Double versus single intensive phototherapy with LEDs in treatment of neonatal hyperbilirubinemia

Effectiveness of Dual-Blanket Phototherapy Compared With Combination Phototherapy on Rate of Bilirubin Decline and Treatment Duration

INTRODUCTION

The purpose of this study was to evaluate the effectiveness of dual light-emitting diode (LED) blanket phototherapy compared with combination LED phototherapy on the rate of total serum bilirubin (TSB) decline and treatment duration among full-term neonates with hyperbilirubinemia.

METHODS

A retrospective chart review of 255 newborns with hyperbilirubinemia admitted to a free-standing, university-affiliated, nonprofit, tertiary care Children's Hospital was conducted. Phototherapy type, duration, and rate of TSB decline were compared.

RESULTS

The rate of TSB decline was significantly higher among neonates treated with combination LED phototherapy than neonates treated with dual-blanket phototherapy (p <.0001). There was no significant difference in phototherapy duration.

DISCUSSION

Combination phototherapy resulted in a more rapid decline in TSB but did not shorten phototherapy duration compared to dual-blanket phototherapy. Phototherapy duration may have been confounded by variability in the timing of TSB laboratory draws. Further comparative effectiveness studies are recommended.

Efficacy of Circumferential Intensive Phototherapy in Treating Neonatal Hyperbilirubinemia: A Pilot Study

OBJECTIVE

The present study was aimed at developing a circumferential phototherapy unit using 3M reflective materials in the double-sided phototherapy unit and investigating its efficacy in treating neonatal hyperbilirubinemia.

STUDY DESIGN

Forty-two infants with neonatal hyperbilirubinemia were selected from our hospital; they were randomly divided into control (n = 21) and experimental groups (n = 21). The experimental group was treated with the circumferential phototherapy unit, while the control group was treated with an ordinary phototherapy unit.

RESULTS

No significant differences were noted between the two groups in the levels of transcutaneous bilirubin before phototherapy (p > 0.05). After 12 hours of phototherapy, the value of transcutaneous bilirubin decreased significantly in the experimental group compared with that of the control group (p < 0.05). Additionally, the two groups did not exhibit any significant difference in the side effects (p > 0.05).

CONCLUSION

Our results indicated that the circumferential phototherapy unit was more effective than the ordinary phototherapy unit in treating neonatal hyperbilirubinemia.

KEY POINTS

· A circumferential phototherapy unit was developed using 3M reflective materials.. · The circumferential phototherapy unit was more effective than the ordinary.. · The two groups did not exhibit any significant difference in the side effects..

Preliminary observations of a system for determination of phototherapy exposure over a neonate body shape

While it is possible to determine the irradiance and spectral content for a given neonatal phototherapy device at various locations over a neonate's surface, this does not allow estimation of the total rate of energy delivery within a specific spectral range over the neonate's exposed body surface. A series of 192 blue wavelength enhanced silicon photodiodes was distributed over the surface of a commercially available newborn body shape and connected to a specially designed interface circuit. Placement of photosensors over the surface of the baby shape was determined with consideration of the surface area of twelve specific anatomical areas where each was allocated 16 individual photodiodes. Calibration of detection channels for specific wavelength intervals was undertaken using a Bentham dmc150 spectroradiometer system and also a separate hand held spectroradiometer. This made it possible to estimate the effective integrated dose rate in Watts for specific wavelength intervals such as 460 nm to 490 nm as identified by the American Academy of Pediatrics for phototherapy lamp devices. This allowed identification of dose rate contributions from specific anatomical areas. Initial observations are reported for a range of phototherapy lamp systems and the findings are discussed in terms of their predicted relative clinical effectiveness. Options are also discussed in relation to the future development of the reported measurement system.

ABO haemolytic disease of the newborn: Improved prediction by novel integration of causative and protective factors in newborn and mother

BACKGROUND AND OBJECTIVES

Prediction of haemolytic disease of the foetus and newborn (HDFN) caused by maternal anti-A/-B enables timely therapy, thereby preventing the development of kernicterus spectrum disorder. However, previous efforts to establish accurate prediction methods have been only modestly successful.

MATERIALS AND METHODS

In a case-control study, we examined 76 samples from mothers and 76 samples from their newborns; 38 with and 38 without haemolysis. The IgG subclass profile of maternal anti-A and anti-B was determined by flow cytometry. Samples from newborns were genetically analysed for the A² subgroup, secretor and FcγRIIa receptor alleles.

