Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2022 Mar 2;3(3):CD011997.
doi: 10.1002/14651858.CD011997.pub2.

Periodic change of body position under phototherapy in term and preterm neonates with hyperbilirubinaemia

Anu Thukral  1 , Ashok Deorari  2 , Deepak Chawla  3
Affiliations

Periodic change of body position under phototherapy in term and preterm neonates with hyperbilirubinaemia

Anu Thukral et al. Cochrane Database Syst Rev. .

Abstract

Background: Phototherapy is the mainstay of treatment of neonatal hyperbilirubinaemia. Periodic change in position of the neonate under phototherapy (from supine to prone or lateral positions) may improve the efficiency of phototherapy by hastening the access of phototherapy light to bilirubin deposited in different parts of the skin and subcutaneous tissue.

Objectives: To evaluate the effects of periodic change of body position during phototherapy as compared to no prescribed change in body position, on serum total bilirubin level and duration of treatment in neonates with unconjugated hyperbilirubinaemia during the first 28 days of life. Secondary objectives of the review included evaluation of the efficacy of periodic change of body position on the need for or number of exchange transfusions, incidence of bilirubin-induced neurological damage (BIND), side effects of phototherapy, and sudden infant death syndrome (SIDS).

Search methods: We used the standard search strategy of Cochrane Neonatal to run comprehensive searches in the Cochrane Central Register of Controlled Trials (CENTRAL; 2021, Issue 3) in the Cochrane Library and Ovid MEDLINE and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions on 5 March 2021. We also searched clinical trials databases and the reference lists of included studies and relevant reviews for randomised controlled trials (RCTs) and quasi-RCTs.

Selection criteria: We included RCTs and quasi-RCTs if they enrolled neonates (term and preterm) of either gender with unconjugated hyperbilirubinaemia requiring phototherapy and compared periodic change of the body position of the infant under phototherapy with no prescribed change in body position.

Data collection and analysis: Two review authors independently assessed trial quality and extracted data, consulting with a third review author in the case of disagreement. We used standard Cochrane methodological procedures, including assessing the risk of bias of included studies. We used the GRADE approach to assess the certainty of evidence. Primary outcomes were the duration of phototherapy and rate of fall of serum bilirubin at 24 hours. Secondary outcomes included the need for exchange transfusion, number of exchange transfusions, incidence of BIND, and SIDS.

Main results: We included five studies (343 neonates) with an overall high risk of bias in the review. The body position under phototherapy was changed every two hours or every two-and-a-half hours in two studies each, and every three hours in one study. Three of the five studies included healthy term neonates, whilst the other two studies also included preterm neonates (≥ 33 weeks' gestation); however, separate data about review outcomes in preterm neonates were not available. Periodic change in body position may lead to little or no difference in the duration of phototherapy (mean difference (MD) 1.71 hours, 95% confidence interval (CI) -3.17 to 6.59 hours; I² = 58%; 4 studies, 231 participants; low certainty evidence). Only one study reported the rate of fall of serum total bilirubin at 24 hours of starting the phototherapy. Periodic change in body position may lead to little or no difference in the rate of fall of serum total bilirubin at 24 hours (MD 0.02 mg/dL/h, 95% CI -0.02 to 0.06 mg/dL/h; 1 study, 100 participants; low certainty evidence). We downgraded the certainty of evidence to low due to risk of bias and imprecision. None of the included studies reported the need for or number of exchange transfusions, incidence of BIND, or SIDS. Lack of separate data precluded subgroup analysis.

Authors' conclusions: The available evidence is insufficient to determine the effects of periodic change of body position compared with no prescribed change of body position under phototherapy. There is low certainty evidence that there may be little or no difference in the duration of phototherapy and rate of fall in bilirubin at 24 hours of starting phototherapy between periodic change in body position and no prescribed change of body position under phototherapy in term and preterm neonates. None of the included studies reported the effect of change of position on the need for or number of exchange transfusions, incidence of BIND, or SIDS. One study is awaiting classification and could not be included in the review. Further studies are needed to evaluate the effect of periodic change in body position under phototherapy, especially in neonates with haemolytic hyperbilirubinaemia and in very preterm neonates. The results of this systematic review apply mainly to neonates born at late-preterm or term gestation receiving phototherapy for non-haemolytic hyperbilirubinaemia.

