Use of reflective materials during phototherapy for infants with jaundice

Review question: We wanted to find out whether use of curtains made from reflective materials hung from the side of phototherapy units improves the effectiveness of phototherapy.

Background: Jaundice (yellow discolouration of the skin) occurs in up to 60% of babies. This is due to accumulation of bilirubin. Mild elevations in bilirubin are considered normal, but when levels are very high, bilirubin could enter the brain and cause brain damage. Treatment using age- and risk-specific guidelines is aimed at preventing bilirubin from reaching these levels. Phototherapy (exposing the body to light of a specific wavelength) is the usual treatment, and the intensity of light on the skin is one of the factors determining the rate of decline in bilirubin. A potentially inexpensive method to increase the intensity of light is to use reflective materials. One of the concerns is that these curtains might obscure the view of the baby.

Study characteristics: We included randomised controlled trials (RCTs). The search is up-to-date as of the first of November 2019.

Key results: We found 12 studies with a total of 1288 babies. Of these, 11 compared a single unit of light with or without reflective materials around the lights. One trial compared a single unit of light and reflective materials with two units of light without curtains. Types of reflective materials included white plastic, white linen, and aluminium draped on three or four sides of the baby's cot.

We found sufficient data on the primary outcome - decline in bilirubin - in 11 studies including 1132 babies: 10 for the first comparison and one for the second comparison.

Three studies reported a decline in bilirubin at four to eight hours. Moderate-certainty evidence shows a small but clinically important difference favouring the use of curtains. Decline in bilirubin over 24 hours was measured in nine studies. All studies showed a faster decline in bilirubin in the curtains group, but the decline varied so widely that it was not meaningful to estimate the size of the effect. Four studies reporting the duration of phototherapy showed that it was shorter when reflective curtains were used, but this is of very low certainty. Moderate-certainty evidence from two studies shows that the intervention reduces hospital stay by almost two days. There were no reports of any important adverse events, such as temperature instability or acute life-threatening events due to curtains obscuring the baby, nor of other minor effects. This means that overall reflective curtains might provide benefit, but we are uncertain about whether there are any harms. None of the studies reported parent or healthcare personnel satisfaction with the curtains, or whether the curtains had any effect on breastfeeding rates.

One trial compared use of one light unit with curtains to use of two light units without curtains and showed similar results for both intervention and control groups.

Certainty of evidence: Evidence is of moderate certainty.

Authors' conclusions: 

Moderate-certainty evidence shows that the use of reflective curtains during phototherapy may result in greater decline in SB. Very low-certainty evidence suggests that the duration of phototherapy is reduced, and moderate-certainty evidence shows that the duration of hospital stay is also reduced. Available evidence does not show any increase in adverse events, but further studies are needed.

Read the full abstract...
Background: 

Phototherapy is a well-established effective therapy for treating babies with significant neonatal jaundice. Studies have shown that increasing light intensity will increase its efficiency. A potentially inexpensive and easy way of increasing the intensity of light on the body of the infant may be to hang reflective materials from the sides of phototherapy units.

Objectives: 

To assess the effects of reflective materials in combination with phototherapy compared with phototherapy alone for unconjugated hyperbilirubinaemia in neonates.

Search strategy: 

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 11), in the Cochrane Library; Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions(R); and the Cumulative Index of Nursing and Allied Health Literature (CINAHL), on 1 November 2019. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

Selection criteria: 

We included randomised and quasi-randomised controlled trials if the participants, who were term or preterm infants, received phototherapy with curtains made of reflective materials of any type in the treatment arm, and if those in the comparison arm received similar phototherapy without curtains or other intensified phototherapy, such as a double bank of lights.

Data collection and analysis: 

We used standard methodological procedures expected by Cochrane. We used the GRADE approach to assess the certainty of evidence.

Main results: 

Of 15 studies identified, we included 12 (1288 babies) in the review - 11 comparing phototherapy with reflective materials and phototherapy alone, and one comparing a single phototherapy light bank with reflective materials with double phototherapy. All reflective materials consisted of curtains on three or four sides of the cot and were made of white plastic (five studies), white linen (two studies), or aluminium (three studies); materials were not specified in two studies. Only 11 studies (10 comparing reflective materials versus none and one comparing reflective curtains and a single bank of lights with a double (above and below) phototherapy unit) provided sufficient data to be included in the meta-analysis. Two excluded studies used the reflective materials in a way that did not meet our inclusion criteria, and we excluded one study because it compared four different phototherapy interventions not including reflective materials. The risk of bias of included studies was generally low, but all studies had high risk of performance bias due to lack of blinding of the intervention.

Three studies (281 participants) reported a decline in serum bilirubin (SB) (μmol/L) at four to eight hours (mean difference (MD) -14.61, 95% confidence interval (CI) -19.80 to -9.42; I² = 57%; moderate-certainty evidence). Nine studies (893 participants) reported a decline in SB over 24 hours and showed a faster decline in SB in the intervention group, but heterogeneity (I² = 97%) was too substantial to permit a meaningful estimate of the actual effect size (very low-certainty evidence). Subgroup analysis by type of reflective material used did not explain the heterogeneity. Exchange transfusion was reported by two studies; both reported none in either group. Four studies (466 participants) reported the mean duration of phototherapy, and in each of these studies, it was reduced in the intervention group but there was substantial heterogeneity (I² = 88%), precluding meaningful meta-analysis of data. The only two studies that reported the mean duration of hospital stay in hours showed a meaningful reduction (MD -41.08, 95% CI -45.92 to -36.25; I² = 0; moderate-certainty evidence).

No studies reported costs of the intervention, parental or medical staff satisfaction, breastfeeding outcomes, or neurodevelopmental follow-up.

The only study that compared use of curtains with double phototherapy reported similar results for both groups.

Studies that monitored adverse events did not report increased adverse events related to the use of curtains, including acute life-threatening events, but other rarer side effects could not be excluded.

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