Neonatal hyperbilirubinemia

Itoh S, et al. Phototherapy for neonatal hyperbilirubinemia. Pediatr Int. 2017 May 31.

About 60 years ago in England, phototherapy for neonatal hyperbilirubinemia was actually used in clinical practice. It was introduced in Japan about 50 years ago. However, the mechanism of how the serum bilirubin concentration was decreased by the phototherapy was still unknown. The mechanism was identified by chemists, biochemists, and pediatricians. Clarification started with the report that unconjugated bilirubin was excreted into bile after the photoirradiation of Gunn rats. After the molecular conformation of bilirubin by X-ray analysis, the mechanism for bile excretion of unconjugated bilirubin was verified based on geometric configurational photoisomers in the Gunn rat. Finally, the reaction and excretion of structural bilirubin photoisomers was proved to be the main mechanism for the decrease in serum bilirubin during phototherapy for neonatal hyperbilirubinemina, which differs from the mechanism in the Gunn rat. However, the most effective and safest light source and the optimal method to evaluate phototherapy remain unknown. Moreover, as for bronze baby syndrome which is a well-known adverse reaction to phototherapy, the substances as the etiological origin are unclear. Hence, we review phototherapy for hyperbilirubinemia including a fundamental understanding of the bilirubin photochemical reactions, and discuss the subclinical carcinogenic risk of phototherapy and the increased mortality rate of extremely very low birth weight infants due to aggressive phototherapy, which is becoming a problem an increasing.

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Maisels MJ. Managing the jaundiced newborn: a persistent challenge. CMAJ. 2015
Mar 17;187(5):335-43.

“In this review, I present an approach to managing the jaundiced newborn that is based on published guidelines. [2-5] The aim is to help clinicians identify and manage jaundice in the newborn, intervene when appropriate and, when possible, prevent bilirubin-induced brain damage. It would be ideal if the published guidelines for the management of hyperbilirubinemia, including treatment with phototherapy and exchange transfusion, were based on estimates of when the benefit of these interventions exceeded their risks and costs. These estimates should come from randomized trials or high-quality, systematic observational studies, but such studies are rare. Guidelines must therefore rely on relatively uncertain estimates of risk and benefits, often from conflicting results.”

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Jaundice

Conjugated Hyperbilirubinemia: Screening and Treatment in Older Infants and Children. (2007)

Jaundice refers to yellow discoloration of the skin, sclera, mucous membranes, and body fluids. It is a common problem that can be the presenting sign for many disorders. The challenge for the physician is to identify patients who need additional evaluation. The differential diagnosis for jaundice is age-specific; this review addresses the causative conditions in infants beyond the newborn period, older children, and adolescents.

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Jaundice in Older Children and Adolescents. (2001)

  1. Describe the basic physiology of bilirubin metabolism, the two standard laboratory methods for its fractionation, and the classification of jaundice.
  2. Characterize the features of Gilbert disease.
  3. Identify the leading infectious cause of acute jaundice in older children and adolescents.
  4. Delineate the clinical and biochemical features of Wilson disease and autoimmune hepatitis.
  5. Compare and contrast liver function tests and tests of liver function.
  6. Describe the “worrisome” clinical and laboratory signs of hepatic synthetic dysfunction in jaundiced patients that should prompt an immediate referral to a center whHere liver transplantation is available.

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Diagnostic approach to the patient with jaundice. (2011)

Jaundice is caused by many disease processes ranging from benign to life threatening. History and physical examination remain important tools in evaluating the etiology of jaundice. The conjugation state of bilirubin, along with other laboratory tests judiciously ordered, can guide the provider toward category of illness. Hyperbilirubinemia may be categorized as to its etiology: unconjugated/prehepatic, intrahepatic, or extrahepatic/obstructive. Referral should be considered when likelihood of malignancy, chronic autoimmune condition, or need for intervention exists.

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Book Chapter: Diagnostic Approach to Jaundice from Feldman: Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, 9th ed. (2010)

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