Hyperbilirubinaemia is a ubiquitous transitional morbidity in the vast majority of newborns and a leading cause of hospitalisation in the first week of life worldwide. While timely and effective phototherapy and exchange transfusion are well proven treatments for severe neonatal hyperbilirubinaemia, inappropriate or ineffective treatment of hyperbilirubinaemia, at secondary and tertiary hospitals, still prevails in many poorly-resourced countries accounting for a disproportionately high burden of bilirubin-induced mortality and long-term morbidity. As part of the efforts to curtail the widely reported risks of frequent but avoidable bilirubin-induced neurologic dysfunction (acute bilirubin encephalopathy (ABE) and kernicterus) in low and middle-income countries (LMICs) with significant resource constraints, this article presents a practical framework for the management of late-preterm and term infants (≥ 35 weeks of gestation) with clinically significant hyperbilirubinaemia in these countries particularly where local practice guidelines are lacking. Standard and validated protocols were followed in adapting available evidence-based national guidelines on the management of hyperbilirubinaemia through a collaboration among clinicians and experts on newborn jaundice from different world regions. Tasks and resources required for the comprehensive management of infants with or at risk of severe hyperbilirubinaemia at all levels of healthcare delivery are proposed, covering primary prevention, early detection, diagnosis, monitoring, treatment, and follow-up. Additionally, actionable treatment or referral levels for phototherapy and exchange transfusion are proposed within the context of several confounding factors such as widespread exclusive breastfeeding, infections, blood group incompatibilities and G6PD deficiency, which place infants at high risk of severe hyperbilirubinaemia and bilirubin-induced neurologic dysfunction in LMICs, as well as the limited facilities for clinical investigations and inconsistent functionality of available phototherapy devices. The need to adjust these levels as appropriate depending on the available facilities in each clinical setting and the risk profile of the infant is emphasised with a view to avoiding over-treatment or under-treatment. These recommendations should serve as a valuable reference material for health workers, guide the development of contextually-relevant national guidelines in each LMIC, as well as facilitate effective advocacy and mobilisation of requisite resources for the optimal care of infants with hyperbilirubinaemia at all levels.
BACKGROUND: Cultural practice have often overlooked when providing maternal and child health care services. Low birth weight is the second cause of neonatal mortality in the world but it is a major factor in a developing country such as Indonesia. The purpose of this study is to predict the neonatal mortality among low birth weight babies in Aceh Province Indonesia.
METHODS: Unmatched case control study was conducted using data from year 2010 to 2012 in 8 selected districts of Aceh Province Indonesia. A total of 500 samples were obtained. There were 250 of the samples died in neonatal period (case group) and 250 who were alive (control group). There were 26 variables studied and were grouped into 4 factors: neonatal factor, maternal factor, maternal and child health services and neonatal care practices. The data was analysed using bivariate logistic regression and multivariate logistic regression.
RESULTS: There were 13 out of 26 variables found as determinant factors of neonatal mortality among low birth weight babies in Aceh Province. The predictors found in this study were: boy (aOR1.80, 95% CI: 1.09-2.96), moderate low birth weight (aOR17.84, 95% CI: 6.20-51.35), preterm (aOR1.84, 95% CI: 1.07- 3.17), presence of maternal illnesses (aOR1.87, 95% CI: 1.06-3.30), too short or too long birth interval (aOR1.80, 95% CI: 1.20-2.91), inappropriate antenatal care (aOR2.29, 95% CI: 1.34-3.91), inappropriate neonatal visit (aOR7.04, 95% CI: 3.67-13.49), not practicing kangaroo mother care (aOR15.32, 95% CI: 2.85-82.56), not using warm bottle padding (aOR20.70, 95% CI: 6.32-67.80), not practicing 'didaring' (aOR4.33, 95% CI: 1.83-10.19), late initiation of breastfeeding (aOR2.03, 95% CI: 1.09-3.80), discard colostrums (aOR3.53, 95% CI: 1.93-6.43) and not practicing exclusive breastfeeding (aOR5.58, 95% CI: 2.89-10.77).
CONCLUSIONS: Cultural practices are strongly seen among Acehnese. Inappropriate antenatal care and neonatal care, late initiation of breastfeeding, discarding colostrums and not practicing exclusive breastfeeding were related to cultural practices. Improving knowledge heat preservation to prevent hypothermia using Kangaroo mother care, warm bottle padding and 'didaring' were proven methods to reduce neonatal mortality. Strengthening of health services in screening for high risk cases and anticipate intervention tailored to cultural practices are important to decrease neonatal mortality among low birth weight.
An in-house radioimmunoassay (RIA) for the measurement of androstenedione levels in serum was established and validated. Levels of androstenedione were measured by RIA using serum samples from various normal population groups and patients with congenital adrenal hyperplasia (CAH). Analytical recovery and linearity results were > 95%, while intra- and inter-assay CVs were < 10% and < 22% respectively. The assay sensitivity was 0.5 nmol/l or 25 fmol/tube. In normal population groups, the highest androstenedione levels were found in preterm neonates (1.6-12.4 nmol/l), followed by adult females (1.5-10.2 nmol/l), adult males (1.6-8.0 nmol/l) and term neonates (0.8-8.8 nmol/l), while the lowest values were observed in prepubertal children (0.5-3.4 nmol/l). There were no significant differences in diurnal variation and between follicular and luteal phases. The range of androstenedione levels in untreated or poorly controlled CAH patients (7.6-355.0 nmol/l, median 42.5 nmol/l, n = 20) were significantly higher (p < 0.001) than the upper normal limit of 3.4 nmol/L for prepubertal children. The normal androstenedione reference ranges for paediatric and adult groups have thus been established.
A prospective study of 486 high risk neonates admitted to a level II nursery in a relatively poor and rural area of Malaysia was carried out to determine the incidence, the spectrum of micro-organisms and predisposing factors in relation to early onset septicaemia. The incidence of proven or probable septicaemia was 57.61 per 1000 high risk newborns over 1.5 kg. The case fatality was 10.71 per cent. Coagulase negative staphylococci, Streptococcus Group B and Klebsiella species were the most commonly isolated organisms. Meconium staining of liquor was the most common risk factor for admission to the nursery, and prematurity was the most significant risk factor for early neonatal infection (P < 0.005) followed by small for gestational age (P < 0.04). Although the incidence of septicaemia was quite high in the level II nursery, the mortality rate was comparable to established figures.