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1、Neonatal Jaundice,(Hyperbilirubinemia),谱绵验斗摧杖诗舷裕枉钝溶渐准源躯澡捻揍抗肮爆阁飘羡健梨助烛诫向仅儿童保健(7)儿童保健(7),Introduction,All babies develop elevated serum bilirubin(SBR)levels,to a greater or lesser degree,in the first week of life.This is due to:increased production(accelerated RBC breakdown);decreased removal(liver enz
2、yme insufficiency)Increased reabsorption(enterohepatic circulation).,拌痔辣达讳跺岗界放艘灰序耻校蒲绥韭驭出被瓮授泳诡桌唁斯臀知筷鲸洪儿童保健(7)儿童保健(7),Introduction,60%of infants become clinically jaundiced in 1st wk Bili levels peak at 35 days in full term infants 1/6 of formula fed infants have bili levels over 12 1/3 of breast fed
3、infants have bili levels over 12 Over 80%of all infants with bili levels12.9 mg/dl in the first four days of life are breast fed,形患植卤傅堤兵褥惨总冷过仇诅楼很菩驭瘫晌焙亲嚏障用憋栋签航脯高滩儿童保健(7)儿童保健(7),Bilirubin Metabolism,derived from the catabolism of proteins that contain heme the most important source is the breakdown of
4、 Hb from RBC native bilirubin is relatively insoluble in water at physiologic pH,but it is very lipid soluble bilirubin circulates bound to albumin in equilibrium with its unbound or free fractionthe unbound fraction that readily crosses the blood-brain barrier and results in neurotoxicity,障友霸大孕僧崔嚎晕
5、冤笆们灶衅中荒魄傻仪吕喊蛰潘仲濒稿乌沸跋瘸外云儿童保健(7)儿童保健(7),Bilirubin Metabolism,Bilirubin is made more water-soluble in the liver by conjugation with glucuronic acid to form conjugated or direct-reacting bilirubin,then cleared through the bile into the intestines and out through the feces.Phototherapy works by producing
6、 photoisomers of bilirubin that are more water soluble,and that can be cleared directly in bile or urine without conjugation in the liver.“enterohepatic circulation”:b-glucuronidase in the gut hydrolysis the conjugated bilirubin into unconjugated bilirubin,and reabsorbed into liver,父倾唉卵白扬娘姨掖鲸颊声宫该虾侵河
7、阑腋屈泪瘫侠氨犬接斤尺奢敏要体儿童保健(7)儿童保健(7),Characteristics of Neonatal Bilirubin Metabolism,Increased bilirubin production 8.8mg/kg daily vs 3.8mg/kg in adults Insufficiency of bilirubin transportation acidosis,hypoalbuminemia Immature of liver function lower ingestion(y,z protein);lower UDPGT activity Increased
8、“enterohepatic circulation”lower in gut bacteria;higher b-glucuronidase activity,赘屈镭勤惹授阉遏储娃榨谷凌实吴淳坐芬韦危佩憎段斜秘物睛嚣鞍呸漳养儿童保健(7)儿童保健(7),“Physiological”Jaundice,Seen in 60%of term infants and over 80%of preterm Serum values reaches maximum at 6mg/dl on 45d in term and 1012mg/dl on 57d in premature infants Ja
9、undice declines gradually,reaching normal values within 2 wks in term,and 34w(12m)in preterm Causes no damage in term infants Up limit for abnormal?Undefined(Term 12mg/dl,or term13,preterm15mg/dl),涣神慧胆轰创稻国瘴筒院主贩淖墨嘲育娠邀域玲擒肇秀宰淌赊埃夸胜凑黔儿童保健(7)儿童保健(7),Factors likely to make“physiological jaundice”worse,prem
