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Comparison of efﬁcacy and safety of exchange transfusion through different catheterizations: Femoral vein versus umbilical vein versus umbilical artery/vein*
Yi-Hao Weng, MD; Ya-Wen Chiu, PhD
Objective: To compare the efﬁcacy and safety of exchange transfusion (ET) via three different catheterization methods: femoral vein (FV); umbilical vein (UV); and umbilical artery/vein (UA/V). Design: A retrospective cohort of neonates who underwent ET for hyperbilirubinemia between 1996 and 2007 was surveyed. Subjects with gestational age <33 wks were excluded. Setting: Neonatal intensive care units in a tertiary referral hospital. Patients: A total of 109 neonates with 128 ET procedures (33 via FV, 35 via UV, and 60 via UA/V routes) were analyzed. Measurements and Main Results: There was no signiﬁcant difference in the decline of total serum bilirubin between each group. When compared with the UA/V group, the transfusion rate was slower in the FV and UV groups (p < .001). Adverse events with clinical signiﬁcance were more common in ET via the UA/V route than ET via the FV and UV routes (p < .05; odds ratio, 2.4; 95% conﬁdence interval, 1.2–5.0). Neonates with ET via the UA/V route tended to have more asymptomatic laboratory aberrances (p < .01; odds ratio, 2.5; 95% conﬁdence interval, 1.3– 4.6). There were no signiﬁcant differences in the transfusion rate (p .498) and adverse events (p .822) between the FV and UV groups. Conclusions: ET through the FV route is an effective and secure method for the treatment of neonatal hyperbilirubinemia when the UV route is unavailable. Physicians should be cautious when using UA/V catheterization for ET. (Pediatr Crit Care Med 2011; 12: 61– 64) KEY WORDS: exchange transfusion; neonatal hyperbilirubinemia; femoral vein; umbilical artery; umbilical vein
evere neonatal hyperbilirubinemia carries a substantial risk for long-term neurologic sequelae and even death (1). Exchange transfusion (ET) is useful in rapidly lowering serum bilirubin level (2). It requires vascular access to push and pull blood. ET for neonatal hyperbilirubinemia has been thoroughly investigated (3–13). The standard catheterization is through the umbilical vein (UV), because the technique is simple and no skin puncture is made (1, 13). ET via both umbilical artery and vein (UA/V) catheter-
*See also p. 110. From the Department of Pediatrics (YHW), Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan; and the Division of Health Policy Research and Development (YWC), Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan. This study was supported, in part, by the National Health Research Institutes. The authors have not disclosed any potential conﬂicts of interest. For information regarding this article, E-mail: email@example.com Copyright © 2011 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies DOI: 10.1097/PCC.0b013e3181dbeb78
izations has also been used (9, 14). Umbilical catheterizations, however, may fail because of a healed umbilicus or because the pediatrician lacks sufﬁcient experience in the procedure. Other alternatives include peripheral and femoral vessels. ET, using peripheral vessels, has been shown to be as effective as ET, using umbilical vein (5, 15). Nevertheless, concerns remain regarding extravasation, ischemia, and the level of skill required for the procedure (16). Femoral vein (FV) catheterization has also been used as a substitute to umbilical and peripheral routes (17, 18), but the efﬁcacy and security have not yet been studied. In addition, the effectiveness and adverse events of ET through UA/V have received little attention in recent decades (9). The current study is the ﬁrst to investigate the efﬁciency and complication rate of ET via FV and UA/V routes by contrasting ET via UV route. This study will shed some light on the use of catheterizations for ET in the treatment of neonatal hyperbilirubinemia.
