Phototherapy to Prevent Severe Neonatal Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation Vinod K.

Bhutani and the Committee on Fetus and Newborn Pediatrics 2011;128;e1046; originally published online September 26, 2011; DOI: 10.1542/peds.2011-1494

The online version of this article, along with updated information and services, is located on the World Wide Web at:
http://pediatrics.aappublications.org/content/128/4/e1046.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2011 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org by guest on September 24, 2012

TECHNICAL REPORT

Phototherapy to Prevent Severe Neonatal Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation abstract
OBJECTIVE: To standardize the use of phototherapy consistent with the American Academy of Pediatrics clinical practice guideline for the management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. METHODS: Relevant literature was reviewed. Phototherapy devices currently marketed in the United States that incorporate uorescent, halogen, ber-optic, or blue light-emitting diode light sources were assessed in the laboratory. RESULTS: The efcacy of phototherapy units varies widely because of differences in light source and conguration. The following characteristics of a device contribute to its effectiveness: (1) emission of light in the blue-to-green range that overlaps the in vivo plasma bilirubin absorption spectrum ( 460 490 nm); (2) irradiance of at least 30 Wcm 2nm 1 (conrmed with an appropriate irradiance meter calibrated over the appropriate wavelength range); (3) illumination of maximal body surface; and (4) demonstration of a decrease in total bilirubin concentrations during the rst 4 to 6 hours of exposure. RECOMMENDATIONS (SEE APPENDIX FOR GRADING DEFINITION): The intensity and spectral output of phototherapy devices is useful in predicting potential effectiveness in treating hyperbilirubinemia (group B recommendation). Clinical effectiveness should be evaluated before and monitored during use (group B recommendation). Blocking the light source or reducing exposed body surface should be avoided (group B recommendation). Standardization of irradiance meters, improvements in device design, and lower-upper limits of light intensity for phototherapy units merit further study. Comparing the in vivo performance of devices is not practical, in general, and alternative procedures need to be explored. Pediatrics 2011;128:e1046e1052
Vinod K. Bhutani, MD, and THE COMMITTEE ON FETUS AND NEWBORN
KEY WORDS phototherapy, newborn jaundice, hyperbilirubinemia, light treatment ABBREVIATION LEDlight-emitting diode This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have led conict of interest statements with the American Academy of Pediatrics. Any conicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

www.pediatrics.org/cgi/doi/10.1542/peds.2011-1494 doi:10.1542/peds.2011-1494 All technical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reafrmed, revised, or retired at or before that time. PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright 2011 by the American Academy of Pediatrics

e1046

FROM THE AMERICAN ACADEMY OF PEDIATRICS

Downloaded from pediatrics.aappublications.org by guest on September 24, 2012

I. COMMERCIAL LIGHT SOURCES

INTRODUCTION Clinical trials have validated the efcacy of phototherapy in reducing excessive unconjugated hyperbilirubinemia, and its implementation has drastically curtailed the use of exchange transfusions.1 The initiation and duration of phototherapy is dened by a specic range of total bilirubin values based on an infants postnatal age and the potential risk for bilirubin neurotoxicity.1 Clinical response to phototherapy depends on the efcacy of the phototherapy device as well as the balance between an infants rates of bilirubin production and elimination. The active agent in phototherapy is light delivered in measurable doses, which makes phototherapy conceptually similar to pharmacotherapy. This report standardizes the use of phototherapy consistent with the American Academy of Pediatrics clinical practice guideline for the management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation.

PEDIATRICS Volume 128, Number 4, October 2011 Distance to Patient (cm) Footprint Area (Length Width, cm2) % Treatable BSA Spectrum, Total (nm) Bandwidth* (nm) Peak (nm) Min 30 5 45 45 45 0 45 45 0 0 0 45 23 0 150 (10 15) 117 (9 13) 280 (8 35) 490 (25 diam) 1530 (30 51) 825 (25 33) 490 (25 diam) 490 (25 diam) 54 54 24 19 53 54 100 71 2928 (48 2928 (48 2928 (48 693 (21 61) 61) 61) 33) 100 100 100 71 1152 (48 1740 (30 24) 58) 100 100 420540 425540 380720 400550 400626 400560 350800 370850 390600 400560 400560 400560 400717 400670 20 27 69 35 69 80 190 200 70 45 45 45 63 40 462 463 578 445 437 450 580 590 533 513 513 513 445 453 12 40 6 11 13 14 1 1 9 8 6 1 12 1 Footprint Irradiance ( W/cm2/nm) Max 37 76 10 22 23 59 19 17 31 30 11 11 49 52 Mean 30 67 8 17 19 36 7 5 20 16 8 6 28 25 7 8 1 2 3 2 5 5 6 6 1 3 11 16 SD

