lari Kuitunen , 2· Panu KiIviranta , · Ulla Sankilampi , · Marjo Renko ,

Keywords Jaundice · Phototherapy · Unconjugated hyperbilirubinemia · Ursodeoxycholic acid

tInroduction

Neonatal hyperbilirubinemia is a common finding, as approximately 50% of term neonates and 80% of preterm neonates develop hyperbilirubinemia. Approximately 10%of infants show increased levels of bilirubin up to 1 month of age [ 1, 2]. Between 5% and 15% of neonates require close monitoring and phototherapy, which is typically initiated at 2—5 days postnatally [ 1, 3, 4]. The indication for phototherapy is a rapidly rising or high serum total bilirubin level [ 5,6], and the aim is to prevent neurotoxicity caused by unconjugated free bilirubin that crosses the blood-brain barrier.

Phototherapy was introduced 60 years ago [ 7], and it has remained the standard treatment for neonatal hyperbilirubinemia [ 8]. If bilirubin levels continue to rise despite phototherapy, exchange transfusion might be needed to treat severe hyperbilirubinemia. The typical duration of phototherapy is between 12 and 48 hours [ 9]. Phototherapy is used widely, and in addition to prolonged hospitalization,short-term harms include erythematous rash, retinal damage,irritability, loose stools, dehydration, feeding diffi culties and the “bronze-baby” syndrome [ 10, 11]. Recently, the potential long-term harms of neonatal phototherapy have been discussed, as phototherapy has been associated with slightly increased rates of infant and childhood cancer [ 12, 13], the number of melanocyte nevi [ 14] and epileptic convulsions during childhood [ 15, 16].

Potential pharmacological therapies for unconjugated hyperbilirubinemia have gained interest, both to reduce lengths of hospital stays and to avoid more intensive therapies and their harmful side eff ects, such as those seen with exchange transfusions. A few studies have evaluated whether ursodeoxycholic acid (UDCA) would be eff ective as an adjuvant therapy [ 17— 24]. UDCA is a bile acid, and it has been hypothesized to work by preventing the reabsorption of bilirubin from the intestines and thus occupying enterohepatic circulation [ 25, 26]. Although UDCA is an off -label treatment in neonates, it is widely used in conjugated hyperbilirubinemia and liver disorders [ 27— 29]. UDCA is generally well tolerated [ 27]. UDCA was reported to be eff ective in reducing the duration of phototherapy in healthy term neonates [ 17— 21], in sick neonates [ 23] and among neonates with G6PD def iciency [ 24]. One previous study found no additional value of combining UDCA with standard phototherapy [ 22].

The aim of this systematic review and meta-analysis is to analyze the eff ect of UDCA as an adjuvant to phototherapy in neonates with unconjugated hyperbilirubinemia.

Methods

Search strategies

The databases searched in this systematic review were Pub-Med (MEDLINE), the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science and Scopus. The literature search was conducted on September 1, 2021. The following phrase was used in the search: (“ursodeoxycholic acid”) AND (neonat* OR newborn*) AND (jaundice* OR bilirubin* OR phototherap*). We used neither language nor time restrictions. The results were then uploaded to the Covidence software (Covidence, Melbourne, Australia).

Inclusion and exclusion criteria

All randomized controlled trials with or without placebo and regardless of blinding were included. Reports had to focus on UDCA use on newborns, but those including sick neonates, conjugated hyperbilirubinemia or only glucose-6-phosphate dehydrogenase def iciency (G6PD) were excluded. If newborns with more intensive hemolysis, such as Rh immunization or ABO incompatibility, were included in trials, randomization needed to be stratif ied to prevent imbalance between treatment groups. We had no exclusion criteria regarding prematurity or birthweight in our review.

Review process

Two authors (KI and KP) individually screened the abstracts,and conf licts were resolved by a third author (RM) or mutual consensus. Full texts were then assessed by two authors (KI,KP), and data were extracted using the Covidence 2.0 data extraction templates. The risk of bias was assessed according to the Cochrane tool for assessment by one author (KI), and a senior author (RM) was consulted if needed [ 30]. The risk of bias is reported in the Cochrane Risk of Bias 2.0 table,and it is presented by generating plots with the Robvis package [ 31]. Reporting quality was assessed using the Grading of Recommendations Assessment, Development and Evaluation methodology [ 32]. Background information on studies and study populations are presented in tables. A f lowchart of the study process is presented in Fig. 1.

