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Honbe K, Hayakawa M, Morioka I, Arai H, Maruo Y, Kusaka T, Kunikata T, Iwatani S, Okumura A. Current status of neonatal jaundice management in Japan. Pediatr Int 2023; 65:e15617. [PMID: 37658617 DOI: 10.1111/ped.15617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 06/16/2023] [Accepted: 06/27/2023] [Indexed: 09/03/2023]
Abstract
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.
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Affiliation(s)
- Kazuya Honbe
- Department of Pediatrics, Tosei General Hospital, Seto, Japan
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan
| | - Masahiro Hayakawa
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan
| | - Ichiro Morioka
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Hiroshi Arai
- Department of Pediatric Neurology, Bobath Memorial Hospital, Osaka, Japan
| | - Yoshihiro Maruo
- Department of Pediatrics, Shiga University of Medical Science, Otsu, Japan
| | - Takashi Kusaka
- Department of Pediatrics, Kagawa University School of Medicine, Miki-cho, Kita-gun, Japan
| | - Tetsuya Kunikata
- Department of Pediatrics, Division of Neonatal Medicine, Saitama Medical University Hospital, Moroyama-machi, Iruma-gun, Japan
| | - Sota Iwatani
- Department of Neonatology, Kobe Children's Hospital, Kobe, Japan
| | - Akihisa Okumura
- Department of Pediatrics, Aichi Medical University, Nagakute, Japan
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Nagano N, Katayama D, Imaizumi T, Hijikata M, Okahashi A, Tsuji Y, Morioka I. Fluctuations in unbound bilirubin levels during acetaminophen therapy for patent ductus arteriosus. Pediatr Int 2023; 65:e15434. [PMID: 36478301 DOI: 10.1111/ped.15434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 11/26/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Nobuhiko Nagano
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Daichi Katayama
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Takayuki Imaizumi
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Midori Hijikata
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Aya Okahashi
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Yasuhiro Tsuji
- Center for Pharmacist Education, School of Pharmacy, Nihon University, Funabashi, Japan
| | - Ichiro Morioka
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
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Hegyi T, Kleinfeld A. Neonatal hyperbilirubinemia and the role of unbound bilirubin. J Matern Fetal Neonatal Med 2021; 35:9201-9207. [PMID: 34957902 DOI: 10.1080/14767058.2021.2021177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Neonatal jaundice occurs in more than 80% of newborn infants. Although mild jaundice is physiologic and possibly neuroprotective, severe hyperbilirubinemia can lead to neurologic dysfunction and death. Hyperbilirubinemia is due to an imbalance between bilirubin production and the developing excretory capacity in the first days of life. Management utilizes total serum bilirubin (TSB) levels, although recent advances suggest a role for unbound bilirubin. GOALS The goal of this review is to examine bilirubin biology, toxicology, and clinical effects, discuss preventive and therapeutic measures, describe neurodevelopmental consequences, and propose that, with the advent of new technology, unbound bilirubin is the optimal measurement for the management. METHODS Comprehensive review on neonatal hyperbilirubinemia. RESULTS Neonatal hyperbilirubinemia can be prevented by tin mesoporphyrin to limit heme oxygenase activity, a key enzyme in bilirubin production, or restricting bilirubin's absorption from the gastrointestinal tract. Treatment modalities include removing bilirubin from the body by exchange transfusion, binding to immunoglobulin, or converting it to a water-soluble isomer with phototherapy. While these approaches have evolved during the past decades, the diagnosis, intervention indications, and prognosis have consistently relied on TSB concentration despite its poor ability to predict an outcome. CONCLUSIONS Total serum bilirubin is inadequate to optimize care of the term and preterm infant with hyperbilirubinemia. A rapid, accurate, and more effective indicator of bilirubin neurotoxicity is needed to manage jaundiced infants and for the universal screening of newborn infants. Future measurements of free bilirubin unattached to albumin will improve the management of neonatal hyperbilirubinemia.
