Normally, bilirubin bound to serum albumin stays in the intravascular space. However, bilirubin can cross the blood-brain barrier and cause kernicterus when serum bilirubin concentration is markedly elevated (hyperbilirubinemia), serum albumin concentration is markedly low (eg, in preterm infants), or bilirubin is displaced from albumin by competitive binders (eg, sulfisoxazole, ceftriaxone, and aspirin; free fatty acids and hydrogen ions in fasting, septic, or acidotic infants).
In preterm infants, kernicterus may not cause recognizable clinical symptoms or signs. Early symptoms of kernicterus in term infants are lethargy, poor feeding, and vomiting. Opisthotonos, oculogyric crisis, seizures, and death may follow. Kernicterus may result in intellectual disability, choreoathetoid cerebral palsy, sensorineural hearing loss, and paralysis of upward gaze later in childhood. It is unknown whether minor degrees of kernicterus can cause less severe neurologic impairment (eg, perceptual-motor problems, learning disorders).
There is no treatment once kernicterus develops; it must be prevented by treating hyperbilirubinemia.
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