The "bronze" baby syndrome: a complication of phototherapy

Impact of Saccharomyces boulardii on jaundice in premature infants undergoing phototherapy

OBJECTIVES

To evaluate the therapeutic effect of Saccharomyces boulardii supplementation on jaundice in premature infants undergoing phototherapy.

METHODS

In this article, the authors reviewed 100 hospitalized jaundiced premature infants under 35 weeks of gestational age. All infants were assigned to a control group (n = 45) and a treatment group (n = 55) randomly. The infants in the treatment group received S. boulardii supplementation by undergoing phototherapy and the infants in the control group were only treated by phototherapy. The total serum bilirubin levels were detected before and at the end of phototherapy, and transcutaneous bilirubin levels were measured on the 1st, 4th, 8th and 15th day of treatment. The duration of jaundice resolution and phototherapy, stool frequency, and characteristics were compared after phototherapy.

RESULTS

The duration of jaundice resolution and phototherapy were shortened. Total serum bilirubin level was lower than the control group at the end of phototherapy (p < 0.05). Transcutaneous bilirubin levels decreased more significantly on the 8th and 15th day of treatment (p < 0.05), while there were no significant differences on the post-treatment 1st and 4th day (p > 0.05). In addition, bowel movements including stool frequency and Bristol Stool Form Scale ratings of stools also improved after treatment.

CONCLUSIONS

S. boulardii in combination with phototherapy is effective and safe in reducing bilirubin levels and duration of phototherapy, accelerating jaundice resolution in premature infants with jaundice. The procedure also provided an ideal therapeutic effect of diarrhea induced by phototherapy to promote compliance and maternal-infant bonding.

Management of severe hyperbilirubinemia in the cholestatic neonate: a review and an approach

A review of the literature demonstrates that severe total hyperbilirubinemia (total serum bilirubin ≥ 20 mg/dL [340 µmol/L]) in some cholestatic term (≥37 weeks) and late-preterm (≥34^0/7-36^6/7 weeks) gestation neonates poses a risk for bilirubin-induced brain damage. When the direct bilirubin fraction is <50% of the total serum bilirubin this risk is associated with the total serum bilirubin alone and treatment decisions should be based on the total serum bilirubin. On the other hand, there are limited data on the risk of bilirubin-induced brain damage in the neonate with severe total hyperbilirubinemia and a direct bilirubin fraction that is equal to or exceeds 50% of the total serum bilirubin. When this rare combination occurs, efforts to keep the indirect bilirubin fraction from reaching severe levels might, nevertheless, be prudent.

Efficacy of oral agar in management of indirect hyperbilirubinemia in full-term neonates

Aim: This prospective randomized case control study aimed to investigate effect of oral agar administration in reducing total serum bilirubin (TSB) levels in full-term neonates with jaundice in comparison with control.Materials and methods: One hundred sixty full-term neonates were enrolled with TSB 10-19 mg/dl at first week of age from Assiut University Children's Hospital. Neonates were divided according to TSB into outpatient group (n = 100) (TSB 10-15 mg/dl) and admitted group (n = 60) (TSB > 15-19 mg/dl). Outpatients group were subdivided into agar group received oral agar and control group received placebo. Admitted group were subdivided into agar group received oral agar plus phototherapy combination and control group received phototherapy alone. Neonates in the agar supplementation received oral agar 600 mg/kg/day dissolved in 10 ml distilled water twice daily till TSB decreased to 7 mg/dl. Daily weight, stool frequency and side effects of treatment were observed for each group. TSB was determined pretreatment then serially every 48 h until TSB level reaching ≤7 mg/dl.Results: Agar fed was effective in lowering TSB in neonates with TSB 10-15 mg/dl. TSB percentage changes were not significantly lower in agar-fed newborn with TSB >15-19 mg/dl compared with control groups after 24 h and 7 days. Age fed shortened the time required to decrease TSB and increased stooling frequency.Conclusions: Oral agar supplemented feeding at 600 mg/kg/day is safe for full-term neonates and useful in decreasing TSB and phototherapy duration. The efficacy of phototherapy in decreasing TSB level in neonatal hyperbilirubinemia can be augmented with oral agar usage.

