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Nigerian J Paediatrics 2017 vol 44 issue 1

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Irradiance levels of phototherapy devices fabricated in Nigeria
Niger J Paediatr 2018; 45 (4):180 184
ORIGINAL
Abdulkadir I
CC BY Irradiance levels of phototherapy
Adebiyi NM
Hassan L
devices fabricated in Nigeria
Abdullahi F
Ogala WN
Slusher TM
Vreman HJ
DOI:http://dx.doi.org/10.4314/njp.v45i4.3
Accepted: 11th November 2018
Abstract : Background: Photo-
source to meter sensor.
therapy (PT) remains difficult to
Results: The irradiance of the fab-
Abdulkadir I
(
)
deliver
in
many
resource-
ricated devices (F1-4) and com-
Adebiyi NM, Hassan L,
constrained countries, including
mercial device (C) measured at the
Abdullahi F, Ogala WN
Nigeria due to the unavailability
most common clinically-used dis-
Department of Paediatrics,
of devices that can deliver inten-
tance of 30 cm for intensive PT
sive PT (irradiance ≥30 W/cm /
2
Ahmadu Bello University/
were 29.5 6.3, 30.3 5.3, 25.8
Teaching Hospital Zaria, Kaduna
nm) needed to treat the more se-
5.0,49.0 10.5 and 39.2
13.6W/cm /nm respectively with
2
State, Nigeria.
vere cases of hyperbilirubinaemia.
Email:isaburamla@yahoo.com;
The basic equipment is expensive
corresponding maximum central
isaabdulkadir@abu.edu.ng
and replacement parts are often
irradiance of 36.4, 32.1, 31.2,59.5
not available.
and 54.5 W/cm 2 /nm. At a dis-
Slusher TM
Objective: To compare the blue
tance of 25cm, all devices deliv-
ered irradiance ≥ 30W/cm /nm.
2
Department of Pediatrics,
light irradiance of four locally
University of Minnesota &
designed and fabricated PT de-
The cost of each local device was
Hennepin County Medical Center,
vices with a proprietary device.
less than 12% of the commercial
Minneapolis, MN 55415, USA
Materials and Methods: Four
one.
types of intensive PT devices
Conclusions: Locally fabricated
Vreman HJ
were locally fabricated. Irradiance
devices cost much less and were
Department of Pediatrics,
was measured using an Olympic
suitable for delivery of intensive
phototherapy ( ≥30 W/cm /nm) at
2
Stanford University Medical
Medical Bili-Meter. The mean
Center, Stanford, CA94305-5208,
irradiance of triplicate measure-
a distance of 25cm.
USA
ments at three positions in the
light footprint of each device was
Keywords : Affordable, photother-
determine that distances of 10, 20,
apy, devices, irradiance, neonatal
30, 40, 50, 60cm from light
jaundice.
Introduction
sold for approximately between 100,000 to 200,000 and
1,500,000 to 2,000,000 Naira each respectively at an
Neonatal hyperbilirubinaemia (HB) and its visual mani-
exchange rate of 315 naira/ USD. The much higher cost
festation as jaundice occur world wide in up to 60% of
of intensive PT devices leaves most clinical services no
term newborns and in about 80% of preterm babies .
1
other option but procuring the far less expensive, but
Severe HB >20 to30 mg/dL total bilirubin poses a risk
inferior, conventional devices, without adequate irradi-
ance if they have any resources at all. Thus, most new-
3
of acute bilirubin encephalopathy (ABE) and kernicterus
in Nigeria.
2-4
born clinical services are unable to treat severe HB
quickly and effectively enough to prevent the serious
Phototherapy (PT), the principal treatment of HB, re-
5
sequelae of this condition.
mains inaccessible to many newborn clinical facilities in
low-income countries.
2-6
This is due to a number of fac-
In an effort to prevent such scenarios from happening in
tors, including the prohibitively high cost of PT devices
the future, we endeavored to determine if we could de-
relative to the local economy, lack of spare parts, espe-
sign, and locally fabricate, affordable PT devices that
cially lamps, and erratic electrical power delivery.
2-6
The
could deliver irradiances high enough to qualify for the
devices presently used to provide PT can be classified
delivery of intensive PT, as defined by the AAP guide-
lines.
5
into those providing conventional and intensive PT on
the basis of delivering irradiances of >8 to 10 and ≥
7-10
30W/cm /nm, respectively.
