A Controlled Trial of High-Intensity Double-Surface Phototherapy on a Fluid Bed Versus Conventional Phototherapy in Neonatal Jaundice

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914 PEDIATRICS Vol. 95

No.

6 June

1995

A

Controlled

Trial

of High-Intensity

Double-Surface

Phototherapy

on a

Fluid

Bed

Versus

Conventional

Phototherapy

in Neonatal

Jaundice

A.

K. Garg,

MBBS,

DCH,

FRCP(I);

R. S. Prasad,

MBBS,

DCH,

MRCP;

and

I. Al

Hifzi,

MBBS,

DCH,

MRCP,

CABP

ABSTRACT. Objective. To evaluate a simple, relatively

inexpensive

method

using

the

fluid

bed

to provide

high-intensity

double-surface

(HIDS)

phototherapy

and

to

confirm

that

the

method

described

is more

effective

than

conventional phototherapy (CPT) in the treatment of

neonatal hyperbilirubinemia.

Design. Prospective controlled study.

Method.

HIDS

phototherapy (26 to 30 pW/cm2 per

nanometer)

on the

fluid

bed

(n

22) versus

conventional

(7

to 10 pW/cm2 per nanometer) phototherapy (n =

28)

was used to treat neonates weighing more than 1500 g

with hyperbilirubinemia.

Results. After 24 hours of therapy, the bilirubin in the

group

receiving

HIDS

phototherapy was significantly

lower. The mean rate of fall of bilirubin was 5.34

pmol/L

per hour in the group receiving HIDS phototherapy

ver-sus

0.7

pmol/L

per hour in the group receiving CPT.

HIDS

phototherapy on a fluid bed was well tolerated.

Conclusion.

HIDS

phototherapy on the fluid bed is

significantly

more

effective

in

reducing

bilirubin

than

CPT.

It can be easily and economically provided using

equipment currently available in most neonatal units.

Pediatrics

1995;95:914-916; high-intensity double-surface

phototherapy, conventional phototherapy, neonatal

hy-perbilirubinemia, jaundice, fluid bed.

ABBREVIATIONS.

CPT, conventional

phototherapy;

HIDS,

high-intensity double-surface; SBR, serum bilirubin.

The

current

dose

of phototherapy

is based

on

what

is convenient

to

administer

and

not

the

most

effec-tive

dose.1

The

dose

of

phototherapy

is determined

by

the

intensity

of

light

irradiation

and

the

area

of

skin

exposed

at

any

one

time.

There

is

a

dose-re-sponse

relationship

to

bilirubin

degradation

until

reaching

the

saturation

dose.2’

This

can

be

achieved

by

exposing

the

maximum

skin

surface

to an

irradi-ance

of

40

pW/cm2

per

nanometer

of

appropriate

light.4’

A further

increase

in irradiance

has

no

addi-tional

benefits.

The

fiber-optic

blanket

has

been

used

along

with

conventional

phototherapy

(CPT)

to

irra-diate

the

front

and

back

of an

infant

simultaneously.6

The

dose

of

phototherapy

is

thus

increased

by

exposing

a

larger

surface

area

of

the

skin

to

the

conventional

irradiance

of

7

to

10

pW/cm2

per

nanometer.

From the North West Armed Forces Hospital, Tabuk, Saudi Arabia.

Received for publication Jun 16, 1994; accepted Oct 3, 1994.

Reprint requests to (A.K.G.) Department of Pediatrics, North West Armed

Forces Hospital, P0 Box 100, Tabuk, Kingdom of Saudi Arabia.

Acad-emy of Pediatrics.

Despite

the

proven

efficacy,

no

significant

practi-cal

changes

in

instituting

high-intensity

photother-apy

have

been

established

during

the

last

decade

because

of technical

difficulties

in

delivering

a high

intensity

of appropriate

light

by

an

easy,

convenient,

and

economical

delivery

system.

We

describe

a simple

system

to provide

irradiance

up

to

26

to

30

pW/cm2

per

nanometer

versus

the

current

irradiance

of 7 to 10 pW/cm2

per

nanometer

used

in

CPT

or

the

fiber-optic

blanket

system.

