PHOTOTHERAPY • Jaundice: the yellow appearance of the skin that occurs

• A treatment for jaundice where the exposure of skin to a with the deposition of bilirubin in the dermal and
light source converts unconjugated bilirubin molecules into subcutaneous tissues and the sclera.
water soluble isomers that can be excreted by the usual
pathways.
• Phototherapy, also known as light therapy, is a procedure
that uses blue-green light to treat jaundice in newborns. The
light breaks down bilirubin in the baby's skin so it can be
excreted in urine and stool.
• Phototherapy is the use of visible light to treat severe
jaundice in the neonatal period.
• Approximately 60% of term babies and 85% preterm babies
may develop clinically apparent jaundice, which classically
becomes visible on day 3, peaks days 5 -7.
• Resolves by 14 days of age in a term infant and by 21 days
in the preterm infant.
• Treatment with phototherapy is implemented in order to
prevent the neurotoxic effects of high serum unconjugated
bilirubin.
• Phototherapy is a safe, effective • Jaundice, also known as
method for decreasing or hyperbilirubinemia, is defined
preventing the rise of serum as a yellow discoloration of the
unconjugated bilirubin levels and body tissue resulting from the
reduces the need for exchange accumulation of excess
transfusion in neonates. bilirubin.
• Phototherapy is a dependent • Deposition of bilirubin
nursing intervention. happens only when there is an
• Physician’s order is needed excess of bilirubin, and this
before a nurse can start administering phototherapy. indicates increased production
or impaired excretion. The
Phototherapy should be instituted when the total serum normal serum levels of
bilirubin level is : bilirubin are less than 1
• at or above 15 mg per dL milligram per deciliter
(257 mol per L) in infants 25 to (mg/dL).
48 hours old, • However, the clinical presentation of jaundice with
• 18 mg per dL (308 mol per L) peripheral yellowing of the eye sclera, also called scleral
in infants 49 to 72 hours old, icterus, is best appreciated when serum bilirubin levels
and exceed 3 mg/dl.
• 20 mg per dL (342 mol per L) • With further increase in serum bilirubin levels, the skin will
in infants older than 72 hours. progressively discolor ranging from lemon yellow to apple
green, especially if the process is long-standing: the green
color is due to biliverdin.

It includes 3 phases: Prehepatic, Hepatic and Post hepatic.

PREHEPATIC
• Bilirubin is the end product of heme, which is released by
senescent or defective RBCs. In the reticuloendothelial cells of
spleen, liver and bone marrow, heme released from the RBC
undergoes a series of reactions.

HEPATIC
• Hepatocellular uptake - The bilirubin released from the
reticuloendothelial system is in an unconjugated form (ie.,
non-soluble) and gets transported to the hepatocytes bound
to albumin which accomplishes solubility in blood.

• The albumin-bilirubin bond is broken, and the bilirubin

alone is then taken into the hepatocytes through a carrier-
membrane transport and bound to proteins in the cytosol to
decrease the efflux of bilirubin back into the plasma.

Conjugation of bilirubin - This unconjugated bilirubin then

proceeds to the endoplasmic reticulum, where it undergoes
conjugation to glucuronic acid resulting in the formation of
conjugated bilirubin, which is soluble in the bile. This is
rendered by the action of UDP-.
POSTHEPATIC PARA MAGETS ETO SIYA:
Bile secretion from hepatocytes- Conjugated Prehepatic (Before the Liver)
bilirubin is now released into the bile • Red blood cells (RBCs) naturally wear out over time.
canaliculi into the bile ducts, stored in the When they break down, they release heme (a part of
gallbladder, reaching the small bowel hemoglobin).
through the ampulla of Vater. • This happens in special cells in the spleen, liver, and
bone marrow (called the reticuloendothelial
system).
ETIOLOGY • Heme is broken down into biliverdin, which is then
[Link] HYPERBILIRUBINEMIA converted into unconjugated bilirubin (a yellow
• Pre-hepatic pigment).
- increases the load of bilirubin to be metabolized by the liver. • This unconjugated bilirubin is not water-soluble, so
it binds to albumin (a protein in the blood) and is
2. CONJUGATED HYPERBILIRUBINEMIA transported to the liver.
• Hepatocellular 2. Hepatic (In the Liver)
-damages or reduces the action of enzyme or hepatocyte • The liver takes in the bilirubin from the blood.
• Post-hepatic • Inside liver cells (hepatocytes), bilirubin unbinds
-also called obstructive jaundice, is caused interruption to the from albumin and is processed.
drainage of bile in the system. • The liver then attaches glucuronic acid to bilirubin (a
process called conjugation)—this makes it water-
• PRE-HEPATIC soluble so it can be excreted in bile.
Hemolytic anemias: Polycythemia; Shortened red cell life as a 3. Posthepatic (After the Liver)
result of immaturity or transfused cells; Drug induced • The now water-soluble bilirubin is released into bile
(antimalarias):G- 6PD;etc. and moves through bile ducts.
• HEPATOCELLULAR • It travels to the gallbladder (for storage) or flows
Viruses:Hepatitis(A,B,C,D,E); CMV,EBV:Drugs: Autoimm..... into the small intestine through the ampulla of
Hepatitis;Wilson's Disease; Right Heart Failure: Drug Vater.
induced(Paracetamol, Isoniazid, rifampicin,pyrazinamide); etc. • In the intestine, bacteria help convert bilirubin into
• POST-HEPATIC urobilinogen, which is either excreted in stool (as
Extrinsic obstruction of the bile duct;Biliary atresia;Common stercobilin, giving stool its brown color) or
bile duct gallstones;Drugs induced (steroids, flucloxacilin);etc. reabsorbed and excreted in urine (as urobilin, giving
urine its yellow color).