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Affiliation(s)
- Thomas Hegyi
- Department of Pediatrics, Division of Neonatology, Robert Wood Johnson Medical School, Rutgers, The State University of New Jersey, New Brunswick, NJ, USA
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Ichimura S, Kakita H, Asai S, Mori M, Takeshita S, Ueda H, Kondo T, Ohashi W, Okumura A, Yamada Y. Acetaminophen elevates unbound bilirubin levels by the glucose oxidase-peroxidase method. Pediatr Int 2021; 63:1069-1074. [PMID: 33464662 DOI: 10.1111/ped.14608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/17/2020] [Accepted: 01/14/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Acetaminophen is widely administered to neonates but its effect on unbound bilirubin (UB) levels remains unclear. The aim of this study was to clarify whether administration of acetaminophen is related to an elevation of UB levels. METHOD Infants with a birthweight of ˂1,500 g admitted to our neonatal intensive care unit between January 2017 and April 2020 were retrospectively reviewed. Seventy-one infants were enrolled, five of whom had received acetaminophen. Clinical data were analyzed when the highest UB value (UB peak) in each infant was recorded. Demographic data and information on treatment within the 24 h before the UB peak were also collected. UB was determined by the glucose oxidase-peroxidase (GOD-POD) method. Infants were categorized according to the presence or absence of acetaminophen administration (acetaminophen and no acetaminophen groups) within 24 h of the UB peak. The relationship between UB values and various clinical variables was then compared. RESULTS Both the peak UB value and the ratio of gastrointestinal disease were higher in the acetaminophen group than in the no acetaminophen group. Univariate analysis revealed that a total of seven variables were potentially correlated with UB peak values (P < 0.10). Multivariate analysis showed that acetaminophen and direct bilirubin were independently associated with UB peak values. CONCLUSION Our study suggests that administration of acetaminophen is related to higher UB levels by the GOD-POD method. UB values measured by the GOD-POD method should not be used in infants treated with acetaminophen for evaluation of bilirubin neurotoxicity avoidance.
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Affiliation(s)
- Shintaro Ichimura
- Department of Perinatal and Neonatal Medicine, Aichi Medical University, Aichi, Japan
| | - Hiroki Kakita
- Department of Perinatal and Neonatal Medicine, Aichi Medical University, Aichi, Japan
| | - Shimpei Asai
- Department of Perinatal and Neonatal Medicine, Aichi Medical University, Aichi, Japan
| | - Mari Mori
- Department of Perinatal and Neonatal Medicine, Aichi Medical University, Aichi, Japan
| | - Satoru Takeshita
- Department of Perinatal and Neonatal Medicine, Aichi Medical University, Aichi, Japan
| | - Hiroko Ueda
- Department of Perinatal and Neonatal Medicine, Aichi Medical University, Aichi, Japan
| | - Tomoko Kondo
- Department of Perinatal and Neonatal Medicine, Aichi Medical University, Aichi, Japan
| | - Wataru Ohashi
- Department of Biostatistics, Clinical Research Center, Aichi Medical University, Aichi, Japan
| | - Akihisa Okumura
- Department of Pediatrics, Aichi Medical University, Aichi, Japan
| | - Yasumasa Yamada
- Department of Perinatal and Neonatal Medicine, Aichi Medical University, Aichi, Japan
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Hegyi T, Kleinfeld A, Huber A, Weinberger B, Memon N, Carayannopoulos M, Oh W. Unbound bilirubin levels in phototherapy-treated preterm infants receiving soy-based lipid emulsion. Pediatr Int 2020; 62:1357-1363. [PMID: 32535983 DOI: 10.1111/ped.14346] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/26/2020] [Accepted: 06/05/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Phototherapy is an effective treatment for neonatal jaundice. Treatment indication uses total serum bilirubin (TSB), although unbound bilirubin (Bf) more accurately predicts disability risk. The goals of this investigation were to examine the response of Bf and TSB to phototherapy in preterm infants, and we hypothesized that (i) TSB and Bf respond differently; (ii) the relationship between TSB and Bf is altered; and (iii) unexpected Bf elevations are found. METHODS One hundred and seventeen preterm infants <2 kg at birth and receiving (IL) were enrolled; and measurements of TSB and Bf were obtained. TSB was measured by the diazo method and Bf with a fluorescent Bf sensor BL22P1B11-Rh. RESULTS Initial