E 11 Phototherapy Lights

This equipment is important for the treatment of jaundice

Subsection of this chapter:

  1. Clinical Problem
  2. Assessment
  3. Management
  4. Infection Prevention
  5. Complications
  6. Care & Maintenance
  7. Troubleshooting & Repair

NEST360°. Newborn Essential Solutions and Technologies- Education – Clinical Modules: Phototherapy. (June 2020). License: CC BY-NC-SA 4.0

Clinical Problem

Infants have a large volume of bilirubin in the bloodstream because they have a high red cell mass (haemoglobin) and rapid breakdown of red blood cells in the first days of life. A newborn’s immature liver is often unable to rapidly remove bilirubin, leading to an excess of unconjugated bilirubin and thus jaundice.

Phototherapy should be commenced for neonates with:

Phototherapy should also be considered for neonates with jaundice and the following complications:

Initiation of phototherapy is very rarely required after 14 days of life in term infants and 21 days in preterm infants.1 Jaundice due to breast feeding may last for a long time (but the baby is well). Prolonged jaundice (>14 days) warrants further investigation and discussion for possible referral to a tertiary centre.

Assessment

Phototherapy uses blue light transmitted on the patient’s skin within the wavelengths of 425 to 475 nm2 to break down unconjugated bilirubin to a water-soluble, non-toxic form that can be easily excreted.3

Phototherapy lights may be integrated into units with overhead (2.1), over- and underbody (2.2), or flexible blanket lights. (2.3) Most phototherapy units can be used in tandem with other devices (e.g., radiant warmers, incubators, and oxygen therapy). This clinical module will provide guidelines for the use of overhead phototherapy lights.


Phototherapy lights are most effective when providing blue light within 425 to 475 nm via LEDs.

Other types of bulbs providing blue light within 425 to 475 nm (e.g., halogen or fluorescent) are less effective for treating jaundice, have a shorter lifetime, and are not as sustainable for long term use. Halogen and fluorescent bulbs are less efficient than LEDs and may also be a source of heat, introducing a potential risk for hyperthermia.4,5 Other types of phototherapy are also used, but are typically not recommended:

Need for Phototherapy

There are different methods to determine need for phototherapy, all of which rely on measuring or estimating the bilirubin levels in the blood. Bilirubin levels can be measured in all babies using a blood test and transcutaneous devices10,11 or estimated through visual assessment with reference to the Kramer’s scale. (2.4)

In the absence of timely availability of serum bilirubin measurements, which are the gold standard, phototherapy should be started for any visible jaundice on day one of life (make sure to press nose, look in mouth and check conjunctiva), or at a Kramer's level of 3 for jaundice on day 2 of life and later (when jaundice is visible below the umbilicus). See Alert 2.1 for detailed information about the Kramer's scale. Assessment should be made in natural or white light to ensure results are accurate. Both transcutaneous bilirubin12 and the Kramer's scale are less precise in determining serum levels after phototherapy has begun. Some units may plot bilirubin levels using nomograms as well. Ensure a reference is used which is consistent with unit policy.

If serum bilirubin or transcutaneous bilirubin is available, Table 2.1 provides reference levels for when to start phototherapy or consider an exchange transfusion.13,14

TABLE 2.1 JAUNDICE & PHOTOTHERAPY VS TRANSFUSION

Treatment Day of Life Healthy Term Baby Premature <35wks,
LBW or sick baby
Phototherapy

Jaundice of these
levels is treated with
phototherapy

Day 1

 Treat any visible jaundice with phototherapy

Day 2

 15mg/dl
260mmol/l		 10mg/dl
170mmol/l

Day 3

18 mg/dl
310 mmol/l		 15mg/dl
260mmol/l

Day 4 onwards

 20mg/dl
340mmol/l		 17mg/dl
290mmol/l
!!! Exchange
Transfusion

Jaundice of these
levels or above is
dangerous and the
baby requires urgent
referral for possible
exchange transfusion

Day 1 15mg/dl
260mmol/l		 10mg/dl
220mmol/l
Day 2 25mg/dl
425mmol/l		 15mg/dl
260mmol/l
Day 3 25mg/dl
425mmol/l		 20mg/dl
340mmol/l
Day 4 onwards 25mg/dl
425mmol/l		 20mg/l
340mmol/l

If a baby needs a possible exchange transfusion, intensive phototherapy should be given while waiting to be transferred.

