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Neonatal

Hyperbilirubinemia

and Physical

and

Cognitive

Performance

at 17 Years

of Age

Daniel

S. Seidman,

MD*;

Ido Paz,

BMScf;

David

K. Stevenson,

MD;

Arie

Laor,

MD, MScII;

Yehuda

L. Danon,

MDI!

II

;

and Rena

Gale,

MD*

From the *Depment of Obstetrics and Gynecology, Sheba Medical Center,

Tel-Hashomer, Israel; the epartment of Neonatology, Bikur Cholim Hospital, Jerusalem, Israel; the IlDivision of Pediatric Immunology, Beleinson Medical Center, Sackler School of Medicine, Tel-Aviv University, Israel; the #{182}MedicalStatistics Branch, Israel Defence Forces Corps; the §Department of Pediatrics, Stanford University School of Medicine, Stanford, California

ABSTRACT. To estimate the effect of neonatal hyperbil-irubinemia on long-term cognitive ability in full-term newborns with a negative Coombs test, we performed a

17-year historical prospective study of 1948 subjects.

Intelligence tests and medical examinations performed

at the military draft board were stratified according to serum bilirubin concentration. A logistic regression

analysis was used to adjust for the confounding effects of gestational age, birth weight, Apgar score, ethnic origin,

socioeconomic class, paternal education, birth order, and the administration of phototherapy and exchange

trans-fusion. No direct linear association was shown between neonatal bilirubin levels and intelligence test scores or school achievement at 17 years of age. However, the risk for low intelligence test scores (IQ score <85) was found

to be significantly higher (P = .014) among full-term male subjects with serum bilirubin levels above 342 zmol/ L (20 mg/dL) (odds ratio, 2.96; 95% confidence interval, 1.29-6.79). This association was not observed among

female subjects. We conclude that severe neonatal hyper-bilirubinemia, among full-term male newborns with a negative Coombs test, could be associated with lower IQ

scores at 17 years of age. Pediatrics 1991;88:828-833;

neonatal hyperbilirubinemia, jaundice, long-term outcome,

cognitive performance, intelligence test scores.

data on the subtle, long-term neurologic conse-quences of neonatal jaundice is needed as tradi-tional action levels for treatment are ques-tioned.46 The few studies currently available ex-amining the association between neonatal bilirubin concentration and cognitive outcome have been limited either by a short follow-up period7’#{176} or by

the small number of subjects studied.’1’12

We have matched data from the neonatal medical records of neonates born at a single maternity ward

in Jerusalem between November 1970 and

Decem-ber 1971 with their medical examination records and intelligence test scores at the age of 17 years at the military draft board. The aim of the present

study was to examine the effect of increased serum

bilirubin levels in full-term newborns with a nega-tive Coombs test on growth parameters, general health, and cognitive performance at 17 years of age.

METHODS

Hyperbilirubinemia is diagnosed frequently dur-ing the neonatal period. Recent studies have drawn

attention to the fact that little evidence exists to

support a significant effect of bilirubin in full-term neonates with nonhemolytic jaundice.’3 Therefore,

Received for publication Oct 15, 1990; accepted Jan 28, 1991. Reprint requests to (D.S.S.) Dept of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer 52621, Israel.

PEDIATRICS (ISSN 0031 4005). Copyright © 1991 by the American Academy of Pediatrics.

The study population included all subjects born

at the Hadassah Hebrew University Medical

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ARTICLES

829

weight, gestational age, 1-minute and 5-minute Ap-gar scores, bilirubin determinations performed when there was a clinical indication, jaundice work-up when undertaken, and type and duration of treatment administered. Only singletons were

in-cluded in this study.

Intelligence test scores and findings of physical examination at 17 years of age, as well as detailed

demographic data, were available from the comput-erized records of the Israel Defence Forces draft

medical examination. The intelligence test scores were determined by a translated version of the

verbal Otis test and a version of a nonverbal mat-rices test.15 The intelligence test scores presented

were transformed into values that correlate with

the Wechsler Adult Intelligence Scale (WAIS), the most widely used intelligence test for adults. The examiners were blinded to the subjects’ neonatal

data.

The general physique of the subjects and the

function of their various organs were assessed and

expressed in a numerical scale or health profile. Impaired function of a certain organ could include abnormalities of both acquired and genetic etiology. Although the severity of each health profile

cate-gory was subdivided into seven classes, these were

not considered in the present study to simplify the

analysis. The data for each individual were matched using an eight-digit identification number. The completeness of the match was confirmed by com-paring sex, maternal identity number, and date of birth.

