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Neonatal Jaundice

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Objectives

Introduction

To define the neonates who should have serum bilirubin test
To describe risk factors for bilirubin encephalopathy
To describe the use of Nomograms to determine appropriate intervention
To illustrate the correct use of phototherapy

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Introduction

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Introduction

Jaundice is a yellowish discoloration of the skin, sclerae, and mucous membranes caused by tissue deposition of pigmented bilirubin

1.Willy T, Hansen R. Core Concepts . Bilirubin Metabolism.NeoReviews: 2010;11(6).

2.Bhutani VK, et al .Predischarge screening for severe neonatal hyperbilirubinemia identifies infants who need phototherapy. J Pediatr.

> 60%

> 80%

Term neonates²

Preterm neonates²

Introduction

Neonatal jaundice - usually observed in first week of life when total serum bilirubin level reaches 86 micromol/L (5 mg/dL )¹.

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High levels of haemoglobin lead to high levels of bilirubin

Intrauterine environment – relatively hypoxic

Extrauterine environment

- high oxygen concentration

Anemia and Polycythemia in the Newborn Erica Hyman Kates, Jacqueline S. Kates Pediatrics in Review Jan 2007,

Foetal Hb has enhanced oxygen binding capacity
High Hb at term

(Hb 19.3 +/- 2.2g/dl)

Lower Hb
Increase in adult Hb

At birth

Introduction

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Care of the jaundiced neonate, Stevenson DK, Maisels MJ, Watchko JF (Eds), McGraw Hill Companies, New York 2012

High bilirubin level can cause irreversible brain damage.

Bilirubin Metabolism

Bilirubin metabolism

Chief rationale of treating newborn jaundice is the prevention of kernicterus

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Why worry about high levels of unconjugated bilirubin ?

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Bilirubin Encephalopathy

Kernicterus or bilirubin encephalopathy

is a neurologic syndrome resulting from the deposition of unconjugated bilirubin in the basal ganglia and brainstem nuclei

Karimzadeh P, Fallahi M, Kazemian M, Taslimi Taleghani N, Nouripour S, Radfar M. Bilirubin Induced Encephalopathy. Iran J Child Neurol. 2020;14(1):7-19.

Bilirubin Encephalopathy

Bilirubin encephalopathy occurs in 2 forms:

Acute bilirubin encephalopathy
Chronic bilirubin encephalopathy

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Signs of bilirubin encephalopathy

First year: hypotonia, hyperreflexia, delayed motor skills, obligatory tonic neck reflexes
After first year: sensorineural hearing loss, upward gaze, dental enamel hypoplasia, movement disorders (dystonia and athetosis),

Phase 1 (first 1–2 days): decreased alertness, poor feeding, hypotonia and weak Moro
Phase 2 (middle of first week): irritability, hypertonia of extensor muscles, opisthotonos
Phase 3 (after the first week): hypotonia, apnoea

Acute Form

Chronic Form

Usman F, Diala UM, Shapiro SM, Le Pichon JB, Slusher TM. Acute bilirubin encephalopathy and its progression to kernicterus: current perspectives. Research and Reports in Neonatology. 2018;8:33-44 https://doi.org/10.2147/RRN.S125758

Bilirubin Encephalopathy

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Risk factors for Bilirubin Encephalopathy

High total serum bilirubin levels
Hemolysis
Preterm infants
Acidosis
Sepsis
Hypercarbia
Hypoxia
Asphyxia
Dehydration

Usman F, Diala UM, Shapiro SM, Le Pichon JB, Slusher TM. Acute bilirubin encephalopathy and its progression to kernicterus: current perspectives. Research and Reports in Neonatology. 2018;8:33-44 https://doi.org/10.2147/RRN.S125758

Danger signs

Poor feeding
Lethargy
Fever
Irritability
Seizures

Bilirubin Encephalopathy

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Management of Indirect Hyperbilirubinaemia

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Primary Prevention and Early Detection

.

