PEDIATRICS Vol. 114 No. 4 October 2004, pp. 1134-1135 (doi:10.1542/peds.2004-1584)
Hyperbilirubinemia Guidelines and Unintended Harms
J. Ben Worsley, MDFort Worth Pediatrics, PA
Fort Worth, TX 76132
To the Editor.—
I applaud the Subcommittee on Hyperbilirubinemia on its most recent clinical practice guideline.1 The sheer enormity of information to analyze and the complexity of all the clinical variables make such a topic truly daunting, and the subcommittee deserves commendation for all their effort.
Unfortunately, I find several of the recommendations troubling and not supported by the meta-analysis cited as a chief source of the recommendations ("An Evidence-Based Review of Important Issues Concerning Neonatal Hyperbilirubinemia"2), and like most of my fellow general pediatricians, I believe the new guidelines will be incredibly difficult to implement. I envision that it will be far from easy to convince a multiparous mother of the sudden necessity of bringing in her new, healthy infant into my office for an examination at day 3 to 5 when the mother’s other children suffered no problems during infancy. Additionally, the demands on the resources of a general pediatric practice to see all children for 1 more visit will no doubt be draining (not to mention the potential problems with managed care).
Despite the promise of greater precision and guidance, the nomograms provided by the subcommittee were far less helpful than the previously published guidelines. The first nomogram specifically emphasizes that it "should not be used to represent the natural history of neonatal hyperbilirubinemia."1(p301) I am puzzled, then, as to what use the nomogram is to the general pediatrician who is called on to recognize and treat such a condition and the exact condition the guidelines purport to address. The second nomogram provided states that it is a guideline for phototherapy in hospitalized infants and that it is "an option to provide conventional phototherapy in hospital or at home for TSB [total serum bilirubin] 2–3 mg/dL (35–50 mmol/L) below those shown."1(p304) I hope that the subcommittee realizes that presently a majority of phototherapy in term infants is probably provided outside the hospital setting and that, by these guidelines, they are advocating that pediatricians begin conventional phototherapy at home in a completely healthy, term infant 72 hours of age with a total serum bilirubin of 15 mg/dL. Alternatively, if a pediatrician chose to admit such a patient, I doubt many communities and health care systems could easily manage the rise in hospital admissions under this guideline. I see these guidelines as a dramatic departure from the previous recommendations of considering phototherapy in the same 3-day-old, healthy infant with a bilirubin of 
17 mg/dL and starting phototherapy at 20 mg/dL.3 The subcommittee presents no compelling data whatsoever that such a change is prudent.
In fact, I would argue that the increased pressure to evaluate and provide treatment for hyperbilirubinemia will actually decrease the incidence of successful breastfeeding, a primary objective of the American Academy of Pediatrics. In explaining the most common reasons for hyperbilirubinemia in a breastfed infant, one must discuss the critical role of sufficient enteral feeding. Despite a physician’s encouragement and reassurance as to the infant’s adequate hydration and acceptable weight loss, a mother might easily infer that she is not providing for her infant. In fact, such a mother would mirror the conclusions of the review in that "phototherapy combined with cessation of breastfeeding and substitution with formula was found to be the most efficient treatment protocol for healthy term or near-term infants with jaundice."2
If we become much more aggressive without any evidence to support such a position (ironically echoed in the same volume of Pediatrics in which Blackmon et al4 cite the vast knowledge gaps we have in the science of hyperbilirubinemia), we risk needlessly alienating our patients, reducing breastfeeding, and placing more demands on an already stressed system of American health care. I found it curious that also in the very same journal, Ip et al5 seemed to argue for additional study and a realization that increasing phototherapy is a poor way to prevent the tragic but exceedingly rare complication of kernicterus in a term newborn without other risk factors. I found it even more curious that these same authors from Boston, Massachusetts, were, along with the members of the subcommittee, the main contributors to "An Evidence-Based Review of Important Issues Concerning Neonatal Hyperbilirubinemia."2 It seems that 2 very disparate philosophies emerged from the review, but 1 viewpoint predominated. Although it is debatable whether the new guidelines will substantially decrease the incidence of severe hyperbilirubinemia and its sequelae, I believe they will fail miserably in "minimizing the risks of unintended harm such as maternal anxiety, decreased breastfeeding, and unnecessary costs or treatment."1(p297)
I also find it surprising that the American Academy of Pediatrics would promote such a drastic change in approach to an issue that concerns general pediatricians without having greater input from this particular group of physicians. The majority of the Subcommittee on Hyperbilirubinemia is comprised of neonatologists and public health physicians despite the fact that general pediatricians will be the group of physicians most profoundly affected. If we, as general pediatricians, pursue this more aggressive approach, we doubtlessly will be testing more infants and providing more therapy without compelling evidence of necessity.
Finally, I happened to notice that 3 of the 8 subcommittee members acknowledged financial relationships to companies that might benefit from such increased evaluation. Interesting.
REFERENCES
- American Academy of Pediatrics, Provisional Committee for Quality Improvement and Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation.
Pediatrics. 2004;114
:297
–316
[Abstract/Free Full Text] - Ip S, Chung M, Kulig J, et al. An evidence-based review of important issues concerning neonatal hyperbilirubinemia. Pediatrics. 2004;114 (1). Available at: www.pediatrics.org/cgi/content/full/114/1/e130
- American Academy of Pediatrics, Provisional Committee for Quality Improvement and Subcommittee on Hyperbilirubinemia. Practice parameter: management of hyperbilirubinemia in the healthy term newborn.
Pediatrics. 1994;94
:558
–562
[Abstract/Free Full Text] - Blackmon LR, Fanaroff AA, Raju TNK. Research on prevention of bilirubin-induced brain injury and kernicterus: National Institute of Child Health and Human Development Conference executive summary.
Pediatrics. 2004;114
:229
–233
[Abstract/Free Full Text] - Ip S, Lau J, Chung M, et al. Hyperbilirubinemia and kernicterus: 50 years later [commentary].
Pediatrics. 2004;114
:263
–264
[Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics
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Related articles in Pediatrics:
- Hyperbilirubinemia Guidelines and Unintended Harms: In Reply
- M. Jeffrey Maisels and on behalf of the Subcommittee on Hyperbilirubinemia, American Academy of Pediatrics
Pediatrics 2004 114: 1135-1137.[Extract] [Full Text]
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