ORIGINAL ARTICLE: HEPATOLOGY

Effect of Ursodeoxycholic Acid on Indirect

Hyperbilirubinemia in Neonates Treated
With Phototherapy

Naser Honar, yElham Ghashghaei Saadi, zForough Saki, Narjes Pishva,
y
Nader Shakibazad, and jjSaeed Hosseini Teshnizi

ABSTRACT

Background: Hyperbilirubinemia is a common neonatal problem. The

What Is Known
present study aimed to investigate the effect of ursodeoxycholic acid in
reducing indirect hyperbilirubinemia of infants under phototherapy.  Unconjugated hyperbilirubinemia affects half of the
Methods: This double-blind randomized clinical trial was conducted
full term and almost all of the preterm infants.
on neonates with jaundice, who had received phototherapy in the  Phototherapy is used for unconjugated hyperbiliru-
hospitals affiliated with the Shiraz University of Medical Sciences in
binemia treatment; however, it disrupts mother-child
2013. A total of 80 neonates were enrolled in the study and were
bounding and has potential complications.
randomly divided into 2 groups. The intervention group (n 40) with  Ursodeoxycholic acid is a safe drug used in the
indirect hyperbilirubinemia received 10 mg  kg1  day1 divided every
treatment of cholestatic liver disorders in children,
12 hours Ursobil (capsule 300 mg) in addition to phototherapy, whereas
but it has not yet been studied in neonates.
the control group (n 40) received only phototherapy. Total bilirubin
levels were measured every 12 hours until reaching <10 mg/dL, and then
What Is New
phototherapy was disrupted. The duration of phototherapy was measured.
The 2 groups were compared regarding total bilirubin levels at different  Adding ursodeoxycholic acid to phototherapy in
time points and duration of phototherapy using the generalized
unconjugated hyperbilirubinemia neonates is more
estimating equation (GEE) test.
effective than phototherapy alone in reducing
Results: The mean of total bilirubin in the intervention group was 12  1.6,
serum bilirubin.
10  1.1, and 9.8  0.2 mg/dL 12, 24, and 48 hours after the beginning of  Ursodeoxycholic acid therapy during the first 48
phototherapy, respectively. On the contrary, these measures were 14.4  1.3,
hours of hospitalization decreases the duration of
12.5  1.4, and 10.1  1.1 mg/dL in the control group, respectively,
phototherapy needed for controlling neonatal
(P < 0.05). The mean time required for phototherapy to decrease the
unconjugated hyperbilirubinemia.
bilirubin level to <10 mg/dL was 15.5  6 and 44.6  13.3 hours in the
case and the control group, respectively, (P 0.001).
Conclusions: Ursodeoxycholic acid had additive effect with phototherapy in
neonates with indirect hyperbilirubinemia. This drug also reduced the time Key Words: neonatal indirect hyperbilirubinemia, neonatal jaundice,
period needed for phototherapy and, consequently, decreased the ursodeoxycholic acid
hospitalization period.
(JPGN 2016;62: 97100)

Received December 3, 2014; accepted May 19, 2015.

From the Pediatric Gastroenterology and Hepatology Department, the
yPediatrics Department, the zShiraz Endocrinology and Metabolism
Research Center, the Neonatal Research Center, Shiraz University of
Medical Sciences, Shiraz, and the jjHormozgan University of Medical
Science, Bandar Abbas, Iran.
Address correspondence and reprint requests to Forough Saki, MD, Shiraz
Endocrinology and Metabolism Research Center, Shiraz University of
Medical Sciences, PO Box 71345-1744, Shiraz, Iran (e-mail: Sakeif@
sums.ac.ir).
This article was adapted from Elham Ghashghaei Saadis thesis for special-
ization in pediatrics.
This study was supported in part by grant no. 3827 from the research vice-
chancellor of Shiraz University of Medical Sciences, Shiraz, Iran.
The authors report no conflicts of interest.
Copyright # 2015 by European Society for Pediatric Gastroenterology,
Hepatology, and Nutrition and North American Society for Pediatric
Gastroenterology, Hepatology, and Nutrition
DOI: 10.1097/MPG.0000000000000874
H yperbilirubinemia is a common problem during infancy and
affects half of the full term and almost all of the preterm
infants (1). Typically, phototherapy is used for reducing bilirubin in
neonates; however, it has disadvantages, such as being expensive
and preventing the relationship between the mother and the child
because of the need for incubator and closure of the infants eyes
(2,3). Potential complications, such as retinal degenerative changes,
water, and electrolyte disorders, bronze baby syndrome, and ther-
mal instability, also threaten such infants. Therefore, using adjuvant
therapies, which reduce the duration of phototherapy and hyperbi-
lirubinemia, can be highly effective (2,3).
Up to now, several drugs, such as activated charcoal,
D-penicillamine, phenobarbital, metalloporphyrin, clofibrate, and
bile salts, have been used for the treatment of indirect hyperbilir-
ubinemia (47). Several studies have shown phenobarbital to be
effective in reducing indirect hyperbilirubinemia and decreasing the
duration of phototherapy (8). Nevertheless, it has complications,
including increase in drowsiness, reduction of breast-feeding,

