Effective phototherapy for neonatal jaundice

for pediatricians and neonatologists

1. Effective Phototherapy L S Deshmukh DM ( Neonatology ) [email protected]

2. Introduction Phototherapy - mainstay of treatment unconj . Hyperbili . PT is effective in reducing excessive unconj . Hyperbili . drastically curtailed the use of ET Phototherapy should be regarded as a drug, with an appropriate dose and duration

3. PT – Indication The initiation and duration of PT decided by - total bilirubin values - an infant’s postnatal age - the potential risk for bilirubin neurotoxicity

4. PT – Indication ( ≥35 wk ) 2004 AAP guideline

5. J Clin Neonatol . 2013 PT - Indication(≤ 35 wk )

6. The Mechanism Of Phototherapy Advances in Neonatal Care • Vol. 11, No. 5S, 2011

7. Efficacy of PT Devices Depends on - Spectral qualities of the light source used (wavelength range and peak) Intensity of the light (irradiance) Body surface area exposed by the irradiated field or “footprint.” Distance between the light and the infant’s skin Advances in Neonatal Care • Vol. 11, No. 5S, 2011

8. Optimal Administration of PT – Practical Considerations Light source (wavelength) (nm) Light irradiance (W·cm2·nm1) Body surface area (cm2) Continuity of therapy Efficacy of intervention Duration of therapy

9. Optimal Administration of PT Light source (wavelength) (nm)

10. Practice Considerations - Light source (nm) Recommendation - Wavelength spectrum in 460- 490-nm blue-green light region Imp. - Know the spectral output of the light source Pediatrics 2011;128;e1046

11. Light source /Wavelength visible white light spectrum - 350 to 800 nm Bilirubin absorbs visible light most strongly in the blue region of the spectrum (~460 nm ) the most effective light in vivo is probably in the blue-to-green region ( 460–490 nm).

12. Light source /Wavelength Commercial Light Sources Fluorescent - cool white daylight - blue [B ] - special blue [BB] Turquoise and green narrow-band special blue bulbs - TL52/20W [Phillips] or - F20T12/BB [GE] - More effective

13. Light source /Wavelength Special blue (BB ) fluorescent lights - not be confused with white lights painted blue or covered with blue plastic sheaths Unless specified otherwise, plastic covers or optical filters need to be used to remove potentially harmful UV light.

14. Light source /Wavelength commercial compact fluorescent-tube light (CFL) sources LEDs of narrow spectral bandwidth - used as over- and under-the-body devices. Fiberoptic - pads, blankets Halogen - spotlights

15. Light source /Wavelength High intensity gallium nitride LEDs with emission within the 460- to 490-nm regions are as effective as CFL / Conventional - lower heat output, - low infrared emission, and - no ultraviolet emission - a longer lifetime (20 000 hours) Adv Biomed Res. 2012; 1: 51.

16. Optimal Administration of PT Light Irradiance

17. Light Irradiance ( intensity ) Light intensity or energy output is defined by irradiance number of photons (spectral energy) that are delivered per unit area ( cm2) of exposed skin The dose of phototherapy - measure of the irradiance delivered for a specific duration and adjusted to the exposed body surface area (µW·cm2·nm)

18. Light Irradiance Recommendation : Use optimal irradiance The recommended minimal irradiance levels are 8– 12 µW⁄cm2 ⁄nm for intensive PT ≥30 W·cm2·nm within the 460- to 490-nm waveband Imp: Ensure uniformity over the light footprint area Pediatrics 2011;128;e1046

19. Light Irradiance Devices that emit lower irradiance may be supplemented with auxiliary devices bringing the light source close to the infant increases irradiance - Caution : not be done with halogen lights The ideal distance and orientation of the light source should be maintained according to the manufacturer’s recommendations The irradiance of all lamps decreases with use

20. Optimal Administration of PT Body surface area (cm2)

21. Practice Considerations – Body surface area (cm2) Recommendation : Expose maximal skin area Imp : Reduce blocking of light Pediatrics 2011;128;e1046

22. Body Surface Area Complete (100 %) exposure of the total body surface to light is impractical and limited by use of eye masks and diapers Circumferential illumination achieves exposure of approximately 80 % of the total body surface. In clinical practice , exposure is usually planar (ventral or dorsal) Approximately 35% of the total body surface is exposed with either method

23. Body Surface Area Changing the infant’s posture every 2 to 3 hrs -maximizes the area exposed to light Exposed body surface area treated rather than the number of devices (double , triple, etc) used clinically more important Physical obstruction of light by equipment decreases the exposed skin surface area Pediatrics 2011;128;e1046

