Do/Did you have a newborn infant undergoing phototherapy treatment for jaundice?

Does/Did your child have proper eye protection?  My Grandson didn't.


Main Page - Inadequate Eye protection for my Grandson during phototherapy treatment.          Letter to Hospital Administration

On this page are a few emails I have received concerning my letter and some sources I have found online.


Emails Received and Sources


I had a reply back from Natus, the makers of the neoBLUE.   Here's how that went:

 

----- Original Message -----

From: Technical Service

To: dannfox@comcast.net

Sent: Tuesday, March 18, 2008 6:49 PM

Subject: RE: the importance of keeping baby's eyes covered during phototherapy to treat jaundice.

Dear Ms. Fox

Thank you for your inquiry concerning the phototherapy treatment and eye protectors. Natus Medical is a medical device manufacturer and does not have advice nurses, audiologist, or staff available to speak to the general public. All requests concerning the phototherapy treatment should be directed to the health care provider who is performing this treatment. I would encourage you to speak with your grandchild's attending physicians. Sorry I am unable to offer you more assistance.

Best Regards,

Bill Douglas

Natus Medical Technical Service

 

My REPLY:

Unfortunately, I am not able to speak to one of the baby's physicians since they have no set schedule to do their rounds, and Grandparent's visiting hours are from 10:00 - 10:30 a.m. and 8:00 - 8:30 p.m. and I've NEVER seen a Dr. during those hours.

Below is some text that is on the Natus website.

WHY ARE MY BABIES EYS COVERED?

Eyeshades must be used during phototherapy to protect your baby's eyes from excessive light exposure. Your nurse will take the eyeshades off when the neoBLUE light is turned off.

On the Bili-Mask page it says:

A safe, proven means of protecting babies' eyes during phototherapy. Easy to put on, stays in place & no light leaks.

 

All I want to know is what kind of damage can be done to a baby's eyes when they are are not properly shielded from the phototherapy lights?

I did not get any answer from the nursing staff because they kept telling me that it won't cause any harm at all.

Obviously it could cause some harm or it would not be all over the internet, including the Natus website, to keep the babies eyes covered.

If these products can be used on the General Public then where can the General Public find out the necessary information.

Is it ok for these nurses to use these lights on these babies WITHOUT proper eye protection?

Surely someone at Natus would know the answer, as not only do they market the product, but the eye masks as well.


Donna Ann Fox

Email: dannfox@comcast.net

cc: customer_service@natus.com

 


 

Email received from a Children's Hospital. - March 19, 2008

I have not read current research related to eye protection for newborns under phototherapy; however, it is obviously common practice to provide the eye protection

 As a grandmother, you have a right and obligation to advocate for your grandchild.  If I were you, I would ask to speak with a nursing manager or director at the hospital and explain each and every one of your concerns. 

 There is no excuse for not properly fitting and securing eyewear on infants under phototherapy.  Equally important is maintaining appropriate body temperature.  This needs to be controlled through the temperature regulator on the isolette itself.  The nursing staff needs to be checking the infantís body temperature on a regularly scheduled basis to ensure that his/her body temperature is being maintained appropriately. 

 


Email from the March of Dimes: - March 21, 2008

Dear Ms. Fox,
Thank you for your recent request for information from the March of Dimes.

The March of Dimes has not produced material on this specific topic. 
(Of course they haven't as no one can, that is not a study that can be done, and why protectional measures have to be taken.)  When March of Dimes literature is unavailable, we attempt to provide people with information from another source and/or a referral to an agency or agencies that might be able to assist them.  You may wish to link to one of the following sites.  They sent me a list of sites, below.

Stanford School of Medicine

WHY ARE THE BABY'S EYES COVERED?

In adults, prolonged exposure to blue light can cause retinal damage.  Although retinal damage from phototherapy has not been reported, eye covers for newborns are standard prophylaxis.

 

WebMD - Fundamentals of Phototherapy for Neonatal Jaundice

Nursing Care of The Infant Receiving Phototherapy

Phototherapy is much more than just switching on a light. The efficiency with which phototherapy achieves a decline in the serum bilirubin level is largely determined by nursing care. Appropriate nursing care also minimizes the potential side effects and complications of phototherapy.

