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ABSTRACT

OBJECTIVE: To assess the knowledge of mothers regarding Neonatal Jaundice.STUDY DESIGN: A Cross sectional study.

st th PLACE AND DURATION: At Paediatric Department of Rawal Institute of Health Sciences (RIHS) Islamabad from 1 July 2014 to 30 June 2015.METHODOLOGY: A total of 200 mothers presenting with jaundiced neonates within first two weeks of life were enrolled. Data was collected through a structured questionnaire. Each question was scored and maternal knowledge was categorized as "Adequate" and "Inadequate". RESULTS: The mean (SD) age of all mothers was 27.3 (± 4.2) years. A substantial majority of mothers, 132 (66.0%) were aged younger than 30 years. Out of 200, 175 (86.5%) mothers lived in urban areas. The mean (SD) age of neonate was 8.7 (± 3.3) days. Majority of neonates, 93 (46.5%) were aged between 6 and 10 days. Out of 200, 106 (53.0%) mothers had 1 to 2 children, while 80 (40.0%) mothers had 3 to 4 children. 111 (55.5%) mothers had education up to graduation, whereas 35 (17.5%) mothers had primary level education. 150 (75.0%), were housewives, 149 (74.5%) mothers reported that their previous child also had neonatal jaundice. 10 was total knowledge score and the mean (SD) knowledge score was 6.2 (± 1.9). 105 (52.5%) mothers had inadequate knowledge score, while 95 (47.5%) mothers had adequate knowledge score. CONCLUSIONS: The mother's knowledge regarding neonatal jaundice (NNJ) is quite poor. KEY WORDS: Neonatal Jaundice, Knowledge, Neonate.

ORIGINAL ARTICLE ISRA MEDICAL JOURNAL | Volume 8 - Issue 1 | Jan - Mar 2016

INTRODUCTION

Neonatal jaundice (NNJ) occurs in 60% of term and 80% of 1preterm infants . A study conducted in Bangladesh reveals that

out of 426 neonates with NNJ the most common cause was physiological jaundice (26.7%) followed by jaundice of prematurity (20.9%) and haemolytic jaundice (11.3%). Severe

2hyperbilirubinemia can lead to encephalopathy in 2.1% . Other complications include sensioneural hearing loss, paralysis of

3.upward gaze and dental enamel dysplasiaThe severity of neurological complications depends on duration of exposure to high bilirubin levels. Khalesi et al found that the risk progressively increased from 2.3% in neonates with exposure of six hours to high bilirubin levels to 26% when the

4exposure time increased to >12 hours . Mezaal et al reviewed 50 young adult men with cerebral palsy through their medical records and found kernicterus to be the most common cause

5resulting in cerebral palsy. It occurred in 14 (28%) of cases . So timely intervention can prevent acute complications and long

6term morbidity . However, there is often a delay in seeking medical advice and parents and family usually do self-medication with herbal medicines and homemade remedies

due to inadequate knowledge. Maternal diet is often restricted 4with avoidance of raisins, dates and nuts . Other

misconceptions include the beneficial role of sunlight in reducing severe jaundice. Aladag et al report that out of 118 parents interviewed, 12.7% considered sunlight to be useful for

7neonates with jaundice . The mean (SD) knowledge score about NNJ was found to be 7.25 (± 2.1) (out of 13.5) in a study conducted in Iran. Only 37% mothers had information about all symptoms of jaundice, about

th1/5 mothers were not at all aware of complications of jaundice 4and others had poor knowledge . Similar results were obtained

from a study conducted on Malaysian mothers who had a poor knowledge regarding onset, causes and complications of jaundice. The mean of knowledge score was 7.4 out of 15. Moreover 83.1% of multiparous mothers were in practice of putting their babies under direct sun for neonatal jaundice and only 27.1% were aware that it can lead to dehydration and

8worsening of NNJ . Sutcuoglu et al found that out of 300 Turkish mothers, 161 (56.3%) had inadequate knowledge and 46.3% had adequate knowledge regarding neonatal jaundice. The knowledge of mothers was dependent on education level and

9having a previous offspring with NNJ . This study was con ducted to identify misconceptions prevailing in our set up about NNJ, which result in late presentation to health care facilities as knowledge correlates directly to behaviour and practices. As a result, a number of babies suffering from this apparently benign condition, end up having lots of complications.

