Speak to your midwife, health visitor or GP if your baby develops jaundice. They'll be able to assess whether treatment is needed. Treatment is usually only needed if your baby has high levels of a substance called bilirubin in their blood, so tests need to be carried out to check this. See diagnosing jaundice in babies for more information about the tests used. Most babies with jaundice do not need treatment because the level of bilirubin in their blood is found to be low. In these cases, the condition usually gets better within 10 to 14 days and will not cause any harm to your baby. If treatment is
not needed, you should continue to breastfeed or bottle feed your baby regularly, waking them up for feeds if necessary. If your baby's condition gets worse or does not disappear after 2 weeks, contact your midwife, health visitor or GP. Newborn jaundice can last longer than 2 weeks if your baby was born prematurely or is solely breastfed. It usually improves without treatment. But further
tests may be recommended if the condition lasts this long, to check for any underlying health problems. If your baby's jaundice does not improve over time, or tests show high levels of bilirubin in their blood, they may be admitted to hospital and treated with phototherapy or an exchange transfusion. These treatments are recommended to reduce the risk of a rare but serious complication of newborn jaundice called
kernicterus, which can cause brain damage. PhototherapyPhototherapy is treatment with a special type of light (not sunlight). It's sometimes used to treat newborn jaundice by making it easier for your baby's liver to break down and remove the bilirubin from your baby's blood. Phototherapy
aims to expose your baby's skin to as much light as possible. Your baby will be placed under a light either in a cot or incubator with their eyes covered.
It will usually be stopped for 30 minutes so you can feed your baby, change their nappy and give them a cuddle. If your baby's jaundice does not improve, intensified phototherapy may be offered. This involves increasing the
amount of light used or using another source of light, such as a light blanket, at the same time. Treatment cannot be stopped for breaks during intensified phototherapy, so you will not be able to breastfeed or hold your baby. But you can give your baby expressed milk. During phototherapy, you baby's temperature will be monitored to make sure they're not getting too hot, and they'll be checked for signs of
dehydration. Intravenous fluids may be needed if your baby is becoming dehydrated and they are not able to drink enough. The bilirubin levels will be tested every 4 to 6 hours after phototherapy has started, to check if the treatment is working. Once your baby's bilirubin levels have stabilised or started to fall, they will be
checked every 6 to 12 hours. Phototherapy will be stopped when the bilirubin levels fall to a safe level, which usually takes a day or two. Phototherapy is generally very effective for newborn jaundice and has few side effects. Exchange transfusionIf your baby has a very high level of bilirubin in their blood or phototherapy has not been effective, they may
need a complete blood transfusion, known as an exchange transfusion. During an exchange transfusion, your baby's blood will be removed through a thin plastic tube placed in blood vessels in their umbilical cord, arms or legs. The blood is replaced with blood from a suitable matching donor (someone with the same
blood group). As the new blood will not contain bilirubin, the overall level of bilirubin in your baby's blood will fall quickly. Your baby will be closely monitored throughout the transfusion process, which can take several hours to complete. Any problems that may arise, such as bleeding, will be treated. Your baby's blood will be
tested within 2 hours of treatment to check if it's been successful. If the level of bilirubin in your baby's blood remains high, the procedure may need to be repeated. Other treatmentsIf jaundice is caused by an underlying health problem, such as an infection, this usually needs to be treated. If the jaundice is caused by rhesus disease (when the mother has rhesus-negative blood and the baby has rhesus-positive blood), intravenous immunoglobulin (IVIG) may be used. IVIG is usually only used if phototherapy alone has not worked and the level of bilirubin in the blood is continuing to rise. Page last reviewed: 03 February 2022
Next review due: 03 February 2025 Note: This guideline is currently under review. Introduction
Aim Definition of Terms
Assessment Managment
Potiential Complications Discharge Planning
Family Centered Care Special Considerations
Companion Documents Links
Evidence Table References
IntroductionThis 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 visible on day 3, peaks days 5-7 and resolves by 14 days of age in a term infant and by 21 days in the preterm infant. 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. AimThis 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. Hyperlink to
RCH Specimen Collection handbook.
- 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.
AssessmentPlease
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. Ensure the Phototherapy tick box in the EMR Flowsheets is activated and document time of commencement and cessation.Obtain blood sample to measure total serum bilirubin levels (either venous, arterial or capillary)
- Document hourly the type and
number of light banks and the presence of eye protection.
- Obtain blood sample to measure total serum bilirubin levels (either venous, arterial or capillary) Hyperlink to RCH Specimen Collection handbook) Ensure the lights are turned off during sampling so accuracy of current blood levels can be attained. Initially SBR levels may need to be assessed every 4-6
hours until reduction. Follow medical advice and ordering of SBR levels according to acuity of levels and plot on appropriate line of the chart. Observe for signs of lethargy and poor feeding (insert link to assessing for Jaundice)
- 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
Management (link to phototherapy management document) NutritionBreastfed 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. In the case of infants nearing exchange transfusion level, the infant should not come out of phototherapy to feed as this is a medical emergency. All feeds should be given via a bottle or NGT if feeding is deemed safe
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 however this should be guided by hydration status and electrolyte monitoring.
Parenteral nutrition and IV fluids should continue as ordered and may also need to be increased by 10% to account for insensible fluid loss.
Phototherapy- 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”) In severe cases, the nappy may need to be removed and a urine bag applied to maximise skin exposure.
- 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 managementDocumentation in the neonates discharge letter and Child Health Booklet
should include details about TSB/SBR levels and duration of phototherapy treatment.
Family Centered CareExplain 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 ConsiderationsNormal 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- RCH Phototherapy Trial Chart - COMING SOON
- RCH Exchange Transfusion Chart
- RCH Phototherapy competency
- RCH: Neonatal Clinical Practice Guideline: Exchange Transfusion http://www.rch.org.au/uploadedFiles/Main/Content/neonatal_rch/EXCHANGE_TRANSFUSION.pdf
- RCH Clinical Practice Guideline: Jaundice in early infancy
http://www.rch.org.au/clinicalguide/guideline_index/Jaundice_in_Early_Infancy/
- RCH Clinical Guideline (Nursing): Ward Management of a Neonate
http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Ward_Management_of_a_Neonate/
- RCH Policy: Isolette use in Paediatric Wards http://www.rch.org.au/policy/policies/Isolette_Use_in_Paediatric_Wards/
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 remember to read
the disclaimer. The development of this nursing guideline was coordinated by Jessica Smith, Clinical Nurse Educator, Butterfly, and approved by the Nursing Clinical Effectiveness Committee. Updated December 2018.
What are the side effects of phototherapy in newborns?
The short-term side effects of phototherapy include interference with maternal-infant interaction, imbalance of thermal environment and water loss, electrolyte disturbance, bronze baby syndrome and circadian rhythm disorder.
What are the risks of phototherapy?
Phototherapy Complications. Signs of infection, including fever and chills.. Redness around the skin lesions or any discharge.. Severe skin burning, pain or blistering.. Side effects you experienced due to the treatment continue or worsen.. Development of new symptoms.. What is the most serious complication of hyperbilirubinemia in a newborn?
Kernicterus is a rare but serious complication of untreated jaundice in babies. It's caused by excess bilirubin damaging the brain or central nervous system.
Does phototherapy affect direct bilirubin?
Results: Following phototherapy both the direct bilirubin level and direct bilirubin/total bilirubin ratio increased (p<0.001 and p<0.001, respectively). The frequency of phototherapy-related direct hyperbilirubinemia was found to be 0.9% if the direct bilirubin/total bilirubin cut-off level was set to 20%.
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