SDMS ID: P2010/0390-001 WACSCLINProc4.

14 Title: Replaces: Description: Target Audience: Key Words: Policy Supported: Phototherapy on the Postnatal Ward New Guideline Postnatal ward management phototherapy for neonatal jaundice Midwives and medical officers, QVMU Phototherapy, newborn jaundice P2010/0389-001 Newborn Transcutaneous Bilirubin Assessment

Purpose The aim is to lower the bilirubin level avoiding maternal newborn separation and to facilitate breastfeeding in term newborns. Phototherapy on the postnatal ward may be implemented for well newborns with: physiological jaundice birth trauma eg cephalhaematoma or bruising as the initial mode of therapy whilst awaiting further investigation. Phototherapy will be initiated following review by the paediatric registrar who will document the management plan and order any relevant investigations. Phototherapy Phototherapy uses light of a specific wavelength to convert fat-soluble unconjugated bilirubin into water-soluble lumirubin that can be excreted through the kidneys. Once phototherapy commences then repeat serum bilirubin estimations are essential as the skin colour will no longer be a guide to the level. The frequency of the blood sampling will depend on the diagnosis, gestational age and postnatal age of the infant. Early feeding assists the elimination of meconium, reducing the available bilirubin for reabsorption. Effective Irradiance Position the phototherapy lamp, blanket or mattress to provide the most complete skin exposure. The Medela Bilibed The mattress is removed from the newborns cot and replaced with the Bilibed. The baby is placed supine on the Bilibed wearing only a nappy. The power source can then be turned on. Eye protection is not required when using a Bilibed. The newborns temperature should be monitored 4 hourly. The Drager 4000 phototherapy lamp The Drager 4000 phototherapy lamp should be positioned 40cm above the newborn in an open cot or incubator. The largest surface area of the infants body, the trunk, should be
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positioned in the centre of the light, where irradiance is highest. In most cases it is not necessary to remove the nappy. (Removal of the nappy is recommended for newborns requiring intensive phototherapy where serum bilirubin is approaching exchange transfusion level). Consider comfort measures such as nesting (provide a boundary with nappy rolls along the sides and at the bottom of the cot). Frequent turning to expose different areas of the skin has not been shown to improve the effectiveness of single phototherapy. Opaque eye shields must be used during this form of phototherapy to protect the newborns eyes from retinal damage. The eye protection should be removed whenever the baby is removed from the phototherapy eg. feeding, nappy change. Thermoregulation Newborns undergoing phototherapy can easily develop hypothermia or hyperthermia during phototherapy. Some phototherapy units can cause a significant increase in the newborns body temperature. When phototherapy is directed over an incubator, immediate and sustained fluctuations can occur in the thermal environment. It is necessary to maintain a thermo-neutral environment appropriate for the age and size of the baby. The suggested crib temperature range for term newborns is 28 - 30C. When lights are turned off the newborns temperature can drop precipitously. The newborns temperature needs to be monitored closely until stable and thereafter 4 hourly. Hydration Breastfeeding should continue with a maximum of four hours interval between feeds. Urine output must be monitored. For term newborns who are breastfeeding adequately (suck code 6), additional fluids are not usually required. There is an increase in transepidermal water loss during phototherapy in an open cot or incubator. For breastfed newborns with evidence of dehydration, additional fluids may be required and referral to the Lactation Consultant is appropriate for the development of a breastfeeding management plan. If additional fluids are required the first choice would be expressed breast milk. Promote Parent-Newborn Interaction Set up phototherapy at the mothers bedside, encouraging parental involvement and contact. Phototherapy can safely be interrupted to allow breastfeeding, parental contact and skin to skin care. The length of interruptions in phototherapy treatment for feeding should be limited to facilitate the effectiveness of treatment. Remove eye coverings during these contact periods. Monitoring Bilirubin Levels Phototherapy lamps must be turned off while taking blood for serum bilirubin testing. The most significant decline in bilirubin level occurs in the first 4 to 6 hours after initiating phototherapy. After discontinuing phototherapy, the bilirubin level often rises slightly. The paediatric registrar should be informed of all SBR results. The paediatric registrar should review of newborn and the management plan daily.

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Attachments
Attachment 1 Attachment 2 Attachment 3 Causes of Newborn Jaundice Investigation of Newborn Jaundice References

Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years via Policy and Procedure working group coordinated by the Clinical and Quality improvement midwife. November 2009 Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Stakeholders: Developed by:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: _________________________

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ATTACHMENT 1 Causes of Newborn Jaundice Physiological Jaundice: This is caused by increased production, increased enterohepatic circulation and decreased excretion of bilirubin in a normal baby. Haemolytic Jaundice: Maternal-fetal blood group incompatibility (rhesus, ABO, Kell, Duffy, etc) Extravascular haemolysis reabsorption of haematoma and petechiae Congenital disorders of the red cell congenital spherocytosis, haemoglobinopathies, glucose 6-phosphate dehydrogenase deficiency, pyruvate kinase deficiency Infections: Bacterial (generally Gram negative E coli, Klebsiella, Pseudomonas) Viral hepatitis, herpes, cytomegalovirus, rubella, other virus infections Other infections toxoplasmosis, syphilis Obstructive jaundice Congenital atresia of the bile ducts Choledochal cyst Inspissated bile or cholestasis syndrome Cystic fibrosis Alpha-1-antitrypsin deficiency Other causes of neonatal jaundice Hypothyroidism Galactosaemia Breastmilk jaundice Polycythaemia Drugs sulphonamides, vitamin K Hereditary hepatic enzyme deficiencies Crigler-Najjar hyperbilirubinaemia, Gilberts syndrome, Dubin-Johnsonn syndrome, Rotors syndrome Oxytocin in labour

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ATTACHMENT 2 Investigation of Newborn Jaundice Jaundice appearing in the first 24 hours of life This is always important and must be investigated. It will most likely be due to haemolytic disease either associated with ABO incompatibility, rhesus isoimmunisation or due to one of the other rare antigens. If the infant shows evidence of skin haemorrhages such as petechiae, then a non-bacterial transplacental infection such as cytomegalovirus, toxoplasmosis, herpes or rubella is a possibility. Syphilis should also be considered. Jaundice occurring after the first day Jaundice occurring on the second or third day of life is most likely to be due to physiological jaundice of the newborn. However, if the newborn appears unwell in any way, then other causes must be considered. Physiological jaundice is a diagnosis only arrived at by exclusion of more serious conditions. Jaundice occurring beyond the fourth or fifth day Generally this is not due to haemolytic disease so one must be on the lookout for bacterial infection particularly of the urinary tract or septicaemia. Again prenatally acquired infections should be considered. Jaundice due to drug interference is a possibility, and in infants of Asian or Mediterranean parents, glucose 6-phosphate dehydrogenase deficiency should be considered. Jaundice persisting beyond the first two weeks of life If bilirubin is mainly in the unconjugated form and the above conditions have been excluded then breastmilk jaundice, hypothyroidism, galactosaemia and some of the other less common causes of jaundice should be considered. Conjugated Hyperbilirubinaemia If the total bilirubin levels contain a high conjugated level, then an anatomical obstruction or neonatal hepatitis is the most likely cause. ATTACHMENT 3 References Drager Medical 2005 Photo-Therapy 4000 Product Information Maisels, M, Jeffrey, M & McDonagh, A 2008, Phototherapy for neonatal jaundice, New England Journal of Medicine, vol 358, no 9, pp 920-928. Stokowski, L, Short, M & Witt, C 2006, Fundamental of phototherapy for neonatal jaundice, Advances in Neonatal Care, vol 6, no 6, pp 303-312.

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