#377 - 💡 Rethinking Phototherapy – Phototherapy as Pharmacotherapy with Dr. Daniel Rauch
- Mickael Guigui
- 9 hours ago
- 25 min read
Hello friends 👋
In the second installment of our Rethinking Phototherapy series, Ben and Daphna welcome Dr. Daniel Rauch, Professor of Pediatrics at the Hackensack Meridian School of Medicine and Division Chief of Pediatric Hospital Medicine and General Academic Pediatrics at Joseph Sanzari Children’s Hospital. Dr. Rauch co-authored the AAP technical report on phototherapy and brings a unique perspective on how light therapy should be understood and applied in clinical practice.
This conversation reframes phototherapy as a true pharmacotherapy—an intervention that must be delivered in precise doses with attention to wavelength, irradiance, body surface exposure, and treatment duration. Dr. Rauch explains why more light is not always better, how technology has evolved from “easy-bake oven” style lamps to modern LED systems, and why maximizing body surface exposure often matters more than piling on extra light banks. The discussion also touches on cycling strategies, the value and limitations of transcutaneous monitoring, and the potential of home phototherapy to reduce unnecessary hospitalizations while supporting family bonding.
Listeners will gain practical insights into the art and science of phototherapy: how to optimize treatment, minimize harm, and communicate clearly with families navigating jaundice management.
Link to episode on youtube: https://youtu.be/RuSA184zcI0
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Short Bio: Daniel A. Rauch, MD is a Professor of Pediatrics at the Hackensack Meridian School of Medicine, where he also serves as Vice Chair for Community Relations and Division Chief of Pediatric Hospital Medicine and General Academic Pediatrics at the Joseph M. Sanzari Children’s Hospital. A nationally recognized leader in pediatrics, he has authored more than 40 peer-reviewed articles, edited multiple books, and delivered over 180 national presentations. Most recently, he coauthored the American Academy of Pediatrics Technical Report on Phototherapy to Prevent Severe Neonatal Hyperbilirubinemia , which will be the focus of today’s discussion.
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The article covered on today’s episode of the podcast can be found here 👇
Bhutani VK, Wong RJ, Turkewitz D, Rauch DA, Mowitz ME, Barfield WD; COMMITTEE ON FETUS & NEWBORN.Pediatrics. 2024 Sep 1;154(3):e2024068026. doi: 10.1542/peds.2024-068026.PMID: 39183672 Review.
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The transcript of today's episode can be found below 👇
Ben Courchia (00:00.856)
Hello everybody, welcome back to the Incubator podcast. We're back today to continue our discussion on hyperbilirubinemia and phototherapy. Daphna, good morning. How are you?
Daphna Yasova Barbeau (00:09.307)
Good morning, I'm doing well. I'm going to call out my division chief from fellowship. We talk about bilirubin and he'd say, "Just don't let the baby get kernicterus." But I think through our discussions, we're learning there's just so much more to phototherapy than they taught us in fellowship.
Ben Courchia (00:30.466)
That's exactly right. And today to discuss that with us, we are joined by Dr. Daniel Rauch. Dr. Rauch, welcome to the podcast. For people who may not be familiar with your work, you're a professor of pediatrics at the Hackensack Meridian School of Medicine, where you also serve as vice chair for community relations and division chief of pediatric hospital medicine and general academic pediatrics at the Joseph M. Sanzari Children's Hospital. You're recognized nationally as a leader in pediatrics with more than 40 peer-reviewed articles, multiple edited books, over 180 national presentations. Most recently, you co-authored the American Academy of Pediatrics technical report on phototherapy to prevent severe neonatal hyperbilirubinemia, which we'll be focusing on today. It's a pleasure to have you on the show.
Daniel Rauch (01:15.509)
Thank you. And full disclosure, not a neonatologist, take care of well newborns and full-term babies.
