Introduction
Among the common issues necessitating phototherapy in neonates, hyperbilirubinemia stands out. Neonates exhibit clinical jaundice when serum bilirubin levels exceed 5-7 mg%.1
Jaundice is a frequent clinical finding in newborns. Studies suggest an incidence of neonatal jaundice in India ranging from 54.6% to 77%.2 Jaundice emerges when the immature neonatal liver cannot efficiently eliminate bilirubin from the blood, resulting in a yellowing of the skin due to unconjugated lipid-soluble bile pigment accumulation.3 Pathological jaundice occurs in 4-8% of neonates, often due to prematurity, G6PD deficiency, blood group incompatibility, or sepsis. 4, 5
Differentiating jaundice requires daylight assessments. The skin is pressed over a bony area, blanching it, to observe the yellow hue underneath. 6
The management of neonatal hyperbilirubinemia necessitates different approaches based on clinical scenarios and gestational age. Phototherapy and exchange transfusion recommendations by the American Academy of Pediatrics form the foundation for treating neonatal jaundice in infants over 35 weeks gestation.5 Phototherapy proves to be a safe, cost-effective, and efficient approach. This study focuses on the clinical characteristics, etiology, and maternal/neonatal risk factors of hospitalized neonates with hyperbilirubinemia. 7
Materials and Methods
This research was conducted at the Neonatal Intensive Care Unit (NICU) of IGIMS, Patna, Bihar, India. It encompassed infants admitted with serum bilirubin levels exceeding 12 mg/dl. The study, conducted with parental consent, spanned from October 2019 to October 2020.
Case selection
This study spanned a year and included infants both born at IGIMS and referred from other facilities. It encompassed healthy and ill late preterm and full-term infants.
Sample size
The sample consisted of 210 newborns admitted to the NICU at IGIMS, Patna, who experienced jaundice (serum bilirubin >12mg/dl) during the study duration.
Sampling method
Total of 210 newborns meeting the selection criteria within the hospital were included.
Methods
Clinical assessment and biochemical analysis were employed to diagnose and evaluate jaundice. Clinical estimation of jaundice employed Kramer's rule, confirmed by serum bilirubin levels. Comprehensive prenatal, birth, and postpartum histories were obtained. Clinical risk factors for jaundice were recorded, and infants requiring jaundice treatment underwent neurological assessments including a BIND score. Infants with bilirubin levels above 18 mg/dl underwent basic aetiological assessments (CBP, Reticulocyte count, G6PD, and DCT).
Serum bilirubin concentration was determined using the Van den Bergh technique, limited to infants with levels exceeding 12 mg/dl. Neonates were subjected to phototherapy and/or exchange transfusion as per American Academy of Pediatrics guidelines. Serum bilirubin levels were monitored, and infants received routine care and observation. Adverse effects of phototherapy and/or DVET were documented.
Results
The study's findings, which focused on the distribution of newborns by birth weight and the causes of several illnesses linked to birth weight, are presented in the publication. The study also examines the distribution of newborns based on the modality of therapy used during treatment and the blood bilirubin levels at the time of initiating phototherapy. The difficulties that newborns face during phototherapy are also looked at.
The distribution of newborns by birth weight is shown in Table 1. The bulk of the 210 newborns in the research weigh between 2001 and 2500 grammes (27.14%), followed by 250 to 3000 grammes (47.62%). Additionally, a sizable proportion of newborns (10.48%) and those with birth weights of more than 3000 grammes (19.05%) were noted.
The aetiology of a few medical problems related to birth weight is revealed in Table 2. Among the neonates, physiological causes accounted for 129 instances, making them the most frequent cause. Notably, foetal preterm and birth asphyxia were reported in 30 and 7 instances, respectively, while extended labour was shown to be a relevant cause in 18 cases. 28 instances were caused by idiopathic causes, whereas 7 cases each of ABO and Rh incompatibility were found. G6PD insufficiency was only found to exist in one instance.