METHODOLOGY

The cross sectional study was done at the outpatient and inpatient of Paediatrics department of Rawal Institute of Health

1 1 2ASMA YAQUB , FATIMA SAFDAR , ZEESHAN GHANI

TO ASSESS THE KNOWLEDGE OF MOTHERS REGARDING NEONATAL JAUNDICEPRESENTING TO RAWAL INSTITUTE OF HEALTH SCIENCES ISLAMABAD

1. Assistant Professor of Paediatrics Rawal Institute of Health Sciences Islamabad2. Assistant Professor of Paediatrics Al Nafees Medical College and Hospital Isra University, Islamabad Campus Pakistan

Correspondence to:Asma YaqubAssistant Professor of Paediatrics Rawal Institute of Health Sciences IslamabadEmail: yaqubasma@yahoo.com

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DISCUSSION

More than 50% of newborns clinically have jaundice during the 10.first week of life Babies affected by severe neonatal

hyperbilirubinemia are increasing in number and cases of cerebral palsy resulting from hyperbilirubinemia increasing in

11, 12. frequency in Europe and North America Timely recognition and prompt treatment of hyperbilirubinemia limit these sequelae so that cases of cerebral palsy resulting from

13, 14hyperbilirubinemia may be preventable.A cross-sectional study done to know about the knowledge, behaviour and attitude of mothers regarding neonatal jaundice at Ali-Ebne Abitaleb Hospital in Zaheban, Iran. Four hundred mothers were interviewed to complete a 21-point questionnaire. 7.25 (±2.1) out of 13.5 was mean (SD) of knowledge score. Although knowledge of mothers regarding methods for diagnosing hyperbilirubinemia was acceptable, but it was insufficient regarding causes, complications harmful symptoms and prevention of the disease. 18.5 (±3.7) out of 25 was mean (SD) attitude score and 6.8 (±2.3) out of 10.5 was mean (SD) behaviour score. Knowledge had a significant association with history of neonatal jaundice (P=0.033), mother's age (P<0.001), and child's birth rank (P=0.001). There was also a significant association between mother's educational level and their attitude (P<0.001). Furthermore, they found a direct correlation between knowledge, attitude and behaviour (P<0.001). The researchers concluded that the increasing mothers' knowledge through education programmes during

st Sciences Islamabad (RIHS) over a period one year from 1 July th2014 to 30 June 2015using Non-probability, consecutive

sampling technique. Total 200 mothers presenting with jaundiced babies were enrolled. A structured questionnaire was used to collect data. Scoring was done for each questions and maternal knowledge was categorized as "Adequate" and "Inadequate”. Mothers were asked about neonatal jaundice, its causes, how to identify neonate with jaundice, danger signs, how to diagnose jaundice in a baby, what are its complications and different treatment options according to them. For variables like maternal age, neonates age and knowledge score of mothers, mean with standard deviation, median and range (minimum and maximum) was calculated .For categorical variables like occupation, education of mothers, and knowledge categories (adequate and inadequate) frequencies and percentages were calculated.

RESULTS

The mean (SD) age of all mothers was 27.3 (± 4.2) years. The median age was 27.0 years. The minimum age was 20 years while the maximum age was 36 years. A majority of mothers, 132 (66.0%) were aged younger than 30 years while 55 (27.5%) mothers were aged between 30 and 34 years. 175 (86.5%) mothers lived in urban areas while only 25 (12.5%) mothers belonged to rural areas .The mean (SD) age of new born was 8.7 (± 3.3) days. The median age was 8.0 days. The minimum age was 4 days while the maximum age was 14 days. 93 (46.5%) were aged between 6 to 10 days, while 54 (27.0%) new borns were aged more than 10 days and 53 (26.5%) were aged up to 5 days. 106 (53.0%) mothers had 1 to 2 children, while 80 (40.0%) mothers had 3 to 4 children. Remaining 14 (7.0%) mothers had five or more children .111 (55.5%) mothers had education up to graduation, whereas 35 (17.5%) mothers had primary level education. Another 36 (18.0%) mother had secondary level education while 18 (9.0%) mothers' attained master level education Figure - 1 .150 (75.0%) mothers were housewives, whereas 18 (9.0%) mothers had office jobs. Another 17 (8.5%) mother were teachers while 15 (7.5%) mothers were doing other works.149 (74.5%) mothers reported that their previous child also had neonatal jaundice, whereas 51 (25.5%) mothers replied that their previous child did not have neonatal jaundice. Table - I. The total knowledge score was 10. The mean (SD) knowledge score was 6.2 (± 1.9). The median knowledge score was 6.5. The minimum knowledge score was 2 while the maximum score was 9.5.Figure - 2. Out of 200, 105 (52.5%) mothers had inadequate knowledge score (less than 7) while 95 (47.5%) mothers had adequate knowledge score (7 and above).

