Childhood Seizures After Phototherapy

Splanchnic and cerebral oxygenation during cyclic phototherapy in preterm infants with hyperbilirubinemia

Cyclic phototherapy (cPT) can achieve a reduction in total serum bilirubin comparable to that achieved with standard continuous PT in preterm infants. Our aim was to assess the effect of cPT on splanchnic (rSO2S) and cerebral (rSO2C) oxygenation measured by near-infrared spectroscopy (NIRS). We prospectively studied 16 infants with a gestational age of 25-34 weeks with hyperbilirubinemia requiring PT. Splanchnic regional oxygenation (rSO2S), oxygen extraction fraction (FOES), and cerebro-splanchnic oxygenation ratio (CSOR) were recorded before, during, and after cPT discontinuation. We found that rSO2S, FOES, and CSOR did not change during the study period. The overall duration of single or multiple courses of PT was 6.5 (6.0-13.5) h, but by cycling PT, the actual exposure was 3.0 (1.5-4.9) h. Twelve patients (75%) required 15 min/h cPT, and four (25%) required prolonging cPT to 30 min/h. None of the patients developed enteral feeding intolerance. Conclusions: cPT treatment of hyperbilirubinemia in preterm infants does not affect splanchnic oxygenation or intestinal oxygen blood extraction, likely due to the short exposure to PT light, and it could contribute to decreasing the risk of feeding intolerance.

Phototherapy Alters the Plasma Metabolite Profile in Infants Born Preterm with Hyperbilirubinemia

OBJECTIVE

To investigate the effects of gestational age (GA) and phototherapy on the plasma metabolite profile of preterm infants with neonatal hyperbilirubinemia (NHB).

STUDY DESIGN

From a cohort of prospectively enrolled infants born preterm (n = 92), plasma samples of very preterm (VPT; GA, 28 + 0 to 31 + 6 weeks, n = 27) and moderate/late preterm (M/LPT; GA, 32 + 0 to 35 + 6 weeks, n = 33) infants requiring phototherapy for NHB were collected prior to the initiation of phototherapy and 24 hours after starting phototherapy. An additional sample was collected 48 hours after starting phototherapy in a randomly selected subset (n = 30; VPT n = 15; M/LPT n = 15). Metabolite profiles were determined using ultraperformance liquid chromatography tandem mass spectroscopy. Two-way ANCOVA was used to identify metabolites that differed between GA groups and timepoints after adjusting for total serum bilirubin levels (false discovery rate q-value < 0.05). Top impacted pathways were identified using pathway over-representation analysis.

RESULTS

Phototherapy was initiated at lower total serum bilirubin (mean ± SD mg/dL) levels in VPT compared with M/LPT infants (7.3 ± 1.4 vs 9.9 ± 1.9, P < .01). We identified 664 metabolites that were significant for a phototherapy effect, 191 metabolites significant for GA, and 46 metabolites significant for GA × phototherapy interaction (false discovery rate q-value < 0.05). Longer duration phototherapy had a larger mean effect size (24 hours postphototherapy: d = 0.36; 48 hours postphototherapy: d = 0.43). Top pathways affected by phototherapy included membrane lipid metabolism, one-carbon metabolism, creatine biosynthesis, and oligodendrocyte differentiation.

CONCLUSION

Phototherapy alters the plasma metabolite profile more than GA in preterm infants with NHB, affecting pathways related to lipid and one-carbon metabolism, energy biosynthesis, and oligodendrocyte differentiation.

Abdominal obesity in youth: the associations of plasma Lysophophatidylcholine concentrations with insulin resistance

BACKGROUD

This study aimed to explore the associations of lysophosphatidylcholines (LPCs) with insulin resistance (IR) and abdominal obesity among children and adolescents.

METHODS

A cross-sectional study was conducted on 612 young individuals, aged 7 to 18 years in Tianjin City, China. LC-MS metabolomic analysis was used to measure LPCs levels. The Homeostasis Model Assessment was used to estimate IR. Waist circumference measurements were used to assess abdominal obesity. Logistic regression models were employed to explore the relationships between LPCs and IR and abdominal obesity. Mediation analyses were performed to analyze whether LPCs affected IR through abdominal obesity.

RESULTS

Compared to their counterparts, five specific LPCs were significantly different in youth with IR. The levels of LPC 24:0 and 26:0 were significantly associated with IR after adjustment. Both decreased levels of LPC 24:0 and 26:0 associated with the increased risks of IR (OR: 0.64, 95%CI: 0.38-0.95; OR: 0.66, 95%CI: 0.40-1.00), and the ORs for abdominal obesity were 0.68 (95%CI: 0.38-1.00) and 0.51 (95%CI: 0.28-0.90), respectively. Mediation analysis indicated that abdominal obesity mediated the association between LPC 26:0 and IR, with a total effect (c) of -0.109 (P < 0.05), a direct effect (c') of -0.055 (P > 0.05), and an indirect effect through obesity (a × b) path with "a" of -0.125 (P < 0.05) and "b" of 0.426 (P < 0.05).

CONCLUSION

Overall findings suggest that decreased levels of LPC 24:0 and 26:0 were associated with increased risks of IR and abdominal obesity. Importantly, addressing abdominal obesity may mediate the impact of IR driven by LPC 26:0.

Duration of a standard phototherapy course in jaundiced newborns with no neurotoxicity risk

In this study, we aimed to determine an ordinary/empiric/standard phototherapy treatment protocol for duration without controlling total serum bilirubin (TSB) levels after initiating phototherapy in early-term and full-term jaundiced newborns who had no hyperbilirubinemia neurotoxicity risk factors. We compared two groups, each receiving either 24 h (Group I) or 18 h (Group II) of continuous phototherapy in terms of demographic characteristics and efficacy (rate of decrease in TSB levels with phototherapy). No control TSB measurements were performed in the study groups until the end of phototherapy for the predetermined durations. Declines in TSB after phototherapy were significantly greater in Group I than in Group II, both in terms of mg/dl (11.81 ± 2.93 mg/dl vs. 10.75 ± 2.48 mg/dl, P = .0008) and percentage (56.71 ± 9.06% vs. 52.86 ± 8.37%, P = .0002). However, the rate of TSB reduction after phototherapy in mg/dl/h (0.59 ± 0.13 mg/dl/h vs. 0.49 ± 0.12 mg/dl/h, P = <.0001) and percentage per hour (2.93 ± 0.37% vs. 2.36 ± 0.46%, P = <.0001) were significantly higher in Group II than in Group I. This indicates an inverse time-response relationship between the duration of phototherapy and the response rate in the study groups. Although the 24-h phototherapy course showed greater efficacy concerning the primary bilirubin outcome measures (decline in TSB in mg/dl and %), the 18-h course of phototherapy treatment provided better hourly outcomes and reached its saturation point around the 18th hour. Therefore, an 18-h phototherapy without TSB monitoring until the end of the phototherapy should be considered for jaundiced newborns lacking neurotoxicity risk factors.