Outcome measures

Our primary outcomes were changes in the total bilirubin level 24 hours after the initiation of phototherapy and phototherapy treatment duration. Secondary outcomes were return to hospital after discharge, harms of the treatment and costeff ectiveness. A subgroup analysis of preterm neonates was planned to be conducted if information was available.

Fig. 1 PRISMA f lowchart of the review process. PRISMA preferred reporting items for systematic reviews and meta-analyses

Statistics

Review Manager version 5.4 (the Cochrane Collaboration,London, UK) was used for the meta-analysis. Data analyses were performed according to the Cochrane handbook of systematic review guidelines. We calculated mean diff erences for continuous outcomes, as all the included studies used the same continuous outcome measurements. Risk ratios would have been calculated for dichotomous outcomes. Forest plots are presented for primary outcomes.The inconsistency index statistic

I

2 for heterogeneity was conducted, and if

I

2 ＞ 50%, a random eff ect model was used.If heterogeneity was low (＜ 50%), the f ixed eff ect model was chosen.

All the included studies reported a baseline level of bilirubin and post-intervention level in mg/dL and had standard deviations (SD) reported. However, only two studies reported the absolute mean change with SD. Therefore,we had to calculate the SD for change, as described in the Cochrane handbook, chapter 6.5.2.8 [ 33]. We decided to use the method in which one of the included studies is used for the calculation of the correlation coeffi cient. The correlation coeffi cient describes how similar the baseline and post-intervention measurements were across participants.We selected the work of Shahramian et al. [ 19], as in that work, the correlation coeffi cients were above 0.5 in both the treatment and control groups. If the correlation coeffi cient is below 0.5, post-intervention measures can be presented and interpreted directly. As the coeffi cient was above 0.5,we used the measured change from the baseline in reporting.The following formula was used for the calculation of the correlation coeffi cient.

The mean of correlation coeffi cients, 0.73 (treatment group 0.83 and control group 0.63), calculated from Shahramian et al. [ 19], was used in the following formula to calculate the SD for mean change from baseline 24 hours after the initiation of phototherapy.

Protocol registration

This systematic review and meta-analysis has been reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses [ 34] (Supplementary Table 1).The protocol has been registered in Prospero. The registration number is CRD42021278172, and the protocol is available from https:// www. crd. york. ac. uk/ prosp ero/ displ ay_ record. php? ID= CRD42 02127 8172.

Results

The initial search yielded 376 studies, of which 17 were further assessed in the full text phase. Six RCTs were found,and of these, two were excluded: in the study by Ughasoro et al., randomization was not stratif ied, and children with ABO immunizations and septic newborns were included[ 23]; Rezaie et al. included only neonates with G6PD def iciency [ 24]. Four RCTs were included from the initial search[ 18, 20— 22], and two additional RCTs were found from the references of included articles and included in the systematic review and meta-analysis [ 17, 19] (Fig. 1).

The six included studies had a total of 880 neonates. Five studies were conducted in Iran and one in Egypt. Four studies used UDCA 10 mg/kg divided into two daily doses, and two studies used 15 mg/kg divided into two daily doses. The inclusion and exclusion criteria in the selected studies were practically identical. Funding sources were not reported in four of the studies, and conf licts of interest were not reported by the authors in two studies (Table 1). Background characteristics of the study populations in the included studies are reported in Table 2. Only one study reported the gestational age of the neonates, and one study did not report any background information.

Risk of bias

The risk of bias was assessed in f ive domains and overall.Overall, f ive of the studies had some concerns about the risk of bias assessment. One study had a high risk of bias due to randomization, and four of the studies did not report any adverse events between groups, leading to concern about bias in the selected reported results (Fig. 2).

Bilirubin level changes during the f irst 24 hours

The mean decrease of total bilirubin during the f irst 24 hours in the included six studies (880 neonates) ranged from 2.5 to 11.1 mg/dL in the UDCA + phototherapy group and from 1.9 to 7.7 mg/dL in the phototherapy group. The weighted mean diff erence in total bilirubin decrease in the random eff ect model was 2.06 mg/dL [95% conf idence interval (CI)0.82—3.30], favoring the UDCA + phototherapy (Fig. 3). We ranked the quality of evidence as low (Table 3).