Sixty years of phototherapy for neonatal jaundice - from serendipitous observation to standardized treatment and rescue for millions

A breakthrough discovery 60 years ago by Cremer et al. has since changed the way we treat infants with hyperbilirubinemia and saved the lives of millions from death and disabilities. "Photobiology" has evolved by inquiry of diverse light sources: fluorescent tubes (wavelength range of 400-520 nm; halogen spotlights that emit circular footprints of light; fiberoptic pads/blankets (mostly, 400-550 nm range) that can be placed in direct contact with skin; and the current narrow-band blue light-emitting diode (LED) light (450-470 nm), which overlaps the peak absorption wavelength (458 nm) for bilirubin photoisomerization. Excessive bombardment with photons has raised concerns for oxidative stress in very low birthweight versus term infants treated aggressively with phototherapy. Increased emphasis on prescribing phototherapy as a "drug" that is dosed cautiously and judiciously is needed. In this historical review, we chronicled the basic to the neurotoxic components of severe neonatal hyperbilirubinemia and the use of standardized interventions.

[Bronze baby syndrome, an unpredictable complication of phototherapy: A case report]

The bronze baby syndrome is an infrequent dyschromia resulting from phototherapy in newborn babies with neonatal jaundice. Even though the common phenotype has been described in patients with direct neonatal hyperbilirubinemia secondary to cholestasis, several cases of patients with indirect neonatal hyperbilirubinemia who have managed to reverse it have been reported, as well as patients with isolated hyperbilirubinemia.Currently, the physiopathology of this condition is still a subject of controversy and, therefore, there is a lack of clear conducts for its correct diagnosis and treatment.Generally, this syndrome has been considered as a mild condition that is resolved with the suspension of phototherapy. Its duration is usually not greater than the neonatal period, and it has no long-term sequelae. However, its occurrence is considered an absolute contraindication for the continuation of phototherapy. In case of persistence, the recommendation is to decrease bilirrubin levels and proceed with exchange transfusion; this procedure, however, represents risks for the newborn, so our recommendation is to suspend phototherapy and reinitiate it if the direct bilirrubin value decreases, andcholestasis compromise has been discarded. Serial evaluations of acute encephalopathy caused by bilirrubin are absolutely recommended.The objective of this paper was to describe the case of a newborn with ABO incompatibility who developed the bronze baby syndrome. This patient responded satisfactorily to the suspension and resumption of phototherapy without exchange transfusion.

Role of massage therapy on reduction of neonatal hyperbilirubinemia in term and preterm neonates: a review of clinical trials

BACKGROUND

Neonatal hyperbilirubinemia (NNH) is one of the leading causes of admissions in nursery throughout the world. It affects approximately 2.4-15% of neonates during the first 2 weeks of life.

AIMS

To evaluate the role of massage therapy for reduction of NNH in both term and preterm neonates.

METHOD

The literature search was done for various randomized control trials (RCTs) by searching the Cochrane Library, PubMed, and EMBASE.

RESULTS

This review included total of 10 RCTs (two in preterm neonates and eight in term neonates) that fulfilled inclusion criteria. In most of the trials, Field massage was given. Six out of eight trials reported reduction in bilirubin levels in term neonates. However, only one trial (out of two) reported significant reduction in bilirubin levels in preterm neonates. Both trials in preterm neonates and most of the trials in term neonates (five trials) reported increased stool frequencies.

CONCLUSION

Role of massage therapy in the management of NNH is supported by the current evidence. However, due to limitations of the trials, current evidences are not sufficient to use massage therapy for the management of NNH in routine practice.

