Practice Patterns in Neonatal Hyperbilirubinemia
Lawrence M. Gartner, MD*; Carla T. Herrarias, MPH‡; and Robert H. Sebring, PhD‡
ABSTRACT. Objective. To determine practice pat-terns of office-based pediatricians and neonatologists in the treatment of neonatal hyperbilirubinemia in healthy, term newborns during 1992, before the publication of the practice guideline for treatment of neonatal jaundice by the American Academy of Pediatrics (AAP).1The survey was undertaken to inform the AAP’s Subcommittee on Hyperbilirubinemia on current practices and to aid it in its preparation of the guidelines. It was also anticipated that this survey would serve as a basis for comparison for a second survey to be performed several yearsafter the publication of the practice guidelines.
Methods. A self-administered questionnaire describ-ing a sdescrib-ingle case of a jaundiced, breastfed 36-hour-old healthy, full-term infant with a total serum bilirubin concentration of 11.0 mg/dL (188 mM/L) was sent to a random sample of 600 office-based pediatricians and 606 neonatologists who were members of the AAP. The final response rate was 74%. Respondents were asked to an-swer questions regarding treatment of the case based on their actual practices. Ranges of total serum bilirubin concentration were provided as possible answers to questions on initiation of phototherapy and exchange transfusion, and interruption of breastfeeding. Respon-dents were also queried about frequency of serum bili-rubin testing, locations of phototherapy administration, and factors influencing their therapeutic decisions.
Results. Four hundred forty-two office-based pedia-tricians and 444 neonatologists completed the survey. There was a tendency for neonatologists to initiate both phototherapy and exchange transfusions at lower serum bilirubin concentrations than office-based general pedi-atricians. At a serum bilirubin of 13 to 19 mg/dL (222 to 325mM/L), 54% of office-based pediatricians stated they would initiate phototherapy whereas 76% of neonatolo-gists would do so. Forty percent of office-based practi-tioners said they would perform exchange transfusions at serum bilirubin levels of 20 to 25 mg/dL (342 to 428 mM/L), whereas 60% of neonatologists said they would. Only a small percentage of both office-based practi-tioners (13%) and neonatologists (16%) indicated they would interrupt breastfeeding at 8 to 13 mg/dL (137 to 222 mM/L); but with each incremental level of serum biliru-bin, an increasing proportion of neonatologists would interrupt breastfeeding. Little correlation was found be-tween treatment practices and demographic characteris-tics except for years in practice; physicians with the few-est years in practice (5 years or less) differed significantly
from all other groups of physicians in initiating exchange transfusions at higher serum bilirubin concentrations.
Conclusions. The results of this survey indicated a wide range of variation ofopinionamong both groups of physicians, most likely a reflection of the uncertainty and controversy surrounding these issues. The data may also reflect a possible wide range of “acceptable practice” as opposed to a narrow treatment standard. Office-based practitioners more closely approximated the new 1994 recommendations than neonatologists.1 Pediatrics 1998; 101:25–31; bilirubin, hyperbilirubinemia, neonatal jaun-dice, exchange transfusion, phototherapy, neonatology, practice parameters, breastfeeding, clinical practice.
ABBREVIATION. AAP, American Academy of Pediatrics.
S
ince the earliest recognition of the potential for hyperbilirubinemia in the newborn to produce brain damage,2 physicians have concernedthemselves with the development of guidelines for diagnostic and therapeutic procedures to prevent such outcomes.3Some criteria that had been widely
accepted in the past, such as the 20 mg/dL total serum bilirubin concentration for initiation of ex-change transfusion in full-term infants, have been seriously questioned recently4,5and new
recommen-dations published.1 Other recommendations have
been debated without general consensus, such as the use of variable bilirubin concentrations for exchange transfusions in premature infants based on weight or gestational age6and the treatment of jaundice in the
breastfed infant.7,8Thus, physicians may well be
in-creasingly uncertain about when to initiate a diag-nostic work-up for neonatal jaundice, how fre-quently to perform serum bilirubin determinations, and when to initiate phototherapy and an exchange transfusion. This may be particularly so for the larg-est single group of infants with exaggerated neonatal jaundice—apparently normal, full-term newborns.
