Analysis Of Main Causes,treatments And Prognosis Of Severe Hyperbilirubinemia In Full-term Infants Of Hebei Province

Objective:Jaundice occurs in most neonates.It is often discovered in 2~3days and reach the peak in 5~6 days after birth.Most jaundice is slight,but because of the potential toxicity of bilirubin,newborn infants must be monitored to identify those who might develop severe hyperbilirubinemia,or even acute bilirubin encephalopathy and kernicterus,which may do great harm to the family and the society.Although kernicterus should almost always be preventable,cases continue to occur.Insufficient understanding of jaundice,inadequate recognition,and lack of effective follow-up measures are the main causes of severe hyperbilirubinemia and bilirubin encephalopathy.Because of the different races,region,environment,the peak time of neonatal jaundice is also different,In China,medical resource distribution is not balanced between the area.and also asians itself is high-risk groups of severe hyperbilirubinemia,.Meanwhile,The research in the field of neonal jaundice in China is relatively backward,especially lack of the epidemiological data,and a large,multicenter epidemiological data,so the incidence of bilirubin encephalopathy and kernicterus may be higher than the western countries.We consider the total serum bilirubin(TSB)>342 μmoL/L(20mg/d1)as severe hyperbilirubinemia,and TSB>428μmoL/L(25mg/d1)or 513μmo L/L(30mg/d1)extremely severe hyperbilirubinemia.But in some cases,the lower TSB may lead to bilirubin encephalopathy,while the extremely severe hyperbilirubinemia may do not necessarily causes brain damage,It is associated with the age,and the complication of the neonates.such as the hemolytic disease,suffocation,acidosis,sepsis,high temperature,low temperature,hypoalbuminemia,hypoglycemia,G-6pd defection and so on.Some severe jaundice may have a genetic basis.Scholars have found that in the south of china,severe jaundice have something to do with UGT1A1 mutations.In order to reduce the total serum bilirubin level as soon as possible,we can take the routine treatments,such as intensive phototherapy,albumin infusion and so on,exchange transfusion is also an effective way to relieve jaundice.Exchange transfusion can replace the bilirubin,antibodies,and sensitization red blood cells and other harmful substances in the blood quickly,so it can avoid or reduce the happening of bilirubin encephalopathy.But there is potential risk for the exchange transfusion,many parents have scruples with it.So some neonates who have extremely severe hyperbilirubinemia,but in good condition,accept the routine treatment.How about the prognosis of babies with the two treatments? we still need to verify it with the time goes on.In this paper,we will analyse the main causes and treatments of severe hyperbilirubinemia in full-term infants and prognosis in the multicenter of hebei province.Methods:During June 2014 to December 2015,474 full-term infants with the serum total bilirubin level ≥342.2 μmol/L in neonatal multicenter of hebei province were included.The neonates must meet the criteria as follows : gestational age: 37~41weeks;TSB≥342.2μmol/L,give priority to unconjugated bilirubin;birth weight≥ 2500 g,except for these neonates of application of ototoxic drug,intracranial hemorrhage,intracranial infection,severe asphyxia,otitis media,familial deafness and congenital aplasia of brain.we recorded the general conditions of the babies,profession of the parents,perinatal high-risk factors,comorbidities,bilirubin peak,treatment and clinical outcomes and so on.In December 2015,We made the telephone follow-up by using the questionnaire survey of standardized Denver developmental screening test,We have 474 neonates in all,from 1 month to 18 months.we investigated and evaluated hearing,intelligence,and neurological development.Results:1 General conditions analysis: 7 hospitals take part in this survey,and 474 full-term infants with the serum total bilirubin level ≥342..2μmol/L were included.275 male,199 female.With an average of gestational age(38.41+1.71)weeks,an average of birth weight(3306.9 + 450.4)g,an average of hospitalized days of age(6.08 ± 1.49)d,an average of appearance time of jaundice(2.94 + 1.66)d,an average of duration of jaundice(4.52 + 3.77)d;Cesarean section 189 cases(39.8%),natural birth 285 