low- and middle-income countries. Several system-based constraints sometimes limit the ability to provide timely ETs for all infants at risk of kernicterus, thus necessitating a treatment triage to optimize available resources. This article proposes a practical priority-setting model for term and near-term infants requiring ET after the first 48 h of life. The proposed model combines plasma/serum bilirubin estimation, clinical signs of acute bilirubin encephalopathy and neurotoxicity risk factors for predicting the risk of kernicterus based on available evidence in the literature.
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Abstract
OBJECTIVES To identify the predictors of repeat exchange transfusion among infants with severe hyperbilirubinemia. DESIGN Retrospective cross-sectional study. SETTING A referral children's hospital in inner-city Lagos, Nigeria. PATIENTS Infants who received exchange transfusion for severe hyperbilirubinemia from January 2012 to December 2014. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS The predictors of repeat exchange transfusion were identified among all infants who had at least one exchange transfusion using multivariable logistic regression. A total of 352 infants with mean peak total serum bilirubin of 26.32 ± 7.96 mg/dL received exchange transfusion; of these, 49 (13.9%) with mean peak total serum bilirubin of 32.85 ± 10.54 mg/dL had repeat exchange transfusion. More than two thirds of infants who received exchange transfusion and repeat exchange transfusion were male, and at least one third had ABO incompatibility. No infant had more than two exchange transfusions. The mean age of admission was approximately 5 days (range, 1-14 d). Peak total serum bilirubin greater than or equal to 30 mg/dL (odds ratio, 2.88; 95% CI, 1.46-5.70) and acute bilirubin encephalopathy (odds ratio, 2.37; 95% CI, 1.18-4.77) were predictive of repeat exchange transfusion. CONCLUSIONS Acute bilirubin encephalopathy and excessive total serum bilirubin levels at least 30 mg/dL are predictive of repeat exchange transfusion. A risk assessment framework that combines total serum bilirubin levels, acute bilirubin encephalopathy status, and risk factors of neurotoxicity should be considered for the timely detection and monitoring of infants at risk of repeat exchange transfusion.
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Early formation of bilirubin isomers during phototherapy for neonatal jaundice: effects of single vs. double fluorescent lamps vs. photodiodes. Pediatr Res 2015; 78:56-62. [PMID: 25794186 DOI: 10.1038/pr.2015.61] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 12/18/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND In neonatal jaundice, phototherapy converts bilirubin to more polar photoisomers which can be excreted without conjugation. We measured changes in the concentration of bilirubin Z,E-photoisomer during the first 4 h of intensive phototherapy using single fluorescent lights as a reference, compared to double fluorescent lights, and a single unit of photodiodes. METHODS Neonates (N = 42; birth weight: 1,200-4,690 g; gestational age: 28-42 wk) were studied during phototherapy. Infants were randomized to: (i) single, or (ii) double fluorescent phototherapy; or (iii) single unit photodiodes. Irradiance was measured. Serum bilirubin (by cooximetry) and Z,E bilirubin (by high-pressure liquid chromatography) were measured at 0,15, 30, 60, 120, and 240 min after the start of phototherapy. Data were analyzed with a linear mixed model. RESULTS There was a highly significant increase of Z,E-bilirubin over time (P < 0.0001), starting at 15 min. Photoisomers reached ~25% of total bilirubin concentration after 4 h. However, there were no significant differences between the three randomized groups in spite of significantly higher irradiance using double fluorescent lights vs. single fluorescent or photodiodes. CONCLUSION Formation of bilirubin photoisomers is rapid, and occurs early during intensive phototherapy for neonatal jaundice. The rate and level of photoisomerization was not influenced by irradiance and light source.
