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PEDIATRICS Vol. 111 No. 5 May 2003, pp. 1110-1112

EXPERIENCE AND REASON

Unbound Bilirubin in a Term Newborn With Kernicterus

Charles E. Ahlfors, MD and Oded Herbsman, MD

Department of Pediatrics
California Pacific Medical Center
San Francisco, California 94118

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Abbreviations: K, equilibrium association binding constant • ABR, auditory brainstem response • G6PD, glucose-6-phosphate dehydrogenase

The first 300 words of the full text of this article appear below.


   INTRODUCTION
 
In premature newborns, bilirubin-induced changes in the auditory brainstem response (ABR) begin at unbound (nonalbumin-bound or "free") bilirubin levels above .5 µg/dL,1 and kernicterus becomes likely at levels between ~1 and 1.5 µg/dL (.017-.026 µmol/L).2,3 In term newborns, however, unbound bilirubin levels between .9 and 2 µg/dL, which would be associated kernicterus in premature newborns, produce only subtle, reversible changes in ABR wave latency and amplitude.4 Although the unbound bilirubin levels associated with kernicterus in term newborns are unknown, they clearly are greater than the levels associated with kernicterus in premature infants. This indicates that, as with the total bilirubin and total bilirubin/albumin ratio, the unbound bilirubin levels associated with kernicterus increase as birth weight and gestation increase.1,5

We have been using a Food & Drug Administration-approved method6 for measuring unbound bilirubin in jaundiced newborns as an adjunct to their clinical care since 1998. We use a weight-based unbound bilirubin reference value of 1.3 µg/dL/kg (the level of unbound bilirubin at which exchange transfusion should be considered) up to a maximum of 4 µg/dL to accommodate the need to increase the reference unbound bilirubin as birth weight increases and to incorporate the solubility limits of unbound bilirubin at ph 7.4 (~4 µg/dL) into the reference criteria.1–5,7–9

We recently encountered a term, jaundiced newborn that developed acute shock and died, apparently from kernicterus. This report describes the infant’s clinical course and bilirubin-albumin binding data. This case provides insight into the levels of unbound bilirubin associated with kernicterus in term infants as well as the acute changes in distribution of the bilirubin load (miscible bilirubin pool) between the tissues and the vascular space following the onset of kernicterus.


   CASE REPORT
 
A 110-hour-old (4.5-day-old) Nigerian male newborn presented to the emergency department of our hospital with an 18-hour history of moaning and refusing to . . . [Full Text of this Article]

Reprint requests to (C.E.A.) Division of Neonatology, Department of Pediatrics, California Pacific Medical Center, 3850 California St, San Francisco, CA 94118. E-mail: ligand@centurytel.net


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