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426 Original article

Effect of phototherapy on serum calcium level in neonatal

jaundice
Mohammed Hamed Bahbaha, Fathia Mohamed El Nemra,
Rania Salah El Zayata, Elham Aziz Khalid Azizb
a
Department of Pediatrics, Faculty of Medicine,
Menoufia University, bDepartment of Pediatrics,
Tala Central Hospital, Menoufia, Egypt
Correspondence to Elham Aziz Khalid Aziz,
Department of Pediatrics, Tala Central Hospital,
Menoufia, Egypt
Tel: +20 100 843 8672;
e-mail: dr.lolo10@yahoo.com
Received 17 June 2014
Accepted 14 October 2014
Menoufia Medical Journal 2015, 28:426430
Objectives
The aim of the study was to determine the effect of phototherapy on serum calcium level in
neonatal jaundice.
Background
Phototherapy plays a significant role in the treatment and prevention of hyperbilirubinemia
in neonates. However, this treatment modality may result in the development of some
complications such as induction of hypocalcemia.
Patients and methods
This study included 50 full-term neonates with jaundice (25 males and 25 females) who
received phototherapy for treatment of neonatal indirect hyperbilirubinemia and 25 neonates
(13 males and 12 females) complaining of exaggerated physiological hyperbilirubinemia taken
as control not exposed to phototherapy. Serum calcium was checked before and 48 h after
starting phototherapy. A comparative study was conducted between these groups to determine
the effect of phototherapy on serum calcium level.
Results
In the neonates of the study group, the serum bilirubin level before phototherapy was 15.48
1.94 mg/dl. However, the serum bilirubin level after phototherapy was 12.41 2.10 mg/dl. There
was highly statistically significant decrease of the serum bilirubin levels after phototherapy as
compared with serum bilirubin levels before phototherapy in the study group (P < 0.001). With
respect to the calcium level, the total serum calcium level before phototherapy was 9.36
0.29 mg/dl, whereas the serum calcium level after phototherapy was 8.58 0.76 mg/dl. There
was highly statistically significant decrease of the serum calcium levels after phototherapy as
compared with serum calcium levels before phototherapy in the study group.
Conclusion
Hypocalcemia is a common complication of phototherapy.

Keywords:
hyperbilirubinemia, hypocalcemia, phototherapy

Menoufia Med J 28:426430

2015 Faculty of Medicine, Menoufia University
1110-2098

curve, depth of penetration), the distance between

Introduction
Hyperbilirubinemia is the most common abnormal
physical finding in the first week of life in neonates
and is observed in 60% of term neonates and 80%
of preterm infants [1]. In Egypt, about 20.4% develop
jaundice yearly. Incidence of jaundice was found to be
higher in low birth weight neonates (35.6%) compared
with normal birth weight infants (16.9%) [2]. Although
most infants with jaundice are otherwise perfectly
healthy, they make us anxious because bilirubin is
potentially toxic to the central nervous system [3].
Phototherapy plays a significant role in the treatment
and prevention of hyperbilirubinemia in neonates. 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 [4].
The effectiveness of phototherapy depends upon the
type of light source used (i.e. dose, spectral emission
1110-2098 2015 Faculty of Medicine, Menoufia University
the light and the infant, the surface area treated, the
etiology of the jaundice, and total serum bilirubin
level at the onset of phototherapy [5]. However,
this treatment modality may itself result in the
development of some complications. Among these are
loose stools, erythematous macular rash, overheating,
dehydration, damage to DNA, retinal injury, and a
benign condition called bronze baby syndrome in
cholestasis [6].
Melatonin stimulates secretion of corticosterone, which
decreases calcium absorption by bones. Phototherapy
leads to inhibition of pineal gland by transcranial
illumination, resulting in a decline in melatonin level
and as a result, hypocalcemia develops [7].
The aim of the work was to study the effect of
phototherapy on serum calcium level in neonatal
jaundice.
DOI: 10.4103/1110-2098.163896
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Hypocalcemia is a complication of phototherapy Bahbah et al. 427

