,431RTH Vol. 12:3, Suppl, Fall 1985 15

Copyright 0 1985 BIRTH

Home Phototherapy for Newborn Jaundice

Judith Ellis, Ph. 0.

ABSTRACT: Home phototherapy programs for otherwise healthy term newborns are be- coming popular because they do not necessitate the separation of the newborn from the family and are less costly than the same care delivered in hospital. Home phototherapy may operate under the auspices of a hospital or affiliated home health care agency, a private pediatric practice, or an independent nurse practice. Important elements of all programs include mechanisms for referral, criteria for selection of fmilies, and monitoring the use of the bililights and the baby’s progress during home visits by nurses. Programs we surveyed have been well received by parents. Caregivers report few problems orcomplications. (BIRTH 12:3, Suppl, Fall 1985)

Phototherapy (exposure to bright blue or white light) is standard treatment for physio- logic jaundice of the newborn, having been found effective in reducing bilirubin levels and thereby preventing the sometimes serious sequelae of severe neonatal jaundice. Photo- therapy using “bililights” is usually begun when bilirubin levels reach 10-14 mg/dl, or when the baby shows clinical signs of jaundice. If bilirubin levels reach 20 mg/dl exchange transfusion has generally been recommended.1*2

Controversy centers now on determining when phototherapy or exchange transfusion is necessary. Some practitioners believe that if a baby is sick enough to require phototherapy he should be in the hospital, while a growing num- ber of physicians believe that physiologic jaun- dice is not an indication for phototherapy, but that bilirubin levels over 20 mg/dl require exchange transfusion. Many practitioners believe that mild to moderate physiologic jaundice will resolve by itself or can best be treated at home by exposing the baby to sunlight and giving increased fluids.

Judith Ellis is a graduate of the London School of Economics and has a doctorate in sociology. As a certified childbirth educa- tor she has taught expectant and new parents for 8 years. She is a health services analyst with the Alameda County Health De- partment in Oakland, California. Address reprint requests to the author at 1333 Grant Street, Berkeley, CA 94703.

While these viewpoints are debated, the ma- jority of pediatricians continue to prescribe phototherapy for newborns with jaundice. More often they give this care at home rather than in the hospital. Home phototherapy has much to recommend it. First, since bilirubin levels gen- erally begin to rise on the second or third day after birth, just when the mother is going home from the hospital, home treatment for neonatal jaundice avoids separation of family members. Indeed, with current obstetric practice, many mothers go home within 12 to 24 hours of birth, and a rise in bilirubin level means returning the baby to the hospital for treatment. This separa- tion occurs at an important time in the process of integrating a new member into the family, and disrupts efforts to establish a good breast- feeding relationship. Home treatment, while it does limit the time parents can spend holding their new baby, at least keeps all family mem- bers under the same roof. Home phototherapy is also considerably less expensive than the same treatment given in the hospital, and insurance companies are beginning to cover such care.

Home phototherapy programs have been described in the recent l i t e r a t ~ r e . ~ . ~ We inter- viewed practitioners of four types of programs around the country. The first type is hospital- based or affiliated. These were begun by pedia- tricians, neonatologists, or nursery nurses, and run initially by nursery staff. The neonatal in- tensive care nursery at Lutheran General Hospital

16 BIRTH Vol. 12:3, Suppl, Fall 1989

in Park Ridge, Illinois, for example, began a home phototherapy program which was later transferred to the hospital’s Home Health services agency. The neonatologists continue to consult for the program.

Private pediatric practices have also begun home phototherapy programs. The oldest we heard about was that of Berkeley Pediatric Group, which began a home phototherapy pro- gram 14 years ago at the request of a parent who had no insurance and was seeking an alternative to hospital care. The pediatrician agreed to give it a try and the results were so successful that the group has continued home phototherapy since, monitoring the treatment and the infant in pediatric home visits.

The third type of program is the independent nurse practice of home phototherapy, organized and coordinated by nurses with back-up from local pediatric and neonatology groups. Terry Hysmith, R.N., of Edmonds, Washington, has one of the longest established home photo- therapy services and offers a pamphlet about her program.5

Referral and Selection of Patients

In all instances, referral to the home treat- ment is made by the attending pediatrician after making the decision that phototherapy is needed, and after assessing the suitability of the family for a home treatment program. In one teaching hospital, referrals for home phototherapy are made jointly by the pediatric resident and the nursery’s discharge planner. The nurses who visit the home first make a call to the parents to assess their suitability for the program. If they do not think the family can comply with the program requirements, they discuss this with the pediatrician and re-evaluate the referral. Some programs have written protocols for referral, but many do not.

