Treatment Options in Neonatal Jaundice

30 June, 2011 by: colinparker

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Phototherapy treatment will be sufficient for the vast majority of infants with unconjugated hyperbilirubinaemia who need treatment.  When it gets more serious, we turn to higher-risk treatments like IntraVenous Immunoglobulin or exchange transfusion. What evidence do we have to guide our decisions here?

Every Special Care Nursery in the world has a bilirubin chart on the wall to guide us in terms of phototherapy limits and when to consider exchange transfusion.  Many of these are based on a study backed by the American Academy of Pediatrics from 2004.  More recently, the National Institute for Clinical Excellence in the UK have released some consensus guidelines on the treatment of neonatal jaundice.  In this podcast, we explore some of the literature relating to the care of jaundiced neonates.

Outline: Jaundice Treatment PEMcast

[CP]  intro, disclaimer

1 umol/L of bilirubin = 17.1 mg/dL

Honourable Mentions:
Maisels 2008
Hansen 2010

Exchange transfusion:

Mechanism, indications, risks, guidelines
[RR] quotes [AAP 2004 guidelines]
Risks of exchange transfusion: Jackson 1997
[KB] NICE CG 98 – threshold graphs in spreadsheet format

IV Ig evidence?

[RR] Alcock 2009 – Cochrane Review
[KB] Nasseri 2006 – not mentioned in Cochrane (not excluded, just ignored…probably due to language barrier, or repeat publication in 2009 without content update)

Albumin evidence?

[RR] Lack of evidence supporting use of Albumin for neonatal jaundice
Djokomuljanto 2006 – white curtains
Glacier analogy – free vs bound bilirubin (Hansen 2010)

Pharmacologic treatments on the horizon

[CP] Cuperus 2009
NICE CG 98 advises against multiple unproven therapies
Bili blanket not recommended for term babies (do not cover sufficient skin surface)

All: Summary, goodbye

Further Reading: The Papers that got away

Predicting Risk of Kernicterus: single SBR level?
(gestational age, genomic profile)
Ip 2004
Skae 2005
Ahlfors 2010

Early detection of EHBA (for early Kasai) improves outcome
Hsiao 2008 (stool colour card Taiwan)

Phototherapy: mechanism, light source, wavelength, etc
Maisels 2008

Hansen 2010
Djokomuljanto 2006 – white curtains

Breast-milk jaundice: what causes it, and is it entirely benign?
Gourley 2002
Gourley 2005


Maisels MJ, McDonagh AF.
Phototherapy for neonatal jaundice.
N Engl J Med. 2008 Feb 28;358(9):920-8. Review. PubMed PMID: 18305267.

Ruud Hansen TW.
Phototherapy for neonatal jaundice–therapeutic effects on more than one level?
Semin Perinatol. 2010 Jun;34(3):231-4. Review. PubMed PMID: 20494740.

American Academy of Pediatrics Subcommittee on Hyperbilirubinemia.
Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation.
Pediatrics. 2004 Jul;114(1):297-316. Erratum in: Pediatrics. 2004 Oct;114(4):1138. PubMed PMID: 15231951.

Jackson JC.
Adverse events associated with exchange transfusion in healthy and ill newborns.
Pediatrics. 1997 May;99(5):E7. PubMed PMID: 9113964.

National Institute for Health and Clinical Excellence
Clinical Guideline CG 98: Neonatal Jaundice
May 2010

Alcock GS, Liley H.
Immunoglobulin infusion for isoimmune haemolytic jaundice in neonates.
Cochrane Database Syst Rev. 2002;(3):CD003313. Review. PubMed PMID: 12137687.

Nasseri F, Mamouri GA, Babaei H.
Intravenous immunoglobulin in ABO and Rh hemolytic diseases of newborn.
Saudi Med J. 2006 Dec;27(12):1827-30. PubMed PMID: 17143357.

Djokomuljanto S, Quah BS, Surini Y, Noraida R, Ismail NZ, Hansen TW, Van Rostenberghe H.
Efficacy of phototherapy for neonatal jaundice is increased by the use of low-cost white reflecting curtains.
Arch Dis Child Fetal Neonatal Ed. 2006 Nov;91(6):F439-42. Epub 2006 Jul 28. PubMed PMID: 16877479.

Cuperus FJ, Hafkamp AM, Hulzebos CV, Verkade HJ.
Pharmacological therapies for unconjugated hyperbilirubinemia.
Curr Pharm Des. 2009;15(25):2927-38. Review. PubMed PMID: 19754369.

Ip S, Chung M, Kulig J, O’Brien R, Sege R, Glicken S, Maisels MJ, Lau J; American Academy of Pediatrics Subcommittee on Hyperbilirubinemia.
An evidence-based review of important issues concerning neonatal hyperbilirubinemia.
Pediatrics. 2004 Jul;114(1):e130-53. Review. PubMed PMID: 15231986.

Skae MS, Moise J, Clarke P.
Is current management of neonatal jaundice evidence based?
Arch Dis Child Fetal Neonatal Ed. 2005 Nov;90(6):F540. PubMed PMID: 16244219.

Ahlfors CE.
Predicting bilirubin neurotoxicity in jaundiced newborns.
Curr Opin Pediatr. 2010 Apr;22(2):129-33. Review. PubMed PMID: 20125026.

Hsiao CH, Chang MH, Chen HL, Lee HC, Wu TC, Lin CC, Yang YJ, Chen AC, Tiao MM, Lau BH, Chu CH, Lai MW; Taiwan Infant Stool Color Card Study Group.
Universal screening for biliary atresia using an infant stool color card in Taiwan.
Hepatology. 2008 Apr;47(4):1233-40. PubMed PMID: 18306391.

Gourley GR.
Breast-feeding, neonatal jaundice and kernicterus.
Semin Neonatol. 2002 Apr;7(2):135-41. Review. PubMed PMID: 12208098.

Gourley GR, Li Z, Kreamer BL, Kosorok MR.
A controlled, randomized, double-blind trial of prophylaxis against jaundice among breastfed newborns.
Pediatrics. 2005 Aug;116(2):385-91. PubMed PMID: 16061593.

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