Efficacy of light-emitting diode versus other light sources for treatment of neonatal hyperbilirubinemia: a systematic review and meta-analysis

Light-Emitting Diode (LED) Phototherapy versus Non-LED Phototherapy Devices for Hyperbilirubinemia in Neonates: A Systematic Review and Meta-analysis

This review was conducted to evaluate the efficacy of light-emitting diode (LED) phototherapy as compared with the conventional phototherapy in neonates with unconjugated hyperbilirubinemia and their adverse effects. We searched the following databases right from their inception till April, 2021: MEDLINE, EMBASE, Cochrane Library, and LILACS. Randomized clinical trials (RCTs) comparing the LED phototherapy with other light sources, which enrolled newborns (term and preterm) with unconjugated hyperbilirubinemia were included. We included 21 articles in this review. The treatment with the LED light therapy had a lower failure rate as compared with the non-LED one (RR = 0.60, 95% CI: 0.39-0.94). The mean duration of phototherapy was significantly shorter in the group with the LED light source as compared with the one with the non-LED light source (mean difference [hours]: -8.07, 95% CI: -8.45 to -7.68), regardless of the type of non-LED units. However, the rate of bilirubin showed a comparable decline (mean difference [mg/dL/h]: 0.01, 95% CI: -0.00, 0.03) in both the light sources, irrespective of irradiance or distance. No studies reported primary outcomes related to the neurotoxicity effects of hyperbilirubinemia in neonates. The LED light devices caused a significantly higher risk of hypothermia. Neonates were at a lower risk of developing hyperthermia and skin rash with the LED light therapy. Our findings provide support for the use of LED light source phototherapy due to its better clinical efficacy, which is evidenced by its shorter duration and lower rate of treatment failure, as compared with the non-LED light sources. KEY POINTS: · The efficacy of phototherapy is dependent on specific characteristics of light sources of phototherapy devices.. · LED phototherapy demonstrated better efficacy with shorter duration and lower rate of treatment failure.. · Adverse effects of phototherapy devices such as hypothermia, hyperthermia, and skin rash should be monitored..

"Light" on Phototherapy-Complications and Strategies for Shortening Its Duration, A Review of the Literature

Neonatal hyperbilirubinemia is an extremely common metabolic complication of the neonatal period which may be associated with bilirubin encephalopathy and even death. Adverse neurological consequences are preventable if a timely diagnosis and treatment are provided. Phototherapy is usually the preferred option to decrease hyperbilirubinemia. Although considered to be safe, evidence in recent years has shown that this treatment may not be free of side effects and short- and long-term unfavorable outcomes. These are usually mild or rare, but should be decreased or avoided if possible. Many useful complementary measures and treatments have been described that could shorten the duration of exposure to phototherapy. However, there is no current unequivocal recommendation to use any of the methods presented in this review. Our review aims to depict the wide range of possible complementary treatments to phototherapy, and to provide the scientific and clinical evidence available regarding their usefulness. It is essential that, while utilizing the full potential of phototherapy to treat hyperbilirubinemia, caregivers are aware of its side effects and possible inherent dangers, and seek ways to minimize the exposure to phototherapy to what is really needed for the newborn. Further studies are needed to clarify the preferred complementary treatments that could reduce the duration of exposure to phototherapy without impairing its effectiveness.

Implementation of neonatal phototherapy with the BiliCocoon Bag® device in the maternity ward and impact on mother-infant separation

BACKGROUND

Free bilirubin jaundice is a frequent pathology in the neonatal period. The major complication is neurological toxicity, the most severe form of which is kernicterus. Overall, 5%-10% of jaundiced neonates require treatment. The first-line treatment is phototherapy, with intensive phototherapy being the gold standard. Other equipment is also available, including the BiliCocoon Bag®. It is a safe and controlled therapy that can be performed in the mother's room in the maternity ward, thereby avoiding separation and allowing for breast- or bottle-feeding during treatment. It is easy to install and does not require protective glasses, thus no scope or hospitalization. In our maternity ward, all neonates requiring intensive phototherapy are hospitalized in the neonatology ward.

OBJECTIVE

The objective of our study was to evaluate the number of avoided hospitalizations in neonatology for free bilirubin jaundice since the introduction, according to a strict protocol, of the BiliCocoon Bag® device.