Ben Courchia (01:24.684)
Yeah, that's right. In the prior episode, we've reviewed with Dr. Kemper the AAP guidelines. So if we refer to them and you have any questions as the audience, please refer to that prior episode. Today we'll be focusing on phototherapy as a pharmacotherapy, a true dose-dependent intervention. And that's, I guess, where I'd like to begin, Dr. Rauch. I mean, Dr. Rauch was my mentor in residency. I cannot call him by his first name. I'm just going to... I know this is the rule of the podcast, but this is just not going to happen. Phototherapy in the paper you write needs to be delivered in measurable doses, irradiance, which makes it conceptually similar to pharmacotherapy. How does this analogy to drug dosing change how we should maybe order, monitor, and document phototherapy?
Daniel Rauch (02:12.775)
It changes how we think of it in a couple different ways. And I'll start on one end of loosely thinking about it. So when you think about a lot of drug dosing, let's say antibiotic dosing, there's a range that you're shooting for. So it doesn't have to be specific. We'd like to deliver phototherapy, but it doesn't have to be 24 hours. It could be 23 hours. It could be 22 hours, depending on how serious the level of hyperbilirubinemia is. And we don't need to be rigid about that. I've been in hospital systems where the nurses in particular are fanatical. The baby has to be under lights constantly and you shouldn't even look at the baby, nevermind take the baby out to feed or swaddle or change. And that's not true. We're looking for overall dosing. We're not looking for consistent 100% of the time with rare circumstances. Obviously a child who's near the exchange transfusion threshold, or you're worried that they are already exhibiting signs of kernicterus or bilirubin encephalopathy, that's different. Very small percentage of babies, though. The overwhelming majority of babies, we want to expose them, we want to expose them for a majority of the time they're in our treatment, but we don't have to be crazy about it. The other end of that is, if we're going to deliver a medication, we want to deliver the medication. So you don't rub amoxicillin on a child, you deliver it orally. You don't put them in a room with light and hope something good happens. You want to put them in a room with the right light that's delivering the right frequency and make sure that happens. I vividly remember a child who did not respond to phototherapy and everybody accused the mother of taking the child out all the time. And it turns out the lights had been sent to biotech and were not delivering the right frequency of light. So the mom was completely innocent.
Daphna Yasova Barbeau (04:01.556)
Oh man.
Daniel Rauch (04:04.129)
And we were the problem because we weren't delivering the right medication.
Ben Courchia (04:09.772)
Yeah, and what's interesting is you do summarize that in the paper where it says, record of therapy provided is best described by: one, duration; number of devices; three, daily measure at the skin level exposure; and three, the percent of body surface area exposed. Do you think NICUs realistically are tracking all this? And do you think that for those who are not, they should?
Daniel Rauch (04:36.481)
So no, and there was a little bit of back and forth on measuring exposure as being something that's probably not being done and probably not feasible in most nurseries. I don't think it's being done in most NICUs and it's certainly not being done in level one and level two nurseries around the country. I do think body surface area and the amount that's exposed makes a big difference and I trained in the time the lights were different and there was single therapy, double therapy, quadruple therapy. The light technology has changed. It's sort of like candlelight. There's different equivalences now. But if a baby's lying on a bed, that's half of their body surface area that's not being exposed. If they're clothed or if they have diapers and they have things on their face, that's another good percentage of their body surface area that's not being exposed. And critically important is not just that their body surface area is exposed, but it's exposed at the right angle to the light. So tangential just doesn't work as well. And I actually saw your episode on the bilirubin hut. And the concept of rotating the lights so that they hit the body surface area at a perpendicular angle is so critical. So you can bake the child. Essentially, the early lights in the warmers were easy-bake ovens. And we pushed a number of kids to have fevers and drove full sepsis workups on babies who were completely iatrogenic. But stacking them doesn't really increase the exposure, it just increases the heat and the brightness.
Daphna Yasova Barbeau (06:02.584)
Mm-hmm.
Ben Courchia (06:09.859)
Yeah.
