In 2004 the American Academy of Pediatrics (AAP) revised its guidelines for management of severe hyperbilirubinaemia in the newborn.¹ The objective was to strike a balance between preventing severe hyperbilirubinaemia and its sequelae on the one hand and minimising overinvestigation and treatment of physiological jaundice on the other.

BACKGROUND TO THE REVISION OF THE 1994 GUIDELINES

The previous guidelines, published in 1994,² reflected a “kinder, gentler” approach to neonatal jaundice.³ Thanks to improvements in the management of rhesus isoimmunisation, bilirubin encephalopathy and kernicterus had virtually disappeared among term infants in the western world. Many paediatricians were concerned that this experience was extrapolated inappropriately to neonatal jaundice in general, and that infants with physiological and breast milk jaundice were undergoing unnecessary investigation and treatment. The 1994 guidelines were directed to reducing such intervention. They included the recommendation, however, that all infants discharged within 48 hours of birth should be followed up within three days.

Increasingly early postnatal discharge of term and near term infants, and initiatives to promote breast feeding, coincided with the more relaxed approach to neonatal jaundice. Ironically, these developments may have contributed to the re-emergence of severe jaundice and bilirubin encephalopathy in North America and Europe.^4–6 Reported associations included relatively short gestation⁷ and comorbidity, particularly glucose-6-phosphate dehydrogenase deficiency.⁴ Possibly early discharge, before jaundice has reached a maximum and breast feeding is established, leaves some infants, particularly if immature or ill, vulnerable to severe jaundice, which would previously have been identified during inpatient postnatal stay. Non-white infants may be particularly vulnerable because, compared with white infants, jaundice is more difficult to evaluate clinically and glucose-6-phosphate dehydrogenase deficiency is more common.

The pendulum thus swung away from the “kinder, gentler” approach and led to the recent revision of the AAP guidelines. The experts who revised them …