NEONATAL JAUNDICE 新生儿黄疸,Xiangya Hospital， C.S.U Jiang Ling 中南大学湘雅医院 姜 玲,2,新生儿黄疸 NEONATAL JAUNDICE,3,Adult 成人,Jaundice 黄疸,Pathological 病理性的,Newborn 新生儿,NEONATAL JAUNDICE 新生儿黄疸,60% fullterm baby 80% preterm baby 60%足月儿 80%早产儿,Why newborns are prone to jaundice?新生儿为什么易发生黄疸？special metabolism of bilirubin 胆红素的特殊代谢,4,NEONATAL JAUNDICE 新生儿黄疸,5,Where does bilirubin come from? 胆红素来自哪里？,Overproduction 胆红素生成多 Bilirubin 8.8 mg/kg a day (3.8 mg/ kg adult) 每日生成胆红素 8.8 mg/kg ( 成人 3.8 mg/ kg ),6,THE FEATURES OF NEONATAL BILIRUBIN METABOLISM 新生儿胆红素代谢的特征,Lower conveying capability 转运胆红素能力不足Acidosis, low plasma protein. 酸中毒，血浆蛋白量低。,7,THE FEATURES OF NEONATAL BILIRUBIN METABOLISM 新生儿胆红素代谢的特征,liver function is underdeveloped.肝功能未发育完善,8,Y,Z protein is low in liver cells 肝细胞内 Y，Z 蛋白含量低,THE METABOLIC FEATURES OF NEONATAL BILIRUBIN 新生儿胆红素代谢的特征,9,Uridine diphosphate glucuronyl transferase （UDPGT） has insufficient activity ,is less than 30% of normal one 尿苷二磷酸葡萄糖醛酸基转移酶（UDPGT）活性不足，为正常 30 % 以下 The excretion of conjugated bilirubin is poor 排泄结合胆红素的功能差,THE METABOLIC FEATURES OF NEONATAL BILIRUBIN 新生儿胆红素代谢的特征,Increased enterohepatic circulation肠肝循环增加,10,There is too little intestinal bacteria to restore bilirubin back into feces and urobilinogen 肠道内细菌量少，不能将肠道内的胆红素还原成粪、尿胆原,THE FEATURES OF NEONATAL BILIRUBIN METABOLISM 新生儿胆红素代谢的特征,11,Activity of -glucuronidase is high, can hydrolyze conjugated bilirubin into unconjugated bilirubin, the latter is absorbed by the intestine to the liver. -葡萄糖醛酸酶活性高，能将结合胆红素水解成未结合胆红素，后者又被肠吸收进入肝脏。,Increased enterohepatic circulation肠肝循环增加,THE FEATURES OF NEONATAL BILIRUBIN METABOLISM 新生儿胆红素代谢的特征,Jaundice may be normal ! 黄疸可能正常！,12,Jaundice of newborn,physiological,pathological,怎样区分病理性和生理性黄疸？ How to distinguish them,NEONATAL JAUNDICE 新生儿黄疸,13,新生儿生理黄疸与病理性黄疸鉴别,14,Identification of neonatal physiological jaundice and pathological jaundice,Causes of pathological jaundice,15,overproduction,underdeveloped liver function,Obstructive disease,1,2,3,NEONATAL JAUNDICE 新生儿黄疸,Overproduction 胆红素生成多,新生儿溶血病 (hemolytic disease) 红细胞增多症 (polycythemia) 血管外溶血 (extravascular blood) 感染 (infection),16,肠肝循环增加 (increased enterohepatic circulation ) 血红蛋白病 ( hemoglobin disease ) 红细胞膜异常(abnormal membrane of RBC),17,Overproduction 胆红素生成多,Decreased liver function 肝功能减弱,Hypoxia :asphyxia; heart failure Crigler-Najjar syndrome ; Gilbert syndrome ; Lucey-Driscoll syndrome缺氧:窒息；心力衰竭 Crigler-Najjar综合征 , Gilbert综合征 , Lucey-Driscoll综合征,18,Drugs: sulfonamides; indomethacin Others ： hypothyroidism ； Dawns syndrome药物：磺胺；消炎痛 其他:甲状腺功能低下; 21-三体综合征,19,Lower liver function 肝功能减弱,胆道闭锁(biliary atresia) 新生儿肝炎(hepatitis of newborn) 先天性代谢缺陷病（EMI: inborn errors of metabolism ） Dubin-Johnson综合征(Dubin-Johnson syndrome),20,Obstructive disease 阻塞性疾病,Treatment of neonatal jaundice 新生儿黄疸治疗方法,Inhibition of resorption 抑制重吸收 Phototherapy 光疗 Drug 药物 Exchange transfusion 换血,21,关于新生儿黄疸的几点思考和建议 Some reflections and suggestions on neonatal jaundice,北京协和医院 丁国芳全国第九届新生儿学术会议2010、9 西安,过度诊治Excessive diagnosis and treatment,忽视日龄的影响 Ignore the impact of days age 缺乏敏感性和特异性较好的方法测定游离胆红素水平 具体到每一个病人，应根据胎龄、日龄、是否存在高危因素 the lack of sensitive and specific methods to test free bilirubin level Be Specific to each patient, should according to the gestational age, day age, whether there are high risk factors or not.,过度诊治,血浆胆红素水平是判断胆红素脑病风险的重要标准，但不是唯一标准 关注高水平胆红素持续时间和分布 Plasma bilirubin level is an important standard to judge the risk of bilirubin encephalopathy, but it is not the only standard Attach importance to the high level of bilirubin duration and distribution,过度诊治,实验组：140例胆红素峰值大于25mg/dl 新生儿，其中130例胆红水平2529.2mg/dl，10例大于30mg/dl，136例接受光疗，5例接受换血对照组：10万名足月新生儿中随机抽查419例作为对照 Experimental group: 140 cases of neonatal bilirubin peak is greater than 25mg/dl, including 130 cases of bilirubin level is 2529.2mg/dl, 10 cases of bilirubin level is more than 30mg/dl, 136 patients received light therapy, 5 patients received blood transfusion Control group: randomly selected 419 cases from one hundred thousand full-term neonates as control milligram/deciliter,过度诊治,美国儿科学会2004年新生儿黄疸干预指南：胎龄大于38周,没有高危因素的足月新生儿,生后大于72小时的光疗标准是17mg/dl以上. The American pediatrics academy neonatal jaundice intervention guide in 2004 : the full- term newborn gestational age is greater than 38 weeks without risk factors whose phototherapy standard is 17 mg/dl and above when is more than 72 hours after delivery,延误诊治,基层医疗机构的核黄疸是一个非常严峻的问题 某医院7年中收治的158例高胆红素血症的病人中有25例出现胆红素脑病，平均峰值32加减(plus or minus )10.24mg/dl jaundice is a very serious problem in the primary health care institutions. The hospital received 158 patients with hyperbilirubinemia a for 7 years ,25 cases of them have bilirubin encephalopathy, the average peak is 32 +/- 10.24mg/dl,延误诊治,24小时出院的新生儿，尤其是35至37周的近足月儿生后24小时内出现黄疸且未对胆红素水平监测的新生儿 对高危因素和黄疸临床表现的严重程度缺乏认识 Neonatal within 24 hours after discharge, especially infants whose gestational age are 35w to 37 weeks The bilirubin level of neonates are not tested but Jaundice occurred within 24 hours after birth . A lack of awareness of the severity of risk factors and clinical manifestation of jaundice,