Sunday, January 14, 2007

Phototherapy

I'm guessing that a lot of you know what phototherapy is. It's when we shine lights on babies to help make their jaundice, the yellow tint to the skin that so many babies get, go away. We've been using phototherapy for about 50 years, since the late 1950's when some infant caregivers noticed that babies in the sunlight had less jaundice than others. We use phototherapy very commonly, especially in premature babies, because bilirubin, the chemical that causes jaundice, can also cause brain damage. It's thought to be one of the safest therapies we use, with very few side effects. It can contribute to a baby getting a little dried out, just like laying on a sunny beach all day, but that can usually be easily managed by giving the baby some more fluid.

The last decade or so has seen the development of improved phototherapy, some powerful light systems that can make the jaundice go away even faster. Such systems have been accepted pretty readily into neonatal practice. When the alternative to phototherapy is the possible need for an exchange transfusion - where we replace the baby's blood over about an hour's time with a couple of units from the blood bank - we're happy to have effective phototherapy to use.

I read with interest, then, a Medscape news blurb about a recent study that claims that neonatal phototherapy increases the risk of a child developing nevi, those little brownish things on our skin that are commonly called moles. In a study in the December Archives of Dermatology, French investigators reported that 8 to 9 year old kids who had received phototherapy as newborns had more nevi sized 2 to 5 millimeters than kids who did not receive phototherapy. The significance of this is that nevi can turn into melanoma, a deadly skin cancer. The more nevi one has, perhaps the greater risk of melanoma.

This study, however, did not show that phototherapy increased the risk of melanoma, just the risk of more nevi. A couple of other studies in the past have not demonstrated an increased risk of melanoma with phototherapy, either. Also, this study was pretty small, including only 18 phototherapy exposed kids, and it did not show a dose response relationship. That is, kids who got more phototherapy did not get more nevi than kids who got lesser amounts of phototherapy, which I would expect if the phototherapy were really causing the nevi.

Will phototherapy be one of those neonatal therapies that historically neonatologists thought were safe, like oxygen, chloramphenacol, benzoyl alcohol, phenobarbital for prevention of brain bleeding, and steroids for BPD treatment, that subsequently turned out to be harmful? I don't really think so. We've used it for so long that by now we probably would have discovered any harmful effects that occur frequently. Also, phototherapy is better than the alternatives: exchange transfusions or no treatment, which can lead to brain damage, so I'm still going to light up the babies. The study won't change my practice. It will just make me worry more when I give phototherapy. Great....

P.S. While surfing the web yesterday, I discovered that I have been nominated for a 2006 Medical Weblog Award in the Best Health Policies/Ethics Weblog category. I'm flattered as all get out to be nominated and would like to thank ex utero for nominating me. (Apparently it only takes one person to nominate you. Maybe it's not as great an honor as I thought!) The voting ends today, January 14, so there's no sense in putting one of those Weblog Award Nominee pictures in my sidebar (as if I could figure out how to do it.) Forgive me for tooting my own horn here, but I just couldn't not tell you. Onward and upward!

35 Comments:

Blogger Dream Mom said...

I voted for you (and the other categories) on the first day. You did a great job raising ethical issues, especially in the first six months of your blog, which is precisely why he nominated you. Congratulations.

8:49 PM  
Anonymous Anonymous said...

yea for neo! you rock sir!

10:16 PM  
Anonymous Anonymous said...

oh and i forgot ,i would daerly love to form the gulf shores nursing society for jaundiced babies and would love for you to be our medical director,please.have a wonderful evening sir.

10:19 PM  
Anonymous Liza said...

Light 'em up, by all means, please. All three of mine had high bilirubin levels. The one whose level was the highest (it was 23 two days after birth at thirty-five weeks, two days) now has dyspraxia with hypotonia of the upper body and evidence of multiple sensory integration issues as a kindergartener, and we think about that number a lot and how our general ped refused to test the baby in-house and sent us home to have the level discovered at the two-day-old visit. Test 'em all, and light 'em up, even the ones that are big for gestational age and breathing and eating fine. It wasn't until our second thirty-five weeker was tested (under protest from the pediatricians, and at my insistence) in-house, and kept in another three days for phototherapy (by the third one we had figured out that it was ABO-incompatability and went home with a term baby and a bili-blanket; while I received rhogam as an rh neg mom of positive kids we didn't think of our specific blood types until my obstetrician said something). Probably the number had nothing to do with the kid's issues, because the second one has them even worse and their number was barely more than half the first one's. Who knows. Light 'em up all the same, so nobody else has to retroactively consider these things.