Home Phototherapy Requirements and Criteria

In most programs treatment is for referred newborns with bilirubin levels between 10 and 14 mg/dl, especially if they also show clinical signs of jaundice. All refer to the home treat- ment program only for physiologic jaundice, after ruling out other causes of jaundice such as blood incompatibility, liver disease, intestinal obstruction, or infection. Most, but not all, require that the infant be full term. The family

must be willing to leave the baby in the crib exposed to the lights for long periods, held only during feedings. Some programs require a small room to be used, where temperatures can be better controlled in order to minimize the baby’s heat loss. Parents keep a daily log of the baby’s temperature, weight, fluid intake and output, stools, and feedings. Parents may be asked to sign a consent form.

Home Bililights

Bililights are provided by the programs, and the rental charge is included in the treatment fee. Most programs we reviewed used the same lights as those used at the hospital. However, portable lights are now available from Rocky Mountain Medical Corp., 5680 S. Syracuse Circle, Suite 100, Greenwood Village, CO 801 11, (800) 233-3556, and from Olympic Medical, 4400 7th Ave. S., Seattle, WA 98108, (800) 426-0353.

Borne Visits

Daily home visits are an essential feature of all programs. At the initial visit, made after an in- troductory phone call, a nurse takes the lights to the home and sets them up. She instructs the parents in their proper use, and in the necessary charting and recording procedures. She also in- structs them about the amount of time the baby is to remain’under the lights, on how to shield the baby’s eyes, and about appropriate dress for the baby, if any. All programs leave written in- formation with the parents. The nurse visits each day, reviews the chart, answers questions, and draws blood for the bilirubin testing. In most programs, the nurse also takes the blood specimen to the laboratory for testing, receives the results, and calls both the pediatrician and family to discuss further treatment plans. In the private pediatric practice, all babies also receive a home visit by a pediatrician, since this is part of the regular routine for all newborns in this practice.

cost

Costs vary from $50 to $250 a day, with the more expensive programs hoping to reduce their fees as soon as the lights are paid for. The price includes rental of the lights, home visits, other equipment such as eye patches, and blood draw- ing. There is usually an additional fee for the

BIRTH Vol. 12:3, Suppl, Fall 1985 17

laboratory testing. All but one of the programs surveyed reported that both private insurance companies and Medicaid will pay for the treat- ment at home.

The majority of babies stay in the program about 2 to 3 days, after which they are suffi- ciently improved that treatment can be discon- tinued. Very few problems have been reported. In the programs surveyed one infant was re- hospitalized at the parents’ request since they did not feel able to handle the care at home; one was rehospitalized for developing sepsis, and one for increasing bilirubin levels. It is not clear what percentage of cases this represents since few of the groups surveyed keeps these statistics. There were no reports of any burns or other accidents to the baby or any other family member as a result of the presence of bililights in the home.

The programs are well received by parents who appreciate having their babies within reach. The nurses who go out on the daily visits report that they do much teaching on topics besides the care of a baby with jaundice, such as care of the cord or circumcision, advice on breastfeed- ing or sibling jealousy, bathing, and so forth. Many of the nurses we spoke to felt pleased at this opportunity to offer additional support to new families.

Home phototherapy programs offer an option to nurses who may be looking for additional ways to use their skills. Home phototherapy practice involves as many or few working hours as desired, some flexibility in work schedules, and a wide range of activities involving both clini- cal skills and community-based health education.

Experience to date with home phototherapy programs suggest that, given careful screening and selection of appropriate candidates, and good parent education, the risks are minimal, and the benefits to families over hospital photo- therapy are great.

Acknowledgements

The author wishes to thank Dr. David N. Sheftel of Lutheran General Hospital in Illinois, Nancy Becker, R.N., of Parkside Home Health Services, Park Ridge, Illinois, Robin Calo, R N . and Pat Spottiswood. R.N., of Alta Bates Hospital in Berkeley, California, Judy Johnson, R.N., of the Berkeley Visiting Nurse Association, Inc. of Berkeley, Dr. Alexander G. Rogerson of Berkeley Pediatric Group, and Terry Hysmith, R.N., of Edmonds, Washington.

REFERENCES

1. Simkin P, Simkin PA, Edwards M: “Physiologicaly’ jaundice of the newborn. Birth Family J. 1979; 6:23.

2. Watchko JF, Oski FA: Bilirubin 20 mg/dl = Viginti- phobia. Vigintiphobia: A one-act play. Pediatrics. 1983; 71:660.

3. Slater L, Brewer MF: Home versus hospital photo- therapy for term infants with hyperbilirubinemia: A comparative study. Pediatrics. 1984; 73:515.

4. Treatment of Newborn Jaundice Comes Home. ICEA NEWS 24(1):10 Feb 1985.

5. Hysmith T: Home Phototherapy Service, Inc., 8605- 244th Street SW, #C, Edmonds, WA 98020. (206) 771-2361.

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