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Clinical Decisionmaking

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Following a rigorous protocol for in-hospital and postdischarge management may lower rates of neonatal jaundice

Neonatal jaundice (hyperbilirubinemia) strikes an estimated 60 percent of term newborns in the first week of life, with about 2 percent developing severe jaundice (total serum bilirubin levels of 20 mg/dL or more). Severe jaundice can lead to kernicterus, a buildup of bilirubin in the brain, which can cause cerebral palsy, hearing loss, and other problems. Kernicterus was rarely seen in the decades after the introduction of exchange transfusion and phototherapy to treat jaundice. However, it is on the rise again, even in apparently healthy newborns, perhaps due to early hospital discharge without prompt medical followup.

Researchers led by R. Heather Palmer, M.B., B.Ch., S.M., F.A.A.P., of the Harvard School of Public Health, have developed a rigorous protocol of care to improve management of jaundice that is based on neonatal risk factors for jaundice. It includes vigilant monitoring for jaundice in the hospital, with higher risk newborns tested more often, followup nurse care visits, and neonatal phototherapy if needed.

With support from the Agency for Healthcare Research and Quality (HS09782), the researchers conducted a 3-year prospective study in the Henry Ford Health System (HFHS) on 5,507 healthy, racially and ethnically diverse newborns of 35 or more weeks' gestational age. They compared rates of severe jaundice from HFHS to those of 11 other hospitals reported to have less rigorous jaundice management.

Severe jaundice was associated with exclusive or partial breastfeeding, younger gestational age, male sex, and older mothers. Babies with any of these risk factors had a lower risk for severe jaundice at HFHS than at the comparison hospitals. Also, the HFHS group was 89 percent more likely to have jaundice detected than the non-HFHS group. These results suggest that better access to care and continuity of care lead to higher rates of jaundice detection.

See "Management of hyperbilirubinemia in newborns: Measuring performance by using a benchmarking model," by Shu-Chiung Chou, Ph.D., Dr. Palmer, Sudhakar Ezhuthachan, M.D., D.C.H., F.A.A.P., and others, in the December 2003 Pediatrics 112(6), pp. 1264-1273.

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