新生儿排尿方式的研究
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摘要
背景和目的
尿液经肾脏形成后经输尿管贮存于膀胱中,一定量后排出体外的过程称为排尿。尿液在膀胱中贮存到一定量后,膀胱扩张至膀胱壁受牵张,壁内牵张感受器产生充胀感觉,引发原发性刺激。但是,排尿是一种复杂的受中枢神经系统控制的反射活动。
新生儿排尿量变化较大,每次排尿量不均衡,似乎与排尿反射是由于膀胱容量达一定限度而引起的简单脊髓反射理论相违背。新生儿开始排尿时的膀胱容量可从其功能性膀胱容量的30%到100%变化不等,其变化原因并不清楚,但新生儿睡觉之后开始排尿的膀胱容量则会升高。
1岁之内的儿童膀胱容量并不随年龄或体重呈线性增长。膀胱容量的快速增长分两个阶段。第一阶段在出生前后,增长约4倍,而体重仅增长3倍。有关自由排尿试验报道称,孕32周的早产儿膀胱平均容量约为12ml,3月龄足月儿约为52ml。第二阶段为如厕训练获得控制排尿时的年龄(约3岁左右)。儿童夜间不再尿床或已获得控尿能力是膀胱容量在此阶段增长的主要原因,夜间不排尿使膀胱容量不断增加。提示导致膀胱输尿管返流及后尿道瓣膜男性患儿膀胱容量增长的原因是由夜间膀胱容量增加引起的。同时,经坐便训练后的健康儿童功能性膀胱容量增加的决定因素亦为夜间膀胱容量。1岁之内的小儿可使用公式：膀胱容量(ml)=25+(月龄×3)进行膀胱容量的评估,其膀胱容量多少与年龄并不呈线性关系,较大儿童预测膀胱容量采用公式：预期膀胱容量(m1)=30+[年龄(岁)x30]。
婴幼儿排尿的特点是逼尿肌一括约肌协同失调,表现为排尿中断和排尿后残余尿量的增加。Jansson等人研究报道,2岁之内小儿排尿后有残余尿量。这种现象同样可在尿动力学检查中观察到,盆底肌电活动在排尿时间断增加,伴逼尿肌压力波动。从出生至3岁儿童自由排尿纵向调查研究显示,随着年龄增长,逼尿肌一括约肌协同失调逐渐消失,经排便训练后将不再出现。此外,另外一种逼尿肌过度活动形式很有可能存在于1个月以内的新生儿。研究发现,20%的新生儿膀胱压力测定中充盈少量液体时,出现漏尿,引发自发性逼尿肌收缩过早。新生儿膀胱容量在膀胱压力测定中比自由排尿观察中少。这些研究发现均提示,此年龄组小儿排尿反射易在膀胱压力测定中插入导管及输注生理盐水时引发。几个月后逼尿肌过度活动会消失,且膀胱容量增加。
传统观点认为婴幼儿期膀胱充盈到一定容量时自发地引起排尿,膀胱功能不受大脑控制。近来研究报道称大脑影响排尿反射自婴儿出生即开始。此观点可以通过大多数新生儿排尿前出现觉醒征象来说明,提示此年龄组婴幼儿连接大脑皮层的反射通路已建立并得到发展。但是,婴幼儿排尿是受到一定程度信号的影响,并非有意识的及随意的。国外学者对1岁之内的婴幼儿进行研究发现,坐便训练受一定程度的信号影响。因此,婴幼儿达到有意识地自主排尿需要不断发育成熟及进行排尿训练。
目前,如何诊断新生儿膀胱功能障碍是临床工作中的一个难题。这主要是因为新生儿无自主排尿能力、排尿异常的临床表现不明显及无法用儿童及成人排尿参数作为新生儿的诊断标准等都增加了新生儿排尿异常诊断的难度。新生儿膀胱功能评估临床上主要采用尿动力学检查方法,因其具有一定的侵入性及难在新生儿身上操作,因此,我们对新生儿自由排尿进行观察,了解新生儿排尿方式,以便为临床提供新生儿排尿方面的参考数据,研究设计分为三部分,如下：
第一部分：足月儿与早产儿排尿方式的比较研究；
第二部分：新生儿随年龄变化排尿方式的变化研究；
第三部分：排尿方式的影响因素研究(包括：性别、体重的影响；疾病的影响；外因影响)。
第一部分：足月儿与早产儿排尿方式的比较研究
材料和方法
选取2010年3-5月入住郑州大学第一附属医院新生儿室的出生后3-7d的足月儿12例与早产儿14例作为研究对象,足月儿孕(38.3+1.1)周,体重(3.1+0.4)kg,早产儿孕(32.5+1.6)周,体重(1.7±0.4)kg。观察新生儿在12h内(早9点-晚9点)的自由排尿情况,记录排尿次数及排尿时间、每次排尿量、残余尿量、排尿时的意识状态(清醒／睡眠)等参数,同时记录液体摄入量(包括饮奶量及液体输入量)及摄入时间,液体摄入量按标准进行。每次排尿量相当于排尿前后尿垫重量之差,残余尿量由超声检测仪测得。共观察记录了220例次。
结果
足月儿的每次排尿量、残余尿量、排尿次数、排尿时意识清醒状态百分比分别为(19.8±10.9)ml、(1.55±1.01)ml、(7.2±1.9)次、(43.5±26.8)%,早产儿分别为(11.1±7.5)ml、(1.82±0.88)ml、(9.6±2.5)次、(24.7±19.1)%。两组相关数据经统计学分析,早产儿残余尿量及排尿次数大于足月儿,而每次排尿量及排尿时意识清醒状态百分比小于足月儿,均具有统计学意义(P<0.05)。
第二部分：新生儿随年龄变化排尿方式的变化
材料和方法
1.选取郑州大学第一附属医院的21例健康新生儿作为观察对象,男性11例,女性10例。其中,10例为足月儿,孕(38.5±1.3)周,(37-40)周,出生体重(3.2±0.4)kg；11例为早产儿,孕(32.7±1.6)周,(29-36)周,出生体重(1.8±0.5)kg。所有新生儿均无尿路病变或症状。
2.所有新生儿在出生后第1、4、7、14、28天分别进行观察,经12h(早9点-晚9点)自由排尿情况观察。
3.采用SPSS13.0统计学软件包对数据进行处理。利用t检验对新生儿不同年龄组之间的每次排尿量、残余尿量、排尿时意识状态及排尿次数进行比较分析。
结果
1.共进行778例次排尿观察。4例新生儿在前4h观察中无排尿,排尿发生在出生后第5或第6小时。新生儿之间排尿次数、每次排尿量及排尿后残余尿量变化较大,标准差较大。
2.相同年龄的足月儿在出生后第14天、第28天排尿次数较早产儿少(P<0.05),出生后第4天、第7天、第14天及第28天每次排尿量均较早产儿高(P<0.05),残余尿量则在出生后第4天、第28天较早产儿高(P<0.05)。
3.早产儿第4天排尿次数较第1天明显增加,第7天较第4天又明显增加,第28天又较第14天明显增加(p<0.01)。每次排尿量仅在从14天到28天的早产儿中明显增加(p<0.05)。足月儿第7天排尿次数较第4天明显增加(p<0.01)。每次排尿量从第1天到第4天及从第14天到第28天明显增加(p<0.01)。残余尿量从第1天到第4天明显增加,明显减少出现在第4天到第7天,第14天到第28天再次出现明显增加(p<0.05)。
4.早产儿中间断排尿占70%,而足月儿仅占40%。足月儿第28天膀胱排空率较早产儿高(56%vs.40%)。早产儿第28天觉醒排尿比例不超过30%,而足月儿达到60%。
第三部分：新生儿排尿方式的影响因素
性别、体重对新生儿排尿方式的影响
材料和方法
1.男性新生儿与女性新生儿：选取2010年3月-2011年3月我院新生儿室的(3-7)d的早产儿54例和足月儿48例作为观察对象。其中早产儿男26例,胎龄(34.2±1.8)周,日龄(3.5±1.8)d；女28例,胎龄(34.4±1.3)周,天龄(3.3±2.1)d。足月儿男30例,胎龄(39.5±0.9)周,日龄(4.2±1.6)d；女18例,胎龄(39.7±0.8)周,日龄(4.3±1.4)d。
2.低出生体重新生儿(Low birth weight infant, LBWI)与正常体重新生儿：选取2010年3月-6月入住我院新生儿室的33例新生儿(7-28d),其中LBWI15例,正常体重新生儿18例。LBWI体重(1.88±0.32)kg、胎龄(33.6+1.5)周、日龄(15±8.3)d；正常体重儿体重(3.24+0.43)kg、胎龄(34.2±1.5)周、日龄(11.8±2.2)d。
3.连续观察新生儿12h,详细记录排尿具体时间、排尿间隔时间(Voiding interval time, VTT)、每次排尿量(排尿前／后尿垫重量)、残余尿量、最大膀胱容量(Bladder capacity, BC)、膀胱排空率(Bladder empty percentage, BEP)、排尿时意识状态(睡眠/清醒),同时记录患儿液体摄入量及大便排泄情况。
4.采用SPSS13.0软件进行统计学分析,数据采用(平均数±标准差)进行表示,检验水准为P=0.05。利用t检验对男性新生儿组与女性新生儿组、LBWI组与正常体重新生儿组之间每次排尿量、残余尿量、排尿次数等参数进行比较分析,利用卡方检验对男性新生儿组与女性新生儿组、LBWI组与正常体重新生儿组之间排尿时意识清醒状态百分比、BEP等进行比较分析。
结果
1.男女新生儿之间比较：
54例早产儿共排尿318次,其中男156次,女162次。男女早产儿之间平均残余尿量、BER相比较,差异具有统计学意义(P<0.01)；但是,排除BER影响后,残余尿量在男女早产儿之间相比差异无统计学意义。
48例足月儿共排尿350次,其中男222次,女128次,43次排尿时伴大便排出,其中男32次,女11次。男女足月儿BER相比,差异具有统计学意义(P<0.01)。
排尿伴大便排出时,不同性别早产儿及足月儿之间的BER相比(25.0%Vs.41.7%,28.1%vs.36.4%),差异无统计学意义。
