{"id":28229,"date":"2019-09-25T11:18:50","date_gmt":"2019-09-25T11:18:50","guid":{"rendered":"http:\/\/biomedpharmajournal.org\/?p=28229"},"modified":"2020-04-22T10:02:47","modified_gmt":"2020-04-22T10:02:47","slug":"a-treatment-profile-of-neonatal-hyper-bilirubinemia-in-a-tertiary-health-care-hospital","status":"publish","type":"post","link":"https:\/\/biomedpharmajournal.org\/staging\/vol12no3\/a-treatment-profile-of-neonatal-hyper-bilirubinemia-in-a-tertiary-health-care-hospital\/","title":{"rendered":"A Treatment Profile of Neonatal Hyper-Bilirubinemia in a Tertiary Health Care Hospital"},"content":{"rendered":"

Introduction<\/strong><\/p>\n

Neonatal hyperbilirubinemia, the most common health problem in newborns and requires an essential medical attention. Normally, jaundice occurs in 60% of the term babies and 80% of the preterm babies within the first week of life [1,2]. Neonatal jaundice is prone to appear when the serum bilirubin level exceeds 5 mg\/DL. In term babies, physiological jaundice appears between 30-72 hours of age and proceeds to a maximum intensity on fourth day which eventually disappears by 10th<\/sup>day of life [3]. The serum bilirubin level in above case does not exceed 15 mg\/DL.\u00a0 Physiological jaundice in preterm babies is similar to term babies with maximum intensity reaching on 5-6 day and may persist up to 14 days. The serum bilirubin level in these babies may exceed 15 mg\/DL. At normal concentration, bilirubin acts as an antioxidant, whereas when the concentration is increased they become as severe neurotoxin and responsible to produce acute or chronic bilirubin encephalopathy which leads to irreversible brain damage [4]. A study carried in Australia exhibited the incidence level of neonatal jaundice between 7.1 and 45 per 10,000 birth and kernicterus of 0.4-2.7 [5]. The other study conducted among Indian workers identified the overall incidence rate to be 54% to 77%. The\u00a0 various reasons and\u00a0 risk factors associated for the hyperbilirubinemia in neonates\u00a0 are ABO\u00a0 and other\u00a0 blood group incompatibility,glucose-6-phosphate dehydrogenase deficiency, infections, prematurity, low birth weight, lactation failure in excessive breastfeeding, cephalohematoma or bruises, babies of diabetic mother, hypothyroidisim, rare conditions such as Gilbert’s syndrome, Crigler-Najjar syndrome and family history of neonatal jaundice in siblings[6]. A worldwide study conducted in low- income population identified around 14 million newborns with jaundice and required phototherapy [7]. The bilirubin level in the skin was measured with the help of hand-held device, transcutaneous bilirubinometer. In absence of this instrument, jaundice can be assessed visually. The relationship between serum bilirubin levels and the progression of skin discoloration can be described using kramer’s rule. According to this rule, appearance of yellow colour in head and neck region indicates total serum bilirubin levels to be 4-8 mg \/DL, in upper trunk (above umbilicus), to be 5-12 mg\/DL, in lower trunk and thighs (below umbilicus), to be 8-16 mg\/DL, in arms and lower legs to be 11-18 mg\/DL and in palms and soles to be ><\/u> 18mg\/dl.<\/p>\n

Many developmental changes were introduced in the management of neonatal jaundice. Hour\u2013Specific monogram for predicting neonatal hyperbilirubinemia was imported by Bhutani et al which was also supported by American Academy of Paediatrics. Hence the present study was carried to evaluate the occurrence, various aetiologies and treatment profile for neonatal jaundice in a tertiary care hospital[8].<\/p>\n

