Revised guidance to help prevent kernicterus

Issue 18, published in April 2001, of Sentinel Event Alert (1) discussed the risk factors, root causes, risk reduction strategies and follow up recommendations to guide health care organizations in the prevention, early detection, and treatment of hyperbilirubinemia leading to kernicterus—a highly preventable condition of newborns that leads to severe brain damage or death. 

In July 2004, the American Academy of Pediatrics (AAP) issued an updated clinical practice guideline, "Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation,"  (2) for hospitals and for health care professionals who care for newborn infants both in the hospital and upon discharge. While kernicterus is considered a rare but highly preventable condition, recent reports of kernicterus indicate that the condition is still occurring. The revised clinical practice guideline is intended to provide health care professionals with specific information to prevent occurrences of kernicterus, ease parents' anxiety and concerns about kernicterus, and educate the public about the risks and complications of severe hyperbilirubinemia leading to kernicterus.

The updated clinical practice guideline, a product of the AAP Subcommittee on Hyperbilirubinemia, stresses the importance of universal systematic assessment while the newborn is in the hospital, close monitoring and follow-up upon discharge, and prompt intervention once jaundice is diagnosed.

Key elements of the updated guideline

The essential elements of the recommendations provided by the updated guideline suggest that clinicians should:

1. Promote and support successful breastfeeding.
2. Establish nursery protocols for the identification and evaluation of hyperbilirubinemia.
3. Measure the total serum bilirubin (TSB) or transcutaneous bilirubin (TcB) level of infants jaundiced in the first 24 hours.
4. Recognize that visual estimation of the degree of jaundice can lead to errors, particularly in darkly pigmented infants.
5. Interpret all bilirubin levels according to the infant's age in hours.
6. Recognize that infants <38 weeks' gestation, particularly those who are breastfed, are at higher risk of developing hyperbilirubinemia and require closer surveillance and monitoring.
7. Perform a systematic assessment for the risk of severe hyperbilirubinemia on all infants prior to discharge.
8. Provide parents with written and oral information about newborn jaundice.
9. Provide appropriate follow-up based on the time of discharge and the risk assessment.
10. Treat newborns, when indicated, with phototherapy or exchange transfusion.

"The overall aim of the guideline is to promote an approach that significantly reduces the risk of kernicterus while minimizing the risk of unintended harm such as increased anxiety, decreased breastfeeding, or unnecessary costs and treatment," says Jeffrey Maisels, M.B., B.Ch., chair of the AAP Subcommittee on Hyperbilirubinemia. "The analysis of recently reported cases of kernicterus suggests that if health care personnel follow the recommendations in the guideline, kernicterus would be largely preventable."

"Through the updated guideline, AAP has brought additional evidence to the jaundice management dialogue that supports a systems-based approach to preventing kernicterus, including the finding that measuring the TSB or TcB and plotting it on a nomogram is the best documented method for assessing the risk of hyperbilirubinemia," says Sue Sheridan, spokesperson for the advocacy, educational and support group PICK, Parents of Infants and Children with Kernicterus.

"To ensure a safe first week after birth for all newborns, birthing institutions need to address the well-recognized impediments to continuity of care and implement practical, relevant and seamless solutions," says Vinod K. Bhutani, M.D., clinical professor of pediatrics, University of Pennsylvania School of Medicine. "Institutions and care providers are advised to examine their institutional policies and establish a systematic assessment, prior to discharge, based on patient safety.  It is important to provide early and focused follow-up based on the risk assessment; limit reliance on visual recognition of jaundice and allow nurses unfettered access to bilirubin testing; initiate prompt treatment with phototherapy or exchange transfusion when indicated; and support and promote breastfeeding with on-site, certified lactation counseling in support of breastfeeding."

Joint Commission recommendations

The Joint Commission recommends that all hospitals and health care professionals caring for newborn infants both inside the hospital and after discharge from the hospital observe the recommendations cited in the updated clinical practice guideline, "Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation," and that:

1. All newborns be assessed prior to hospital discharge for the risk of developing severe hyperbilirubinemia after discharge.
2. The newborn be scheduled for a follow-up visit within three to five days of age, when the baby's bilirubin level is highest.
3. Women who are breastfeeding receive appropriate oral and written instructions about newborn jaundice. Infants should be breastfed at least eight to 12 times a day for the first few days to stimulate milk production and help keep the baby's bilirubin level down.

References

1. "Kernicterus Threatens Healthy Newborns," Issue 18, April 2001, Sentinel Event Alert, Joint Commission on Accreditation of Healthcare Organizations
2. "Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation," Subcommittee on Hyperbilirubinemia; PEDIATRICS, Vol. 114 No. 1, July 2004, pp. 297-316, http://www.aap.org/
3. Kernicterus video material from the Centers for Disease Control and Prevention