This study set out to establish the views of mothers on a novel treatment of neonatal jaundice with FSPT in a clinical setting that is frequently constrained to deliver effective conventional blue-light phototherapy. This is against the backdrop of reported concerns regarding the safety of sunlight exposure for therapeutic purposes including the treatment of jaundice [20–22]. In fact, several clinical guidelines for the management of neonatal jaundice expressly prohibit exposure to sunlight as a form of treatment [23–26], perhaps, except in Ghana where the national treatment guidelines for newborn care made a cursory allowance for sunlight exposure of jaundiced infants .
The overarching finding in this study is that mothers whose jaundiced infants received FSPT were quite satisfied with this form of treatment despite needing to keep their infants exposed throughout the day. Regardless of the reservations expressed by a few mothers on sunlight exposure, the vast majority expressed willingness to accept this treatment in future, if required, and were confident enough to recommend it to other mothers. As this is the first survey among mothers regarding FSPT, there are no comparable studies yet. However, two studies have explored maternal knowledge, attitude and practice regarding exposure of babies to “unfiltered” sunlight [9, 22]. In the first study from Australia among 114 Caucasian women, 36% thought it was a good idea to sun their baby to treat jaundice; 21.1% disagreed and the rest (43%) were unsure . In fact, one-third of the mothers indicated that they would sun their baby with suspected jaundice without recourse to a doctor. About 24% of the mothers had sunned their baby to treat jaundice either through a window, on a veranda or exposed to direct sunlight. Women who had sunned their baby suspected with jaundice were found to be significantly more likely than other women to be in favor of this treatment (p = 0.00001). It was further reported that 41% of the mothers were advised to sun their baby to treat jaundice by a hospital nurse/midwife, 28% by a pediatrician/medical officer and 6% by both physicians and nurses. A second study conducted in Turkey, sought the views of 118 mothers regarding the possible use of sun exposure as treatment for jaundice . About 15 (12.7% of 118 or 14% of the 107 mothers who responded) indicated that sunlight was good for jaundice but there was no information on the number of mothers who had actually used this form of treatment. Of those who responded to this question on the use of sunlight for treating jaundice, 7 (6.5%) mothers did consider this treatment as good while the vast majority (79.4%) had no idea. Besides treatment for neonatal jaundice, sun exposure is also used in these two countries by mothers to alleviate nappy rash, ensure adequate production of vitamin D and for bone development unlike the practice in our study population where sun exposure is predominantly associated with treatment of jaundice.
In settings with good access to functional conventional phototherapy, FSPT would probably be unnecessary. Educational intervention to discourage mothers and health professionals from using unfiltered sunlight treatment for newborns with jaundice in such settings may therefore be justified [20, 21]. However, where access to conventional phototherapy is lacking, FSPT needs to be considered for infants at risk of severe jaundice and kernicterus as the benefit is likely to exceed any potential harm. It is important to make a clear and emphatic distinction between untested films or filters and FSPT that pre-tested films that are duly approved by the relevant Safety Regulatory Authorities. Exposure of newborns to direct and unfiltered sunlight should under any circumstances be discouraged because of the potential and invisible harms from ultraviolet radiation and infrared rays. This is because mothers are likely to be dissuaded by the widely publicized therapeutic effect of this age-long practice on the child. As our study would suggest, a high proportion of mothers are likely to learn about neonatal jaundice from health workers usually during antenatal clinics. This forum provides opportunity for proper education on the dangers of indiscriminate exposure of jaundice babies to sunlight.
Where FSPT is contemplated, the ideal sunlight PT film should: (i) block ultraviolet radiation to <1% that of unfiltered sunlight (~2000 μW/cm2); (ii) block infrared sufficiently to maintain patient thermostasis; (iii) transmit sufficient level of therapeutic blue light; and (iv) be transparent to facilitate visibility of the patient for purposes of clinical management . The two films used for this study excluded virtually all UVA, UVB and UVC radiation. For instance, the film chosen for use during overcast sky periods, transmitted 79% of the >400–520 nm wavelength blue light and only 0.1% of the 315–400 nm UVA while the film chosen for periods of direct sunlight, transmitted 33% of the 400–520 nm wavelength light and 0.4% of the UVA radiation [13, 14]. The two films provided partial shade that reduced the temperature under a cloudy and cloudless sky by 6°C and 9.5°C, respectively. However, studies reporting the use of some form of “filtered” sunlight phototherapy in which the baby is shielded with tinted glass window rarely provide safety data on the level of radiation which makes comparison with our study or an independent assessment difficult [9, 28]. One study from Bangladesh, for example, only reported that infants were exposed to the sun for 1-2hours in the early morning and afternoon using a “filter of tinted glass” .
The opportunity to feed and bond with child while receiving treatment was appreciated by mothers, unlike when they have to be separated under conventional phototherapy. Our study also highlights other essential components of maternal satisfaction with FSPT such as adequacy of information provided regarding the treatment, the physical environment, quality of nursing care received which would include friendliness of the health workers, and the concept of group FSPT under a single canopy which offered opportunity for socializing with other mothers. The higher level of satisfaction among the multiparous mothers could be a reflection of their experience with newborn care and the fact that this treatment did not require any form of medication, unlike other childhood illnesses. Our study also suggests that mothers who belonged to high social class by virtue of their (and spouse’s) educational status, and who ordinarily would have chosen to deliver in a private hospital, are likely to be more sensitive to the physical ambience of the test environment in this public hospital. Efforts towards improving the ambience of the test environment should also be considered in offering FSPT.
While the safety and efficacy of the FSPT used in this population have been rigorously demonstrated , its widespread promotion is still subject to further evaluation especially regarding how to handle interruptions due to inclement weather conditions. The findings in this present study should, therefore, be considered as exploratory, as with most innovative health care interventions. One limitation of this study is that we were not able to determine if maternal satisfaction was correlated with the severity of jaundice and age of the child on enrolment as only infants with mild to moderate jaundice were treated. We could not ascertain maternal views on preterm infants who were jaundiced as they were excluded from FSPT treatment. The psychometric properties of the questionnaire were not statistically evaluated. However, considering that the questionnaire was adapted from a properly validated questionnaire earlier used among a different set of mothers in a multi-centre survey in three distinct geographical regions in the country, there is no reason to doubt its validity in this study population . Moreover, the overall maternal satisfaction ratings were consistent with the expected efficacy of FSPT on the enrolled infants as earlier reported [13, 14].