Saudi Journal of Medical and Pharmaceutical Sciences ISSN 2413-4929 (Print)

Scholars Middle East Publishers ISSN 2413-4910 (Online)

Dubai, United Arab Emirates
Website: https://saudijournals.com/ DOI: 10.36348/sjmps.2017.v03i04.008

Original Research Article

Neonatal Hyperbilirubinemia: An Experience of 212 Cases From a Tertiary Care

Setup
Dr. Payal Mittal1, Dr. Priyanka Tank2, Dr. Yuthika Agarwal3, Dr. Rakesh Tank4, Dr. Abhishek Singh5, Dr. Vipin
Goyal6
1
Senior Resident, Department of Pediatrics, FH Medical College, NH-2, Tundla, Uttar Pradesh, India
2
Senior Resident, Department of Pediatrics, SHKM Govt. Medical College, Mewat, Haryana, India
3
Demonstrator, Department of Biochemistry, SHKM Govt. Medical College, Mewat, Haryana, India
4
Assistant Professor, Department of Internal Medicine, SHKM Govt. Medical College, Mewat, Haryana, India
5
Assistant Professor, Department of Community Medicine, SHKM Govt. Medical College, Mewat, Haryana, India
6
Assistant Professor, Department of Chest and TB, SHKM Govt. Medical College, Mewat, Haryana, India

*Corresponding Author:
Dr. Abhishek Singh
Email: abhishekparleg@gmail.com

Abstract: Etiological factors leading to hyperbilirubinemia vary among different geographic regions. The present study
was planned to study the pattern, causes, risk factors, treatment and outcome of neonatal hyperbilirubinemia in a tertiary
care setup from northern India. A retrospective cohort of jaundiced neonates seeking care for their illness at this tertiary
care centre during formed the study population. All treated cases of neonatal hyperbilirubinemia were analyzed and data
on gender, gestation age, mode of delivery, blood group incompatibility, sepsis, parity and birth weight were obtained.
The commonest cause of neonatal hyperbilirubinemia was physiological jaundice (41.04%). Mean bilirubin values for
pathological cases (18.11± 5.54 mg/dl) were higher than physiological jaundice (12.06 ± 3.59 mg/dl). Top three causes of
pathological hyperbilirubinemia were ABO incompatibility (32.55%), Rh incompatibility (11.79%) and breast feeding
(6.13%). Mean age of presentation with jaundice was three days. Majority (48.58%) of the cases had their total bilirubin
levels equal to or below 15mg/dl. Almost all the neonates showed improvement with phototherapy and exchange
transfusion. Hyperbilirubinemia is a commonly encountered problem in our NICUs. ABO and Rh incompatibility are
mainly responsible for pathological jaundice. Phototherapy is found to be a safe and cost-effective way to manage
neonatal jaundice.
Keywords: Neonatal, hyperbilirubinemia, pathological, physiological, phototherapy

INTRODUCTION adopted a bilirubin level more than 20 mg/dl as

Neonatal hyperbilirubinemia is one of the indicator of vulnerability to neurotoxicity [6].
commonest causes of admission of neonates in the
Neonatal intensive care units. Jaundice may be noticed Etiological factors leading to
in 60% of term babies and 80% of pre-terms [1]. hyperbilirubinemia vary among different geographic
Incidence of neonatal jaundice is around 60∼70% in regions. Even the bilirubin concentrations considered
Western countries and even higher among newborns of harmful or neurotoxic may vary with geographical
Asian ethnicity [2]. Neonatal jaundice is associated with conditions and ethnic groups [7]. Therefore this study
increased unconjugated bilirubin concentrations caused was planned to analyze and ascertain the pattern,
by the breakdown of red blood cells. Bilirubin can causes, risk factors, treatment and outcome of neonatal
damage neurologic tissue and lead to bilirubin-induced hyperbilirubinemia in a tertiary care setup from
neurologic dysfunction [3]. northern India.
MATERIALS & METHODS
Bilirubin is potentially toxic to the central
The current study was planned and executed
nervous system hence early detection and appropriate
by the Department of Pediatrics in collaboration with
management of neonatal jaundice is of paramount
other departments of a tertiary care health center of
importance, especially when bilirubin even in
Northern India. A retrospective cohort of jaundiced
physiological ranges may cause permanent neuronal
neonates seeking care for their illness at this tertiary
injury [4, 5]. Although a safe threshold for total serum
care centre during formed the study population. In this
bilirubin has not been defined, most physicians have

