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

Transcutaneous bilirubinometry for detecting jaundice in term or late preterm neonates

BACKGROUND

The American Academy of Pediatrics and the Canadian Paediatric Society both advise that all newborns should undergo bilirubin screening before leaving the hospital, and this has become the standard practice in both countries. However, the US Preventive Task Force has found no strong evidence to suggest that this practice of universal screening for bilirubin reduces the occurrence of significant outcomes such as bilirubin-induced neurologic dysfunction or kernicterus.

OBJECTIVES

To evaluate the effectiveness of transcutaneous screening compared to visual inspection for hyperbilirubinemia to prevent the readmission of newborns (infants greater than 35 weeks' gestation) for phototherapy.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, ICTRP, and ISRCTN in June 2023. We also searched conference proceedings, and the reference lists of included studies.

SELECTION CRITERIA

We included randomized controlled trials (RCTs), quasi-randomized, cluster-randomized, or prospective cohort studies with control arm that evaluated the use of transcutaneous bilirubin (TcB) screening for hyperbilirubinemia in newborns before hospital discharge.

DATA COLLECTION AND ANALYSIS

We used standard methodologic procedures expected by Cochrane. We evaluated treatment effects using a fixed-effect model with risk ratio (RR) and 95% confidence intervals (CI) for categorical data and mean, standard deviation (SD), and mean difference (MD) for continuous data. We used the GRADE approach to evaluate the certainty of evidence.

MAIN RESULTS

We identified one RCT that met our inclusion criteria. The study included 1858 African newborns at 35 weeks' gestation or greater who were receiving routine care at a well-baby nursery, and were randomly recruited prior to discharge to undergo TcB screening. The study had good methodologic quality. TcB screening versus visual assessment of hyperbilirubinemia in newborns: - probably reduces readmission to the hospital for hyperbilirubinemia (RR 0.25, 95% CI 0.14 to 0.46; P < 0.0001; moderate-certainty evidence); - may have little or no effect on the rate of exchange transfusion (RR 0.20, 95% CI 0.01 to 14.16; low-certainty evidence); - probably increases the number of newborns who require phototherapy prior to discharge (RR 2.67, 95% CI 1.56 to 4.55; moderate-certainty evidence). - may have little or no effect on the rate of acute bilirubin encephalopathy (RR 0.33, 95% CI 0.01 to 8.18; low-certainty evidence). The study did not evaluate or report cost of care.

AUTHORS' CONCLUSIONS

Moderate-certainty evidence suggests that TcB screening probably reduces hospital readmission for hyperbilirubinemia compared to visual inspection. Low-certainty evidence also suggests that TcB screening may have little or no effect on the rate of exchange transfusion compared to visual inspection. However, moderate-certainty evidence suggests that TcB screening probably increases the number of newborns that require phototherapy before discharge compared to visual inspection. Low-certainty evidence suggests that TcB screening may have little or no effect on the rate of acute bilirubin encephalopathy compared to visual inspection. Given that we have only identified one RCT, further studies are necessary to determine whether TcB screening can help to reduce readmission and complications related to neonatal hyperbilirubinemia. In settings with limited newborn follow-up after hospital discharge, identifying newborns at risk of severe hyperbilirubinemia before hospital discharge will be important to plan targeted follow-up of these infants.

Community health worker-led household screening and management of neonatal hyperbilirubinemia in rural Bangladesh: a cluster randomized control trial protocol

BACKGROUND

Extreme hyperbilirubinemia leading to neurologic disability and death is disproportionately higher in low- and middle-income countries (LMIC) such as Bangladesh, and is largely preventable through timely treatment. In LMICs, an estimated half of all newborns are born at home and few receive screening or treatment for hyperbilirubinemia, leading to 6 million newborns per year who need phototherapy treatment for hyperbilirubinemia but are untreated. Household screening and treatment for neonatal hyperbilirubinemia with phototherapy administered by a trained community health worker (CHW) may increase indicated treatment for neonatal hyperbilirubinemia in comparison to the existing care system in Bangladesh.

METHODS

530 Bangladeshi women in their second or third trimester of pregnancy from the rural community of Sakhipur, Bangladesh will be recruited for a cluster randomized trial and randomized to the intervention arm - home screening and treatment for neonatal hyperbilirubinemia - or the comparison arm to receive usual care. In the intervention arm, CHWs will provide mothers with two prenatal visits, visit newborns by 2 days of age and then daily for 3 days to measure transcutaneous bilirubin (TcB) and monitor for clinical danger signs. Newborns without danger signs but with a TcB above the treatment threshold, but >15 mg/dL will be treated with light-emitting diode (LED) phototherapy at home. Newborns with danger signs or TcB ≥15 mg/dL will be referred to a hospital for treatment. Treatment rates for neonatal hyperbilirubinemia in each arm will be compared.

CONCLUSION

This study will evaluate the effectiveness of CHW-led home phototherapy to increase neonatal hyperbilirubinemia treatment rates in rural Bangladesh. LMICs are expanding access to postnatal care by using CHWs, and our work will give CHWs a curative treatment option for neonatal hyperbilirubinemia. Similar projects in other LMICs can be pursued to dramatically extend healthcare access to vulnerable newborns with hyperbilirubinemia.

Community health worker-led household screening and management of neonatal hyperbilirubinemia in rural Bangladesh: a cluster randomized control trial protocol

Background

Extreme hyperbilirubinemia leading to neurologic disability and death is disproportionately higher in low- and middle-income countries (LMIC) such as Bangladesh, and is largely preventable through timely treatment. In LMICs, an estimated half of all newborns are born at home and few receive screening or treatment for hyperbilirubinemia, leading to 6 million newborns per year who need phototherapy treatment for hyperbilirubinemia but are untreated. Household screening and treatment for neonatal hyperbilirubinemia with phototherapy administered by a trained community health worker (CHW) may increase indicated treatment for neonatal hyperbilirubinemia in comparison to the existing care system in Bangladesh.

Methods

530 Bangladeshi women in their second or third trimester of pregnancy from the rural community of Sakhipur, Bangladesh will be recruited for a cluster randomized trial and randomized to the intervention arm - home screening and treatment for neonatal hyperbilirubinemia - or the comparison arm to receive usual care. In the intervention arm, CHWs will provide mothers with two prenatal visits, visit newborns by 2 days of age and then daily for 3 days to measure transcutaneous bilirubin (TcB) and monitor for clinical danger signs. Newborns without danger signs but with a TcB above the treatment threshold, but >15 mg/dL will be treated with light-emitting diode (LED) phototherapy at home. Newborns with danger signs or TcB ≥15 mg/dL will be referred to a hospital for treatment. Treatment rates for neonatal hyperbilirubinemia in each arm will be compared.

Conclusion

This study will evaluate the effectiveness of CHW-led home phototherapy to increase neonatal hyperbilirubinemia treatment rates in rural Bangladesh. LMICs are expanding access to postnatal care by using CHWs, and our work will give CHWs a curative treatment option for neonatal hyperbilirubinemia. Similar projects in other LMICs can be pursued to dramatically extend healthcare access to vulnerable newborns with hyperbilirubinemia.

Transcutaneous bilirubinometry versus total serum bilirubin measurement for newborns

BACKGROUND

Jaundice is a very common condition in newborns, affecting up to 60% of term newborns and 80% of preterm newborns in the first week of life. Jaundice is caused by increased bilirubin in the blood from the breakdown of red blood cells. The gold standard for measuring bilirubin levels is obtaining a blood sample and processing it in a laboratory. However, noninvasive transcutaneous bilirubin (TcB) measurement devices are widely available and used in many settings to estimate total serum bilirubin (TSB) levels.

OBJECTIVES

To determine the diagnostic accuracy of transcutaneous bilirubin measurement for detecting hyperbilirubinaemia in newborns.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and trial registries up to 18 August 2022. We also checked the reference lists of all included studies and relevant systematic reviews for other potentially eligible studies.

SELECTION CRITERIA

We included cross-sectional and prospective cohort studies that evaluated the accuracy of any TcB device compared to TSB measurement in term or preterm newborn infants (0 to 28 days postnatal age). All included studies provided sufficient data and information to create a 2 × 2 table for the calculation of measures of diagnostic accuracy, including sensitivities and specificities. We excluded studies that only reported correlation coefficients.

DATA COLLECTION AND ANALYSIS

Two review authors independently applied the eligibility criteria to all citations from the search and extracted data from the included studies using a standard data extraction form. We summarised the available results narratively and, where possible, we combined study data in a meta-analysis.

MAIN RESULTS

We included 23 studies, involving 5058 participants. All studies had low risk of bias as measured by the QUADAS 2 tool. The studies were conducted in different countries and settings, included newborns of different gestational and postnatal ages, compared various TcB devices (including the JM 101, JM 102, JM 103, BiliChek, Bilitest and JH20-1C) and used different cutoff values for a positive result. In most studies, the TcB measurement was taken from the forehead, sternum, or both. The sensitivity of various TcB cutoff values to detect significant hyperbilirubinaemia ranged from 74% to 100%, and specificity ranged from 18% to 89%.

AUTHORS' CONCLUSIONS

The high sensitivity of TcB to detect hyperbilirubinaemia suggests that TcB devices are reliable screening tests for ruling out hyperbilirubinaemia in newborn infants. Positive test results would require confirmation through serum bilirubin measurement.

