Original Paper
Neonatology 2017;112:103–109 Received: November 23, 2016
DOI: 10.1159/000464318
Heating of Newborn Infants due to
Blue Light-Emitting Diode Fibreoptic
Phototherapy Pads
Pei Ling Ng a Tony Carlisle a, b Marleesa Ly d Scott Adam Morris a, c
a
Neonatal Unit and b Biomedical Engineering, Flinders Medical Centre, and c School of Medicine, Flinders University,
Bedford Park, SA, and d School of Medicine, University of Adelaide, Adelaide, SA, Australia
Keywords
Phototherapy · Neonatal jaundice · Temperature ·
Fibreoptic technology
Abstract
Background: Surface temperatures of fibreoptic photother-
apy 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 fi-
breoptic 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 mea-
sured before, during and after a 12-h period of phototherapy
(10 different LED light box-pad combinations). A prospec-
tive, cohort study of well babies at >34 weeks’ gestation re-
ceiving 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) be-
fore 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 =
© 2017 S. Karger AG, Basel
E-Mail karger@karger.com
www.karger.com/neo
Accepted after revision: February 21, 2017
Published online: April 27, 2017
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 tem-
perature 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 ba-
bies should be monitored closely during LED fibreoptic pho-
totherapy. A temperature probe placed between the skin
and the pad will not accurately reflect the core temperature
during fibreoptic phototherapy. © 2017 S. Karger AG, Basel
Introduction
Light-emitting diode (LED) fibreoptic phototherapy is
commonly used in the treatment of neonatal hyperbiliru-
binaemia. LED fibreoptic systems emit more intense nar-
row bandwidth blue light when compared to fibreoptics
using a halogen light source [1]. Fibreoptic phototherapy
systems in general are advantageous in that they allow
Dr. P.L. Ng, Dr. T. Carlisle and Dr. S.A. Morris are joint first authors hav-
ing made equal contributions to the study and manuscript.
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Dr. Scott Adam Morris
School of Medicine, Flinders University
Sturt Road
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Bedford Park, SA 5042 (Australia)
E-Mail scott.morris @ sa.gov.au
close contact between babies and mothers without inter-
rupting phototherapy [2]. Halogen fibreoptic systems
have been studied and shown to be effective at reducing
bilirubin levels [3]. Fibreoptic systems are frequently used
in combination with overhead lights to maximise the rate
of fall of plasma bilirubin [4].
A perceived advantage of LED fibreoptic photothera-
py over halogen light sources is the delivery of more in-
tense blue light without heating [5–7]. Published data on
halogen fibreoptic pads have shown a maximum pad sur-
face temperature of 23 ° C in bench-top studies [5, 8]. We
performed a systematic literature search and found no
published surface temperature evaluations of LED fibre-
optic phototherapy pads. Product information for a wide-
ly used LED fibreoptic phototherapy pad device (BiliSoft,
GE Healthcare, Aurora, OH, USA) and for the plastic fi-
breoptic components of this device (Lumitex Medical
Devices, Strongsville, OH, USA) do not suggest that the
pads are heated during phototherapy [6, 7]. However, we
have noted babies sweating and phototherapy pads get-
ting wet during LED fibreoptic phototherapy suggesting
significant warming.
The narrow spectrum blue light generated by LEDs is
“cold” in the sense that there is no infrared light gener-
ated. However, blue light is absorbed by plastic materials
and skin, and is converted to thermal energy when ab-
sorbed. Therefore, despite a “cold” light source, LED blue
light will generate heat in proportion to the intensity of
the light. Given the very high irradiances generated by the
pads, there is a high potential for clinically important
heating.
In this study, we first aim to measure the temperature
of fibreoptic phototherapy pads during phototherapy in
a bench-top study. We test the hypothesis that blue LED
light is absorbed by the plastic materials comprising the
pad resulting in heating. The bench-top study allows the
