Department of Neonatology, Women and Children's Hospital, School of Medicine, Xiamen university, Xiamen, 361003, China.
Xiamen Key Laboratory of Perinatal-Neonatal Infection, Xiamen, China.
BMC Pediatr. 2023 May 20;23(1):250. doi: 10.1186/s12887-023-04068-0.
It is proposed that the development of parenteral nutrition-associated cholestasis (PNAC) was significantly associated with preterm birth, low birth weight, infection, etc.; however, the etiology and pathogenesis of PNAC are not fully understood. Most of the studies examining PNAC-associated risk factors were single-center studies with relatively small sample sizes.
To analyze the risk factors associated with PNAC in preterm infants in China.
This is a retrospective multicenter observational study. Clinical data on the effect of multiple oil-fat emulsions (soybean oil-medium chain triglycerides-olive oil-fish oil, SMOF) in preterm infants were collected from a prospective multicenter randomized controlled study. A secondary analysis was performed in which preterm infants were divided into the PNAC group and the non-PNAC group based on the PNAC status.
A total of 465 cases very preterm infants or very low birth weight infants were included in the study in which 81 cases were assigned to the PNAC group and 384 cases were assigned to the non-PNAC group. The PNAC group had a lower mean gestational age, lower mean birth weight, longer duration of invasive and non-invasive mechanical ventilation, a longer duration oxygen support, and longer hospital stay (P < 0.001 for all). The PNAC group had higher respiratory distress syndrome, hemodynamically significant patent ductus arteriosus, necrotizing enterocolitis (NEC) with stage II or higher, surgically treated NEC, late-onset sepsis, metabolic bone disease, and extrauterine growth retardation (EUGR) compared to the non-PNAC group (P < 0.05 for all). In contrast with the non-PNAC group, the PNAC group received a higher maximum dose of amino acids and fat emulsion, more medium/long-chain fatty emulsion, less SMOF, had a longer duration of parenteral nutrition, lower rates of breastfeeding, higher incidence of feeding intolerance (FI), more accumulated days to achieve total enteral nutrition, less accumulated days of total calories up to standard 110 kcal/kg/day and slower velocity of weight growth (P < 0.05 for all). Logistic regression analysis indicated that the maximum dose of amino acids (OR, 5.352; 95% CI, 2.355 to 12.161), EUGR (OR, 2.396; 95% CI, 1.255 to 4.572), FI (OR, 2.581; 95% CI, 1.395 to 4.775), surgically treated NEC (OR, 11.300; 95% CI, 2.127 ~ 60.035), and longer total hospital stay (OR, 1.030; 95% CI, 1.014 to 1.046) were independent risk factors for the development of PNAC. SMOF (OR, 0.358; 95% CI, 0.193 to 0.663) and breastfeeding (OR, 0.297; 95% CI, 0.157 to 0.559) were protective factors for PNAC.
PNAC can be reduced by optimizing the management of enteral and parenteral nutrition and reducing gastrointestinal comorbidities in preterm infants.
据提出，肠外营养相关性胆汁淤积症（PNAC）的发展与早产、低出生体重、感染等显著相关；然而，PNAC 的病因和发病机制尚未完全阐明。大多数研究检查与 PNAC 相关的风险因素的研究都是单中心研究，样本量相对较小。
分析中国早产儿 PNAC 的相关危险因素。
这是一项回顾性多中心观察性研究。从一项前瞻性多中心随机对照研究中收集了关于早产儿使用多种油脂肪乳剂（大豆油-中链甘油三酯-橄榄油-鱼油，SMOF）的临床效果数据。对早产儿根据 PNAC 状态分为 PNAC 组和非-PNAC 组进行二次分析。
共有 465 例极早产儿或极低出生体重儿纳入研究，其中 81 例被分配到 PNAC 组，384 例被分配到非-PNAC 组。PNAC 组的平均胎龄、出生体重均较低，有创和无创机械通气时间较长，氧支持时间较长，住院时间较长（均 P<0.001）。PNAC 组呼吸窘迫综合征、有临床意义的动脉导管未闭、坏死性小肠结肠炎（NEC）Ⅱ级或以上、需要手术治疗的 NEC、晚发性败血症、代谢性骨病和宫外生长迟缓（EUGR）的发生率均高于非-PNAC 组（均 P<0.05）。与非-PNAC 组相比，PNAC 组接受了更高的氨基酸和脂肪乳最大剂量，更多的中/长链脂肪乳，较少的 SMOF，肠外营养时间更长，母乳喂养率更低，喂养不耐受（FI）发生率更高，达到完全肠内营养的累积天数更多，达到标准 110kcal/kg/天的总热量累积天数更少，体重增长速度更慢（均 P<0.05）。Logistic 回归分析表明，氨基酸最大剂量（OR，5.352；95%CI，2.355 至 12.161）、EUGR（OR，2.396；95%CI，1.255 至 4.572）、FI（OR，2.581；95%CI，1.395 至 4.775）、需要手术治疗的 NEC（OR，11.300；95%CI，2.127 至 60.035）和更长的总住院时间（OR，1.030；95%CI，1.014 至 1.046）是 PNAC 发生的独立危险因素。SMOF（OR，0.358；95%CI，0.193 至 0.663）和母乳喂养（OR，0.297；95%CI，0.157 至 0.559）是 PNAC 的保护因素。
通过优化早产儿肠内和肠外营养管理，减少胃肠道合并症，可以减少 PNAC 的发生。
