Discussion
Few studies have examined the use of HPT. Apart from Chang and Waite, most studies had small sample sizes. Our report adds to the increasing evidence on the effectiveness of HPT.3
The breastfeeding rate in both the HPT and IPT group was similar. In the study of Chang and Waite, breastfeeding rate was much higher at 90%, so breast milk jaundice may have been more prevalent in their population.3
In our HPT group, 8 (8%) were DCT positive; one required two sessions of HPT, none showed signs of haemolysis. Chang and Waite found that although 10% of their cohort were DCT positive, 5.7% required readmission or another session of HPT.3
The duration of HPT in our cohort was shorter (43 hours) when compared with the reports by Chang and Waite (53 hours) and Thakkar et al (57 hours).3 13 When compared with IPT, the duration of HPT was longer. This could be explained by greater parental adherence to treatment due to direct patient supervision and more frequent SBR checks in hospital. This was shown in the longer total duration of HPT compared with the phototherapy unit timer reading. However, IPT (mean 26±9 hours) was of similar duration to HPT as measured by the device timer (mean 24±10 hours). Our findings agree with Slater and Brewer who reported that the duration of IPT was shorter than HPT.14 However, Eggert et al found that duration of treatment was similar in both IPT and HPT.4 On the other hand, Zainab and Adlina reported the duration of HPT was shorter than IPT.15
Effectiveness and re-admissions
The rate of bilirubin reduction was similar in both HPT and IPT groups. No infant in HPT showed a progressive rise in SBR level. Similarly, the meta-analysis done by Chu et al showed that there was no difference in bilirubin reduction rate between HPT and IPT.1 On the other hand, Zainab and Adlina reported the rate of fall was higher in HPT group compared with controls. However, it is unclear whether the devices used for HPT and IPT delivered the same irradiance.15
In our cohort, HPT was successful in the majority of infants with three (3%) readmissions due to concerns over treatment failure and non-compliance. Two infants required more than one session of HPT; one had suspected Gilbert syndrome. Chang and Waite reported a readmission rate of 1.9%. However, they used different treatment thresholds.3 Reducing readmission rates help NICUs maintain available maternity beds for high-risk intrauterine transfers requiring delivery in tertiary perinatal centres. It also reduces bed occupancy on paediatric wards freeing beds for acutely unwell children.
Parental feedback on HPT
In our cohort, the responses to the initial questions in the questionnaire indicated high levels of satisfaction with the service. All parents agreed that staff had sufficiently explained how to use the equipment, and that the NCOT had contacted them daily until 1 day after phototherapy was stopped. Similarly, Jackson et al reported that all parents were highly satisfied that all information concerning the HPT had been supplied to them.16 However, they received feedback from only 28 parents.
A minority of parents in our HPT group did experience some difficulties with the equipment, such as struggling to put the eye masks on their infants and the eye masks slipping during treatment. Similarly, a few parents reported the mask causing discomfort to their baby who then needed frequent picking up in order to settle.
In the second part of the questionnaire, when asked about the main advantages of HPT, the two most common themes in the responses were being in the home environment and around their families. A number of parents expressed relief at not having to be in hospital in order to receive phototherapy. Additionally, having support from other family members and spending time with other children was cited as another advantage. Ease and convenience were also common themes, with several parents noting how simple the equipment was to use. A number of parents cited comfort, both for the baby and themselves, as the main advantage. Similarly, in the study by Jackson et al, 86% of parents reported that HPT always fitted with their family routine.16
For a balanced assessment, parents were also asked to list any disadvantages they had encountered. Eighty-five per cent found no disadvantages with HPT, however, some concerns were expressed. The two main disadvantages were equipment issues, with a few parents finding the equipment bulky and difficult to store, 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.
It is comforting that 95 (97%) parents stated the overall experience of HPT was good and 95 (98%) reported that they would choose HPT if they had to do it all over again and be advocates for the service to other families. Two parents (2%) stated a preference to IPT in future, having found HPT too stressful. Our team has used the few reported difficulties by some parents especially with the eye masks to forewarn future families along with suggestions as to how this could be overcome which could further reduce the parental anxiety this might produce.
Feasibility
Our results show that infants ≥2 kg and ≥35 weeks CGA can be treated with HPT. Zainab et al included infants ≥37 weeks while Chang and Waite only included infants with SBR levels 34-51 µmol/L below treatment thresholds as per the American Academy of Pediatrics (AAP) guidelines.3 15 The NICE treatment thresholds are quite different from the AAP thresholds. Whereas NICE guidelines offer gestation-specific thresholds at weekly intervals up to 38 weeks, the AAP guidelines offer a composite guideline for infants ≥35 weeks. Further, AAP guidelines advise against the use of HPT unless the bilirubin levels are 34-51 μmol/L below the treatment thresholds. In UK practice, phototherapy is commenced if SBR level is above NICE treatment thresholds. So, we included infants who met that criteria that is, infants who normally need admission to hospital for phototherapy, this means infants included in the Chang et al report would not have met the NICE criteria for treatment. It is also possible to treat carefully selected infants with mild haemolysis with HPT.
Infants in the control group could have been candidates for HPT. However, they were not offered HPT due to either (1) the lack of knowledge of junior doctors about HPT especially at the launch of the service and during change over period of new junior doctors, (2) the lack of availability of trained personnel during out of hours to teach parents how to use equipment, (3) parents did not feel confident to use HPT or (4) parents were not conversant in English.
Resource use
The average length of IPT was 51 hours which equates to 2.1 bed days per infant that could be saved. This potentially saves 204 bed days for 97 HPT infants as three (3%) required readmission. This could help in improving patient flow on maternity wards. While a comprehensive economic analysis was outside the scope of this observational study, baseline data from our hospital and the costing of HPT service demonstrated clearly the efficiency of delivering care in this manner. The one-off cost of machinery and ongoing costs of home visits have to be weighed against the costs of occupying acute beds and the difficulties mothers experience when away from their families.17 In light of the COVID-19 pandemic, we need to find different ways of providing care to keep families together and safe.
Considerations for healthcare professionals
Although HPT is a convenient alternative to IPT, it is not suitable for all infants and families. Infants with very high bilirubin levels may not be eligible for HPT due to the lack of direct supervision in the community and the need for intensive IPT. HPT relies on parental compliance and confidence to use the equipment without constant supervision. This requires clear and effective communication, which may be impeded by failure to employ translators where language differences exist.
We sought the feedback of our service users as user feedback is a powerful developmental tool for any service. Measurements of patient satisfaction using appropriately designed and delivered surveys provide robust measures of the quality of care and can help improve services and their delivery.18 On the contrary, dissatisfaction with healthcare leads to poor compliance and in extreme cases, patients resorting to negative word-of-mouth reports that discourage others from seeking healthcare from the system.19 The HPT service perfectly complements the recently launched NHS At Home, a drive to give people more personalised, supported and connected care in their own homes which reduces the need for hospital attendances or admissions.20
Strengths and limitations
To our knowledge, this is the largest cohort of HPT for neonatal jaundice in the UK. Our report not only demonstrates the feasibility of incorporating HPT in UK clinical practice but also is supported by overwhelmingly positive parental experiences.
However, our study is limited by the inherent limitations of retrospective studies. It was not possible to measure the exact duration of HPT. Although the NeoMedLight devices have a timer display which records treatment duration, the data were only available in 66 (66%) cases. The way in which we have measured the duration of HPT likely over-estimated the total duration of HPT. Selection bias may have been introduced in parental feedback because feedback was received from parents who agreed for their infants to received HPT in the first place. However, it is not possible to get feedback about a service from people who did not receive that service.