|Year : 2017 | Volume
| Issue : 2 | Page : 128-133
Screening for neonatal jaundice in El Galaa Teaching Hospital: A Egyptian Maternity Hospital – Can the model be replicated?
Hoda B. H. Basheer1, Mona S. H. Makhlouf1, Fatheya El Halawany2, Nahed Fahmy3, Iman F Iskander3
1 Department of Pediatrics, El Galaa Teaching Hospital, General Organization of Teaching Hospitals and Institutes, Cairo, Egypt
2 Department of Statistics, Faculty of Science, King Abdulaziz University, Jeddah, Saudi Arabia
3 Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt
|Date of Web Publication||13-Apr-2017|
Hoda B. H. Basheer
41,26 July Street, Down Town, Cairo
Source of Support: None, Conflict of Interest: None
Screening for neonatal jaundice may allow early detection and treatment of severe cases and thus help prevent kernictrus.
Aim: This pilot study aims to evaluate the effectiveness as well as the practicality of screening for neonatal jaundice at the same time of the Egyptian obligatory thyroid screening program among a sample of non-hospitalized newborns. Subjects and Methods: A population of 3834 term and near-term newborns delivered at El Galaa Teaching Hospital, Cairo, Egypt, was screened for neonatal jaundice at its Maternal Child Health Center within the 1st week of life at the time of thyroid screening (3rd-7th day postnatal). A transcutaneous bilirubinometer (BiliCheck, Respironics, Philips) was used, and bilirubin levels were plotted on the hour-specific bilirubin nomogram. Accordingly, parents were either given a specific date for rescreening or were immediately referred for appropriate intervention. Results: The mean Transcutaneous bilirubin (TcB) measurement was 16.1 mg/dl in 1.9% of the studied newborns placing them in the high-risk zone and requiring immediate referral for serum bilirubin ± phototherapy. In addition, 3.3% of cases had a mean TcB of 14.4 mg/dl (high-intermediate zone) requiring close follow-up. The TcB levels in the remaining babies placed them either in the low or low-intermediate risk zones of the bilirubin nomogram. All babies in the intermediate zone (n = 440) were advised to return for repeat TcB within 48 h. Of 155 babies attending rescreening, 1 case was in the high-risk zone with TcB of 17.2 mg/dl. By the end of the study, 1.2% of all the tested babies had required admission for phototherapy. Conclusion: The already established thyroid screening program offers a golden opportunity for concomitant screening for neonatal jaundice and the detection and management of missed cases of severe hyperbilirubinemia. However the set timing (3-7 days of life) might be quite late for hemolytic cases who develop severe hyperbilirubinemia early.
Keywords: Jaundice, kernicterus, screening, TcB
|How to cite this article:|
Basheer HB, Makhlouf MS, El Halawany F, Fahmy N, Iskander IF. Screening for neonatal jaundice in El Galaa Teaching Hospital: A Egyptian Maternity Hospital – Can the model be replicated?. J Clin Neonatol 2017;6:128-33
|How to cite this URL:|
Basheer HB, Makhlouf MS, El Halawany F, Fahmy N, Iskander IF. Screening for neonatal jaundice in El Galaa Teaching Hospital: A Egyptian Maternity Hospital – Can the model be replicated?. J Clin Neonatol [serial online] 2017 [cited 2019 Dec 6];6:128-33. Available from: http://www.jcnonweb.com/text.asp?2017/6/2/128/204519
| Introduction|| |
Hyperbilirubinemia though a common benign occurrence in the 1st week of life can sometimes progress to critical levels. Severe hyperbilirubinemia if improperly treated can cause long-term, irreversible and devastating, neurological impairment, or sometimes death.
The goal of screening for neonatal jaundice is to promote early identification and prompt intervention to avoid severe or critical hyperbilirubinemia that causes kernicterus. It also prevents overtreatment of neonatal jaundice in newborns whose total serum bilirubin (TSB) will never reach critical levels and will resolve spontaneously without harm.
