Did exclusive breast-feeding and early discharge lead to excessive bilirubin levels in newborns in Antigua and Barbuda?
Hyperbilirubinaemia is a common neonatal problem worldwide and is the leading cause of admission to the Special Care Nursery in Antigua and Barbuda. In 1990, the Innocenti Declaration in support of breast-feeding led to the adoption of the Baby-Friendly Hospital Initiative in many countries of the Caribbean, including Antigua and Barbuda. Comparing 1989 to the years 1992 to 1994, the Special Care Nursery at Holberton Hospital experienced a 40% increase in newborns admitted with hyperbilirubinaemia (peak total bilirubin > 12 mg/dl or 205 mumol/l). A retrospective review of Special Care Nursery and Maternity Ward records was undertaken to determine the incidence and aetiology of hyperbilirubinaemia from 1992 to 1994. There were 3721 infants born in Antigua and Barbuda in those years, 98% of Afro-Caribbean or mixed ancestry. The overall incidence of peak total bilirubin over 12 mg/dl (205 mumol/l) was 12.5% (466/3721), not inconsistent with the reported incidence of 8 to 20% in other countries. However, the incidence of higher levels of hyperbilirubinaemia in Antigua and Barbuda exceeded those reported for other countries. In Antigua and Barbuda, total bilirubin of 15 mg/dl (255 mumol/l) or higher was found in 263 of 3721 infants (7.1%) compared to 5.9% in India and 2% of breast-fed infants in the United States of America (USA). Total bilirubin of 20 mg/dl (340 mumol/l) or higher was seen in 91 of 3721 infants (2.5%) exceeding reported prevalence in the USA for both African-American and Caucasian infants (1%) and equal to the reported prevalence in Asian infants (2%). The possible aetiologies of hyperbilirubinaemia in neonates with total bilirubin 18 mg/dl (306 mumol/l) or higher in our patients were investigated. Medical records of 134 of 156 (86%) infants having this level of hyperbilirubinaemia were available for review. The possible reason for hyperbilirubinaemia was ABO incompatibility in 4/134 (3%), Rh incompatibility in 1/134 (1%), prematurity in 12/134 (9%) and sepsis neonatorum in 21/134 (16%). The hyperbilirubinaemia was idiopathic in 96/134 (71%) infants. Newborns in Antigua and Barbuda were discharged 3.7 days after their mothers' admission, with 50% discharged prior to 48 hours of age. Early discharge in developed countries has led to increased readmissions for hyperbilirubinaemia. Following the appointment of a dietitian to supervise breast-feeding, admissions for hyperbilirubinaemia fell by 50% by 1998. These data suggest that exclusive breast-feeding and early discharge led to an epidemic of neonatal hyperbilirubinaemia in Antigua and Barbuda.