As part of the process of developing a practice guideline on the treatment of neonatal hyperbiliru-binemia in the healthy, term newborn,1and to assess
current thinking about the therapeutic treatment of neonatal jaundice by clinical practitioners, a survey of American Academy of Pediatrics (AAP) fellows was conducted. The primary intention of the inves-tigation was to determine current practices of office-based general pediatricians and to compare them to practices of neonatologists, the other major group of pediatricians likely to be making decisions on such cases. This information on the range of actual perfor-mance practices contributed to the development of the neonatal hyperbilirubinemia practice guideline From the *Departments of Pediatrics and Obstetrics & Gynecology, the
University of Chicago, Chicago, Illinois; and the ‡Division of Quality Care, American Academy of Pediatrics, Elk Grove Village, Illinois.
Received for publication Feb 10, 1997; accepted Jun 4, 1997.
Reprint requests to (L.M.G.) The University of Chicago, 5841 S Maryland Ave, Chicago, IL 60637.
by the AAP Subcommittee on Hyperbilirubinemia.1
The survey data also provides a background against which efforts to effect change through education may be assessed in the future.
METHODS
A random sample of 600 office-based pediatricians and 606 neonatologists was obtained from AAP membership lists. The survey on current management of neonatal hyperbilirubinemia was a self-administered, three-page questionnaire consisting of seven clinical questions and five demographic questions. A single case history was provided of a full-term, healthy, breastfeeding neonate whose total serum bilirubin concentration was 11.0 mg/dL (188mM/L) at 36 hours of life. No pathologic or high risk factors were present. By using the least complex case, it was hoped that variability would be minimized and fundamental responses obtained. Respondents were asked to answer the questions based on actual practice performance. The survey was pilot tested for accuracy and usability on a sample of 20 office-based pediatricians followed by a mailing of the questionnaire to all 1206 selected recipients in September 1992. From October through December 1992, two additional questionnaires and one postcard reminder were mailed to all nonresponders. No attempt was made to con-tact nonresponders beyond the four mailings.
Data entry was conducted by The Data Shop, Inc, Janesville, Wisconsin, and provided as a single data file on diskette to the AAP staff. Twenty respondents were unreachable at the recorded address and provided no forwarding address. An additional 18 respondents were excluded from the study because they indicated that they did not treat neonatal hyperbilirubinemia. Of the poten-tial 1168 remaining potenpoten-tial responders, a total of 886 usable surveys were returned for an overall response rate of 75.9%. Four hundred forty-two office-based pediatricians and 444 neonatolo-gists completed and returned the questionnaires.
The following questions were posed on the survey instrument:
1. At what level of total serum bilirubin do you actually imple-ment phototherapy in this case? Serum bilirubin levels in ranges of 13 to 19 mg/dL (222 to 325mM/L), 20 to 25 mg/dL (342 to 428mM/L), or 26 to 30 mg/dL (445 to 513mM/L) were provided as possible answers. An additional space for desig-nating an individual answer was also provided. The answers did not contain any statement of age of the infant or indication that an answer relating to a future period of time was expected. 2. At what total serum bilirubin level do you implement exchange transfusion in a case identical with the one presented regardless of age? Response ranges were the same as for the previous
question, with the addition of a lower range of 8 to 13 mg/dL (137 to 222 mM/L). This expanded range was used for all subsequent questions, as well.
3. When total serum bilirubin is at the following levels at 48 hours of age, how many times do you actually test bilirubin levels during the next 24 hours while considering phototherapy? 4. Do you recommend temporary cessation of breastfeeding in
this case?
5. At what level of total serum bilirubin would you recommend cessation of breastfeeding?
6. Would you administer phototherapy in the hospital, office, or in the home?
7. What factors (in rank order) influence your decision to initiate phototherapy?
Data analysis was conducted using SPSS-PC1(SPSS Inc, Chi-cago, IL) software to calculate frequencies and correlation with type of practice, length of practice experience, and location of practice. Where appropriate, tests of significance were performed using the correctedx2test for observed differences in proportions.
Analysis of variance was used to determine relationships between practice and demographic variables. Significant differences were accepted with aPvalue of less than .05.
