晚期早产儿脑损伤的常见发病因素

晚期早产儿又称近足月儿.该胎龄的早产儿外表接近成熟,由于器官发育不成熟,比足月儿存在更大发病风险,脑损伤与足月儿相比发病风险明显增加,脑性瘫痪的发病率增加3倍,生长发育/心理发育迟缓也有明显增多,这主要与晚期早产儿脑发育不成熟有关.晚期早产儿其他系统的常见病发生率也比较高,如窒息、低血糖、高胆红素血症、呼吸窘迫综合征、...     

早产儿血清脂联素与骨密度的关系

目的 检测早产儿血清脂联素水平,探讨早产儿血清脂联素与骨密度的关系.方法 共选取72 例新生适于胎龄儿为研究对象,根据胎龄分为早期早产儿组(31~33+6 周,13 例)、晚期早产儿组(34~~36+6周,16 例)、足月儿组(37~42 周,43 例).生后1 周内采集静脉血测定血清脂联素水平;同时行超声定量技术测量左侧胫骨声波的传导速度(SOS)来评估骨密度.结果 早期早产儿组胫骨SOS 值低于晚期早产儿组和足月儿组,晚期早产儿组胫骨SOS 值低于足月儿组,差异均具有统计学意义(P<0.05).早期早产儿组血清脂联素水平低于晚期早产儿组和足月儿组,晚期早产儿组血清脂联素水平低于足月儿组,差异均具有统计学意义/(P<0.05).早产儿血清脂联素水平与胫骨SOS 值呈正相关(r=0.664,P<0.05).多元线性回归分析显示血清脂联素和出生体重是早产儿胫骨SOS 值的独立影响因素.结论 早产儿血清脂联素水平低于足月儿,与早产儿骨密度呈正相关.     

晚期早产儿的临床特点及神经发育异常的风险

晚期早产儿又称近足月儿,是一种特殊胎龄段的早产儿,因其具有独特的生理及病理特点,逐渐引起人们的重视,并从早产儿中单独分出.晚期早产儿虽然外表接近成熟,但相比足月儿仍存在很大发病风险,是一个不可忽视的高危新生儿人群.     

晚期早产儿的临床回顾分析

目的 研究晚期早产儿存在的临床问题.方法 回顾性总结我院新生儿病房及新生儿监护病房2007年9月至2008年9月收治的晚期早产儿508例、足月儿1 514例的临床资料.记录低体温、呼吸窘迫、暂时性呼吸增快、低血糖、黄疸、颅内出血的发生率及临床转归.结果 与足月儿相比.晚期早产儿低体温(13.4%vs 0)、低血糖(19.9%vs 3.0%)、呼吸窘迫(38.6%vs 10.8%)、暂时性呼吸增快(31.0%vs 13.1%)、颅内出血(5.1%vs 2.3%)、黄疽(55.0%vs 33.0%)及喂养不耐受(52.4%vs 14.2%)的发生率高,差异有非常显著性(P＜0.01).晚期早产儿接受机械通气、应用肺表面活性物质和经鼻持续气道正压通气呼吸支持的比例高于足月儿(P＜0.05,P＜0.01).晚期早产儿未完成治疗的比例高于足月儿(P＜0.01).结论 晚期早产儿比足月儿存在更多的临床问题,是不应被忽视的高危人群.     

晚期早产儿-大自然未完成的杰作

晚期早产儿（late preterm infants）是指胎龄为34~36+6周的早产儿。由于生理和代谢功能不成熟，与足月儿相比，晚期早产儿发病率和病死率较高。晚期早产儿是“极好的冒充者和假装者”，因为他们冒充并假装成足月儿。因其体型大小与足月儿相似，他们常常被当作足月儿，从而造成潜在的不良后果。本综述阐述了晚期早产的发生率和高危因素、早期疾病、晚期并发症，以及医疗护理。我们使用关键词“晚期早产儿”和“近足月儿”对2005年1月至2012年3月期间PubMed、OVID、Embase等计算机数据库的文献进行了检索。通过详细检索，我们获得了用于晚期早产儿监护的一些循证指南。     