Materials and Method<\/strong><\/p>\n

The present retrospective study was carried in a tertiary care teaching hospital for\u00a0 2017-2018. All the live births in the hospital during the study period\u00a0were taken from Medical record department. Neonates admitted in neonatal ward with a visible jaundice during the study period\u00a0were\u00a0included. The most common treatment for non-severe\u00a0hyperbilirubinemia\u00a0was phototherapy\u00a0and sunbath. The data collected for the study includes gestational age, gender, birth weight, birth order, mode of delivery, peak serum bilirubin level and the treatment profile.\u00a0Aetiologies\u00a0identified by thorough examinations in neonates were noted. An automated analyzer with\u00a0calorimetric\u00a0method was used to measure the serum bilirubin levels in the blood sample (venous) collected from the neonates. The clinical picture of neonatal jaundice was confirmed by carrying required test. The severity was categorized depending on bilirubin levels and it was grouped above 18 mg\/DL in preterm babies and above 20 mg\/DL in term babies.<\/p>\n

Results and Discussion<\/strong><\/p>\n

The total number of live births in 2017-2018 was 1748 and 74 neonates were identified and treated for hyperbilirubinemia. The present study showed the incidence to be more in female babies than male babies. The female babies were about 55% and male babies were 44% (Table 1). The preterm babies were 21% and term babies were 78% (Table 1). The mode of delivery through LSCS was 56% and normal vaginal delivery was 43% (Fig 1).\u00a0 Hyperbilirubinemia seen in Multiparous was around 64% and in primiparous was around 35% (Fig 2). Majority of the newborns were in normal weights and physiological jaundice was the most common type of jaundice seen in newborns. Single surface phototherapy was the common treatment given to the newborns which was similar to other studies (Table 2). The next cause of jaundice was due to prematurity. There were various causes to jaundice which was shown in Table 2. A positive correlation was seen with birth weight and the peak bilirubin values in neonates (Table 3).<\/p>\n

Table 1: Male and Female Ratio with Gestational Age in Percentage<\/strong>.<\/p>\n\n\n\n\n\n\n\n
Characteristics\u00a0 related with Neonatal Hyperbilirubinemia in percentage<\/strong><\/td>\n<\/tr>\n
Gender<\/strong><\/td>\nMale<\/td>\n44.59 %<\/td>\n<\/tr>\n
Female<\/td>\n55.40 %<\/td>\n<\/tr>\n
Gestational Age<\/strong><\/td>\nTerm<\/td>\n78.37 %<\/td>\n<\/tr>\n
Preterm<\/td>\n21.62 %<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n


\nTable 2: Birth weight, Treatment profile and Aetiology of Jaundice.<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n\n\n
Birth weight (in grams) and Treatment<\/strong><\/td>\npercentage<\/strong><\/td>\nEtiology<\/strong><\/td>\n\u00a0percentage<\/strong><\/td>\n<\/tr>\n
Normal (>2500 g)<\/td>\n79.72 %<\/td>\nCephalohematoma<\/td>\n1.35 %<\/td>\n<\/tr>\n
Low birth weight (1500 \u2013 2500 g)<\/td>\n16.21 %<\/td>\nPhysiological jaundice<\/td>\n66.21 %<\/td>\n<\/tr>\n
Very low birth weight (1000-1500 g)<\/td>\n2.70 %<\/td>\nPrematurity<\/td>\n16.21 %<\/td>\n<\/tr>\n
Extremely low birth weight (<1000 g)<\/td>\n1.35 %<\/td>\nSepsis<\/td>\n6.75 %<\/td>\n<\/tr>\n
Single surface phototherapy<\/td>\n81.08 %<\/td>\nABO incompatibility<\/td>\n2.70 %<\/td>\n<\/tr>\n
Double surface phototherapy<\/td>\n2.70\u00a0 %<\/td>\nRh incompatibility<\/td>\n1.35 %<\/td>\n<\/tr>\n
Both(single and double surface phototherapy)<\/td>\n14.86 %<\/td>\nBreast milk jaundice<\/td>\n5.40 %<\/td>\n<\/tr>\n
Triple and single surface Phototherapy<\/td>\n1.35 %<\/td>\n–<\/td>\n–<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n


\nTable 3: Correlation of Birth Weight with Peak bilirubin levels.<\/strong><\/p>\n\n\n\n\n\n
Groups<\/strong><\/td>\nMean+ <\/u>SD<\/strong><\/td>\n\u00a0Correlation of Coefficient<\/strong><\/td>\nSig.<\/strong><\/td>\n<\/tr>\n
Birth weight (in grams)<\/td>\n2.884 +<\/u> 0.68<\/td>\n\u00a0r = +0.267<\/td>\n0.021<\/p>\n

