title: Referral Patterns and Factors Influencing Age at Admission of Infants with Cholestasis in India.
abstract: OBJECTIVE
  To define the recognition, age at admission, referral time and referral pattern of neonatal cholestasis in India.
  
  
  METHODS
  This prospective, observational study was conducted from February 2015 through March 2016 in the Pediatric gastroenterology unit of JIPMER, Pondicherry in infants with cholestasis < 6 mo of age.
  
  
  RESULTS
  Among 64 infants, median age of admission was 52 d (IQR 28-63 d). Fifty of sixty four infants (78.1%) came with parent-reported cholestasis-related symptoms of either jaundice alone (57.8%) or bleeding manifestations (20.3%). In 21.9% infants, jaundice was detected by physicians at a median age of 45 d (IQR 38.5-53.2 d). Two infants had intracranial bleed. Only 34% infants with pale stools were identified by the mother. The median healthcare-seeking time was 5.5 d (IQR 2.5-12 d). Among infants presenting to primary healthcare physicians (PHPs) with cholestasis-related symptoms, median time to referral was 5 d (IQR 2.5-12 d). The first point of healthcare contact in 54.7% was a PHP; 17.1% PHPs had reassured the parents. Herbal preparations were prescribed by 14.3%. Only 11.8% of those with jaundice as the only problem were given vitamin K before referral. Biliary atresia (﻿BA) was missed in neonatal intensive care units in 9 cases.
  
  
  CONCLUSIONS
  The above issues need to be accounted for before evaluating or implementing screening strategies in India.
authors.affiliation: Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Pondicherry, 605006, India.
authors.forename: Gopinathan
authors.initials: G
authors.lastname: Mathiyazhagan
authors.affiliation: Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Pondicherry, 605006, India. barathjag@yahoo.com.
authors.forename: Barath
authors.identifier: http://orcid.org/0000-0002-2108-9054
authors.initials: B
authors.lastname: Jagadisan
mesh_terms: D000367:Age Factors; D002779:Cholestasis / Q000150:complications / Q000175:diagnosis / Q000628:therapy*; D005260:Female; D006801:Humans; D007194:India; D007223:Infant; D007231:Infant, Newborn; D007232:Infant, Newborn, Diseases / Q000175:diagnosis / Q000628:therapy; D007565:Jaundice / Q000209:etiology; D007567:Jaundice, Neonatal / Q000209:etiology; D008297:Male; D010343:Patient Admission / Q000706:statistics & numerical data*; D012017:Referral and Consultation / Q000706:statistics & numerical data*
keywords: Neonatal cholestasis; Primary health care; Referral