Due to optimal newborn care and preven-tion of Rh immunization, bilirubin neuro-toxicity is not a common problem of term babies in more developed countries; however, it is still a serious threat to the neuro-development of many children in Turkey. One of the main problems in our country is that, on admission to the hospital, the serum bilirubin levels of some newborns have already reached 20 mg/dl or higher. This is due to the fact that many families are unaware of the seriousness of the jaundice, and often do not even realize that their child needs medical care until the symptoms of bilirubin encephalopathy are obvious. There is an established belief that the jaundice is nearly always a self-limited physio-logic condition of newborns. This belief, rather than awareness of jaundice causes late admis-sion for medical care.

Although, the relationship between serum indirect bilirubin level and neurologic outcome has been investigated for years, there are only a few reports indicating the relation- ship between the duration of jaundice and prognosis(1-3). Similarly, there are no animal studies investigating whether the severity of the brain damage is correlated with the time of the bilirubin exposure. However, our previous observations suggested that the duration of jaundice may have an important role on the prognosis. To investigate whether the babies with delayed admission are at increased risk of neurological sequelae resulting from bilirubin neurotoxicity, this retrospective study was performed. As Drs. Dutta and Singh have indicated, the onset of jaundice depends on the observation of the family in the study. In industrialized countries, even healthy new-borns have the chance of staying at the hospital long enough to be observed by medical staff. However, recent reports from developed countries have suggested that early discharges of newborns may result in a high proportion of hospital readmissions due to hyperbilirubi-nemia and the effect of early discharge on the increase of cases with severe neonatal hyper-bilirubinemia has been discussed(4-8). Unfortunately, nearly half of the patients in this study were born at home or in other hospitals where rapid patient discharge is an obligation due to high birth rate. Therefore, we did not have a chance of evaluating the onset and level of jaundice except for the history obtained from the family. This was not a bias, but an obligation.

We could not find any report in the literature confirming the authors’ proposal that "established encephalopathy is a contraindica-tion for performing an exchange transfusion". It is accepted that the aim in the management of neonatal hiperbilirubinemia is removing bilirubin as soon as possible. To decrease the possible severe complications of bilirubin neurotoxicity, every attempt is justified.

All of our patients with Rh or ABO incompability had clinical and laboratory findings of hemolysis. So, they had iso-immunization. Thanks for the attention for correcting the term incompatibility.

Finally, contrary to the Drs. Dutta and Singh’s belief, we have not tried to find a relationship between the outcome and the duration, irrespective of the level of jaundice (the last key message was "In addition to high serum bilirubin levels, the duration of jaundice should be considered during the management of neonatal indirect hyperbilirubinemia.")(9). We have tried to find a reasonable approach to patients with long duration in addition to moderate or high levels of indirect bilirubin. Should our approach be different for long lasting hyperbilirubinemia than for the newborns with the same serum bilirubin levels with a short duration?

It was our hope that our paper could open a discussion about the importance of the duration of neonatal hyperbilirubinemia for neurologic prognosis. We are looking forward for the results of clinicians who treat babies with long duration of the bilirubin exposure.