PubMed Disclaimer

Conflict of interest statement

Anu Thukral co‐authored Bhethanabhotla 2013. This study was not funded.

Ashok Deorari co‐authored Bhethanabhotla 2013. This study was not funded.

Deepak Chawla has no interest to declare.

Deepak Chawla extracted the data from Bhethanabhotla 2013.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1: Turning position versus supine under phototherapy, Outcome 1: Duration of phototherapy
1.2
1.2. Analysis
Comparison 1: Turning position versus supine under phototherapy, Outcome 2: Per cent fall in bilirubin at 24 hours of starting phototherapy
1.3
1.3. Analysis
Comparison 1: Turning position versus supine under phototherapy, Outcome 3: Rate of fall of serum total bilirubin at 24 hours of starting phototherapy
1.4
1.4. Analysis
Comparison 1: Turning position versus supine under phototherapy, Outcome 4: Serum total bilirubin at 24 hours of starting phototherapy
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Bhethanabhotla 2013 {published data only}
    1. Bhethanabhotla S, Thukral A, Sankar MJ, Agarwal R, Paul VK, Deorari AK.Effect of position of infant during phototherapy in management of hyperbilirubinemia in late preterm and term neonates: a randomized controlled trial. Journal of Perinatology 2013;33(10):795-9. [DOI: 10.1038/jp.2013.54] [PMID: ] - DOI - PubMed
Chen 2002 {published data only}
    1. Chen CM, Liu SH, Lai CC, Hwang CC, Hsu HH.Changing position does not improve the efficacy of conventional phototherapy. Acta Paediatrica Taiwanica 2002;43(5):255-8. [PMID: ] - PubMed
Donneborg 2010 {published data only}
    1. Donneborg ML, Knudsen KB, Ebbesen F.Effect of infants' position on serum bilirubin level during conventional phototherapy. Acta Paediatrica 2010;99(8):1131-4. [DOI: 10.1111/j.1651-2227.2010.01885.x] [PMID: ] - DOI - PubMed
Mohammadzadeh 2004 {published data only}
    1. Mohammadzadeh A, Bostani Z, Jafarnejad F, Mazloom R.Supine versus turning position on bilirubin level during phototherapy in healthy term jaundiced neonates. Saudi Medical Journal 2004;25(12):2051-2. [PMID: ] - PubMed
Shinwell 2002 {published data only}
    1. Shinwell ES, Sciaky Y, Karplus M.Effect of position changing on bilirubin levels during phototherapy. Journal of Perinatology 2002;22(3):226-9. [DOI: 10.1038/sj.jp.7210678] [PMID: ] - DOI - PubMed

References to studies excluded from this review

Caldera 1984 {published data only}
    1. Caldera R, Maigret P, Maynier M, Larbey P, Fermanian J, Dahan R.Results of 2 prospective surveys on phototherapy of neonatal jaundice in 274 subjects. Study of the influence of light energy intensity and continuous or discontinuous mode of treatment. Annales de Pédiatrie 1984;31(4):297-301. [PMID: ] - PubMed
Fakhraee 2011 {published data only}
    1. Fakhraee SH, Kazemian M, Afjeh SA, Rozati M, Shahsanai A.Effect of infants' position during phototherapy on the level of serum bilirubin. Journal of Isfahan Medical School 2011;29(153):1169-75. [DOI: 10.1111/j.1651-2227.2010.01885.x] [PMID: ] - DOI - PubMed
Lee Wan Fei 2015 {published data only}
    1. Lee Wan Fei S, Abdullah KL.Effect of turning vs. supine position under phototherapy on neonates with hyperbilirubinemia: a systematic review. Journal of Clinical Nursing 2015;24(5-6):672-82. [DOI: 10.1111/jocn.12712] [PMID: ] - DOI - PubMed
Pritchard 2004 {published data only}
    1. Pritchard MA, Beller EM, Norton B.Skin exposure during conventional phototherapy in preterm infants: a randomized controlled trial. Journal of Paediatrics and Child Health 2004;40(5-6):270-4. [DOI: 10.1111/j.1440-1754.2004.00362.x] [PMID: ] - DOI - PubMed
Stanley 2004 {published data only}
    1. Stanley IP, Chung M, Kulig J, O'Brien R, Sege R, Glicken S, et al, American Academy of Pediatrics Subcommittee on Hyperbilirubinemia.An evidence-based review of important issues concerning neonatal hyperbilirubinemia. Pediatrics 2004;114(1):130-53. [DOI: 10.1542/peds.114.1.e130] [PMID: ] - DOI - PubMed
Yamauchi 1989 {published data only}
    1. Yamauchi Y, Kasa N, Yamanouchi I.Is it necessary to change the babies' position during phototherapy? Early Human Development 1989;20(3-4):221-7. [DOI: 10.1016/0378-3782(89)90008-x] [PMID: ] - DOI - PubMed

