極低出生體重早產兒以家庭為中心之介入計畫的母嬰互動與發展預後療效

背景與目的：極低出生體重早產兒 (出生體重低於 1,500 公克)相較於足月兒有較高的風險會出現認知、語言、動作和行為方面的問題。先前的研究發現極低出生體重早產兒接受門診介入計畫和居家介入計畫後，其發展預後與母嬰互動療效不同。因此，本研究結合此兩種介入計畫發展以家庭為中心介入計畫，探討相較於常規照顧計畫對於極低出生體重早產兒之發展預後和母嬰互動品質之療效，並瞭解母嬰互動是否中介發展預後之療效。方法：本研究為多院之隨機對照試驗，共有269位極低出生體重之早產兒參加 (129位以家庭為中心之早產兒介入計畫組和140位常規照顧組)。本研究之以家庭為中心介入計畫和常規照顧計畫提供從住院期至矯正年齡12個月的服務，且所有參與本研究之極低出生體重早產兒於矯正年齡6和12個月以第三版貝萊氏嬰幼兒發展量表評估其認知、語言和動作功能和以六分鐘與母親自由玩樂的方式評估其母嬰互動行為。結果：兩組極低出生體重早產兒在發展分數沒有顯著的差異，進一步的分組分析結果顯示接受以家庭為中心介入計畫的第一胎嬰兒在語言發展分數顯著的高於常規照顧組 (6個月：100.1±7.7相對97.5±9.2；12個月：95.1±7.9相對93.0±8.0，p=0.03)，而非第一胎的嬰兒在發展上則無組間差異。而在母嬰互動評估，接受以家庭為中心介入計畫的母親較常規照顧組母親顯著地有較多高品質行為(6個月：67.7%±20.4%比上60.0%±24.1%；12個月：73.7%±21.9%比上67.0%±19.7%，p =0.01)和較少不主動行為 (6個月：16.0%±15.7%比上23.7%±20.5%；12個月：14.1%±16.7%比上18.8%±16.8%，p<0.01)，而接受以家庭為中心介入計畫的親子有較多的和諧模式(6個月：43.1%±22.1%比上41.3%±22.6%；12個月：49.8%±22.6%比上43.9%±20.1%，p=0.10)、較多的孩子失調之親子模式(6個月：29.5%±19.4%比上22.2%±16.1%；12個月：29.5%±17.5%比上28.4%±15.7%，p =0.03)和較少的母親失調之親子模式(6個月：8.6%±12.3%比上15.4%±18.0%；12個月：6.5%±11.7%比上10.3%±12.6%，p<0.01)。中介因子分析發現當分別納入母親的高品質和不主動行為、母親失調之親子模式及親子的和諧模式後會分別明顯降低以家庭為中心介入計畫對於第一胎早產兒的語言發展療效。結論：以家庭為中心之早產兒介入計畫可改善極低出生體重早產兒於第一年的母親互動行為和親子互動模式，然而卻只改善第一胎極低出生體重早產兒之語言發展。而以家庭為中心介入計畫對於第一胎極低出生體重早產兒的語言療效似乎是藉由改善其母嬰互動的品質。

關鍵字

兒童發展；早期介入；療效；以家庭為中心照顧；母嬰互動

並列摘要

Background and Purposes: Preterm birth with very low birth weight (VLBW, birth weight <1500 g) is associated with high risk of motor, cognitive, language, and behavioral disorder. One prior study showed differential effects of clinic- and home-based intervention programs on developmental outcomes and mother-infant interaction in VLBW preterm infants. Therefore, this study was aimed to investigate the effect of a family-centered intervention program (FCIP) that combined these two intervention services on developmental outcomes and quality of mother-infant interaction in VLBW preterm infants with respect to a usual care program (UCP), and to examine whether mother-infant interaction mediated intervention effect on developmental outcomes. Method: This multi-site randomized controlled study included 269 VLBW preterm infants (129 in the FCIP group and 140 in the UCP group). The FCIP and UCP services lasted from hospitalization to 12 months of corrected age. All preterm infants and mothers were examined for child cognitive, language, and motor development by the Bayley Scales of Infant and Toddler Development- 3rd edition and for quality of interaction during a 6-min free play procedure at 6 and 12 months of corrected age. Results: The FCIP and UCP groups showed comparable developmental scores across ages. However, subgroup analysis revealed significantly higher language score in the FCIP group than in the UCP group among those firstborn (6 months: 100.1±7.7 vs. 97.5±9.2; 12 months: 95.1±7.9 vs. 93.0±8.0, p=0.03) but no group difference in the developmental scores among those not firstborn. The FCIP dyads demonstrated more high-quality (6 months: 67.7±20.4 vs. 60.0±24.1; 12 months: 73.7±21.9 vs. 67.0±19.7, p=0.01) and less inactive maternal interactive behavior (6 months: 16.0%±15.7% vs. 23.7%±20.5%; 12 months: 14.1%±16.7% vs. 18.8%±16.8%, p<0.01) together with more concordant pattern (6 months: 43.1%±22.1% vs. 41.3%±22.6%; 12 months: 49.8%±22.6% vs. 43.9%±20.1%, p=0.10) and child discordant pattern (6 months: 29.5%±19.4% vs. 22.2%±16.1%; 12 months: 29.5%±17.5% vs. 28.4%±15.7%, p=0.03) and less mother discordant pattern (6 months: 8.6%±12.3% vs. 15.4%±18.0%; 12 months: 6.5%±11.7% vs. 10.3%±12.6%, p<0.01), but comparable child interactive behavior than the UCP dyads. Mediator analysis revealed that adding high-quality maternal behavior, inactive maternal behavior, concordant dyadic pattern and mother discordant pattern had each markedly attenuated the intervention effect on language outcome among firstborn preterm infants. Conclusions: The FCIP benefited maternal interactive behavior and dyadic interactive pattern in VLBW preterm infants at 6 and 12 months of corrected age. However, the intervention improved the language development at 6 and 12 months of corrected age in firstborn preterm infants only. Furthermore, the language effect appeared to be mediated via enhanced mother-infant interaction among firstborn preterm infants.

並列關鍵字

Developmental outcome ； early intervention ； effectiveness ； family-centered care ； mother-infant interaction

參考文獻

Chen, P. S., Jeng, S. F., & Tsou, K. I. (2004). Developmental function of very-low-birth-weight infants and full-term infants in early childhood. J Formos Med Assoc, 103(1), 23-31.

Chen, Y. Y., Chen, C. H., Wang, T. M., & Hsu, C. C. (2008). Developmental Outcomes among Very Low Birth Weight Infants with Normal Cranial Ultrasound Images. Clinical Neonatology, 15(1), 5-9.

Tseng, H. I., & Chen, S. J. (2004). Outcomes of Very Low Birth Weight Infants until 2 Years of Age in Taiwan. Clinical Neonatology, 11(2), 51-56.

Achenbach, T. M., Howell, C. T., Aoki, M. F., & Rauh, V. A. (1993). Nine-year outcome of the Vermont intervention program for low birth weight infants. Pediatrics, 91(1), 45-55.

Achenbach, T. M., Phares, V., Howell, C. T., Rauh, V. A., & Nurcombe, B. (1990). Seven-year outcome of the Vermont Intervention Program for Low-Birthweight Infants. Child Dev, 61(6), 1672-1681.

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極低出生體重早產兒以家庭為中心之介入計畫的母嬰互動與發展預後療效

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