Revisiting the Criteria for Exchange Transfusion for Severe Neonatal Hyperbilirubinemia in Resource-Limited Settings

Abstract

Background: Exchange transfusion (ET) for severe neonatal hyperbilirubinemia (SNH) is frequently undertaken in low- and middle-income countries (LMIC), in sharp contrast to the prevailing practice in high-income countries. However, the criteria for initiating this procedure in settings with limited resources for treating infants with SNH have not been systematically explored. Objective: To identify key considerations for initiating ET in resource-poor countries to curtail its unnecessary use for the prevention of kernicterus. Methods: A review of the existing guidelines and literature on the management of neonatal hyperbilirubinemia worldwide was conducted to identify criteria and underlying factors for initiating ET. Results: There is a dearth of evidence from randomized clinical trials to support clear criteria for indicated ET worldwide. Because risk assessment for kernicterus based solely on the levels of total serum bilirubin (TSB) has often proved inadequate, a combination of plasma/serum bilirubin estimation and clinical evaluation for acute bilirubin encephalopathy (ABE) has been recommended for predicting the risk of kernicterus. However, there is a lack of consistency regarding the TSB levels for which ET should be initiated in relation to the clinical signs/symptoms of ABE and hemolytic disorders. Conclusions: A decision-making framework that combines TSB thresholds and evidence of neurotoxicity is needed for evaluating the risk of kernicterus and prioritising infants for ET in LMICs to curtail unnecessary interventions.

Neonatal Jaundice in Low- and Middle-Income Countries: Lessons and Future Directions from the 2015 Don Ostrow Trieste Yellow Retreat

“…A recent review noted the lack of empirical evidence of the efficacy of such programs in reducing the risk of severe hyperbilirubinemia, but nevertheless echoed this recommendation on the basis of the available evidence and understanding [1,9,10,31,53,56,62,63,64,65,66]. While screening of cord-blood for G6PD deficiency is of relatively low cost, the experience of the DOTYR-15 participants is that there would need to be a substantial investment in infrastructure to support universal screening programs.…”

“…Furthermore, the lack of affordable tools for the real-time objective measurement and monitoring of bilirubin levels continues to be a challenge [1,31]. Health facilities often face long delays for TSB results and in primary health care settings or remote areas, testing is usually unavailable.…”

“…The classification of hyperbilirubinemia in the countries included in this article was usually established at a local level, with the exception of Malaysia and Egypt which adopted the AAP guidelines for NNJ management. Despite these limitations, the prevalence is said to be high in LMICs, where records and documentation of the incidence of NNJ, ABE and CBE are usually poor and variable [1,20,31]. …”

Use of Transcutaneous Bilirubin to Determine the Need for Phototherapy in Resource-Limited Settings

“…In a small proportion of the affected newborns, unconjugated hyperbilirubinemia may necessitate early detection, monitoring, and treatment to prevent bilirubin-induced neurologic dysfunction such as acute bilirubin encephalopathy and kernicterus [3,4]. Timely and effective phototherapy curtails the need for exchange transfusion with its potential complications especially among infants at a high risk of bilirubin-induced neurologic dysfunction [5,6]. …”

“…Accurate total serum/plasma bilirubin (TSB) determination is crucial for any objective risk-assessment for neonatal hyperbilirubinemia and treatment efficacy, but entails an invasive, time-consuming, and often painful blood draw [6]. Because of its high correlation with TSB across various racial groups [7], noninvasive, rapid, and simple-to-use transcutaneous bilirubin (TcB) is widely promoted as a prescreening technique and proxy for TSB [8].…”