MATERIAL AND METHOD

This was a single-center retrospective cohort study using data of newborns usually collected as part of standard care. Children born in our maternity ward during an 18-month period (August 1, 2020 to January 31, 2022) were included. Causes of jaundice, age at the beginning and mode of treatment, number of sessions for each device, and length of stay were compared. Results are presented as number and percentage with median (25th-75th) or mean (extremes) values for categorical and continuous variables, respectively. A t-test was used to compare the means of the independent groups.

RESULTS

A total of 316 newborns were included. Physiological jaundice was the main cause of jaundice. The median age for the first phototherapy treatment was 54.5 h (30-68). The 316 neonates needed 438 phototherapy sessions: 235 (74%) neonates required only one phototherapy session, 85 (36%) of them were treated with the BiliCocoon Bag®. For the 81 children who needed two or more phototherapy sessions, 19 children (23.5%) were treated by tunnel phototherapy and then the BiliCocoon Bag®, and eight children (10%) by BiliCocoon Bag® alone. The BiliCocoon Bag® enabled a relative reduction in the hospitalization rate of 38% and avoided hospitalization for approximately one third of the newborns treated. The BiliCocoon Bag® failure rate was 3.6% and the average length of stay was comparable between the two types of treatment.

CONCLUSION

Following a strict protocol of use, the BiliCocoon Bag® is a reliable method and a good alternative to intensive phototherapy for newborns in the maternity ward, as it avoids hospitalization and mother-infant separation.

History and current standard of postnatal management in hemolytic disease of the fetus and newborn

Since the discovery of the Rh blood group system in 1940, a greater understanding of hemolytic disease of the fetus and newborn (HDFN) was gained. In the years thereafter, researchers and clinicians came to the current understanding that fetal and neonatal red blood cells (RBC) are hemolyzed by maternal alloantibodies directed against RBC antigens potentially leading to severe disease. Preventative measures, such as Rhesus(D) immunoprophylaxis (RhIG), have greatly decreased the prevalence of Rh(D)-mediated HDFN, although a gap between high-income countries and middle- to low-income countries was created largely due to a lack in availability and high costs of RhIG. Other important developments in the past decades have improved the identification, monitoring, and care of pregnancies, fetuses, and neonates with HDFN. Prenatally, fetal anemia may occur and intrauterine transfusions may be needed. Postnatally, pediatricians should be aware of the (antenatally determined) risk of hemolysis in RBC alloimmunization and should provide treatment for hyperbilirubinemia in the early phase and monitor for anemia in the late phase of the disease. Through this review, we aim to provide an overview of important historic events and to provide hands-on guidelines for the delivery and postnatal management of neonates with HDFN. Secondarily, we aim to describe recent scientific findings and evidence gaps.

CONCLUSION

 Multiple developments have improved the identification, monitoring, and care of pregnancies and neonates with HDFN throughout the centuries. Pediatricians should be aware of the (antenatally determined) risk of hemolysis in RBC alloimmunization and should provide treatment for hyperbilirubinemia in the early phase and monitor for late anemia in the late phase of the disease. Future studies should be set in an international setting and ultimately aim to eradicate HDFN on a global scale.

WHAT IS KNOWN

• Developments have led to a greater understanding of the pathophysiology, an improved serological identification and monitoring of at-risk cases and the current pre- and postnatal treatment.

WHAT IS NEW

• This review provides the pediatrician with hands-on guidelines for the delivery and postnatal management of neonates with HDFN. • Future studies should be set in an international setting with the ultimate aim of eradicating HDFN.

Current status of neonatal jaundice management in Japan

BACKGROUND

This nationwide survey aimed to determine the status of jaundice management in Japan.

METHODS

A questionnaire about bilirubin level measurements and neonatal jaundice treatment was sent to 330 institutions providing neonatal care. The responses were analyzed according to institution level.

RESULTS

Of 330 institutions, 172 responded (52.1% response rate). Total bilirubin levels were measured in the central laboratory using spectrophotometry at 134 institutions and a blood gas analyzer at 81 institutions. Unbound bilirubin (UB) levels were measured by 79 institutions, while transcutaneous bilirubin measurements were taken at 63 institutions. There was no association between institution level and UB or transcutaneous bilirubin measurement. For phototherapy criteria, the Murata-Imura criteria were adopted by 67 institutions, Nakamura criteria by 36, and Morioka criteria by 39. Light-emitting diodes (LED) were used by 160 institutions versus fluorescent lights by 31. When a blue LED was used, 119 institutions used the high mode. There is no standard for increasing light intensity. No association was found between institution level and phototherapy criteria. UB was measured in 14 of 63 institutions using the Murata-Imura criteria.

