Clinical Guidelines (Nursing)

Phototherapy for neonatal jaundice

  • Note: This guideline is currently under review.  



      Introduction

      Aim

      Definition of Terms

      Assessment

      Managment

      Potiential Complications

      Discharge Planning

      Family Centered Care

      Companion Documents

      Links

      Evidence Table

      References

       

      Introduction

      This guideline applies to neonates within the first two weeks of life.

      Phototherapy is the use of visible light to treat severe jaundice in the neonatal period. Approximately 60% of term babies and 85% preterm babies will develop clinically apparent jaundice, which classically becomes visibly apparent on day 3, peaks days 5-7 and resolves by 14 days of age. Treatment with phototherapy is implemented in order to prevent the neurotoxic effects of high serum unconjugated bilirubin. Phototherapy is a safe, effective method for decreasing or preventing the rise of serum unconjugated bilirubin levels and reduces the need for exchange transfusion in neonates.

      Aim

      This guideline provides health care providers with information to understand the causes of neonatal jaundice, the rationale for the use of phototherapy and outlines the care of neonates receiving phototherapy in order to enhance effective phototherapy delivery and minimise complications of phototherapy.

      Definition of Terms

      • Jaundice: the yellow appearance of the skin that occurs with the deposition of bilirubin in the dermal and subcutaneous tissues and the sclera.
      • Bilirubin: the orange-yellow pigment of bile, formed principally by the breakdown of haemoglobin in red blood cells at the end of their normal life-span. Neonate’s bilirubin production rate is double that of adults and their clearance of bilirubin is reduced, hence the importance of monitoring levels and detecting jaundice in this early post-natal period. 
      • Bilirubinaemia: the presence of bilirubin in the blood.
      • Hyperbilirubinaemia: the excess of bilirubin in the blood. Types of Neonatal Hyperbilirubinaemia:
        • Unconjugated: most common form of neonatal hyperbilirubinaemia. The bilirubin has not been metabolised 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.
        • Conjugated: less common in neonates. The bilirubin has been metabolised and is water soluble, but accumulates in the blood usually due to hepatic dysfunction. Conjugated bilirubin does not cross the blood-brain barrier. 
      • Serum Bilirubin (SBR): reports the unconjugated and conjugated bilirubin levels. This is the usual specimen requested by Medical staff on the pathology slip at RCH. 
      • Total serum bilirubin levels (TSB): measure used when charting serum bilirubin results onto Phototherapy and/or Exchange transfusion charts. TSB is the sum of unconjugated + conjugated serum bilirubin. A TSB can be requested on the pathology slip at RCH, but only the total combined conjugated and unconjugated bilirubin level is reported.
      • Breast milk jaundice: develops within 2-4 days of birth, is most likely related to limited fluid intake as breast milk supply is established, may peak at 7-15 days of age and may persist for weeks.
      • 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. Blue-green light is most effective for phototherapy as it both penetrates the skin and is absorbed by bilirubin to have the photochemical effect. 
      • 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.
      • Kernicterus: the pathogenic diagnosis characterised 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.
      • Single Light: One neoBLUE LED phototherapy unit (mini or standard)
      • Double Lights: Two neoBLUE LED phototherapy unit’s (mini or standard) or One neoBLUE LED phototherapy unit (mini or standard) + One biliblanket
      • Triple Lights: Three neoBLUE LED phototherapy unit’s (mini or standard) or Two neoBLUE LED phototherapy unit (mini or standard) + One biliblanket 

      **All phototherapy units are to be set on high intensity at all times, regardless of the amount of units in use. This ensures delivery of adequate amounts of blue light via light emitting diodes (LEDs). Therefore, a single unit is classified as a single light and single, double or triple lights refers to the amount of units not the intensity setting. 
       
      **As per Natus neoBLUE LED phototherapy in-service guide (available on the intranet), mini neoBlue LED phototherapy units deliver the same intensity as the standard unit set on high intensity; the only difference is in the surface area coverage.


      Assessment

      Please note that when charting the TSB level onto the Phototherapy or Exchange Transfusion charts, in the presence of risk factors (sepsis, haemolysis, acidosis, asphyxia, hypoalbuminaemia) TSB values should be plotted on the range 1 lower than the neonate’s gestational age/weight. This is because the risk of developing kernicterus increases in the presence of the above risk factors.
      The Phototherapy and Exchange Transfusion charts onto which total SBR is plotted are for the first 7.5 and 5 days of life respectively. After the first 5-7 days continue utilising these charts, as levels plateau and can continue to be documented.

      • Assess general skin colour whenever measuring and recording vital signs. 
      • Obtain blood sample to measure total serum bilirubin levels (either venous, arterial or capillary) 
      • Observe for signs of lethargy and poor feeding (insert link to assessing for Jaundice)

      During phototherapy neonates require ongoing monitoring of:

      • adequacy of hydration (urine output) and nutrition(weight gain) 
      • temperature
      • clinical improvement in jaundice
      • TSB or SBR levels
      • potential signs of bilirubin encephalopathy

      Investigations

      • Initial TSB/SBR measurement should be requested based on clinical observation and the following factors:
        • any neonate <24 hours age with clinically apparent jaundice
        • any neonate where there is clinical doubt about the degree of jaundice
        • any unwell neonate with jaundice
        • any neonate with risk factors for jaundice (ABO/ Rh incompatibility, sepsis, acidosis, asphyxia, hypoalbuminaemia)
      • Ongoing TSB/SBR measures should be repeated at intervals depending on the initial level and rate of rise. For example: 6 hourly measures may be required if the level is very high and the neonate is being treated with multiple phototherapy lights.
      • A TSB/SBR may be requested within 24 hours of ceasing phototherapy to assess for rebound hyperbilirubinaemia. Neonates at increased risk of clinically significant rebound hyperbilirubinaemia include those born less than 37 weeks gestation, those not feeding optimally or those with haemolytic disease.
      • Further Bloods and investigations include
        • Maternal and infant blood type
        • Direct Coombs test
        • Haemoglobin
        • Full blood count for red cell morphology; reticulcyte, haematocrit and platelet counts and white blood cell differential
        • Urinalysis for reducing substances
        • Sepsis screen if sepsis suspected
        • G6PD and galactosaemia screens if suspected
        • Serum thyroxine and thyroid-stimulating hormone levels

