京都大学 / 新制・課程博士 / 博士(医学) / 甲第23078号 / 医博第4705号 / 新制||医||1049(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 稲垣 暢也, 教授 万代 昌紀, 教授 小杉 眞司 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Die doel van hierdie studie is die ontwikkeling van 'n ouerleidingsprogram vir moeders wat hul premature babas in 'n kangaroemoedersorgprogram versorg. Die program het ten doel om die moeders in die onmiddelikke versorging, sowel as die toekomstige begeleiding van hut kinders, toe te rus. 'n Literatuuroorsig word gegee van prematuriteit as fenomeen en van kangaroemoedersorg (KMS) as versorgingswyse, met spesifieke verwysing na die toepassing daarvan in Kalafonghospitaal. Die grondslae van ouerteiding word uit die literatuur opgesom en riglyne word ook gestef vir die samestelling van 'n ouerfeidingprogram. Die kwalitatiewe navorsingsmetode word gebruik om die inhoud van die ouerfeidingsprogram te bepaal en om ondersoek in te stel na die mees geskikte aanbiedingswyses. Die verslag word afgesluit met riglyne vir die samestelling van 'n prakties-toepasbare ouerleidingsprogram waarin inhoudsmoontlikhede, idees vir aanbieding en wyses vir die bepaling van gestelde uitkomste uiteengesit word. / The aim of this study is the development of parental guidance for mothers who take care of their premature babies in a programme of Kangaroo Mother Care. The programme aims to equip mothers for immediate and future care of their children. A literature review of prematurity as phenomenon and of kangaroo mother care as care method is presented with specifK: reference to the way it is applied in Kalafong-hospital. The basics of parental care are summated from literature and guidelines are set to design a parental guidance programme. The qualitative research method is put into operation to determine the content of the parental guidance programme and to investigate the most appropriate method of presentation. The report is concluded with guidelines for setting up a practical and applicable parental guidance programme in which subject possibilities, ideas for presentation and means for determining set outcomes are explained. / Educational Studies / M.Ed.(Spesialisering in voorligting)

Os recém-nascidos de muito baixo peso ao nascer alcançam taxas de sobrevivência cada vez maiores. No entanto, eles ainda apresentam problemas como déficit de crescimento, atrasos do desenvolvimento, baixa prevalência de aleitamento materno exclusivo e dificuldades de vinculação afetiva com a família. Essa problemática resulta da condição de nascimento dessas crianças, das conseqüências do tratamento intensivo necessário à sua sobrevivência, e das peculiaridades da assistência neonatal tradicional cujos procedimentos impõem a separação entre a mãe e o bebê. A observação de aspectos relativos aos problemas citados sinaliza que algumas dessas dificuldades poderiam ser atenuadas, quando não resolvidas, por um modelo de assistência neonatal que privilegiasse a interação entre a mãe e o bebê. Visando a elucidar tal questão, compararam-se os resultados obtidos com setenta bebês, divididos em dois grupos, um assistido pelo método Mãe-canguru e outro pelo método Tradicional de assistência neonatal. Foi realizado um estudo de coorte prospectivo que contemplou duas abordagens: uma análise epidemiológica dos dados objetivos referentes às características comparáveis entre os dois grupos, ou seja, atributos maternos, dados sobre a gestação, o parto e o nascimento, eventos da evolução clínica, parâmetros do crescimento e do desenvolvimento e marcos do processo de aleitamento materno; além da outra abordagem que se constituiu como uma análise compreensiva dos dados subjetivos através do método fenomenológico. Constatou-se que o crescimento das crianças estudadas manteve-se aquém da referência ideal preconizada, a saber, o crescimento intra-uterino, sendo que as medidas antropométricas mostraram-se menores entre as crianças do método Canguru. As diferenças encontradas entre os dois métodos quanto ao desenvolvimento neurossocial não foram estatisticamente significativas. O método Canguru favoreceu a prática de aleitamento materno exclusivo, mesmo após a alta hospitalar. A compreensão e a interpretação dos depoimentos das mães, através do método fenomenológico, permitiram que se vislumbrassem as repercussões dessa situação sobre a função materna, e as suas conseqüências sobre