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In an interesting recent article Wheeler reflects on the lack of involvement of parents of children discussed in UK hospital clinical ethics committees (CEC).1 Our CEC at Oslo University Hospital, Norway started gaining experience with patient participation in deliberations almost two decades ago.2 Previously a so-called patient representative represented a generic ‘patient perspective’, but we believed that this did not fully represent the unique aspects of individual patients. Initially having patients and/or kin participate in a deliberation was emotionally taxing for CEC members, accompanied …

Bilirubin is the end product of heme catabolism formed during a process that involves oxidation-reduction reactions and conserves iron body stores. Unconjugated hyperbilirubinemia is common in newborn infants, but rare later in life. The basic physiology of bilirubin metabolism, such as production, transport, and excretion, has been well described. However, in the neonate, numerous variables related to nutrition, ethnicity, and genetic variants at several metabolic steps may be superimposed on the normal physiological hyperbilirubinemia that occurs in the first week of life and results in bilirubin levels that may be toxic to the brain. Bilirubin exists in several isomeric forms that differ in their polarities and is considered a physiologically important antioxidant. Here we review the chemistry of the bilirubin molecule and its metabolism in the body with a particular focus on the processes that impact the newborn infant, and how differences relative to older children and adults contribute to the risk of developing both acute and long-term neurological sequelae in the newborn infant. The final section deals with the interplay between the brain and bilirubin and its entry, clearance, and accumulation. We conclude with a discussion of the current state of knowledge regarding the mechanism(s) of bilirubin neurotoxicity.

AIM: Limited information is available about how guidelines on phototherapy for neonatal jaundice are applied in practice and toxicity is a concern. We studied the use of phototherapy in relation to birthweight and gestational age (GA) in Norwegian neonatal intensive care units (NICUs). METHODS: The study population was all 5382 infants admitted to the 21 NICUs in Norway between September 1, 2013 and August 31, 2014. Data were recorded daily in the Norwegian Neonatal Network database and anonymised data on patient characteristics, diagnoses, duration, the ages at the start and discontinuation of phototherapy were analysed. RESULTS: More than a quarter (26.6%) of all infants admitted to Norwegian NICUs during the study period received phototherapy. The use of phototherapy was inversely related to GA and birthweight. More than 80% of the preterm infants under 28 weeks of GA received phototherapy. The duration was significantly longer in the lowest birthweight and GA groups and decreased with increasing birthweight and GA. CONCLUSION: Phototherapy is proved to be a strong candidate for the most common therapeutic modality in NICU infants. However, in the light of reported toxicity in the smallest, most vulnerable infants, we recommend increased emphasis on quality control. The final version of this research has been published in Acta Paediatrica. © 2017 Wiley

A breakthrough discovery 60 years ago by Cremer et al. has since changed the way we treat infants with hyperbilirubinemia and saved the lives of millions from death and disabilities. "Photobiology" has evolved by inquiry of diverse light sources: fluorescent tubes (wavelength range of 400-520 nm; halogen spotlights that emit circular footprints of light; fiberoptic pads/blankets (mostly, 400-550 nm range) that can be placed in direct contact with skin; and the current narrow-band blue light-emitting diode (LED) light (450-470 nm), which overlaps the peak absorption wavelength (458 nm) for bilirubin photoisomerization. Excessive bombardment with photons has raised concerns for oxidative stress in very low birthweight versus term infants treated aggressively with phototherapy. Increased emphasis on prescribing phototherapy as a "drug" that is dosed cautiously and judiciously is needed. In this historical review, we chronicled the basic to the neurotoxic components of severe neonatal hyperbilirubinemia and the use of standardized interventions.

