Abstract
Hyperbilirubinaemia is a ubiquitous transitional morbidity in the vast majority of newborns and a leading cause of hospitalisation in the first week of life worldwide. While timely and effective phototherapy and exchange transfusion are well proven treatments for severe neonatal hyperbilirubinaemia, inappropriate or ineffective treatment of hyperbilirubinaemia, at secondary and tertiary hospitals, still prevails in many poorly-resourced countries accounting for a disproportionately high burden of bilirubin-induced mortality and long-term morbidity. As part of the efforts to curtail the widely reported risks of frequent but avoidable bilirubin-induced neurologic dysfunction (acute bilirubin encephalopathy (ABE) and kernicterus) in low and middle-income countries (LMICs) with significant resource constraints, this article presents a practical framework for the management of late-preterm and term infants (≥35 weeks of gestation) with clinically significant hyperbilirubinaemia in these countries particularly where local practice guidelines are lacking. Standard and validated protocols were followed in adapting available evidence-based national guidelines on the management of hyperbilirubinaemia through a collaboration among clinicians and experts on newborn jaundice from different world regions. Tasks and resources required for the comprehensive management of infants with or at risk of severe hyperbilirubinaemia at all levels of healthcare delivery are proposed, covering primary prevention, early detection, diagnosis, monitoring, treatment, and follow-up. Additionally, actionable treatment or referral levels for phototherapy and exchange transfusion are proposed within the context of several confounding factors such as widespread exclusive breastfeeding, infections, blood group incompatibilities and G6PD deficiency, which place infants at high risk of severe hyperbilirubinaemia and bilirubin-induced neurologic dysfunction in LMICs, as well as the limited facilities for clinical investigations and inconsistent functionality of available phototherapy devices. The need to adjust these levels as appropriate depending on the available facilities in each clinical setting and the risk profile of the infant is emphasised with a view to avoiding over-treatment or under-treatment. These recommendations should serve as a valuable reference material for health workers, guide the development of contextually-relevant national guidelines in each LMIC, as well as facilitate effective advocacy and mobilisation of requisite resources for the optimal care of infants with hyperbilirubinaemia at all levels.Electronic supplementary materialThe online version of this article (doi:10.1186/s12887-015-0358-z) contains supplementary material, which is available to authorized users.
Highlights
Neonatal hyperbilirubinaemia is a leading cause of hospital admission/re-hospitalisation in the first week of life globally [1,2,3]
Based on prior in-depth reviews of the literature from 1970 to 2013 on the burden of neonatal hyperbilirubinaemia and current management practices in Low- or middle-income country (LMIC) [17,22], we identified four major themes for improving the care of affected infants namely: primary prevention, early detection and monitoring, treatment and follow-up
Immediate exchange transfusion is warranted when phototherapy has failed to effectively curtail the rate of bilirubin rise and the total plasma/serum bilirubin (TSB)/transcutaneous bilirubin (TcB) measurement is near exchange levels or the infant has any of the signs of moderate to advanced acute bilirubin encephalopathy (ABE) regardless of the TSB/TcB levels (Figure 1, Table 3)
Summary
Neonatal hyperbilirubinaemia is a leading cause of hospital admission/re-hospitalisation in the first week of life globally [1,2,3]. We adopted the tabular format in the Kenya 2013 guidelines (see Additional file 1: Table S1) for ease of reference at all levels of care These conservative bilirubin levels may be warranted in settings where the incidence of severe hyperbilirubinaemia is high, late presentation common, determination of haemolytic risk (Blood type/Rh/G6PD) is not possible routinely at birth, and quality of phototherapy is sub-optimal. Immediate exchange transfusion is warranted when phototherapy has failed to effectively curtail the rate of bilirubin rise and the TSB/TcB measurement is near exchange levels or the infant has any of the signs of moderate to advanced ABE regardless of the TSB/TcB levels (Figure 1, Table 3) This treatment is most likely to be available at tertiary hospitals with trained personnel and facilities for special care, including monitoring and resuscitation capabilities. Several low-cost and simple-to-use validated tools for early developmental assessment as well as approaches to effective intervention in resource-limited settings have been documented [74,75]
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