o desenvolvimento e a prevalência do aleitamento materno. Deslindou-se, assim, a influência direta da qualidade da interação entre a mãe e o bebê sobre a experiência de se tornar mãe nessas circunstâncias. Nessa perspectiva, concluiu-se que o cuidado dispensado a recém-nascidos de muito baixo peso ao nascer exige, além do emprego da alta tecnologia, a priorização da permanência da mãe junto ao filho e a aptidão da equipe de assistência neonatal para abordar o bebê e a mãe em conjunto, como componentes de um sistema que se distinguem entre si, mas não se separam. / Very low birthweight infants have achieved increasing survival rates over time. However, they still suffer from problems such as growth deficit, developmental delays, low exclusive breastfeeding prevalence and difficulties with the bond formation process. These problems result from birth circumstances, consequences of survival-necessary intensive care and peculiarities of traditional neonatal care, whose procedures impose a prolonged separation between mother and baby. Observation of aspects relative to these problems indicates that some of those difficulties might be lessened, if not altogether solved, by a neonatal care model that favors the mother-child interaction. Aiming to clarify this matter, a comparison of results obtained for seventy babies was carried out. Infants were divided in two groups, one treated by means of the Kangaroo Mother Method and the other by means of the Traditional Neonatal Care Method. A prospective cohort study was carried out which included two approaches. The first approach was an epidemiological analysis of objective data concerning comparable characteristics of the two groups, such as maternal characteristics, data about pregnancy, labor and birth, clinical evolution events, developmental and growth parameters and landmarks of the breastfeeding process. The second approach was a comprehensive study of subjective data by means of the Phenomenological Method. It was found that growth of studied children was consistently below intrauterine growth, the established ideal. Antropometrical measures were smaller for children in the Kangaroo Mother Method group than for those treated by means of the Traditional Method. No statistically meaningful differences were found concerning neurosocial development. The Kangaroo Mother Method was found to favor the practice of exclusive breastfeeding even after child discharge. Phenomenological comprehension and interpretation of oral accounts given by the mothers of studied infants about their experiences with their preterm children revealed the repercussions of this situation on maternal function and the resulting consequences to development and breastfeeding prevalence. The direct influence that the quality of interaction between mother and baby has on the experience of becoming a mother under such circumstances was thereby unveiled. Under this perspective, it was concluded that care given to very low birthweight infants requires, in addition to the employment of high technology, that the staying of mothers beside their infants be prioritized and that the neonatal care team be made able to handle mother and infant as a compound unit, as two components of a system that are distinct, yet not separate.

Os recém-nascidos de muito baixo peso ao nascer alcançam taxas de sobrevivência cada vez maiores. No entanto, eles ainda apresentam problemas como déficit de crescimento, atrasos do desenvolvimento, baixa prevalência de aleitamento materno exclusivo e dificuldades de vinculação afetiva com a família. Essa problemática resulta da condição de nascimento dessas crianças, das conseqüências do tratamento intensivo necessário à sua sobrevivência, e das peculiaridades da assistência neonatal tradicional cujos procedimentos impõem a separação entre a mãe e o bebê. A observação de aspectos relativos aos problemas citados sinaliza que algumas dessas dificuldades poderiam ser atenuadas, quando não resolvidas, por um modelo de assistência neonatal que privilegiasse a interação entre a mãe e o bebê. Visando a elucidar tal questão, compararam-se os resultados obtidos com setenta bebês, divididos em dois grupos, um assistido pelo método Mãe-canguru e outro pelo método Tradicional de assistência neonatal. Foi realizado um estudo de coorte prospectivo que contemplou duas abordagens: uma análise