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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 5  |  Issue : 2  |  Page : 100-105

Can use of low-cost white reflecting curtains increase the efficacy of phototherapy?


1 Department of Pediatrics, Miami Children's Hospital, Miami, Florida, USA
2 Department of Pediatrics, Calcutta National Medical College and Hospital, Kolkata, West Bengal, India

Date of Web Publication8-Apr-2016

Correspondence Address:
Subhrajit Lahiri
7, Prince Golam Mohammed Road, 3rd Floor, PS Tollygunge, Kolkata - 700 026, West Bengal
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2249-4847.179907

Clinical trial registration CTRI/2013/02/003370

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  Abstract 

Context: In the face of a steep rise in the rate of bilirubin in neonates, we often seek improvisations to increase the efficacy of phototherapy machines. In addition, in resource-limited setup, a need is felt for the methods of reducing the duration of phototherapy so that the same machine can be used for more number of neonates. Aim: To study the effect of using white reflecting curtains around phototherapy machines on the efficacy of phototherapy for the treatment of neonatal jaundice. Settings and Design: Double-blind, parallel, randomized controlled trial. Level 2 Neonatal Intensive Care Unit and Neonatal Ward of a tertiary care hospital between June 2011 and May 2012. Subjects and Methods: About 102 term neonates with jaundice were randomized into two groups of 51 neonates each. Group A (the study group) received curtains and Group B (the control group) did not receive curtains during phototherapy. Two phototherapy units were designed so that the white curtains could be hung or removed as required. Along with baseline variables including blood count, reticulocyte count, and G6PD, total serum bilirubin (TSB) was measured for each neonate at 4, 12, and 24 h from the initiation of phototherapy. The primary outcome measure was the mean difference in TSB measured at baseline and after 4, 12, and 24 h of phototherapy. The secondary outcome was the duration of phototherapy in hours and also the mean difference in bilirubin between 12 and 24 h. Results: The mean bilirubin concentration of Group A was significantly less (17.42 ± 1.04 mg/dL at 4 h, 14.52 ± 1.05 mg/dL at 12 h, and 11.33 ± 1.11 mg/dL at 24 h of phototherapy) than Group B (18.02 ± 1.13 mg/dL at 4 h, 17.6 ± 1.09 mg/dL at 12 h, and 16.65 ± 1.11 mg/dL at 24 h) with similar bilirubin concentrations initially. The mean duration of phototherapy in Group A (28.87 ± 4.11 h) was significantly less than Group B (51.14 ± 18.62 h) (P < 0.01). Conclusions : Using white reflecting curtains significantly reduces the mean bilirubin concentration and the duration of phototherapy in jaundiced neonates.

Keywords: Curtains, jaundice, phototherapy


How to cite this article:
Lahiri S, Datta S, Chakraborty D, Das P, Mondal D, Nandi D. Can use of low-cost white reflecting curtains increase the efficacy of phototherapy?. J Clin Neonatol 2016;5:100-5

How to cite this URL:
Lahiri S, Datta S, Chakraborty D, Das P, Mondal D, Nandi D. Can use of low-cost white reflecting curtains increase the efficacy of phototherapy?. J Clin Neonatol [serial online] 2016 [cited 2021 Apr 12];5:100-5. Available from: https://www.jcnonweb.com/text.asp?2016/5/2/100/179907


  Introduction Top


Neonatal jaundice is a common problem worldwide, and it is effectively treated with phototherapy. [1] Ever since Cremer et al first reported phototherapy as an effective treatment modality for neonatal jaundice, there have been considerable variations among the different phototherapy techniques in terms of irradiance, area irradiated, and spectral output. [2] Increase in irradiance increases the rate of decline of bilirubin in improving the efficacy of phototherapy. [3] However, light intensity and the area of light-exposed skin can also be increased through the use of reflecting surfaces (e.g., white curtains hung from the sides of the phototherapy unit). [4] If it could be proved that single phototherapy unit with low-cost reflecting curtains is more effective than single phototherapy alone, it might be a valuable alternative to using multiple phototherapy units in the treatment of infants with jaundice. This is of particular relevance in developing nations where the number of babies with jaundice is high. To the best of our knowledge, three studies have so far compared conventional single phototherapy with single phototherapy augmented with low-cost reflecting surfaces in the phototherapy units with variable outcomes in different clinical settings in terms of race, country, and type of material used. [5],[6]

We conducted this study to evaluate the effect of phototherapy with white curtains (which are easily available locally) hanging from the sides of the phototherapy unit on the rate of decrease of total serum bilirubin (TSB) and on the total duration of phototherapy in full-term jaundiced neonates.