Understanding the risk factors for adverse events during exchange transfusion in neonatal hyperbilirubinemia using explainable artificial intelligence

OBJECTIVE

To understand the risk factors associated with adverse events during exchange transfusion (ET) in severe neonatal hyperbilirubinemia.

STUDY DESIGN

We conducted a retrospective study of infants with hyperbilirubinemia who underwent ET within 30 days of birth from 2015 to 2020 in a children's hospital. Both traditional statistical analysis and state-of-the-art explainable artificial intelligence (XAI) were used to identify the risk factors.

RESULTS

A total of 188 ET cases were included; 7 major adverse events, including hyperglycemia (86.2%), top-up transfusion after ET (50.5%), hypocalcemia (42.6%), hyponatremia (42.6%), thrombocytopenia (38.3%), metabolic acidosis (25.5%), and hypokalemia (25.5%), and their risk factors were identified. Some novel and interesting findings were identified by XAI.

CONCLUSIONS

XAI not only achieved better performance in predicting adverse events during ET but also helped clinicians to more deeply understand nonlinear relationships and generate actionable knowledge for practice.

Challenges and recommendations to improve implementation of phototherapy among neonates in Malawian hospitals

Background

Severe neonatal jaundice can result in long term morbidities and mortality when left untreated. Phototherapy is the main-stay intervention for treating moderate jaundice and for prevention of the development of severe jaundice. However, in resource-limited health care settings, phototherapy has been inconsistently used. The objective of this study is to evaluate barriers and facilitators for phototherapy to treat neonatal jaundice at Malawian hospitals.

Methods

We conducted a convergent mixed-method study comprised of a facility assessment and qualitative interviews with healthcare workers and caregivers in southern Malawi. The facility assessment was conducted at three secondary-level hospitals in rural districts. In-depth interviews following a semi-structured topic guide were conducted at a district hospital and a tertiary-level hospital. Interviews were thematically analysed in NVivo 12 software (QSR International, Melbourne, Australia).

Results

The facility assessment found critical gaps in initiating and monitoring phototherapy in all facilities. Based on a total of 31 interviews, participants identified key challenges in diagnosing neonatal jaundice, counselling caregivers, and availability of infrastructure. Participants emphasized the need for transcutaneous bilirubinometers to guide treatment decisions. Caregivers were sometimes fearful of potential harmful effects of phototherapy, which required adequate explanation to mothers and family members in non-medical language. Task shifting and engaging peer support for caregivers with concerns about phototherapy was recommended.

Conclusion

Implementation of a therapeutic intervention is limited if accurate diagnostic tests are unavailable. The scale up of therapeutic interventions, such as phototherapy for neonatal jaundice, requires careful holistic attention to infrastructural needs, supportive services such as laboratory integration as well as trained human resources.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03430-y.

Pattern of serum bilirubin changes following double volume exchange blood transfusion in neonates at a tertiary health facility in Nigeria

Introduction

exchange blood transfusion (EBT) is a form of massive transfusion useful in rapidly reducing serum bilirubin levels, but serum bilirubin levels frequently rebound within hours of completing the procedure, due to equilibration of extravascular bilirubin as well as on-going hemolysis. The study was carried out to determine the pattern of reduction in serum bilirubin levels following EBT among neonates with severe hyperbilirubinemia, as well as the factors contributing to this pattern, so as to establish evidence-based expectations following EBT.

Methods

a retrospective descriptive study covering a two-year period in a Nigerian tertiary hospital. Details of the EBT procedures, including serial serum bilirubin levels, were obtained from the hospital records of all newborn babies who had double volume EBT done for severe hyperbilirubinaemia during the study period. Data was analyzed using the statistical software SPSS version 21.0.

Results

the mean total serum bilirubin (TSB) before EBT in the 36 babies was 17.9 ± 6.3 mg/dl. The mean percentage decrease in TSB immediately following EBT was 44.3 ± 10.2%. Six hours after EBT, TSB levels had increased from the immediate post-EBT values by an average of 57.5 ± 32.2%. Twenty-four hours after the procedure, TSB values in most (87.1%) cases were still higher than the immediate post-EBT values, but lower than the pre-EBT values. Post-EBT anemia was recorded among 33.3% of the babies.

Conclusion

EBT is effective in rapidly reducing serum bilirubin levels and preventing acute bilirubin encephalopathy in neonates with severe hyperbilirubinemia, despite the rebound increase that occurs in TSB values after the procedure.

Neonatal Hyperbilirubinemia treatment by Locally Made Low-Cost Phototherapy Units

Background

Hyperbilirubinemia is a very common finding in neonates and may occasionally cause severe morbidity and even mortality. Severe hyperbilirubinemia is typically treated, either with phototherapy or exchange transfusions. This study assessed the effectiveness of a locally manufactured phototherapy device for reducing serum bilirubin in neonates with severe hyperbilirubinemia.

Methods

Retrospective chart review was carried out to assess the outcome of 32 infants who were treated for neonatal hyperbilirubinemia at Jimma Medical Center (JMC) from May, 2017 to April, 2018. RESULTS: Out of 75 charts reviewed, only 32 had subsequent bilirubin level determination, 18(56.3%) of them were males. The age at which jaundice was noticed and confirmed with plasma bilirubin level was 4 ± 2.7 days (mean±SD). Sepsis was thought to be the cause of hyperbilirubinemia in 13(40.5%) of the cases, while hemolysis from ABO incompatibility or RH incompatibility contributed in 5(15.6%) and 3(9.4) of the infants respectively. The mean (minimum, maximum) level of baseline TSB was 21.4(14, 55) mg/dL. Five infants (15.6%) had exchange transfusions because of extreme hyperbilirubinemia. The duration of phototherapy and decline in TSB were 5.34 ±2.8 days and 2.2±1.5mg/dl/day (mean±SD) respectively. The levels of TSB before and at the end of phototherapy were significantly different (p<0.001).

Conclusion

Acceptable reduction of TSB was achieved by using locally manufactured PT devices. Benefits included better accessibility and lower price and maintenance costs. High mean baseline TSB was observed, and duration of phototherapy is prolonged which could indicate late diagnosis compared to similar studies.

Causes of severe neonatal hyperbilirubinemia: a multicenter study of three regions in China

BACKGROUND

Available evidence suggests that our country bear great burden of severe hyperbilirubinemia. However, the causes have not been explored recently in different regions of China to guide necessary clinical and public health interventions.

METHODS

This was a prospective, observational study conducted from March 1, 2018, to February 28, 2019. Four hospitals in three regions of China participated in the survey. Data from infants with a gestational age ≥ 35 weeks, birth weight ≥ 2000 g, and total serum bilirubin (TSB) level ≥ 17 mg/dL (342 µmol/L) were prospectively collected.

RESULTS

A total of 783 cases were reported. Causes were identified in 259 cases. The major causes were ABO incompatibility (n = 101), glucose-6-phosphate dehydrogenase deficiency (n = 76), and intracranial hemorrhage (n = 70). All infants with glucose-6-phosphate dehydrogenase deficiency were from the central south region. Those from the central south region had much higher peak total bilirubin levels [mean, 404 μmol/L; standard deviation (SD), 75 μmol/L] than those from the other regions (mean, 373 μmol/L; SD, 35 μmol/L) (P < 0.001).

CONCLUSIONS

ABO incompatibility was the leading cause in the east and northwest regions, but cases in the central south region were mainly caused by both ABO incompatibility and glucose-6-phosphate dehydrogenase deficiency, and infants in this region had a much higher peak total bilirubin level. Intracranial hemorrhage may be another common cause. More thorough assessments and rigorous bilirubin follow-up strategies are needed in the central south region.

Societal awareness on neonatal hyperbilirubinemia: A systematic review and meta-analysis

Early recognition of neonatal hyperbilirubinemia is essential for prevention of bilirubin neurotoxicity and its long-term sequelae. High rates of home delivery in low- and middle-income countries (LMICs) as well as early discharge post-delivery (within 24hours) make community surveillance for neonatal hyperbilirubinemia highly important. Here, we performed a literature review to estimate the level of societal awareness of neonatal hyperbilirubinemia. We searched several databases for studies assessing the knowledge and awareness of neonatal hyperbilirubinemia. We retrieved 211 citations from 206 databases with five being in the grey literature. 52 selected articles were further reviewed. Data from these studies were then analyzed using Stata software (Statacorp® LLC Texas USA). We found that the pooled estimate of societal awareness of neonatal hyperbilirubinemia was 67% (95% confidence interval [CI]: 60, 74). There however was a publication bias (Begg test: P ≤ 0.01; Egger P = 0.06). Studies that scored or graded knowledge reported lower estimates [adjusted odds ratio (aOR) = -0.17; 95% CI: -0.32-0.02; P = 0.03]. Hospital location was an important determinant of awareness of complications [aOR = 0.30; 95% CI: 0.30-0.57; P = 0.03]. We therefore concluded that there is a significant need to improve societal awareness of neonatal hyperbilirubinemia.