Provide Eye Protection

Opaque eye shields must be used during phototherapy to protect the infant's eyes from retinal damage.  To adequately block the transmission of light, carefully apply eye coverings by first closing the infant's eyes and then applying shields securely. Avoid eye patches that are too tight, because they might apply undue pressure to the infant's delicate eyes. Turn off the phototherapy unit and remove the eye patches periodically to assess the eyes for drainage, edema, and evidence of infection; to provide visual stimulation; and to encourage parent-infant interaction as appropriate based on the infant's clinical status.

Assess and Adjust Thermoregulation Devices

Some phototherapy units can cause a significant increase in the infant's body temperature. When phototherapy is directed over an incubator, immediate and sustained fluctuations can occur in the thermal environment. Thermal instability can occur when using either the skin-control or air-control mode of the incubator. With inadequate monitoring, vigilance, and adjustments to the thermal environment, the infant can easily develop hypothermia or hyperthermia during phototherapy.

 

Investigative Ophthalmology and Visual Science

Phototoxicity to the newborn primate retina

KH Messner, MJ Maisels and AE Leure-DuPree
 

Newborn stump-tail monkeys were continuously exposed to 400 f-c of cool, white, fluorescent light for periods varying from 12 hr to 7 days. The right eye of each monkey was occluded by a patch of black velour material to serve as a control. The protected eyes retained normal ultrastructure; the exposed eyes showed progressive damage to the retina from the 12 hr to the 7-day exposure periods. Early changes were evident in the outer nuclear layer with darkly staining pyknotic nuclei and electrondense cytoplasmic processes that could be traced to their synaptic terminals. Late changes included marked distortion, vacuolization, and fragmentation of the rod and cone outer segments. The potential for phototoxicity to be additive to the normal aging of the retina is proposed, and we conclude that there is a sound basis for the current practice of patching the eyes of infants undergoing phototherapy.

 

Phototherapy and retinal damage

Duration of exposure to the lights can range from a few hours to 6 or more days of continuous or intermittent (e.g., 6 hours on, 2 hours off) exposure.

There is concern about possible deleterious side-effects of the treatment. One hazard which has concerned investigators is the possibility of retinal damage to infants exposed to phototherapy continuously for several days. The basis for concern about retinal damage lies in several studies in the animal literature which have shown structural and functional changes in the retinal photoreceptors following extended periods of exposure to illumination, even at levels considerably lower than those used in phototherapy.

In summary, studies of rats and piglets have indicted that continuous exposure to levels of illumination similar to those used to treat hyperbilirubinemia (jaundice) in newborn infants can result in severe photoreceptor damage.  Furthermore, severe damage to the photoreceptors of animals has been found subsequent to several weeks of exposure to room lights 24 hours day. (Which is why many nurseries now have diffused or dimmed lighting).  These results indicate that care must be taken to protect both the eyes of infants exposed to phototherapy and the eyes of infants who are lying adjacent to a phototherapy unit or who must remain for a number of days under nursery lights 24 hours a day.


Jaundice, Neonatal

Key points in the practical execution of phototherapy are maximizing energy delivery and the available surface area.
  • The infant should be naked except for diapers (use these only if deemed absolutely necessary and cut them to minimum workable size), and the eyes should be covered to reduce risk of retinal damage.
Generally, phototherapy is very safe and may have no serious long-term effects in neonates; however, the following adverse effects and complications have been noted:
  • Retinal damage has been observed in some animal models during intense phototherapy. In an NICU environment, infants exposed to higher levels of ambient light were found to have an increased risk of retinopathy. Therefore, covering the eyes of infants undergoing phototherapy with eye patches is routine. Care must be taken lest the patches slip and leave the eyes uncovered or occlude one or both nares.

 

March 24, 2008

I just received one answer from a Pediatric Website.

