Síndrome del bebe bronceado, una complicación impredecible de la fototerapia / Bronze baby syndrome, an unpredictable complication of phototherapy: A case report

Resumen El síndrome del bebe bronceado es una rara discromía que se presenta como una complicación de la fototerapia en recién nacidos con ictericia neonatal. Aunque el fenotipo común se ha descrito en pacientes con hiperbilirrubinemia directa secundaria a colestasis, también se conocen casos con hiperbilirrubinemia indirecta en quienes se invierte el patrón de hiperbilirrubinemia e, incluso, otros con hiperbilirrubinemia indirecta aislada. La fisiopatología de la enfermedad sigue siendo motivo de controversia, por lo que no se ha establecido claramente cuál es la mejor aproximación diagnóstica y terapéutica. En general, el síndrome se considera leve y se resuelve con la suspensión de la fototerapia; no suele prolongarse más allá del periodo neonatal y no tiene secuelas a largo plazo. Sin embargo, su aparición constituye una contraindicación absoluta para continuar la fototerapia. En caso de persistir, se recomienda disminuir los niveles de bilirrubina y recurrir a la exanguinotransfusión, pero dado que esta implica riesgos para el neonato, una conducta adecuada sería suspender la fototerapia y reiniciarla si la bilirrubina directa disminuye y se ha descartado el compromiso colestásico, aunque siempre evaluando en forma seriada posibles manifestaciones de encefalopatía aguda por bilirrubina. El objetivo de este estudio fue presentar el caso de un recién nacido con incompatibilidad de grupo sanguíneo ABO que presentó el síndrome del bebé bronceado. El bebé respondió satisfactoriamente a la suspensión de la fototerapia y a su posterior reanudación, sin necesidad de recurrir a la exanguinotransfusión.

Abstract The bronze baby syndrome is an infrequent dyschromia resulting from phototherapy in newborn babies with neonatal jaundice. Even though the common phenotype has been described in patients with direct neonatal hyperbilirubinemia secondary to cholestasis, several cases of patients with indirect neonatal hyperbilirubinemia who have managed to reverse it have been reported, as well as patients with isolated hyperbilirubinemia. Currently, the physiopathology of this condition is still a subject of controversy and, therefore, there is a lack of clear conducts for its correct diagnosis and treatment. Generally, this syndrome has been considered as a mild condition that is resolved with the suspension of phototherapy. Its duration is usually not greater than the neonatal period, and it has no long-term sequelae. However, its occurrence is considered an absolute contraindication for the continuation of phototherapy. In case of persistence, the recommendation is to decrease bilirrubin levels and proceed with exchange transfusion; this procedure, however, represents risks for the newborn, so our recommendation is to suspend phototherapy and reinitiate it if the direct bilirrubin value decreases, and cholestasis compromise has been discarded. Serial evaluations of acute encephalopathy caused by bilirrubin are absolutely recommended. The objective of this paper was to describe the case of a newborn with ABO incompatibility who developed the bronze baby syndrome. This patient responded satisfactorily to the suspension and resumption of phototherapy without exchange transfusion.

From suffering to resignation: Grounded Theory approach to maternal experience with newborn in phototherapy / Do sofrimento à resignação: experiência materna com recém-nascido em fototerapia na abordagem Grounded Theory

Abstract Objectives: understanding the experience of puerperal womenwith newborn in phototherapy treatment in rooming-in care. Methods: qualitative research analyzed according to the Grounded Theory and the results discussed in the light of Symbolic Interactionism. The interviews were audiotaped and transcribed in full. The theoretical saturation was based on the analysis of the 15th interview with puerperal women, undergoing the experience in the maternity of the Public Hospital of São Paulo State. Results: from the analysis emerged four categories (sub processes): getting disappointed with the bad news; feeling recluse, separated from her baby, accountable and with not enough support for care; resigning to the protective role of mother of a baby in suffering and at risk; seeking strategies to deal with the situation. From the realignment of these categories (sub processes) emerged the core category (process): from suffering to resignation in order to deal with the maternal experience with NB in phototherapy. Conclusions: the symbolic intervening component, mother's protective role, prompted her to attempt to cope with the challenging experience by feeling compelled to exercise the function of caretaker. The same way that the rooming-in care team emerged in the experience of the mother, using the same symbol, to hold her accountable for constant vigilance in maintaining the integrity of baby's vision.

Resumo Objetivos: compreender a experiência de puérperas com recém-nascido em tratamento fototerápico em alojamento conjunto. Métodos: pesquisa qualitativa analisada segundo a Teoria Fundamentada nos Dados e os resultados discutidos à luz do Interacionismo Simbólico. As entrevistas foram audio-gravadas e transcritas na íntegra. A saturação teórica deu-se a partir da análise da 15ª entrevista com puérperas, vivenciando a experiência em maternidade de Hospital Público do Estado de São Paulo. Resultados: da análise emergiram quatro categorias (subprocessos): decepcionando-se com a má notícia; sentindo-se reclusa, apartada do bebê, responsabilizada e com apoio insuficiente para o cuidado; resignando-se ao papel protetor de mãe de bebê em sofrimento e em risco; buscando estratégias para lidar com a situação. Do realinhamento dessas categorias (subprocessos) emergiu a categoria central (processo): do sofrimento à resignação para enfrentar a experiência materna com recém-nascido em fototerapia. Conclusões: o componente interveniente simbólico, papel protetor de mãe, impulsionou-a a tentativas de lidar com a experiência desafiante ao se sentir compelida ao exercício de cuidadora. Da mesma forma que, a equipe do alojamento conjunto emergiu na vivência dessa mãe, utilizando-se do mesmo símbolo, para responsabilizá-la pela vigilância constante na manutenção da integridade da visão do bebê.

