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Phototherapy for Jaundice Periprocedural Care

  • Author: Taylor L Sawyer, DO, MEd, FAAP, FACOP; Chief Editor: Ted Rosenkrantz, MD  more...
 
Updated: Dec 06, 2015
 

Patient Education & Consent

Patient Instructions

Elements of Informed Consent

According to the American Academy of Pediatrics Clinical Practice Guidelines on the management of hyperbilirubinemia in infants 35 or more weeks’ gestation, all hospitals should provide verbal or written information to parents explaining jaundice, the need to monitor infants for jaundice, and details on how that monitoring should be done.[6] An a example of such a handout is provided by the American Academy of Pediatrics.

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Equipment

Several devices can be used to provide phototherapy. These include tungsten-halogen lamps, fluorescent tubes, fiberoptic systems, and gallium nitride LED lights. All these devices are capable of emitting light in the 430-490 nm band at standard spectral irradiance levels of 8-10 mW/cm2 per nm. However, when intensive phototherapy is required either ”special blue” fluorescent tubes or specially designed LED devices should be used because these are the only devices that can reliably provide more than 30 mW/cm2 per nm in the 430-490 nm band.4 16

Halogen-based phototherapy lamps

Halogen-based phototherapy lamps, or spotlights, use a commercially available tungsten- halogen light bulb and direct a strong beam of white/yellow light towards the infant. These devices are typically free-standing on a pole, or available as part of a radiant warmer. Halogen-based spot lights are the most heat producing of all the available phototherapy lights. Care must be taken not to place the devices closer to the infant than recommended by the manufacturer to avoid overheating the infant. Additionally, due to the associated heat output, halogen lights may result in increased insensible water loss in infants receiving phototherapy.

See the image below.

Infant under Ohmeda halogen lamp with eye protecti Infant under Ohmeda halogen lamp with eye protection.

Fluorescent tubes

Fluorescent tubes used to deliver phototherapy have been classified as ”daylight,” ”blue,”’ and ”special blue.” A commercially available daylight tube is the F20T12/D (General Electric, Westinghouse, Sylvania). A commercially available blue florescent tube is the F20T12/B (General Electric, Westinghouse, Sylvania). Special blue fluorescent tubes include those labeled TL52/20W (Philips, Endhoven, The Netherlands) or F20T12/BB (General Electric, Westinghouse, Sylvania).

In prior clinical studies, only the special blue fluorescent tubes were able to reliably emit light at more than 30 mW/cm2 per nm in the 430-490 nm band.[16] Special blue tubes are most effective because they emit light in the blue-green spectrum, which penetrates skin well and is maximally absorbed by bilirubin. Fluorescent tubes are typically housed in a commercially available device which holds 4-8 tubes that are 24 inches. The device is typically attached to a pole and the height of the lighting device can be adjusted up and down. One commercially available device, the Bili Bassinet (Olympic Medical; Seattle, WA), contains special blue fluorescent tubes in a housing both above and below the infant.

Fiberoptic phototherapy

Fiberoptic phototherapy devices deliver light form a high intensity lamp to a fiberoptic blanket. These BiliBlanket devices are typically used in conjunction with overhead halogen, fluorescent, or LED systems. These devices are also commonly used to provide home phototherapy. A disadvantage of using fiberoptic pads is that they cover a fairly small surface area. Therefore, 2-3 pads may be needed to provide effective phototherapy.[16] This is one reason why home phototherapy is reserved only for use in low-risk infants with total bilirubin levels 2-3 mg/dL lower than that recommended for intensive phototherapy.[6] See the image below.

Infant under neoBLUE phototherapy light and lying Infant under neoBLUE phototherapy light and lying on fiberoptic phototherapy blanket.

LED phototherapy systems

LED phototherapy systems, which use gallium nitride LEDs, are the newest devices used to provide phototherapy. Gallium nitride LEDs emit high-intensity light in the blue-green portion of the spectrum within a narrow wavelength (460-485 nm).[17] LEDs offer some advantages to other phototherapy sources. Their narrow wavelength of emission is close to the wavelength at which light is maximally absorbed by bilirubin. Additionally, the spectral quality of the LED device can be customized by the use of varying proportions of blue, blue-green, and green LEDs. Also, LEDs generate less heat than either halogen or fluorescent lamps, and can thus be positioned very close to the skin without significant risk of overheating or burns.

Prior studies have shown that using an array of 600, 3-mm blue LEDs, at a short distance from an infant can achieve an irradiance of more than 200 mW/cm2 per nm.[17] Specially designed LED systems, such as the neoBLUE LED Phototherapy system (Natus Inc; San Carlos, CA), are recommended by the American Academy of Pediatrics for use during intensive phototherapy.[6] See the image below.

neoBLUE light-emitting diode (LED) phototherapy sy neoBLUE light-emitting diode (LED) phototherapy system.
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Patient Preparation

Positioning

Infants receiving phototherapy should be placed lying flat on a radiant warmer or in a bassinet. Small or premature infants can remain in an infant incubator during phototherapy. The infant should be naked with the exception of eye protection and a diaper to maximize the surface area of skin exposed to light. The phototherapy device should be placed at the side of the infant’s bed with the light shining on the infant and covering as much surface area as possible.