References to studies awaiting assessment

IRCT201111063250N4 {published data only}IRCT201111063250N4
    1. IRCT201111063250N4.The effect of changing position on bilirubin levels in term healthy neonates with jaundice during phototherapy. www.irct.ir/trial/3324 (first received 4 December 2011).

Additional references

AAP 2004
    1. American Academy of Pediatrics Subcommittee on Hyperbilirubinemia.Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics 2004;114(1):297–316. [DOI: 10.1542/peds.114.1.297] [PMID: ] - DOI - PubMed
Bergman 1985
    1. Bergman I, Hirsch RP, Fria TJ, Shapiro SM, Holzman I, Painter MJ.Cause of hearing loss in high risk premature infant. Journal of Pediatrics 1985;106(1):95-101. [DOI: 10.1016/s0022-3476(85)80476-5] [PMID: ] - DOI - PubMed
Bhutani 2013
    1. Bhutani VK, Wong RJ.Bilirubin neurotoxicity in preterm infants: risk and prevention. Journal of Clinical Neonatology 2013;2(2):61-9. [DOI: 10.4103/2249-4847.116402] [PMID: ] - DOI - PMC - PubMed
Cashore 1990
    1. Cashore WJ.The neurotoxicity of bilirubin. Clinics in Perinatology 1990;17(2):437-47. [PMID: ] - PubMed
Covidence [Computer program]
    1. Covidence.Version accessed 5 March 2021. Melbourne, Australia: Veritas Health Innovation. Available at covidence.org.
Cremer 1958
    1. Cremer RJ, Perryman PW, Richards DH.Influence of light on the hyperbilirubinaemia of infants. Lancet 1958;1(7030):1094-7. [DOI: 10.1016/s0140-6736(58)91849-x] [PMID: ] - DOI - PubMed
Dennery 2001
    1. Dennery PA, Seidman DS, Stevenson DK.Neonatal hyperbilirubinemia. New England Journal of Medicine 2001;344(8):581-90. [DOI: 10.1056/NEJM200102223440807] [PMID: ] - DOI - PubMed
Feldman 2014
    1. Feldman A, Suchy FJ.Approach to the infant with cholestasis . In: Suchy FJ, Sokol RJ, Balistreri WF, editors(s). Liver Disease in Children. New York City: Cambridge University Press, 2014:101–10.
Gkoltsiou 2008
    1. Gkoltsiou K, Tzoufi M, Counsell S, Rutherford M, Cowan F.Serial brain MRI and ultrasound findings: relation to gestational age, bilirubin level, neonatal neurologic status and neurodevelopmental outcome in infants at risk of kernicterus. Early Human Development 2008;84(12):829-38. [DOI: 10.1016/j.earlhumdev.2008.09.008] [PMID: ] - DOI - PubMed
GRADEpro GDT [Computer program]
    1. GRADEpro GDT.Version accessed 31 March 2021. Hamilton (ON): McMaster University (developed by Evidence Prime). Available at gradepro.org.
Hansen 2010
    1. Hansen TW.Twists and turns in phototherapy for neonatal jaundice. Acta Paediatrica 2010;99:1117-8. [DOI: 10.1111/j.1651-2227.2010.01898.x.] - DOI - PubMed
Higgins 2011
    1. Higgins JP, Altman DG, Sterne JA: on behalf of the Cochrane Statistical Methods Group and the Cochrane Bias Methods Group.Chapter 8: Assessing risk of bias in included studies. In: Higgins JP, Green S, editor(s). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available from training.cochrane.org/handbook/archive/v5.1/.
Higgins 2021
    1. Higgins JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, editor(s).Cochrane Handbook for Systematic Reviews of Interventions Version 6.2 (updated February 2021). Cochrane, 2021. Available from training.cochrane.org/handbook.
