Developmental follow-up of breastfed term and near-term infants with marked hyperbilirubinemia

Management challenges in the treatment of severe hyperbilirubinemia in low- and middle-income countries: Encouraging advancements, remaining gaps, and future opportunities

Neonatal jaundice (NJ) is common in newborn infants. Severe NJ (SNJ) has potentially negative neurological sequelae that are largely preventable in high resource settings if timely diagnosis and treatment are provided. Advancements in NJ care in low- and middle-income countries (LMIC) have been made over recent years, especially with respect to an emphasis on parental education about the disease and technological advancements for improved diagnosis and treatment. Challenges remain, however, due to lack of routine screening for SNJ risk factors, fragmented medical infrastructure, and lack of culturally appropriate and regionally specific treatment guidelines. This article highlights both encouraging advancements in NJ care as well as remaining gaps. Opportunities are identified for future work in eliminating the gaps in NJ care and preventing death and disability related to SNJ around the globe.

Hyperbilirubinemia in the Term Infant: Re-evaluating What We Think We Know

This article attempts to highlight contemporary issues relating to term neonatal hyperbilirubinemia and to focus attention on controversial issues and concepts with the potential to effect change in clinical approach. On the one hand, the focus is bilirubin neurotoxicity, which is now known to encompass a wide, diverse spectrum of features. The various aspects of this spectrum are outlined and defined. On the other hand, bilirubin also possesses antioxidant properties. As such, mild hyperbilirubinemia is suggested as actually offering the neonate some protective advantage.

Childhood neurodevelopmental outcomes of survivors of acute bilirubin encephalopathy: A retrospective cohort study

BACKGROUND

Reports on childhood neurodevelopmental and neurosensory outcomes following acute bilirubin encephalopathy from low- and middle-income countries are scarce.

AIM

This study aimed to analyze the neurodevelopmental and neurosensory outcomes of survivors of acute bilirubin encephalopathy.

STUDY DESIGN

Retrospective cohort.

SUBJECTS

Neonates with admission diagnosis of acute bilirubin encephalopathy were followed up and assessed for neuromotor, neurodevelopmental and neurosensory functions between 18 m and 12.5 years of age.

RESULTS

In 67 neonates with acute bilirubin encephalopathy, a composite outcome of cerebral palsy or death was observed in 33 (49%) subjects. Choreo-athetoid cerebral palsy [19 (73%)] was the most common type observed. Sensori-neural hearing loss was observed in 46 (79%) subjects. Subjects with cerebral palsy had significantly low Developmental profile-3 scores in all assessed domains. Neonates with an early-stage acute bilirubin encephalopathy (aOR (95% C.I): 0.12 (0.05-0.71); p = 0.02) and those with a normal neurological examination at discharge (aOR (95% C.I): 0.11 (0.06-0.7); p = 0.049) had significantly lower odds of the primary outcome.

CONCLUSIONS

Majority of survivors of acute bilirubin encephalopathy had adverse outcomes during childhood in the form of cerebral palsy and sensory-neural hearing loss. Cognitive functions were better preserved than the language and general development in the affected children.

G6PD Deficiency Prevalence as a Cause of Neonatal Jaundice in a Neonatal Ward in Dohuk, Iraq

OBJECTIVE

The current study initiated to address the effect of glucose-6-phosphate dehydrogenase (G6PD) deficiency on the pathogenesis and the severity of neonatal hyperbilirubinemia (NHB).

STUDY DESIGN

A total of 100 newborns with moderate to severe indirect hyperbilirubinemia and 50 normal neonates without hyperbilirubinemia had been enrolled in the current case-control study. All enrolled neonates had been tested for ABO and Rh(D) blood grouping, Total serum bilirubin measurement, complete blood count, morphology, reticulocyte counts, direct Coombs' test, and G6PD enzyme assay.

RESULTS

From all enrolled hyperbilirubinemic neonates, 16% were G6PD deficient and this displays a statistically significant difference in comparison to controls (only 6% were G6PD deficient). Also, significant difference was found in the level of serum indirect bilirubin among G6PD-deficient neonate in comparison to G6PD nondeficient neonates which had contributed significantly to the difference in the duration of phototherapy and hospitalization among deficient neonate. Despite this, no significant difference found in the onset of presentation, reticulocytes count, and age of neonates between the two groups (G6PD-deficient and G6PD nondeficient neonates).

CONCLUSION

The current study augments the etiological role of G6PD in the causation and severity of NHB in the region; however, in the absence of significant difference in the reticulocytes and the hemoglobin level, the underlying mechanism cannot be backed to the excess hemolysis alone.

Early Neurodevelopmental Outcome of Neonates with Gestation 35 Weeks or More with Serum Bilirubin in Exchange Range Without Encephalopathy: A Prospective Observational Study

OBJECTIVE

To describe early neurodevelopment outcomes of neonates with severe hyperbilirubinemia without acute bilirubin encephalopathy (ABE).

METHODS

Neonates born at gestation ≥35 weeks, admitted to NICU with total serum bilirubin (TSB) in exchange range with no features of ABE, were followed up until the age of 6 months. Infants were assessed for impaired hearing and neurodevelopment at 3 months and 6 months of age.

RESULTS

A total of 59 neonates were enrolled in the study. At 3 months of age, 7.6 percent of neonates were found to have hypotonia and motor delay, whereas 42.3 percent had abnormal brainstem evoked response audiometery. At 6 months, 6.4 percent of neonates were found to have persistent neurodevelopmental impairment.

CONCLUSION

Severe hyperbilirubinemia is associated with impaired neurodevelopment and hearing even in infants without ABE. Peak TSB level strongly correlates with abnormal outcomes.

Analysis on the MRI and BAEP Results of Neonatal Brain With Different Levels of Bilirubin

BACKGROUND

To explore whether there is abnormality of neonatal brains' MRI and BAEP with different bilirubin levels, and to provide an objective basis for early diagnosis on the bilirubin induced subclinical damage on brains.

METHODS

To retrospectively analyze the clinical data of 103 neonatal patients, to conduct routine brain MRI examination and BAEP testing, and to analyze BAEP and MRI image results of the neonatal patients, who were divided into three groups based on the levels of total serum bilirubin concentration (TSB): 16 cases in mild group (TSB: 0.0-229.0 ěmol/L), 49 cases in moderate group (TSB: 229.0-342.0 ěmol/L), and 38 cases in severe group (TSB ≥ 342.0 ěmol/L).

