Letters to the Editor
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Intervention Recommendations for Neonatal
Hyperbilirubinemia
To the Editor.
In their recent article describing a benchmarking model for the
management of hyperbilirubinemia, Chou et al1 are to be com-
mended for creating within their health care organization a sys-
tematic approach to the prevention of hyperbilirubinemia. At the
same time, the prominent inclusion of a full-color nomogram in
the article is a potential disservice for the reader.
To their credit, the authors indicate that their model for a
laminated pocket card was developed prior to the 1994 publica-
tion of the American Academy of Pediatrics (AAP) practice guide-
lines,2 but readers are encouraged to examine carefully the very
significant differences. Unlike the AAP guidelines, the pocket card
has no adjustment for consideration of lower birth weights, nor
does it reflect the recommendation for more aggressive manage-
ment when hemolysis is present. The area shaded in blue suggests
that an infant with a bilirubin level as high as 20 mg/dL at 3 days
of age need not start phototherapy if repeat measurement is
performed and implies that phototherapy is optional for a level as
high as 24 mg/dL at 4 days of age, 2 examples inconsistent with
the AAP practice guidelines. The pocket card has the words
Photo Rx in one area, whereas the reverse side notes that this
means at least double phototherapy; with some confusion, the
words intensive phototherapy are said to refer to double or
triple phototherapy. The pocket card suggests that an umbilical
cord bilirubin level of 8 mg/dL could be managed simply with
repeat measurement, a practice not well addressed by the AAP
practice guideline and not consistent with the current approach of
most neonatologists to start phototherapy immediately for such an
infant in hopes of avoiding exchange transfusion.
The reader therefore is encouraged to compare and contrast a
similar nomogram, developed for use at Boulder Community
Hospital (Boulder, CO) in 2000 and shared with Maisels1 at that
time (Fig 1). The similarities are striking in the color portrayal, but
the differences are critically important to the appropriate manage-
ment of hyperbilirubinemia.
Fig 1. A graphic interpretation of current recommendations for
intervention at various levels of total bilirubin. For any plotted
value of total bilirubin versus age in days, follow the colored zone
to the far right to read an abbreviated summary of current recom-
mendations for intervention.
322 PEDIATRICS Vol. 114 No. 1 July 2004
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First, it should be noted that the graph included with this
commentary is in no way a new suggestion for the management of
hyperbilirubinemia; it is, instead, a good-faith effort to capture the
recommendations of the AAP 1994 published practice parameter
in a graphic format. The panels recommendations, although not
necessarily perfect, represent the best consensus of a group of
experts and continue to serve as a guideline for the medical
community.
In translating the intention of that panel, it is quickly apparent
that the format of their recommendations using age spans (ex-
pressed in hours) proves to be quite problematic. For example, the
panel describes 1 measure of hyperbilirubinemia as a total serum
bilirubin measurement of 12 mg/dL at 25 to 48 hours, but an
infant with a bilirubin of 12 mg/dL at 25 hours of age is clearly of
much greater worry than an infant with the same measurement at
48 hours of age.2 Because of this very serious limitation of the 1994
recommendations, the midpoint of each recommended range was
used in creating the graph shown (in this example, the level of 12
mg/dL would be plotted graphically at 36 hours of age). Using
specific total bilirubin levels provided by the panel (with each
level plotted at the midpoint of the consensus time range) allows
for the creation of a series of 3 parallel smooth curves, character-
ized by an initial rising threshold for intervention. Extrapolation
of the resulting curves to the left provides some suggestion of
appropriate management during the first few hours of life, such as
with the interpretation of umbilical cord bilirubin measurements.
The graph is designed to portray the panels recommendations
for beginning phototherapy and does not pretend to assist the
practitioner in deciding when to discontinue phototherapy after
improvement has been measured. For measurements of total bil-
irubin plotted against age in hours, each color zone can be fol-
lowed without interruption to the right side of the page, at which
a succinct summary of the panels recommendation is found. (For
simplicity, the use of more intensive phototherapy for higher
bilirubin levels is implied rather than stated specifically.) Using
this format, the nuances of management for lower birth weights or
in the presence of hemolysis can be included according to the
panels consensus.
At Boulder Community Hospital, the graph has been used for
hundreds of jaundiced infants as a full-page worksheet, with the
inclusion of areas for recording the birth weight, blood types of
the infant and mother, Coombs test results, and each numeric
value of sequential bilirubin measurements. Interestingly, the
graph has been reduced to a laminated pocket card in our hospital
as well.
