Comment
Sunlight phototherapy for neonatal jaundice—time for its
day in the sun?
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 colleagues1
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,1 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,2 then FSPT might not be a
good use of limited resources, despite the potentially
low costs of the treatment, which are unfortunately
www.thelancet.com/lancetgh Published online August 28, 2018 http://dx.doi.org/10.1016/S2214-109X(18)30396-6 1
not reported by Slusher and colleagues.1 Economic Lancet Glob Health 2018
evaluation is required to establish whether FSPT would Published Online
August 28, 2018
be worth including in cost-effective essential health http://dx.doi.org/10.1016/
packages in low-resource settings.3,4 S2214-109X(18)30396-6
See Online/Articles
Logistics, systems, and preferences also need to
http://dx.doi.org/10.1016/
be considered. The upgraded FSPT room with a S2214-109X(18)30373-5
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.6 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.6
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 hyper­
bilirubinaemia? Slusher and colleagues, citing other
studies in their discussion,1 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
 Comment
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.
*Tim Colbourn, Charles Mwansambo
UCL Institute for Global Health, University College London,
30 Guilford Street, London WC1N 1EH, UK (TC); and Ministry of
Health, Government of Malawi, Lilongwe, Malawi (CM)
t.colbourn@ucl.ac.uk
2 www.thelancet.com/lancetgh Published online August 28, 2018 http://dx.doi.org/10.1016/S2214-109X(18)30396-6
We declare no competing interests.
Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open
Access article under the CC BY 4.0 license.
1 Slusher 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)30373-5
2 Bhutta 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: 347–70.
3 WHO. Making choices in health: WHO guide to cost-effectiveness analysis.
Geneva: World Health Organisation, 2003.
4 Woods B, Revill P, Sculpher M, Claxton K. Country-level cost-effectiveness
thresholds: initial estimates and the need for further research. Value Health
2016; 19: 929–35.
5 Chi Luong K, Long Nguyen T, Huynh Thi DH, Carrara HP, Bergman NJ. Newly
born low birthweight infants stabilize better in skin-to-skin contact than
when separated from their mothers: a randomised controlled trial.
Acta Paediatr 2016; 105: 381–90.
6 WHO, UNICEF. Every newborn: an action plan to end preventable deaths.
Geneva: World Health Organization, 2014.