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Phototherapy
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Phototherapy
, Bilirubin Lights, Bili Lights
See Also
Exchange Transfusion in Newborns
Risk Score for Neonatal Hyperbilirubinemia
Nonphysiologic Neonatal Jaundice
Neonatal Jaundice
Neonatal Bilirubin
Acute Bilirubin Encephalopathy
Chronic Bilirubin Encephalopathy
(
Kernicterus
)
Exchange Transfusion
Indications
Preterm Infant
Weight <1250 grams
Uncomplicated:
Total Bilirubin
> 13 mg/dl
Complicated:
Total Bilirubin
> 10 mg/dl
Weight <1500 grams
Uncomplicated:
Total Bilirubin
> 15 mg/dl
Complicated:
Total Bilirubin
> 13 mg/dl
Weight <2000 grams
Uncomplicated:
Total Bilirubin
> 17 mg/dl
Complicated:
Total Bilirubin
> 15 mg/dl
Weight <2500 grams
Uncomplicated:
Total Bilirubin
> 18 mg/dl
Complicated:
Total Bilirubin
> 17 mg/dl
Weight >2500 grams
Uncomplicated:
Total Bilirubin
> 20 mg/dl
Complicated:
Total Bilirubin
> 18 mg/dl
Indications
Term Infant Overview
Age <24 hours
See
Nonphysiologic Neonatal Jaundice
Age 25-48 hours
Uncomplicated:
Total Bilirubin
15-25 mg/dl
Complicated:
Total Bilirubin
12 mg/dl or higher
Exchange Transfusion for
Bilirubin
25 mg/dl or higher
Age 49-72 hours
Uncomplicated:
Total Bilirubin
18-30 mg/dl
Complicated:
Total Bilirubin
15 mg/dl or higher
Exchange Transfusion for
Bilirubin
30 mg/dl or higher
Age >73 hours
Uncomplicated:
Total Bilirubin
20-30 mg/dl
Complicated:
Total Bilirubin
17 mg/dl or higher
Exchange Transfusion for
Bilirubin
30 mg/dl or higher
Indications
Phototherapy in term infants (>36 weeks and >2 kg, or >35 weeks and >2.5 kg)
See
Severe Neonatal Hyperbilirubinemia Risk Factor
Phototherapy is indicated when a threshold is crossed based on an infants
Hyperbilirubinemia
risk factors
High Risk Infant
Gestational age
>35 weeks AND <38 weeks AND
Severe Neonatal Hyperbilirubinemia Risk Factor
Intermediate Risk Infant
Gestational age
>38 weeks AND
Severe Neonatal Hyperbilirubinemia Risk Factor
OR
Gestational age
>35 weeks AND <38 weeks AND No Risk Factors
Low Risk Infant
Gestational age
>38 weeks AND No Risk Factors
Age 12 hours of life
High risk Infant:
Serum Bilirubin
>3.9 mg/dl
Intermediate risk Infant:
Serum Bilirubin
>5 mg/dl
Low risk Infant:
Serum Bilirubin
>7.1 mg/dl
Minimal risk transcutaneous
Bilirubin
<4 mg/dl
Age 24 hours of life
High risk Infant:
Serum Bilirubin
>4.9 mg/dl
Intermediate risk Infant:
Serum Bilirubin
>6 mg/dl
Low risk Infant:
Serum Bilirubin
>7.7 mg/dl
Minimal risk transcutaneous
Bilirubin
<5.5 mg/dl
Age 36 hours of life
High risk Infant:
Serum Bilirubin
>7 mg/dl
Intermediate risk Infant:
Serum Bilirubin
>9 mg/dl
Low risk Infant:
Serum Bilirubin
>11 mg/dl
Minimal risk transcutaneous
Bilirubin
<8 mg/dl
Age 48 hours of life
High risk Infant:
Serum Bilirubin
>8.6 mg/dl
Intermediate risk Infant:
Serum Bilirubin
>10.8 mg/dl
Low risk Infant:
Serum Bilirubin
>13.1 mg/dl
Minimal risk transcutaneous
Bilirubin
<9 mg/dl
Age 60 hours of life
High risk Infant:
Serum Bilirubin
>9.6 mg/dl
Intermediate risk Infant:
Serum Bilirubin
>12.7 mg/dl
Low risk Infant:
Serum Bilirubin
>15.2 mg/dl
Minimal risk transcutaneous
Bilirubin
<10 mg/dl
Age 72 hours of life
High risk Infant:
Serum Bilirubin
>11.2 mg/dl
Intermediate risk Infant:
Serum Bilirubin
>13.4 mg/dl
Low risk Infant:
Serum Bilirubin
>16 mg/dl
Minimal risk transcutaneous
Bilirubin
<12.5 mg/dl
Age 84 hours of life
High risk Infant:
Serum Bilirubin
>11.6 mg/dl
Intermediate risk Infant:
Serum Bilirubin
>14.7 mg/dl
Low risk Infant:
Serum Bilirubin
>16.7 mg/dl
Age 96 hours of life
High risk Infant:
Serum Bilirubin
>12.4 mg/dl
Intermediate risk Infant:
Serum Bilirubin
>15.2 mg/dl
Low risk Infant:
Serum Bilirubin
>17.4 mg/dl
Age 108 hours of life
High risk Infant:
Serum Bilirubin
>12.9 mg/dl
Intermediate risk Infant:
Serum Bilirubin
>15.5 mg/dl
Low risk Infant:
Serum Bilirubin
>17.6 mg/dl
Age 120 hours of life
High risk Infant:
Serum Bilirubin
>13.3 mg/dl
Intermediate risk Infant:
Serum Bilirubin
>15.8 mg/dl
Low risk Infant:
Serum Bilirubin
>17.7 mg/dl
Age 132 hours of life
High risk Infant:
Serum Bilirubin
>13.2 mg/dl
Intermediate risk Infant:
Serum Bilirubin
>15.6 mg/dl
Low risk Infant:
Serum Bilirubin
>17.5 mg/dl
Age 144 hours of life
High risk Infant:
Serum Bilirubin
>13.2 mg/dl
Intermediate risk Infant:
Serum Bilirubin
>15.3 mg/dl
Low risk Infant:
Serum Bilirubin
>17.3 mg/dl
References
AAP: Management of
Hyperbilirubinemia
in Infant > 35 weeks
http://pediatrics.aappublications.org/content/114/1/297.full#F2
Monitoring
During intensive Phototherapy in hospital
Monitor with
Serum Bilirubin
Do not use transcutaneous
Bilirubin
meter to monitor while on Phototherapy
Initial monitoring
Anticipate total
Serum Bilirubin
decrease by 6-20%
Total Bilirubin
>25 mg/dl: Recheck every 2-3 hours
Total Bilirubin
20-25 mg/dl: Recheck every 3-4 hours
Total Bilirubin
14-20 mg/dl: Recheck every 4-5 hours
Total Bilirubin
<14 mg/dl: Stop Phototherapy and recheck
Bilirubin
within 24 hours
Further hospital observation for repeat
Serum Bilirubin
is not needed
Significant rebound
Hyperbilirubinemia
is rare
Maisels (2002) Arch Pediatr Adolesc Med 156(7): 669-72 [PubMed]
Later monitoring once
Bilirubin
level is trending downward
Recheck
Total Bilirubin
every 8-12 hours
Contraindications
Conjugated Hyperbilirubinemia
Risk of bronze baby syndrome (see adverse effects)
Mechanism
Bilirubin
absorbs light
Most sensitive to blue-green light (460 to 490 nm)
Photoisomerization
Converts 4Z,15Z
Bilirubin
(toxic) to 4Z,15E
Bilirubin
Converted unconjugated isomer excreted in bile
Technique
Standard Phototherapy light configuration
Conventional light source (halogen or fluorescent) or light emitting diode (LED)
Four overhead centrally placed blue bulbs (F20T12/BB)
Two daylight fluorescent bulbs on each side of infant
Double Phototherapy light configuration
Light configuration above and
Fiber
-optic pad (e.g. bili-blanket) beneath infant
Infant protocol
Place each light 15-20 cm from newborn (except pad)
Infant naked except for eye shields and diaper
Concurrent
Bilirubin
monitoring
Formula fed: Anticipate 1-2 mg/dl decrease q4-6 hours
Breast
fed: Anticipate 2-3 mg/dl decrease per day
Discontinue Phototherapy when
Bilirubin
<15 mg/dl
Adverse Effects
Loose stools
Skin Rashes
Overheating
Dehydration
Insensible water loss
Diarrhea
Electrolyte
disturbance
Hyponatremia
Hypokalemia
Chilling from exposure of infant
Bronze baby syndrome
Dark, grayish brown discoloration of skin
May persist for months
Associated with
Conjugated Hyperbilirubinemia
Resources
Bilirubin
Tool
http://www.bilitool.com
References
Behrman (2000) Nelson Pediatrics, Saunders, p. 518
Muchowski (2014) Am Fam Physician 89(11): 873-8 [PubMed]
Porter (2002) Am Fam Physician 65:599-614 [PubMed]
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