Paediatrica Indonesiana

VOLUME 51 NUMBER 5 September 2O11

Original Article
256 Paediatr Indones, Vol. 51, No. 5, September 2011
Effectiveness of phototherapy with reflecting curtains
on neonatal jaundice
Ari Kurniasih, Guslihan Dasa Tjipta, Muhammad Ali, Emil Azlin, Pertin Sianturi
Abstract
Background Althou,h phototherapv has been used in clinical
practice for 1O vears, there is still much debate on how to provide
the most efficacious phototherapv. Phototherapv with white
reflectin, curtains mav increase the avera,e spectral irradiance
provided, as well as decrease serum bilirubin concentrations at a
faster rate in neonates with jaundice.
Objective 1o determine if addin, low cost, white, reflectin,
curtains to a standard phototherapv unit can increase the
effectiveness of phototherapv for neonatal jaundice.
Methods A randomized, controlled, open trial was conducted at
H. Adam Malik and Pirn,adi Hospitals, Medan, from Mav to
December 2OO9. 1he criteria for inclusion in the studv were full
term newborns with neonatal jaundice presentin, in their first
week of life. Sin,le phototherapv with white curtains han,in,
from the sides of the phototherapv unit (studv ,roup, n~3O)
was compared to sin,le phototherapv without curtains (control
,roup, n~3O). 1he primarv outcomes measured were the mean
difference in total serum bilirubin levels and avera,e spectral
irradiation levels measured at baseline, and after 12 hours and
21 hours of phototherapv.
Results 1he sum of avera,e spectral irradiance in the curtained
phototherapv unit was si,nificantlv hi,her than that of the
standard phototherapv unit without curtains (P < O.O5). 1he
decrease of total serum bilirubin levels after 12 and 21 hours of
phototherapv was si,nificantlv ,reater in the studv ,roup (3.71
and 9.7 m,/dl, respectivelv) than in the control ,roup (O.1 and
3.o m,/dl, respectivelv), both P <O.O5.
Conclusion White, reflectin, curtains in phototherapv units
was si,nificantlv more effective than phototherapv without
curtains for treatment of neonatal jaundice. [Paediatr Indones.
2011;51:256-61].
Keywords: neonatal jaundice, white reflecting
curtains, spectral irradiance, phototherapy, bilirubin
1his studv was presented at Pl1 lV, Medan, lebruarv 22- 21, 2O1O.
lrom the Department of Child Health, Universitv of North Sumatera
Medical School, H. Adam Malik Hospital, Medan, lndonesia.
Reprint requests to: Ari Kurniasih, MD, Department of Child Health,
Universitv of North Sumatera Medical School, Adam Malik Hospital, Jl.
Bun,a lau No. 17 Medan. 1el. 62-61-o361721, 62-61-o365663, lax
62-61-o361721. l-mail : kurniasih_ari _vahoo.com
T
he American Academv of Pediatrics reported
on the efficacv of phototherapv as a
treatment for neonatal hvperbilirubinaemia.
1
Despite the lon, period of development
since the ori,inal paper of Cremer et al
2
, there are still
considerable variations in spectral output, irradiance
levels, and irradiated area provided by commercial
phototherapy systems, as noted in the American
Academv of Pediatrics report.
3
It is clear that irradiance
is an important factor, with several studies showin, that
increased irradiance produces a faster decrease of serum
bilirubin levels.
4
A dose-response relationship exists between
the amount of irradiation and reduction in serum
bilirubin, up to an irradiation level of 3O-1O uW/
cm
2
/nm. Newer phototherapv units, when properlv
confi,ured, and the use of reflectin, curtains mav
deliver li,ht ener,v up to 1O uW/cm
2
/nm, su,,ested
to be the saturation level.
5
Single phototherapy with
low cost, white, reflectin, curtains mav be more
Ari Kurniasih et al: lffectiveness of phototherapv with reflectin, curtains on neonatal jaundice
Paediatr Indones, Vol. 51, No. 5, September 2011 257
effective than sin,le phototherapv alone, providin, a
less expensive alternative to double phototherapv for
treatment of infants with jaundice.
6
We aimed to compare the spectral irradiance and
decrease in serum bilirubin levels in neonates usin,
sin,le phototherapv without curtains to those usin,
sin,le phototherapv with white, reflectin, curtains.
