Comparison of etiological factors of full term neonates with severe and moderate hyperbilirubinemia: a tertiary hospital based study in Eastern region of India

INTRODUCTION

In approximately 60% of term infant and 80% 0f preterm infant developed hyperbilirubinemia in the first week of life.¹ In most of the cases neonatal hyperbilirubinemia is seen among the preterm neonates and is a benign problem. It is also well established that high level of unconjugated bilirubin can cause neurological impairment even in full-term neonates. A recent study was done in the tribal communities of Meghalaya, showed that total serum bilirubin was higher among the term neonates, birth weight 2500gm or above, female sex and ABO incompatibility.^1-2 The etiology of hyperbilirubinemia is easily affected by environment and other relative factors.²

Therefore, the analysis of the etiology of neonates with severe and moderate hyperbilirubinemia in eastern India is of great significance to reduce the incidence of hyperbilirubinemia and its serious complications in this region.

The objective of the present study was to compare the etiological factors responsible for severe and moderate hyperbilirubinemia in full term neonates in eastern zone of India.

METHODS

Research approach and design

This study was a tertiary hospital based descriptive survey research.

Study location, duration and population

Study was conducted in the Sick Neonatal Care Unit of Dr. B.C. Roy P.G.I.P.S in Kolkata which is one of the largest tertiary care pediatric hospital in Eastern India. Data were collected between December 2000 to March 2022. All full-term neonates with severe and moderate hyperbilirubinemia were included as study population.

Sample size, sampling technique and criteria for sample selection

Non probability convenience sampling technique was adopted to select the 80 full term neonates in each group with severe and moderate hyperbilirubinemia admitted in the sick new born care unit according to inclusion and exclusion criteria after obtaining informed consent from the parents or legal guardians of the neonates (Figure 1).

Variables

Age of the neonate, gestational age, gender, birth weight, and religion, education of the father and mother, socioeconomic status and the etiological factors were the measurable variables.

Data collection tools and technique

The data were collected after approval from institutional ethics committee in a pretested proforma. Demographic tools and etiological factors were self-structured. Data sources were history, blood for total serum bilirubin, complete blood count, DCT, reticulocyte count, mother and baby’s blood grouping. G6PD Level, RH typing. All the ethical principles of research were followed though out the data collection process. Strobe checklist guideline for observational study was followed for preparation of the manuscript. Standard Kuppuswami scale was used to categorize the parent’s socioeconomic status.^7-8

Statistical methods

Descriptive statistics were used to find the frequency, percentage, range, mean, median, standard deviations and normally distributed data of all the variables of the study and for analytical statistics chai square test of association was calculated. The statistical tools used to compute the data was MS Excel 07 and IBM SPSS-N-23.

RESULTS

Demographic characteristics of the study participants

73.75% of the neonates with severe and 60% with moderate hyperbilirubinemia were in the age group of 1-5 days.85% of the neonates with severe hyperbilirubinemia and 81.25% with moderate hyperbilirubinemia had gestational age between 37-39 weeks. 67.50% and 76.25% of neonates with severe and moderate hyperbilirubinemia respectively were having birth weight more than 2500gm. 53.75% in severe group and 61.25% in the moderate group were male.52.50% in the severe group and 53.75% in moderate group belonged to Hindu religion. 60% of the fathers in the severe group and 47.50% of the fathers from the moderate group were educated to the secondary level. 62.50% of mothers from the severe group and 60% from the moderate group were educated to the secondary level. 61.25% of parents in the severe group and 67.50% of parents in the moderate group belonged to lower middle class. No family belonging to upper class was found to be included in the study belonged to upper class (Table 1).

Comparison of gestational age, postnatal age, birth weight and TSB level of neonates

In the severe group the mean TSB level was 25.17mg/dl with a range between 39.9-19.96 mg/dl, and the median was 24.2. In the moderate group the mean TSB level was 16.67 mg/dl with a range between 19.4-13.9 mg/dl and the median was 16.8. So, data obtained were normally distributed.

In the severe group the mean birth weight was 2.69 kg with a range between 3.7 -1.6 kg and the median was 2.7. In the moderate group the mean birth weight was 2.66 with a range between 4-1.67 kg and the median was 2.67kg (Table 2).

