High levels of pathological jaundice in the first 24 hours and neonatal hyperbilirubinaemia in an epidemiological cohort study on the Thailand-Myanmar border

Mother, child and adolescent health outcomes in two long-term refugee camp settings at the Thai-Myanmar border 2000-2018: a retrospective analysis

AIM

The study assessed mothers, children and adolescents' health (MCAH) outcomes in the context of a Primary Health Care (PHC) project and associated costs in two protracted long-term refugee camps, along the Thai-Myanmar border.

BACKGROUND

Myanmar refugees settled in Thailand nearly 40 years ago, in a string of camps along the border, where they fully depend on external support for health and social services. Between 2000 and 2018, a single international NGO has been implementing an integrated PHC project.

METHODS

This retrospective study looked at the trends of MCAH indicators of mortality and morbidity and compared them to the sustainable development goals (SDGs) indicators. A review of programme documents explored and triangulated the evolution and changing context of the PHC services, and associated project costs were analysed. To verify changes over time, interviews with 12 key informants were conducted.

FINDINGS

While maternal mortality (SDG3.1) remained high at 126.5/100,000 live births, child mortality (SDG 3.2) and infectious diseases in children under 5 (SDG 3.3) fell by 69% and by up to 92%, respectively. Maternal anaemia decreased by 30%; and more than 90% of pregnant women attended four or more antenatal care visits, whereas 80% delivered by a skilled birth attendant; caesarean section rates rose but remained low at an average of 3.7%; the adolescent (15-19 years) birth rate peaked at 188 per 1000 in 2015 but declined to 89/1000 in 2018 (SDG 3.7).

CONCLUSION

Comprehensive PHC delivery, with improved health provider competence in MCAH care, together with secured funding is an appropriate strategy to bring MCAH indicators to acceptable levels. However, inequities due to confinement in camps, fragmentation of specific health services, prevent fulfilment of the 2030 SDG Agenda to 'Leave no one behind'. Costs per birth was 115 EURO in 2018; however, MCAH expenditure requires further exploration over a longer period.

Jaundice and its associated factors among neonates admitted to selected referral hospitals in southwest oromia, Ethiopia: Multi-center cross-sectional study

Background

Jaundice is a common clinical problem during the first month of birth throughout the world. Mainly, it is the leading cause of neonatal morbidity and mortality in developing countries.

Objectives

The aimed of this studied was to assess predictors of jaundice among neonates admitted to selected referral hospitals in southwest Oromia, Ethiopia, 2021.

Methods

An Institutional based cross-sectional study was implemented among 205 admitted neonates at selected referral hospitals in southwest Oromia, Ethiopia from October 05 to November 5, 2021. Jimma medical center (JMC), Wollega University referral hospital (WURH), and Ambo University Referral hospital (AURH) were selected by simple random sampling technique. A pretested structured interviewer-administered questionnaire and medical record review was used to collect data. Both binary and multivariable logistic regression analyses were performed to identify factors associated with neonatal jaundice. Logistic regression analyses were performed to identify factors associated with neonatal jaundice. Statistical Significance was declared at P-value less than 0.05 in the final model, and if the confidence interval does not include the null hypothesis value.

Results

The prevalence of neonatal jaundice was 20.5% (95%CI: 1.74-1.85). The mean age of neonates was 8.6 ± 7.8 days. Traditional medicine use during current pregnancy (AOR: 5.62, 95%CI: 1.07, 9.52), Rh incompatibility (AOR: 0.045, 95%CI: 0.01, 0.21), gestational age (AOR: 4.61, 95%CI: 1.05, 10.3), premature rupture of membrane (AOR: 3.76, 95%CI: 1.58, 8.93) and hypertension (mother) (AOR: 3.99, 95%CI: 1.13, 14.02) were factors significantly associated with neonatal jaundice.

Conclusion

Neonatal jaundice was relatively higher in the current study. Traditional medicine use, Rh incompatibility, premature ruptures of membrane, hypertension, and preterm gestational age were factors associated with neonatal jaundice.

Born too soon in a resource-limited setting: A 10-year mixed methods review of a special care baby unit for refugees and migrants on the Myanmar-Thailand border

Background

Preterm birth is a major public health concern with the largest burden of morbidity and mortality falling within low- and middle-income countries (LMIC).

Materials and methods

This sequential explanatory mixed methods study was conducted in special care baby units (SCBUs) serving migrants and refugees along the Myanmar-Thailand border. It included a retrospective medical records review, qualitative interviews with mothers receiving care within SCBUs, and focus group discussions with health workers. Changes in neonatal mortality and four clinical outcomes were described. A mix of ethnographic phenomenology and implementation frameworks focused on cultural aspects, the lived experience of participants, and implementation outcomes related to SCBU care.

