早产儿强化静脉营养的临床研究
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摘要
目的：早产儿尤其是极低出生体重儿和超低出生体重儿由于缺乏宫内营养物质储备，胃肠道发育不成熟及各种疾病等原因常需静脉营养。早期营养状况对早产儿体重增长、并发症的发病率、死亡率及远期生长发育都是非常重要的。早期强化应用氨基酸和脂肪乳可以提供充分的氮、能量以维持机体营养平衡，促进体重增长、减少并发症、缩短住院时间。脂肪乳可提供长链必需脂肪酸如二十二碳六烯酸和花生四烯酸以减少脑及其他器官损害，改善生存质量。本课题旨在研究早产儿对早期强化静脉营养的耐受性和近期临床效果。方法：总计86例早产儿随机分为二组，强化组45例，平均出生体重为1290±215g，孕龄30.2±1.2w，生后第一天静脉应用氨基酸和脂肪乳各为1.0g／kg.d，每天增加1.0g／kg至氨基酸3.0g／kg.d，脂肪乳3.0～4.0g／kg.d。对照组41例，平均出生体重1310±235g，孕龄30.4±1.6w，尘后第三天静脉应用氨基酸0.5g／kg.d，每天增加0.5g／kg至3.0g／kg.d，生后第四天开始应用脂肪乳0.5g／kg.d，每天增加0.5g／kg至3.0g／kg.d。静脉营养液采用“全合一”方式，包括葡萄糖、氨基酸、脂肪乳、维生素、微量元素，经外周静脉24小时均匀输入。统计学使用t检验或卡方检验处理。结果：1．两组之间血甘油三酯、胆红素、BUN、BE无统计学差别。两组均未发生高胆红素血症及肝肾功能损害。2．与对照组相比，强化组住院期间体重增长较快(强化组32.0±8.5克／天，对照组21.8±7.8
忿文 早产儿掰a静版学赤肘瞄床研穷
克／天，p功刀 1）；需静脉营养时间短（强化组静脉营养时间 9．5H石天，
对照组13．4土4．2天，p叩01）；住院时间缩短（强化组19二门0．5天，
对照组 25．sill．3天，p刃刀1人 并发症减少（强化组发生率 26石7％，
对照组发生率48．78O，p叼．05人3．两组死亡率无差别。
结论：早产儿能够接受早期强化静脉营养，未见明显副作用。与
对照组相比，早期强化静脉营养能够改善住院期间的体重增长，缩短
需要静脉营养的时间及住院时问，减少并发症。
Objectives: Preterm infants especially very low birth-weight infants (VLBWI) and extremely low birth-weight infants (ELBWI) often need parenteral nutrition because of their lack of intrauterine deposition of nutrients (both carbohydrates and fats), immature gastroenteral function and the diseases related to premature birth. Nutrition is very important to the preterm infants because the nutritional state had influences on weight gain, the morbidity of complications, mortality and the long term developmental outcome of the preterm infants. Early and aggressive use of amino acids and fat emulsion could provide adequate essential nutrients such as nitrogen and energy and maintain nutritional integrity of the body, promote weight gain, decrease growth problems, lessen complications, shorten hospital stay. Fat emulsion could prevent the lack of long-chain polyunsaturated fatty acids such as docosahexaenoic acid(DHA) and arachidonic acid(AA) so as to decrease the damage of the brain and other organs and improve the
living quality of the preterm infants.This study aimed to investigate the intolerance and short term clinical outcomes in preterm infants receiving an aggressive regimen of parenteral nutrition. Metheds: Total of 86 preterm infants were assigned into two groups randomly. Forty five were in aggressive group, mean birth weight was 1290+215g, gestational age was 30.2+1.2w. Amino acid solution and fat emulsion were started beginning on the first day of life. Amino acids were l.Og/kg.d, increased by l.Og/kg.d up to a maximum of 3.0g/kg.d. Lipids were l.Og/kg.d, increased by l.Og/kg.d up to a maximum of 3.0-4.Og/kg.d. Forty one were in control group, mean birth weight was 1310+235g,
gestational age was 30.4+1.6w. Amino acid solution was started on the third day of life. Amino acids were started with 0.5g/kg.d, increased by 0.5g/kg.d up to a maximum of 3.0g/kg.d. Lipids were started beginning on the forth day of life with 0.5g/kg.d, increased by 0.5g/kg.d up to a maximum of 3.0g/kg.d. Nutritional solution was "all in one" including glucose, amino acids, lipids vitamins and trace elements. Parenteral nutrition was administrated through peripheral veins in 24 hours a day. Statistical analysis was done using Student's t test or X2 test. Result: 1.There were no differences of the concentrations of triglyceride (TG), bilirubin(Bil), blood urea nitrogen(BUN) and base excess(BE) between two groups. No hyperbilirubinemia, liver or kidney damages occurred in both groups. 2. Compared to control group, preterm infants receiving an aggressive regimen had a more rapid weight gain(32.0?.5g/d vs 21.8+7.8g/d, p<0.01), shorter parenteral nutrition time(9.5+3.6 vs 13.4+4.2 days, p<0.01), shorter hospital
