2006

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Author(s)
Citation
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Neonatal hyperbilirubinemia: long-term neurophysiological and

neurodevelopmental outcomes
Chen, Wenxiong;
Chen, W. []. (2006). Neonatal hyperbilirubinemia : longterm neurophysiological and neurodevelopmental outcomes.
(Thesis). University of Hong Kong, Pokfulam, Hong Kong SAR.
Retrieved from http://dx.doi.org/10.5353/th_b3748938
2006
http://hdl.handle.net/10722/52281
The author retains all proprietary rights, (such as patent rights)

and the right to use in future works.
Abstract of dissertation entitled
Neonatal hyperbilirubinemia: Neurophysiological and

neurodevelopmental outcomes
Submitted by
CHEN Wen Xiong
For the Degree of Master of Philosophy at The University of Hong Kong

in August 2006
Objective: To evaluate the effects of bilirubin on auditory brainstem pathway and

neurodevelopment in Chinese term neonates with severe non-hemolytic or hemolytic
hyperbilirubinemia.
Subject and Methods:

128 Chinese term-infants with hyperbilirubinemia were retrospectively studied.
Subjects were divided into two groups: Non-hemolytic group (N=99; mean peak total
serum bilirubin [TSB]: 21 mg/dl) and Hemolytic group (N=29; mean peak TSB: 20.6
mg/dl). All subjects received phototherapy, while 7 had additional exchange
transfusion. The Non-hemolytic group was divided into three sub-groups according
to the peak TSB: Moderate group (N=30; mean peak TSB: 18.8 mg/dl); Severe group
(N=63; mean peak TSB: 21.6 mg/dl); and Super group (N=6; mean peak TSB: 26.7
mg/dl).
The initial brainstem auditory evoked potential (BAEP) was recorded in

Non-hemolytic group (mean age: 3.1 months) and in Hemolytic group (mean age:
3.2 months). Serial BAEPs were performed until 2 years old in 3 subjects from
Hemolytic group and 18 from Non-hemolytic group. Of the 18 Non-hemolytic
subjects, 9 with initial abnormal BAEP were classified under the Abnormal group
while 9 with initial normal BAEP were considered as Control. All 128 subjects had
physical, neurological, visual and auditory evaluations every 3 to 6 months until 3
years old.
Results:
Although there was no significant difference by the demographic data, the rate of
treatment with exchange transfusion was significantly higher in Hemolytic group
(13.8%) than in Non-hemolytic group (3%) (P<0.05). None of the subjects who
received the exchange transfusion had abnormal BAEP or neurodevelopment
outcome.
Initial BAEP abnormalities occurred in 9 (9.1%) subjects from the Non-hemolytic

group and 3 (10.4%) from the Hemolytic group. At 2 years old, BAEP returned to
normal in all except 3 subjects with slightly increased hearing threshold; two subjects
(2%) were from Non-hemolytic group with 50 dB nHL and 1 (3.5%) from Hemolytic
group at 60 dB nHL. All 9 subjects in the Control group remained normal all along.
No significant correlation was found between Hemolytic and Non-hemolytic groups
in the rate of initial or serial BAEP abnormalities.
The initial BAEP abnormalities in Non-hemolytic group were not associated with
any demographic factors. The rate of initial BAEP abnormalities did not differ
significantly among the Moderate (10%), Severe (7.9%) and Super (16.7%) groups.
All subjects had normal neurodevelopment at initial assessment except 5 individuals

with mild motor delay and hypotonia (2 [2%] in Non-hemolytic group and 3 [10.4%]
in Hemolytic group), and they returned to normal after 2 years old. All 5 individuals
with initially abnormal neurodevelopment had normal BAEP. The rate of abnormal
neurodevelopment was higher in the Hemolytic group although with no significant
difference from the Non-Hemolytic group (P=0.08). No significant correlation was
found in the rate of neurodevelopmental abnormalities among the Moderate (3.3%),
Severe (1.6%) and Super (0%) groups.
Conclusion: The toxic effects of bilirubin on auditory brainstem pathway and

neurodevelopment in Chinese term neonates with non-hemolytic or hemolytic
hyperbilirubinmia were transient and mild provided that early interventions are
initiated.
(Total words: 484)
Neonatal hyperbilirubinemia: Neurophysiological

and neurodevelopmental outcomes
By
CHEN Wen Xiong

(MD)
A dissertation submitted in partial fulfillment of the requirements for the Degree of

Master of Philosophy at the University of Hong Kong
August 2006
Declaration
I declare that this thesis represents my own work, except where due
acknowledgement is made, and that it has not been previously included in a thesis,
dissertation or report submitted to this University or to any other institution for a
degree, diploma or other qualification.
Signed ________________________________________
CHEN Wen Xiong
Acknowledgements
I would like to take this opportunity to express my sincere gratitude to my supervisors,

Professor Virginia Wong and Dr Raymond Cheung for their continuous guidance and
encouragement throughout the years. I would like to give my special thanks to
Professor Virginia Wong for giving me a chance to help in the project, use the data
obtained to write up my dissertation and give valuable advice during the project. I
have to thank Dr KY Wong from the Department of Pediatrics and Adolescent
Medicine, Queen Mary Hospital for his generous support in releasing related data for
my dissertation use.
I would like to thank Mr. Josef PK Yan and technicians from Neurophysiology
Laboratory of Department of Pediatrics and Adolescent Medicine, Queen Mary
Hospital for their helping recording brainstem auditory evoked potential. In addition,
I gratefully thank the Child Assessment Centre of Duchess of Kent Childrens
Hospital for conducting part of evaluations. Last but not least, I have to thank Mr.
Wilfred Wong, for his statistical advice and help.
ii
Contents
Declaration
Acknowledges
ii
Tables of Contents
iii
List of Tables and Figures
vii
List of Publications
ix
Abbreviations
Chapter 1 Introduction
1.1 History
1.2 Epidemiology
1.3 Bilirubin physiology
1.4 Risk factors
1.5 Bilirubin toxicity
1.5.1 Cellular toxicity
1.5.2 Kernicterus
1.5.2.1 Etiology: Non-hemolytic and hemolytic
1.5.2.2 Clinical features
1.5.2.3 Neurodevelopment
1.6 Neurophysiology
10
1.6.1 Brainstem auditory evoked potential (BAEP)
iii
10
1.6.2 Visual evoked potential (VEP)

1.7 Treatment
12
16
1.7.1 Phototherapy
17
1.7.2 Exchange transfusion
18
1.7.3 Approach in Hong Kong
19
1.7.3.1 Early surveillance and intervention approach
19
1.7.3.2 Monitoring and rehabilitation system
19
1.8. Current concerns
19
1.9 Objectives
20
Chapter 2 Subjects and Methods

2.1 Inclusion criteria
22
2.2 Subjects
22
2.3 Brainstem auditory evoked potential (BAEP)
24
2.3.1 Brainstem auditory evoked potential test protocol
24
2.3.2 Criteria of abnormal brainstem auditory evoked potential
25
2.3.3 Time of brainstem auditory evoked potential test
26
2.4 Neurodevelopmental evaluations
27
2.5 Statistical Analysis
27
2.5.1 Non-hemolytic study
28
2.5.2 Hemolytic study
28
iv
Chapter 3 Results
3.1 Non-hemolytic cohort
29
3.1.1 Demographic data
29
3.1.2 Outcomes of brainstem auditory evoked potential
29
3.1.2.1 Initial BAEP outcomes
29
3.1.2.2 Serial BAEP outcomes
30
3.1.3 Outcomes of neurodevelopment
31
3.1.4 Long-term effects of phototherapy
37
3.2 Hemolytic cohort
37
3. 2 1 Demographic data
37
37
3.2.3 Outcomes of neurodevelopment
38
3.2.4 Etiologic distribution and BAEP or neurodevelopment outcomes
39
39
Chapter 4 Discussion
4.1 Non-hemolytic cohort: Neurophysiological and neurodevelopmental outcomes in
severe neonatal non-hemolytic hyperbilirubinemia
44
4.1.1 Brainstem auditory evoked potential: Short-term outcomes in neonatal

non-hemolytic hyperbilirubinemia
44
4.1.2 Brainstem auditory evoked potential: Long-term outcomes in neonatal

48
4.1.3 Neurodevelopment in neonatal non-hemolytic hyperbilirubinemia
50
4.2 Hemolytic cohort: Neurophysiological and neurodevelopmental outcomes in

severe neonatal hemolytic hyperbilirubinemia
52

hemolytic hyperbilirubinemia
53

53
4.2.3 Neurodevelopment in neonatal hemolytic hyperbilirubinemia
54
4.2.4 Etiology in neonatal hemolytic hyperbilirubinemia
55
4.2.4.1 Rh hemolytic disease of the newborn
55
4.2.4.2 Glucose-6-Phosphate Dehydrogenase deficiency
56
4.2.4.3 ABO hemolytic disease of the newborn
57
4.2.4.4 ABO incompatibility combined with G-6-PD deficiency
59
4.3 Phototherapy in neonatal hyperbilirubinemia
59
4.4 Limitation and future research
61
4.5 Conclusion
62
Reference
63
vi
List of tables
Table 1:
Comprehensive risk factors for neonatal hyperbilirubinemia
Studies of visual evoked potential in neonatal hyperbilirubinemia
15
Management of hyperbilirubinemia in the healthy term newborn
16
Demographic data of children with non-hemolytic hyperbilirubinemia
32
Logistic regression analysis of effect of demographic factors on BAEP
33
Table 2:
Table 3:
Table 4:
Table 5:
Table 6:
Comparison of BAEP and neurodevelopment outcomes of children with
34
Table 7:
Demographic
data
of
children
hyperbilirubinemia
with
hemolytic
or
non-hemolytic
40
Table 8:
Comparison of BAEP and neurodevelopment outcomes between hemolytic
and non-hemolytic groups
41
vii
Table 9:
Etiologic distribution and BAEP or neurodevelopment outcomes in
hemolytic group
42
Table 10:
Studies
of
short-term
effect
of
non-hemolytic
or
hyperbilirubinemia on BAEP
hemolytic
45
Table 11:
Studies
of
long-term
effect
of
non-hemolytic
hyperbilirubinemia on BAEP
or
hemolytic
49
List of Figures
Figure 1:
BAEP report recording from a normal child aged 3 months
11
Figure 2:
BAEP outcomes in non-hemolytic group at initial evaluation
35
Figure 3:
The distribution of serial BAEP tests in non-hemolytic group
36
Figure 4:
BAEP outcomes in hemolytic group at initial evaluation
viii
43
List of Publications
1. Chen WX, Wong V. Prognosis of Bell's palsy in children-analysis of 29

cases. Brain & Development 2005; 27(7):504-8.
2. Chen
WX,
Wong
V.
Visual
Evoked
Potentials
in
Neonatal
Hyperbilirubinemia. J Child Neurol 2006; 21(1):5862.