Phototherapy for neonatal hyperbilirubinemia

Approximately 60 years ago in England, phototherapy for neonatal hyperbilirubinemia was used in clinical practice. It was introduced in Japan approximately 50 years ago. At that time, the mechanism underlying the serum bilirubin concentration decrease by phototherapy was still unknown. The mechanism was identified by chemists, biochemists, and pediatricians. Clarification started with the report that unconjugated bilirubin was excreted into bile after photoirradiation in Gunn rats. After confirmation of the molecular structure of bilirubin on X-ray analysis, the mechanism for bile excretion of unconjugated bilirubin was verified based on geometric configurational photoisomers in the Gunn rat. Finally, the reaction and excretion of structural bilirubin photoisomers was proved to be the main mechanism for the decrease in serum bilirubin during phototherapy for neonatal hyperbilirubinemia, which differs from the mechanism in the Gunn rat. The most effective and safest light source and the optimal method to evaluate phototherapy, however, remain unknown. Moreover, as for bronze baby syndrome, which is a well-known adverse reaction to phototherapy, the etiology is unclear. Hence, we review phototherapy for hyperbilirubinemia including a fundamental understanding of the bilirubin photochemical reactions, and discuss the subclinical carcinogenic risk of phototherapy and the increased mortality rate of extremely low-birthweight infants due to aggressive phototherapy, which is becoming an increasing problem.

Role of Saccharomyces boulardii in Reduction of Neonatal Hyperbilirubinemia

INTRODUCTION

Probiotics are known to reduce the severity of hyperbilirubinemia.

AIM

This study was done to evaluate the effect of probiotic on neonatal hyperbilirubinemia in term neonates.

MATERIALS AND METHODS

A total of 181 healthy term neonates after birth were divided into a control group (n=95) and a treatment group (n=86) randomly and treated with placebo and probiotic (Saccharomyces boulardii) respectively. A total of two doses were given orally in the first two consecutive days. The serum bilirubin levels were detected on day three of life. Babies were exclusively breastfed, clinical outcome was recorded. Comparison between groups was made by the non-parametric Mann-Whitney test. Analysis of Variance (ANOVA) was used to assess the quantitative variables. A p-value of <0.05 using a two-tailed test was taken as being of significance for all statistical tests.

RESULTS

On day 3, mean total serum bilirubin in control group among patient who has not developed clinical jaundice is 6.5mg% and in the treatment group is 5mg%. In patient with clinical jaundice, it is 13.6mg% in control group and 10.7mg% in the treatment group. The p-value was found to be <0.05 which is statistically significant. No obvious adverse reactions noted in either group.

CONCLUSION

Probiotics lowered the serum bilirubin level of healthy neonate with jaundice safely and significantly without any adverse reaction.

Phototherapy rash in newborn infants: does it differ between conventional and light emitting diode phototherapy?

Data comparing the cutaneous side effects of light emitting diode (LED) phototherapy (LP) and conventional phototherapy (CP) devices in jaundiced newborn infants are very limited. We investigated the incidence and extent of skin eruptions caused by different phototherapy devices in preterm infants who are more prone to neonatal jaundice. This prospective, randomized controlled trial was conducted in the neonatal intensive care unit (NICU) of Hacettepe University Ihsan Dogramaci Childrens' Hospital in Ankara, Turkey. Preterm infants without skin lesions before and requiring phototherapy in the first week of life were included in the study. The infants were randomly assigned to receive CP or LP and were monitored closely for skin eruptions during phototherapy. Fifty-eight infants were included in the study: 25 (43.1%) received CP while 33 (56.9%) received LP. The duration of phototherapy was similar in the two groups (30.4 ± 9.6 hours and 31.8 ± 15.6 hours, respectively). Baseline and control bilirubin levels were similar for the two groups (p = 0.101 and p = 0.105, respectively). The frequency of skin eruptions was 36% in the CP group and 33% in the LP group (p = 0.83). The skin eruptions were macules in 13 (22.4%), papules in 5 (8.6%), and maculopapular rashes in 2 (3.4%) infants.There were no differences in the incidence and extent of skin eruptions in preterm infants who received CP or LP.

