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Nigerian J Paediatrics 2018 vol 45 issue 2

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An evaluation of phototherapy services in newborn units in Kaduna State
Niger J Paediatr 2018; 45 (2): 76 – 80
ORIGINAL
Abdulkadir I
CC – BY An evaluation of phototherapy
Adebiyi NM
Adeoye G
services in newborn units in
Ogala WN
Kaduna State Nigeria
DOI:http://dx.doi.org/10.4314/njp.v45i2.1
Accepted: 21st March 2018
Abstract : Background
Results: None of the 31 public
Phototherapy (PT) for unconju-
secondary health care facilities
Abdulkadir I (
)
gated
hyperbilirubinaemia
re-
operated a newborn unit nor pro-
Adebiyi NM, Adeoye G
mains an important and invaluable
vided management for neonatal
Ogala WN
intervention in the management of
jaundice. Overall 15 facilities pro-
Department of Paediatrics,
neonatal jaundice when appropri-
vided PT services of which 87%
Ahmadu Bello University
ately and optimally employed.
were non-government facilities
Teaching Hospital, Zaria, Kaduna
The efficiency of PT greatly de-
made up of 15% faith based and
State, Nigeria
pends on the irradiance of the
85% private for profit facilities.
Email: isaburamla@yahoo.com;
device, which is measured using
Only 13.3% facilities had PT de-
isaabdulkadir@abu.edu.ng
an irradiance meter. Available
vices which offered irradiance (>
optimal phototherapy is a key
10 µW/cm 2 / nm) suitable for con-
desirable newborn service that
ventional PT at the facilities’ tradi-
should be offered and accessible
tional PT distance this however,
in secondary and tertiary health
increased to 7 (46.7%) facilities
care facilities.
with adjusted distances. Only 3
Objective: The study aimed at
(20%) facilities had devices that
determining the availability and
could
offer
intensive
PT
(irradiance > 30 µW/cm / nm) at
2
irradiance measure of photother-
apy devices in neonatal units in
varying distances. None of the
Kaduna state, Northwestern Nige-
surveyed facilities had a radiome-
ria.
ter nor knew irradiance of their PT
Materials and Methods: The
devices and neither did any have a
study was an action research sur-
written protocol for the manage-
vey of all hospitals providing
ment of neonatal jaundice. Exper-
newborn care in Kaduna state
tise for and availability of ex-
including public and private profit
change blood transfusion (EBT)
and nonprofit faith based facili-
services was available only in
ties. Phototherapy devices in use
26.7% of the facilities.
in the facilities were documented
Conclusions: Private health care
(types, brand and bulbs). The av-
facilities constitute a major pro-
erage irradiance of PT device was
vider of neonatal jaundice health-
measured using model 22 Olym-
care services however the services
pic Bili – Meter
TM
at facility tradi-
were grossly suboptimal and in-
tional PT distance and distance of
adequate and will need significant
optimal irradiance was also deter-
and urgent improvement to en-
mined and documented. Facilities
hance newborn health and indices.
were introduced to and educated
on protocols on neonatal jaundice
Keywords : phototherapy, neonatal
and how to ensure optimization of
jaundice, newborn care,
irradiance and management of
kernicterus, action research
neonatal jaundice.
Introduction
tries due to lack of timely recognition and access to in-
tervention as compared to developed countries.
1-3
Neonatal Jaundice, a common cause of newborn mor-
Phototherapy (PT), a key component in the management
bidity, occurs in about 60% and 80% of term and pre-
of unconjugated neonatal hyperbilirubinaemia, signifi-
term newborns respectively. The unconjugated type
1
cantly reduces both the need for exchange blood transfu-
may be associated with increased mortality particularly
sion (EBT) and neurologic complications of hyper-
bilirubinaemia.
4 -7
when severe, while survivors may have life-changing
The efficiency of phototherapy is in-
complications which are rampant in developing coun-
fluenced by several factors including the wavelength of
77
the bulbs used, the distance of the light source from the
mation on brand of phototherapy, types and colour of
newborn and the surface area exposed to the light. Ar-
5
tubes/ light source used, frequency and reason of replac-
guably, of more importance however, is the amount of
ing bulbs and distances at which phototherapy was being
photo-energy – the irradiance - produced by the photo-
conducted as well as the irradiance measure at the facil-
therapy device, which is a measure of the light energy at
ity standard distance and distance of best irradiance
the skin surface expressed as µW/cm / nm; the higher
2
were documented. Irradiance was measured using model
The
22 Olympic Bili – Meter
TM
the irradiance the more efficient the PT device.