RESULTS

Surprisingly, we found a correlation between the newborn secretor allele and haemolysis (p = 0.034). No correlation was found for FcγRIIa alleles. The A² subgroup was found only in newborns without haemolysis. Unexpectedly, different reaction patterns were found for maternal anti-A and anti-B; consequently, the results were treated separately. For the prediction of haemolysis in A-newborns, the maternal IgG1 subclass determination resulted in an accuracy of 83% at birth. For B-newborns, an accuracy of 91% was achieved by the maternal IgG2 subclass determination.

CONCLUSION

We improved the prediction of ABO-HDFN by characterizing maternal anti-A and anti-B by flow cytometry and we presented genetic traits in newborns with correlation to haemolysis. We propose a new understanding of A- and B-substances as immunogens that enhance the maternal immune response and protect the newborn, and we suggest that the development of ABO-HDFN is different when caused by maternal anti-A compared to maternal anti-B.

Prediction of ABO hemolytic disease of the newborn using pre- and perinatal quantification of maternal anti-A/anti-B IgG titer

BACKGROUND

Hemolysis in fetus/newborns is often caused by maternal antibodies. There are currently no established screening procedures for maternal ABO antibodies harmful to fetus/newborn. We investigated the clinical significance, and predictive value of maternal anti-A/B titer for hyperbilirubinemia in ABO-incompatible newborns.

METHODS

We conducted a case-control study of blood group O mothers and their ABO-compatible (O) vs. -incompatible (A/B) newborns receiving phototherapy, and of ABO-incompatible newborns receiving phototherapy vs. no phototherapy. Newborn data and treatment modalities were recorded, and total serum bilirubin and hemoglobin were measured. Maternal anti-A/B immunoglobulin-γ (IgG) titers were measured prenatally and perinatally, and negative and positive predictive values (NPV, PPV) were calculated to assess the risk of developing hyperbilirubinemia requiring phototherapy.

RESULTS

We found a significantly higher maternal IgG antibody titer in the case group (p < 0.001). Maternal anti-A/B titers at first trimester had modest predictive values: NPV = 0.82 and PPV = 0.65 for neonatal hyperbilirubinemia; titers at birth improved the predictive values: NPV = 0.93 and PPV = 0.73. Newborn hemoglobin was significantly lower in incompatibles compared to compatibles (p = 0.034). Furthermore, increased anti-A/B IgG production during pregnancy was associated with hyperbilirubinemia and hemolysis in incompatible newborns.

CONCLUSIONS

There was a significant association between maternal anti-A/B IgG titer and hyperbilirubinemia requiring treatment.

IMPACT

Maternal anti-A/B IgG titer in the first trimester and at birth is predictive of hemolytic disease of the ABO-incompatible newborn. Increased IgG anti-A/B production throughout pregnancy in mothers to ABO-incompatible newborns developing hyperbilirubinemia contrasts a constant or reduced production in mothers to newborns not developing hyperbilirubinemia. Screening tools available in most immunohematology laboratories can identify clinically important IgG anti-A/B. Use of maternal samples taken at birth yielded NPV = 0.93 and PPV = 0.73.

Effect of blue LED phototherapy centered at 478 nm versus 459 nm in hyperbilirubinemic neonates: a randomized study

BACKGROUND

Treatment of choice for hyperbilirubinemic neonates is blue light matching the absorption spectrum of bilirubin-albumin in vitro with maximum absorption at 459 nm. Blue LED light centered at 478 nm was hypothesized as being more efficient than that centered at 459 nm. This study compares the bilirubin-reducing effect of the two light qualities with equal irradiance in a randomized nonblinded clinical trial.

METHODS

Inclusion criteria were healthy hyperbilirubinemic neonates with gestational age ≥33 weeks. Forty-nine neonates included in each group received phototherapy from above for 24 h. Mean irradiances were 9.2 × 10¹⁵ and 9.0 × 10¹⁵ photons/cm²/s for the 478 and 459 nm groups, respectively.

RESULTS

Mean [95% CI] decreases in total serum bilirubin were 150 [141, 158] and 120 [111, 130] µmol/L for the 478 and 459 nm groups, respectively; mean difference was 29 [17, 42] µmol/L. Mean [95% CI] percentage decreases in bilirubin were 54.8% [52.5, 57.0] and 41.8% [39.3, 44.3]; mean difference was 12.9 [9.6, 16.3] percentage points. After adjustment this difference was 13.4 [10.2, 16.7] percentage points. All differences were highly statistically significant (P < 0.001).

