The natural history of jaundice in predominantly breastfed infants

Preventive effect of prenatal maternal oral probiotic supplementation on neonatal jaundice (POPS Study): A protocol for the randomised double-blind placebo-controlled clinical trial

INTRODUCTION

Neonatal jaundice is a common and life-threatening health problem in neonates due to overaccumulation of circulating unconjugated bilirubin. Gut flora has a potential influence on bilirubin metabolism. The infant gut microbiome is commonly copied from the maternal gut. During pregnancy, due to changes in dietary habits, hormones and body weight, maternal gut dysbiosis is common, which can be stabilised by probiotics supplementation. However, whether probiotic supplements can reach the baby through the mother and reduce the incidence of neonatal jaundice has not been studied yet. Therefore, we aim to evaluate the effect of prenatal maternal probiotic supplementation on the incidence of neonatal jaundice.

METHODS AND ANALYSIS

This is a randomised double-blind placebo-controlled clinical trial among 94 pregnant women (47 in each group) in a tertiary hospital in Hong Kong. Voluntary eligible participants will be recruited between 28 and 35 weeks of gestation. Computer-generated randomisation and allocation to either the intervention or control group will be carried out. Participants will take either one sachet of Vivomixx (450 billion colony-forming units per sachet) or a placebo per day until 1 week post partum. Neither the study participants nor researchers will know the randomisation and allocation. The intervention will be initiated at 36 weeks of gestation. Neonatal bilirubin level will be measured to determine the primary outcome (hyperbilirubinaemia) while the metagenomic microbiome profile of breast milk and maternal and infant stool samples as well as pregnancy outcomes will be secondary outcomes. Binary logistic and linear regressions will be carried out to assess the association of the microbiome data with different clinical outcomes.

ETHICS AND DISSEMINATION

Ethics approval is obtained from the Joint CUHK-NTEC Clinical Research Ethics Committee, Hong Kong (CREC Ref: 2023.100-T). Findings will be published in peer-reviewed journals and presented at international conferences.

TRIAL REGISTRATION NUMBER

NCT06087874.

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.

Hyperbilirubinemia and Associated Factors Among Neonates Admitted to the Neonatal Care Unit in Jimma Medical Center

Background

Neonatal hyperbilirubinemia is a widespread and significant clinical problem among neonates worldwide. Globally, every year about 1.1 million babies develop it and the vast majority reside in South Asia and sub-Saharan Africa. Studies on the magnitude and factors associated with neonatal hyperbilirubinemia are limited in Ethiopia. So this study was aimed at assessing the prevalence and associated factors of neonatal hyperbilirubinemia among hospitalized neonates in the neonatal intensive care unit of Jimma Medical Center (JMC), Jimma, South West Ethiopia.

Design

Hospital-based cross-sectional study was conducted at JMC from July 24 to October 19, 2020.

Methods

A total of 222 neonates with their mothers were included and conveniently selected. Data was collected by interviewing mothers through structured questionnaires and reviewing neonates' medical records using a checklist. Multivariable binary logistic regression analyses were employed to identify factors associated with neonatal hyperbilirubinemia.

Results

from a total of neo-maternal pairs included in the studies; the proportion of Neonatal hyperbilirubinemia was found to be 94 (42.3%). Neo-maternal ABO incompatibility 33 (35.1%), prematurity 41 (43.6%), sepsis 35 (37.2%), Neonatal birth asphyxia 20 (21.2%), and Rh isoimmunization 10 (10.6%) was significantly associated with neonatal hyperbilirubinemia.

Conclusion

The prevalence of neonatal hyperbilirubinemia in the study setting was high. Antenatal care (including both mother and fetus detail examination and follow-ups) as well as cautions during labor need to focus on since Neonatal hyperbilirubinemia-associated factors were maternal and neonatal. Hence, further assessment, early intervention, and timely treatment are important to mitigate the burdens in neonates due to hyperbilirubinemia.

[Interpretation of the 2022 American Academy of Pediatrics guidelines for the management of hyperbilirubinemia in newborn infants]

The American Academy of Pediatrics updated the guidelines for the management of hyperbilirubinemia in the newborn infants with a gestational age of ≥35 weeks in September 2022. Based on the evidence over the past 18 years, the guidelines are updated from the aspects of the prevention, risk assessment, intervention, and follow-up of hyperbilirubinemia in the newborn infants with a gestational age of ≥35 weeks. This article gives an interpretation of the key points in the guidelines, so as to safely reduce the risk of bilirubin encephalopathy and unnecessary intervention.

An Implicit Cause of Prolonged Neonatal Jaundice: Vitamin B12 Deficiency

Objective Prolonged jaundice is defined as a serum bilirubin level of more than 5 mg/dL, which persists at postnatal 14 days in term infants and 21 days following birth in preterm infants. Although the underlying causes cannot be found in the majority of prolonged jaundice cases, this may be the first sign of a serious issue. Therefore, this study aimed to evaluate the association between vitamin B12 deficiency and prolonged jaundice in newborns.

Material and Methods This descriptive cross-sectional study was performed in a university hospital between January 1, 2015 and October 1, 2020. All participants consisted of infants who were admitted to the pediatric outpatient clinics. Infants > 35 weeks of gestation and with prolonged jaundice of unknown etiology were included in the study group. The control group consisted of infants > 35 weeks of gestation without prolonged jaundice. Demographic and clinical characteristics and serum vitamin B12 levels were evaluated comparatively.

