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Phototherapy

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Phototherapy is a treatment using 200-400-watt light with wavelength of 400-500 nanometers. The light may be fluorescent lights or special blue lights. The minimum brightness of the light to be effective is 4 microwatt per cubic meter, to treat an infant with jaundice or high level of bilirubin. The light will stimulate bilirubin to move from the skin to the plasma and then be excreted through urine and stool.

Jaundice in newborns
Jaundice in newborns, especially in the first week after birth, is normal. It is caused by the buildup of bilirubin, a yellow substance created by the body as it breaks down red blood cells. The treatment to reduce bilirubin levels must be carried out immediately to prevent brain damage.
 
High-Risk Newborns
  • The newborn that becomes jaundiced within 24 hours of birth.
  • The newborn that becomes visibly jaundiced before going home.
  • The newborn with a sibling who had jaundice.
  • The newborn born at 35 to 37 weeks of gestation.
  • The newborn who is exclusively breastfed.
  • The newborn with bruising or bleeding in the brain (cephalhematoma).
  • Male newborns.
*** If there are several risk factors at the same time, the risk of jaundice increases. ***
 
Types of Newborn Jaundice
  1. Physiological (normal) jaundice is found in more than half of all newborns and usually does not require treatment, except in premature infants who present with coexisting illness.
  • A newborn’s liver is not yet fully developed and thus bilirubin removal is slow, leading to jaundice that usually appears on the second to fourth day after birth and which disappears on its own by 1-2 weeks after birth.
  • A newborn’s body usually produces twice as much bilirubin as older children and adults as their red blood cells have shorter lifespans.
  1. Pathological jaundice
    1. Overproduction of bilirubin
  • Hemolytic disease of the newborn (HDN) occurs when the mother’s blood group is different from the baby’s, causing the mother’s body to create antibodies against her baby’s blood. These antibodies can pass to the newborn and destroy their red blood cells. ABO incompatibility is the most common type of hemolytic disease of the newborn (HDN) found in Thailand. It occurs when a mother’s blood group is O and her baby’s blood group is B. Rh incompatibility is rare and currently occurs less and less in the West due to the Rh immunoglobulin that is given to the mother within 72 hours of birth.
  • Abnormality of the covering of red blood cells, shortening their lifespans.
  • Abnormality of the red blood cells, making them prone to breaking, which can be caused by a number of conditions, including G6PD (glucose-6-phosphate dehydrogenase) or pyruvate kinase deficiency.
  • Thalassemia.
  • Excessive internal bleeding, such as bleeding in the brain or intestines, causing a higher than normal level of bilirubin.
  • Polycythemia.
    1. Increased absorption of bilirubin by the intestines due to certain circumstances, including:
  • The newborn is not able to breastfeed adequately/well.
  • Intestinal obstruction, causing bilirubin to be retained and a higher amount is then absorbed into the liver.
    1. Diminished ability of the liver to process bilirubin
    2. Infection in utero, such as cytomegalovirus (CMV), Toxoplasmosis, German measles, herpes simplex, syphilis, and hepatitis.
    3. Premature babies.
  1. Breastmilk jaundice
 
Signs and Symptoms
  • Yellow skin is usually first noticed at the face, especially if you press down on the forehead. Premature infants have thinner skin and the yellow is more obvious than in full-term infants with the same bilirubin levels. As the bilirubin levels rise, the yellowing will move down to the body and limbs respectively, as seen in the image below.
  • Bruising along the body or bleeding at the skin in certain spots. Listlessness, if bilirubin is very high.
  • Enlarged liver or spleen, found in hemolytic disease of the newborn (HDN) or in the newborn with intrauterine infection.
  • Newborn with jaundice due to blood group incompatibility with its mother or newborn experiencing hemolysis (abnormally high reticulocyte count and hematocrit less than 40%) or newborn with birth weight less than 2,500 grams. If less than 48 hours old, use phototherapy when bilirubin is greater than 10 milligrams per deciliter; if older than 48 hours old, use phototherapy when bilirubin is greater than 15 milligrams per deciliter.
  • In the case of blood group incompatibility without hemolysis or any other abnormalities that can cause bilirubin encephalopathy, such as infection in the blood or acidosis, for newborns between 48 and 72 hours old, use phototherapy when bilirubin is greater than 15 milligrams per deciliter. For newborns older than 72 hours, use phototherapy when bilirubin is greater than 20 milligrams per deciliter.
  • Phototherapy should not be done if there are indications for blood exchange or symptoms of direct hyperbilirubinemia.
  1. The doctor will order laboratory tests to measure the newborn’s bilirubin levels. These tests may include blood grouping, Coombs’ test (or similar), complete blood count (CBC), smear and reticulocyte count, and test for G6PD (glucose-6-phosphate dehydrogenase).
  2. The nurse will provide information to the newborn’s parents regarding the importance of the newborn being under the lights.
  3. The nurse will explain criteria to stop the phototherapy.
  1. Monitor jaundice. Record the date and time when jaundice began, the rate of increase of bilirubin, the maximum level of bilirubin in the blood, the mother’s blood group, and the newborns condition and symptoms.
  2. Inspect equipment.
  3. Take temperature of the newborn and monitor vitals every 2-4 hours.
  4. Monitor fluid intake (usually breastfeed every 3 hours).
  5. Prevent complications from breastfeeding, such as spitting up or choking, by burping the newborn between and/or after feeds.
  6. Assess stool and urine output. Colors of stool and urine will change slowly as the newborn undergoes phototherapy; stool will transition from black and green (meconium) to yellow.
  7. Assess frequency of bowel movement and urination (normally a newborn will pass stool more than 6 times in 24 hours). Frequent urination can cause a diaper rash. Clean the area with water and dry thoroughly each time.
  8. In case the mother has no breast milk, newborn can by fed formula by the mother; always turn off phototherapy light when taking newborn to be fed.
  9. Expose as much of the newborn’s skin to the light as possible by removing their clothes so that their chest and back are in contact with the light. Keep a small diaper on in the case that the newborn has frequent stools.
  10. Protect the newborn’s eyes. Cover the newborn’s eyes and remove the cover for 15-30 minutes every 4 hours and clean their eyes with normal saline solution.
  • Increased metabolic rate, causing weight loss.
  • Dehydration due to evaporation of moisture because of the increased temperature, requiring fluid replacement intravenously.
  • Diarrhea from phototherapy, causing injury to the lining of the intestines and lactase enzyme deficiency. This is temporary and will improve once treatment is completed. Nurse the newborn frequently to prevent dehydration and increase bowel movements. If the feeding is inadequate, introduce intravenous fluids.
  • If the newborn’s eyes are not properly covered, injury may occur to the retina. Long-term exposure to the lights can also lead to blindness. Thus, a newborn’s eyes should be covered well during treatment.
  • The newborn’s skin may darken due to long-term exposure to ultraviolet light.
  • Phototherapy may reduce the time that the mother can hold and touch her newborn, thus it is important to allow plenty of opportunities to nurse or bottle-feed her child to strengthen their relationship.
  • Newborn’s body temperature may be higher or lower than normal so assess body temperature every four hours.
  • Temporary rash on the body.

There are no limitations for travel before or after the procedure.

Bilirubin levels usually return to the normal range.
 
What if this procedure is not performed?
The jaundice may become out of control and lead to serious complications that affect the brain.
 
  • Blood exchange is indicated in case of bilirubin is higher than maximum limits.
  • Medication, such as phenobarbital, which can increase liver metabolism and reduce the bilirubin level.

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