Bilirubin levels can be estimated visually or measured transcutaneously or in blood. The visual assessment of jaundice is based on the degree of yellowish pigmentation of the skin, which has been the mainstay of screening for neonatal jaundice. Currently, in developed countries, predischarge risk assessment of bilirubin levels is done either by TcB or TSB knowing that the latter is more accurate. The values are plotted on the hour-specific nomogram [Figure 1]. whereby, using bilirubin level and postnatal age in hours, the physician or nurse can assign the risk for clinically significant hyperbilirubinemia and advice regarding further testing, therapy, and follow-up.
|Figure 1: Total serum bilirubin nomogram for risk designation of term and late preterm neonates|
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Although TSB provides the most accurate bilirubin measure, it remains an invasive, painful, stressful, and time-consuming procedure. Repeated blood sampling may be associated with the risk of infection and scar formation. Depending on the location of laboratory services, there may be delay before TSB results are available for initiating treatment. A more user-friendly tool currently available is transcutaneous bilirubinometry, which allows a quick estimation of bilirubin concentration through the spectral reflectance of an infant's skin. If the reading is high, babies should be referred for serum bilirubin measurement which is more accurate.
In Egypt, severe hyperbilirubinemia and bilirubin encephalopathy are still being reported in numbers that cannot be ignored. Predischarge screening for neonatal jaundice or for risk factors for severe hyperbilirubinemia is not routinely performed except in private practice. To date, all available data are hospital based and not representing the general population. A study from Cairo University Children's Hospital reported more than ten cases of confirmed kernicterus in a 1-year period.
In 2005, Helal in a study on 18 public sector Egyptian Neonatal Intensive Care Units (NICUs) found the diagnosis of neonatal jaundice to represent 36.4% of admissions of whom 44% required exchange transfusions.
A national obligatory thyroid screening program exists in Egypt since the year 2000, whereby all Egyptian newborns are required to attend to Maternal Child Health Centers (MCHCs) between days 3 and 7 of life for screening and for their first vaccination. This could provide a window of opportunity for picking up cases of severe neonatal jaundice.
El Galaa Teaching Hospital is one of the biggest public maternity hospitals in Cairo with >18,000 deliveries annually. It has a follow-up clinic for discharged newborns and an affiliated MCHC on its premises where thyroid screening is performed twice weekly.
The aim of this pilot study was to incorporate transcutaneous bilirubinometry as a bilirubin screening method with the obligatory thyroid screening at the MCHC Center of Al Gala Hospital to (a) determine the overall prevalence and severity of neonatal jaundice among a sample of nonhospitalized healthy term and near-term babies; (b) evaluate the practicality of screening for neonatal jaundice in a MCHC at the time of thyroid screening; and (c) provide instructions for rescreening and follow-up or referral for further investigation and phototherapy to prevent bilirubin encephalopathy and kernicterus.
| Subjects and Methods|| |
This prospective study included newborns delivered in the Obstetrics Department of El Galaa Teaching Hospital, Cairo, Egypt, between May 2009 and 2011. At discharge, all parents were instructed to return to its MCHC for neonatal follow-up between days 3 and 7 of life for routine thyroid screening. On return, date of birth, gestational age, weight, mode of delivery, and gender were recorded. Inclusion criteria into the study were gestational age >35 weeks, weight ≥2500 kg. Any sick newborn requiring NICU admission was excluded from the study.
In addition, some cases returned to hospital earlier than the due appointment date due to visible jaundice in their newborns.
Thyroid screening, transcutaneous bilirubinometry (TcB), and plotting the bilirubin level on the Bhutani nomogram were performed for all included babies. Although thyroid screening was done only on Tuesdays and Saturdays of every week, any baby presenting to the follow-up clinic on any day within the 1st week of life was screened for hyperbilirubinemia for the purpose of the study.
Transcutaneous bilirubin level (TcB) was measured with a hand-held device that uses multiwavelength spectral reflectance analysis to measure TcB (BiliCheck, Respironics, Philips). The device consists of a light source, a microspectrophotometer, a fiberoptic probe, and a microprocessor control circuit with firmware for analysis and interpretation of bilirubin measurement. It has a fiber optic probe strategically placed to allow for a convenient application to the infant's forehead. The infants were placed in a supine position. A disposable clean tip was placed in contact with the skin, covering the probe, and light pressure was applied. The light source is triggered after appropriate skin application is established. All measurements were taken in the morning ambient light. All determinations were obtained from both the forehead and sternum of the infants while they were in a quiet state.
Before each measurement, the device was calibrated to a standard reference placed in direct contact with the fiberoptic probe tip. The light source in the device was triggered for five spectral collections that were then averaged to provide 1 TcB measurement.
TcBs were then plotted on the hour-specific bilirubin nomogram (Bhutani et al., 1999) [Figure 1] to assign the babies to their specific risk zones. Any baby with TcB level exceeding the 95th centile for age was considered high risk and referred for TSB measurement and treated accordingly.
