Phototherapy for Neonatal Jaundice in Hyderabad, India - Cost & Procedure Benefits

Phototherapy is a treatment for newborns using blue lights to treat conditions like:

• Jaundice: Phototherapy is commonly used to treat jaundice in newborns, particularly those with high total serum bilirubin levels. It is initiated when bilirubin levels are at or above 15 mg/dL, 18 mg/dL for infants aged 49-72 hours, and 20 mg/dL for infants over 72 hours.

• ABO and rhesus incompatibility: Phototherapy is frequently utilized to treat jaundice, a condition resulting from blood group incompatibility between the mother and baby.

• Anaemia: Phototherapy is a treatment option for anemia caused by gradual bleeding from a newborn cephalohematoma.
  

Phototherapy, while widely used to treat neonatal hyperbilirubinemia, has several contraindications that must be considered:

• Porphyria: Neonates with porphyria, a rare genetic disorder, should not undergo phototherapy. This condition causes blisters and skin fragility when exposed to certain types of light, including the wavelengths used in phototherapy.

• Photosensitizing Drugs: If a neonate is receiving photosensitizing drugs, phototherapy should be used with caution. These medications can increase the skin's sensitivity to light, potentially leading to adverse effects.

• Obstructive Jaundice: Phototherapy is not recommended for neonates with obstructive jaundice, as it can lead to a condition known as bronze baby syndrome. This syndrome causes the skin and urine to turn a bronze or grayish-brown color.

• Conjugated Hyperbilirubinemia: Neonates with conjugated hyperbilirubinemia, a condition characterized by elevated levels of direct-reacting bilirubin, should not receive phototherapy. This type of jaundice can cause skin discoloration and may indicate an underlying liver or biliary tract disorder. In summary, while phototherapy is generally safe and effective for treating neonatal hyperbilirubinemia, it should be avoided in cases of porphyria, photosensitizing drug use, obstructive jaundice, and conjugated hyperbilirubinemia to prevent potential complications and adverse effects.
  

Prior to a neonatal jaundice phototherapy procedure, one might need consider outlined below: 

• Risk aspects: If the baby's bilirubin level is more than the phototherapy reference range for their weight and gestation, or if they have risk factors such as a mother who intends to breastfeed solely or a sibling who experienced jaundice, phototherapy may be required. 

• Preparation: Get ready by talking to the parents about the process and making sure the equipment is kept up to date and routinely inspected. 

• Safety: Make sure the baby's face and genitalia are covered and wrap their eyes with opaque eye coverings. 

• Positioning: Set up the phototherapy device near the baby's bedside, with the infant in a bassinet or warmer and wearing a diaper. 

• Light type: The light source is placed near to the baby's skin as close as possible, ideally not more than 10 cm away, for both LED and fluorescent lamps. To prevent overheating with halogen spotlights, adherence to the manufacturer's suggested distance is recommended.

• Temperature: Infant's temperature should be monitored before each feeding. Between 36.5 and 37.2 degrees Celsius is considered typical. 

• Feeding: Unless otherwise advised, breastfed infants should continue to be breastfed; however, if their bilirubin level is high, feed may need to be cut short to 20 minutes.
  

During the procedure

Phototherapy procedures require personal protective equipment, such as eye protection, to be worn before UV light is turned on, with each treatment's UV light path being unique.

• UVB light: UVB light therapy involves standing in a box-like structure, like an upright tanning bed, where a light source passes over the skin. Providers turn on lights for a set time, or one can sit or lie down and have a light wand applied.

• UVA light: Psoralen UVA treatment involves a similar procedure to UVB, with sometimes medications. Psoralen, a plant chemical, increases skin sensitivity to UVA light. The treatment begins with a bath containing psoralen or its oral application before treatment.

• Excimer laser light: Excimer laser light delivers focused ultraviolet light to smaller body areas, requiring patient to lie on a table before the laser light is moved over the targeted area.
  

After the procedure

Following a phototherapy procedure, the doctor will provide the patient with instructions on how to safeguard their skin, which may include:

• Sunscreen is a protective measure that can be applied to treated skin areas or wearing clothing to shield the skin from harmful UV rays.

• It is essential to wear eye protection when going outdoors.

• To prevent dry skin, usage of moisturizer is recommended every day and to avoid sun exposure and tanning beds to reduce the risk of burns.
  

The phototherapy procedure can be discussed in three segments, that include:

• Interaction between light and bilirubin
• Photodegradation of Unconjugated Bilirubin
• Effects on Bilirubin Excretion

Interaction between light and bilirubin

• Phototherapy is a treatment method for neonatal hyperbilirubinemia, based on the interaction between light and bilirubin.
• The process of photoisomerization, where bilirubin is converted into water-soluble isomers, reduces serum bilirubin levels. The effectiveness of phototherapy depends on light intensity, wavelength, and distance from the infant.
• The blue component of the spectrum, particularly around 460 nm, is particularly efficient for phototherapy.

