Editor's Corner

Point–Counterpoint: Kernicterus

Recent recommendations from the American Academy of Pediatrics have stirred some controversy over the cost and practicality of administering routine hyperbilirubinemia tests to detect kernicterus. We offer the following discussions of both sides of the issue.

Point

An article by Suresh & Clark and an accompanying editorial in the October 2004 issue of Pediatrics (Pediatrics 2004;114(4):917-24 and 1086-1088) address the issue of cost-effectiveness for the new AAP guidelines for management of hyperbilirubinemia. The authors of the article calculate that the cost to prevent one case of kernicterus would vary from approximately $5 million to $10 million, depending upon the specific strategy used. They estimate the total national health care expenditure for this program between $112 million and $202 million annually. The authors conclude that widespread implementation of the new strategies "is likely to increase health care costs significantly with uncertain benefits" and that "it is premature to implement routine predischarge serum or transcutaneous bilirubin screening on a large scale."

The accompanying editorial by Dr. Holtzman at Johns Hopkins University questions the strength of the evidence on which the AAP guidelines were based. He notes that none of the studies were in the highest category of evidence and that most were in the lowest or next to lowest categories. He believes that we do not know the actual incidence of kernicterus and whether or not that incidence is rising. We need more studies about the optimal management of bilirubin in healthy infants with early discharge. While theoretically appealing, he notes that there is insufficient evidence that phototherapy decreases the incidence of neurologic abnormalities in these patients. Holtzman concludes that the vast amount of money required for this project could be better spent on other health care issues for children.

by Martin I. Lorin, M.D., Professor of Pediatrics
Baylor College of Medicine

Counterpoint

Kernicterus, a neurologically devastating condition due to bilirubin toxicity, leaves a child severely disabled, and enormous emotional, financial, and social impacts on the family. Although most pediatric neurologists regularly see such children in their practice, most pediatricians today have not seen an affected child. The Web site for P.I.C.K. (Parents of Infants and Children with Kernicterus) gives you the opportunity to see the impact of this condition yourself.

Although the exact incidence is unknown, kernicterus continues to occur throughout the U.S. and the world. Many factors appear to contribute including: early discharge, since most newborns experience their peak serum bilirubin concentration at home, and initial follow-up visits at one week of age, after the optimal time to assess jaundice.

Kernicterus has no known treatment so prevention is the only tool currently available. Unfortunately, neonatal jaundice affects approximately 60 percent of otherwise healthy newborns, while kernicterus is an uncommon event. If we can identify infants who are at high risk of developing severe hyperbilirubinemia and provide appropriate treatment (phototherapy or exchange transfusion), we can potentially prevent kernicterus. At this time, the best-studied method to assess the risk of subsequent hyperbilirubinemia needing treatment is to measure the bilirubin level (serum or transcutaneous) and compare it to an hour-specific nomogram. Although much more work is needed to confirm these observations, many experts think that sufficient data exist to alter clinical practice now.

The AAP guideline was developed by a group of experts (neonatologists and pediatricians) in the evaluation and management of jaundice. The key messages of the guideline include:

• Evaluate every infant for risk of developing severe hyperbilirubinemia before hospital discharge.
• Evaluate every infant at the time of peak serum bilirubin concentration—3 to 5 days of age.
• Ensure every breastfeeding mother is provided appropriate lactation support.

The guideline outlines a reasonable approach to the prevention of severe hyperbilirubinemia and its consequences until additional information is available. In fact, this center is participating in a multi-center study funded by the Health Resources and Services Administration to prospectively evaluate screening strategies to identify infants at risk for severe hyperbilirubinemia.

Although cost-effectiveness is an important consideration in evaluating new strategies, current data are limited. Thus, an analysis such as that done by Suresh and Clark must rely on retrospective data and numerous assumptions that may or may not be valid. More data are needed to provide an accurate assessment of the costs and effectiveness of the guideline. We agree with Dr. Holtzman that the strength of the evidence supporting the guideline is not as high as we would like. Hopefully, studies such as the one we are undertaking will provide more evidence.

As pediatricians, our primary responsibility is to the welfare of our patients. In most cases, kernicterus is a preventable disability. Although we must consider health care costs, we strongly suggest that pediatricians follow the AAP guideline in an attempt to prevent this devastating condition until further information is available.

by Ann R. Stark, M.D., Professor of Pediatrics
Director, Neonatal-Perinatal Fellowship Program
Baylor College of Medicine
and
Leonard E. Weisman, M.D., Professor of Pediatrics
Head, Section of Neonatology
Baylor College of Medicine