Results A total of 126 infants, 66 of whom had prolonged jaundice, were included. The mean gestational week of the study group was 38.4 ± 1.8, and the control group was 38.6 ± 1.9 weeks. There was no difference between the groups in terms of demographics and laboratory data. The vitamin B12 level of the study group was significantly lower (median = 170 pg/mL) than the control (median = 268 pg/mL).

Conclusion Based on the findings of this study, vitamin B12 deficiency was thought to be an important cause of prolonged jaundice, and further studies are needed to explain the role of vitamin B12 deficiency in the etiology of prolonged jaundice.

Better assessment of neonatal jaundice at home (BEAT Jaundice @home): protocol for a prospective, multicentre diagnostic study

INTRODUCTION

Severe neonatal hyperbilirubinaemia can place a neonate at risk for acute bilirubin encephalopathy and kernicterus spectrum disorder. Early diagnosis is essential to prevent these deleterious sequelae. Currently, screening by visual inspection followed by laboratory-based bilirubin (LBB) quantification is used to identify hyperbilirubinaemia in neonates cared for at home in the Netherlands. However, the reliability of visual inspection is limited. We aim to evaluate the effectiveness of universal transcutaneous bilirubin (TcB) screening as compared with visual inspection to: (1) increase the detection of hyperbilirubinaemia necessitating treatment, and (2) reduce the need for heel pricks to quantify bilirubin levels. In parallel, we will evaluate a smartphone app (Picterus), and a point-of-care device for quantifying total bilirubin (Bilistick) as compared with LBB.

METHODS AND ANALYSIS

We will undertake a multicentre prospective cohort study in nine midwifery practices across the Netherlands. Neonates born at a gestational age of 35 weeks or more are eligible if they: (1) are at home at any time between days 2 and 8 of life; (2) have their first midwife visit prior to postnatal day 6 and (3) did not previously receive phototherapy. TcB and the Picterus app will be used after visual inspection. When LBB is deemed necessary based on visual inspection and/or TcB reading, Bilistick will be used in parallel. The coprimary endpoints of the study are: (1) hyperbilirubinaemia necessitating treatment; (2) the number of heel pricks performed to quantify LBB. We aim to include 2310 neonates in a 2-year period. Using a decision tree model, a cost-effectiveness analysis will be performed.

ETHICS AND DISSEMINATION

This study has been approved by the Medical Research Ethical Committee of the Erasmus MC Rotterdam, Netherlands (MEC-2020-0618). Parents will provide written informed consent. The results of this study will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

Dutch Trial Register (NL9545).

Assessment, management, and incidence of neonatal jaundice in healthy neonates cared for in primary care: a prospective cohort study

Jaundice caused by hyperbilirubinaemia is a common phenomenon during the neonatal period. Population-based studies evaluating assessment, management, and incidence of jaundice and need for phototherapy among otherwise healthy neonates are scarce. We prospectively explored these aspects in a primary care setting via assessing care as usual during the control phase of a stepped wedge cluster randomised controlled trial.We conducted a prospective cohort study embedded in the Screening and TreAtment to Reduce Severe Hyperbilirubinaemia in Infants in Primary care (STARSHIP) Trial. Healthy neonates were included in seven primary care birth centres (PCBCs) in the Netherlands between July 2018 and March 2020. Neonates were eligible for inclusion if their gestational age was ≥ 35 weeks, they were admitted in a PCBC for at least  2 days during the first week of life, and if they did not previously receive phototherapy. Outcomes were the findings of visual assessment to detect jaundice, jaundice incidence and management, and the need for phototherapy treatment in the primary care setting.860 neonates were included of whom 608 (71.9%) were visibly jaundiced at some point during admission in the PCBC, with 20 being 'very yellow'. Of the latter, four (20%) did not receive total serum bilirubin (TSB) quantification. TSB levels were not associated with the degree of visible jaundice (p = 0.416). Thirty-one neonates (3.6%) received phototherapy and none received an exchange transfusion. Five neonates did not receive phototherapy despite having a TSB level above phototherapy threshold.Jaundice is common in otherwise healthy neonates cared for in primary care. TSB quantification was not always performed in very jaundiced neonates, and not all neonates received phototherapy when indicated. Quality improvement initiatives are required, including alternative approaches to identifying potentially severe hyperbilirubinaemia.Trial registration: NL6997 (Dutch Trial Register; Old NTR ID 7187), registered 3 May 2018.

Technical Report: Breastfeeding and the Use of Human Milk

Breastfeeding and human milk are the normative standards for infant feeding and nutrition. The short- and long-term medical and neurodevelopmental advantages of breastfeeding make breastfeeding or the provision of human milk a public health imperative. The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for approximately 6 months after birth. Furthermore, the AAP supports continued breastfeeding, along with appropriate complementary foods introduced at about 6 months, as long as mutually desired by mother and child for 2 years or beyond. These recommendations are consistent with those of the World Health Organization (WHO). Medical contraindications to breastfeeding are rare. The AAP recommends that birth hospitals or centers implement maternity care practices shown to improve breastfeeding initiation, duration, and exclusivity. The Centers for Disease Control and Prevention and The Joint Commission monitor breastfeeding practices in United States hospitals. Pediatricians play a critical role in hospitals, their practices, and communities as advocates of breastfeeding and, thus, need to be trained about the benefits of breastfeeding for mothers and children and in managing breastfeeding. Efforts to improve breastfeeding rates must acknowledge existing disparities and the impact of racism in promoting equity in breastfeeding education, support, and services.

