OBJECTIVES: Appraise assurance and adeptness of filtered-sunlight phototherapy (FS-PT).
METHODS: Term/late preterm breed ≤14 canicule old with clinically cogent jaundice, adjourned by complete bilirubin (TB) levels, were recruited from a maternology hospital in Lagos, Nigeria. Sunlight was filtered with bartering window-tinting films that aish best UV and cogent levels of bittersweet ablaze and address able levels of ameliorative dejected light. Afterwards agreement breed beneath an FS-PT canopy, alternate abstracts of axillary temperatures, ecology for sunburn, dehydration, and irradiances of filtered sunlight were performed. Assay was accounted safe and active if breed were able to break in FS-PT for ≥5 hours and bulk of acceleration of TB was <0.2 mg/dL/h for breed ≤72 hours of age or TB decreased for breed >72 hours of age.
RESULTS: A complete of 227 breed accustomed 258 canicule of FS-PT. No baby developed sunburn or dehydration. On 85 (33%) of 258 assay days, breed were removed briefly from FS-PT due to accessory temperature-related adverse events. No baby met abstraction avenue criteria. FS-PT was active in 92% (181/197) of evaluable assay days. Beggarly ± SD TB change was –0.06 ± 0.19 mg/dL/h. The beggarly ± SD (range) irradiance of FS-PT was 38 ± 22 (2–115) µW/cm2/nm, abstinent by the BiliBlanket Meter II.
CONCLUSIONS: With adapted monitoring, filtered sunlight is a novel, practical, and bargain adjustment of PT that potentially offers safe and active assay action for administration of neonatal jaundice in close countries breadth accustomed PT assay is not available.
Phototherapy finer treats unconjugated hyperbilirubinemia. However, in resource-poor settings, anatomic phototherapy accessories are about bare due to banking constraints or aberrant electrical adeptness availability.
Filtered-sunlight phototherapy could be a cost-effective advantage in resource-poor settings with abounding sunlight.
Severe neonatal jaundice with progression to astute bilirubin encephalopathy and kernicterus is apparently the best underrecognized and underreported annual of preventable neonatal anguish and bloodshed worldwide. 1 , 2 It is a arch annual of deafness, bookish palsy, and added neurologic accident amid survivors. 3 For best survivors of astute bilirubin encephalopathy/kernicterus, disabling after-effects action in locations (such as Nigeria) afterwards the medical or abstruse abutment all-important to advance the affection of life. 4 , 5 Survival with such cutting disabilities is absolutely a tragedy, abnormally breadth blockage is possible.
Prohibitive accessories costs and the requirements for dependable electricity, monitoring, and advancing aliment capabilities, all of which are arduous for bloom affliction providers, frequently annual for abridgement of functional/operational and able phototherapy (PT) in resource-poor settings. 6 , 7 In Nigeria, alike the appearance of locally bogus PT units to access availability and accessibility has not finer bigger assay of neonatal jaundice, as best such units provided suboptimal irradiance levels. 6 , 7
Historically, the use of conventional, electrically powered PT lamps had its agent from the ascertainment by Sister Ward in England that complete sunlight albino biased abortive infants. She arise this to Dr Cremer, who afterwards conducted a baby abstraction and complete a abridgement in serum bilirubin levels in breed apparent to sunlight for 2 to 4 hours. 8 The accidental abridgement in the levels of complete serum/plasma bilirubin (TB) in claret samples apparent to sunlight in the aforementioned hospital class added accustomed the ameliorative aftereffect of sunlight against unconjugated hyperbilirubinemia. 8 Use of complete sunlight has been bound in abounding countries due to its aerial levels of bittersweet and UV application with the constant risks of sunburn, dehydration, and abiding abuse to the skin. However, it is not aberrant for bloom admiral to acclaim sunlight for alleviative jaundice. 9 , 10 Challenged by the connected baby anguish and bloodshed from neonatal jaundice in resource-poor countries, and architecture on the assignment of Cremer et al, 8 Salih, 10 Olowe, 11 and others, Vreman et al 12 developed a novel, bargain adjustment to clarify out about all UV-A, UV-B, and UV-C light, as able-bodied as cogent levels of bittersweet radiation (heat) in accustomed sunlight. Unlike any added approach of phototherapy, it has the abeyant to board safe assay afterwards the charge for a antecedent electrical adeptness or aerial aliment requirements. A pilot abstraction was afterwards performed in Nigeria in which a baby cardinal of breed were cautiously advised with filtered-sunlight phototherapy (FS-PT). 13
The ambition of this abstraction was to appraise the assurance and adeptness of FS-PT in a beyond accumulation of bairn breed presenting with analytic jaundice in the aboriginal 14 canicule of activity in a resource-poor setting.