11:11 PM  
Blogger Awesome Mom said...

Lol I thought you already knew! I even voted for you.

11:30 PM  
Blogger my4kids said...

Light em up! I say. My 33 weeker had quite a bit of it and has no nevi still I might add at 10. So nothing to worry about it for him.

3:12 AM  
Anonymous Chris and Vic (CAK) said...

Neonatal Doc, you definitely have a talent for writing and for honesty, as has been noted---even when an award was not under discussion. Jaundice is an example of how you can clearly define a medical condition/practice for readers who may not have a medical background. If you educate your parents with such clear explanations, they, no doubt can understand their children's conditions and make informed choices---and not be so tortured by anger and guilt in the long term. Rock on!!!

7:40 AM  
Blogger Anne K. said...

Congrats on the nomination...I'm going to vote for you right away! You and your commenting readers continue to inspire my sewing and knitting for NICU babies (and I stay away from yellow fabrics and yarns, so as not to accentuate the very jaundice you discuss today!!) Congrats and thanks again for all you share.

9:27 AM  
Blogger OHN said...

Son #3 Came home from the hospital with a lighted pad wrapped around him...in the dark he looked like a little glow worm--very cute.

11:10 AM  
Anonymous Liza said...

Oh, and all three of mine have nevi out the ying-yang and I still say light 'em up. Skin cancer is in our family history so we monitor all of the various moles, red patches, and cafe au lait marks diligently anyway and could care less if there is an increase in risk in an area that is highly treatable and does not directly affect ones mood, mind, and senses. And the glow-worm thing? Absolutely. The earliest documented incident of inter-sibling abuse in our house came when a two-and-a-half-year-old turned the knob on a newborn's take-home biliblanket down to "low" and the home-care company was like "wow, we've never seen a kid's level come down so slowly, has the baby really been on that light a week now?" and were getting ready to do some invasive liver-type tests when I discovered the older little monster fondling the knob. I still feel ill when I think of how many heel-sticks that baby had :-( But all three of them are (despite various issues including the term one with the LOW level eating SHS products through a PEG) now healthy enough to abuse each other in more outright, brute-force and fine- and gross-motor ways, and I still call it a win :-D

Now I'm off to go vote.

1:25 PM  
Blogger Candy said...

I've had my experience with jaundice, too. My oldest daughter born full-term via c/s after 2.5 hrs pushing had a decent little case of it. Levels were upper teens, 17 or 19, can't remember now. My 25 wkr was jaundiced, too, but nothing like my oldest. I've never heard the possible relationship of the lights to levi's, but it seems to me that fighting the jaundice is more important than what "might" happen in the future.....at least for now.

btw, got through reading your blog up into March '06 and enjoyed it.

1:30 PM  
Anonymous Scientist said...

What would be really good is if we worked out how the wavelengths present in the light ('blue' is as far as we've got, so far) match the sensitivity of the reactions that clear the bilirubin. That way, we could develop light sources which aren't pumping out photons which aren't doing anything except heat up the baby. But, hey, 'blue' works for now!

3:36 PM  
Blogger Maggie Rosethorn said...

Both my kids had jaundice, both ABO induced (and how come no one tell you about this in nursing school? They only preach the Rh factor stuff). 8 hours of lights for the first when I refused to leave her in the hospital and promised to keep her in the sunshine at home, feed often and come back for testing in 24 hours. No lights for the second, just the same sunshine and fluids. But their levels weren't too bad....about 19, 20 or so, IIRC. 37 weeks and 36 weeks so we had a little time to watch and wait since term kids aren't as susceptible to the brain problems.

4:23 PM  
Blogger NeoNurseChic said...

I was lit and I have a ton of freckles and nevi. do I care? No... Maybe when I was a kid and it wasn't cool to have freckles. Now I kinda like them. As many as I have, I know when I get new ones. The summer sun turns me into a giant freckle...which I suppose is better than being turned into a giant mole. ;)

26 years later, I think the lights did no harm on me! I was under 'em for 2-3 days, I think. I can't really recall. ;)

Take care and congrats on the nomination - I voted for ya!
Carrie :)

4:55 PM  
Anonymous Helen Harrison said...

