|Year : 2020 | Volume
| Issue : 3 | Page : 873-877
The effect of head covering in the prevention of phototherapy-induced hypocalcemia in icterus newborns
Maha A Tawfik1, Fady M Elgendy1, Rania El-Sayed Z. Aman2
1 Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebin Al-Kom, Egypt
2 Department of Pediatrics, Tala General Hospital, Menoufia, Egypt
|Date of Submission||10-Dec-2018|
|Date of Decision||04-Feb-2019|
|Date of Acceptance||10-Feb-2019|
|Date of Web Publication||30-Sep-2020|
Rania El-Sayed Z. Aman
Source of Support: None, Conflict of Interest: None
The aim of the study was to determine the prevalence of phototherapy-induced hypocalcemia in icterus newborns and to evaluate the role of head covering in preventing the occurrence of hypocalcemia in the neonatal ICU of Menoufia University hospitals.
Neonatal jaundice is defined as the yellowish discoloration of the sclera and skin caused by hyperbilirubinemia, which is one of the most common conditions confronting neonatologists daily. About 60% of term and 80% of preterm infants develop jaundice in the first week of life. Phototherapy is the primary treatment in neonates with unconjugated hyperbilirubinemia
Patients and methods
Our study was conducted on 200 neonates recruited from the neonatal ICU in Menoufia University hospitals, and they were divided into two groups: group A comprised 100 term babies with head covering (hat) during phototherapy. Group B comprised 100 term babies without head covering during phototherapy. Total serum calcium was checked on arrival and 48 h after starting phototherapy.
There was a highly significant increase in total calcium 48 h after phototherapy (mg/dl) and ionized calcium 48 h after phototherapy (mg/dl) in neonates with head covering compared with neonates without head covering. In contrast, there was no significant difference (P > 0.05) between both groups with regard to total and ionized calcium on admission (mg/dl).
Covering the head of infants under phototherapy using a hat was an effective, safe, noninvasive, and cheap method for the prevention of phototherapy-induced hypocalcaemia.
Keywords: head covering, icterus, newborn, phototherapy, serum calcium
|How to cite this article:|
Tawfik MA, Elgendy FM, Aman RSZ. The effect of head covering in the prevention of phototherapy-induced hypocalcemia in icterus newborns. Menoufia Med J 2020;33:873-7
|How to cite this URL:|
Tawfik MA, Elgendy FM, Aman RSZ. The effect of head covering in the prevention of phototherapy-induced hypocalcemia in icterus newborns. Menoufia Med J [serial online] 2020 [cited 2020 Nov 26];33:873-7. Available from: http://www.mmj.eg.net/text.asp?2020/33/3/873/296680
| Introduction|| |
Neonatal jaundice, the yellow discoloration of the sclera and skin caused by hyperbilirubinemia, is one of the most common conditions confronting neonatologists daily. About 60% of term and 80% of preterm infants develop jaundice in the first week of life . In Egypt, about 20.4% of the neonates develop jaundice yearly. The incidence of jaundice was found to be higher in low-birth-weight infants (35.6%) compared with normal-birth-weight infants (16.9%) . Jaundice in the newborn can occur from an underlying pathological condition. Although most infants with jaundice are otherwise perfectly healthy, they make us anxious because bilirubin is potentially toxic to the central nervous system . Phototherapy is the primary treatment in neonates with unconjugated hyperbilirubinemia . This relatively common therapy lowers the serum bilirubin level by transforming bilirubin into water-soluble isomers that can be eliminated without conjugation in the liver  to prevent the occurrence of encephalopathy or kernicterus and to prevent the total serum bilirubin from rising to a level that requires exchange transfusion . The effectiveness of phototherapy depends upon the type of light source used (i.e., dose, spectral emission curve, depth of penetration), the distance between the light and the infant, the surface area treated, the etiology of the jaundice, and total serum bilirubin level at the onset of phototherapy . However, this treatment modality may lead to complications including skin rash, diarrhea, hyperthermia, chills, dehydration, DNA damage to lymphocytes, retinal degeneration, bronze baby syndrome, especially in cholestatic jaundice, patent ductus arteriosus (PDA) opening in low birth weight (LBWs) and hypocalcemia . Very soon, the detrimental effects of phototherapy on the eye and genitalia have been shown. Nonetheless, no change in blood ions/metabolites has been reported except for calcium concentration; a drop in serum calcium has been noticed in patients undergoing phototherapy . Total serum calcium levels of less than 7.5 mg/dl in preterm and less than 8 mg/dl in the term infant generally define hypocalcemia . Hypocalcemia may be asymptomatic, particularly early-onset hypocalcemia, or symptomatic in the form of jitteriness, lethargy, apnea, hypotonia, high-pitched cry, stridor, irritability, and seizures. Uninhibited effect of corticosteroids due to decreased synthesis of melatonin from the pineal gland under phototherapy is thought to be responsible for hypocalcemia . There is some evidence that the use of a stockinet cap to cover the head prevents phototherapy-induced hypocalcemia .
