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首页医源资料库在线期刊中华现代护理学杂志2011年第8卷第21期

先天性心脏病婴幼儿营养状况及影响因素

来源:中华现代护理学杂志
摘要:【摘要】目的了解先天性心脏病患儿营养状况及影响因素。结果大部分先天性心脏病患儿出生时,体重与健康新生儿无明显差异,但部分患儿出生就已存在营养不良。先天性心脏病根治术前,患儿营养不良程度与疾病严重程度呈正相关。胃食管反流是影响先心病患儿生长的常见危险因素。...

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【摘要】  目的 了解先天性心脏病患儿营养状况及影响因素。方法 回顾国外和国内文献 。结果 大部分先天性心脏病患儿出生时,体重与健康新生儿无明显差异,但部分患儿出生就已存在营养不良;先天性心脏病根治术前,患儿营养不良程度与疾病严重程度呈正相关;紫绀型先心病慢性营养不良的发生率明显高于非紫绀型先心病;胃食管反流是影响先心病患儿生长的常见危险因素;心力衰竭也严重地影响患儿营养;肺动脉高压为影响患儿营养状况的最重要因素。先心病患儿营养不良影响因素为能量摄入不足、能量需求提高、营养吸收能力受损、外科手术或介入治疗增加围术期患儿的营养风险。结论 先心病患儿是营养不良的高发人群,术前的营养状况是影响术后营养恢复的主要因素,早期营养干预可以帮助患儿减少术前营养耗竭,临床营养干预必须贯穿于诊断、围术期、术后康复期的整个过程中,依据营养不良的严重程度、相关因素而不断调整营养护理方案,使先天性心脏病患儿尽快追赶上正常儿童生长发育水平。

【关键词】  先天性心脏病患儿; 营养; 影响因素

   Objective To investigate the nutritional status and its influencing factors of children with congenital heart disease. Methods Reviewed the foreign and domestic literature.Results There was no significant difference in weight between most children with congenital heart disease and healthy neonates,but some children had been born in malnutrition;the malnutrition of children and the disease severity were positively correlated before radical surgery was done on the congenital heart disease;the incidence of chronic malnutrition on cyanotic congenital heart disease was significantly higher than non-cyanotic congenital heart disease;gastroesophageal reflux was the common risk factor that affectted the growth of children with congenital heart disease;heart failure also seriously affected the nutrition of children;pulmonary hypertension was the most important factor affecting the nutritional status of children. Insufficient energy intake,increasing demand for energy,impaired nutrient absorption,surgical or interventional therapy in children with increased perioperative risk of nutrition were the influencing factors of the malnutrition of children with congenital heart disease.Conclusion Congenital heart disease was a high risk of malnutrition,preoperative nutritional status was the major factor in affectting postoperative nutritional recovery,early nutrition intervention could help children reduce preoperative nutritional depletion,clinical nutrition interventions must run through the diagnostic, perioperative and postoperative rehabilitation period, nutritional care program should be continually adjusted according to the severity of malnutrition and related factors in order to make the children with congenital heart disease catch up with the level of growth and development of normal children as soon as possible.

  [Key words] congenital heart disease;nutrition;influencing factors

  随着现代医学飞速发展,诊治方法不断进步,先天性心脏病(简称先心病)的治疗越来越向低龄、低体重、复杂型发展,与之相适应的围术期护理和营养支持重要性显得日益突出。先心病患儿是营养不良的高发人群,本文通过文献回顾,综述先心病患儿不同时期营养问题的特点及影响因素,对先心病营养支持提出建议。

  1 先心病新生儿期营养状况

  大部分先心病患儿出生时,体重与健康新生儿无明显差异,但部分患儿出生就已存在营养不良。国外早在1960年就已经开始对先心病新生儿出生体重进行调查[1~5],先心病患儿小于胎龄儿的发生率远远高于健康婴儿[4]。室间隔缺损、法洛四联症、主动脉缩窄患儿中低体重儿发生率较高,大动脉转位的患儿体重基本正常甚至高出平均水平[1~3]。排除紫绀组中大动脉转位的患儿,紫绀组与非紫绀组患儿出生体重基本无差异[5]。而国内对先心病患儿出生体重的调查不多。2003年香港某医院对先心病新生儿体重调查,结果与国外类似,出生体重平均为2.91kg,孕周为38.8周。15%先心病新生儿出生体重低于平均出生体重2SD,低出生体重发生率高于城市平均水平,仅大动脉转位患儿无明显体重/胎龄偏小[6]。对低体重儿、极低体重儿的调查也显示该人群中先心病发病率要明显高出正常水平[7]。

