Prevention of severe neonatal hyperbilirubinemia in healthy infants of 35 or more weeks of gestation: implementation of a systems-based approach.

Newbornswith jaundice or unrecognized hyperbilirubinemia are a vulnerable population which is likely to be deprived from preventive and/or therapeutic healthcare services in their transition from birthing hospital to their homes. Of the 4million infants born each year in the United States, over 3.5 million are born at 35 or more weeks of gestation. Most have benign outcomes with little or no threat of neurological compromise from medical conditions during their first year of life. Over the past 4decades, provenpreventivehealth measures provided at well-baby nurseries and at delivery rooms have been effective in reducing infant mortality and morbidity. However, nearly all healthy infants have some degree of hyperbilirubinemia and over 60% develop jaundice during their firstweekof life.Whenunmonitored or untreated in a timelymanner, hyperbilirubinemia canbecomeexcessive and may be unrecognized if the infant is not under medical supervision. An adverse outcome could be a spectrum of bilirubin-induced neurologic dysfunction (BIND) and its severest manifestation: kernicterus, a lifelong athetoid cerebral palsy with sensorineural auditory impairment. Hyperbilirubinemia increases within hours after birth. Hourspecific total serum bilirubin (TSB) levels > 95th percentile (for healthy infants) is equivalent to > 17 mg/dL beyond the age of 72 hours. This cohort of “at-risk” infants could be vulnerable to BIND if the progression to excessive hyperbilirubinemia is unmonitored. Most of these “at-risk” infants have increased bilirubin production and/or impaired bilirubin elimination. Delay in the natural ability to eliminate bilirubin is evident in infants < 38 weeks of gestation, and in thosewith decreased milk intake or with intercurrent infection. Severe hyperbilirubinemia, either based on the risk for neurotoxicity as defined by TSB threshold levels (20mg/dL ormore for a term healthy low-risk infant), or as a TSB increase > 0.20 mg/dL /hr, 3,4 has called forth the recommendation for intervention with intensive phototherapy. Clinicians have recognized that infants at risk for severe hyperbilirubinemia have more complex healthcare needs. These needs are often confounded by fractured healthcare services encountered by families during the first 2-3 weeks after birth.