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The WHO is to be commended on its recent (2005) publication
"Pocketbook of Hospital Care for Children: Guidelines for the Management
of Common Illnesses with Limited Resources" (1). This book, which is aimed
at physicians and other health workers in developing countries, was
recently favourably reviewed in Archives of Disease in Childhood (2).
With regard to the management of neonatal hyperb...
With regard to the management of neonatal hyperbilirubinaemia in the
chapter on the care of the newborn (3), I would like to point out that
kernicterus, although rare, is a tragic but potentially preventable
condition. As this condition continues to be encountered even in
developed countries (4,5,6) the guidelines for the management of severe
hyperbilirubinaemia have been dynamic and are constantly being reviewed
and adapted. Accordingly, the Subcommittee on Hyperbilirubinemia of the
American Academy of Pediatrics (AAP) recently revised its guidelines (7)
and published an updated statement (8). In that statement, the thresholds
for phototherapy and exchange transfusion are considerably lower than
those published in the WHO book.
In a review of the evidence behind the WHO recommendations for
exchange transfusion, special attention was drawn to the recent AAP
guideline (9). It was suggested that, in view of the dearth of evidence
based data, the AAP guidelines now be recommended. However, as the WHO
and AAP statements were most likely in the process of being published
concurrently, and as the review containing the caveat regarding the AAP
guidelines was posted subsequent to publication of the WHO book, it is
possible that many readers may be unaware of the subsequent qualification.
Users of the otherwise excellent WHO publication should be aware of
the latest AAP guidelines and take them into consideration, in conjunction
with the WHO guide, when confronted with management decisions in
Michael Kaplan, MB ChB,
Department of Neonatology, Shaare Zedek Medical Center; Faculty of
Medicine of the Hebrew University, Jerusalem, Israel.
1. World Health Organization. Pocket book of hospital care for
children: Guidelines for the management of common illnesses with limited
resources. 2005. WHO Press, Geneva.
2. Thomson J, Chavan A. Pocket book of hospital care for children:
guidelines for the management of common illnesses with limited resources.
Arch Dis Child 2006;91:624-625.
3. World Health Organization. Jaundice, in Problems of the neonate
and young infant, in Pocket book of hospital care for children: Guidelines
for the management of common illnesses with limited resources. 2005. WHO
Press, Geneva. Available at http://www.who.int/child-adolescent-
4. Bhutani VK, Johnson LH, Jeffrey Maisels M, Newman TB, Phibbs C,
Yeargin-Allsopp M. Kernicterus: epidemiological strategies for its
prevention through systems-based approaches. J Perinatol. 2004;24:650-662.
5. AlOtaibi, SF; Blaser, S; MacGregor, DL. Neurological
complications of kernicterus. Can J Neurol Sci. 2005;32:311-315.
6. Ebbesen F. Recurrence of kernicterus in term and near-term
infants in Denmark. Acta Paediatr. 2000;89:1213-1217.
7. American Academy of Pediatrics Practice Parameter. Management of
hyperbilirubinemia in the healthy term newborn. Pediatrics. 1994;94: 558-
8. American Academy of Pediatrics Subcommittee on
Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant
35 or more weeks of gestation. Pediatrics. 2004;114:297-316.
9. Nightingale S, Kaplan M (reviewers). When should exchange
transfusion be performed in hyperbilirubinaemia? International Child
Health Review Collaboration. 2006. Available at