RESULTS

We found the following: A. Comparison of the bilirubin value of the different group: The bilirubin value of the mild group is 171.99 ± 33.50 ěmol/L, the moderate group is 293.98 ± 32.09 ěmol/L, and the severe group is 375.59 ± 34.25 ěmol/L. The comparison of bilirubin values of the three groups of neonates (p < 0.01) indicates the difference is statistically significant (p < 0.01). B. The weight value of the <2,500 g group is 2.04 ± 0.21 and the ≥2,500 g group is 3.39 ± 0.46; the weight comparison of the two groups indicates that the difference is statistically significant (p < 0.01). C. Comparison of the abnormal MRI of the different groups: The brain MRI result's abnormal ratio of the mild group is 31.25%, the moderate group is 16.33%, and the severe group is 21.05%, but the comparison of brain MRI results of the three neonates groups indicates that the difference is not statistically significant (p > 0.05). D. Comparison of abnormal MRI signal values of globus pallidus on T1WI in different groups: 1. The comparison of normal group signal values with that of mild group (p < 0.05), with that of moderate group, and with that of severe group (p < 0.01) indicates that the difference is statistically significant.

CONCLUSION

At low level of bilirubin, central nervous system damage may also occur and can be detected as abnormality by MRI and BAEP. Meanwhile, MRI and BAEP can also provide early abnormal information for the judgment of central nervous system damage of the children with NHB who have no acute bilirubin encephalopathy (ABE) clinical features, and provide clues for early treatment and early intervention.

Molecular Physiology and Pathophysiology of Bilirubin Handling by the Blood, Liver, Intestine, and Brain in the Newborn

Bilirubin is the end product of heme catabolism formed during a process that involves oxidation-reduction reactions and conserves iron body stores. Unconjugated hyperbilirubinemia is common in newborn infants, but rare later in life. The basic physiology of bilirubin metabolism, such as production, transport, and excretion, has been well described. However, in the neonate, numerous variables related to nutrition, ethnicity, and genetic variants at several metabolic steps may be superimposed on the normal physiological hyperbilirubinemia that occurs in the first week of life and results in bilirubin levels that may be toxic to the brain. Bilirubin exists in several isomeric forms that differ in their polarities and is considered a physiologically important antioxidant. Here we review the chemistry of the bilirubin molecule and its metabolism in the body with a particular focus on the processes that impact the newborn infant, and how differences relative to older children and adults contribute to the risk of developing both acute and long-term neurological sequelae in the newborn infant. The final section deals with the interplay between the brain and bilirubin and its entry, clearance, and accumulation. We conclude with a discussion of the current state of knowledge regarding the mechanism(s) of bilirubin neurotoxicity.

Long-term Effects of Indirect Hyperbilirubinemia on Auditory and Neurological Functions in Term Newborns

Objective:

The aim of this study was to investigate the long-term effects of hyperbilirubinemia on neurological and hearing function in otherwise healthy term newborns with neonatal indirect hyperbilirubinemia.

Method:

This study was performed prospectively in 41 term newborns hospitalized for indirect hyperbilirubinemia. Patients with no signs of hemolysis were categorized in 3 groups based on stabil levels as sTB <20 mg/dl, 20-24.9 mg/dl, and =>25 mg/dl. Patients with total bilirubin level =>20 mg/dl and hemolytic disease were classified as the fourth group. The relationship between maximum sTB level, duration of exposure to sTB levels >20 mg/dl and etiology of jaundice with neurological and auditory functions was investigated. Detailed neurological examination, Denver II developmental screening test and hearing tests (otoacoustic emissions, OAE and auditory brainstem responses, ABR) were performed to all patients between 18-24 months of age.

Results:

Neurodevelopmental disorder was found in 5 (12.2%) patients. Hemolytic disease was detected in two of these patients. Hearing loss was found in 4 (9.8%) of the patients. Two of these patients had auditory neuropathy spectrum disorder and the other two had cochlear hearing loss. The sTB levels of all these patients were above 25 mg/dl. No neurological disorder or hearing loss was found in the patients who had stabil of <25 mg/dl. Exposure time to sTB levels above 20 mg/dl was significantly longer in patients with neurological dysfunction and pathologic ABR results (p:0.007, p:0.007; p<0.05).

Conclusion:

This study demonstrates that kernicterus may develop in term newborns with severe hyperbilirubinemia (sTB>25 mg/dl) without any finding of significant hemolysis. Not only the bilirubin level but also the duration of exposure to high bilirubin levels may be effective in the development of bilirubin neurotoxicity. The high rate of hearing loss in our patients emphasizes the importance of screening for infants with severe hyperbilirubinemia using comprehensive auditory evaluation for early diagnosis of possible hearing loss.

Extreme neonatal hyperbilirubinemia and kernicterus spectrum disorder in Denmark during the years 2000-2015

OBJECTIVE

To determine the incidence and etiology of extreme neonatal hyperbilirubinemia, defined as total serum bilirubin (TSB) ≥450 µmol/L, and kernicterus spectrum disorder (KSD) in Denmark between 2000 and 2015.

STUDY DESIGN

We identified all infants born between 01.01.2000 and 31.12.2015 with TSB ≥450 µmol/L, ratio of conjugated to TSB <0.30, gestational age ≥35 weeks, and postnatal age ≤4 weeks, using Danish hospitals' laboratory databases.

RESULT

We included 408 infants. The incidence of extreme neonatal hyperbilirubinemia among infants with gestational age ≥35 weeks was 42/100,000 during the study period with a seemingly decreasing incidence between 2005 and 2015. Twelve of the 408 infants developed KSD, (incidence 1.2/100,000) Blood type ABO isohemolytic disease was the most common explanatory etiology.

CONCLUSIONS

Our study stresses the importance of a systematic approach to neonatal jaundice and ongoing surveillance of extreme neonatal hyperbilirubinemia and KSD.

Sixty years of phototherapy for neonatal jaundice - from serendipitous observation to standardized treatment and rescue for millions

A breakthrough discovery 60 years ago by Cremer et al. has since changed the way we treat infants with hyperbilirubinemia and saved the lives of millions from death and disabilities. "Photobiology" has evolved by inquiry of diverse light sources: fluorescent tubes (wavelength range of 400-520 nm; halogen spotlights that emit circular footprints of light; fiberoptic pads/blankets (mostly, 400-550 nm range) that can be placed in direct contact with skin; and the current narrow-band blue light-emitting diode (LED) light (450-470 nm), which overlaps the peak absorption wavelength (458 nm) for bilirubin photoisomerization. Excessive bombardment with photons has raised concerns for oxidative stress in very low birthweight versus term infants treated aggressively with phototherapy. Increased emphasis on prescribing phototherapy as a "drug" that is dosed cautiously and judiciously is needed. In this historical review, we chronicled the basic to the neurotoxic components of severe neonatal hyperbilirubinemia and the use of standardized interventions.