Educate PG women on recognition of NNJ^1.
Determine mother’s blood type and timely provision of anti-D globulin¹.
Pre-discharge counselling of mothers
Good lactational support²

Examine newborns within 24hrs and in the following 2 days.
Caregivers be encouraged to look for jaundice
Monitoring of high risk infants
Ongoing HCW training on S/S of acute bilirubin encephalopathy and timely treatment

Prevention

Early detection

Bhutani VK, Zipursky A, Blencowe H, Khanna R, Sgro M, Ebbesen F, et al.Neonatal hyperbilirubinemia and Rhesus disease of the newborn: incidenceand impairment estimates for 2010 at regional and global levels. Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #22: guidelines for management of jaundice in the breastfeeding infant equal to or greater than 35 weeks' gestation.

Prevention of Neonatal Jaundice

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Phototherapy

Breakdown of Rbc and hemoglobin

Enhancing conversion of the lipid soluble unconjugated bilirubin to harmless water soluble bilirubin

Unconjugated bilirubin

Phototherapy

Water soluble isomers

Easily excreted in urine and feaces

Lipid soluble ; can cross the blood brain barrier

Bilirubin encephalopathy

Jasprova J, Dal Ben M, Vianello E, Goncharova I, Urbanova M, Vyroubalova K, et al. (2016) The Biological Effects of Bilirubin Photo isomers.

PLoS ONE 11(2): e0148126. doi:10.1371/journal.pone.0148126

Converts

No intervention

Phototherapy

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Goals of Phototherapy

Kernicterus is a devastating, permanently disabling neurologic condition resulting from bilirubin neurotoxicity²

This requires timely detection , diagnosis and appropriate management¹

Olusanya et al. Management of late-preterm and term infants with hyperbilirubinaemia in resource-constrained settings. BMC Pediatr. 2015;15:39.Okolie F, South-Paul JE, Watchko JF. Combating the Hidden Health Disparity of Kernicterus in Black Infants: A Review JAMA Pediatr. 2020;

Management of Neonatal Jaundice

Main purpose of treatment of hyperbilirubinemia is to prevent encephalopathy.

Mothers should be shown how to recognize jaundice very early and seek timely health care. Best time to teach mothers- antenatal period

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Principles of Phototherapy

Treatment of significant hyperbilirubinemia.^.
Delivered by light-emitting diode (LED), fibreoptic or fluorescent lamps or tubes or bulbs.
Maximize BSA exposed to phototherapy - diaper only and eyes must be covered
Maintain hydration and urine output

Vandborg PK, M HB, Greisen G, Ebbesen F. Dose-response relationship of phototherapy for hyperbilirubinemia. Pediatrics¹ 2012;130(2):e352-e7¹Olusanya BO, Ogunlesi TA, Kumar P, et al. Management of late-preterm and term infants with hyperbilirubinaemia in resource-constrained settings. BMC Pediatr. 2015;15:39. Published 2015 Apr 12. doi:10.1186/s12887-015-0358-z

Management of Neonatal Jaundice

.

Not indicated in conjugated hyperbilirubinemia-- will develop “Bronze baby syndrome”

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Principles of Phototherapy

Phototherapy for JaundiceUpdated: May 01, 2018 ; Author: Taylor L Sawyer, DO, MEd, FAAP, FACOP; Chief Editor: Dharmendra J Nimavat, MD, FAAP

Management of Neonatal Jaundice

Dose depends on wave length, average spectral irradiance and surface area

Wavelengths – 430 - 490nm and blue - green range
Irradiance is the amount of energy flowing out the light received by the exposed body surface area
Higher spectral irradiance- faster decline in the bilirubin levels

Standard Phototherapy irradiance 25-30 μW/cm²/nm.

Intensive phototherapy- irradiance 30-35 μW/cm²/nm

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Intensified phototherapy

Consider intensified phototherapy to treat if the serum bilirubin is:

Rising rapidly >8.5 μmol/l per hour
Is 50 μmol/l below threshold for exchange transfusion
Continues to rise or does not fall within 6 hours of starting phototherapy.

