ARTICLES
Reduction of Severe Hyperbilirubinemia After
Institution of Predischarge Bilirubin Screening
AUTHORS: Michael P. Mah, MD, Steven L. Clark, MD, Efe
Akhigbe, MD, MPH, Jane Englebright, RN, PhD, Donna K.
Frye, RN, Janet A. Meyers, RN, Jonathan B. Perlin, MD,
PhD, Mitch Rodriguez, MD, and Arthur Shepard, MD
Hospital Corporation of America, Nashville, Tennessee
KEY WORDS
universal bilirubin screening, bilirubin encephalopathy,
hyperbilirubinemia, kernicterus, neonate
ABBREVIATIONS
AAP—American Academy of Pediatrics
HCA—Hospital Corporation of America
www.pediatrics.org/cgi/doi/10.1542/peds.2009-1412
doi:10.1542/peds.2009-1412
Accepted for publication Jan 7, 2010
Address correspondence to Steven L. Clark, MD, Hospital
Corporation of America, Women and Newborn Clinical Services,
PO Box 404, Twin Bridges, MT 59754. E-mail:
steven.clark@mountainstarhealth.com
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2010 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
PEDIATRICS Volume 125, Number 5, May 2010
WHAT’S KNOWN ON THIS SUBJECT: Universal predischarge
bilirubin screening in a small, regional population is effective in
reducing readmissions for moderate degrees of
hyperbilirubinemia.
WHAT THIS STUDY ADDS: Universal predischarge bilirubin
screening in a very large, multistate national population is
effective in eliminating readmissions for both moderate and
severe degrees of hyperbilirubinemia in normal newborns whose
parents are compliant with care instructions.
abstract
OBJECTIVE: The objective of this study was to demonstrate efficacy of
universal predischarge neonatal bilirubin screening in reducing po-
tentially dangerous hyperbilirubinemia in a large, diverse national
population.
METHODS: This was a 5-year prospective study directed at neonates
who were aged ⱕ28 days and evaluated at facilities of the Hospital
Corporation of America with a serum bilirubin level of ⱖ20.0 mg/dL.
This time frame includes periods before, during, and after the initiation
of systemwide institution of a program of universal predischarge neo-
natal bilirubin screening. The primary outcome measures were serum
bilirubin 25.0 to 29.9 and ⱖ30.0 mg/dL. Neonatal phototherapy use
during these years was also analyzed.
RESULTS: Of the 1 028 817 infants who were born in 116 hospitals be-
tween May 1, 2004, and December 31, 2008, 129 345 were delivered
before implementation and 899 472 infants were delivered after imple-
mentation of this screening program in their individual hospitals. With
a program of universal screening, the incidence of infants with total
bilirubin 25.0 to 29.9 mg/dL declined from 43 per 100 000 to 27 per
100 000, and the incidence of infants with total bilirubin of ⱖ30.0 mg/dL
dropped from 9 per 100 000 to 3 per 100 000 (P ⫽ .0019 and P ⫽ .0051,
respectively). This change was associated with a small but statistically
significant increase in phototherapy use.
CONCLUSIONS: A comprehensive program of prevention, including
universal predischarge neonatal bilirubin screening, significantly re-
duces the subsequent development of bilirubin levels that are known to
place newborns at risk for bilirubin encephalopathy. Pediatrics 2010;
125:e1143–e1148
e1143
As the incidence of Rh isoimmunization
waned in the post-Rhogam era, pedia-
tricians were urged to adopt a “kinder,
gentler approach” to bilirubin man-
agement.1 Other authors disagreed
with this approach, suggesting that a
loss of concern about jaundice may re-
sult in a reemergence of kernicterus.2
Managed care policies also resulted in
a sharp decrease in newborn length of
stay.3 Beginning in the mid-1990s, a se-
ries of reports demonstrated the con-
tinuing occurrence of kernicterus in
healthy, term newborns.2,4–6 Further-
more, the Pilot Kernicterus Registry
suggested an increasing incidence of
reported cases of kernicterus,7 a prob-
lem that may be compounded by the
increased incidence of late preterm
births and the known effect of
lower gestational age on hyperbiliru-
binemia.8 Similar observations were
made in reports from Denmark and
Brazil.9,10 In 2001, statements issued by
the Joint Commission on Accreditation
of Healthcare Organizations11 and the
Centers for Disease Control and Pre-
vention12 warned practitioners of the
increasing threat of kernicterus and
suggested that changes in practices
were required to prevent kernicterus.
