“PREDICTION OF SIGNIFICANT NEONATAL

HYPERBILIRUBINEMIA IN HEALTHY TERM NEWBORNS USING

CORD BILIRUBIN AND 24TH HOUR SERUM BILIRUBIN”

- A Prospective Study

A Dissertation submitted to
The Rajiv Gandhi University of Health Sciences
Bangalore, Karnataka.
In partial fulfillment of the requirements for the
Award of
DOCTOR OF MEDICINE
IN
PEDIATRICS
o-o-o-o
Submitted by
Dr. Gautam Chawla

Under the guidance of

Dr. S. V. Patil MD
Professor of Pediatrics
o-o-o-o

B. L. D. E. Association’s
Shri B. M. Patil Medical College Hospital & Research Centre
Bijapur – 586103

2006
 Certificate
This is to certify that this dissertation entitled “Prediction of Significant
Neonatal Hyperbilirubinemia in Healthy Term Newborns Using
Cord Bilirubin & 24th Hour Serum Bilirubin” is a bonafide research work
done by Dr. Gautam Chawla, post graduate in pediatrics during the period of October
2003 to August 2006 at Shri B.M. Patil Medical College, Bijapur.

It was carried out under my direct supervision and guidance at Shri B.M. Patil
Medical College Hospital, Bijapur, in partial fulfillment of the regulations for the award
of M.D. (Pediatrics) degree of Rajiv Gandhi University of Health Sciences, Bangalore to
be held in September 2006.

I have great pleasure in forwarding this dissertation to Rajiv Gandhi University of

Health Sciences, Bangalore.

Date:
Place: Bijapur
Dr. S. V. Patil
Professor & Unit Chief
Department of Pediatrics
Shri B.M. Patil Medical College
Bijapur.

i
 Certificate
This is to certify that this dissertation entitled “Prediction of Significant
Neonatal Hyperbilirubinemia in Healthy Term Newborns Using
Cord Bilirubin & 24th Hour Serum Bilirubin” is a bonafide research work
done by Dr. Gautam Chawla, post graduate in Pediatrics at Shri B.M. Patil
Medical College, Bijapur. He has undergone the prescribed course of studies in pediatrics
for a continuous period of three years.

It was carried out under the direct supervision and guidance of Dr. S V Patil,
Professor of Pediatrics, under my overall supervision at Shri B.M. Patil Medical College
Hospital, Bijapur, in partial fulfillment of the regulations for the award of M.D.
(Pediatrics) degree of Rajiv Gandhi University of Health Sciences, Bangalore to be held in
September 2006.

I have great pleasure in forwarding this dissertation to Rajiv Gandhi University of

Health Sciences, Bangalore.

Date:
Place: Bijapur
Dr. A. S. Akki
Professor & Head
Department of Pediatrics
Shri B.M.Patil Medical College
Bijapur.

ii
 Certificate
This is to certify that this dissertation entitled “Prediction of Significant
Neonatal Hyperbilirubinemia in Healthy Term Newborns Using
Cord Bilirubin & 24th Hour Serum Bilirubin” is a bonafide research work
done by Dr. Gautam Chawla, post graduate in the department of pediatrics, under
the guidance of Dr. S V Patil, Professor at B.L.D.E.A’s Shri B.M. Patil Medical
College Hospital & Research Centre, Bijapur in partial fulfillment of the regulations for
the award of M.D. (Pediatrics) degree examination to be held in September 2006.

I have satisfied myself about the authenticity of his observations noted in this
dissertation and it confirms to the standards of Rajiv Gandhi University of Health
Sciences, Bangalore.

Date:
Place: Bijapur

Principal
Shri B.M. Patil Medical College
Bijapur.

iii
 Declaration
I hereby solemnly declare that this dissertation entitled “Prediction of
Significant Neonatal Hyperbilirubinemia in Healthy Term Newborns
Using Cord Bilirubin & 24th Hour Serum Bilirubin” is a genuine research
work of mine under the direct supervision and guidance of Dr. S V Patil, Professor,
Department of Pediatrics at Shri B.M. Patil Medical College, Bijapur and is submitted
to Rajiv Gandhi University of Health Sciences in partial fulfillment of the regulations
governing the award of DOCTOR OF MEDICINE IN PEDIATRICS.

This work is original and has not been submitted previously to any University by
me for the award of any Degree or Diploma.

Date:
Place: Bijapur
Dr. Gautam Chawla

iv
 Copyright
I hereby declare that Rajiv Gandhi University of Health Sciences, Bangalore,
Karnataka, shall have the rights to preserve, use and disseminate this dissertation / thesis
in print or electronic format for academic / research purpose.

Date:
Place: Bijapur
Dr. Gautam Chawla

© Rajiv Gandhi University of Health Sciences

v
 Acknowledgements
As I complete this humble contribution to scientific pursuit, it gives me
immense pleasure to acknowledge the guidance provided by my mentors.

First and foremost, with proud privilege, utmost gratitude & deep sense of
respect I like to express my thanks and indebtedness to my Guru and Guide
Dr. S. V. Patil M.D , Professor, Department of Pediatrics, Shri B. M. Patil Medical
College, Bijapur. His never tiring zeal, constructive criticism and persistent
enthusiasm regarding the progress of study deserves a very big praise. He was willing
to help at all times, often infringing on his personal hours. Thank you sir once again,
for the immense effort, extensive encouragement and support rendered in pursuit of
my post graduate studies and moulding this dissertation into its present form.

I take this opportunity to express my indebtedness & gratitude for

Prof. Dr. A. S. Akki MD , Head of the Department of Pediatrics, for his unruffled
patience, invaluable suggestion and encouragement. His constant review of this
manuscript from time to time inspired me to go on and complete this dissertation.

Words fail to express my deep sense of reverence & gratitude to Prof. & Unit
Chief Dr. R. H. Gobbur MD. I am indebted to him for his constant inspiration and
guidance during quest for my knowledge.

I am forever grateful to Prof. Dr. D. B. Meundi MD , Assoc. Prof.

Dr. N. S. Pangi MD , Lect. Dr. Vijay B. M. MD , Lect. Dr. S. S. Kalyanshettar MD ,
Lect. Dr. M. M. Patil MD , Lect. Dr (Mrs.) M. K. Jayalakshmi DCH ,
Lect. Dr. (Mrs.) J. S. Dillon DCH, for their valuable guidance and help.

I am grateful to Dr. R. C. Bidri MD , Principal of B.L.D.E.A’s Shri B M Patil

Medical College & Research Center, Bijapur, for permitting me to utilize resources in
completion of my work.
 Thanks to my fellow post graduates Vasant, Raghavendra Reddy, Ramesha,
Raghavendra Vanaki, Halemani, Veeresh, Mahesh, Raghunath & Hanumesh for
giving me continuous support and boosting my morale in times most needed.

A word of appreciation towards Dr. Ranjanpreet, Dr. Prajna for their kind
cooperation and valuable help in collection of cord blood during my study.

Staff sisters of labor room deserve mention for their role in dispatching the
samples and collection of reports in time.

I also convey my thanks to Mr. S. S. Walvekar Lecturer & Biochemist and all
the biochemistry lab technicians for their kind cooperation and valuable help in
processing of the samples during my study.

Special thanks to Record section and Library section for their assistance in
collection of data.

My thanks to Mr. Sunil Tatuskar for putting my dissertation in a right format.

My Heartfelt gratitude to all the Newborns and special thanks to their parents
without whose cooperation this manuscript would not have been able to see the light
of the day.

Lastly but not the least, I bow down to thank my Father whose qualities of
grit, determination and will to succeed helped me paving the way for this dissertation
from the beginning…to the…end. To my Mother and my sweet Sisters whose virtues
of patience and perseverance were my beacons throughout.
 LIST OF ABBREVIATIONS

ƒ AAP : American Academy of Pediatrics

ƒ ATP : Adenosine Triphosphate
ƒ BIND : Bilirubin Induced Neurological Dysfunction
ƒ BOH : Bad Obstetric History
ƒ CO : Carbon Monoxide
ƒ CPD : Cephalo Pelvic Disproportion
ƒ DCT : Direct Coomb’s Test
ƒ ETCOC : End Tidal Carbon Monoxide
ƒ FTND : Full Term Normal Delivery
ƒ HDN : Hemolytic Disease of Newborn
ƒ HO : Heme Oxygenase
ƒ LSCS : Lower Segment Cesarean Section
ƒ Multi : Multigravida
ƒ NEFA : Non Esterified Fatty Acids
ƒ NICU : Neonatal Intensive Care Unit
ƒ OPD : Out Patient Department
ƒ PCV : Packed Cell Volume
ƒ Primi : Primigravida
ƒ PIH : Pregnancy Induced Hypertension
ƒ PROM : Premature Rupture of Membranes
ƒ RBC : Red Blood Corpuscle
ƒ STB : Serum Total Bilirubin
ƒ TOF : Tracheo Esophageal Fistula
ƒ TSB 1 : Total Serum Bilirubin at 22-26 hours
ƒ TSB S : Total Serum Bilirubin at 72 hours
ƒ UDP : Uridine Diphosphate
ƒ UGT : Uridine Glucuronyl Transferase
 ABSTRACT

Title: Prediction of Significant Neonatal Hyperbilirubinemia in Healthy Term

Newborns using Cord Bilirubin and 24th Hour Serum Bilirubin.

- A Prospective Study.

Patil S V, Chawla G

Department of Pediatrics, BLDEA’s Shri B.M. Patil Medical College & Research Centre,

Bijapur.

Background & Objectives:

Visible jaundice occurs in approximately half to one-third of term neonates.

Neonatal hyperbilirubinemia still remains a public health concern as documented by

reports of kernicterus in otherwise healthy term or near term newborns. Prevention of

kernicterus is a laudable pursuit provided excessive hyperbilirubinemia for age is

promptly identified and appropriately treated. With increasing emphasis on initiation

of breast feeding soon after birth and thereafter early discharge of healthy babies, the

study aim was to predict using serum bilirubin level measured 22 to 26 hours after

birth, the occurrence of peak serum bilirubin level >15mg/dl (hyperbilirubinemia)

anytime from the second to fifth post natal day. The study hypothesis was that serum

bilirubin level of the first postnatal day is a good predictor of its own peak achieved

later in the first week.

Methods:

The study was conducted on a prospective cohort of 250 term neonates born at

a tertiary level hospital with NICU facility in North Karnataka. The main outcome

measured was hyperbilirubinemia.

Serum bilirubin level was estimated soon after delivery (cord blood) and then

at 24 ± 2 hours of age. Exclusion criteria were Rh incompatibility, ABO

incompatibility, asphyxia, life threatening congenital malformations and neonates of

women with gestational diabetes or history of intake of drugs affecting the fetal liver.

Results:

Total 250 newborns were enrolled and followed up. All babies were

exclusively breast fed. Mean age at bilirubin estimation was 24.3 ± 2 hours with mean

TSB of 4.06 ± 1.2 mg/dl. Clinically detectable jaundice was present in 150/250 (60%)

and hyperbilirubinemia occurred in 13 (5.2%) newborns. A TSB level of ≤ 5.0 mg/dl

at 24 ± 2 hours was present in 211 (84.4%) newborns and only 2 newborns developed

hyperbilirubinemia subsequently. In the remaining 39 (15.6%) newborns with TSB >

5.0 mg/dl, subsequent hyperbilirubinemia developed in 11 (84.61%) {Sensitivity:

84.62%, specificity: 88.18%, positive predictive value 28.20%, negative predictive

value 99.05%, likelihood ratio of positive test 7.05 and likelihood ratio of negative

test 0.175}. Babies with TSB levels higher than 5 mg/dl had a significant risk of

developing hyperbilirubinemia.

Conclusion:

A TSB level of ≤ 5.0 mg/dl at 24 ± 2 hours of age predicts neonates who

would not develop hyperbilirubinemia.

Keywords: Neonatal jaundice; Prediction; Hyperbilirubinemia; Kernicterus.

 CONTENTS

PAGE #

1. INTRODUCTION..........................................................................1

2. AIMS AND OBJECTIVES ...........................................................4

3. REVIEW OF LITERATURE.......................................................5

4. MATERIAL AND METHODS ..................................................43

5. OBSERVATION AND RESULTS .............................................50

6. DISCUSSION ...............................................................................92

7. CONCLUSIONS ........................................................................109

8. SUMMARY ................................................................................110

9. BIBLIOGRAPHY ......................................................................113

10. ANNEXURE

i. CONSENT FORM

ii. PHOTOGRAPHS

iii. MASTER CHART

 LIST OF Graphs

No. Graph PAGE #

I Birth Weight Distribution 51

II Sex Distribution 53

III Type of Delivery 53

IV High Risk Antenatal Factors 55

V Blood Group Distribution 57

VI Rhesus Group Distribution 57

VII Gestational Age Distribution 59

VIII Birth Weight Distribution acc. to Gestational Age 61

IX Cord Bilirubin Levels 63

X Cord Bilirubin and Birth Weight 65

XI TSB 1 Levels at 22-26 hours 68

XII TSB 1 levels and Birth Weight 70

XIII TSB 1 levels and Gestational Age 73

XIV Distribution on the basis of Arbitrary Cut Off Value 76

XV Distribution on the basis of Average Value 76

XVI Risk Stratification 78

XVII Subsequent Risk Categorization at 72 hours 80

XVIII Subsequent Risk Categorization of Low Risk Zone 80

XIX Subsequent Risk Categorization of Intermediate Risk Zone 82

XX Subsequent Risk Categorization of High Risk Zone 82

XXI Distribution of Significant Hyperbilirubinemia 88

 LIST OF TABLES

No. Table PAGE #

I Birth Weight Distribution 52

II Sex Ratio 54

III Type of Delivery 54

IV High Risk Antenatal Factors 56

V Blood Group Distribution 58

VI Rhesus Group Distribution 58

VII Gestational Age Distribution 60

VIII Birth Weight (2500-3000gms.) Distribution acc. to Gestational Age 62

IX Birth Weight (3001-3500gms.) Distribution acc. to Gestational Age 62

X Birth Weight (≥ 3501gms.) Distribution acc. to Gestational Age 62

XI Cord Bilirubin Levels 64

XII Cord Bilirubin Levels acc. to Birth Weight (2500-3000gms.) 66

XIII Cord Bilirubin Levels acc. to Birth Weight (3001-3500gms.) 66

XIV Cord Bilirubin Levels acc. to Birth Weight (≥ 3501gms.) 67

XV Bilirubin Level (TSB 1) Distribution 69

XVI TSB 1 Distribution acc. to Birth Weight (2500-3000gms.) 71

XVII TSB 1 Distribution acc. to Birth Weight (3001-3500gms.) 71

XVIII TSB 1 Distribution acc. to Birth Weight (≥ 3501gms.) 72

XIX TSB 1 Distribution acc. to Gestational Age 36-37 weeks 74

XX TSB 1 Distribution acc. to Gestational Age 38-39weeks 74

XXI TSB 1 Distribution acc. to Gestational Age 40-41 weeks 75

XXII TSB 1 Distribution acc. to Gestational Age ≥ 42weeks 75

XXIII Distribution on the Basis of Arbitrary Cut Off Value 77

 No. Table PAGE #

XXIV Distribution on the Basis of Average Bilirubin Value 77

XXV Risk Stratification of Study Population 79

XXVI Subsequent Risk Categorization of Study Population 81

XXVII Subsequent Risk Categorization of Low Risk Newborns 81

XXVIII Subsequent Risk Categorization of Intermediate Risk Newborns 83

XXIX Subsequent Risk categorization of High Risk Newborns 83

XXX Characteristics of Newborns with Significant Hyperbilirubinemia 84

XXXI Distribution of Parity & High Risk Antenatal Factors in Newborns 85

with Significant Hyperbilirubinemia

XXXII Sex Distribution & Type of Delivery in Newborns with Significant 86

Hyperbilirubinemia

XXXIII Distribution of Cord Bilirubin, TSB 1 Levels & Risk Stratification 87

in Newborns with Significant Hyperbilirubinemia

XXXIV Distribution of 13 newborns with Hyperbilirubinemia on the Basis 89

of Arbitrary Cut off Value

XXXV Distribution of 13 newborns with Hyperbilirubinemia on the Basis 90

of Average Bilirubin Value

XXXVI Predictive Characteristics as Risk Demarcators for Subsequent 91

Significant Hyperbilirubinemia
 INTRODUCTION

“In every child who is born, under no matter

what circumstances, and of no matter what parents,
the potentiality of the human race is born again, and
in him too, once more, and in each of us, our terrific
responsibility towards human life.”

