Neonatal jaundice and its management: knowledge, attitude and practice of community health workers in Nigeria

Community health worker knowledge and perceptions of neonatal jaundice in Kumasi, Ghana

Background

This study sought to understand community health workers' (CHW) knowledge and perceptions of community beliefs surrounding neonatal jaundice (NNJ), a treatable but potentially fatal condition prevalent in sub-Saharan Africa.

Methods

In this cross-sectional qualitative study, CHWs in Kumasi, Ghana, completed in-depth interviews with trained research assistants using a semi-structured interview guide. Interviews were audiotaped, transcribed verbatim, and analyzed using grounded theory methodology.

Results

Knowledge of NNJ varied widely among the 23 respondents: 74% knew NNJ could cause death, 57% knew how to screen for NNJ. 35% of CHWs favored home treatment (sunlight therapy or watchful waiting). Three main themes emerged: CHWs perceived that caregivers prefer home treatment, equating hospital care with death; sunlight and herbs are the most common home treatments; and caregivers attribute NNJ to supernatural causes, delaying jaundice diagnosis.

Interpretation

Incomplete understanding of NNJ among trained CHWs and local communities will require improved education among both groups to improve outcomes.

Neonatal jaundice detection in low-resource Mexican settings: possibilities and barriers for innovation with mobile health

BACKGROUND

Neonatal jaundice is a common condition that can lead to brain damage and disabilities when severe cases go undetected. Low- and middle-income countries often lack accurate methods for detecting neonatal jaundice and rely on visual assessment, resulting in a higher incidence of adverse consequences. Picterus Jaundice Pro (Picterus JP), an easy-to-use and affordable smartphone-based screening device for the condition, has demonstrated higher accuracy than visual assessment in Norwegian, Philippine and Mexican newborns. This study aimed to identify the barriers and facilitators to implementing Picterus JP in public health services in low-income settings in Mexico by exploring the current process of neonatal jaundice detection and stakeholders' perspectives in that context.

METHODS

Qualitative data collection techniques, including one focus group, 15 semi-structured interviews and four observations, were employed in urban and rural health facilities in Oaxaca, Mexico. The participants included medical doctors, nurses and health administrators. The data were analysed by thematic analysis guided by the Consolidated Framework for Implementation Research.

RESULTS

The analysis yielded four main themes: (I) the current state of neonatal care and NNJ detection, (II) the needs and desires for enhancing NNJ detection, (III) the barriers and facilitators to implementing Picterus JP in the health system and (IV) HCWs' expectations of Picterus JP. The findings identify deficiencies in the current neonatal jaundice detection process and the participants' desire for a more accurate method. Picterus JP was perceived as easy to use, useful and compatible with the work routine, but barriers to adoption were identified, including internet deficiencies and costs.

CONCLUSIONS

The introduction of Picterus JP as a supporting tool to screen for neonatal jaundice is promising but contextual barriers in the setting must be addressed for successful implementation. There is also an opportunity to optimise visual assessment to improve detection of neonatal jaundice.

Demystifying non-invasive approaches for screening jaundice in low resource settings: a review

All national and international pediatric guidelines universally prescribe meticulous bilirubin screening for neonates as a critical measure to mitigate the incidence of acute bilirubin encephalopathy (ABE) and Kernicterus. The prevailing gold standard for jaundice detection in neonates necessitates invasive blood collection, followed by subsequent biochemical testing. While the invasive procedure provides dependable bilirubin measurements and continues to be the sole gold standard diagnostic method for assessing bilirubin concentration. There exists a pressing need to innovate non-invasive screening tools that alleviate the sampling stress endured by newborns, mitigate iatrogenic anemia, and expedite the turnaround time for obtaining results. The exploration of non-invasive modalities for bilirubin measurements is gaining momentum, driven by the overarching goal of minimizing the number of pricks inflicted upon neonates, thereby rendering screening a swift, efficient, comfortable, and dependable process. This comprehensive review article delves extensively into the array of non-invasive approaches and digital solutions that have been proposed, implemented, and utilized for neonatal bilirubin screening, with a particular emphasis on their application in low-resource settings. Within this context, the review sheds light on the existing methodologies and their practical applications, with a specific focus on transcutaneous bilirubin meters. Moreover, it underscores the prevailing open challenges in this domain and outlines potential directions for future research endeavors. Notably, the review underscores the imperative need for robust educational programs targeted at both families and healthcare personnel to expedite the process of seeking timely care for neonatal jaundice. Additionally, it underscores the necessity for the development of enhanced screening and diagnostic tools that can offer greater accuracy in clinical practice.