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Smerud OJO, Solevåg AL, Hansen TWR, Grønn M. 14 dager gammel gutt med gulsott og apnéanfall. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2015; 135:2167-70. [DOI: 10.4045/tidsskr.15.0519] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Hu W, Cheng X, Ye X, Zhao L, Huang Y, Zhu H, Yan Z, Wang X, Wang X, Bai G, Gao H. Ex vivo (1)H nuclear magnetic resonance spectroscopy reveals systematic alterations in cerebral metabolites as the key pathogenetic mechanism of bilirubin encephalopathy. Mol Brain 2014; 7:87. [PMID: 25424547 PMCID: PMC4252999 DOI: 10.1186/s13041-014-0087-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 11/13/2014] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Bilirubin encephalopathy (BE) is a severe neurologic sequelae induced by hyperbilirubinemia in newborns. However, the pathogenetic mechanisms underlying the clinical syndromes of BE remain ambiguous. Ex vivo (1)H nuclear magnetic resonance (NMR) spectroscopy was used to measure changes in the concentrations of cerebral metabolites in various brain areas of newborn 9-day-old rats subjected to bilirubin to explore the related mechanisms of BE. RESULTS When measured 0.5 hr after injection of bilirubin, levels of the amino acid neurotransmitters glutamate (Glu), glutamine (Gln), and γ-aminobutyric acid (GABA) in hippocampus and occipital cortex significantly decreased, by contrast, levels of aspartate (Asp) considerably increased. In the cerebellum, Glu and Gln levels significantly decreased, while GABA, and Asp levels showed no significant differences. In BE 24 hr rats, all of the metabolic changes observed returned to normal in the hippocampus and occipital cortex; however, levels of Glu, Gln, GABA, and glycine significantly increased in the cerebellum. CONCLUSIONS These metabolic changes for the neurotransmitters are mostly likely the result of a shift in the steady-state equilibrium of the Gln-Glu-GABA metabolic cycle between astrocytes and neurons, in a region-specific manner. Changes in energy metabolism and the tricarboxylic acid cycle may also be involved in the pathogenesis of BE.
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Affiliation(s)
- Wenyi Hu
- Radiology Department of the Second Affiliated Hospital, Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China.
- Institute of Metabonomics & Medical NMR, School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, 325035, Zhejiang, China.
| | - Xiaojie Cheng
- Radiology Department of the Second Affiliated Hospital, Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China.
| | - Xinjian Ye
- Radiology Department of the Second Affiliated Hospital, Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China.
| | - Liangcai Zhao
- Institute of Metabonomics & Medical NMR, School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, 325035, Zhejiang, China.
| | - Yanan Huang
- Radiology Department of the Second Affiliated Hospital, Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China.
| | - Huanle Zhu
- Radiology Department of the Second Affiliated Hospital, Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China.
| | - Zhihan Yan
- Radiology Department of the Second Affiliated Hospital, Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China.
| | - Xuebao Wang
- Institute of Metabonomics & Medical NMR, School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, 325035, Zhejiang, China.
| | - Xiaojie Wang
- Institute of Metabonomics & Medical NMR, School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, 325035, Zhejiang, China.
| | - Guanghui Bai
- Radiology Department of the Second Affiliated Hospital, Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China.
| | - Hongchang Gao
- Institute of Metabonomics & Medical NMR, School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, 325035, Zhejiang, China.
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Abstract
Central apnea, defined as cessation of breathing for ≥20s, is frequent in premature infants born at <34 weeks׳ gestation but uncommon among healthy late preterm (34(0/7)-36(6/7) weeks׳ gestation) and term (≥37 weeks׳ gestation) infants, where it is usually a clinical manifestation of a neurological or metabolic problem. There is growing evidence that marked unconjugated hyperbilirubinemia is associated with central apnea in neonates. This article explores the reported association between acute bilirubin encephalopathy and symptomatic apneic events in newborns and the possible mechanisms involved in the pathogenesis of this phenomenon. The prevalence of symptomatic apneic events in reports of acute bilirubin encephalopathy suggests this clinical finding should be considered a sign of bilirubin neurotoxicity.
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Affiliation(s)
- Sanjiv B Amin
- Division of Neonatal Medicine, Department of Pediatrics, University of Rochester, Rochester, NY
| | - Vinod K Bhutani
- Division of Neonatal and Developmental Medicine, Department of Pediatrics Lucile Packard Children׳s Hospital at Stanford University, Stanford University, Palo Alto, CA
| | - Jon F Watchko
- Division of Newborn Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Magee-Womens Hospital, 300 Halket St, Pittsburgh, PA 15213.