      Risk Factors

      • Mothers with a positive antibody screen
      • A family history of G6PD deficiency
      • A previously affected sibling
      • Cephalhaematoma, bruising and trauma from instrumental birth
      • Delayed passage of meconium
      • Prematurity
      • Dehydration
      • Inadequate breastfeeding
      • ABO incompatibility
      • Rh incompatibility

      Nutrition

      Breastfed babies who require phototherapy should continue to breastfeed unless clinically contra-indicated due to other pathology; the neonate’s sucking, attachment and mother’s milk supply should be monitored.
      Neonates who are receiving enteral feeds of EBM or infant formula should continue to do so. The total fluid intake (TFI) for a 24 hour period may need to be increased by at least 10% to account for insensible fluid loss when a neonate is receiving phototherapy.
      Parenteral nutrition and IV fluids should continue as ordered and may also need to be increased by 10% to account for insensible fluid loss.

      Management

      (link to phototherapy management document)

      • Commence phototherapy once TSB/SBR is greater than the appropriate reference range for neonate’s gestation/weight and presence of risk factors.
      • Neonates should be nursed naked apart from a nappy under phototherapy and will need to be nursed in an Isolette to maintain an appropriate neutral thermal environment. (Link to:” Ward Management of a Neonate” and “Isolette use in Paediatric Wards”)
      • Positon phototherapy units no more than 30.5cm from the patient. neoBLUE® LED phototherapy unit can be positioned as close as 15cm to patient. Refer to specific phototherapy units manufacturing guidelines for more details
      • Expose as much of the skin surface as possible to the phototherapy light. To maximise skin exposure, dress the baby in a nappy and their protective eye covers only.
      • Cover the eyes with appropriate opaque eye covers e.g Natus Biliband® Eye Protector (available from Butterfly ward). 
      • Ensure eye covers are removed 4-6 hourly for eye care during infant cares or feeding. Observe for discharge/infection/damage and document any changes.
      • Daily fluid requirements should be reviewed and individualised for gestational and postnatal age. 
      • Maintain a strict fluid balance chart. 
      • Breast feeds may need to be limited to 20 minutes if bilirubin level is high to minimise amount of time out of the lights
      • Monitor vital signs and temperature at least 4 hourly, more often if needed
      • Cover lipid lines with light resistant, reflective tape to avoid peroxidation
      • Ensure that phototherapy unit is turned off during collection of blood for TSB/SBR levels, as both conjugated and unconjugated bilirubin are photo-oxidized when exposed to white or ultraviolet light.
      • Observe for signs of potential side effects.


      Potential Complications

      • Overheating – monitor neonate’s temperature 
      • Water loss from increased peripheral blood flow and diarrhoea (if present)
      • Diarrhoea from intestinal hypermotility
      • Ileus (preterm infants)
      • Rash
      • Retinal damage
      • ‘bronzing’ of neonates with conjugated hyperbilirubinaemia 
      • Temporary lactose intolerance

      Discharge planning and community-based management

      Documentation in the neonates discharge letter and Child Health Booklet should include details about TSB/SBR levels and duration of phototherapy treatment.

      Family Centered Care

      Explain to parents the need for and actions of phototherapy, particularly in relation to the need for skin surface to be exposed to the phototherapy light, and hence the need to care for neonates receiving phototherapy to be nursed in a neutral thermal environment. Potential complications of phototherapy and the need for protective eye coverings during phototherapy treatment should be explained. The need for measuring the TSB and need for blood sampling should also be explained.

      Neonates receiving phototherapy (where there are no other contraindications) can have brief periods where the phototherapy is ceased so that they can be cuddled/breastfed and have their eye covers removed for parent-baby interaction to occur.

      Special Considerations

      Normal hand hygiene measures should be attended to during care of a neonate receiving phototherapy.

      More details on the neoBLUE LED lights can be found in the definition of terms

      Companion Documents


      Links


      Evidence Table

      Click here to view the evidence table for this guideline. 

      References

      • Bhutani, V.K. and the Committee on Fetus and Newborn (2011) Phototherapy to prevent severe neonatal hyperbilirubinaemia in the newborn infant 35 or more weeks gestation, Pediatrics 128(4); e1046e1052
      • http://www.health.vic.gov.au/neonatalhandbook/comditions/jaundice-in-neonates.htm retrieved 12/06/14
      • Maisels, M.J. & McDonagh, A.F. (2008) Phototherapy for neonatal jaundice, New England Journal of Medicine 358(9): 920-928
      • Neonatal Hyperbilirubinaemia, retrieved from 
      • http://www.merckmanuals.com/professional/pediatrics/metabolic_electrolyte_and_toxic_disorders_in_neonates/neonatal_hyperbilirubinemia.html 16/01/2014
      • NICE clinical guideline 98 (2010) Neonatal Jaundice, guidance.nice.uk/cg98 
      • Queensland Maternity and Neonatal Clinical Guideline Neonatal Jaundice: prevention, assessment and management, Queensland Government (2009)


      Please remeber to read the disclaimer

       

      The development of this nursing guideline was coordinated by Jacquie Whitelaw, PIPER Nurse Educator, and approved by the Nursing Clinical Effectiveness Committee. Updated April 2015.