An evidence-based review of important issues concerning neonatal hyperbilirubinemia

Effect of vitamin E supplementation on bilirubin levels in infants with hyperbilirubinemia: a double-blind randomized clinical trial

BACKGROUND

The effect of vitamin E supplementation on bilirubin levels in infants was previously explored, but the results were inconclusive.

PURPOSE

To examine the effect of vitamin E supplementation on bilirubin levels in term infants in the neonatal intensive care unit (NICU).

METHODS

This interventional double-blind randomized clinical trial was conducted in the Sanandaj Besat Hospital NICU. Enrolled newborns were between 37 and 42 weeks and 6 days of gestation and required phototherapy according to American Academy of Pediatrics clinical guidelines. A total of 138 infants were randomly assigned to vitamin E (n=68) or placebo (n=70) groups. In addition to phototherapy, the vitamin E group received 0.5 mL (5 IU) of supplemental vitamin E daily, whereas the placebo group received 0.5 mL of oral dextrose daily. STATA 17 was used for the data analysis.

RESULTS

Changes in bilirubin levels at 24 hours postintervention did not differ significantly from baseline in either group. Vitamin E supplementation did not significantly reduce total bilirubin levels at 24 hours postintervention (mean difference [MD], -0.18; P=0.204; 95% confidence interval [CI], -1.39 to 1.02). However, the vitamin E group exhibited lower total bilirubin levels than the placebo group at 48 hours postintervention (MD, 0.18; P=0.365; 95% CI, -0.89 to 1.27) and 72 hours (MD, 0.36; P=0.356; 95% CI, -2.34 to 1.61), although the differences were not statistically significant. A subgroup analysis revealed that female infants experienced a greater reduction in total bilirubin levels than male infants.

CONCLUSION

Infants administered vitamin E versus placebo demonstrated similar reductions in bilirubin levels and hospital stays. Although the average bilirubin changes did not differ significantly between groups, the vitamin E group showed a more noticeable reduction over time, indicating a positive effect of vitamin E supplementation on serum bilirubin reduction. Trial registration: IRCT20220806055625N2 (registered December 26, 2022; http://irct.ir/trial/67135).

Bilirubin Measurement and Phototherapy Use After the AAP 2022 Newborn Hyperbilirubinemia Guideline

BACKGROUND AND OBJECTIVES

Guidelines for the management of neonatal hyperbilirubinemia have helped to reduce rates of significant hyperbilirubinemia. However, recent evidence suggesting overtreatment and potential harms of phototherapy have informed the American Academy of Pediatrics clinical practice guideline revision and the accompanying increase in phototherapy thresholds. These changes are predicted to safely reduce overuse; however, to date, the exact effect of these guidelines has not been established.

METHODS

We conducted a retrospective study of newborns born at ≥35 weeks' gestation across a network of 8 hospitals between January 2022 and June 2023. Outcomes included rates of phototherapy and total serum bilirubin (TSB) measurements before and after guideline publication, as well as clinical outcomes, including length of stay, readmissions, and duration of phototherapy.

RESULTS

In our cohort of >22 000 newborns, we observed a 47% decrease in phototherapy utilization, from 3.9% to 2.1% (P < .001). TSB measurements were reduced by 23%, from 712 to 551 measurements per 1000 newborns (P < .001), without an increase in outpatient TSB measurements. We did not observe an increase in readmissions receiving phototherapy, and length of stay increased by only 1 hour (P < .001).

CONCLUSIONS

Our study reveals that the publication of the updated American Academy of Pediatrics 2022 hyperbilirubinemia guidelines has likely yielded a significant reduction in phototherapy use and serum bilirubin measurement. Dedicated quality improvement initiatives may help determine which implementation strategies are most effective. Further population-level studies are needed to confirm safety with ongoing guideline uptake.

Advances to diminish global newborn kernicterus mortality

OBJECTIVE

Initiatives, "Every Newborn Action Plans" and "Sustainable Developmental Goals," are profoundly shaping global infant mortality trends. Concurrently, professional organizations recommended curricula to prevent extreme hyperbilirubinemia (EHB) sequelae. Therefore we assessed if these efforts have successfully decreased EHB-related mortality over time.

STUDY DESIGN

We used the Global Burden of Diseases 2019 database to determine neonatal and infant mortality and the burden of kernicterus from 1990-2019.

RESULTS

Globally, kernicterus accounted for 2.8 million infant deaths and trended downwards significantly from 1990 to 2019. By 2019, kernicterus-related mortality was 4 and 293 per million livebirths in high (HICs) and low income countries (LICs), respectively. 82% of deaths occurred in LICs and lower-middle income-countries. Average declines of mortality rates were 6.2% and 3.0% for HICs and LICs, respectively.

CONCLUSIONS

Kernicterus-related mortality has been effectively reduced to <5 per million in HICs. Skills and knowledge transfer can potentially transform frontline services to bridge discordant kernicteric outcomes worldwide.

Demystifying non-invasive approaches for screening jaundice in low resource settings: a review

All national and international pediatric guidelines universally prescribe meticulous bilirubin screening for neonates as a critical measure to mitigate the incidence of acute bilirubin encephalopathy (ABE) and Kernicterus. The prevailing gold standard for jaundice detection in neonates necessitates invasive blood collection, followed by subsequent biochemical testing. While the invasive procedure provides dependable bilirubin measurements and continues to be the sole gold standard diagnostic method for assessing bilirubin concentration. There exists a pressing need to innovate non-invasive screening tools that alleviate the sampling stress endured by newborns, mitigate iatrogenic anemia, and expedite the turnaround time for obtaining results. The exploration of non-invasive modalities for bilirubin measurements is gaining momentum, driven by the overarching goal of minimizing the number of pricks inflicted upon neonates, thereby rendering screening a swift, efficient, comfortable, and dependable process. This comprehensive review article delves extensively into the array of non-invasive approaches and digital solutions that have been proposed, implemented, and utilized for neonatal bilirubin screening, with a particular emphasis on their application in low-resource settings. Within this context, the review sheds light on the existing methodologies and their practical applications, with a specific focus on transcutaneous bilirubin meters. Moreover, it underscores the prevailing open challenges in this domain and outlines potential directions for future research endeavors. Notably, the review underscores the imperative need for robust educational programs targeted at both families and healthcare personnel to expedite the process of seeking timely care for neonatal jaundice. Additionally, it underscores the necessity for the development of enhanced screening and diagnostic tools that can offer greater accuracy in clinical practice.

Light-Emitting Diode (LED) Phototherapy versus Non-LED Phototherapy Devices for Hyperbilirubinemia in Neonates: A Systematic Review and Meta-analysis

This review was conducted to evaluate the efficacy of light-emitting diode (LED) phototherapy as compared with the conventional phototherapy in neonates with unconjugated hyperbilirubinemia and their adverse effects. We searched the following databases right from their inception till April, 2021: MEDLINE, EMBASE, Cochrane Library, and LILACS. Randomized clinical trials (RCTs) comparing the LED phototherapy with other light sources, which enrolled newborns (term and preterm) with unconjugated hyperbilirubinemia were included. We included 21 articles in this review. The treatment with the LED light therapy had a lower failure rate as compared with the non-LED one (RR = 0.60, 95% CI: 0.39-0.94). The mean duration of phototherapy was significantly shorter in the group with the LED light source as compared with the one with the non-LED light source (mean difference [hours]: -8.07, 95% CI: -8.45 to -7.68), regardless of the type of non-LED units. However, the rate of bilirubin showed a comparable decline (mean difference [mg/dL/h]: 0.01, 95% CI: -0.00, 0.03) in both the light sources, irrespective of irradiance or distance. No studies reported primary outcomes related to the neurotoxicity effects of hyperbilirubinemia in neonates. The LED light devices caused a significantly higher risk of hypothermia. Neonates were at a lower risk of developing hyperthermia and skin rash with the LED light therapy. Our findings provide support for the use of LED light source phototherapy due to its better clinical efficacy, which is evidenced by its shorter duration and lower rate of treatment failure, as compared with the non-LED light sources. KEY POINTS: · The efficacy of phototherapy is dependent on specific characteristics of light sources of phototherapy devices.. · LED phototherapy demonstrated better efficacy with shorter duration and lower rate of treatment failure.. · Adverse effects of phototherapy devices such as hypothermia, hyperthermia, and skin rash should be monitored..