2.LBWI与正常体重新生儿之间比较：
LBWI组每次排尿量明显低于正常体重组(P<0.05),而排尿次数、残余尿量较正常体重组无明显差异,不具有统计学意义。正常体重组的BEP及排尿时意识清醒状态百分比则明显高于LBWI组。
疾病对新生儿排尿方式的影响
材料和方法
1.缺血缺氧性脑病(Hypoxic-ischemic encephalopathy, HIE)患儿：选取2010年9月-11月在我院新生儿室住院的21例HIE患儿(天龄7.7±4.1d)作为观察对象,19例健康早产儿(天龄7.5+4.6d)为对照组,所有新生儿观察期间天龄为(4-21)d。其中,HIE患儿男性14例,女性7例,平均孕龄(33.4±1.7)周,(30-36)周,出生体重(2.0±0.6)kg,(1.17-3.2)kg。
2.胆红素血症患儿：选取2010年3月-2011年1月在我院新生儿室入住的(4-15)d高胆红素血症新生儿33例作为观察对象。其中,轻中度高胆红素血症(Mild to moderate hyperbilirubinemia, MHB)组18例,男9例,女9例,胎龄(38.6±2.1)周,出生体重(3.1±0.3)kg,年龄(10.9±2.4)d,221μmol/l342μmol/l,平均(402±32)μmol/l。同时,选取胆红素水平正常的新生儿19例为对照组,胎龄(38.5±1.4)周,出生体重(3.4±0.5)kg,年龄(11.2±2.9)d,Tbi1(81±28)μmol/l,头颅MRI检查无异常。
3.轻度窒息史患儿：选取2010年3月-6月入住新生儿室的34例有轻度窒息史患儿作为观察对象,出生体重(2.56±0.29)kg,胎龄(33.8±3.1)周,天龄(13.8±3.1)d。33例无窒息史且无下尿路疾患的新生儿为对照组,出生体重(2.63±0.41)kg,胎龄(34.1±3.5)周,天龄(12.7±2.7)d。其中窒息史正常体重(Asphyxiation normal weight, ANW)新生儿16例,出生体重(2.83±0.31)kg,胎龄(34.6±2.5)周,天龄(11.1±2.7)d；窒息史低体重(Asphyxiation low weight, ALW)新生儿18例,出生体重(1.68±0.54)kg,胎龄(33.2±1.6)周,天龄(14.5±7.6)d。无窒息史正常体重(Non asphyxiation normal weight, NANW)新生儿18例,出生体重(3.24±0.43)kg,胎龄(34.2±1.5)周,天龄(11.8±2.2)d；15例无窒息史低体重(Non asphyxiation low weight, NALW)新生儿,体重(1.88±0.32)kg,胎龄(33.6±1.5)周,天龄(15±8.3)d。
4.记录新生儿的每次排尿时间、排尿量、残余尿量、排尿时意识状态(清醒／睡眠)及饮奶量和输入液体量。HIE患者需要使用心电监护仪及脑电图仪记录心率(Heart rate, HR)、呼吸频率(Respiratory frequency, RF)及脑电图(Electroencephalography, EEG)情况。
5.采用SPSS13.0软件进行数据统计学处理分析。HIE患儿与正常早产儿之间参数的差异采用t检验及卡方检验分析。MHB、SHB及对照组三组间的参数比较采用单因素方差分析。ANW组和NANW组,ALW组和NALW组间的参数比较用t检验。
结果
1.HIE患儿与正常早产儿比较：
共观察144例次排尿。4h排尿观察中每例HIE新生儿排尿2-6次(平均4次)。平均每次排尿量为10.8m1,中位数9.3m1,范围(1.2-34)ml。平均残余尿量为1.6m1,中位数1.62m1,范围(0-38)m1。4h排尿观察中发现,至少有57.1%(12/21)HIIE新生儿在1次排尿后无残余尿量。
10例HIE新生儿在整个观察过程中一直处于睡眠状态。16.34%(平均0.67次,中位数1次,范围(0-2)次)的排尿伴觉醒信号出现,如肢体活动、呜咽、短暂哭闹等。83.65%排尿在无干扰的睡眠中完成。10例HIE新生儿在排尿观察中无任何觉醒信号出现。HIE新生儿排尿前后HR、RF及EEG频率无改变。
HIE新生儿与无HIE新生儿排尿方式比较发现两者的每次排尿量明显不同,10.8+6.5ml v.s.14.1±7.1ml(p<0.05)。残余尿量在HIE新生儿及无HIE新生儿中分别为(1.6±1.0)ml和(1.2±0.9)ml(p<0.05)。两者排尿次数明显不同,分别为(4.0±1.1)v.s.(3.2±0.9)(p<0.05)。HIE新生儿睡眠中无觉醒信号排尿次数占总排尿次数的83.7%,而在无HIE新生儿中为42.9%。
2.高胆红素血症患儿与对照组的比较：
共观察排尿328次,详细记录了排尿次数、每次排尿量、残余尿量、是否觉醒状态排尿及液体摄入量。SHB组排尿次数、残余尿量明显高于对照组和MHB组,而每次排尿量则明显低于正常对照组和MHB组(P<0.05)。三组新生儿排尿时清醒状态百分比无显著差异(P>0.05)。
3.轻度窒息史患儿与对照组的比较：
共进行533次排尿观察。ANW组排尿次数明显高于NANW组(P<0.01),但排尿量和残余尿量差异不具有统计学意义(P>0.05)。ALW组与NALW组的排尿次数、每次排尿量和残余尿量差异无统计学意义(P>0.05)。ANW组的排尿次数、每次排尿量明显高于ALW组(P<0.05),但是,两组的残余尿量却无明显差异(P>0.05)。NANW组每次排尿量明显高于NALW组(P<0.05),但排尿次数和残余尿量(P>0.05)差异却无统计学意义。BEP和排尿时清醒百分率在ANW和NANW两组中均较高,二者差异不明显；在ALW组和NALW组中差异也不明显。
外因(湿度、温度)对新生儿排尿方式的影响
材料和方法
1.本研究于2011年3月在郑州大学第一附属医院新产儿重症监护病房实施进行。将500m1生理盐水液体瓶置于每片尿垫的中上方,尿垫包裹液体瓶,建立超低出生体重儿的排尿量测量模型。
2.干尿垫组：将恒温箱湿度调至85%,放入6片称重后的尿垫,每隔1h拿出一片尿垫称重并记录,之后放回恒温箱,共记录6h。待完成后,再将湿度分别调至80%、75%、65%、60%、55%,重复上述操作。
湿尿垫组：将5ml0.9%生理盐水注入尿垫中,以便模拟新生儿排尿,操作方法同上。
3.应用SPSS13.0软件对数据进行分析处理,多组间比较应用Kruskal-Wallis检验方法,两两比较应用Dunnett检验方法。测量数据采用中位数表示,检验水准α=0.05。
结果
1.干尿垫组：随着湿度的不断增加,同一时间点的干尿垫重量不断增加,各时间点的增重均具有统计学意义(p<0.05)
2.湿尿垫组：当恒温箱湿度由55%增至65%时,同一时间点下湿尿垫增重不明显(p>0.05)；当湿度≥70%时,随着湿度不断增加,同一时间点下湿尿垫增重明显,具有统计学意义(p<0.05)。
结论
1.足月儿与早产儿排尿方式明显不同,推断足月儿膀胱功能发育情况较早产儿成熟,早产儿膀胱功能受控制的神经系统发育明显滞后于足月儿。
2.随着年龄增长,新生儿的排尿方式发生不断变化。
3.男女新生儿排尿方式存在一定差异,与女性相比,男性新生儿BER较差,易发生排尿后膀胱残余尿的现象。
4. LBWI比正常体重新生儿每次排尿量小,排空率低,排尿时清醒比例小,提示LBWI的膀胱功能发育和大脑参与排尿的程度较正常体重新生儿低。
5.HIE新生儿与无HIE新生儿排尿方式的不同提示高级中枢神经系统参与新生儿排尿。HIE明显影响早产儿排尿方式。
6.SHB新生儿排尿方式明显改不同于正常新生儿。重度高胆红素血症是否会影响新生儿排尿方式有待进一步研究。
7.出生时轻度窒息史对正常体重新生儿的排尿次数有着明显影响,而每次排尿量、残余尿量、BEP、清醒排尿百分比在两者之间无统计学差异。
8.新生儿排尿方式尤其是排尿量,除受性别／体重、影响神经系统发育的疾病影响外,还受外界因素如温度／湿度的影响。尿垫预湿有可能成为一种评估新生儿尿量更为准确、严谨的检测方法。
Background and Objective
Voiding is the process that after the formation in the kidneys, urine is temporarily stored in the bladder by ureter, then excreted by transurethral. Urination is a complex reflex activity controlled by the central nervous system. The expansion of the bladder increases the bladder wall tension, the inflated feeling of the stretch receptors in the bladder wall is produced, which lead to voiding. The greater the traction tension, the stronger the inflated feeling.
