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DRIVE-BY DELIVERIES INCREASE THE RISK OF NEONATAL BRAIN DAMAGE

The drive to reduce the length of hospital stays has included healthy term or near-term newborns – and the trend has led to neurological complications that should be of concern to neurologists. The decrease started with the women's movement in the 1970s and was further pushed by health maintenance organizations in the late 1980s and early 1990s. In the 1970s, the mean length of hospital stay for a healthy term baby was between five and seven days; in the 1990s, length of stay went down to less then 24 hours.

There have been attempts to curb these practices referred to as “drive-by deliveries”, but with varying success. The Newborns' and Mothers' Health Protection Act–legislation that passed in 1996 and became federal law in 1998 – mandates that all insurance agencies pay for hospital stays of at least 48 hours for a vaginal delivery and 96 hours for a C-section. But follow up requirements after discharge were left unregulated and vary in different states.

PROBLEMS WITH BREASTFEEDING

Neurologists should be concerned about these “drive-by” deliveries because these and related changes in clinical practice have increased the risks for neurological insults to the developing brain that can be devastating. Discharging a healthy full-term breastfeeding newborn at 48 hours without a follow up visit scheduled in one to two days clearly increases the risk of hyperbilirubinemia, hypernatremic dehydration, venous thrombosis, and brain injury (Pediatrics 2003;112(6):1388–1393; Pediatr Emerg Care 2001;17(3):175–180).

Some of these neurological risks are related to breastfeeding practices. In the past decade, the benefits of breastfeeding have been lauded for infants and mothers, including fewer infections, enhanced bonding, cost savings on formula feeding, and better brain development in low birth weight babies. The Centers for Disease Control and Prevention has advocated a goal of 75 percent in breastfeeding which is not usually started until 96 hours after birth – and 20 percent of primigravida women do not succeed (Pediatrics 2003;112(6):1388–1395; Pediatr Emerg Care 2001;17(3):175–180). Without breastfeeding, risks increase for kernicterus, hypernatremic dehydration, and dural venous thrombosis.

Figure

Caroline Roche

NEUROLOGICAL COMPLICATIONS

Hyperbilirubinemia is usually benign in the newborn period, occurring in about half of term newborns (Clin I Perinatol 1998;25(3):555–570; Pediatrics 2003; 112:1264–1273). When feeding is not adequate, the formation of stools may be impaired, and the bilirubin can be reabsorbed from the gut lumen (Pediatrics 2003;112(6):1388–1393).

Hyperbilirubinemia, which can cause kernicterus, practically vanished in the 1970s. but since 1992, 125 new cases of kernicterus were identified by Johnson and Bhutani (J Pediatr 2002; 140:396–403). In 80 cases – for which treatment information was available there were severe kernicterus complications; 76 percent of them (61 infants) developed kernicterus in the first week of life and nearly all had not had a follow-up-visit scheduled in two to three days as outlined by the American Academy of Pediatric Guidelines for infants discharged at or before 48 hours. Fourteen infants who were seen on the second and third day still developed extreme hyperbilirubinemia. Fifty-nine of the 61 cases were breastfed infants.

Nineteen infants with kernicterus in the registry had glucose-6-phosphate dehydrogenase (G6PD) deficiency, which can cause jaundice and a hemolytic reaction if certain drugs are taken. Testing for G6PD deficiency is not universal on all states' newborn screens and, if drawn, is usually pending at the time of discharge and therefore not diagnosed.

To decrease the increase in kernicterus cases, health care professionals can reinforce the need for follow-up appointments two-to-three days after early discharge, pay greater attention to the dangerous levels of jaundice in infants, as well improve education on breastfeeding and patient compliance.

Figure

Dr. Steven M. Shapiro

Kernicterus results in serious brain damage with dystonic and choreoathetoid cerebral palsy associated with hearing loss and gaze paralysis. In addition, severe hypernatremic dehydration resulting from inadequate (and undetected) breastfeeding problems may cause cerebral edema, seizures, and dural venous thrombosis.

This extreme hyperbilirubinemia is most frequent between the third and fifth day of life (Pediatrics 2003; 112(6):1388–1393).

Severe hypernatremic dehydration is another consequence of failed breastfeeding and has also become a problem. Investigators have noted that cases of hypernatremic dehydration are also linked to the increased number of breastfeeding mothers, the failure rate of first-time breastfeeding mothers, and early discharge of healthy term or near-term newborns.

EARLY FOLLOW-UP

Early follow up after discharge of a healthy term baby is encouraged because the length of stay for a newborn is so brief. Practice guidelines for managing hyperbilirubinemia in the healthy term newborn published by the American Academy of Pediatrics – advise that all newborns discharged at less than 48 hours should seen by a health care professional within two to three days after discharge (Pediatrics 1994:94:558–565). The current practice for a healthy term newborn follow-up with the pediatrician is one to two weeks after birth, however.

So what can be done to ameliorate the increase in preventable neurological diseases in health term or near-term breasfed newborns? For one, greater efforts could be made to identify high-risk newborns, standardize and assess breastfeeding education before discharge, and examine the child within 48 hours. The use of home health nursing services can be valuable assets toward this goal. Neurologists can also do their part by joining in the lobbying efforts on a state level to standardize safe follow-up practice guidelines for healthy term or near-term babies discharged from the hospital at or before 48 hours.

REFERENCES

• Thilo EH, Townsend SF, Merenstein GB. The history of policy and practice related to the perinatal hospital stay. Clin Perinatol 1998;25(2):257–269.
• Johnson L, Bhutani VK. Guidelines for management of the jaundiced term and near-term infant. Clin Perinatol 1998;25(3):555–570.
• Egerter SA, Braveman PA, Marchi KS. Follow-up of newborns and their mothers after early •hospital discharge. Clin Perinatol 1998;25(2):471–481.
• American Academy of Pediatrics, Provisional Committee for Quality Improvement. Practice parameter: management of hyperbilirubinemia in the healthy term newborn. Pediatrics 1994;94:558–565.
• Palmer RH, Clanton M, Ezhuthachan S, Newman C, Maisels J, Plsek P, Salem-Schatz S. Applying the “10 Simple Rules” of the Institute of Medicine management of hyperbilirubinemia in newborns. Pediatrics 2003;112(6):1388–1393.
• van Amerongen RH, Moretta AC, Gaeta TJ. Severe hypernatremic dehydration and death in a breast-fed infant. Pediatr Emerg Care 2001;17(3):175–180.
• Ahluwalia IB, Morrow B, Hsia J, Grummer-Strawn LM. Who is breast-feeding? Recent trends from the pregnancy risk assessment and monitoring system. J Pediatr 2003;142:486–491.