Randomized controlled trial of light-emitting diode phototherapy

Light-Emitting Diode (LED) Phototherapy versus Non-LED Phototherapy Devices for Hyperbilirubinemia in Neonates: A Systematic Review and Meta-analysis

This review was conducted to evaluate the efficacy of light-emitting diode (LED) phototherapy as compared with the conventional phototherapy in neonates with unconjugated hyperbilirubinemia and their adverse effects. We searched the following databases right from their inception till April, 2021: MEDLINE, EMBASE, Cochrane Library, and LILACS. Randomized clinical trials (RCTs) comparing the LED phototherapy with other light sources, which enrolled newborns (term and preterm) with unconjugated hyperbilirubinemia were included. We included 21 articles in this review. The treatment with the LED light therapy had a lower failure rate as compared with the non-LED one (RR = 0.60, 95% CI: 0.39-0.94). The mean duration of phototherapy was significantly shorter in the group with the LED light source as compared with the one with the non-LED light source (mean difference [hours]: -8.07, 95% CI: -8.45 to -7.68), regardless of the type of non-LED units. However, the rate of bilirubin showed a comparable decline (mean difference [mg/dL/h]: 0.01, 95% CI: -0.00, 0.03) in both the light sources, irrespective of irradiance or distance. No studies reported primary outcomes related to the neurotoxicity effects of hyperbilirubinemia in neonates. The LED light devices caused a significantly higher risk of hypothermia. Neonates were at a lower risk of developing hyperthermia and skin rash with the LED light therapy. Our findings provide support for the use of LED light source phototherapy due to its better clinical efficacy, which is evidenced by its shorter duration and lower rate of treatment failure, as compared with the non-LED light sources. KEY POINTS: · The efficacy of phototherapy is dependent on specific characteristics of light sources of phototherapy devices.. · LED phototherapy demonstrated better efficacy with shorter duration and lower rate of treatment failure.. · Adverse effects of phototherapy devices such as hypothermia, hyperthermia, and skin rash should be monitored..

History and current standard of postnatal management in hemolytic disease of the fetus and newborn

Since the discovery of the Rh blood group system in 1940, a greater understanding of hemolytic disease of the fetus and newborn (HDFN) was gained. In the years thereafter, researchers and clinicians came to the current understanding that fetal and neonatal red blood cells (RBC) are hemolyzed by maternal alloantibodies directed against RBC antigens potentially leading to severe disease. Preventative measures, such as Rhesus(D) immunoprophylaxis (RhIG), have greatly decreased the prevalence of Rh(D)-mediated HDFN, although a gap between high-income countries and middle- to low-income countries was created largely due to a lack in availability and high costs of RhIG. Other important developments in the past decades have improved the identification, monitoring, and care of pregnancies, fetuses, and neonates with HDFN. Prenatally, fetal anemia may occur and intrauterine transfusions may be needed. Postnatally, pediatricians should be aware of the (antenatally determined) risk of hemolysis in RBC alloimmunization and should provide treatment for hyperbilirubinemia in the early phase and monitor for anemia in the late phase of the disease. Through this review, we aim to provide an overview of important historic events and to provide hands-on guidelines for the delivery and postnatal management of neonates with HDFN. Secondarily, we aim to describe recent scientific findings and evidence gaps.

CONCLUSION

 Multiple developments have improved the identification, monitoring, and care of pregnancies and neonates with HDFN throughout the centuries. Pediatricians should be aware of the (antenatally determined) risk of hemolysis in RBC alloimmunization and should provide treatment for hyperbilirubinemia in the early phase and monitor for late anemia in the late phase of the disease. Future studies should be set in an international setting and ultimately aim to eradicate HDFN on a global scale.

WHAT IS KNOWN

• Developments have led to a greater understanding of the pathophysiology, an improved serological identification and monitoring of at-risk cases and the current pre- and postnatal treatment.

WHAT IS NEW

• This review provides the pediatrician with hands-on guidelines for the delivery and postnatal management of neonates with HDFN. • Future studies should be set in an international setting with the ultimate aim of eradicating HDFN.

Management challenges in the treatment of severe hyperbilirubinemia in low- and middle-income countries: Encouraging advancements, remaining gaps, and future opportunities

Neonatal jaundice (NJ) is common in newborn infants. Severe NJ (SNJ) has potentially negative neurological sequelae that are largely preventable in high resource settings if timely diagnosis and treatment are provided. Advancements in NJ care in low- and middle-income countries (LMIC) have been made over recent years, especially with respect to an emphasis on parental education about the disease and technological advancements for improved diagnosis and treatment. Challenges remain, however, due to lack of routine screening for SNJ risk factors, fragmented medical infrastructure, and lack of culturally appropriate and regionally specific treatment guidelines. This article highlights both encouraging advancements in NJ care as well as remaining gaps. Opportunities are identified for future work in eliminating the gaps in NJ care and preventing death and disability related to SNJ around the globe.

