ORIGINAL ARTICLE

COMPARISON OF CONTINUOUS WITH INTERMITTENT

PHOTOTHERAPY IN THE TREATMENT OF NEONATAL
JAUNDICE
Abdul Khaliq
1
Department of Accident and ABSTRACT
Emergency (EDCC-Paediatric Objective: To compare the mean decrease in serum bilirubin after intermittent
Emergency), MTI Lady Reading versus continuous phototherapy in the treatment of jaundice neonatorum.
Hospital, Peshawar - Pakistan.
Address for correspondence: Methodology: This randomized controlled study was carried out on neonates
Dr. Abdul Khaliq admitted to the neonatal unit of Department of Paediatric Medicine, Ward A,
Department of Accident and Lady Reading Hospital, Peshawar from 1st October 2012 to 31st march 2013. A
Emergency (EDCC-Paediatric total of 258 patients were enrolled for the study after fulfilling the inclusion/
Emergency), MTI Lady Reading exclusion criteria to compare the decrease in serum bilirubin after applying
Hospital, Peshawar - Pakistan. continuous/intermittent phototherapy for the treatment of neonatal jaundice.
E-mail: drabdulkhaliq1982@
gmail.com Results: Mean age of the patients was 3.89±1.83(p=.91) days, the mean base-
Date Received: line bilirubin was 17.56mg/dl±1.42 (p=.36), while the mean follow-up bilirubin
December 01, 2015 was 12.85mg/dl±1.65 (p=.95), and the mean difference between the base-
Date Revised: line and follow-up bilirubin was 4.7mg/dl±1.19 (p=.32). For the group A ba-
February22, 2016 bies, the mean difference between the baseline and follow-up bilirubin was
Date Accepted: 4.78mg/dl±1.20(p=.32). For the group B babies, the mean difference between
March 06, 2016 the baseline and follow-up bilirubin was 4.63mg/dl±1.18(p=.32). The differ-
ence between the mean age on admission, mean baseline bilirubin, mean
follow-up bilirubin, and the mean decrease in serum bilirubin for both the
groups A and B was statistically not significant.
Conclusion: Intermittent and continuous phototherapies were found to be
equally effective. Because of its additional benefits intermittent phototherapy
can be adopted as a routine procedure instead of continuous phototherapy
in neonatal care unites.
Key Words: Neonatal jaundice, Phototherapy, Continuous phototherapy, In-
termittent phototherapy

This article may be cited as: Khaliq A. Comparison of continuous with intermittent phototherapy in the treat-
ment of neonatal jaundice. J Postgrad Med Inst 2016; 30(2): 173-6.

totherapy depends upon the light energy emitted in the

INTRODUCTION
effective range of wavelengths, the distance between
Jaundice is the yellow discoloration of the skin and the light source and the skin, and the surface area of
sclera that results from accumulation of bilirubin in the the baby exposed to the light2. Photoisomerization is
skin and mucous membranes. It is the commonest clin- a rapid process, in a study it was found that significant
ical condition requiring medical attention in the new- amount of 4Z, 15E photo isomers were formed in 15
born babies1. It affects 60% of term and 80% of preterm
minutes6.
infants2. In our area jaundice neonatorum affects 39.7
babies per 1000 live births3. This unconjugated bilirubin Phototherapy can be applied both in continuous and
is an end product of heme-protein catabolism, and its intermittent fashion. In a study, comparing intermittent
raised levels are potentially neuro toxic2. Irrespective of and continuous phototherapy, it was found that there
the cause of jaundice, the aim of therapy is to prevent is no significant difference in the efficacy of continuous
unconjugated bilirubin related neurotoxicity4. and intermittent phototherapy7. In this study, the mean
Phototherapy is the main stay of treatment of neo- total serum bilirubin at 36th hour was 9.17 ± 1.83mg/dl
natal jaundice5. It acts by converting unconjugated bil- in continuous group and 9.02 ± 1.94mg/dl in the inter-
irubin to more polar stereoisomer, which are less neu- mittent phototherapy group. The mean decrease in bili-
rotoxic (cannot cross blood brain barrier) and can easily rubin from baseline was 7.43 ± 0.07mg/dl in continuous
be excreted in bile and urine6. The effectiveness of pho- group and 7.31 ± 0.48mg/dl in the intermittent group7.