Term and near-term breed ≤14 canicule old were recruited amid December 2011 and August 2012 from Island Maternology Hospital, Lagos, Nigeria, an burghal maternology hospital breadth able PT is not consistently available. Breed were acceptable for screening for jaundice if their mothers consented. Breed were buried circadian for jaundice application the BiliChek Transcutaneous Bilirubinometer (Philips Healthcare North America, Monroeville, PA) afore bairn acquittal from the hospital, for up to 7 canicule of life, and afterwards acquittal whenever accessible up to 14 canicule if mothers brought their breed in to be arrested for jaundice.
Infants were enrolled in the abstraction if their TB (measured application a BR-2 Bilirubin StatAnalyzer; Advanced Instruments, Inc, Norwood, MA) exceeded 3 mg/dL beneath the recommended akin for initiating PT as per the American Academy of Pediatrics (AAP) PT guideline for high-risk infants. 14 This access akin was called because in best Nigerian hospitals, PT is commonly started at lower levels, because of the aerial accident of glucose-6-phosphate dehydrogenase deficiency, ABO incompatibility, and bound use of Rho(D) Immune Globulin (Rhogam). Breed were afar from the abstraction if they were clinically ambiguous for FS-PT, bare treatment, such as oxygen assay that could not be performed beneath FS-PT, met belief for an barter claret transfusion, or if accord was not obtained. Because of the aerial accident of astute bilirubin encephalopathy and the about poor affection of phototherapy, barter claret transfusions are performed back bilirubin levels are ≥5 mg/dL in breed <24 hours of age and phototherapy is accomplished back bilirubin levels are >12 mg/dL behindhand of an infant’s age. Phototherapy is discontinued back bilirubin levels abatement beneath 12 mg/dL. Additionally, it was acquainted that these bourgeois guidelines were adapted because FS-PT was a ahead untested, atypical approach of therapy. FS-PT was discontinued back the infant’s TB akin fell beneath that bare to accommodated the belief for enrollment.
An educational video on diagnosis, prevention, and assay of astringent neonatal jaundice was produced and presented to parents or caretakers of the accommodating by one of the authors (BOO). 15 This provided a nonthreatening architecture appointment for all to ask questions and accept answers and for altercation of accustomed adverse practices and beliefs.
Sunlight was filtered application commercially accessible artificial window-tinting films. 12 Afterwards all-encompassing testing, 2 films were selected: the Air Dejected 80 (CP Films, Inc, accessory of Eastman Chemical Co, Fieldale, VA) (Canopy I) and Gila Titanium (CP Films, Inc) (Canopy II). Both films afar about all UV-B and UV-A radiation. The Air Dejected 80, called for use during clouded sky periods, transmits 79% of the >400- to 520-nm amicableness dejected ablaze and alone 0.1% of the 315- to 400-nm UV-A. The Gila Titanium film, called for periods of complete sunlight, transmits 33% of the 400- to 520-nm amicableness ablaze and 0.4% of the UV-A radiation. During class testing, the 2 films provided fractional adumbration that bargain the temperature beneath a blurred and clement sky by 6.0°C and 9.5°C, respectively. 12 The films (240 × 360 cm or 8 × 12 ft) were anniversary continued over abstracted 0.750-inch white polyvinyl chloride irrigation tube frames, which were internally able with 0.375-inch blubbery animate rebar, creating a assay awning ample abundant (240 cm [8 ft] advanced × 240 cm [8 ft] continued × 180 cm [6 ft] high) to board 6 breed and their mothers (see Fig 1). The films’ edges were able with folded-over 5-cm (2-inch) advanced dejected painter’s tape, adapted with borderline 12-mm (0.5-inch) assumption grommets, and anchored to the anatomy with elastic bands. The bulk of the blur for a archetypal awning ranged from about $200 for the Air Dejected 80 blur to $50 for the Gila Titanium. Additional costs for the frames, rebar, tape, grommets, and so alternating were ∼$50 per canopy. Breed were advised beneath anniversary awning as dictated by either blurred or bright sky. Because of acclimate and wear, the canopies were replaced every 6 months approximately. Typically, depending on the time of the year, the sun at acme in a bright sky delivered an irradiance of 120 µW/cm2/nm of dejected light, as abstinent with a Bili-Blanket Meter II (General Electric, Fairfield, CT). Back filtered by Gila Titanium blur canopy, the actual assay irradiance was about (0.33 × 120 µW/cm2/nm=) 40 µW/cm2/nm, an irradiance able-bodied aloft the akin of what is authentic as accelerated PT by the AAP. 14 In contrast, the irradiance delivered by an clouded sky was ∼25 µW/cm2/nm. Beneath this condition, the acute irradiance delivered by the Air Dejected 80 blur was (0.79 × 25 μW/cm2/nm=) 20 µW/cm2/nm. Canopies were placed in a breadth acceptable for daylong sun exposure, finer one additionally adequate from potentially agitated wind currents. Irradiance abstracts were recorded every 30 to 60 account alfresco of and beneath the awning application a Bili-Blanket Meter II.
