中華兒科雜志2005年12月第43卷第12期 Chin j pediatr, December2005,Vol43,No.12論著影響極低出生體重兒體重增長(zhǎng)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(zhǎng)的相關(guān)因素。方法對(duì)1998年7月—2004年3月重慶醫(yī)科大學(xué)兒童醫(yī)院新生兒病房收治的51例ⅵLBW進(jìn)行回顧性分析。結(jié)果單因素分析發(fā)現(xiàn)早開奶、熱卡攝入量和蛋白質(zhì)攝入量對(duì)體重增長(zhǎng)有顯著性影響(P<0.05)。多元逐步回歸分析結(jié)果示熱卡攝入量和蛋白質(zhì)攝入量是影響體重增長(zhǎng)的顯著因素冋歸方程為Y(體重增長(zhǎng))=-6.426+0.120X(熱卡攝入量)+3.737X蛋白質(zhì)攝入量XP<0.01)達(dá)到體重增長(zhǎng)目標(biāo)對(duì)象中單純胃腸內(nèi)營(yíng)養(yǎng)組和部分胃腸外營(yíng)養(yǎng)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(tǒng)計(jì)學(xué)意義(P<0.05)。早開奶組出生體重恢復(fù)時(shí)間、住院時(shí)間和胃腸外營(yíng)養(yǎng)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,晚開奶組分別為33.00、32.48、31.83差異有統(tǒng)計(jì)學(xué)意義(P<0.05)結(jié)論BW在生后應(yīng)保證足量熱卡和蛋白質(zhì)的供給對(duì)于小于胎齡兒和有嚴(yán)重并發(fā)癥的患兒更應(yīng)該加強(qiáng)營(yíng)養(yǎng)的補(bǔ)充對(duì)ⅥLBW應(yīng)盡早喂養(yǎng)同時(shí)需要胃腸外營(yíng)養(yǎng)作為腸內(nèi)營(yíng)養(yǎng)的補(bǔ)充?！娟P(guān)鍵詞】嬰兒極低岀生體重;體重增長(zhǎng);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(guó)煤化工極低出生體重兒(VBW)由于宮內(nèi)生活時(shí)間短CNMHG難而其能量需求高易出現(xiàn)營(yíng)養(yǎng)不良及相應(yīng)的并發(fā)癥。早期的營(yíng)養(yǎng)不良作者單位丬004重慶醫(yī)科大學(xué)附屬兒童醫(yī)院新生兒科第一將直接影響到生后體格、神經(jīng)系統(tǒng)發(fā)育和今后的追作者現(xiàn)在綿陽(yáng)市中心醫(yī)院兒科工作621000趕生長(zhǎng),因此如何在生后盡快加強(qiáng)營(yíng)養(yǎng)對(duì)VLBW至通信作有旁級(jí)搪uhum)關(guān)重要。體重增長(zhǎng)可以直接反映ⅥLBW營(yíng)養(yǎng)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(dāng)、病情變化及生長(zhǎng)發(fā)育情況?？梢愿鶕?jù)體重增長(zhǎng)情況對(duì)液體量、營(yíng)養(yǎng)方案做岀及時(shí)調(diào)整并可以把結(jié)果它作為評(píng)判疾病治療效果的一個(gè)指標(biāo)。本研究對(duì)1.多項(xiàng)影響因素與體重增長(zhǎng)的關(guān)系(表1)按1998年7月—2004年3月在重慶醫(yī)科大學(xué)兒童醫(yī)性別胎齡與體重關(guān)系、疾病情況、開奶時(shí)間、營(yíng)養(yǎng)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(zhǎng)情況進(jìn)行t檢驗(yàn)分析。除探討影響VLBW體重增長(zhǎng)的相關(guān)因素。開奶時(shí)間早晚與體重增長(zhǎng)差異有統(tǒng)計(jì)學(xué)意義外(P<0.05)其余各因素差異均無(wú)統(tǒng)計(jì)學(xué)意義(P<對(duì)象與方法0.05)將多項(xiàng)計(jì)量資料胎齡、出生體重、PN>75%時(shí)對(duì)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(jié)果見(jiàn)表2。表2顯示胎齡、1500g(2)生后24h內(nèi)收住院〔3)住院時(shí)間>7出生體重、PN>75%時(shí)間與體重增長(zhǎng)關(guān)系不密切,d(4)定期測(cè)體重而熱卡攝入量和蛋白質(zhì)攝入量與體重增長(zhǎng)顯著相關(guān)2.方法回顧性統(tǒng)計(jì)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(fù)時(shí)間、營(yíng)養(yǎng)方式胃腸外營(yíng)養(yǎng)四)體量長(zhǎng)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PN>75%時(shí)開奶時(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(zhǎng)量、住院逐步回歸分析。