In-service education on "Phototherapy"

Content

 Risk Factors for Hyperbilirubinemia

 Screening of Hyperbilirubinemia
 Management of Hyperbilirubinemia
 Introduction to Phototherapy
 Indication for phototherapy/ Phototherapy threshold
 Nursing Care and Procedure for phototherapy
 Complications

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.

 Clinical assessment
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  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.
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).

Prompt management of high bilirubin level is important to prevent irreversible brain damage.
Management of baby with bilirubin encephalopathy includes symptomatic management and
reducing bilirubin level.

 Admission in tertiary level hospital

 Manage convulsion if present
 Phototherapy
 Exchange transfusion according to need.
 Phenobarbital therapy induces hepatic microsomal enzymes and increases bilirubin
conjugation and excretion. A loading dose of 10 mg/kg on day 1 and maintenance dose of
5–8 mg/kg/day for next 4 days is given. It takes 3–7 days to be effective. However, as a
prophylaxis, it may be used in the mother for 1-2 weeks prior to delivery in the dose of 90
mg/day with known severe hemolytic disease which will reduce the risk by reducing infant’s
hepatic enzymes as well as increase hepatic intake of bilirubin and excretion of bilirubin into
the bile.
 Surgery: in case of biliary atresia
 Treatment of hemolytic disease
o Exchange transfusion
o Replaced blood
o Give acid citrate dextrose, calcium gluconate
o Intrauterine transfusion in case of erythroblastosis fetalis

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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.
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. (Phototherapy for
neonatal). This reduces TSB to safe levels and reduces the risk of bilirubin toxicity and the need for
exchange transfusion. Phototherapy is started based on risk factors and the TSB levels on the
bilirubin nomogram. (Ansong-Assoku, 2020)
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/cm 2 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 is guided by the gestational age, the hour-specific TSB, and the
presence of risk factors for bilirubin neurotoxicity.
Based on Clinical Practice Guideline Revision: Management of Hyperbilirubinemia in the
Newborn Infant 35 or More Weeks of Gestation; American Academy of Pediatrics, 2022
Intensive phototherapy is recommended at the total serum bilirubin thresholds on the basis of
gestational age, hyperbilirubinemia neurotoxicity risk factors, and age of the infant in hours.
Figure 1 provides suggested phototherapy thresholds if there are no known hyperbilirubinemia
neurotoxicity risk factors in addition to gestational age.

Figure 1: Phototherapy thresholds by gestational age and age in hours for infants with no
recognized hyperbilirubinemia neurotoxicity risk factors other than gestational age.

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Figure 2 should be used if there are any hyperbilirubinemia neurotoxicity risk factors other than
gestational age.

Figure 2 Phototherapy thresholds by gestational age and age in hours for infants with any
recognized hyperbilirubinemia neurotoxicity risk factors other than gestational age.
[Hyperbilirubinemia neurotoxicity risk factors include gestational age <38 weeks; albumin <3.0
g/dL; isoimmune hemolytic disease, glucose-6-phosphate dehydrogenase (G6PD) deficiency, or
other hemolytic conditions; sepsis; or any significant clinical instability in the previous 24 hours.]
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.
 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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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.

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 •
Fig biliblanket
Nursing Care and Procedure for phototherapy