all data were tabulated and analyzed statistically to

Patients and methods
This study was conducted on 50 full-term neonates
with jaundice (25 males and 25 females) who received
phototherapy for treatment of neonatal indirect
hyperbilirubinemia (exaggerated physiological
jaundice) and 25 neonates (13 males and 12 females)
complaining of physiological hyperbilirubinemia taken
as controls not exposed to phototherapy.
Cases were selected from those admitted to neonatal
ICU of Tala Hospital, and controls were selected from
outpatient clinic.
detect hypocalcemia as a complication of phototherapy.
Statistical data analysis
Statistical presentation and analysis of the present
study was conducted by SPSS, V. 20. Quantitative data
were analyzed by the Student t-test and paired t-test.
Qualitative data were analyzed by the c2-test and
Fishers exact test. The test is considered significant
when P value is less than 0.05.

After approval of the ethical committee, informed consents Results

were obtained from the parents of the selected neonates.
All cases chosen fulfilled the following criteria.
(1) Icteric stable neonates.
(2) Neonates who required management with
phototherapy (exaggerated physiological jaundice).
(3) Fed with full strength formula or breast fed.
We excluded any neonates suffering from birth
asphyxia, congenital malformation, septicemia, and
hypothyroidism, infant of diabetic mother, hemolytic
anemia, any newborn needing exchange transfusion,
neonatal hypocalcemia, or ABO or Rh incompatibility.
The neonates in the control group were babies who
had physiological neonatal jaundice managed without
phototherapy or exchange transfusion.
The study group included 50 neonates, 25 boys (50%)
and 25 girls (50%), with mean gestational age of 38.28
0.99 weeks and mean postnatal age 4.26 1.12 days.
There were 20 neonates (40%) delivered by normal
vaginal delivery and 30 neonates (50%) delivered by
Cesarean section (Table1).
There was no statistically significant difference between
both groups regarding gestational age, postnatal age,
sex, and mode of delivery (P > 0.05) (Table2).
All cases of the study group presenting with neonatal
hyperbilirubinemia were managed with phototherapy
only and closely observed for the possibility of
developing phototherapy-induced hypocalcemia.
The serum bilirubin level among neonates of the study
group was 15.4 1.94 mg/dl, whereas the serum bilirubin

In contrast, patients in the studied group were placed

Table 1 Sociodemographic data of the study group
under phototherapy. The phototherapy unit used was
Variables N (%)
four blue light lamps, 20 W, which supplies spectral Age (mean SD) (days) 4.26 1.12
irradiance of 5 mW/cm2/nm at 450470 nm/cm2. Naked Gestational age (mean SD) (weeks) 38.28 0.99
neonates were placed while covering eyes and genitalia at Sex
a distance of 4550 cm from phototherapy unit and were Male 25 (50)
managed with continuous phototherapy in open bed. Female 25 (50)
The position of the baby was changed from time to time. Mode of delivery
Normal 20 (40)
Each case was subjected to detailed history taking Cesarean section 30 (60)

(gestational age, mode of delivery, detailed prenatal

and natal history, age on admission, and day of onset Table 2 Comparison between two groups regarding
of jaundice and family history of neonatal jaundice) thesociodemographic characters
and clinical examination, which included general and Variables Cases Controls Test P value
local examination with special emphasis on weight, (N = 50) (N = 25)
(mean SD) (mean SD)
length, head circumference, and manifestations of Age (days) 4.26 1.12 4.32 0.74 0.27 0.78
hypocalcemia (jitteriness, irritability, and convulsion). Gestational age (weeks) 38.28 0.99 38.72 1.06 1.77 0.08
Sex [n (%)]
Laboratory investigations were applied including total Male 25 (50.0) 13 (52) 0.02 0.87
serum bilirubin before and 48 h after phototherapy, Female 25 (50.0) 12 (48)
total serum calcium before and after 48 h after starting Mode of delivery [n (%)]
of phototherapy, blood group to infant and mother, Normal 20 (40.0) 14 (56) 1.72 0.18
reticulocytic count, and hemoglobin level. Thereafter, Cesarean section 30 (60.0) 11 (44)
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428 Menoufia Medical Journal

