Sunlight for the prevention and treatment of hyperbilirubinemia in newborns

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Review question

How safe and effective is sunlight for treating or preventing jaundice (yellowing of the skin, called hyperbilirubinemia) in newborns?

Background

Babies with jaundice are often treated with phototherapy lamps, which emit blue-green light that alters the bilirubin (yellow substance found naturally in the baby’s blood) so that it can be more easily excreted.

Sunlight emits light in a similar spectrum. However, sunlight also emits harmful ultraviolet rays and infrared radiation, which can cause sunburn and skin cancer. Further, exposing babies to sunlight might mean they could get too warm or too cold, depending on the climate.

In low- and middle-income countries (LMIC) phototherapy is not always available for babies who need it. Further, babies in these countries can be at increased risk for dangerous jaundice, where the bilirubin in their blood reaches levels that allow it to cross the blood-brain barrier and cause damage to the brain. Babies in LMIC are at increased risk for jaundice for a number of reasons, including poor access to maternal care during pregnancy, increased numbers of blood disorders causing jaundice, and increased risk of infection or birth trauma.

Given that sunlight is readily available, there is an urgent need to determine if sunlight is safe and effective at treating jaundice in babies in LMIC.

Study characteristics

We included three clinical trials containing 1103 infants from two countries. The trials included infants born at or near their due date (35 weeks of gestation or later) who were less than two weeks old. One study evaluated healthy babies, and the other two evaluated babies with jaundice. In one study, the babies received either sunlight therapy or no treatment to assess sunlight for the prevention or reduction of jaundice. In the other two studies, infants with jaundice were randomly assigned to receive treatment with phototherapy machines or to receive sunlight through a light-filtering tent that blocked ultraviolet light and infrared radiation, and these groups were compared for improvement in their jaundice. One study did not comment on funding. The other two studies were funded by the Thrasher Research Fund. Evidence is current to June 2020.

Key results

Sunlight versus no treatment: babies exposed to sunlight may have a reduced occurrence of jaundice and be jaundiced for fewer days compared to babies who have no preventive treatment for jaundice. There was no reduction in readmission to hospital for jaundice in babies exposed to sunlight compared to babies who were not treated.

Sunlight versus other sources of phototherapy: when compared to babies who were exposed to electric phototherapy treatment, babies exposed to sunlight had a similar rate of decline in bilirubin levels. Using light-filtering films, babies exposed to sunlight did not have increased rates of sunburn, dehydration, or hypothermia. Babies exposed to sunlight were at an increased risk of hyperthermia. The effectiveness of sunlight might not be inferior to phototherapy, if sunlight can be delivered for at least four hours per day, and electric phototherapy can be delivered at night when needed.

Certainty of the evidence

The certainty of the evidence for outcomes in all three studies was very low to moderate. It was very low for all the main outcomes in each study. We are uncertain whether sunlight is effective for the prevention or treatment of hyperbilirubinemia in term or late preterm neonates.

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Authors’ conclusions: 

Sunlight may be an effective adjunct to conventional phototherapy in LMIC settings, may allow for rotational use of limited phototherapy machines, and may be preferable to families as it can allow for increased bonding. Filtration of sunlight to block harmful ultraviolet light and frequent temperature checks for babies under sunlight may be warranted for safety. Sunlight may be effective in preventing hyperbilirubinemia in some cases, but these studies have not demonstrated that sunlight alone is effective for the treatment of hyperbilirubinemia given its sporadic availability and the low or very low certainty of the evidence in these studies.

