for pediatricians and neonatologists

1. Effective Phototherapy
L S Deshmukh
DM ( Neonatology )
deshmukhls@yahoo.com

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
• Eye 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/cm2 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