Maternal Instruction About Jaundice and the Incidence of Acute Bilirubin Encephalopathy in Nigeria

Considerations for applying emerging technologies in paediatric laboratory medicine

Emerging technology in laboratory medicine can be defined as an analytical method (including biomarkers) or device (software, applications, and algorithms) that by its stage of development, translation into broad routine clinical practice, or geographical adoption and implementation has the potential to add value to clinical diagnostics. Paediatric laboratory medicine itself may be considered an emerging area of specialisation that is established relatively recently following increased appreciation and understanding of the unique physiology and healthcare needs of the children. Through four clinical (neonatal hypoglycaemia, neonatal hyperbilirubinaemia, sickle cell disorder, congenital adrenal hyperplasia) and six technological (microassays, noninvasive testing, alternative matrices, next generation sequencing, exosome analysis, machine learning) illustrations, key takeaways of application of emerging technology for each area are summarised. Additionally, nine key considerations when applying emerging technology in paediatric laboratory medicine setting are discussed.

Antenatal jaundice instruction and acute bilirubin encephalopathy in Nigeria

BACKGROUND

Acute Bilirubin Encephalopathy (ABE) is common in Nigeria. Parents' inability to recognize jaundice and delays in seeking care are significant barriers to its prevention.

METHODS

We compared associations of (1) interactive antenatal maternal jaundice instruction with postnatal reinforcement, (2) standard postnatal instruction, and (3) no maternal instruction with the incidence of ABE among 647 jaundice admissions stratified for risk factors identified in initial descriptive analysis.

RESULTS

Eighty-three (83/647;12.8%) admissions developed ABE including eleven jaundice-related deaths. ABE was present at admission in 20/22 (90.9%) if mothers received no jaundice instruction and no antenatal care, 42/182 (23.1%) if received antenatal care but no instruction, 16/95 (16.8%) if received postnatal instruction only, and 4/337 (1.2%) if mothers received both antenatal and postnatal instruction (p < .001). ABE was highly associated with out-of-hospital delivery, number of antenatal clinic visits, and birth attendant, but these risks were mitigated by antenatal/postnatal instruction. Admission rates with bilirubin levels below treatment guidelines (12 mg/dL) were higher following instruction (30.7%) than with no instruction (14.4%). Limiting subjects to those meeting admission criteria increased ABE rates in all groups without altering conclusions.

CONCLUSION

Interactive antenatal instruction with postnatal reinforcement resulted in timely care seeking and a lower incidence of ABE.

IMPACT

Empowering mothers to participate in neonatal jaundice management is critical in low-income countries where jaundice monitoring and follow up are unreliable. Instructing mothers about jaundice in antenatal clinics with postnatal reinforcement is more effective than standard postpartum instruction in facilitating jaundice detection, timely care seeking, and lowering the incidence of acute bilirubin encephalopathy (ABE). Antenatal training also mitigates risks for ABE associated with out-of-hospital deliveries, limited antenatal care, and unskilled birth attendants.

IMPACT

Adding structured jaundice instruction in antenatal clinics could greatly reduce bilirubin induced brain injury in countries where ABE is common.

[Global disease burden of neonatal jaundice from 1990 to 2019]

OBJECTIVES

To examine the global, regional, and national disease burden of neonatal jaundice.

METHODS

The 2019 Global Burden of Disease database was searched to collect incident cases/incidence and deaths/mortality of neonatal jaundice, as well as global socio-demographic index (SDI) and universal health coverage index (UHCI). The epidemiological trend of neonatal jaundice from 1990 to 2019 was analyzed. The correlations between incidence/mortality of neonatal jaundice and SDI and UHCI were evaluated.