The subjects were divided into three groups: mild,

moderate, and severe bilirubinemia.

“Nonphysio-logic” hyperbilirubinemia was defined following the most commonly accepted guidelines.’6 Subjects who

did not seem jaundiced clinically and for whom

bilirubin measurements were not obtained were included in the mild bilirubinemia group. Moderate

bilirubinemia was defined as total serum bilirubin

levels of 86 to 137 zmol/L (5 to 8 mg/dL) on the first day of life, 171 to 256 1umol/L (10 to 15 mgI

dL) on the second day of life, or 223 to 342 jmol/L

(13 to 20 mg/dL) thereafter. Severe bilirubinemia was defined as total serum bilirubin level exceeding

137 tmol/L (8 mg/dL) on the first day of life, 256

jmol/L (15 mg/dL) on the second day of life, and 342 j.mol/L (20 mg/dL) thereafter.

Mean intelligence scores presented as IQ-equiv-alent scores were calculated for each bilirubin cat-egory. The distribution of the test results were determined for the mild, moderate, and severe bil-irubin groups. The data were examined separately for each sex.

A multiple linear regression analysis with the REG procedure of the SAS software17 was

per-formed to adjust for the effect of the independent variables studied. Least square means were deter-mined by this method. The intelligence test score was used as the dependent variable.

The independent variables used in the analysis were bilirubin group, phototherapy, exchange transfusion, birth weight (500-g categories from

<2500 g to 4500 g), gestational age, 5-minute

Apgar scores, ethnic origin (defined according to paternal country of birth), social class (determined by area of residence, classified according to munic-ipal tax level13), paternal educational attainment

(years of schooling), and birth order. All variables which were significant at the .05 level were added

to the regression model.

To determine the independent relationship be-tween hyperbilirubinemia and low cognitive ability

(IQ test scores of <85) while simultaneously

con-trolling for all other factors, a logistic regression

analysis was used. The LOGIST procedure of the

SAS software17 was performed by a stepwise method to adjust for the effect of the independent variables studied. The results of the logistic regres-sions are presented as adjusted odds ratios and their 95% confidence intervals (ie, e#{176}6 S, where b is the

logistic regression coefficient and S is the estimated standard error).

RESULTS

Bilirubin values were obtained in 585 (30.0%) of the 1948 infants included in the study. Based on the definition described under “Methods,” 308

(15.8%) infants had moderate hyperbilirubinemia and 144 (7.4%) had severe hyperbilirubinemia. Be-cause icterus is normally visible during neonatal life only when serum bilirubin levels reach 119

.tmol/L (7 mg/dL)’8 the normal control group

prob-ably included some subjects with undetected

mod-erate hyperbilirubinemia. The population charac-teristics of the three bilirubin groups are described in Tables 1 and 2.

The mean intelligence test scores at 17 years of age by hyperbilirubinemia group are presented in Table 3. The mean IQ score was significantly lower

(P < .03) only for the male subjects that were found to have severe neonatal hyperbilirubinemia. How-ever, after either excluding preterm newborns or adjusting by a linear regression analysis for the possible confounding effect of birth weight, gesta-tional age, 5-minute Apgar score, ethnic origin,

birth order, paternal education, and social class, no

significant effect of hyperbilirubinemia on IQ test

scores could be demonstrated for either sex (Table

3). Thirty-three percent ofthe variance in IQ scores among male subjects and 30% among female

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TABLE 1. Percent Distrib

gonies and Sex

ution of Study Popu lation Ch aracteri stics by Bili rubin

Cate-Bilirubin Category* Male Female

Mild Moderate Severe Mild Moderate Severe

Number 762 184 85 734 124 59

Ethnic origin

Israel 13 8 13 11 7 6

Asia 18 25 29 20 24 30

Euro-America 43 43 37 42 48 34

Africa 26 24 21 27 22 30

Birth weight, g

<2500 9 10 10 6 3 10

2500-4000 g 88 83 86 91 86 78

>4000g 3 7 4 3 11 12

Gestational age, wk

<37 7 18 25 8 22 33

37-40 71 71 65 66 65 53

>40 22 11 10 26 13 14

Paternal education, y

<9 21 20 27 18 16 23

9-12 40 42 43 45 44 41

>12 39 38 30 37 40 36

* See definition in text under “Methods.”

