Newborn or Neonatal Jaundice is the most common condition affecting full-term and premature babies. For most of them, it is harmless or just a hindrance because it results in prolonged hospitalization and no long-term consequences.
However, for the very few, it may have debilitating effects and cause even death. Given these rare, devastating outcomes, parents of affected children may be interested in having their child’s hospitalization chart reviewed to determine if there were any deviations from recommendations for managing this condition.
In my article below, I will share my experience managing babies with jaundice and the most common avoidable errors physicians commit.
The latter part comes from my experience reviewing neonatal charts as a peer reviewer. The two most common issues that prompt hospitals to request my opinion on cases are newborn resuscitation and jaundice management.
Basic information about Newborn Jaundice
As mentioned above, neonatal jaundice is a common condition managed in newborn nurseries, NICUs, pediatric floors, and sometimes outpatient pediatric offices.
It manifests itself as yellow skin in a newborn. The culprit is a chemical called bilirubin. We all produce bilirubin in our bodies and excrete it with stool and urine. Due to their physiology, all neonates produce more bilirubin per unit of their weight than adults. If additional pathologic factors exist, babies may end up with dangerous levels if not treated promptly.
Bilirubin, if its levels are increased, can go into the skin, giving that yellow color. When bilirubin reaches exceptionally high levels, it can enter brain cells, causing temporary or permanent neurological damage (the latter is known as “kernicterus” or “encephalopathy”).
If you want to learn more about jaundice, different types, diagnosis, and treatment, please read the several articles I wrote on my website for parents and families NeoPedEdu.com (use separate search terms: jaundice, hyperbilirubinemia, and incompatibility).
Why Newborn Jaundice may lead to malpractice lawsuits
The most dangerous and consequential complication of jaundice is called kernicterus or encephalopathy. It may lead to long-term disability or even death. We could avoid many kernicterus cases if we follow guidelines, diagnose jaundice promptly, and manage it well.
According to one source, in Western countries, kernicterus occurs at a rate of 1 to 2 per 100,000 live births. Putting this number in context means that in the US, we may have 30 to 60 cases of kernicterus each year.
In my opinion, at least half of these cases are preventable.
Common errors in the management of jaundice
During my career as a neonatologist, I dealt with jaundice every day. Many factors make the management of jaundice a complex undertaking. Some of these factors are listed below:
- There is no single level of bilirubin that is normal or at which we need to start a treatment.
- Normal bilirubin levels and treatment levels depend on the baby’s gestational age, age after birth, cause of jaundice, and general health condition.
- Jaundice may quickly get worse.
- After discharge home, the baby may still need follow-up for jaundice, including on weekends, when pediatricians may not be readily available.
- Since almost all babies develop some jaundice, and for most, it is a benign condition, some parents and healthcare providers don’t take it seriously enough.
Prevention and diagnosis
Doctors and nurses caring for newborns must know the factors associated with a higher risk of developing significant jaundice in the hospital or after discharge home. Some of them are listed below:
- Prematurity
- Visible jaundice in first 24 hrs of life
- Predischarge bilirubin levels close to the phototherapy levels
- Hemolysis of red blood cells
- The need for phototherapy before discharge
- Parent or sibling requiring phototherapy in the past
- Family history of G6PD (genetic condition)
- Exclusive breastfeeding
- Hematoma or significant bruising on the scalp from birth trauma
- Down Syndrome, also known as trisomy 21
- Large baby born to a mother with diabetes
In addition, once jaundice is recognized, there are known factors that are associated with a greater risk for neurological damage:
- Gestational age of less than 38 weeks
- Albumin levels less than 3 g/dl
- Severe infection or sepsis
- Significant clinical instability
- Immune hemolytic disease (read my article on ABO incompatibility and Rh incompatibility)
To diagnose jaundice early, experts recommend assessing each baby in the hospital at least every 12 hours and performing a bilirubin level (skin or blood measurement) between 24 and 48 hours of life or before discharge if that occurs earlier.
Treatment Errors
I have seen multiple cases where a doctor diagnosed significant jaundice but did not start therapy immediately or took too long to transfer a child to an institution where the patient could receive it (source article).
Often times these delays in treatment are due to institution-related errors. Some of them include a lack of pharmacists on duty at night, not having immunoglobulin on site, or not having enough phototherapy lamps or nurses who could initiate therapy. All these issues can lead to hospitals’s liability in malpractice suits (my full article on this subject here).
Phototherapy
Phototherapy is the first line of treatment for significant neonatal hyperbilirubinemia. It is easy to administer and for most patients without significant side effects.
Occasionally, parents are against starting it when the mother is concerned about interrupting the breastfeeding process or being separated from her infant during phototherapy.
Medical providers must explain the rationale for the treatment and document all that in charts.
Below, I listed common errors related to starting phototherapy:
- Delaying therapy despite indications for it
- Not having phototherapy lamps on site
- Malfunctioning phototherapy lamps due to infrequent servicing
- Not ordering repeat bilirubin levels while on phototherapy
- Not following the hydration and nutritional status of the baby while on the phototherapy
- Poor communication with parents regarding goals for therapy and follow-up
Immunoglobulin
Immunoglobulin is an intravenous medication that may be indicated in severe jaundice due to immune hemolysis resistant to phototherapy. It can be a very effective treatment when used early and for appropriate indications.
Unfortunately, some hospitals do not want to stock it or do not have the knowledge and expertise to prepare and administer the solution. Again, given the importance of this medication to babies with severe hemolytic jaundice, it is inexcusable for the hospital not to be ready to provide this treatment to their patients.
Exchange transfusion
Exchange transfusion is a procedure during which we replace the patient’s blood with the blood from the blood bank. The idea is to replace double blood volume so we can significantly decrease bilirubin levels.
We must perform this procedure if the patient maintains dangerous bilirubin levels despite intensive phototherapy and immunoglobulin administration (if it was indicated). It is a last-resort therapy. However, doctors and hospitals not offering this therapy should plan and transport patients promptly to other institutions that can provide it.
Occasionally, errors associated with ordering or administering the wrong blood may result in devastating complications and malpractice suits.
Lack of appropriate follow-up
Bilirubin levels change in infants a lot during the first month after birth. Typically, bilirubin levels increase during the first 3-5 days. Then, they slowly come down to what would be expected in healthy adults.
However, this is not a rule. Some babies with breast milk jaundice or genetic syndromes may have peak bilirubin levels several weeks after birth.
Some babies treated with phototherapy who achieved “a safe” level may rebound again.
All pediatricians and neonatologists must develop routines allowing to follow every patient under their care until complete resolution of jaundice or until they are entirely out of danger.
Risk management in Neonatal Jaundice care
Kernicterus cases are relatively infrequent, but when they occur, they lead to disastrous consequences for the patient and often to costly legal judgments against doctors and hospitals.
Each pediatric and neonatal department should develop policies and procedures to diagnose and treat jaundice effectively.
The risk management plan should also cover the necessary training for stakeholders such as nurses, nurse practitioners, doctors, laboratory workers, emergency room providers, and administrators.
To avoid missing patients to follow-up, the plan must cover communication with outpatient providers and provide availability for testing bilirubin levels after hours and on weekends.
Recommended Articles:
Neonatologist talks about most common causes of malpractice suits in neonatology.
When hospital can be found liable in litigation involving newborns treated in the NICU?