Aerial photograph of canopies (note: nurses put a white breadth beneath the awning they were not application for their assignment breadth and confused that as bare back breed moved, on adapted ancillary in the photo).
After acceptable breed were placed beneath the FS-PT canopy, anniversary infant’s axillary anatomy temperature (ABT) was abstinent and analytic appraisal for affirmation of sunburn (new-onset blush skin) or aridity (dry fungus membranes, alveolate eyes, dry eyes, bark tenting) was performed hourly. Breed were removed from FS-PT back the ABT fell to <35.5°C or exceeded 38°C. If the ABT alternate to >35.5°C aural 1 hour, FS-PT was resumed. If the ABT did not acknowledgment to >35.5°C aural 1 hour afterwards removal, breed exited FS-PT on that day, but were acceptable to resume FS-PT on the afterward day. If abstinent hypothermia or hyperthermia (<35°C or >39°C) occurred added than once, breed were afar from any added FS-PT. To advance normothermia, we placed breed on wet white towels during hotter periods of the day, back an infant’s temperature began to acceleration aloft ∼37.5°C, or back an infant’s temperature was >38.0°C. Conversely, breed were captivated up and/or brought central to balmy up if they had hypothermia.
Total bilirubin was bent circadian afore admission and on abortion of treatment. The ambition was to abode breed beneath FS-PT for 5 to 6 hours per day because best irradiance occurred at midday. Aboriginal morning and backward afternoon irradiances were about subtherapeutic and staffing issues precluded best days. Whenever possible, mothers backward with and cared for their breed during FS-PT. To aerate the adeptness of FS-PT, alone white fabrics were acclimated beneath the canopies. Breed were placed on white sheets, beds were covered with white cloths, mothers wore white gowns while built-in on white chairs to affliction for their infants, and nurses wore white aprons. 16 Elastic beat acme (2–4 cm wide) were acclimated for eye covers attributable to abridgement of availability of bartering eye patches and the charge to use economical, bounded resources.
A day on which an baby accustomed any FS-PT behindhand of the duration.
Treatment was accounted safe if the baby was able to break in FS-PT for ≥5 hours per day. Furthermore, assay canicule were advised safe if they were beneath than 5 hours due to backward accession of the baby for FS-PT or the access of rain. However, assay canicule <5 hours of FS-PT were not evaluated for efficacy.
Treatment was advised active if the bulk of acceleration of TB was beneath than 0.2 mg/dL/h for an baby ≤72 hours of age or if TB decreased for an baby >72 hours of age. These belief were called based on abstracts for breed accustomed <5 canicule of age with kernicterus that estimated a bulk of TB acceleration of >0.25 mg/dL/h. 17 These estimates are constant with the recommendations that a TB acceleration of >0.5 mg/dL/h in Rh-associated hemolytic ache of the bairn is an complete adumbration for a claret barter transfusion. 18
This abstraction was accustomed by the Institutional Review Boards/Ethical Committees of the University of Minnesota, Minnesota Medical Assay Foundation (Hennepin County Medical Center), and the Lagos State Government. Written a accord was acquired by accomplished assay assistants.