Phototherapy is the main treatment for neonatal hyperbilirubinemia. In acute treatment of extreme hyperbilirubinemia, intensive phototherapy may have a role in 'detoxifying' the bilirubin molecule to more polar photoisomers, which should be less prone to crossing the blood-brain barrier, providing a 'brain-sparing' effect. This article reviews the biology of bilirubin isomers. Although there is evidence supporting the lower toxicity of bilirubin photoisomers, there are studies showing the opposite. There are methodologic weaknesses in most studies and better-designed experiments are needed. In an infant acutely threatened by bilirubin-induced brain damage, intensified phototherapy should be used expediently and aggressively.

Hyperbilirubinaemia, presenting as jaundice, is a ubiquitous and frequently benign condition in newborn babies but is a leading cause of hospitalisation in the first week of life. In some infants jaundice can become severe, progressing to acute bilirubin encephalopathy and kernicterus with a substantial risk of neonatal mortality and long-term neurodevelopmental impairments. Severe hyperbilirubinaemia and its sequelae continue to occur in industrialised countries with functioning medical systems and a disproportionately high burden also persists in low-income and middle-income countries due primarily to delays in delivering effective treatments that are routinely available in high-income countries. In this Review we summarise up-to-date evidence on the epidemiology of neonatal jaundice including its global burden based on estimates of its prevalence, and both fatal and non-fatal health outcomes. We also discuss the management of severe hyperbilirubinaemia including the prevention of kernicterus, and highlight future directions for research.

Aim We examined how physicians in different medical specialties would evaluate treatment decisions for vulnerable patients in need of resuscitation. Methods A survey depicting six acutely ill patients from newborn infant to aged, all in need of resuscitation with similar prognoses, was distributed (in 2009) to a representative sample of 1650 members of the Norwegian Medical Association and 676 members of the Norwegian Pediatric Association. Results There were 1335 respondents (57% participation rate). The majority of respondents across all specialties thought resuscitation was in the best interest of a 24 weeks' gestation preterm infant and would resuscitate the patient, but would also accept palliative care on the family's demand. Accepting a family's refusal of resuscitation was more common for the newborn infants. Specialists were overall similar in their answers, but specialty, age and gender were associated with different answers for the patients at both ends of the age spectrum. Conclusion Resuscitation decisions for the very young do not always seem to follow the best interest principle. Specialty and personal characteristics still have an impact on how we consider important ethical issues. We must be cognisant of our own valuations and how they may influence care.

We describe an infant who was readmitted from home at 14 days of age with jaundice and a history of apnoea and episodes of retrocollis/opisthotonos. He had been only mildly jaundiced on discharge from the maternity clinic at 2 days of age. The total serum bilirubin (TSB) on admission was 542 µmol/L, and the infant was treated intensively with triple phototherapy and exchange transfusion. In contrast to what is recommended in Norwegian national guidelines for management of neonatal jaundice, the parents had apparently neither received oral nor written information about jaundice and its follow-up at the time of discharge from maternity. They therefore contacted their child healthcare centre when they had questions about jaundice, though the national guidelines specifically state that follow-up for neonatal jaundice during the first 2 weeks of life is the responsibility of the birth hospital. Inappropriate advice resulted in delayed referral, and the child has been diagnosed with chronic kernicterus, probably the first such case in Norway since national guidelines were formalised in 2006. Genetic work-up disclosed compound heterozygosity for Crigler-Najjar syndrome type I, to the best of our knowledge the first instance of this disorder ever to have been diagnosed in Norway. The incidence of kernicterus is Norway is much lower than in other industrialised countries. This is most likely due to national guidelines for management of neonatal jaundice, which place the responsibility for management and follow-up of jaundice with the birth hospital during the crucial first 2 weeks of life. This case report reminds us that tragedies may occur when guidelines are disregarded.

