早产儿母乳喂养强化方法的探讨

目的通过回顾性队列研究评价早产儿母乳喂养强化时机对早产儿住院期间生长的影响,探讨早产儿母乳喂养强化的最佳时机和进程。方法选择2009年11月至2011年3月在4家三甲医院新生儿重症监护病房住院治疗、住院期间母乳喂养量大于总喂养量50％并应用母乳强化剂的早产儿为研究对象。根据开始添加母乳强化剂的时间分为早强化组[奶量〈90ml／（kg·d）即开始强化]和晚强化纽[奶量≥90ml／（kg·d）开始强化],再根据从开始添加母乳强化剂至足量强化的时间分为快强化组（1～3天完成足量强化）和慢强化组（≥4天完成足量强化）。对不同组间早产儿的合并症、肠内营养情况及生长情况进行比较。结果符合入选标准的早产儿共67例。早强化组32例,晚强化组35例,两组基本情况、坏死性小肠结肠炎（NEC）等合并症发生率、住院期间体重增长速率差异均无统计学意义（P〉0．05）。早强化组出院时小于胎龄儿（SGA）比例与出生时比较差异无统计学意义（P〉0．05）,晚强化组出院时SGA比例较出生时增多（72．7％比42．9％,P=0．013）。快强化组41例,慢强化组26例,两组基本情况、NEC等合并症发生率差异无统计学意义（P〉0．05）。快强化组住院时间更短[（34．0±15．6）天比（43．0-4-13．6）天,P=0．02],住院期间体重增长速率更快[（18．3±5．3）g／（kg·d）vs（15．7±3．7）g／（kg·d）,P=0．03]。快强化组出院时SGA比例与出生时比较差异无统计学意义（P〉0．05）,慢强化组出院时SGA比例较出生时更多（65．4％比30．8％,P=0．012）。结论早产儿母乳喂养晚强化或慢强化均加剧宫外生长迟缓,早强化或快强化对早产儿是安全的。建议在早产儿母乳喂养量达90ml／（kg·d）之前开始添加母乳强化剂;足量强化应尽量在3天内完成。

Exploration of human milk fortification in preterm infants

Objective To explore the optimal timing to initiate and course to advance feeding of premature infants with human milk fortification. Methods The current retrospective cohort study enrolled Premature infants either were born at, or were transported into the four tertiary hospitals within 12 hours of birth between Nov. 2009 and Mar. 2011. All the participate infants had birth weights 〈~ 1800 g and had more than 50% of total milk intake during hospitalization from maternal breast milk supplemented with human milk fortifier （HMF）. Based on the timing of HMF fortified breast milk introduction, the infants were separated into two groups： Early Fortification Group with HMF fortification before enteral intake reached 90 ml/（kg-d） ; and Late Fortification Group with HMF fortification when enteral intake I〉90 ml/（kg, d）. Based on the speed of HMF fortified milk titration, the infants were also divided into Rapid Fortification Group for which time from receiving HMF to full fortification is within 3 days, and Slow Fortification Group for which time from starting HMF to full fortification is ≥4 days. Infant morbidity, enteral nutrition and growth rate among the different groups were compared. Results Sixty seven infants were included. Fortification was started when enteral intake reached （67.2 ± 20. 3） ml/kg and （127.0 ± 37.0 ）ml/kg in the early and late fortification groups respectively. There were no significant differences in infant characteristics, incidence of necrotic enteral colitis （NEC） or other complications between the two groups. In the late fortification group, the incidence of growth failure had increased significantly （72.7% vs. 42.9% , P = 0.013 ） over time, however, did not change significantly in early fortification group. In the slow fortification group, the incidence of growth failure also increased significantly （65.4% vs. 30.8% , P =0. 012） over time, but did not change significantly in rapid fortification group. Infants in the rapid fortification group also had shorter length of hospitalization [（34.0±15.6） days vs. （43.0±13.6） days,P=0.02] and greater gain in weight [（18.3 ±5.3） g/（kg·d） vs. （15.7±3.7） g/（kg·d） , P =0.03] than the slow fortification group. Conclusions For treatment of extrauterine growth restriction, both early and rapid fortification of human milk were well tolerated. It is suggested that HMF supplementation of human milk fortifier should be initiated before enteral milk intake reaches 90 ml/kg · d and that full fortification of HMF should be achieved within 3 days.