CONCLUSIONS

There is a large variation in the management and treatment of neonatal jaundice among institutes in Japan.

Discharge of newborns with risk factors of severe hyperbilirubinemia: description of a hospital at home-based care monitoring and phototherapy

Neonatal jaundice is common and associated with delay in hospital discharge and risk of neurological sequelae if not treated. The objectives of the study were to report on our experience of the monitoring and treatment of neonatal jaundice in a home care setting and its feasibility and safety for neonates with high risk of severe hyperbilirubinemia. The 2-year study has been led in the greater Paris University Hospital At Home (Assistance Publique-Hôpitaux de Paris). The device of the intervention was the Bilicocoon® Bag, a light-emitting diode sleeping bag worn by the neonate when the total serum bilirubin value exceeds intensive phototherapy threshold, according to the guidelines from the American Academy of Pediatrics. One hundred and thirty-nine neonates had participated in the intervention and 39 (28%) were treated by phototherapy at home, as continuation of inpatient phototherapy or started at home. Seventy-five percent of the sample had more than two risk factors for development of severe hyperbilirubinemia. Twenty five percent of the cohort who received phototherapy at home had lower gestational age (p < 0.014) and had younger age at discharge from maternity (p < 0.09). Median length of stay in hospital at home was 5 days. Two patients needed readmission in conventional hospital (1%) for less than 24 h. In multivariate model, the length of stay decreased with the higher gestational age (p < 0.001) and increased significantly with the older age at discharge, the birth weight < 10th percentile, and a treatment by phototherapy at home.    Conclusion: Hospital at home, which is a whole strategy using an effective and convenient phototherapy device combined with a specialized medical follow-up, could be an alternative to conventional hospitalization for neonates at high risk of severe jaundice. The maternity discharge is facilitated, the mother-infant bonding can be promoted, and the risk of conventional rehospitalization is minimal, while guaranteeing the safety of this specific care. What is Known: • Managing neonatal jaundice is provided in conventional hospital with phototherapy. • Neonatal jaundice increases the risk of prolonged hospitalization or readmission. What is New: • Phototherapy is feasible in hospital at home for neonates with high risk of severe hyperbilirubinemia. • The care pathway of neonates from conventional hospital to hospital at home is described.

Challenges and recommendations to improve implementation of phototherapy among neonates in Malawian hospitals

Background

Severe neonatal jaundice can result in long term morbidities and mortality when left untreated. Phototherapy is the main-stay intervention for treating moderate jaundice and for prevention of the development of severe jaundice. However, in resource-limited health care settings, phototherapy has been inconsistently used. The objective of this study is to evaluate barriers and facilitators for phototherapy to treat neonatal jaundice at Malawian hospitals.

Methods

We conducted a convergent mixed-method study comprised of a facility assessment and qualitative interviews with healthcare workers and caregivers in southern Malawi. The facility assessment was conducted at three secondary-level hospitals in rural districts. In-depth interviews following a semi-structured topic guide were conducted at a district hospital and a tertiary-level hospital. Interviews were thematically analysed in NVivo 12 software (QSR International, Melbourne, Australia).

Results

The facility assessment found critical gaps in initiating and monitoring phototherapy in all facilities. Based on a total of 31 interviews, participants identified key challenges in diagnosing neonatal jaundice, counselling caregivers, and availability of infrastructure. Participants emphasized the need for transcutaneous bilirubinometers to guide treatment decisions. Caregivers were sometimes fearful of potential harmful effects of phototherapy, which required adequate explanation to mothers and family members in non-medical language. Task shifting and engaging peer support for caregivers with concerns about phototherapy was recommended.

Conclusion

Implementation of a therapeutic intervention is limited if accurate diagnostic tests are unavailable. The scale up of therapeutic interventions, such as phototherapy for neonatal jaundice, requires careful holistic attention to infrastructural needs, supportive services such as laboratory integration as well as trained human resources.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03430-y.