JAMES AGEE

Hyperbilirubinemia is universally present in the newborn period and is

recognized as clinical jaundice in approximately 50% infants. It is still one of the

most discussed topics in neonatology. The sheer prevalence of neonatal jaundice and

periodic occurrence of bilirubin associated encephalopathy ensures sustained interest

on this subject.

The fear for the level of 20mg/dl has given anxious moments to doctors and

the relatives of the ‘jaundiced infant’. To the pediatrician jaundice remains the most

common and perhaps the most vexing problem in the well baby nursery. Jaundice is

observed during the first week of life in ~ 60% of healthy term newborns and 80% of

preterm newborns. It is a cause of concern for the parents as well as for the

pediatricians. Bilirubin production is 2-3 times higher in normal term newborns

compared with adults. The color in jaundice usually results from accumulation in the

skin of unconjugated, nonpolar, lipid soluble, bilirubin pigment (indirect reacting)

formed from hemoglobin by the action of heme oxygenase, biliverdin reductase and

non enzymatic reducing agents in the reticulo endothelial cells1.

Under normal circumstances, the level of indirect reacting bilirubin in

umbilical cord serum is 1-3mg/dl and rises at a rate of less than 5mg/dl/24hrs. Thus

jaundice becomes visible on the 2nd- 3rd day (36-72hrs) usually peaking by the 3rd day

at 5-6mg/dl and decreasing to below 2mg/dl between 5th and 7th day of life1.

1
 Bilirubin induced neurological dysfunction does not occur in the absence of

hyperbilirubinemia. Kernicterus is a rare but devastating condition that is not extinct.

It is usually associated with complicating conditions such as isoimmunization or other

causes of hemolysis, prematurity, sepsis, other illness or constitutional defects in

hepatic bilirubin clearance2-5. However as has been documented in several recent

reports6-11, it occasionally occurs in healthy breast or bottle fed infants born at or near

term in the absence of diagnosed complicating factor.

Quantifying the level of jaundice has been the foundation for satisfactory

management of hyperbilirubinemia. The observer variability and the influence of skin

color in clinically evaluating hyperbilirubinemia by ‘Kramer index’12 has been the

Achilles’ heel of this method. Moreover the current risk factors to recognize infants

who are likely to require treatment for hyperbilirubinemia are not adequate.

While jaundice per se is not preventable none the less early detection of

threatening bilirubin levels permit initiation of phototherapy and prevents higher risk

and high cost exchange transfusion therapy or kernicterus. The AAP (American

Academy of Pediatrics) recommends13 that newborns discharged before or within 48

hours. should have a follow-up visit after 2-3 days to detect significant jaundice and

other problems. This is not possible in our country due to limited follow up facilities.

The concept of prediction of jaundice offers an attractive option to pick up

babies at risk for neonatal hyperbilirubinemia. An association between bilirubin levels

and subsequent risk of hyperbilirubinemia has been reported14,15. Infants who are

clinically jaundiced in the first few days are more likely to develop

hyperbilirubinemia16,17.

The gold standard for deciding therapy to prevent encephalopathy continues to

be serum bilirubin levels for want of better parameters. The clinical practice of

2
reporting bilirubin on the basis of age in days was misleading and confusing. It should

be remembered that bilirubin rises by the “hours” of life and hence the time of

sampling must be as ‘hours of life’ and not ‘day of life’.

Hour specific percentile charts based on serum bilirubin at different postnatal

ages have been developed18. They show that subsequent hyperbilirubinemia can be

predicted with reasonable accuracy by plotting for specific bilirubin on these charts.

There is paucity of literature on this concept of prediction of hyperbilirubinemia.

The present study was carried out to evaluate the predictive value of specific

bilirubin level at 22 hours to 26 hours of postnatal age for identifying term neonates at

risk for subsequent hyperbilirubinemia.

3
 AIMS AND OBJECTIVES

♦ To study the cord blood bilirubin levels at birth.

♦ To determine the predictive ability of hour specific (22 hours to 26 hours)

bilirubin for subsequent significant hyperbilirubinemia in healthy term

newborns.

♦ To study the outcome of babies for development of hyperbilirubinemia during

their neonatal stay.

♦ To establish the cut-off values and comparison of the obtained value for

prediction of neonatal hyperbilirubinemia.

4
 REVIEW OF LITERATURE

“All seems infected that th’ infected spy,

as all looks yellow to the jaundiced eye”.

- Alexander Pope

An important relation between bilirubin and injury to neonatal central nervous

system has been recognized for many years19, 20.

The first comprehensive description of the most overt form of bilirubin

encephalopathy was provided by Schmorl21 in 1903.

Bilirubin turnover:

Bilirubin is the end product of catabolism of heme, the major source of which

is circulating hemoglobin.
Blood Bilirubin - Albumin Complex
Hemoglobin
↓
↓ Hepatocyte Bilirubin
↓
Heme Bilirubin diglucuronide
↓
↓ Heme Oxygenase
Bile Ductule Bilirubin diglucuronide

Biliverdin

↓ Biliverdin Reductase

Bilirubin

5
 75% of total production of bilirubin is from normal destruction of circulating

red blood cells. 25% is from other sources i.e. ineffective erythropoesis or turnover of

non hemoglobin source of heme (cytochromes/catalase).

Bilirubin leaves the site of production in the reticuloendothelial system and is

transported in plasma bound to albumin.

Human albumin has a single tight high affinity site for bilirubin and one or more,

weaker & lower affinity binding sites. The capacity of serum bilirubin to bind

bilirubin is known as binding capacity and strength of Bilirubin-Albumin bond is

referred to as binding affinity. The amount of free bilirubin i.e. bilirubin not bound to

albumin is very low at physiological pH. These three characterizations of serum i.e.

binding capacity/affinity/free bilirubin gives approximate idea of the amount of

bilirubin that may be available to cause neuronal injury.

Hepatic uptake: Hepatocytes have a selective and highly efficient system for

removing unconjugated bilirubin from plasma protein or ligandin.

Conjugation:

6
 UDP-Glucose → UDP-Glucuronic Acid

UDP-Glucuronic Acid + Bilirubin → Bilirubin monoglucuronide + UDP

UDP-Glucuronic Acid + Bilirubin monoglucuronide → Bilirubin diglucuronide + UDP

The conversion of bilirubin to excrete mono and di conjugates is carried out

primarily by microsomal enzyme UDP-glucuronyl transferase. The di conjugate

accounts for approximately 90% of total bilirubin glucuronyl conjugates.

Excretion: The conjugated bilirubin is excreted into the bile. Because this event

occurs across a concentration gradient, an energy dependent transport system is

involved.

Enterohepatic circulation: Intestinal β-glucuronidase hydrolyzes the conjugated

bilirubin, releasing free bilirubin which is then reabsorbed and transported by portal

circulation to the liver.

Fetal Bilirubin Metabolism

During intrauterine life most of the fetal removal of bilirubin is accomplished

by way of the placenta and maternal-fetal circulation and the bilirubin in cord blood is

virtually all unconjugated. Formation of conjugated bilirubin is limited in the fetus

because of decreased fetal hepatic blood flow and decreased UDPG-T activity.

Physiologic Jaundice:

Jaundice is the visible manifestation in skin and sclera of elevated serum

concentrations of bilirubin. Most adults are jaundiced when serum total bilirubin

(STB) levels exceed 2.0 mg/dl. Neonates however, may not appear jaundiced until the

STB concentration exceeds 5.0 to 7.0 mg/dl.

7
Assessment of Severity of Jaundice

Visual assessment of STB levels12 relies on cephalocaudal progression of

jaundice with a rising STB level (Head & neck 4 – 8 mg/dl; Upper trunk 5 – 12 mg/dl;

Lower trunk & thighs 8 – 16 mg/dl; Palms & soles > 15 mg/dl).

Cephalocaudal progression of jaundice is apparently related to the relative

thickness of skin at various parts, skin being thinnest on the face & extremely thick

over the palms & soles. The cephalocaudal color difference may be related to

difference in blood flow or lipid content of skin and due to conformational changes in

the newly formed bilirubin-albumin complexes.

The severity of jaundice should be assessed in natural day light by observing

cepalocaudal progression.

Various modalities of assessment of jaundice

♦ Icterometer: Matching skin color with the color codes depicted on

plastic strip.

♦ Transcutaneous billimeter: Works on principle of computerized

spectro-photometery.

8
 ♦ Conventional Van den Bergh test22: It is a quantitative method for

bilirubin assay and is based on the coupling of diazotized sulfanilic

acid (Ehrlich’s diazoreagent) and bilirubin to produce a reddish-purple

azo compound. Direct and indirect reactions: Bilirubin as such is

insoluble in water while the conjugated bilirubin is soluble. Van den

Bergh reagent reacts with conjugated bilirubin and gives a purple color

(normally within 30 sec.) Addition of methanol dissolves the

unconjugated bilirubin which then gives the Van den Bergh reaction

(normally within 30 min.)

The form of bilirubin that reacts without the addition of methanol is

termed “direct bilirubin”; to that form of bilirubin which is measured

only after the addition of methanol is termed “indirect reacting”.

♦ End tidal carbon monoxide levels (ETCOc): It is an index of the rate

of bilirubin production. Breakdown of heme by the rate limiting

enzyme heme oxygenase (HO) leads to the formation of equimolar

amounts of CO & biliverdin, with biliverdin immediately reduced to

bilirubin; the measurement of CO in the exhaled breath of the newborn

can be used as an index of heme degradation and bilirubin production.

Chemical hyperbilirubinemia, defined as an STB level of 2.0 mg/dl or more, is

virtually universal in newborns during the first week of life. Debate and controversy

remain in efforts to define either normal or physiologic ranges of STB concentration

in newborns.

Traditionally, a distinction has been made between benign physiologic

jaundice and hyperbilirubinemia, which is either pathologic in origin or severe enough

for further evaluation and intervention. This latter entity has been called

9
“nonphysiologic”, although frequently no disease is identified as being causative or

consequent.

Serum total bilirubin (STB) concentrations have been defined as

nonphysiologic if the concentration exceeds 5 mg/dl on the first day of life in a term

neonate, 10 mg/dl on the second day, or 12 to 13 mg/dl thereafter23. The elevation of

STB concentration in healthy appearing newborns results from the convergence of

several developmental factors specific to the neonate. Gartner and coworkers24

divided the clinical course of physiologic jaundice into two phases:

♦ Phase 1: it includes the first 5 days of life in term newborns and is

characterized by a rapid increase in STB level for 3 - 4 days, after

which the level begins to decline.

♦ Phase 2: it is characterized by stable, but elevated STB levels lasting

about two weeks.

A rise up to 12 mg/dl is in the physiological range. In premature newborns the

peak may be 10-12 mg/dl on Day 5 possibly rising over 15 mg/dl without any specific

abnormality of bilirubin metabolism.

10
This “normal jaundice” is attributed to the following mechanisms:

A. Increased bilirubin production due to increased RBC volume/kg and

decreased RBC survival (90 day versus 120 day), increased ineffective

erythropoiesis and increased turnover of non hemoglobin heme proteins.

B. Increased enterohepatic circulation caused by high levels of intestinal β-

glucuronidase, preponderance of bilirubin monoglucuronide rather than

diglucuronide, mild alkaline pH of the proximal intestine, decreased intestinal

bacteria and decreased gut motility with poor evacuation of bilirubin laden

meconium.

C. Defective uptake of bilirubin from plasma caused by decreased ligandin and

binding of ligandin by other anions.

D. Defective conjugation due to decreased UDPG-T activity.

E. Decreased hepatic excretion of bilirubin.

Criteria that rule out diagnosis of physiologic jaundice20:

¾ Clinical jaundice in first 24 hours of life.

¾ TSB (total serum bilirubin) increasing by 0.5mg/dl/hr.

¾ TSB >12.9mg/dl in full term, 15mg/dl in preterm newborns.

¾ Direct serum bilirubin >1.5-2mg/dl

¾ Clinical jaundice persisting > 1week in full term neonate & 2weeks in

premature neonate.

Breast feeding and Jaundice:

Two separate patterns of jaundice in breast feeding neonates have been

described:

a. Breast feeding associated jaundice or breast feeding failure jaundice.

b. Breast milk jaundice.

11
 • Breast feeding failure jaundice25: It occurs in the first week of life and its

cause may be nutritional and that it can be prevented by frequent breast

feeding in first 3 days of life and avoidance of supplementation with water or

glucose solutions26,27. Breast fed newborn pass fewer stools in the first few

days of life suggesting that increased amounts of bilirubin are absorbed into

the enterohepatic circulation. To overcome this, early and frequent feeding

may increase evacuation and decrease intestinal transit time. It is a diagnosis

of exclusion and most important, increased bilirubin production must be

eliminated as a contributory cause.

• Breast milk jaundice: It is of late onset and has an incidence in term

newborns of 2 to 4 %. By day 4, instead of the usual fall in the serum bilirubin

level, the bilirubin level continues to rise and may reach 20 to 30 mg/dl by 14

days of age. If breast feeding is stopped the bilirubin level will fall rapidly in

48 hours. These neonates show good weight gain, have normal liver function

test results and show no evidence of hemolysis. The mechanism of true breast

milk jaundice is unknown but is thought to be due to an unidentified factor (or

factors) in breast milk interfering with bilirubin metabolism28.

Additionally, compared with formula fed newborns, breast fed newborns are

more likely to have increased enterohepatic circulation because they ingest the β-

glucuronidase present in breast milk, are slower to be colonized with intestinal

bacteria that convert conjugated bilirubin to urobilinoids, and excrete less stool.

Unconjugated hyperbilirubinemia:

Overproduction of bilirubin combined with immature mechanism for

conjugation and enhanced intestinal enterohepatic circulation of bilirubin contributes

to the development of neonatal jaundice. In most newborns, this increase in serum

12
total bilirubin is mild enough to be considered physiologic and non toxic, and the

excess bilirubin is composed entirely of the unconjugated form. When excessive

production of bilirubin saturates the immature mechanism for bilirubin uptake and

conjugation, however, or, when the process of bilirubin uptake and conjugation is

defective or deficient, the level of unconjugated bilirubin in the serum can accumulate

to toxic concentrations.

Although the relationship between serum levels of unconjugated bilirubin and

neurotoxicity is not simple, general risk can be discerned between neonatal

hyperbilirubinemia and acute neuronal injury.

Causes of Unconjugated hyperbilirubinemia29

A. Excessive production of i. Blood group hetero specificity

bilirubin (Hemolysis)
iii.
B. Impaired conjugation /
Excretion
C. Enhanced enterohepatic
circulation
(incompatibility)
ƒ Rh
ƒ ABO
ƒ Minor blood group
ii. Red blood cell enzyme abnormalities
ƒ G-6 PD
ƒ Pyruvate kinase
Red blood cell membrane defects
ƒ Hereditary spherocytosis
ƒ Elliptocytosis
ƒ Poikilocytosis
i. Hormonal deficiency
ƒ Hypothyroidism
ƒ Hypopituitarism
ii. Disorders of bilirubin metabolism
ƒ Crigler Najjar syndrome type 1
ƒ Crigler Najjar syndrome type 2
(Arias disease)
ƒ Gilbert disease
ƒ Lucey Driscoll syndrome
i. Intestinal obstruction, pyloric stenosis
ii. Ileus, bile plug, cystic fibrosis

13
Excessive production of bilirubin (hemolytic disease of newborn)

i. Blood group incompatibility

9 Rh Isoimmunization: Erythryblastosis due to Rh incompatibility is still

an important cause of hyperbilirubinemia in our country. There are no

inborn antibodies in the Rhesus blood group system. The Rh antibody

is produced by a Rh negative mother in response to the presence of Rh

antigen on the fetal RBC membrane. The initial maternal response to

this antigenic stimulus produces IgM antibodies, which do not cross

the placenta in significant amounts. Later IgG antibodies are formed

that cross into the fetus and attaches to antigenic sites on the RBC

membrane. 15 % to 20 % of Rh positive newborns born to Rh negative

sensitized mothers show no clinical signs of illness, whereas 25 %

have severe disease with fetal death, hydrops or severe anemia.

