!Si ECON.D O~PJNItNS

Keeping kernicterus in checkAnAAPNews article recently encouraged pediatricians

to renew their efforts to keep kernicterus in check(O'Keefe L. AA4P News. 2001;18:231). The article recom-mended that pediatricians follow the established AAPpractice parameter regarding neonatal hyperbilirubine-mia (Pediatrics. 1994;92:558-565). Unfortunately, the arti-cle then goes on to offer its own recommendation, onewhich is contrary to theAAP practice parameter and onethat could potentially be harmful to many infants.TheAAPNewsarticle recommends that all infants with

a bilirubin- level exceeding 25 mg/dL be hospitalizedimmediately and treated with intensive phototherapy.The practice parameter actually recommends thisapproach only for selected babies -term infants who arehealthy, with no evidence ofhemolysis, and over 48 hoursofage. Anybabywho is a) less than 37 weeks gestation, b)showing signs ofan underlying serious illness, c) demon-strating evidence ofhemolysis or d) less than 48 hours ofage probably should be prepared for an exchange trans-fusion and not a trial of phototherapy. While it is appro-priate to institute phototherapyupon adrnission oftheseinfants while preparing for the exchange transfusion,phototherapy does not eliminate the need for anexchange transfusion in these high-risk newborns.

Marcus C. Hermansen, M.D., FAAPNashua, N.H.

Responsefrom JeffreyMaisels, M.D., FAAP, chair oftheAAPSubcommittee on Neonatal Hyperbilirubinemia:

Dr. Hermansen is correct that the criteriafor e-xchange trans-fusion in high-risk infants are differentfrom those ofhealthyinfants. However, the AAP News recommendation is not"....contrary to theAAP practice parameter.. ."Thefinal paragraph ofthe article states that infants with a

bilirubin level exceeding 25 mgldL should be hospitalizedand placed under intensive phototherapy immediately. Thisis correctand is, indeed, thefirststep to be taken in any infantofany age or clinical condition who has a bilirubin levelexceeding25mgldL. Thepurposeofthestatementistoempha-size that infants with these bilirubin levels should be treatedexpeditiou-sly. Itsays nothingabouta trial ofphototherapy nordoes it imply that immediate exchange transfusion should notbe considered. Clearly this type ofnews article cannot dealwith every eventuality, and a decision regarding exchangetransfusion should certainly take into account the riskfactorslisted by Dr. Hermansen.

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AAP News, the official newsmagazine of theAmerican Academy of Pediatrics, is dedicated toinforming, educating and inspiring readers on

matters related to pediatric health care.

EDITORAnne Hegland

ASSOCIATE EDITORTrisha KoriothSTAFF WRITERSCarla Kemp

Alyson Sulaski WyckoffEDITORIAL INTERNAmy CynkarART DIRECTORMichael Hayes

PRE-PRESS ASSISTANTMark Krajecki

WASHINGTON CORRESPONDENTPoppy Meier

EDrMRLAL ADVISORY BOARDStuart J. Brink, M.D., FAAP

Waltham, Mass.William L. Coleman, M.D., FAAP

Chapel Hi/ll N.CGilbert L. Fuld, M.D., FAAP

Keene, N.H.Mika Hliramatsu, M.D., FAAP

Castro Valley, Calif.Daniel Levy, M.D., FAAP

Owingzs Mills, Md.Moll A. OGorman, M.D. FAP

Salt Lake C;v. UtahJohqn M. Pas(coe, M. D., FAAPz

Michael J. Welfch, M.D., FAAPSan Diego,Caif.

Patriotism runs deep among these four siblings, whocelebrated Independence Day in style.

Persuading parentsDr. Michael Welcl's approach for explaining the use of

inhaled steroids to parents, presented in the MayAAPNews(2001;18:214), will help pediatricians win acceptance ofthisimportant medicine. I have found two additional steps to bepersuasive.

I ask reluctant parents to keep a detailed daily diary ofsigns, symptoms and peak flow scores for two weeks. Theyare often surprised at the frequency ofcough or minor inter-ference with activity, symptoms that theyhad not attributedto asthma.Almost all parents understand that a child, for whom

inhaled steroids are prescribed, may have to take them foryears. Many are loath to make such a commitment. I askthem to agree to a one-month trial so they can observe theeffect inhaled steroids have on their child. At the follow-upvisit, almost all ofthem agree that the benefit is much greaterthan they had imagined and agree to continue using thiseffective medicine.

Thomas F. Plaut, M.D., PAAPAmherst, Mass.

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'You know honey, sometimnes I miss the bickering'

22 AAP News July 2001