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In spite of advances in medical science, Rh alloimmunisation remains one of the leading causes of preventable neuro-morbidities and significant neonatal hyperbilirubinemia in lower-middle income countries. Despite availability of effective antenatal preventive strategy (Anti-D), its uptake in antenatal period is low due to ignorance. Further, once diagnosed, there is lack of adequate antenatal follow up in health care facility. Some of these cases even remain undiagnosed in antenatal period only to present as a case of severe hyperbilirubinemia and kernicterus in late neonatal period. Thus, there is an urgent need for creating awareness and educating health care professionals for early detection and timely management in both antenatal and postnatal period. Following two doses of anti-D prophylaxis (one in antenatal period and one in immediate postnatal period) the incidence of Rh alloimmunisation can reduce to

To evaluate the efficacy of oral clofibrate as an adjunct to phototherapy for unconjugated hyperbilirubinemia in term neonates. This randomized controlled trial was done in the level III neonatal intensive care unit (NICU) of a tertiary care hospital. Ninety term neonates with unconjugated hyperbilirubinemia with serum bilirubin 15–25 mg/dl were randomized to either intervention group (single dose of clofibrate in a dose of 50 mg/kg prior to starting phototherapy) or standard care group (only phototherapy). Primary outcome was absolute fall in bilirubin by 48 h. Secondary outcomes were duration of phototherapy, absolute fall in bilirubin levels at 12, 24, 36, 48 h, need for exchange transfusion and incidence of side-effects. After 48 h of intervention, significantly lower bilirubin levels were noted in the intervention group compared to standard care group with a mean difference of 7 mg/dl (95% CI 6.7 mg/dl to 7.2 mg/dl). Duration of phototherapy required was less in the intervention group compared to standard care group with mean difference of 23.82 h (95% CI 30.46 h to 17.18 h). Exchange transfusion was needed for 4 neonates in the standard care group and none in the intervention group. No side-effects were noted with clofibrate. Single dose clofibrate prior to starting phototherapy in term neonates with uncomplicated unconjugated hyperbilirubinemia reduces the duration of phototherapy significantly.

Hyperleukocytosis is defined as peripheral blood leukocyte count exceeding 100,000/mm(3). Acute leukemia is the most common etiology in pediatric practice. Hyperleukocytosis is a medical emergency. The increased blood viscosity, secondary to high white cell count and leukocyte aggregates, results in stasis in the smaller blood vessels. This predisposes to neurological, pulmonary or gastrointestinal complications. In addition, patients are at risk for tumor lysis syndrome due to the increased tumor burden. Initial management includes aggressive hydration, prevention of tumor lysis syndrome, and correction of metabolic abnormalities. A red cell transfusion is not indicated in a hemodynamically stable child, as it adversely affects the blood viscosity. Leukapheresis is the treatment of choice for a very high count, or in patients with symptomatic hyperleukocytosis. The technical expertise required, a relative difficult venous access in younger children, risk of anticoagulation and possible non-availability of the procedure in emergency hours are limitations of leukapheresis. However, it is a rewarding procedure and performed with relative ease in centers that perform the procedure frequently. An exchange transfusion is often a practical option when hyperleukocytosis is complicated with severe anemia. The partial exchange aids in correcting both, without the risk of volume overload or hyperviscosity, which are the limitations of hydration and blood transfusion, respectively. Etiology and management of hyperleukocytosis in relevance to the pediatric emergency room is outlined.

Polycythemia is defined as a venous hematocrit of over 65%. The hematocrit in a newborn peaks at 2 hours of age and decreases gradually after that. The etiology of polycythemia is related either to intra-uterine hypoxia or secondary to fetal transfusion. The relationship between hematocrit and viscosity is almost linear till 65% and exponential thereafter. Increased viscosity of blood is associated with symptoms of hypo-perfusion. Clinical features related to polycythemia-hyperviscosity syndrome may affect all organ systems and this entity should be screened for in high-risk infants. Polycythemia may or may not be symptomatic and guidelines for management of both the types based on the current evidence are provided in the protocol.