Characteristics and outcome of newborn admitted with acute bilirubin encephalopathy to a tertiary neonatal intensive care unit

BACKGROUND

Acute bilirubin encephalopathy (ABE) still represents a significant cause of morbidity and mortality throughout the world, especially in developing countries. We aimed to determine the prevalence of ABE based on the Johnson bilirubin-induced neurologic dysfunction (BIND) score and to describe the discharge outcomes.

METHODS

We prospectively studied all newborns ≥ 35 weeks with ABE by evaluating signs of mental sensorium, muscle tone, and cry patterns over 1 year.

RESULTS

12% (81 out of 674) of the newborns admitted for neonatal hyperbilirubinemia had a BIND score > 1. Their admission age was 6 ± 4.1 days; total serum bilirubin (TSB) was 31.2 ± 10 mg/dL (range 17.5-75.2). Of these newborns, 40.7% and 21% had evidence of haemolysis and sepsis, respectively. Overall mortality was 9.9%; 58% of the newborns showed signs of mild-to-moderate BIND at discharge, while 32.1% survived with an apparently normal outcome. Admission BIND score was significantly correlated with admission TSB (r = 0.476, P < 0.001). Similarly, BIND score at discharge was correlated with admission TSB (r = 0.442, P < 0.001) and admission BIND score (r = 0.888, P < 0.001). The regression model showed that admission TSB (P < 0.001) and maternal illiteracy (P = 0.034) were predictors of the BIND score at admission, while admission BIND score was the best indicator of the discharge score (P < 0.001).

CONCLUSIONS

ABE is still a major problem in our community. Admission TSB and maternal illiteracy are good predictors of bilirubin encephalopathy at admission and discharge.

Emergency release uncross-matched packed red blood cells for immediate double volume exchange transfusion in neonates with intermediate to advanced acute bilirubin encephalopathy: timely but insufficient?

Given the urgency of double volume exchange transfusion (ExT) in an infant with intermediate to advanced stages of acute bilirubin encephalopathy (ABE), it has been suggested that emergency release uncross-matched packed red blood cells (ER-PRBC) be used. The efficacy of an ExT in removing bilirubin from the brain, however, is a direct function of the mass of albumin exchanged. The very low albumin content of ER-PRBC may fail to be neuroprotective. Predicted changes in total serum bilirubin (TSB), serum albumin, the bilirubin/albumin (B/A) ratio, plasma volume (PV), and bilirubin equilibration from the extravascular space during ER-PRBC ExT are described. ExT using ER-PRBC is efficacious in lowering the TSB. However, this result is falsely reassuring as significant concurrent serum albumin loss, resultant hypoalbuminemia, contraction of PV, limited bilirubin clearance from the extravascular space, and sustained B/A ratio elevations above recommended ExT treatment thresholds suggest that bilirubin neurotoxicity will continue.

Biology of Bilirubin Photoisomers

Phototherapy is the main treatment for neonatal hyperbilirubinemia. In acute treatment of extreme hyperbilirubinemia, intensive phototherapy may have a role in 'detoxifying' the bilirubin molecule to more polar photoisomers, which should be less prone to crossing the blood-brain barrier, providing a 'brain-sparing' effect. This article reviews the biology of bilirubin isomers. Although there is evidence supporting the lower toxicity of bilirubin photoisomers, there are studies showing the opposite. There are methodologic weaknesses in most studies and better-designed experiments are needed. In an infant acutely threatened by bilirubin-induced brain damage, intensified phototherapy should be used expediently and aggressively.

A decision-making tool for exchange transfusions in infants with severe hyperbilirubinemia in resource-limited settings

Late presentation and ineffective phototherapy account for excessive rates of avoidable exchange transfusions (ETs) in many low- and middle-income countries. Several system-based constraints sometimes limit the ability to provide timely ETs for all infants at risk of kernicterus, thus necessitating a treatment triage to optimize available resources. This article proposes a practical priority-setting model for term and near-term infants requiring ET after the first 48 h of life. The proposed model combines plasma/serum bilirubin estimation, clinical signs of acute bilirubin encephalopathy and neurotoxicity risk factors for predicting the risk of kernicterus based on available evidence in the literature.

Severe Neonatal Hyperbilirubinemia Decreased after the 2007 Canadian Guidelines

OBJECTIVES

To estimate the incidence of severe neonatal hyperbilirubinemia in Canada from 2011-2013 following the implementation of the Canadian Pediatric Society's published guidelines on the management of hyperbilirubinemia in 2007. Our previously reported incidence of hyperbilirubinemia in Canada was 1 in 2480.

STUDY DESIGN

Term infants ≤ 60 days of age, with a peak serum total bilirubin level > 425 μmol/L or who had an exchange transfusion were followed prospectively through the Canadian Pediatric Surveillance Program from 2011-2013. Infants with rhesus isoimmunization or born < 35 weeks gestation were excluded.

RESULTS

Ninety-one cases of severe neonatal hyperbilirubinemia were confirmed. Sixty-nine infants (76%) were readmitted to hospital, 47 (52%) of them within 6 days of age. The remaining 22 infants (24%) were identified with severe neonatal hyperbilirubinemia before they were discharged from the hospital. The mean reported peak bilirubin level was 484 μmol/L (range 181-788; SD ± 92). An etiology was identified in 57 (63%) cases, with ABO incompatibility (n = 35) and glucose-6-phosphate dehydrogenase deficiency (n = 11) being the most common. An infant was 3.5 times more likely to be diagnosed with severe neonatal hyperbilirubinemia from 2002-2004 compared with 2011-2013 (95% CI 2.72-4.47).

CONCLUSIONS

The minimum estimated incidence of severe neonatal hyperbilirubinemia in Canada is 1 in 8352 live births. Introduction of the Canadian Pediatric Society guidelines and improved physician awareness of severe neonatal hyperbilirubinemia in the last 10 years likely made positive contributions to this trend.

Effect of breast-feeding frequency on hyperbilirubinemia in breast-fed term neonate

BACKGROUND

Hyperbilirubinemic neonates have significantly less bodyweight gain from nursery discharge to outpatient department (OPD) follow up. We tested the hypothesis that discharge instructions encouraging frequent breast-feeding given in the nursery would increase infant bodyweight gain and decrease the incidence of hyperbilirubinemia.