Ictericia neonatal / Neonatal jaundice

Tipos de ictericia. Origen de la bilirrubina. Toxicidad de la bilirrubina. Tratamiento

Evidências no uso de fototerapia convencional em neonatos com icterícia / Evidence on the use of phototherapy in neonates with jaundice

Este artigo apresenta uma revisão sistemática do uso de fototerapia convencional na redução da bilirrubina indireta emrecém-nascidos com icterícia patológica. Teve por objetivo analisar as condutas de fototerapia convencional descritas em ensaiosclínicos controlados aleatórios para o tratamento de icterícia em neonatos. A amostra foi composta por 9 artigos publicados em8 periódicos internacionais, todos em inglês, em 2008 e 2009. Constatou-se a existência de recomendação do uso de lâmpadasfluorescentes brancas e azuis associadas.

This paper presents a systematic review on the use of conventional phototherapy for reducing indirect bilirubinin newborn infants with pathological jaundice. It aimed to analyze the conducts of conventional phototherapy described inrandomized controlled clinical trials for the treatment of jaundice in newborn infants. The sample consisted of 9 papers publishedin 8 international journals, all in English, in 2008 and 2009. The existence of a recommendation to use combined white and bluefluorescent lamps was found.

En este artículo se presenta una revisión sistemática del uso de la fototerapia convencional en la reducción de labilirrubina indirecta en recién nacidos con ictericia patológica. El objetivo fue analizar las conductas de fototerapia convencionaldescritas en ensayos clínicos controlados aleatorios para el tratamiento de ictericia en recién nacidos. La muestra fue compuesta por9 artículos publicados en 8 revistas internacionales, todos en inglés, en 2008 y 2009. Se constató la existencia de recomendacióndel uso de lámparas fluorescentes blancas y azules asociadas.

Desafios maternos frente à fototerapia neonatal: estudo descritivo / Motherly challenges when facing neonatal phototherapy treatment: a descriptive study / Retos maternos de la fototerapia neonatal: estudio descriptivo

OBJETIVO: revelar os desafios enfrentados por mães de recém-nascidos submetidos ao tratamento de fototerapia neonatal em alojamento conjunto. MÉTODO: estudo descritivo, com abordagem qualitativa, realizado por meio de entrevista com 10 mães que vivenciaram o tratamento de fototerapia neonatal no alojamento conjunto, no período de junho a outubro de 2014, em uma instituição pública da cidade do Rio de Janeiro. Os dados foram alicerçados na análise de conteúdo de Bardin. RESULTADO: emergiram três categorias analíticas: Sentimentos e Reações das mães frente ao tratamento fototerápico; O desconhecimento frente a uma nova realidade e A equipe como rede de apoio às mães. DISCUSSÃO: Apesar de o tratamento fototerápico ser simples, ele gera para as mães muitas dúvidas e sentimentos negativos de angústia, tristeza e culpa. CONCLUSÃO: a equipe de enfermagem deve estar sensível a ouvir e orientar as mães diante da fototerapia, considerando que é uma vivência adversa durante a internação do recém-nascido.

AIM: To expose the challenges faced by mothers of newborn babies who are submitted to phototherapy treatment in a rooming-in setting. METHODS: A descriptive study, using a qualitative approach, conducted by interviewing 10 mothers whose babies experienced neonatal phototherapy while rooming-in between the months of June and October of 2014 in a public health institution in the city of Rio de Janeiro. Bardin's Content Analysis was used for analysis. RESULTS: Three analytical categories emerged: Mothers' feelings and reactions towards phototherapy treatment; The lack of knowledge when facing a new reality and The healthcare team as a support network for the mothers. DISCUSSION: Despite the simplicity of phototherapy treatment, it makes the mothers feel negative emotions such as anguish, sadness and guilt. CONCLUSION: The nursing staff must be prepared to hear and guide the mothers throughout phototherapy, taking into consideration that it is a negative experience during the newborn hospitalization.

OBJETIVO: revelar los retos que son enfrentados por las madres de los recién nacidos sometidos al tratamiento de fototerapia neonatal en alojamiento conjunto. MÉTODO: estudio descriptivo con enfoque cualitativo, se realiza a través de entrevista con 10 madres que experimentaron el tratamiento de fototerapia neonatal en el alojamiento conjunto en el período de junio a octubre de 2014, en una institución pública de la ciudad de Río de Janeiro. Los datos se basan en el análisis de contenido de Bardin. RESULTADO: surgieron tres categorías analíticas: Sentimientos y Reacciones de las madres frente a un tratamiento fototerápico; La ignorancia frente a una nueva realidad y el equipo como red de apoyo a las madres. DISCUSIÓN: A pesar del tratamiento fototerápico ser simple, genera para las madres muchas dudas y sentimientos negativos de angustia, tristeza y culpa. CONCLUSIÓN: El equipo de enfermería debe estar sensible a escuchar y guiar las madres delante de la fototerapia, considerando que es una experiencia adversa durante la hospitalización del recién nacido.

