Nigerian Journal of Paediatrics

Prevalence of exchange blood transfusion in severe hyperbilirubinaemia and outcome at the University of Maiduguri Teaching Hospital Maiduguri North eastern Nigeria

Niger J Paediatr 2017; 44 (2): 50 – 55

ORIGINAL

Pius S

Prevalence of exchange blood

Bello M

Mava Y

transfusion in severe hyper-

Djossi S

bilirubinaemia and outcome at the

Ambe JP

University of Maiduguri Teaching

Hospital Maiduguri, North-

eastern Nigeria

DOI:http://dx.doi.org/10.4314/njp.v44i2.2

Accepted: 9th November 2015

Abstract : Background: Exchange

12 months. Of this number, 64

blood transfusion (EBT) is carried

(10%) had neonatal jaundice.

Pius S (

)

out for the treatment of conditions

Thirty (46.9%) of the 64 neonates

Bello M, Djossi S, Ambe JP

presenting with severe hyper-

with NNJ had EBT, their

pre-

Dapartment of Paediatrics,

bilirubinaemia and anaemia, such

EBT, serum bilirubin (SB) level

University of Maiduguri Teaching

as ABO incompatibility, sepsis,

ranged from 15mg/dL to 28.5mg/

Hospital Maiduguri, Nigeria

prematurity and birth trauma

dL with mean of 21.5 ±13.0mg/dL,

Email:

among others. While it is fast be-

while the post EBT SB ranged

simonpius2000@yahoo.co.uk

ing abandoned as treatment mo-

from 3.0mg/dL to 11.3mg/dl with

dality for severe neonatal jaundice

mean of 7.2±8.3mg/dL. The aetio-

Mava Y

in the resource rich countries, it is

logical risk factors of severe hy-

Department of Paediatrics,

still a backbone of treatment for

perbilirubinaemia in the newborns

Bingham University Teaching

severe neonatal jaundice in re-

who had EBT include ABO in-

Hospital, Jos, Nigeria

source limited settings.

Since

compatibility 17(56.7%), sepsis 12

such a study has not been done in

(40.0%), prematurity 10(33.3%).

this centre before now, we de-

Out of 30 neonates had EBT, 25

cided to study the positive effects

(83.3%) survived and were dis-

of exchange blood transfusion in

charged, 5(16.7%) died and 3 with

Maiduguri, North-Eastern Nige-

bilirubin

encephalopathy,1with

ria.

severe perinatal asphyxia with

Objective:

determine

the

hypoxic ischaemic encephalopathy

prevalence, indications and out-

stage II while the fifth death was a

come of exchange blood transfu-

preterm extreme low birth weight.

sion at the Special Care Baby Unit

Conclusion: In our setting, the

of the University of Maiduguri

prevalence of exchange blood

Teaching Hospital, Maiduguri.

transfusion is high and this is be-

Methods: This is a retrospective

cause a large number of our pa-

study which examined the records

tients had severe NNJ at presenta-

of babies admitted into the SCBU

tion, some with bilirubin encepha-

between 1 January to December

lopathy. Exchange blood transfu-

31 2014 with the aim of deter-

sion remains one of the most reli-

mining the prevalence of EBT at

able and effective treatment mo-

the Special Care Baby Unit

dality to prevent bilirubin encepha-

(SCBU) of the University of

lopathy especially in settings

Maiduguri Teaching

Hospital

where babies are brought late to

(UMTH), Maiduguri.The indica-

health facility. Effort at health edu-

tions for EBT and mortality

cation of the population at risk,

among babies who had EBT are

especially pregnant women on

also highlighted.

early recognition and referral to

Results: A total of 639 babies

appropriate health facility for

with gestational ages between

prompt treatment to prevent severe

30weeks to 42weeks were admit-

NNJ and bilirubin encephalopathy

ted into the Special Care Baby

is highlighted.

