Neonatal jaundice and phototherapy

Easy Diagnosis of Jaundice: A Smartphone-Based Nanosensor Bioplatform Using Photoluminescent Bacterial Nanopaper for Point-of-Care Diagnosis of Hyperbilirubinemia

One of the concerns of parents in the first days of their baby's birth is the baby's risk of jaundice/hyperbilirubinemia. This is because more than 60% of babies are born with jaundice that, if not timely diagnosed and subsequently treated, can lead to serious damage to their health. On the other hand, despite recent progress in sensor technology for clinical applications, the development of easy-to-use, cost-effective, sensitive, specific, and portable diagnostic devices, which use nontoxic and biodegradable materials in their design and fabrication, is still in high demand. Herein we present an easy-to-use, cost-effective, selective, nontoxic, and disposable photoluminescent nanopaper-based assay kit with a smartphone readout for easy diagnosis of neonatal jaundice through visual determination of Bilirubin (BR) in infants' blood samples. The developed BR assay kit comprises highly photoluminescent carbon dot (CD) sensing probes embedded in a bacterial cellulose (BC) nanopaper substrate (CDBN). The photoluminescence (PL) of the developed BR sensor is quenched in the presence of BR as a PL quencher and then selectively recovered upon blue light (λ = 470 nm) exposure, due to conversion of the unconjugated BR to the colorless oxidation products (non-PL quencher) through BR photoisomerization and photooxidation, that subsequently leads to selective PL enhancement of CDBN. The recovered PL intensity of the developed BR assay kit, which was monitored by integrated smartphone camera, was linearly proportional to the concentration of BR in the range of 2-20 mg dL^-1. The feasibility of real application of the fabricated smartphone-based BR assay kit was also confirmed via comparing the results of our method with a clinical reference method for determination of BR concentration in infant's blood samples. With the advantages of nontoxicity and the extraordinary physicochemical properties of photoluminescent BC nanopaper as the sensing substrate, along with those of smartphone technology, we believe that our developed smartphone-based BR assay kit, as an easy-to-use, cost-effective (∼0.01 Euro per test), portable and novel sensing bioplatform, can be potentially exploited for sensitive, specific, rapid, and easy BR detection and jaundice diagnosis at the point of care (POC) and in routine clinical laboratories as well.

Exchange transfusion for neonatal hyperbilirubinemia: an 8-year single center experience at a tertiary neonatal intensive care unit in Turkey

OBJECTIVE

The aim of present study was to evaluate the indications and the complications associated with neonatal exchange transfusion (ET) performed for hyperbilirubinemia.

METHODS

This study included overall 306 neonates who underwent ET between 2005 and 2012. The demographic characteristics of patients, causes of jaundice and adverse events occurred during or within 1 week after ET were recorded from their medical files. Those newborns that underwent ET were classified as either "otherwise healthy" or "sick" group.

RESULTS

Of the 306 patients who underwent ET, 244 were otherwise healthy and had no medical problems other than jaundice. The remaining 62 patients were classified as sick that had medical problems other than jaundice ranging from mild to severe. The mean gestational age was 37.6 ± 2.5 weeks and the mean peak total bilirubin levels was 25.8 ± 6.6 mg/dl. The mean age at presentation was 5.4 ± 3.8 d for all infants. The most common cause of hyperbilirubinemia was ABO isoimmunization (27.8%). None of newborns died secondary to ET. Three infants had had necrotizing enterocolitis, and also three infants had had acute renal failure. The most common encountered complications of ET procedure were hyperglycemia (56.5%), hypocalcaemia (22.5%) and thrombocytopenia (16%).

CONCLUSIONS

Our data showed that ABO isoimmunization was the most common cause of hyperbilirubinemia. Even mortality was not seen, very rare but major gastrointestinal and renal complications were associated with ET. The majority of adverse events associated with ET were laboratory abnormalities mainly hyperglycemia, hypocalcaemia and thrombocytopenia which were asymptomatic and treatable.

Physiological serum bilirubin concentrations are inversely associated with the prevalence of cardiovascular autonomic neuropathy in patients with Type 2 diabetes

AIMS

Although severe hyperbilirubinaemia causes kernicterus in neonates, normal to modestly elevated bilirubin concentrations have been reported to be neuroprotective. However, the relationship between serum bilirubin concentrations and cardiovascular autonomic neuropathy in patients with Type 2 diabetes is currently unknown. This study assessed the relationships between physiological serum total bilirubin concentrations and cardiovascular autonomic neuropathy in patients with Type 2 diabetes.