2
We thus, designed and built four types of PT devices,
In Nigeria, PT devices are quite expensive with conven-
loosely patterned after locally used devices. We subse-
tional and intensive irradiance delivering devices being
quently evaluated their efficacy and that of a commer-
181
cially- obtained device by measuring the irradiance at
der the circuit board. Each tube is powered by 100-265
varying distances between light source and meter at
V AC and consumes up to 20 Watt of power. The LEDs
three different positions in the light foot print.
of the tube emit light at a 90 ˚ angle with a spectral
wavelength range of 400 to 530 nm, a bandwidth of 455
to 479 nm, and peak wavelength of 467 nm. Each LED
has an estimated lifetime of ~30,000hr.The fixture was
Materials and Methods
painted white, inside and out. With three tubes, it weighs
1.4kg. The tubes, which were special ordered from the
The four devices were produced by a Nigerian engineer-
supplier, each costs 8,000 Naira or US $20. The total
ing team which also ensured that all electrical work con-
cost of all parts was 134,000 Naira.
formed to mechanical and electrical safety requirements.
All devices were attached to a horizontal arm of a 4-
4. LED Tube Device with five tubes(Figure 1, F-4),is
wheeled dolly for ease of mobility. After proper train-
essentially the same as device F-3, but it is fitted with
ing, all devices were tested by the clinical staff of the
five instead of three LED tubes in order to deliver maxi-
neonatal ward as described under irradiance measure-
mum intensive PT irradiance for treatment of severe HB.
ment Protocol, below.
The weight of this device was1.8kg and the total cost of
all parts was 150,000 Naira.
Devices
5. Commercial Intensive PT Device This is a com-
1. Fluorescent Tube Device (Figure 1, F-1) consists of a
mercially-obtained intensive PT device (Phototherapy
wood panel with fenestrations for air circulation. It has
4000 Drger Medical GmbH, Lbeck, Germany) which
the following dimensions: 70 x 40 x 6 cm (L xW x H).
delivers irradiation in a central area (EBi) of 1.6 0.3
mW/cm with four blue and two white lamps and EBi of
2
Two sets of five opposing lamp holders were mounted 4
2.3 0.4 mW/cm with six blue fluorescent lights at 40
2
cm apart, along the short sides of the panel. The holders
were fitted with five blue light fluorescent tube lamps
cm distance. The lamps (Draeger Fluorescent light
(TL-52, T8, 60x2.5cm, 20 Watt, Philips, Eindhoven,
blue 2M 21 010) deliver blue light with a spectral
The Netherlands). Mechanical ballasts (Philips) were
wavelength of 400 to 550 and a peak of450nm.The fix-
mounted to supply the lamps with the necessary regu-
ture has the following dimensions: 54 x 28.5 x 13.5 cm
lated power. The lamps emit blue light with a spectral
(L x W x H) and weighs 7.2 kg It was obtained at a cost
range of 400-626 nm, a bandwidth of 403-472 nm, and a
of $4000(1,600,000Naira).
peak wavelength of 437 nm. The panel also contained
11
a power connector, fuse and switch. The lamps cost
Irradiance Measurement Protocol
8000 Naira each. The total cost of all materials was
120,000 Naira.
The efficacy of the fabricated and commercial devices
was determined through irradiance measurements in the
2. Compact Fluorescent Lamp Device (Figure 1, F-2):
light footprint of each device, with a handheld clinical
The lamp fixture has the following dimensions: 55 x
irradiance meter (Bili-Meter, Model 22, Olympic Medi-
29.5 x 15.5cm (L x W x H).It contains six compact fluo-
cal- now Natus Medical, San Carlos, CA, USA) which
rescent
U-tubes
(DELUX,
18Watt/71,
Blue
has a band width and peak sensitivity of 425-475 and
2G11,Osram, Muenich, Germany) spaced as seen in the
450 nm, respectively. It measures irradiance in terms of
W/cm /nm. Specifically, triplicate measurements of
2
Figure. The lamps deliver blue light with a spectral
wavelength of 400 to 500 nm and peak of 460nm.The
irradiance were made at three different sites in the light
fixture with lamps weighs 5.9kg. The lamps, which have
footprint (center and two peripheral positions, 5 cm
a life span of 1000 hours, cost 8,000 Naira each. The
from each of the short edges) at 10, 20, 30, 40, 50, and
cost of all materials was 180,000 Naira.
60 cm distance from the light emission surface of the
device to the upper surface of the irradiance sensor. For
3. Light-emitting diode (LED) Tube Device with three
each distance, the irradiance was determined through
tubes (Figure 1, F-3), is based on domestication of the
calculating the mean of the triplicate measurements at
design developed by HJV using 1.5x1.5x1/16 inch
each of the three footprint sites, thus a total of 9 meas-
(2.54cm/inch) aluminum angle frame, which is readily
urements.
available and affordable in Nigeria. The dimensions are
64 x34 x 5cm(L x W x H). Inside the fixture, two sets of
five lamp holders were mounted, 6.0 cm apart, along the
opposite short edges of the frame, as seen in the Figure.
