极低及超低出生体重儿肺出血的影响因素及预后分析

目的 探讨极低及超低出生体重(出生体重≤1200g)早产儿肺出血的影响因素及预后.方法 回顾性分析2010年1月至2015年12月于中国医科大学附属盛京医院第二新生儿科住院、出生体重≤1200g、住院期间发生肺出血的极低及超低出生体重儿临床资料,同期住院、相同体重范围非肺出血早产儿作为对照组.比较两组母孕期及新生儿期特点,多元回归分析探讨肺出血影响因素,了解肺出血新生儿的近期预后.结果 肺出血新生儿(肺出血组)71例,对照组364例.肺出血发生于 3d 以内者57例(占80.3%),肺出血组胎龄(28.2±1.7)周、出生体重(936±192)g,均明显低于对照组[(29.5±2.1)周,(1033±134)g,t分别为4.776、-5.145,P<0.01].肺出血组呼吸窘迫综合征(RDS)(76.1%)、肺表面活性物质治疗(76.1%,其中≥2次使用率9.9%)、动脉导管未闭(PDA)(66.2%)比例均明显高于对照组[41.2%、30.8%(4.1%)和38.7%,χ2值分别为33.457、28.970(4.074)和32.798,P<0.05].肺出血组产前类固醇激素治疗率(21.1%)亦明显低于对照组(41.2%,χ2=10.177,P<0.01).多因素Logistic逐步回归分析显示,RDS(OR=3.739,95%CI 1.383-10.113,P<0.05)、PDA(OR=2.206,95%CI 1.205-4.093,P<0.05)及5 min Apgar评分<7(OR=2.851,95%CI 1.191-6.828)是肺出血的独立危险因素;出生体重大(OR=0.998,95%CI 0.996-1.000,P<0.05)及母孕期应用激素 (OR=0.432,95%CI 0.224-0.834,P<0.05)是肺出血的保护因素.肺出血组颅内出血、早产儿视网膜病及重度支气管肺发育不良发生率(16.9%、12.7%及18.3%)明显高于对照组(5.8%、4.4%及2.2%,χ2值分别为36.824、7.520及33.568,P<0.01).肺出血组病死率(49.3%)亦明显高于对照组(14.0%,χ2=46.634,P<0.01).结论 多种围生期因素与肺出血有关;预防早产及产前类固醇激素治疗有助于预防肺出血;肺出血新生儿不良预后发生率高.     

极低及超低出生体重儿的预后因素分析

目的 分析极低及超低出生体重儿（出生体重≤ 1 200 g）的临床资料,为其预后及临床干预提供预警指标。方法 回顾性分析108 例极低及超低出生体重儿的母孕期病史、新生儿出生时情况、诊治经过及预后,采用非条件logistic 回归分析筛选预后的影响因素。结果 108 例极低及超低出生体重儿,出生体重范围在结论 极低及超低出生体重儿的病死率较高,且随着日龄的增加,影响早产儿生存的预后因素不同,临床上应针对这些因素制定合理的管理方案,提高早产儿生存率。     

不同输血策略对贫血的极低出生体重儿治疗转归的影响

目的：观察限制性输血、非限制性输血两种不同输血策略对极低出生体重儿的病情及预后的影响,为制定输血策略、合理输血提供依据。方法：首次入住我院NICU,住院期间接受输血治疗的93例早产极低出生体重儿资料进行回顾性分析。其中35例接受限制性输血,58例接受非限制性输血。结果：①限制性输血组输血次数比非限制性输血组多（2.6±1.8 vs 1.8±1.0, P<0.05）,且机械辅助通气天数比非限制性输血组明显增多（8.0±5.9 d vs 5.5±4.2 d, P<0.05）。②非限制性输血的患儿恢复至出生体重所需时间比限制性输血患儿少(中位数：10 d vs 13 d,P<0.01)。③两组患儿呼吸暂停及院内感染的发生率差异无显著性。结论：非限制性输血可能更利于临床恢复,部分患儿因保守输血而出现的临床并发症使得输血次数或输血量增多。在输血策略上,不要一味追求保守输血策略,要权衡利弊,科学合理用血。［中国当代儿科杂志,2010,12（1）：9-12］     

Transthyretin levels are not related to Apgar score in low birth weight and very low birth weight infants