3, 7-9
and phototherapy classified
American Academy of Pediatrics recommends an irradi-
as conventional/ simple or intensive phototherapy. Units
ance of at least 30 µW/cm / nm for intensive photother-
2
were also asked for guidelines for commencing and dis-
apy.
7, 8
For conventional phototherapy, the limits are less
continuation of phototherapy, when and whether or not
well defined; generally, an irradiance of 8-10 µW/cm /
2
exchange blood transfusion is conducted and by whom.
nm is thought to be effective.
10, 11
Concerns have been
Neonatal unit staff were then introduced to protocols for
expressed about translating measured irradiance to clini-
the management of neonatal jaundice and were practi-
cal efficacy; however, currently there are no practical
cally walked through how to improve the efficiency of
alternatives to measure efficiency of phototherapy other
their PT devices and how to determine when to change
than measuring the irradiance of the PT device. Irradi-
12
device tubes particularly stressing the significance and
ance measurement, achieved using an irradiance meter,
use of an irradiance meter. A stake holders meeting was
is a standard procedure in many centers in developed
planned through the state ministry of health to formerly
countries.
11, 13
Studies have shown wide variability in the
present the findings of the survey and disseminate useful
irradiance levels of phototherapy devices between hospi-
tools and information to improve and to standardize the
tals in developed countries.
8, 10, 14, 15
Availability of ex-
management of neonatal jaundice in neonatal units in
pensive medical equipment, such as a radiometer, in
Kaduna state.
resource-constrained communities is limited because of
The study was approved by the health research ethics
lack of affordability and maintenance capability.
12
It is
committee of the Kaduna state ministry of health.
conceivable therefore, that centers in such communities
may be offering inefficient PT services.
In an effort to contribute towards ending preventable
Results
deaths of newborns and reducing neonatal mortality, one
of the targets of SGD 3 , we set out to conduct an action
There were 31 secondary and 7 tertiary public nonprofit
research on phototherapy services in hospitals offering
health care facilities in Kaduna state. Twenty eight of
neonatal care in Kaduna state, Northwestern Nigeria
the secondary facilities are state owned and are distrib-
with the aim to
uted across the 23 local government area of the state.
1.
Document availability of phototherapy devices in
Three (3) of the 31 secondary health care facilities are
use in newborn care facilities in Kaduna state
federal government owned and ran by institutions for
2.
Document the irradiance of phototherapy devices in
staff. One (14%) of the tertiary health care facilities is
newborn care facilities in Kaduna state
owned by the state government and ran by a tertiary
institution while the other 6 (86%) are federal owned
institutions. Three (50%) of the 6 federal owned tertiary
health care institutions are mono -specialty facilities
Method
while the other 3 provided multi-specialty care including
paediatric services out of which only 2 offered neonatal
The study was an action research cross sectional survey
health care services. One of these 2 facilities was the
of all hospitals providing newborn care in Kaduna state
ABUTH which was excluded from subsequent analysis.
including public nonprofit, private profit and faith based
A total of 15 non-government facilities made up of 13
facilities. Government facilities providing secondary and
private for profit and 2 faith- based non-profit health
tertiary health care were identified from the HMIS from
care facilities providing neonatal health care services
the ministry of health while those offering neonatal ser-
were identified within the state. Two (2) private for
vices were subsequently identified by contact and phone
profit facilities declined consent and were excluded from
conversation. Private and faith based facilities were
the study
identified via contact and from the guild of private medi-
cal practitioners. Each facility identified and included in
None of the 31 secondary health care facilities operated
the research was visited and after properly securing
a newborn unit nor provided phototherapy and or man-
clearance and permission from the appropriate authority
agement for neonatal jaundice. Overall 15 facilities pro-
an interaction with the neonatal staff ensued using a
vided Phototherapy services of which 13/ 15 (87%) were
predesigned proforma to document their neonatal jaun-
non-government facilities made up of 2/13 (15%) faith
dice services. The Ahmadu Bello University Teaching
based and 11/13 (85%) private for profit facilities. The
Hospital Zaria (ABUTH), a federal tertiary health facil-
only state owned tertiary institution operated a neonatal
ity with more than 30 intensive phototherapy devices
unit and offered neonatal jaundice management services.
