新生儿高胆红素血症就诊延迟的影响因素分析

Analysis of influencing factors for delayed treatment of neonatal hyperbilirubinemia

目的探讨新生儿高胆红素血症就诊延迟的相关因素,减少急性胆红素脑病(acute bilirubin encephalopathy,ABE)的发生。方法2018年1月至2020年12月,就诊于山西省儿童医院新生儿科的患儿中,纳入128例血清总胆红素(total serum bilirubin,TSB)达换血水平的高胆红素血症新生儿为研究对象。根据患儿就诊日龄分为2组:≤7 d组(n=88)和>7 d组(n=40),比较2组患儿的ABE及不良预后的发生情况。分析围产因素、喂养方式、分娩医院因素、母亲因素、疾病因素和居住地因素对就诊时机的影响。统计学方法采用t检验、χ^(2)检验、Fisher确切概率法,多因素Logistic回归分析。结果TSB达换血水平的高胆红素血症新生儿占同期住院新生儿的0.87%(128/14652)。就诊日龄≤7 d组的ABE发生率低于>7 d组[31.8%(28/88)与80.0%(32/40),χ^(2)=25.637,P<0.001]。随访至10~18月龄,≤7 d组不良预后发生率低于>7 d组[13.3%(11/82)与38.1%(12/31),χ^(2)=8.879,P=0.003]。比较就诊日龄≤7 d组与>7 d组的胎龄[(38.8±1.5)与(37.9±2.1)周,t=2.502,P=0.015]、剖宫产比例[36.4%(32/88)与12.5%(5/40),χ^(2)=7.620,P=0.006]、配方乳喂养的比例[76.1%(67/88)与20.0%(8/40),χ^(2)=35.719,P<0.001]、产科出院医嘱黄疸随访日龄≤3 d的比例[83.0%(73/88)与5.0%(2/40),P<0.001]、母亲受教育程度大专及以上的比例[81.8%(72/88)与42.5%(17/40),χ^(2)=20.067,P<0.001]、溶血性黄疸的比例[55.7%(49/88)与10.0%(4/40),χ^(2)=23.654,P<0.001]、社区有黄疸检测手段的比例[58.0%(51/88)与27.5%(11/40),χ^(2)=10.212,P=0.001],就诊日龄≤7 d组均高于>7 d组。多因素Logistic回归分析结果显示,母亲受教育程度高中及以下(OR=15.119,95%CI:1.966~116.246,P=0.009)、非溶血性黄疸(OR=11.602,95%CI:1.427~94.322,P=0.022)、母乳喂养(OR=51.635,95%CI:5.968~446.728,P<0.001)、产科出院医嘱黄疸随访日龄>3 d(OR=255.857,95%CI:16.827~3890.365,P<0.001)、胎龄小(OR=1.768,95%CI:1.069~2.924,P=0.026)为患儿就诊延迟的危险因素(P值均<0.05)。结论为降低新生儿ABE发病率,应当指导新生儿出院后继续监测黄疸、合理母乳喂养,扩大科普知识受众面,加强产儿科医师对高胆红素血症高危因素的识别及诊断能力,进而改善疾病预后。

Objective To investigate influencing factors for delayed treatment of neonatal hyperbilirubinemia,with the aim of finding a solution to reduce the occurrence of acute bilirubin encephalopathy(ABE).Method From January 2018 to December 2020,the 128 neonates who met the exchange transfusion criteria at admission in the Department of Neonatology,Shanxi Children's Hospital,who were selected as the research objects.According to the visiting age,they were divided into≤7 d group(n=88)and>7 d group(n=40).The incidence of ABE and poor prognosis were compared between the two groups.Perinatal factors,feeding patterns,delivery hospital factors,maternal factors,disease factors and residence factors were analyzed.The t test,χ^(2) test,Fisher exact probability method and multivariate Logistic regression analysis were adopted.Result 128 neonates who met the exchange transfusion criteria accounted for 0.87%(128/14652)of all neonates who required hospitalization.The incidence of ABE in the≤7 d group was lower than that in the>7 d group[31.8%(28/88)vs 80.0%(32/40),χ^(2)=25.637,P<0.001].All enrolled neonates were followed up to 10-18 months of age.The incidence of adverse prognosis in the≤7 d group was significantly lower than that in the>7 d group[13.3%(11/82)vs 38.1%(12/31),χ^(2)=8.879,P=0.003].The gestational age[(38.8±1.5)vs(37.9±2.1)weeks,t=2.502,P=0.006]and the proportion of cesarean section[36.4%(32/88)vs 12.5%(5/40),χ^(2)=7.620,P=0.006],the proportion of formula feeding[76.1%(67/88)vs 20.0%(8/40),χ^(2)=35.719,P<0.001],the proportion of obstetrical discharge instruction jaundice followup age≤3 d[83.0%(73/88)vs 5.0%(2/40),P<0.001],the proportion of mothers with college education or above[81.8%(72/88)vs 42.5%(17/40),χ^(2)=20.067,P<0.001],the proportion of hemolytic jaundice[55.7%(49/88)vs 10.0%(4/40),χ^(2)=23.654,P<0.001],the proportion of jaundice detection methods in the community[58.0%(51/88)vs 27.5%(11/40),χ^(2)=10.212,P=0.001],≤7 d group were higher than that in the>7 days group.Multivariate Logistic regression analysis showed that the mothers had high school education or below(OR=15.119,95%CI:1.966-116.246,P=0.009),non-hemolytic jaundice(OR=11.602,95%CI:1.427-94.322,P=0.022),breast feeding(OR=51.635,95%CI:5.968-446.728,P<0.001),follow-up age in discharge instructions of obstetrics>3 d(OR=255.857,95%CI:16.827-3890.365,P<0.001),low gestational age(OR=1.768,95%CI:1.069-2.924,P=0.026)were the risk factors affecting the timely treatment of children(all P<0.05).Conclusion In order to reduce the incidence of neonatal ABE,it is necessary to monitor the neonatal jaundice after discharge,rationalizing breastfeeding,make the popular science knowledge about jaundice to more people,strengthen the ability of paediatricians and obstetricians to identify and diagnose high risk factors of hyperbilirubinemia,so as to improve the prognosis.