Effect of Oral Zinc Supplementation on Serum Bilirubin Levels in Term Neonates With Hyperbilirubinemia Undergoing Phototherapy: A Double-blind Randomized Controlled Trial

BACKGROUND

Background: Enterohepatic bilirubin circulation is one of the determinants of neonatal jaundice.

OBJECTIVE

To evaluate the role of oral zinc in reducing serum bilirubin in term neonates with hyperbilirubinemia.

STUDY DESIGN

Double-blind, randomized, placebo-controlled trial.

PARTICIPANTS

106 term neonates with jaundice within the phototherapy range admitted to a level III neonatal intensive care unit.

INTERVENTION

Neonates were randomized and allocated to receive either oral zinc sulfate (5 mg/day) or matching placebo for 5 days. Both groups received conventional phototherapy as per American Academy of Pediatrics (AAP) guidelines.

OUTCOMES

Primary: Reduction in total serum bilirubin levels at 24, 48, 72, and 96 hr after intervention. Secondary: Duration of phototherapy, and hospital stay.

RESULTS

The mean (SD) total serum bilirubin levels in zinc and placebo groups were 15.3 (2.85) vs 17.1 (2.21) mg/dL (MD 1.74; P<0.001) at 24 h; 11.7 (4.46) vs. 14.62 (3.83) mg/dL (MD 2.89; P<0.001) at 48 h; 6.7 (4.77) vs 9.5 (3.70) mg/dL (MD 2.79; P <0.001) at 72 h; and 5.1 (3.95) vs 6.5 (3.70) mg/dL (MD 1,49; P=0.045) after 72 hr, respectively. The mean (SD) duration of phototherapy was significantly lower in zinc group than placebo group [ 53.42 (19.62) vs 71.4 (19.43) h; P<0.001]. There was no significant difference in hospital stay between the two groups [mean (SD) 81.05 (19.43) vs 86.25 (20.02) h; P= 0.227].

CONCLUSION

Oral zinc sulfate supplementation at a dose of 5 mg once a day along with phototherapy significantly reduced total and indirect serum bilirubin levels and also reduced the total duration of phototherapy required in the term neonatal hyperbilirubinemia, with minimal or no adverse effects.

Intrapartum Maternal Prophylactic Antimicrobial Treatment and Neonatal Jaundice

Intrapartum antibiotics are widely used and may potentially affect bilirubin levels and neurotoxicity in the newborn. The aim of this study was to examine the effect of intrapartum antibiotic exposure on neonatal jaundice. We retrospectively collected data from 972 neonates born to 963 mothers. Five hundred forty-five mothers (56.6%) received intrapartum antibiotics. There were no statistically significant differences in maximum bilirubin level (7.82 ± 3.65 vs 7.63 ± 3.71, P = .43) or need for phototherapy (9 [1.62%] vs 4 [0.94%], P = .52) between exposed and non-exposed newborns. The rate of phototherapy was significantly higher only in the group of infants born to mothers who received broad-spectrum antibiotics at 2 to 3.9 hours prior to delivery (χ2 = 10.453, P = .015) and was not higher in the group of exposure >4 hours, which may represent a short transient effect of antibiotics exposure on bilirubin turnover. Further studies are needed to validate this finding.

Therapeutic efficacy and safety of Yinzhihuang granules with phototherapy in neonatal pathologic jaundice: An updated systematic review and meta-analysis

BACKGROUND

Yinzhihuang granule, consisting of extracts of Artemisia capillaris Thunb., Gardenia jasminoides Ellis, Lonicera japonica Thunb., and Scutellaria baicalensis Georgi is a well-known traditional Chinese patent medicine for patients with liver injury in China. However, the effects and safety of its use for pathologic jaundice in newborns require further systematic evaluation.

PURPOSE

To systematically evaluate the efficacy and safety of Yinzhihuang granules for the treatment of neonatal pathologic jaundice and to provide clinical evidence.

METHODS

Chinese databases (China Network Knowledge Infrastructure, Wan Fang Database, and VIP Database) and English databases (PubMed, EmBase, and the Cochrane Library) were thoroughly investigated through screening randomized controlled trials on Yinzhihuang granules for neonatal pathologic jaundice from the establishment of all databases to November 18, 2021. A meta-analysis was performed for selected data using STATA software. TSA software was used for trial sequential analyses of the total effective rate and adverse reactions.

RESULTS

A total of 19 trials and 2,221 newborns with pathologic jaundice were included in this study. Outcome measures of clinical efficacy in the experimental group were higher than in controls, including total bilirubin (WMD = -30.34, 95% CI = -35.44 to -25.23, p < 0.001), direct bilirubin (WMD = -15.03, 95% CI = -23.54 to -6.52, p < 0.001), indirect bilirubin (WMD = -11.22, 95% CI = -17.50 to -4.95, p < 0.001), recovery time (WMD = -2.96, 95% CI = -3.92 to -2.00, p < 0.001), hospitalization time (WMD = -3.83, 95% CI = -4.89 to -2.76, p < 0.001), and liver function indices. There were statistically significant differences between the two groups. Likewise, the incidence of adverse reactions, including diarrhea, erythra, and fever decreased remarkably in the trial group (RR = 0.44, 95% CI =  0.33 to 0.59, p < 0.001). Publication bias did not exist. We verified the efficacy and safety of Yinzhihuang granules with phototherapy for pathologic jaundice in newborns according using TSA analysis.

CONCLUSION

Yinzhihuang granules with phototherapy for neonatal pathologic jaundice are more effective than phototherapy alone. The incidence of ADRs does not increase with the application of Yinzhihuang granules. Due to the heterogeneity across the included studies, additional multicenter clinical trials with follow-ups are needed to confirm our findings.

Ethnomedicine for neonatal jaundice: A cross-sectional survey in Qom, Iran

ETHNOPHARMACOLOGICAL RELEVANCE

Traditional Medicine (TM) is popularly used for neonatal jaundice in Iran.

OBJECTIVE

to provides evidence for characteristics of traditional medicine use in the treatment of neonatal jaundice in Qom, Iran.

MATERIALS AND METHODS

Field surveys were carried out during July 2015 - August 2015 in Qom through structured questionnaire in Persian from 212 parents of children with neonatal jaundice. All plant species recorded for the treatment of neonatal jaundice were sampled. Samples were identified by a botanist and obtained a voucher specimens number and deposited in the Shiraz School of Pharmacy Herbarium. The information such as scientific name, family, local name, parts used and preparation method were provided. The Use Value (UV), Frequency of Citation (FC), Relative Frequency of Citation (RFC) and Relative Family Importance Value (FIV) are also calculated.