RESULTS Phototherapy
More than one-half of both groups would have initiated phototherapy at 13 to 19 mg/dL (222 to 325 mM/L); 76% of neonatologists but only 54% of office-based pediatricians selected that category (P,.0001; Fig 1). Forty percent of office-based pediatricians surveyed would have instituted phototherapy only when the serum bilirubin concentration exceeded 19 mg/dL (325mM/L) whereas fewer than 20% of the neonatologists would have used concentrations that high (P , .05; Fig 1). From the responses it is not possible to determine whether respondents were providing answers based on the infant’s current age of 36 hours, as implied in the question, or were projecting to a future age period.
The factors influencing the decision to initiate pho-totherapy at whatever level indicated were similar in both groups (Table 1) and there were no significant
differences in responses or ranking of the order of importance except for a slightly greater, but statisti-cally insignificant (P5 .113), dependence on rate of rise of serum bilirubin by office-based pediatricians (38.9%) who gave this as the leading reason com-pared with neonatologists (32.7%) who listed this as the second most important reason, behind clinical risk (45%). Both groups of physicians placed cost and convenience lowest in the ranking of factors on which they base their decision to implement photo-therapy (Table 1).
Home phototherapy is used approximately five times more frequently by office-based practitioners than by neonatologists. Fifty-two percent of office-based pediatricians indicated that they never use home phototherapy, whereas almost 70% of neona-tologists never use it. The vast majority of the re-maining office-based pediatricians indicated that they use a mix of hospital, office, and home photo-therapy (47%), with only 2% exclusively using home phototherapy.
Exchange Transfusion
The responses of the two groups to the question regarding total serum bilirubin concentration at which an exchange transfusion is indicated paral-leled that of the response to phototherapy (Fig 2). The majority of neonatologists (60%) used 20 to 25 mg/dL (342 to 428 mM/L) as the level at which to
perform an exchange transfusion whereas the pre-dominant response of the office-based practitioners was in the 26 to 30 mg/dL (445 to 513mM/L) range (43%), with only 40% in the 20 to 25 mg/dL (342 to 428mM/L;P,.05) range. Approximately 41% of the office-based practitioners would have waited until the serum bilirubin concentration exceeded 25 mg/dL (428mM/L), whereas only 32% of neonatol-ogists would have used that high a level (P,.0001).
Frequency of Bilirubin Testing
With regard to frequency of need for serum bili-rubin determinations, an issue about which there is much less advice in the literature, office-based prac-titioners indicated less need for serum bilirubin de-terminations than did neonatologists. Thus, at serum bilirubin concentrations of 8 to 13 mg/dL (137 to 222 mM/L) nearly 40% of office-based pediatricians felt no need for additional testing, whereas only 25% of neonatologists would not repeat the determination in this low-risk, term infant (P , .0001). At serum bilirubin concentrations of 14 to 19 mg/dL (239 to 325 mM/L), only 30% of office-based practitioners, but nearly 50% of neonatologists would have per-formed two bilirubin determinations in the next 24 hours (P , .0001). Even at total serum bilirubin concentrations of 20 to 25 mg/dL (342 to 428mM/L), office-based pediatricians would have performed fewer determinations than neonatologists (Fig 3).
TABLE 1. Factors Influencing Clinical Decision-making*
Factor Neonatologists
(n5444)
Office-based Pediatricians (n5442)
Clinical risk for higher serum bilirubin levels 200 (45.0) 171 (38.7)
Rate of rise of serum bilirubin concentration 145 (32.7) 172 (38.9)
Benefits to patient 118 (26.6) 99 (22.4)
Legal liability protection 18 (4.1) 13 (2.9)
Potential harms of phototherapy 10 (2.3) 9 (2.1)
Local standard of care 8 (1.8) 13 (2.9)
Hospital protocol 5 (1.3) 5 (1.3)
Convenience factor (eg, day before weekend, discharge, etc) 6 (1.3) 3 (0.3)
Costs 7 (1.6) 1 (0.2)
Other 11 (2.5) 5 (1.3)
* Number of office-based pediatricians and neonatologists who rated the following factors number one for initiating phototherapy (percentages are in parentheses).