Unit (SCBU) over the period of

Introduction

There were no documentations on EBT, its indications

and outcome in Maiduguri and the North-Eastern part of

Exchange blood transfusion (EBT) is a procedure done

Nigeria. Therefore we decided to retrospectively review

for removal of antibodies coated red blood cells and/or

the prevalence, indications and outcome of exchange

products of haemolysis in a variety of neonatal condi-

blood transfusion at the Special Care Baby Unit

tions which present with severe unconjugated hyper-

(SCBU), University of Maiduguri Teaching Hospital,

bilirubinaemiadue such as prematurity, rhesus isoimmu-

Maiduguri; North-Eastern Nigeria.

nization, ABO incompatibility. or non immune haemo-

lytic anaemia as in Glucose 6 phosphate dehydrogenase

(G6PD) deficiency. It is also done in conditions like

severe neonatal sepsis for there moval of bacterial tox-

Subjets and methods

ins, severe respiratory distress syndrome, perinatal as-

phyxia, disseminated intravascular coagulopathy and

This was a retrospective study conducted at the Special

poisoning among others.

2-6

Care baby Unit (SCBU) of the University of Maiduguri

Teaching Hospital, Maiduguri, Borno state Nigeria. The

EBT involves removing aliquots of patient’s blood and

SCBU admits newborns as referrals from other hospitals

replacing it with donors. The prevalence of EBT re-

in addition to newborns delivered at the centre and ad-

ported from Nigeria by Owa and Ogunlesi Onyearugha

mitted for various illnesses including neonatal jaundice.

et al were high while reports from developed countries

The SCBU is run by two consultants, a senior registrar,

showed that EBT is now rarely carried out especially for

two registrars, two interns and three nursing staffs on

unconjugated hyperbilirubinaemia because of the effi-

every shift.

cacy of phototherapy in reducing plasma bilirubin con-

Data were extracted from the folders of all babies who

centrationsthus preventing cerebral damage.

4,5

Also,

had exchange blood transfusion for their conditions at

another report from South-western Nigeria showed that

the SCBU, thus constituting the subjects for the study.

more than 5% of neonates in their unit had EBT. Re-

Informations extracted includes, patients age, sex, gesta-

ports from the developed world has demonstrated the

tional age, maternal/paternal and babies blood group,

efficiency of phototherapy in the treatment of neonatal

Rhesus typing, weight as at admission and relevant in-

jaundice, thereby abandoning EBT, but such cannot be

vestigations done include bilirubin estimation both total

said for developing countries like Nigeria where patients

and conjugated fractions, packed cell volume, complete

presents very late to health facilities, often with severe

blood count, blood culture among others. The treatment

neonatal jaundice, some with bilirubin encephalopathy.

administered to the patients such as phototherapy, EBT,

Indications for exchange blood transfusion for healthy

antibiotics, intravenous fluid and intranasal oxygen

term babies is done at TSB level of >25mg/dl, however;

among others and outcome of the patients such as

clinical signs of bilirubin encephalopathy is also an indi-

whether patients got well and discharged home, left

cation for EBT whatever the TSB level. In sick new-

against medical advice or died were all documented.

borns, intervention is required at lower TSB levels men-

Patients who had transfusion or EBT elsewhere before

tioned above. For the preterm, the rule of 10 is applied

presenting to our facility were excluded because that

where by the birth weight is multiplied by 10 and the

might interfere with the actual picture of the conditions

figure obtained is the EBT TSB level. Besides the TSB

due to interventions received before referral.

level, there are many known factors like higher perme-

ability of blood brain barrier, hypoxia, hypercarbia, sep-

At presentation, these patients were placed on photother-

sis and various unknown factors for bilirubin toxicity

apy while awaiting for their serum bilirubin results

which will require EBT to be done at lower TSB levels.

which was obtained from the laboratory within

10, 11

1-2hours. Exchange blood transfusion was carried out

EBT especially double volume exchange had succeeded

on all patients who had high unconjugated hyper-

in reducing mortality from 35-40% pre EBTera to less

bilirubinaemia. Exchange blood transfusion was per-

than 20% and the risk of neurological sequelle from

formed at serum bilirubin of 20mg/dl or below this level

90% to 30%

12,13

if the conjugated fraction was less than 20% of total

This beneficial live saving method of treatment of neo-

bilirubin level in term newborn, while in preterm’s ex-

natal conditions has its complications including air em-

change blood transfusion was performed at level 10-

bolism, metabolic derangements, transmission of infec-

12mg/dl or less in the presence of other factors such as

tions and gut perforation among others

1,14

Mortality of

septicaemia, severe birth asphyxia and other co-

between 10%-17.5% has been recorded.