晚期早产儿呼吸系统疾病患病临床特点

目的：探讨晚期早产儿呼吸系统疾病患病的临床特点。方法：选取2009年1月至2010年12月在我院产科出生的新生儿,其中晚期早产儿 (胎龄34~36+6周)630例,足月儿4401例,早期早产儿（胎龄≤33+6周）328例。其中患呼吸系统疾病者包括晚期早产儿84例,足月儿135例,早期早产儿182例。比较3组新生儿呼吸系统疾病发病情况、临床特点及危重程度。结果：（1）晚期早产儿组呼吸系统疾病发生率、病死率及危重症比例均高于足月儿组,而低于早期早产儿组(P<0.01)。（2）晚期早产儿组呼吸困难起病时间早于足月儿组,晚于早期早产儿组（P<0.01）;呼吸增快百分比较其他两组高,而三凹征百分比较低(P<0.05); 晚期早产儿组需氧疗及机械通气的比例均明显高于足月儿组,而低于早期早产儿组(P<0.05)。（3）多元线性回归分析发现血氧分压降低、红细胞压积减低、血pH值减低、呼吸减慢、动脉血氧饱和度减低、动脉收缩压减低、5 min Apgar评分减低、胎龄较小、血尿素氮增高、心率增快、呼吸增快是新生儿呼吸系统疾病危重症的影响因素。结论：晚期早产儿比足月儿更容易出现呼吸系统疾病,危重程度较重,需加强呼吸支持。晚期早产儿呼吸困难多表现为呼吸增快,起病时间早于足月儿而晚于早期早产儿。对于晚期早产儿,如发现呼吸困难、心率、血压异常及多系统受累表现,常提示其病情危重,应积极治疗。     

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目的 探讨早期、晚期早产儿与足月儿呼吸窘迫综合征(RDS)的发病趋势和临床特征的差异,为临床合理诊治提供依据。方法 2006年1月至2010年12月在郑州大学第三附属医院住院的963例RDS患儿根据胎龄不同分为早期早产儿组(<34周)679例,晚期早产儿组(34～<37周)204例,足月儿组(≥37周)80例,分别对各组患儿的发病率、入院情况、高危因素、临床诊治、预后及并发症进行比较。结果 RDS的发病率逐年增加,均以早期早产儿占多数,晚期早产儿和足月儿RDS比例有增多趋势;RDS患儿男婴超过女婴(P<0.05),且胎龄和体重越大,男婴比例越高;足月儿RDS组产前糖皮质激素使用率明显低于早产儿组;早产儿发生RDS的高危因素主要有胎膜早破、胎盘异常、母亲妊娠高血压疾病,足月儿发生RDS的高危因素主要是择期剖宫产与感染;晚期早产儿与足月儿RDS的临床诊断和应用肺泡表面活性物质(PS)时间均晚于早期早产儿;足月儿RDS应用机械通气比例明显高于早产儿,其临床治愈率高(P<0.05),在死亡率方面与早产儿组无差别;但并发气胸的比例高于早产儿组(P<0.05)。结论 新生儿呼吸窘迫综合征(NRDS)发病率逐年增高,晚期早产儿和足月儿RDS比例有增多趋势;早期、晚期早产儿与足月儿RDS在性别比例、高危因素、起病特点、治疗反应与并发症方面均存在差异,RDS的诊治需要考虑胎龄因素。足月儿RDS多与择期剖宫产、感染有关,发病相对较晚,容易合并气胸,应引起足够重视。     

晚期早产儿的研究进展

当前国外把34周≤胎龄(gestational age,GA)＜37周的早产儿视为早产儿亚群,定义为接近足月儿/晚期早产儿(Late Preterm Infants, LPIs)[1].因为"晚期早产儿"能更好地反映出接近足月儿人群有着较高风险的并发症,所以推荐使用"晚期早产儿"取代"接近足月儿"[2].虽然与出生体重600 g的微型儿相比,晚期早产儿的发病率很轻微,但其人数众多,却成了巨大的医疗负担[3].     

晚期早产儿的母源性影响因素及其近远期风险

晚期早产儿,为胎龄介于34+ (0-7)至36 +(6-7)孕周出生的新生儿.虽然晚期早产儿的外观发育特点与足月儿相近,但因其各系统尚未完全发育成熟,导致其并发症发生率与病死率均高于足月儿.人们逐渐认识到,要降低晚期早产率必须研究其发生原因并进行本质干预.目前发现母亲孕期某些高危因素与晚期早产的发生有着密切联系,如妊娠期高血压、妊娠期贫血、胎膜早破等,并且这些母源性因素将对晚期早产儿出生后的生长发育有重要影响.     

