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  • 學位論文

探討早產兒準備經口進食之相關決定因素

Exploring Factors Related to Oral Feeding Readiness in Preterm Infants

指導教授 : 陳宣志
共同指導教授 : 楊順發(Shun-Fa Yang)
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摘要


研究目的: 欲引進合適的早產兒準備經口進食量表進行台灣繁體中文版之驗證和臨床應用,期待能對早產兒最佳開始經口進食的時間點做出最佳的臨床決策。本研究分為三個目的: (1)進行「台灣早產兒準備經口進食評估量表-繁體中文版」(Taiwan version of the Traditional Chinese Preterm Oral Feeding Readiness Assessment Scale; TW-POFRAS)之驗證(2) 探討「TW-POFRAS」量表的臨床應用和早產兒經口進食之相關因素。(3) 進行量表內容之修訂,使其內容更為精簡。 研究方法與步驟: 本研究參考「跨文化適應過程指南」的建議程序,進行TW-POFRAS驗證。採用專家內容效度、皮爾森相關分析與Cronbach's alpha係數分析來驗證量表,並使用接受者操作特性曲線(receiver operating characteristic curve; ROC)分析,找出台灣版量表的最佳切節分數。使用student’s t檢定或Mann-Whitney U檢定對二組連續變項進行分析;使用卡方檢定或費雪正確性檢定對二組類比變相進行分析;使用K-W檢定(Kruskal-Wallis Test) 對大於二組的連續變項進行分析。本研究以生理狀況穩定的健康早產兒(懷孕週數 < 37周)為收案對象,納入81位符合條件的早產兒進行TW-POFRAS量表評估,並依照是否可以順利經口喝奶5 mL被分為「非經口進食組」和「經口進食組」兩組。比較「醫囑判定」和「TW-POFRAS 評分」兩者對判定的精準度和特異性,並探討兩組早產兒的各種出生特徵與出生至「初次穩定經口進食天數」、「完全穩定經口進食天數」和「住院天數」之間的相關性。 最後並使用探索式因素分析精簡量表內容,刪除解釋力不夠的項目。 研究結果:TW-POFRAS在清晰度和相關性兩部分的專家效度均為1.00。量表各題項間有不錯的內部一致性,整體Cronbach's alpha= 0.804 (95% CI = 0.736-0.862)。使用ROC曲線分析,TW-POFRAS的最佳臨界值為29 (Youden’s Index = 0.879),敏感度為0.938,特異性為0.941,整體準確性為92.2% (AUROC = 0.922, 95% CI = 0.841-0.970),可以有效地區辨早產兒可以開始經口進食時機。 「醫囑判定」(敏感度:98.4%)略高於「TW-POFRAS 評分」(敏感度: 93.8%)。但是「醫囑判定」的特異性為41.2% (7/17)明顯低於「TW-POFRAS 評分」的94.1%。本研究「非經口進食組」和「經口進食組」兩組早產兒在出生平均年齡、出生體重、實際年齡、Apgar 分數(出生第一分鐘和第五分鐘)、「出生至初次穩定經口進食天數」、「出生至完全穩定經口進食天數」均有顯著差異;在性別和評估當天的實際體重上並無顯著差異。兩組在量表的各項類別和總分也都有顯著差異。早產兒不同的出生週數和出生體重在「出生至初次穩定經口進食天數」、「出生至完全穩定經口進食天數」、「住院天數」均有顯著差異。大部分的早產兒可以在出生一周內達到整天穩定完全經口進食,並在一個月內出院。但是對於出生體重小於1500公克和出生週數小於32周的早產兒,至少要等到出生後年齡達到35周才能順利達到經口喝奶5 mL。 修訂後的量表,刪除了5個題目,整體準確性為92.2%,最佳臨界值為19,敏感性與特異性與TW-POFRAS相同。 結論與建議: TW-POFRAS經過驗證後呈現出良好的一致性和有效性,如果只使用「醫囑判定」作為判斷早產兒是否適合經口進食的標準,可能會存在強制餵食的風險,建議可以將此工具做為臨床醫護人員判斷早產兒經口進食成熟度的有效參考工具。並且建議針對出生體重小於1500公克和出生週數小於32周的早產兒,至少等到出生後年齡達到35周才開始嘗試經口進食。而修訂後的量表未來可以更進一步地在臨床上應用並加以驗證。