Policy Statement: Breastfeeding and the Use of Human Milk

Breastfeeding and human milk are the normative standards for infant feeding and nutrition. The short- and long-term medical and neurodevelopmental advantages of breastfeeding make breastfeeding, or the provision of human milk, a public health imperative. The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for approximately 6 months after birth. Furthermore, the AAP supports continued breastfeeding, along with appropriate complementary foods introduced at about 6 months, as long as mutually desired by mother and child for 2 years or beyond. These recommendations are consistent with those of the World Health Organization (WHO). Medical contraindications to breastfeeding are rare. The AAP recommends that birth hospitals or centers implement maternity care practices shown to improve breastfeeding initiation, duration, and exclusivity. The Centers for Disease Control and Prevention (CDC) and The Joint Commission monitor breastfeeding practices in US hospitals. Pediatricians play a critical role in hospitals, their practices, and communities as advocates of breastfeeding and, thus, need to be trained about the benefits of breastfeeding for mothers and children and in managing breastfeeding.

Infant Feeding Practices And Childhood Acute Leukemia: Findings From The Childhood Cancer & Leukemia International Consortium

Increasing evidence suggests that breastfeeding may protect from childhood acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML). However, most studies have limited their analyses to any breastfeeding, and only a few data have examined exclusive breastfeeding, or other exposures such as formula milk. We performed pooled analyses and individual participant data meta-analyses of data from sixteen studies (N=17,189 controls; N=10,782 ALL and N=1,690 AML cases) from the Childhood Leukemia International Consortium (CLIC) to characterize the associations of breastfeeding duration with ALL and AML, as well as exclusive breastfeeding duration and age at introduction to formula with ALL. In unconditional multivariable logistic regression analyses of pooled data, we observed decreased odds of ALL among children breastfed 4-6 months (0.88, 95% CI 0.81-0.96) or 7-12 months (OR 0.85, 0.79-0.92). We observed a similar inverse association between breastfeeding ≥4 months and AML (0.82, 95% CI 0.71-0.95). Odds of ALL were reduced among children exclusively breastfed 4-6 months (OR 0.73, 95% CI 0.63-0.85) or 7-12 months (OR 0.70, 95% CI 0.53-0.92). Random effects meta-analyses produced similar estimates, and findings were unchanged in sensitivity analyses adjusted for race/ethnicity or mode of delivery, restricted to children diagnosed ≥1 year of age, or diagnosed with B-ALL. Our pooled analyses indicate that longer breastfeeding is associated with decreased odds of ALL and AML. Few risk factors for ALL and AML have been described, therefore our findings highlight the need to promote breastfeeding for leukemia prevention.

Effects of a breastfeeding coaching program on growth and neonatal jaundice in late preterm infants in South Korea

PURPOSE

This study examined the effects of a breastfeeding coaching program for mothers on growth and neonatal jaundice in late preterm infants (LPIs).

METHODS

This was a quasi-experimental study (non-randomized intervention) with a time-series design. The study was conducted among 40 LPIs who were admitted to the neonatal intensive care unit of a university hospital in Daegu, South Korea. In the order of admission, the first 21 infants were assigned to the experimental group, and 19 were assigned to the control group. The intervention program consisted of home- based and web-based practical breastfeeding support education for mothers across a total of 5 sessions. Infant growth was measured using body weight, length, and head circumference, and neonatal jaundice was assessed using transcutaneous bilirubin levels.

RESULTS

The likelihood of breastfeeding for infants in the experimental group at 4 weeks after discharge was the same as on the day of discharge, whereas it steadily decreased in the control group. There were significant differences in head circumference between the groups. However, weight, length, and transcutaneous bilirubin levels did not show a significant group-time interaction.

CONCLUSION

A formal breastfeeding coaching program should be considered in clinical settings and at home within the first few weeks postpartum.

Transcutaneous Bilirubin Levels and Risk of Significant Hyperbilirubinemia in Early-Term and Term Newborns

OBJECTIVE

To compare the course of the transcutaneous bilirubin (TcB) values of early-term newborns with those of term newborns in the first month of life and to investigate whether early-term newborns have an increased risk of significant hyperbilirubinemia requiring treatment.

DESIGN

A prospective, controlled cohort analysis.

SETTING

A tertiary level mother-child birth and health care center.

PARTICIPANTS

Four hundred early-term (37 0/7 to 38 6/7 weeks) and 320 term (39 0/7 to 41 6/7 weeks) newborns born during a 27-month period.

METHODS

A total of six TcB measurements in a longitudinal manner were made in early-term and term newborns: the first two at 6 and 48 hours after birth and the next four on routine examination days (Days 4, 7, 15, and 30). Demographic characteristics, values of daily TcB measurements, number of newborns with significant hyperbilirubinemia, and risk of jaundice requiring treatment were compared between the two groups.

RESULTS

All six TcB values were significantly greater in the early-term group than in the term group (p < .001 for each). Early-term newborns had a statistically significant increased risk of jaundice requiring treatment compared to term newborns (risk ratio = 1.91; 95% confidence interval [1.23-2.96]; p = .0046). Results of the repeated-measures analysis of variance and post hoc adjusted multiple comparison analysis showed that TcB levels increased to and peaked at 96 hours after birth and then gradually decreased to baseline (first measurement) levels at 30 days after birth in each group.

CONCLUSIONS

Early-term newborns should not be treated as full-term newborns because they have significantly higher TcB levels. These newborns should be closely monitored for pathologic jaundice because they have increased risk for significant hyperbilirubinemia requiring phototherapy.