Photodegradation of unconjugated bilirubin

• The photodegradation of unconjugated bilirubin involves the conversion of non-polar bilirubin into water-soluble isomers through photoisomerization.
• The rate of photodegradation is influenced by light source, wavelength, and intensity. In vitro studies show that unconjugated bilirubin is highly susceptible to photoirradiation, producing photoproducts like lumirubin, which may have neuro-inflammatory effects.
• Light irradiation also alters bilirubin's spectrometric characteristics and affects DNA properties.

Effects on bilirubin excretion

• Phototherapy is a widely used treatment for neonatal hyperbilirubinemia, converting non-polar unconjugated bilirubin into water-soluble isomers for excretion.
• This method reduces serum bilirubin levels and increases bilirubin excretion. However, it can cause potential adverse effects like burns, retinal damage, and skin irritation. Therefore, careful consideration and close monitoring are crucial for neonates' well-being.
  

The safety and effectiveness of the phototherapy procedure can be understood if we consider the below mentioned three parameters:

• Clinical effectiveness of phototherapy
• Adverse effects and concerns
• Risk-benefit analysis

Clinical effectiveness of phototherapy

• Phototherapy is a versatile and effective treatment modality for various skin conditions, including neonatal jaundice. It offers benefits in treating atopic dermatitis, psoriasis, and eczema in newborns, and has a favorable safety profile.
• It is also used in the elderly population for various skin disorders and improving quality of life. Blue-green light therapy is a specific form of phototherapy that has shown effectiveness in treating certain conditions.
• Despite its safety, potential limitations like costs and specialized staff need to be considered when considering phototherapy.

Adverse effects and concerns

• Phototherapy is a proven effective and safe treatment for neonatal jaundice, reducing the need for exchange transfusions. It includes HPT, integral phototherapy, and filtered sunlight. 
• Studies show its efficacy in treating both physiological and pathological jaundice, with integral phototherapy using less radiant energy. The evolution of phototherapy has led to more efficient and effective treatments for neonatal jaundice.

Risk-benefit analysis

• Phototherapy has revolutionized neonatal treatment for severe hyperbilirubinemia, reducing the need for exchange transfusions. It offers a safer alternative to traditional treatments, with intermittent phototherapy (IPT) showing comparable effectiveness to continuous phototherapy (CPT).
• However, potential risks include oxidative stress in low birthweight infants, leading to cautious dosing.
• Side effects like skin irritation, dehydration, and phototoxicity also need careful management. A nuanced risk-benefit analysis is crucial, considering the specific clinical needs of the infant and the potential risks and benefits associated with phototherapy, ensuring a well-informed decision-making process in neonatal care.
  

The innovative and technological advancements of phototherapy are well appreciated after:

• Development of improved light sources
• Integration of monitoring and control systems
• Advancements in home-based phototherapy

Development of improved light sources: Phototherapy, including LED, low-cost home-based systems, and wearable devices, is a crucial treatment for neonatal hyperbilirubinemia, promoting breastfeeding, continuous treatment, and a family-centered approach.

Integration of monitoring and control systems: Remote-monitoring high-performance thermotherapy devices and wearable devices for real-time jaundice detection have revolutionized treatment approaches, emphasizing parental compliance and confidence. These developments integrate monitoring and control systems, enhancing efficacy and parental involvement in neonatal jaundice treatment.

Advances in home-based phototherapy: Home-based phototherapy (HPT) is a cost-effective treatment for infants, improving maternal-infant bonding and reducing parent-infant separation. A randomized controlled trial found a 71% cost reduction per patient. HPT enhances access to care, fosters bonding, and improves patient satisfaction. Collaboration among insurance carriers, device manufacturers, and hospitals has led to successful HPT programs.

Phototherapy is a safe and effective treatment, making it the preferred first-line option for managing neonatal jaundice. Here are some key advantages of this therapeutic approach:

• Reduces Bilirubin Levels: Phototherapy facilitates the breakdown and elimination of bilirubin from a newborn's bloodstream through the liver. When the body replaces aging red blood cells, bilirubin can accumulate, leading to jaundice, characterized by yellowing of the skin and eyes. Phototherapy helps to lower these elevated bilirubin levels effectively.

• Prevents Brain Damage: One of the critical benefits of phototherapy is its ability to prevent irreversible brain damage associated with bilirubin accumulation in brain tissue. By reducing bilirubin levels, phototherapy safeguards against potential neurological complications, ensuring better long-term outcomes for affected infants. In summary, phototherapy not only effectively lowers bilirubin levels but also plays a crucial role in protecting the brain from damage, making it an essential treatment for neonatal jaundice.