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Paediatrica Indonesiana

VOLUME 50 November  NUMBER 6

Original Article

Incidence of neonatal hyperbilirubinemia in low,


intermediate-low, and intermediate-high risk group infants
Ahmedz Widiasta, Lelani Reniarti, Abdurachman Sukadi

H
Abstract yperbilirubinemia is a common problem
Background Neonatal hyperbilirubinemia is commonly found LQ QHZERUQV ZKLFK PD\ GHYHORS WR
in newborns. Assessment of the risk of hyperbilirubinemia severe hyperbilirubinemia if not managed
and information on the average time of the occurrence of
properly. Early discharge of healthy-
hyperbilirubinemia are important to prevent the development of
severe hyperbilirubinemia. WHUP QHZERUQ DQG LQDGHTXDWH EUHDVWIHHGLQJ PLJKW
Objective To find out the incidence of and the time of the OHDG WR XQGHWHFWHG K\SHUELOLUXELQHPLD ZKLFK FDQ
development of hyperbilirubinemia in healthy-term newborns. FDXVH .HUQ LFWHUXV D UHHPHUJHQF\ FRQGLWLRQ 
Method A cohort prospective study was done on healthy-term 7KHUHIRUHHDUO\GHWHFWLRQRIDQGDFNQRZOHGJLQJWKH
QHZERUQV ERUQ DW +DVDQ 6DGLNLQ +RVSLWDO EHWZHHQ 1RYHPEHU
DQG'HFHPEHU6XEMHFWVZHUHGLYLGHGLQWRJURXSVRIULVN
risk factors of hyperbilirubinemia are important to
DWGLVFKDUJHGEDVHGRQ%KXWDQLQRUPRJUDP$VHULDOELOLUXELQ be conducted before discharging newborns from the
level measurement were performed within 6 days. hospital. 
Results 2QH RI  QHZERUQV DW ORZ ULVN JURXS GHYHORSHG %KXWDQLQRPRJUDPZKLFKZDVGHYHORSHGEDVHG
K\SHUELOLUXELQHPLD EXW GLG QRW QHHG SKRWRWKHUDS\ 6L[ RI
on postnatal age (in hours) and total serum bilirubin
 QHZERUQV DW LQWHUPHGLDWHORZ ULVN JURXS GHYHORSHG
K\SHUELOLUXELQHPLD  RI WKHP QHHGHG SKRWRWKHUDS\ ZLWK WRWDO OHYHOLVDQHVVHQWLDOWRROWRSUHYHQWVHYHUHK\SHUELOL-
VHUXPELOLUXELQOHYHORIPJG/DWKRXUVDQGPJG/DW rubinemia. This nomogram consists of four risk zones
KRXUV1LQHRIQHZERUQVRILQWHUPHGLDWHKLJKULVNJURXS IRUWKHLQFLGHQFHRIVHYHUHK\SHUELOLUXELQHPLDLHORZ
GHYHORSHGK\SHUELOLUXELQHPLDRIWKHPQHHGHGSKRWRWKHUDS\ LQWHUPHGLDWHORZ LQWHUPHGLDWHKLJK DQG KLJK ULVN
ZLWK WRWDO VHUXP ELOLUXELQ OHYHO RI  PJG/ DW  KRXUV
There was no newborn cathegorized as high risk group in this
zone. The incidence of severe hyperbilirubinemia
study. The median time the occurrence of hyperbilirubinemia in LQ KLJK LQWHUPHGLDWHKLJK LQWHUPHGLDWHORZ DQG
LQWHUPHGLDWHORZDQGLQWHUPHGLDWHKLJKULVNJURXSZDVKRXUV ORZ ULVN JURXSV DUH    DQG 
DQGKRXUVUHVSHFWLYHO\7KHUHZDVQRVLJQLILFDQWGLIIHUHQFHLQ respectively.
survival curve between intermediate-high and intermediate-low
ULVNJURXSV &, 
Conclusion The incidence of hyperbilirubinemia was not different
between intermediate-low and intermediate-high risk babies.
[Paediatr Indones. 2010;50:351-4].
)URP WKH 'HSDUWPHQW RI &KLOG +HDOWK 3DGMDMDUDQ 8QLYHUVLW\ +DVDQ
6DGLNLQ+RVSLWDO%DQGXQJ,QGRQHVLD
Keywords: neonatal hyperbilirubinemia, survival,
risk. Reprint request to$KPHG]:LGLDVWD0''HSDUWPHQWRI&KLOG+HDOWK
3DGMDMDUDQ8QLYHUVLW\+DVDQ6DGLNLQ+RVSLWDO-O3DVWHXU1R%DQGXQJ
,QGRQHVLD7HO(PDLOahmedzwidiasta@gmail.
com.

