影響極低出生體重兒體重增長(cháng)的多因素分析

中華兒科雜志2005年12月第43卷第12期 Chin j pediatr, December2005,Vol43,No.12論著(zhù)影響極低出生體重兒體重增長(cháng)的多因素分析吳翼君余加林古銳【摘要】目的探討影響極低出生體重兒(VLBW)體重增長(cháng)的相關(guān)因素。方法對1998年7月—2004年3月重慶醫科大學(xué)兒童醫院新生兒病房收治的51例ⅵLBW進(jìn)行回顧性分析。結果單因素分析發(fā)現早開(kāi)奶、熱卡攝入量和蛋白質(zhì)攝入量對體重增長(cháng)有顯著(zhù)性影響(P<0.05)。多元逐步回歸分析結果示熱卡攝入量和蛋白質(zhì)攝入量是影響體重增長(cháng)的顯著(zhù)因素冋歸方程為Y(體重增長(cháng))=-6.426+0.120X(熱卡攝入量)+3.737X蛋白質(zhì)攝入量XP<0.01)達到體重增長(cháng)目標對象中單純胃腸內營(yíng)養組和部分胃腸外營(yíng)養組熱卡攝入量分別為(520.62±21.59)kJ/(kgd)[(124.43±5.16)keal/(kg:d)](451.49±68.4l)kJ/(kgdI(107.98±16.35)keal(kg:d)]差異有統計學(xué)意義(P<0.05)。早開(kāi)奶組出生體重恢復時(shí)間、住院時(shí)間和胃腸外營(yíng)養液體量占總液量比例>75%時(shí)間平均秩分別為18.58、20.24、20.11,晚開(kāi)奶組分別為33.00、32.48、31.83差異有統計學(xué)意義(P<0.05)結論BW在生后應保證足量熱卡和蛋白質(zhì)的供給對于小于胎齡兒和有嚴重并發(fā)癥的患兒更應該加強營(yíng)養的補充對ⅥLBW應盡早喂養同時(shí)需要胃腸外營(yíng)養作為腸內營(yíng)養的補充?！娟P(guān)鍵詞】嬰兒極低岀生體重;體重增長(cháng);回顧性研究Multiple-factor analysis of weight gain in very low birth weight infants WU Yi-jun, yU Jia-lin, GURui. Department of neonatology, Chongging Children's Hospital Chongging University of Medical SciencesChongging 400014, ChinaAbstract] Objective To investigate the correlative factors of weight gain in very low birth weightinfants( VLBW ) Methods Fifty-one cases of VlBW from July 1998 to March 2004 were analyzeretrospectively. Results Twenty two cases were small for gestational age( SGA) and 29 cases wereappropriate for gestational age( AGA ). The age of first feeding was( 2. 35 + 2. 29 )d. Caloric intake was(37761±121.50)kJ/(kg·dI(90.25±29.04)kca(kgd)] and protein intake was(2.18±0.83)kg.d). The age of birth weight regained was(7. 41+3. 57)d and the velocity of weight gain was(16. 38#9. 29)g/d or( 12. 63+7. 15)g( kg.d). Single factor analysis found that early feeding andcaloric supplyP<0.05)multivariate linear analysis showed that the significant risk factors were associated with supply of calorie andprotein. The equation was Y( weight gain )=-6.426 +0. 120X, caloric supply )+3. 737X, proteino>ply x P<0. 01 ). The caloric supply of the cases that achieved the nutritional goal was 468.+11)kI( kg.d),[(111. 90+ 16.04)kcal kg. d)], and that with enteral nutrition and partialparenteral nutrition was [(520. 62 +21. 