早產(chǎn)兒臨床營養(yǎng)支持策略(最全版)

早產(chǎn)兒臨床營養(yǎng)支持策略（最全版）/r/n據(jù)世界衛(wèi)生組織/r/n(WHO)/r/n1/r/n200/r/n150/r/nNICU/r/n和區(qū)域性轉(zhuǎn)運(yùn)/r/n系統(tǒng)的相繼建立、全國性窒息復(fù)蘇項(xiàng)目的培訓(xùn)、機(jī)械通氣與持續(xù)呼吸道正壓通氣以及肺表面活性物質(zhì)治療的普及和各種新技術(shù)的開展，新生兒特別/r/n1宮外生長發(fā)育遲緩(EUGR)與積極的營養(yǎng)支持策略/r/nBarker/r/nEUGR，即早產(chǎn)兒出生后的生長速度次于宮內(nèi)/r/n124/r/nNICU/r/n的/r/n24/r/n000/r/n兒進(jìn)行/r/nEUGR/r/nEUGR/r/n定義為出院時(shí)生長指標(biāo)≤第/r/n10/r/n10/r/n的發(fā)生率以體質(zhì)量、身長、頭圍為指標(biāo)分別為/r/n28%/r/n、/r/n34%/r/n、/r/n16%；無論哪個(gè)指標(biāo)，胎齡和出生體質(zhì)量越小，EUGR/r/n的發(fā)生率越高[/r/n600g/r/n2/r/n10/r/n80%/r/n加強(qiáng)早產(chǎn)兒的早期營養(yǎng)支持可以減少/r/nEUGR/r/n，加快體格生長，促進(jìn)智/r/n1000/r/n/r/ng/r/n(ELBW)/r/n1/r/n89%/r/n10%，恢復(fù)出生體質(zhì)量所需的天數(shù)預(yù)/r/n示了其出生后生長發(fā)育遲緩的嚴(yán)重程度。/r/nStephens/r/n等[/r/n124/r/n例/r/nELBW的早期營養(yǎng)攝入對體格生長與神經(jīng)運(yùn)動(dòng)發(fā)育的影響，能量攝入由第/r/n1/r/n周的/r/n60/r/nkcal/(k/r/nd/r/n4/r/n周的/r/n105/r/nkcal/(k/r/nd)(1/r/nkca/r/n＝4.184/r/nkJ/r/n1.8/r/ng/(k/r/nd/r/n4/r/n周的/r/n3.5/r/ng/(k/r/nd/r/n18/r/n1/3/r/n10/r/n的早產(chǎn)/r/n70/r/nLogistic/r/n1/r/n18/r/n1/r/n提高能量攝入/r/n10/r/n/r/nkcal/(k/r/nd/r/n4.6/r/n分，每增加蛋白質(zhì)/r/n攝入/r/n1/r/n/r/ng/(k/r/ng/r/nd/r/n8.2/r/n少生長落后的發(fā)生。/r/n為了使早產(chǎn)兒出生后達(dá)到理想的體格生長與智能發(fā)育水平，近年來主/r/n100/r/nkcal/(k/r/nd/r/n能量比適/r/n(>3./r/n～/r/n3.6/r/ng/100/r/nkca/r/n且攝入能量/r/n>100/r/nkcal/(k/r/ng/r/nd/r/n2010/r/n110/r/n～/r/n135/r/nkcal/(k/r/nd/r/n<1000/r/ng/r/n/r/n的早產(chǎn)兒，蛋白質(zhì)推薦量為/r/n4./r/n～4.5/r/ng/(kg/r/nd/r/n1/r/n000/r/n～1/r/n800/r/ng/r/n的早產(chǎn)兒，蛋白質(zhì)推薦量為/r/n3./r/n～4.0/r/ng/(k/r/nd/r/n"營養(yǎng)程序化"理論與適度的營養(yǎng)支持策略/r/nLucas[/r/n10/r/n新生兒出生體質(zhì)量