PATIENTS AND METHODS
Approval to collect the data was granted by the Institutional Review Board of Chang Gung
Memorial Hospital. Medical charts of neonates who had received ET through FV, UV, or UA/V catheterizations for hyperbilirubinemia in the neonatal intensive care units of Chang Gung Children’s Hospital from 1996 to 2007 were reviewed. To help eliminate confounding factors, neonates with gestational age of 33 wks were not included, because they are vulnerable to ET (8 –10). In addition, subjects who underwent ET via other catheterization routes (such as peripheral vessels) or ET for conditions other than hyperbilirubinemia (such as polycythemia) were excluded. Any possible etiologies causing neonatal hyperbilirubinemia— such as glucose-6-phosphate dehydrogenase (G6PD) deﬁciency, infants of diabetic mothers, polycythemia, congenital hypothyroidism, spherocytosis, bacterial infection (sepsis, urinary tract infection, omphalitis), gastrointestinal obstruction, breast milk feeding, extravascular hemorrhage (cephalohematoma, bruise), ABO incompatibility (deﬁned as any blood group A or B neonate of group O mother), and Rh incompatibility (deﬁned as Rh-positive infants born to Rh-negative mothers)—were recorded. Any abnormality that occurred within 7 days after ET was classiﬁed as an adverse event. A clinical event was deﬁned as any permanent serious sequela (such as death), transient or prolonged complication (such as necrotizing enterocolitis, leg ischemia, catheter malfunction, sepsis, omphalitis, apnea, brady-
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cardia, cyanosis, respiratory distress, hypotension, hypertension, seizure, or renal failure), or laboratory abnormality requiring treatment (sodium, 120 mEq/L or 160 mEq/L; potassium, 2.5 mEq/L or 9.0 mEq/L; calcium, 6.5 mg/dL (term)/6 mg/dL (late preterm), or 13 mg/dL; platelet count, 10,000/ L; glucose 50 mg/dL) (10). A subclinical event was deﬁned as any laboratory aberrance without clinical manifestation and treatment (sodium, 120 –130 mEq/L or 150 –160 mEq/L; potassium, 2.5–3 mEq/L or 7–9 mEq/L; calcium, 6.5– 8 mg/dL (term)/6 –7 mg/dL (late preterm), or 11–13 mg/dL; platelet count, 10,000 –50,000/ L). The indications for ET were based on established guidelines set up by our institution: peak total serum bilirubin (TSB) value 10 mg/dL at 24 hours old, 15 mg/dL at 24 – 47 hours old, 20 mg/dL at 48 –95 hours old and 25 mg/dL at 96 hours old. Catheterization procedures were performed by senior pediatric residents or fellows. In the FV method, a 4F 150-mm radioopaque polyurethane catheter (Becton Dickenson, Franklin Lakes, NJ) was inserted, using the Seldinger procedure (17). All catheterizations were performed under sterile conditions. Location of catheters was conﬁrmed by radiologic survey before ET. Catheters were removed when it was apparent that another ET would not be needed. Donor blood used for ET was from either Rh negative or O type red cells mixed with AB type plasma. Isovolemic double-volume procedure was carried out by residents and medical interns. A cycle of ET was completed by withdrawal and infusion with an aliquot of 5 mL/ kg. Calcium gluconate (0.1 g) was infused every ﬁve cycles of ET. In the UA/V group, blood was withdrawn from the UA catheter and infused into the UV catheter. As for FV and UV groups, blood was withdrawn from and infused into the same catheter. All infants received prophylactic antibiotics and phototherapy during the period of ET. The statistical analyses were conducted, using a commercially available program (SPSS for Windows, version 12.0, SPSS, Inc., Chicago, IL). Categorical variables were analyzed, using the chi-square test or Fisher’s exact test. For comparison between groups with quantitative variables, the null hypothesis that there was no difference between each group was tested by analysis of variance. Signiﬁcance was deﬁned as p .05. The adverse event related to ET was calculated by the number of procedures, rather than the number of neonates. Logistic regression was used to examine relationships among variables.
