Newborn jaundice, regardless of its etiology, is a matter of newborn safety, and when it is unrecognized or unmonitored or progresses untreated, it can lead to severe hyperbilirubinemia.1–5 Because kernicterus is preventable, but not treatable, public health policies need to be focused and rooted in a preventive approach.6 Thus, neonatal hyperbilirubinemia not only is an important public health issue but also has significant clinical, societal, and economic consequences for both maternal–child health care and educational systems in the United States. Of the approximately 4 million live births each year, over 80% of term infants, and most preterm infants, manifest jaundice during the first week after birth.6–8 Progression to severe hyperbilirubinemia is due to either increased bilirubin production or impaired bilirubin elimination.9–11 From 1967 to 2000, about 0.14–0.16% of term infants without known Rh disease (140–160/100,000 live births) developed severe hyperbilirubinemia (total serum bilirubin [TSB] levels >20 mg/dL) that required emergency treatment, such as an exchange transfusion, and were at risk for adverse neurologic outcomes.10,12–14 Kernicterus, the ultimate manifestation of irreversible bilirubin-induced neurologic dysfunction (BIND), is more evident among infants with concurrent hemolytic disorders, prematurity, sepsis, and glucose-6-phosphate dehydrogenase (G6PD) deficiency. In about half of the reported cases of kernicterus in the United States, the cause is not diagnosed or investigated.3 Estimates of the incidence of kernicterus range from 1 to 5.8 per 100,000.15 The incidence of hazardous hyperbilirubinemia (TSB >30 mg/dL) ranges from 25 to 60 per 100,000, whereas the risk of kernicterus in this subpopulation is estimated at 1 in 4.12 In the context of prevailing clinical practices, both the use of exchange transfusion and the occurrence of kernicterus are unusual (Figure 12-1), based on reports from health care systems that have accessible service infrastructures and the ability to respond in a timely manner.16–18 Another public health issue is the association of the intent to breastfeed and the severity of hyperbilirubinemia that has often led to the inappropriate withholding of breast milk intake.2,5 The societal costs of neonatal hyperbilirubinemia include the cost of predischarge risk assessment in the context of routine newborn care, interrupted breastfeeding, readmission for treatment with phototherapy and/or an urgent need for an exchange transfusion, parental–infant separation, and the onset and persistence of neurologic injury with lifelong learning and movement disorders.19
Infant with acute advanced bilirubin encephalopathy (post-exchange transfusion). Note the classic facies, hypertonia with retrocollis, opisthotonus, and cephalohematoma. (Photograph contributed by Dr Numan Alhamdani, Children's Hospital, Baghdad, Iraq, 2010.)
This chapter summarizes key and pertinent maternal–child health and other related societal issues pertaining to neonatal jaundice. It also raises key policy issues with respect to maternal–child health care practices during the first week after birth, and highlights the importance of family/ societal education in ...