Estimated disease burden and lost economic productivity due to glucose-6-phosphate dehydrogenase deficiency in Nigerian newborns

Glucose-6-phosphate dehydrogenase (G6PD) deficiency rarely manifests as extreme hyperbilirubinemia [EHB, total serum/plasma bilirubin > 25 mg/dL (428 µmol/L)]. It is a major preventable cause of newborn morbidity and mortality. In resource-constrained communities of Nigeria, experts have observed its significant clinical burden. We accessed a previously published pooled model of G6PD deficiency and determined its prevalence, subsequent risk of EHB, kernicterus, and death to be 26.4% [95% confidence interval (CI): 19.5, 33.2%]; 33.3% (95%CI: 16.6, 50%); and 22.7% (95% CI: 16.5, 28.9%), respectively. The total number of disability-adjusted life years (DALYs) lost to symptomatic G6PD deficiency was 54,251 (95% CI: 6,039, 189,149). Estimated national average economic deficits due to mortality and disability ranged from $309 to $584 million. G6PD deficiency, when symptomatic in Nigerian newborns, is a significant disease burden, placing 1% of annual births at increased risks of neonatal mortality and morbidity, which contribute to significant economic productivity losses.

Knowledge, Observation and Practices Related to Neonatal Jaundice in a Rural Community in Kano, Nigeria

BACKGROUND

Neonatal jaundice (NNJ) is a common condition and when not adequately treated leads to acute bilirubin encephalopathy/kernicterus. This largely preventable condition is an important cause of death and disability in low- and middle-income countries. Education, early detection and effective management are key for prevention and require an understanding of community knowledge and practices to foster appropriate behavior to prevent severe NNJ. Therefore, the aim of this study was to identify knowledge, observation for jaundice (both active and passive) and practices related to NNJ in northern Nigeria.

METHODS

This descriptive, correlational and cross-sectional study enrolled 298 household members with an average age of 29.8 years in Kano, Nigeria. A structured questionnaire regarding knowledge of, potential sequelae and causes and local practices related to NNJ was administered and data were analyzed using descriptive and Chi-square statistics.

RESULTS

Participants reported: 85% NNJ to be a sign of illness; 3% understood that NNJ could cause brain damage; 94% did not actively observe for jaundice in their newborns; 56% did not know what causes NNJ; 88% would seek care if their newborn developed jaundice. Significant relationships between educational levels and what study participants would do if a newborn develops jaundice and between occupation, educational level and knowledge about causes of NNJ were noted, consistent with a difference in active jaundice observation between ethnic groups.

CONCLUSION

A public health approach to NNJ with a strong community education program is a crucial next step in the fight to eliminate severe NNJ.

Neonatal Jaundice: Perception of Pregnant Women Attending Antenatal Clinic at a Tertiary Hospital in Southwest, Nigeria

Background: Severe neonatal jaundice (NNJ) remains a leading cause of preventable brain damage, mental handicap, physical disabilities, and early death among infants. Methods: Using a descriptive cross-sectional study design, information was gathered using a structured, pretested questionnaire from 518 pregnant women who attended the antenatal clinic at a tertiary Hospital in Southwest Nigeria. Results: Most (77%) of the respondents have heard about NNJ prior the survey. Most respondents (69.5%) demonstrated poor knowledge of the causes of NNJ. The majority, 98.4% had good attitude toward treatment of NNJ. Most respondents (72.1%) demonstrated poor knowledge of the correct treatment of NNJ. A quarter of the respondents knew no danger sign of NNJ. Conclusion: There is serious knowledge gap among the respondents about the causes, treatment, dangers signs and complications of NNJ. There is need for increased awareness campaign using every available means of reaching women of reproductive age group to reduce the consequences of this common neonatal problem.

A single-center experience on exchange transfusion therapy in 123 full-term cases of severe neonatal hyperbilirubinemia in Wuhan

OBJECTIVE

To describe the clinical experience in application of exchange transfusion therapy (ETT) in the treatment of severe neonatal hyperbilirubinemia.

METHODS

The clinical data and examination results of severe neonatal hyperbilirubinemia full-term cases treated by ETT were analyzed retrospectively, the etiology and risk factors of severe neonatal hyperbilirubinemia were statistically analyzed, and the statistical characteristics of the children in each etiological group and the incidence of adverse events of ETT were analyzed.

RESULTS

The age of jaundice, peak total bilirubin after phototherapy and ETT in 123 full-term infants were 2.0 (1.0, 3.0) days, 4.0 (2.0, 7.0) days and 4.0 (2.0, 7.0) days, respectively, of which 68 were male and 55 were female. The main pathogeny of severe neonatal hyperbilirubinemia was blood group incompatibility hemolytic disease of newborn (HDN). Age of ETT, total bilirubin after ETT, gender and BAEP results were different between ABE and non-ABE infants. Weight loss can be used as a predictor of hospitalization length. The major adverse events related to ETT were hypocalcemia, hypomagnesemia, hyponatremia and thrombocytopenia.

CONCLUSIONS

ETT can rapidly reduce the level of total bilirubin to prevent ABE and play an important role in the treatment of neonatal hyperbilirubinemia, but the whole process of ETT needs to be closely monitored.

Acute bilirubin encephalopathy and its associated risk factors in a tertiary care hospital, Pakistan

OBJECTIVE

To determine the incidence of acute bilirubin encephalopathy (ABE) and its risk factors in neonates presenting with hyperbilirubinemia in a tertiary care children hospital.

METHODS

This descriptive observational study was conducted from June 2018 to June 2019. A total of 300 infants who were admitted in neonatal ICU with diagnosis of hyperbilirubinemia in The Children's Hospital & The Institute of Child Health, Multan, Pakistan were included in this period. Incidence of ABE was noted. ABE was divided into two categories on the basis of severity of symptoms; mild ABE and moderate to severe ABE. Total serum bilirubin (TSB) in all neonates was measured in all patients in hospital laboratory using colorimetric method. ABO incompatibility and Rh factor incompatibility was also noted for each neonate.

RESULTS

Out of 300 neonates who presented with hyperbilirubinemia, ABE was diagnosed in only 42 (14.0%) neonates (mild ABE in 17 (5.7%) and moderate in 25 (8.3%). Out of 42 neonates of ABE, total serum bilirubin levels were 20-29.9 mg/dL in 24 (40.5%) neonates, and >30 mg/dL in 18 (42.8%) neonates. Pre-term birth was a significant risk factor of ABE; 23.8% in ABE and 10.70% in non-ABE (p-value 0.01). During treatment, 02 (4.76%) neonates expired due to ABE.

CONCLUSION

In present study, ABE was diagnosed in 14.0% neonates who presented with hyperbilirubinemia. We found pre-term delivery as a significant risk factor of ABE.

Molecular Physiology and Pathophysiology of Bilirubin Handling by the Blood, Liver, Intestine, and Brain in the Newborn

Bilirubin is the end product of heme catabolism formed during a process that involves oxidation-reduction reactions and conserves iron body stores. Unconjugated hyperbilirubinemia is common in newborn infants, but rare later in life. The basic physiology of bilirubin metabolism, such as production, transport, and excretion, has been well described. However, in the neonate, numerous variables related to nutrition, ethnicity, and genetic variants at several metabolic steps may be superimposed on the normal physiological hyperbilirubinemia that occurs in the first week of life and results in bilirubin levels that may be toxic to the brain. Bilirubin exists in several isomeric forms that differ in their polarities and is considered a physiologically important antioxidant. Here we review the chemistry of the bilirubin molecule and its metabolism in the body with a particular focus on the processes that impact the newborn infant, and how differences relative to older children and adults contribute to the risk of developing both acute and long-term neurological sequelae in the newborn infant. The final section deals with the interplay between the brain and bilirubin and its entry, clearance, and accumulation. We conclude with a discussion of the current state of knowledge regarding the mechanism(s) of bilirubin neurotoxicity.

Maternal Instruction About Jaundice and the Incidence of Acute Bilirubin Encephalopathy in Nigeria

OBJECTIVE

To evaluate whether teaching mothers about neonatal jaundice will decrease the incidence of acute bilirubin encephalopathy among infants admitted for jaundice.

STUDY DESIGN

This was a multicenter, before-after and cross-sectional study. Baseline incidences of encephalopathy were obtained at 4 collaborating medical centers between January 2014 and May 2015 (Phase 1). Structured jaundice instruction was then offered (May to November 2015; Phase 2) in antenatal clinics and postpartum. Descriptive statistics and logistic regression models compared 3 groups: 843 Phase 1 controls, 338 Phase 2 infants whose mothers received both antenatal and postnatal instruction (group A), and 215 Phase 2 infants whose mothers received no instruction (group B) either because the program was not offered to them or by choice.

RESULTS

Acute bilirubin encephalopathy occurred in 147 of 843 (17%) Phase 1 and 85 of 659 (13%) Phase 2 admissions, which included 63 of 215 (29%) group B and 5 of 338 (1.5%) group A infants. OR for having acute bilirubin encephalopathy, comparing group A and group B infants adjusted for confounding risk factors, was 0.12 (95% CI 0.03-0.60). Delayed care-seeking (defined as an admission total bilirubin ≥18 mg/dL at age ≥48 hours) was the strongest single predictor of acute bilirubin encephalopathy (OR 11.4; 6.6-19.5). Instruction decreased delay from 49% to 17%. Other major risk factors were home births (OR 2.67; 1.69-4.22) and hemolytic disease (hematocrit ≤35% plus bilirubin ≥20 mg/dL) (OR 3.03; 1.77-5.18). The greater rate of acute bilirubin encephalopathy with home vs hospital birth disappeared if mothers received jaundice instruction.