9 ABO Incompatibility: The cause is reaction of maternal anti-A or anti-

B antibodies to the A or B antigen on the red blood cells of the fetus or

newborn. It is seen usually only in type A or B neonates born to type O

mothers because these mothers make anti-A or anti-B antibodies of the

IgG class which crosses the placenta, while mothers of type A or B

usually make anti-A or anti-B antibodies of IgM class which do not

cross the placenta. Severity of hemolysis is more in OA

incompatibility compared to OB incompatibility. Jaundice of ABO

incompatibility usually appears within the first 24 to 72 hours after

birth.

14
 ii. Red blood cell enzyme abnormalities

9 G-6 PD deficiency: It is a heterogeneous sex-linked recessive trait.

Severe neonatal jaundice is the most common clinical manifestation. In

G-6 P deficiency RBC’s cannot activate the pentose phosphate

metabolic pathway and therefore are unable to defend adequately

against oxidant stresses. As a result severe hyperbilirubinemia result

from hemolysis associated with sepsis, exposure to chemicals (e.g.

naphtha) or administration of pharmaceutical drugs (e.g. quinine,

primaquine, nitrofurantoin, acetylsalicylic acid, Vit. K etc). exposure

of the newborn to a hemolytic agent can occur transplacentally, via

breast milk, or directly by inhalation, ingestion or injection.

9 Pyruvate Kinase deficiency: It is the second most common cause of

enzymatic related hemolytic anemia. It is an autosomal recessive

disorder. PK is a key enzyme in the production of adenosine

triphosphate (ATP) in RBC’s; its deficiency leads to shortened RBC

survival, with excess hemolysis.

iii. Red blood cell membrane defects

9 Hereditary Spherocytosis: It is characterized by spherocytic

erythrocytes that are abnormally fragile under osmotic stress owing to

the abnormalities of the RBC cytoskeleton. It is inherited as an

autosomal dominant trait. Cells from persons with spherocytes also

contain less lipid than the normal. Jaundice develops in approximately

50% of newborns with spherocytes. The diagnosis is made by

15
 peripheral smear examination and recognition of the abnormal shape of

erythrocytes.

9 Hereditary Elliptocytosis: It is a heterogeneous group of autosomal

dominant defects that result in an abnormal RBC cytoskeleton. The

membrane defect is caused by abnormalities of either spectrin or

glycophorin C. This disorder is usually asymptomatic in the newborn

period. The peripheral smear in these cases demonstrates mainly

budding erythrocytic forms30.

iv. Infectious causes

Sepsis is one of the important treatable problems associated with

bilirubin production. The hyperbilirubinemia in septic neonates is

thought to be a consequence of rapid hemolysis. Neonatal erythrocytes

are susceptible to cell injury and heinz body formation in response to

oxidative stress. In addition heme oxygenase (HO) is induced by

oxidants and its induction could lead to increased catabolism of heme

to bilirubin. Intrauterine infections of TORCH complex may cause

giant cell hepatitis and jaundice anytime during neonatal period.

Jaundice is a recognized feature of Congenital & Neonatal malaria.

v. Extravascular blood

Common sites for substantial collections of blood in term newborns are

cephalhematomas and the space beneath the galeal aponeurosis.

Presence of blood that has been swallowed or remains entrapped after

a hemorrhagic event such as with severe bruising, cephalhematoma, or

liver, splenic, adrenal hemorrhages commonly leads to

hyperbilirubinemia because of the excess bilirubin production resulting

16
 from the breakdown of extravasated RBC’s. It must be remembered

that approximately 1 gm. of extravasated hemoglobin yields to the

production of 35 mg. of bilirubin.

vi. Polycythemia

Neonatal erythrocytes have a shorter life span than that of erythrocytes

of older infants and children; an excess in the number of erythrocytes

at birth can be associated with increased heme degradation and

bilirubin production. As polycythemia is associated with specific

clinical entities such as late cord clamping, trisomy 21 or maternal

diabetes, these conditions can be associated with increased risk of

neonatal jaundice.

Impaired conjugation / excretion

i. Hormonal deficiency

9 Hypothyroidism: Prolonged hyperbilirubinemia (unconjugated)

presumably as a result of a delay in maturation of the bilirubin

conjugating enzymes31 may be the sole manifestation of congenital

hypothyroidism. The prolonged jaundice may stem from a delayed

maturation of the ability of the liver to conjugate bilirubin because of

the hormone dependent variations in UGT activity. Clinically similar

picture is seen in newborns with congenital hypopituitarism.

ii. Inherited disorders of bilirubin metabolism

9 Crigler-Najjar syndrome type І

9 Crigler-Najjar syndrome type ІІ

9 Gilbert disease

9 Lucey-Driscoll syndrome

17
 Crigler-Najjar syndrome:

It is the most severe form of a group of inherited disorders of bilirubin

metabolism that result from reduction or absence of UGT activity. Response to

the use of Phenobarbital or other substances known to induce enzyme activity

differentiates the two types of Crigler-Najjar syndrome32.

The entire group of nonhemolytic unconjugated hyperbilirubinemia

can be simplistically divided into three major types according to the degree of

Bilirubin UGT activity and response to enzyme inducing agents such as

Phenobarbital. The pattern of inheritance is different among these groups as

well.

Congenital Nonhemolytic Unconjugated Hyperbilirubinemia:

Clinical Syndromes33
Severity
Marked Moderate (Arias Mild (Gilbert
Characteristic (Crigler-Najjar) disease, Crigler- Disease)
Syndrome type Najjar) Syndrome
І type ІІ
Steady state serum > 20 mg/dl < 20 mg/dl < 5 mg/dl
total bilirubin
Range of bilirubin 14-50 mg/dl 5.3-37.6 mg/dl 0.8-10 mg/dl
values
Total bilirubin in < 10 mg/dl 50-100 mg/dl Normal
bile
Conjugated Absent Present Present
bilirubin in bile
Bilirubin clearance Extremely Markedly decreased 20-30% of
decreased normal
Hepatic bilirubin Normal Normal Reduced
uptake
Bilirubin UGT None detected None detected Decreased
activity
Genetics Autosomal Heterogenecity of Genetic
recessive defect distinctly polymorphisms
possible

18
Lucey-Driscoll syndrome:

It presents as intense, transient hyperbilirubinemia of unexplained cause.

Originally described in 24 newborns born to eight mothers; kernicterus developed in

four of them as a result of intense hyperbilirubinemia due to transplacental passage of

glucuronyl transferase inhibiting substance (believed to be a gestational hormone)

from mother to fetus.

Homozygous alpha thalassemia:

It is a rare condition in our country, by and large, is limited to Orientals where

in alpha chain production is deficient while excess gamma chains combine to form

Bart’s hemoglobin. Outcome is generally fatal.

Drugs & Neonatal Jaundice

Several drugs may aggravate neonatal jaundice or predispose occurrence of

bilirubin encephalopathy at lower serum bilirubin levels. The drugs may aggravate

neonatal jaundice by causing

• Hemolysis (vit. k in large doses)

• Blocking Y-acceptor protein (vit. k & kanamycin)

• Competing with glucuronyl transferase for hepatic conjugation

(novobiocin, gentamycin, moxalactam, chloramphenicol)

• Blocking bilirubin binding sites in the albumin (salicylates,

furosemide, sodium benzoate, caffeine, fusidic acid)

• Increased osmotic fragility of RBC’s (oxytocin)

19
Conjugated hyperbilirubinemia:

It is due to failure to excrete conjugated bile from the hepatocyte into the

duodenum. It is manifested as conjugated bilirubin level over 2.0 mg/dl or a

conjugated bilirubin level greater than 15 % of the total bilirubin level. It is also

known as cholestatic disorder and includes retention of conjugated bile, bile acids

and other components of bile.

Excessive bilirubin load (inspissated bile syndrome)

It is a self limited cholestatic jaundice during the course of Rh-HDN due to

transient disparity between the maturity of conjugatory and excretory function of

hepatocytes resulting in accumulation of conjugated bilirubin.

Bile flow obstruction (biliary atresia, extrahepatic or intrahepatic)

• Biliary atresia: It is rather complex and obscure anomaly; etiology is

controversial (whether it is developmental in origin or evolve as a

consequence of inflammatory or toxic process in the liver) posing a

therapeutic challenge.

• Extrahepatic bile duct atresia: It may be isolated or associated with a

choledochal cyst, trisomy 13 or 18, or polysplenia. Jaundice usually occurs

after first week of life. Stools are persistently clay-colored or even cheesy

white.

• Intrahepatic bile duct atresia: It may be associated with the Watson-Alagille

syndrome (cholestasis & facial dysmorphism), Aagenaes syndrome

(intrahepatic atresia with lymph edema). Jaundice occurs around 4 weeks of

age and is associated with marked and rapid elevation of transaminases,

alkaline phosphate and lipid fraction.

20
Neonatal hepatitis

It can occur from a variety of intrauterine viral, parasitic, spirochetal

infections. Onset of jaundice is anytime during the neonatal period. There is marked

elevation of serum bilirubin and gross elevation of transaminases. Urine and stools are

bile stained. Intermittent stools may be acholic or clay colored.

Bilirubin Toxicity, Encephalopathy and Kernicterus -

Important determinants of neuronal injury by bilirubin:

• Concentration of serum unconjugated bilirubin and free bilirubin.

• Concentration of serum albumin.

• Bilirubin binding to albumin.

• Concentration of Hydrogen ions.

• Blood brain barrier.

• Neuronal susceptibility.

Unconjugated bilirubin:

Although it is generally recognized that serum levels of unconjugated bilirubin

must be elevated to cause neurotoxicity, the relation between such level and brain

injury is not simple. In the full term infant with marked hyperbilirubinemia secondary

to hemolytic disease a clear correlation can be discerned between occurrence of

kernicterus and maximal recorded level of serum bilirubin. The neural risk of marked

hyperbilirubinemia in full term neonate without hemolysis is less clear34. The

concentration of free bilirubin i.e. quantity of that fraction of unconjugated bilirubin

not bound to albumin is also related to neurotoxicity.

21
 Concentration of Serum Albumin is important in determining neurotoxicity

of bilirubin. At lower concentration of serum albumin the overall reaction will favor

the formation of unbound bilirubin anion and ultimately bilirubin acid. Indeed in

experimental systems the toxic effects of bilirubin on enzymatic systems or on

cultured cells of normal origin can be reversed by addition of albumin.

The capacity of serum Albumin to bind bilirubin depends on such factors as

the affinity for bilirubin and competition between bilirubin and other endogenous and

exogenous anion for albumin binding sites. The affinity for bilirubin is lower in

newborn than in the older infant. Adult levels of affinity are not reached until as late

as 5 months of age.

Endogenous anions that may compete with bilirubin for albumin binding sites

include (NEFA) Non Esterified Fatty Acids and other organic anions. NEFA are

anions at physiologic pH and are present in high concentration with hypothermia,

hypoxemia, hypoglycemia, sepsis, starvation and administration of heparanized blood

or intravenous alimentation with lipids.

Factors of potential importance in enhancing bilirubin neurotoxicity with

asphyxia:

9 Impaired bilirubin – albumin binding and increased proportion of free

bilirubin.

9 Increased blood brain transport of bilirubin (hypercarbia and/or increase

bilirubin acid)

9 Enhanced susceptibility of neurons to bilirubin injury (Hypoxic ischemia)

9 Enhanced susceptibility of neurons to hypoxic ischemic excitotic injury (free

bilirubin)

22
 The blood brain barrier, composed of the brain capillary endothelial cells protects

brain neurons from direct exposure to serum bilirubin.

Bilirubin transport and blood brain barrier -

Bilirubin transport across intact blood brain barrier:

9 Unbound free bilirubin, bilirubin phospholipid complex.

9 Increased cerebral blood flow (Hypercarbia, Seizures)

9 Bilirubin transport across disrupted blood brain barrier.

9 Hyperosmolar load (Hyperosmolar solution, Exchange transfusion)

9 Hypercarbia with acidosis.

9 Asphyxia.

9 Acidosis

9 Vasculitis.

9 Abrupt increase in arterial or venous pressure.

Mechanism of bilirubin toxicity:

¾ Oxidative phosphorylation, ATP level.

¾ DNA synthesis.

¾ Protein synthesis.

¾ Many enzymes (e.g. Synapsin І)

¾ Protein phosphorylation.

¾ Neurotransmitter synthesis.

¾ Ion transport.

¾ Synaptic transmission.

¾ Excitatory amino acid homeostasis.

23
Potential sequence for bilirubin neurotoxicity:

• Extracellular bilirubin binds to phospholipids and ganglioside of

neuronal plasma membrane.

• This bilirubin anion binds to phospholipids of membrane of

mitochondria, endoplasmic reticulum and nucleus.

• There is formation of bilirubin acid at same subcellular site which

gives rise to neuronal death.

Neuropathology:

The classic neuropathology of acute bilirubin encephalopathy consists of two

essential features:

i. Bilirubin staining of specific nuclear groups.

ii. Neuronal necrosis.

Three neuropathological states should be recognized in association with bilirubin

staining of brain nuclei in the newborn.

i. Acute bilirubin encephalopathy or kernicterus of full term newborn with

marked hyperbilirubinemia.

ii. Acute bilirubin encephalopathy or kernicterus of premature neonate without

marked hyperbilirubinemia.

iii. Secondary bilirubin staining of brain nuclei of premature neonate (without

hyperbilirubinemia).

24
 Comparative neuropathology of acute bilirubin encephalopathy / kernicterus

Topography of injury Full term newborn, marked Premature newborn, no

hyperbilirubinemia marked hyperbilirubinemia

Globus pallidus + +

Subthalamus + +

Hypothalamus + −

Hippocampus + +

Substantia nigra + +

Cranial nerve nuclei + +

Reticular formation + +

Cerebellum

Dentate nuclei + +

Pukinjee cells − +

Spinal cord / ant. horn cells + +

Clinical aspects of acute and chronic bilirubin encephalopathies:

i. Occurrence of clinical features in acute bilirubin encephalopathy

Clinical features % of cases

No definite neurological deficits 15 %

Equivocal neurological signs 20-30 %

Definite neurological signs 55-65 %

25
 ii. The evolution of neurological features can be divided into three major

phases

Phase Neurological signs Approximate time of

occurrence

Poor sucking, Decreased

Stage 1 activity, Hypotonia, Slight First days of life

high pitched cry

Retrocollis, Opisthotonus,

Stage 2 High pitched irritable cry, Middle of first week

Fever

Hypertonia, Marked

Stage 3 Retrocollis, Opisthotonus, After first week

Stupor or Coma

Chronic post kernicteric bilirubin encephalopathy following marked neonatal

hyperbilirubinemia:

¾ Extrapyramidal abnormalities (especially choreoathetosis).

¾ Gaze abnormalities (especially limitation of upward gaze).

¾ Auditory disturbances (especially sensorineural deafness).

¾ Intellectual deficits but minimally in mentally retarded range.

There is considerable debate regarding the potential dangers of

hyperbilirubinemia in full term newborn who does not have isoimmune/other types of

hemolytic disease4. Although very rare classic kernicterus can occur in apparently

26
healthy full term breast fed newborns who do not have hemolytic disease or other

discernible cause for their jaundice. Such extreme elevations of serum bilirubin are

rare and we do not know how often newborns with such high serum bilirubin levels

escape harm. We also have no reliable method for identifying these neonates in early

neonatal period.

The cases of kernicterus that have been reported in term and near term babies

were the babies who were apparently healthy at hospital discharge and were

exclusively breast fed35. They all were discharged at Day 2 / less; none was given an

early follow up appointment. In the recent past the average duration of post partum

stay has decreased from 5-7 days to 3-4 days36. In the last few years, the hospital stay

is as short as 24-48 hours. AAP has recommended an early post discharge follow up

for such newborns13.

Early discharge37-39, without early post discharge monitoring for feeding

problems, jaundice and intercurrent illness, decrease concern about toxic potential of

hyperbilirubinemia40-42, the desire to minimize lab testing and medical treatment to

those absolutely needed43-45, inexperience of younger professionals with the

appearance of severe newborn jaundice and pathogenesis of kernicterus6 has led to

increased incidence of hyperbilirubinemia.

Serum bilirubin levels >20mg/dl occur in only 1.2 % of healthy newborns

in countries where breast feeding is common46,47.

It is in this small subset of neonates if left unmonitored and untreated that

Kernicterus can occur. This presents a dilemma for the pediatrician practicing in a

climate of cost containment and recognition of the importance of breast feeding48.

How much time and money should be spent in pre discharge and post

discharge monitoring for problems with breast feeding / jaundice / dehydration and

27
sepsis; conditions that have been shown for hospital readmission after early

discharge49-52?

