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Neonatal Jaundice

Article  in  Journal of Tropical Pediatrics · October 2012

DOI: 10.1093/tropej/fms051 · Source: PubMed

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JOURNAL OF TROPICAL PEDIATRICS, VOL. 58, NO. 5, 2012
Editorial
Neonatal Jaundice
As 2015 approaches, progress in the Millennium
Development Goals (MDGs) comes under the spot-
light. The target for MDG 4 is to reduce the mortal-
ity rate by two-thirds, between 1990 and 2015, in
children aged <5 years, and while the mortality rate
is falling, the world is not going to meet this ambi-
tion. Neonatal mortality now makes up !40% of all
deaths in children aged <5 years, and action on this
problem has rightly become a focus in the drive to
reduce all child deaths.
We know that intrapartum asphyxia, prematurity
and neonatal sepsis are the most important causes of
neonatal mortality, and initiatives to tackle these
issues are evolving. For instance, the American
Academy of Pediatrics and partners recently created
a neonatal resuscitation programme called ‘Helping
Babies Breathe’, which focuses on simple resuscita-
tion strategies, including stimulation, drying and suc-
tion. It also uses a ‘Golden Minute’ concept to ensure
those infants who need ventilatory support receive it
in a timely fashion; with an effective bag and mask
technique within 60 s [1]. In 2012, the World Health
Organization and partners published the first Global
Action Report on Preterm Birth. This takes a holistic
view of the problem of premature infants and
considers antenatal and perinatal issues and care of
premature infants. It emphases key low-cost inter-
ventions that could benefit the 80% of premature
infants born between 32 and 37 weeks of gestation,
such as thermal care, infection prevention with good
cord and skin care, support for breast feeding and
safe oxygen use [2].
We know that neonatal jaundice is also an import-
ant sign of neonatal illness [3] and that the pathology
can be complex. In developed health care systems,
the emphasis is on identifying first day jaundice as
a marker of significant haemolysis and on prolonged
jaundice as a sign of obstructive jaundice, in particu-
lar biliary atresia. This is because other jaundice is
routinely identified, investigated and treated with
phototherapy or occasionally exchange transfusion.
But this is not the case around the world; so what is
the current situation in resource-poor settings in the
issues of identifying, investigating and managing neo-
natal jaundice?
At present, transcutaneous measurement of biliru-
bin is prohibitively expensive. There are a number of
prospective cohort studies that have investigated the
accuracy of visual assessment of neonatal jaundice,
and these show conflicting results [4–9]. In general,
clinical estimation of jaundice was shown to correlate
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doi:10.1093/tropej/fms051
poorly with serum bilirubin levels; however, the stu-
dies do suggest that visual assessment may be useful
as a negative predictor.
Some studies have looked at clinical risk factors to
predict infants who are at risk of developing neonatal
jaundice; however, there was considerable variability
in criteria used between studies [10–12]. Research is
now needed to validate the accuracy and reliability of
specific risk factors as predictors, and to evaluate
Downloaded from http://tropej.oxfordjournals.org/ at University of Warwick on April 9, 2016
which risk factors are predictive in preterm infants
and racially diverse populations.
In resource-poor settings, laboratory tests are an
expensive commodity; therefore, it is important that
their use is justified. In their article, Besser et al. [13]
evaluated the efficacy of standard laboratory tests
recommended by the American Academy of Paedia-
trics on neonates undergoing phototherapy in Israel.
This retrospective cohort study involved reviewing
the charts of 282 neonates with birth weight
>2.5 kg who were treated with phototherapy during
the first month of their life. All laboratory tests
undertaken and their results were documented to-
gether with primary and maximum bilirubin values,
time to jaundice (in days) and the number of days in
follow-up. Laboratory tests conducted included
G6PD activity, blood type, direct Coombs’ test, re-
ticulocyte count, total and direct (conjugated) biliru-
bin and liver function tests. The authors suggest that
there is no benefit in conducting a full laboratory
investigation to identify the cause of jaundice in neo-
nates undergoing phototherapy when jaundice pre-
sents >48 h from birth, unless bilirubin levels are
continuing to rise 8 h after starting phototherapy.
In babies who present with early jaundice (<48 h
from birth) and need phototherapy, the chance of
encountering haemolysis is high; therefore, these
babies should ideally have a full blood count, reticu-
locyte count, G6PD activity test and blood type
(where appropriate) assessed. More research is
needed to determine whether the same is true or
whether diagnostic blood tests have a better yield in
countries with higher incidences of G6PD deficiency
and neonatal infection. In resource-poor settings,
however, the majority of these tests and indeed treat-
ments for non-physiological jaundice are unlikely to
be available; therefore, there is a pragmatic argument
in these situations for not performing any tests on
babies unless they fail to respond to phototherapy.
Treatment of neonatal jaundice requires blue light,
wavelength of 420–448 nm, which oxidizes the biliru-
bin to biliverdin, a soluble product that does not
339

contribute to kernicterus. Phototherapy machines
imported into resource-poor settings often have a
short working life, limited by problems maintaining
the equipment. Some novel ideas to create effective
phototherapy machines with locally available re-
sources are in development [14, 15], but these still
need testing and widespread dissemination.
To conclude, neonatal jaundice is an important
aspect of neonatal morbidity. There are well-de-
veloped systems to identify, investigate and manage
the problem in developed health care systems, but
much research and development is still needed to ad-
dress the problem in resource-poor settings.
D. SIMKISS, and R. MARTIN
References
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EDITORIAL
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Journal of Tropical Pediatrics Vol. 58, No. 5