並列摘要


Purpose: A clinically useful measure of oral feeding readiness would help nurses initiate implementation of the cue-based feeding model in Taiwan. This study includes three aims: (1) to assess the validity and reliability of Taiwan version of the Traditional Chinese Preterm Oral Feeding Readiness Assessment Scale (TW-POFRAS;TC-POFRAS) (2) to evaluate the clinical application in the decision making of feeding readiness of preterm infants. (3) TW-POFRAS was also reconstructed to develop a more streamlined and efficient tool as “a Revised TW-POFRAS” (TW-POFRAS®). Design and Methods: This was a single-center observational cross-sectional study. 81 preterm infants were enrolled and assessed by TW-POFRAS regarding their oral feeding readiness. A cross language validation procedure was conducted and the item-level content validity index (I-CVIs) for content validity was estimated. The internal consistency of each category and total scale were estimated using the Cronbach’s alpha analysis. A receiver operating characteristic (ROC) curve was estimated to explore the scale’s performance. The optimal cut-off value of TW-POFRAS was identified by the best Youden’s Index [maximum (sensitivity + specificity – 1)]. The sensitivities and specificities of physicians’ orders and scores on TW-POFRAS for readiness in oral feeding among preterm infants were compared. Lengths of stay from admission to initial one-meal oral feeding, to one-day all-meal oral feeding, and to discharge were analyzed. Exploratory factor analysis was used to uncover the underlying structure. TW-POFRAS® was developed and a new cut-off score was established. Results: All of the I-CVIs were 1.00. The whole Cronbach's alpha for internal consistency was 0.804 (95% CI = 0.736-0.862), and Cronbach's alpha values were between 0.538 (95% CI = 0.332-0.689) and 0.687 (95% CI = 0.572-0.781) for categories. The area under ROC was 92.2%, and an optimal cut-off value of TW-POFRAS was 29 (sensitivity: 0.938, specificity: 0.941). When comparing the sensitivities and specificities of physicians’ orders and the POFRAS, we found the sensitivity of physicians’ orders (98.44%) to be higher than that of the scale (93.75%) and the specificity of physicians’ orders (41.18%) to be lower than that of the scale (94.10%). Most preterm infants can begin to consume one meal of the least 5 mL of milk smoothly and proceed to consume a full day of meals with a week; they are typically discharged from the hospital within a month, except for those with a birth weight less than 1,500 g or a GA less than 32 weeks. Participants with a birth weight less than 1,500 g or GA less than 32 weeks were able to meet the 5-mL standard by the postmenstrual age of 35 weeks, at latest. Based on the statistical analysis, the TW-POFRAS®’s global accuracy was 92.1%. The cut-off value of 19 was the one that presented the most optimization of sensitivity based on specificity. Conclusions: The results showed the both valid and reliable of TW-POFRAS were good for screening the initiation of oral feeding in preterm infants. However, following physicians’ orders alone may result in earlier initiation of oral feeding, although the higher sensitivity for the initial oral feeding depends primarily on physicians’ orders. We recommend using the postmenstrual age of 35 weeks as a developmental indicator for oral feeding readiness for preterm infants with a birth weight less than 1,500 g or a GA less than 32 weeks. Practice Implications: The TW-POFRAS containing the oral feeding readiness behavior cues should be used in conjunction with physicians’ orders in clinical decision-making. In the future, the researchers can application TW-POFRAS and TW-POFRAS® with more preterm infants with a lower PMA and lower current weight in the evaluation.

參考文獻


英文參考文獻
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