3. Chen WX, Wong V, Wong KY. Neurodevelopmental outcome of Severe
Neonatal
Hemolytic
Hyperbilirubinemia.
Child
Neurol
2006;
21(6):474-479.
4. Wong V, Chen WX, Wong KY. Short and long term outcome of severe
neonatal Non-hemolytic hyperbilirubinemia. J Child Neurol 2006; 21(4):
309-315.
5. Wong V, Chen WX. Is acupuncture useful for cerebral palsy? What
evidence do we have? As a chapter Focus on Cerebral Palsy2006 in
press
6. Chen WX, Cheuk DKL, Wong V. Acupuncture for autistic spectrum
disorder. (Manuscript).
7. Chen WX, Liu WL, Wong V. Body acupuncture for children with autism:
a pilot study. (Manuscript).
ix
Abbreviations
BAEP: Brainstem auditory evoked potential
VEP: Visual evoked potential
TSB: Total serum bilirubin
G-6-PD: Glucose-6-phosephate dehydrogenase
UDPGT: Uridine diphosphate glucuronosyltransferase
IQ: Intelligent Quotient
PT: Phototherapy
ET: Exchange transfusion
PTA: Pure Tone Audiometry
VRA: Visual Reinforcement Audiometry
Chapter 1
Introduction
1.1 History
Although neonatal jaundice, or icterus neonatorum, has long been noticed, it was
Baumes who first scientifically described the clinical course of neonatal jaundice in
10 neonates, and as a result, he was awarded a prize from the University of Paris in
1785 (1).
Hervieus (1) in 1847 first depicted brain jaundice with variable intensity of staining
in 31 of 44 autopsied cases. Thereafter, Orth (2) in 1875 reported that the brain of
one autopsied jaundiced-term infant was remarkable with an intense yellow staining
in the basal ganglia, the wall of the third ventricle, the hippocampus, and the central
parts of the cerebellum.
Subsequently, Schmorl (3) in 1903 described two forms of brain icterus in 120
autopsied jaundiced infants. The first form is characterized by a diffuse yellow
coloration of the entire brain substance, while the second one is distinguished by the
jaundiced coloration appearing to be completely circumscribed and limited to the
so-called kern or nuclear region of the brain. For this latter form, Schmorl coined
the term kernicterus to refer to the yellow staining of the basal ganglia observed in
infants who died with severe jaundice.
1.2 Epidemiology
Neonatal hyperbilirubinemia, defined as total serum bilirubin (TSB) level above 5
mg/dl (86 mol/L), is a frequently encountered problem in newborns (4). Each year
approximately 60% of 4 million newborns in the United States are reported to be
clinically jaundiced (5). The prevalence of neonatal jaundice is 50-60% in term and
80% in preterm infants (6).
The average peak TSB concentrations of East Asian and Native American infants are
significantly higher than those of Caucasian infants (7). One multi-center (Northeast,
North and South of China) study (8) reported that among 875 Chinese full-term
infants, 34.4% had TSB level higher than 13 mg/dl (220.5 mol/L), and the mean
peak TSB level in these infants was significantly higher than that of Caucasian
infants.
Neonatal jaundice runs in families (9). As a group, male infants consistently have
higher bilirubin levels than females (10).
A Hong Kong study (11) found that the incidence of G-6-PD deficiency in the
Chinese male population was 3.6% while another (12) reported that the incidence of
ABO hemolytic disease of the newborn in a cohort of Hong Kong infants with severe
hyperbilirubinemia was 1 in 5 among infants with TSB level of 17.5 mg/dl (300
mol/L) or more.
1.3 Bilirubin physiology

The predominant source of bilirubin is the breakdown of hemoglobin in senescent or
hemolyzed red cells. Heme is degraded by heme oxygenase, resulting in the release
of iron and the formation of carbon monoxide and biliverdin. Biliverdin is further
reduced to bilirubin by biliverdin reductase. Bilirubin then enters the liver and is
modified to an excretable conjugated form that enters the intestinal lumen but can be
deconjugated by bacteria and reabsorbed into the circulation.
Total serum bilirubin is a combination of conjugated and unconjugated bilirubin. In

neonates, TSB is almost completely composed of unconjugated bilirubin and it is
bound to protein in the blood. Unconjugated bilirubin (also known as indirect
bilirubin because of its indirect reaction in the diazo assay used to measure bilirubin),
a breakdown product of the porphyrin ring of red blood cell hemoglobin, is lipid
soluble, water insoluble, and neurotoxic. Unconjugated bilirubin is conjugated in the
liver by uridine diphosphate glucuronosyltransferase (UDPGT) to a water soluble,
non-toxic glucuronide, known as conjugated bilirubin (also known as direct
bilirubin because of its direct reaction in the diazo assay).
Two-thirds or more of newborns will appear clinically jaundiced, and this type of
transient hyperbilirubinemia has been called physiologic jaundice. Infants have

higher rates of bilirubin production than adults. In newborn infants, unconjugated
bilirubin is not readily excreted, and the ability to conjugate bilirubin is limited.
Together, these limitations are responsible for physiologic jaundice of the neonate.
Features of pathologic jaundice include the appearance of jaundice within 24 hours

after birth, a rapidly rising TSB level (increase of more than 5 mg/dl [86 mol/L] per
day), and a TSB level higher than 17 mg/dl (291 mol/L) in a term newborn (13).
Increased production of bilirubin, deficiency of hepatic uptake, impaired conjugation
of bilirubin, and increased enterohepatic circulation of bilirubin account for most
cases of pathologic jaundice in newborn infants (14).
1.4 Risk factors

Comprehensive risk factors for severe hyperbilirubinemia are reviewed in a recent
article (13) (shown in Table 1), while the common clinical risk factors have been
identified by an epidemiological study (15).
Table 1: Comprehensive risk factors for neonatal hyperbilirubinemia (13)

Maternal factors
Race or ethnic group
Asian
Native American
Greek Islander
Complications during pregnancy
Diabetes mellitus
Rh incompatibility
ABO incompatibility
Use of oxytocin in hypotonic solutions during labor
Brest-feeding*
Perinatal factors
Birth trauma
Cephalhematoma
Ecchymoses
Infection
Bacterial
Viral
Protozoal
Neonatal factors
Prematurity
Genetic factors
Familial disorders of conjugation
Gilberts syndrome
Crigler-Najjar syndrome types I and II
Other enzymatic defects
Glucose-6-phosphate dehydrogenase deficiency
Pyruvate kinase deficiency
Hexokinase deficiency
Congenital erythropoietic porphyria
Erythrocyte structural defects
Spherocytosis
Elliptocytosis
Polycythemia
Drugs
Streptomycin
Chloramphenicol
Benzyl alcohol
Sulfisoxazole
Low intake of breast milk (early-onset breast-milk jaundice)
* Breast milk is a competitive inhibitor of hepatic uridine diphosphate glucuronosyltransferase (late-onset breast-milk
jaundice).
1.5 Bilirubin Toxicity
1.5.1 Cellular toxicity

Bilirubin can inhibit mitochondrial enzymes and interfere with DNA synthesis, as
well as inhibit protein synthesis and phosphorylation (16). Bilirubin also inhibits the
function of N-methyl-D-aspartate-receptor ion channels (17), which suggests that it
can interfere with neuroexcitatory signals and impair nerve conduction. Bilirubin can
inhibit ion exchange and water transport in renal cells (18), which may explain the
neuronal swelling that occurs in the bilirubin encephalopathy associated with
kernicterus.
1.5.2 Kernicterus
Strictly speaking, kernicterus is a pathological diagnosis describing yellow staining
of the basal ganglia, which is also used to describe the clinical features of bilirubin
encephalopathy, although the underlying mechanism is still uncertain.
The cells, which are metabolically active and receive the largest blood flow, are most
prone to this type of damage, and which therefore become stained by the bilirubin to
give kernicterus. In neonates these are the cells of the basal ganglia and the mid-brain.
The damage is caused by free bilirubin in the extracellular fluid binding to neuronal
cell membranes, with severe and complex biochemical sequelae for the cell.
In a registry of term and nearly full-term infants born from 1984 to 1999, the
mortality rate among infants with kernicterus was 4% (19). Specific changes on
magnetic resonance imaging increased signal intensity in the globus palidus on T2
weighted imaging (20), which are closely correlated with the deposition of bilirubin
in the basal ganglia.
1.5.2.1 Etiology: Hemolytic and non-hemolytic
Hsia et al.1952 (21) and Mollison et al.1954 (22) first established the link between
bilirubin levels and brain damage in the early 1950s, when they demonstrated that
the risk of kernicterus in infants with Rh hemolytic disease increased dramatically
with rising bilirubin levels. Subsequent studies (23, 24) suggested that, in untreated
infants with hemolytic disease, the incidence of kernicterus was much higher than the
incidence in markedly jaundiced infants without hemolytic disease. The reasons for
this are not clear, although it has been suggested that infants with hemolytic disease
may have a decrease in their bilirubin-binding capacity. Similarly, there is no obvious
explanation for the increased risk of bilirubin encephalopathy in infants with G-6-PD
deficiency.
1.5.2.2 Clinical features
The clinical features of kernicterus vary, and up to 15% of infants have no obvious
neurologic symptoms. In the acute phase, severely jaundiced infants become
lethargic, hypotonic and suck poorly. If the hyperbilirubinemia is not treated, the
infant becomes hypertonic and may develop a fever and a high-pitch cry. The
hypertonia is manifested by backward arching of the neck (retrocollis) and trunk
(opisthotonus). Surviving infants usually develop a severe form of athetoid cerebral
palsy, hearing loss, dental dysplasia, paralysis of upward gaze and, less often,
intellectual and other handicaps.
1.5.2.3 Neurodevelopment
Some researches (25-28) have studied the association between neurodevelopment