RESULTS

In total, 165 (78%) of participants reported the use of traditional methods for their neonates. The use of herbal remedies was the most popular form of these traditional interventions. A total of 8 plant species belonging to 7 families were identified. Cotoneaster nummularioides Pojark. Cichorium intybus L. Alhagi maurorum Medik. Descurainia sophia (L.) Webb ex Prantl were most frequent herbs used by neonates and their feeding mother to treat jaundice. Manna was the most popular plant part and distillation and soaking were most frequent preparation methods in these patients. The use of TM in these patients is associated with their previous experience on TM use and their view on its potential risk.

CONCLUSIONS

This study provided information on the prevalence, associated factors and characteristics of traditional medicine use along with ethnomedicinal knowledge from Qom in Iran on neonatal jaundice.

[An alternative method of treatment for the icteric-anemic form of neonatal iso-immunization to rhesus factor]

Neonatal iso-immunization to rhesus factor is a rather well studied pathology. Negative rhesus factor in a pregnant women is a ground to determine anti-D-antibody titers during pregnancy, which allows one to define the tactics of pregnancy management and neonatal treatment just after birth.

Gemfibrozil in late preterm and term neonates with moderate jaundice: a randomized controlled trial

OBJECTIVE

To determine, if oral Gemfibrozil is effective in decreasing the duration of phototherapy by at least 24 hours in neonates >34 weeks gestation with non-hemolytic jaundice, as compared to placebo.

DESIGN

Double blind placebo controlled randomized controlled trial.

SETTING

Tertiary care neonatal unit in north India.

SUBJECTS

Ninety seven neonates >34 weeks gestation with non-hemolytic jaundice within first 7 days of life requiring phototherapy.

INTERVENTION

Two doses of Gemfibrozil (60 mg/kg/dose) or placebo, 12 hours apart. Babies were treated with single surface special blue light phototherapy. Serum total bilirubin (STB) was measured 8 hourly. Phototherapy was stopped if two consecutive STB values were below phototherapy zone.

PRIMARY OUTCOME MEASURE

Duration of phototherapy.

RESULTS

The median (IQR) duration of phototherapy was 40 (30, 60) hours in Gemfibrozil and 36 (19, 55) hours in the placebo group (P=0.13). The peak STB levels were 16.8 +/- 2.7 mg/dL and 16.3 +/- 2.3 mg/dL in Gemfibrozil and placebo groups, respectively. No side effect of the drug or placebo was noticed.

CONCLUSION

Two doses of gemfibrozil (60 mg/kg/dose) given 12 hours apart were not able to reduce the duration of phototherapy, or peak bilirubin level in babies > 34 weeks gestation with non-hemolytic jaundice in the first week of life. Gemfibrozil was not associated with any side effects.

Role of bilirubin as antioxidant in neonatal jaundice and effect of ethanolic extract of sweet lime peel on experimentally induced jaundice in rat

Bilirubin above a threshold level is toxic to human system and is excreted in urinary and through gastrointestinal tract. The role of bilirubin as antioxidant is debatable. This paper aims at elucidating the role of bilirubin as an antioxidant in neonatal jaundice patients. It is observed that bilirubin up to 6 mg/dl in blood acts as an antioxidant and above 12.5 mg/dl is strongly prooxidant. Phototherapy is the accepted therapeutic management of neonatal jaundice and has been shown to enhance the oxidative stress. Approaches have been taken to formulate a herbal medication which will reduce bilirubin level in the neonates without inducing additional damages. The ethanolic extract of sweet lime peel, administered orally at a dose of 72 microg is found to reduce the oxidative stress in erythrocytes of phenylhydrazine-induced jaundiced rats treated with phototherapy.

Efficacy of clofibrate on severe neonatal jaundice associated with glucose-6-phosphate dehydrogenase deficiency (a randomized clinical trial)

Glucose-6-phosphate dehydrogenase (G6PD) deficiency may cause severe hyperbilirubinemia with bilirubin encephalopathy unless intervention is initiated. The aim of this study was to assess the efficacy of clofibrate in full term G6PD deficient neonates with jaundice. A randomized clinical trial study was performed in two groups of full-term G6PD deficient jaundiced neonates (clofibrate treated group, n = 21; control group, n = 19). Infants in the clofibrate group received a single oral dose of 100 mg/kg clofibrate, whereas control group received nothing. Both groups were treated with phototherapy. Serum total and direct bilirubin levels were measured at the onset of treatments, 16, 24 and 48 hours later. On enrollment, the mean total serum bilirubin (TSB) level in the clofibrate treated group was 18.40 +/- 2.41 and in the control group was 17.49 +/- 1.03 (p = 0.401). At 16, 24 and 48 hours of treatment, the mean TSB in the clofibrate group were 15.2 +/- 1.9, 12.6 +/- 2.4, and 10.1 +/- 2.4 and in the control group were 16.5 +/- 1.2, 13.3 +/- 2.2 and 11.4 +/- 2.4, respectively (p = 0.047). At 48 hours, 7 (33%) cases in the clofibrate group and one (5%) case in the control group were discharged with a TSB < 10 mg/dl (p = 0.031). No side effects were observed on serial examinations during hospitalization, or on the 1st and 7th days after discharge. The results show that clofibrate induces a faster decline in serum total bilirubin level, a shorter duration of phototherapy, and hospitalization with no side effects in full-term G6PD deficient neonates with jaundice.

[Clinical study of early interventions for ABO hemolytic disease of the newborn]

OBJECTIVE

To investigate therapeutic effect of high-dose intravenous immunoglobulin (IVIG) for early management of ABO hemolytic disease of the newborn (ABO-HDN).

METHODS

A total of 121 cases with ABO-HDN were randomly divided into treatment group (n=61) and control group (n=60). In addition to the routine treatment of the control group, IVIG were given at a daily dose of 400 mg/kg to the cases in the treatment group for 2-3 times, and therapeutic effects were evaluated and compared between the two groups.

