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Exchange transfusion is recommended for newborns with total serum bilirubin TSB levels thought to place them at risk for cerebral palsy CP However the excess risk for CP among these infants is unknown To quantify the risks for CP and CP consistent with kernicterus that are associated with high TSB levels based on the 2004 American Academy of Pediatrics exchange transfusion threshold ETT guidelines We enrolled 2 cohorts from a population of 525 409 infants in the Late Impact of Getting Hyperbilirubinemia or Phototherapy LIGHT birth cohort Eligible infants were born at a gestational age of at least 35 weeks at 15 hospitals within the Kaiser Permanente Northern California integrated medical care delivery system from January 1 1995 through December 31 2011 The exposed cohort included all 1833 infants with at least 1 TSB measurement at or above the ETT based on age at testing gestational age and results of direct antiglobulin testing The unexposed cohort was a 20 random sample of 104 716 infants with TSB levels below the ETT A pediatric neurologist blinded to the TSB levels reviewed medical records to determine the presence of CP defined as a nonprogressive congenital motor dysfunction with hypertonia or dyskinesia Cerebral palsy was judged to be consistent with kernicterus if magnetic resonance imaging of the brain revealed bilateral globus pallidus injury in the setting of dyskinetic CP We identified CP in 7 of 1833 exposed 0 4 vs 86 of 104 716 unexposed 0 1 infants relative risk 4 7 95 CI 2 2-10 0 Absolute risk differences were 0 2 95 CI 0 -0 5 for a TSB level 0 to 4 9 mg dL above the ETT n 1705 0 9 95 CI 0 1 -5 3 for a TSB level 5 0 to 9 9 mg dL above the ETT n 102 and 7 6 95 CI 2 1 -24 1 for a TSB level 10 mg dL or more above the ETT n 26 Cerebral palsy consistent with kernicterus occurred in 3 infants incidence 0 57 per 100 000 births all 3 had TSB levels of more than 5 0 mg dL above the ETT and at least 2 risk factors for neurotoxicity such as prematurity glucose-6-phosphate dehydrogenase deficiency or hypoxia-ischemia Cerebral palsy consistent with kernicterus occurred only in infants with 2 or more risk factors for neurotoxicity and TSB levels of more than 5 mg dL above the ETT Among infants with lower degrees of TSB level elevation the excess risk for CP is minimal

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Risk for cerebral palsy in infants with total serum bilirubin levels at or above the exchange transfusion threshold: a p...