極低出生體重早產兒以家庭為中心早期介入計畫之發展療效及身體姿勢與居家活動配合度對其之影響

Family-Centered Intervention for Very Low Birth Wight Preterm Infants: Developmental Outcomes and Influences of Body Position of Activities and Adherence of Home Programs

賴宛榆(Wan-Yu Lai)

指導教授 ： 鄭素芳

國立臺灣大學/醫學院/物理治療學研究所/碩士(2016年)

https://doi.org/10.6342/NTU201603232

摘要

背景與目的：極低出生體重早產兒(出生體重＜1,500公克)是發展高風險族群，西方國家基於以家庭為中心照護的理念發展出許多不同的介入計畫，並發現有短到中期的療效；然而，環境因素以及家長居家活動配合度對於介入計畫之發展療效的影響仍然未知。因此，本研究旨在針對臺灣極低出生體重早產兒，施予合併門診及家訪介入之以家庭為中心早期介入計畫，探討一歲以內之發展療效及活動姿勢是否影響發展療效，並檢視家長居家活動配合度對發展療效之影響。方法：本臨床隨機研究共收取269位極低出生體重早產兒(129位介入組及140位常規組)，介入組接受住院期介入、門診及家庭介入計畫內容至矯正年齡12個月；常規組於住院期接受常規照護、出院後則接受電話訪問諮詢至矯正年齡12個月。所有嬰兒於矯正年齡6及12個月時接受貝萊氏嬰幼兒發展量表第三版測驗，以及由主要照顧者於矯正年齡6個月填寫身體活動姿勢問卷；介入組另於矯正年齡0、1、2、4、6、9與12個月介入期間完成居家活動記錄。結果：以家庭為中心之介入計畫對於認知、語言及動作發展分數並無明顯療效，然而對於矯正年齡6至12個月中曾經發生過動作遲緩的比例有臨界療效(11%及19.1%，p=0.1)。兩組於睡覺及清醒活動姿勢並無顯著差異；然而影響因子的分析顯示，矯正年齡0-6個月的清醒趴姿超過40分鐘者較少於40分鐘者，曾經發生動作遲緩的比例明顯較低(組別:勝算比及95%信賴區間從0.6 [0.3,1.3]，p=0.2； 趴姿:0.1 [0.0,0.6]，p=0.007)。家長居家活動配合度於矯正年齡0-6個月每週執行6-7天(2.6%)、執行項目>91%(5.3%)及於矯正年齡6-12個月每週執行5-6天(3.3%)，其曾經發生動作遲緩的比例較常規組顯著為低(所有p＜0.05)。結論：極低出生體重早產兒以家庭為中心之介入計畫，對於一歲以內曾經發生動作遲緩的比例有臨界療效；早期將早產兒在清醒時擺置趴姿，似可降低動作發展遲緩的風險；另外，家長執行以家庭為中心居家活動的頻率及項目涵蓋程度，對於動作發展預後則有明顯的影響。本研究結果可提供未來早產兒介入計畫內容設計及居家活動執行的重要參考。

關鍵字

早產 ； 早期介入 ； 身體姿勢 ； 發展 ； 療效 ； 配合度

並列摘要

Background and purposes: Preterm infants with very low birth weight (VLBW, birth weight ＜1,500g) are at high risk of developmental disorders. Several intervention programs grounded on family-centered care have been developed in Western countries that yielded short-to-medium term developmental benefits. However, the influences of environmental factors and parental adherence of home program on intervention effect remain unclear. Therefore, the purposes of this study were to evaluate the effectiveness of a family-centered intervention program (FCIP) consisting of clinic- and home-based intervention in comparison with a usual care program (UCP) on developmental outcomes for VLBW preterm infants in Taiwan, to examine whether the body position of activities influenced the developmental outcomes, and to evaluate the influence of parental adherence of home activities on the developmental outcomes during the first year of age. Methods: This randomized controlled trial included 269 VLBW preterm infants (129 in the FCIP and 140 in the UCP). The FCIP consisted of in-hospital intervention, and clinic- and home-based intervention; the UCP consisted of standard care in hospitalization and telephone consultation until 12 months of corrected age (CA). All infants were assessed the Bayley Scales of Infants and Toddler Development-Third Edition at 6 and 12 months CA and the Wakeful Position Questionnaire at 6 months CA. The FCIP-group parents additionally recorded the Home Activity Diary at term age, 1, 2, 4, 6, 9, and 12 months CA. Results: The FCIP showed no developmental benefit, except for a borderline effect on lowering the rate of ever motor delay during 6 to 12 months CA than the UCP (11% vs. 19.1%, p=0.1). The groups were comparable in the sleep and wakeful positions. However, analysis of influencing factors revealed that awaked prone position time >40 min during 0-6 months CA was significantly associated with a lower rate of ever motor delay compared with awaked prone position time <40 min (group: OR [95%CI]=0.6 [0.3, 1.3], p=0.2; position: OR [95%CI]=0.1 [0.0, 0.6], p=0.007). Furthermore, parental adherence of home activities with frequency of 6-7 days/week (2.6%), item administered >91% during 0-6 months CA (5.3%), and with frequency of 5-6 days/week during 7-12 months CA (3.3%) were significantly associated with lower rate of ever motor delay in comparison with the UCP during the first year of age (19.1%) (all p＜0.05). Conclusions: The FCIP yielded a borderline effect of decreasing the rate of ever motor delay than the UCP in VLBW preterm infants during infancy. Early placement of preterm infants in prone position when awaked reduced the risk of ever motor delay. Frequency and comprehensiveness were important indices of parental adherence of home activities may influence the motor outcome in preterm infants under the FCIP. The results provide insightful information for the design and execution of family-centered intervention for preterm infants.

並列關鍵字

Preterm ； early intervention ； body position ； development ； effectiveness ； adherence

參考文獻

14. Chang SC, Lin CH, Lin YJ, Yeh TF. Mortality, morbidity, length and cost of hospitalization in very-low-birth-weight infants in the era of national health insurance in taiwan: A medical center's experience. Acta Paediatr Taiwan. 2000:41:308-12.

1. Glass HC, Costarino AT, Stayer SA, Brett CM, Cladis F, Davis PJ. Outcomes for extremely premature infants. Anesth Analg. 2015:120:1337-51.

2. Grisaru-Granovsky S, Reichman B, Lerner-Geva L, Boyko V, Hammerman C, Samueloff A, et al. Population-based trends in mortality and neonatal morbidities among singleton, very preterm, very low birth weight infants over 16 years. Early Hum Dev. 2014:90:821-7.

3. Chen SD, Lin YC, Lu CL, Chen SC. Changes in outcome and complication rates of very-low-birth-weight infants in one tertiary center in southern taiwan between 2003 and 2010. Pediatr Neonatol. 2014:55:291-6.

4. Marret S, Marchand-Martin L, Picaud JC, Hascoet JM, Arnaud C, Roze JC, et al. Brain injury in very preterm children and neurosensory and cognitive disabilities during childhood: The eippage cohort study. PLoS One. 2013:8:e62683.