ORIGINALNiger J Paediatr 2018; 45 (2): 76 –80

Abdulkadir IAdebiyi NMAdeoye GOgala WN

An evaluation of phototherapyservices in newborn units inKaduna State Nigeria

Accepted: 21st March 2018

Abdulkadir IAdebiyi NM, Adeoye GOgala WNDepartment of Paediatrics,Ahmadu Bello UniversityTeaching Hospital, Zaria, KadunaState, NigeriaEmail: isaburamla@yahoo.com;isaabdulkadir@abu.edu.ng

( )

DOI:http://dx.doi.org/10.4314/njp.v45i2.1

Abstract: BackgroundPhototherapy (PT) for unconju-gated hyperbilirubinaemia re-mains an important and invaluableintervention in the management ofneonatal jaundice when appropri-ately and optimally employed.The efficiency of PT greatly de-pends on the irradiance of thedevice, which is measured usingan irradiance meter. Availableoptimal phototherapy is a keydesirable newborn service thatshould be offered and accessiblein secondary and tertiary healthcare facilities.Objective: The study aimed atdetermining the availability andirradiance measure of photother-apy devices in neonatal units inKaduna state, Northwestern Nige-ria.Materials and Methods: Thestudy was an action research sur-vey of all hospitals providingnewborn care in Kaduna stateincluding public and private profitand nonprofit faith based facili-ties. Phototherapy devices in usein the facilities were documented(types, brand and bulbs). The av-erage irradiance of PT device wasmeasured using model 22 Olym-pic Bili – MeterTM at facility tradi-tional PT distance and distance ofoptimal irradiance was also deter-mined and documented. Facilitieswere introduced to and educatedon protocols on neonatal jaundiceand how to ensure optimization ofirradiance and management ofneonatal jaundice.

Results: None of the 31 publicsecondary health care facilitiesoperated a newborn unit nor pro-vided management for neonataljaundice. Overall 15 facilities pro-vided PT services of which 87%were non-government facilitiesmade up of 15% faith based and85% private for profit facilities.Only 13.3% facilities had PT de-vices which offered irradiance (>10 µW/cm2/ nm) suitable for con-ventional PT at the facilities’ tradi-tional PT distance this however,increased to 7 (46.7%) facilitieswith adjusted distances. Only 3(20%) facilities had devices thatcould o ffe r intensive PT(irradiance > 30 µW/cm2/ nm) atvarying distances. None of thesurveyed facilities had a radiome-ter nor knew irradiance of their PTdevices and neither did any have awritten protocol for the manage-ment of neonatal jaundice. Exper-tise for and availability of ex-change blood transfusion (EBT)services was available only in26.7% of the facilities.Conclusions: Private health carefacilities constitute a major pro-vider of neonatal jaundice health-care services however the serviceswere grossly suboptimal and in-adequate and will need significantand urgent improvement to en-hance newborn health and indices.

Keywords: phototherapy, neonataljaundice, newborn care,kernicterus, action research

CC –BY

Introduction

Neonatal Jaundice, a common cause of newborn mor-bidity, occurs in about 60% and 80% of term and pre-term newborns respectively.1 The unconjugated typemay be associated with increased mortality particularlywhen severe, while survivors may have life-changingcomplications which are rampant in developing coun-

tries due to lack of timely recognition and access to in-tervention as compared to developed countries.1-3

Phototherapy (PT), a key component in the managementof unconjugated neonatal hyperbilirubinaemia, signifi-cantly reduces both the need for exchange blood transfu-sion (EBT) and neurologic complications of hyper-bilirubinaemia.4 -7 The efficiency of phototherapy is in-fluenced by several factors including the wavelength of

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the bulbs used, the distance of the light source from thenewborn and the surface area exposed to the light.5 Ar-guably, of more importance however, is the amount ofphoto-energy – the irradiance - produced by the photo-therapy device, which is a measure of the light energy atthe skin surface expressed as µW/cm2/ nm; the higherthe irradiance the more efficient the PT device.3, 7-9 TheAmerican Academy of Pediatrics recommends an irradi-ance of at least 30 µW/cm2/ nm for intensive photother-apy.7, 8 For conventional phototherapy, the limits are lesswell defined; generally, an irradiance of 8-10 µW/cm2/nm is thought to be effective.10, 11 Concerns have beenexpressed about translating measured irradiance to clini-cal efficacy; however, currently there are no practicalalternatives to measure efficiency of phototherapy otherthan measuring the irradiance of the PT device.12 Irradi-ance measurement, achieved using an irradiance meter,is a standard procedure in many centers in developedcountries.11, 13 Studies have shown wide variability in theirradiance levels of phototherapy devices between hospi-tals in developed countries.8, 10, 14, 15 Availability of ex-pensive medical equipment, such as a radiometer, inresource-constrained communities is limited because oflack of affordability and maintenance capability.12 It isconceivable therefore, that centers in such communitiesmay be offering inefficient PT services.