Data were collected, revised, and entered into the computer. Data were analyzed using the SPSS statistical package version 19 (Armonk, NY: IBM Corp.). Excel computer program was used to tabulate the results and represent them graphically.
For the quantitative variables which are normally distributed, one-way ANOVA test was used to declare the statistically significant difference between groups at P< 0.05. Duncan multiple comparisons test at P< 0.05 was used to declare the significant difference between each two groups.
Qualitative variables were expressed as counts and percentages.
| Results|| |
Out of 30,124 babies discharged from maternity hospital during the study period, 4642 newborns came back for follow-up representing15.4% of total deliveries. Only 3834 (12.7%) full-term or near-term babies were included in this study because any baby ≤35 weeks was excluded from the study.
The studied population included 2015 males (52.5%) and 1819 females (47.5%); 30% of babies were delivered by cesarean section (CS). The average time of discharge following vaginal delivery ranged from 4 to 10 h with a mean of 6 h whereas the average time following an uncomplicated CS was 24 h (18–48 h) [Table 1].
The procedure of performing TcB measurement in addition to the already performed thyroid screening took between 15 and 65 s with a mean of 26.7 s as compared to thyroid screening alone. The extra cost was only the cost of the measuring instrument and its tips. None of the parents complained of delays.
Tables 2 shows the the results of TcB measurement on dfferent days of the week and their distribution according to the risk zones on the Bhutani normogram [Table 2], 8.1% of the babies were in the low-intermediate zone (mean TcB: 12 mg/dl), 3.3% in the high-intermediate zone (mean TcB: 14.4 mg/dl) while only 1.9% were in the high-risk zone with a mean TcB of 16.1 mg/dl. The latter group was immediately referred for serum bilirubin measurement and admission for phototherapy if indicated. It is worthy to mention that out of the 72 babies found to be in the high risk zone, 33 cases (46%) presented at <48 hours [Figure 2] and [Table 3] of life while only 54% presented between days 3 and 7 of life. Screening for risk factors of severe hyperbilirubinemia is not routinely done for newborn before discharge from the delivery hospital. As shown in [Table 2], there was a significant difference betweenthe mean TcB levels in the different risk zones (P value > 0.001).
|Table 2: Risk zone distribution of study cases according to transcutaneous bilirubin|
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|Figure 2: Percentage of cases in each risk group according to the day of presentation|
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|Table 3: Number and percentage of cases within the risk groups according to the days of presentation|
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All babies found to be in the intermediate zone (n = 440) were given clear instructions to come back for rescreening within 48 h. Only 155 babies responded representing 35.2%. TcB levels in 153/155 babies were either in the low or low-intermediate risk zones, while one patient was in the high-intermediate risk zone with Tcb of 14.3 mg/dl and one patient was in the high-risk zone with TcB of 17.2 mg/dl. Both were referred for TSB measurement and phototherapy if indicated.
During the whole study period, a total of 73 babies (1.9%) were referred for TSB, of whom 49 (1.2%) required immediate phototherapy.
The steps of the study at the follow-up clinic are shown in [Figure 3].
| Discussion|| |
Since health policies worldwide have changed favoring shorter hospital stays and early discharge for mothers and their newborns after delivery; kernicterus, which was thought to have almost completely disappeared, remerged and is of greater concern for neonatologists and pediatricians.
In this study of 3834 babies between 2009 and 2011, the average time of discharge following vaginal delivery was 6 h sometimes being as short as 4 h. This means that most cases of neonatal jaundice would only appear after discharge of the baby from hospital and may be overlooked unless very severe or alarming signs of bilirubin encephalopathy develop.
In Egypt, several other factors predispose to severe hyperbilirubinemia and kernicterus. These include inappropriate maternal knowledge about the possible risks of severe neonatal jaundice, delay in seeking medical advice, home therapy for jaundice using neon lamps that do not provide the required wavelength, and difficulty in finding adequate medical care especially in remote areas when required.
In this study, only 12% of the babies delivered at Al Galaa Hospital returned for the obligatory thyroid screening at its MCHC despite the confirmed data from the Egyptian Ministry of Health showing that 90% of the population are compliant in attending the first postnatal health care visit in different MCHC all over the country. This is explained by the fact that most mothers referred to Al Galaa Maternity Hospital for delivery choose to follow-up at MCHC closer to their home once they are discharged from hospital and are in stable conditions.