AIM: This study compared the use of phototherapy for neonatal jaundice in all 21 Norwegian neonatal intensive care units (NICUs) from 2013-2014 to improve practice. METHODS: Information on all types of phototherapy devices was collected, and irradiance was measured from random units at 20 cm and 50 cm from the light source. We gathered information on local practice rules, including the use of single, double or triple phototherapy, how infants were positioned, the frequency of blood sampling, rules for using reflective surfaces and interrupting phototherapy. In every NICU, we asked one nurse with more than five years of experience and one with less than one year to set up phototherapy equipment, then measured the irradiance and distance. RESULTS: Photodiodes were the most common of the eight types of phototherapy devices used. Rules for the distance from the device to the infant varied from 10 to 40 cm and in practice they varied from 15 to 48 cm, with irradiance ranging from 11.1-56.1 W/m2 . There were significant variations between NICUs with regard to the overall treatment duration and duration in most birthweight categories. CONCLUSION: There were considerable variations in phototherapy practices among Norwegian NICUs. In particular, the significant variations in duration need to be addressed. The final version of this research has been published in Acta Paediatrica. © 2017 Wiley

OBJECTIVE: Ethically and legally, assertions that resuscitation is in a patient's best interest should be inversely correlated with willingness to forego intensive care (and accept comfort care) at the surrogate's request. Previous single country studies have demonstrated a relative devaluation of neonates when compared with other critically ill patients.STUDY DESIGN: In this international study, physicians in Argentina, Australia, Canada, Ireland, The Netherlands, Norway and the United States were presented with eight hypothetical vignettes of incompetent critically ill patients of different ages. They were asked to make assessments about best interest, respect for surrogate autonomy and to rank the patients in a triage scenario.RESULTS: In total, 2237 physicians responded (average response rate 61%). In all countries and scenarios, participants did not accept to withhold resuscitation if they estimated it was in the patient's best interest, except for scenarios involving neonates. Young children (other than neonates) were given high priority for resuscitation, regardless of existing disability. For neonates, surrogate autonomy outweighed assessment of best interest. In all countries, a 2-month-old-infant with meningitis and a multiply disabled 7-year old were resuscitated first in the triage scenario, with more variable ranking of the two neonates, which were ranked below patients with considerably worse prognosis.CONCLUSIONS: The value placed on the life of newborns is less than that expected according to predicted clinical outcomes and current legal and ethical theory relative to best interests. Value assessments on the basis of age, disability and prognosis appear to transcend culture, politics and religion in this domain.Journal of Perinatology advance online publication, 13 October 2016; doi:10.1038/jp.2016.168.

BACKGROUND: Even relatively low serum bilirubin concentrations can cause neurodevelopmental impairment in extremely low birth weight (EBWL) infants, while sequelae from hyperbilirubinemia in late preterm and term infants are rare and occur only at very high serum bilirubin lev-els. Phototherapy is the current treatment of choice.OBJECTIVE: To present an update on the most important issues involved in phototherapy for jaundiced infants.RESULTS: Light absorption by bilirubin in the skin transforms the native Z,Z-bilirubin to conformational photoisomers Z,E-bilirubin and E,Z-bilirubin and structural photoisomers E,Z-lumirubin and E,E-lumirubin. Formation and excretion of Z,E-bilirubin and E,Z-lumirubin are both im-portant routes of elimination of bilirubin through bile and urine, although the precise contributions of the various photoisomers to the overall elim-ination of bilirubin are unknown. It appears that the photoisomers of bili-rubin are predominantly formed in the plasma, and the rate of formation is affected by the hemoglobin concentration. Phototherapy lights with an emission spectrum of 460-490 nm provide the most efficient bilirubin-reducing light. LEDs should replace fluorescent tubes and halogen spot-lights as the preferred light sources. Recent data raise concerns that sick ELBW infants under prolonged phototherapy may have an in-creased risk of death, though survivors may benefit from reduced rates of neurodevelopmental impairment. Comparison of the efficacy of cy-cled vs. continuous phototherapy has given divergent results. Changing the infant's position does not increase the efficacy of phototherapy.CONCLUSION: During the last decade we have made progress in our un-derstanding of how and where phototherapy works and in its practical applications.