CONCLUSION

Blue LED light centered at 478 nm had a greater bilirubin-reducing effect than that centered at 459 nm with equal irradiance quantified as photon fluence rate.

IMPACT

Blue LED light centered at 478 nm had a greater in vivo bilirubin-reducing effect than blue LED light centered at 459 nm with equal irradiance quantified as photon fluence rate in the treatment of hyperbilirubinemic late preterm or term neonates. LED light centered at 478 nm might reduce the duration of phototherapy compared to LED light centered at 459 nm as the same effect can be obtained while exposing the infants to fewer photons. Blue light matching the absorption spectrum of the bilirubin-albumin complex in vitro with peak absorption at 459 nm is used worldwide as it is considered to be the most effective light for phototherapy of jaundiced neonates. This study showed that blue LED light centered at 478 nm had a greater bilirubin-reducing effect than blue LED light centered at 459 nm. Therefore, blue LED light centered at 478 nm should be used instead of blue light centered at 459 nm. By this, the risk of potential side effects might be minimized, and the duration of phototherapy potentially reduced.

The effectiveness of phototherapy using blue-green light for neonatal hyperbilirubinemia - Danish clinical trials

The effectiveness of phototherapy for neonatal hyperbilirubinemia based on Danish clinical trials is presented. Randomized controlled trials on the quality of light showed that blue-green fluorescent light (peak emission at 490 nm) was more efficient than blue fluorescent light (peak emission at 452 nm); blue-green light-emitting diode (LED) light (peak emission at 478 nm) was more efficient than blue LED light (peak emission at 459 nm); and blue-green LED light (peak emission at 497 nm) was equivalent to blue LED light (peak emission at 459 nm). Bilirubin-reducing effects correlated with irradiance, dependent on hemoglobin concentration, and independent of rotating infants. Phototherapy from both above and below was more efficient than therapy applied only from above at high levels of irradiance. In conclusion, we estimate and recommend the use of blue-green LED light (peak emission at 480 nm) rather than blue light (peak emission at 460 nm) for treating of neonatal hyperbilirubinemia.

Challenges of phototherapy for neonatal hyperbilirubinemia (Review)

Phototherapy is universally recognized as the first option for treating neonatal jaundice due to its unparalleled efficiency and safety in reducing the high serum free bilirubin levels and limiting its neurotoxic effects. However, several studies have suggested that phototherapy may elicit a series of short- and long-term adverse reactions associated with pediatric diseases, including hemolysis, allergic diseases, DNA damage or even cancer. The aim of the present review was to summarize the etiology, mechanism, associated risks and therapeutic strategies for reducing high neonatal serum bilirubin levels. In order to shed light on the negative effects of phototherapy and to encourage implementation of a reasonable and standardized phototherapy scheme in the clinic, the present review sought to highlight the current understanding of the adverse reactions of phototherapy, as it is necessary to further study the mechanism underlying the development of the adverse effects of phototherapy in infants in order to explore novel therapeutic alternatives.

Efficacy of double versus single phototherapy in treatment of neonatal jaundice: a meta-analysis

To assess the efficacy of double phototherapy in managing neonatal jaundice compared to single phototherapy in infants with different birth weight and gestational age. CENTRAL, PubMed, clinicaltrials.gov, and gray literature sources were searched from date of inception of these databases till August 2019. Primary outcome was decline of total serum bilirubin (TSB) per hour. Ten studies were eligible. Our meta-analysis showed significant difference between double phototherapy versus single phototherapy in decline of TSB per hour in preterm infants (standardized mean difference [SMD] = 2.28 [0.79-3.76], p = 0.003) and a significant decrease in TSB levels at 24 h of phototherapy in infants with birth weight ≥ 1500 g (mean difference [MD] = - 61.70 μmol/L, [- 107.96, - 15.43], p = <0.001).Conclusion: Double phototherapy is effective in reducing TSB in infants of different gestational ages and birth weights with the most important finding regarding preterm infants, who are more susceptible to kernicterus.What is Known:• Double phototherapy has shown to be more efficacious than single phototherapy in treating neonatal jaundice.• Double phototherapy efficacy on neonates with different gestational ages and birth weights still remain ambiguous in treating neonatal jaundice.What is New:• The results of this meta-analysis show that double phototherapy is effective in reducing TSB in infants of different gestational ages and birth weights with the most important finding regarding preterm infants, who are more susceptible to kernicterus.