8,12, 15, 16

EBT is

morbidities like disseminated intravascular coagulation

(DIC), kernicterus, anaemia. Double volume (160ml/

now rarely carried out in developed countries because of

the availability of efficient phototherapy units coupled

kg) of fresh citrate phosphate dextrose anticoagulant

with early detection and reporting to health facility with

containing whole blood which was usually less than

prompt monitoring of the patients. Shortage of photo-

24hours, however blood less than three days was also

therapy machines in many centres, interrupted power

accepted for EBT in severe hyperbilirubinaemia, while a

supply and late presentation of patients to hospitals,

single volume (80ml/kg) for treatment of severe anaemia

makes it almost impossible to rely mainly on photother-

and at aliquots of 5ml/kg according to the standard pro-

tocol.

11, 15, 17

apy as treatment modality in severe neonatal jaundice

(NNJ) in the developing countries, such as Nigeria.

The patients had EBT on admission using the pull and

push method through an umbilical catheter and lasted

Table 1: Socio-demographic characteristics of the 64 patients

between 45-60 minutes and 1ml of 10% calcium

with jaundice

gluconate was administered after every 100ml of blood

Characteristics

Frequency

Percentage

exchanged in accordance with standard protocol.

Pre-

EBT and post-EBT serum bilirubin were estimated

Mothers age

which was used to compare the efficacy of the proce-

<16

06.7

dure. In some patient, EBT had to done twice or more

16-25

40.0

before the desired reduction in the serum bilirubin was

26-35

46.6

obtained.

>35

06.7

Total

100.0

Statistical Analysis

Maternal blood group

A+

33.3

Statistical analysis was done by SPSS version 16, Illi-

B-

10.0

nois, Chicago USA. Simple descriptive tests were done,

O+

56.7

Student t-test to compare mean values between groups

Total

100.0

and Chi squared test to test association between cate-

Patients blood group

gorical variables. A P-value<0.05 was considered sig-

A+

23.3

nificant. Tables were appropriately used for illustration.

B+

33.3

O+

43.4

Total

100.0

Paternal blood group*

A+

23.3

Results

B+

26.7

O+

6.7

A total of 639 babies whose gestational age at birth

Total

56.7

ranged from 30 weeks to 42 weeks with various condi-

Patients weight (gm)

tions were admitted into the Special Care Baby Unit

800 — 1499

20.0

(SCBU) during the study period, between 1 January and

1500-2499

13.3

31 December 2014. Of this number, 64 (14.6%) had

2500-3999

63.3

neonatal jaundice. Thirty (46.9%) of the 64 neonates had

>4000

03.4

severe hyperbilirubinaemia and required EBT. All the

Total

100.0

30 neonates had EBT carried out at admission because

Age at admission

they had severe hyperbilirunaemia on arrival at our fa-

<7days

23.3

cility and their pre-EBT serum bilirubin (SB) level

7-28days

76.7

ranged from 15mg/dL to 28.5mg/dL with mean of 21.5

Place of delivery

±13.0mg/dL, while the post EBT SB ranged from

Inborn

33.3

3.0mg/dL to 11.3mg/dl with mean of 7.2±8.3mg/dL.

Outborn

66.7

Eight patients that had a second session of EBT before

their serum bilirubin levels dropped down to acceptable

*The paternal blood group was only available in 17 cases

level, were from the out borns, the remaining 22

(73.1%) did well on one first session of EBT and follow

Table 2: Shows the clinical features of patients who had

up phototherapy. Taking a leap from the results follow-

EBT. Twenty three (76.7%0) of the patients had pyrexia

ing EBT procedures, there was rapid and significant

and of these patients all the 30 (100.0) had jaundice.

reduction in the serum bilirubin levels of these patients

Severe anaemia accounted for 16 patients (53.3%) and

who had exchange blood transfusion therapy.

most of these patients had more than one symptom at the

There were 22 males and8 females with a M: F of 2.8:1.

time of admission.

