In-service education on "Phototherapy"

Content

 Terminologies relevant to phototherapy

 Risk factors for hyperbilirubinemia
 Screening of hyperbilirubinemia
 Management of hyperbilirubinemia
 Introduction to phototherapy
 Indication for phototherapy/ phototherapy threshold
 Lights and equipment’s used in phototherapy
 Nursing care and procedure for phototherapy
 Complications

Terminologies relevant to phototherapy:

1. Hyperbilirubinemia: the excess of bilirubin in the blood.

2. Unconjugated Hyperbilirubinemia: the bilirubin has not been metabolized and

hence cannot be excreted via the normal pathways in the urine and bowel.
Unconjugated bilirubin binds with lipids and albumin, and results in the yellow
appearance of the skin and sclera. Unconjugated bilirubin can cross the blood-brain
barrier and cause neurotoxic effects.

3. Conjugated Hyperbilirubinemia: less common in neonates. The bilirubin has been

metabolized and is water soluble, but accumulates in the blood usually due to hepatic
dysfunction. Conjugated bilirubin does not cross the blood-brain barrier.

4. Serum Bilirubin (SBR)/total serum bilirubin (TSB): the unconjugated and

conjugated bilirubin levels.

5. Rebound TSB: the measurement of serum bilirubin after completion of a threshold

period of phototherapy. It may be after 4-6 hours up to the completion of 24 hours of
phototherapy.

6. Phototherapy: a treatment for jaundice where the exposure of skin to a light source
converts unconjugated bilirubin molecules into water soluble isomers that can be
excreted by the usual pathways. It could be single, double or triple phototherapy.
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 7. Irradiance: It is the radiant flux received by a surface per unit area. The SI unit of
irradiance is watt per square meter.

8. Bilirubin encephalopathy: the acute manifestations of bilirubin toxicity seen in the

first few weeks after birth. Signs include lethargy, hypotonia and poor suck
progressing to hypertonia, opisthotonos, high-pitched cry and eventually to seizures
and coma.

9. Kernicterus: the pathogenic diagnosis characterized by bilirubin staining of the brain

stem and cerebellum. Also the term used to refer to chronic bilirubin encephalopathy.
Clinical findings include cerebral palsy, developmental and intellectual delay, hearing
deficit, dental dysplasia and oculomotor disturbances.

Risk Factors for Developing Significant Hyperbilirubinemia

 Lower gestational age (ie, the risk increases with each additional week less than 40
wk)
 Jaundice in the first 24 h after birth
 Predischarge transcutaneous bilirubin (TcB) or total serum bilirubin (TSB)
concentration close to the phototherapy threshold
 Hemolysis from any cause, if known or suspected based on a rapid rate of increase in
the TSB or TcB of >0.3 mg/dL per hour in the first 24 h or >0.2 mg/dL per hour
thereafter.
 Phototherapy before discharge
 Parent or sibling requiring phototherapy or exchange transfusion
 Family history or genetic ancestry suggestive of inherited red blood cell disorders,
including glucose-6-phosphate dehydrogenase (G6PD) deficiency
 Exclusive breastfeeding with suboptimal intake
 Scalp hematoma or significant bruising
 Down syndrome
 Macrosomic infant of a diabetic mother (Kemper et al, 2022)

Screening of Hyperbilirubinemia (Kemper et al, 2022)

All infants should be visually assessed for jaundice at least every 12 hours following delivery
until discharge. TSB or TcB should be measured as soon as possible for infants noted to be
jaundiced.
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  Clinical assessment
 Transcutaneous bilirubin (TcB)
 Total bilirubin (TSB)

1. Clinical assessment: Visual estimation is routinely used to guide decisions about

obtaining TcB or TSB measures.

