极低/超低出生体重儿母乳喂养的研究现状与进展

极低/超低出生体重儿的死亡人数占全部新生儿死亡人数的一半以上,相比低出生体重儿(即≥1 500 g),相关并发症发生率更高,预后相对更差,母乳喂养已被证实可以帮助改善其临床结局。本文对极低/超低出生体重儿母乳喂养的研究现状与进展进行综述。     

Respiratory symptoms at age 8 years in a cohort of very low birth weight children.

The childhood respiratory consequences of very low birth weight (birth weight < or =1,500 g) are incompletely understood, especially since the introduction of recent changes in neonatal care. To assess prevalence, trends, and risk factors for respiratory symptoms, the authors followed to age 8 years a cohort of 384 very low birth weight children from six regional neonatal intensive care units in Wisconsin and Iowa who were born between August 1, 1988, and June 30, 1991. A control group of 154 Wisconsin schoolchildren was also assembled. Respiratory symptoms in the past 12 months and history of asthma ("asthma ever") were reported by parents on a questionnaire used in the International Study of Asthma and Allergies in Childhood (ISAAC). Control group prevalence resembled ISAAC prevalence worldwide and in Canada, but respiratory symptoms were twice as common among very low birth weight children. With advent of the availability of pulmonary surfactants, the prevalence of wheezing at age 8 decreased from 50% to 16% (p = 0.002) among children with bronchopulmonary dysplasia, but it increased from 14% to 38% among those with milder neonatal respiratory disease. Bronchopulmonary dysplasia, family history of asthma, smoking in the household, and patent ductus arteriosus were predictive of wheezing in the previous 12 months. Antenatal steroid therapy had a borderline-significant protective association with wheezing (odds ratio = 0.56, 95% confidence interval: 0.29, 1.1). There were interaction effects between several of the predictors.     

Neurodevelopmental outcome at age two years amongst very low birth weight infants: results from a district general hospital

Objectives:

To describe the survival and neurodevelopmental outcome at age 2 years of very low birth weight infants from routinely collected information in a district general hospital setting.

Design:

Case note review and child heath surveillance information was collected on all liveborn < 1,501 ginfants born in our district general hospital over 4 year 1989–1992. Main outcome measures were (a) death before discharge, (b) normal neurodevelopment at age 2 years, (c) minor impairment at age 2 years, (d) major impairment at age 2 years. Comparability with other published work was examined.

Setting:

Rotherham District General Hospital, a maternity unit with neonatal intensive care facilities. Selected infants were transferred for continuing neonatal intensive care to a tertiary unit. Most infants were followed up to age 2 years in a dedicated clinic.

Subjects:

Liveborn very low birth weight infants.

Results:

Over the 4 year period there were 125 liveborn infants < 1,501 g; 93 (74%) survived to discharge home. Defined neurodevelopmental outcome measures were easily retrievable in 92 children at age 2 years from hospital case notes or child health surveillance records. Sixty-four children (70%) were neuro-developmentally normal 10 children (11%) had a major impairment (mostly cerebral palsy) and 18 (19%) had an isolated minor impairment.

Conclusions:

The incidence of major impairment amongst very low birth weight infants in our district general unit is broadly comparable with other published series. Outcome measures of neurodevelopmental status are available from routinely collected clinical information. The use of such measures to make detailed comparisons between units is problematical because of a wide range of confounding variables.     

不同时期极低和超低出生体重儿神经发育预后比较

目的 探讨极低出生体重儿(very low birth weight infant, VLBWI)和超低出生体重儿(extremely birth weight infant, ELBWI)不同时期神经发育损害发生的变化趋势。方法 复旦大学附属儿科医院新生儿科2005年10月1日-2010年12月31日收治并救治成活的VLBWI和ELBWI, 纠正胎龄18～42个月, 完成贝莉婴儿发育量表-Ⅱ(Bayley Scales of Infant Development-Ⅱ, BSID-Ⅱ)的患儿有143例, 按入院时间分为两个阶段, 第一阶段为2005年10月1日-2008年12月31日入院的患儿, 共54例;第二阶段为2009年1月1日-2010年12月31日入院的患儿, 共89例。比较两个阶段患儿的神经发育预后情况。结果 两个阶段的研究对象在性别、胎龄、出生体重及分布上均相似。第一阶段患儿的智力发育指数得分(88.6±19.2)显著低于第二阶段(97.0±14.6)(P=0.004);第一阶段患儿智力发育指数<70的发生率(14.8%)显著高于第二阶段(3.4%)(P=0.014)。第一阶段患儿总体神经发育损害的发生率(22.2%)高于第二阶段(13.5%), 脑瘫发生率(9.3%)高于第二阶段(2.3%), 心理运动发育指数得分(83.6±16.1)低于第二阶段(85.0±13.6), 心理运动发育指数<70分的发生率(16.7%)高于第二阶段(12.4%), 但这几个方面的差异均无统计学意义。结论 医生和家长均应重视VLBWI和ELBWI的出院后随访及早期干预, 以改善患儿的神经发育预后。     

