强光疗治疗新生儿高胆红素血症的疗效及安全性

目的 探讨采用强光疗治疗新生儿高胆红素血症的疗效及安全性。方法 对144 例新生儿高胆红素血症患儿进行前瞻性随机分组,其中强光疗组和传统光疗组各72 例,对两组疗效及并发症等情况进行比较。结果 光疗后12 h 内强光疗组患儿血总胆红素水平明显低于传统光疗组(P<0.05),且胆红素下降幅度明显高于传统光疗组(P<0.05)。强光疗组患儿总光疗时间明显短于传统光疗组(P<0.05)。两组患儿光疗后发热、腹泻、皮疹、低钙血症发生率及光疗后血钙水平和血红蛋白下降水平等比较差异均无统计学意义。结论 强光疗在光疗开始初期可迅速有效降低高胆红素血症患儿血中胆红素水平,缩短总光疗时间,且不增加不良反应的发生率,是一种优于传统光疗的治疗措施。     

新生儿高胆红素血症光疗的副作用

自上世纪50年代以后,蓝光被广泛使用于新生儿高胆红素血症的治疗中。新生儿光疗可有效降低血清未结合胆红素,预防胆红素脑病的发生,极大地降低了交换输血疗法的使用频率。普遍认为光疗副作用轻微并且容易控制。但是最近研究提供了光疗副作用的新证据。光疗近期副作用包括影响母婴互动、体温失衡和水分丢失、电解质紊乱、生理节律紊乱和青铜症等。此外,光疗可能与黑素痣和皮肤癌、动脉导管未闭、视网膜损伤及成年生殖能力受损等远期副作用相关。因此,需要制定完善的循证指南,发展包括光导纤维光毯和发光二极管在内的新设备,以及光疗替代制剂,并在此基础上探讨个体化治疗,以最大程度减少光疗副作用。     

Fiberoptic vs conventional home phototherapy for neonatal hyperbilirubinemia.

Two methods of administering home phototherapy were compared. Twenty-two infants received home phototherapy with a fiberoptic cummerbund, and 26 infants received home phototherapy with a conventional four-bul "bililight." The two treatment modalities proved equally effective in lowering bilirubin levels. The duration of treatment was a mean of 3.09 days in the fiberoptic group and 2.77 days in the bililight group, and the daily decline in bilirubin levels was a mean of 1.84 mg/dL/day in the fiberoptic group and 2.18 mg/dL/day in the bililight group. Differences were not statistically significant (Student's t-test, two-tailed). Upon completion of therapy, mothers responded to 15 statements intended to measure attitudes and perceptions regarding home phototherapy. In four of the 15 statements there was a statistically significant preference for fiberoptic therapy, as measured with the chi-square statistic (p less than .05), while in the remaining statements there were no preferences expressed toward either treatment modality. Fiberoptic home phototherapy appears to be as effective as home phototherapy administered with conventional bililights and may be better accepted by parents.     

Evaluation of phototherapy devices used for neonatal hyperbilirubinemia

Objective  

To compare phototherapy devices based on their physical and photo-biological characteristics viz spectral properties, maximum and mean irradiance, treatable percentage of body surface area, decay of irradiance over time and in vitro photoisomerisation of bilirubin.     

High-intensity phototherapy for the treatment of severe nonhaemolytic neonatal hyperbilirubinemia

Aim: To describe the clinical approach to term and near‐term newborn infants with severe hyperbilirubinaemia and to analyse the effect of high‐intensity phototherapy on total serum bilirubin (TSB) levels. Methods: We analysed a cohort of 116 newborn infants with severe nonhaemolytic hyperbilirubinaemia (TSB ≥ 20 mg/dL/342 μmol/L). All patients were treated with high‐intensity phototherapy. The main outcomes were reduction in TSB levels in the first 24 h of phototherapy, incidence of exchange transfusion, pathological brainstem auditory evoked responses and pathological findings on neurological examination at discharge. Results: The mean birth weight and gestational age were 3161 ± 466 g and 37.8 ± 1.6 weeks. Mean initial TSB concentration was 22.4 ± 2.4 mg/dL. Per cent decreases in TSB after 2, 4, 6, 12, 18 and 24 h of phototherapy were 9.4%, 16%, 23%, 40%, 44% and 50%, respectively. No infant was treated with exchange transfusion. Brainstem evoked response audiometry (BAER) was performed in 100% of the patients, and in three of them, this examination was altered. However, when repeated 3 months later, these BAER examinations were normal. Neurological examination was normal in all patients. Conclusions: High‐intensity phototherapy significantly reduces TSB in nonhaemolytic severe hyperbilirubinaemia and decreases the need for exchange transfusion.     