"There is very little literature to exactly determine what is the extent of eye damage that can take place if the baby is kept without eye protection with phototherapy. Since phototherapy is known to damage the eyes, thus no study would be available where baby is not given eye protection. "

 

 

Received April 8, 2008

Another answer from the Pediatric Department of a major hospital.

Thank you for your email of March 25. 

Because of the animal studies that suggest that phototherapy lights can be damaging to a baby*s retina, we recommend that the baby*s eyes be covered with an opaque patch.  There is no doubt, however, that achieving this can be a challenge and requires considerable vigilance on the part of the nursing staff.  Notwithstanding the animal data, it is
true that we have no evidence that any baby*s eyes have been damaged by phototherapy lights so it is possible that we are being over protective.  Nevertheless, we feel that the safest approach is to continue to cover the eyes.  In our NICU we use the Neotech system and this works quite well although vigilance is still required to make sure that the infant*s eyes are adequately covered.


Some online sources:

The New England Journal of Medicine

Clinical Evidence

Phototherapy was evaluated in a number of randomized trials conducted from the 1960s through the early 1990s.  Although these trials helped to establish the efficacy of phototherapy as it was used during this period, none used the relatively high light doses used today. Current ethical standards would prevent any trial comparing phototherapy with placebo.

Because light can be toxic to the immature retina, the infant's eyes should always be protected with opaque eye patches.

 

Fundamentals of phototherapy for neonatal jaundice.

Phototherapy is the use of visible light for the treatment of hyperbilirubinemia in the newborn. This relatively common therapy lowers the serum bilirubin level by transforming bilirubin into water-soluble isomers that can be eliminated without conjugation in the liver. The dose of phototherapy largely determines how quickly it works; the dose, in turn, is determined by the wavelength of the light, the intensity of the light (irradiance), the distance between the light and the infant, and the body surface area exposed to the light. Commercially available phototherapy systems include those that deliver light via fluorescent bulbs, halogen quartz lamps, light-emitting diodes, and fiberoptic mattresses. Proper nursing care enhances the effectiveness of phototherapy and minimizes complications. Caregiver responsibilities include ensuring effective irradiance delivery, maximizing skin exposure, providing eye protection and eye care, carefully monitoring thermoregulation, maintaining adequate hydration, promoting elimination, and supporting parent-infant interaction.

 

Nurse's Responsibilities In Phototherapy

Nursing care and procedure for photo therapy:

1. Undress the baby completely.

2. The baby's eyes are shielded by an opaque mask to prevent exposure to the light.

3. The eye shield should be properly sized and correctly positioned to cover the eye completely but prevent any occlusion of the nares.

4. The baby's eyelids are closed before the mask is applied, because the corneas may become excoriated if they come in contact with the dressing.

5. On each nursing shift the eyes are checked for evidence of discharge, excessive pressure on the lids or corneal irritation.

6. Eye shields are removed during feedings, which provide the opportunity to provide visual and sensory stimulation.

Photo therapy is not a harmless intervention. It can produce adverse effects on the baby and may disturb medical and nursing personnel

 

a. Lethargy

b. Loose green stool-weigh often and compensate

c. Increased insensible water loss- provide more frequent extra breastfeeding

d. Dark Urine.

e. Temperature elevation.

f. Skin changes - greenish colour, rash due to capillary dilation - skin rashes - no need to discontinue photo therapy.

g. Turn infant on abdomen for short period of time and will cease priapism (persistent abnormal erection of penis)

h. Retina damage: prevented by shielding the eyes.

i. Hypo or hyperthermia: Monitor temperature frequently (There were numerous times when my Grandson's temp. was 101.5, 101.6, etc. and it should not have been that high)

j. Increased metabolic rate, dehydration, and electrolyte disturbances such as hypocalcemia.

 


Development of an eye protector for phototherapy on newborns:

A study revealed that, of the types of lamps utilized in phototherapy, blue lamps provide more effective treatment than halogen lamps. However, one of the complications of the method is that is causes degeneration of the retina through exposure to light. Therefore, it is crucial to protect the eyes properly. Some authors say this protection can be provided by bandages, blindfolds or strips of gauze.