JPGN  Volume 62, Number 1, January 2016 97

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 Saki et al
dehydration, and neurological disorders (7). Thus, performing
studies on medications with lower complications seems necessary.
On the contrary, ursodeoxycholic acid (UDCA) is a bile acid
that is widely used in the treatment of cholestatic liver disorders. It
protects the liver against oxidative stress, prevents cell apoptosis,
stimulates the bile flow, and suppresses the confounding factors in
immunological mechanisms (9). UDCA is well tolerated and has
limited complications in pediatrics (10).
One study, which was conducted on the effect of UDCA
and phototherapy on unconjugated bilirubin (UCB) in rats,
showed that UDCA increased the turnover of UCB by its fecal
disposal (11).
Owing to the lack of sufficient data about the effect of UDCA
on neonatal unconjugated hyperbilirubinemia, the present study
aimed to investigate the effect of UDCA on reducing the UCB of
the infants undergoing phototherapy, with the hope to reduce the
lengths of phototherapy and hospitalization.
METHODS
The present double-blind, randomized clinical trial was
conducted on neonates with jaundice who were treated through
phototherapy in the neonatal wards affiliated with the Shiraz
University of Medical Sciences in 2013. Shiraz is the capital city
of Fars Province, located in the south of Iran. The patients were
selected with simple random sampling and were also blindly
divided in groups of case (who were treated with photothera-
py UDCA) and control (who were treated with photothera-
py placebo) by a single observer (a nurse who blindly treated
the neonates with UDCA or placebo and observed the outcome).
Only 1 physician knew the code of neonates who received the
UDCA and did not have any contact with either the parents or the
medical team (including the nurses). Neither the nurse nor the
parents knew which neonate received the UDCA. One statistics
specialist calculated the sample size using a sample size formula
for comparing 2 independent groups (a 0.05, b 0.2,
d m1m2 0.95, s1 1.5, and s2 1.5); sample size was calcu-
lated as 40 patients for each group.
Thus, 40 neonates for the case and 40 neonates for the control
group were enrolled. Statistical power analysis at the end of the
study was calculated as 92%, which was greater than power
(1-b 80%). Neonates entered the study after obtaining written
informed consents from their parents.
The inclusion criteria of the study were birth weights of 2500
to 4000 g, being exclusively breast-fed, gestational age of 38 to 41
weeks, being >3 days old, total bilirubin level of 14 to 20 mg/dL,
and direct bilirubin level <2 mg/dL. Infants with ABO and RH
incompatibility, glucose-6-phosphate dehydrogenase (G6PD)
deficiency, direct hyperbilirubinemia, septicemia, and diseases
leading to hyperbilirubinemia (Crigler-Najjar syndrome, Gilbert
syndrome, hypothyroidism/hyperthyroidism, liver diseases, etc),
premature neonates, and the infants of diabetic mothers were
excluded from the study.
The intervention group, which included 40 infants with
unconjugated hyperbilirubinemia, received 10 mg  kg1  day1
TABLE 1. General characteristics of the neonates
Variables Intervention group
Age 3.7  1
Sex (female, male) (%) 21 (52.5), 19 (47.5)
Mean total bilirubin on admission, mg/dL 15.9  1.7
Weight on admission, g 2970  292
98
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JPGN  Volume 62, Number 1, January 2016
divided q12 h Ursobil (UDCA, capsule 300 mg; provided by Dr
Abidi Company, Tehran, Iran) that was diluted with water (and was
sucked by the babies) according to weight by pharmacist in addition
to phototherapy, whereas the control group (n 40) received
placebo (which was water) and phototherapy. Phototherapy was
performed continuously using daylight fluorescent bulbs (Westing-
house, Pittsburgh, PA) in an Air Shields unit (Drager, London, UK).
The distance between the lamp and the baby was 30 to 35 cm. The
duration of phototherapy was measured using a timer. It should be
noted that the lamps of the phototherapy device were at a standard
distance from the patients and were changed after 250 hours. During
phototherapy, genitalia and both eyes of infants were covered.
On the first day of hospitalization, complete history and
physical examination, total and direct bilirubin, reticulocyte count,
Coombs test, G6PD level, complete blood count, Rh, and blood
group experiments were performed for both groups. In addition,
total bilirubin levels were measured by diazo method, every
12 hours until the total bilirubin level reached <10 mg/dL and
phototherapy was disrupted, thereafter total bilirubin levels were
not checked. (Table 1). All of the information was recorded on a
data collection form, and the 2 groups were compared regarding
total bilirubin levels at different time points, the time duration
in which bilirubin levels reached <10, and the duration of
phototherapy.
The study was approved by the ethics committee of the
Shiraz University of Medical Sciences, Shiraz, Iran, and was
registered in the Iranian Registry of Clinical Trials (ID:
IRCT2013020512370N1). The parents signed written informed
consent forms.
Data Analysis
All of the data analyses were performed using the SPSS
statistical software (SPSS18, IBM SPSS Software, Armonk, NY).
Data were mentioned as mean  SD. Normality of data distribution
was evaluated by Kolmogorov-Smirnov test. Independent sample t
test was used to compare the mean of bilirubin in the 2 groups.
Owing to some missing data (those bilirubin which were not
checked when the neonate had 1 bilirubin test <10 mg/dL during
phototherapy), the association between changes of bilirubin over
time in each group were checked by the generalized estimating
equation (GEE) method with linear link function and unstructured
working correlation matrix. P <0.05 was considered as statistically
significant.
RESULTS
The mean age of the studied subjects was 3.7  1 (36 days)
and 3.6  1 days (37 days) in the intervention and the control
groups, respectively, and no significant difference was found
between the 2 groups in this regard (P 0.44). Considering sex
distributions in the intervention group, 21 subjects (52.5%) were
female, and 19 (47.5%) were male. In the control group, in contrast,
22 (55%) subjects were female. Table 1 summarized the general
characteristics.
Control group P
3.6  1 0.44
22 (55), 18 (45) 0.78
16.3  1.5 0.44
2985  312 0.651
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TABLE 2. Comparison of the case and control groups regarding the mean of total bilirubin at different time points after admission

