Neonatal jaundice - Emerging treatments

Stannsoporfin

Stannsoporfin (also known as tin-mesoporphyrin) works by inhibiting haem oxygenase, an important initial step in the production of bilirubin. Not approved in many countries as yet, but it has been used on a compassionate basis.[79] An alternative option, if this treatment fails, would be an exchange transfusion. Stannsoporfin can be used in all neonates not responding to intensive phototherapy, in an attempt to avoid exchange transfusion and can be given any time while on phototherapy.[80] A single intramuscular injection given prior to discharge decreased the duration of phototherapy, reversed the trajectory of total bilirubin levels, and reduced subsequent hyperbilirubinaemia severity.[81] The drug has received fast track status from the FDA. In August 2018, the FDA rejected approval of the drug requesting further evaluation to be considered before resubmitting an application for approval.

Filtered sunlight

In a non-inferiority randomised controlled trial conducted in Nigeria, filtered sunlight was found to be as safe and effective as conventional phototherapy.[82] It is important to note that this study was conducted in infants who were at least 35 weeks of gestation or weighed >2.2 kg, had a postnatal age of up to 14 days, and had bilirubin levels not exceeding 257 micromol/L (15 mg/dL).[82]

Ursodiol

A hydrophilic bile acid which has multiple mechanisms of action, including protection of injured cholangiocytes against toxic effects of bile acids, stimulation of impaired biliary secretion, stimulation of detoxification of hydrophobic bile acids, and inhibition of apoptosis of hepatocytes which may improve neonatal cholestatic disorders.[83][84] The risk/benefit profile is unknown.

Clofibrate

Clofibrate enhances activity of the glucuronyl transferase enzyme, thus increasing the conjugation of unconjugated bilirubin in the liver. Meta-analyses of clinical trials have suggested that clofibrate therapy decreases the need and duration of phototherapy as well as the peak total serum bilirubin levels. These effects were more obvious for term infants and in those without haemolytic disease. However, none of the studies reported on bilirubin encephalopathy or neonatal mortality rates.[85][86] [ ] A study from 2017 reported that a single dose of clofibrate prior to starting phototherapy resulted in a significant reduction in the duration of phototherapy.[87] Thus, while there appears to be some short-term benefit of this therapy, additional trials are needed to confirm long-term neurodevelopmental outcomes before definite recommendations can be made.[88]