Why we are still doing so many exchange blood transfusion for neonatal jaundice in Nigeria

Treatment of neonatal jaundice with filtered sunlight in Nigerian neonates: study protocol of a non-inferiority, randomized controlled trial

Background

Severe neonatal jaundice and its progression to kernicterus is a leading cause of death and disability among newborns in poorly-resourced countries, particularly in sub-Saharan Africa. The standard treatment for jaundice using conventional phototherapy (CPT) with electric artificial blue light sources is often hampered by the lack of (functional) CPT devices due either to financial constraints or erratic electrical power. In an attempt to make phototherapy (PT) more readily available for the treatment of pathologic jaundice in underserved tropical regions, we set out to test the hypothesis that filtered sunlight phototherapy (FS-PT), in which potentially harmful ultraviolet and infrared rays are appropriately screened, will be as efficacious as CPT.

Methods/design

This prospective, non-blinded randomized controlled non-inferiority trial seeks to enroll infants with elevated total serum/plasma bilirubin (TSB, defined as 3 mg/dl below the level recommended by the American Academy of Pediatrics for high-risk infants requiring PT) who will be randomly and equally assigned to receive FS-PT or CPT for a total of 616 days at an inner-city maternity hospital in Lagos, Nigeria. Two FS-PT canopies with pre-tested films will be used. One canopy with a film that transmits roughly 33% blue light (wavelength range: 400 to 520 nm) will be used during sunny periods of a day. Another canopy with a film that transmits about 79% blue light will be used during overcast periods of the day. The infants will be moved from one canopy to the other as needed during the day with the goal of keeping the blue light irradiance level above 8 μW/cm²/nm.

Primary outcome: FS-PT will be as efficacious as CPT in reducing the rate of rise in bilirubin levels. Secondary outcome: The number of infants requiring exchange transfusion under FS-PT will not be more than those under CPT.

Conclusion

This novel study offers the prospect of an effective treatment for infants at risk of severe neonatal jaundice and avoidable exchange transfusion in poorly-resourced settings without access to (reliable) CPT in the tropics.

Trial registration

ClinicalTrials.gov Identifier: NCT01434810

Evaluation of window-tinting films for sunlight phototherapy

We evaluated nine semi-transparent plastic window-tinting films for their ability to block ultraviolet A (UVA) and infrared (IR) radiation and transmit therapeutic blue light (400-520 nm) for treating jaundiced newborns. For indoor testing, three light sources (TL/52 special blue fluorescent, Black Light UVA and IR heat lamps) were positioned above each film and measured successively using a thermocouple thermometer, UVA radiometer and blue light irradiance meter, placed below each film. For outdoor testing, the same setup was used with the sun at zenith and a cloudless sky. Compared with unfiltered radiation, blue light transmission through films ranged from 24 to 83%, UVA transmission was 0.1-7.1% and reductions in IR heat were 6-12°C and 5-10°C for heat lamp and sun, respectively. The data suggest that most of the relatively low-cost window-tinting films tested can effectively reduce sunlight UV and IR and offer a range of significant attenuations of therapeutic blue light.

Outcome of exchange blood transfusions done for neonatal jaundice in abakaliki, South eastern Nigeria

Background:

Neonatal jaundice (NNJ) is a major cause of morbidity and mortality among neonates in Nigeria and exchange blood transfusion (EBT) is a common modality of its treatment in Ebonyi State University Teaching Hospital (EBSUTH), Abakaliki. This communication aims to audit this service.

Materials and Methods:

A 3-year retrospective review of the case files of all neonates that had EBT for NNJ at the new born special care unit of EBSUTH.

Result:

Two hundred and thirty seven (17.25%) out of 1374 neonatal admissions had NNJ. EBT was performed for 40 (16.9%) of them. The commonest indications for EBT were low birth weight/prematurity, ABO blood group incompatibility, sepsis and glucose 6 phosphate deficiencies. The mean serum bilirubin at which EBT was done was 28.3 mg/dl. The EBT was uneventful in 36 cases while in four (10%) cases there were reported adverse events. Seven neonates (17.5%) died after the procedure and documented causes of death include bilirubin encephalopathy, respiratory failure, and septic shock and disseminated intravascular coagulopathy.

Conclusion:

There is high rate of EBT use in the management of severe neonatal hyperbilirubinemia with significant morbidity and mortality in this study site. There is need to review the contribution of factors such as late presentation in the hospital to this and proffer solutions to it.

