|Year : 2018 | Volume
| Issue : 2 | Page : 128-134
Determinants of delay in presentation and clinico-laboratory features of newborns admitted for neonatal jaundice in a tertiary hospital in south-east Nigeria
Uchenna Ekwochi1, Chidiebere D I Osuorah2, Ikenna K Ndu1
1 Department of Pediatrics, Enugu State University of Science and Technology, Enugu State, Nigeria
2 Child Survival Unit, Medical Research Council UK, The Gambia Unit, Fajara, The Gambia
|Date of Web Publication||17-Jul-2019|
Dr. Chidiebere D I Osuorah
Child Survival Unit, Medical Research Council UK, The Gambia Unit, Fajara
Source of Support: None, Conflict of Interest: None
Background: Neonatal jaundice (NNJ) is one of the most common causes of hospital visit in the first 30 days of life. It is one of nine danger signs of neonatal illness recognized by the World Health Organization. Understanding its clinical and laboratory features will enhance early diagnosis and management to forestall associated morbidities. This study explored the clinical and laboratory features of newborns admitted for NNJ in a tertiary hospital in the south-eastern Nigeria. Methods: It is a descriptive study carried out prospectively over a 18-month period on all newborns admitted for jaundice at the Enugu State University Teaching Hospital. Patients were enrolled consecutively at presentation and relevant clinical and laboratory features in these newborns were documented in a structured admission register designed for this study. These data were subsequently transferred to Microsoft Excel and analyzed with SPSS version 20. Results: A total of 83 (17.0%) out of 487 newborns were admitted for NNJ during the study period. More female newborns (P = 0.321), newborns delivered outside Enugu State University Teaching Hospital (P = 0.09), mothers ≤ 30 years (P = 0.648), and mothers with lower educational attainment (P = 0.502) had delayed presentation to hospital. Poor suckling (42%), fever (38%), and depressed primitive reflexes (38%) were the most common clinical features seen in admitted newborns. Yellowish discoloration of newborns was noticed within the first 24 h of life in only 13%, between 2 and 7 days in 81%, and after the seventh day of life in 6% of newborns. The median (interquartile range, IQR) of the age jaundice was first noticed and when infant was brought to the hospital for evaluation was 3.0 days (IQR 2–5) and 5.0 days (IQR 4–7), respectively. This resulted to a mean onset–presentation delay time of 2.8 ± 2.3 days (∼67.2 h). The mean total serum bilirubin and unconjugated hyperbilirubinemia was 307 ± 145.2 and 257.5 ± 127.6 μmol/L, respectively. Malaria parasite (17%), glucose-6-phosphate deficiency (5%), and ABO incompatibility was seen in 8% of newborns surveyed. Conclusions: NNJ remains a common health problem in our setting. This underscores the need to upscale education of the mothers and caregivers especially those that prefer to deliver outside a tertiary health institution on the need for early presentation in newborns with jaundice associated with poor suckling and reduced activities.
Keywords: Bilirubin, Enugu, jaundice, newborns
|How to cite this article:|
Ekwochi U, Osuorah CD, Ndu IK. Determinants of delay in presentation and clinico-laboratory features of newborns admitted for neonatal jaundice in a tertiary hospital in south-east Nigeria. J Med Trop 2018;20:128-34
|How to cite this URL:|
Ekwochi U, Osuorah CD, Ndu IK. Determinants of delay in presentation and clinico-laboratory features of newborns admitted for neonatal jaundice in a tertiary hospital in south-east Nigeria. J Med Trop [serial online] 2018 [cited 2020 Jul 11];20:128-34. Available from: http://www.jmedtropics.org/text.asp?2018/20/2/128/262754
| Introduction|| |
Jaundice is a yellowish discoloration of the sclera and/or skin and mucous membrane due to accumulation of unconjugated bilirubin. It is one of nine danger signs of neonatal illness recognized by the World Health Organization (WHO). Jaundice is a very common condition worldwide that occurs in up to 60% of term and 80% of preterm newborns in the first week of life., It is a neonatal emergency and should be reviewed as urgently as possible to identify the associated clinical features, causative factors, and the best treatment option to avert neurological damage. In developed countries, fetomaternal blood group incompatibility is a major factor associated with jaundice whereas in developing countries, additional factors like infection, prematurity, glucose-6-phosphate (G6PD) deficiency, use of herbal concoction in pregnancy, application of dusting powder on babies, and storage of baby’s clothes with naphthalene balls have been associated with neonatal jaundice (NNJ).,, Some of the documented neurological sequel of severe jaundice in the newborn period include, but are not limited to, sensorineural hearing loss, cerebral palsy, epilepsy, intellectual deficit, and behavioral problems., As a result of irreversible brain damage by bilirubin (kernicterus), a nongovernmental organization known as “Parents of Infants and Children with Kernicterus (PICK)” was founded in the United States in the year 2000. Their mission was to partner with healthcare system to prevent kernicterus, provide comfort, support and information on treatment options for families of children with kernicterus, and establish a model for a family-centered system-based approach for a constructive parent/healthcare partnerships to address preventable disabilities.