? ALERT 2.1 Physical exam estimation of serum bilirubin

Measurement of serum bilirubin is the best assessment of neonatal jaundice. However, when timely serum bilirubin measurements are unavailable, Kramer's is the only studied physical exam proxy for estimating serum bilirubin levels in neonates.

The Kramer's scale has shown observer to observer variance, especially at high bilirubin levels.15-17 However, when ruling out jaundice of bilirubin levels >12 mg/dL (215 mmol/L), studies have shown that the Kramer's scale can be used pre-phototherapy in term infants if limited to zones 1,2.16,17

Usual optimal spectral irradiance for conventional phototherapy is 25-30µW/cm2 as measured by a phototherapy light meter. Higher optimal spectral irradiances of 30-35 µW/cm2 may be used for intensive phototherapy for at risk infants.18 Most jaundiced patients require treatment for 24 to 48 hours, and typically do not require treatment for any longer than 7 days. If jaundice persists, further investigation into the cause of the jaundice should be conducted.

Management

Management of an overhead phototherapy unit covers how to use the device in a variety of settings, including set up for a patient, patient preparation & commencement, care whilst on the device & removal of the patient from the device.

SETTING UP FOR A PATIENT

  1. Collect:
  2. Plug in phototherapy device. Turn on and check for blue light from the overhead light elements. NOTE: Some phototherapy lights may have white examination lights. In most models, if light emitting from this type of device is white, it is not therapeutic.
  3. Turn on light meter if available. Place light meter on the mattress where the patient needing phototherapy will be located. (3.1)


  4. The phototherapy unit is typically set at a point where the overhead lights are approximately 20 - 30 cm above a typical cot. Check that irradiance provided at this height is within therapeutic ranges and adjust the height if necessary. (3.2)

Light should cover the entire surface on which the patient will be treated.

PREPARING A PATIENT

  1. Always explain the purpose, risks and benefits of a procedure to guardians BEFORE performing the procedure.
  2. Follow handwashing protocol.
  3. Collect:
  4. Remove all clothes. The diaper should cover the minimum necessary to keep the baby clean.
  5. Place eye mask so that it fully covers the patient’s eyes. (3.3) The mask should be tight enough that it will remain in place should the patient be active, but not so tight that it is visibly uncomfortable or cutting into the patient’s skin. If a ready-made eye mask is not available, use gauze to cover the eyes and tape to secure in place. Avoid putting tape on the eyebrows and hair.

STARTING A PATIENT

Place patient directly under phototherapy lights that are switched on in a prepared cot, warming crib or incubator. (3.4) Always document the date and time that phototherapy was started.

CARING FOR A PATIENT

  1. Babies should receive as continuous phototherapy treatment as possible.
  2. Monitor according to clinical condition, or in accordance to local policy:
  3. At every monitoring point (4 hourly), check that:
  4. If serum bilirubin levels or jaundice areas are increasing:
  5. Always document the date and time that phototherapy settings were changed.

? ALERT 3.1
When feeding and not under the blue light, remove the patient’s eye mask and check for any signs of infection. The baby can be removed from the phototherapy unit and fed in mother’s arms. This will facilitate mother-child bonding. Keep mother and baby together as much as possible whilst still allowing effective treatment time.

