Study on Newborn Babies With a Yellow Skin Color (Neonatal Jaundice Study)
Study on Newborn Babies With a Yellow Skin Color (Neonatal Jaundice Study)
Background:

 Neonatal hyperbilirubinemia is the most common reason for admission in the neonatal period
 (first month of life) worldwide and at SMRU. The skin of the newborn baby becomes jaundiced,
 which is caused by a high level of bilirubin in the blood. In some neonates the level of
 bilirubin increases to a level that can cause braindamage or even death. There are different
 causes known that can lead to higher levels of bilirubin, for example G6PD deficiency and
 prematurity. In case of neonatal hyperbilirubinemia the neonate needs to be treated with
 phototherapy (blue light therapy). If there is prolonged jaundice (≥ 21 days), further
 investigations needs to be done.

 Objectives:

 Primary objective:

 To determine the etiology of neonatal hyperbilirubinemia in neonates with a gestational age
 of ≥ 28 weeks from the refugee and migrant population, on the Thai-Myanmar border.

 Secondary objective:

 -  Establishing the incidence of neonatal hyperbilirubinemia

 -  Determine the risk factors for the development of neonatal hyperbilirubinemia

 -  Determine the incidence of prolonged neonatal jaundice

 -  Determine the neurodevelopmental outcome, at the age of 6 and 12 months

 -  Determine the body composition, using air-displacement plethysmography, at birth, 1, 2
 and 3 months of age

 -  Determine the incidence of anaemia and illness episodes during the first year of life

 -  Determine the incidence of helminthic infection at the age of one year

 -  Assess the knowledge level and misbeliefs on neonatal hyperbilirubinemia among the
 mothers and SMRU health care staff

 Research design:

 The study will conduct an exhaustive prospective descriptive study, all eligible newborns
 will be enrolled after obtaining the informed consent from their mothers. During pregnancy
 and delivery we will collect clinical data about the mother. At birth we will take umbilical
 cord blood (9 ml) to test for different causes of neonatal hyperbilirubinemia. In the first
 week of life we plan 4 moments to measure the bilirubin and hematocrit level (0.05 ml),
 weight and ask questions about feeding and other practices. Based on the bilirubin results we
 will determine whether the neonate needs phototherapy. After the first week we weekly
 follow-up will be conducted and in case of visible jaundice we will measure the bilirubin
 level. If the neonate is still jaundiced after the age of 21 days we will further investigate
 the cause. In the infant period, until the age of one year, we plan to have monthly follow-up
 to assess the health and growth of the child and at the age of 3, 6 and 12 months we will do
 a neurodevelopmental test.

 An improved understanding of the pathological processes contributing to the development of
 neonatal hyperbilirubinemia is needed in order to to identify neonates at risk and develop
 improved management.
PROCEDURES DURING PREGNANCY

 During the first antenatal care visit the mother will have a gestational dating ultrasound to
 determine the accurate gestational age. During all antenatal care visits information about
 the mother will be collected as part of standard obstetric care:

 -  Ethnicity

 -  Age

 -  Medical history

 -  Blood transfusion in history

 -  Chronic diseases

 -  Obstetric history

 -  Parity and gravida

 -  Previous neonatal deaths and reason of death

 -  Previous preterm delivery

 -  Previous child with neonatal hyperbilirubinemia

 -  Pregnancy

 -  Gestational dating ultrasound

 -  Obstetric problems

 -  Malaria and morbidity episodes during pregnancy

 -  BMI, MUAC and weightgain

 -  Laboratory results

 -  Hepatitis B status*

 -  HIV status*

 -  Syphilis serology*

 -  G6PD status

 -  Hemoglobinopathy

 -  ABO blood group

 -  Rhesus D blood group

 Testing for STD and HIV is routine practice at the SMRU clinics. Before the screening
 permission from the mother is requested. Life-long antiretroviral triple therapy is available
 in case of a positive HIV test.