Methods
We conducted a randomized, controlled, open clinical
trial in Haji Adam Malik and Pirn,adi Hospitals,
Medan, lndonesia in Mav to December 2OO9. All
babies admitted to the special care nurserv of both
hospitals durin, the studv period, with uncomplicated
neonatal jaundice and requirin, phototherapv, were
eli,ible for the studv. Subjects were included bv
simple randomization. 1he need for phototherapv was
determined usin, the American Academv of Pediatrics
,uidelines for mana,ement of jaundice in healthv term
newborns. We excluded babies with serum bilirubin
levels close to the exchan,e transfusion limit, elevated
direct bilirubin, hemolvtic disease and con,enital
anomalies. 1his studv was approved bv the Medical
lthics Committee, Universitv of Sumatera Utara
Medical School.
Sample size needed was estimated to be 3O
neonates for each ,roup. 1he followin, demo,raphic
and laboratorv data obtained included a,e, sex,
hemo,lobin and albumin levels. Neonates were
randomized to receive either sin,le phototherapv
without curtains (control ,roup) or sin,le photo-
therapv with white curtains around the sides of the
phototherapv units. 1he white curtain and plastic were
hun, around the phototherapv unit. li,ht intensitv was
measured as spectral irradiance (uW/cm
2
/nm) usin, a
Dale 1O li,ht intensitv meter (Dale 1O, USA).
Phototherapv units were manufactured bv
1essna, USA (1essna phototherapv unit with five
compact blue fluorescent lamps). 1he distance
between the phototherapv unit and the infant was
standardized at 15 cm. Serum bilirubin and spectral
irradiance were measured at baseline, and after 12
hours and 21 hours of phototherapv. 1he safetv of both
methods was assessed and compared by monitoring
bodv temperature, hvdration status (monitored
clinicallv and bv wei,ht), skin problems (such as
rashes) and ,astrointestinal problems (such as loose
stools or feedin, intolerance).
The association between phototherapy type and
serum bilirubin levels was analvzed bv Student's t-test.
Spectral irradiance was analvzed bv comparin, means
with the Mann-Whitnev U test. We analvzed data with
Figure 1. Study prole
9 excluded:
- 4 with direct
hyperbilirubinemia
- 3 with congenital
anomalies
- 2 did not consent
72 neonates with
hyperbilirubinemia
63 neonates with indirect
hyperbilirubinemia
1 dropped
out: death
Single phototherapy
without curtains n= 32
Single phototherapy
with curtains n= 31
2 dropped
out:
damaged
blood
samples
Included in follow-up and data analysis
Ari Kurniasih et al: lffectiveness of phototherapv with reflectin, curtains on neonatal jaundice
258 Paediatr Indones, Vol. 51, No. 5, September 2011
SPSS version 11.O. 1he si,nificance level was accepted
as P < O.O5, with 95' confidence intervals (95' Cl).
Results
We evaluated 72 neonates with hvperbilirubinemia.
Nine neonates were excluded (1 with direct hvper-
bilirubinemia, 3 with con,enital anomalies and 2
infants' parents did not consent). 1he remainin, 63
enrolled in our studv. 1hree babies were excluded from
the final analvsis as one from the intervention ,roup
died and two from the control ,roup had dama,ed
blood samples (Figure 1).
Both ,roups had similar characteristics at
baseline includin, a,e, sex, wei,ht, temperature,
serum bilirubin, albumin and hemo,lobin levels
(Table 1).
1here was no si,nificant decrease in total serum
bilirubin after 12 hours of phototherapv without
curtains (P > O.O5). However, there was a si,nificant
decrease in total serum bilirubin after 12 hours of
phototherapv with white, reflectin, curtains, (P <
O.O5), as shown in Table 2.
Table 3 shows si,nificantlv ,reater decrease
in bilirubin levels in the sin,le phototherapv
with curtains ,roup at 12 hours and 21 hours of
phototherapy compared to single phototherapy
without curtains (P < O.O5).
1he spectral irradiance at the start, 12 and
21 hours was si,nificantlv different between sin,le
phototherapv with curtains and without curtains
(P<O.O5).
We monitored subjects for adverse effects of
treatment. Hvperthermv (1>37.5C) was experienced
bv 5 subjects (o.3' of total), 3 in the sin,le
phototherapv with curtains ,roup and 2 in the sin,le
phototherapv without curtains ,roup. ther potential
side effects, such as diarrhea and dehvdration, were
not observed durin, the studv period.