晚期早产儿近期并发症及智能发育前瞻性研究

目的前瞻性观察晚期早产儿与足月儿生后各系统近期并发症发生率及智能发育情况。方法收集2011年上海交通大学医学院附属新华医院产科出生的新生儿,将晚期早产儿(胎龄34~36周)和足月儿(胎龄37~42周)作为观察对象,记录两组新生儿出生早期各系统并发症发生情况,包括呼吸、循环、消化系统等;随机选择部分转入新生儿科的晚期早产儿,通过多种社会因素配对后,相应选择部分转入新生儿科的足月儿,两组在校正年龄6个月、1周岁及2周岁时进行智能测试,比较其各年龄段智能水平。结果研究期间共纳入晚期早产儿183例,足月儿2 144例。晚期早产儿先天畸形(14.8%比4.5%)和喂养不耐受(7.1%比0.1%)发生率均高于足月儿(P<0.05)。转入新生儿科治疗的晚期早产儿88例,足月儿364例,住院治疗的晚期早产儿低血糖(23.9%比3.0%)、低钙血症(4.6%比0.8%)、呼吸窘迫综合征(10.2%比0)、呼吸暂停(12.5%比0)、吸入性肺炎(31.8%比6.9%)、先天性心脏病(40.9%比14.6%)、心肌损害(25.0%比11.8%)、脑室周围-脑室内出血(22.7%比3.3%)、缺氧缺血性脑病(4.6%比0.3%)及败血症(10.2%比2.2%)发生率均高于足月儿(P<0.05)。1周岁时晚期早产儿粗、细动作落后于足月儿,2周岁时细动作、语言、应人能力落后于足月儿,差异有统计学意义(P<0.05)。结论晚期早产儿生后近期各系统并发症发生率较高,智能发育欠佳,需加强监护并进行针对性干预。     

287例晚期早产儿早产危险因素及并发症研究

目的：探讨晚期早产儿(late preterm infant, LPI) 早产相关危险因素及临床常见并发症。方法：对287例LPI临床资料进行回顾性分析,同时随机抽取288例同期住院的足月新生儿作对照,应用logistic回归分析的方法筛选LPI早产的危险因素,并分析其常见临床并发症的发生等情况。结果：Logistic回归显示双胎、妊娠期糖尿病、先兆子癎及子癎、前置胎盘、胎盘早剥及胎膜早破为LPI早产发生的危险因素。LPI住院时间明显长于足月儿,其各系统并发症发生率均较高,其中以贫血、吸入性肺炎、低血糖症、颅内出血等为主。结论：LPI生后易发生多种并发症,应注意密切观察,及时救治。避免围产期异常分娩因素的发生是降低LPI出生的关键。     

"Late-preterm" infants: a population at risk

Late-preterm infants, defined by birth at 34(0/7) through 36(6/7) weeks' gestation, are less physiologically and metabolically mature than term infants. Thus, they are at higher risk of morbidity and mortality than term infants. The purpose of this report is to define "late preterm," recommend a change in terminology from "near term" to "late preterm," present the characteristics of late-preterm infants that predispose them to a higher risk of morbidity and mortality than term infants, and propose guidelines for the evaluation and management of these infants after birth.     

The late preterm infant

Late preterm birth refers to birth at 34–36 weeks of gestation, which can occur for many different maternal and fetal reasons. Infants born late preterm represent almost three quarters of all preterm births, yet they have been studied much less than their more immature counterparts born at the limits of viability. Whilst problems of late preterm infants are generally fewer and milder than those of the most immature infants, nevertheless they are at increased risk of adverse neonatal outcomes. Mortality rates are higher than term infants and common morbidities in the neonatal period for late preterm infants include hypothermia, hypoglycaemia, difficulties in establishing oral feeding, jaundice and respiratory compromise. Long term health and neurodevelopmental problems, as well as educational difficulties are also known to occur, and effects of prematurity in this group may extend into adolescence and adulthood. Currently neonatal care for late preterm infants is delivered in a variety of settings and management varies between centres. This review aims to identify some of the key themes in the available evidence for late preterm babies and consider how this may impact upon health outcomes for these babies now and in future life.     

Role of the Pediatric Nurse Practitioner in Promoting Breastfeeding for Late Preterm Infants in Primary Care Settings

The preterm birth rate has been increasing steadily during the past two decades. Up to two thirds of this increase has been attributed to the increasing rate of late preterm births (34 to < 37 gestational weeks). The advantages of breastfeeding for premature infants appear to be even greater than for term infants; however, establishing breastfeeding in late-preterm infants is frequently more problematic. Because of their immaturity, late preterm infants may have less stamina; difficulty with latch, suck, and swallow; temperature instability; increased vulnerability to infection; hyperbilirubinemia, and more respiratory problems than the full-term infant. Late preterm infants usually are treated as full term and discharged within 48 hours of birth, so pediatric nurse practitioners in primary care settings play a critical role in promoting breastfeeding through early assessment and detection of breastfeeding difficulties and by providing anticipatory guidance related to breastfeeding and follow-up. The purpose of this article is to describe the developmental and physiologic immaturity of late preterm infants and to highlight the role of pediatric nurse practitioners in primary care settings in supporting and promoting breastfeeding for late preterm infants.     

