深圳早产儿矫正月龄1岁内体格发育与营养状况研究

发布时间：2018-05-15 17:12

本文选题：早产儿 + 体格发育　；参考：《南方医科大学》2014年硕士论文

【摘要】：[研究背景] 随着现代医学的迅速发展,我国早产儿的成活率和治愈率显著提高,早产儿出院后更多的挑战也随之而来：胎龄小、出生体重低的早产儿由于其解剖生理特点,各系统器官功能发育不成熟,生活能力低下,易发生各种并发症及营养不良等问题。一岁内是儿童生长发育最快的时期,也是早产儿追赶性生长的关键期,研究表明早产儿婴儿期的生长发育是其成年后身体健康与疾病的重要影响因素。对出院后的早产儿进行干预能提高早产儿学龄期的智力分数,减轻养育人的心理压力,减少营养不良与死亡率的发生,减少早产儿成年后的行为问题：提高早产儿及其家庭的生活质量。为此,卫生部组织了17家医疗单位,开展“早产(儿)干预研究项目”,制定了“早产儿保健服务指南”,指南强调管理的日标应当基于不同出生体重和不同年龄阶段,营养策略应随不同体重标准、年龄段不同而不同,早产儿干预应讲求“个体化”,出院后的随访与干预内容包括神经、体格发育监测,早期发现生长发育相关问题,防治营养不良,纠正营养性疾病等。按照以上原则,2012年3月到2013年12月期问,我们对本院出生的272名早产儿进行了累计1243次监测随访,探讨早产儿整体和“个体化”的营养状况与生长发育规律。 [目的和意义] 为了解早产儿生长发育特点,探讨不同出生胎龄及不同出生体重早产儿体格生长规律、营养状况及其影响因素,分析其中关系。防法] 1.研究对象选择2012年3月～2013年10月在深圳市妇幼保健院出生且愿意在儿童保健科随访的早产儿,经口喂养顺利,调查前2周内无喂养不耐受、无肺炎、腹泻等疾病情况,长期深圳市居住,口头知情同意时接受调查者。排除患有严重影响生长发育的疾病或不接受调查的早产儿。共纳入272名早产儿,出生胎龄(32.90±2.43)周,出生体重(1.93±0.49)kg,男婴153人,女婴119人。其中双胎41对(82人)；73名SGA早产儿；60名极低出生体重儿。共计1243次随访记录。 2.分组 ①根据出生胎龄分为二组,晚期早产儿(34周≤出生胎龄37周,Late preterm infant, LPI)和早期早产儿(出生胎龄34周,Early preterm infant, EPI); EPI148人,出生胎龄(31.17±1.93)周,出生体重(1.66±0.41)kg; LPI124人,出生胎龄(35.00±0.84)周,出生体重(2.25±0.39)kg。 ②根据出生体重分三组,分为极低出生体重儿(出生体重1000g～1499g,Very low birth weight, VLBW),低出生体重儿(1500g出生体重2499g, Low birth weight, LBW),正常出生体重儿(出生体重≥2500g,Normal birth weight, NBW); VLBW60人,出生胎龄(30.03±2.48)周,出生体重(1.23±0.16)Kg；LBW178人,出生胎龄(33.44±1.87)周,出生体重(1.99±0.27) kg; NBW34人,出生胎龄(34.69±1.18)周,出生体重(2.75±0.20)kg。 ③根据早产儿喂养的乳品量占总奶量的比例分为三组：母乳组[母乳占一日奶量的75%以上(不包含用母乳强化剂的8例)]；普奶组(普通配方奶占一日总奶量的75%以上)；早奶组[早产儿(出院后)配方奶占一日总奶量的75%以上]。母乳组54人,出生胎龄(33.34+2.18)周,出生体重(2.04±0.55)kg；早奶组61人,出生胎龄(31.41±2.38)周,出生体重(1.75±0.44)kg；普奶组有61人,出生胎龄(33.79±2.15)周,出生体重(2.06±0.47)kg。早奶组出生胎龄、出生体重小于母乳组和普奶组(P0.01)。各组早产儿在各矫正月龄身长、体重、头围、BMI、LAZ、BMIZ、WAZ、 WLZ、HCZ例数相同。以上三种分组方法中各组内评估时月龄、性别比例差异无统计学意义(P0.1) 3.分析及观察指标 ①体格发育指标：早产儿身长及其Z值,体重及其Z值,头围及其Z值,身体质量指数及其Z值；身长、体重、头围增长速率； ②血液指标：末梢血血红蛋白值、微量元素铜、锌、钙、镁、铁及血铅； ③膳食分析指标：摄入膳食中的能量、蛋白质、碳水化合物、脂肪、元素铁、钙、锌； ④营养评价指标：体重、身长、头围EUGR发生率,低体重、生长迟缓、消瘦、超重、头围小于2个标准差发生率。 4.膳食调查抽取600人次早产儿进行膳食调查,分为两组：①矫正胎龄0月～6月早产儿组：300人次：采用24小时回顾性膳食调查法。矫正月龄0-6月：300人次：采用三天食物记录法。剔除比基础消耗能量更少的数据后,得到矫正胎龄0-6月早产儿(出生胎龄33.97±4.50周,出生体重2.00±0.51kg)282人次；矫正月龄6月～1岁(出生胎龄31.92±6.46周,出生体重1.83-0.51kg)80人次。计算每天摄入的能量、蛋白质、脂肪、碳水化合物、元素铁、锌、钙值。 5.随访矫正月龄6月内每月随访1次,矫正月龄6月后每2月随访1次。记录早产儿随访时的体格测量结果,收集早产儿出生时情况、既往史、家庭史、出院诊断等相关资料；干预内容包括体格监测、营养评估与指导,预防性用药。对早产儿矫正月龄0～2月、3月、6月、12月测量末梢血血常规,矫正月龄6月、12月测量末梢血微量元素。 6.统计学分析用Epidata3.1录入,建立数据库。用SPSS13.0软件进行统计学分析。首先进行正态性和方差齐性检验,符合方差齐性的正态分布资料两组均数比较采用t检验,多组数据比较之间用方差分析,两两比较用SNK方法；不符合正态分布的数据经对数转换后用参数分析,若仍不符合的用非参数检验。