Neonates and infants void at varying bladder volumes during infancy and this is contrary to the belief that the voiding reflex is a simple spinal reflex elicited by a constant bladder volume. This has been shown in free voiding studies of both pre-term15and full-term infants13in whom bladder volume initiating voiding varies from30%to100%of functional bladder capacity. The reason for this variation is unknown, but the bladder volume initiating micturition is higher after a period of sleep.
Increase of bladder capacity is not linear to age or weight during the first years of life. There are two periods when the increase is accelerated. The first is during the first months of life. In free voiding studies of pre-term infants in gestation week32, median bladder capacity was12ml and in similar studies of full-term babies3months of age median capacity was52ml. The capacity is almost unchanged at1and 2years of age (67and68ml, respectively). At3years of age, on the other hand, the median capacity is123ml, meaning a doubling during the third year of life. The first step in increase of bladder capacity is thus around birth and is a fourfold increase, which should be compared with the increase in body weight, which is only three-fold. The second step is at the age of toilet-training when gaining control over voidings. The main stimulant for this second increase in bladder capacity can be suggested to be due to the fact that the child starts to get dry at night, which means higher overnight bladder volumes. Indications for such a connection are the finding that high overnight bladder volumes have been shown to be responsible for development of high bladder capacity in patients with VUR and also in boys with posterior urethral valves. Overnight bladder volume has also been shown to be the determinant for functional bladder capacity in healthy children after potty-training. The relationship between free voiding and cystometric capacity changes during the first years of life. In the neonatal period, cystometric capacity is lower as compared to free voiding capacity, whereas after the infant year the opposite is seen. This can be partly attributed to the fact that older children postpone voiding at cystometry due to fear of voiding with a catheter in the bladder and of the unfamiliar situation of the assessment. This fear cannot be expected in the neonatal child and voiding is thus not postponed for this reason. Another possible explanation for the low cystometric capacity in the neonatal period might be the overactivity suggested by Bachelard et al, shown as an ease to induce detrusor contractions prematurely in catheter investigations. Even if development of bladder capacity during the first years of life is not linear, we suggest that a linear formula is used for calculation of expected bladder capacity for age as a simple rule of thumb. We have chosen to use:Expected bladder capacity (ml)=30+(age in years X30) since this linear increase in capacity is very similar to the nonlinear increase in capacity as described by Jansson et all investigating children longitudinally from birth to age3years in free voiding studies.
The infant's voiding is also characterized by a physiological form of detrusor-sphincter dyscoordination, which has been shown in free voiding studies as interrupted voidings and increase in post-void residual urine. This phenomenon has also been observed in urodynamic studies as an intermittent increase in the electromyographic (EMG) activity of the pelvic floor during voiding, concomitant with fluctuations in voiding detrusor pressure. A longitudinal study of free voidings from birth to age3years revealed that the suggested dyscoordination disappears successively, and is not seen after potty-training age. Another important observation in the study by Jansson et all is the increase in post-void residual urine during the first couple of years of life. The reason for the incomplete emptying in infancy is probably the physiological form of dyscoordination discussed above, with interruption of the urine stream before the bladder is empty. However, with the acquisition of continence the residual volume decreased in this group of healthy children and the ability to empty the bladder was complete at the age of3.
Bladder function during infancy has previously been regarded as automatic, with voiding induced by a constant volume in the bladder and without cerebral influence. During the last decade it has been shown convincingly that the brain is already involved in the voiding reflex from birth. This is best illustrated by the finding that in the majority of cases newborn babies wake up or show signs of arousal before voiding. This means that the reflex pathway connection to the cerebral cortex is anatomically already developed in this age group; however, voiding is neither conscious nor voluntary-the infant is only disturbed by the signal. Both maturation and probably training are needed for the voidings to be conscious and voluntary.
How to diagnose the bladder dysfunction in newborns is challenging, not only due to the practical difficult in manipulation of the newborns, but also the normal value of voiding pattern in newborns is still unclear. This study was included by3parts:
Part Ⅰ:A study on voiding pattern of term and preterm newborns;
Part Ⅱ:The change of voiding pattern of newborns with the development of age;
Part Ⅲ:The effects of voiding pattern of newborns.
Part Ⅰ:A study on voiding pattern of term and preterm newborns
Materals and Methods
A total of26hospitalized newborn aged3to7days at The First Affiliated Hospital of Zhengzhou University from Mar to May2010were included in this study. Twelve of them were term newborns (38.3±1.1weeks of gestation) with weight (3.1±0.4) kg, another14preterm newborns (32.5±1.6weeks of gestation) with weight (1.7±0.4) kg. The voiding volumes, post-void residual volumes, state of consciousness at voiding, voiding time, voiding frequency per12hours, and meanwhile, the quantity of intake milk, liquid within the same time schedule for12hours from9AM to9PM were recorded. The liquid intake was given according to standards protocol. The diaper weight difference before and after voiding was defined as voiding volumes. The post-void residual volumes was determined by ultrasound.
Results
Comparing term with preterm newborns, voiding volumes and consciousness voiding rate was significant higher [(19.8±10.9) ml vs (11.1±7.5) ml and (43.5±26.8)%vs (24.7±19.1)%,(P<0.05), respectively], whereas post-void residual volumes and voiding frequency were significant lower [(1.55±1.01) ml vs (1.82±0.88) ml,(P<0.05) and (7.2±1.9) times vs (9.6±2.5) times per12hours,(P<0.05), respectively].
Part Ⅱ:The change of voiding pattern of newborns with the development of age
Materals and Methods
1. Healthy newborns (11males and10females) during the first28days of their life at the First Affiliated Hospital of Zhengzhou University were included in the study. Of the newborns10were full term (38.5±1.3gestational weeks, range37to40; weighing3.2±0.4kg at birth) and11were preterm (32.7±1.6gestational weeks, range29to36; weighing1.8±0.5kg at birth). None of the newborns had any signs of urinary tract symptoms.
2. All newborns were observed for12h by well trained urologists according to International Children's Continence Society (ICCS) standards. The subjects were observed from9a.m. to9p.m. at day1,4,7,14and28.
3. Student's t-test was used for statistical analysis and p<0.05was considered significantly.
Results
1. Altogether778voids were recorded. Four newborns did not void during their first4hours observation and their first voiding occurred at the5th or6th hour after birth. Voiding frequency, voiding volume and post residual volume varied between newborns, with a high standard deviation.
2. Comparing fullterm to preterm at the same day age after birth, voiding frequency was lower at day14(P<0.01) and day28(P<0.05), and voiding volume was higher at day4(P<0.01), day7(P<0.05), day14(P<0.05) and day28(P<0.01), and post residual volume was higher at day4(P<0.05) and day28(P<0.05).