Assessing knowledge and skills of maternity care professionals regarding neonatal hyperbilirubinaemia: a nationwide survey

BACKGROUND

Neonatal hyperbilirubinaemia is a physiologic phenomenon, but, when severe, may cause lifelong disability. Maternity care assistants (MCAs) play an important role in timely recognition of severe neonatal jaundice. We assessed knowledge and skills of MCAs regarding neonatal hyperbilirubinaemia.

METHODS

All Dutch MCAs (n = 9065) were invited to fill out a questionnaire assessing knowledge, expertise, and handling of neonatal jaundice. Additionally, we developed an e-learning and provided training sessions to a subgroup of MCAs (n = 99), and assessed their knowledge on neonatal hyperbilirubinaemia before and after the training.

RESULTS

One thousand four hundred sixty-five unique online questionnaires were completed (response 16.2%). The median number of correctly answered knowledge questions was 5 (out of six; IQR 1). Knowledge was significantly better when respondents had had in-service training on neonatal hyperbilirubinaemia in the previous year (p = 0.024). Although 82% of respondents felt highly skilled or skilled to assess jaundice, accuracy of estimation of total serum bilirubin levels by assessing skin colour was generally poor and prone to underestimation. Among participants attending a training session, those who completed the e-learning beforehand had higher pre-training scores (5 (IQR 1) vs. 4 (IQR 2); p < 0.001). The median post-training score was higher than pre-training (6 (IQR 1) vs. 5 (IQR 2); p < 0.001).

CONCLUSIONS

Background knowledge of MCAs regarding neonatal hyperbilirubinaemia was adequate, but can be improved by further training. Estimation of total serum bilirubin levels based on skin colour was often inadequate. Approaches to improve timely recognition of jaundiced neonates are needed.

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.

Prevalence and risk factors for hyperbilirubinemia among newborns from a low-risk birth setting using delayed cord clamping in Japan

AIM

Neonatal jaundice is a common problem among infants. Among the several risk factors are East Asian race and delayed cord clamping. Birth centers manage low-risk term deliveries using physiological management, which may include delayed cord clamping. This study aimed to investigate the occurrence of hyperbilirubinemia, a pathological process of jaundice, and its risk factors among neonates born at a Japanese birth center.

METHODS

This was a retrospective cohort study. Data were collected from March 2006 to October 2014 from healthy mothers and neonates at a birth center in a metropolitan area of Japan. Demographic data and background factors of hyperbilirubinemia, including blood and transcutaneous values of jaundice, were collected and statistically analyzed.

RESULTS

Of the 1,211 neonates analyzed, 4.7% exceeded the standard transcutaneous bilirubin value, and 1.8% needed phototherapy. Multiple logistic regression with adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) was used to identify the risk factors of hyperbilirubinemia, which were found to be cephalohematoma (OR = 30.18, 95% CI 5.63-161.69), delay of meconium elimination (OR = 2.66, 95% CI 1.28-5.51), previous history of phototherapy of siblings (OR = 10.28, 95% CI 3.53-29.92), and primiparity (OR = 4.55, 95% CI 2.59-8.02).

CONCLUSIONS

In low-risk Japanese neonates delivered at a birth center expected to practice delayed cord clamping, the rate of neonates requiring phototherapy was not high compared to previous studies, and the identified risk factors of hyperbilirubinemia were related to bilirubin metabolism.

Hyperbilirubinemia in pediatrics: Evaluation and care

Hyperbilirubinemia is a common laboratory finding for children, especially in infancy. It represents a broad range of diagnoses from benign physiologic changes to severe systemic illness. This paper addresses the evaluation and differential diagnosis of hyperbilirubinemia for infants and older children based on the most recent guidelines published by the American Academy of Pediatrics (AAP) (1), the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) (2).

Large scale validation of a new non-invasive and non-contact bilirubinometer in neonates with risk factors

The study was aimed to evaluate the performance of a newly developed non-invasive and non-contact bilirubin measurement device (AJO-Neo) as an alternative to the conventional invasive biochemical method of total serum bilirubin (TSB) estimation in preterm and term neonates suffering from hyperbilirubinemia associated with risk factors, and/or undergoing phototherapy. The safety and efficacy of the device were assessed in 1968 neonates with gestational ages ranging from 28 to 41 weeks and suffering from incidences of hyperbilirubinemia. Linear regression analysis showed a good correlation between AJO-Neo and the conventional method of TSB (Pearson’s coefficient, r = 0.79). The small bias (0.27 mg/dL) and limits of agreements (− 3.44 to 3.99 mg/dL) were within the range of clinical acceptance. The device was also precise in the measurement of bilirubin levels in all subgroups of the study. The receiver operator curve (ROC), that takes account of both sensitivity and specificity of a device showed high efficacy of the device (area under the curve, AUC = 0.83) in the detection of bilirubin. While monitoring the bilirubin level during phototherapy, the device indicated promising results showing good agreement with TSB. Specificities and sensitivities of the device indicated a much higher accuracy in neonates with associated risk factors for hyperbilirubinemia. Hence, the newly developed device (AJO-Neo) is reliable in measuring bilirubin level in preterm, and term neonates irrespective of gestational or postnatal age, sex, risk factors, feeding behavior or skin color.

