NEONATAL JAUNDICE EXCHANGE TRANSFUSION
Category: Child Health
Abstract : neonatal jaundice exchange transfusion Exchange transfusion is indicated for avoiding bilirubin neurotoxicity when other therapeutic modalities have failed. In addition, the procedure may be indicated in infants with erythroblastosis presenting with severe anemia, hydrops, or both, even in the absence of high serum bilirubin levels. Exchange transfusion once was a common procedure. A significan
neonatal jaundice exchange transfusion
Exchange transfusion is indicated for avoiding bilirubin neurotoxicity when other therapeutic modalities have failed. In addition, the procedure may be indicated in infants with erythroblastosis presenting with severe anemia, hydrops, or both, even in the absence of high serum bilirubin levels. Exchange transfusion once was a common procedure.
A significant proportion was performed in infants with Rh isoimmunization. Immunotherapy in Rh-negative women at risk for sensitization has reduced the incidence of severe Rh erythroblastosis significantly. Therefore, the number of infants requiring exchange transfusion is now much smaller, and even large NICUs may perform only a few procedures per year. ABO incompatibility has become the most frequent cause of hemolytic disease in industrialized countries.
Recently, immunotherapy has been introduced as treatment in the few remaining sensitized infants. Results are promising and suggest that the number of infants requiring exchange transfusion may be reduced further.
• Early exchange transfusion usually has been performed because of anemia (cord hemoglobin <11 g/dL) and/or elevated cord bilirubin (level >70 μmol/L or 4.5 mg/dL). A rapid rate of increase in the serum bilirubin level (>15-20 μmol/L /h or 1 mg/dL/h) was an indication for exchange transfusion, as was a more moderate rate of increase (>8-10 μmol/L/h or 0.5 mg/dL/h) in the presence of moderate anemia (11-13 g/dL).
• The serum bilirubin level that triggered an exchange transfusion in infants with hemolytic jaundice was 350 μmol/L (20 mg/dL) or a rate of increase that predicted this level or higher. Strict adherence to the level of 20 mg/dL has been jocularly referred to as vigintiphobia (fear of 20).
• Currently, most experts encourage an individualized approach, recognizing that exchange transfusion is not a risk-free procedure, that effective phototherapy converts 15-25% of bilirubin to nontoxic isomers, and that transfusion of a small volume of packed red cells may correct anemia. Administration of IV immunoglobulin 500 mg/kg has been shown to reduce red cell destruction and limit the rate of increase of serum bilirubin levels.
Current AAP guidelines distinguish between infants younger and older than 48 hours. In infants younger than 48 hours, exchange transfusion is recommended when the serum bilirubin level remains greater than 430 μmol/L (25 mg/dL) despite adequately administered phototherapy. In infants older than 48 hours with serum bilirubin levels greater than 510 μmol/L (30 mg/dL), the AAP recommends intensive phototherapy while preparing for an exchange transfusion. If phototherapy has not lowered serum bilirubin levels significantly, the transfusion should be performed.
• The AAP guidelines do not offer specifics regarding the intervention limits for infants with hemolytic jaundice. The practitioner must judge each patient individually, weighing the specifics of the case history and clinical findings.
• Many physicians believe that hemolytic jaundice represents a greater risk for neurotoxicity than nonhemolytic jaundice, although the reasons for this belief are not intuitively obvious, assuming that total serum bilirubin levels are equal. In animal studies, bilirubin entry into or clearance from the brain was not affected by the presence of hemolytic anemia.
• The technique of exchange transfusion, including adverse effects and complications, is discussed extensively elsewhere.
Other therapies (neonatal jaundice):
Oral bilirubin oxidase can reduce serum bilirubin levels, presumably by reducing enterohepatic circulation; however, its use has not gained wide popularity. The same may be said for agar or charcoal feeds, which act by binding bilirubin in the gut. Bilirubin oxidase is not available as a drug, and for this reason, its use outside an approved research protocol probably is proscribed in many countries. Prophylactic treatment of Rh-negative women with Rh immunoglobulin has significantly decreased the incidence and severity of Rh-hemolytic disease.
Surgical Care (neonatal jaundice):
• Surgical care is not indicated in infants with physiologic neonatal jaundice.
• Surgical therapy is indicated in infants in whom jaundice is caused by bowel or external bile duct atresia.
Consultations (neonatal jaundice):
• For infants with physiologic neonatal jaundice, no consultation is required.
• Gastroenterologists and surgeons may be consulted regarding infants with jaundice resulting from hepatobiliary or bowel disease.
Diet (neonatal jaundice):
Breastfeeding concerns associated with neonatal jaundice are as follows:
• Incidence and duration of jaundice have increased as breastfeeding has become more popular. The factors in breast milk that contribute to this phenomenon are unclear. In selected infants, interruption of breastfeeding and its replacement for 24-48 hours by a breast milk substitute may be indicated. This decision should always be discussed in person with the mother before implementation.
• With increasing emphasis on breastfeeding, some new mothers may have difficulty admitting (even to themselves) to a lack of success in establishing lactation. Occasionally, infants of breastfeeding mothers are admitted to hospitals with severe jaundice. They typically weigh significantly less than their birthweight at a time when they should have regained and surpassed that weight. Presumably, the process is one of increased enterohepatic circulation, as bilirubin is left longer in the proximal gut for lack of milk to bind it and carry it onward and out. The author refers to this condition as lack-of-breast-milk jaundice. These infants may respond dramatically to phototherapy plus oral feedings of milk ad libitum.
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