母乳喂养质量改进对极/超低出生体重儿的影响

目的 分析母乳喂养质量改进对极/超低出生体重儿的影响,为对极/超低出生体重儿救治提供有效措施.方法 以本院2018年1月-2019年12月出生且收治入院、出生体重＜1500g的160例早产儿为研究对象,以2019年为干预年,2018年收治的87例新生儿为对照组,2019年收治的73例新生儿为干预组,采用母乳喂养质量改进...     

维生素D水平与极低出生体重儿临床结局的相关性研究

目的分析出生时血清25-羟维生素D[25-(OH)D]水平对极低出生体重儿临床结局的影响,为早产儿相关疾病的预防和治疗提供新的方向。方法选取2019年9月-2020年9月在济宁医学院附属医院NICU住院治疗的105例极低出生体重儿为研究对象,根据出生24 h内血清25-(OH)D水平,将患儿分为维生素D严重缺乏组(A组)、维生素D缺乏组(B组)及维生素D正常组(对照组),对三组母婴一般资料、住院期间的治疗情况、合并症及临床转归进行比较。结果所有患儿出生时血清25-(OH)D平均值为(14.33±3.60)ng/ml,维生素D缺乏的发生率为79.1%。夏秋季节出生的患儿血清25-(OH)D明显高于冬春季节(t=2.71,P=0.01)。A组、B组患儿的出生体重、出生体重Z评分及1 min Apgar评分均较对照组低(F=0.86、 5.43、9.05,P<0.01)。母亲年龄越大,维生素D水平越低,差异有统计学意义(F=8.40,P<0.01)。A组、B组患儿住院时间、用氧时间、机械通气时间、无创通气时间均高于对照组,差异有统计学意义(F=19.65、7.45、15.97、4...     

早期母乳喂养对极低出生体重儿IgA水平和感染状况的影响

[目的]研究早期纯母乳喂养对极低出生体重儿IgA水平和感染状况的影响. [方法]将71例极低出生体重儿随机分为纯母乳早期喂养组36例,早产儿配方乳早期喂养组35例,观察两组患儿生后24 h内和第7 d的IgA水平与两组患儿住院4周内发生感染指征的例数和抗生素使用天数,并进行比较. [结果]生后24 h IgA水平两组无差异性,生后第7 d IgA水平母乳喂养组显著高于配方乳组.母乳喂养组第7 d IgA水平高于生后24 h内,配方乳组生后24 h内和第7 d IgA水平无差异性.母乳喂养组住院4周内感染指征发生率显著低于配方乳组,母乳喂养组抗生素使用天数短于配方乳组. [结论]早期纯母乳喂养町提高极低出生体重儿IgA水平,具有良好的抗病能力.     

母乳喂养质量改进对极低和超低出生体重儿母乳喂养率的影响

目的 研究母乳喂养质量改进措施对极低和超低出生体重儿母乳喂养率的作用,为临床推广应用提供依据。方法 回顾性分析2016年5月-2017年12月医院收治的258例极低和超低出生体重儿临床资料,根据是否实施母乳喂养质量改进措施将其分为对照组100例和改进组158例,对照组患儿采用常规母乳喂养,改进组患儿实施母乳喂养质量改进措施。比较两组患儿母乳喂养情况,住院期间亲母母乳喂养率、喂养量和患儿住院期间生长指标以及总并发症发生率。结果 改进组患儿首次亲母母乳喂养时间、母乳强化剂开始添加时间、达全肠道喂养时间及静脉营养时间均显著短于对照组患儿(P<0.05),亲母母乳喂养率和喂养量明显高于对照组,患儿住院期间体重、身长和头围增长均明显大于对照组(P＜0.05)。改进组患儿喂养不耐受发生率、总并发症发生率明显低于对照组患儿(P＜0.05)。结论 母乳喂养质量改进能明显改善极低和超低出生体重儿母乳喂养情况,提高母乳喂养率和喂养量,促进患儿生长,并可减少并发症发生。     