Results
The fixture also contained a fused power inlet unit with
detachable power cord, and a power switch. The fixture
The mean irradiances of the locally- fabricated devices
was fitted with three T8 custom-developed led Tubes
(F1-4) and the commercial device (C) are documented in
(Grandol Industry Ltd., ShenZhen, China) equally
Table 1. The maximum central irradiance measure for
spaced as seen in the Figure. Each 60cmx2.5cm diame-
the devices F1- 4 and the commercial device at 30 cm
distance were 36.4, 32.1, 31.2, 59.5 and 54.5W/cm /
2
ter aluminum tube had nine 3-Watt LEDs mounted, 5.5
cm apart on a central circuit board. The power supply
nm respectively (Table 1). Figure 2, graphically displays
(driver) is mounted within the aluminum tube space un-
the distances at which the different PT devices begin to
182
2
deliver mean irradiance for intensive phototherapy indi-
cm /nm at a distance of 26 cm. The locally fabricated
cated by the red line on the graph; devices F-1 and F-2
devices cost between 120,000 180,000 naira in materi-
provided irradiance of 30W/cm /nm at a distance of
2
als. The cost of labour was not determined, as this is
30cm, while devices C and F-4 provided irradiance of
strongly influenced by the size of a production run.
30 W/cm /nm at distances of 39 and 49 cm respec-
2
Overall none of the fabricated devices cost up to 12% of
tively. F-3 could only provide an irradiance of 30 W/
the commercial device.
Table 1: Mean (SD) irradiance and Maximum Central Irradiance at various device distances from irradiance meter
Device
Distances (cm) between phototherapy device and irradiance meter
10
20
30
40
50
60
Cost (Naira)
F-1
80.3(17.9)
43.3(11.9)
29.5(6.3)
21.0(5.8)
14.7(2.3)
10.9(2.0)
120,000
{101}
{56.1}
{36.4}
{25}
{17.4}
{13.2}
F-2
83.8(14.1)
45.3(7.5)
30.3(5.3)
18.3(3.8)
13.1(1.5)
9.0(0.7)
180,000
{99.9}
{53.5}
{32.1}
{22.1}
{14.6}
{9.8}
F-3
40.1(9.7)
33.8(7.1)
25.8(5.0)
19.4(4.8)
16.2(3.4)
13.1(1.1)
134,000
{51.2}
{41.4}
{31,2}
{23.7}
{19.4}
{15.0}
F-4
99.9(7.6)
66.5(10.2)
49.0(10.5)
38.3(7.6)
26.1(4.6)
20.1(4.2)
150,000
{106.7}
{76.4}
{59.5}
{47.0}
{33.2}
{25.1}
C
69.6(69.6)
49.3(86.5)
39.2(13.6)
23.2(4.0)
15.3(1.7)
10.7(1.1)
1,600,000
{150}
{91.4}
{54.5}
{27.8}
{17.2}
{11.7}
Values are given as mean SD of triplicate measurements at each of three light foot print sites (n=9 measurements total).
Figures in round brackets are standard deviations
Figures in squiggle brackets are Maximum Central Irradiance readings
One Nigerian Naira = 0.04USD
Fig 2: Irradiance (W/cm /nm) delivered by the five PT de-
2
Fig 3
vices as a function of distance (cm) between the device light
2
emission surface and detector. (Red line indicates 30 W/cm /
nm)
Fig 4
Fig 1
Fig C
Fig 2
Fig 1; Locally fabricated (F) phototherapy devices F 1- 4 and a
commercially-obtained (C) device. F1, 2, and C use fluores-
cent lamps, while F3 and 4 use led-tubes as light sources.
Discussion
The efficacy of a PT device is in large part a function of
the deliverable irradiance to the skin of a jaundiced pa-
tient. For the efficacy to be optimal, it has to be deliv-
12
ered to the largest possible body surface area (BSA).
12,13
183
Thus, it is important that the light footprint of a device is
reach an efficacy plateau.
11
sufficiently large to cover the entire BSA. Hence, we
have built devices that all have a light emission surface
In infants with total bilirubin levels at or near exchange
area and a corresponding light footprint measuring at
blood transfusion (EBT) levels(> 20 mg/dL) or in in-
least approximately 30 x 60 cm, large enough to treat the
fants with signs of acute bilirubin encephalopathy
bodies of even the largest term newborns.
(ABE), urgently bringing down bilirubin levels is a nec-
essary strategy towards preventing the complications
Traditionally, the irradiance is measured at a distance
and sequelae of both the treatment (EBT) and the dis-
ease (ABE).