epidemiológica dos dados objetivos referentes às características comparáveis entre os dois grupos, ou seja, atributos maternos, dados sobre a gestação, o parto e o nascimento, eventos da evolução clínica, parâmetros do crescimento e do desenvolvimento e marcos do processo de aleitamento materno; além da outra abordagem que se constituiu como uma análise compreensiva dos dados subjetivos através do método fenomenológico. Constatou-se que o crescimento das crianças estudadas manteve-se aquém da referência ideal preconizada, a saber, o crescimento intra-uterino, sendo que as medidas antropométricas mostraram-se menores entre as crianças do método Canguru. As diferenças encontradas entre os dois métodos quanto ao desenvolvimento neurossocial não foram estatisticamente significativas. O método Canguru favoreceu a prática de aleitamento materno exclusivo, mesmo após a alta hospitalar. A compreensão e a interpretação dos depoimentos das mães, através do método fenomenológico, permitiram que se vislumbrassem as repercussões dessa situação sobre a função materna, e as suas conseqüências sobre o desenvolvimento e a prevalência do aleitamento materno. Deslindou-se, assim, a influência direta da qualidade da interação entre a mãe e o bebê sobre a experiência de se tornar mãe nessas circunstâncias. Nessa perspectiva, concluiu-se que o cuidado dispensado a recém-nascidos de muito baixo peso ao nascer exige, além do emprego da alta tecnologia, a priorização da permanência da mãe junto ao filho e a aptidão da equipe de assistência neonatal para abordar o bebê e a mãe em conjunto, como componentes de um sistema que se distinguem entre si, mas não se separam. / Very low birthweight infants have achieved increasing survival rates over time. However, they still suffer from problems such as growth deficit, developmental delays, low exclusive breastfeeding prevalence and difficulties with the bond formation process. These problems result from birth circumstances, consequences of survival-necessary intensive care and peculiarities of traditional neonatal care, whose procedures impose a prolonged separation between mother and baby. Observation of aspects relative to these problems indicates that some of those difficulties might be lessened, if not altogether solved, by a neonatal care model that favors the mother-child interaction. Aiming to clarify this matter, a comparison of results obtained for seventy babies was carried out. Infants were divided in two groups, one treated by means of the Kangaroo Mother Method and the other by means of the Traditional Neonatal Care Method. A prospective cohort study was carried out which included two approaches. The first approach was an epidemiological analysis of objective data concerning comparable characteristics of the two groups, such as maternal characteristics, data about pregnancy, labor and birth, clinical evolution events, developmental and growth parameters and landmarks of the breastfeeding process. The second approach was a comprehensive study of subjective data by means of the Phenomenological Method. It was found that growth of studied children was consistently below intrauterine growth, the established ideal. Antropometrical measures were smaller for children in the Kangaroo Mother Method group than for those treated by means of the Traditional Method. No statistically meaningful differences were found concerning neurosocial development. The Kangaroo Mother Method was found to favor the practice of exclusive breastfeeding even after child discharge. Phenomenological comprehension and interpretation of oral accounts given by the mothers of studied infants about their experiences with their preterm children revealed the repercussions of this situation on maternal function and the resulting consequences to development and breastfeeding prevalence. The direct influence that the quality of interaction between mother and baby has on the experience of becoming a mother under such circumstances was thereby unveiled. Under this perspective, it was concluded that care given to very low birthweight infants requires, in addition to the employment of high technology, that the staying of mothers beside their infants be prioritized and that the neonatal care team be made able to handle mother and infant as a compound unit, as two components of a system that are distinct, yet not separate.

