Every year thousands of newborn babies in the USA receive phototherapy treatment before their discharge home. In fact, the need for phototherapy will be one of the main reasons to delay discharge home in otherwise healthy full-term newborns.
Phototherapy (light therapy) is used to treat newborn jaundice. This therapy can be administered using special fluorescent tubes, LEDs, and fiberoptic light sources. For phototherapy to be effective, it must utilize a specific wavelength spectrum. Blue and green lights are most efficient in lowering bilirubin levels that are responsible for jaundice in newborns.
How does phototherapy work? Its specific light waves transform bilirubin (the culprit in jaundice) into water-soluble products that can be excreted from the body.
Types of phototherapy lamps (machines) and how phototherapy is provided?
Phototherapy can be provided using banked overhead lamps, spotlights (one bulb), or bili-blankets. Bili-blanket looks literally like a flat blanket with tiny LEDs or fiberoptic lights in it. It is flexible; thus, we can use it during feedings and different procedures.
For phototherapy to be effective, we have to expose as much of the baby’s skin to it as possible. Usually, the baby will be lying naked under phototherapy lamps wearing only a small diaper and protective eye goggles. If the baby requires only single phototherapy, we may lay the baby on the bili-blanket and then put a shirt over it and swaddle with a regular baby blanket.
Double phototherapy is provided by lying the baby on the bili-blanket or table lamps and placing the second lamp over the baby’s body. In triple phototherapy, we would add the third lamp (usually spot lamp) from the side.
In olden days we had to be very careful not to overheat baby with phototherapy. Nowadays, it occurs very rarely because modern lamps do not produce that much heat anymore.
What level of bilirubin requires phototherapy?
Frequently, parents ask the question: when does my baby with jaundice need phototherapy? There is no single level of bilirubin at which doctors start phototherapy.
The decision to start phototherapy will depend on numerous factors (I listed only some of them here):
- Gestational age at birth
- The current age in hours since birth
- Presence of ABO or Rh incompatibility
- History of G6PD disease in the family or the baby
- Overall health status
- Race of the baby
- Speed of increase in bilirubin levels
- Presence of clinical symptoms such as lethargy, poor feedings, temperature instability
In general, it is better to start phototherapy sooner than guidelines suggest than being too late and risk that the baby will need more aggressive treatment such as blood exchange transfusion.
I will give you examples of when one could start phototherapy for babies with jaundice in Table 1.
I created the table based on the recommendations issued by the American Academy of Pediatrics (AAP) in their clinical practice guideline on “Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation.”
Values at which one would consider starting phototherapy will be different depending on which group your baby belongs to:
- Group 1 – Infants born at 38 weeks of gestational age or more and without any additional risk factors for jaundice.
- Group 2 – Infants born at 38 weeks or more with risk factors for jaundice
- Group 3 – Infants born at 35 weeks without any risk factors for jaundice
- Group 4 – Infants born at 35 weeks with additional risk factors for jaundice
In order to know the approximate values for babies at gestational ages different from 38 weeks or 35 weeks, one has to extrapolate the values of bilirubin up or use the referenced above article.
Risk factors that would place your baby in Groups 2 or 4 are:
- Isoimmune hemolytic disease (ABO or Rh conflict)
- G6PD condition (inadequate amount of glucose-6-phosphate dehydrogenase) – can be diagnosed with a blood test
- Asphyxia at birth – very low Apgar score at birth
- Significant lethargy
- Temperature instability
- Sepsis = overwhelming infection
- Acidosis – more acid in the blood than normal
- Low albumin level in the blood (if measured)
Table 1: Bilirubin levels in “mg/dl” at which one may want to start phototherapy.
|Age in hours||12 hrs||24 hrs||36 hrs||48 hrs||72 hrs|
Please note that the above chart by no means constitutes absolute levels at which phototherapy should or should not be started. Also, note that Group 2 and 3 have the same values of bilirubin, and that is intentional.
After analysis of Table 1, you can conclude that we begin phototherapy much sooner for babies born at lower gestational age, with younger age in hours after birth and babies with other medical problems.
If you are from the UK or Europe, you may be interested in reading the resource I linked here. Importantly, Europeans use different units to measure jaundice. They measure bilirubin levels in units called “micromol/liter.” The source I linked will provide you values of bilirubin in those units and recommendations when phototherapy and follow up bilirubin levels are needed.
How long do babies with jaundice need phototherapy?
It isn’t very easy to predict how long your baby will need phototherapy. In most cases, it will be anywhere from 1 to 3 days. However, some babies need phototherapy even for one week or longer. Babies who have hemolytic jaundice or G6PD are more likely to require long phototherapy.