RESULTS

The serum total billirubin concentration on the third day after treatment (153.42-/+45.21 micromol/L) and mean daily serum total billirubin concentration reduction (56.49-/+24.05 micromol/L) in treatment group were lower than those in the control group (P<0.01). The jaundice resolution time (23.51-/+11.19 h) and the phototherapy time (3.01-/+0.89 h) for billirubinemia treatment in treatment group were shorter than those in the control group (P<0.01). The patients in the the treatment group had higher hemoglobin level after treatment (15.59-/+2.01 g/L) than those of the control group (P<0.01).

CONCLUSION

High-dose IVIG can effectively arrest the progression of hemolytic disease, quickly reduce serum total billirubin concentration and shorten phototherapy time for early treatment of ABO-HDN.

Systemic effects of orally-administered zinc and tin (IV) metalloporphyrins on heme oxygenase expression in mice

Some metalloporphyrins (Mps) inhibit heme oxygenase (HO), the rate-limiting enzyme in the production of bilirubin, and are potential compounds for the treatment of neonatal jaundice. We studied the safety and efficacy of Mps following oral administration. Adult HO-1-luc reporter mice were administered 30 micromol/kg body weight of tin mesoporphyrin (SnMP), zinc bis glycol deuteroporphyrin (ZnBG), or zinc protoporphyrin (ZnPP), or vehicle by oral gavage. Bilirubin production was measured as total body carbon monoxide (CO) excretion (VeCO). HO activity was quantitated via CO measurements by gas chromatography. HO-1 protein was determined by Western blot. HO-1 transcription levels were assessed by in vivo bioluminescence imaging. A significant 28% decrease in bilirubin production occurred within 3 h of SnMP treatment and persisted beyond 48 h. Bilirubin production decreased 15% and 9% by 3 h after administration of ZnBG and ZnPP, respectively, but returned to baseline within 48 h. Maximal inhibition of liver, spleen, and intestine HO activity was seen at 3 h with inhibitory effects decreasing in the order: SnMP > or = ZnBG > or = ZnPP. After SnMP treatment, HO-1 transcription increased 5.7-fold after 24 h. Furthermore, liver and spleen HO-1 protein significantly increased 3.7- and 2.0-fold, respectively, after 24 h. HO-1 transcription and protein were not affected in ZnBG- or ZnPP-treated mice. We conclude that the three Mps are absorbed at different rates in the mouse and affect bilirubin production and HO-1 expression in a tissue- and time-dependent manner.

Extreme hyperbilirubinemia in newborn infants

This study was undertaken to determine the frequency and investigate the etiology of extreme hyperbilirubinemia (total serum bilirubin [TSB]>or=25 mg/dL [428 micromol/L]) in newborns admitted to a neonatal intensive care unit in southern Turkey. The charts of 93 term and near-term infants admitted with TSB levels of 25 mg/dL (428 micromol/L) or greater in the first 30 days after birth were retrospectively reviewed. During the 4.5-year study period, 774 infants were admitted to our unit with neonatal jaundice. Ninety-three (12%) of these infants had TSB levels of 25 mg/dL (428 micromol/L) or greater. The mean TSB level in the 93 cases was 30.1+/-5.7 mg/dL (514.7+/-97.5 micromol/L), and the peak levels ranged from 25.0 to 57.4 mg/dL (428-981.5 micromol/L). Thirty-three (35.5%) of the 93 babies had TSB levels of 30 mg/dL (513 micromol/L) or greater. Eighty-nine of 93 infants were being exclusively breast-fed. Nineteen babies were isoimmunized, 7 were bacteremic, 2 of the 39 babies tested for glucose-6-phosphate dehydrogenase had this enzyme deficiency, and 1 of the 71 infants tested for thyroid function had hypothyroidism. No cause for extreme hyperbilirubinemia was found in 61 (65.6%) cases.

Hemolytic disease of the newborn due to anti-Dib: a case study and review of the literature

BACKGROUND

The severity of hemolytic disease of the newborn (HDN) due to Diego(b) (Di(b)) mismatch ranges from no symptoms to severe jaundice that requires exchange transfusion (ET). The clinical significance of anti-Di(b) is incompletely recognized.

CASE REPORT

A male newborn, referred with jaundice, was revealed to have HDN due to Di(b) mismatch and was treated successfully with phototherapy and high-dose intravenous gamma globulin (IVGG).

STUDY DESIGN AND METHODS

The literature of HDN caused by Di(b) mismatch was reviewed. The cases were classified into three groups according to their severity: the mildest needed no therapy (NO), the moderate group received phototherapy alone (PHOTO), and the most severe was treated with ET and/or high-dose IVGG therapy plus phototherapy (ET/IVGG).

RESULTS

Among 27 cases of HDN due to Di(b) reported to date, 10, 6, and 11 cases required NO, PHOTO, and ET/IVGG, respectively. A significant correlation (p < 0.01) was found between the maternal anti-Di(b) titer and the severity of the disease when the ET/IVGG group was compared with the NO group. All mothers of the group that needed ET/IVGG had an anti-Di(b) titer of 64 or greater.

CONCLUSION

A maternal high titer (> or =64) of anti-Di(b) is associated with a higher risk of severe hyperbilirubinemia for mismatched newborns.

The use of riboflavin and metalloporphyrins in cytochrome P-450 content in Wistar rats

Phototherapy is commonly used for the treatment of neonatal jaundice. Riboflavin is a photosensitizer that generates singlet oxygen, which promotes bilirubin photodecomposition. Metalloporphyrins are also effective photosensitizers. The effect of a combined dosing regimen of riboflavin and metalloporphyrins was studied, with the aim of increasing the efficiency of the phototherapeutic treatment of hyperbilirubinemia. It was envisaged that riboflavin and the metalloporphyrins, by promoting the photodecomposition of bilirubin, would thereby lead to a reduction of the toxic side effects associated with phototherapy. The results shows that a phototherapeutic treatment, in which riboflavin and metalloporphyrins were co-administered, was effective in reducing Heme Oxygenase activity. However, a comprehensive study of the possible side effects of metalloporphyrin treatment in the wavelength under consideration is essential prior to utilizing these compounds for any clinical applications.

[Clinical study on effect of tuihuan decoction rectoclysis in hyperbilirubinemia of newborn]

OBJECTIVE

To study the therapeutic effect and feasibility of rectoclysis with Tuihuang decoction (RTD) in treating hyperbilirubinemia of newborns.