level among the neonates of the control group was

Discussion
6.6 0.79 mg/dl. There was highly statistical significant
In our study, the first group (jaundiced neonates
difference between both studied groups regarding total
treated with phototherapy as the study group
serum bilirubin level (P < 0.001) (Table3). with bilirubin level 15.4 1.94 mg/dl) included
The serum calcium level of neonates of the study
group before phototherapy was 9.3 0.29 mg/dl. Table 3 Comparison between two groups regarding
However, the serum calcium level among neonates of theresults of TSB and serum calcium before phototherapy
the control group was 9.1 1.29 mg/dl. There was no Variables Cases Controls t-test P value
statistical significant difference between both studied (n = 50) (n = 25)
(mean SD) (mean SD)
groups regarding total serum calcium level on arrival
TSB (mg/dl) 15.48 1.94 6.65 0.79 21.81 (0.000)<0.001
(P > 0.05). Serum calcium 9.36 0.29 9.18 0.90 1.29 >0.05
(mg/dl)
In the neonates of the study group, the serum bilirubin TSB, total serum bilirubin.
level before phototherapy was 15.4 1.94 mg/dl,
whereas the serum bilirubin level after phototherapy was
Table 4 Comparison between TSB and serum calcium measures
12.4 2.10 mg/dl. There was highly statistically significant before and after phototherapy treatment among cases
decrease of the serum bilirubin levels after phototherapy, as Before After
Paired P value
compared with serum bilirubin levels before phototherapy t-test
in the study group (P < 0.001) (Table4). TSB (mg/dl) 15.48 1.94 12.41 2.10 23.65 (0.000)<0.001
Serum calcium 9.36 0.29 8.58 0.76 8.27 (0.000)<0.001
With respect to the calcium level, the total serum calcium (mg/dl)
level before phototherapy was 9.3 0.29 mg/dl, whereas TSB, total serum bilirubin.
the serum calcium level before phototherapy was 8.5
0.76 mg/dl. There was highly statistically significant Table 5 The descriptive data of hypocalcemia and symptoms
decrease of the serum calcium levels after phototherapy, as among cases
compared with serum calcium levels before phototherapy Variables N = 50 [n (%)]
in the study group (P<0.001) (Table4). Hypocalcemia 13 (26)
Normal calcium 37 (74)
Neonates with hypocalcemia represented 13 cases Jitteriness 7 (14)
Convulsions 5 (10)
(26%) and those with normal calcium represented 37
cases (74%). Neonates with jitteriness represented seven
cases (14%) and those with convulsions represented Table 6 Severity of hypocalcemia in hypocalcemic neonates
five cases (10%) of hypocalcemic neonates (Table5). Variables Serum calcium N = 13 [n (%)]
level (mg/dl)
The severity of hypocalcemia in hypocalcemic neonates Mild hypocalcemia 87.5 8 (61.5)
was 61.5% mild and 38.5% severe (Table 6,Figs 1 and 2). Severe hypocalcemia Below 7.5 5 (38.5)