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Most of the institutions use it in continuous way, but All neonates were randomly allocated in two groups
the intermittent application is more acceptable, easy by lottery method. Group A patients received continu-
and pleasant to the parents, better for neonate’s feed- ous phototherapy (2 hours on and 20 minutes off) while
ing, promotes mother-infant bonding and also easy for Group B patients received intermittent phototherapy
hospital staff. Moreover some other beneficial proce- (one hour on and 30 minutes off). The on off timing,
dures like baby massage and Kangaroo Mother Care, of phototherapy was observed by the researcher. Blood
could better be applied in intermittent phototherapy8,9. samples were taken and sent to hospital labs, (on arrival
before starting phototherapy, every 8 hourly while on
The present study was designed to compare the
phototherapy, and at 36th hour), by the researcher, to
mean decrease in serum bilirubin using continuous
look for serum bilirubin levels. The results were collect-
and intermittent phototherapy techniques for neonatal
ed from the lab by the researcher and the serum biliru-
jaundice. This study was aimed to determine the local
bin levels were noted down in the Proforma. Exclusion
results of the both intermittent and continuous photo-
criteria were followed, strictly, to control confounders
therapy techniques.
and bias in the study results. All the laboratory investi-
METHODOLOGY gations were done from hospital laboratory.

This Randomized controlled study was carried out on Data was analyzed using SPSS version 16. Quanti-
neonates admitted to the neonatal unit of Department tative variables such as age, serum bilirubin at start of
of Paediatric Medicine, Ward A, Lady Reading Hospital, phototherapy and serum bilirubin at 36th hour were pre-
Peshawar from 1st October 2012 to 31st march 2013. A sented as mean ± SD. Qualitative variables such as gen-
der were presented as %age and frequencies. To com-
total of 258 patients were selected by non-probability
pare the mean of decrease in serum bilirubin between
consecutive sampling., 129 in each group using 7.31±
the two groups, t-test was applied and p value ≤0.05
0.48mg/dl decrease in serum bilirubin after intermittent
were considered statistically significant. All results were
phototherapy and 7.43 ± 0.07mg/dl decrease in serum
presented as tables.
bilirubin after continuous phototherapy, 95% confi-
dence interval and 80% power of the test. RESULTS
Neonatal Jaundice was defined as serum indirect There were 258 patients in our study. Mean age of
bilirubin level of more than 12mg/dl in term neonates the patients was 3.89±1.83 (p= .91), the mean baseline
measured in the laboratory. Intermittent phototherapy bilirubin of patients was 17.56mg/dl±1.42 (p=.36), while
means observing on-off schedule for the application of the mean follow-up bilirubin was 12.85mg/dl±1.65
phototherapy. (p=.95), and the mean difference between the baseline
Inclusion criteria were full term neonates (≥37weeks) and follow-up bilirubin was 4.7mg/dl±1.19 (p=.32).
with age >24 hours and ≤10days and serum indirect For the group A babies, who received continu-
bilirubin level between 12 to 20mg/dl. APGAR at 5 min- ous phototherapy, the mean age on admission was
utes greater than 6 (as mentioned in patient hospital 3.91±1.82 (p=.91), the mean baseline bilirubin was
record file). Exclusion criteria were patients on intensive 17.64mg/dl±1.37 (p=.36), the mean follow-up biliru-
care i.e. ventilator, endotracheal intubation, and perito- bin was 12.86mg/dl±1.53 (p=.95) and the mean differ-
neal dialysis. Also patients with major congenital mal- ence between the baseline and follow-up bilirubin was
formation like cardiac, skeletal, renal, dysmorphism etc 4.78mg/dl±1.20 (p=.32).
and sepsis i.e. positive blood culture, fits, reluctance to
feed, platelets <50000. For the group B babies who received intermit-
tent phototherapy, the mean age on admission was
Informed consents were taken from the parents, (fa- 3.88±1.84 (p=.91), the mean baseline bilirubin was
ther/mother, which one available) of those babies ful- 17.48mg/dl±1.47 (p=.36), the mean follow-up bilirubin
filling the inclusion criterion, and which were enrolled was 12.85mg/dl±1.76 (p=.95), and the mean differ-
in the study from the Neonatal unit of Children A Ward, ence between the baseline and follow-up bilirubin was
Lady reading Hospital Peshawar. We conducted this 4.63mg/dl±1.18 (p=.32).
study by enrolling 258 babies, the male/female ratio,
and mean baseline bilirubin level was matched between Gender wise distribution is shown in Table 2.
the two groups A and B. Group A received continuous
DISCUSSION
phototherapy, while group B received intermittent pho-
totherapy. Both the groups received phototherapy from We planned this study to find a way of decreasing
apparatus of same manufacturer and same age. The burden on hospital staff, and providing the parents a
height of phototherapy light (distance between the light more acceptable way of treating their jaundiced babies.
source and the infant) was kept similar for both groups. In this study we compared two types of delivering pho-
The follow up bilirubin was measured at 36 hours. totherapy to the jaundiced newborns, continuous and

