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58

Bangladesh Journal of Medical Science Vol. 13 No. 01 January’14

Original article:

Evaluation of attributes to hyperbilirubinaemia in neonates in a tertiary care hospital in the Dhaka city

Choudhury S1, H Shaila2, Islam MZ3, Akhter S4, Arifa S5, Hayat SMS6

Abstract
Objective: The study was aimed to evaluate the attributes related to hyperbilirubinaemia
among neonates. Materials and methods: A total number of 120 neonates with hyperbiliru-
binemia included in the study. Data were collected using hospital records and by face-to-face
interview of mother of those neonates using a predesigned questionnaire. Data were expressed
as mean±SD and number (percent) as appropriate. Both descriptive and inferential statistics
were considered in data analysis. Statistical analyses were performed using SPSS Software.
Result: Of the total neonates, 57% were baby boys. In age group of 2nd to 7th days were 59.2%
of neonates. According to the birth weight, neonates distribution was 38.3% in very low
(<2000g), 42.5% low (2001-2500g) and 19.2% normal (>2500g) birth weight group. ABO
incompatibility was found in 14.2% and Rh 8.3% cases of hyperbilirubinaemia. Birth trauma
was found in 7.5% and congenital anomalies 3.3% neonates. Pre-maturity (gestational age <37
wks) was found in 73.3% cases. Normal vaginal delivery was performed in 59.2% of cases.
Exclusive breast feeding was given by 43.33% mothers. Of the mothers 93.4% were house-
wives. Thirty percent (30%) of mothers were adolescents (<20 years) and 27.5% young adults
(20 to 25 years). Of the 120 mothers 56.7% had primary level education. Low birth weight
(<2000g to 2500g) neonates had significantly higher (p<0.005) serum bilirubin than the nor-
mal birth weight counterpart. Among the neonates of the mothers with GDM, 9.2% had serum
bilirubin level above 20mg/dl and the distribution showed significant association (p<0.005).
Conclusions: It is concluded that low birth weight and prematurity remained to the major caus-
es of neonatal hyperbilirubinemia in neonates. Other common causes, particularly ABO and Rh
incompatibility, are also present which could be avoided by meticulous clinical practice and
burden of neonatal morbidity and mortality related to hyperbilirubinemia can be reduced.

Keywords: Neonates, Hyperbilirubinaemia, Prematurity, Low birth weight.

1. Dr. Shamima Choudhury, Lecturer, Department of Community Medicine, Ibn Sina Medical College,
Kallyanpur, Dhaka.

2. Prof. Dr. Shaila Hossain, Head, Department of Community Medicine, National Institute of Preventive and
Social Medicine (NIPSOM), Mohakhali, Dhaka.

3. Dr. Md. Ziaul Islam, Associate Professor, Department of Community Medicine, NIPSOM, Mohakhali, Dhaka.
4. Dr. Shaheen Akhter, Consultant, Sonologist, CMUD, 20 Green Road, Dhaka.
5. Dr. Sonia Arifa, Lecturer, Department of Community Medicine, Ibn Sina Medical College, Kallyanpur, Dhaka.
6. Dr. Syed Muhammad Shahin-ur Hayat, Medical Officer, ICU, Ibn Sina Hospital, Dhanmondi, Dhaka.

Corresponds to: Dr. Shamima Choudhury, Lecturer, Department of Community Medicine, Ibn Sina Medical College,
1/1-B, Kallyanpur, Dhaka, 1216, Bangladesh

Introduction
Neonatal hyperbilirubinaemia resulting in clinical
jaundice is a common problem among neonates, par-
ticularly during the first weeks of life1. Cephalo-cau-
dal progression of staining correlates with increasing
level of serum bilirubin1. At birth and early days of
life, serum bilirubin more that 7mg/dl becomes visi-
ble as jaundice; rise in bilirubin in newborn remains
undetectable for some time until bilirubin rises2.