Premature infants at the limits of viability raise difficult ethical, legal, social and economic questions. Neonatologists attending an international Collegium were surveyed about delivery room behaviour, and the approach taken by selected countries practicing 'modern' medicine was explored. Conclusion There were strong preferences for comfort care at 22 weeks and full resuscitation at 24 weeks. Resuscitation was a grey area at 23 weeks. Cultural, social and legal factors also had a considerable impact on decision-making. ©2014 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd.

The balance between our responsibilities toward the child patient and our responsibilities toward the parents is a precarious one (Hansen 2016). Countries that have ratified the United Nations (UN)...

Neonatal jaundice was a topic of significant interest in French medical literature during the 18(th) and 19(th) centuries, particularly for students writing graduation theses (1-9). These publications provide a fascinating insight into how doctors worked and thought during this period. In light of new knowledge some case histories may tentatively be assigned a diagnosis. In 1817 Louis Sylvestre Beraud defended his graduation thesis "Observation sur l'ictere congenital" (Observations on congenital jaundice) at the University of Montpellier, France (10) (Fig. 1). He was 47 years old at the time of his graduation from medical school, but as a former naval and army surgeon and thus an already experienced physician. This career path was not unusual in 18-19(th) century French medicine (11). © 2012 The Author(s)/Acta Paediatrica © 2012 Foundation Acta Paediatrica.

To study attitudes regarding life-saving interventions.An Internet questionnaire describing 6 patients of different ages needing resuscitation was sent to members of the Norwegian Pediatric Association (n = 676): a 24-week gestational age infant, a term infant, a 2-month-old infant, a 7-year, a 50-year, and an 80-year-old individual. Neonates had similar or better described outcomes than older patients.A total of 266 people responded (39.4%). The majority would resuscitate all the patients except the 80-year-old. The majority thought that resuscitation was in the best interest of the younger 5 patients, but fewer thought so for neonates (P.05). Although the majority of the respondents thought that resuscitation was in the neonates' best interest (71% for 24-week-old and 75% for term infant), significantly more would accept comfort care at parental demand (62% for 24-week-old and 72% for term infant), unlike for other scenarios. Quality of life was used to justify decision making; 25% used the length of the life for neonates to motivate their answers. Patients were prioritized for resuscitation in the following order: 2-month-old infant, 7-year-old child with multiple disabilities, 50-year-old adult, the neonates, and lastly the 80-year-old individual.There are challenges in reconciling best interest and parental exercise of autonomy in pediatric life-or-death situations. Neonates seem to be devalued.

We describe an infant who was readmitted from home at 14 days of age with jaundice and a history of apnoea and episodes of retrocollis/opisthotonos. He had been only mildly jaundiced on discharge from the maternity clinic at 2 days of age. The total serum bilirubin (TSB) on admission was 542 µmol/L, and the infant was treated intensively with triple phototherapy and exchange transfusion. In contrast to what is recommended in Norwegian national guidelines for management of neonatal jaundice, the parents had apparently neither received oral nor written information about jaundice and its follow-up at the time of discharge from maternity. They therefore contacted their child healthcare centre when they had questions about jaundice, though the national guidelines specifically state that follow-up for neonatal jaundice during the first 2 weeks of life is the responsibility of the birth hospital. Inappropriate advice resulted in delayed referral, and the child has been diagnosed with chronic kernicterus, probably the first such case in Norway since national guidelines were formalised in 2006. Genetic work-up disclosed compound heterozygosity for Crigler-Najjar syndrome type I, to the best of our knowledge the first instance of this disorder ever to have been diagnosed in Norway. The incidence of kernicterus is Norway is much lower than in other industrialised countries. This is most likely due to national guidelines for management of neonatal jaundice, which place the responsibility for management and follow-up of jaundice with the birth hospital during the crucial first 2 weeks of life. This case report reminds us that tragedies may occur when guidelines are disregarded.