Ruthenium-Based Photoactivated Chemotherapy

Ruthenium(II) polypyridyl complexes form a vast family of molecules characterized by their finely tuned photochemical and photophysical properties. Their ability to undergo excited-state deactivation via photosubstitution reactions makes them quite unique in inorganic photochemistry. As a consequence, they have been used, in general, for building dynamic molecular systems responsive to light but, more particularly, in the field of oncology, as prodrugs for a new cancer treatment modality called photoactivated chemotherapy (PACT). Indeed, the ability of a coordination bond to be selectively broken under visible light irradiation offers fascinating perspectives in oncology: it is possible to make poorly toxic agents in the dark that become activated toward cancer cell killing by simple visible light irradiation of the compound inside a tumor. In this Perspective, we review the most important concepts behind the PACT idea, the relationship between ruthenium compounds used for PACT and those used for a related phototherapeutic approach called photodynamic therapy (PDT), and we discuss important questions about real-life applications of PACT in the clinic. We conclude this Perspective with important challenges in the field and an outlook.

Bilirubin-Induced Transcriptomic Imprinting in Neonatal Hyperbilirubinemia

Recent findings indicated aberrant epigenetic control of the central nervous system (CNS) development in hyperbilirubinemic Gunn rats as an additional cause of cerebellar hypoplasia, the landmark of bilirubin neurotoxicity in rodents. Because the symptoms in severely hyperbilirubinemic human neonates suggest other regions as privileged targets of bilirubin neurotoxicity, we expanded the study of the potential impact of bilirubin on the control of postnatal brain development to regions correlating with human symptoms. Histology, transcriptomic, gene correlation, and behavioral studies were performed. The histology revealed widespread perturbation 9 days after birth, restoring in adulthood. At the genetic level, regional differences were noticed. Bilirubin affected synaptogenesis, repair, differentiation, energy, extracellular matrix development, etc., with transient alterations in the hippocampus (memory, learning, and cognition) and inferior colliculi (auditory functions) but permanent changes in the parietal cortex. Behavioral tests confirmed the presence of a permanent motor disability. The data correlate well both with the clinic description of neonatal bilirubin-induced neurotoxicity, as well as with the neurologic syndromes reported in adults that suffered neonatal hyperbilirubinemia. The results pave the way for better deciphering the neurotoxic features of bilirubin and evaluating deeply the efficacy of new therapeutic approaches against the acute and long-lasting sequels of bilirubin neurotoxicity.

Global Prevalence of Severe Neonatal Jaundice among Hospital Admissions: A Systematic Review and Meta-Analysis

Evidence regarding the adverse burden of severe neonatal jaundice (SNJ) in hospitalized neonates in resource-constrained settings is sparse. We attempted to determine the prevalence of SNJ, described using clinical outcome markers, in all World Health Organization (WHO) regions in the world. Data were sourced from Ovid Medline, Ovid Embase, Cochrane Library, African Journals Online, and Global Index Medicus. Hospital-based studies, including the total number of neonatal admissions with at least one clinical outcome marker of SNJ, defined as acute bilirubin encephalopathy (ABE), exchange blood transfusions (EBT), jaundice-related death, or abnormal brainstem audio-evoked response (aBAER), were independently reviewed for inclusion in this meta-analysis. Of 84 articles, 64 (76.19%) were from low- and lower-middle-income countries (LMICs), and 14.26% of the represented neonates with jaundice in these studies had SNJ. The prevelance of SNJ among all admitted neonates varied across WHO regions, ranging from 0.73 to 3.34%. Among all neonatal admissions, SNJ clinical outcome markers for EBT ranged from 0.74 to 3.81%, with the highest percentage observed in the African and South-East Asian regions; ABE ranged from 0.16 to 2.75%, with the highest percentages observed in the African and Eastern Mediterranean regions; and jaundice-related deaths ranged from 0 to 1.49%, with the highest percentage observed in the African and Eastern Mediterranean regions. Among the cohort of neonates with jaundice, the prevalence of SNJ ranged from 8.31 to 31.49%, with the highest percentage observed in the African region; EBT ranged from 9.76 to 28.97%, with the highest percentages reported for the African region; ABE was highest in the Eastern Mediterranean (22.73%) and African regions (14.51%). Jaundice-related deaths were 13.02%, 7.52%, 2.01% and 0.07%, respectively, in the Eastern Mediterranean, African, South-East Asian and European regions, with none reported in the Americas. aBAER numbers were too small, and the Western Pacific region was represented by only one study, limiting the ability to make regional comparisons. The global burden of SNJ in hospitalized neonates remains high, causing substantial, preventable morbidity and mortality especially in LMICs.

Jaundice and its associated factors among neonates admitted to selected referral hospitals in southwest oromia, Ethiopia: Multi-center cross-sectional study

Background

Jaundice is a common clinical problem during the first month of birth throughout the world. Mainly, it is the leading cause of neonatal morbidity and mortality in developing countries.

Objectives

The aimed of this studied was to assess predictors of jaundice among neonates admitted to selected referral hospitals in southwest Oromia, Ethiopia, 2021.

Methods

An Institutional based cross-sectional study was implemented among 205 admitted neonates at selected referral hospitals in southwest Oromia, Ethiopia from October 05 to November 5, 2021. Jimma medical center (JMC), Wollega University referral hospital (WURH), and Ambo University Referral hospital (AURH) were selected by simple random sampling technique. A pretested structured interviewer-administered questionnaire and medical record review was used to collect data. Both binary and multivariable logistic regression analyses were performed to identify factors associated with neonatal jaundice. Logistic regression analyses were performed to identify factors associated with neonatal jaundice. Statistical Significance was declared at P-value less than 0.05 in the final model, and if the confidence interval does not include the null hypothesis value.

Results

The prevalence of neonatal jaundice was 20.5% (95%CI: 1.74-1.85). The mean age of neonates was 8.6 ± 7.8 days. Traditional medicine use during current pregnancy (AOR: 5.62, 95%CI: 1.07, 9.52), Rh incompatibility (AOR: 0.045, 95%CI: 0.01, 0.21), gestational age (AOR: 4.61, 95%CI: 1.05, 10.3), premature rupture of membrane (AOR: 3.76, 95%CI: 1.58, 8.93) and hypertension (mother) (AOR: 3.99, 95%CI: 1.13, 14.02) were factors significantly associated with neonatal jaundice.

Conclusion

Neonatal jaundice was relatively higher in the current study. Traditional medicine use, Rh incompatibility, premature ruptures of membrane, hypertension, and preterm gestational age were factors associated with neonatal jaundice.

Feasibility and acceptability of home-based neonatal hyperbilirubinemia screening by community health workers using transcutaneous bilimeters in Bangladesh

BACKGROUND

Universal screening for neonatal hyperbilirubinemia risk assessment is recommended by the American Academy of Pediatrics to reduce related morbidity. In Bangladesh and in many low- and middle-income countries, there is no screening for neonatal hyperbilirubinemia. Furthermore, neonatal hyperbilirubinemia may not be recognized as a medically significant condition by caregivers and community members. We aimed to evaluate the acceptability and operational feasibility of community health worker (CHW)-led, home-based, non-invasive neonatal hyperbilirubinemia screening using a transcutaneous bilimeter in Shakhipur, a rural subdistrict in Bangladesh.

METHODS

We employed a two-step process. In the formative phase, we conducted eight focus group discussions with parents and grandparents of infants and eight key informant interviews with public and private healthcare providers and managers to explore their current knowledge, perceptions, practices, and challenges regarding identification and management of neonatal hyperbilirubinemia. Next, we piloted a prenatal sensitization intervention and home-based screening by CHWs using transcutaneous bilimeters and evaluated the acceptability and operational feasibility of this approach through focus group discussions and key informant interviews with parents, grandparents and CHWs.

RESULTS

Formative findings identified misconceptions regarding neonatal hyperbilirubinemia causes and health risks among caregivers in rural Bangladesh. CHWs were comfortable with adoption, maintenance and use of the device in routine home visits. Transcutaneous bilimeter-based screening was also widely accepted by caregivers and family members due to its noninvasive technique and immediate display of findings at home. Prenatal sensitization of caregivers and family members helped to create a supportive environment in the family and empowered mothers as primary caregivers.

CONCLUSION

Adopting household neonatal hyperbilirubinemia screening in the postnatal period by CHWs using a transcutaneous bilimeter is an acceptable approach by both CHWs and families and may increase rates of screening to prevent morbidity and mortality.

Phototherapy and risk of developmental delay: the Japan Environment and Children's Study

This observational cohort study aimed to examine the association between the duration of phototherapy for neonatal jaundice and the risk of developmental delay at 3 years of age using nationwide birth cohort data. Data from 76,897 infants were analyzed. We divided participants into four groups: no phototherapy, short phototherapy (1-24 h), long phototherapy (25-48 h), and very long phototherapy (> 48 h). The Japanese version of the Ages and Stages Questionnaire-3 was used to evaluate the risk of developmental delay at 3 years of age. Logistic regression analysis was performed to assess the impact of phototherapy duration on the prevalence of developmental delay. After adjustment for potential risk factors, a dose-response relationship was identified between the duration of phototherapy and Ages and Stages Questionnaire-3, and the differences were significant in four domains; odds ratio for communication delay was associated with short, long, and very long phototherapy = 1.10 (95% confidence interval 0.97-1.26), 1.32 (1.04-2.66), and 1.48 (1.11-1.98), respectively; for gross motor delay = 1.01 (0.89-1.15), 1.28 (1.03-2.58), and 1.26 (0.96-1.67); for problem solving delay = 1.13 (1.03-1.25), 1.19 (0.99-1.43), and 1.41 (1.11-1.79); and for personal social delay = 1.15 (0.99-1.32), 1.10 (0.84-1.44), and 1.84 (1.38-2.45).

