Neonatal jaundice. Strategies to reduce bilirubin-induced complications

Evaluation of thiol-disulfide homeostasis and oxidative stress parameters in newborns receiving phototherapy

The aim of our study was to evaluate oxidative stress and thiol-disulfide homeostasis in term newborns receiving phototherapy. The study was planned as a single-blind, intervention study in a single center with level 3 neonatal intensive care unit to investigate the effect of phototherapy on the oxidative system in term newborns with hyperbilirubinemia. Neonates with hyperbilirubinemia were treated with total body exposure phototherapy technique for 18 h using a Novos^® device. Blood samples of 28 term newborns were taken before and after phototherapy. Total and native thiol, total antioxidant status (TAS) and total oxidant status (TOS), and oxidative stress index (OSI) levels were measured. The 28 newborn patients included 15 (54%) males and 13 (46%) females with a mean birthweight of 3080.1 ± 366.5 g. Native and total thiol levels were found to be decreased in patients receiving phototherapy (p = 0.021, p = 0.010). Besides, significantly lower TAS and TOS levels were found after phototherapy (p < 0.001, p < 0.001). We found that decreased thiol levels were related to increased oxidative stress. We also determined significantly the lower bilirubin levels after phototherapy (p < 0.001). In conclusion, we found that phototherapy treatment induced decreased oxidative stress associated with hyperbilirubinemia in neonates. Thiol-disulfide homeostasis can be used as a marker of oxidative stress due to hyperbilirubinemia in the early period.

The effect of hyperbilirubinemia on motor repertoire of infants between 3 and 5 months of age

Jaundice is a common problem and occurs as a result of the increase in bilirubin level in infants. Infants may be adversely affected by this situation. The aim of this study is to determine whether neonatal jaundice affects the movements and postures of 3- to 5-month-old infants with hyperbilirubinemia and the correlation of motor repertoire at the same age with bilirubin levels. The study group included 30 infants (9 girls, 21 boys) with hyperbilirubinemia and a control group of 30 infants (11 girls, 19 boys) with typical development without hyperbilirubinemia. The motor repertoires of the infants were evaluated through detailed general movement (GM) analysis using video recordings made at 9-17 weeks post-term. The infants with hyperbilirubinemia had lower motor optimality score and subcategory scores (including observed movement patterns, age-adequate movement repertoire, observed postural patterns, and movement character) compared with the control group. The fidgety movement scores decreased as bilirubin value increased in infants.Conclusion: Infants with hyperbilirubinemia had poorer motor repertoire when compared to a control group. For this reason, detailed GM analysis of these infants will predict probable neurodevelopmental problems and infants with needs can begin individualized early intervention suitable for movement repertoire and posture at the earliest time. What is Known: • GMs of infants with hyperbilirubinemia were previously described. • However, the motor repertoires of infants with hyperbilirubinemia were not described in detail. What is New: • Infants with hyperbilirubinemia had poorer motor repertoire when compared to peers. • This is important in determining the need for individualized early intervention.

Direct antiglobulin test in the prediction of hyperbilirubinemia and predischarge bilirubin levels in infants with mother-infant blood type incompatibility

BACKGROUND

This research evaluated the association between the mother-infant blood type or rhesus (ABO or Rh) incompatibility, the pattern of neonatal jaundice, and serum bilirubin (TSB) values obtained prior to discharge from hospital of healthy born neonates with gestational age >34 weeks and birth weight >2000 g.

METHODS

We utilized a laboratory and neonatal database to identify the cord blood ABO/Rh and direct antiglobulin test (DAT) and TSB measured during hospitalization and re-admission with hyperbilirubinemia for phototherapy treatment. We used hour-specific TSB to analyze the TSB levels for ABO/Rh compatibility and isoimmunization using chi-square, analysis of variance, and regression models.

RESULTS

Of the 901 infants studied, 158 (17.5%) had ABO/Rh incompatibility, including 27 with positive DAT. Hyperbilirubinemia was diagnosed in 33.3% DAT positive, 6.9% DAT negative, and 4.6% of infants with compatible blood types. Increased predischarge TSB was observed in DAT positive infants at 48-72 h of postnatal age (P < 0.001). After controlling for age at TSB testing and weight loss percentage, multiple regression analysis did not show any impact of ABO/Rh incompatibility and DAT results on the predischarge TSB levels.

CONCLUSION

Blood type incompatibility increases the frequency of hyperbilirubinemia only in the DAT-positive infants. Irrespective of the isoimmunization status, it does not significantly affect the level of predischarge TSB.

