新生儿黄疸诊治.ppt

1 新生儿黄疸诊治新生儿黄疸诊治 Paediatrics&Child Health 1999;4(2):161-164 Reference No.FN98-02 Revision in progress May 2007 Paediatrics&Child Health 2007;12(5):1B-12B Reference No.FN07-02 Guidelines for detection,management and prevention of hyperbilirubinemia in term and late preterm newborn infants 参考文献 Hyperbilirubinemia is very common and usually benign in the term newborn infant and the late preterm infant at 35 to 36 completed weeks.Critical hyperbilirubinemia is uncommon but has the potential for causing long-term neurological impairment.Early discharge of the healthy newborn infant,particularly those in whom breastfeeding may not be fully established,may be associated with delayed diagnosis of significant hyperbilirubinemia.高胆红素血症很常见，多为良性。危险的高胆红素血症并不常见，但是有潜在的导致长期神经损害的可能。胆红素水平与胆红素脑病发生胆红素水平与胆红素脑病发生 It is estimated that 60%of term newborns develop jaundice and 2%reach a TSB concentration greater than 340 mol/L(19.8mg/dl).Acute encephalopathy does not occur in full-term infants whose peak TSB concentration remains below 340 mol/L and is very rare unless the peak TSB concentration exceeds 425 mol/L(24.85mg/dl).Above this level,the risk for toxicity progressively increases.More than three-quarters of the infants in the United States kernicterus registry(between 1992 and 2002)had a TSB concentration of 515 mol/L(30.1mg/dl)or greater,and two-thirds had a concentration exceeding 600 mol/L(35mg/dl).Even with concentrations greater than 500 mol/L(29.2mg/dl),there are still some infants who will escape encephalopathy.Kernicterus（核黄疸核黄疸）:the pathological finding of deep-yellow staining of neurons and neuronal necrosis of the basal ganglia（基底节）and brainstem nuclei（脑干神经元）.Acute bilirubin encephalopathy（急性胆红素脑病）（急性胆红素脑病）:a clinical syndrome,in the presence of severe hyperbilirubinemia,of lethargy（昏睡）,hypotoniaand（肌张力减低）poor suck,which may progress to hypertonia(with opisthotonos（角弓反张）and retrocollis（颈后倾）)with a high-pitched cry and fever,and eventually to seizures（发作）and coma.Chronic bilirubin encephalopathy（慢性胆红素脑病）（慢性胆红素脑病）:the clinical sequelae of acute encephalopathy with athetoid cerebral palsy（手足徐动症样大脑麻痹）with or without seizures,developmental delay,hearing deficit,oculomotor（眼球运动异常）disturbances,dental dysplasia（牙发育异常）and mental deficiency.Severe hyperbilirubinemia（严重的高胆红素血症）（严重的高胆红素血症）:a total serum bilirubin(TSB)concentration greater than 340 mol/L at any time during the first 28 days of life.Critical hyperbilirubinemia（危险的高胆红素血症）（危险的高胆红素血症）:a TSB concentration greater than 425 mol/L during the first 28 days of life.具有危险因素人群中患者与非患者之比相当于不具有危险因素人群中患者与非患者之比的倍数具有危险因素人群中患者与非患者之比相当于不具有危险因素人群中患者与非患者之比的倍数 脱水，高渗，呼吸窘迫，水肿，早产，酸中毒，低白蛋白血症，缺氧，抽搐可增加急性脑病的发生率 与败血症的关系?All of the reasons for the variable susceptibility of infants are not known;however,dehydration,hyperosmolarity,respiratory distress,hydrops,prematurity,acidosis,hypoalbuminemia,hypoxia and seizures are said to increase the risk of acute encephalopathy in the presence of severe hyperbilirubinemia,although reliable evidence to confirm these associations is lacking.In addition,some infants with severe hyperbilirubinemia are found to have sepsis,but both sepsis and hyperbilirubinemia are common in the neonatal period,and sepsis appears to be uncommon in the well-appearing infant with severe hyperbilirubinemia.黄疸的发生（总体发生情况）Early(days 1-2)-uncommon Haemolytic jaundice(ABO,others)Normal(days 3-10)-very common Uncomplicated Complicated-see below Late(days 14+)Breast milk-common Conjugated jaundice-uncommon Inherited deficiency of glucuronyl transferase enzymes-very rare Investigations:Measurement of bilirubin 经皮测并不准确（与是否光疗后，皮肤颜色及厚度都有关）经皮测并不准确（与是否光疗后，皮肤颜色及厚度都有关）There are several limitations to TcB measurements:they become unreliable after initiation of phototherapy,and they may be unreliable with changes in skin colour and thickness.However,the results are more accurate at lower levels of bilirubin,and therefore,use of TcB as a screening device is reasonable Clinical evaluation Kramers Rule Rather than estimating the level of jaundice by simply observing the babys skin colour,one can utilise the cephalocaudal progression of jaundice.Kramer drew attention to the observation that jaundice starts on the head,and extends towards the feet as the level rises.This is useful in deciding whether or not a baby needs to have the SBR measured.Kramer divided the infant into 5 zones,the SBR range associated with progression to the zones is as follows:Clinical management of hyperbilirubinemia in infants TABLE 1:Laboratory investigation for hyperbilirubinemia in term newborn infants Indicated(if bilirubin concentrations reach phototherapy levels)Serum total or unconjugated bilirubin concentration Serum conjugated bilirubin concentration Blood group with direct antibody test(Coombs test)Hemoglobin and hematocrit determinations Optional(可选择的)Complete blood count including manual differential white cell count Blood smear for red cell morphology Reticulocyte count Glucose-6-phosphate dehydrogenase scree