极低出生体重儿胃肠道内喂养方法探讨

Clinical research of the enteral feeding of very low birth weight infants guided with a scoring system

目的探讨安全有效的VLBWI胃肠道内喂养方案。方法本研究经北京协和医院伦理委员会批准。所有患儿其家长均签署了知情同意书。根据影响喂养的各种因素与达到足量喂养时间的相关程度赋予不同分值，从而制定相应的评分体系，并制定VLBWI胃肠道内喂养方案及监测方案。对比应用评分法前后VLBWI胃肠道内喂养的安全性及有效性。结果应用评分法前的VLBWI为A组，应用评分法后的VLBWI为B组。A组48例，胎龄（30．0±2．1）周，出生体重（1173±170）g；B组48例，胎龄（30．3±1．7）周，出生体重（1133±238）g。两组的胎龄、出生体重差异无统计学意义，B组发生新生儿呼吸窘迫综合征的比例显著高于A组（44／48VS35／48，P=0．016），B组脐静脉置管时间显著长于A组（12．0vs5．5d，P=0．000），其他各种并发症两组差异无统计学意义。两组开奶日龄差异无统计学意义，B组的开奶量、第3、7、14、21、28天奶量较A组显著增多[5．6VS3．5ml／（kg·d），P=0．008]，[12．3VS5．7ml／（kg·d），P：0．000]，[29．1vs8．9ml／（kg·d），P=0．000]，[62．5VS44．6ml／（kg·d），P=0．020]，[98．1VS71．5ml／（kg·d），P=0．005]，[128．0VS102．4ml／（kg·d），P=0．011]。B组达足量胃肠道内喂养时间较A组显著缩短（26．7vs32．9d，P=0．007）。两组可疑坏死性小肠结肠炎的发生率差异无统计学意义，B组确诊坏死性小肠结肠炎的比例较A组显著减少（0／48vs4／48，P=0．041）。两组应用氨基酸的总量差异无统计学意义，B组应用脂肪乳的总量显著低于A组（50．3vs73．9g／kg，P=0．000）。B组应用胃肠道外营养时间显著短于A组（31．5VS37．8d，P=0．016），两组的住院时间差异无统计学意义。B组较A组较早开始增长体重[5．0（4．3，6．0）vs5．0（5．0，7．0）d，P=0．028]、较快恢复出生体重（9．2vs11．6d，P=0．001）、第2周增长的体重较多（178VS138g，P=0．020）。结论依据评分体系制定的VLBWI喂养方案可以在不增加坏死性小肠结肠炎发生率的前提下，显著加快VLBWI的喂养进程，尽早达到足量喂养，缩短肠外营养的时间。

Objective Along with the elevation of survival rate of very low birth weight infants （ VLBWI）, the enteral feeding of VLBWI has become one of the most important factors, which influence the length of stay, short and long-term prognosis. This study aimed to explore safe and effective clinical protocols of VLBWI enteral feeding. Method According to different correlative degree of related factors to VLBWI enteral feeding, different scoring system was formulated for the enteral feeding and monitoring proposal of VLBWI. The safety and efficacy of the score system was evaluated. Result Forty-eight VLBWIs in group A was not treated with any score system, gestational age （30. 0 ±2. 1 ） weeks, birth weight （1173 ± 170） g; while 48 VLBWIs in group B were guided with the scoring system, gestational age （ 30. 3 ± 1.7 ） weeks, birth weight （1133 ± 238） g, there was no significant difference between two groups. The incidence of newborn respiratory distress syndrome of group B was significantly higher than that of group A （P = 0. 016）. The time of umbilical catheterization of group 13 was longer than that of group A. There was no significant difference in the incidence of other complications between two groups. The beginning milk volume, milk volume on the third, seventh, fourteenth, twenty-first, twenty-eight day of group B were significantly higher than that of group A [ 5.6 vs. 3.5 ml/（ kg · d）, P = O. 008,12. 3 vs. 5.7 ml/（ kg · d）, P = 0. 000 ,29. 1 vs8.9 ml/（kg.d）, P=O. 000 ,62.5 vs. 44.6 ml/（kg· d）, P=0.020,98.1 vs. 71.5 ml/（kg· d）, P = 0. 005,128.0 vs. 102. 4 ml/（ kg · d） , P = 0. 0111- The time achieving full enteral feeding of group B was shorter than that of group A （ 26. 7 vs 32. 9d, P = 0. 007 ）. The incidence of neerotizing enteroeolitis in group B was lower than that of group A（0/48 vs. 4/48, P =0. 041 ）. There was no significant difference of the total amino acid dosage between two groups. The total dosage of fatty emulsion was less, and the duration of parenteral nutrition was shorter in group B than in group A （50. 3 vs. 73.9 g/kg, P =0. 000, 31.5 vs. 37.8 d, P =0. 016）. There was no signifieant difference in length of stay between two groups. VLBWI of group B began to gain weight earlier [5.0（4.3, 6.0）vs. 5.0 （5.0, 7.0） d , P=0.0283 , regained birth weight earlier（9. 2 vs. 11.6 d, P =0. 001 ）, and got more weight in the second week（ 178 vs. 138 g, P = 0 .020）. Conclusion VLBWI guided with the scoring system achieved full enteral feeding faster, and shortened the duration of parenteral nutrition without increasing the incidence of neerotizing enteroeolitis.