BACKGROUND: Previous studies have reported an increased incidence of thyroid dysfunction in premature/low birth weight infants. The cord blood concentrations of transthyretin (TTR), a thyroid hormone binding protein, have also been found to be decreased in preterm infants. While thyroid hormone concentrations are decreased in sick infants, it is not known if physical condition influences TTR levels. Serial concentrations of TTR following birth have not previously been reported. AIMS: To measure serial serum concentrations of TTR in premature infants following birth, and determine whether TTR levels are related to physical condition. METHODS: A cohort of 65 premature very low birth weight (VLBW) and LBW infants were studied. Serum samples were obtained on the day of birth, and for 8 weeks following birth. Apgar scores at birth as well as the incidence of respiratory distress syndrome (RDS) were noted. RESULTS: Baseline serum T4 concentrations and Apgar scores were significantly lower in VLBW infants, while the severity of RDS was significantly higher in the VLBW group. Multivariate analyses revealed that T4 levels were negatively associated with RDS, while TSH concentrations were positively related to gestational age. TTR concentrations were not related to gestational age at birth, Apgar score, or RDS, and did not change markedly over 8 weeks. CONCLUSIONS: These findings suggest that serum TTR concentrations are not related to birth weight/gestational age and are not associated with either clinical condition at birth (as assessed by Apgar score) or the occurrence of RDS. Reference values for TTR concentrations in VLBW and LBW infants are provided from birth to 8 weeks of age.     

极低出生体质量儿闪光视觉诱发电位检测的临床意义

目的 研究极低出生体质量儿闪光刺激视觉诱发电位(FVEP)检测的临床意义.方法 应用英国Oxford公司Medelecsynergy诱发电位仪对43例极低出生体质量儿进行FVEP检测,并选择56例正常足月儿做对照.结果 极低出生体质量儿N1、P1、N2波潜伏期值分别为(181.43±26.73)ms、(217.27±26.54)ms、(249.21±26.49)ms,足月儿分别为(159.51±18.27)ms、(200.26±13.94)ms、(231.56±5.72)ms,两组比较差异有显著性(P＜0.05,P＜0.001).极低出生体质量儿P1波的异常率为75.6%,足月儿为0.极低出生体质量儿P1波异常相关影响因素的主效应模型为3.898-2.861颅内病变,颅内病变是独立影响因素(OR=0.057,95%CI 0.006～0.579,P=0.015).结论 极低出生体质量儿FVEP检测P1波异常率高,FVEP异常改变与颅内病变关系密切.极低出生体质量儿在生后1个月内和矫正胎龄42周后至少进行两次FVEP检查,动态观察FVEP改变.     

极低出生体重儿肠内营养与生长速度的研究进展

本文阐述了极低出生体重儿消化系统特点、肠内营养方式、乳类选择、开始时间、奶量增长速度及理想的生长速度,旨在了解不同的肠内营养开始时间对极低出生体重儿消化功能及生长速度的影响,以期寻找极低出生体重儿适宜的肠内营养开始时间,为临床制定极低出生体重儿肠内营养方案提供依据.     

Population-based study of bronchopulmonary dysplasia in very low birth weight infants in Switzerland

In Switzerland, data are collected prospectively by collaborators from all nine neonatal intensive care units and their affiliated paediatric units caring for neonates, to determine survival and (pulmonary) outcome of infants with birth weights ranging from 501 to 1500 g. To assess the pulmonary outcome of very low birth weight (VLBW) infants in Switzerland in 1996 and 2000, factors associated with bronchopulmonary dysplasia (BPD) were identified and compared with pulmonary outcomes from the Vermont Oxford Network data. BPD was defined as a requirement for supplemental oxygen at 36 weeks postmenstrual age. Complete data were available for 600 and 636 VLBW infants in 1996 and in 2000, respectively. Mortality rates in Switzerland were significantly higher (1996: 19.2%, 2000: 20.8%) than in the Vermont Oxford Network (1996: 14%, 2000: 14%). Expressed as percentage of infants still hospitalised at 36 weeks postmenstrual age, 16.7% and 13.2% of Swiss VLBW infants were diagnosed with BPD in 1996 and 2000, respectively. These rates were significantly lower than in the Vermont Oxford Network (1996: 28%, 2000: 35%). Infants exposed to factors previously shown to be associated with BPD were investigated: in Switzerland, infants with a history of surfactant replacement therapy and/or mechanical ventilation had a significantly higher rate of BPD in both cohorts. Infants with postnatal transport, sepsis proven by positive blood culture and patent ductus arteriosus had a higher BPD rate only in the 1996 cohort. Between 1996 and 2000, mortality rates and incidence of BPD in VLBW infants remained unchanged in Switzerland. BPD rates in Switzerland are lower than those found in the Vermont Oxford Network whereas a mortality rate comparison displays an inverted picture. We suspect that these effects are interrelated and may be due in part to a selective approach of Swiss neonatologists to resuscitation of infants in the smallest birth weight stratum. Conclusion:The factors listed above have apparently become less important in the context of bronchopulmonary dysplasia and other influences, including prenatal conditions, will need to be investigated.     