发生率比较采用卡方检验和fisher确切概率法检验。logistic回归、多元线性回归分析分析数据相关性。营养素的计算在SPSS里用compute程序实现。 [结果] 1.身长生长规律矫正月龄1岁内早产儿身长生长趋势与正常足月儿相似,身长50%生长曲线较WHO足月儿50%标准生长曲线左移。自矫正胎龄40周起,每个矫正月龄早产儿的LAZ均值均大于0.2,在矫正月龄2月达到高峰。不同出生胎龄早产儿分析结果显示,矫正胎龄40周、矫正月龄2月,EPI的LAZ均值小于LPI,而在矫正月龄8～12月,EPI的LAZ均值大于LPI(P0.05)。EPI和LPI的LAZ高峰分别在矫正月龄10月、2月。不同出生体重早产儿分析结果显示,在矫正月龄0-5月、8月,VLBW的LAZ比LBW、NBW的均小(P0.01)。LBW的LAZ峰在矫正月龄2月,VLBW的LAZ高峰在矫正月龄10月。 2.体重生长规律矫正月龄1岁内早产儿体重生长趋势与正常足月儿相似,早产儿体重50%生长曲线较WHO足月儿50%标准生长曲线左移。早产儿每个矫正月龄段的WAZ值均值均大于0,WAZ高峰在矫正月龄2月。不同出生胎龄早产儿分析结果显示,在矫正月龄2、3、5月,EPI的WAZ均值小于LPI(P0.05)；EPI的WAZ高峰在矫正月龄6月,LPI的WAZ高峰在矫正月龄2月。不同出生体重早产儿分析结果显示,矫正胎龄40周,矫正月龄2～5月,VLBW的WAZ小于LBW、NBW(P0.05):矫正月龄2～5月、8月,LBW的WAZ值小于NBW(P0.05):LBW的WAZ高峰在矫正月龄2月,VLBW的LAZ高峰在矫正月龄10月。 3.头围生长规律早产儿头围生长趋势与足月儿相似。HCZ高峰值在矫正胎龄40周,除矫正胎龄40周外,每月Z值均值都在0以下。不同出生胎龄早产儿分析结果显示,在矫正月龄2月、3月,EPI的HCZ均值小于LPI,在矫正月龄10～12月,EPI的HCZ高于LPI(P0.05)。EPI的HCZ高峰在矫正月龄10月,LPI的HCZ高峰在矫正月龄2月。不同出生体重早产儿分析结果显示,在矫正胎龄40周、矫正月龄2～5月,VLBW的HCZ小于NBW早产儿(P0.05)；矫正胎龄40周、矫正月龄2～3月、5月,VLBW的HCZ值小于LBW早产儿(P0.05)。VLBW的HCZ高峰在矫正胎龄10月,LBW的HCZ高峰在矫正胎龄40周。 4.BMI规律各矫正月龄早产儿BMI生长趋势与足月儿基本相似。BMI50%曲线较WHO足月儿50%标准生长曲线左移。BMIZ在矫正月龄2月达高峰。不同出生胎龄早产儿分析结果显示,在矫正月龄2、3、5月,EPI的BMIZ均值低于LPI(P0.05)。LPI的BMIZ高峰值出现在矫正月龄3月,EPI的BMIZ高峰值在矫正月龄1月。不同出生体重早产儿分析结果显示,在矫正月龄2月～5月、8月,VLBW和LBW的BMIZ殖均小于NBW(P0.05)。VLBW的BMIZ高峰在矫正月龄1月,LBW的BMIZ高峰在矫正月龄2月。其他矫正月龄各组WAZ、LAZ、HCZ、BMIZ比较差异无统计学意义(P0.05)。 5.EUGR情况及影响因素 272例早产儿体重EUGR发生率26.5%；身长EUGR发生率12.1%；头围EUGR发生率7.1%。其中EPI的体重EUGR发生率为29.73%,明显高于LPI的16.13%(P0.01)；VLBW早产儿的体重EUGR发生率58.33%、身长EUGR发生率31.67%高于LBW早产儿的体重EUGR发生率16.38%与身长EUGR发生率7.34%(P0.05)；SGA早产儿的体重EUGR发生率43.84%、身长EUGR发生率27.40%高于AGA早产儿的18.59%、6.53%(P0.001)。身长EUGR危险因素：出生身长、身长增长速率、是否是SGA；体重EUGR的危险因素：出生体重,生长速度,是否是SGA；头围EUGR的危险因素:头围增长速率、出生身长(P0.05)。 6.营养状况 272名早产儿中有154名测量血常规,95名儿童测量微量元素.贫血发生率为16.88%,锌缺乏症发生率为88.42%,铁缺乏症发生率为24.21%。微量元素铜、钙、镁和血铅都在正常范围。 7.摄入膳食情况及对体格发育影响矫正月龄6月～矫正月龄12月早产儿摄入能量、蛋白质、碳水化合物、钙、铁、锌均比矫正月龄0～6月早产儿摄入多(P0.05)。矫正月龄0～6月早产儿摄入能量／体重、蛋白质/体重比较矫正月龄6月～矫正月龄12月早产儿较多。矫正月龄0-6月早产儿摄入能量、脂肪、蛋白质、元素铁、锌、钙均超过我国居民膳食营养素参考摄入标准(P0.01),矫正月龄6月～矫正月龄12月早产儿摄入能量、元素铁、锌、钙均未达到参考摄入量(P0.01)。母乳组、早奶组、普奶组三组EUGR发生率差异无统计学意义,由出生体重、头围矫正后早奶组评估时体重、头围高于母乳组(P0.05)。VLBW早产儿中母乳组早产儿EUGI发生率85.7%高于早奶组的40%。 [结论] 本研究中早产儿整体在1岁内完成追赶性生长；干预后早产儿生长趋势与正常足月儿相似；矫正胎龄2月左右是追赶性生长的关键期。EPI身长、头围、体重在矫正月龄6月龄后赶上LPI。VLBW身长、体重、头围追赶性生长较困难。早产儿贫血,锌、铁缺乏症发生率较高。强化营养对早产儿的体格发育有积极促进作用。VLBW、生长速率慢、SGA等早产儿要加强管理,积极强化营养。积极营养强化的同时,要全面评估早产儿的出生、住院情况,合理考虑早产儿的喂养耐受性,科学选择设计强化方案。
[Abstract]:[research background]