Read the full abstract…

Background: 

Acute bilirubin encephalopathy (ABE) and the other serious complications of severe hyperbilirubinemia in the neonate occur far more frequently in low- and middle-income countries (LMIC). This is due to several factors that place babies in LMIC at greater risk for hyperbilirubinemia, including increased prevalence of hematologic disorders leading to hemolysis, increased sepsis, less prenatal or postnatal care, and a lack of resources to treat jaundiced babies. Hospitals and clinics face frequent shortages of functioning phototherapy machines and inconsistent access to electricity to run the machines. Sunlight has the potential to treat hyperbilirubinemia: it contains the wavelengths of light that are produced by phototherapy machines. However, it contains harmful ultraviolet light and infrared radiation, and prolonged exposure has the potential to lead to sunburn, skin damage, and hyperthermia or hypothermia.

Objectives: 

To evaluate the efficacy of sunlight administered alone or with filtering or amplifying devices for the prevention and treatment of clinical jaundice or laboratory-diagnosed hyperbilirubinemia in term and late preterm neonates.

Search strategy: 

We used the standard search strategy of Cochrane Neonatal to search CENTRAL (2019, Issue 5), MEDLINE, Embase, and CINAHL on 2 May 2019. We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials (RCTs), quasi-RCTs, and cluster RCTs.

We updated the searches on 1 June 2020.

Selection criteria: 

We included RCTs, quasi-RCTs, and cluster RCTs. We excluded crossover RCTs. Included studies must have evaluated sunlight (with or without filters or amplification) for the prevention and treatment of hyperbilirubinemia or jaundice in term or late preterm neonates. Neonates must have been enrolled in the study by one-week postnatal age.

Data collection and analysis: 

We used standard methodologic procedures expected by Cochrane. We used the GRADE approach to assess the certainty of evidence. Our primary outcomes were: use of conventional phototherapy, treatment failure requiring exchange transfusion, ABE, chronic bilirubin encephalopathy, and death.

Main results: 

We included three RCTs (1103 infants). All three studies had small sample sizes, were unblinded, and were at high risk of bias. We planned to undertake four comparisons, but only found studies reporting on two.

Sunlight with or without filters or amplification compared to no treatment for the prevention and treatment of hyperbilirubinemia in term and late preterm neonates

One study of twice-daily sunlight exposure (30 to 60 minutes) compared to no treatment reported the incidence of jaundice may be reduced (risk ratio [RR] 0. 61, 95% confidence interval [CI] 0.45 to 0.82; risk difference [RD] −0.14, 95% CI −0.22 to −0.06; number needed to treat for an additional beneficial outcome [NNTB] 7, 95% CI 5 to 17; 1 study, 482 infants; very low-certainty evidence) and the number of days that an infant was jaundiced may be reduced (mean difference [MD] −2.20 days, 95% CI −2.60 to −1.80; 1 study, 482 infants; very low-certainty evidence). There were no data on safety or potential harmful effects of the intervention. The study did not assess use of conventional phototherapy, treatment failure requiring exchange transfusion, ABE, and long-term consequences of hyperbilirubinemia. The study showed that sunlight therapy may reduce rehospitalization rates within seven days of discharge for treatment for hyperbilirubinemia, but the evidence was very uncertain (RR 0.55, 95% CI 0.27 to 1.11; RD −0.04, −0.08 to 0.01; 1 study, 482 infants; very low-certainty evidence).

Sunlight with or without filters or amplification compared to other sources of phototherapy for the treatment of hyperbilirubinemia in infants with confirmed hyperbilirubinemia

Two studies (621 infants) compared the effect of filtered-sunlight exposure to other sources of phototherapy in infants with confirmed hyperbilirubinemia. Filtered-sunlight phototherapy (FSPT) and conventional or intensive electric phototherapy led to a similar number of days of effective treatment (broadly defined as a minimal increase of total serum bilirubin in infants less than 72 hours old and a decrease in total serum bilirubin in infants more than 72 hours old on any day that at least four to five hours of sunlight therapy was available). There may be little or no difference in treatment failure requiring exchange transfusion (typical RR 1.00, 95% CI 0.06 to 15.73; typical RD 0.00, 95% CI −0.01 to 0.01; 2 studies, 621 infants; low-certainty evidence). One study reported ABE, and no infants developed this outcome (RR not estimable; RD 0.00, 95% CI −0.02 to 0.02; 1 study, 174 infants; low-certainty evidence). One study reported death as a reason for study withdrawal; no infants were withdrawn due to death (RR not estimable; typical RD 0.00, 95% CI −0.01 to 0.01; 1 study, 447 infants; low-certainty evidence). Neither study assessed long-term outcomes.