Managing neonatal hyperbilirubinemia: An updated guideline

ABSTRACT

More than 80% of newborn infants experience jaundice as a result of elevated bilirubin during the first few weeks after birth. In most cases, hyperbilirubinemia is physiologic, but persistent and extreme elevations can lead to serious long-term complications, such as kernicterus. To avoid these complications and help clinicians in the successful assessment, evaluation, and treatment of hyperbilirubinemia, the American Academy of Pediatrics updated its clinical practice guideline for neonatal hyperbilirubinemia. This article reviews the guideline and highlights significant updates, such as an elevation in the threshold for phototherapy and exchange transfusion, inclusion of gestational age, and removal of racially based norms.

Risk of childhood neoplasms related to neonatal phototherapy- a systematic review and meta-analysis

CONTEXT

Observational studies have shown conflicting results as to whether exposure to neonatal phototherapy is associated with increased rates of childhood cancer.

OBJECTIVE

To describe the rates of childhood neoplasms and cancer after neonatal phototherapy.

DATA SOURCES

The CENTRAL, PubMed, Scopus, and Web of Science databases.

STUDY SELECTION

Observational studies regardless of design were included.

DATA EXTRACTION

The data were extracted by one author and validated by another. The risk-of-bias assessment was performed using the ROBINS-E and Joanna Briggs Institute critical appraisal tools.

RESULTS

Six cohort and 10 case-control studies were included. The overall risk of bias was high in seven and low in nine studies. In cohort studies, the odds ratio (OR) was increased for hematopoietic cancer (1.44; confidence interval [CI]: 1.16-1.80) and solid tumors (OR: 1.18; CI: 1.00-1.40). In case-control studies, the OR was 1.63 (CI: 0.99-2.67) for hematopoietic cancers and 1.18 (CI: 1.04-1.34) for solid tumors.

CONCLUSIONS

Children with a history of neonatal phototherapy had increased risk of hematopoietic cancer and solid tumors. The evidence quality was limited due to the high risk of bias and potential residual confounding.

IMPACT STATEMENT

Exposure to neonatal phototherapy increased later risk of hematopoietic cancer and solid tumors. This is the most comprehensive study on the association between phototherapy and cancer, but the evidence quality was limited due risk of bias and residual confounding. Future large scale well conducted studies are still needed to better estimate the association and.

Bilirubin measurements in neonates: uniform neonatal treatment can only be achieved by improved standardization

Measurement of total bilirubin (TBil) concentration in serum is the gold standard approach for diagnosing neonatal unconjugated hyperbilirubinemia. It is of utmost importance that the measured TBil concentration is sufficiently accurate to prevent under treatment, unnecessary escalation of care, or overtreatment. However, it is widely recognized that TBil measurements urgently require improvement in neonatal clinical chemistry. External quality assessment (EQA) programs for TBil assess for differences between laboratories and provide supporting evidence of significant differences between various methods, manufacturers and measurement platforms. At the same time, many countries have adopted or only slightly adapted the neonatal hyperbilirubinemia management guidelines from the USA or UK, often without addressing differences in the methodology of TBil measurements. In this report, we provide an overview of the components of bilirubin that are measured by laboratory platforms, the availability of current reference measurement procedures and reference materials, and the role of EQA surveys in this context. Furthermore, the current status of agreement in neonatal bilirubin against clinical decision thresholds is reviewed. We advocate for enhancements in accuracy and comparability of neonatal TBil measurements, propose a path forward to accomplish this, and reflect on the position of the International Federation for Clinical Chemistry and Laboratory Medicine (IFCC) Working Group Neonatal Bilirubin (WG-NB) in this matter.

Phototherapy to Prevent Severe Neonatal Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation: Technical Report

OBJECTIVE

To summarize the principles and application of phototherapy consistent with the current 2022 American Academy of Pediatrics "Clinical Practice Guideline Revision for the Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation."

METHODS

Relevant literature was reviewed regarding phototherapy devices in the United States, specifically those that incorporate blue to blue-green light-emitting diode, fluorescent, halogen, or fiberoptic light sources, and their currently marketed indications.

RESULTS

The efficacy of phototherapy devices varies widely because of nonstandardized use of light sources and configurations and irradiance meters. In summary, the most effective and safest devices have the following characteristics: (1) incorporation of narrow band blue-to-green light-emitting diode lamps (∼460-490 nm wavelength range; 478 nm optimal) that would best overlap the bilirubin absorption spectrum; (2) emission of irradiance of at least 30 µW/cm2/nm (in term infants); and (3) illumination of the exposed maximal body surface area of an infant (35% to 80%). Furthermore, accurate irradiance measurements should be performed using the appropriate irradiance meter calibrated for the wavelength range delivered by the phototherapy device.

CONCLUSIONS

With proper administration of effective phototherapy to an infant without concurrent hemolysis, total serum or plasma bilirubin concentrations will decrease within the first 4 to 6 hours of initiation safely and effectively.

Neonatal phototherapy and risk of epilepsy-A Danish population based study

To evaluate the risk of epilepsy in children who received neonatal phototherapy. A cohort of live singletons born at a Danish hospital (2002-2016) with a gestational age ≥ 35 weeks. We used Cox regression to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) of epilepsy in children treated with neonatal phototherapy compared to children not treated with neonatal phototherapy in the general population, and in a subpopulation of children who had serum bilirubin measurement. Adjusted HRs (aHR) were computed using multivariable and propensity score matching models to take maternal and neonatal factors into consideration. Children were followed from day 29 after birth to diagnosis of epilepsy, death, emigration, or December 31, 2016. Among 65,365 children, 958 (1.5%) received neonatal phototherapy. Seven children (incidence rates (IRs): 10.8 /10,000 person-years) who received neonatal phototherapy and 354 children (IR: 7.7) who did not receive neonatal phototherapy were diagnosed with epilepsy. Neonatal phototherapy was not associated with an increased risk of epilepsy using the multivariable (aHR 0.95, 95% CI: 0.43-2.09) and propensity score matched (aHR 0.94, 95% CI: 0.39-2.28) models. In the subpopulation of 9,378 children with bilirubin measurement, 928 (9.9%) received neonatal phototherapy. In the analysis of the subpopulation in which bilirubin level and age at the time of bilirubin measurement were further taking into consideration, neonatal phototherapy was not associated with an increased risk of epilepsy using the multivariable (aHR 1.26, 95% CI: 0.54-2.97) and propensity score matched (aHR 1.24, 95% CI: 0.47-3.25) models,Conclusions: Neonatal phototherapy was not associated with an increased risk of epilepsy after taking maternal and neonatal factors into consideration. What is known: • A few studies have suggested that neonatal phototherapy for hyperbilirubinemia may increase the risk of childhood epilepsy. • Whether the observed associations contribute to hyperbilirubinemia, phototherapy, or underlying factors requires further investigation. What is new: • This study revealed no increased risk of epilepsy in children treated with neonatal phototherapy compared to children not treated with phototherapy after taking maternal and neonatal factors into consideration. • After further taking bilirubin level and age at the time of bilirubin measurement into consideration, neonatal phototherapy was not associated with an increased risk of epilepsy.

Hypertensive disorders of pregnancy increase the incidence of febrile seizures in offspring

BACKGROUND

Intrauterine exposure to hypertensive disorders of pregnancy (HDP) may increase the risk of neuropsychiatric disorders. This investigation examined for associations between maternal HDP and febrile seizures (FS) in offspring by the age of three years.