Table 1. Demographic and clinical characteristics FV (27),a n (%) Frequency of ET procedure Once Twice Thrice Four times Gender Male Female Birth place Inborn Outborn Delivery mode Cesarean section Vaginal delivery Gestational age, wks Mean SD Birth weight, g Mean SD Symptoms except jaundice With Without Age at ET, days 7 7–30 Hemoglobin, g/dL 13 13–22 Etiology Blood group incompatibility G6PD deﬁciency Breast feeding Infection Extravascular hemorrhage Other Unknown UV (33),a n (%) UA/V (49),a n (%)
23 (85.6) 3 (11.1) 0 (0.0) 1 (3.7) 20 (74.1) 7 (25.9) 7 (25.9) 20 (74.1) 6 (22.2) 21 (77.8) 38.3 3116 1.8 479
31 (93.9) 2 (6.1) 0 (0.0) 0 (0.0) 17 (51.5) 16 (48.5) 9 (27.3) 24 (72.7) 10 (30.3) 23 (69.7) 37.7 2930 2.2 475
40 (81.6) 8 (16.3) 0 (0.0) 1 (2.1) .203 30 (61.2) 19 (38.8) .787 16 (32.7) 33 (67.3) .422 18 (36.7) 31 (63.3) .423 37.9 3149 1.6 .138 525 .035
12 (44.4) 15 (55.6) 7 (25.9) 20 (74.1) 17 (63.0) 10 (37.0) 6 (22.2) 18 (66.7) 8 (29.7) 1 (3.7) 1 (3.7) 3 (11.1) 1 (3.7)
5 (15.2) 28 (84.8) 29 (87.9) 4 (12.1) 15 (45.5) 18 (54.5) 16 (48.4) 12 (36.4) 2 (6.1) 2 (6.1) 0 (0.0) 2 (6.1) 6 (18.2)
12 (24.5) 37 (75.5) .001 42 (85.7) 7 (14.3) .401 26 (53.1) 23 (46.9) 30 (61.2) 9 (18.4) 7 (14.2) 1 (2.0) 4 (8.2) 4 (8.2) 3 (6.1) .005 .001 .041 .637 .216 .778 .094
FV, femoral vein; UV, umbilical vein; UA/V, umbilical artery/vein; ET, exchange transfusion; G6PD, glucose-6-phosphate dehydrogenase. a Number of neonates; bp values were by 2 test, Fisher’s exact test, and analysis of variance when appropriate.
A total of 109 neonates were enrolled, including 27 via FV, 33 via UV, and 49 via
UA/V routes. Table 1 summarizes the demographic data and clinical presentations by the three different catheterizations. Ninety-four (86.2%) neonates received ET once; 13 (11.9%) required a second procedure; and two (1.9%) underwent ET four times (Table 1). There was no signiﬁcant difference in the frequency of ET among the FV, UV, and UA/V groups (p .518). Birth place, gender, birth weight, gestational age, and delivery mode carried no signiﬁcant differences between each group. Before ET, 29 (26.6%) neonates had clinical manifestations other than jaundice, including irritability, poor appetite, hypotonia, opisthotonos, seizure, fever, lethargy, apnea, respiratory distress, and high-pitched cry. These manifestations were more common in the FV group than the UV and UA/V groups. In the UV and UA/V groups, most neonates were 7 days old at the time of ET. In contrast, approximately
three quarters of neonates with ET via FV route were 7 days old. Age was signiﬁcantly older in the FV group than the UV and UA/V groups. Furthermore, no significant difference was noticed in anemia between each group. The most common factor leading to neonatal hyperbilirubinemia was blood group incompatibility (47.7%), followed by G6PD deﬁciency (35.8%) and breast milk feeding (15.6%). The other causes included bacterial infection (3.7%), extravascular hemorrhage (4.6%), hereditary spherocytosis (2.8%), polycythemia (1.8%), gastrointestinal obstruction (0.9%), infant of diabetic mother (0.9%), herb intake (0.9%), and congenital hypothyroidism (0.9%). Only 9.2% of neonates did not have known underlying cause. Blood group incompatibility was less common in the FV group than the UV and UA/V groups. By contrast, G6PD deﬁciency and breast milk
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Table 2. Levels of total serum bilirubin before exchange transfusion Total Serum Bilirubin, mg/dL Mean Range
29.8 7.4 12.0–47.6
26.0 6.2 14.9–47.2
23.4 6.2 11.6–42.1
FV, femoral vein; UV, umbilical vein; UA/V, umbilical artery/vein. Number of procedures.