When fluorescent tubes or LED devices are used, the infant should be placed as close as possible to the light source, typically within 10 cm.[6] This increases the spectral irradiance of the light delivered. Halogen-based devices emit greater amounts of heat than fluorescent or LED devices and therefore need to be positioned at a greater distance from the infant. Providers should follow the manufacturer’s recommendations on how far to position the halogen light source from the infant.

Fiberoptic pads can be positioned directly underneath the infant to provide an additional source of phototherapy. The fiberoptic pads do not emit significant heat. Due to their relatively hard surface, phototherapy pads should be used with caution in extremely low birth weight infants or other infants who are at risk for skin break down from pressure sores.

If phototherapy is provided through the top of an infant, incubator the light source should be kept perpendicular to the surface of the isolette to decrease light reflectance off the plastic, which diminishes the amount of light that reaches the infant inside the isolette. In cases of severe hyperbilirubinemia, white towels or aluminum foil can be placed around the interior of the bassinet to reflect light back on the infant and increase surface area exposure.[6]

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Monitoring & Follow-up

Monitoring of serial bilirubin values in infants on phototherapy is important to confirm that the therapy is effective. With intensive phototherapy (>30 mW/cm2 per nm), a decrease in bilirubin concentration by 30-40% can be expected within the first 24 hours.[6] The most significant drop in bilirubin concentration is typically seen within the first 4-6 hours of phototherapy.[6] Thus, bilirubin concentrations are typically checked prior to the start of phototherapy, after 4-6 hours of phototherapy to confirm effectiveness, and then repeated at 12-24 hour intervals until levels are low enough to stop phototherapy. Although no standard is noted for the discontinuation of phototherapy, current guidelines suggest stopping phototherapy on infants 35 or more weeks’ gestation at birth readmitted after their birth hospitalization when the levels of total bilirubin fall below 13-14 mg/dL.[6]

For infants with hemolytic disease, and in those younger than 3-4 days, a ”rebound” bilirubin should be checked within 24 hours after discontinuation of phototherapy.[6] This 24-hour rebound bilirubin check can also be considered in infants 35 or more weeks’ gestation at birth with nonhemolytic jaundice who are readmitted with hyperbilirubinemia.[6]

No evidenced-based guidelines to indicate when phototherapy should be discontinued in premature infants. In general, phototherapy is stopped when the total serum bilirubin level is several points lower than when it was started. Most practitioners routinely check a rebound bilirubin in all premature infants within 24-48 hours after discontinuation of phototherapy, or sooner if a hemolytic process is present.

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Contributor Information and Disclosures
Author

Taylor L Sawyer, DO, MEd, FAAP, FACOP Assistant Professor of Pediatrics, University of Washington School of Medicine; Associate Director, Neonatal-Perinatal Fellowship, Seattle Children's Hospital

Taylor L Sawyer, DO, MEd, FAAP, FACOP is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, American College of Osteopathic Pediatricians, American Medical Association, American Osteopathic Association, Association of American Medical Colleges, Society for Simulation in Healthcare, International Pediatric Simulation Society

Disclosure: Nothing to disclose.

Coauthor(s)

Daniel P Chiles, DO Chief Resident, Department of Pediatrics, Tripler Army Medical Center

Daniel P Chiles, DO is a member of the following medical societies: American Academy of Pediatrics, American Osteopathic Association

Disclosure: Nothing to disclose.

Luke J Lindley, MD Resident Physician, Department of Pediatrics, Tripler Army Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Ted Rosenkrantz, MD Professor, Departments of Pediatrics and Obstetrics/Gynecology, Division of Neonatal-Perinatal Medicine, University of Connecticut School of Medicine

Ted Rosenkrantz, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, Eastern Society for Pediatric Research, American Medical Association, Connecticut State Medical Society, Society for Pediatric Research

Disclosure: Nothing to disclose.

Acknowledgements

Disclaimer

The views expressed in this manuscript are those of the author(s) and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. Government.

References
  1. Maisels MJ, McDonagh AD. Phototherapy for Neonatal Jaundice. N Engl J Med. 2008. 358:920-928.

  2. Maisel MJ. Neonatal Jaundice. Pediatrics in Review. 2006. 27(12):443-453.

  3. Cremer RJ, Parryman PW, Richards DH. Influence of light on the hyperbilirubinemia of infants. Lancet. 1958. 1:1094-1097.

  4. Slusher TM, Olusanya BO, Vreman HJ, Brearley AM, Vaucher YE, Lund TC, et al. A Randomized Trial of Phototherapy with Filtered Sunlight in African Neonates. N Engl J Med. 2015 Sep 17. 373 (12):1115-24. [Medline].

  5. Slusher TM, Vreman HJ, Olusanya BO, Wong RJ, Brearley AM, Vaucher YE, et al. Safety and efficacy of filtered sunlight in treatment of jaundice in African neonates. Pediatrics. 2014 Jun. 133 (6):e1568-74. [Medline].