 <\/td>\n<\/tr>\n

Peak bilirubin\u00a0\u00a0(in gm\/DL)<\/td>\n14.90 +<\/u> 3.51<\/td>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Correlation is significant at 0.05 level (2-tailed)<\/p>\n\n\n\n
\"Figure<\/td>\nFigure 1: Mode of Delivery in Percentage.<\/strong><\/p>\n

 <\/p>\n

Click here to view figure<\/a><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n\n
\"Figure<\/td>\nFigure 2: Status of Parity in Percentage.<\/strong><\/p>\n

 <\/p>\n

Click here to view figure<\/a><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n


\nDiscussion<\/strong><\/p>\n

Mild increase in bilirubin level often disappears within two-three weeks in newborns whereas in-case of moderate to severe raised levels, an appropriate treatment is required[9].\u00a0Phototherapy, using conventional or fiber optic lights and exchange transfusion was the common and frequently used treatment to reduce the serum bilirubin levels. During\u00a0phototherapy, exposure of skin to\u00a0\u00a0light source converts\u00a0unconjugated\u00a0bilirubin to water-soluble form and can be easily excreted by the normal mechanism. The blue-green light source was used in\u00a0phototherapy\u00a0for\u00a0a better\u00a0penetration into the skin and removes the\u00a0unconjugated\u00a0bilirubin by undergoing\u00a0photochemical\u00a0reaction [10]. Single, double and triple surface photo-therapies are available to decrease the bilirubin levels. Single surface\u00a0phototherapy\u00a0was found to be effective when compared to double surface which was used only to avoid the exchange transfusion [11]. In present study, only single surface\u00a0phototherapy\u00a0was used in major cases which was similar to previous studies. Exchange transfusion can be used in case if there is a risk of\u00a0kernicterus, blood incompatibility or after intense\u00a0phototherapy\u00a0was unsuccessful [12]. Double volume\u00a0phototherapy\u00a0replaces 86% of blood and 63% in single volume\u00a0phototherapy. Exchange transfusion may produce many adverse effects like\u00a0thrombocytopenia, portal vein thrombosis, necrotizing\u00a0enterocolitis , arrhythmia, cardiac, arrest,\u00a0 hypocalcemia,\u00a0hypomagnesemia, hypoglycemia, respiratory and metabolic acidosis and other complications due to blood transfusion [13]. The practice of using\u00a0the high\u00a0dose intravenous immunoglobulin (iv\u00a0IG) has reduced the need for exchange transfusion with Rh,\u00a0ABO\u00a0[14]. In present study, the absence of exchange transfusion indicates the lack of occurrence in\u00a0the critical\u00a0bilirubin levels in newborns. Krishna\u00a0veni\u00a0et al\u00a0conducted a study to know the effect of gender on bilirubin levels and the study showed female babies to be more affected than male babies which was similar to our study [15]. Mostly term babies were affected with physiological jaundice which requires phototherapy for a short period as a treatment and this study also stipulates similar result [16].<\/p>\n

Phenobarbitone, an\u00a0antiepileptic\u00a0drug has been used as a prophylactic treatment in the\u00a0pre-term\u00a0babies where there is a higher risk of jaundice. These drugs act by inducing the activity of\u00a0uridine-di-phosphate\u00a0glucuronosyl\u00a0transferase\u00a0enzyme and enhance the excretion of bilirubin and thereby reduce the concentration in newborn babies.\u00a0Phenobarbitone\u00a0can be used\u00a0prophylactically\u00a0in order to avoid exchange transfusion in babies which\u00a0result\u00a0in many complications.17<\/sup> Alternate to conventional treatment, there are other pharmacological treatments to reduce neonatal jaundice. These include\u00a0metalloporphyrins,\u00a0clofibrate, bile salts, laxative, indole-3-\u00a0carbinol\u00a0and bilirubin oxidase which are under clinical trial.\u00a0Metalloporphyrins, synthetic heme analogs can reduce the production of\u00a0unconjugated\u00a0bilirubin by competitively inhibiting heme\u00a0oxygenase.18<\/sup><\/p>\n