新生儿高胆红素血症光疗不良反应研究进展

光疗作为一种有效的新生儿高胆红素血症的治疗手段,在临床得到广泛应用。最近研究显示,新生儿期光疗可通过氧化应激、DNA损伤等机制增加极低出生体质量儿病死率,并与儿童期肿瘤、黑色素痣、过敏性疾病及癫痫等有相关联系。因此需要进一步探索和优化光疗光源设备、改变光疗方式等,减少光疗的不良反应。文章就新生儿高胆红素血症光疗的不良反应研究进展进行综述。     

Intensive phototherapy with a blue double lamp in the treatment of neonatal hyperbilirubinemia

The purpose of this study was to investigate the effect of "intensive phototherapy" (blue double light, 2 X 30 microW/cm2) on neonatal hyperbilirubinemia in 41 infants, compared to a control group treated with "single light" phototherapy (1 X 30 microW/cm2). The double light treatment enhances the photodegradation of bilirubin. The number of exchange transfusions was reduced, and no further exchange transfusions had to be carried out. No significant clinical side effects during the phototherapy were observed.     

A guide to the use of phototherapy in the management of neonatal hyperbilirubinemia.

Nomograms have been designed to provide rational and consistent guidelines for the use of phototherapy in the management of neonatal hyperbilirubinemia. In the management of 195 neonates in the first week of life, phototherapy, given according to these nomograms, was successful, except in some severe cases of Rhesus incompatability, in controlling hyperbilirubinemia in both premature and term neonates. When compared to the more random use before the introduction of the nomograms, phototherapy was reduced significantly without an increase in the requirement for exchange transfusions.     

Results of exercise testing at a mean age of 10 years after neonatal arterial switch operation

Aim: This prospective follow-up study investigated long-term exercise capacity at a mean age of 10 y after neonatal arterial switch operation for transposition of the great arteries in a large group of homogeneous unselected children. Methods: 56 asymptomatic children, aged 7.9-14.3 y (10.5 3 1.6, mean 3 SD), were examined with respect to exercise tolerance, electrocardiographic (ECG) response and activity of biochemical markers for myocardial injury. The protocol included standard electrocardiography, M-mode and two-dimensional echocardiography at rest, a Bruce walking treadmill test to voluntary exhaustion, and determination of cardiac troponin I and T, creatine kinase and myoglobin from venous blood samples at rest and 4 h after exercise. Heart rate, blood-pressure response to exercise stress and endurance time were compared with published results of age-matched normal children. Results: 54 patients (96.4%) had normal exercise capacity; a reduction in 2 patients was not due to cardiac disease. Heart rate and systolic blood pressure rose significantly between rest and peak exercise and did not differ from normal controls, whereas diastolic blood pressure was lower. ECG remained normal at rest and on exercise in 54 children (96.4%). Serum values of cardiac troponin I and T, creatine kinase and myoglobin were normal at rest and after exercise in all patients.

Conclusion: The study demonstrates excellent long-term exercise capacity after neonatal arterial switch operation. Exercise testing is a useful and non-invasive screening method to detect patients with clinically relevant exercise-induced myocardial ischaemia and should be routinely performed in growing patients.     