and
peak
TSB.
Collaborative
Perinatal
Project
(25)
reported
that
neurodevelopment during the first year of life was correlated with the peak TSB soon
after birth. In a multicenter survey (26), a dose-response relation between peak TSB
and risk of delay in development was found at two years of age only among children
who had weighed less than 1500 grams at birth, but there was no correlation at five
years of age (27). A 17-year follow-up study (28) revealed an association between
severe hyperbilirubinemia and lower IQ in boys, but not in girls.
Some studies (29, 30, 31) have explored the relationship between neurodevelopment
and the duration of exposure to TSB levels, although many of the infants in these
studies either had hemolytic disease or were premature. In one Turkish study (29),
exposure to TSB level greater than 20 mg/dl (342 mol/L) for less than 6 hours
showed incidence of neurologic abnormalities was 2.3%, which increased to 18.7%
if the exposure lasted between 6 to 11 hours and to 26% with 12 or more hours of
exposure.
A 6-year follow-up National Institute of Child Health and Human Development

clinical trial (30) reported that 224 control infants who did not receive phototherapy
and who had birth weights of less than 2000 grams showed no association between
IQ and duration of exposure to hyperbilirubinemia.
In one Norwegian study (31), a cohort of 55 boys with a history of neonatal

hyperbilirubinemia was recruited at 18 years old during military draft. There were no
significant difference regarding the outcomes of physical, visual, auditory and IQ
tests compared with the total cohort of conscripts. However, 7 boys having a history
of positive Coombs tests and bilirubin in excess of 15 mg/dl (257 mol/L) for more
than 5 days had significantly lower IQ scores than the national average.
Although there is no doubt about the relationship between elevated TSB level and
brain damage, the ability of a single peak TSB to predict long-term
neurodevelopmental outcomes is poor (32, 33). In one evidence-based review with
many case reports of kernicterus analyzed systematically by authors (32, 33), it was
impossible to know if the putative peak TSB levels (measured in some cases more
than 7 days after birth) were true peak levels, and many cohort studies have
significant problems with blinding of the examiners and dropouts (32-34).
1.6 Neurophysiology
There is lack of an objective method to evaluate the toxic cerebral effects of
hyperbilirubinemia during acute management of hyperbilirubinemia. Evoked
potentials are noninvasive tools to evaluate the integrity and functional maturation of
the afferent pathways of the central and peripheral nervous system.
1.6.1 Brainstem auditory evoked potential (BAEP)

The BAEP test is an accurate and noninvasive means of assessing the functional
status of the auditory nerve and the brainstem auditory pathway. Studies (35, 36) in
both animals and humans have suggested that wave I represents activity of the
auditory nerve, wave II represents activity of the cochlear nuclei, wave III represents
activity of the superior olive, and waves IV and V represent activity of the inferior
colliculus.
Figure 1 shows the BAEP report recording from a normal child aged 3 months in the
Neurophysiology Laboratory, Department of Paediatrics and Adolescent Medicine,
Queen Mary Hospital. The latency for wave I represents the peripheral conduction
time. Latency of waves III and V and the interpeak latency of waves I to III, III to V,
and I to V all represent measurements of central conduction time. The interpeak
latency I to V is referred to as the brainstem conduction time. The report also
includes amplitudes of the waveforms, which may decrease or be lost in response to
various insults.
10
Figure 1: Brainstem auditory evoked potential report recording from a normal child aged 3 months
BAEP has been demonstrated to be a useful tool in detecting the acute neurotoxicity
of bilirubin in the peripheral and central auditory pathways (37).
In order to categorize studies of neonatal hyperbilirubinemia, if the effects of

hyperbilirubinemia on BAEP were assessed before 1 year of age, the study was
defined as short-term, and if they were assessed after 1 year of age, it was defined as
11
long-term.
Studies published in the 1980s (38-40) were mainly explorative in the use of BAEP
in neonatal hyperbilirubinemia during the acute phase with serial BAEP assessments
recorded just before and after treatment by either phototherapy and/or exchange
transfusion. These studies showed that the abnormalities of BAEP in premature or
term neonates with hyper-bilirubinemia improved after phototherapy and/or
exchange transfusion.
Short-term outcome studies (41-53), however, have remained quite controversial in

their final outcome. The ethnic distributions of these studies were 4 in India (41-44),
2 in Italy (45, 46), 2 in Japan (47, 48), 2 in Hong Kong (49, 50), and 1each in Korea
(51), Turkey (52) and Hungary (53). Most short-term studies (41-45, 49-52)
evaluated the short-term effect within 6 months.
There were a few long-term studies: 1 in Germany (54), 2 in Turkey (29, 55-56) and
2 in Hong Kong (49, 50). Serial BAEPs were performed at different age periods of
15 to 80 months (54), 2-6 years (55, 56), 2 years (49, 50) and 8-13 years (29).
1.6.2 Visual evoked potential (VEP)

Visual evoked potential (VEP) is a measurement of transmission along a complex
visual pathway, and is the only physiological technique available in a clinical setting
12
to assess the functional state of the visual nervous system beyond the retinal ganglion
cells (57). Hyperbilirubinemia in moderate concentrations have been associated with
a higher increase in bilirubin-to-brain transfer to the auditory areas followed by
visual and extrapyramidal system (58).
There are only 6 published studies up to present (4 for humans [29, 39, 59-60] and 2
for animal models [61, 62]) that have explored the effects of hyperbilirubinemia on
VEP. Two Gunn rat studies (61, 62) found that jaundiced rats exhibited prolonged
wave latencies and decreased in wave amplitudes during the third week of postnatal
life compared to non-jaundiced littermates. The results of neonatal studies (3 for term
[29, 59, 60] and 1 for preterm [39]) are shown in Table 2.
In our long-term study (Chen et al. 2006) (60) published recently, 24 term neonates
with hyperbilirubinemia (Moderate group [N=16] with mean peak TSB 19 mg/dl
[322.7 mol/L] and Severe group [N=8] with mean peak TSB 22 mg/dl [375.1
mol/L]) were evaluated prospectively with serial VEPs until 2 years of age. All
infants had regular neurodevelopmental evaluations until 3 years of age.
Four (16%) out of 24 infants had abnormal VEP at initial assessment, but VEP results
in all returned to normal after 1 year of age. There was no significant difference in
VEP abnormalities between both groups. Chin et al 1985 (39) and Chen et al. 1995
(59) also reported that the acute phase or short-term harmful effects of bilirubin on
13
VEP were found in either preterm (39) or term infants (59). One Turkish long-term
study (29) revealed that there is no difference between the different severity
hyperbilirubinemia groups in their average VEP latencies at 8-13 years.
All cases in the present study (60) had normal neurodevelopment over 3-year serial
follow-up except 1 case from the Severe group with ABO incompatibility who had
transient mild motor delay and hypotonia.
There are few published studies regarding the effects of phototherapy on VEP in
infants with hyperbilirubinemia. In fact, we could not exclude the possible influence
of phototherapy as all neonates in our study had received phototherapy. However, we
did not find any effects of phototherapy on VEP after one year of age as the results of
VEP of all subjects were normal by that age.
Although our sample size is small, the results suggest that the effects of
hyperbilirubinemia on VEP might be transient.
14
Table 2: Studies of visual evoked potential in neonatal hyperbilirubinemia

Study
subjects
Tests
Duration of study
Results
Chin KC
2 preterm infants
VEP
Before and after ET
Improvement in latencies of
(32 and 33 weeks
BAEP
in day 3 and day1 after
both VEP and BAEP after ET
(1985)
gestation)
birth
Chen YJ
72 term infants
VEP
Serial VEP compared
VEP latencies increased in
(1995)
divided into Mild,
DDST
in 4 sessions for 8 weeks
hyperbilirubinemia groups than
after birth; DDST at 1 year
in Control; 4 of 18 in Severe
Moderate, Severe groups

based on peak TSB
group had poor motor skill and 1

out
of
had
generalized
hypotonia
Ozmert E
102 term infants
VEP
recruited retrospectively, age
No difference in latencies of
(1996)
divided into 5 groups
BAEP
range=8 to 13 years
VEP and BAEP; Coombs
based on peak SIB
WISC-RT
test positive groups had lower IQ
and Coombs test
scores and more prominent

neurrologic abnormalities; 9 with
prominent
neurologic
abnormalities associated with

abnormal BAEP; duration of SIB
level more than 342mol/L was
a risk factor
Chen WX
24 term infants
VEP
Serial VEPs until 2 years old
(2006)
divided into Moderate,
Neurodevelopment ; neurodevelopmental
neurodevelopmental outcome between
and Severe groups
evaluations
groups; 4 had initial abnormal VEP but
evaluations until 3 years
No difference in VEP or
all returned to normal after 2 years old; 1

had
initial
mild
abnormal
neurodevelopment but all were normal

after 3 years of age
VEP: Visual Evoked Potential;

BAEP: Brainstem Auditory Evoked Potential;
DDST: Denver Developmental Screening Test;
WISC-RT: Wechsler intelligence scale for childrenRevised for Turkish Children;
TSB: total serum bilirubin;
SIB: serum indirect bilirubin;
ET: Exchange Transfusion;
IQ: Intelligence Quotient
15
1.7 Treatment
Many variables can affect the severity of neonatal hyperbilirubinemia, making it
difficult to develop a simple algorithm for intervention. For term infants with no
evidence of hemolysis, the American Academy of Pediatrics recommends a guideline
(5) (shown in Table 3) which initiates phototherapy according to a threshold for
serum bilirubin depending on infants age.
Table 3: Management of hyperbilirubinemia in the healthy term newborn (5)