結(jié)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(yǎng)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(zhǔn)營(yíng)養(yǎng)方式分為胃腸內(nèi)和長(zhǎng))=-6.426+0.120X(熱卡攝入量)+3.737X部分胃腸外營(yíng)養(yǎng)2組無(wú)完全胃腸外營(yíng)養(yǎng)患兒每日(蛋白質(zhì)攝入量)(R2=0.726,F=62.198,P<體重增長(zhǎng)是指出生體重恢復(fù)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(zhǎng)的長(zhǎng)值2。顯著因素。3.統(tǒng)計(jì)學(xué)分析:采用SPSS11.0統(tǒng)計(jì)軟件包進(jìn)3.疾病與營(yíng)養(yǎng)攝入關(guān)系根據(jù)是否患敗血癥和行t檢驗(yàn)和 Pearson相關(guān)分析,P<0.05為差異有統(tǒng)(或)壞死性小腸結(jié)腸炎將其分為2組比較兩組熱計(jì)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(jié)果示患病組(38例)熱卡表1多項(xiàng)影響因素與體重增長(zhǎng)的t檢驗(yàn)分析結(jié)果因素例數(shù)體重增長(zhǎng)g(kg:d)T值因素例數(shù)體重增長(zhǎng)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(nèi)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(yīng)激性潰瘍無(wú)1.684無(wú)電解質(zhì)紊亂無(wú)壞死性小腸結(jié)腸炎12.93±7.26無(wú)1)58±7.17黃疸無(wú)0.745中國(guó)煤化工27±7.98有49±6.84開奶時(shí)硬腫癥無(wú)YHCNMHG03±7.282.06812.92±7.361U.95±6.68營(yíng)養(yǎng)方式低體溫?zé)o胃腸內(nèi)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(shù)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不同開奶時(shí)間組出生體重恢復(fù)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兩組差開奶時(shí)例數(shù)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(tǒng)計(jì)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(xiàng)影響因素與體重增長(zhǎng)的Pea題。找出影響其生后發(fā)育的因素并及時(shí)予以干預(yù),相關(guān)系數(shù)(n=51)對(duì)提高其生存質(zhì)量十分重要體重日增長(zhǎng)(g)相關(guān)系數(shù)P值1.VLBW能量需求∶VLBW能量?jī)?chǔ)備低處于高胎齡周)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(zhuǎn)化率高。達(dá)到推薦營(yíng)養(yǎng)攝入量熱卡攝入量k(kgd)]05( recommended dietary intakes , RDIS)即供能至少達(dá)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(zhǎng)關(guān)系:至少3g(kg:d)理論上才能讓LBW按宮內(nèi)生ⅥLBw體重增長(zhǎng)目標(biāo)是使其發(fā)育接近宮內(nèi)生長(zhǎng)曲長(zhǎng)曲線生長(zhǎng)7。熱量供給不足,尤其蛋白質(zhì)供給不線即以144-16.1g(kg:d)速度增長(zhǎng)3。我們足是VBW不能達(dá)到宮內(nèi)生長(zhǎng)速度的主要原因。對(duì)達(dá)到體重增長(zhǎng)目標(biāo)者熱卡攝入量進(jìn)行統(tǒng)計(jì)達(dá)到本研究中多元逐步回歸分析的結(jié)果也顯示熱卡和蛋體重增長(zhǎng)目標(biāo)組21例,未達(dá)到體重增長(zhǎng)目標(biāo)組30質(zhì)攝入量是影響體重增長(zhǎng)的顯著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(dá)到體重增長(zhǎng)目標(biāo)對(duì)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(nèi)營(yíng)養(yǎng)組16例)對(duì)象熱卡攝入量是低于RDS的。