A wide selection of commercial phototherapy devices is available in the United States. A complete discussion of devices is beyond the scope of this review; some are described in Tables 1 and 2. Phototherapy devices can be categorized according to their light source as follows: (1) uorescent-tube devices that emit different colors (cool white daylight, blue [B], special blue [BB], turquoise, and green) and are straight (F20 T12, 60 cm, 20 W), U-shaped, or spiral-shaped; (2) metal halide bulbs, used in spotlights and incubator lights; (3) light-emitting diodes (LEDs) or metal halide bulbs, used with ber-optic light guides in pads, blankets, or spotlights; and (4) high-intensity LEDs, used as over- and under-the-body devices.

TABLE 1 Phototherapy Devices Commonly Used in the United States and Their Performance Characteristics

Device

Manufacturer

Natus Medical, San Carlos, CA Stanford University, Stanford, CA

Olympic Medical, San Carlos, CA Olympic Medical, San Carlos, CA Olympic Medical, San Carlos, CA Medela, McHenry, IL

Downloaded from pediatrics.aappublications.org by guest on September 24, 2012

Light Emitting Diodes [LED] neoBLUE PortaBed Fluorescent BiliLite CW/BB BiliLite BB BiliLite TL52 BiliBed Halogen MinBiliLite Phototherapy Lite Halogen beroptic BiliBlanket Wallaby II Preterm Wallaby II Term SpotLight 1000 PEP Model 2000 Bili Soft

Olympic Medical, San Carlos, CA Philips Inc, Andover, MA

FROM THE AMERICAN ACADEMY OF PEDIATRICS

Ohmeda, Faireld, CT Philips, Inc, Andover, MA Philips, Inc, Andover, MA Philips, Inc, Andover, MA PEP, Fryeburg, ME GE Healthcare, Laurel, MD

e1047

Data in Table 1 are expanded and updated from that previously reported by Vreman et al.3 The denitions and standards for device assessment are explained below. EMISSION SPECTRAL QUALITIES: Measured data of the light delivered by each of the light sources are presented as the minimum, maximum and range. Light source emission spectra within the range of 300 700 nm were recorded after the device had reached stable light emission, using a miniature beroptic radiometer (IRRAD2000, Ocean Optics, Inc, Dunedin, FL). For precision based device assessment, the spectral bandwidth (*), which is dened as the width of the emission spectrum in nm at 50% of peak light intensity, is the preferred method to distinguish and compare instead of the total range emission spectrum (data usually provided by manufacturers). Emission peak values are also used to characterize the quality of light emitted by a given light source. IRRADIANCE: Measured data are presented as mean standard deviation (SD), representing the irradiance of blue light (including spectral bandwidth), for each devices light footprint at the manufacturer-recommended distance. To compare diverse devices, the spectral irradiance ( W/cm2/nm) measurements were made using calibrated BiliBlanket Meters I and II (Ohmeda, GE Healthcare, Faireld, CT), which were found to yield identical results with stable output phototherapy devices. This type of meter was selected from the several devices with different photonic characteristics that are commercially available, because it has a wide sensitivity range (400 520 nm with peak sensitivity at 450 nm), which overlaps the bilirubin absorption spectrum and which renders it suitable for the evaluation of narrow and broad wavelength band light sources. The devices have been found exceptionally stable during several years of use and agree closely after each annual calibration. FOOTPRINT: The minimum and maximum irradiance measured (at the intervals provided or dened) in the given irradiance footprint of the device (length width). The footprint of a device is that area which is occupied by a patient to receive phototherapy. The irradiance footprint has greater dimensions than the emission surface, which is measured at the point where the light exits a phototherapy device. The minimum and maximum values are shown to indicate the range of irradiances encountered with a device and can be used as an indication of the uniformity of the emitted light. Most devices conform to an international standard to deliver a minimum/maximum footprint light ratio of no lower than 0.4. BSA: BODY SURFACE AREA refers to percent (%) exposure of either the ventral or dorsal planar surface exposed to light and Irradiance measurements are accurate to 0.5. All of the reported devices are marketed in the United States except the PortaBed, which is a non-licensed Stanford-developed research device and the Dutch Crigler-Najjar Association (used by Crigler-Najjar patients).