  2 先心病婴幼儿期营养状况及其影响因素

  2.1 疾病与营养不良

  未行先心病根治术前,患儿营养不良程度与疾病严重程度直接相关[8 ]。出生后未能早期行纠治术的患儿,随病程发展营养不良往往会加剧[9]。Staebel对Belgian地区先心病患儿的随访发现,出生时仅1/3患儿存在营养不良,再次入院时1/2患儿出现了营养不良[10]。早期营养干预可以帮助患儿减少术前营养耗竭。心脏畸形可分为紫绀型和非紫绀型。紫绀组与非紫绀组急性营养不良发生率无明显差别,但慢性营养不良的发生率前者明显高于后者[11]。按心脏畸形类型的不同,小儿可呈现不同类型的生长不良[12]。紫绀型先心病患儿身高和体重往往同时增长不良[13]。低氧血症的严重程度与营养状况不直接相关,但伴随时间长短与生长滞后的发生密切相关[14,15],如果还并发心脏衰竭,患儿生长将会受到更严重的影响[15]。非紫绀型先心病中,以肺动脉血流增多为主要特点的先心病早期影响体重而不影响身高[13]。当严重的分流和(或)肺动脉高压显著,身高增长不理想,从而身高、体重的生长均滞后[16,17]。而瓣膜狭窄,如未并发心脏衰竭,通常不会导致明显的生长发育不良[14]。严重型的瓣膜狭窄对身高的影响比对体重还要大,易出现身高生长受损[17,18]。

  2.2 并发症与营养不良

  先心病患儿容易并发肺动脉高压与心脏衰竭,两者均会加剧患儿营养状况的恶化。肺动脉高压是影响生长发育的一个重要因素。室间隔缺损的患儿中,同时存在肺动脉高压婴儿的身高明显受阻[14]。Varan[19]把肺动脉高压列为影响患儿营养状况的最重要因素,紫绀型同时又存在肺动脉高压的婴儿最易出现营养不良。心力衰竭的并发也严重地影响患儿营养。心力衰竭的患儿临床易出现呼吸急促、肝肿大、心动过速、胃肠道功能改变,能量摄入减少、代谢增加,因而影响患儿营养[20,21]。

  2.3 其他危险因素

  胃食管反流是影响先心病患儿生长的常见危险因素,尤其是临床症状明显的患儿[9]。食胃管反流的控制一般性的应对措施有少食多餐、保持竖立的喂养姿势、加稠喂养食物、止吐药等的运用[14]。如以上措施不能解决问题,就可能需要使用鼻胃管、胃管、空肠造口管。目前食胃管反流的患儿是否应该加稠食物仍有争议。部分研究结果示食物加稠后呕吐频率下降,也有研究表示加稠后呕吐持续时间延长。除此之外,影响生长的其他因素包括早产、心脏以外的畸形、反复呼吸道感染等[14,22]。

  2.4 先心病患儿营养不良的机制

  先心病患儿营养不良与多种因素相关,各因素之间又相互影响,但最终可归纳为三个方面:能量摄入不足、能量需求提高、营养吸收能力受损。先心病患儿往往能量摄入不足,这被普遍认为是营养不良的主要因素[23~25]。经口喂养往往是一项挑战,呼吸急促、易疲倦、肝肿大导致胃容量减少等导致不能摄入足够的能量[26]。并发呼吸道感染时,进一步会影响患儿进食。液体限制、利尿剂的使用也会影响能量的摄入,加速离子、微量元素的排泄[27]。Hansen和Dorup[24 ]研究提示按照实际体重的标准,先心病患儿能量摄入仅达到FAO/WHO/UNU推荐量的88%。同时,先心病患儿各营养素的摄入还存在不均衡。对住院0~2岁先心患儿3天饮食摄入情况,结果发现能量摄入量低于RDA, 蛋白质、碳水化合物、钙摄入量高于RDA,而纤维、钾、铁摄入不足[28]。能量消耗增加也是先心病患儿营养不良的另一个原因[25,29]。Kuip对先心病婴儿能量代谢的meta分析结果提示,先心病患儿日总能量消耗为376kJ/kg,与健康婴儿相比增加了35%。先心病患儿心脏、呼吸耗能比健康婴儿要高3~5倍,胸肌顺应性的下降、心肌扩张、肥厚也会增加耗氧量[30]。其次,先心病患儿体质较为消瘦,脂肪构成比的降低也有可能是代谢率增加的原因之一[29]。吸收不良也是患儿营养不良的另一个影响因素[31]。在充血性心力衰竭和紫绀的婴儿中发现了轻微的蛋白质吸收不良和明显的脂肪吸收不良[32]。Yahav等[33]发现高热量喂养的先心病儿童存在脂肪泻、胆汁盐丢失和胃排空延缓引起的脂肪吸收不良。心力衰竭、消化系统组织的缺氧状态均会影响其消化吸收能力,最终导致喂养量、奶液能量浓度、喂养时间均被迫调整,从而影响饮食的摄入。