An investigation of motor development and sensory processing skills in infants with a history of hyperbilirubinemia

BACKGROUND

Hyperbilirubinemia is a clinical picture frequently occurring in the neonatal period and may negatively affect the development of infants.

AIMS

To evaluate term infants with hyperbilirubinemia in terms of both motor development and sensory processing skills and to compare them with their healthy peers without hyperbilirubinemia.

STUDY DESIGN

A cross-sectional study.

SUBJECTS

Children born at term, aged 10-18 months, with and without a history of hyperbilirubinemia were included in the study.

OUTCOME MEASURES

After demographic information was recorded, motor development was evaluated with the Peabody Motor Development Scale-2 and sensory processing skills were evaluated with the Test of Sensory Function in Infant.

RESULTS

A total of 42 children (mean ± SD age of the children 13.07 ± 1.47 months, 22 with hyperbilirubinemia and 20 without hyperbilirubinemia) were included in the study. A statistically significant difference was found in the gross motor (p = 0.02), fine motor (p = 0.03), and total motor (p = 0.017) development scores of the Peabody Motor Development Scale-2 and in the adaptive motor functions (p = 0.004), visual tactile integration (p < 0.001), and total scores (p = 0.004) of The Test of Sensory Function in Infant in favor of the control group.

CONCLUSIONS

The motor and sensory processing skills of children born at term with hyperbilirubinemia may be negatively affected. Infants with hyperbilirubinemia should be evaluated from the early period not only in terms of motor but also sensory processing skills and should be supported with appropriate intervention programs.

Knowledge and Attitudes of Parents Regarding Neonatal Jaundice in Bisha City, Saudi Arabia

Background Neonatal jaundice (NNJ) is one of the most common neonatal illnesses around the world. It continues to be a leading cause of avoidable brain damage, physical and mental impairment, and death in neonates. Neonatal morbidity due to NNJ has a significant impact and cost on families and healthcare resources. The majority of instances are addressed without intervention, but others require assessment and assistance in the form of follow-up or treatment. Inadequate family awareness and understanding of this frequent newborn condition can contribute to delays and difficulties. Aim This study aimed to assess the knowledge and attitudes of parents regarding NNJ in Bisha City, Saudi Arabia. Methodology A cross-sectional study involving 242 participants was carried out. Data were collected using an online questionnaire. The knowledge score differences between groups were analyzed using a Wilcoxon rank sum test and the Kruskal-Wallis rank test. Results In this study of 242 participants from Bisha, we found that the majority were female (155, 64.0%), employed (129, 53.3%), and held a postgraduate degree (150, 62.0%). Regarding knowledge of NNJ, 109 (45.0%) have correctly defined it as yellow pigmentation in the sclera and 64 (26.4%) as yellow pigmentation of the skin. Of most participants, 132 (54.5%) recognized that NNJ could cause complications, but 53 (40.2%) of these were unaware of what these complications might be. Notably, only 89 (36.8%) of respondents believed they had sufficient knowledge about NNJ. The median knowledge score was 3.0 (IQR, 1.0-4.0), and higher scores were significantly associated with being female and reporting sufficient knowledge about the disease. Strategies suggested for improving awareness included campaigns (98, 40.5%) and social networking programs (81, 33.5%). The data suggest a need for enhanced public education regarding NNJ. Conclusion The study highlights the need for increased awareness and education among parents in Bisha, Saudi Arabia, about NNJ. The findings suggest that campaigns and social networking programs could effectively educate people about the condition. Additionally, the study provides insights into the factors associated with higher knowledge scores, such as gender and having a child with NNJ. The results of this study may help healthcare professionals develop effective educational programs and interventions to improve parents' knowledge and attitudes toward NNJ.

Feasibility and acceptability of home-based neonatal hyperbilirubinemia screening by community health workers using transcutaneous bilimeters in Bangladesh

BACKGROUND

Universal screening for neonatal hyperbilirubinemia risk assessment is recommended by the American Academy of Pediatrics to reduce related morbidity. In Bangladesh and in many low- and middle-income countries, there is no screening for neonatal hyperbilirubinemia. Furthermore, neonatal hyperbilirubinemia may not be recognized as a medically significant condition by caregivers and community members. We aimed to evaluate the acceptability and operational feasibility of community health worker (CHW)-led, home-based, non-invasive neonatal hyperbilirubinemia screening using a transcutaneous bilimeter in Shakhipur, a rural subdistrict in Bangladesh.