Objective. To determine the prognostic value of indirect and direct hyperbilirubinemia in neonates with jaundice. Methods. A cohort of 92 consecutive neonates reporting with hyperbilirubinemia to a tertiary care center were followed up till well and discharged, or, till death to assess risk and rate of mortality. Results. The baseline median values of total, direct and indirect bilirubin in the cohort of 21.8, 1.6 and 18.6 mg/dl, respectively, were used as cut-offs for high and low levels. Using survival analyses i.e. Kaplan-Meier plots, logrank tests and multivariate Cox proportional hazards regression models to adjust for other strong predictors such as receipt of breastfeeding, being small for gestational age (SGA) and exchange transfusion, high direct bilirubin ( ≥ median value of 1.6 mg/dl) was independently associated with a higher and faster mortality. Conclusion. This study showed that direct bilirubin has independent and additive prognostic value and due attention should be given to newborns with raised levels. [Indian J Pediatr 2007; 74 (9) : 819-822] E-mail : manjumamtani@rediffmail.com

To estimate the incidence of blood exchange and determine causes and complication of blood exchange and identify strategies for risk reduction of Kernicterus in newborn with jaundice. From March 2004 to March 2006 in neonatal Department in children hospital, medical center Tehran, Iran, 346 neonates were admitted as neonatal jaundice without sign and symptoms of infections. We identified causes and complications of exchange. Of 346 infants with jaundice who received phototherapy. 50, 14.45 percent cases underwent exchange transfusion with mean age 9.38 + 5.75 days. The mean total Serum bilirubin level was 29.39 + 6.13 mg/dl. ABO incompatibility was the most common cause for hyperbilirubinemia. The incidence of apnea was 12% there was no direct death from exchange transfusion. To make payment women aware to observe jaundice regularly after birth of their child and short breast feeding to control dehydration.

Recurrent Guillain-Barre Syndrome is a rare condition. IVIg and plasmapheresis are costly therapies and may not be affordable. We report a 6-yr-old boy in whom two severe episodes of Guillain-Barre Syndrome were successfully treated by exchange transfusion. Possible explanation for its effectiveness is discussed with respect to available literature.

Objective: To evaluate the role of intravenous immunoglobulins in Rh hemolytic disease of newborn.Methods: The study included all DCT positive Rh isoimmunized babies admitted in the unit from August 2000 to February 2001. Intravenous immunoglobulins in the dose of 500 mg/kg on day 1 and day 2 of life in addition to the standard therapy. Babies who received IVIG were compared with those who did not receive IVIG for the peak bilirubin levels, duration of phototherapy, number of exchange transfusions, discharge PCV and the need for blood transfusions for late anemia till 1 months of age.Results: A total of 34 babies were eligible for the study. 8 babies received IVIG and 26 babies only standard treatment. The mean maximum bilirubin levels were significantly lower in the IVIG group compared to the group who received NO IVIG (16.52 ± 2.96 Vs 22.72 ± 8.84, p=0.004). Five babies in the IVIG group (62.5%) and 23 babies in the NO IVIG group required exchange transfusions (88.5%, p=0.014). 12 of the 26 babies in the NO IVIG group required multiple exchange transfusions while none of the babies in IVIG group required more one exchange transfusion (p=0.03). The mean duration of phototherapy was 165 ± 109 hours in the IVIG group as against 119 ± 56 hours in the NO IVIG group (p=0.29). Blood transfusion for anemia was more common in the IVIG group (37.5 % Vs 11.5% p=0.126) though the packed cell volumes at discharge were similar in both the groups (39.5 ±11 Vs 40 ± 5.1, P=0.92).Conclusion; Intravenous immunoglobulins is effective in decreasing the maximum bilirubin levels and the need for repeated exchange transfusions in Rh hemolytic disease of newborn. There is however an increased need for blood transfusions for late anemia in the babies treated with IVIG.