stay (19.2+10.5 vs 25.8+11.3 days, p<0.01) and fewer complications (26.67% vs 48.78%, p<0.05) . 3. There was no difference of mortality between two groups. Conclusion: Preterm infants could receive an early and aggressive parenteral nutrition regimen without apparent side effects. Compared to control group, early and aggressive parenteral nutrition could improve the weight gain, shorten parenteral nutrition time, shorten hospital stay, and decrease complications of preterm infants.
Chenkai (Pediatrics) Directed by Litang
忿文 早产儿掰a静版学赤肘瞄床研穷
克／天，p功刀 1）；需静脉营养时间短（强化组静脉营养时间 9．5H石天，
对照组13．4土4．2天，p叩01）；住院时间缩短（强化组19二门0．5天，
对照组 25．sill．3天，p刃刀1人 并发症减少（强化组发生率 26石7％，
对照组发生率48．78O，p叼．05人3．两组死亡率无差别。
结论：早产儿能够接受早期强化静脉营养，未见明显副作用。与
对照组相比，早期强化静脉营养能够改善住院期间的体重增长，缩短
需要静脉营养的时间及住院时问，减少并发症。
Objectives: Preterm infants especially very low birth-weight infants (VLBWI) and extremely low birth-weight infants (ELBWI) often need parenteral nutrition because of their lack of intrauterine deposition of nutrients (both carbohydrates and fats), immature gastroenteral function and the diseases related to premature birth. Nutrition is very important to the preterm infants because the nutritional state had influences on weight gain, the morbidity of complications, mortality and the long term developmental outcome of the preterm infants. Early and aggressive use of amino acids and fat emulsion could provide adequate essential nutrients such as nitrogen and energy and maintain nutritional integrity of the body, promote weight gain, decrease growth problems, lessen complications, shorten hospital stay. Fat emulsion could prevent the lack of long-chain polyunsaturated fatty acids such as docosahexaenoic acid(DHA) and arachidonic acid(AA) so as to decrease the damage of the brain and other organs and improve the
living quality of the preterm infants.This study aimed to investigate the intolerance and short term clinical outcomes in preterm infants receiving an aggressive regimen of parenteral nutrition. Metheds: Total of 86 preterm infants were assigned into two groups randomly. Forty five were in aggressive group, mean birth weight was 1290+215g, gestational age was 30.2+1.2w. Amino acid solution and fat emulsion were started beginning on the first day of life. Amino acids were l.Og/kg.d, increased by l.Og/kg.d up to a maximum of 3.0g/kg.d. Lipids were l.Og/kg.d, increased by l.Og/kg.d up to a maximum of 3.0-4.Og/kg.d. Forty one were in control group, mean birth weight was 1310+235g,
gestational age was 30.4+1.6w. Amino acid solution was started on the third day of life. Amino acids were started with 0.5g/kg.d, increased by 0.5g/kg.d up to a maximum of 3.0g/kg.d. Lipids were started beginning on the forth day of life with 0.5g/kg.d, increased by 0.5g/kg.d up to a maximum of 3.0g/kg.d. Nutritional solution was "all in one" including glucose, amino acids, lipids vitamins and trace elements. Parenteral nutrition was administrated through peripheral veins in 24 hours a day. Statistical analysis was done using Student's t test or X2 test. Result: 1.There were no differences of the concentrations of triglyceride (TG), bilirubin(Bil), blood urea nitrogen(BUN) and base excess(BE) between two groups. No hyperbilirubinemia, liver or kidney damages occurred in both groups. 2. Compared to control group, preterm infants receiving an aggressive regimen had a more rapid weight gain(32.0?.5g/d vs 21.8+7.8g/d, p<0.01), shorter parenteral nutrition time(9.5+3.6 vs 13.4+4.2 days, p<0.01), shorter hospital
stay (19.2+10.5 vs 25.8+11.3 days, p<0.01) and fewer complications (26.67% vs 48.78%, p<0.05) . 3. There was no difference of mortality between two groups. Conclusion: Preterm infants could receive an early and aggressive parenteral nutrition regimen without apparent side effects. Compared to control group, early and aggressive parenteral nutrition could improve the weight gain, shorten parenteral nutrition time, shorten hospital stay, and decrease complications of preterm infants.