METHODS

We employed a two-step process. In the formative phase, we conducted eight focus group discussions with parents and grandparents of infants and eight key informant interviews with public and private healthcare providers and managers to explore their current knowledge, perceptions, practices, and challenges regarding identification and management of neonatal hyperbilirubinemia. Next, we piloted a prenatal sensitization intervention and home-based screening by CHWs using transcutaneous bilimeters and evaluated the acceptability and operational feasibility of this approach through focus group discussions and key informant interviews with parents, grandparents and CHWs.

RESULTS

Formative findings identified misconceptions regarding neonatal hyperbilirubinemia causes and health risks among caregivers in rural Bangladesh. CHWs were comfortable with adoption, maintenance and use of the device in routine home visits. Transcutaneous bilimeter-based screening was also widely accepted by caregivers and family members due to its noninvasive technique and immediate display of findings at home. Prenatal sensitization of caregivers and family members helped to create a supportive environment in the family and empowered mothers as primary caregivers.

CONCLUSION

Adopting household neonatal hyperbilirubinemia screening in the postnatal period by CHWs using a transcutaneous bilimeter is an acceptable approach by both CHWs and families and may increase rates of screening to prevent morbidity and mortality.

Neonatal Jaundice: Knowledge and Practices of Healthcare Providers and Trainees in Southwest Nigeria

Severe neonatal jaundice (SNNJ) is a leading cause of neonatal morbidity and mortality in low- and middle-income countries (LMICs). Risk mitigation and management modalities for SNNJ have led to marked reduction in complications in high-income countries but not in LMICs likely in part due to knowledge gaps among healthcare providers. This study, a cross-sectional study conducted in Ogbomosho, Nigeria, aimed to identify SNNJ knowledge and practices among Nigerian healthcare providers/trainees. Healthcare providers/trainees completed a structured questionnaire. Healthcare providers/trainees included are nurse midwives (33.4%), nurses (18.6%), nursing students (15.2%), traditional birth attendants (TBAs) (12.7%), physicians (10.2%), and medical students (9.9%). Most physicians were aware of the common causes of SNNJ; however, knowledge deficits in other groups were notable. Despite most providers endorsing that glucose-6-phosphate dehydrogenase deficiency can cause SNNJ (91% of physicians, 60% of nurses, 71% of midwives, 81% of medical students, 43% of nursing students, 7% of TBAs), very few providers recognized that it is common, ranging from 3% in nurses up to a high of 47% among medical students. Gaps in provider knowledge regarding preventative measures and sequela were also noted. These data identified significant knowledge gaps regarding the etiology of SNNJ among healthcare providers/trainees, which can lead to missed opportunities in effective prevention and treatment. These deficits must be addressed if we are to eliminate tragic and preventable complications from SNNJ in Nigeria and other LMICs.

KNOWLEDGE OF HEALTH WORKERS ON CHOLERA MANAGEMENT IN OYO STATE: RESULTS OF A TRAINING INTERVENTION

INTRODUCTION

Primary Health Care (PHC) workers are usually the frontline health workers involved in disseminating health education to the community and implementing cholera prevention and management guidelines. Given that inadequate health worker performance has been a problem in resource-limited settings such as Nigeria and poor health worker knowledge has been implicated in poor health status in developing nations, continuous training of health workers to improve their knowledge has been recommended to improve health outcomes.

OBJECTIVE

This study seeks to ascertain the level of improvement in the knowledge of health workers on cholera, if any, after one of such interventions was carried out in Oyo State. Similarly, the study seeks to discern the specific domains of knowledge on cholera, if any, which were significantly affected by the intervention.

METHODS

The research was conducted utilizing a pre-post study design to recruit PHC health workers from four local government areas of Oyo State between October and November 2016. Baseline and endline data were collected at both intervention and control sites using a self-administered questionnaire with sections eliciting responses to questions on general knowledge of symptoms of cholera, prevention methods, knowledge and practice of safety procedures health workers. Descriptive statistics and chi-square tests were used to present the data and test for statistical associations between categorical variables at 5% respectively.

