PEDIATRICS Vol. 107 No. 5 May 2001, pp. 1075-1080
Developmental Follow-Up of Breastfed Term and Near-Term Infants With Marked Hyperbilirubinemia
Received Apr 9, 1999; accepted Jun 19, 2000.
,
From the * Division of Neonatology and Division of General
Pediatrics, Department of Pediatrics, and the § Division of
Neuroradiology, Department of Radiology, Children's Hospital of
Philadelphia and Hospital of the University of Pennsylvania, University
of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
Objective. In recent years, the
increased prevalence of breastfeeding in conjunction with early
discharge practices has increased the risk for marked
hyperbilirubinemia in neonates. This has resulted in the potential for
bilirubin brain injury in affected infants. The purpose of this study
was to identify all infants 
36 weeks' gestational age with bilirubin
levels >25 mg/dL and evaluate them for early and late evidence of
bilirubin brain injury.
Methods. We reviewed the charts of all infants (from
1993-1996) 36 weeks' gestational age who were readmitted to the
hospital during the first week of life with bilirubin levels >25
mg/dL. Readmission records were reviewed for early signs of bilirubin
encephalopathy. Magnetic resonance imaging (MRIs) and Brainstem
auditory-evoked responses (BAERs) were reviewed for evidence of
bilirubin toxicity. At follow-up, study infants had a complete
neurodevelopmental examination, repeat MRIs, and behavioral hearing
evaluations.
Results. From 1993 to 1996, we identified 6 term and near-term infants readmitted to the hospital within the first week of life with peak bilirubin values ranging from 26.4 mg/dL (451 µmol/L) to 36.9 mg/dL (631 µmol/L). Five of 6 infants had bilirubin values >30 mg/dL (513 µmol/L). All were exclusively breastfed or fed a combination of breast and bottle feedings. Five of 6 infants presented with abnormal neurologic signs. Four infants had initial MRIs, 3 of whom had increased signal intensity in the basal ganglia consistent with kernicterus. Two infants had abnormal BAERs; both also had abnormal MRIs. Five of 6 infants received exchange transfusions and all were treated with phototherapy and intravenous fluids. Follow-up examinations between 3 months and 2 years showed resolution of clinical signs in all but 1 infant. Four infants had a subsequent normal MRI and 1 had residual hearing impairment. One infant demonstrated severely abnormal developmental evaluations, as well as both an abnormal initial MRI and BAERs. Follow-up MRI showed evidence of encephalomalacia with changes not characteristic of kernicterus.
Conclusions. We observed transient neurologic abnormalities in 5 of 6 infants readmitted to the hospital during the first week of life with marked hyperbilirubinemia. The abnormalities resolved following aggressive management using hydration, phototherapy, and exchange transfusion and may not correlate with long-term prognosis. Less aggressive therapy may be associated with residual neurologic abnormalities. We speculate that inadequate establishment of breastfeeding coupled with early discharge practices may play a role in the development of marked hyperbilirubinemia in these infants. Key words: bilirubin, brain injury, kernicterus.
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