Figure 1 Figure 2

TSB among the study group and the control group before phototherapy. TSB and serum calcium level of neonates in the study group before
TSB, total serum bilirubin. and after phototherapy. TSB, total serum bilirubin.
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Hypocalcemia is a complication of phototherapy Bahbah et al. 429
50 neonates, 25 boys (50%) and 25 girls (50%) with
mean gestational age 38.28 weeks. The second group
(physiological jaundiced neonates treated without
phototherapy as the control group with bilirubin
level 6.6 0.79 mg/dl) included 25 neonates, 13 boys
(52%) and 12 girls (48%) with mean gestational age
38.7 weeks.
In our study, hypocalcemia was assessed as a
complication of phototherapy in newborns managed
for neonatal hyperbilirubinemia.
Before phototherapy, there was no statistically
significant difference between serum calcium level
in cases (9.3 mg/dl) and in controls (9.18 mg/dl).
However, after 48 h of treatment of cases with
phototherapy, serum calcium level decreased
to 8.5 mg/dl, and we found highly statistically
significant difference between serum calcium level
before and after exposure to phototherapy where
P value was less than 0.01.
This was in agreement with several previous studies.
In studies by Karamifar et al. [7] and Ehsanipour
et al. [6] the incidence of hypocalcemia after 48 h of
phototherapy was 15 and 14.4%, respectively.
In addition, Jain et al. [8] noticed that 55% of preterm
neonates and 30% of full-term neonates developed
hypocalcemia after being subjected to phototherapy.
In addition, Sethi et.al. [9] noticed hypocalcemia
after 48 h of phototherapy. Sixty neonates with
hyperbilirubinemia were included in their study.
There were 20 preterm (group A) and 20 full-
term (group B) neonates. Ten neonates from each
group formed the control group. The study group
neonates were managed with phototherapy, whereas
the control group neonates were not subjected to
phototherapy. Serum calcium levels of the two groups
were studied. In all, 90% preterm neonates and 75%
full-term neonates developed hypocalcemia after
being subjected to phototherapy. There was a highly
significant decrease in total as well as ionized calcium
levels in the study group in contrast to the control
group. They recommended that neonates under
phototherapy should be given supplemental calcium
to prevent hypocalcemia.
Mostafa et al. [10] also found hypocalcemia after
exposure to phototherapy, with a higher percentage
among the preterm neonates, as compared with full-
term neonates.
The etiology of hypocalcemia in infants treated with
phototherapy is believed to be caused by a decrease in
melatonin level and corticosterone secretion [7]. In
addition, urinary calcium excretion is increased after
exposure to phototherapy [11].
This decrease in calcium can be explained by
melatonin secretion [12]. Melatonin stimulates
secretion of corticosterone, which decreases
calcium absorption by bones. Phototherapy leads
to inhibition of pineal gland by transcranial
illumination, resulting in a decline in melatonin level
and as a result, hypocalcemia develops [7]. Cortisol
exerts a direct hypocalcemic effect by decreasing the
absorption of Ca and PO4 ions from the intestine
by antivitamin D action and by increasing the renal
excretion of these ions and also accelerates the bone
uptake of calcium [13].
In addition, urinary calcium excretion is increased after
exposure to phototherapy as shown by Hooman and
Honarpisheh [11].
The reason for a higher incidence of hypocalcemia in
preterm infants is still unknown.
Prevention of hypocalcemia in infants undergoing
phototherapy has been trialed by this research group
and others. The researchers studied 100 preterm
newborns to verify whether calcifediol (25(OH)
D3) could be useful to prevent the phototherapy-
induced hypocalcemia. Results obtained show that
calcifediol is not able, anyway, to lower the increase of
the phototherapy-induced hypocalcemia in preterm
infants. Vitamin D is therefore unlikely to play any
important role in the pathogenesis of phototherapy-
induced hypocalcemia [12]. Zecca et al. [12] also
found that vitamin (25(OH)D3) is ineffective in the
prevention of hypocalcemia induced by phototherapy
in newborns.
Suggestions to possibly prevent development of
hypocalcemia in phototherapy-treated newborn
include either giving them oral calcium as prophylaxis
or covering their heads and occipital area using a
special hat during phototherapy, so that light effect
from phototherapy on newborns pineal gland and
consequently melatonin decreases and hypocalcemia
can be prevented [7].
No researchers demonstrated symptomatic
hypocalcemia in infants treated with phototherapy.
Conclusion
Hypocalcemia is a complication of phototherapy.
However, the clinical relevance of this finding needs
further study.
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430 Menoufia Medical Journal
Acknowledgements
Conflicts of interest
There are no conflicts of interest.
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