Perceptions, practices, and traditional beliefs related to neonatal jaundice among Egyptian mothers: A cross-sectional descriptive study

Neonatal jaundice (NNJ) is one of the most common neonatal disorders worldwide. It is still a main cause of avoidable brain damage, physical and mental impairment, and probable death in newborns.We aimed to assess perceptions, practices, and traditional beliefs among Egyptian mothers toward NNJ that may contribute to delayed presentation and inappropriate management of hyperbilirubinemia.This descriptive, cross-sectional study was conducted from January to May 2015. We interviewed 400 Egyptian mothers who gave birth in <1 month before the study using a structured questionnaire. Participants were recruited from outpatients of Cairo University Teaching Hospital.This study revealed unexpected moderate knowledge and attitude scores of Egyptian mothers in most domains with a mean of 6.6 and 20.6, respectively, although the majority of them were illiterate or had low educational attainment. In terms of knowledge, 52.3% of participants had adequate knowledge about NNJ in the aspects of awareness, risk factors, management, and complications. Almost all participants exhibited moderate (89.8%) and high levels (10%) of positive attitudes toward NNJ. Maternal sociodemographic factors influenced knowledge level, attitudes, and behaviors related to NNJ in Egypt. Working mothers and those residing in urban areas were significantly more knowledgeable (P = 0.023 and 0.021, respectively), and attained higher attitude scores (P < 0.001 and P < 0.001, respectively) than housewives and rural ones. Moreover, significantly higher attitude scores (P < 0.001) were attained by those who had completed their university [22.3 (SD = 3.1)] or postgraduate education [22.2 (SD = 3.6)].The majority of Egyptian mothers have a satisfactory level of knowledge and attitudes related to NNJ. However, cultural beliefs and traditional infant care practices still have an impact on mothers regardless of their educational level.

Antioxidant status in neonatal jaundice before and after phototherapy

Background:

Neonatal jaundice refers to yellow coloration of the skin and the sclera (whites of the eyes) of newborn babies that result from the accumulation of bilirubin in the skin and mucous membranes. Because bilirubin is potentially toxic to the central nervous system. Genetic disorders of bilirubin conjugation, particularly the common Gilbert's syndrome, can also contribute to neonatal hyperbilirubinemia.

Objective:

The aim of this study was to evaluate the lipid per-oxidation and antioxidant enzyme activities in patients with neonatal jaundice before and after phototherapy.

Materials and Methods:

The study includes 50 neonatal jaundice patients with average age 2-15 days. All patients of neonatal jaundice receiving phototherapy except feeding, cleaning. Subjects selected were from the patients attending Pediatrics Department. Plasma malondialdehyde (MDA), erythrocyte glutathione peroxidase (GPX), superoxide dismutase and catalase (CAT) to monitor the bilirubin level.

Results:

The results show increased levels of bilirubin compared with controls (P < 0.001) shows the level of plasma MDA in control, before and after phototherapy. Represents the level of GPX was significantly increased in after the phototherapy group when compared with before phototherapy and control SPSS soft ware: (P < 0.001). Shows the reduced glutathione (GSH) level in plasma was significantly decreased in the after phototherapy group when compared with before phototherapy and control (P < 0.001). And finally with ascorbic acid and CAT.

Conclusion:

It is evident from the study that increased oxidative stress in neonatal jaundice babies leads to decrease in the levels of antioxidants like GSH and ascorbic acid and disturb their metabolism, that weaken their ability to fight the growing stress. Intense oxidative stress and decreased antioxidants may contribute to neural cell death and alter the erythrocytomembrane structure processing in neonatal jaundice.

Efficacy of double and triple phototherapy in term newborns with hyperbilirubinemia: the first clinical trial

BACKGROUND

Icterus is the most common medical problem in neonates and phototherapy is the standard treatment for neonatal hyperbilirubinemia. This study aimed to compare the efficacy and length of hospital stay of double and triple phototherapy in newborns with indirect hyperbilirubinemia.

METHODS

In a clinical trial, 40 healthy term newborns (gestational age >37 weeks) with bilirubin > or =12 and > or =15 mg/dL in the second and third day, respectively, were randomly assigned to triple (n=20) or double phototherapy (n=20) groups. Total and direct serum bilirubin were measured at admission, 8, 16, and 24 hours after beginning of phototherapy, and every 12 hours thereafter until discharge (when bilirubin levels reached < or =10 mg/dL).

RESULTS

There were 21 male (52%) and 19 female (48%) term neonates, with significant difference between patients' age, weight, and age of icterus. There was no significant difference in the rate of bilirubin decline between the two groups within the first 8, 16 and 24 hours. There was no significant difference in mean length of hospital stay between the two groups. Analysis of complications showed no difference between triple and double groups.

CONCLUSION

Triple phototherapy failed to reduce total serum bilirubin and shorten length of hospitalization more rapidly than double phototherapy.

Understanding neonatal jaundice: UK practice and international profile

Over the last 25 years there have been considerable advances in the treatment and technologies used in the care of newborn infants. Most of these advances are related to the care of the premature infants and there have been few changes in the management of conditions commonly seen in term infants.

Neonatal jaundice is one of the commonest neonatal disorders and has been recognized since early history. Early neonatal jaundice is usually caused by the physiological destruction of red blood cells in the infant and its importance lies in the ability of the bilirubin pigment so produced to cross the blood brain barrier resulting in neurotoxicity. Prolonged neonatal jaundice (after 14 days of age) may be an indication of an underlying liver disorder. The approach to neonatal jaundice has remained largely unchanged over the last two to three decades. We continue to rely on visual inspection to assess the severity of early neonatal jaundice. We have technology that is effective in reducing the level of bilirubinaemia but in the UK there is no clear consensus as to the level at which jaundice should be treated. We do not have a standardized approach to the management of prolonged jaundice and there is potential for infants with significant liver problems to be diagnosed at a relatively late stage. Some countries (for example the US) have professional bodies who have introduced guidelines to ensure a standardized approach to the jaundice infant. We have little information about neonatal jaundice treatment in other parts of the developing world.