METHODS

A total of 2991 patients with Type 2 diabetes were investigated in this cross-sectional study. Cardiovascular autonomic neuropathy was diagnosed by a cardiovascular reflex test. According to the American Diabetes Association criteria, the degree of cardiovascular autonomic dysfunction was graded into normal, early, definite and severe. Cardiovascular autonomic neuropathy was either definite or severe in the present study. An analysis of covariance after adjustment for other covariates was performed. A logistic regression model was used to assess an association of cardiovascular autonomic neuropathy with serum total bilirubin tertiles.

RESULTS

Serum total bilirubin concentrations were significantly lower in subjects with cardiovascular autonomic neuropathy. The mean total bilirubin values differed significantly according to the severity of cardiovascular autonomic dysfunction (normal 13.0 μmol/l; early 12.3 μmol/l; definite 11.8 μmol/l; severe 10.1 μmol/l; P for trend < 0.001) after adjustment for other covariates. In multivariate analysis, serum total bilirubin levels were significantly associated with cardiovascular autonomic neuropathy (odds ratio 0.36; 95% CI 0.21-0.63 for the highest vs. the lowest bilirubin tertile, P < 0.001).

CONCLUSIONS

Serum total bilirubin concentrations within the physiologic range are inversely associated with the prevalence of cardiovascular autonomic neuropathy in patients with Type 2 diabetes.

Uniform treatment thresholds for hyperbilirubinemia in preterm infants: background and synopsis of a national guideline

BACKGROUND

To prevent severe hyperbilirubinemia and bilirubin neurotoxicity, the American Academy of Pediatrics' management guideline for hyperbilirubinemia in near term infants is used worldwide. A leading guideline for jaundiced preterm infants is lacking whereas the risk on severe hyperbilirubinemia is high in these infants. Our aim was to define uniform treatment thresholds for jaundiced preterm infants. In this article we present the history and a synopsis of this novel national guideline.

STUDY DESIGN

A survey on guidelines for hyperbilirubinemia in preterm infants was sent to all Dutch Neonatal Intensive Care Units (NICUs). After comparison with international guidelines, a new consensus-based guideline was developed.

RESULTS

Treatment thresholds of all 10 NICUs were based on Total Serum Bilirubin (TSB) and related to birth weight (n = 9) and gestational age (n = 1). NICUs used age-specific (n = 6) or fixed (n = 4) TSB-thresholds resulting in a large range of thresholds (maximal 170 μmol/L for phototherapy and 125 μmol/L for exchange transfusion). Acidosis, asphyxia, sepsis, active hemolysis and intraventricular hemorrhage were the most frequently used risk factors. Consensus was agreed upon TSB-based treatment thresholds, categorized in 5 birth weight groups and divided in high and low risk infants.

CONCLUSION

There was no standardized care for jaundiced preterm infants in the Netherlands. In addition to the internationally used guideline for (near) term infants, a novel "consensus based" guideline for preterm infants with a gestational age of less than 35 weeks has been developed and implemented in the Netherlands. This guideline is approved and recommended by the Dutch Society of Pediatrics.

Neonatal exchange transfusion: a Jordanian experience

The aetiology and complications of exchange transfusion (ET) were studied over a 6-year period in northern Jordan. During that time, 336 neonates (0.46% of total live births) underwent 386 ETs. There was a yearly reduction in the number of ETs, varying from 8.2% in the 1st year of the study to 2.7% in the last year. Thirty-nine (11.9%) required more than one ET. Twenty-five (7.4%) were preterm babies and the remainder full-term. The commonest cause of ET overall was G6PD deficiency, either alone or concomitant with ABO incompatibility (38.1%). ET complications occurred in 51 neonates (15.2%), the commonest being anaemia and bradycardia. Septicaemia occurred in only 3% of cases. Only one baby died. G6PD deficiency, either alone or concomitant with ABO isoimmunization, is the most common cause of ET in northern Jordan. Fewer preterm babies require ET and there is a low incidence of septicaemia following ET.