Effect of hyperbilirubinaemia depends on its cause
and the degree of elevation3. The situation of neona-
tal jaundice in developing countries is relatively
same to that of developed countries4. In Bangladesh
60% neonates found to be admitted in hospitals due
to neonatal jaundice5. Major factors related to neona-
tal jaundice found to be male gender, low birth
weight, prematurity, ABO incompatibility, mode of
delivery, birth trauma, neonatal infection,

DOI: http://dx.doi.org/10.3329/bjms.v13i1.17430
Bangladesh Journal of Medical Science Vol. 13 No. 01 January '14 Page 58-62



Gestational DM and breast feeding6. The mortality
and morbidity picture of neonatal jaundice is
markedly different in the developed and developing
countries. Neonatal jaundice is a fairly common
cause of morbidity in Bangladesh but little informa-
tion is available on patterns of neonatal jaundice.
Attitude and health care pattern of people and early
detection of high risk groups are of paramount
importance in preventing complications of neonatal
jaundice4. Considering the realities of multiple risk
factors of neonatal hyperbilirubinaemia, the study
tried to determine the independent contribution of
each risk factor. As a global problem, preventive and
control strategies of hyperbilirubinaemia should be
based on adequate knowledge and information
regarding the incidence and risk factors, which are
not available in the developing countries where the
vast majority of births occur at home. Identifying
infants at risk of severe hyperbilirubinaemia and early
intervention may reduce the levels of morbidity and
mortality associated with bilirubin encephalopathy7.
This study was designed to access neonatal and
maternal risk factors related to the hyperbilirubi-
naemia among the neonates. The study findings may
contribute to formulation of guidelines and strategies
for better management and prevention of hyperbiliru-
binaemia among the vulnerable neonates.

Materials and Methods
This descriptive cross-sectional study was conduct-
ed to evaluate the attributes of hyperbilirubinaemia
among the neonates admitted in the Department of
Neonatology, Dhaka Medical College and Hospital.
A total number of 120 neonates with jaundice were
purposively recruited. Data were collected by face-
to-face interview and reviewing medical documents.
Neonatal factors considered for study were prematu-
rity, birth weight, ABO and Rh incompatibility, birth
trauma, gender, congenital anomalies and septi-
caemia and, maternal factors gestational age, mode
of delivery and breast-feeding. Maternal co-morbidi-
ties were gestational diabetes, hypothyroidism and
hepatitis B considered. Data regarding socio-demo-
graphic profile of mothers were age, religion, educa-
tional status and occupation.

Statistical Analysis
Data were expressed as mean±SD and number
(percent) as appropriate. Proportion and chi-squared
(Fisher’s Exact) tests were performed as applicable.
Data were analyzed using Statistical Package for

Social Science (SPSS) Version 18. A two tailed p value
less than 0.05 was considered statistical significant.

Ethical issue 
The study was approved by the Ethical Committee
of NIPSOM and all ethical considerations thorough-
ly followed. 

Result
Of the total 120 neonates, 57% were baby boys. Age
range of the 120 neonates was 1-21 days. Mean±SD
age of the neonates was 5.36±4.43 days. Distribution
of the neonates was 15.0%, 59.2% and 25.8% in 1,
2-7 and more than 7 days group respectively (Figure
1). Total serum bilirubin level varied from 12 – 23.8
mg/dl and 63.3% (76 out of 120) had the level
between 17 to 20 mg/dl.

Figure 1: Distribution of subjects on the basis of
duration of age (days).
Mean (±SD) birth weight (g) of the neonates was
2291± 461. Of the neonates 38.3% had very low
(<2000g), 42.5% low (2001g to 2500g), and 19.2%
normal birth weight (Figure 2). Among them, 17
(14.2%) had ABO incompatible, 10 (8.3%) Rh
incompatible and 29 (24%) had septicemia as major
causes of hyperbilirubinaemia. Birth trauma was
found in 9 (7.5%) neonates while congenital anom-
alies were found only in 4 (3.3%) cases (Table 1).

Figure 2: Distribution of neonates on the basis of
birth weight.

59

Hyperbilirubinaemia in neonates in a tertiary care hospital

15%

59.20%

25.80%

1 day 2-7 days > 7 days 

0%
5%

10%
15%
20%
25%
30%
35%
40%
45%

< 2000 2001-2500 >2500

Birth weight (g)



Table 1: Neonatal factors related to hyperbiliru-
binaemia

Maternal related risk factors
Of 73.3% of neonates with jaundice had gestational
age was less than 37 weeks. Of the neonates under
study mother of 59.2% cases had normal vaginal
delivery. Exclusive breastfeeding was given to
43.3%, formula feeding 20.8% and mixed feeding
35.9% neonates (Figure 3).

Figure 3: Distribution mothers provided their
neonates exclusive breastfeeding.
Maternal co-morbidity GDM was found in 19
(15.8%), hypothyroidism 8 (6.7%) and hepatitis B
positive 11 (9.2%) cases (Table 2).

