|Year : 2018 | Volume
| Issue : 2 | Page : 117-123
Clinical and sociodemographic correlates of neonatal jaundice at a tertiary health facility in Lagos, Nigeria
Oyejoke Oyapero1, Aruma E Disu2, Fidelis O Njokanma2
1 Department of Paediatrics, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria
2 Department of Paediatrics, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria
|Date of Web Publication||8-May-2018|
Department of Paediatrics, Lagos State University Teaching Hospital, Ikeja, Lagos
Source of Support: None, Conflict of Interest: None
Background: Varied aetiologies have been proposed for the prevalence of neonatal jaundice (NNJ) in different parts of Nigeria. The aim of this study was to determine the clinical and sociodemographic correlates of NNJ in a cohort of neonates presenting at a Tertiary health Facility in Lagos, Nigeria. Materials and Methods: One hundred and fifty consecutive neonates that presented at the neonatal unit of the hospital were enlisted for the study after checking them with set inclusion and exclusion criteria. The transcutaneous bilirubin (TcB) readings of the individuals were obtained on the forehead, sternum and abdomen of the calm neonate in a supine position and blood samples for total serum bilirubin estimation were drawn from a peripheral vein within 10 min of TcB measurement. Results: One hundred and fifty neonates were included in the study of which 89 (59.33%) were males and 61 (40.67%) were females. Mothers that had only a primary level of education had babies that presented with significantly higher bilirubin values (P = 0.000). Male neonates, those that presented after 48 h, those between 40 and 42 weeks' gestational age and those that were <2.5 kg birth weight also had higher values though it was not statistically significant. Those that were delivered at home or in a church, delivered by an auxiliary nurse or a traditional birth attendant and those with jaundice extending to the sole of the feet also presented with significantly higher mean bilirubin scores (P = 0.000). Conclusion: Majority of individuals in this study with NNJ were males, while those delivered at home or in a church or by traditional birth attendants and auxiliary nurses and had mothers that were poorly educated had higher mean bilirubin values. It is thus imperative that advocacy is increased to intervene on modifiable risk factors for this condition.
Keywords: Neonatal jaundice, sociodemographic correlates, total serum bilirubin, transcutaneous bilirubinometry
|How to cite this article:|
Oyapero O, Disu AE, Njokanma FO. Clinical and sociodemographic correlates of neonatal jaundice at a tertiary health facility in Lagos, Nigeria. Adv Hum Biol 2018;8:117-23
|How to cite this URL:|
Oyapero O, Disu AE, Njokanma FO. Clinical and sociodemographic correlates of neonatal jaundice at a tertiary health facility in Lagos, Nigeria. Adv Hum Biol [serial online] 2018 [cited 2020 Jul 8];8:117-23. Available from: http://www.aihbonline.com/text.asp?2018/8/2/117/232027
| Introduction|| |
Neonatal jaundice (NNJ) is one of the leading causes of neonatal morbidity accounting for between 10% and 35% of neonatal admissions., While most neonates experience physiologic NNJ, the incidence of significant levels of NNJ varies with race or ethnicity. Some authors have observed jaundice prevalence rates ranging from 35% to 45.6% in different centres in Nigeria. Ethnic variability in the incidence and severity of NNJ may be related to differences in the distribution of the genetic variants in bilirubin metabolism. Serum bilirubin concentration reflects a combination of the effects of bilirubin production, conjugation and enterohepatic circulation. The factors that affect these processes account for the bilirubinemia that occurs in virtually all newborns.
Physiological jaundice of the newborn is as a result of a complex interaction of a number of factors which include an increased load to the liver due to relatively high foetal red cell mass in the newborn, reduced red cell lifespan when compared to adult red cells and also an increased release of haem from ineffective erythropoiesis. Other causes of physiologic jaundice are a reduced hepatic uptake of bilirubin due to relatively low ligandin (Y protein) levels and reduced conjugation from relatively low UDGP-T activity; inefficient bilirubin excretion; and increased enterohepatic circulation due to the absence of gut bacteria that break down bilirubin, gut stasis from any cause and increased activity of beta glucuronidase. Physiological jaundice does not usually exceed 10 mg/dl in term and 15 mg/dl in preterm babies and it is clinically undetectable after 14 days.