We

performed

a prospective

controlled

trial

to compare

the

efficacy

of our

method

of high-intensity

double-surface

(HIDS)

phototherapy

on

a fluid

bed7

with

CPT.

METHODS

This study was approved by the Ethical Committee of the

North West Armed Forces Hospital. Informed consent was

ob-tamed from parents for high-intensity phototherapy on a fluid

bed.

Fifty neonates with jaundice born between February and

Au-gust 1993 requiting phototherapy were studied. The criteria for

inclusion into the study were: (1) neonates with serum bilirubin

(SBR)

levels greater than the phototherapy level using a

photo-therapy chart;8 and (2) infants with birth weights greater than 1500

g.

The

criteria for exclusion were: (1) infants with initial SBR levels

of 24 mg/dL (410 pmol/L) or greater; (2) infants with

hyperbil-irubinemia caused by hemolytic disease, ie, ABO blood group and

Rhesus isoimmunization or glucose-6-phosphate dehydrogenase

deficiency; and (3) infants requiring ventilatory support.

The neonates were assigned to the study groups on the basis of

the last digits of their medical registration numbers. Odd numbers

were assigned to the group receiving CPT, and even numbers

were assigned to the group receiving HIDS. This achieved

satis-factory randomization, because the medical numbers had been

allotted to them before and were independent of their enrollment

in the study.

CPT was administered with a standard phototherapy unit (Air

Shield, Narco Scientific, USA), each with four blue fluorescent

lamps, No. F2OT12/BB,9 placed 40 cm above the bed surface. This

distance is required if an incubator is used for nursing. This

provides an irradiance of 7 to 8 pw/cm2 per nanometer at the skin

surface as measured with a Photoradiometer PR III (Air Shield,

Narco Scientific), which has maximum sensitivity at a wavelength

of 470 nm.

HIDS phototherapy was given on a fluid bed in a unit with a

regular bassinet frame adapted to hold a standard phototherapy

unit approximately 1 cm from the floor of the bassinet (Figure).

This provides an irradiance of 26 to 30 pW/cm2 per nanometer at

the skin surface irrespective of the infant’s position on the fluid

bed. In addition,

CPT was given from above or from an angle if a

radiant heater was required to maintain the infant’s temperature.

Phototherapy was continued for at least 24 hours.

All

the infants were nursed unclothed with disposable diapers

cut to minimum effective size, held in place with cling film. They

were removed from under the light only for feeding, changing,

and blood sampling. Standard precautions for phototherapy and

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TABLE 2. Comparative Results in the Two Groups Receiving

Phototherapy (Mean ± SD)

nursing on the fluid bed were taken. The babies were weighed

daily, and fluid therapy was managed by the neonatologists.

The total SBR concentration was measured just before the

corn-mencement of phototherapy (0 hour) and then every 4 to 8 hours.

Other investigations done were complete blood count, liver

func-tion tests, urea, and electrolytes, at 0 and 24 hours. Coomb’s test,

a blood group test, X matching, and a G6PD screen were done in

infants anticipated to require exchange transfusions.

Outcome variables were the decline in SBR after 24 hours of

treatment, the rate of decline per hour, and the percentage of fall

in 24 hours.

The

sample size was determined to be 22 per group to

demonstrate statistical significance with an a of 0.05 (5% chance of

a type I error) and a j3 of 0.1 (10% chance of a type II error) using

the Student’s t test assuming a difference in SBR of 2 mg/dL (34

pmol/L)

between the two groups as significant after 24 hours of therapy.

CPT P Value

ARTICLES

915

Figure. High-intensity phototherapy

unit with the fluid bed.

RESULTS

There

were

no

significant

differences

between

the

two

groups

in

clinical

or

laboratory

characteristics

(Table

1).

There

was

a significant

difference

in the

SBR

levels

in the

two

groups

after

24 hours

of treatment

(Table

2). Two

infants

who

received

CPT

had

a rapid

rise

of

SBR

approaching

the

exchange

transfusion

level.

They

were

treated

with

HIDS

phototherapy

on

the

fluid

bed

with

satisfactory

control

of the

SBR

levels.

They

were

excluded

from

the

study.

