I read an article on Medscape last week, at
http://www.medscape.com/govmt/CDC/MMWR/2001/06.01/mmwr5023.04/mmwr5023.04.ht
ml

They referred to 90 cases occurring from 1984 to June 2001, or about 5 cases
each year.  As it is not a reportable condition in the US, no one knows what
the prevalence is with any reliability.  They then gave 4 case reports,
after recruiting a 'convenience sample' of 15 cases of whom seven did not
complete the first follow-up questionnaire and four did not fit the
definition of kernicterus in healthy term infants.
In the first, there was no planned follow up between discharge at 20 hours
post partum, until 2 weeks later.  On day 9 parents sought medical attention
because of visible jaundice (baby was described as pumpkin-colored), which
was not treated and no blood test seems to have been done, though the
clinician felt the jaundice was 'the result of breastfeeding'.  The next day
the parents called their own doctor, told them of the baby's condition and
got an appointment for the NEXT DAY.  Baby was seen on day 11 with a serum
bili of 41.5 mg/dL (705 for us in Europe), weighing 17 per cent less than at
birth and developed kernicterus despite aggressive treatment instituted more
than two days AFTER the parents first sought help.

In the second case, the baby was noted to be jaundiced at 17, 23 and 33
hours post partum but this was never investigated with blood tests.  He was
discharged at 36 hours with planned follow up a week later.  He was
readmitted to hospital on day 5, one day after parents noted lethargy and
poor feeding.  On admission his serum bilirubin was 34.6 mg/dL (588 in
Europe) and he started showing neurologic pathology the same day.

In the third case, the baby was discharged at 22 hours with a known heart
murmur and cephalhematoma.  The next day the parents took him to a clinic
where the heart murmur was found to be resolved but he was jaundiced, and
the parents were instructed to place him in sunlight for 15 minutes daily.
Over the next four days he became lethargic and fed poorly.  They took him
back on day 6 when someone finally found it worth their while to check his
bilirubin which was 27 mg/dL (459), and rose despite institution of
phototherapy, to 33.4 mg/dL (567), when he was given an exchange
transfusion.  His weight is not noted.

In the last case the baby was born by vacuum extraction and there was a
known AO incompatibility between mother and baby.  Baby's Rh status is
unknown.  He was jaundiced at 22 hours but no tests seem to have been taken
then or before discharge at 52 hours, though parents were advised to place
him in sunlight, time unspecified.  Unlike the others he was feeding well
according to parents.  He was re-examined on day 12, when he appeared
jaundiced, and that's when his bilirubin level was measured for the first
time, apparently.  It was 23.6 mg/dL (401) and peaked at 29.4 mg/dL (500)
and he was admitted to hospital that day for phototherapy.

As a clinician with most of my experience in following babies through the
first two weeks of life, I feel that each of these babies suffered from lack
of good care in hospital and lack of adequate follow-up after discharge.
None of these babies should have developed kernicterus if the hospitals had
held their ends up.  No measurements of bili levels, no follow up of
lethargic, poorly feeding babies, no sense of urgency about doing a proper
work-up on a baby who on day 9 is brought to a clinic by concerned parents
and MUST have been looking kind of shriveled already at that point, and no
increased watchfulness for a baby born by VE and with a known blood
incompatibility: I hope you get the picture.

If these cases are representative of how haphazardly newborns are looked
after, then I think it is high time the hospitals pulled their socks up.
Even a mediocre malpractice lawyer should be able to work these into
lucrative cases.

Having a place for parents to come at the first sign of breastfeeding
problems, and letting them know how important a sign that is, would be a
terrific start.  I am a pessimist about such things, though, so I imagine
all babies will now have a serum bilirubin level drawn at discharge (with
the PKU) and then be ordered to return for a new blood test within a certain
time period, and recommended to give formula if the bili is at all elevated,
which is the CYA (cover your a**) approach.

Rachel Myr (midwife, IBCLC)
feeling very judgmental in Kristiansand, Norway

             ***********************************************
The LACTNET mailing list is powered by L-Soft's renowned
LISTSERV(R) list management software together with L-Soft's LSMTP(TM)
mailer for lightning fast mail delivery. For more information, go to:
http://www.lsoft.com/LISTSERV-powered.html