Phototherapy

1. See Also
   1. Exchange Transfusion
2. Indications: Preterm Infant
   1. Weight <1250 grams
      1. Uncomplicated: Total Bilirubin > 13 mg/dl
      2. Complicated: Total Bilirubin > 10 mg/dl
   2. Weight <1500 grams
      1. Uncomplicated: Total Bilirubin > 15 mg/dl
      2. Complicated: Total Bilirubin > 13 mg/dl
   3. Weight <2000 grams
      1. Uncomplicated: Total Bilirubin > 17 mg/dl
      2. Complicated: Total Bilirubin > 15 mg/dl
   4. Weight <2500 grams
      1. Uncomplicated: Total Bilirubin > 18 mg/dl
      2. Complicated: Total Bilirubin > 17 mg/dl
   5. Weight >2500 grams
      1. Uncomplicated: Total Bilirubin > 20 mg/dl
      2. Complicated: Total Bilirubin > 18 mg/dl
3. Indications: Term Infant
   1. Age <24 hours
      1. See Nonphysiologic Neonatal Jaundice
   2. Age 25-48 hours
      1. Uncomplicated: Total Bilirubin 15-25 mg/dl
      2. Complicated: Total Bilirubin 12 mg/dl or higher
      3. Exchange Transfusion for Bilirubin 25 mg/dl or higher
   3. Age 49-72 hours
      1. Uncomplicated: Total Bilirubin 18-30 mg/dl
      2. Complicated: Total Bilirubin 15 mg/dl or higher
      3. Exchange Transfusion for Bilirubin 30 mg/dl or higher
   4. Age >73 hours
      1. Uncomplicated: Total Bilirubin 20-30 mg/dl
      2. Complicated: Total Bilirubin 17 mg/dl or higher
      3. Exchange Transfusion for Bilirubin 30 mg/dl or higher
4. Monitoring: During intensive Phototherapy in hospital
   1. Do not use transcutaneous Bilirubin meter to monitor while on Phototherapy
   2. Initial monitoring
      1. Total Bilirubin >25 mg/dl: Recheck every 2-3 hours
      2. Total Bilirubin 20-25 mg/dl: Recheck every 3-4 hours
      3. Total Bilirubin 14-20 mg/dl: Recheck every 4-5 hours
      4. Total Bilirubin <14 mg/dl: Stop Phototherapy and recheck Bilirubin within 24 hours
   3. Later monitoring once Bilirubin level is trending downward
      1. Recheck Total Bilirubin every 8-12 hours
5. Contraindications
   1. Conjugated Hyperbilirubinemia
      1. Risk of bronze baby syndrome (see adverse effects)
6. Mechanism
   1. Bilirubin absorbs light
      1. Most sensitive to blue light (420-470 nm)
   2. Photoisomerization
      1. Converts 4Z,15Z Bilirubin (toxic) to 4Z,15E Bilirubin
      2. Converted unconjugated isomer excreted in bile
7. Technique
   1. Standard Phototherapy light configuration
      1. Four overhead centrally placed blue bulbs (F20T12/BB)
      2. Two daylight fluorescent bulbs on each side of infant
   2. Double Phototherapy light configuration
      1. Light configuration above and
      2. Fiber-optic pad (e.g. bili-blanket) beneath infant
   3. Infant protocol
      1. Place each light 15-20 cm from newborn (except pad)
      2. Infant naked except for eye shields
   4. Concurrent Bilirubin monitoring
      1. Formula fed: Anticipate 1-2 mg/dl decrease q4-6 hours
      2. Breast fed: Anticipate 2-3 mg/dl decrease per day
      3. Discontinue Phototherapy when Bilirubin <15 mg/dl
8. Adverse Effects
   1. Loose stools
   2. Skin Rashes
   3. Overheating
   4. Dehydration
      1. Insensible water loss
      2. Diarrhea
   5. Electrolyte disturbance
      1. Hyponatremia
      2. Hypokalemia
   6. Chilling from exposure of infant
   7. Bronze baby syndrome
      1. Dark, grayish brown discoloration of skin
      2. May persist for months
      3. Associated with Conjugated Hyperbilirubinemia
9. Resources
   1. Bilirubin Tool
      1. http://www.bilitool.com
10. References
    1. Behrman (2000) Nelson Pediatrics, Saunders, p. 518
    2. Porter (2002) Am Fam Physician 65:599-614