Chenkai (Pediatrics) Directed by Litang
引文
1 张家骧，魏克伦，薛辛东．新生儿急救学．人民卫生出版社，2000；170
2 Sittlington N, Tubman R, Halliday HL. Surfactant replacement therapy for severe neonatal respiratory distress syndrome: implications for nursing care. Midwifery 1991 Mar;7(1):20-4
3 Thureen PJ, Hay WW Jr. Intravenous nutrition and postnatal growth of the micropremie. Clin Perinatol 2000 Mar;27(1): 197-219
4 Dudrick SJ, Wilmore DW, Vars HM, et al. Long-term total parenteral nutrition with growth, development, and positive nitrogen balance. Surgery 1968 Jul;64(1): 134-42
5 金汉珍，黄德珉，官希吉．实用新生儿学．人民卫生出版社，1990；31-33
6 Stopfkuchen H, Racke K, Schworer H, et al. Effects of dopamine infusion on plasma catecholamines in preterm and term newbom infants. Eur J Pediatr 1991 May; 150(7):503-6
7 Bauer K, Linderkamp O, Versmold HT. Systolic blood pressure and blood volume in preterm infants. Arch Dis Child. 1994 May;70(3 Spec No):F230-1
8 William C. The importance of early nutritional management of low-birthweight infants. Pediatrics in Review. 1999,20:e43-e44
9 Hack M, Breslau N, Weissman B, et al. Effects of very low birthweight and subnoumal head size on cognitive abilities at school age. N Engl J Med. 1991;325:231-237
10 Hay WW Jr. Nutritional requirements of extremely low birthweight
infants. Acta Paediatr Suppl 1994;402:94-9
11 Simopoulos AP. Omega-3 fatty acids in health and desease and in growth and development. AM J Clin Nutr.l991;54:438-463
12 Woltil HA, van Beusekom CM, Schaafsma A, et al. Long-chain polyunsaturated fatty acid status and early growth of low birth weight infants. Eur J Pediatr.l998;157:146-152
13 Goel R, Hamosh M, Stahl GE, et al. Plasma lecithin: cholesterol acyltransferase and plasma lipolytic activity in preterm infants given total parenteral nutrition with 10% or 20% Intralipid. Acta Paediatr 1995 Sep;84(9) : 1060-4
14 Sauer PJ, Carnielli VP, Sulkers EJ, et al. Substrate utilization during the first weeks of life. Acta Paediatr Suppl 1994 Dec;405:49-53
15 Denne S, Karn CA, Ahlrichs JA, et al. Proteolysis and phenylalanine hydroxylation in response to parenteral nutrition in extremely premature and normal newborns. J Clin Invest 1996;97:746-754
16 Sunehag A, Ewald U, Gustafsson J. Extremely preterm infants (< 28 weeks) are capable of gluconeogenesis from glycerol on their first day of life. Pediatr Res 1996 Oct;40(4) :553-7
17 Patti J, Thureen MD. Early aggressive nutrition in the neonate. Pediatrics in Review. 1999;20:e45-e55
18 Van Goudoever JB, Colen T, Wattimena JL, et al. Immediate commencement of amino acid supplementation in preterm infants: Effect on serum amino acid concentrations and protein kinetics on the first day of life. J Pediatr. 1995 Sep; 127(3) :458-465
19 Murdok N, Crighton A, Nilson LM. Low birthweit infants and total parenteral nutrition immediately after birth. II .Randomised study of biochemical tolerance of intravenous glucose, amino acids, and lipid. Arch Dis Child 1995; 73: F8-F12
20 Kalhan SC. Estimation of glucose turnover and 13C recycling in the human newborn by simultaneous [1-13C]glucose and
[6,6-1H2] glucose tracers. Journal of Clinical Endocrinology & Metabolism, Vol 50, 456-460
21 Lee EJ, Simmer K, Gibson RA. Essential fatty acid deficiency in parenterally fed preterm infants. J Paediatr Child Hialth 1993 Feb;29(l):51-5
