- 學位論文
哺餵母乳新生兒體重過度喪失之母親與臨床因子回溯性世代研究
A Retrospective Cohort Study on Maternal and Clinical Factors for Excess Body Weight Loss among Breast-fed Neonates
摘要
哺餵母乳是人們養育嬰兒最自然的方式，亦是新生兒最佳的營養來源，十多年來衛生福利部國民健康署積極推行母乳哺育推廣計畫，有愈來愈多母親選擇哺餵母乳，產後母乳哺育率也大幅提升，因此除了教導母嬰如何正確有效地吃到母奶之外，避免體重喪失過多而導致合併症發生是目前非常重要的議題。故本研究的目的是要了解哺餵母乳新生兒出生後體重變化情形及影響新生兒體重下降之母親相關因素，希望藉由減少新生兒體重過度喪失的情形，降低高膽紅素血症的發生，減少對新生兒健康所造成之危害，進而減少因補充配方奶餵食而影響成功哺乳的機會。 筆者希望藉由母親的屬性分析、剖腹生產輸液情形、自然生產產程進展情形、母親產後的泌乳及哺餵狀況，以分析哺餵母乳新生兒出生後體重變化情形及影響新生兒體重下降的相關因素。本研究為量性、描述相關性研究設計，採回溯性世代研究，以立意取樣之方式，在台北市一所有兒童醫院設立的醫學中心進行資料收集，收案對象為健康足月的新生兒及其母親，新生兒需符合（1）單胞胎、（2）出生週數≧37週、（3）出生體重≧2500公克，若住院期間發生任何高膽紅素血症以外之疾病需進一步治療之新生兒、母親需住加護病房治療或非全母乳哺餵者予排除收案。出生時間自2014年1月1日至2014年12月31日，共2931位新生兒出生，出生後進入嬰兒室且出生體重≧2500公克之新生兒共1838位，參照嬰兒室中2014年每個月新生兒人數與全年總人數之百分比，視病歷調閱情況做部份調整，先將當月新生兒進行編碼， 1到10號以抽籤方式決定，接下來每增加10號為收案對象，共收集406對新生兒及母親，新生兒平均出生體重為3214.50 ± 355.31公克，男嬰224人，女嬰182人。資料收集方式為研究者進入病歷室閱覽病歷、電子病歷。依據自擬之哺餵母乳新生兒體重變化相關之母親因子資料收集表進行病歷資料收集，個案資料經編碼後電腦資料建檔。研究所得資料以SPSS for Windows 21.0版套裝軟體建檔並進行分析處理，採用之分析方法包括：次數分佈、百分比、平均數、中位數、眾數、標準差、最大值、最小值、t檢定（t-test）、卡方檢驗、皮爾森相關係數（Pearson correlation coefficient）、廣義估計方程式（Generalized Estimating Equation, GEE）、分類樹（classification trees）。 重要研究結果如下: 一、全體新生兒平均出生體重3214.50 ± 355.31公克。 二、全體新生兒在出生後第一天體重平均下降5.04 ± 2.25％，出生後第二天體重平均下降8.34 ± 1.50％，出生後第三天體重平均下降9.06 ± 2.46％。自然產及剖腹產新生兒均於出生後第三天體重下降最多，平均分別為8.27％和9.44％。剖腹產新生兒於出生第四天後(體重平均下降8.19 ± 2.45％)開始回升，出生第五天後體重平均下降 7 ± 2.81％。住院期間曾經發生新生兒體重過度喪失共179人(44.1%)；新生兒體重過度喪失發生於出生後第三天為最多，共125人（30.79%）。於出生後第二天體重下降超過7％共341人，佔83.99％。住院期間曾因高膽紅素血症接受照光治療的新生兒共53人，佔13.1%，其中22人（41.5％）發生住院期間體重過度喪失。 三、新生兒返診日齡平均為出生後35 ± 4.37天，平均體重為4508 ± 522.95公克，較出生時平均體重成長約出生體重的1.4倍（重量包含衣服及尿布）。 四、母親高齡產婦、產前體重愈重、剖腹產、生產失血量多、延遲泌乳者其新生兒發生體重過度喪失比例較高，其中又以延遲泌乳為最重要的影響因子。 五、母親於懷孕期間體重增加愈多、母親孕前BMI愈低、產前BMI＞30 kg/m2、懷孕期間BMI變化愈大、初產婦、止痛藥物使用（無痛分娩）、非預期剖腹產、第二產程時間超過一小時、第三產程時間長、預期剖腹產母親從NPO到進開刀房前靜脈總輸液量愈多者（對應待產期間NPO時間較長），容易發生延遲泌乳的情形。 六、高膽紅素血症與母親延遲泌乳有顯著相關，延遲泌乳為新生兒體重喪失重要的影響因子，新生兒體重下降愈多，血清膽紅素值愈高。 結論：本研究結果顯示新生兒體重過度喪失是值得臨床醫護人員關切的議題，於產前衛教門診提供完善的生產教育，協助母親能做好生產及哺餵母乳的準備，如良好控制體重、適度的運動...等。對於初產婦、入院待產期間NPO時間長、產前BMI＞30 kg/m2、體力消耗較多的母親給予更多的關懷及支持，幫助預防母親延遲泌乳及新生兒體重過度喪失的情形發生，以上做為未來研究及臨床工作者之參考。
並列摘要
Breastfeeding is unquestionably the most natural way for a mother to nourish her baby, not to mention the fact that breast milk is the best source of nutrition for neonates. For more than a decade, the Health Promotion Administration Ministry of Health and Welfare has actively promoted breastfeeding programs, with more and more mothers choosing to breastfeed their babies. Given that the postpartum breastfeeding rate has risen sharply, it is critical not only to teach mothers how to breastfeed efficiently but also to educate them on the dangers of excess weight loss and subsequent complications. Therefore, this study aims to examine in depth the fluctuations in the body weight of neonates who are breastfed and mother-related factors that can lead to a decline in the birth weight, in hope of staving off excess loss in birth weight and reducing the incidence of hyperbilirubinemia and thus detrimental effects on the health of neonates. Ultimately, this will reduce the negative impacts of the use of supplementary infant formula on the success of breastfeeding. We aim to analyze the maternal factors, intravenous fluid administration over the course of the cesarean section, the course of spontaneous delivery, the postpartum lactation and breastfeeding conditions, and the body weight changes of the neonates. This is a quantitative, descriptive, and retrospective cohort study. Cases were randomly collected from a children’s hospital under a leading medical center in Taipei City. The neonates satisfied the following conditions (1) single births, (2) birth after ≧37 weeks of pregnancy, and (3) birth weight of ≧2500g. We excluded neonates who required further treatment for diseases other than hyperbilirubinemia, whose mothers required stay in the intensive care unit, or whose mothers did not breastfeed entirely. From January 1, 2014 to December 31, 2014, 2931 neonates were born in said children’s hospital, and