Efficacy of single phototherapy with low-cost reflective sheets versus single phototherapy alone in mild-to-moderate unconjugated hyperbilirubinaemia in full-term neonates

BACKGROUND

An economical alternative method of increasing the light intensity of phototherapy for neonatal jaundice is the use of reflective sheets placed on the sides of the incubator.

AIM

To determine whether reflective sheets in addition to phototherapy increase the reduction of bilirubin levels and the duration of hospital stay.

METHODS

The study was undertaken in the neonatal intensive care unit of Cairo University Children's Hospital. There were two groups: a study group of 90 full-term neonates with neonatal jaundice who received single phototherapy in incubators covered with white plastic reflective sheets and a control group of 90 full-term neonates with neonatal jaundice who received single phototherapy without the reflective sheets.

RESULTS

The mean (SD) rate of bilirubin decline in the first 24 hours of phototherapy was greater in the study group [3.7 (0.86) µmol/L/hr] than in the control group [2.2 (0.14) µmol/L/hr] (p<0.001).

CONCLUSION

Use of reflective sheets decreases the total duration of phototherapy and the cost and duration of hospitalisation without any added complications.Abbreviations: AAP: American Academy of Pediatrics; HIDS: high-intensity double-surface; LMIC: low- and middle-income countries; MCTP: mirror-covered tunnel phototherapy; NICU: neonatal intensive care unit; TSB: total serum bilirubin.

Standardization of phototherapy for neonatal hyperbilirubinemia using multiple-wavelength irradiance integration

BACKGROUND

Phototherapy with radiation of 460-490 nm wavelengths provides the most potent therapeutic effect for neonatal jaundice. However, the efficacy of phototherapy has been estimated using single-wavelength detectors with sensitivity at approximately 460 nm. Cyclobilirubin formation capacity (CFC), which comprises the sum of the irradiance values from three wavelengths multiplied by their specific coefficients, has been proposed as an alternative marker to evaluate the efficacy of phototherapy. This study aimed to test whether two types of phototherapy devices with distinct spectral characteristics provide similar therapeutic effects on adjustment of device-to-patient distances to deliver similar CFCs.

METHODS

Using a three-wavelength spectroradiometer, CFCs and footprints of the light-emitting diode and fluorescent tube devices were assessed. Having determined the device-specific distances that ensured similar CFCs, 32 newborn infants, requiring phototherapy for hyperbilirubinemia, were randomized into the light-emitting diode and fluorescent tube groups. The total serum bilirubin levels before and after phototherapy were assessed.

RESULTS

The light-emitting diode and fluorescent tube devices had comparable CFCs at distances of 60 and 50 cm, respectively. Phototherapy reduced the total serum bilirubin levels from 18.1 to 14.6 mg/dL and from 19.1 to 15.1 mg/dL in the light-emitting diode and fluorescent tube groups, respectively. The two groups did not differ significantly with respect to the patients' clinical backgrounds, serum bilirubin levels, or changes before and after phototherapy.

CONCLUSION

At similar CFCs, the two phototherapy devices reduced the total serum bilirubin levels by comparable amounts. Hence, determining CFCs may help predict phototherapy efficacy. This may ensure better safety and greater efficacy of the treatment for newborn infants.

New high intensity fibreoptic phototherapy devices in healthy newborns: a single pad wrapped around the neonate body in comparison with a double pad device

Background

Fibreoptic Phototherapy (FPT) allows to lower total serum bilirubin (TSB) levels in healthy neonates maintained in rooming-in with their mothers. The 2004 Cochrane review showed that, differently from preterm neonates, FPT was not as effective as traditional phototherapy in term neonates (TN), unless the simultaneous utilization of two FPT devices. Aim of this study was to compare the efficacy of two FPT devices, both equipped with a single light-emitting diode (LED): the first one has a single large pad wrapped around the infant body (Bilisoft, GE Health Care) (device A), the second one is a double-pad phototherapy device (BiliCocoon, CremascolieIris) (device B).

Methods

We studied 172 healthy neonates with non-hemolytic hyperbilirubinaemia: 57 TN and 57 late preterm neonates (LPN) treated with device A (Group 1); 47 TN and 11 LPN treated with device B (Group 2). We evaluated the differences between groups by the Student’s t-test for continuous variables and by chi square test for categorical data. A two tailed p < 0.05 was considered significant.