Die doel van hierdie studie is die ontwikkeling van 'n ouerleidingsprogram vir moeders wat hul premature babas in 'n kangaroemoedersorgprogram versorg. Die program het ten doel om die moeders in die onmiddelikke versorging, sowel as die toekomstige begeleiding van hut kinders, toe te rus. 'n Literatuuroorsig word gegee van prematuriteit as fenomeen en van kangaroemoedersorg (KMS) as versorgingswyse, met spesifieke verwysing na die toepassing daarvan in Kalafonghospitaal. Die grondslae van ouerteiding word uit die literatuur opgesom en riglyne word ook gestef vir die samestelling van 'n ouerfeidingprogram. Die kwalitatiewe navorsingsmetode word gebruik om die inhoud van die ouerfeidingsprogram te bepaal en om ondersoek in te stel na die mees geskikte aanbiedingswyses. Die verslag word afgesluit met riglyne vir die samestelling van 'n prakties-toepasbare ouerleidingsprogram waarin inhoudsmoontlikhede, idees vir aanbieding en wyses vir die bepaling van gestelde uitkomste uiteengesit word. / The aim of this study is the development of parental guidance for mothers who take care of their premature babies in a programme of Kangaroo Mother Care. The programme aims to equip mothers for immediate and future care of their children. A literature review of prematurity as phenomenon and of kangaroo mother care as care method is presented with specifK: reference to the way it is applied in Kalafong-hospital. The basics of parental care are summated from literature and guidelines are set to design a parental guidance programme. The qualitative research method is put into operation to determine the content of the parental guidance programme and to investigate the most appropriate method of presentation. The report is concluded with guidelines for setting up a practical and applicable parental guidance programme in which subject possibilities, ideas for presentation and means for determining set outcomes are explained. / Educational Studies / M.Ed.(Spesialisering in voorligting)

A sobrevivência de recém-nascidos pré-termo de muito baixo peso (RNPT MBP) aumentou marcadamente nas últimas décadas, mas não acompanhada por redução das taxas de morbidade relacionadas à prematuridade. O parto prematuro é apontado como um importante fator de desajuste no equilíbrio emocional materno e nas suas relações familiares e sociais. O prejuízo emocional materno representa potencial risco ao desenvolvimento neuropsicológico da criança. Mães de RNPT MBP apresentam maior incidência de sintomas de ansiedade e depressão, bem como pior percepção de bem-estar, do que mães de recém-nascidos a termo (RNT). No entanto, ainda é pouco conhecida a associação entre as comorbidades relacionadas à prematuridade (displasia broncopulmonar, retinopatia e hemorragia peri-intraventricular) e a intensidade de sintomas depressivos maternos. O objetivo do presente estudo foi verificar a intensidade de sintomas depressivos em mães de RNPT MBP durante 36 meses após o parto e sua possível associação com características sociodemográficas, clínicas e qualidade de vida das mães e com características clínicas dos RNPT MBP. Setenta e cinco mães de RNPT (≤ 34 semanas de idade gestacional) MBP (peso ao nascer ≤ 1.500g) internados numa unidade de terapia intensiva neonatal (UTIN) participaram de um estudo longitudinal e responderam ao Inventário de Depressão de Beck (IDB) e ao WHOQOL-abreviado, em seis momentos ao longo de 36 meses após o parto. A análise fatorial foi utilizada para identificar possíveis clusters do IDB e a regressão linear múltipla para avaliar a contribuição de cada variável independente na variação do escore global do IDB. A análise fatorial do IDB identificou a presença de dois fatores: baixa autoestima / insatisfação e sintomas somáticos. As medianas dos escores do IDB foram maiores (p = 0,03) no momento da alta materna (9,0; 0-56) em comparação com os obtidos 6 meses pós-parto (6,0; 0-27), mantendo-se estáveis com doze (5,0; 0-36), dezoito (7,0; 0-33), 24 (7,0; 0-33) e 36 (6,5; 0-34) meses. As medianas dos escores do cluster sintomas somáticos foram maiores (p = 0,00) no momento da alta materna (6,0; 0-23) e aos seis meses (5,0; 0-17) do que doze (4,0; 0-11), dezoito (3,0; 0-13), 24 (3,5; 0-16) e 36 (3,0; 0-15) meses após o parto. Os modelos da regressão explicaram grande parte da variação dos escores do IDB em todos os períodos do estudo (0,19 ≤ R2 ajustado ≤ 0,64; p < 0,01). Os domínios do WHOQOL-abreviado (físico, psicológico, social e meio ambiente) foram as variáveis que