Hunt 2003
    1. Hunt CE, Lesko SM, Vezina RM, McCoy R, Corwin MJ, Mandell F, et al.Infant sleep position and associated health outcomes. Archives of Pediatrics & Adolescent Medicine 2003;157(5):469–74. [DOI: 10.1001/archpedi.157.5.469] [PMID: ] - DOI - PubMed
Hyman 1969
    1. Hyman CB, Keaster J, Hansen V, Harris I, Sedgwick R, Wursten H, et al.CNS abnormalities after neonatal hemolytic disease or hyperbilirubinemia. A prospective study of 405 patients. American Journal of Diseases of Children 1969;117(4):395-405. [DOI: 10.1001/archpedi.1969.02100030397002] [PMID: ] - DOI - PubMed
Jackson 1997
    1. Jackson JC.Adverse events associated with exchange transfusion in healthy and ill newborns. Pediatrics 1997;99(5):E7. [DOI: 10.1542/peds.99.5.e7] [PMID: ] - DOI - PubMed
Jeffery 1999
    1. Jeffery HE, Megevand A, Page HD.Why the prone position is a risk factor for sudden infant death syndrome. Pediatrics 1999;104(2 Pt 1):263-9. [DOI: 10.1542/peds.104.2.263] [PMID: ] - DOI - PubMed
Johnson 1974
    1. Johnson L, Boggs TR.Bilirubin-dependent brain damage: incidence and indications of treatment. In: Odell GB, Schaffer R, Sionpuolous AP, editors(s). Phototherapy in Newborn: an Overview. Washington National Academy of Sciences, 1974.
Lau 1984
    1. Lau SP, Fung KP.Serum bilirubin kinetics in intermittent phototherapy of physiological jaundice. Archives of Disease in Childhood 1984;59(9):892-4. [DOI: 10.1136/adc.59.9.892] [PMID: ] - DOI - PMC - PubMed
Maisels 1986
    1. Maisels MK, Gifford K.Normal serum bilirubin levels in the newborn and the effect of breast-feeding. Pediatrics 1986;78(5):837-43. [PMID: ] - PubMed
Maisels 2001
    1. Maisels MJ.Phototherapy - traditional and nontraditional. Journal of Perinatology 2001;21(Suppl 1):S93–7; Discussion S104–7. [DOI: 10.1038/sj.jp.7210642] [PMID: ] - DOI - PubMed
Maisels 2008
    1. Maisels MJ, McDonagh AF.Phototherapy for neonatal jaundice. New England Journal of Medicine 2008;28(9):920-8. [DOI: 10.1056/NEJMct0708376] [PMID: ] - DOI - PubMed
Mitchell 1999
    1. Mitchell EA, Thach BT, Thompson JM, Williams S.Changing infants' sleep position increases risk of sudden infant death syndrome. New Zealand Cot Death Study. Archives of Pediatric and Adolescent Medicine 1999;153(11):1136-41. [DOI: 10.1001/archpedi.153.11.1136] [PMID: ] - DOI - PubMed
NICE 2016
    1. National Institute for Health and Care Excellence.Neonatal jaundice. www.nice.org.uk/CG98 (accessed prior to 21 June 2019).
Polin 1990
    1. Polin RA.Management of neonatal hyperbilirubinemia: rational use of phototherapy. Biology of the Neonate 1990;58(Suppl 1):32-43. [DOI: 10.1159/000243298] [PMID: ] - DOI - PubMed
Pratesi 1989
    1. Pratesi R, Agati G, Fusi F.Phototherapy for neonatal hyperbilirubinemia. Photo-dermatology 1989;6(6):244-57. [PMID: ] - PubMed
Rennie 2010
    1. Rennie J, Burman-Roy S, Murphy MS, Guideline Development Group.Neonatal jaundice: summary of NICE guidance. BMJ 2010;340:c2409. [DOI: 10.1136/bmj.c2409] [PMID: ] - DOI - PubMed
Review Manager 2014 [Computer program]