Results

There were no differences in term of duration of FPT, TSB hourly reduction, percentage of TSB reduction after FPT, TSB maximum rebound, percentage of TSB increase after FPT discontinuation and number of after-discharge checks. Two neonates treated with device B showed no decrease in TSB values during FPT. Seven infants treated with device B experienced hyperpyrexia.

Conclusions

The two LED FPT devices were both effective in lowering TSB either in TN or LPN. Device A was effective in all treated neonates without negative side effects during treatment; device B was effective in all but 2 infants and 12% of the neonates in the same group experienced hyperpyrexia. According to our results, the single big pad wrapped around the infant body has the same efficacy as a double FPT device in TN and LPN.

LED-phototherapy does not induce oxidative DNA damage in hyperbilirubinemic Gunn rats

BACKGROUND

Phototherapy (PT) is the standard treatment of neonatal unconjugated hyperbilirubinemia. Fluorescent tube (FT)-emitted PT light is known to induce oxidative DNA damage in neonates. Nowadays, however, FTs have largely been replaced by light-emitting diodes (LEDs) for delivering PT. Until now, it is unknown whether LED-PT causes oxidative DNA damage. We aim to determine whether LED-PT induces oxidative DNA damage in hyperbilirubinemic rats.

METHODS

Adult Gunn rats, with genetically unconjugated hyperbilirubinemia, received LED-PT in the clinically relevant doses of 10 or 30 µW/cm²/nm. Urine was collected at 0, 24, and 48 h of PT. A group of young Gunn rats received intensive LED-PT of 100 µW/cm²/nm for 24 h. Urine was collected every 8 h and analyzed for the levels of oxidative DNA damage marker 8-hydroxy-2'deoxyguanosine (8-OHdG) and creatinine. DNA damage was evaluated by immunohistochemistry (γH2AX) of skin and spleen samples.

RESULTS

LED-PT of 10 and 30 µW/cm²/nm did not affect urinary concentrations of 8-OHdG and creatinine or the 8-OHdG/creatinine ratio. Likewise, intensive LED-PT did not affect the 8-OHdG/creatinine ratio or the number of γH2AX-positive cells in the skin or spleen.

CONCLUSIONS

Our results show that LED-PT does not induce oxidative DNA damage in hyperbilirubinemic Gunn rats either at clinically relevant or intensive dosages.

[Effectiveness and safety of two phototherapy devices for the humanised management of neonatal jaundice]

INTRODUCTION

Neonatal jaundice is common, especially in premature infants. Compliance with treatment protocols and standard serum bilirubin curves forces the clinician to separate the child from the mother after birth for short phototherapy. The objective of this study is to evaluate the effectiveness and safety of two innovative devices for phototherapy including a LED light mesh: one sleeping bag and one blanket compared to conventional hospital or ambulatory phototherapy.

METHODS

Two randomised clinical trials were conducted: one with newborns >2,000g at birth in the Neonatal Care Unit and the other with premature infants followed-up in an outpatient clinic (PMC). The gold standard for bilirubin measurement was serum bilirubin, and ambulatory controls were performed with the Bilicheck®. Parents and health personnel completed a questionnaire on comfort and perceptions.

RESULTS

In the study using the bag, a linear regression was performed for the decrease in bilirubin in mg/dL/h, controlling by early jaundice (<36h) and the device type. The results were similar between the 2 devices. For the blanket trial in the PMC, the decrease in bilirubin levels with the new device was significantly greater with no differences in temperatures, duration of phototherapy, re-admission, mortality, or side effects for both trials. Parents and staff satisfaction with the two devices was identical for the 2 trials.

CONCLUSION

These 2 small studies add a 'grain of sand' to humanisation of newborn care, avoiding the mother-and-child separation for both the intra-hospital high-risk hyperbilirubinaemia, as well as for the lower-risk hyperbilirubinaemia in an outpatient clinic.

Variation in the Phototherapy Practices and Irradiance of Devices in a Major Metropolitan Area

BACKGROUND

Phototherapy (PT) is widely used to prevent and treat severe hyperbilirubinemia and its associated risks for both acute and chronic bilirubin encephalopathy. Intensive PT, recommended for inpatient treatment of hyperbilirubinemia in term and near-term infants, is defined as having a spectral irradiance of ≥30 μW/cm2/nm.

OBJECTIVES

We aimed to assess local PT practices by measuring the irradiance of PT devices in local neonatal intensive care units and newborn nurseries.

METHODS

The irradiance footprint, including maximum irradiance at the center of the footprint, of 39 PT devices in 7 area hospitals was measured according to current practice in these facilities.