The time that NNJ appears may be a pointer to its nature. NNJ appearing within 24 h could be due to haemolytic disease of the newborn, Rhesus, ABO and minor blood group incompatibility, infectious origin or glucose-6 phosphate dehydrogenase deficiency. NNJ appearing between 24 and 72 h of life could be physiological, could be due to sepsis neonatorum, polycythemia and concealed haemorrhages such as cephalohaematoma or subarachnoid bleeding. It could also be due to increased enterohepatic circulation. Beyond 72 h of life, the identified causes are sepsis neonatorum, neonatal hepatitis, extrahepatic biliary atresia and breast milk jaundice. Breast milk is a competitive inhibitor of hepatic uridine diphosphate glucuronosyltransferase (late onset breast-milk jaundice). Infants that are exclusively breastfed have an increased risk for severe hyperbilirubinaemia in the first 2–5 days of life compared to formula-fed infants. One review of 12 studies involving more than 8000 neonates in the first week of life revealed that compared to formula-fed infants, breastfed infants had significantly higher maximum total serum bilirubin (TSB) levels. Exclusively breastfed infants are thus at a higher risk of developing NNJ.
Pathological jaundice should be suspected when there is a high red cell mass such as in polycythaemia, increased haemolysis due to blood group incompatibilities or isoimmunisation syndromes such as ABO, rhesus and other minor blood groups. Other causes of pathological jaundice are deficiency of red cell enzymes such as glucose-6 phosphate dehydrogenase, defects in red cell membrane, infections, the use of haemolytic agents and extravasated blood. It may also result from liver cell membrane defects such as Gilbert's disease, defective conjugation and other conditions such as prematurity, Down's syndrome and infants of diabetic mothers. Some of these conditions such as Gilbert's disease are however not common in Nigeria. Pathological jaundice could also be the cause of rise in serum bilirubin by more than 5 mg/dl/day, serum bilirubin more than 15 mg/dl or clinical jaundice persisting beyond 14 days of life.
NNJ has always been a common paediatric problem in various parts of Nigeria.,,, Community-based data on severe NNJ in Nigeria suggest an incidence of 55 per 1000 infants requiring phototherapy and 19 per 1000 infants requiring exchange blood transfusion (EBT). Similarly, it accounted for 35% of all neonatal intensive care unit (NICU) admissions in Abakaliki, southeast Nigeria. In Ile Ife, southwest Nigeria, NNJ accounted for 45% of admission to NICU. About 5.5% of all newborns were estimated to have clinically significant NNJ requiring phototherapy and/or EBT in Nigeria, probably one of the highest rates. NNJ requiring EBT was predictive of sensorineural hearing loss with a population attributable risk of about 11% and the risk of hearing loss for EBT was significantly higher than for phototherapy. Many tertiary institutions in Nigeria still have exceptionally high rates of EBT daily. Adequate comparisons among different data obtained in some of the studies are however limited due to differences in methodology and inadequate differentiation between physiologic and pathologic jaundice in some of the prevalence data. Varied aetiologies have been proposed for the prevalence of NNJ in different parts of Nigeria.
The aim of this study was to determine the clinical and sociodemographic correlates of NNJ in a cohort of neonates presenting at a tertiary health facility in Lagos, Nigeria.
| Materials and Methods|| |
This prospective descriptive study that aimed to determine the clinical and sociodemographic correlates of NNJ at a tertiary health facility in Lagos, Nigeria was conducted at the Lagos State University Teaching Hospital (LASUTH).
Study setting and location
The study was carried out at the neonatal wards of LASUTH which is a tertiary health facility situated in the capital of Lagos State and financed by the Lagos State Government. LASUTH is a referral centre meeting the health needs of most residents within Lagos and its environs. A few cases are also referred from neighbouring states. It is a multispecialist hospital with a bed complement of 741, with about 110 paediatric beds of which nearly half are for neonates.
Consecutive neonates that were brought to the LASUTH neonatal unit were enlisted for the study after screening them and checking them with set inclusion and exclusion criteria.
Sample size determination
This was determined using the formulae: N=Z pq/d 2
Using a prevalence of NNJ in a previous study, a total of 150 patients were recruited.
Term neonates with gestational age of 37 completed weeks and above and with a birth weight not <2500 g, that presented with jaundice or were deemed to have jaundice by the attending physician.
Neonates who may require urgent emergency treatment; those whose parents were unwilling to give their informed consent and did not want to participate in the study and neonates that had been exposed to sunlight and those that were given phenobarbitone which causes significant reduction in plasma bilirubin levels were excluded from the study.
Ethical clearance for the study was obtained from the Ethics and Research Committee of the LASUTH. The title of the research was registered by the same committee. Written consent from each caregiver was also obtained before being included in the study. Those who agreed to participate in the study were assured of their confidentiality and that there was no undesirable consequence for those that declined.
Data collection was accomplished using a structured interviewer-administered questionnaire to document the parents' medical, social and behavioural information, the neonate's gestational age at birth, postnatal age at the time of transcutaneous bilirubin
(TcB) and the mother's ethnicity. The individuals' comprehensive medical history and physical examination results were also documented and a provisional clinical diagnosis was made.
