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Indian Pediatr 2010;47: 3 96-397 |
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Treatment of Jaundice in the Newborn Infant -
"Many Roads to Rome" |
Thor Willy Ruud Hansen
Department of Neonatology, Women’s & Children’s Clinic,
Oslo University Hospital HC - Rikshospitalet; and
Institute of Clinical Medicine, Faculty of Medicine, University of Oslo,
Norway.
Correspondence to: Thor Willy Ruud Hansen,
Nyfodtavdelingen, Kvinne - & Barneklinikkn, HF - Rikshospitalet, N-0027
Oslo, Norway.
Email: [email protected]
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J aundice is the most common reason,
aside from screening and prophylaxis, for testing and treatment of newborn
infants. Thus, considerable health care resources are invested in this
phenomenon world wide. Although treatment in the form of phototherapy is
simple, the necessary equipment may not be available in settings where
health care resources are scarce. In the current issue of Indian
Pediatrics, Chawla and Parmar(1) present a meta-analysis of the use of
phenobarbital for the management of jaundice in preterm infants, a group
where the incidence of neonatal jaundice is distinctly higher than in
infants born at term. They conclude that phenobarbital reduces both peak
serum bilirubin, need for as well as duration of phototherapy, and finally
the need for exchange transfusion in preterm very low birthweight infants.
Wisely, the authors strike a note of caution when they suggest that
further studies are warranted to evaluate adverse effects and
neurodevelopmental outcome.
While the authors’ findings are intriguing, readers
should note the fact that the authors found only three studies which
satisfied the entrance criteria for the Cochrane-type analysis they
performed. Although the number of patients studied was almost 500, two of
the three studies were more than twenty years old. This is a problem
because phototherapy today is likely to be - indeed should be -
much more effective than in the 1980s. Also, intravenous immune globulin
is available to treat severe jaundice due to ABO and Rhesus
incompatibility. Using these tools, exchange trans-fusion has become a
rare event in many nurseries, and close to a "never-event" in premature
infants(2). This greatly reduces the generalizability of the authors’
conclusions as far as exchange transfusion.
The meta-analysis showed that using phenobarbital as
suggested did not obviate the need for phototherapy. This to some extent
weakens the argument as far as the usefulness of this drug in settings
where phototherapy equipment is not available. However, we must concede
the point that the need for transfer to another unit which possesses such
equipment is reduced, which may be highly relevant for families who cannot
afford such treatment. Also, if each baby spends less time in
phototherapy, it means that more babies may be treated with the same unit.
However, practitioners should also note that time in phototherapy may be
reduced significantly without drug therapy by simple efforts to increase
spectral power, as shown by studies both from Brazil and Malaysia(3,4).
Drawbacks of phenobarbital treatment in newborns
include somnolence. There are studies which appear to show negative
long-term effects on cognition in children receiving phenobarbital for
febrile seizures, and these observations are of concern(5). However, the
implications, if any, for short-term treatment of neonatal jaundice are
unknown. We have recently documented the potential reversibility of acute
intermediate stage bilirubin encephalopathy (kernicterus) and suggested
that there may potentially be a role for phenobarbital in the management
of some such infants(6).
In the end, the decision of whether to use
phenobarbital in the routine treatment of neonatal jaundice must depend on
a careful evaluation of local circumstances. I am open to the possibility
that there may be settings where the benefits of phenobarbital treatment
as outlined by Chawla and Parmar(1) may outweigh the possible risks.
However, I find myself agreeing with these authors that further studies
are warranted and, indeed, highly desirable.
Funding: None.
Competing interests: None stated.
References
1. Chawla D, Parmar V. Phenobarbitone for prevention
and treatment of unconjugated hyperbilirubinemia in preterm neonates: a
systematic review and meta-analysis. Indian Pediatr 2010; 47: 401-407.
2. Huizing KMN, Røislien J, Hansen TWR. Intravenous
immune globulin significantly reduces the need for exchange transfusions
in infants with Rhesus and ABO incompatibility. Acta Paediatr 2008; 97:
1362-1365.
3. De Carvalho M, De Carvalho D, Trzmielina S, Lopes
JMA, Hansen TWR. Intensified phototherapy using daylight fluorescent
lamps. Acta Paediatr 1999; 88: 768-771.
4. Djokomuljanto S, Quah BS, Surini Y, Noraida R,
Ismail NZN, Hansen TWR, et al. Efficacy of phototherapy for
neonatal jaundice is increased by the use of low-cost white reflecting
curtains. Arch Dis Child 2006; 91: F439-442.
5. Farwell JR, Lee YJ, Hirtz DG, Sulzbacher SI,
Ellenberg JH, Nelson KB. Phenobarbital for febrile seizures—effects on
intelligence and on seizure recurrence. N Engl J Med 1990; 322:
364-369.
6. Hansen TWR, Nietsch L, Norman E, Bjerre JV, Hascoet JM, Mreihil K,
et al. Apparent reversibility of acute intermediate phase bilirubin
encephalopathy. Acta Paediatr 2009; 98: 1689-1694.
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