Epidemiology of neonatal jaundice at the University Hospital of the West Indies / Epidemiología de la ictericia neonatal en el Hospital Universitario de West Indies

OBJECTIVE: To describe the epidemiology of neonatal jaundice at the University Hospital of the West Indies (UHWI). METHODS: A retrospective review of all neonates at the UHWI with clinically significant jaundice between January 1, 2006 and June 30, 2007 was performed. Demographic, clinical and laboratory data were collected. Descriptive analyses were performed. RESULTS: The incidence of clinically significant neonatal jaundice at the UHWI was 4.6% for the study period. There were 103 male (61%) and 67 (39%) female infants. The aetiology of jaundice in the infant was attributed to ABO incompatibility in 59 (35%), infection in 30 (18%), prematurity in 19 (11%), G6PD deficiency in 8 (5%), Rhesus incompatibility in 6 (3.5%) and no cause was identified in 16 (9%) infants. There was a low incidence (26%) of screening for G6PD deficiency although it was the most common aetiology for infants presenting from home. Nine (5%) neonates required exchange blood transfusion. Infants admitted from home had a significantly higher mean total bilirubin value at presentation, a significantly higher mean peak bilirubin level and presented significantly later than those who were admitted from the postnatal ward (p < 0.001). One patient was discharged with a diagnosis of bilirubin encephalopathy but defaulted from follow-up. Two neonates died but from causes unrelated to neonatal jaundice. Sixty-two patients (37%) were followed-up post discharge; 50% had hearing tests done, all tests were normal. Sixty-one (98%) infants had normal development at the time of the study; one patient had impaired motor development but this infant also had a myelomeningocoele. CONCLUSION: To further reduce morbidity associated with neonatal jaundice at the UHWI, there should be increased screening for G6PD deficiency; current systems in place for follow-up and monitoring of infants discharged from hospital prior to 72 hours must also be expanded and strengthened.

OBJETIVO: Describir la epidemiología de ictericia neonatal en el Hospital Universitario de West Indies (UHWI). MÉTODOS: Se llevó a cabo una revisión retrospectiva de todos los recién nacidos con ictericia clínicamente significativa, en UHWI entre el 1ero de enero de 2006 y el 30 de junio de 2007. Se recogieron datos demográficos, clínicos y de laboratorio. Se realizaron análisis descriptivos. RESULTADOS: La incidencia de la ictericia neonatal clínicamente significativa en UHWI fue de 4.6% para el periodo en estudio. Había 103 recién nacidos varones (61%) y 67 (39%) hembras. La etiología de la ictericia en los neonatos se atribuyó a la incompatibilidad de ABO en 59 (35%), infección en 30 (18%), prematuridad en 19 (11%), deficiencia de G6PD en 8 (5%), e incompatibilidad de Rhesus en 6 (3.5%). No se identificó ninguna causa en 16 (9%) de los recién nacidos. Hubo una baja incidencia (26%) de tamizaje para la deficiencia de G6PD, aún cuando ésta es la etiología más común en el caso de los infantes provenientes de casa. Nueve (5%) recién nacidos requirieron cambio de sangre mediante transfusión. Infantes ingresados desde sus casas presentaban un valor promedio de bilirrubina total significativamente mayor en el momento de su hospitalización, así como un nivel pico promedio de bilirrubina significativamente más alto, y se presentaron significativamente más tarde que aquellos ingresados directamente de las sala de atención postnatal (p < 0.001). Un paciente fue dado de alta con un diagnóstico de encefalopatía bilirrubínica, pero no se presentó a las sesiones de seguimiento. Dos recién nacidos murieron, pero por causas no relacionadas con la ictericia neonatal. Sesenta y dos pacientes (37%) tuvieron seguimiento luego del alta; al 50% se les realizó pruebas de audición; todas las pruebas arrojaron resultados normales. Sesenta y un infantes (98%) presentaban un desarrollo normal en el momento del estudio. Un paciente tenía discapacidad del desarrollo motor, pero también presentaba un mielomeningocele CONCLUSIÓN: A fin de lograr una reducción de la morbosidad asociada con la ictericia neonatal en UHWI, debe realizarse un tamizaje de la deficiencia de G6PD. Asimismo, es necesario ampliar y fortalecer los sistemas actuales establecidos para el seguimiento y monitoreo de los infantes dados de alta del hospital antes de las 72 horas.

Effect of induction of meconium evacuation using per rectal laxatives on neonatal hyperbilirubinemia in term infants: A systematic review of randomized controlled trials.