Total serum bilirubin (TSB) Level, mg/dl (
mol/L)
Age,
Hours
_____________________________________________________________________
Consider
Phototherapy
Phototherapy
Exchange transfusion
Exchange transfusion
if intensive phototherapy
and intensive phototherapy
Fails#
#
24
25-48
12 (170)
15 (260)
20 (340)
25 (430)
49-72
15 (260)
18 (310)
25 (430)
30 (510)
>72
17 (290)
20 (340)
25 (430)
30 (510)
______________________________________________________________________________
Phototherapy at these TSB levels is a clinical option, meaning that the intervntion is available and may be used on the basis
of individual clinical judgment.
# Intensive phototherapy should produce a decline of TSB of 1 to 2 mg/dl within 4 to 6 hours and the TSB level should
continue to fall and remain below the threshold level for exchange transfusion. If this does not occur, it is considered a failure
of phototherapy.
Term infants who are clinically jaundiced at 24 hours old are not considered healthy and require further evaluation.
However, this guideline may not apply to worldwide since these values are not based
on large prospective studies. Furthermore, the absence of hemolysis can be difficult
to gauge in the first few days of life. In addition, serum bilirubin levels considered
harmful might vary with ethnic groups or geographic locations (5).
16
Currently no guidelines have been published for preterm infants, but published
recommendations that are based on gestational age, birth weight, and relative health
can be followed (14).
1.7.1 Phototherapy
Phototherapy has remained the standard of care for the treatment of
hyperbilirubinemia in infants for four decades (63). Two factors determine the rate of
lumirubin formation: the spectrum (64) and the total dose of light delivered (65).
Blue lamps (with a wavelength of approximately 450 nm) are most effective in
reducing hyperbilirubinemia (65), but fluorescent white light is the most common
form of phototherapy.
Some ways such as the number of lights, distance from infant, use of double
phototherapy and use of special lights can increase the intensity of the phototherapy,
although in many situations intensive phototherapy is not needed (5). However, if the
serum bilirubin level is still rising despite conventional phototherapy or the serum
bilirubin level of infant hospitalized is within the exchange transfusion range,
intensive phototherapy should be performed pending exchange transfusion (5).
The possibility of delayed effects on growth and development (66-69), vision (70),
and skin abnormalities (71) have been reported for phototherapy, although a
multicenter randomized controlled study published in 1990 concluded that
17
phototherapy can effectively control neonatal hyperbilirubinemia without adverse

outcome at 6 years of age (30).
The pattern of use of phototherapy in full-term infants has changed along with
postpartum discharge practices (72). Intensive phototherapy may eliminate the need
for exchange transfusion (73); however, the neurologic outcome was not assessed in
these few infants, so the safety of this practice has not been established yet (13).
1.7.2 Exchange Transfusion

Exchange transfusion was the first successful therapy for severe neonatal jaundice
(74). This technique rapidly eliminates bilirubin from the circulation and circulating
antibodies that target the erythrocytes. Exchange transfusion is especially beneficial
in infants who have ongoing hemolysis from any cause. Many complications of
exchange transfusions have been reported, including thrombocytopenia, portalvein
thrombosis, necrotizing enterocolitis, electrolyte imbalance, graft-versus-host disease,
and infection (13).
In a recent retrospective study, 2% of 106 infants with a variety of illnesses died after
exchange transfusion, and 12% had severe complications (75). Therefore, exchange
transfusion should be reserved for infants with hemolysis if intensive phototherapy
has failed or if the serum bilirubin concentration is rising at a rate, which suggests
that it will probably reach 25mg/dl (428 mol/L) within 48 hours (5).
18
1.7.3 Approach in Hong Kong
1.7.3.1 Early surveillance and intervention approach
In Queen Mary Hospital of the University of Hong Kong, all full term neonates with
TSB level 15 mg/dl (255 mol/L) receive phototherapy after investigations for
underlying causes have been performed; and exchange transfusion is performed if
TSB level is 20 mg/dl (342 mol/L) or if there is rapid increase in bilirubin level
within 24 hours in infants with hemolytic causes. For those infants with hemolytic
hyperbilirubinemia with a rapid increase in serum bilirubin level, double
phototherapy is given at a serum bilirubin level lower than 20 mg/dl (342 mol/L),
pending exchange transfusion.
1.7.3.2 Monitoring and rehabilitation system
BAEP is performed on all neonates with TSB level 20 mg/dl (342 mol/L) and
regular neurodevelopment is evaluated after discharge. Those with severe neonatal
hyperbilirubinemia will be followed-up regularly and those who may suffer from
neurodevelopmental abnormalities will be referred to multidisciplinary intervention
team including Child neurologist, Developmental pediatrician, Clinical psychologist,
Physiotherapist, Occupation therapist, and Speech therapist for further intervention.
1.8 Current concerns

19
Although kernicterus became much less common owing to the introduction of

exchange transfusion, the incidence of kernicterus has again increased recently in
some areas of the world (76-79). Most of these diagnosed infants did not have
obvious hemolytic disease or another recognized cause of neonatal jaundice. Many
appeared to be otherwise healthy, breastfeeding newborns. A significant proportion
were < 38 weeks gestation (near-term infants) (19).
Despite advances in the treatment of hyperbilirubinemia in recent decades,

neonatologist continue to face the issue of Vigintiphobia (fear of bilirubin level: 20
mg/dl [342 mol/L]) while facing a neonate with increasing trend of
hyperbilirubinemia (80). The treatment of non-hemolytic, hyperbilirubinemic
neonates with bilirubin level 20 mg/dl (342 mol/L) is still controversial (24).
The criteria of total or even unbound serum bilirubin level considered neurotoxic
may vary with ethnic groups. The reasons for ethnic differences in risk of kernicterus
are not clear (5). The different etiologies for different ethnic origins might be
contributory e.g. G-6-PD deficiency is common in the Orientals whereas Rhesus
incompatibility is very rare.
1.9 Objectives:
To date, there is no study regarding the short or long-term effects of
hyperbilirubinemia on auditory brainstem pathway and neurodevelopment in Chinese
20
neonates.
The present study included two sub-studies based on different etiologies as follows:
1. Non-hemolytic study: To evaluate the short and long-term effects of bilirubin on

auditory brainstem pathway and neurodevelopment in Chinese term neonates
with severe non-hemolytic hyperbilirubinemia.
2. Hemolytic study: To evaluate the short and long-term effects of bilirubin on

auditory brainstem pathway and neurodevelopment in Chinese term neonates
with severe hemolytic hyperbilirubinemia.
21
Chapter 2
Subjects and Methods
Chinese full term infants with hyperbilirubinemia born in Queen Mary Hospital of
the University of Hong Kong during 1995-2000 were recruited.
2.1 Inclusion criteria:

1. Indirect hyperbilirubinemia with bilirubin levels above the physiologic values
(above 5 mg/dl [86 mol/L]).
2. Chinese full-term neonates (Birth weight 2500g, and gestational age 37
weeks).
3. Absence of any congenital or metabolic anomalies or any syndromal disorders.
4. Absence of asphyxia, sepsis, meningitis, intracranial hemorrhage or other brain
anomalies.
For Hemolytic hyperbilirubinemia: This condition is due to isoimmunization

diseases (ABO or Rh incompatibility) or Glucose 6 phosphate dehydrogenase
(G-6-PD) deficiency. ABO incompatibility is defined as any blood group A or B
neonates of blood group O mother with or without a positive direct Coombs test
(81).
2.2 Subjects
22
A total of 128 neonates were retrospectively studied and were divided into two
groups based on different etiologies:
1, Non-hemolytic group: Neonates who met inclusion criteria with non-hemolytic

hyperbilirubinemia were recruited as a Non-hemolytic group. A total of 99 cases
were recruited in Non-hemolytic group with average peak TSB of 21 mg/dl (359.7
mol/L) (range=17.5-29.2 mg/dl [300-500 mol/L]).
The severity of non-hemolytic hyperbilirubinemia was classified according to peak

TSB level into three sub-categories: Moderate hyperbilirubinemia (15 to < 20 mg/dl
[257 to < 342 mol/L]), Severe hyperbilirubinemia (20 to < 25 mg/dl [342 to < 428
mol/L]), and Super hyperbilirubinemia 25 mg/dl (428 mol/L). Thus, the 99
cases in the Non-hemolytic group were further divided into three sub-groups based
on severity of hyperbilirubinemia as follows:
Moderate group: Total 30 cases were recruited with average peak TSB level of 18.8
mg/dl (320.7 mol/L) (range=17.5 to < 20 mg/dl [300 to < 342 mol/L])
Severe group: Total 63 cases were recruited with average peak TSB level of 21.6
mg/dl (369.0 mol/L) (range=20 to <25 mg/dl [342 to < 428 mol/L]).
Super group: Total 6 cases were recruited with average peak TSB level of 26.7 mg/dl
23
(range=25-29.2 mg/dl [428-500 mol/L]).
2, Hemolytic group: Neonates who met inclusion criteria with hemolytic

hyperbilirubinemia were included as a Hemolytic group. Total 29 cases were
recruited with average peak TSB level of 20.6 mg/dl (352.6 mol/L)
(range=12.8-37.3 mg/dl [218-637 mol/L]).
2.3 Brainstem auditory evoked potential (BAEP)
2.3.1 Brainstem auditory evoked potential test protocol

BAEP was performed with Nicolet Viking IIIP machine in Neurophysiology
Laboratory, Department of Paediatrics and Adolescent Medicine, Queen Mary
Hospital. BAEP was recorded in a quiet room 2 hours after feeding, with sedation
using chloral hydrate (50 mg/kg) if the neonate could not remain still for the whole
procedure. Silver chloride electrodes filled with conducting paste were applied to the
scalp at the vertex (Cz) and the ipsilateral mastoids (A1/A2) in response to
rarefaction click stimuli presented monaurally at a rate of 1.1 Hz. The bandpass
frequency was 150-3,000 Hz, with speed duration of 10 ms. Impedance was
maintained below 5 k. Two averages, each consisting of 2000 sweeps, were
performed. At least two repeatable waveforms were obtained for each subject. BAEP
protocol consisted of a test at an intensity of 80 dB nHL hearing level. If no
repeatable wave V was present, the intensity was increased by 10 dB nHL steps until
24
a repeatable wave V was detected or until a maximum of 105 dB nHL, the maximum
output of the machine, was reached. If a repeatable response appeared at 80 dB nHL,
the intensity was reduced to 40 dB nHL; and if no response occurred at 40 dB nHL,
the intensity was increased by 10 dB nHL steps until a repeatable wave V was
acquired. As an auditory screening tool, 40 dB nHL was the lowest intensity used in
this study.
2.3.2 Criteria of abnormal brainstem auditory evoked potential