    1. Review Manager 5 (RevMan 5).Version 5.3. Copenhagen: Nordic Cochrane Centre, The Cochrane Collaboration, 2014.
Rubin 1979
    1. Rubin RA, Balow B, Fisch RO.Neonatal serum bilirubin levels related to cognitive development at ages 4 through 7 years. Journal of Pediatrics 1979;94(4):601-4. [DOI: 10.1016/s0022-3476(79)80022-0] [PMID: ] - DOI - PubMed
Scheldt 1977
    1. Scheldt PC, Mellits ED, Hardy JB, Drage JS, Boggs TR.Toxicity to bilirubin in neonates: infant development during first year in relation to maximal neonatal serum bilirubin concentration. Journal of Pediatrics 1977;92(2):292-7. [DOI: 10.1016/s0022-3476(77)80835-4] [PMID: ] - DOI - PubMed
Schünemann 2013
    1. Schünemann H, Brożek J, Guyatt G, Oxman A, editor(s).Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach (updated October 2013). GRADE Working Group, 2013. Available from gdt.guidelinedevelopment.org/app/handbook/handbook.html.
Shapiro 2005
    1. Shapiro SM.Definition of the clinical spectrum of kernicterus and bilirubin-induced neurologic dysfunction (BIND). Journal of Perinatology 2005;25(1):54-9. [DOI: 10.1038/sj.jp.7211157] [PMID: ] - DOI - PubMed
Smitherman 2006
    1. Smitherman H, Stark AR, Bhutani VK.Early recognition of neonatal hyperbilirubinemia and its emergent management. Seminars in Fetal & Neonatal Medicine 2006;11(3):214-24. [DOI: 10.1016/j.siny.2006.02.002.] - DOI - PubMed
Vogl 1974
    1. Vogl TP.Phototherapy of neonatal hyperbilirubinemia: bilirubin in unexposed areas of the skin. Journal of Pediatrics 1974;85(5):707-10. [DOI: 10.1016/s0022-3476(74)80524-x] [PMID: ] - DOI - PubMed
Vogl 1978
    1. Vogl TP, Hegyi T, Hiatt IM, Polin RA, Indyk L.Intermediate phototherapy in the treatment of jaundice in the premature infant. Journal of Pediatrics 1978;92(4):627-30. [DOI: 10.1016/s0022-3476(78)80308-4] [PMID: ] - DOI - PubMed
Vreman 2004
    1. Vreman HJ, Wong RJ, Stevenson DK.Phototherapy: current methods and future directions. Seminars in Perinatology 2004;28(5):326-33. [DOI: 10.1053/j.semperi.2004.09.003] [PMID: ] - DOI - PubMed
Wells 2013
    1. Wells C, Ahmed A, Musser A.Strategies for neonatal hyperbilirubinemia: a literature review. MCN: The American Journal of Maternal/Child Nursing 2013;38(6):377-82. [DOI: 10.1097/NMC.0b013e3182a1fb7a] [PMID: ] - DOI - PubMed
Willinger 1991
    1. Willinger M, James LS, Catz C.Defining the sudden infant death syndrome (SIDS): deliberations of an expert panel convened by the National Institute of Child Health and Human Development. Pediatric Pathology 1991;11(5):677-84. [DOI: 10.3109/15513819109065465] [PMID: ] - DOI - PubMed
Wong 2019
    1. Wong RJ, Bhutani VK.Pathogenesis and etiology of unconjugated hyperbilirubinemia in the newborn. www.uptodate.com/contents/pathogenesis‐and‐etiology‐of‐unconjugated‐hype... Accessed 15 December 2018.

References to other published versions of this review

Thukral 2015
    1. Thukral A, Deorari A, Chawla D.Periodic change of body position under phototherapy in term and late preterm neonates with hyperbilirubinemia. Cochrane Database of Systematic Reviews 2015, Issue 12. Art. No: CD011997. [DOI: 10.1002/14651858.CD011997] - DOI - PMC - PubMed

Publication types