我們?cè)賹渭兾负筒糠治改c外營(yíng)養(yǎng)組(35例)熱卡攝入量分別為腸內(nèi)營(yíng)養(yǎng)者和部分胃腸外營(yíng)養(yǎng)者熱卡攝入量進(jìn)行比(520.62±21.59)kJ/(kg:d)[(124.43±5.16)ko較結(jié)果后者明顯低于前者差異有統(tǒng)計(jì)學(xué)意義。我(kg:d)](451.49±68.41)kJ/(kg·d)[(107.98們認(rèn)為胃腸外營(yíng)養(yǎng)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不同開奶時(shí)間的參數(shù)比較表3)開始喂養(yǎng)能量需要較胃腸道營(yíng)養(yǎng)時(shí)低。全胃腸外營(yíng)養(yǎng)時(shí)每日時(shí)間最早為生后05h最長(zhǎng)為生后114早開奶組供給33-418kJkg(80-100kckg已能滿足開始喂養(yǎng)時(shí)間為8.40±8.09)h晚開奶組開始喂VBW生長(zhǎng)發(fā)育需要養(yǎng)時(shí)間為(74.13±52.74)。用秩和檢驗(yàn)對(duì)早開奶本研究中性別、胎齡、小于胎齡兒SGA入出生和晚開奶組的出生體重恢復(fù)時(shí)間住院時(shí)間進(jìn)行比體重對(duì)體重增長(zhǎng)影響不大但Bndt等對(duì)sGA的較行部分胃腸外營(yíng)養(yǎng)ⅥBw中對(duì)早開奶和晚ⅥLBW進(jìn)行隨訪發(fā)現(xiàn)早期喂養(yǎng)(生后3-6h內(nèi)和開奶組的ⅨN>75%時(shí)間比較。示早開奶岀生體重高能量的供給組12個(gè)月時(shí)頭圍實(shí)現(xiàn)了追趕生長(zhǎng)恢復(fù)時(shí)間、住院時(shí)間和胃腸外營(yíng)養(yǎng)液體量占總液量在18個(gè)月-6歲的長(zhǎng)期隨訪結(jié)果發(fā)現(xiàn)該組兒童智比例>75%時(shí)間平均秩較晚開奶組短差異有統(tǒng)計(jì)力明顯高于對(duì)照組。因此SA的LBW更應(yīng)該加學(xué)意義(P均<0.05)強(qiáng)營(yíng)養(yǎng)中國(guó)煤化工增長(zhǎng)無(wú)太大影響這與討論RickHCNMHG發(fā)現(xiàn)患有嚴(yán)重感染如大量文獻(xiàn)指出胐出生后短期的營(yíng)養(yǎng)情況與早產(chǎn)敗血癥、壞死性小腸結(jié)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(zhǎng)良的VLBW體重增長(zhǎng)比對(duì)照組要慢,但未報(bào)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(duì)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(xiàn)患病組營(yíng)養(yǎng)供給量明顯高于對(duì)照組(P<白質(zhì)的供給對(duì)于小于胎齡兒和有嚴(yán)重并發(fā)癥的患0.05)故推測(cè)可以通過(guò)加強(qiáng)營(yíng)養(yǎng)來(lái)減少疾病對(duì)體兒更應(yīng)該加強(qiáng)營(yíng)養(yǎng)的補(bǔ)充。應(yīng)盡早喂養(yǎng)這對(duì)提高重的影響喂養(yǎng)耐受性促進(jìn)胃腸道組織成熟極其重要。同時(shí)2.營(yíng)養(yǎng)供給途徑〔1)胃腸外營(yíng)養(yǎng)∶與ⅥLBW需要胃腸外營(yíng)養(yǎng)作為腸內(nèi)營(yíng)養(yǎng)的補(bǔ)充。這將大大提高代謝、高需求不相適應(yīng)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(zhǎng)因子合成有實(shí)現(xiàn)追趕生長(zhǎng)。限應(yīng)激狀況較炙呼吸道綜合征、感染等)因此在參考文獻(xiàn)生后短時(shí)間內(nèi)僅腸道攝入常難以達(dá)到生理需要量。盧憲梅等對(duì)生后24h內(nèi)的VLBW開始行胃腸外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(yǎng)發(fā)現(xiàn)其體重較對(duì)照組增長(zhǎng)更快,住院時(shí)間縮人民衛(wèi)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(yǎng)胃腸外營(yíng)養(yǎng)能促進(jìn)體重迅preterm neonates weighting less than 1500 grams. J Pediatr, 1991速增長(zhǎng)。