The hearing threshold, latencies of wave I, III, and V, and inter-peak latencies of I-III,
III-V, and I-V were analyzed. On the basis of the results, subjects were classified into
the following types:
Normal: a repeatable wave V detectable at 40 dB nHL and latencies and interpeak
latencies within 2 standard deviations of normal for appropriate age groups of the
authors laboratory.
Abnormal: having conductive or sensorineural hearing impairment or hearing loss:
(i)
Conductive type:
The hearing threshold was above 40 dB nHL; Latencies of
waves I, III and V are increased > 2 standard deviations of age-matched

normal value; and normal inter-peak latencies of I-III, III-V, and I-V.
25
(ii)
Sensorineural type:
The hearing threshold was above 40 dB nHL; normal
latencies and interpeak latencies or increased latencies of wave V and/or III

and increased interpeak latencies I-V, III-V.
(iii)
Hearing Loss:
Only those with elevated threshold were defined as having
hearing loss.
2.3.3 Time of brainstem auditory evoked potential test
Non-hemolytic group:
Initial BAEP test: All 99 children in the Non-hemolytic group had BAEP performed at
an average age of 3.1 months.
Serial BAEPs test: 18 children were evaluated by serial BAEPs until 2 years of age
with a total of 61 tests, and were divided into two sub-groups as follows:
(i)
Abnormal group:
(ii)
Control group:
9 children had abnormal initial BAEP.
9 others with initially normal BAEP were randomly recruited.
Hemolytic group:
26
Initial BAEP test: All 29 children in the Hemolytic group had BAEP performed at an
average age of 3.2 months.
Serial BAEPs test: Serial BAEPs were performed in 3 children with initial abnormal
BAEP until 2 years of age, of which 2 children had 2 BAEPs performed and 1 child
had 5 BAEPs.
2.4 Neurodevelopmental evaluations

All infants recruited had regular physical, neurological, developmental, visual and
auditory evaluation every 3 to 6 months until 3 years of age.
1. The physical, developmental and neurological evaluations were performed by a

Pediatric Neurologist.
2. The
visual
evaluation
including
Visual
Acuity,
Static
Retinoscopy,
Ophthalmoscopy, and Slit-lamp Biomicroscopy were conducted by an

optometrist.
3. The auditory evaluation including Pure Tone Audiometry (PTA), Sound Field
Visual Reinforcement Audiometry (VRA) and Tympanometry were performed by
an audiologist.
2.5 Statistical Analysis

27
2.5.1 Non-hemolytic study:

One-way post-hoc analysis of variance (ANOVA) was used to compare the
demographic data among the Moderate, Severe and Super groups. Students t-test
was used to compare the demographic data between Control and Abnormal groups.
The effect of demographic factors (gender, gestational age, birth weight, peak TSB,
predischarge TSB) on outcome of initial BAEP was analyzed by logistic regression.
Chi-square test was used to compare BAEP and neurodevelopment outcomes among
the Moderate, Severe and Super groups.
2.5.2
Hemolytic study:
Students t-test was used to compare the demographic data between Hemolytic and
Non-hemolytic groups. Chi-square test was used to compare outcomes of BAEP,
neurodevelopment and treatment method between Hemolytic and Non-hemolytic
groups.
All analyses were conducted using SPSS 11.5.1 software. A P value of < 0.05 was
regarded as significant.
28
Chapter 3
Results
3.1 Non-hemolytic cohort

The demographic data of children with non-hemolytic hyperbilirubinemia is shown
in Table 4. There was no significant difference in demographic data among the
Moderate, Severe and Super groups except for the peak TSB (P<0.05). The
Abnormal and Control groups were also not statistically different with regard to
demographic data (P>0.05).
All subjects in the study received phototherapy with 3 individuals (3%) receiving
exchange transfusion (2 in Severe group; 1 in Super group). None of the infants
receiving
exchange
transfusion
had
abnormal
outcome
in
BAEP
or
neurodevelopment during regular follow-up.
Three infants (3%) were readmitted due to rebound of bilirubin (2 in Moderate group;
1 in Super group).
3.1.2.1 Initial BAEP outcomes:
29
The initial BAEP outcome of 99 children of average age 3.1 months (range=1-9
months) is shown in Figure 2. Nine (9.1%) out of 99 children had abnormal BAEP at
initial assessment.
The logistic regression analysis of effect of various demographic factors (gender,

gestation age, birth weight, peak TSB, and predischarge TSB [for 3 readmitted cases,
the predischarge TSB level at first admission was adopted for statistics]) on BAEP is
shown in Table 5. The abnormalities in BAEP were not associated with any
demographic factors (P>0.05).
The comparison of BAEP outcomes among the Moderate, Severe and Super groups
is shown in Table 6. There was no significant difference in the rate of initial BAEP
abnormalities between Moderate (10%), Severe (7.9%) and Super groups (16.7%)
(P>0.05).
3.1.2.2 Serial BAEPs Outcomes:
The distribution of serial BAEP tests for a total of 61 tests based on age is shown in
Figure 3. The outcome of BAEP of 9 children in Abnormal group returned to normal
after 2 years of age except for 2 cases in Severe group with slightly elevated hearing
threshold (50 dB nHL) while 9 others in Control group remained normal throughout
the study.
30
3.1.3 Outcomes of Neurodevelopment

The comparison of neurodevelopment among the Moderate, Severe and Super groups
is shown in Table 6. There was no significant difference in the rate of abnormalities
of neurodevelopment among the Moderate (3.3%), Severe (1.6%) and Super (0%)
groups (P>0.05).
All children except 2 had normal neurodevelopment over 3-year serial evaluations.
Two cases (1 in Moderate group; 1 in Severe group) with initial normal BAEP had
mild motor delay and hypotonia at age of 3 months but they returned to normal at
age of 6 months and 11 months respectively.

No abnormal effect of phototherapy on skin or vision was found in all 99 babies with
non-hemolytic hyperbilirubinemia up to 3 years of age. In addition, no any adverse
effects of phototherapy on neurodevelopment after the age of 11 months was found
as the neurodevelopment was normal in our non-hemolytic cohort by that age.
31
Table 4: Demographic data of children with non-hemolytic hyperbilirubinaemia
Group
Number
Gender
Gestation
Birth weight
Peak TSB
Predischarge TSB BAEP Test
(M/F)
(Weeks)
(g)
(
mol/L)
(
mol/L)
(Months)
(MSD)
(MSD)
(MSD)
(MSD)
(MSD)
All
99
60/39
38.711.38 3171.2393.2
359.737.4
196.225.2
3.11.8
Moderate
30
18/12
38.351.67 3095.7372.4
320.712.6
198.822.9
3.01.6
Severe
63
38/25
38.861.21 3181.8399.7
369.018.3
195.826.7
3.22.0
Super
4/2
38.921.23 3438.3351.4
457.228.0
188.022.2
2.71.8
P>0.05#
P<0.05#
P>0.05#
P>0.05#
P value
P>0.05#
Comparison of serial BAEP in 18 children:
Control
3/6
39.11.65 3087.8403.2
330.620.8
207.629.4
Abnormal 9
6/3
38.70.89 3202.8430.6
361.041.8
184.624.9
P>0.05
P>0.05
P>0.05
P value
P>0.05
#: Between groups
M/F: Male/Female
MSD: Mean Standard deviation
32
Table 5: Logistic regression analysis of effect of demographic factors on Brainstem Auditory Evoked Potential
95% C.I. for Expected (
)
Regression
Variables
P value
coefficient (
)
Lower
Upper
Likelihood
Gestation age
Birth weight
Gender
Maximum TSB
Discharged TSB
0.669
0.483
0.808
0.990
0.118
-0.133
0.001
-0.187
0.000
-0.022
0.475
0.999
0.185
0.981
0.952
1.612
1.003
3.730
1.019
1.006
57.652
33
Table 6: Comparison BAEP and Neurodevelopment outcomes of children with non-hemolytic hyperbilirubinaemia
Brainstem Auditory Evoked Potential

Neurodevelopment

Group
Normal
Abnormal
Normal
Abnormal
Moderate
(N=30)
30
30
1#
Severe
(N=63)
58
61
Super
(N=6)
P value
P>0.05
P>0.05
: Between groups.
# : Mild motor delay and hypotonia at 3 month and normal at 6 months.
: Mild motor delay and hypotonia at 3 month and normal at 11 months.
34
Peak total serum levels (mol/L)
35
Figure 3. Serial BAEP tests in Non-hemolytic group (months, total 61 tests)
36
3.2 Hemolytic cohort

The
demographic
data
of
children
with
hemolytic
or
non-hemolytic
hyperbilirubinemia is shown in Table 7. Although there was no significant difference

by the demographic data, the rate of treatment with exchange transfusion was
significantly higher in Hemolytic group (13.8%) than in Non-hemolytic group (3%)
(P <0.05).
All infants in Hemolytic group received phototherapy with 4 receiving exchange

transfusion (2 with G-6-PD deficiency, 1 with Rh incompatibility and 1 with ABO
incompatibility). None of the subjects receiving exchange transfusion had abnormal
outcome in BAEP or neurodevelopment during regular follow-up.
Three infants with ABO incompatibility were readmitted due to rebound of bilirubin.
The readmission rate was higher in Hemolytic group (10.4%) than in Non-hemolytic
group (3%) although with no significant difference between both groups (P>0.05).