Table 2. Mean decrease in total serum bilirubin after 12 hours and 24 hours of phototherapy in the
two groups, with and without curtains
Type of phototherapy Mean (SD) 95% CI P
After 12 hours without curtains, mg/dl
After 24 hours without curtains, mg/dl
After 12 hours with curtains, mg/dl
After 24 hours with curtains, mg/dl
0.1 (0.01)
3.8 (1.35)
3.8 (0.91)
9.7 (1.42)
- 0.0 to 0.1
3.5 to 4.5
3.4 to 4.0
6.9 to 7.9
0.059
0.0001
0.0001
0.0001
Table 3. Bilirubin levels in both groups at baseline and after 12 and 24 hours of phototherapy
Phototherapy
with curtains
Phototherapy
without curtains
95% CI P
Mean initial bilirubin, mg/dL (SD)
After 12 hours
After 24 hours
18.7 (1.81)
14.9 (1.98)
9.0 (2.24)
17.7 (1.45)
17.6 (1.44)
13.9 (1.85)
0.06 to 1.76
-3.62 to -1.83
-5.50 to -3.59
0.38
0.0001
0.0001
Table 1. Baseline characteristics of subjects
Intervention
group(n=30)
Control
Group (n=30)
Sex, male/female
Mean age, days (SD)
Mean weight, grams (SD)
Mean temperature, 0C (SD)
Mean total serum bilirubin before phototherapy, mg/dL (SD)
Mean albumin, g/dL (SD)
Hemoglobin, g/dL (SD)
15/15
5.0 ( 1.36)
2761.4 ( 203.70)
36.9 (0.31)
18.7 (1.81)
2.9 (0.22)
14.0 (1.72)
17/13
4.9 (1.34)
2720.3 (180.80)
36.8 (0.27)
17.7 (1.45)
2.7 (0.13)
14.0 (1.00)
Ari Kurniasih et al: lffectiveness of phototherapv with reflectin, curtains on neonatal jaundice
Paediatr Indones, Vol. 51, No. 5, September 2011 259
Discussion
Phototherapv is the use of visible li,ht for the treatment
of hvperbilirubinemia in newborns. 1his relativelv
common therapv lowers serum bilirubin levels bv
transformin, bilirubin into water soluble isomers that
can be eliminated without conju,ation in the liver. 1he
dose of phototherapv lar,elv determines how quicklv
this process can occur. 1he dose is determined bv
the wavelen,th of li,ht, the intensitv of the li,ht, the
distance between the li,ht and the infant and the bodv
surface area exposed to li,ht (irradiance).
7,o
ur results showed that the use of white
curtains on the sides of phototherapv units can safelv
increase the efficacv of phototherapv. 1his simple and
inexpensive method mav be of ,reat use to neonatal
units in developin, countries, where acquisition and
maintenance of a sufficient number of phototherapv
units mav challen,e limited bud,ets.
1he reduction of bilirubin after 12 and 21 hours
of phototherapv in the sin,le phototherapv with
curtains ,roup was clearlv ,reater than in the sin,le
phototherapv without curtains ,roup. 1he reason
for this findin, was most likelv due to the increased
surface area exposed to phototherapv since the white
curtains reflected li,ht, leadin, to increased bilirubin
decomposition.
7
ur studv results were consistent with a
Malavsian studv usin, sin,le phototherapv with and
without white reflectin, curtains. 1hev found bilirubin
reduction after 1 hours of sin,le phototherapv with
curtains and without curtains to be 1.62 m,/dl vs O.23
m,/dl, respectivelv. We observed the reduction of
serum bilirubin after 12 hours of sin,le phototherapv
with curtains and without curtains to be 3.o m,/dl
vs O.1 m,/dl, respectivelv. 1heir serum bilirubin
reduction rate was O.1 m,/dl/h, whereas ours was
O.3 m,/dl/h.
6
lrradiance is the li,ht intensitv or number of
photons delivered per square centimeter of exposed
bodv surface. 1he delivered irradiance determines the
effectiveness of phototherapv in that hi,her irradiance
causes faster decline in serum bilirubin levels. Spectral
irradiance quantified as uW/cm
2
/nm, largely depends
on the desi,n of the li,ht source. lt can be measured
with a spectral radiometer sensitive to the effective
wavelen,th of li,ht.