In an effort to contribute towards ending preventabledeaths of newborns and reducing neonatal mortality, oneof the targets of SGD3, we set out to conduct an actionresearch on phototherapy services in hospitals offeringneonatal care in Kaduna state, Northwestern Nigeriawith the aim to1. Document availability of phototherapy devices in

use in newborn care facilities in Kaduna state2. Document the irradiance of phototherapy devices in

newborn care facilities in Kaduna state

Method

The study was an action research cross sectional surveyof all hospitals providing newborn care in Kaduna stateincluding public nonprofit, private profit and faith basedfacilities. Government facilities providing secondary andtertiary health care were identified from the HMIS fromthe ministry of health while those offering neonatal ser-vices were subsequently identified by contact and phoneconversation. Private and faith based facilities wereidentified via contact and from the guild of private medi-cal practitioners. Each facility identified and included inthe research was visited and after properly securingclearance and permission from the appropriate authorityan interaction with the neonatal staff ensued using apredesigned proforma to document their neonatal jaun-dice services. The Ahmadu Bello University TeachingHospital Zaria (ABUTH), a federal tertiary health facil-ity with more than 30 intensive phototherapy devicesand from where the protocols were designed was ex-cluded from the survey to remove bias. Phototherapydevices in use in the facilities were identified and infor-

mation on brand of phototherapy, types and colour oftubes/ light source used, frequency and reason of replac-ing bulbs and distances at which phototherapy was beingconducted as well as the irradiance measure at the facil-ity standard distance and distance of best irradiancewere documented. Irradiance was measured using model22 Olympic Bili – MeterTM and phototherapy classifiedas conventional/ simple or intensive phototherapy. Unitswere also asked for guidelines for commencing and dis-continuation of phototherapy, when and whether or notexchange blood transfusion is conducted and by whom.Neonatal unit staff were then introduced to protocols forthe management of neonatal jaundice and were practi-cally walked through how to improve the efficiency oftheir PT devices and how to determine when to changedevice tubes particularly stressing the significance anduse of an irradiance meter. A stake holders meeting wasplanned through the state ministry of health to formerlypresent the findings of the survey and disseminate usefultools and information to improve and to standardize themanagement of neonatal jaundice in neonatal units inKaduna state.The study was approved by the health research ethicscommittee of the Kaduna state ministry of health.

Results

There were 31 secondary and 7 tertiary public nonprofithealth care facilities in Kaduna state. Twenty eight ofthe secondary facilities are state owned and are distrib-uted across the 23 local government area of the state.Three (3) of the 31 secondary health care facilities arefederal government owned and ran by institutions forstaff. One (14%) of the tertiary health care facilities isowned by the state government and ran by a tertiaryinstitution while the other 6 (86%) are federal ownedinstitutions. Three (50%) of the 6 federal owned tertiaryhealth care institutions are mono -specialty facilitieswhile the other 3 provided multi-specialty care includingpaediatric services out of which only 2 offered neonatalhealth care services. One of these 2 facilities was theABUTH which was excluded from subsequent analysis.A total of 15 non-government facilities made up of 13private for profit and 2 faith- based non-profit healthcare facilities providing neonatal health care serviceswere identified within the state. Two (2) private forprofit facilities declined consent and were excluded fromthe study

None of the 31 secondary health care facilities operateda newborn unit nor provided phototherapy and or man-agement for neonatal jaundice. Overall 15 facilities pro-vided Phototherapy services of which 13/ 15 (87%) werenon-government facilities made up of 2/13 (15%) faithbased and 11/13 (85%) private for profit facilities. Theonly state owned tertiary institution operated a neonatalunit and offered neonatal jaundice management services.None of the surveyed facilities had a radiometer norknew irradiance of their PT devices and neither did anyhave a written protocol for the management of neonatal