Daphna Yasova Barbeau (06:10.532)
Makes sense.
Daniel Rauch (06:25.665)
So having an understanding of the technical aspects really should help drive appropriately the intervention that you're doing.
Ben Courchia (06:34.124)
Yeah, and one of the points about exposure and making sure that as much of the body surface area is exposed came up in the paper in the recommendations regarding the use of diapers. And I thought that that particular recommendation was almost humorous because of the way it was written. I'm going to quote the paper. It says, "Concerns for the long-term effects of continuous phototherapy exposure of the reproductive systems have been raised, but not substantiated." And that's the funny line. "Diapers are used for hygienic purposes and not for gonadal protection."
Daphna Yasova Barbeau (06:44.89)
Hmm?
Daniel Rauch (07:04.469)
Right, so at the risk of being incredibly cynical, I will tell you that that recommendation came from a legal perspective of somebody getting sued and being told they didn't protect the gonads while they were having treatment.
Ben Courchia (07:18.508)
Wow.
Daniel Rauch (07:18.617)
There is nobody who's gotten that. There is no evidence to suggest that's a risk, but that came out of, there has to be some statement saying we're aware of it and there's no proof of that. So ironically, the reason it was put in there is exactly what you're implying, but in reverse, it's covering that it's not a concern or a risk.
Ben Courchia (07:42.156)
So it's a statement that feels frivolous, but actually has some real-world applications.
Daniel Rauch (07:46.961)
Very real-world practical applications.
Ben Courchia (07:49.282)
All right, switching gears a little bit. There's a section in the technical report about emerging technologies and non-invasive bilirubin measurements. And one of the things that stood out is the section on using a standard iPhone camera and an algorithm that can make the measurement. And you mentioned that it was more designed for low and middle-income countries. How close do you think we are to actually making this a mainstream technique for bilirubin monitoring in the US? And what would be the obstacles to its adoption?
Daniel Rauch (08:22.045)
So there's two things. One is, I don't think we're that far away because the technology is out there and it's been shown to work. The limitation in this country, by the way, is not the technology. The limitation is the regulatory agencies. So in order to get approval for something like this to be used for medical purposes, you have to show benefit. You have to show that it's safe and it's effective. And we don't even have good standards of how to measure that.
So you're going to have to have something that's comparable to the transcutaneous bilirubinometer, which itself has not been shown to do anything. We believe it does, and there's logic suggesting it probably does, but we have no true evidence-based proof of that. So you're going to have to do a standard measurement, and then you're going to have to show that you have less error than the standard. And there are a number of studies that have been done in low and middle-income countries because they don't have access to the technology.
And secondly, they don't have the regulatory agencies to have to approve it. It's clearly cheaper. And they were just able to show that you could do it well and it worked and it was reliable and it wasn't harmful. And there were a bunch of papers that came out showing that. But they don't have those regulatory agencies and you don't have to prove benefit from doing it. So I'm not suggesting we start doing this on people in the United States, but the barrier is regulatory rather than technical.
Ben Courchia (09:50.35)
That's fascinating. And so, I mean, I guess you were alluding to it with the TCB, the transcutaneous bilirubin monitoring. And I wanted to ask you about that because there is also a section in the paper that relates to the TCB device, and the paper reviews that there is data suggesting that it's inaccurate after phototherapy initiation. And to me, that was quite striking. So what should people who are starting phototherapy and are looking to monitor, what should they do? Should they just ignore TCB? Should they space out the TSB checks?
that if we're using phototherapy as a medication, we want to know whether the levels are going down. What are we supposed to do then?
Daniel Rauch (10:33.269)
So I think what I would suggest is that we use it the same way that we use glucose monitoring at the bedside. When you use the stick for glucose monitoring at the bedside, you don't confirm it with a glucose level from a serum draw unless it's critically high or critically low. And even then, you don't not treat because of waiting for the lab result. So TCBs are inherently less accurate than serum levels, and TCBs after phototherapy are even less accurate.
