Clinical Stages And Consequences


Kernicterus is a chronic neurologic situation brought on by the neurotoxic effects of bilirubin on the brain tissues of neonates. This happens when bilirubin, a byproduct of the breakdown of red blood cells, is present in abnormally elevated levels in the newborn. Kernicterus is preventable as jaundice, the term utilized to describe the clinical presentation of yellow skin and eye sclera, can be treated. Also, threat elements for improvement of this devastating neurologic situation can be identified and really should prompt close surveillance of total bilirubin levels in the serum of the infant who is at threat for improvement of 1 of the acute clinical phases of neurologic harm that comprise the syndrome of bilirubin induced neurologic dysfunction.

Kernicterus is a reasonably uncommon result in of serious lifelong disability in infants who are otherwise typical, but it can be prevented. Serious or intense levels of bilirubin in the serum result in an encephalopathy and bilirubin has been extended recognized as a neurotoxin that benefits in the death and destruction of brain cells.

Acute Bilirubin Encephalopathy

Acute bilirubin encephalopathy is characterized by elevated bilirubin that has crossed the blood-brain barrier. When diagnosed clinically, the presentation of symptoms is wide-ranging and contains feeding issues, lethargy, hypo-or hypertonia, opisthotonus, fever, seizures, a higher-pitched cry and spasmodic torticollis. Acute bilirubin encephalopathy has 3 clinical phases that each and every has distinct qualities. The initially phase happens with a handful of days right after birth and symptoms consist of stupor, hypotonia, and poor sucking. The second phase is characterized by hypertonia, with arching of the trunk (opisthotonos) or retrocollis, which is backward arching of the neck. Infants who attain this stage create chronic bilirubin encephalopathy. The third phase happens right after a week and the hypertonia disappears. There is rigidity of the muscle tissues, paralysis of upward gaze, periodic oculogyric crisis, and, in the terminal phase, irregular respirations are prominent. At this third phase, 4 % of impacted infants die.

Chronic Bilirubin Encephalopathy

Chronic bilirubin encephalopathy is also recognized as kernicterus. The term refers to the lifelong disability resulting from bilirubin induced neurologic dysfunction. Kernicterus is characterized by poor feeding in the initially year. A higher-pitched cry is a different characteristic of kernicterus.

Infants with kernicterus will have hypotonia but will retain great deep tendon reflexes. There is presence of a tonic neck reflex and righting reflex. Motor abilities are delayed, with some youngsters walking at age five.

Soon after the initially year of life, clinical attributes that are prominent in youngsters with chronic bilirubin encephalopathy consist of extrapyramidal problems such as tremors, dysarthria, athetosis and ballismus. There is harm to the cochlear nuclei in the brainstem that benefits in hearing loss, and there is ordinarily a limitation of upward gaze. Athetosis ordinarily develops at sometime amongst the age of 18 months and eight years. Some youngsters only knowledge hearing loss and have no other symptoms.

Imaging Research in Diagnosis of Kernicterus

When kernicterus is investigated, higher serum bilirubin levels are present in most circumstances. Imaging research that are most valuable are MRI. On magnetic resonance imaging, there is typically enhanced signal intensity in the globus pallidus.

How Frequent is Kernicterus?

In the United States, there is a voluntary kernicterus registry and 90 circumstances had been reported throughout the time period from 1984 to 2001. Given that all circumstances are not reported, the correct incidence is not recognized.

Kernicterus is Preventable

Kernicterus is extremely preventable when higher-threat infants are closely monitored and treated aggressively. With out therapy, nevertheless, jaundice from elevated bilirubin can outcome in permanent brain harm and some youngsters might create cerebral palsy, dental enamel hypoplasia and mental retardation as a outcome. However, despite the fact that neonatal jaundice is widespread, intense hyperbilirubinemia is significantly less widespread and the assessment of this situation has regularly been inadequate.

Suggestions by JCAHO in their Sentinal Occasion Alert of 2001

JCAHO is the Joint Commission on Accreditation of Healthcare Organizations and in April of 2001 they issued a 'Sentinel Occasion Alert' on kernicterus. They compiled a root result in evaluation and identified 4 patient care processes that failed in circumstances that resulted in the improvement of kernicterus. These incorporated: – Patient assessment – Continuum of care – Patient and loved ones education – Remedy

With respect to patient assessment, JCAHO noted the failure to measure bilirubin levels in jaundiced infants inside the initially 24 hours, failure to recognize jaundice or its severity primarily based upon visual assessment, and unreliability of visual assessment of jaundice in newborns with dark skin. The continuum of care was inadequate in circumstances of discharge just before 48 hours with out adhere to up inside 1 to two days, specifically in infants significantly less than 38 weeks gestation. Failure to give early adhere to-up and physical assessment of infants with jaundice prior to discharge and failure to give continuing lactation help to keep adequacy of intake in breast fed newborns had been also identified as issues in the continuum of care. Patient and loved ones education was discovered inadequate in circumstances when acceptable information and facts was not offered to parents about jaundice and when physicians failed to respond to parental issues about a jaundiced newborn, issues with lactation or alterations in the activity and behavior of the newborn. Remedy failures occurred by failure to recognize, evaluate and treat total bilirubin levels that had been swiftly increasing and by failure to treat serious hyperbilirubinemia aggressively and immediately with intensive phototherapy or exchange transfusion.

Suggestions of the American Academy of Pediatrics

The Clinical Practice Guideline Management of Hyperbilirubinemia in the Newborn Infant 35 or Far more Weeks of Gestation was published in Pediatrics in 2004 and essential suggestions incorporated help of effective breastfeeding, establishment of protocols inside the nursery for identification and evaluation of hyperbilirubinemia, measurement of total serum bilirubin or transcutaneous bilirubin levels in infants who present with jaundice inside the initially 24 hours of life, and recognition that visual assessment is inadequate. Also, the Academy suggested that all bilirubin levels be interpreted working with a nomogram which permitted an interpretation primarily based upon the hours of life, that infants born at significantly less than 38 weeks' gestation had been at larger threat of improvement of serious hyperbilirubinemia and that these infants who had been breastfed had been at larger threat. The Academy suggested that a systematic assessment really should be performed on all infants just before discharge to decide the threat of serious hyperbilirubinemia and that parents be offered with each written and verbal information and facts about neonatal jaundice. Stick to-up really should be arranged at the time of discharge and threat assessment and newborns really should be promptly treated when therapy indications are evident, working with phototherapy or exchange transfusion.


Adherence to these clinical practice recommendations can stop lifelong disability and despite the fact that kernicterus is reasonably uncommon, newborn jaundice is widespread and really should be completely assessed in light of threat elements and measurement of total serum bilirubin or transcutaneous bilirubin. Prompt therapy is critical.