Initial BAEP recorded at an average age of 3.2 months (range=1-12 months) in
Hemolytic group (Figure 4) shows that 3 infants (10.4%) had abnormalities,
although 9 subjects (9.1%) in Non-hemolytic group had initial abnormal BAEP
37
(Figure 2). However, all individuals with initial abnormal BAEP in both groups
returned to normal after 2 years of age except for 3 infants with slightly increased
hearing threshold, of whom 1 (3.5%) was in the Hemolytic group with ABO
incompatibility at 60 dB nHL and 2 (2%) were in the Non-hemolytic group at 50 dB
nHL (Figure 3).
The comparison of BAEP outcomes between Hemolytic and Non-hemolytic groups

(Table 8) shows that there were no significant differences in the rate of initial or
serial BAEP abnormalities between the groups.
3.2.3 Outcomes of Neurodevelopment

The outcome of neurodevelopment in children with hemolytic or non-hemolytic
hyperbilirubinemia is shown in Table 8. All children had normal neurodevelopment
over 3-year serial evaluations with the exception of 3 cases (10.4%) (2 with ABO
incompatibility and 1 with G-6-PD deficiency) in Hemolytic group and 2 (2 %) in
Non-hemolytic group, having mild motor delay and hypotonia noted at initial
evaluation. However, all cases with initial abnormal outcomes of neurodevelopment
returned to normal after 2 years of age. None had features of choreoathetoid type of
cerebral palsy.
There was a higher rate of abnormal outcomes of neurodevelopment in Hemolytic

than in Non-hemolytic group although with no significant difference (P=0.08). None
38
of the children with abnormal neurodevelopment in both groups had abnormal initial
BAEP. There was no relationship between abnormal initial BAEP and final
neurodevelopmental outcome.
3.2.4 Etiologic distribution and BAEP or neurodevelopment outcomes

Etiologic distribution and the outcome of BAEP or neurodevelopment in Hemolytic
group are shown in Table 9. There was a higher rate of abnormal BAEP outcomes in
children with ABO incompatibility than those with other etiologies, although the rate
of abnormal neurodevelopment in children with ABO incompatibility (10.5% [2 out
of 19]) was nearly similar to those with G-6-PD deficiency (12.5% [1 out of 8]).
3.2.5
Long-term effects of phototherapy
No abnormal effect of phototherapy on skin or vision was found in all 29 babies with
hemolytic hyperbilirubinemia up to 3 years of age. In addition, no any adverse
effects of phototherapy on neurodevelopment after the age of 24 months was found
as the neurodevelopment was normal in our hemolytic cohort by that age.
39
Table 7: Demographic data of children with hemolytic or nonhemolytic hyperbilirubinemia

Group
Number
Gender
Gestation
Birth weight
Peak TSB
BAEP Test
(M/F)
(Weeks)
(gram)
(
mol/L)
(Months)
(MSD)
(MSD)
(MSD)
(MSD)
Treatment
Readmission
(PT/PT+ET) (Yes/Not)
(MSD)
Hemolytic
29
15/14
39.01.20
3270.6504.3
352.671.0
3.22.2
25/4
4/25
Non-hemolytic
99
60/39
38.711.38 3171.2393.2
359.737.4
3.11.8
96/3
3/96
P>0.05
P>0.05
P>0.05
P>0.05
P<0.05
P>0.05
P value
P>0.05
M/F: Male/Female
MSD: Mean Standard deviation
PT: Phototherapy
ET: Exchange Transfusion
40
Table 8: Comparison of BAEP and neurodevelopment outcomes between Hemolytic and Non-hemolytic groups
BAEP (short-term)
Group
Normal
Abnormal
BAEP (long-term)
Normal
Abnormal
Neurodevelopment
Normal
Abnormal
Hemolytic
26
28
26
3#
90
97
97
(N=29)
Non-hemolytic
(N=99)
P value
P>0.05
P>0.05
P>0.05 (P=0.08)
: Tested at mean age of 3.2 months in Hemolytic group and 3.1 months in Non-hemolytic group respectively
: Tested until 2 years in both groups
# : Mild motor delay and hypotonia at 3 month but normal at 6 months, 11months and 24 months respectively
: Mild motor delay and hypotonia at 3 month but normal at 6 months and 11 months respectively
41
Table 9: Etiologic distribution and BAEP or neurodevelopment outcomes in Hemolytic group

Etiology
Peak TSB
(mol/L)
BAEP (short-term) #
BAEP (long-term)
Neurodevelopment
Normal
Normal
Normal
Abnormal
Abnormal
Abnormal
ABO incompatible
345.3
16
18
17
218
386.6
26
28
26
(N=19)
Rh incompatible
(N=1)
G6PD deficiency
(N=8)
ABO incompatible
355
Combined with
G6PD deficiency
(N=1)
Total
351.3
(N=29)

: Mean
#: Tested at mean age of 3.2 months
: Tested until 2 years
42
Figure 4.
Peak total serum levels (mol/L)
43
Chapter 4
Discussion
4.1
Non-hemolytic
cohort:
Neurophysiological
and
neurodevelopmental outcomes in severe neonatal non-hemolytic

hyperbilirubinemia
Our study has shown that the short and long term neurophysiological (BAEP) and
neurodevelopmental effects of non-hemolytic hyperbilirubinemia in our Chinese
cohort are favorable, if early close surveillance and intervention approach were
followed.
The salient features in our non-hemolytic study included the following: (1) the peak
TSB of neonates recruited was greater than 17.5 mg/dl (300 mol/L); (2) the average
peak TSB of all recruited was above 20 mg/dl (342 mol/L); (3) Etiology is
non-hemolytic in nature; (4) Pure ethnic group was recruited with stringent inclusion
criteria; (5) All were treated by standard phototherapy if TSB was > 15 mg/dl (256
mol/L); (6) Both short-term (BAEP at average age of 3.1 months and
Neurodevelopment at 3 months of age) and long-term (BAEP until 2 years and
Neurodevelopment until 3 years) effects were studied.
44
The studies of short-term effect of non-hemolytic (41-49, 51-53) or hemolytic (50,
52) hyperbilirubinemia on BAEP are summarized in Table 10.
Table 10: Studies of short-term effect of non-hemolytic or hemolytic hyperbilirubinemia on BAEP

Authors/geographic location
BAEP test age
BAEP Outcomes
(Abnormal rate)
Non-hemolytic etiology
Gupta et al 1990 (41)/India
3 months
0/25 (0%)
Sabatino et al 1996 (45)/Italy
3 months
0/48 (0%)
Wong et al 2006 (49)/Hong Kong
3.1 months (mean age)
9/99 (9.1%)
Agrawal et al 1998 (42)/India
2-4 months
7/30 (23.3%)
Sharma et al 2006 (44)/India
2-4 months
7/30 (23.3%)
Gupta et al 1998 (43)/India
6 months
4/60 (6.7%)
Rhee et al 1999 (51)/Korea
6 months
2/11 (18.2%)
Funato et al 1996 (47)/Japan
6 months
2/10 (20%)
Yilmaz et al 2001 (52)/Turkey
6 months
2/22 (9%)
Katona et al 1989 (53)/Hungary
12months
7/39 (17.9%)
Pallotta et al 1984 (46)/Italy
12months
0/23 (0%)
Hosono et al 2002 (48)/Japan
12months
3/58 (5.2%)
6 months
2/22 (9%)
3.2 months (mean age)
3/29 (10.4%)
(Only 5/22 with non-hemolytic etiology)
Hemolytic etiology
Yilmaz et al 2001 (52)/Turkey
(17/22 with hemolytic etiology)
Chen et al 2006 (50)
We did not find any significant relationship between various demographic factors
45
and BAEP outcome using logistic regression analysis (Table 5).
There were few studies that have explored the possible effect of predischarge TSB on
BAEP, although measurement of a serum or transcutaneous bilirubin level of every
infant before discharge has been recommended as a standard screening procedure to
identify the level of risk for severe hyperbilirubinemia (82, 83). The average
predischarge TSB in our study was 11.5 mg/dl (196.2 mol/L), and all were below
14 mg/dl (238 mol/L) with the exception of 1 case with 15.3 mg/dl (262 mol/L)
who was readmitted due to rebound of bilirubin. We did not find any significant
relationship between predischarge TSB and BAEP (Table 5).
Similarly, there was no significant association between the peak TSB and BAEP in
our study (Table 5). Thoma et al. 1986 (54) and Ogun et al. 2003 (55, 56) have also
found no significant correlation between these parameters. However, two Indian
studies (41, 43) reported that neonatal jaundice was associated with significant
transient abnormalities of BAEP.
We evaluated the short-term effect on BAEP in Chinese full-term infants with

non-hemolytic hyperbilirubinmia. A total of 9.1% cases in our study had
abnormalities of initial BAEP at an average age of 3.1 months (Figure 2). An Italian
study (45) recruited 48 term non-hemolytic hyperbilirubinemic infants with peak
TSB of 14 to 26 mg/dl (238 to 442 mol/L). Acute phase BAEPs and serial BAEPs
46
until 3 months of age were performed. The initial BAEP for patient group was
significantly higher than the control group, but post-therapy, none of cases in patient
group had abnormal BAEP, which was interpreted that hyperbilirubinemia can alter
central neurotransmission in auditory brainstem pathways, but the effect was only
transient.
One Indian study (41) reported that none of 25 cases with hyperbilirubinemia had
BAEP abnormalities within 3 months of age follow-up and concluded that a transient
toxic effect of bilirubin on the brainstem. However, other Indian studies (43, 44)
found 4 patients out of 60 (6.7%) (43) and 7 out of 30 (23.3%) (44) had persistent
BAEP abnormalities over 2-4 months (44) or 6 months (43) serial assessments.
Hosono et al. 2002 (48) revealed 3 infants in a study of 58 (5.2%) term infants had
abnormal BAEP in serial tests until 12 months of age, while Katona et al. 1989 (53)
claimed 7 out of 39 (17.9%) had BAEP abnormalities assessed at age of 1 year, with
2 infants of the 7 found suffering serious hearing loss and therefore needing hearing
aid, while 5 others had sub-clinical BAEP changes. Other studies (51, 47) that
recruited a small number of subjects (<11 subjects) reported up to 20% patients with
abnormal BAEP within 6 months follow-up.
In contrast, some studies (42, 46) have explored the effects of moderate instead of
severe hyperbilirubinmia on BAEP. In one Italian study (46), the BAEP of 23
47
subjects was tested at 1 year of age, and no significant difference in the BAEP
outcomes was found between the patient and control groups. They concluded that a
low to moderate degree of hyperbilirubinemia at birth should not be considered a
potential risk factor affecting the auditory brainstem pathways maturation and
functionality. However, another Indian study (42) including 30 full term infants with
moderate hyperbilirubinemia (<15 mg/dl) found 7 infants (23.3%) had abnormal
BAEP over 2-4 months of age assessment.
There was no significant difference in our study among the Moderate, Severe and
Super groups, with regard to the distribution of abnormal BAEP (Table 6). Our study
included some subjects with super hyperbilirubinemia (TSB range=25.3-29.2 mg/dl
[432-500 mol/L]) although only 6 cases were recruited (Table 4). None of them had
BAEP abnormalities, neurodevelopmental sequelae or needed readmission due to
bilirubin rebound with the exception of one infant with abnormal BAEP at age of 2
months but which returned to normal at the age of 5 months. A recent study
(Newman et al 2003) (84) also found no serious neurodevelopmental sequelae in 11
infants with peak TSB equal or above 30 mg/dl (513 mol/L) including one with
peak TSB of 45.5 mg/dl (778.1 mol/L).
4.1.2 Brainstem auditory evoked potential: long-term outcomes in neonatal