METHODS

We enrolled consecutively live-born neonates who were discharged from the nursery and who received OPD follow up within the first 2 weeks of birth in 2011. The nursing staff discussed the discharge instructions with the parents at the time of nursery discharge. Parents were asked to fill in a nursing information form to record the frequency of breast-feeding and diaper change per day.

RESULTS

Parents of 98 breast-fed term neonates provided complete nursing information forms. These 98 neonates were classified into two groups according to breast-feeding frequency, namely <8 times/day (63 neonates) and ≥8 times/day (35 neonates). A significant positive correlation between breast-feeding frequency and diaper change frequency per day indicated that the data were highly reliable. The gestational age, Apgar score, birthweight, and bodyweight at nursery discharge and at OPD were similar between the two groups. Neonates who were breast-fed ≥8 times/day had a significantly lower incidence of hyperbilirubinemia.

CONCLUSIONS

Nursery discharge instructions that encouraged mothers to breast-feed their newborns frequently decreased the rate of hyperbilirubinemia in exclusively breast-fed term neonates.

Early formation of bilirubin isomers during phototherapy for neonatal jaundice: effects of single vs. double fluorescent lamps vs. photodiodes

BACKGROUND

In neonatal jaundice, phototherapy converts bilirubin to more polar photoisomers which can be excreted without conjugation. We measured changes in the concentration of bilirubin Z,E-photoisomer during the first 4 h of intensive phototherapy using single fluorescent lights as a reference, compared to double fluorescent lights, and a single unit of photodiodes.

METHODS

Neonates (N = 42; birth weight: 1,200-4,690 g; gestational age: 28-42 wk) were studied during phototherapy. Infants were randomized to: (i) single, or (ii) double fluorescent phototherapy; or (iii) single unit photodiodes. Irradiance was measured. Serum bilirubin (by cooximetry) and Z,E bilirubin (by high-pressure liquid chromatography) were measured at 0,15, 30, 60, 120, and 240 min after the start of phototherapy. Data were analyzed with a linear mixed model.

RESULTS

There was a highly significant increase of Z,E-bilirubin over time (P < 0.0001), starting at 15 min. Photoisomers reached ~25% of total bilirubin concentration after 4 h. However, there were no significant differences between the three randomized groups in spite of significantly higher irradiance using double fluorescent lights vs. single fluorescent or photodiodes.

CONCLUSION

Formation of bilirubin photoisomers is rapid, and occurs early during intensive phototherapy for neonatal jaundice. The rate and level of photoisomerization was not influenced by irradiance and light source.

Brain magnetic resonance imaging and magnetic resonance spectroscopy findings of children with kernicterus

Background

The term kernicterus, or bilirubin encephalopathy, is used to describe pathological bilirubin staining of the basal ganglia, brain stem, and cerebellum, and is associated with hyperbilirubinemia. Kernicterus generally occurs in untreated hyperbilirubinemia or cases where treatment is delayed. Magnetic resonance imaging (MRI)-based studies have shown characteristic findings in kernicterus. The objective of our study was to describe the role of ¹H magnetic resonance spectroscopy (MRS) in demonstrating these metabolic changes and to review conventional MRI findings of kernicterus.

Material/Methods

Forty-eight pediatric cases with kernicterus were included in this study. MRI and MRS examinations were performed on variable dates (10–29 days after birth). NAA, Cr, Cho, NAA/Cr, NAA/Cho, and Cho/Cr values were evaluated visually and by computer analysis.

Results

There was no statistically significant difference between the NAA and Cho levels in the acute kernicterus patients and the control group (healthy patients), whereas both were significantly elevated in the chronic kernicterus patients. Both the mean NAA/Cr and Cho/Cr ratio values were significantly higher in the acute and chronic cases compared to the control group. The NAA/Cho ratio value was statistically lower in the acute cases than in the control group while it was similar in the chronic cases.

Conclusions

Conventional MR imaging and ¹H-MRS are important complementary tools in the diagnostics of neonatal bilirubin encephalopathy. This study provided important information for applying these MR modalities in the evaluation of neonates with bilirubin encephalopathy.

Magnetic resonance imaging of bilirubin encephalopathy: current limitations and future promise

Infants with chronic bilirubin encephalopathy often demonstrate abnormal bilateral, symmetric, high-signal intensity on T2-weighted magnetic resonance imaging of the globus pallidus and subthalamic nucleus, consistent with the neuropathology of kernicterus. Early magnetic resonance imaging of at-risk infants, while frequently showing increased T1-signal in these regions, may give false-positive findings due to the presence of myelin in these structures. Advanced magnetic resonance imaging including diffusion-weighted imaging, magnetic resonance spectroscopy, and diffusion tensor imaging with tractography may shed new insights into the pathogenesis of bilirubin-induced brain injury and the neural basis of long-term disability in infants and children with chronic bilirubin encephalopathy.

Apnea in acute bilirubin encephalopathy

Central apnea, defined as cessation of breathing for ≥20s, is frequent in premature infants born at <34 weeks׳ gestation but uncommon among healthy late preterm (34(0/7)-36(6/7) weeks׳ gestation) and term (≥37 weeks׳ gestation) infants, where it is usually a clinical manifestation of a neurological or metabolic problem. There is growing evidence that marked unconjugated hyperbilirubinemia is associated with central apnea in neonates. This article explores the reported association between acute bilirubin encephalopathy and symptomatic apneic events in newborns and the possible mechanisms involved in the pathogenesis of this phenomenon. The prevalence of symptomatic apneic events in reports of acute bilirubin encephalopathy suggests this clinical finding should be considered a sign of bilirubin neurotoxicity.

Incidence, risk factors and causes of severe neonatal hyperbilirubinemia in the South of iran (fars province)

BACKGROUND

Today, Severe hyperbilirubinemia is the most common cause of neonatal readmissions. Identification of the cause of neonatal hyperbilirubinemia is useful in determining whether therapeutic interventions can prevent severe hyperbilirubinemia.

OBJECTIVES

We conducted this study to estimate the incidence of severe hyperbilirubinemia in Fars province and to determine the underlying causes and risk factors, which would be of value in identifying and implementing strategies to prevent morbidity from this condition.

PATIENTS AND METHODS

All infants less than 28 days referred due to severe indirect hyperbilirubinemia were included. Complete history, physical examination and lab work up were performed. This is a longitudinal prospective study in 2009-2010.