  Subjects And Methods Top


This was a single-center, randomized, controlled, double blind, parallel group study conducted in Neonatal Intensive Care Unit and Neonatal ward of a tertiary care center between June 2011 and May 2012. The study was approved by the Research and Ethics Committee. Written parental consent of the neonates included in the study was also obtained. All term neonates with jaundice fulfilling the following inclusion criteria were included in the study:

  1. Age >24 h (hours) and ≤10 days
  2. Apgar at 5 min >6
  3. Serum total bilirubin <20 mg/dL
  4. Exclusively breast fed
  5. Body weight >2.5 kg
  6. Gestational age ≥37 weeks.


Neonates with hyperbilirubinemia requiring exchange transfusion, Rh hemolytic disease, and evidence of hemolysis in peripheral blood smear, positive Direct Coombs' test, G6PD deficiency, conjugated hyperbilirubinemia, and major congenital malformations were excluded from the study population.

About 102 term neonates with jaundice were randomized into two groups of 51 neonates each. Group A (the Study Group) received curtains and Group B (the Control Group) did not receive curtains during phototherapy.

At the beginning, a detailed history of antenatal events was taken from the mother. The maturity of the neonates was determined by the New Ballard Score™. A thorough clinical examination with emphasis on neurological examination of the neonates was done at the beginning and end of the study. At recruitment, venous blood sample of the neonates for complete blood count including reticulocyte count, serum total and unconjugated bilirubin, peripheral blood smear, ABO and Rh grouping and typing (of the mother as well), Direct Coombs' test, G6PD screen, and sepsis screen was done.

The decision to start phototherapy was based on AAP guidelines for term and near-term babies. The eligible infants were randomized to a compact fluorescent light (CFL) phototherapy unit either with (Group A) or without curtain (Group B).

The phototherapy units (Atico Medicare Pvt., Ltd, Model No., AM-1411) were fitted with six light sources (Philips 18W/71), four blue CFLs, and two white CFLs. Two such phototherapy units were designated to be used exclusively for the study, and the white reflecting material could be hung to any of these units by a thin wire which was passed through a tunnel made at the margin of the curtain by folding a thin rim of the 100% cotton cloth on itself. This method ensured that the same phototherapy unit could be used with or without curtains consisting of white cotton sheets with reflecting inner surface. The curtains covered three sides of the unit. The remaining side was left open for uninterrupted observation of the neonate. The phototherapy was administered in the postnatal wards on the babies' cribs near the mothers' cots. The distance between the lamps and the surface of baby was kept constant at 45 cm.

During phototherapy, TSB was measured at 4 h, 12 h, and 24 h. About 1 ml of venous blood samples were obtained in plain vials spun and sent en masse to the biochemistry department, where they were analyzed by Jendrassik Grof method. All neonates wore eye pads while under phototherapy. Rooming-in and exclusive breast feeding were encouraged. Neonates' axillary temperature was monitored at 4 h, 12 h, and 24 h. If phototherapy was started after 72 h of age, it was discontinued if two consecutive TSB levels measured 8-12 h apart were <15 mg/dL. If phototherapy was started before 72 h of age, it was discontinued when two consecutive TSB values measured 8-12 h apart were less than the age-specific threshold for initiating phototherapy. Side effects such as loose stools, feed intolerance, and skin rashes were recorded. Duration of phototherapy was calculated from an hour counter which was kept with the mother and operated by the on-duty nurse who switched it off during breast feeding.

Statistical analysis

Sample size


The number of participants needed was calculated on the basis of the main outcome measure (mean difference in TSB between that measured at baseline and at 4 h after phototherapy) by selecting a power of 0.9 and a two-tailed alpha = 0.05. The sample size was estimated to be fifty neonates for each group to show a 1.4 mg difference in serum bilirubin between study groups.