mean (± SD) TSB and Bf levels (41.4 ± 6.9 h) were 8.0 ± 9.0 mg/dL and 16.9 ± 12.4 nmol/L (P < 0.05). The rates of rise (ROR) were 0.21 ± 0.10 mg/dL/h for TSB and 0.38 ± 0.33 nmol/L/h for Bf. Phototherapy reduced TSB from 8.0 ± 9.0 to 5.8 ± 9.4 mg/dL (P = 0.068) but Bf did not change (16.9 ± 12.4 to 14.1 ± 9.4 nmol/L P = n.s.). Bf levels were >11 nmol/L in 64, >17 nmol/L in 18, and >22 nmol/L in 7 infants. CONCLUSIONS Bf and TSB responded differently. While TSB and Bf correlated well before phototherapy, they did not correlate during phototherapy. TSB showed a trend toward a reduction with treatment, Bf did not. While TSB ROR information is not helpful, ROR Bf data can be utilized to anticipate treatment. Potentially high Bf levels existed before and after phototherapy and the mean Bf level at phototherapy termination remained elevated in a significant proportion of infants.
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Affiliation(s)
- Thomas Hegyi
- Department of Pediatrics, Robert Wood Johnson Medical School, Rutgers, The State University of NJ, New Brunswick, NJ, USA
| | | | | | - Barry Weinberger
- Division of Neonatal-Perinatal Medicine, Cohen Children's Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
| | - Naureen Memon
- MidAtlantic Neonatology Associates, Morristown, NJ, USA
| | - Mary Carayannopoulos
- Pathology, Robert Wood Johnson Medical School, Rutgers, The State University of NJ, New Brunswick, NJ, USA
| | - William Oh
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, RI, USA
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Iwatani S, Kataoka D, Tamaki S, Yokota T, Yoshimoto S. High prevalence of cholestasis at a tertiary neonatal intensive care unit. Pediatr Int 2020; 62:749-751. [PMID: 32478458 DOI: 10.1111/ped.14180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 01/15/2020] [Accepted: 01/31/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Sota Iwatani
- Department of Neonatology, Hyogo Prefectural Kobe Children's Hospital Perinatal Center, Kobe, Hyogo, Japan
| | - Dai Kataoka
- Department of Neonatology, Hyogo Prefectural Kobe Children's Hospital Perinatal Center, Kobe, Hyogo, Japan
| | - Shoko Tamaki
- Department of Neonatology, Hyogo Prefectural Kobe Children's Hospital Perinatal Center, Kobe, Hyogo, Japan
| | - Tomoyuki Yokota
- Department of Neonatology, Hyogo Prefectural Kobe Children's Hospital Perinatal Center, Kobe, Hyogo, Japan
| | - Seiji Yoshimoto
- Department of Neonatology, Hyogo Prefectural Kobe Children's Hospital Perinatal Center, Kobe, Hyogo, Japan
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TSUJIMAE SAEKO, YOSHII KATSUHIKO, YAMANA KEIJI, FUJIOKA KAZUMICHI, IIJIMA KAZUMOTO, MORIOKA ICHIRO. Hyperbilirubinemia in Term Newborns Needing Phototherapy within 48 Hours after Birth in a Japanese Birth Center. Kobe J Med Sci 2018; 64:E20-E25. [PMID: 30282894 PMCID: PMC6192821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 02/09/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Hyperbilirubinemia in term newborns needing phototherapy within 48 hours after birth, early-onset hyperbilirubinemia, has not been evaluated in recent Japanese healthy birth centers. In this study, we sought to determine the cause of early-onset hyperbilirubinemia in a Japanese healthy birth center and to evaluate the 1992 Kobe University phototherapy treatment criterion requiring total serum bilirubin (TSB) and unbound bilirubin (UB). METHODS In this retrospective observational study, we collected data on newborns diagnosed with early-onset hyperbilirubinemia between 2009 and 2016 at the Chibune General Hospital. Causes of the disease were investigated, as well as which index (TSB or UB) was used for treatment decisions. RESULTS Overall, 76 term newborns were included in the analysis. Twenty-seven newborns (36%) found the cause (ABO blood type incompatibility [n=17, 22%], polycythemia [n=8, 11%], and cephalohematoma [n=2, 3%]). However, 49 newborns (64%) did not find any causes (i.e., idiopathic hyperbilirubinemia). Of these, 27 observed more than 5% weight loss from birth weight. Seventy (92%) newborns had abnormal TSB only, and 5 (7%) had abnormal TSB and UB values. Only 1 (1%) newborn with only abnormal UB values received phototherapy. CONCLUSIONS Altogether, data from this Japanese healthy birth center suggest that many apparently healthy newborns with or without excessive weight loss develop early-onset hyperbilirubinemia. In the 1992 Kobe University phototherapy treatment criterion, TSB, not UB, was the main index used to make treatment decisions in these patients.