METHODS

The present cohort study analyzed data from the Japan Environment and Children's Study, a large national birth cohort. We included mother-child pairs recruited between January 2011 and March 2014. Information regarding maternal HDP, the presence of FS in offspring up to 3 years of age, and potential confounding factors were assessed using written questionnaires administered to mothers.

RESULTS

A total of 77,699 mother-child dyads were analyzed. The prevalence of FS was 8.4% in children without HDP exposure, 10.6% in those exposed to mild HDP, and 10.4% in those with severe HDP exposure. Among children with full-term birth, logistic regression analysis indicated that exposure to mild or severe HDP was significantly associated with a higher incidence of FS (adjusted odds ratio [95% confidence interval]: 1.27 [1.05-1.53] and 1.27 [0.90-1.78], respectively, P for trend = 0.008), compared with children without HDP exposure.

CONCLUSION

In children with full-term birth, intrauterine exposure to HDP was significantly associated with FS by the age of three years.

IMPACT

This study revealed a significant association between intrauterine exposure to hypertensive disorders of pregnancy (HDP) and the subsequent development of febrile seizures (FS) in offspring by three years. This increased incidence of FS by HDP was independent of preterm birth status. This is the first large nationwide birth cohort study showing the impact of intrauterine exposure to HDP on FS in early childhood.

Neonatal Phototherapy-The Need to Measure and Document

This Viewpoint discusses the need for universal standards of recording and measuring phototherapy administered to infants to monitor for potential adverse effects in the long term.

Management of Neonatal Hyperbilirubinemia: Shedding Light on the American Academy of Pediatrics 2022 Clinical Practice Guideline Revision

Neonatal hyperbilirubinemia is one of the most common conditions managed by pediatricians. Although many infants are affected, most will experience complete resolution without complication. Acute bilirubin encephalopathy and kernicterus are rare yet debilitating sequelae of severe hyperbilirubinemia that can be avoided through careful monitoring and treatment with phototherapy. Appropriate management of neonatal hyperbilirubinemia must balance the risks of these severe conditions with the effects of overtreatment. Released in 2022, the American Academy of Pediatrics revised the clinical practice guideline for the management of hyperbilirubinemia, which aims to provide that balance through updates to the previous guideline. This article will provide the reader with (1) an evidence-based harm and benefit analysis of the guideline, (2) an overview of key changes and clarifications made in the new guideline, and (3) a practical summary of guideline updates. [Pediatr Ann. 2024;53(6):e208-e216.].

Bilirubin Measurement and Phototherapy Use After the AAP 2022 Newborn Hyperbilirubinemia Guideline

BACKGROUND AND OBJECTIVES

Guidelines for the management of neonatal hyperbilirubinemia have helped to reduce rates of significant hyperbilirubinemia. However, recent evidence suggesting overtreatment and potential harms of phototherapy have informed the American Academy of Pediatrics clinical practice guideline revision and the accompanying increase in phototherapy thresholds. These changes are predicted to safely reduce overuse; however, to date, the exact effect of these guidelines has not been established.

METHODS

We conducted a retrospective study of newborns born at ≥35 weeks' gestation across a network of 8 hospitals between January 2022 and June 2023. Outcomes included rates of phototherapy and total serum bilirubin (TSB) measurements before and after guideline publication, as well as clinical outcomes, including length of stay, readmissions, and duration of phototherapy.

RESULTS

In our cohort of >22 000 newborns, we observed a 47% decrease in phototherapy utilization, from 3.9% to 2.1% (P < .001). TSB measurements were reduced by 23%, from 712 to 551 measurements per 1000 newborns (P < .001), without an increase in outpatient TSB measurements. We did not observe an increase in readmissions receiving phototherapy, and length of stay increased by only 1 hour (P < .001).

CONCLUSIONS

Our study reveals that the publication of the updated American Academy of Pediatrics 2022 hyperbilirubinemia guidelines has likely yielded a significant reduction in phototherapy use and serum bilirubin measurement. Dedicated quality improvement initiatives may help determine which implementation strategies are most effective. Further population-level studies are needed to confirm safety with ongoing guideline uptake.

"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.

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.

Neonatal Phototherapy and Clinical Characteristics: The Danish National Patient Registry 2000-2016

Purpose

Phototherapy is the standard treatment for neonatal hyperbilirubinemia. It is important to collect data on phototherapy to support research related to the efficacy and safety of phototherapy. We explored the registration of phototherapy in the Danish National Patient Registry (DNPR) and the clinical characteristics of neonates treated with phototherapy.

Methods

We identified children born alive in Denmark from 1 January 2000 through 30 November 2016 from the DNPR (N=1,044,502). We calculated the proportion of children registered that received phototherapy during the neonatal period and examined temporal trends, both nationwide and at the level of individual hospitals. In a sub-cohort of children born at Aarhus University Hospital (AUH) in 2002-2016 (N=71,781), we analyzed the proportions of children registered that received phototherapy, according to sex, gestational age, birth weight, and neonatal characteristics, like Apgar score, birth asphyxia, and infections.

Results

We identified 11,295 (1.1%) registered that received phototherapy. The proportions of children registered that received phototherapy differed among hospitals (range: 0 to 4.1%). Nationwide registration was low during the study period, but it increased to 1.8% in 2016. For the AUH sub-cohort the proportion of children registered with phototherapy averaged 4.4% (N=3182, range:3.9-5.1%). The proportion of children registered with phototherapy was inversely correlated with gestational age and birth weight, and positively correlated with neonatal characteristics, including low Apgar score, birth asphyxia, and infections.

Conclusion

Phototherapy was under-reported in the DNPR and the proportions of children registered that received phototherapy differed among hospitals. The non-compulsory policy for reporting treatment and care in hospitals to the DNPR might explain the variation. The most consistent reporting was observed among children born in an university hospital, where 4.4% of children registered that received phototherapy, and phototherapy was inversely associated with gestational age, birth weight, and positively associated with clinical characteristics like birth asphyxia, and infections.

[Interpretation of the 2022 American Academy of Pediatrics guidelines for the management of hyperbilirubinemia in newborn infants]

The American Academy of Pediatrics updated the guidelines for the management of hyperbilirubinemia in the newborn infants with a gestational age of ≥35 weeks in September 2022. Based on the evidence over the past 18 years, the guidelines are updated from the aspects of the prevention, risk assessment, intervention, and follow-up of hyperbilirubinemia in the newborn infants with a gestational age of ≥35 weeks. This article gives an interpretation of the key points in the guidelines, so as to safely reduce the risk of bilirubin encephalopathy and unnecessary intervention.