All the TcB recordings were performed by the principal investigator (OO) with the Minolta Konica Jaundice Meter, JM-103™ (Daisennishimachi, Sakaiku, Osaka, Japan). The readings were done on the forehead, sternum and abdomen of the tranquil neonate in a supine position. The forehead recording was taken 2 cm above the glabella with the eyes shielded appropriately while taking it while the abdominal recordings were taken 3 cm above the umbilicus. The sternal recording was taken at the midpoint of the sternum. The probe was disinfected with 70% isopropyl alcohol after utilising it on each baby. The recordings over each measurement site were displayed as the TcB level in mg/dl and an average value of three readings from each site in mg/dl was documented.
Total serum bilirubin estimation
The blood samples for TSB were obtained by the principal investigator (OO) in the neonatology unit from a peripheral vein within 10 min of TcB measurement and transferred into heparinised specimen bottles. These bottles were placed in a light-proof box and transported to the laboratory immediately for total bilirubin determination. TSB levels were measured in the hospital's Clinical Chemistry laboratory using Beckman CoulterSynchron CX5® Automated Chemistry Analyser utilising the diazo method. The Beckman CoulterSynchron CX5® Automated Chemistry Analyser was calibrated daily according to the manufacturers' prerequisite using a commercially obtainable control serum supplied with the machine by the medical laboratory scientist to ensure accuracy and consistency of the results obtained. The values gotten from the TSB result was recorded for each patient.
Data were managed and analysed using the Statistical Package for the Social Sciences version 20.0 software for Windows (SPSS Inc., Chicago, IL, United States). The Chi-square test was used to decide the level of association among the categorical variables, while the paired Student's t-test and ANOVA test were used to compare the means of TcB readings and TSB levels. Pearson's correlation analysis with linear regression was performed to test the relationship between TSB and TcB values as well as for TcB measurements taken at different sites. All tests were carried out at 5% level of significance.
| Results|| |
One hundred and fifty neonates were included in the study of which 89 (59.33%) were males and 61 (40.67%) were females. Majority of the individuals (129; 86%) were of 37–39 weeks' gestational age while others were 40–42 weeks. Almost one-third (56; 37.33%) presented in the clinic between 24 and 48 h of life with NNJ [Table 1].
[Table 2] describes the maternal profile of the study individuals. Majority of them were from the Yoruba Tribe (94; 62.67%), had a secondary level of education (76; 50.67%) and had 1 or 2 children (103; 68.67%). Most of the mothers (60; 40%) experienced a moderate level of distress when their babies had a venepuncture procedure.
[Table 3] describes some of the antenatal, perinatal and postnatal characteristics of the study individuals. Majority of the study individuals had antenatal care (145; 96.67%), were born in general hospitals (106; 70.67%) and had a normal delivery (89; 59.33%). Most of the mothers (123; 82%) were attended to by obstetricians/medical doctors at delivery.
|Table 3: Antenatal, perinatal and postnatal characteristics of the study participants|
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[Table 4] describes the association between NNJ and neonatal/maternal features of study individuals. Mothers that had only a primary level of education had babies that presented with significantly higher bilirubin values (P = 0.000). Male neonates, those that presented after 48h, those between 40 and 42 weeks' gestational age and those that were < 2.5 kg birth weight also had higher values though it was not statistically significant.
|Table 4: Association between neonatal jaundice and neonatal/maternal features of study participants|
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[Table 5] presents the association between NNJ and antenatal, perinatal and postnatal features of study individuals. Those that were delivered at home or in a church, delivered by an auxiliary nurse or a traditional birth attendant and those with jaundice extending to the sole of the feet presented with significantly higher mean bilirubin scores (P = 0.000).
|Table 5: Association between neonatal jaundice and antenatal, perinatal and postnatal features of study participants|
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| Discussion|| |
The sociodemographic profile of the individuals in this study was similar to that observed by other researchers. Majority of individuals in this sample were male. Previous researchers have demonstrated that males have higher bilirubin levels than females,, and not surprisingly, they are overrepresented in the cohort of infants readmitted to the hospital for evaluation and management of NNJ. The higher risk observed among males is consistent with findings in populations where G-6-PD deficiency is prevalent due to its sex-linked mode of inheritance., These findings suggest an increased risk for marked jaundice and an increased susceptibility to bilirubin-induced injury in the male neonate. Most of the individuals in this present study were of gestational age between 37 and 39 weeks and of birth weights between 2.5 and 2.99 kg. This finding was in agreement with the findings by other authors , who observed that term neonates that were of 37 and 38 weeks' gestational age had a higher incidence of NNJ than those that were of 39–40 weeks of age. It may be imperative that term neonates of low gestational age and low birth weight are appropriately screened for jaundice before discharge.
