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Care of the Infant Requiring Phototherapy for the Management of Hyperbilirubinemia (Jaundice) (Pediatric) (15.13P)

Care of the Infant Requiring Phototherapy for the Management of Hyperbilirubinemia (Jaundice) (Pediatric) (15.13P) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Procedures from Other Departments

15.13P

NURSING PATIENT CARE POLICY & PROCEDURE




Effective Date:
May 20, 2016
Administrative Manual
Nursing Manual (Red)
Other _______________
Policy #: 15.13P
Original
Revision
Page
1
of 5
Title: Care of the Infant Requiring
Phototherapy for the Management of
Hyperbilirubinemia (Jaundice) (Pediatric)

I. PURPOSE

To provide guidance for the care of the infant at-risk for or experiencing
hyperbilirubinemia.

II. POLICY

A. Universal screening should be used to identify elevated bilirubin levels in
newborns and initiate phototherapy when appropriate in order to prevent acute
bilirubin encephalopathy and kernicterus. Screening should be done through risk
factor assessment and obtaining a serum or transcutaneous bilirubin level. Visual
inspection alone is not adequate to assess for hyperbilirubinemia.
B. Major risk factors for the development of severe hyperbilirubinemia include birth
hospitalization pre-discharge total serum bilirubin (TSB) or transcutaneous
bilirubin (TcB) level in the high risk zone on the hour specific Bhutani nomogram
(see Appendix A), jaundice observed in the first 24 hours of life, blood group
incompatibility (ABO/Rh(D)), other known hemolytic diseases (i.e., G6PD
deficiency), suboptimal breastfeeding, gestational age less than 38 weeks, a
sibling requiring phototherapy, cephalohematoma or significant bruising, and East
Asian race.
C. Bilirubin levels should be reported in terms of the infant’s age both gestationally
and hours of life, not days, so that the infant can be assessed for risk of
developing severe hyperbilirubinemia and need for phototherapy.
D. Optimal breastfeeding should be promoted and supported. Assessment of
breastfeeding should be documented in the infant’s clinical record.
E. Nurses should be familiar with phototherapy equipment, associated
policies/procedures and the manufacturer’s directions regarding the care and use
of equipment.
F. Phototherapy must be ordered by a provider.

III. EQUIPMENT

A. Phototherapy lights (neoBLUE®) from Central Services (CS) and/or BiliSoft
LED® phototherapy blanket from CS with disposable cover.
B. Radiant warmer or incubator
C. Phototherapy Eye Shields

IV. EQUIPMENT TYPES AND USE

A. neoBLUE® overhead LED phototherapy light

Page 2 of 4

1.Irradiance: The neoBLUE® overhead light can deliver both lower doses of
irradiance or higher doses of irradiance by adjusting the switch on the
light. High intensity is most often preferred.
2.Exposed surface area: The neoBLUE® overhead light can be positioned to
expose light over the infant’s entire body. Use the red target light to center
output over the infant.
3.Distance between light and the infant: The neoBLUE® overhead light
should be no more than 12 inches from the patient, unless using on a
patient in an incubator, then light may be placed over the top of the
incubator.
B. BiliSoft LED®
1. The The BiliSoft LED® blanket can be used by itself or in conjunction with
an overhead device to increase the exposed body surface area to phototherapy.
2. A disposable BiliSoft cover should be put on the pad of the blanket and the
blanket placed directly under the infant, covering as much surface area of the
body as possible.
3. If the infant does not require overhead phototherapy (just the LED blanket),
the infant can be held.
4. When using the blanket in a crib, warmer, or incubator, lay the infant on the
panel so that the top of the panel is under the infant’s head and the cord
extends below the infant’s legs. Do not use a biliblanket on top of the infant.
5. If the infant is only requiring the blanket, the infant can be swaddled or placed
in a sleeper, assuring the covered blanket paddle is in direct contact with the
infant’s exposed skin.
6. Eye protection is required with the use of the BiliSoft LED® blanket.
7. Place the illuminator unit on a secure surface less than four feet from the
infant. Ensure nothing obstructs the fan to avoid overheating.
C. Irradiance testing
1. Irradiance testing for phototherapy equipment will be performed by clinical
engineering according to manufacturer’s recommendations. The bedside nurse
is not required to perform irradiance testing at the bedside during
phototherapy administration.

V. PROCEDURE

A. Verify orders.
B. Order all equipment needed from CS. Communicate the urgency of needed
supplies by calling extension 3-7071. If there is difficulty or a delay in obtaining
needed supplies, the CS supervisor may be reached via pager 6291.
C. Implement therapy.
1. All infants under phototherapy should have eye protection in place any
time the light is on. Protective eye shields should fully cover the infant’s
eyes and avoid occluding the infant’s nares. Inspect the eyes for drainage,
pressure areas and abrasion when the lights are turned off. Remove the eye
shields for feedings or parental visits.
2. Monitor vital signs as you would routinely for an infant. If using a radiant
warmer or incubator the skin servo-control mode should be used to
maintain a neutral thermal temperature.