METHODS

One hundred and seventy-five newborns with hyperbilirubinemia were randomly divided into the treated group and the control group. They were treated with western medicine plus double faced blue treatment while the treated group were given RTD additionally. Blood bilirubin was detected by micro-bilirubin detector daily during the treatment course. The time of jaundice regression, the speed of blood bilirubin reducing, liver function, and condition of rebounding were observed.

RESULTS

The 7-day curative rate of jaundice in the treated group was superior to that in the control group, showing significant difference (P < 0.05). The average speed of blood bilirubin reducing daily in the treated group was quicker than that in the control group (P < 0.01). The improvement of liver function, such as AST, ALT and gamma-GT in the treated group was superior to that in the control group (P < 0.01). Rebound rate of blood bilirubin in the control group was significantly higher than that in the treated group (P < 0.05).

CONCLUSION

RTD is an ideal therapy for treatment of hyperbilirubinemia of newborn, it shows obvious clinical efficacy and can effectively prevent the rebound of blood bilirubin.

Metalloporphyrins for the treatment of neonatal jaundice

PURPOSE OF REVIEW

To evaluate the safety and efficacy of metalloporphyrins for the treatment of neonatal hyperbilirubinemia.

RECENT FINDING

Since the 1980s and 1990s, there have been no publications on trials to determine the efficacy of metalloporphyrins in the treatment of neonatal jaundice. In the past year, a single case report was presented on the compassionate use of tin mesoporphyrin in a very low birth weight infant with intrauterine growth retardation who did not respond to phototherapy. Subcutaneous administration of a single dose of tin mesoporphyrin at 46 hours of life was associated with a greater than 25% reduction in serum bilirubin. This further supports existing evidence that tin mesoporphyrin is efficacious in lowering bilirubin production. In the laboratory, most metalloporphyrins were shown to induce heme oxygenase, and in addition, metalloporphyrins modulate cardiac cell function in vitro. These observations suggest that the therapeutic benefits may be obviated if such considerations hold true in humans.

SUMMARY

Recent case reports and previous evidence from larger clinical trials conducted in Greece and Argentina in the 1980s and 1990s demonstrate that tin mesoporphyrin is useful in the treatment of neonatal jaundice. Its long-term safety is not well understood but will be important to determine, before its widespread or prophylactic use in neonates with hyperbilirubinemia can be recommended.

Recent advances in the pharmacotherapy for hyperbilirubinaemia in the neonate

Jaundice is a common cause for diagnostic works-up and therapeutic intervention in neonates. This is motivated by the risk for severe neurological sequelae (kernicterus). The mainstays of treatment for the past decades have been exchange transfusion and phototherapy. Exchange transfusion is now becoming rare due to immune prophylaxis in Rhesus-negative women, and treatment of sensitised infants with intravenous immunoglobulin. Several different pharmacological approaches have been studied as far as the treatment of neonatal jaundice. Of these, the focus of attention in recent years has been on the haem oxygenase inhibitors (metal meso- and protoporphyrins). These are effective inhibitors of bilirubin production and have been shown to significantly reduce peak serum bilirubin levels in several clinical trials, both when used prophylactically and therapeutically. However, questions remain regarding long-term safety, as well as the advisability of whole-scale inhibition of bilirubin production. Nevertheless, in selected infants with a high risk of severe jaundice, the use of haem oxygenase inhibitors may be acceptable. Pharmacotherapy in jaundiced infants is fraught with risks, as many drugs may increase the entry of bilirubin into the brain and presumably, the risk for neurotoxicity. Both the displacement of bilirubin from its albumin binding and interference with the function of phosphoglycoprotein in the blood-brain barrier are documented mechanisms in this respect.

Effect of clofibrate in jaundiced term newborns

OBJECTIVE

Clofibrate is a glucuronosyl transferase inducer that has been proposed to increase the elimination of bilirubin in neonates with hyperbilirubinemia. The aim of this study was to characterize the therapeutic effect of clofibrate in neonates born at full term and present with non-hemolytic jaundice.

METHODS

A clinical controlled study was performed in two groups of healthy full term neonates. Thirty neonates were treated with a single oral dose of clofibrate (100 mg/kg) plus phototherapy (clofibrate-treated group) while another 30 neonates (control group) received only phototherapy.

RESULT

The mean plasma total bilirubin levels of 12th, 24th and 48th hours were significantly lower in the clofibrate-treated group as compared with the control group (P < 0.0001, P < 0.0001 and P = 0.004, respectively). Treatment with clofibrate also resulted in a shorter duration of jaundice and a decreased use of phototherapy (P < 0.0001). No side effects were observed.

CONCLUSION

Although other pharmacological agents such as metalloporphyrins and Sn-mesoporphyrin also seem to be effective in decreasing bilirubin production, these products are not available for routine use and cannot be used because the safety of these drugs has to be confirmed prior to their widespread use. Therefore, clofibrate is now the only available pharmacological treatment of neonatal jaundice.

Tin-mesoporphyrin in the treatment of severe hyperbilirubinemia in a very-low-birth-weight infant

Tin-mesoporphyrin (SnMP) is a competitive inhibitor of microsomal heme oxygenase (the rate-limiting enzyme in the heme catabolic pathway). It was administered as a single intramuscular dose at 46 hours of life to a very-low-birth-weight infant with severe hemolytic hyperbilirubinemia who had been awaiting an exchange transfusion. This case documents the effective elimination of the need for an exchange transfusion in a very-low-birth-weight infant and is a confirmation of the experience of others for the use of SnMP in reducing bilirubin production.

Pharmacological interventions for the treatment of neonatal jaundice

In the neonate, hyperbilirubinaemia is usually due to a combination of an increased bilirubin load and decreased bilirubin elimination. Despite an understanding of the enzymatic pathways leading to bilirubin production and elimination, very few pharmacological interventions to prevent hyperbilirubinaemia are utilized and the mainstay of treatment remains phototherapy. Previously studied pharmacological agents such as D-penicillamine, phenobarbital and clofibrate may yet prove useful. Recent clinical trials using metalloporphyrins to inhibit heme catabolism and bilirubin production provides a novel pharmacological intervention for the treatment of neonatal jaundice. The safety and efficacy of these therapies will need to be confirmed prior to widespread use.