Ten of them were preterm’s, 19 term babies and one was

post term baby. Nineteen of the babies (63.3% ) were of

Table 2: Clinical characteristics of the 64 patients with

jaundice

normal birth weight, 10 (33.3%) has LBW, all were pre-

term infants with one macrosomic infant. The weight

Clinical features

Frequency

Percentage

distribution of the babies range from 800gm -4300gm

Temperature

with the mean weight of 2550 ±750gm.

>37.5

(hyperthermia)

76.7

Table I. Shows the socio demographic characteristics of

36.5-37.5(normothermia)

10.0

the study population,

<36.5

(hypothermia)

13.3

Fever

66.7

Forteen (47.0%) of the mother were of younger age

Refusal to feed

60.0

group (<16-<25yrs). ABO in compatibility was respon-

Anaemia*

53.3

sible for more than half of the causes of neonatal jaun-

Difficulty in breathing

36.7

dice.

Cycling movement

10.0

Bleeding

10.0

Convulsion

10.0

*Severe anaemia, defined by PCV<35%, a patient had more

than one symptoms

Table 3 Shows the aetiological risk factors of severe

Abakaliki, might have been more enlightened on the

hyperbilirubinaemia, 17 (56.7%) of the children, the

dangerous effect of neonatal hyperbilirunaemia to their

jaundice was due ABO incompatibility, 12 (40%) pa-

newborns and so presented in large number and early

tients had blood culture proven sepsis. Prematurity was

enough to the health facility where they received inter-

responsible for severe hyperbilirubinaemia in 10

vention.

(33.3%).

The prevalence rate of EBT of 46.9% was higher than

the finding reported from Canada with an EBT rate of

Table 3: Risk factor of neonatal jaundice

22.1% for NNJ and reason being attributed to the prac-

Risk factor

Number of patients

Percentage

tice of early discharge of patients home usually within

ABO

56.7

24hours only to be re-admitted with severe NNJ jaun-

dice warranting EBT. The effectiveness of exchange

Sepsis

40.0

Prematurity

33.3

blood transfusion therapy as the most efficient modality

Asphyxia

26.7

of management of severe hyperbilirubinaemia in our

Birth trauma

20.0

setting like in other under resources setting, was clear

Unknown

40.0

judging from the differences between the pre-EBT se-

rum bilirubin results and the post-EBT results which

*some patients had more than one problem

showed a significant reduction in the serum bilirubin

level.

9, 11

The common presentation observed among the

Table 4 shows the outcome of the EBT in the 30 neo-

children that had EBT for severe hyperbilirubinaemia

nates. 25 (83.3%) of the patients recovered and were

was jaundice 30(100%), others include fever/pyrexia in

discharged and subsequently seen in the neonatal clinic

about 20(66.7%) patients, refusal to feed in 18(60.0%)

follow-up up to the age of three months before some

patients, severe anaemia in 16(53.3%) patients, the rea-

were lost to follow up.

son might be because in our patient Sepsis was second

only to ABO incompatibility as possible cause of NNJ

Table 4: Outcome of the patients Following EBT

which also has been reported in other studies.

21, 22

Other

Outcome

Frequency

Percentage

manifestations observed in the children that had EBT

Discharge

83.3

included opisthotonus, bleeding and convulsion.

Died

16.7

Total

100.0

This study has demonstrated that ABO incompatibility

17(56.7%) accounted for aetiological risk factor of neo-

While 5(16.7%) died, of these three had kernicterus

natal jaundice, this was followed by sepsis which was

even before EBT was done all died within 24hrs after

responsible for 12(40.0%) and prematurity 10 (33.3%)

EBT, while the one with severe perinatal asphyxia died

as the leading aetiological risk factors for neonatal jaun-

three days after EBT, and the fifth death was preterm

dice, and sepsis was more among the outborns, while

extreme low birth weight who weigh 800gm at birth and

prematurity were mainly in the inborns, this finding was

in keeping with the report from South-eastern Nigeria,

presented within 24hrs to hospital, had EBT successfully

and South-East Asia.

but died on the 7 day of admission ( χ=0.32, P>0.05)