與遠(yuǎn)期智能發(fā)育的關(guān)系，顯示出生體質(zhì)量較輕的新生兒遠(yuǎn)期智能發(fā)育水平低下，同卵雙胎的新生兒出生體質(zhì)量差距與遠(yuǎn)期智能發(fā)/r/nELBW/r/n的研究[/r/n12/r/n～/r/n21/r/n/r/ng/(kg/r/nd/r/n4/r/n組，隨訪至校正月齡/r/n18/r/n～/r/n22/r/n/r/n個(gè)月，并/r/n對其體格生長指標(biāo)、神經(jīng)運(yùn)動(dòng)發(fā)育、心理智力水平等進(jìn)行測試和評(píng)價(jià)。發(fā)/r/n<70/r/n分、神/r/n經(jīng)系統(tǒng)檢查異常的發(fā)生率顯著降低；在新生兒期平均體質(zhì)量增長速度/r/n21/r/ng/(k/r/ng/r/nd/r/n29%/r/n/r/n，而在新生兒期平均體/r/n質(zhì)量增長速度為/r/n12/r/n/r/ng/(kg/r/nd/r/n55%/r/n/r/n然而，"積極的"營養(yǎng)支持策略導(dǎo)致的體質(zhì)量過度增長，可能會(huì)付出遠(yuǎn)/r/n期健康的代價(jià)，如肥胖、高血壓、動(dòng)脈粥樣硬化、冠狀動(dòng)脈粥樣硬化性心/r/n樣兒的研究，分析了出生后體質(zhì)量追趕生長速度與青春期智能發(fā)育水平、/r/n小樣兒出生后體質(zhì)量追趕生長速度與遠(yuǎn)期智能發(fā)育水平的關(guān)系，但發(fā)現(xiàn)足/r/n月小樣兒出生后體質(zhì)量追趕生長速度與青春期體質(zhì)量、血膽固醇水平、頸/r/n50/r/n足月兒出生后"追趕生長是兒童及成年人肥胖與心血管疾病的發(fā)育起源因/r/n由于新生兒追趕生長有利于遠(yuǎn)期智能發(fā)育水平，同時(shí)新生兒追趕生長/r/n23/r/n～27/r/n周的/r/n21/r/ng/(k/r/ng/r/nd/r/n35/r/n～/r/n37/r/n周的/r/n12/r/n/r/ng/(k/r/ng/r/nd/r/n16/r/n/r/ng/(kg/r/nd/r/n3/r/n養(yǎng)支持策略，目標(biāo)體質(zhì)量增長追趕宮內(nèi)生長速度；足月兒出生后，宜采取/r/n循證醫(yī)學(xué)推薦的早產(chǎn)兒營養(yǎng)攝入指南/r/n早產(chǎn)兒營養(yǎng)的主要目標(biāo)是使其宮外生長速度與相應(yīng)胎齡的胎兒宮內(nèi)生/r/n1987/r/n年/r/n歐洲兒科胃腸病學(xué)與營養(yǎng)學(xué)會(huì)/r/n(ESPGAN)/r/n1/r/n(ASNS)/r/n(LSRO)/r/n2002/r/n年發(fā)/r/n布，并于/r/n2005/r/n2009/r/n年[/r/n于/r/n2010/r/n"2010/r/n/r/nESPGHAN/r/n1/r/n800/r/ng/r/n指南。這些建議均是基于可靠的科學(xué)研究得出的，對于存在的爭議均經(jīng)過/r/n專家們的討論并達(dá)成一致。