RESULTS

A total of 542 health workers divided into 2 groups (intervention and control), were interviewed at baseline and at endline. At baseline, the 40-49 years age group was the most represented in the intervention arm (40.0%), the 30-39 years age group was the most represented in the control arm (34.2%). At baseline, only 35.2% of health workers in the intervention sites had good knowledge on cholera. This figure was increased to 52.7% after the intervention. This difference in proportions was also statistically significant (p=0.004). In the control sites, the opposite was observed as the proportion of health workers with good knowledge on cholera slightly reduced from 47.2% to 43.6%. This difference was however not statistically significant (p=0.563).

CONCLUSION

The results from the evaluation of the intervention show that the training significantly improved the overall knowledge of health workers. However, future training interventions can be aimed at improving knowledge of health workers on alert threshold of cholera. In addition, continuous education programs on disease and surveillance and notification should be planned for PHC workers to improve their knowledge.

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.

Breastfeeding in Relation to Neonatal Jaundice in the First Week After Birth: Parents' Perceptions and Clinical Measurements

Background: Parents may consider interrupting breastfeeding to manage neonatal jaundice (NJ). Our aims were to determine correlations of breastfeeding with NJ by examining infants' manifestations in the first week after birth and to understand parents' perceptions toward NJ in relation to breastfeeding. Materials and Methods: This prospective cross-sectional study was conducted in a tertiary medical center by examining infants and administering a questionnaire survey to their parents. All healthy infants admitted to the well-baby nursery were eligible for enrollment. A 16-item questionnaire was distributed to parents of enrolled infants from October 2017 to February 2019. Items of the questionnaire included perceptions and knowledge of NJ. In addition, clinical information of enrolled infants was obtained from medical records. Hyperbilirubinemia was defined as a peak transcutaneous bilirubinometer value ≥15 mg/dL. Results: In total, 449 parents completed the consent form and participated in the study. Results showed that exclusive breastfeeding was more common in infants with a vaginal delivery (p < 0.001), who were nonprimiparous (p = 0.004) and who had weight loss of >7% (p < 0.001). There was no significant correlation of exclusive breastfeeding with hyperbilirubinemia (p = 0.414). Approximately two-thirds of parents were worried about NJ occurring in their child. Most parents were aware of phototherapy as management of NJ. However, their knowledge of risk factors, complications, and assessments of NJ was relatively deficient. Overall, 29.6% of parents rated breastfeeding as a risk factor for NJ, and 24% of parents indicated that cessation of breastfeeding was a management option for NJ. Conclusions: The results indicated that NJ in the first few days after birth poses a significant barrier to breastfeeding. Our findings provide critical information for plotting strategies to enhance parents' willingness to continue breastfeeding.

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.

Neurodevelopmental outcome of healthy term newborn with serum bilirubin >15 mg/dl at one year

BACKGROUND

Neonatal hyperbilirubinemia is a common medical emergency in early neonatal period. Unconjugated bilirubin is neurotoxic and can lead to lifelong neurological sequelae in survivors.

OBJECTIVE

To find out the association between serum bilirubin and neurodevelopmental outcome at 1 year of age using Development Assessment Scale for Indian Infants (DASII).

METHODS

A prospective cohort study was conducted in the Department of Pediatrics of a tertiary care institution of Central India between January 2018 and August 2019. Total 108 term healthy neonates, with at least one serum bilirubin value of >15 mg/dl, were included. Subjects were divided into three groups based on the serum bilirubin; group 1: (15-20 mg/dl) -85(78.7%) cases, group 2: (20-25 mg/dl) -17(15.7%), and group 3: (>25 mg/dl) -6(5.5%). Developmental assessment was done using DASII at 3, 6, 9, 12 months of age.

RESULTS

Out of 108 cases, 101(93.5%) received phototherapy, and 7(6.5%) received double volume exchange transfusion. Severe delay was observed in 5(4.6%) and mild delay in 2(1.9%) cases in the motor domain of DASII at one year. Severe delay in the motor domain was associated with mean TSB of 27.940±2.89 mg/dl and mild delay with mean TSB of 22.75±1.76 mg/dl (p = 0.001). On cluster analysis, delay was observed in locomotion 1 score in 11(13%) cases (p = 0.003) and manipulation score in 6(7.1%) cases in group 1.

CONCLUSION

Increased serum bilirubin was a significant risk factor for the delayed neurodevelopment in babies with neonatal jaundice. Even a moderate level of bilirubin significantly affects the developmental outcome.

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

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.

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.