RESULTS

The mean ± SD (range) footprint irradiance was 20.7 ± 5.8 (8.8-29.4) μW/cm2/nm. The mean ± SD maximum irradiance at the footprint center for all devices at a mean clinically used treatment distance of 33.1 ± 9.3 (25.5-60.0) cm was 27.8 ± 7.0 (14.7-42.0) μW/cm2/nm. Sixty-two percent of the devices did not meet the minimum recommended spectral irradiance for intensive PT. For the sites without irradiance-based protocols, the maximum irradiance of the devices (n = 33) at the treatment distances was 25.8 ± 6.1 μW/cm2/nm.

CONCLUSIONS

Despite established PT guidelines, local protocols and practices vary. Based on an assessment of 7 local hospitals, intensive PT was suboptimal for 62% of devices. Straightforward changes, such as decreasing the distance between an infant and the light source and establishing a consistent irradiance-based protocol, could substantially improve the quality of the intervention.

Heating of Newborn Infants due to Blue Light-Emitting Diode Fibreoptic Phototherapy Pads

BACKGROUND

Surface temperatures of fibreoptic phototherapy pads using a high intensity blue light-emitting diode (LED) light source have not been studied.

OBJECTIVES

The aim of this study was to measure the temperature of LED fibreoptic phototherapy pads during phototherapy in a bench-top study, and to determine temperature effects on babies during phototherapy.

METHODS

A commercially available LED fibreoptic phototherapy system was tested. In a bench-top setting, pad surface temperatures were measured before, during and after a 12-h period of phototherapy (10 different LED light box-pad combinations). A prospective, cohort study of well babies at >34 weeks' gestation receiving phototherapy was then conducted to determine changes in pad and body temperatures during a 90-min phototherapy period.

RESULTS

In the bench-top study, the mean (95% CI) pad temperature was 21.8°C (21.5-22.1) before lights, 27.0°C (26.5-27.5) after 12 h of lights, and 22.1°C (21.9-22.4) 8 h after turning off the lights (F = 366.1, p < 0.0005). The magnitude of change in pad temperature with phototherapy was linearly correlated with irradiance (r = 0.89, p < 0.0005). The pad plastic covering absorbed 13% of blue light from fibres. In the clinical study, the warmest pad temperature during phototherapy was 38.9°C. Axillary temperature increased by a mean (95% CI) of 0.3°C (0.1-0.5), p < 0.019, and exceeded 37.5°C in 4 babies.

CONCLUSIONS

LED fibreoptic phototherapy pads are heated by high-intensity blue light. The thermal environment and temperature of babies should be monitored closely during LED fibreoptic phototherapy. A temperature probe placed between the skin and the pad will not accurately reflect the core temperature during fibreoptic phototherapy.

High-intensity light-emitting diode vs fluorescent tubes for intensive phototherapy in neonates

BACKGROUND

Special blue fluorescent tubes are recommended by the American Academy of Pediatrics (AAP) as the most effective light source for lowering serum bilirubin. A high-intensity light-emitting diode ('super LED') could render intensive phototherapy more effective than the above conventional methods. This study compared the efficacy and safety of a high-intensity light-emitting diode bed vs conventional intensive phototherapy with triple fluorescent tube units as a rescue treatment for severe unconjugated neonatal hyperbilirubinaemia.

METHOD

This was a randomised, prospective trial. Two hundred jaundiced neonates ≥ 35 weeks gestation who met the criteria for intensive phototherapy as per AAP guidelines were randomly assigned to be treated either with triple fluorescent tube units (group 1, n = 100) or a super LED bed (group 2, n = 100). The outcome was the avoidance of exchange transfusion by successful control of hyperbilirubinaemia.

RESULTS

Statistically significant higher success rates of intensive phototherapy were achieved among neonates treated with super LED (group 2) than in those treated conventionally (group 1) (87% vs 64%, P = 0.003). Significantly higher 'bilirubin decline' rates were reported in both haemolytic and non-haemolytic subgroups treated with the super LED bed compared with a similar sub-population in the conventionally treated group. Comparable numbers of neonates in both groups developed rebound jaundice (8% vs 10% of groups 1 and 2, respectively). Side-effects were mild in both groups, but higher rates of hyperthermia (12% vs 0%, P = 0.03), dehydration (8% vs 2%, P = 0.26) and skin rash (39% vs 1%, P = 0.002) were reported in the fluorescent tubes-treated group compared with the LED group.

CONCLUSIONS

Super LED is a safe rescue treatment for severe neonatal hyperbilirubinaemia, and its implementation may reduce the need for exchange transfusion.