/r/n液體/r/n早產(chǎn)兒的皮膚發(fā)育不成熟，出生后的最初幾天液體經(jīng)皮膚和呼吸道大/r/n(insensible/r/n/r/nwater/r/n/r/nlo/r/ns/r/nIWL)]，是導(dǎo)致早產(chǎn)兒脫水和/r/n2～3/r/nd/r/n性利尿與尿鈉排泄增加，是導(dǎo)致早產(chǎn)兒體質(zhì)量下降與電解質(zhì)紊亂的重要原/r/n美國兒科學(xué)會(huì)/r/n(AAP)/r/nELBW/r/n早產(chǎn)兒出生/r/n1/r/n周內(nèi)維持環(huán)境濕度/r/n80%/r/n以上，第/r/n1/r/n/r/n天液體/r/n/r/n100/r/n～/r/n120/r/nmL/(kg/r/nd/r/n)，第/r/n/r/n2/r/n/r/n天液體/r/n/r/n120/r/n～/r/n140mL/(kg/r/nd/r/n3/r/n天液體/r/n140/r/n～180/r/nmL/(kg/r/nd/r/nESPGHAN/r/n/r/n18/r/n135/r/nmL/(kg/r/nd/r/n200/r/nmL/(kg/r/nd/r/n150/r/n～/r/n180/r/nmL/(kg/r/n/r/nd/r/n素的需求。/r/n熱卡/r/n新生兒維持基礎(chǔ)代謝所需熱卡約為/r/n40/r/n/r/nkcal/(k/r/nd/r/n量每增長/r/n1/r/ng/r/n5/r/nkcal//r/n；按宮內(nèi)平均生長速度/r/n16/r/ng/(kg/r/nd)/r/n120/r/nkcal/(k/r/nd/r/n1/r/n1/r/n目標(biāo)是維持早產(chǎn)兒生命體征的穩(wěn)定及營養(yǎng)和代謝的平衡，宜采取"基礎(chǔ)的"/r/n3～4/r/nd/r/n1/r/n天早產(chǎn)兒宜給予/r/n50/r/n～/r/n100/r/ng/L/r/n4/r/n～/r/n8/r/nmg/(kg/r/nmin)/r/n，每天增加/r/n1/r/n～/r/n2/r/nmg/(kg/r/nmin)/r/n，最大速度/r/n12/r/nmg/(kg/r/nmin)/r/n，目標(biāo)是維持血/r/n糖水平/r/n>450/r/n/r/n～500/r/n/r/nmg/L/r/n；出生第/r/n1/r/n天早產(chǎn)兒可給予小兒氨基酸/r/n1/r/n～2/r/ng/(k/r/ng/r/nd/r/n3./r/n～3.5/r/ng/(k/r/nd/r/n24/r/n～/r/n48/r/nh/r/n開始給予/r/n20%中長鏈脂肪乳劑/r/n0./r/n～1.0/r/ng/(k/r/nd/r/n0./r/n～/r/n1.0/r/ng/(k/r/nd/r/n1/r/n周內(nèi)逐步增加至/r/n3.0/r/ng/(kg/r/nd/r/n2/r/n2/r/n周臨床/r/n狀況穩(wěn)定至出院，目標(biāo)是追趕胎兒宮內(nèi)的生長速率，目標(biāo)體質(zhì)量增長速度/r/n18/r/n/r/ng/(kg/r/nd/r/n110/r/n～135/r/n/r/nkcal/(k/r/nd/r/n3/r/nl/r/n3.3蛋白質(zhì)/r/n3.3蛋白質(zhì)/r/n早產(chǎn)兒的蛋白質(zhì)供應(yīng)量需補(bǔ)償其出生后數(shù)周內(nèi)的蛋白質(zhì)累積不足，蛋/r/n白質(zhì)供應(yīng)上限可達(dá)/r/n4.5/r/ng/(kg/r/nd/r/n。根據(jù)蛋白質(zhì)的需要量和氮利用率，蛋白質(zhì)的最低攝入量為/r/n3.0/r/ng/(k/r/nd/r/n當(dāng)?shù)鞍踪|(zhì)攝入量為/r/n3./r/n～4.5/r/ng/(k/r/nd/r/n時(shí)/r/n體質(zhì)量增長速度與蛋白質(zhì)攝入量呈線性增長關(guān)/r/n系/r/n。