Possible harms: both studies showed a probable increased risk for hyperthermia (body temperature greater than 37.5 °C) with FSPT (typical RR 4.39, 95% CI 2.98 to 6.47; typical RD 0.30, 95% CI 0.23 to 0.36; number needed to treat for an additional harmful outcome [NNTH] 3, 95% CI 2 to 4; 2 studies, 621 infants; moderate-certainty evidence). There was probably no difference in hypothermia (body temperature less than 35.5 °C) (typical RR 1.06, 95% CI 0.55 to 2.03; typical RD 0.00, 95% CI −0.03 to 0.04; 2 studies, 621 infants; moderate-certainty evidence).

Health topics: 

Child health > Neonatal care > Neonatal jaundice

Neonatal care > Neonatal jaundice

FAQs About Phototherapy | Newborn Nursery

Phototherapy lights emit light in the blue-green spectrum (wavelengths 430-490nm).  It is NOT ultraviolet light.

“Intensive phototherapy” means the irradiance of the light is at least 30µW/cm2 per nm as measured at the baby’s skin below the center of the phototherapy lamp.   A hand-held radiometer can be used to measure the spectral irradiance emitted by the light.  Because measurements taken directly under the lights will be higher, measurements should ideally be made at several locations and averaged.  The appropriate radiometer will vary based on the phototherapy system used, so manufacturer recommendations should be followed.

With “Conventional phototherapy” the irradiance of the light is less, but actual numbers vary significantly between different manufacturers.  In general, it is not necessary to rountinely measure irradiance when administering phototherapy, but units should be checked periodically to ensure that the lamps are providing adequate irradiance, according to the manufacturer’s guidelines.

In adults, prolonged exposure to blue light can cause retinal damage.  Although retinal damage from phototherapy has not been reported, eye covers for newborns are standard prophylaxis.

A rare complication (bronze baby syndrome) occurs in some infants with cholestatic jaundice when treated with phototherapy.   With  exposure to phototherapy lamps, these infants develop a dark, gray-brown discoloration of skin, urine, and serum.  Although the exact etiology is not understood, this effect is thought to be the result of an accumulation of porphyrins and other metabolites.

Another possibility is the development of purpura or bullae in infants with cholestatic jaundice or congenital erythropoietic porphyria.  Because the photosensitivity and blistering can be severe in infants with porphyria, infants who have this diagnosis or a positive family history for this disorder, have an absolute contraindication for phototherapy.

No, although some people who are around blue lights for prolonged periods will feel nauseated. Yellow plastic placed on the outside of the isolette may mitigate this effect.

There are no specific guidelines for when to discontinue phototherapy.  Evidence of hemolysis and age of the infant will impact the duration.  In some cases, phototherapy will only be needed for 24 hours or less, in some cases, it may be required for 5 to 7 days.   The AAP Guidelines suggest that an infant readmitted for hyperbilirubinemia, with a level of 18 mg/dL or more, should have a level of 13 – 14 mg/dL in order to discontinue phototherapy.  In general, serum bilirubin levels should show a significant decrease before the lights are turned off. 

Physical examination for jaundice is not helpful once treatment has started as the yellow color of the skin is temporarily “bleached” by the phototherapy.

The effectiveness of phototherapy is determined largely by the distance between the lamps and the infant, so phototherapy can easily be intensified by bringing the lamps closer to the infant. Because a closed isolette does not allow the lamps to be moved in close, if there is a concern about the effectiveness of phototherapy, an isolette should not be used.

