www.jpeds.

com THE EDITORS’ PERSPECTIVES

January 2018 • Volume 192 Copyright © 2018 by Elsevier Inc.

The uncomfortable
problem of
U nbound, unconjugated bilirubin is neurotoxic and increased levels lead to bili-
rubin encephalopathy in newborn infants. Clinical evaluation of unbound bili-
rubin is not typically available and potentially neurotoxic levels must be inferred from
unbound bilirubin the total serum bilirubin level that reflects both albumin-bound unconjugated biliru-
bin and unbound bilirubin. Inferring safe levels of unbound bilirubin is less reliable
in extremely in preterm compared with full term infants, and in this volume of The Journal, Amin
preterm infants et al explore this problematic situation. Unbound bilirubin was measured prospec-
tively during the first postnatal week in preterm infants and as expected, infants born
— Raye-Ann deRegnier, MD at <30 weeks of gestation had reduced bilirubin binding affinity. More unexpectedly,
the authors observed an uncoupling of the relationship between unbound bilirubin
and total serum bilirubin: even as total serum bilirubin levels decreased, unbound bili-
rubin continued to rise, potentially increasing the risk of neurotoxicity. The confi-
dence limits for this finding were broad, suggesting considerable individual variation
that needs further investigation.
This study adds to the uncomfortable problem of jaundice in extremely preterm infants.
It is not clear whether neonatologists should have a high level of concern about unbound
bilirubin in routine patient care as we seldom identify extremely preterm infants with
symptoms of acute bilirubin encephalopathy. We do not know if this is because symp-
toms rarely occur or if they are just very difficult to identify in this population. The
long-term implications have not been evaluated, and the balance of risks and benefits
of phototherapy may be more complicated than is currently understood (Clin Perinatol
2016;43:291-5). This study should spur further investigation in many directions with
a goal to better understand the causes and effects of unbound hyperbilirubinemia in
extremely preterm infants.
Article page 47 ▶

Newborn
screening in the
N ewborn screening for treatable conditions is a foundation of pediatric practice.
For example, prior to universal implementation of newborn screening for con-
genital hypothyroidism in the United States, it was a leading cause of intellectual dis-
United States ability. In this volume of The Journal, a study by Kilberg et al describes the approaches
to newborn screening for congenital hypothyroidism across the US. Their main finding
may miss mild is that many programs do not adjust TSH cutoffs according to the infant’s age, despite
persistent protocols in which initial or repeat TSH measurements may be performed outside of
the age for which the cutoffs were established. Because TSH peaks in the first few days
hypothyroidism of life and then falls rapidly, mild elevations in TSH outside of the recommended testing
— David M. Maahs, MD, PhD period may be misclassified as normal. Although the impact of mild elevations of TSH
and Phil Zeitler, MD, PhD are controversial, some studies have shown that a substantial number of these pa-
tients will have permanent primary hypothyroidism.
The authors recommend that all newborn screening programs provide age adjusted
TSH cutoffs, a potentially rapid and inexpensive response to the data. The authors also
discuss the wide array of approaches and algorithms for screening used by the different
states and suggest that it may be time for programs and relevant academic societies to
work together at a national level to develop a standard approach to screening for con-
genital hypothyroidism across the US, likely a more long-term, but worthwhile endeavor.
Article page 204 ▶

1
THE JOURNAL OF PEDIATRICS • www.jpeds.com

Is it the baby or
the beds?
S ince the 1960s, reductions in neonatal mortality in the United States track closely
with the increased availability of neonatal intensive care unit beds. Not surpris-
ingly, as the number of intensive care unit beds have increased, the number of babies
— Clyde Wright, MD admitted to these units to fill these beds has increased. While there is no doubt that
the large proportion of these admissions are necessary and result in improved out-
comes, there is also the possibility that the mere prospect of bed availability drives NICU
admission. In this volume of The Journal, Harrison et al use large national data sets to
determine the relationship between NICU admission and regional bed supply. Impor-
tantly, the authors have uncovered regional variation in NICU bed availability that is
not explained by validated markers of need. Furthermore, it appears that bed avail-
ability may drive NICU admission rates, especially for larger (potentially “less sick”)
babies. The implications for resource allocation and utilization are staggering. These
results scratch the surface of a complex set of issues and reveal important questions
that we must begin to answer in order to provide responsible, appropriate, and effec-
tive health care. We must do better in deciding where to provide services, and work
hard and continually re-evaluate whether the services we provide are safe, necessary,
beneficial, and cost-effective.
Article page 73 ▶

The need to prevent

cardiovascular
I n this volume of The Journal, Gidding et al, representing the TODAY study, report
longitudinal data on cardiac biomarkers and their relationship to cardiovascular disease
(CVD) risk factors and left ventricular structure and function in youth with type 2 dia-
disease in youth betes (T2D). BNP, TNF-a, and troponin were elevated and increased over the 5-year
study. However, these markers did not necessarily persist in individuals or in relation-
onset type 2 ship to glycemia or CVD structure or function. The authors conclude that elevated serum
diabetes concentrations of cardiac biomarkers were common in youth with T2D, but their clini-
cal significance is unclear and will require further long-term study.
— David M. Maahs, MD, PhD The authors also emphasize that these biomarkers should be interpreted with caution—
an important message if a youth with T2D has these labs drawn in an emergency de-
partment or otherwise. Given the adverse outcomes being reported in adulthood in
people who were diagnosed with T2D in youth, these data highlight the need for on-
going study to address a potential major public health problem in the US and worldwide.
Article page 86 ▶

2 Volume 192