TABLE 2. Characteristi cs of Study Po pulation by Bili rubin Categor ies and Sex (me an ± SE)

Bilirubin Category* Male Female

Mild Moderate Severe Mild Moderate Severe

Number 762 184 85 734 124 59

Birth weight, g 3457 ± 17 3390 ± 42 3390 ± 56 3339 ± 0.2 3171 ± 53 3236 ± 78

Gestational age, wk 39.5 ± 0.06 38.7 ± 0.1 38.5 ± 0.2 39.6 ± 0.1 38.4 ± 0.2 38.4 ± 0.3

Apgar score

1mm 8.6 ± 0.1 8.7 ± 0.1 8.6 ± 0.2 8.8 ± 0.1 8.8 ± 0.1 8.4 ± 0.2

5 mm 8.9 ± 0.1 8.9 ± 0.9 8.9 ± 0.3 8.9 ± 0.1 8.9 ± 0.1 8.7 ± 0.2

Paternal education, y 12.3 ± 0.2 12.3 ± 0.3 11.7 ± 0.4 12.3 ± 0.1 12.6 ± 0.4 12.1 ± 0.5

Social class (1, high; 6, 3.9 ± 0.1 3.9 ± 0.1 3.7 ± 0.2 3.8 ± 0.1 3.7 ± 0.2 3.8 ± 0.2 low)

Birth order 2.3 ± 0.1 2.2 ± 0.1 2.5 ± 0.2 2.2 ± 0.1 2.2 ± 0.1 2.2 ± 0.2

Body mass index, kg/rn2 21.2 ± 0.1 21.2 ± 0.1 20.9 ± 0.2 21.1 ± 0.1 21.0 ± 0.3 21.4 ± 0.4

* See definition in text under “Methods.”

:1:P < .05; Tukey student’s range test; compared with the bilirubin category.

TABLE 3. Intelligence Test Scores at 17 Years of Age by Neonatal Bilirubin Categories

and Sex*

Bilirubin Cate-gonies

N Mean ± SE Means ± SE Adjusted

Mean ± SE

Adjusted Mean ± SE

Male

Mild 762 108.5 ± 0.5 109.5 ± 0.5 102.8 ± 2.5 105.2 ± 1.7

Moderate 184 108.9 ± 1.1 109.3 ± 1.0 103.0 ± 2.6 105.5 ± 1.9

Severe 85 105.1 ± 1.5! 106.5 ± 1.5 102.0 ± 2.4 103.9 ± 2.4 Female

Mild 734 106.5 ± 0.5 108.1 ± 0.4 102.0 ± 2.9 103.4 ± 1.5

Moderate 124 108.3 ± 1.2 106.5 ± 1.0 103.1 ± 2.9 104.7 ± 1.9

Severe 59 107.1 ± 1.9 103.9 ± 1.9 103.6 ± 2.6 102.4 ± 2.6

* Results after adjusting by multiple regression analysis for the confounding effects of

birth weight, gestational age, 5-minute Apgar score, ethnic origin, social class, paternal

education, phototherapy, and exchange transfusion.

:1:Excluding preterm (<37 wk) infants and all subjects with a positive Coombs test.

§See definition in text under “Methods.”

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‘85 85-93 94-101 102-108 IQ test score

108-lie

EIMILD M0DERATE SEVERE

Fig 1. Percent distribution of intelligence test scores of 17-year-old male subjects according to neonatal bilirubin

level.

30%

20%

1::1j

i-il

‘85 85-93 94-101 102-108 108-118 ‘116

10 test score

EIMILD MODERATE SEVERE

Fig 2. Percent distribution of intelligence test scores of 17-year-old female subjects according to neonatal biliru-bin level.

ARTICLES

831

jects, could be accounted for by the independent variables included in the final regression model (ethnic origin, paternal education, social class, and

birth weight).