The

frequency

of

stools

was

greater

in

the

group

receiving

HIDS,

but

it did

not

pose

any

problems.

Skin

rash

was

not

a problem

in either

group

and

was

not

more

frequent

in the

group

receiving

HIDS

pho-TABLE 1. Data of P atients in the Two Groups (M ean ± SD)

CPT HIDS

Phototherapy

P Value

Number of patients

Birth weight, kg

Gestational age, wk

Hematocrit, %

28 2.74 ± 0.69

37.6 ± 3.3 54.0 ± 7.5

22 2.58 ± 0.62

37.2 ± 3.1 54.4 ± 8.2

>05

HIDS

Phototherapy

Initial bilirubin 16.14 ± 2.06 17.01 ± 2.67 >05

(mg/dL)

(pmol/L) 276 ± 35.3 291 ± 45.6

Bilirubin at 24 h 15.10 ± 2.50 9.65 ± 2.85 <.0005

(mg/dL)

(pmol/L) 258.3 ±42.8 165 ±48.7

Absolute fall at 24 h 1.03 ± 2.04 7.37 ± 2.44 <.0005

(mg/dL)

(pmol/L) 17.7 ± 35.03 126 ± 41.76

Rate of fall (mg/ 0.043 ± 0.079 0.312 ± 0.91 <.0005

dL/h)

(pmol/L/h) 0.74 ± 1.36 5.34 ± 1.56

% fall in SBR at 24 h 3.8 ± 12.9 43.7 ± 13.75 <.0005

totherapy.

There

was

no

problem

with

temperature

stability

in either

group.

DISCUSSION

HIDS

phototherapy

on

the

fluid

bed

was

signifi-cantly

more

effective

than

CPT

in

lowering

the

SBR

level.

HIDS

phototherapy

on

the

fluid

bed

increases

the

irradiance

at the

skin

surface

and

also

the

area

of

the

skin

surface

exposed.

Although

certain

photore-actions

during

phototherapy

reach

the

peak

at

rela-tively

low

levels

of

irradiance

(6 to

9 pW/cm2

per

nanometer),

production

of lumirubin

is thought

to be

directly

proportional

to

the

energy

output

to

the

skin.”1#{176}Lumirubin

may

be the

more

significant

mode

of excretion

of bilirubin

in

high-intensity

photother-apy.

Intermittent

skin

exposure

by

turning

the

infant

while

irradiating

from

one

light

source,

without

in-creasing

the

total

energy

output

to the

skin,

does

not

improve

the

efficacy

of

112

No

long-term

complications

of high-intensity

pho-totherapy

have

been

reported

since

it was

described

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(3)

916 HIGH-INThNSITY DOUBLE-SURFACE PHOTOTHERAPY

by Tan

in 1977.

In vitro

genotoxicity

of light

in the

400-

to

500-nm

range’3

may

not

be

predictive

of

human

risk.14

The

amount

of

light

to

which

one

is

exposed”

during

phototherapy

is minute

compared

with

the

exposure

later

in life,

even

during

the

first

year.1

The

fluid

bed

acts

as a thermal

reservoir,

smooth-ing

out

the

temperature

fluctuations.

The

fluid

ab-sorbs

and

dissipates

the

heat

generated

by

the

light

source,

allowing

the

close

proximity

necessary

for

the

high

irradiance

of

26 to 30 pW/cm2

per

nanom-eter.

The

close

proximity

of

the

light

source

below

the

cot

also

reduces

the

scalier

and

glare

of the

blue

light,

decreasing

the

inconvenience

to the

attending

personnel.15

The

infants

tolerated

the

fluid

bed

well.

It is softer,

probably

more

physiological

and

comfortable

for

the

newborn

infant

than

a hard

mattress

or

the

perspex

floor

of a bassinet.

The

system

we

have

described

is simple,

easy

to

assemble

using

equipment

available

in most

neona-tal

units.

The

modifications

are

reversible

and

can

be

done

by

the

maintenance

department

of

any

hospi-tal;

thus

the

additional

cost

is

virtually

nil.

These

factors

take

greater

importance

when

the

financial

outlay

for

new

high-technology

equipment

and

their

spare

parts,

along

with

the

waiting

period

for

servic-ing,

is considered

in the

current

cost-cutting

environ-ment,

especially

in developing

countries.