Table-2: Maternal related factors in cases of
neonatal jaundice

NVD, Normal vaginal delivery; CS, Caesarian sec-
tion; GDM, Gestational diabetes mellitus Mean

(±SD) age (yrs) of the mothers was 23.73±5.44
(Table 3). Frequency distribution regarding maternal
age was shown in figure 4. Of the 120 mothers 30%
were adolescents (<20 yrs) and 27.5% young adult
(20 to 25 years). Of the total mothers 93.4% were
housewives. Mother’s formal education status was
as follows: 20.8% illiterate, 56.7% primary level and
22.5% secondary level (Table 3).

Figure 4: Distribution of mother with neonatal
jaundice on the basis of their age.

Table 3: Socio-demographic profile of mothers
of neonates

Different level of bilirubin in neonates was explored
with their birth weight. Distribution of number of
neonates in three levels of total bilirubin showed sig-
nificant association (p<0.005) (Table 4).

Table 4: Distribution of neonates with different level
of total bilirubin on the basis of birth weight Birth
weight group Total bilirubin level (mg/dl)

Of the 120 neonates 9.2% had bilirubin level more than
20 mg/dl and 5% between 17-20 mg/dl. None of the
neonate was in group of bilirubin level 12-16.9 mg/dl.
Of the 103 neonates of ABO compatible had bilirubin

60

Choudhury S, H Shaila, Islam MZ, Akhter S, Arifa S, Hayat SMS

30.0% 

27.5% 17.5% 

35.0% 

< 20 yrs >20-25 yrs >25-30 yrs > 30 yrs 

Attributes Findings
Gestational age (mean ±SD, wks) 35.4±2.3 
Mode of delivery [NVD (CS)] (%) 59.2 (40.8) 
Feeding pattern (%) 

Exclusive breast feeding 52 (43.33) 
Formula feeding 25 (20.84) 
Mixed feeding  43 (35.83) 

History of Jaundice of previous baby 33 (27.5%) 
GDM 19 (15.8%) 
Hypothyroidism 8 (6.7%) 
Hepatitis B   11 (9.2%) 

Total bilirubin level (mg/dl) 

12-16.9 17-20 >20 Birth weight group  
N (%) N (%) N (%) 

<2000 (g) 0 (0) 35 (29.1) 11 (9.2) 
2000-2500 (g) 10 (8.3) 41 (34.2) 0 (0) 
>2500(g) 23 (19.2) 0 (0) 0 (0)

Attributes Findings
Age of mother (mean±SD, yrs) 23.73±5.44 
Religion [Islam (Hinduism)] (%) 90 (10) 
Education [N (%)] 

Illiterate  25 (20.8) 
Primary 68 (56.7)
Secondary 27 (22.5)

Occupation of mother 
Job (%) 8 (6.6) 
Housewife (%) 112 (93.4) 

Attributes Findings 
Gender [Male (Female)] (%) 57 (51) 
Age [mean ±SD, days] 5.36±4.43 
Birth weight [Mean ±SD, g] 2291±461 
ABO incompatibility [N (%)] 17 (14.2%) 
Rh incompatibility [N (%)] 10 (8.3%) 
Septicaemia [N (%)] 29 (24%) 
Birth trauma [N (%)] 9 (7.5%) 
Congenital anomalies [N (%)]  4 (3.3%) 



level up to 16.9 mg/dl. The distribution showed statis-
tical significant associated (p<0.001) (Table 5).

Table-5: Distribution of neonates with ABO
incompatibility in relation to total bilirubin level 

Gestational diabetes mellitus was present in 19
mothers. Baby of the 19 mother 11 (9.2% of total)
had bilirubin more than 20 mg/dl and none of those
with normal glucose. In 56.5% of neonates bilirubin
levels was between 17-20 mg/dl. At same bilirubin
level 6.7% cases of neonate mothers had GDM. This
distribution showed statistical significant association
(p<0.005) (Table 6).