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Bortolussi G, Baj G, Vodret S, Viviani G, Bittolo T, Muro AF. Age-dependent pattern of cerebellar susceptibility to bilirubin neurotoxicity in vivo in mice. Dis Model Mech 2014; 7:1057-68. [PMID: 25062689 PMCID: PMC4142726 DOI: 10.1242/dmm.016535] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Neonatal jaundice is caused by high levels of unconjugated bilirubin. It is usually a temporary condition caused by delayed induction of UGT1A1, which conjugates bilirubin in the liver. To reduce bilirubin levels, affected babies are exposed to phototherapy (PT), which converts toxic bilirubin into water-soluble photoisomers that are readily excreted out. However, in some cases uncontrolled hyperbilirubinemia leads to neurotoxicity. To study the mechanisms of bilirubin-induced neurological damage (BIND) in vivo, we generated a mouse model lacking the Ugt1a1 protein and, consequently, mutant mice developed jaundice as early as 36 hours after birth. The mutation was transferred into two genetic backgrounds (C57BL/6 and FVB/NJ). We exposed mutant mice to PT for different periods and analyzed the resulting phenotypes from the molecular, histological and behavioral points of view. Severity of BIND was associated with genetic background, with 50% survival of C57BL/6‑Ugt1−/− mutant mice at postnatal day 5 (P5), and of FVB/NJ-Ugt1−/− mice at P11. Life-long exposure to PT prevented cerebellar architecture alterations and rescued neuronal damage in FVB/NJ-Ugt1−/− but not in C57BL/6-Ugt1−/− mice. Survival of FVB/NJ-Ugt1−/− mice was directly related to the extent of PT treatment. PT treatment of FVB/NJ-Ugt1−/− mice from P0 to P8 did not prevent bilirubin-induced reduction in dendritic arborization and spine density of Purkinje cells. Moreover, PT treatment from P8 to P20 did not rescue BIND accumulated up to P8. However, PT treatment administered in the time-window P0–P15 was sufficient to obtain full rescue of cerebellar damage and motor impairment in FVB/NJ-Ugt1−/− mice. The possibility to modulate the severity of the phenotype by PT makes FVB/NJ-Ugt1−/− mice an excellent and versatile model to study bilirubin neurotoxicity, the role of modifier genes, alternative therapies and cerebellar development during high bilirubin conditions.
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Affiliation(s)
- Giulia Bortolussi
- International Centre for Genetic Engineering and Biotechnology (ICGEB), 34149 Trieste, Italy
| | - Gabriele Baj
- Basic Research and Integrative Neuroscience (BRAIN) Centre for Neuroscience, Department of Life Sciences, University of Trieste, 34127 Trieste, Italy
| | - Simone Vodret
- International Centre for Genetic Engineering and Biotechnology (ICGEB), 34149 Trieste, Italy
| | - Giulia Viviani
- International Centre for Genetic Engineering and Biotechnology (ICGEB), 34149 Trieste, Italy
| | - Tamara Bittolo
- Basic Research and Integrative Neuroscience (BRAIN) Centre for Neuroscience, Department of Life Sciences, University of Trieste, 34127 Trieste, Italy
| | - Andrés F Muro
- International Centre for Genetic Engineering and Biotechnology (ICGEB), 34149 Trieste, Italy
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Abstract
This is the text of the William A Silverman lecture given by Dr David K Stevenson at the Pediatric Academic Societies Annual Meeting in Washington, DC, May 4-7, 2013.
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Babu TA, Bhat BV, Joseph NM. Neurobehavior of term neonates with neonatal hyperbilirubinemia. J Pediatr Neurosci 2013; 8:11-4. [PMID: 23772236 PMCID: PMC3680887 DOI: 10.4103/1817-1745.111414] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective: To find the effect of neonatal hyperbilirubinemia on neurobehavior of term infants. Materials and Methods: This study was undertaken in the neonatal unit of our tertiary care hospital. Term neonates who developed jaundice with serum bilirubin value of above 15 mg/dl within 1st week of life were enrolled in the study. Peak total serum bilirubin (PSB) levels of cases were recorded. Age and sex matched normal controls were assigned to every case. Both the groups were assessed by Brazelton′s neurobehavioral assessment scale (NBAS) and the scores of the individual clusters were compared. Results: Habituation, range of state, autonomic regulation and regulation of state clusters were significantly altered in the case group, while motor organization cluster was mainly affected in neonates with severe jaundice (PSB > 25 mg/dl). No differences were noted in the reflex and orientation NBAS clusters. Conclusion: Neonatal hyperbilirubinemia causes definite alteration in the neonatal neurobehavior.