TABLE - I:K� NOWLEDGE SCORE DISTRIBUTION OF ALL THEENROLLED MOTHERS (n=200)

Knowledge ScoreMean

Standard deviationMedian

Range (min - max)

Number6.2

±1.96.5

(2.0 - 9.5)

FIGURE - 1:D� ISTRIBUTION OF ALL THE ENROLLEDMOTHERS BY EDUCATIONAL STATUS (n=200)

FIGURE-2: DISTRIBUTION OF ALL THE ENROLLED MOTHERSBY KNOWLEDGE SCORE CATEGORIES (n=200)

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moderate-to-high level of knowledge. Almost 1/3rd of the mothers visited a physician in 24 hour of jaundice appearance in neonate and 13.8% admitted that they waited and before they sought medical advices they managed their babies with traditional remedies. 32.2% of the mothers discontinued feeding their babies with colostrums and coloured foods. Hence, 42.8% of the mothers acted weakly regarding their jaundiced neonates. The health care workers were major source of information for participants regarding neonatal jaundice. The study concluded that the knowledge of Iranian mothers was

16.inadequate In Turkey, researchers conducted a study on 161 mothers who had given birth to healthy newborns at Izmir Aegean Gynaecology and Obstetrics Hospital between January 2010 and April 2010 by questionnaire to assess the mothers' knowledge on neonatal jaundice. Knowledge was evaluated as "sufficient" or "insufficient" based on responses. The rate of insufficiently informed mothers was 53.6%. Low education level was found to increase the probability of the mothers' knowledge level to be insufficient by 2.1 folds. Being informed beforehand by a previous baby with jaundice increased the probability of the mothers' knowledge to be sufficient by 2 folds. It was concluded that the mothers' knowledge regarding

9neonatal jaundice was insufficient in Turkey . Another observational cross-sectional study was conducted in Provincial General Hospital (PGH), Badulla, Sri Lanka to know the knowledge, behavior and attitude of postnatal mothers

st regarding neonatal jaundice. A total of 396 mothers from 1 May th2010 to 15 June 2010, were interviewed using a structured

questionnaire. The mean (SD) knowledge score was 31 (±14), the mean (SD) attitude score 65.7 (±20.6) and the mean (SD) behaviour score 66.1 (±18.8) on neonatal jaundice. The knowledge of neonatal jaundice among postnatal mothers was low. There was significant correlation between mothers'

17. attitude and behaviour scores with the knowledge scoreA study was conducted on perceptions of mother towards neonatal jaundice and its management in India. The results show that some mothers believed that they had caused the jaundice using phrases like “got it from me, did something wrong. Not being a good mother”. Most mothers informed that the blood testing was difficult procedure to watch and mothers used “screamed” or “suffered” to describe reactions of their neonates. Study showed that mother's concerns increased as bilirubin levels increased and higher levels of interventions were needed. Mothers were concerned that neonate would become blind or overheat and that the lights would be insufficient in reducing bilirubin levels. Several mothers admitted that the yellow eyes of their babies made them worry

18about their infant's visionA study conducted by Eneh and Ugwu to know the knowledge of the mothers regarding causes, treatment and complications of neonatal jaundice attending Children Outpatient (CHOP) and Immunization clinics on at the Department of Paediatrics and Child Health, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria by using structured questionnaire. Total 255 mothers were interviewed. (11.8%) 30 of them have never had heard anything about neonatal jaundice while (88.2%) 225 have