Sixty years of phototherapy for neonatal jaundice - from serendipitous observation to standardized treatment and rescue for millions

A breakthrough discovery 60 years ago by Cremer et al. has since changed the way we treat infants with hyperbilirubinemia and saved the lives of millions from death and disabilities. "Photobiology" has evolved by inquiry of diverse light sources: fluorescent tubes (wavelength range of 400-520 nm; halogen spotlights that emit circular footprints of light; fiberoptic pads/blankets (mostly, 400-550 nm range) that can be placed in direct contact with skin; and the current narrow-band blue light-emitting diode (LED) light (450-470 nm), which overlaps the peak absorption wavelength (458 nm) for bilirubin photoisomerization. Excessive bombardment with photons has raised concerns for oxidative stress in very low birthweight versus term infants treated aggressively with phototherapy. Increased emphasis on prescribing phototherapy as a "drug" that is dosed cautiously and judiciously is needed. In this historical review, we chronicled the basic to the neurotoxic components of severe neonatal hyperbilirubinemia and the use of standardized interventions.

Current phototherapy practice on Java, Indonesia

Background

In Indonesia, the burden of severe hyperbilirubinemia is higher compared to other countries. Whether this is related to ineffective phototherapy (PT) is unknown. The aim of this study is to investigate the performance of phototherapy devices in hospitals on Java, Indonesia.

Methods

In 17 hospitals we measured 77 combinations of 20 different phototherapy devices, with and without curtains drawn around the incubator/crib. With a model to mimic the silhouette of an infant, we measured the irradiance levels with an Ohmeda BiliBlanket Meter II, recorded the distance between device and model, and compared these to manufacturers’ specifications.

Results

In nine hospitals the irradiance levels were less than required for standard PT: < 10 μW/cm²/nm and in eight hospitals irradiance failed to reach the levels for intensive phototherapy: 30 μW/cm²/nm. Three hospitals provided very high irradiance levels: > 50 μW/cm²/nm. Half of the distances between device and model were greater than recommended. Distance was inversely correlated with irradiance levels (R² = 0.1838; P < 0.05). The effect of curtains on irradiance levels was highly variable, ranging from − 6.15 to + 15.4 μW/cm2/nm, with a mean difference (SD) of 1.82 (3.81) μW/cm2/nm (P = 0.486).

Conclusions

In half of the hospitals that we studied on Java the levels of irradiance are too low and, in some cases, too high. Given the risks of insufficient phototherapy or adverse effects, we recommend that manufacturers provide radiometers so hospitals can optimize the performance of their phototherapy devices.

Electronic supplementary material

The online version of this article (10.1186/s12887-019-1552-1) contains supplementary material, which is available to authorized users.

LED-phototherapy does not induce oxidative DNA damage in hyperbilirubinemic Gunn rats

BACKGROUND

Phototherapy (PT) is the standard treatment of neonatal unconjugated hyperbilirubinemia. Fluorescent tube (FT)-emitted PT light is known to induce oxidative DNA damage in neonates. Nowadays, however, FTs have largely been replaced by light-emitting diodes (LEDs) for delivering PT. Until now, it is unknown whether LED-PT causes oxidative DNA damage. We aim to determine whether LED-PT induces oxidative DNA damage in hyperbilirubinemic rats.

METHODS

Adult Gunn rats, with genetically unconjugated hyperbilirubinemia, received LED-PT in the clinically relevant doses of 10 or 30 µW/cm²/nm. Urine was collected at 0, 24, and 48 h of PT. A group of young Gunn rats received intensive LED-PT of 100 µW/cm²/nm for 24 h. Urine was collected every 8 h and analyzed for the levels of oxidative DNA damage marker 8-hydroxy-2'deoxyguanosine (8-OHdG) and creatinine. DNA damage was evaluated by immunohistochemistry (γH2AX) of skin and spleen samples.

RESULTS

LED-PT of 10 and 30 µW/cm²/nm did not affect urinary concentrations of 8-OHdG and creatinine or the 8-OHdG/creatinine ratio. Likewise, intensive LED-PT did not affect the 8-OHdG/creatinine ratio or the number of γH2AX-positive cells in the skin or spleen.

CONCLUSIONS

Our results show that LED-PT does not induce oxidative DNA damage in hyperbilirubinemic Gunn rats either at clinically relevant or intensive dosages.