Measuring bilirubin and knowing the level in relation to the age in hours are very important in the proper management of severe neonatal jaundice as visual assessments may be fraught with inaccuracy  and neonatal jaundice itself may not cause parental anxiety until encephalopathy starts to happen.
The aim of this study was to incorporate screening for severe neonatal hyperbilirubinemia using TcB with the routine neonatal thyroid screening already being performed at the MCHC of Al Galaa Teaching Hospital to provide a rough estimate of the prevalence of severe hyperbilirubinemia among normal full- and near-term babies and to determine whether this would provide a real opportunity for early detection of cases with severe hyperbilirubinemia and thus help prevent kernicterus.
The process of performing TcB measurement took between 15 and 65 s (mean 26.7 s) in addition to that required for thyroid screening per patient. Although it was longer than the 5.5 s noted by Maisels et al., it did not represent any time constraint for the parents compared to another visit to the pediatrician or the laboratory for bilirubin measurement. This was followed by plotting of the TcB reading on the Bhutani nomogram and providing instructions to the parents regarding follow-up appointments or referral.
Not only was this an opportunity to provide advice on jaundice management but also it provided much needed advice on breastfeeding. The whole process took an additional 5–10 min to the original visit and increased parent satisfaction with the service. The workers did not complaint of increased workload in our study, and minimal incentives were provided for encouragement.
The previous research has suggested that transcutanous bilirubinometry is a safe procedure and Bilicheck ® has been shown to be noninvasive, simple, easy to use, and a reliable method for bilirubin screening in neonatal jaundice, especially in neonates with bilirubin levels ≤15 mg/dl. However, at higher levels, it is not that accurate and might underestimate bilirubin by >3 mg% and requires verification by TSB measurement. This can be time-consuming and represent an extra cost for parents particularly in low-income countries. The availability of a low-cost point of care machine that measures TSB in MCHC could provide immediate accurate bilirubin levels on which management decisions could be quickly and correctly based.
In our study, 73 cases (1.9%) had TcB levels in the high-risk zone requiring referral for serum bilirubin measurement and 1.2% of all studied babies required admission. These numbers are similar to the results reported by the Canadian Pediatric Society where 2% of their newborns developed severe hyperbilirubinemia with a smaller number reaching critical levels that could cause kernicterus and permanent neurodevelopmental delay.
Timely effective phototherapy for severe hyperbilirubinemia reduces the need for exchange transfusion and decreases the risk of bilirubin encephalopathy. We, therefore, suggest that screening Egyptian infants for severe hyperbilirubinemia could be effective in reducing kernicterus. Some studies do not agree with our opinion implying to the high cost of universal screening and suggesting it would inappropriately increase phototherapy rates. We, however, still argue that in a country like Egypt, with a reported 2 million new births in 2016 and many medically underserviced areas, screening would be cost-effective. This is because limited expenditure is expected on the screening process since the thyroid screening program is already set up and functioning and the cost would just be that of the screening tools. In addition, screening will facilitate early detection of neonatal severe hyperbilirubinemia and allow early treatment which in turn will reduce chronic bilirubin encephalopathy  and the load such handicap represents on both parents and health authorities.
Although the thyroid screening program is performed only twice weekly in MCHCs all over the country and receives babies from the 3rd to 7th day of life, some mothers – specially working ones presented to the clinic on other days of the week for different concerns. During this study period, whenever parents came to the clinic (at any day of the week), the baby was examined and Bilicheck was performed if baby was <7 days old.
In the current study, it was noted that 46% of the cases whose TcB level was in the high-risk zone presented in the first 48 h of life. Those babies were brought in before their appointment because of parental concern. An important cause for early severe hyperbilirubinemia is blood group incompatibility with hemolysis. It usually presents within the first 24–48 h of life and requires rapid intervention otherwise bilirubin levels soar, and the risk of acute bilirubin encephalopathy becomes very high, which would have happened had these babies waited for their official screening appointment. It is therefore extremely important that cases with risk factors for severe hyperbilirubinemia  should be screened before discharge from the maternity hospital and mothers with Rh negative or O blood groups be educated about neonatal jaundice and the importance of early follow-up.
| Conclusion|| |
The combination of screening for neonatal jaundice in Egypt with the already established thyroid screening program can be easy to implement at minimal cost since the setup and personnel already exist. It provides a golden opportunity to identify missed cases of severe hyperbilirubinemia allowing timely intervention. However, newborns with risk factors for severe hyperbilirubinemia might develop severe jaundice much earlier and should always be screened before maternity hospital discharge.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]