Back in 1984, Dr. John Scanlon reported in the newsletter "Perinatal Press" that an (in vitro) study had shown phototherapy destroys DNA in human cells and that this damage increases 40 fold in the presence of bilirubin. In an editorial comment, Dr. Scanlon wrote: "This discovery is a Pandora's Box of great complexity, anxiety, and consequence...[the effects]may be rare, or subtle, or not become manifest for many, many years. Additionally, damage to DNA in ...developing ovaries and testes, or in the developing nervous system, implies effects of unknown consequence which potentially involve future generations." [Scanlon JW. DNA damage from phototherapy. _Perinatal Press_ 1984;8:84.]

Others have suggested a link between nursery lighting (not just phototherapy) and childhood leukemia. [Angier N. "Theory Links Nursery Lights to Childhood Leukemia" _New York Times_ 7/29/92.

I'm glad the issue continues to be studied.

And congratulations on your nomination! You are bringing up important issues that deserve to be widely discussed.

5:49 PM  
Anonymous Anonymous said...

Well I enjoy reading your blog. It fascinates me and is extremely thought-provoking.

But I couldn't vote for you. I perceive you as a doctor who may be competent and even eloquent, but you giggle like a morally repressed adolescent at the sight of nipples or upper lip hair. The steady stream of racial/social bias also makes it difficult to support you for an ethics award.

Nominate him for something else, ex utero, and I'll vote for him in a second!

7:23 PM  
Blogger neonataldoc said...

Thanks, everyone, for the kind words. Dream mom, I had to chuckle at your comment. I know my blog's been all downhill since the six month mark! As for the gulf shores society for jaundiced babies, count me in.

Liza, the American Academy of Pediatrics put out a new statement about jaundice two years ago. Now pediatricians should not be hesitant to order a bilirubin level. Also, it's good to hear your kids are engaging in normal sibling behavior.

Scientist, there's an old article in a Pediatric Clinics of North America, or maybe Clinics in Perinatology, that talks about green light, blue light, and white light, and comes to the conclusion that the answer is usually more light. The power of the phototherapy is probably more important than the color. Although you're right, it would be nice to tailor the light wavelength exactly to its need.

9:56 PM  
Blogger Dream Mom said...

NND-I meant no disrespect. I think all of our blogs change after six months-there are only so many issues to cover and then you have to branch out a little bit. For example, debating over the "moustache" post wouldn't fall into the "ethical" category, but it was entertaining to read.

I know with my own Dear Son, I always worry I am going to run out of material.

11:34 PM  
Blogger Jennifer said...

Hi there - this is the first time I have read your blog, and I found it to be very interesting :-) I will be back!

Jen

2:23 AM  
Blogger stockingup99 said...

Wondering if anyone has a link to support that the premature clamping of the umbillical cord may be the cause of high bilirubin levels.

Many natural birthers believe that you should at least wait for the cord to stop pulsing before clamping it. This allows the blood to go where it needs to. Funny thing is when I asked to delay clapming the cord at an OB practice, all four doctors gave me different answers why they had to clamp right away. Two were in direct conflict. One said the baby will get to much blood, another said that baby will loose blood back into the mom, another said mom would bleed too much, and the other said they needed to get the baby under the warmer right away or the baby would get cold. Funny none of that happened when I had a baby at the midwife's birth center, where they wrapped up the placenta and put baby, husband and I down for a nap, in the same bed, before clamping and cutting the cord hours later.

Sure, if neohero needs to help the baby, waiting for dad to fumble the scissors is silly, but for healthy full term babies I don't see the rush.

8:16 AM  
Anonymous Chris and Vic said...

Running out of material? Suggestions: What about all the psych meds/antidepressants that women are on, where they continue these meds while pregnant? Namely, the possibility of these meds affecting the infants? Lately, we have a lot of "history of depression" or "bi-polar" women in our units . . .

What about family-centered care issues, such as assessing the mother for depression while her baby has a long stay in the NICU?
And collaborating with the OB about this? Team practice among nurses, docs, respiratory therapists, social workers, discharge planners, who should take notice if the mother is showing signs and symptoms of depression.

What about the structure and content of care conferences that are ongoing during the infant's stay in the NICU?