Phototherapy in transport for neonates with unconjugated hyperbilirubinaemia

AIM

In Victoria, neonates with severe unconjugated hyperbilirubinaemia at risk of requiring exchange transfusion are retrieved by the Paediatric Infant Perinatal Emergency Retrieval Service and transferred to a Neonatal Intensive Care Unit where an exchange transfusion can be performed if necessary. Transfer may result in prolonged periods without phototherapy in neonates at risk of developing bilirubin encephalopathy. We aimed to describe our experience of the introduction of phototherapy using a portable phototherapy unit during transport.

METHODS

Neonates with a primary diagnosis of severe unconjugated hyperbilirubinaemia were identified from the Paediatric Infant Perinatal Emergency Retrieval clinical database over an 11-year period. Demographic and clinical data including gestation, age at transport, serum bilirubin levels pre- and post-transport, use of phototherapy during transport (PTDT), likely diagnosis, and use of exchange transfusion were included.

RESULTS

A total of 147 neonates were included with 104 neonates receiving PTDT and 43 who did not. Neonates who received PTDT were less likely to require exchange transfusion, 19.2% versus 34.9%, odds ratio 0.44 (95% CI 0.2-0.98), P = 0.05. However, after correction for factors appearing to be related to use of exchange transfusion, the odds ratio increased to 0.58 (95% CI 0.21-1.63), P = 0.3. There was a greater reduction in the pre- to post-transport total serum bilirubin levels (μmol/L) for the group receiving PTDT (mean 46.3, SD 64.6) versus no PTDT (mean 26.1, SD 62.5), but this did not reach significance, P = 0.08.

CONCLUSIONS

Phototherapy during neonatal transport is feasible and safe and may result in a decreased requirement for subsequent exchange transfusion.

LED versus daylight phototherapy at low irradiance in newborns ≥35 weeks of gestation: randomized controlled trial

OBJECTIVE

To compare the decline in TSB after 24 h of LED or fluorescent phototherapy from below in breastfed neonates ≥35 weeks of gestation.

METHODS

Seventy-four neonates treated with a 17-bulb blue LED were compared with 76 neonates treated with a 7-bulb daylight device in a rooming-in unit. Spectral irradiance was measured at 5 points on a 30 × 60 cm rectangle on the gel transparent mattress.

RESULTS

TSB of 14.0 ± 1.2 mg/dL at 64 ± 15 h after birth when starting phototherapy were similar in both groups. TSB declined by 0.16 ± 0.09 in the LED versus 0.16 ± 0.08 mg/dL/hour in the daylight group after 24 h of therapy (p = 0.87). Mean irradiance (μW/cm(2)/nm) was 10.5 ± 0.9 (32.5 at the central, 5.9 at the superior and 3.9 for the inferior points) in the LED versus 8.7 ± 0.6 (range, 8.3 to 9.8) in the daylight group (p < 0.001). Hypothermia (<36.0 °C) was more frequent in LED than in fluorescent (23% versus 9%; p = 0.02) group.

CONCLUSION

LED with heterogeneous irradiance was as effective as daylight phototherapy with homogeneous irradiance; however there is a greater need for rigorous control of the room temperature (NCT01340339).

The effects of phototherapy on eosinophil and eosinophilic cationic protein in newborns with hyperbilirubinemia

Newborns with jaundice requiring or not requiring phototherapy (PT) are at greater risk of developing asthma later in life. In this study, we investigated the effect of PT treatment on eosinophil and eosinophilic cationic protein (ECP) levels in newborns with severe hyperbilirubinemia. Thirty newborns diagnosed with severe hyperbilirubinemia and exposed to light-emitting diode (LED) PT were enrolled into the study. Total serum bilirubin (TSB) levels, complete blood count and serum ECP concentrations were measured before and after PT. TSB and hemoglobin (Hb) counts were lower after PT (p = 0.001). There was no difference between leukocyte, lymphocyte, neutrophil and platelet count before and after PT. Eosinophil levels were increased after PT, although not significantly. ECP levels were higher after PT (p = 0.006). It may be speculated that newborns treated with LED PT, increased ECP might play a role in developing allergic diseases later in life.

Phototherapy rash in newborn infants: does it differ between conventional and light emitting diode phototherapy?

