Background
Methods
Study design and setting
No | Issue | Current Practice | New Protocol | Rationale for Change |
---|---|---|---|---|
1. | What clinical assessment and laboratory investigations are needed in the initial assessment of PNNJ? | Clinical assessment is not emphasised, and a routine list of laboratory investigation is done according to local/national protocol for all term babies with jaundice at 14 days of life. | Low risk babies At day 14: Do a complete clinical assessment using the assessment form and take total serum bilirubin with differential At day 21 if still jaundice: Repeat clinical assessment and carry out a simple list of lab investigation - Total serum bilirubin with differentials - Full blood count and reticulocyte count - Urine dipstick & microscopy test and - Free T4, TSH Intermediate/ high risk babies Refer to Paediatric team for further management | New system aims to focus on good clinical assessment. In well, breastfed term babies half of them will have jaundice resolved by 21 days of life [30]. Prompt referral of babies with risks and unwell babies to paediatricians. |
2. | Is there a checklist for clinical assessment? | No | Yes, serves both as a checking list and referral sheet. | Ensure all essential clinical assessments are done for risk stratification |
3. | Where could the initial assessment take place? | Paediatric clinics only. | Any nearby health clinics or district hospitals. | This aims to empower health clinics/ district hospitals to do the initial clinical assessment and workup and follow up on the low-risk babies. Specialist clinics will focus more on intermediate or high-risk cases. |
4. | Heel prick capillary bilirubin vs total serum bilirubin with differential | Babies with PNNJ undergo repeated heel-prick capillary bilirubin in the health clinics, until the jaundice resolved. | Total serum bilirubin with differential is needed at 14 days and only repeated as necessary | Main aim of total serum bilirubin with differential is to pick up conjugated hyperbilirubinaemia [2] Heel-prick capillary bilirubin is not useful in the management of PNNJ. |
5. | Urine sampling | Babies with PNNJ undergo urine culture, whereby sampling is done by clean catch, bladder catheterization or suprapubic aspiration. | Only urine dipstick & microscopy test and is needed. Sampling via urine bag is acceptable. Urine culture will be considered for suspected cases [18]. | The incidence of UTI in asymptomatic, afebrile and jaundiced babies ranged from 5.5–21% [31]. There is a role of urine dipstick & microscopy only in the screening of UTI in well, jaundiced babies [18]. |
6. | Thyroid function tests (Free T4/ TSH) | This is conducted for all babies with PNNJ at day 14 | This is conducted for all intermediate or high-risk babies and low risk babies if still jaundice at day 21 | Thyroid function test is necessary to detect congenital hypothyroidism cases that are missed by the newborn screening programme [32]. |
7. | Full blood picture | This is conducted for all babies with PNNJ at day 14 | Full blood count and reticulocyte counts are conducted for all intermediate or high-risk babies and low risk babies if still jaundice at day 21. Full blood picture is considered only if there is a suspicion of ongoing or significant haemolysis (eg: low haemoglobin / pallor/ hepatosplenomegaly/ family history/ significant neonatal jaundice) | No more routine full blood picture in the workup for PNNJ. |
8. | Assessment of stool colour by history or inspection | Not emphasised | Assessment of stool colour by history or inspection is emphasised. | Pale stool signifies obstructive jaundice [21]. |
