Literature Review of Objective 3 According to Mosby's Medical Dictionary, 8th edition,2009, interventions such preventive measures as frequent feedings

during the first 6 to 12 hours of life to increase GI motility have little justification. Infants with mild jaundice require no treatment, only observation. Phototherapy is the usual treatment for severe or increasing hyperbilirubinemia. If hyperbilirubinemia is the result of increased hemolysis caused by blood group incompatibility, exchange transfusion may be done. It is usually indicated if laboratory analysis reveals a positive antiglobulin test result, a hemoglobin concentration of the cord blood below 12 g/dl, or a bilirubin level of 20 mg/dl or more in a full-term infant or 15 mg/dl or more in a premature infant. Phototherapy may be used in conjunction with exchange transfusion, except in cases of Rh incompatibility. If used immediately after the initial exchange transfusion, phototherapy may remove enough bilirubin from the tissues to make subsequent transfusions unnecessary. Pharmacologic management, such as the use of barbiturates to stimulate protein synthesis that in turn increases albumin for conjugating bilirubin and promotes hepatic glucuronyl transferase synthesis, is indicated in some instances; however, this form of therapy is controversial because of the known side effects of the drugs. Porter ,M.L. and Dennis, B.D in 2002, proposed that before

treatment is initiated, the minimum evaluation should include the infant's age and postnatal course, a maternal and gestational history, physical examination of the infant, and determination of the total serum bilirubin level and the rate at which it is rising. Phototherapy employs blue wavelengths of light to alter unconjugated bilirubin in the skin. The bilirubin is converted to less toxic water-soluble photoisomers that are excreted in the bile and urine without conjugation. The decision to initiate phototherapy is based on the newborn's age and total serum bilirubin level. The efficacy of phototherapy depends on several important factors. The ideal configuration is four special blue bulbs (F20T12/BB) placed centrally, with two daylight fluorescent tubes on either side. The power output of the lights (irradiance) is directly related to the distance between the lights and the newborn. Ideally, all lights should be 15 to 20 cm from the infant. To expose the greatest surface area, the newborn should be naked except for eye shields. For double phototherapy, a fiber-optic pad can be placed under the newborn. This method is twice as effective as standard phototherapy. The only contraindication to the use of phototherapy is conjugated hyperbilirubinemia, as occurs in patients with

cholestasis and hepatic disease. In this setting, phototherapy may cause a dark grayish-brown discoloration of the skin (bronze baby syndrome). Potential problems that may occur with phototherapy include burns, retinal damage, thermoregulatory instability, loose stools, dehydration, skin rash, and tanning of the skin. Because phototherapy is continuous, treatment also involves significant separation of the infant and parents. With intensive phototherapy, the total serum bilirubin level should decline by 1 to 2 mg per dL (17 to 34 mol per L) within four to six hours. The bilirubin level may decline more slowly in breastfed infants (rate of 2 to 3 mg per dL per day) than in formula-fed infants. Phototherapy usually can be discontinued when the total serum bilirubin level is below 15 mg per dL. The average rebound bilirubin level after phototherapy is below 1 mg per dL. Therefore, hospital discharge of most infants does not have to be delayed to monitor for rebound elevation. If the total serum bilirubin level remains elevated after intensive phototherapy or if the initial bilirubin level is meets defined critical levels based on the infant's age, preparations should be made for exchange transfusion. Exchange transfusion is the most rapid method for lowering serum bilirubin concentrations. This treatment is rarely needed when intensive phototherapy is effective. The procedure removes partially hemolyzed and antibody-coated erythrocytes and replaces them with uncoated donor red blood cells that lack the sensitizing antigen. In the presence of hemolytic disease, severe anemia, or a rapid rise in the total serum bilirubin level (greater than 1 mg per dL per hour in less than six hours), exchange transfusion is the recommended treatment. Exchange transfusion should be considered in a newborn with nonhemolytic jaundice if intensive phototherapy fails to lower the bilirubin level. Complications of exchange transfusion can include air embolism, vasospasm, infarction, infection, and even death. Because of the potential seriousness of these complications, intensive phototherapy efforts should be exhausted before exchange transfusion is initiated. Ouwehond WH cited in 2000, that intravenous immunoglobulin G (IVIG) has been used in immunological neonatal disorders including alloimmune and autoimmune neonatal thrombocytopaenia1. IVIG is also used as an adjuvant therapy in neonatal sepsis2. Its use in neonatal Rh hemolytic disease has stemmed from its antenatal administration to pregnant women to salvage fetuses

with severe Rh isoimmunization3 in addition to its indication in other neonatal immunological disorders. The trials describing the administration of IVIG in hemolytic disease of the newborn have involved mostly babies with Rh hemolytic disease and very few babies with ABO hemolytic disease4-8. Hyperbilirubinemia due to ABO hemolytic disease is the major indicator for exchange transfusion in our institute. Against this background we set out to investigate whether IVIG administration to babies with significant hyperbilirubinemia due to ARO hemolytic disease would reduce the need for exchange transfusion. Dennery,P.A. proposed in 2001, the standard treatment for neonatal jaundice is phototherapy. Affected infants are placed under lights, and photons are absorbed by bilirubin as it circulates in skin capillaries. This energy transfer results in conversion of bilirubin to lumirubin and other products which, in contrast to bilirubin, are more water-soluble and readily excreted. The rate of bilirubin elimination depends upon both the wavelength of light used and its dose. Blue light (460 to 490 nm) is the most effective, but such light causes eye strain in those monitoring the baby, making it difficult to detect other conditions such as cyanosis. The most frequently used form of phototherapy is standard fluorescent white light.In severe cases of neonatal jaundice, another effective treatment is exchange transfusion. In this procedure, small amounts of blood (and hence bilirubin) are removed from the baby and replaced with donor blood; this procedure is repeated until roughly twice the blood volume has been replaced. Exchange transfusion also eliminates antibodies against red blood cells, which may be the inciting factor in development of hyperbilirubinemia. Neonatal jaundice almost certainly occurs in animals other than humans, but, by it self, is not recognized as a significant disorder. Immune-mediated hemolytic anemias are relatively common in foals, calves and piglets, and may lead to jaundice. However, the most serious aspect of this disease is the anemia, rather than jaundice per se.

References http://www.aafp.org/afp/2002/0215/p599.html http://medicaldictionary.thefreedictionary.com/hyperbilirubinemia+of+the+newbor n http://www.redorbit.com/news/health/115304/intravenous_immunogl obulin_g_ivig_therapy_for_significant_hyperbilirubinemia_in_abo http://www.vivo.colostate.edu/hbooks/pathphys/digestion/liver/neoja undice.html