Data comparing the cutaneous side effects of light emitting diode (LED) phototherapy (LP) and conventional phototherapy (CP) devices in jaundiced newborn infants are very limited. We investigated the incidence and extent of skin eruptions caused by different phototherapy devices in preterm infants who are more prone to neonatal jaundice. This prospective, randomized controlled trial was conducted in the neonatal intensive care unit (NICU) of Hacettepe University Ihsan Dogramaci Childrens' Hospital in Ankara, Turkey. Preterm infants without skin lesions before and requiring phototherapy in the first week of life were included in the study. The infants were randomly assigned to receive CP or LP and were monitored closely for skin eruptions during phototherapy. Fifty-eight infants were included in the study: 25 (43.1%) received CP while 33 (56.9%) received LP. The duration of phototherapy was similar in the two groups (30.4 ± 9.6 hours and 31.8 ± 15.6 hours, respectively). Baseline and control bilirubin levels were similar for the two groups (p = 0.101 and p = 0.105, respectively). The frequency of skin eruptions was 36% in the CP group and 33% in the LP group (p = 0.83). The skin eruptions were macules in 13 (22.4%), papules in 5 (8.6%), and maculopapular rashes in 2 (3.4%) infants.There were no differences in the incidence and extent of skin eruptions in preterm infants who received CP or LP.

The effect of hematocrit on the efficacy of phototherapy for neonatal jaundice

BACKGROUND

The therapeutic phototherapy action spectrum ranges from 420 to 500 nm. However, a recent report of improved efficacy of fluorescent "turquoise" light (~490 nm) as compared with blue light (~450 nm) underscores the need to define an optimal action spectrum for precision-targeted phototherapy using very narrow wavelength ranges.

METHODS

We used a current semi-empirical model of the optical properties of skin for robust calculations of the fraction of light absorbed by bilirubin at various wavelengths that could be confounded by hemoglobin (Hb), melanin, and skin thickness. Applying assumptions regarding the wavelength dependence of bilirubin photochemistry, "action spectra" were assembled from the calculated values.

RESULTS

All the calculated action spectra displayed a peak between 472 and 480 nm (most at 476 nm), which is a significant shift from the well-reported 460 nm absorption peak of bilirubin. Of note, the relative amplitudes of the action spectra showed an inverse relationship with hematocrit (Hct).

CONCLUSION

We speculate that a narrow range of light at 476 nm would be 60% more effective than blue (broadband) fluorescent lamps. Because Hb serves as a major competitor of bilirubin for light absorption, the calculations also predict that the efficacy of phototherapy is dependent on the Hct. A high Hct could reduce therapeutic efficiency.

Efficacy of phototherapy devices and outcomes among extremely low birth weight infants: multi-center observational study

OBJECTIVE

Evaluate the efficacy of phototherapy (PT) devices and the outcomes of extremely premature infants treated with those devices.

STUDY DESIGN

This substudy of the National Institute of Child Health and Human Development Neonatal Research Network PT trial included 1404 infants treated with a single type of PT device during the first 24±12 h of treatment. The absolute (primary outcome) and relative decrease in total serum bilirubin (TSB) and other measures were evaluated. For infants treated with one PT type during the 2-week intervention period (n=1223), adjusted outcomes at discharge and 18 to 22 months corrected age were determined.

RESULT

In the first 24 h, the adjusted absolute (mean (±s.d.)) and relative (%) decrease in TSB (mg dl(-1)) were: light-emitting diodes (LEDs) -2.2 (±3), -22%; Spotlights -1.7 (±2), -19%; Banks -1.3 (±3), -8%; Blankets -0.8 (±3), -1%; (P<0.0002). Some findings at 18 to 22 months differed between groups.

CONCLUSION

LEDs achieved the greatest initial absolute reduction in TSB but were similar to Spots in the other performance measures. Long-term effects of PT devices in extremely premature infants deserve rigorous evaluation.

Prospective randomized controlled study comparing low-cost LED and conventional phototherapy for treatment of neonatal hyperbilirubinemia

Our objective was to carry out a prospective, randomized, single-blind study to evaluate whether light emitting diode (LED) phototherapy using a low-cost set of lights is as effective as conventional phototherapy in treating hyperbilirubinemia in neonates. The study included 45 pre-term neonates requiring phototherapy as per American Academy of Pediatrics guidelines; participants were randomized to receive phototherapy using LED-based lights, conventional fluorescent blue lights or conventional halogen lights. There were no statistically significant differences in the average bilirubin levels at the onset, at the maximum and at the end of treatment, nor in the duration of phototherapy treatment and the rate of decrease in bilirubin levels in the neonates receiving conventional fluorescent blue light, conventional halogen light and LED phototherapy. (Differences were considered significant at p < 0.05). The average rate of decrease of bilirubin levels was 0.047 ± 0.037 mg dl(-1) h(-1), 0.055 ± 0.056 mg dl(-1) h(-1) and 0.057 ± 0.045 mg dl(-1) h(-1) in the groups receiving conventional fluorescent blue light, conventional halogen light and LED phototherapy, respectively. The average duration of phototherapy treatment in the three groups was 108.8 ± 85.9 h, 92.8 ± 38.1 h, 110.4 ± 42.6 h, respectively. In this pilot study, LED phototherapy using a simple, low-cost set of lights was as effective as conventional phototherapy in the treatment of neonatal hyperbilirubinemia. LED phototherapy lights that deliver 30-40 µW cm(-2 )nm(-1) can be assembled in small quantities for <US$ 100 each using off-the-shelf parts; such lights may enable phototherapy to be safely and reliably delivered in low-resource settings.