Phototherapy duration

Five studies (780 neonates) reported the overall duration of phototherapy. The duration range varied from 12.3 to65.2 hours in the UDCA + phototherapy group and from 41.1 to 82.5 hours in the phototherapy group. The weighted mean diff erence in phototherapy duration in the random eff ect model was 19.7 hours (95% CI 10.4—29.1), favoring the UDCA + phototherapy group (Fig. 4). We ranked the overall quality of evidence as low (Table 3).

Table 1 Characteristics of included studies

Confl ict of interest Not reported None to report Not reported Public funding Rh or ABO incompatibility,prematurity, sepsis or maternal diabetes None to report None to report No funding received Not reported Prematurity,severe hemolysis, sepsis, or cholestasis Rh or ABO incompatibility,G6PD defi ency,conjugated hyperbilirubinemia, speticemia,diseases leading to hyperbilirubinemia (criglernajjar syndrome,gilbert syndroSme, hypo/hyperthyroidism,liver diseases),prematurity,maternal diabetes Inclusion criteria Exclusion criteria Funding Normal birthweight, age 3—7 d, breast-fed,total bilirubin 14—20 mg/dL,direct bilirubin ＜ 2 mg/dL Birth weight 2500—4000 g,breast-fed, gestational age 3841 wk, being ＞ 3 d old, total bilirubin level 14—20 mg/dL,direct bilirubin level ＜ 2 mg/dL 10 mg/kg per d in two doses 10 mg/kg per d in two doses Participants, n Dose of UDCA 200 80 Placebo No Double-blind Yes 2014—2015 Unknown 2013 Country Study period Blinding Iran Study Hassan et al. [ 17] Iran Honar et al. [ 18]ABO and Rh incompatibility,G6PD defi -ciency, direct hyperbilirubinemia, septicemia,and diseases leading to hyperbilirubinemia(Crigler-Najjar syndrome, Gilbert syndrome,hypo/hyperthyroidism, liver diseases), prematurity, maternal diabetes Aged 3 d or more, weighed 2.5—4 kg,total bilirubin 14—20 mg/dL Birth weight of 2.5 to 4 kg, breastfed, gestational age 38—41 wk,age 3—5 d, total bilirubin level 12—22 mg/dL,direct bilirubin level ＜ 2 mg/dL 10 mg/kg per d in two doses 15 mg/kg per d in two doses 100 200 2016—2017 Not blinded No Double-blind No 2017 Egypt Iran El-Gendy et al.[ 20]Shahramian et al.[ 19]

Table 1 (continued)

ursodeoxycholic acid, glucose-6-phosphate dehydrogenase

Confl ict of interest None to report Not reported Not reported Not reported ABO and RH incompatibility,septicemia or having diseases resulting in indirect hyperbilirubinemia including crigler—najjar syndrome, Gilbert, hypothyroidism, preterm neonates,neonates with hemolysis or G6PD defi -ciency, maternal diabetes low hemoglobin and weight loss ＞ 10%Rh or ABO incompatibility(with positive direct coombs test), G6PD defi ciency, direct hyperbilirubinemia, sepsis,crigler-najjar syndrome, thyroid disorders,hepatic diseases,maternal diabetes Inclusion criteria Exclusion criteria Funding Weight of 2500—4000 g,breast milk fed,gestational age:37—41 week, age over 48 h, total bilirubin 14—20 and direct bilirubin ＜ 1 mg/dL Birth weight ＞ 2500 g,gestational age ＞ 35 wk,total bilirubin level 14—25 mg/dL, direct bilirubin level ＜ 2 mg/dL 10 mg/kg per d in two doses 15 mg/kg per d in two doses Participants, n Dose of UDCA 80 Placebo 2017—2018 Double-blind Not specifi ed 220 Double-blind Yes Country Study period Blinding 2017 Iran Iran Study Akefi et al. [ 22]Gharehbaghi et al.[ 21]