UNLABELLED: Jaundice is the most common reason for instituting treatment in otherwise healthy as well as sick newborn infants. Herein, we describe the process employed in Norway to forge agreement on a set of treatment guidelines that are now used across the country. The Norwegian Pediatric Association was a key resource in this process, which involved contacts with all paediatric departments in Norway. We have also performed an international survey regarding the use of such national guidelines, showing that the majority of those queried confirm having national guidelines. The evidence base for any neonatal jaundice guideline is weak; therefore, it is not surprising that the various guidelines differ both in format and in specifics. In the Norwegian guidelines, treatment indications are based on bilirubin concentrations and related to birth weight. Postnatal age is also factored in because jaundice develops gradually during the first 3-4 days before it levels off. CONCLUSION: Following the introduction of these guidelines, fewer babies in Norway receive phototherapy, and no cases of chronic kernicterus have been reported during this period.

Aim: To assess the need for and quality of neonatal transports. Material and methods: Prospective observational study of consecutive transports from a level II neonatal unit. Results: 500 transports were undertaken 1982-2010 in 445 patients, representing 0.7% of liveborn infants (n = 61 450). Indications were congenital malformations in 223 (45%), prematurity/respiratory distress syndrome (RDS) in 87 (17%), and other conditions in 190 (38%). For patients ventilated during transport (n = 121) mean pCO2 was improved at arrival, and for spontaneously breathing patients mean pH, pCO2, and base excess (p < 0.05). After establishing a local respirator programme from 1989, transports for prematurity/RDS declined from 3.4 per 1000 live born infants in 1982-88 to 0.8 per 1 000 in 1989-2010 (p < 0.0001), and night-time transports (departure between 22.00 pm - 06.00 am) declined from 24/119 (20%) to 38/381 (10%) (p = 0.003). Technical mishaps or severe clinical deterioration occurred in 16 (3%) of the transports. Conclusions: Neonatal transport carries risks, but also an opportunity for further stabilization and improvement. A local respirator programme reduced the need for transfer of premature infants with RDS as well as for transports during night-time.

Aim: To document nurses’ opinions about their assessments of oxygen requirements in ventilated preterm infants receiving oxygen supplementation. Methods: Survey design with descriptive statistics. The sample consisted of 111 nurses employed in clinical positions in neonatal intensive care units within Norway’s five regional hospitals. The questionnaire included questions about physiological and clinical observations used when assessing oxygen administration in ventilated preterm infants. Results: A major finding was the gap between the criteria laid down in professional and research literature, vs the criteria nurses perceived they were using when they assessed the oxygen requirements of preterm infants. The respondents stated that they used oxygen saturation to assess the infants’ oxygen requirements when adjusting oxygen supplementation. Only 17% of the nurses used the oxygen-haemoglobin dissociation curve in their assessments. Those who responded that they used the curve did not use it correctly. Conclusion: Assessment of O2 requirement is based on insufficient information and calls for evaluation of local, national as well as international education. Close collaboration between doctors and nurses is essential in planning care for individual patients.

Objectives The majority of drugs used in sick newborns receiving intensive care are unlicensed and off-label, exposing infants to greater risk of adverse drug reactions (ADRs). Our aim was to study the compatibility of co-infusions for a selected group of drugs and nutrition solutions as part of our quality assurance programme in the neonatal intensive care unit. Methods The authors reviewed drug studies in the literature. Documented compatibility or the lack thereof was the main end point for the 1042 co-infusions investigated. The results of searches were reviewed against predetermined criteria for co-infusion of 13 intensive care drugs with 66 other drugs and two nutrition solutions and albumin. Results 33/820 (4%) co-infusions were documented as compatible without any restrictions. 212/820 (26%) drug co-infusions were compatible, but 196 of the 212 (93%) had restrictions on infusion fluid, concentration or contact time. 608/820 (74%) drug co-infusions in neonates have either been shown to be incompatible or have not been tested. Among those not tested, 163/486 (34%) entailed major differences in pH level which could cause co-infusion instability. Conclusion There is a lack of data on compatibility for the majority of drugs used for co-infusions in neonates. Caregivers therefore need to pay special attention to infusion lines when drugs are co-administered. Our results suggest that further studies on drug compatibility are needed to reduce possible ADRs and toxicity, and avoid precipitation and occlusion of infusion lines in critically ill neonates.