Bilirubin, copper-porphyrins, and the bronze-baby syndrome

Controlled in vitro spectroscopic measurements reveal that bilirubin does not photosensitize the degradation of copper-porphyrins, as has been proposed for the mechanism of the bronze-baby syndrome, an uncommon side-effect of phototherapy. Calculations also show that copper-porphyrins are unlikely to cause the "bronzing." In conclusion, the copper-porphyrin hypothesis is photochemically implausible.

Pulse oximetry interference in bronze baby syndrome

A case of a neonate with Rhesus hemolytic disease of the newborn who went on to develop bronze baby syndrome (BBS) is reported. During his admission, inconsistencies between pulse oximetry saturations (SpO(2)) and his arterial partial pressure of oxygen (PaO(2)) measurements raised the suspicion of interference with our SpO(2) monitoring. Although bilirubin has been heavily investigated with respect to SpO(2) interference, a brown pigment has been shown to be produced in patients with BBS, which exhibits spectral absorbances that may cause interference with the pulse oximeter. This needs further exploration, but highlights the need to interpret SpO(2) readings with caution in neonates with BBS.

Bronze baby syndrome and the risk of kernicterus

AIM

The problem of kernicterus in infants with bronze baby syndrome (BBS) has been reviewed on the basis of cases reported in the literature. In addition, a new case concerning an infant with severe Rh haemolytic disease, who presented with BBS and who has developed neurological manifestations of kernicterus with magnetic resonance images showing basal ganglia abnormalities, is presented. In this patient, the total serum bilirubin (TSB) concentration ranged from 18.0 to 22.8 mg/dl (306 to 388 micromol/l) and the bilirubin/albumin (B/A) ratio was 6.0 (mg/g) (6.8 is the value at which an exchange transfusion should be considered). The case presented is important due to the fact that kernicterus appeared after an exchange transfusion was performed when the TSB level reached 22.8 mg/dl (388 micromol/l) on 6th day of life while the haematocrit was 30%. From this case and from other cases reported in the literature, we must stress that, even if the level at which hyperbilirubinemia poses a threat remains undefined, BBS may constitute an additional risk of developing kernicterus.

CONCLUSION

The possible strategies for implementing an approach to the management of hyperbilirubinemia (especially the haemolytic kind) in the presence of BBS may include an exchange transfusion carried out at lower TSB concentration than previously recommended or an early administration of Sn-mesoporphyrin.

Treatment of jaundice in low birthweight infants

Exchange transfusion and phototherapy remain the staples of intervention for the jaundiced newborn. Clinical management of the jaundiced low birthweight infant is discussed.

What's new in pediatric dermatology

This report discusses some of the newly described diseases in pediatric dermatology and recent developments in other diseases that are pertinent to this field.

Hyperbiliverdinemia in the bronze baby syndrome

The bronze baby syndrome is an unusual complication of phototherapy for hyperbilirubinemia in the neonate. The pigment or pigments responsible for the discoloration in this syndrome have not yet been identified. Suspected pigments include photodegradation products of bilirubin and copper-porphyrins. We present here the case of a neonate with bronze baby syndrome whose serum had increased spectral absorbance in the region of maximum absorbance for biliverdin. We suggest that biliverdin pigments may also contribute to the "bronze" color associated with this syndrome.

Bronze baby syndrome, biliary hypoplasia, incomplete Beckwith-Wiedemann syndrome and partial trisomy 11

A premature infant with duplication of material from chromosome 11 and some features of the Beckwith-Wiedemann syndrome developed the bronze baby syndrome when exposed to phototherapy. He subsequently developed hepatocellular dysfunction and died aged 5 weeks. Post mortem examination revealed striking hypoplasia of intralobular bile ducts but little inflammatory change or necrosis in the liver.

Bronze baby syndrome. Report of a case

A newborn female infant suddenly developed a generalized gray-brown discoloration of her skin while receiving phototherapy for hyperbilirubinemia. The discoloration waned over the succeeding weeks. Her serum contained an unknown pigment that had a characteristic absorbance on spectrophotometry. The distinctive findings and some possible causes of the bronze baby syndrome are discussed. The findings are compared to other causes of dusky-hued skin in the neonate. The bronze baby syndrome is usually innocuous but can signal life-threatening disease.