Blue-Green (~480 nm) versus Blue (~460 nm) Light for Newborn Phototherapy-Safety Considerations

We have previously shown that the phototherapy of hyperbilirubinemic neonates using blue-green LED light with a peak wavelength of ~478 nm is 31% more efficient for removing unconjugated bilirubin from circulation than blue LED light with a peak wavelength of ~452 nm. Based on these results, we recommended that the phototherapy of hyperbilirubinemic newborns be practiced with light of ~480 nm. Aim: Identify and discuss the most prominent potential changes that have been observed in the health effects of phototherapy using either blue fluorescent- or blue LED light and speculate on the expected effects of changing to blue-green LED light phototherapy. Search the phototherapy literature using the terms neonate, hyperbilirubinemia, and phototherapy in the PubMed and Embase databases. Transitioning from blue fluorescent light to blue-green LED light will expose neonates to less light in the 400-450 nm spectral range, potentially leading to less photo-oxidation and geno-/cytotoxicity, reduced risk of cancer, and decreased mortality in extremely low-birthweight neonates. The riboflavin level may decline, and the increased production and retention of bronze pigments may occur in predisposed neonates due to enhanced lumirubin formation. The production of pre-inflammatory cytokines may rise. Hemodynamic responses and transepidermal water loss are less likely to occur. The risk of hyperthermia may decrease with the use of blue-green LED light and the risk of hypothermia may increase. Parent-neonate attachment and breastfeeding will be positively affected because of the shortened duration of phototherapy. The latter may also lead to a significant reduction in the cost of phototherapy procedures as well as the hospitalization process.

Technical Report: Diagnosis and Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation

CONTEXT

Severe hyperbilirubinemia is associated with kernicterus. Informed guidance on hyperbilirubinemia management, including preventive treatment thresholds, is essential to safely minimize neurodevelopmental risk.

OBJECTIVE

To update the evidence base necessary to develop the 2022 American Academy of Pediatrics clinical practice guideline for management of hyperbilirubinemia in the newborn infant ≥35 weeks' gestation.

DATA SOURCE

PubMed.

STUDY SELECTION

English language randomized controlled trials and observational studies. Excluded: case reports or series, nonsystematic reviews, and investigations focused on <35-weeks' gestation infants.

DATA EXTRACTION

Topics addressed in the previous clinical practice guideline (2004) and follow-up commentary (2009) were updated with new evidence published through March 2022. Evidence reviews were conducted for previously unaddressed topics (phototherapy-associated adverse effects and effectiveness of intravenous immune globulin [IVIG] to prevent exchange transfusion).

RESULTS

New evidence indicates that neurotoxicity does not occur until bilirubin concentrations are well above the 2004 exchange transfusion thresholds. Systematic review of phototherapy-associated adverse effects found limited and/or inconsistent evidence of late adverse effects, including cancer and epilepsy. IVIG has unclear benefit for preventing exchange transfusion in infants with isoimmune hemolytic disease, with a possible risk of harm due to necrotizing enterocolitis.

LIMITATIONS

The search was limited to 1 database and English language studies.

CONCLUSIONS

Accumulated evidence justified narrowly raising phototherapy treatment thresholds in the updated clinical practice guideline. Limited evidence for effectiveness with some evidence of risk of harm support the revised recommendations to limit IVIG use.

Risk Factors and Predictors of Rebound Hyperbilirubinemia in a Term and Late-Preterm Infant with Hemolysis

OBJECTIVE

This study aimed to assess the incidence and predictors of rebound in term and late-preterm infants with hemolytic hyperbilirubinemia postphototherapy.

STUDY DESIGN

A 4-year retrospective data analysis of neonates with hemolytic indirect hyperbilirubinemia admitted to the neonatal intensive care unit (NICU) of Medina Maternity and Children's Hospital was conducted. Bilirubin rebound was defined as the return of total serum bilirubin (TSB) to phototherapy threshold within 72 hours of postphototherapy.

RESULTS

Of 386 identified neonates; 44 (11%) experienced rebound. Neonates in the rebound group demonstrated significantly higher levels of peak TSB, TSB at discontinuation of phototherapy, and lower value of relative TSB (difference between TSB at phototherapy termination and the American Academy of Pediatrics [AAP] threshold for phototherapy at concurrent age) compared with nonrebound group (p-value: <0.001, <0.001, and 0.007, respectively). Lower value of relative TSB at stoppage of phototherapy was the single independent predictor for rebound hyperbilirubinemia by mutivariate regression (p < 0.001). A cut-off value for relative TSB at stoppage of phototherapy of 190 µmol/L had 98% sensitivity and 32% specificity to predict rebound hyperbilirubinemia.

CONCLUSION

Relative TSB at phototherapy termination is the best predictor for postphototherapy rebound hyperbilirubinemia in neonates with hemolytic etiology.

KEY POINTS

· 11% of neonates showed postphototherapy rebound.. · The relative TSB at stoppage of phototherapy is the best predictor for rebound hyperbilirubinemia.. · The first cohort to assess rebound in neonates with hemolysis..

Effectiveness of Dual-Blanket Phototherapy Compared With Combination Phototherapy on Rate of Bilirubin Decline and Treatment Duration

INTRODUCTION

The purpose of this study was to evaluate the effectiveness of dual light-emitting diode (LED) blanket phototherapy compared with combination LED phototherapy on the rate of total serum bilirubin (TSB) decline and treatment duration among full-term neonates with hyperbilirubinemia.

METHODS

A retrospective chart review of 255 newborns with hyperbilirubinemia admitted to a free-standing, university-affiliated, nonprofit, tertiary care Children's Hospital was conducted. Phototherapy type, duration, and rate of TSB decline were compared.

RESULTS

The rate of TSB decline was significantly higher among neonates treated with combination LED phototherapy than neonates treated with dual-blanket phototherapy (p <.0001). There was no significant difference in phototherapy duration.

DISCUSSION

Combination phototherapy resulted in a more rapid decline in TSB but did not shorten phototherapy duration compared to dual-blanket phototherapy. Phototherapy duration may have been confounded by variability in the timing of TSB laboratory draws. Further comparative effectiveness studies are recommended.

The Effect of Readmission for Phototherapy on Early Breast Milk Feeding

OBJECTIVES

To estimate the effect of readmission for inpatient phototherapy on parent-reported exclusive and any breast milk feeding at 2-month well-child visits.

METHODS

We performed a retrospective cohort study using electronic health record data. From births at 16 Kaiser Permanente Northern California hospitals (2013-2017), we identified a cohort of infants ≥35 weeks' gestation with outpatient total serum bilirubin levels ranging from 1 mg/dL below to 2.9 mg/dL above the American Academy of Pediatrics phototherapy threshold at <15 days of age. We compared breast milk feeding at 2-month well-child visits among those readmitted and not readmitted to the hospital for phototherapy, adjusting for bilirubin and other confounding variables.

RESULTS

Approximately one-quarter (26.5%) of the cohort (n = 7729) were readmitted for phototherapy. Almost half (48.5%) of the infants who were not readmitted for phototherapy received exclusively breast milk at the 2-month visit compared with slightly fewer infants who were readmitted (42.9%). In both groups of infants, most (82.2% not readmitted and 81.2% readmitted) received any breast milk. Readmission for phototherapy was associated with a lower adjusted risk of exclusive breast milk feeding (adjusted risk ratio 0.90; 95% confidence interval [CI], 0.84 to 0.96), corresponding to a marginal absolute reduction in exclusive breast milk feeding of 5.0% (95% CI, -7.9% to -2.1%). It was not associated with a reduction in any breast milk feeding (adjusted risk ratio, 1.00; 95% CI, 0.97 to 1.02).

CONCLUSIONS

Infants readmitted for phototherapy were more likely to receive any formula, but no less likely to receive any breast milk at 2-month well-child visits.