Page 3 of 4

3. Undress infant except for diaper. Use smallest size diaper to cover gonadal
area. The greater the surface area of the skin exposed, the greater the rate
of total bilirubin decline.
4. Light exposure increases bilirubin excretion, so continuous phototherapy
is more effective than intermittent phototherapy.
5. Intensive phototherapy should be administered continuously when
bilirubin levels are very high until an acceptable decrease in the total
serum bilirubin level occurs or exchange transfusion is initiated. Discuss
with provider if interrupting overhead phototherapy is permissible for
parental visits, holding, and feeding.
6. Turn infants with cares Assess for any areas of redness or skin breakdown.
7. Decreased maternal-infant interaction is a common side effect associated
with phototherapy. This can be overcome by providing emotional support
during periods of separation, and scheduling feeding times during parental
visits.
8. Continued breastfeeding should be supported and encouraged throughout
the duration of phototherapy.
9. When bilirubin levels are drawn, phototherapy lights must be turned off to
avoid false lab values. When analyzing bilirubin results, be aware that
bilirubin levels (for physiologic jaundice) typically reach their highest
levels at 72-96 hours of age for term infants. Peak levels are delayed in
late preterm and very preterm infants.
10. During phototherapy, the infant's temperature, hydration status, time of
exposure, and Total Bilirubin are monitored. LED-based devices emit low
levels of heat, and thus fluid loss is less of a concern with these devices.
11. Return equipment to CS upon completion of use for appropriate cleaning.


VI. DOCUMENTATION

A. In the electronic health record, add documentation rows for “Infant Radiant
Warmer” (if one is being used), and “Phototherapy for Hyperbilirubinemia.”
Document accordingly.

VII. UWHC CROSS REFERENCES

A. Appendix A (see Related Resources)
B. Assessment and Management of Neonatal Jaundice in Term and Near-Term
Neonates – Neonatal – Inpatient/Ambulatory Clinical Practice Guideline
C. Health Facts For You 7434, Jaundice in Newborns (Hyperbilirubinemia)
D. Nursing Patient Care Policy 4.20P, Neonatal Thermoregulation (Pediatric)

VIII. REFERENCES

A. American Academy of Pediatrics (2004). Management of hyperbilirubinemia in
the newborn infant 35 or more weeks of gestation. Pediatrics, 114(1), 297-316.
B. Bhutani, V. K., & Committee on Fetus and Newborn (2011). Phototherapy to
prevent severe neonatal hyperbilirubinemia in the newborn infant 35 or more
weeks of gestation. Pediatrics, 128(4), e1046-e1052.

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C. Bhutani, V. K., Vilms, R. J., & Hamerman-Johnson, L. (2010). Universal
bilirubin screening for severe neonatal hyperbilirubinemia. Journal of
Perinatology, 30, S6-15.
D. GE Healthcare: BiliSoft LED Phototherapy System. (2013). Retrieved March 28,
2013 from http://www3.gehealthcare.com/en/Products/Categories/Maternal-
Infant_Care/Phototherapy/BiliSoft_Phototherapy_System
E. Lee Wan Fei, S., & Abdullah, K. L. (2015). Effect of turning vs. supine position
under phototherapy on neonates with hyperbilirubinemia: a systematic review.
Journal Of Clinical Nursing, 24(5/6), 672-682 11p. doi:10.1111/jocn.12712
F. Natus Newborn Care: neoBLUE LED Phototherapy. (2012). Retrieved March 28,
2013 from
http://www.natus.com/index.cfm?page=products_1&crid=36&contentid=88
G. Muchowski, K.E. 2014. Evaluation and treatment of neonatal hyperbilirubinemia.
Am Fam Physician. 89(11), 873-878.
H. Tartaglia KM, Campbell J, Shaniuk P, McClead RE. A Quality Project to Improve
Compliance With AAP Guidelines for Inpatient Management of Neonatal
Hyperbilirubinemia. Hospital Pediatrics. 2013;3(3):251-257.
I. The Academy of breastfeeding medicine protocol committee. 2010. ABM
Clinical Protocol #22: Guidelines for the management of jaundice in the
breastfeeding infant equal to or greater than 35 weeks’ gestation. Breastfeeding
medicine. 5(2), 87-93
J. Wolff M, Schinasi DA, Lavelle J, Boorstein N, Zorc JJ. Management of neonates
with hyperbilirubinemia: improving timeliness of care using a clinical pathway.
Pediatrics.Dec 2012;130(6):e1688-1694.

IX. REVIEWED BY

Clinical Nurse Specialist, Universal Care Unit
Clinical Nurse Specialist, Neonatal Intensive Care Unit (NICU)
Manager, Central Services
Nursing Patient Care Policy and Procedure Committee, May 2016

SIGNED BY

Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer