Mothers' Knowledge and Attitude Regarding Neonatal Hyperbilirubinemia

Introduction

Hyperbilirubinemia is an abnormally elevated serum bilirubin level characterized by yellowing of the skin and other tissues of a newborn infant. It is the most common condition that requires medical attention in newborns (Hockenberry and Wilson, 2013). The most prevalent and easily identified symptom of both types of hyperbilirubinemia is jaundice, in neonates, clinical jaundice diagnosed if the total serum bilirubin is ≥7 mg/dl.  It affects 60% of term and 80% of preterm infants in the first week of life (Allahony et al., 2016).

Physiological jaundice is an elevated serum bilirubin in a newborn by third or fourth day of life, due to immaturity of the liver's capacity to handle a substantial amount of bilirubin leading to jaundice and reduced life span of red blood cells 45-90 days. It usually takes the newborn’s liver a week or two to mature enough to handle the build-up of bilirubin in the blood, while preterm or late preterm newborn at 5th day of life will have a peak bilirubin level of 15 mg/d (Vandborg et al., 2012).

Pathologic Jaundice is an elevated serum bilirubin level in a newborn, defined as an elevated bilirubin level >5 mg/dL within the first twenty-four hours of life, an increase in the bilirubin level of more than 0.5 mg/dL /hour, and this due to hemolytic diseases as RH incompatibilities, ABO incompatibilities (Maisels et al., 2012).

The most obvious sign of hyperbilirubinemia is jaundice, the yellowish discoloration primarily of the sclera, nails, or skin. The intensity of the jaundice not always related to the degree of hyperbilirubinemia; therefore, trans-cutaneous screening or serum bilirubin levels are necessary. The associated signs include poor at sucking or feeding, sleepy, and have a high-pitched cry (Hockenberry et al., 2016).

Most jaundice is benign and resolves within 7 to 10 days in term newborns. However, severe hyperbilirubinemia may develop in 8% to 9% of all newborns during the first postnatal week. Because of the potential for bilirubin toxicity, newborns require assessment to identify those at risk for severe hyperbilirubinemia or, in rare cases, bilirubin encephalopathy or kernicterus (Kamath et al., 2011). Hyperbilirubinemia leads to neurotoxicity by a number of mechanisms that include; cellular death by interfering with DNA synthesis, disruption of protein synthesis and phosphorylation, impairment of nerve conduction (particularly the auditory nerve), and by inhibition of ion exchange and water transport in renal cells leading to neural swelling (Khalifa, 2015).

Nurses play an integral role in the routine physical assessment includes observing for evidence of jaundice at regular intervals. Jaundice is most reliably assessed by observing the infant’s skin color from head to toe and the color of the sclera and mucous membranes. Applying direct pressure to the skin, especially over bony prominences such as the tip of the nose or the sternum, causes blanching and allows the yellow stain to be more pronounced (Hockenberry et al., 2016).

In Egypt, several other factors predispose to severe hyperbilirubinemia and kernicterus. These include inappropriate maternal knowledge about the possible risks of severe neonatal jaundice, delay in seeking medical advice, home therapy for jaundice using neon lamps that do not provide the required wavelength, and difficulty in finding adequate medical care especially in remote areas when required (Iskander et al., 2012). It is suggested that the mother, as the primary caretaker, should have a clear understanding of how to recognize NNJ and how to respond appropriately, as early recognition and prompt treatment decrease the likelihood of development of the potentially permanent complication. Therefore, mothers should be adequately educated about the care of jaundiced baby and early identification of danger signs and also its complications. It helps in effective treatment and also in the prevention of jaundice complications (Allahony et al., 2016)

Significance of the study

Newborns are discharged early from hospitals, therefore mothers play an important role to recognize jaundice and control it properly. Mothers had moderate knowledge on neonatal jaundice, especially very low knowledge over complications and types of neonatal jaundice, which has to be improved through adequate education from antenatal period itself. Positive attitude to be improved in breastfeeding the child during neonatal jaundice as it is essential to prevent the complications (Rabiyeepoor et al., 2014).

In Egypt, severe hyperbilirubinemia and bilirubin encephalopathy are still being reported in numbers that cannot be ignored. Pre-discharge screening for neonatal jaundice or for risk factors for severe hyperbilirubinemia is not routinely performed except in private practice. To date, all available data are hospital based and not representing the general population (Basheer et al., 2017).

Fewer studies could be located that has assessed the mothers’ knowledge and attitude regarding neonatal hyperbilirubinemia. Hence, the current study is under taken to explore the knowledge and attitude of the mothers concerning hyperbilirubinemia among newborn infants. Results of the current study may help in evaluation of the mother’s knowledge and attitude as well as providing guidance, evidences and recommendations that should be reflected in neonatal nursing education and practice. Hopefully, the results of the current study could help clinical neonatal nurses design appropriate discharge education programs for mothers of newborn infants having hyperbilirubinemia.