CONCLUSIONS

Providing information about jaundice to mothers was associated with a reduction in the incidence of bilirubin encephalopathy per hospital admission.

Neonatal Jaundice: awareness, perception and preventive practices in expectant mothers

Background

Neonatal jaundice (NNJ) is a preventable cause of neonatal morbidity and mortality. Improving mothers' knowledge will help with early recognition of NNJ, prompt and appropriate intervention. This study highlights the knowledge, attitude and practice regarding neonatal jaundice among expectant mothers attending the antenatal clinics of Korle-Bu Teaching Hospital and Mamprobi Polyclinic in Accra.

Methods

This was a cross-sectional study involving 175 expectant mothers. Interviewer based questionnaire was used to obtain data on knowledge, attitude and practice concerning NNJ. The study was conducted between 1^st and 17^th November 2013 at two antenatal clinics in Accra.

Results

Out of the 175 respondents, 135 (77.1%) had heard about NNJ but only 37 (27.4%) of them heard it from the hospital. Among those who had heard about NNJ, 98 (72.6%) knew at least one symptom of NNJ; 125 (92.6%) did not know the causes of jaundice or had the wrong information and there was no significant association with their level of education (X² =6.757, p=0.15). Only 7(5.2%) knew one or more correct forms of treatment of NNJ; 67(49.6%) knew one or more danger signs and 86(63.5%) knew one or more complications.

Conclusion

Majority of expectant mothers attending antenatal clinics at a Teaching Hospital and a Polyclinic in Accra, Ghana are aware of NNJ but have poor knowledge about the causes, danger signs and treatment of NNJ, irrespective of their level of education or their parity.

Funding

None declared

Evaluation of Rh-Hemolytic Disease in Neonates and Management with Early Intensive Phototherapy in the Neonatal Intensive Care Unit

BACKGROUND OF THE STUDY

In neonates with Rh-hemolytic disease, light emitting diode (LED) phototherapy allows delivery of high spectral irradiance (SI). A linear correlation exists between SI and efficacy of phototherapy with no saturation point. There is scant data on evaluation and early phototherapy using LED units in Rh-hemolytic disease.

OBJECTIVE

This study aimed to describe the hemoglobin (Hb), hematocrit (Hct), total serum bilirubin (TSB), phototherapy parameters and short-term outcomes in neonates with Rh-hemolytic disease.

METHODOLOGY

Maternal parameters for Rh-isoimmunization were recorded and monitoring of fetal anemia by Doppler ultrasound was done. Early intensive phototherapy within 1 h of birth was initiated for cord blood Hb below 13.6 g/dl and/or TSB greater than 2.8 mg/dl.

RESULTS

Fifty Rh positive neonates were enrolled of which 11/50 (22%) received intrauterine transfusions. The maximum TSB remained below 18 mg/dl in 42/50 (84%) of neonates. The mean SI on the trunk was 56.260 ± 8.768 µW/cm2/nm and duration of phototherapy was 7 ± 3.29 days (mean ± SD). There was a positive correlation between strength of indirect antiglobulin test and cord blood Hb: correlation coefficient (r) = 0.295; direct antiglobulin test and duration of phototherapy: r = 0.331. Early packed red blood cell (PRBC) transfusion was required in 8/50 (16%) neonates while 20/50 (40%) required late transfusions.

CONCLUSION

With a mean SI of 56.260 ± 8.768 µW/cm2/nm on the trunk, TSB remained below 18 mg/dl in majority thereby avoiding exchange transfusion. Early or late PRBC transfusion requirement was 1 (1-2) (median ± interquartile range).

Neonatal exchange transfusions at a tertiary care centre in north India: an investigation of historical trends using change-point analysis and statistical process control

Background

The need for exchange transfusion (ET) as a treatment modality for neonatal hyperbilirubinaemia declined in developed countries with the advent of effective phototherapy. The trends of ET from India are unknown. Our objective was to investigate the trends of ET in India.

Methods

Retrospective data (January 2006-December 2016) was collected on total outborn neonatal admissions and ET procedures from a centre in north India. A combination of change-point analysis (CPA) and statistical process control (SPC) was used to investigate the trends of ET.

Results

During the study period, a total of 39 217 outborn neonates were admitted and 1575 (4%) underwent 1816 ET procedures. The CPA unravels four critical change points (October 2009, May 2011, September 2011 and November 2014) in ET rates. An SPC chart showed a decline in mean ET rate from 89.3 (upper control limit [UCL] 176.9, lower control limit [LCL] 1.7)/1000 neonatal admissions at the start of the study to 7.7 (UCL 34.6, LCL 0)/1000 at the end of the study. The greatest decline in ET rate was witnessed in October 2009, from 89.3 (UCL 176.9, LCL 1.7)/1000 neonatal admissions to 34.8 (UCL 87.1, LCL 0)/1000 neonatal admissions.

Conclusions

Our study demonstrated a progressive decline in the number of neonatal ET procedures over 11 y.

Birthplace is a risk factor for exchange transfusion in outborn infants admitted for jaundice in Myanmar: a case-control study

Aim: To evaluate the role of pathway to admission for jaundice among the risk factors for exchange transfusion in outborn infants in a low resource setting.Methods: This retrospective case-control study (1:1 ratio) was carried out at the Yankin Children's Hospital in Yangon (Myanmar). All cases were neonates admitted for treatment of jaundice between March 2013 and February 2014 and who required an exchange transfusion. Each control was the next noncase neonate admitted for treatment of jaundice and treated with phototherapy. Infant characteristics, pathways of admission and clinically relevant factors for exchange transfusion were collected.Results: One hundred thirty-four cases and 134 controls were included in the study. Among cases, home was the most common place of birth while public hospital was the most frequent source of referral. Among controls, private/public hospitals were the commonest places of birth and referral. At multivariable analysis, homebirth was associated with increased likelihood of receiving exchange transfusion at admission (OR 3.30, 95% C.I. 1.31-8.56).Conclusion: Homebirth was an independent risk factor for exchange transfusion at admission for jaundice in a low-resource setting. Appropriate health education of pregnant women and traditional/home birth attendants may contribute to reduce the need for exchange transfusion in low-resource settings.

Filtered sunlight versus intensive electric powered phototherapy in moderate-to-severe neonatal hyperbilirubinaemia: a randomised controlled non-inferiority trial

BACKGROUND

Kernicterus resulting from severe neonatal hyperbilirubinaemia is a leading cause of preventable deaths and disabilities in low-income and middle-income countries, partly because high-quality intensive phototherapy is unavailable. Previously, we showed that filtered-sunlight phototherapy (FSPT) was efficacious and safe for treatment of mild-to-moderate neonatal hyperbilirubinaemia. We aimed to extend these studies to infants with moderate-to-severe hyperbilirubinaemia.

METHODS

We did a prospective, randomised controlled non-inferiority trial in Ogbomoso, Nigeria-a simulated rural setting. Near-term or term infants aged 14 days or younger who were of 35 weeks or more gestational age and with total serum bilirubin concentrations at or above the recommended age-dependent treatment levels for high-risk neonates were randomly assigned (1:1) to either FSPT or intensive electric phototherapy (IEPT). Randomisation was computer-generated, and neither clinicians nor the parents or guardians of participants were masked to group allocation. FSPT was delivered in a transparent polycarbonate room lined with commercial tinting films that transmitted effective phototherapeutic light, blocked ultraviolet light, and reduced infrared radiation. The primary outcome was efficacy, which was based on assessable treatment days only (ie, those on which at least 4 h of phototherapy was delivered) and defined as a rate of increase in total serum bilirubin concentrations of less than 3·4 μmol/L/h in infants aged 72 h or younger, or a decrease in total serum bilirubin concentrations in those older than 72 h. Safety was defined as no sustained hypothermia, hyperthermia, dehydration, or sunburn and was based on all treatment days. Analysis was by intention to treat with a non-inferiority margin of 10%.

FINDINGS

Between July 31, 2015, and April 30, 2017, 174 neonates were enrolled and randomly assigned: 87 to FSPT and 87 to IEPT. Neonates in the FSPT group received 215 days of phototherapy, 82 (38%) of which were not assessable. Neonates in the IEPT group received 219 treatment days of phototherapy, 67 (31%) of which were not assessable. Median irradiance was 37·3 μW/cm²/nm (IQR 21·4-56·4) in the FSPT group and 50·4 μW/cm²/nm (44·5-66·2) in the IEPT group. FSPT was efficacious on 116 (87·2%) of 133 treatment days; IEPT was efficacious on 135 (88·8%) of 152 treatment days (mean difference -1·6%, 95% CI -9·9 to 6·7; p=0·8165). Because the CI did not extend below -10%, we concluded that FSPT was not inferior to IEPT. Treatment was safe for all neonates.

INTERPRETATION

FSPT is safe and no less efficacious than IEPT for treatment of moderate-to-severe neonatal hyperbilirubinaemia in near-term and term infants.

