Interventions Could Reduce Racial Disparity in Neonatal Kernicterus

By Will Boggs MD

July 08, 2020

NEW YORK (Reuters Health) - Various interventions could reduce the largely overlooked high kernicterus rate among Black infants, a new review suggests.

Black neonates account for about 14% of births in the U.S. but more than 25% of reported cases of kernicterus. Similarly, in the UK and Ireland, bilirubin encephalopathy is more common among Black infants, suggesting that the disparity is not limited to the U.S.

In a paper online in JAMA Pediatrics, Dr. Jon F. Watchko from the University of Pittsburgh School of Medicine and colleagues highlight the many biologic and nonbiologic factors contributing to kernicterus risk and approaches to reduce the racial disparity.

Paradoxically, while Black neonates have a lower overall incidence of significant bilirubin elevations, hazardous hyperbilirubinemia (total serum bilirubin of at least 30 mg/dL) is far more common among Black neonates (about 1 in 8,000) than among White neonates (about 1 in 33,000).

Biological contributors to this disparity include higher rates of glucose-6-phosphate dehydrogenase (G6PD) deficiency, ABO hemolytic disease of the newborn, and late preterm delivery among Black neonates.

Unreliable clinical assessment of jaundice in Black newborns, misperception that Black infants are at lower risk for hazardous hyperbilirubinemia, failure to recognize G6PD deficiency as a kernicterus risk in African American neonates, and limited parental health literacy and care-seeking practices are among the nonbiological contributors to the kernicterus disparity.

The authors offer several practical recommendations for healthcare professionals to minimize the risk of kernicterus among Black infants.

General recommendations include checking the predischarge bilirubin level and managing TSB levels greater than the 75th percentile as high risk; booking follow-up appointments prior to hospital discharge; communicating with the community care clinician responsible for follow-up; and providing verbal and written instruction to parents on jaundice detection, signs of acute bilirubin encephalopathy, and when and how to contact outpatient clinicians.

Specific recommendations address screening for and management of G6PD, testing for and management of ABO incompatibility, and bilirubin surveillance of late preterm infants.

"Continued study is imperative to understand the current scope of kernicterus and its occurrence in Black neonates," the authors conclude. "Increased enrollment of African American participants in such research is also essential to ensure more balanced and powered evaluations of kernicterus risk and associated conditions, such as G6PD deficiency."

Dr. David L. Schutzman from Einstein Medical Center, Philadelphia, Pennsylvania, who recently reviewed heme oxygenase-1 genetic variants and hyperbilirubinemia in African-American newborns, told Reuters Health by email, "Universal screening for hyperbilirubinemia is essential during the birth hospitalization. Rigorous follow-up of infants after discharge following the recommendations of the Bhutani nomogram is also essential. Hospital-based physicians may want to consider monitoring an infant's bilirubin level even after discharge until it is safely decreasing."

Also important is "promoting parental health literacy regarding jaundice as well as highlighting that severe jaundice can appear suddenly in infants with G6PD deficiency and requires immediate attention," he said.

"Ideally a study that combines point of care identification of G6PD deficiency with intensive parental education about jaundice might hopefully be able to demonstrate a decreased incidence of readmission for severe hyperbilirubinemia," Dr. Schutzman said.

Dr. Watchko did not respond to a request for comments.

SOURCE: JAMA Pediatrics, online July 6, 2020.