9. | Is warning signs for serious conditions (especially biliary atresia) routinely given? | No | Yes | This is to create awareness and serves as a safe-netting mechanism. |
10. | Follow-up plans for well babies who are still jaundice (low risk cases) | No. Babies are rendered heel-prick capillary bilirubin till jaundice resolves. | If day-21-tests were normal, the baby could be discharged with warning signs and reviewed during routine medical examination at 1 and 2 months old. | This will reduce unnecessary investigations, clinic visits and improve compliance to follow up. |
Meeting and consensus among stakeholders
Implementation of the new protocol
Data analysis
Results
The changes seen in practice after implementing the new protocol
Management of prolonged neonatal jaundice | Mean (SD) | p value* | |
---|---|---|---|
Pre (n = 199 cases) | Post (n = 145 cases) | ||
Postnatal age upon referral (day) | 16.54 (± 5.46) | 20.01 (±11.14) | p = 0.001 |
Days taken to be seen at hospital level after referral (days) | 20.9 (±11.38) | 21.5 (±9.69) | p = 0.617 |
Clinical Assessment | |||
●5 important points in patient history taking (score)a | 3.26 (±1.58) | 4.44 (±0.92) | p < 0.001 |
●4 important points in family history taking (score)b | 0.53 (±1.10) | 2.14 (±1.89) | p < 0.001 |
●5 important points in physical examinations (score)c | 3.78 (±1.50) | 4.49 (±1.00) | p < 0.001 |
Number of lab investigations done before referral to the hospital | 2.22 (±2.09) | 1.57 (±1.68) | p = 0.020 |
Total number of laboratory investigations done per patient at the hospital level | 9.01 (±2.99) | 5.81 (±3.12) | p < 0.001 |
Total number of visits per patient from the time of referral to discharge | 2.46 (±1.27) | 2.20 (±0.92) | p = 0.040 |
Warning sign givend | NA | 75.2% | NA |
Pre-interventione | Post-interventionf | ||
---|---|---|---|
Type of laboratory investigation | The number of laboratory investigations; n = 1758 | Type of laboratory investigation | The number of laboratory investigations; n = 811 |
Total serum bilirubin without differential | 249 (14.2) | Serum bilirubin with differential | 203 (25.0) |
Urine culture and sensitivity test | 237 (13.5) | Urine dipstick & microscopy test | 107 (13.2) |
Liver function test | 198 (11.3) | Free T4/TSH | 105 (12.9) |
Serum bilirubin with differential | 194 (11.0) | Full blood counts | 98 (12.1) |
Free T4/TSH | 180 (10.2) | Reticulocyte count | 86 (10.6) |
Full blood counts | 165 (9.4) | Total serum bilirubin without differential | 39 (4.8) |
Full blood picture | 139 (7.9) | Urine culture and sensitivity test | 25 (3.1) |
Urine dipstick & microscopy test | 131 (7.5) | Liver function test | 63 (7.8) |
Reticulocyte count | 102 (5.8) | Renal Profile | 24 (3.0) |
Renal Profile | 87 (4.9) | Full blood picture | 21 (2.6) |
G6PD | 47 (2.7) | G6PD | 9 (1.1) |
Blood Group | 24 (1.4) | Blood Group | 0 (0.0) |
Ultrasound | 3 (0.2) | Ultrasound | 3 (0.4) |
TORCHES | 2 (0.1) | TORCHES | 4 (0.5) |
Urine dipstick | 0 (0.0) | Urine dipstick | 24 (3.0) |
Self-reporting surveillance system
Prolonged neonatal jaundice registry
Month | Total Live Birth, n | Total PNNJ Case, n (%) | Facility of Detection, n (%) | Risk Stratification, n (%) | |||
---|---|---|---|---|---|---|---|
Clinic | Hospital | Low | Intermediate | High | |||
Jan | 2436 | 430 (17.7) | 325 (75.6) | 105 (24.4) | 413 (96.0) | 13 (3.0) | 4 (1.0) |
Feb | 1657 | 226 (13.6) | 154 (68.1) | 72 (31.9) | 212 (94.0) | 5 (2.0) | 9 (4.0) |
Mar | 2681 | 494 (18.4) | 396 (80.2) | 98 (19.8) | 445 (90.0) | 20 (4.0) | 29 (6.0) |
Apr | 3193 | 426 (13.3) | 366 (85.9) | 60 (14.1) | 388 (91.0) | 26 (6.0) | 13 (3.0) |
Total | 9967 | 1576 (15.8) | 1241 (78.7) | 335 (21.3) | 1450 (92.0) | 63 (4.0) | 63 (4.0) |