Phototherapy in neonatal jaundice

Phototherapy in neonatal jaundice: Introduction, definition, indication, purposes, rule of thumb, lights used in phototherapy mechanism of phototherapy, techniques of phototherapy, phototherapy units, nursing care in phototherapy, short term and long term complications, nursing diagnosis in phototherapy.

1. PHOTOTHERAPY Presented by: Ms. Manisha Thakur Child Health Nursing M.Sc (N) 2 nd Year

2. INTRODUCTION CONSIDERED AS “DRUG” WITH APPROPRIATE DOSE AND DURATION

3. EFFECTIVENESS OF PHOTOTHERAPY DEPENDS ON: LIGHTCOLOR OF THE LIGHT DURATION OF EXPOSURE EEXPOSED BODY SURFACE INTENSITY OF THE LIGHT

4. INTRODUCTION Phototherapy has been used since 1958 for the treatment of neonatal hyperbilirubinaemia . It causes unconjugated bilirubin to be mobilised from the skin by structural isomerisation to a water soluble form ( lumirubin ) that can be excreted in the urine. The aim of phototherapy is to decrease the level of unconjugated bilirubin in order to prevent acute bilirubin encephalopathy, hearing loss and kernicterus.

5. CONT… Lamps emitting light between the wavelengths of 400 - 500 nanometres (peak at 460nm) are specifically used for administering phototherapy as bilirubin absorbs this wavelength of light. The light is visible blue light and contains no ultraviolet light.

6. DEFINITION Phototherapy (light therapy) is a way of treating jaundice. Special lights help break down the bilirubin in your baby's skin so that it can be removed from his or her body. This lowers the bilirubin level in your baby's blood. It is defined as exposure of skin to a specialised light sources that converts unconjugated bilirubin into water soluble conjugated molecules that can be excreted through normal pathway ( through urine and feces)

7. APP recommends phototherapy should be started if serum bilirubin level is 15 mg/dl in full term baby

8. Rule of thumb If jaundice is pathological then phototherapy should be started only when the bilirubin level is more than 5 times of birth weight. E.g. birth weight of new born: 4 kg Then, 4 X 5 = 20 mg/dl

9. PURPOSE To support the care of babies with hyperbilirubinemia . To decrease infant serum bilirubin levels. To maintain phototherapy treatment safely and effectively. To minimize infant-maternal separation and facilitate breastfeeding.

10. INDICATION OF PHOTOTHERAPY WEIGHT ( gms ) PHOTOTHERAPY(mg/dl) 500-700 5-8 750-1000 6-10 1000- 1250 8-10 1250-1500 10-12 1500-2500 15-18

11. LIGHTS USED IN PHOTOTHERAPY Micro White Halogen lights They deliver light via a quartz halogen bulb and have a tendency to become quite hot so should not be positioned closer to the infant than the manufacturers recommendations of 52cm. The lights can continue to be bright despite having low irradiance levels. Fluoro - 2 Blue and 2 White Fluorescent lights The fluorescent blue tubes must have the serial number F20T12/BB or TL52/20W to be special phototherapy lights. Blue light is the most effective light for reducing the bilirubin.

12. CONT… Ohmeda Biliblanket - Blue Halogen light This uses a halogen bulb directed into a fiberoptic mat. There is a filter that removes the ultraviolet and infrared components and the eventual light is a blue-green colour . Biliblankets are not to be used on infants less than 28 weeks gestation or infants with broken or reduced skin integrity . Blue Fluorescent light A blue fluorescent tube is fitted into a plastic crib with a stretched plastic cover over the top for the baby to lie on

13. TYPES OF PHOTOTHERAPY UNITS Single surface unit . Double surface unit. Triple surface unit.

14. PHOTOTHERAPY TECHNIQUES Perform hand wash. Place baby naked in cradle or incubator. Fix eye shades & genital area. Keep baby at least 45 cm from lights,if using closer monitor temperature of baby. Start phototherapy. Frequent extra breast feeding every 2 hourly . Turn baby after each feed. Temperature record 2 to 4 hourly. Weight record- daily. Monitor urine frequency. Monitor bilirubin level.

