Wilson-Costello D, Borawski E, Friedman H, Redline R, Fanaroff A A, Hack M
Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio, USA.
Pediatrics. 1998 Aug;102(2 Pt 1):315-22. doi: 10.1542/peds.102.2.315.
The etiology of neurologic impairments among very low birth weight (VLBW, <1.5 kg) children is poorly understood. We sought to investigate the perinatal predictors of major neurologic impairment, including cerebral palsy, among VLBW children.
Antenatal, intrapartum, and neonatal events and therapies were compared between 72 singleton inborn VLBW children born between 1983 to 1991 who had neurologic impairment at 20 months corrected age (including 50 with cerebral palsy and 22 with other neurologic impairments) and 72 neurologically normal VLBW children matched by birth weight, gestational age, race, and sex via a retrospective case-control method. Multiple logistic regression was conducted, entering only those variables found to be significant at the bivariate level.
There were no significant differences in the rates of pregnancy-induced hypertension, maternal tocolytic use including magnesium, or antenatal steroid therapy. Higher rates of clinical chorioamnionitis were found among the mothers of the neurologically impaired children as compared with controls (31% vs 11%), but not among the subgroup of mothers of children with cerebral palsy (22% vs 12%). Significant differences in neonatal factors among the total neurologically-impaired group (n = 72) versus controls included oxygen dependence at 36 weeks (31% vs 15%), septicemia (53% vs 31%), severe cranial ultrasound abnormality (50% vs 17%), and hypothyroxinemia (43% vs 25%). In the subgroup with cerebral palsy (n = 50), significant differences included days on the ventilator (23 vs 14 days), septicemia (54% vs 33%), and severe cranial ultrasound abnormality (52% vs 12%). Multivariate analysis controlling for birth weight, gestational age, race, sex, and the birth period (before 1990 versus 1990 and after) revealed direct and independent effects of clinical chorioamnionitis [odds ratio (OR), 3. 79; confidence interval (CI), 1.34-10.78], severe cranial ultrasound abnormality (OR, 9.97; CI, 3.84-25.87), and septicemia (OR, 2.46; CI, 1.10-5.52) on total neurologic impairment. Consideration of the 50 cases with cerebral palsy revealed direct and independent effects of severe cranial ultrasound abnormality only (OR, 15.01; CI, 4.34-51. 93).
Both antenatal and neonatal risk factors contribute to the development of severe neurologic impairment, including cerebral palsy among VLBW children. Because prevention of chorioamnionitis may not be feasible in the near future, attempts to decrease neonatal risk factors such as severe cranial ultrasound abnormalities and sepsis may be most feasible at this time.
极低出生体重（VLBW，<1.5 kg）儿童神经功能障碍的病因尚不清楚。我们试图研究极低出生体重儿童中主要神经功能障碍（包括脑瘫）的围产期预测因素。
采用回顾性病例对照研究方法，对1983年至1991年间出生的72例单胎极低出生体重儿进行比较，这些患儿在矫正年龄20个月时存在神经功能障碍（包括50例脑瘫患儿和22例其他神经功能障碍患儿），并与72例出生体重、胎龄、种族和性别相匹配的神经功能正常的极低出生体重儿进行比较。进行多因素logistic回归分析，仅纳入在双变量分析中具有显著性的变量。
妊娠高血压、包括镁剂在内的母体宫缩抑制剂使用情况或产前类固醇治疗的发生率无显著差异。与对照组相比，神经功能障碍患儿母亲的临床绒毛膜羊膜炎发生率更高（31%对11%），但脑瘫患儿母亲亚组中无此差异（22%对12%）。在总的神经功能障碍组（n = 72）与对照组之间，新生儿因素的显著差异包括36周时的氧依赖（31%对15%）、败血症（53%对31%）、严重颅脑超声异常（50%对17%）和低甲状腺素血症（43%对25%）。在脑瘫亚组（n = 50）中，显著差异包括机械通气天数（23天对14天）、败血症（54%对33%）和严重颅脑超声异常（52%对12%）。在控制出生体重、胎龄、种族、性别和出生时期（1990年之前与1990年及之后）后进行多因素分析，结果显示临床绒毛膜羊膜炎[比值比（OR），3.79；可信区间（CI），1.34 - 10.78]、严重颅脑超声异常（OR，9.97；CI，3.84 - 25.87）和败血症（OR，2.46；CI，1.10 - 5.52）对总的神经功能障碍有直接和独立的影响。对50例脑瘫病例的分析显示，仅严重颅脑超声异常有直接和独立的影响（OR，15.01；CI，4.34 - 51.93）。
产前和新生儿危险因素均会导致极低出生体重儿童发生严重神经功能障碍，包括脑瘫。由于在近期预防绒毛膜羊膜炎可能不可行，因此目前尝试降低新生儿危险因素，如严重颅脑超声异常和败血症，可能是最可行的。
