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Published on: November 20, 2015
Kernicterus in late preterm infants cared for as term healthy infants
Vinod K Bhutani1, Lois Johnson
1Department of Neonatal and Developmental Medicine, Lucile Salter Packard Children's Hospital, Stanford University, Palo Alto, CA 94305, USA. bhutani@stanford.edu
Insights
Preterm infants with jaundice are not adequately assessed, leading to severe complications like kernicterus. Healthcare providers often overlook prematurity as a risk factor for hyperbilirubinemia, impacting infant health outcomes.
Area of Science:
- Neonatal Medicine
- Pediatric Neurology
Background:
- Newborn jaundice and hyperbilirubinemia are common, with preterm infants (<37 weeks gestation) being particularly vulnerable.
- Kernicterus, a severe form of bilirubin neurotoxicity, can cause permanent neurological damage.
Purpose of the Study:
- To compare clinical management and healthcare experiences for newborn jaundice in preterm infants cared for as term infants.
- To identify factors contributing to acute and chronic posticteric sequelae in this population.
Main Methods:
- Retrospective study using data from the Pilot Kernicterus Registry (1992-2003).
- Inclusion criteria required infants to meet definitions for acute bilirubin encephalopathy and/or kernicterus.
- Compared etiology, severity, and duration of extreme hyperbilirubinemia (TSB >20 mg/dL) and response to interventions between preterm and term infants.
Main Results:
- Preterm infants received no targeted risk assessment for jaundice before discharge.
- Late preterm infants (34-36 weeks) and large-for-gestational-age infants had higher rates of kernicterus.
- Clinical management was not influenced by gestational age, signs, or risk assessment, leading to more severe sequelae in late preterm infants.
Conclusions:
- Healthcare providers frequently failed to recognize late prematurity as a risk factor for hazardous hyperbilirubinemia.
- Biologic risk factors for hyperbilirubinemia and bilirubin neurotoxicity were often unidentified before or after discharge.
- Unsuccessful lactation was a common experience, contributing to management challenges.
Objective:
To compare the clinical profile and health care experiences related to management of newborn jaundice and hyperbilirubinemia in preterm infants (<37(0/7) weeks gestation) who are cared for as term infants (> or =37(0/7) weeks) and develop acute and/or chronic posticteric sequelae.
Methods:
Retrospective study of a convenient sample of term and near term infants voluntarily reported to the Pilot Kernicterus Registry (1992-2003). Study infants were required to meet the clinical definitions for acute bilirubin encephalopathy (moderate or advanced severity) and/or the classical signs of kernicterus. Main outcome measures were the comparison of etiology, severity and duration of extreme hyperbilirubinemia (TSB levels >20 mg/dL), response to interventions of intensive phototherapy and exchange transfusion, and health care delivery experiences in preterm as compared with term infants.
Results:
No targeted attention was accorded to preterm infants during their neonatal health care experiences as related to predischarge risk assessment, feeding, discharge follow-up instructions, or breastfeeding, regardless of the known vulnerability of preterm infants to safely transition during the first week after birth. The TSB levels, age at re-hospitalization, and birth weight distribution were similar for late preterm and term infants. Large for gestational age and late preterm infants disproportionately developed kernicterus as compared with those who were appropriate for gestational age and term. Clinical management of extreme of hyperbilirubinemia, by the attending clinical providers, was not impacted or influenced by the gestational age, clinical signs, or risk assessment. This resulted in severe posticteric sequelae which was more severe and frequent in late preterm infants.
Conclusions:
Late prematurity (34(0/7) to 36(6/7) weeks) of healthy infants was not recognized as a risk factor for hazardous hyperbilirubinemia by clinical practitioners. Unsuccessful lactation experience was the most frequent experience; being large for gestational age as well as the other known biologic risk factors for hyperbilirubinemia and bilirubin neurotoxicity were not identified by the clinical care providers either before discharge or at immediate postdischarge follow up.