TABLE 2 Maximum Spectral Irradiance of Phototherapy Devices (Using Commercial Light Meters at Manufacturer Recommended Distances) Compared
to Clear-Sky Sunlight
Light Meter [Range, Peak] Halogen/Fiberoptic BiliBlanket Wallaby (Neo) II @ Contact BiliBlanket Meter II [400520, 450 nm] Bili-Meter, Model 22 [425475, 460 nm] Joey Dosimeter, JD-100 [420550, 470 nm] PMA-2123 Bilirubin Detectora (400520, 460 nm) GoldiLux UVA Photometer, GRP-1b [315400, 365 nm] 34 29 53 24 0.04 III @ 10 cm 40 49 88 35 0.04 Footprint Irradiance, ( W/cm2/nma) Fluorescent PEP Bed Martin/Philips BB @ 25 cm 69 100 174 70 0.04 neoBLUE LED PortaBed Sunlight @ Zenith on 8/31/05 Level Ground 144 65** 304** 81 2489

@ Contact 28 16 51 24 0.04 34 32 60 37 0.04

@ 30 cm 34 25 84 38 0.04

@ 10 cm 76 86 195 73 0.04

Data in Table 2 were tested and compiled by Hendrik J. Vreman (June 2007 and reveried December 2010). ** Irradiance presented to this meter exceeded its range. Measurement was made through a stainless-steel screen that attenuated the measured irradiance to 57%, which was subsequently corrected by this factor. a Solar Light Company, Inc., Glenside, PA 19038. b Oriel Instruments, Stratford, CT 06615 and SmartMeter GRP-1 with UV-A probe. GRP-1 measures UV-A light as W/cm2. No articial light source delivered signicant ( 0.04 W/cm2) UV-A radiation at the distances measured.

II. STANDARDS FOR PHOTOTHERAPY DEVICES

Methods for reporting and measuring phototherapy doses are not standardized. Comparisons of commercially available phototherapy devices that use in vitro photodegradation techniques may not accurately predict clinical efcacy.2 A recent report explored an approach to standardizing and quantifying the magnitude of phototherapy delivered by various devices.3 Table 1 lists technical data for some of the devices marketed in the United States.3 Factors to consider in prescribing and implementing phototherapy are (1) emission range of the light source, (2) the light intensity (irradiance), (3) the exposed (treatable) body surface area illuminated, and (4) the decrease in total bilirubin concentration. A measure of the effectiveness of phototherapy to rapidly congure the bilirubin molecule to less toxic photoisomers (measured in seconds) is not yet clinically available. A. Light Wavelength The visible white light spectrum ranges from approximately 350 to 800 nm. Bilirubin absorbs visible light most strongly in the blue region of the spectrum ( 460 nm). Absorption of
e1048 FROM THE AMERICAN ACADEMY OF PEDIATRICS

light transforms unconjugated bilirubin molecules bound to human serum albumin in solution into bilirubin photoproducts (predominantly isomers of bilirubin).2,4,5 Because of the photophysical properties of skin, the most effective light in vivo is probably in the blue-to-green region ( 460 490 nm).2 The rst prototype phototherapy device to result in a clinically signicant rate of bilirubin decrease used a blue (B) uorescent-tube light source with 420- to 480-nm emission.6,7 More effective narrow-band special blue bulbs (F20T12/BB [General Electric, Westinghouse, Sylvania] or TL52/20W [Phillips]) were subsequently used.8,9 Most recently, commercial compact uorescent-tube light sources and devices that use LEDs of narrow spectral bandwidth have been used.914 Unless specied otherwise, plastic covers or optical lters need to be used to remove potentially harmful ultraviolet light. Clinical Context Devices with maximum emission within the 460- to 490-nm (blue-green) region of the visible spectrum are probably the most effective for treating hyperbilirubinemia.2,4 Lights with broader emission also will work, al-