The Joint Commission’s Sentinel Event
Alert11 listed universal predischarge
bilirubin screening first in its list of
risk-reduction strategies. In 2004, the
American Academy of Pediatrics (AAP)
revised its Clinical Practice Guideline13
on hyperbilirubinemia in the healthy
newborn. The new guideline included
recommendations for a systematic ap-
proach to predischarge risk assess-
ment for severe hyperbilirubinemia
for all infants. While calling universal
screening the “best documented
method for assessing risk of subse-
quent hyperbilirubinemia,” the AAP
gave physicians a choice of 2 predis-
charge risk assessment strategies: bil-
irubin measurement incorporating
hour-specific bilirubin nomograms for
e1144 MAH et al
stratifying risk groups14,15 or clinical
risk assessment.
Since the publication of the AAP Clini-
cal Practice Guideline in 2004, the ef-
ficacy of universal predischarge bili-
rubin screening has remained in
question. A 2006 report by Eggert et
al16 described the result of implement-
ing universal predischarge bilirubin
screening in an 18-hospital regional
health care system. They showed sig-
nificant reductions in the incidence of
bilirubin levels of ⱖ20.0 and ⱖ25.0
mg/dL (430.0 ␮mol/L). For bilirubin
levels of ⱖ30.0 mg/dL (510.0 ␮mol/L),
the level defined by the National Quality
Forum as a reportable event,17 there
was a trend toward reduction, but the
study was insufficiently powered for
significance in these very rare out-
comes. Our much larger study reports
the results of instituting universal pre-
discharge bilirubin screening in a na-
tionwide hospital system that delivers
⬃5% of US births.
METHODS
The Hospital Corporation of America
(HCA) is the largest hospital system in
the United States, with facilities in 21
states. Previous publications sug-
gested that the demographic makeup
of this patient population is represen-
tative of the United States as a
whole.18,19 In 2003, on the recommen-
dation of its Perinatal Clinical Work
Group, the HCA committed to an
enterprise-wide program of univer-
sal predischarge neonatal bilirubin
screening in an effort to eliminate bili-
rubin levels of ⬎30.0 mg/dL in normal,
healthy, inborn neonates. Each HCA fa-
cility was asked to endorse and imple-
ment policies for universal predis-
charge screening that included
either serum or transcutaneous hour-
specific bilirubin assessment, as well
as provisions for neonatal follow-up
guided by nomograms developed by
Bhutani et al.14 These guidelines pro-
vide for the identification of neonates
who are at high risk and the timing of
neonatal follow-up and repeat biliru-
bin assessment on the basis of an
hour-specific predischarge bilirubin
level. Such measurements augmented
the adoption of protocols set forth in
the revised Clinical Practice Guidelines
of the AAP.13 Of the 126 HCA hospitals
that delivered infants at the start of the
project, 10 were excluded because
they either ceased doing obstetrics or
were divested from the company be-
fore completion of the study. An official
start date for universal bilirubin
screening was obtained for each hos-
pital. Monthly figures for live births
and for infants with hyperbiliru-
binemia were prospectively collected
from each facility. These infants were
assigned to either the unscreened or
the screened group for analysis. For
start dates that fell after the first of the
month, the hospital’s births for the
month were adjusted accordingly.
All neonates who were evaluated at an
HCA facility within 28 days of birth with
total serum bilirubin levels of ⱖ20.0
mg/dL between May 1, 2004, and De-
cember 31, 2008, were identified from
a common laboratory computer sys-
tem. For patients with multiple results,
only the highest value was used for the
analysis. Neonates with bilirubin val-
ues of ⱖ25.0 mg/dL were segregated
into the unscreened or screened
group on the basis of the screening
start date at the hospital where they
presented. Outborn infants were in-
cluded in the study, because deidenti-
fied patient data made it impossible to
distinguish hospital of birth. Data were
collected by 2 specified individuals
(the perinatal nurse manager and the
risk management director) in each fa-
cility to ensure accuracy and submit-
ted on a quarterly basis to our central
data repository for this project.
The hypothesis that guided the data
analysis was that institution of predis-
 ARTICLES

charge bilirubin screening would de-
crease the incidence of subsequent
bilirubin values of ⱖ25.0 mg/dL, and
especially bilirubin values of ⱖ30.0
mg/dL. A second hypothesis was that
this reduction would be accomplished
without increasing the total number of
bilirubin values of ⱖ20.0 mg/dL (used
as a surrogate of increased resource
use). The number and proportion of to-
tal inborn infants who underwent pho-
totherapy were also analyzed for each
year of the study.
