*"It doesn't matter if the cat is black or white as long as it catches
mice."*

Deng Hsaio P'ing 1904-1997

This a page for sharing "what works" as seen in the published literature
as well as what is done at sites that care for American Indian/Alaskan
Native children. If you have any suggestions, comments or questions
please contact Steve Holve, MD, Chief Clinical Consultant in Pediatrics
at sholve@tcimc.ihs.gov

IHS Child Health Notes

April 2005

# Quote of the month

*" From doubt comes inquiry and from inquiry comes truth."*

Peter Abelard 1231-1287

**Articles of Interest**

Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks
of Gestation Subcommittee on Hyperbilirubinemia

## PEDIATRICS Vol. 114 No. 1 July 2004, pp. 297-316

<http://pediatrics.aappublications.org/cgi/content/full/114/1/297?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=Jaundice&searchid=1112395843388_17675&stored_search=&FIRSTINDEX=0&sortspec=relevance&journalcode=pediatrics>

Exaggerated jaundice in Navajo neonates. The role of bilirubin
production.\
Am J Dis Child. 1986 Sep;140(9):889-90.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&DB=pubmed

Bilirubin 20 mg/dL = vigintiphobia.\
Pediatrics. 1983 Apr;71(4):660-3. No abstract available

Frank paper on vigintiphobia

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=Pager&DB=pubmed>

**Editorial Comment**

"Few issues in neonatal medicine have generated such longstanding
controversy as the possible adverse consequences of neonatal jaundice
and when to begin treatment." That was from the AAP report 10 years ago
on treatment guidelines for jaundice. The same issues are still with us
10 years later. Kernicterus is a devastating and irreversible
neurological disease that may follow exposure to high bilirubin levels.
It is fortunately rare and should be preventable by early intervention.
The guidelines also acknowledge that over-treatment of physiologic
jaundice in well infants has medical, psychological and financial
downsides.

Infants jaundiced within the first 24 hours of life, near term infants
(35-37 weeks gestation) and infants in whom a previous sibling required
phototherapy were at particularly high risk. Checking bilirubin levels
at discharge and plotted on a by hour nomogram can reliably identify who
is low risk and does not require close follow-up. Unfortunately,
discharge bilirubin testing will label as "moderate to high risk" a
large number of well infants with physiologic jaundice. The key is
follow-up for all infants with possible risk in 3- 4 days after birth.
The most common cause of for significant jaundice is a failure to
establish successful breastfeeding so close attention to follow-up
weight and hydration is critical. It was of interest that no cases of
kernicterus were found in formula fed infants in the past decade.

For those serving American Indian and Alaskan Native infants these
guidelines present particular challenges. Many of our patients live a
great distance from health facilities such that returning to clinic at
3-4 days after birth will be a significant hardship. There is also some
evidence that Native Americans, like Asians, may have higher levels of
bilirubin as part of their normal newborn period, without an increased
risk of kernicterus. Each nursery needs to establish a system to
identify patients at risk and arrange for follow-up in a timely fashion
if needed.

The article by Frank Oski provides an interesting historical background.
His commentary was unusual by medical journal standards: it was both
insightful and funny. In an era in which healthy term infants with
bilirubin levels of 20mg/dl were treated with double volume exchange
transfusions, Dr. Oski was one of the first to raise questions about the
utility of treating yellow, but healthy infants with a potentially
lethal therapy. We need to keep in mind that despite all of the concern
that kernicterus is very rare: somewhere between 1/100,000 and
1/1,000,000 term births.

# Recent literature on American Indian/Alaskan Native Health

# Analysis of prior health system contacts as a harbinger of subsequent fatal injury in American Indians. J Rural Health. 2005 Winter;21(1):65-9. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&DB=pubmed

-   Prior contact with the health system was not a marker for fatal
    injury

-   Prior contact with the health system for an alcohol related visit
    was a significant marker for later fatal injury

-   We need to think of how to follow-up with these patients to possible
    prevent later mortality