京都大学 / 新制・論文博士 / 博士(医学) / 乙第13580号 / 論医博第2302号 / 新制||医||1069(附属図書館) / (主査)教授 平井 豊博, 教授 江木 盛時, 教授 齋藤 潤 / 学位規則第4条第2項該当 / Doctor of Medical Science / Kyoto University / DFAM

Background Modern neonatal care has improved the survival rate of extremely preterm infants. These infants are at high risk of malnutrition and growth failure during 3-4 months of hospital care. The objectives of this study was to investigate nutritional intakes during hospitalization and explore associations between nutritional intakes, postnatal growth and retinopathy of prematurity (ROP). Perioperative nutrition in infants undergoing surgery for patent ductus arteriosus (PDA) was also investigated. Methods This is a population-based study of Swedish extremely preterm infants (<27 weeks) born during 2004-2007 (n=602). Detailed data on nutritional supply and anthropometric measurements during hospitalization were retrospectively retrieved from hospital records. Comprehensive data on cohort characteristics, neonatal morbidity and infant mortality were obtained from the Extremely Preterm Infants in Sweden Study (EXPRESS). Results During the first 70 days of life, intakes of energy, protein and several micronutrients, with the exception of iron and some vitamins, were less than estimated requirements, and infants showed severe postnatal growth failure. Energy and protein intake predicted growth in all anthropometric outcomes even when adjusting for severity of illness, and fat intake was positively associated with head growth. Low folate intake was positively correlated with poor weight and length gain while high iron intake, mainly explained by blood transfusions, was negatively associated with poor length gain. Furthermore, a low energy intake was associated with severe ROP (stage 3-5). An increased energy intake of 10 kcal/kg/d was associated with 24% decrease in severe ROP (p=0.01). During the first month, 99% of the infants were exclusively fed human milk. Infants who underwent surgery for PDA (n=140) were malnourished, with energy and macronutrient intakes below minimum estimated requirements before, during and after surgery. Conclusions The severe postnatal growth failure observed in Swedish extremely preterm infants may be prevented by improved intakes of energy, protein, fat and folate and a reduction of the number of blood transfusions. Human milk is the main enteral food source and analyses of human milk macronutrient contents facilitates individualized fortification. Provision of adequate energy intakes during the first four weeks of life may be an effective way to reduce the risk of severe ROP. Perioperative nutrition in infants undergoing PDA surgery needs to be improved. The study results have important implications for nutritional regimens, postnatal growth and health outcome in this new generation of survivors.

Abstrakt Bakgrund: Sverige är idag världsledande gällande överlevnaden hos extremt underburna barn. Den högspecialiserade vården i Sverige är centraliserad till regionsjukhus vilket leder till att flertalet av dessa barn behöver transporteras från hemsjukhus till regionsjukhus för fortsatt vård. Motiv: Föräldrars känslor i samband med att deras barn behöver neonatal intensivvård är väl studerat i tidigare forskning både internationellt och nationellt. Då det finns begränsat med kunskap angående dessa föräldrars behov av stöd i samband med flytt av deras extremt underburna barn till annat sjukhus finns det möjligheter till förbättring inom området. Syfte: Syftet med studien var att belysa vilket stöd föräldrar till extremt underburna barn önskade när deras barn behövde flyttas till en annan neonatalavdelning på ett annat sjukhus.Metod: Studien genomfördes som en kvalitativ enkätstudie med öppna frågor med empirisk design. Enkäterna analyserades via en kvalitativ innehållsanalys med induktiv ansats av Elo & Kyngnäs. Föräldrarna (n=63) rekryterades via ett strategiskt urval från hela Sverige. Resultat: Resultatet delas in i två huvudkategorier; ”Föräldrars behov av förberedelser inför flytt till annat sjukhus” samt ”Föräldrars behov av emotionellt och personligt stöd”. Resultatet visar att det finns ett stort behov av stöd hos föräldrarna för att minimera de negativa upplevelser som kan uppstå då deras extremt underburna barn behöver flyttas till en annan neonatalavdelning. Föräldrarna beskriver att de önskar få information om avdelningen de flyttar till avseende rutiner och faciliteter samt när flytt förväntas ske och att denna information idag är bristfällig. Föräldrarna beskriver även att deras känslor och upplevelser behöver bli bekräftade av personalen och att behovet av en kontaktperson är stort. Konklusion: Resultatet belyser vilket stöd föräldrar efterfrågar i samband med flytt av sitt extremt underburna barn vilket skapar möjligheter för en framtida utveckling av neonatalvården. Implementering av stödjande vårdrutiner samt förbättrat samarbete mellan sjukhusen skulle öka möjligheterna för en förbättrad föräldraupplevelse och därmed minskad psykisk ohälsa. / AbstractBackground: Sweden is world-leading when it comes to survival rates among extremely preterm infants. Highly specialized care units are centralized to regional hospitals, resulting in that many extremely preterm infants need to be moved from their home hospital to a regional hospital for additional care. Motive: Parents' emotions when their extremely preterm infant requires neonatal intensive care is a well-studied area in both national and international studies. The authors therefore believe that there is a reason for further research regarding parents’ need for support in connection to the relocation of their extremely preterm infant to another hospital. Since there is limited research regarding the needs of these parents, there are opportunities for improvement in the area.Aim: The purpose of this study was to illustrate what support parents of extremely preterm infants need when their infant needs to be moved to another neonatal unit at another hospital. Methods: The study was conducted as a qualitative questionnaire study with open questions with empirical design. The questionnaires were analysed using a qualitative content analysis with an inductive approach by Elo & Kyngnäs. The parents (n=63) were recruited via a strategic selection from all over Sweden.Result: The result is divided into two main categories; “Parents’ need for preparation when moving to another hospital” and “Parents’ need for emotional and personal support”. The result shows that there is a great need for support among parents to minimize the negative experiences that can occur when their extremely preterm infant needs to be moved to another neonatal unit. The parents describe that they wish to receive more information about routines and facilities at the unit they are moving to, and then the move is expected to take place. The parents also describe that their feelings and experiences could be further confirmed by the staff and that they have a need for establishing a relation with a contact person. Conclusion: The result highlights what support parents request in relation to transportation of their extremely preterm infant, creating opportunities for further improvements in neonatal care. Implementation of supportive care routines and improved collaboration between hospitals could increase the opportunities for an improved parental experience and by that reduced mental illness.