PHOTOTHERAPY FOR NEWBORN JAUNDICE : PHOTOTHERAPY FOR NEWBORN JAUNDICE Amanpreet kaur M.Sc (N) 1 st yr INTRODUCTION : INTRODUCTION Phototherapy is the use of light to treat newborn jaundice. Newborn jaundice is due to the presence of higher than normal level of bilirubin in blood. Historically, in England some nurses reported that a new, well lit nursery had significantly lesser cases of newborn jaundice when compared to the hospital's older, darker nursery. PowerPoint Presentation: Also, some observant nurses from other parts of world reported that babies placed in cribs closer to the window had less jaundice than other babies in the ward. Such observations led to the discovery of the therapeutic effect of light in newborn jaundice. DEFINITION : DEFINITION When baby is placed under a source of blue-green light (of wavelength 425 to 550 nm), light reacts with bilirubin in the blood flowing through the baby's skin INDICATIONS FOR PHOTOTHERAPY : INDICATIONS FOR PHOTOTHERAPY Phototherapy should be instituted when the total serum bilirubin level is at or above 15 mg per dL in infants 25 to 48 hours old, 18 mg per dL in infants 49 to 72 hours old, and 20 mg per dL in infants older than 72 hours. Few term newborns with hyperbilirubinemia have serious underlying pathology .. Cont….: Cont…. Jaundice is considered pathologic if it presents within the first 24 hours after birth, the total serum bilirubin level rises by more than 5 mg per dL per day or is higher than 17 mg per dL or an infant has signs and symptoms suggestive of serious illness. The management goals are to exclude pathologic causes of hyperbilirubinemia and initiate treatment to prevent bilirubin neurotoxicity PRINCIPAL ON WHICH PHOTOTHERAPY WORKS : PRINCIPAL ON WHICH PHOTOTHERAPY WORKS Photo therapy works on the principal of photo-oxidation and configurational isomerization . PURPOSES : PURPOSES The purpose of phototherapy is to convert bilirubin to lumirubin to correct hyperbilieubinemia , Bilirubin which is water insoluble is converted to substances like lumirubin which are water soluble and hence easily excreted through urine. Formation of lumirubin is the most important way of excreting the excessive bilirubin . There are other less important ways by which phototherapy aids in excreting bilirubin which includes. TYPES OF PHOTOTHERAPY: TYPES OF PHOTOTHERAPY PHOTOTHERAPY UNIT BILIRUBIN BLANKETS BILIBLANKET CAN BE GIVEN IN TWO WAYS SINGLE SIDED AND DOUBLE SIDED MISCONCEPTION : MISCONCEPTION Contrary to the popular misconception, Ultra violet rays are not used in phototherapy. What little UV light that the light sources emit, are of longer wavelength than those causing redness, and even such small amount of emitted UV rays are absorbed by the glass wall of the tubes. RATE OF ACTION : RATE OF ACTION The rate at which bilirubin is reduced depends on many factors- REBOUND JAUNDICE : REBOUND JAUNDICE Rebound jaundice is a surge in bilirubin levels soon after phototherapy is stopped. Rebound jaundice is significant in preemies, babies with positive direct coomb's test (indicating hemolysis ) and in babies who have received less than 72 hours of phototherapy. In such cases, a repeat blood test 24 hours after discharge may be necessary. CONTRAINDICATIONS : CONTRAINDICATIONS Phototherapy is usually a safe procedure. In a rare genetic condition called, 'congenital porphyria ', phototherapy is contraindicated as it causes severe blistering. In jaundice due to liver disease, phototherapy can lead to pigmentation of skin and urine called 'bronze baby syndrome' and in such cases alternative treatment like exchange transfusion is considered. Blistering can also occur in obstructive jaundice. COMPLICATIONS OF PHOTOTHERAPY : COMPLICATIONS OF PHOTOTHERAPY Phototherapy has been in use for more than three decades and millions of babies have benefited from phototherapy. Serious side effects are rare and phototherapy is generally considered a simple, safe and cheap procedure. Minor side effects are Cont…: Cont… Frequent loose stools - green or watery stool is common. This along with increased insensible water loss can lead to dehydration. Frequent bowel movements help in excreting bilirubin and will stop when phototherapy is discontinued. Babies are required to be fed frequently. Dehydration may have to be corrected by supplementing with formula or fluid administration. Over-heating can also occur but is uncommon