Results

From 2008-2017, mortality was reduced by 68% and 53% in very (EGA 28-32 weeks) and moderate (EGA 33-36 weeks) preterm neonates, respectively. Median SCBU stay was longer in very compared to moderate preterm neonates: 35 (IQR 22, 48 days) vs. 10 days (IQR 5, 16). Duration of treatments was also longer in very preterm neonates: nasogastric feeding lasted 82% (IQR 74, 89) vs. 61% (IQR 40, 76) of the stay, and oxygen therapy was used a median of 14 (IQR 7, 27) vs. 2 (IQR 1, 6) days respectively. Nine interviews were conducted with mothers currently receiving care in the SCBU and four focus group discussions with a total of 27 local SCBU staff. Analysis corroborated quantitative analysis of newborn care services in this setting and incorporated pertinent implementation constructs including coverage, acceptability, appropriateness, feasibility, and fidelity. Coverage, acceptability, and appropriateness were often overlapping outcomes of interest highlighting financial issues prior to or while admitted to the SCBU and social issues and support systems adversely impacting SCBU stays. Interview and FGD findings highlight the barriers in this resource-limited setting as they impact the feasibility and fidelity of providing evidence-based SCBU care that often required adaptation to fit the financial and environmental constraints imposed by this setting.

Discussion

This study provides an in-depth look at the nature of providing preterm neonatal interventions in a SCBU for a vulnerable population in a resource-limited setting. These findings support implementation of basic evidence-based interventions for preterm and newborn care globally, particularly in LMICs.

Technical evaluation and usability of a quantitative G6PD POC test in cord blood: a mixed-methods study in a low-resource setting

OBJECTIVES

New point-of-care (POC) quantitative G6PD testing devices developed to provide safe radical cure for Plasmodium vivax malaria may be used to diagnose G6PD deficiency in newborns at risk of severe neonatal hyperbilirubinaemia, improving clinical care, and preventing related morbidity and mortality.

METHODS

We conducted a mixed-methods study analysing technical performance and usability of the 'STANDARD G6PD' Biosensor when used by trained midwives on cord blood samples at two rural clinics on the Thailand-Myanmar border.

RESULTS

In 307 cord blood samples, the Biosensor had a sensitivity of 1.000 (95% CI: 0.859 to 1.000) and a specificity of 0.993 (95% CI: 0.971 to 0.999) as compared with gold-standard spectrophotometry to diagnose G6PD-deficient newborns using a receiver operating characteristic (ROC) analysis-derived threshold of ≤4.8 IU/gHb. The Biosensor had a sensitivity of 0.727 (95% CI: 0.498 to 0.893) and specificity of 0.933 (95% CI: 0.876 to 0.969) for 30%-70% activity range in girls using ROC analysis-derived range of 4.9-9.9 IU/gHb. These thresholds allowed identification of all G6PD-deficient neonates and 80% of female neonates with intermediate phenotypes.Need of phototherapy treatment for neonatal hyperbilirubinaemia was higher in neonates with deficient and intermediate phenotypes as diagnosed by either reference spectrophotometry or Biosensor.Focus group discussions found high levels of learnability, willingness, satisfaction and suitability for the Biosensor in this setting. The staff valued the capacity of the Biosensor to identify newborns with G6PD deficiency early ('We can know that early, we can counsel the parents about the chances of their children getting jaundice') and at the POC, including in more rural settings ('Because we can know the right result of the G6PD deficiency in a short time, especially for the clinic which does not have a lab').

CONCLUSIONS

The Biosensor is a suitable tool in this resource-constrained setting to identify newborns with abnormal G6PD phenotypes at increased risk of neonatal hyperbilirubinaemia.

Establishment and Evaluation of Influencing Factors and Risk Prediction Model of Severe Neonatal Hyperbilirubinemia Complicated with Acute Bilirubin Encephalopathy

Objective

To explore the influencing factors of severe hyperbilirubinemia in neonates complicated with acute bilirubin encephalopathy (ABE) and then build relevant prediction models and evaluate the prediction performance of the models.

Methods

The data of 120 neonates with severe hyperbilirubinemia were collected by retrospective analysis. Univariate and multivariate analysis methods were used to analyze the data of 120 children. R software was used to visualize the results of multivariate analysis, and a nomogram model was obtained. The receiver operating characteristic curve (ROC), calibration curve, and decision-making curve (DC) were used to evaluate the discrimination, accuracy, and clinical net profit rate of the model.

Results

Multivariate analysis showed that nonfull breastfeeding, high-risk symptoms, and pregnancy complications were independent risk factors for ABE in neonates with severe hyperbilirubinemia. At the same time, the risk of ABE in neonates with severe hyperbilirubinemia increased with the increase of B/A and Hb levels. The ROC curve showed that the area under the curve for the model was 0.908 (95% CI: 0.839-0.960). The calibration curve shows that the actual prediction curve of the model is in good agreement with the corrected prediction curve. Using the cutoff value of the ROC curve as the diagnostic criterion, the threshold probability of the model was calculated to be 38%. The decision curve shows that when 38% is used as the basis for judging whether to take measures to intervene, the profit rate is 61%.