Critical to averting the physical and psychosocial stress associated with NNJ is early presentation and institution of adequate care early enough in the clinical course of the disease. Available treatment options include phototherapy, exchange blood transfusion, and pharmacotherapy. These options can be used alone or in combinations to treat NNJ. Determinants of the treatment option include the serum bilirubin level and the clinical features. The authors aimed at documenting clinical and laboratory findings in NNJ in the study center and determining factors that result in delayed presentation of newborn with jaundice. It is hoped that the findings will be a useful tool to clinicians in strategizing interventions in the care of newborns presenting with jaundice in the study settings and other settings with similar demographics.
| Methodology|| |
The study was carried out at the Special Care Baby Unit of Enugu State University Teaching Hospital (ESUTH), Enugu, Nigeria. The hospital serves as a major referral center for maternal and newborn health services for the state and its environments. Currently, it has a 24-bed capacity ward equipped with facilities and manpower for level III neonatal care. Available equipment for neonatal care includes, but are not limited to, neonatal ventilator, radiant warmer, incubators, apparatus for continuous positive airway pressure, Light emitting diode (LED) phototherapy units, electrical and manual suction apparatus, and oxygen delivery units. The unit is manned by two consultant neonatologists, residents rotating through neonatal postings, pediatric nurses, and other supporting staff.
This is a descriptive study carried out over a 19-month period from April 2015 to October 2016. Data was obtained from newborns who presented with jaundice in the study center. All babies who presented with jaundice and whose mothers have signed an informed written consent for study participation were consecutively enrolled. The mothers were informed that participation, as well as withdrawal, is voluntary at any stage of the study. They were assured that the volunteered information will be confidential and be utilized for the research only.
The following demographic characteristics of enrolled newborns were documented: age when jaundice was noticed, age at presentation to the hospital, gender, birth weight, gestational age, place of birth, duration of hospital stay, and outcome (dead or survived). Maternal age, highest educational attainment, and socioeconomic class of the mother was documented using the Olusanya, Okpere, and Ezimokhai socioeconomic indices. In view of establishing complications at presentation, the presence or absence of clinical features through physical examination were also documented in enrolled newborns. The physical examinations were carried out on admission by the pediatric resident on duty and each finding were confirmed by a neonatologist. Likewise, wherever possible, relevant laboratory findings done to ascertain the level of serum bilirubin at presentation and the possible causative factors were recorded in a structured admission register. These tests include serum bilirubin level (total and direct), hemoglobin level, maternal and baby’s blood group and Rhesus status, G6PD status for males, blood film for malaria parasite, complete blood count, and others. For the sake of this study, delay in presentation was defined as presentation to the hospital after 24 h of noticing jaundice in the newborn.