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Affiliation(s)
- SAEKO TSUJIMAE
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
- Department of Pediatrics, Chibune General Hospital, Osaka, Japan
| | - KATSUHIKO YOSHII
- Department of Pediatrics, Chibune General Hospital, Osaka, Japan
| | - KEIJI YAMANA
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - KAZUMICHI FUJIOKA
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - KAZUMOTO IIJIMA
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - ICHIRO MORIOKA
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
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Abstract
In 1992, Kobe University proposed treatment criteria for hyperbilirubinemia in newborns using total serum bilirubin and serum unbound bilirubin reference values. In the last decade, chronic bilirubin encephalopathy has been found to develop in preterm infants in Japan because it can now be clinically diagnosed based on an abnormal signal of the globus pallidus on T2-weighted magnetic resonance imaging and abnormal auditory brainstem response with or without apparent hearing loss, along with physical findings of kinetic disorders with athetosis. We therefore revised the Kobe University treatment criteria for preterm hyperbilirubinemic infants in 2017. The three revised points are as follows: (i) newborns are classified under gestational age at birth or corrected gestational age, not birthweight; (ii) three treatment options were created: standard phototherapy, intensive phototherapy, and albumin therapy and/or exchange blood transfusion; and (iii) initiation of standard phototherapy, intensive phototherapy, and albumin therapy and/or exchange blood transfusion is decided based on the total serum bilirubin and serum unbound bilirubin reference values for gestational weeks at birth at <7 days of age, and on the reference values for corrected gestational age at ≥7 days of age. Studies are needed to establish whether chronic bilirubin encephalopathy can be prevented using the 2017 revised Kobe University treatment criteria for preterm infants in Japan.
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Affiliation(s)
- Ichiro Morioka
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan.,Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
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Amin SB, Wang H. Bilirubin Albumin Binding and Unbound Unconjugated Hyperbilirubinemia in Premature Infants. J Pediatr 2018; 192:47-52. [PMID: 29132818 PMCID: PMC5732858 DOI: 10.1016/j.jpeds.2017.09.039] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/12/2017] [Accepted: 09/15/2017] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To evaluate the associations between unbound bilirubin (UB) and total serum bilirubin (TSB), bilirubin:albumin molar ratio (BAMR), and bilirubin albumin binding affinity (Ka) as a function of gestational age (GA) in infants born at 24-33 weeks GA. STUDY DESIGN In a prospective observational study, TSB and UB were measured twice daily at least 8 hours apart during the first postnatal week. Serum albumin was measured to calculate BAMR on each day. The highest UB on each day, corresponding TSB, and serum albumin were used to calculate the Ka on each day. RESULTS For the 166 infants studied, peak UB significantly correlated with concomitant Ka (r = -0.44, P = .001) but not with concomitant TSB or BAMR after adjusting for GA. On multiple regression analyses, there was a significant association of concomitant Ka (-0.06, 95% CI -0.08 to -0.04, P = .0001), but not concomitant TSB or BAMR with peak UB after controlling for GA, birth weight, race, and sex. GA group was a significant effect modifier for the association between Ka and peak UB (0.03, 95% CI 0.02-0.04, P < .001). Interaction analyses showed the association between concomitant Ka and peak UB was significant for the 24-30 weeks GA group infants, but not for the 301/7-33 weeks GA group infants. CONCLUSIONS Peak UB was primarily associated with a decrease in binding affinity in infants ≤30 weeks GA. Interventions aimed at improving binding affinity may be important in decreasing the risk of bilirubin-induced neurotoxicity.