though not as effectively. Special blue (BB) uorescent lights are effective but should not be confused with white lights painted blue or covered with blue plastic sheaths, which should not be used. Devices that contain highintensity gallium nitride LEDs with emission within the 460- to 490-nm regions are also effective and have a longer lifetime ( 20 000 hours), lower heat output, low infrared emission, and no ultraviolet emission. B. Measuring Light Irradiance Light intensity or energy output is dened by irradiance and refers to the number of photons (spectral energy) that are delivered per unit area (cm2) of exposed skin.1 The dose of phototherapy is a measure of the irradiance delivered for a specic duration and adjusted to the exposed body surface area. Determination of an in vivo doseresponse relationship is confounded by the optical properties of skin and the rates of bilirubin production and elimination.1 Irradiance is measured with a radiometer (Wcm 2) or spectroradiometer ( Wcm 2nm 1) over a given wavelength band. Table 2 compares the spectral irradiance of some of the devices in the US market, as measured with different brands of me-

Downloaded from pediatrics.aappublications.org by guest on September 24, 2012

FROM THE AMERICAN ACADEMY OF PEDIATRICS

ters. Often, radiometers measure wavelengths that do not penetrate skin well or that are far from optimal for phototherapy and, therefore, may be of little value for predicting the clinical efcacy of phototherapy units. A direct relationship between irradiance and the rate of in vivo total bilirubin concentration decrease was described in the report of a study of term healthy infants with nonhemolytic hyperbilirubinemia (peak values: 1518 mg/dL) using uorescent Philips daylight (TL20W/54, TL20W/52) and special blue (TLAK 40W/03) lamps.15,16 The American Academy of Pediatrics has recommended that the irradiance for intensive phototherapy be at least 30 Wcm 2nm 1 over the waveband interval 460 to 490 nm.1 Devices that emit lower irradiance may be supplemented with auxiliary devices. Much higher doses ( 65 Wcm 2nm 1) might have (as-yet-unidentied) adverse effects. Currently, no single method is in general use for measuring phototherapy dosages. In addition, the calibration methods, wavelength responses, and geometries of instruments are not standardized. Consequently, different radiometers may show different values for the same light source.2 Clinical Context For routine measurements, clinicians are limited by reliance on irradiance meters supplied or recommended by the manufacturer. Visual estimations of brightness and use of ordinary photometric or colorimetric light meters are inappropriate.1,2 Maximal irradiance can be achieved by bringing the light source close to the infant1; however, this should not be done with halogen or tungsten lights, because the heat generated can cause a burn. Furthermore, with some xtures, increasing the proximity may reduce the exposed body surface area. Irradiance distribution in the illuminated area
PEDIATRICS Volume 128, Number 4, October 2011

(footprint) is rarely uniform; measurements at the center of the footprint may greatly exceed those at the periphery and are variable among phototherapy devices.1 Thus, irradiance should be measured at several sites on the infants body surface. The ideal distance and orientation of the light source should be maintained according to the manufacturers recommendations. The irradiance of all lamps decreases with use; manufacturers may provide useful-lifetime estimates, which should not be exceeded. C. Optimal Body Surface Area An infants total body surface area can be inuenced by the disproportionate head size, especially in the more preterm infant. Complete (100%) exposure of the total body surface to light is impractical and limited by use of eye masks and diapers. Circumferential illumination (total body surface exposure from multiple directions) achieves exposure of approximately 80% of the total body surface. In clinical practice, exposure is usually planar: ventral with overhead light sources and dorsal with lighted mattresses. Approximately 35% of the total body surface (ventral or dorsal) is exposed with either method. Changing the infants posture every 2 to 3 hours may maximize the area exposed to light. Exposed body surface area treated rather than the number of devices (double, triple, etc) used is clinically more important. Maximal skin surface illumination allows for a more intensive exposure and may require combined use of more than 1 phototherapy device.1 Clinical Context Physical obstruction of light by equipment, such as radiant warmers, head covers, large diapers, eye masks that enclose large areas of the scalp, tape, electrode patches, and insulating plastic covers, decrease the exposed skin
17