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Table 1: Type of phototherapy, age of patient, baseline bilirubin, follow-up bilirubin, and the
difference b/w baseline and follow-up bilirubin
Difference be-
Type of phototherapy Age of patients in Follow up biliru- tween baseline
Baseline bilirubin
given to patients days bin after 36 hours and follow-up
bilirubin
Continuous mean 3.9109 17.6434 12.8605 4.7822
N 129 129 129 129
Std. Deviation 1.8234 1.37238 1.53279 1.20231
% Of total sum 50.2% 50.2% 50.0% 50.8%
Intermittent mean 3.8857 17.4814 12.8473 4.6341
N 129 129 129 129
Std. Deviation 1.8395 1.47382 1.76742 1.18694
% Of total sum 49.8% 49.8% 50.0% 49.2%
Total mean 3.8983 17.5624 12.8539 4.7081
N 258 258 258 258
Std. Deviation 1.8279 1.42354 1.65106 1.19463
% Of total sum 100.0% 100.0% 100.0% 100.0%

Table 2: Gender distriubtion (n=258)

Group-A Group-B
Gender
(n=129) (n=129)
No. of patients % No. of patients %
Male 69 53.5 70 54.3
Female 60 46.5 59 45.7
Total 129 100 129 100

intermittent. It also helps to promote mother infant rum bilirubin level before the start of phototherapy was
bonding in a cost effective manner. No such study has 16.60mg/dl±1.67 for continuous and 16.33mg/dl±1.46
been conducted in Pakistan and this study will provide for intermittent group, and the mean serum bilirubin
the base line data for our setup10. at 36 hours was 9.17mg/dl±1.83 for continuous and
9.02±1.94 for intermittent group, while in our study the
Gender wise the difference between the two groups,
A and B, was statistically not significant. The difference mean serum bilirubin before the start of photothera-
between the mean decrease in serum bilirubin of both py was17.64mg/dl±1.37 for continuous and 17.48mg/
groups was statistically not significant. dl±1.47 for intermittent group, and the mean serum bil-
irubin at 36 was 12.86mg/dl±1.53 for continuous and
The difference between the mean age on admis- 12.85mg/dl±1.76. In other words, in our study, the mean
sion, mean baseline bilirubin, mean follow-up bilirubin, decrease in serum bilirubin was far less than theirs. This
and the mean decrease in serum bilirubin for both the may be because of difference in the apparatus7.
groups A and B was statistically not significant. (Table
1). Our results of this study were similar to those of Ni- In intermittent phototherapy group, we applied the
knafs et al in that there was statistically no significant phototherapy for one hour and observed 30 mints off,
difference in the effectiveness (mean decrease in serum because we consider thirty minutes time is sufficient for
bilirubin) of both types of phototherapy. Although we baby cleaning, feeding, and other helpful interventions
applied phototherapy for prolonged duration (2 hours if needed. We avoided short on and prolonged off pe-
on and 20 minutes off for continuous, and one hour on riods, because this was 1st local effort, and we do not
and 30 minutes off for intermittent group) compared took the possible risk of slow recovery of the neonate
to the above mentioned study (2 hours on and 30 min- from jaundice. Now when the results are same, we are
utes off for continuous and one hour on and one hour able to encourage more extensive studies, with prolong
off for intermittent group). In their study the mean se- off time.