Do not interrupt intensive phototherapy for feeding ,but continue administering enteral feeds using the NGT, If indicated- IV fluids

https://www.nice.org.uk/guidance/cg98/evidence/addendum-pdf 2490921037file:///C:/Users/Lenovo/Downloads/KPA%20PROTOCAL%20(E.%20WEB%20FEb%2024th(4)%20(1).pdf

Olusanya et al. Management of late-preterm and term infants with hyperbilirubinaemia in resource-constrained settings. BMC Pediatr. 2015

Expect ↓ 34 μmol/l within 6 hrs

Management of Neonatal Jaundice

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Role of Filtered Sunlight

Phototherapy

Filtered sunlight

Filtered sunlight is noninferior to conventional phototherapy for the treatment of neonatal hyperbilirubinemia²

Do not recommend the use unfiltered sunlight

Risks- UV radiation, hyperthermia and sun burn¹.

Role of filtered sunlight – where Film canopies are used to Filter out most Ultraviolet A,B and C and infrared (heat) radiation.
After filtering allows passage of therapeutic blue light 400-520 nm

Filtered sunlight provides above the threshold of intensive phototherapy(at least 30uW/cm²/nm)

. A Randomized Trial of Phototherapy with Filtered Sunlight in African Neonates. N Engl J Med. 2015;373(12):1115-1124.² doi:10.1056/NEJMoa1501074

Management of Neonatal Jaundice

By avoiding endotracheal intubation and mechanical

ventilation, the constant distending pressure maintained in

the lung by CPAP may also provide some physiologic

benefits regarding lung protection and development. In

utero the transpulmonary pressure of the fluid-filled developing

lung is approximately 3–4 cm H2O.51 Coincidently,

CPAP at 5 cm H2O results in nasal pharyngeal

distending pressure of approximately 2–3 cm H2O.52 In

theory, spontaneous breathing, at a constant “low” distending

pressure, as provided by CPAP, would seem to be

more likely to provide some mechanical similarities to the

lungs in the intrauterine environment, promoting lung

growth/development and protection, than would mechanical

ventilation, which uses relatively high inflation pressure.

Much of the experimental evidence used to evaluate

these physiologic effects has been limited to a few studies

using animal models of prematurity

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Assessment of Hyperbilirubinemia

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Assessment of hyperbilirubinaemia

Assessment can be done in three ways:

Using the Kramer’s scale

Visual estimation of cephalocaudal progression

Transcutaneous bilirubin measurement(TcB)

Total serum bilirubin levels(TSB)

1

2

3

Objective assessment by means of a TcB or TSB measurement

Assessment of Neonatal Jaundice

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1. Kramer’s scale

Kramer LI. Advancement of Dermal Icterus in the Jaundiced Newborn. Am J Dis Child. 1969;118(3):454–458. doi:10.1001/archpedi.1969.02100040456007

Area of body	level	serum bilirubin
Head and neck	1	68-133
Upper trunk(above umbilicus)	2	85-204
Lower trunk and thighs(below umbilicus	3	136-272
Arms and legs	4	187-306
Palms and soles	5	≥306

The Kramer's scale is based on a 1969 study of 108 full term infants which found that bilirubin concentrations. were correlated to five specific dermal zones. At 24 and 48 hours, the infant's skin was blanched using thumb.

Check baby in bright and preferably natural light

Assessment of Neonatal Jaundice

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2. Transcutaneous bilirubin levels

If TcB ≥ 250 μmol/l or ≤ 50 μmol/l /L below threshold for phototherapy measure the TSB.

Okwundu CI, Uthman OA, Suresh G, et al Transcutaneous bilirubinometry versus total serum bilirubin measurement for newborns. Mabogunje CA, Imosemi DO, Emokpae AA. Transcutaneous bilirubin nomograms in African neonates. PLoS One. 2017;12(2):e0172058. Published 2017 Feb 13.; Cochrane Database of Systematic Reviews 2017, Issue 5. Art. No.: CD012660. DOI:² McGillivray A, Polverino J, Badawi N, Evans N.