  6. [Guideline] American Academy of Pediatrics. Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. Pediatrics. 2004. 114 (1):297-316.

  7. Francisco Sweeney NM. Neonatology. Custer JW and Rau Rachele. The Harriet Lane Handbook. 8th Ed. Philadelphia: Elsevier Mosby, Inc.; 2009. 497.

  8. Gomella TL. Hyperbilirubinemia. Neonatology. 4th Ed. Connecticut: Appleton & Lange, Stamford; 1999. 235.

  9. Muchowski KE. Evaluation and treatment of neonatal hyperbilirubinemia. Am Fam Physician. 2014 Jun 1. 89 (11):873-8. [Medline]. [Full Text].

  10. Tan KL. The pattern of bilirubin response to phototherapy for neonatal hyperbilirubinemia. Pediatric Research. 1982. 16:670-674.

  11. Messner KH, Maisel MJ, Leure-DuPree AE. Phototoxicity to the newborn primate retina. Invest Ophthalmol Vis Sci. 1978. 17:178-182.

  12. Zhang AY, Elston DM. Drug-Induced Photosensitivity. Medscape Reference. Available at http://emedicine.medscape.com/article/1049648-overview. Accessed: April 25, 2011.

  13. Maayan-Metzger A, Yosipovitch G. Hadad E, Sirota L. Transepidermal Water Loss and Skin Hydration in Preterm Infants During Phototherapy. Am J Perinatology. 2001. 18(7):393-396.

  14. Furchgott RF. Endothelium-dependent relaxation, endothelium-derived relaxingfactor and photorelaxation of blood vessels. Semin Perinatol. 1991. 15:11-15.

  15. Grunhagen DJ, De Boer MG, De Beaufort AJ, Walther FJ. Transepidermal Water Loss During Halogen Spotlight Phototherapy in Preterm Infants. Pediatric Research. 2002. 5(3):402-405.

  16. Maisel MJ. Why use homeopathic doses of phototherapy. Pediatrics. Pediatrics. 1996. 98:283-287.

  17. Seidman DS, Moise J, Ergaz Z, Laor A, Vreman HJ, Stevenson DK, et al. A new blue light-emitting phototherapy device: A prospective randomized controlled study. J Pediatr. 2000. 136:771-774.

  18. Olusanya BO, Ogunlesi TA, Kumar P, Boo NY, Iskander IF, de Almeida MF, et al. Management of late-preterm and term infants with hyperbilirubinaemia in resource-constrained settings. BMC Pediatr. 2015 Apr 12. 15:39. [Medline]. [Full Text].

 
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Infant under Ohmeda halogen lamp with eye protection.
Infant under neoBLUE phototherapy light and lying on fiberoptic phototherapy blanket.
neoBLUE light-emitting diode (LED) phototherapy radiometer.
neoBLUEcozy light-emitting diode (LED) phototherapy bed.
neoBLUE light-emitting diode (LED) phototherapy lamp.
neoBLUE light-emitting diode (LED) phototherapy system.
Causes of hyperbilirubinemia in newborn infants. Adapted from Maisel MJ. Neonatal Jaundice. Pediatrics in Review. 2006; 27: p. 445.
Mechanism of phototherapy: Blue-green light in the range of 460-490 nm is most effective for phototherapy. The absorption of light by the normal bilirubin (4Z,15Z-bilirubin) generates configuration isomers, structural isomers, and photooxidation products. The 2 principal photoisomers formed in humans are shown. Configurational isomerization is reversible and much faster than structural isomerization. Structural isomerization is slow and irreversible. Photooxidation occurs more slowly than both configurational and structural isomerization. Photooxidation products are excreted mainly in urine. Adapted from Maisel MJ, McDonagh AD. Phototherapy for Neonatal Jaundice. N Engl J Med. 2008;358:920-928.
Factors that affect phototherapy: The 3 factors that affect the dose of phototherapy include the irradiance of light used, the distance from the light source, and the amount of skin exposed. Standard phototherapy is provided at an irradiance of 8-10 microwatts per square centimeter per nanometer (mW/cm2 per nm). Intensive phototherapy is provided at an irradiance of 30 mW/cm2 per nm or more (430–490 nm). For intensive phototherapy, an auxiliary light source should be placed under the infant. The auxiliary light source could include a fiber-optic pad, a light-emitting diode (LED) mattress, or a bank of special blue fluorescent tubes. Term and near-term infants should receive phototherapy in a bassinet and the light source should be brought as close as possible to the infant, typically within 10-15 cm. However, if halogen or tungsten lights are used, providers should follow the manufacturer recommendation on the distance of the light from the infant to avoid overheating. Preterm infant can be treated in an incubator, but the light rays from the phototherapy device should be perpendicular to the surface of the incubator to minimize light reflectance. Adapted from Maisel MJ, McDonagh AD. Phototherapy for Neonatal Jaundice. N Engl J Med. 2008;358:920-928.
 
 
 
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