Fig: Kramer's criteria to clinically estimate the severity of jaundice

Zone Estimated bilirubin (mg/dl)

1 (Face) 4-6

2 (Upper trunk) 6-8

3 (Lower trunk and thighs) 8 - 12

4 (Arms and Lower legs) 12-14

5 (Palms and Soles) >15

2. Transcutaneous bilirubin (TcB): Transcutaneous bilirubin (TcB) measurement is a non-

invasive method for measuring serum bilirubin level. Transcutaneous bilirubinometry
works by directing light into the skin and measuring the intensity of the wavelength of
light that is returned.Frequent re-assessment if TcB closes to the phototherapy threshold
or rapidly rising. Drawback- overestimate in dark and underestimate fair-skinned people

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3. Total bilirubin (TSB): A bilirubin test is a diagnostic blood test performed to measure
levels of bile pigment in an individual's blood serum and to help evaluate liver function.
TSB is the definitive test to guide phototherapy and escalation-of-care decisions,
including exchange transfusion. TSB should be measured if the TcB exceeds or is within
3 mg/dL of the phototherapy treatment threshold or if the TcB is more or equal to 15
mg/dL.

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Management of Hyperbilirubinemia

The goal of management is to reduce levels of bilirubin and preventing brain damage which
includes:

1. Phototherapy,
2. Exchange transfusion and
3. Drugs (Phenobarbitone)

Introduction to Phototherapy

Phototherapy is a major effective therapeutic treatment modality in dermatology. It consists

of a controlled administration of non-ionizing radiation to the skin. It can be used to treat
neonatal jaundice and mostly used to treat various common skin disorders such as psoriasis,
chronica, eczema, atopic dermatitis, vitiligo, and many others. (Dipali,2022)

The use of phototherapy was first discovered, accidentally, at Rochford Hospital in Essex,
England, when a nurse, Sister Jean Ward, noticed that babies exposed to sunlight had reduced
jaundice, and a pathologist, Dr. Perryman, who noticed that a vial of blood left in the sun had
turned green.

Mechanism of action of phototherapy:

Phototherapy is used to treat unconjugated hyperbilirubinemia and jaundice in the newborn

infant. Phototherapy uses visible blue spectrum light which photo-isomerises unconjugated
bilirubin into a water-soluble form which can be easily excreted without conjugation by the
liver. This reduces TSB to safe levels and reduces the risk of bilirubin toxicity and the need
for exchange transfusion.

The effectiveness of phototherapy is dependent on the intensity of phototherapy administered

and the surface area of the infant exposed to phototherapy. The general approach is to provide
intensive phototherapy to as much of the infant’s surface area as possible. Intensive
phototherapy requires a narrow-spectrum LED blue light with an irradiance of at least 30

µW/cm2 per nm at a wavelength around 475 nm. Light outside the 460 to 490 nm range
provides unnecessary heat and potentially harmful wavelengths. (AAP, 2022)

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Indication for phototherapy/ Phototherapy threshold

Decisions to initiate phototherapy are guided by the gestational age, the hour-specific TSB,
and the presence of risk factors for kernicterus (prematurity or co-existence of illness such as
sepsis, perinatal asphyxia and acidosis).

Paediatric Protocols – Patan Hospital Neonatology Protocol Department of Pediatrics,

Patan Hospital, 2014

 Check serum bilirubin level and plot the level on the gestational age appropriate
"threshold graphs" issued by NICE guidelines on neonatal jaundice.
 Start phototherapy as per the graph and keep the graph in the baby's notes in order to
plot subsequent bilirubin levels.
 Use double phototherapy on infants with rapidly rising bilirubin or nearer the
threshold for exchange transfusion.
 Convert serum Bilirubin values from mg/dl to micromol/L, by multiplying by 17,
before plotting it in the NICE guideline graphs NICE guidelines for treatment of
neonatal jaundice.

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 Refer to Paediatric Protocols – Patan Hospital Neonatology Protocol Department
of Pediatrics, Patan Hospital, 2014, pp 39 to 41 for treatment threshold graph for
newborn from 26 weeks gestation to 38 weeks gestation.

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Types of Lights used in Phototherapy

1. Micro White Halogen lights

They deliver light via a quartz halogen bulb and have a tendency to become quite hot
so should not be positioned closer to the infant than the manufacturers
recommendations of 52cm. The lights can continue to be bright despite having low
irradiance levels.
2. Fluoro- 2 Blue and 2 White Fluorescent lights
The fluorescent blue tubes must have the serial number F20T12/BB or TL52/20W to
be special phototherapy lights. Blue light is the most effective light for reducing the
bilirubin.
3. Biliblanket - Blue Halogen light
This uses a halogen bulb directed into a fiberoptic mat. There is a filter that removes
the ultraviolet and infrared components and the eventual light is a blue-green colour.
Biliblankets are not to be used on infants less than 28 weeks gestation or infants with
broken or reduced skin integrity.
4. Blue Fluorescent light
A blue fluorescent tube is fitted into a plastic crib with a stretched plastic cover over
the top for the baby to lie on.