Bilirubin is formed in the reticuloendothelial system as the end product of heme catabolism through a series of oxidation-reduction reactions. The predominant bilirubin isomer in humans is IX-alpha (Z,Z), which, because of its lipophilic nature, can cross phospholipid membranes. In fetal life, this characteristic permits passage of bilirubin through the placenta into the maternal organism for excretion. Postpartum, this same characteristic enables passage of bilirubin across the blood-brain barrier, which is why clinicians worry about jaundice in newborns. Bilirubin is transported in serum bound to albumin. When the bilirubin-albumin complex reaches the liver, bilirubin is transferred into the hepatocytes, where it is bound to ligandin. The next step, which occurs inside the hepatocyte, is binding of bilirubin to glucuronic acid (conjugation) through the enzyme uridine diphosphate glucuronyl transferase (UDPGT). Both ligandin and UDPGT have very low concentrations and activities in the fetus, but activity increases greatly after birth. However, during the time required to increase these enzyme activities, bilirubin accumulates. An important factor in this process is increased bilirubin production through the breakdown of fetal erythrocytes. Once conjugated in the liver, bilirubin is excreted into the bile and transported through the gut with food and further broken down, contributing to the color of stool. Deconjugation and reabsorption of bilirubin can occur in the bowel, a process known as enterohepatic circulation. Increased enterohepatic circulation is believed to contribute to prolonged jaundice in some newborns and may be partially responsible for human milk-associated jaundice. Some of the steps in bilirubin metabolism can be influenced by drugs or feeding.

The discussion following the publication of the SUPPORT trial (Drazen, Solomon, and Greene 2013; Hudson, Guttmacher, and Collins 2013; Macklin and Shepherd 2013; Magnus and Kaplan 2013; Rich et al....

To date, few Norwegian clinical ethics committees (CECs) have included patients or next of kin in case discussions. In 2008, Rikshospitalet's (The National Hospital‘s) CEC began to routinely invite patients and relatives into case discussions. In this paper, we describe seven cases discussed by this committee in 2008. Six involved life and death decision-making in collaboration with the next of kin, while one related case did not include relatives. In our opinion, representing the patient's perspective was advantageous to the discussion itself, to the conclusion made and to the next of kin's acceptance of the resolution. We believe that if the patient had been represented in the last case, the outcome might have been different. We conclude that successful patient involvement will rely on well-structured case discussions, an open atmosphere and good preparation and follow-up.

We present 2 Norwegian siblings who we believe to be the first cases of pyrimidine 5′-nucleotidase deficiency diagnosed in the Scandinavian countries. In addition to the features presented by previously published cases, our patients exhibited signs of intravascular haemolysis with haemoglobinuria and increased loss of iron in the urine. The loss of iron has made iron medication necessary from time to time. A kidney biopsy from the oldest patient revealed accumulation of iron in the epithelium of the proximal tubuli. The kidneys were considerably enlarged in both patients, but with normal function tests.