surface area. Circumferential phototherapy maximizes the exposed area. Combining several devices, such as uorescent tubes with ber-optic pads or LED mattresses placed below the infant or bassinet, will increase the surface area exposed. If the infant is in an incubator, the light rays should be perpendicular to the surface of the incubator to minimize reectance and loss of efcacy.1,2 D. Rate of Response Measured by Decrease in Serum Bilirubin Concentration The clinical impact of phototherapy should be evident within 4 to 6 hours of initiation with an anticipated decrease of more than 2 mg/dL (34 mol/L) in serum bilirubin concentration.1 The clinical response depends on the rates of bilirubin production, enterohepatic circulation, and bilirubin elimination; the degree of tissue bilirubin deposition15,16,18; and the rates of the photochemical reactions of bilirubin. Aggressive implementation of phototherapy for excessive hyperbilirubinemia, sometimes referred to as the crash-cart approach,19,20 has been reported to reduce the need for exchange transfusion and possibly reduce the severity of bilirubin neurotoxicity. Clinical Context Serial measurements of bilirubin concentration are used to monitor the effectiveness of phototherapy, but the value of these measurements can be confounded by changes in bilirubin production or elimination and by a sudden increase in bilirubin concentration (rebound) if phototherapy is stopped. Periodicity of serial measurements is based on clinical judgment.

III. EVIDENCE FOR EFFECTIVE PHOTOTHERAPY

Light-emission characteristics of phototherapy devices help in predicting
e1049

Downloaded from pediatrics.aappublications.org by guest on September 24, 2012

TABLE 3 Practice Considerations for Optimal Administration of Phototherapy

Checklist Light source (nm) Light irradiance ( Wcm 2nm 1) Body surface area (cm2) Timeliness of implementation Continuity of therapy Efcacy of intervention Duration of therapy Recommendation Wavelength spectrum in 460- 490-nm blue-green light region Use optimal irradiance: 30 Wcm 2nm 1 within the 460- to 490-nm waveband Expose maximal skin area Urgent or crash-cart intervention for excessive hyperbilirubinemia Briey interrupt for feeding, parental bonding, nursing care Periodically measure rate of response in bilirubin load reduction Discontinue at desired bilirubin threshold; be aware of possible rebound increase Implementation Know the spectral output of the light source Ensure uniformity over the light footprint area Reduce blocking of light May conduct procedures while infant is on phototherapy After conrmation of adequate bilirubin concentration decrease Degree of total serum/plasma bilirubin concentration decrease Serial bilirubin measurements based on rate of decrease

b. Use of eye masks: Eye masks to prevent retinal damage are used routinely, although there is no evidence to support this recommendation. Retinal damage has been documented in the unpatched eyes of newborn monkeys exposed to phototherapy, but there are no similar data available from human newborns, because eye patches have always been used.2224 Purulent eye discharge and conjunctivitis in term infants have been reported with prolonged use of eye patches.25,26 c. Use of diapers: Concerns for the long-term effects of continuous phototherapy exposure of the reproductive system have been raised but not substantiated.2729 Diapers may be used for hygiene but are not essential. d. Other protective considerations: Devices used in environments with high humidity and oxygen must meet electrical and re hazard safety standards.21 Phototherapy is contraindicated in infants with congenital porphyria or those treated with photosensitizing drugs.1 Prolonged phototherapy has been associated with increased oxidant stress and lipid peroxidation30 and riboavin deciency.31 Recent clinical reports of other adverse outcomes (eg, malignant melanoma, DNA damage, and skin changes) have yet to be validated.1,2,32,33 Phototherapy does not exacerbate hemolysis.34

their effectiveness (group B recommendation) (see Appendix). The clinical effectiveness of the device should be known before and monitored during clinical application (group B recommendation). Local guidelines (instructions) for routine clinical use should be available. Important factors that need to be considered are listed in Table 3. Obstructing the light source and reducing the exposed body surface area must be avoided (group B recommendation). These recommendations are appropriate for clinical care in high-resource settings. In low-resource settings the use of improvised technologies and affordable phototherapy device choices need to meet minimum efcacy and safety standards.

