Vol 17821 April 2003
EBM IN ACTION
The Medical Journal of Australia ISSN: 0025-729X 21
April 2003 178 8 403-403
©The Medical Journal of Australia 2003
EBM in Action
reduction of jaundice. A randomised controlled trial com-
paring sunlight exposure to no treatment or another treat-
ment would be the most appropriate study design to answer
this clinical question.
“Is sunlight an effective treatment for jaundice in term infants?”
A women’s health educator at Southern Health wanted to
know if there was any evidence that sunlight helps to reduce
physiological jaundice in healthy term infants.
The formulated search question followed a standard
patients/interventions/comparisons/outcomes (PICO) for-
mat. Patients were term newborn infants with physiological
jaundice (see Box), and the intervention was exposure to
sunlight. Clinical outcomes of interest were primarily a
The search terms “neonatal jaundice”, “hyper-
bilirubin(a)emia” or “icterus” were combined with the
treatment search terms “sunlight”, “heliotherapy” or
“phototherapy”. We searched the following electronic
databases: the Cochrane Library, Best Evidence, MEDLINE,
CINAHL (Cumulative Index to Nursing and Allied Health
Literature), Current Contents and Biological Abstracts.
MEDLINE indexes articles published since 1966, but a
widely cited and historically important article that pro-
vided the first English-language report of an association
between light and a reduction in neonatal jaundice was
published in 1958.2 In light of this, we hand-searched the
print versions of Index Medicus and Science Citation Index
from 1958 to 1966. We also searched the websites of a
number of organisations: Bandolier, University of Michi-
gan Department of Pediatrics (Evidence-Based Pediatrics),
US National Guidelines Clearinghouse, National Health
and Medical Research Council of Australia (Publications
Catalogue), Scottish Intercollegiate Guidelines Network,
and UK National Health Service (Institute of Health
Sciences Guideline Project).
Summary of findings
Our extensive search identified only the one, original study
that examined sunlight exposure as a treatment for neonatal
jaundice.2 This was a case series reporting the effect of
sunlight in jaundiced preterm, rather than term, infants.
The same authors then reported a case series of artificial
light therapy for jaundiced preterm infants, which stimu-
lated the subsequent considerable volume of research arti-
cles on the effectiveness of phototherapy for neonatal
jaundice in both term and preterm infants. Current recom-
mendations for artificial phototherapy are summarised else-
where.3 We found no controlled trials comparing sunlight
against either no treatment or artificial light treatment for
jaundice. The use of sunlight appears to have resulted from
anecdotal reports of its effectiveness4 rather than from
rigorous medical evidence. And if the effectiveness of sun-
light exposure for jaundice is unknown, so too is the
incidence of potential risks to the neonate — for example,
sunburn or photosensitivity.
There is insufficient evidence to support exposure to sun-
light for the treatment of jaundice. The persistence of this
practice 40 years after publication of a report on a single
case series raises questions about the influence of evidence
on the beliefs of professional healthcare workers. Based on
our search results, a recommendation against using sunlight
exposure to treat jaundice was distributed to Southern
Health staff and used in an education program for midwives.
Renea V Johnston,* Jeremy N Anderson†
*Research Officer, †Associate Professor, and Director
Centre for Clinical Effectiveness, Monash Institute of Health Services Research
Southern Health, Monash Medical Centre, Clayton, VIC
Women's Health Educator
Monash Medical Centre, Moorabbin, VIC
1. Levene MI, Tudhope DI, Thearle MJ, editors. Essentials of neonatal medicine. 3rd
ed. Massachusetts: Blackwell Science, 2000: 143.
2. Cremer RJ, Perryman PW, Richards DH. Influence of light on the hyperbiliru-
binaemia of infants. Lancet 1958; i: 1094-1097.
3. American Academy of Pediatrics. Practice parameter: management of hyper-
bilirubinaemia in the healthy term newborn. Pediatrics 1994; 94: 558-565.
4. Harrison SL, Buettner PG, MacLennan R. Why do mothers still sun their infants? J
Paediatr Child Health 1999; 35: 296-299.
(Received 3 Oct 2002, accepted 8 Dec 2002)
Is sunlight an effective treatment for infants with jaundice?
Renea V Johnston, Jeremy N Anderson and Cheryl Prentice
Definition of physiological jaundice1
Physiological jaundice is a diagnosis of exclusion. It should not fill
any of the following criteria:
■ Clinical jaundice in the first 24 hours of life;
■ Total serum bilirubinlevel >300?mol/L in a term infant or
>255?mol/L in a preterm infant;
■ Direct reacting serum bilirubin level >30?mol/L, persisting more
than 10 days in a term infant or 14 days in a preterm infant.
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