Rationale and Design of Khuzestan Vitamin D Deficiency Screening Program in Pregnancy: A Stratified Randomized Vitamin D Supplementation Controlled Trial

BACKGROUND

Although there have been marked improvements in our understanding of vitamin D functions in different diseases, gaps on its role during pregnancy remain. Due to the lack of consensus on the most accurate marker of vitamin D deficiency during pregnancy and the optimal level of 25-hydroxyvitamin D, 25(OH)D, for its definition, vitamin D deficiency assessment during pregnancy is a complicated process. Besides, the optimal protocol for treatment of hypovitaminosis D and its effect on maternal and neonatal outcomes are still unclear.

OBJECTIVE

The aim of our study was to estimate the prevalence of vitamin D deficiency in the first trimester of pregnancy and to compare vitamin D screening strategy with no screening. Also, we intended to compare the effectiveness of various treatment regimens on maternal and neonatal outcomes in Masjed-Soleyman and Shushtar cities of Khuzestan province, Iran.

METHODS

This was a two-phase study. First, a population-based cross-sectional study was conducted; recruiting 1600 and 900 first trimester pregnant women from health centers of Masjed-Soleyman and Shushtar, respectively, using stratified multistage cluster sampling with probability proportional to size (PPS) method. Second, to assess the effect of screening strategy on maternal and neonatal outcomes, Masjed-Soleyman participants were assigned to a screening program versus Shushtar participants who became the nonscreening arm. Within the framework of the screening regimen, an 8-arm blind randomized clinical trial was undertaken to compare the effects of various treatment protocols. A total of 800 pregnant women with vitamin D deficiency were selected using simple random sampling from the 1600 individuals of Masjed-Soleyman as interventional groups. Serum concentrations of 25(OH)D were classified as: (1) severe deficient (<10ng/ml), (2) moderate deficient (10-20ng/ml), and (3) normal status (>20ng/ml). Those with severe and moderate deficiency were randomly divided into 4 subgroups and received vitamin D3 based on protocol and were followed until delivery. Data was analyzed according to the intention-to-treat principle.

RESULTS

Recruitment commenced in July, 2014, and as estimated, nearly 3.5 years is needed to complete the study. Results of this study will (1) provide reliable information regarding the prevalence of vitamin D deficiency during pregnancy using universal vitamin D screening approach and (2) determine the beneficial effects of universal screening and compare the various treatment protocols in terms of pregnancy outcomes.

CONCLUSIONS

Since vitamin D deficiency is a prevalent disorder in pregnancy among Iranian population, this study will ensure creation of reliable evidence-based findings and will enable clinicians to better evaluate and treat vitamin D deficient pregnant women.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number (ISRCTN): 2014102519660N1; http://www.irct.ir/searchresult.php?keyword=&id=19660&number=1&prt=7805&total=10&m=1 (Archived by WebCite at http://www.webcitation.org/6p3lkqFdV).

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.

Primary health workers' knowledge and practices relating to neonatal jaundice in Ibadan, Nigeria

Background

Over half of births and newborn care occur in primary healthcare facilities in Nigeria, but information on activities of personnel working there is scarce.

Aim

To assess the knowledge and practices relating to neonatal jaundice (NNJ) among community health workers (CHWs) and community birth attendants (CBAs) in Nigeria.

Setting

We conducted a cross-sectional survey of all 227 CHWs and 193 registered CBAs in Ibadan, Nigeria.

Methods

Knowledge and practices regarding NNJ were measured using a pretested questionnaire. Knowledge and practices were assessed on a 33-point scale and a 13-point scale, respectively. Scores ≤ 17 and ≤ 9 was regarded as poor knowledge and as wrong practice, respectively.

Results

Many (64.5%) of the respondents could not correctly describe examination for NNJ (CHWs: 49.4%; CBAs: 50.6%). Of the 200 (47.6%) who treated NNJ 3 months prior to the study, 62.5% (CHWs: 66.9% and CBAs: 53.7%) treated NNJ with orthodox drugs. Drugs prescribed included: antibiotics (93.3%), antimalarials (5.3%), multivitamins (28.0%), paracetamol (6.2%) and phenobarbitone (7.1%). Significantly more CHWs than CBAs practiced exposure to sunlight (33.1% versus 16.4%) and administration of glucose water (28.6% versus 14.9%), while 58.0% of all respondents referred cases to secondary health facilities. Overall, 80.2% had poor knowledge (CHWs: 78.9%; CBAs: 81.9%) and 46.4% engaged in wrong practices (CHWs: 57.3%; CBAs: 33.7%). CHWs were more likely to indulge in wrong practices than CBAs (OR = 2.22, 95% CI = 1.03, 4.79).

