Sunlight phototherapy for neonatal jaundice—time for its day in the sun?
Authors: Tim Colbourn, Charles Mwansambo
Journal: The Lancet Global Health (2018)

Sunlight is available in abundance in most low-income and middle-income countries, but is grossly underused. Any research to maximise exploitation of this readily available resource should be commended, especially if its aim is to improve the care and wellbeing of neonates. In The Lancet Global Health, Tina M Slusher and colleagues1Slusher TM Vreman HJ Brearley AM et al.Filtered sunlight versus intensive electric powered phototherapy in moderate-to-severe neonatal hyperbilirubinaemia: a randomised controlled non-inferiority trial.Lancet Glob Health. 2018; (published online Aug 28.)http://dx.doi.org/10.1016/S2214-109X(18)30373-5Summary Full Text Full Text PDF PubMed Scopus (12) Google Scholar show, in a rigorous study with clear results, that filtered-sunlight phototherapy (FSPT) can be as efficacious and safe as conventional intensive electric phototherapy (IEPT) for treatment of moderate-to-severe neonatal hyperbilirubinaemia in a simulated rural Nigerian setting. FSPT was efficacious on 116 (87·2%) of 133 treatment days and IEPT was efficacious on 135 (88·8%) of 152 treatment days (mean difference −1·6% [95% CI −9·9 to 6·7]; p=0·8165). Treatment was safe for all neonates. The authors concluded that their results support the use of FSPT in conjunction with IEPT, and we agree, assuming that FSPT is cheaper than the already available IEPT and feasible to set up. Questions remain though as to whether FSPT should, and could, be used alone in settings without electricity or IEPT. Whether FSPT should be used alone in low-income rural settings is a question of health economics: could the resources required be better spent on other interventions that could save more babies? Whether it could be used is a question of space, health systems, logistics, caregiver and clinician preferences, and health economics. To address the economics, it is necessary to consider what the burden of death and disability from hyperbilirubinaemia is in neonates eligible for FSPT—ie, neonates of at least 35 weeks' gestational age, who weigh more than 2·2 kg, and who have uncomplicated disease that does not necessitate referral or other treatment such as oxygen or intravenous fluids. If FSPT is to be given alone without IEPT at night—a scenario unlike that in Slusher and colleagues' study,1Slusher TM Vreman HJ Brearley AM et al.Filtered sunlight versus intensive electric powered phototherapy in moderate-to-severe neonatal hyperbilirubinaemia: a randomised controlled non-inferiority trial.Lancet Glob Health. 2018; (published online Aug 28.)http://dx.doi.org/10.1016/S2214-109X(18)30373-5Summary Full Text Full Text PDF PubMed Scopus (12) Google Scholar in which IEPT was available as a back-up at night—then eligibility criteria might be even more restrictive. If the burden of hyperbilirubinaemia is not large relative to that of other causes of neonatal mortality for which interventions remain underfunded,2Bhutta ZA Das JK Bahl R et al.Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost?.Lancet. 2014; 384: 347-370Summary Full Text Full Text PDF PubMed Scopus (762) Google Scholar then FSPT might not be a good use of limited resources, despite the potentially low costs of the treatment, which are unfortunately not reported by Slusher and colleagues.1Slusher TM Vreman HJ Brearley AM et al.Filtered sunlight versus intensive electric powered phototherapy in moderate-to-severe neonatal hyperbilirubinaemia: a randomised controlled non-inferiority trial.Lancet Glob Health. 2018; (published online Aug 28.)http://dx.doi.org/10.1016/S2214-109X(18)30373-5Summary Full Text Full Text PDF PubMed Scopus (12) Google Scholar Economic evaluation is required to establish whether FSPT would be worth including in cost-effective essential health packages in low-resource settings.3WHOMaking choices in health: WHO guide to cost-effectiveness analysis. World Health Organisation, Geneva2003Google Scholar, 4Woods B Revill P Sculpher M Claxton K Country-level cost-effectiveness thresholds: initial estimates and the need for further research.Value Health. 2016; 19: 929-935Summary Full Text Full Text PDF PubMed Scopus (421) Google Scholar Logistics, systems, and preferences also need to be considered. The upgraded FSPT room with a polycarbonate roof and walls lined with imported film used in the study, although simple, might not be readily available in most low-income and middle-income countries. Outside the research setting, there is a risk that substandard filters that do not meet safety standards could be used. Rural health facilities in low-income settings might not have suitable physical space to build such a facility, and available space could perhaps be better used for skin-to-skin kangaroo care for premature neonates. Skin-to-skin care could also be combined with FSPT, because it is associated with a more rapid rate of decline in total bilirubin concentrations compared with FSPT alone, possibly as a result of improved breastfeeding, increased temperature stability, and generally improved wellbeing.6WHOUNICEFEvery newborn: an action plan to end preventable deaths. World Health Organization, Geneva2014Google Scholar How FSPT can be linked to community diagnosis also needs to be investigated, as does linkage to any post-treatment follow-up services required. Overall, the place of FSPT in integrated care for neonates and mothers also needs to be worked out, especially at primary or lower-level health-care facilities in rural areas.6WHOUNICEFEvery newborn: an action plan to end preventable deaths. World Health Organization, Geneva2014Google Scholar If FSPT were used without IEPT back-up being available for nights or rainy days, would it be effective? What is the minimum number of hours of FSPT needed per 24 h to treat moderate-to-severe neonatal hyperbilirubinaemia? Slusher and colleagues, citing other studies in their discussion,1Slusher TM Vreman HJ Brearley AM et al.Filtered sunlight versus intensive electric powered phototherapy in moderate-to-severe neonatal hyperbilirubinaemia: a randomised controlled non-inferiority trial.Lancet Glob Health. 2018; (published online Aug 28.)http://dx.doi.org/10.1016/S2214-109X(18)30373-5Summary Full Text Full Text PDF PubMed Scopus (12) Google Scholar suggest that 12 h or less could be sufficient for effective FSPT, but further study in real rural settings is needed. Such studies also need to follow-up neonates after treatment to establish the effects of FSPT on health outcomes rather than total serum bilirubin concentrations, and, via economic evaluations, to establish whether FSPT is cost effective when given without IEPT in such routine situations. Which neonates can have FSPT alone safely and in which neonates FSPT could be effective need to be considered carefully. The views of both clinicians and caregivers also need to be considered via integrated qualitative assessment. As Slusher and colleagues point out, whether temperature monitoring by simple means by caregivers is desirable and feasible needs to be established. Clearly further study is needed to define what role, if any, FSPT has in rural health facilities in low-income settings. Whether FSPT is worth adopting and scaling up in the many rural areas without IEPT or electricity, where referrals to higher levels of care can be challenging or impossible, needs to be assessed in terms of usability, acceptability, affordability, and sustainability. Slusher and colleagues have done important groundwork, but more information is needed before FSPT might have its day in the sun. We declare no competing interests. Filtered sunlight versus intensive electric powered phototherapy in moderate-to-severe neonatal hyperbilirubinaemia: a randomised controlled non-inferiority trialFSPT is safe and no less efficacious than IEPT for treatment of moderate-to-severe neonatal hyperbilirubinaemia in near-term and term infants. Full-Text PDF Open Access