RESULTS

From 601 681 in 1990 to 626 005 in 2019, with a 4.04% increase in global incident cases of neonatal jaundice. The overall age-standardized incidence rate exhibited an increase [estimated annual percent change=0.13 (95%CI: 0.03 to 0.23)] during this period. Additionally, deaths due to neonatal jaundice decreased by 58.83%, from 128 119 in 1990 to 52 742 in 2019. The overall age-standardized mortality rate showed a decrease [estimated annual percent change=-2.78 (95%CI: -3.00 to -2.57)] over the same period. Countries with lower SDI, such as India, Pakistan, and Nigeria, reported a higher proportion of neonatal morbidity and mortality. In 2019, a negative correlation was observed between estimated annual percent change in age-standardized mortality rate and SDI (ρ=-0.320, P<0.05) or UHCI (ρ=-0.252, P<0.05).

CONCLUSIONS

The global incidence of neonatal jaundice is on the rise, while the mortality rate is declining. The burden of neonatal jaundice is influenced by social development, economic factors, and the level of medical care.

Global Prevalence of Severe Neonatal Jaundice among Hospital Admissions: A Systematic Review and Meta-Analysis

Evidence regarding the adverse burden of severe neonatal jaundice (SNJ) in hospitalized neonates in resource-constrained settings is sparse. We attempted to determine the prevalence of SNJ, described using clinical outcome markers, in all World Health Organization (WHO) regions in the world. Data were sourced from Ovid Medline, Ovid Embase, Cochrane Library, African Journals Online, and Global Index Medicus. Hospital-based studies, including the total number of neonatal admissions with at least one clinical outcome marker of SNJ, defined as acute bilirubin encephalopathy (ABE), exchange blood transfusions (EBT), jaundice-related death, or abnormal brainstem audio-evoked response (aBAER), were independently reviewed for inclusion in this meta-analysis. Of 84 articles, 64 (76.19%) were from low- and lower-middle-income countries (LMICs), and 14.26% of the represented neonates with jaundice in these studies had SNJ. The prevelance of SNJ among all admitted neonates varied across WHO regions, ranging from 0.73 to 3.34%. Among all neonatal admissions, SNJ clinical outcome markers for EBT ranged from 0.74 to 3.81%, with the highest percentage observed in the African and South-East Asian regions; ABE ranged from 0.16 to 2.75%, with the highest percentages observed in the African and Eastern Mediterranean regions; and jaundice-related deaths ranged from 0 to 1.49%, with the highest percentage observed in the African and Eastern Mediterranean regions. Among the cohort of neonates with jaundice, the prevalence of SNJ ranged from 8.31 to 31.49%, with the highest percentage observed in the African region; EBT ranged from 9.76 to 28.97%, with the highest percentages reported for the African region; ABE was highest in the Eastern Mediterranean (22.73%) and African regions (14.51%). Jaundice-related deaths were 13.02%, 7.52%, 2.01% and 0.07%, respectively, in the Eastern Mediterranean, African, South-East Asian and European regions, with none reported in the Americas. aBAER numbers were too small, and the Western Pacific region was represented by only one study, limiting the ability to make regional comparisons. The global burden of SNJ in hospitalized neonates remains high, causing substantial, preventable morbidity and mortality especially in LMICs.

Management challenges in the treatment of severe hyperbilirubinemia in low- and middle-income countries: Encouraging advancements, remaining gaps, and future opportunities

Neonatal jaundice (NJ) is common in newborn infants. Severe NJ (SNJ) has potentially negative neurological sequelae that are largely preventable in high resource settings if timely diagnosis and treatment are provided. Advancements in NJ care in low- and middle-income countries (LMIC) have been made over recent years, especially with respect to an emphasis on parental education about the disease and technological advancements for improved diagnosis and treatment. Challenges remain, however, due to lack of routine screening for SNJ risk factors, fragmented medical infrastructure, and lack of culturally appropriate and regionally specific treatment guidelines. This article highlights both encouraging advancements in NJ care as well as remaining gaps. Opportunities are identified for future work in eliminating the gaps in NJ care and preventing death and disability related to SNJ around the globe.