Image source https://philipsproductcontent.blob.core.windows.net/assets/20170616/f722df04b6ce4e7dad79a7940147347a.pdf

Based on optical spectroscopy

Advantages

Non invasive- sternum or forehead
Immediate results ^/prescreening
Less costly
Viable alternative.

Assessment of Neonatal Jaundice

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2. Transcutaneous bilirubin levels

Disadvantages

Affected by gestational age and skin colour.
TcB overestimates in dark skin colour.
Not recommended if:

Jaundice is prolonged or conjugated hyperbilirubinemia , Baby on phototherapy or had phototherapy
Baby had an exchange transfusion

Assessment of Neonatal Jaundice

Okwundu CI, Uthman OA, Suresh G, et al Transcutaneous bilirubinometry versus total serum bilirubin measurement for newborns. Mabogunje CA, Imosemi DO, Emokpae AA. Transcutaneous bilirubin nomograms in African neonates. PLoS One. 2017;12(2):e0172058. Published 2017 Feb 13.; Cochrane Database of Systematic Reviews 2017, Issue 5. Art. No.: CD012660. DOI:² McGillivray A, Polverino J, Badawi N, Evans N.

Image source https://philipsproductcontent.blob.core.windows.net/assets/20170616/f722df04b6ce4e7dad79a7940147347a.pdf

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3.Total serum bilirubin (TSB) levels

Do TSB immediately for any baby with suspected or obvious jaundice:

First 24 hours of life and Gestational age of less than 35 weeks

Repeat within 6 hours in all babies when levels are 1-50 μmol/l below phototherapy threshold

Olusanya BO, Ogunlesi TA, Kumar P, et al. Management of late-preterm and term infants with hyperbilirubinaemia in resource-constrained settings. BMC Pediatr. 2015;15:39.

TSB-Gold standard for diagnosing hyperbilirubinaemia

Assessment of Neonatal Jaundice

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3.Total serum bilirubin (TSB) levels

For monitoring babies under phototherapy:
TSB 4–6 hourly until the rise of serum bilirubin is controlled, then 12–24 hourly.
Guides on when to stop phototherapy

Stop when TSB is greater than 50 μmol/l below line and
Recheck in 12–24 hours-for rebound hyperbilirubinemia

Visual estimation leads to errors esp. in darker skin tones or those receiving phototherapy

Assessment of Neonatal Jaundice

Olusanya BO, Ogunlesi TA, Kumar P, et al. Management of late-preterm and term infants with hyperbilirubinaemia in resource-constrained settings. BMC Pediatr. 2015;15:39.

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Assessment of Neonatal Jaundice

Assessing the severity of Jaundice

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Determining which Therapy to use��

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Phototherapy – Determining Use

Nomograms help determine need for phototherapy & irradiance mode to use based on the neonate’s;

Total serum bilirubin
Postnatal age (hours)
Presence of risk factors
Gestation
Weight (for those less than 35 weeks)

Before initiating phototherapy;

Assess neonate for jaundice
Measure total serum bilirubin (TSB) levels for patients with jaundice
Determine if TSB levels are within phototherapy threshold using available nomograms

Use of Phototherapy

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Phototherapy – Nomograms

Nomogram A: Jaundice Management for a baby greater than 38 weeks gestation

Exchange transfusion with risk factors

Exchange transfusion without risk factors

Phototherapy without risk factors

Phototherapy with risk factors

Queensland Clinical Guideline: Neonatal jaundice June 2019

Phototherapy Nomograms

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Phototherapy – Nomograms

Queensland Clinical Guideline: Neonatal jaundice June 2019

Phototherapy Nomograms

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Questions to ask when using Nomograms

What is the baby’s gestation? If the baby is less than 35 weeks, what is the weight? – To decide on which nomogram to use (A, B, C, D, E, F)
Are there risk factors for kernicterus? – To decide which curves (thresholds) to use. Continuous curve for no risk factors or broken curve with risk factors
What is the TSB level? What is the baby’s age in hours?
Where on the curve does the TSB and age in hours meet?