Pilot study of home phototherapy for neonatal jaundice monitored in maternity ward during the enforced Italy-wide COVID-19 national lockdown

In Italy, where neonatal jaundice treatment is required, it is largely carried out in hospitals. However, it is possible to safely administer home phototherapy (HPT). We report our pilot center's experience of HPT and its potential benefits during the COVID-19-enforced national lockdown. This is an observational study performed at the Policlinic Abano Terme, a suburban hospital that covers a large catchment area near the Euganean Hills in Northeast Italy with around 1000 deliveries per year. HPT was started after regular nursery discharge, and the mothers brought the neonates back to the hospital maternity ward each day to check infants' bilirubin levels, weight, and general state of health, until it was deemed safe to stop. The efficacy of HPT in bilirubin reduction, hospital readmission rates, and parental satisfaction were evaluated. Thirty infants received HPT. In 4 of these infants, HPT was associated with total serum bilirubin (TSB) between 75 and 95^th percentile (high-intermediate-risk zone) and in 26 infants HPT was associated with TSB > 95^th percentile (high-risk zone) of the Bhutani nomogram. Among these 30 infants, 27 (90%) completed the HPT with a progressive decrease of TSB levels with 4 neonates requiring a second course and 3 infants requiring a third course of 24-h HPT. Three (10%) neonates failed HPT and were readmitted after one 24-h phototherapy course. No abnormalities of breastfeeding, body weight (defined as > 10% decrease), temperature, nor COVID infections were detected following HPT consultation in the neonatal ward. Home treatment efficacy with varying degrees of parental satisfaction occurred in all but 3 cases that involved difficulties with the equipment and inconsistent lamp manipulation practices.

CONCLUSION

Our pilot study suggests that HPT for neonatal jaundice can be carried out effectively and with parental satisfaction as supported by daily back bilirubin monitoring in the maternity ward during the enforced COVID-19 national lockdown in Italy.

WHAT IS KNOWN

• No high-quality evidence is currently available to support or refute the practice of phototherapy in patients' own homes.

WHAT IS NEW

• Phototherapy can be delivered at home in a select group of infants and could be an ideal option if parents are able to return with their infants to the hospital maternity ward for daily follow-up. • It can be as effective as inpatient phototherapy and potentially helps in delivering family-centered care.

Home phototherapy for hyperbilirubinemia in term neonates-an unblinded multicentre randomized controlled trial

The aim of this study was to assess whether home phototherapy was feasible and safe in a cohort of otherwise healthy term-born neonates who fulfilled the criteria for in-hospital phototherapy. This was a randomized controlled trial in which term newborns with a total serum bilirubin of 18-24 mg/dL (300-400 μmol) were randomized to either home phototherapy or conventional in-hospital phototherapy. The primary outcome measurements were safety and efficacy, length of stay and the number of failed treatments. The secondary outcomes were the number of blood samples and weight gain during treatment. One hundred forty-seven patients were recruited, 69 patients randomized to conventional phototherapy and 78 to home phototherapy. The results showed that no patients needed blood exchange and only 4% of the patients allocated to home phototherapy were admitted to the hospital. The duration of phototherapy, length of stay, amount of blood tests and weight change showed no statically significant differences.Conclusion: Home phototherapy could be a safe alternative to inpatient phototherapy for otherwise healthy newborns with hyperbilirubinemia if daily checkups and 24/7 telephone support can be provided. The parents should be informed to contact the hospital immediately if they fail to perform the treatment at home.Trial registration: Clinicaltrials.gov NCT03536078 What is Known: • Phototherapy in the hospital is a safe and effective treatment without major side effects. • Fibre optic equipment has made the choice of home phototherapy possible. What is New: • This is the first randomized controlled trial comparing home phototherapy with hospital phototherapy. • Results indicate that home phototherapy could be considered as a safe and feasible alternative when performed according to instructions given, to hospital treatment for otherwise healthy term newborns.