Table 3. Efﬁcacy and rate of exchange transfusion FV (30) Total serum bilirubin reduction, % Mean SD Range Rate, mL/kg/min Mean SD Range UV (35) UA/V (57) p .394 34.9 13.7 7.7–60.3 1.02 0.33 0.52–1.98 33.4 9.6 9.5–48.5 0.97 0.26 0.43–1.79 31.4 12.1 4.4–53.5 .001 1.33 0.47 0.66–2.57
FV, femoral vein; UV, umbilical vein; UA/V, umbilical artery/vein. Table 4. Adverse events of exchange transfusion FV (33), n (%) Total clinical events Death Leg ischemia Catheter malfunction Infection Apnea Bradycardia Cyanosis Hypotension Renal failure Sodium imbalancea Potassium imbalanceb Hypercalcemiac Hypocalcemiad Platelet 10,000/ L Total subclinical events Sodium imbalancea Potassium imbalanceb Hypocalcemiad Platelet 10,000–50,000/ L 8 (1.9) 2 (6.1) 0 (0.0) 2 (6.1) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (3.0) 1 (3.0) 1 (3.0) 1 (3.0) 0 (0.0) 5 (3.8) 0 (0.0) 0 (0.0) 0 (0.0) 5 (15.2) UV (35), n (%) 3 (0.7) 0 (0.0) 0 (0.0) 0 (0.0) 1 (2.9) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (2.9) 0 (0.0) 0 (0.0) 1 (2.9) 0 (0.0) 12 (8.6) 1 (2.9) 2 (5.7) 6 (17.1) 3 (8.6) UA/V (60), n (%) 23 (2.9) 1 (1.7) 1 (1.7) 2 (3.3) 2 (3.3) 3 (5.0) 2 (3.3) 4 (6.7) 3 (5.0) 1 (1.7) 1 (1.7) 1 (1.7) 0 (0.0) 1 (1.7) 1 (1.7) 34 (14.2) 4 (6.7) 1 (1.7) 7 (11.7) 22 (36.7)
subclinical events. Three neonates died within 3 days after ET, including two in the FV group and one in the UA/V group. All three had a peak TSB level of 45 mg/dL. There were signiﬁcant differences in both clinical and subclinical adverse events among the three groups, especially thrombocytopenia. Speciﬁcally, the adverse events with clinical signiﬁcance were more common in ET via UA/V route than ET via FV and UV routes (p .015; odds ratio, 2.4; 95% conﬁdence interval, 1.2–5.0). Neonates with ET via UA/V route tended to have asymptomatic laboratory aberrances (p .003; odds ratio, 2.5; 95% conﬁdence interval, 1.3– 4.6), mainly in thrombocytopenia (p .001; odds ratio, 4.3; 95% conﬁdence interval, 1.8 –10.7). In addition, the overall adverse events were not signiﬁcantly different between the FV and UV groups (p .822).
p .012 .229 .565 .354 .580 .175 .316 .096 .175 .565 .890 .600 .255 .890 .565 .003 .264 .266 .056 .002
FV, femoral vein; UV, umbilical vein; UA/V, umbilical artery/vein. a Sodium, 120 mEq/L or 160 mEq/L in clinical events, 120 –130 or 150 –160 mEq/L in subclinical events; bpotassium, 2.5 mEq/L or 9.0 mEq/L in clinical events, 2.5–3 mEq/L or 7–9 mEq/L in subclinical events; ccalcium, 13 mg/dL; dcalcium, 6.5 mg/dL (term)/6 mg/dL (late preterm) in clinical events, 6.5– 8 mg/dL (term)/6 –7 mg/dL (late preterm) in subclinical events.