Is it below the phototherapy curve?
Is it on the phototherapy curve?
Is it above the phototherapy curve and below the exchange transfusion curve?
Is it on or above the exchange transfusion curve?

What is the correct intervention to give?

Using Nomograms

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Using Nomograms

Nomogram A: Jaundice Management for a baby greater than 38 weeks gestation

Irradiance threshold for a baby who is term, 24 hours old with risk factors

Exchange transfusion with risk factors

Phototherapy with risk factors

Phototherapy Nomograms

No Phototherapy

Standard Phototherapy

Intensive Phototherapy

No Phototherapy BUT check TSB level after 6 - 24hrs

0 - 50μmol/l

Exchange transfusion

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Using Nomograms

Nomogram A: Jaundice Management for a baby greater than 38 weeks gestation

Irradiance threshold for a baby who is term, 24 hours old without risk factors

Exchange transfusion without risk factors

Phototherapy without risk factors

Phototherapy Nomograms

No Phototherapy

Standard Phototherapy

Intensive Phototherapy

No Phototherapy BUT check TSB level after 6 - 24hrs

0 - 50μmol/l

Exchange transfusion

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Using TSB to determine treatment

Phototherapy Nomograms

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Using Nomograms – Scenario

Scenario: Baby J, Birthweight - 1100gms, Gestation 30 weeks, Jaundiced,

TSB - 180μmol/l at 48 hours of age. Has Respiratory Distress Syndrome

Nomogram E: Jaundice Management for a baby less than 35 weeks gestation 1000 - 1499gm birth weight

4 small boxes below the line for exchange transfusion with risk factors - 40μmol/l

For Intensive irradiance - 30 - 35 μW/cm2/nm

180

Exchange transfusion with risk factors

Phototherapy Nomograms

Phototherapy with risk factors

Steps in using the nomogram;

Choose the correct nomogram based on baby’s gestation & weight - <35 weeks & 1000 - 1499gms
Determine presence of risk factors - They include; dehydration, preterm births; respiratory distress; sepsis; hypoxia; seizures; acidosis; rate of increase of bilirubin level.
Get TSB in micromoles/l and locate it on the Y axis – 190μmol/l
Locate the postnatal age in hours on the X axis – 48 hours
Locate where the TSB & Postnatal age meet on the nomogram. Mark this point
Based on this mark, determine if you need phototherapy or blood exchange

If TSB level is within 1-50μmol/l below the level of phototherapy to more than 50μmol/l below the level of exchange transfusion.
Use intensive irradiance if the TSB level within 50μmol/l below exchange transfusion

Determine the curve to use based on presence of risk factors - Use the blue dotted & the red broken curve because the baby has risk factors - Prematurity & RDS are present
Count the number of small boxes above and below this mark. The mark is 3 boxes below the blue broken line and 7 boxes above the red broken line. Each small box on the Y axis represents 10micrmols/l
For blood exchange since the TSB is 30micromols/l (less than 50micromols/l) from the blood exchange threshold (the blue broken curve). Start intensive phototherapy as the TSB is 70micromols/l above the phototherapy threshold (red broken line)

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Assess severity of jaundice and give correct treatment

Assessment and treatment

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Providing Phototherapy��

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Phototherapy – Light Sources

Vassilios F., Michele M., Antonio., Bo S., Dorret I. B., Gavino F., Antonio G. "Phototherapy in the newborn: what’s new?" Journal of Pediatric and Neonatal Individualized Medicine 2015;4(2):e040255 doi: 10.7363/040255

Fluorescent lights

LED lights

Phototherapy lights

As we have already discussed, phototherapy involves the use of light to convert unconjugated bilirubin to conjugated bilirubin
In our setting, the commonly used devices are Fluorescent Lights and Light emitting diodes (LED) lights.
Although they are both similar in efficacy, they have some differences.
Although more expensive, LEDs are recommended because of their added advantages