Impact of a standardized protocol for the Management of Prolonged Neonatal Jaundice in a regional setting: an interventional quasi-experimental study

Background

Prolonged neonatal jaundice (PNNJ) is often caused by breast milk jaundice, but it could also point to other serious conditions (biliary atresia, congenital hypothyroidism). When babies with PNNJ receive a routine set of laboratory investigations to detect serious but uncommon conditions, there is always a tendency to over-investigate a large number of well, breastfed babies. A local unpublished survey in Perak state of Malaysia revealed that the diagnostic criteria and initial management of PNNJ were not standardized. This study aims to evaluate and improve the current management of PNNJ in the administrative region of Perak.

Methods

A 3-phase quasi-experimental community study was conducted from April 2012 to June 2013. Phase l was a cross-sectional study to review the current practice of PNNJ management. Phase ll was an interventional phase involving the implementation of a new protocol. Phase lll was a 6 months post-interventional audit. A registry of PNNJ was implemented to record the incidence rate. A self-reporting surveillance system was put in place to receive any reports of biliary atresia, urinary tract infection, or congenital hypothyroidism cases.

Results

In Phase I, 12 hospitals responded, and 199 case notes were reviewed. In Phase II, a new protocol was developed and implemented in all government health facilities in Perak. In Phase III, the 6-month post-intervention audit showed that there were significant improvements when comparing mean scores of pre- and post-intervention: history taking scores (p < 0.001), family history details (p < 0.05), physical examination documentation (p < 0.001), and total investigations done per patient (from 9.01 to 5.81, p < 0.001). The total number of patient visits reduced from 2.46 to 2.2 per patient. The incidence of PNNJ was found to be high (incidence rate of 158 per 1000 live births).

Conclusions

The new protocol standardized and improved the quality of care with better clinical assessment and a reduction in unnecessary laboratory investigations.

Trial registration

Research registration number: NMRR-12-105-11288.

Electronic supplementary material

The online version of this article (10.1186/s12887-019-1550-3) contains supplementary material, which is available to authorized users.

Screening and treatment to reduce severe hyperbilirubinaemia in infants in primary care (STARSHIP): a factorial stepped-wedge cluster randomised controlled trial protocol

INTRODUCTION

Jaundice caused by hyperbilirubinaemia is a physiological phenomenon in the neonatal period. However, severe hyperbilirubinaemia, when left untreated, may cause kernicterus, a severe condition resulting in lifelong neurological disabilities. Although commonly applied, visual inspection is ineffective in identifying severe hyperbilirubinaemia. We aim to investigate whether among babies cared for in primary care: (1) transcutaneous bilirubin (TcB) screening can help reduce severe hyperbilirubinaemia and (2) primary care-based (versus hospital-based) phototherapy can help reduce hospital admissions.

METHODS AND ANALYSIS

A factorial stepped-wedge cluster randomised controlled trial will be conducted in seven Dutch primary care birth centres (PCBC). Neonates born after 35 weeks of gestation and cared for at a participating PCBC for at least 2 days within the first week of life are eligible, provided they have not received phototherapy before. According to the stepped-wedge design, following a phase of 'usual care' (visual assessment and selective total serum bilirubin (TSB) quantification), either daily TcB measurement or, if indicated, phototherapy in the PCBC will be implemented (phase II). In phase III, both interventions will be evaluated in each PCBC. We aim to include 5500 neonates over 3 years.Primary outcomes are assessed at 14 days of life: (1) the proportion of neonates having experienced severe hyperbilirubinaemia (for the TcB screening intervention), defined as a TSB above the mean of the phototherapy and the exchange transfusion threshold and (2) the proportion of neonates having required hospital admission for hyperbilirubinaemia treatment (for the phototherapy intervention in primary care).

ETHICS AND DISSEMINATION

This study has been approved by the Medical Research Ethics Committee of the Erasmus MC Rotterdam, the Netherlands (MEC-2017-473). Written parental informed consent will be obtained. Results from this study will be published in peer-reviewed journals and presented at (inter)national meetings.

TRIAL REGISTRATION NUMBER

NTR7187.

Meconium microbiome associates with the development of neonatal jaundice

Objective

Neonatal jaundice is a common disease that affects up to 60% of newborns. Gut microbiota mediated the excretion of bilirubin from the human body. However, the relationship between early gut microbiome and development of neonatal jaundice is not fully understood. Here we sought to characterize meconium microbiome of newborns and to clarify its association with risk of neonatal jaundice.

Methods

We conducted a nested case–control study with 301 newborns providing meconium samples from 2014 to 2015. The main outcome was the development of neonatal jaundice at 42 day follow-up. 16S rRNA gene sequencing was performed to profile the meconium microbiome. LEfSe was employed to identify different features between control and case groups. Logistic regression was used to estimate the risk effect of early gut microbiome on neonatal jaundice.

Results

Logistic regression models suggested that higher ɑ-diversity was significantly associated with lower risk of jaundice in cesarean infants (OR 0.72, 95% CI 0.52–0.98), but not in infants born naturally. Higher relative abundance of Bifidobacterium pseudolongum in newborn meconium was significantly associated with lower risk of jaundice both in cesarean-born infants and in the total subjects (OR 0.24, 95% CI 0.07–0.68; OR 0.55, 95% CI 0.31–0.95, respectively). Spearman’s correlations showed that relative abundance of B. pseudolongum was significantly correlated with ɑ-diversity (P < 0.01).

Conclusion

Preventive and treatment methods implying early gut microbiome intervention could be promising for the management of neonatal jaundice.