Data entry and analysis
The above clinical and laboratory measures were documented at presentation in the relevant sections of the proforma originally designed for this study by the authors. The data were subsequently transferred into a Microsoft Excel Sheet. Distribution of the measures of predictor and outcome variables were analyzed and recorded in percentages. Patients with significant missing information were excluded from the data analysis. Data were analyzed using IBM SPSS version 20, 2005 edition (SPSS Inc., Chicago, IL, USA). Mean with standard deviation, median with interquartile range, and Chi-square statistical stools were employed in data analysis. Statistical significance was set at P<0.05.
| Results|| |
Characteristics of babies admitted for NNJ
A total of 83 newborns were admitted during the 19-month period of this study from April 2015 to October 2016. Forty-one percent (41%) were inborn whereas the remainder were born outside and referred to ESUTH. About two-thirds, 53 (65%), were term deliveries and a male–female ratio of 1.4:1. The mean birth weight was 2.72 ± 0.9 kg. Jaundice was noticed within the first 24 h of life in only 13% (10/83) of the admitted neonates. In a clear majority (81%), the yellowish discoloration was first noticed between the second and seventh day of life whereas in 6% of the surveyed newborns, it was noted after 7 days of life. Age at admission to the special care baby unit was ≤48 h (10%), 2 to 7 days (71%), and more than 7 days in 19% of cases with a median age of 5.0 days (IQR 4–7). Eleven (13%) of neonates were brought to the hospital within 24 h after jaundice was noticed by the caregivers with 87% brought in after 24 h. Majority of the neonates were on admission for more than 10 days during management of NNJ while 6% of the newborns died while still on hospital admission [Table 1].
|Table 1: Characteristics of babies admitted for neonatal jaundice to the Special Care Baby Unit of ESUTH from April 2015 to October 2016|
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[Table 2] shows the sociodemographic characteristics of mothers of enrolled neonates. The median age of mothers was 30 (IQR 28–35) years. The proportion of mothers ≤30 years and >30 years was 49% and 51%, respectively. Twenty-six mothers (36%) were educated to university or higher level whereas one out of two had completed a secondary school or postsecondary school education but not acquired a bachelor-level degree. Majority of the mothers (66%) were either unemployed or in unskilled occupation and the reminder had jobs that were in the semiskilled (28%) and skilled (6%) occupational category. Overall, mothers from the high, middle, and low socioeconomic class represented 13%, 36%, and 51% of respondents, respectively.
|Table 2: Sociodemographic characteristics of mothers whose babies were admitted for neonatal jaundice in the Special Care Baby Unit of ESUTH|
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Delay in hospital presentation and sociodemographic characteristics
[Table 3] shows some descriptive statistics of newborns managed for jaundice during the study period. The mean age when jaundice was first noticed and when infant was brought to the hospital for evaluation was 3.6 ± 2.2 and 5.7 ± 3.8, respectively, giving a mean onset–presentation delay time of 2.8 ± 2.3 days (∼67.2 h). More female newborns were brought to the hospital 24 h after jaundice was noticed compared to male (91.2% vs. 83.7%, P = 0.321). Also, more newborns delivered outside ESUTH (94.1%) delayed in presentation to the hospital compared to those born in ESUTH (81.6%, P = 0.09). Furthermore, higher proportion of mothers ≤30 years presented after 24 h of noticing jaundice in their newborn compared to those >30 years (88.2% vs. 84.4%, P = 0.648). Finally, mothers with university or higher educational attainment (84.6%) had less delays in presenting their newborns to the hospital compared to those with lower educational attainment, that is, 91.9% and 88.0% of mothers with secondary and primary/no education, respectively (P = 0.502).
|Table 3: Baseline parameters of babies admitted with neonatal jaundice at the Special Care Baby Unit of ESUTH|
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Clinical and laboratory characteristics of newborns admitted for NNJ
[Table 4] outlines the clinical features encountered in newborns admitted for NNJ. Poor suckling (42%), fever (38%), and depressed primitive reflexes were, by far, the most common clinical features seen in admitted newborns whereas cephalohematoma (1%), splenomegaly (1%), and shrill cry (3%) were the least common features encountered. Other clinical features seen in these newborns included, but not limited to, pallor (17%), hepatomegaly (14%), hypertonia (8%), vomiting (6%), subtle seizure (5%), and floppiness (4%).