With the rapid development of modern medicine, the survival rate and cure rate of preterm infants in our country have been greatly improved, and the more challenges of premature infants after discharge are followed: the premature infants with low birth weight and low birth weight are immature because of their anatomical and physiological characteristics, the function of each organ is immature, the living ability is low, and various complications and malnutrition are prone to occur. One year old is the fastest growing period of children's growth and development, and it is also the key period for the chasing growth of preterm infants. The study shows that the growth and development of preterm infants are the important factors affecting the health and disease of the children after their adulthood. Psychological pressure, reducing the occurrence of malnutrition and mortality, reducing the behavior problems of prematurity children: improving the quality of life of premature infants and their families. To this end, the Ministry of health organized 17 medical units, carried out the "premature birth (children) intervention research project", formulated the "preterm infant health care service guide", the guide stressed that the daily standard of management should be emphasized. Based on different birth weight and different age stages, nutritional strategies should vary with different weight standards and age groups. The intervention of premature infants should be "individualized". Follow-up and intervention after discharge include nerve, physical development monitoring, early discovery of growth and development related problems, prevention and treatment of malnutrition, and correction of nutritional diseases. According to the above principles, from March 2012 to December 2013, we conducted a total of 1243 follow-up visits to 272 preterm infants born in our hospital to explore the overall and "individualized" nutritional status and growth and development of preterm infants.
[purpose and significance]
In order to understand the growth and development characteristics of preterm infants, the physical growth regularity, nutritional status and influencing factors of premature infants with different birth gestational age and different birth weight were discussed, and the relationship between them was analyzed.
Anti Law]
1. research objects