Randomization

Simple randomization was done with internet randomization at www.sealedenvelope.com. Whenever we noticed a neonate meeting the inclusion criteria and whose parents consented for the study, we placed the patient id and the password of the study at the website. They would immediately mail the researcher the group of the patient allocated either as A or B. Then, their groups were written and put inside an envelope with the id of the patient written on top. Only the nurses who put the baby on phototherapy opened the envelope to see the group assigned. The person who noted the patient id and corresponding bilirubin levels was thus blinded from the group allocation by the envelope. Whereas patients and physicians working in the unit allocated to the intervention group were aware of the allocated arm, data analysts were kept blinded to the allocation by the envelope. In addition, the same phototherapy machine was used with and without curtains to maintain as much similarity in the intervention as possible.

Data were entered and analyzed using MedCal™ statistical software.

  1. The duration of phototherapy in the two groups was compared with Kaplan-Meier survival analysis. (Event being defined as the age-appropriate TSB level when phototherapy can be discontinued; there was no censored observation)
  2. The decrease in serum bilirubin was analyzed by comparing the means with independent t-tests and paired t-test.



  Results Top


Of about 500 term babies with physiological jaundice between June 2011 and May 2012 presenting to the nursery, 124 neonates were approached, out of which 102 fitted the inclusion criteria initially. They were recruited and measurements were carried out on them according to the protocol. They were discharged when their TSB was normal.

Out of the 100 babies analyzed, Group A consisted of 51 subjects and Group B had 49 subjects [Figure 1].
Figure 1: Participant flow

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The mean birth weight of the two groups was found to be 2.72 ± 0.37 kg in Group A and 2.69 ± 0.47 kg in Group B. There were 25 male (49.01%) and 26 female (50.99%) newborns in Group A. Furthermore, the number of neonates born by normal deliveries in Group A was 29 (56.86%) and the remaining 23 (43.13%) were born by cesarean section [Table 1].
Table 1: Demographic data


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The male and female neonate count in Group B was 30 (61.2%) and 19 (38.9%), respectively. The number of normal deliveries was 16 (32.65%) and cesarean section was 33 (67.35%) in Group B.

The mean of the spectral irradiance measured at 12 h interval on the surface of the machine showed a significant difference between the two groups (OLYMPIC Bili-Meter™). The mean spectral irradiance of phototherapy with curtains was 7.85 ± 0.31 uw/cm 2 /nm and that without the curtains was 6.52 ± 0.35 uw/cm 2 /nm.

The mean bilirubin concentration of the babies in Group A at the beginning and at 4 h, 12 h, and 24 h of phototherapy was found to be 18.17 ± 1.06 mg/dL, 17.42 ± 1.04 mg/dL, 14.52 ± 1.05 mg/dL, and 11.33 ± 1.11 mg/dL, respectively [Table 2].
Table 2: Comparison of mean bilirubin concentration between the two groups at different times


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The mean bilirubin concentration of the babies in Group B at the beginning of phototherapy was 18.14 ± 1.31 mg/dL. The bilirubin concentration at 4 h, 12 h, and 24 h was 18.02 ± 1.13 mg/dL, 17.6 ± 1.09 mg/dL, and 16.65 ± 1.11 mg/dL, respectively.

The unpaired t-test done at 0 h, 4 h, 12 h, and 24 h with the mean bilirubin concentration of Group A and Group B showed statistically significant values between the two groups. The mean bilirubin at the beginning of the treatment was not different between the two groups (P = 0.88) [Figure 2].
Figure 2: Bilirubin levels in case and controls at 0,4,12 and 24 hours

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The paired t-test between the mean bilirubin levels of Group A at 0 h and 4 h, 12 h, and 24 h revealed highly significant values. However, the paired t-test in Group B failed to show significant values in the first 4 h, though the bilirubin levels thereafter were significantly reduced.

