Glycerin Suppositories to Reduce Jaundice in Premature Infants
Glycerin Suppositories to Reduce Jaundice in Premature Infants
The purpose of this study is to find out if giving glycerin suppositories will help decrease
 the length of time premature infants need phototherapy.

 The investigators hypothesize that glycerin suppositories (initiated along with phototherapy)
 will have no effect on reducing duration of phototherapy in premature infants with jaundice.
Neonatal jaundice is one of the most common clinical problems in the neonatal period
 (Maisels). Physiologic hyperbilirubinemia is usually benign and transient in nature.
 Bilirubin overproduction, delayed hepatic clearance, and increased enterohepatic circulation
 of bilirubin all contribute to neonatal jaundice (Bader). Previous studies have shown that
 delayed meconium evacuation might be an important contributing factor in the development and
 persistence of neonatal jaundice (Rosta and Porto). Once conjugated bilirubin is excreted
 from the liver to the small intestine, it is often deconjugated in the presence of alkaline
 media and beta-glucorinase enzymes which are present in abundance in premature infants. Once
 deconjugated, unconjugated bilirubin is reabsorbed leading to entero-hepatic circulation,
 which plays a significant role in the development on neonatal jaundice.

 Previous studies have shown that early meconium evacuation was associated with lower total
 serum bilirubin levels and decreased risk for clinically significant neonatal jaundice
 (Jirsova, DeCarvalho, Boyer, Gourley, Salariya and Gourley). Other studies in healthy term
 neonates have shown no benefit from rectal glycerin in reducing peak serum bilirubin levels.
 Bader et al performed a prospective study to evaluate the general effect of glycerin
 suppository administration in reducing total serum bilirubin levels in healthy term neonates.
 Glycerin suppositories were given immediately after birth and every 4 hours thereafter, until
 evacuation of first stool. The suppositories had no effect on mean total serum bilirubin
 levels at 48 hours of age. It was concluded that glycerin suppositories should not be
 routinely recommended as a means for reducing the severity of neonatal jaundice. However, it
 was found that in a subgroup of male infants with blood group type A there were significantly
 lower mean total serum bilirubin levels after induction of earlier meconium evacuation with
 glycerin suppositories. Weisman et al performed a similar prospective study in healthy term
 neonates and found that giving glycerin suppositories does hasten the passage of meconium and
 transitional stool; however, there was no effect on peak serum bilirubin levels during the
 first 3 days of life and no effect on need for phototherapy. Chen et al described a
 prospective, randomized controlled trial with two groups of healthy term neonates. The
 experimental group received glycerin enemas at 30 minutes and 12 hours of life. Bilirubin
 levels were followed for the first 7 days of life. The intervention had no effect on peak
 serum bilirubin levels or serum bilirubin levels in the first 7 days of life.

 No data exist on the use of glycerin suppositories in premature neonates, although its use is
 a common practice to increase meconium clearance and stooling in the case of
 hyperbilirubinemia. However, it may not be a justified practice, based on data for full-term
 infants. Experts argue that premature neonates may have upward of 25% more enterohepatic
 circulation than full-term neonates (S. Amin, personal communication). Therefore, because
 premature neonates have the potential to recirculate bilirubin, increasing stool frequency
 through schedule glycerin suppositories might play a therapeutic role in the management of
 hyperbilirubinemia in this population.

 It is a common practice in our unit to provide glycerin suppositories every 8 hours to
 infants under phototherapy in an attempt to more rapidly reduce bilirubin levels by
 decreasing enterohepatic circulation of unconjugated bilirubin. This practice is not
 evidence-based, nor is it standard practice in many NICUs throughout the country. Glycerin
 suppositories are not without risk. They can lead to rectal fissures and tears, bloody stools
 and unnecessary vagal stimulation.

 If administration of glycerin shaves decreases length of phototherapy to a clinically
 significant extent, there may be improved success with feedings including breastfeeding,
 improved infant-parent bonding, shortened length of stay and overall increased family
 satisfaction. However, if glycerin suppositories are not shown to reduce duration of
 phototherapy, reduce peak total serum bilirubin (TSB) levels, reduce the number of TSB levels
 drawn and increase the rate of decline of hyperbilirubinemia, then a potentially useless
 therapy with potential for untoward side effects may be avoided.
Inclusion Criteria:

 1. Baby born between 30 to 34 6/7 weeks gestational age (GA) at birth and admitted to
 NICU

 2. Baby with physiologic hyperbilirubinemia requiring phototherapy by current NICU
 criteria.

 3. Parental permission.

 Exclusion Criteria:

 1. Babies less than 30 weeks GA or greater than 34 6/7 weeks GA

 2. Non-physiologic hyperbilirubinemia: (1) positive Coombs test and (2) hematocrit < 5th
 percentile for GA (see Jopling J, Henry E, Wiedmeier SE, Christensen RD, Reference.
 Ranges for Hematocrit and Blood Hemoglobin Concentration During the Neonatal Period:
 Data From a Multihospital Health Care System. Pediatrics 2009; 123(2):e333 -e337.) and
 (3) ABO or Rh incompatibility.

 3. Any infant with bilirubin level within 2 mg/dL of exchange transfusion.

 4. Any infant who has phototherapy started prior to reaching light level (prophylactic)

 5. Baby with any GI abnormalities such as NEC, intestinal perforation, gastroschisis,
 omphalocele, malrotation and or volvulus, duodenal atresia, intestinal
 strictures/adhesions, imperforate anus.

 6. Any infant begun on triple or greater phototherapy at time of initiation of treatment.

 7. Any infant judged by the attending physician to be placed at increased risk by study
 participation.