The premature infants who were born in Shenzhen maternal and child health care hospital from March 2012 to October 2013 and were willing to be followed up in the children health care department were fed smoothly through oral feeding. There was no feeding intolerance, no pneumonia, diarrhea and other diseases within the first 2 weeks of the investigation. The long-term Shenzhen city lived and the oral and informed consent was received by the investigators. A total of 272 preterm infants, birth gestational age (32.90 + 2.43) weeks, birth weight (1.93 + 0.49) kg, 153 male baby and 119 baby, 41 pairs of twins (82 people), 73 SGA preterm infants and 60 very low birth weight infants. Total follow-up records were included in the follow-up.
2. grouping
(1) according to the birth gestational age, it is divided into two groups: Advanced preterm infants (34 weeks less than birth gestational age 37 weeks, Late preterm infant, LPI) and early preterm infants (34 weeks of birth gestational age, Early preterm infant, EPI); EPI148, birth gestational age (31.17 + 1.93) weeks, birth weight (1.66 + 0.41) kg; LPI124 people, birth gestational age (35 + 0.84) weeks, birth weight (2.25 + 0.39) kg.
(2) according to the birth weight of three groups, divided into very low birth weight infants (birth weight 1000g to 1499g, Very low birth weight, VLBW), low birth weight infants (1500g birth weight 2499g, Low birth weight), normal birth weight infants (birth weight > 2.48) weeks, birth body age (30.03 + 2.48) weeks, birth body Heavy (1.23 + 0.16) Kg; LBW178 people, birth gestational age (33.44 + 1.87) weeks, birth weight (1.99 + 0.27) kg; NBW34 people, birth gestational age (34.69 + 1.18) weeks, birth weight (2.75 + 0.20) kg.
(3) three groups were divided according to the amount of milk that was fed by preterm infants: breast milk group [breast milk accounted for more than 75% of milk in one day (8 cases without breast milk fortifier); milk group (ordinary formula milk accounted for more than 75% of the total milk per day); early milk group [preterm infant (after discharge) formula milk accounted for more than 75% of the total milk volume of one day]. Breast milk group 54 people. Birth gestational age (33.34+2.18) week, birth weight (2.04 + 0.55) kg, early milk group 61, birth gestational age (31.41 + 2.38) weeks, birth weight (1.75 + 0.44) kg, milk group were 61, birth gestational age (33.79 + 2.15) weeks, birth weight (2.06 + 0.47) kg. early milk group birth birth age, birth weight is less than the breast milk group and the milk group (P0.01).