RESULTS

More common causes of severe indirect hyperbilirubinemia were blood group incompatibility, G6PD deficiency, sepsis and unknown. Risk factors of severe hyperbilirubinemia were Male sex, previous siblings with severe hyperbilirubinemia, early discharge, NVD, Breast feeding and cultural background of mothers.

CONCLUSIONS

Our study showed severe neonate indirect hyperbilirubinemia is still prevalence in Fars province and ethnic and cultural background of the mothers was more effective than school education in preventing hyperbilirubinemia complication.

Usefulness of (1) H-MRS in differentiating bilirubin encephalopathy from severe hyperbilirubinemia in neonates

PURPOSE

To evaluate the usefulness of (1) H-MRS in differentiating bilirubin encephalopathy from severe hyperbilirubinemia in neonates.

MATERIALS AND METHODS

There were 11 patients enrolled in the neonatal bilirubin encephalopathy (NBE) group, 8 patients in the neonatal hyperbilirubinemia (NH) group, and 9 healthy, age-matched neonates were included as controls. All patients and controls underwent (1) H-MRS and conventional magnetic resonance (MR) sequences. The spectroscopic regions of interest were the bilateral basal ganglia and the thalamus, and a spatial resolution of 1.0 cm(3) was obtained.

RESULTS

Peak-area ratios of NAA/Cr and NAA/ Cho in the basal ganglia were found to be significantly lower for the NBE group compared with the NH and control groups (P < 0.05). In contrast, there was no significant difference in the NAA/Cr ratios calculated for basal ganglia of the NH and control groups. Peak-area ratios of NAA/Cr and NAA/Cho in the thalamus were decreased for the NBE group compared with the NH and control groups, but the differences were not significant (P > 0.05). There was a significant correlation between NAA/Cr ratios for basal ganglia and the total serum bilirubin (TSB) peak level in the NBE group (P < 0.05).

CONCLUSION

(1) H-MRS is useful in the differential diagnosis of NBE from severe hyperbilirubinemia in neonates, especially when the symptoms of NBE are atypical (subtle) and MRI does not reveal clear abnormalities.

Diffusion-weighted imaging of patients with neonatal bilirubin encephalopathy

PURPOSE

The aim of the study is to evaluate neonatal bilirubin encephalopathy in the acute period by the DWI.

MATERIALS AND METHODS

Thirty newborn babies with hyperbilirubinemia at the gestational age of 38-40 weeks, diagnosed with acute neonatal bilirubin encephalopathy as a result of clinical findings were included in the study, and a further 24 newborn babies, whose ages, weights and gestational ages were equalized, were regarded as a control group. DWI was performed on both patient and control groups.

RESULTS

When DWI apparent diffusion coefficients (ADC) of both neonatal bilirubin encephalopathy patients and the control group were compared, ACD values of neonatal bilirubin encephalopathy patients were found to be statistically significantly highly compared to that of the control group (p < 0.001). There was a significant correlation between bilirubin values and DWI findings (r = 0.41, p < 0.05).

CONCLUSION

The ADC measurement could be a promising parameter in detecting neonatal bilirubin encephalopathy.

Relation between serum bilirubin levels ≥450 μmol/L and bilirubin encephalopathy; a Danish population-based study

AIM

Describe the relation between levels of total serum bilirubin (TsB) ≥450 μmol/L and acute intermediate, acute advanced and chronic bilirubin encephalopathy.

MATERIAL AND METHODS

All infants born at gestational age ≥35 weeks in Denmark between 2000 and 2007 with a TsB ≥450 μmol/L according to the national laboratory information system. Infants diagnosed with bilirubin encephalopathy were found in the Danish National Registry of Patients.

RESULTS

502,766 infants at gestational age ≥35 weeks were identified. Two hundred twenty-four developed a TsB ≥450 μmol/L, equivalent to an incidence of 45/100,000/year, and it increased during the period. Incidence of infants with peak TsB of 450-499, 500-599 and 600-1000 μmol/L were 29.6, 12.7 and 2.2 per 100,000, respectively. Three infants had acute advanced bilirubin encephalopathy and got severe sequelae, whereas the two infants with acute intermediate encephalopathy developed normally. Their peak TsB was ≥544 μmol/L. Having a peak TsB 600-1000 μmol/L, the risk of acute advanced and chronic bilirubin encephalopathy was 27% (95% CI 6;61), and the incidence of these conditions was 0.6 (95% CI 0.1;1.7) per 100,000.

CONCLUSION

The incidence of infants with TsB ≥450 μmol/L was 45/100,000/year. Infants with a TsB ≥600 μmol/L had a substantial risk of developing acute advanced and chronic bilirubin encephalopathy, and the incidence of these conditions was 0.6 per 100,000.

Risk factors for hyperbilirubinemia in breastfed term neonates

Increased breastfeeding was suggested as a contributing factor to significant hyperbilirubinemia. The aim of this study was to identify the risk factors associated with jaundice in exclusively breastfed term neonates. We retrospectively reviewed all consecutively live-born neonates from August 2009 to July 2010 who had complete outpatient department (OPD) follow-up at ≤14 days old. Hyperbilirubinemia was defined as a transcutaneous bilirubin (TcB) value of ≥15 mg/dl. During the study period, there were 718 deliveries, of which 152 neonates were transferred to the special care nursery or neonatal intensive care unit; 566 neonates were discharged from the nursery, and 243 neonates were excluded: 83 did not return to the OPD, 46 were older than 14 days at OPD follow-up, 44 were <37 weeks of gestational age, and 70 had been fed formula. In total, 323 neonates were enrolled and classified into the hyperbilirubinemic (114 neonates) and non-hyperbilirubinemic groups (209 neonates). The gender, gestational age, Apgar score, age at nursery discharge, birth weight, and body weight at nursery discharge and at OPD were comparable between the two groups. TcB values at nursery discharge were positively correlated with TcB values in the OPD. Infants with hyperbilirubinemia exhibited significantly greater body weight loss from birth to the OPD follow-up and significantly less body weight gain from nursery discharge to OPD follow-up.

CONCLUSION

High TcB values at nursery discharge and a smaller body weight gain are associated with hyperbilirubinemia in term neonates who are exclusively breastfed.