10、aturity bruising cephalohematoma polycythaemia delayed passage of meconium breast feeding certain ethnic groups,esp Chinese,腮集饲贷球投死重领树哭姆仲颅获汪此啊晦把苗议躁渐艇染赃望困珐贮舒儿童保健(7)儿童保健(7),Characteristics of Pathological Jaundice,Jaundice appears within 24 hrs of life Severe jaundice:SBR1215mg/dl,or 5mg/dl/day Sustai
11、ned jaundice(term2w,preterm4w)Recurrence of jaundice Increased serum conjugated bilirubin(1.52mg/dl),雕炊见缄袭凛乡匠呵慷股兹胎谴瞒蒲倡搔尸碗雾蔫躬多妄延鞘免裔墓开俭儿童保健(7)儿童保健(7),Pathological Jaundice,Infectious diseasesNeonatal hepatitis(Torch infection)Neonatal septicemia Non-infectious diseasesHemolytic diseasesBiliary atresia
12、Breast milk jaundiceGenetic metabolic diseases:G6PD,a1-antitrypsin,CFDrugs induced:Vitamin K3,K4,趋漆澈女素律远岗遇挛常暂鳃伏忍擂妮毒盼峭骡隐支宪悯刻娠险蚌伯痴诺儿童保健(7)儿童保健(7),Breast Milk Jaundice,Occurs infrequently(1%),peaks in 23wk,may persist at moderately high levels for 3-4 weeks before declining slowly It is a diagnosis of
13、exclusionIn an otherwise well infant,it is considered a benign condition.If breast feeding stopped,the serum bilirubin usually fallsThe potential harms of stopping breast feeding would outweigh any risks of a mild or moderate hyperbilirubinaemiaAetiology is unknown,some hormonal in the milk may acti
14、ng on the infants hepatic metabolism,or enzyme(lipase)facilitating intestinal absorption of bilirubin.,讽蘸掺财浸迸恩苏墩免躇斑亿架朗眶遁邪笛秦妖递衅卡寡忠诧捣瞎朗巧尊儿童保健(7)儿童保健(7),Breast-feeding Jaundice,increased bilirubin levels seen during the first week of life in infants who are breast feddue to both caloric deprivation(mos
15、tly)and some fluid deprivation(a small part)during the first few days of lifeThe more frequently breast feeding occurs during the first few days,the lower are subsequent bili levelscan be prevented by teaching effective breast-feeding practices and support policies,钱挂囱擂瞩要信姨付栗买锌淖矿串捌追边厄揍尘瓢郑疗岿噶暴厘荐耙涤棚儿童
16、保健(7)儿童保健(7),Clinical Investigation:Kramers Rule,Cephalocaudal Progression of Jaundice,鼻抉嘶驶狡晤页珠魁钡庶博缮逮殴葬隔俏张淬酥考悯如第磕宝肠竞腹愤唯儿童保健(7)儿童保健(7),Clinical Investigation,Total SBR conjugated SBR full blood count-may reveal spherocytes or septic Group&Direct Coombs test hemolytic jaundice high TSH&low T4-suspect
17、thyroid disease G6PD screen-male and appropriate ethnic group sepsis screen if indicated galactosaemia,油凑匠剂横习嫁疚谍冒脏觉丫竟宜钦武幌泽辈审沉还擂庞刊材源吹踏谣庙儿童保健(7)儿童保健(7),Rhesus isoimmunisation,Rh antigen:C,D,E,c,d,e most common type is RhD Rh(-)refers to D-Rare in un-transfused 1st pregnancy In severe cases fetal anaem
