Introduction

This guideline applies to neonates within the first two weeks of life.

Phototherapy is the use of visible light to treat severe jaundice in the neonatal period. Approximately
60% of term babies and 85% preterm babies will develop clinically apparent jaundice, which classically
becomes visible on day 3, peaks days 5-7 and 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 method for decreasing or
preventing the rise of serum unconjugated bilirubin levels and reduces the need for exchange transfusion
in neonates.

Aim
This guideline provides health care providers with information to understand the causes of neonatal
jaundice, the rationale for the use of phototherapy and outlines the care of neonates receiving
phototherapy in order to enhance effective phototherapy delivery and minimise complications of
phototherapy.

Definition of Terms

 Jaundice: the yellow appearance of the skin that occurs with the deposition of bilirubin in the
dermal and subcutaneous tissues and the sclera.
 Bilirubin: the orange-yellow pigment of bile, formed principally by the breakdown of
haemoglobin in red blood cells at the end of their normal life-span. Neonate’s bilirubin
production rate is double that of adults and their clearance of bilirubin is reduced, hence the
importance of monitoring levels and detecting jaundice in this early post-natal period. 
 Bilirubinaemia: the presence of bilirubin in the blood.
 Hyperbilirubinaemia: the excess of bilirubin in the blood. Types of Neonatal
Hyperbilirubinaemia:

o Unconjugated: most common form of neonatal hyperbilirubinaemia. The bilirubin has

not been metabolised and hence cannot be excreted via the normal pathways in the urine
and bowel. Unconjugated bilirubin binds with lipids and albumin, and results in the
yellow appearance of the skin and sclera. Unconjugated bilirubin can cross the blood-
brain barrier and cause neurotoxic effects.
o Conjugated: less common in neonates. The bilirubin has been metabolised and is water
soluble, but accumulates in the blood usually due to hepatic dysfunction. Conjugated
bilirubin does not cross the blood-brain barrier. 
 Serum Bilirubin (SBR): reports the unconjugated and conjugated bilirubin levels. This
is the usual specimen requested by Medical staff on the pathology slip at RCH. Hyperlink
to RCH Specimen Collection handbook.
 Total serum bilirubin levels (TSB): measure used when charting serum bilirubin results
onto Phototherapy and/or Exchange transfusion charts. TSB is the sum of unconjugated +
 conjugated serum bilirubin. A TSB can be requested on the pathology slip at RCH, but
only the total combined conjugated and unconjugated bilirubin level is reported.
 Breast milk jaundice: develops within 2-4 days of birth, is most likely related to limited
fluid intake as breast milk supply is established, may peak at 7-15 days of age and may
persist for weeks.
 Phototherapy: a treatment for jaundice where the exposure of skin to a light source
converts unconjugated bilirubin molecules into water soluble isomers that can be
excreted by the usual pathways. Blue-green light is most effective for phototherapy as it
both penetrates the skin and is absorbed by bilirubin to have the photochemical effect. 
 Bilirubin encephalopathy: the acute manifestations of bilirubin toxicity seen in the first
few weeks after birth. Signs include lethargy, hypotonia and poor suck progressing to
hypertonia, opisthotonos, high-pitched cry and eventually to seizures and coma.
 Kernicterus: the pathogenic diagnosis characterised by bilirubin staining of the brain
stem and cerebellum. Also the term used to refer to chronic bilirubin encephalopathy.
Clinical findings include cerebral palsy, developmental and intellectual delay, hearing
deficit, dental dysplasia and oculomotor disturbances.
 Single Light: One neoBLUE LED phototherapy unit (mini or standard)
 Double Lights: Two neoBLUE LED phototherapy unit’s (mini or standard) or One
neoBLUE LED phototherapy unit (mini or standard) + One biliblanket
 Triple Lights: Three neoBLUE LED phototherapy unit’s (mini or standard) or Two
neoBLUE LED phototherapy unit (mini or standard) + One biliblanket 

**All phototherapy units are to be set on high intensity at all times, regardless of the amount of units in
use. This ensures delivery of adequate amounts of blue light via light emitting diodes (LEDs). Therefore,
a single unit is classified as a single light and single, double or triple lights refers to the amount of units
not the intensity setting. 
 