Bronchopulmonary dysplasia in very low birth weight infants

Objective  The developments in newborn care have enabled many more very low birth weight premature infants to live. The aim of our study was to determine the risk factors for bronchopulmonary dysplasia (BPD) development by evaluating mild and moderate/severe BPD in extramural neonates with a birth weight <1501 g. Methods  A case-control study was conducted between January 1, 2004- December 31, 2006 at the Dr. Sami Ulus Children’s Hospital Neonatal Intensive Care Unit. Patients with BPD and without BPD were compared. Bronchopulmonary dysplasia was diagnosed and classified according to the Bancalari criteria. One-hundred and six (106) extramural premature infants with a birth weight <1501 g and admitted to the Neonatal Unit in the first three days of life and survived for more than 28 postnatal days were included. Patients with multiple congenital anomalies and complex cardiac pathologies were excluded. The maternal and neonatal risk factors, clinical features, mechanical ventilation treatment were compared. The principal risk factors for BPD development were analyzed and followed by logistic regression test. Results  The diagnosis was mild BPD in 27 of the 106 patients and moderate/severe BPD in 29. The incidence of BPD was 52.8%. Fifty of 106 patients had no BPD. Analysis of risk factors revealed that gestational age ≤28 weeks (p=0.019), birth weight ≤1000 g (p=0.007), hypothermia (p=0.003), acidosis (p=0.003) and hypotension (p=0.005) at admission, respiratory distress syndrome (RDS) ( p<0.001), mechanical ventilation therapy (p<0.001), surfactant therapy (p=0.005), higher amount of mean fluid therapy on 7^th days (p=0.008), nosocomial infection (p<0.001), higher amount of mean packed red cell transfusions (p<0.001) and more than two packed red cell transfusions (p=0.033) were risk factors associated with the development of BPD. Multivariant logistic regression analysis showed acidosis at admission (OR 5.12, 95%CI 1.17–22.27, p=0.029), surfactant treatment (OR 7.53, 95%CI 2.14–26.45, p=0.002), nosocomial infections (OR 4.66, 95%CI 1.27–17.12, p=0.02) and PDA (OR 9.60, 95%CI 2.23–41.22, p=0.002) were risk factors increasing the severity of BPD. Conclusion  The most important risk factors for BPD development in our study were RDS and nosocomial infections while the presence of acidosis at admission, surfactant administration, nosocomial infections and the presence of PDA were the most important risk factors regarding BPD severity. Presence of acidosis at admission as a risk factor emphasized the importance of suitable transport conditions for premature infants.     

Early enteral feeding in very low birth weight infants

Background/aim

Debate exists about when to initiate enteral feeding (EF) in very low birth weight (VLBW) preterm infants. This retrospective study compared the effectiveness of an education-based quality improvement project and the relationship of time of the first EF to necrotizing enterocolitis (NEC) or death incidence and parenteral nutrition (PN) days in VLBW infants.

Study design/subjects

VLBW infants born in 2 epochs were compared for hour of the first feed, PN days, NEC or death incidence, and feeding type. The 2 epochs were temporally divided by a quality improvement initiative to standardize initiation of EF in postnatal hours 6–24.

Results

603 VLBW infants were included. Median time of feed initiation decreased from 33 (Epoch 1) to 14 h (Epoch 2) (p < 0.0001). Median PN days were 14 vs. 12, respectively (p = 0.07). The incidence of NEC or death was 13.4% vs. 9.5%, respectively (p = 0.14). When controlling for birth weight, gestational age, race, gender, and time period, earlier feed initiation was associated with decreased NEC or death (p = 0.003). Evaluation of the relationship of early EF (defined as within the first 24 h) in Epoch 2 alone showed that early EF was significantly associated with decreased NEC or death (6.3 vs 15.1%) (RR, 95% CI = 0.28, 0.13–0.58) and less PN days (p < 0.0001).

