Hyperbilirubinemia in Term and Near-Term Infants: Kernicterus on the Rise?

Shari Steffensrud, MS, RNC, NNP

NAINR. 2004;4(4) 

In This Article

Abstract and Introduction

Jaundice in term and near-term (35 to 37 week) infants is generally benign, however, concern has surfaced in recent years regarding reemergence of kernicterus in this patient population. An increasing number of litigation cases centering on kernicterus have arisen and increasingly apparent is the fact that otherwise healthy newborn infants may be at risk for this potentially devastating neurologic condition. The purpose of this article is to provide a review on hyperbilirubinemia in term and near-term infants. Historical perspective, brief review of bilirubin physiology, and etiologies of hyperbilirubinemia will be followed by a discussion of physiologic effects/clinical symptoms of elevated serum bilirubin levels, kernicterus, and potential sequale. Methods for evaluation, treatment, and prevention of significant hyperbilirubinemia will be included.

In the early 1950s, the link between hyperbilirubinemia and neurologic dysfunction was scientifically established and treatment with exchange transfusion was found to decrease neurological impact in infants with hemolytic conditions.[1,2] Serendipitously during this time, the discovery was made that infants exposed to sunlight were less jaundiced than their nonexposed counterparts.[3] Thus began the era of phototherapy, which was widely used by the late 1960s.

Phototherapy and exchange transfusion resulted in the virtual disappearance of kernicterus until the early 1990s when questions were raised regarding possible "overtreatment" of elevated bilirubin levels in healthy full-term infants without risk factors for hemolysis.[4] Studies suggested that there was no evidence for kernicterus in this particular patient population and proffered the belief that many of these infants were unnecessarily treated for jaundice.[5] Based on these findings, the American Academy of Pediatrics (AAP) published a practice parameter in 1994 for management of hyperbilirubinemia in healthy term infants with nonhemolytic jaundice. Recommendations were given for initiation of phototherapy at various serum levels, based on infant's age in hours, to keep bilirubin levels <20 mg/dL. Allowance for serum levels as high as 25 mg/dL in infants >72 hours of life was suggested before considering exchange transfusion.[6] Based on these recommendations, physicians began cutting back on treatment of elevated serum bilirubin levels in nonhemolytic term newborn infants.

Changes in management of hyperbilirubinemia in healthy term infants have not been the only changes in newborn care during the last 10 to15 years. An upsurge in breastfeeding and shorter hospital stays (sometimes <24 hours) have become more commonplace, leaving less time available for new mothers to receive adequate instruction and assistance to ensure successful breastfeeding. Shorter hospital stays also mean decreased observation time of the infant for development of jaundice.[7]

The 1990s saw a significant increase in the number of published cases of kernicterus. In April 2001, the Joint Commission on Accreditation of Health Care Organizations (JCAHO) issued a sentinel event alert on the apparent increase of kernicterus in otherwise healthy term and near-term infants.[8] In June 2001, the Center for Disease Control (CDC) also reported cases of kernicterus occurring in healthy infants.[9] Failure of health care providers to recognize severity of jaundice, early discharge from the hospital (<48 hrs) without close follow-up, failure to provide continued lactation support to breastfeeding mothers, lack of family education regarding jaundice, and failure of health care providers to respond appropriately to parental concerns about jaundice were cited as root causes for the apparent increase in reported cases.[8]


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