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Payal Mittal et al.; Saudi J. Med. Pharm. Sci.; Vol-3, Iss-4 (Apr, 2017):278-281
study, all the jaundiced neonates with serum bilirubin > oxytocin administration during labour, were also
5mg/dl admitted in PNC and NICU wards over a period recorded. Serum bilirubin was also noted. Serial
of ten months were included in the study. The data were measurements were undertaken as per the requirements
collected retrospectively. Study tools were records of of individual case till serum bilirubin returned to the
the study subjects such as information from MRD physiological range.
department and clinical case sheets. During the study
period a total of 226 jaundiced neonates were eligible to All the proforma were manually checked and
enter in this study but data of 14 jaundiced neonates edited for completeness and consistency and were then
was discarded from the analysis because it was found coded for computer entry. After compilation of
incomplete while data cleaning. Thus finally data of 212 collected data, analysis was done using Statistical
jaundiced neonates was analyzed. Package for Social Sciences (SPSS), version 20 (IBM,
Chicago, USA). The results were expressed using
A proforma was designed to capture such appropriate statistical methods.
details. Details of newborns admitted to the neonatal
intensive care units with a diagnosis of Neonatal RESULTS
hyperbilirubinemia irrespective of other associated Data of 212 study subjects was analyzed in this
illnesses were studied. Serum bilirubin was monitored study. The mean age of neonates was 3.83 ± 2.6 days.
12 hourly for all babies and after 2 hours and 6 hours The mean age of mothers was 23.7 ± 3 years. The mean
following all exchange transfusions. The physical gestation age was calculated to be 38.01 ± 2 weeks.
examination findings revealing the presence of Around one fourth of neonates were preterm. Mean
cephalohematoma or suspicion of sepsis was noted. A bilirubin values for pathological cases (18.11± 5.54
complete hemogram including reticulocyte count, mg/dl) were significantly higher than physiological
hematocrit, total and differential leucocyte counts, jaundice (12.06 ± 3.59 mg/dl). The mean age of
blood grouping for mother and baby (ABO and Rh presentation with jaundice was three days. ABO and Rh
blood typing), blood culture, direct Coomb's test and incompatibility cases presented earlier on (within 3-4
screening for G6PD deficiency were done as a part of days) with jaundice than breast feeding jaundice cases
jaundice workup for all babies. Special investigations (6-7 days).
like T3, T4 and TSH levels, direct-reacting bilirubin
and Liver function tests, TORCH antibodies and Physiological jaundice was most common
metabolic screening were undertaken in selected cases. form (41.04%) of hyperbilirubinemia. Top three causes
Phototherapy and exchange blood transfusion were used or aggravating factors of pathological
to treat hyperbilirubinemia as per standard guidelines. hyperbilirubinemia were ABO incompatibility
The course of events on phototherapy (age of starting, (32.55%), Rh incompatibility (11.79%) and breast
duration, rate of fall of serum bilirubin, complications feeding (6.13%). Single cases of Significant bruising,
etc) and exchange transfusion (i.e. number of exchange Hypothyroidism and Galactosemia were also noted
transfusion per neonate, complications and mortality) down (Table 1).
were also noted down. Various details of newborns like
sex, weight, geatation, parity of mother, history of

Table 1: Causes and factors aggravating hyperbilirubinemia among study subjects

Cause or aggravating factor Number of cases Percentage
Physiological 87 41.04
Pathological ABO incompatibility 69 32.55
Rh incompatibility 25 11.79
Breast feeding 13 6.13
Birth asphyxia 6 2.83
Sepsis 5 2.36
Idiopathic 4 1.89
Significant bruising 1 0.47
Hypothyroidism 1 0.47
Galactosemia 1 0.47

Majority (48.58%) of the cases had their total comprising the physiological cases of
bilirubin levels equal to or below 15mg/dl mainly hyperbilirubinemia (Table 2).

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Payal Mittal et al.; Saudi J. Med. Pharm. Sci.; Vol-3, Iss-4 (Apr, 2017):278-281
Table 2: Distribution of bilirubin levels among study subjects
Bilirubin levels (mg/dl) Number of cases Percentage
Equal to or < 15 103 48.58
15-20 52 24.53
20-25 46 21.69
>25 11 5.18

Almost all the neonates showed improvement exposure until improvement. Exchange transfusion was
with phototherapy and exchange transfusion. Sixteen given only in six severe cases of jaundice due to ABO
physiologically jaundiced neonates improved without incompatibility (Table 3).
any active treatment. They were advised daily sun

Table 3: Management modality used among study subjects

Management modality used Number of cases Percentage
Phototherapy 190 89.62
Exchange transfusion 6 2.83
No treatment required 16 7.54

DISCUSSION undergo exchange transfusion that removes partially

The etiology and risk factors for indirect hemolysed and antibody coated blood cells [5].
neonatal hyperbilirubinemia is varied and Recently even Intravenous immunoglobins have been
multifactorial. The causes and risk factors associated used as additional treatment modality in cases of blood
were ABO and other blood group incompa- tibilities, group incompatibility to reduce the bilirubin levels [7].
glucose-6-phoshate-dehydrogenase deficiency, With such efficient treatment modalities available, all
infections, prematurity, male gender, ethnicity, that is needed is to identify such neonates at risk. A
breastfeeding and early hospital discharge [8]. Knowing Taiwanese study evaluated data on 11,328 children and
the risk factors and causes would help in devising concluded that neonatal jaundice increases the rate and
strategies in managing hyperbilirubinemia and also in complications of childhood allergic rhinitis [16]. This
counselling parents. suggests that children treated for neonatal
hyperbilirubinemia may require further childhood
We observed that around one fourth of follow up.
neonates were preterm. Prematurity is a prominent risk
factor for neonatal hyperbilirubinemia. Another study CONCLUSION
from Gujarat observed that 30% cases to be preterm On the basis of findings of this study it can be
babies like our study [9]. Preterm babies are at risk of concluded that hyperbilirubinemia is a common
developing jaundice due to the immature liver. problem encountered in our Neonatal Intensive Care
Generally babies with bilirubin levels above 20 mg/dl Units. Physiological hyperbilirubinemia is commonest
are considered to be at higher risk of developing cause of jaundice. ABO and Rh incompatibility are
kernicterus, however several studies have shown mainly responsible for pathological jaundice.
kernicterus to appear at much lower levels of 10 -18 Phototherapy is found to be a safe and cost-effective
mg/dl in premature infants [10]. way to manage neonatal jaundice.

