Aggressive treatment may be warranted in some newborns with jaundice

May 06, 2001

Philadelphia, Pa. -- In a small fraction of newborns with jaundice, aggressive medical treatment may be necessary to avoid long-term neurological injury, say researchers from The Children's Hospital of Philadelphia. Reporting in the May issue of the journal Pediatrics, the researchers also suggest that early hospital discharge and inadequate counseling about breastfeeding played a role in the jaundice, also called hyperbilirubinemia, found in the infants they studied.

Hyperbilirubinemia is an excessive amount of the blood compound bilirubin, which at severe levels can lead to brain damage, called kernicterus. Hyperbilirubinemia is more common among babies who breastfeed. It also is more common in premature babies, although the newborns in the current study were term or near-term.

Reported cases of kernicterus have increased in the United States since 1990. On May 2, the Joint Commission on Accreditation of Healthcare Organizations issued a special alert to 5,000 U.S. hospitals drawing their attention to existing guidelines for identifying and following newborns with high bilirubin levels. Children who survive kernicterus may suffer cerebral palsy, hearing loss and other neurological problems.

"Before 1990, kernicterus in a previously healthy term infant was extraordinarily rare, and most pediatricians were unlikely to see the disease in a lifetime of practice," said Mary Catherine Harris, M.D., an attending neonatologist at The Children's Hospital of Philadelphia, and lead author of the study. "The increase in reported cases may result from more relaxed guidelines for treatment of hyperbilirubinemia, combined with shorter hospital stays, increased breastfeeding and reduced opportunity for adequate breastfeeding counseling," added Dr. Harris.

Approximately 60 percent of newborns in the United States become jaundiced each year, according to the American Academy of Pediatrics. Jaundice appears as a yellow color in the skin, a sign of excess bilirubin, a chemical normally produced by the breakdown of red blood cells. In the vast majority of cases, jaundice disappears in one to two weeks as the baby's liver rids the body of excess bilirubin. High levels of bilirubin in newborns are treatable, although physicians may disagree about the timing and extent of therapy.

The Children's Hospital team retrospectively reviewed the charts of all term and near-term infants admitted to Children's Hospital between 1993 and 1996 with blood levels of bilirubin higher than 25 milligrams per deciliter during the first week of life. They found six such infants, five of whom had had neurological symptoms, such as lethargy and abnormal muscle tone. After aggressive treatment using intravenous fluids, phototherapy (exposure to light rays, which help to break down bilirubin), and blood transfusions, all but one of the children had normal neurological examinations at follow-up three months to two years later.

The study is the first to show that abnormalities of the brain on magnetic resonance imaging (MRI) images revert to normal by the time of follow-up examinations. "We suspect that these changes reflect early, aggressive treatment of the problem, although the significance of those MRI findings for revealing brain injury in such cases remains largely unexplored," said Dr. Harris.

All six infants in the study had been breastfed. For reasons that are not fully understood, breastfeeding is a risk factor for hyperbilirubinemia. When breastfeeding is not fully established, a newborn may become dehydrated, which also raises the risk of hyperbilirubinemia. "We certainly don't want to discourage new mothers from breastfeeding," said Dr. Harris. "We believe that early hospital discharge, along with inconsistent follow-up, may contribute to this condition, because new mothers may not receive adequate breastfeeding counseling, and thus may not be adequately breastfeeding at home."

The authors speculate that less aggressive treatment of infants with hyperbilirubinemia may contribute to long-term neurological problems, such as hearing loss. Dr. Harris added that further studies are needed comparing treatments and outcomes for infants with moderate hyperbilirubinemia.
Co-authors of the study with Dr. Harris, all from Children's Hospital, are Judy C. Bernbaum, M.D., director of the Neonatology Follow-up Program; Robert Zimmerman, M.D., chief of the Division of Neuroradiology; and Richard A. Polin, M.D., and Jessica R. Polin, of the Division of Neonatology.

Founded in 1855 as the nation's first pediatric hospital, The Children's Hospital of Philadelphia is ranked today as the best pediatric hospital in the nation by a comprehensive Child Magazine survey. Its pediatric research program is among the largest in the country, ranking second in National Institutes of Health funding.

Children's Hospital of Philadelphia

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