Conclusion

The occurrence of ABE in neonates with severe hyperbilirubinemia is affected by many factors, and there is a certain degree of interaction between these factors. Combining multiple factors to construct a risk nomogram model can provide a reference for early clinical detection of high-risk neonates.

Contribution of genetic factors to high rates of neonatal hyperbilirubinaemia on the Thailand-Myanmar border

Very high unconjugated bilirubin plasma concentrations in neonates (neonatal hyperbilirubinaemia; NH) may cause neurologic damage (kernicterus). Both increased red blood cell turn-over and immaturity of hepatic glucuronidation contribute to neonatal hyperbilirubinaemia. The incidence of NH requiring phototherapy during the first week of life on the Thailand-Myanmar border is high (approximately 25%). On the Thailand-Myanmar border we investigated the contribution of genetic risk factors to high bilirubin levels in the first month of life in 1596 neonates enrolled in a prospective observational birth cohort study. Lower gestational age (<38 weeks), mutations in the genes encoding glucose-6-phosphate dehydrogenase (G6PD) and uridine 5'-diphospho-glucuronosyltransferase (UGT) 1A1 were identified as the main independent risk factors for NH in the first week, and for prolonged jaundice in the first month of life. Population attributable risks (PAR%) were 61.7% for lower gestational age, 22.9% for hemi or homozygous and 9.9% for heterozygous G6PD deficiency respectively, and 6.3% for UGT1A1*6 homozygosity. In neonates with an estimated gestational age ≥ 38 weeks, G6PD mutations contributed PARs of 38.1% and 23.6% for "early" (≤ 48 hours) and "late" (49-168 hours) NH respectively. For late NH, the PAR for UGT1A1*6 homozygosity was 7.7%. Maternal excess weight was also a significant risk factor for "early" NH while maternal mutations on the beta-globin gene, prolonged rupture of membranes, large haematomas and neonatal sepsis were risk factors for "late" NH. For prolonged jaundice during the first month of life, G6PD mutations and UGT1A1*6 mutation, together with lower gestational age at birth and presence of haematoma were significant risk factors. In this population, genetic factors contribute considerably to the high risk of NH. Diagnostic tools to identify G6PD deficiency at birth would facilitate early recognition of high risk cases.

Risk factors for neonatal hyperbilirubinemia: a systematic review and meta-analysis

BACKGROUND

Hyperbilirubinemia is the most common cause of neonatal hospitalization and, although it generally has a good prognosis, a significant percentage of neonatal patients maintain a high bilirubin level, which can lead to severe complications, including lifelong disability such as growth retardation, encephalopathy, autism and hearing impairment. The study of risk factors for neonatal hyperbilirubinemia has been controversial. Therefore, we evaluated the risk factors of neonatal hyperbilirubinemia using a meta-analysis.

METHODS

Relevant English and Chinese studies that discussed risk factors for neonatal hyperbilirubinemia were retrieved from the PubMed, EMBASE, Medline, Central, China National Knowledge Infrastructure (CNKI), Wanfang and China Science Digital Library (CSDL). The literature took newborns as the research object, set up a control group, and observed the relationship between exposure factors and neonatal hyperbilirubinemia. The combined effect size was expressed by odds ratio (OR) and 95% confidence interval (CI). The Chi-square test was used to test heterogeneity of the studies, and if it existed, subgroup analyses were used to explore the source of heterogeneity, and the random-effects model was selected for the combined analysis. The fixed-effects model was chosen for the combined analysis if there was no heterogeneity. Publication bias was assessed using Egger's test and funnel plot.

RESULTS

Risk factors for neonatal hyperbilirubinemia were exclusive breastfeeding (BF: OR =1.74, 95% CI: 1.42, 2.12, Z=5.43, P<0.00001); glucose-6-phosphate dehydrogenase deficiency (G6PD: OR =1.62, 95% CI: 1.44, 1.81, Z=8.39, P<0.00001); maternal-fetal ABO blood group incompatibility (OR =1.64, 95% CI: 1.42, 1.89, Z=6.75, P<0.00001); and preterm birth (PTB: OR =1.31, 95% CI: 1.17, 1.47, Z=4.60, P<0.00001); there was no heterogeneity or publication bias among the studies (BF: χ²=5.34, P=0.25, I²=25%; G6PD: χ²=4.40, P=0.49, I²=0%; ABO: χ²=1.91, P=0.75, I²=0%; PTB: χ²=0.81, P=0.67, I²=0%).

CONCLUSIONS

Exclusive breastfeeding, G6PD deficiency, ABO incompatibility and premature birth were confirmed as risk factors for neonatal hyperbilirubinemia. Pregnant women with risk factors should be monitored more closely and clinical intervention should be given in a timely manner.