Conclusions

In a VLBW infant cohort, an education-based process improvement initiative decreased time of EF initiation to a median of 14 h with no associated increase in NEC or death. In fact, results suggest that earlier feeding is associated with decreased NEC or death.     

极低出生体重儿的产房管理质量改进

新生儿出生时产房发生的事件影响其近期及远期的结局,尤其是对于极低出生体重儿.对极低出生体重儿进行产房管理质量改进,通过产前、产时及产后的各种措施,包括脐带延迟结扎、温度控制、进行产房持续气道正压呼吸(continuous positive airway pressure,CPAP)及用低浓度氧开始复苏等干预手段,可以降低极低出生体重儿病死率,提高其生存质量.该文就目前国内外产房质量改进进展作一综述,总结具体措施,以便于更好地降低极低出生体重儿的住院时间及改善远期预后.     

Risk factors associated with extubation failure in preterm infants with very low birth weight

Repeated endotracheal intubation is associated with complications and additional risks for a preterm infant. The aim of this study was to determine the risk factors related to extubation failure (EF) in preterm newborns.

母乳喂养质量改进对极低和超低出生体重儿亲母母乳喂养率的影响

目的 探讨NICU 中母乳喂养质量改进措施对极低和超低出生体重儿亲母母乳喂养率的影响。方法 回顾性调查收集2014 年7 月至2015 年7 月收治的极低和超低出生体重儿（质量改进前组）以及实施母乳质量改进措施后的2015 年8 月至2016 年6 月的极低和超低出生体重儿（质量改进后组）资料。对两组患儿住院期间亲母母乳喂养情况（喂养率、喂养量、喂养时间）、静脉营养持续时间、达到全肠道喂养的时间,喂养不耐受发生率等指标进行比较。结果 实施质量改进后,亲母母乳喂养率和喂养量均明显增高,母乳强化剂添加时间、静脉营养时间、达全肠道喂养时间均较改进前提前,喂养不耐受的发生率较改进前有所改善,差异有统计学意义。结论 亲母母乳喂养质量改进措施可提高NICU 亲母母乳喂养率,改善早产儿消化系统相关并发症。     

超低和极低出生体重儿神经发育结局及影响因素分析

目的 评估超低/极低出生体重儿 （ELBWI和VLBWI） 在纠正年龄 （CA） 18月时神经发育结局,探讨影响神经发育结局的因素。方法 收集2013年1月至2014年6月入住新生儿重症监护病房并存活出院的ELBWI和VLBWI病例,在CA40周、1、3、6、12、18月定期随访,评估神经发育结局。按神经发育状况分为神经发育正常组和神经发育异常组,比较两组临床资料的差异,分析ELBWI和VLBWI神经发育的危险因素。结果 共338例ELBWI和VLBWI纳入研究,15例在住院期间死亡。CA18月时,145例 （44.9%） 存活且随访资料完整,75例 （23.2%） 死亡,失访103例 （31.9%）。CA18月时,145例患儿中神经发育损伤71例 （49.0%）,3例 （2.1%） 脑性瘫痪;未发现单眼或双眼失明的视觉损伤及需要助听器的听觉损伤。Logistic回归分析发现BPD和败血症是ELBWI和VLBWI神经发育异常的独立危险因素 （OR=3.530,P < 0.001;OR=2.528,P=0.035）,BPD发生程度越重,神经发育异常的发生率越高。结论 败血症、BPD （尤其是重度BPD） 是ELBWI和VLBWI神经发育异常的危险因素。     

Plasma amino acid patterns in very low birth weight infants during parenteral nutrition

Plasma amino acids were measured in eight very low birth weight infants (≤ 1000 gm) before and after infusion of parenteral alimentations with Freamine III. Significant elevation in serum threonine, valine, isoleucine, methionine, serine, proline, glycine and omithine was noted after twenty four hours of infusion. On the other hand, significant decreases in taurine and tyrosine levels were noted. Our study suggests that current solution is not optimal for premature neonates and the amount of protein administered during the first week in infants weighing ≤ 1000 gm should be decreased from the recommended 2.5–3.0 gm/kg/day.     