What about supplying breastmilk to the sick neonate? Encouraging/supporting mothers to do this for the very long NICU stays? Is there a lactation consultant in the NICU?

What about breaking bad news to parents in the NICU? Who? How? Doc's role? Nurses roles? Consultants in the NICU?

What about Kangarooing in the NICU? How important is it? How widespread? Is anyone keeping data on whether/if it shortens the hospital stay, as indicated in the research?

To what degree, in what ways, are parents encouraged to participate in the plan of care for the infant in the NICU? Examples.

What about continuity of care, when several NICU docs and many nurses are caring for the baby over the weeks/months? When NICU docs differ on the treatments, how can this be rationalized for the parents' understanding? How much teamwork, really, is there among all the different practitioners?

Do all the NICUs have follow-up clincs? Do all NICU infants qualify to be followed up? For how long? What is the plan for follow-up? How fequently are infants seen in follow-up clinics? Until what age are they followed up? Is data collected from these follow ups?

In my NICU, I am participating in a study about parent mentors for NICU parents. That is, former NICU parents, who have an ex-preemie at home, who are willing to be in touch with NICU parents for the purpose of support and inspiration.
Is anybody else doing this? Does anybody else see the value in this?

What about "Resolve Through Sharing" in the NICU, when an infant dies? Do all NICUs think this is a worthwhile support program?

What about teaching CPR to parents at the bedside when their kids are going home on oxygen and montors? Is this a universal practice? What kind of follow-up is there for parents whose kids are at home on oxygen and on CR monitors?

What about child abuse/neglect of ex-preemies, whose parents may not have had access, or enough access, to bond well with them? Are there studies/records kept in YOUR NICU?
How do we recogize "failure to bond"? If we believe a child is at-risk, what follow-up is suggested?
(If the pediatricians are reading this, please chime in!)

On the preemie support lists online, there is a frequent complaint, which goes something like this: While my baby was in the NICU, s/he didn't seem to belong to ME---rather, the baby seemed to belong to the nurses and doctors . . . What about this? How is it that so many parents FEEL this? What do we do that gives this impression to parents?

Developmental care principles in the NICU---such as dim lights, clustering of cares, less noise, fewer interruptions of the infant's sleep, less frequent weighing in the first few weeks . . . How universal is developmental care? How is it explained to parents? Do they participate in developmental care? In what ways?

How many units have infant massage? Containment to quiet the baby? Time-outs? A plan of care for recognizing and addressing infant pain? Describe.

I have lots of ideas . . . after 17 years in the NICU . . .
Chris and Vic (CAK)

10:13 AM  
Blogger The Preemie Experiment said...

Awesome suggestions Chris!

10:43 AM  
Anonymous Anonymous said...

I am the mom of preemie multiples, one of whom died soon after birth and I was just made aware of your blog. I only read a few postings but I do have a comment. I hope you realize that your blog is read by parents of preemies and that what you are writing has a significant effect on them. I do agree with a lot of what you say and I find your blog compelling.
I know many parents of preemies and am heavily involved in prematurity causes and one area that is coming to the forefront as a big need is support for parents in the first years after discharge, because parents are often overwhelmed not only by the treatment they must oversee but by their worry for the future. Your brief discussions of some of the studies regarding outcomes creates the opportunity for parents who are stuck at home with fragile children to obsess over your comments and the myriad of horrible possibilities that the future holds. I appreciate the argument that they can choose to not read your blog (unlikely, it is compelling for parents like me). I also very much appreciate your need to unload, you have one of the toughest jobs in the world and take it from me, I worship people like you with the fortitude and brains to do it. I am eternally grateful. However, I just hope that you consider the effect your words will have on parents like me. It is not crazy to say that some mothers will cry for most of today after reading some of your blogs. I also know parents (smart, educated, monogamous parents) who stop attending follow up clinics because they are too overwhelmed by the information. These parents need to be handled so carefully, not for their own sakes, but for the babies you are working so valiantly to save. You, better than I, know the key to these kids futures are their parents. I want my final words to you to be this, however: Thanks for all you do. People like you have changed my life forever in the best and most important way.

12:12 PM  
Blogger neonataldoc said...

Interesting comments! Dream Mom, I know what you mean.

Chris and Vic, excellent suggestions. I'll probably use some of them in the future.

