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Treatment

Recommendations
See the end of Section 7.2.3.

Additional fluids/feeds during phototherapy

Clinical question
Is it beneficial to give additional fluids (cup feeds, fluids) during treatment with phototherapy?
What is the effectiveness of nutritional support and/or rehydration during treatment with
phototherapy in babies with neonatal hyperbilirubinaemia?
– oral – top up milk feeds by bottle/cup/spoon or other liquids (water/juice)
– parenteral feeds

The electronic searches (which were not restricted by study methodology) identified 1831
references although the majority were excluded on the basis of title and abstract. The main
reasons for exclusion at this stage were either that the reference dealt with a non-interventional
study or that feeding was not the intervention being examined but was mentioned in passing.

Of the 20 references that were requested as hard-copy articles, four were included and 16 were
excluded for the following reasons: babies were not jaundiced (five studies), not randomised
(five studies), no clear intervention (four studies), comparison of phototherapy with interruption
of breastfeeding (one study), and the comparison of hospital routines which included feeding
(one study).
The included studies were divided into two groups: one group dealt with fluids or feeds given in
combination with phototherapy and the other dealt with additional fluids or feeds as
interventions to minimise the rise in serum bilirubin and reduce the need for phototherapy.

Description of included studies
Four RCTs (n = 278) dealt with additional fluids or feeds alongside phototherapy for the
treatment of hyperbilirubinaemia. Two studies used computer-generated 133 or block
randomisation 174 and two studies 174;175 used sealed envelopes to conceal allocation. Where
reported, the mean birthweight of the samples ranged from 2936 ± 473 g to 3404 ± 361 g, the
mean gestational age ranged from 37.6 ± 0.9 weeks to 39.4 ± 0.9 weeks, the mean age at entry
to the study ranged from 95 ± 17.7 hours to 139 ± 47 hours, and the mean serum bilirubin
levels ranged from 254 ± 22 micromol/litre to 377 ± 66 micromol/litre. Of the combined
sample, 188 participants (67.6%) were male.
Review findings
The first RCT(n = 74), from India, 174 compared giving extra fluids to babies undergoing
phototherapy with a control group receiving standard hydration. Babies in the ‘extra fluids’
group received intravenous fluid supplementation with 1/5 normal saline in 5% dextrose for a
period of 8 hours before phototherapy. Standard care consisted of conventional phototherapy
combined with 30 ml/kg per day of extra oral feeds (expressed breast milk or formula) until
phototherapy was discontinued. Subjects were randomised in stratified blocks according to
serum bilirubin levels at entry to the study. Sealed envelopes were used to conceal the
allocation. Statistically significantly more exchange transfusions were needed among babies
receiving standard hydration (RR 3.3, 95% CI 1.51 to 7.35). The ‘extra fluids’ group also
showed a statistically significantly greater mean reduction in serum bilirubin
(MD = 26 micromol/litre, 95% CI 10.60 to 41.40 micromol/litre) over 24 hours and a shorter
duration of phototherapy (MD = 21 hours, 95% CI 9.45 to 32.55 hours). [EL 1++]
The second RCT(n = 54), from Malaysia, 175 also examined the supplementation of phototherapy
and enteral feeds with intravenous fluids. All babies received daily maintenance fluids at
90 ml/kg on day 2, 120 ml/kg on day 3 and 150 ml/kg per day from day 4 onwards. They were
also given an additional 10% of their respective total daily fluid requirement to compensate for
fluid loss during phototherapy. The enteral feeds group was given eight divided feeds at 3-hour
intervals. Breastfed babies were fed on demand. In addition, the breastfed babies were given
half the volume of formula feeds that formula-fed babies received. In the intravenous group,

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