3. In preterm group, voiding frequency increased significantly at day4compared to day1, at day7compared to day4(p<0.01), and decreased at day28compared to day14(p<0.01). voiding volume increased significantly only once in the preterm, from day14to day28(p<0.05). In fullterm group, voiding frequency increased significantly at day7compared to day4(p<0.01). voiding volume increased significantly twice in fullterm, from day1to day4and from day14to day28(p<0.01). Post-void residual volumes was increased from day1to day4, but was decreased at day4to day7, and increased again at day14to day28significantly (p<0.05).
4. Percentage of intermittent voiding occurred in70%preterms, but only40%in full terms. Bladder empty percentage was higher in full terms at day28(56%vs.40%), but awake voiding percentage was no more than30%in the preterms, being60%in full terms at day28after birth.
Part Ⅲ:The effects of voiding pattern of newborns The effects of age and weight on voiding pattern
Materals and Methods
1. One hundred and two healthy, single birth newborns (54preterm and48full term) without low urinary tract pathological diseases, hospitalized in NICU from Mar.2010to Mar.2011were recruited in this study. Twelve hours (9:00am～9:00pm) observation of free voiding was performed. The voiding interval time, voiding volumes, post-void residual volumes, bladder capacity, voiding times, state of consciousness at voiding and the number of defecate simultaneously at voiding as well as fluid intake were recorded and analyzed retrospectively.
2. A total of33newborns were included in this study. The newborns aged7～28days old, without low urinary tract pathological diseases, single birth,were divided into two groups,15cases of low weight newborns (birth weight1.88±0.32kg, gestational age33.6±1.5weeks, aged15±8.3days old),18cases of normal weight newborns (birth weight3.24±0.43kg, gestational age34.2±1.5weeks, aged11.8±2.2days old). Each group undertook12hours (9:00am～21:00pm) free voiding observation, recording voiding time, the voiding volume, post-voiding residual urine(PVR) by ultrasound, awake or sleep when voiding.
Results
1. The total number of voiding and defecate simultaneously at voiding of the preterm neonates was318and40respectively. VIT and BC between male and female preterm newborns had no statistical significance, whereas, the mean PRV of the male was larger ((1.9±0.9) mL vs.(0.9±0.8) mL) and the bladder emptying rate was lower (8.3%vs.44.1%) than those of the female newborns (P<0.05). If reject the effect of BER, the difference of PRV between the two genders ((2.1±0.5) mL vs.(1.8±0.6) mL) do not have statistical significance any more. The total number of voiding and DSV of the term neonates was350and43respectively. The BER of the female term neonates was higher than that of the male term neonates (43.0%vs.15.3%; P<0.05). BC and the mean PRV between the two genders of term newborns have no statistical significance. Comparing with the female neonates of the same gestational age, the difference of BER of the male neonates do not have statistical significance any more when defecated simultaneously at voiding (preterm41.7%vs.25.0%; term36.4%vs.28.1%,P>0.05).
2. The frequency, voiding volume, PVR, voidng empty percentage and awake percentage in two groups are7.1±2.2times vs7.7±2.4times,21.1±11ml vs13.1±6.2ml,1.52±1.33ml vs1.86±1.08ml,34.6%vs14.8%,40.9%vs18.3%, respectively. There were significantly difference of voiding volume in two groups (T=2.5010, P<0.05)
The effects of disorders on voiding pattern
Materals and Methods
1. A total of40hospitalized newborns aged4to21days were included in this study. Twenty-one of them were preterm newborns with HIE, another19preterm newborns without HIE. The voided volume, post void residual volume, consciousness at voiding, voiding time, voiding frequency as well as the quantity of intake milk and liquid within4hours from8AM to12AM were recorded. The liquid intake was same in both groups according to standard protocol. The diaper weight difference before and after voiding was defined as voided volume. The post void residual volume was determined by ultrasound. The state of consciousness at voiding was monitored by electroencephalography.
2. Fifty-two newborns with the gestational ages ranged from37to42weeks were observed by4-hour observation, of whom,18were newborns with mild to moderate hyperbilirubinemia, blood total bilirubin level (Tbil) ranging from221μmol/l to342μmol/l, and15with severe hyperbilirubinemia, Tbi1>342μmol/l. Nineteen ones with normal bilirubin level, Tbi1<221μmol/l. The voiding frequency, voiding volume, post-voided residual volume, and percentage of awake voiding of every infant were recorded from8AM to12AM. A total of328voidings were observed in this study.
3. A total of67newborns,34cases with mild asphyxiation and33cases normal, without low urinary tract pathological diseases, single birth, hospitalized in NICU at the First Teaching Hospital of Zhengzhou University from March to May2010were included in this study. They were divided into4groups as16cases of asphyxiation with normal weight (ANW),18cases of asphyxiation with low weight (ALW),18cases of no asphyxiation with normal weight (NANW) and15cases of no asphyxiation with low weight (NANW). Voiding time, voiding volume, post-voided residual volume by ultrasound, empty voiding percentage and awake or sleep when voiding were recorded in12h observation (9Am-9Pm).
Results
1. Voided volume and rate of consciousness at voiding was significant lower in newborns with HIE compared with the control group [(10.8±6.5) ml,(16.3±17.1)%vs.(14.1±7.1) ml,(57.1±21.0)%,(P<0.05), respectively], whereas post void residual volume and voiding frequency were significant higher [(1.6±1.0) ml,(4.0±1.1) times vs.(1.2±0.9) ml,(3.2±0.9) times per4hours,(P<0.05), respectively].
2. The voiding frequency and post-void residual volume [(3.28±1.18) times, (1.82±0.53) ml] of severe hyperbilirubinemia is higher than NB[(2.71±0.84) times,(1.26±0.83) ml] and mild to moderate hyperbilirubinemia [(2.75±0.81) times,(1.41±0.72) ml],(P<0.05). The voided volume of severe hyperbilirubinemia (23.05±8.34) ml is lower than normal bilirubin (27.75±7.29)ml and mild to moderate hyperbilirubinemia (26.88±5.59)ml,(P<0.05).There is no difference of percentage of awake voiding among3groups.
3. All newborns voided totally533times. The voiding frequency in ANW is higher than NANW (P<0.05), but the voiding volume and post-voided residual volume are no significant difference (P>0.05). The voiding frequency, volume and post-voided residual volume in ALW and NALW are no significant difference (P>0.05).The voiding frequency and volume in ANW is higher than ALW (P<0.05), but post-voided residual volume is no significant difference (P>0.05). The voiding volume in NANW is higher than NALW (P<0.05), but the voiding frequency and post-voided residual volume are no significant difference (P>0.05). Voiding empty and awake percentage are higher in ANW and NANW, but no difference; voiding empty and awake percentage in LNW and NALW are no difference.
The effects of humidity/temporature on voiding pattern
Materals and Methods
Six dry diapers were placed into seven levels of humidity, between55%and85%inclusive, in an incubator set at37℃. Hourly weight increments were recorded. The study was repeated with5ml of normal saline added to the center part of diaper to mimic prior urine output.
Results
Dry diapers increased in weight for each humidity level after1h (p<0.001). This was significantly greater at higher humidity (75%). The maximum increase was an average of (2.34±0.12)g at85%humidity after6hrs. When5mL of0.9%saline had been added, the diaper weight changes depended on environmental relative humidity. At≥80%humidity, the diapers continued to gain weight; at70%or75%humidity, they did not change weight.
Conclusions
1. Both term and preterm newborns have shown a high post void residual volume indicating the incomplete voiding pattern exists in newborns. The difference of voiding patterns between term and preterm newborns evidenced the different stages of bladder function development, more maturation of bladder function in term than those of preterm newborns.
2. Voiding pattern in the preterm has shown many differences from those of fullterms in the very beginning of life. Frequent interrupted and incomplete voiding pattern in the preterm newborns indicated a disrupted coordination of the detrusor-sphincter and a delayed maturation of the neural maturation center.
3. Compared to female, male newborns are more likely to have post-void residual volumes.
4. Voiding volume, emptying and awake percentage are lower in low birth weight newborns comparing to normal weight newborns. The bladder function and the degree of the brain involved in urination are lower in low birth weight newborns.
5. The differences in voiding pattern supported the concept that the higher centers of the central nervous system were involved in the control of voiding, HIE had a significant effect on voiding pattern of preterm newborn.
6. There is a significant change of voiding pattern in newborn with severe hyperbilirubinemia indicating the severe hyperbilirubinemia has an effect on the nerve micturition center.
7. Mild asphyxiation induced more voiding frequencies for more fluid intake in NANW,the lower weight,the lighter;but it had little influence on voiding volume, PVR, empty voiding percentage and awake voiding percentage.
