BIND score: A system to triage infants readmitted for extreme hyperbilirubinemia.

Extreme hyperbilirubinemia [EHB, total serum bilirubin (TB) >25 mg/dL]) can lead to death, acute bilirubin encephalopathy (ABE), exchange transfusion, and/or bilirubin-induced neurologic dysfunction (BIND). In specific low- to middle-income countries, an "epidemic" exists, therefore, a simplified triage management system is needed. Here, we studied a cohort of 72 infants readmitted for EHB (TB: 28.1 ±â€¯2.5; range: 25-42 mg/dL). Of these, 15/72 (20.8%) newborns had BIND scores ≥4. Eleven (15.3%) infants with BIND scores of 4 to 6 developed moderate ABE, with 6/11 (54.5%) with TB of 28.1 ±â€¯4.8 mg/dL having post-icteric sequelae. Eight infants (TB of 32.1 ±â€¯3.5 mg/dL) had BIND scores >6 and developed adverse outcomes. One infant, who had Rh disease and a BIND score of 8 died. We report that the key determinants for adverse outcomes were TB >30 mg/dL and a BIND score ≥4 and may be useful for a systems approach to triage infants readmitted for EHB.

Assessment of adherence level for neonatal hyperbilirubinemia management by various physicians in Iraq: a multi-clinic study.

Background: Neonatal jaundice is a physiological process that occurs normally for every infant to a varying degree. In some cases, this process becomes pathological and imposes an increased risk of morbidity and mortality for the infant. The aim of this study was to assess the adherence level of various physicians to different guidelines of management of neonatal hyperbilirubinemia in Iraq. Methods: An observational cross-sectional study was conducted in multiple outpatient clinics in various Iraqi provinces, from February 2018 to February 2019. The study involved 130 physicians, who were divided into emergency physicians (EPs), general practitioners (GPs), and pediatricians (PDs), and assessed their compliance to guidelines for management of neonatal hyperbilirubinemia using a questionnaire, which included providing the correct management for a test case scenario. Results: PDs had significantly longer discharge times compared to EPs and GPs. In total, 91.7 % of PDs always tested the neonate for bilirubin levels before discharge, while 5.5 % of GPs and 0% of EP did so. Regarding follow-up visits, 16.7 %, 4.8% and 45.2% of PDs, EPs and GPs, respectively, scheduled a follow-up between 49-72 hours; 47.6 % and 38.1% of EPs scheduled a follow-up at ≤24 hours and 25-48 hours, respectively . In addition, 91.7% of PDs gave the correct answer for the management of the test case scenario, followed by 58.9% of GPs, and 38.1% of EPs . About half of PDs extended neonates length of stay beyond 48 hours. Conclusion: GPs and EPs show lower adherence levels for the management of neonatal jaundice than PDs, which indicates that these physicians adhere well to current management guidelines from the WHO, AAP, and NICE.

The use of continuous positive airway pressure in preterm babies with respiratory distress syndrome: a report from Baghdad, Iraq.

OBJECTIVES: To study maternal and neonatal risk factors related to outcome of preterm babies with respiratory distress syndrome (RDS) on Continuous Positive Airway Pressure (CPAP) in a tertiary Iraqi NICU. METHODS: A prospective case study carried out from January 5, 2011 to January 5, 2012, on 70 preterm neonates with RDS who were started on CPAP. Maternal and infant variables of preterm babies with successful or failed CPAP therapy were compared. RESULTS: Seventy neonates, 44 (63%) males and 26 (37%) females were included. Mean (SD) gestation was 32.8 (2.8) weeks and mean (SD) birth weight was 1860 (656) g. Thirty-seven (52.9%) babies failed CPAP, of them 29 (78.3%) were started on mechanical ventilation. The variables associated with failure of CPAP were: Birth weight ≤1500 g, gestational age ≤30 weeks, white out on the chest X-ray, FiO2 ≥50% at 20 min of CPAP, PEEP ≥5.5 cm H2O. Mortality rates were 94.6% in CPAP failures versus 5.4% in CPAP successes (p = 0.001). In infants surviving till discharge, duration of hospital stay was longer in babies who were CPAP successes (9.6 ± 3.7 versus 3.0 ± 2.7 days, p = 0.001). CONCLUSIONS: Gestational age, birth weight, whiteout chest X-ray, and FiO2 are important predictive values for success of CPAP therapy. A larger prospective multicenter controlled trial is needed to determine the benefits and risks of CPAP and predictors of its failure in our setting. Our results may be useful for others practicing in similar settings as us.

Severe neonatal hyperbilirubinemia and adverse short-term consequences in Baghdad, Iraq.

BACKGROUND: Severe neonatal hyperbilirubinemia, when unmonitored or untreated, can progress to acute bilirubin encephalopathy (ABE). Initiatives to prevent and eliminate post-icteric sequelae (kernicterus) are being implemented to allow for timely interventions for bilirubin reduction. OBJECTIVES: We report an observational study to determine the clinical risk factors and short-term outcomes of infants admitted for severe neonatal jaundice. METHODS: A post-discharge medical chart review was performed for a cohort of infants admitted for management of newborn jaundice to the Children Welfare Teaching Hospital during a 4-month period in 2007 and 2008. Immediate outcomes included severity of hyperbilirubinemia, association of ABE, need and impact of exchange transfusion, and survival. Short-term post-discharge follow-up assessed for post-icteric sequelae. RESULTS: A total of 162 infants were admitted for management of severe jaundice. Incidences of severe sequelae were: advanced ABE (22%), neonatal mortality within 48 h of admission (12%) and post-icteric sequelae (21%). Among the cohort, 85% were <10 days of age (median 6 days, IQR 4-7 days). Readmission total serum bilirubin ranged from 197 to 770 µM; mean 386 ± 108 SD µM (mean 22.6 ± 6.3 SD mg/dl; median 360, IQR 310-445 µM). The major contributory risk factor for the adverse outcome of kernicterus/death was admission with advanced ABE (OR 8.03; 95% CI 3.44-18.7). Other contributory factors to this outcome, usually significant, but not so for this cohort, included home delivery, sepsis, ABO or Rh disease. Absence of any detectable signs of ABE on admission and treatment of severe hyperbilirubinemia was associated with no adverse outcome (OR 0.34; 95% CI 0.16-0.68). CONCLUSIONS: Risks of mortality and irreversible brain injury among healthy infants admitted for newborn jaundice are urgent reminders to promote education of communities, families and primary health care providers, especially in a fractured health system. Known risk factors for severe hyperbilirubinemia were overwhelmed by the effect of advanced ABE.