Optimization of the incubator air temperature during LED phototherapy treatment for the preterm infant

Light-emitting diode phototherapy treatment for jaundice of the preterm infant presents adverse effects, such as discomfort, changes in metabolism, and overheating. This study quantified the body heat exchanges between the environment and a simulated preterm infant requiring phototherapy treatment in a closed incubator. Phototherapy treatment increased the mean incubator roof temperature by 2.9 °C (p < 0.001) and the incubator air temperature by 1 °C (p < 0.001). Analytical calorimetry was used to calculate the additional energy received during phototherapy and thus deduce the optimal incubator air temperature for ensuring thermoneutrality and preventing hyperthermia. The optimal air temperature settings inside the incubator during phototherapy were - 0.51 to - 1.25 °C lower than references, for preterm infant weighing 500 to 2000 g.Conclusion: Phototherapy treatment for jaundice of the preterm infant increased the incubator air temperature. To prevent overheating in the preterm during phototherapy, new curves for optimal air temperature settings inside the incubator were calculated with analytic calorimetry. What is Known •Phototherapy treatment is the first-line treatment for jaundice in the preterm infant. •Phototherapy treatment increases the risk of overheating. What is New •The heat transfers and risk of overheating were quantified using a thermal manikin during phototherapy treatment. •Phototherapy treatment increased the incubator roof temperature and heat transfers. •New incubator's air temperature settings during phototherapy treatment were calculated with analytical calorimetry for preterm infant weighing 500-2000 g.

Efficacy of double versus single phototherapy in treatment of neonatal jaundice: a meta-analysis

To assess the efficacy of double phototherapy in managing neonatal jaundice compared to single phototherapy in infants with different birth weight and gestational age. CENTRAL, PubMed, clinicaltrials.gov, and gray literature sources were searched from date of inception of these databases till August 2019. Primary outcome was decline of total serum bilirubin (TSB) per hour. Ten studies were eligible. Our meta-analysis showed significant difference between double phototherapy versus single phototherapy in decline of TSB per hour in preterm infants (standardized mean difference [SMD] = 2.28 [0.79-3.76], p = 0.003) and a significant decrease in TSB levels at 24 h of phototherapy in infants with birth weight ≥ 1500 g (mean difference [MD] = - 61.70 μmol/L, [- 107.96, - 15.43], p = <0.001).Conclusion: Double phototherapy is effective in reducing TSB in infants of different gestational ages and birth weights with the most important finding regarding preterm infants, who are more susceptible to kernicterus.What is Known:• Double phototherapy has shown to be more efficacious than single phototherapy in treating neonatal jaundice.• Double phototherapy efficacy on neonates with different gestational ages and birth weights still remain ambiguous in treating neonatal jaundice.What is New:• The results of this meta-analysis show that double phototherapy is effective in reducing TSB in infants of different gestational ages and birth weights with the most important finding regarding preterm infants, who are more susceptible to kernicterus.

Knowledge of Neonatal Hyperbilirubinemia Among Primary Health Care Physicians: A Single-Center Experience

Background and objectives:

To evaluate the knowledge of the primary health care physicians (PHCP) in Kalubia governorate, Egypt, about the causes, diagnosis, complications, and treatment of neonatal hyperbilirubinemia (NHB).

Methods:

Cross-sectional survey distributed by interview to 500 physicians working in the primary health care (PHC) sector in Kalubia.

Results:

Out of 500 distributed surveys, 419 (84%) PHCP completed the questionnaire. They represent 174 (90%) out of 193 PHC units and centers. About 18% were males and 82% females with mean age of 28.5 ± 5.2 years, and mean duration of work was 3.3 ± 4.4 years. All of the respondents have patients with NHB in their daily practice. The knowledge of the PHCP was good in some aspects about NHB; however, it was poor and may be even hazardous in other aspects.

Conclusions:

Many areas of defects are detected in PHCP knowledge about NHB. Pre-service and continuous training of the PHCP about the diagnosis and management of NHB are essential.

Phototherapy and its effect on some physiological functions in newborns

Phototherapy represents the most common therapeutic intervention at neonatology departments in the first days of life. The beneficial effects of light on the decrease of the serum bilirubin level were first described by Cremer et al. in 1950’s (1). Since then phototherapy has been successfully used to treat severe hyperbilirubinaemia and has almost completely replaced exchange transfusion. Phototherapy is a relatively non-invasive method. However, along with decreasing bilirubin level, it can also influence some other functions: perfusion of organs, predominantly skin; peripheral vascular resistance; distribution of blood flow; heart activity and, thus, also systemic blood pressure along with breathing. A side component of applied light is a certain amount of heat which warms the body surface up and, therefore, the risk of exogenous overheating and increased water loss through the skin arise. Maternal-infant separation, modification of calcium homeostasis, disturbed circadian rhythm, or changes of the hemodynamics of various organ systems are only a few of the undesired effects which prove phototherapy not to be a treatment without any side effects. Careful indication of phototherapy is essential, particularly in premature infants.