Maternal knowledge, attitudes and practices related to neonatal jaundice and associated factors in Shenzhen, China: a facility-based cross-sectional study

OBJECTIVE

This study aimed to assess knowledge, attitudes and practices related to neonatal jaundice among mothers in Shenzhen, China, and analyse associated factors.

DESIGN

A cross-sectional study.

SETTING

This study was conducted in Shenzhen Hospital, Southern Medical University, a university-affiliated, tertiary level A, public hospital in China. On average, 4000 mothers are discharged from this hospital after childbirth each year, most of whom can access a mobile phone and the internet.

PARTICIPANTS

Participants were 403 mothers discharged from the study hospital within 48-72 hours after vaginal delivery or 96-120 hours after caesarean delivery between April and June 2021. Participants were recruited using convenience sampling.

PRIMARY OUTCOME

Mothers' knowledge, attitudes and practices related to neonatal jaundice, modelled using binary logistic regression.

SECONDARY OUTCOMES

Factors associated with mothers' knowledge, attitudes and practices related to neonatal jaundice.

RESULTS

The questionnaire was reliable (Cronbach's alpha=0.802) and valid (scale-level content validity index=0.958). The valid response rate was 96.4%. Only 46.4% of participating mothers had good knowledge about neonatal jaundice and 41.7% indicated they would seek information about neonatal jaundice. A binary logistic regression analysis showed good knowledge about jaundice was associated with a high education level (ie, master's degree or above; OR=5.977, 95% CI: 1.994 to 17.916, p=0.001), prior education on neonatal jaundice (OR=3.617, 95% CI: 1.637 to 7.993, p=0.001) and male babies (OR=1.714, 95% CI: 1.122 to 2.617, p=0.013). A positive attitude toward jaundice was associated with being cared for by a 'yuesao' (maternity matron specialised in caring for mothers and newborns) (OR=1.969, 95% CI: 1.264 to 3.066, p=0.003) and good knowledge about jaundice (OR=1.804, 95% CI: 1.194 to 2.726, p=0.005). Finally, good practices related to neonatal jaundice were associated with prior education on neonatal jaundice (OR=2.260, 95% CI: 1.105 to 4.625, p=0.026) and good knowledge about jaundice (OR=3.112, 95% CI: 2.040 to 4.749, p<0.001).

CONCLUSION

Many mothers have poor knowledge about jaundice, especially regarding causes, danger signs and breast milk jaundice. Maternal information-seeking behaviour about neonatal jaundice needs to be improved. Medical staff should incorporate information about the causes/danger signs of jaundice and breast milk jaundice in maternal health education. It is also necessary to strengthen health education for mothers, especially those with low education and no yuesao, and provide reliable websites where mothers can obtain information about neonatal jaundice.

Neonatal Jaundice: Knowledge and Practices of Healthcare Providers and Trainees in Southwest Nigeria

Severe neonatal jaundice (SNNJ) is a leading cause of neonatal morbidity and mortality in low- and middle-income countries (LMICs). Risk mitigation and management modalities for SNNJ have led to marked reduction in complications in high-income countries but not in LMICs likely in part due to knowledge gaps among healthcare providers. This study, a cross-sectional study conducted in Ogbomosho, Nigeria, aimed to identify SNNJ knowledge and practices among Nigerian healthcare providers/trainees. Healthcare providers/trainees completed a structured questionnaire. Healthcare providers/trainees included are nurse midwives (33.4%), nurses (18.6%), nursing students (15.2%), traditional birth attendants (TBAs) (12.7%), physicians (10.2%), and medical students (9.9%). Most physicians were aware of the common causes of SNNJ; however, knowledge deficits in other groups were notable. Despite most providers endorsing that glucose-6-phosphate dehydrogenase deficiency can cause SNNJ (91% of physicians, 60% of nurses, 71% of midwives, 81% of medical students, 43% of nursing students, 7% of TBAs), very few providers recognized that it is common, ranging from 3% in nurses up to a high of 47% among medical students. Gaps in provider knowledge regarding preventative measures and sequela were also noted. These data identified significant knowledge gaps regarding the etiology of SNNJ among healthcare providers/trainees, which can lead to missed opportunities in effective prevention and treatment. These deficits must be addressed if we are to eliminate tragic and preventable complications from SNNJ in Nigeria and other LMICs.

