# Phototherapy

## Overview

This module describes how to administer phototherapy to treat neonatal jaundice.

## Indications

1. Unconjugated hyperbilirubinaemia in neonates

## Contraindications

1. Neonates requiring an exchange transfusion

2. Conjugated hyperbilirubinaemia
   Conjugated hyperbilirubinaemia

   Phototherapy in these babies might cause the 'bronze baby' syndrome- an intense grey/brown discolouration of the skin, sclera and urine with anaemia.

## Patient information and consent

### How do I explain this procedure?

“Your baby has jaundice, a common condition of newborns that requires a once-off treatment, and has no long-term effects. Jaundice means the body is producing too much of a certain chemical causing the skin to turn yellow. When we place your baby under special lights, it breaks down this yellow pigment in the skin so that the baby can get rid of it through their urine and stool.”

### What can my patient expect?

“Your baby will be in the incubator or the cot with a lamp over it. We will protect the eyes with eye pads. We will be taking blood every 12 hours from your baby's heel or arm to monitor the level of the chemical. Once it has dropped to a safe level we can remove your baby from under the lights. It may take a day or up to several days. The therapy is not painful for the baby, but they might be more thirsty and need to drink more.”

### What is my patient’s role?

“Please keep your baby undressed and the nappy open and underneath the baby while he/she is under the lights as the skin needs to be exposed to the light for it to work. The eye pads must remain on while the baby is under the lights but you can remove them while feeding your baby. Please inform a nurse or a doctor if you notice loose stools, a rash, the baby is too hot or too cold, dehydration or anything else that worries you about the baby.”

## Preparation

Familiarise yourself with the lights that are available in the nursery of your institution and check that these are

in working order

in working order

Fluorescent tubes should be changed at regular intervals as specified by the manufacturer. Generally these are 1000 hours for fluorescent tubes, 800 hours for halogen bulbs and 3000 hours for LED lights. The tube is covered by a plexiglass shield.

. If you have a radiometer, confirm

adequate

adequate

It should be more than 8-9 µW/Cm2/nm.

irradiance.

###

### Documentation

1. Patient notes

2. Nursing notes with instructions for the number of lights, the period of phototherapy and any other nursing instructions

3. A phototherapy chart including an exchange transfusion chart

### Equipment

1. A light source with lightwave length between approximately

   420-490 nm
   420-490 nm

   This would amount to:

   - A bank of 4-8 cool white daylight fluorescent tubes
   - A bank of 4-8 blue or special blue fluorescent tubes
   - A bank of 4-8 fluorescent tubes (white or blue)
   - A bank of 8 halogen bulbs
   - A single tungsten halogen lamp or LED lights

2. Eye pads

3. A thermometer

4. Equipment for

   sampling blood
   sampling blood

   Familiarise yourself with the protocol at your institution.

   , either via capillary blood sampling or venous blood sampling.

## Site & Positioning

Position

Position

Check the manufacturer’s instructions if you are unsure.

the tubes as close as possible to the baby’s skin without causing hyperthermia. In an open bassinet, this could be as close as 10 cm, otherwise 20 cm, but no more than 40 cm away from the infant. A combination of two banks can be used simultaneously for intensive phototherapy.

## Procedure

Follow medical asepsis without gloves.

1. Perform hand hygiene.

2. Cover the infant’s eyes with

   eye pads
   eye pads

   Gauze pads may also be used. Eye pads should be removed and the eyes checked for conjunctivitis with every feed.

   and ensure that the nostrils are not occluded.

3. Undress the infant and place naked under the lights with the nappy open underneath the infant.

4. Turn the infant every 2-3 hours.

5. Monitor the infant’s temperature and ensure

   adequate fluid intake
   adequate fluid intake

   Oral hydration is preferred. Give breast milk on demand or expressed breast milk. Consider giving an extra 10% fluids if fluorescent lights are used.

   .

6. In severe jaundice,

   check
   check

   Visual assessment of jaundice is unreliable once the infant is under phototherapy.

   the total serum bilirubin 3-hourly.

7. Successful phototherapy should achieve a decline in TSB of 17-34 µmol/L within 4-6 hours and the TSB should

   continue to fall
   continue to fall

   The TSB should remain below the threshold for exchange transfusion or it is considered a failure.

   .

8. Phototherapy can be

   discontinued
   discontinued

   After stopping phototherapy in babies with haemolytic disease, the TSB should be checked 12-24 hours later for any significant rebound.

   if the TSB is more than 50 µmol/L below the phototherapy line.

## Troubleshooting

I do not have a phototherapy or exchange transfusion chart.

The nursery and paediatric ward usually has one. If not, search for a local guideline online or request one from a senior.

The TSB is continuing to rise or remains the same, but is still below the exchange transfusion line.

If capillary blood sampling was used, take venous blood to confirm, but place the neonate under double lights in the interim. If the TSB continues to rise, monitor closely to ensure it does not reach exchange transfusion levels. Consult a senior if unsure.

## Risks

1. Skin rash

2. Hypo- or hyperthermia

3. Increased insensible water loss

4. Dehydration

5. Loose stools

6. Bronze baby syndrome

7. Retinal damage

8. Prolonged separation from mother

## References

1. Rathod D, Muneer H, Masood S. Phototherapy. [Updated 2021 Oct 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK563140/

2. Henning P. Neonatal Jaundice. In Neonatology: A guide for doctors. Department of Paediatrics and Child Health and Stellenbosch University. Tygerberg Hospital South Africa. 2012. p. 49

3. Joolay Y, Horn A, et al. Phototherapy: some aspects. In: Neonatal Guidelines and Drug Dosages. Division of Neonatal Medicine Groote Schuur Hospital. 2012. p. 40-41