explicaram as variações do escore global do IDB (-0,34 ≤β≤-0,12; p < 0,01). Mães de RNPT MBP apresentaram maior intensidade de sintomas depressivos no momento da sua alta hospitalar. A presença de sintomas depressivos associa-se, sobretudo, com pior qualidade de vida em mães de RNPT MBP. / The survival rate of very low birth weight preterm infants (VLBW) has increased markedly in recent decades but has not been accompanied by a reduction in prematurity related morbidities. Preterm birth is reported as an important factor of imbalance in maternal emotional health and in their family and social relationships. Maternal emotional impairment represents a potential risk to child's neuropsychological development. Mothers of VLBW infants have a higher incidence of anxiety and depression symptoms as well as a worse perception of well-being than mothers and full-term infants. However, the association between comorbidities related to prematurity (bronchopulmonary dysplasia, retinopathy and peri-intraventricular hemorrhage) and the severity of maternal depressive symptoms are still unknown. The objective of the present study was to verify the intensity of depressive symptoms in mothers of VLBW infants for 36 months after delivery and its possible association with mothers’ quality of life and sociodemographic and clinical characteristics and with VLBW infants’ clinical characteristics. Seventy five mothers of VLBW infants (≤ 34 gestational age weeks and birth weight ≤ 1,500g) admitted to a neonatal intensive care unit (NICU) participated in a longitudinal study and responded to the Beck Depression Inventory (BDI) and WHOQOL-Bref, at six times over 36 months postpartum. The factorial analysis was used to identify possible BDI clusters and multiple linear regression was used to evaluate the contribution of each independent variable in the variation of the overall BDI score. The BDI factorial analysis identified the presence of two factors: low self-esteem / dissatisfaction and somatic symptoms. Mothers’ median BDI scores were higher (p = 0.03) at discharge (9.0; 0-56) than 6 months postpartum (6.0; 0-27) and remained stable with twelve (5.0, 0-36), eighteen (7.0, 0-33), 24 (7.0, 0-33) and 36 (6.5, 0-34) months. The somatic symptoms cluster meadian scores were higher (p = 0.00) at the time of maternal discharge (6.0, 0-23) and at six months (5.0; 0-17) than twelve (4, 0, 0-11), eighteen (3.0; 0-13), 24 (3.5; 0-16) and 36 (3,0; 0-15) months postpartum. The regression models explained a large part of the BDI scores variation in all study periods (0.19 ≤ adjusted R2 ≤ 0.64, p <0.01). The WHOQOL-Bref domains (physical, psychological, social and environment) were the variables that explained the variations in the overall BDI scores (-0.34 ≤β≤-0.12; p <0.01). Mothers of VLBW infants present greater intensity of depressive symptoms at the moment of their hospital discharge. The presence of depressive symptoms is mainly associated with poorer quality of life in VLBW infants’ mothers. / Tese (Doutorado)

L'augmentation de la survie des grands prématurés fait de la réduction des séquelles dans cette population un enjeu majeur. Alors qu'il influence leur devenir, le support nutritionnel des grands prématurés échoue souvent à prévenir le déficit protéino-énergétique, les carences nutritionnelles, et les ralentissements de croissance, aggravant leur pronostic. Nos recherches investiguaient plusieurs axes des stratégies nutritionnelles actuelles, leurs limites ainsi que les perspectives d'améliorations : I) parentérales, II) entérales, III) préventions des complications, IV) évaluation de la croissance. Il s'agissait d'un ensemble d'études cliniques, qui révélaient : I) Des variations significatives d'apports parentéraux à l'intérieur des centres, ainsi qu'une sous-utilisation des lipides, participant au déficit protéino-énergétique précoce. Un impact des lipides sur la croissance, le développement cérébral, voire l'incidence de complications était suggéré. II) Des avantages de l'utilisation de lait maternel frais dans la 1ère semaine de vie sur la poursuite de l'allaitement des nouveau-nés hospitalisés, ainsi que des variations importantes de sa composition. Une augmentation des taux d'allaitement sur les périodes d'études révélait un effet bénéfique de la recherche, même « observationnelle », sur l'allaitement. III) Une augmentation du risque d'hyperglycémie en cas de diminution de la phosphatémie. IV) Des répercussions modérées de la restriction de croissance