The percent distribution of intelligence test scores at 17 years of age according to sex and

bilirubin level are presented is Figures 1 and 2. The

excess of low IQ scores among subjects with severe hyperbilirubinemia was examined using a logistic regression analysis. The confounding effect of birth weight, gestational age, low Apgar scores, ethnic origin, paternal education, and social class was controlled. The adjusted odds ratio for low IQ score (<85) among male subjects with severe neonatal

hyperbilirubinemia was 2.43 (95% confidence

inter-val, 1.22-4.84; P = .012). After excluding preterm (<37 weeks gestation) infants and all subjects with positive Coombs test, the results remained

signifi-cant (odds ratio, 2.81; 95% confidence interval,

1.23-6.40; P = .014). Because the subjects included in the present study were born in the early days of neonatal intensive care, we repeated the logistic

regression excluding all subjects with birth weight <2500 g. The odds ratio for severe

hyperbilirubi-nemia remained significantly higher (P = .006; odds ratio, 2.61; 95% confidence interval, 1.32-5.16). No significant association was found between low in-telligence scores and hyperbilirubinemia for female subjects. This at least in part may be due to the fact that some severely retarded or handicapped subjects are exempted from the military draft ex-ams, and that female subjects may be more fre-quently excused, as suggested by their underrepre-sentation in our sample (47.0%). Another possible explanation is the smaller number of women with low IQ scores (Fig 2). This may have decreased the

power of the logistic regression analysis.

The addition of phototherapy and exchange transfusion as independent variables to both linear

and logistic regression models, revealed no effect of

these therapeutic modes on the mean IQ scores or the risk of low IQ score (<85) at 17 years of age.

The school achievement (<12 years of schooling;

12 years of schooling and professional nontech-nologic education) was not influenced by bilirubin levels in both male and female subjects.

No association was found between neonatal hy-perbilirubinemia levels and the various health

pro-file classes, representing functional impairment of the organ systems. Of special interest is the lack of effect of hyperbilirubinemia in the newborn period

on hearing, vision, and neurologic performance. The exclusion of subjects without serum bilirubin

determinations from the low bilirubinemia group had no effect on any of the data analyses performed.

‘lie We repeated our linear and logistic regression

anal-yses using the peak total serum bilirubin value as

the predictor variable. The subjects were grouped

into four groups, maximal bilirubin values of <223

tmol/L (<13 mg/dL), 223 to 287 mol/L (13 to 16.9 mg/dL), 228 to 341 tmol/L (17 to 19.9 mgI

dL), and 342 mol/L (20 mg/dL) or more. Again, no association was found between peak bilirubin

values and mean IQ scores, whereas maximal bili-rubin concentrations of 342 amol/L (20 mg/dL) or higher significantly increased (P < .014) the risk of

low IQ scores (<85) among full-term Coombs-neg-ative male subjects (adjusted odds ratio, 2.96; 95% confidence interval, 1.29-6.79).

DISCUSSION

The results of this study support the conclusion

that the risk is low for mental or physical impair-ment in full-term babies without hemolysis until

serum bilirubin levels increase well above 342 tmol/

L (20 mg/dL). However, interpretation of the

epi-demiologic evidence warrants considerable

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spection to avoid unsupported and misleading con-clusions. It must be remembered that clinical

ex-periences, no matter how they are described

statistically, or how much statistical power they

have to convince us of their findings because of sample size, are not experiments. Therefore, inter-pretation is limited strictly with respect to clinical relevance. It seems fair to conclude that, from the perspective of a population of full-term newborns without hemolytic disease, but with a range of

serum bilirubin levels in the transitional period, that neonatal hyperbilirubinemia is not related to

an increased risk of functional impairment on phys-ical examination performed at 17 years of age. Furthermore, after statistically controlling for the confounding effect of birth weight, gestational age, Apgar score, ethnic origin, paternal education, and social class, no association between the level of hyperbilirubinemia during the newborn period and

intelligence test score or school achievement at 17

years of age could be demonstrated. However,

among male full-term infants with a negative

Coombs test and a birth weight 2500 g, severe neonatal hyperbilirubinemia was found to be asso-ciated with a significantly increased risk of low IQ

scores (<85) at 17 years of age. This latter finding

reinforces the concept that there may be a threshold level of serum bilirubin above which there is a real danger. That not all neonates who obtained a serum

bilirubin level at this threshold were impaired does not obviate this conclusion. Furthermore, it cannot

be concluded that all full-term infants without he-molytic disease and with levels <342 tmol/L (20 mg/dL) are safe and will not be injured by bilirubin, nor can these observations be extrapolated to any other segment of the neonatal population.

The association of neonatal hyperbilirubinemia and early neurodevelopmental abnormalities has been suggested by several studies in 1- and 2-year-old infants.10”9 However, when the same study co-horts were followed up at 4 to 7 years, the results did not support the original hypothesis that ele-vated bilirubin levels are predictive of long-term cognitive impairment.7’2#{176} Nilsen et al’2 examined the general intelligence scores of 39 male subjects with neonatal hyperbilirubinemia at 18 years of age. Only 19 of these subjects had a negative Coombs test. Significantly poorer intelligence test

results were found exclusively among seven

Coombs-positive infants with hyperbilirubinemia

(15 mg/dL) lasting for more than 5 days. No other

study extending for more than a decade is available.

