Phototherapy Induced Hypocalcaemia

A Prospective Study Dr vikas moudgil

J L N HOSPITAL AND R C BHILAI

Introduction

Jaundice –most common abnormal physical finding in first week of life

Physiological jaundice Pathological

Introduction

Common side effects of phototherapy are loose stools, hyperthermia, dehydration and fluid losses, skin rashes and skin burns, photo retinitis, Bronze Baby syndrome, DNA damage.

A lesser known but potential complication of phototherapy is hypocalcaemia.

PathophysiologyPhototherapy inhibits pineal secretion of melatonin

Melatonin blocks the hypocalcaemia effects of endogenous steroids

Low serum concentration of melatonin permits unopposed hypocalcaemia effects of endogenous steroids

Phototherapy Induced Hypocalcaemia

Aims and objectives

1. To study effect of phototherapy on serum total calcium level in icteric newborn

2. To compare the effect on serum total calcium values in preterm(>32-<37 weeks) and full term(>37-<40weeks) newborn receiving phototherapy

Materials and Methods

Study area- J.L.N Hospital & RC BhilaiStudy period- Dec 2009 to March 2010Study design-longitudinal observational

studyCase selection-on consecutive mannerTotal babies studied- 200Group A preterm 50, Group B full term 50Each group 50 babies control

Materials and MethodsExposed to phototherapy

Babies having hyperbilirubinemia and requiring phototherapy as management

Total 100 neonates 50 term and 50 preterm

Guidelines followed1. AAP guidelines 20042. AIIMS phototherapy

Protocol

Controls Babies with

hyperbilirubinemia but not requiring phototherapy

Total 100 neonates 50 term and 50 preterm

Materials and MethodsInclusion criteria for cases Icteric stable neonates On breast feeding and

standard formula feeding

Exclusion criteria Who developed jaundice in

first 24 hours, exchange transfusion

Suffering from birth asphyxia

Congenital malformation Sepsis, hypothyroidism Infant of diabetic mother Newborn on I.V. Therapy Infant of mothers with

anticonvulsants ABO/Rh incompatibility G6PD, PKD.LFD,IUGR

Materials and Methods

Babies having hypocalcaemia prior to phototherapy excluded from both study and controls groups

Babies having hypoproteinemia prior to therapy and developing during therapy excluded from study

Materials and Methods

Serum calcium was done at start and after 48 hours of phototherapy

Serum calcium in control group was also done at starting and after 48 hours of study

Hypocalcaemia was defined as serum values of calcium less than 7mg/dl . (Cloherty)

Babies with hypocalcaemia were treated with IV calcium

Observations

Observations

Control groupDistribution

Hypocalcaemia

percentage

Term 50 0 0

preterm 50 8 16%

total 100 8 8%

Not exposed to phototherapy

Total 8%

Observation

Phototherapy induced hypocalcaemia 43%

Control group

hypocalcaemi

a8%

Z value 5.68p

value<0.005

Significant

Observation

Total calcium in mg/dl±SDFrom total

study subjects

Control post study

8.79±0.677

Cases pre study

8.415±0.461

Observation

Significance in fall of calcium in phototherapy exposed 100 cases

Z value 13.36

P value<0.05

Significant fall

ObservationPreterm groupSerum calcium

values in mg/dl±SD

Controls pre study

8.855±0.593

Controls post study 8.59±0.88

Cases post study

7.136±0.437

Cases pre study

8.118±0.169

Observation

Significance in fall of calcium in phototherapy exposed 50 preterm

cases

Z value 14.78

p value<0.005Significant

Observation

Serum calcium values in full term group in

mg/dl±SD

Controls post study

8.986±0.271

Cases pre study

8.712±0.471

Observation

Significance in fall of calcium in phototherapy exposed 50 full term cases

Z value9.41

p value<0.005significant

Discussion

• Total occurrence of hypocalcaemia in phototherapy exposed groups

• Total occurrence of hypocalcaemia in phototherapy exposed preterm group

• T Total occurrence of hypocalcaemia in phototherapy exposed term groups

• Fall of serum calcium after phototherapy in total, preterm and fullterm

43% 60%

26%Significant fall with p

value <0.05

Discussion

Romagnoli et al 1979 Phototherapy induced

hypocalcaemia in 52.3% preterm

Found hypocalcaemia in 12.2% preterm control

Hakanson & Bergstrom 1981 Premature infants under going phototherapy have increased incidence of hypocalcaemia

Gutcher et al 1982 Phototherapy produced a significant fall in serum calcium after exposure

Discussion

Sethi et al 1993 90% preterm and 75% full term developed hypocalcaemia after

phototherapy exposure

Jain B K et al1998

55% preterm and 30% full term developed hypocalcaemia after

phototherapy

Eghbalian F et al 2002 Phototherapy in icteric newborn lowers serum calcium significantly

Conclusions

Phototherapy induces significant fall in serum calcium levels In Preterm babies higher occurrence of hypocalcaemia induced by

phototherapy , Risk is also in full term

Recommendations

Calcium supplementation in babies under phototherapy

Serum calcium should be monitored regularly under phototherapy

References• Manual of Neonatal Care,6th edition.John P Cloherty• Nelson text book of Pediatrics ,18th edition• CARE of the NEWBORN ,sixth edition Meharban singh• Romagnoli CG, Polidori L, Cataldi G et al. Phototherapy

induced hypocalcaemia. J Pediatr 1979;94:813-816• Hakanson DO, Bergstrom WH. Phototherapy Induced

hypocalcaemia in newborn infants; Prevention by melatonin. Science 1981;214:807-809

• Gutcher GR et al. Hypocalcaemia associated with phototherapy newborn rats:Light source dependance. Photochem photobiol 1983;37(2):177-180

• Jain BK, Singh H, Toor NS (1998) Phototherapy induced hypocalcaemia. Indian Pediatrics.35:566-567.

• Eghbalian F, Monosef A (2002)Phototherapy Induced Hypocalcaemia in icteric newborns.IJMS 27:169-171