Most preterm neonates and 85% of term newborns experience clinical jaundice. In addition, 6.1% of healthy babies have a peak total bilirubin level >12.9 mg/dL. 3% of normal term newborns have total bilirubin levels greater than 15 mg/dL [1]. Total serum bilirubin levels exceeding 5mg/day are considered hyperbilirubinemia in term newborns². Icterus that occurs within 24 hours of birth and goes away in 5-7 days is considered normal. If an icterus develops within the first 24 hours of delivery, the total blood bilirubin level increases by more than 5 mg/dL per day or reaches 17 mg/dL, or if any other major illness-related signs and symptoms arise, this is considered pathological [2]. In the first week of life, 60% of term and 80% of preterm newborns experience neonatal hyperbilirubinemia and of those, 5%–10% require treatment to lower bilirubin levels.

Need of Study 

The majority of the time, phototherapy is utilised in medicine; nevertheless, prolonged use can have a number of negative effects. Inhibition of the mother-newborn bonding process, an unbalanced temperature environment, dehydration and loose motions are some of the side effects of phototherapy. Alterations in the electrolyte, DNA damage, Bronze baby syndrome, abnormalities in circadian rhythm, hypocalcaemia, bullous and purpuric eruptions, retinal harm [3].

Hence, this study was conducted to compare continuous and intermittent phototherapy while treating neonatal hyperbilirubinemia in tertiary health care, Bangalore.

Aim

To assess the therapeutic efficacy of continuous and intermittent phototherapy in infants with hyperbilirubinemia.

Objective of the Study

• Compare the efficacy of intermittent and continuous phototherapy for the treatment of neonatal hyperbilirubinemia

• To compare the side effects of continuous and intermittent phototherapy 

This was a hospital based prospective randomized control study. All neonates born in The Tertiary health care center, Bangalore, after fulfilling inclusion criteria and with parent consent were included in the study. The study was conducted for a period of 18 months (March 2021 to September 2022).

Inclusion Criteria

• Birth weight >2.5 kg

• Gestation age >37 week

• Term neonates with neonatal hyperbilirubinemia who need phototherapy according to American Academy of Paediatrics hyperbilirubinemia curve

Exclusion Criteria

• Babies with risk factor of asphyxia, sepsis

• Babies with major congenital anomaly

• Conjugated hyperbilirubinemia

• Parents not giving consent

According to the American Academy of Paediatrics chart for hyperbilirubinemia, the level of total serum bilirubin determines whether phototherapy, exchange transfusions, or both are necessary, as indicated (Figure 1).

According to the Kramer Criteria [4], babies were routinely checked for clinical icterus. When icterus was found, bilirubin levels were tested in the lab using the DIAZO method. After considering the inclusion and exclusion criteria, newborns whose bilirubin levels on the American Academy of Paediatrics hyperbilirubinemia charts [5] above the threshold level on days 2 to 7 of the investigation were enrolled in my study.

Before starting the study, the birth parents who were willing to participate in it signed a written informed consent form after being informed about it. Then, newborns were divided into two groups at random by having their parents choose up sealed envelopes that each included information about the type of phototherapy they would receive-either continuous phototherapy or intermittent phototherapy.

Using a pre-structured and pre-designed proforma, data including demographic information, physical examinations and investigations were gathered after the newborn had been assigned to the appropriate group.

Double surface phototherapy was applied until the bilirubin level dropped below the American Academy of Paediatric curve chart's suggested level [6]. 

When bilirubin levels during phototherapy exceeded the therapeutic range and required exchange transfusions or other interventions, the kid was treated as necessary in accordance with the recommended protocols.

Statistical Analysis

Quantitative variables such as age, serum bilirubin at 24 hours of phototherapy were presented as Mean + SD. Qualitative variables such as gender were presented as % and frequencies. To compare the mean of a decrease in serum bilirubin between the two groups, a t-test were applied and p-value <0.5 were considered statistically significant.

Interferential Statistics

Data was entered in the excel spread sheet. SPSS version 20 was used to perform the statistical analysis. Descriptive statistics of the explanatory and outcome variables were calculated by mean, standard deviation for quantitative variables, frequency and proportions for qualitative variables. Chi square was applied to test the statistical association between qualitative variables. Unpaired t test was applied to test the mean difference of quantitative variables between two groups. Paired test was used to test the mean difference of serum lactate of the same individual at different time intervals. The level of significance was set at 5%.

Figure 1: American Academy of Pediatrics Guidelines for Management of Neonatal Hyperbilirubinemia based on Total Serum Bilirubin Levels

Out of total 210 newborn babies, 105 in each of the continuous and intermittent phototherapy groups, were enrolled in my study.

In the group receiving continuous phototherapy, 65 infants (61.9% male) and 40 (38.2% female). The bulk of the infants in the intermittent phototherapy group were male, numbering 66 (62.9%) and female 39 (37.2%). The mean age of newborn baby in both continuous and intermittent phototherapy group was 3.23±1.42 and 3.30+1.59 (p = 0.75) days respectively,

Baby birth weight was measured after removing all clothes and diaper. The mean weight of newborn baby in continuous and intermittent phototherapy group was 3.03+0.403 and 3.06+0.29 respectively. The mean difference of weight between both group was -0.029, (p-0.601).