Aetiological risk factors were not found in 12 (40.0%),

this has also been reported earlier and since we are inca-

Discussion

pable do screening for other causes of NNJ like G6PD

deficiency, we cannot say with certainty it had not con-

tributed to the jaundice observed in this study. The out-

The prevalence of exchange blood transfusion (EBT) in

this study was 46.9%, this was higher than 5.8% re-

come of EBT in these neonates was categorized into the

ported by Owa et al, from South-western Nigeria and

proportion of 25(83.2%) responded well to the treat-

the report by Mills, however, this may not be the whole

ment and was discharged home and subsequently seen at

picture of the burden as their study was the proportion of

follow-up in neonatal clinic up to the age of three

the whole admission. The finding in our study was also

months with no apparent problems. In this study mortal-

much higher than the report by Onyearugha et al,

ity rate of 5(16.7%) was obviously high compare to the

Ibekwe et al from Abakaliki, South-eastern Nigeria, who

0.34%-10% finding reported earlier from South-western

part of Nigeria, and those from outside Nigeria 0.5% in

reported the EBT rate of 20.8%, 17% respectively in

USA, 0.75% in Greece and 1.5% from Iran, the possi-

their survey,

8, 9, 11, 19

the reason for the differences may

be that while in our study it was over one year and ma-

ble explanation may be that our patient were mostly

jority of the newborns were delivered at home or poorly

referred from outside and often presented late to the

equipped health facility and we only saw them when

hospital and another plausible explanation include ram-

they presented with severe neonatal jaundice.

pant interruption of power supply leading to ineffective

phototherapy regiment, these was acknowledged by oth-

ers,

9,11

Also mothers of these patients were not much aware of

however it was similar to the finding reported

from Abakaliki South-eastern Nigeria, who found mor-

the severity and the effect of neonatal jaundice on their

babies, in their survey and they had a large number of

tality rate 17.5% and that from Canada mortality rate of

20.8% for obvious reasons mentioned earlier.

patients with neonatal jaundice managed in their NICU.

Secondly the mothers of the patients studied at

Just like in other low resources setting, payment for

medical care was usually out of pocket expenses, such a

bills has negative effect on prompt intervention. To

lack of fund lead to delay presentation to hospital. As

improve on this problems of severe NNJ, there is the

such 66.7% of the patients presented after first week of

need for health education of the general population, es-

life with severe jaundice, we infer it might be attributed

pecially the pregnant women on the danger of severe

the delay to lack of finance. Some researchers have

NNJ and the need for early booking, regular antenatal

demonstrated that measuring the serum bilirubin level

care and delivery in appropriate health facility, as well

within the first 24hours of life is said to be helpful in

as early recognition of NNJ and prompt presentation of

predicting which infants will experience severe hyper-

the affected newborn for appropriate medical interven-

bilirubinaemia with hope of early detection and monitor-

tion must be implemented in order to reduce this pre-

ing of the condition.

Most of our patients that are de-

ventable condition.

livered at our health facility and are not discharged

within 24hours after birth, but for those referred from

outside hospital which present mostly with severe NNJ.

Limitation

Mass media enlightenment of the population and espe-

Our chemical pathology laboratory is not equipped to be

cially pregnant women on the need to encourage them

able evaluate glucose-6-phosphate dehydrogenase

to book and have their pregnancy, delivery supervised at

enzyme deficiency which may contribute to the aetiol-

health facility so as to detect these conditions early and

ogy of neonatal jaundice. In our study, there were 12

tackled them promptly in order to prevent severe hyper-

cases of neonatal jaundice that had EBT and the causes

bilirubinaemia and its complications will go long way to

were unclear, which might have been due to G6PD defi-

reduce these problem.

ciency. Also, being a retrospective study and the small

number of data in the study may limit the results for

generalization.

Conclusion

Authors Contribution

The high rate of exchange blood transfusion in the man-

All the authors conceived, wrote the draft and reviewed

agement of severe hyperbilirubinaemia and significant

the final article.

mortality associated with hyperbilirubinaemia has been

Conflict of Interest: None

demonstrated in this study. The role played by lack of

Funding: None

facility to provide qualitative and intensive phototherapy

cannot be overemphasized. The provision of uninter-

rupted power supply and upgrading the phototherapy

Acknowledgement

machines to modern fibro-optic phototherapy blanked is

urgently needed. The significant contribution of late

The authors are particularly grateful to the staff of the

presentation to hospital, out of pocket payment of health

Special Care Baby Unit and the Medical Record Depart-

ment of UMTH for their support during the study.

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