BILI BLANKET FOR NEONATAL JAUNDICE

INTRODUCTION
Hyperbilirubinemia, or jaundice, is a life threatening disorder in newborns. It is a
multifactorial disorder with many symptoms. Generally, the physiological jaundice is the most
prevalent type however in some regions pathological jaundice is also common.

Incidence
Neonatal hyperbilirubinemia is a common clinical problem encountered during the
neonatal period, especially in the first week of life . Nearly 8% to 11% of neonates develop
hyperbilirubinemia. When the total serum bilirubin (TSB) rises above the 95th percentile for age
(high-risk zone) during the first week of life, it will be considered as hyperbilirubinemia

TYPES OF HYPERBILIRUBINEMIA

Several types of Bilirubinemia have been reported in neonates including

1. physiological jaundice,
2. pathological jaundice,
3. jaundice due to breastfeeding or breast milk and
4. hemolytic jaundice including three subtypes due to
 Rh factor incompatibility,
 ABO blood group incompatibility and
 Jaundice associated with Glucose-6-phosphate dehydrogenase (G6PD) deficiency

PHYSIOLOGICAL JAUNDICE
It is the most abundant type of newborn hyperbilirubinemia, having no serious
consequences . Neurodevelopmental abnormalities including as athetosis, loss of hearing, and in
rare cases intellectual deficits, may be related to high toxic level of bilirubin .

Jaundice attributable to physiological immaturity which usually appears between 24–72 h

of age and between 4th and -5th days can be considered as its peak in term neonates and in
preterm at 7th day, it disappears by 10–14 days of life . Unconjugated bilirubin is the
predominant form and usually its serum level is less than 15 mg/dl . Based on the recent
recommendations of the AAP, bilirubin levels up to 17–18 mg/dl may be accepted as normal in
term of healthy newborns .

PATHOLOGICAL JAUNDICE
Bilirubin levels with a deviation from the normal range and requiring intervention would
be described as pathological jaundice Appearance of jaundice within 24 h due to increase in
serum bilirubin beyond 5 mg/dl/day, peak levels higher than the expected normal range, presence
of clinical jaundice more than 2 weeks and conjugated bilirubin (dark urine staining the clothes)
would be categorized under this type of jaundice.

BREAST FEEDING AND BREAST MILK JAUNDICE

Exclusively infants with breastfeeding have a different physiological pattern for jaundice
compared with artificially feed babies . Jaundice in breast fed babies usually appears between
24–72 h of age, peaks by 5–15 days of life and disappears by the third week of life. Higher
bilirubin levels have been reported in these infants . In case of breastfed newborns, mild jaundice
may take 10–14 days after birth or may reoccur during the breast feeding period . Very large
amounts of bilirubin rarely accumulate in the blood and cause cerebral lesions, a situation known
as nuclear jaundice . These cuts may be followed by hearing loss, mental retardation, and
behavioral disorders. A mild clinical jaundice has been observed in one third of all breastfed
babies in the third week of life, which may persist for 2 to 3 months after birth in a few babies .
Decreased frequency of breastfeeding is associated with exaggeration of physiological jaundice.
One of the significant procedures to manage the jaundice in a term healthy baby is the mothers’
encouragement to breastfeed their babies at least 10–12 times per day .

Hyperbilirubinemia is also associated with breast milk of mother in neonates . About

2%–4% of exclusively breastfed babies have jaundice in excess of 10 mg/deal in the third week
of life. These babies in the third week of life with bilirubin serum levels higher than 10mg/dl
should be considered for prolonged jaundice . A diagnosis of breast milk jaundice should be
investigated if the serum bilirubin is predominantly unconjugated, other causes of prolonged
jaundice have been eliminated and the infant is in good health, vigorous and feeding well and
gaining weight adequately . Mothers should be advised to continue breastfeeding at more
frequent intervals and bilirubin levels usually diminish gradually. Discontinuity of breastfeeding
is not recommended unless levels exceed 20 mg/dl .

HEMOLYTIC JAUNDICE
The most common causes of hemolytic jaundice include (a) Rh hemolytic disease, (b) ABO
incompatibility and (c) Glucose-6-phosphate dehydrogenase (G-6-PD) deficiency and minor
blood group incompatibility.

(A) RH FACTOR HEMOLYTIC DISEASE

Rhesus hemolytic disease of the newborns (RHDN) results from maternal red-cell
alloimmunization . Maternal antibodies are produced against the fetal red blood cells, when fetal
red blood cells are positive for a certain antigen, usually at what time a baby having Rh positive
born to an Rh-negative mother (and Rh-positive father), then maternal immunoglobulin (IgG)
antibodies might cross the placenta into the fetal circulation and cause a wide variety of
symptoms in the fetus, ranging from mild to severe hemolytic anaemia and fetal hydrops .