Causes of High Bilirubin (Hyperbilirubinemia)

1. Unconjugated Hyperbilirubinemia (Prehepatic
Causes)
o The liver is overwhelmed with too much
bilirubin to process.
o Causes: Hemolytic anemia (excess RBC
breakdown), G6PD deficiency, malaria,
sickle cell disease, blood transfusion
reactions.
2. Conjugated Hyperbilirubinemia (Hepatic Causes)
o The liver is damaged and cannot properly
process bilirubin.
o Causes: Hepatitis (A, B, C, D, E), Wilson’s
disease, cirrhosis, drug-induced liver injury
(paracetamol, rifampicin, isoniazid).
3. Post-Hepatic Hyperbilirubinemia (Obstructive
Jaundice)
o Bilirubin cannot drain properly due to a bile
duct blockage.
o Causes: Gallstones, bile duct tumors, biliary
atresia, pancreatic cancer, drug-induced
obstruction (steroids, flucloxacillin).

Summary
• Bilirubin comes from old RBCs breaking down
(Prehepatic).
• The liver processes bilirubin to make it soluble
(Hepatic).
• It is then excreted through bile and removed via
stool/urine (Posthepatic).
• If bilirubin levels are too high, the cause depends on
where the problem is (before, in, or after the liver).
BILIRUBIN : the yellowish substance/ pigment of bile, formed PATHOLOGIC JAUNDICE
principally by the breakdown of hemoglobin in red blood cells • Bilirubin levels with deviation from the normal range and
at the end of their normal life-span. requiring intervention within 24 hours due to an increase in
BILIRUBINANEMIA: the presence of bilirubin in the blood. serum bilirubin beyond 5 mg/dL/day. Peak levels are higher
HYPERBILIRUBINANEMIA: the excess of bilirubin in the than the normal range, with the presence of clinical jaundice
blood. lasting more than two weeks and conjugated bilirubin (dark
urine staining the clothes).
CONJUGATED BILIRUBIN (DIRECT BILIRUBIN)
• a type of bilirubin that is not reabsorbed from the proximal BREAST MILK JAUNDICE
intestines and is degraded in the digestive tract. • Develops within 2-4 days of birth, is most likely related to
limited fluid intake as breast milk supply is established, may
UNCONJUGATED BILIRUBIN (INDIRECT BILIRUBIN) peak at 7-15 days of age, and may persist for weeks. Rarely, a
• bilirubin that is partially reabsorbed across the lipid very large amount of bilirubin accumulates and causes
membrane of the small intestinal epithelium and undergoes problems. Management: In term and healthy babies,
enterohepatic circulation. breastfeeding 10-12 times a day and monitoring is
recommended.

HEMOLYTIC JAUNDICE
• Incompatibility of blood groups with ABO and RH factors—
when the fetus and mother have incompatible blood groups,
the fetus' blood crosses the umbilical cord barrier before
birth, causing blood hemolysis due to a severe immune
response.

HOW PHOTOTHERAPY WORKS

ISOIMMUNIZATION
• A condition that happens when a pregnant woman's blood
protein is incompatible with the baby's, causing her immune
system to react and destroy the baby's blood cells.

KERNICTERUS
• is a type of brain damage that can result from high level of
bilirubin in the baby’s blood
• It can cause athetoid cerebral palsy and hearing loss.
Kernicterus also causes problems with vision and teeth and
sometimes can cause intellectual disabilities.