measurement of pad temperature without the confound-
ing influence of a baby’s warm skin touching the pad. Our
second aim is to conduct a prospective clinical study to
determine the extent of heating of pads and babies during
fibreoptic phototherapy.
Methods
LED Fibreoptic Phototherapy Device
All experiments used the BiliSoft LED phototherapy system.
This system has an LED light box generating a narrow blue spectral
output between 430 and 490 nm [6]. A detachable fibreoptic cable
comprising plastic optic fibres transmits light to the pad [6]. The
system has two pad sizes, a large 25 × 30 cm pad designed for term
104 Neonatology 2017;112:103–109
DOI: 10.1159/000464318
infant phototherapy, and a small 15 × 30 cm pad designed for pre-
term infant phototherapy. Both pads have plastic optic fibres wo-
ven into a mesh and a clear plastic polymer covering the optic fibres
(Tecoflex Polymer, Lubrizol Corp, Cleveland, OH, USA). Micro-
bends created in the optic fibres during the manufacture of the mesh
deflect light through the fibre cladding and result in light emission
[7]. Bilisoft Product Information states that spectral irradiance is 49
μW/cm2/nm ± 25% for the large pad, and 70 μW/cm2/nm ± 25% for
the small pad when measured at the plastic surface [6].
Temperature Measurement
Temperature measurements in bench-top and clinical studies
used thermistor probes (Fisher and Paykel, “Sure-Sense” part
#NC020-01, Fisher and Paykel Healthcare, Auckland, New Zea-
land) secured with a hydrogel adhesive cover with a foil backing
(Dräger Thermopads, MX11002, Dräger Medical GmbH, Lübeck,
Germany). Temperature data were collected continuously every
second through the connection of sensors to a datalogger (Omega
Model OM-DAQPRO-5300, Omega Engineering, Stamford, CT,
USA), and analysed as corrected temperatures based on calibra-
tion of the probe and datalogger with a reference electronic ther-
mometer (Fluke model 1523, Fluke Corporation, Everett, WA,
USA) having a traceable uncertainty of 0.02 ° C. All sensors were
accurate to <0.1 ° C over a temperature 21–38 ° C.
Bench-Top Study
Five light boxes, 5 large pads and 5 small pads were tested. Each
light box was tested with a single large or small pad (5 box-pad
pairings for both large and small pads). Each pad was placed in a
Perspex open basinet, a temperature probe attached to the geomet-
ric centre of the pad, and the pad covered with a sheet and light-
weight synthetic blanket. A second probe outside of the basinet
recorded the room temperature.
Pad and ambient room temperatures were monitored in three
experimental periods: before the light source was turned on, after
12 h of lights-on, and then 8 h after turning off the lights. Tem-
peratures from the last 10 min of each study period (last 600 tem-
perature readings) were averaged to arrive at a single temperature
(period mean). Each box-pad combination was tested in triplicate.
For each given box-pad combination, the mean of triplicate period
means was the temperature analysed for that period.
The mean photo-irradiance at the pad surface was determined
for each light box-pad combination using a phototherapy radiom-
eter (Model PR 450, Macam Photometrics Limited, Livingston,
UK). Another large pad had the polymer coating cut away from
the underlying optic fibre mesh and light absorbance by the poly-
mer was determined by the difference in irradiance.
Clinical Study
An observational cohort study was conducted in the Flinders
Medical Centre Neonatal Unit. The study was approved by the
Southern Adelaide Clinical Human Research Ethics Committee.
Written parental consent was obtained. We studied the large fibre-
optic phototherapy pads with the standard manufacturer’s fabric
pad cover.
A convenience sample of babies was chosen. Inclusion criteria
were post-conceptional age >34 + 0 days, clinically well and a sta-
ble axillary temperature at ambient Neonatal Unit temperature
(between 25 and 27 ° C). Babies with uncomplicated physiological
hyperbilirubinaemia or without hyperbilirubinaemia were eligi-
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 Start phototherapy Cease phototherapy 28 *
37.5 Large pads
Phase 1 Phase 2 Phase 3 27 Small pads