The ␹2 test with Yates correction
(InStat3 [GraphPad Software, La Jolla,
CA]) was used to evaluate the signifi-
cance of differences between the
groups. Only the 2-tailed P values are
reported.
This was a quality improvement project
that used deidentified data for analy-
sis. Exemption from institutional re-
view board review was obtained on
the basis of 45CFR46.101(b) (2) and
46.102(f) as well as 45CFR164.514(a) to
(c) of the Health Insurance Portability
and Accountability Act.
TABLE 1 Incidence of Bilirubin Levels of 25.0 to 29.9 mg/dL and ⱖ30 mg/dL in Unscreened Versus
Screened Populations
Parameter Total Births
Screened 899 472
Unscreened 129 345
OR (95% CI) NA
P NA
OR indicates odds ratio; CI, confidence interval.
rate of ⱖ98% in each quarter of the
study.
Infants with bilirubin levels of ⱖ25.0
mg/dL detected between May 2004 and
December 2008 were assigned to ei-
ther unscreened or screened status
on the basis of the policy in effect at the
presenting hospital. Table 1 demon-
strates that institution of universal
predischarge bilirubin screening was
followed by a marked decrease in both
levels of hyperbilirubinemia of 25.0 to
29.9 mg/dL and of bilirubin levels of
ⱖ30.0 mg/dL. The incidence of biliru-
bin levels of 25.0 to 29.9 mg/dL de-
clined by 38%, and bilirubin levels of
ⱖ30.0 mg/dL dropped by 65%. These
Peak Bilirubin Level Peak Bilirubin Level
of 25.0–25.9 mg/dL of ⬎30.0 mg/dL
(n/rate per 100 000) (n/rate per 100 000)
238/26.5 27/3.0
55/42.5 11/8.5
0.62 (0.46–0.83) 0.35 (0.18–0.71)
.0019 .0051
reductions were highly statistically
significant with odds ratios and confi-
dence intervals of 0.62 (0.46 – 0.83) and
0.35 (0.18 – 0.71), respectively.
For infants with bilirubin levels of 20.0
to 24.9 mg/dL, there was small but
highly significant (P ⫽ .0027) decrease
in severe hyperbilirubinemia from
2004 to 2005 coincident with the imple-
mentation of universal screening.
Figure 1, showing the incidence of
hyperbilirubinemia cases by year,
demonstrates the magnitude of the
reduction continuing to increase in
subsequent years. We observed no
adverse clinical effects of bilirubin
screening.

RESULTS
A total of 1 028 817 infants were deliv-
ered at the 116 study hospitals be-
tween May 2004 and December 2008.
On the basis of hospital-declared start
dates, 129 345 births occurred be-
fore implementation of universal
bilirubin screening. The remaining
899 472 births occurred after routine
predischarge bilirubin screenings were
implemented at their birth hospitals.
At the beginning of the study period, a
small number of hospitals were al-
ready practicing universal screening.
There was a rapid shift in the latter
part of 2004 such that by 2005 most
infants were being screened. All cen-
ters had implemented universal pre-
discharge screening by January 1, FIGURE 1
Incidence of severe hyperbilirubinemia by year. a Data from May 1 to December 31, 2004, consisted of
2006. Beyond this time, we observed 832 cases of 149 727 births. b For all of 2005, there were 1048 cases in 216 880 births, significantly
a systemwide screening compliance different from the 2004 incidence at P ⫽ .0027. Additional declines were seen in each subsequent year.

PEDIATRICS Volume 125, Number 5, May 2010 e1145

TABLE 2 Neonatal Phototherapy Use, 2004 –2008
Year Total Neonates Neonates Undergoing
Phototherapy
2004 211 079 9296
2005 214 793 10 794
2006 223 300 11 219
2007 224 451 10 256
2008 218 283 11 186
This reduction in severe hyperbiliru-
binemia was associated with a small
but highly significant increase in the
use of neonatal phototherapy in each
year after the initiation of universal
screening (Table 2). The fraction of ne-
onates who received phototherapy in-
creased from 4.4% of all deliveries in
2004 to 5.1% of all deliveries in 2008,
with a mean of 4.9% during years
2005–2008. Of the 11 186 infants who
received phototherapy in 2008, 10 541
(94.2%) were treated during the birth
admission only, 565 (5.1%) were not
treated during the birth admission but
required later hospitalization for pho-
totherapy, and 80 (0.7%) received pho-
totherapy both during the birth admis-
sion and subsequently.
