Investigation and management of neonatal jaundice: a problem-orientated case record

Comparison between infants receiving traditional supplements (camel thorn, flix weed, and sugar water) and exclusively breast fed infants

OBJECTIVE

Although breast milk is considered the best nutritional option for neonates, use of traditional supplements such as sugar water, camel thorn, and flix weed in the first week of life of infants is quite common in Iran and many other countries. The aim of this study was to evaluate whether consuming such supplements has any impact on infant's breastfeeding behavior.

MATERIALS AND METHODS

Four hundred fifty four term infants who were referred to the neonatal clinic of Ghaem hospital were enrolled and divided into two groups. Control (exclusively breastfed infants, N=243) and case (breast milk feeding plus traditional remedies such as sugar water, camel thorn, and flix weed, N=211). Spss 19.5 was used for statistical analysis. T-test and Man-Whitney tests were used. A p-value of <0.05 was considered as significant.

RESULTS

The two groups were similar in their baseline data. Regarding duration of breastfeeding and breastfeeding frequency, use of these supplements resulted in a reduction in both breastfeeding frequency and duration (p<0.05). Breastfeeding problems such as poor let-down reflex and incorrect breastfeeding position were more common among mothers feeding these supplements to their infants. Moreover, infants with delayed initiation of first breastfeeding were more likely to receive these supplements.

CONCLUSION

Based on the results of this study, feeding infants with sugar water, camel's thorn, and flix weed is clearly associated with breast feeding problems such as poor let down reflex and incorrect breast feeding position. Use of these supplements resulted in a reduction in frequency and duration of breast feeding. Infants with delayed initiation of breast feeding are more likely to receive these supplementations. Therefore, any attempts to improve the community's culture would be of great benefit to the health and well being of our babies.

The Effect of Traditional Remedies (Camel's Thorn, Flixweed and Sugar Water) on Idiopathic Neonatal Jaundice

OBJECTIVE

Jaundice is the most common reason of newborn's admission to neonatal ward. Many Iranian families give traditional remedies like sugar water, camel's thorn and flixweed extracts to breast-fed babies for reducing jaundice. This study investigated the effect of traditional remedies on idiopathic neonatal jaundice.

METHODS

This prospective study has been performed on 336 babies with idiopathic jaundice in a four year period (2005-2009) at Ghaem hospital, Mashhad, Iran. The babies were divided into two groups. In case group (n=234) breast-fed babies received no remedy and in control group (n=102), traditional remedies were given additional to breast milk and the results recorded and compared.

FINDINGS

In the present study significant differences were observed between the two groups in age of admission (6.8±3.2 vs 9.2±3.7 day, P<0.001), serum bilirubin values (17.8 vs 21.3 mg/dl, P<0.001) and percent of weight loss (P<0.01). There were no significant differences between the two groups in birth weight, sex, gestational age and duration of hospitalization, age at jaundice remission, hematocrit value and maternal factors (age, gestational order, pregnancy and labor problems)(P>0.05).

CONCLUSION

Traditional remedies (camel's thorn, flixweed and sugar water) cause more weight loss and delayed reexamination of newborns leading to increased hyperbilirubinemia. These remedies may raise pseudo confidence in parents, which postpones reexamination and follow up of the newborns.

Neonatal liver disease

Establishing a rapid and accurate diagnosis of the cause of neonatal liver disease is an urgent matter. The initial detection of this condition relies on the sensitivity of the primary care provider or pediatrician to the signs and symptoms of jaundice and abnormal stool and urine color. It is critical to evaluate jaundice in any infant older than 2 weeks with measurement of fractionated bilirubin, and further assessment is necessary if the direct value is above 1.0 mg/dL in the setting of a total bilirubin of less than 5.0 mg/dL or a direct bilirubin of more than 20% of total if the total is more than 5.0 mg/dL. A diagnostic algorithm for the evaluation of infants who meet these criteria can guide physicians in selecting appropriate and timely diagnostic testing and referral to pediatric gastroenterology for these patients, whose outcome will rely on rapid diagnosis.