REMOVING A PATIENT

  1. If referring to the Kramer's scale, stop phototherapy when jaundice is limited to area 1 in premature infants and areas 1 & 2 in term infants. (Alert 3.2) When serum bilirubin or transcutaneous bilirubin measurement is available, stop phototherapy when the measurement is less than 50mmol/L or 3mg/dl below the level requiring treatment.
  2. Turn off the phototherapy light. Gently remove the eye covering from the patient and dispose of the covering. (3.5)

  3. Continue to monitor the baby for jaundice over the next 24-48 hours in case the bilirubin level rises again.

? ALERT 3.2 Discontinuation of phototherapy when serum bilirubin measurements unavailable

In the absence of timely serum bilirubin measurement, there is no evidence-based method for determining when to remove a patient from phototherapy. WHO Europe guideline suggests a “minimum of 12 hours phototherapy” which is too short for most preterm infants or deeply jaundiced term infants. WHO Pocket Book for Children does not provide guidance on how to stop phototherapy in the absence of utilising serum bilirubin.1,19,20

Thus, based on expert opinion, although there are no studies addressing the accuracy of the Kramer's scale after starting phototherapy, it was determined best to give some physical exam guidance based on the Kramer's scale for when to discontinue phototherapy. Additionally, in the absence of bilirubin levels, cleared conjunctiva are often used as indicating that jaundice has resolved sufficiently to stop treatment. This has not been formally evaluated.

Alternately, if choosing to discontinue phototherapy using length of therapy, based on expert opinion we would recommend a minimum of 24 hours of phototherapy for term infants and longer for preterm infants.

Infection Prevention

Routine and adequate cleaning of medical devices is critical to prevent hospital-acquired infections in newborn care units. If devices and equipment are not disinfected or re-processed promptly or adequately between patients, they may pose a significant infection risk.

GENERAL INFECTION PREVENTION

  1. Clean hands with soap and water or alcohol before and after placing a patient under phototherapy or handling any materials that will be used on a patient (e.g., eye covers).
  2. Ensure that all patient-related equipment (including eye coverings) are new or have been cleaned thoroughly before use. Any patient-related materials, including cot linen, must be cleaned before they are placed on a patient under a phototherapy device.
  3. All patient-related equipment should be stored in a clean, dry location. Any cables should be loosely wrapped and secured, preventing sharp bends or kinks, which will decrease the lifetime of the cables. Do not pinch or bend the cables.
  4. Only one baby should be under each phototherapy unit. Sharing of a phototherapy
    5. light in one cot poses a high risk for infection transmission between patients. Some phototherapy units may be able to provide therapeutic light to multiple patients in several cots at once; though this inevitably means that the cots are close to each other and increases the likelihood of infection transmission. The light should always be tested for efficacy using a light meter near the location in which the patient will be placed.

DISINFECTION AFTER USE

  1. Turn off phototherapy light and unplug. Disinfect handle of phototherapy light meter and LCD controls using alcohol. (4.1)
  2. Housing of the phototherapy unit (including the casing on the LEDs or lightbulbs) should be cleaned thoroughly according to ward guidelines for disinfecting surfaces.
? ALERT 4.1 Equipment Disinfection

Disinfection of equipment should always comply with manufacturer guidelines. General guidance on environmental cleaning and disinfection of equipment was taken from the Infection Prevention and Control: Reference Manual for Health Care Facilities with Limited Resources, Jhpiego, Module 621 which lists isopropyl alcohol (70-90%), sodium hypochlorite (0.05% or > 100ppm available chlorine) quaternary ammonium, and Iodophor germicidal detergent as appropriate for low level disinfection. Phenolic germicidal detergent is also listed in this category but should not be used in neonatal wards since affordable, effective alternatives are available; and, there are concerns it may cause hyperbilirubinemia and/or neurotoxicity in neonates.22

When utilizing re-processed devices meant for single-use (like temperature probes), careful attention must always be paid to assure that devices are continuing to function properly.

Complications

Introduction of equipment in newborn care units poses clinical and device complications for patients. Awareness of potential complications is critical to maximise patient safety.