The idea of benchmarking presented by Chou et al is laudable.
Nevertheless, it is suggested that physicians use a tool that more
accurately reflects the expert opinions of the AAP panel of experts.
With such a tool, investigators may even eventually exceed the
results of the Henry Ford Health Systems in the prevention of
hyperbilirubinemia. Additionally, rather than waiting for neces-
sity to once again become the mother of invention, the AAP panel,
if and when it reconvenes, would be well advised to present their
consensus in a graphic format for more rapid acceptance and ease
of use.
Albert L. Mehl, MD, FAAP
Pediatrics
Kaiser Permanente
Boulder, CO 80304
REFERENCES
1. Chou S, Palmer R, Ezhuthachan S, et al. Management of hyperbiliru-
binemia in newborns: measuring performance by using a benchmarking
model. Pediatrics. 2003;112:1264 1273
2. American Academy of Pediatrics, Provisional Committee for Quality
 Improvement. Practice parameter: management of hyperbilirubinemia in
the healthy term newborn [published correction appears in Pediatrics.
1995;95:458 461]. Pediatrics. 1994;94:558 565
Hyperbilirubinemia Benchmarking
To the Editor.
Chou et al1 recently reported on their experience with neonatal
hyperbilirubinemia in the Henry Ford Hospital System (HFHS).
They suggested that rates of hyperbilirubinemia obtained with a
rigorous protocol for hyperbilirubinemia management at HFHS
could be used as a benchmark for other healthcare systems. They
compared their results with those we reported from the Northern
California Kaiser Permanente Medical Care Program (NC-KPMCP)2
and speculated that the significantly lower rates of hyperbiliru-
binemia at HFHS were due to their more rigorous management
protocols.
Although we agree that it can be helpful to compare rates of
hyperbilirubinemia across health systems and appreciate their
attention to our work, we have some reservations about their
methods and conclusions. First, the definition of hyperbiliru-
binemia they used was the total serum bilirubin (TSB) level at
which the American Academy of Pediatrics (AAP) 1994 guide-
line3 recommends phototherapy be considered, ie, a TSB level of
17 mg/dL at 72 hours of age. This level is too low to use
as a benchmarking outcome, because it primarily reflects the
underlying prevalence of risk factors for hyperbilirubinemia
rather than perinatal management decisions. In both the HFHS
and NC-KPMCP studies, the main risk factors for hyperbiliru-
binemia were race, gestational age, maternal age, gender, and
breastfeeding. Of these, the only one that pediatric health care
providers might be able to influence is breastfeeding. However,
greater success at encouraging breastfeeding would lead to higher
rates of hyperbilirubinemia, because breastfeeding is a risk factor
for hyperbilirubinemia. It is noteworthy that only 30% of new-
borns in the HFHS study were exclusively breastfed, compared
with 66% in the NC-KPMCP study.
The authors also compared rates of severe hyperbiliru-
binemia, defined as TSB 20 mg/dL, between the HFHS and the
NC-KPMCP studies. Although a little more clinically relevant, a
TSB level of 20 mg/dL is still too low for benchmarking, because
the proportion of newborns reaching that level would be mini-
mally affected by adherence to treatment recommendations. For
well, term newborns 72 hours old, phototherapy is recom-
mended by the AAP above this level. If the HFHS protocol called
for phototherapy at lower levels than those in the 1994 AAP
guideline, then they could at least partially attribute a lower
incidence of newborns with TSB 20 mg/dL to their more rigor-
ous protocols. Surprisingly, however, the laminated pocket card
with the HFHS bilirubin management guidelines, depicted in their
Figure 1, calls for considerably less phototherapy treatment than
recommended by the AAP. For example, for healthy term infants
120 hours old, the card suggests that phototherapy is optional
for a TSB level of 22 to 25 mg/dL and required for aTSB 25
mg/dL. It is hard to understand how implementation of such an
explicitly lenient guideline could be responsible for a low rate of
hyperbilirubinemia.
There are at least 2 better explanations for the lower rate of TSB
20 mg/dL reported in the HFHS study, compared with the
NC-KPMCP study. The first, as mentioned above, is case mix.
Although the authors used Poisson regression to adjust for case-
mix differences, they did so only 1 variable at a time. This does not
work. For example, the difference in the rate of hyperbiliru-
binemia between white newborns from the NC-KPMCP (1.7%)
and HFHS (1.2%) studies reported in Table 3 of the Chou et al
article can be explained by the greater proportion of exclusive
breastfeeding in the NC-KPMCP study (66% vs 30%).