Neonatal jaundice--traditional Chinese medicine approach

Herbal treatment of neonatal jaundice (NNJ) has been practiced in China for a long time. Even to-date, a variety of herbal items, including "Yin-chin" (Artemisia), "Huang-qin" (Scutellaria), "Da-huang" (Rheum officinale), "Gan-cao" (Glycyrrhiza), and "Huang-lin" (Coptis chinesis), are still being prescribed to jaundiced infants, often in combination with modern treatment such as phototherapy and exchange transfusion. Their efficacy has, however, not been tested by properly conducted randomised controlled trial. On the other hand, exposure to herbs either before or after birth has been suspected to be a cause of hemolysis and jaundice in the newborns. It is also widely believed in the Chinese community that a number of herbal items are hemolytic agents in infants deficient in the enzyme glucose-6-phosphate dehydrogenase (G6PD). The belief is so deep rooted that each infant detected to have G6PD deficiency by neonatal cord blood screening is given a G6PD deficiency alert card, which states that the child must avoid these herb items for life. In a cohort of 1008 mother-infant pairs, however, we have previously shown that there was no association between maternal herb consumption during pregnancy and the incidence or severity of neonatal hyperbilirubinemia in their offsprings, including those who were deficient in G6PD. A thorough search of medical literature also fails to detect any evidence that any of the herbs stated in the G6PD deficiency alert card causes hemolysis in G6PD-deficient subjects. Thus, there are many misunderstandings and unsubstantiated beliefs about the relationship between herbal medicine and NNJ. Given the potential usefulness of Chinese traditional medicine, which has been practiced for almost 3000 years and is still gaining momentum in the modern days, extensive scientific studies to determine the therapeutic efficacy and potential harmful effects of the various herbal items are warranted.

Exchange transfusion treatment in a newborn with phenobarbital intoxication

A comatose, 14-day-old boy was referred to our emergency department (ED) after an overdose of phenobarbital, which was used for the treatment of long-standing jaundice. Plasma phenobarbital concentration was 112.4 microg/ml before treatment. One hour after giving albium transfusion, an exchange transfusion, which took about 45 minutes, was performed. Volume of exchange was 400 ml (volume of exchange (ml) = 2 x 85 ml/kg). After the exchange transfusion, the phenobarbital concentration decreased to 50.84 microg/ml. At clinical and laboratory follow-up, the patient recovered fully. This case suggests that exchange transfusion is an effective and successful treatment for phenobarbital intoxication in newborn.

[Pharmacologic treatment of neonatal jaundice. A new approach]

Pharmacological treatment of neonatal jaundice is again topical. At the beginning of the eighties, clofibrate was added to phenobarbital which was difficult to use and inefficient. Clofibrate is a better enhancer of glucuronosyl transferase induction than phenobarbital and causes 100% increase of hepatic bilirubin clearance within 6 hours. In the treatment of early jaundice in full term neonate, it significantly reduces bilirubinemia in 16 hours, and decreases the intensity and duration of jaundice and also phototherapy requirement. At the end of the eighties, new molecules inhibiting hepatic production of heme to bilirubin, like metalloporphyrins, were introduced. These molecules block the transformation of heme to biliverdin and bilirubin. Among them, the Sn-mesoporphyrin seems to have the best efficacy when used prophylactically in premature infants between 30 and 36 weeks of gestational age, and also curatively in full-term neonates, with minimal side effects. However the product is not yet manufactured and can not be used in pediatrics practice. Therefore clofibrate represents the only pharmacological treatment of neonatal jaundice actually available.

Tin-metalloporphyrins: an answer to neonatal jaundice?

Hyperbilirubinemia is a common problem, affecting 45-60 percent of term infants and up to 80 percent of premature neonates. Phototherapy, the standard treatment for neonatal hyperbilirubinemia, is effective but has the potential for adverse effects. Prevention of bilirubin formation, rather than dependence on therapeutic measures to remove excess bile pigment, is a logical alternative. Metalloporphyrins--specifically tin-protoporphyrin (SnPP) and tin-mesoporphyrin (SnMP)--are being used experimentally to prevent and treat neonatal hyperbilirubinemia. This article reports the findings of studies exploring the use of SnPP and SnMP.

Current drug treatment options in neonatal hyperbilirubinaemia and the prevention of kernicterus

Neonatal jaundice is a frequent problem in neonatology, but the advent of phototherapy which has simplified its treatment, it no longer represents a major concern. Early hospital discharge of neonates has now resulted in a re-emergence of kernicterus. Neonatal jaundice is principally the result of a transient deficiency of bilirubin conjugation, of a partial deficiency of hepatic bilirubin uptake and intracellular transport and of an increased enterohepatic circulation of the pigment. The fact that bilirubin production in the neonate is 2 or more times greater than in the adult per kilogram of bodyweight represents the mainstay of this condition. Prevention of kernicterus in full term infants is based on the detection of neonates at risk for developing hyperbilirubinaemia, and can be accomplished with simple tests performed on umbilical cord blood such as blood type, Rh, Coombs' test and glucose-6-phosphate dehydrogenase, in order to detect haemolytic diseases. The daily evaluation of transcutaneous bilirubin measurement gives additional information on the rise of serum bilirubin level, and can help to distinguish physiological from nonphysiological hyperbilirubinaemia. A significant hyperbilirubinaemia is more frequent in infants born before term, and in neonates who do not feed well and lose more than 10% of bodyweight. In preterm infants the typical clinical feature of kernicterus is seen very rarely, and kernicterus is now a very infrequent postmortem observation. Since it is very difficult to distinguish the effects of bilirubin from other potentially toxic factors, it is difficult to give guidelines for the treatment of jaundice in very low birthweight infants other than to keep the serum bilirubin levels to a lower level than in full term infant (e.g. 10 mg/dl lower than in full term babies). The intramuscular administration of a single dose of Sn-mesoporphyrin (6 mumol/kg bodyweight) in healthy term or near-term infants seems to be a promising treatment modality for controlling hyperbilirubinaemia.

Treatment of obstructive jaundice in erythroblastosis fetalis with ursodeoxycholic acid (UDCA): a case report

OBJECTIVE

To report a significant improvement of direct hyperbilirubinemia values, in an infant with cholestasis secondary to erythroblastosis fetalis, after treatment with ursodeoxycholic acid (UDCA).

STUDY DESIGN

Case report.