24. Body Surface Area Combining several devices, will increase the surface area exposed. - placing a light source beneath the infant reflecting material around the incubator or radiant warmer bed useful Pediatrics 2011;128;e1046

25. Imp Factors in the Efficacy of PT N Engl J Med 2008;358:920-8.

26. Optimal Administration of PT Continuity of therapy

27. Practice Considerations Continuity of therapy as far as possible Recommendation : Briefly interrupt for feeding, parental bonding , nursing care Imp : After confirmation of adequate bilirubin concentration decrease Pediatrics 2011;128;e1046

28. Optimal Administration of PT Efficacy of intervention

29. Practice Considerations Efficacy of intervention Recommendation : Periodically measure rate of response in bilirubin load reduction Imp : to look at , Degree of total serum bilirubin concentration decrease Pediatrics 2011;128;e1046

30. Efficacy of intervention - Rate of Response The clinical response depends on the rates of bilirubin production enterohepatic circulation bilirubin elimination the degree of tissue bilirubin deposition the rates of the photochemical reactions of bilirubin .

31. Efficacy of intervention - Rate of Response The clinical impact of phototherapy should be evident within 4 to 6 hours Decrease of more than 2 mg/ dL in serum bilirubin concentration. Periodicity of serial measurements is based on clinical judgment.

32. Optimal Administration of PT Practice Considerations - Duration of therapy Recommendation : Discontinue at desired bilirubin threshold, be aware of possible rebound increase Imp : Serial bilirubin measurements based on rate of decrease Pediatrics 2011;128;e1046

33. Failure of PT an inability to observe a decline in bilirubin of 1-2 mg/ dL after 4-6 hours and/or to keep the bilirubin below the BET level. ? Consider intensive PT No Role of prophylactic PT in preterm babies NNFguidelines2010

34. Stopping Phototherapy serum bilirubin level has fallen below 2mgs/ dL lower than threshold Check for rebound Consider if prematurity, direct Coombs test positivity, and those treated < 72 hours. Not indicated if, non-hemolytic etiology and an early follow up after discharge NNFguidelines2010

35. Phototherapy Infants ≤ 35 weeks GA Generally used in a prophylactic mode goal - to prevent further elevation TSB at least in infants with BW<750 g, initiate phototherapy at lower irradiance levels increase irradiance levels, or increase the surface area of the infant exposed to PT, if the TSB continues to rise MJ Maisels et al , 2012

36. Measuring Light Irradiance Visual estimations of brightness & use of ordinary photometric/colorimetric light meters are inappropriate measured with a radiometer (W·cm2) or spectroradiometer (W·cm2·nm1 ) over a given wavelength band .

37. Measuring Light Irradiance Irradiance should be measured at several sites on the infant’s body surface different radiometers may show different values for the same light source Use manufacturer recommended

38. Measuring Light Irradiance For improving the application of effective phototherapy, need to develop an affordable, user-friendly, handheld, universal irradiance meter which accurately measures irradiance delivered by all types of phototherapy light sources. Vreman HJ, Indian Pediatr, 2010

39. Safety And Protective Measures Four decades of neonatal phototherapy use - no serious adverse clinical effects Ensure adequate hydration, nutrition, and temperature control . Devices - Must meet electrical and fire hazard safety standards (IEC )

40. Safety And Protective Measures E ye patches - Purulent eye discharge and conjunctivitis in term infants with prolonged use Use of diapers : Diapers may be used for hygiene but are not essential . PT Contraindication - infants with congenital porphyria or those treated with photosensitizing drugs.

41. PT- Sunlight Sunlight will lower the serum bilirubin level, the practical difficulties involved in safely exposing a naked newborn to the sun either inside or outside (and avoiding sunburn) preclude the use of sunlight as a reliable therapeutic tool .

42. Transcutaneous Bilirubinometry ( TcB ) Pathak U et al, IJP, 2013

43. Key Messages 1 Use special blue tubes or LED light source with output in blue-green spectrum If special blue fluorescent tubes are used, bring tubes as close to infant as possible to increase irradiance For intensive PT, expose maximum surface area of infant to PT. Place lights above and fiber-optic pad or special blue fluorescent tubes* below the infant. 

44. Key Messages 2 Intensive PT requires >30 μW /cm 2  per nm. For maximum exposure, line sides of bassinet, warmer bed, or incubator with aluminum foil. Use intensive PT for higher TSB levels.  Periodically measure rate of response Monitor Irradiance

45. Thank you