The spectrum of surgical jaundice in infancy

BACKGROUND

Conjugated jaundice arising during infancy may be caused by a number of different surgical conditions. The aim of this study was to compare clinical features, management, and outcome of all types of surgical jaundice presenting in the first year of life.

METHODS

A retrospective review was conducted of all infants born in the United Kingdom with jaundice caused by a surgical cause referred to the authors' institution from January 1992 to December 1999.

RESULTS

There were 171 infants who could be separated into 3 specific groups: biliary atresia (BA, n = 137), inspissated bile syndrome (IBS; n = 14), and choledochal malformation (CM; n = 12) together with a group containing various miscellaneous conditions (n = 8). Infants with BA had higher bilirubin (P <.01) and aspartate aminotransferase levels (P <.001) and came to surgery earlier (P <.01) than infants with either IBS or CM. Infants with IBS and CM were more likely to be premature and have other malformations, respectively. Ultrasound scan was the principal investigation in the differentiation of BA from other causes of jaundice. Accurate prelaparotomy diagnosis was made by percutaneous liver biopsy in 87% of cases later shown to be BA. Currently, 88 (64%) of children with BA are alive with their native liver postportoenterostomy, 4 have died, and 45 have undergone liver transplantation (with 1 death postoperatively). A policy of primary portoenterostomy for BA followed by transplantation, if necessary, resulted in a survival rate of over 95%. All children in the other diagnostic groups are alive and anicteric after appropriate surgical intervention.

CONCLUSIONS

Approximately 80% of infants presenting with surgical jaundice have biliary atresia, whereas those with inspissated bile syndrome and choledochal malformations make up most of the remainder. Mortality in this age-group is confined to infants with BA, but even on these infants an overall survival rate of greater than 95% is currently expected.

Screening of newborn infants for cholestatic hepatobiliary disease with tandem mass spectrometry

OBJECTIVE

To assess the feasibility of screening for cholestatic hepatobiliary disease and extrahepatic biliary atresia by using tandem mass spectrometry to measure conjugated bile acids in dried blood spots obtained from newborn infants at 7-10 days of age for the Guthrie test.

SETTING

Three tertiary referral clinics and regional neonatal screening laboratories.

DESIGN

Unused blood spots from the Guthrie test were retrieved for infants presenting with cholestatic hepatobiliary disease and from the two cards stored on either side of each card from an index child. Concentrations of conjugated bile acids measured by tandem mass spectrometry in the two groups were compared.

MAIN OUTCOME MEASURES

Concentrations of glycodihydroxycholanoates, glycotrihydroxycholanoates, taurodihydroxycholanoates, and taurotrihydroxycholanoates. Receiver operator curves were plotted to determine which parameter (or combination of parameters) would best predict the cases of cholestatic hepatobiliary disease and extrahepatic biliary atresia. The sensitivity and specificity at a selection of cut off values for each bile acid species and for total bile acid concentrations for the detection of the two conditions were calculated.

RESULTS

218 children with cholestatic hepatobiliary disease were eligible for inclusion in the study. Two children without a final diagnosis and five who presented at <14 days of age were excluded. Usable blood spots were obtained from 177 index children and 708 comparison children. Mean concentrations of all four bile acid species were significantly raised in children with cholestatic hepatobiliary disease and extrahepatic biliary atresia compared with the unaffected children (P<0.0001). Of 177 children with cholestatic hepatobiliary disease, 104 (59%) had a total bile acid concentration >33 micromol/l (97.5th centile value for comparison group). Of the 61 with extrahepatic biliary atresia, 47 (77%) had total bile acid concentrations >33 micromol/l. Taurotrihydroxycholanoate and total bile acid concentrations were the best predictors of both conditions. For all cholestatic hepatobiliary disease, a cut off level of total bile acid concentration of 30 micromol/l gave a sensitivity of 62% and a specificity of 96%, while the corresponding values for extrahepatic biliary atresia were 79% and 96%.