但本研究發(fā)現(xiàn)全胃腸營(yíng)養(yǎng)組和部分胃腸3 Richard E,JesA,AwyA,ea. Longitudinal growth外營(yíng)養(yǎng)組體重增長(zhǎng)無(wú)顯著性差異,可能是因?yàn)樵谥蝖ospitalized very low birth weight infant. Pediatr, 1999, 104 280289療方法上我們對(duì)一般情況差、口服不能達(dá)滿意營(yíng)養(yǎng)4 Lucas A, Morley R, Cole TJ. Randomized trial of early diet in供給者才采用腸外營(yíng)養(yǎng)而一般情況較好的患兒多preterm babies and later intelligence quotient, BMJ1481-148僅用糖水補(bǔ)充供能或者胃腸外營(yíng)養(yǎng)時(shí)間較短。(2)5 Hadders-Algra M, Touwen B. Body measurements, neurological and胃腸營(yíng)養(yǎng)早期喂養(yǎng)是指岀生后24h內(nèi)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(yǎng)。在本研究中,早開奶組體重恢復(fù)時(shí)間、住院時(shí)6許植之.新生兒胃腸道外營(yíng)養(yǎng).中國(guó)實(shí)用兒科雜志,19J14間、ⅨN>75%時(shí)間較晚開奶組均顯著縮短提示早70-272.7 American Academy of Pediatr, Committee on Nutrition( AAPCON開奶能刺激胃腸道的生長(zhǎng)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(yǎng)。我們的研究還發(fā)現(xiàn)PN>75%時(shí)Nutrition Handbook. American Academy of Pediatrics, Elk grooveVillage,199855-79間和早期喂養(yǎng)對(duì)短期體重增長(zhǎng)影響不大。 Richard8李鳳英陳自勵(lì).極低出生體重兒全靜脈營(yíng)養(yǎng)應(yīng)用.臨床兒科等的研究結(jié)果也是如此但指出第一次腸道喂養(yǎng)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(zhǎng)速度會(huì)減少umference 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(yǎng),preterm infants and mental development to adulthood. J Pediatr2003142463468即使有嚴(yán)重疾病,一旦開始喂養(yǎng)就會(huì)出現(xiàn)正常胃腸10盧憲梅任青.極低體重兒早期靜脈營(yíng)養(yǎng)的臨床探討,山東大學(xué)肽分泌高峰不會(huì)增加胃腸負(fù)擔(dān)。 Troche等l研究學(xué)報(bào)(醫(yī)學(xué)版),2002,40#55451 1 Richard E, Naji Y, Avroy F, et al. Effect of nutritional practices on發(fā)現(xiàn)患危重疾病需要機(jī)械通氣的ⅥLBW能較好耐daily weight gain in VLBW infants. Pediatries Research 1996, 39受生后24h內(nèi)的微量喂養(yǎng)同時(shí)早喂養(yǎng)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(yǎng)建立每日喂養(yǎng)奶量10Neonate 1995 67 72-18120ml(kg:d)是安全的3l因此,早期喂養(yǎng)可以13 Macagno F, Demarini S. Techniques of enteral feeding in thenewborn. Acta Pediatr 1994 402( Suppl ) 11-13提高喂養(yǎng)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(yīng)保證其足量熱卡和蛋本文編輯關(guān)衛(wèi)屏李貴存)作者須知投稿請(qǐng)?zhí)峁﹤惱砦瘑T會(huì)批準(zhǔn)文件及受試對(duì)象中國(guó)煤化工知情同意書的通知CNMHG根據(jù)中華醫(yī)學(xué)會(huì)雜志社的相關(guān)規(guī)定當(dāng)論文的主體是以的)所制定的倫理學(xué)標(biāo)準(zhǔn)并提供該委員會(huì)的批準(zhǔn)文件及受人為研究對(duì)象的試驗(yàn)時(shí)作者應(yīng)該說(shuō)明其遵循的程序是否符試對(duì)象的知情同意書合負(fù)責(zé)人體試媵員會(huì)(單位性的、地區(qū)性的或國(guó)家性