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Watchko JF, Painter MJ, Panigrahy A. Quantitative ADC in bilirubin encephalopathy. Jpn J Radiol 2013; 31:299-300. [PMID: 23377767 DOI: 10.1007/s11604-013-0181-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 01/15/2013] [Indexed: 11/28/2022]
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Ye HB, Shi HB, Wang J, Ding DL, Yu DZ, Chen ZN, Li CY, Zhang WT, Yin SK. Bilirubin induces auditory neuropathy in neonatal guinea pigs via auditory nerve fiber damage. J Neurosci Res 2012; 90:2201-13. [PMID: 22847875 DOI: 10.1002/jnr.23107] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2012] [Revised: 05/28/2012] [Accepted: 05/31/2012] [Indexed: 11/07/2022]
Abstract
Bilirubin can cause temporary or permanent sensorineural deafness in newborn babies with hyperbilirubinemia. However, the underlying targets and physiological effects of bilirubin-induced damage in the peripheral auditory system are unclear. Using cochlear functional assays and electron microscopy imaging of the inner ear in neonatal guinea pigs, we show here that bilirubin exposure resulted in threshold elevation in both compound action potential (CAP) and auditory brainstem response (ABR), which was apparent at 1 hr and peaked 8 hr after drug administration. The threshold elevation was associated with delayed wave latencies and elongated interwave intervals in ABR and CAP. At 72 hr postinjection, these measures returned to control levels, except for the CAP amplitude. Cochlear microphonics remained unchanged during the experiment. Morphological abnormalities were consistent with the electrophysiological dysfunction, revealing fewer auditory nerve fibers (ANFs) in the basal turn, myelin sheath lesions of spiral ganglion neurons (SGNs) and ANFs, and loss of type 1 afferent endings beneath inner hair cells (IHCs) without loss of hair cells at 8 hr posttreatment. Similar to the electrophysiological findings, morphological changes were mostly reversed 10 days after treatment, except for the ANF reduction in the basal turn. These results suggest that hyperbilirubinemia in neonatal guinea pigs impaired auditory peripheral neuromechanisms that targeted mainly the IHC synapses and the myelin sheath of SGNs and their fibers. Our observations indicate a potential connection between hyperbilirubinemia and auditory neuropathy.
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Affiliation(s)
- Hai-Bo Ye
- Department of Otorhinolaryngology, Affiliated Sixth People's Hospital of Shanghai Jiaotong University, Shanghai, China
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Bhutani VK. Phototherapy to prevent severe neonatal hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics 2011; 128:e1046-52. [PMID: 21949150 DOI: 10.1542/peds.2011-1494] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To standardize the use of phototherapy consistent with the American Academy of Pediatrics clinical practice guideline for the management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. METHODS Relevant literature was reviewed. Phototherapy devices currently marketed in the United States that incorporate fluorescent, halogen, fiber-optic, or blue light-emitting diode light sources were assessed in the laboratory. RESULTS The efficacy of phototherapy units varies widely because of differences in light source and configuration. The following characteristics of a device contribute to its effectiveness: (1) emission of light in the blue-to-green range that overlaps the in vivo plasma bilirubin absorption spectrum (~460-490 nm); (2) irradiance of at least 30 μW · cm(-2) · nm(-1) (confirmed with an appropriate irradiance meter calibrated over the appropriate wavelength range); (3) illumination of maximal body surface; and (4) demonstration of a decrease in total bilirubin concentrations during the first 4 to 6 hours of exposure. RECOMMENDATIONS (SEE APPENDIX FOR GRADING DEFINITION): The intensity and spectral output of phototherapy devices is useful in predicting potential effectiveness in treating hyperbilirubinemia (group B recommendation). Clinical effectiveness should be evaluated before and monitored during use (group B recommendation). Blocking the light source or reducing exposed body surface should be avoided (group B recommendation). Standardization of irradiance meters, improvements in device design, and lower-upper limits of light intensity for phototherapy units merit further study. Comparing the in vivo performance of devices is not practical, in general, and alternative procedures need to be explored.
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Abstract
Although its cause, jaundice in the newborn, is extremely common, the disabling neurological disorder kernicterus is very rare. Kernicterus may be prevented by selecting those infants who are at risk of extreme jaundice or who may be particularly vulnerable to bilirubin neurotoxicity. Because the tools for achieving that goal are inadequate, a secondary strategy is needed. This involves a plan for emergency treatment of severely jaundiced infants, in particular those who present with neurological symptoms. In this paper I review the strategies for preventing extreme jaundice, and for reversing neurotoxicity in those infants for whom the principal strategies fail. Briefly, the tools for prevention include measurement of bilirubin while the infant is staying in the maternity unit, plotting the value on an hour-specific chart, assessing other risk factors for jaundice, and educating the parents. Emergency treatment should include immediate, high-irradiance phototherapy, consideration of intravenous immune globulin, and preparation for an exchange transfusion.
