Treatment of Neonatal Jaundice With Filtered Sunlight Phototherapy: Safety and Efficacy in African Neonates

The primary objective of this study is to determine the safety and efficacy of filtered sunlight phototherapy. Sunlight will be filtered by flexible (window-tinting) film. The subject population will be neonates born at Island Maternity Hospital, Lagos, Nigeria. The rationale for conducting the study is that in Nigeria, and other countries that may not have effective commercial light devices or have reliable access to electric power to operate them, filtered sunlight phototherapy might offer a safe and effective treatment for neonatal jaundice. Phase I of the study focused on the safety and efficacy of filtered sunlight phototherapy. Phase II of the study was a randomized controlled non-inferiority clinical trial comparing the efficacy of filtered sunlight phototherapy with conventional phototherapy.

Study Overview

• Status: Completed
• Conditions: Jaundice, Neonatal
• Intervention / Treatment: Device: Filtered-sunlight phototherapy; Device: Conventional phototherapy

Detailed Description

Numerous studies from resource-limited countries suggest that severe neonatal jaundice (NNJ) represents the largest unrecognized cause of neonatal morbidity and mortality in the world. Several studies from Africa rank jaundice as a leading cause of death in newborn nurseries. In Nigeria, Owa and Osinaike reported that jaundice (14%) was the second leading cause of death, while Ugwu et al, found that mortality from severe jaundice was comparable to birth asphyxia but greater than sepsis in neonates >24 hrs old to 7 days old. In Kenya, English et al reported NNJ as the third leading cause of both newborn admissions and deaths. Studies from Nigeria, Zimbabwe, Turkey, North Vietnam, Oman, and India listed acute bilirubin encephalopathy (ABE) and/or severe NNJ as a significant cause of morbidity, many of whom required exchange blood transfusion (EBT) in their nurseries. Unfortunately, phototherapy, as important as it is, may not be available to many infants with NNJ in these countries because of the lack of devices and/or of unreliable electrical power supply. Commercial phototherapy (PT) devices are expensive, often break down due to surges in electrical power, and are difficult to maintain due to unavailability of spare parts. Even where PT devices are available, most hospitals in these countries lack the resources to replace the fluorescent light bulbs at the recommended 2000-3000 hrs of use and simply leave ineffective tubes in place until they burn out. Moreover, very few hospitals have appropriate irradiance meters for monitoring the intensity of the blue light emitted by the lamps. In a recent study in Nigeria by Owa et al, none of the tested PT devices provided the level of irradiance required for intensive PT.

Often, the only treatment a healthcare provider can suggest to the parents/guardians of jaundiced infants is to place their babies in sunlight. However, this practice is unsuitable due to several safety concerns. For instance, exposure to ultraviolet (UV) light may cause sunburn, while infrared (IR) light may cause the body to overheat. Moreover, the infant may lose body heat from the uncovered skin during treatment, with potential for dehydration. A safer, yet practical and economical, solution is needed, providing the basis for our proposal of filtered sunlight PT.

The primary aims of this study were safety, efficacy and non-inferiority of filtered sunlight phototherapy compared to conventional phototherapy. Phase I of the study focused on the safety and efficacy of filtered sunlight phototherapy. Phase II focused on non-inferiority of efficacy as compared to conventional phototherapy while continuing to evaluate safety.

• Study Type: Interventional
• Enrollment (Actual): 447
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Nigeria
  • Lagos, Nigeria
    • Island Maternity Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: No older than 1 year (Child)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

Subjects will be eligible to participate in the study if all of the following conditions exist:

1. At time of birth, infant is > 35 weeks gestation (or > 2.2 kg if gestational age is not available
2. Infant is < 14 days old at the time of enrollment
3. At time of enrollment, infant has an elevated TcB defined as 3 mg/dL below the level recommended for high-risk infants per AAP guidelines or higher
4. Parent or guardian has given consent for the infant to participate

Exclusion Criteria:

Subjects will be excluded from participation in the study if any of the following conditions exist at the time of enrollment:

1. Infants with a condition requiring referral for treatment not available at the hospital study site and/or conventional phototherapy unit.
2. Infants with a life-expectancy of < 24 hours
3. Infants requiring oxygen therapy
4. Infants clinically dehydrated or sunburned
5. Infants with a temperature < 35.5 or > 38 degrees Centigrade
6. Infants with ABE on clinical exam
7. Infants meeting the criteria for EBT

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Filtered-sunlight phototherapy; Infants will receive six hours per day of filtered-sunlight phototherapy for 1 to 10 days. The filtering will be done using window tinting film. Window tinting films by Solutia, Inc., and V-KOOL, Inc.	Device: Filtered-sunlight phototherapy; Infants will receive six hours per day of filtered-sunlight phototherapy for 1 to 10 days. The filtering will be done using window tinting film. Window tinting films by Solutia, Inc., and V-KOOL, Inc.
Active Comparator: Conventional phototherapy; Infants will receive six hours per day of conventional phototherapy for 1 to 10 days.	Device: Conventional phototherapy; Infants will receive six hours per day of conventional phototherapy for 1 to 10 days.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Safety of Phototherapy	For a given treatment day, the phototherapy treatment was deemed safe if that infant on that day did not have to be withdrawn from treatment due to hypo- or hyperthermia, sunburn or dehydration. Therefore safety is reported as a percentage of the total treatment days (i.e. number of safe treatment days divided by total number of treatment days).	Four to ten days
Efficacy of Phototherapy	For a given evaluable treatment day, the phototherapy treatment was deemed effective if that infant on that day had a decrease in serum bilirubin level or (if <72hrs old) an rate of increase of less than 0.2 mg/dL/h. Therefore efficacy is reported as a percentage of the evaluable treatment days (i.e. number of effective evaluable treatment days divided by total number of evaluable treatment days).	Four to ten days

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of Participants Requiring Exchange Blood Transfusion	Exchange blood transfusion required to lower the bilirubin level. Serum bilirubin will be measured twice daily during filtered sunlight or conventional phototherapy exposure, for an expected average of four days, and a maximum of ten days.	Four to ten days

Collaborators and Investigators

• Sponsor: University of Minnesota
• Collaborators: Thrasher Research Fund
• Investigators: Principal Investigator: Tina M Slusher, MD, University of Minnesota

Publications and helpful links

General Publications

• Slusher TM, Olusanya BO, Vreman HJ, Brearley AM, Vaucher YE, Lund TC, Wong RJ, Emokpae AA, Stevenson DK. A Randomized Trial of Phototherapy with Filtered Sunlight in African Neonates. N Engl J Med. 2015 Sep 17;373(12):1115-24. doi: 10.1056/NEJMoa1501074.
• Slusher TM, Olusanya BO, Vreman HJ, Wong RJ, Brearley AM, Vaucher YE, Stevenson DK. Treatment of neonatal jaundice with filtered sunlight in Nigerian neonates: study protocol of a non-inferiority, randomized controlled trial. Trials. 2013 Dec 28;14:446. doi: 10.1186/1745-6215-14-446.

Study record dates

Study Major Dates

• Study Start: November 1, 2011
• Primary Completion (Actual): September 1, 2013
• Study Completion (Actual): September 1, 2013

Study Registration Dates

• First Submitted: August 30, 2011
• First Submitted That Met QC Criteria: September 14, 2011
• First Posted (Estimate): September 15, 2011

Study Record Updates

• Last Update Posted (Actual): February 5, 2019
• Last Update Submitted That Met QC Criteria: January 31, 2019
• Last Verified: January 1, 2019

More Information

Terms related to this study

• Keywords: Hyperbilirubinemia, Neonatal
• Additional Relevant MeSH Terms: Pathologic Processes; Infant, Newborn, Diseases; Skin Manifestations; Hyperbilirubinemia; Hyperbilirubinemia, Neonatal; Jaundice; Jaundice, Neonatal
• Other Study ID Numbers: 1108M03601

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No