Universal bilirubin screening to target early post discharge follow up and

serum bilirubin measurement to those newborns at highest risk while minimizing or

eliminating repeat bilirubin measurements in newborns at lower risk46,47 has been

proposed. The purpose of predictive bilirubin monogram is to provide a practical,

readily available guide for monitoring severity of jaundice so as to allow both timely

institution of simple preventive measures such as counseling about feeding & care,

use of formula or expressed breast milk supplements or phototherapy.

Problem with implementation of AAP Practice Parameter:

Practice parameter given by AAP for management of hyperbilirubinemia in healthy

term newborns13.

TSB levels mg/dl

Consider Phototherapy Exchange Exchange

Age in hours phototherapy* transfusion if transfusion &

phototherapy intensive

fails phototherapy

< 24 … … … …

25 – 48 ≥ 12 ≥ 15 ≥ 20 ≥ 25

49 – 72 ≥ 15 ≥ 18 ≥ 25 ≥ 30

> 72 ≥ 17 ≥ 20 ≥ 25 ≥ 30

* Phototherapy at these TSB level is a clinical option meaning that

intervention is available and may be used on the basis of individual clinical judgment.

28
 Intensive phototherapy should produce a decline of TSB of 1-2 mg/dl within

4-6 hours and the TSB level should continue to fall and remain below the threshold

level for exchange transfusion.

Term neonates, who are clinically jaundiced at ≤ 24hrs. are not considered

healthy and require further evaluation.

Clinical experience and recent reports suggest increased occurrence of

kernicterus in otherwise healthy newborn53,54. This has been attributed to decreased

clinical concern about toxic potential of bilirubin. Statistically newborns with TSB

>17 mg/dl during the first week after birth represent a small segment of the

population, the study of Bhutani et al shows that this value is above 95th centile at

about 84hr. of age and beyond. It is this group of newborns who are at potential risk

for (BIND) bilirubin induced neurological damage including kernicterus. Strategies to

prevent BIND need to be practical, safe, effective and based on risk assessment55,56.

Recognizing this as a matter of public health concern the (AAP) American Academy

of Pediatrics developed a detailed consensus based practical parameter for the

management of hyperbilirubinemia in healthy term newborns and institution of

preventive phototherapy. Although effective when implemented as intended, clinical

use of the guidelines has been limited by the absence of prospective risk assessment

and dependence on visual assessment of jaundice.

Early visual recognition of jaundice and accurate estimation of its severity is

crucial for implementation of AAP guidelines. Unfortunately the presence of

excessive jaundice for age is often missed clinically, which means that the trigger for

measuring the first bilirubin level and electing subsequent AAP algorithm

recommendation is not set. This is a potentially serious problem. There is variability

in the time of appearance of jaundice from newborn – newborn and in the ability of

29
professionals to see jaundice and estimate its severity and there is considerable range

of TSB values associated with cepalocaudal progression. Additionally in most of the

recently reported healthy term newborn who developed kernicterus, significant

jaundice was almost certainly present before the first hospital discharge, judging from

the height of TSB for age in hours at readmission. Either the early icterus had not

been noted or its pathological intensity for post natal age was not appreciated. TSB

values must be excessive for age in hours in otherwise healthy term and near term

newborns to be potential risk for BIND. It is in this context of identifying such

dangerous levels are reached that universal TSB screen before discharge is

recommended as a more specific predictive vector than clinically recognized jaundice.

The practice parameter for the management of hyperbilirubinemia in the

healthy newborn published in 1994 by the AAP recommended that a serum

bilirubin be done on any neonate noted to jaundiced by visual assessment in the

first 24 hrs after birth. It also states that follow up by a health care professional

should be scheduled within 2-3 days for all neonates discharged within 48 hrs after

birth. The need for measurement of serum bilirubin at follow up is left to the

judgment of the professional providing care based on his / her visual estimation of the

severity of jaundice. Phototherapy is recommended if the TSB is rising at the rate of

6mg/dl or more/24 hrs, when the TSB reaches 18mg/dl by age 49-72 hrs, 20mg/dl

after age 72 hrs or if for any reason the newborn is not well.

Unfortunately unless the visual estimate of severity of jaundice is fairly

accurate and there is concern about its intensity, especially as related to neonate age in

hours, bilirubin levels can rise to dangerous levels before being diagnosed as

excessive and treated.

30
Rationale for universal bilirubin screening:

Bedside assessment of jaundice before discharge is part of usual hospital

routine but varies from one well baby nursery to another; visual recognition of

jaundice is inaccurate and varies with level of training of nurses, resident physicians

and attending staff.

Routine measurement of TSB before discharge would help to minimize these

practical difficulties when these levels are related to newborns post natal age. It may

more accurately define the population with higher than appropriate TSB values for

age and therefore need for closer follow up. Prediction of subsequent significant

hyperbilirubinemia may also be improved when the TSB is qualified by presence of

clinical demographic risk factors such as bruising, gestational age more than 38

weeks, breastfeeding practices, maternal diabetes and ethnicity. A TSB screen at

discharge may also identify a low risk population in whom jaundice is of minimal

toxic risk. Follow up of such babies by visual assessment by a well trained provider

may well be all that needed. Thus based on the percentile level of universally sampled

TSB for the newborns age in hours, a predictive nomogram can be developed to

provide rationale, safe and cost effective framework to facilitate the individualized

implementation of practice parameter.

Vectors to predict hyperbilirubinemia and develop a predictive nomogram:

The lab based vectors that may predict the severity of subsequent

hyperbilirubinemia include serum bilirubin and expired carbon monoxide values

measured within first 3 days of life57,58. Serum bilirubin at any age reflects the

individual / combined effects of increased bilirubin production or clearance. The later

may be a result of placental (Perinatal) or hepatic (Postnatal) excretion or caused by

enterohepatic circulation or / postnatal maturation of newborn.

31
Role of Hour Specific Bilirubin Value:

The clinical practice of reporting bilirubin on the basis of age in days was

misleading and confusing. It should be remembered that bilirubin rises by the “hours”

of life and hence the time of sampling must be as ‘hours of life’ and not ‘day of

life’59. It is no more difficult and far more accurate to report bilirubin level according

to age in hours2. This allows placement of the level in a predictive percentile tract for

hour specific bilirubin values18.

Study of Bhutani et al18:

The first report of predictive value of hour specific bilirubin was published by

Bhutani et al.

In this study, TSB levels were obtained at the time of routine metabolic screen

in all term and near term newborns.

Postnatal age (in hours) at the time of TSB measurement was recorded. A

percentile based bilirubin nomogram for the first week was constructed from hour

specific pre and post discharge TSB values of newborns.

The nomogram has following zones:

ƒ High risk zone ≥ 95th centile

ƒ Intermediate risk zone

9 Upper intermediate: 76th – 95th centile

9 Lower intermediate: 40th – 75th centile

ƒ Low risk zone < 40th centile

32
 Based on their data, the probability of subsequent hyperbilirubinemia as whole

was expressed as a ratio of 1:22 for disease/no disease. The overall risk is none in low

risk zone, nearly halved (1:45) in lower intermediate zone, tripled in upper

intermediate zone (1:7) and increased 14 fold in the high risk zone (2:3).

Outcome
Hours Significant hyper- Probability of disease
Specific Percentile Total bilirubinemia
TSB zone P A P:A Probability of LR
ratio disease
High risk > 95 104 68 104 2:3 2/5 3.08
Upper int. 76 – 95 356 46 310 1:7 1/8 3.20
Lower int. 40 – 75 556 12 544 1:45 1/46 0.48
Low risk < 40 1756 0 1756 0 0 0
Total 2840 126 2714 1:22 1/23

The appeal of nomogram lies in its simplicity, availability and cost

effectiveness. A software program has been developed for office use to record

demographic risk factors, automatically calculate age in hour for hour specific

33
bilirubin value and plot the values on the percentile curve for quick visual

interpretation. The nomogram allows each practice to define its standards for further

investigation and intervention and facilitates implementation of AAP

recommendations.

Awasthi and Rehman60 in a cohort of 275 healthy term neonates found that

by using TSB 18-24 hrs. as the prediction test approximately two third of neonates

were test negative and had about one in ten chances of readmission for treatment of

hyperbilirubinemia.

Alpay et al61 in a cohort of 500 healthy term newborns found that a serum

bilirubin measurement and the critical bilirubin level of 6mg/dl in the first 24 hrs. of

life will predict nearly all of term newborns who will have significant

hyperbilirubinemia.

Agarwal et al62 in a prospective study of neonates with gestation ≥ 35 weeks

showed that TSB level of ≤ 6mg/dl at 24 ± 6 hrs. of life predicts absence of

subsequent hyperbilirubinemia.

Early discharge and risk of hyperbilirubinemia

The approach to identification, follow up and management of jaundice in

newborn has to be changed.

The old guidelines were based on a population of babies who remained in

hospital for 3-5 days; significant jaundice was almost always identified before

discharge.

If babies leave hospital before they are 36 hrs. old, their peak bilirubin level

will occur after they are discharged. Thus jaundice today is largely OPD problem and

if we want to ensure that we do not miss the occasional baby who develops very high

34
bilirubin level we need to reconsider our approach. In the past, textbooks suggested an

evaluation for the causes of jaundice whenever serum bilirubin reached

nonphysilogical level i.e. (12-13mg/dl) or increase more than 5mg/dl/day. Today it

can be emphasized more strongly that all evaluation and interpretation of serum

bilirubin must be done with reference to baby’s age in hours not days63. For

neonates who stay less than 36 hrs. after delivery reference to a bilirubin on day 1/

day 2 is both incorrect and misleading. It must be recognized that 25 hours and 47

hours would both be 2nd day, but the risk for encephalopathy for same levels of serum

bilirubin would be much higher for the earlier hours. This significance would be

missed if the ‘day of life’ were to be the criterion.

This is illustrated as follows: where serum bilirubin level of 8mg/dl in a baby

on day 2 leads to entirely different responses depending upon whether the baby is

21.4 or 30 or 47.58 hrs old.

Day Hours Bilirubin Percentile Response

2 24.1 8 95 Evaluate & follow

2 30.0 8 80 Follow

2 47.9 8 50 Normal

The data of Bhutani et al47 show that a bilirubin of 8mg/dl at age 24 hrs. is at

the 95th centile and requires an evaluation for the presence of hemolysis (blood type,

coomb’s test) and close follow up. A level of 8 mg/dl at 30 hrs. is at 80th centile and

requires no investigations but baby should be followed because subsequent course is

not entirely predictable. The same level at 48 hrs. in otherwise healthy neonate is at

50th centile and requires no further intervention.

35
Who needs watching and who needs evaluation:

Assuming that most babies leave the hospital within 24-36 hrs. of delivery;

how do we identify those who are (or are not) at the risk of developing significant

jaundice and if we can not do it with reasonable degree of certainty how can we avoid

missing the rare baby who develops a very high bilirubin level. The obstetrics and

neonatal factors that are known to increase risk of non-hemolytic jaundice are:

9 Maternal diabetes mellitus

9 Previous jaundiced sibling

9 East Asian

9 Decreasing gestation

9 Oxytocin

9 Male sex

9 Breast feeding

9 G-6 PD deficiency

Unfortunately these risk factors are so common that their usefulness as

predictors of significant hyperbilirubinemia is limited. Although we lack precise

predictive value, neonates who have several of these risk factors are much more likely

to develop significant hyperbilirubinemia than those who have none of them.

Sokolne et al64 and other various studies have shown that discharge at any

time less than 72 hrs. significantly increases the risk for readmission with increased

bilirubin when compared with discharge after 72 hrs. It is not clear why babies

discharged early should be at greater risk for developing hyperbilirubinemia than

those discharged later, unless some intervention occur in the later group that affects

their subsequent bilirubin levels. Perhaps mothers who have more time to receive

counseling from nursing staff and in particular lactation counseling during their

36
hospital stay nurse their babies more effectively. There is evidence that more frequent

and effective lactation as well as improved caloric intake decrease the likelihood of

hyperbilirubinemia25,26. There is also evidence that early discharge might affect the

ability of the mother to assimilate and process information that they receive regarding

lactation and infant care.

Eidelman et al65 showed that women on first post partum day scored

significantly lower than non pregnant women on standardized tests of cognitive

function. These mothers leaving the hospital within 36 hrs. might not be able reliably

to integrate information given to them by caregivers and this could have an impact on

newborn’s well being in the next several days. Some mothers who have good support

systems at home may choose to be discharged within 24 hrs. given the choice;

however most would probably elect an extra day /or two in the hospital.

37
 Historical Overview

• Bile: from latin bilis (“bile”), but the latin probably had Celtic origins

(bistilis)

• Bilirubin and biliverdin: simply “red bile” and “green bile”, Latinized.

• Icterus: from Greek ikteros, meaning “yellow colored”, a word applied to a

yellow bird as well.

• Jaundice: from Old French jaundice, a word rooted in the Latin gabinus,

meaning “greenish yellow”, from galbus (“yellow”)

9 Orth, (1875) were the first to observe and describe the relation between the

clinical encephalopathy and the gross pathological changes seen as yellow

staining of specific areas of the central nervous system.

9 Schorml, (1904) coined the term kernicterus for focal pigmentation in

degenerated zones of the brain (kern, “nucleus” or “ganglion”, and ikterus,

“yellow”)

9 Beneke, (1907) was the first to suggest that septicemia might play an

important role in icterus gravis neonatorum.

9 Guthrie, (1913); Spiller, (1915) described jaundice as the casual agent in

children who survived severe neonatal jaundice with resultant mental

retardation and neuro muscular dysfunction.

9 Van den Bergh & Muller, (1916) observed that serum from patients with

hemolytic jaundice could be differentiated from serum of patients with

obstructive jaundice on the basis of chemical reactions.

38
9 Van den Bergh & Muller, (1916) termed these reactions “indirect” and

“direct” which have come to be recognized as unconjugated and conjugated

bilirubin respectively.

9 Hart, (1925) reported the first successful exchange transfusion.

9 Diamond et al, (1932) coined the term erythroblastosis fetalis.

9 Levine & Stetson, (1939) demonstrated the serologic basis for maternal fetal

blood group incompatibility.

9 Land Steiner & Weiner, (1940) identified the Rh system of antigens.

9 Diamond et al, (1946) introduced the technique of alternate removal and

administration of blood for each transfusion via umbilical vein catheterization.

9 Crigler & Najjar, (1952) found kernicterus as a process related more to

elevated unconjugated bilirubin levels than to specific blood group

incompatibilities or even hemolysis.

9 Hsia et al, (1952) concluded “kernicterus is likely to occur in babies with

serum bilirubin above 30mg/100 cc and unlikely to occur when serum

bilirubin remains below 20mg/100 cc.

9 Sister J. Ward’s, (1956) interesting observation at Rockford General

Hospital, Essex, England led to the concept of ‘phototherapy’ for jaundiced

babies.

9 RJ Cremer & RH Dobbs, (1956) established that bilirubin was in some way

affected by direct exposure and it was not ultraviolet but visible blue light that

was most effective; secondly it was only unconjugated bilirubin that was

affected.

9 Cremer et al, (1958) first proposed phototherapy for neonatal

hyperbilirubinemia.

39
9 Cremer, Perryman & Richards, (1958) explained the effect of light on

bilirubin as photo oxidation or dehydrogenation to intermediate products

which are more easily excretable than bilirubin.

9 Kramer, (1969) suggested visual assessment of STB levels which relies on

the cephalo caudal progression of jaundice with a rising STB level.

9 Speck & Rosenkranz, (1976) showed irradiation of cell with light intensity

similar to those used in phototherapy can produce DNA damage.

9 Hardy et al (1979) showed that neurodevelopment during the first year of life

was correlated with maximal STB concentration soon after birth.

9 Wennberg et al, (1982) & Nwaesei et al (1984) showed that BAER testing

could be used to screen hyperbilirubinemic full term and premature infants for

sensorineural hearing loss.

9 Granati et al, (1984); Teberg et al (1977) reported no changes in growth

development or infant behavior in long term follow up studies of infants who

received phototherapy.

9 Costarino et al, (1985) showed phototherapy as the most common treatment

for neonatal hyperbilirubinemia.

9 Lester, (1987) measured cry characteristics in newborns with elevated STB

levels.

9 Mc Donagh & Lightner, (1988) showed the production of configurational

isomers (changes in shape of bilirubin molecule & not its structure) as a result

of phototherapy.