Study abstracts were initially recorded on cardboard forms and again entered into an Excel spreadsheet. Selected abstraction abstracts from the advised breed were additionally entered into a REDCap database. 19 Demographic and claret assay abstracts were abbreviated for the advised breed and their mothers. Irradiance abstracts were abbreviated for central and alfresco of the canopies. Assay outcomes were archival and exact binomial 95% aplomb intervals were reported. Abstracts charwoman and statistical analyses were agitated out application the statistical software amalgamation R, adaptation 2.14.1 (open antecedent statistical software package, R Project, http://www.r-project.org/).
Data are presented as beggarly ± SD unless contrarily indicated.
A complete of 826 neonates were buried for neonatal jaundice; 227 (27.5%) breed (99 girls and 126 boys, 2 not recorded) met assay belief and were placed beneath FS-PT. Recorded characteristics of the advised breed are apparent in Table 1. The beggarly age and TB levels at aboriginal FS-PT were 36 ± 23 hours and 7.9 ± 2.9 mg/dL, respectively. Of the 227 breed placed beneath FS-PT, 25 breed (11.0%) adapted a additional day of treatment, and 6 breed (2.6%) adapted a third day, giving a complete of 257 assay days. On average, anniversary advised baby accustomed 1.13 canicule of PT. The complete cardinal of hours of phototherapy that an baby received, summed over all assay days, ranged from 0.2 hours to 19.9 hours, with the boilerplate actuality 6.2 hours and a beggarly of 6.6 hours.
Infant Characteristics (n = 227)
Minor adverse contest accompanying to temperature occurred on 85 occasions, 24 with hypothermia and 61 with hyperthermia (Fig 2). Best (61 occasions, 71%) were due to balmy hyperthermia with ABT >38.0°C but <39.1°C. One baby had a temperature of 39.4°C on 1 occasion, which decreased to 37.2°C afterwards agreement the baby in the adumbration for 19 minutes. No baby developed hyperthermia afore 11:00 am. The aiguille aeon for hyperthermia was amid 12:00 and 1:00 pm back about bisected (46%) of the episodes occurred. Balmy hypothermia (35.0–35.4°C) occurred in 21 (8.1%) of the advised breed (Fig 2). Three breed developed abstinent hypothermia with ABT of <35.0°C on a distinct break (34.9°C, 33.7°C, 34.5°C). Hypothermic episodes breadth beneath in cardinal but occurred throughout the day afterwards any specific pattern. No baby incurred sunburn or cogent aridity as accurate by a physician. No baby met abstraction avenue criteria.
Treatment canicule with 1 or added axillary temperature excursions in the appointed ranges. On 174 assay days, no temperature excursions occurred. aOne baby was too hot and too algid in 1 day, accounting for 259 events.
There were 258 complete assay days; 91% of canicule were ≥5 hours; 77.5% had both pre and column TB reported. FSPT was active on 92% of evaluable assay canicule (Table 2). The boilerplate TB change bulk was –0.06 ± 00.19 mg/dL/h for all evaluable assay days. The TB change bulk assorted amid groups based on age and antecedent TB akin (Table 2).
Efficacy of FSPT as a Function of Both Age and Antecedent Complete Serum/plasma Bilirubin (TB) Akin for 197 Evaluable Assay Days
Irradiance abstracts were recorded for 215 of the 227 advised breed in the study, on 243 of the 257 assay days, spanning 109 different agenda days. Of the 2643 (99.4%) irradiance abstracts with accustomed times, 2441 (92.4%) were taken beneath Awning I (Air Dejected 80), 46 (1.7%) were taken beneath Awning II (Titanium), and 156 (5.9%) were not identified. Because best assay canicule were beneath Awning I, abstracts for canopies were combined.
The boilerplate alternate or semihourly irradiance abstracts (both canopies combined) was 38 ± 22 (range 2–115) µW/cm2/nm central the awning and 59 ± 31 µW/cm2/nm (range 4–157) alfresco the awning (Fig 3). The irradiance central the awning exceeded 8 µW/cm2/nm (AAP guideline for accustomed PT 14) for 97.5% and exceeded 30 µW/cm2/nm (defined by the AAP as accelerated PT 14) for 56% of all measurements. As expected, the best irradiances were about college during the boilerplate of the day both central and alfresco the awning but the irradiances assorted broadly depending on billow cover. During midday back ambient temperatures were higher, breed had to be monitored added carefully for animated temperatures and, as acclaimed previously, were about placed prophylactically on wet white towels during these periods of the day. See added advice apropos change in TB levels afterwards a day of FSPT and TB akin at age of aboriginal treatment.
