Double versus Single Phototherapy in Term Newborns with

Significant Hyperbilirubinemia
by S. Ümit Sarici, Faruk Alpay, Bülent Ünay, Okan Özcan, and Erdal Gökçay
Department of Pediatrics, Gülhane Military Medical Academy, Ankara, Turkey

Summary
The efficacy of double phototherapy, in the form of conventional phototherapy with special blue light
plus fiberoptic phototherapy, was compared with conventional phototherapy consisting of special
blue lamps alone in a relatively larger series of term newborns with significant hyperbilirubinemia.
During the study period the sum of the average spectral irradiances in the double phototherapy
group was significantly higher than that of the single phototherapy group ( p < 0:05). Phototherapy
was effective in decreasing bilirubin levels in both groups, but the response was greater in the double
phototherapy group; the duration of exposure to phototherapy was significantly shorter (31:2 6 8:5
vs. 38:98 6 14:7 h, p < 0:05), and the overall bilirubin decline rate as mmol/l/h and per cent/h was
significantly greater in the double phototherapy group (4:1 6 1:37 vs. 3:3 6 0:86 mmol/l/h, and
1:29 6 0:38 vs. 1:02 6 0:44 per cent/h, p < 0:05). In phototherapy treatment of term newborns with
significant hyperbilirubinemia, double phototherapy provided more rapid and effective bilirubin
reduction than conventional phototherapy alone due to higher spectral irradiance and larger body
surface area exposed to phototherapy. The value of double phototherapy in the treatment of
newborns with hemolytic hyperbilirubinemia remains to be determined.

Introduction studies with relatively small numbers of preterm infants

Although phototherapy has been in clinical practice for
40 years, there is still much debate about how the most
efficacious phototherapy application can be provided. In
the past a clear dose–response relationship between the
light dose (average spectral irradiance) provided by the
phototherapy and the response of decrease in serum
bilirubin concentration, and the need of a spectral
irradiance at doses of 40 mW/cm2 /nm or higher to
reach saturation level were demonstrated.1;2 Although
which part of the newborn body is more sensitive to
light than another has not been shown yet, it has been
recommended that the effectiveness of a phototherapy
system must be determined with average spectral
power, which can be defined as the product of the
skin surface area irradiated and the average irradiance
across this surface area.3 In order to increase average
spectral power, not only the distance between the lamp
and the patient was minimized,4;5 but the impractical
double-surface systems were also used.1;4;6¹9
With the advent of fiberoptic phototherapy, double
phototherapy by administering conventional photother-
apy from above the infant, while the infant lies on a
fiberoptic phototherapy pad has made it possible to
increase average spectral power practically, and recent
Correspondence: S. Ümit Sarici, Department of Pediatrics,
Gülhane Military Medical Academy, 06018 Etlik, Ankara,
Turkey. Tel. 90 312 321 20 63 Fax 90 312 321 77 78 E-mail
<cocuksag@gata.edu.tr>.
have demonstrated more satisfactory reduction in serum
bilirubin levels when compared to conventional photo-
therapy.10¹12 In two studies comparing the efficacy of
the two forms of single phototherapy in term newborns,
i.e., fiberoptic phototherapy and conventional photo-
therapy, the latter was reported to be more effective.12;13
In the only study comparing double phototherapy with
conventional phototherapy in term newborns, bilirubin
levels were, however, not so significantly high, and
double phototherapy was compared with conventional
daylight phototherapy and fiberoptic phototherapy, but
not with conventional special blue light phototherapy.12
In this study the efficacy of double phototherapy, in
the form of conventional phototherapy with special
blue light plus fiberoptic phototherapy, was compared
with single conventional phototherapy consisting of
special blue lamps in a relatively larger series of term
newborns with more significant hyperbilirubinemia than
in previous studies.
Materials and Methods
This study was performed at the Department of
Pediatrics of Gülhane Military Academy. The study
was approved by the local ethics committee, and written
informed consent was obtained from the parents before
entry into the study. Healthy term newborns with
birthweights of more than 2500 g and non-hemolytic
indirect hyperbilirubinemia, with normal hemogram, no
evidence of blood group isoimmunization, negative