The aim of the study was to determine the prevalence of phototherapy-induced hypocalcemia in full-term newborns and to evaluate the role of head covering in preventing the occurrence of hypocalcemia.
| Patients and Methods|| |
This was a prospective study carried out from June 2017 to April 2018 after approval of the institutional review board. An informed written consent was taken from every patient care giver before participation in the study.
The newborn included in this study were divided into two groups: group A comprising 100 term babies with head covering (hat) during phototherapy. Group B comprising 100 term babies without head covering during phototherapy; these babies had symptoms, signs, and laboratory findings of neonatal indirect hyperbilirubinemia treated with phototherapy. Apart from jaundice, their physical examination was apparently normal. For systemic allocation, the case and control groups were determined randomly using a coin at first. Thereafter, the infants were placed into the case and then the control group one by one.
We excluded from the study neonates who were babies with intrauterine growth retardation (IUGR), infants of diabetic mothers, babies delivered with prolonged and difficult labor, babies with sepsis, cases under treatment of exchange transfusion, and neonates with hypoclacemia from any other causes. After taking the consent from parents of the neonates, the two groups underwent detailed prenatal, natal, and postnatal history, detailed clinical examination, laboratory investigations including total serum bilirubin and direct bilirubin at the start of phototherapy, follow-up of total serum bilirubin after 48 h or according to the case, other investigations including neoantal blood grouping and Rh, mother blood grouping and Rh, hematocrit and reticulocyte count when needed for neonates, and measurement of serum calcium, total and ionized at the onset and after 48 h of phototherapy.
Calcium level measurement requires 2 ml blood sample from the peripheral vein. The measurement of calcium in the sample is based on the formation of color complex between calcium and o-cresolphtalein in alkaline medium. The intensity of the color formed is proportional to the calcium concentration in the sample. We designed a hat from a dark color cloth that could cover all the head including the occipital area, ears, and neck to prevent passage of light. The hat was used from admission and for 48 h of treatment with phototherapy.
| Results|| |
Our study showed a highly significant increase in total calcium 48 h after phototherapy (mg/dl) and ionized calcium 48 h after phototherapy (mg/dl) in neonates with head covering compared with neonates without head covering. In contrast, there was no significant difference (P > 0.05) between both groups with regard to total and ionized calcium on admission (mg/dl). There was a highly significant increase in total leukocytic count (cells/cm 3) in neonates without head covering compared with neonates with head covering. Platelets' count was increased in neonates with head covering compared with neonates without head covering. In contrast, there was no significant difference (P > 0.05) between both groups with regard to their hemoglobin (g/dl), hematocrit, and reticulocytes [Table 1]. Total bilirubin on admission and after 48 h (mg/dl), as well as direct bilirubin after 48 h (mg/dl) were significantly increased in neonates with head covering compared with neonates without head covering, whereas there was no significant difference (P > 0.05) between both groups with regard to direct bilirubin on admission (mg/dl) [Table 2]. There was a highly significant increase in total calcium 48 h after phototherapy (mg/dl) and ionized calcium 48 h after phototherapy (mg/dl) in neonates with head covering compared with neonates without head covering. In contrast, there was no significant difference (P > 0.05) between both groups with regard to total and ionized calcium on admission (mg/dl) [Table 3].