  3 先心病患儿围手术期营养风险

  婴儿或儿童期,外科手术或介入治疗必然会增加围手术期患儿的营养风险。术后患儿处于高代谢状态,1周后才能恢复术前水平[34]。液体限制、喂养不耐受、术后并发症(乳糜胸、肾衰竭、吞咽障碍、坏死性结肠炎等)是先心病患儿术后营养支持的主要障碍[35;36],住院期间的营养支持很难满足患儿能量需求,患儿围手术期体重常出现下降。Verger等[37]对先心病患儿术后进行每日体重监测,结果示术后1~3天,患儿体重增加,随后体重下降,在第8天体重降至低谷后逐步回升,但超过一半的患儿在出院时体重仍未恢复至术前水平,平均每日体重下降(8.66±18.44)g,与性别、手术方式无明显关联。Boctor[38]对足月产先心病患儿术后体重监测,患儿体重下降115g/d,术后体重的改变与心脏畸形类型、住院天数不相关,而与喂养方式有关。奶瓶喂养的婴儿体重平均增加20g/d(包括母乳置于奶瓶喂养),混合喂养的婴儿体重增加5g/d,母乳喂养的婴儿体重下降了49g/d,奶瓶喂养可以调节奶液的能量密度,从而有利于患儿体重恢复。心脏手术后采用营养液能量浓度更快速的强化策略来促进能量摄入及体重增长。Pillo-Blocka等[39]将患儿术后喂养奶液能量密度在3天内从20cal/oz加至30cal/oz,实验组体重增长20g/d,而对照组体重下降35g/d,术后住院时间也显著缩短。以上研究结果提示营养液浓度及时强化对患儿术后体重恢复有显著促进作用。

  4 先心病患儿根治术后的营养恢复

  先心病患儿行心脏根治术后,心脏畸形基本得以纠正,血流动力学基本恢复正常,患儿能量代谢率也逐步恢复正常水平[34,40 ],患儿出现一段时间的追赶生长[41]。Schuurmans[42]对先心病患儿术后生长发育情况长期的监测,结果示术后大多数患儿呈现良好的追赶生长,但大型室间隔缺损、法洛四联症患儿仍不能恢复正常发育水平,身高的追赶生长情况与手术年龄未发现显著关联,而与术前营养不良的严重情况相关(r=0.92,P<0.05)。对于室间隔缺损、大动脉转位的患儿而言,早期的纠治术能够使其基本恢复正常的生长发育水平,追赶生长在6~12个月可以实现[43,44],但室间隔缺损患儿中低体重儿体重、身高、头围均未能恢复正常[43]。Levy等[45]在1978年对1210例行纠治术的室间隔缺损的患儿进行随访,患儿体重能基本恢复正常水平,但身高恢复不太理想,多元回归结果示小儿远期的生长决定因素为合并非心脏畸形、出生体重<2.5kg,就诊年龄>2岁、有心衰史、肺分流比例。 与室间隔缺损、大动脉转位的患儿相比,法洛四联症(TOF)患儿心脏畸形在新生儿期不能得到纠治,术后营养恢复较差、时间也较长。Page等[46]1978年对73例TOF小儿(平均年龄83.3个月)术后进行2年的随访,仅23例体重、身高增长有所提升,11例小儿体重、身高仍低于3%水平。Cheung[47]也对术后TOF小儿进行了随访,与Page不同的是小儿的手术年龄明显减小,随访中术后患儿均有一定的追赶生长,追赶生长维持1~2年,但仍不能达到正常水平。土耳其学者对60例心脏根治术患儿随访1年结果示大部分患儿在营养充足的情况下手术1年后可追赶上正常生长发育水平。家庭收入、饮食摄入、术前营养情况对患儿体重均有影响,而疾病的严重程度与体重增长未发现显著关联[48]。印度学者对先心病患儿根治术后3个月的随访结果示营养状况有了显著改善,体重/身高、体重/年龄、身高/年龄三个Z值均有显著的升高[49],2年后的随访结果提示虽然营养状况与术前相比有了很大的改善,但是仍有27.3%患儿营养仍处于不良状况,术前营养状态、出生体重、父母身高等与患儿营养状况改善不佳相关[50]。综合以上随访研究均提示术前的营养状况是影响术后营养恢复的主要因素。低出生体重对患儿术后的营养恢复也不容忽视。低出生体重的大型室间隔缺损小儿、TOF小儿术后体重、身高的恢复都受到一定影响。低出生体重对后期生长发育的影响提示孕产期发育不良会限制远期的生长潜能[51]。而手术年龄对术后营养恢复的影响,研究结果不一致,早期研究、发展中国家的研究结果往往提示手术年龄是术后营养恢复的重要决定因素,这可能与研究纳入的样本往往未能及时纠治、手术年龄较大相关。