IV. SAFETY AND PROTECTIVE MEASURES

A clinician skilled in newborn care should assess the neonates clinical status during phototherapy to ensure adequate hydration, nutrition, and temperature control. Clinical improvement or progression of jaundice should also be assessed, including signs suggestive of early bilirubin encephalopathy such as changes in sleeping pattern, deteriorating feeding pattern, or inability to be consoled while crying.1 Staff should be educated
e1050 FROM THE AMERICAN ACADEMY OF PEDIATRICS

regarding the importance of safely minimizing the distance of the phototherapy device from the infant. They should be aware that the intensity of light decreases at the outer perimeter of the light footprint and recognize the effects of physical factors that could impede or obstruct light exposure. Staff should be aware that phototherapy does not use ultraviolet light and that exposure to the lights is mostly harmless. Four decades of neonatal phototherapy use has revealed no serious adverse clinical effects in newborn infants 35 or more weeks of gestation. For more preterm infants, who are usually treated with prophylactic rather than therapeutic phototherapy, this may not be true. Informed staff should educate parents regarding the care of their newborn infant undergoing phototherapy. Devices must comply with general safety standards listed by the International Electrotechnical Commission.21 Other clinical considerations include: a. Interruption of phototherapy: After a documented decrease in bilirubin concentration, continuous exposure to the light source may be interrupted and the eye mask removed to allow for feeding and maternal-infant bonding.1

V. RESEARCH NEEDS
Among the gaps in knowledge that remain regarding the use of phototherapy to prevent severe neonatal hyperbilirubinemia, the following are among the most important: 1. The ability to measure the actual wavelength and irradiance delivered by a phototherapy device is urgently needed to assess the efciency of

Downloaded from pediatrics.aappublications.org by guest on September 24, 2012

FROM THE AMERICAN ACADEMY OF PEDIATRICS

phototherapy in reducing total serum bilirubin concentrations. 2. The safety and efcacy of home phototherapy remains a research priority. 3. Further delineation of the shortand long-term consequences of exposing infants with conjugated and unconjugated hyperbilirubinemia to phototherapy is needed. 4. Whether use of phototherapy reduces the risk of bilirubin neurotoxicity in a timely and effective manner needs further exploration.

face area, have an irradiance level of 30 Wcm 2nm 1 (conrmed with accuracy with an appropriate spectral radiometer) over the waveband of approximately 460 to 490 nm, and are implemented in a timely manner. Standard procedures should be documented for their safe deployment.
LEAD AUTHOR
Vinod K. Bhutani, MD

FORMER COMMITTEE MEMBER

David H. Adamkin, MD

LIAISONS
CAPT Wanda Denise Bareld, MD, MPH Centers for Disease Control and Prevention William H. Barth Jr, MD American College of Obstetricians and Gynecologists Ann L. Jefferies, MD Canadian Paediatric Society Rosalie O. Mainous, PhD, RNC, NNP National Association of Neonatal Nurses Tonse N. K. Raju, MD, DCH National Institutes of Health Kasper S. Wang AAP Section on Surgery

COMMITTEE ON FETUS AND NEWBORN, 2010 2011

Lu-Ann Papile, MD, Chairperson Jill E. Baley, MD Vinod K. Bhutani, MD Waldemar A. Carlo, MD James J. Cummings, MD Praveen Kumar, MD Richard A. Polin, MD Rosemarie C. Tan, MD, PhD Kristi L. Watterberg, MD

CONSULTANTS
M. Jeffrey Maisels, MBBCh, DSc Antony F. McDonagh, PhD David K. Stevenson, MD Hendrik J. Vreman, PhD