Total serum bilirubin was measured in both group before and after 24 hour of phototherapy. T-test was used to analyze the data. The mean baseline bilirubin was 15.43mg/dL±1.99 and 15.68mg/dL+1.95 (p = 0.36) respectively, while the mean follow-up bilirubin after 24 hour of phototherapy was 13.79mg/dL±2.15 and 14.23mg/dL+2.29 (p = 0.95) respectively and the mean difference between the baseline and follow-up bilirubin between both group was 1.63 (p = 0.001) and 1.45 (p = 0.001) respectively. 

Baby weight was measured daily in the morning. The mean weight difference between before and after phototherapy of continuous and intermittent phototherapy group was 0.013 (p = 0.001) and 0.01(p = 0.007) respectively (Table 1).

The most frequent newborn condition that needs testing and treatment is hyperbilirubinemia. Jaundice, the clinical sign of hyperbilirubinemia, affects 60% of healthy neonates. This can be overshadowed and not receive the attention it needs, which could have disastrous consequences. Preventive measures, such as newborn nursery jaundice screening, lactation support, parental education, prompt post-discharge follow-up and appropriate treatment when clinically indicated, are the best clinical strategy to prevent the development of marked hyperbilirubinemia and the risk of acute bilirubin encephalopathy in neonates [5]. 

Table 1: Baseline Demographic Characteristics and Clinical Outcomes of Newborns Receiving Continuous Versus Intermittent Phototherapy

Regular neonatal weight checks and the provision of lactation support during this time and the early post-discharge period are helpful in addressing lactation difficulties and in identifying mother-infant pairs that are more likely to breastfeed insufficiently and unsuccessfully. A brief hospital stay (less than 48 hours following delivery), while it may be allowed for certain healthy term babies. The current 2004 practise criteria clearly supports the AAP's advice for all babies to have close post-discharge follow-up, which is especially important for late-preterm neonates [7]. Consideration of phototherapy and exchange transfusion treatment thresholds as a function of gestational age and risk when severe hyperbilirubinemia occurs is a crucial part of efforts to prevent brain injury. Serum bilirubin levels remain the gold standard for selecting a preventive therapy for encephalopathy [8]. Serum bilirubin levels should be checked after 48 hours of life 8–12 times per hour, six times per hour, four times per hour and more regularly at higher values [9].

In terms of the bilirubin level after 24 hours of phototherapy, the continuous and intermittent phototherapy groups' mean bilirubin levels are 13.79 and 14.22, respectively, with p value of 0.155, which is statistically insignificant. Similar study conducted by Zhou et al. [10] the mean bilirubin level in continuous and intermittent phototherapy group was 11.75 and 11.77 respectively. Another study Niknafs et al. [11] the mean bilirubin level in continuous and intermittent phototherapy group was 11.06 and 10.86 respectively. Both the previous study had p-value of >0.05. So, no correlation in bilirubin level after phototherapy between continuous and intermittent phototherapy.

The mean drop in bilirubin value before and after the 24-hour intervention was 15.43 and 13.79, respectively, in the continuous phototherapy group, while it was 15.68 and 14.23, respectively, in the intermittent phototherapy group, with a p-value of 0.001. Similar research was done by Zhou et al. [12], who found that intermittent phototherapy had a mean decrease in bilirubin value of 15.75 and continuous phototherapy had a mean decrease of 15.79 before and after the 24-hour intervention, with a p-value of 0.001. This signifies that both continuous and intermittent phototherapy decreases bilirubin level significantly.

With reference to mean weight reduction before and after the 24-hour intervention, continuous phototherapy had 2.83 and 2.82, respectively, with a p-value of 0.001, whereas intermittent phototherapy had 2.84 and 2.83, respectively, with a p-value of 0.007. This shows that continuous phototherapy has a greater impact on weight loss than intermittent phototherapy. 

Concerning negative impacts such skin reaction, temperature and weeping pattern, the p-value was >0.05, which was statistically insignificant.

Although phototherapy is the most widely used, well-recognized and effective treatment for hyperbilirubinemia, it also has both short- and long-term drawbacks. Since phototherapy is currently used more frequently to treat hyperbilirubinemia, all of its long-term effects have not yet been fully evaluated, necessitating further study. Therefore, it is crucial to only use phototherapy when necessary and to closely monitor for any issues.

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2. Porter, M.L. and B.L. Dennis. “Hyperbilirubinemia in the term newborn.” American Family Physician, vol. 65, no. 4, 2002, p. 599.

3. Taksande, A. and S. Selvam. “Side effects of phototherapy in neonatal hyperbilirubinemia.” Acta Scientific Pediatrics, vol. 1, 2018, pp. 24–30.

4. Kramer, L. “Advancement of dermal icterus in jaundiced newborn.” American Journal of Diseases of Children, vol. 118, 1969, pp. 454–458.

5. American Academy of pediatrics subcommittee on hyperbilirubinemia. “Management of Hyperbilirubinemia in the Newborn Infants 35 or More Weeks of Gestation.” Pediatrics, vol. 114, 2004, pp. 297–316.

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9. Bhutani, V.K. et al. “Universal newborn bilirubin screening.” Pediatric Research, vol. 41, 1997, p. 191A.

10. Zhou, S. et al. “Analysis of therapeutic effect of intermittent and continuous phototherapy on neonatal hemolytic jaundice.” Experimental and Therapeutic Medicine, vol. 17, no. 5, 2019, pp. 4007–4012.

11. Niknafs, P. et al. “Intermittent versus continuous phototherapy for reducing neonatal hyperbilirubinemia.” Iranian Journal of Pediatrics, vol. 18, 2008, pp. 251–256.