Department of Pediatrics, Lady Hardinge Medical College and Smt Sucheta Kriplani Hospital, New Delhi, India.
Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India.
Cochrane Database Syst Rev. 2022 Mar 2;3(3):CD011997. doi: 10.1002/14651858.CD011997.pub2.
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.
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).
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.
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.
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.
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.
光疗是治疗新生儿高胆红素血症的主要方法。在光疗过程中定期改变新生儿的体位（从仰卧位到俯卧位或侧卧位）可能会通过加速光疗光到达皮肤和皮下组织中不同部位沉积的胆红素来提高光疗的效率。
评估与无规定体位改变相比，在出生后 28 天内患有未结合高胆红素血症的新生儿光疗过程中定期改变体位对血清总胆红素水平和治疗持续时间的影响。本综述的次要目标包括评估定期改变体位对换血需求或换血次数、胆红素诱导的神经损伤（BIND）发生率、光疗副作用和婴儿猝死综合征（SIDS）的影响。
我们使用 Cochrane 新生儿试验的标准检索策略在 Cochrane 图书馆的 Cochrane 对照试验中心注册库（CENTRAL；2021 年第 3 期）、Ovid MEDLINE 和 Epub 提前在线、处理中及其他非索引引文、每日和版本中进行全面检索，检索日期为 2021 年 3 月 5 日。我们还检索了临床试验数据库和纳入研究及相关综述的参考文献，以查找随机对照试验（RCT）和准随机对照试验。
如果试验纳入了需要光疗的性别不限的足月和早产新生儿（无论性别），并且比较了光疗下婴儿体位的定期变化与无规定体位改变，我们将纳入 RCT 和准 RCT。
两名综述作者独立评估试验质量并提取数据，如果存在分歧，则与第三名综述作者协商。我们使用了标准的 Cochrane 方法学程序，包括评估纳入研究的偏倚风险。我们使用 GRADE 方法评估证据的确定性。主要结局是光疗持续时间和 24 小时内血清胆红素下降率。次要结局包括换血需求、换血次数、BIND 发生率和 SIDS。
我们纳入了五项研究（343 名新生儿），总体存在高偏倚风险。两项研究中，光疗下的体位每两小时或每两小时半改变一次，另外两项研究中，每三小时改变一次。五项研究中的三项研究纳入了健康的足月新生儿，而另外两项研究也纳入了早产儿（≥33 周妊娠）；然而，关于早产儿的综述结局的单独数据不可用。定期改变体位可能导致光疗持续时间的差异较小或无差异（平均差值 1.71 小时，95%置信区间 -3.17 至 6.59 小时；I² = 58%；4 项研究，231 名参与者；低确定性证据）。只有一项研究报告了开始光疗后 24 小时内血清总胆红素下降率。定期改变体位可能导致 24 小时内血清总胆红素下降率的差异较小或无差异（MD 0.02mg/dL/h，95%置信区间 -0.02 至 0.06mg/dL/h；1 项研究，100 名参与者；低确定性证据）。我们因偏倚和不精确而将证据的确定性降为低。纳入的研究均未报告换血需求或换血次数、BIND 发生率或 SIDS。缺乏单独的数据，排除了亚组分析。
目前的证据不足以确定与无规定体位改变相比，光疗下定期改变体位的效果。有低确定性证据表明，在足月和早产儿新生儿中，定期改变体位与无规定体位改变相比，光疗持续时间和开始光疗后 24 小时内胆红素下降率可能差异较小或无差异。纳入的研究均未报告改变体位对换血需求或换血次数、BIND 发生率或 SIDS 的影响。一项研究正在等待分类，因此无法纳入本综述。需要进一步的研究来评估光疗下定期改变体位的效果，特别是在患有溶血性高胆红素血症和极早产儿中的效果。本系统评价的结果主要适用于接受非溶血性高胆红素血症光疗的晚期早产儿或足月出生的新生儿。