9 Palmer & Smith, (1990) proposed Nuclear Magnetic Resonance (NMR)

techniques as a rapid, non invasive measure of impending or actual brain cell

injury in the face of hyperbilirubinemia.

40
9 Seidman et al, (1991) revealed an association between severe

hyperbilirubinemia and low intelligence quotient (IQ) in boys.

9 Penn et al, (1994); Martich-Kriss et al (1995) studied the conventional

images in brain after exposure to extreme hyperbilirubinemia.

9 Gartner, (1994) suggested breast feeding need not be routinely interrupted

solely for the purpose of establishing a diagnosis of breast milk or breast

feeding jaundice.

9 Garg et al, (1995) proved high intensive phototherapy to be significantly

more effective at reducing bilirubin levels than conventional phototherapy.

9 Johnson & Brown, (1991) reviewed the incidence of kernicterus and

attributed the increase in incidence partly to shorter hospital stays, decreased

vigilance in diagnosing jaundice and an altered physician perception of the

toxicity of bilirubin.

9 Johnson & coworkers, (1999) developed the scoring system to assess the

severity of the neurological sequel associated with excessive

hyperbilirubinemia.

9 Bhutani et al, (1999) found the practice of reporting the STB level on basis of

age in days rather than hours to be misleading and ineffective at accurate

prediction of infants at risk for severe hyperbilirubinemia.

9 Bhutani et al, (1999) generated the percentile based bilirubin nomogram

using hour specific pre discharge STB levels.

9 Dennery et al, (2001); Garg et al, (1995) showed conventional phototherapy

involves exposing a maximal area of skin to an irradiance of 6 to

12µW/cm2/nm.

41
9 Stevenson et al, (2001) showed that ETCOc measurement at 30 ± 6 hours in

combination with an STB measurement did not improve the predictive ability

of the hours of age specific TSB.

42
 MATERIAL & METHODS

I. Study design.

The present study is a hospital based prospective study undertaken to

determine the bilirubin levels at birth and the goal of our study was to

determine predictive ability of hour specific bilirubin (at 22 hrs. to 26 hrs.) for

subsequent hyperbilirubinemia in healthy term neonates.

II. Sample size.

Total of 250 healthy term newborns delivered at Shri B M Patil Medical

College teaching hospital, Bijapur were included with birth weight ≥ 2500

grams.

III. Setting.

The study, approved by ethical committee, was undertaken in the postnatal

care ward in a tertiary level teaching hospital with NICU facility of Shri B M

Patil Medical College, Bijapur, Karnataka.

IV. Period of study.

The study covered a period of one year & two months from February 2005 to

January 2006 as per following schedule:

a) Data collection: February 2005 – January 2006 (12 Months).

b) Data analysis and write up of report: February and March 2006.

V. Selection of study subjects.

The study subjects comprised of 250 healthy term newborns delivered during

the study period.

Exclusion Criteria:

¾ Preterm (28-34weeks) and Post term (≥ 42weeks) neonates.

¾ Rh Incompatibility

43
 ¾ ABO Incompatibility

¾ Newborns with obvious life threatening congenital malformation

[Tracheo esophageal fistula (TOF), Anorectal malformation]

¾ Admission / treatment in NICU for neonatal illness.

¾ NICU admission > 12 hours.

¾ Babies with birth asphyxia (APGAR < 5 at 5 minutes or requiring

intubation lasting for more than 4mins.)

¾ History of intake of drugs in mother affecting fetal liver e.g.

Sulphonamides, Nitrofurantion, Antimalarials.

VI. Methodology.

The Study group was evaluated by a designed protocol.

In all newborns detailed history, gestational assessment by Expanded Ballard

score, systemic general examination with particular attention to the factors

known to be associated with hyperbilirubinemia was carried out.

History:

• Maternal (Antenatal history)

9 Parity (Primi, 2nd/3rd, Multi)

9 Antenatal registration

• H/o maternal illness in pregnancy/ high risk factors namely

9 Pregnancy induced hypertension

9 Bad obstetric history

9 Premature rupture of membranes > 18 hours

9 Medical disease in pregnancy (Heart disease, Diabetes mellitus)

9 Others (Anemia, CPD)

• HIV / HBsAg status of mother

44
 • Blood group with Rh factor

• H/o Jaundice in previous sibling

• Type of delivery:

9 Full term normal delivery

9 Instrumentation – forceps/vacuum

9 LSCS (Lower segment cesarean section)

• Neonatal examination:

9 Birth weight / Sex

9 Gestational age

9 Blood group / DCT (in relevant case)

9 Frequency of breast feeding and time of initiation of breast

feeding

9 The time of passing meconium

VII. Laboratory evaluation (Bilirubin estimation).

Serum bilirubin estimation was done using monoreagent “Jendrassic and

Grof”66,67 method. Whole blood was taken in micro-capillary and centrifuged

at the rate of 3000 rpm for 5 minutes. Bilirubin estimation was done

spectrophotometrically using the wavelength (530-560nm) and Bichromatic

wavelength used is 540nm. (Bil Micrometer – Semi Auto Analyser, RA-50

Chemistry System, Bayer Production, Japan).

Principle:

Total bilirubin in the sample reacts with diazotized sulphanilic acid in the

presence of caffeine.

Direct bilirubin reacts in acid environment with diazotized sulphanilic acid.

The formed colored azobilirubin is measured photometrically at 570nm.

45
¾ Cord bilirubin levels were estimated soon after delivery by above method.

¾ 1st Bilirubin estimation (TSB 1)

TSB was estimated at 22 – 26 hrs by above method.

¾ The neonates were followed up clinically every 12 hrs for 72hrs (till

discharge)

¾ 2nd Bilirubin estimation (TSB S) was done whenever clinical suspicion of

jaundice was present.

¾ Primary outcome was defined as presence of hyperbilirubinemia

(TSB ≥ 15mg/dl)

Depending upon the first TSB (TSB1) value the newborns were classified into

two groups using two available protocols.

¾ Protocol 1: Using cut off value of 5mg/dl62

9 Group 1: Serum bilirubin level more than 5mg/dl.

9 Group 2: Serum bilirubin level less than 5 mg/dl.

¾ Protocol 2: Using average value of 4.06mg%60

9 Group 1: Neonates with bilirubin level more than 4.06mg%

9 Group 2: Neonates with bilirubin level less than 4.06mg%

Additionally newborns were also divided in three risk zones according to

study done by Bhutani et al18.

46
 • High risk zone

Bilirubin level above 95th centile.

• Intermediate risk zone

Bilirubin level between 40th to 95th centile

• Low risk zone

Bilirubin level less than 40th centile.

9 Blood group and DCT was done in children of O +ve mothers

9 Newborns of Rh -ve mother if they were also Rh -ve or had no

evidence of hemolysis were included in the study

9 Neonates who developed direct hyperbilirubinemia, features

suggestive of sepsis, respiratory distress were excluded from the study

9 Phototherapy was started for newborns with significant

hyperbilirubinemia (> 15mg/dl)

VIII. Statistical Analysis

Maternal and neonatal data were collected in predesigned and pretested

proforma. Sensitivity, specificity, negative and positive predictive values and

likelihood ratio of the test were calculated. For determining significance of

each test p value was used. Bilirubin values were plotted on previously

published nomograms18.

47
 CASE PROFORMA

Sl. No.: IP No. : DOA: DOD:

Name :

Address :

Date and time of delivery :

Sex of the infant : Gestational age :

Wt. Of the infant :

Antenatal Factors

Age :

Parity :

High Risk Factors :

Past h/o Jaundice in other children :

H/o intake of Drugs :

Hbs Ag :

HIV :

Blood Group :

Intranatal Factors

Type of Delivery

FTND

LSCS Elective Emergency

Instrumentation Vacuum Forceps

Oxytocin

CIAB (Cried Immediately After Birth)

Cord Clamping

48
Blood Group

DCT

Postnatal Factors

F/s/o illness in the Neonate :

Frequency of feeding :

Meconium passed at :

Frequency of stools :

Investigations

Hb % PCV

Bilirubin at Birth :

(Cord Blood)

Bilirubin at 24 hrs. :

(Venous Blood)

Icterus at 48-72 hrs :

Bilirubin at 72 hrs :

(Venous Blood)

49
 OBSERVATION AND RESULTS

Total 250 healthy term newborns were evaluated.

The baseline characteristics of mothers and newborns were noted.

(N = 250)

Characteristics No. (%)

Maternal
Type of delivery
Full term normal vaginal delivery (FTND) 180 (72)
Cesarean 62 (24.8)
Instrumentation 8 (3.2)
Parity
1 95 (38)
2 81 (32.4)
3 44 (17.6)
≥4 30 (12)
Oxytocin use 100 (40)
Rupture of membranes (≥ 18 hrs) 19 (7.6)
Bad obstetric history 15 (6)
Pregnancy induced hypertension 9 (3.6)
Gestation # (Mean) 38 ± 1.4 (range 37-42)
Blood group
A 78 (31.2)
B 87 (34.8)
AB 17 (6.8)
O 68 (27.2)
Neonatal
Sex
Males 122 (48.8)
Females 128 (51.2)
Birth weight (gm)/# (Mean) 2950 ± 430 (range 2500-3800)
H/o Icterus in previous sibling 5 (2)

50
 Birth Weight Distribution

100 2500-3000
90
69.6
80 3001-3500
70

60 > 3501
Percent 50

40 24.8
30

20 5.6

10

0
2500-3000 3001-3500 > 3501
Birth Weight (in grams)

51
 Table – I

Birth Weight Distribution of Study Population

Weight (in grams) Number of newborns Percent

2500-3000 174 69.6

3001-3500 62 24.8

> 3501 14 5.6

Total 250 100

♦ Maximum newborns (69.9%) had birth weight between 2.5 to 3.0 Kg.

♦ Only 14 (5.6%) newborns had birth weight more than 3.5 Kg.

52
 Sex Distribution

Male
49%

Female
51%

Type of Delivery

FTND
72%

LSCS
Forceps 25%
3%

53
 Table – II

Sex Ratio

Sex Number of newborns Percent

Male 122 48.8

Female 128 51.2

Total 250 100

( Among 250 newborns enrolled, 51.2% of the babies were females and 48.8%

were males with a ratio of 1.05:1.

Table – III

Distribution of Study Population acc. to Type of Delivery

Type of delivery Number of newborns Percent

FTND 180 72.0

LSCS 62 24.8

Forceps 8 3.2

Total 250 100

♦ Oxytocin was used in 40% subjects and solely for augmentation of labor.

♦ Maximum number of women i.e. 180/250 had full term normal delivery.

♦ 62 women required Cesarean section and main indication for it was CPD.

♦ Only 8 women required some instrumentation in the form of forceps.

54
 50 Antenatal Risk Factors 45

40

No. 30
of
Mothers 19
18
20 15

9
10
2
1

0
ROM ≥ BOH PIH Heart Diabetes Others CPD
18hrs Disease Mellitus (Anemia)

Risk Factors

55
 Table – IV
Distribution of High Risk Antenatal Factors

Antenatal factors Number of mothers Percent

ROM ≥ 18hrs 19 7.6

BOH 15 6.0

PIH 9 3.6

Heart Disease 2 0.8

Diabetes Mellitus 1 0.4

Others (Anemia) 45 18

CPD 18 7.2

Total 109 43.6

• Anemia (45 women) was the most common high risk factor associated with

pregnancy.

• Rupture of membranes (≥ 18hrs.) was the second most common high risk

factor associated with pregnancy.

• CPD was present in 18 women.

• Only 1 mother had diabetes mellitus.

( All newborns were exclusively breast fed.

( Meconium was passed by all newborns within 24 hours of life.

56
 Blood Group Distribution
B
32%

A
28% AB
30%
O
10%

Rhesus Group Distribution

Positive
94%

Negative
6%

57
 Table – V

Blood group Distribution of Study Population

Blood group Number of newborns Percent

A 69 27.6

B 83 33.2

AB 74 29.6

O 24 9.6

Total 250 100

• “B” blood group was the most common (83 newborns) blood group.

• Only (24 newborns) had “O” blood group.

Table – VІ

Rhesus group Distribution of Study Population

Rhesus group Number of newborns Percent

Positive 236 94.4

Negative 14 5.6

Total 250 100

ƒ Maximum newborns i.e. 236/250 had Rh positive group.

ƒ Only 14 newborns born to Rh negative mothers and who were Rh negative are

included in the study.

9 Cord blood Bilirubin level was estimated soon after delivery.

9 The first serum Bilirubin level (TSB 1) was estimated at 22-26 hours of life.

58
 Gestational Age Distribution

150
132
140

130

120

110

100 88

90
No.
of 80
Newborns 70

60

50

40 27
30

20
3
10

0
36-37 38-39 40-41 ≥ 42
Weeks

59
 Table – VII

Gestational Age Distribution of Study population

Gestational age Number of newborns Percent

(weeks)

36-37 88 35.2

38-39 132 52.8

40-41 27 10.8

≥ 42 3 1.2

Total 250 100

9 Majority (52.8%) babies had gestational age of 38-39 weeks.

9 Only 3 (1.2%) newborns had gestational age of 42 weeks.

60
 Birth Weight & Gestational Age

100 92
Birth weight (grams) 2500-3000
90

80
Birth weight (grams) 3001-3500
67
70 Birth weight (grams) > 3501

60
No.
of 50
Newborns
33
40

30 19
15
20 9
7
2 3 2
10 0 1

0
36-37 38-39 40-41 ≥ 42
Gestational Age in Weeks

61
 Table - VIII

Distribution of Birth weight range 2500-3000 (grams) acc. to Gestational age

Gestational age (weeks) Number Percent

36-37 67 38.5
38-39 92 52.87
40-41 15 8.62
≥ 42 – –
Total 174 100
Ž Majority of newborns 92/174 (52.87%) had gestational age of 38-39 weeks.
Ž No baby had gestational age of 42 weeks.

Table - IX

Distribution of Birth weight range 3001-3500 (grams) acc. to Gestational age

Gestational age (weeks) Number Percent

36-37 19 30.64
38-39 33 53.22
40-41 9 14.51
≥ 42 1 1.61
Total 62 100
Ž Maximum number of newborns 33/62 (53.22%) had gestational age of 38-39 weeks.
Ž Only 1 baby had gestational age of 42 weeks.

Table - X

Distribution of Birth weight range ≥ 3501 (grams) acc. to Gestational age

Gestational age (weeks) Number Percent

36-37 2 14.28
38-39 7 50
40-41 3 21.42
≥ 42 2 14.28
Total 14 100
Ž Majority (50%) newborns had gestational age of 38-39 weeks.
Ž Only 2 babies had gestational age of 42 weeks.

62
 Cord Bilirubin levels

250

200

No. 150
115
of
Newborns 90
100

35
50
7 3

0
0.5-0.9 1.0-1.4 1.5-1.9 2.0-2.4 > 2.5
Bilirubin levels (mg/dl)

63
 Table –XI
Cord Bilirubin levels (0 hrs)
Cord Bilirubin (mg/dl) Number of newborns Percent

0.5-0.9 7 2.8

1.0-1.4 115 46

1.5-1.9 90 36

2.0-2.4 35 14

> 2.5 3 1.2

Total 250 100

( Majority (46%) of the newborns had cord bilirubin level of 1.0-1.4 mg/dl.

( 90 (36%) newborns had cord bilirubin level between 1.5-1.9 mg/dl.

( 35 (14%) newborns had cord bilirubin level between 2.0-2.4 mg/dl.

( Only 3 (1.2%) newborns had cord bilirubin level > 2.5 mg/dl.

( The range of cord bilirubin was 0.5-2.8 mg/dl.

64
 Cord bilirubin distribution acc. to birth weight

Birth weight (grams) 2500-3000

100

90
Birth weight (grams) 3001-3500
80

70
58.06 Birth weight (grams) > 3501
57.14
60
Percent
50
40.22 38.50
35.48
40

30
17.81
14.28 14.28 14.28
20

2.29
10 1.61 3.22 1.14 1.61 0.00

0
0.5-0.9 1.0-1.4 1.5-1.9 2.0-2.4 > 2.5

Cord bilirubin (mg/dl)

65
 Table – XII

Distribution of Cord bilirubin levels in the Birth weight range 2500-3000 (grams)

Cord bilirubin (mg/dl) Number Percent

0.5-0.9 4 2.29
1.0-1.4 70 40.22
1.5-1.9 67 38.50
2.0-2.4 31 17.81
≥ 2.5 2 1.14
Total 174 100

9 Majority (40.22%) newborns had cord bilirubin levels between 1.0-1.4 mg/dl.

9 31 (17.81%) newborns had cord bilirubin levels between 2.0-2.4 mg/dl.