We also evaluated the long-term effects of bilirubin on BAEP outcome by serial
48
BAEP assessments until 2 years of age. BAEP was normal for all after the age of 2
years except 2 cases with elevated sub-clinical hearing threshold (50 dB nHL)
(Figure 3). The rate of abnormal BAEP in our Chinese term neonates with
Non-hemolytic severe hyperbilirubinemia until 2 years was only 2%. Thus, the toxic
effects of hyperbilirubinemia on central neurotransmission in auditory brainstem
pathways might be transient.
The studies of long-term effect of non-hemolytic (29, 49, 54-56) or hemolytic (29, 50)
hyperbilirubinemia on BAEP are summarized in Table 11.
Table 11: Studies of long-term effect on BAEP in non-hemolytic or hemolytic hyperbilirubinemia
Authors/geographic location
BAEP test age
BAEP outcomes
(Abnormal rate)
Non-hemolytic etiology
Thoma et al 1986 (54)/Germany
Aged 15-80 months
NA
Ozmert et al 1996 (29)/Turkey
Aged 8-13 years
28/85 (32.9%)
Wong et al 2006 (49)/Hong Kong
Aged 2 years
2/99 (2%)
Ogun et al 2003 (55); Duman et al 2004 (56)/Turkey
Aged 2-6 years
0/30 (0%)
Chen et al 2006 (50)/Hong Kong
Aged 2 years
1/29 (3.5%)
Ozmert et al 1996 (29)/Turkey
Aged 8-13 years
7/17 (41.2%)
(85/102 with non-hemolytic etiology)
Hemolytic etiology
(Only 17/102 with hemolytic etiology)
49
Ogun et al. 2003 (55, 56) prospectively studied the outcomes of BAEP and
neurodevelopment of 30 children aged 2-6 years who were term infant with
non-hemolytic marked hyperbilirubinemia treated by phototherapy only. None had
hearing loss and there was no difference between the study and control groups in
their average BAEP latencies and developmental scores.
Thoma et al.1986 (54) evaluated 85 infants aged from birth to 9 months with
hyperbilirubinemia without kernicterus by BAEP. Thirty-four out of 85 infants aged
between 15 and 80 months were further assessed by serial BAEPs. No significant
correlation was found between serum bilirubin level and BAEP. They conclude that
neonatal hyperbilirubniemia did not affect neonatal hearing function if treated
promptly.
Ozmert et al. 1996 (29) evaluated 102 children aged between 8 and 13 years with
hyperbilirubinemia of 17 to 48 mg/dl (290 to 820 mol/L) during neonatal period, of
which 17 was hemolytic in nature. No significant difference was found between
different severity hyperbilirubinemia groups with regard to average BAEP latencies.
4.1.3 Neurodevelopment in neonatal non-hemolytic hyperbilirubinemia

Our study has shown that all studied cases had normal neurodevelopment over 3-year
serial evaluations with the exception of 2 cases (2 %) with normal BAEP at initial
assessment having mild motor delay and hypotonia at age of 3 months, although all
50
of them returned to normal after 11 months of age (Table 6). BAEP and
neurodevelopmental outcome were not significantly correlated in our study.
One
Italian
study
(45)
also
reported
that
there
was
no
subsequent
neurodevelopmental abnormality for all patients with serial neuropsychological

evaluations over a 3-year follow-up. However, Funato et al. 1996 (47) revealed that
delay in improvement of BAEP abnormalities might be used as an early predictor for
chronic bilirubin encephalopathy. Agrawal et al. 1998 (42) also supposed that serial
BAEP was a useful noninvasive tool to detect neurodevelopmental delay secondary
to neonatal hyperbilirubinemia.
A long-term Turkish study (29) also reported 9 children with neonatal

hyperbilirubinemia with prominent neurological abnormalities having abnormal
BAEP whereas another long-term Turkish study (55, 56) found none had
developmental delay or abnormal neurological findings.
One recent case control study (Newman et al. 2006) (86) recruited 140 infants with
neonatal serum bilirubin levels of at least 25 mg/dl (428 mol/L) and 419 controls
(randomly selected from a cohort of 106,627 term and near term infants in northern
California), reported that there were no cases of kernicterus. Neither crude nor
adjusted scores on cognitive tests differed significantly between the two groups, and
there was no significant difference between groups in the proportion of children with
51
abnormal neurologic findings on physical examination or with documented

diagnoses of neurologic abnormalities (86).
4.2 Hemolytic cohort: Neurophysiological and neurodevelopmental

outcomes in severe neonatal hemolytic hyperbilirubinemia
The exact bilirubin concentration associated with kernicterus in the term infant is
unknown and it varies with ethnic groups, maturation, and the presence of hemolytic
diseases (5, 85). Neonates with hemolytic hyperbilirubinemia can be treated more
aggressively than those with non-hemolytic jaundice since they are more vulnerable
to bilirubin toxicity (21, 24).
No significant difference by demographic data between the Hemolytic and

Non-hemolytic groups was found in our study with the exception of the rate of
treatment with exchange transfusion, which was significantly higher (P<0.05) in the
Hemolytic group (13.8%) than Non-hemolytic group (3%) (Table 7).
Neonatal hyperbilirubinemia is extremely common in Orientals. A close surveillance

of the TSB for high risky neonates in The University of Hong Kong based hospital
was performed, especially for those cases with a rapid increase in TSB level within
the first 24 hours of life, or those blood groups A or B babies born to blood group O
mothers known before delivery, or when the G-6-PD status was known within 24
52
hours using cord blood screening.
A standard interventional approach with phototherapy and even early exchange

transfusion will be implemented if needed. Thus, the rate of neurophysiological
(BAEP) abnormalities and neurodevelopmental abnormalities are only transient, as
shown both in hemolytic and non-hemolytic etiologies.
4.2.1 Brainstem auditory evoked potential: Short-term outcomes in hemolytic

hyperbilirubinemia
In our cohort, there was no significant difference between the groups in the effect of
hyperbilirubinemia on BAEP as 10.4% (Figure 4) in Hemolytic group had abnormal
initial BAEP tests as compared to 9.1% (Figure 2) in Non-hemolytic group.
Yilmaz et al. 2001 (52) reported the short-term effect of hyperbilirubinemia on

BAEP and found 2 cases out of 22 (9 %) with BAEP abnormalities within 6 months
follow-up although only 17 out of 22 had hemolytic hyperbilirubinemia due to Rh or
ABO incompatibility (Table 10).

No significant differences were found in serial BAEP outcomes between Hemolytic
and Non-hemolytic groups in our cohort at 2 years of age. Only 3.5% of cases in
53
Hemolytic group and 2% in Non-hemolytic group had abnormal BAEP with slightly
increased hearing threshold (Table 8).
Ozmert et al. 1996 (29) have also reported no significant difference between
hemolytic and non-hemolytic groups in the average BAEP latencies, although only
17 of 120 cases in their study were with hemolytic etiology (Table 11).
4.2.3 Neurodevelopment in neonatal hemolytic hyperbilirubinemia

All children in our cohort had normal neurodevelopmental outcome over 3-year
serial evaluations with the exception of 10.4% in the Hemolytic group and 2% in the
Non-hemolytic group (Table 8), having minor and transient abnormalities, with mild
motor delay and hypotonia. All children in our cohort with transient abnormal
neurodevelopmental outcome, however, had normal initial BAEP, suggesting that
there is a lack of correlation of initial BAEP and later neurodevelopment outcome.
Yilmaz et al. 2001 (52) also reported that neurological distributions due to bilirubin
neurotoxicity could be seen in those with normal BAEP, but those with abnormal
BAEP might not have any neurological dysfunction apart from speech retardation.
Another Turkish study (29), however, reported 9 children with abnormal BAEP had
prominent neurological abnormalities. They also reported that infants with
isoimmunization were affected dramatically as the IQs of the Coombs-test-positive
54
children were significantly lower than those of infants without isoimmunization (29).
In one case control study, Newman et al. 2006 (86) found that neonates with positive
direct antiglobulin tests had lower scores on cognitive testing but not in neurologic or
behavioral problems.
4.2.4 Etiology in neonatal hemolytic hyperbilirubinemia
4.2.4.1 Rh hemolytic disease of the newborn
Kernicterus was detected in 8% of infants with Rh incompatibility having TSB levels

of 19 to 24 mg/dl (325 to 410 mol/L), 33% of infants with levels of 25 to 29 mg/dl
(428 to 496 mol/L), and 73% of infants with levels of 30 to 40 mg/dl (513 to 684
mol/L) (21).
In one controlled clinical trial conducted on the treatment of hemolytic disease of the
newborn, Mollison et al. 1954 (85) demonstrated beyond reasonable doubt that
exchange transfusion in these infants improved their chance of survival and
decreased the risk of fatal kernicterus.
Rh incompatibility is extremely rare in Chinese and the only one case in our cohort
had exchange transfusion performed at a relatively low TSB level of 12.8 mg/dl (218
mol/L) and the final outcome was normal (Table 9).
55
Johnson et al. 1967 (87) studied 129 infants born in the late 1950s, all of whom had
indirect-reacting serum bilirubin levels higher than 20 mg/dl (342 mol/L).
Ninety-two infants with Rh hemolytic disease were followed over 5-6 years of age
and assessed with detailed psychometric, neurologic and audiologic evaluations. One
subject of 92 had a minimal sensorineural hearing loss and a normal IQ and another
infant had mild athetosis, moderate sensorineural hearing loss, and a normal IQ. Thus,
the risk of bilirubin encephalopathy in their cohort with Rh disease was
approximately 2%.
4.2.4.2 Glucose-6-Phosphate Dehydrogenase deficiency
G-6-PD deficiency occurs in 11% to 13% Blacks and is more common among
immigrants from the Mediterranean countries and Southeast Asia (88). G-6-PD
deficiency is common in Chinese.
Lai et al. 1968 (11) reported that G-6-PD deficiency accounts for 15.4% of 117 cases
of neonatal jaundice recruited in their study, and the relative importance of G-6-PD
deficiency as a cause of neonatal jaundice does not differ materially in male and
female mutants. Neonatal jaundice can occur in all genotypes of G-6-PD mutation in
Chinese (11).
Eight cases with G-6-PD deficiency (1 out of 8 with the maximum peak TSB level of
56
37.3 mg/dl [637 mol/L] in our cohort) were recruited in our study. All had normal
BAEP or neurodevelopment outcome except 1 with transient hypotonia and motor
delay (Table 9).
In the United States cases with Kernicterus due to G-6-PD deficiency have been
reported (19, 76). In a recent report, G-6-PD deficiency was considered to be the
cause of hyperbilirubinemia in 19 of 61 (31.5%) infants who developed kernicterus
(79).
4.2.4.3 ABO Hemolytic Disease of the newborn
Approximately 45% of Americans of western European descent have type O blood,