CONCLUSION

Longer duration of phototherapy is a predictive factor for developmental delay, making it important to avoid extended periods of phototherapy. However, whether it increases the prevalence of developmental delay remains unclear.

WHAT IS KNOWN

• Phototherapy is a common treatment for neonatal jaundice, associated with both short-term and long-term complications. • However, an association between phototherapy and the prevalence of developmental delay has not been revealed in a large cohort study.

WHAT IS NEW

• We identified that a long duration of phototherapy was a predictive factor for developmental delay at 3 years of age. • However, whether a long duration of phototherapy increases the prevalence of developmental delay remains unclear.

Petukhov P, Kurilova OV, Ilinsky VV, Trakhtman PE, Dadali EL, Samokhodskaya LM, Kamalov AA, Kost OA. Blood ACE Phenotyping for Personalized Medicine: Revelation of Patients with Conformationally Altered ACE

Background: The angiotensin-converting enzyme (ACE) metabolizes a number of important peptides participating in blood pressure regulation and vascular remodeling. Elevated blood ACE is a marker for granulomatous diseases and elevated ACE expression in tissues is associated with increased risk of cardiovascular diseases. Objective and Methodology: We applied a novel approach -ACE phenotyping-to find a reason for conformationally impaired ACE in the blood of one particular donor. Similar conformationally altered ACEs were detected previously in 2-4% of the healthy population and in up to 20% of patients with uremia, and were characterized by significant increase in the rate of angiotensin I hydrolysis. Principal findings: This donor has (1) significantly increased level of endogenous ACE inhibitor in plasma with MW less than 1000; (2) increased activity toward angiotensin I; (3) M71V mutation in ABCG2 (membrane transporter for more than 200 compounds, including bilirubin). We hypothesize that this patient may also have the decreased level of free bilirubin in plasma, which normally binds to the N domain of ACE. Analysis of the local conformation of ACE in plasma of patients with Gilbert and Crigler-Najjar syndromes allowed us to speculate that binding of mAbs 1G12 and 6A12 to plasma ACE could be a natural sensor for estimation of free bilirubin level in plasma. Totally, 235 human plasma/sera samples were screened for conformational changes in soluble ACE. Conclusions/Significance: ACE phenotyping of plasma samples allows us to identify individuals with conformationally altered ACE. This type of screening has clinical significance because this conformationally altered ACE could not only result in the enhancement of the level of angiotensin II but could also serve as an indicator of free bilirubin levels.

Evidence Suggests a Decrease in the Incidence of Kernicterus in California

We identified children diagnosed with kernicterus in the California Department of Developmental Services and estimated an incidence of 0.42 per 100 000 births from 1988 to 2014, significantly decreasing to 0.04 per 100 000 births after 2009. We also examined national infant kernicterus mortality from 1979 to 2016 using CDC data. It did not decrease significantly.

Pharmaceutical strategies for preventing toxicity and promoting antioxidant and anti-inflammatory actions of bilirubin

Bilirubin (BR) is the final product of haem catabolism. Disruptions along BR metabolic/transport pathways resulting from inherited disorders can increase plasma BR concentration (hyperbilirubinaemia). Unconjugated hyperbilirubinemia may induce BR accumulation in brain, potentially causing irreversible neurological damage, a condition known as BR encephalopathy or kernicterus, to which newborns are especially vulnerable. Numerous pharmaceutical strategies, mostly based on hemoperfusion, have been proposed over the last decades to identify new valid, low-risk alternatives for BR removal from plasma. On the other hand, accumulating evidence indicates that BR produces health benefits due to its potent antioxidant, anti-inflammatory and immunomodulatory action with a significant potential for the treatment of a multitude of diseases. The present manuscript reviews both such aspects of BR pharmacology, gathering literature data on applied pharmaceutical strategies adopted to: (i) reduce the plasma BR concentration for preventing neurotoxicity; (ii) produce a therapeutic effect based on BR efficacy in the treatment of many disorders.

Efficacy and Safety Concerns with Sn-Mesoporphyrin as an Adjunct Therapy in Neonatal Hyperbilirubinemia: A Literature Review

Neonatal hyperbilirubinemia is a frequently observed clinical situation that, sometimes, may result in complications ranging from mild neurodevelopment impairment to serious outcome of kernicterus. The rationale logic of heme oxygenase enzyme inhibition to lower bilirubin levels is intriguing. In compliance with that rationale, metalloporphyrin was discovered. After successful results in in-vitro and animal studies, tin mesoporphyrin is now under phase II clinical trial to test for preventive and therapeutic efficacy in unconjugated hyperbilirubinemia. This review evaluates in-vitro studies, animal studies, and clinical trials for the efficacy and safety of tin analogues of metalloporphyrin. Few alternatives to metalloporphyrins are also available, synchronizing with the same rationale logic of inhibition of bilirubin production, which need further research.

A Prospective Comparison of Serum and Transcutaneous Bilirubin in Indian Neonates

The objective of this study was to compare the transcutaneous bilirubin (TcB) with total serum bilirubin (TSB) and to find out the effect of phototherapy on correlation of TcB and TSB during and after phototherapy in Indian neonates. Prospective observational study was performed at neonatal intensive care unit of Uttar Pradesh University of Medical Sciences, Saifai, Etawah, India. Blood samples for TSB estimation of 276 jaundiced neonates were sent, and simultaneously, TcB was measured at forehead and sternum on admission and 12 hourly till discontinuation of phototherapy as per the American Academy of Pediatrics nomogram chart and their correlation was assessed. The effect of phototherapy on correlation of TcB and TSB during and after phototherapy was also observed. The correlation between TSB and TcB was linear and significant for the entire study population over forehead (Pearson's r  = 0.802, R ²  = 0.644, p  < 0.001) as well as over sternum (Pearson's r  = 0.825, R ²  = 0.681, p  < 0.001) before starting the phototherapy. This correlation becomes slightly lower for TSB versus TcB forehead (Pearson's r  = 0.753, R ²  = 0.568, p  < 0.001) and for TSB versus TcB sternum (Pearson's r  = 0.754, R ²  = 0.569, p  < 0.001) after giving phototherapy for at least 24 hours. The correlation coefficients for TSB versus TcB measurements over forehead and sternum were 0.758 and 0.806, respectively, after 36 hours of phototherapy. TcB measurements using the transcutaneous bilirubinometer correlate closely with TSB levels, so it can be used as an easy and rapid noninvasive method of bilirubin measurement in jaundiced neonates.

Periodic change of body position under phototherapy in term and preterm neonates with hyperbilirubinaemia

BACKGROUND

Phototherapy is the mainstay of treatment of neonatal hyperbilirubinaemia. Periodic change in position of the neonate under phototherapy (from supine to prone or lateral positions) may improve the efficiency of phototherapy by hastening the access of phototherapy light to bilirubin deposited in different parts of the skin and subcutaneous tissue.

OBJECTIVES

To evaluate the effects of periodic change of body position during phototherapy as compared to no prescribed change in body position, on serum total bilirubin level and duration of treatment in neonates with unconjugated hyperbilirubinaemia during the first 28 days of life. Secondary objectives of the review included evaluation of the efficacy of periodic change of body position on the need for or number of exchange transfusions, incidence of bilirubin-induced neurological damage (BIND), side effects of phototherapy, and sudden infant death syndrome (SIDS).

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to run comprehensive searches in the Cochrane Central Register of Controlled Trials (CENTRAL; 2021, Issue 3) in the Cochrane Library and Ovid MEDLINE and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions on 5 March 2021. We also searched clinical trials databases and the reference lists of included studies and relevant reviews for randomised controlled trials (RCTs) and quasi-RCTs.

SELECTION CRITERIA

We included RCTs and quasi-RCTs if they enrolled neonates (term and preterm) of either gender with unconjugated hyperbilirubinaemia requiring phototherapy and compared periodic change of the body position of the infant under phototherapy with no prescribed change in body position.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data, consulting with a third review author in the case of disagreement. We used standard Cochrane methodological procedures, including assessing the risk of bias of included studies. We used the GRADE approach to assess the certainty of evidence. Primary outcomes were the duration of phototherapy and rate of fall of serum bilirubin at 24 hours. Secondary outcomes included the need for exchange transfusion, number of exchange transfusions, incidence of BIND, and SIDS.