9 Only 2 (1.14%) babies had cord bilirubin level ≥ 2.5 mg/dl.

Table – XIII

Distribution of Cord bilirubin levels in the Birth weight range 3001-3500 (grams)

Cord bilirubin (mg/dl) Number Percent

0.5-0.9 1 1.61
1.0-1.4 36 58.06
1.5-1.9 22 35.48
2.0-2.4 2 3.22
≥ 2.5 1 1.61
Total 62 100

9 Majority (58.06%) newborns had cord bilirubin levels between 1.0-1.4mg/dl.

9 2 (3.22%) newborns had cord bilirubin levels between 2.0-2.4 mg/dl.

9 Only 1 (1.61%) baby had cord bilirubin level ≥ 2.5 mg/dl.

66
 Table – XIV

Distribution of Cord bilirubin levels in the Birth weight range ≥ 3501 (grams)

Cord bilirubin (mg/dl) Number Percent

0.5-0.9 2 14.28
1.0-1.4 8 57.14
1.5-1.9 2 14.28
2.0-2.4 2 14.28
≥ 2.5 – –
Total 14 100

9 Majority (57.14%) newborns had cord bilirubin levels between 1.0-1.4 mg/dl.

9 No baby had cord bilirubin level ≥ 2.5 mg/dl.

67
 TSB 1 levels at 22-26 hours
100

90 81
78
80

70

No. 60
of
Newborns 50
38
40 32

30

20 12
5
10 1

0
1.0-1.9 2.0-2.9 3.0-3.9 4.0-4.9 5.0-5.9 6.0-6.9 7.0-7.9

Bilirubin level (mg/dl)

68
 Table – XV
Bilirubin level (TSB 1) at 22-26 hours

Bilirubin level Number of newborns Percent

(mg/dl)

1.0-1.9 5 2

2.0-2.9 38 15.2

3.0-3.9 78 31.2

4.0-4.9 81 32.4

5.0-5.9 32 12.8

6.0-6.9 12 4.8

7.0-7.9 1 0.4

8.0-8.9 3 1.2

Total 250 100

• Majority (80.8%) of the newborns had first serum bilirubin level ≤ 4.9 mg/dl

(Corresponding to the low risk zone)

• 45 (18%) newborns had their level between 5.0-7.9 mg/dl

(Corresponding to intermediate risk zone)

• Only 3 (1.2%) newborns had serum bilirubin level between 8.0-8.9 mg/dl

(Corresponding to high risk zone)

• The range of bilirubin value at 24 hours was 1.4-8.8 mg/dl.

• The average bilirubin value was 4.06 mg/dl.

69
 TSB I levels and birth weight
70

59
60
53

Birth weight (grams) 2500-3000

50

No. Birth weight (grams) 3001-3500

of 40
Newborns Birth weight (grams) > 3501
30
24
22
21
20 17

10 10 10
10 6
4
2 1 1 1 2 1
1 0 0 0
0
1.0-1.9 2.0-2.9 3.0-3.9 4.0-4.9 5.0-5.9 6.0-6.9 7.0-7.9

Bilirubin level (mg/dl)

70
 Table – XVI
Distribution of TSB 1 levels in the Birth weight range 2500-3000 (grams)
Bilirubin level (mg/dl) Number Percent
1.0-1.9 4 2.29
2.0-2.9 24 13.79
3.0-3.9 59 33.90
4.0-4.9 53 30.45
5.0-5.9 21 12.06
6.0-6.9 10 5.74
7.0-7.9 1 0.57
8.0-8.9 2 1.14
Total 174 100
Ž Majority (80.45%) newborns had 24 hour serum bilirubin level in the Low risk zone
(≤ 4.9 mg/dl).
Ž 32 (18.39%) newborns had 24 hour serum bilirubin level in the Intermediate risk
zone (5.0-7.9 mg/dl).
Ž Only 2 (1.14%) newborns were in the High risk zone (≥ 8.0 mg/dl).

Table – XVII
Distribution of TSB 1 levels in the Birth weight range 3001-3500 (grams)
Bilirubin level (mg/dl) Number Percent
1.0-1.9 1 1.61
2.0-2.9 10 16.12
3.0-3.9 17 27.41
4.0-4.9 22 35.48
5.0-5.9 10 16.12
6.0-6.9 1 1.61
7.0-7.9 – –
8.0-8.9 1 1.61
Total 62 100
Ž Majority (80.64%) newborns had 24 hour serum bilirubin level in the Low risk zone
(≤ 4.9 mg/dl).
Ž 11 (17.74%) newborns had 24 hour serum bilirubin level in the Intermediate risk
zone (5.0-7.9 mg/dl).
Ž Only 1 (1.61%) newborn was in the High risk zone (≥ 8.0 mg/dl).

71
 Table – XVIII
Distribution of TSB 1 levels in the Birth weight range ≥ 3501 (grams)
Bilirubin level (mg/dl) Number Percent

1.0-1.9 – –
2.0-2.9 4 28.57
3.0-3.9 2 14.28
4.0-4.9 6 42.85
5.0-5.9 1 7.14
6.0-6.9 1 7.14
7.0-7.9 – –
8.0-8.9 – –
Total 14 100

Ž Majority (85.71%) newborns had 24 hour serum bilirubin level in the Low risk zone
(≤ 4.9 mg/dl).
Ž Only 2 (14.28%) newborns had 24 hour serum bilirubin level in the Intermediate
risk zone (5.0-7.9 mg/dl).
Ž No newborn was in the High risk zone (≥ 8.0 mg/dl).

72
 TSB I levels and Gestational Age
50
47

45 Gestational age (weeks) 36-37

40 Gestational age (weeks) 38-39
40
Gestational age (weeks) 40-41
35 32
Gestational age (weeks) ≥ 42
No.
of 30 27

Newborns 23
25
19
20

15
9 9
10
6 6
5 5
4 3
5 2 3 2
1 2 1 1 1 1
0 0 0 1 0 0
0 0 0
0
1.0-1.9 2.0-2.9 3.0-3.9 4.0-4.9 5.0-5.9 6.0-6.9 7.0-7.9 8.0-8.9

Bilirubin Levels (mg/dl)

73
 Table –XIX
Distribution of TSB 1 level in the Gestational age of 36-37 weeks
Bilirubin level (mg/dl) Number Percent
1.0-1.9 2 2.38
2.0-2.9 9 10.71
3.0-3.9 32 38.09
4.0-4.9 27 32.14
5.0-5.9 9 10.71
6.0-6.9 3 3.57
7.0-7.9 1 1.19
8.0-8.9 1 1.19
Total 84 100

Ž Majority (83.33%) newborns had 24 hour serum bilirubin level in the Low risk zone
(≤ 4.9 mg/dl).
Ž 13 (15.47%) newborns had 24 hour serum bilirubin level in the Intermediate risk
zone (5.0-7.9 mg/dl).
Ž Only 1 (1.19%) newborns were in the High risk zone (≥ 8.0 mg/dl).

Table – XX
Distribution of TSB 1 level in the Gestational age of 38-39 weeks
Bilirubin level (mg/dl) Number Percent
1.0-1.9 1 0.72
2.0-2.9 23 16.66
3.0-3.9 40 28.98
4.0-4.9 47 34.05
5.0-5.9 19 13.76
6.0-6.9 6 4.34
7.0-7.9 – –
8.0-8.9 2 1.44
Total 138 100

Ž Majority (80.43%) newborns had 24 hour serum bilirubin level in the Low risk zone
(≤ 4.9 mg/dl).
Ž 25 (18.11%) newborns had 24 hour serum bilirubin level in the Intermediate risk
zone (5.0-7.9 mg/dl).
Ž Only 2 (1.45%) newborns were in the High risk zone (≥ 8.0 mg/dl).

74
 Table – XXI
Distribution of TSB 1 level in the Gestational age of 40-41 weeks
Bilirubin level (mg/dl) Number Percent
1.0-1.9 2 8
2.0-2.9 5 20
3.0-3.9 5 20
4.0-4.9 6 24
5.0-5.9 4 16
6.0-6.9 3 12
7.0-7.9 – –
8.0-8.9 – –
Total 25 100

Ž Majority (72%) newborns had 24 hour serum bilirubin level in the Low risk zone
(≤ 4.9 mg/dl).
Ž Only 7 (28%) newborns had 24 hour serum bilirubin level in the Intermediate risk
zone (5.0-7.9 mg/dl).
Ž No newborn was in the High risk zone (≥ 8.0 mg/dl).

Table – XXII
Distribution of TSB 1 level in the Gestational age of ≥ 42 weeks
Bilirubin level (mg/dl) Number Percent
1.0-1.9 – –
2.0-2.9 1 33.33
3.0-3.9 1 33.33
4.0-4.9 1 33.33
5.0-5.9 – –
6.0-6.9 – –
7.0-7.9 – –
8.0-8.9 – –
Total 3 100

Ž All (100%) newborns were in the Low risk zone (≤ 4.9 mg/dl).

75
 Distribution on the basis of
cut off value of 5 mg/dl
≤ 5.0

84% > 5.1

16%

Distribution on the basis of

average value of 4.06 mg/dl
< 4.06
> 4.06
55%

45%

76
 Table – XXIII

Protocol 1

Distribution of Newborns on the basis of Arbitrary Cut-off Value of

5 mg%62

Bilirubin value Number of newborns Percent

(mg %)

≤ 5.0 211 84.4

> 5.1 39 15.6

Total 250 100

♦ Maximum number of newborns 211/250 had their Bilirubin level ≤ 5 mg/dl.

Table – XXIV

Protocol 2

Distribution of Newborns on the basis of Average Bilirubin value of 4.06 mg%60

Average Bilirubin value Number of newborns Percent

(mg %)

< 4.06 138 55.2

> 4.06 112 44.8

Total 250 100

9 The Average value of 4.06 corresponds to low risk zone of the nomogram.

77
 Risk Stratification
Low risk (< 40th centile)
Intermediate risk (40-75th centile)
81% High Risk (> 95th centile)

1% 18%

78
 Table – XXV
Risk Stratification of the Study Population

Bhutani et al Our study Percent

Risk zone Number of newborns

Low risk (< 40th centile) 202 80.8

Intermediate risk 45 18.0

(40-95th centile)

High Risk (> 95th centile) 3 1.2

Total 250 100

• Subsequent Bilirubin estimation was done when there was clinical suspicion

of jaundice.

• The subsequent Bilirubin level of newborns in each risk category was as

follows:

79
 Subsequent Risk Categorization
at 72 hrs
191
200
Low risk zone < 40th centile
180
Intermediate risk zone 40th -
160 95th centile
140 High risk zone > 95th centile

120
No.
of 100
Newborns
80
60
40
15 12
10 8 10
20 0 0 1 0 0 3

0
Low risk Low intermediate High intermediate High risk

Risk Zone

Low risk zone < 40th centile

Low risk
Low intermediate
High intermediate
95% High risk

0%

0% 5%

80
 Table – XXVI
Subsequent Risk Categorization of the Study Population

22-26 hours Subsequent risk categorization at 72 hours (TSB S)

Risk zone No. of Low risk Low High High

newborns intermediate intermediate risk

Low risk zone

< 40th centile 202 191 10 – –

Intermediate risk zone

40th -95th centile 45 15 8 12 10

High risk zone

> 95th centile 3 – – – 3

Total 250 205 19 13 13

( Total 13 newborns developed significant hyperbilirubinemia.

( Newborns that developed significant hyperbilirubinemia were subjected to

phototherapy.

Table – XXVII
Subsequent Risk Categorization of Low risk zone
22-26 hours Subsequent risk categorization at 72 hours (TSB S)
Risk zone No. of Low risk Low High High risk
newborns intermediate intermediate
Low risk
zone 202 191 10 0 0
th
< 40 centile

( No newborn belonging to low risk developed significant hyperbilirubinemia.

81
 Intermediate risk zone
40th -95th centile
Low risk
Low intermediate
High intermediate
High risk
22%
33%

27%
18%

High risk zone > 95th centile

Low risk
Low intermediate
High intermediate
High risk

82
 Table – XXVIII
Subsequent Risk Categorization of Intermediate risk zone
22-26 hours Subsequent risk categorization at 72 hours (TSB S)
Risk zone No. of Low risk Low High High risk
newborns intermediate intermediate
Intermediate
risk zone 45 15 8 12 10
40th -95th
centile

( 15/44 newborns belonging to intermediate risk zone remained in low risk zone.

( 8/44 newborns in the intermediate risk zone went up to low intermediate risk zone.

( 12/44 newborns in the intermediate risk zone went up to high intermediate risk

zone.

( 10/44 newborns belonging to intermediate risk zone went into high risk zone.

Table – XXIX
Subsequent Risk Categorization of High risk zone

22-26 hours Subsequent risk categorization at 72 hours (TSB S)

Risk zone Number of Low risk Low High High risk
newborns intermediate intermediate
High risk
zone 3 0 0 0 3
th
> 95 centile

( All of the 3 newborns belonging to high risk zone remained in high risk

zone.

83
 Table – XXX
Characteristics of Newborns who developed Significant Hyperbilirubinemia

No. Parity High Blood Type of Birth Sex GA Cord TSB 1 Risk zone TSB S Duration
of risk group delivery wt. (weeks) Bilirubin 24 ± 2 72 of photo
mother factor of (kg) (mg/dl) hours. hours therapy
mother (mg/dl) (mg/dl) (hours)

1 2nd Anemia B+ FTND 3.1 M 39 1.0 5.0 Intermediate 17.6 18

2 Primi None O+ LSCS 2.7 F 37 0.8 7.2 Intermediate 17.2 22

3 Multi ROM A+ LSCS 2.6 F 40 1.0 6.7 Intermediate 16.9 10

4 Multi None A+ FTND 3.3 M 38 1.2 5.5 Intermediate 16.2 16

5 2nd None O+ FTND 2.7 M 37 2.0 6.5 Intermediate 18.2 46

6 Primi BOH O+ LSCS 2.9 F 39 2.0 6.0 Intermediate 18.4 48

7 Primi None AB + FTND 2.5 M 37 1.8 8.8 High 17.5 30

8 2nd None B+ FTND 2.8 F 38 2.1 6.8 Intermediate 16.9 14

9 2nd PIH O+ LSCS 3.2 F 39 2.3 8.7 High 19.3 54

nd
10 2 ROM B+ Forceps 2.9 M 39 2.1 8.8 High 19.0 48

11 Primi None O+ LSCS 3.3 M 40 2.8 6.8 Intermediate 17.0 12

12 Primi ROM A+ LSCS 2.6 M 38 1.7 5.0 Intermediate 16.2 18

13 Primi None O+ FTND 2.6 F 38 2.2 5.3 Intermediate 18.1 44

ƒ All newborns were exclusively breast fed stating within 2 hours of birth.

ƒ No baby required Exchange transfusion.

ƒ No newborn developed Kernicterus.

84
 Table – XXXI
Distribution of Parity & High Risk Factors in Newborns with Significant
Hyperbilirubinemia
Sl. Parity High risk Cord bilirubin TSB 1 24 ± 2 hours TSB S 72 hours

No. factor (mg/dl) (mg/dl) (mg/dl)

1 2nd Anemia 1.0 5.0 17.6

2 Primi None 0.8 7.2 17.2
3 Multi ROM 1.0 6.7 16.9
4 Multi None 1.2 5.5 16.2
5 2nd None 2.0 6.5 18.2
6 Primi BOH 2.0 6.0 18.4
7 Primi None 1.8 8.8 17.5
nd
8 2 None 2.1 6.8 16.9
9 2nd PIH 2.3 8.7 19.3
10 2nd ROM 2.1 8.8 19.0
11 Primi None 2.8 6.8 17.0
12 Primi ROM 1.7 5.0 16.2
13 Primi None 2.2 5.3 18.1

9 Parity of mother has no role in development of significant hyperbilirubinemia.

9 Mother of 1/13 newborn had PIH.

9 Mother of 1/13 newborn had BOH.

9 Mother of 3/13 newborns had PROM ≥ 18 hours.

9 7/13 newborns born to mothers with no antenatal risk factors developed

significant hyperbilirubinemia.