Paediatr Indones, Vol. 50, No. 6, November 2010351


Ahmedz Widiasta et al: Incidence of neonatal hyperbilirubinemia in risky infants

It is commonly found in developing countries Results


that parents do not bring their newborn baby to
the health services for follow up evaluation due to 'XULQJ WKH VWXG\ SHULRG WKHUH ZHUH  QHZERUQV
financial problem. This may result in late detection FRQVLVWHGRIORZULVNEDELHVLQWHUPHGLDWHORZ
RIK\SHUELOLUXELQHPLD7KHUHIRUHDVWXG\RIVXUYLYDO ULVNEDELHVLQWHUPHGLDWHKLJKULVNEDELHVDQGQRQH
analysis is needed to find out more accurately when RIKLJKULVNEDELHV2IQHZERUQVWKHUHZHUH
hyperbilirubinemia develops. PDOHVDQGIHPDOHV$OORIWKHQHZERUQVGLGQRW
have a history of hyperbilirubinemia of their sibling(s).
7KHPHDQDJHRIPRWKHULQORZLQWHUPHGLDWHORZDQG
Methods LQWHUPHGLDWHKLJKULVNJURXSZHUH 6' 
DQG 6' \HDUVFRQVHFXWLYHO\
This prospective cohort study was conducted on 6L[WHHQ RI    QHZERUQV GHYHORSHG
KHDOWK\WHUP QHZERUQV ZKR ZHUH ERUQ DW +DVDQ K\SHUELOLUXELQHPLD FRQVLVWHG RI  IHPDOHV DQG 
6DGLNLQ +RVSLWDO EHWZHHQ  1RYHPEHU DQG  PDOHV+\SHUELOLUXELQHPLDRFFXUUHGLQRIORZULVN
'HFHPEHU:HLQFOXGHGVLQJOHEDE\VSRQWDQHRXV QHZERUQV  RI LQWHUPHGLDWHORZ ULVN QHZERUQV
GHOLYHU\WHUPDSSURSULDWHIRUJHVWDWLRQDODJHURRPHG DQGRILQWHUPHGLDWHKLJKULVNQHZERUQV
LQ ZLWK WKH PRWKHU SDUHQWV OLYHG LQ %DQGXQJ DQG The characteristics of the newborns in a low risk
obtained parental written consent. We excluded group are presented in Table 1. Most newborns were
QHZERUQV IURP XQPDUULDJH FRXSOHV DQG KDV $%2 EUHDVWIHG2IWKHEUHDVWIHGQHZERUQVRQHGHYHORSHG
LQFRPSDWLELOLW\$PLQLPDOVDPSOHVL]HRILQHDFK hyperbilirubinemia. The mean of birth weight was
group was needed.  6' JUDPVDJHDWGLVFKDUJHZDV 6'
Total serum bilirubin level examination was  KRXUVDQGELOLUXELQVHUXPOHYHODWGLVFKDUJH
SHUIRUPHG DW WKH WLPH RI GLVFKDUJH HYHU\  ZDV 6' PJG/
KRXUVDIWHUZDUGVXQWLOWKHDJHRIKRXUVRULQFDVH (LJKWRI  QHZERUQVLQLQWHUPHGLDWH
hyperbilirubinemia occurred (total serum bilirubin ORZULVNJURXSZHUHEUHDVWIHGRIWKHPGHYHORSHG
level > PJG/  7RWDO VHUXP ELOLUXELQ OHYHO hyperbilirubinemia. (Table 2). The mean of birth
according to newborns age (in hours) was plotted ZHLJKWZDV 6' JUDPVDJHDWGLVFKDUJH
WR K\SHUELOLUXELQHPLD QRPRJUDP RI %KXWDQL WKHQ ZDV 6' KRXUVDQGELOLUXELQVHUXPOHYHODW
categorized as low risk (lower than 40thSHUFHQWLOH  GLVFKDUJHZDV 6' PJG/
intermediate -low risk (40 th -75 th  SHUFHQWLOH  ,QLQWHUPHGLDWHKLJKULVNJURXS  RI
intermediate-high risk (75ththSHUFHQWLOH DQGKLJK the newborns developed hyperbilirubinemia. Most
ULVNJURXS KLJKHUWKDQth percentile). Risk factors  RIWKHQHZERUQVLQWKLVJURXSZHUHEUHDVWIHG
of severe hyperbilirubinemia were recorded from )LIW\VHYHQSHUFHQW  RIEUHDVWIHGQHZERUQVDQG
mothers and newborns. Time of hyperbilirubinemia RQH QHZERUQ   ZKR ZDV JLYHQ IRUPXOD PLON
in each group were analyzed with survival analysis developed hyperbilirubinemia (Table 3). The mean
and comparison between each survival curve were ELUWK ZHLJKW ZDV  6'   JUDPV DJH DW
analyzed by Gehan log-rank test. All statistical analysis GLVFKDUJHZDV 6' KRXUVDQGELOLUXELQVHUXP
ZDVGRQHZLWK6366VRIWZDUH OHYHODWGLVFKDUJHZDV 6' PJG/

