Impact of a standardized protocol for the Management of Prolonged Neonatal Jaundice in a regional setting: an interventional quasi-experimental study

Hui-Siu Tan,Ranjit-Kaur Praim Singh,Fatimahtuz-Zahrah Muhamad Damanhuri,Inthira-Sankari Balasubramaniam,May-Luu Yeong,Santhi Verasingam,Ai-Yuin Leow,Chii-Chii Chew,Amar-Singh Hss

doi:10.1186/s12887-019-1550-3

Hui-Siu Tan, Ranjit-Kaur Praim Singh + Show 7 more

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https://doi.org/10.1186/s12887-019-1550-3

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Abstract

BackgroundProlonged neonatal jaundice (PNNJ) is often caused by breast milk jaundice, but it could also point to other serious conditions (biliary atresia, congenital hypothyroidism). When babies with PNNJ receive a routine set of laboratory investigations to detect serious but uncommon conditions, there is always a tendency to over-investigate a large number of well, breastfed babies. A local unpublished survey in Perak state of Malaysia revealed that the diagnostic criteria and initial management of PNNJ were not standardized. This study aims to evaluate and improve the current management of PNNJ in the administrative region of Perak.MethodsA 3-phase quasi-experimental community study was conducted from April 2012 to June 2013. Phase l was a cross-sectional study to review the current practice of PNNJ management. Phase ll was an interventional phase involving the implementation of a new protocol. Phase lll was a 6 months post-interventional audit. A registry of PNNJ was implemented to record the incidence rate. A self-reporting surveillance system was put in place to receive any reports of biliary atresia, urinary tract infection, or congenital hypothyroidism cases.ResultsIn Phase I, 12 hospitals responded, and 199 case notes were reviewed. In Phase II, a new protocol was developed and implemented in all government health facilities in Perak. In Phase III, the 6-month post-intervention audit showed that there were significant improvements when comparing mean scores of pre- and post-intervention: history taking scores (p < 0.001), family history details (p < 0.05), physical examination documentation (p < 0.001), and total investigations done per patient (from 9.01 to 5.81, p < 0.001). The total number of patient visits reduced from 2.46 to 2.2 per patient. The incidence of PNNJ was found to be high (incidence rate of 158 per 1000 live births).ConclusionsThe new protocol standardized and improved the quality of care with better clinical assessment and a reduction in unnecessary laboratory investigations.Trial registrationResearch registration number: NMRR-12-105-11288.

Highlights

Prolonged neonatal jaundice (PNNJ) is often caused by breast milk jaundice, but it could point to other serious conditions
Prolonged neonatal jaundice (PNNJ) is defined as visible jaundice with yellowish staining of the skin, mucous membrane and conjunctival icterus or serum bilirubin > 85 μmol/L that persists beyond 14 days of life in a term baby and 21 days in a preterm baby [1, 2]
Prolonged neonatal jaundice could be an early presentation of serious conditions such as biliary atresia [7, 8]

Summary

Introduction

Prolonged neonatal jaundice (PNNJ) is often caused by breast milk jaundice, but it could point to other serious conditions (biliary atresia, congenital hypothyroidism). Breast milk jaundice is the most common cause of PNNJ It is almost always benign [3], presenting as prolonged unconjugated hyperbilirubinaemia, and occurs in up to one-third of healthy breastfed newborns [4]. It develops as the result of poor calories intake associated with breast-feeding difficulties [5], liver immaturity and the inhibitory effect of mother’s milk in the clearance of unconjugated bilirubin [6]. Other pathological causes of prolonged neonatal jaundice are urinary tract infection, sepsis, congenital hypothyroidism, metabolic and haemolytic disorders [16]

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