Aim of the study

The aim of the current study was to assess mothers’ knowledge and attitude regarding neonatal hyperbilirubinemia.

Research Questions

• What are the mothers knowledge regarding neonatal hyperbilirubinemia and its management?
• What are mother's attitudes toward neonatal hyperbilirubinemia?
• Is there a difference between mothers having babies with hyperbilirubinemia and mothers without having babies with hyperbilirubinemia before?

Subject and Method

Research design:

A descriptive exploratory research design was utilized for the current study.

The primary objective of descriptive exploratory research is to explore a problem to provide insights into and comprehension for more precise investigation. It focuses on the discovery of ideas and thoughts. The exploratory research design is suitable for studies which are flexible enough to provide an opportunity for considering all the aspects of the problem.

Setting:

The study was conducted in postpartum unit at Minia University Hospital for Obstetrics and Pediatrics.

Sample:

A convenient sample of 375 mothers that admitted to postpartum unit at Minia University Hospital for Obstetrics and Pediatrics. The determination of the sample size is based upon the confidence level 95%, margin of error 5%, and population size 14600 mothers’ (total number of women was delivered in Minia University Hospital for obstetrics and pediatrics at 2014).

Inclusion criteria:

• Primipara and multipara mothers admitted in postpartum unit.
• Mothers who were willing to participate in the research

Exclusion criteria:

• Mothers have a newborn baby with multi congenital anomalies
• Mothers with chronic diseases and unable to participate in the study

Data collection Tool:

Structured interview questionnaire: It was developed by the researcher in Arabic language after reviewing related literature. It covered the following parts:

Part I: Personal data sheet: Personal data covered 5 items including mother’s age, place of residence, occupation, education level of mothers and father.

Part II: level of mother’s knowledge regarding neonatal hyperbilirubinemia: It covered 32 questions such as “definition, risk factors, causes, early signs and symptoms, prevention…etc.

Part III: Attitude of mothers regarding hyperbilirubinemia by using Likert scale that involved 15 elements includes five points as completely agree, agrees, not identified, disagree, and completely disagree. Their attitude as worry for appearance of jaundice on their child, go with baby that has neonatal hyperbilirubinemia to physician, worry about blood sample aspiration for their infant because it causes anemia ……. etc.

Scoring system:

Scoring system for mother’s knowledge regarding neonatal hyperbilirubinemia, each correct response took two scores, incorrect response took one score. It contained 32 questions, so score of general mother’s knowledge regarding neonatal hyperbilirubinemia was 64 score. The total score of mother’s knowledge less than 60% was considered as unsatisfactory knowledge, while score more than 60% was considered as satisfactory knowledge. As regards mother’s attitude regarding neonatal hyperbilirubinemia, it include 15 questions and score 5 (strongly agree), score 4 (agree), score 3 (don’t identified), score 2 (disagree), and score 1 (strongly disagree).

Procedure:

An official permission was obtained from the director of the Minia University Hospital for Obstetrics and Pediatrics, and permission from the head of department after explaining the aim and nature of the study. Mothers’ was interviewed on individual bases to explain the nature and purpose of the study. Measures were taken to protect mothers' ethical rights. Mothers' knowledge and attitude regarding neonatal hyperbilirubinemia was assessed using the structured interview questionnaire. The interview took place in the inpatient rooms of postpartum unit at Minia University Hospital for Obstetrics and Pediatrics. The researcher asked mothers questions in questionnaire and marked their response in structured interview questionnaire. The time taken to conduct the structured interview questionnaire for each mother was ranged from 20 to 30 minutes and at rate of 10 to 12 mothers/ week. Data collection was conducted over a six months period extending from May 2016 till November 2016.

Pilot study

A pilot study was done on 10 % of total sample (38 mothers) to test the content validity and feasibility of designed tools and estimate the time required for filling the tool. Modifications were done accordingly.

Tool Validity and Reliability

The tools were given to a panel of three experts in the field of neonatology and pediatric nursing to examine the content validity. Modifications of the content were done according to the panel judgment on the clarity of sentences, appropriateness of content and sequences of items. Reliability of tools was performed to confirm its consistency by Cronbach’s Alpha reliability was 0.834 and 0.75 respectively

Ethical considerations:

A primary approval was obtained from the research ethics committee, Faculty of Nursing, Minia University. Oral Informed consent was obtained from mothers before data collection, after full explanation purpose of the study, benefits, rights for privacy, confidentiality and rights to withdraw at any time.

Statistical design

The collected data were coded and entered into the Statistical Package for the Social Science (SPSS 20.0). Data were presented using appropriate descriptive and inferential statistical tests in the form of frequencies and percentages for categorical variables.  Statistical significant was considered at p -value ≤ 0.05.