Table 2 Background characteristics of study populations in included studies

ursodeoxycholic acid, standard deviation, /not applicable

Study Birth weight (kg), mean(SD)Gestational age(wk), mean (SD)Gender (female),%Age at the time of initiation of phototherapy (d), mean(SD)Mean bilirubin level at the start of the phototherapy(mg/dL), mean (SD)UDCA Control UDCA Control UDCA Control UDCA Control UDCA Control Hassan et al. [ 17] 3.1 (0.4) 3.1 (0.4) N/A N/A 44 49 5.4 (1.4) 5.3 (1.5) 16.3 (1.7) 16.5 (2.9)Honar et al. [ 18] 2.97 (0.29) 2.99 (0.31) N/A N/A 53 55 3.7 (1.0) 3.6 (1.0) 15.9 (1.7) 16.3 (1.5)El-Gendy et al. [ 20] N/A N/A N/A N/A 40 48 4.9 (1.4) 4.9 (1.6) 16.5 (1.4) 16.4 (1.5)Shahramian et al. [ 19] N/A N/A N/A N/A N/A N/A N/A N/A 15.79 (2.18) 16.89 (2.49)Akef i et al. [ 22] N/A N/A N/A N/A 47 56 5.3 (2.9) 4.9 (2.1) 16.85 (2.4) 15.75 (2.6)Gharehbaghi et al. [ 21] 2.96 (0.56) 3.19 (0.43) 38 39 N/A N/A 5.1 (2.5) 5.9 (2.5) 19.33 (2.51) 19.76 (2.64)

Fig. 2 Risk of bias summarized in Cochrane risk of bias two format

Fig. 3 Forest plot of mean bilirubin decrease (mg/dL) during the f irst 24 hours after the initiation of phototherapy. Random eff ect model reported as mean diff erence with 95% CIs. CI conf idence intervals, UDCA ursodeoxycholic acid, SD standard deviation

Table 3 Grading of recommendations assessment, development and evaluation assessment of evidence

Quality of evidence Low Low Low Publication bias Serious limitations Verylow Imprecision Noseriouslimitations Undetected Noseriouslimitations Undetected Noseriouslimitations Undetected Indirectness Not applicable Not applicable Inconsistency No serious limitations Direct No serious limitations Direct No serious limitations Direct N/A Quality assessment Risk of bias(second studies), unclear allocation (second Serious limitations: blinding not performed studies), randomization not described (fi rst study), no placebo (fourth studies), background characteristics not presented (fi rst study)(second studies), unclear allocation (second studies), randomization not described (fi rst study), no placebo (fourth studies), background characteristics not presented (fi rst study)(second studies), unclear allocation ( second studies), randomization not described (fi rst study), no placebo (fourth studies)adverse outcomes and side eff ects Serious limitations: blinding not performed Serious limitations: blinding not performed Serious limitations: only one study reported No. of partici-pants 880 880 780 880 Included studies 6 6 5 6 Variables Total bilirubin at 24 h Mean decrease in bilirubin during the fi rst 24 h Phototherapy dura-tion Possible side eff ects

Possible side eff ects and adverse outcomes

Only one study discussed possible side eff ects and stated that these were not detected in either group. None of the studies underwent follow-up after discharge. The evidence regarding possible side eff ects and adverse outcomes was very low (Table 3).

Discussion

Six RCTs with 880 neonates demonstrated that neonates that received UDCA together with phototherapy was eff ective in reducing total serum bilirubin levels during the f irst 24 hours. Five RCTs with 780 neonates showed that UDCA combined with phototherapy was eff ective and decreased the phototherapy duration by nearly 20 hours compared to standard phototherapy.

The decrease of the total bilirubin level during the f irst 24 hours of treatment together with the 20-hour reduction in the total duration of phototherapy are potentially clinically signif icant and benef icial results for patients. These reductions would most likely decrease the rates of acute[ 10, 11] and long-term harms and adverse eff ects related to phototherapy [ 12— 16]. The shorter hospital stay could potentially decrease costs related to neonatal hyperbilirubinemia and enable the relocation of healthcare resources.Previous reports have stated that neonates requiring phototherapy have more problems with breastfeeding [ 35, 36]. It can be speculated that the shortened phototherapy and hospital stays might help to improve breastfeeding rates. This could produce additional value for these neonates [ 37], but this issue was not evaluated in the original papers. There are no previous meta-analyses on this topic, and therefore, our results cannot be compared to previous reports.