I am now going to invite Sam from CPHD to describe some LED machines which are available in the Kenyan market
We are using the machines as an example because it will be supplied by NEST to NBUs in Kenya.
It is important to note that the principles and parts he will describe apply to whichever LED machine you have available in your facility and you should always follow the manufacturers instructions when using the machines
Welcome Sam

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Phototherapy – Lights

Power cable

Adjustable unit head (Rotated)

LED Lights

c

Adjustable unit head (Flat)

b

Control Panel

Adjustable height

Adjustable unit head

Stand

Lockable castors

a

Image source: NEST Clinical Modules www.nest360 ⁰ .org

Phototherapy lights

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Phototherapy – Lights

e

Reset Timer

Therapy mode buttons

a

c

b

Light meter & cable

Power cable

Light meter port & cable

Adjustable unit head (Back view)

d

Image source: NEST Clinical Modules www.nest360 ⁰ .org

Phototherapy lights

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Phototherapy – Lights

Control Panel

Light Meter

a

d

c

LED Lights

b

Image source: NEST Clinical Modules www.nest360 ⁰ .org

Phototherapy lights

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Initiating Phototherapy��

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Phototherapy – Requirements

Linen

Eye shields

Room Thermometer

Phototherapy lamp

Cot/Incubator/Radiant warmer

Images source: NEST Clinical Modules www.nest360 ⁰ .org

Phototherapy requirements

Light meter

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Phototherapy – Family Centered Care

Vassilios F., Michele M., Antonio., Bo S., Dorret I. B., Gavino F., Antonio G. "Phototherapy in the newborn: what’s new?" Journal of Pediatric and Neonatal Individualized Medicine 2015;4(2):e040255 doi: 10.7363/040255

Eileen M., Eileen T., regina K. 2018.Phototherapy nursing guideline. Ret. From https://www.olchc.ie/Healthcare-Professionals/Nursing-Practice-Guidelines/Phototherapy-2018.pdf

Discuss with the mother/caregiver the:

Need for, action & outcomes of phototherapy
Need to cover eyes
Need to expose as much skin as possible
Feeding plan
Need for periodic assessment & blood sampling
Potential complications

Standard phototherapy - Short Breast feeding session (30min) 3hourly
Intensive phototherapy - Nasal Gastric tube feeding with expressed breast milk

Phototherapy requirements

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Phototherapy – Preparing the Baby

Phototherapy for neonatal jaundice (N.D.) Ret .From https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Phototherapy_for_neonatal_jaundice/

Images source: NEST Clinical Modules www.nest360 ⁰ .org

1. Ensure hand hygiene

3. Assess vitals & risk factors

4. Remove all the baby’s clothes

5. Insert NG tube if Indicated

Preparing the baby

2. Prepare cot & warm environment

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Phototherapy – Preparing the Baby

6. Cover the baby’s eyes with an eye shield

7. Ensure the eye shield is snuggly fit and place baby in the center of the cot/incubator/radiant warmer

Phototherapy for neonatal jaundice (N.D.) Ret .From https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Phototherapy_for_neonatal_jaundice/

Images source: NEST Clinical Modules www.nest360 ⁰ .org

Preparing the baby

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Phototherapy – Preparing the Machine

Position the LED phototherapy unit above the baby’s cot/incubator/radiant warmer
Plug power cable on the machine and turn on the machine.
Ensure the lights cover the baby’s entire body

Preparing the Machine

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Phototherapy – Preparing the Machine

Select the irradiance mode (standard or intensive)
Adjust the height of the lamp to desired irradiance
Reset patient therapy time to zero and initiate phototherapy

Images source: NEST Clinical Modules www.nest360 ⁰ .org

Preparing the Machine

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Phototherapy – Irradiance

Always use the light meter to measure desired Irradiance

Standard irradiance - 25 - 30 μW/cm²/nm

Intensive irradiance - 30 - 35 μW/cm²/nm

http://pediatrics.aappublications.org/content/128/4/e1046 & Image source: The Firefly phototherapy user manual

Phototherapy Intensity

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Phototherapy – Avoid incorrect practices at all times!