Health economic aspects of late preterm and early term birth

Despite an increasing body of knowledge on the adverse clinical sequelae associated with late preterm birth and early term birth, little is known about their economic consequences or the cost-effectiveness of interventions aimed at their prevention or alleviation of their effects. This review assesses the health economic evidence surrounding late preterm and early term birth. Evidence is gathered on hospital resource use associated with late preterm and early term birth, economic costs associated with late preterm and early term birth, and economic evaluations of prevention and treatment strategies. The article highlights the limited perspective and time horizon of most studies of economic costs in this area; the limited evidence surrounding health economic aspects of early term birth; the gaps in current knowledge; and it discusses directions for future research in this area, including the need for validated tools for measuring preference-based health-related quality-of-life outcomes in infants that will aid cost-effectiveness-based decision-making.     

Visual function assessment in late-preterm newborns

Aim

To describe the development of visual functions in a population of low-risk late preterm infants.

Subjects and methods

Eighty low-risk late preterm with a gestational age between 34.0 and 36.9 weeks were assessed at birth and at term equivalent age (TEA) using a structured visual assessment battery. The results were compared to those previously obtained in term born infants using the same battery.

Results

For 5 items (spontaneous ocular motility, ocular motility with target, fixation, horizontal tracking and color tracking) the results were similar both at birth and TEA; for the other 4 (vertical and arc tracking, ability to discriminate striped black/white targets and attention at distance) visual findings at TEA were more mature than at birth. Comparing the responses in late preterm at TEA and term-born infants at 48 h of life, only 2 items (attention at distance, ability to discriminate black/white stripes) were different, with more mature findings in late preterm infants.

Conclusions

Our results show that in late preterm some aspects of visual functions have a progressive maturation infants between birth and TEA, confirming that the time between birth and term age appears to be crucial for the development of these abilities.     

新生儿出生后24小时内凝血功能检测的临床意义分析

目的探讨不同胎龄以及不同体重新生儿凝血功能指标的差异,为判断凝血功能指标的临床意义提供参考。方法2015年1月至2018年12月期间,在解放军总医院第五医学中心新生儿科住院治疗的新生儿中,纳入170例胎龄28~42周、出生8 h内入院的新生儿,其中男性87例,女性83例。按胎龄分为早期早产儿组、晚期早产儿组和足月儿组。按新生儿出生体重分为正常出生体重组、低出生体重组和极低出生体重组。按是否小于胎龄分为早产适于胎龄儿组、早产小于胎龄儿组、足月适于胎龄儿组、足月小于胎龄儿组。于生后24 h内抽取静脉血,检测活化部分凝血活酶时间(activatedpartial thromboplastin time,APTT)、凝血酶原时间(prothrombin time,PT)、纤维蛋白原(fibrinogen,FIB)、凝血酶时间(thrombin,TT)及D-二聚体(D-dimer)。结果早期早产儿组的APTT、PT、D-二聚体水平均高于晚期早产儿组及足月儿组(P值均<0.05),FIB水平低于晚期早产儿组及足月儿组(P值均<0.05);晚期早产儿组的APTT、PT水平均高于足月儿组(P值均<0.05),但两组间D-二聚体、FIB水平比较,差异无统计学意义(P值均>0.05)。极低出生体重组的APTT、PT、D-二聚体水平均高于低出生体重组及正常出生体重组(P值均<0.05),FIB水平低于低出生体重组及正常出生体重组(P值均<0.05);低出生体重组的APTT、PT水平均高于正常出生体重组(P值均<0.05),但两组间D-二聚体、FIB水平比较,差异无统计学意义(P值均>0.05)。早产小于胎龄儿组D-二聚体水平高于早产适于胎龄儿组(P<0.05),其余指标比较差异无统计学意义(P值均>0.05);足月适于胎龄儿与足月小于胎龄儿组的凝血指标比较,差异均无统计学意义(P值均>0.05)。早产儿出血发生率高于足月儿[26.6%(29/109)与8.2%(5/61),χ^2=9.019,P=0.003]。结论新生儿凝血指标有胎龄和体重差异,胎龄越小、体重越低的新生儿凝血功能越不完善。     