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The limitation of our study was that we did not in- and Children’s Health. Neonatal Jaundice. London: RCOG
clude the adverse effects in our data analysis, but fortu- Press; 2010.
nately, it was observed that no adverse effects occurred
2. Maheshwari A, Carlo WA. Digestive system disorders. In:
in our patients. It is same as observed by Maisels MJ,
Kliegman RM, Stanton BF, Geme JW, Schor NF, Behrman
that phototherapy has significantly lower adverse ef-
RE, editors. Nelson textbook of pediatrics. 19th ed. Phila-
fects with the use of an appropriate nursing care.11
delphia: Saunders Elsevier; 2011:600-12.
In agreement with published data, it seems unneces-
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sary to maintain newborns hospitalized after treatment
GL, Zaidi AK. Incidence of neonatal hyperbilirubinemia:
with phototherapy for possible rebound in bilirubin lev-
a population-based prospective study in Pakistan. Trop
els12,13.
Med Int Health 2010; 15:502-7.
Intermittent phototherapy will also help in maintain-
4. Ahlfors CE, Parker AE. Unbound bilirubin concentration
ing mother-infant bonding, and breast feeding, and
is associated with abnormal automated auditory brain-
through this it will help in achieving well-nourished
stem response for jaundiced newborns. Pediatrics 2008;
and healthy babies. Moreover by involving mothers of
121:976-8. 
the patients in the nursing care (like cleaning, feeding,
changing diapers) of the babies, so the burden is shared 5. Kumar P, Chawla D, Deorari A. Light-emitting diode pho-
between the mother and staff. In this way the mother totherapy for unconjugated hyperbilirubinaemia in neo-
will look after their babies, they will visit their babies nates. Cochrane Database Syst Rev 2011; 12:CD007969.
after every 60 minutes and they will spend more time
6. Mreihil K, McDonagh AF, Nakstad B, Hansen TW. Early
(30 minutes off time) with their babies, so they will be
isomerization of bilirubin in phototherapy of neonatal
more satisfied.
jaundice. Pediatr Res 2010; 67:656-9.
It will help in promoting exclusive breast-feeding for
7. Niknafs P, Mortazavi AA, Torabinejad MH, Bijari BB, Ni-
1st six months, will reduce diarrhoeal diseases and respi-
knafs N. Intermittent versus continuous phototherapy for
ratory tract infections, and hence will help in reducing
reducing neonatal hyperbilirubinemia. Iran J Pediatr 2008;
infant and childhood morbidity and mortality.
18:251-6.
CONCLUSION 8. Chen J, Sadakata M, Ishida M, Sekizuka N, Sayama M.
Intermittent and continuous phototherapies were Baby massage ameliorates neonatal jaundice in full-term
found to be equally effective. Because of its additional newborn infants. Tohoku J Exp Med 2011; 22:97-102.
benefits intermittent phototherapy can be adopted as 9. Samra NM, El Taweel A, Cadwell K. The effect of kangaroo
a routine procedure instead of continuous photothera- mother care on the duration of phototherapy of infants
py in neonatal care unites, however it need to be con- re-admitted for neonatal jaundice. J Matern Fetal Neona-
firmed by large scale RCTs. tal Med 2012; 25:1354-7.

RECOMMENDATIONS 10. Szucs KA, Rosenman MB. Family-centered, evidence-based

phototherapy delivery. Pediatrics 2013; 131:1982-5. 
On the bases of our study results we strongly recom-
mend further such studies, to find some solution to the 11. Maisels MJ. Phototherapy. In: Maisels MJ, Watcho JF, edi-
increasing staff-patient difference, decrease the worries tors. Neonatal jaundice. Amsterdam: Harwood Academic;
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12. Maisels MJ, McDonagh AF. Phototherapy for neonatal
additional beneficial therapies like kangaroo mother
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