Objective: To study the efficacy of early meconium evacuation using per rectal laxatives on the level of serum bilirubin and the need for phototherapy in healthy term infants. Materials and Methods: Systematic review of randomized controlled trials comparing per rectal laxatives versus no intervention was conducted using English language articles identified from the Cochrane Central Register of Controlled Trials, Medline, Ovid, and CINAHL databases and bibliographies of selected articles. Eligible studies were assessed for the risk of bias in conduct and reporting. Results: A total of three trials (n = 469) mostly with "unclear risk" were eligible for inclusion. Two trials used glycerin suppository whereas one used glycerin enema for meconium evacuation. Meta-analysis was not possible due to clinical heterogeneity in the choice of laxatives and frequency of intervention. In all the three studies, serum bilirubin levels at 48 h and the need for phototherapy was not significantly different between the two groups. Passage of first meconium and the transitional stools occurred significantly early in the intervention group compared to controls. Conclusion: Early evacuation of meconium using per rectal laxatives does not offer any significant clinical advantage for neonatal jaundice.

Comparison of two phototherapy methods [prophylactic vs therapeutic] for management of hyperbilirubinemia in very low birth weight newborns

Preterm and low birth weight [LEW] infants are at greater risk of developing bilirubin-associated brain damage compared with term infants. Certainly, phototherapy, if used appropriately, is capable of controlling the bilirubin levels in LBW infants; but there is not a unique phototherapy treatment strategy in LBW infants. This study was designed to compare the prophylactic phototherapy and late treatment of jaundiced newborns weighing 1000-1500 grams. Sixty newborns with birth weight 1000-1500 g were studied. They were divided into two groups: the [Prophylactic] group, in which phototherapy started within six hours after birth and continued for at least 96 hours, and the [Treatment] group, which received phototherapy when indicated according to birth weight and suspended when bilirubin level fell below 50% of bilirubin level for blood exchange. Mean value of daily transcutaneous bilirubin [TCB], duration of phototherapy, the need for blood exchange, and the highest TCB value in both groups were analyzed. In the prophylactic group, the highest daily mean rate of TCB was 7.71 +/- 1.84 mg/dl, which happened on the third day. In the treatment group, it was 8.74 +/- 1.72 mg/dl on the fourth day after birth. The TCB values in prophylactic group were significantly less than those of the treatment group only on the fourth and fifth days after birth [P<0.001]. Although the median duration of phototherapy in the treatment group was shorter than that of the prophylactic group [137.60 +/- 57.39 vs 168.71 +/- 88.01 hours, respectively], this difference was not statistically significant. Only one neonate needed blood exchange in the treatment group. The prophylactic phototherapy treatment for babies weighing 1000-1500 g significantly decreases bilirubin levels on the fourth and fifth days after birth but the clinical course of hyperbilirubinemia does not alter in LBW infant, as indicated by the non-significant change in the duration of phototherapy

Comparison between continuous and intermittent phototherapy in the management of neonatal jaundice

Since 1950s, phototherapy had been the treatment of choice for neonatal jaundice. Continuous phototherapy was the pattern used for many years; however intermittent phototherapy was also used with conflicting and controversial results. This work aim is to assess intermittent phototherapy for the treatment of neonatal jaundice in comparison with continuous phototherapy. In a prospective clinical study all newborns with neonatal jaundice admitted to neonatology department of Raperin hospital in Arbil, between August 2009 and February 2010, for phototherapy were included in the study. The patients were randomly divided into 2 groups. In the control group continuous phototherapy defined as two hours on and half an hour off was used while in the study group intermittent phototherapy defined as one hour on and one hour off was used. Mean total serum bilirubin level in both continuous and intermittent phototherapy groups were compared after each 12, 24, 36, 48, and 72 hours of commencing phototherapy. The effect of biodemographic characteristics [gender, gesta-tional age, birth weight, age in hours, and bilirubin levels at admission] were also studied. There was no any significant difference between the two groups regarding mean total serum bilirubin measured at every 12 hours. There was no any significant difference between the 2 groups regarding biodemographic characteristics [p> 0.05]. Intermittent phototherapy is as effective as continuous one in the treatment of indirect hyperbilirubinemia in full term infants and in the absence of hemolytic causes

Desenvolvimento de dispositivo inteligente para monitoramento da radiação em fototerapia neonata / Development of smart device for radiation monitoring in neonatal phototherapy

Introdução: a fototerapia é atualmente a modalidade terapêutica mais utilizada para o tratamento da hiperbilirrubinemia ou icterícia neonatal. Apesar de bastante simples e eficiente, essa terapia demanda alguns cuidados e acompanhamentos criteriosos para garantir sua segurança e eficácia. Dentre os fatores que interferem na eficiência do tratamento, destacam-se, sobretudo, a radiância e o comprimento de onda da fonte de luz utilizada e a superfície corpórea do neonato exposto à radiação. Nesse sentido, a necessidade de controle e monitoramento da dose de radiação incidente em neonatos ictéricos sob tratamento fototerápico é um tema atual e bastante oportuno. Objetivo: este trabalho teve como objetivo desenvolver e avaliar o desempenho de sensores de acúmulo de dose de radiação de baixo custo (< R$ 0,10), de fácil manuseio e leitura para monitoramento da radiação azul proveniente de equipamento composto por LEDs, administrada em fototerapia neonatal. Método: filmes poliméricos foram fabricados com materiais orgânicos luminescentes e expostos a diferentes doses de radiação. Resultados: os filmes poliméricos preparados mostraram variação de fluorescência do vermelho ao verde, passando pelo laranja e pelo amarelo, à medida que eram expostos à radiação. Esses resultados possibilitaram a confecção de sensores de acúmulo de dose de radiação do tipo "semáforo inteligente" cuja alteração de cores do vermelho ao verde é facilmente controlada com a manipulação química dos materiais orgânicos utilizados. Conclusão: o desenvolvimento e a utilização de selos inteligentes constituem, sem dúvida, proposta inovadora para garantir o controle e a eficiência dos tratamentos fototerápicos

