An Evidence-Based Review of Important Issues Concerning Neonatal Hyperbilirubinemia

Abstract

This article is adapted from a published evidence report concerning neonatal hyperbilirubinemia with an added section on the risk of blood exchange transfusion (BET). Based on a summary of multiple case reports that spanned more than 30 years, we conclude that kernicterus, although infrequent, has at least 10% mortality and at least 70% long-term morbidity. It is evident that the preponderance of kernicterus cases occurred in infants with a bilirubin level higher than 20 mg/dL. Given the diversity of conclusions on the relationship between peak bilirubin levels and behavioral and neurodevelopmental outcomes, it is apparent that the use of a single total serum bilirubin level to predict long-term outcomes is inadequate and will lead to conflicting results. Evidence for efficacy of treatments for neonatal hyperbilirubinemia was limited. Overall, the 4 qualifying studies showed that phototherapy had an absolute risk-reduction rate of 10% to 17% for prevention of serum bilirubin levels higher than 20 mg/dL in healthy infants with jaundice. There is no evidence to suggest that phototherapy for neonatal hyperbilirubinemia has any long-term adverse neurodevelopmental effects. Transcutaneous measurements of bilirubin have a linear correlation to total serum bilirubin and may be useful as screening devices to detect clinically significant jaundice and decrease the need for serum bilirubin determinations. Based on our review of the risks associated with BETs from 15 studies consisting mainly of infants born before 1970, we conclude that the mortality within 6 hours of BET ranged from 3 per 1000 to 4 per 1000 exchanged infants who were term and without serious hemolytic diseases. Regardless of the definitions and rates of BET-associated morbidity and the various pre-exchange clinical states of the exchanged infants, in many cases the morbidity was minor (eg, postexchange anemia). Based on the results from the most recent study to report BET morbidity, the overall risk of permanent sequelae in 25 sick infants who survived BET was from 5% to 10%.

Adverse Events of Exchange Transfusion in Neonatal Hyperbilirubinemia

“…Whole blood collected in CDPA compa ble to mother and baby was used. Removal and infusion of small aliquots of blood was performed in all neonates through umbilical vein catheteriza on as per the standard published guidelines 8 . The catheter was removed a er the procedure.…”

“…The modality of exchange transfusion in the treatment of hyperbilirubinemia was a proven therapy, probably two decades back, however with the availability of highly eff ec ve double surface and LED phototherapy and administra on of intravenous immunoglobulin G (IVIg) in preven on of isoimmuniza on / blood group incompa bility, the number of exchange transfusions have signifi cantly reduced 7 . However, despite having adverse events, it leads to a rapid decline in serum bilirubin levels in symptoma c neonates suffi cient enough to minimize the brain damage 8 . We report our observa ons on effi cacy, adverse events and factors contribu ng to mortality related with ET performed for the treatment of neonatal hyperbilirubinemia at a ter ary-care centre.…”

Acompanhamento da icterícia neonatal em recém-nascidos de termo e prematuros tardios

“…Using intensive phototherapy equipment with rehospitalized children allowed shorter duration treatments (< 48 hours), with reductions in length of hospital stay, costs and stress to family members with consequences for the future 21 and avoids exchange transfusions with the elevated costs and risks they involve. 30 Finally, the adoption of the regime used at our service suggests that it is possible to significantly reduce the costs of monitoring jaundiced neonates without causing any increase to the risk they are submitted.…”

Effects of sample dilution, peroxidase concentration, and chloride ion on the measurement of unbound bilirubin in premature newborns

“…The plasma or serum total bilirubin concentration (TBC) is the conventional laboratory criterion used for evaluating and treating jaundiced newborns [4][5][6][7]. Evidence in both animals [8] and humans [9][10][11], however, suggests that the minute fraction of TBC not bound to albumin, referred to as the unbound or "free" bilirubin concentration (B f ), correlates more strongly with bilirubin toxicity than the TBC.…”