The mean fall in bilirubin at 4 h, 12 h, and 24 h in Group A was more and was 0.75 ± 0.19 mg/dL, 3.64 ± 0.6 mg/dL, and 6.83 ± 0.65 mg/dL, respectively. The mean fall in bilirubin concentration in Group B at 4 h, 12 h, and 24 h from the initial concentration was 0.12 ± 0.01 mg/dL, 0.53 ± 0.27 mg/dL, and 1.48 ± 0.18 mg/dL, respectively [Table 3]. The unpaired t-test between the mean decreases in bilirubin at each of the intervals showed a significant P value [Figure 3].
Table 3: Mean fall in bilirubin concentration at 4 h, 12 h, and 24 h


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Figure 3: Trend of mean bilirubin concentration in the two groups

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The mean rate of fall during the 24 h in Group A was, therefore, 0.28 ± 0.02 mg/dL/h and that in Group B, it was 0.06 ± 0.007 mg/dL/h, and the t-test indicated P < 0.0001.

The mean duration of phototherapy in Group A was 28.87 ± 4.11 h and that in Group B, it was 51.14 ± 18.62 h. Unpaired t-test was done and it was found to be significantly different in the two groups [Table 4].
Table 4: Mean duration of phototherapy in hours between the two groups


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Multiple regression equation was constructed with duration of phototherapy as dependent variable, and bilirubin at 0 h, 4 h, 12 h, and 24 h along with birth weight and blood group as independent variables, and it was found that only bilirubin levels at 24 h had a significant relationship with the duration of phototherapy.

The median reduction of duration of phototherapy was analyzed by Kaplan-Meier survival method and plotted [Figure 4]. The median duration of phototherapy was 29.11 h in Group A and 54.08 h in Group B (χ2 = 57.98, significance P < 0.0001, hazard ratio = 0.2922, confidence interval = 0.183-0.464). Hence, there was a median reduction of 24.97 h in Group A in comparison to Group B.
Figure 4: Kaplan-Meir survival curve to compare duration of phototherapy

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  Discussion Top


Neonatal unconjugated hyperbilirubinemia is one of the most common problems in the neonatal period worldwide, especially in developing nations where the number of neonates afflicted with jaundice is high. The overall incidence of neonatal jaundice as reported by various Indian workers varies from 54.6% to 77%. [7] Neonatal jaundice is most commonly and effectively managed by phototherapy. The direct relationship between irradiance of the phototherapy units and the rate of decline of unconjugated bilirubin levels makes it imperative to come up with methods to obtain the maximum possible effect from each phototherapy unit.

Our randomized controlled trial study using phototherapy units shrouded with white-reflecting curtains showed a significant decline in the mean bilirubin concentrations as well as the duration of phototherapy in Group A as compared to Group B. The mean bilirubin concentration of the test group (Group A) was significantly less in comparison to the control group (Group B) with similar bilirubin concentrations in the beginning.

Mean bilirubin in Groups A and B at the onset was 18.17 ± 1.06 mg/dL and 18.14 ± 1.31 mg/dL, respectively, in our study. It was 16.6 ± 2.4 mg/dL versus 16.1 ± 2.2 mg/dL in the study conducted by Sivanandan et al., [8] who did not find significant reduction in the duration of phototherapy, probably due to this lower threshold of bilirubin to start with.

The mean decrease in TSB at 4 h in Group A was 0.75 ± 0.19 mg/dL and that in Group B, it was 0.12 ± 0.01 mg/l in our study, which was statistically significant. Djokomuljanto et al. [5] showed that the mean decrease in serum bilirubin after 4 h of phototherapy in the intervention group was 1.62 ± 1.47 mg/dL. Hence, we observed a lesser fall of bilirubin than this study.

In our study, the mean duration of phototherapy in Group A was 28.87 ± 4.11 h and that in Group B, it was 51.14 ± 18.62 h. Hence, there was a mean reduction of 22.27 h in the duration of phototherapy in Group A. In addition, the mean rate of fall of bilirubin during the first 24 h of phototherapy in Group A (0.28 ± 0.02 mg/dL/h) was higher than in Group B (0.06 ± 0.007 mg/dL/h) (P < 0.0001).

