Question

• In premature infants, is fiberoptic phototherapy (i.e. Biliblanket) as effective in the treatment of hyperbilirubinemia when compared to conventional phototherapy?

Clinical Bottom Lines

1. There was no significant difference in the duration of phototherapy or need for additional phototherapy when comparing fiberoptic and conventional phototherapy in the treatment of hyperbilirubinemia in premature infants.
2. Both transepidermal water loss and post-prandial mesenteric blood flow were shown to be increased in preterm infants with fiberoptic phototherapy.
3. Research on other possible advantages of fiberoptic phototherapy over conventional phototherapy is still needed.
   

Summary of Key Evidence

1. Meta-analysis of 24 randomized or quasi-randomized trials evaluating the efficacy of fiberoptic phototherapy in a number of different clinical situations and patient populations, of which nine included only preterm infants, or contained some preterm infants and reported results for them separately.¹
2. Duration of phototherapy was not significantly different between the groups (WMD 2 hours, 95% CI -3.52, 7.52).
3. There was no greater use of additional phototherapy in the fiberoptic group (RR 1.07, 95% CI 0.27, 4.27).
4. The percentage change in SBR after 24 hours of treatment was not significantly different betaween the groups (WMD 1.7%, 95% CI -2.65, 6.05).
5. The use of repeat phototherapy for rebound jaundice was no higher in the fiberoptic group (RR 2, 95% CI 0.71, 5.63).
6. The percentage change in SBR per hour and per day was significantly affected by heterogeneity. Some factors that may have attributed to this include different types of fiberoptic therapies, different irradiance settings of the biliblanket, different lamp colors/types for conventional PT, phototherapy instituted at different SBR levels.
7. The review appeared to be valid as it appeared to be an exhaustive search, methodological quality of both the index trials and review process was high, and results were reproducible.
8. The incidence of kernicterus was not included in any of the studies.
9. Included studies did not share a common primary outcome measure, making a meta-analysis including all studies impossible without individual patient data.
10. Trans-epidermal water loss (WMD 17 ml/m2/hr, 95% CI 7.26, 26.74) and mesenteric blood flow velocity (WMD 0.11m/s, 85% CI 0.1, 0.12) after feeding were significantly higher in infants treated with fiberoptic devices.

Additional Comments

• AAP guidelines most recently released in 2004 were revised in an attempt to lower the incidence of bilirubin encephalopathy, including acute bilirubin encephalopathy and kernicterus. However, these guidelines are targeted towards infants of an EGA of 35 weeks or greater.²
• Premature infants often are at greater risks of developing severe hyperbilirubinemia and neurologic sequelae secondary to the condition. In extremely low birth weight infants, advanced, irreversible signs of toxicity may be masked by concurrent life-threatening illnesses. It has also been hypothesized that they may be more susceptible secondary to their tendency to be hypoalbuminemic, thus leaving more free bilirubin to potentially cross the blood-brain barrier.³
• Studies as to any advantages (including cost-benefit analysis, harmful side effects, parent-child bonding, nurse and maternal satisfaction) of fiberoptic phototherapy vs conventional phototherapy in preterm neonates may help further in making choices in treatment of hyperbilirubinemia.
  

Citation

1. Mills JF, Tudehope D. Fiberoptic phototherapy for neonatal jaundice. The Cochrane Database of Systematic Reviews 2001, Issue 1. Art. No.:CD002060. DOI: 10.1002/14561858.CD002060.
2. Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics. 2004;114:297-316.
3. Bhutani VK, Johnson LH, Shapiro SM. Kernicterus in sick and preterm infants (1999-2002): a need for an effective preventive approach. Seminars in Perinatology. 2004;28(5):319-25.

CAT Author: Cecile Danao, MD

CAT Appraisers: John Frohna, MD

Date appraised: May 17, 2006