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PEDIATRICS Vol. 111 No. 6 June 2003, pp. 1303-1311

Infants With Bilirubin Levels of 30 mg/dL or More in a Large Managed Care Organization

Thomas B. Newman, MD, MPH*,{ddagger},§, Petra Liljestrand, PhD*,§ and Gabriel J. Escobar, MD§,¶

* Departments of Epidemiology and Biostatistics
{ddagger} Pediatrics, School of Medicine, University of California, San Francisco, California
§ Division of Research, KPMCP, Oakland, California
Department of Pediatrics, Kaiser Permanente Medical Center, Walnut Creek, California

Objective. To describe the incidence, etiology, treatment, and outcome of newborns with total serum bilirubin (TSB) levels ≥30 mg/dL (513 µmol/L).

Design. Population-based case series.

Setting. Eleven Northern California Kaiser Permanente Medical Care Program hospitals and 1 affiliated hospital.

Patients. Eleven infants with TSB levels of ≥30 mg/dL in the first 30 days after birth, identified using computer databases from a cohort of 111 009 infants born 1995–1998.

Outcome Measures. Clinical data from the birth hospitalization, rehospitalization, and outpatient visits in all infants; psychometric testing at age 5 (N = 3), neurologic examinations by child neurologists at age 5 (N = 3), or primary care providers (N = 7; mean age: 2.2 years); Parent Evaluation of Developmental Status (N = 8; mean age: 4.2 years).

Results. Maximum TSB levels of the 11 infants ranged from 30.7 to 45.5 mg/dL (525 µmol/L to 778 µmol/L; mean: 34.9 mg/dL [597 µmol/L]). Four were born at 35 to 36 weeks gestation, and 7 were exclusively breastfed. Two had apparent isoimmunization; the etiology for the other 9 remained obscure, although only 4 were tested for glucose-6-phosphate dehydrogenase deficiency and 1 was bacteremic. None had acute neurologic symptoms. All received phototherapy and 5 received exchange transfusions. One infant died of sudden infant death syndrome; there was no kernicterus at autopsy. Two were lost to follow-up but were neurologically normal when last seen for checkups at 18 and 43 months. One child was receiving speech therapy at age 3. There were no significant parental concerns or abnormalities in the other children.

Conclusions. In this setting, TSB levels ≥30 mg/dL were rare and generally unaccompanied by acute symptoms. Although we did not observe serious neurodevelopmental sequelae in this small sample, additional studies are required to quantify the known, significant risk of kernicterus in infants with very high TSB levels.

Key Words: bilirubin • blood • jaundice • neonatal • kernicterus/prevention and control • cohort studies • health maintenance organizations • follow-up studies • neurologic examination

Abbreviations: AAP, American Academy of Pediatrics • TSB, total serum bilirubin • KPMCP, Kaiser Permanente Medical Care Program • G6PD, glucose-6-phosphate dehydrogenase • JIFee, Jaundice and Infant Feeding Study • PEDS, Parent Evaluation of Developmental Status • DAT, direct antiglobulin test • Rh, rhesus • G, gravida • P, para

Received for publication Jul 8, 2002; Accepted Nov 12, 2002.




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