9,1O
ln our studv, spectral irradiance of sin,le
phototherapv with curtains was approximatelv
2 times ,reater than that of sin,le phototherapv
without curtains. 1he Malavsian studv found spectral
irradiance of sin,le phototherapv with white reflectin,
curtains to be approximatelv 1.5 times that of sin,le
phototherapv without curtains.
11
Figure 2. Spectral irradiance in both groups of phototherapy
Initial 12 Hours 24 Hours
Phototherapy duration
S
p
e
c
t
r
a
l

I
r
r
a
d
i
a
n
c
e

(
P
W
/
c
m
2
/
n
m
)
16
14
12
10
8
6
4
2
0
13.6 13.6 13.6
6.6 6.6 6.6
Single without curtanin
Single with curtanin
Ari Kurniasih et al: lffectiveness of phototherapv with reflectin, curtains on neonatal jaundice
260 Paediatr Indones, Vol. 51, No. 5, September 2011
Blue li,ht with a wavelen,th of 125 - 175
nm is best for lowerin, levels of indirect bilirubin.
Several clinical trials showed that blue li,ht was
better at reducin, bilirubin levels compared to li,ht
at other wavelengths.
11,12
Blue li,ht has a shorter
wavelength than visible light, other than violet light.
Since wavelength is inversely proportional to energy,
shorter wavelen,th will produce ,reater ener,v, thus
reducin, bilirubin levels at a faster rate than other
light.
13
We used blue li,ht and measured its intensitv
at baseline, 12 hours and 21 hours of phototherapv
in both ,roups. 1here were si,nificant differences in
spectral irradiance with and without white reflectin,
curtains, (P< O.O5).
Neonates treated for hi,h bilirubin levels
mav also suffer from dehvdration and mav require
additional fluid intake.
14
Increased body and
environmental temperature, insensible water loss,
respiratorv rate and blood flow to the skin are
determined bv neonatal maturitv, adequate caloric
intake, temperature of the phototherapv unit,
distance between the neonate and the photolight,
as well as the incubator heat loss. lncreased blood
flow to the peripherv can increase fluid loss, requirin,
adjustment of intravenous fluids.
15,16
Chan,es in skin
such as rashes, darker skin colour and burns mav
occur if neonates are over-exposed to fluorescent
light.
15
A studv in the Netherlands found that durin,
intensive phototherapv, a 2O' increment of total
fluid requirement can prevent increased bodv
temperature.
17
Durin, this studv, bodv temperature
and fluid administration were strictlv monitored, with
fluids ,iven everv 2 hours.
lor breastfed neonates, phototherapv was
stopped temporarilv while the infant was fed bv the
mother.
1o,19
We observed none of the ne,ative effects
mentioned above, but hvperthermv (1 > 37.5 C)
was observed in 3 (5' of total subjects) neonates
in the sin,le phototherapv with curtains ,roup and
in 2 (3.3' of total subjects) neonates in the sin,le
phototherapv without curtains ,roup.
A previous studv noted a stron, association
between breastfeedin, and hvperbilirubinemia
in healthv newborns durin, the first week of life.
Phototherapv effectivelv reduced bilirubin levels
in breastfed newborns with hvperbilirubinemia, but
these patients showed a si,nificantlv slower response
to treatment than that of mixed-fed newborns.
2O
A limitation of our studv was that we did not
differentiate between breastfed and formula-fed
neonates.
The evidence that phototherapy with simple
white curtains hun, on sides of phototherapv units is
more effective than phototherapv without curtains is
quite stron,. 1his findin, mav translate into potential
cost reductions in two wavs. lirst, shorter duration of
treatment means that more patients can be treated
with fewer phototherapv units, resultin, cost savin,s
from decreased acquisition and maintenance of
phototherapv units. Second, shorter duration of
treatment would shorten the len,th of hospitalization.
1hese advanta,es would be of major importance in
developin, countries, but are also valid for developed
countries, where cost effectiveness is becomin,
increasingly important.
We demonstrated that sin,le phototherapv
with white reflectin, curtains was more effective
than sin,le phototherapv without curtains in
reducin, serum bilirubin levels in term infants
with hvperbilirubinemia, at the 12 and 21 hour
measurement periods. ln addition, spectral irradiance
produced bv sin,le phototherapv with white, reflectin,
curtains was hi,her than that of sin,le phototherapv
without curtains.
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