Universal Bilirubin Screening, Guidelines, and Evidence

In a commentary1 and update of the 2004 American Academy of Pediatrics (AAP) guideline “Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation”2 in this issue of Pediatrics , Maisels et al recommend that all newborns have a bilirubin measurement before discharge from their birth hospitalization. In contrast, a recommendation statement from the US Preventive Services Task Force (USPSTF),3 supported by a systematic review,4concludes that evidence is insufficient to make that recommendation. As an author of the commentary1 and the 2004 AAP jaundice guideline2 who also has been critical of guidelines based on insufficient evidence,5–11 I have felt particularly torn about this recommendation. Perhaps partly because I have served as an expert consultant on dozens of heartbreaking kernicterus legal cases,12 I find the argument in favor of universal bilirubin screening and systematic follow-up persuasive. We know kernicterus is devastating and that, although rare, cases are continuing to occur. Furthermore, anecdotal evidence suggests that many cases could have been prevented by earlier measurement of bilirubin levels, leading to closer follow-up and earlier initiation of appropriate therapy.13,14 We have not had randomized trials to show that universal screening and systematic follow-up will lead to a reduction in kernicterus, but considerable research in the area of optimizing patient safety suggests that there is room for improvement in the 2004 guidelines. Specifically, we know that in the absence of universal screening, detection and management of clinically significant hyperbilirubinemia during the birth hospitalization relies on several imperfect steps: (1) nurses and doctors need to remember to examine the infant for jaundice; (2) they need to distinguish visually between jaundice that is and is not clinically significant for the infant's age in hours; and … Address correspondence to Thomas B. Newman, MD, MPH, University of California, Department of Epidemiology and Biostatistics, Box 0560, San Francisco, CA 94143. E-mail newman{at}epi.ucsf.edu