intra-utérine sur le neuro-développement des prématurés, malgré des réserves auxologiques. Ces travaux permettaient donc d'identifier plusieurs barrières, et d'envisager différentes stratégies d'amélioration du soutien nutritionnel. Ils soulignent la complexité et l'importance des liens entre nutrition, croissance et développement neurologique des enfants à risques. Des efforts supplémentaires sont nécessaires pour optimiser les connaissances, les recommandations et les pratiques dans ce domaine / Facing to increasing survival of very preterm neonates, reducing sequelae in this population became a major public issue. Nutritional support of preterm neonates has a durable impact on their future. However, it often fails to prevent the protein-energetic imbalance, nutritional deficiencies, and post-natal growth restriction, which act as aggravating factors. Our researches evaluated different axes of current nutritional strategies, limitations and possible improvements: I) parenteral, II) enteral, III) prevention of complications, IV) growth assessment. Most relevant findings of these clinical studies were: I) Significant variations of parenteral intakes in the centres, as well as inadequate use of lipids, involved in early energetic-protein deficit. Impact of lipids on growth, brain development, and even the incidence of complications were suggested. II) Advantages in using fresh raw mother's own milk in the early days to enhance breastfeeding in hospitalized neonates, as well as important changes in mother's milk composition. An increase in breastfeeding rates over the periods of studies showed a beneficial effect of the research, although "observational", on breastfeeding. III) An increased risk of hyperglycemia in case of low phosphatemia. IV) A moderate impact of being small for gestational age on neuro-development in a preterm cohort, and related auxologic limitations. This work allowed to recognize some barriers of the nutritional support, and to consider different improvement strategies. It emphasizes the close and important links between nutrition, growth and neurological development of vulnerable infants. Further efforts are needed to optimize knowledge, recommendations and practices in this area

Indiana University-Purdue University Indianapolis (IUPUI) / Objectives: To determine (1) whether prescribed and delivered energy and protein intakes during the first two weeks of life met Ziegler’s estimated requirements for Very Low Birth Weight (VLBW) infants, (2) if actual energy during the first week of life correlated with time to regain birth weight and reach full enteral nutrition (EN) defined as 100 kcal/kg/day, (3) if growth velocity from time to reach full EN to 36 weeks’ postmenstrual age (PMA) met Ziegler’s estimated fetal growth velocity (16 g/kg/day), and (4) growth outcomes at 36 weeks’ PMA. Study design: Observational study of feeding, early nutrition and early growth of 40 VLBW infants ≤ 30 weeks GA at birth in three newborn intensive care units NICUs. Results: During the first week of life, the percentages of prescribed and delivered energy (69% [65 kcal/kg/day]) and protein (89% [3.1 g/kg/day]) were significantly less than theoretical estimated requirements. Delivered intakes were 15% less than prescribed because of numerous interruptions in delivery and medical complications. During the second week, the delivered intakes of energy (90% [86 kcal/kg/day]) and protein (102% [3.5 g/kg/day]) improved although the differences between prescribed and delivered were consistently 15%. Energy but not protein intake during the first week was significantly related to time to reach full EN. Neither energy nor protein intake significantly correlated with days to return to birth weight. The average growth velocity from the age that full EN was attained to 36 weeks’ PMA (15 g/kg/day) was significantly less than the theoretical estimated fetal growth velocity (16 g/kg/day) (p<0.03). A difference of 1 g/kg/day represents a total deficit of 42 - 54 grams over the course of a month. At 36 weeks’ PMA, 53% of the VLBW infants had extrauterine growth restriction, or EUGR (<10th percentile) on the Fenton growth grid and 34% had EUGR on the Lubchenco growth grid. Conclusions: The delivered nutrient intakes were consistently less than 15% of the prescribed intakes. Growth velocity between the age when full EN was achieved and 36 weeks’ PMA was 6.7% lower than Ziegler’s estimate. One-third to one-half of the infants have EUGR at 36 weeks’ PMA.