Figure: Biliblanket

Types of phototherapy units

1. single surface unit

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 2. double surface unit
3. triple surface unit

Nursing Care and Procedure for phototherapy

Assessment before phototherapy

 Gestational age of the baby
 Weight
 Postnatal age
 Types of jaundice
 Level of jaundice
Before:

1. Explain the procedure to the parents.

2. Check the baby's temperature before starting phototherapy.
3. Wash hands with soap and water and dry thoroughly with clean towel.
4. Cleanse the baby's eyes with normal saline soaked cotton swab. And shield by an
opaque mask to prevent exposure to the light and prevent from corneal damage.
5. Undress the baby and keep the genitals covered with a small diaper.
During phototherapy:
6. Place the baby under the phototherapy light and adjust the height of the phototherapy
to 45cm above the baby.
7. On each nursing shift the eyes are checked for evidence of discharge, excessive
pressure on the lids or corneal irritation.
8. Eye shields are removed during feedings, which provide the opportunity to provide
visual and sensory stimulation.
9. Measure temperature every 3 hours and ensure that the baby's temperature is within
36.5° C to 37° C.
10. Ensure that the baby is fed.
 Encourage the mother to breastfeed on demand but at least every 2 hours. During
feeding, remove the baby from the phototherapy unit and remove the eye patches.
 If the baby is receiving IV fluid or expressed breast milk, increase the volume of
fluid and or milk by 10% of the total daily volume per day for as long as the baby
is under the phototherapy lights.
 If the baby is receiving IV fluid or is being fed by gastric tube, do not remove the
baby from the phototherapy lights.

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 11. Position change every 3 hours.
12. Note the number and consistency of stools.
13. Frequently assess skin and sclera color to check the degree of jaundice.
14. Estimate fluid losses and check for dehydration. If dehydration occurs, inform the on-
duty doctor.
15. Check the serum bilirubin level every 4 to 8 hours to determine the effectiveness of
phototherapy. Discontinue phototherapy when the serum bilirubin level is below the
level at which phototherapy was started or 15 mg/dl (260 mmol) whichever is lower.
16. Record and report of the baby's condition regularly.
17. Watch for side effects of phototherapy.
 Frequency loose green stools, resulting from increased bile flow and peristalsis.
This cause more rapid excretion of the bilirubin but may be damaging to the
skin and fluid loss.
 Skin rash
 Hyperthermia
After phototherapy:
18. After phototherapy has been discontinued;
 Observe the baby for 24 hours, and repeat the serum bilirubin measurement.
Check for rebound of significant hyperbilirubinaemia with a repeat serum
bilirubin measurement 12–18 hours after stopping phototherapy.
 Teach the mother to assess jaundice, and advise her to return if the baby
becomes more jaundiced.
Complications

1. Hyperthermia
2. Retinal damage
3. Diarrhoea
4. Rash.
5. Bronze baby syndrome
6. Temporary lactose intolerance.
7. Others: sleepiness, disinterest in breast feeding, rashes, hyperthermia, increased
metabolic rate.

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References:

1. Kemper AR, Newman TB, Slaughter JL, Maisels MJ, Watchko JF, Downs SM, Grout
RW, Bundy DG, Stark AR, Bogen DL, Holmes AV. Clinical practice guideline
revision: management of hyperbilirubinemia in the newborn infant 35 or more weeks
of gestation. Pediatrics. 2022 Aug 1;150(3). Available from DOI:10.1542/peds.2022-
058859
2. Phototherapy for neonatal jaundice Available from:
https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Phototherapy_for_n
eonatal_jaundice/
3. Rathod DG, Muneer H, Masood S.Phototherapy. Statpearl [Internet]. 2022. Available
from https://europepmc.org/books/nbk563140
4. Paediatric Protocols – Patan Hospital Neonatology Protocol Department of Pediatrics,
Patan Hospital, 2014
5. Tuitui R. Mannual of Midwifery III. 15th edition.Vidyarthi Pustak Bhandar,
Bhotahity, Kathmandu. 2020.

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