晚期早产儿细胞免疫及体液免疫特点研究

目的 探讨晚期早产儿外周血淋巴细胞亚群和体液免疫指标的特点。方法 选择2012年6月至2013年6月在我院产科出生并除外窒息、感染、免疫缺陷等疾病的晚期早产儿（胎龄34~36周）为观察组,选择同期的早期早产儿（胎龄〈34周）和足月儿（胎龄37~42周）为对照组。所有新生儿均于生后24 h内检测外周血T淋巴细胞亚群分布情况及体液免疫水平。结果符合纳入标准的新生儿共203例,早期早产儿组、晚期早产儿组和足月儿组分别为57例、58例和88例。早期早产儿和晚期早产儿生后24 h内外周血CD3＋、CD4＋、CD8＋及CD4＋/CD8＋均低于足月儿[CD3＋：（47.3%±6.9%）、（60.6%±7.7%）比（73.8%±8.4%）,CD4＋：（27.1%±5.5%）、（37.1%±9.1%）比（50.8%±6.1%）,CD8＋：（14.9%±5.7%）、（17.9%±4.4%）比（21.4%±3.8%）,CD4＋/CD8＋：（1.8±0.5）、（2.1±0.3）比（2.5±0.7）,P〈0.05],晚期早产儿高于早期早产儿（P〈0.05）。早期早产儿和晚期早产儿IgG、IgM均低于足月儿[IgG：（5.33±3.05）、（8.81±2.97）比（12.65±2.21）,IgM：（0.23±0.07）、（0.31±0.14）比（0.45±0.12）,P〈0.05],晚期早产儿高于早期早产儿（P〈0.05）;各组IgA水平差异无统计学意义（P〉0.05）。结论 晚期早产儿的T淋巴细胞亚群水平和体液免疫功能较早期早产儿有所提高,但仍低于健康足月儿,临床工作中应重视对晚期早产儿的护理和预防感染。     

晚期早产儿和早期足月儿1岁时神经心理发育水平的随访研究

目的 探讨晚期早产儿和早期足月儿1岁时的神经心理发育水平。方法 选择矫正年龄为1岁的1 257名儿童为研究对象。根据其出生时胎龄分为4组：早期早产儿（胎龄28~33⁺⁶周）、晚期早产儿（胎龄34~36⁺⁶周）、早期足月儿（胎龄37~38⁺⁶周）及完全足月儿（胎龄39~41⁺⁶周）。采用Gesell发展量表评估其神经心理发育水平，比较各组儿童在1岁时神经心理发育状况。结果 4组儿童1岁时5大能区（适应性、大运动、精细动作、语言、个人社交）发育商的差异均有统计学意义（P < 0.05），且均表现为完全足月儿 > 早期足月儿 > 晚期早产儿 > 早期早产儿的趋势（P < 0.05）；各能区发育迟缓率也均表现为完全足月儿最低，早期早产儿最高（P < 0.05）。与完全足月儿相比，早期足月儿适应能力发育落后的风险增加（OR=1.796，P < 0.05）；晚期早产儿适应能力和精细动作发育落后的风险较高，OR值分别为2.651、2.679（P < 0.05）；早期早产儿适应能力、精细动作和个人社交能力发育落后的风险较高，OR值分别为4.069、3.710、3.515（P < 0.05）。结论 儿童1岁时神经心理发育落后的风险随出生胎龄的增加而降低，呈现剂量反应效应。早期足月儿和晚期早产儿仍然存在不同程度的发育落后，应重视早期足月儿和晚期早产儿的保健随访。     

Clinical Issues in the Management of Late Preterm Infants

Prematurity is defined as birth before 37 weeks of gestation and is the major determinant of morbidity and mortality in newborns. The gestational ages known as near term or late preterm represent about 75% of preterm births and are the fastest growing subgroups of premature infants. These infants range in gestational age from 34 0/7 to 36 6/7 weeks and are at greater risk of morbidity, such as respiratory complications, temperature instability, hypoglycemia, kernicterus, feeding problems, neonatal intensive care unit admissions, and adverse neurological sequelae when compared with term infants. Long-term neurological and school-age outcomes of late preterm infants are concerns of major public health importance because even a minor increase in the rate of neurological disability and scholastic failure in this group can have a huge impact on the health care and educational systems. There is an urgent need to educate health care providers and parents about the vulnerability of late preterm infants, who are in need of diligent monitoring and care during the initial hospital stay and a comprehensive follow-up plan for post neonatal and long-term evaluations. Clinicians involved in the day-to-day care of late preterm infants, as well as those developing guidelines and recommendations, would benefit from having a clear understanding of the potential differences in risks faced by these infants, compared with their more mature counterparts.