Breastfeeding
Only 13% of office-based practitioners and 16% of neonatologists would have temporarily interrupted breastfeeding in the original case scenario with a serum bilirubin concentration of 11 mg/dL (188 mM/L) at 36 hours, a difference that was not signif-icant. At 20 to 25 mg/dL (342 to 428 mM/L), the lowest level at which most authors have suggested temporary interruption of breastfeeding, 46% of neo-natologists and 40% of office-based practitioners would have interrupted nursing (Fig 4). At serum bilirubin concentrations of 19 mg/dL (325mM/L) or less, 30% of neonatologists would have interrupted breastfeeding compared with 22% of the office-based
practitioners (P, .003; Fig 4). At the other extreme, 13% of neonatologists and 16% of office-based phy-sicians would have allowed breastfeeding to con-tinue without interruption even at serum bilirubin concentrations.30 mg/dL (Fig 4).
Demographic Characteristics
The survey looked at years in practice and years at the present practice, location of practice including region and community population size, and type of practice setting to see if these variables contributed in any way to differences in management of neonatal hyperbilirubinemia (Table 2). Approximately one-half of the respondents in both groups had been in
Fig 3. Number of serum bilirubin determinations per 24 hours at total serum bilirubin levels of 20 to 25 mg/dL.
practice .10 years. The largest single segment of both groups were in practice between 6 and 10 years (office-based practitioners, 27%; neonatologists, 29%) but at their present practice location 5 years or less (practitioners, 45%; neonatologists, 42%). There were no significant differences in geographic location with both groups being fairly evenly distributed through-out the United States. The majority of respondents were situated in areas with populations between 50 000 and 1 000 000 persons (practitioners, 51%; neonatologists, 57%). As would be expected, the hos-pital was the primary practice setting for the majority of neonatologists (51%), whereas most practitioners were situated either in solo practice (25%) or private group practice (33%). Years in practice and geo-graphic location had no significant impact on the level at which phototherapy was initiated; nor did geographic location influence levels at which
ex-change transfusion was implemented. However, both office-based pediatricians and neonatologists with the least amount of experience (,5 years in practice) differed from most other groups in using higher levels of bilirubin as indications for exchange transfusion (P 5 .05). Furthermore, a number of these younger pediatricians were also indecisive in their responses; 29 out of 212 (14%) did not answer the question and 23 (11%) referred the patient to a consultant or responded by saying that it depended on other factors. None of the more experienced pe-diatricians or neonatologists failed to respond or vacillated. Practice setting did not impact treatment decisions for either phototherapy or exchange transfusion.
DISCUSSION
This survey indicates a significant bias for neona-tologists to be more aggressive than office-based general pediatricians in their treatment of neonatal jaundice in the healthy term infant. However, there is wide variation of opinion among members of both groups as to how to handle the healthy full-term infant with early onset of exaggerated unconjugated hyperbilirubinemia. This probably reflects the uncer-tainties, controversies, and confusion in the literature on virtually all these issues. No large scale clinical trial of treatment of term newborns with jaundice has ever been undertaken.
Office-based practitioners as a group more closely reflect the latest published recommendations for ex-change transfusion than the neonatologists, who tend to be more aggressive in treatment.1 It is of
interest that .5% of office-based practitioners and 2% of neonatologists responded that they would not perform an exchange transfusion at all on this type of child regardless of serum bilirubin concentration. This remains the minority position, however, among those writing on the subject and does not concur with recent AAP guidelines.1
The results of a survey of this type must be inter-preted cautiously. Respondents, even when in-structed to report their actual practice, may report what they believe to be acceptable or recommended practices rather than what they actually do, leading to conclusions that approximate the standard or norm. Nevertheless, the responses are likely to rep-resent the general philosophical position of the groups and the range of these practices. Significant differences between the two groups are also likely to remain, as is apparent in this study.
