超低出生体重儿肠外营养中的钙磷添加

Supplementation of calcium and phosphorus in parenteral nutrition for extremely low-birth-weight infants

目的 观察超低出生体重（ELBW）儿3种不同的肠外营养（PN）钙磷添加治疗方案,探讨ELBW儿如何用PN的方式补充钙磷.方法 2009年6月至2012年12月同济医院新生儿重症监护病区收治、进行PN治疗、符合纳入标准、顺利完成研究的66例ELBW儿按随机数字表法分为无添加组（n=28）、钙剂添加组（n=21）和钙磷添加组（n=17）,分别给予单纯的PN营养液、PN添加钙剂、PN添加钙剂和磷盐,每周（共4周）测定血清离子钙、血清磷水平,随机尿中尿钙及尿肌酐含量,测定治疗开始时及治疗期末骨密度值（SOS）.结果 经过添加治疗后,与无添加组比较,钙剂添加组离子钙水平明显升高[14 d,（1.82±0.35）mmol/L比（1.14±0.47）mmol/L,t=5.800,P=0.005;1 d,（1.77±0.45） mmol/L比（1.07±0.43） mmol/L,t=5.492,P=0.004;28 d,（1.61±0.58）mmol/L比（0.92±0.44） mmol/L,t=4.556,P=0.025],钙磷添加组离子钙水平亦明显升高[14 d,（1.55±0.30） mmol/L比（1.14±0.47） mmol/L,t=3.570,P=0.001；21 d,（1.58±0.38） mmol/L比（1.07±0.43） mmol/L,t=4.151,P=0.000; 28d,（1.55±0.35） mmol/L比（0.92±0.44） mmol/L,t=5.302,P=0.003].钙磷添加组血清磷水平与无添加组比较明显升高[14 d,（1.86±0.10） mmol/L比（1.65±0.17）mmol/L,t=5.217,P=0.012;21 d,（1.88±0.14） mmol/L比（1.61±0.13） mmol/L,t=6.442,P=0.003; 28 d,（1.89±0.15） mmol/L比（1.58±0.14） mmol/L,t=6.891,P=0.000],也明显高于钙剂添加组[14 d,（1.86±0.10）mmol/L比（1.53±0.15）mmol/L,t=8.100,P=0.000; 21d,（1.88±0.14） mmol/L比（1.57±0.14） mmol/L,t=6.787,P=0.000;28 d,（1.89±0.15） mmol/L比（1.62 ±0.18） mmol/L,t=5.043,P=0.000].与无添加组比较,钙剂添加组的尿钙/肌酐比明显升高（14 d,0.69±0.18比0.33±0.14,t=7.601,P=0.000；21 d,0.66±0.16比0.37±0.14,t=6.62,P=0.001; 28 d,0.62 ±0.15比0.39±0.12,t=5.776,P=0.005）,而钙磷添加组的尿钙/肌酐比明显降低（14 d,0.14±0.10比0.33±0.14,t=5.294,P=0.010; 21 d,0.13±0.12比0.37±0.14,t=6.102,P=0.002; 28d,0.12±0.11比0.39±0.12,t =7.711,P=0.000）.28 d时钙磷添加组的骨SOS值增加量明显高于无添加组和钙剂添加组[（381±87） m/s比（135±87） m/s,t=9.815,P=0.000; （381±87） m/s比（146±68） m/s,t=9.774,P=0.000].结论 给予ELBW儿比例适当的钙磷添加治疗可使血清钙磷水平稳步升高,且避免了高钙尿症,增加了骨矿含量.对ELBW儿的PN钙磷添加治疗还需进行大样本研究和长期观察.

Objective To investigate the usefulness of calcium and phosphorus supplementation in parenteral nutrition for extremely low-birth-weight （ELBW） infants.Methods According to the inclusion criteria,66 ELBW infants hospitalized after birth in neonatal ward of Tongji Hospital from June 2009 to December 2012 were divided into three groups with random number table：28 infants in the first group were treated with parenteral nutrition without calcium and phosphorus supplementation,21 infants in the second group were treated with parenteral nutrition with calcium supplementation only,and 17 infants in the third group was treated with parenteral nutrition with calcium and phosphorus supplementation.The blood levels of ionic calcium,blood phosphorus,and urine calcium and creatinine were determined once a week （total of 4 times）.The speed of sound （SOS） was detected for shin bones by quantitative ultrasound at the date of admitting and the end of 4weeks.Results After administrations of supplementation,the blood levels of ionic calcium in the second group were significantly higher than those in the first group [on the 14th day,（1.82 ± 0.35） mmol/L vs.（1.14 ±0.47） mmol/L,t=5.800,P=0.005;onthe21stday,（1.77±0.45） mmol/Lvs.（1.07±0.43） mmol/L,t=5.492,P=0.004; on the 28th day,（1.61±0.58） mmol/Lvs.（0.92±0.44） mmol/L,t=4.556,P=0.025].The blood levels of ionic calcium in the third group were also significantly higher than those in the first group [on the 14th day,（1.55 ± 0.30） mmol/L vs.（1.14 ± 0.47） mmol/L,t =3.570,P =0.001 ; on the 21st day,（1.58 ±0.38） mmol/L vs.（1.07 ±0.43） mmol/L,t =4.151,P=0.000; on the 28th day,（1.55 ±0.35） mmol/L vs.（0.92 ±0.44） mmol/L,t =5.302,P =0.003].The blood levels of phosphorus were significantly elevated in the third group compared with those in the first group [on the 14th day,（1.86 ±0.10） mmol/L vs.（1.65 ±0.17） mmol/L,t=5.217,P=0.012; on the21st day,（1.88 ±0.14） mmol/Lvs.（1.61 ±0.13） mmol/L,t =6.442,P=0.003; on the 28th day,（1.89 ±0.15） mmol/L vs.（1.58 ±0.14） mmol/L,t =6.891,P =0.000] and the second group [on the 14th day,（1.86 ± 0.10） mmol/L vs.（1.53 ±0.15） mmol/L,t =8.100,P=0.000; on 21st day,（1.88 ±0.14） mmo/Lvs.（1.57 ±0.14） mmol/L,t =6.787,P =0.000; on the 28th day,（1.89 ± 0.15） mmol/L vs.（1.62 ± 0.18） mmol/L,t =5.043,P =0.000].The calcium-to-phosphorus ratios markedly increased in the second group compared with those in the first group （on the 14th day,0.69 ±0.18 vs.0.33 ±0.14,t =7.601,P =0.000; on the 21st day,0.66±0.16 vs.0.37 ±0.14,t =6.62,P=0.001 ; on the 28th day,0.62 ±0.15 vs.0.39 ±0.12,t =5.776,P =0.005） while declined in the third group （on the 14th day,0.14 ± 0.10 vs.0.33 ± 0.14,t =5.294,P =0.010; on the 21st day,0.13 ± 0.12 vs.0.37 ± 0.14,t =6.102,P =0.002; on the 28th day,0.12 ± 0.11 vs.0.39 ± 0.12,t =7.711,P =0.000）.The third group showed significantly increased SOS values than those in the first and second groups [（381 ± 87） m/s vs.（135 ± 87） m/s,t =9.815,P =0.000;（381 ±87） m/s vs.（146 ±68） m/s,t =9.774,P=0.000].Conclusions Proper supplementation of calcium and phosphorus via parenteral nutrition can achieve increased bone mineral contents and stable blood ionic calcium and phosphorus levels,and avoid hypercalciuria in ELBW infants.PN therapy with calcium and phosphorus supplementation in ELBW infants needs further studies.