Phototherapy device effectiveness in Nigeria: irradiance assessment and potential for improvement

This study investigated the effectiveness of simple-to-implement adjustments of phototherapy devices on irradiance levels in a cross-section of Nigerian hospitals. A total of 76 phototherapy devices were evaluated in 16 hospitals while adjustments were implemented for a subset of 25 devices for which consent was obtained. The mean irradiance level was 7.6 ± 5.9 µW/cm(2)/nm for all devices prior to adjustments. The average irradiance level improved from 9.0 µW/cm(2)/nm to 27.3 µW/cm(2)/nm for the adjusted group (n = 25) compared with 6.8 ± 5.4 µW/cm(2)/nm for the unadjusted group (n = 51). Simple, inexpensive adjustments to phototherapy devices with sub-optimal irradiance levels can significantly improve their effectiveness to acceptable international standards and should be widely promoted in resource-constrained settings.

Paediatricians' perspectives on global health priorities for newborn care in a developing country: a national survey from Nigeria

BACKGROUND

An understanding of the perception of paediatricians as key stakeholders in child healthcare delivery and the degree of congruence with current investment priorities is crucial in accelerating progress towards the attainment of global targets for child survival and overall health in developing countries. This study therefore elicited the views of paediatricians on current global priorities for newborn health in Nigeria as possible guide for policy makers.

METHODS

Paediatric consultants and residents in the country were surveyed nationally between February and March 2011 using a questionnaire requiring the ranking of nine prominent and other neonatal conditions based separately on hospital admissions, mortality, morbidity and disability as well as based on all health indices in order of importance or disease burden. Responses were analysed with Friedman test and differences between subgroups of respondents with Mann-Whitney U test.

RESULTS

Valid responses were received from 152 (65.8%) of 231 eligible physicians. Preterm birth/low birthweight ranked highest by all measures except for birth asphyxia which ranked highest for disability. Neonatal jaundice ranked next to sepsis by all measures except for disability and above tetanus except mortality. Preterm birth/low birthweight, birth asphyxia, sepsis, jaundice and meningitis ranked highest by composite measures while jaundice had comparable rating with sepsis. Birth trauma was most frequently cited under other unspecified conditions. There were no significant differences in ranking between consultants and residents except for birth asphyxia in relation to hospital admissions and morbidity as well as sepsis and tetanus in relation to mortality.

CONCLUSIONS

Current global priorities for neonatal survival in Nigeria largely accord with paediatricians' views except for neonatal jaundice which is commonly subsumed under "other" or "miscellaneous" neonatal conditions. While the importance of these priority conditions extends beyond mortality thus suggesting the need for a broader conceptualisation of newborn health to reflect the current realities, paediatricians should be actively engaged in advancing the attainment of global priorities for child survival and health in this population.

Irradiance readings of phototherapy equipment: Nigeria

Phototherapy devices (n = 63) at twelve nurseries in Nigeria were evaluated. Irradiance was measured using the BiliBlanket Meter II. Irradiance readings ranged from 0.5 to 18.4 μW/cm(2)/nm; phototherapy units varied widely, including locally made units, reconditioned machines, and modern equipment. Imported "intact" machines with all blue bulbs had higher irradiance readings than locally made devices using primarily daylight bulbs (2.5-18.4 μW/cm(2)/nm vs 0.5-4.2 μW/cm(2)/nm). The distance between infant and phototherapy units ranged from 45 to 60 cm, far exceeding the recommended distance of about 10 cm. Only 6% of the machines provided irradiance of >10 μW/cm(2)/nm. None delivered intensive phototherapy (irradiance ≥ 30 μW/cm(2)/nm). Phototherapy devices in developing countries should be assessed for irradiance, and the infant be placed at a distance of about 10 cm from the device. Phototherapy devices with adequate irradiance would reduce the need for exchange blood transfusion and the burden of acute bilirubin encephalopathy in developing countries.

Neonatal screening for glucose-6-phosphate dehydrogenase deficiency: biochemical versus genetic technologies

Glucose-6-phosphate dehydrogenase (G-6-PD) deficiency, a commonly occurring genetic condition, is associated in neonates with severe hemolytic episodes, extreme hyperbilirubinemia, and bilirubin encephalopathy. Neonatal screening programs for the condition should increase parental and caretaker awareness, thereby facilitating early access to treatment with resultant diminished mortality and morbidity. However, screening for G-6-PD deficiency is not widely performed. Although G-6-PD-deficient males may be accurately identified, females are more difficult to categorize because many in this group may be heterozygotes with phenotype overlap between normal homozygotes, heterozygotes, and deficient homozygotes. Screening methodologies include biochemical qualitative assays, quantitative enzymatic activity measurements and DNA-based polymerase chain reaction molecular screening. The appropriateness of any of these technologies for any particular population group or geographic area must be assessed before setting up a screening program. The pros and cons of each method, including ease of testing, cost, need for sophisticated laboratory equipment and degree of personnel training, as well as the ability to identify females, are discussed.