Newman and Maisels5 recommend initiation of
phototherapy in this low-risk clinical situation only when the total serum bilirubin exceeds 17.5 to 22.0 mg/dL (299 to 376 mM/L); Gartner and Lee,9 and
Whitington and Gartner10only when in excess of 20
mg/dL (342mM/L), and Lewis and colleagues11only
when in excess of 18.8 mg/dL. The AAP guidelines on treatment of neonatal hyperbilirubinemia state that phototherapy should be initiated when bilirubin levels exceed 15 mg/dL for a 36-hour-old term infant and.18 to 20 mg/dL in the term neonate.48 hours of age in the absence of hemolysis and other high risk states. The 1992 AAPGuidelines for Perinatal Carealso
TABLE 2. Characteristics of Neonatologists and Office-based Pediatricians Surveyed (numbers in parentheses are percent)
Neonatologists (n5444)
Office-based Pediatricians (n5442)
Years in practice
0–5 95 (21.4) 117 (26.5)
6–10 129 (29.1) 121 (27.4)
11–15 113 (25.5) 72 (16.3)
16–20 72 (16.2) 50 (11.3)
21–25 19 (4.2) 22 (5.0)
25–30 12 (2.7) 25 (5.7)
more than 30 4 (0.9) 35 (7.9)
Years at present practice
0–5 200 (45.0) 186 (42.1)
6–10 118 (26.6) 101 (22.9)
11–15 79 (17.8) 54 (12.2)
16–20 38 (8.6) 38 (8.6)
21–25 8 (1.9) 21 (4.8)
26–30 0 (0.0) 18 (4.1)
more than 30 1 (0.2) 24 (5.4)
Region of practice
Northeast 101 (22.7) 122 (27.6)
Southeast 79 (17.8) 70 (15.8)
Great Lakes 67 (15.1) 58 (13.1)
Midwest 38 (8.6) 29 (6.6)
South 57 (14.4) 43 (9.7)
Northwest 16 (3.6) 19 (4.3)
Southwest 79 (17.8) 80 (18.1)
Canada 0 (0.0) 0 (0.0)
Other 3 (0.6) 3 (0.6)
Missing 4 (0.9) 18 (4.1)
Population size
One million and over 157 (35.6) 112 (25.3)
50 000–999 000 252 (56.8) 223 (50.5)
2501–49 999 30 (6.8) 87 (19.7)
Less than 2500 0 (0.0) 1 (0.2)
Missing 5 (1.1) 19 (4.3)
Practice setting (Primary Activity)
Solo/two-physician practice 47 (10.6) 112 (25.3) Private pediatric group (.3) 46 (10.4) 144 (32.6)
Multispecialty group 22 (5.0) 52 (11.8)
Health Maintenance Organization 6 (1.4) 30 (6.8)
Neighborhood health center 0 (0.0) 7 (1.6)
Medical school (or parent university)
61 (13.7) 14 (3.2)
Hospital (government, university, private)
226 (51.0) 48 (10.9)
Clinic (government, university, private)
2 (0.4) 7 (1.6)
Other 19 (4.3) 10 (2.3)
suggests that there is no evidence that phototherapy is beneficial if utilized when serum bilirubin concen-trations are,20 mg/dL.12 Despite this, it is evident
from these data that the majority of both office-based pediatricians (55%) and neonatologists (77%) were using criteria for the initiation of phototherapy at serum bilirubin concentrations that were lower than recent recommendations, more closely reflecting older recommendations.13
The tendency toward intervention at lower serum bilirubin concentrations by some physicians may represent a conservative approach to malpractice risk. The more aggressive approach of the neonatol-ogists may reflect the greater frequency with which neonatologists are sued. Different interpretations of the case, different assumptions that individuals may read into the case, and different interpretations of the questions asked may also introduce variability and obscure the actual viewpoint of the respondent. Thus, the case presented is positioned in time at 36 hours of age when it is uncertain what the progres-sion of the serum bilirubin concentration will be during the next 24 to 48 hours. For the phototherapy treatment question, some respondents may have as-sumed a future period, particularly a period beyond 48 hours of age. This would have provided allow-ance for use of a higher serum bilirubin concentra-tion than if the infant was ,48 hours of age. The exchange transfusion question specified “regardless of age” and was probably interpreted by most re-spondents as applying to infants .48 hours of age. With a more detailed case report, it is possible that the spread of answers might have been narrowed. The wide range of answers may also reflect basic differences in philosophies of medical treatment. Certainly, the more aggressive and interventionist attitude of neonatologists as compared with the of-fice-based pediatricians must represent the personal orientation of the intensivists, resulting from training and experience skewed to the highest risk infants with the worst outcomes. Primary care pediatricians would be influenced by the generally favorable out-comes they observe in their patients.