85
 Table – XXXII
Sex Distribution & Type of Delivery in Newborns with Significant Hyperbilirubinemia
Sl Type of Sex Cord bilirubin TSB 1 24 ± 2 hours TSB S 72 hours
(mg/dl) (mg/dl)
No. delivery (mg/dl)

1 FTND M 1.0 5.0 17.6

2 LSCS F 0.8 7.2 17.2
3 LSCS F 1.0 6.7 16.9
4 FTND M 1.2 5.5 16.2
5 FTND M 2.0 6.5 18.2
6 LSCS F 2.0 6.0 18.4
7 FTND M 1.8 8.8 17.5
8 FTND F 2.1 6.8 16.9
9 LSCS F 2.3 8.7 19.3
10 Forceps M 2.1 8.8 19.0
11 LSCS M 2.8 6.8 17.0
12 LSCS M 1.7 5.0 16.2
13 FTND F 2.2 5.3 18.1

9 6/13 newborns were delivered by normal vaginal delivery.

9 6/13 newborns were extracted by LSCS.

9 Only 1/13 newborn required instrumentation in the form of outlet forceps

application.

9 7/13 (53.84%) males developed significant hyperbilirubinemia.

9 6/13 (46.15%) females developed significant hyperbilirubinemia.

9 Male : Female ratio was 1.16:1

86
 Table – XXXIII
Distribution of Cord Bilirubin, TSB 1 Levels & Risk Stratification in Newborns with
Hyperbilirubinemia
Sl Cord bilirubin TSB 1 24 ± 2 hours Risk Zone TSB S 72 hours
No. (mg/dl) (mg/dl) (mg/dl)
1 1.0 5.0 Inter 17.6
2 0.8 7.2 Inter 17.2
3 1.0 6.7 Inter 16.9
4 1.2 5.5 Inter 16.2
5 2.0 6.5 Inter 18.2
6 2.0 6.0 Inter 18.4
7 1.8 8.8 High 17.5
8 2.1 6.8 Inter 16.9
9 2.3 8.7 High 19.3
10 2.1 8.8 High 19.0
11 2.8 6.8 Inter 17.0
12 1.7 5.0 Inter 16.2
13 2.2 5.3 Inter 18.1

9 7/13 newborns had cord bilirubin level ≥ 2.0 mg/dl.

9 5/13 newborns had cord bilirubin level between 1.0 - 1.8 mg/dl.

9 Only 1 baby had cord bilirubin level < 1.0 mg/dl.

9 All newborns had their 24 hour Bilirubin level (TSB 1) in Intermediate or

High risk zone.

87
 Significant Hyperbilirubinemia
Number of newborns

250 211
Frequency of
newborns with
200 significant
hyperbilirubinemia

No.
of 150
Newborns

100
39

50 11 2

0
> 5.1 ≤ 5.0
TSB 1 Levels (mg/dl)

88
 Table – XXXIV
Protocol 1: Distribution of 13 Newborns with Significant Hyperbilirubinemia
into 2 groups on the basis of Arbitrary cut off value of 5 mg %

TSB 1 Number of newborns Frequency of newborns with

(22-26 hrs) mg/dl significant hyperbilirubinemia

≤ 5.0 211 2

> 5.1 39 11

Total 250 13

The predictive ability of cut off level of 5 mg% is as follows:

 Specificity : 88.18 %

 Sensitivity : 84.62 %

 Positive predictive value : 28.20 %

 Negative predictive value : 99.05 %

 P value : < 0.01 [Z = 3.74]

(Highly Significant)

89
 Table – XXXV
Protocol 2: Distribution of 13 Newborns with Significant Hyperbilirubinemia
into 2 groups on the basis of Average Bilirubin value of 4.06 mg %

Average Bilirubin Number of newborns Frequency of newborns with

value (mg/dl) significant Hyperbilirubinemia

≤ 4.06 138 –

> 4.06 112 13

Total 250 13

The predictive ability of this average bilirubin level is as follows:

 Specificity : 58.23 %

 Sensitivity : 100 %

 Positive predictive value : 11.61 %

 Negative predictive value : 100 %

 P value : < 0.01 [Z = 3.83]

(Highly Significant)

Hence newborns having 22 to 26 hours bilirubin value less than 4.06 mg% have

no risk of developing significant hyperbilirubinemia

90
 Table – XXXVI
Predictive characteristics of Percentile tracts as Risk Demarcators for
Subsequent Significant Hyperbilirubinemia

Location of Outcome
predictive subsequent Predictive characteristics
predischarge Hyperbilirubinemia
Bilirubin value
Percentile Number Present Absent Positive Negative Sensitivity Specificity
track as risk of N =13 N = 237 predictive predictive % %
demarcators newborns value % value %
th
Above 95 3 2 1
centile
66.66 95.54 15.38 99.57
Below 95th
247 11 236
centile
Above 75th 16 11 5
centile
68.75 99.14 84.61 97.89
Below 75th
234 2 232
centile
Above 40th 48 13 35
centile
27.08 100 100 85.23
Below 40th
202 0 202
centile

91
 DISCUSSION

Recent case reports and experience of neonatologists and “bilirubinologists”

who provide expert advice in medico legal cases suggest the possible re-emergence of

kernicterus from a state of near extinction to one that is of concern to

pediatricians6,8,10,68,69. Because there has been no uniform surveillance for reporting of

such cases over the last three to four decades, no uniform case definition for

kernicterus and most important no denominators for the case reports listed, we have

no way of accurately comparing the incidence of kernicterus in the population today

with the incidence in last 30 years.

Whatever are the demographic risk factors, one thing is certain if babies leave

the hospital before they are 36 hours old, their peak bilirubin level will occur after

they are discharged. Thus, jaundice today is largely an outpatient problem and if we

want to ensure that we do not miss the occasional baby who develops a very high

bilirubin level, we need to reconsider our approach. We know that babies who are

clinically jaundiced in the past few days are much more likely to develop significant

hyperbilirubinemia later on64,70.

Recognizing bilirubin induced neurologic dysfunction (BIND) as a matter of

public health concern, the AAP developed a detailed, consensus based practice

parameter for the management of hyperbilirubinemia in healthy term newborns and

institution of preventive phototherapy. Although effective by the absence of

prospective risk assessment and by dependence on visual assessment of jaundice.

Predischarge Jaundice as predictor vector for subsequent hyperbilirubinemia:

Quantifying the level of jaundice has been the foundation for satisfactory

management of hyperbilirubinemia. Early visual recognition of jaundice and accurate

92
estimation of its severity is crucial for effective implementation of the AAP

guidelines. The gold standard for deciding therapy to prevent encephalopathy

continues to be serum bilirubin levels for want of better parameters. After 48 hours of

life, serum bilirubin should be evaluated 8-12 hourly if levels are above 14 mg/dl; 6th

hourly if above 16 mg/dl; 4th hourly if above 18 mg/dl and more frequently at higher

values59.

Unfortunately, the presence of excessive jaundice for age is often missed

clinically which means that the trigger for measuring the first serum bilirubin level

and electing subsequent AAP algorithm is not set. This is a potentially serious

problem.

Serum bilirubin levels are usually 1-3 mg/dl at birth and rise at rate of less

than 5 mg/dl per day peaking at 2-3 days in term and 5-7 days in preterm. It should be

remembered that bilirubin rises by the ‘hours’ of life and hence the time of sampling

must be as ‘hours of life’ and not ‘day of life’.

Our study hypothesis was that a high serum bilirubin level soon after birth

would also predict a high peak later in life.

250 normal healthy term newborns were evaluated in tertiary care hospital in

Bijapur, Karnataka for neonatal hyperbilirubinemia using cord bilirubin and total

serum bilirubin (TSB) level at 22-26 hours as predictor. We have considered peak

Serum bilirubin level > 15 mg/dl as “Hyperbilirubinemia” since specific treatment is

usually considered at or above this level13,71.

A. Birth weight:

The birth weight of the newborns was recorded (Table I)

ƒ 174/250 (69.6%) newborns had their birth weight between 2.5-3.0Kg.

ƒ Only 14/250 (5.6%) newborns had their birth weight more than 3.5Kg.

93
 B. Exclusion criteria:

ƒ Newborns with birth weight less than 2.5Kg i.e. LBW babies.

ƒ Newborns that had not completed 37 weeks of gestation i.e. premature

neonates.

ƒ Newborns with obvious life threatening congenital malformation i.e.

B/L choanal atresia, tracheoesophageal fistula, anorectal malformation,

symptomatic congenital heart disease.

ƒ Newborns with Rh, ABO incompatibility.

ƒ Newborns requiring NICU admission for early sepsis, hypoglycemia,

HIE etc.

The exclusion criteria considered were similar to those in earlier studies.

Parameter Agarwal et al Bhutani et al Our Study

Gestational age ≥ 35 ≥ 36 ≥ 37

(weeks)

Birth weight (Kg) ≥ 1.75 ≥ 2.0 ≥ 2.5

In a study done by Agarwal et al62, all newborns with gestational age of 35

weeks or more were included. The range of birth weight for these children was from

1.75-4.0 Kg. Neonates with Rh incompatibility were excluded in this study also.

However in this study prediction of hyperbilirubinemia in patients with ABO

incompatibility was also attempted. In the study done by Bhutani et al18 all newborns

with birth weight more than 2.0 Kg for GA of ≥ 36 weeks and birth weight ≥ 2.5 Kg

for GA of 35 weeks were included. Newborns with Rh & ABO incompatibility were

excluded from their study. In another study done by Awasthi et al60, babies with birth

94
asphyxia, Rh incompatibility, life threatening congenital malformations and babies

with GA < 37 weeks were excluded.

C. Sex:

The sex distribution of the newborns was recorded (Table II)

Incidence of Subsequent hyperbilirubinemia in Males

Study Incidence

Narang et al 64.2%

Singhal et al 56.8%

Our study 53.84%

Among 250 newborns enrolled, 51.2% babies were females and 48.8% were

male babies in the ratio of 1.05:1. Male gender is a known risk factor for

hyperbilirubinemia38. In our study, 53.84% (7/13) newborns who developed

significant hyperbilirubinemia were male babies (Table XVIII, XVIII (b)). In a study

from Chandigarh done by Narang et al72, incidence of hyperbilirubinemia in males

was 64.2%. Also in another study done at Delhi by Singhal et al73, incidence of

hyperbilirubinemia in males was 56.8%.

D. Method of Delivery:

The type of delivery was recorded (Table III)

ƒ 180/250 (72.0%) newborns were delivered vaginally without any

instrumentation.

ƒ 62/250 (24.8%) newborns were extracted by LSCS.

95
 ƒ Only 8/250 (3.2%) newborns required instrumentation in the form of

outlet forceps application.

ƒ Oxytocin was mainly used to augment labor in 40% of women.

We found that peak serum bilirubin levels are higher in neonates born after

Oxytocin induction of labor and delivery by Cesarean section (Table XVIII, XVIII

(b)) and similar findings have been reported by others71,74.

E. Risk factors associated with Pregnancy:

Detailed maternal history was recorded, high risk factors in the pregnancy

were noted (Table IV)

ƒ 45/250 (18%) mothers had Anemia.

ƒ 19/250 (7.6%) mothers had PROM ≥ 18 hours.

ƒ 15/250 (6.0%) mothers had BOH.

ƒ 9/250 (3.6%) mothers had PIH.

ƒ 1/250 (0.4%) mother had DM.

The distribution of risk factors is comparable to those in the study done by

Agarwal et al. In this study 5.6% patients had pregnancy induced hypertension (PIH),

3.3% of mothers had premature rupture of membranes more than 18 hours (PROM ≥

18 hours), and 3.8% of mothers had multiple gestations.

All of these variables have been associated with high serum bilirubin levels in

the first postnatal week20,21,75,76.

96
 F. Cord Bilirubin:

The cord blood bilirubin was done immediately after delivery.

Higher cord blood bilirubin levels among neonates who later become

jaundiced compared to cord bilirubin levels in non jaundiced neonates indicate that

mechanisms of importance for subsequent jaundice are already active in later fetal

life. Nearly all fetal bilirubin is unconjugated, due to a limited ability of the fetal liver

to conjugate bilirubin. In plasma, unconjugated bilirubin is tightly bound to albumin,

which is the dominant bilirubin-binding protein in plasma. Under normal

circumstances no bilirubin deposition takes place in fetal tissue. Unconjugated

bilirubin is rapidly transferred to the maternal circulation by the placenta, whereas

only small quantities of conjugated bilirubin cross the placenta77. Thus bilirubin

produced by fetus is excreted by the mother, who presumably has a large reserve

capacity for bilirubin excretion, and only minor differences in maternal bilirubin

concentration can be expected. In consequence, increased fetal bilirubin in blood is a

reflection either of increased bilirubin production, impaired removal of bilirubin from

fetal plasma, or increased ability of fetal plasma to bind bilirubin.

The distribution of cord bilirubin in present study was as shown in Table IX

Table – IX

Cord Bilirubin levels (0 hrs)

Cord Bilirubin (mg/dl) Number of newborns Percent

0.5-0.9 7 2.8
1.0-1.4 115 46
1.5-1.9 90 36
2.0-2.4 35 14
> 2.5 3 1.2
Total 250 100

97
 ƒ The range of cord blood bilirubin in our study was from 0.5mg/dl to 2.8mg/dl.

In the present study newborns with hyperbilirubinemia had significantly

higher levels of cord bilirubin than neonates without hyperbilirubinemia (Table

XVIII, XVIII (c)).

Table – XVIII (c)

Sl Cord bilirubin TSB 1 24 ± 2 hours Risk Zone TSB S 72 hours

No. (mg/dl) (mg/dl) (mg/dl)

1 1.0 5.0 Inter 17.6

2 0.8 7.2 Inter 17.2

3 1.0 6.7 Inter 16.9

4 1.2 5.5 Inter 16.2

5 2.0 6.5 Inter 18.2

6 2.0 6.0 Inter 18.4

7 1.8 8.8 High 17.5

8 2.1 6.8 Inter 16.9

9 2.3 8.7 High 19.3

10 2.1 8.8 High 19.0

11 2.8 6.8 Inter 17.0

12 1.7 5.0 Inter 16.2

13 2.2 5.3 Inter 18.1

In a study done by Knudsen78, neonates with clinical jaundice had

significantly higher levels of cord bilirubin than neonates without jaundice. They have

shown that the number of newborns who needed phototherapy was significantly

higher if cord bilirubin was higher than 40μmol/L (2.33 mg/dl) when compared to the

number of jaundiced newborns with need for phototherapy and cord bilirubin at

40μmol/L or lower. In their study the probability that a newborn with cord bilirubin

98
higher than 30μmol/L (1.75 mg/dl) would later become jaundiced (positive predictive

value) was 67%. The negative predictive value, the probability of non jaundice given

a cord bilirubin lower or equal to 30μmol/L was 82%.

Our cord blood bilirubin findings in the present study are in accordance with

the study of Knudsen A.

G. Estimation of TSB 1 (24 ± 2 hours)

The first bilirubin level was done at 22-26 hours of birth.

There is variability in the time of appearance of jaundice from newborn-

newborn and in the ability of professionals to see jaundice and estimate its severity

coupled with the considerable range of TSB associated with its cephalocaudal

progression. Moreover the observer variability and the influence of the skin color in

clinically evaluating hyperbilirubinemia by ‘Kramer index’ has been the Achilles’

heel of this method.

Criteria to estimate clinical jaundice (Kramer index)

Area of body Range of bilirubin

(mg/100ml)

Face 4-8

Upper trunk 5-12

Lower trunk and thighs 8-16

Arms and lower legs 11-18

Palms and soles > 15

In most of the recently reported healthy term newborns that developed

kernicterus, significant jaundice was almost certainly present before the first hospital

discharge, judging from the height of TSB for age in hours at admission.

99
 Indeed there is association between bilirubin levels in cord blood and

subsequent risk of jaundice. Bhutani47 and co-workers obtained serum bilirubin

levels between 20-28 hours of age in 1097 newborns. Nobody who had bilirubin level

of less than 5 mg/dl at 24 hours developed a serum bilirubin level of more than or

equal to 17 mg/dl; whereas 33% of those whose 24 hours serum bilirubin level was at

least 8 mg/dl developed a serum bilirubin level of at least 17 mg/dl.

Seidman et al79 used a similar approach in Israeli newborns and found that the

risk of bilirubin level of at least 17 mg/dl was 1.6% in those whose bilirubin levels

were less than 5 mg/dl at 24 hours versus 6.6% of those whose bilirubin levels were at

least 5 mg/dl at 24 hours.

In the study done by Agarwal et al62, TSB was estimated at 24 ± 6 hours. In

another Indian study done by Awasthi et al60 the level was estimated at 18-24 hours.