As part of our quality improvement ef-
fort, additional clinical data were ex-
tracted for each of the 8 infants who
presented in 2008 with bilirubin lev-
els of ⱖ30.0 mg/dL. Two infants
had glucose-6-phosphate dehydroge-
nase deficiency, a congenital condition
of special importance in select black
infants at risk.20 In addition, 1 infant
had hypothyroidism and 1 had multi-
ple, ultimately lethal anomalies. Two
infants were outborn at non-HCA cen-
ters. In the remaining 2 cases, the par-
ents had failed to keep scheduled
follow-up appointments.
DISCUSSION
In this contemporary series encom-
passing ⬎1 million births, the imple-
mentation of a program of universal
predischarge bilirubin screening was
associated with a dramatic and statis-
tically significant decline in the inci-
e1146 MAH et al
% P (vs Baseline 2004)
4.4 NA
5.0 ⬍.001
5.0 ⬍.001
4.6 .008
5.1 ⬍.001
dence of neonates with bilirubin 25.0
to 29.9 mg/dL and in those with biliru-
bin levels of ⱖ30.0 mg/dL (Table 1). Al-
though similar results for infants in
the former group were previously
demonstrated with universal screen-
ing in a much smaller regional popula-
tion and in pilot projects, these data
are the first to demonstrate efficacy
of such a program in a large, de-
mographically heterogeneous popula-
tion.16,21,22 This report is also the first
to show a statistically significant
drop in infants with bilirubin levels
of ⱖ30.0 mg/dL.
The true incidence of hyperbiliru-
binemia is not well documented. Bhu-
tani et al23 estimated the incidence
of severe (ⱖ20.0 mg/dL), extreme
(ⱖ25.0 mg/dL), and hazardous (ⱖ30.0
mg/dL) hyperbilirubinemia by combin-
ing data from a number of disparate
studies. Their approximate incidences
per 100 000 births were 1400, 140, and
10, respectively. For bilirubin levels of
ⱖ25.0 mg/dL, our baseline incidence
of 50 per 100 000 births was lower
than the estimates of Bhutani et al.
This may be related to differences in
the demographics of these popula-
tions or in practice patterns versus the
older studies. For bilirubin levels of
ⱖ30.0 mg/dL, the preintervention inci-
dence was comparable to the 10 per
100 000 estimate of Bhutani et al. The
current incidence of clinical ker-
nicterus and bilirubin encephalopathy
in the United States is unknown; how-
ever, estimates including data from
Denmark and the United Kingdom sug-
gesting an incidence in the range of 1
per 50 000 births suggest that ⬃8
cases of kernicterus may have been
prevented in this population by our
policy of universal screening.6,23,24 Ad-
ditional research into the actual inci-
dence of kernicterus and bilirubin
encephalopathy and the ability of in-
terventions to prevent new cases is
needed.
The study of Eggert et al16 excluded out-
born infants from the analysis. The
combination of losing inborn infants to
other centers and excluding outborn
infants would result in an artificially
low incidence figure. Our analysis in-
cluded outborn patients, allowing us to
approximate better the actual inci-
dence of varying levels of hyperbiliru-
binemia in the population. Inclusion of
such infants would not materially af-
fect our primary results for 2 reasons.
In many regions, HCA has a vertically
integrated system whereby patients
would be referred for specialty care to
other HCA facilities, limiting loss of pa-
tients to outside centers. More impor-
tant, this was a comparative study; we
have no reason to think that the in-
gress and efflux of hyperbilirubinemia
cases differed before and after the in-
stitution of universal bilirubin screen-
ing. Furthermore, the inclusion of such
infants would, if anything, result in an
apparent attenuation rather than ex-
aggeration of the effects of our screen-
ing program.
The measurement of predischarge se-
rum bilirubin level could not have re-
sulted in a decrease in the number
of infants with severe hyperbiliru-
binemia in the absence of increased
phototherapy use. Our demonstration
(Table 2) of a modest but statistically
significant increase in neonatal photo-
therapy use would therefore be ex-
pected. This finding is an additional im-
portant validation that the decrease
in infants with severe hyperbiliru-
binemia was linked causally to the in-
troduction of universal screening and

subsequent treatment of appropriate
infants rather than any change in pa-
tient demographics or disease fre-
quency over time.