15. MECHANISM OF PHOTOTHERAPY STRUCTURAL ISOMERIZATION PHOTO-OXIDATION CONFIGURATIONAL ISOMERISATIOBN

16. MECHANISM OF PHOTOTHERAPY Blue-green light in the range of 460-490 nm is most effective for phototherapy. The absorption of light by the normal bilirubin (4Z,15Z-bilirubin) generates configuration isomers, structural isomers, and photooxidation products. The 2 principal photoisomers formed in humans are shown. Configurational isomerization is reversible and much faster than structural isomerization. Structural isomerization is slow and irreversible. Photooxidation occurs more slowly than both configurational and structural isomerization. Photooxidation products are excreted mainly in urine.

17. Nursing care of phototherapy SKIN CARE Keep the infant clean and dry. Clean only with water. Do not apply oils or creams to the exposed skin . Eucerin has been proven to be safe for use when the infant is receiving phototherapy. Infants nursed in nappies where the buttocks are not exposed may have zinc and castor oil applied to areas of skin excoriation.

18. Cont … OBSERVATION All infants in Newborn Care receiving phototherapy should have a temperature, pulse and respiration rate documented 4 hourly & prevent dehydration. If an infant requires continuous cardiorespiratory monitoring for other reasons, then, this should continue whilst under phototherapy EYE CARE Eye pads should be removed 4 hourly and eye cares attended with normal saline. • There have never been human studies showing that retinal damage occurs from with phototherapy.

19. FLUID REQUIREMENTS Accurately document fluid intake (oral or intravenous) and output. Urinalysis and specific gravity should be checked 8 hourly. Assess and record stools. Breast fed infants should continue on demand breast feeds. Bottle fed infants should be fed on demand 4-6th hourly. The daily fluid rate may need to be increased by 10ml-15ml/kg/day to prevent dehydration. Cont …

20. SIDE EFFECTS OF PHOTOTHERAPY Increased insensible water loss. Loose stools. Intestinal absorption of water, NaCl and k+ is impaired. Skin rash. Due to phototherapy lights Bronze baby syndrome. Increase porphyrins due to cholestasis leads to increase in copper level in serum and liver. This can resolves in 3 days. Hyperthermia . It can occur due to phototherapy lights. Upsets maternal baby interaction. May result in hypocalcemia Increased calcium excretion leads to decrease in total ionized calcium level of neonates. Phototherapy leads to pineal secretion of melatonin causing hypocalcemia

21. Riboflavin deficiency LONG TERM COMPLICATIONS PDA: photons acts on heart muscles leading to vasodilation and relaxation of cardiac muscles Occular manifestation: ROP, Uveal melanoma Skin cancer

22. NURSING DIAGNOSIS Fluid volume deficit r/t inadequate fluid intake, phototherapy , and diarrhea . Increased body temperature r/t effects of phototherapy . Risk for injury r/t effects of phototherapy . Impaired skin integrity r/t hyperbilirubinemia and diarrhea. Impaired parenting r/t separation. Anxiety : parents r/t therapy given to infants.

23. Cont. Fluid volume deficit r/t inadequate fluid intake, phototherapy, and diarrhea . Assess the general condition of the baby. Monitor the intake and output chart of the baby. Administer IV fluid as prescribed by the Dr. Check skin turgidity. Encourage breatfeeding .

24. Cont … Altered body temperature r/t effects of phototherapy. Assess the general condition of the baby. Monitor the temperature. Keep the phototherapy on manual mode. Impaired skin integrity r/t hyperbilirubinemia and diarrhea. Assess skin color every 2 hours Monitor direct and indirect bilirubin Change positions every 2 hours Massage prominent area Keep your skin clean and moisture

25. Cont.. Impaired parenting r/t separation. Bring the baby to the mother for breastfeeding Encourage parents to talk to their children. Involve parents in care when possible. Encourage parents to express feelings.