Phototherapy

Aka: Phototherapy, Bilirubin Lights, Bili Lights

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II. 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

III. Indications: Term Infant Overview

  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

IV. Indications: Phototherapy in term infants (>36 weeks and >2 kg, or >35 weeks and >2.5 kg)

  1. See Severe Neonatal Hyperbilirubinemia Risk Factor
  2. Phototherapy is indicated when a threshold is crossed based on an infants Hyperbilirubinemia risk factors
    1. High Risk Infant
      1. Gestational age >35 weeks AND <38 weeks AND Severe Neonatal Hyperbilirubinemia Risk Factor
    2. Intermediate Risk Infant
      1. Gestational age >38 weeks AND Severe Neonatal Hyperbilirubinemia Risk Factor OR
      2. Gestational age >35 weeks AND <38 weeks AND No Risk Factors
    3. Low Risk Infant
      1. Gestational age >38 weeks AND No Risk Factors
  3. Age 12 hours of life
    1. High risk Infant: Serum Bilirubin >3.9 mg/dl
    2. Intermediate risk Infant: Serum Bilirubin >5 mg/dl
    3. Low risk Infant: Serum Bilirubin >7.1 mg/dl
    4. Minimal risk transcutaneous Bilirubin <4 mg/dl
  4. Age 24 hours of life
    1. High risk Infant: Serum Bilirubin >4.9 mg/dl
    2. Intermediate risk Infant: Serum Bilirubin >6 mg/dl
    3. Low risk Infant: Serum Bilirubin >7.7 mg/dl
    4. Minimal risk transcutaneous Bilirubin <5.5 mg/dl
  5. Age 36 hours of life
    1. High risk Infant: Serum Bilirubin >7 mg/dl
    2. Intermediate risk Infant: Serum Bilirubin >9 mg/dl
    3. Low risk Infant: Serum Bilirubin >11 mg/dl
    4. Minimal risk transcutaneous Bilirubin <8 mg/dl
  6. Age 48 hours of life
    1. High risk Infant: Serum Bilirubin >8.6 mg/dl
    2. Intermediate risk Infant: Serum Bilirubin >10.8 mg/dl
    3. Low risk Infant: Serum Bilirubin >13.1 mg/dl
    4. Minimal risk transcutaneous Bilirubin <9 mg/dl
  7. Age 60 hours of life
    1. High risk Infant: Serum Bilirubin >9.6 mg/dl
    2. Intermediate risk Infant: Serum Bilirubin >12.7 mg/dl
    3. Low risk Infant: Serum Bilirubin >15.2 mg/dl
    4. Minimal risk transcutaneous Bilirubin <10 mg/dl
  8. Age 72 hours of life
    1. High risk Infant: Serum Bilirubin >11.2 mg/dl
    2. Intermediate risk Infant: Serum Bilirubin >13.4 mg/dl
    3. Low risk Infant: Serum Bilirubin >16 mg/dl
    4. Minimal risk transcutaneous Bilirubin <12.5 mg/dl
  9. Age 84 hours of life
    1. High risk Infant: Serum Bilirubin >11.6 mg/dl
    2. Intermediate risk Infant: Serum Bilirubin >14.7 mg/dl
    3. Low risk Infant: Serum Bilirubin >16.7 mg/dl
  10. Age 96 hours of life
    1. High risk Infant: Serum Bilirubin >12.4 mg/dl
    2. Intermediate risk Infant: Serum Bilirubin >15.2 mg/dl
    3. Low risk Infant: Serum Bilirubin >17.4 mg/dl
  11. Age 108 hours of life
    1. High risk Infant: Serum Bilirubin >12.9 mg/dl
    2. Intermediate risk Infant: Serum Bilirubin >15.5 mg/dl
    3. Low risk Infant: Serum Bilirubin >17.6 mg/dl
  12. Age 120 hours of life
    1. High risk Infant: Serum Bilirubin >13.3 mg/dl
    2. Intermediate risk Infant: Serum Bilirubin >15.8 mg/dl
    3. Low risk Infant: Serum Bilirubin >17.7 mg/dl
  13. Age 132 hours of life
    1. High risk Infant: Serum Bilirubin >13.2 mg/dl
    2. Intermediate risk Infant: Serum Bilirubin >15.6 mg/dl
    3. Low risk Infant: Serum Bilirubin >17.5 mg/dl
  14. Age 144 hours of life
    1. High risk Infant: Serum Bilirubin >13.2 mg/dl
    2. Intermediate risk Infant: Serum Bilirubin >15.3 mg/dl
    3. Low risk Infant: Serum Bilirubin >17.3 mg/dl
  15. References
    1. AAP: Management of Hyperbilirubinemia in Infant > 35 weeks
      1. http://pediatrics.aappublications.org/content/114/1/297.full#F2

V. Monitoring: During intensive Phototherapy in hospital

  1. Monitor with Serum Bilirubin
    1. Do not use transcutaneous Bilirubin meter to monitor while on Phototherapy
  2. Initial monitoring
    1. Anticipate total Serum Bilirubin decrease by 6-20%
    2. Total Bilirubin >25 mg/dl: Recheck every 2-3 hours
    3. Total Bilirubin 20-25 mg/dl: Recheck every 3-4 hours
    4. Total Bilirubin 14-20 mg/dl: Recheck every 4-5 hours
    5. Total Bilirubin <14 mg/dl: Stop Phototherapy and recheck Bilirubin within 24 hours
      1. Further hospital observation for repeat Serum Bilirubin is not needed
      2. Significant rebound Hyperbilirubinemia is rare
      3. Maisels (2002) Arch Pediatr Adolesc Med 156(7): 669-72 [PubMed]
  3. Later monitoring once Bilirubin level is trending downward
    1. Recheck Total Bilirubin every 8-12 hours

VI. Contraindications

  1. Conjugated Hyperbilirubinemia
    1. Risk of bronze baby syndrome (see adverse effects)

VII. Mechanism

  1. Bilirubin absorbs light
    1. Most sensitive to blue-green light (460 to 490 nm)
  2. Photoisomerization
    1. Converts 4Z,15Z Bilirubin (toxic) to 4Z,15E Bilirubin
    2. Converted unconjugated isomer excreted in bile

VIII. Technique

  1. Standard Phototherapy light configuration
    1. Conventional light source (halogen or fluorescent) or light emitting diode (LED)
    2. Four overhead centrally placed blue bulbs (F20T12/BB)
    3. 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 and diaper
  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

IX. 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

X. Resources

  1. Bilirubin Tool
    1. http://www.bilitool.com

XI. References

  1. Behrman (2000) Nelson Pediatrics, Saunders, p. 518
  2. Muchowski (2014) Am Fam Physician 89(11): 873-8 [PubMed]
  3. Porter (2002) Am Fam Physician 65:599-614 [PubMed]

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