MAIN RESULTS

We included five studies (343 neonates) with an overall high risk of bias in the review. The body position under phototherapy was changed every two hours or every two-and-a-half hours in two studies each, and every three hours in one study. Three of the five studies included healthy term neonates, whilst the other two studies also included preterm neonates (≥ 33 weeks' gestation); however, separate data about review outcomes in preterm neonates were not available. Periodic change in body position may lead to little or no difference in the duration of phototherapy (mean difference (MD) 1.71 hours, 95% confidence interval (CI) -3.17 to 6.59 hours; I² = 58%; 4 studies, 231 participants; low certainty evidence). Only one study reported the rate of fall of serum total bilirubin at 24 hours of starting the phototherapy. Periodic change in body position may lead to little or no difference in the rate of fall of serum total bilirubin at 24 hours (MD 0.02 mg/dL/h, 95% CI -0.02 to 0.06 mg/dL/h; 1 study, 100 participants; low certainty evidence). We downgraded the certainty of evidence to low due to risk of bias and imprecision. None of the included studies reported the need for or number of exchange transfusions, incidence of BIND, or SIDS. Lack of separate data precluded subgroup analysis.

AUTHORS' CONCLUSIONS

The available evidence is insufficient to determine the effects of periodic change of body position compared with no prescribed change of body position under phototherapy. There is low certainty evidence that there may be little or no difference in the duration of phototherapy and rate of fall in bilirubin at 24 hours of starting phototherapy between periodic change in body position and no prescribed change of body position under phototherapy in term and preterm neonates. None of the included studies reported the effect of change of position on the need for or number of exchange transfusions, incidence of BIND, or SIDS. One study is awaiting classification and could not be included in the review. Further studies are needed to evaluate the effect of periodic change in body position under phototherapy, especially in neonates with haemolytic hyperbilirubinaemia and in very preterm neonates. The results of this systematic review apply mainly to neonates born at late-preterm or term gestation receiving phototherapy for non-haemolytic hyperbilirubinaemia.

Applicability of the hour of life approach in hyperbilirubinemia among Filipino term infants

BACKGROUND

Hyperbilirubinemia remains a common morbidity among infants. Additional research on bilirubin kinetics and associated risk factors will contribute to providing a more targeted management approach for the Filipino infant.

OBJECTIVE

To develop a Filipino bilirubin nomogram by studying bilirubin patterns during the first 5 days of life.

METHODOLOGY

This prospective study recruited 1,412 stable, full-term infants (≥37 weeks age of gestation) born at the Philippine General Hospital (PGH). Using the Dräger-Minolta JM-103 jaundice meter, transcutaneous bilirubin (TcB) levels were determined at the 3rd, 6th, 12th, 24th, 36th, 48th, 72nd, 96th, and 120th hour of life (HOL). A bilirubin nomogram was created using the averages of 3 TcB forehead and sternal measurements at each time epoch. Simultaneous measurement of TcB and total serum bilirubin (TsB) on a subset of 106 infants was done to determine correlation.

RESULTS

Correlation coefficients were high between TsB and forehead TcB (r² = 0.88), and between TsB and sternal TcB (r² = 0.91). The Filipino bilirubin nomogram reflected a steep rise until the 48th hour, followed by plateauing of values. Inadequate nursing and bilirubin levels at 12th and 48th HOL were risk factors for developing significant hyperbilirubinemia at 72nd HOL.

CONCLUSION

TcB is a reliable, non-invasive bilirubin screening tool. Among healthy, full-term, Filipino infants, their nomogram features a sudden increase in bilirubin values during the first 48 h, followed by a plateau. To aid in identification of infants at risk for significant hyperbilirubinemia, healthcare providers can assess breastfeeding adequacy and perform bilirubin screening at the 24th-48th HOL. Registration No. (RGAO-2016-0686).

Impact of in-utero antiretroviral drug exposure on expression of membrane-associated transporters in mouse placenta and fetal brain

OBJECTIVE

Although antiretroviral therapy (ART) during pregnancy is effective in limiting vertical HIV transmission, adverse outcomes persist amongst uninfected children exposed to antiretroviral drugs in utero. Membrane-associated drug transporters, metabolic enzymes, and tight junction proteins play important roles in adult antiretroviral drug disposition and toxicity; however, the fetal expression of these proteins in the context of ART, and their impact on in-utero antiretroviral drug distribution remain poorly understood. This study aimed to characterize the role of these proteins in modulating in-utero antiretroviral drug exposure.

METHODS

Pregnant mice were exposed to an ART regimen consisting of lamivudine, abacavir, atazanavir, and ritonavir, at clinically relevant doses. Fetal brain, liver, placenta amniotic fluid, and maternal plasma were collected on gestational day 18.5 and concentration of antiretroviral drugs in fetal tissues was measured by LC/MS/MS, whereas transporter expression was assessed by qPCR.

RESULTS

Abacavir and lamivudine were detected in fetal brain and amniotic fluid, whereas atazanavir and ritonavir were detected in amniotic fluid only. Robust mRNA expression of key transporters was observed in adult and fetal tissues, and sex differences were identified in the expression of Abcc1 and Slc29a1 in the placenta. Antiretroviral drug exposure was associated with a reduction in relative placental Abcg2, Abcc1, and Slc29a1 expression.

CONCLUSION

These findings identify a novel effect of fetal sex and antiretroviral drug treatment on the expression of placental transporters in a mouse model, and characterize the penetration of lamivudine and abacavir into fetal brain, uncovering a potential role of transporters in modulating fetal exposure to antiretroviral drugs.

Evaluating the effect of ursodeoxycholic acid on total bilirubin of neonates with glucose-6-phosphate dehydrogenase deficiency complicated by indirect hyperbilirubinaemia

AIM

This study aimed to investigate the effect of adding ursodeoxycholic acid (UDCA) to phototherapy in neonates with glucose-6-phosphate dehydrogenase (G6PD) deficiency and hyperbilirubinaemia. G6PD deficiency is a common cause of severe hyperbilirubinaemia in neonates.

METHODS

This study was a triple blind, clinical trial study of 40 neonates with G6PD deficiency and hyperbilirubinaemia who admitted for phototherapy in hospitals affiliated to the University of Medical Sciences. The treatment group (n = 20) received UDCA 10 mg/kg (2 cc/kg) daily divided into 2 doses every 12 h. The control group (n = 20) received the same volume of placebo syrup. The drug and placebo treatments were continued until the bilirubin level dropped below 171 μmol/L. Both the control and treatment group received continuous phototherapy. Independent sample t-test, survival analysis and logrank test were used to statistically analyse the results.

RESULTS

The mean total bilirubin level was 231.9 ± 18.8 μmol/L and 184.3 ± 18.6 μmol/L in the control and intervention group respectively, 24 h after drug administration and 209.7 ± 19.3 μmol/L and 157.4 ± 16.4 μmol/L, respectively, 48 h after intervention (P < 0.05). The median length of hospitalisation in the treatment group was approximately 1 day lower than the control group (logrank test P value: <0.001).

CONCLUSION

The study showed that the addition of UDCA to phototherapy accelerates the reduction of total bilirubin level in neonates with G6PD deficiency and can reduce the duration of hospitalisation.

Determinants of Neonatal Readmission in Healthy Term Infants: Results from a Nested Case-Control Study

OBJECTIVE

The aim of this study was to estimate the incidence and identify the factors associated with neonatal readmission among healthy term infants.

STUDY DESIGN

A nested case-control study with matching was conducted at a large level III perinatal hospital with approximately 8,700 deliveries each year. Each case infant (n = 130) was matched to two control infants (n = 260) on the case infant's date of birth (±7 days) and the mother's maternal age (<20 years, 20-29, 30-39, and >39 years). All infants were selected from a cohort of eligible term, healthy, in-state infants admitted to the newborn unit postdelivery from January 1, 2016 to May 8, 2017. Data were analyzed using hierarchical conditional logistic regression.

RESULTS

The incidence of neonatal readmission was 2.2%, and all readmissions occurred within 8.6 days of birth. Earlier gestational age (37 weeks; odds ratio [OR]: 4.11, 95% confidence interval [CI]: 1.79-9.45; 38 weeks OR: 1.29, CI 0.60-2.75; [ref] 39 weeks), jaundice on day two of life (OR: 2.45; CI: 1.40-4.30), maternal group B streptococcus chemoprophylaxis (OR: 2.55; CI: 1.23-5.28 [Ref N/A]) were associated with readmission. Delivery by cesarean section (OR: 0.31, CI: 0.12-0.79) and each milliliter of formula [first three days] (OR: 0.96; CI: 0.993-0.999) were protective.

CONCLUSION

Neonatal readmission in healthy term infants may potentially be reduced with identification of modifiable determinants of readmission prior to discharge. Policies to capture the true incidence of neonatal readmissions should include admissions to hospitals other than the birth hospital.