Effect of phototherapy and exchange transfusion on primary bile acids in the serum of hyperbilirubinaemic newborns

Serum primary bile acid (cholic (CA) and chenodeoxycholic (CDCA) acid) concentrations were measured in 14 preterm and 11 full-term hyperbilirubinaemic newborns at the beginning and end of, and 24 and 72 hours following phototherapy. Only in the preterm newborns with gestational ages of 35-38 weeks there was a significant decrease of mean serum bile acid concentrations which could be shown 72 hours after the beginning of phototherapy. It can be hypothesized that the decrease was a result of a direct effect of light on the excretory liver function. Serum CA and CDCA concentrations were also measured in 5 hyperbilirubinaemic newborns at the beginning and end, and 24, 48 and 72 hours after the end of exchange transfusion. Exchange transfusion caused a clear immediate decrease in the mean serum primary bile acid concentrations. However, on day 2 after exchange transfusion the mean serum concentration of CA was about 150% and that of CDCA about 110% of the initial values. The most hyperbilirubinaemic newborns had extremely high primary bile acid serum concentrations before therapy. As bile acids compete with bilirubin for albumin binding it should be considered whether high bile acids in the serum of hyperbilirubinaemic newborns presuppose exchange transfusions.

The bronze baby syndrome

Phototherapy with either daylight or blue lamps resulted in the development of the bronze baby syndrome in 13 infants. 'Thermotherapy' with an incandescent bulb emitting light mainly in wavelengths not effective for phototherapy caused this syndrome in the 14th infant with respiratory failure. Hepatic dysfunction was present in all infants. The infants were well in spite of the bronzing, after their initial condition had improved. Bronzing disappeared within two months in all but one infant; in eight infants with regular blood examination, the hepatic function became normal by ten months of age, but spectroscopy demonstrated the presence of the pigment(s) even at one year. Normal development was observed.

Low reserve albumin for binding of bilirubin in neonates with deficiency of bilirubin excretion and bronze baby syndrome

The plasma reserve albumin concentration for binding of bilirubin was found to be low in four newborn infants with deficiency of bilirubin excretion, of whom two had the bronze baby syndrome. Thus, the risk of bilirubin encephalopathy was increased. Also the ratio of binding fraction of albumin, i.e. unconjugated bilirubin plus reserve albumin, to total albumin was low. Possible causes of the low reserve albumin concentration and the ratio are discussed.

Light- and electron microscopic studies of the liver in "bronze baby" syndrome

The light- and electron-microscopic changes of the hepatic tissue of a case with the "bronze baby" syndrome were described. The light-microscopic examinations revealed intrahepatic cholestasis of the hepatocanalicular type associated with portal inflammation. The electron-microscopic examinations showed dense deposits in the hepatic cells, Kupffer cells and in the bile canaliculi. The bile canaliculi were distended, the canalicular membrane severely destructed. The patient included in the study has been free of symptoms for 2 years.

Follow-up study of phototreated fullterm newborns

A follow-up study including examinations made by a paediatrician, an ophthalmologist and a psychologist and complemented with EEG-recordings and a number of laboratory determinations was performed at the age of 3 years on 41 children who had received phototherapy during the first week of life and on 42 control children of the same age. No differences were found in growth, development, social maturity, neurological or ophthalmologic disorders, EEG-recordings or laboratory determinations between both groups. It seems unlikely that phototherapy causes any harmful longterm effects provided that the eyes are shielded.

Evidence of riboflavin depletion in breast-fed newborns and its further acceleration during treatment of hyperbilirubinemia by phototherapy

Phototherapy in the treatment of newborns with hyperbilirubinemia, resulting in degradation of bilirubin, also appears to have other photodynamic effects on metabolism. We studied flavin adenine dinucleotide (FAD) saturation of erythrocyte glutathione reductase, which should reflect riboflavin nutritional status, in 28 healthy newborns, and followed 37 newborns with hyperbilirubinemia prior to the start of and during phototherapy. The results indicate that healthy newborns on human milk feeding, relatively poor in riboflavin, have evidence of a transient riboflavin depletion soon after birth. This effect is made more pronounced by phototherapy and partially prevented by parenteral or oral administration of moderate amounts of riboflavin.