Efficacy of light-emitting diode versus other light sources for treatment of neonatal hyperbilirubinemia: a systematic review and meta-analysis

Various light-emitting diode (LED) phototherapy devices have been trialled on the assumption of a more effective spectral distribution of the light emitted. We reviewed the current literature to determine whether LED is more effective than other types of phototherapy. Eligible studies were randomized controlled trials of LED versus other phototherapies. Studies were found to be of medium quality based on a components approach. Data were statistically aggregated within a very homogeneous population (term or late preterm neonates). Results appeared robust at sensitivity analysis. Five hundred and eleven neonates were included in the meta-analysis. LED and other phototherapy devices appeared to be equally effective in reducing total serum bilirubin (TSB) in term or late preterm neonates. The pooled mean TSB rate of decrease was 3.269 μmol/L/h (0.191 mg/dL/h) and 3.074 μmol/L/h (0.18 mg/dL/h) in the LED and conventional arms, respectively [average difference in TSB rate of decrease = 0.194 μmol/L/h (0.011 mg/dL/h) in favour of LED phototherapy; p = 0.378].

CONCLUSION

No significant difference in TSB rate of decrease was detected between LED and other types of phototherapy. Further randomized controlled trials are needed to ascertain whether LED phototherapy may be more effective when increasing the spectral power, or in certain selected subpopulations.

Light-emitting diode phototherapy for unconjugated hyperbilirubinaemia in neonates

BACKGROUND

Phototherapy is the mainstay of treatment of neonatal hyperbilirubinaemia. The commonly used light sources for providing phototherapy are special blue fluorescent tubes, compact fluorescent tubes and halogen spotlights. However, light emitting diodes (LEDs) as light sources with high luminous intensity, narrow wavelength band and higher delivered irradiance could make phototherapy more efficacious than the conventional phototherapy units.

OBJECTIVES

To evaluate the effect of LED phototherapy as compared to conventional phototherapy in decreasing serum total bilirubin levels and duration of treatment in neonates with unconjugated hyperbilirubinaemia.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2010, Issue 1), MEDLINE (1966 to April 30, 2010) and EMBASE (1988 to July 8, 2009). Handsearches of the proceedings of annual meetings of The European Society for Paediatric Research and The Society for Pediatric Research were conducted through 2010.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials were eligible for inclusion if they enrolled neonates (term and preterm) with unconjugated hyperbilirubinaemia and compared LED phototherapy with other light sources (fluorescent  tubes, compact fluorescent tubes, halogen spotlight; method of administration: conventional or fibreoptic).

DATA COLLECTION AND ANALYSIS

We used the standard methods of The Cochrane Collaboration and its Neonatal Review Group for data collection and analysis.

MAIN RESULTS

Six randomised controlled trials met the inclusion criteria for this review. Four studies compared LED and halogen light sources. Two studies compared LED and compact fluorescent light sources. The duration of phototherapy (six studies, 630 neonates) was comparable in LED and non-LED phototherapy groups (mean difference (hours) -0.43, 95% CI -1.91 to 1.05). The rate of decline of serum total bilirubin (STB) (four studies, 511 neonates) was also similar in the two groups (mean difference (mg/dL/hour) 0.01, 95% CI -0.02 to 0.04). Treatment failure, defined as the need of additional phototherapy or exchange blood transfusion (1 study, 272 neonates), was comparable (RR 1.83, 95% CI 0.47 to 7.17). Side effects of phototherapy such as hypothermia (RR 6.41, 95% CI 0.33 to 122.97), hyperthermia (RR 0.61, 95% CI 0.18 to 2.11) and skin rash (RR 1.83, 95% CI 0.17 to 19.96) were rare and occurred with similar frequency in the two groups.

AUTHORS' CONCLUSIONS

LED light source phototherapy is efficacious in bringing down levels of serum total bilirubin at rates that are similar to phototherapy with conventional (compact fluorescent lamp (CFL) or halogen) light sources. Further studies are warranted for evaluating efficacy of LED phototherapy in neonates with haemolytic jaundice or in the presence of severe hyperbilirubinaemia (STB ≥ 20 mg/dL).