RESULTS

A full term infant, with total and direct bilirubin values of 26 mg/dl (445 micromol/l) and 24.5 mg/dl (419 micromol/l), respectively, on the third day of life, had total and direct bilirubin values of 8.2 mg/dl (140 micromol/l) and 6.9 mg/dl (118 micromol/l), respectively, after 2 days of treatment with UDCA. Because the natural course of this cholestasis takes several weeks to resolve, the observed improvement is highly suggestive of a direct effect of UDCA on the disease course.

CONCLUSION

This treatment may add a new therapeutic option to the limited measures available for this condition, although further studies regarding safety and its mechanism of action are needed before it can be routinely recommended.

[The Amben correction of disorders in the intestinal microbial colonization of newborn infants with perinatal pathology]

The examination of 49 newborn infants revealed that at the early neonatal period the character of the microbial colonization of the intestine depended on the kind of perinatal pathology: in lesions of the central nervous system and conjugation jaundice the deficiency of Bifidobacterium and Escherichia was detected; in hemolytic disease opportunistic bacteria were dominant simultaneously with the deficiency of lactoflora. The study of these infants, divided into two groups differing in the administration of Amben (an inhibitor of proteolytic enzymes), showed the efficiency of Amben which stimulated the growth and development of resident microflora in the intestine, thus contributing to the maintenance of eubiosis in a given group of infants with perinatal pathology.

[A clinical study on the effect of kaisailu on alleviating neonatal jaundice]

The effects of kaisailu defecation on alleviating neonatal jaundice were studied. 203 case of newborns fed with total mother breast milk were divided into two groups: experimental group (100 cases) received routine treatment and kaisailu (10 ml per rectum) control group (103 cases) only received routine treatment. The findings were as follows: excretory time of meconium in experimental group was more ahead than that in control group; the excretory meconium volume of the first time was obviously higher in experimental group; time of meconium changed yellow was distinctly shorter and the bilirubin index (measured by transcortical bilirubin method) lowered more rapidly in experimental group than that in control group. The results suggested that kaisailu defecation can alleviate neonatal jaundice.

Traditional Chinese medicine and treatment of neonatal jaundice

OBJECTIVE

Treatment with herbs may increase the risk of neonatal jaundice (NNJ). It is logical to look into the current practice in some hospitals in China where herbs are being used in the treatment of NNJ. It is also the purpose of this study to find out the chemical constituents and actions of the herbs, and the rationale of the treatment.

METHODS

Twenty reports, from 1973 to 1989, from different parts of China, come in a published book and the paediatric journals written in the Chinese language. The Zhong Yao Da Zi Dian, an encyclopedia of Chinese materia medica, and other books on the pharmacology and applications of Chinese materia medica were also referred to in the study.

FINDINGS

Yin-chen (oriental wormwood or Artemisia) was the most commonly used herbs for NNJ (95%). Others were Da-huang (rhubarb or Rheum officinale), Huang-qin (skullcap root or Scutellaria), Gan-cao (licorice or glycyrrhiza) and Huang-lian (goldthread rhizome or Copts chinesis). Huang-lian, which contains the alkaloid berberine, was used in 4 centers (20%). Berberine can cause severe acute hemolysis in babies with G6PD deficiency. Currently, Yin-chen comes as a decoction Artemisia composita and an intravenous preparation. These preparations have potential central nervous system and cardiovascular toxicities.

CONCLUSIONS

Chinese herbs have many pharmacological substances and therefore multiple actions. In recent years, Chinese herbs are used in conjunction with "Western" drugs, rendering the study of the effects of herbs on NNJ extremely difficult. The efficacy and safety of phototherapy for NNJ have been firmly established, thus diminishing the need for drug treatment. What is the present day role, therefore, of herbal medicine for NNJ? Is there a place for further research of these herbal medicines?

Visual evoked potential abnormalities in jaundiced Gunn rats treated with sulfadimethoxine

The manifestations of bilirubin encephalopathy include disturbances in the visual pathway (visual gaze paralysis and distorted visual perception). In the young jaundiced Gunn rat (jj) model of hyperbilirubinemia, significant differences in visual evoked potential (VEP) patterns have been recorded during development. In the present study, the effects of sulfadimethoxine (SDM) on VEP and electroretinogram (ERG) were examined in 3-wk-old jj rats. This drug displaces bilirubin from its albumin binding sites in the circulation, shifting it into tissues including the brain. Marked latency prolongations (11-20%) and reduced amplitudes (20-64%) were observed in the different wave components of the VEP. These changes were evident as early as 2 h after injection of the drug and persisted thereafter for another 4 h. On the other hand, ERG changes (significant prolongation of wave b) became apparent in these animals only 6 h after SDM injection. These results suggest that, although some changes in the retina may occur after a massive entry of bilirubin into the nervous system, the primary damage in the visual pathway after bilirubin exposure is probably beyond the retina.

[Pharmacokinetics of clofibrate in jaundiced newborn infants at term]

BACKGROUND

Clofibrate (CFB) has been proposed to increase elimination of bilirubin in neonates with hyperbilirubinemia. Nevertheless, its disposition, at this age, remains unknown. The aim of this work was to characterize pharmacokinetics of an oil formulation of CFB in neonates at term with jaundice.

PATIENTS AND METHODS

Two groups (G1 and G2) of eight neonates, presenting with jaundice, entered an open, non randomized and comparative study. Five blood samples were collected over 50 hours following a single oral administration of 100 mg/kg or 50 mg/kg CFB, respectively, in G1 and G2. Serum concentrations of both CFB and clofibric acid (CFA) were measured by HPLC and the pharmacokinetic analysis was made by a non-compartmental method. Data were compared to those obtained in adults receiving 2 g dose of CFB.

RESULTS

Tolerance to the treatment was excellent. Pharmacokinetic profiles were similar in both groups of infants. There was a slow and prolonged formation of CFA whose serum concentrations remained high 50 hours after drug administration. Non-hydrolyzed CFB was found in the blood of three neonates. Elimination of CFA was prolonged corresponding to a terminal half-life (t1/2m) often above 100 hours and sometimes incalculable. MRTo-->50 (h) was similar in both groups (ie 26.2 +/- 2.0 vs 25.5 +/- 1.3, respectively). The decrease of t1/2m was related to the decrease of the clearance of CFA.

CONCLUSIONS

The decrease in CFB's metabolism in newborns is probably the result of at least two concurrent phenomenons: partial hydrolysis of CFA, especially at high doses, and decrease in the hepatic capacity to conjugate the active metabolite. A single oral administration of 50 mg/kg CFB seems to be a suitable schedule.