Table 6: Distribution of neonates with their
mother’s diabetes status in relation to total
bilirubin level

Discussion:
Proportion of male neonates with hyperbilirubinemia
in the present study was 57.0% which found to be
almost similar to that of earlier reported by Zabeen et
al7. They have demonstrated that 11.6% of their
neonates had serum total bilirubin ³20 mg/dl where as
in the present study the proportion was 9.2%. In the
present study 17 (14.2%) neonates had ABO and 10
(8.3%) Rh incompatibility. Proportion of neonates
with ABO incompatibility in these study subjects
found to be consistent with the other studies. The
study carried out on Iranian population showed the
ABO incompatibility to be 12%8 and earlier study in
Bangladesh 11.3%5. ABO incompatibility was
reported to be the commonest cause of neonatal
hyperbilirubinemia according to the study conducted
in UAE7. However, Rh incompatibility relatively
higher the present study than the previous study
(5.4%)5. This feature may be attributed to the rela-
tively small number of samples. Prematurity is one of
the major causes of neonatal jaundice. In this study
77.3% (88 out of 120) neonates were premature

which is almost similar to the findings of Dawodu and
his group7. The study reconfirmed the prematurity as
prominent cause of hyperbilirubinemia in neonates. It
is usually seen that in most of the cases hyperbiliru-
binemia present within the first week of life. The
present study the scenario was also similar where in
74.2% of the neonates had 7 days or less. 

Birth weight is regarded as the indicator of fetal well
being and used to assess risk of neonatal morbidity
and mortality. Low birth weight babies are found to
be susceptible to develop hyperbilirubinemia. In the
present study 38.3% of the neonates were of low
birth weight (<2500g) which is consistent with other
studies5,7. These low birth weight babies had signif-
icantly higher level of bilirubin compared to the
other groups (Table 4). This finding highlighted fact
of low birth increase the risk of development of
hyperbilirubinemia and its level.

In the present study 15.8% of mothers of hyper-
bilirubinemic neonates had GDM which is lower
than the earlier report that showed very high propor-
tion (35%) of mothers with GDM, this variation,
however, might be explained by the fact of recruiting
the cases from BIRDEM Hospital5 for the later
study. On the other hand 15.8% of GDM mothers in
the present study appeared to be markedly high to
that of 3.3% in another study9 where, however,
number of study samples was much higher. Study
involving large number of subjects and adaptation of
more stringent inclusion criteria may explain the
issue clearly. It is important to note that significant-
ly more neonates of GDM (9.2%) than non-GDM
mothers had higher bilirubin level (p<0.005) which
strengthened the notion that neonates of GDM moth-
ers are more likely to suffer from neonatal hyper-
bilirubinemia. 

The present study demonstrated that normal vaginal
delivery was done in 59.2% cases and rest had
Caesarian section which is almost similar (63.6% vs
36.4% respectively) to other report8. Relatively high
proportion of delivery done caesarian section might
have been compounded by the fact that in case of
normal vaginal delivery mother and the newborn left
the hospital much earlier than their counterpart and
in case need sought clinical advice elsewhere but
those with caesarian section stayed in the hospital till
6th or 7th postoperative day and the neonates repre-
sented relatively higher number.

61

Hyperbilirubinaemia in neonates in a tertiary care hospital

Total bilirubin level (mg/dl) 

12- 16.9 17-20 > 20 ABO incompatibility 

N (%) N (%) N (%) 

ABO incompatible 0 (0) 6 (5) 11 (9.2) 

ABO compatible 33 (27.5) 70 (58.3) 0 (0) 

Total bilirubin level (mg/dl) 
12- 16.9 17-20 > 20 GDM 

N (%) N (%) N (%) 
Yes 0 (0) 8 (6.7) 11 (9.2) 

No 33 (27.5) 68 (56.6) 0 (0) 

Fisher’s Exact Test = 47.833, p value <0.005, CI = 95%) 



Exclusive breast feeding argued to be beneficial to
neonates in many ways. However, breast fed babies
often shows early onset of jaundice may be due to
ineffective lactation in first few days after birth result-
ing in dehydration or in some instances use of water
or glucose in water finally cause aggravation of jaun-
dice. The condition is also seen in successful feeding
as well. It is suggested that glucuronidase containing
breast milk may have a role in this respect. In
neonates intestinal absorption of bilirubin appears to
be enhanced by breast-feeding and by decrease or
delay in the passage of muconium. In the present
study 43.33% of the respondents had history of exclu-
sive breast feeding. Higher proportion of neonates

with hyperbilirubinemia was also shown by in anoth-
er study8.  Neonatal sepsis was found to be present in
24% of hyperbilirubinemic cases which was consis-
tent with other study where it was demonstrated
26.6%7. This finding excluded sepsis as a major
cause of jaundice in the neonates. It is concluded that
low birth weight and prematurity remained to the
major causes of neonatal hyperbilirubinemia in
neonates. Other common causes, particularly ABO
and Rh incompatibility, are also present which could
be avoided by meticulous clinical practice and burden
of neonatal morbidity and mortality related to hyper-
bilirubinemia can be reduced. 

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