Letters to the Editor
Newborns with Significant Jaundice for Their Age Should Be Tested for Hyperbilirubinemia
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Am Fam Physician. 2011 Oct 15;84(8):854-856.
Original Article: Screening of Infants for Hyperbilirubinemia to Prevent Chronic Bilirubin Encephalopathy [Putting Prevention into Practice]
Issue Date: August 15, 2010
Available at: http://www.aafp.org/afp/2010/0815/p411.html
to the editor: We were disappointed with the “Putting Prevention into Practice” article on screening for hyperbilirubinemia. The case study described K.J., a 24-hour-old full-term boy, who was noted to be jaundiced on his chest. The third case study question is, “Based on K.J.'s risk factors for hyperbilirubinemia, what is the appropriate next step?” The answer listed as correct is, “Do not screen K.J. because there is not enough evidence to recommend screening.”
We disagree with this answer. Screening is defined as “the application of a test to detect a potential disease or condition in people with no known signs or symptoms of that disease or condition.”1 A lack of evidence to recommend screening for hyperbilirubinemia does not apply to K.J., because he is jaundiced on his chest at 24 hours of age. This is an unusual and potentially worrisome finding. Although visual estimation of jaundice is only approximate, jaundice on the chest suggests a total serum bilirubin level of somewhere between 6 and 12 mg per dL (102.62 and 205.25 μmol per L).2 At 24 hours of age, the high-risk zone for total serum bilirubin begins at about 8 mg per dL (136.83 μmol per L), and the American Academy of Pediatrics recommends phototherapy in otherwise full-term newborns at 11.7 mg per dL (200.12 μmol per L).3 Thus, K.J.'s jaundice is a sign of possible hyperbilirubinemia that may require treatment, and the appropriate next step for K.J. is to measure a serum bilirubin level.
As Dr. Ganiats wrote in an editorial in the same issue of American Family Physician, “A more aggressive approach to screening for hyperbilirubinemia does not have good evidence to support it, nor is it justified to abandon what we have been taught just because there is insufficient evidence at this time. In this case, a middle ground is best: continuing current practice while we wait for better evidence.” 4 Current practice, as described in virtually every textbook and in the American Academy of Pediatrics guidelines for the past 16 years, is to measure a bilirubin level in newborns with jaundice in the first 24 hours after birth.3,5 Any other recommendation presents a potentially dangerous departure from current practice and a misinterpretation of the U.S. Preventive Services Task Force report on screening for hyperbilirubinemia.
1. Eddy DM. Common Screening Tests. Philadelphia, Pa.: American College of Physicians; 1991.
2. Keren R, Tremont K, Luan X, Cnaan A. Visual assessment of jaundice in term and late preterm infants. Arch Dis Child Fetal Neonatal Ed. 2009;94(5):F317–F322.
3. American Academy of Pediatric Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation [published correction appears in Pediatrics. 2004; 114(4):1138]. Pediatrics. 2004;114(1):297–316.
4. Ganiats TG. Bilirubin screening in newborns: what should we do? Am Fam Physician. 2010;82(4):336.
5. Practice parameter: management of hyperbilirubinemia in the healthy term newborn. American Academy of Pediatrics. Provisional Committee for Quality Improvement and Subcommittee on Hyperbilirubinemia [published correction appears in Pediatrics. 1995;95(3):458–461]. Pediatrics. 1994;94(4 pt 1):558–565.
in reply: After reviewing our case study and the U.S. Preventive Services Task Force (USPSTF) recommendation statement on screening infants for hyperbilirubinemia to prevent chronic bilirubin encephalopathy,1 we agree with the concerns expressed by Drs. Newman and Maisels. The USPSTF recommendation statement applies only to healthy term or near-term infants (at least 35 weeks' gestational age) without signs or symptoms of hyperbilirubinemia. The patient in our original case study was visibly jaundiced within the first 24 hours of life and, therefore, measurement of a serum bilirubin level would be indicated as a diagnostic, rather than a screening test. We have corrected the online version of the case study to state that the infant, K.J., was not visibly jaundiced at the time of the physician's examination.
1. U.S. Preventive Services Task Force. Screening of infants for hyperbilirubinemia to prevent chronic bilirubin encephalopathy: U.S. Preventive Services Task Force recommendation statement. Pediatrics. 2009;124(4):1172–1177.
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