Introduction: phototherapy is currently the most widely used therapy for treatment of neonatal hyperbilirrubinemy or jaundice. Although simple and effective, this therapy requires caution and careful follow up to ensure the safety and effectiveness . Among the factors that influence the treatment effectiveness stands out above all the radiance and the wavelenght of the light source and the infantïs body surface exposed to radiation. Therefore, the need for control and monitoring of the incident radiation in jaundiced newborns under phototherapy treatment is current and timely. Objective: this study aimed to develop and evaluate the low cost (<$ 0.10) accumulated radiation dose sensors performance, of easy handling and reading, for radiation monitoring equipment composed of blue LEDs, administered in neonatal phototherapy. Method: polymer films made of luminescent organic materials and exposed to radiation. Results: the prepared polymer films showed fluorescence variation from red to green, passing by orange and yellow, while being exposed to the radiation. These results made possible to make sensors of accumulate doses of radiation of the kind "smart semaphore" whose color alteration from red to green is easily controlled with chemical manipulation of the organic materials used. Conclusion: the development and use of smart labels are certainly innovative proposal to ensure the control and effectiveness of phototherapy treatments

Role of intravenous immunoglobulin in iso-immune jaundice in neonate

To show that intravenous immunoglobulin is safe and effective alternative treatment in newborn with iso-immune hemolytic jaundice. This study was carried out in neonatal unit in King Hussein Medical Center [KHMC] and Queen Alia Hospital during two years period of all cases who presented with jaundice either RH or ABO iso-immune jaundice in the first day of life. All patients received phototherapy and intravenous immunoglobulin. There were 91 patients with iso-immune jaundice admitted to the neonatal unit in their first day of life. Eighty five patients out of 91 [93.4%] were due to ABO incompatibility. Six patients out of 91 [6.6%] were due to RH incompatibility. Direct coombs test was positive in all cases of RH incompatibility and in 16 cases of ABO incompatibility. Intravenous immunoglobulin [0.5g/kg] was given to all patients over four hours every 24 hours for three doses. Exchange transfusion was done for one patient only [1%]. Blood transfusion was given for 22 patients out of 91 [24%]. Hospital stay was around 3-4 days in majority of cases. Intravenous immunoglobulin in newborn with ABO or RH hemolytic jaundice is effective in reducing hemolysis, serum bilirubin level and the need for exchange transfusion

The effect of clofibrate with phototherapy in late pre-term newborns with non-hemolytic jaundice.

Background : Despite an understanding of the enzymatic pathways leading to bilirubin production and degradation, very few pharmacologic interventions are utilized and the mainstay of treatment remains phototherapy. Aims : To evaluate the efficacy of clofibrate in reducing total serum bilirubin levels in late pre-term neonates with non-hemolytic jaundice. Design and Setting : Double-blind, placebo-controlled, randomized trial; tertiary level neonatal unit. Materials and Methods : A randomized controlled study was carried out in the neonatal ward of Children's Hospital, Tabriz, Iran, over a 1-year period. Sixty-eight healthy late pre-term infants readmitted with non-hemolytic hyperbilirubinemia were randomized to receive phototherapy and clofibrate (n= 35) or phototherapy and placebo (n= 33). Statistical Analysis Used : Chi-square test and independent sample 't' test. Results : There were no significant differences in the weight, gender, modes of delivery and age of neonates between the two groups. Similarly the mean total serum bilirubin (TSB) level at the time of admission was not significantly different between the two groups [mean± SD: 19.72 ± 1.79 (95% confidence interval: 19.12-20.54 mg/dL) vs. 20.05 ± 2.82 (95% confidence interval, 19.54-22.04 mg/dL), P= 0.57]. The mean TSB 48 hours after phototherapy [mean± SD: 8.06± 1.34 (95% confidence interval: 7.94-10.18 mg/dL) vs.10.94 ± 2.87 (95% confidence interval: 9.92-12.16 mg/dL), P= 0.02] and the mean duration of phototherapy [mean± SD: 64.32 ± 12.48 (95% confidence interval: 60-81.6 hours) vs. 87.84 ± 29.76 (95% confidence interval: 79.2-108 hours), P< 0.001] were significantly lower in the clofibrate-treated group. Conclusions : Clofibrate is an effective adjunctive drug in neonatal hyperbilirubinemia, which results in decreased TSB level and reduced duration of phototherapy in late pre-term newborns.

Effect of sling application on efficacy of phototherapy in healthy term neonates with nonhemolytic jaundice: a randomized conrolled trial.