In our study, most common risk factor was REFERENCES

ABO incompatibility. These observations are similar to 1. Maisels, M. J., & McDonagh, A. F. (2008).
the results of other study from Turkey [11]. Another Phototherapy for neonatal jaundice. New England
study from Iran disclosed that the most common causes Journal of Medicine, 358(9), 920-928.
of severe indirect hyperbilirubinemia were sepsis, blood 2. Hardy, J. B., Drage, J. S., & Jackson, E. C. (1979).
group incompatibility, G6PD deficiency, and unknown The first year of life: The collaborative perinatal
[12]. Sepsis was found to be commonest cause of project of the National Institutes of Neurological
pathological jaundice in studies from Shimla and and Communicative Disorders and Stroke.
Bangladesh respectively [13, 14]. Another study by Baltimore, John Hopkins University Press, p 104.
Narang A et al. found G6PD deficiency (17%) to be the 3. Gazzin, S., & Tiribelli, C. (2011). Bilirubin-
leading cause of pathological jaundice followed by induced neurological damage. J Matern Fetal
sepsis (9 %) [15]. Neonatal Med, 24 Suppl, 1154–155.
4. Johnson, L., & Bhutani, V. K. (2011, June). The
Almost all the neonates showed improvement clinical syndrome of bilirubin-induced neurologic
with phototherapy. A majority of jaundiced neonates dysfunction. In Seminars in perinatology (Vol. 35,
recover with phototherapy, very few who don’t, need to No. 3, pp. 101-113). WB Saunders.

Available Online: https://saudijournals.com/ 280

Payal Mittal et al.; Saudi J. Med. Pharm. Sci.; Vol-3, Iss-4 (Apr, 2017):278-281
5. Porter, M., & Dennis, B. (2002).
Hyperbilirubinemia in healthy term newborn. Am
Fam Physician, 65, 599- 606.
6. Maisels, M. J. (1994). Jaundice. In: Neonatology:
Pathophysiology and Management of Newborn.
Ed. Avery GB. Philadelphia, J P Lippincott
Company, pp 630-725.
7. Weng, Y. H., & Chiu, Y. W. (2009). Spectrum and
outcome analysis of marked neonatal
hyperbilirubinemia with blood group
incompatibility. Chang Gung Med J, 32(4), 400-
408.
8. McGillivray, A., & Evans, N. (2012). Severe
neonatal jaundice: Is it a rare event in Australia?.
Journal of paediatrics and child health, 48(9), 801-
807.
9. Shah, A., Shah, C. K., & Shah, V. (2012). Study of
hematological parameters among neonates admitted
with neonatal jaundice. Journal of Evolution of
Medical and Dental Sciences, 1(3), 203.
10. Maisels, M. J., & Newman, T. B. (1999).
Predicting hyperbilirubinemia in newborns: the
importance of timing. Pediatrics, 103(2), 493-494.
11. Davutoglu, M., Garipardiç, M., Güler, E.,
Karabiber, H., & Erhan, D. (2010). The etiology of
severe neonatal hyperbilirubinemia and
complications of exchange transfusion. The Turkish
journal of pediatrics, 52(2), 163.
12. Najib, K. S., Saki, F., Hemmati, F., & Inaloo, S.
(2013). Incidence, risk factors and causes of severe
neonatal hyperbilirubinemia in the South of iran
(fars province). Iranian Red Crescent Medical
Journal, 15(3), 260-263.
13. Bahl, L. A. L. I. T. A., Sharma, R. A. K. E. S. H.,
& Sharma, J. A. I. S. H. R. E. E. (1994). Etiology
of neonatal jaundice at Shimla. Indian pediatrics,
31(10), 1275-8.
14. Habibur, C., Hasan, A., & Yasmin, F. (2010).
Outcome of neonatal hyperbilirubinemia in a
tertiary care hospital in Bangladesh. Malaysian
Journal Med Sci, 17 (2), 40-44.
15. Narang, A., Gathwala, G., & Kumar, P. (1997).
Neonatal jaundice: an analysis of 551 cases. Indian
pediatrics, 34, 429-432.
16. Sun, H. L., Lue, K. H., & Ku, M. S. (2013).
Neonatal jaundice is a risk factor for childhood
allergic rhinitis: a retrospective cohort study.
American journal of rhinology & allergy, 27(3),
192-196.

Available Online: https://saudijournals.com/ 281