 

Light transmission of Phototherapy Eye Shields

Recently there has been concern that bright ambient light may be an important factor in the pathogenesis of retinopathy of prematurity,' yet small preterm jaundiced infants may be exposed to high levels of light during phototherapy. As a direct consequence of studies in animals that showed the damaging effects of phototherapy light on the neonatal retina, human neonates receiving phototherapy now have their eyes covered routinely with eye shields.


Phototherapy:

Light intensities inside phototherapy units greatly exceed NICU ambient levels. We estimate them to be at least 10,000 lux, and even higher in some of the newer units with tungsten sources. Because much of the energy is at short wavelengths, we should be particularly cautious about measuring only illuminances - there may be sufficient intensity in the short wavelengths for photo-chemical damage to the retina. This is particularly true in the units that use only blue fluorescent lights.

Infants receiving phototherapy typically have their eyes covered with protective shields. When properly fitted, the commercially available occluders are quite effective in blocking light, especially when coupled with closed eyelids.

However, mere use of occluders does not necessarily protect the retina. Staff sometimes use makeshift occluders made from, for example, stacks of gauze pads, which may not attenuate sufficiently, and even the best occluders may not stay in place well. In a minute-by-minute study of infants in an NICU, it was observed that for those receiving phototherapy, the occluders slipped and no longer fully covered the eyes more than 50 percent of the time. This observation is easy to confirm anecdotally in conversation with NICU staff. Often the slippage exposed only one eye, another factor that predicts the possibility of monocular damage.

There are some animal data on exposure to phototherapy units. Piglets and infant macaque monkeys raised in human phototherapy units without occluders but with the ability to close their eyes suffered considerable histological damage to their retinas. In the latter study, newborn macaques were exposed to illuminance of about 4300 lux for periods from 12 hours to four days. Even after 12 hours, there was some immediate damage to photoreceptors. Ten months later, all exposed eyes showed some recovery, but many eyes were histologically abnormal, particularly if exposed for three or four days. Thus, there is reason to be concerned for infants receiving phototherapy. What is less obvious is that there might be even greater risk for infants in NICUs who are the neighbors of infants receiving phototherapy. It is not generally the practice to shield the eyes of infants next to those being photo-treated, yet there can be a significant increase in total light exposure for such patients, as our data on control infants demonstrates.


FUNDAMENTALS OF PHOTOTHERAPY FOR NEONATAL JAUNDICE.
 

FOUNDATIONS IN NEWBORN CARE

Advances in Neonatal Care. 6(6):303-312, December 2006.
STOKOWSKI, LAURA A. RN, MS

Abstract:
Phototherapy is the use of visible light for the treatment of hyperbilirubinemia in the newborn. This relatively common therapy lowers the serum bilirubin level by transforming bilirubin into water-soluble isomers that can be eliminated without conjugation in the liver. The dose of phototherapy largely determines how quickly it works; the dose, in turn, is determined by the wavelength of the light, the intensity of the light (irradiance), the distance between the light and the infant, and the body surface area exposed to the light. Commercially available phototherapy systems include those that deliver light via fluorescent bulbs, halogen quartz lamps, light-emitting diodes, and fiberoptic mattresses. Proper nursing care enhances the effectiveness of phototherapy and minimizes complications. Caregiver responsibilities include ensuring effective irradiance delivery, maximizing skin exposure, providing eye protection and eye care, carefully monitoring thermoregulation, maintaining adequate hydration, promoting elimination, and supporting parent-infant interaction.

(C) 2006 National Association of Neonatal Nurses


 

Needless to say, there are hundreds of websites stating that the eyes must be protected and the infants temperature monitored carefully.  I'm not going to list each and every one.

 


Sep 12, 2008:  It looks like after 6 months and a 2nd eye exam we are unfortunately, finally getting some answers.  Apparently my grandson cannot focus either up close or far away.    SEE UPDATE

 

It makes one wonder just how many children's severe eye problems SHOULD BE linked to improper eye care and protection during phototherapy, yet is only linked to prematurity?

 


 

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