Pathogenesis and Management of Indirect Hyperbilirubinemia in Preterm Neonates Less Than 35 Weeks: Moving Toward a Standardized Approach.

Premature infants have a higher incidence of indirect hyperbilirubinemia than term infants. Management of neonatal indirect hyperbilirubinemia in late preterm and term neonates has been well addressed by recognized, consensus-based guidelines. However, the extension of these guidelines to the preterm population has been an area of uncertainty because of limited evidence. This leads to variation in clinical practice and lack of recognition of the spectrum of bilirubin-induced neurologic dysfunction (BIND) in this population. Preterm infants are metabolically immature and at higher risk for BIND at lower bilirubin levels than their term counterparts. Early use of phototherapy to eliminate BIND and minimize the need for exchange transfusion is the goal of treatment in premature neonates. Although considered relatively safe, phototherapy does have side effects, and some NICUs tend to overuse phototherapy. In this review, we describe the epidemiology and pathophysiology of BIND in preterm neonates, and discuss our approach to standardized management of indirect hyperbilirubinemia in the vulnerable preterm population. The proposed treatment charts suggest early use of phototherapy in preterm neonates with the aim of reducing exposure to high irradiance levels, minimizing the need for exchange transfusions, and preventing BIND. The charts are pragmatic and have additional curves for stopping phototherapy and escalating its intensity. Having a standardized approach would support future research and quality improvement initiatives that examine dose and duration of phototherapy exposure with relation to outcomes.

Elevated triglycerides levels in two infants with hypoxic-ischemic encephalopathy undergoing therapeutic hypothermia and receiving parenteral nutrition.

Therapeutic hypothermia has been widely applied to improve the survival/neurodevelopmental outcomes among infants with moderate-to-severe hypoxic ischemic encephalopathy (HIE). Due to their critical condition and concerns over feeding tolerance, it is not uncommon to withhold enteral feeds and provide parenteral nutrition (PN) during hypothermia and early rewarming. Here we report 2 infants with HIE undergoing therapeutic hypothermia, and receiving PN, who exhibited early elevated triglyceride levels. Hypertriglyceridemia can be associated with neurologic complications, ranging from altered mental status, or irritability to seizures. Given the possible altered lipid metabolism under hypothermic conditions, we advocate close monitoring of lipid tolerance and conducting further prospective trials to elucidate lipid metabolism in these infants.