Published online February 1, 2006
PEDIATRICS Vol. 117 No. 2 February 2006, pp. 474-485 (doi:10.1542/10.1542/peds.2005-0395)
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REVIEW ARTICLE

Toward Understanding Kernicterus: A Challenge to Improve the Management of Jaundiced Newborns

Richard P. Wennberg, MDa, Charles E. Ahlfors, MDb, Vinod K. Bhutani, MDc, Lois H. Johnson, MDd and Steven M. Shapiro, MDe

a Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, Washington
b LW Ligand, LLC, Vashon, Washington
c Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
d Section on Newborn Pediatrics, Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, Pennsylvania
e Department of Neurology, Medical College of Virginia, Richmond, Virginia

PURPOSE. We sought to evaluate the sensitivity and specificity of total serum bilirubin concentration (TSB) and free (unbound) bilirubin concentration (Bf) as predictors of risk for bilirubin toxicity and kernicterus and to examine consistency between these findings and proposed mechanisms of bilirubin transport and brain uptake.

METHODS. A review of literature was undertaken to define basic principles of bilirubin transport and brain uptake leading to neurotoxicity. We then reviewed experimental and clinical evidence that relate TSB or Bf to risk for bilirubin toxicity and kernicterus.

RESULTS. There are insufficient published data to precisely define sensitivity and specificity of either TSB or Bf in determining risk for acute bilirubin neurotoxicity or chronic sequelae (kernicterus). However, available laboratory and clinical evidence indicate that Bf is better than TSB in discriminating risk for bilirubin toxicity in patients with severe hyperbilirubinemia. These findings are consistent with basic pharmacokinetic principles involved in bilirubin transport and tissue uptake.

CONCLUSIONS. Experimental and clinical data strongly suggest that measurement of Bf in newborns with hyperbilirubinemia will improve risk assessment for neurotoxicity, which emphasizes the need for additional clinical evaluation relating Bf and TSB to acute bilirubin toxicity and long-term outcome. We speculate that establishing risk thresholds for neurotoxicity by using newer methods for measuring Bf in minimally diluted serum samples will improve the sensitivity and specificity of serum indicators for treating hyperbilirubinemia, thus reducing unnecessary aggressive intervention and associated cost and morbidity.

Key Words: bilirubin–albumin binding • brainstem auditory evoked potentials • bilirubin • hyperbilirubinemia • kernicterus

Abbreviations: TSB—total serum bilirubin concentration • AAP—American Academy of Pediatrics • BBB—blood-brain barrier • Bf—free bilirubin concentration • AB—albumin-bound bilirubin concentration • A—serum albumin concentration • ABR—brainstem auditory evoked response • AN—auditory neuropathy • AD—auditory dyssynchrony • G6PD—glucose-6-phosphate dehydrogenase

Accepted May 31, 2005.


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