The distribution of bilirubin levels in present study was as shown in Table XI.

Table – XI

Bilirubin level (TSB 1) at 22-26 hours

Bilirubin level (mg/dl) Number of newborns Percent

1.0-1.9 5 2

2.0-2.9 38 15.2

3.0-3.9 78 31.2

4.0-4.9 81 32.4

5.0-5.9 32 12.8

6.0-6.9 12 4.8

7.0-7.9 1 0.4

8.0-8.9 3 1.2

Total 250 100

100
 ƒ The range of bilirubin value was from 1.4 mg/dl to 8.8 mg/dl, average

bilirubin value being 4.06 mg/dl.

In the study done by Awasthi et al60, the average bilirubin level was found to

be 3.99 mg/dl.

All newborns in our study were exclusively breast fed and feeding was

initiated within first 4 hours of birth. This is in contrast with the study done by

Bhutani et al where significant proportion of newborns (40%) was formula fed for

various reasons.

Also in our study initiation of breast feeding within first 4 hours was not found

to be associated with peak serum bilirubin of the first 3 days. This is different from

what has been reported previously80. This lack of association may be compounded by

the feeding given in the next few days, but as this was not our study question, we do

not have data on the daily intake. Further studies are needed to test the validity of this

association.

Similar type of this lack of association as observed in our study was reported

in the study done by Awasthi et al60.

H. Evaluation of bilirubin value to predict Neonatal Hyperbilirubinemia

using available protocols:

a. Protocol 1: Depending on the first bilirubin level (TSB 1) we divided our

newborns in two groups using arbitrary cut off value of 5.0mg%62.

101
 Table – XIV

Protocol - 1

Distribution of Newborns on the basis of Arbitrary Cut-off Value of 5 mg%

Bilirubin value (mg %) Number of newborns Percent

≤ 5.0 211 84.4

> 5.1 39 15.6

Total 250 100

When newborns were classified into two groups using cut off value of 5 mg%,

no newborn that had bilirubin < 5 mg% developed significant hyperbilirubinemia

requiring phototherapy. Out of 39 newborns that had their first bilirubin level more

than 5 mg%, 11 developed significant hyperbilirubinemia requiring phototherapy.

Thus the cut off value of 5.0mg% can predict subsequent significant

hyperbilirubinemia with sensitivity of 84.62% and specificity of 88.18%.

P value is less than 0.01 indicating the significance.

In one study Alpay et al61 reported that TSB level ≥ 6.0 mg/dl in the first 24

hours of life will predict nearly all of the term newborns who will have significant

hyperbilirubinemia and will determine all those who will require phototherapy

treatment later during the first days of life.

102
 Arbitrary Neonates with Neonates with

Study cut off hyperbilirubinemia hyperbilirubinemia Sensitivity Specificity

bilirubin above the cut off below the cut off

value value value

Agarwal 6.0 mg/dl 21/77 (27.2%) 1/136 (< 1%) 95% 70.6%

et al

Our 5.0mg/dl 11/39 (28.8%) 2/211 (< 1%) 84.62% 88.18%

study

Agarwal et al62 did one study to evaluate predictive value of TSB level 6.0

mg% at 24 ± 6 hours postnatal age in identifying near term and term newborns that do

not develop hyperbilirubinemia subsequently. In this study first bilirubin estimation

was done at 24 ± 6 hours. Subsequent bilirubin estimation was done whenever clinical

suspicion of jaundice exceeded 10.0 mg%. Out of 220 newborns studied, 22

developed significant hyperbilirubinemia requiring phototherapy. TSB level of 6

mg/dl or less was present in 136 (63.8%) newborns and only one developed

hyperbilirubinemia. In the remaining 77 (36.2%) neonates with TSB > 6 mg/dl

subsequent hyperbilirubinemia developed in 21 (sensitivity 95%, specificity 70.6%).

They concluded that Ideal cut off value was 5.0 mg/dl and babies with TSB levels

higher than 6.0 mg% had a significant risk of developing hyperbilirubinemia.

b. Protocol 2: Depending on the average bilirubin value we divided our

newborns in two groups using average value of 4.06mg%60.

103
 Table – XV

Protocol - 2

Distribution of Newborns on the basis of Average Bilirubin value of 4.06 mg%

Average Bilirubin value (mg %) Number of newborns Percent

< 4.06 138 55.2

> 4.06 112 44.8

Total 250 100

When newborns were divided in two groups using average value of 4.0 mg%,

no newborn less than 4.06 mg% developed significant hyperbilirubinemia. Out of 112

newborns that had their bilirubin value more than 4.06 mg% 13 developed significant

hyperbilirubinemia requiring phototherapy. Thus the average value can predict

subsequent significant hyperbilirubinemia with specificity of 58.23% and sensitivity

of 100%.

P value is less than 0.01 indicating the significance.

Average Bilirubin Awasthi S et al Our Study

value (mg/dl) 3.99 4.06

Sensitivity 68.6% 100%

Specificity 65.7% 58.23%

In the study done by Awasthi S et al60, a value of 3.99 mg/dl (average value

of first day TSB) was used to predict occurrence of subsequent hyperbilirubinemia.

The sensitivity and specificity of this test was 67%. However this study had major

flaws. Complete follow up was present in newborns who stayed in the hospital either

104
for neonatal illness or some maternal reason, such as cesarean section. More than 50%

of newborns, who were healthy thus discharged early, were not followed up.

c. Risk Stratification:

Bhutani et al18 did a study to assess the predictive ability of universal

predischarge serum bilirubin measurement to screen for the risk of subsequent

significant hyperbilirubinemia in direct coomb’s negative healthy term / near term

newborns during first postnatal week. TSB was obtained at the time of routine

metabolic screen in all term / near term newborns. A percentile based nomogram for

the first week was constructed from hour specific predischarge and postdischarge

TSB values of newborn.

The nomogram has 3 risk zones

( Low risk zone < 40th centile.

( Intermediate risk zone

Ž Low intermediate 40th – 75th centile.

Ž High intermediate 75th – 95th centile.

( High risk zone > 95th centile.

Newborns were divided into three risk zones as mentioned above.

Table – XVI
Risk Stratification of the Study Population
Bhutani et al Our study Percent

Risk zone Number of newborns

High Risk (> 95th centile) 3 1.2

Intermediate risk (40-75th centile) 45 18.0

Low risk (< 40th centile) 202 80.8

Total 250 100

105
 When newborns in our study were divided in 3 risk zones using nomogram

prepared by Bhutani et al

( (3/250) newborns were in high risk zone i.e. bilirubin value more than

95th centile.

( (45/250) newborns were in intermediate risk zone i.e. bilirubin value

between 40th – 95th centile.

( (202/250) newborns were in low risk zone i.e. bilirubin value less than

40th centile.

The low risk zone of this nomogram corresponds to the average bilirubin

value. Subsequent bilirubin estimation was done whenever there was clinical

suspicion of jaundice.

I. On subsequent follow up:

a) Of (202/250) i.e. 80.8% newborns in low risk zone

ƒ 191 (94.5%) newborns remained in low risk zone subsequently.

ƒ 10 (4.95%) newborns went up to low intermediate risk zone.

ƒ Only 1 (0.49%) newborn went up to high intermediate risk zone.

ƒ No newborn went into high risk zone.

ƒ No newborn, thus belonging to low risk zone developed significant

hyperbilirubinemia requiring phototherapy.

b) Of (45/250) i.e. 18% newborns in intermediate risk zone

ƒ 10 (22.22%) newborns went into high risk zone, developed

significant hyperbilirubinemia requiring phototherapy.

ƒ 8 (17.77%) newborns moved down to low intermediate risk zone.

ƒ 15 (33.33%) newborns moved down to low risk zone.

ƒ 12 (26.66%) newborns went up to high intermediate risk zone

106
 c) Of (3/250) i.e. 1.2% newborns in high risk zone

ƒ All 3 (100%) newborns remained in high risk zone, developed

significant hyperbilirubinemia and required phototherapy.

Table – XXI

Statistical significance is as depicted in the following table:

Predictive characteristics (for subsequent significant

hyperbilirubinemia

Placement of first TSB Positive Negative

predictive value predictive value Specificity Sensitivity
vector in risk zone
% % % %
High Risk Zone 66.66 95.54 99.57 15.38

Intermediate Risk Zone 68.75 99.14 97.89 84.61

Low Risk Zone 27.08 100 85.23 100

In the study done by Bhutani et al18, predischarge 6.1 % of the study

population was in high risk zone, of these 39.5 % remained in this zone. Predischarge

32.1 % population had TSB values in the intermediate risk zone. In a clinically

significant minority of these newborns, the post discharge TSB moved into the high

risk zone. The predischarge TSB in 61.8 % newborns was in low risk zone and there

was no measurable risk for significant hyperbilirubinemia. The authors concluded that

an hour specific TSB before discharge can predict which newborn is at high /

intermediate / low risk for developing clinically significant hyperbilirubinemia.

J. Outcome:

Total of 13 newborns out of 250 developed significant hyperbilirubinemia

requiring phototherapy.

¾ All these 13 newborns had their first bilirubin level more than 4.06 mg/dl.

107
 ¾ 11 newborns had their first bilirubin level more than 5.0 mg/dl.

¾ Only 2 newborns had first bilirubin equal to 5.0 mg/dl.

¾ 3 of these 13 newborns had their first TSB value in high risk zone, 10

newborns had their first TSB value in intermediate risk zone and none had

first TSB value in low risk zone.

Comparing the various protocols following results were obtained:

Test Sensitivity Specificity Positive Negative

predictive value predictive value

Using cut off 84.62 88.18 28.20 99.05

5.0 mg%

Average bilirubin 100 58.23 11.61 100

value 4.06 mg%

Low Risk Zone 100 85.23 27.08 100

9 In each test negative predictive value is more significant, proving that

newborn with bilirubin less than cut off value or bilirubin level in low risk

zone can be discharged safely and early.

9 Comparing the two protocols there was only marginal difference in the

negative predictive value using cut off value 5.0 mg% and average bilirubin

value 4.06 mg%. However it can be conclusively commented upon by using

large sample size.

9 It also highlights that the risk stratification is an excellent method of tracking

newborns with hyperbilirubinemia as newborns with hour specific bilirubin

value in low risk zone have no risk of developing subsequent significant

hyperbilirubinemia.

108
 CONCLUSIONS

¾ In our study we observed male babies (53.84%) are at high risk for

developing significant hyperbilirubinemia.

¾ Babies born out of Cesarean section (46.15%), Oxytocin induction of labor

as observed had high total serum bilirubin levels, hence are at risk approach.

¾ Presence of high risk antenatal factors (46.15%) & no antenatal risk factors

(53.84%) share equal incidence of development of subsequent significant

hyperbilirubinemia.

¾ Elevated cord bilirubin levels can define a group of neonates at risk of

developing jaundice in early neonatal period.

¾ Hour specific bilirubin level i.e. total serum bilirubin (TSB) level of less than

5.0 mg% or 4.06 mg% at 22 -26 hours of life predicts absence of subsequent

hyperbilirubinemia with high probability.

¾ Term neonates whose first bilirubin level is above the cut off value

(hypothetical value of 5.0 mg/dl or average value of 4.06 mg/dl) are more

prone to develop significant hyperbilirubinemia requiring phototherapy.

¾ Neonates in Low risk zone (100%) are at the least risk hence can be

discharged safely & early.

¾ Neonates in Intermediate risk zone (22.22%) are the most vulnerable for

developing hyperbilirubinemia; requiring intensive monitoring & watchful

evaluation to prevent significant morbidity.

¾ Neonates in High risk zone (100%) require appropriate intervention at the

earliest to prevent BIND & kernicterus.

¾ The hour specific percentile curves developed for North American

population can be used for Indian babies.

109
 SUMMARY

Kernicterus, one of the most easily preventable causes of brain injury from

severe neonatal jaundice, has re-emerged in our country and other nations with well

developed health care systems as a public and societal health concern. Kernicterus, in

its usually recognized form, causes devastating disabilities including athetoid cerebral

palsy (CP) and speech and hearing impairment. It represents the severe manifestations

of bilirubin induced neurologic dysfunction (BIND) syndrome. And for the child with

kernicterus (usually remarkably intelligent, but trapped in an uncontrollable body),

grief and frustration are enormous.

The re-emergence of kernicterus is the result of interacting phenomena

including a) early hospital discharge (before extent of jaundice is known and signs of

impending brain damage have appeared); b) lack of adequate concern for the risk of

severe jaundice in healthy term and near term newborns; c) an increase in breast

feeding without adequate instruction, monitoring and support; d) medical care cost

constraints leading to early discharge with loss of supervision; e) paucity of

educational materials to enable parents to participate in safeguarding their newborns;

and f) limitations within the health care systems to provide continuity of care.

Kernicterus in such newborns is preventable, provided excessive

hyperbilirubinemia for age is promptly identified and treated.

The concept of prediction of jaundice offers an attractive option to pick up

babies at risk for hyperbilirubinemia. Newborns that are clinically jaundiced in the

first few days are more likely to develop hyperbilirubinemia. Moreover higher cord

bilirubin levels among newborns who later became jaundiced compared to cord

bilirubin levels in non jaundiced newborns indicate that mechanism of importance for

the subsequent jaundice are already active in late fetal life. Using hour specific

110
bilirubin levels subsequent hyperbilirubinemia can be predicted with reasonable

accuracy.

250 normal neonates were studied. Umbilical cord blood bilirubin was done

immediately after delivery. The range of cord bilirubin was 0.5-2.8 mg/dl.

First bilirubin estimation (TSB1) was done between 22 hours to 26 hours of

birth (24 ± 2 hours). The range of bilirubin was 1.4-8.8 mg/dl with average being 4.06

mg/dl.

Depending upon the first bilirubin value newborns were divided into groups

using the two available protocols to predict neonatal hyperbilirubinemia i.e. using

arbitrary cut off value of 5.0 mg% and 4.06 mg%. Newborns were further divided into

three risk zones to track subsequent hyperbilirubinemia.

Using Protocol 1 i.e. hypothetical cut off value of 5.0 mg%, 211/250 (84.4%)

newborns had bilirubin value less than or equal to 5.0 mg%, 39/250 (15.6%)

newborns had bilirubin value more than 5.0 mg%. Using Protocol 2 i.e. average

bilirubin value of 4.06 mg%, 138/250 (55.2%) newborns had bilirubin value less than

4.06 mg%, 112/250 (44.8%) newborns had bilirubin value more than 4.06 mg%.

Using Risk stratification 3/250 newborns were in high risk zone (above 95th centile),

45/250 newborns were in intermediate risk zone (40th – 95th centile), 202/250

newborns were in low risk zone (below 40th centile).

Subsequent bilirubin estimation was done whenever clinical suspicion of

jaundice was present. 13/250 newborns (5.2%) developed significant

hyperbilirubinemia requiring phototherapy with no newborn requiring exchange

transfusion and none developed kernicterus.

None had their first bilirubin level in low risk zone. All these 13 newborns

had their first bilirubin level in either intermediate or high risk zone. 2/13 newborns

111
that developed significant hyperbilirubinemia had their first bilirubin level equal to

5.0 mg/dl with all the newborns having first bilirubin level more than 4.06 mg/dl also

indicating that this value of 4.06 mg% corresponds to the bilirubin level in the low

risk zone.

Thus bilirubin cut off value of 5.0 mg/dl can predict subsequent

hyperbilirubinemia with sensitivity of 84.62% and specificity of 88.18%. The average

bilirubin value can predict subsequent hyperbilirubinemia with sensitivity of 100%

and specificity of 58.23%. Bilirubin value in low risk zone can predict subsequent

hyperbilirubinemia with sensitivity of 100% and specificity of 85.23%.

( From the above it can be concluded that negative predictive value of

bilirubin less than 4.06 mg% or less than 5.0 mg% done at 22 hours to 26

hours after birth, in a term healthy neonate for developing significant

hyperbilirubinemia is 100%.

( Prediction of neonatal hyperbilirubinemia has widespread implication

especially in our country where there are limited resources with tendency for

early discharge especially in breast fed babies.

( Risk based guidelines are available to target, evaluate, intervene and follow

up of neonates according to AAP’s practice parameter. Hence application of

the predictive bilirubin nomogram would help in the prevention of bilirubin

induced neurological damage and kernicterus.

( Preventive and system based strategies offer a safer and gentler means to

prevent BIND (bilirubin induced neurological damage) including Kernicterus.

112
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