The question of efficiency and utility of various frequencies of serum bilirubin determinations in ne-onates is difficult to resolve without an extremely complex study. In the face of severe hemolytic dis-ease, such as Rh erythroblastosis, recommendations from the 1950’s and 1960’s were to perform the stud-ies at least every 4 hours until the serum bilirubin began to decline.14 In the absence of hemolytic
dis-ease, a frequency of ,6 times per 24 hours seems reasonable, but whether four per 24 hours has greater clinical return and safety than two per 24 hours is unknown. Because the sample case indi-cated that this child had only a single serum bilirubin determination of 11 mg/dL at 36 hours, a relatively high level for this age, it might be considered impor-tant and useful to repeat the determination at least once in the following 12 to 24 hours to estimate the accuracy of the initial value and determine the rate of rise. In the sample case, no information was pro-vided as to whether the infant had any type of hemolysis, except to state that the infant had no
cephalhematoma or glucose 6-phosphate dehydro-genase deficiency. Even with a somewhat elevated serum bilirubin level at 36 hours, the great majority of infants would be unlikely to rise to levels requir-ing intervention with phototherapy or exchange transfusion. The financial and psychosocial cost of repeat testing in relation to clinical benefit is likely to be quite large in this low-risk infant. Yet, to do no repeat testing could place a small number of infants at risk, particularly in an unrecognized situation of hemolysis. It may be of interest to health economists, ethicists, and health care managers that both groups of physicians ranked cost and convenience lowest among the factors on which they based their treat-ment decisions.
The question of clinical ability to judge levels of hyperbilirubinemia from skin intensity and distribu-tion must also be raised. The accuracy of such esti-mates by individual physicians is unknown, but is known to vary widely among individuals and to be influenced by experience, illumination, skin color, and many other factors. The AAP practice parameter suggests that decisions on diagnostic work-ups re-quire individual judgment based on family history, clinical course, and other clinical observations. Therefore, at a serum bilirubin concentration of 11.0 mg/dL (188mM/L), it is unclear whether or not it is necessary to repeat the bilirubin test at least once more to establish whether further work-up, particu-larly for hemolysis is indicated. Some authorities have suggested the level of 12 to 14 mg/dL as indi-cating need for additional diagnostic testing, partic-ularly to rule out hemolysis.5 Recently, it has been
suggested that more intensive surveillance of new-borns is now needed because of the discharge of newborns from the hospital at increasingly younger ages.15 Use of the recently developed noninvasive
expired carbon monoxide monitor may provide this data more readily and accurately, facilitating predic-tions of existing hemolytic problems and need for additional work-up.16
The relatively liberal attitude of respondents, es-pecially office-based pediatricians, in allowing con-tinued breastfeeding, more closely approximates the British attitude on this matter, which is to continue breastfeeding regardless of serum bilirubin concen-tration and treat the hyperbilirubinemia in other ways.17 The young age of the infant in the sample
case (36 hours) may have influenced the decision of many respondents to continue breastfeeding because they may have considered breastfeeding an unlikely cause of such early jaundice in an otherwise healthy infant. Breast milk jaundice does not occur at 36 hours of age, although breastfeeding jaundice, the newborn equivalent of starvation jaundice, might present as early as the second day of life.18Excessive
supple-mentation with formula and temporary interruption of breastfeeding are also suggested to accommodate the mother’s preference and physician judgment.8
The physician that will never interrupt breastfeeding may adhere to a belief that jaundice in the healthy breastfed infant, regardless of serum bilirubin con-centration, does not produce bilirubin encephalopa-thy; scientific evidence for that conclusion is lacking, however. In fact, recent reports of kernicterus in full-term breastfed infants substantiate the rare but real occurrence of severe unconjugated hyperbiliru-binemia in excess of 35 mg/dL (595 mM/L) with brain damage, usually as a result of poor breastfeed-ing practices and insufficient milk.15
CONCLUSIONS
This survey suggests that there is a very wide range of “acceptable” practice in the treatment of the well, term newborn with hyperbilirubinemia. It would be of great interest and of potential practical importance to gain a greater understanding of the thinking of the practitioner when making decisions on such matters. Surveys of this type may also pro-vide a basis for measuring the impact of economic, legal, and educational pressures brought to bear on practitioners. This survey will provide a baseline for the comparison of treatment of neonatal jaundice several yearsafterpublication of the AAP 1994 prac-tice parameter on neonatal jaundice.1
ACKNOWLEDGMENTS
We thank Susan Fox, MPH, for assistance with data analysis. We also thank those on the Subcommittee on Hyperbilirubinemia who assisted in developing the survey, and Data Shop, Inc, for providing data entry services.
