早期介入對於極低出生體重早產兒之發展預後及情緒調控療效研究

Intervention Effects on Developmental Outcomes and Emotion Regulation in Preterm Infants with Very Low Birth Weight

吳盈瑾(Ying-Chin Wu)

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(2014年)

https://doi.org/10.6342/NTU.2014.02626

摘要

背景與目的:早產兒為發展遲緩、情緒困難以及行為問題之高危險性族群，過去西方國家及中國已有研究顯示早期介入能夠增進早產兒短期動作發展及長期認知發展，然而各國之醫療照護系統及家庭結構相異，針對臺灣早產兒設計符合社會現況且有效的介入計畫有其必要性。因此，本研究的目的為長期追蹤門診介入計畫以及家訪介入計畫相較於常規照護計畫，對於臺灣極低出生體重早產兒的發展預後、行為預後、以及情緒調控之療效，並探討療效可能的中介因子。方法:本臨床隨機實驗共收錄178名極低出生體重早產兒，並隨機分配至門診介入計畫（n=57）、家訪介入計畫（n=63）或常規照護計畫（n=58）。自住院期至矯正年齡12個月期間，門診介入計畫及家訪介入計畫提供相同的兒童、家長與親子相關介入內容，唯門診介入計畫於診間執行，家訪介入計畫則於居家執行。所有嬰孩於矯正年齡12個月時，使用自由玩耍實驗評估親子互動行為，於矯正年齡12、18、及24個月時，使用玩具移除實驗觀察負向情緒反應及自我調控行為，再於矯正年齡24個月時，分別使用貝萊氏嬰幼兒發展量表第三版及兒童行為檢核表1.5-5歲版評估嬰孩之發展及行為預後。結果:門診介入組早產兒比常規照護組早產兒在矯正年齡12至24個月時，出現較少之抽離調控行為（差異為-0.84，95%信賴區間為-1.57至-0.10），並在矯正年齡24個月時有較高之認知分數（差異為4.4，95%信賴區間為0.8至7.9）以及較低之動作遲緩發生率（勝算比為0.29，95%信賴區間為0.08至0.99）；家訪介入組早產兒比起常規照護組早產兒在矯正年齡12至24個月時，出現較少之玩具注視調控行為（差異為-1.60，95%信賴區間為-3.07至-0.13），並在矯正年齡24個月時有較低之睡眠行為問題分數（差異為-1.4，95%信賴區間為-2.5至-0.3）以及較低之內化行為問題發生率（勝算比為0.51，95%信賴區間為0.28至0.93）（以上p<0.05）。此外，多變項線性迴歸分析顯示納入矯正年齡12個月時之母親及親子互動行為至線性迴歸模型，明顯降低門診介入計畫與認知分數之關係；而納入注視玩具或是注視轉移至線性迴歸模型，則明顯降低家訪介入計畫與睡眠問題或內化行為問題之關係。結論:早期介入有助於增進極低出生體重早產兒之認知、動作、行為、及情緒調控發展預後；而早期介入對於認知及行為之療效，似乎分別透過改善親子互動及早產兒情緒調控之途徑。此研究結果提供療效達成之社會及發展途徑訊息，並將有助於日後精化針對具有發展及行為問題風險早產兒之介入計畫。

關鍵字

早產兒 ； 早期介入 ； 發展 ； 療效 ； 行為 ； 親子互動 ； 情緒調控 ； 中介因子

並列摘要

Background and Purposes: Preterm infants with VLBW sustain a higher risk of delayed development, emotional difficulties, and behavioral problems than term counterparts. Several intervention studies for preterm infants in Western countries and China have yielded short-term motor benefits in early infancy and long-term cognitive benefits till preschool age. Given substantial variations in health care systems and family structures among societies, the effect of intervention programs needs to be investigated in relevant cultural contexts. Therefore, the purposes of this study were to longitudinally examine the intervention effect of the clinic-based intervention program (CBIP) and home-based intervention program (HBIP) in comparison with a usual care program (UCP) on preterm infants’ development, emotion regulation, and behavior, and to identify the possible mediators of effective interventions. Methods: In this randomized controlled trial, 178 VLBW preterm infants were enrolled and randomly allocated to the CBIP (n=57), HBIP (n=63), or usual care (n=58). The CBIP and HBIP contained identical services from hospitalization until 12 months of corrected age but the interventions after discharge were respectively delivered at clinic and at home. At 12 months of corrected age, dyadic interaction was observed during free play. At 12, 18, and 24 months of corrected age, infants’ emotion regulation was assessed using the toy-behind-barrier procedure. At 24 months of corrected age, infants’ developmental and behavioral outcomes were assessed using the Bayley Scales of Infant and Toddler Development-3rd edition and the Child Behavior Checklist for Ages 1.5-5, respectively. Results: Compared with infants under usual care, the CBIP-group infants exhibited shorter durations of avoidance (difference [95% CI]=-0.84 [-1.57 to -0.10]) from 12 to 24 months, and showed higher cognitive composite scores (difference [95% CI]=4.4 [ 0.8 to 7.9]) and a lower rate of motor delay (odds ratio (OR) [95% CI]=0.29 [0.08 to 0.99]). The HBIP-group infants exhibited shorter durations of visual orientation to a toy (difference [95% CI]=-1.60 [-3.07 to -0.13]), and had lower sleep problem scores (difference [95% CI]=-1.4 [-2.5 to -0.3]) and a lower rate of internalizing problems at 24 months (OR [95% CI]=0.51 [0.28 to 0.93]) (all p<0.05). The CBIP’s effect on cognitive outcome was attenuated when maternal or dyadic interactive behavior was considered; whereas the HBIP’s effect on sleep and internalizing behavior was attenuated when duration of orientation to a toy or reorientation was considered. Conclusions: Interventions enhanced the cognitive, motor, and behavioral outcomes and emotion regulation in VLBW preterm infants. The effects on cognitive and behavioral outcomes might be mediated by early improved mother-infant interaction and infant emotional regulation, respectively. The findings provide insightful information regarding the social and developmental pathways of effective interventions for VLBW preterm infants. Furthermore, our data are helpful for planning effective interventions for preterm infants who are at risk of developmental and behavioral disorder in Taiwan.

並列關鍵字

preterm infants ； early intervention ； development ； effectiveness ； behavior ； mother-infant interaction ； emotion regulation ； mediator

參考文獻

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