Un risque un peu accru d’épilepsie après une photothérapie néonatale (Dr Jean-Marc Retbi, Journal International de Médecine)
La photothérapie est souvent utilisée chez les nouveau-nés à des taux de bilirubine inférieurs aux valeurs-seuils recommandées (courbes de l’American Academy of Pediatrics), dans le but d’éviter des réadmissions pour ictère après la sortie de maternité. Cette pratique suscite des inquiétudes parce que l’exposition à la lumière bleue pourrait favoriser la survenue de cancers, d’autisme, de diabète sucré de type 1 et d’épilepsie dans l’enfance.
L’étude LIGHT (Light Impact of Getting Hyperbilirubinemia or photoTherapy) a évalué les risques de ces pathologies après photothérapie néonatale dans une cohorte de 500 000 enfants nés à ≥ 35 sem., de 1995 à 2011, dans le Nord de la Californie. C’est une étude rétrospective dont les données sont tirées de bases administratives et des dossiers médicaux informatisés. Ses trois premiers volets ont établi que les cancers, l’autisme et le diabète de type 1 n’étaient pas liés à la photothérapie. Son 4e volet recherche un lien entre les convulsions/l’épilepsie, caractérisées par au moins une consultation pour convulsions et au moins une prescription d’un antiépileptique, et la photothérapie.
Après exclusion des enfants dont le taux de bilirubine a dépassé la valeur-seuil de l’exsanguino-transfusion et de ceux qui ont convulsé avant 2 mois, 7,6 % des enfants restants (37 683/496 632) ont reçu une photothérapie. Le suivi a duré en moyenne 8,1 ans par enfant.
Les convulsions/l’épilepsie ont eu une incidence de 1,24 cas pour 1 000 personne-années après exposition à une photothérapie versus 0,76 cas pour 1 000 personne-années sans exposition, soit un ratio des taux d’incidence bruts de 1,63 (Intervalle de Confiance de 95 % : 1,44-1,85 ; p < 0,0001). L’écart entre les incidences cumulatives des convulsions/épilepsie après photothérapie et sans photothérapie se creuse avec les années (courbes de Kaplan-Meir des incidences cumulatives).
Après ajustement par diverses covariables, dont les bilirubinémies, le risque de convulsions/épilepsie est un peu accru par la photothérapie chez l’ensemble des enfants (Hazard Ratio ajusté [HRa] = 1,22 ; p < 0,01) et chez les garçons (HRa = 1,33 ; p <0,005), mais pas chez les filles, l’interaction avec le sexe n’étant pas significative (p = 0,17).
Le risque absolu de convulsions/épilepsie à 10 ans est de 1,26 % chez l’ensemble des enfants exposés à une photothérapie vs 1,03 % chez les enfants non exposés (p < 0,01) et de 1,44 % chez les garçons exposés vs 1,08 % chez les garçons non exposés (p <0,005), alors qu’il ne diffère pas entre les filles exposées et non exposées.
Confirmation d’une augmentation du risque d’environ 20 %
L’étude confirme une étude danoise plus ancienne : le risque de convulsions/épilepsie est un peu augmenté – d’environ 20 % – chez les enfants, surtout les garçons, exposés à une photothérapie néonatale. Elle permet d’incriminer la photothérapie elle-même et pas les taux de bilirubine. Il aurait été utile de connaître l’intensité et la durée de la photothérapie.
Ces résultats impliquent d’éviter d’utiliser la photothérapie à des taux inférieurs aux valeurs-seuils recommandées. Allant plus loin, le Northern California Neonatal Consortium propose d’augmenter de 0 à 51 μmol/l les valeurs-seuils de bilirubine pour la photothérapie (2). D’après JA Taylor « même une petite élévation des seuils de la photothérapie peut faire diminuer ses risques d’une façon substantielle, et réduire à la fois les coûts des soins de santé et le risque de conséquences néfastes sans augmenter le risque d’ictère nucléaire » (3).
RÉFÉRENCES
- Newman TB et coll. : Chilhood seizures after phototherapy. Pediatrics 2018 ; 142(4) : e20180648
2. www.phototherapyguidelines.com/NeoHyperbilirubinemiaGuidelineFINAL2018-0209.docx
3. Taylor JA. Phototherapy and seizures : should we change practice ? Pediatrics 2018 ; 142(4) : e20182241
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References:
JBH News