OBJECTIVE: To evaluate the efficacy of white reflecting material (slings) hung from the sides of compact fluorescent lamp (CFL) phototherapy equipment in reducing the duration of phototherapy in healthy term neonates with non-hemolytic jaundice. DESIGN: Randomized controlled trial. SETTING: Postnatal ward of a tertiary level neonatal unit. PARTICIPANTS AND INTERVENTION: Healthy term neonates with non-hemolytic jaundice between 24 hours and 10 days of age were randomly assigned to receive single surface phototherapy with (n=42) or without slings (n=42). OUTCOME MEASURE: Duration of phototherapy in hours (h) and the requirement of exchange transfusion. RESULTS: Birthweight (2790+/-352 vs. 2923+/-330 g), gestation (38+/-1.3 vs. 37+/-1.0 wk) and initial serum total bilirubin (STB) (16.6+/-2.4 vs. 16.1+/-2.2 mg/dL) were comparable between the two groups. There was no significant difference in the duration of phototherapy (mean+/-SD) between the Sling (23.3+/-12.9 h) and No sling (24.9+/-15.4 h) groups (P=0.6). The irradiance of photo-therapy equipment (microwatt/cm2, mean+/-SD) was higher in Sling group compared to No sling group (195.8+/-24.2 versus 179.7+/-27.7, P=0.01). There was a trend towards a higher rate of fall of serum total bilirubin (mg/dL, mean +/-SD) in the Sling group (0.23+/-0.49) compared to No sling group (0.03+/-0.47) (P=0.06). CONCLUSION: Though hanging of white reflective sling on sides of CFL phototherapy equipment resulted in marginal increase in irradiance, it did not decrease the duration of phototherapy.

Role of intravenous extra fluid therapy in icteric neonates receiving phototherapy

To evaluate the role of intravenous extra fluid therapy in accelerating the reduction of jaundice in newborns who received phototherapy. This study was performed on 100 terms, jaundiced neonates who had a total bilirubin of 18mg/dl or more in the Pediatrics Ward of Ghaem Hospital, Mashhad, Iran from October 2007 to April 2008. The patients were randomly divided into 2 equal groups; group I [case group] were given extra parenteral fluid besides breast feeding, and group II [control group] received only breast milk. The rate of bilirubin decrement, length of hospital stay, and rate of blood exchange were compared. The rate of serum bilirubin decrease per hour in the first 12 hours after admission in group I [0.41mg/dl [95%CI 0.1] versus 0.38mg/dl in group II [95% CI 0.3], [p=0.22]]. It was 0.4lmg/dl for group I [95% CI 0.0001], and 0.21mg/dl [95%CI 0.06] for group II in the second 12 hours [p=0.02]. After 24 hours, it was 0.38mg/dl in group I [95% CI 0.0001], and 0.29mg/dl in group II [95% CI=0.09] [p=0.037]. The mean hospital stay was 68.5 hours in group I, and 67.4 hours in group II [p=0.95]. Additional parenteral fluid therapy in icteric newborns can accelerate reduction in serum bilirubin levels in the first 24 hours

Evidências no uso da fototerapia convencional em neonatos com icterícia / The use of conventional fototherapy in the new born babies who suffer from pathological ictericy

A icterícia neonatal é caracterizada pelo surgimento de uma tonalidade amarelada na pele e esclera dos recém- nascidos (RN) a termo bem como os pré e pós-termo e está frequentemente presente no período neonatal comprometendo de metade a dois terços dos recém nascidos. Caracteriza-se por níveis elevados de bilirrubina indireta (BI) ou bilirrubina não conjugada na concentração sérica superior a 1,5mg/dl. Este estudo constitui-se em revisão sistemática sobre o uso eficiente da fototerapia convencional na redução da bilirrubina indireta em recém- nascidos comicterícia patológica. Teve como objetivo geral evidenciar as condutas no uso da fototerapia convencional no tratamento da icterícia patológica de neonatos em publicações científicas do tipo ensaio clínico controlado aleatório. A amostra foi composta por nove artigos publicados em oito periódicos internacionais, todos em língua inglesa, no período de 2008 a fevereiro de 2009. Recomenda-se o uso de lâmpadas fluorescentes e azuis associadas, dando preferência ao uso de quatro lâmpadas fluorescentes e quatro lâmpadas azuis ou três lâmpadas fluorescentes e duas lâmpadas azuis. Embora os resultados permitam fazer recomendações, é importante a realização de novas pesquisas, com amostra maior e calculada a priori, para aprofundar o conhecimento sobre as condutas, além de identificar consequencias indesejáveis da fototerapia e os cuidados para prevení-las.

Fototerapia causa danos ao DNA de leucócitos mononucleares periféricos em recém-nascidos a termo / Phototherapy causes DNA damage in peripheral mononuclear leukocytes in term infants