But when you're under phototherapy and the transcutaneous bilirubin level is low, I think you can actually accept that as a reasonable measurement. When you get a measurement that is high, you should confirm that. If you get a high measurement at any time, you should actually confirm that with a serum level. The serum levels, ironically, also are not incredibly accurate. We talked in the prior discussion the different amounts of time that different laboratories have to get back results.
There's a lot of variability that's allowed in the lab results. it would be helpful if that was tightened up a little bit and there was more standardization that's required. So I'm not suggesting that we become laissez-faire and we don't ever draw levels, but I think we could accept monitoring in the same way we do with glucose monitoring at the bedside and use TCBs after phototherapy is started if they come back really low or trending downward. I think we have to be smart about how we're using it and we have to understand the limitations of it.
Daphna Yasova Barbeau (12:12.271)
You mentioned earlier, like the kind of technical specifications about phototherapy and how we should be utilizing it, thinking about like body surface area and angle and all those things. And so I actually wondered what your thoughts are about using phototherapy in isolettes. know...
there's so much variability across units, but some units are very routine about putting kids in the isolette. But for me, especially if I'm using multiple lights, I feel like that kind of limits, you know, the angle at which we can use the light and how much kind of body surface area we can expose. Do you have any thoughts about phototherapy in isolettes?
Daniel Rauch (12:56.053)
So I think your thinking is correct and it probably limits it a little bit. If you've got a baby who's got more significant challenges, being in the isolette may be important because it allows you to control the temperature, it allows you to control the humidity, it allows you to control a variety of factors. So the reason you're doing it is not because you think the isolette is going to be more effective for phototherapy, it's going to be more effective for other things that have nothing to do with the phototherapy.
You can still do very effective phototherapy in an isolette, but you're not helping yourself by using the isolette for phototherapy. You might be helping yourself for all the other monitoring that's going on.
Daphna Yasova Barbeau (13:38.071)
Yeah, I agree with that. So thinking about like babies who are term, pretty healthy, except that they need phototherapy. Do you have any thoughts about keeping those infants with the parents? I think there's been some changes in practice lately. like, as you mentioned earlier, a lot of these kids are going to do fine no matter what we do for them. And I think we're learning more about the implications of separation from the mother.
Daniel Rauch (14:09.173)
So I'll start with an analogy to IV antibiotics. There was a time when if a child needed IV antibiotics, we admitted them. And then what we learned is there were kids who could safely be treated as outpatients with either once a day dosing or they could come back for additional doses. And the same thing happened with CF kids. There was a time when CF kids who needed...
quote unquote tuneups would have to be admitted to the hospital. And what they learned was they could be in their own environment, in their own home, with their own bacteria, that they were exposed to anyway, and they could be at home and you could do an intervention at home that decreased medicalization, led to overall healthier kids, mentally and emotionally, and also physically.
So I'm a huge believer in not over-medicalizing kids if we don't need to. And whether it's rooming in or whether it's home phototherapy, the key with hyperbilirubinemia is not that we are going to make the kid better, it's that the phototherapy is going to be delivered and then ultimately the baby is going to get through this.
So if the baby is relatively healthy, most babies are going to get through this. And if we choose to room in with mom to allow bonding and decrease the medicalization of this, I think that's a net benefit, even though it probably leads to slightly less efficient delivery of phototherapy.
Ben Courchia (15:55.532)
Yeah, I mean, I think this whole concept of the least amount of medicalization really is a thread that runs through this whole entire conversation.
Daniel Rauch (16:05.047)
Yeah, I hope so. I hope I don't come off as cavalier because I think kernicterus is critically important and we should do everything that we possibly can to prevent it. But I do think we have a tendency to overtreat things because we...
Because we want to be sure and because we want to err on the side of caution and I think we can do both. I think we can follow the new AAP guidelines which are incredibly generous compared to prior ones and also not overmedicalize the baby in the process.
