OSCE Counselling: A Parent Asking for Home Phototherapy

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Practise counselling a parent about jaundice: why this baby needs hospital phototherapy, why water and sunlight are unsafe, and what happens next.

OSCE counselling stationNeonatal jaundiceAAP 2022

A worried mother wants phototherapy at home, and her baby doesn’t meet the criteria. Can you explain why hospital is the safer place, correct some well-meant but unsafe advice, and keep her on side?

What this station tests

Clear, kind communication built on accurate content: explaining why phototherapy is needed, why this baby needs it in hospital, and what the family can expect next.1

Candidate instructions

You are the paediatric registrar on the postnatal ward. Baby Omar is 4 days old. He was born at 37 weeks, is breastfed, and went home at 48 hours without phototherapy. Today his community total serum bilirubin (TSB) is 0.5 mg/dL above his phototherapy threshold. He is well and feeding well, and his weight loss is within the expected range.

His mother, Mrs Sara Hassan, has been asked to come back. Explain why Omar needs phototherapy and why it should be given in hospital, then answer her questions.

Suggested time: 10 minutes. The scenario and names are fictional. Values are in mg/dL as the AAP guideline uses (1 mg/dL ≈ 17.1 μmol/L).

Practising with a partner?

Role brief for the person playing Mrs Hassan

You are a tired, frustrated first-time mother. A friend’s baby had phototherapy at home. Open with: “My friend had the light machine at home. Why can’t we do that? I don’t want to be stuck in hospital again.” Then raise these points in turn:

  1. “Why not at home? He looks fine.”
  2. “My mother says to give him water, or put him in the sun by the window.”
  3. “Should I stop breastfeeding? Is my milk causing this?”
  4. “Can I stay with him? Can I still feed him under the lights?”
  5. “Is the light safe? Can the jaundice damage his brain?”
  6. “When can we go home, and will it come back?”

Calm down when you get a clear reason and a plan. Get more frustrated if you feel brushed off.

Her questions, and what a strong answer covers

Try answering each one out loud before you open the model response.

Question 1

“Why does he need the lights at all? He looks fine.”

Show model response
  • His bilirubin is above the treatment level for his age in hours, how many weeks he was born at, and his other risk factors.1
  • The light helps his body break down and clear the bilirubin, which lowers the chance of it climbing high enough to need more intensive treatment.1
“Omar looks well, which is really reassuring. His blood test shows the yellow pigment is just above the level where we start light treatment. The lights help bring it down so it doesn’t keep rising.”

AAP 2022, section III.A and Key Action Statement 10

Question 2

“Why can’t we do it at home like my friend?”

Show model response
  • Home phototherapy is an option only for babies born at 38 weeks or more with no risk factors that make bilirubin more likely to affect the brain, among other conditions.1
  • Being born before 38 weeks is one of those risk factors, so Omar does not meet the criteria. This is a safety rule about his gestation, not a judgement about the family.1
“Your friend’s baby must have met the criteria for home treatment. One of them is being born at 38 weeks or later. Omar came a little earlier, at 37 weeks, and babies born a bit early are more sensitive to bilirubin, so the guidance is to treat them in hospital where we can keep a closer eye.”

AAP 2022, Key Action Statement 11 and the neurotoxicity risk factors

Question 3

“My mother says to give him water, or put him in the sun.”

Show model response
  • Giving water or sugar water to lower bilirubin is not recommended.1
  • Sunlight is not recommended either, because it can’t be used reliably or safely without the risk of sunburn.1
“Your mum is trying to help, and a lot of families hear this advice. Water doesn’t bring the jaundice down, and sunlight isn’t safe or reliable for a newborn, so we’d ask you not to use either. Feeding him is what helps.”

AAP 2022, Key Action Statement 2 and section III.A

Question 4

“Should I stop breastfeeding? Is my milk causing this?”