4pregnancy about neonatal jaundice could be the first step towards improving healthy behaviours.An ethnographic study from the United States of America (USA) evaluated maternal concerns regarding neonatal jaundice. Total 47 mothers were interviewed of healthy breastfeeding babies with jaundice. 27 years was mean maternal age. More than half of multiparous mothers had a previous baby with jaundice and three-quarters of them had breastfed a previous baby. Neonatal jaundice was defined as serum bilirubin > 170 µM/L. Mothers were interviewed between 2.5 and 14.5 weeks postpartum. (55%) 26 mothers had believe that the quantity and quality of breastfeeding was responsible for this. (57%) 27 mothers assumed neonatal jaundice to be a dangerous condition. 10 out of 20 unconcerned mothers revealed that their baby were healthy and were feeding well inspite of being jaundiced. The remaining ten women had received prompt reassurance and proper information regarding jaundice. Maternal anxiety was directly proportional to the severity of neonatal jaundice. Most women preferred to be informed prenatally about jaundice, while others were of opinion to get informated at discharge or only when their baby becomes jaundiced. Communicating sources for information were written pamphlets, videos, individual talk, and small group discussions. Mothers wanted more detailed information regarding causes of neonatal jaundice, potential effects of jaundice, expected jaundice duration, treatment options and remedies that mothers could take for prevention of jaundice

15.and to take care of babies with jaundice Another study was conducted among Malaysian mothers to know the gaps of practices of neonatal jaundice care and their knowledge. Total 400 mothers from the obstetric outpatient or inpatient of a general hospital were enrolled in cross sectional study. They were assessed through a structured questionnaire. The results revealed that most (93.8%) of them were aware of neonatal jaundice, and 71.7% knew that jaundice extending beyond two weeks was abnormal, but only 34.3% knew that jaundice in first 36 hours of neonate's life was pathological. Only 20% knew about fetal-maternal blood incompatibilities and glucose-6-phosphate dehydrogenase deficiency. Mothers knew that severe jaundice could cause death and brain damage were 71.7% and 69.7% respectively. Only 38.4% of them knew that hearing impairment could be caused by severe jaundice. A very low percentage (27.1%) knew that putting jaundiced infants in direct sunlight could cause worsening of jaundice and dehydration. Out of score of 15, the mean maternal knowledge score was 7.4. Most of the multiparous mothers (83.1%) with history of neonatal jaundice in previous baby practiced direct sunlight exposure to their infants. The study showed a wide gap regarding knowledge of care of neonatal jaundice among Malaysian mothers. Direct sunlight exposure was still a common

8.practiceA study conducted on 1666 Iranian mothers between June 2004 and February 2007 with icteric neonates hospitalised to a single centre in order to identify any wrong knowledge and faulty practices regarding neonatal jaundice. A knowledge score calculated on response basis. The mean (SD) knowledge score was 3.38 (±1.23) out of 6. About 77% of the mothers had

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3. Shaw E, Grenier D. Prevention of kernicterus. Can Fam Physician. 2008; 54(4): 575 - 76.

4. Khalesi N, Rakhshani F. Knowledge, attitude and behaviour of mothers on neonatal jaundice. J Pak Med Assoc. 2008; 58(12): 671 - 74.

5. Mezaal MA, Nouri KA, Abdool S, Safar KA, Nadeem ASM. Cerebral palsy in adults consequences of non progressive pathology. Open Neurol J. 2009; 3: 24 - 26.

6. Evans D. Neonatal jaundice. BMJ Clin Evid (online). 2007: 0319.

7. Aladag N, Filiz TM, Topsever P, Gorpelioglu S. Parents knowledge and behaviour concerning sunning their babies; a cross sectional descriptive sstudy. BMC Pediatr. 2006; 6: 27.

8. Boo NY, Gan CY, Gian YW, Lim KS, Lim MW, Krishna-Kumar H. Malaysian mothers' knowledge & practices on care of neonatal jaundice. Med J Malaysia. 2011; 66(3): 239 - 43.

9. Sutcuoglu S, Dursun S, Halicioglu O, Ozturk C, Akman S, Yaprak I, et al. Evaluation of maternal knowledge level about neonatal jaundice. J Matern Fetal Neonatal Med. 2012; 25(8): 1387 -89.

10. Holtrop PC, Maisels MJ. Hyperbilirubinemia in Intensive Care of the Fetus and Neonate. Philadelphia, PA: Mosby-Year Book; 1996:888-98.