Ben Courchia (16:42.72)
I mean, in a way, I feel like you're really living and exemplifying what you guys wrote in the paper, because at one point you write that phototherapy is one of the most common interventions used in neonates. It's a major contributor to NICU admissions and resource utilization and yet simultaneously the literature around its effectiveness and use is limited. If you were able to work on one research question related to phototherapy effectiveness with unlimited resources,
unlimited time, what would you pick? What's the one thing we need to know about phototherapy the most?
Daniel Rauch (17:18.459)
you know, there are two practical things that I would be interested in. One is better defining what dosing is going to be effective. And the second one is more rigorously studying the home phototherapy, getting it to be more sophisticated, so we could actually deliver at home for larger amounts of babies. Because I think as technology is improving, the idea of this being...
something we ultimately figure out how to deliver home and follow with either transcutaneous monitoring or ultimately I think there will be some sort of camera technology that allows us to follow. But I think better defining the dose effectiveness and then better defining the technology is what I would go for if I had unlimited resources.
Ben Courchia (18:09.698)
Yeah, it's funny because earlier in the conversation we talked about the need to measure bilirubin levels at the skin and ensuring that they meet a certain irradiance threshold. And now what I'm hearing you say is there's almost like opportunity to measure this at a much more macro level to understand what dosing do you need. And so I think that's fascinating because it points back to...
This is an intervention we use all the time, but we understand so little of it. I thought the comment you were making about exchange transfusions was also really interesting. I think I'd never thought about it that way, that if we use phototherapy to reduce the amount of exchange transfusions and we lose that skill, then exchange transfusions become that much riskier. And that's something that I'd never thought about until you mentioned it. And I thought that was quite fascinating.
Daniel Rauch (19:01.867)
It's a law of unintended consequences. There are procedures that I literally was trained to do in residency that just aren't done anymore. And there are advantages of that because I was trained to do procedures on 30-week babies and now those babies generally aren't intubated anymore. And that is a net benefit to that. So being forced to do a procedure so that somebody knows how to do it is
not necessarily a good thing. But the reality is there are some babies who have developed such significant hyperbilirubinemia that exchange transfusion may actually be a lifesaving procedure and if nobody knows how to do it then that could be catastrophic.
Ben Courchia (19:49.708)
All right, so last question as we're wrapping up. This is something that I wanted to ask you because this is something that I think about, but I'm interested to hear your perspective on it because you are quite involved in advocacy and policy work and I think that gives you a different perspective than neonatologists who are mostly clinicians. In this review, you review safety considerations for phototherapy and there's a whole section about eye protection. I think eye shields are by and large one of the most annoying things about phototherapy for the families. I feel like every single parent I've ever taken care of, the eye shield is off. The baby has eyes wide open under the phototherapy and the parents say, "Well, we just took it off for a second."
And I know you write that there is no identified cases in the literature of ocular injury, but yet you write that that the eye shields remain recommended. And so I think what I was wondering as we were reading this was from a policy perspective, if you're going to write a recommendation in the textbook or in a statement, do you have to recommend it if we know it's not being used? So if you know that the parents are taking them off, why include them if there's no evidence of harm?
Daniel Rauch (21:02.279)
So I think that what we did in this document is we said out loud something that I think people are thinking or experiencing, but don't ever say out loud. And so I think that if you survey family members of babies who've been treated with phototherapy and you ask them how often the shields were on, they would tell you honestly not very often. And if you spoke to nurses who work in newborn nurseries, they would tell you they're...
They're annoying. They fall off. You worry about the baby being at risk if they're not properly fitted because they're blocking airways. I mean, there's all this angst around them. And yet because there's a theoretical concern that light could have some adverse effect on the eyes, they're left on. And so I think your question is the exactly right one, which is you're calling it out because it's written down in the guidelines.