Phototherapy use

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Phototherapy – Avoid incorrect practices at all times!

Phototherapy use

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Monitoring during Phototherapy��

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Phototherapy – Monitoring

Vassilios F., Michele M., Antonio., Bo S., Dorret I. B., Gavino F., Antonio G. "Phototherapy in the newborn: what’s new?" Journal of Pediatric and Neonatal Individualized Medicine 2015;4(2):e040255 doi: 10.7363/040255 & Eileen M., Eileen T., regina K. 2018.Phototherapy nursing guideline. Ret. From https://www.olchc.ie/Healthcare-Professionals/Nursing-Practice-Guidelines/Phototherapy-2018.pdf

http://pediatrics.aappublications.org/content/128/4/e1046

Skin Exposure

Expose as much skin as possible

Eye Care

Ensure the eyes are well covered

Monitor vitals every 3 hours - Temp
Maintain 3 hourly breastfeeding (BF) for standard therapy or NGT feeding for intensive therapy
Reposition the baby every 3 hours
Monitor urine output - Four or more wet nappies per day
Weigh the baby on alternate days
Check for potential signs of bilirubin encephalopathy – lethargy, poor feeding, seizures, vomiting
Watch out for potential complications
Repeat total serum bilirubin level 6 hrs after starting phototherapy

Monitoring

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Monitoring bilirubin levels

http://pediatrics.aappublications.org/content/128/4/e1046 & Queensland Clinical Guideline: Neonatal jaundice June 2019

Monitoring

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Stopping phototherapy

American Academy of Pediatrics. Management of hyperbilirubinaemia in the newborn infant 35 weeks or more of gestation. Pediatrics 2004;114(1):297-316.¹ Chang PW, Kuzniewicz MW, McCulloch CE, Newman TB. A clinical prediction rule for rebound hyperbilirubinemia following inpatient phototherapy. Pediatrics 2017;139(3)2 Wong R, Bhutani VK. Patient education: Jaundice in newborn infants (Beyond the Basics). 3http://guidance.nice.org.uk/CG98/treatmentthresholdgraph/xls/English⁴

Rebound hyperbilirubinaemia

Repeat TSB in 12-24 hours⁴.

If baby had haemolytic jaundice or other early onset jaundice and is discharged before 3–4 days

Organize follow up TSB 24 hours after discharge

Discontinue phototherapy when TSB reduces by more than 50umol/l below treatment threshold .

Stopping Phototherapy

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Complications of phototherapy

Short term complications

Interference with maternal–infant bonding¹

Diarrhea¹

Hypothermia (LED light) if not in thermoneutral environment

No increase in incidence of total cancer and type 1 DM,

Muchowski KE. Evaluation and treatment of neonatal hyperbilirubinemia. Am Fam Physician. 2014;89(11):873-8781¹ Kahveci H, Phototherapy causes a transient DNA damage in jaundiced newborns. Drug ChemToxicol. 2013;36(1):88–92² Newman TB, Wickremasinghe AC, Walsh EM, Grimes BA, McCulloch CE, Kuzniewicz MW. Retrospective Cohort Study of Phototherapy and Childhood Cancer in Northern California. Pediatrics. 2016;. Phototherapy and Risk of Type 1 Diabetes. Pediatrics. 2016;138(5):e20160687. doi:10.1542/peds.2016-0687⁴

Small increased risk for seizures (approximately 1-2 infants per 10,000 treated)

Skin rash

Complications of Phototherapy

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Questions

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Summary

High bilirubin level can cause irreversible brain damage.
Chief rationale of treating newborn jaundice is the prevention of kernicterus
Screening and early recognition of risk factors for bilirubin encephalopathy is important in prevention of kernicterus
Adjust phototherapy irradiance depending on the serum bilirubin level