Table 1
Distribution according tobirth weight
|
S.No. |
Weight (Grams) |
Frequency |
Percentage |
|
1 |
1000-1500 |
3 |
1.43 % |
|
2 |
1501-2000 |
22 |
10.48 % |
|
3 |
2001-2500 |
57 |
27.14 % |
|
4 |
2501-3000 |
100 |
47.62 % |
|
5 |
>3000 |
40 |
19.05 % |
Table 2
Distribution based on birth weight
Table 3
Distribution based on sr. Bilirubin when starting phototherapy
|
S.No. |
Sr. Bilirubin level (mg/dl) |
Frequency |
Percentage |
|
1. |
12-15 |
123 |
58.57 % |
|
2. |
15.1-18 |
41 |
19.52 % |
|
3. |
18.1-20 |
21 |
10 % |
|
4. |
>20 |
25 |
11.91 % |
|
Total |
210 |
210 |
100 % |
Table 4
Distribution ofneonates based on mode of therapy
|
S.No. |
Mode of Therapy |
Frequency |
Percentage |
|
1. |
Phototherapy Alone |
206 |
98.10 % |
|
2. |
Exchange Transfusion and Phototherapy |
4 |
1.90 % |
|
Total |
210 |
210 |
100 % |
Table 5
Complications developed during treatment
|
Complications during phototherapy |
Number of patients |
|
Loose motions |
4 |
|
Rash |
3 |
|
Total |
7 |
Based on their blood bilirubin levels at the time of phototherapy commencement, the distribution of newborns is examined in Table 3. Among the 210 newborns, 41 neonates (19.52%) and 123 neonates (58.57%) had serum bilirubin levels between 12 and 15 mg/dl and 15.1 and 18 mg/dl, respectively. In addition, 25 newborns (11.91%) had values over 20 mg/dl, and 21 neonates (10%) had levels between 18.1 and 20 mg/dl.
The type of therapy used throughout treatment is shown in Table 4. With 206 cases (98.10%), phototherapy was the only treatment given to the majority of newborns. Four patients (1.90%) received exchange transfusions in addition to phototherapy.
The issues that arose during phototherapy are shown in Table 5 . Four of the 210 newborns had loose movements, and three of the neonates got rashes. It is significant to highlight that in this investigation, exchange transfusion-related problems were not recorded.
Discussion
The study investigated a cohort of 210 neonates with neonatal hyperbilirubinemia, revealing a male predominance with 56.2% being male. Among them, 21.90% were born prematurely, while 78.10% were born after completing 37 weeks of gestation. Prematurity emerged as the second most prevalent contributor to hyperbilirubinemia, affecting 47.9% of preterm infants.8, 9 The average age at which infants were admitted for phototherapy was 5 days. The majority of newborns exhibited birth weights ranging from 250 to 3000 grams. Notably, low birth weight (LBW) was observed in 35.71% of infants, with factors such as maternal malnutrition and economic constraints being implicated. 10, 11
The study delved into the risk factors associated with neonatal hyperbilirubinemia. Maternal factors encompassed prolonged rupture of membranes (PROM) and extended labor. Among fetal factors, prematurity and birth asphyxia were notable contributors.12 Physiological hyperbilirubinemia was identified in 141 infants, which typically resolved within a specific timeframe. Idiopathic hyperbilirubinemia accounted for 13.33% of cases. Septicemia emerged as a causative factor in 12.40% of the afflicted infants. Rh and ABO incompatibility were found in 3.33% each, whereas G6PD deficiency was detected in only one neonate. 13
Among the cases, three infants necessitated exchange transfusion due to Rh incompatibility. Strikingly, none of the infants exhibited symptoms of BIND (Bilirubin-induced neurologic dysfunction). 14 The average BIND score for the study cohort was 1.8, and the absence of encephalopathy cases could be attributed to early intervention and referrals by the vigilant pediatricians. 15
Conclusion
Physiological, septicemia and idiopathic aetiologies were revealed to be the most frequent causes of newborn hyperbilirubinemia. Less frequent reasons were blood group compatibility issues. An inexpensive and efficient method to lower bilirubin levels in newborn jaundice is phototherapy. Thanks to pediatricians' increased knowledge and caution, the need for exchange transfusions has been greatly decreased. Exchange transfusion is a safe treatment that needs to be taken into account when BIND is present.
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