Screening of newborn infants for congenital hip dysplasia may be done by clinical examination, ultrasound, or radiography--or a combination of these. Studies that have used clinical examination followed by ultrasound imaging for infants with certain risk factors have shown excellent results, but they were performed by very experienced practitioners. We wanted to find out whether the results of such screening would be equally good with less optimal staffing. Thus, we evaluated the real-life performance of a screening program for detection of congenital hip dysplasia in newborn infants.We performed a retrospective chart review of all infants (n = 1,983) referred for evaluation for suspected congenital hip dysplasia from one single obstetric hospital, where 19,820 infants had been screened from 1992 through 2001. Infants were referred either because of a positive finding during the Ortolani and Barlow examinations or because of the presence of risk factors.The reasons for referral of the 1,983 infants (10% of those examined) were: positive clinical signs in 255 (1.3% of all examined) and risk factors in 1,547 (7.8%), and a combination of both in 114 (0.6%). 67 other infants (0.3%) who had passed the initial pediatric screening were later referred from the local health centers. Finally, 23 of the 1,983 infants were subsequently referred again by their health center for renewed orthopedic evaluation. Of the infants who were treated (298/1,983 = 15% of those referred), those with a pathological examination result were represented proportionately more than infants who were referred because of risk factors (0.8% as opposed to 0.5%). Delayed diagnoses occurred in 1.7/1,000 infants.The performance of a screening protocol for congenital hip dysplasia in a real-life setting involving several physicians both on the pediatric and orthopedic side may not live up to expectations based on the use of such a protocol in an optimized setting. This type of analysis of screening data may serve to pinpoint weaknesses, and thus lead to adjustments that may enhance quality.

UNLABELLED The increasing number of case reports on neurologic sequelae related to hyperbilirubinaemia may represent a re-emergence of kernicterus in the industrialized world. However, not much has been written about infants who survived extreme levels of serum bilirubin without neurologic damage. We present three cases of extreme neonatal hyperbilirubinaemia, all with peak serum bilirubin levels >600 micromol/L. Two of the infants developed neurologic sequelae, but the third infant did not. In contrast to the two with sequelae, the infant without sequelae was female, had a positive Coombs' test, less clinical signs compatible with bilirubin encephalopathy, and a shorter exposure to serum bilirubin values >400 micromol/L. CONCLUSION The basic mechanism of bilirubin neurotoxicity remains unknown, and it is not clear why some infants do not develop neurologic injury at serum bilirubin levels at which others do. We speculate that a comparison between patients with sequelae and those without may yield important information.

Jaundice is a common reason for therapeutic intervention in newborn infants and phototherapy is effective treatment if enough light energy is delivered to a skin surface area of sufficient size. Narrow spectrum blue light is superior to white light, but in developing countries fluorescent blue lamps often have to be imported and are much more expensive than white lamps. We developed a phototherapy unit in which seven daylight fluorescent tubes are placed immediately under the floor of a transparent plexiglass crib. The efficacy of this unit, delivering approximately 19 microW/cm2/nm, was compared with that of two conventional phototherapy units using overhead lamps placed 35 cm above the infants. One unit used daylight fluorescent tubes and delivered approximately 4 microW/cm2/nm, the other unit used special blue fluorescent tubes and delivered approximately 22 microW/cm2/nm. Fifty-one infants were included in the analyses, all of them breastfed on demand. Serum bilirubin levels were determined spectrophotometrically at 0, 12 and 24 h. The decrement in serum bilirubin concentrations was significantly greater in infants undergoing phototherapy with the new device or with special blue lamps compared to conventional overhead daylight lamps (p < 0.001 both at 12 and at 24 h). We conclude that highly efficient phototherapy may be delivered with daylight fluorescent lamps placed in very close proximity to the patient. Thus, lack of access to expensive imported special blue lamps does not preclude delivery of effective phototherapy in developing countries.

Changes in the presentation and course of neonatal jaundice associated with breastfeeding have been recognized for some time now and have been the subject of scientific study for the past twenty years. Though the data still tend to be conflicting a reasonable summary of current knowledge suggests that breastfeeding is associated with an increased incidence of neonatal jaundice compared with formula feeding. Furthermore that jaundice in breast-fed infants tends to be more severe and thirdly that the duration of measurable hyperbilirubinaemia may extend for weeks or even months in some cases. Feeding the newborn infant at the breast has become the rule for the majority of mothers in many industrialized countries particularly in Scandinavia. Questions related to breastfeeding-associated jaundice have become a common occurrence in the well baby nursery as well as in the follow-up of healthy infants born in our hospital. (excerpt)