Trends and Resource Utilization for Neonatal Jaundice Hospitalizations in the United States

OBJECTIVES

To evaluate the trends in hospitalization for neonatal jaundice and its management with phototherapy and exchange transfusion in the United States from 2006 through 2016.

METHODS

Repeated, cross-sectional analysis of the 2006 to 2016 editions of the Kids' Inpatient Database. All neonatal hospitalizations with an International Classification of Diseases, 9th or 10th Revision, Clinical Modification code for jaundice and admitted at age ≤28 days were included. The outcome measures were changes in the diagnosis of jaundice (expressed as a proportion) and its management over the years.

RESULTS

Among 16 094 653 neonatal hospitalizations from 2006 to 2016, 20.5% were diagnosed with jaundice. While the incidence of jaundice remained stable over the years, 20.9% to 20.5% (P = .1), the proportion with jaundice who received phototherapy increased from 22.5% to 27.0% (P < .0001) between 2006 and 2016. There was no significant change in the exchange transfusion rate per year among neonatal hospitalizations with jaundice.

CONCLUSIONS

While the proportion of newborns with jaundice remained stable between 2006 and 2016, the use of phototherapy significantly increased with no significant change in exchange transfusion rate. The impact of these changes on the prevention of acute bilirubin encephalopathy needs further examination in future studies.

Ursodeoxycholic acid as adjuvant treatment to phototherapy for neonatal hyperbilirubinemia: a systematic review and meta-analysis

BACKGROUND

Neonatal hyperbilirubinemia is observed in most newborns, and 5-15% of neonates require phototherapy. Phototherapy is effective but often prolongs hospitalization and has both short-term and potential long-term harms. The aim of this systematic review and meta-analysis was to evaluate the role of ursodeoxycholic acid (UDCA) combined with phototherapy in neonatal hyperbilirubinemia.

METHODS

A literature search was conducted on September 1, 2021; 590 studies were screened, and 17 full texts were assessed by two authors. We included randomized controlled trials with or without placebo intervention. Primary outcomes were changes in total bilirubin levels at 24 hours and phototherapy duration. We calculated mean differences with 95% confidence intervals (CI).

RESULTS

Six studies with 880 neonates were included. Of these studies, only two used a placebo-controlled double-blinded design. The overall risk of bias was high in one and moderate in four of the included studies. The mean decrease in the total bilirubin level during the first 24 hours was 2.06 mg/dL (95% CI 0.82-3.30; six studies) greater in the UDCA treatment group. The phototherapy duration was 19.7 hours (95% CI 10.4-29.1; five studies) shorter in the UDCA treatment group.

CONCLUSIONS

We found low-quality evidence that UDCA as an adjuvant to phototherapy seems to decrease total bilirubin faster and shorten phototherapy duration compared to standard treatment. Further studies are needed to confirm the efficacy, acute and long-term outcomes, and safety before implementing UDCA as an adjuvant to phototherapy in neonatal hyperbilirubinemia.

Stannsoporfin with phototherapy to treat hyperbilirubinemia in newborn hemolytic disease

OBJECTIVE

To evaluate the efficacy and safety of tin mesoporphyrin (SnMP) in neonates with hyperbilirubinemia (HB) due to hemolysis.

STUDY DESIGN

This multicenter, placebo-controlled phase 2b study (NCT01887327) randomized newborns (35-42 weeks) with hemolysis started on phototherapy (PT) to placebo (Ctrl), SnMP 3.0 mg/kg, or SnMP 4.5 mg/kg given once IM within 30 min of initiation of PT.

RESULTS

In all, 91 patients were randomized (Ctrl: n = 30; 3 mg/kg SnMP: n = 30; 4.5 mg/kg SnMP: n = 31). At 48 h TSB significantly increased in Ctrl by 17.5% (95% CI 5.6-30.7; p = 0.004) and significantly decreased by -13% (95% CI -21.7 to -3.2; p = 0.013) in the 3.0 mg/kg and by -10.5% (95% CI -19.4 to -0.6; p = 0.041) in the 4.5 mg/kg group. Decreases in SnMP groups were significant (p < 0.0001) vs Ctrl.

CONCLUSION

SnMP with PT significantly reduced TSB by 48 h. SnMP may be useful as a treatment for HB in neonates with hemolysis.

The effect of hospital phototherapy on early breastmilk feeding

BACKGROUND

The effect of phototherapy on breastmilk feeding is unclear.

OBJECTIVE

To estimate the effect of inpatient phototherapy on breastmilk feeding at 2-month well-child visits.

METHODS

We performed a retrospective cohort study using electronic health record data. From births at 16 Kaiser Permanente Northern California hospitals (2013-2017), we identified a cohort of infants ≥ 35 weeks' gestation with total serum bilirubin levels close to the American Academy of Pediatrics 2004 phototherapy threshold during their birth hospitalisation. We compared self-reported breastmilk feeding at 2-month well-child visits among those who had and had not received birth hospitalisation phototherapy, adjusting for bilirubin levels and other confounding variables. We used multiple imputation (K = 200) to address missing data.

RESULTS

Approximately a quarter of infants in the cohort (24.5%) received phototherapy during their birth hospitalisation. At the 2-month visit, exclusive breastmilk feeding was less common (RR 0.91, 95% interval [CI] 0.88, 0.95) among those who received phototherapy (41.3%) than those who did not (45.2%). However, no association remained after adjusting for potential confounders (RR 0.99, 95% CI 0.95, 1.04; average treatment effect on the treated [ATET] -0.2%, 95% CI -2.0%, 1.5%). In contrast, any breastmilk feeding was similar between infants who did (76.8%) and did not get phototherapy (77.9%). After adjusting for confounders, phototherapy had a slightly positive association with any breastmilk feeding at 2 months (RR 1.02, 95% CI 1.00, 1.04). Among infants who received phototherapy, the proportion being fed any breastmilk at the 2-month visit was an estimated 1.6 percentage points higher than it would have been if they had not received phototherapy (ATET 1.6%, 95% CI 0.1%, 3.1%). Multiple imputation results were similar.

CONCLUSIONS

Birth hospitalisation phototherapy can be delivered in a way that does not adversely affect breastmilk feeding at 2 months.

Improvement Initiative: End-Tidal Carbon Monoxide Measurement in Newborns Receiving Phototherapy

OBJECTIVES

To determine, as part of our Utah Newborn Nursery Bilirubin Management Program, whether end-tidal carbon monoxide concentration (ETCOc) measurements in all newborns in our nursery receiving phototherapy were associated with outcomes related to the management of hyperbilirubinemia, including time (hours after birth) when phototherapy was initiated, total duration of phototherapy during the nursery stay, repeat phototherapy treatments, and hospital readmission for phototherapy.

STUDY DESIGN

We performed a planned interim analysis of a component of our program in which we measured ETCOc noninvasively using CoSense on each newborn in our nursery receiving phototherapy and recorded specific outcomes related to phototherapy management.

RESULTS

Of 1856 newborns admitted to our nursery in a 6-month period in 2020, 170 (9.8%) were treated with phototherapy. An ETCOc reading was successfully obtained in 145 of 151 attempts (96%). Higher ETCOc values were associated with earlier institution of phototherapy and longer duration of phototherapy. For every 1-ppm increase in ETCOc, phototherapy was started 9 hours earlier (95% CI, 3.3-14.8; P = .002) and was administered for an additional 9.3 hours (95% CI, 4.1-14.6; P < .001). Three newborns were readmitted to the hospital for intensive phototherapy; while in the nursery, all 3 had an elevated ETCOc (2.2, 2.6, and 2.9 ppm).