Clinical efficacy, onset time and safety of bright light therapy in acute bipolar depression as an adjunctive therapy: A randomized controlled trial

BACKGROUND

Bright light therapy (BLT) is an effective treatment for seasonal affective disorder and non- seasonal depression. The efficacy of BLT in treating patients with bipolar disorder is still unknown.

AIMS

The aim of this study is to examine the efficacy, onset time and clinical safety of BLT in treating patients with acute bipolar depression as an adjunctive therapy (trial registration at ClinicalTrials.gov: NCT02009371).

METHODS

This was a multi-center, single blind, randomized clinical trial. Seventy-four participants were randomized in one of two treatment conditions: BLT and control (dim red light therapy, dRLT). Sixty-three participants completed the study (33 BLT, 30 dRLT). Light therapy lasted for two weeks, one hour every morning. All participants were required to complete several scales assessments at baseline, and at the end of weeks 1 and 2. The primary outcome measures were the clinical efficacy of BLT which was assessed by the reduction rate of HAMD-17 scores, and the onset time of BLT which was assessed by the reduction rate of QIDS-SR16 scores. The secondary outcome measures were rates of switch into hypomania or mania and adverse events.

RESULTS

1) Clinical efficacy: BLT showed a greater ameliorative effect on bipolar depression than the control, with response rates of 78.19% vs. 43.33% respectively (p < 0.01). 2) Onset day: Median onset day was 4.33 days in BLT group. 3) BLT-emergent hypomania: No participants experienced symptoms of hypomania. 4) Side effects: No serious adverse events were reported.

CONCLUSION

BLT can be considered as an effective and safe adjunctive treatment for patients with acute bipolar depression.

Patched Skin Bilirubin Assay to Monitor Neonates Born Extremely Preterm Undergoing Phototherapy

OBJECTIVE

To verify the reliability and safety of transcutaneous bilirubin (TcB) measurements in patched skin areas in neonates born extremely preterm under phototherapy.

STUDY DESIGN

Sixty neonates (<30 weeks' gestation) receiving phototherapy were enrolled and TcB was measured via a second-generation transcutaneous bilirubinometer in patched skin areas (of at least 2.5 cm diameter). Total serum bilirubin (TSB), lactate, pH, hemoglobin, and skin temperature were measured within 10 minutes of the TcB assay. Clinicians were blinded to TcB values, and clinical decisions about phototherapy were made with the TSB measurement only.

RESULTS

TcB and TSB significantly were correlated (r = 0.84; P <.001), even after adjustment for hemoglobin, pH, lactate, gestational and postnatal age (standardized β = 0.8; P <.001; adjusted R² = 0.75), or treatment duration (standardized β = 0.8; P <.001; adjusted R² = 0.7). When the Bland-Altman analysis was used, TcB overestimated TSB at high values (mean difference TSB - TcB: -2.8 [2.4] mg/dL). If clinicians used the TcB only, no neonate would have had phototherapy stopped prematurely, and 21 (35%) would have continued phototherapy when it could have been stopped.

CONCLUSIONS

The correlation between TSB and TcB (measured in patched skin areas) was comparable with that obtained in more mature neonates, and it was not influenced by clinical variables or factors affecting skin bilirubin passage. TcB overestimated TSB, and this may expose infants born preterm to unnecessary phototherapy, although it could spare approximately 65% of TSB assays.

