Kernicterus in Late Preterm Infants Cared for as Term Healthy Infants

https://doi.org/10.1053/j.semperi.2006.04.001Get rights and content

Objective

To compare the clinical profile and health care experiences related to management of newborn jaundice and hyperbilirubinemia in preterm infants (<370/7 weeks gestation) who are cared for as term infants (≥370/7 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 (340/7 to 366/7 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.

Section snippets

Pilot Kernicterus Registry

The Pilot Kernicterus Registry was initiated at the Pediatric Academic Society Kernicterus Symposium in 1992.10, 11 Voluntary reporting by colleagues, parents, and medico-legal consultations were followed by a compilation of available clinical history, medical records, case reports in the medical literature, and parent interviews. Cases are scrutinized for eligibility and to avoid duplication with strict adherence to patient and clinician privacy and confidentiality. Summarized data are entered

Results

A total of 125 eligible infants reported to the Pilot Kernicterus Registry were cared for as healthy infants and received clinically supervised services. Of these, 5 (4%) were delivered at home at maternal request. A total of 119 infants were cared for and discharged from the well baby nurseries, while 1 infant remained hospitalized. A total of 114 infants (including all 4 home births) were hospitalized within age 3 to 14 days; 3 (including one home birth) were admitted between 2 to 4 weeks

Discussion

Jaundice in late preterm infants results from an increased bilirubin load due to increased bilirubin production and/or decreased bilirubin elimination. The latter may be due to decreased hepatic uptake of bilirubin from the plasma, a delayed bilirubin conjugation, or an increased entero-hepatic circulation of bilirubin. Hyperbilirubinemia in late preterm infants is more prevalent, more severe, and its course more protracted than in term neonates and that they manifest deleterious consequences

Acknowledgments

We remember the late Audrey K. Brown, MD and value her immeasurable contributions to the initiation and maintenance of the Pilot Kernicterus Registry. We thank Karen Karp, RN, and Emidio Sivieri, MS, for their useful advice and for their dedicated work on the research database. We are grateful to the Eglin Fund at the Pennsylvania Hospital for their generous support of the Pilot Kernicterus Registry. This investigation was supported, in part, by grant number MM-00480 from the AAMC-CDC.

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