CONCLUSIONS

Our findings provide answers to questions raised in the 2004 American Academy of Pediatrics bilirubin guidelines. In our neonatal nursery, measuring ETCOc in all phototherapy recipients was feasible and safe, and the results were associated with multiple aspects of phototherapy management. Higher ETCOc values predicted earlier and longer phototherapy courses.

Choosing Wisely in Pediatric Hospital Medicine: 5 New Recommendations to Improve Value

OBJECTIVES

The health care system faces ongoing challenges due to low-value care. Building on the first pediatric hospital medicine contribution to the American Board of Internal Medicine Foundation Choosing Wisely Campaign, a working group was convened to identify additional priorities for improving health care value for hospitalized children.

METHODS

A study team composed of nominees from national pediatric medical professional societies was convened, including pediatric hospitalists with expertise in clinical care, hospital leadership, and research. The study team surveyed national pediatric hospitalist LISTSERVs for suggestions, condensed similar responses, and performed a literature search of articles published in the previous 10 years. Using a modified Delphi process, the team completed a series of structured ratings of feasibility and validity and facilitated group discussion. The sum of final mean validity and feasibility scores was used to identify the 5 highest priority recommendations.

RESULTS

Two hundred seven respondents suggested 397 preliminary recommendations, yielding 74 unique recommendations that underwent evidence review and rating. The 5 highest-scoring recommendations had a focus on the following aspects of hospital care: (1) length of intravenous antibiotic therapy before transition to oral antibiotics, (2) length of stay for febrile infants evaluated for serious bacterial infection, (3) phototherapy for neonatal hyperbilirubinemia, (4) antibiotic therapy for community-acquired pneumonia, and (5) initiation of intravenous antibiotics in infants with maternal risk factors for sepsis.

CONCLUSIONS

We propose that pediatric hospitalists can use this list to prioritize quality improvement and scholarly work focused on improving the value and quality of patient care for hospitalized children.

Treatment practices and implementation of guidelines for hyperbilirubinemia and rebound hyperbilirubinemia

BACKGROUND

Hyperbilirubinemia (HB), defined as elevated total serum bilirubin (TSB) levels, commonly affects neonates and requires prompt treatment to prevent neurological complications. Up to 10%of neonates experience rebound hyperbilirubinemia (RHB), requiring re-initiation of treatment. Unfortunately, treatment guidelines lack practical recommendations surrounding subthreshold phototherapy, treatment termination, and RHB investigations. We examined local management practices for HB and RHB treatment in a well newborn nursery. As a secondary aim, we investigated the association between treatment practices and RHB rates.

METHODS

Retrospective chart review identified neonates treated for hyperbilirubinemia between January 2015 and December 2019 during their birth hospitalization at a tertiary care centre. Standardized data collection sheets were used to record treatment parameters.

RESULTS

Over the 5-year period, there were 9683 births and 305 (3.15%) neonates received phototherapy. Of the treated cases, 20-25%were subthreshold to practice guideline values. Upon treatment termination 25-55%of cases had TSB levels within 3 mg/dL, which may increase the risk of RHB. In our cohort, 20.3%of treated cases experienced one episode of RHB and 3.9%experienced two episodes of RHB. Although clinicians evaluated neonates for RHB 0-12 hours following treatment termination prior to discharge, many cases were identified in outpatient settings and required re-admission for phototherapy.

CONCLUSION

When managing HB and RHB, treatment practices such as when to terminate treatment in relation to threshold values, and timing of RHB investigations, are largely inconsistent amongst clinicians. Future studies are required to better understand the landscape of hyperbilirubinemia treatment beyond initiation of phototherapy.

A New Hour-Specific Serum Bilirubin Nomogram for Neonates ≥35 Weeks of Gestation

OBJECTIVE

To develop a statistically rigorous, hour-specific bilirubin nomogram for newborns based on a very large data set; and use it prospectively as a replacement for the 1999 Bhutani nomogram.

STUDY DESIGN

This was a retrospective analysis of first total serum bilirubin (TSB) measurements from 15 years of universal bilirubin screening during birth hospitalizations at 20 Intermountain Healthcare hospitals. Hour-specific TSB values were assembled into a nomogram by percentile, and subgroups were compared.

RESULTS

The information obtained included robust data in the first 12 hours after birth (which was not included in the 1999 nomogram), general agreement with the 1999 nomogram for values in the first 60 hours, but higher 75th and 95th percentile TSB values thereafter in the new version, no difference in TSB between male and female infants, higher TSB values among earlier gestation neonates (35^0/7-36^6/7 weeks vs ≥37 weeks, P < .0001), and lower TSB values in neonates of Black race (P < .0001) and higher values in neonates of Asian race (P < .001).

CONCLUSIONS

An updated and more informative Bhutani neonatal bilirubin nomogram, based on 140 times the number of subjects included the 1999 version, is now in place in our health care system.

Association between type of phototherapy management and hospital and patient-related outcomes in neonates with non-haemolytic jaundice at an Australian community hospital

AIM

To evaluate the associations between type of light-emitting diode phototherapy intervention and hospital and patient related outcomes in term neonates with non-haemolytic jaundice.

METHODS

A retrospective observational study in a community hospital within a disadvantaged area in Australia was conducted. Data was extracted from hospital systems and medical records regarding the use of three types of phototherapy surface-area exposure for term neonates ≤28 days with non-haemolytic neonatal jaundice. Associations between type of phototherapy management and length of stay (LOS), rate of serum bilirubin (SBR) decline and duration of phototherapy were estimated using the general linear mixed model or linear regression.

RESULTS

Of 102 neonates diagnosed with non-haemolytic jaundice between 1 June 2016 and 31 August 2017, 82 were included in final analyses. Neonates treated for jaundice during their first (birth) admission had a median LOS of 118 h for single-sided and 125 h for maximal double-sided phototherapy. Differences by phototherapy type were not statistically significant (P = 0.06). SBR rate of decline increased as surface-area of phototherapy increased (P < 0.001) with the fastest decline seen in maximal double-sided phototherapy. Estimated duration of phototherapy did not vary by phototherapy type but did vary by age at initiation of phototherapy (P = 0.006), with 16 fewer hours of phototherapy if commenced at ≥72 to <96 h versus ≥24 to 48 h of age (difference -16.4 h, 95% confidence interval -29.1 to -3.7 h).

CONCLUSIONS

LOS and phototherapy duration were not associated with phototherapy type. Older neonates with neonatal jaundice required shorter phototherapy duration. Double-sided phototherapy was associated with faster reduction in SBR.