Very low birth weight (VLBW) neonates born between January 1995 to December 1998, who survived for2 days, were studied for the incidence, causes and interventions required for neonatal jaundice. Significant neonatal jaundice was defined as the total serum bilirubin (TSB) level beyond which baby required intervention (phototherapy and/or exchange transfusion) for neonatal jaundice. The incidence of significant neonatal jaundice (NNJ) was 76.6% and 37.3% required exchange transfusion. It was 82.9% at gestational ageor = 28 weeks reduced whereas to 56.9% at gestational age of 35-36 weeks. The incidence was 75.3%, 78.5% and 76.7% in the birth weight group of 750-799 grams, 1000-1249 grams and 1250-1499 grams respectively. Glucose 6 phosphatase dehydrogenase (G-6-PD) deficiency (12.1%) was the commonest cause of jaundice. There is a need for evaluation of prophylactic therapies that enhances liver function or decreases production of bilirubin, which would prevent the rise of TSB to dangerous levels and thus would decrease the need for exchange transfusions.

The technique of ABR testing was applied to 25 infants with neonatal hyperbilirubinemia at levels exceeding that for exchange transfusion, in an attempt to study potential influence of bilirubin toxicity on the auditory brainstem pathway. The test was performed at a mean conceptional age of 40.4 +/- 0.6 weeks just after discharge. Twenty normal term neonates of comparable birth weights and conceptional ages, who had no hyperbilirubinemia, were also examined for comparison. Fifty six percent (n = 14) of the hyperbilirubinemic neonates had some abnormality in the ABR pattern, the major one being a transient increase in the threshold of wave V (7, fail-30; 5, fail-45). Wave V, however, was consistently present at 30 dBnHL click stimulus in all the normal neonates (pass-30; normal threshold). Further, mean ABR latencies (wave III, V) and 1-V interpeak latency (brainstem conduction time) were significantly prolonged in jaundiced neonates as compared with controls (P less than 0.01). ABR changes were strongly correlated with the serum bilirubin levels (P less than 0.001). On follow up retesting at 3 months, however, all infants were found to have normal ABR latencies and threshold. Neonatal jaundice was associated with significant transient aberrations of ABR, suggestive of a transient toxic brainstem encephalopathy.

Ten cases of neonatal polycythemia are presented to highlight the severity and management of this potentially fatal though uncommonly recognised disorder. Hemoglobin (Hb) and hematocrit (Hct) levels were determined in these neonates as they appeared plethoric within first few days of life. The study includes two cases of fetofetal transfusion, two of maternofetal transfusion, four of intrauterine growth retardation (IUGR), one of Trisomy 18, and one infant of diabetic mother. Symptomatic infants with venous hematocrits above 70 percent received plasma exchange transfusion via umbilical vein. Three of the ten infants expired, one of congestive cardiac failure (CCF) and cerebral infarction and the other two of unrelated causes.

Fourteen neonates who were given a total of 27 exchange transfusions during the period from July 1964 up to August, 1968, have been analysed. The hyperbilirubinaemia was due to Rh-incompatibility in 11 cases and in one case each was due to ABO incompatibility, septicaemia and the Criggler-Najjar syndrome. One case out of nine survivors showed evidence of kernicterus on subsequent follow up. The transfusion mortality rate was 11%, and the immediate and overall patient mortality rates were 21.4 and 28.6 per cent respectively. A critical evaluation of different factors must be made in every new born with severe jaundice, weighing the dangers of kernicteurs against the possible hazards of the exchange transfusion procedure itself.

Five cases of patients in hepatic coma treated with exchange transfusion are reported. Two of them fully recovered. Two others died in the postexchange period without fully recovering consciousness, one due to haemorrhage and infection and the other due to severe hypoglycaemia. One who showed an initial good response succumbed later due to the associated degenerative disease.

The mortality of exchange transfusions and risks associated with hyperbilirubinemia experienced with 202 exchange transfusions performed on 143 newborn infants, have been reviewed. A large proportion of the infants belonged to the groups with ABO or no incompatibility.