feeding were more common in the FV group. The TSB levels before ET are presented in Table 2. There were 128 ET procedures: 33 via FV, 35 via UV, and 60 via UA/V routes. The TSB levels were signiﬁcantly higher in the FV group than the UV and UA/V groups. Table 3 illustrates the efﬁcacy and rate of ET. Six procedures were excluded due to termination in the middle of ET; these involved two required resuscitations and four
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catheter malfunctions. There was no signiﬁcant difference in the reduction of TSB level at 1 hr after ET between each group. However, the speed of ET was signiﬁcantly faster in the UA/V group than the other two groups (p .001). Furthermore, there were no signiﬁcant differences in the transfusion rate between the FV and UV groups (p .498). The adverse events attributed to ET are summarized in Table 4. There were 85 abnormal episodes: 34 clinical and 51
To date, there are limited data comparing the efﬁcacy and safety of ET via FV method versus ET via UV methods. Our study has revealed, for the ﬁrst time, that ET via FV route is as effective and secure as ET via UV route. The reason for this effectiveness is that the tips of catheters in both FV and UV routes are all located in the inferior vena cava. There is increasing evidence that percutaneous insertion of femoral venous catheters is a safe procedure with few complications for neonates (17, 18). Although bacterial infection after femoral venous insertion has been reported (19), our study did not ﬁnd any condition of bacterial infection in neonates with ET, using FV catheterizations. Sterile procedure, removal of catheterizations as soon as ET was not indicated, and prophylactic use of antibiotics may decrease the risk of infection. Even though neonates undergoing ET via FV route had higher TSB levels and more clinical manifestations than those undergoing ET via UV route, the effectiveness and adverse events of ET were not different between these two groups. In our study, neonates with ET via UA/V route experienced more adverse events than those via FV and UV routes. This ﬁnding is similar to the results of a study (9) showing that the complication rate in ET through UA/V catheterization was higher than that of ET through other catheterizations. Our study has further extended their inquiry by identifying the transfusion rate of ET via FV route was distinct from ET via FV and UV routes. ET
carried out by simultaneous pull and push of blood could speed up the procedure (14). In addition, our study found neonates with ET via UA/V route tended to have platelets 50,000/ L, which is probably due to platelet consumption or insufﬁcient platelet production during fast ET in these patients. Except thrombocytopenia, there was no signiﬁcant difference in each adverse event among the three groups as a result of low incidence. Taken together, we suggest that ET procedure via UA/V route may increase the risks of adverse events. Our study has two important clinical implications. First, FV route serves as a safe and efﬁcient alternative to UV catheterization. The umbilical route may be not available for ET in some circumstances, such as closure of umbilical vessels or inexperienced hands. Furthermore, pediatricians have often used FV catheterization (20). Thus, FV catheterization is a necessary substitute for UV catheterization. Second, adverse events were more common in neonates with ET via UA/V route. A number of studies have shown a link between umbilical arterial catheterization and serious complications (9, 21, 22). As reported in those studies, our ﬁndings suggest that ET, using UA/V catheterization, should not be recommended even though it can save time. The mortality rate of ET has been estimated to be around 2% (10). In our study, three neonates with maximum TSB value of 45 mg/dL died (mortality rate, 2.3%). As none of the survivors had peak TSB levels exceeding those of the three fatalities, we assumed that death was due, at least in part, to acute bilirubin encephalopathy. In addition, the three infants who died were unstable before ET. Several publications (5, 9, 10) showed that unstable neonates are more susceptible to complications in ET. These ﬁndings indicate that physicians should be cautious when employing ET for ill neonates. In this study, the most common etiology for hyperbilirubinemia was blood group incompatibility, followed by G6PD deﬁciency. Blood group incompatibility and G6PD deﬁciency have been characterized as two major causes of neonatal hyperbilirubinemia in Taiwan (2, 23, 24). Neonates with blood group incompatibility often present with early-onset hyperbilirubinemia (2). In contrast, the development of hyperbilirubinemia at age 7
days old is more common in G6PDdeﬁcient newborns (23). Furthermore, attempts at umbilical catheterization usually fail in neonates 7 days of age. These differences account for the distinct characteristics between FV catheterization and umbilical catheterization groups. There were several limitations to this study. First, our study was not a randomized clinical trial. To the best of our knowledge, a randomized trial comparing these three models of ET has yet to be published. Second, we did not compare our three methods with other catheterizations, such as single umbilical artery and peripheral vessels. Third, the differences in clinical characteristics among the three groups may lead to bias regarding the safety and efﬁciency of ET. But the regression analysis revealed that differences in the adverse events were not inﬂuenced by other factors, including initial symptoms, bilirubin levels, age at ET, hemoglobin value, and causes of neonatal hyperbilirubinemia (data not shown). In conclusion, ET via UA/V method is associated with more adverse events than ET via FV and UV methods. Physicians should be cautious when using the UA/V route for ET. As ET via FV and ET via UV have similar efﬁcacy and risk of adverse events, we conclude that FV is a useful alternative route for ET. This study provides support for the use of FV catheterization for ET in the treatment of neonatal hyperbilirubinemia when UV catheterization is not available.