|Table 1: Comparison between both groups with regard to the hematological parameters|
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|Table 2: Comparison between both groups with regard to jaundice and bilirubin level|
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Although there was a significant difference between calcium level on admission and after 48 h of phototherapy in both groups under study, calcium level was decreased after 48 h of phototherapy in both groups compared with on admission. In contrast, there was a significant difference between ionized calcium level on admission and after 48 h of phototherapy in both groups under study. Ionized calcium level was decreased after 48 h of phototherapy in both groups compared with on admission [Table 4].
|Table 4: The change in the mean total serum calcium and ionized serum calcium induced by phototherapy in each group|
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There was a highly significant difference between the two groups as regards the percentage of neonatal hypocalcemia after phototherapy (P = 0.000). About 56 (56%) neonates in group B developed hypocalcemia as compared with only 10 (10%) neonates in group A [Table 5].
|Table 5: The percentage of neonates who developed hypocalcemia after 48 h of phototherapy|
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| Discussion|| |
Phototherapy is the primary treatment in neonates with unconjugated hyperbilirubinemia . However, this treatment modality may itself result in the development of some complications .
Hypocalcemia is one of the known adverse effects. Ninety percent of preterm and 75% full-term neonates develop hypocalcemia after being subjected to phototherapy . Hypocalcemia can create serious adverse effects including convulsions, jitteriness, lethargy, and irritability .
In our study
The aim of the study was to determine the effect of covering the head on phototherapy-induced hypocalcemia in jaundiced newborns. We conducted a randomized controlled study that included 200 full-term and preterm neonates with hyperbilirubinemia treated with phototherapy. They were divided into two groups: group A comprising 100 infants undergoing the routine phototherapy with hats and group B 100 infants without hats that covered the occipital area during phototherapy. Total and ionized serum calcium levels were measured on admission and after 48 h of phototherapy. All the studied neonates were matched with regard to age, sex, birth weight, blood group, and serum bilirubin level. In our study, we found that 66 (33%) infants developed hypocalcemia after 48 h of starting phototherapy. There was a highly significant difference (P = 0.000) between the incidence of hypocalcemia in group A (with hats) comprising 10 (10%) infants and group B (without hats) during phototherapy comprising 56 (56%) infants. There was a significant difference in total and ionized calcium 48 h after phototherapy between the two groups.
Neonates with hypocalcemia represented 66 (33%) cases and with normal calcium represented 120 (60%) cases. Neonates with symptomatic hypocalcemia represented 14 (7%) cases. Jitteriness was observed in 10 (5%) cases, lethargy in four (2%) cases, and none had convulsion. There was a highly significant difference between the two groups in neonates as regards the development of hypocalcemia signs, and there was a significant difference between the two groups in neonates who developed jitteriness and no significant difference in neonates who developed lethargy.
Our results are in agreement with the following studies:
Bayomy and Solaiman  reported that there were statistically significant differences between total and ionized calcium in the control group and group I without head cover. There were no statistically significant differences between total and ionized calcium in the control group and group II with head cover. As regards ionized calcium, they detected hypocalcemia with ionized calcium (<1.2 mg/dl) in 24 (34.3%) cases of icteric neonates. Hypocalcemia was seen in 17 (48.6%) neonates in the group without hats and in seven (20%) neonates in the group with hats. In group I, the difference between ionized calcium level before and 48 h after phototherapy (1.32 ± 0.17 and 1.16 ± 0.17) was statistically significant. In group II, the difference between ionized calcium level before and after 48 h phototherapy (1.34 ± 0.14 and 1.34 ± 0.15) was statistically insignificant.
Kargar et al.  found that 14 (38.8%) newborns in the control group (without hats) and five (13.8%) in the case group (wearing a hat) had hypocalcemia after phototherapy. A significant difference was found between the incidence of hypocalcemia in these two groups. However, magnesium levels did not change significantly.