I don't think anybody who works in newborn nurseries is under the belief that kids are consistently going around with eye patches on. And yet we recommend it. So it's similar to my comment about diapering. On the one hand, it's to cover you for somebody saying there could be an adverse event, which there's no evidence there is, or there's precedent. So babies in the past have had this done. So we continue to do it. If a baby is truly under constant phototherapy,
let's say for more severe hyperbilirubinemia. I probably would do my best to keep the eye shields on because there's no downside and there's theoretical upside. But when a baby is going in and out of phototherapy and the overwhelming majority of babies who need phototherapy aren't getting anywhere near exchange transfusion levels. I don't know that we're really providing significant benefit. There's probably no harm either. And so we recommend it as a general thing.
But in truth, this is similar to asking the nurse, you should make sure all babies are being swaddled, all babies are on their backs, all babies' fingernails are cut. The reality is it doesn't always happen that way. And so I think that that's one of the things that we were trying to be a little more flexible about.
Daphna Yasova Barbeau (23:14.967)
I think that's...
Ben Courchia (23:16.558)
Yeah.
Daphna Yasova Barbeau (23:19.817)
I think it's good. I think it's, you know, kind of bringing the parents and patients more into the discussion. I wanted to ask you about kind of the risks of phototherapy and, you know, you talked about separation. So not necessarily the phototherapy itself, but the process of, you know, phototherapy. And, know, one of the things we talk about on the podcast is kind of the exposure that we, as providers, had to phototherapy. We all got to see it in the nursery. We all got to see it in the NICU. We talked about it all the time.
for a parent whose only exposure to phototherapy may be on TV. Babies under blue lights can be really frightening. And so I wonder kind of your recommendations about, know, we've showed photos of babies under phototherapy. Those babies look sick, even though they're not. They look really uncomfortable. And so I wonder your recommendations for
you know, getting parents to feel more comfortable with phototherapy and broach those topics that, you know, it does have to do with separation potentially, but it's still safe and effective for the baby.
Daniel Rauch (24:29.707)
So I think that the more we can explain to families and bring them into the shared decision-making, the better. And I think the more we can demedicalise this and normalize it, the better. And that can come in a variety of forms. I mean, one is education. If you've ever seen...
There's a sign in most newborn nurseries and delivery areas about neonatal sepsis that shows this really sick-looking baby with pustules and all sorts of horrible things and then it says, "Could be GBS disease." That's insane. could come up with 10 pictures that would reflect what GBS disease looks like that wouldn't look as bad as those pictures. But it's taking the most extreme thing and putting it out there.
Daphna Yasova Barbeau (25:09.627)
Mm-hmm. Mm-hmm.
Daniel Rauch (25:19.487)
And I think parents look at things and they either don't register them or they register them as being catastrophic. There's nothing in between. And the babies who have hyperbilirubinemia are somewhere in that middle. It's actually literally a spectrum. I am not suggesting we don't treat kids, but I think...
The more you can educate and explain, those babies that you showed, those pictures looked sick because they're under lights and in an isolette. If they took the isolette off and there was a picture of the baby in a blanket on mom's chest, that would look different. And that would not be that uncommon a picture. If you look at the babies in home phototherapy, they don't look that way. So I think the more we can make it normal, the more we can talk to families about the fact that this is relatively short-term,
generally speaking very safe, we're going to watch this baby, the baby's going to be fine. And we say that not to be cavalier and we mean it, right? Which is we can be very confident in their numbers. And we can also remind them that we're taking this seriously, we're watching them, we're following their bilirubin levels, and we're going to do the right thing. So I'm trying to make it less scary.
Ben Courchia (26:39.33)
Yeah, I mean, and that's something that I think as clinicians we learned quickly. And I remember personally in my training being told to do this. You're about to come in, you're going to tell parents about phototherapy. And what I feel like people do well is they say, "Hey, I'm going to be talking about phototherapy. It's a very common condition." But what they fail to say right upfront is that it resolves on its own. I think that's something that is sometimes maybe delayed in the conversation.