Neonatal hyperbilirubinemia management: Clinical assessment of bilirubin production

The predominant cause of elevated total/plasma bilirubin (TB) levels is from an increase in bilirubin production primarily because of ongoing hemolysis. If undiagnosed or untreated, the risk for developing extreme neonatal hyperbilirubinemia and possibly bilirubin-induced neurological dysfunction (BIND) is increased. Since carbon monoxide (CO) and bilirubin are produced in equimolar amounts during the heme catabolic process, measurements of end-tidal CO levels, corrected for ambient CO (ETCOc) can be used as a direct indicator of ongoing hemolysis. A newly developed point-of-care ETCOc device has been shown to be a useful for identifying hemolysis-associated hyperbilirubinemia in newborns. This review summarizes the biology of bilirubin production, the clinical utility of a novel device to identify neonates undergoing hemolysis, and a brief introduction on the use of ETCOc measurements in a cohort of neonates in China.

Challenges of phototherapy for neonatal hyperbilirubinemia (Review)

Phototherapy is universally recognized as the first option for treating neonatal jaundice due to its unparalleled efficiency and safety in reducing the high serum free bilirubin levels and limiting its neurotoxic effects. However, several studies have suggested that phototherapy may elicit a series of short- and long-term adverse reactions associated with pediatric diseases, including hemolysis, allergic diseases, DNA damage or even cancer. The aim of the present review was to summarize the etiology, mechanism, associated risks and therapeutic strategies for reducing high neonatal serum bilirubin levels. In order to shed light on the negative effects of phototherapy and to encourage implementation of a reasonable and standardized phototherapy scheme in the clinic, the present review sought to highlight the current understanding of the adverse reactions of phototherapy, as it is necessary to further study the mechanism underlying the development of the adverse effects of phototherapy in infants in order to explore novel therapeutic alternatives.

Blue LED phototherapy in preterm infants: effects on an oxidative marker of DNA damage

BACKGROUND

Phototherapy is used on the majority of preterm infants with unconjugated hyperbilirubinaemia. The use of fluorescent tube phototherapy is known to induce oxidative DNA damage in infants and has largely been replaced by blue light-emitting diode phototherapy (BLP). To date, it is unknown whether BLP also induces oxidative DNA damage in preterm infants.

OBJECTIVE

To determine whether BLP in preterm infants induces oxidative DNA damage as indicated by 8-hydroxy-2'deoxyguanosine (8-OHdG).

DESIGN

Observational cohort study.

METHODS

Urine samples (n=481) were collected in a cohort of 40 preterm infants (24-32 weeks' gestational age) during the first week after birth. Urine was analysed for the oxidative marker of DNA damage 8-OHdG and for creatinine, and the 8-OHdG/creatinine ratio was calculated. Durations of phototherapy and levels of irradiance were monitored as well as total serum bilirubin concentrations.

RESULTS

BLP did not alter urinary 8-OHdG/creatinine ratios (B=0.2, 95% CI -6.2 to 6.6) at either low (10-30 µW/cm²/nm) or high (>30 µW/cm²/nm) irradiance: (B=2.3, 95% CI -5.7 to 10.2 and B=-3.0, 95% CI -11.7 to 5.6, respectively). Also, the 8-OHdG/creatinine ratios were independent on phototherapy duration (B=-0.1, 95% CI -0.3 to 0.1).

CONCLUSIONS

BLP at irradiances up to 35 µW/cm²/nm given to preterm infants ≤32 weeks' gestation does not affect 8-OHdG, an oxidative marker of DNA damage.

Comparison of end-tidal carbon monoxide measurements with direct antiglobulin tests in the management of neonatal hyperbilirubinemia

OBJECTIVE

Determine whether management of neonatal hyperbilirubinemia differs if one used end-tidal carbon monoxide (CO) corrected for ambient CO (ETCO_c) measurements instead of direct antiglobulin test (DAT) results to assess the severity of hemolysis.

STUDY DESIGN

Retrospective chart review of infants with total bilirubin and ETCO_c levels measured from July 2016 to August 2018. The reported treatment is the hypothetical management infants might have received had there been strict adherence to American Academy of Pediatrics guidelines, rather than the actual management they received.

RESULT

Only 27.2% of 191 DAT(+) infants were hemolyzing based on ETCO_c, while 29.1% of DAT (-) infants were hemolyzing based on ETCO_c. Management of 18 (9.4%) infants differed depending if ETCO_c or DAT were used to determine hemolysis. Eight fewer infants would have received phototherapy if ETCO_c was used.

CONCLUSIONS

ETCO_c is a more accurate determinant of hemolysis in the newborn, and its use can lead to less phototherapy.

Cycled Phototherapy Dose-Finding Study for Extremely Low-Birth-Weight Infants: A Randomized Clinical Trial

Importance

Cycled (intermittent) phototherapy (PT) might adequately control peak total serum bilirubin (TSB) level and avoid mortality associated with usual care (continuous PT) among extremely low-birth-weight (ELBW) infants (401-1000 g).

Objective

To identify a cycled PT regimen that substantially reduces PT exposure, with an increase in mean peak TSB level lower than 1.5 mg/dL in ELBW infants.

Design, Setting, and Participants

This dose-finding randomized clinical trial of cycled PT vs continuous PT among 305 ELBW infants in 6 US newborn intensive care units was conducted from March 12, 2014, to November 14, 2018.

Interventions

Two cycled PT regimens (≥15 min/h and ≥30 min/h) were provided using a simple, commercially available timer to titrate PT minutes per hour against TSB level. The comparator arm was usual care (continuous PT).

Main Outcomes and Measures

Mean peak TSB level and total PT hours through day 14 in all 6 centers and predischarge brainstem auditory-evoked response wave V latency in 1 center. Mortality and major morbidities were secondary outcomes despite limited power.

Results

Consent was requested for 452 eligible infants and obtained for 305 (all enrolled) (mean [SD] birth weight, 749 [152] g; gestational age, 25.7 [1.9] weeks; 81 infants [27%] were multiple births; 137 infants [45%] were male; 112 [37%] were black infants; and 107 [35%] were Hispanic infants). Clinical and demographic characteristics of the groups were similar at baseline. After a preplanned interim analysis of 100 infants, the regimen of 30 min/h or more was discontinued, and the study proceeded with 2 arms. Comparing 128 infants receiving PT of 15 min/h or more with 128 infants receiving continuous PT among those surviving to 14 days, mean peak TSB levels were 7.1 vs 6.4 mg/dL (adjusted difference, 0.7; 95% CI, 0.4-1.1 mg/dL) and mean total PT hours were 34 vs 72 (adjusted difference, -39; 95% CI, -45 to -32). Wave V latency adjusted for postmenstrual age was similar in 37 infants receiving 15 min/h or more of PT and 33 infants receiving continuous PT: 7.42 vs 7.32 milliseconds (difference, 0.10; 95% CI, -0.11 to 0.30 millisecond). The relative risk for death was 0.79 (95% CI, 0.40-1.54), with a risk difference of -4.5% (95% CI, -10.9 to 2.0). Morbidities did not differ between groups.

Conclusions and Relevance

Cycled PT can substantially reduce total PT with little increase in peak TSB level. A large, randomized trial is needed to assess whether cycled PT would increase survival and survival without impairment in small, preterm infants.

Trial Registration

ClinicalTrials.gov Identifier: NCT01944696.