37.0 26

Temperature, °C
Temperature, °C

25
36.5
24

36.0 23

22
Pad
35.5 Back
Axilla 21

35.0
60 150 210 Before lights Lights on Lights off
on for 12 h for 8 h
Time, min
Study period

Fig. 1. Graph from one study baby illustrating the study protocol.
For each baby, the temperature recorded for a given phase was the
average of the last 10 min of that phase.
Fig. 2. Change in the temperature of LED fibreoptic phototherapy
pads when lights are switched on and off. Pad temperature after
12 h of phototherapy lights-on was statistically different to pre and
post temperatures for both large and small pads (* p < 0.0005 com-
pared to baseline).

ble. Babies nursed in an incubator where this was turned off and
at 25–27 ° C were included. Babies who were unwell or with un-
   
stable temperatures were excluded from study entry. Withdrawal
of babies occurred at parental request if the baby was unable to
complete the study protocol due to needing a feed.
Babies were nursed undressed on their back with skin in direct
contact with a synthetic material pad cover, with a sheet and a
light-weight synthetic blanket, and face and head exposed. Tem-
perature probes were placed in the axilla, in contact with the pad
and in contact with the skin of the back. The hydrogel adhesive
probe cover provided partial isolation of back and pad surface tem-
perature measurements. The study protocol is illustrated by data
from one baby shown in Figure 1. Study phase 1 comprised 60 min
with the phototherapy light off, to allow back and axilla tempera-
tures to stabilise. The phototherapy lights were then turned on for
90 min (phase 2), followed by a 60-min period where lights were
turned off (phase 3). The total time period for the study (210 min)
was based on the practical constraints of timing of feeds and nappy
changes, both of which require handling and consequently disturb
temperature measurement. No baby received overhead photo-
therapy.
A control group of babies was studied to determine the effect
of babies’ skin temperature on the pad temperature. This group
was managed in exactly the same way as the study babies with the
exception that the lights were not turned on over the study period.
At the conclusion of the study, temperature data for each baby
were graphed as in Figure 1, and each graph was reviewed by the
authors. Babies were excluded from the final analysis if the data
from study phases 2 or 3 were uninterpretable due to artefact. For
each study period, the final 10 min of temperature data for each
baby were averaged to give a single temperature representative of
Statistical Methods
All statistical analyses used IBM SPSS software version 22 (IBM
Corp, Chicago, IL, USA), or Stata version 13.0 (StataCorp, College
Station, TX, USA). An alpha level of 0.05 was used for all analyses.
For the bench-top study, changes in pad temperature between the
three study periods were analysed using repeated measures analy-
sis of variance, with the study period as the independent variable
and temperature as the dependent variable. A Bonferroni correc-
tion was used for post hoc pairwise comparisons. Changes in tem-
perature from baseline following 12 h of phototherapy were com-
pared between large and small pads using an independent samples
t test. Bivariate correlation was used to determine the association
between change in the temperature and photo-irradiance.
For the clinical study, clinical characteristics were analysed us-
ing an independent samples t test or Fisher’s exact test where ap-
propriate. Absolute temperatures and changes in temperature
were modelled using ordinary least squares regression. Study
phase, treatment arm and probe location were included as covari-
ates. The models were used to calculate adjusted linear predictions
for each covariate combination. Post-estimation Wald tests were
performed to examine pairwise differences between adjusted lin-
ear predictions for different covariate combinations.
Results
Bench-Top Study
Pad temperature data for the bench-top study are
shown in Figure 2. The mean (95% CI) pad temperature
was 21.8 ° C (21.5–22.1) before lights, 27.0 ° C (26.5–27.5)

that period. after 12 h of lights, and 22.1 ° C (21.9–22.4) 8 h after turn-

   
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 6.5 Pad Back Axilla
r = 0.89, p = 0.001
6.0
* * * * *
39
Rise in temperature, °C

5.5 38

5.0

Temperature, °C
37

4.5 36

4.0 35

34
3.5
60 80 100 120 140
33
Irradiance, μW/cm2/nm

1 2 3 1 2 3 1 2 3
Fig. 3. Relationship between irradiance of individual LED fibreop- a Study phase
tic phototherapy pads and increase in pad temperature after 12 h
of phototherapy lights-on. Pad Back Axilla
39

38
ing off lights (F = 366.1, p < 0.0005). Pad temperature was
Temperature, °C
higher after 12 h of lights being on compared to either pre 37

or post light periods for large and small pads (p < 0.0005). 36
The mean (95% CI) increase in temperature was greater
for small pads than large pads, 5.9 ° C (5.7–6.1) versus     35
4.5 ° C (4.0–4.9), p < 0.0005. The mean (95% CI) irradi-
   