Current Trends in Neonatal Morbidity and Mortality: Experiences from a Tertiary Center in Lagos, Nigeria

Neonatal mortality is a major contributor to under-five mortality, and Nigeria has the second-highest number of neonatal deaths globally. The country has introduced evidence-based interventions to improve newborn care over the years. The aim of this study was to determine the current trends in neonatal morbidity and mortality at the Lagos University Teaching Hospital, monitor progress over time, and identify areas for improvement. The admission registers and case files of all the neonatal ward admissions were reviewed from January 2018 to April 2020; the age at admission, gestational age, sex, inborn or out-born status, diagnosis, and outcome were recorded and analyzed. Of the 2,959 admissions during the study period, 68.4% were out-born and 77.9% were term gestation infants. The most common diagnoses were neonatal jaundice (NNJ; 28.4%), infection (28.0%), prematurity with associated complications (22.1%), and hypoxic ischemic encephalopathy (HIE; 18.2%). The overall mortality rate was 17.6%. Prematurity with associated complications (39.2%), HIE (24.8%), congenital anomalies (CAs; 12.7%), and NNJ (11.5%) were the most common conditions associated with mortality. Of those who died, the most common diagnoses were term infants with HIE (40.7%), CAs (21.8%), NNJ (18.9%), and infection (15.5%); respiratory distress syndrome (52.4%), infection (31.8%), and CAs (7.8%) were the most common diagnoses in preterm infants. The high risk of mortality with HIE, jaundice, infections, and CAs in this cohort reflects the national figures and trends. Efforts to improve neonatal care, especially respiratory support and education of the populace on NNJ, should be intensified to reduce neonatal mortality in the country.

Screening methods for neonatal hyperbilirubinemia: benefits, limitations, requirements, and novel developments

Severe neonatal hyperbilirubinemia (SNH) is a serious condition that occurs worldwide. Timely recognition with bilirubin determination is key in the management of SNH. Visual assessment of jaundice is unreliable. Fortunately, transcutaneous bilirubin measurement for screening newborn infants is routinely available in many hospitals and outpatient settings. Despite a few limitations, the use of transcutaneous devices facilitates early recognition and appropriate management of neonatal jaundice. Unfortunately, however, advanced and often costly screening modalities are not accessible to everyone, while there is an urgent need for inexpensive yet accurate instruments to assess total serum bilirubin (TSB). In the near future, novel icterometers, and in particular optical bilirubin estimates obtained with a smartphone camera and processed with a smartphone application (app), seem promising methods for screening for SNH. If proven reliable, these methods may empower outpatient health workers as well as parents at home to detect jaundice using a simple portable device. Successful implementation of ubiquitous bilirubin screening may contribute substantially to the reduction of the worldwide burden of SNH. The benefits of non-invasive bilirubin screening notwithstanding, any bilirubin determination obtained through non-invasive screening must be confirmed by a diagnostic method before treatment. IMPACT: Key message: Screening methods for neonatal hyperbilirubinemia facilitate early recognition and timely treatment of severe neonatal hyperbilirubinemia (SNH). Any bilirubin screening result obtained must be confirmed by a diagnostic method. What does this article add to the existing literature? Data on optical bilirubin estimation are summarized. Niche research strategies for prevention of SNH are presented. Impact: Transcutaneous screening for neonatal hyperbilirubinemia contributes to the prevention of SNH. A smartphone application with optical bilirubin estimation seems a promising low-cost screening method, especially in low-resource settings or at home.