 To assess the knowledge and beliefs on neonatal jaundice among the mothers we will perform a
 short questionnaire. This questionnaire will help the study team to assess the level of
 knowledge and the misbeliefs on neonatal hyperbilirubinemia. The study team will also ask the
 subjects about the use of naphthalene containing moth balls and explain them the danger in
 case the subject's baby will be G6PD deficient.

 PROCEDURES AT BIRTH

 Eligibility:

 At birth the neonate will be excluded if the gestational age is < 28 weeks.

 Questionnaire:

 Detailed data about the delivery will be collected:

 -  Duration of maternal membrane rupture before delivery

 -  Mode of delivery

 -  Presence of maternal fever in labour and use of antibiotics

 -  Use of oxytocin

 -  Complications

 -  Gestational age

 -  Confirmed by ultrasound if presenting < 24 weeks (CRL < 14 weeks, HC 14-23+6) or,
 in case of late ultrasound, determined with the Dubowitz gestational age assessment
 (performed 6-72 hours after birth)

 -  Apgar score and need for resuscitation

 -  Gender

 Laboratory Investigations:

 Umbilical cord blood will be obtained for laboratory investigations as below;

 ABO and Rhesus D blood group 0.1 ml., G6PD fluorescent test 0.005 ml., G6PD
 spectrophotometric assay 0.05 ml., G6PD flow cytometric assay 0.05 ml., Coomb's test (Direct
 Antiglobulin Test) 3 ml., Albumin 3 ml., Genotyping (G6PD, SAO, UGT1A1 mutations) 2 ml.,

 Total volume 8.205 ml (For practical reason we will take 9 ml.)

 Clinical assessment:

 Birthweight, length and head circumference will be determined. The body composition will be
 measured using air-displacement plethysmography (PeaPod) . A newborn physical examination
 (including vital signs) will be performed within the first 24 hours, as part of normal
 neonatal care:

 Observations:

 -  skin colour (pale/cyanosed/jaundiced/normal),

 -  skin rash

 -  description of anterior fontanelle (raised/normal/depressed),

 -  bruising on the body: location

 -  swelling on the head

 -  2 diameters will be measured

 -  swelling crossing the scalp sutures

 -  diagnose: caput succedaneum, cephalhematoma or subgaleal hemorrhage

 -  abnormality of the face

 -  abnormality of palate, mouth

 -  abnormality of limbs, fingers or toes

 Cardiovascular examination: heart rate(per minute), heart sounds, femoral pulses

 Respiratory examination: respiratory rate (per minute), lung sounds, signs of respiratory
 distress (chest indrawing/nasal flaring/head bobbing)

 Abdominal examination: abdominal mass, enlarged liver or spleen, genitalia, anus

 Neurological examination: muscle tone, moving of limbs, eye red reflex

 PROCEDURES DURING NEONATAL FOLLOW-UP

 In the first week after birth there are four moments when the neonate will be assessed. This
 will be 24 hours [range 22-26 hours], 48 hours [range 36-60 hours], 84 hours [range 70-96
 hours] and on day 6 [range day 5-8]. After this week the mother will be asked to come back
 for weekly follow-up until the age of one month. At one month of age the body composition
 will be measured using PeaPod.

 Questionnaire:

 The mother will be asked questions:

 First 24 hours after delivery:

 -  Age (in hours) of initiation of feeding

 -  Feeding:

 -  How is the baby being fed (exclusive breastmilk, supplementary or mixed feeding)

 -  If supplementary feeding, what is the reason for this?

 -  Does the baby suck well?

 -  Use of drugs or herbal medicine by mother in first 24 hours

 -  Use of herbal preparations for neonate

 -  Age (in hours) at passage of first stool and urine

 -  Use of napthalene balls for storing of baby clothes

 During every follow-up the mother the questions about feeding will be repeated.