OBJETIVO: Determinar se a fita de DNA de leucócitos mononucleares endógenos é alvo de fototerapia. MÉTODOS: O estudo incluiu 65 recém-nascidos a termo com idades entre 3 e 10 dias que haviam sido expostos a fototerapia intensiva (n = 23) ou convencional (n = 23) por pelo menos 48 horas devido à icterícia neonatal, além de um grupo controle (n = 19). Dano ao DNA foi avaliado por eletroforese alcalina em gel de célula única (ensaio cometa). A capacidade antioxidante total plasmática e os níveis de estado oxidativo total também foram medidos, e a correlação entre danos ao DNA e estresse oxidativo foi investigada. RESULTADOS: Os valores médios de escores de danos ao DNA nos grupos de fototerapia intensiva e convencional foram significativamente maiores do que os do grupo controle (p < 0,001). Os valores médios e desvio padrão foram 32 (9), 28 (9), 21 (7) unidades arbitrárias, respectivamente. Os níveis de estado oxidativo nos grupos de fototerapia intensiva e convencional foram significativamente maiores do que os do grupo controle (p < 0,005). Os valores médios (desvio padrão) foram 18, 1 (4,2), 16.9 (4,4), 13,5 (4,2) µmol H2O2 equivalente/L, respectivamente. De maneira semelhante, os níveis de estresse oxidativo nos grupos de fototerapia intensiva e convencional foram significativamente maiores do que os do grupo controle (p = 0,041). A capacidade antioxidante total plasmática e os níveis de bilirrubina total não diferiram entre os grupos (p > 0,05). Não houve correlações significativas entre escores de danos ao DNA e bilirrubina, estado oxidante total e níveis de estresse oxidativo entre os grupos de fototerapia (p > 0,05). CONCLUSÕES: Tanto a fototerapia intensiva quanto a convencional causam danos ao DNA dos leucócitos mononucleares endógenos em recém-nascidos a termo com icterícia.

OBJECTIVE: Our aim was to determine whether endogenous mononuclear leukocyte DNA strand is a target of phototherapy. METHODS: The study included 65 term infants aged between 3-10 days that had been exposed to intensive (n = 23) or conventional (n = 23) phototherapy for at least 48 hours due to neonatal jaundice, and a control group (n = 19). DNA damage was assayed by single-cell alkaline gel electrophoresis (comet assay). Plasma total antioxidant capacity and total oxidant status levels were also measured, and correlation between DNA damage and oxidative stress was investigated. RESULTS: Mean values of DNA damage scores in both the intensive and conventional phototherapy groups were significantly higher than those in the control group (p < 0.001). Mean values and standard deviation were 32 (9), 28 (9), 21 (7) arbitrary unit, respectively. Total oxidant status levels in both the intensive and conventional phototherapy groups were significantly higher than those in the control group (p = 0.005). Mean (standard deviation) values were 18.1 (4.2), 16.9 (4.4), 13.5 (4.2) µmol H2O2 equivalent/L, respectively. Similarly, oxidative stress index levels in both the intensive and conventional phototherapy groups were significantly higher than those in the control group (p = 0.041). Plasma total antioxidant capacity and total bilirubin levels did not differ between the groups (p > 0.05). There were no significant correlations between DNA damage scores and bilirubin, total oxidant status and oxidative stress levels in either phototherapy group (p > 0.05). CONCLUSIONS: Both conventional phototherapy and intensive phototherapy cause endogenous mononuclear leukocyte DNA damage in jaundiced term infants.

Enfermagem humanística: ênfase na comunicação com mães de neonatos sob fototerapia / Humanization of assistance: nurse-patient relations

Este livro nos apresenta uma experiência emocional e concreta de trajetória apoiada nos pressupostos da Teoria Humanística. A primeira fase é o vir a conhecer, abordada com extrema competência quando descreve a evolução histórica da compreensão da icterícia neonatal e dos seus tratamentos, em particular a fototerapia. Apropriando o conhecimento científico, percebe-se que apenas ele não responde aos questionamentos, emoções, ansiedades da mãe. É preciso ir além, usar a intuição e se dispor a vivenciar com o outro o paradoxo da saúde, da doença, do cuidado...

Prevalence of readmission for hyperbilirubinemia in healthy newborns

The aim of this study was estimation of prevalence of jaundice readmission and observes neonatal jaundice risk factors in singleton infant with birth weight more than 2500 gr. This study was done among women who delivered a normal singleton infant with birth weight of >/= 2500 gr in Najmieh Hospital, Tehran, from 2004-2005. Maternal age, race, blood group and Rh, drug consumption during pregnancy, oxytocin consumption during labour, rupture of membranes together with neonatal sex, weight, maturity, gravity and length of nursery stay were recorded. The infants were followed during neonatal period to see if they were readmitted, and the reason of admission. The prevalence of readmission for neonatal jaundice was assessed and the risk factors for neonatal jaundice were compared between the icteric and non-icteric babies. The prevalence of readmission because of jaundice was 12.6%. The maternal data recorded from all mother-baby pairs were not significantly different except for maternal race, Rh group and drug consumption during pregnancy. Arab mothers compared with other race groups had more icteric babies [P=0.001]. Rh-negative mothers had more icteric infants [17.9%] compared with Rh-positive mothers [12%] [P=0.01]. Premature infants were hospitalized significantly more than mature babies [20.3% versus 12.1%, P=0.04]. The length of primary nursery stay differed significantly between two groups [mean [SD] 27 [9.8] hours for icterics versus 30 [2.5] hours for non-icterics, P < 0.001]. The mean age of readmission was fifth postnatal day. We conclude that infants, especially infants of Arab or negative Rh group mothers and premature babies, discharged early from the nursery should be advised to visit a pediatrician within the next 48-72 hours of birth to avoid complications of severe jaundice

