Less aggressive treatment of neonatal jaundice and reports of kernicterus:Lessons about practice guidelines

The publication of guidelines calling for less aggressive treatment of jaun dice in newborns has been followed by a reappearance of case reports of ker nicterus. These case reports illustrate important issues for writers and co nsumers of practice guidelines. One issue is the particular salience of ide ntified patients with bad outcomes, and their potentially disproportionate influence on decision-makers. A second issue is whether, when good evidence of treatment benefit is lacking, policymakers should recommend what has tr aditionally been done, recommend less treatment, or not make recommendation s at all. Finally, the cases raise the question of whether treatment guidel ines should be more conservative than their authors actually believe is nec essary, to take into account the likelihood that they will not be closely f ollowed. We believe that case reports can serve as an important early warning system , but policymakers should be aware of their potentially disproportionate in fluence. In the long run, patients and clinicians will be best served by gu idelines that summarize and acknowledge the limitations of existing evidenc e, that allow a wide range of treatment options when evidence is weak, and that recommend what the guideline authors actually believe should be done. In the short run a period of readjustment may be required, however, as clin icians become accustomed to guidelines written to be followed, rather than bent.