(B) ABO INCOMPATIBILITY

The incidence of the incompatibility of the ABO blood groups of the mother and fetus, when the
mother has the blood group O and the newborn has the A or B blood group, is 15–20% of all
pregnancies . Babies with O-blood group mothers should be closely checked for and discharged
after 72 h. Routine cord blood screening is not recommended for newborns with O-group
mothers . Jaundice owing to ABO incompatibility usually appears 24 h after the birth. In the
presence of significant jaundice or jaundice appearing within 24 h, the work up for pathological
jaundice should be done . Intensive phototherapy is advised at SB 12–17 mg/dl depending upon
postnatal age of the baby. Exchange blood transfusion is indicated at TSB. The weight at birth as
a criterion for phototherapy and ET may be used for preterm newborns .

(C) JAUNDICE ASSOCIATED WITH G6PD DEFICIENCY

Deficiency, hereditary spherocytosis, and minor group incompatibilities should be managed

similar to ABO incompatibility. G6PD, most common enzymopathy, is the deficiency of an
enzyme in RBCs . It is the most vital disease of the pathway of hexose monophosphate .
Investigations for G6PD deficiency should be considered in infants with severe jaundice in a
family with a history of significant jaundice or in a geographic origin associated with G-6-PD
deficiency . Decreased bilirubin conjugation resulted from variation in the UGT1A1 and OATP2
genes play an important role in the progression of hyperbilirubinemia in G6PD deficient
newborns .

PHOTOTHERAPY
Hyperbilirubinemia can be treated easily without or with a minimal adverse effect with
phototherapy . The efficacy of phototherapy depends on surface area exposed to phototherapy:
Double surface phototherapy may be more effective than single surface phototherapy

(A) CONVENTIONAL PHOTOTHERAPY

One can use conventional or fiber-optic phototherapy units provided jaundice is non-hemolytic
or its progression is slow.

(B) INTENSIVE PHOTOTHERAPY

In the circumstances including hemolytic jaundice, rapidly increasing bilirubin, or
ineffectiveness of a conventional unit, using of intensive phototherapy is warranted. Placing the
baby on the bili-blanket and using additional overhead phototherapy units contain blue lights and
then lowering the phototherapy units to within a distance of 15–20 cm are two significant
remedies .

BILIBLANKET

A Bili Blanket is a portable phototherapy device consisting of a fiber-optic pad and a portable
illuminator for the treatment of neonatal jaundice (hyperbilirubinemia) in the home. The light
emitted from biliblanket is used to break up bilirubin in the baby’s blood, reducing the yellowing
effect in baby’s skin and whites of the eyes.

While using this system parents can still hold, feed and play with their child. The Biliblanket is a
flexible wand with a disposable sleeve that wraps around the baby’s mid-section to provide
maximum coverage during phototherapy treatment. A blue light comes through the sleeve, which
reduces dangerous bilirubin levels.

DEFINITION

When a baby is placed under a source of blue green light of (wavelength 425 to 550 nm ), light
reacts with bilirubin in the blood flowing through the baby’s skin.

PURPOSES

The purpose of phototherapy is to convert bilirubin to lumirubin to correct hyperbilirubinemia.

Bilirubin which is water insoluble is converted in to substances like luirubin which are water
soluble and hence easily excreted through urine . formation of lumirubin is the most important
way of excreting the excessive bilirubin. There are other less important ways by which
phototherapy aids in excreting bilirubin which includes :

 Jaundice is considered pathologic if it presents within the first 24 hours after birth, the
total serum bilirubin level rises by more than 5mg per dL per day or is higher than 17 mg
per dL or an infant has signs and symptoms suggestive of serious illness. The
management goals are to exclude pathlogic causes of hyperbilirubineemia and initate
treatment to prevent bilirubin neurotoxicity.

INDICATIONS

 Phototherapy should be instituted when the total serum bilirubin is at or above 15mg per
dL in infants 49 to 72 hours old , and 20mg per dL in infants older than 72 hours old.

 Rebound jaundice

Rebound jaundice is a surge in bilirubin levels soon after phototherapy is stopped.

