先天性小儿脑性瘫痪发病危险因素的多因素条件Logistic回归分析(英文)

Multi-factor Logistic regression analysis on risk factors of prenatal infantile cerebral palsy

背景:孕期危险因素作用于发育中的胎儿,使得胎儿在出生后出现脑性瘫痪的表现。因此,应把脑性瘫痪病因学的研究转入胚胎发育生物学领域,重视对孕期孕母所处相关的环境、遗传因素及相关疾病等多种因素的分析。目的:分析引起小儿脑性瘫痪的主要发病危险因素。设计:1∶2配对设计,多因素条件Logistic回归分析。单位:佳木斯大学预防医学教研室和哈尔滨医科大学公共卫生学院流行病教研室。对象:选择2002-12/2003-09在佳木斯脑瘫疗育中心、沈阳儿童医院及青岛儿童医院收治的103例脑性瘫痪患儿,男68例,女35例。监护人对调查项目知情同意。采用1∶2配对原则,选择同期本院就诊的非患脑性瘫痪及神经系统疾病的患儿和健康儿童206例作为对照。选择对照的匹配条件为:同性别,同民族,年龄相差±3个月。方法:①自拟脑性瘫痪患儿和健康儿童调查表,调查因素主要包括:分娩前因素(遗传因素:类似疾病家族史;母亲因素:一般情况:如职业、学历、分娩时年龄;生育行为因素:包括孕次、产次、异常产史;孕期保健和营养:如产前检查、各类食物摄入情况;孕期患病或异常表现:包括病原体感染、妊娠综合征、阴道出血等;孕期服药情况;胎儿胎盘因素:如脐带绕颈、出生质量、双胎妊娠等)、分娩过程因素(产时并发症、分娩方式等)和新生儿期因素(新生儿期所患各类疾病)。通过查阅医疗记录和询问知情人来完成调查问卷。②进行单因素、多因素条件Logistic回归分析,对单因素分析具有统计学意义,差异有显著性(P<0.05)和P值接近于0.05的因素,建立脑性瘫痪主要危险因素的多元Logistic回归模型,进行条件Logistic回归分析。主要观察指标:影响脑性瘫痪发病的孕期分娩前、分娩过程和新生儿期因素分析。结果:脑性瘫痪患儿103例,健康及非脑性瘫痪患儿206例均进入结果分析。①母亲因素:母亲职业因素与脑性瘫痪有联系,母亲职业为工人与年龄≥34岁为脑性瘫痪危险因素(OR=13.333,2.864,P<0.05)。②产前因素:孕早期呕吐、孕期吃鱼及海产品、产前体温、出生体质量>4000g、孕周37～42周为脑性瘫痪保护因素(OR=0.028～0.576,P<0.05～0.01);异常产史、孕期阴道出血为脑性瘫痪危险因素(OR=2.313～4.095,P<0.05～0.01)。③产时因素:Apgar评分和剖宫产是脑性瘫痪保护因素(OR=0.458,0.343,P<0.01);产钳助产和应用催产素是脑性瘫痪危险因素(OR=16.338,2.116,P<0.01,0.05)。④新生儿期因素:缺氧缺血性脑病、新生儿窒息和新生儿颅内出血是脑性瘫痪危险因素(OR=3.586,20.667,32.247,P<0.01)。⑤Logistic回归分析结果:产钳助产最危险(OR=70.668),其他危险因素由高到低依次为新生儿窒息、母亲妊娠年龄偏大、孕期阴道出血和出生体质量异常(OR=19.083～4.138,P<0.05～0.01),孕期吃鱼和海产品与剖宫产是保护因素(OR=0.324,0.262,P<0.01,0.05)。结论:脑性瘫痪的危险因素主要集中在孕期和围产期,应积极预防和消除各种产前、产时、产后脑性瘫痪危险因素(如产钳助产、新生儿窒息、母亲妊娠年龄偏大、孕期阴道出血和出生体质量异常),降低脑性瘫痪发病率。

