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Randomised controlled trial of home phototherapy in term neonates: Pertinent issues

I read with interest the study ‘home phototherapy of term neonates improves parental bonding and stress’ by Pettersson et al.1 The authors’ findings are truly remarkable, considering that no previous randomised study has explored the effects of home phototherapy on parent– child bonding compared to hospitalbased management. Homebased phototherapy is not a new proposition just as one of the driving factors for home management in neonatal practice is avoidance of parent– baby separation. Recent evidence favours the use of home phototherapy in a select subgroup of neonates with hyperbilirubinemia. Nevertheless, conclusions from these studies must be weighed against the most dreaded risk of dangerous elevation of bilirubin during home treatment considering the obstacles and complex milieus such as clarity and level of parental understanding, sociocultural, environmental and logistic barriers, apart from composite family backgrounds. As an anecdote, the authors earlier reported two instances of the parents partaking inhome treatment using phototherapy equipment only for 8 h and 9.5 h during the previous 24 h due to ‘misunderstanding’ and three instances involving some of the factors I have stated above.2 We must be cognizant that such incidents could arise despite daily hospital visits and 24/7 telephone support. On a positive note, readmission rates in studies on home phototherapy have been reported as low (from zero to 4%). In my view, the study baseline variables could have included a parameter to reflect the effectiveness of phototherapy such as the rate of fall of bilirubin, considering the mean total bilirubin of 21 mg/ dl at the recruitment point was much higher than previous studies.2 Parental bonding and parental stress in the early postpartum period are complex biopsychosocial constructs. Diverse instruments have been used to assess maternal confidence and parental stress in the postpartum period. Consequently, in the present study, some of the factors that merit consideration in baseline data include maternal and paternal age, maternal parity, literacy, employment and socioeconomic status. Though Postpartum Bonding Questionnaire (PBQ) developed in 2001 is shown to be a sensitive and valid screening tool, its factorial structure is still considered contentious.3 Alternative tools such as MotherInfant Bonding Questionnaire are also considered reliable and valid. The authors reported some important disparities in parent– infant bonding and stress scores between mothers and fathers. Throwing more light on this finding, recent literature suggests that parental postpartum bonding is directly linked to paternal mental health after delivery and is positively correlated with paternal anxiety (moderate strength) and maternal stress (strong correlation).4 Firsttime fathers could feel less confident than firsttime mothers and find it challenging to adjust to their new role and to meet new demands after childbirth. Paternal leave, time spent with family and paternal psychological distress during pregnancy are likely to play a role. A conceptual framework to interpret father– infant bonding is proposed.5 To conclude, some of the key confounders stated above need due consideration in interpreting the study results. Seemingly, future studies need to deliberate qualitative and mixed methods research designs to understand the phenomenology of parental bonding and postpartum stress in the realm of perinatology and psychopathology.