Phenobarbitone, an\u00a0antiepileptic\u00a0drug has been used as a prophylactic treatment in the\u00a0pre-term\u00a0babies where there is a higher risk of jaundice. These drugs act by inducing the activity of\u00a0uridine-di-phosphate\u00a0glucuronosyl\u00a0transferase\u00a0enzyme and enhance the excretion of bilirubin and thereby reduce the concentration in newborn babies.\u00a0Phenobarbitone\u00a0can be used\u00a0prophylactically\u00a0in order to avoid exchange transfusion in babies which\u00a0result\u00a0in many complications [17]. Alternate to conventional treatment, there are other pharmacological treatments to reduce neonatal jaundice. These include\u00a0metalloporphyrins,\u00a0clofibrate, bile salts, laxative, indole-3-\u00a0carbinol\u00a0and bilirubin oxidase which are under clinical trial.\u00a0Metalloporphyrins, synthetic heme analogs can reduce the production of\u00a0unconjugated\u00a0bilirubin by competitively inhibiting heme\u00a0oxygenase [18].<\/p>\n

A study conducted in India for a period of 7 years in a tertiary care hospital identified around 65% morbidity among extremely low birth weight babies [19]. Even,the chance of occurrence in\u00a0kernicterus\u00a0were more common in\u00a0the very\u00a0low birth weight than normal weight babies [20].\u00a0In\u00a0present study,it is observed that the correlation of birth weight and peak bilirubin levels\u00a0were\u00a0statistically significant and this was supported by the data which indicated the presence of only 20% with\u00a0a low\u00a0birth weight and rest all have normal birth weight [21].\u00a0The\u00a0study data also showed the absence of severe neonatal\u00a0hyperbilirubinemia\u00a0and a conventional treatment of\u00a0phototherapy\u00a0was only used. Mode of delivery also had influence to induce jaundice in newborns and there were higher chances\u00a0of the jaundice\u00a0in babies who were born by cesarean section than through normal vaginal delivery. In our study, around 56% of babies were delivered through cesarean section who were affected with jaundice when compared with normal delivery (43%) [22].\u00a0Mikael\u00a0et al\u00a0conducted a study to analyze various risk factors for\u00a0non-hemolytic\u00a0jaundice in neonates and identified\u00a0primiparous\u00a0to be one of the\u00a0reason,\u00a0and this was in contrary with the result of the present study[23].<\/p>\n

Conclusion<\/strong><\/p>\n

Hyperbilirubinemia in neonates are more dangerous when they are not provided with appropriate treatment. Therefore in order to reduce the severity of jaundice in newborns, preventive steps should be taken in co-operation with physician and parents for early diagnosis and treatment of babies. Mothers can be educated about various factors which induce neonatal jaundice before delivery itself. A practice of routine bilirubin level assessment in the neonates before discharge will help in reducing re-admission of babies. Even with the availability of recent techniques like hour specific nomograms in identifying jaundice still, more research is required by research scientist to help the doctors by introducing easy techniques for early treatment for the babies.<\/p>\n

Acknowledgements<\/strong><\/p>\n

The authors are thankful to Dr. Prashanth. R, 3rd<\/sup> year MD, Social and Preventive Medicine in helping for carrying\u00a0 statistical analysis.<\/p>\n

Conflict of Interest<\/strong><\/p>\n

The authors declare that there is no conflict of interest<\/p>\n

Funding source<\/strong><\/p>\n

There is no funding source.<\/p>\n

References<\/strong><\/p>\n

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    Introduction Neonatal hyperbilirubinemia, the most common health problem in newborns […]<\/p>\n","protected":false},"author":9,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[71],"tags":[],"class_list":["post-28229","post","type-post","status-publish","format-standard","hentry","category-vol12no3"],"_links":{"self":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts\/28229","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/users\/9"}],"replies":[{"embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/comments?post=28229"}],"version-history":[{"count":6,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts\/28229\/revisions"}],"predecessor-version":[{"id":31923,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts\/28229\/revisions\/31923"}],"wp:attachment":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/media?parent=28229"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/categories?post=28229"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/tags?post=28229"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}