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Affiliation(s)
- Sanjiv B Amin
- Department of Pediatrics, Division of Neonatology, University of Rochester School of Medicine and Dentistry, Rochester, NY.
| | - Hongyue Wang
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry
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Hegyi T, Kleinfeld A, Huber A, Weinberger B, Memon N, Shih WJ, Carayannopoulos M, Oh W. Effects of Soybean Lipid Infusion on Unbound Free Fatty Acids and Unbound Bilirubin in Preterm Infants. J Pediatr 2017; 184:45-50.e1. [PMID: 28108102 PMCID: PMC5403563 DOI: 10.1016/j.jpeds.2016.12.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 11/09/2016] [Accepted: 12/08/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess the effects of a soybean lipid emulsion infusions on levels of unbound (free) bilirubin (Bf) and unbound free fatty acids (FFAu) as well as changes in Bf and total serum bilirubin (TSB) during phototherapy in infants born preterm. STUDY DESIGN Ninety-seven infants born preterm (birth weight: 500-2000 g; gestational age: 23-34 weeks) were enrolled to investigate the effect of 0, 1, 2, and 3 g/kg/d of intralipid infusion on Bf and FFAu. Pre- and postphototherapy TSB, FFAu, and Bf also were analyzed in 91 infants to assess the effects of phototherapy. FFAu levels were measured with the fluorescent probe ADIFAB2 and Bf by the fluorescent Bf sensor BL22P1B11-Rh during intralipid infusion and at start and end of phototherapy. TSB and plasma albumin were measured by the diazo and bromcresol green techniques, respectively. Bilirubin-albumin dissociation constants were calculated based on Bf and plasma albumin. RESULTS Bf and FFAu increased with increasing intralipid dosage across all gestational ages. TSB and Bf were correlated significantly when infants received 0 or 1 g/kg/d of intralipid but not at greater doses of intralipid (2 and 3 g/kg/d). Although phototherapy effectively reduced both TSB and Bf in the total phototherapy group (by 32% and 12%, respectively), it reduced TSB, but not Bf, in infants less than 28 weeks of gestation. CONCLUSIONS Increasing intralipid doses result in increasing FFAu levels, which are associated with increased Bf independent of TSB. In infants born extremely preterm (<28 weeks of gestation), phototherapy effectively reduces TSB but not Bf.
