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1、1 新生儿黄疸诊治 Paediatrics 4 2 161 164 Reference No FN98 02 Revision in progress May 2007 Paediatrics 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 benig
2、n 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 est
3、ablished 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 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 o
4、ccur 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 regis
5、try 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 the pathological fi
6、nding 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 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 wit
7、h 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 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 defici
8、t 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 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 a TSB concentration greater than 425
9、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 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 hyp
10、oalbuminemia 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 an
11、d 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 Breas
12、t 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 There are several limitations to TcB measurements they become unreliable after initiation of phototherapy and they may be unre
13、liable 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 Kramer s Rule Rather than estimating the level of jaundice by simply observing the baby s skin colour o
14、ne 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 th
15、e 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 bilirubi
16、n 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 screen Serum electrolytes and albumin or protein concentrations Timed TSB measurements 定时胆红素水平监测 适时干预 Umbilical cord blood TSB 脐带血胆红素水平并无特异性 A TSB concentration greater than 30 mol