Guidelines for detection, management and prevention of hyperbilirubinemia in term and late preterm newborn infants (35 or more weeks' gestation) - Summary

Hyperbilirubinemia is very common and usually benign in the term newborn infant and the late preterm infant at 35 and 36 completed weeks' gestation. Critical hyperbilirubinemia is uncommon but has the potential for causing long-term neurological impairment. Early discharge of the healthy newborn infant, particularly those in whom breastfeeding may not be fully established, may be associated with delayed diagnosis of significant hyperbilirubinemia. Guidelines for the prediction, prevention, identification, monitoring and treatment of severe hyperbilirubinemia are presented.

Prevention of neurodevelopmental sequelae of jaundice in the newborn

Although its cause, jaundice in the newborn, is extremely common, the disabling neurological disorder kernicterus is very rare. Kernicterus may be prevented by selecting those infants who are at risk of extreme jaundice or who may be particularly vulnerable to bilirubin neurotoxicity. Because the tools for achieving that goal are inadequate, a secondary strategy is needed. This involves a plan for emergency treatment of severely jaundiced infants, in particular those who present with neurological symptoms. In this paper I review the strategies for preventing extreme jaundice, and for reversing neurotoxicity in those infants for whom the principal strategies fail. Briefly, the tools for prevention include measurement of bilirubin while the infant is staying in the maternity unit, plotting the value on an hour-specific chart, assessing other risk factors for jaundice, and educating the parents. Emergency treatment should include immediate, high-irradiance phototherapy, consideration of intravenous immune globulin, and preparation for an exchange transfusion.

Acute neurological findings in a national cohort of neonates with severe neonatal hyperbilirubinemia

OBJECTIVE

To describe and compare infants with severe hyperbilirubinemia, who presented with and without abnormal neurological findings and to identify associated risk factors.

STUDY DESIGN

Data on infants with severe hyperbilirubinemia (>425 μmol l(-1) and/or received exchange transfusion) were collected prospectively through the Canadian Paediatric Surveillance Program (CPSP) from 2002 to 2004. Cases were categorized into two groups on the basis of information provided by the reporting physician: neurologically normal or abnormal. Demographic characteristics were compared and univariate logistic regression was performed to identify factors associated with acute neurological abnormalities in infants.

RESULT

Of the initial cohort of 258 infants, 32 (12.4%) were identified to have neurological abnormalities. Infants in the highest peak bilirubin level group (>550 μmol l(-1)) had the greatest risk of acute neurological abnormalities. The mid range (451 to 550 μmol l(-1)) and lowest level (450 μmol l(-1)) groups were less likely to have abnormalities (odds ratio (OR)=0.174; P=0.0013 and 0.402; P=0.0613, respectively). Exchange transfusion and presentation within the first 2 days of age were positively associated with abnormal neurological findings in infants (OR=3.332, P=0.003 and OR=2.572, P<0.0001, respectively).

CONCLUSION

In this national cohort of infants with severe hyperbilirubinemia, a significant percentage of infants developed acute bilirubin encephalopathy. Long-term neurodevelopmental follow-up is necessary to determine the incidence of permanent neurological sequelae.

Neonatal screening for glucose-6-phosphate dehydrogenase deficiency: biochemical versus genetic technologies

Glucose-6-phosphate dehydrogenase (G-6-PD) deficiency, a commonly occurring genetic condition, is associated in neonates with severe hemolytic episodes, extreme hyperbilirubinemia, and bilirubin encephalopathy. Neonatal screening programs for the condition should increase parental and caretaker awareness, thereby facilitating early access to treatment with resultant diminished mortality and morbidity. However, screening for G-6-PD deficiency is not widely performed. Although G-6-PD-deficient males may be accurately identified, females are more difficult to categorize because many in this group may be heterozygotes with phenotype overlap between normal homozygotes, heterozygotes, and deficient homozygotes. Screening methodologies include biochemical qualitative assays, quantitative enzymatic activity measurements and DNA-based polymerase chain reaction molecular screening. The appropriateness of any of these technologies for any particular population group or geographic area must be assessed before setting up a screening program. The pros and cons of each method, including ease of testing, cost, need for sophisticated laboratory equipment and degree of personnel training, as well as the ability to identify females, are discussed.

The role of phototherapy in the crash-cart approach to extreme neonatal jaundice

Extreme neonatal jaundice occurs infrequently but carries a high risk of permanent sequelae (kernicterus) when it does. Rapid therapeutic intervention has the potential to reduce this risk in some infants. Several case reports of infants with acute intermediate to advanced bilirubin encephalopathy shows that reversal may be possible. Phototherapy can be instituted at the flip of a switch, whereas other therapeutic measures necessarily involve delays. Therefore, high-intensity phototherapy must be regarded as an emergency measure in infants presenting with extreme jaundice and even more so in the presence of neurological symptoms. The principal and well-described effect of phototherapy involves conversion of bilirubin IXα (z, z) to more polar isomers, which are excreted in bile and urine. When care is taken to maximize the spectral power of phototherapy lights, and whenever possible with measures added to reduce the enterohepatic circulation of bilirubin, very rapid reductions in total serum bilirubin levels are possible. A hypothesis has been advanced that conversion of bilirubin to more polar photoisomers, which can reach relative concentrations of 20%-25% of total serum bilirubin within 1-2 hours, might have a direct neuroprotective effect. This theory posits that because polar molecules generally require a transporter to cross the blood-brain barrier, bilirubin photoisomers should be less prone to enter the brain. Although this theory has some support in in vitro toxicity studies, the evidence is controversial. Until further experimental support can be gained, photoconversion of bilirubin does not constitute a viable argument against instituting further measures against bilirubin neurotoxicity, such as intravenous immune globulin (when indicated) and exchange transfusion. Conversely, neither is the state of evidence an argument against immediate and effective phototherapy in the medical emergency of extreme neonatal jaundice.

Evidence suggests there was not a "resurgence" of kernicterus in the 1990s

BACKGROUND

Although some have suggested that kernicterus disappeared in the United States in the 1970s to 1980s and dramatically reappeared in the 1990s, population-based data to support such a resurgence are lacking.

METHODS

We used diagnosis codes on data collection forms from the California Department of Developmental Services (DDS) to identify kernicterus cases among children born from 1988 to 1997. We examined kernicterus mortality trends in the United States from 1979 to 2006 using death certificate data from the National Center for Health Statistics.