8. The humidity/temporature may have effect on the voiding pattern of newborns. This study demonstrates the need for caution when interpreting this measure, and we discuss some possible clinical approaches to ameliorate this difficulty.
尿液经肾脏形成后经输尿管贮存于膀胱中,一定量后排出体外的过程称为排尿。尿液在膀胱中贮存到一定量后,膀胱扩张至膀胱壁受牵张,壁内牵张感受器产生充胀感觉,引发原发性刺激。但是,排尿是一种复杂的受中枢神经系统控制的反射活动。
新生儿排尿量变化较大,每次排尿量不均衡,似乎与排尿反射是由于膀胱容量达一定限度而引起的简单脊髓反射理论相违背。新生儿开始排尿时的膀胱容量可从其功能性膀胱容量的30%到100%变化不等,其变化原因并不清楚,但新生儿睡觉之后开始排尿的膀胱容量则会升高。
1岁之内的儿童膀胱容量并不随年龄或体重呈线性增长。膀胱容量的快速增长分两个阶段。第一阶段在出生前后,增长约4倍,而体重仅增长3倍。有关自由排尿试验报道称,孕32周的早产儿膀胱平均容量约为12ml,3月龄足月儿约为52ml。第二阶段为如厕训练获得控制排尿时的年龄(约3岁左右)。儿童夜间不再尿床或已获得控尿能力是膀胱容量在此阶段增长的主要原因,夜间不排尿使膀胱容量不断增加。提示导致膀胱输尿管返流及后尿道瓣膜男性患儿膀胱容量增长的原因是由夜间膀胱容量增加引起的。同时,经坐便训练后的健康儿童功能性膀胱容量增加的决定因素亦为夜间膀胱容量。1岁之内的小儿可使用公式：膀胱容量(ml)=25+(月龄×3)进行膀胱容量的评估,其膀胱容量多少与年龄并不呈线性关系,较大儿童预测膀胱容量采用公式：预期膀胱容量(m1)=30+[年龄(岁)x30]。
婴幼儿排尿的特点是逼尿肌一括约肌协同失调,表现为排尿中断和排尿后残余尿量的增加。Jansson等人研究报道,2岁之内小儿排尿后有残余尿量。这种现象同样可在尿动力学检查中观察到,盆底肌电活动在排尿时间断增加,伴逼尿肌压力波动。从出生至3岁儿童自由排尿纵向调查研究显示,随着年龄增长,逼尿肌一括约肌协同失调逐渐消失,经排便训练后将不再出现。此外,另外一种逼尿肌过度活动形式很有可能存在于1个月以内的新生儿。研究发现,20%的新生儿膀胱压力测定中充盈少量液体时,出现漏尿,引发自发性逼尿肌收缩过早。新生儿膀胱容量在膀胱压力测定中比自由排尿观察中少。这些研究发现均提示,此年龄组小儿排尿反射易在膀胱压力测定中插入导管及输注生理盐水时引发。几个月后逼尿肌过度活动会消失,且膀胱容量增加。
传统观点认为婴幼儿期膀胱充盈到一定容量时自发地引起排尿,膀胱功能不受大脑控制。近来研究报道称大脑影响排尿反射自婴儿出生即开始。此观点可以通过大多数新生儿排尿前出现觉醒征象来说明,提示此年龄组婴幼儿连接大脑皮层的反射通路已建立并得到发展。但是,婴幼儿排尿是受到一定程度信号的影响,并非有意识的及随意的。国外学者对1岁之内的婴幼儿进行研究发现,坐便训练受一定程度的信号影响。因此,婴幼儿达到有意识地自主排尿需要不断发育成熟及进行排尿训练。
目前,如何诊断新生儿膀胱功能障碍是临床工作中的一个难题。这主要是因为新生儿无自主排尿能力、排尿异常的临床表现不明显及无法用儿童及成人排尿参数作为新生儿的诊断标准等都增加了新生儿排尿异常诊断的难度。新生儿膀胱功能评估临床上主要采用尿动力学检查方法,因其具有一定的侵入性及难在新生儿身上操作,因此,我们对新生儿自由排尿进行观察,了解新生儿排尿方式,以便为临床提供新生儿排尿方面的参考数据,研究设计分为三部分,如下：
第一部分：足月儿与早产儿排尿方式的比较研究；
第二部分：新生儿随年龄变化排尿方式的变化研究；
第三部分：排尿方式的影响因素研究(包括：性别、体重的影响；疾病的影响；外因影响)。
第一部分：足月儿与早产儿排尿方式的比较研究
材料和方法
选取2010年3-5月入住郑州大学第一附属医院新生儿室的出生后3-7d的足月儿12例与早产儿14例作为研究对象,足月儿孕(38.3+1.1)周,体重(3.1+0.4)kg,早产儿孕(32.5+1.6)周,体重(1.7±0.4)kg。观察新生儿在12h内(早9点-晚9点)的自由排尿情况,记录排尿次数及排尿时间、每次排尿量、残余尿量、排尿时的意识状态(清醒／睡眠)等参数,同时记录液体摄入量(包括饮奶量及液体输入量)及摄入时间,液体摄入量按标准进行。每次排尿量相当于排尿前后尿垫重量之差,残余尿量由超声检测仪测得。共观察记录了220例次。
结果
足月儿的每次排尿量、残余尿量、排尿次数、排尿时意识清醒状态百分比分别为(19.8±10.9)ml、(1.55±1.01)ml、(7.2±1.9)次、(43.5±26.8)%,早产儿分别为(11.1±7.5)ml、(1.82±0.88)ml、(9.6±2.5)次、(24.7±19.1)%。两组相关数据经统计学分析,早产儿残余尿量及排尿次数大于足月儿,而每次排尿量及排尿时意识清醒状态百分比小于足月儿,均具有统计学意义(P<0.05)。
第二部分：新生儿随年龄变化排尿方式的变化
材料和方法
1.选取郑州大学第一附属医院的21例健康新生儿作为观察对象,男性11例,女性10例。其中,10例为足月儿,孕(38.5±1.3)周,(37-40)周,出生体重(3.2±0.4)kg；11例为早产儿,孕(32.7±1.6)周,(29-36)周,出生体重(1.8±0.5)kg。所有新生儿均无尿路病变或症状。
2.所有新生儿在出生后第1、4、7、14、28天分别进行观察,经12h(早9点-晚9点)自由排尿情况观察。
3.采用SPSS13.0统计学软件包对数据进行处理。利用t检验对新生儿不同年龄组之间的每次排尿量、残余尿量、排尿时意识状态及排尿次数进行比较分析。
结果
1.共进行778例次排尿观察。4例新生儿在前4h观察中无排尿,排尿发生在出生后第5或第6小时。新生儿之间排尿次数、每次排尿量及排尿后残余尿量变化较大,标准差较大。
2.相同年龄的足月儿在出生后第14天、第28天排尿次数较早产儿少(P<0.05),出生后第4天、第7天、第14天及第28天每次排尿量均较早产儿高(P<0.05),残余尿量则在出生后第4天、第28天较早产儿高(P<0.05)。
3.早产儿第4天排尿次数较第1天明显增加,第7天较第4天又明显增加,第28天又较第14天明显增加(p<0.01)。每次排尿量仅在从14天到28天的早产儿中明显增加(p<0.05)。足月儿第7天排尿次数较第4天明显增加(p<0.01)。每次排尿量从第1天到第4天及从第14天到第28天明显增加(p<0.01)。残余尿量从第1天到第4天明显增加,明显减少出现在第4天到第7天,第14天到第28天再次出现明显增加(p<0.05)。
4.早产儿中间断排尿占70%,而足月儿仅占40%。足月儿第28天膀胱排空率较早产儿高(56%vs.40%)。早产儿第28天觉醒排尿比例不超过30%,而足月儿达到60%。
第三部分：新生儿排尿方式的影响因素
性别、体重对新生儿排尿方式的影响
材料和方法
1.男性新生儿与女性新生儿：选取2010年3月-2011年3月我院新生儿室的(3-7)d的早产儿54例和足月儿48例作为观察对象。其中早产儿男26例,胎龄(34.2±1.8)周,日龄(3.5±1.8)d；女28例,胎龄(34.4±1.3)周,天龄(3.3±2.1)d。足月儿男30例,胎龄(39.5±0.9)周,日龄(4.2±1.6)d；女18例,胎龄(39.7±0.8)周,日龄(4.3±1.4)d。
2.低出生体重新生儿(Low birth weight infant, LBWI)与正常体重新生儿：选取2010年3月-6月入住我院新生儿室的33例新生儿(7-28d),其中LBWI15例,正常体重新生儿18例。LBWI体重(1.88±0.32)kg、胎龄(33.6+1.5)周、日龄(15±8.3)d；正常体重儿体重(3.24+0.43)kg、胎龄(34.2±1.5)周、日龄(11.8±2.2)d。
3.连续观察新生儿12h,详细记录排尿具体时间、排尿间隔时间(Voiding interval time, VTT)、每次排尿量(排尿前／后尿垫重量)、残余尿量、最大膀胱容量(Bladder capacity, BC)、膀胱排空率(Bladder empty percentage, BEP)、排尿时意识状态(睡眠/清醒),同时记录患儿液体摄入量及大便排泄情况。
4.采用SPSS13.0软件进行统计学分析,数据采用(平均数±标准差)进行表示,检验水准为P=0.05。利用t检验对男性新生儿组与女性新生儿组、LBWI组与正常体重新生儿组之间每次排尿量、残余尿量、排尿次数等参数进行比较分析,利用卡方检验对男性新生儿组与女性新生儿组、LBWI组与正常体重新生儿组之间排尿时意识清醒状态百分比、BEP等进行比较分析。
结果
1.男女新生儿之间比较：
54例早产儿共排尿318次,其中男156次,女162次。男女早产儿之间平均残余尿量、BER相比较,差异具有统计学意义(P<0.01)；但是,排除BER影响后,残余尿量在男女早产儿之间相比差异无统计学意义。