CLINICAL COMPLICATIONS

  1. Dehydration: neonatal patients under phototherapy with lights other than LEDs may require more fluid than maintenance volumes. It is important to ensure the patient is feeding well and to monitor for signs of dehydration (not passing urine, weight loss >= 5%, prolonged skin turgor). Additional feeds or intravenous fluids may be required. Dehydration may be worsened by diarrhoea which is a recognised complication of jaundice.23
  2. Hypothermia: temperature should be carefully monitored as patients are nearly naked under phototherapy. Phototherapy devices are not intended as heating devices. LED bulbs used in most modern devices are very efficient so generate minimal heat; a warming device may be required to avoid hypothermia.
  3. Retinal damage: consistent exposure of the eyes to strong light has been shown to cause retinal damage in adults. Although this has not been tested in neonates, care should be taken to keep the eyes covered at all times during treatment. (5.1)
  4. Eye infections: check for redness, swelling or discharge. The skin under the eye pads should be cleaned daily with warm sterile water to prevent infection.
  5. Bronze baby syndrome: some babies develop a greyish colour to their skin (difficult to see in pigmented babies), urine, and plasma during phototherapy. This is attributed to increased accumulation of bilirubin photoisomers, degradation products, or copper- porphyrin conjugates. The true cause remains uncertain. It is self-limiting, resolves after phototherapy is stopped, and has no long-term sequelae.24–26


  6. Acute bilirubin encephalopathy (Kernicterus)extremely high levels of bilirubin can cross the blood brain barrier causing kernicterus. This may manifest as hypertonia and seizures. If the jaundice is not promptly and appropriately treated with adequate phototherapy light, permanent brain damage may occur e.g., development of deafness, choreoathetoid movements, and cerebral palsy. In addition to phototherapy, exchange transfusions are required for serious jaundice.23

DEVICE COMPLICATIONS

  1. Inadequate light: after a set period of use (about 20,000 – 50,000 hours, depending on manufacturer recommendations), phototherapy devices may lose their ability to provide therapeutic light. It is important to test the capacity of the phototherapy regularly to ensure that the phototherapy light is still providing a therapeutic range (25 – 35 µW/cm2 ).

Care & Maintenance

Users are responsible for basic first-line care and maintenance to ensure equipment lasts to their potential lifetime.

POWER SOURCE

Phototherapy units may be powered via mains or grid power with a rechargeable battery, depending on model

WARD LOCATION

Phototherapy devices are usually rolling units with breakable caster wheels. Devices may be rolled from patient bed to patient bed as needed.

USER PREVENTIVE MAINTENANCE

Test the light for therapeutic light levels once a week using the phototherapy light meter, following the steps in Phototherapy: Management | Setting Up for a Patient.

Troubleshooting & Repair

Although users are not responsible for repairing their devices, there are steps that may be taken to troubleshoot first-line errors that may occur before contacting maintenance or engineering support.

1 The phototherapy light does not turn on.
  • Check that the power cable is securely attached to the phototherapy device (7.1) and that the switch and power outlet are turned on.
  • If the phototherapy unit still does not turn on, contact your maintenance department.
2 The phototherapy light turns on, but only some of the lights are functional. (7.2)
  • Contact your maintenance department and ask for replacement bulbs.
  • Some phototherapy units have different switches for the white examination lights and the blue phototherapy lights. Each set of lights must be switched on separately. Examination lights do not treat jaundice. Blue phototherapy lights are therapeutic and must be replaced in order for treatment to be effective.