|Table 4: Clinical features encountered in babies admitted for neonatal jaundice at the Special Care Baby Unit of ESUTH|
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The mean total serum bilirubin was 307 ± 145.2 μmol/L in surveyed neonates. Unconjugated hyperbilirubinemia was the most common (92%) laboratory finding seen with a mean level of 257.5 ± 127.6 μmol/L whereas conjugated hyperbilirubinemia was seen in 8% of newborns with a mean level of 48.7 ± 83.7 μmol/L. G6PD was deficient in four (5%) of the newborns and malaria parasite was seen in the blood film of 14 (17%) admitted newborns. Thirty-five percent of the neonates had total white cell count outside the normal range of 4 to 11 × 109. Band cells and toxic granulations were seen in 15/36 (33%) and 4/46 (9%) of blood films evaluated. ABO incompatibility was observed between mother–neonate dyads in 8/56 (14%) of cases. Pack cell volume below the accepted level of 40% were found in 15/47 (32%) of surveyed newborns [Table 5].
|Table 5: Initial laboratory findings of babies presenting with neonatal jaundice at the Special Care Baby Unit of ESUTH|
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| Discussion|| |
In this study, the occurrence of NNJ was significantly higher among the outborn than the inborn babies. This is consistent with the findings from other parts of Nigeria and Africa.,,, This may be because most mothers of outborn babies are not booked for antenatal care and these mothers tend to take herbal medications that are significantly associated with NNJ., In addition, sepsis, which has been reported to occur more in outborn babies, has been identified as one of the leading causes of severe NNJ.,, Therefore, regular attendance to antenatal care and delivery in appropriate healthcare facilities can help to reduce the incidence of severe NNJ in the community.
This study also revealed that most of the cases of NNJ were first noticed during early neonatal life, that is, within 7 days of birth. Similar findings have been reported by other studies.,,, This has been attributed to the association between the major causes of NNJ such as prematurity and sepsis with early neonatal life.,
Delay in the presentation of neonates with jaundice at the hospital was a reason for the persistence of the severe forms of jaundice. The current study showed that mothers with tertiary education had less delays in presenting their newborns to the hospital compared to those with lower educational attainment. This is in keeping with findings of several studies that assessed maternal knowledge and care-seeking behaviors for newborn jaundice.,,, Women with tertiary education are more likely to be associated with appropriate care-seeking practices for infants with NNJ and this can reduce the risk of complications., Similarly, newborns born outside the study center were also noted to present late compared to those who were delivered within the study hospital. This is hardly surprising as mother will naturally take their sick child to facilities where they delivered their babies. These facilities either manage the sick child or refer to a specialized health facility in cases of worsening symptoms or when there is no clinical improvement. All these adds to the delay in mother finally presenting to a specialized facility, like ours, for proper evaluation and management.The risk factors associated with NNJ identified by this study include sepsis, preterm deliveries, congenital malaria, ABO incompatibility, and G6PD deficiency in that order. These have all been reported in a review of NNJ in Nigeria. The anemia seen in jaundiced newborn in this study is likely a complication. Sepsis and preterm delivery were found to be the main associated risk factors for NNJ in this study. Similar findings were reported by other studies on NNJ.,, However, these other studies, identified sepsis and G6PD deficiency as the major etiological factors., The reason for the low incidence of G6PD deficiency and increased incidence of prematurity as risk factors in this study is not clear. Congenital malaria has been suggested to have a plausible but unverified link to NNJ. This may be related to the increased breakdown of newborn red blood cells and effect on the immature liver. This reiterates the need for further research efforts.
| Conclusion|| |
In this study, births outside our health facility and low maternal education were modifiable factors associated with late presentation of newborn with jaundice to the hospital. The major clinical findings at presentation were poor suckling, depressed primitive reflexes, and fever. These represent possible complications and hence underscores the need to upscale education of the mothers and caregivers on the need for early presentation.
The sacrificial efforts of residents, nurses, and other supporting staff in caring for newborns in the study center are hereby acknowledged. The management of ESUTH and the government of Enugu State are also applauded for providing the facilities for neonatal services in the hospital.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]