with LEDs that produce less heat and with fiber-optic blankets. BILIRUBIN : BILIRUBIN A by-product of the breakdown of red blood cells, is bound to albumin and is eliminated via the liver. Infants who cannot completely metabolize and excrete bilirubin deposit the substance in other tissues, namely the skin(jaundice) or to brain tissue ( Kernicterus ). DEFINITION OF RADIOMETER: DEFINITION OF RADIOMETER Radiometer is the instrument used to determine the amount of irradiance produced by the bulbs that are in use. This is measured in uW /Cm2/nm (Microwatts per square centimeter per manometer) INDICATIONS : INDICATIONS Phototherapy should be used when the level of bilirubin may hazardous to infant if it were to increase, even though it has not reached exchange transfusion levels. baby and cause headache and nausea to caregivers. TECHNIQUE : TECHNIQUE Bilirubin absorbs light maximally in the blue range (420-500 nm).daylight and cool white lamps have a spectral peak between 550-600 nm and are less effective than special blue lamps,which have a range of 420-480 nm.blue lamps interfere with observation of skin color. EQUIPMENT: EQUIPMENT Assemble the following: Antibacterial soap Phototherapy light source box( es ), Disposable covers Thermometer Daily log sheets Patient Family Educational Material Radiometer; Protective eye shields; Heat lamp (optional). OBSERVATIONS : OBSERVATIONS SKINCARE OF THE CORD : WEIGHT : CARE OF THE EYES : CARE OF THE GENITALS : INPUT AND OUTPUT : PROCEDURE : PROCEDURE Note physician’s order for phototherapy . Obtain infant’s auxiliary temperature and record in the patient’s electronic. Infants receiving phototherapy may receive therapy in mom’s room. The nurse will educate the family about the need for phototherapy and explain safety information related to the therapy . Cont…….: Cont……. While on a radiant warmer or in an isolate, the infant is to be placed on servo control and infant’s temperature is to be monitored per physician order.5. If the infant is in an open crib, the infant’s auxiliary temperature will be taken and recorded every hour until stable, then every 4 hours. Monitor intake and output due to risk of dehydration. Cont……: Cont…… If the infant is in an open crib, the infant’s auxiliary temperature will be taken and recorded every hour until stable, then every 4 hours. Monitor intake and output due to risk of dehydration. The light meter should be used at the initial set-up of the therapy, then once a day unless the set-up is changed. Measure at the level of the baby’s skin, under the center of the light source Cont….: Cont…. Apply eye patches ensuring correct fit while taking care not to obstruct nostrils. Remove all clothing; cover male testes with a surgical mask. Eye patches will be checked and documented hourly and PRN for proper placement. The patches must be removed during feedings and when assessing the baby to provide a good view of the eyes, and to provide infant with visual stimulation and interaction with parents and caregivers. Infant position does not have to be changed from front to back per the AAP guidelines. Cont…..: Cont….. Biliblankets can be used under the baby to add additional light. For infants receiving phototherapy via1 or 2 biliblanket (s): Place disposable biliblanket cover on biliblanket . Eye patches are not necessary unless, infant’s position on the biliblanket cannot be secured (i.e., a very active baby or baby who becomes unswaddled easily and eye may be exposed to bililight ). Cont…..: Cont….. The bili bed is another option. The baby can be either prone or supine as per the instructions for use provided by the company. Remove infant from phototherapy for feedings, for lab tests, or as ordered by the physician. The baby can be out from under the lights no more than 3 hours out of every 12 hours. If a bili blanket is used, it can be held with the baby during feeding to provide continuous treatment. Cont………: Cont……… Note physician’s orders for lab tests to follow the progress of treatment. Turn off bili lights prior to drawing lab work inorder to maintain integrity of lab sample. PATIENT EDUCATION : PATIENT EDUCATION DOCUMENTATION : DOCUMENTATION Document in electronic medical record each shift: Skin color, skin turgor , fontanel assessment, any changes in tone, activity level or feedings, characteristics of stool, length of time out of phototherapy treatment and Radiometer reading.