and a similar percentage is type A, with types B and AB making up the balance.
African Americans are 50% type O, 29% type A, 17% type B, and 4% AB (89).
Hemolytic disease related to ABO incompatibility is generally limited to group A or
B infants born to group O mothers, and it tends to run in families. One study found
an 88% risk of recurrence of ABO hemolytic disease in ABO incompatible newborns
born to parents whose first-born child was similarly affected (90).
Feng et al.1990 (12) found that only two combinations (O-A and O-B mother-infant
pairs) in a group of Hong Kong babies with severe neonatal jaundice were
responsible for ABO hemolytic disease of the newborn, for which the incidence was
1 in 5 among infants with a serum bilirubin level of 17.5 mg/dl (300 mol/L) or
57
more.
Many hospitals are no longer performing routine blood typing in infants of group O
mothers so that the ABO status of the infant is often unknown (88). In Contrast,
Queen Mary Hospital of The University of Hong Kong routinely performs blood
grouping for all neonates, so that babies with group O mothers are monitored
regularly.
There was a higher rate of abnormal BAEP outcomes in children with ABO
incompatibility than those with other etiologies in our study, although the rate of
abnormal neurodevelopment in children with ABO incompatibility (10.5% [2 out of
19]) was nearly similar to those with G-6-PD deficiency (12.5% [1 out of 8]) (Table
9).
It is, however, difficult to interpret the BAEP or Neurodevelopmental outcomes

between different etiologic groups in our hemolytic study since those with ABO
incompatibility accounted for approximately 70% of all cases compared with only 1
case with Rh incompatibility in our Hemolytic cohort (Table 9).
In fact, it is difficult to define the risk of abnormal outcome in infants with hemolysis
from causes such as red cell membrane defects and G-6-PD deficiency, although the
risk of bilirubin encephalopathy in G-6-PD deficiency appears to be similar to that of
58
Rh hemolytic disease (91).
Two children with ABO incompatibility in our cohort had only transiently mild
neurodevelopmental abnormality although 1 had slightly increased hearing threshold
until 2 years of age. The good prognosis in our hemolytic ABO incompatibility
cohort might be due to our aggressive early intervention protocol.
4.2.4.4 ABO incompatibility combined with G-6-PD deficiency
We had one case with hyperbilirubinemia due to ABO incompatibility and G-6-PD
deficiency, and the outcome was normal. Other studies (92, 93) have also not found
an additive effect of ABO blood group incompatibility on G-6-PD deficiency. Kaplan
et al.1998 (81) compared combined ABO incompatibility with G-6-PD deficiency
neonates to those with either condition alone and did not find an increased risk for
hemolysis.
4.3 Phototherapy in neonatal hyperbilirubinemia

Phototherapy is useful for the acute management of neonatal hyperbilirubinemia,
although some studies (66-71) have reported possible various adverse effects. Other
studies (30, 94) including multicenter randomized controlled study (30) published in
1990 have, however, concluded that phototherapy can effectively control neonatal
hyperbilirubinemia without adverse outcome at 6 years and is at least as effective as
exchange transfusion alone.
59
Intensive phototherapy may eliminate the need for exchange transfusion (73).
However, the neurologic outcome was not assessed in these few infants, so the safety
of this practice has not been established (13).
In fact, the main aim of our study was to evaluate the effects of bilirubin on BAEP
and neurodevelopment, and we could not exclude the possible influence of
phototherapy as all neonates in our study had phototherapy (and some received
intensive phototherapy). However, we did not find any adverse effects of
phototherapy on neurodevelopment after the age of 24 months as the
neurodevelopment was normal in both non-hemolytic and hemolytic cohorts.
In addition, 3 infants in the non-hemolytic cohort and 4 in the hemolytic cohort

additionally had exchange transfusion and none showed abnormal outcome after 24
months of age.
4.4 Limitation and future research

There are three main limitations to our study. One limitation is that we did not have
any untreated cases as a control group due to ethical reasons, although few studies
(30, 85, 86) have recruited control cases.
A second limitation was that we did not explore the relationship between the
60
outcome of BAEP or neurodevelopment and the duration of exposure to

hyperbilirubinemia, since the level of bilirubin in the brain and the duration of
exposure to bilirubin are both important determinants of the neurotoxic effects of
bilirubin.
Additionally, the current research did not study the relationship between the outcome
of BAEP or neurodevelopment and the unconjugated bilirubin level. The relationship
between unconjugated bilirubin level and abnormalities in the BAEP have been
found in some studies (95, 96, 97, 98) with some (97, 98) reporting more reliable
correlations between abnormalities of BAEP and unconjugated bilirubin level than of
TSB level.
A third limitation of our study is that we did not perform psychometric assessments
such as IQ test for recruited cases as children with transient auditory neuropathy and
BAEP abnormalities may be at risk for later developing central auditory processing
disorders (99).
It is recommended that a future study be carried out on the children recruited in the
current study to further evaluate the more long-time effects of hyperbilirubinemia on
neurophysiological and neurodevelopmental outcomes, especially for those who had
suffered from abnormalities either in BAEP or in neurodevelopment.
61
More evaluations including psychometric assessments are recommended for future

research.
4.5 Conclusion:
Although the incidence of kernicterus has again increased in some areas of the world
recently, our study found that the toxic effects of hyperbilirubinemia on auditory
brainstem pathways and neurodevelopment in Chinese term neonates with
non-hemolytic or hemolytic hyperbilirubinmia were transient and mild, with the
exception of a slightly raised BAEP threshold. The optimistic prognosis in our severe
non-hemolytic or hemolytic hyperbilirubinmic cohort might be due to our early
intervention approach.
Although BAEP is a useful neurophysiological tool for monitoring for possible

neurological complications, it is not a useful tool to predict final neurological
outcome.
Although we do not have untreated cases as a control group due to ethical reasons,
we did find that by adopting early surveillance and intervention approach to neonatal
non-hemolytic or hemolytic hyperbilirubinemia, kernicterus can be prevented.
62
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Title

Neonatal hyperbilirubinemia: long-term neurophysiological and

The author retains all proprietary rights, (such as patent rights)

Abstract of dissertation entitled

Neonatal hyperbilirubinemia: Neurophysiological and

For the Degree of Master of Philosophy at The University of Hong Kong

Objective: To evaluate the effects of bilirubin on auditory brainstem pathway and

Subject and Methods:

The initial brainstem auditory evoked potential (BAEP) was recorded in

Initial BAEP abnormalities occurred in 9 (9.1%) subjects from the Non-hemolytic

All subjects had normal neurodevelopment at initial assessment except 5 individuals

Conclusion: The toxic effects of bilirubin on auditory brainstem pathway and

(Total words: 484)

Neonatal hyperbilirubinemia: Neurophysiological

CHEN Wen Xiong

A dissertation submitted in partial fulfillment of the requirements for the Degree of

I would like to take this opportunity to express my sincere gratitude to my supervisors,

List of Tables and Figures

1.3 Bilirubin physiology

1.4 Risk factors

1.5 Bilirubin toxicity

1.5.1 Cellular toxicity

1.5.2.1 Etiology: Non-hemolytic and hemolytic

1.5.2.2 Clinical features

1.6.1 Brainstem auditory evoked potential (BAEP)

1.6.2 Visual evoked potential (VEP)

1.7.2 Exchange transfusion

1.7.3 Approach in Hong Kong

1.7.3.1 Early surveillance and intervention approach

1.7.3.2 Monitoring and rehabilitation system

1.8. Current concerns

Chapter 2 Subjects and Methods

2.3 Brainstem auditory evoked potential (BAEP)

2.3.1 Brainstem auditory evoked potential test protocol

2.3.2 Criteria of abnormal brainstem auditory evoked potential

2.3.3 Time of brainstem auditory evoked potential test

2.4 Neurodevelopmental evaluations

2.5 Statistical Analysis

2.5.1 Non-hemolytic study

2.5.2 Hemolytic study

3.1.1 Demographic data

3.1.2 Outcomes of brainstem auditory evoked potential

3.1.2.1 Initial BAEP outcomes

3.1.2.2 Serial BAEP outcomes

3.1.3 Outcomes of neurodevelopment

3.1.4 Long-term effects of phototherapy

3.2 Hemolytic cohort

3.2.2 Outcomes of brainstem auditory evoked potential

3.2.3 Outcomes of neurodevelopment

3.2.4 Etiologic distribution and BAEP or neurodevelopment outcomes

3.2.5 Long-term effects of phototherapy

4.1.1 Brainstem auditory evoked potential: Short-term outcomes in neonatal

4.1.2 Brainstem auditory evoked potential: Long-term outcomes in neonatal

4.1.3 Neurodevelopment in neonatal non-hemolytic hyperbilirubinemia

4.2 Hemolytic cohort: Neurophysiological and neurodevelopmental outcomes in

4.2.1 Brainstem auditory evoked potential: Short-term outcomes in neonatal

4.2.2 Brainstem auditory evoked potential: Long-term outcomes in neonatal

4.2.3 Neurodevelopment in neonatal hemolytic hyperbilirubinemia

4.2.4 Etiology in neonatal hemolytic hyperbilirubinemia

4.2.4.1 Rh hemolytic disease of the newborn

4.2.4.2 Glucose-6-Phosphate Dehydrogenase deficiency

4.2.4.3 ABO hemolytic disease of the newborn

4.2.4.4 ABO incompatibility combined with G-6-PD deficiency

4.3 Phototherapy in neonatal hyperbilirubinemia