The

efficacy

and

ease

of HIDS

phototherapy

on

the

fluid

bed

may

be

further

enhanced

by

a better

light

source

and

a disposable

custom-made

plastic

fluid

bed.

We

recommend

HIDS

phototherapy

on

the

fluid

bed

as the

treatment

of choice

during

critical

periods

of hyperbilirubinemia,

when

rapid

control

of

hyper-biirubinemia

is desirable.

REFERENCES

I. Ennever JF. Blue light, white light, more light: treatment for neonatal

jaundice. Clin Perinatology. 1990;17:467-481

2. Tan KL, Lim CC, Boey KW. Efficacy of “high intensity” blue light and

“standard” daylight phototherapy for non haemolytic

hyperbiliru-bmemia. Acta Paediatr. 1992;81:870-874

3. Modi N, Keay AJ. Phototherapy for neonatal hyper-biirubinemia: the

importance of dose. Arch Dis Child. 1983;58:406-409

4. Tan KL. The pattern of bilirubin response to phototherapy for neonatal

hyperbilirubinemia. Pediatr Res. 1982;16:670-674

5. Tan KL. The nature of the dose-response relationship of phototherapy

for neonatal hyperbilirubinemia. IPediatr. 1977;90:448-452

6. Holtrop PC, Ruedisueli K, Maisels MJ. Double versus single

photother-apy in low birth weight newborn. Pediatrics. 1993;90:674-677

7. Garg AK, Ward OC. Double surface phototherapy on a fluid bed. Ann

Trop Paeditr. 1994;14:81-84

8. Durbin GM, InsleyJ. The newborn. In: InsleyJ, Wood B, mis. A Pediatric Vaddmecum. London: Lloyds Luke; 1982:76-101

9. Ennever JF, McDonagh AF, Speck WT. Phototherapy for neonatal

jaundice: optimal wavelength of light. IPediatr. 1983;103:295-299 10. Costarino AT, Ennever JF, Brumgart 5, Spect WT, Paul M, Poun R.

Bilirubin photoisomerization in premature neonates under low and

high dose phototherapy. Pediatrics. 1985;75:519-522

I I. Tan KL. Comparison of the effectiveness of single direction and double

direction phototherapy for neonatal jaundice. Pediatrics. 1975;56:

550-553

12. Yamauchi Y, Kasa N, Yamanouchi I. Is it necessary to change babies’

position during phototherapy? Early Hum Dcv. 1989;20:221-227

13. Bradley MO, Sharkey NA. Mutagenicity and toxicity of visible

fluores-cent light to cultural mammalian cells. Nature. 1977;266:724-726

14. Tennant RW, Margolin BH, Shelby MD, et at. Prediction of chemical

carcinogenicity in rodents from in vitro genetic toxicity assays. Science.

1987;236:933-941

15. Tan KL. Phototherapy for neonatal jaundice. Clin Perinatol. 1991;18:

3423-3439

ETHICAL

DECISIONS

Of

the

many

theories

that

have

been

propounded

for

ethical

decision-making,

three

are

particularly

useful

in

helping

us

think

through

the

twin

rights

of moral

dilemmas:

1)

Ends-Based Thinking:

Do

whatever

produces

the

greatest

good

for

the

greatest

number;

2)

Rule-Based

Thinking:

Follow

only

the

principle

that

you

want

everyone

else

to

follow;

and

3)

Care-Based Thinking: Do to others what you would like them to do to you.

Kidder RK. How Good

People Make Tough Choices.

NY: Harper Row; 1995.

Submitted

by

Student

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1995;95;914

Pediatrics

A. K. Garg, R. S. Prasad and I. Al Hifzi

Versus Conventional Phototherapy in Neonatal Jaundice

A Controlled Trial of High-Intensity Double-Surface Phototherapy on a Fluid Bed

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1995;95;914

Pediatrics

A. K. Garg, R. S. Prasad and I. Al Hifzi

Versus Conventional Phototherapy in Neonatal Jaundice

A Controlled Trial of High-Intensity Double-Surface Phototherapy on a Fluid Bed

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