**As per Natus neoBLUE LED phototherapy in-service guide (available on the intranet), mini neoBlue
LED phototherapy units deliver the same intensity as the standard unit set on high intensity; the only
difference is in the surface area coverage.

Assessment
Please note that when charting the TSB level onto the Phototherapy or Exchange Transfusion charts, in
the presence of risk factors (sepsis, haemolysis, acidosis, asphyxia, hypoalbuminaemia) TSB values
should be plotted on the range 1 lower than the neonate’s gestational age/weight. This is because the risk
of developing kernicterus increases in the presence of the above risk factors.
The Phototherapy and Exchange Transfusion charts onto which total SBR is plotted are for the first 7.5
and 5 days of life respectively. After the first 5-7 days continue utilising these charts, as levels plateau
and can continue to be documented.

 Assess general skin colour whenever measuring and recording vital signs. Ensure the
Phototherapy tick box in the EMR Flowsheets is activated and document time of commencement
and cessation.Obtain blood sample to measure total serum bilirubin levels (either venous, arterial
or capillary)
 Document hourly the type and number of light banks and the presence of eye protection.
  Obtain blood sample to measure total serum bilirubin levels (either venous, arterial or
capillary) Hyperlink to RCH Specimen Collection handbook) Ensure the lights are turned off
during sampling so accuracy of current blood levels can be attained.  Initially SBR levels may
need to be assessed every 4-6 hours until reduction.  Follow medical advice and ordering of SBR
levels according to acuity of levels and plot on appropriate line of the chart. Observe for signs of
lethargy and poor feeding (insert link to assessing for Jaundice)
 Observe for signs of lethargy and poor feeding (insert link to assessing for Jaundice)

During phototherapy neonates require ongoing monitoring of:

 adequacy of hydration (urine output) and nutrition(weight gain) 

 temperature
 clinical improvement in jaundice
 TSB or SBR levels
 potential signs of bilirubin encephalopathy

Investigations

 Initial TSB/SBR measurement should be requested based on clinical observation and the
following factors:

o any neonate <24 hours age with clinically apparent jaundice

o any neonate where there is clinical doubt about the degree of jaundice
o any unwell neonate with jaundice
o any neonate with risk factors for jaundice (ABO/ Rh incompatibility, sepsis, acidosis,
asphyxia, hypoalbuminaemia)
 Ongoing TSB/SBR measures should be repeated at intervals depending on the initial
level and rate of rise. For example: 6 hourly measures may be required if the level is very
high and the neonate is being treated with multiple phototherapy lights.
 A TSB/SBR may be requested within 24 hours of ceasing phototherapy to assess for
rebound hyperbilirubinaemia. Neonates at increased risk of clinically significant rebound
hyperbilirubinaemia include those born less than 37 weeks gestation, those not feeding
optimally or those with haemolytic disease.
 Further Bloods and investigations include
o Maternal and infant blood type
o Direct Coombs test
o Haemoglobin
o Full blood count for red cell morphology; reticulcyte, haematocrit and platelet counts and
white blood cell differential
o Urinalysis for reducing substances
o Sepsis screen if sepsis suspected
o G6PD and galactosaemia screens if suspected
o Serum thyroxine and thyroid-stimulating hormone levels
Risk Factors

 Mothers with a positive antibody screen

 A family history of G6PD deficiency
 A previously affected sibling
 Cephalhaematoma, bruising and trauma from instrumental birth
 Delayed passage of meconium
 Prematurity
 Dehydration
 Inadequate breastfeeding
 ABO incompatibility
 Rh incompatibility

Nutrition
Breastfed babies who require phototherapy should continue to breastfeed unless clinically contra-
indicated due to other pathology; the neonate’s sucking, attachment and mother’s milk supply should be
monitored.  In the case of infants nearing exchange transfusion level, the infant should not come out of
phototherapy to feed as this is a medical emergency.  All feeds should be given via a bottle or NGT if
feeding is deemed safe
Neonates who are receiving enteral feeds of EBM or infant formula should continue to do so. The total
fluid intake (TFI) for a 24 hour period may need to be increased by at least 10% to account for
insensible fluid loss when a neonate is receiving phototherapy however this should be guided by
hydration status and electrolyte monitoring.
Parenteral nutrition and IV fluids should continue as ordered and may also need to be increased by 10%
to account for insensible fluid loss.