1. Explain the procedure to the parents.

2. Check the baby's temperature before starting phototherapy Wash hands with soap and water
and dry thoroughly with clean towel.
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.
5. Place the baby under the phototherapy light. Place the baby as close to the light as the
manufacturer's instructions or adjust the height of the phototherapy to 45cm above the baby
using a tape measure. Place it too close to the infant could result in fever or burns. Placing it
too far away will make the treatment ineffective.
6. The baby's eyes are shielded by an opaque mask to prevent exposure to the light.
7. The eye shield should be properly sized and correctly positioned to cover the eye completely
but prevent any occlusion of the nares.
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8. The baby's eyelids are closed before the mask is applied, because the corneas may become
excoriated if they come in contact with the dressing.
9. On each nursing shift the eyes are checked for evidence of discharge, excessive pressure on
the lids or corneal irritation.
10. Eye shields are removed during feedings, which provide the opportunity to provide visual
and sensory stimulation.
11. Undress the baby and keep the genitals covered with a small diaper.
12. Turn on the phototherapy light.
13. Measure the baby's temperature is more than 37.5°C, adjust the temperature of the room or
temporarily remove the baby from the phototherapy unit until baby's temperature is 36.5° C
to 37.C.
14. Turn the baby after each feed to expose maximum surface area of baby to light.
15. 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.
16. During breastfeeding switch off the photo therapy unit.
17. Note the number and consistency of stools. Baby's stool may become loose and yellow
while the baby is receiving phototherapy. This does not require specific treatment.
18. Clean the neonate's buttocks after each stool to help maintains skin integrity.
19. Check the eye mask (Patches) and diaper over the genitalia frequently to ensure they are
properly placed
20. Frequently assess skin and sclera color to check the degree of jaundice.
21. Estimate fluid losses and check for dehydration. If dehydration occurs, inform the on-duty
doctor.
22. Continue other prescribed treatment and tests:
 Remove the baby from the phototherapy unit only for procedures that cannot be
performed while under the phototherapy lights.
 If the baby is receiving oxygen, briefly turn off the lights when observing the baby for
central cyanosis (blue tongue and lips)

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 23. Check the serum bilirumin level every 4 to 8 hours to determine the effectiveness of
phottherapy.
 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.
 If the serum bilirubin is close to the level requiring exchange transfusion organize
transfer and urgently refer the baby to a tertiary hospital for exchange transfusion, if
possible, send a sample of the mother's and the baby's blood.
24. If the serum bilirubin cannot be measured, discontinue phototherapy after three days.
Bilirubin in the skin rapidly disappears under phototherapy. Skin colour cannot be used as a
guide to serum bilirubin level while the baby is receiving phototherapy and for 24 hours
after discontinuing phototherapy.
25. Record and report of the baby's condiiton regularly.
26. 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
27. After phototherapy has been discontinued;
 Observe the baby for 24 hours, and repeat the serum bilirubin measurement, if
possible, or estimate jaundice using the clinical method.
 If jaundice has returned to or is above the level at which phototherapy was started,
repeat phototherapy for the same length of time as originally given. Repeat this step
each time phototherapy is discontinued until the measured or estimated bilirubin
stays below the level requiring phototherapy.
28. If phototherapy is no longer required, the baby is feeding well, and these are no other
problems requiring hospitalization, discharge the baby.
29. Teach the mother to assess jaundice, and advise her to return if the baby becomes more
jaundiced.
Complications

1. Hyperthermia: Phototherapy causes in insensible water loss especially in premature infants.

In addition, stool tends to be looser and more frequent. The loss must be compensated for by
increasing fluid intake by 25% over that required before phototherapy. Babies under
phototherapy should have regular measurement of temperature and get weighed twice daily.
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 2. Retinal damage effect of high, intensity light on growing retina is uncertain. But animal
studies indicate that retinal degenerating may occur after several days of continuous
exposure.
3. Water loss from increased peripheral blood flow and diarrhoea (if present)
4. Diarrhoea from intestinal hypermotility.
5. Ileus (preterm infants)
6. Rash.
7. Retinal damage.
8. Bronze baby syndrome: In this condition the skin, urine and serum become brownish black
after several days of phototherapy. It is seen more often in neonates with conjugated
hyperbilirubinemia. Babies recover fully after several days once that phototherapy is
discontinued.
9. Temporary lactose intolerance.
10. Electric shocks: Electric shocks due to poor grounding.
11. Others: sleepiness, disinterest in breast feeding, rashes, hyperthermia, increased metabolic
rate.

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_ne
onatal_jaundice/
3. Paediatric Protocols – Patan Hospital Neonatology Protocol Department of Pediatrics, Patan
Hospital, 2014
4. Tuitui R. Mannual of Midwifery III. 15th edition..Vidyarthi Pustak Bhandar, Bhotahity,
Kathmandu. 2020.

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