Childhood neurodevelopmental outcomes of survivors of acute bilirubin encephalopathy: A retrospective cohort study

BACKGROUND

Reports on childhood neurodevelopmental and neurosensory outcomes following acute bilirubin encephalopathy from low- and middle-income countries are scarce.

AIM

This study aimed to analyze the neurodevelopmental and neurosensory outcomes of survivors of acute bilirubin encephalopathy.

STUDY DESIGN

Retrospective cohort.

SUBJECTS

Neonates with admission diagnosis of acute bilirubin encephalopathy were followed up and assessed for neuromotor, neurodevelopmental and neurosensory functions between 18 m and 12.5 years of age.

RESULTS

In 67 neonates with acute bilirubin encephalopathy, a composite outcome of cerebral palsy or death was observed in 33 (49%) subjects. Choreo-athetoid cerebral palsy [19 (73%)] was the most common type observed. Sensori-neural hearing loss was observed in 46 (79%) subjects. Subjects with cerebral palsy had significantly low Developmental profile-3 scores in all assessed domains. Neonates with an early-stage acute bilirubin encephalopathy (aOR (95% C.I): 0.12 (0.05-0.71); p = 0.02) and those with a normal neurological examination at discharge (aOR (95% C.I): 0.11 (0.06-0.7); p = 0.049) had significantly lower odds of the primary outcome.

CONCLUSIONS

Majority of survivors of acute bilirubin encephalopathy had adverse outcomes during childhood in the form of cerebral palsy and sensory-neural hearing loss. Cognitive functions were better preserved than the language and general development in the affected children.

BIND score: A system to triage infants readmitted for extreme hyperbilirubinemia

Extreme hyperbilirubinemia [EHB, total serum bilirubin (TB) >25 mg/dL]) can lead to death, acute bilirubin encephalopathy (ABE), exchange transfusion, and/or bilirubin-induced neurologic dysfunction (BIND). In specific low- to middle-income countries, an "epidemic" exists, therefore, a simplified triage management system is needed. Here, we studied a cohort of 72 infants readmitted for EHB (TB: 28.1 ± 2.5; range: 25-42 mg/dL). Of these, 15/72 (20.8%) newborns had BIND scores ≥4. Eleven (15.3%) infants with BIND scores of 4 to 6 developed moderate ABE, with 6/11 (54.5%) with TB of 28.1 ± 4.8 mg/dL having post-icteric sequelae. Eight infants (TB of 32.1 ± 3.5 mg/dL) had BIND scores >6 and developed adverse outcomes. One infant, who had Rh disease and a BIND score of 8 died. We report that the key determinants for adverse outcomes were TB >30 mg/dL and a BIND score ≥4 and may be useful for a systems approach to triage infants readmitted for EHB.

Exchange transfusion for neonatal hyperbilirubinemia: A multicenter, prospective study of Turkish Neonatal Society

Objective

The frequency of neonatal exchange transfusion has declined in recent years, but is still performed in many countries. The procedure is associated with complications. The aim of the study was to determine the clinical features and etiologies of infants with hyperbilirubinemia who underwent exchange transfusion and evaluate the adverse events and clinical outcomes.

Material and Methods

We performed a secondary analysis of the multicenter Turkish Neonatal Jaundice Online Registry data. Otherwise healthy newborns born ≥35 weeks of gestation who were hospitalized for jaundice and underwent exchange transfusion were included.

Results

One-hundred thirty-two patients with a mean serum bilirubin level on admission of 24.9±9.1 mg/dL were enrolled in the study. The most common cause for exchange transfusion was hemolytic jaundice (63.6%), followed by lack of proper feeding (12.9%). It was found that the infants with lack of proper feeding were discharged earlier from the maternity ward (p=0.02), but they were admitted to hospital later (p<0.001) with a higher bilirubin level (p=0.001), and geater weight loss (p=0.04). The reported rate of adverse events associated with exchange transfusion was 11.4%. The most common complication was thrombocytopenia (40%). None of the infants died during the procedure. Acute bilirubin encephalopathy was reported in 13 (9.8%) patients.

Conclusion

Severe hyperbilirubinemia requiring exchange transfusion and acute bilirubin encephalopathy are still challenging problems in neonatal periodin our country. The policies including blood group analysis of pregnant women, programs informing parents about breastfeeding and jaundice, and monitoring bilirubin levels of high-risk newborns should be developed to reduce the necessitating for exchange transfusion and to avoid related complications.

Differential effects of antiretroviral drug toxicity in male versus female children who are HIV-exposed but uninfected

: In recent years, widespread use of antiretroviral therapy (ART) during pregnancy has been increasingly effective in reducing risk of vertical transmission of HIV, with over 80% of pregnant women living with HIV now accessing ART, and a 41% reduction in new infections in children between 2010 and 2018. Despite these strides, the developmental toxicity of widely administered antiretroviral drugs (ARVs) remains poorly described and existing literature often fails to account for fetal and infant sex as a variable. Recent reports have identified associations between in-utero exposure to commonly used antiretroviral regimens and alteration in neurodevelopment, growth, and metabolism amongst children who are HIV-exposed but uninfected, with findings of sex differences in the prevalence and severity of ARV toxicity. These differences are potentially explained by variable exposure to ARV drugs in utero or exacerbation of existing sex-linked risk factors. Fetal ARV exposure is mediated by placental and fetal drug transporters and metabolic enzymes, which may contribute to the manifestation of sex differences. Existing evidence of sex differences in ARV toxicity in fetal development is concerning, and demands further research to guide optimal treatment options for maternal health and prevention of vertical HIV transmission.

The Association between Serum Bilirubin and Kernicterus Spectrum Disorder: A Systematic Review and Meta-Analysis

BACKGROUND

Total serum bilirubin (TSB) is used in managing neonates with jaundice, but clear evidence on its association with major outcomes is lacking.

OBJECTIVES

We evaluated the association between TSB and kernicterus spectrum disorder (KSD).

METHODS

We searched PubMed, EMBASE, and CENTRAL till July 2021. Two authors independently selected relevant cohort studies, extracted data (CHARMS checklist), assessed risk of bias (RoB) (QUIPS tool), and rated certainty-of-evidence (Grades of Recommendation, Assessment, Development, and Evaluation). We pooled adjusted odds ratio (aOR) (random-effect) via generic inverse variance methods.

RESULTS

From 2,826 records retrieved, we included 37 studies (n = 648,979). Fifteen studies had low, 16 moderate, and 6 high RoB, with majority having concerns on confounder adjustment and statistical analysis. Twenty-two studies contributed meta-analysis data, and 15 were summarized narratively. TSB appears associated with KSD in infants with certain risk factors (aOR 1.10, 95% CI: 1.07-1.13; 5 studies [n = 4,484]). However, TSB (aOR 1.10, 95% CI: 0.98-1.23; 1 study [n = 34,533]) or hyperbilirubinemia (aOR 1.00, 95% CI: 0.51-1.95; 2 studies [n = 56,578]) have no clear association with kernicterus or neurological diagnosis in overall neonatal population (moderate-certainty-evidence). One study shows that infants with hyperbilirubinemia appear likelier to develop attention-deficit disorder (aOR 1.90, 95% CI: 1.10-3.28) and autistic spectrum disorder (aOR 1.60, 95% CI: 1.03-2.49, n = 56,019) (low-certainty-evidence). Certain clinical factors appear associated with KSD, although very few studies contributed to the analyses.

CONCLUSIONS

Despite the importance of this question, there is insufficient high-quality evidence on the independent prognostic value of TSB for adverse neurodevelopmental outcomes in most neonatal populations. Future studies should incorporate all known risk factors alongside TSB in a multivariable analysis to improve certainty-of-evidence.

Neurodevelopmental outcome of healthy term newborn with serum bilirubin >15 mg/dl at one year

BACKGROUND

Neonatal hyperbilirubinemia is a common medical emergency in early neonatal period. Unconjugated bilirubin is neurotoxic and can lead to lifelong neurological sequelae in survivors.

OBJECTIVE

To find out the association between serum bilirubin and neurodevelopmental outcome at 1 year of age using Development Assessment Scale for Indian Infants (DASII).

METHODS

A prospective cohort study was conducted in the Department of Pediatrics of a tertiary care institution of Central India between January 2018 and August 2019. Total 108 term healthy neonates, with at least one serum bilirubin value of >15 mg/dl, were included. Subjects were divided into three groups based on the serum bilirubin; group 1: (15-20 mg/dl) -85(78.7%) cases, group 2: (20-25 mg/dl) -17(15.7%), and group 3: (>25 mg/dl) -6(5.5%). Developmental assessment was done using DASII at 3, 6, 9, 12 months of age.

