Bilirubin recommendations present problems: new guidelines simplistic and untested

Newman and Maisels1 raise strong arguments to change our approach to neonatal jaundice in the wellbaby nursery. The plea for a more gentle approach to the jaundiced newborn is long overdue, but what do we then do? Newman and Maisels not only identify the problem, but they offer a detailed solution which would significantly alter standards of practice for neonates. While one might bicker about their selection of evaluation tests to be conducted in the nursery, the proposed guidelines present two more fundamental problems: (1) the recommendation for intervention (total bilirubin concentration 25 to 29 mg/dL) sustains the myth that the total unconjugated bilirubin is the best clinical predictor of kernicterus and ignores known and proposed pathochemical processes involved in bilirubin encephalopathy, and (2) no mechanism is proposed to evaluate the safety and efficacy of their proposal.