體質(zhì)/r/n量/r/n</r/n/r/n1/r/n/r/n000/r/n/r/ng/r/n的早產(chǎn)兒/r/nESPGHAN/r/n /r/n推薦蛋白質(zhì)攝入量為/r/n4./r/n4.5/r/ng/(k/r/nd/r/n；體質(zhì)量/r/n1/r/n000/r/n～1/r/n/r/n800/r/n/r/ng/r/n/r/n的早產(chǎn)兒，ESPGHAN 推薦的蛋白質(zhì)攝入量為/r/n/r/ng/(k/r/ng/r/nd/r/n。因此，早產(chǎn)兒的蛋白質(zhì)推薦攝入量/r/n3./r/n～/r/n4.5/r/ng/(kg/r/nd/r/n或/r/n3./r/n～/r/n4.1g/100kcal。/r/n3.4脂肪/r/n膳食脂肪為早產(chǎn)兒提供大量的能量以及長鏈多不飽和脂肪酸/r/n(LCPUFA)/r/n3.0/r/ng/(k/r/nd/r/n4.8/r/ng/(k/r/ng/r/nd/r/n才能滿足上述需要/r/n。/r/nESPGHAN/r/n /r/n專家建議：脂肪的最低攝入量為/r/n4.8/r/ng/(k/r/nd/r/nESPGHAN/r/n /r/n和/r/nLSRO/r/n/r/n推薦的脂肪攝入量上限分別為/r/n6.0g/100/r/nkcal/r/n占能量的/r/n54%)/r/n和/r/n5.7/r/ng/100/r/nkcal/r/n占能量的/r/n51%)/r/n，這個(gè)值與/r/n母乳中所檢測到的脂肪含量接近。由于部分早產(chǎn)兒需嚴(yán)格控制液體量，必須攝入高脂肪以滿足能量需求，因此，對絕大部分早產(chǎn)兒來說，推薦的膳/r/n食脂肪攝入量為/r/n/r/n4./r/n～/r/n6.6/r/ng/(kg/r/nd/r/n)/r/n或/r/n/r/n4./r/n～/r/n6.0/r/ng/100/r/n/r/nkcal/r/n占能量的/r/n40%/r/n/r/n～55%)/r/n；如果在早產(chǎn)兒配方奶中添加中鏈脂肪酸，起始量應(yīng)為總脂/r/n肪含量的/r/n40%/r/n/r/n目前已知的必需脂肪酸包括?油/r/n酸/r/n(LA/r/n和/r/n?麻/r/n酸/r/n(ALA)/r/n/r/nLA/r/n是合成二十碳四烯/r/n酸/r/n花生四烯酸/r/n的前體/r/n通常/r/nLA/r/n的攝入水平為/r/n385/r/n～1/r/n/r/n540/r/n/r/nmg/(kg/r/n/r/nd/r/n或/r/n350/r/n～/r/n1/r/n/r/n400/r/n/r/nmg/100/r/n/r/n/r/nkcal(3.2/r/n%/r/n～12.6%)/r/n。/r/nALA/r/n/r/n是合成二十碳五烯/r/n酸/r/n(EPA)/r/n和二十二碳六烯/r/n酸/r/n(DHA)/r/n的前體；早產(chǎn)兒/r/nALA/r/n/r/n的最低攝入量為/r/n55/r/nmg/(kg/r/n/r/nd/r/n或/r/n50/r/nmg/100/r/nkcal(0.45%)/r/n/r/n。臨床試/r/n驗(yàn)顯示/r/n喂養(yǎng)含有/r/nAA/r/n/r/n和/r/nDHA/r/n/r/n的早產(chǎn)兒配方奶的早產(chǎn)兒，在出生后第/r/n1/r/n年的視覺和認(rèn)知發(fā)育較好，免疫表型較好/r/n建議在早產(chǎn)兒/r/n配方奶中添加/r/nAA/r/n/r/n和/r/nDHA/r/n/r/nESPGHAN/r/n /r/n推薦/r/nAA(20/r/n4/r/nn-6/r/n攝入量為/r/n18/r/n～/r/n42/r/nmg/(kg/r/nd/r/n16/r/n～39/r/nmg/100kcal/r/n，DHA(22/r/n：6/r/n12/r/n～/r/n30/r/nmg/(kg/r/nd/r/n11/r/n～27/r/nmg/100/r/nkcal/r/nAA/r/n/r/n和/r/n1。