RESULTS

Out of 108 cases, 101(93.5%) received phototherapy, and 7(6.5%) received double volume exchange transfusion. Severe delay was observed in 5(4.6%) and mild delay in 2(1.9%) cases in the motor domain of DASII at one year. Severe delay in the motor domain was associated with mean TSB of 27.940±2.89 mg/dl and mild delay with mean TSB of 22.75±1.76 mg/dl (p = 0.001). On cluster analysis, delay was observed in locomotion 1 score in 11(13%) cases (p = 0.003) and manipulation score in 6(7.1%) cases in group 1.

CONCLUSION

Increased serum bilirubin was a significant risk factor for the delayed neurodevelopment in babies with neonatal jaundice. Even a moderate level of bilirubin significantly affects the developmental outcome.

Nomogram for Acute Bilirubin Encephalopathy Risk in Newborns With Extreme Hyperbilirubinemia

Background and Objectives: This work aimed to develop a predictive model of neonatal acute bilirubin encephalopathy.

Methods: We retrospectively analyzed the data on extreme hyperbilirubinemia (EHB) newborns hospitalized in the First Hospital of Jilin University from January 1, 2012 to December 31, 2019. The demographic characteristics, pathological information, and admission examination results of newborns were collected to analyze the factors affecting acute bilirubin encephalopathy and to establish a predictive model.

Results: A total of 517 newborns were included in this study, of which 102 (19.7%) had acute bilirubin encephalopathy. T1WI hyperintensity [18.819 (8.838–40.069)], mother's age > 35 years [2.618 (1.096–6.2530)], abnormal white blood cell (WBC) [6.503 (0.226–18.994)], TSB level [1.340 (1.242–1.445)], and albumin level [0.812 (0.726–0.907)] were independently associated with neonatal acute bilirubin encephalopathy (ABE). All independently associated risk factors were used to form an ABE risk estimation nomogram. The bootstrap validation method was used to internally validate the resulting model. The nomogram demonstrated good accuracy in predicting the risk of ABE, with an unadjusted C index of 0.943 (95% CI, 0.919–0.962) and a bootstrap-corrected C index of 0.900.

Conclusion: A nomogram was constructed using five risk factors of ABE. This model can help clinicians determine the best treatment for neonatal hyperbilirubinemia.

A single-center experience on exchange transfusion therapy in 123 full-term cases of severe neonatal hyperbilirubinemia in Wuhan

OBJECTIVE

To describe the clinical experience in application of exchange transfusion therapy (ETT) in the treatment of severe neonatal hyperbilirubinemia.

METHODS

The clinical data and examination results of severe neonatal hyperbilirubinemia full-term cases treated by ETT were analyzed retrospectively, the etiology and risk factors of severe neonatal hyperbilirubinemia were statistically analyzed, and the statistical characteristics of the children in each etiological group and the incidence of adverse events of ETT were analyzed.

RESULTS

The age of jaundice, peak total bilirubin after phototherapy and ETT in 123 full-term infants were 2.0 (1.0, 3.0) days, 4.0 (2.0, 7.0) days and 4.0 (2.0, 7.0) days, respectively, of which 68 were male and 55 were female. The main pathogeny of severe neonatal hyperbilirubinemia was blood group incompatibility hemolytic disease of newborn (HDN). Age of ETT, total bilirubin after ETT, gender and BAEP results were different between ABE and non-ABE infants. Weight loss can be used as a predictor of hospitalization length. The major adverse events related to ETT were hypocalcemia, hypomagnesemia, hyponatremia and thrombocytopenia.

CONCLUSIONS

ETT can rapidly reduce the level of total bilirubin to prevent ABE and play an important role in the treatment of neonatal hyperbilirubinemia, but the whole process of ETT needs to be closely monitored.

Neonatal Indirect Hyperbilirubinemia

Neonatal indirect hyperbilirubinemia (IHB) is caused by an imbalance in bilirubin production and elimination. Approximately 60% of term and 80% of preterm infants develop jaundice in the first week of age. This review seeks to provide the reader with a thorough understanding of the physiology of bilirubin, etiology of IHB, and management of severe IHB. Phototherapy and exchange transfusion remain the mainstays of treatment for severe IHB. Noninvasive screening tools, innovative treatments, and a better understanding of how prematurity and genetics contribute to severe IHB have improved our understanding of IHB and may help eliminate the hazards associated with severe IHB, including kernicterus spectrum disorder.

Molecular Physiology and Pathophysiology of Bilirubin Handling by the Blood, Liver, Intestine, and Brain in the Newborn

Bilirubin is the end product of heme catabolism formed during a process that involves oxidation-reduction reactions and conserves iron body stores. Unconjugated hyperbilirubinemia is common in newborn infants, but rare later in life. The basic physiology of bilirubin metabolism, such as production, transport, and excretion, has been well described. However, in the neonate, numerous variables related to nutrition, ethnicity, and genetic variants at several metabolic steps may be superimposed on the normal physiological hyperbilirubinemia that occurs in the first week of life and results in bilirubin levels that may be toxic to the brain. Bilirubin exists in several isomeric forms that differ in their polarities and is considered a physiologically important antioxidant. Here we review the chemistry of the bilirubin molecule and its metabolism in the body with a particular focus on the processes that impact the newborn infant, and how differences relative to older children and adults contribute to the risk of developing both acute and long-term neurological sequelae in the newborn infant. The final section deals with the interplay between the brain and bilirubin and its entry, clearance, and accumulation. We conclude with a discussion of the current state of knowledge regarding the mechanism(s) of bilirubin neurotoxicity.

Use of reflective materials during phototherapy for newborn infants with unconjugated hyperbilirubinaemia

BACKGROUND

Phototherapy is a well-established effective therapy for treating babies with significant neonatal jaundice. Studies have shown that increasing light intensity will increase its efficiency. A potentially inexpensive and easy way of increasing the intensity of light on the body of the infant may be to hang reflective materials from the sides of phototherapy units.

OBJECTIVES

To assess the effects of reflective materials in combination with phototherapy compared with phototherapy alone for unconjugated hyperbilirubinaemia in neonates.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 11), in the Cochrane Library; Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions(R); and the Cumulative Index of Nursing and Allied Health Literature (CINAHL), on 1 November 2019. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials if the participants, who were term or preterm infants, received phototherapy with curtains made of reflective materials of any type in the treatment arm, and if those in the comparison arm received similar phototherapy without curtains or other intensified phototherapy, such as a double bank of lights.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

Of 15 studies identified, we included 12 (1288 babies) in the review - 11 comparing phototherapy with reflective materials and phototherapy alone, and one comparing a single phototherapy light bank with reflective materials with double phototherapy. All reflective materials consisted of curtains on three or four sides of the cot and were made of white plastic (five studies), white linen (two studies), or aluminium (three studies); materials were not specified in two studies. Only 11 studies (10 comparing reflective materials versus none and one comparing reflective curtains and a single bank of lights with a double (above and below) phototherapy unit) provided sufficient data to be included in the meta-analysis. Two excluded studies used the reflective materials in a way that did not meet our inclusion criteria, and we excluded one study because it compared four different phototherapy interventions not including reflective materials. The risk of bias of included studies was generally low, but all studies had high risk of performance bias due to lack of blinding of the intervention. Three studies (281 participants) reported a decline in serum bilirubin (SB) (μmol/L) at four to eight hours (mean difference (MD) -14.61, 95% confidence interval (CI) -19.80 to -9.42; I² = 57%; moderate-certainty evidence). Nine studies (893 participants) reported a decline in SB over 24 hours and showed a faster decline in SB in the intervention group, but heterogeneity (I² = 97%) was too substantial to permit a meaningful estimate of the actual effect size (very low-certainty evidence). Subgroup analysis by type of reflective material used did not explain the heterogeneity. Exchange transfusion was reported by two studies; both reported none in either group. Four studies (466 participants) reported the mean duration of phototherapy, and in each of these studies, it was reduced in the intervention group but there was substantial heterogeneity (I² = 88%), precluding meaningful meta-analysis of data. The only two studies that reported the mean duration of hospital stay in hours showed a meaningful reduction (MD -41.08, 95% CI -45.92 to -36.25; I² = 0; moderate-certainty evidence). No studies reported costs of the intervention, parental or medical staff satisfaction, breastfeeding outcomes, or neurodevelopmental follow-up. The only study that compared use of curtains with double phototherapy reported similar results for both groups. Studies that monitored adverse events did not report increased adverse events related to the use of curtains, including acute life-threatening events, but other rarer side effects could not be excluded.

AUTHORS' CONCLUSIONS

Moderate-certainty evidence shows that the use of reflective curtains during phototherapy may result in greater decline in SB. Very low-certainty evidence suggests that the duration of phototherapy is reduced, and moderate-certainty evidence shows that the duration of hospital stay is also reduced. Available evidence does not show any increase in adverse events, but further studies are needed.