Trends in neonatal exchange transfusions at Yodogawa Christian Hospital

A review was conducted to determine the trends in exchange transfusion (ET) of newborn infants at the Yodogawa Christian Hospital during the past 18 years. At that hospital in 1957, the first ET was performed on a term infant with severe hemolytic jaundice caused by rhesus factor (Rh) incompatibility. By 1989, ET had been performed in more than 1400 newborn infants. These cases of newborns who had had ET were retrospectively reviewed, with a focus on every 3 year period from 1974 to 1992. The total number of infants requiring ET noticeably decreased from 68 cases (14.0% of total admissions) in 1974 to 19 cases (6.1% of total admissions) in 1992. (chi 2, P < 0.001) There were three major significant changes in ET during those years. The first was a change in the subjects for ET. The incidence of ET for term infants showed a marked decrease, while the incidence of ET for preterm infants, especially for very low birthweight (VLBW) infants (< 1500 g), noticeably increased. The second was a change in indications for ET. There was a marked decrease in the need for ET as a result of hyperbilirubinemia, while the incidence of ET because of other etiologies, such as septicemia and/or disseminated intravascular coagulopathy, noticeably increased. The third was a change in the technical methods of ET. Now at the Yodogawa Christian Hospital, 100% of the infants are given ET with an automated peripheral two-site method, instead of the Diamond method. Although ET might still be a useful treatment for severe hyperbilirubinemia and other acute problems, the total number of ET noticeably decreased in accord with a decrease in the number of severe hyperbilirubinemia in term newborns. On the other hand, the incidence of ET in preterm infants increased relatively, accompanied by an increase in the survival of VLBW infants. The automated two-site method is the preferred technique for ET at the Yodogawa Christian Hospital, rather than the Diamond method. Further changes in ET might occur in accord with new alternative measures in future.

Efficacy of phototherapy for hyperbilirubinaemia in infants with the respiratory distress syndrome

OBJECTIVE

To evaluate the efficacy of phototherapy for hyperbilirubinaemia in preterm infants with and without the respiratory distress syndrome (RDS).

METHODOLOGY

Prospective cohort study of preterm infants cared for at Kandang Kerbau Hospital, Singapore: 170 with RDS and 477 without RDS, sepsis or other complications (control group) presenting with non-haemolytic hyperbilirubinaemia at about the same time were exposed to daylight phototherapy when bilirubin concentrations exceeded 255 mumol/L or 222 mumol/L if < 48 h of age. Bilirubin values were monitored 6-hourly during exposure, and daily for at least 2 days post-phototherapy.

RESULTS

The infants were comparable in birthweight, gestational age, postnatal age, haemoglobin, haematocrit and bilirubin values, at start. The response to phototherapy of the infants with RDS was comparable to that of the well preterm infants; the duration of exposure was 50.1 +/- 1.6 (mean +/- s.e.m.) versus 50.1 +/- 1.4 h, 24-hour decline rate 25.71 +/- 1.29% versus 26.32 +/- 0.65, and overall decline rate 0.96 +/- 0.03%/h versus 0.95 +/- 0.02%/h.

CONCLUSION

The presence of RDS did not affect the efficacy of phototherapy for neonatal hyperbilirubinaemia in preterm infants.

Phototherapy for neonatal jaundice in infants with cephalhematomas

The efficacy of phototherapy in a group of infants with nonhemolytic hyperbilirubinemia and no cephalhematomas was compared with a second group of infants with large cephalhematomas (> 7 cm across), but similar in all other aspects. The cephalhematoma group demonstrated significantly lower hemoglobin (Hb) and hematocrit (hct) values (P < .0001, P < .002 respectively) than the standard group, even after the latter group had been adjusted by stratification (P < .0001, P < .005) such that the starting bilirubin concentration, birth weight, and gestational age were highly comparable to the cephalhematoma group. The bilirubin concentrations of the cephalhematoma, original, and adjusted groups were 277.8 +/- 5.8 mumol/L (16.24 +/- 0.03 mg/dL), [mean +/- sem], 265.2 +/- 0.5 mumol/L (15.50 +/- 0.03 mg/dL), and 275.2 +/- 0.9 mumol/L (16.09 +/- 0.05 mg/dL), respectively. The postnatal age at the start of phototherapy in the cephalhematoma group was comparable with that of the standard group before and after adjustment. Phototherapy was equally effective in the cephalhematoma and standard (original and adjusted) groups of infants, in terms of duration, 24-hr decline, and overall decline/hr for the duration of exposure. The proportionate 24-hr decline was 24.02 +/- 1.90% vs 20.99 +/- 0.23% and 22.61 +/- 0.48% and overall decline/hr was 0.83 +/- 0.06% vs 0.74 +/- 0.01% and 0.78 +/- 0.01%. We conclude that the sequestrated blood in the cephalhematomas did not significantly interfere with the efficacy of phototherapy.