and from where the protocols were designed was ex-
None of the surveyed facilities had a radiometer nor
cluded from the survey to remove bias. Phototherapy
knew irradiance of their PT devices and neither did any
devices in use in the facilities were identified and infor-
have a written protocol for the management of neonatal
78
jaundice. All facilities except 2 will change their PT
Table 1: The irradiance of Phototherapy devices at traditional
device’s bulbs only when the tubes became dim or no
distance for phototherapy
longer lit or after 2 years, while the 2 exceptions, which
Facility
Irradiance at
traditional
Maximum
Distance at
traditional
distance of photo-
attainable
Maximum
were private for profit, changed tubes after 2000 – 3000
distance
therapy (cm)
irradiance
irradiance
(µW/cm /nm)
2
(µW/cm / nm)
2
hours. The decision to commence or discontinue photo-
(cm)
therapy was largely on visual assessment of jaundice in
F1
5.1
55
11.1
35
6 (40%) of the facilities while in the remaining facilities
F2
2.7
50
8.8
10
varying levels of serum bilirubin (SB) ranging from 6 to
F3
3.3
50
11.5
10
15 mg/dl was considered starting levels; 3 of the facili-
F4
-
-
-
-
F5
3.2
55
6.2
10
ties will commence phototherapy at SB of < 10 mg/dl,
F6
13.6
50
32.9
25
4will commence at 10- 14 mg/dl while only in 1 facility
F7
5.7
45
11
10
will phototherapy be commenced at SB ≥15 mg/dl. In
F8
3.1
47
4.6
10
one of the facilities commencement of PT was based on
F9
5.1
50
6
10
F10
3.8
55
8.4
10
Serum bilirubin levels and age in days. None of the fa-
F11
1.6
40
2.3
10
cilities discontinued PT at SB ≥15 mg/dl, 2 will discon-
F12
9.4
75
34.5
25
tinue at SB 10- 14 mg/dl while 5 of the facilities discon-
F13
33
25
40
10
tinued PT only when SB was < 10 mg/dl.
F14
9.7
40
10.5
10
F15
6
45
26.1
25
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 profit
and the state owned tertiary facility
Discussion
A total of 54 PT devices were studied. Eight (15%) of
Newborn jaundice healthcare services were provided
the PT devices were located in the 2 government tertiary
mainly (85% PT, 75% EBT) by non-government facili-
facilities while the remaining 30 (56%) and 16 (29%)
ties in Kaduna state as documented in the study. This
were located in the private and faith based facilities re-
establishes an important role being played by private
spectively. The highest number of PT devices found in
health facilities in the provision of specialized neonatal
any single facility was (14) in a faith based facility.
care, a key step towards reducing neonatal and under-
Only 6 (11%) of the PT devices used special blue lights
five mortality in the state and the country at large. It was
(light source with intense energy and narrow blue spec-
difficult however, to identify which facilities provided
trum wavelength in the range 450- 470 nm) while ma-
newborn services from the HIMS in the state ministry.
jority of the devices 43 (80%) used ordinary blue and 5
This suggests a gap that may make partnership and su-
(9%) devices used white light. All the PT devices used
pervision to improve efficiency of specialized newborn
fluorescent tubes. Twenty two (41%) of the PT devices
care suboptimal. The fact that none of the government
were commercially sourced branded devices while the
secondary health care facilities offer neonatal jaundice
majority (59%) were varyingly fabricated devices with
healthcare services also implies that services are possi-
no two facilities having a similar fabricated device. All
bly insufficiently available to the large number of new-
the (8) PT devices in the 2 government facilities were
borns that may develop jaundice and require care and
branded devices accounting for 36% (8/22) of the com-
thus leaves them with the alternative to explore and pa-
mercial devices. Only 2 (13.3%) facilities had PT de-
tronize other unorthodox and perhaps even harmful care.
vices which offered irradiance (> 10 µW/cm / nm) suit-
2
able for conventional phototherapy at the facilities’ tra-
The provision of services across facilities in the survey
ditional PT distance this however, increased to 7
where quite varied. While none of the facilities had a
(46.7%) facilities with varying PT distances up to a
written protocol for management of neonatal jaundice,
minimum of 10 cm to obtain best irradiance. Only 3
practice varied remarkably. As many as 40% of the sur-
(20%) facilities had devices that could offer intensive
veyed facilities will commence phototherapy with vis-
phototherapy (irradiance > 30 µW/cm / nm) at varying
2
ual/ clinical jaundice, a highly subjective method of as-
distances. (Table 1)
sessment of level or severity of jaundice which may lead
to inappropriate and inefficient management of jaundice
as it may lead to under or over treatment of jaundice.
