Post-phototherapy neonatal bilirubin rebound: a potential cause of significant hyperbilirubinaemia

Abstract

Aim: To determine the incidence of post-phototherapy neonatal plasma total bilirubin (PTB) rebound. Methods: A prospective clinical survey was performed on 226 term and near-term neonates treated with phototherapy in the well baby nursery of the Shaare Zedek Medical Center from January 2001 to September 2002. Neonates were tested for PTB 24 hours (between 12 and 36 hours) after discontinuation of phototherapy, with additional testing as clinically indicated. The main outcome measure, significant bilirubin rebound, was defined as a post-phototherapy PTB >256 mmol/l. Phototherapy was not reinstituted in all cases of rebound, but rather according to clinical indications. Results: A total of 30 (13.3%) neonates developed significant rebound (mean (SD) PTB 287 (27) mmol/l, upper range 351 mmol/l). Twenty two of these (73%) were retreated with phototherapy at mean PTB 296 (29) mmol/l. Multiple logistic regression analysis showed significant risk for aetiological risk factors including positive direct Coombs test (odds ratio 2.44, 95% CI 1.25 to 4.74) and gestational age ,37 weeks (odds ratio 3.21, 95% CI 1.29 to 7.96). A greater number of neonates rebounded among those in whom phototherapy was commenced (72 hours (26/152, 17%) compared with .72 hours (4/74, 5.4%) (odds ratio 3.61, 95% CI 1.21 to 10.77). Conclusion: Post-phototherapy neonatal bilirubin rebound to clinically significant levels may occur, especially in cases of prematurity, direct Coombs test positivity, and those treated (72 hours. These risk factors should be taken into account when planning post-phototherapy follow up.

The effect of hematocrit on the efficacy of phototherapy for neonatal jaundice

“…Articles to accommodate transport from outside the vasculature, indicates that the blood compartment is an important site with regard to phototherapy (22).The "rebound" in serum bilirubin sometimes observed after cessation of phototherapy generally reflects continued bilirubin production due to hemolysis and not re-entrance into the blood from extravascular sites (23,24). How would the presence of bilirubin outside the vasculature complicate the model used here?…”

Tin-mesoporphyrin in the treatment of refractory hyperbilirubinemia due to Rh incompatibility

“…The availability of intensive phototherapy led to a prolonged hospitalization with no clear end in sight. In infants who receive phototherapy before discharge from the hospital, the risk of significant rebound ranges from 8 to 15% 12,13 and is likely to be higher in infants who have documented, direct antiglobulin test-positive hemolytic disease. The magnitude of the rebound in this infant (Figure 1) even after 15 days of intensive phototherapy and the declining hemoglobin levels, reflect ongoing hemolysis.…”

Israel guidelines for the management of neonatal hyperbilirubinemia and prevention of kernicterus

“…Follow-up after discontinuation of phototherapy Post-phototherapy bilirubin rebound has been studied including two Israeli centers. [43][44][45] In the absence of hemolysis, rebound did not appear to be a serious phenomenon. 43 However, when all newborns requiring phototherapy were evaluated in a Jerusalem population, rebound to levels of STB>15 mg per 100 ml and even exceeding 20 mg per 100 ml was reported.…”

“…43 However, when all newborns requiring phototherapy were evaluated in a Jerusalem population, rebound to levels of STB>15 mg per 100 ml and even exceeding 20 mg per 100 ml was reported. 44 Levels of STB reported may be of clinical significance or concern in the presence of hemolysis or additional risk factors. Subgroups at high risk for rebound included neonates with positive DAT, gestational age <37 weeks and in those in whom phototherapy was commenced within the first 3 days of life.…”