Show model response
  • Keep breastfeeding. Feeding helps clear bilirubin and prevents dehydration.1
  • A top-up of her expressed milk or formula can sometimes help. Decide on it together, weighing the effect on her milk supply; it is not an instruction.1
“Please don’t stop. Your milk is helping him get rid of the bilirubin. Sometimes a little extra, ideally your own expressed milk, can help, and we can talk through whether that’s right for you both.”

AAP 2022, sections I.B and III.A

Question 5

“Can I stay with him and still feed him?”

Show model response
  • Where possible, phototherapy is given in the mother’s room or somewhere she can stay with him.1
  • Short breaks from the lights to breastfeed don’t make the treatment less effective.1
“We’ll do everything we can to keep you together. You can take him out of the lights to feed. Short breaks don’t stop the treatment working.”

AAP 2022, section III.A

Question 6

“Is the light safe? Can this damage his brain?”

Show model response
  • The treatment levels are set far below the levels at which bilirubin causes brain injury.1
  • Be honest: some evidence suggests phototherapy may slightly increase the later risk of epilepsy. Experts judge that the benefit outweighs this once the treatment level is reached.1,2
“We’re treating well before the level where the brain is at risk, and that’s exactly why we’re starting now. No treatment is completely risk-free. There’s some evidence of a small possible risk later on, but at this level the benefit clearly comes first.”

AAP 2022, section III.A; AAP technical report

Question 7

“When can we go home, and will it come back?”

Show model response
  • His bilirubin will be rechecked within 12 hours of starting.1
  • The lights can come off once bilirubin is at least 2 mg/dL below the level at which treatment began.1
  • Levels can rise again after treatment, so there will be a blood test or check-up 1–2 days after stopping.1
“We’ll check his level again within 12 hours. Once it has come down enough, the lights can stop. Because it can creep back up, we’ll see him again a day or two later to make sure it’s staying down.”

AAP 2022, Key Action Statements 12, 15 and 16

How to come across

Do

  • Introduce yourself and your role, and check who you’re speaking to
  • Ask what she already knows and what worries her
  • Acknowledge her frustration before explaining
  • Use plain words: “yellow pigment”, not “neurotoxicity”
  • Check understanding and invite questions
  • Make decisions together where there is a choice

Avoid

  • Agreeing to home treatment to keep her happy
  • Brushing off grandma’s advice without explaining
  • Hinting that breastfeeding is to blame
  • False reassurance that treatment has no risks at all
  • Leaving without a clear plan for what happens next

Mark yourself

A passing performance covers at least 6 of the 8 points and communicates well, including both points in red. Missing either red point fails the station, whatever the total.

  • Introduction, role, confirms identity, explores her understanding
  • Explains why treatment is needed: TSB above the threshold for age, gestation and risk factors
  • Declines home phototherapy safely: born under 38 weeks means he doesn’t meet the criteria
  • Corrects unsafe advice: no water or sugar water, no sunlight
  • Encourages breastfeeding; feeding breaks are fine; any top-up decided together
  • Keeps mother and baby together where possible
  • Honest, balanced answer on safety, including the small possible epilepsy risk
  • Clear plan: recheck within 12 hours, when the lights stop, follow-up 1–2 days after stopping
Good to know

These criteria come from the AAP guideline, which was designed for high-resource settings. Always use the full guideline charts and follow your local policy.1

References

  1. Kemper AR, Newman TB, Slaughter JL, et al. Clinical Practice Guideline Revision: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. Pediatrics. 2022;150(3):e2022058859. doi:10.1542/peds.2022-058859
  2. Slaughter JL, Kemper AR, Newman TB. Technical Report: Diagnosis and Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. Pediatrics. 2022;150(3). doi:10.1542/peds.2022-058865
Tiny Taught · Neonatal & Paediatric EducationFor exam preparation and education only, not for clinical decisions. The scenario is fictional. Suggested phrases are examples, not scripts to memorise; follow the full guideline and your local policy.

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