The goal for phototherapy is to stop a rapid rise in bilirubin and decrease bilirubin concentration if it is at dangerous levels. In most cases, after a few days, a newborn baby’s body will be able to resolve jaundice on its own. Frequently treatment is discontinued in stages; we go from triple phototherapy to double and then to single.
After discontinuation of phototherapy baby may need at least one follow up bilirubin level. Depending on specific circumstances, repeat bilirubin levels can be done in the hospital before discharge or as an outpatient.
Learn more about jaundice and hyperbilirubinemia from my article here.
Complications of phototherapy.
Phototherapy has been around for several decades, and millions of newborn babies received that treatment without any complications. In the past, before we had modern phototherapy lamps, babies could have suffered from overheating; however, nowadays, this occurs very rarely.
Babies who have obstructive jaundice or have an increased amount of direct bilirubin (also called conjugated bilirubin) may develop “bronze baby syndrome.”It is greyish-brown discoloration of the skin and urine that may occur in those rare conditions – it is not life-threatening.
Babies with congenital porphyria (rare metabolic disorder) may react with severe purpura and blistering bullous rash. If we notice such severe photosensitivity in any baby, we will stop phototherapy right away.
Some people are concerned about the effects of phototherapy on immature eyes. To prevent any unlikely eye damage due to phototherapy, we cover babies’ eyes with special goggles to eliminate any risks from prolonged exposure to intense light.
How can you help your baby under phototherapy?
Having your baby under phototherapy is very difficult. The time that you will be allowed to hold your baby may be limited to maximize the time your baby spends under phototherapy lights. If your baby needs a very intensive light therapy and is receiving “double” or “triple” phototherapy, you may be prevented from holding your baby at all.
Whenever I have a patient under intensive phototherapy, I want to allow the mother to breastfeed her baby, but I prefer to limit it to 15 minutes if possible. Once the baby is improving; read bilirubin levels are stable or decreasing, I can be more liberal with time allowed without light therapy. Sometimes, when the baby needs only single phototherapy such as bili-blanket, the mother can hold her baby and feed it without discontinuing the treatment.
Since proper hydration and nutrition will help baby resolve jaundice, efficient feeding is essential. In cases when doctors do not want to discontinue phototherapy for a feeding, you may need to pump breast milk. If the baby is dehydrated, it may be beneficial for your baby to receive formula or IV fluids.
What questions to ask as a parent if your baby is receiving phototherapy?
If you are a parent of baby receiving or about to receive phototherapy the following are the questions you may want to ask your nurse or doctor who is taking care of your little one:
- Can I continue breastfeeding?
- Can we interrupt phototherapy so I can hold my baby for 15 minutes at the time?
- What is the actual reason for my baby’s jaundice?
- Are any other treatments needed? (IV fluids, Immunoglobulin infusion or double exchange blood transfusion)
- What are the chances that my baby may need a double volume exchange blood transfusion?
- Is it possible for my baby to go home and receive phototherapy at home?
- How often will you be checking the level of jaundice (bilirubin level), and at what point do you expect to stop phototherapy?
- Will I be able to take my baby home right after you stop phototherapy, or will I have to wait for a “rebound” bilirubin level?
- What can I do to help my baby resolve jaundice sooner?
- How can I help my baby tolerate phototherapy better?
Can phototherapy be administered at home?
Some companies provide phototherapy equipment that can be rented and delivered to your home. This service is available only in larger cities and may not be covered by your health insurance company. Doctors are reluctant to manage newborn baby’s jaundice with home light therapy.
Most doctors think that the baby will be better served if we delay discharge or readmit the baby with jaundice to the hospital. In the hospital, we have more effective phototherapy lamps, we can modify and adjust our treatments more often, nurses can continuously observe babies under phototherapy, and it is easy to draw blood for all necessary tests and evaluations.
Should I place my baby under the sun or near a window to treat jaundice?
It is not recommended to place your baby exposed to the sun as a treatment for jaundice in developed countries. Baby’s skin is sensitive, and sun exposure may easily cause irritation or burns in your baby. If the baby is having clinically significant jaundice requiring treatment, the treatment should be delivered utilizing equipment that can provide light therapy in a measured and safe way.
You should not be deciding whether your baby needs treatment for jaundice. If you have concerns regarding your baby having yellowish skin, you should contact your doctor without any delay.
You can learn about newborn jaundice (hyperbilirubinemia) from my article here.
This article is only for general information purposes. It should not be viewed as any medical advice. There is a chance that information here may be inaccurate. It would be best if you always discussed all health-related matters with your doctor before making any decisions that may affect your health or health of your family members.