With the infant in an open bassinet, it is possible to bring the lamps to within 10 cm of the infant. An undressed term infant with not be overheated with this arrangement, however, is is important that halogen spotlights NOT be used. Halogen lights can get hot, and burns may result if used this way.  Special blue, regular blue, and cool white lights are all acceptable alternatives.

Increasing the skin surface area exposed to phototherapy will also maximize treatment.  Commonly, an overhead phototherapy unit is combined with a bili blanket that can be place under the infant. Some of these blankets or pads are rather small, so 2 or 3 of these units may be needed to supply more complete coverage from below. Lining the sides of the bassinet with white blankets or aluminum foil can also increase the effectiveness of phototherapy.

Breastfeeding with jaundice | how to do it right

The experience of generations shows that it is quite possible to cure the jaundice of a newborn only by sunbathing. After all, this is how our grandmothers and their grandmothers, and many people before us, were treated. The sunbathing method is old, so it seems tried and true. And mothers today do not see the need for phototherapy, believing that lying in the sun for a child will be much more useful than under the light of complex medical devices.

However, modern research shows that sunbathing is not only ineffective, it is also dangerous. Of course, it is possible to cure jaundice with their help, but only in theory. In practice, the child must be healthy as an ox to survive such therapy. Let’s see why.

Ultraviolet exposure

Many doctors recommend avoiding sun exposure even for adults, let alone a child. During sunbathing, not only useful, healing light, but also harmful ultraviolet radiation enters the skin. It is carcinogenic and causes cancer.

Unlike solar treatments, phototherapy involves the use of soft blue light, without any ultraviolet light. It best breaks down bilirubin molecules and is safe for the child.

Burns and overheating

Coming south, we try to avoid long exposure to the sun until the skin tans. However, we consider it normal to place the baby in direct sunlight as a treatment. Meanwhile, the delicate skin of a child is not yet able to defend itself from the aggressive effects of the heavenly body. Yes, and thermoregulation in a newborn is poorly developed. As a result, during “useful baths”, the baby will easily get burned or sunstroke.

Certified phototherapy equipment goes through many tests to ensure that the baby is safe. The thermal effect there is minimal, so burns are excluded, as well as overheating.

Unfortunate climate

Children are born all year round, and the climate in many places on the planet is far from sunny. In winter, the healing sun still needs to be caught. However, in summer the number of clear days also depends on the location of the windows, the weather. At the same time, the treatment of neonatal jaundice requires an almost continuous presence of the child in the light. To provide it with the help of sunbathing is simply impossible.

Restrictions on treatment time

Due to the risk of burns, heat stroke, the harmfulness of ultraviolet radiation, it is impossible to organize sunbathing for longer than 15 minutes. But, even if it is possible to organize several sessions a day, this is not enough to cure jaundice. The minimum rate is 96 hours, and the faster they pass, the less the risk of complications from elevated bilirubin. Phototherapy makes it possible to treat the baby with long sessions at any time of the day. At the same time, he is comfortable and calm.

Hypothermia and colds

Another risk of sunbathing is hypothermia. When lying in the sun, the child should be naked, which means that he can freeze. It is almost impossible to create a comfortable temperature during the procedure. But it is available to those who have chosen phototherapy: a heater can be placed near the lamp, and the device itself can be placed away from drafts and open windows.

Unpredictable effect

We cannot regulate the sun, so no one can guarantee the effectiveness of sunbathing. Sometimes the sun is too strong and burns the baby’s skin. On other days, on the contrary, it shines too weakly and does not help to remove toxic bilirubin. In general, even if the baby managed to lie in the sun for 96 hours, there is no guarantee that it will work. The photo lamp always shines in the same way with exactly the intensity that is needed. At the same time, its radiation is completely safe.