Quantification of the cost-effectiveness
of universal bilirubin screening pro-
grams is beyond the scope of this anal-
ysis. We measured the incidence of hy-
perbilirubinemia levels of 20.0 to 24.9
mg/dL—a level generally associated
with readmission—and found a small
but significant decrease in the 2004 –
2005 data and larger decreases in sub-
sequent years (Fig 1). This suggests
that universal screening does not in-
crease overall rehospitalization rates,
potentially generating cost savings.
Conversely, such savings must be
weighed against the cost of photother-
apy and a potential increase in length
of stay in an additional 0.5% of infants.
In a similar manner, calculations place
the cost per case of kernicterus pre-
vented by universal screening in the
range of millions of dollars per case,
balanced by lifetime costs of care for
patients with kernicterus in the same
REFERENCES
1. Newman TB, Maisels MJ. Evaluation and
treatment of jaundice in the term newborn:
a kinder, gentler approach. Pediatrics.
1992;89(5 pt 1):809 – 818
2. Brown AK, Johnson L. Loss of concern
about jaundice and the reemergence of
kernicterus in full-term infants in the era
of managed care. In: Fanaroff AA, Klaus
MH, eds. The Year Book of Neonatal and
Perinatal Medicine. Philadelphia, PA:
Mosby Yearbook; 1996:17–28
3. Braveman P, Egerter S, Pearl M, Marchi K,
Miller C. Problems associated with early
discharge of newborn infants: early dis-
charge of newborns and mothers—a criti-
cal review of the literature. Pediatrics.
1995;96(4 pt 1):716 –726
4. Penn AA, Enzmann DR, Hahn JS, Stevenson
DK. Kernicterus in a full term infant. Pediat-
rics. 1994;93(6 pt 1):1003–1006
5. Maisels MJ, Newman TB. Kernicterus
in otherwise healthy, breast-fed term
newborns. Pediatrics. 1995;96(4 pt 1):
730 –733
6. Ebbesen F. Recurrence of kernicterus in
PEDIATRICS Volume 125, Number 5, May 2010
range.25,26 It should be noted that uni-
versal predischarge bilirubin screen-
ing was recently endorsed by the
Canadian Paediatric Society27 in an en-
vironment where health care is large-
ly government owned and operated
and cost-effectiveness is of para-
mount concern.
Although gratifying in demonstrating
the sustainable impact of the interven-
tion, the data presented in Fig 1 sug-
gest that universal bilirubin screening
in isolation was not responsible for all
of the observed improvement in out-
comes. With publication of the 2004
AAP Clinical Practice Guideline,13 the
Perinatal Clinical Workgroup believed
that it could not endorse predischarge
bilirubin screening without concur-
rently implementing the rest of the AAP
recommendations. Moreover, chang-
ing the practices and perceptions of
the thousands of nurses and physi-
cians involved in care of infants is a
lengthier process than implementing
a laboratory test.28 It is likely that fac-
tors such as additional staff educa-
term and near-term infants in Denmark.
Acta Paediatr. 2000;89(10):1213–1217
7. Bhutani VK, Johnson L. Synopsis report
from the pilot USA Kernicterus Registry. J
Perinatol. 2009;29(suppl 1):S4 –S7
8. Keren R, Tremont K, Luan X, et al: Visual as-
sessment of jaundice in term and late pre-
term infants. Arch Dis Child Fetal Neonatal
Ed. 2009;94(5):F317–F322
9. Ebbesen F, Andersson C, Verder H, et al. Ex-
treme hyperbilirubinemia in term and
near-term infants in Denmark. Acta Paedi-
atr. 2005;94(1):59 – 64
10. Facchini FP, Mezzacappa MA, Rosa IR, Mez-
zacappa Filho F, Aranha-Netto A, Marba
ST. Follow-up of neonatal jaundice in term
and late premature newborns[in Portu-
guese]. J Pediatr (Rio J). 2007;83(4):
313–322
11. Joint Commission on Accreditation of
Healthcare Organizations. Kernicterus
threatens healthy newborns. Sentinel Event
Alert. 2001;18(18):1– 4
12. Centers for Disease Control and Prevention.
ARTICLES
tion, improved physician and paren-
tal awareness of hyperbilirubinemia
and kernicterus, and enhanced lac-
tation support all contributed to the
ongoing reduction in hyperbiliru-
binemia; however, universal predis-
charge bilirubin measurement was
the lynchpin of a larger systematic
program for prevention of hyperbil-
irubinemia, the full effects of which
are still being revealed. This pro-
gram was well accepted by the over-
whelming majority of nurses, physi-
cians, and parents.