The need for large-scale, long-term studies is thus apparent.

In an analysis of 41 444 infants, Naeye8 observed an increase in the frequency of IQ scores <90 at 4

years of age with peak neonatal bilirubin levels 120 mol/L (7 mg/dL). We found a similar

significantly increased risk of low IQ scores (<85) among subjects with neonatal hyperbilirubinemia, but only at much higher bilirubin concentrations. In contrast to Naeye’s study, however, our sample did not include premature infants and babies with

hemolysis. The possible relationship between low

IQ scores and severe hyperbilirubinemia is of con-cern. The fact that this observation was found only among male subjects in our sample may reflect a possible selection bias in the present data. Because retarded and severely handicapped subjects, as well

as poorly educated female subjects are occasionally

exempted from examination, the present results may underestimate any adverse effect of hyperbili-rubinemia. The finding of a higher risk of low IQ

scores among subjects with elevated neonatal serum

bilirubin does not necessarily imply a causal link.

Numerous confounders may contribute to both

higher bilirubin levels and mental impairment. The benefits of interventions to reduce maximal biliru-bin concentrations thus may reflect the contribu-tion of peak bilirubin levels better. However, no effect of treatment was observed. This is consistent with data from the National Institute of Child Health and Human Development collaborative phototherapy trial showing a significant reduction

in peak bilirubin levels with no effect on IQ scores.2’

Here again is a point that must be made with some reservation. The present study cannot claim as a conclusion that treatment is not beneficial, because treatment was not controlled in this experience. The bias that bilirubin is dangerous confounds the behaviors, and there is no way to analyze retro-spectively the effect of treating infants who did not need to be treated and would not be expected to benefit from treatment.

Mores et al22 suggested more than three decades ago that “it is useless to perform an exchange transfusion on full-term infants without isoimmu-nization because these infants are neither in dan-ger, nor ill, they are only icteric.” In a recent extensive review of the literature, Newman and Maisels3 could find no conclusive evidence that

shows an increased risk for mental or physical

impairment in full-term babies without hemolysis until serum bilirubin levels increase well above 342 tmo1/L (20 mg/dL). The present study failed to reveal any long-term physical and cognitive impair-ment in subjects with neonatal serum bilirubin

levels of up to 137 mol/L (8 mg/dL) on the first

(6)

ARTICLES

833

association found between severe neonatal

hyper-bilirubinemia and IQ scores less than 85 was not demonstrated in the statistically more powerful multiple linear regression using IQ scores as a con-tinuous factor. This may suggest that some individ-uals are thus more affected by bilirubin and are overrepresented at the lower end of the IQ score

distribution. A subgroup of neonates more sensitive

to bilirubin, characterized by a possible common genetic or environmental factor, other than pre-maturity and Rhesus incompatability, may thus exist. However, more research is required on how to identify who is at risk and why they are at risk, before the minimum bilirubin level necessitating treatment in full-term newborns with a negative Coombs test can be redetermined. Once such rec-ommendations are reached, in a way that ensures that safe decisions are made for individual patients, medical care costs could be substantially re-duced.’5’23 Accordingly, undue risks for the child could be prevented,24 if higher thresholds for serum bilirubin were set for intervention in this segment of the neonatal population. In the meantime, severe neonatal hyperbilirubinemia should remain a cause for concern in all newborns either as a primary neurotoxic factor or as a predictor variable for long-term neurologic risk.

REFERENCES

1. Watchko JF, Oski FA. Bilinubin 20 mg/dL

=

vigintiphobia. Pediatrics. 1983;71:660-663

2. Maisels MJ, Gifford K, Antle CE, Leib GR. Jaundice in the healthy newborn infant: a new approach to an old problem. Pediatrics. 1988;81:505-511

3. Newman TB, Maisels MJ. Does hyperbilirubinemia damage the brain of healthy full term infants. Clin Perinatol. 1990;17:331-358

4. Gale R, Seidman DS, Dollberg 5, Stevenson DK. Epide-miology of neonatal jaundice in the Jerusalem population. J Pediatr Gastroenterol Nutr. 1990;10:82-86

5. Newman TB, Maisels MJ. Bilirubin and brain damage: what do we do now? Pediatrics. 1989;83:1062-1065

6. Roth P, Polin RA. Controversial topics in Kernicterus. Clin Perinatol. 1988;15:965-990

7. Rubin R, Balow B, Fisch R. Neonatal serum bilirubin levels related to cognitive development at ages 4 through 7 years.