RESULTS

We identified 25 cases of physician-diagnosed kernicterus. This figure was augmented to reflect estimates of cases lost to infant mortality, yielding incidence estimates of 1 in 200 000 California live births, 1 in 2500 among children who received services from DDS, and 1 in 400 children with cerebral palsy. There was no significant trend in kernicterus incidence from 1988 to 1997 (P = .77). Incidence before and after the 1994 publication of the AAP practice parameter for hyperbilirubinemia in healthy term infants was not significantly different (P = .92). Nationally, there were 3 reported infant deaths from kernicterus in 1994 and 2 or fewer in the other 28 years from 1979 to 2006 (0.28 deaths per million live births): there was no significant increase in kernicterus mortality over this period.

CONCLUSION

Data from California do not support a resurgence of kernicterus in the 1990s. Deaths from kernicterus in the United States have remained rare, with no apparent increase during the last 25 years.

Influence of breast-feeding on weight loss, jaundice, and waste elimination in neonates

BACKGROUND

The Baby-Friendly Hospital Initiative began promoting exclusive breast-feeding in 2001 in Taiwan; however, few studies have investigated its impact. This study evaluated the influence of breast-feeding on Taiwanese neonates with regard to the frequency of jaundice, body weight loss (BWL), and elimination of both urine and stool.

METHODS

The medical records of 313 healthy mother-neonate pairs admitted at our hospital were reviewed retrospectively and divided into three groups: exclusively breast-feeding (n=161), mixed (breast/formula) feeding (n=80), and exclusively formula feeding (n=72).

RESULTS

Compared with the exclusively formula feeding group, in the exclusively breast-fed neonates, the average total serum bilirubin level at 3 days after birth (p < 0.001) and the rate of significant hyperbilirubinemia ≥ 15 mg/dL (p<0.05) were significantly higher; the average BWLs at 2 and 3 days after birth (p < 0.001, p < 0.001) and the rate of BWL ≥ 10% (p < 0.05) were significantly higher; the average frequency of stool passage at 2 and 3 days after birth (p < 0.001, p < 0.001) and urination at 1, 2, and 3 days after birth (p < 0.001, p < 0.001, p < 0.001) were significantly less. The factors associated with a mother's choice of infant feeding type include maternal age and delivery method.

CONCLUSION

Breast-feeding during the initial days of life has a significant influence on the degree of jaundice, amount of BWL, and the frequency of stool passage and urination.

Severe neonatal hyperbilirubinemia and kernicterus: are these still problems in the third millennium?

Despite efforts to eliminate permanent and irreversible brain damage due to bilirubin encephalopathy and kernicterus, these conditions continue to accompany us into the third millennium. This phenomenon occurs not only in developing countries with emerging medical systems, but in Westernized countries as well. Comprehensive guidelines to detect newborns with jaundice and treat those in whom hyperbilirubinemia has already developed have been formulated in several countries, but have not been successful in completely eliminating the problem. In this appraisal of the situation we review selected aspects of bilirubin encephalopathy and/or kernicterus. We highlight recent reports of severe hyperbilirubinemia and kernicterus, discuss some of the factors responsible for the continuing appearance of these conditions, and briefly review what can be done to decrease bilirubin-related morbidity and mortality to the minimum.

Universal bilirubin screening for severe neonatal hyperbilirubinemia

To reduce the incidence of severe neonatal hyperbilirubinemia affecting newborns with jaundice in the United States and to prevent kernicterus, there is a need to implement proven prevention strategies for severe neonatal hyperbilirubinemia as recommended in the 2004 American Academy of Pediatrics Guidelines for newborns >35 weeks gestational age. The purpose of universal predischarge bilirubin screening is to identify infants with bilirubin levels >75th percentile for age in hours and track those with rapid rates of bilirubin rise (>0.2 mg per 100 ml per h). Early identification has been reported to predict severe hyperbilirubinemia and allow for evidence-based targeted interventions. A systems approach is likely to reduce the preventable causes of acute bilirubin encephalopathy. To do so, highest priority should be given to (i) designating extreme hyperbilirubinemia (total serum bilirubin >427 μmol l(-1) or >25 mg per 100 ml) as a reportable condition by laboratories and health-care providers through public health mandates; (ii) implementation of Joint Commission's Sentinel Report for kernicterus; (iii) nursing outreach to communities for education of prospective parents; (iv) development of clinical pathways to monitor, evaluate and track infants with extreme hyperbilirubinemia; and (v) societal awareness. These efforts should be monitored by a state and national surveillance system in order to critically improve the timeliness and completeness of notifications and to allow evaluation and interventions at the policy and individual family level.

Neurodevelopmental outcome of acute bilirubin encephalopathy

The aim of the study was to determine the neurodevelopmental outcome of acute bilirubin encephalopathy (ABE) in children who underwent double volume exchange transfusion (DVET). The 25 referred newborns of ≥ 35 weeks gestation with total serum bilirubin >20 mg dl(-1) and signs of ABE were enrolled and followed up at 3, 6, 9 and 12 months. Denver Development Screening Test (DDST), Neurological examination along with MRI at discharge and brain stem evoked response audiometry (BERA) at 3 months were done. Abnormal neurodevelopment was defined as either (i) cerebral palsy or (ii) abnormal DDST or (iii) abnormal BERA. The mean bilirubin at admission was 37 mg dl(-1). MRI and BERA were abnormal in 61% and 76%. At 1 year, DDST and neurological abnormality were seen in 60% and 27% and 80% had combined abnormal neurodevelopment. MRI had no relation (P = 0.183) but abnormal BERA had a significant association (P = 0.004) with abnormal outcome. Intermediate and advanced stages of ABE associated with significant adverse outcome in spite of DVET.

Phototherapy for neonatal jaundice--therapeutic effects on more than one level?

Phototherapy for jaundice is a common treatment in neonatal medicine and is used to prevent the neurotoxic effects of bilirubin. Studies have assessed the optimal wavelength of phototherapy light, the importance of irradiance and spectral power, and the types of light source, including the use of single versus multiple light sources. Outcome measures have been duration of need for phototherapy or rate of reduction of serum bilirubin over a given time. An apparent resurgence of kernicterus in recent years has forced us to focus on the emergency management of severely jaundiced infants. Several studies have shown that very rapid reductions of total serum bilirubin levels are possible. The speed with which photoisomers are formed appears to be important both from this perspective and theoretically may also be neuroprotective because of the more polar nature of the photoisomers. This work reviews the evidence concerning the speed of photoisomer formation, as well as the evidence regarding the relative neurotoxicity of bilirubin isomers.