Phototherapy

 Commence phototherapy once TSB/SBR is greater than the appropriate reference range for
neonate’s gestation/weight and presence of risk factors.
 Neonates should be nursed naked apart from a nappy under phototherapy and will need to be
nursed in an Isolette to maintain an appropriate neutral thermal environment. (Link to:” Ward
Management of a Neonate” and “Isolette use in Paediatric Wards”)  In severe cases, the nappy
may need to be removed and a urine bag applied to maximise skin exposure.
 Positon phototherapy units no more than 30.5cm from the patient. neoBLUE® LED
phototherapy unit can be positioned as close as 15cm to patient. Refer to specific phototherapy
units manufacturing guidelines for more details
  Expose as much of the skin surface as possible to the phototherapy light. To maximise skin
exposure, dress the baby in a nappy and their protective eye covers only.
 Cover the eyes with appropriate opaque eye covers e.g. Natus Biliband® Eye Protector
(available from Butterfly ward).
 Ensure eye covers are removed 4-6 hourly for eye care during infant cares or feeding. Observe
for discharge/infection/damage and document any changes.
 Daily fluid requirements should be reviewed and individualised for gestational and postnatal
age. 
 Maintain a strict fluid balance chart. 
 Breast feeds may need to be limited to 20 minutes if bilirubin level is high to minimise amount
of time out of the lights
 Monitor vital signs and temperature at least 4 hourly, more often if needed
 Cover lipid lines with light resistant, reflective tape to avoid peroxidation
 Ensure that phototherapy unit is turned off during collection of blood for TSB/SBR levels, as
both conjugated and unconjugated bilirubin are photo-oxidized when exposed to white or
ultraviolet light.
 Observe for signs of potential side effects.

Potential Complications

 Overheating – monitor neonate’s temperature 

 Water loss from increased peripheral blood flow and diarrhoea (if present)
 Diarrhoea from intestinal hypermotility
 Ileus (preterm infants)
 Rash
 Retinal damage
 ‘bronzing’ of neonates with conjugated hyperbilirubinaemia 
 Temporary lactose intolerance

Discharge planning and community-based management

Documentation in the neonates discharge letter and Child Health Booklet should include details about
TSB/SBR levels and duration of phototherapy treatment. 

Family Centered Care

Explain to parents the need for and actions of phototherapy, particularly in relation to the need for skin
surface to be exposed to the phototherapy light, and hence the need to care for neonates receiving
phototherapy to be nursed in a neutral thermal environment. Potential complications of phototherapy and
the need for protective eye coverings during phototherapy treatment should be explained. The need for
measuring the TSB and need for blood sampling should also be explained.

Neonates receiving phototherapy (where there are no other contraindications) can have brief periods
where the phototherapy is ceased so that they can be cuddled/breastfed and have their eye covers
removed for parent-baby interaction to occur.