59)kJ/( kg. d)],[(124. 43+5. 16) kcal/( kg. d), ( 451. 49+68.41)kj m( kg.d)],[( 107. 98+ 16. 35) kcal/ kg.d)] respectively. There was significantdifference between the two groups( P<0. 05 ) The mean rank of time of birth weight regaining the time inhospital stay and duration of parenteral nutrition providing at least 75% of the total daily fluid volume was18. 58 20. 24 and 20. 11 in the group of early feeding and it was 33. 00 32 48 and 31. 83 in the group oflate feeding, respectively. There were significant differences between the two groups( P<0. 05)Conclusion Sufficient supply of calorie and protein should be ensured in VLBW infants especially in SGAand severely ill infants. It was very important to feed VLBW infants as early as possible, which couldimprove feeding tolerance and gastrointestinal maturation. VLBW infants should receive parenteral nutritioas supplements to enteral feeding.Key words] Infant, very low birth weight: Weight gain;RetrTV中國煤化工極低出生體重兒(VBW)由于宮內生活時(shí)間短CNMHG難而其能量需求高易出現營(yíng)養不良及相應的并發(fā)癥。早期的營(yíng)養不良作者單位丬004重慶醫科大學(xué)附屬兒童醫院新生兒科第一將直接影響到生后體格、神經(jīng)系統發(fā)育和今后的追作者現在綿陽(yáng)市中心醫院兒科工作621000趕生長(cháng),因此如何在生后盡快加強營(yíng)養對VLBW至通信作有旁級搪uhum)關(guān)重要。體重增長(cháng)可以直接反映ⅥLBW營(yíng)養是否中華兒科雜志2005年12月第43卷第12期 Chin i pediatr, December2005,Vol43,No.12得當、病情變化及生長(cháng)發(fā)育情況?？梢愿鶕w重增長(cháng)情況對液體量、營(yíng)養方案做岀及時(shí)調整并可以把結果它作為評判疾病治療效果的一個(gè)指標。本研究對1.多項影響因素與體重增長(cháng)的關(guān)系(表1)按1998年7月—2004年3月在重慶醫科大學(xué)兒童醫性別胎齡與體重關(guān)系、疾病情況、開(kāi)奶時(shí)間、營(yíng)養方院新生兒病房住院的ⅥLBW有關(guān)資料進(jìn)行分析以式等分組比較體重增長(cháng)情況進(jìn)行t檢驗分析。除探討影響VLBW體重增長(cháng)的相關(guān)因素。開(kāi)奶時(shí)間早晚與體重增長(cháng)差異有統計學(xué)意義外(P<0.05)其余各因素差異均無(wú)統計學(xué)意義(P<對象與方法0.05)將多項計量資料胎齡、出生體重、PN>75%時(shí)對象:本組51例選自在我院新生兒病房住院的150例VLBN。入選條件為(1)出生體重<行Pom相關(guān)分析結果見(jiàn)表2。表2顯示胎齡、1500g(2)生后24h內收住院〔3)住院時(shí)間>7出生體重、PN>75%時(shí)間與體重增長(cháng)關(guān)系不密切,d(4)定期測體重而熱卡攝入量和蛋白質(zhì)攝入量與體重增長(cháng)顯著(zhù)相關(guān)2.方法回顧性統計VLBW性別、胎齡、出生體(P<0.05重、胎齡與出生體重關(guān)系、患病情況、開(kāi)奶時(shí)間、出生2.進(jìn)一步采用多元逐步回歸分析影響體重增體重恢復時(shí)間、營(yíng)養方式胃腸外營(yíng)養四)體量長(cháng)的因素將單因素分析篩選出的有意義的變量即占總液量比例>75%的時(shí)間(簡(jiǎn)稱(chēng)PN>75%時(shí)開(kāi)奶時(shí)間、熱卡攝入量和蛋白質(zhì)攝入量再進(jìn)行多元間)熱卡攝入量、蛋白質(zhì)攝入量、體重增長(cháng)量、住院逐步回歸分析。結果示熱卡攝入量(X1)和蛋白質(zhì)時(shí)間等。所患疾病診斷及營(yíng)養方式分組以《實(shí)用新攝入量(ⅹ2)被引入。逐步回歸方程為Y(體重增生兒學(xué)X第3版)為準營(yíng)養方式分為胃腸內和長(cháng))=-6.426+0.120X(熱卡攝入量)+3.737X部分胃腸外營(yíng)養2組無(wú)完全胃腸外營(yíng)養患兒每日(蛋白質(zhì)攝入量)(R2=0.726,F=62.198,P<體重增長(cháng)是指出生體重恢復后每日的體重增0.01)示熱卡和蛋白質(zhì)攝入量是影響體重增長(cháng)的長(cháng)值2。顯著(zhù)因素。3.統計學(xué)分析:采用SPSS11.0統計軟件包進(jìn)3.疾病與營(yíng)養攝入關(guān)系根據是否患敗血癥和行t檢驗和 Pearson相關(guān)分析,P<0.05為差異有統(或)壞死性小腸結腸炎將其分為2組比較兩組熱計學(xué)意義,有意義者再進(jìn)行逐步回歸分析?？ê偷鞍踪|(zhì)攝入情況。結果示患病組(38例)熱卡表1多項影響因素與體重增長(cháng)的t檢驗分析結果因素例數體重增長(cháng)g(kg:d)T值因素例數體重增長(cháng)g(kg·d)T值性別男12.64±6.240.001窒息無(wú)12,43±6.990.384女3112.63±7.79有13.37±8.0胎齡與體重關(guān)系敗血癥無(wú)12,08±7.341.0480.989AGA顱內出血肺炎無(wú)3.479.740無(wú)13.03±7.4410.79±5.64缺氧缺血性腦病應激性潰瘍無(wú)1.684無(wú)電解質(zhì)紊亂無(wú)壞死性小腸結腸炎12.93±7.26無(wú)1)58±7.17黃疸無(wú)0.745中國煤化工27±7.98有49±6.84開(kāi)奶時(shí)硬腫癥無(wú)YHCNMHG03±7.282.06812.92±7.361U.95±6.68營(yíng)養方式低體溫無(wú)胃腸內10.40±5.941.526有11.53±6.86部分胃腸外3513.65±7.50注:P萬(wàn)振中位數918中華兒科雜志2005年12月第43卷第12期 Chin j pediatr, December2005,Vol43,No.12和蛋白質(zhì)攝入量分別為[(452.25±64.60)表3不同開(kāi)奶時(shí)間組出生體重恢復時(shí)間、住院時(shí)kJ(kg:d)〔108.09±16.44)keal(kg:d)]和PN>75%時(shí)間比較(2.60±0.54)g(kgd)未患病組13例)分別為ka(kg:d)200.、ND兩組差開(kāi)奶時(shí)例數也生體重、住院時(shí)間PN>75%時(shí)間[(352.08±126.48)kJ/(kg:d)(84.15±30.23)20.2420.11異有統計學(xué)意義(t值分別為3.602和2.979P均兩組比較z值2,144-2,843<0.05)P<0.05表2多項影響因素與體重增長(cháng)的Pea題。找出影響其生后發(fā)育的因素并及時(shí)予以干預,相關(guān)系數(n=51)對提高其生存質(zhì)量十分重要體重日增長(cháng)(g)相關(guān)系數P值1.VLBW能量需求∶VLBW能量?jì)涞吞幱诟咛g周)代謝狀態(tài)(心、腦、肝等代謝活躍器官占自體比重出生體重g)>0.05PN>75%時(shí)間d)0.1550.05高)蛋白質(zhì)合成轉化率高。達到推薦營(yíng)養攝入量熱卡攝入量k(kgd)]05( recommended dietary intakes , RDIS)即供能至少達蛋白質(zhì)攝入量g(kgd)]0.783到520.1kJ/(kg:d120kca/(kg:d)蛋白質(zhì)4.熱卡和蛋白質(zhì)攝入量與體重增長(cháng)關(guān)系:至少3g(kg:d)理論上才能讓LBW按宮內生ⅥLBw體重增長(cháng)目標是使其發(fā)育接近宮內生長(cháng)曲長(cháng)曲線(xiàn)生長(cháng)7。熱量供給不足,尤其蛋白質(zhì)供給不線(xiàn)即以144-16.1g(kg:d)速度增長(cháng)3。我們足是VBW不能達到宮內生長(cháng)速度的主要原因。對達到體重增長(cháng)目標者熱卡攝入量進(jìn)行統計達到本研究中多元逐步回歸分析的結果也顯示熱卡和蛋體重增長(cháng)目標組21例,未達到體重增長(cháng)目標組30質(zhì)攝入量是影響體重增長(cháng)的顯著(zhù)因素例熱卡攝入量分別為(464.01±67.11)kJ/(kg但是在本研究中達到體重增長(cháng)目標對象的熱d)[(110.90±16.04)keal/(kg·d)](314.22±卡攝入量為(468.19±67.11)kJ/(kg:d)11062)kJ(kg:dI(7.10±244)kel(kg:d)][(11.+16.04)kcl(kg:d)]即有部分研究(t=5.524P<0.05)其中單純胃腸內營(yíng)養組16例)對象熱卡攝入量是低于RDS的。