Effect of Red Light-Emitting Diodes Irradiation on Hemoglobin for Potential Hypertension Treatment Based on Confocal Micro-Raman Spectroscopy

Red light-emitting diodes (LED) were used to irradiate the isolated hypertension hemoglobin (Hb) and Raman spectra difference was recorded using confocal micro-Raman spectroscopy. Differences were observed between the controlled and irradiated Hb by comparing the spectra records. The Raman spectrum at the 1399 cm-1 band decreased following prolonged LED irradiation. The intensity of the 1639 cm-1 band decreased dramatically in the first five minutes and then gradually increased in a time-dependent manner. This observation indicated that LED irradiation increased the ability of oxygen binding in Hb. The appearance of the heme aggregation band at 1399 cm-1, in addition to the oxygen marker band at 1639 cm-1, indicated that, in our study, 30 min of irradiation with 15.0 mW was suitable for inhibiting heme aggregation and enhancing the oxygen-carrying capacity of Hb. Principal component analysis showed a one-to-one relationship between irradiated Hb at different time points and the corresponding Raman spectra. Our approach could be used to analyze the hemoglobin from patients with confocal micro-Raman spectroscopy and is helpful for developing new nondrug hypertension therapy.

Management of late-preterm and term infants with hyperbilirubinaemia in resource-constrained settings

Hyperbilirubinaemia is a ubiquitous transitional morbidity in the vast majority of newborns and a leading cause of hospitalisation in the first week of life worldwide. While timely and effective phototherapy and exchange transfusion are well proven treatments for severe neonatal hyperbilirubinaemia, inappropriate or ineffective treatment of hyperbilirubinaemia, at secondary and tertiary hospitals, still prevails in many poorly-resourced countries accounting for a disproportionately high burden of bilirubin-induced mortality and long-term morbidity. As part of the efforts to curtail the widely reported risks of frequent but avoidable bilirubin-induced neurologic dysfunction (acute bilirubin encephalopathy (ABE) and kernicterus) in low and middle-income countries (LMICs) with significant resource constraints, this article presents a practical framework for the management of late-preterm and term infants (≥35 weeks of gestation) with clinically significant hyperbilirubinaemia in these countries particularly where local practice guidelines are lacking. Standard and validated protocols were followed in adapting available evidence-based national guidelines on the management of hyperbilirubinaemia through a collaboration among clinicians and experts on newborn jaundice from different world regions. Tasks and resources required for the comprehensive management of infants with or at risk of severe hyperbilirubinaemia at all levels of healthcare delivery are proposed, covering primary prevention, early detection, diagnosis, monitoring, treatment, and follow-up. Additionally, actionable treatment or referral levels for phototherapy and exchange transfusion are proposed within the context of several confounding factors such as widespread exclusive breastfeeding, infections, blood group incompatibilities and G6PD deficiency, which place infants at high risk of severe hyperbilirubinaemia and bilirubin-induced neurologic dysfunction in LMICs, as well as the limited facilities for clinical investigations and inconsistent functionality of available phototherapy devices. The need to adjust these levels as appropriate depending on the available facilities in each clinical setting and the risk profile of the infant is emphasised with a view to avoiding over-treatment or under-treatment. These recommendations should serve as a valuable reference material for health workers, guide the development of contextually-relevant national guidelines in each LMIC, as well as facilitate effective advocacy and mobilisation of requisite resources for the optimal care of infants with hyperbilirubinaemia at all levels.

Influence of hyperbilirubinemia and phototherapy on markers of genotoxicity and apoptosis in full-term infants

Concerns of possible genotoxic effects of hyperbilirubinemia and phototherapy were raised from experimental and observational studies in neonates. This study aimed to assess the impact of hyperbilirubinemia and phototherapy on DNA damage and apoptosis in peripheral blood lymphocytes in healthy full-term infants. This study was conducted in the Children's Hospital, Mansoura University. Patients enrolled in this study were classified into three groups (each with 45 full-term infants): group 1 was composed of infants with hyperbilirubinemia requiring phototherapy, group 2 infants with physiological jaundice not requiring phototherapy, and group 3 infants without clinical jaundice. All enrolled infants were subjected to assessment of DNA damage and apoptosis in peripheral blood lymphocytes, using the comet assay and P53 by flow cytometry, consecutively. In group 1, measurements were done twice, before starting phototherapy and just before its discontinuation. DNA damage was not significantly different in the three groups, but it significantly increased after exposure to phototherapy compared to pre-phototherapy levels. There was no significant difference in P53 level in the three groups; however, it significantly increased after exposure to phototherapy. There were significant positive correlations between the duration of phototherapy and markers of DNA damage and apoptosis.

CONCLUSIONS

Hyperbilirubinemia does not influence DNA damage and apoptosis, whereas phototherapy causes DNA damage and induces apoptosis in peripheral blood lymphocytes of full-term infants.