Association between maternal hypertensive disorders of pregnancy and child neurodevelopment at 3 years of age: a retrospective cohort study

Hypertensive disorders of pregnancy (HDP) affect up to 10% of women during pregnancy and influence child neurodevelopment, including mental and motor function. We assessed whether HDP, including gestational hypertension, preeclampsia, superimposed preeclampsia, and eclampsia, correlate with motor and mental developmental abnormalities in 3-year-old children, using data obtained between April 2004 and March 2013 through a mandatory population-based health checkup of mothers and children in Kobe city, Japan. The primary outcome was motor and mental developmental abnormalities at 3 years of age; parental-reported questionnaires and physician's medical examinations were evaluated. The association between maternal HDP and child neurodevelopmental abnormality was evaluated using a logistic regression model. Of the 43,854 participating children, 1120 were born to women with HDP and 42,734 were born to women without HDP. The prevalence of motor developmental abnormality was 1.7% in the exposed group and 0.95% in the control group; the prevalence of mental developmental abnormality was 2.41% in the exposed group and 1.22% in the control group. Children born to mothers with HDP did not have an increased risk of motor developmental abnormality at the age of 3 years [adjusted odds ratio (OR) 1.17, 95% confidence interval 0.72-1.91], but had an increased risk of mental developmental abnormality (adjusted OR 1.80, 95% confidence interval 1.21-2.69). Maternal HDP were associated with mental development abnormality in 3-year-old children. These findings may be clinically relevant; mental abnormality in children born to women with HDP could be detected during early stages, which would facilitate early intervention.

Baby-Friendly Hospital Initiative Is Associated with Lower Rates of Neonatal Hyperbilirubinemia

Background: The Baby-Friendly Hospital Initiative (BFHI) advances practices that support exclusive breastfeeding. BFHI practices are associated with increased breastfeeding rates, however, other patient outcomes are not well described. This study examined the association of BFHI practices with hyperbilirubinemia and phototherapy between groups of newborns born before and after BFHI implementation at an urban, tertiary academic medical center in South Carolina. Materials and Methods: We conducted a retrospective study of healthy, term newborns born between July and September 2011 (n = 956), before BFHI implementation, and newborns born during the same period in 2013 (n = 1,131) after BFHI implementation. Primary outcomes were neonatal hyperbilirubinemia, phototherapy treatment, and hospital readmissions for hyperbilirubinemia within 30 days of discharge. We compared rates of outcomes between the study groups using unadjusted and adjusted odds ratios (OR). Results: Among newborns born before versus after BFHI implementation, 20.3% versus 6.98% were diagnosed with hyperbilirubinemia (p < 0.001), 5.75% versus 1.95% received phototherapy (p < 0.001), and 0.31% versus 0.35% were readmitted to the hospital for hyperbilirubinemia within 30 days (p = 0.88). In adjusted analyses, newborns born after BFHI implementation were significantly less likely to develop neonatal hyperbilirubinemia (OR 0.28 [95% confidence intervals; CI 0.20-0.37]) and receive phototherapy treatment (OR 0.27 [95% CI 0.15-0.49]) than newborns born before BFHI implementation. Conclusions: Implementation of BFHI practices is associated with significant decreases in neonatal hyperbilirubinemia and phototherapy without affecting readmission rates. Exclusive breastfeeding has traditionally been considered a risk factor for the development of neonatal jaundice. This study demonstrates that BFHI practices may mitigate that risk.

A clinical prediction rule for acute bilirubin encephalopathy in neonates with extreme hyperbilirubinemia: A retrospective cohort study

To establish a clinical prediction rule for acute bilirubin encephalopathy (ABE) in term/near-term neonates with extreme hyperbilirubinemia.A retrospective cohort study was conducted between January 2015 and December 2018. Six hundred seventy-three out of 26,369 consecutive neonates with extreme hyperbilirubinemia were enrolled in this study. Data included demographic characteristics, total serum bilirubin (TSB), albumin, bilirubin/albumin ratio (B/A), direct antiglobulin test, glucose-6-phosphate deficiency, asphyxia, sepsis, acidosis. ABE was defined as a bilirubin induced neurological dysfunction score of 4 to 9. We used stepwise logistic regression to select predictors of ABE and devised a prediction score.Of the 673 eligible infants, 10.8% suffered from ABE. Our prediction score consisted of 3 variables: TSB (as a continuous variable; odds ratio [OR] 1.16; 95% confidence interval [CI], 1.02-1.31; logistic coefficient 0.15), B/A (as a continuous variable; OR 1.88; 95% CI, 1.19-2.97; logistic coefficient 0.67), and sepsis (OR 3.78; 95% CI, 1.40-10.21; logistic coefficient 1.19). Multiplying the logistic coefficients by 10 and subtracting 75, resulted in the following equation for the score: Score = 12 × (if sepsis) + 1.5 × (TSB) + 7 × (B/A) - 75. The model performed well with an area under the curve of 0.871.The risk of ABE can be quantified according to TSB, B/A, and sepsis in term/near-term neonates with extreme hyperbilirubinemia.

Improving Evaluation and Treatment of Hyperbilirubinemia in Late Preterm Infants

Late preterm (LPT) infants are at an increased risk for hyperbilirubinemia. Accurate identification and early treatment are needed for optimal health outcomes. In a newborn nursery at an academic medical center, bilirubin levels were drawn at 24 hours of life, per protocol. These infants were rarely treated at this time. Rather, predischarge bilirubin levels (at about 48 hours of life) would indicate treatment, often leading to increased length of hospital stay. The practice change evaluation was conducted using retrospective medical record review. Practice change to test serum bilirubin levels at 36 hours of life rather than 24 hours of life. Compliance with the practice change was achieved (P < .05). More LPT infants were identified and treated for hyperbilirubinemia without an increase in length of stay. Readmissions for hyperbilirubinemia and blood draw rates also declined. Although more LPT infants were identified and treated for hyperbilirubinemia, there is room for improvement, and increased adherence to the policy might yield an even greater impact on quality and safety of care surrounding bilirubin management.

How Often Are Patient-Important Outcomes Represented in Neonatal Randomized Controlled Trials? An Analysis of Cochrane Neonatal Reviews

BACKGROUND

Research findings based on patient-important outcomes (PIOs) provide more useful conclusions than those that are based on surrogate outcomes. It is unclear to what extent PIOs are represented in neonatal randomized controlled trials (RCTs).

OBJECTIVES

We determined the proportion of PIOs in neonatal RCTs included in Cochrane Neonatal reviews.

METHODS

We extracted up to 5 outcomes from each RCT included in Cochrane Neonatal reviews published until January 2018, with independent determination of PIOs among authors followed by a discussion leading to a consensus. We defined PIOs as outcomes that matter to patient care, such as clinical events or physiological or laboratory parameters that are widely used to guide management.

RESULTS

Among 6,832 outcomes extracted from 1,874 RCTs included in 276 reviews, 5,349 (78.3%) were considered PIOs; 461 studies (24.5%) included 5 or more PIOs, 1,278 (68.2%) included 1-4 PIOs, while 135 (7.2%) had no PIO included. PIOs were observed more often among dichotomous than among continuous outcomes (94.9 vs. 61.5%; RR: 1.54; 95% CI: 1.50-1.58), and more among subjective than among objective outcomes (95.9 vs. 76.8%; RR: 1.25; 95% CI: 1.22-1.28). Newer studies were more likely to have a greater number of PIOs (adjusted OR: 1.033 [95% CI: 1.025-1.041] with each publication year).

CONCLUSIONS

The large and increasing representation of PIOs over the years suggests an improving awareness by neonatal trialists of the need to incorporate important outcomes in order to justify the utilization of resources. Further research should explore the reasons for non-inclusion or non-reporting of PIOs in a small proportion of RCTs.

The Choice of Population and Outcomes in Neonatal Trials on Hyperbilirubinemia: Are They Relevant? An Analysis of Cochrane Neonatal Reviews

BACKGROUND

Neonates with jaundice are usually managed according to their serum bilirubin despite an unclear overall correlation between bilirubin levels and patient-important outcomes (PIOs) such as kernicterus spectrum disorder (KSD).

OBJECTIVES

We examined data from Cochrane Neonatal reviews to assess whether conditions that constituted KSD were included as key outcomes and how commonly they occurred in the population studied.

METHODS

We identified Cochrane reviews, published till November 2017 that evaluated interventions for neonatal jaundice (NNJ). We extracted the following information at the review and study levels: included population, outcomes assessed (in particular, whether PIOs such as KSD were listed as the primary outcomes), as well as their cumulative incidence in the reviews.

RESULTS

Out of 311 reviews, 11 evaluated interventions for NNJ with 78 randomized controlled trials (RCTs) included. Among the reviews, a total number of 148 outcomes were predefined and 30 (20.3%) were PIOs related to KSD, with 11 (36.7%) listed as primary outcomes. Among the 78 included RCTs (total participants = 8,232), 38 (48.7%) enrolled predominantly high-risk and 40 (51.3%) enrolled predominantly low-risk population. A total number of 431 outcomes were reported, and 40 (9.2%) were PIOs related to KSD (of which 37 were from studies with high-risk infants), with 13 (32.5%) listed as primary outcome. Cumulatively, no infant developed KSD across all studies.

