新生儿重症监护病房极早产儿宫外生长受限状况调查

Investigation of extrauterine growth restriction in very preterm infants in Chinese neonatal intensive care units

目的综合评估我国新生儿重症监护病房(NICU)极早产儿宫外生长受限(EUGR)的现状及相关影响因素。方法队列研究。研究对象为6179例2019年入住中国新生儿协作网(CHNN)57家医院NICU且住院时间≥7 d的出生胎龄<32周的早产儿(极早产儿)。采用EUGR的横断面定义(出院体重低于相应胎龄儿的P10)、纵向定义(出生至出院时体重Z值下降>1)和体重增长速度全面评估极早产儿出生后的生长状况。采用两独立样本t检验、Mann-Whitney U检验或χ^(2)检验进行EUGR组和非EUGR组的组间比较。应用多因素Logistic回归模型评估不同定义的EUGR发生与母婴因素、临床治疗措施和早产儿主要疾病的关联。结果6179例极早产儿中男3474例(56.2%),出生胎龄为(29.8±1.5)周,出生体重为(1365±304)g。极早产儿出院时EUGR发生率横断面定义为48.4%(2992例),纵向定义为74.9%(4628例)。出生时体重Z值为(0.13±0.78),出院时体重Z值下降至(-1.35±0.99)。体重增长速度为10.13(8.42,11.66)g/(kg·d)。多因素Logistic回归分析发现在出生后可干预的影响因素中,达到完全肠内喂养日龄大(OR_(调整)=1.01,95%CI 1.01~1.02,P<0.001;OR_(调整)=1.01,95%CI 1.01~1.02,P<0.001)和坏死性小肠结肠炎≥Ⅱ期(OR_(调整)=2.64,95%CI 1.60~4.35,P<0.001;OR_(调整)=1.62,95%CI 1.10~2.40,P<0.001)及动脉导管未闭(OR_(调整)=1.94,95%CI 1.50~2.51,P<0.001;OR_(调整)=1.63,95%CI 1.29~2.06,P<0.001)均是横断面定义EUGR和纵向定义EUGR的危险因素。开始肠道内喂养日龄大(OR_(调整)=1.06,95%CI 1.02~1.09,P=0.020)和呼吸窘迫综合征(OR_(调整)=1.45,95%CI 1.24~1.69,P<0.001)均与横断面定义EUGR风险增加相关。母乳喂养与纵向定义EUGR的高风险相关(OR_(调整)=1.33,95%CI 1.05~1.68,P<0.001)。结论中国极早产儿EUGR的发生比例较高,对EUGR可干预风险因素的识别为改善极早产儿出生后的生长提供了优先实施的领域,对极早产儿的营养管理和降低并发症发生率依然是目前临床管理的重点工作。

Objective To comprehensively assess the current status of extrauterine growth restriction(EUGR)in very preterm infants(VPI)and its associated factors in Chinese neonatal intensive care units(NICU).Methods In this cohort study,6179 preterm infants born at<32 weeks′gestation were included,who were admitted to 57 hospitals in the China Neonatal Network in 2019 and hospitalized for≥7 days.EUGR was evaluated by a cross-sectional definition(weight at discharge<10th percentile for postmenstrual age),a longitudinal definition(decline in weight Z score>1 from birth to discharge),and weight growth velocity.The comparison between infants with and without EUGR was conducted by t‐test,Mann-Whitney U test or χ^(2) test as appropriate.Multivariable Logistic regression models were used to evaluate associations between EUGR with different definitions and maternal and neonatal factors,clinical practices,and neonatal morbidities.Results A total of 6179 VPI were enrolled in the study,with a gestational age of(29.8±1.5)weeks and birth weight of(1365±304)g;56.2%(3474)of them were male.Among them,48.4%(2992 VPI)were cross-sectional EUGR and 74.9%(4628 VPI)were longitudinal EUGR.Z score of weight was(0.13±0.78)at birth and decrease to(-1.35±0.99)at discharge.The weight growth velocity was 10.13(8.42,11.66)g/(kg·d).Multivariate Logistic regression analysis showed that among the influential factors that could be intervened after birth,late attainment of full enteral feeds(OR_(adjust)=1.01,95%CI 1.01-1.02,P<0.001;OR_(adjust)=1.01,95%CI 1.01-1.02,P<0.001),necrotizing enterocolitis≥Ⅱstage(OR_(adjust)=2.64,95%CI 1.60-4.35,P<0.001;OR_(adjust)=1.62,95%CI 1.10-2.40,P<0.001)and patent ductus arteriosus(OR_(adjust)=1.94,95%CI 1.50-2.51,P<0.001;OR_(adjust)=1.63,95%CI 1.29-2.06,P<0.001)were all associated with increased risks of both cross-sectional and longitudinal EUGR.In addition,late initiation of enteral feeds(OR_(adjust)=1.06,95%CI 1.02-1.09,P=0.020)and respiratory distress syndrome(OR_(adjust)=1.45,95%CI 1.24-1.69,P<0.001)were all associated with cross-sectional EUGR.Breast milk feeding(OR_(adjust)=1.33,95%CI 1.05-1.68,P<0.001)was associated with a higher risk of longitudinal EUGR.Conclusions The incidence of EUGR in VPI in China is high.Some modifiable risk factors provide priorities to improve postnatal growth for VPI.Nutritional management of VPI and the efforts to decrease the incidence of complications are still the focus of clinical management in China.