REFERENCES
1. 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 –565
2. Schmorl G. Zur kenntnis des ikterus neonatorum, Insbesondere der dabei auftretenden gehirnveranderunger.Verh Dtsch Ges Pathol. 1904; 15:109
3. Maisels MJ. Jaundice. In: Avery GB, Fletcher MA, MacDonald MG, eds.
Neonatology: Pathophysiology and Management of the Newborn. 4th ed. Philadelphia, PA: JB Lippincott Co; 1994:687–708
4. Watchko JF, Oski FA. Bilirubin 20 mg/dL5vigintiphobia.Pediatrics. 1983;71:660 – 663
5. Newman TB, Maisels MJ. Evaluation and treatment of jaundice in the term infant: a kinder, gentler approach.Pediatrics. 1992;89:809 – 818 6. Brown AK, Kim MH, Wu PYK, et al. Efficacy of phototherapy in
prevention and management of neonatal hyperbilirubinemia.Pediatrics. 1985;75(suppl):393– 400
7. Gartner LM, Auerbach KG. Breast milk and breastfeeding jaundice.Adv Pediatr. 1987;34:249 –274
8. Martinez JC, Maisels MJ, Otheguy L, et al. Hyperbilirubinemia in the breast-fed newborn: a controlled trial of four interventions.Pediatrics. 1993;91:470 – 473
9. Gartner LM, Lee KS, Morecki R. Jaundice and liver disease. In: Fanaroff AA, Martin R, eds.Neonatal-Perinatal Medicine: Diseases of the Fetus and Infant. 4th ed. St Louis, MO: CV Mosby; 1991:1075–1104
10. Whitington PF, Gartner LM. Disorders of bilirubin metabolism. In: Nathan DG, Oski FA, eds.Hematology of Infancy and Childhood. 4th ed. Philadelphia, PA: WB Saunders; 1993:74 –114
11. Lewis HM, Campbell RH, Hambleton G. Use or abuse of phototherapy for physiological jaundice of newborn infants.Lancet. 1982;2:408 – 410 12. American Academy of Pediatrics and American College of
Obstetri-cians and Gynecologists. In: Freeman RK, Poland RL, eds.Guidelines for Perinatal Care. 3rd ed. Elk Grove Village, IL, and Washington, DC: 1992:208 –210
13. Brown AK, Seidman DS, Stevenson DK. Jaundice in healthy term neonates: do we need new action levels or new approaches?Pediatrics. 1992;89:827
14. Allen FH, Diamond LK.Erythroblastosis Fetalis Including Exchange Trans-fusion Technique. Boston, MA: Little, Brown; 1958
15. Maisels MJ, Newman TB. Kernicterus in otherwise healthy, breast-fed newborns.Pediatrics. 1995;96:730 –733
16. Seidman DS, Shiloh M, Stevenson DK. Role of hemolysis in neonatal jaundice associated with glucose-6-phosphate dehydrogenase defi-ciency.J Pediatr. 1995;127:804 – 806
17. Dodd KL. Neonatal jaundice—a lighter touch.Arch Dis Child. 1993;16: 529 –532
DOI: 10.1542/peds.101.1.25
1998;101;25
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Lawrence M. Gartner, Carla T. Herrarias and Robert H. Sebring
Practice Patterns in Neonatal Hyperbilirubinemia
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