SUMMARY
Clinicians and hospitals should ensure that the phototherapy devices they use fully illuminate the patients body surREFERENCES
1. American Academy of Pediatrics, Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation [published correction appears in Pediatrics. 2004; 114(4):1138]. Pediatrics. 2004;114(1): 297316 2. McDonagh AF, Agati G, Fusi F, Pratesi R. Quantum yields for laser photocyclization of bilirubin in the presence of human serum albumin: dependence of quantum yield on excitation wavelength. Photochem Photobiol. 1989;50(3):305319 3. Vreman HJ, Wong RJ, Murdock JR, Stevenson DK. Standardized bench method for evaluating the efcacy of phototherapy devices. Acta Paediatr. 2008;97(3):308 316 4. Maisels MJ, McDonagh AF. Phototherapy for neonatal jaundice. N Engl J Med. 2008; 358(9):920 928 5. McDonagh AF, Lightner DA. Phototherapy and the photobiology of bilirubin. Semin Liver Dis. 1988;8(3):272283 6. Cremer RJ, Perryman PW, Richards DH. Inuence of light on the hyperbilirubinaemia of infants. Lancet. 1958;1(7030):1094 1097 7. Ennever JF, McDonagh AF, Speck WT. Phototherapy for neonatal jaundice: optimal wavelengths of light. J Pediatr. 1983;103(2): 295299 8. Ennever JF, Sobel M, McDonagh AF, Speck WT. Phototherapy for neonatal jaundice: in vitro comparison of light sources. Pediatr Res. 1984;18(7):667 670

STAFF
Jim Couto, MA

9. Nakamura S, Fasol G. InGaN singlequantum-well LEDs. In: The Blue Laser Diode. Berlin, Germany: Springer-Verlag; 1997:201221 10. Vreman HJ, Wong RJ, Stevenson DK, et al. Light-emitting diodes: a novel light source for phototherapy. Pediatr Res. 1998;44(5): 804 809 11. Maisels MJ, Kring EA, DeRidder J. Randomized controlled trial of light-emitting diode phototherapy. J Perinatol. 2007;27(9): 565567 12. Seidman DS, Moise J, Ergaz Z, et al. A new blue light-emitting phototherapy device: a prospective randomized controlled study. J Pediatr. 2000;136(6):771774 13. Martins BM, de Carvalho M, Moreira ME, Lopes JM. Efcacy of new microprocessed phototherapy system with ve high intensity light emitting diodes (Super LED) [in Portuguese]. J Pediatr (Rio J). 2007;83(3): 253258 14. Kumar P, Murki S, Malik GK, et al. Lightemitting diodes versus compact uorescent tubes for phototherapy in neonatal jaundice: a multi-center randomized controlled trial. Indian Pediatr. 2010;47(2): 131137 15. Tan KL. The nature of the dose-response relationship of phototherapy for neonatal hyperbilirubinemia. J Pediatr. 1977;90(3): 448 452 16. Tan KL. The pattern of bilirubin response to phototherapy for neonatal hyperbilirubinaemia. Pediatr Res. 1982;16(8):670 674

17. Mosteller RD. Simplied calculation of bodysurface area. N Engl J Med. 1987;317(17): 1098 18. Jhrig K, Jhrig D, Meisel P. Dependence of the efciency of phototherapy on plasma bilirubin concentration. Acta Paediatr Scand. 1982;71(2):293299 19. Johnson L, Bhutani VK, Karp K, Sivieri EM, Shapiro SM. Clinical report from the pilot USA Kernicterus Registry (1992 to 2004). J Perinatol. 2009;29(suppl 1):S25S45 20. Hansen TW, Nietsch L, Norman E, et al. Reversibility of acute intermediate phase bilirubin encephalopathy. Acta Paediatr. 2009; 98(10):1689 1694 21. International Electrotechnical Commission. International standard: medical electrical equipment part 2-50 particular requirements for the safety of infant phototherapy equipment 60601-2-50, ed2.0. (2009-03-24). Available at: http://webstore.iec.ch/ webstore/webstore.nsf/Artnum_PK/42737. Accessed December 21, 2010 22. Ente G, Klein SW. Hazards of phototherapy. N Engl J Med. 1970;283(10):544 545 23. Messner KH, Maisels MJ, Leure-DuPree AE. Phototoxicity to the newborn primate retina. Invest Ophthalmol Vis Sci. 1978;17(2): 178 182 24. Patz A, Souri EN. Phototherapy and other ocular risks to the newborn. Sight Sav Rev. 1972;42(1):29 33 25. Paludetto R, Mansi G, Rinaldi P, Saporito M, De Curtis M, Ciccimarra F. Effects of