强化母乳喂养在预防极低出生体重儿感染中的作用

目的 分析强化母乳喂养在预防极低出生体重儿感染中的作用。方法 2015年1月-2016年8月本院新生儿科的极低出生体重儿(1 000 g≤出生体重<1 500 g)80例根据入选标准纳入研究,根据喂养方式不同分为强化母乳实验组40例[住院期间母乳量占喂养总量的75%以上,母乳均来自患儿自己的母亲,母乳喂养量达80 ml/(kg·d)时,添加母乳强化剂(母乳不足部分由早产配方奶补充)],早产配方奶对照组40例(住院期间全部早产配方奶喂养)。比较两组患儿达到全肠道喂养的时间、喂养不耐受情况、院内感染以及新生儿坏死性小肠结肠炎的发生率。结果 两组早产儿在胎龄、性别、体重等方面差异无统计学意义(P>0.05),具有可比性。实验组达到全肠道喂养的时间为(15.22±4.37) d,对照组达到全肠道喂养的时间为(17.38±5.44) d,实验组显著低于对照组(P<0.05)。实验组喂养不耐受发生例数为7例,对照组喂养不耐受发生例数为15例,实验组显著少于对照组(P<0.05)。实验组院内感染2例,对照组院内感染7例,实验组显著少于对照组(P<0.05)。实验组坏死性小肠结肠炎1例,对照组坏死性小肠结肠炎3例,两组差异无统计学意义(P>0.05)。结论 极低出生体重儿实行强化母乳喂养可缩短达到全肠道喂养的时间,减少喂养不耐受的发生,降低院内感染的发生率,同时不增加坏死性小肠结肠炎的发生率。     

强化母乳喂养对住院早产超低和极低出生体质量儿生长发育及内环境的影响

目的分析强化母乳喂养对住院早产超低和极低出生体质量儿生长发育和内环境的影响。方法随机抽取2017年6月-2018年5月秦皇岛市妇幼保健院的早产超低和极低出生体质量儿共134例,根据治疗时间的先后顺序,分为对照组与观察组,每组各67例。两组早产儿均采取常规措施,对照组早产儿采用配方奶粉进行营养补充,观察组早产儿采用强化母乳喂养方式。观察两组早产儿身高、体质量、头围,血清钙、磷、血红蛋白、碱性磷酸酶(AKP)水平,并发症发生率。结果两组早产儿平均日增长体质量、平均周增长身高、最低体质量出现时间、恢复出生体质量时间比较差异均有统计学意义(均P<0. 05)。两组早产儿平均周增长头围比较差异无统计学意义(P>0. 05)。两组早产儿出院前血清AKP水平比较差异有统计学意义(P<0. 05)。两组早产儿喂养不耐受、败血症、支气管肺发育不良发生率比较差异均有统计学意义(均P<0. 05)。结论强化母乳喂养可以显著降低住院早产超低和极低出生体质量儿在治疗护理过程中的并发症发生率,帮助早产儿达到正常的生长发育水平,临床效果显著。     

Follow up of extremely low birth weight infants at the age of 8-11 years (late prognosis of perinatal factors)

Thirty-four long-term survivors of a five-year period (1977-1981) weighing 1000 g or less at birth were followed-up at 8-11 years of age. Fifty per cent of this population was qualified as normal. The great majority of the children (24) attended normal school but 7 (20.6%) with need of special help. There were only three children (8.8%) with severe functional impairment. The rate of survival was 30% at the Neonatal Intensive Care Unit of the Department of Pediatrics, University Medical School, Debrecen at that period of time. The authors analyze in detail the connections of the perinatal events and the outcome. While survival was influenced primarily by hemorrhagic complications beyond immaturity, the long-term prognosis depended on birth asphyxia, recurrent apneic spells and requirements for oxygen therapy.     