Table 1. Characteristics of newborns in low risk group


Characteristics Bilirubin level
n = 14 <13 mg/dL >13 mg/dL
Breastfed 11 1
Formula milk 2 0
Male 5 0
Female 8 1
Birth weight (g) 2965.8 (334.6) 2700
Age on discharge (SD) (hours) 15.4 (9.6) 38
Bilirubin level on discharge (SD) (mg/dL) 3.1 (0.8) 6.96

352Paediatr Indones, Vol. 50, No. 6, November 2010


Ahmedz Widiasta et al: Incidence of neonatal hyperbilirubinemia in risky infants

Table 2. Characteristics of newborns in intermediate-low group


Characteristics Bilirubin level
n = 14 <13 mg/dL >13 mg/dL
Breastfed 6 2
Formula milk 2 4
Male 2 3
Female 6 3
Birth weight (g) 3137.5 (332.5) 2825.0 (91.7)
Age on discharge (SD) (hours) 25.9 (8.0) 30.3 (4.2)
Bilirubin level on discharge (SD) (mg/dL) 6.5 (1.1) 6.3 (1.5)

Table 3. Characteristics of newborns in intermediate-high risk group


Characteristics Bilirubin level Total
n = 15 <13 mg/dL >13 mg/dL
Breastfed 6 8 14
Formula milk 0 1 1
Male 1 3 4
Female 5 6 11
Birth weight (g) 3017.5 (234.8) 2933.3 (339.1)
Age on discharge (SD) (hours) 22.6 (8.9) 30.0 (7.4)
Bilirubin level on discharge (SD) (mg/dL) 9.8 (1.6) 9.9 (1.5)

