Risk factors for acute bilirubin encephalopathy on admission to two Myanmar national paediatric hospitals

Abstract

BackgroundJaundice is the commonest neonatal ailment requiring treatment. Untreated, it can lead to acute bilirubin encephalopathy (ABE), chronic bilirubin encephalopathy (CBE) or death. ABE and CBE have been largely eliminated in industrialised countries, but remain a problem of largely undocumented scale in low resource settings. As part of a quality-improvement intervention in the Neonatal Care Units of two paediatric referral hospitals in Myanmar, hospitals collected de-identified data on each neonate treated on new phototherapy machines over 13–20 months. The information collected included: diagnosis of ABE at hospital presentation; general characteristics such as place of birth, source of referral, and sex; and a selection of suspected causes of jaundice including prematurity, infection, G6PD status, ABO and Rh incompatibility. This information was analysed to identify risk factors for hospital presentation with ABE, using multiple logistic regression.ResultsData on 251 neonates was recorded over 20 months in Hospital A, and 339 neonates over 13 months in Hospital B; the number of outborn neonates presenting with ABE was 32 (12.7 %) and 72 (21.2 %) respectively. In the merged dataset the final multivariate model identified the following independent risk and protective factors: home birth, ORadj = 2.3 (95 % CI: 1.04-5.4); self-referral, ORadj = 2.6 (95 % CI: 1.2-6.0); prematurity, ORadj = 0.40 (95 % CI: 0.18-0.85); and a significant interaction between hospital and screening status because screening positive for G6PD deficiency was a strong and significant risk factor at Hospital B (ORadj = 5.9; 95 % CI: 3.0-11.6), but not Hospital A (ORadj = 1.1; 95 % CI: 0.5-2.5).ConclusionThe study identifies home birth, self-referral and G6PD screening status as important risk factors for presentation with ABE; prematurity was protective, but this is interpreted as an artefact of the study design. As operational research, there is likely to be substantial measurement error in the risk factor data, suggesting that the identified risk factor estimates are robust. Additional interventions are required to ensure prompt referral of jaundiced neonates to treatment facilities, with particular focus on home births and communities with high rates of G6PD deficiency.

Knowledge about Neonatal Jaundice among Nepalese Mothers

“…3 A study conducted in Myanmar reported that neonatal jaundice was the major cause of neonatal morbidity and mortality and was responsible for 46% of hospital admission of neonates in the country. 8 In 2015, a cross sectional study was conducted in Islamabad among 200 respondents to assess the knowledge of mother regarding neonatal jaundice. The study showed that 52.5% mothers had inadequate score while 47.5% mothers had adequate knowledge score.…”

Neonatal Jaundice in Low- and Middle-Income Countries: Lessons and Future Directions from the 2015 Don Ostrow Trieste Yellow Retreat

“…A recent review noted the lack of empirical evidence of the efficacy of such programs in reducing the risk of severe hyperbilirubinemia, but nevertheless echoed this recommendation on the basis of the available evidence and understanding [1,9,10,31,53,56,62,63,64,65,66]. While screening of cord-blood for G6PD deficiency is of relatively low cost, the experience of the DOTYR-15 participants is that there would need to be a substantial investment in infrastructure to support universal screening programs.…”

“…The importance of Rh disease varies widely with the prevalence of Rh-negative maternal status, but the issue of affordable prophylaxis is clearly a priority for many LMICs. The lack of routine maternal and neonatal blood testing in many LMICs is also a barrier, and also impacts the management of ABO incompatibility as a risk factor for serious NNJ [7,32,53,56,57,58,59]. …”

“…A study of neonates treated with phototherapy in 2 specialized pediatric referral hospitals identified home-births, self-referrals and G6PD screening status as important risk factors for presentation with ABE [53]. …”

Glucose-6-Phosphate Dehydrogenase Deficiency among Children Attending the Emergency Department of Yankin Children’s Hospital, Yangon

“…3,4 This enzyme deficiency also contributed to 17%-36% of phototherapy needed neonatal jaundice in neonatal units of children hospitals in this country. 5 Although there is a high prevalence of this enzyme deficiency in Myanmar, most people are not aware of their G6PD status because screening of the disease is not a routine practice yet and most of the affected persons are asymptomatic. However, if G6PD deficient people are exposed to oxidative stress, acute intravascular hemolysis may occur leading to heart failure and even death, if there is no timely intervention.…”