Humanized UGT1 Mice, Regulation of UGT1A1, and the Role of the Intestinal Tract in Neonatal Hyperbilirubinemia and Breast Milk-Induced Jaundice

Neonatal hyperbilirubinemia and the onset of bilirubin encephalopathy and kernicterus result in part from delayed expression of UDP-glucuronosyltransferase 1A1 (UGT1A1) and the ability to metabolize bilirubin. It is generally believed that acute neonatal forms of hyperbilirubinemia develop due to an inability of hepatic UGT1A1 to metabolize efficiently bilirubin for clearance through the hepatobiliary tract. Newly developed mouse models designed to study bilirubin metabolism have led to new insight into the role of the intestinal tract in controlling neonatal hyperbilirubinemia. Humanization of mice with the UGT1 locus (hUGT1 mice) and the UGT1A1 gene provide a unique tool to study the onset of hyperbilirubinemia since the human UGT1A1 gene is developmentally regulated during the neonatal period in hUGT1 mice. A new mechanism outlying developmental expression of intestinal UGT1A1 is presented and its implications in the control of neonatal hyperbilirubinemia discussed. New findings linking breast milk protection against necrotizing enterocolitis and intestinal control of UGT1A1 may help explain the contribution of breast milk toward the development of neonatal hyperbilirubinemia. Our findings outline a new model that includes an active intestinal ROS /IκB kinase/nuclear receptor corepressor 1 loop that can be applied to an understanding of breast milk-induced jaundice.

Fifteen-minute consultation: liver disease in children

Liver disease in children can present in many ways from the frequently encountered prolonged neonatal jaundice to the comparatively rare acute liver failure. In this article, we will discuss 'red flags' of liver disease, the initial investigations required and when to refer to a specialist liver centre. Across all presentations, the degree of elevation of alanine aminotransferase or aspartate aminotransferase provides only little diagnostic information. Measurement of clotting is vital, and coagulopathy should be followed by a trial of intravenous vitamin K before being repeated.

Adherence to hyperbilirubinemia guidelines by midwives, general practitioners, and pediatricians in Indonesia

Severe hyperbilirubinemia, which may result in kernicterus, is seen more frequently in low and middle-income countries, such as Indonesia, than in high-income countries. In Indonesia midwives, general practitioners (GPs), and pediatricians are involved in the care of jaundiced newborn infants. It is unknown whether the high incidence of severe hyperbilirubinemia in this country is related to a lack of awareness of existing hyperbilirubinemia guidelines issued by, for example, the World Health Organization, the American Academy of Pediatrics, or the Indonesian Health Ministry, or to a lack of adherence to such guidelines. The aim of this questionnaire study was to assess health professionals’ awareness of existing guidelines and their adherence to these guidelines in daily practice. We handed out a ten-question questionnaire to midwives, GPs, and pediatricians that included questions about the professionals themselves as well as clinical questions. The midwives completed 291 questionnaires, the GPs 206, and the pediatricians 154, all of which we used for our analysis. Almost 30% of the midwives and 23% of the GPs were either unaware of any existing guidelines or they did not adhere to them. Only 54% of the midwives recognized the warning signs of severe hyperbilirubinemia correctly, compared to 68% of the GPs and 89% of the pediatricians. Twenty-eight percent of the midwives and 31% of the GPs indicated that their first follow-up visit was after 72 hours, while 90% of them discharged infants after less than 48 hours after birth. The awareness of and adherence to guidelines for preventing and treating hyperbilirubinemia is low amongst the midwives and GPs in Indonesia. This may be an important contributing factor in the high incidence of severe hyperbilirubinemia in Indonesia.

Direct bilirubin levels observed in prolonged neonatal jaundice: a retrospective cohort study

OBJECTIVE

Prolonged neonatal jaundice is common and usually benign; however, assessment of bilirubin fractions is recommended to determine the need for further assessment for congenital liver disease, particularly biliary atresia. The direct (conjugated) bilirubin thresholds currently used are variable and poorly evidenced. Hence, we aimed to delineate direct bilirubin levels in disease-free neonates with prolonged jaundice.

METHODS

We performed a retrospective cohort analysis of split bilirubin levels, and subsequent follow-up, for all neonates initially assessed in our prolonged neonatal jaundice clinic over 2 years. We plotted centile charts for total, direct and direct-total bilirubin ratio levels against age at sampling. The association was assessed using linear regression analysis.

RESULTS

Data were collected for 420 neonates (501 blood samples) across an age range of 10-70 days. No significant liver disease was found. For each day of older age, total bilirubin fell by 3.72 µmol/L (95% CI 2.46 to 5.00) and direct bilirubin fell by 0.39 µmol/L (0.18 to 0.59). The ratio between the two did not change significantly (-0.0006 to +0.0034). The 95th centile for direct bilirubin was stable at ~25 µmol/L. Direct-total bilirubin ratio was very variable with some 95th centiles >30%.

CONCLUSIONS

In a clinically relevant population of disease-free neonates with prolonged jaundice both the total and the direct bilirubin decreased with age. The absolute direct bilirubin is more useful clinically than the direct-total bilirubin ratio. Our results support National Institute for Health and Care Excellence guidance that conjugated bilirubin >25 µmol/L, or even more stringent criteria, constitutes an appropriate threshold for further investigation for neonatal liver disease.