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Affiliation(s)
- Thor W R Hansen
- Department of Neonatology, Women's and Children's Division, Oslo University Hospital - Rikshospitalet, and Institute of Clinical Medicine, University of Oslo, Norway.
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Kaplan M, Hammerman C. Neonatal screening for glucose-6-phosphate dehydrogenase deficiency: biochemical versus genetic technologies. Semin Perinatol 2011; 35:155-61. [PMID: 21641489 DOI: 10.1053/j.semperi.2011.02.010] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Glucose-6-phosphate dehydrogenase (G-6-PD) deficiency, a commonly occurring genetic condition, is associated in neonates with severe hemolytic episodes, extreme hyperbilirubinemia, and bilirubin encephalopathy. Neonatal screening programs for the condition should increase parental and caretaker awareness, thereby facilitating early access to treatment with resultant diminished mortality and morbidity. However, screening for G-6-PD deficiency is not widely performed. Although G-6-PD-deficient males may be accurately identified, females are more difficult to categorize because many in this group may be heterozygotes with phenotype overlap between normal homozygotes, heterozygotes, and deficient homozygotes. Screening methodologies include biochemical qualitative assays, quantitative enzymatic activity measurements and DNA-based polymerase chain reaction molecular screening. The appropriateness of any of these technologies for any particular population group or geographic area must be assessed before setting up a screening program. The pros and cons of each method, including ease of testing, cost, need for sophisticated laboratory equipment and degree of personnel training, as well as the ability to identify females, are discussed.
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Affiliation(s)
- Michael Kaplan
- Department of Neonatology, Shaare Zedek Medical Center, Jerusalem, Israel.
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Abstract
Extreme neonatal jaundice occurs infrequently but carries a high risk of permanent sequelae (kernicterus) when it does. Rapid therapeutic intervention has the potential to reduce this risk in some infants. Several case reports of infants with acute intermediate to advanced bilirubin encephalopathy shows that reversal may be possible. Phototherapy can be instituted at the flip of a switch, whereas other therapeutic measures necessarily involve delays. Therefore, high-intensity phototherapy must be regarded as an emergency measure in infants presenting with extreme jaundice and even more so in the presence of neurological symptoms. The principal and well-described effect of phototherapy involves conversion of bilirubin IXα (z, z) to more polar isomers, which are excreted in bile and urine. When care is taken to maximize the spectral power of phototherapy lights, and whenever possible with measures added to reduce the enterohepatic circulation of bilirubin, very rapid reductions in total serum bilirubin levels are possible. A hypothesis has been advanced that conversion of bilirubin to more polar photoisomers, which can reach relative concentrations of 20%-25% of total serum bilirubin within 1-2 hours, might have a direct neuroprotective effect. This theory posits that because polar molecules generally require a transporter to cross the blood-brain barrier, bilirubin photoisomers should be less prone to enter the brain. Although this theory has some support in in vitro toxicity studies, the evidence is controversial. Until further experimental support can be gained, photoconversion of bilirubin does not constitute a viable argument against instituting further measures against bilirubin neurotoxicity, such as intravenous immune globulin (when indicated) and exchange transfusion. Conversely, neither is the state of evidence an argument against immediate and effective phototherapy in the medical emergency of extreme neonatal jaundice.
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Affiliation(s)
- Thor Willy Ruud Hansen
- Department of Neonatology, Women's and Children's Division, Oslo University Hospital-Rikshospitalet, Oslo, Norway.
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Abstract
UNLABELLED Jaundice is the most common reason for instituting treatment in otherwise healthy as well as sick newborn infants. Herein, we describe the process employed in Norway to forge agreement on a set of treatment guidelines that are now used across the country. The Norwegian Pediatric Association was a key resource in this process, which involved contacts with all paediatric departments in Norway. We have also performed an international survey regarding the use of such national guidelines, showing that the majority of those queried confirm having national guidelines. The evidence base for any neonatal jaundice guideline is weak; therefore, it is not surprising that the various guidelines differ both in format and in specifics. In the Norwegian guidelines, treatment indications are based on bilirubin concentrations and related to birth weight. Postnatal age is also factored in because jaundice develops gradually during the first 3-4 days before it levels off. CONCLUSION Following the introduction of these guidelines, fewer babies in Norway receive phototherapy, and no cases of chronic kernicterus have been reported during this period.
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Affiliation(s)
- D Bratlid
- Department of Laboratory Medicine, Children's and Women's Health, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway.
