M. Jeffrey Maisels, M.B., B.Ch., and Antony F. McDonagh, Ph.D.
Phototherapy for Neonatal Jaundice
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This Journal feature begins with a case vignette that includes a therapeutic recommendation. A discussion of the clinical problem and the mechanism of benefit of this form of therapy follows. Major clinical studies, the clinical use of this therapy, and potential adverse effects are reviewed. Relevant formal guidelines, if they exist, are presented. The article ends with the authors’ clinical recommendations.
A male infant weighing 3400 g was born at 37 weeks’ gestation after an uncomplicated pregnancy. The mother is a 24-year-old primipara who has type A Rh-positive blood. The infant’s course in the hospital nursery was uncomplicated. Although his mother needed considerable help in establishing effective breast-feeding, he was exclusively breast-fed. Jaundice was noted at the age of 34 hours. The total serum bilirubin level was 7.5 mg per deciliter (128 µmol per liter). The infant was discharged at the age of 40 hours and is seen in the pediatrician’s office 2 days later, now with marked jaundice. The results of his physical examination are otherwise normal, but his weight, at 3020 g, is 11% below his birth weight. His total serum bilirubin level is 19.5 mg per deciliter (333 µmol per liter), and his conjugated (direct) bilirubin level 0.6 mg per deciliter (10 µmol per liter). The complete blood count and peripheral-blood smear are normal. The infant has type A Rh-positive blood. The pediatrician consults a neonatologist regarding the need for phototherapy.
The Clinical Problem
Some 60% of normal newborns become clinically jaundiced sometime during the first week of life. Unconjugated (indirect) hyperbilirubinemia occurs as a result of excessive bilirubin formation and because the neonatal liver cannot clear bilirubin rapidly enough from the blood.1,2 Although most newborns with jaundice are otherwise healthy, they need to be monitored because bilirubin is potentially toxic to the central nervous system. Sufficiently elevated levels of bilirubin can lead to bilirubin encephalopathy and subsequently kernicterus, with devastating, permanent neurodevelopmental handicaps.3
Fortunately, current interventions make such severe sequelae rare. But because neonatal jaundice is so common, many infants — most of whom will be unaffected — are monitored and treated to prevent substantial damage that would otherwise occur in a few. Data from 11 hospitals in the northern California region of the Kaiser Permanente medical system4 and from the 18-hospital Intermountain Health Care system5 suggest that the total serum bilirubin level is 20 mg per deciliter (342 µmol per liter) or higher in approximately 1 to 2% of infants born at a gestational age of at least 35 weeks. Hospital-based studies in the United States have shown that 5 to 40 infants per 1000 term and late-preterm infants receive phototherapy before discharge from the nursery and that an equal number are readmitted for phototherapy after discharge.5,6,7 These data do not include the use of home phototherapy, which is prevalent in some regions.8,9 In some hospitals and in other countries,10 phototherapy is used more frequently.