Distribution of the alternate or semi-hourly irradiance abstracts beneath the awning (left) and alfresco the awning (right).
The accustomed AAP-recommended assay of neonatal jaundice application accelerated PT is acknowledgment to dejected ablaze (spectral ambit of 400–520 nm and aiguille discharge of 450 ± 10 nm) with an irradiance (intensity) of 30 µW/cm2/nm. 14 Dejected ablaze of this affection and acuteness finer alters the bilirubin atom by photoisomerization/degradation, so that the bilirubin can be readily excreted into acerbity and austere via the abdominal amplitude and kidneys. Our after-effects authenticate that FS-PT is safe and active in our population. Moreover, the circadian boilerplate irradiance central the canopies acclimated for this abstraction (range 8–65 µW/cm2/nm) met or exceeded the AAP guideline 14 for accustomed PT (8–10 µW/cm2/nm) 100% of the time (243/243 canicule measured) and exceeded that bare for accelerated PT (≥30 µW/cm2/nm) 69% of the time. Currently accessible bartering PT accessories application fluorescent, halogen, fiberoptic, or light-emitting diode lamps bear irradiances amid 10 and 60 μW/cm2/nm, depending on the device. 20 Although the accessories with aerial irradiance arise to be best effective, maximally able irradiance levels accept not yet been established.
FS-PT was able-bodied accustomed by both mothers and hospital staff. Application ample canopies kept mothers and their breed together, facilitating bonding, care, and feeding. It additionally answer socialization amid mothers and enabled accompanying assay of assorted mother/infant pairs. Low bulk and acceptable measures, such as agreement the baby on a wet anhydrate back the ambient temperature was aerial or back the infant’s temperature began to acceleration bigger the assurance profile. Added bargain measures that bigger assurance and/or adeptness included lining the bed with white cloths, 16 and accouterment white aprons for the mothers and bargain eye patches fabricated from beat tops.
The account of FS-PT depends on the bulk of circadian sunlight accessible and is accordingly best acceptable to be applicative in geographic areas breadth the admeasurement of circadian complete sunlight is aerial and breadth melancholia aberration is reduced. Additionally, this abstraction would charge to be replicated in added locations and added climates to advance bounded adaptations to accomplish it both safe and able in low-resources settings. However, because sunlight appears to be added able than accustomed PT, a beneath aeon of assay may be required. 10 Solar-powered or array backups for accustomed PT accessories would be adapted to board PT about the alarm or during times back sunlight was inadequate. In colder climates, a allowance with a glass/plexiglass roof would be adapted to advance normothermia. Furthermore, a abiding or semipermanent anatomy to assure the films from rain and storms would decidedly advance the constancy of the films and would be accessible against authoritative FS-PT acceptable in low-resource settings. No accountable progressed to an barter claret admixture level. However, due to our abstraction design, breed were buried aboriginal and alike in the absence of any analytic jaundice. Therefore, back FS-PT is acclimated in added added accepted settings afterwards the access of analytic neonatal jaundice, it would be accustomed that some breed adeptness advance to barter levels.
Strengths of FS-PT accommodate the adeptness to board able bargain PT afterwards electricity and almost big-ticket accustomed PT devices; to board a appointment to brainwash both mothers and bloom affliction providers on the prevention, recognition, and assay of neonatal jaundice; and to acquiesce mothers to collaborate with anniversary added as able-bodied as with the bloom affliction providers while caring for their breed afterwards arresting therapy.
The limitations of FS-PT in this abstraction accommodate the charge to acceptation the blur material, locally accomplish the canopies, as able-bodied as difficulties of attention the films during bitter weather, abridgement of adeptness to board FS-PT at night or on backing days, and disability to use advancing canopies in colder climates. However these limitations can be addressed by auspicious bounded assembly of films and/or befitting acceptation costs low by alive with companies advance in resource-poor settings, architecture glass- or plexiglass-roofed barrio for beyond bloom affliction centers or hospitals application this technology, and heating these structures in colder climates. Additionally, because FS-PT was a new therapy, this balloon was not advised to assay best analytic efficacy.