Direct comparison of Sn-mesoporphyrin, an inhibitor of bilirubin production, and phototherapy in controlling hyperbilirubinemia in term and near-term newborns

BACKGROUND

Sn-mesoporphyrin (SnMP) is a potent inhibitor of bilirubin production. In our previous studies a single dose (6 mumol/kg birth weight) significantly moderated hyperbilirubinemia and reduced phototherapy (PT) time by > 75% when administered within 24 hours of birth to preterm infants.

OBJECTIVE

To directly compare the efficacy of SnMP and PT for controlling hyperbilirubinemia in term and near-term infants.

METHODS

Two randomized, sequentially analyzed trials (Study I: male term infants; Study II: infants of both sexes and gestational age [GA] 245-265 days) were conducted. SnMP (6 mumol/kg birth weight) or PT (Phillips F20T12/BB lamps) was administered to paired infants according to strict criteria of plasma bilirubin levels and age. Time of enrollment and closure of cases and crossover, if necessary, of SnMP infants to PT or all infants to exchange transfusion were precisely defined in each pair. SnMP or PT was considered superior if the time between enrollment and closure of the case was reduced by > 24 hours over the alternative treatment or if crossover had occurred.

RESULTS

None of the 44 SnMP-treated infants required supplemental PT. Of the 22 pairs of term infants enrolled in Study I, SnMP proved superior to PT in 20 and equal in two. Of the 20 pairs of near-term infants enrolled in Study II, SnMP was superior in 12 and PT in two; six were tied. Two SnMP-treated infants were unpaired. The PT-treated infants in Study I required an average of 33 hours of treatment; those in Study II, 48 hours. None of the enrolled infants required exchange transfusion or interruption of breast-feeding. In both studies, times between case enrollment and closure were reduced by > 30 hours in SnMP compared with PT infants; requirements for additional days of medical observation and bilirubin measurements were also significantly less in SnMP infants.

CONCLUSION

A single dose of SnMP entirely supplanted the need for PT in jaundiced term and near-term newborns and significantly reduced medical resource use to monitor hyperbilirubinemia.

Effects of ursodeoxycholic acid treatment on essential fatty acid deficiency in patients with biliary atresia

To assess whether ursodeoxycholic acid (UDCA) treatment has any beneficial effect on essential fatty acid (EFA) deficiency in patients who have had a Kasai operation for extrahepatic atresia (EBA), responses of serum fatty acids to UDCA administration (15 mg/kg/d) were investigated in eight jaundice-free patients and in eight patients with jaundice (serum total bilirubin > or = 1.0 mg/dL). All patients were also given taurine supplementation (100 mg/kg/d). Serum fatty acid composition was determined before and 6 months after UDCA treatment. Serum total bile acid concentration and serum total bilirubin value, as a part of conventional liver function tests, were measured before and during UDCA therapy. Before UDCA treatment, the concentrations of linoleic acid and arachidonic acid were significantly lower (P > .05 for the former; P > .01 for the latter) in both the jaundice and jaundice-free groups than in the controls. After 6 months of treatment, the linoleic acid concentration significantly increased (P > .05), to the normal range, in the jaundice-free group, but not in the jaundice group. The arachidonic acid concentration did not increase significantly in either group. The serum total bile acid concentration was lower in six of the eight jaundice-free patients and in four of the eight jaundice patients. The serum total bilirubin value decreased in six of the eight jaundice-free patients and in four of the eight jaundice patients; however, the degree of improvement was not statistically significant in either group. No side effects developed, and there were no changes in blood chemistry values unrelated to liver disease.(ABSTRACT TRUNCATED AT 250 WORDS)

An old traditional herbal remedy for neonatal jaundice with a newly identified risk

Yin-chen (Artemisia scoparia) is a very popular intravenous herbal preparation used for the treatment of neonatal jaundice in China. Bilirubin-protein titration studies with the horse radish peroxidase method have shown that the herb is highly effective in displacing bilirubin from its protein binding. Free bilirubin is liberated in this process and this could increase the risk of brain damage in jaundiced infants. With the present state of knowledge, the use of traditional herbal therapies should be strongly discouraged in neonates.

Superiority of oral agar and phototherapy combination in the treatment of neonatal hyperbilirubinemia

OBJECTIVE

To determine the value of oral agar in the treatment of neonatal hyperbilirubinemia and to compare it with two other treatment modalities: phototherapy alone and phototherapy plus oral agar.

METHODS

Two hundred eight jaundiced full-term newborns were divided into four groups. They were given either phototherapy alone, phototherapy plus oral agar, oral agar alone, or no treatment (control group). The changes in the serum bilirubin values were determined and the results were compared statistically, mainly using analysis of variance.

RESULTS

In all three therapy groups, the time required to reduce the bilirubin level to either 15 mg/dL or to 10 mg/dL was significantly shorter than that required by the control group. Although oral agar was found to be as effective as phototherapy, the most significant decrease in bilirubin level was in the combination group.

CONCLUSIONS

The efficacy of phototherapy in decreasing the serum bilirubin level in neonatal hyperbilirubinemia can be augmented with the use of oral agar. Oral agar can also be used as a single agent for the treatment of neonatal hyperbilirubinemia, since it is as effective as phototherapy.

Targeting zinc protoporphyrin liposomes to the spleen using reticuloendothelial blockade with blank liposomes

Metalloporphyrin inhibitors of heme oxygenase have been studied for use in the prevention of hyperbilirubinemia of the neonate. One report has suggested that incorporation of these drugs into liposomes can increase their localization to the spleen, dramatically reducing heme oxygenase activity in that important heme-degrading organ. We sought to further increase porphyrin delivery to the spleen by using reticuloendothelial blockade with blank liposomes 2 h before injection of 0.3 microns extruded zinc protoporphyrin liposomes (L-ZnPP). Control adult rats without hemolysis had splenic heme oxygenase activity of 1.07 +/- 0.09 nmol carbon monoxide (CO)/h/mg protein. Rats treated with L-ZnPP alone had splenic heme oxygenase activity of 0.53 +/- 0.16 nmol CO/h/mg protein 6 h after L-ZnPP dosing. However, rats treated with 1000 mumol of blank liposomes per kg to saturate the reticuloendothelial system 2 h before L-ZnPP administration had splenic heme oxygenase activity of 0.25 +/- 0.16 nmol CO/h/mg protein at t = 6 h, which is significantly less than that of the L-ZnPP alone group (p < 0.05). In adult rats treated with heat-damaged red blood cells (RBC) to simulate hemolysis, treatment with 10 mumol of aqueous ZnPP per kg or 10 mumol of untargeted L-ZnPP per kg did not produce a difference from control in total body bilirubin production as estimated by CO excretion. However, RBC-treated rats given 1000 mumol of blank liposomes per kg 2 h before L-ZnPP administration produced significantly less CO than control, aqueous ZnPP-treated, and untargeted L-ZnPP-treated rats from 8 to 12 h after RBC treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