48例足月儿共排尿350次,其中男222次,女128次,43次排尿时伴大便排出,其中男32次,女11次。男女足月儿BER相比,差异具有统计学意义(P<0.01)。
排尿伴大便排出时,不同性别早产儿及足月儿之间的BER相比(25.0%Vs.41.7%,28.1%vs.36.4%),差异无统计学意义。
2.LBWI与正常体重新生儿之间比较：
LBWI组每次排尿量明显低于正常体重组(P<0.05),而排尿次数、残余尿量较正常体重组无明显差异,不具有统计学意义。正常体重组的BEP及排尿时意识清醒状态百分比则明显高于LBWI组。
疾病对新生儿排尿方式的影响
材料和方法
1.缺血缺氧性脑病(Hypoxic-ischemic encephalopathy, HIE)患儿：选取2010年9月-11月在我院新生儿室住院的21例HIE患儿(天龄7.7±4.1d)作为观察对象,19例健康早产儿(天龄7.5+4.6d)为对照组,所有新生儿观察期间天龄为(4-21)d。其中,HIE患儿男性14例,女性7例,平均孕龄(33.4±1.7)周,(30-36)周,出生体重(2.0±0.6)kg,(1.17-3.2)kg。
2.胆红素血症患儿：选取2010年3月-2011年1月在我院新生儿室入住的(4-15)d高胆红素血症新生儿33例作为观察对象。其中,轻中度高胆红素血症(Mild to moderate hyperbilirubinemia, MHB)组18例,男9例,女9例,胎龄(38.6±2.1)周,出生体重(3.1±0.3)kg,年龄(10.9±2.4)d,221μmol/l
3.轻度窒息史患儿：选取2010年3月-6月入住新生儿室的34例有轻度窒息史患儿作为观察对象,出生体重(2.56±0.29)kg,胎龄(33.8±3.1)周,天龄(13.8±3.1)d。33例无窒息史且无下尿路疾患的新生儿为对照组,出生体重(2.63±0.41)kg,胎龄(34.1±3.5)周,天龄(12.7±2.7)d。其中窒息史正常体重(Asphyxiation normal weight, ANW)新生儿16例,出生体重(2.83±0.31)kg,胎龄(34.6±2.5)周,天龄(11.1±2.7)d；窒息史低体重(Asphyxiation low weight, ALW)新生儿18例,出生体重(1.68±0.54)kg,胎龄(33.2±1.6)周,天龄(14.5±7.6)d。无窒息史正常体重(Non asphyxiation normal weight, NANW)新生儿18例,出生体重(3.24±0.43)kg,胎龄(34.2±1.5)周,天龄(11.8±2.2)d；15例无窒息史低体重(Non asphyxiation low weight, NALW)新生儿,体重(1.88±0.32)kg,胎龄(33.6±1.5)周,天龄(15±8.3)d。
4.记录新生儿的每次排尿时间、排尿量、残余尿量、排尿时意识状态(清醒／睡眠)及饮奶量和输入液体量。HIE患者需要使用心电监护仪及脑电图仪记录心率(Heart rate, HR)、呼吸频率(Respiratory frequency, RF)及脑电图(Electroencephalography, EEG)情况。
5.采用SPSS13.0软件进行数据统计学处理分析。HIE患儿与正常早产儿之间参数的差异采用t检验及卡方检验分析。MHB、SHB及对照组三组间的参数比较采用单因素方差分析。ANW组和NANW组,ALW组和NALW组间的参数比较用t检验。
结果
1.HIE患儿与正常早产儿比较：
共观察144例次排尿。4h排尿观察中每例HIE新生儿排尿2-6次(平均4次)。平均每次排尿量为10.8m1,中位数9.3m1,范围(1.2-34)ml。平均残余尿量为1.6m1,中位数1.62m1,范围(0-38)m1。4h排尿观察中发现,至少有57.1%(12/21)HIIE新生儿在1次排尿后无残余尿量。
10例HIE新生儿在整个观察过程中一直处于睡眠状态。16.34%(平均0.67次,中位数1次,范围(0-2)次)的排尿伴觉醒信号出现,如肢体活动、呜咽、短暂哭闹等。83.65%排尿在无干扰的睡眠中完成。10例HIE新生儿在排尿观察中无任何觉醒信号出现。HIE新生儿排尿前后HR、RF及EEG频率无改变。
HIE新生儿与无HIE新生儿排尿方式比较发现两者的每次排尿量明显不同,10.8+6.5ml v.s.14.1±7.1ml(p<0.05)。残余尿量在HIE新生儿及无HIE新生儿中分别为(1.6±1.0)ml和(1.2±0.9)ml(p<0.05)。两者排尿次数明显不同,分别为(4.0±1.1)v.s.(3.2±0.9)(p<0.05)。HIE新生儿睡眠中无觉醒信号排尿次数占总排尿次数的83.7%,而在无HIE新生儿中为42.9%。
2.高胆红素血症患儿与对照组的比较：
共观察排尿328次,详细记录了排尿次数、每次排尿量、残余尿量、是否觉醒状态排尿及液体摄入量。SHB组排尿次数、残余尿量明显高于对照组和MHB组,而每次排尿量则明显低于正常对照组和MHB组(P<0.05)。三组新生儿排尿时清醒状态百分比无显著差异(P>0.05)。
3.轻度窒息史患儿与对照组的比较：
共进行533次排尿观察。ANW组排尿次数明显高于NANW组(P<0.01),但排尿量和残余尿量差异不具有统计学意义(P>0.05)。ALW组与NALW组的排尿次数、每次排尿量和残余尿量差异无统计学意义(P>0.05)。ANW组的排尿次数、每次排尿量明显高于ALW组(P<0.05),但是,两组的残余尿量却无明显差异(P>0.05)。NANW组每次排尿量明显高于NALW组(P<0.05),但排尿次数和残余尿量(P>0.05)差异却无统计学意义。BEP和排尿时清醒百分率在ANW和NANW两组中均较高,二者差异不明显；在ALW组和NALW组中差异也不明显。
外因(湿度、温度)对新生儿排尿方式的影响
材料和方法
1.本研究于2011年3月在郑州大学第一附属医院新产儿重症监护病房实施进行。将500m1生理盐水液体瓶置于每片尿垫的中上方,尿垫包裹液体瓶,建立超低出生体重儿的排尿量测量模型。
2.干尿垫组：将恒温箱湿度调至85%,放入6片称重后的尿垫,每隔1h拿出一片尿垫称重并记录,之后放回恒温箱,共记录6h。待完成后,再将湿度分别调至80%、75%、65%、60%、55%,重复上述操作。
湿尿垫组：将5ml0.9%生理盐水注入尿垫中,以便模拟新生儿排尿,操作方法同上。
3.应用SPSS13.0软件对数据进行分析处理,多组间比较应用Kruskal-Wallis检验方法,两两比较应用Dunnett检验方法。测量数据采用中位数表示,检验水准α=0.05。
结果
1.干尿垫组：随着湿度的不断增加,同一时间点的干尿垫重量不断增加,各时间点的增重均具有统计学意义(p<0.05)
2.湿尿垫组：当恒温箱湿度由55%增至65%时,同一时间点下湿尿垫增重不明显(p>0.05)；当湿度≥70%时,随着湿度不断增加,同一时间点下湿尿垫增重明显,具有统计学意义(p<0.05)。
结论
1.足月儿与早产儿排尿方式明显不同,推断足月儿膀胱功能发育情况较早产儿成熟,早产儿膀胱功能受控制的神经系统发育明显滞后于足月儿。
2.随着年龄增长,新生儿的排尿方式发生不断变化。
3.男女新生儿排尿方式存在一定差异,与女性相比,男性新生儿BER较差,易发生排尿后膀胱残余尿的现象。
4. LBWI比正常体重新生儿每次排尿量小,排空率低,排尿时清醒比例小,提示LBWI的膀胱功能发育和大脑参与排尿的程度较正常体重新生儿低。
5.HIE新生儿与无HIE新生儿排尿方式的不同提示高级中枢神经系统参与新生儿排尿。HIE明显影响早产儿排尿方式。
6.SHB新生儿排尿方式明显改不同于正常新生儿。重度高胆红素血症是否会影响新生儿排尿方式有待进一步研究。
7.出生时轻度窒息史对正常体重新生儿的排尿次数有着明显影响,而每次排尿量、残余尿量、BEP、清醒排尿百分比在两者之间无统计学差异。
8.新生儿排尿方式尤其是排尿量,除受性别／体重、影响神经系统发育的疾病影响外,还受外界因素如温度／湿度的影响。尿垫预湿有可能成为一种评估新生儿尿量更为准确、严谨的检测方法。
Background and Objective
Voiding is the process that after the formation in the kidneys, urine is temporarily stored in the bladder by ureter, then excreted by transurethral. Urination is a complex reflex activity controlled by the central nervous system. The expansion of the bladder increases the bladder wall tension, the inflated feeling of the stretch receptors in the bladder wall is produced, which lead to voiding. The greater the traction tension, the stronger the inflated feeling.
