Birth Injury Legal Resources

Brain Injury from Jaundice (Kernicterus)

An important but fortunately uncommon type of birth-related brain injury occurs when the baby has jaundice (yellowing of the skin) at birth and does not receive adequate treatment to lower the blood levels of the substance that causes yellowing: bilirubin. This excess bilirubin, if the level is not brought down promptly, can get into brain tissue and damage the brain permanently. This damage is called kernicterus. When physicians do not take newborn jaundice seriously enough or fail for whatever reason to treat it aggressively, and the baby then suffers brain injury, a legal consultation with an attorney may be appropriate.

Here is some information written by physicians who specialize in this injury, from the website: www.kernicterus.org.

Introduction to Kernicterus

Kernicterus is a form of brain damage caused by excessive jaundice. The substance which causes jaundice, bilirubin, is so high that it can move out of the blood into brain tissue. When babies begin to be affected by excessive jaundice, when they begin to have brain damage, they become excessively lethargic. They are too sleepy, and they are difficult to arouse - either they don't wake up from sleep easily like a normal baby, or they don't wake up fully, or they can't be kept awake. They have a high-pitched cry, and decreased muscle tone, becoming hypotonic or floppy) with episodes of increased muscle tone (hypertonic) and arching of the head and back backwards. As the damage continues, they may develop fever, may arch their heads back into a very contorted position known as opisthotonus or retrocollis.

About 60% of newborn infants in the United States are jaundiced, that is they look yellow. Excessive jaundice in newborn infants may cause brain damage. Jaundice is caused by a high level of bilirubin in the blood (hyperbilirubinemia) and tissues. When bilirubin gets too high it can be treated. Norms exist for bilirubin in term and nearly term babies based on the age in hours after birth. Other factors, such as prematurity, blood group incompatibilities between infant and mother including Rh and ABO blood types, and bruising, especially cephalohematomas and caputs, can increase bilirubin production and lead to excessive jaundice.

Babies with high bilirubin levels can be effectively treated. Phototherapy (treatment with light) is usually very effective. It is the blue color that alters the bilirubin from a toxic form to a water soluble, non-toxic form that can be eliminated. At higher, more dangerous levels of bilirubin, or in certain situations where the bilirubin is expected to rise very rapidly, such as Rh or other hemolytic diseases of the newborn, a more extreme treatment may be used, exchange transfusion, to rapidly remove toxic bilirubin from the blood.

Treatment Issues with High Bilirubin

When signs of acute kernicterus occur in a jaundiced baby, permanent brain damage is occurring. Immediate treatment should be done to prevent further damage, and because perhaps some of the damage is reversible.

When infants have signs of brain dysfunction from bilirubin toxicity, immediate treatment is needed to minimize permanent brain damage. The signs of acute bilirubin toxicity are: 1) abnormalities of tone, including increased tone (hypertonia), decreased tone (hypotonia), or a variation in tone from hypertonia to hypotonia, 2) lethargy, difficulty in arousing the baby, 3) a high-pitched cry, 4) arching the back and spine (retrocollis or opisthotonus), and 5) fever. Feeding or nursing is decreased, which makes matters worse not only because of dehydration, but because bilirubin is eliminated via the stool, and decreased feeding prevents bilirubin from being eliminated from the body. Expert neonatologists say that the most common cause of bilirubin levels rising high enough after discharge from the hospital to require readmission is inadequate feeding.

Treatment should be immediate triple-bank phototherapy lights put as close as possible to the baby, a stat measurement of blood bilirubin should be sent, but the phototherapy should be started before the bilirubin results come back. The baby should be hydrated with fluids and probably be tube fed an elemental infant formula. The baby should be blood typed for a possible exchange transfusion which should be done as soon as possible unless there is a large drop in the bilirubin and the baby improves before the blood is ready for an exchange transfusion.

Common Mistakes Made in Treating Jaundiced Babies

When bilirubin is very high, do not make or let your child's physicians make any of the following mistakes in care:

Not believing the bilirubin level from the lab, and delaying treatment while it is repeated. There is no problem in repeating the test, but don't delay treatment for an instant while waiting for the repeat - you have nothing to lose by treating with a huge dose of phototherapy, gavage feeding, hydrating, ordering a type and cross match and blood. If the bilirubin drops rapidly to a relatively safe level, and the child is aysmptomatic, the exchange transfusion can be cancelled.
Delaying treatment or interrupting phototherapy for diagnostic testing to determine the risk of an exchange. If a sepsis workup or LP is needed, or an echocardiogram etc., do it under the lights. If it's not possible, keep the lights on every possible minute. If the baby needs to go for a test out of the unit, the lights go with him or her.
Not examing the baby for signs of acute kernicterus .
Using the indirect bilirubin instead of the total serum bilirubin. Although it is true that the direct (conjugated) bilirubin is non-toxic, it binds to the same serum albumin site as toxic bilirubin, displacing it into brain tissue. Use the total bilirubin.
Allowing the bilirubin to reach potentially dangerous levels. Visual inspection by experienced personnel, transcutaneous bilirubins, blood bilirubin are all easy to do. It's much easier to prevent bilirubin from rising too high than to treat it when it does.
Measuring the bilirubin and not comparing it to hour-specific norms. This is very important. A bilirubin level in a one-day-old may be normal or dangerously high depending on whether the baby is 24 or 47 hours old. A level of 8.5 would be in a high-risk zone (95th percentile) in a 24h old baby, and in a low risk zone (40th percentile) in a 47h old baby.

End of excerpt from www.kernicterus.org.

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