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April 2018

Initiating Phototherapy at Subthreshold LevelsThe Slippery Slope

Author Affiliations
  • 1Department of Pediatrics, University of Washington, Seattle
  • 2Seattle Children’s Hospital, Seattle, Washington
JAMA Pediatr. 2018;172(4):322-324. doi:10.1001/jamapediatrics.2017.5744

Perhaps it is human nature that when given a specific cutoff value for initiating therapy for a specific condition, health care professionals actually begin treatment at ever lower values over time in anticipation of the patient approaching the treatment threshold. This can occur even when the threshold values are established more to provide a wide range of safety than to delineate the line between sick and well.

This slippery slope effect is dramatically illustrated in the report by Wickremasinghe et al1 in this issue of JAMA Pediatrics. These investigators report that in a large health care organization (Kaiser Permanente Northern California hospitals), phototherapy was frequently initiated in newborns with total serum bilirubin (TSB) levels 0.1 to 3.0 mg/dL below the treatment threshold recommended in the 2004 American Academy of Pediatrics (AAP) hyperbilirubinemia guideline, which takes into account a neonate’s age (by hours), TSB level, and neurotoxicity risk factors.2 Over a 5-year period (2010-2014), among 25 895 newborns with TSB levels within this range during their birth hospitalizations, 4956 (19.1%) received phototherapy. Ostensibly, phototherapy was initiated at subthreshold TSB levels to prevent hospital readmissions. In fact, the investigators found that this early use of phototherapy was effective in preventing readmissions; only 4.9% of newborns receiving phototherapy when their TSB levels were subthreshold were readmitted compared with 12.8% of those with similar TSB levels who did not receive phototherapy during their birth hospitalization. Unfortunately, the use of subthreshold phototherapy increased the average length of stay during the birth hospitalization by approximately 22 hours, and the calculated number needed to treat to prevent 1 readmission was 14, suggesting that this practice led to substantial unnecessary treatment.