Different etiological factors and their incidence in the development of neonatal hyperbilirubinemia

No cause (idiopathic) was found in 16.25% of severe and 13.75% of moderate hyperbilirubinemia. Among the known causes, 48.75% in the severe group and 36.25% in the moderate group were attributed to ABO incompatibility. 16.25% in severe group and 13.75% in moderate group had G6PD deficiency. 11.25% in severe group and 13.75% in moderate group had polycythemia as the causative factor. 2.50% in each group had cephalhematoma. Rh incompatibility was the causative factor in 2.50% in severe group and 3.75% in moderate group. 2.50% had sepsis in severe group whereas 13.75% had sepsis in moderate group. There was no case of breast-milk jaundice in severe group but 2.50% cases in the moderate group had breast-milk jaundice (Table 3).

Major causes of moderate and severe hyperbilirubinemia

ABO incompatibility (48.75% In severe group and 36.25% In moderate group), G6PD deficiency (16.25%in severe group and 13.75% in moderate group), polycythaemia (11.25% in the severe group and 13.75% in the moderate group) and sepsis (2,50% in severe group and13.75% in moderate group) are found to be the major causes of moderate and severe hyperbilirubinemia. Idiopathic cases (16.25% in severe group and 13,75% in moderate group) constituted another major cause (Table 3).

Causes of hyperbilirubinemia and mean TSB values

Mean TSB values were higher in cephalhematoma, G6PD deficiency, Rh incompatibility, ABO incompatibility, polycythemia, sepsis and in idiopathic cases in the severe group as well as in moderate group (Table 3).

Association of severe hyperbilirubinemia with etiology and demographic factors

There was no association of severe hyperbilirubinemia with etiology of jaundice, birth weight, gestational age, sex, religion, socioeconomic status and education of the parents of the neonates. The association of severe hyperbilirubinemia was found only with the age (1-5 days) of the neonate (p=0.01).

DISCUSSION

ABO incompatibility (48.75% in severe group and 36.25% in moderate group), G6PD 8 (16.25%in severe group and 13.75% in moderate group), polycythaemia (11.25% in the severe group and 13.75% in the moderate group) and sepsis (2.50% in severe group and 13.75% in moderate group) are found to be the major causes of moderate and severe hyperbilirubinemia. Idiopathic cases (16.25% in severe group and 13.75% in moderate group) constituted another major cause. Considering the mean serum bilirubin level, this result was supported by Jia-Xin Xu et al, Mohan et al, Kalraiya et al considering the mean serum bilirubin level.^1-3

The present study showed that mean total serum bilirubin tends to be higher with the etiology of ABO incompatibility, G6PD deficiency, polycythemia, sepsis and idiopathic cases. Higher mean TSB Levels are also found with the etiology of G6PD deficiency, Rh, ABO incompatibility and in idiopathic cases in the study done by Mohan et al.¹

The commonest cause of hyperbilirubinemia was ABO incompatibility and this was supported by the study of Kalraiya et al and Xu et al.^3,2

The association of severe hyperbilirubinemia was found in the neonates of 1-5 days. This study was supported by Mohan et al.¹

There was no association of severe hyperbilirubinemia with etiology of jaundice, birth weight, gestational age, sex. This is not supported by study of Rithanya et al, Sahoo et al in Andhra Pradesh and Bhal et al.^4-6

This study adds that cephalhematoma and polycythemia are also the contributing factors of jaundice in both the group whereas breast feeding jaundice is only seen in moderate hyperbilirubinemia group.

Limitations

During inclusion of subject’s randomization was not done. It is a single center study.

CONCLUSION

Hemolytic disease like ABO incompatibility followed by G6PD deficiency and idiopathic causes are the main causes for the full term neonates in Eastern India. Hyperbilirubinemia can cause hearing loss, motor and intellectual development disorders, and even death. This can cause heavy burden for the family as well as nation. Awareness among the health care delivery members as well as among the parents is important. Specific prevention and treatment according to the etiology may reduce the ill effect of hyperbilirubinemia.

ACKNOWLEDGEMENTS

We would like to thank all the parents or legal guardians of the neonates who had given time to the researcher to complete the study. The researchers are grateful to all the health team members who helped for the data collection for the present study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

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