Prenatal Exposure to Antibiotics and Development of Epilepsy in Children

We aimed to confirm or reject previous reports on the association of prenatal antibiotic exposure and development of epilepsy in offspring by accounting for known and unidentified confounding factors. In a retrospective cohort investigation, we enrolled children aged 3-18 years born between 1998 and 2012 at a single regional hospital and their mothers. A computerized medication database was linked with hospital records. The exposed group included children whose mothers purchased 1 or more antibiotic medications for use during pregnancy. Epilepsy was defined by epilepsy diagnosis and/or by chronic dispensing of antiepileptic drugs. We analyzed maternal exposure to antibiotics 2 years after delivery (but not during pregnancy and/or the 2 years following delivery) as part of the specificity analysis. We enrolled 88 899 children and their 74 416 mothers. The group exposed prenatally to antibiotics comprised 36 622 children (41.2%). Of them, 326 (0.9%) developed epilepsy compared with 370 of 52 277 (0.7%) in the unexposed group (relative risk [RR], 1.24; 95% confidence interval [CI], 1.07-1.44: P = .004). Exposure during the first, second, and third trimesters was characterized by incidence of epilepsy in 0.8% (P = .943), 0.9% (P = .266), and 0.9% (P = .073) of children, respectively, compared with the unexposed group, with an RR of 1.01 (95%CI, 0.83-1.23), 1.12 (95%CI, 0.92-1.36), and 1.19 (95%CI, 0.98-1.45), respectively. Similarly, prenatal exposure by antibiotic class was associated with epilepsy. Nevertheless, the specificity analysis strongly suggested the possibility of confounding by indication. Our findings indicated that pregnant women should receive the indicated antibiotic treatment with no fear of the development of epilepsy in their children.

Unbound bilirubin measurements in term and late-preterm infants

Background: Hyperbilirubinemia occurs in over 80% of newborns, and severe bilirubin toxicity can lead to neurological dysfunction and death. Unbound bilirubin (Bf) levels predict the risk of neurodevelopmental handicap, although total serum bilirubin (TSB) is used to manage care.Objective: To measure Bf levels in healthy infants, its relationship to TSB, and its response to phototherapy. We hypothesize unexpectedly high Bf levels, poor correlation with TSB and unpredictable response to phototherapy.Design/methods: Healthy infants were studied with simultaneous TSB and Bf measurements. The clinical data recorded included ethnicity, gender, birth weight, gestational age, and mode of delivery, Apgar scores, breast/formula feeds, and phototherapy.Results: One hundred thirty-two infants (3248.9 ± 509.2g, GA 38.7 ± 1.4 weeks), at mean age of the initial sample of 28.5 ± 15.6 h, had a TSB of 7.9 ± 2.7 mg/dl, and a Bf of 5.2 ± 3.2 nM. The correlation between Bf and TSB was significant but not between Bf and TSB for TSB >12 mg/dl. Bf >11nm were in 22.7% and >17 nM in 3.8% of infants. Post-phototherapy TSB and Bf levels were similar to those before treatment.Conclusions: The relationship between TSB and Bf in healthy infants is complex, with the inability of one to predict the other's level in infants with elevated TSB. The mechanism of bilirubin-related neurotoxicity suggests that the management of jaundice in healthy infants requires Bf measurements. Management of jaundice with TSB may result in more infants exposed to phototherapy. However, unexpected elevations of Bf occur in an apparently healthy population.

Pathogenesis and Management of Indirect Hyperbilirubinemia in Preterm Neonates Less Than 35 Weeks: Moving Toward a Standardized Approach

Premature infants have a higher incidence of indirect hyperbilirubinemia than term infants. Management of neonatal indirect hyperbilirubinemia in late preterm and term neonates has been well addressed by recognized, consensus-based guidelines. However, the extension of these guidelines to the preterm population has been an area of uncertainty because of limited evidence. This leads to variation in clinical practice and lack of recognition of the spectrum of bilirubin-induced neurologic dysfunction (BIND) in this population. Preterm infants are metabolically immature and at higher risk for BIND at lower bilirubin levels than their term counterparts. Early use of phototherapy to eliminate BIND and minimize the need for exchange transfusion is the goal of treatment in premature neonates. Although considered relatively safe, phototherapy does have side effects, and some NICUs tend to overuse phototherapy. In this review, we describe the epidemiology and pathophysiology of BIND in preterm neonates, and discuss our approach to standardized management of indirect hyperbilirubinemia in the vulnerable preterm population. The proposed treatment charts suggest early use of phototherapy in preterm neonates with the aim of reducing exposure to high irradiance levels, minimizing the need for exchange transfusions, and preventing BIND. The charts are pragmatic and have additional curves for stopping phototherapy and escalating its intensity. Having a standardized approach would support future research and quality improvement initiatives that examine dose and duration of phototherapy exposure with relation to outcomes.

Evidence-Based Updates on the First Week of Exclusive Breastfeeding Among Infants ≥35 Weeks

The nutritional and immunologic properties of human milk, along with clear evidence of dose-dependent optimal health outcomes for both mothers and infants, provide a compelling rationale to support exclusive breastfeeding. US women increasingly intend to breastfeed exclusively for 6 months. Because establishing lactation can be challenging, exclusivity is often compromised in hopes of preventing feeding-related neonatal complications, potentially affecting the continuation and duration of breastfeeding. Risk factors for impaired lactogenesis are identifiable and common. Clinicians must be able to recognize normative patterns of exclusive breastfeeding in the first week while proactively identifying potential challenges. In this review, we provide new evidence from the past 10 years on the following topics relevant to exclusive breastfeeding: milk production and transfer, neonatal weight and output assessment, management of glucose and bilirubin, immune development and the microbiome, supplementation, and health system factors. We focus on the early days of exclusive breastfeeding in healthy newborns ≥35 weeks' gestation managed in the routine postpartum unit. With this evidence-based clinical review, we provide detailed guidance in identifying medical indications for early supplementation and can inform best practices for both birthing facilities and providers.

Improving the Bilirubin Management Program in the Newborn Nursery: Background, Aims, and Protocol

BACKGROUND

Practices to detect and manage hyperbilirubinemia in newborn nurseries are highly variable. American Academy of Pediatrics guidelines in 1999, 2004, and 2009 have generated, perhaps unintentionally, divergent practices that might not all be of equivalent value. Evidence-based progress is needed to define less invasive, less expensive, uniform, and safe methods to reduce ER visits and hospital readmissions for jaundice treatment and bilirubin encephalopathy.

OBJECTIVES

This research briefing is intended to inform readers of a new prospective quality improvement program aimed at testing the value of specific changes in newborn nursery hyperbilirubinemia detection and management. This new program includes predetermined means of assessing those specific changes, which relate to diagnosis, safety, outcomes, and cost.

METHODS

In this briefing, we present the perceived problems in our present bilirubin management system, as voiced by stakeholders. We report our proposed means to test minimization of those problems utilizing already acquired data on approximately 400,000 well babies in the Intermountain Healthcare system of hospitals in the western USA. We then describe our methods of assessing specific outcomes in a pre- versus postpractice change analysis.

RESULTS AND CONCLUSIONS

The University of Utah Newborn Nursery will implement a quality improvement project in bilirubin management during 2020 to test the feasibility and effectiveness of several changes to our current bilirubin management program. We maintain that the improved understanding generated by this project will be a step toward new evidence-based strategies for reducing ER visits and hospital readmissions for jaundice treatment and preventing bilirubin encephalopathy.