Result:

Table1: The percentage distribution of mothers according to their personal data (n=375)

Table 1: shows the percentage distribution of mothers according to their personal data. It was found that mother's age from 18-and less than 27 years equal to mother is age from 27- and less than 42 years were 42.9% respectively of each one and the mean age of mother was 28.1 ± 6.3 years.  More two thirds of mothers (68.5%) were housewives and 41.9% came from rural area. The one third of mothers (37.9%) and fathers (32.8%) were illiterate.

Table 2: the percentage distribution of mothers according to their past experience related to hyperbilirubinemia (n=375)

Table (2): presents the percentage distribution of mothers according to their past experience related to hyperbilirubinemia. It was noticed that more than one third (38.9%) of had previous experience of hyperbilirubinemia and more than half (52.1%) out of them had one child affected with hyperbilirubinemia before, and more than two thirds of affected newborn (69.2%) not treated at hospital. It was found that 53.3% of hospitalized child treated with phototherapy and 84.4% of neonates discharged from hospital with complete recovery and 69.9% go to hospital for investigation firstly if jaundice developed.

Table 3A:  Percentage distribution of mother’s regarding to general knowledge about hyperbilirubinemia (n=375)

Table 3A: shows the percentage distribution of mother’s regarding to general knowledge about hyperbilirubinemia. It presented that 87.2% heard about hyperbilirubinemia and main source of information was health team members 46.6% while the neighbor and friends play an important role in information of mothers which represented 30.1% from mothers. It was found that 61.6% of mothers do not know the definition. More than half of mothers (56.6%) checked for jaundice every day for the first two weeks of life and 10.1% checked every day in the first four weeks while 31.7% did not know the time of checking. It was noticed that 57.9% of mothers mentioned that face was the first site of appearance and 56.5% of them response that appearance occurred at every day of the first two weeks of life, while 59.2% of them replied that appearance of hyperbilirubinemia occur in the eye. It was observed that 55.5%-visited physician immediately when observe hyperbilirubinemia.

Table 3B: Percentage distribution of mother’s regarding to general knowledge about hyperbilirubinemia (n=375)

Table 3B: presents the Percentage distribution of mother’s regarding to general knowledge about hyperbilirubinemia continue. It summarized that more than one third (36%) of mothers do not know the early signs, while 17.6% of them said change in infant suck and feed were the early signs and 26.1% said that high pitched cry are the early signs. It was found that 39.5% of mothers do not know the causes and 23.5% of them mentioned premature labor was one of the causes. It was observed 60.8% of mothers do not know the types, while physiological hyperbilirubinemia was reported by 20.3% of mothers.  It illustrated that 34.7% of mothers said that phototherapy was the treatment, and 49.3% of them do not know the complications, while acute bilirubin encephalopathy as a complication was answered by 13.9% of mothers.

Table 4: The Percentage distribution of mother’s regarding to their attitude toward hyperbilirubinemia (n=375)

Table 4: presents the percentage distribution of mother’s regarding to their attitude toward hyperbilirubinemia. It was revealed that, the majority (94%) of mothers’ worry for appearance of jaundice, followed by them go with their babies to physician (89%). It was observed that 87% of mothers worry about sample aspiration of their babies, and 83% of them have agreement that jaundice it can be easily treated when it early diagnosed and taken suitable treatment. It was reported that 80% of mothers have an agreement that jaundice in early life easily treated at hospital and 45% of them agree that prematurity increase the incidence of jaundice. It was reflected that small numbers of mothers 21% agree that sun light exposure help in treatment of jaundice.

Figure 1: The Percentage distribution of mother’s regarding to total knowledge score 

Figure 1: illustrates the percentage distribution of mother’s regarding to total knowledge scores. It was found that more than half of mothers 52% have unsatisfactory knowledge about hyperbilirubinemia and 48% of them have satisfactory knowledge, which Mean ± SD was 34.4 ± 3.1.

Figure 2: The Percentage distribution of mother’s regarding to attitude score

Figure 2: presents the Percentage distribution of mother’s regarding to total attitude scores. It was illustrated that majority of mothers (96%) had agreed attitudes which Mean ± SD 52.9 ± 4.9

Table 5 correlation between total knowledge, attitude scores and personal data of the mothers

  **statistical significance at level ≤ 0.01

Table 5: illustrates correlation between total knowledge, attitude scores and personal data. It was represented that a fair association between occupation and educational level of mothers and their total knowledge score with highly statistically significant difference. However, there were a weak association between their total attitude score and their age.

Table 6 relation between total knowledge scores and previous experience with hyperbilirubinemia

                             **highly statistical significance at level ≤ 0.01

Table 6: illustrates relation between total knowledge scores and previous experience with hyperbilirubinemia. It was presented that 146 of mothers have previous experience with hyperbilirubinemia and more than half of them (53.9%) of them have satisfactory knowledge with statistically significance difference which p ≤ 0.000.