Societal awareness on neonatal hyperbilirubinemia: A systematic review and meta-analysis

Early recognition of neonatal hyperbilirubinemia is essential for prevention of bilirubin neurotoxicity and its long-term sequelae. High rates of home delivery in low- and middle-income countries (LMICs) as well as early discharge post-delivery (within 24hours) make community surveillance for neonatal hyperbilirubinemia highly important. Here, we performed a literature review to estimate the level of societal awareness of neonatal hyperbilirubinemia. We searched several databases for studies assessing the knowledge and awareness of neonatal hyperbilirubinemia. We retrieved 211 citations from 206 databases with five being in the grey literature. 52 selected articles were further reviewed. Data from these studies were then analyzed using Stata software (Statacorp® LLC Texas USA). We found that the pooled estimate of societal awareness of neonatal hyperbilirubinemia was 67% (95% confidence interval [CI]: 60, 74). There however was a publication bias (Begg test: P ≤ 0.01; Egger P = 0.06). Studies that scored or graded knowledge reported lower estimates [adjusted odds ratio (aOR) = -0.17; 95% CI: -0.32-0.02; P = 0.03]. Hospital location was an important determinant of awareness of complications [aOR = 0.30; 95% CI: 0.30-0.57; P = 0.03]. We therefore concluded that there is a significant need to improve societal awareness of neonatal hyperbilirubinemia.

Knowledge, Observation and Practices Related to Neonatal Jaundice in a Rural Community in Kano, Nigeria

BACKGROUND

Neonatal jaundice (NNJ) is a common condition and when not adequately treated leads to acute bilirubin encephalopathy/kernicterus. This largely preventable condition is an important cause of death and disability in low- and middle-income countries. Education, early detection and effective management are key for prevention and require an understanding of community knowledge and practices to foster appropriate behavior to prevent severe NNJ. Therefore, the aim of this study was to identify knowledge, observation for jaundice (both active and passive) and practices related to NNJ in northern Nigeria.

METHODS

This descriptive, correlational and cross-sectional study enrolled 298 household members with an average age of 29.8 years in Kano, Nigeria. A structured questionnaire regarding knowledge of, potential sequelae and causes and local practices related to NNJ was administered and data were analyzed using descriptive and Chi-square statistics.

RESULTS

Participants reported: 85% NNJ to be a sign of illness; 3% understood that NNJ could cause brain damage; 94% did not actively observe for jaundice in their newborns; 56% did not know what causes NNJ; 88% would seek care if their newborn developed jaundice. Significant relationships between educational levels and what study participants would do if a newborn develops jaundice and between occupation, educational level and knowledge about causes of NNJ were noted, consistent with a difference in active jaundice observation between ethnic groups.

CONCLUSION

A public health approach to NNJ with a strong community education program is a crucial next step in the fight to eliminate severe NNJ.

Neonatal Jaundice: Perception of Pregnant Women Attending Antenatal Clinic at a Tertiary Hospital in Southwest, Nigeria

Background: Severe neonatal jaundice (NNJ) remains a leading cause of preventable brain damage, mental handicap, physical disabilities, and early death among infants. Methods: Using a descriptive cross-sectional study design, information was gathered using a structured, pretested questionnaire from 518 pregnant women who attended the antenatal clinic at a tertiary Hospital in Southwest Nigeria. Results: Most (77%) of the respondents have heard about NNJ prior the survey. Most respondents (69.5%) demonstrated poor knowledge of the causes of NNJ. The majority, 98.4% had good attitude toward treatment of NNJ. Most respondents (72.1%) demonstrated poor knowledge of the correct treatment of NNJ. A quarter of the respondents knew no danger sign of NNJ. Conclusion: There is serious knowledge gap among the respondents about the causes, treatment, dangers signs and complications of NNJ. There is need for increased awareness campaign using every available means of reaching women of reproductive age group to reduce the consequences of this common neonatal problem.