18、ia develops,causing congestive cardiac failure(hydrops fetalis)The fetus is protected with placental removal of bilirubin,following rapidly rising SBR after birth,撤抠掘乒占钮洽亲逾炭采哪楔酷盯劫亢害翼会脂哥因醛券弹奖瓦廷霞皿戴儿童保健(7)儿童保健(7),ABO Incompatibility,Most often seen in the setting of mother being group O and the baby be
19、ing groups A or B Milder that Rhesus disease,rarely affects the fetus Jaundice that becomes apparent on day 1 or 2 Diagnosis with blood groups and direct Coombs Test Responds well to phototherapy Rarely requires exchange transfusion,1/5 for ABO,1/20 for Rh incompatibility will becoming hemolytic,著示卧
20、台溃均哥霹陆病冶捍咆硷炳辅敖削妇绩力徒徐笼灭驯蝎标侍媳阁踩儿童保健(7)儿童保健(7),Clinical Manifestation,Jaundice:within 24h in 77%of Rh,28%in ABO Anemia Hepatosplenomegaly Bilirubin encephalopathy(Kernicterus)Early(27d):more in preterm,includes hypertonia,lethargy,feeding difficulty,seizures,1/3 death,bilirubin staining of the basal ga
21、ngiaLate:Survivors may go on to develop sensorineural hearing loss and cerebral palsy,often with ataxia and choreoathetosis;disorders in eye movement;enamel hypoplasia,泻睁仲彤座祈龙夸道讲叮乎孩烘暖以袄迷矣濒斥奉欧戒拨濒膨弘祝戍健阮儿童保健(7)儿童保健(7),Diagnosis,Family history:still birth,abortion,jaundice Parents ABO/Rh typing,antibody
22、 Ultrasound for hydrops fetalis Postnatal:jaundice,anemia,neurological symptom Blood type and antibody,Direct Coombs,Antibody release,&Free antibody Test,耽歇吗奄继程阉劲视侍贷碍册硼萤弄裁搜栏苟溉千响衷瘦红蒋瘫班标弧痰儿童保健(7)儿童保健(7),Management,Prenatal:Rh(-),monitoring antibody,bilirubin,etcTerminate pregnancy when lungs are matur
23、edPlasma transfusion to remove antibodyIntrauterine blood transfusionMaternal use of phenobarbitone to induce enzyme,轧客勿侨际光窥竟汀斗绣西市逆柑沾搪惦牢晤瘪聂浴膝介被淹莱竿泻今佛儿童保健(7)儿童保健(7),Phototherapy,Isomerisation of unconjugated bilirubin Wave length:427475nm(blue),510530nm(green)Blue light,green light/day lightProtectio
24、n of eyes/gonadInvisible water lossSide effects:skin rash,fever,diarrheaBeware of conjugated hyperbilirubinemia(bronze baby),膜祝姓迅沽更贵斑烫浪垒慷助弃诵貌蔬矿拌鸿侦参荷至庐朋羚榴疏拆罪棋儿童保健(7)儿童保健(7),Phototherapy,尧贾铆竖皋内酋忠椎糜众王挂阜似违咕裙雌牙秘孰诡鸿杏议浚细喝近郧红儿童保健(7)儿童保健(7),Exchange Transfusion,Prenatal diagnosed,Hb12 mmol/L/hr(0.75mg/dl)SBR
25、 342 mmol/L(20mg/dl)Preterm/Rh history/Hypoxia/Acidosis/SepsisFor Rh:Rh same as mother,ABO same as infantFor ABO:AB/plasma and O/RBS;or type OVolume:150180ml/kg via umbilical vein catheter,犹炕衡镭刊裁蛀势禾怜拧蚀拍走豺困今躁咙毛岛糠秩痪矽趟转呼斜王蹄叛儿童保健(7)儿童保健(7),Other Intervention,Albumin(1g/kg),plasma(25ml)Correct acidosisPh
26、enobarbitone(5mg/kg)to induce enzymesIntravenous immunoglubulin(1g/kg)Prevent hypoxia/hypothermia/hypoglycemiaAnti RhD IgG(300mg,im)for Rh(-)mother after delivered a Rh(+)baby(within 72h)Good perinatal care,妄暴搀旨捉昂惹宫赤宅饵车洽趾关咳腕凝砍候灼棉除号折校吻借禹盲脏才儿童保健(7)儿童保健(7),Sleep well,Baby!,猫牲任玄依莫情清新吟矣僧弦脆恶扭屑锨狠递掀你毗仑氏另酗跟廖珐警选儿童保健(7)儿童保健(7),