FUNDING

Thrasher Research Fund and National Center for Advancing Translational Sciences.

Patterns of acute bilirubin encephalopathy in Nigeria: a multicenter pre-intervention study

BACKGROUND

Acute bilirubin encephalopathy (ABE) is an important cause of neonatal morbidity in Nigeria, accounting for 5-14% of neonatal deaths. Most newborns with severe ABE have irreversible damage before receiving treatment emphasizing the need for timely pre-admission monitoring and referral. There is limited evidence that educational interventions targeting mothers and health care providers will reduce delayed care.

OBJECTIVE

To provide baseline data on the incidence of ABE and associated pre-admission risk factors in five centers of Nigeria in order to evaluate the effect of subsequent educational interventions on outcome.

STUDY DESIGN

The incidence of ABE among newborns treated for hyperbilirubinemia was documented prospectively. Bivariate analysis and multivariate logistic regression were used to evaluate risk factors for acute bilirubin encephalopathy and reasons for regional differences in its occurrence.

RESULTS

Of 1040 infants, 159 treated for hyperbilirubinemia (15.3%) had mild to severe bilirubin encephalopathy (including 35 deaths), but the incidence ranged from 7 to 22% between centers. Logistic regression identified four common predictors: total serum bilirubin (odds ratio 1.007 per mg/dl rise), out-of-hospital births (OR 2.6), non-alloimmune hemolytic anemia (OR 2.8), and delayed care seeking (OR 4.3).

CONCLUSION

The high occurrence of bilirubin encephalopathy in Nigeria is due in large part to a delay in seeking care. A planned intervention strategy will target conditions leading to severe hyperbilirubinemia and delay.

Follow-up of Children with Kernicterus in Kano, Nigeria

INTRODUCTION

Acute bilirubin encephalopathy (ABE) is associated with long-term sequelae (kernicterus). It continues to be a significant issue in our region of Nigeria, accounting for much morbidity and mortality. Herein we report the outcome of neonates with ABE seen at our centre.

METHODOLOGY

We established a surveillance of children who had ABE and returned to follow-up from prospective cases of ABE (2012-2014). ABE was diagnosed based on a bilirubin-induced neurologic dysfunction score of ≥ 1. Kernicterus was subsequently established based on a history of developmental delays, hearing impairments and abnormal physical and neurologic examinations at follow-up age ≥3 months.

RESULT

Five hundred fifty-one neonates had hyperbilirubinaemia of whom 104 (18.8%) had ABE. Mean transcutaneous bilirubin using the Ingram icterometer was 18.3 mg/dl  ±  SD 1.9 [(12.5-19.1), total serum bilirubin of 18.1 ± 10.9] (range: 10.3-64 mg/dl). Sixty-five infants returned for follow-up (41 males and 24 females); mean age 9 months (22 days to 17 months). Most (58 of 65; 89.2%) had abnormal neurological findings and 15 (25.9%) had probable kernicterus.

CONCLUSION

There is a critical need for a National Kernicterus Registry to document all cases of kernicterus and formulate an effective treatment and prevention policy.

Attenuation of neuro-inflammation improves survival and neurodegeneration in a mouse model of severe neonatal hyperbilirubinemia

All pre-term newborns and a high proportion of term newborns develop neonatal jaundice. Neonatal jaundice is usually a benign condition and self-resolves within few days after birth. However, a combination of unfavorable complications may lead to acute hyperbilirubinemia. Excessive hyperbilirubinemia may be toxic for the developing nervous system leading to severe neurological damage and death by kernicterus. Survivors show irreversible neurological deficits such as motor, sensitive and cognitive abnormalities. Current therapies rely on the use of phototherapy and, in unresponsive cases, exchange transfusion, which is performed only in specialized centers. During bilirubin-induced neurotoxicity different molecular pathways are activated, ranging from oxidative stress to endoplasmic reticulum (ER) stress response and inflammation, but the contribution of each pathway in the development of the disease still requires further investigation. Thus, to increase our understanding of the pathophysiology of bilirubin neurotoxicity, encephalopathy and kernicterus, we pharmacologically modulated neurodegeneration and neuroinflammation in a lethal mouse model of neonatal hyperbilirubinemia. Treatment of mutant mice with minocycline, a second-generation tetracycline with anti-inflammatory and neuroprotective properties, resulted in a dose-dependent rescue of lethality, due to reduction of neurodegeneration and neuroinflammation, without affecting plasma bilirubin levels. In particular, rescued mice showed normal motor-coordination capabilities and behavior, as determined by the accelerating rotarod and open field tests, respectively. From the molecular point of view, rescued mice showed a dose-dependent reduction in apoptosis of cerebellar neurons and improvement of dendritic arborization of Purkinje cells. Moreover, we observed a decrease of bilirubin-induced M1 microglia activation at the sites of damage with a reduction in oxidative and ER stress markers in these cells. Collectively, these data indicate that neurodegeneration and neuro-inflammation are key factors of bilirubin-induced neonatal lethality and neuro-behavioral abnormalities. We propose that the application of pharmacological treatments having anti-inflammatory and neuroprotective effects, to be used in combination with the current treatments, may significantly improve the management of acute neonatal hyperbilirubinemia, protecting from bilirubin-induced neurological damage and death.

Burden of severe neonatal jaundice: a systematic review and meta-analysis

CONTEXT

To assess the global burden of late and/or poor management of severe neonatal jaundice (SNJ), a common problem worldwide, which may result in death or irreversible brain damage with disabilities in survivors. Population-based data establishing the global burden of SNJ has not been previously reported.

OBJECTIVE

Determine the burden of SNJ in all WHO regions, as defined by clinical jaundice associated with clinical outcomes including acute bilirubin encephalopathy/kernicterus and/or exchange transfusion (ET) and/or jaundice-related death.

DATA SOURCES

PubMed, Scopus and other health databases were searched, without language restrictions, from 1990 to 2017 for studies reporting the incidence of SNJ.

STUDY SELECTION/DATA EXTRACTION

Stratification was performed for WHO regions and results were pooled using random effects model and meta-regression.

RESULTS

Of 416 articles including at least one marker of SNJ, only 21 reported estimates from population-based studies, with 76% (16/21) of them conducted in high-income countries. The African region has the highest incidence of SNJ per 10 000 live births at 667.8 (95% CI 603.4 to 738.5), followed by Southeast Asian, Eastern Mediterranean, Western Pacific, Americas and European regions at 251.3 (132.0 to 473.2), 165.7 (114.6 to 238.9), 9.4 (0.1 to 755.9), 4.4 (1.8 to 10.5) and 3.7 (1.7 to 8.0), respectively. The incidence of ET per 10 000 live births was significantly higher for Africa and Southeast Asian regions at 186.5 (153.2 to 226.8) and 107.1 (102.0 to 112.5) and lower in Eastern Mediterranean (17.8 (5.7 to 54.9)), Americas (0.38 (0.21 to 0.67)), European (0.35 (0.20 to 0.60)) and Western Pacific regions (0.19 (0.12 to 0.31). Only 2 studies provided estimates of clear jaundice-related deaths in infants with significant jaundice [UK (2.8%) and India (30.8%).

CONCLUSIONS

Limited but compelling evidence demonstrates that SNJ is associated with a significant health burden especially in low-income and middle-income countries.

Factors influencing irradiance of locally fabricated phototherapy devices in Jos, north-central Nigeria

Locally fabricated phototherapy devices (LFPDs) are widely used in Nigeria for the treatment of neonatal jaundice. Ours was a cross-sectional observational study of all LFPDs in major hospitals in Jos between January and March 2015. We evaluated a total of 24 LFPDs. The irradiance at the level of the baby was in the range of 2-23.9 µW/cm²/nm. Fourteen devices had the recommended irradiance of ≥10 µW/cm²/nm and none had irradiance in the intensive range. Decreasing distance from the baby, presence of reflectors and increasing number of flourecent tubes significantly contributed to higher irradiance. A combination of six tubes, presence of reflectors and a distance of 10 cm from the baby produced a mean irradiance of 23.40 µW/cm²/nm. The irradiance of LFPDs varies widely and can be improved by simple modifications.

Filtered sunlight, solar powered phototherapy and other strategies for managing neonatal jaundice in low-resource settings

Challenges in treating severe neonatal jaundice in low and middle-income country settings still exist at many levels. These include: a lack of awareness of causes and prevention by families, communities and even sometimes health care professionals; insufficient, ineffective, high quality affordable diagnostic and therapeutic options; limited availability of rehabilitation provision for kernicterus. Collectively these challenges lead to an unacceptably high global morbidity and mortality from severe neonatal jaundice. In the past decade, there has been an explosion of innovations addressing some of these issues and these are increasingly available for scale up. Scientists, healthcare providers, and communities are joining hands to explore educational tools, low cost screening and diagnostic options including at point-of-care and treatment modalities including filtered sunlight and solar powered phototherapy. For the first time, the possibility of eliminating the tragedy of preventable morbidity and mortality from severe NNJ is on the horizon, for all.