Efficacy of phototherapy in neonatal hyperbilirubinaemia associated with glucose-6-phosphate dehydrogenase deficient status

The efficacy of phototherapy in a group of 427 infants with hyperbilirubinaemia associated with glucose-6-phosphate dehydrogenase (G6PD) deficiency and a comparable group of 3924 G6PD normal infants with non-haemolytic hyperbilirubinaemia was evaluated. Phototherapy was highly effective in reducing bilirubin levels in both groups of infants, being significantly more effective in the group with normal G6PD status. Failure rate was very low (2.03/1000) in the group with normal G6PD status and nil in the G6PD deficient group. Bilirubin rebound after phototherapy was unremarkable with very few infants requiring a second exposure--4.68/1000 in the G6PD deficient group and 6.37/1000 in the G6PD normal group. All the babies tolerated phototherapy well. Phototherapy would therefore seem to be a simple and effective method for the management of severe jaundice associated with G6PD deficiency.

Efficacy of "high-intensity" blue-light and "standard" daylight phototherapy for non-haemolytic hyperbilirubinaemia

We report our clinical experience with phototherapy in 3802 infants; 3629 were exposed to "standard" daylight phototherapy and 173 to "high-intensity" blue-light phototherapy. High-intensity blue-light phototherapy was twice as effective as standard daylight phototherapy in decreasing bilirubin concentrations. No failures occurred with high-intensity phototherapy compared with an overall failure rate of 1.84/1000 with daylight lamps; these cases were transferred to high-intensity phototherapy with prompt response. Rebound after cessation of phototherapy was greater in those exposed to high-intensity blue light with a significantly greater number requiring a second exposure. However, the incidence was still low. No third exposure was required in any infant. Nursing of infants under high-intensity blue light was more difficult and inconvenient as was clinical monitoring. The light also caused more stress on the nursing and medical personnel. However, the infants tolerated both types of phototherapy equally well. High-intensity blue-light phototherapy would seem to be the treatment of choice for infants with rapidly increasing or very high bilirubin levels, as well as in those not responding adequately to daylight phototherapy.

Efficacy of phototherapy in non-haemolytic hyperbilirubinaemia

Clinical experience of phototherapy for non-haemolytic hyperbilirubinaemia in 3999 infants in Kandang Kerbau Hospital, Singapore, is documented. Phototherapy was most effective in extremely preterm infants with very low birth weight (gestation less than or equal to 32 weeks, birth weight less than or equal to 1500 g) and least effective in full term infants with very low birth weight (gestation greater than or equal to 37 weeks, birth weight less than or equal to 1500 g) and large preterm infants (gestation less than 37 weeks, birth weight greater than 2270 g). Overall, phototherapy was effective in almost all the infants, with a failure rate of only 2.00/1000 infants. No characteristic features common to all the failures could be detected. The bilirubin rebound was usually mild; repeat phototherapy was required in only 30 infants (7.50/1000), with the response to the second exposure comparable to that to the first. No infant required a third exposure. All the infants tolerated phototherapy well, none developing any illness that could be attributed to the treatment. This clinical experience shows that phototherapy for the treatment of nonhaemolytic hyperbilirubinaemia is effective and safe.

Randomized trial of prophylactic phototherapy in the infant with very low birth weight

Twenty-two preterm infants (birth weight 850 +/- 220 gm) were randomly assigned to receive phototherapy either soon after birth or after the serum bilirubin concentration reached 5 mg/dl. Infants receiving prophylactic phototherapy were placed under lights at a significantly earlier age and lower serum bilirubin concentration than infants in the routine group (P less than 0.001). There was no significant difference between groups in peak serum bilirubin concentration, age at which it peaked, rate of rise in serum bilirubin concentration, or serum bilirubin concentration at any time during the study. Infants assigned to the prophylactic phototherapy group were under lights for a significantly longer time than those in the routine group (P less than 0.05). There was a significant rise in both configurational and structural photo-isomers (P less than 0.005) independent of serum bilirubin concentration after phototherapy in all patients. These data suggest that the clinical course of hyperbilirubinemia is not altered in infants with very low birth weight receiving prophylactic phototherapy compared with infants with phototherapy begun at a bilirubin concentration of 5 mg/dl.

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.

Late anaemia in infants with rhesus haemolytic disease treated with intensive phototherapy

The purpose of the present study was to determine the incidence of late anaemia in infants with rhesus haemolytic disease (RHD) who had received intensive phototherapy. Sixty infants with RHD and with strongly positive direct Coombs' tests who had received intensive phototherapy (blue double light) were followed as out-patients with regard to development of late anaemia. Fifteen (25%) infants developed moderate anaemia and 5 (8%) severe anaemia, one of the latter requiring a blood transfusion. The incidence of late anaemia was equal in "non-exchanged" infants and those who required exchange transfusion. The former developed anaemia significantly earlier than the latter, and in both groups the declining Hb level caused a marked reticulocyte response which was equal in both groups. This response may explain the low incidence of anaemia in both the "non-exchanged" and "exchanged" infants. From the present study and previous investigations it can be concluded that phototherapy, especially intensive phototherapy, is of great value in the treatment of rhesus haemolytic disease.