ance in the middle of the pad was higher for the small
pads at 120.9 μW/cm2/nm (107.9–133.9) vs. 70.8 (61.4–
80.3) for large pads; p < 0.0005. The magnitude of change
in pad temperature was linearly correlated with irradi-
ance in the middle of the pad (r = 0.89, p < 0.0005), as
shown in Figure 3. A mean of approximately 12.9% of
blue light emitted from exposed optic fibres was absorbed
by the plastic cover. Room temperature was constant dur-
ing the studies, with a mean (range) of 21.3 ° C (20.3–22.4).    
Clinical Study
Of 43 babies enrolled in the phototherapy group, 4 ba-
bies were withdrawn due to needing a feed, and data from
another 10 babies were excluded due to movement arte-
fact, leaving data from 29 babies for analysis. Of 11 babies
enrolled in the control group, 3 were excluded due to
needing a feed. Baseline clinical data are shown in Ta-
ble 1. The control babies tended to have a lower birth ges-
tation and weight, but weight and corrected gestations
34
33
1 2 3 1 2 3 1 2 3
b Study phase
Fig. 4. a Pad, back and axillary temperatures in babies receiving
phototherapy over the three study phases (n = 29). Boxes are the
25th and 75th percentiles with the median line shown, and whis-
kers the 5th and 95th percentile. All data including outlying data
are shown, and were included in analysis. Phase 1 is a 60-min pre-
phototherapy, phase 2 is during 90 min of phototherapy and phase
3 is 60 min post phototherapy. b Temperature measurements in a
comparison group of babies not receiving phototherapy (n = 9).
* p < 0.05.
Statistically significant increases in pad, back and axillary
temperatures were noted during 90 min of phototherapy.
The highest pad surface temperature recorded was 38.9 ° C.    

were similar at the time of study. Axillary temperatures were greater than 37.5 ° C in 4 ba-    

Table 2 shows mean (95% CI) temperatures for the pad bies, with a peak of 37.7 ° C. Pad and back temperature fell
   

surface, skin of the back and axilla in phototherapy and
control (no-phototherapy) cohorts. The raw data for the
two groups are summarised using boxplots in Figure 4.
after turning the phototherapy lights off, but mean axillary
temperature did not fall over this period and continued to
rise in 8 babies. Two babies had low phase 1 axillary tem-
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 Table 1. Clinical characteristics of study and control babies

Phototherapy group No phototherapy group p value

(n = 29) (n = 9)

Age post conception at birth, days 246±25 233±26 0.176

Age post conception at study, days 264±16 259±16 0.245
Birth weight, g 2,667±1,033 2,039±980 0.116
Weight at study, g 2,914±662 2,620±606 0.245
Gender, M:F 20:9 6:3 1.0
Jaundice, n 9 2 1.0
Nursed in an incubator, n 5 3 0.117

Data are presented as means ± SD or number.

Table 2. Temperatures (°C) in each study phase and changes in temperature between study phases for babies re-
ceiving phototherapy (n = 29) and for comparison babies not receiving phototherapy (n = 9)

Phase 1 Phase 2 Phase 3 Change 1 >2 Change 2 >3

Pad
PT 36.2 37.0 36.4 1.7* (1.4, 1.9) –1.4* (–1.6, –1.2)
No PT 36.3 36.3 36.3 0.2 (–0.3, 0.6) –0.1 (–0.5, 0.3)
Back
PT 36.6 37.5 36.9 0.6* (0.3, 0.8) –0.4* (–0.6, –0.2)
No PT 36.7 36.8 36.7 0.1 (–0.3, –0.5) 0.0 (–0.4, 0.4)
Axilla
PT 36.4 37.2 36.6 0.3* (0.1, 0.5) –0.1 (–0.3, 0.1)
Control 36.5 36.6 36.5 –0.1 (–0.5, 0.3) –0.1 (–0.5, 0.3)

Data are means (95% CI). * p < 0.05.

peratures (Fig. 4); however, these were artefactual due to is due to blue light absorption. During clinical use, pad
intermittent loss of probe contact in the last 10 min of temperatures of up to 38.9 ° C were recorded. The extent
   

phase 1. Exclusion of these babies in the statistical model
had no effect on results and so these data were included in
the analysis. No changes in pad, back or axillary tempera-
tures were noted across study periods in the control co-
hort. Pad, back and axillary temperatures were higher dur-
of pad heating is sufficient to cause net heat transfer to
babies and reduce conductive heat loss. Under our study
conditions, a statistically detectable increase in axillary
temperature occurred after 90 min of phototherapy. Axil-
lary temperature exceeded 37.5 ° C in several babies over

