title: Risk factors for acute bilirubin encephalopathy on admission to two Myanmar national paediatric hospitals.
abstract: BACKGROUND
  Jaundice is the commonest neonatal ailment requiring treatment. Untreated, it can lead to acute bilirubin encephalopathy (ABE), chronic bilirubin encephalopathy (CBE) or death. ABE and CBE have been largely eliminated in industrialised countries, but remain a problem of largely undocumented scale in low resource settings. As part of a quality-improvement intervention in the Neonatal Care Units of two paediatric referral hospitals in Myanmar, hospitals collected de-identified data on each neonate treated on new phototherapy machines over 13-20 months. The information collected included: diagnosis of ABE at hospital presentation; general characteristics such as place of birth, source of referral, and sex; and a selection of suspected causes of jaundice including prematurity, infection, G6PD status, ABO and Rh incompatibility. This information was analysed to identify risk factors for hospital presentation with ABE, using multiple logistic regression.
  
  
  RESULTS
  Data on 251 neonates was recorded over 20 months in Hospital A, and 339 neonates over 13 months in Hospital B; the number of outborn neonates presenting with ABE was 32 (12.7 %) and 72 (21.2 %) respectively. In the merged dataset the final multivariate model identified the following independent risk and protective factors: home birth, ORadj = 2.3 (95 % CI: 1.04-5.4); self-referral, ORadj = 2.6 (95 % CI: 1.2-6.0); prematurity, ORadj = 0.40 (95 % CI: 0.18-0.85); and a significant interaction between hospital and screening status because screening positive for G6PD deficiency was a strong and significant risk factor at Hospital B (ORadj = 5.9; 95 % CI: 3.0-11.6), but not Hospital A (ORadj = 1.1; 95 % CI: 0.5-2.5).
  
  
  CONCLUSIONS
  The study identifies home birth, self-referral and G6PD screening status as important risk factors for presentation with ABE; prematurity was protective, but this is interpreted as an artefact of the study design. As operational research, there is likely to be substantial measurement error in the risk factor data, suggesting that the identified risk factor estimates are robust. Additional interventions are required to ensure prompt referral of jaundiced neonates to treatment facilities, with particular focus on home births and communities with high rates of G6PD deficiency.
authors.affiliation: Thrive Networks, Oakland, CA USA ; School of Public Health & Community Medicine, Faculty of Medicine, University of New South Wales, Wales, NSW Australia.
authors.forename: G
authors.identifier: 0000-0003-4948-7633
authors.initials: G
authors.lastname: Arnolda
authors.affiliation: Department of Paediatrics, University of Medicine (1), Yangon, Myanmar.
authors.forename: H M
authors.initials: HM
authors.lastname: Nwe
authors.affiliation: Amici della Neonatologia Trentina, Trento, Italy ; Children and Women's Health Department, Medical School University of Padua, Padua, Italy.
authors.forename: D
authors.initials: D
authors.lastname: Trevisanuto
authors.affiliation: Mandalay Children's Hospital (300), Mandalay, Myanmar.
authors.forename: A A
authors.initials: AA
authors.lastname: Thin
authors.affiliation: Department of Neonatology, University of Medicine (1), Yangon, Myanmar.
authors.forename: A A
authors.initials: AA
authors.lastname: Thein
authors.affiliation: Department of Surgery, Liege University Hospital, Liege, Belgium.
authors.forename: T
authors.initials: T
authors.lastname: Defechereux
authors.affiliation: Thrive Networks, Oakland, CA USA.
authors.forename: D
authors.initials: D
authors.lastname: Kumara
authors.affiliation: Thrive Networks, Oakland, CA USA ; Amici della Neonatologia Trentina, Trento, Italy.
authors.forename: L
authors.initials: L
authors.lastname: Moccia
keywords: Acute Bilirubin Encephalopathy; Chronic Bilirubin Encephalopathy; Hyperbilirubinaemia; Kernicterus; Neonatal jaundice