This becomes even more worrisome when this finding is
compared with the efficiency of the units being used to
offer intensive phototherapy; where there is need to ur-
gently bring down the level of serum bilirubin such that
a baby subjectively assessed to have jaundice though
high enough is exposed to a not optimal treatment. It
also makes communication and research difficult as
practice cannot be compared as no standards are being
followed and as such efficiency of interventions in the
state and across centres cannot be reliably studied.
Overall, protocols provide minimum standard guides for
care and, with respect to neonatal jaundice, will guide
79
providers in the entire management of newborns with
PT have 0% chance of having Intensive PT and a 25%
jaundice but more so define who receives intensive
chance of having EBT with PT in a public facility.
PT.Availability of EBT services was found in only 27%
Overall these findings suggest a great limitation in pro-
of the facilities ľ of which were private for profit which
vision of services for the management of severe neonatal
suggests a dearth of facilities providing such services
jaundice and neonates with this condition are unlikely to
and may at the same time mean increase work burden
access the required intervention and therefore highly at
for the few facilities providing this service with a ten-
risk of bilirubin encephalopathy.
dency to inefficiency. All these will negatively impact
None of the facilities had an irradiance meter a simple
on the desired target of reducing neonatal mortality a
tool to measure the irradiance of devices. Availability of
major target of the SDG 3 .
such tool will empower facilities to evaluate their de-
vices and take appropriate measures to improve and at-
Eighty five percent of the facilities which provided pho-
tain the desired irradiance for optimal PT.
totherapy services were non-government facilities and
fabricated PT devices were commonly used possibly
because they were cheaper, more affordable and avail-
able in comparison to the branded devices which were
Conclusion
likely to be more expensive and unavailable. The use of
local fabricated devices though encouraging as it en-
Private health care facilities constitute a major provider
sured availability, however, did not, like the branded,
of neonatal jaundice healthcare services which may con-
guarantee efficient phototherapy.
Overall majority
stitute a limitation to accessibility and affordability in
(86.7%) of the phototherapy devices studied at the facil-
view of their profit orientation. Overall, however, the
ity traditional PT distance provided irradiance of < 10
services including protocol availability, phototherapy
µW/cm / nm which is sub optimal. A similar study in
2
and EBT were grossly suboptimal and inadequate and
Netherland found 50% of the devices studied below this
will need significant and urgent improvement to enhance
threshold. . The low suboptimal irradiance in this study
17
newborn health and indices and as well guarantee a posi-
is attributable to the protocol for the use and features of
tive march towards attainment of SDG3.
the PT devices. These include not measuring or knowing
the irradiance of devices before commencement of pho-
totherapy and lack of satisfactory irradiance for simple
Recommendation
phototherapy from the devices even after assessment of
the devices. The latter resulting from use of inappropri-
We recommend that the SMOH should update and gen-
ate bulbs (ordinary blue as against the special blue tubes,
erate a comprehensive documentation of all healthcare
few tubes and poorly lighting/ expired tubes) and use of
facilities (government and non-government) that provide
devices at a distance which gave poor irradiance.
different specialized newborn health care in the state.
Though in a few of the devices some improvement was
The ministry should lead and improve partnership with
made by varying the distance, in others this could not be
private health facilities providing newborn care with an
done either because the devices were fixed or could not
aim to support, standardize and improve neonatal jaun-
be further adjusted due to design. For some of the de-
dice care services. This should include focus on improv-
vices which had improved irradiance suitable for simple
ing efficiency of locally fabricated PT devices and pro-
PT ( ≥10 µW/cm 2 / nm) after distance adjustment, the
vision of protocols and guidelines for management of
effective irradiance distance (10 cm) was found not
neonatal jaundice.
clinically suitable for phototherapy as the device became
too close to the neonate and increased the risk of hyper-
thermia with its sequelae of increased insensible loss
and dehydration as well as physical injury including
Funding: None
burns.
Conflict of interest: None
Only 20% of the studied facilities and all of which were
private for profit could provide intensive phototherapy
which helps to reduce the rate of EBT. Owa and col-
Acknowledgement
leagues in their study of 12 neonatal centres in South-
2
western Nigeria found none able to provide intensive
We are highly indebted to Prof. Tina of the Minnesota
phototherapy. Similarly the expertise for and availability
University USA for her numerous advice and Dr Bhut-
of EBT services were available only in 4/ 15 (27%) of
tawa of the Kaduna State Ministry of health for his sup-
the facilities made up of 3 private for profit and a state
port.
owned tertiary facility. These imply that neonates with
severe jaundice who require intensive PT or EBT with
80
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