Neonates and infants void at varying bladder volumes during infancy and this is contrary to the belief that the voiding reflex is a simple spinal reflex elicited by a constant bladder volume. This has been shown in free voiding studies of both pre-term15and full-term infants13in whom bladder volume initiating voiding varies from30%to100%of functional bladder capacity. The reason for this variation is unknown, but the bladder volume initiating micturition is higher after a period of sleep.
Increase of bladder capacity is not linear to age or weight during the first years of life. There are two periods when the increase is accelerated. The first is during the first months of life. In free voiding studies of pre-term infants in gestation week32, median bladder capacity was12ml and in similar studies of full-term babies3months of age median capacity was52ml. The capacity is almost unchanged at1and 2years of age (67and68ml, respectively). At3years of age, on the other hand, the median capacity is123ml, meaning a doubling during the third year of life. The first step in increase of bladder capacity is thus around birth and is a fourfold increase, which should be compared with the increase in body weight, which is only three-fold. The second step is at the age of toilet-training when gaining control over voidings. The main stimulant for this second increase in bladder capacity can be suggested to be due to the fact that the child starts to get dry at night, which means higher overnight bladder volumes. Indications for such a connection are the finding that high overnight bladder volumes have been shown to be responsible for development of high bladder capacity in patients with VUR and also in boys with posterior urethral valves. Overnight bladder volume has also been shown to be the determinant for functional bladder capacity in healthy children after potty-training. The relationship between free voiding and cystometric capacity changes during the first years of life. In the neonatal period, cystometric capacity is lower as compared to free voiding capacity, whereas after the infant year the opposite is seen. This can be partly attributed to the fact that older children postpone voiding at cystometry due to fear of voiding with a catheter in the bladder and of the unfamiliar situation of the assessment. This fear cannot be expected in the neonatal child and voiding is thus not postponed for this reason. Another possible explanation for the low cystometric capacity in the neonatal period might be the overactivity suggested by Bachelard et al, shown as an ease to induce detrusor contractions prematurely in catheter investigations. Even if development of bladder capacity during the first years of life is not linear, we suggest that a linear formula is used for calculation of expected bladder capacity for age as a simple rule of thumb. We have chosen to use:Expected bladder capacity (ml)=30+(age in years X30) since this linear increase in capacity is very similar to the nonlinear increase in capacity as described by Jansson et all investigating children longitudinally from birth to age3years in free voiding studies.
The infant's voiding is also characterized by a physiological form of detrusor-sphincter dyscoordination, which has been shown in free voiding studies as interrupted voidings and increase in post-void residual urine. This phenomenon has also been observed in urodynamic studies as an intermittent increase in the electromyographic (EMG) activity of the pelvic floor during voiding, concomitant with fluctuations in voiding detrusor pressure. A longitudinal study of free voidings from birth to age3years revealed that the suggested dyscoordination disappears successively, and is not seen after potty-training age. Another important observation in the study by Jansson et all is the increase in post-void residual urine during the first couple of years of life. The reason for the incomplete emptying in infancy is probably the physiological form of dyscoordination discussed above, with interruption of the urine stream before the bladder is empty. However, with the acquisition of continence the residual volume decreased in this group of healthy children and the ability to empty the bladder was complete at the age of3.
Bladder function during infancy has previously been regarded as automatic, with voiding induced by a constant volume in the bladder and without cerebral influence. During the last decade it has been shown convincingly that the brain is already involved in the voiding reflex from birth. This is best illustrated by the finding that in the majority of cases newborn babies wake up or show signs of arousal before voiding. This means that the reflex pathway connection to the cerebral cortex is anatomically already developed in this age group; however, voiding is neither conscious nor voluntary-the infant is only disturbed by the signal. Both maturation and probably training are needed for the voidings to be conscious and voluntary.
How to diagnose the bladder dysfunction in newborns is challenging, not only due to the practical difficult in manipulation of the newborns, but also the normal value of voiding pattern in newborns is still unclear. This study was included by3parts:
Part Ⅰ:A study on voiding pattern of term and preterm newborns;
Part Ⅱ:The change of voiding pattern of newborns with the development of age;
Part Ⅲ:The effects of voiding pattern of newborns.
Part Ⅰ:A study on voiding pattern of term and preterm newborns
Materals and Methods
A total of26hospitalized newborn aged3to7days at The First Affiliated Hospital of Zhengzhou University from Mar to May2010were included in this study. Twelve of them were term newborns (38.3±1.1weeks of gestation) with weight (3.1±0.4) kg, another14preterm newborns (32.5±1.6weeks of gestation) with weight (1.7±0.4) kg. The voiding volumes, post-void residual volumes, state of consciousness at voiding, voiding time, voiding frequency per12hours, and meanwhile, the quantity of intake milk, liquid within the same time schedule for12hours from9AM to9PM were recorded. The liquid intake was given according to standards protocol. The diaper weight difference before and after voiding was defined as voiding volumes. The post-void residual volumes was determined by ultrasound.
Results
Comparing term with preterm newborns, voiding volumes and consciousness voiding rate was significant higher [(19.8±10.9) ml vs (11.1±7.5) ml and (43.5±26.8)%vs (24.7±19.1)%,(P<0.05), respectively], whereas post-void residual volumes and voiding frequency were significant lower [(1.55±1.01) ml vs (1.82±0.88) ml,(P<0.05) and (7.2±1.9) times vs (9.6±2.5) times per12hours,(P<0.05), respectively].
Part Ⅱ:The change of voiding pattern of newborns with the development of age
Materals and Methods
1. Healthy newborns (11males and10females) during the first28days of their life at the First Affiliated Hospital of Zhengzhou University were included in the study. Of the newborns10were full term (38.5±1.3gestational weeks, range37to40; weighing3.2±0.4kg at birth) and11were preterm (32.7±1.6gestational weeks, range29to36; weighing1.8±0.5kg at birth). None of the newborns had any signs of urinary tract symptoms.
2. All newborns were observed for12h by well trained urologists according to International Children's Continence Society (ICCS) standards. The subjects were observed from9a.m. to9p.m. at day1,4,7,14and28.
3. Student's t-test was used for statistical analysis and p<0.05was considered significantly.
Results
1. Altogether778voids were recorded. Four newborns did not void during their first4hours observation and their first voiding occurred at the5th or6th hour after birth. Voiding frequency, voiding volume and post residual volume varied between newborns, with a high standard deviation.
2. Comparing fullterm to preterm at the same day age after birth, voiding frequency was lower at day14(P<0.01) and day28(P<0.05), and voiding volume was higher at day4(P<0.01), day7(P<0.05), day14(P<0.05) and day28(P<0.01), and post residual volume was higher at day4(P<0.05) and day28(P<0.05).