Stockingup99, there are some interesting studies going on about the benefits of delayed clamping of the cord. I think we need some more study before we can say for sure. Delayed clamping may have benefits, but it would be more likely to raise the bilirubin level than to lower it, since it will put more blood cells into the baby.

Anonymous 12:12, that's really food for thought. Thank you.

1:05 PM  
Anonymous Helen Harrison said...

If parents are fully and honestly informed before their children are enrolled in "the preemie experiment" none of this information would come as a surprise or a shock.

It is sad that so many parents are sent out into the world (or into their homes) with little or no information of what may lie ahead. They then become shocked and "obsessed" when they find out what they weren't previously told.

In the "older but wiser" lists for school-aged preemies, the refrain is the opposite: "Why didn't anyone tell me these things!!!"

If we gear this discussion to the comfort level of new parents, who weren't fully informed to begin with and wish to maintain their innocence, that will only stifle the very discussion neonatal doc says he wants to have.

2:10 PM  
Blogger WendyLou said...

Blood transfusion or lights? Hmmm

One involves the transfer of possibly contaminated (with something we don't know about yet) bodily fluids, the other my baby laying in a blue tanning bed.

Not a hard choice.

My baby spent 4(I think I was kinda drugged) days under the lights. I still have her little mask, and I put it into her scrap book.

She does not have moles, but we will be cautious about skin cancer as it runs in the family.

I would like to see your takes on some of the suggested posts as well. I very much felt that my baby belonged to the NICU, not me. I could go on about why, but I'll save that for my blog.

If you take on that topic, so will I.

5:26 PM  
Anonymous Helen Harrison said...

Could we also discuss the ongoing controversies about when/whether "high" bilirubin needs treating?

7:01 PM  
Anonymous crunchy mom said...

Mine needed lights, born (extracted actually) at 42 weeks, from ABO incompatibility. And joy of joys, my husband is AB and I'm O, so all of my babies will have A or B blood and likely jaundice.

I had no problem with four days of lights in the hospital. I had no problem with two weeks of lights and daily visits from the nurse at home.

I had a HUGE problem with the neonatologist insisting on formula supplementation. I had a pretty huge supply of colostrum within an hour after birth, and my real milk was in by the end of the second day (when she was one day old), and they force-fed her formula anyway. She had horrible nipple confusion and I had to pump exclusively for months before I could get her to latch. And I was (and am) hugely dedicated to breastfeeding. Any mom with even an iota less dedication would have given up. With all the issues surrounding too few women in this country breastfeeding, you'd think they'd at least try to support the moms who want to!

9:13 PM  
Anonymous Anonymous said...

dear crunchy,there IS a rationale for supplementing breastfeeding with formula in jaundiced babies.i hope someone of the nicu folks can clarify for you.(i primarily deal with well-babies)

10:48 PM  
Anonymous frectis said...

I practice delayed cord clamping, which is probably more correctly stated as physiologic cord clamping due to the fact I don't cut it before it's done pulsing and certainly not before the placenta is delivered. I have not seen pathologic jaundice as a result. Just one person's testimony.

(FTR I am not insenstive to jaundice as my own daughter and I had the old ABO incompatibility and she spent some time under lights herself. Nevi galore.)

11:23 PM  
Anonymous crunchy mom said...

Anonymous 10:48, if you know a better rationale than the lame one the neo at our hospital tried to feed us (which all the other literature we found on the subject, much of it peer-reviewed, contradicted), please, I'm waiting with baited breath. If I hadn't had such an abundance of milk by the time the jaundice was even caught, I could understand the need for supplementation-- I do know that bilirubin goes through the liver and not the kidneys, so pooping it out is important. But I was producing more milk than she was drinking from the get-go-- no need to replace perfect nutrition with inferior nutrition. Even one supplemental feeding has implications, never mind the nipple confusion that lasted for months. SO not worth it-- her bili levels never went above 18.

10:53 PM  
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11:44 PM  
Blogger teja ul said...

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7:00 AM  
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5:39 AM  
Anonymous ibis said...

This blog is very informative, neonatal jaundice is the one of the main problems with infants. It can occur when the baby is having higher levels of bilirubin (yellowish substance) in the blood. So the phototherapy treatment can be done to eradicate the jaundice and to lower bilirubin levels. Phototherapy treatment is the one of the main and more effective treatment with best result. Ibis Medical is the one of the major manufacturer of the neonatal products which has worldwide distribution network.

2:51 AM  

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