Discomfort for child and parents

Children do not like bright lights. Being under the sun, they cry, act up. Moms and dads also have to face inconvenience: they have to either bring the baby to the window, or rearrange the crib. Using a photo lamp, parents simply rock the baby in a special hammock, where he sleeps peacefully. The bed lamp is easy to move around the apartment, you can even take it with you to bed.

Complications and risk of hospitalization

Sunbathing is not effective enough, so the child needs additional treatment. As a rule, these are medicines, which, however, also do not always help to achieve the desired result. In the testimony of many, there is not even information that they can be used to treat neonatal jaundice. But there are side effects:

Why do doctors still use them? They follow outdated treatment standards that were developed in case the clinic did not have phototherapy lamps.

The higher the bilirubin level rises, the more the child’s condition worsens. As a result, the doctor may decide to put the baby in a hospital. Most often, a mother with a newborn will not be able to lie down together, because he will be placed in a special room under photo lamps. As a result, the child will still undergo phototherapy, but with stress for the whole family, interruption of breastfeeding and deterioration in the general condition of the body. The effects of stress at an early age will undoubtedly manifest a little later in adulthood in the form of weakness, morbidity, and sometimes deterioration in cognitive functions.

Phototherapy at home is no different from hospital phototherapy. But at home, the baby does not face stress, eats well, gains weight, recovers faster.

Having examined all the shortcomings of sunbathing, we can make an unambiguous conclusion: they are not suitable as the main method of treating jaundice. Moreover, it is better to exclude them altogether, limiting the time the child spends in the sun for a quarter of an hour.

How much sun is enough for your child? – Magazine

Bone health is essential for upright posture and stable walking. Only sunlight, more precisely, ultraviolet radiation, allows the children’s skeleton to develop. Most of the bones of a newborn are made up of cartilage, which undergoes gradual ossification. Bone mineralization itself begins when children receive calcium and phosphorus from their diet: both trace elements are then incorporated into bone development under the influence of vitamin D.

Most foods contain only small amounts of vitamin D, although fish oils and oily fish contain quite a lot. But thanks to UV radiation, we can produce the necessary amount of vitamin D ourselves: this happens when enough sunlight hits the skin.

If there is a lack of vitamin D, the bones cannot develop properly. In infants, acute vitamin D deficiency can lead to rickets, so taking this vitamin, for example, is recommended for babies in Germany. While breast milk, the best food for infants, contains relatively little vitamin D, commercial infant formula should be fortified with vitamin D (up to 15 micrograms or 600 IU/litre).

To ensure sufficient vitamin D in the skin, infants and older toddlers should be exposed to the sun for 30-60 minutes a day: enough if only the face is exposed and facing a clear sky. Babies don’t need direct sunlight, and they certainly shouldn’t be out in the open without clothes, losing body heat.

But too much sunlight can be harmful, especially for babies and young children. At a tender age, a baby’s skin is thin and has few melanocytes (skin cells that produce the protective pigment melanin). This means that even a relatively short period of sun exposure can cause sunburn. Like any other burn, it is manifested by reddening of the skin, and in severe cases leads to the formation of blisters. Sun exposure during childhood can greatly increase the risk of developing skin cancer. This is partly because the child’s immune system is not yet fully developed, so it cannot repair the cell damage caused by the sun’s rays.

Use a sunscreen with a high SPF of at least 20 and up to 50 for your child. avoidable sun exposure.

• The younger the child, the more important it is not to stay under the scorching rays of the sun (especially during the daytime from 11:00 to 16:00).
• The child’s skin should always be covered with light cotton clothing and the head covering should shade the skin of the neck.
• Use sunscreen factor 20 or higher without fragrance or preservatives.
• Sun lotion or cream should be used with extreme caution on the ears, nose and tops of the feet.

Even if sunscreen is applied, this does not mean that children can be exposed to direct sunlight for a longer period of time. If exposure to the sun, despite the precautions mentioned above, has led to sunburn, this condition requires immediate effective treatment.