Comparison of the effectiveness of phototherapy and exchange transfusion in the management of nonhemolytic neonatal hyperbilirubinemia

Forgoing Exchange Transfusion in Neonatal Hyperbilirubinemia: A Single-Center Retrospective Cohort Study

INTRODUCTION

Unconjugated hyperbilirubinemia is part of the everyday life of the neonatal period as it reflects the adaptation of the metabolism of bilirubin. The neonatal hyperbilirubinemia usually resolves spontaneously, but it can also be the cause of an acute or chronic encephalopathy known as kernicterus. Regardless of the cause, the goal of therapy is to prevent this neurotoxicity while not causing undue harm. Phototherapy and, if it is unsuccessful, exchange transfusion (ECT) remain the primary treatment modalities used to keep the maximal total serum bilirubin (TSB) below pathologic levels.

MATERIALS AND METHODS

This is a descriptive retrospective cohort study of 69 live neonates hospitalized in the Department of Neonatology and Neonatal Resuscitation of Mohammed VI University Hospital with unconjugated hyperbilirubinemia requiring ECT and treated with intensive phototherapy instead, spanning five years from March 2016 to March 2021. We aim to demonstrate the effectiveness of phototherapy in achieving prolonged reduction of bilirubin levels and the prevention of neurological complications and to compare our results with those in the literature.

RESULTS

The use of intensive phototherapy in the treatment of neonatal unconjugated hyperbilirubinemia is very effective in lowering total serum bilirubin when its level is in the range of exchange transfusion, and it has succeeded in preventing the neurological complications of severe hyperbilirubinemia.

CONCLUSION

Through this study, it can be seen that phototherapy is an efficacious, simpler, and less hazardous alternative to exchange transfusion in achieving a sustained reduction of bilirubin levels and preventing neurological complications.

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.

Acute management of extreme neonatal jaundice--the potential benefits of intensified phototherapy and interruption of enterohepatic bilirubin circulation

Increasing numbers of neonates are being admitted to hospital because of extreme jaundice. Phototherapy should be very effective in such infants, because the efficacy of phototherapy is proportional to the concentration of bilirubin in the skin. Here, I report on four infants who were admitted for indirect serum bilirubin levels of >500 micromol/l (>>30 mg/dl). In one of them, unrecognized Rhesus immunization was the main cause of hyperbilirubinemia, while in the other three increased enterohepatic circulation of bilirubin was thought to be an important contributory factor. In all four infants phototherapy (11-14 microW/cm2/nm) with whole body exposure plus ad lib feeding with milk were initiated immediately upon admission to the nursery. After 2h serum bilirubin values were reduced by 170-185 micromol/l (10-11 mg/dl) in the first three infants, while in the fourth infant a reduction of 195 micromol/l (11.3 mg/dl) was seen in the 5 h interval between the first and second bilirubin measurement. This experience suggests that in some infants with extreme jaundice, intensified phototherapy plus feeding with milk may be very effective in reducing serum bilirubin levels. Even if an exchange transfusion is performed, using this strategy in the waiting period may be beneficial, as both the rapid reduction in serum bilirubin levels as well as the conversion of significant amounts of bilirubin into water-soluble isomers may reduce the risk of neurotoxicity.

Phototherapy for neonatal jaundice

Exchange transfusion for severe neonatal jaundice is a tedious and expensive procedure with high morbidity and mortality rates, and is followed by a prompt and marked bilirubin rebound. It has largely been replaced by phototherapy, which though more gradual in its effect results in a prolonged reduction of the bilirubin concentration. Its efficacy is influenced by the gestational age, birthweight and postnatal age of the infant, the aetiology of the jaundice, and the spectral emission and intensity (dose) of the light; its dose-response relationship enables it, at the optimal dose, to control very severe jaundice or a rapidly rising bilirubin concentration, including severe haemolysis. Its relative freedom from complications together with its non-invasive nature, ease of usage and convenience has resulted in widespread acceptance in virtually all neonatal units.

Phototherapy and the brain-stem auditory evoked response in neonatal hyperbilirubinemia

The latencies of peak V and interpeaks I-V and III-V in the brain-stem auditory evoked response of infants with hyperbilirubinemia before phototherapy were significantly greater than those in a control group of infants. These values of the brain stem auditory-evoked response improved significantly during phototherapy and correlated significantly with the declining bilirubin levels. Improvement continued after phototherapy, despite a rebound of serum bilirubin concentrations.

Efficacy of phototherapy and/or exchange transfusions in neonatal jaundice

In a review of treatment of neonatal jaundice, the authors studied the impact of phototherapy on outcome. From comparing exchange transfusion treatment over a 39-month period prior to the availability of phototherapy to a 39-month period incorporating phototherapy in the treatment regimen, the authors conclude that phototherapy (1) acts slowly but constantly to reduce bilirubin levels and (2) is effective even in severe hemolytic jaundice, but its effectiveness is inversely related to the degree of hemolysis. While phototherapy can never totally replace exchange transfusion, it can certainly reduce the number of transfusions needed.

Intermediate phototherapy in the treatment of jaundice in the premature infant

A controlled trial of the use of intermittent phototherapy for the treatment of hyperbilirubinemia in newborn infants is reported. Periods of illumination of (1) 15 minutes light on, 15 minutes light off, (2) 15 minutes on, 30 minutes off, and (3) 15 minutes on, 60 minutes off are as effective as is continuous illumunation. A comparison with previous trials of intermittent phototherapy is made and differences in results are explained using as a model the action of light on bilirubin.

The nature of the dose-response relationship of phototherapy for neonatal hyperbilirubinemia

The nature of the dose response relationship of phototherapy for neonatal hyperbilirubinemia was studied in 110 infants divided into ten comparable groups; each group was subjected to phototherapy of different intensity. The response to phototherapy increases with increasing dose, but the rate of this response progressively decreases with increasing radiance till a "saturation point" is reached, beyond which no further increase in response occurs to further increase in radiance, i.e., an asymptotic regression was demonstrated. The minimal radiance at which phototherapy begins to be effective for neonatal hyperbilirubinemia was also determined. The rebound after cessation of phototherapy was similar in all groups of infants, despite the shorter duration of exposure required for the groups subjected to intense phototherapy.