11. Manning D, Todd P, Maxwell M, Platt MJ. Prospective surveillance study of severe hyperbilirubinaemia in the newborn in the UK and Ireland. Arch Dis Child Fetal Neonatal Ed. 2007; 92.

12. Bhutani VK, Johnson L. Kernicterus in the 21st century. Frequently asked questions. J Perinatol. 2009;29:127-31.

13. Bhutani V, Maisels M, Stark K, Buonocore G. Management of jaundice and prevention of severe neonatal hyperbilirubinaemia in infants >35 weeks gestation. Neonatology. 2008; 94: 63 - 67.

14. Kaplan M, Hammerman C. American Academy of Pediatrics guidelines for detecting neonatal hyperbilirubinaemia and preventing kernicterus. Arch Dis Child Fetal Neonatal Ed. 2005; 90(6):448-49.

15. Hannon PR, Willis SK, Scrimshaw SC. Persistence of maternal concerns surrounding neonatal jaundice Arch Pediatr Adolesc Med. 2001; 155: 1357 - 63.

16. Amirshaghaghi A, Ghabili K, Shoja MM, Kooshavar H. Neonatal jaundice: knowledge and practice of Iranian mothers with icteric newborns. Pak J Biol Sci. 2008; 11(6): 942 - 45.

17. Rodrigo BKNR, Cooray G. The knowledge, attitude and behaviour on neonatal jaundice of postnatal mothers in Provincial General Hospital, Badulla. Sri Lanka Journal of Child Health. 2011; 40(4): 164 - 68.

18. Patricia R, Hannon MD, Sharla K, Susan C. Perception of neonatal jaundice. Indian J Pediatr. 2003; 70(6): 463 - 66.

19. Eneh AU, Ugwu RO. Perception of neonatal jaundice among women attending children out patient and immunization clinics of the UPTH Port Harcourt. Niger J Clin Pract. 2009; 12(2): 187 - 91.

some knowledge and only those were further explored. The age ranged from 16 to 47 years with mean (SD) age 27.1 (±3.3) years. Median parity was 2. 122 (54.2%) women had tertiary education. 174 (77.3%) defined correctly neonatal jaundice, and in 114 (44.7%) source of information was from talk in the clinic. 75 (33.3%), and 50 (22.2%) believed that main causes of neonatal jaundice were eating too much groundnut during pregnancy and mosquito bites respectively, while 55 (24.4%) answered correctly that it was due to mother and baby's blood mismatch. Only few were aware of fact that dusting powder use on baby's cord, storing baby's clothes in camphorand prematurity, were risk factors for NNJ. 114 (50.7%) and 60 (26.7%), believed wrongly that sunlight exposure and glucose drinks were the main source of treatment and 50 (22.2%) knew that brain damage was a possible complication. The study concluded that there was a misconception regarding causes, treatment and risk factors of neonatal jaundice among Nigerian

19women.Mothers' level of knowledge about neonatal jaundice is unsatisfactory in our study. In order to enhance healthy behaviours, education programmes should be organized for mothers both during pregnancy and just before hospital discharge. At same time, preventive measures like administration of anti- D immune globulin at 28 weeks' gestation to rhesus-negative pregnant women or during immediate post-partum period should also be discussed with primary health care workers and mothers. Moreover neurotoxic effect of unconjugated bilirubin should also be discussed with mothers as severely affected babies either die or have to live with severe mental and physical handicap.

CONCLUSION

The knowledge of mothers regarding neonatal jaundice (NNJ) is quite poor.

RECOMMENDATIONS

There is a need to conduct further studies, particularly using qualitative study design, to explore more about it. At the same time, a detailed strategy should be made to provide awareness about NNJ and its complication to all women during pregnancy, as well as and soon after delivery through community health workers programmes in Pakistan so that timely recognition and appropriate treatment of jaundiced babies limit sequelae especially hyperbilirubinemia associated cerebral palsy.

REFERENCES

1. Piazza AJ, Stoll BJ. Digestive system disorders. In: Kleigman, Behrman, Jenson, Stardon, editors. Nelson text book of paediatrics. Philadelphia: Saunders; 2007: 756 - 65.

2. Rasul CH, Hassan MA, Yasmin F. Outcome of neonatal hyperbilirubinemia in a tertiary care hospital in Bangladesh. Malays J Med Sci. 2010; 17(2): 40 - 44.

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