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Neonatal jaundice

babies were given half of their daily fluid requirement as eight divided feeds at 3-hour intervals.
The remaining half of their daily fluid requirement was given as continuous intravenous 1/5
normal saline and 5% dextrose infusion. Blinding was not reported but subjects were stratified
by serum bilirubin level, hydration status and usual type of feed before randomisation. Sealed
envelopes were used to conceal the allocation. Fewer babies in the un-supplemented group
needed an exchange transfusion but this difference was not statistically significant. There was a
greater decrease in serum bilirubin in the babies given supplemental intravenous fluids, but
again this difference was not statistically significant. [EL 1+]
An RCT(n = 125) carried out in Argentina 133 compared conventional phototherapy combined
with either breastfeeding (usual care) or with formula feeds. No information was given on the
contents of the formula feeds. Blinding was not reported although subjects were randomised
using a computer-generated sequence of numbers. There was no statistically significant
difference between the two groups in mean decrease in serum bilirubin over the 48 hours of
phototherapy. [EL 1+]
The final RCT(n = 25), from Thailand, 176 compared the effect on serum bilirubin of different
types of formula feeds in combination with phototherapy. The formula feed Enfamil® was
compared with the lactose-free formula Enfamil ProSobee®. These feeds have compatible
energy, carbohydrate, fat and mineral content: Enfamil ProSobee has a slightly higher protein
content that Enfamil. Babies were fed with 3 ounces of formula eight times a day over 72 hours
of conventional phototherapy. Blinding and randomisation methods were not reported. There
was no statistically significant difference between the types of formula in mean decrease in
serum bilirubin during phototherapy. [EL 1−]
Evidence summary

Evidence from good-quality RCTs [EL 1+ or EL 1++] on the effectiveness of the addition of
intravenous fluids to phototherapy shows contrasting results. One study showed that fewer
babies given additional intravenous fluids during phototherapy needed exchange transfusion,
they have a greater reduction in mean serum bilirubin, and need shorter duration of
phototherapy compared with babies given only enteral feeds. The second study did not confirm
these findings.
In one EL I− RCT, formula feeds was no more effective than breastfeeding in reducing serum
bilirubin during phototherapy. In another study, lactose-containing formula was no more
effective than lactose-free formula during phototherapy.

No studies examining additional fluids in preterm babies receiving phototherapy were
identified.

GDG translation from evidence
Additional fluids given to term babies receiving phototherapy shorten the duration of treatment
and reduce the number of exchange transfusions required. However, the GDG considers that
the automatic prescription of additional fluids when phototherapy is initiated is not warranted as
this can hinder successful breastfeeding. The NICE guideline on ‘Postnatal care’ recommends
that ‘breastfed babies should not be routinely supplemented with formula, water or dextrose
water for the treatment of jaundice’ (www.nice.org.uk/CG37). All the studies examined were
performed before modern LED phototherapy devices were developed, devices which are
claimed to reduce fluid losses. The GDG’s opinion is that the need for additional fluids during
phototherapy should be considered on an individual clinical basis. If additional fluids are
indicated, the GDG supports maternal expressed breast milk as the additional fluid of choice.
Recommendations

See the end of Section 7.2.3.
Adverse effects of phototherapy

Several concerns have been raised about the immediate and long-term potential adverse effects
of phototherapy for neonatal hyperbilirubinaemia.

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