Inadequate Documentation and Follow-Up Alleged for Infant’s Irreversible Brain Damage

Allegation 

Pediatrician violated the standard of care by failing to document jaundice and hyperbilirubinemia at discharge and failing to provide appropriate follow up. 

Case Details 

A 6 lb, 7 oz. male infant was born via spontaneous vaginal delivery at 38 5/7 weeks. At 37 hours old, the newborn’s total bilirubin was 9.6 (1.0-10.5) and direct bilirubin was 0.3 (0-1.3.) The infant weighed 6 lb, 4 oz. with a transcutaneous bilirubin of 11.6. The defendant pediatrician noted the infant's risk levels for developing complications from elevated bilirubin were in the high-intermediate range. Absent other risk factors, the infant did not require additional treatment. Later that day, he was breast feeding well and was discharged home with instructions to the mother to notify the doctor if the infant was yellow or had poor feeding, decreased activity, white stools, dark urine, or no wet diapers. The pediatrician allegedly instructed the mother to call in three days to provide a report on how the infant was doing; however, this was not documented. The discharge summary noted that the mother was to call to set up an appointment in a week. 

Two days after discharge, the mother noticed the baby was not eating well, was sleepy, had one episode of emesis and had not voided in several hours. The infant was taken to the hospital at approximately 96 hours old with a total bilirubin of 38.9 and a direct bilirubin of 4.4. A CBC and BMP were reassuring. An IV was placed and IV fluids were initiated. 

The following day, the infant was transferred to the NICU at a local children’s hospital for further care. The infant was hypertonic with a high-pitched cry. The infant received an exchange transfusion and phototherapy before the total and direct bilirubin began trending downward. A head ultrasound showed no bleeds and he had intermittent tachycardia that was not associated with crying. A subsequent MRI showed symmetric, bilateral T1 hyperintensity in the globus pallidus, which was compatible with bilirubin encephalopathy. The MRI also showed diffuse excessive high T2 signal in the bihemispheric white matter. The patient received PT and OT during this admission. The remainder of the NICU course was remarkable for E. Coli sepsis and septic ileus. 

After discharge from the NICU, repeat testing confirmed the diagnosis of glucose-6-phosphate-dehydrogenase deficiency (G6PD). Neurology noted the patient had kernicterus and hypertonia with dystonic posturing of the extremities. The patient also suffered from bilateral auditory neuropathy spectrum, cholestasis, cerebral palsy, developmental delay, exotropia, failure to thrive, hyperbilirubinemia, hypertonia, inguinal hernia, nasal congestion, and vitamin D & E deficiency. The patient needed aggressive PT and OT and he was started on gabapentin to improve his tone. 

Over the course of the next two and a half years, the child was diagnosed with a myriad of conditions, including oropharyngeal dysphagia, an ileus, generalized dystonia and athetosis, severe global developmental delay, and bilateral hearing impairment. 

At age 2 years 11 months, the patient was unable to roll over in any direction with poor head control and did not reach for objects. Language was limited to babbling. The patient continued to demonstrate athetosis and would need a gait trainer and wheelchair for school. Otolaryngology recommended a tonsillectomy, possible revision adenoidectomy, laryngoscopy, bronchoscopy, and possible supraglottoplasty for treatment of severe obstructive sleep apnea. 

At age 3 YO, the patient was hospitalized with apparent seizures. A continuous EEG showed these were very severe dystonic episodes. An MRI of the brain showed bilateral mesial temporal sclerosis, diffuse symmetric bilateral cerebral volume loss, and diffuse increased T2 signal intensity in bilateral globus pallidus consistent with chronic injury. 

Expert Testimony 

Experts for the plaintiff stated the pediatrician failed to institute proper follow-up upon discharge as the infant should have been seen within 24 hours of discharge. One expert opined that the pediatrician failed to properly investigate the cause of the child’s elevated bilirubin value. The same expert also noted that, had the child been seen within 24 hours, jaundice would not have progressed and there would have been an opportunity for intervention and to avoid irreversible brain damage. 

Several defense experts took the position that the defendant physician’s treatment fell within the standard of care. The patient did not have any particular risk factors for developing hyperbilirubinemia, as the patient fell on the line between low-intermediate risk zone and high-intermediate risk zone. Defense experts also noted that the patient was below the levels for phototherapy based on his serum bilirubin. One expert opined that it was appropriate for the defendant physician to follow up early the next week and the patient’s mother was given clear instructions on what symptoms would suggest hyperbilirubinemia. 

Resolution 

The case was settled for an undisclosed amount. 

Risk Reduction Strategies 

From a risk management standpoint, an emphasis on documentation and follow-up within the first two days after birth can improve claim defensibility. This is especially true with patients who present with recognized risk factors. 

The American Academy of Pediatric Guidelines was drafted to reduce the incidence of severe hyperbilirubinemia and bilirubin encephalopathy while minimizing the risks of unintended harm. Risk factors include a pre-discharge TcB level in the high-risk zone, exclusive breastfeeding, male gender, and black race, all of which this infant had. 

Additionally, the Journal of Pediatrics states most infants discharged at less than 72 hours should be seen within two days of discharge. Earlier follow-up might be necessary for infants who have risk factors for severe hyperbilirubinemia. 

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