22 Neuringer M, Connor WE. N-3fatty acid in the brain and retina: evidence for their essentiality. Nutr Rev.l986;44:285-294
23 Birch EE, Hoffman DR, Uauy RD. et al. Dietary essential fatty acid supply and visual acuity development. Invest Ophthalmol Vis Sci.l992;33:3242-53
24 Birch DG, Birch EE, Hoffman DR, et al. Retinal development in very-low-birth-weight infants fed diets differing in omega-3 fatty acids. Invest Ophthalmol Vis Sci.l992;33:2365-76
25 Rubin M, Naor N, Sirota L, et al. Are bilirubin and plasma lipid profiles of premature infants dependent on the lipid emulsion infused? J Pediatr Gastroenterol Nutr. 1995 Jul;21(1) :25-30
26 Papadopoulos A, Hamosh M, Chowdhry P, et al. Lecithin-cholesterol acyltransferase in newborn infants: low activity level in preterm nfants. J Pediatr 1988 Nov;113(5) :896-8
27 Amr S, Chowdhry P, Hamosh P et al. Low levels of apolipoprotein Al are not contributors to the low lecithin-cholesterol acyl transferase activity in premature newborn infants. Pediatr Res 1988 Aug;24(2) : 191-3
28 Hilliard JL, Shannon DL, Hunter MA, et al. Plasma lipid levels in preterm neonates receiving parenteral fat emulsions. Arch Dis Child 1983 an;58(1) :29-33
29 Helbock HJ, Ames BN. Use of intravenous lipids in neonates. J Pediatr 1995 May;126(5 Pt ):747-8
30 Battaglia FC, Meschia G. Principal substrates of fatal metabolism. Pysiol Rev. 1978;58:499-531
31 Sunehag A, Ewald U, Larsson A, et al. Glucose production rate in extremely immature neonates (< 28 weeks) studied by use of deuterated glucose. Pediatr Res 1993 Feb;33(2) :97-100
32 Hertz DE, et al. Intravenous glucose suppresses glucose production but not proteolysis in extremely premature newborns. J Clin Invest 1993 ct;92(4) : 1752-8
2 Sittlington N, Tubman R, Halliday HL. Surfactant replacement therapy for severe neonatal respiratory distress syndrome: implications for nursing care. Midwifery 1991 Mar;7(1):20-4
3 Thureen PJ, Hay WW Jr. Intravenous nutrition and postnatal growth of the micropremie. Clin Perinatol 2000 Mar;27(1): 197-219
4 Dudrick SJ, Wilmore DW, Vars HM, et al. Long-term total parenteral nutrition with growth, development, and positive nitrogen balance. Surgery 1968 Jul;64(1): 134-42
5 金汉珍，黄德珉，官希吉．实用新生儿学．人民卫生出版社，1990；31-33
6 Stopfkuchen H, Racke K, Schworer H, et al. Effects of dopamine infusion on plasma catecholamines in preterm and term newbom infants. Eur J Pediatr 1991 May; 150(7):503-6
7 Bauer K, Linderkamp O, Versmold HT. Systolic blood pressure and blood volume in preterm infants. Arch Dis Child. 1994 May;70(3 Spec No):F230-1
8 William C. The importance of early nutritional management of low-birthweight infants. Pediatrics in Review. 1999,20:e43-e44
9 Hack M, Breslau N, Weissman B, et al. Effects of very low birthweight and subnoumal head size on cognitive abilities at school age. N Engl J Med. 1991;325:231-237
10 Hay WW Jr. Nutritional requirements of extremely low birthweight
infants. Acta Paediatr Suppl 1994;402:94-9
11 Simopoulos AP. Omega-3 fatty acids in health and desease and in growth and development. AM J Clin Nutr.l991;54:438-463
12 Woltil HA, van Beusekom CM, Schaafsma A, et al. Long-chain polyunsaturated fatty acid status and early growth of low birth weight infants. Eur J Pediatr.l998;157:146-152