1. Dennery PA, Seidman DS, Stevenson DK: Neonatal hyperbilirubinemia. N Engl J Med 2001; 344:581–590 2. Weng YH, Chiu YW: Spectrum and outcome analysis of marked neonatal hyperbilirubinemia with blood group incompatibility. Chang Gung Med J 2009; 32:400 – 408 3. Behjati S, Sagheb S, Aryasepehr S, et al: Adverse events associated with neonatal exchange transfusion for hyperbilirubinemia. Indian J Pediatr 2009; 76:83– 85 4. Salas AA, Mazzi E: Exchange transfusion in infants with extreme hyperbilirubinemia: An experience from a developing country. Acta Paediatr 2008; 97:754 –758 5. Chen HN, Lee ML, Tsao LY: Exchange transfusion using peripheral vessels is safe and effective in newborn infants. Pediatrics 2008; 122:e905– e910 6. Badiee Z: Exchange transfusion in neonatal hyperbilirubinaemia: Experience in Isfahan, Iran. Singapore Med J 2007; 48:421– 423 7. Al-Hiali S, Al-Diwan JK, Al-Janabi M, et al:
Exchange transfusion in a neonatal unit in western Iraq. Ann Trop Paediatr 2007; 27: 155–156 Sanpavat S: Exchange transfusion and its morbidity in ten-year period at King Chulalongkorn Hospital. J Med Assoc Thai 2005; 88:588 –592 Patra K, Storfer-Isser A, Siner B, et al: Adverse events associated with neonatal exchange transfusion in the 1990s. J Pediatr 2004; 144:626 – 631 Jackson JC: Adverse events associated with exchange transfusion in healthy and ill newborns. Pediatrics 1997; 99:E7 Keenan WJ, Novak KK, Sutherland JM, et al: Morbidity and mortality associated with exchange transfusion. Pediatrics 1985; 75: 417– 421 Tan KL, Phua KB, Ang PL: The mortality of exchange transfusions. Med J Aust 1976; 1:473– 476 Farquhar JW, Smith H: Clinical and biochemical changes during exchange transfusion. Arch Dis Child 1958; 33:142–159 Ata M, Holman CA: Simultaneous umbilical arteriovenous exchange transfusion. Br Med J 1966; 2:743–745 Fok TF, So LY, Leung KW, et al: Use of peripheral vessels for exchange transfusion. Arch Dis Child 1990; 65:676 – 678 Scheer B, Perel A, Pfeiffer UJ: Clinical review: Complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine. Crit Care 2002; 6:199 –204 Wardle SP, Kelsall AW, Yoxall CW, et al: Percutaneous femoral arterial and venous catheterisation during neonatal intensive care. Arch Dis Child Fetal Neonatal Ed 2001; 85:F119 –F122 Serrao PR, Jean-Louis J, Godoy J, et al: Inferior vena cava catheterization in the neonate by the percutaneous femoral vein method. J Perinatol 1996; 16:129 –132 Asnes RS, Arendar GM: Septic arthritis of the hip: a complication of femoral venipuncture. Pediatrics 1966; 38:837– 841 Kanter RK, Zimmerman JJ, Strauss RH, et al: Central venous catheter insertion by femoral vein: Safety and effectiveness for the pediatric patient. Pediatrics 1986; 77:842– 847 Hilliard J, Schreiner RL, Priest J: Hemoperitoneum associated with exchange transfusion through an umbilical arterial catheter. Am J Dis Child 1979; 133:216 Malloy MH, Nichols MM: False abdominal aortic aneurysm: An unusual complication of umbilical arterial catheterization for exchange transfusion. J Pediatr 1977; 90: 285–286 Weng YH, Chiu YW: Clinical characteristics of G6PD deﬁciency in infants with marked hyperbilirubinemia. J Pediatr Hematol Oncol 2010; 32:11–14 Weng YH, Chou YH, Lien RI: Hyperbilirubinemia in healthy neonates with glucose-6phosphate dehydrogenase deﬁciency. Early Hum Dev 2003; 71:129 –136
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