[The effect of human albumin in association with intensive phototherapy in the management of neonatal jaundice]

BACKGROUND

The effectiveness of phototherapy in lowering serum bilirubin levels in neonates varies inversely with the rate and degree of hemolysis. Combining this therapy with albumin perfusion could enhance its effectiveness. This study examines total, unconjugated and unbound fractions of bilirubin in infants treated by phototherapy alone or by phototherapy plus albumin.

PATIENTS AND METHODS

The files of 211 neonates treated from January 1990 to March 1991 for severe neonatal jaundice were analysed. Jaundice was due to ABO incompatibility in 113 cases and hereditary hemolytic anemia in 6 cases; its cause was unknown in 92 patients. Other causes of jaundice such as Rh incompatibility, premature delivery before 34 gestational weeks and neonatal infections were excluded from the study. All 211 neonates were given phototherapy from admission with similar light energy. 114 babies (group I) received only phototherapy, while the 97 others (group II) were also given human albumin, (1.5 g/kg), during the first 2 hours of phototherapy.

RESULTS

The decrease in serum unconjugated and unbound bilirubin after 4 hours of phototherapy was 34% in group I and 45% in group II (p < 0.0005). There was no difference between both groups after 24 hours of phototherapy. Other factors such as the initial concentration of serum unconjugated and unbound bilirubin, age at the onset of therapy, and ethnic skin color also influenced the decrease in bilirubin after 4 and 24 hours of phototherapy, in addition to albumin perfusion.

CONCLUSIONS

Albumin perfusion plus phototherapy appears to induce a rapid and early decrease in unconjugated, unbound bilirubin, the fraction that is potentially neurotoxic, while phototherapy alone acts over a longer period.

Selection of metalloporphyrin heme oxygenase inhibitors based on potency and photoreactivity

The heme oxygenase inhibitor, tin protoporphyrin, is being studied for the prevention of neonatal jaundice. This potential drug, however, is also a photosensitizer that could cause serious and unknown side effects when administered to newborns. Therefore, we have developed in vitro and in vivo procedures for the screening and further characterization of potentially safe heme oxygenase inhibitors. The ideal inhibitor: 1) contains a biocompatible metal, 2) is not degraded in tissues, 3) is a highly potent inhibitor of heme oxygenase, and 4) does not participate in photochemical reactions. Proto- and mesoporphyrin derivatives with the tin, zinc, manganese, chromium, nickel, and magnesium were screened in vitro for suitability. Chromium protoporphyrin and mesoporphyrin were further studied in vitro and in vivo and were found to meet the ideal criteria. Chromium mesoporphyrin appeared to be the most potent in vitro inhibitor of adult Wistar rat tissue heme oxygenase. Four mumol of chromium protoporphyrin or chromium mesoporphyrin/kg body weight, administered intraperitoneally to adult male Wistar rats given a heme load through intraperitoneal administration of 30 mumol heme/kg body weight, caused significant suppression of hemolysis-induced increase in carbon monoxide production to 72 and 44% of control, respectively, 5.5 h after treatment. At t = 6 h, the tissue heme oxygenase activity, measured in vitro, was significantly reduced to 33 and < 5% in liver and to 22 and < 5% in spleen after the administration of chromium protoporphyrin and mesoporphyrin, respectively, but was not reduced in brain. The results show that there exist effective metalloporphyrin heme oxygenase inhibitors without photosensitizing properties.

Induction of hepatic bilirubin and drug metabolizing enzymes by individual herbs present in the traditional Chinese medicine, yin zhi huang

Yin Zhi Huang (YZH) is a decoction of four plants which is widely used in Asia to treat neonatal jaundice. This study compares the ability of phenobarbital and the individual herbs comprising YZH, Artemisia, Gardenia, Rheum, and Scutellaria baicalensis, to induce hepatic drug and bilirubin metabolizing enzymes in rats. Herbal decoctions (30 ml/kg/day) or phenobarbital (60 mg/kg/day) were administered for 5 days. Only phenobarbital increased cytochrome P-450 levels whereas Gardenia slightly decreased levels. Artemisia, Rheum and phenobarbital increased bilirubin glucuronyl transferase activity. Glucuronidation of alpha-naphthol was increased by Gardenia and phenobarbital, whereas Artemisia and Rheum were ineffective inducers. Phenobarbital was the most effective inducer of glutathione-S-transferase (GSHT) activity. Phenobarbital and Gardenia both induced delta 5-3-ketosteroid isomerase activity, a marker for the Ya subunit of GSHT responsible for intracellular bilirubin transport in liver. The selective patterns of enzyme induction suggest potential value for using specific plant decoctions to modify drug and bilirubin metabolic pathways.

Oral treatment for jaundice using immobilized bilirubin oxidase

Jaundice is characterized by an excessive accumulation of bilirubin in the blood and tissues. A novel approach to reduce plasma levels of bilirubin by blocking its enterohepatic circulation was investigated. The treatment consisted of oral administration of immobilized bilirubin oxidase, which could oxidize bilirubin in the intestine to less toxic and more water-soluble products. In vivo administration of 0.1 to 2.0 mg/day of immobilized enzyme over a four-day period to chronically jaundiced Gunn rats effectively lowered plasma bilirubin levels, but only when the molar ratio of total serum bilirubin to rat serum albumin (B/RSA) was larger than 0.35. Plasma bilirubin concentration decreased in that group from an initial value of 11.3 to 6.3 mg/dl (-40%, n = 5) after eight days. This decrease was statistically significant (p < 0.05 by Student's t test). However, administration of bilirubin oxidase to rats with a B/RSA ratio less than 0.35 (n = 10) resulted in no statistically significant change in plasma bilirubin concentration.