Unpaired t-test was done and it was found to be significantly different in the two groups. However, Sivanandan et al. [8] did not show a significant difference in the duration of phototherapy between the two groups. However, Djokomuljanto et al. [5] and De Carvalho et al. [9] have reported a significant increase in irradiance and shortening in the duration of phototherapy on using curtains of white cotton sheets similar to our study.

Out of the total 100 neonates studied, 55 (55.1%) were males and 45 (44.9%) were females. This supports the fact noticed by others that the incidence of neonatal jaundice is more in males. [10]

No relationship was found between the birth weights, the blood groups, or the modes of delivery of the neonates of both the groups with the duration of phototherapy or the rate of fall of bilirubin. No significant complications including hyperthermia, hypothermia, rashes, diarrhea, and dehydration were noticed in Group A in comparison with Group B.

The mean spectral irradiance of phototherapy with curtains in Group A was higher than in Group B, similar to the other studies.

Limitations

  1. We estimated the total bilirubin (and not the photo-altered structural isomer lumirubin which would have been a better indicator of efficacy) for monitoring the response to phototherapy
  2. Since the retrospectively calculated power of the study is <80%, the study may be underpowered to find a difference in the duration of phototherapy between the two groups
  3. The sample size was small. A larger sample size is needed to come up with more definite conclusions
  4. The phototherapy units and the spectrophotometers used in the study were dated and would have required more frequent maintenance services. This combined with the wearing away of the machines may have had some influence on the results. However, it was ensured that the CFL lights were replaced at regular intervals as recommended by the manufacturer.


Acknowledgments

The authors thank Dr. B.C. Mondal, Head of the Department of Pediatrics, for his constant support. And also, they would like to thank Dr. Bhaswati Ghoshal, Assistant Professor, for encouragement to take up the project and initial intellectual advises. The study would not have been possible without the unending support of the nursing staff of the Calcutta National Medical College and Hospital. The authors would also like to thank the Department of Biochemistry, Calcutta National Medical College and Hospital, for performing the laboratory measurements for the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
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. 1
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2.
Cremer RJ, Perryman PW, Richards DH. Influence of light on the hyperbilirubinaemia of infants. Lancet 1958;1:1094-7.  Back to cited text no. 2
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3.
Sarici SU, Alpay F, Unay B. "Double versus single phototherapy in term newborns with significant neonates. Multiple phototherapy units are sometimes used to increase the light intensity and thus hyperbilirubinemia." J Trop Pediatr 2000;46:36-9.  Back to cited text no. 3
    
4.
Hansen TW. Jaundice, Neonata; 11 th August, 2006. Available from: http://www.emedicine.com/ped/topic1061.htm. [Last accessed on 2013 Oct 10].  Back to cited text no. 4
    
5.
Djokomuljanto S, Quah BS, Surini Y, Noraida R, Ismail NZ, Hansen TW, et al. Efficacy of phototherapy for neonatal jaundice is increased by the use of low-cost white reflecting curtains. Arch Dis Child Fetal Neonatal Ed 2006;91:F439-42.  Back to cited text no. 5
    
6.
Kurniasihi A, Dasa TG, Ali M, Azlin E, Sianturi P. "Effectiveness of phototherapy with white reflecting curtains on neonatal jaundice." Paediatr Indones 2011;51:256-61.  Back to cited text no. 6
    
7.
Anand VR, Magotra ML. Neonatal jaundice: Its incidence and aetiology. Indian Pediatr 1978;15:155-60.  Back to cited text no. 7
[PUBMED]    
8.
Sivanandan S, Chawla D, Misra S, Agarwal R, Deorari AK. Effect of sling application on efficacy of phototherapy in healthy term neonates with nonhemolytic jaundice: A randomized controlled trial. Indian Pediatr 2009;46:23-8.  Back to cited text no. 8
    
9.
De Carvalho M, De Carvalho D, Trzmielina S, Lopes JM, Hansen TW. Intensified phototherapy using daylight fluorescent lamps. Acta Paediatr 1999;88:768-71.  Back to cited text no. 9
    
10.
Bahl L, Sharma R, Sharma J. Etiology of neonatal jaundice at Shimla. Indian Pediatr 1994;31:1275-8.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


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