PEDIATRICS Volume 128, Number 4, October 2011

Downloaded from pediatrics.aappublications.org by guest on September 24, 2012

e1051

different ways of covering the eyes on behavior of jaundiced infants treated with phototherapy. Biol Neonate. 1985;47(1): 1 8 26. Fok TF, Wong W, Cheung KL. Eye protection for newborns under phototherapy: comparison between a modied headbox and the conventional eyepatches. Ann Trop Paediatr. 1997;17(4):349 354 27. Ko H, Altunhan H, Dilsiz A, et al. Testicular changes in newborn rats exposed to phototherapy. Pediatr Dev Pathol. 1999;2(4): 333336

28. Wurtman RJ. The effects of light on the human body. Sci Am. 1975;233(1):69 77 29. Cetinkursun S, Demirbag S, Cincik M, Baykal B, Gunal A. Effects of phototherapy on newborn rat testicles. Arch Androl. 2006;52(1): 6170 30. Lightner DA, Linnane WP, Ahlfors CE. Bilirubin photooxidation products in the urine of jaundiced neonates receiving phototherapy. Pediatr Res. 1984;18(8):696 700 31. Sisson TR. Photodegradation of riboavin in neonates. Fed Proc. 1987;46(5): 18831885

32. Bauer J, Bttner P, Luther H, Wiecker TS, Mhrle M, Garbe C. Blue light phototherapy of neonatal jaundice does not increase the risk for melanocytic nevus development. Arch Dermatol. 2004;140(4):493 494 33. Tatli MM, Minnet C, Kocyigit A, Karadag A. Phototherapy increases DNA damage in lymphocytes of hyperbilirubinemic neonates. Mutat Res. 2008;654(1):9395 34. Maisels MJ, Kring EA. Does intensive phototherapy produce hemolysis in newborns of 35 or more weeks gestation? J Perinatol. 2006;26(8):498 500

APPENDIX Denition of Grades for Recommendation and Suggestion for Practice

Grade A B C Denition This intervention is recommended. There is a high certainty that the net benet is substantial This intervention is recommended. There is a moderate certainty that the net benet is moderate to substantial This intervention is recommended. There may be considerations that support the use of this intervention in an individual patient. There is a moderate to high certainty that the net benet is small This intervention is not recommended. There is a moderate to high certainty that the intervention has no net benet and that the harms outweigh the benets The current evidence is insufcient to assess the balance of benets against and harms of this intervention. There is a moderate to high certainty that the intervention has no net benet and that the harms outweigh the benets. Evidence is lacking, of poor quality, or conicting, and the balance of benets and harms cannot be determined Suggestion for Practice Offer and administer this intervention Offer and administer this intervention Offer and administer this intervention only if other considerations support this intervention in an individual patient Discourage use of this intervention If this intervention is conducted, the patient should understand the uncertainty about the balance of benets and harms

D I

US Preventive Services Task Force Grade denitions, May, 2008 (available at www.uspreventiveservicestaskforce.org/3rduspstf/ratings.htm).

e1052

FROM THE AMERICAN ACADEMY OF PEDIATRICS

Downloaded from pediatrics.aappublications.org by guest on September 24, 2012

Phototherapy to Prevent Severe Neonatal Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation Vinod K. Bhutani and the Committee on Fetus and Newborn Pediatrics 2011;128;e1046; originally published online September 26, 2011; DOI: 10.1542/peds.2011-1494
Updated Information & Services including high resolution figures, can be found at: http://pediatrics.aappublications.org/content/128/4/e1046.full. html This article cites 32 articles, 2 of which can be accessed free at: http://pediatrics.aappublications.org/content/128/4/e1046.full. html#ref-list-1 This article has been cited by 1 HighWire-hosted articles: http://pediatrics.aappublications.org/content/128/4/e1046.full. html#related-urls This article, along with others on similar topics, appears in the following collection(s): Premature & Newborn http://pediatrics.aappublications.org/cgi/collection/premature _and_newborn Committee on Fetus & Newborn http://pediatrics.aappublications.org/cgi/collection/committee _on_fetus__newborn Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://pediatrics.aappublications.org/site/misc/Permissions.xht ml Information about ordering reprints can be found online: http://pediatrics.aappublications.org/site/misc/reprints.xhtml

References

Citations

Subspecialty Collections

Permissions & Licensing

Reprints

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2011 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org by guest on September 24, 2012