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. 2018 Jun 12;18(1):190.
doi: 10.1186/s12887-018-1165-0.

Indirect Neonatal Hyperbilirubinemia in Hospitalized Neonates on the Thai-Myanmar Border: A Review of Neonatal Medical Records From 2009 to 2014

Free PMC article

Indirect Neonatal Hyperbilirubinemia in Hospitalized Neonates on the Thai-Myanmar Border: A Review of Neonatal Medical Records From 2009 to 2014

L Thielemans et al. BMC Pediatr. .
Free PMC article


Background: Indirect neonatal hyperbilirubinemia (INH) is a common neonatal disorder worldwide which can remain benign if prompt management is available. However there is a higher morbidity and mortality risk in settings with limited access to diagnosis and care. The manuscript describes the characteristics of neonates with INH, the burden of severe INH and identifies factors associated with severity in a resource-constrained setting.

Methods: We conducted a retrospective evaluation of anonymized records of neonates hospitalized on the Thai-Myanmar border. INH was defined according to the National Institute for Health and Care Excellence guidelines as 'moderate' if at least one serum bilirubin (SBR) value exceeded the phototherapy threshold and as 'severe' if above the exchange transfusion threshold.

Results: Out of 2980 records reviewed, 1580 (53%) had INH within the first 14 days of life. INH was moderate in 87% (1368/1580) and severe in 13% (212/1580). From 2009 to 2011, the proportion of severe INH decreased from 37 to 15% and the mortality dropped from 10% (8/82) to 2% (7/449) coinciding with the implementation of standardized guidelines and light-emitting diode (LED) phototherapy. Severe INH was associated with: prematurity (< 32 weeks, Adjusted Odds Ratio (AOR) 3.3; 95% CI 1.6-6.6 and 32 to 37 weeks, AOR 2.2; 95% CI 1.6-3.1), Glucose-6-phosphate dehydrogenase deficiency (G6PD) (AOR 2.3; 95% CI 1.6-3.3), potential ABO incompatibility (AOR 1.5; 95% CI 1.0-2.2) and late presentation (AOR 1.8; 95% CI 1.3-2.6). The risk of developing severe INH and INH-related mortality significantly increased with each additional risk factor.

Conclusion: INH is an important cause of neonatal hospitalization on the Thai-Myanmar border. Risk factors for severity were similar to previous reports from Asia. Implementing standardized guidelines and appropriate treatment was successful in reducing mortality and severity. Accessing to basic neonatal care including SBR testing, LED phototherapy and G6PD screening can contribute to improve neonatal outcomes.

Keywords: (LED-) phototherapy; Indirect neonatal hyperbilirubinemia; Jaundice; Low-resource; Migrant; Mortality; Neonates; Refugee; Resource-limited setting.

Conflict of interest statement

Ethics approval and consent to participate

This retrospective analysis of anonymized data was exempted from formal ethical review (confirmed by Oxford Tropical Research Ethics Committee (OxTREC) on February 2017) and discussed with the Tak Province Border Community Ethics Advisory Board (T-CAB-01/FEV/2017). The retrospective anonymized dataset made the requirement for individual informed consent not applicable for this study.

Competing interests

All authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.


Fig. 1
Fig. 1
Evolution of care over time. Treatment, diagnostic tools, guidelines and experience of the staff developed over time. Cut off values for phototherapy was based on different guidelines and the type of phototherapy available changed: home built phototherapy units with fluorescent light were available initially and then manufactured bulbs (Philips TL20 W) were used until LED-lights became available. In 2013, collaboration with a tertiary hospital in Thailand was set up to refer neonates who needed exchange transfusion. The condition for referral was a bilirubin more than 550 μmol/L not responding to phototherapy
Fig. 2
Fig. 2
Records of neonates born after 28 weeks of gestational age hospitalized between 2009 and 2014
Fig. 3
Fig. 3
Timing of first serum bilirubin confirming the degree of severity of INH. Each neonate is represented once, when the SBR measurement reached the moderate threshold (and never passed the severe threshold) or reached the severe threshold for the first time in the first 14 days of life

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