13 Goel R, Hamosh M, Stahl GE, et al. Plasma lecithin: cholesterol acyltransferase and plasma lipolytic activity in preterm infants given total parenteral nutrition with 10% or 20% Intralipid. Acta Paediatr 1995 Sep;84(9) : 1060-4
14 Sauer PJ, Carnielli VP, Sulkers EJ, et al. Substrate utilization during the first weeks of life. Acta Paediatr Suppl 1994 Dec;405:49-53
15 Denne S, Karn CA, Ahlrichs JA, et al. Proteolysis and phenylalanine hydroxylation in response to parenteral nutrition in extremely premature and normal newborns. J Clin Invest 1996;97:746-754
16 Sunehag A, Ewald U, Gustafsson J. Extremely preterm infants (< 28 weeks) are capable of gluconeogenesis from glycerol on their first day of life. Pediatr Res 1996 Oct;40(4) :553-7
17 Patti J, Thureen MD. Early aggressive nutrition in the neonate. Pediatrics in Review. 1999;20:e45-e55
18 Van Goudoever JB, Colen T, Wattimena JL, et al. Immediate commencement of amino acid supplementation in preterm infants: Effect on serum amino acid concentrations and protein kinetics on the first day of life. J Pediatr. 1995 Sep; 127(3) :458-465
19 Murdok N, Crighton A, Nilson LM. Low birthweit infants and total parenteral nutrition immediately after birth. II .Randomised study of biochemical tolerance of intravenous glucose, amino acids, and lipid. Arch Dis Child 1995; 73: F8-F12
20 Kalhan SC. Estimation of glucose turnover and 13C recycling in the human newborn by simultaneous [1-13C]glucose and
[6,6-1H2] glucose tracers. Journal of Clinical Endocrinology & Metabolism, Vol 50, 456-460
21 Lee EJ, Simmer K, Gibson RA. Essential fatty acid deficiency in parenterally fed preterm infants. J Paediatr Child Hialth 1993 Feb;29(l):51-5
22 Neuringer M, Connor WE. N-3fatty acid in the brain and retina: evidence for their essentiality. Nutr Rev.l986;44:285-294
23 Birch EE, Hoffman DR, Uauy RD. et al. Dietary essential fatty acid supply and visual acuity development. Invest Ophthalmol Vis Sci.l992;33:3242-53
24 Birch DG, Birch EE, Hoffman DR, et al. Retinal development in very-low-birth-weight infants fed diets differing in omega-3 fatty acids. Invest Ophthalmol Vis Sci.l992;33:2365-76
25 Rubin M, Naor N, Sirota L, et al. Are bilirubin and plasma lipid profiles of premature infants dependent on the lipid emulsion infused? J Pediatr Gastroenterol Nutr. 1995 Jul;21(1) :25-30
26 Papadopoulos A, Hamosh M, Chowdhry P, et al. Lecithin-cholesterol acyltransferase in newborn infants: low activity level in preterm nfants. J Pediatr 1988 Nov;113(5) :896-8
27 Amr S, Chowdhry P, Hamosh P et al. Low levels of apolipoprotein Al are not contributors to the low lecithin-cholesterol acyl transferase activity in premature newborn infants. Pediatr Res 1988 Aug;24(2) : 191-3
28 Hilliard JL, Shannon DL, Hunter MA, et al. Plasma lipid levels in preterm neonates receiving parenteral fat emulsions. Arch Dis Child 1983 an;58(1) :29-33
29 Helbock HJ, Ames BN. Use of intravenous lipids in neonates. J Pediatr 1995 May;126(5 Pt ):747-8
30 Battaglia FC, Meschia G. Principal substrates of fatal metabolism. Pysiol Rev. 1978;58:499-531
31 Sunehag A, Ewald U, Larsson A, et al. Glucose production rate in extremely immature neonates (< 28 weeks) studied by use of deuterated glucose. Pediatr Res 1993 Feb;33(2) :97-100
32 Hertz DE, et al. Intravenous glucose suppresses glucose production but not proteolysis in extremely premature newborns. J Clin Invest 1993 ct;92(4) : 1752-8