Mean of total bilirubin Case group, mg/dL
At the time of hospitalization 15.9  1.7
12 h after hospitalization 12  1.6
24 h after hospitalization 10  1.1
48 h after hospitalization 9.8  0.2

Total bilirubin was checked and recorded till 10 mg/dL.
The mean of total bilirubin was 16.1  1.6 mg/dL at the time
of hospitalization. It was 15.9  1.7 (range 13.220 mg/dL) and
16.3  1.5 mg/dL (range 1420 mg/dL) in the intervention and the
control groups, respectively, (P 0.44). The mean of total bilirubin
in the 2 study groups at the time of hospitalization and 12, 24, 48,
60, and 72 hours after hospitalization is presented in Table 2. The
results of GEE showed that the bilirubin levels over time within
each group were significantly different (P 0.008) (Fig. 1). Gener-
ally, the mean of bilirubin levels over time was significantly less
than the control group (P < 0.001). In the intervention group, the
bilirubin levels had decreased 1.65, 3.82, and 6.37 mg/dL, after 12,
24, and 48 hours, respectively. There was no significant association
with age and sex in this regard.
The mean duration of time required for phototherapy for
decreasing the bilirubin level to <10 mg/dL was 15.5  6 and
44.6  13.3 hours in the case and the control groups, respectively,
and the difference was statistically significant (P 0.001) (Fig. 2).
The intervention group was also examined regarding Ursobil
complications, such as diarrhea and vomiting; however, no com-
plications were detected in any of our patients.
DISCUSSION
The results of the present study showed that 12 and 24 hours
after hospitalization, the mean total bilirubin level had significantly
decreased in patients receiving Ursobil and phototherapy compared
with those who had only underwent phototherapy (P < 0.05). It
seems that the combination of Ursobil and phototherapy leads to a
much more reduction in the total bilirubin levels in comparison with
phototherapy alone. No significant difference was found between
the 2 groups regarding the total bilirubin levels, however, 48 hours
after hospitalization, which shows that the highest effect of
phototherapy accompanied by Ursobil occurs in the first 48 hours
of hospitalization. Moreover, the mean duration of phototherapy
significantly decreased in the neonates receiving phototherapy and
Ursobil compared with those who only underwent phototherapy
18
16
14
12
10
Bilirubin
8 Intervention
6 Control
4 0.0
2
0 without Ursobil
Baseline 12 h 24 h 48 h
Time
FIGURE 1. Results of GEE analysis of the total bilirubin levels in the
case and control groups during therapy. GEE generalized estimating
equation.
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Ursobils Effect on Neonatal Hyperbilirubinemia
Standard, mg/dL P 95% Confidence interval
16.3  1.5
14.4  1.3 <0.001 2.15 to 1.5
12.5  1.4 <0.001 4.21 to 3.42
10.1  1.1 <0.001 6.89 to 5.84
(P < 0.05). In this study, no significant difference was observed
between the 2 groups regarding the sex. Most of the study patients
were 3 days old (52% in the case and 70% in the control groups).
This is consistent with other studies conducted on this issue (12).
UDCA is commonly used for the treatment of cholestatic liver
diseases. Previous studies revealed that there were 3 major mech-
anisms of action for UDCA: first, changes in the composition of
mixed phospholipid-rich micelles, reduction of bile acid cytotoxi-
city of bile, and, maybe, reduction of the hydrophobic bile acid
concentration in the cholangiocytes could protect cholangiocytes
against cytotoxicity of hydrophobic bile acids; second, stimulation
of hepatobiliary secretion, via Ca2-dependent mechanisms and
protein kinase C-adependent mechanisms may caused insertion of