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.

Lack of effect of phototherapy on plasma cyclic-AMP in newborn infants

The effect of phototherapy on plasma cyclic-AMP in newborn infants has been studied. Our results suggest that phototherapy does not produce appreciable changes in plasma cyclic-AMP levels.

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.

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

The relative effectiveness of phototherapy and exchange transfusion for nonhemolytic neonatal hyperbilirubinemia was compared in two closely matched groups of infants. Although the exchange transfusion achieved an immediate reduction of bilirubin level, the "rebound" was rapid and tended to offset this reduction. The more gradual and steady effect of phototherapy resulted in a significantly lower serum bilirubin level at 1, 2, and 3 days after commencement of therapy; the rebound after phototherapy was small. Phototherapy was demonstrated to be more effective than exchange transfusion in achieving prolonged reduction of bilirubin levels for nonhemolytic hyperbilirubinemia. With more efficient lamps delivering more energy in the desired spectrum, it would seem feasible to treat hyperbilirubinemia of whatever etiology with this safer and more convenient form of therapy, though sometimes only as in adjunct therapy.

Growth hormone and cortisol in neonates during phototherapy

In 22 neonates plasma growth hormone (GH) and cortisol concentrations were measured during phototherapy which was administered because of hyperbilrubinemia. These values were compared to the hormone levels before and after therapy and to control values taken from healthy nursery infants. Phototherapy significantly increased GH concentrations to 195% plus or minus 108 (SD)(healthy control group = 100%). Cortisol was not found to be augmented. There was no correlation between GH and cortisol, nor between bilirubin and GH or cortisol. The mechanisms by which phototherapy induces GH increase are not evident. However, this may be due to constant covering of the eyes, deprivation of the day-night rhythm, or other environmental alterations that are brought about by incubator care.

Time-limited phototherapy of term newborns in ABO hemolytic disease and hyperbilirubinaemia

"Limited" phototherapy was used to treat full term babies with and without ABO-isoimmunization. Serum indirect bilirubin levels calling for irradiation during the first five days of life are summarized in a diagram (Fig. 1). Seperate indications were given for babies with different etiologies of jaundice, maturity (gestational age and birthweight) and indicational levels were correlated with the postnatal age (days and hours) of the infant. After a fall or harmless stagnation of bilirubin levels irradiation was stopped. Clinical assessment of the treatment of 17 babies with ABO-isiommunization, and 16 newborns without it and with hyperbilirubinemia is given in detail. Results were compaired with the outcome of treatment of 44 newborns who received the same care in every respect, but phototherapy. These control cases, selected by pairs, were similar. Exchange transfusion, based on identical indications was necessary in 13 of the 44 babies treated without and only 3 of the 33 infants treated with phototherapy. The billirubin levels of the treated babies were lower during the whole course of the irradiation. The difference in favor of the treated babies was significant on the second and third days of life incases of ABO-hemolytic disease, and from the 4th day of life in cases of hyperbilirubinemia. The values of standard deviations, important in view of the indication for exchange transfusion were also lower in the light treated babies. Successful irradiation required on average of 44 hours (30-72 hours) in cases of ABO-isoimmunization and 40 hours (18-50) in cases of hyperbilirubinemia, respectively. Re-elavation of the bilirubin level after finishing phototherapy was not observed.

Phototherapy for neonatal hyperbilirubinemia in mature newborn infants with erythrocyte G-6-PD deficiency

Phototherapy was employed in treatment of newborn infants with erythrocyte G-6-PD deficiency whose serum bilirubin concentrations exceeded 10 mg/100 ml on the second or third day of life. Exchange transfusions were required for two of the 12 treated babies and for six of the 12 control infants. It is noteworthy that exposure to light did not affect the erythrocyte GSH content nor did it increase hemolysis.

Neonatal jaundice and maternal oxytocin infusion

A prospective study of 78 neonates provides evidence for an association between maternal oxytocin infusion and neonatal jaundice. On the second and fifth days infants of mothers whose labour had been induced by amniotomy followed immediately by intravenous oxytocin (group C) had mean total bilirubin levels significantly higher (P <0.05) than did infants whose mothers had had a spontaneous onset of labour and did not require oxytocin (group A). Bilirubin levels in infants of mothers whose onset of labour was spontaneous but required oxytocin to accelerate progress (group B) did not differ significantly from group A.Though these findings suggest a dose dependent effect of oxytocin, other possible explanations are suggested which take into account other drugs administered to the mother and also differences in the corticosteroid status of the groups of infants.