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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 5  |  Issue : 3  |  Page : 153-156

Efficacy of different types of phototherapy devices: A 3-year prospective study from Northern India


1 Department of Pediatrics, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
2 Department of Anesthesiology and Critical Care, Government Medical College, Srinagar, Jammu and Kashmir, India

Date of Web Publication28-Sep-2016

Correspondence Address:
Dr. Javeed Iqbal Bhat
Department of Pediatrics, Sher-I-Kashmir Institute of Medical Sciences, Srinagar - 190 011, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2249-4847.191245

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  Abstract 

Objective: To evaluate the efficacy of light-emitting diode (LED) over conventional phototherapy in near-term and term Rh-compatible otherwise healthy neonates in resource-constrained settings. Design: This was a 3-year prospective observational study. Setting: The study was conducted in the neonatal unit of a teaching hospital. Patients: Near-term and term (≥35 weeks of gestation) Rh-compatible, otherwise healthy, newborns were included in the study. Interventions: Single surface LED or conventional phototherapy was performed. Main Outcome Measures: The primary outcome variable was the duration of phototherapy, and the secondary outcome variables were a rate of fall in the total serum bilirubin (TSB) and need for exchange transfusion. Results: A total of 406 patients constituted the study population. Two hundred and thirty patients received LED phototherapy, and 176 patients received conventional phototherapy. The birth weight, gestational age, gender, mean TSB, and other baseline laboratory parameters were similar in both groups. The median duration of phototherapy in the LED group (22.0 h [95% confidence interval: 20.47, 23.53]) was significantly less than that in the conventional phototherapy group (32.0 h [95% confidence interval: 29.8, 34.1]). Similarly, the rate of fall of TSB at 6, 12, and 18 h was significantly higher in LED group than in the conventional group. Fifteen patients (6.5%) received double volume exchange transfusion in LED group and twenty patients (11.4%) in the conventional group. Conclusions: LED phototherapy was found more efficacious than conventional phototherapy in resource-constrained settings, where the majority of jaundiced patients are managed with latter one and because of limited resources irradiance is never checked or checked inappropriately, which can be a source of serious error.

Keywords: Jaundice, light-emitting diode, phototherapy


How to cite this article:
Bhat JI, Qazi IA, Ahangar AA, Charoo BA, Ahmed A, Ahmad I. Efficacy of different types of phototherapy devices: A 3-year prospective study from Northern India. J Clin Neonatol 2016;5:153-6

How to cite this URL:
Bhat JI, Qazi IA, Ahangar AA, Charoo BA, Ahmed A, Ahmad I. Efficacy of different types of phototherapy devices: A 3-year prospective study from Northern India. J Clin Neonatol [serial online] 2016 [cited 2019 Dec 9];5:153-6. Available from: http://www.jcnonweb.com/text.asp?2016/5/3/153/191245


  Introduction Top


Neonatal jaundice remains a colossal issue worldwide, especially in developing countries where resources are always limited. It affects 84% of term newborn babies.[1] The majority of these neonates has benign course; however, in 2%-5% of cases, serum bilirubin can go up to dangerous levels, leading to permanent brain damage.[2] Phototherapy is an effective treatment for hyperbilirubinemia and is easily available and devoid of major complications compared to double volume exchange transfusion (DVET) which has got a complication rate of 4%-5%.[3] The efficacy of phototherapy depends on the spectrum of light emitted (optimal within blue to green spectrum of 460-490 NM), irradiance, and footprint (body surface area [BSA] covered).[3],[4] Conventional phototherapy devices are cheap, widely used in developing countries. However, they generate considerable heat and cannot be applied too closely to the patient. Furthermore, the average life is <1000 h, so the irradiance needs to be checked once a week with a radiometer; otherwise, the efficacy is severely compromised.[5] Light-emitting diode (LED) lights are increasingly being used in tertiary care centers of our country. The cost is higher than conventional phototherapy units. Advantages include low power consumption, low heat production, thus can be placed very close to the patient, and a much longer life span of the light-emitting units (20,000 h) compared with conventional light sources.[3] We performed this prospective observational study to compare the efficacy of LED phototherapy with conventional phototherapy in resource-constrained settings.

Objective

The objective of this article is to study the efficacy of LED phototherapy over conventional phototherapy in resource-constrained settings.


  Subjects and Methods Top


Study design

This was a 3-year prospective cohort study.

Setting

The study was conducted from June 2012 to May 2015 conducted in a neonatal unit of a teaching hospital in the northernmost state of India (Kashmir).