transporter molecules into the hepatocyte canalicular membrane
and, maybe, activation of inserted carriers; third, hepatocytes
protection against bile acidinduced apoptosis (13). According
to the present study results, Ursobil led to an 24-hour reduction
in the duration of phototherapy in the neonates suffering from
indirect hyperbilirubinemia most probably by increasing unconju-
gated bilirubin turnover through its fecal disposal (14). The only
study on the effect of UDCA on decreasing UCB is the one
conducted by Cuperus et al (11) on rats in 2009; the findings of
that study, showed that UDCA increased UCB turnover through
increasing its fecal disposal. Reduction of UCB in the present study
also seems to result from the same mechanism. Nonetheless,
Mendez-Sanchez et al (9) investigated the effect of UDCA in rats
and mice and showed the increase of enterohepatic UCB after the
oral consumption of UDCA.
The findings of the present study showed no short-term
complication resulting from Ursobil. Long-term follow-up should
80.0
70.0
Phototherapy time, h
60.0
50.0
40.0
30.0
20.0
10.0
Phototherapy Phototherapy
with Ursobil
Group
FIGURE 2. Duration of phototherapy for the treatment of hyperbilir-
ubinemia in both groups (the mean time in the case group was
15.5  6 hours and in the control group it was 44.6  13.3 hours).
The difference was statistically significant (P 0.001).
99
 Saki et al
be done, however, to confirm the safety of this drug in neonates.
Some studies have confirmed the safety and tolerability of this
medication for children (10). During this study, none of the
neonates developed adverse effects of UDCA.
The present study was the first one that investigated the effect
of UDCA on reducing the UCB of the infants undergoing photo-
therapy; with the hope to reduce the lengths of phototherapy and
hospitalization, there was some limitation in our study. Small sample
size of this study limit us to compare different doses of UDCA to
evaluate the best effective dose in the treatment of unconjugated
hyperbilirubinemia in neonates; as a result of lack of similar studies
about the effect of UDCA in unconjugated hyperbilirubinemia of
neonates, we could not predict all of the variables that had important
effect in this regard; so further studies need to evaluate the efficacy of
UDCA in the treatment of unconjugated hyperbilirubinemia of
neonates. Also, to evaluate the long-term adverse effects of UDCA
in the next step, we should design a 10-year follow-up study in our
patients. Further investigation with larger sample size and long-term
follow-up is suggested to use UDCA safely in improving the treat-
ment of neonatal hyperbilirubinemia.
CONCLUSIONS
It can be concluded that adding UDCA to phototherapy in
neonates with indirect hyperbilirubinemia is more effective com-
pared with the treatment by phototherapy alone. Other than being
highly effective in reducing the levels of total bilirubin, the admin-
istration of UDCA immediately after or during the first 48 hours of
hospitalization will also decrease the time period required for
phototherapy.
Acknowledgments: The authors thank the team at the Shiraz
Neonatal Research Center for their cooperation. The authors also
thank the Research Improvement Center of Shiraz University of
Medical Sciences and Ms A. Keivanshekouh for improving the use
of English in the manuscript. The authors also thank Dr Asma
Erjaee at the Center for Development of Clinical Research of
Nemazee Hospital for editorial assistance.
100
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JPGN  Volume 62, Number 1, January 2016
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