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Kaplan M, Bromiker R, Hammerman C. Severe neonatal hyperbilirubinemia and kernicterus: are these still problems in the third millennium? Neonatology 2011; 100:354-62. [PMID: 21968213 DOI: 10.1159/000330055] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Despite efforts to eliminate permanent and irreversible brain damage due to bilirubin encephalopathy and kernicterus, these conditions continue to accompany us into the third millennium. This phenomenon occurs not only in developing countries with emerging medical systems, but in Westernized countries as well. Comprehensive guidelines to detect newborns with jaundice and treat those in whom hyperbilirubinemia has already developed have been formulated in several countries, but have not been successful in completely eliminating the problem. In this appraisal of the situation we review selected aspects of bilirubin encephalopathy and/or kernicterus. We highlight recent reports of severe hyperbilirubinemia and kernicterus, discuss some of the factors responsible for the continuing appearance of these conditions, and briefly review what can be done to decrease bilirubin-related morbidity and mortality to the minimum.
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Affiliation(s)
- Michael Kaplan
- Department of Neonatology, Shaare Zedek Medical Center, Jerusalem, Israel.
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Route of exchange transfusion in neonates with hyperbilirubinemia. Pediatr Crit Care Med 2011; 12:110-1. [PMID: 21209575 DOI: 10.1097/pcc.0b013e3181dd514d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ruud Hansen TW. Treatment of jaundice in the newborn infant — “Many roads to Rome”. Indian Pediatr 2010; 47:396-7. [DOI: 10.1007/s13312-010-0070-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Affiliation(s)
- Thor Willy Ruud Hansen
- Department of neonatology, Women's & Children's Clinic, Oslo University Hospital, Rikshospitalet and Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
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Abstract
Phototherapy for jaundice is a common treatment in neonatal medicine and is used to prevent the neurotoxic effects of bilirubin. Studies have assessed the optimal wavelength of phototherapy light, the importance of irradiance and spectral power, and the types of light source, including the use of single versus multiple light sources. Outcome measures have been duration of need for phototherapy or rate of reduction of serum bilirubin over a given time. An apparent resurgence of kernicterus in recent years has forced us to focus on the emergency management of severely jaundiced infants. Several studies have shown that very rapid reductions of total serum bilirubin levels are possible. The speed with which photoisomers are formed appears to be important both from this perspective and theoretically may also be neuroprotective because of the more polar nature of the photoisomers. This work reviews the evidence concerning the speed of photoisomer formation, as well as the evidence regarding the relative neurotoxicity of bilirubin isomers.
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Affiliation(s)
- Thor Willy Ruud Hansen
- Neonatal Intensive Care Unit, Women's and Children's Clinic, Oslo University Hospital-Rikshospitalet, Oslo, Norway.
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Mreihil K, McDonagh AF, Nakstad B, Hansen TWR. Early isomerization of bilirubin in phototherapy of neonatal jaundice. Pediatr Res 2010; 67:656-9. [PMID: 20308939 DOI: 10.1203/pdr.0b013e3181dcedc0] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Neonatal jaundice is usually treated with phototherapy that converts bilirubin to more polar stereoisomers. These should theoretically be less able to cross the blood-brain barrier. The rates of photoisomer formation and concentrations accumulating in the circulation may have a bearing on the risk of kernicterus. The purpose of this study was to determine the rate of appearance of the major 4Z, 15E photoisomer of bilirubin during the early stages of phototherapy. Twenty jaundiced neonates were treated with phototherapy, and blood samples were drawn before and at approximately 15, 30, 60, and 120 min (10 infants) or at approximately 15, 60, 120, and 240 min (10 infants) after beginning phototherapy. Blood samples were analyzed for total serum bilirubin (TSB) and the 4Z, 15E photoisomer of bilirubin. Significant (p<0.0001) formation of the 4Z, 15E photoisomer was detectable within 15 min. The change in TSB from time 0 was insignificant at 120 min but reached significance at 240 min (p<0.001). The 4Z, 15E bilirubin constituted up to 20-25% of TSB at 2 h and may not have peaked by 4 h. Further studies are needed to determine whether this early shift in balance between bilirubin isomers with different polarities may impact the risk of bilirubin encephalopathy even before TSB starts to fall.
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Affiliation(s)
- Khalaf Mreihil
- Neonatal Intensive Care Unit, Children's and Youth Clinic, Akershus University Hospital, N-1478 Nordbyhagen, Norway
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