我們再將單純胃和部分胃腸外營(yíng)養組(35例)熱卡攝入量分別為腸內營(yíng)養者和部分胃腸外營(yíng)養者熱卡攝入量進(jìn)行比(520.62±21.59)kJ/(kg:d)[(124.43±5.16)ko較結果后者明顯低于前者差異有統計學(xué)意義。我(kg:d)](451.49±68.41)kJ/(kg·d)[(107.98們認為胃腸外營(yíng)養時(shí)由于食物特殊動(dòng)力作用耗能減16.35)kcl/(kg:d)It=3.917P<0.05少大便能量損失少寒冷刺激和活動(dòng)減少故實(shí)際5不同開(kāi)奶時(shí)間的參數比較表3)開(kāi)始喂養能量需要較胃腸道營(yíng)養時(shí)低。全胃腸外營(yíng)養時(shí)每日時(shí)間最早為生后05h最長(cháng)為生后114早開(kāi)奶組供給33-418kJkg(80-100kckg已能滿(mǎn)足開(kāi)始喂養時(shí)間為8.40±8.09)h晚開(kāi)奶組開(kāi)始喂VBW生長(cháng)發(fā)育需要養時(shí)間為(74.13±52.74)。用秩和檢驗對早開(kāi)奶本研究中性別、胎齡、小于胎齡兒SGA入出生和晚開(kāi)奶組的出生體重恢復時(shí)間住院時(shí)間進(jìn)行比體重對體重增長(cháng)影響不大但Bndt等對sGA的較行部分胃腸外營(yíng)養ⅥBw中對早開(kāi)奶和晚ⅥLBW進(jìn)行隨訪(fǎng)發(fā)現早期喂養(生后3-6h內和開(kāi)奶組的ⅨN>75%時(shí)間比較。示早開(kāi)奶岀生體重高能量的供給組12個(gè)月時(shí)頭圍實(shí)現了追趕生長(cháng)恢復時(shí)間、住院時(shí)間和胃腸外營(yíng)養液體量占總液量在18個(gè)月-6歲的長(cháng)期隨訪(fǎng)結果發(fā)現該組兒童智比例>75%時(shí)間平均秩較晚開(kāi)奶組短差異有統計力明顯高于對照組。因此SA的LBW更應該加學(xué)意義(P均<0.05)強營(yíng)養中國煤化工增長(cháng)無(wú)太大影響這與討論RickHCNMHG發(fā)現患有嚴重感染如大量文獻指出胐出生后短期的營(yíng)養情況與早產(chǎn)敗血癥、壞死性小腸結腸炎和慢性支氣管肺發(fā)育不兒尤其是ⅥLBW神經(jīng)體格發(fā)育及早期追趕生長(cháng)良的VLBW體重增長(cháng)比對照組要慢,但未報道( catch-up_ growth)密切相關(guān)。低出生體重兒尤BW每日熱卡和蛋白質(zhì)攝入量。我們將患有上述其是ⅥLR備警程代謝有很多值得我們探討的問(wèn)前兩者疾病組的熱卡及蛋白質(zhì)供給量與對照組進(jìn)行中華兒科雜志2005年12月第43卷第12期 Chin j Pediatr, December2005,Vol43,No.12比較發(fā)現患病組營(yíng)養供給量明顯高于對照組(P<白質(zhì)的供給對于小于胎齡兒和有嚴重并發(fā)癥的患0.05)故推測可以通過(guò)加強營(yíng)養來(lái)減少疾病對體兒更應該加強營(yíng)養的補充。應盡早喂養這對提高重的影響喂養耐受性促進(jìn)胃腸道組織成熟極其重要。同時(shí)2.營(yíng)養供給途徑〔1)胃腸外營(yíng)養∶與ⅥLBW需要胃腸外營(yíng)養作為腸內營(yíng)養的補充。這將大大提高代謝、高需求不相適應的是不成熟的胃腸道功能。高VLBW生存率避免今后體格及智力發(fā)育落后,由于其胃腸蠕動(dòng)較慢腸道消化酶、生長(cháng)因子合成有實(shí)現追趕生長(cháng)。限應激狀況較炙呼吸道綜合征、感染等)因此在參考文獻生后短時(shí)間內僅腸道攝入常難以達到生理需要量。盧憲梅等對生后24h內的VLBW開(kāi)始行胃腸外1金漢珍黃德珉宮希吉主編實(shí)用新生兒學(xué)第3版)北京營(yíng)養發(fā)現其體重較對照組增長(cháng)更快,住院時(shí)間縮人民衛生出版社2003.3-586-102342-348508-5122 Bauer K, Bovermann G, Roithmaier A, et al. Body composition短而生化、肝功、腎功、血脂無(wú)異常。說(shuō)明VLBnutrition and fluid balance during the first two weeks of life in早期能耐受胃腸外營(yíng)養胃腸外營(yíng)養能促進(jìn)體重迅preterm neonates weighting less than 1500 grams. J Pediatr, 1991速增長(cháng)。