ing phototherapy when compared to the control group
(pad: p = 0.002; back and axilla: p < 0.001).
Discussion
Pad surface temperature increases during photothera-
py, and the increase correlates with light intensity. Ab-
sorption of blue light by the pad plastic has also been
demonstrated. These results suggest that heating of pads
this short period indicating mild over-heating. This study
brings to clinical attention the fact that babies receiving
LED fibreoptic phototherapy at high irradiance are effec-
tively nursed on a warming blanket.
Heating of LED fibreoptic pads has not been recog-
nised in the literature. There have been no published clin-
ical studies addressing temperature changes in the pad
materials or effects of high intensity LED fibreoptic pho-
totherapy on body temperature. Existing studies of fibre-
optic phototherapy have used older systems, typically a
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quartz halogen light source, and quoted irradiances of 35
μW/cm2/nm or less [3, 5, 8–10]. Temperature side-effects
in babies were not reported in a Cochrane meta-analysis
of randomised controlled trials of fibreoptic photothera-
py using these older systems [3]. In the Cochrane review
of largely overhead LED phototherapy for neonatal hy-
perbilirubinaemia, only the study of Maisels et al. [9] uti-
lised fibreoptic phototherapy and this was with a halogen
light source with no reported hyperthermia [11]. Pezzati
et al. [10] is the only clinical paper that has specifically
measured skin temperature in contact with a halogen
light source fibreoptic pad. The authors measured skin
temperature before and after 2 h of phototherapy in 20
term babies and found no change [10]. Our data suggest
that the relevance of these older data to modern, higher
intensity systems is questionable.
The findings of our study have two clinical implica-
tions. First, there is a need for awareness of babies’ ther-
mal environment and temperature monitoring during fi-
breoptic phototherapy. Second, placing a temperature
probe between a preterm baby’s skin and the mattress is
frequently utilised as a means of continuously estimating
core temperature using the assumption of zero heat flux
[12–14]. This method cannot be reliably used during
phototherapy with a fibreoptic pad.
There are a number of limitations to our study. The du-
ration of phototherapy was short, and the impact of more
prolonged phototherapy cannot be determined from our
data. Whether further heating occurs or whether an equi-
librium state is achieved would depend on individual en-
vironmental conditions. We only tested babies who were
close to term-corrected age and used large pads. The effect
of the warmer small pads used with preterm babies has not
been explored. While some babies were nursed in incuba-
tors, ambient incubator temperatures were similar to
nursery temperatures and statistical modelling showed no
effect of incubator status on temperature. Attrition and
selection bias in results are also possible due to patient
withdrawal and the rejection of some temperature data
due to artefact. In view of these limitations, the clinical sig-
nificance of the observed heating of the pads is not fully
defined. The absence of dangerous hyperthermia is reas-
suring within the limits of the study design.
While we only tested one commercial LED photother-
apy system, this is a widely used device and the heating of
plastics is fundamental for similar devices. Although the
majority of babies in the clinical study were not hyper-
bilirubinaemic, this variable is not relevant to heating of
plastics and no statistical effect of hyperbilirubinaemia on
temperature was noted. Pad temperature measurement
108 Neonatology 2017;112:103–109
DOI: 10.1159/000464318
was not completely isolated from body temperature in the
clinical study with the temperature probes used as shown
by higher baseline pad temperatures. However, warming
of pads above body temperature and the absence of
change over time in control babies indicate that light ab-
sorption was the cause of pad heating.
The American Academy of Pediatrics recommends
that an irradiance of at least 30 μW/cm2/nm be used dur-
ing intensive phototherapy, based on the study of Tan
showing a plateau in efficacy above this threshold [1, 4,
15]. More recently, Vandborg et al. [16] showed no ap-
parent plateau in the rate of bilirubin decline of up to 50
μW/cm2/nm. While a saturation point for bilirubin deg-
radation with increasing irradiance is undetermined,
there is equally no evidence that more extreme irradiance
is beneficial. Aydemir et al. [17] observed higher body
temperatures in babies receiving overhead LED blue light
phototherapy of >60 μW/cm2/nm, when compared to ba-
bies receiving lower light intensities. This may suggest di-
rect heating of skin following blue light absorption. We
suggest that more is not necessarily better, and one po-
tential downside of very high irradiances delivered via
modern LED fibreoptic pads is heating.
Conclusion
While the LED blue light source commonly used for
fibreoptic phototherapy is “cold,” the plastic polymer of
the phototherapy pad is heated at high intensities of blue
light. The thermal environment should be considered
during LED fibreoptic phototherapy and temperature of
babies monitored closely. Temperature measurement be-
tween a baby’s skin and the mattress is not accurate dur-
ing fibreoptic phototherapy.
Acknowledgements
The Flinders Medical Centre Neonatal Unit and Biomedical
Engineering staff are thanked and acknowledged.
Disclosure Statement
The authors declare no conflicts of interest.
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