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Affiliation(s)
- Thomas Hegyi
- Department of Pediatrics, Robert Wood Johnson Medical School, Rutgers, The State University of NJ
| | | | | | - Barry Weinberger
- Department of Pediatrics, Cohen Children's Medical Center, New Hyde Park, NY
| | - Naureen Memon
- MidAtlantic Neonatology Associates, Goryeb Children's Hospital, Morristown, NJ
| | - Weichung Joe Shih
- Rutgers School of Public Health, Rutgers University, New Brunswick, NJ
| | - Mary Carayannopoulos
- Department of Pediatrics, Robert Wood Johnson Medical School, Rutgers, The State University of NJ
| | - William Oh
- Department of Pediatrics, Alpert Medical School of Brown University
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Amin SB, Wang H. Unbound unconjugated hyperbilirubinemia is associated with central apnea in premature infants. J Pediatr 2015; 166:571-5. [PMID: 25596965 PMCID: PMC4344891 DOI: 10.1016/j.jpeds.2014.12.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 10/24/2014] [Accepted: 12/02/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate whether jaundice, indexed by unbound bilirubin (UB), is associated with central apnea in premature infants. STUDY DESIGN A prospective observational study was performed with 27-33 weeks' gestational age infants who were not requiring either mechanical ventilation or noninvasive ventilation with continuous positive airway pressure beyond 24 hours after birth. Infants with congenital infections, chromosomal disorders, craniofacial anomalies, and/or family history of hearing loss were excluded. Total serum bilirubin and UB were measured twice daily during the first postnatal week and then when clinically indicated. Central apnea was evaluated by visual inspection of continuous, electronic cardiorespiratory recordings until 2 weeks of age. RESULTS One hundred infants were subdivided into 2 groups via median peak UB level: the high UB group (greater than median) and low UB group (less than median). The high UB group had an increased frequency of apnea events during the first 2 weeks compared with infants in the low UB group. After we controlled for confounders, the high UB group had more events of apnea during the first 2 postnatal weeks compared with the low UB group (incidence rate ratio: 1.9, 95% CI 1.2-3.2). CONCLUSIONS Our findings suggest that jaundice, as indexed by UB, is associated with central apnea in premature infants.
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Affiliation(s)
- Sanjiv B Amin
- Division of Neonatology, Department of Pediatrics, The University of Rochester School of Medicine and Dentistry, Rochester, NY.
| | - Hongyue Wang
- Department of Biostatistics, The University of Rochester School of Medicine and Dentistry
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12
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Abstract
Central apnea, defined as cessation of breathing for ≥20s, is frequent in premature infants born at <34 weeks׳ gestation but uncommon among healthy late preterm (34(0/7)-36(6/7) weeks׳ gestation) and term (≥37 weeks׳ gestation) infants, where it is usually a clinical manifestation of a neurological or metabolic problem. There is growing evidence that marked unconjugated hyperbilirubinemia is associated with central apnea in neonates. This article explores the reported association between acute bilirubin encephalopathy and symptomatic apneic events in newborns and the possible mechanisms involved in the pathogenesis of this phenomenon. The prevalence of symptomatic apneic events in reports of acute bilirubin encephalopathy suggests this clinical finding should be considered a sign of bilirubin neurotoxicity.
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Affiliation(s)
- Sanjiv B Amin
- Division of Neonatal Medicine, Department of Pediatrics, University of Rochester, Rochester, NY
| | - Vinod K Bhutani
- Division of Neonatal and Developmental Medicine, Department of Pediatrics Lucile Packard Children׳s Hospital at Stanford University, Stanford University, Palo Alto, CA
| | - Jon F Watchko
- Division of Newborn Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Magee-Womens Hospital, 300 Halket St, Pittsburgh, PA 15213.
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Ichinomiya K, Inoue F, Koizumi A, Inoue T, Fujiu T, Maruyama K. Problems with using total serum bilirubin as a criterion for phototherapy in extremely low-birthweight infants. Pediatr Int 2014; 56:731-4. [PMID: 24689889 DOI: 10.1111/ped.12351] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 03/12/2014] [Accepted: 03/18/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Despite the early use of phototherapy and exchange transfusion in premature infants based on total serum bilirubin (TSB), the reemergence of kernicterus has been reported. The aim of this study was to assess the validity of using TSB as the criterion for phototherapy in extremely low-birthweight infants (ELBWI). METHODS We reviewed the medical charts of 43 ELBWI admitted to hospital between January 2009 and December 2010, and analyzed the relationship between TSB and unbound bilirubin (UB). RESULTS No infant underwent exchange transfusion or developed acute bilirubin encephalopathy. There was a significant correlation between TSB and UB measured immediately before phototherapy during the first 7 days of life (r = 0.657, P < 0.001), but none thereafter (r = 0.120, P = 0.213). Thirty-seven percent of infants who underwent phototherapy during the first 7 days of life had suprathreshold USB but subthreshold TSB, whereas this rose to 97% thereafter. CONCLUSIONS No correlation was observed between TSB and UB in ELBWI after the first 7 days of life, and almost all phototherapy sessions were initiated based on the UB criterion, even though TSB was below the accepted threshold. UB may be high if jaundice is evaluated solely on the basis of TSB.