极低体重儿的营养支持

随着极低体重婴儿存活率的增加，营养支持显得越来越重要。本文介绍了近年有关的进展，简单提及孕母与胎儿葡萄糖、氨基酸及脂肪的关系，主要总结了极低体重儿肠道营养的重要性及方法，以及静脉营养的重要性和各成份在极低体重儿应用的特点。     

低出生体重儿液体配方奶对极低/超低出生体重儿生后早期生长发育的影响

目的:研究低出生体重儿液体配方奶对极低/超低出生体重早产儿生后早期生长发育的影响,进而评估其临床应用效果。方法:选择胎龄≤32周住院的极低/超低出生体重儿,分为观察组和对照组,分别给予低出生体重儿液体配方奶和普通早产儿配方奶粉喂养,观察喂养后体格发育指标、喂养相关指标、合并疾病等方面的差异,进行统计学分析。结果:应用低出生体重儿液体配方奶喂养的极低和超低出生体重早产儿体重增长速率高于对照组;体重增长所需热量、恢复至出生体重所需时间、喂养耐受时间、静脉营养应用时间均低于对照组;感染、贫血和高间接胆红素血症的发生率低于对照组,差异具有统计学意义(P<0.05)。结论:低出生体重儿液体配方奶由于可提供高热量,有效利用度高,肠道负荷小,且应用方便、能保证极低和超低出生体重儿生后早期良好的生长发育,同时可减少其并发症的发生。     

极低和超低出生体重儿并发脑室出血危险因素研究

目的 分析极低出生体重儿和超低出生体重儿发生脑室出血的危险因素,为临床治疗提供依据。方法 收集2016年7月—2018年7月广东医科大学附属医院新生儿科住院的185例极低、超低出生体重患儿临床资料,对可能影响脑室出血的因素进行单因素分析和多因素Logistic回归分析。结果 Logistic回归分析显示,低血糖(OR=8.772,95%CI:2.880～26.720,P＜0.01)、低血细胞压积(OR=0.211,95%CI:0.072～0.618,P=0.005)、脓毒血症(OR=6.427,95%CI:2.306～17.911,P＜0.01)和机械通气(OR=2.984,95%CI:1.013～8.785,P=0.047)是脑室出血的独立危险因素。结论 极低出生体重儿和超低出生体重儿并发脑室出血的高危因素较多,积极预防低血糖、低血红蛋白压积、感染及合理的机械通气有助于减少极低出生体重儿和超低出生体重儿并发脑室出血。     

Vitamin requirements of very low birth weight infants: a review

This review of the nutritional needs of very low birth weight infants (VLBW) concluded that vitamin supplementation was indicated for vitamins A, D, C, and folic acid. With breast feeding or other circumstances, there may be marginal needs for vitamin E, K, B1, B2, and B6. Supplementation of VLBW depends upon the gestation age, which is related to the placental transfer and body stores at birth, and vitamin content of breast milk or formula (feeds), and volume and micronutrient composition of feeds. The infant's vitamin stores at birth are dependent on the nutritional status of the mother, particularly lipid soluble vitamins, which have been found to be higher in fetal cord blood than in maternal blood. The exception is B6, which crosses the placental barrier with difficulty. Preterm infants and infants of undernourished mothers usually have reduced levels of water soluble vitamins at birth. There is some variability in nutrients of feeds. Breast milk, for instance, has lower levels of vitamins D and K than recommended levels. Needs will also very with the presence of particular nutrients. For example, B6 requirements will vary with protein intake. Vitamin E requirements will depend on the amount of linoleic acid or polyunsaturated fatty acids in the diet. Tryptophan in the presence of B6 allows the synthesis of niacin. Volume of feeding affects nutritional needs. The recommended daily allowance (RDA) of specific nutrients for an infant up to 6 month of age and weighing 3-8 kg requires consumption of 500-1000 ml of breast milk or formula per day. A full term infant can receive sufficient nutrients with 450-750 ml, but below 400 would result in a deficit of vitamins. Unfortunately, the volume of feeds for VLBWs is too low in the first two weeks of life or until the body weight of 2000 g is reached; thus supplementation was recommended. Late anemia due to vitamin E deficiency may be prevented when the alpha tocopherol per gram of polyunsaturated fatty acids ratio is equal to or higher than the recommended levels. When intake of vitamin K at birth is insufficient, deficiencies may appear later; the recommendation was .2 to 1.0 mg at birth as a preventive regimen. Vitamin D was also recommended for both breast and formula fed infants. Pyridoxine/ g protein intake, folic acid, and vitamin C should be provided VLBW infants as indicated.     