The survival analysis showed that the median and asphyxia. 1RQH RI WKH VXEMHFWV LQ WKLV VWXG\
of time of the occurrence of hyperbilirubinemia in had siblings with a history of hyperbilirubinemia.
low risk group was not able to be determined. In Previous studies showed that the incidence of severe
LQWHUPHGLDWHORZ DPG LQWHUPHGLDWH KLJK ULVN JURXS hyperbilirubinemia were found more common in
K\SHUELOLUXELQHPLD RFFXUUHG DW  KRXUV DQG RI  intermediate-high than intermediate-low risk zone
KRXUVUHVSHFWLYHO\ &,  Figure 1). and none in low risk zone. Our study showed that
hyperbilirubinemia occurred earlier in intermediate-
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the latest in low risk zone.
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Hyperbilirubinemia in this case was probably caused by
EUHDVWPLONMDXQGLFH1RSKRWRWKHUDS\ZDVUHTXLUHG
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Figure. 1. Survival curve in low risk, intermediate-low, SKRWRWKHUDS\ZLWKWRWDOVHUXPELOLUXELQOHYHORI
and intermediate-high risk with Gehan log-rank test. PJG/DWKRXUV LQWHUPHGLDWHKLJKULVN]RQH DQG
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Discussion %RWK ZHUH IHPDOHV DGHTXDWHO\ EUHDVWIHG FRPELQHG
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Hyperbilirubinemia in a healthy-term newborn was respectively. The probable causes of hyperbilirubinemia
influenced by a history of hyperbilirubinemia in were G6PD deficiency or other genetic factors. G6PD
VLEOLQJVPDOHJHQGHUPRWKHUVDJH!\HDUVGLDEHWLF ZDVH[DPLQHGLQWKLVVWXG\EXWWKHUHVXOWZDVQRWYDOLG
PRWKHULQDGHTXDWHEUHDVWIHHGLQJFHSKDOKHPDWRPD because of procedural error.

Paediatr Indones, Vol. 50, No. 6, November 2010353


Ahmedz Widiasta et al: Incidence of neonatal hyperbilirubinemia in risky infants

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newborns developed hyperbilirubinemia and one neonatal care. 5th ed. Philadelphia: Lippincott Williams &
needed phototherapy with bilirubin serum level of :LOONLQVS
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hyperbilirubinemia was G-6-PD deficiency or other PHGLFLQH th HG 3KLODGHOSKLD 0RVE\ (OVHYLHU  S
genetic factors. 
A newborn at low risk could become intermediate-  $OSD\ ) 6DULFL 68 7RVXQFXN +' 6HUGDU 0$ ,QDQF 1
ORZULVN]RQHZKLOHQHZERUQVDWLQWHUPHGLDWHORZULVN Gokcay E. The value of first-day bilirubin measurement in
could become intermediate-high or high risk in the predicting the development of significant hyperbilirubinemia
first week of life. These changes were in accordance LQKHDOWK\WHUPQHZERUQV3HGLDWULFVH
with those of Bhutanis study.:LWKVXUYLYDODQDO\VLV  *RPHOOD 7/ &XQQLQJKDP ' (\DO )* =HQN .(
at low risk zone there was no median survival time +\SHUELOLUXELQHPLD1HRQDWRORJ\PDQDJHPHQWSURFHGXUHV
RIK\SHUELOLUXELQHPLDDWLQWHUPHGLDWHORZULVN]RQH RQFDOO SUREOHPV GLVHDVHV DQG GUXJV th HG 1HZ <RUN
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KRXUV DQG DW LQWHUPHGLDWHKLJK ULVN ]RQH ZDV   6HLGPDQ '6 6WHYHQVRQ '. (UJD] = *DOH 5 +RVSLWDO
hours. readmission due to neonatal hyperbilirubinemia. Pediatrics.
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in intermediate-low and intermediate-high groups is  6WHYHQVRQ'.)DQDURII$$0DLVHOV0-<RXQJ%:<:RQJ
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occured were different in each group of newborns. QHDUWHUPDQGWHUPLQIDQWV-3HULQDWRO6
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for severe neonatal hyperbilirubinemia. Neonatol Rev.
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 $PHULFDQ $FDGHP\ RI 3HGLDWULFV 6XEFRPPLWWHH RQ QHRQDWDO MDXQGLFH LPSRUWDQFH RI WLPLQJ ,QGLDQ - 3HGLDWU
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 0DUWLQ &5 &ORKHUW\ -3 1HRQDWDO K\SHUELOLUXELQHPLD ,Q medscape.com

354Paediatr Indones, Vol. 50, No. 6, November 2010

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