Special Considerations
Normal hand hygiene measures should be attended to during care of a neonate receiving phototherapy.
 SUMMARY
Phototherapy is the use of visible light to treat severe jaundice in the neonatal period. This guideline
provides health care providers with information to understand the causes of neonatal jaundice, the
rationale for the use of phototherapy and outlines the care of neonates receiving phototherapy in order to
enhance effective phototherapy delivery and minimise complications of phototherapy. Note that when
charting the TSB level onto the Phototherapy or Exchange Transfusion charts, in the presence of risk
factors (sepsis, haemolysis, acidosis, asphyxia, hypoalbuminaemia) TSB values should be plotted on the
range 1 lower than the neonate’s gestational age/weight. This is because the risk of developing
kernicterus increases in the presence of the above risk factors. he Phototherapy and Exchange
Transfusion charts onto which total SBR is plotted are for the first 7.5 and 5 days of life respectively.
After the first 5-7 days continue utilising these charts, as levels plateau and can continue to be
documented. During phototherapy neonates require ongoing monitoring of adequacy of hydration (urine
output) and nutrition(weight gain), temperature, clinical improvement in jaundice, TSB or SBR levels
and potential signs.of bilirubin encephalopathy.
For Phototherapy, commence phototherapy once TSB/SBR is greater than the appropriate reference
range for neonate’s gestation/weight and presence of risk factors, neonates should be nursed naked apart
from a nappy under phototherapy and will need to be nursed in an Isolette to maintain an appropriate
neutral thermal environment. (Link to:” Ward Management of a Neonate” and “Isolette use in Paediatric
Wards”)  In severe cases, the nappy may need to be removed and a urine bag applied to maximise skin
exposure, positon phototherapy units no more than 30.5cm from the patient. neoBLUE® LED
phototherapy unit can be positioned as close as 15cm to patient. Refer to specific phototherapy units
manufacturing guidelines for more details, Expose as much of the skin surface as possible to the
phototherapy light. To maximise skin exposure, dress the baby in a nappy and their protective eye
covers only, cover the eyes with appropriate opaque eye covers e.g. Natus Biliband® Eye Protector
(available from Butterfly ward), ensure eye covers are removed 4-6 hourly for eye care during infant
cares or feeding. observe for discharge/infection/damage and document any changes, Daily fluid
requirements should be reviewed and individualised for gestational and postnatal age, Maintain a strict
fluid balance chart, Breast feeds may need to be limited to 20 minutes if bilirubin level is high to
minimise amount of time out of the lights, Monitor vital signs and temperature at least 4 hourly, more
often if needed, cover lipid lines with light resistant, reflective tape to avoid peroxidation, ensure that
phototherapy unit is turned off during collection of blood for TSB/SBR levels, as both conjugated and
unconjugated bilirubin are photo-oxidized when exposed to white or ultraviolet light, and observe for
signs of potential side effects.
Breastfed babies who require phototherapy should continue to breastfeed unless clinically contra-
indicated due to other pathology; the neonate’s sucking, attachment and mother’s milk supply should be
monitored.  In the case of infants nearing exchange transfusion level, the infant should not come out of
phototherapy to feed as this is a medical emergency.  All feeds should be given via a bottle or NGT if
feeding is deemed safe.
For Family Centered Care, explain to parents the need for and actions of phototherapy, particularly in
relation to the need for skin surface to be exposed to the phototherapy light, and hence the need to care
for neonates receiving phototherapy to be nursed in a neutral thermal environment. Potential
complications of phototherapy and the need for protective eye coverings during phototherapy treatment
should be explained. The need for measuring the TSB and need for blood sampling should also be
explained.
REACTION
Phototherapy is used for the treatment of jaundice where the exposure of skin to a light source converts
unconjugated bilirubin molecules into water soluble isomers that can be excreted by the usual pathways.
Blue-green light is most effective for phototherapy as it both penetrates the skin and is absorbed by
bilirubin to have the photochemical effect. Phototherapy is the use of visible light to treat severe
jaundice in the neonatal period. Approximately 60% of term babies and 85% preterm babies will
develop clinically apparent jaundice, which classically becomes visible on day 3, peaks days 5-7 and
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 method for decreasing or preventing the rise of serum
unconjugated bilirubin levels and reduces the need for exchange transfusion in neonates.
As a student nurse, knowing about phototherapy and the use of it is really helpful, because it is said that
phototherapy is safe and is use to treat severe jaundice, and as we go on our duty, it is possible that we
can encounter a situation that is related to this. I am thankful by this article because it added something
in my knowledge which is very useful as go on our exposure in the medical areas.
BIBLIOGRAPHY

 Bhutani, V.K. and the Committee on Fetus and Newborn (2011) Phototherapy to prevent severe
neonatal hyperbilirubinaemia in the newborn infant 35 or more weeks gestation, Pediatrics
128(4)
 http://www.health.vic.gov.au/neonatalhandbook/comditions/jaundice-in-neonates.htm retrieved
12/06/14
 Maisels, M.J. & McDonagh, A.F. (2008) Phototherapy for neonatal jaundice, New England
Journal of Medicine 358(9): 920-928
 Neonatal Hyperbilirubinaemia, retrieved from 
 http://www.merckmanuals.com/professional/pediatrics/metabolic_electrolyte_and_toxic_disorde
rs_in_neonates/neonatal_hyperbilirubinemia.html 16/01/2014
 NICE clinical guideline 98 (2010) Neonatal Jaundice, guidance.nice.uk/cg98 
 Queensland Maternity and Neonatal Clinical Guideline Neonatal Jaundice: prevention,
assessment and management, Queensland Government (2009)