Phototherapy in jaundice

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1. Phototherapy for Jaundice Sunil Kumar Daha

2. Phototherapy Goal: to treat ing neonatal hyperbilirubinemia and prevent related neurotoxicity Decreases the need for exchange transfusion E xposure of the skin of the jaundiced baby to blue or cool white light of wavelength 425-475 nm Toxic b ilirubin molecule isomerizes to non-toxic product

3. Guidelines for Phototherapy

4. Suggested TSB cut-offs for phototherapy and exchange transfusion in preterm infants <35 weeks Gestation (Completed weeks) Phototherapy Exchange Transfusion <28 5-6 11-14 28 to 29 6-8 12-14 30 to 31 8-10 13-16 32 to 33 10-12 15-18 34 12-14 17-19 Guidelines for Phototherapy

5. Phototherapy The mainstay of treating hyperbilirubinemia in neonates Acts by converting insoluble bilirubin (unconjugated) into soluble isomers; excreted in urine and feces Uses blue- green light (460-490nm) The product is harmless isomers Acts only on bilirubin present in skin

6. Mechanism of Phototherapy Configurational Isomerization Structural Isomerization Photo oxidation

7. Configurational isomerization light Z-isomer E-isomer Reversible as it reaches bile duct. Constitute about 25% of TSB (non-toxic), after 8-12 hrs. Excreted slowly from body

8. Structural Isomerization Bilirubin Lumirubin This reaction is directly proportional to dose of phototherapy Coverts 2-6% of TSB, which is excreted rapidly from body

9. Photo oxidation M inor reaction F orms photo- products that are excreted in the urine

10. Types of phototherapy lights Fluorescent lamps Colors : Cool white, blue, green, blue-green or torquoise Shapes: Straight, or U-shaped (CFL) Halogen bulbs High Intensity Light Emitting Diodes (LED) Fibro-optic lights

11. Maximizing efficacy of phototherapy A minimum level of 30 microW/cm^2/nm in 460-490 nm must be ensured Lamp should be changed if : Lamps are flickering Ends blackened Irradiance falls below specified level Maximum surface area of baby should be exposed Blocking of light by equipment is avoided Avoid large diaper or eye patch, cap, tape, dressing etc. Minimize interruption of phototherapy during feeding sessions

12. Light should fall on baby perpendicularly if the baby is in incubator Maximizing efficacy of phototherapy

13. Phototherapy

14. Administering Phototherapy Make sure ambient room temperature is optimum 25° - 28° C Remove all clothes of baby except the diaper Cover the eyes with eye patches Place naked baby under the lights in a cot or bassinet: weight >2 kg or in an incubator or radiant warmer: weight <2kg Keep baby at a distance of 30-45 cm from light sources En sure optimum breastfeeding.

15. Monitoring and stopping phototherapy Monitor temperature every 2 – 4 hrs. Measure TSB level every 12-24 hrs. Discontinue - once two TSB values fall below age specific cutoffs, twelve hours apart Monitored for rebound bilirubin rise within 24 hrs. after stopping phototherapy

16. References Ghai Essential Pediatrics, 8 th Edition Nelson Textbook Pediatrics, 20 th Edition Up-to-date 21.2 http:// www.ncbi.nlm.nih.gov/pubmed/11722753

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