Phototherapy to prevent severe neonatal hyperbilirubinemia in the newborn infant 35 or more weeks of gestation

OBJECTIVE

To standardize the use of phototherapy consistent with the American Academy of Pediatrics clinical practice guideline for the management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation.

METHODS

Relevant literature was reviewed. Phototherapy devices currently marketed in the United States that incorporate fluorescent, halogen, fiber-optic, or blue light-emitting diode light sources were assessed in the laboratory.

RESULTS

The efficacy of phototherapy units varies widely because of differences in light source and configuration. The following characteristics of a device contribute to its effectiveness: (1) emission of light in the blue-to-green range that overlaps the in vivo plasma bilirubin absorption spectrum (~460-490 nm); (2) irradiance of at least 30 μW · cm(-2) · nm(-1) (confirmed with an appropriate irradiance meter calibrated over the appropriate wavelength range); (3) illumination of maximal body surface; and (4) demonstration of a decrease in total bilirubin concentrations during the first 4 to 6 hours of exposure. RECOMMENDATIONS (SEE APPENDIX FOR GRADING DEFINITION): The intensity and spectral output of phototherapy devices is useful in predicting potential effectiveness in treating hyperbilirubinemia (group B recommendation). Clinical effectiveness should be evaluated before and monitored during use (group B recommendation). Blocking the light source or reducing exposed body surface should be avoided (group B recommendation). Standardization of irradiance meters, improvements in device design, and lower-upper limits of light intensity for phototherapy units merit further study. Comparing the in vivo performance of devices is not practical, in general, and alternative procedures need to be explored.

The side effects of phototherapy for neonatal jaundice: what do we know? What should we do?

Neonatal phototherapy (NNPT), a noninvasive, easily available therapy, has been widely used for the treatment of neonatal jaundice for more than half a century. Its efficiency in decreasing plasma bilirubin concentration is well documented, and NNPT leads to greatly reduced exchange transfusion rates for neonates with hyperbilirubinemia. It is generally accepted that the side effects of NNPT are not serious and seem to be well controlled. This review will focus on these possible side effects as well as the approaches to minimize them.

The need to implement effective phototherapy in resource-constrained settings

Phototherapy is the treatment of choice to reduce the severity of neonatal unconjugated hyperbilirubinemia regardless of its etiology. Its implementation requires a technical framework that conforms to existing evidence-based guidelines that promote its safer and effective use worldwide. Optimal use of phototherapy has been defined by specific ranges of total serum bilirubin thresholds configured to an infant's postnatal age (in hours) and potential risk for bilirubin neurotoxicity. Effective phototherapy implies its use at specific blue light wavelengths (peak emission, 450 ± 20 nm) and emission spectrum (range, 400-520 nm), preferably in a narrow bandwidth that is delivered at an irradiance of ≥30 μW/cm(2)/nm to up to 80% of an infant's body surface area. However, this is often not feasible in clinical settings with limited or constrained resources. To identify and bridge implementation barriers, we propose minimum criteria for device performance for safe and practical use of phototherapy as a prophylactic intervention to prevent severe hyperbilirubinemia.

Overhead is superior to underneath light-emitting diode phototherapy in the treatment of neonatal jaundice: a comparative study

AIM

To compare the efficacy of overhead and underneath light-emitting diode (LED) devices in the treatment of neonatal jaundice.

METHODS

We compared two LED phototherapy devices: the neoBLUE device, which provides overhead illumination, and the neoBLUE cozy device, which provides illumination from underneath the infant. The models we used had similar LED sources and provided similar light intensities (30 microW/cm(2)/nm). Infants with hyperbilirubinemia were assigned to one of two groups according to the phototherapy device used (group 1, overhead illumination, 181 infants; group 2, underneath illumination, 61 infants). Recorded variables included birthweight, gender, family history, aetiology of jaundice, total duration of phototherapy and total serum bilirubin (TSB) concentration at the initiation of phototherapy, at 12-hour intervals and just before the cessation of phototherapy. The rates of decrease in TSB concentration were calculated.

RESULTS

There were significant differences in the mean duration of phototherapy and in the rate of decrease in TSB concentration between the two groups. The mean duration of phototherapy in group 2 was higher than in group 1 (P= 0.037). The rate of decrease in TSB in group 1 was higher than in group 2 (P= 0.01).

CONCLUSION

These results suggest that when phototherapy is used in the treatment of neonatal jaundice, the direction from which the light is applied should be considered in addition to light source intensity.