3. In preterm group, voiding frequency increased significantly at day4compared to day1, at day7compared to day4(p<0.01), and decreased at day28compared to day14(p<0.01). voiding volume increased significantly only once in the preterm, from day14to day28(p<0.05). In fullterm group, voiding frequency increased significantly at day7compared to day4(p<0.01). voiding volume increased significantly twice in fullterm, from day1to day4and from day14to day28(p<0.01). Post-void residual volumes was increased from day1to day4, but was decreased at day4to day7, and increased again at day14to day28significantly (p<0.05).
4. Percentage of intermittent voiding occurred in70%preterms, but only40%in full terms. Bladder empty percentage was higher in full terms at day28(56%vs.40%), but awake voiding percentage was no more than30%in the preterms, being60%in full terms at day28after birth.
Part Ⅲ:The effects of voiding pattern of newborns The effects of age and weight on voiding pattern
Materals and Methods
1. One hundred and two healthy, single birth newborns (54preterm and48full term) without low urinary tract pathological diseases, hospitalized in NICU from Mar.2010to Mar.2011were recruited in this study. Twelve hours (9:00am～9:00pm) observation of free voiding was performed. The voiding interval time, voiding volumes, post-void residual volumes, bladder capacity, voiding times, state of consciousness at voiding and the number of defecate simultaneously at voiding as well as fluid intake were recorded and analyzed retrospectively.
2. A total of33newborns were included in this study. The newborns aged7～28days old, without low urinary tract pathological diseases, single birth,were divided into two groups,15cases of low weight newborns (birth weight1.88±0.32kg, gestational age33.6±1.5weeks, aged15±8.3days old),18cases of normal weight newborns (birth weight3.24±0.43kg, gestational age34.2±1.5weeks, aged11.8±2.2days old). Each group undertook12hours (9:00am～21:00pm) free voiding observation, recording voiding time, the voiding volume, post-voiding residual urine(PVR) by ultrasound, awake or sleep when voiding.
Results
1. The total number of voiding and defecate simultaneously at voiding of the preterm neonates was318and40respectively. VIT and BC between male and female preterm newborns had no statistical significance, whereas, the mean PRV of the male was larger ((1.9±0.9) mL vs.(0.9±0.8) mL) and the bladder emptying rate was lower (8.3%vs.44.1%) than those of the female newborns (P<0.05). If reject the effect of BER, the difference of PRV between the two genders ((2.1±0.5) mL vs.(1.8±0.6) mL) do not have statistical significance any more. The total number of voiding and DSV of the term neonates was350and43respectively. The BER of the female term neonates was higher than that of the male term neonates (43.0%vs.15.3%; P<0.05). BC and the mean PRV between the two genders of term newborns have no statistical significance. Comparing with the female neonates of the same gestational age, the difference of BER of the male neonates do not have statistical significance any more when defecated simultaneously at voiding (preterm41.7%vs.25.0%; term36.4%vs.28.1%,P>0.05).
2. The frequency, voiding volume, PVR, voidng empty percentage and awake percentage in two groups are7.1±2.2times vs7.7±2.4times,21.1±11ml vs13.1±6.2ml,1.52±1.33ml vs1.86±1.08ml,34.6%vs14.8%,40.9%vs18.3%, respectively. There were significantly difference of voiding volume in two groups (T=2.5010, P<0.05)
The effects of disorders on voiding pattern
Materals and Methods
1. A total of40hospitalized newborns aged4to21days were included in this study. Twenty-one of them were preterm newborns with HIE, another19preterm newborns without HIE. The voided volume, post void residual volume, consciousness at voiding, voiding time, voiding frequency as well as the quantity of intake milk and liquid within4hours from8AM to12AM were recorded. The liquid intake was same in both groups according to standard protocol. The diaper weight difference before and after voiding was defined as voided volume. The post void residual volume was determined by ultrasound. The state of consciousness at voiding was monitored by electroencephalography.
2. Fifty-two newborns with the gestational ages ranged from37to42weeks were observed by4-hour observation, of whom,18were newborns with mild to moderate hyperbilirubinemia, blood total bilirubin level (Tbil) ranging from221μmol/l to342μmol/l, and15with severe hyperbilirubinemia, Tbi1>342μmol/l. Nineteen ones with normal bilirubin level, Tbi1<221μmol/l. The voiding frequency, voiding volume, post-voided residual volume, and percentage of awake voiding of every infant were recorded from8AM to12AM. A total of328voidings were observed in this study.
3. A total of67newborns,34cases with mild asphyxiation and33cases normal, without low urinary tract pathological diseases, single birth, hospitalized in NICU at the First Teaching Hospital of Zhengzhou University from March to May2010were included in this study. They were divided into4groups as16cases of asphyxiation with normal weight (ANW),18cases of asphyxiation with low weight (ALW),18cases of no asphyxiation with normal weight (NANW) and15cases of no asphyxiation with low weight (NANW). Voiding time, voiding volume, post-voided residual volume by ultrasound, empty voiding percentage and awake or sleep when voiding were recorded in12h observation (9Am-9Pm).
Results
1. Voided volume and rate of consciousness at voiding was significant lower in newborns with HIE compared with the control group [(10.8±6.5) ml,(16.3±17.1)%vs.(14.1±7.1) ml,(57.1±21.0)%,(P<0.05), respectively], whereas post void residual volume and voiding frequency were significant higher [(1.6±1.0) ml,(4.0±1.1) times vs.(1.2±0.9) ml,(3.2±0.9) times per4hours,(P<0.05), respectively].
2. The voiding frequency and post-void residual volume [(3.28±1.18) times, (1.82±0.53) ml] of severe hyperbilirubinemia is higher than NB[(2.71±0.84) times,(1.26±0.83) ml] and mild to moderate hyperbilirubinemia [(2.75±0.81) times,(1.41±0.72) ml],(P<0.05). The voided volume of severe hyperbilirubinemia (23.05±8.34) ml is lower than normal bilirubin (27.75±7.29)ml and mild to moderate hyperbilirubinemia (26.88±5.59)ml,(P<0.05).There is no difference of percentage of awake voiding among3groups.
3. All newborns voided totally533times. The voiding frequency in ANW is higher than NANW (P<0.05), but the voiding volume and post-voided residual volume are no significant difference (P>0.05). The voiding frequency, volume and post-voided residual volume in ALW and NALW are no significant difference (P>0.05).The voiding frequency and volume in ANW is higher than ALW (P<0.05), but post-voided residual volume is no significant difference (P>0.05). The voiding volume in NANW is higher than NALW (P<0.05), but the voiding frequency and post-voided residual volume are no significant difference (P>0.05). Voiding empty and awake percentage are higher in ANW and NANW, but no difference; voiding empty and awake percentage in LNW and NALW are no difference.
The effects of humidity/temporature on voiding pattern
Materals and Methods
Six dry diapers were placed into seven levels of humidity, between55%and85%inclusive, in an incubator set at37℃. Hourly weight increments were recorded. The study was repeated with5ml of normal saline added to the center part of diaper to mimic prior urine output.
Results
Dry diapers increased in weight for each humidity level after1h (p<0.001). This was significantly greater at higher humidity (75%). The maximum increase was an average of (2.34±0.12)g at85%humidity after6hrs. When5mL of0.9%saline had been added, the diaper weight changes depended on environmental relative humidity. At≥80%humidity, the diapers continued to gain weight; at70%or75%humidity, they did not change weight.
Conclusions
1. Both term and preterm newborns have shown a high post void residual volume indicating the incomplete voiding pattern exists in newborns. The difference of voiding patterns between term and preterm newborns evidenced the different stages of bladder function development, more maturation of bladder function in term than those of preterm newborns.
2. Voiding pattern in the preterm has shown many differences from those of fullterms in the very beginning of life. Frequent interrupted and incomplete voiding pattern in the preterm newborns indicated a disrupted coordination of the detrusor-sphincter and a delayed maturation of the neural maturation center.
3. Compared to female, male newborns are more likely to have post-void residual volumes.
4. Voiding volume, emptying and awake percentage are lower in low birth weight newborns comparing to normal weight newborns. The bladder function and the degree of the brain involved in urination are lower in low birth weight newborns.
5. The differences in voiding pattern supported the concept that the higher centers of the central nervous system were involved in the control of voiding, HIE had a significant effect on voiding pattern of preterm newborn.
6. There is a significant change of voiding pattern in newborn with severe hyperbilirubinemia indicating the severe hyperbilirubinemia has an effect on the nerve micturition center.
7. Mild asphyxiation induced more voiding frequencies for more fluid intake in NANW,the lower weight,the lighter;but it had little influence on voiding volume, PVR, empty voiding percentage and awake voiding percentage.
8. The humidity/temporature may have effect on the voiding pattern of newborns. This study demonstrates the need for caution when interpreting this measure, and we discuss some possible clinical approaches to ameliorate this difficulty.
引文
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