To determine whether the addition of low-cost reflecting curtains to a standard phototherapy unit could increase effectiveness of phototherapy for neonatal jaundice.Randomised controlled clinical trial.Level-one nursery of the Hospital Universiti Sains Malaysia, Kelantan, Malayasia.Term newborns with uncomplicated neonatal jaundice presenting in the first week of life.Phototherapy with white curtains hanging from the sides of the phototherapy unit (study group, n = 50) was compared with single phototherapy without curtains (control group, n = 47).The primary outcome was the mean difference in total serum bilirubin measured at baseline and after 4 h of phototherapy. The secondary outcome was the duration of phototherapy.The mean (standard deviation) decrease in total serum bilirubin levels after 4 h of phototherapy was significantly (p0.001) higher in the study group (27.62 (25.24) micromol/l) than in the control group (4.04 (24.27) micromol/l). Cox proportional hazards regression analysis indicated that the median duration of phototherapy was significantly shorter in the study group (12 h) than in the control group (34 h; chi(2) change 45.2; p0.001; hazards ratio 0.20; 95% confidence interval 0.12 to 0.32). No difference in adverse events was noted in terms of hyperthermia or hypothermia, weight loss, rash, loose stools or feeding intolerance.Hanging white curtains around phototherapy units significantly increases efficacy of phototherapy in the treatment of neonatal jaundice without evidence of increased adverse effects.

Background/methods: Nils Andreas Quisling was born in Telemark, Norway, in 1854 and became an obstetrician. In 1893 he published a monograph on neonatal jaundice. This monograph was studied and compared with other published sources from the same time period. Results: Quisling discussed four theories on the cause of neonatal jaundice. “Suppression jaundice” held that jaundice was the result of suppressed liver function. “Haematogenous jaundice” claimed that bilirubin was formed from haemoglobin outside the liver, and had nothing to do with the liver. “Polycholia” held that neonatal jaundice was due to an increased secretion of all the constituents of bile. Quisling rejected these and supported the “hepatogenous” theory–jaundice was always a liver-related phenomenon. He described 50 cases of neonatal jaundice. The incidence of neonatal jaundice at the Kristiania Maternity Foundation was 26%. In Quisling's cases, gastrointestinal disturbances were common, and he felt this to be an under-reported complication of neonatal jaundice. He found that neonatal jaundice was often accompanied by fever. Conclusion: Gastrointestinal disturbances were causally involved in neonatal jaundice, resulting in impeded bile drainage. At the time of Quisling's study (1887), this ‘hepatogenous” theory of neonatal jaundice probably still had majority support in the European literature.

Studies on primary cultures of newborn rodent neurons have suggested that neuronal death induced by unconjugated bilirubin (UCB) is mainly apoptotic in nature. We exposed a human teratocarcinoma-derived cell line, NT2-N neurons, to different concentrations of UCB and albumin at a 1.5 molar ratio and used multiple, independent measures of cell damage to evaluate neuronal injury after 6, 24, and 48 h. Low doses of UCB (0.66, 2, and 5 microM) induced a moderate loss of 3-4[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazoliumbromide (MTT) cleavage accompanied by delayed morphologic changes consistent with apoptosis (2 and 5 microM). Moderate concentrations of UCB (10 and 25 microM) resulted in early (6 h) necrosis in a subset of neurons, while remaining neurons underwent progressive impairment of MTT cleavage and increasing lactate dehydrogenase (LDH) release accompanied by predominantly delayed apoptosis. High concentrations of UCB (100 microM) induced severe impairment of MTT cleavage, extensive LDH release, and morphologic changes consistent with necrosis within 6 h. Used as a positive control for apoptosis, 2 microM STS induced progressive impairment of MTT cleavage and morphologic changes consistent with apoptosis over the entire observation period. DNA electrophoresis at 48 h was compatible with apoptosis both after treatment with STS and UCB concentrations