The number of preterm infants in each group was the same in length, weight, head circumference, BMI, LAZ, BMIZ, WAZ, WLZ, HCZ. There was no significant difference in sex ratio between each group in the three groups (P0.1).
3. analysis and observation index
(1) physical development indicators: premature infants' body length and Z value, body weight and Z value, head circumference and Z value, body mass index and Z value; body length, weight and head circumference growth rate;
Blood index: peripheral blood hemoglobin value, trace element copper, zinc, calcium, magnesium, iron and blood lead;
(3) dietary indicators: intake of energy, protein, carbohydrate, fat, iron, calcium and zinc in diet.
(4) nutritional assessment indicators: body weight, body length, head circumference EUGR incidence, low body weight, growth retardation, wasting, overweight, and head circumference less than 2 standard deviation rates.
4. dietary survey
600 cases of preterm infants were investigated and divided into two groups: (1) the correction of fetal age from 0 months to June: 300 times: 24 hours retrospective dietary survey method. The correction of month old 0-6 months: 300 times: three days food recording method. After eliminating the data with less energy consumption than the base, the correction of fetal age 0-6 months premature infant (birth) was obtained. The gestational age was 33.97 + 4.50 weeks, the birth weight was 2 + 0.51kg) 282 person times, and the correction month was from June to 1 years (31.92 + 6.46 weeks and the birth weight 1.83-0.51kg) 80 times. The daily intake of energy, protein, fat, carbohydrate, element iron, zinc, calcium value were calculated.
5. follow up
The month of age of June was followed up 1 times a month and 1 times per month after the month of June. The results of physical measurement in the follow-up of preterm infants were recorded, the conditions of birth, previous history, family history and discharge diagnosis were collected. The contents of intervention included physical monitoring, nutritional assessment and guidance, and preventive medication. The correction of preterm infants was 0~2 months of age of 0~2. In March, June, December, the peripheral blood routine was measured, corrected in June, and the trace elements in peripheral blood were measured in December.
6. statistical analysis
Epidata3.1 input, set up a database and use SPSS13.0 software to carry out statistical analysis. First, the normal and variance homogeneity test is carried out. The average number of two groups of normal distribution data conforming to the homogeneity of variance is compared with the t test, the multi group data comparison is analyzed with variance, and 22 is compared with the SNK method; the data that do not conform to the normal distribution are logarithmic through the logarithm. After changing the parameter analysis, if the nonparametric test is still not consistent, the incidence rate is compared with the chi square test and the Fisher exact probability method to test the.Logistic regression, and the multivariate linear regression analysis is used to analyze the data correlation. The nutrient calculation is realized by the compute program in SPSS.
[results]
The growth law of 1. body long
The growth trend of premature infants within 1 years old is similar to that of normal feet. The growth curve of body length 50% is shifted left than the 50% standard growth curve of WHO foot. From 40 weeks of orthodontic gestational age, the mean LAZ mean of each correction month is more than 0.2, reaching the peak in February.
The analysis of preterm infants with different birth gestational age showed that the corrected gestational age was 40 weeks, and the LAZ mean of EPI was less than LPI in February, while the LAZ average of EPI was greater than LPI (P0.05).EPI and LPI at correction month of age in October, February, respectively.
The analysis of different birth weight premature infants showed that in August, the LAZ of VLBW was smaller than that of LBW and NBW (P0.01).LBW LAZ peak in the correction month of August, and the LAZ peak of VLBW was in February, and the LAZ peak of VLBW was corrected in October.
2. rule of body weight growth
The trend of weight growth of premature infants within 1 years old was similar to that of normal feet. The 50% growth curve of weight in premature infants shifted left than the 50% standard growth curve of WHO foot. The mean WAZ value of each correction month of preterm infants was more than 0, and the peak of WAZ was in February.
The analysis of preterm infants at different birth gestational age showed that the WAZ mean of EPI was less than LPI (P0.05) at 2,3,5 months of correction, and the peak of WAZ in EPI was in June, and the WAZ peak of LPI was corrected in February.