Participants

The annual neonatal admission in our hospital is 2000. All otherwise healthy jaundiced babies with no Rh-incompatibility and gestational age ≥35 weeks who needed phototherapy were enrolled in the study. Entry criteria to phototherapy followed the American Academy of Pediatrics' (AAP) Practice Parameter.[3]

Outcome variables

The primary outcome variable was the duration of phototherapy, and the secondary outcome variables were rate of fall in the total serum bilirubin (TSB) and need for exchange transfusion. Rate of fall was measured every 6 h till phototherapy was discontinued.

Data source/measurements

Our nursery has four LED phototherapy units (Lullaby LED phototherapy system, GE Health care, United States) and three conventional phototherapy units (Ameda Phototherapy System, Bavaria Germany); all are in working condition. Since we are not able to check spectral irradiance of our phototherapy units due to nonavailability of radiometer, we change tubes only when the ends blacken or tubes flicker. Patients were put either on LED phototherapy or on conventional phototherapy depending on availability of the unit. Patients were continued on the same phototherapy unit until two consecutive TSB values obtained 6 h apart were below the phototherapy zone. We have a uniform policy of placing baby as close as possible to LED phototherapy and 20 cm from the conventional phototherapy to prevent neonatal hyperthermia in case of latter. Except for eyes and genitals, we keep all areas uncovered.

The demographic and clinical variables recorded in the study included birth weight, postnatal age, gestational age, sex, family history, blood group of mother and baby, duration of phototherapy, exchange transfusion if needed. The gestational age was calculated from the mother's last menstrual period. Laboratory evaluations include measurement of TSB every 6 h as per unit protocol, baby blood group, glucose-6-phosphate dehydrogenase status, reticulocyte count, and blood culture. Patients with positive blood culture were excluded from the study.

Statistics

Data were entered in Microsoft Excel 2007. Continuous variables with normal distribution were analyzed by unpaired Student's t-test and expressed as mean ± standard deviation. Nonparametric continuous variables were analyzed by the Mann-Whitney U-test and expressed as median (interquartile range). Normality of data was checked by Shapiro-Wilk test and by examining Q-Q plots. Categorical data were analyzed by Chi-square/Fisher's exact test. Kaplan-Meier survival analysis was done to compare duration of phototherapy between the two groups. A P < 0.05 was considered statistically significant. We used  SPSS 20 version (IBM Corp., Armonk, NY, USA) for statistical analysis of our data.


  Results Top


A total of 420 patients were enrolled in the study. Of these, 14 patients were excluded in view of the positive blood culture report. The remaining 406 infants constituted the study population. Two hundred and thirty patients received LED phototherapy, and 176 patients received conventional phototherapy. The baseline demographic and laboratory parameters of two groups are shown in [Table 1]. The birth weight, gestational age, gender, and baseline laboratory parameters were similar in the neonates enrolled in LED or conventional group. The mean TSB before starting phototherapy was similar in two groups. [Table 2] shows the rate of drop in serum bilirubin between two groups and a number of patients who received DVET in each group. It is seen from [Table 2] that the rate of fall in serum bilirubin was significantly higher in the LED group at 6 h, 12 h, and 18 h of phototherapy. Further, number of patients who received DVET was less in LED group although the difference did not reach the statistical significance (0.085).
Table 1: Baseline demographic and laboratory parameters of the two groups


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Table 2: Final outcomes of the two groups


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Kaplan-Meier analysis of the duration of phototherapy in the two groups was performed [Figure 1]. The median duration of the LED group (22.0 h (95% confidence interval: 20.47, 23.53)) was significantly less than that in the conventional phototherapy group (32.0 h (95% confidence interval: 29.8, 34.1)), the difference being significant (P value of log rank test = 0.00).
Figure 1: Survival curve comparing duration of phototherapy

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  Discussion Top


Our main objective of this study was to assess efficacy of LED phototherapy over conventional phototherapy. We enrolled 406 near-term and term healthy Rh-compatible newborn babies who received either LED or conventional phototherapy as per the AAP Practice Parameter 2004.[3] We indeed found superiority of LED phototherapy over conventional phototherapy both in terms of the rate of fall in serum bilirubin and the total duration of phototherapy needed, and the difference was statistically significant. In addition, number of patients who underwent DVET was lower in the former group though the difference did not reach statistical significance.