A Survey of Practice and Knowledge of Refugee and Migrant Pregnant Mothers Surrounding Neonatal Jaundice on the Thailand-Myanmar Border

BACKGROUND

In populations with a high prevalence of glucose-6-phosphate dehydrogenase deficiency, practices that can induce haemolysis need to be identified to raise awareness of preventable risks. The aim of this survey was to determine the proportion of prospective mothers using haemolytic agents and their knowledge and practice surrounding neonatal jaundice.

METHODS

Pregnant mothers were invited to participate in a cross-sectional survey conducted at Shoklo Malaria Research Unit on the Thailand-Myanmar border.

RESULTS

From 12 April 2015 to 12 June 2015, 522 pregnant women completed the survey. Mothball use in the household was reported by 41.4% (216 of 522) of prospective mothers and menthol containing products on baby skin by 46.7% (244 of 522).

CONCLUSION

Just over 40% of the households reported use of naphthalene-containing mothballs. Future health promotion activities that focus on reducing naphthalene mothball and menthol-containing products use have the potential to reduce rates of severe neonatal jaundice in this population.

Glucose-6-Phosphate Dehydrogenase Deficiency and the Need for a Novel Treatment to Prevent Kernicterus

Hyperbilirubinemia occurs frequently in newborns, and in severe cases can progress to kernicterus and permanent developmental disorders. Glucose-6-phosphate dehydrogenase (G6PD) deficiency, one of the most common human enzymopathies, is a major risk factor for hyperbilirubinemia and greatly increases the risk of kernicterus even in the developed world. Therefore, a novel treatment for kernicterus is needed, especially for G6PD-deficient newborns. Oxidative stress is a hallmark of bilirubin toxicity in the brain. We propose that the activation of G6PD via a small molecule chaperone is a potential strategy to increase endogenous defense against bilirubin-induced oxidative stress and prevent kernicterus.

Facility-based constraints to exchange transfusions for neonatal hyperbilirubinemia in resource-limited settings

Several clinical guidelines for the management of infants with severe neonatal hyperbilirubinemia recommend immediate exchange transfusion (ET) when the risk or presence of acute bilirubin encephalopathy is established in order to prevent chronic bilirubin encephalopathy or kernicterus. However, the literature is sparse concerning the interval between the time the decision for ET is made and the actual initiation of ET, especially in low- and middle-income countries (LMICs) with significant resource constraints but high rates of ET. This paper explores the various stages and potential delays during this interval in complying with the requirement for immediate ET for the affected infants, based on the available evidence from LMICs. The vital role of intensive phototherapy, efficient laboratory and logistical support, and clinical expertise for ET are highlighted. The challenges in securing informed parental consent, especially on religious grounds, and meeting the financial burden of this emergency procedure to facilitate timely ET are examined. Secondary delays arising from post-treatment bilirubin rebound with intensive phototherapy or ET are also discussed. These potential delays can compromise the effectiveness of ET and should provide additional impetus to curtail avoidable ET in LMICs.

Heliotherapy for Neonatal Hyperbilirubinemia in Southwest, Nigeria: A Baseline Pre-Intervention Study

Background

A novel filtered-sunlight phototherapy (FSPT) device has been demonstrated to be safe and efficacious for treating infants with neonatal jaundice in resource-constrained tropical settings. We set out to provide baseline data for evaluating the clinical impact of this device in a referral pediatric hospital.

Methods

We reviewed the medical records of infants admitted for neonatal hyperbilirubinemia in an inner-city Children’s Hospital in Lagos, between January 2012 and December 2014 to determine the pattern, treatment and outcomes during the pre-intervention period. Factors associated with adverse outcomes were identified through multivariable logistic regression.

Results

Of the 5,229 neonatal admissions over the period, a total of 1,153 (22.1%) were admitted for neonatal hyperbilirubinemia. Complete records for 1,118 infants were available for analysis. The incidence of acute bilirubin encephalopathy (ABE) and exchange transfusion (ET) were 17.0% (95% CI: 14.9%–19.3%) and 31.5% (95% CI: 28.8%–34.3%) respectively. A total of 61 (5.5%, 95% CI: 4.3%–6.9%) of the jaundiced infants died. Weight on admission, peak total serum bilirubin (TSB), sepsis and exposure to hemolytic products were predictive of ABE, while age on admission, peak TSB, ABO incompatibility and ABE were predictive of ET. Rhesus incompatibility, asphyxia, exposure to hemolytic substances and ABE were associated with elevated mortality risk, while ET was a protective factor. Lack of routine irradiance monitoring and steady energy supply were frequent challenges for conventional blue-light phototherapy.

Conclusions

Severe hyperbilirubinemia is associated with high rates of ABE and ET in this setting, and remains a significant contributor to neonatal admissions and mortality. To be impactful, FSPT, complemented with improved diagnostic facilities, should effectively curtail jaundice-related adverse outcomes in this and comparable settings.

Predictors of Repeat Exchange Transfusion for Severe Neonatal Hyperbilirubinemia

OBJECTIVES

To identify the predictors of repeat exchange transfusion among infants with severe hyperbilirubinemia.

DESIGN

Retrospective cross-sectional study.

SETTING

A referral children's hospital in inner-city Lagos, Nigeria.

PATIENTS

Infants who received exchange transfusion for severe hyperbilirubinemia from January 2012 to December 2014.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

The predictors of repeat exchange transfusion were identified among all infants who had at least one exchange transfusion using multivariable logistic regression. A total of 352 infants with mean peak total serum bilirubin of 26.32 ± 7.96 mg/dL received exchange transfusion; of these, 49 (13.9%) with mean peak total serum bilirubin of 32.85 ± 10.54 mg/dL had repeat exchange transfusion. More than two thirds of infants who received exchange transfusion and repeat exchange transfusion were male, and at least one third had ABO incompatibility. No infant had more than two exchange transfusions. The mean age of admission was approximately 5 days (range, 1-14 d). Peak total serum bilirubin greater than or equal to 30 mg/dL (odds ratio, 2.88; 95% CI, 1.46-5.70) and acute bilirubin encephalopathy (odds ratio, 2.37; 95% CI, 1.18-4.77) were predictive of repeat exchange transfusion.

CONCLUSIONS

Acute bilirubin encephalopathy and excessive total serum bilirubin levels at least 30 mg/dL are predictive of repeat exchange transfusion. A risk assessment framework that combines total serum bilirubin levels, acute bilirubin encephalopathy status, and risk factors of neurotoxicity should be considered for the timely detection and monitoring of infants at risk of repeat exchange transfusion.

Revisiting the Criteria for Exchange Transfusion for Severe Neonatal Hyperbilirubinemia in Resource-Limited Settings

BACKGROUND

Exchange transfusion (ET) for severe neonatal hyperbilirubinemia (SNH) is frequently undertaken in low- and middle-income countries (LMIC), in sharp contrast to the prevailing practice in high-income countries. However, the criteria for initiating this procedure in settings with limited resources for treating infants with SNH have not been systematically explored.

OBJECTIVE

To identify key considerations for initiating ET in resource-poor countries to curtail its unnecessary use for the prevention of kernicterus.

METHODS

A review of the existing guidelines and literature on the management of neonatal hyperbilirubinemia worldwide was conducted to identify criteria and underlying factors for initiating ET.

RESULTS

There is a dearth of evidence from randomized clinical trials to support clear criteria for indicated ET worldwide. Because risk assessment for kernicterus based solely on the levels of total serum bilirubin (TSB) has often proved inadequate, a combination of plasma/serum bilirubin estimation and clinical evaluation for acute bilirubin encephalopathy (ABE) has been recommended for predicting the risk of kernicterus. However, there is a lack of consistency regarding the TSB levels for which ET should be initiated in relation to the clinical signs/symptoms of ABE and hemolytic disorders.

CONCLUSIONS

A decision-making framework that combines TSB thresholds and evidence of neurotoxicity is needed for evaluating the risk of kernicterus and prioritising infants for ET in LMICs to curtail unnecessary interventions.

Evaluation of a simple intervention to reduce exchange transfusion rates among inborn and outborn neonates in Myanmar, comparing pre- and post-intervention rates

Background

In Myanmar, approximately half of all neonatal hospital admissions are for hyperbilirubinaemia, and tertiary facilities report high rates of Exchange Transfusion (ET). The aim of this study was to evaluate the effectiveness of the pilot program in reducing ET, separately of inborn and outborn neonates.

Methods

The study was conducted in the Neonatal Care Units of four national tertiary hospitals: two exclusively treating inborn neonates, and two solely for outborn neonates. Prior to intervention, no high intensity phototherapy was available in these units. Intervention in late November 2011 comprised, for each hospital, provision of two high intensity LED phototherapy machines, a photo radiometer, and training of personnel. Hospital-specific data were assessed as Relative Risk (RR) ratios comparing ET rates pre- and post-intervention, and individual hospital results were pooled when appropriate.

Results

In 2011, there were 118 ETs among inborn neonates and 140 ETs among outborn neonates. The ET rate was unchanged at Inborn Hospital A (RR = 1.07; 95 % CI: 0.80–1.43; p = 0.67), and reduced by 69 % at Inborn Hospital B (RR = 0.31; 95 % CI: 0.17–0.57; p < 0.0001). For outborn neonates, the pooled estimate indicated that ET rates reduced by 33 % post-intervention (RR_MH = 0.67; 95 % CI: 0.52–0.87; p = 0.002); heterogeneity was not a problem.

