Kernicterus

Eugene L. Mahmoud
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Kernicterus - Treatment
Presently there is sufficient and direct laboratory and clinical literature that the use of phototherapy and/or exchange transfusion used in infants with excessive
hyperbilirubinemia can prevent extreme hyperbilirubinemia and kernicterus. And in infants with acute bilirubin encephalopathy, exchange transfusion (with and without phototherapy) can prevent or minimize the chronic sequelae of bilirubin-induced dysfunction. It also should be clear that there are fundamental behaviors needed to avoid the risk of hyperbilirubinemia. The purpose should not be to blame, but to establish a safety culture. Performance of root-cause studies leading to the implementation of changes or reinforcing safe and effective behavior should be undertaken in the future. Defined behaviors should be driven by considerations that are not financial. Instead they should be focused on commitment, and should be universal, despite the cost pressures, liability constraints, and resistance to change. We must also respond adequately to the concerns of parents regarding the evolution of neonatal jaundice, poor feeding, breastfeeding difficulties, or changes in behavior or activities of the newborn, and failure to treat appropriately severe hyperbilirubinemia without taking into consideration the child’s age in hours after birth. . In many health care institutions nurses have been given the prerogative of doing transcutaneous bilirubin testing, as well as ordering serum bilirubin, with a physician bearing the responsibility for a systems failure.
Prevention of hyperbilirubinemia is the best way to minimize the incidence of kernicterus. However, because some babies develop kernicterus with relatively modest bilirubin levels, no known absolute level of bilirubin below which the infant is completely safe is recognized. Also other factors contribute to the ability of bilirubin to cross the blood-brain barrier. So today, not withstanding the efforts of some hospital systems and the American Academy of Pediatrics to standardize this aspect of newborn care, approaches to the surveillance and management of hyperbilirubinemia remain individualized, both throughout the United States and the world.
Safe management of neonatal jaundice can be attained by adhering to the proposed management of neonatal jaundice provided in the American Academy of Pediatrics
Guidelines as the main tool used to avoid the risk of damage. Total serum bilirubin or transcutaneous bilirubin is to be performed on every neonate either at the recognition of clinical jaundice or before discharge regardless of whether jaundice was observed. For non-jaundiced neonates, the nursery staff is encouraged to
obtain the screening total serum bilirubin at the same time they obtained the state-mandated newborn screen for inborn errors of metabolism. Bilirubin values are plotted on an hour-specific nomogram and the corresponding percentile used to guide evaluation, therapy and follow-up. Any newborn with bilirubin values in the High Risk or Intermediate High Risk Zones requires a repeat total serum bilirubin value within 8-12 hours.
It also should be clear that there are fundamental behaviors needed to avoid the risk of hyperbilirubinemia. The purpose should not be to blame, but to establish a safety culture. Performance of root-cause studies leading to the implementation of changes or reinforcing safe and effective behavior should be undertaken in the future. Defined behaviors should be driven by considerations that are not financial. Instead they should be focused on commitment, and should be universal, despite the cost pressures, liability constraints, and resistance to change. We must also respond adequately to the concerns of parents regarding the evolution of neonatal jaundice, poor feeding, breastfeeding difficulties, or changes in behavior or activities of the newborn, and failure to treat appropriately severe hyperbilirubinemia without taking into consideration the child’s age in hours after birth.


References
Kernicterus Kernicterus 02/13/2016
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