以家庭為中心介入計劃於極低出生體重早產兒之新生兒時期神經行為與神經生理功能預後療效探討

Effectiveness of a Family-Centered Intervention Program on Neonatal Neurobehavioral and Neurophysiological Functions in Preterm Infants with Very Low Birth Weight

游硯婷(Yen-Ting Yu)

指導教授 ： 鄭素芳

國立臺灣大學/醫學院/物理治療學研究所/博士(2017年)

https://doi.org/10.6342/NTU201701923

摘要

背景：以家庭為中心之早產兒的早期介入在西方社會執行時呈現短至中期的療效，然而其在東方社會的介入療效與神經機制卻很少被探討。本研究主要有四個目的: (1)探討臺灣極低出生體重早產兒(出生體重低於1,500公克)實施以家庭為中心之早期介入計劃與醫院現行的常規照護，於新生兒階段的醫療狀況、神經行為以及神經生理功能之療效；(2)檢驗介入組早產兒家長的介入依從性與孩子神經行為發展之相關性；(3)檢驗兩組早產兒之神經行為與神經生理功能之間的關聯性；以及(4)探討子宮內生長狀況是否調節早期介入於神經生理功能的效果。方法：本研究為隨機分配與預後評估者單盲實驗設計，於臺灣的三家醫學中心招募251名無嚴重新生兒併發症之極低出生體重早產兒。介入組於住院期接受五次介入，出院後至矯正年齡一歲則接受7次介入；常規組則是在住院期接受醫院現行常規照護，在出院後接受七次電話諮詢，諮詢的時間點與介入組接受介入的時間點相同。在新生兒階段測量各項合併症之比率、餵食、生長、神經行為(使用中文版新生兒神經行為評估量表測量)以及神經生理功能(使用腦波圖/事件相關電位技術測得睡眠時腦部電位關聯性以及特異刺激作業時之錯配負向波)。結果：介入組早產兒比常規組早產兒呈現較早完全以口進食(β= –1.1週, 95%信賴區間= –1.9至–0.2週, p=0.02)、較早出院(β值= –0.6週, 95%信賴區間= –1.1至–0.1週, p值=0.03)、較多的體重增加(β值=3.3 克/天, 95%信賴區間=0.1至6.6克/天, p值=0.04)、較佳的神經行為表現 (β值=1.2分, 95%信賴區間=0.2至2.3分, p值=0.03)以及較成熟的神經生理表現(介入組在前額葉與額葉位置所測得的錯配負向波平均振幅負值更大；且在體重低於懷孕週數標準的早產兒次群體中，介入組同側腦半球前額葉到中央區位置之腦部電位關聯性較常規組為低；但在體重符合懷孕週數標準的早產兒次群體中，介入組兩側腦半球額葉位置之腦部電位關聯性較常規組為高)。此外，家長參與介入的動機越高、介入目標是否達成以及居家活動項目執行的完整度越高，則早產兒之神經行為表現和體重增加的就越好(r=0.20至0.31, 所有p<0.05)。至於體重符合懷孕週數標準的早產兒之同側腦半球額葉位置腦部電位關聯性與新生兒神經行為總分顯著相關(r=0.20, p=0.05)，同時所有早產兒之錯配負向波的平均振幅則與肌肉張力與動作模式分數呈現臨界相關 (r= –0.13,p=0.09)。結論：以家庭為中心的早期介入有助於臺灣極低出生體重早產兒，於新生兒階段的餵食、體重增加、住院天數、神經生理成熟度和的神經行為的表現，而介入組神經行為的療效可能是因為家長的高動機參予介入活動與對居家活動的高依從性所致。再而，子宮內生長狀況扮演了調節介入對於神經生理功能療效的角色。而且，早期神經生理功能的改變可能是早產兒早期介入神經行為療效的中介機制。

關鍵字

早產兒 ； 以家庭為中心介入計畫 ； 腦波圖/事件相關電位 ； 錯配負向波 ； 介入療效 ； 神經行為發展

並列摘要

Background and Purposes: Family-centered care for preterm infants in Western societies has yielded short- to medium-term effects. However, such benefits have rarely been validated in Eastern societies and the underlying neurological mechanisms remain unclear. This study aimed for four purposes: (1) to examine the short-term effects of the family-centered care intervention program (FCIP) on the medical outcome, neurobehavioral performance, and neurophysiological function in preterm infants with very low birth weight (VLBW, birth weight < 1,500 g) in Taiwan during the neonatal period compared to a usual care program (UCP), (2) to assess the relations of parental adherence with neurobehavioral performance in the FCIP group, (3) to investigate the relation of neurophysiological function with neurobehavioral performance in all preterm infants, and (4) to determine whether intrauterine growth status moderated the intervention effect on preterm infants’ neurophysiological function. Method: This study was a randomized controlled trial and assessor blind design. Two hundred and fifty-one VLBW preterm infants without severe perinatal complications were recruited from three medical centers in Taiwan. The FCIP group infants received 5-session in-hospital intervention and 7-session after-discharge intervention until 12 months of corrected age (CA). The control group infants received standard developmental care during hospitalization and then regular telephone calls after discharge scheduled at the same time as the FCIP. Infant morbidities, feeding, growth, neurobehavioral performance (using the Neonatal Neurobehavioral Examination-Chinese version) and neurophysiological function (using the electroencephalography/event-related potentials [EEG/ERPs] to obtain brain coherence in sleep and mismatch negativity [MMN] in an auditory oddball procedure, respectively) were evaluated during the neonatal period. Results: The FCIP promoted earlier full enteral feeding (β= –1.1 weeks, 95% CI= –1.9 to –0.2 weeks, p=0.02) and hospital discharge (β= –0.6 week, 95% CI= –1.1 to –0.1 weeks, p=0.03), greater weight gain (β=3.3 g/day, 95% CI=0.1 to 6.6 g/day, p=0.04), better neurobehavioral performance (β=1.2 points, 95% CI=0.2 to 2.3 points, p=0.03), and more mature neurophysiological function than the UCP (greater negative MMN mean amplitude in the prefrontal and frontal regions, lower intra-hemispheric prefrontal to central coherence among preterm infants with small for gestational age [SGA], and higher inter-hemispheric frontal coherence among preterm infants with appropriate for gestational age [AGA]). Furthermore, a higher degree of parental motivation in intervention, goal attainment and comprehensiveness of home activities were significantly associated with greater effects in infants’ neurobehavioral performance and weight gain (r=0.20 to 0.31, all p<0.05). The inter-hemispheric frontal coherence was associated with the total neurobehavioral score among preterm infants with AGA (r=0.20, p=0.05), while the right prefrontal MMN mean amplitude had a borderline association with the tone and motor patterns scores in all preterm infants (r= –0.13, p=0.09). Conclusions Family-centered care facilitates neonatal feeding, weight gain, hospital discharge, neurophysiological maturation and neurobehavioral performance in VLBW preterm infants in Taiwan. The neurobehavioral benefit in the FCIP-group infants might be via their higher parental motivation and parental adherence to home activities. Intrauterine growth status plays a moderating role in the neurophysiological function in preterm infants following intervention. Furthermore, the early changes of neurophysiological functions may underlie the neurobehavioral effect in preterm infants under intervention.

並列關鍵字

preterm infants ； family-centered intervention ； electroencephalography / event related potential ； mismatch negativity ； intervention effect ； neurobehavioral development

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