超低出生体重儿住院、转归及其随访研究

目的探讨超低出生体重儿(ELBWI)的住院、转归及其随访情况。 方法选择2010年1月1日至2016年5月31日,于广西壮族自治区妇幼保健院、玉林市妇幼保健院、钦州市妇幼保健院等10家医疗机构的新生儿重症监护病房接受住院治疗的276例ELBWI为研究对象。对其临床病例资料及随访资料,进行回顾性分析,内容包括孕母及ELBWI一般临床资料,ELBWI新生儿期常见临床症状、并发症、转归及出院后随访情况等。采用χ²检验及Mann-Whitney U检验,对ELBWI出生胎龄<28周与出生胎龄≥28～32周,并存活出院者的呼吸支持治疗情况进行统计学比较。本研究遵循的程序符合2013年修订的《世界医学协会赫尔辛基宣言》要求。 结果①本研究分娩ELBWI的209例孕妇中,双胎妊娠孕妇占31.6%(66/209)。这209例分娩ELBWI孕妇的前3位妊娠期并发症依次为：胎膜早破(27.3%,57/209),妊娠期高血压疾病(19.6%,41/209)及妊娠期糖尿病(17.7%,37/209)。②本研究276例ELBWI中,新生儿期前4位常见临床症状依次为：呼吸困难(91.7%,253/276),反应差(75.7%,209/276),口唇或全身青紫(67.8%,187/276)及腹胀(40.6%,112/276)。③本研究276例ELBWI中,新生儿期前6位并发症依次为：高胆红素血症(81.2%,224/276),呼吸窘迫综合征(RDS)(75.7%,209/276),早产儿贫血(64.1%,177/276),宫内感染性肺炎(50.0%,138/276),支气管肺发育不良(BPD)(48.6%,134/276)及败血症(45.7%,126/276)。④存活出院的128例ELBWI中,出生胎龄<28周ELBWI的呼吸机辅助通气治疗率及治疗时间分别为92.6%和8.0 d(3.0～16.0 d)、连续气道正压通气(CPAP)治疗率及治疗时间,分别为96.3%和16.0 d(11.0～25.0 d),均显著高于或长于出生胎龄≥28～32周者的67.2%、2.0 d(0～7.5 d)、73.4%、7.5 d(0～20.0 d),并且差异均有统计学意义(χ²＝11.321、P＝0.001,Z＝－3.994、P<0.001,χ²＝11.329、P＝0.001,Z＝－3.301、P＝0.001)。⑤本研究276例ELBWI救治存活率为46.4%(128/276),其中88例为治愈出院,40例为好转出院,137例(49.6%)死亡(36例因抢救无效死亡,101例因家属放弃治疗后很快死亡),其余11例由家属签字出院后结局不详。⑥对128例存活出院ELBWI进行随访的结果显示,25例失访,失访率为19.5%(25/128)。103例完成随访ELBWI中,4例于生后6个月内死亡;48.1%(39/81)听性脑干反应测听未通过,69.4%(59/85)合并早产儿视网膜病(ROP)。完成随访并且存活的99例ELBWI中,运动、语言发育落后者分别占27.3%(27/99)、17.2%(17/99),仅37.4%(37/99)按时接受《盖塞尔发育量表》评估,或于新生儿科/康复科接受随访。 结论ELBWI发生的常见原因为双胎、孕妇胎膜早破及妊娠期高血压疾病。ELBWI新生儿期并发症多,死亡率高,出院后应对其密切随访。     

21例极低出生体重儿临床分析

目的:通过分析极低出生体重儿的临床特点,探讨如何提高VLBWI的存活率。方法:回顾性分析我院2年间收治的21例VLBWI患儿的资料。结果:21例VLBWI患儿中伴低体温61.9%,伴并发症71.4%,合并感染性疾患47.6%,死亡14.3%,好转及放弃42.9%,存活38.1%。结论:由于VLBWI患儿各脏器功能不成熟,易引起一系列病理生理改变,存活率低。临床上合理喂养,维持正常体温,治疗并发症、防治感染、呼吸暂停,是提高低体重儿存活的关键。     

极低出生体重儿早期营养状况对神经发育的影响

目的探讨新生儿重症监护病房极低出生体重儿早期营养状况对其后期神经发育的影响。方法 2013年1月-2014年6月在广州市妇女儿童医疗中心NICU住院的极低出生体重儿86例,出院后定期在本院高危儿门诊随访,根据其矫正年龄3个月发育评估测试所得发育商(DQ)分为神经发育正常组和神经发育异常组,对两组患儿住院期间的营养状况进行分析。结果神经发育正常组生后第4、7、14天总能量、肠内能量所占比例及第4、7天氨基酸供给量均高于神经发育异常组,差异具有统计学意义(P0.05);神经发育正常组体重下降严重程度较神经发育异常组轻,恢复出生体重时间及达到全胃肠道喂养时间较神经发育异常组早,两组差异具有统计学意义(P0.05)。结论极低出生体重儿早期良好的营养状况可明显改善其神经系统发育结局。