a total of 1838 neonates with body weight equal to or more than 2500 gm were admitted to the baby room. We made adjustments accordingly based on the percentage of neonates per month and the number of neonates per year, and the completeness of the medical records. We numbered the neonates sequentially each month, with the first 10 cases each drawing a number randomly from 1 to 10. The next 10 would draw a number randomly from 11 to 20, and so forth. The study included a total of 406 mother-neonate pairs, with 224 boys and 182 girls and an average neonate birth weight of 3214.50 ± 355.31 grams. The data were canvassed from written or electronic medical records and subsequently numbered and stored in the computer. The data was analyzed with the SPSS for Windows 21.0 software package, using frequency distribution, percentage, mean, median, mode, standard deviation, maximum value, minimum value, t-test, Chi-square test, Pearson correlation coefficient, generalized estimating equation (GEE), and classification tree. The results of the study are as follows: 1.The mean birth body weight was 3214.50 ± 355.31 gm. 2.A mean weight loss of 5.04 ± 2.25％, 8.34 ± 1.50％, 9.06 ± 2.46％, 7 ± 2.81％ of the birth weight was recorded at age 24, 48, 72, and 120 hours, respectively. The babies delivered via cesarean section experienced weight loss of 8.19 ± 2.45％ before gaining after 4 days. However, all babies delivered by either via normal spontaneous delivery or cesarean section typically lost at least 8.27% and 9.44% by 72 hours of age. Out of the 406 babies, 176 babies (44.1%) experienced excess weight loss during hospitalization and often before 72 hours of age (125 babies, 30.79%), while 341 (83.99%) experienced weight loss of >7% at 48 hours of age. During hospitalization, 53 babies (13.1%) were administered the phototherapy treatment for Hyperbilirubinemia, among which 22 babies (41.5%) experienced excess body weight loss. 3.The mean age of the first baby clinic health follow-up was around 35 ± 4.37 days old, with a mean body weight of 4508 ± 522.95 grams, a gain of 1.4 times. 4.The risk factors underpinning excess weight loss in neonates were advanced reproductive age, excess gestational weight gain by the mother, cesarean section, postpartum hemorrhage, and delayed onset of lactation. The risk was especially great if the mother had delayed the onset of lactation. 5.Certain conditions may result in a delayed onset of lactation, e.g. excess gestational weight gain by the mother,the lower pre-pregnancy BMI, BMI before delivery of >30 kg/m2, excess fluctuations in gestational weight, nulliparous women, painless labor, postpartum hemorrhage of >400ml, unanticipated cesarean section, Stage II labor duration of >1 hours, prolonged Stage III labor duration, and prolonged duration of intrapartum prophylaxis. 6.Some conditions may result in a delayed onset of lactation such as the mother’s excess gestational weight gain, pre-pregnancy BMI of ≦20 kg/m2, BMI before delivery of >30 kg/m2, gestational weight changes, nulliparous women, painless labor, postpartum hemorrhage of >400ml, unexpected cesarean section, stage II labor duration of >1 hours, prolonged stage III labor duration, and prolonged duration of intrapartum. 7.Hyperbilirubinemia is significantly related to the delayed onset of lactation. The delayed onset of lactation was a risk factor for excess weight loss in neonates. The greater the body weight loss in neonates, the higher the bilirubin values. In conclusion, it is recommended that expecting mothers undergo adequate education at prenatal clinics to ensure a healthy pregnancy and to assist the mother in managing the discomforts of pregnancy, diet, exercise, and other lifestyle changes during pregnancy such as breastfeeding. These could aid nulliparous women, mothers with prolonged duration of hospitalization, BMI before delivery of >30 kg/m2, exhaustion, etc. Furthermore, healthy pregnancy may prevent delayed lactation or excess body weight loss in neonates.