cases(60.2%);an average of TSB peak(417.17 + 82.32)μmol/L,an average of B/A(0.78±0.15).49 cases(10.3%)with the clinical manifestation of acute bilirubin encephalopathy(ABE).2 Causes of jaundice analysis: headed by iso-immune hemolysis(157 cases,33.1%),the second was infection-related jaundice(121 cases,29.5%),the third one was unsupplemented breasted-related jaundice in the first few days after birth(111 cases,27.1%),late onset breasted-related jaundice of 4th(44 cases,9.2%).3 Analysis of treatments: 65 cases(13.7%)received exchange transfusion treatment,the others received phototherapy(routine therapy group).For further analysis of the two groups: There were no statistical significant differences in the way of birth,birth weight,feeding way,jaundice duration,the beginning time of jaundice between the two groups(P>0.05).But in average hospitalized days of age,total bilirubin,B/A,NBNA score on admission,history of jaundice,there was statistical significance(P<0.05).Causes analysis of jaundice :there were 37 cases(56.9%)of iso-immune hemolysis in exchange transfusion group,While 120 cases(29.3%)in routine group,there were distinctive difference(P<0.05);There were 22 cases(33.8%)of infection-related jaundice in exchange transfusion group,While 99 cases(24.2%)in routine group,there were no distinctive difference(P>0.05).There was only 1 cases(1.5%)of unsupplemented breasted-related jaundice in the first few days after birth in exchange transfusion group,and 110 cases(46.8%)in routine group.There were 48 cases(43.8%)of acute bilirubin encephalopathy in exchange transfusion group and 1 case(0.24%)in routine group,because the parents refused exchange transfusion,and required routine treatment.4 The BAEP test results: There were only two hospitals could take the examination of brainstem auditory evoked potential(BAEP)among 7 hospitals.43 newborns took the BAEP examination,8 cases(18.6%)in the exchange transfusion group,and 35 cases(81.4%)in the routine group.3 cases of hearing impairment(6 months after birth no listening improvement)were found,2 cases in exchange transfusion group,and 1 case in routine group.there were statistically significant difference between the two groups(P<0.05).They are accepting the listening training in the specialized hospital.5 There were distinctive difference of globus pallidus in the magnetic resonance imaging(MRI)-T1 WI and T2 WI high signal: 74 abnormal cases were found,20 cases(30.7%)in exchange transfusion group and 54 cases(13.2%)in routine group,all with T1 WI high signal change.3 months after hospital discharge,there was 1 case(1.8%)with high T2 WI signal change in routine group,2 cases(10%)in exchange transfusion group,there were statistically significant difference between the two groups(P<0.05);6 Outcome of therapy:of 474 cases with severe jaundice,1 baby died of electrolyte imbalance after exchange transfusion.86 cases improved,required to discharge.387 cases were cured,normal discharged.Of 473 cases of telephone follow-up,351 cases(74.2%)were willing to accept the telephone survey,13 cases(2.7%)refused to answer question,59 cases(12.4%)had no answer,21 cases(4.4%)were invalid,29 cases(6.1%)replaced telephone number,the rate of losing follow-up was 25.8%.Evaluate the results of DDST: exchange transfusion group :suspicious: 5 cases(7.6%),abnormal: 3 cases(4.6%);routine group:suspicious: 3 cases(0.7%),abnormal: 1 cases(0.2%).Conclusion:1 The average TSB peak of exchange transfusion group was(496.83 + 126.42)μmol/L,The routine group was(404.00+64.22)μmol/L,the former is significantly higher than the latter.2 The common causes of severe hyperbilirubinemia in full term infants of Hebei Province are iso-immune hemolysis,infections,and unsupplemented breast feeding in the first few days after birth.3 Change blood group is given prio to with iso-immune hemolysis,and the average days of age < 7 days;In the routine group with breast-feeding jaundice is given priority to,the average days of age > 7 days.4 Denver developmental screening test(DDST)telephone follow-up results suggest that the ratio of suspicious and abnormal neonates in exchange transfusion group is higher than that in routine group.exchange transfusion can reduce or avoid the happening of kernicterus when the baby has ABE,routine treatment may increase the risk of kernicterus.,when the baby does not have ABE.