Rebound jaundice is significant in preemies, babies with positive direct coomb’s test and
in babies who have received less than 72 hours of phototherapy. In such cases, a
discharge may be necessary

MISCONCEPTION

 Contrary to the popular misconception, ultra violet rays are not used in phototherapy. What
little UV light that the light source emit, are of longer wavelength . than those causing
redness and even such small amount of emitted. UV rays are absorbed by glass walls of
the tubes.

COMPLICATIONS OF PHOTOTHERAPY

Phototherapy has been in use for more than three decades and millions of babies have benefited
from phototherapy is generally considered a simple, safe and cheap procedure. Minor side effects
are

 Frequent loose stools, green or watery stool is common.

 This along with increased insensible water loss can lead to dehydration.
 Frequent bowel movements help in excreting bilirubin and will stop when phototherapy
is discontinued. Babies are required to be fed frequently.

 Dehydration may have to be corrected by supplementing with formula or fluid

administration.

 Over heating can also occur but is uncommon with LED’s that produce less heat and with
fiber optic blanket’s.

CONTRAINDICATION

Phototherapy is usually a sfe procedure.

 In a rare genetic disorder called congenital porphyria , phototherapy is contraindicated as

it causes severe blistering

 In jaundice, due toliver disease, phototherapy can lead to pigmentation of skin and urine
called “Bronze baby syndrome”. And in such conditions alternative treatment like
exchange transfusion is considered. Blistering can also occur in obstructive jaundice.

PROCEDURE

 Note the Doctor’s order for phototherapy.

 Obtain infant’s auxillary temperature and record in patient’s card.

  Infants receiving phototherapy can receive treatment in mom’s rrom and the nurse can
educate the family about the need for phototherapy and explain safety information related
to the therapy.

EQUIPMENT

 Antibacterial soap

 Phototherapy light source boxes

 Disposable covers

 Thermometer

 Daily log sheets

 Patient family education material

 Radiometer

 Protective eye shields

 Heat lamp(optional)

TECHNIQUE

 Bilirubin absorbs light maximally in the blue range (420 - 500 nm). Daylight and cool
white lamps have a spectral peak between 550 – 600nm and are less effective than a
special blue lamp which have a range of 420 – 480nm. Blue lamp interfere with
observation of skin colour.

 Apply eye patches ensuring correct fit while taking care not to obstruct the nostrils.
Remove all clothing, cover male testis with surgical mask.

 Eye patches will be checked and documented hourly and PRN for proper placement. The
patches must be removed during feedings and when assessing the bay to provide a good
view of the eyes and to provide the infant with visual stimulation and interaction with
parents and care givers.
 Infant’s position does not have to be changed from front and back per AAP guidelines.

 If the infant is in open crib, the infant’s auxillary temperature will be taken and recorded
every hour until satble, then every four hours.

 Monitor intake and output due to risk of dehydration.

 The light meter should be used at the initial set up of the therapy. Then once a day at the
level of the baby’s skin, under the centre of the light source

 While on radiant warmer or in an isolate, the infant is to be placed on serve control and
infant temperature is to be montored per physician order

 Note physician orders for lab test to follow the progress of treatment. Turn off billi lights
prior to lab investigstions.

 The billi bed is an another option. The baby can be placed either in prone or supine
position as per the instruction.

 Remove infant frm phototherapy for feedings or for lab tests or as orderd by the
physician. The baby can be out from lights no more than 3 hours out of every 12 hours.

 If a billi blanket is used, it can be held with the baby during each feeding to provide
continuous treatment.

 Billi blankets are used under the baby to add additional lights.

 Document in electronic medical record each shift the following

 Skin colour

 Skin turgor

 Fontanel assessment

 Any changes in tone activity level of feeding

  Chracteristics of stools

 Length and time out of phototherapy treatment and radiometer reading.

DIFFERENCE BETWEEN HOME & HOSPITAL TREATMENT

For over 30 years, phototherapy treatment has been used in hospitals. Hospital treatment
involves rows of lights shining directly on an undressed baby (with a diaper on) whose eyes
would need protection from the light with soft eye patches applied.

Technology advancements have led to home phototherapy treatment through the use of
BiliBlankets. The blanket is tied to baby (usually on the back) and a pad of woven fibers is used
to transport light to your baby.

Home treatment is quite popular with parents, doctors, and insurance companies because you
avoid higher costs of inpatient treatment. With home phototherapy, your child can be diapered,
clothed, held, and nursed during treatment. Some also consider it a better option because the
newborn does not have to be separated from the parents and does not need to lie alone in a box
with their eyes covered.

Prof. A. Hamidhunniza MSc(Nuring)

HOD, Department of OBG,

Nandha College of Nursing, Erode.