Moreover, Yadav et al. , observed a significant fall in ionized calcium level in 66.6% of term and 80% of preterm neonates after 48 h of exposure to phototherapy in the study group. There were eighteen (25.7%) cases of icteric neonates. Hypocalcemia was observed in 12 (34.3%) neonates in the group without hats and in six (17.1%) neonates in the group with hats. In group I without hats, the difference between total calcium level before and after 48 h of phototherapy (9.15 ± 1.00 and 8.45 ± 1.08) was statistically significant. In group II with hats, the difference between total calcium level before and after 48 h of phototherapy (9.39 ± 0.86 and 9.28 ± 0.84) was statistically insignificant. The hat blocked the effect of phototherapy by preventing the passage of light to the head of the infant.
Our results in hypocalcaemia detected by total calcium are in consistence with the following studies: Gusain et al.  concluded that of these 200 neonates, 155 were term and 45 were preterm neonates. After 48 h of continuous phototherapy, serum calcium levels were significantly lowered in both term [62 (40%)] and preterm neonates [24 (53.33%)]. Of the 62 term neonates who had hypocalcemia, 13 (20.97%) were symptomatic, and, of the 24 preterm neonates who had hypocalcemia, 12 (50%) were symptomatic. Most of the symptomatic neonates showed jitteriness (11% term and 33% preterm) and lethargy (10% term and 16.67% preterm), and none developed apnea or convulsions.
Bahbah et al.  found that neonates with hypocalcemia represented 13 (26%) cases of 50 neonates on phototherapy. Neonates with jitteriness represented seven (14%) cases.
Arora et al.  concluded that hypocalcemia was observed in 20 of 46 preterms (43%) and 30 of 54 term neonates (56%) after 48 h of continuous phototherapy.
Our results in hypocalcemia prevalence are higher than the study carried out by Gheshmi et al. , wherein, among the 100 newborns studied, 54% had decreased calcium levels after phototherapy. The prevalence of hypocalcemia was 9% only. Furthermore, in the Taheri et al.  study, 83 (56%) newborns had a decline in serum calcium level, and only 7% had hypocalcaemia. They reported a significant difference between serum calcium level before and after phototherapy. In the Tehrani, et al.  study, 15 (7.5%) neonates developed hypocalcaemia. After 48 h of phototherapy, there were significant differences between serum calcium levels from baseline values of 9.46 ± 0.8–9.12 ± 0.83 mg/dl.
In the Ezzeldin et al.  study, they found no difference in the mean calcium levels in the two groups on admission. However, after 48 h of phototherapy, there was a trend toward an increased calcium level in the group with the hat: 8.74 ± 0.95 versus 8.51 ± 0.24 mg/dl in the control group without the hat. Moreover, there was a statistically significant decrease in the incidence of neonates with hypocalcemia in group B (with hat) in only six (9.7%) cases, compared with 15 (24.2%) cases in group A (without hat; P = 0.031). This proves the protective role of the head covering in the prevention of phototherapy-induced hypocalcaemia, which is in agreement with our study. In addition, as regards the study carried out by Samane and Minoo , their results showed that the average calcium level was significantly higher in the infants of the test group who wore the hat, 48 h after starting phototherapy compared with the infants of the control group who did not wear the hat.
Our results are not in agreement with Asl et al. . They found no significant difference between serum calcium levels before and after phototherapy. Therefore, they do not suggest calcium prophylaxis before and during phototherapy.
No side effects were detected from using the hat during this study. The hat is the safest method in the prevention of phototherapy-induced hypocalcaemia, as it is noninvasive method and maintains the normal and physiological pattern of melatonin secretion.
Using prophylactic calcium supplementation can cause some side effects such as constipation, belching, and gas. Some possible side effects of calcium are more serious and include kidney stones, excessive drowsiness, muscle weakness, nausea, vomiting, frequent urination, changes in heart rate, confusion, and allergic reactions.
| Conclusion|| |
Covering the head of infants under phototherapy using a hat was an effective, safe, noninvasive, and cheap method for prevention of phototherapy-induced hypocalcaemia.
All neonates should be regularly evaluated for total and ionized serum calcium levels 48 h after continuous exposure to phototherapy and should be managed accordingly.
Future studies including preterm and full-term neonates are needed to compare between covering the heads and prophylactic calcium supplementation to support our findings.
Further studies, including detection of the levels of vitamin D and magnesium for preterm and full-term neonates under phototherapy, are needed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]