 Laboratory Investigations:

 During every neonatal follow-up until the visit on day 6 [range day 5-8], a SBR and
 haematocrit will be measured. The SBR result will be plotted, by age on a jaundice treatment
 graph specific for the gestational age and the need for phototherapy or more intense
 follow-up will be determined. During weekly follow-up after the age of 8 days, only a SBR and
 hematocrit will be measured in case of visible jaundice. At the age of one month, a
 hematocrit will be measured for anemia screening and the G6PD fluorescent test will be
 repeated as below.

 Serum bilirubin 0.05 ml. x 5, Haematocrit 0.05 ml. x 5, G6PD fluorescent test 0.005 ml.

 Total 0.205 ml.

 Clinical assessment:

 A physical examination (including vital signs) will be performed at every visit and the
 weight will be measured. Weightloss or -increase will be calculated and if there is ≥ 10%
 weightloss, the neonate will be reviewed carefully for any underlying cause of this
 weightloss and supplementary feeding (expressed breastmilk or powdermilk) will be started.

 PROCEDURES WHEN DELIVERY OUTSIDE SMRU

 In case of delivery in another clinic or at home, but the mother and neonate visit a SMRU
 clinic within the first 48 hours after delivery, the neonate can still be included in the
 study.

 If a neonate is born outside SMRU and does not visit the clinic within 48 hours after
 delivery, but presents with neonatal hyperbilirubinemia in the first 8 days of life, this
 neonate can be included in the study as well. Because no umbilical cord blood was taken, a
 limited set of laboratory investigations will be performed, as described as below;.

 ABO and Rhesus D bloodgroup 0.075 ml., G6PD fluorescent test 0.005 ml., G6PD
 spectrophotometric assay 0.05 ml., G6PD flow cytometric assay 0.05 ml., Serum bilirubin 0.05
 ml., Haematocrit 0.05 ml., Genotyping 2 ml.,

 Total volume 2.23 ml.

 PROCEDURES DURING INFANT FOLLOW-UP

 Infant follow-up will take place every month until the age of 12 months.

 Questionnaire:

 At every visit the mother will be asked about feeding practices and after the age of 6 months
 about neurodevelopmental milestones.

 Laboratory investigations:

 Due to the problems of anaemia in this population (50% of the infants are reported to have a
 haematocrit of < 33% at the age of 6 months; personal communication Dr. Rose McGready)
 haematocrit will be measured monthly, by finger prick, and anaemia will be treated if
 necessary. At the age of one year a stool test for parasitology screening will be taken and
 the infant will be treated if necessary. Finally at one year of age the infant will be
 screened for hemoglobinopathy due to contradictory reports of the association between
 neonatal hyperbilirubinemia and hemoglobinopathy as below:

 Haematocrit 0.05 ml. x11, Hemoglobin typing 3 ml.

 Total volume 3.55 ml.

 Clinical assessment:

 A physical examination (including vital signs) will be performed at every visit and the
 weight will be measured. At the age of 2 and 3 month a body composition will be measured
 using PeaPod. At 3, 6, 9 and 12 months the length and head circumference will be measured.

 At the age of 3, 6 months and 12 months the infant will be assessed with the Shoklo
 Developmental Test 53 and the results compared to age specific norms developed for this
 population.
Inclusion Criteria:

 -  Written or thumb print informed consent from the mother during pregnancy

 -  Neonates who are born to mothers who followed antenatal care at SMRU antenatal clinics

 -  Neonates who are born in a SMRU clinic OR neonates who are born outside SMRU but visit
 a SMRU clinic within 48 hours after birth OR neonates who are born outside SMRU and
 present with neonatal jaundice at any moment in the first 8 days

 Exclusion Criteria:

 -  No written or thumb print informed consent from the mother during pregnancy

 -  Neonates who are born to mothers who did not follow antenatal care

 -  Neonates < 28 weeks gestation

 -  Neonate born outside SMRU and present > 48 hours after delivery without jaundice