A global need for affordable neonatal jaundice technologies

Globally, health care providers worldwide recognize that severe neonatal jaundice is a "silent" cause of significant neonatal morbidity and mortality. Untreated neonatal jaundice can lead to death in the neonatal period and to kernicterus, a major cause of neurologic disability (choreo-athetoid cerebral palsy, deafness, language difficulty) in children who survive this largely preventable neonatal tragedy. Appropriate technologies are urgently needed. These include tools to promote and enhance visual assessment of the degree of jaundice, such as simpler transcutaneous bilirubin measurements and readily available serum bilirubin measurements that could be incorporated into routine treatment and follow-up. Widespread screening for glucose-6-phoshate dehydrogenase deficiency is needed because this is often a major cause of neonatal jaundice and kernicterus worldwide. Recognition and treatment of Rh hemolytic disease, another known preventable cause of kernicterus, is critical. In addition, effective phototherapy is crucial if we are to make kernicterus a "never-event." Finally it is essential that we conduct appropriate population-based studies to accurately elucidate the magnitude of the problem. However, knowledge alone is not sufficient. If we are to implement these and other programs and technologies to relegate severe neonatal jaundice and its sequelae to the history books, screening and interventions must be low cost and technologically appropriate for low and middle income nations.

The need to implement effective phototherapy in resource-constrained settings

Phototherapy is the treatment of choice to reduce the severity of neonatal unconjugated hyperbilirubinemia regardless of its etiology. Its implementation requires a technical framework that conforms to existing evidence-based guidelines that promote its safer and effective use worldwide. Optimal use of phototherapy has been defined by specific ranges of total serum bilirubin thresholds configured to an infant's postnatal age (in hours) and potential risk for bilirubin neurotoxicity. Effective phototherapy implies its use at specific blue light wavelengths (peak emission, 450 ± 20 nm) and emission spectrum (range, 400-520 nm), preferably in a narrow bandwidth that is delivered at an irradiance of ≥30 μW/cm(2)/nm to up to 80% of an infant's body surface area. However, this is often not feasible in clinical settings with limited or constrained resources. To identify and bridge implementation barriers, we propose minimum criteria for device performance for safe and practical use of phototherapy as a prophylactic intervention to prevent severe hyperbilirubinemia.

Predictors of acute bilirubin encephalopathy among Nigerian term babies with moderate-to-severe hyperbilirubinaemia

OBJECTIVE

To determine predictors of acute bilirubin encephalopathy (ABE) among term infants presenting with moderate-to-severe hyperbilirubinaemia.

METHODS

Babies with total serum bilirubin >15 mg/dl at the point of admission were studied in a Nigerian tertiary health facility using bivariate and multivariate analysis.

RESULTS

Out of 152 babies, 75 (49.3%) had ABE: 73 had ABE at presentation while two developed ABE after admission. Bivariate analysis showed that body weight <2.5 kg, outside delivery, low maternal education, low socio-economic status, severe anaemia, glucose-6-phosphate dehydrogenase deficiency and metabolic acidosis were significantly associated with ABE. Multivariate analysis also showed that only outside delivery, weight <2.5 kg, presence of severe anaemia and acidosis were the predictors of ABE in this cohort of term babies.

CONCLUSION

The identified predictors of ABE are modifiable and can be used to draw up screening tools for term babies at risk of ABE especially in the developing world.

Severe neonatal hyperbilirubinemia and kernicterus: are these still problems in the third millennium?

Despite efforts to eliminate permanent and irreversible brain damage due to bilirubin encephalopathy and kernicterus, these conditions continue to accompany us into the third millennium. This phenomenon occurs not only in developing countries with emerging medical systems, but in Westernized countries as well. Comprehensive guidelines to detect newborns with jaundice and treat those in whom hyperbilirubinemia has already developed have been formulated in several countries, but have not been successful in completely eliminating the problem. In this appraisal of the situation we review selected aspects of bilirubin encephalopathy and/or kernicterus. We highlight recent reports of severe hyperbilirubinemia and kernicterus, discuss some of the factors responsible for the continuing appearance of these conditions, and briefly review what can be done to decrease bilirubin-related morbidity and mortality to the minimum.

Auditory neuropathy spectrum disorder in late preterm and term infants with severe jaundice

OBJECTIVE

To evaluate if severe jaundice is associated with acute auditory neuropathy spectrum disorder in otherwise healthy late preterm and term neonates.

METHODS

In a prospective observational study, all neonates who were admitted with severe jaundice at which exchange transfusion may be indicated as per American Academy of Pediatrics guidelines had comprehensive auditory evaluation performed before discharge to home. Neonates with infection, perinatal asphyxia, chromosomal disorders, cranio-facial malformations, or family history of childhood hearing loss were excluded. Comprehensive auditory evaluations (tympanometry, oto-acoustic emission tests, and auditory brainstem evoked responses) were performed by an audiologist unaware of the severity of jaundice. Total serum bilirubin and serum albumin were measured at the institutional chemistry laboratory using the Diazo and Bromocresol purple method, respectively.