但本研究發(fā)現全胃腸營(yíng)養組和部分胃腸3 Richard E,JesA,AwyA,ea. Longitudinal growth外營(yíng)養組體重增長(cháng)無(wú)顯著(zhù)性差異,可能是因為在治hospitalized very low birth weight infant. Pediatr, 1999, 104 280289療方法上我們對一般情況差、口服不能達滿(mǎn)意營(yíng)養4 Lucas A, Morley R, Cole TJ. Randomized trial of early diet in供給者才采用腸外營(yíng)養而一般情況較好的患兒多preterm babies and later intelligence quotient, BMJ1481-148僅用糖水補充供能或者胃腸外營(yíng)養時(shí)間較短。(2)5 Hadders-Algra M, Touwen B. Body measurements, neurological and胃腸營(yíng)養早期喂養是指岀生后24h內進(jìn)行胃腸營(yíng)behavioral development in six-year-old children born preterm and/orsmall-for-gestational-age. Early Hum Dev a 990 22:1-13養。在本研究中,早開(kāi)奶組體重恢復時(shí)間、住院時(shí)6許植之.新生兒胃腸道外營(yíng)養.中國實(shí)用兒科雜志,19J14間、ⅨN>75%時(shí)間較晚開(kāi)奶組均顯著(zhù)縮短提示早70-272.7 American Academy of Pediatr, Committee on Nutrition( AAPCON開(kāi)奶能刺激胃腸道的生長(cháng)發(fā)育和成熟使VLBW更Nutritional needs of preterm infants. In: Kleinman R, ed. Pediatric好耐受胃腸喂養。我們的研究還發(fā)現PN>75%時(shí)Nutrition Handbook. American Academy of Pediatrics, Elk grooveVillage,199855-79間和早期喂養對短期體重增長(cháng)影響不大。 Richard8李鳳英陳自勵.極低出生體重兒全靜脈營(yíng)養應用.臨床兒科等的研究結果也是如此但指出第一次腸道喂養志20032173-79 Brandt I, Stickee EJ, Lentze M. Catch-up growth of head時(shí)間如果被延遲到1周后則體重增長(cháng)速度會(huì )減少u(mài)mference of very-low-birth-weight small-for-gestational age2~4g/d。同時(shí)VLBW能夠耐受早期的胃腸營(yíng)養,preterm infants and mental development to adulthood. J Pediatr2003142463468即使有嚴重疾病,一旦開(kāi)始喂養就會(huì )出現正常胃腸10盧憲梅任青.極低體重兒早期靜脈營(yíng)養的臨床探討,山東大學(xué)肽分泌高峰不會(huì )增加胃腸負擔。 Troche等l研究學(xué)報(醫學(xué)版),2002,40#55451 1 Richard E, Naji Y, Avroy F, et al. Effect of nutritional practices on發(fā)現患危重疾病需要機械通氣的ⅥLBW能較好耐daily weight gain in VLBW infants. Pediatries Research 1996, 39受生后24h內的微量喂養同時(shí)早喂養的LBW較12 Troche B, Harvey-Wilkes K, Engle WD, et al. Early minimal少發(fā)生低血糖、脫水、高膽紅素血癥、氮質(zhì)血癥及骨feedings promote growth in critically ill premature infants. Biol質(zhì)疏松癥。一旦胃腸營(yíng)養建立每日喂養奶量10Neonate 1995 67 72-18120ml(kg:d)是安全的3l因此,早期喂養可以13 Macagno F, Demarini S. Techniques of enteral feeding in thenewborn. Acta Pediatr 1994 402( Suppl ) 11-13提高喂養耐受促進(jìn)胃腸組織發(fā)育,切不可忽視(收稿日期200502-25)總之VLBW在出生后應保證其足量熱卡和蛋本文編輯關(guān)衛屏李貴存)作者須知投稿請提供倫理委員會(huì )批準文件及受試對象中國煤化工知情同意書(shū)的通知CNMHG根據中華醫學(xué)會(huì )雜志社的相關(guān)規定當論文的主體是以的)所制定的倫理學(xué)標準并提供該委員會(huì )的批準文件及受人為研究對象的試驗時(shí)作者應該說(shuō)明其遵循的程序是否符試對象的知情同意書(shū)合負責人體試媵員會(huì )(單位性的、地區性的或國家性