Synergistic effects of polymer adsorbents on the performance of bilirubin hemoperfusion

Neonatal hyperbilirubinemia (jaundice) is a common disease with high incidence. Currently, the clinical inefficiency of adult bilirubin hemoperfusion medical adsorbent is a major technical barrier for the application of hemoperfusion treatment to rescue the severe neonatal jaundice. Based on the well-known principle of synergistic effects, a series of customized bilirubin polymeric compounds, comprised of one or more of the following components (glycidyl methacrylate, sodium acrylate, methacrylic acid isooctyl, hexamethylene diamine, albumin), were designed and fabricated based on molecular design. Their adsorption performances upon bilirubin were investigated and compared under the same conditions, and the compound with the highest adsorption performance was then subject to preliliminary safety assessments and compared with a commercial one (BS330). The results showed that positive synergistic effects appeared on the adsorption performance to adsorb bilirubin based on this study, and the one comprised of glycidyl methacrylate+sodium acrylate+methacrylic acid isoocty+hexamethylene diamine+albumin possesses the highest adsorption performance as well as outome clinical acceptable medical safety assessments, and its adsorption efficiency was up to 46% while the commerical one's was about 26% under the same conditions. This study sheds a new light on how to design and develop hemoperfusion bilirubin adsorbents with good overall clinical performance, as well as providing a novel idea and experimental referrences for future related topics.

Intestinal NCoR1, a regulator of epithelial cell maturation, controls neonatal hyperbilirubinemia

Severe neonatal hyperbilirubinemia (SNH) and the onset of bilirubin encephalopathy and kernicterus result in part from delayed expression of UDP-glucuronosyltransferase 1A1 (UGT1A1) and the inability to metabolize bilirubin. Although there is a good understanding of the early events after birth that lead to the rapid increase in serum bilirubin, the events that control delayed expression of UGT1A1 during development remain a mystery. Humanized UGT1 (hUGT1) mice develop SNH spontaneously, which is linked to repression of both liver and intestinal UGT1A1. In this study, we report that deletion of intestinal nuclear receptor corepressor 1 (NCoR1) completely diminishes hyperbilirubinemia in hUGT1 neonates because of intestinal UGT1A1 gene derepression. Transcriptomic studies and immunohistochemistry analysis demonstrate that NCoR1 plays a major role in repressing developmental maturation of the intestines. Derepression is marked by accelerated metabolic and oxidative phosphorylation, drug metabolism, fatty acid metabolism, and intestinal maturation, events that are controlled predominantly by H3K27 acetylation. The control of NCoR1 function and derepression is linked to IKKβ function, as validated in hUGT1 mice with targeted deletion of intestinal IKKβ. Physiological events during neonatal development that target activation of an IKKβ/NCoR1 loop in intestinal epithelial cells lead to derepression of genes involved in intestinal maturation and bilirubin detoxification. These findings provide a mechanism of NCoR1 in intestinal homeostasis during development and provide a key link to those events that control developmental repression of UGT1A1 and hyperbilirubinemia.

Transcutaneous Bilirubin Levels during the First Month of Life in Term and Late-preterm Newborns

OBJECTIVE

We aimed to develop a transcutaneous bilirubin (TcB) nomogram for assessment of the risk of significant hyperbilirubinemia and prolonged jaundice during the first month of life in term and late-preterm Turkish newborns.

METHODS

On the basis of the daily (3rd, 7th, 15th and 30th days) TcB measurements, 3rd, 10th, 25th, 50th, 75th, 90th and 97th percentiles, and 5 percentile tracks were obtained. TcB measurements were made by a transcutaneous bilirubinometer (JaundiceDetector JH20-1C).

RESULTS

We screened 729 healthy term and late-preterm Turkish infants 3-30 days old and developed a nomogram of TcB levels. TcB level was ≥5 mg/dl in 41.98% and 25.9% of infants at age 15.0  ±  2.1 days and 30.9  ±  2.6 days, respectively. The TcB measurement-based nomogram values of the 97th percentiles (cutoff values) at age 15.0  ±  2.1 and 30.9  ±  2.6 days were 11.4 (10.82-12.13) mg/dl and 10.0 (9.40-10.70) mg/dl, respectively.

CONCLUSION

This nomogram can be used to determine the risk status of Turkish newborns regarding significant hyperbilirubinemia and prolonged jaundice on the basis of TcB measurement in the first month of life.

When babies turn yellow

Neonatal jaundice is a common condition seen in the primary care setting. Most afflicted babies have physiological jaundice and their prognosis is good. However, others have pathological jaundice, which must be detected early. High levels of serum bilirubin can also result in bilirubin encephalopathy. This article describes consultation tasks in the primary care setting with the aim of providing a guide for the safe management of neonatal jaundice. They include clinical assessment of the baby's well-being; looking out for features that suggest pathological jaundice; assessment for the presence of high-risk features; utilising appropriate laboratory tests for monitoring; assessing the degree of jaundice to decide if the child can be safely followed up in primary care; and providing advice on primary prevention measures and allaying parental concerns. The importance of stool colour examination and its role in early detection of cholestatic jaundice is emphasised.

Prolonged indirect hyperbilirubinemia in a moderately preterm boy with Mediterranean glucose-6-phosphate dehydrogenase and glutathione S-transferase Mu 1 null mutations

A 33-week gestation boy with Mediterranean glucose-6-phosphate dehydrogenase (G6PD) and a glutathione S-transferase Mu 1 null mutations (GSTM1*0/*0) developed prolonged indirect hyperbilirubinemia (PIH). He had no laboratory evidence of haemolysis or infection, and no exposure to oxidising agents. He has two full-term older brothers who have no history of neonatal hyperbilirubinemia. One brother, who was exclusively breast fed, has only Mediterranean G6PD and the other has only GSTM1*0/*0. The three boys have no mutation in the uridine diphosphate glucuronosyltransferase 1A1 gene. This suggests that a combination of all or any two of prematurity, G6PD deficiency and GSTM1*0/*0 is a possible risk factor for PIH. However, this remains to be confirmed.