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Affiliation(s)
- Kenji Ichinomiya
- Department of Neonatology, Gunma Children's Medical Center, Gunma, Japan
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Abstract
OBJECTIVE The objective of this study was to determine if plasma unbound or 'free' bilirubin concentration (B(f)) measured during the first 30 days of life is associated with subsequent abnormal hearing screening testing by automated auditory brainstem response (AABR) in a diverse population of newborns. STUDY DESIGN An observational study of newborns receiving AABR, plasma total bilirubin concentration (TBC) and B(f) measurements and without underlying conditions known to affect hearing was conducted. Logistic regression was used to determine associations between abnormal AABR and B(f) or TBC. The impacts of a variety of clinical factors on the regression model were also assessed. RESULT A total of 191 patients with birth weights and gestations ranging from 406 to 4727 g and 24 to 42 weeks, respectively, were studied. Among them, 175 (92%) had normal (bilateral PASS) AABR and 16 had abnormal AABR (6 had unilateral REFER AABR, and 10 had bilateral REFER AABR). Mean TBC was not significantly different in babies with normal or abnormal AABR, but mean B(f) was greater in the latter group (1.76 versus 0.93 microg per 100 ml, respectively, P=0.012). B(f), but not TBC, was associated with an abnormal AABR (B(f) adjusted odds ratio 3.3, 95% CI 1.8 to 6.1). Comparing receiver-operating characteristics curves, the B(f)/TBC ratio was a better predictor of an abnormal AABR than B(f) alone. Intraventricular hemorrhage was the only confounding clinical variable. CONCLUSION An abnormal AABR is associated with an elevated B(f) or B(f)/TBC ratio, but not the TBC alone. The prevalence of bilirubin neurotoxicity as a cause of audiological dysfunction may be underestimated if the TBC alone is used to assess the severity of newborn jaundice.
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Ahlfors CE, Vreman HJ, Wong RJ, Bender GJ, Oh W, Morris BH, Stevenson DK. Effects of sample dilution, peroxidase concentration, and chloride ion on the measurement of unbound bilirubin in premature newborns. Clin Biochem 2007; 40:261-7. [PMID: 17069786 PMCID: PMC1945224 DOI: 10.1016/j.clinbiochem.2006.09.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2006] [Revised: 09/07/2006] [Accepted: 09/13/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To assess the effects of sample dilution, peroxidase concentration, and chloride ion (Cl(-)) on plasma unbound bilirubin (B(f)) measurements made using a commercial peroxidase methodology (UB Analyzer) in a study population of ill, premature newborns. DESIGN AND METHODS B(f) was measured with a UB Analyzer in 74 samples at the standard 42-fold sample dilution and compared with B(f) measured at a 2-fold sample dilution using a FloPro Analyzer. B(f) was measured at two peroxidase concentrations to determine whether the peroxidase steady state B(f) (B(fss)) measurements were significantly less than the equilibrium B(f) (B(feq)), in which case it was necessary to calculate B(feq) from the two B(fss) measurements. B(f) was also measured before and after adding 100 mmol/L Cl(-) to the UB Analyzer assay buffer. RESULTS B(feq) at the 42-fold dilution was nearly 10-fold less than but it correlated significantly with B(feq) at the 2-fold dilution (mean 8.2+/-5.2 nmol/L versus 73.5+/-70 nmol/L, respectively, p<0.0001; correlation r=0.6). The two UB Analyzer B(fss) measurements were significantly less than B(feq) in 42 of 74 (57%) samples, and Cl(-) increased B(feq) in 66 of 74 (89%) samples by a mean of 82+/-67%. CONCLUSIONS B(fss) measured by the UB Analyzer at the standard 42-fold sample dilution using assay buffer without Cl(-) and a single peroxidase concentration is significantly less than the B(feq) in undiluted plasma. Accurate B(f) measurements can be made only in minimally diluted serum or plasma.
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