PHOTO THERAPY

OVERVIEW
Phototherapy is used to treat hyperbilirubinemia in newborns.
Hyperbilirubinemia is an abnormally high concentration of serum bilirubin resulting from
the abnormal breakdown, processing, and/or excretion of the heme (iron) component of red
blood cells (RBCs) (Figure 1). Normally, these components are transported to the liver, where
they are processed and excreted into the bile. However, because of immaturity of the liver
at birth and the increased breakdown of RBCs, the newborn's system cannot effectively
process and excrete the bilirubin, causing jaundice. ,
29

Jaundice is present in at least 60% of term newborns and 80% of preterm newborns after 24
hours.  Bilirubin levels usually peak between days 3 and 5 of life,  but severe
9 11

hyperbilirubinemia may occur in up to 8% of newborns after the first week and persist for
more than 2 weeks. 9
 There are two types of bilirubin: , 9 11

 Direct (conjugated): Water-soluble bilirubin

o Excreted from the liver into the bile to be eliminated through the intestines
o Requires the presence of intestinal flora for excretion through stool or urine
o Becomes elevated because of liver or gallbladder pathology
o May be reabsorbed as unconjugated bilirubin because of the high levels of the
enzyme β-glucuronidase present in newborns' intestines
o Non-toxic to tissues
 Indirect (unconjugated): Lipid-soluble bilirubin
o Requires binding with albumin for transport to the liver for conjugation
o Becomes elevated when the body's bilirubin binding and transportation processes
are disrupted
o If unbound by albumin, deposits in skin and mucous membranes, giving the
newborn a jaundiced appearance and may also cross the blood-brain barrier causing
neurotoxicity
o Can be transformed into nontoxic water-soluble isomers by various means of
phototherapy
 Side Effects
o Common: Insensible water loss contributing to
dehydration (especially with preterm newborns),
decreased maternal-newborn interaction, lack of visual
sensory input
o Less common: Skin rashes, hypocalcemia, weight loss,
gastrointestinal problems, loose watery stools,
thermoregulation issues, thermal injury with some types
of lights, or "bronzed-baby syndrome," a grayish-brown
skin discoloration that occurs only in phototherapy-treated
newborns with elevated direct serum bilirubin levels (the
skin discoloration resolves as liver function improves).10,12
 PATIENT AND FAMILY EDUCATION
 Provide the family with oral and written explanations of newborn jaundice.
 Explain the phototherapy procedure including need for eye protection to
prevent ocular damage.
 Educate the family about the potential side effects of phototherapy
 Instruct the family about the newborn's expected length of stay, which may
cause the family to experience anxiety if the newborn's hospital discharge is
delayed because of the need for phototherapy. Discharge is usually dependent
upon the identification of risk factors and response to phototherapy. Once
phototherapy is discontinued, delaying home discharge while observing for
rebound may not be necessary
 Advise the family to contact the practitioner if they believe the newborn
shows increased jaundice, does not meet minimum eating and elimination
patterns, or exhibits a change in behavior (cry, muscle tone, mental status).
 Instruct the family regarding the importance of keeping follow-up
appointments with the pediatrician
 ASSESSMENT AND PREPARATION

Review the newborn's history to assess for risk factors for severe hyperbilirubinemia.
a. Major risk factors:3

i. Jaundice in the first 24 hours

ii. Blood group incompatibilities (ABO, Rh, and others) or other hemolytic
disease (G6PD deficiency)
iii.Gestational age 35 to 36 weeks
iv.Previous sibling receiving phototherapy
v. Ineffective breastfeeding
vi.Cephalohematoma or significant bruising
b. Minor risk factors: 3

i. Gestational age 37 to 38 weeks

ii. Jaundice observed before discharge
iii.Previous sibling with jaundice
iv.Macrosomic newborn of a mother with diabetes
v. Maternal age 25 years or greater
vi.Male sex
c. Other reported clinical risk factors:
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i. Polycythemia
ii. Pitocin use during labor
iii.Certain maternal drugs that affect bilirubin–albumin binding (sulfa
compounds, aspirin, phenylbutazone, and ceftriaxone)
iv.Forceps application or vacuum suction delivery
v. Birth trauma
vi.Dehydration
vii.Sepsis
viii.Acidosis
ix.Hypoalbuminemia
x. Poor feeding
d,. Risks related to gestational age:
3

xi.Low risk: Well newborns at 38 weeks or longer

xii.Medium risk: Newborns at 38 weeks or longer with risk factors; well
newborns at 35 to 37 6/7 weeks
xiii.Higher risk: Newborns at 35 to 37 6/7 weeks with risk factors
 Preparation
• Obtain the practitioner's orders for phototherapy.
• Gather supplies, obtaining phototherapy equipment as ordered.
• Prepare the warmer bed or incubator.

Supplies
 Radiant warmer, incubator
 Phototherapy equipment (as ordered by practitioner):
o Halogen lamps
o Fluorescent bank lights
o Phototherapy blanket
 Tape measure
 Newborn thermometer
 Eye protection
 Gloves
 Transcutaneous bilirubin meter, if indicated
 Laboratory supplies
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•
•
 MONITORING AND CARE
• Turn phototherapy lights off and remove eye protection during feedings, physical
examinations, and parental visits, and examine the eye area for exudate and abrasions.
• Monitor the newborn's skin condition.
• Monitor TSB levels as ordered by the practitioner.
• Obtain irradiance readings every shift or per organization policy and after replacing
bulbs or equipment.
• Calculate newborn's intake and output and assess for dehydration. Promote and support
frequent, successful breastfeeding
• Limit interruptions to phototherapy. Phototherapy may be temporarily stopped for
feedings, parental visits, physical assessment, weighing, and obtaining specimens for
laboratory analysis.9
• Perform systematic assessment before discharge (according to organization policy) on
all newborns at risk for severe hyperbilirubinemia. 3,11
• After phototherapy has been discontinued, clean all equipment per organization policy.
• Assess, treat, and reassess pain according to organization standard.
EXPECTED OUTCOMES

 Decreased TSB level

 No complications from phototherapy treatment
 Adequate parenting and bonding

UNEXPECTED OUTCOMES

 Increased serum bilirubin levels

 Hyper- or hypothermia
 Burns
 Eye damage or infection
 Dehydration
 Poor bonding

DOCUMENTATION

 Locations of jaundice
 TcB or TSB levels before beginning phototherapy and TSB levels performed after phototherapy has been initiated
 Type and number of lights, and distance positioned from the newborn
 Readings obtained from irradiance meter and corrective measures taken if too low
 Newborn temperatures, positions, intake and output, skin and eye condition per organization policy
 Family bonding and education
 
 REFERENCES

Mosby SDL Taif University