BlueCross BlueShield of Tennessee Medical Policy Manual

Home Phototherapy for Neonatal Jaundice

DESCRIPTION

Phototherapy with a fluorescent, tungsten-halogen lamp or fiberoptic cable attached to a transparent flat mat (e.g. BiliBlanket, Wallaby) may be used in the management of jaundice in the healthy term newborn in the home setting. Eighty-five percent of healthy, term newborn babies have some jaundice, which is a yellow discoloration of the skin and eyes caused by elevated serum bilirubin concentration (hyperbilirubinemia). Jaundice can be a normal response to the baby's limited ability to excrete bilirubin in the first 1-2 weeks of life.

The American Academy of Pediatrics (AAP) encourages prenatal care, breastfeeding and establishing protocols for the identification and evaluation of newborn jaundice. Key elements of the recommendations are: measurement of the total serum bilirubin (TSB) on jaundiced newborns should be interpreted according to the infant’s age in hours, assessment of risk factors should be an ongoing process, and appropriate follow-up should be provided after discharge.

Phototherapy can have temporary side effects, including a skin rash and loose bowel movements. In breast fed infants receiving phototherapy, supplementation with expressed breast milk or formula is appropriate if the infant’s intake seems inadequate Overheating and dehydration can occur if the infant does not get enough breast milk or formula. Therefore, the infant's skin color, body temperature, and number of wet diapers need to be closely monitored. After home phototherapy has been started if the TSB does not decrease or increases, this strongly suggests the presence of hemolysis. Once at home the bilirubin levels should be assessed daily. Neonates of any age whose TSB is greater than 25mg/dl are at risk for developing bilirubin encephalopathy or kernicterus.

POLICY

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

Risk factors included in the American Academy of Pediatrics’ (AAP) guideline include: no prenatal care, significant cephalhematoma or bruising, weight loss of greater than or equal to 10%, signs or symptoms of a serious illness, jaundice ≤ 24 hours, elevated direct-reacting bilirubin, ABO incompatibility, isoimmune hemolytic disease, asphyxia, significant lethargy, temperature instability, suspected or confirmed G6PD deficiency, suspected sepsis, acidosis, hypothyroidism, galactosemia, cholestasis, suspected hemolysis or suspected hepatic disorder. 

Once at home the bilirubin levels should be assessed daily. Neonates of any age whose TSB is greater than 25mg/dL are at risk for developing bilirubin encephalopathy or kernicterus.

Table for AAP Recommendations for Home Phototherapy for Low-Risk Infant:

Age in Hours

AAP recommendation to begin home phototherapy for low risk infant

AAP recommendation for further studies or re-admission of low risk infant

Total Serum Bilirubin level in mg/dL

24-35

7.0 - 15.0

≥ 15.1

36-47

9.5 - 16.0

≥ 16.1

48-59

11.0 - 17.0

≥ 17.1

60-71

12.5 - 18.0

≥ 18.1

72-83

13.5 - 18.5

≥ 18.6

84-95

15.0 - 19.0

≥ 19.1

96 or more

15.5 - 19.0

≥ 19.1

Scientific evidence is lacking in the form of well-designed studies in peer-reviewed journals regarding the utilization of home phototherapy for any other conditions or diseases.

SOURCES

American Academy of Pediatrics. (1994, October). Practice Parameter: Management of hyperbilirubinemia in the healthy term infant. Retrieved October 22, 2014 from http://pediatrics.aappublications.org.

American Academy of Pediatrics. (2004, October). Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Retrieved October 22, 2014 from http://pediatrics.aappublications.org.

American Academy of Pediatrics. (2004, October). Management of hyperbilirubinemia in the newborn infant greater than or equal to 35 weeks of Gestation: an update with clarifications. Retrieved October 3, 2017 from http://pediatrics.aappublications.org.

Atkinson, L., Escobar, G., Takayama, J., and Newman, T. (July, 2003). Phototherapy Use in Jaundice Newborns in a Large Managed Care Organization: Do Clinicians Adhere to the Guidelines? Pediatrics, 2003 (111), 555-e561. (Level 4 evidence)

Bhutani VK, and the Committee on Fetus and Newborn. (2011). Phototherapy to prevent severe neonatal hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics, 128 (4). (Level 3 evidence)

Bhutani, V., and Wong, R. (2013). Bilirubin Neurotoxicity in Preterm Infants: Risk and Prevention. Journal of Clinical Neonatology, 2 (2), 61-69. (Level 3 evidence)

National Institute of Health and Care Excellence. (2010, May). Jaundice in newborn babies under 28 days. Retrieved October 24, 2016 from: http://www.nice.org.uk.

Tennessee Code: Title 68: Health, Safety and Environmental Protection: Chapter 11: Part 226: (a) Licensing of home medical equipment provider. Retrieved October 3, 2017 from: http://www.lexisnexis.com/hottopics/tncode.

U. S. Food and Drug Administration. (2003, December). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K040068, Retrieved August 28, 2009 from: http://www.accessdata.fda.gov.

U. S. Food and Drug Administration. (2006, April). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K053568. Retrieved August 28, 2009 from: http://www.accessdata.fda.gov.

U. S. Food and Drug Administration. (2009, February). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K083179, Retrieved October 21, 2014 from: http://www.accessdata.fda.gov.

Wolff, M., Schinasi, D., Lavelle, J., Boorstein, N., and Zorc, J. (2012) Management of neonates with hyperbilirubinemia: improving timeliness of care using a clinical pathway. Pediatrics. Vol 130. No. 6 1689-1694. (Level 4 evidence)

ORIGINAL EFFECTIVE DATE:  11/1986

MOST RECENT REVIEW DATE:  11/9/2017

ID_BT     

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