Early isomerization of bilirubin in phototherapy of neonatal jaundice

Neonatal jaundice is usually treated with phototherapy that converts bilirubin to more polar stereoisomers. These should theoretically be less able to cross the blood-brain barrier. The rates of photoisomer formation and concentrations accumulating in the circulation may have a bearing on the risk of kernicterus. The purpose of this study was to determine the rate of appearance of the major 4Z, 15E photoisomer of bilirubin during the early stages of phototherapy. Twenty jaundiced neonates were treated with phototherapy, and blood samples were drawn before and at approximately 15, 30, 60, and 120 min (10 infants) or at approximately 15, 60, 120, and 240 min (10 infants) after beginning phototherapy. Blood samples were analyzed for total serum bilirubin (TSB) and the 4Z, 15E photoisomer of bilirubin. Significant (p<0.0001) formation of the 4Z, 15E photoisomer was detectable within 15 min. The change in TSB from time 0 was insignificant at 120 min but reached significance at 240 min (p<0.001). The 4Z, 15E bilirubin constituted up to 20-25% of TSB at 2 h and may not have peaked by 4 h. Further studies are needed to determine whether this early shift in balance between bilirubin isomers with different polarities may impact the risk of bilirubin encephalopathy even before TSB starts to fall.

Reversibility of acute intermediate phase bilirubin encephalopathy

AIM

To show the potential for reversing acute intermediate to advanced phase bilirubin encephalopathy.

METHODS

Case studies.

RESULTS

Six extremely jaundiced infants had symptoms of intermediate to advanced phase acute bilirubin encephalopathy. The infants were treated aggressively. Two patients had brain magnetic resonance imaging showing increased signals in the globus pallidus. On follow-up, all infants are neurologically normal.

CONCLUSIONS

Intermediate-to-advanced stage acute bilirubin encephalopathy may occasionally be reversible. These cases provide a strong argument in favour of rapid and aggressive intervention in infants presenting with extreme jaundice and neurological symptoms.

Screening for severe neonatal hyperbilirubinemia

Screening for severe neonatal hyperbilirubinemia is integral to newborn care. Predischarge risk assessment relies on documentation of visual jaundice: age at onset and progression; identification of clinical risk such as late prematurity and bruising; with determination of total bilirubin (blood or transcutaneous assay) adjusted for age in hours. Along with promotion of breastfeeding, coordination between birthing hospital and medically supervised outpatient follow-up, a systems approach allows for a safer and effective means to prevent adverse effects of extreme hyperbilirubinemia.

Kernicterus in preterm infants

OBJECTIVE

We sought to clarify the features of kernicterus in preterm infants.

METHODS

The subjects of this study were 8 preterm infants with athetoid cerebral palsy whose gestational ages were < or =34 weeks. We retrospectively investigated clinical, laboratory, MRI, and brainstem auditory evoked potential (BAEP) findings.

RESULTS

Gestational age was < or =26 weeks in 6 of the 8 infants, and birth weight was <1000 g in 5 infants. Serious postnatal complications with systemic deterioration were observed in 3 infants. Total bilirubin levels were measured frequently in the majority of infants; peak values of >15 mg/dL were observed in 3 infants. No infant showed neurologic symptoms characteristic of classical acute bilirubin encephalopathy during the neonatal period. Dystonic posture and abnormal muscle tone were first recognized within 6 months' corrected age in all patients. During infancy, MRI was performed in 7 infants. Abnormal high-intensity areas were observed in the bilateral globi pallidi in all 7 infants. However, MRI during the neonatal period or after 1 year's corrected age showed no abnormal findings. BAEP measurements were abnormal in 7 of the 8 infants.

CONCLUSIONS

Preterm infants with athetotic cerebral palsy showed rather homogeneous features, similar to term infants with kernicterus, with marked hyperbilirubinemia. This combination of clinical, laboratory, neuroimaging, and neurophysiological data will contribute to the increased recognition of preterm infants with kernicterus.

Late preterm birth: a new nursing issue

Late preterm infants are those born between 34 and 36 6/7 completed weeks' gestation. In the last decade, late preterm infants have become the fastest growing subset of preterm infants and now account for 74% of all preterm births. They are at greater risk for feeding problems, dehydration, hypothermia, jaundice, and hypoglycemia and are more likely to be readmitted to the hospital in the first weeks after birth and accrue greater healthcare costs as a result. Despite the alarming growth of this population and the acknowledgment of increased risk in the literature, there is limited information available to the clinical nurse and few evidence-based guidelines to direct the care of these infants specifically. This article describes what is known to date about this issue and what nurses need to do to appropriately care for late preterm infants.

Serial brain MRI and ultrasound findings: relation to gestational age, bilirubin level, neonatal neurologic status and neurodevelopmental outcome in infants at risk of kernicterus

AIMS

To describe cranial ultrasound (cUS) and magnetic resonance imaging (MRI) findings in neonates at risk of kernicterus, in relation to gestational age (GA), total serum bilirubin (TSB), age at imaging and neurodevelopmental outcome.

PATIENTS AND METHODS

Neonates with peak TSB > 400 micromol/L and/or signs of bilirubin encephalopathy. Review of neonatal data, cUS, preterm, term and later MRI scans and neurodevelopmental outcome.

RESULTS

11 infants were studied, two < 31, four 34-36 and five 37-40 weeks GA. TSB levels: 235-583 micromol/L (preterms); 423-720 micromol/L (terms). Neonatal neurological examination was abnormal in 8/10. cUS showed increased basal ganglia (BG) in 4/9 infants and white matter (WM) echogenicity, lenticulostriate vasculopathy (LSV) and caudothalamic hyperechogencity/cysts (GLCs) in 5/9 infants. MRI showed abnormal signal intensity (SI) in the globus pallidum (GP) in 1/2 preterm, 8/9 term and 9/11 later scans. Abnormal WM SI occurred in 2 preterm, 7 term and 10/11 later scans. Seven infants developed athetoid/dystonic cerebral palsy (CP) and 6 hearing loss (HL). Adverse outcome was associated with abnormal BG on cUS (3/4 CP, 4/4 HL), with high SI in GP (7/9 CP, 6/9 HL) on late T2-weighted MRI (all GA) and on T1/T2-weighted term MRI, mainly in term-born infants. WM abnormalities, GLCs and LSV did not correlate with outcome.

CONCLUSIONS

Severe CP occurred with relatively low TSB levels in preterms but only at high levels in full-terms; HL was difficult to predict. Early scans did not reliably predict motor deficits whilst all children with CP had abnormal central grey matter on later scans. Abnormal WM was seen early suggesting primary involvement rather than change secondary to grey matter damage. Why characteristic central grey matter MRI features of kernicterus are not seen early remains unexplained.