Study of neonatal jaundice in a tertiary care centre of South India

Hyperbilirubinemia is a common problem during the neonatal period occurring in up to 60% of term and 80% of preterm babies in the first week of life. Some of the most common causes of neonatal jaundice include physiological jaundice, breast feeding or non feeding jaundice, breast milk jaundice, prematurity and ABO incompatibility. Aims and objectives of study: To study the incidence, various risk factors in newborns with clinical jaundice progressing to jaundice needing treatment and to assess no of neonates requiring phototherapy & exchange transfusion in ASRAM hospital, during May 2013 to July 2014. Method: The present study was a prospective hospital based study involving all neonates who were born at ASRAM Medical College and Hospital, a tertiary care centre, Eluru, West Godavari District, Andhra Pradesh. Observation: Out of 560 newborns, 273 (48.8%) newborns developed clinical jaundice. Out of 273 newborns with clinical jaundice, 166 (61%) newborns developed physiological jaundice and 107 (39%) newborns developed non physiological jaundice requiring therepeutic intervention in the form of phototherapy or exchange transfusion. Conclusion: Present study concludes that the leading cause of pathological jaundice is breastfeeding jaundice, ABO incompatibility and prematurity.


Introduction
Hyperbilirubinemia is a common problem during the neonatal period occurring in up to 60% of term and 80% of preterm babies in the first week of life. [1,2]. Some of the most common causes of neonatal jaundice include physiological jaundice, breast feeding or non feeding jaundice, breast milk jaundice, prematurity leading to jaundice & various pathological causes like haemolytic disease, liver dysfunction, neonatal sepsis, deficiency of G6PD enzyme, hypothyroidism and rare conditions such as Gilbert's syndrome etc [3,4]. Extreme

Materials and Methodology
The present study was a prospective hospital based study involving all neonates who were born at ASRAM Medical College and Hospital, a tertiary care centre, Eluru, West Godavari District, Andhra Pradesh. The present study was conducted from May 2013 to July 2014 over a period of 14 months. A predesigned proforma has aided the enrollment of newborns into the study. Significant hyperbilirubinemia was defined as the value of bilirubin according to AAP guidelines in term neonates and Cockington's charts in preterm, above which phototherapy or exchange transfusion or both are required [5,6]. Clinical jaundice is visible yellowish discoloration of skin of newborns in day light. The following situations suggest non physiologic jaundice and require evaluation (onset of jaundice occurs before 24 hours of age, elevation of serum bilirubin requires phototherapy, a rise in serum bilirubin levels of 0.2mg/dl/hour, signs of underlying illness in any infant (vomiting, lethargy, poor feeding, excessive weight loss, apnea, tachypnea or temperature instability), jaundice persisting after 8 days in a term baby or after 14 days in a premature infant.[7]

Inclusion Criteria
All babies born at ASRAM who were admitted to NICU and postnatal ward, who had clinical jaundice irrespective of the gestational age and birth weight were included in the present study.

Exclusion Criteria
1. Out born baby admitted in ASRAM NICU.

Babies with major congenital malformations.
3. Newborns who expired before complete evaluation during the period of hospital stay.
Statistical Analysis: Descriptive data are presented as number and percentages. Chi-square test was used to assess the association between neonatal jaundice with various factors.
Microsoft word and SPSS software were used for the analysis of the results.A p value of 0.05 or less was considered for statistical significance.

Results
In the present study, out of 560 newborns delivered during the study period at ASRAM, 273 (48.8%) newborns developed clinical jaundice.
Out of 273 newborns with clinical jaundice, 166 (61%) newborns developed physiological jaundice. The overall incidence of non physiological jaundice in the study group is 19%. (107 out of 560 newborns).
Sex factor had an influence on the incidence of non physiological jaundice among the neonates showing that males 67% (72 out of 107) had higher incidence compared to females 33% (35 out of 107) with with p value <0.05. All 4 (100%) newborns with history of birth asphyxia developed pathological jaundice. Out of 107 babies with pathological jaundice, 5 newborns had Rh incompatibility, 17 newborns had ABO incompatibility, 1 newborn had both Rh and ABO incompatibility.
Out of 273 newborns with clinical jaundice, 2 (1%) newborns required double volume exchange transfusion as a therapeutic intervention for the treatment of jaundice. Both these cases were associated with Rh incompatability as a risk factor for pathological jaundice.

Discussion
Incidence of clinical jaundice in the present study population is 49%. In a study done by Kumar RK in 1999, jaundice was the most common condition requiring medical attention in newborn infants. About 50 percent of term and 80 percent of preterm infants developed jaundice in the first week of life [8].
In the present study the overall incidence of non physiological jaundice is 19% (107 out of 560 In a study from Chandigarh done by Narang et al, incidence of hyperbilirubinemia in males was 64.2%.
[6] In another study done at Delhi by Singhal et al, incidence of hyperbilirubinemia in males was 56.8%. [10] Among them most common cause of jaundice was breast feeding jaundice 52 (48%), second most common cause being due to ABO incompatibility 17 (16%), third common cause being due to newborns were prematurity 8 (7.54). In a study conducted by May-Jen Huang et al., similar patten of distribution has been observed [11].
Breastfeeding jaundice tops the list in nonphysiological jaundice. In a study done by Osborn LM et al, it was found that Breastfed newborns may be at increased risk for early-onset exaggerated physiologic jaundice because of relative caloric deprivation in the first few days of life [12].
In another study done by Schneider AP, it was stated that decreased volume and decreased frequency of feedings may result in mild dehydration and the delayed passage of meconium. Compared with formula-fed newborns, breastfed infants are three to six times more likely to experience moderate jaundice (total serum bilirubin level above 12 mg per dL) [13].
ABO incompatibility has become the second most common cause of non physiological jaundice in newborn in our study.
In a study of a population of newborns in Turkey, there was a 14.8% incidence of ABO incompatibility, with 21.3% of these babies exhibiting significant hyperbilirubinemia and 4.4% exhibiting severe ABO hemolytic disease [14].
Prematurity was third most common cause in our study.
Preterm new borns are prone to developing jaundice due to immaturity of bilirubin conjugating system, higher rate of hemolysis, increased enterohepatic circulation, decreased caloric intake [15].