Conclusion

Together with a photoradiometer and education, intensive phototherapy can significantly reduce the ET rate. Inborn Hospital A had four times as many admissions for jaundice as Inborn Hospital B, and did not reduce ET until it received additional high intensity machines. The results highlight the importance of providing enough intensive phototherapy units to treat all neonates requiring high intensity treatment for a full course.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12615001171505, 2 November 2015.

Albumin administration prevents neurological damage and death in a mouse model of severe neonatal hyperbilirubinemia

Therapies to prevent severe neonatal unconjugated hyperbilirubinemia and kernicterus are phototherapy and, in unresponsive cases, exchange transfusion, which has significant morbidity and mortality risks. Neurotoxicity is caused by the fraction of unconjugated bilirubin not bound to albumin (free bilirubin, Bf). Human serum albumin (HSA) administration was suggested to increase plasma bilirubin-binding capacity. However, its clinical use is infrequent due to difficulties to address its potential preventive and curative benefits, and to the absence of reliable markers to monitor bilirubin neurotoxicity risk. We used a genetic mouse model of unconjugated hyperbilirubinemia showing severe neurological impairment and neonatal lethality. We treated mutant pups with repeated HSA administration since birth, without phototherapy application. Daily intraperitoneal HSA administration completely rescued neurological damage and lethality, depending on dosage and administration frequency. Albumin infusion increased plasma bilirubin-binding capacity, mobilizing bilirubin from tissues to plasma. This resulted in reduced plasma Bf, forebrain and cerebellum bilirubin levels. We showed that, in our experimental model, Bf is the best marker to determine the risk of developing neurological damage. These results support the potential use of albumin administration in severe acute hyperbilirubinemia conditions to prevent or treat bilirubin neurotoxicity in situations in which exchange transfusion may be required.

Risk factors for acute bilirubin encephalopathy on admission to two Myanmar national paediatric hospitals

Background

Jaundice is the commonest neonatal ailment requiring treatment. Untreated, it can lead to acute bilirubin encephalopathy (ABE), chronic bilirubin encephalopathy (CBE) or death. ABE and CBE have been largely eliminated in industrialised countries, but remain a problem of largely undocumented scale in low resource settings.

As part of a quality-improvement intervention in the Neonatal Care Units of two paediatric referral hospitals in Myanmar, hospitals collected de-identified data on each neonate treated on new phototherapy machines over 13–20 months. The information collected included: diagnosis of ABE at hospital presentation; general characteristics such as place of birth, source of referral, and sex; and a selection of suspected causes of jaundice including prematurity, infection, G6PD status, ABO and Rh incompatibility. This information was analysed to identify risk factors for hospital presentation with ABE, using multiple logistic regression.

Results

Data on 251 neonates was recorded over 20 months in Hospital A, and 339 neonates over 13 months in Hospital B; the number of outborn neonates presenting with ABE was 32 (12.7 %) and 72 (21.2 %) respectively. In the merged dataset the final multivariate model identified the following independent risk and protective factors: home birth, OR_adj = 2.3 (95 % CI: 1.04-5.4); self-referral, OR_adj = 2.6 (95 % CI: 1.2-6.0); prematurity, OR_adj = 0.40 (95 % CI: 0.18-0.85); and a significant interaction between hospital and screening status because screening positive for G6PD deficiency was a strong and significant risk factor at Hospital B (OR_adj = 5.9; 95 % CI: 3.0-11.6), but not Hospital A (OR_adj = 1.1; 95 % CI: 0.5-2.5).

Conclusion

The study identifies home birth, self-referral and G6PD screening status as important risk factors for presentation with ABE; prematurity was protective, but this is interpreted as an artefact of the study design. As operational research, there is likely to be substantial measurement error in the risk factor data, suggesting that the identified risk factor estimates are robust. Additional interventions are required to ensure prompt referral of jaundiced neonates to treatment facilities, with particular focus on home births and communities with high rates of G6PD deficiency.

New technologies for essential newborn care in under-resourced areas: what is needed and how to deliver it

Globally, the largest contributors to neonatal mortality are preterm birth, intrapartum complications and infection. Many of these deaths could be prevented by providing temperature stability, respiratory support, hydration and nutrition; preventing and treating infections; and diagnosing and treating neonatal jaundice and hypoglycaemia. Most neonatal health-care technologies which help to accomplish these tasks are designed for high-income countries and are either unavailable or unsuitable in low-resource settings, preventing many neonates from receiving the gold standard of care. There is an urgent need for neonatal health-care technologies which are low-cost, robust, simple to use and maintain, affordable and able to operate from various power supplies. Several technologies have been designed to meet these requirements or are currently under development; however, unmet technology needs remain. The distribution of an integrated set of technologies, rather than separate components, is essential for effective implementation and a substantial impact on neonatal health. Close collaboration between stakeholders at all stages of the development process and an increased focus on implementation research are necessary for effective and sustainable implementation.

Management of late-preterm and term infants with hyperbilirubinaemia in resource-constrained settings

Hyperbilirubinaemia is a ubiquitous transitional morbidity in the vast majority of newborns and a leading cause of hospitalisation in the first week of life worldwide. While timely and effective phototherapy and exchange transfusion are well proven treatments for severe neonatal hyperbilirubinaemia, inappropriate or ineffective treatment of hyperbilirubinaemia, at secondary and tertiary hospitals, still prevails in many poorly-resourced countries accounting for a disproportionately high burden of bilirubin-induced mortality and long-term morbidity. As part of the efforts to curtail the widely reported risks of frequent but avoidable bilirubin-induced neurologic dysfunction (acute bilirubin encephalopathy (ABE) and kernicterus) in low and middle-income countries (LMICs) with significant resource constraints, this article presents a practical framework for the management of late-preterm and term infants (≥35 weeks of gestation) with clinically significant hyperbilirubinaemia in these countries particularly where local practice guidelines are lacking. Standard and validated protocols were followed in adapting available evidence-based national guidelines on the management of hyperbilirubinaemia through a collaboration among clinicians and experts on newborn jaundice from different world regions. Tasks and resources required for the comprehensive management of infants with or at risk of severe hyperbilirubinaemia at all levels of healthcare delivery are proposed, covering primary prevention, early detection, diagnosis, monitoring, treatment, and follow-up. Additionally, actionable treatment or referral levels for phototherapy and exchange transfusion are proposed within the context of several confounding factors such as widespread exclusive breastfeeding, infections, blood group incompatibilities and G6PD deficiency, which place infants at high risk of severe hyperbilirubinaemia and bilirubin-induced neurologic dysfunction in LMICs, as well as the limited facilities for clinical investigations and inconsistent functionality of available phototherapy devices. The need to adjust these levels as appropriate depending on the available facilities in each clinical setting and the risk profile of the infant is emphasised with a view to avoiding over-treatment or under-treatment. These recommendations should serve as a valuable reference material for health workers, guide the development of contextually-relevant national guidelines in each LMIC, as well as facilitate effective advocacy and mobilisation of requisite resources for the optimal care of infants with hyperbilirubinaemia at all levels.

Exchange Transfusion for Severe Neonatal Hyperbilirubinemia: 17 Years' Experience from Vojvodina, Serbia

This study aimed to evaluate the frequency of the main risk factors for severe neonatal hyperbilirubinemia, to determine the incidence of exchange transfusion (ET) in the Autonomous Province of Vojvodina (the northern part of Serbia) and to describe the experience with ET performed in premature and term infants during the past 17 years. We performed a retrospective data analysis of 398 newborn infants who underwent a double volume ET from 1997 to 2013. During the 17 year study period, a decreasing incidence of ET, expressed per thousand newborns, was observed. A total of 468 double volume ET were performed: 328 (82.4 %) infants had one treatment and 70 (17.6 %) had repeated treatments. A total of 262,830 mLs of blood were transfused, an average of 660 mLs per child. There were 221 male and 177 female infants, with a sex ratio 1.25:1. The frequencies of risk factors for developing hyperbilirubinemia were as follows: (1) 38 % RhD incompatibility; (2) 38 % ABO incompatibility (26 % group A infant of group O mother, 12 % group B infant of group O mother); (3) 7 % low birth weight/preterm birth; (4) 17 % other factors. Risk factors for neurotoxicity were identified in 56.3 % of infants. No deaths or complications were reported arising from the treatment. ABO and Rh incompatibilities were found to be the main risk factors for severe neonatal hyperbilirubinemia in Vojvodina. Exchange transfusion, used as therapy for severe hyperbilirubinemia, trended downwards over the period of this study.

A modified Bilirubin-induced neurologic dysfunction (BIND-M) algorithm is useful in evaluating severity of jaundice in a resource-limited setting

Background

Severe neonatal jaundice with associated acute bilirubin encephalopathy occurs frequently in low- and middle-income countries, where advanced diagnostic technology is in short supply. In an effort to facilitate the physical diagnosis of acute bilirubin encephalopathy, we pilot-tested a modified bilirubin induced neurologic dysfunction scoring algorithm in a group of pediatric trainees (residents) and their mentors (consultants) in a resource-constrained setting.