Differences Between Transcutaneous and Serum Bilirubin Measurements in Black African Neonates

BACKGROUND AND OBJECTIVE

Transcutaneous bilirubin (TcB) correlates positively with total serum bilirubin (TSB) across different racial populations. However, little is known about the pattern of divergence between TcB and TSB at individual patient-level and the relationship with TcB measuring techniques among African neonates. This study, therefore, investigates TcB-TSB discrepancies and the contribution of 2 models of transcutaneous bilirubinometers to the observed divergence in a black African population.

METHODS

Medical records were retrieved for late preterm and term infants with 1 to 3 pairs of TcB and TSB measurements between December 2011 to June 2015 in Nigeria. Divergence between TcB and TSB values for each infant was determined and the associated factors explored with generalized estimating equations for logistic regression. Contributions of BiliChek and JM-103 transcutaneous bilirubinometers to the divergence were further explored through linear regression and Bland-Altman analysis.

RESULTS

Overall, 2107 TcB/TSB measurements from 1553 infants were analyzed. TSB was overestimated by ≥2 mg/dL in 64.5%, ≥3 mg/dL in 42.7%, and ≥4 mg/dL in 25.7% of all measurements. In contrast, TSB was underestimated by ≥2 mg/dL in 1.1%, ≥3 mg/dL in 0.5%, and ≥4 mg/dL in 0.3% of all recordings. Postnatal age, feeding mode, and type of TcB instrument were predictive of TSB overestimation. The JM-103 was associated with greater imprecision than BiliChek at all TSB levels.

CONCLUSIONS

BiliChek and JM-103 bilirubinometers significantly overestimate TSB in black African neonates and may result in unnecessary or excessive treatments. Additional development of appropriate bilirubin determination devices for this racial group, especially in resource-limited settings, is warranted.

A Hypothesis for Using Pathway Genetic Load Analysis for Understanding Complex Outcomes in Bilirubin Encephalopathy

Genetic-based susceptibility to bilirubin neurotoxicity and chronic bilirubin encephalopathy (kernicterus) is still poorly understood. Neonatal jaundice affects 60–80% of newborns, and considerable effort goes into preventing this relatively benign condition from escalating into the development of kernicterus making the incidence of this potentially devastating condition very rare in more developed countries. The current understanding of the genetic background of kernicterus is largely comprised of mutations related to alterations of bilirubin production, elimination, or both. Less is known about mutations that may predispose or protect against CNS bilirubin neurotoxicity. The lack of a monogenetic source for this risk of bilirubin neurotoxicity suggests that disease progression is dependent upon an overall decrease in the functionality of one or more essential genetically controlled metabolic pathways. In other words, a “load” is placed on key pathways in the form of multiple genetic variants that combine to create a vulnerable phenotype. The idea of epistatic interactions creating a pathway genetic load (PGL) that affects the response to a specific insult has been previously reported as a PGL score. We hypothesize that the PGL score can be used to investigate whether increased susceptibility to bilirubin-induced CNS damage in neonates is due to a mutational load being placed on key genetic pathways important to the central nervous system's response to bilirubin neurotoxicity. We propose a modification of the PGL score method that replaces the use of a canonical pathway with custom gene lists organized into three tiers with descending levels of evidence combined with the utilization of single nucleotide polymorphism (SNP) causality prediction methods. The PGL score has the potential to explain the genetic background of complex bilirubin induced neurological disorders (BIND) such as kernicterus and could be the key to understanding ranges of outcome severity in complex diseases. We anticipate that this method could be useful for improving the care of jaundiced newborns through its use as an at-risk screen. Importantly, this method would also be useful in uncovering basic knowledge about this and other polygenetic diseases whose genetic source is difficult to discern through traditional means such as a genome-wide association study.

Transcutaneous bilirubinometry is a reliably conservative method of assessing neonatal jaundice

OBJECTIVE

In order to reduce invasive testing in newborns prior to discharge, we tested the direction of the correlation between transcutaneous bilirubin (TcB) and total serum bilirubin (TSB), the likelihood of missing high TSBs with a raised threshold for confirmatory testing, and also calculated potential cost savings from fewer laboratory testing.

METHODS

We performed a cross-sectional analysis of single paired TcB and TSB results measured at 36 ± 2 h of life in neonates ≥37 weeks admitted only to the Level 1 nursery. TcB was measured using the BiliChek® meter.

RESULTS

Of the 552 infants, 512 (92.8%) had TSB levels below TcB values. Correlation between TcB and TSB was 0.69. If TSB confirmation was to be performed at 11.7 mg/dL (medium risk threshold for phototherapy), the negative predictive value was 99.4%, with a potential cost savings of $6555.00 ($1500.00 per 100 patients). Of the 495 infants with TcB <11.7 mg/dL, only 3 had TSB levels higher than 11.7 mg/dL, and none met phototherapy threshold for low risk infants.

CONCLUSIONS

TcB screening at our institution has a high negative predictive value, and can be used as a stand-alone test until values are close to phototherapy threshold, thus reducing invasive testing and cost.