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jaundice. All facilities except 2 will change their PTdevice’s bulbs only when the tubes became dim or nolonger lit or after 2 years, while the 2 exceptions, whichwere private for profit, changed tubes after 2000 – 3000hours. The decision to commence or discontinue photo-therapy was largely on visual assessment of jaundice in6 (40%) of the facilities while in the remaining facilitiesvarying levels of serum bilirubin (SB) ranging from 6 to15 mg/dl was considered starting levels; 3 of the facili-ties will commence phototherapy at SB of < 10 mg/dl,4will commence at 10- 14 mg/dl while only in 1 facilitywill phototherapy be commenced at SB ≥15 mg/dl. Inone of the facilities commencement of PT was based onSerum bilirubin levels and age in days. None of the fa-cilities discontinued PT at SB ≥15 mg/dl, 2 will discon-tinue at SB 10- 14 mg/dl while 5 of the facilities discon-tinued PT only when SB was < 10 mg/dl.Expertise for and availability of exchange blood transfu-sion (EBT) services were available only in 4/ 15 (27%)of the facilities made up of 3 (75%) private for profitand the state owned tertiary facility

A total of 54 PT devices were studied. Eight (15%) ofthe PT devices were located in the 2 government tertiaryfacilities while the remaining 30 (56%) and 16 (29%)were located in the private and faith based facilities re-spectively. The highest number of PT devices found inany single facility was (14) in a faith based facility.Only 6 (11%) of the PT devices used special blue lights(light source with intense energy and narrow blue spec-trum wavelength in the range 450- 470 nm) while ma-jority of the devices 43 (80%) used ordinary blue and 5(9%) devices used white light. All the PT devices usedfluorescent tubes. Twenty two (41%) of the PT deviceswere commercially sourced branded devices while themajority (59%) were varyingly fabricated devices withno two facilities having a similar fabricated device. Allthe (8) PT devices in the 2 government facilities werebranded devices accounting for 36% (8/22) of the com-mercial devices. Only 2 (13.3%) facilities had PT de-vices which offered irradiance (> 10 µW/cm2/ nm) suit-able for conventional phototherapy at the facilities’ tra-ditional PT distance this however, increased to 7(46.7%) facilities with varying PT distances up to aminimum of 10 cm to obtain best irradiance. Only 3(20%) facilities had devices that could offer intensivephototherapy (irradiance > 30 µW/cm2/ nm) at varyingdistances. (Table 1)

Facility Irradiance attraditionaldistance(µW/cm2/ nm)

traditionaldistance of photo-therapy (cm)

Maximumattainableirradiance(µW/cm2/nm)

Distance atMaximumirradiance(cm)

F1 5.1 55 11.1 35F2 2.7 50 8.8 10F3 3.3 50 11.5 10F4 - - - -F5 3.2 55 6.2 10F6 13.6 50 32.9 25F7 5.7 45 11 10F8 3.1 47 4.6 10F9 5.1 50 6 10F10 3.8 55 8.4 10F11 1.6 40 2.3 10F12 9.4 75 34.5 25F13 33 25 40 10F14 9.7 40 10.5 10F15 6 45 26.1 25

Table 1: The irradiance of Phototherapy devices at traditionaldistance for phototherapy

Discussion

Newborn jaundice healthcare services were providedmainly (85% PT, 75% EBT) by non-government facili-ties in Kaduna state as documented in the study. Thisestablishes an important role being played by privatehealth facilities in the provision of specialized neonatalcare, a key step towards reducing neonatal and under-five mortality in the state and the country at large. It wasdifficult however, to identify which facilities providednewborn services from the HIMS in the state ministry.This suggests a gap that may make partnership and su-pervision to improve efficiency of specialized newborncare suboptimal. The fact that none of the governmentsecondary health care facilities offer neonatal jaundicehealthcare services also implies that services are possi-bly insufficiently available to the large number of new-borns that may develop jaundice and require care andthus leaves them with the alternative to explore and pa-tronize other unorthodox and perhaps even harmful care.