The results of different birth weight preterm infants showed that the corrected gestational age was 40 weeks, and the correction of the month was 2~5 months. The WAZ of VLBW was less than LBW, NBW (P0.05): the correction of month age 2~5 months, in August, the WAZ value of LBW was less than NBW (P0.05): LBW WAZ peak was in February of month of correction, and the peak of VLBW was in October of orthodontic month.
The growth law of 3. head circumference
The growth trend of the head circumference of premature infants is similar to that of full term infants. The peak value of.HCZ is at 40 weeks of corrected gestational age, except for 40 weeks of corrected gestational age, the mean value of Z per month is below 0.
The analysis of preterm infants with different birth gestational age showed that the HCZ mean of EPI was less than LPI in February and March. The HCZ of EPI was higher than LPI (P0.05).EPI in October, and HCZ peak of LPI was in February of month.
The results of different birth weight premature infants showed that the HCZ of VLBW was less than NBW premature infant (P0.05) at 40 weeks of corrected gestational age and 2~5 months of age, and 40 weeks of orthodontic gestational age, 2~3 months of correction month, and in May, the HCZ value of VLBW was less than LBW preterm infant (P0.05).VLBW in October, LBW HCZ peak was 40 weeks of gestational age.
4.BMI law
The basic similar.BMI50% curve of BMI growth trend and foot moon in each correction month of preterm infants is higher than that of WHO foot 50% standard growth curve of.BMIZ at the peak of the month of February.
The analysis of preterm infants with different birth gestational age showed that the peak value of the BMIZ mean of EPI was lower than the BMIZ peak value of LPI (P0.05).LPI at the month of 2,3,5 months of age correction, and the peak value of EPI's BMIZ was in the month of January.
The analysis results of different birth weight premature infants showed that in February to May, the BMIZ colonization of VLBW and LBW was less than the BMIZ peak of NBW (P0.05).VLBW in January, and the BMIZ peak of LBW was corrected in February. There was no statistical difference between the WAZ, LAZ, HCZ, and HCZ.
5.EUGR situation and influencing factors
The incidence of weight EUGR in 272 preterm infants was 26.5%, the incidence of body length EUGR was 12.1%, and the incidence of EPI was 29.73% in head circumference EUGR rate 7.1%., significantly higher than 16.13% (P0.01) of LPI, 58.33% in VLBW preterm infant and 31.67% in EUGR incidence rate of 31.67%. The birth rate of 7.34% (P0.05); the incidence of weight EUGR in SGA preterm infants was 43.84%, the incidence of long EUGR 27.40% was 27.40% higher than that of AGA preterm infants, 6.53% (P0.001). The risk factors of long EUGR: birth length, growth rate, SGA, risk factors for weight EUGR: birth weight, growth speed, SGA; head circumference EUGR risk factor: head: head circumference EUGR: head The rate of peri growth, the length of birth (P0.05).
6. nutritional status
Of the 272 preterm infants, 154 were measured in the blood routine, and 95 children measured trace elements. The incidence of anemia was 16.88%, the incidence of zinc deficiency was 88.42%, and the incidence of iron deficiency was 24.21%. trace element copper, calcium, magnesium and blood lead were in normal range.
7. dietary intake and its effect on physical development
After correction month of age from June to December, the intake of energy, protein, carbohydrate, calcium, iron, zinc are more than that of 0~6 month old infants (P0.05). The correction of month old 0~6 month premature infant intake energy / weight, protein / body weight correction month old and correction month of December preterm infants are more. Correction of 0-6 months of age 0-6 months premature infant. The intake of energy, fat, protein, iron, zinc and calcium all exceeded the dietary dietary intake standard (P0.01) of our residents (P0.01) and corrected the energy intake from June to the month of December. The elements of iron, zinc and calcium were not reached the reference intake (P0.01). There was no statistical difference between the three groups of breast milk group, early milk group and general milk group. Body weight, head circumference correction, early milk group evaluation, weight, head circumference is higher than breast milk group (P0.05).VLBW premature infant in premature infant EUGI rate of 85.7% is higher than the early milk group 40%.
[Conclusion]
In this study, the preterm infants completed the catch-up growth at the age of 1, and the growth trend and prematurity of the preterm infants after intervention.

【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R722.6

【参考文献】