50 Years Ago in The Journal of Pediatrics:

Article Outline

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Koch CA, Jones DV, Dine MS, Wagner EA. J Pediatr 1959;55:23-9

In this interesting article, the authors describe the outcomes of preterm infants with varying degrees of hyperbilirubinemia. Serial serum bilirubin concentrations were measured in 100 consecutive preterm infants. Each infant's condition at birth was rated clinically, and the postnatal course was documented. The infants were invited back for clinical assessment at age 2 to 3 years. Of the 100 infants studied, 8 died before discharge and 42 returned for assessment. Seven infants were assessed after discharge at clinics where charts were accessible and were also included in the study. Of the 8 infants who died, 2 had kernicterus diagnosed at autopsy. Of the 49 infants assessed after discharge, 5 had clinical features suggestive of kernicterus. All of the infants with kernicterus had bilirubin levels above 20 mg/dL. Three of the 4 infants with a bilirubin concentration of 30 to 40 mg/dL exhibited evidence of kernicterus. Importantly, none of those infants subsequently diagnosed with kernicterus exhibited clinically specific features before discharge. The authors concluded that exchange transfusion is indicated in all infants who have or are expected to develop a serum bilirubin concentration > 20 mg/dL.

This article provides a glimpse into just how different a preterm infant 's journey was 50 years ago. There are many important differences between then and now. Instead of using an ad hoc clinical score, neonatologists have now universally adopted the Apgar score. The Bloxsom airlock, considered an innovation in neonatal management 50 years ago, is now only found in museums. Back then, conjugated and unconjugated bilirubin could not be easily differentiated, whereas now they can be routinely measured in the modern chemical pathology laboratory as part of the clinical service. With the advent of phototherapy in the 1960s, the use of exchange transfusions to treat hyperbilirubinemia has decreased dramatically. Therefore, the conclusions of Koch et al are no longer applicable in the modern era. But despite these dramatic advances, many questions remain; for example, factors predisposing the human infant brain to the development of kernicterus are still poorly understood. Given the relatively safe option of phototherapy to effectively treat hyperbilirubinemia and the potentially disastrous consequences of kernicterus, ethical constraints make it unlikely that these questions will ever be answered completely.