Attention among very low birth weight infants following early supplementation with docosahexaenoic and arachidonic acid

Aim: To investigate the effect of supplementation with docosahexaenoic acid (DHA) and arachidonic acid (AA) in early neonatal life on cognitive functions among human milk fed very low birth weight infants (<1500 g) at 20 months chronological age. Methods: Randomized, double‐blinded, placebo‐controlled intervention supplementing human milk with 0.5 mL oil (containing 32 mg DHA and 31 mg AA or placebo) per 100 mL milk from 1 week after birth until discharge from hospital (9 weeks on average). The intervention and control group included 44 and 48 children, respectively. Attention capacity was evaluated by two ‘free‐play’ sessions. General cognitive functions were evaluated by the Bayley Mental Development Index (MDI) and an Ages and Stages Questionnaire. Results: The results from the free‐play sessions suggested positive effects from supplementation on functions related to attention. Neither the Bayley MDI nor the Ages and Stages Questionnaire showed significant difference between the intervention and control group. Plasma DHA concentration at discharge was positively correlated with both ‘Sustained Attention’ and the Bayley MDI according to chronological age. Conclusion: A positive effect of early supplementation with DHA and AA on 20 months attention capacity was indicated. These findings need further investigation.     

极低/超低出生体重儿迟发型败血症发生情况及其危险因素分析

目的探讨新生儿重症监护病房(NICU)极低/超低出生体重儿迟发型败血症(LOS)的发生情况及危险因素。方法收集2011年1月至2013年12月入住NICU的极低或超低出生体重儿的临床资料,根据是否合并LOS分为两组:LOS组和无LOS组。回顾性分析LOS的发生率、病死率、常见病原菌及危险因素。结果纳入的226例极低/超低出生体重儿中,117例(51.8%)发生了LOS,其中45例为确诊LOS,72例为临床诊断LOS。LOS组患儿病死率为13.7%(16/117),明显高于无LOS组(5/109,4.6%),差异有统计学意义(P0.05)。共培养出51株病原菌,其中32株(63%)为革兰阴性细菌,16株(31%)为革兰阳性细菌,3株(6%)为真菌。多因素logistic回归分析显示,胎龄、小于胎龄儿、肠外营养持续时间、经外周静脉穿刺中心静脉置管(PICC)、机械通气是极低/超低出生体重儿LOS发生的独立影响因素(OR分别为:0.84、1.59、1.34、3.11、4.55,均P0.05)。结论极低/超低出生体重儿LOS的发生率及病死率较高。LOS常见病原菌为革兰阴性细菌。胎龄低、肠外营养持续时间长、小于胎龄儿、PICC或机械通气的极低/超低出生体重儿LOS的发生危险可能增加。     

极低出生体质量儿远期神经系统发育状况的研究

极低出生体质量儿(very low birth weight,VLBW)的出生率逐年增高,其存活率也随着NICU先进技术的发展日益上升,但VLBW的预后已成为社会关心的问题.近年来越来越多的研究证实,与足月儿相比,VLBW脑结构改变主要表现为脑容积、脑灰质容积和脑白质减少.因此,部分VLBW在儿童期出现了神经系统发育障...     

极低出生体重儿输血治疗及危险因素分析

目的 分析本院极低出生体重儿的输血状况及危险因素.方法 回顾性分析本院2011-2013年收治的胎龄＜37周、出生体重＜1500 g、住院时间≥7天的早产儿资料,按是否输血分为输血组及未输血组,记录并比较两组早产儿的一般情况、合并症、输血组早产儿输血前临床症状、输血前血红蛋白值(Hb)和红细胞压积(Hct)以及输血时间等,Logistic回归分析极低出生体重儿输血的相关因素.结果 研究纳入的142例极低出生体重儿中需输悬浮红细胞51例,占35.9％,68例次;贫血症状主要有需氧疗、经皮氧饱和度不稳定、心率快、需机械通气、体重不增等.输血组出生体重、胎龄低于未输血组,出生窒息、出生需气管插管、CPAP支持、呼吸窘迫综合征(RDS)、肺炎、支气管肺发育不良发生率高于未输血组,住院天数长于未输血组,差异有统计学意义(P＜0.05);两组败血症和坏死性小肠结肠炎发生率差异无统计学意义(P＞0.05).Logistic回归分析显示,胎龄(OR =0.400)和体重(OR=0.994)是极低出生体重儿输血的保护性因素,肺炎(OR=3.620)和RDS(OR =3.863)是极低出生体重儿输血的独立危险因素(P均＜0.05).结论 极低出生体重儿出生胎龄小、体重低、患RDS或肺炎时输血风险明显增加,对于贫血伴有临床缺氧症状的极低出生体重儿应输血治疗.