CONCLUSION

Most children who present with extrahepatic biliary atresia and other forms of cholestatic hepatobiliary disease have significantly raised concentrations of conjugated bile acids as measured by tandem mass spectrometry at the time when samples are taken for the Guthrie test. Unfortunately the separation between the concentrations in these infants and those in the general population is not sufficient to make mass screening for cholestatic hepatobiliary disease a feasible option with this method alone.

Late referral for biliary atresia--missed opportunities for effective surgery

To assess whether clinicopathological features other than the age at operation influence prognosis after surgery for extrahepatic biliary atresia (EHBA) and to determine whether the age at referral has fallen since a previous survey, 50 consecutive cases with EHBA referred between February, 1985, and December, 1987, were reviewed. Liver or spleen size, liver function tests, or histological appearance of liver biopsy specimen before surgery were not predictive of outcome. The jaundice cleared up in 12 of 14 children operated on by age 8 weeks, but in only 13 of 36 operated on later. In 41 referral was delayed. All 25 children in whom surgery was successful are alive and well, while 13 of 25 with unsuccessful surgery have died, at a median age of 1 year. To improve the prognosis of infants with EHBA parents and health staff need a better awareness of the early clinical features of EHBA and of the necessity for prompt referral. Liver disease should be suspected in any infant jaundiced after 14 days of age.

Clinical biochemistry of the neonatal period: immaturity, hypoxia, and metabolic disease

This review attempts to provide practical information on common problems in the laboratory medicine of newborn infants and also considers unresolved problems in achieving neonatal diagnoses. A common cause of upset in the newborn--intrapartum asphyxia--can now be positively diagnosed. This leaves a small group whom it is necessary to investigate because they may have metabolic disease. The initial investigation of metabolic disease at the district general hospital should be limited to the commoner conditions.

Hepatitis syndrome in infancy--an epidemiological survey with 10 year follow up

Fifty four infants with hepatobiliary disease and conjugated hyperbilirubinaemia of more than two weeks' duration were identified in a defined area of south east England in a prospective study between January 1971 and December 1973. The overall incidence was one case per 2500 live births. The cases were regularly reviewed and all survivors except one were assessed at age 10 years. Nine of 11 with extrahepatic biliary atresia died from liver disease by 2 years of age, one died at 5 years, and the survivor has cirrhosis with portal hypertension. Four out of seven with alpha 1 antitrypsin deficiency died aged 1 to 3 years from liver disease and one of the survivors has cirrhosis. All three infants with intrauterine infection and one with chromosomal abnormality died in infancy. Three children with other associated factors, choledochal cyst, galactosaemia, and rhesus isoimmunisation, recovered completely with no persisting liver disease. Two of 29 with cryptogenic hepatitis died, but only a further two have signs of persisting liver disease. Perinatal complications were more common in this group. Four of the 27 children surviving to the age of 10 years are educationally subnormal. Prognosis for infants with intrahepatic liver disease in the absence of known associated factors is good and every effort should be made to minimise the short term effects of cholestasis.

Use or abuse of phototherapy for physiological jaundice of newborn infants

To investigate the need for and effects of phototherapy in full-term otherwise healthy babies with physiological jaundice, 40 consecutive babies with serum bilirubin levels of 250 mumol/l or more were assigned at random to two treatment groups. Phototherapy was started in the early group (n = 20) when serum bilirubin was 250 mumol/l and in the late group (n = 20) when serum bilirubin reached 320 mumol/l; however, only 3 of the late group required treatment. Phototherapy prevented a further rise in bilirubin in almost all treated babies, but the difference in peak bilirubin level between early and late treatment groups was not significant. Early phototherapy produced a more rapid decline in bilirubin; levels fell to below 250 mumol/l in a median of 28 h with early treatment and 54 h with late treatment. In each group the ratio of boys to girls was 2/1 and boys remained jaundiced for significantly longer. Phototherapy therefore curtailed the rise and duration of hyperbilirubinaemia, but the effect was small. Jaundice subsided spontaneously in most of these mature infants, especially girls. Phototherapy can separate mother from baby, and it is physiologically stressful. Treatment may be safely withheld until serum bilirubin exceeds 320 mumol/l.

Water supplementation in jaundiced babies

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