Maame Akosua Serwaa-Gyening: Neonatal Jaundice, chronicles of a paediatric nurse  

The readings on the monitor stopped suddenly, and my heart skipped a beat.

I was not prepared to be the bearer of the news that the newborn twins could not make it. How does the
medical team explain to a couple who had suffered from childlessness for a decade that they had lost their twins, born 5 days ago, to the complications of Neonatal Jaundice?

Prevention of complications of neonatal jaundice is possible even in resource-limited settings.

In my many years of working in the Emergency Room (ER) as a paediatric nurse, this was one of the most challenging tasks I had to carry out with my colleague doctors.

A look at the mother screaming at the top of her voice made tears roll down my face.

I had to excuse myself quickly to maintain my composure. Though it was late in the night, the mother’s screams drew the attention of many people to the ER to find out what was happening. Within a short period, all one could see was a group of people who could not hold back their tears.

What a night duty!

Other members of the night team were just as speechless. What went wrong from the time of birth till their discharge? What were the systems lacking to help these neonates survive? I guess these were the questions they were all asking themselves.

The father of the babies, who had a team of prayer warriors fervently praying with him for a miracle to happen, was not ready to accept any negative news from the medical team. Though the long-term complications of jaundice had been explained to him, he was ready to fight with his last breath to make the children survive.

Suddenly, I heard one woman in the crowd saying, “This same jaundice happened to my daughter, and now she is not talking, walking, or growing like other children. I wish God took her as a baby so I would not need these frequent admissions to the hospital.”

As I listened to this woman talk to the other parents, I realised the struggles mothers living with children with cerebral palsy (a movement disorder due to the complication of conditions like newborn jaundice) had.

Finally, when we managed to calm the parents down and broke the unpleasant news, the father held onto my scrubs tightly and shouted, “Maame Nurse, please do something because my daughters cannot die like that”. That statement hit my bones, and I wished something else could have been done, but they arrived at the hospital too late.

In my country, Ghana, two years after marriage without a child can send a woman to her early grave, and theirs had been ten years of marriage without a child. Only God knows how this couple survived till this time.

Miraculously, God blessed them with a set of twins, two beautiful girls. Pregnancy and delivery were very smooth until they were discharged home. On the third day, the mother noticed that her babies eyes were yellow and not sucking well. She complained to almost everyone who visited that day, but they all said she should expose them to the early morning sun.

This she did for a day without improvement. Finally, the elderly aunty assisting in caring for these babies decided to put glucose on their eyes and give them some to drink.

Later, when the parents noticed the babies had stopped sucking the breastmilk and had developed a change in their posture accompanied by a high-pitched sound when crying, they got alarmed and rushed them to the ER where I work. This was 2 days after the mother first noticed the eyes were yellow.

On arrival at the ER, the paediatrician took the history, thoroughly examined the babies, and confirmed to the parents that the babies had severe jaundice with brain involvement. This, notwithstanding, the medical team put in every effort to treat them but unfortunately, the babies died in less than 24hrs after arrival.

The ER staff deals with this and many other emotionally draining events concerning newborn jaundice. I remember how a man nearly beat his wife after the doctor had told them their baby had jaundice.

According to this man, his wife loved groundnut soup when she was pregnant, and that caused neonatal jaundice. That was when I realised the level of ignorance about neonatal jaundice in my country.

Elsewhere in the developed world, there is no difficulty in the management of neonatal jaundice, but not in Ghana, especially when one of the causes is the first item almost all expectant mothers buy to give a good smell to their baby’s clothes; Camphor, also known as Naphthalene balls or Moth balls.

Statistics have shown that 6 out of 10 babies who are carried to full term and 8 out of 10 premature babies may develop jaundice a few days after birth.

One of the leading causes of neonatal jaundice is the excessive breakdown of red blood cells and the immaturity of the liver to handle it. When red blood cells are broken down, one of the by-products is a pigment known as bilirubin, which causes the yellowish discolouration of the skin and eyes.

It goes through a process with the help of the liver to be conjugated (bound to another substance) and removed from our bodies. However, due to the immaturity of the newborn’s liver, not all the bilirubin gets conjugated, and some remains in the baby’s blood.

In a condition known as glucose -6-phosphate dehydrogenase (G6PD) deficiency, the lack of the enzyme known as G6PD causes red blood cells to break down in excess in response to certain medications or chemicals like camphor or to infections.

The excess breakdown of the red blood cells overwhelms the liver, and jaundice occurs. There are other causes, like blood group and rhesus incompatibility and infections, which all lead to an excessive breakdown of red blood cells in the baby. The unconjugated (unbound) bilirubin can enter the brain and cause brain damage.

Other causes, like liver diseases, may lead to jaundice in the newborn. This demonstrates that pregnant women’s food does not cause neonatal jaundice.

Management of neonatal jaundice includes exposing the babies to a type of blue light called phototherapy, which works very fast to decrease the amount of jaundice in the blood. Another form of treatment is a procedure known as exchange blood transfusion, used in severe cases. In this procedure, blood is removed in small volumes from the baby and fresh blood is given back with each amount that is taken out.

This is done to decrease the amount of blood with bilirubin in the baby. Other causes, like liver diseases, require a different type of management. What about early morning sunbathing, which has been a practice of old?

Sunbathing should not be used in managing babies with jaundice, and neither should they be given glucose, as these cannot decrease the amount of bilirubin in the blood.

The major complication of neonatal jaundice is a condition known as Kernicterus. It is a type of brain injury resulting from a high amount of unconjugated bilirubin in a baby’s blood that crosses into the brain. It can cause cerebral palsy, hearing loss, and epilepsy. As a result, some babies may die, as in the case of the twins described above.

But, who is to be blamed for the complications of neonatal jaundice, which is preventable? Most health facilities in the country do not have phototherapy machines, leading to delays in initiating treatment.

Many people lack adequate education on neonatal jaundice, like the man who accused his wife of causing her newborn to have jaundice by consuming groundnut soup during pregnancy. Family members, friends and sometimes healthcare personnel wrongly prescribe sunbathing to our newborn babies when they become yellow.

As I signed out from my night shift in the morning, I could not stop thinking about this couple and the countless parents who have suffered the same fate due to late presentation and the poor management of newborn jaundice.

• Morbidity and mortality due to neonatal jaundice is easily preventable
• Avoid the use of camphor/naphthalene balls in newborn clothing
• Do not sunbathe babies whose skin or eyes are yellow
• Report to the nearest facility when you see your baby’s eyes are yellow
• Phototherapy units must be available in every health facility where children are born

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Written by Maame Akosua Serwaa-Gyening.
Email: masagg30@albertsore

Source: Ghana News