References

  1. Pocket book of hospital care for children: guidelines for the management of common childhood illnesses. (World Health Organization, 2013).
  2. Granati, B. et al. Efficacy and safety of the ‘integral’ phototherapy for neonatal hyperbilirubinemia. Results of a follow-up at 6 years of age. Clin Pediatr (Phila) 23, 483–486 (1984).
  3. Maisels, M. J. Phototherapy for Neonatal Jaundice. N Engl J Med 358, 2522–2525 (2008).
  4. Kumar, P., Chawla, D. & Deorari, A. Light-emitting diode phototherapy for unconjugated hyperbilirubinaemia in neonates. Cochrane Database Syst Rev CD007969 (2011) doi:10.1002/14651858.CD007969.pub2.
  5. Morris, B. H. et al. Efficacy of phototherapy devices and outcomes among extremely low birth weight infants: multi-center observational study. J Perinatol 33, 126–133 (2013).
  6. Slusher, T. M. et al. Filtered sunlight versus intensive electric powered phototherapy in moderateto-severe neonatal hyperbilirubinaemia: a randomised controlled non-inferiority trial. The Lancet Global Health 6, e1122–e1131 (2018).
  7. Slusher, T. M. et al. Safety and efficacy of filtered sunlight in treatment of jaundice in African neonates. Pediatrics em>133, e1568-1574 (2014).
  8. Slusher, T. M. et al. A Randomized Trial of Phototherapy with Filtered Sunlight in African Neonates. New England Journal of Medicine 373, 1115–1124 (2015).
  9. Vreman, H. J. et al. Evaluation of Window-Tinting Films for Sunlight Phototherapy. Journal of Tropical Pediatrics 59, 496–501 (2013).
  10. Nagar, G., Vandermeer, B., Campbell, S. & Kumar, M. Reliability of Transcutaneous Bilirubin Devices in Preterm Infants: A Systematic Review. PEDIATRICS 132, 871–881 (2013).
  11. Hassan Shabuj, M., Hossain, J. & Dey, S. Accuracy of transcutaneous bilirubinometry in the preterm infants: a comprehensive meta-analysis. J. Matern. Fetal. Neonatal. Med. 32, 734–741 (2019).
  12. Nagar, G., Vandermeer, B., Campbell, S. & Kumar, M. Effect of Phototherapy on the Reliability of Transcutaneous Bilirubin Devices in Term and Near-Term Infants: A Systematic Review and Meta-Analysis. Neonatology 109, 203–212 (2016).
  13. Appendices A-F [Nomograms depicting jaundice management at various gestational periods]. in Queensland Clinical Guidelines:Neonatal Jaundice. 34–39 (Queensland Health, 2019).
  14. WHO recommendations on newborn health: guidelines approved by the WHO Guidelines Review Committee. Geneva: World Health Organization; 2017 (WHO/MCA/17.07). Licence: CC BY-NCSA 3.0 IGO.
  15. Madlon-Kay, D. J. Home health nurse clinical assessment of neonatal jaundice: comparison of 3 methods. Arch Pediatr Adolesc Med 155, 583–586 (2001).
  16. Moyer, V. A., Ahn, C. & Sneed, S. Accuracy of Clinical Judgment in Neonatal Jaundice. ARCH PEDIATR ADOLESC MED 154, 4 (2000).
  17. Szabo, P. et al. Detection of hyperbilirubinaemia in jaundiced full-term neonates by eye or by bilirubinometer? European Journal of Pediatrics 163, 722–727 (2004).
  18. American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics 114, 297–316 (2004).
  19. Moyer, V. A., Ahn, C. & Sneed, S. Accuracy of Clinical Judgment in Neonatal Jaundice. ARCH PEDIATR ADOLESC MED 154, 4 (2000).
  20. Neonatology: Effective Perinatal Care. (World Health Organization Regional Office of Europe, 2010).
  21. Curless MS, Ruparelia CS, Thompson E, and Trexler PA, eds. 2018. Infection Prevention and Control: Reference Manual for Health Care Facilities with Limited Resources. Jhpiego: Baltimore, MD.
  22. Sharma, G. Infection Prevention and Control at Neonatal Intensive Care Units. 134.
  23. Kliegman, R. Nelson textbook of pediatrics. (Elsevier Inc, 2020).
  24. McDonagh, A. F. Bilirubin, copper-porphyrins, and the bronze-baby syndrome. J. Pediatr. 158, 160–164 (2011).
  25. Ottinger, D. Bronze baby syndrome. Neonatal Netw 32, 200–202 (2013).
  26. Rubaltelli, F. F., Da Riol, R., D’Amore, E. S. & Jori, G. The bronze baby syndrome: evidence of increased tissue concentration of copper porphyrins. Acta Paediatr. 85, 381–384 (1996)