A second explanation for differences in the incidence of hyper-
bilirubinemia is much more troublesome, not only for the com-
parison between the HFHS and NC-KPMCP, but for any bench-
marking efforts at all. The problem, which for many years sat like
an ignored elephant in the living room of neonatal jaundice re-
searchers, is interlaboratory variability in measurements of TSB.
This problem finally received much-needed attention at a recent
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National Institute of Child Health and Human Development-
sponsored meeting. However, until more reliable bilirubin stan-
dards can be developed and implemented, any comparisons of
hyperbilirubinemia rates across hospitals must consider the pos-
sibility that differences are caused by different laboratories.
Thomas B. Newman, MD, MPH
Petra J. Liljestrand, PhD
Gabriel J. Escobar, MD
University of California San Francisco
San Francisco, CA 94143-0560
REFERENCES
1. Chou SC, Palmer RH, Ezhuthachan S, et al. Management of hyperbiliru-
binemia in newborns: measuring performance by using a benchmarking
model. Pediatrics. 2003;112:1264 1273
2. Newman TB, Escobar GJ, Gonzales V, Armstrong MA, Gardner M, Folck
B. Frequency of neonatal bilirubin testing and hyperbilirubinemia in a
large health maintenance organization. Pediatrics. 1999;104:1198 1203
3. American Academy of Pediatrics, Provisional Committee for Quality
Improvement and Subcommittee on Hyperbilirubinemia. Practice
parameter: management of hyperbilirubinemia in the healthy term new-
born [published correction appears in Pediatrics. 1995;95:458 461]. Pedi-
atrics. 1994;94:558 565
Early Reversal of Pediatric-Neonatal Septic Shock
by Community Physicians Is Associated With
Improved Outcome
To the Editor.
I read with interest the article by Han et al1 but question the
validity of adjusting their outcome measures by the Pediatric Risk
of Mortality (PRISM) severity-of-illness measure. Adjustments are
made to take into consideration confounding relationships such as
the severity of illness. Unfortunately, the severity-of-illness mea-
sure used for adjusting in this study was measured at an illogical
point in the sequence of events. The severity of illness will deter-
mine if resuscitation is necessary, the extent to which resuscitation
measures need to be implemented, and the outcome of the resus-
citation. Thus, the appropriate time to measure the severity of
illness is at presentation to the community hospital. Because the
PRISM score is measured within 24 hours of admission to the
pediatric intensive care unit (PICU) and is a result of both the
characteristics of the patients illness and the resuscitative efforts
of the community hospital physicians, it is not appropriate to use
it for adjusting the outcome data.
To illustrate this point, I have organized the variables presented
in the articles 3 tables into the sequence: input, process, output,
outcome, and impact categories (Table 1). Inputs into the resusci-
tation process and medical care would be the characteristics of the
patient and the illness. Inputs not presented would be duration of
illness, prior medical intervention, and severity of illness on pre-
sentation to the community hospital. The primary process under
study was the resuscitative effort of the community hospital phy-
sician. Characteristics of the transport process also were included
in the analysis. The output of these 2 processes was a determina-
tion of whether the process was consistent with American College
of Critical Care Medicine Pediatric Advanced Life Support
(ACCM-PALS) guidelines. The outcome of the processes was the
duration of shock, persistence/reversal of shock on arrival of the
transport team, and the PRISM score determined within 24 hours
of arrival at the PICU. The impact of the inputs and process (and
subsequent PICU care) was survival/mortality.
Given my skepticism of the validity of adjusting the data for
PRISM score, I have 3 questions:
1. Are the results the same without the adjustment?
2. Could a pseudo-PRISM score have been constructed retro-
spectively from the community hospital patient notes that de-
scribe the childs condition on presentation to the hospital (or at
the time the decision to resuscitate was made)?
3. How was the adjustment in the data analysis handled for
children who died before they arrived in the PICU and there-
fore did not have a PRISM score? The absence of a value for the
adjusting variable would impact the results. If the PRISM score
LETTERS TO THE EDITOR 323
 Intervention Recommendations for Neonatal Hyperbilirubinemia
Albert L. Mehl
Pediatrics 2004;114;322
DOI: 10.1542/peds.114.1.322
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright 2004 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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 Intervention Recommendations for Neonatal Hyperbilirubinemia
Albert L. Mehl
Pediatrics 2004;114;322
DOI: 10.1542/peds.114.1.322

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/114/1/322.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2004 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from by guest on April 7, 2017