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Referral Patterns and Factors Influencing Age at Admission of Infants with Cholestasis in India
Gopinathan Mathiyazhagan1, Barath Jagadisan2
1Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Pondicherry, 605006, India.
Insights
Early recognition of neonatal cholestasis in India is delayed, with many infants presenting late due to poor symptom identification and delayed referrals. Improving screening strategies requires addressing these diagnostic and healthcare-seeking delays.
Area of Science:
- Pediatrics
- Neonatology
- Gastroenterology
Background:
- Neonatal cholestasis presents diagnostic challenges in India.
- Timely recognition and referral are crucial for optimal infant outcomes.
Purpose of the Study:
- To define the recognition, age at admission, referral time, and referral pattern of neonatal cholestasis in India.
Main Methods:
- Prospective, observational study conducted from February 2015 to March 2016.
- Included infants with cholestasis under 6 months of age at JIPMER, Pondicherry.
Main Results:
- Median admission age was 52 days; 78.1% presented with parent-reported symptoms.
- Physician detection of jaundice occurred at a median of 45 days; only 34% identified pale stools.
- Median healthcare-seeking time was 5.5 days, with 5 days median referral time from primary care physicians (PHPs); 17.1% of PHPs reassured parents, and 14.3% prescribed herbal remedies. Biliary atresia was missed in 9 cases.
Conclusions:
- Significant delays in diagnosis and referral for neonatal cholestasis in India.
- Challenges include poor parental recognition of symptoms like pale stools and physician delays.
- Current healthcare-seeking patterns and referral practices necessitate improvements before implementing screening strategies.
Objectives:
To define the recognition, age at admission, referral time and referral pattern of neonatal cholestasis in India.
Methods:
This prospective, observational study was conducted from February 2015 through March 2016 in the Pediatric gastroenterology unit of JIPMER, Pondicherry in infants with cholestasis < 6 mo of age.
Results:
Among 64 infants, median age of admission was 52 d (IQR 28-63 d). Fifty of sixty four infants (78.1%) came with parent-reported cholestasis-related symptoms of either jaundice alone (57.8%) or bleeding manifestations (20.3%). In 21.9% infants, jaundice was detected by physicians at a median age of 45 d (IQR 38.5-53.2 d). Two infants had intracranial bleed. Only 34% infants with pale stools were identified by the mother. The median healthcare-seeking time was 5.5 d (IQR 2.5-12 d). Among infants presenting to primary healthcare physicians (PHPs) with cholestasis-related symptoms, median time to referral was 5 d (IQR 2.5-12 d). The first point of healthcare contact in 54.7% was a PHP; 17.1% PHPs had reassured the parents. Herbal preparations were prescribed by 14.3%. Only 11.8% of those with jaundice as the only problem were given vitamin K before referral. Biliary atresia (BA) was missed in neonatal intensive care units in 9 cases.
Conclusions:
The above issues need to be accounted for before evaluating or implementing screening strategies in India.