Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Pediatr. May 8, 2016; 5(2): 182-190
Published online May 8, 2016. doi: 10.5409/wjcp.v5.i2.182
Facility-based constraints to exchange transfusions for neonatal hyperbilirubinemia in resource-limited settings
Cecilia A Mabogunje, Sarah M Olaifa, Bolajoko O Olusanya
Cecilia A Mabogunje, Neonatal Unit, Massey Street Children’s Hospital, Lagos, Nigeria
Sarah M Olaifa, Laboratory Services, Massey Street Children’s Hospital, Lagos, Nigeria
Bolajoko O Olusanya, Centre for Healthy Start Initiative, Dolphin Estate, Ikoyi, Lagos, Nigeria
Author contributions: Olusanya BO conceived and designed the study, and drafted the manuscript with input from Mabogunje CA and Olaifa SM; all authors reviewed and approved the final version for submission.
Conflict-of-interest statement: The authors have no conflicts of interest to declare.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Bolajoko O Olusanya, FRCPCH, PhD, Centre for Healthy Start Initiative, Dolphin Estate, Ikoyi, PO Box 75130 VI, Lagos, Nigeria.
Telephone: +234-803-3344300 Fax: +234-803-3344300
Received: August 15, 2015
Peer-review started: August 16, 2015
First decision: September 17, 2015
Revised: December 15, 2015
Accepted: January 5, 2016
Article in press: January 7, 2016
Published online: May 8, 2016

Several clinical guidelines for the management of infants with severe neonatal hyperbilirubinemia recommend immediate exchange transfusion (ET) when the risk or presence of acute bilirubin encephalopathy is established in order to prevent chronic bilirubin encephalopathy or kernicterus. However, the literature is sparse concerning the interval between the time the decision for ET is made and the actual initiation of ET, especially in low- and middle-income countries (LMICs) with significant resource constraints but high rates of ET. This paper explores the various stages and potential delays during this interval in complying with the requirement for immediate ET for the affected infants, based on the available evidence from LMICs. The vital role of intensive phototherapy, efficient laboratory and logistical support, and clinical expertise for ET are highlighted. The challenges in securing informed parental consent, especially on religious grounds, and meeting the financial burden of this emergency procedure to facilitate timely ET are examined. Secondary delays arising from post-treatment bilirubin rebound with intensive phototherapy or ET are also discussed. These potential delays can compromise the effectiveness of ET and should provide additional impetus to curtail avoidable ET in LMICs.

Keywords: Bilirubin encephalopathy, Kernicterus, Intensive phototherapy, Laboratory services, Neonatal care, Developing countries

Core tip: Exchange transfusion (ET) is effective in preventing bilirubin-induced neurologic dysfunction in infants with severe hyperbilirubinemia. However, the timely initiation of this emergency procedure is frequently constrained by delays at various critical stages from the time the decision to commence ET is made and when ET is actually conducted. These delays must be carefully identified and appropriately addressed in each clinical setting to minimize their adverse impact in the provision of effective ET in low- and middle-income countries. Intensive phototherapy should also be considered a priority during this interval to minimize avoidable ETs.