/r/n3.5碳水化合物/r/n碳水化合物是能量的主要來源。葡萄糖是主要的循環(huán)碳水化合物，是/r/n為/r/n13.2/r/ng/(k/r/nd)/r/n(12.0/r/ng/100/r/nkcal/r/n需/r/n11.6/r/ng/(k/r/nd)(10.5/r/ng/100/r/nkca/r/n益生元/r/n(Probiotics)/r/n母乳中含有/r/n130/r/n/r/n多種能在嬰兒腸道中被部分發(fā)酵的低聚糖，稱為益生元。初乳中低聚糖的含量最高，/r/n為/r/n20/r/n～23/r/ng/L，哺乳/r/n第/r/n4/r/n天約為/r/n20/r/n哺乳/r/n4/r/n個(gè)月后約為/r/n9/r/n/r/ng/L/r/n。早產(chǎn)兒可以吸收一些母乳中完整的低聚糖，大部分低聚糖都不能在小腸內(nèi)被消化，只能在結(jié)腸中被酵解。在嬰兒配方奶中添加低聚糖混合物/r/n[90%/r/n的短鏈低聚半乳/r/n糖/r/n(GOS)/r/n＋10%/r/n/r/n的長鏈低聚果糖/r/n已在足月兒和早產(chǎn)兒中進(jìn)行了系統(tǒng)的研究。研究顯示/r/n/r/n＋FOS/r/n/r/n可以增加糞便中雙歧桿菌的數(shù)量，降低大/r/n便/r/npH/r/n/r/n值，降低大便硬度與黏度/r/n加速胃腸道運(yùn)/r/n輸/r/n目前認(rèn)為/r/nGOS/r/n/r/n＋FOS/r/n/r/n能夠加速食物在胃腸道/r/n中的前進(jìn)速度/r/n減少胃腸道并發(fā)癥的發(fā)生/r/n增強(qiáng)免疫功能/r/n減少院內(nèi)感染，/r/n改善遠(yuǎn)期預(yù)后。研究顯示：早產(chǎn)兒使用益生菌能顯著降低壞死性小腸結(jié)腸炎的發(fā)生率，并且能顯著縮短實(shí)現(xiàn)全腸內(nèi)營養(yǎng)所需的時(shí)/r/n間/r/n。盡管現(xiàn)有的研究顯示益生元和益生菌對早產(chǎn)兒腸道有健康的積極作用，但仍無足夠的證據(jù)推薦早產(chǎn)兒常規(guī)使用益生元和益生菌。因此，ESPGHAN 不推薦益生元和益生菌作為早產(chǎn)兒配方乳或母乳強(qiáng)化劑的常規(guī)添加物。/r/nD/r/n鈣在組織的水平達(dá)/r/n60/r/n～90/r/nmg/(kg/r/nd/r/n時(shí)/r/n能減少骨折的發(fā)生/r/n減輕骨/r/n質(zhì)疏松的臨床癥狀，保證極低出生體質(zhì)量/r/n兒/r/n(VLBW)/r/n的骨骼礦物質(zhì)/r/n化/r/n。/r/nESPGHAN/r/n /r/n推薦鈣的攝入量為/r/n120/r/n～/r/n140/r/nmg/(kg/r/n/r/nd/r/n鈣吸收率為/r/n50%/r/n/r/n～60%/r/n/r/n，可以保證鈣的存儲(chǔ)達(dá)/r/n60/r/n～/r/n90/r/n/r/nmg/(kg/r/n/r/nd/r/n。鈣磷攝入比例是決定鈣/r/n的吸收和存儲(chǔ)的重要因/r/n素/r/n。母乳中鈣磷的質(zhì)量比例約為/r/n2/r/n分子比/r/n例為/r/n1./r/n1./r/nESPGHAN/r/n /r/n推薦鈣的攝入量為/r/n120/r/n～/r/n140/r/nmg/(kg/r/n/r/nd)(11/r/n0/r/n～130/r/nmg/100/r/nkcal)/r/n；磷的攝入量為/r/n60/r/n～90/r/nmg/(kg/r/n/r/nd)(5/r/n～80/r/nmg/100/r/n。維生素/r/