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Sudhakar Ezhuthachan, MD, DCH, FAAP
Christine Newman, MS, RNC, CNNP
Henry Ford Health System,
Detroit, MI 48202
M. Jeffrey Maisels, MD, FAAP
William Beaumont Hospital,
Royal Oak, MI 48073
Marcia A. Testa, MPH, PhD
Department of Biostatistics,
Harvard School of Public Health,
Boston, MA 02115
To the Editor.—
We thank Dr Mehl1 for his appreciation of the graphic depiction of the Henry Ford Health System (HFHS) guideline for management of hyperbilirubinemia of the newborn. We agree with him that it is more lenient in its recommendations for use of phototherapy than the 1994 guideline of the American Academy of Pediatrics (AAP),2 but it does address issues not addressed by the AAP guideline such as newborns of <37 weeks’ gestation and the role of home care nurses in postdischarge neonatal care. The guideline was indeed developed prior to the 1994 AAP practice guideline. As an internally developed guideline, it is not subject to the same constraint as the 1994 AAP guideline: that it should adhere strictly to published scientific evidence. Instead, this internal guideline is tailored to the particular practice circumstances faced by HFHS practitioners and extends to issues supported only by expert opinion. For example, the 1994 AAP guideline did not address newborns of <37 weeks’ gestation, because there was so little evidence then about this specific high-risk group, whereas the HFHS guideline does address this risk group.
We disagree with Dr Mehl that the HFHS guideline did not address the issue of lower birth weights or of hemolysis. As we reported on page 1266 of our article3 and in the Appendix, the HFHS guideline recommends, "Follow more closely and intervene at lower levels for newborns of 36 to 37 weeks’ gestation or <2250 to 2700 g of birth weight (unless small for gestational age)." Also, the text that appears on the back of the HFHS guideline card, shown in the Appendix, gives recommendations concerning work-up and use of phototherapy in cases of hemolysis.3 We also do not understand 2 other of Dr Mehl’s comments. There is no recommendation on the pocket card concerning umbilical cord bilirubin. The card text states clearly that the yellow zone means double phototherapy, and the orange zone is double or triple phototherapy with hydration if the infant is feeding poorly.
Dr Mehl goes on to comment on the 1994 AAP guideline. We cannot address these comments, because we do not represent the AAP guideline subcommittee.
The primary purpose of our article was to promote benchmarking, not to promulgate a guideline. Benchmarking is a quality-improvement tool for self-analysis by comparing one’s own results and practices to another’s. We sought to establish that the outcomes achieved by the HFHS could reasonably be used in this style of quality improvement. Another health care organization or practice group seeking to improve its own outcomes could try out elements of the HFHS approach that might best suit their circumstances. We agree with the hope expressed by Dr Mehl that pediatric health care providers eventually may exceed the current results of the HFHS in the prevention of hyperbilirubinemia. That is also a goal at HFHS.
REFERENCES
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