Therapeutic applications of bilirubin and biliverdin in transplantation

Bilirubin is the end product of heme catabolism by heme oxygenases. The inducible form of these enzymes is heme oxygenase-1 (HO-1), which is the rate-limiting enzyme that can degrade heme into equimolar quantities of carbon monoxide (CO), biliverdin, and free iron. Biliverdin is very rapidly converted to bilirubin by the enzyme biliverdin reductase, and free iron upregulates the expression of ferritin. HO-1 is a ubiquitous stress protein and is induced in many cell types by various stimuli. Induced HO-1 exerts antiinflammatory effects and modulates apoptosis. Expression of HO-1 in vivo suppresses the inflammatory responses in endotoxic shock, hyperoxia, acute pleurisy, and organ transplantation, as well as ischemia-reperfusion injury, and thereby provides salutary effects in these conditions. Accumulating evidence indicates that biliverdin/bilirubin can mediate the protective effects of HO-1 in many disease models, such as IRI and organ transplantation, via its antiinflammatory, antiapoptotic, antiproliferative, and antioxidant properties, as well as its effects on the immune response. This review attempts to summarize these protective roles as well as the molecular mechanisms by which biliverdin/bilirubin benefit IRI and solid-organ transplantation, including chronic rejection, and islet transplantation.

Minocycline blocks bilirubin neurotoxicity and prevents hyperbilirubinemia-induced cerebellar hypoplasia in the Gunn rat

Encephalopathy induced by hyperbilirubinemia in infants has been described in the medical literature for over a century but neither the cellular nor molecular mechanisms underlying bilirubin neurotoxicity are well understood. In this study, we have demonstrated that minocycline potently protects primary cultured rat cerebellar granule neurons against bilirubin neurotoxicity (IC50 approximately 2 microm) and almost completely blocks cerebellar hypoplasia and the profound loss of Purkinje and granule neurons observed in homozygous Gunn rats, a genetic model of hyperbilirubinemia-induced neurotoxicity. Minocycline-treated newborn Gunn rats had nearly equivalent numbers of viable Purkinje and granule neurons in the cerebellum as did control animals. Moreover, minocycline inhibits the bilirubin-induced phosphorylation of p38 mitogen-activated protein kinase both in vivo as well as in vitro. Taken together our data demonstrate that minocycline is able to greatly reduce bilirubin-induced neurotoxicity and suggest that minocycline's neuroprotective effects may be due in part to an inhibition of p38 mitogen-activated protein kinase activity. Our findings may lead to novel approaches for treating bilirubin-induced encephalopathy.

Neonatal jaundice: physiologic variation or pathologic process

Neonatal hyperbilirubinemia and jaundice affect approximately 60% of the 4 million newborns in the United States each year. Jaundice results from bilirubin deposition in the skin and mucous membranes, becoming clinically visible at a serum bilirubin level of 5 to 7 mg/dL. At a higher but undefined level, bilirubin may deposit in the brain where it can cause transient dysfunction or permanent neurologic impairment.

An update on the prevalence of glucose-6-phosphate dehydrogenase deficiency and neonatal jaundice in Tehran neonates

OBJECTIVES

The aim of this study was to screen newborns in Tehran for glucose-6-phosphate dehydrogenase (G6PD) deficiency in relation to hyperbilirubinemia and jaundice.

DESIGN AND METHODS

We performed quantitative and qualitative red blood cell (RBC) G6PD assays in cord blood of 2000 male and female at-term neonates. Observations for jaundice and bilirubin determination were made in G6PD-deficient and normal groups. Those with severe jaundice were treated with phototherapy or exchange transfusion.

RESULTS

Our results showed that 2.1% (3.6% of males and 0.6% of females) was G6PD-deficient. Those with severe jaundice and hyperbilirubinemia (160 normal and 17 G6PD-deficient) were hospitalized and treated with phototherapy or exchange transfusion. Bilirubin levels in G6PD-deficient neonates were somewhat higher compared to G6PD-normal babies (18.8 +/- 2.4 mg/dl [321.5 +/- 41 micromol/l] vs. 15.7 +/- 3.2 mg/dl [268.5 +/- 54.7 micromol/l]; P < 0.05). G6PD activity was significantly lower in G6PD-deficient group than in the normal group (2.1 +/- 0.7 vs. 12.5 +/- 5.0 U/g Hb; P < 0.001).

CONCLUSION

This study shows that the incidence of G6PD deficiency in newborns of Tehran is 2.1%, which is relatively high, and also hyperbilirubinemia and jaundice are approximately 3-fold higher in G6PD-deficient group than in the G6PD-normal group (51% vs. 16%). This emphasizes the necessity of neonatal screening on cord blood samples of both sexes for G6PD deficiency and the need to watch closely for development of hyperbilirubinemia.