CONCLUSIONS

There is suboptimal representation of PIOs such as KSD in neonatal trials and Cochrane reviews on NNJ. Over half of the trials included populations with very low risk of KSD, which does not represent judicious use of resources. Amidst our continued search for a more reliable surrogate marker for NNJ, studies should evaluate the whole spectrum KSD alongside serum bilirubin in high-risk populations with sufficiently significant event rates, as this will make the trial methodologically feasible, with findings that will impact the population concerned.

Extreme neonatal hyperbilirubinaemia in refugee and migrant populations: retrospective cohort

OBJECTIVE

To describe neonatal survival and long-term neurological outcome in neonatal hyperbilirubinaemia (NH) with extreme serum bilirubin (SBR) values.

DESIGN

Retrospective chart review, a one-off neurodevelopmental evaluation.

SETTING

Special care baby unit in a refugee camp and clinics for migrant populations at the Thailand-Myanmar border with phototherapy facilities but limited access to exchange transfusion (ET).

PATIENTS

Neonates ≥28 weeks of gestational age with extreme SBR values and/or acute neurological symptoms, neurodevelopment evaluation conducted at 23-97 months of age.

MAIN OUTCOME MEASURES

Neonatal mortality rate, prevalence of acute bilirubin encephalopathy (ABE) signs, prevalence of delayed development scores based on the Griffiths Mental Development Scale (GMDS).

RESULTS

From 2009 to 2014, 1946 neonates were diagnosed with jaundice; 129 (6.6%) had extreme SBR values during NH (extreme NH). In this group, the median peak SBR was 430 (IQR 371-487) µmol/L and the prevalence of ABE was 28.2%. Extreme NH-related mortality was 10.9% (14/129). Median percentile GMDS general score of 37 survivors of extreme NH was poor: 11 (2-42). 'Performance', 'practical reasoning' and 'hearing and language' domains were most affected. Four (10.8%) extreme NH survivors had normal development scores (≥50th centile). Two (5.4%) developed the most severe form of kernicterus spectrum disorders.

CONCLUSION

In this limited-resource setting, poor neonatal survival and neurodevelopmental outcomes, after extreme NH, were high. Early identification and adequate treatment of NH where ET is not readily available are key to minimising the risk of extreme SBR values or neurological symptoms.

Neonatal subgaleal hemorrhage unrelated to assisted vaginal delivery: clinical course and outcomes

PURPOSE

The purpose of the study was to evaluate the occurrence of subgaleal hemorrhage (SGH) following non-assisted vaginal delivery (normal vaginal delivery or cesarean delivery), and to characterize associated factors, clinical course, and outcomes, compared to attempted assisted vaginal delivery (AVD)-associated SGH METHODS: A retrospective cohort study was conducted. All cases of SGH encountered following delivery of a singleton neonate at Hadassah, Hebrew University Medical Center during 2011-2018 were included. Maternal, fetal, intrapartum, and neonatal characteristics and outcomes were compared between AVD-related and non-AVD-related SGH groups.

RESULTS

The overall incidence of SGH was 4.5/1000 (369/82,256) singleton deliveries. The incidences of AVD- and non-AVD-related SGH were 44.6/1000 (350/7852) and 0.3/1000 (19/74,404) singleton deliveries, respectively. Ten (53%) of the 19 non-AVD-related SGH were diagnosed after vaginal delivery and 9 (47%) after an urgent cesarean section. SGH severity was mild, moderate, and severe in 68%, 16%, and 16% of the cases, respectively. SGH severity did not differ between the attempted AVD group and the non-AVD-related SGH group. A higher proportion of neonates with non-AVD SGH required phototherapy treatment than did those diagnosed with AVD-related SGH (56% vs. 24%, P = 0.003). Other neonatal outcomes, including Apgar scores, maximal bilirubin level, length of stay, and the rate of composite adverse outcomes, did not differ between the groups.

CONCLUSIONS

SGH, although rare, may be diagnosed after unassisted vaginal or cesarean delivery in the absence of an AVD attempt. We advocate continuing education for all medical staff who participate in peripartum and neonatal care, regarding the possible occurrence of non-AVD-related SGH.

The efficacy of intravenous fluid supplementation for neonatal hyperbilirubinemia: a meta-analysis of randomized controlled studies

Introduction: The efficacy of intravenous fluid supplementation for neonatal hyperbilirubinemia remains controversial. We conduct a systematic review and meta-analysis to explore the influence of intravenous fluid supplementation on treatment efficacy of neonatal hyperbilirubinemia.Methods: We search PubMed, Embase, Web of Science, EBSCO, and Cochrane Library databases through June 2019 for randomized controlled trials (RCTs) assessing the efficacy of intravenous fluid supplementation for neonatal hyperbilirubinemia. This meta-analysis is performed using the random-effect model.Results: Six RCTs are included in the meta-analysis. Overall, compared with control group for neonatal hyperbilirubinemia, intravenous fluid supplementation is associated with decreased TSB at 8 h (std. MD = -0.82; 95% CI = -1.46 to -0.17; p = .01), 12 h (std. MD = -0.46; 95% CI = -0.81 to -0.10; p = .01), 24 h (std. MD = -0.47; 95% CI = -0.78 to -0.16; p = .003) and 36 h (std. MD = -0.37; 95% CI = -0.73 to -0.02; p = .04), as well as reduced incidence of exchange transfusion (RR = 0.29; 95% CI = 0.14-0.59; p = .0006), but has no significant impact on duration of phototherapy (std. MD = -0.34; 95% CI = -0.88-0.21; p = .22).Conclusions: Intravenous fluid supplementation can provide additional benefits for the treatment of neonatal hyperbilirubinemia.

Characteristics and outcome of newborn admitted with acute bilirubin encephalopathy to a tertiary neonatal intensive care unit

BACKGROUND

Acute bilirubin encephalopathy (ABE) still represents a significant cause of morbidity and mortality throughout the world, especially in developing countries. We aimed to determine the prevalence of ABE based on the Johnson bilirubin-induced neurologic dysfunction (BIND) score and to describe the discharge outcomes.

METHODS

We prospectively studied all newborns ≥ 35 weeks with ABE by evaluating signs of mental sensorium, muscle tone, and cry patterns over 1 year.

RESULTS

12% (81 out of 674) of the newborns admitted for neonatal hyperbilirubinemia had a BIND score > 1. Their admission age was 6 ± 4.1 days; total serum bilirubin (TSB) was 31.2 ± 10 mg/dL (range 17.5-75.2). Of these newborns, 40.7% and 21% had evidence of haemolysis and sepsis, respectively. Overall mortality was 9.9%; 58% of the newborns showed signs of mild-to-moderate BIND at discharge, while 32.1% survived with an apparently normal outcome. Admission BIND score was significantly correlated with admission TSB (r = 0.476, P < 0.001). Similarly, BIND score at discharge was correlated with admission TSB (r = 0.442, P < 0.001) and admission BIND score (r = 0.888, P < 0.001). The regression model showed that admission TSB (P < 0.001) and maternal illiteracy (P = 0.034) were predictors of the BIND score at admission, while admission BIND score was the best indicator of the discharge score (P < 0.001).

CONCLUSIONS

ABE is still a major problem in our community. Admission TSB and maternal illiteracy are good predictors of bilirubin encephalopathy at admission and discharge.

High unbound bilirubin for age: a neurotoxin with major effects on the developing brain

Neonatal hyperbilirubinemia is one of the most frequent diagnoses made in neonates. A high level of unconjugated bilirubin that is unbound to albumin is neurotoxic when the level exceeds age-specific thresholds or at lower levels in neonates with neurotoxic risk factors. Lower range of unbound bilirubin results in apoptosis, while moderate-to-high levels result in neuronal necrosis. Basal ganglia and various brain stem nuclei are more susceptible to bilirubin toxicity. Proposed mechanisms of bilirubin-induced neurotoxicity include excessive release of glutamate, mitochondrial energy failure, release of proinflammatory cytokines, and increased intracellular calcium concentration. These mechanisms are similar to the events that occur following hypoxic-ischemic insult in neonates. Severe hyperbilirubinemia in term neonates has been shown to be associated with increased risk for autism spectrum disorders. The neuropathological finding of bilirubin-induced neurotoxicity also includes cerebellar injury with a decreased number of Purkinje cells, and disruption of multisensory feedback loop between cerebellum and cortical neurons which may explain the clinical characteristics of autism spectrum disorders. Severe hyperbilirubinemia occurs more frequently in infants from low- and middle-income countries (LMIC). Simple devices to measure bilirubin, and timely treatment are essential to reduce neurotoxicity, and improve outcomes for thousands of neonates around the world.