The optimal dose of UDCA remains unsure, as two of the studies used 15 mg/kg daily dose and four studies used 10 mg/kg daily dose. We did not perform any subgroup analysis based on the diff erent doses as it was not preplanned.We observed that the studies with a higher dose [ 19, 21]showed similar results compared to the studies using smaller doses of UDCA. The optimal dose with the best benef it/harm ratio remains to be determined as majority of the studies included in this meta-analysis did not report any adverse eff ects.

We had a few deviations from the original protocol. First,we were prepared to use standardized mean diff erences,as we hypothesized that the studies would not have used the same outcome measure scale. We did not include the use of mean diff erence in the protocol, but this is a minor deviation. Second, we wanted to analyze adverse outcomes(neonatal mortality and return rates to hospital), but none of the included studies reported these. Third, we wanted to perform a subgroup analysis on preterm neonates, but none of the studies reported these data, and therefore, this was not possible.

Fig. 4 Forest plot of phototherapy treatment duration (in hours). Random eff ect model reported as mean diff erence with 95% CIs. CI conf idence intervals, UDCA ursodeoxycholic acid, SD standard deviation

The limitations of this review are largely those of the primary studies. As four of the studies were not placebocontrolled [ 17— 21 ] and one of these did not comment on the blinding at all [ 17], the results presented here are vulnerable to bias. Furthermore, only one of the included studies reported adverse outcomes [ 22], and none of the studies reported rehospitalization rates. In addition, the population characteristics were reported incompletely, which limits the generalizability of the results. Two studies did not state the cutoff bilirubin level to stop phototherapy [ 20, 21]. All the included studies were conducted in relatively small geographical areas (Iran [ 17— 19, 21, 22] and Egypt [ 20]). Due to genetic factors related to bilirubin metabolism, these results may not be valid in other populations. Furthermore, the included studies had some variation in the exclusion criteria,as two studies did not exclude G6PD patients and overall, the exclusion criteria were not as strict in these two studies [ 17,20]. All the studies excluded preterm neonates, which means that these results cannot be generalized to treatment of preterm neonates. UDCA is an off -label drug in newborns and children in Europe and North America. Thus, more studies on its pharmacokinetics and pharmacodynamics, including safety, are needed prior to its implementation into standard treatment of newborns at any indication. None of these studies provided any potential cost-eff ectiveness analyses. As all the studies excluded neonates with signif icant hemolysis, we do not know if UDCA would prevent the need for transfusion, for example. The risk of bias was assessed to be moderate in four of the studies and high in one, and only one study had a low risk of bias. The study with the lowest risk of bias stated that UDCA would not bring additional value to standard phototherapy [ 22]. These concerns should be noted when interpreting the results of our systematic review.

In conclusion, we found low-quality evidence that UDCA is eff ective as an adjuvant treatment with phototherapy in neonatal hyperbilirubinemia. UDCA decreases the duration of phototherapy by nearly 20 hours, which is a clinically signif icant f inding that would benef it patients and families.Mean bilirubin levels decreased more rapidly during the f irst 24 hours. Studies in diff erent geographical locations with double-blinding and placebo-controlling are needed with pharmacological, cost-eff ectiveness and safety analyses before the use of UDCA can be considered a potential option in the standard care of neonatal hyperbilirubinemia.

Supplementary Information The online version contains supplementary material available at https:// doi. org/ 10. 1007/ s12519- 022- 00563-z.

Author contributions

KI contributed to conceptualization, data curation, formal analysis, investigation, methodology, software, visualization, and writing of the original draft. KP contributed to data curation,investigation, software, visualization, reviewing and editing. SU contributed to funding acquisition, resources, reviewing and editing. RM contributed to conceptualization, funding acquisition, project administration, resources, supervision, reviewing and editing. All the authors approved the f inal version of the manuscript.

Funding

Open access funding provided by University of Eastern Finland (UEF) including Kuopio University Hospital.

Data availability

All data used in this study is available upon request from the corresponding author.

Declarations

Ethical approval

An ethics statement is not applicable because this study is based exclusively on published literature. According to Finnish research legislation, systematic reviews do not require study approval,and therefore, it was not obtained.

Conflict of interest

No f inancial or non-f inancial benef its have been received or will be received from any party related directly or indirectly to the subject of this article. The authors have no conf lict of interest to declare.

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