The provision of services across facilities in the surveywhere quite varied. While none of the facilities had awritten protocol for management of neonatal jaundice,practice varied remarkably. As many as 40% of the sur-veyed facilities will commence phototherapy with vis-ual/ clinical jaundice, a highly subjective method of as-sessment of level or severity of jaundice which may leadto inappropriate and inefficient management of jaundiceas it may lead to under or over treatment of jaundice.This becomes even more worrisome when this finding iscompared with the efficiency of the units being used tooffer intensive phototherapy; where there is need to ur-gently bring down the level of serum bilirubin such thata baby subjectively assessed to have jaundice thoughhigh enough is exposed to a not optimal treatment. Italso makes communication and research difficult aspractice cannot be compared as no standards are beingfollowed and as such efficiency of interventions in thestate and across centres cannot be reliably studied.Overall, protocols provide minimum standard guides forcare and, with respect to neonatal jaundice, will guide

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providers in the entire management of newborns withjaundice but more so define who receives intensivePT.Availability of EBT services was found in only 27%of the facilities ¾ of which were private for profit whichsuggests a dearth of facilities providing such servicesand may at the same time mean increase work burdenfor the few facilities providing this service with a ten-dency to inefficiency. All these will negatively impacton the desired target of reducing neonatal mortality amajor target of the SDG3.

Eighty five percent of the facilities which provided pho-totherapy services were non-government facilities andfabricated PT devices were commonly used possiblybecause they were cheaper, more affordable and avail-able in comparison to the branded devices which werelikely to be more expensive and unavailable. The use oflocal fabricated devices though encouraging as it en-sured availability, however, did not, like the branded,guarantee efficient phototherapy. Overall majority(86.7%) of the phototherapy devices studied at the facil-ity traditional PT distance provided irradiance of < 10µW/cm2/ nm which is sub optimal. A similar study inNetherland found 50% of the devices studied below thisthreshold.17. The low suboptimal irradiance in this studyis attributable to the protocol for the use and features ofthe PT devices. These include not measuring or knowingthe irradiance of devices before commencement of pho-totherapy and lack of satisfactory irradiance for simplephototherapy from the devices even after assessment ofthe devices. The latter resulting from use of inappropri-ate bulbs (ordinary blue as against the special blue tubes,few tubes and poorly lighting/ expired tubes) and use ofdevices at a distance which gave poor irradiance.Though in a few of the devices some improvement wasmade by varying the distance, in others this could not bedone either because the devices were fixed or could notbe further adjusted due to design. For some of the de-vices which had improved irradiance suitable for simplePT (≥10 µW/cm2/ nm) after distance adjustment, theeffective irradiance distance (10 cm) was found notclinically suitable for phototherapy as the device becametoo close to the neonate and increased the risk of hyper-thermia with its sequelae of increased insensible lossand dehydration as well as physical injury includingburns.

Only 20% of the studied facilities and all of which wereprivate for profit could provide intensive phototherapywhich helps to reduce the rate of EBT. Owa and col-leagues2 in their study of 12 neonatal centres in South-western Nigeria found none able to provide intensivephototherapy. Similarly the expertise for and availabilityof EBT services were available only in 4/ 15 (27%) ofthe facilities made up of 3 private for profit and a stateowned tertiary facility. These imply that neonates withsevere jaundice who require intensive PT or EBT with

PT have 0% chance of having Intensive PT and a 25%chance of having EBT with PT in a public facility.Overall these findings suggest a great limitation in pro-vision of services for the management of severe neonataljaundice and neonates with this condition are unlikely toaccess the required intervention and therefore highly atrisk of bilirubin encephalopathy.None of the facilities had an irradiance meter a simpletool to measure the irradiance of devices. Availability ofsuch tool will empower facilities to evaluate their de-vices and take appropriate measures to improve and at-tain the desired irradiance for optimal PT.

Conclusion

Private health care facilities constitute a major providerof neonatal jaundice healthcare services which may con-stitute a limitation to accessibility and affordability inview of their profit orientation. Overall, however, theservices including protocol availability, phototherapyand EBT were grossly suboptimal and inadequate andwill need significant and urgent improvement to enhancenewborn health and indices and as well guarantee a posi-tive march towards attainment of SDG3.

Recommendation

We recommend that the SMOH should update and gen-erate a comprehensive documentation of all healthcarefacilities (government and non-government) that providedifferent specialized newborn health care in the state.The ministry should lead and improve partnership withprivate health facilities providing newborn care with anaim to support, standardize and improve neonatal jaun-dice care services. This should include focus on improv-ing efficiency of locally fabricated PT devices and pro-vision of protocols and guidelines for management ofneonatal jaundice.

Funding: NoneConflict of interest: None

Acknowledgement

We are highly indebted to Prof. Tina of the MinnesotaUniversity USA for her numerous advice and Dr Bhut-tawa of the Kaduna State Ministry of health for his sup-port.

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