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• The "kinder, gentler" approach revisited
  Janet Rennie, Kevin Ives
  Published on: 17 August 2023

• Published on: 17 August 2023

  The "kinder, gentler" approach revisited

  • Janet Rennie, Honorary Consultant Neonatologist UCLH London
  • Other Contributors:
    • Kevin Ives, Consultant Neonatologist

  Sir,

  We read the letter from Noureldein and colleagues with interest. As former members of the NICE guideline committee on neonatal jaundice and individuals who have advised on many medico-legal claims involving kernicterus, we retain our interest in the topic. Thirty years after discussions about a “kinder, gentler” approach (1), the choice of threshold values for phototherapy remains contentious. The Birmingham group question whether the decision to treat babies born at 37 weeks gestation differently from those born at 38-42 weeks was justified. It took many years to appreciate that there was a significant difference regarding the risk of transient tachypnoea of the newborn between babies born at 37 weeks compared with more mature babies (2). Similar information about the risk of kernicterus is never likely to be forthcoming.

  The rationale for treating 37 week gestation babies differently from those born at >38 weeks was based in part on the observation that the less mature group were over-represented in the US kernicterus registry of 1992-2004 (3). Denominator numbers are not available but there were 24 cases at 37 weeks, and a total of 71 at >37 weeks. The new AAP guideline notes that the risk of neurotoxicity from hyperbilirubinaemia is higher at <38 weeks, and with an albumin <3 g/dL (4). The evidence examined for the NICE 2010 guideline consistently showed that a gestational age <38 weeks was associated with an increased risk of hyperbi...

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  Sir,

  We read the letter from Noureldein and colleagues with interest. As former members of the NICE guideline committee on neonatal jaundice and individuals who have advised on many medico-legal claims involving kernicterus, we retain our interest in the topic. Thirty years after discussions about a “kinder, gentler” approach (1), the choice of threshold values for phototherapy remains contentious. The Birmingham group question whether the decision to treat babies born at 37 weeks gestation differently from those born at 38-42 weeks was justified. It took many years to appreciate that there was a significant difference regarding the risk of transient tachypnoea of the newborn between babies born at 37 weeks compared with more mature babies (2). Similar information about the risk of kernicterus is never likely to be forthcoming.

  The rationale for treating 37 week gestation babies differently from those born at >38 weeks was based in part on the observation that the less mature group were over-represented in the US kernicterus registry of 1992-2004 (3). Denominator numbers are not available but there were 24 cases at 37 weeks, and a total of 71 at >37 weeks. The new AAP guideline notes that the risk of neurotoxicity from hyperbilirubinaemia is higher at <38 weeks, and with an albumin <3 g/dL (4). The evidence examined for the NICE 2010 guideline consistently showed that a gestational age <38 weeks was associated with an increased risk of hyperbilirubinaemia (section 3.1, internal page 45). Noureldein et al propose a “risk factor based” approach, but do not specify which risk factors should be used if that of gestation <38 weeks is dropped. There are no plans to screen for glucose-6-phosphatase deficiency, and the bilirubin:albumin ratio was not shown to be useful when evaluated by NICE. From legal cases, we have noted kernicterus occurring at lower than expected serum bilirubin levels in the context of low serum albumin and co-existent anaemia.

  Phototherapy thresholds are chosen with a large margin of safety, given that the level of bilirubin which is likely to prove neurotoxic in an individual baby is variable, and free bilirubin cannot be measured routinely. The main downside of a cautious approach is separation, which could be avoided or minimised with suitable home phototherapy programmes that are currently being developed in the UK. In our view, caution regarding threshold level for phototherapy at 37 weeks is justified, and the way forward is to minimise the disruption of treatment.

  Janet Rennie, Honorary Consultant Neonatologist, UCLH London
  Kevin Ives, Consultant Neonatologist, John Radcliffe Hospital, Oxford
  Reference List

  1. Ives NK. Kernicterus in preterm infants; lest we forget (to turn on the lights). Pediatrics. 1992;90:757-9.
  2. Morrison JJ, Rennie JM, Milton PJ. Neonatal respiratory morbidity and mode of delivery at term: influence of timing of elective caesarean section. British Journal of Obstetrics and Gynaecology. 1995;102:101-6.
  3. Johnson L, Bhutani VK, Karp K, Sivieri EM, Shapiro SM. Clinical report from the pilot USA kernicterus registry (1992 to 2004). Journal of Perinatology. 2009;29:S25-S45.
  4. Kemper AR, Newman TB, Slaughter JL, Maisels MJ. Clinical Practice Guideline revision: management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics. 2022;150(3):e2022058859.

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  Conflict of Interest:
  None declared.

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