J Pediatr. 1979;94:601-603

8. Naeye RL. Amniotic fluid infections, neonatal hyperbiliru-binemia and psychomotor impairment. Pediatrics. 1978;62:497-503

9. Culley P, Powell J, Waterhouse J, Wood B. Sequelae of neonatal jaundice. Br Med J. 1970;3:383-386

10. Van de Bor M, Van Zeben-van de Aa TM, Verloove-Van-honick SP, Brand R, Ruys JH. Hyperbilinubinemia in pre-term infants and neurodevelopmental outcome at 2 years of age: results of a national collaborative survey. Pediatrics.

1989;83:915-920

11. Crichton JU, Dunn HG, McBurney AK, Robertson AM, Tredger E. Long-term effects of neonatal jaundice on brain function in children of low birth weight. Pediatrics. 1972;49:656-669

12. Nilsen ST, Finne PH, Bengsjo P, Stamnes 0. Males with neonatal hyperbilirubinemia examined at 18 years of age. Acta Paediatr Scand. 1984;73:176-180

13. Harlap S, Davies AM, Grover NB, Prywes R. The Jerusalem Peninatal Study: the first decade 1964-1973. Isr J Med Sci. 1977;13:1073-1082

14. Kark JD, Kedem R, Revach M. Medical examination of Israeli 17-year-olds before military service as a national resource for health information. Isr J Med Sci.

1986;22:318-325

15. Otis AS. OTIS Group Intelligence Scale. New York: World-book Publishers; 1919

16. Newman TB, Easterling J, Goldman ES, Stevenson DK. Laboratory evaluation of jaundice in newborns. Frequency, cost and yield. AJDC 1990;144:364-368

17. SAS Institute. SAS Users’ Guide. Version 5 Edition. Cary, NC: SAS Institute, mc; 1985

18. Odell GB, Lukier JO, Maglalang AC. Pathogenesis of neo-natal hypenbilirubinemia. In: King DS, Hicks JV, eds. The Neonate. New York: Wiley; 1976:271

19. Scheidt PC, Millits GD, Hardy JB, Drage JS, Boggs TR. Toxicity to bilinubin in neonates: infant development during first year in relation to maximum neonatal serum bilirubin concentration. J Pediatr. 1977;91:292-297

20. Van de Bor M, Veen 5, Ens-Dokkum, Schreuder AM, Brand R, Verloove-Vanhonick SP. Hyperbilirubinemia in preterm infants and neurodevelopmental outcome at 5 years of age. Pediatr Res. 1990:25. Abstract

21. Scheidt PC, Bryla DA, Nelson KB, Hirtz DG, Hoffman HJ. Phototherapy for neonatal hyperbilinubinemia: six-year fol-low-up ofthe National Institute ofChild Health and Human Development clinical trial. Pediatrics. 1990;85:455-463

22. Mores A, Fargasova MI, Minarkova E. The relation of hyperbilirubinemia in newborns without isoimmunization to kernictenus. Acta Paediatr. 1959;590-602

23. Plastino R, Buchner DM, Wagner EH. Impact of eligibility criteria on phototherapy program size and cost. Pediatrics. 1990;85:796-800

24. Kemper K, Forsyth B, McCarthy P. Jaundice, terminating breast-feeding, and the vulnerable child. Pediatrics. 1989;84:773-778

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1991;88;828

Pediatrics

Gale

Daniel S. Seidman, Ido Paz, David K. Stevenson, Arie Laor, Yehuda L. Danon and Rena

Age

Neonatal Hyperbilirubinemia and Physical and Cognitive Performance at 17 Years of

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1991;88;828

Pediatrics

Gale

Daniel S. Seidman, Ido Paz, David K. Stevenson, Arie Laor, Yehuda L. Danon and Rena

Age

Neonatal Hyperbilirubinemia and Physical and Cognitive Performance at 17 Years of

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Figure

Fig 2.Percentbindistributionof intelligencetestscoresof17-year-oldfemalesubjectsaccordingtoneonatalbiliru-level.

References

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