超低出生体重儿4至11岁时的随访结局

A follow-up study of extremely low birth weight infants at four to eleven years of age

目的通过对超低出生体重儿（ extremely low birth weight infant, ELBWl ） 4-11岁时进行随访，分析远期严重并发症发生情况及其与生后住院期间病情的关系，了解本地区危重早产儿救治和随访的情况及存在的问题。方法研究对象为北京地区5家医院2000年1月至2009年12月救治成活的全部ELBWI。2011年5月至2013年8月，对这些ELBWI进行随访。随访内容包括收集研究对象出生时和住院期间的临床资料，并在北京协和医院对随访患儿测量体格发育情况，评估智力和运动发育情况，测定心肺功能。分析各系统疾病的发生和治疗情况，特别是严重并发症的发生情况。对数据资料进行描述性统计分析。结果（1）共随访到48例ELBWI。48例的出生胎龄为24．4-34．0周，平均（29．1±2．4）周；出生体重700-990g，平均（895±68）g；36例（75．0％）因母亲妊娠期高血压早产。39例（81．2％）为小于胎龄儿。随访时年龄4．0-10．6岁，平均年龄为（5．6±1．8）岁。36例（75．0％）来医院进行了体格检查，另12例（25．0％）仅进行电话随访。（2）48例中，31例（64．6％）的体重和28例（58．3％）的身高分别小于同龄儿童平均值。48例中的14例（29．2％）体格发育落后，其中7例仅体重、1例仅身高〈第10百分位，6例身高和体重均〈第10百分位。（3）48例中，42例（87．5％）发生新生儿呼吸窘迫综合征，11例（22．9％）支气管肺发育不良，3例（6．3％）诊断为支气管哮喘。随访时，共28例完成通气功能检查，其中4例（14．3％）为肺功能中度损害，6例（21．4％）为肺功能轻度损害，其余18例（64．3％）患儿肺功能大致正常。（4）48例中，10例（20．8％）住院期间出现动脉导管未闭，发生房室传导阻滞和发生室性早搏、室上性心动过速各1例（各2．1％）。来院随访时，2例（5．6％，2136）发现冠状动脉窦轻度扩张，其余患儿心脏超声、心电图和心功能检查均未见明显异常。（5）6例（12．5％）发生Ⅲ-Ⅳ级脑室内出血，经治疗，均未发生严重后遗症。4例（8．3％）诊断为脑性瘫痪。1例（2．10／0）于幼儿期诊断为癫痫。（6）25例完成智力发育评估，其中2例脑性瘫痪患儿分别为轻度和中度智力低下，4例患儿属于边界智力，其余19例得分在正常范围内。（7）住院期间发生败血症7例（14．6％），均治愈；发生坏死性小肠结肠炎6例（12．5％）。1例（2．10／0）患儿发生脑膜炎，治愈后未发生严重后遗症。（8）发生早产儿视网膜病变7例（14．6％），其中3例行激光手术治疗，4例随访观察后好转，无一例视力损伤。1例（2．1％）随访时发现耳聋。（9）出院后2年内，13例（27．1％）患儿住院1-5次，平均（1．0±0．4）次。其中11例为呼吸道感染，其余分别为因疝修补术和皮肤血管瘤切除术住院者各1例。结论ELBWI生长发育落后发生率较高，未发生严重脑室内出血的ELBWI也可能发生脑性瘫痪。需要进一步探讨治疗策略，改善ELBWI生长发育落后状况，减少严重并发症和后遗症，改善患儿生存质量。

Objective To analyze the relationship between the incidence of complications and disease condition during hospitalization in severe preterm infants after birth, and to understand the situation and problems in treatment of these infants through a follow up study of extremely low birth infants （ELBWls） at four to eleven years of age. Methods A follow up study was carried out in all ELBWIs who were born between January 2000 and December 2009 in five hospitals of Beijing area. The study was conducted from May 20ll to August 2013. Clinical data of these ELBWIs were collected. Development of those ELBWls was measured in the Peking Union Medical College Hospital, including physical, mental and motional development. Their cardiopulmonary functions were also examined. The incidence and treatment of disease in each system was analyzed, especially the incidence of severe complications. Descriptive statistical analysis was performed. Results （l） A total of 48 ELBWIs were followed up, with 24.4 to 34.0 weeks of gestation at birth, averaging （29.1 ± 2.4） weeks. The birth weight of those ELBWIs was 700-900 g, with an average of （895 ± 68） g. Among the 48 ELBWls, 36 （75.0%） preterm infants were delivered for maternal gestational hypertensive disorders. Thirty- nine cases （81.2%） were small for gestational age. Those ELBWIs at 4.0-10.6 years of age were followed up, with an average age of（5.6± 1.8） years. Thirty six cases （75.0%） were followed up at clinic visits, and the other 12 cases （25.0%） were followed up through telephone calls. （2） Among the 48 cases, 31（64.6%） had lower weight, and 28（58.3%） had lower height than the average level. Fourteen children （29.2%） had physical retardation, among whom, seven cases had lower height, one case had lower weight, and six cases had both lower weight and height by 10 percentile. （3） Among the 48 cases, 42 cases （87.5%） had neonatal respiratory distress syndrome, 11（22.9%） had bronchopulmonary dysplasia, and 3（6.3%） had bronchial asthma. During the follow-up, 28 cases underwent ventilatory function tests. Moderately impaired pulmonary function was found in four cases （14.3%） ,mildly impaired pulmonary function in six cases （21.4%） and the pulmonary function was almost normal in the other 18 cases （64.3%）. （4）Among the 48 cases, 10（20.8%） had patent ductus arteriosus, 1（2.1%） had atrioventricular block, and another case （2.1%） had ventricular premature beats and supraventricular tarchycardia. Two cases （5.6%, 2/36） had mildly dilated coronary sinus. （5） Six cases （12.5%） had intracranial hemorrhage of level Ⅲ-Ⅳ , and with no sequelae after treatment. Four cases （8.3%） were diagnosed as cerebral palsy, and one case （2.1%） as epilepsy in early childhood. （6） Mental development assessment was performed in 25 cases. Among them, two cases of cerebral palsy had mild or moderate mental retardation, tour cases had border intelligence, and the other 19 cases had normal intelligence. （7） During hospitalization, sepsis occurred in three cases （14.6%）, necrotizing enterocolitis in six cases （12.5%）, and meningitis in one case （2.1%）. All those cases were cured. （8） Among seven cases （14.6%） of retinopathy of prematurity, three cases received laser treatment, the other four cases improved after observation. None of them had visual impairment. One case （2.1%） had hearing impairment during follow-up. （9） Two years after discharge, 13 cases （27.1%） were rehospitalized for one to five times, with an average of （1.0__＋_ 0.4） times. Eleven of the cases were rehospitalized for respiratory infections, and two cases for hernia or dermal hemangioma, respectively. Conclusions The incidence rate of development retardation in ELBWIs is high in this area. Cerebral palsy may occur in ELBWIs without intracranial hemorrhage. Treatment strategies should be further established to improve the development retardation, reduce severe complications and sequelae, and to improve the quality of life of the children.