CONCLUSIONS
Examination of these data, including
the circumstances of the 8 infants who
had bilirubin levels of ⱖ30.0 mg/dL
and presented in 2008, suggests that
we have largely succeeded in eliminat-
ing levels of neonatal bilirubin as-
sociated with the development of
bilirubin encephalopathy for healthy
infants who are born in HCA hospi-
tals and receive the recommended
follow-up.
Kernicterus in full-term infants: United
States, 1994 –1998. MMWR Morb Mortal
Wkly Rep. 2001;50(23):491– 494
13. American Academy of Pediatrics Subcom-
mittee on Hyperbilirubinemia. Manage-
ment of hyperbilirubinemia in the new-
born infant 35 or more weeks of gestation
[published correction appears in Pediatrics.
2004;114(4):1138]. Pediatrics. 2004;114(1):
297–316
14. Bhutani VK, Johnson L, Sivieri EM. Pre-
dictive ability of a predischarge hour-
specific serum bilirubin for subsequent
significant hyperbilirubinemia in healthy
term and near-term newborns. Pediat-
rics. 1999;103(1):6 –14
15. Johnson LH, Bhutani VK, Brown AK. System-
based approach to management of neona-
tal jaundice and prevention of kernicterus.
J Pediatr. 2002;140(4):396 – 403
16. Eggert LD, Wiedmeier SE, Wilson J, Chris-
tensen RD. The effect of instituting a
prehospital-discharge newborn bilirubin
screening program in an 18-hospital health
system. Pediatrics. 2006;117(5). Available
e1147
 at: www.pediatrics.org/cgi/content/full/
117/5/e855
17. National Quality Forum. Serious reportable
events in healthcare, 2005–2006 update. Avail-
able at: www.qualityforum.org. Accessed Feb-
ruary 15, 2010
18. Clark S, Belfort M, Saade G, et al. Implemen-
tation of a conservative checklist-based
protocol for oxytocin administration: ma-
ternal and newborn outcomes. Am J Obstet
Gynecol. 2007;197(5):480.e1– 480.e5
19. Clark SL, Miller DD, Belfort MA, Dildy GA, Frye
DK, Meyers JA. Neonatal and maternal out-
comes associated with elective term deliv-
ery. Am J Obstet Gynecol. 2009;200(2):
156.e1–156.e4
20. Kaplan M, Herschel M, Hammerman C, et al.
Neonatal hyperbilirubinemia in African
American males: the importance of glucose-6-
e1148 MAH et al
phosphate dehydrogenase deficiency. J Pe-
diatr. 2006;149(1):83– 88
21. Stark AR, Lannon CM. Systems changes to
prevent severe hyperbilirubinemia and pro-
mote breastfeeding: pilot approaches. J
Perinatol. 2009;29(suppl 1):S53–S57
22. Lazarus C, Avchen RN. Neonatal hyperbiliru-
binemia management: a model for change.
J Perinatol. 2009;29(suppl 1):S58 –S60
23. Bhutani VK, Johnson LH, Maisels MJ, et al.
Kernicterus: epidemiological strategies
for its prevention through systems-based
approaches. J Perinatol. 2004;24(10):
650 – 662
24. Manning D, Todd P, Maxwell M, et al. Pro-
spective surveillance study of severe hyper-
bilirubinemia in the newborn in the UK and
Ireland. Arch Dis Child Fetal Neonatal Ed.
2007;92(5):F243–F246
25. Suresh GK, Clark RE. Cost-effectiveness of
strategies that are intended to prevent ker-
nicterus in newborn infants. Pediatrics.
2004;114(4):917–924
26. Centers for Disease Control and Preven-
tion. Kernicterus/jaundice–video tran-
script. Available at: www.cdc.gov/ncbddd/
dd/kernicterus/kernicterusvideos/
kernicterustransc.html Accessed Feb-
ruary 15, 2010
27. Canadian Paediatric Society. Guidelines for
detection, management and prevention of
hyperbilirubinemia in term and late pre-
term newborn infants (35 or more weeks’
gestation): summary. Paediatr Child Health.
2007;12(5):401– 407
28. Schwoebel A, Gennaro S. Neonatal hyperbi-
lirubinemia. J Perinat Neonatal Nurs. 2006;
20(1):103–107