RESULTS

A total of 13 neonates with total serum bilirubin concentration at which exchange transfusion is indicated as per American Academy of Pediatrics were admitted to the Neonatal Intensive Care Unit over 3 month period. Six out of 13 neonates (46%) had audiological findings of acute auditory neuropathy spectrum disorder. There was no significant difference in gestational age, birth weight, hemolysis, serum albumin concentration, peak total serum bilirubin concentrations, and peak bilirubin:albumin molar ratio between six neonates who developed acute auditory neuropathy and seven neonates who had normal audiological findings. Only two out of six infants with auditory neuropathy spectrum disorder had clinical signs and symptoms of acute bilirubin encephalopathy.

CONCLUSIONS

Our findings strongly suggest that auditory neuropathy spectrum disorder is a common manifestation of acute bilirubin-induced neurotoxicity in late preterm and term infants with severe jaundice. Our findings also suggest that comprehensive auditory evaluations should be routinely performed in neonates with severe jaundice irrespective of the presence of clinical findings of acute bilirubin encephalopathy.

Glucose-6-phosphate dehydrogenase deficiency and severe neonatal hyperbilirubinemia: a complexity of interactions between genes and environment

Glucose-6-phosphate dehydrogenase deficiency is a commonly occurring genetic condition, likely to be encountered today in virtually any corner of the globe. Sudden episodes of hemolysis associated with the condition may result in exponential increases in serum total bilirubin concentrations to levels at which bilirubin-induced neurologic damage may occur. The hyperbilirubinemia is the result of complex interactions between genes and environment. Neonatal screening programs coupled with parental and medical caretaker education may be successful in limiting the severity of disease.

Health-care-seeking behaviour for childhood illnesses in a resource-poor setting

AIM

To determine health-care-seeking behaviour for childhood illnesses in a resource-poor setting.

METHOD

Cross-sectional survey was conducted in the children emergency room in a Nigerian tertiary hospital. Socio-demographic data and details of the place and type of care given to ill children before presentation in the tertiary hospital were obtained.

RESULTS

A total of 168 mother-child pairs were studied. The leading illnesses were characterised by fever (35.1%), cough (26.2%) and stooling (19.1%). Initial care was sought within homes (57.1%) and after 24 h of onset (61.9%). A significantly higher proportion of the mothers who sought care within 24 h did so within the homes (P < 0.001). Only 38.1% of the mothers felt that the illnesses were severe. Although 66.7% lived close to orthodox health facilities, only 50.6% utilized such orthodox health facilities. Care was mostly sought outside the homes from drug vendors (55.5%) and private clinics (25.0%). Overall, 72.2% of the mothers administered various drugs to their children before presentation. Home care mainly involved the use of drugs (52.1%) and herbal preparations (15.6%). Care was sought within 24 h of onset for children with fever compared with those with cough (P < 0.001) and stooling (P < 0.001). The leading reasons for not utilising orthodox health services at the onset of illnesses included non-recognition of the severe nature of the illness and poor finances.

CONCLUSION

Care-seeking for childhood illnesses was often delayed beyond 24 h, and most mothers sought care within homes. Health education is required to improve timely seeking of appropriate health care for childhood illnesses.

Preference for private hospital-based maternity services in inner-city Lagos, Nigeria: An observational study

OBJECTIVES

To determine factors associated with maternal preference for delivery in private hospitals in an urban community in sub-Saharan Africa.

METHODS

A cross-sectional study of socio-demographic and obstetric characteristics of mothers and their newborns attending Bacille Calmette-Guérin (BCG) immunization clinics in inner-city Lagos, Nigeria. Factors associated with delivery in private hospitals were determined using multivariable logistic regression analyses.

RESULTS

Of the 3296 mothers enlisted for this study 1659 (50.3%) delivered in private hospitals and 1637 (49.7%) in public hospitals. Government hospitals had a higher proportion of doctors at delivery. Use of private obstetric services was significantly associated with ethnicity, religion, social class and obstetric history. Infants delivered at private hospitals were significantly more likely to be undernourished and have severe hyperbilirubinemia but less likely to be preterm and at no greater risk of hearing loss.

CONCLUSIONS

Current global strategies to expand facility-based deliveries in order to reduce maternal and child mortality rates need to be complemented by improved regulatory/supervisory framework at country levels to better serve mothers and their offspring in urban areas who may opt for private hospitals usually lacking adequate obstetric and pediatric facilities against the backdrop of the rapid urban transition in Africa.