Daniel Rauch (27:05.751)
and your baby's gonna be fine.
Ben Courchia (27:07.724)
And that's, think, that's what I think maybe sometimes gets people the most worried.
Daniel Rauch (27:12.031)
When I teach residents about delivering bad news, I tell them to start at the bottom line. And almost always the bad news is terrible. There's no getting around it. But if you lead off with your baby's going to be fine, the rest of the conversation is going to be very different than if you lead off with, "We have to do something."
Ben Courchia (27:32.622)
All right, so one last question. And this is something that comes up and it came up during the conversation with Dr. Kemper. And this may be very much an area where there is no data. And you were mentioning yourself that some of the limitations of actually getting robust data is the fact that kernicterus is rare. But in the paper you write, the dose of phototherapy has not been evaluated in the rigorous randomized controlled trials needed to fully evaluate its effectiveness in preventing the adverse neurological outcomes of kernicterus. So the question then becomes, how do we know then that phototherapy works? How do we know that we're not causing more harm by intervening? And if we are causing some harm, maybe we can just, if we have all this room up for higher thresholds, maybe we just wait and see?
Daniel Rauch (28:23.093)
So let's go back to the incidence of kernicterus and it's five in a hundred thousand. So statistically think about how many babies we would have to enroll in a study over how many years to have that proof. I could design a study where I smeared peanut butter on kids and I could show that it wasn't harmful. It had no benefit because statistically it's such a rare event that I can't get numbers in the harm to show that. And it's actually interesting that the initial thing that was hoped to be improved by phototherapy wasn't kernicterus. It was actually to reduce the number of kids who got exchange transfusion, because that was a much higher number, and I could statistically show that. And people have questioned whether that was valuable, because if you reduce exchange transfusion, which is still used in some cases, to a point where people don't know how to do it, then exchange transfusion becomes a more risky procedure. And I'm not suggesting we should do exchange transfusions so people know how to do them. But that's ultimately what we were reducing because you just can't show a reduction in kernicterus because of the statistics.
Ben Courchia (33:37.442)
Right.
Ben Courchia (33:47.82)
Yeah, and I think that's the key. And I think that's what I was hoping to get from you with this question is that it is not a theoretical concern with the pathophysiologic mechanism of phototherapy and hyperbilirubinemia. It has to do with Bayesian sort of base rates and statistical power. For the people who are maybe early in their training, just think about how would you design this trial and see all the unethical issues that you're going to fall into if you decide to say, "No, let's randomize them to phototherapy versus no phototherapy and good luck to you."
Daniel Rauch (34:19.445)
Right, it's risk averse. It's the same discussion for febrile infants and nobody wants to tap an infant. First of all, of the blood culture, urine culture and CSF, CSF is the easiest one to do. So I don't know, I never understood why people were averse to doing that. The families don't like it because it looks kind of barbaric, but it's the easiest procedure to do. But the risk was, you know, one in a thousand. So you could in your career treat 100 kids, 200 kids, and you're not going to see that outcome because it's rare. And that's one in a thousand, not a handful in a hundred thousand.
Daphna Yasova Barbeau (34:56.653)
I wanted to revisit, we briefly talked about home phototherapy and I wonder how that fits into your paradigm about less medicalization of the infant. We get to get parents home sooner, potentially going home on bilirubin blankets when available and if insurance allows it. But now they have this piece of medical equipment in their home. And I wonder kind of what your experience with that is. In my practice, it's been pretty well received by families, but I actually recognize that I have no idea what happens once they go home and what happens when the bilirubin blanket has to go back into circulation.