Methods

Jaundiced Nigerian infants were examined by consultant and resident pediatricians. The modified bilirubin induced neurologic dysfunction score assigned by residents was compared with the clinical diagnosis of acute bilirubin encephalopathy by expert consultants. Demographic information was obtained. Known risk factors were also evaluated among infants with and without acute bilirubin encephalopathy in addition to exploratory analyses. Data were analyzed by Statistical Analysis System; statistical significance was set at p < 0.05.

Results

Three hundred and thirty three paired modified bilirubin induced neurologic dysfunction scores (333) were analyzed and showed excellent agreement (weighted Kappa coefficient 0.7969) between residents and consultants. A modified bilirubin induced neurologic dysfunction score greater than or equal to 3 was highly predictive of a clinical diagnosis of acute bilirubin encephalopathy, with sensitivity of 90.7%, specificity of 97.7%, positive predictive value of 88.9%, and negative predictive value of 98.2%. Exposure to mentholated products was strongly associated with increased risk of acute bilirubin encephalopathy among those with known glucose-6-phosphate dehydrogenase deficiency (odds ratio = 73.94; 95% confidence interval = 5.425-infinity) as well as among those whose G6PD phenotype was unknown (odds ratio = 25.88; 95% confidence interval = 2.845-235.4).

Conclusions

The modified bilirubin induced neurologic dysfunction score for neonatal jaundice can be assigned reliably by both residents and experienced pediatricians in resource-limited settings as reflected in the algorithm’s sensitivity and specificity. It may be useful for predicting the development and severity of acute bilirubin encephalopathy in neonates.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-015-0355-2) contains supplementary material, which is available to authorized users.

Why is kernicterus still a major cause of death and disability in low-income and middle-income countries?

Neonatal jaundice is predominantly a benign condition that affects 60%-80% of newborns worldwide but progresses to potentially harmful severe hyperbilirubinaemia in some. Despite the proven therapeutic benefits of phototherapy for preventing extreme hyperbilirubinaemia, acute bilirubin encephalopathy or kernicterus, several low-income and middle-income countries (LMIC) continue to report high rates of avoidable exchange transfusions, as well as bilirubin-induced mortality and neurodevelopmental disorders. Considering the critical role of appropriate timing in treatment effectiveness, this review set out to examine the contributory factors to the burden of severe hyperbilirubinaemia and kernicterus based on the 'three delays model' described by Thaddeus and Maine in the 91 most economically disadvantaged LMICs with Gross National Income per capita ≤US$6000 and median human development index of 0.525 (IQR: 0.436-0.632). Strategies for addressing these delays are proposed including the need for clinical and public health leadership to curtail the risk and burden of kernicterus in LMICs.

Addressing the burden of neonatal hyperbilirubinaemia in countries with significant glucose-6-phosphate dehydrogenase deficiency

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an established worldwide risk factor for severe hyperbilirubinaemia. This literature review examined the pattern and management of severe hyperbilirubinaemia in low- and middle-income countries (LMICs) where G6PD deficiency was 10% or more and found that it was frequently associated with neonatal mortality and, or, neurodevelopmental disorders.

CONCLUSION

Low- and middle-income countries need to pay urgent attention to G6PD deficiency to curtail the preventable burden of jaundice-related morbidity, mortality and disability.

Exchange transfusion for neonatal hyperbilirubinemia: an 8-year single center experience at a tertiary neonatal intensive care unit in Turkey

OBJECTIVE

The aim of present study was to evaluate the indications and the complications associated with neonatal exchange transfusion (ET) performed for hyperbilirubinemia.

METHODS

This study included overall 306 neonates who underwent ET between 2005 and 2012. The demographic characteristics of patients, causes of jaundice and adverse events occurred during or within 1 week after ET were recorded from their medical files. Those newborns that underwent ET were classified as either "otherwise healthy" or "sick" group.

RESULTS

Of the 306 patients who underwent ET, 244 were otherwise healthy and had no medical problems other than jaundice. The remaining 62 patients were classified as sick that had medical problems other than jaundice ranging from mild to severe. The mean gestational age was 37.6 ± 2.5 weeks and the mean peak total bilirubin levels was 25.8 ± 6.6 mg/dl. The mean age at presentation was 5.4 ± 3.8 d for all infants. The most common cause of hyperbilirubinemia was ABO isoimmunization (27.8%). None of newborns died secondary to ET. Three infants had had necrotizing enterocolitis, and also three infants had had acute renal failure. The most common encountered complications of ET procedure were hyperglycemia (56.5%), hypocalcaemia (22.5%) and thrombocytopenia (16%).

CONCLUSIONS

Our data showed that ABO isoimmunization was the most common cause of hyperbilirubinemia. Even mortality was not seen, very rare but major gastrointestinal and renal complications were associated with ET. The majority of adverse events associated with ET were laboratory abnormalities mainly hyperglycemia, hypocalcaemia and thrombocytopenia which were asymptomatic and treatable.

Maternal satisfaction with a novel filtered-sunlight phototherapy for newborn jaundice in Southwest Nigeria

Background

In many resource-limited settings, the availability of effective phototherapy for jaundiced infants is frequently hampered by lack of, or inadequate resources to acquire and maintain conventional electric-powered phototherapy devices. This study set out to ascertain maternal experience and satisfaction with a novel treatment of infants with significant hyperbilirubinemia using filtered sunlight phototherapy (FSPT) in a tropical setting with irregular access to effective conventional phototherapy.

Methods

A cross-sectional satisfaction survey was conducted among mothers of jaundiced infants treated with FSPT in an inner-city maternity hospital in Lagos, Nigeria from November 2013 to March 2014. Mothers’ experience during treatment was elicited with a pretested questionnaire consisting of closed and open-ended items. Satisfaction was rated on a five-point Likert scale. Correlates of overall maternal satisfaction were explored with descriptive and inferential non-parametric statistics.

Results

A total of 191 mothers were surveyed, 77 (40%) of whom had no prior knowledge of neonatal jaundice. Maternal satisfaction was highest for quality of nursing care received (mean: 4.72 ± 0.55, median: 5[IQR: 5–5]) and lowest for physical state of the test environment (mean: 3.85 ± 0.74, median: 4[IQR: 3–4]). The overall rating (mean: 4.17 ± 0.58, median: 4[IQR: 4–5]) and the observed effect of FSPT on the babies (mean: 4.34 ± 0.58, 4[IQR: 4–5]) were quite satisfactory. FSPT experience was significantly correlated with the adequacy of information received (p < 0.0005), test environment (p = 0.002) and the observed effect of FSPT on the child (p < 0.0005). Almost all mothers (98.4%) indicated willingness to use FSPT in future or recommend it to others, although some (30 or 15.7%) disliked the idea of exposing newborns to sunlight.

Conclusions

Mothers of jaundiced newborns in this population are likely to be satisfied with FSPT where it is inevitable as an alternative to conventional electric-powered phototherapy. Adequate information, good test environment and friendly nursing care must be ensured for satisfactory maternal experience.

Pattern and predictors of maternal care-seeking practices for severe neonatal jaundice in Nigeria: a multi-centre survey

BACKGROUND

Nigeria is frequently associated with disproportionately high rates of severe neonatal jaundice (NNJ) underpinned by widespread Glucose-6-phosphate dehydrogenase (G6PD) deficiency. Timely and appropriate treatment of NNJ is crucial for preventing the associated morbidity and neuro-developmental sequelae. Since mothers are likely to be the first mostly to observe the onset of severe illness in their newborns, we set out to identify the pattern and predictors of maternal care-seeking practices for NNJ in three culturally-distinct settings in Nigeria.

METHODS

A multi-centre study was conducted among women attending antenatal clinics in Abuja, Lagos and Port Harcourt from October 2011 to April 2012 using a pretested questionnaire. Predictors of awareness of NNJ, accurate recognition of NNJ, use of potentially harmful therapies and preference for future hospital treatment were determined with multivariate logistic regressions.

RESULTS

Of the 488 participants drawn from the three locations, 431 (88.3%) reported awareness of NNJ, predominantly (57.8%) attributable to professional health workers. A total of 309 (63.3%) mothers with prior knowledge of NNJ claimed they could recognise NNJ, but 270 (87.4%) from this group accurately identified the features of NNJ. Multiparous mothers (Adjusted odds ratio, AOR:4.05; 95% CI:1.75-9.36), those with tertiary education (AOR:1.91; CI:1.01-3.61), and those residing in Lagos (AOR:2.96; CI:1.10-7.97) were more likely to have had prior knowledge of NNJ. Similarly, multiparous mothers (AOR:2.38; CI:1.27-4.46) and those with tertiary education (AOR:1.92; CI:1.21-3.05) were more likely to recognise an infant with jaundice accurately. Mothers educated by health workers were 40% less likely to resort to potentially harmful treatment for NNJ (AOR:0.60; CI:0.39-0.92) but more likely to seek hospital treatment in future for an infant suspected with jaundice (AOR:1.88; CI:1.20-2.95).

CONCLUSIONS

Women with tertiary education and multiparous mothers who attend routine antenatal clinics are more likely than less educated women, to be associated with appropriate care-seeking practices for infants with NNJ regardless of the socio-cultural setting. Systematic efforts by professional health workers are warranted, as part of routine antenatal care, to engage other groups of mothers especially those likely to indulge in self-use of potentially harmful therapies.