Anemia of Prematurity - Portal Neonatal

Prognosis: The spectrum of neurologic disability from kernicterus can range from mild to severe.
Attempts to correlate features of hyperbilirubinemia with prognosis for disability have failed. Despite
multiple attempts, no definitive association has been identified between the degree of deficit and
parameters such as total serum bilirubin level, duration of hyperbilirubinemia, presence of hemolytic
disease, gestational age, birthweight, or concomitant systemic illness.
Patient Education:
• To facilitate the provision of appropriate evaluation and follow-up for babies without
recognized risk factors, the AAP has published an hour-of-age-specific guideline that
correlates total serum bilirubin levels with degree of risk and recommendations for follow-up.
The AAP recommends professional medical evaluation in 2-3 days for babies who are
discharged from the hospital fewer than 48 hours after birth. Babies discharged fewer than 72
hours after birth may also be at risk, and they should be closely monitored as well. Other risk
factors warranting additional vigilance may include unexplained family history of neonatal
hyperbilirubinemia, near-term gestation, low birth weight, excessive bruising or hematomata,
and ethnicity at risk for exaggerated hyperbilirubinemia.
Parents should be informed of the importance of keeping these appointments, as well as be
familiarized with the symptoms of poor feeding in breastfed babies and how to seek help.
MISCELLANEOUS Section 9 of 11
Medical/Legal Pitfalls:
• Theoretically, most cases of kernicterus may be completely prevented by initiation of
phototherapy in every baby shortly after birth. Therefore, this devastating neurologic disease
could be prevented most of the time. As such, a significant component of medicolegal liability
is introduced into the management of hyperbilirubinemia. Clinical reports of kernicterus in the
absence of profound hyperbilirubinemia, coupled with the lack of definitive standards of care
for the initiation of phototherapy, further complicate this exposure. As with all medical care,
conformity with published clinical guidelines, rationale for departure from accepted clinical
norms, and good documentation are the best defenses.
• The numerous areas of uncertainty surrounding the diagnosis and treatment of
hyperbilirubinemia in the infant, coupled with the infrequency of sequelae, foster a cavalier
attitude about the evaluation of a jaundiced infant. However, remembering that physiologic
hyperbilirubinemia is a diagnosis of exclusion is important, and kernicterus, when it occurs, is
devastating. Therefore, failure to evaluate or provide reasonable follow-up of infants at risk for
the development of severe hyperbilirubinemia may place the clinician in a position that could
be difficult to defend.
Sepsis must always be excluded in the jaundiced infant. Uncommon, but treatable, metabolic
causes of jaundice include hypothyroidism and galactosemia. The first sign of occult immune
or nonimmune hemolytic disease may be hyperbilirubinemia. Failure by the clinician to
diagnose an underlying etiology results in considerable medicolegal exposure.