Bilirubin dynamics in the Gunn rat during phototherapy

Bilirubin dynamics were studied in homozygous Gunn rats under normal room lighting conditions and under conditions simulating phototherapy. A kinetic model was developed for the formation, distribution, and elimination of bilirubin. The decrease in plasma bilirubin concentration during illumination with low intensity [300 footcandles (fc)] and high intensity (1000-1100 fc) light was studied. The plasma bilirubin concentration in the rats decreased under phototherapy until a new steady-state concentration was reached, the decline being more rapid under high intensity light conditions. Gunn rats were also injected with a tracer dose of 14C-bilirubin following a period during which the rats were illuminated with low or high intensity light. The distribution and elimination of the labeled bilirubin were followed under continuous illumination. The chosen kinetic model, when adapted to the set of data under investigation, fit all of the data concerning bilirubin kinetics in Gunn rats under continuous illumination.

Phototherapy. Short and long-term complications

Use of phototherapy for hyperbilirubinaemia in 300 consecutively treated infants has shown that minor complications are common. With a knowledge of these complications and measures taken to minimize their effects, phototherapy appears to be safe in the short term. The long-term follow-up study showed that growth, and in particular head circumference, was not affected. There was, however, a higher incidence of squints and abnormal developmental performance in those infants treated with phototherapy. This may not have been due to phototherapy usage per se. However, because of these findings, it is suggested that phototherapy should not be used indiscriminately for hyperbilirubinaemia until the results of further long-term studies are available.

The "bronze baby" syndrome: postmortem data

The case history and autopsy findings of an infant with the "bronze baby" syndrome are presented. These findings substantiate that kernicterus occurs in term infants receiving phototherapy for concentrations of serum indirect bilirubin below 20 mg/dl. The findings at autopsy suggest that the photodecomposed pigmented products of bilirubin are unable to pass the blood-brain barrier. The need for establishing the cause of jaundice prior to initiation of phototherapy is stressed.

Photodynamic action of bilirubin on human erythrocyte membranes. Modification of polypeptide constituents

The photodynamic action of bilirubin on isolated human erythrocyte membranes (ghosts) has been studied. When incorporated into ghosts (pH 8.0,10 degrees) the bile pigment photosensitizes in blue light the peroxidation of unsaturated lipids, as evidenced by a positive color reaction with 2-thiobarbituric acid. Accompanying lipid peroxidation was the disappearance of most of the major membrane proteins (Coomassie Blue staining in sodium dodecyl sulfate-polyacrylamide gel electrophoresis) and appearance of polypeptide photoproducts of greater size (mol wt greater than 250,000). The association of membrane proteins (presumably by cross-linking) was insignificant when bilirubin-ghost suspensions were kept in the dark, or when ghosts were irradiated in the absence of bilirubin. Electrophoretic bands 1 and 2 (Fairbanks, G., Steck, T.L., and Wallach, D. F.H (1971), Biochemistry 10, 2606) diminished rapidly during the photoreaction, whereas band 3 and the three sialoglycoproteins disappeared at a much slower rate. Dispersal of membrane consituents by treatment with sodium dodecyl sulfate prior to irradiation resulted in relatively little peroxidation and no noticeable formation of high molecular weight polypeptide complexes. The possibility that malonaldehyde, a product of lipid peroxidation, is involved in cross-linking during irradiation was studied by incubating ghosts with exogenous malonaldehyde. Although the reagent did cross-link membrane proteins (electrophoretic bands 1, 2, 2.1 2.2, and 4.1 diminished most rapidly and high molecular weight bands appeared), the reaction could only be demonstrated with malonaldehyde concentrations several orders of magnitude greater than those detected in irradiation experiments. If malonaldehyde cross-linking occurs, it does not appeare to be the predominant mechanism of polypeptide association during irradiation of bilirubin-containing ghosts.