36 q Oxford University Press 2000 Journal of Tropical Pediatrics Vol. 46 February 2000
S. ÜMIT ET AL.
result of a direct Coombs test, and normal reticulocyte
count, were eligible for inclusion. Patients with any
congenital malformations, direct hyperbilirubinemia,
enclosed hemorrhage, or infection were not enrolled
into the study. Gestational ages of the newborns were
determined according to the maternal history and Ballard
scoring system.14 Phototherapy was initiated at serum
bilirubin levels of $255 mmol/l.
A total of 111 newborns were allocated sequentially to
receive either double phototherapy or single photother-
apy. Newborns in the single phototherapy group received
conventional phototherapy alone. Conventional photo-
therapy was administered by using a standard photo-
therapy unit (Ohio Medical Products, Airco Inc, WIS,
USA) consisting of five special blue lamps (Philips F20
T 12/BB) and placed 30 cm above the newborn. New-
borns in the double phototherapy group received
conventional phototherapy as described above, and
simultaneously lay on a fiberoptic phototherapy pad
(Wallaby II Phototherapy System, Fiberoptic Medical
Products, Inc, Allentown, PA, USA). In this system light
from a tungsten-halogen lamp is transmitted via
fiberoptic bundles to a fiberoptic pad which is in direct
contact with the skin during phototherapy and provides
an illumination area of 7:6 × 35:5 cm.
The newborns in both groups wore eye patches and
disposable diapers folded to allow maximum skin
exposure to phototherapy. Phototherapy was adminis-
tered continuously except for minor procedures such as
feeding, physical examination and taking capillary blood
samples. Attending neonatologists adjusted the volume
of oral formula milk intake according to clinical status
and bodyweight loss associated with phototherapy.
Newborns were closely monitored for possible side-
effects of phototherapy including changes in skin color,
body temperature and weight, and gastrointestinal
system functions.
Failure of phototherapy was defined as continued
increase in bilirubin concentration on two consecutive
determinations beyond the starting bilirubin value. The
efficacy of phototherapy was assessed by the duration of
phototherapy (h), and the overall decrease in bilirubin
concentration related to the total exposure time and
expressed as a proportionate decrease per hour (mmol/l
decline/h and per cent decline/h).
Clinical and laboratory data of study groups
Double phototherapy
Male to female ratio
Gestational age (weeks)
Birthweight (g)
Age phototherapy initiated (h)
Bilirubin (mmol/l)
Hematocrit (%)
Values are given as mean 6 SD.
Journal of Tropical Pediatrics Vol. 46 February 2000
Total serum bilirubin levels at the study entry and
during the study were measured in capillary blood
samples every 6–8 h by direct spectrophotometry
(Bilirubin Analyzer Bil Micro Meter Erma Kohsoku
Denki Co., Tokyo, Japan). Direct bilirubin measurement,
direct Coombs test, blood group typing, reticulocyte
count, and complete blood count with peripheral smear
were performed at entry into the study.
Phototherapy was terminated when total serum
bilirubin levels had declined to < 205 mmol/l, and
newborns were monitored at least for 24 h to determine
if rebound would occur.
The spectral irradiance of light emitted during
fiberoptic phototherapy was measured with Joey
Dosimeter JD-101 (Fiberoptic Medical Products, Inc,
Allentown, PA, USA) sensitive to wavelengths of 400–
550 nm, and that of the conventional phototherapy
system was measured with a standard radiometer
(Minolta/Air Shields Vickers Fluoro-Lite Meter 451)
sensitive to wavelengths of 400–520 nm. By making
serial measurements at the skin surface level of new-
borns during the study, the average spectral irradiances
were determined for each phototherapy system in the
study groups.
The data were statistically evaluated with the
Student’s t-test.
Results
After entry into and during the study, four newborns in
the double phototherapy group and seven newborns in
the conventional phototherapy group were excluded
from the study as they were determined to be not eligible
for the study due to various diagnoses, such as
hypocalcemia, intestinal atresia, and infection or sepsis.
There were no significant differences between the
double phototherapy and single phototherapy groups
with respect to factors that may influence the efficacy of
phototherapy such as gestational age, birthweight,
postnatal age, and bilirubin and hematocrit values at
the start of treatment (Table 1).
During the study one newborn in the double photo-
therapy group, and two newborns in the single photo-
therapy group had transient erythema, and two newborns
in each group had mild watery defecation not leading to
TABLE 1
Single phototherapy
(n ¼ 50) (n ¼ 50) p
28/22 26/24 > 0:05
38:8 6 0:8 39:4 6 0:5 > 0:05
3310 6 410 3390 6 380 > 0:05
102:9 6 59:4 102:9 6 34:3 > 0:05
319:8 6 54:7 312:9 6 41:0 > 0:05
54:4 6 4:3 55:1 6 3:9 > 0:05
37