Conclusion

Primary Health Workers in Ibadan had poor knowledge and engaged in wrong practices about NNJ. The needs to organise regular training programmes were emphasised.

The Association between Prolonged Jaundice and UGT1A1 Gene Polymorphism (G71R) in Gilbert's Syndrome

INTRODUCTION

Jaundice is a common condition during the neonatal period. Prolonged jaundice occurs in a large number of breastfed infants. Considering the impact of genetic factors on the incidence of jaundice present study was conducted.

AIM

The aim of this study was to determine the association between prolonged jaundice and G71R polymorphism in Gilbert's syndrome.

MATERIALS AND METHODS

This case-control study was conducted at Taleghani Children's Hospital of Gorgan, Iran. The study group consisted of 87 icteric patients (aged more than 2 weeks) with an indirect bilirubin level higher than 10mg/dL. The control group consisted of 81 newborns without jaundice. The two groups were matched in terms of age and gender. DNA extraction was performed by "phenol-chloroform" method. Polymerase Chain Reaction with Confronting Two-Pair Primers (PCR-CTPP) was applied to amplify G71R polymorphism.

RESULTS

Overall, 84% and 64% of subjects in the study and control groups were male, respectively. The distribution of Gilbert genotype was not significantly different between the two groups (p=0.772). There was a correlation between prolonged jaundice in males and UGT1A1 G71R polymorphism (p =0.03). In the study group, 5(5.7%) subjects were homozygous (for A/A), 73 (83.9%) were heterozygous (for A/G), and 9(10.3%) were normal (for G/G). In the control group, 3(3.7%) participants were homozygous (A/A), 68(84%) were heterozygous (A/G) and 10 (12.3%) were normal (G/G).

CONCLUSION

There was no association between prolonged jaundice and G71R polymorphism, even though a relationship was revealed between male gender and the mentioned polymorphism.

Hyperbilirubinemia in Neonates: Types, Causes, Clinical Examinations, Preventive Measures and Treatments: A Narrative Review Article

BACKGROUND

Hyperbilirubinemia, or jaundice, is a life threatening disorder in newborns. It is a multifactorial disorder with many symptoms. Generally, the physiological jaundice is the most prevalent type however in some regions pathological jaundice is also common. This review article focuses on a brief introduction to jaundice, its types and causes, measuring the bilirubin level, clinical approaches towards hyperbilirubinemia, different precautionary measures for the parents of babies suffering from hyperbilirubinemia and different remedial therapeutic measures for its treatment.

METHODS

The main databases including Scopus, Pubmed, MEDLINE, Google scholar and Science Direct were researched to obtain the original papers related to the newborns' hyperbilirubinemia. The main terms used to literature search were "newborns' hyperbilirubinemia", "newborns' jaundice", "Physiological Jaundice" and "Patholigical Jaundice". The timeframe included the obtained articles was from 1952 to 2015.

RESULTS

Neonatal jaundice due to breast milk feeding is also sometimes observed. Hemolytic jaundice occurs because of the incompatibility of blood groups with ABO and Rh factors, when the fetus and mother blood groups are not compatible and the fetus blood crosses the barrier of the umbilical cord before birth causing fetus blood hemolysis owing to severe immune response.

CONCLUSION

Jaundice is easily diagnosable however require quick and on the spot treatment. If not treated properly, it leads to many complications. Currently the treatment options for jaundice include photo therapy, chemotherapy, and vaccinations.

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.

Relation between Neonatal Icter and Gilbert Syndrome in Gloucose-6-Phosphate Dehydrogenase Deficient Subjects

BACKGROUND AND AIM

The pathogenesis of neonatal hyperbilirubinemia hasn't been completely defined in Gloucose-6-Phosphate Dehydrogenase (G6PD) deficient newborns. The aim of this study was to detect the relationship between Gilbert's syndrome and hyperbilirubinemia in Gloucose-6-Phosphate Dehydrogenase (G6PD) deficient neonates.