Daniel Rauch (35:42.465)
So I will fully admit I don't have experience doing this. I have a lot of hearsay and I've spoken to a lot of people like yourself who have done this. I think there are a number of benefits and it speaks to how generous the guidelines are in terms of safety that the children who are on the borderline who we decide to light up probably are fine and are gonna do fine no matter what. We pat ourselves on the back, we've made an intervention, we've saved a baby, but we've probably not done a whole lot. I think it fosters the nonverbal message that this is not a significant thing in your child's life. This has the potential to get bad. So we're using this thing, which we think is safe and effective to protect your baby, but it's really okay. And you can go home. We don't need to over-medicalize this. So it sends another message. It also helps foster that bonding and think about the underlying reasons for hyperbilirubinemia and what we call them. So there's breastfeeding jaundice and breast milk jaundice. And we want to promote breastfeeding as much as we possibly can. And yet we attribute the cause of this thing that medicalizes the child to the very thing that we're trying to promote. And so there's an inherent mixed message there. So if you send them home and you tell them to breastfeed their baby, they're just much more likely to have a bond and continue on things which we have really good evidence is much more impactful on the child's health than what we're doing for them with phototherapy when they're within one milligram of the phototherapy level.
Ben Courchia (37:22.062)
Dr. Rauch, we're getting close to the end of this conversation. So my last question, I think, relates to a topic that comes up in conversations with families. And now that we've reviewed the evidence and we feel like we have a good understanding of the mechanisms behind phototherapy, one question that often comes up, especially for babies that are not yet at that level, is parents ask, "What about if I just expose my baby to sunlight?" And in the paper, we do get a little bit of a historical summary of Sister Jean Ward's initial observation. And there's some very interesting conversation about something that I was not familiar with regarding like filters for windows that would basically filter the sunlight. But sometimes you're almost tempted to say, "Well, if the baby is under the sun, it's not too bad," but there's a lot of considerations to think about. And so can you tell us what we should recommend, advise and what should be taken into consideration as parents are asking that specific question?
Daniel Rauch (38:19.159)
So we should recommend that you not suntan your baby. That's just not a good idea. Again, it's some of the mixed messaging and how to get laypeople to understand dosing and right amount of time. So I certainly would be afraid that people take on the message that direct sunlight is okay for the entire... Sorry. I don't want them to get the wrong message that direct sunlight is okay for the duration of the kid's life. There's also, I'm not aware of any paper that suggested that that's a consistent light source and that it truly does get the same amount of impact on deflecting hyperbilirubinemia that delivered doses through technologic means do. If we think your child is high enough to be at risk, we should do the best and we think safest way of delivering the intervention.
Ben Courchia (38:45.251)
That's OK.
Ben Courchia (39:19.896)
I love it. That's a great final recommendation. Do you have any thoughts about the future of... I always wonder sometimes, you can decide to punt on that question, but I always feel like sometimes we can think of things in medicine and feel like, "Have we worked this out? Have we figured out enough that the landscape is not going to change dramatically in the next 20, 30, 50 years?" Do you see anything dramatic happening in the realm of indirect hyperbilirubinemia and phototherapy in the future based on current evidence and where things are going?
Daniel Rauch (39:54.321)
Well, I think two things are going to happen. One is it's surprising how poorly we understand this given it's been around since we ever had babies. And it's a very common problem. And yet the underlying chemistry is understood, but really how it works in the body and why some kids get kernicterus at 30, some kids at 35, some kids at 40 just isn't well understood. The other issue is improving technology. So we talked a little bit about the development in Europe of using cameras and algorithms for developing phototherapy. I think we're going to develop technology that's going to allow us to deliver interventions at home in a safe way. And we're going to develop non-direct ways or indirect ways of measuring so that we'll be on top of this and it won't be as impactful on families when we do have to intervene. So I think both of those are going in the right direction to demedicalize this and to de-escalate this. It'll still be around obviously, but I think we'll handle this in a much more family-friendly way.
Ben Courchia (41:03.732)
Dr. Rauch, thank you so much for taking the time to answer our questions and coming on the podcast. It's been a pleasure and good luck with the rest of your work.
Daniel Rauch (41:10.651)
Thank you.