Enfermedad hemolítica perinatal por dos aloanticuerpos: presentación de un caso / Alloantibody linked perinatal hemolytic disease: case report

La etiopatogenia de la enfermedad hemolítica del recién nacido está basada en la incompatibilidad de grupo sanguíneo entre la madre y el recién nacido. Los neonatos con enfermedad hemolítica por incompatibilidad ABO usualmente tienen madres de grupo O porque la IgG anti-A y anti-B puede atravesar la placenta y sensibilizar los eritrocitos neonatales. Otros anticuerpos además de los ABO han sido reportados como causa de enfermedad hemolítica del recién nacido, ejemplo: anti-D, anti-C, anti-K, anti-Jk, anti-Fy, anti-S, etc. Presentamos el caso de una mujer de 33 años de edad, que en el segundo trimestre de su segunda gestación presentó una hemorragia que motivó la transfusión de una unidad de concentrado de eritrocitos. No se reportó reacción transfusional. El producto de dicha gestación fue un neonato masculino de 2,5 Kg de peso y apgar 6-8 que presentó íctero a las 24 horas después del parto. El fenotipaje ABO de los eritrocitos maternos y del neonato arrojó que la madre era de grupo O y el neonato de grupo B. La prueba de Coombs directa fue positiva 2+ en el neonato y la prueba de Coombs indirecta resultó positiva 3+ en la madre. Dos aloanticuerpos fueron detectados en el suero materno como causa del íctero neonatal, un anti-A y un anti-Jk b. Los eritrocitos maternos fueron fenotipados como Jk b negativos. El tratamiento con fototerapia al neonato se inició a las 40 horas de edad y se prolongó hasta los 10 días de nacido. Una transfusión simple de concentrado de eritrocitos fenotipados fue administrada al neonato a los 8 días de edad.

Acompanhamento da icterícia neonatal em recém-nascidos de termo e prematuros tardios / Follow-up of neonatal jaundice in term and late premature newborns

OBJETIVO: Relatar os resultados de um projeto de acompanhamento de recém-nascidos de termo e próximos ao termo ictéricos no período neonatal. MÉTODOS: Foram encaminhados a ambulatório especializado neonatos com peso > 2.000 g e/ou idade gestacional > 35 semanas, cuja icterícia na alta foi avaliada inicialmente com o icterômetro de Ingram, Bilicheck® e, se indicado, com bilirrubinômetro Unistat (Leica). A bilirrubinemia destes recém-nascidos situava-se no ou acima do percentil 40 do nomograma elaborado por Bhutani. Todos recém-nascidos tratados com fototerapia durante internação foram reavaliados laboratorialmente 24 horas após suspensão do tratamento. A indicação de reinternação para tratamento fototerápico intensivo foi para paciente com nível > 20 mg/dL. RESULTADOS: De um total de 11.259 neonatos, 2.452 (21,8 por cento) foram encaminhados para acompanhamento, dos quais 87,2 por cento (2.140) retornaram. Oitenta neonatos retornados foram reinternados. Dos 2.452 encaminhados para retorno, 180 (7,3 por cento) tinham bilirrubinemia > 15 mg/dL na alta. Destes, 151 retornaram para acompanhamento. Vinte (13,2 por cento) foram reinternados para tratamento. Do total de reinternados, dois recém-nascidos apresentaram nível > 25 mg/dL e nenhum > 30 mg/dL. Todos responderam rapidamente à fototerapia intensiva, e não houve necessidade de utilizar exsangüinotransfusões. CONCLUSÕES: Nossos resultados sugerem que o esquema adotado é eficiente na detecção e prevenção de hiperbilirrubinemias de risco para produzir encefalopatia bilirrubínica em recém-nascidos de termo e próximos ao termo.

OBJECTIVE: To report on the results of a project following term and near term newborn infants who were jaundiced during the neonatal period. METHODS: Neonates were referred to the follow-up clinic with weight > 2,000 g and/or gestational age > 35 weeks, and jaundice at discharge was initially assessed with an Ingram icterometer or Bilicheck and, if indicated, with a Unistat bilirubinometer (Leica). These newborn infants had bilirubinemia at or above the 40th percentile on the nomogram developed by Bhutani. All infants treated with phototherapy while in hospital were reassessed by laboratory methods 24 hours after withdrawal of treatment. Patients were rehospitalized for intensive phototherapy if their level was greater than or equal to 20 mg/dL. RESULTS: From a total sample of 11,259 neonates, 2,452 (21.8 percent) were referred to the follow-up clinic, 87.2 percent (2,140) of whom did return. Eighty returned neonates were readmitted. Return appointments were set for 2,452 patients, 180 (7.3 percent) of whom had bilirubinemia > 15 mg/dL at discharge. Of these 180, 151 returned for follow-up. Twenty (13.2 percent) were readmitted for treatment. Of the total number of readmitted patients, two newborn infants had levels > 25 mg/dL and none > 30 mg/dL. All responded rapidly to intensive phototherapy, and there was no need for exchange transfusions. CONCLUSIONS: Our results suggest that the regime adopted is effective for detecting and preventing hyperbilirubinemia at risk of causing bilirubin-induced encephalopathy in term and near term newborn infants.