MATERIALS AND METHODS

This case-control study was conducted in Amirkola pediatrics teaching hospital, Babol, Iran. A total number of one hundred four infants were included in the study (51 infants with neonatal jaundice and Gloucose-6-Phosphate Dehydrogenase (G6PD) deficiency admitted to phototherapy or transfusion were selected as the case group and 53 infants with Gloucose-6-Phosphate Dehydrogenase (G6PD) deficiency admitted for other reasons than jaundice were selected as the control group). Exclusion criteria were ABO or Rh incompatibility or other reasons that made Coombs test positive, sepsis, hepatosplenomegaly, metabolic diseases, medical treatment and phototherapy. The promoter and coding regions of Uridine diphosphate Glucuronosyl Transferase 1A1 (UGT1A1) of genomic DNA were amplified by polymerase chain reaction (PCR) isolated from leukocytes. We used chi-square test and t-test to compare cases and controls.

RESULTS

Distribution of Gilbert genome was not significantly different between the two groups; among cases, 33.3% were homozygote, 35.3% heterozygote, and 31.4% normal. Among controls, 22.6% were homozygote, 34% heterozygote, and 43.4% normal (p-value=xxx). Hyperbilirubinemia family history didn't differ significantly between these two groups.

CONCLUSIONS

We showed that in Gloucose-6-Phosphate Dehydrogenase (G6PD) deficient neonates, there was no significant association between Gilbert's syndrome (promoter polymorphism) and hyperbilirubinemia.

Urinary tract infection and indirect hyperbilirubinemia in newborns

Background:

Jaundice is a common problem during the neonatal period. About 60% of the full term and 80% of premature infants develop jaundice. It can be associated with serious illnesses such as Urinary tract infections.

Aims:

The aim of this study is to evaluate the incidence and prevalence of urinary tract infection in newborns with indirect hyperbilirubinemia and to find a relationship with prolonged jaundice.

Patients and Methods:

We retrospectively evaluated asymptomatic, jaundiced neonates for evidence of a urinary tract infection. Data reviewed including demographic and historical data were included with data of blood studies, radiological evaluation and treatment.

Results:

32 neonates of 152 cases had urinary tract infection. Most commonly isolated organisms were Klebsiella and Escherishia coli. Maximum duration of phototherapy was 4 days in the urinary tract infection group versus 7 in the non-urinary tract infection group. Intensive phototherapy was used in 18.7% in the urinary tract infection group versus 29.16% in the non-urinary tract infection group. None of the newborns in the urinary tract infection group underwent exchange transfusion therapy.

Conclusion:

Urinary tract infection can occur in asymptomatic, jaundiced newborns. Thus, it may be the first in these babies before other signs become evident.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Are doctors and nurses associated with coverage of essential health services in developing countries? A cross-sectional study

BACKGROUND

There is broad policy consensus that a shortage of doctors and nurses is a key constraint to increasing utilization of essential health services important for achieving the health Millennium Development Goals. However there is limited research on the quantitative links between health workers and service coverage rates. We examined the relationship between doctor and nurse concentrations and utilization rates of five essential health services in developing countries.

METHODS

We performed cross-national analyses of low- and middle-income countries by means of ordinary least squares regression with coverage rates of antenatal care, attended delivery, caesarean section, measles immunization, tuberculosis case diagnosis and care for acute respiratory infection as outcomes. Doctor, nurse and aggregate health worker (sum of doctors and nurses) concentrations were the main explanatory variables.

RESULTS

Nurses were associated with utilization of skilled birth attendants (P=0.02) and doctors were associated with measles immunization rates (P=0.01) in separate adjusted analyses. Aggregate health workers were associated with the utilization of skilled birth attendants (P<0.01) and measles immunization (P<0.01). Doctors, nurses and aggregate health workers were not associated with the remaining four services.

CONCLUSION

A range of health system and population-level factors aside from health workers influences coverage of health services in developing countries. However, it is also plausible that health workers who are neither doctors nor nurses, such as clinical officers and community health workers, may be providing a substantial proportion of health services. The human resources for health research agenda should be expanded beyond doctors and nurses.

Infants with severe neonatal jaundice in Lagos, Nigeria: incidence, correlates and hearing screening outcomes

OBJECTIVES

To establish the incidence, correlates and hearing screening outcomes of infants with severe neonatal jaundice in Nigeria.

METHODS

Community-based study in which all infants attending Bacille Calmette-Guérin immunisation clinics in inner-city Lagos were enrolled into a universal hearing screening programme during which correlates of severe neonatal jaundice (requiring phototherapy and/or exchange blood transfusion) were explored with multivariable logistic regression.