The highest mean bilirubin scores were also observed in individuals who were brought to the clinic after 72 h after birth. Research has shown that NNJ is a common cause of readmission after early hospital discharge for healthy newborns. Estimation of serum bilirubin by visual inspection of the skin is not sufficiently accurate, especially in newborns of mixed ethnicity or diverse racial backgrounds. Thus, early discharge has been associated with increased readmissions attributable to NNJ. Petersen et al. observed a significant reduction in the number of hospital readmissions for clinically significant NNJ and a significant increase in the monthly incidence of phototherapy treatment before discharge after implementation of TcB measurements. It may be appropriate to screen neonates, especially those of early gestational age for NNJ with TcB before they are discharged from the hospital.
There was a preponderance of the Yoruba Tribe among the study individuals. No worthwhile deduction can be made from this observation with regard to NNJ since the study was conducted in Lagos which is mainly composed of this ethnic group. Majority of the mothers of the study individuals had a secondary level education and had 1–2 children. Almost all the mothers had antenatal care while majority of the individuals were delivered by the spontaneous vertex method in general hospitals. Most of the mothers were also attended to by an obstetrician or a medical doctor at delivery, but those that were delivered by an auxiliary nurse and traditional birth attendant had significantly higher mean bilirubin values. This could be due to the inability of these groups of people to adequately identify the condition. It is however significant to note that over 70% of the mothers expressed a moderate-to-high level of distress on witnessing the routine procedure of venepuncture necessary to obtain blood samples for the TSB investigation. This blood sampling procedure is also painful for the neonate and associated with the possibility of local infection. Previous research has shown that venous blood sampling either by the heel prick or venepuncture procedure is associated with a high level of maternal distress on witnessing the process. This observation, in addition to other benefits described by other investigators,,, has made the use of TcB measurements very appropriate for the screening of NNJ in many countries.
About 21.3% of the study individuals were noted to have a setting for ABO incompatibility, 24.7% had probable neonatal sepsis, while 11.3% had a setting for rhesus incompatibility. This was in agreement with other authors , that observed that ABO incompatibility, rhesus incompatibility and sepsis, in combination with exposure to various household chemicals, have been associated with NNJ with resultant high mortality and long-term morbidity in Nigeria. Rhesus isoimmunisation, once an extremely common cause of severe haemolysis, is for the most part, prevented by administration of anti-D globulin to all Rh-negative mothers during pregnancy, and postnatally to those who have delivered an Rh-positive infant. As a result, direct Coombs' positive ABO blood group incompatibility is the most common immune cause of haemolysis encountered. Clues to an infant's propensity for severe hyperbilirubinemia can thus be obtained from characteristics of the mother and perinatal/neonatal factors. Appropriate screening of mothers for ABO and Rh(D) blood types during antenatal care as well as counselling against the use of these harmful substances could lead to a reduction in NNJ and the sequelae associated with it.
A significant association was observed between the level of maternal education and mean bilirubin scores measured by both TcB and TSB. The highest mean scores were obtained by individuals whose mothers were uneducated. Caldwell  observed that maternal education plays an important role in determining child survival after controlling for a number of socioeconomic factors. Other researchers have also established the influence of maternal education on infant and child morbidity and mortality. Correspondingly, study individuals that were born at home and those that were delivered by traditional birth attendants and auxiliary nurses also had the highest mean bilirubin scores. Olusanya et al. likewise observed that neonates born at home were three times at risk of having NNJ requiring phototherapy. Socioeconomic status is a key determinant in morbidity and mortality outcomes. Poverty undermines maternal and neonatal health in several ways. It can heighten the incidence of direct causes of mortality, such as maternal infections and undernutrition, and also discourage care seeking and access to health-care services. It can also undermine the quality of the services provided even when they are available. These findings suggest that there is a need to improve the health literacy of mothers as well as the need for the socioeconomic empowerment of the populace.
| Conclusion|| |
Majority of individuals in this study with NNJ were males, while those delivered at home or in a church or by traditional birth attendants and auxiliary nurses and had mothers that were poorly educated had higher mean bilirubin values. Even though there are familial and genetic basis for the incidence and distribution of NNJ which is potentially associated with significant morbidity and mortality, sociodemographic characteristics continue to have a major role to play both in the distribution and early identification of this condition, especially in resource-limited environments. It is thus imperative that advocacy is increased to intervene on modifiable risk factors for this condition.
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]