Healthy Children: October 2006

Dr. P's Journal Club

As you loyal readers know, one of my goals with this blog is to help you to be informed consumers of medical literature and pediatric advice. Admittedly, it can be confusing and a daunting task for those of you with little training or appreciation of the scientific method, but it's worth the effort.

Here's another example of how new scientific evidence changes practice. Even if your newborn wasn't jaundiced, watch how yesterdays' state-of-the-art becomes today's out-of-date pediatric care.

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When I was just starting out in my pediatric training, I was taught to obsessively follow bilirubin levels in healthy, full-term newborns because "levels over 20 could cause brain damage."

As a result, we would occasionally perform "exchange transfusions" on healthy, full-term babies (taking out the baby's jaundiced blood and re-infusing blood from a donor, in order to keep the levels below 20). I well remember many an exhausting all-nighter, extracting via a large IV an infant's blood and reinfusing new blood. Out goes the bad blood, in goes the good blood, over and over again. This laborious task took hours, side effects were not rare, and I was a bleary-eyed basket case the next day.

As it turns out, there wasn't a lot of evidence to support this practice but, as often happens, "better safe than sorry" sometimes prevailed and it was pretty much considered the state-of-the-art. (But not everyone. In 1983 a famous and wonderful pediatrician named Frank Oski coined the term "vigintiphobia," meaning "fear of the number 20", to poke fun at what he concluded - correctly, as it turned out - to be an unwarranted phobia.)

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The study:

140 healthy but jaundiced, full-term infants born in 1995-1998 were followed over time.
130 had bilirubin levels between 25-20, and 10 had levels greater than 30.
They were compared to infants born at the same hospital without jaundice (a valid study almost always has a "control" group, i.e., a healthy comparison group).

What the study found:

None suffered brain damage ("kernicterus").
Follow-up neuro-developmental testing two years later or more showed no significant differences between the jaundiced and the control group.
Parents did not report greater behavioral problems or concerns in their formerly jaundiced toddlers.
This information does not imply that jaundice can never cause long term developmental trouble in healthy, full-term newborns, just that the levels most babies experience (less than 30) don't appear to.

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Dr P Comments
I wanted to familiarize you with this study to:

Show how pediatric practice changes in the face of new data.
For those of you whose pediatric providers have not kept up with the latest evidence and still suffer from vitiginophobia and who, as a result, needlessly scared the bejesus out of you in the process.
For you parents who have never shaken that fear and still wonder if their child's newborn jaundice could lead (as has caused) some developmental or behavioral problems in your child.

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Two caveats from Dr. P:

Remember, this evidence applies to full-term healthy infants. Premies and seriously ill newborns are another story.
It will be important to follow these kids as they get older to be sure nothing subtle shows up later on (for example at school age).

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Study cited: "Outcomes among newborns with total serum bilirubin levels of 25 mg per deciliter or more." Newman T., et al. New England Journal of Medicine. May 4, 2006.