5,18
from emission surface to the top of the meter sensor
The use of intensive PT is a primary rea-
unit, the latter which should represent the level of the
son for fewer EBTs in high income countries as com-
pared to Nigeria. The availability of these locally fab-
2,3
patients skin. Because the irradiance, delivered by a
point source of light, is inversely related to the square of
ricated PT devices avails clinicians in neonatal practice
the distance (Inverse Square Law), decreasing the dis-
the opportunity to improve the management outcome of
tance significantly increases a devices irradiance, even
newborns with jaundice in Nigeria and as well possibly
if the light does not strictly originate from a point light
reduce EBT rates in the country.
source, like the TL-52 lamp. This concept is demon-
strated in Table 1, and even more so, by its graphical
There have been concerns about the use of high irradi-
presentation in Figure 2. These results show that four of
ance in the extremely low birth weight infants and con-
cerns are emerging even for term infants.
15- 17
the five devices deliver intensive PT at the most gener-
These con-
ally recommended distance of 30 cm.
cerns support the need for measuring irradiance levels
and ultimately developing protocols, which would pre-
There is no compelling reason why the distance to the
scribe the level of irradiance needed, based on the ma-
skin cannot be reduced however, care needs to be taken
turity of the infant, the risk of ABE and the need for
that lamps which run hot (often the halogen type) are
EBT. While these refinements are outside the scope of
kept far enough from an infant to prevent the skin from
the present study, the present data provide the basis for
overheating. When PT is delivered at 25cm (Figure 2),
determining the irradiance we supply with our devices
all devices will deliver intensive PT at irradiances of ≥
through adjustments of the distance between light-
30W/cm /nm. The literature reports the use of dis-
2
emitting surface and the skin of the patient.
tances as short as 10 cm.
9, 14
If this distance was to be
used with the presently studied devices, the deliverable
None of the fabricated devices cost up to 12% of the
near maximal irradiance would range from 40-100 W/
commercial device. Though the cost of labour was not
cm /nm. It is noteworthy, that the LED tube-based de-
2
imputed, this suggest that such devices could provide
vice with three (3) tubes (F-3), designed for treatment of
cheaper options for achieving capacity to provide cost
moderate HB(15 < 20 mg/dL), delivers the most modest
efficient intensive phototherapy in our facilities.
levels of irradiance at any distance. Use of this device
This study did not evaluate the rate of decay of the PT
lamps. Different light sources decay at different rates.
8
conserves LED tubes and prevents overtreatment of
newborns, especially the vulnerable preterm neonate.
The PT lamp decay is usually specified by the manufac-
turer in usage- or lifetime hours, but this parameter is
The irradiances of devices F-1, 2 and 3 clustered rela-
sometimes greatly affected by a number of factors, in-
tively together while LED tube device F-4, was clearly
cluding wide fluctuations in electrical power, ambient-
capable of delivering the highest irradiance at any dis-
and PT lamp temperatures, and types of ballast used for
tance. The commercial device (C) at shorter distances
fluorescent tubes etc. Life span of PT lamps signifi-
had very high standard deviation because the difference
cantly affects the total cost of a device over time. For
in irradiance between the central and peripheral area was
instance, LED lamps last far longer than fluorescent
quite high due to the use of white light generating bulbs
tubes (50,000 versus 10,000 hrs. and warrantees or 5-
at the extreme ends of the device. These white light gen-
versus 2 yrs.).A follow-up study, to determine the decay
erating bulbs are allegedly used exclusively for the con-
of the light sources we have tested, is planned which is a
venience of nursing personnel who have difficulty toler-
needed next step to complement this study. The frame
ating the intense blue light by attenuating it with the
design for the PT F- 1 is being reviewed to incorporate
white light and are ideally not meant to be used for PT
the use of aluminum as opposed to the wood panel to
but contrariwise usually the case in many LMICs. An
improve safety and make it fire proof.
infant undergoing PT under this device should be posi-
tioned as close to the center of the device as possible or
alternatively replace the white light tubes with blue light
tubes to optimize PT.
Conclusions
The optimum irradiance level towards reducing plasma/
Locally fabricated PT devices are less expensive.
serum total bilirubin levels per hour of therapy has not
Where protocols and guidelines dictate the need for in-
been satisfactorily established.
7, 18- 20
For many years, a
tensive PT, our locally fabricated devices proved to be
level of 35W/cm /nm has been considered optimal,
2
efficient and cost effective. They are suitable for use to
however, more recent works indicate that an irradiance
provide intensive PT at an average distance of 25 cm in
of even above 55 W/cm /nm and as high as 70 did not
2
18
our hospitals. The authors will be happy to share con-
184
struction details with interested parties.
of the Kaduna Polytechnic and his staff for their skills
and efforts towards the construction of the studied PT
devices (F1-4) and the entire staff of the special care
Acknowledgements
baby unit (SCBU) Ahmadu Bello University Teaching
Hospital Zaria, Kaduna.
We acknowledge all colleagues who worked on the
Stopping Kernicterus in Nigeria (SKIN) SLAB project.
Conflict of interest: None
We especially thank Engineer Muhammad Sirajo Lawal
Funding: None
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