  5 主要营养干预先心病患儿营养管理的目标

  在于保证维持生长或追赶生长的能量需求。纠正先心病患儿营养水平,首要是快速增加体重,使体重/身高达到正常水平,之后再是身高、体重同步的增长。为了追赶上同龄婴儿发育水平,先心病患儿每日所需的能量可高达同龄婴儿的1.5~2倍,最终目标要保证先心病患儿摄入能量达到120kcal/(kg·d)甚至150kcal/(kg·d)[21,25]。喂养管理是营养管理的重要部分,需要尽可能增大摄入量或配方奶浓度以增加摄入热量。先心病患儿典型的表现是一时吃的很急,接着马上放弃进食,少量多餐是增加患儿营养摄入的最常见的护理措施[26]。经口喂养难以满足摄入足够量时,需要管道辅助喂养。胃管持续喂养、夜间喂养、微泵注入能减轻喂养压力,在短期能增加营养摄入,是改善营养状态安全有效的方法[52,53]。但是长期的鼻饲喂养存在并发症如鼻咽部的损伤、导管阻塞等。外科或经皮内镜下造口术(PEG)是安全的选择,能贯穿整个围手术期,提供持久的营养支持,临床患儿父母接受程度高[54],但容易发生口运动的延迟发展,胃食管反流增加,吞咽异常等并发症[55]。如果患儿摄入体积以达到或接近最大允许量也不能满足能量需求时,就有必要逐步增加喂养奶的能量浓度。能量的增加是慢慢进行的,根据患儿能量需求,增强至24cal/oz甚至30cal/oz,每次增加1~2kcal/oz婴儿能够耐受[12]。配方奶、母乳能量浓度的增加可以通过多种方法达到。母乳能量浓度的增强可以通过加入母乳强化剂或其他商业配方奶实现,也有学者建议弃用前端奶,采用能量密度更高的后端奶。配方奶加浓最简单的方法是加入更多的奶粉,但缺点是显著增加肾脏负担。此外,还可以选用葡萄糖聚合物、脂肪剂、蛋白质补充剂等强化配方奶或母乳浓度。国外能量补充剂的商业制品也已经发展成熟。葡萄糖聚合物,如polycose(液体2kcal/ml,粉剂23kcal/tbsp),中链脂肪酸如microlipid(4.5kcal/ml)、MCT油(7.7kcal/ml),蛋白质如Promod(3g/tbsp)。掺入脂肪剂能显著增加热量,但会延迟胃排空;长期掺入葡萄糖则需要提防蛋白质缺乏[21]。急性期,比如围手术期,患儿往往需要联合肠外营养。如果超过1周不能肠内营养,需要中心静脉插管进行全肠外营养,以保证足够的葡萄糖、蛋白质、脂肪乳的摄入。

  6 总结

  先心病患儿是营养不良的高发人群,不同时期营养问题有不同特点。临床营养干预必须贯穿于诊断、围手术期、术后康复期的整个过程中,依据营养不良的严重程度、相关因素而不断调整营养护理方案。术前营养状况十分重要,对术后远期的生长发育有重要影响。先心病患儿从确诊时就应该开始营养干预,通过对父母的宣教增加饮食摄入量、增强喂养奶液的浓度均是行之有效的方法,严重者可采用管道辅助喂养或PEG喂养。围手术期应肠内、外营养相结合,减少手术并发症。术后应随访患儿营养情况,及时给父母营养指导,以促进患儿术后恢复。发达国家早在20世纪60、70年代就开始先心病患儿术前营养干预、术后生长发育随访等研究。而发展中国家从20世纪90年代开始才开展术后营养随访。我国因客观因素的限制,术前营养干预目前开展的很少,建议医院应在首次确诊时就给予家长全面的营养指导,术后营养随访也应逐步建立。

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作者: 傅丽娟,余俊娟,张婷婷作者单位:200127 上海,上海 2013-2-27
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