The better efficacy of LED phototherapy over conventional one in our study was in contradiction to a few earlier studies and a recent meta-analysis,[6] where efficacy was found similar. However, majority of these studies has used a strategy of "similar irradiance" where both LED and other source of phototherapy delivered equal levels of flux.[7],[8] In one large multicenter study by Kumar et al.,[9] however, the spectral irradiance (measured in a subset of patients) was reported to be 1.6-fold higher in the LED arm as compared to the conventional arm (P < 0.001). The authors hypothesize that the advantage of the higher spectral irradiance achieved with LED phototherapy might have been neutralized by a smaller surface area irradiated with such devices. The therapeutic efficacy of phototherapy depends on the spectral qualities of the delivered light (wavelength range and peak), intensity of the light (irradiance), exposed BSA. Although we have not measured spectral irradiance in our study due to nonavailability of the said equipment, we believe that it was much higher in LED group because of two reasons; first, longer life of LED (20,000 h)[3] than conventional phototherapy (1000);[5] second, we place LED phototherapy as close as possible to the neonate due to its established safety[3] and keep standard distance of 20 cm in case of conventional phototherapy. This appears to be the important characteristic able to ensure a better efficacy of LED over other conventional sources: In fact, when standardizing for the irradiance over a given surface area, LED devices provides the highest bilirubin degradation rate in vitro.[10],[11] This was also established in a study by Martins et al.;[12] they adjusted the devices to obtain a similarly exposed surface area, but a higher irradiance in the LED group; it resulted in a better efficacy with LED units.


  Conclusions Top


LED phototherapy was found more efficacious than conventional phototherapy. This observation has formidable benefits, especially in resource-constrained settings where majority of jaundiced patients are managed with conventional phototherapy and because of limited resources irradiance is never checked or checked inappropriately, which can prove sometimes fatal.[9] We strongly believe that time appears to be ripe to audit our existing phototherapy practice and replace ineffective, defective, and worn-out phototherapy devices and replace it with newer generation devices which have long life span and can deliver highest spectral irradiance without any extra risk of hyperthermia and dehydration

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Bhutani VK, Stark AR, Lazzeroni LC, Poland R, Gourley GR, Kazmierczak S, et al. Predischarge screening for severe neonatal hyperbilirubinemia identifies infants who need phototherapy. J Pediatr 2013;162:477-82.e1.  Back to cited text no. 1
    
2.
Sgro M, Campbell D, Shah V. Incidence and causes of severe neonatal hyperbilirubinemia in Canada. CMAJ 2006;175:587-90.  Back to cited text no. 2
[PUBMED]    
3.
American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics 2004;114:297-316.  Back to cited text no. 3
[PUBMED]    
4.
Ennever JF. Blue light, green light, white light, more light: Treatment of neonatal jaundice. Clin Perinatol 1990;17:467-81.  Back to cited text no. 4
[PUBMED]    
5.
Meherban S. Care of the Newborn. 7 th ed. New Delhi, India: Sagar Publications; 2010. p. 254-74.  Back to cited text no. 5
    
6.
Seidman DS, Moise J, Ergaz Z, Laor A, Vreman HJ, Stevenson DK, et al. A prospective randomized controlled study of phototherapy using blue and blue-green light-emitting devices, and conventional halogen-quartz phototherapy. J Perinatol 2003;23:123-7.  Back to cited text no. 6
[PUBMED]    
7.
Seidman DS, Moise J, Ergaz Z, Laor A, Vreman HJ, Stevenson DK, et al. A new blue light-emitting phototherapy device: A prospective randomized controlled study. J Pediatr 2000;136:771-4.  Back to cited text no. 7
[PUBMED]    
8.
Tridente A, De Luca D. Efficacy of light-emitting diode versus other light sources for treatment of neonatal hyperbilirubinemia: A systematic review and meta-analysis. Acta Paediatr 2012;101:458-65.  Back to cited text no. 8
[PUBMED]    
9.
Kumar P, Murki S, Malik GK, Chawla D, Deorari AK, Karthi N, et al. Light emitting diodes versus compact fluorescent tubes for phototherapy in neonatal jaundice: A multi center randomized controlled trial. Indian Pediatr 2010;47:131-7.  Back to cited text no. 9
[PUBMED]    
10.
Vreman HJ. Phototherapy: The challenge to accurately measure irradiance. Indian Pediatr 2010;47:127-8.  Back to cited text no. 10
[PUBMED]    
11.
Vreman HJ, Wong RJ, Murdock JR, Stevenson DK. Standardized bench method for evaluating the efficacy of phototherapy devices. Acta Paediatr 2008;97:308-16.  Back to cited text no. 11
[PUBMED]    
12.
Martins BM, de Carvalho M, Moreira ME, Lopes JM. Efficacy of new microprocessed phototherapy system with five high intensity light emitting diodes (Super LED). J Pediatr (Rio J) 2007;83:253-8.  Back to cited text no. 12
[PUBMED]    


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    Tables

  [Table 1], [Table 2]



 

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Abstract
Introduction
Subjects and Methods
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