Further abstraction is bare to accredit businesslike and safe scaling-up of this atypical potentially life-saving assay to added burghal and added alien bloom centers. Accustomed challenges, which are not insurmountable, accommodate aliment of normothermia breadth temperature ecology is not commonly available, ecology TB levels afterwards accepted class analysis, and adapted barometer to a college akin of care. It will be important to appraise this assay of breed with college TB levels in added burning assay scenarios. Until this advice is available, breed placed beneath FS-PT charge to abide to be carefully monitored, as was done in this study. A randomized controlled noninferiority balloon comparing FS-PT with accustomed PT in Nigeria is currently ongoing. 21
With adapted baby temperature monitoring, the use of FS-PT ≥5 hours per day, offers a novel, yet practical, inexpensive, safe, and active action for the administration of neonatal jaundice in areas of the apple breadth no added assay is readily or alone sporadically available.
The authors acknowledge the Agents and Mothers at Island Maternology Hospital, Vinod K. Bhutani, MD, FAAP, assistant of pediatrics, Stanford University, for his addition to the assay of adeptness of the FS-PT and appointment apropos the study, and Tu Quan, MPH, assay manager, and Bonnie Crissman, grants administrator, for their added abutment in administrating this grant.
The basic allegation for this abstraction accept been belvedere presentations at the Annual Meeting of the American Academy of Pediatrics; October 20–23, 2012; New Orleans, LA (Society for International Child Bloom Section: abstruse 17761), and the Pediatric Academic Societies’ Meeting; May 4–7, 2013; Washington, DC (Global Pediatric Research: Perinatal 2830.6). Agreement alone afterwards abstracts appear as follows: Slusher TM, Olusanya BO, Vreman HJ, Wong RJ, Brearley AM, Vaucher YE, Stevenson DK. Assay of neonatal jaundice with filtered sunlight in Nigerian neonates: abstraction agreement of a non-inferiority, randomized controlled trial. Trials. 2013;14:446. doi: 10.1186/1745-6215-14-446.
This balloon has been registered at www.clinicaltrials.gov (identifier NCT01434810).
Dr Slusher conceptualized and advised the study, accustomed the architecture and accomplishing of the study, accommodating and supervised abstracts collection, drafted the antecedent manuscript, and alarmingly advised and revised the manuscript; Dr Vreman contributed to the architecture of the abstraction and took albatross for the alternative of the films, design, accretion and architecture of the assay canopies, and additionally alarmingly advised and revised the abstract manuscript; Dr Olusanya accustomed the architecture and accomplishing of the study, accommodating and supervised abstracts collection, and alarmingly advised and revised the manuscript; Mr Wong and Dr Stevenson contributed to the architecture of the study, alternate in the film-selection studies, and alarmingly advised and revised the abstract manuscript; Dr Brearley served as the statistician for the study, and alarmingly advised and revised the manuscript; Dr Vaucher contributed to abstraction design, abstracts analysis, and arrangement preparation, and additionally alarmingly advised and revised the manuscript; and all authors accustomed the final arrangement as submitted.
FINANCIAL DISCLOSURE: The authors accept adumbrated they accept no banking relationships accordant to this commodity to disclose.
FUNDING: Supported by the Thrasher Assay Fund, Salt Lake City, UT. Philips Healthcare (Monroeville, PA) donated the BiliChek Transcutaneous Bilirubinometer and a allocation of the probes; Advanced Instruments (Norwood, MA) donated the Advanced BR2 Bilirubin Stat-Analyzer. Analytic and Translational Science Institute admission abutment (UL1TR000114 from the National Center for Assay Resources).
POTENTIAL CONFLICT OF INTEREST: The authors accept adumbrated they accept no abeyant conflicts of absorption to disclose.
Slusher T, Cline B, Amubunosi E, Ofovwe G, Wong R, Stevenson D, Vreman H. Selectively filtered sunlight phototherapy for assay of neonatal jaundice in Nigeria. E-PAS2011 2011;2918.254.
Olusanya BO. Educational video for training mothers about neonatal jaundice. 2012.
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