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To the Editor.—
We read with great interest the study of Newman et al1 in which the number of neonates within a health care system, in whom serum total bilirubin (STB) concentrations exceeded 30.0 mg/dL, were documented. Of 111 009 newborns delivered between 1995 and 1998, 11 had STB values ranging from 30.5 to 45.5 mg/dL. There can be no doubt that without the provider’s electronic data-collection system, this information would not have been collected in an organized fashion and studied systematically. Although we agree with the authors’ conclusion that 
1 in 10 000 neonates within this medical care system developed STB concentrations >30.0 mg/dL, we do not concur with the suggestion that this observation is the equivalent of the incidence of STB >30.0 mg/dL. To determine the natural incidence of such extreme hyperbilirubinemia in any given population, one would have to study a large cohort of neonates not subjected to any form of treatment. Obviously, it is not possible to conduct such a study. However, taking into account that these 11 neonates were detected in a system that was treating most of its neonates for lesser degrees of hyperbilirubinemia, it does seem likely that, had bilirubin been allowed to peak without intervention, the incidence of severe hyperbilirubinemia would have been even greater than that observed in the current report.
The authors’ interpretation that STB values >30.0 mg/dL are rare may be correct from an epidemiologic viewpoint. However, from the perspective of the clinician, severe hyperbilirubinemia, bilirubin encephalopathy, and kernicterus are, for the most part, preventable conditions and should hardly occur at all. Except for a few cases of severe, unpredictable, sudden hemolysis in glucose-6-phosphate dehydrogenase-deficient newborns, the health care organization should have been able to prevent STB from reaching such extreme and potentially dangerous levels. What Drs Newman, Liljestrand, and Escobar are actually reporting, therefore, is the number of times the health care system failed to detect or prevent extreme hyperbilirubinemia. Review of the case reports suggests that, although some cases possibly reflect failure of the American Academy of Pediatrics guidelines to prevent extreme hyperbilirubinemia and bilirubin encephalopathy,2 others may have been prevented or ameliorated by adopting more-stringent strategies of patient management. Such approaches include: caring for 35- to 36-week neonates as premature and not as term neonates; regarding jaundice becoming apparent on the first day of life as a manifestation of increased hemolysis and as a predictor of subsequent hyperbilirubinemia; avoiding early discharge; detecting poor feeding patterns and exaggerated weight loss; and taking note of sibling history of neonatal jaundice.
Finally, it would be of great interest if the authors could now retrieve, from the electronic database, the number of cases of STB values >30.0 mg/dL occurring during the years subsequent to the study. Hopefully, the figures will show a substantial decrease, indicative of measures taken by the health service and its physicians to detect and prevent extreme hyperbilirubinemia.
REFERENCES
In Reply.—
We appreciate the comments of Drs Kaplan and Hammerman. We agree that the 1 in 10 000 incidence of total serum bilirubin (TSB) levels 
30 mg/dL that we reported1 does not represent the "natural incidence." Rather, it is the incidence for newborns in the Northern California Kaiser Permanente Medical Care Program from 1995 to 1998, whose hyperbilirubinemia was generally treated at lower levels. The incidence in untreated newborns would be higher; how much higher is not clear. Even high (17 mg/dL) levels of TSB usually decline without treatment.2,3
The low frequency of TSB 30 mg/dL that we reported should not be attributed to close adherence to American Academy of Pediatrics (AAP) guidelines. In 1995–1996, <60% of Kaiser Permanente Medical Care Program newborns for whom the AAP recommended phototherapy received it,4 and only 43% of newborns noted to be jaundiced in the first 24 hours after birth had a TSB measured within 24 hours.5 Thus, even with low adherence to guidelines, TSB levels 30 mg/dL are quite rare.
We also agree that newborns who develop TSB levels 30 mg/dL may have fallen through the cracks in the health care system. Such cases should trigger a careful review to determine what went wrong and what steps, if any, can be taken to prevent future cases. However, not all such cases are easily preventable. In 5 of the 11 cases that we reported, the 1994 AAP jaundice treatment guidelines were followed. Although with hindsight one can argue in some of these cases that clinical judgments could have been better, unless we want to measure a TSB level on every baby every day, a zero incidence of TSB levels 30 mg/dL may not be realistic.
Finally, as suggested, we do plan additional studies to examine time trends in TSB levels as well as in jaundice treatments in the Northern California Kaiser Permanente Medical Care Program.
REFERENCES
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  D. Danschutter, F. Braet, E. Van Gyseghem, S. Hachimi-Idrissi, B. Van Bruwaene, P. Moloney-Harmon, and L. Huyghens Di-(2-ethylhexyl)phthalate and Deep Venous Thrombosis in Children: A Clinical and Experimental Analysis Pediatrics, March 1, 2007; 119(3): e742 - e753. [Abstract] [Full Text] [PDF]
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