应用蓝光发光二极管治疗新生儿高胆红素血症的研究

目的探讨蓝光发光二极管（lightemittingdiodes,LEDs）对新生儿高胆红素血症的光疗效应。方法将LEDs与普通蓝光灯分成四组LEDs组、单面蓝光组、LEDs+单面蓝光组、双面蓝光组。四组光源照射黄疸早产儿,然后应用高效液相色谱仪（HPLC）测定血、尿中胆红素光异构体的变化,同时观察皮疹、体温、大便性状等改变情况,评价LEDs的效应。结果黄疸早产儿分别在四组光源照射6h后,血清胆红素构象异构体（14Z,15E-bilirubinⅨα,ZE）和胆红素结构异构体（lumirubin,LR）的含量LEDs组［（13.0±1.9）、（3.9±1.0）μmol/L］与单面蓝光组［（13.4±2.2）、（4.3±1.2）μmol/L］比较差异无显著性（P＞0.05）;LEDs+单面蓝光组［（21.9±2.3）、（7.2±1.4）μmol/L］与双面蓝光组［（23.1±3.3）、（7.5±1.4）μmol/L］比较差异无显著性（P＞0.05）;而LEDs+单面蓝光组、双面蓝光组均大于LEDs组和单面蓝光组（P＜0.05）。在光照12h后血清ZE的量及12h内尿LR的总排出量四组比较;LEDs+单面蓝光组、双面蓝光组均明显大于LEDs组、单面蓝光组(P＜0.01)。光组12h后血清LR的量,四组比较差异无显著性（P＞0.05）。LEDs光照新生儿未发现皮疹、腹泻及发热,而普通蓝光光照新生儿有个别出现发热和腹泻。结论HPLC测定光照前后血和尿胆红素光异构体的变化,可作为评价光疗效应的指标,而定量测定尿液光异构体LR的量,既可靠、又无创伤性。LEDs能起到普通单面蓝光一样的光疗效果,且副作用并无增多。     

Fiberoptic phototherapy versus conventional daylight phototherapy for hyperbilirubinemia of term newborns.

The efficacy and wavelengths of fiberoptic phototherapy and conventional daylight phototherapy were compared in a relatively larger series of term newborns with nonhemolytic and significant hyperbilirubinemia than reported in previous studies. One hundred and nine term newborns were randomly assigned to receive either fiberoptic phototherapy on a fiberoptic phototherapy pad or overhead conventional phototherapy consisting of five daylight fluorescent lamps. Although the average spectral irradiance measured during the study period was significantly greater in the fiberoptic phototherapy group (9.2+/-1.2 microW/cm2/nm vs 7.1+/-1.1 microW/cm2/mm, p < 0.05), conventional phototherapy was significantly more effective in decreasing bilirubin levels: the duration of exposure to phototherapy was significantly shorter (49.4+/-14.4 hours vs 61+/-13.1 hours, p < 0.05), and overall bilirubin decline rate as mg/dl/h and percent/h was significantly greater in the conventional phototherapy group (0.15+/-0.06 mg/dl/h vs 0.11+/-0.05 mg/dl/h, and 0.81+/-0.34 percent/h vs 0.60+/-0.28 percent/h, p < 0.05). There were four failures of phototherapy in the fiberoptic phototherapy group whereas no phototherapy failure was observed in the conventional phototherapy group (p < 0.05). The emission spectrum of the daylight fluorescent lamp revealed a broad emission between the violet and red spectra with tiny narrow peak emission bands in 405 nm, 436 nm, 546 nm and 577 nm, while a broad emission through the blue and green wavelengths (mainly in the green spectrum) without any peak emissions was detected in the tungsten-halogen lamp of the fiberoptic phototherapy system. Conventional phototherapy with daylight fluorescent lamps should be preferred to fiberoptic phototherapy administered with fiberoptic phototherapy and in the treatment of term newborns with nonhemolytic hyperbilirubinemia.     

Neonatal hyperbilirubinemia and physical and cognitive performance at 17 years of age

To estimate the effect of neonatal hyperbilirubinemia on long-term cognitive ability in full-term newborns with a negative Coombs test, we performed a 17-year historical prospective study of 1948 subjects. Intelligence tests and medical examinations performed at the military draft board were stratified according to serum bilirubin concentration. A logistic regression analysis was used to adjust for the confounding effects of gestational age, birth weight, Apgar score, ethnic origin, socioeconomic class, paternal education, birth order, and the administration of phototherapy and exchange transfusion. No direct linear association was shown between neonatal bilirubin levels and intelligence test scores or school achievement at 17 years of age. However, the risk for low intelligence test scores (IQ score less than 85) was found to be significantly higher (P = .014) among full-term male subjects with serum bilirubin levels above 342 mumol/L (20 mg/dL) (odds ratio, 2.96; 95% confidence interval, 1.29-6.79). This association was not observed among female subjects. We conclude that severe neonatal hyperbilirubinemia, among full-term male newborns with a negative Coombs test, could be associated with lower IQ scores at 17 years of age.