Owing to rigorous quarantine and infectious control measures taken in maternity wards during the COVID-19 outbreak, management strategies of neonatal jaundice, almost universal in newborn infants, have become challenging when it comes to providing holistic mother-infant dyad-centred care . This pilot study suggests that HPT for neonatal jaundice can be effectively carried out/administered despite the hospital restrictions imposed by COVID-19 waves, with high levels of parental satisfaction with the service. Having parents return with their neonates on a daily basis for follow-up with frontline clinicians in the neonatal ward, who collect relevant information, is worth consideration as a safe and feasible strategy for determining whether to continue or discontinue phototherapy treatment. Such a strategy works in favour of maternal mental health, bonding, and breastfeeding success .
HPT has been available in high-income countries for more than 25 years as an alternative to phototherapy in the hospital . Jaundice treatment at home has potential advantages over treatment in the hospital. Disruptions to breastfeeding and parent–infant bonding are minimized at home, whereas in some hospitals, nursery infants may be moved out of the mother’s room for phototherapy, possibly contributing to maternal postpartum psychoemotional distress [4, 5]. Traditional treatment at home may also be more convenient for families, and less costly than hospitalization [4, 5]. However, HPT use among pediatric providers varies and these assumptions may be related to a paucity of evidence, given that few studies have examined the use of home phototherapy. These studies had small sample sizes or restricted eligibility for HPT, and were carried out with differing follow-up strategies, making it harder to draw meaningful conclusions across studies. Of note, a 2014 Cochrane Review by Malwade and Jardine intending to compare home and hospital-based phototherapy in newborns with non-haemolytic jaundice could not be performed due to insufficient evidence to support or refute the practice of home-based phototherapy for non-haemolytic jaundice in infants more than 37 weeks gestational age .
To our knowledge, this is the first cohort study that evaluated the effectiveness of HPT in the current COVID-19 pandemic, based on post-phototherapy neonatal clinical status assessed frontline in the neonatal ward together with the lactation skills of the mothers. While a comprehensive economic analysis was outside the scope of this pilot observational study, baseline data from our combined home and hospital service demonstrated the potential efficiency of delivering care in this manner, so as to give people more personalised, supported, and connected care in their own homes, thereby reducing the need for postpartum hospital visits. Although HPT is not suitable for all infants and families, it may be a convenient alternative to IPT as it resulted successful in 90% of jaundiced infants in this study. Among these, ~ 15%of infants required more than one session of HPT and 10% required readmission for IPT due to non-compliance with the treatment protocol in the presence of a high-bilirubin risk. Chang and Waite reported a readmission rate of 1.9% . However, they used different treatment thresholds and possibly limited non-adherence to the protocol by having a pediatric nurse travel to the home of the neonates to set up the HPT equipment, weigh the infant, check the TSB level at least daily, and provide lactation support as needed. Reducing readmission rates help reduces maternity bed occupancy in pediatric wards, consequently freeing beds for acutely unwell neonates .
Given that this a pilot study, it is unable to compare the features, duration, and efficacy of our portable fiber optic phototherapy to other modalities to administer phototherapy in-hospital or at home which may vary in the particular wavelength of the light used and by the intensity of the light source. There are also several important caveats to consider in evaluating its effectiveness, as it relies on parental compliance and confidence in use of equipment without constant supervision. Moreover, the hour-specific nomogram developed by Bhutani et al. to predict hyperbilirubinemia risk is quite different from AAP and NICE treatment thresholds [10, 12, 15]. Whereas NICE guidelines offer gestation-specific thresholds at weekly intervals up to 38 weeks, the AAP guidelines offer a composite guideline for infants ≥ 35week. In addition, although HPT may seem a convenient alternative to in hospital phototherapy, it is not suitable for infants with very high bilirubin levels or families lacking the ability to return to the hospital daily for follow-up. Nevertheless, measurements of parental satisfaction using appropriately designed and delivered surveys may provide robust quality of care measures and can help improve services and their delivery [15, 16]. Of note, in our cohort, parental feedback on HPT in the questionnaire indicated high levels of satisfaction. Similarly, Jackson et al. reported that all parents were highly satisfied that all information concerning the HPT had been supplied to them . Eighty-five per cent found no disadvantages with HPT, but some concerns were expressed. The two main disadvantages were equipment issues, as well as the baby not settling in the HPT unit. A few parents found being responsible for their baby’s care without constant medical supervision anxiety-inducing and thus did not feel entirely confident. This is relevant, considering that a minority of parents in our pilot study did experience some difficulties with the equipment, such as struggling to put the slipping phototherapy pad on their infants during treatment (1 patient), and non-adherence to protocol (2 patients). Therefore, it would be worthwhile sharing these few reported difficulties, especially equipment issues, with families in advance along with suggestions as to how these difficulties can be overcome, which could further reduce the parental discomfort and anxiety HPT might produce.
In conclusion, this pilot study suggests that HPT for neonatal jaundice can be effectively administered in a select group of infants and also that is viewed very positively by families The study also proves that HPT can be incorporated in clinical practice during the COVID-19 pandemic. It enables mothers and their infants to remain at home receiving family support as hospital-based phototherapy can be challenging for maternal mental health, breastfeeding initiation, and bonding. However, inherent limitations of a pilot studies do not make it possible to measure the exact efficacy, satisfaction difficulties, and costs of HPT.