BACKGROUND： The risks in pregnancy to the developing fetus result in cerebral palsy after delivery. Therefore, the study on etiology of cerebral palsy should transfer to biological field of embryonic development and stress on multi-factor analysis on relevant environment of pregnant mother, hereditary factors and relevant diseases. OBJECTIVE： To analyze the main risks of incidence of infantile cerebral palsy. DESIGN： Pair design at ratio of 1：2 and Logistic regression analysis of multi-factors were applied. SETTING： Prevention Medical Research Room of Jiamusi University and Department of Epidemiology, College of Public Health, Harbin Medical University. PARTICIPANTS： Totally 103 cases of infantile cerebral palsy were collected from Jiamusi Treatment and Education Center of Cerebral palsy, Shanyang Pediatrics Hospital and Qingdao Pediatrics Hospital from December 2002 to September 2003, of which, 68 cases were male and 35 cases were female. The guardians were in the know and agreed with the investigation. The pair principle at ratio of 1：2 was adopted, based on which, 206 cases of sick children with non-cerebral palsy and disorders in neurological system and healthy children treated at same period in the hospitals were collected as the control. The match conditions in the control were same sex, same nationality and difference in age ± 3 months. METHODS： （1） The investigation form of sick children with cerebral palsy and healthy children was self-designed. The investigated items included mainly： Factors before delivery （hereditary factors）： family history of similar disease; mother＇s factor： general situations, such as occupation, educational background and age of delivery; behavioral factors of birth： including times of pregnancy, times of delivery and abnormal delivery; healthcare and nutrient in pregnancy： such as examination before delivery and intakes of various foods; sickness or abnormal manifestations in pregnancy： including pathogen infection, pregnant syndromes and vaginal bleeding; medication in pregnancy, fetal placents factors： such as neck winding, mass weight of birth, twin pregnancy, factors during delivery （complications in delivery, methods of delivery） and neonatal factors （various kinds of disorders in neonates）. Questionnaire of investigation was performed by looking-up medical records and requiring persons in the know. （2） Logistic regression analysis was done on single factor and multi-factors. The factors that presented statistical significance in single-factor analysis, significant difference （P 〈 0.05） and P value near to 0.05 were adopted to establish the model of multiple Logistic regression of main risks of cerebral palsy and conditional Logistic regression analysis was carried on. MAIN OUTCOME MEASURES： Analysis on the effects of factors before delivery, during delivery and in neonatal phase on incidence of cerebral palsy. RESULTS： Totally 103 cases of cerebral palsy and 206 cases of healthy and non-cerebral palsy children all entered result analysis. （1） Mother＇s factors： Occupation of mother was associated with cerebral palsy. Worker and age ≥34 years were the risks of cerebral palsy （0R=13.333, 2.864, P 〈 0.05）. （2） Pre-delivery factors： Vomiting at early stage of pregnancy, eating fish and sea products in pregnancy, pre-delivery body temperature, mass weight of birth 〉 4 000 g and pregnant weeks of 37 to 42 were the protective factors of cerebral palsy （OR=0.028-0.576, P 〈 0.05-0.01）; abnormal delivery history and vaginal bleeding in pregnancy were the risks of cerebral palsy （OR=2.313-4.095, P 〈 0.05-0.01）. （3） Factors during delivery： Apgar score and caesarian section were the protective factors of cerebral palsy （OR=0.458, 0.343, P 〈 0.01）; forceps delivery and delivery with oxytocin were the risks of cerebral palsy （OR=16.338, 2.116, P 〈 0.01, 0.05）. （4） Neonatal factors： Hypoxic-ischemic encephalopathy and asphyxia of newborn and neonatal intracranial hemorrhage were the risks of cerebral palsy （OR=3.586, 20.667, 32.247, P 〈 0.01）. （5） Results of Logistic regression analysis： Forceps delivery was the highest risk （OR=70.668） and the sequence risk degree from high to low was asphyxia of newborn, elder age of pregnant mother, vaginal bleeding in pregnancy and abnormal mass weight of birth （OR=19.083-4.138, P 〈 0.05-0.01）. Eating fish and sea products in pregnancy and caesarian section were the protective factors （OR=0.324, 0.262, P 〈 0.01, 0.05）. CONCLUSION： Risks of cerebral palsy are mainly focused on pregnant period and perinatal period. It is suggested to prevent and eliminate actively various risks of cerebral palsy before, during and after delivery （such as forceps delivery, asphyxia of newborn, elder age of pregnant mother, vaginal bleeding in pregnancy and abnormal mass weight of birth） so as to reduce the incidence rate of cerebral palsy.