• Bilirubin is processed through the liver, where it is

conjugated to glucuronic acid by the enzyme uridine
diphosphate glucuronyl transferase (UGT) 1A1. BLUE-GREEN LIGHT
• This conjugated form of bilirubin is then excreted into the • is most effective for phototherapy as it both penetrates the
bile and removed from the body via the gut. skin and is absorbed by bilirubin to have a PHOTOCHEMICAL
• When this excretion process is low following birth, does not EFFECT.
work efficiently, or is overwhelmed by the amount of
endogenously produced bilirubin, the amount of bilirubin in INDICATION:
the body increases, resulting in hyperbilirubinemia and • indicated for hyperbilirubinemia to decrease the serum
jaundice. bilirubin level to normal.
• Prevent the neurotoxic effects of high serum bilirubin.
The general symptom of neonatal jaundice • Reduces the need for exchange transfusion in neonates.
• Yellow skin
• Yellow eyes (sclera) CONTRAINDICATION
• Sleepiness • Photosensitivity conditions lupus erythematosus
• Poor feeding in infants xeroderma pigmentosum
• Brown urine • History of cutaneous malignancies
• Fever
• High-pitch cry POSSIBLE COMPLICATIONS
• Overheating – monitor neonate’s temperature
• Vomiting
• Water loss from increased peripheral blood flow
and diarrhea (if present)
PHYSIOLOGIC JAUNDICE
• Diarrhea from intestinal hypermotility
• most abundant type of newborn hyperbilirubinemia having
• Ileus (preterm infants)
no serious consequences, usually occurs between 24-72 hours
• Rash
and peaks in 4th-7th day in term ,preterm 7th day, disappears
• Retinal damage
in 10-14 days. Unconjugated bilirubin is the predominant
• ‘Bronzing’ of neonates with conjugated hyperbilirubinemia
form and usually serum level is < 15mg/dl.
• Temporary lactose intolerance
PHOTOTHERAPY LIGHT SOURCES PLANNING
1. LED 1 Check the phototherapy unit to ensure all lights are functioning p
2 Comply to the setting parameters according to the man
instructions.
EQUIPMENTS
3 • eye shields
• diaper of appropriate size
• extra linen
IMPLEMENTATION
4 Perform Hand washing
5 Expose the entire body except for the eyes and genital area. W
damage from phototherapy is rare, using eye covers for ne
standard practice for protection.
6 Turn on the phototherapy unit and avoid placing anything on top
7 Position the infant close to the phototherapy unit accord
manufacturer's instructions, ensuring the eye patch does not
nostrils to avoid obstructing breathing.
8 Encourage breastfeeding, as it's essential for infants u
[Link] FLUORESCENT LIGHT OR CF phototherapy to stay hydrated. Adequate fluid intake helps in th
of bilirubin through urine and stool.
9 Change the infant's position to ensure all body parts are expo
phototherapy light
10 Monitor the infant’s temperature every 2 -4 hours or more freque
is fluctuation in baby ‘s temperature and record
11 Check the baby's weight daily to monitor for increased insensible
due to overhead phototherapy. Daily weights and urine output
recorded every shift.
12 Ensure the baby passes adequate urine 6-8 times per day or rec
weight to monitor for potential increased insensible water l
phototherapy.
13 Monitor bilirubin levels at least once daily, or as per the physicia

Phototherapy should be discontinued when bilirubin returns

value as per the unit protocol
14 Monitor clinically for a rebound rise in bilirubin within 24 h
[Link] BILIBLANKET (BLUE HALOGEN LIGHT) stopping phototherapy, especially in infants with hemolytic disor
15 Monitor for the following complications:
• This uses a halogen bulb directed into a fiberoptic mat.
- diarrhea,
• There is a filter that removes the UV and infrared
- dehydration,
components and eventual light is a blue –green color. - hypo- or hyperthermia.
• Bili blankets are not to be used on infants less than 28 Note that any skin rash is generally temporary and will re
weeks with broken or reduced skin integrity. discontinuation of treatment.

TYPES OF PHOTOTHERAPY UNIT SIDE EFFECT OF PHOTOTHERAPHY

[Link] unit • Increase insensible water loss from increased peripheral
blood flow and diarrhea (if present)
• Loose stools from intestinal hypermotility
• Skin rash
• Bronze baby syndrome
• Hyperthermia
• Upsets maternal baby interaction
• Ileus (preterm infants)
• Retinal damage
[Link] unit
• Temporary lactose intolerance
• may result to hypokalemia

NURSING CONSIDERATIONS
• A SBR should be collected 24 hours post cessation of
phototherapy lights to check for rebound hyperbilirubinemia.
• Remember to change light source i.e, the CFL bulbs every 3-
6 months or every 1000 hours of use when the tube flickers or
[Link] unit ends turn black
•Ensure that the nappy covers as minimum surface as
possible
• While in NICU and infant being monitored ,cover the pulse
oximeter probe properly so to avoid interference of readings
from the phototherapy light