TABLE 2
Responses of groups to phototherapy
Double phototherapy
Duration of phototherapy (h)
Overall decline rate of bilirubin (mmol/l/h)
Overall decline rate of bilirubin (%/h)
Post-treatment bilirubin (mmol/l)
Values are given as mean 6 SD.
dehydration. No serious complications or side-effects
were observed during the study.
No phototherapy failure was observed during treat-
ment in any of the study groups. Phototherapy was
effective in decreasing bilirubin levels in both groups,
but the response was greater in the double phototherapy
group. The duration of exposure to phototherapy was
significantly shorter ( p < 0:05), and the overall bilirubin
decline rate (mmol/l/h and per cent/h) was significantly
greater in the double phototherapy group ( p < 0:05;
Table 2).
After terminating the phototherapy, two newborns
in the double phototherapy group and three newborns in
the single phototherapy group had rebound bilirubin
values exceeding the pretreatment values, and these
babies required a second phototherapy exposure. This
difference was not statistically significant ( p > 0:05).
During the study period the average spectral
irradiances in the double phototherapy group were
18:7 6 0:9 and 9:8 6 0:8 mW/cm2 /nm for the conven-
tional phototherapy unit and the fiberoptic phototherapy
system, respectively. The average spectral irradiance of
the conventional phototherapy unit in the single photo-
therapy group was 18:4 6 1:0 mW/cm2 /nm. The differ-
ence between the average spectral irradiances of the two
conventional phototherapy units in the double photo-
therapy and single phototherapy groups was not
statistically significant ( p > 0:05). However, the sum of
the irradiances in the double phototherapy group
(conventional unit plus fiberoptic phototherapy system)
was significantly higher than that of the single photo-
therapy group (conventional unit alone) ( p < 0:05).
Discussion
In studies comparing the efficacy of fiberoptic and
conventional phototherapies in preterm babies, fiberoptic
phototherapy was reported to be as efficacious as
conventional phototherapy.15;16 Since it is possible and
practical to irradiate the baby’s front and back
simultaneously by administering conventional photo-
therapy from above the infant while the infant lies on a
fiberoptic phototherapy pad, fiberoptic phototherapy has
been used as a component of the combination (double)
phototherapy in preterm babies, and greater efficacy has
been reported with double phototherapy.10;11 The
efficacy of double phototherapy in these two studies
38
S. ÜMIT ET AL.
Single phototherapy p
31:20 6 8:5 38:98 6 14:7 > 0:05
4:1 6 1:37 3:3 6 0:86 > 0:05
1:29 6 0:38 1:02 6 0:44 > 0:05
191:5 6 13:7 188:1 6 15:4 > 0:05
was reported to be due to larger surface area exposed to
phototherapy. Tan12 found double phototherapy very
efficacious in preterm babies, and claimed that this
resulted from the skin properties of preterm babies.
Tan2 demonstrated that the maximum average spectral
irradiance level required to eliminate bilirubin effec-
tively by reaching a saturation point occurred at doses of
40 mW/cm2 /nm or higher. Although the total average
spectral irradiance of 28.5 mW/cm2 /nm in our double
phototherapy group was below that level, we obtained a
satisfactory and safe bilirubin reduction in a given time
period. As the average spectral irradiances of conven-
tional phototherapy units in the double phototherapy and
single phototherapy groups did not significantly differ
from each other, the significantly higher total irradiance
level in the double phototherapy group was provided
with the contribution of irradiance of fiberoptic photo-
therapy system. The greater efficacy of phototherapy in
this group was due to increases in both average spectral
irradiance and body surface area exposed to photo-
therapy. As the average spectral power increased
consequently, it must have provided effective bilirubin
elimination by causing much more lumirubin
production.17
The bilirubin decline with a mean rate of 1.29 per cent/
h in 31.2 h in our double phototherapy group is
seemingly more efficient than that of Tan’s study.
Tan12 reported a mean decline rate of 0.97 per cent/h in
46.4 h with a total irradiance of 25.74 mW/cm2 /nm in
term babies, and stated that double phototherapy in the
combination of conventional phototherapy plus fiber-
optic phototherapy in term babies was not as efficacious
as it was in preterm babies.
There was no phototherapy failure in this study. It may
be due to both the non-hemolytic nature of the
hyperbilirubinemia of our patients and the greater
efficacy of the special blue lamps used in this study as
emphasized previously.18¹20
We observed no acute and severe side-effects, or
complications during double-sided phototherapy with
high irradiance in our study. Granati et al.4 investigated
whether high-dose phototherapy given to newborns
during neonatal period would cause any long-term
negative effects on visual functions, hearing, growth
and neurological developments of patients at 6 years of
age, and reported no difference between the patients
receiving high-dose phototherapy and the control group
Journal of Tropical Pediatrics Vol. 46 February 2000
S. ÜMIT ET AL.
receiving no phototherapy. The fact that double photo-
therapy with a high dose, has no acute or long-term side-
effects or complications renders double phototherapy
safe as well as effective.
In phototherapy treatment of a relatively larger series
of term newborns with more significant hyperbilirubi-
nemia than in the previous studies, we showed that
double phototherapy (i.e., combination of fiberoptic
phototherapy plus conventional phototherapy with
special blue light) provided more rapid and effective
bilirubin reduction than conventional phototherapy
alone, due to higher spectral irradiance and a larger
body surface area exposed to phototherapy. The value of
double phototherapy in the treatment of newborns with
hemolytic hyperbilirubinemia remains to be determined.
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39