RESULTS

Of the 5262 infants enrolled, only 48.7% were born in hospitals although almost all mothers (97.9%) attended antenatal clinics. 6.7% had a history of neonatal jaundice of whom 5.5% (95% CI:4.9-6.2) received phototherapy and 1.9% (95% CI:1.5-2.3) had an exchange blood transfusion. Factors independently associated with severe neonatal jaundice were maternal religion, occupation, use of herbal preparations during pregnancy, infant's gender, weight at screening, multiple gestation and place of birth. All but two infants with severe neonatal jaundice were exclusively breast-fed. Of those who failed the hearing tests, 17.3% were treated with phototherapy and 11.3% had an exchange blood transfusion. At least 8.9% of infants requiring phototherapy and 17.3% of those requiring exchange blood transfusion were at risk of sensorineural hearing loss.

CONCLUSIONS

Severe neonatal jaundice is a significant condition associated with modifiable risk factors in this population. Policy initiatives for prevention, early detection followed by appropriate and timely intervention are urgently needed to reduce the disease burden.

Photoisomers: obfuscating factors in clinical peroxidase measurements of unbound bilirubin?

OBJECTIVES

The objectives of the study were to measure the effect of 4Z,15E-bilirubin on peroxidase free bilirubin measurements and to review the literature on this topic.

METHODS

4Z,15E-Bilirubin was generated in situ in serum or serum albumin solution through controlled irradiation of isomerically pure 4Z,15Z-bilirubin IXalpha, under conditions in which the total amount of bilirubin remained constant. Reactions were monitored by difference spectroscopy, to ensure that solutions were not irradiated beyond the initial photostationary state and that concentrations of other isomers were kept to a minimum. Prepared in this way, 10% to 25% of the total bilirubin in the final solutions was in the form of the 4Z,15E-isomer. Free bilirubin in the solutions was measured with a peroxidase method, before and after irradiation. The use of bovine serum albumin as a surrogate for human albumin in in vitro studies also was investigated.

RESULTS

The findings of previous studies are not altogether consistent, with a common flaw in several being the failure to measure photoisomer concentrations. For bilirubin in serum albumin solution, conversion of approximately 25% of the 4Z,15Z-isomer to 4Z,15E-bilirubin led to a much smaller decrease (<20%) in the apparent free bilirubin concentration; for bilirubin in serum, conversion of approximately 15% of the 4Z,15Z-isomer to photoisomers resulted in a much larger increase ( approximately 40%). Irradiation of bilirubin in bovine serum albumin solution generated a very different array of photoisomers than that observed in human albumin solutions.

CONCLUSIONS

The effect of photoisomers on the accuracy and specificity of free 4Z,15Z-bilirubin measurements remains uncertain. In a clinical setting, free bilirubin measurements need to be interpreted with caution when samples contain photoisomers. Irradiated bovine albumin solutions of isomerically impure bilirubin used in previous studies are poor models for investigating the effects of phototherapy in humans and the albumin binding of photoisomers.

Neonatal jaundice: knowledge and practice of Iranian mothers with icteric newborns

The present study was conducted on a group of Iranian mothers with icteric newborn in order to identify any wrong knowledge and improper practices related to the neonatal jaundice. Such an estimate of knowledge and practices of mothers may be required for implementing the educational programs on which the preventive measures of kernicterus are principally thought to be depended. Between June 2004 and February 2007, 1666 mothers with icteric newborn hospitalized at a single center were enrolled. A questionnaire was used to assess the participants' knowledge and practice of neonatal jaundice. A knowledge score was calculated based on the responses. The mean knowledge score was 3.38 +/- 1.23 (out of 6). About 77% of the mothers had moderate-to-high level of knowledge of neonatal jaundice. Approximately one-third of the mothers consulted a physician within 24 h of appearance of jaundice and 13.8% declared that they waited and managed their children with traditional remedies until they sought medical advices. Furthermore, 32.2% of the mothers discontinued feeding their icteric offspring with colored foods and colostrums. Hence, 42.8% of the mothers acted weakly with regard to their icteric offspring. The health care workers were the participants' major source of information about neonatal jaundice. The present study determined a fairly adequate knowledge of Iranian mothers about the neonatal jaundice with incomparable level of related practices. The findings of this study should be considered seriously by the local health centers and the medical professionals to provide consistent information about jaundice and its causes for the parents.