先天性心臟病學童之能量平衡相關行為、健康體位及相關因素探討

Abstract

研究背景及目的：隨著醫療科技的進步，有先天性缺損的兒童在密集照護下，存活率提升，造成慢性病兒童比例逐年提升；而先天性心臟病因手術技術和照護方式的改善，存活率提高至85%以上，探討的重點不再只拘泥於發生率及死亡率，更要關心各種健康及社會心理等議題，需要長期追蹤及了解。因此，本研究針對輕度及中至重度先天性心臟病學童分為兩群體進行能量平衡相關行為、健康體位及相關因素之探討。 研究方法：本研究採以橫斷性研究設計法﹙cross-sectional designs﹚，採量性研究法﹙quantitative study﹚設計，以結構式問卷測試。問卷內容參考高碧霞等人2013年所發展兒童版「健康生活型態」與父母版「健康生活型態」，內容包含健康情況、家庭社會環境因素和能量平衡相關行為。此外，實際測量兒童及父母的身高、體重，計算出身體質量指數，根據2010年陳偉德和張美惠教授發表台灣地區兒童及青少年生長曲線作為連續型資料，本研究採此資料公布之中位數(50th)為標準，減去先天性心臟病學童BMI得到調整後BMI，將調整後的BMI區分為BMI < 50th及BMI ≥ 50th兩組，來了解這兩組先天性心臟病學童在能量平衡相關行為及其相關因素之間的差異。收案期間為2014年6月3日至2014年10月31日，在台灣北部某兒童醫院兒童心臟科門診、病房及心臟超音波室篩選符合收案條件的先天性心臟病學童及其父母，納入條件：(一)經心臟專科醫師診斷為輕度先天性心臟病（心室中膈缺損、心房中膈缺損及開放性動脈導管）與中至重度先天性心臟病（法洛氏四重症、大動脈轉位及心內膜墊缺損）先天性心臟病之7-12歲學童及其父母；(二)可用國台語溝通及識中文閱讀且學童及父母皆同意參與訪談及問卷調查。以R version 3.1.3版進行描述性、推論性統計分析及迴歸模式做預測分析。

結果： 一、 參與本研究共123組，實際有效個案為97組，其中，診斷為輕度先天性心臟病學童及其父母共72組，而診斷為中至重度先天性心臟病學童及其父母共25組，回應率78.86%。本研究中97位先天性心臟病學童平均年齡為9.73 ± 1.49歲，皆介於7-12歲的國小學童，男童佔53.61%（n = 52）、女童佔46.39%（n = 45）。過輕學童佔19.6%、過重至肥胖者佔14.43%。 二、 輕度先天性心臟病學童體重過重及肥胖比例高於中重度先天性心臟病學童族群，而中重度族群過輕比例高於輕度族群。經中位數50th調整後兒童BMI平均值為-0.09 ± 3.61kg/m2，顯示身體質量指數平均低於健康狀況一般之學童。在心臟大小為正常及介於邊緣值者身體質量指數與水分攝取有顯著相關。 三、 能量平衡相關行為方面，輕度先天性心臟病學童在攝取優酪乳、養樂多、高油零食及餅乾類多於中重度先天性心臟病學童；兩組在動態活動相對時間及靜態活動時間上無顯著差異，但中重度先天性心臟病學童在睡眠時數顯著短於輕度先天性心臟病學童。 四、 綜合探討健康狀況、家庭社會環境及能量平衡相關行為與學童身體質量指數作線性迴歸模式分析，考慮自變項與依變項的相互作用下，最終，以模式4為最佳精簡預測模式，預測因子之解釋變異量為73.49%。顯著正相關的因子，包括：自覺健康狀況與水分攝取之交互作用、心臟擴大與水分攝取之交互作用、服用Aspirin、自覺活動習慣普通、自覺飲食習慣普通、父母之身體質量指數、父親教育程度為高中職、母親職業為專業人員、宵夜外食及從事靜態活動時間。顯著負相關的因子，包括：先天性心臟病疾病分類為中重度、心臟大小為邊緣值、患氣喘、父母教育程度為國中、乘載學童上下學及攝取蔬果。 結論：先天性心臟病除了疾病治療外，在生活方面仍面臨許多挑戰，在照護上需有整體性且持續性的觀點。本研究預測結果可使醫療人員了解影響先天性心臟病學童身體質量指數的可能因素，包括：自身的疾病、家庭社會環境的影響和自身能量平衡的相關行為等三大部分。針對研究結果預測之因素，可提供對於有過重及肥胖風險的學童及其照顧者予以適當的建議；對於BMI過輕之學童可邀請營養師等進行跨團隊的健康指導。在臨床及學校方面，可提供對於先天性心臟病學童有正確的疾病，增進照護上的一致性及連貫性，促使學童有更健康的生活型態。

Background and Purpose: With advances in medical technology and improvement in medical care, survival rates of children with congenital heart disease (CHD) have improved. The survival rate of these children has increased to 85%. The focus is no longer on reporting the incidence and mortality rates related to CHD but on following up health and psychosocial issues in these children. Therefore, this study focused on children with mild and moderate-to-severe CHD to understand energy balance-related behaviors, body mass index (BMI) and other related factors. Methods: A hospital-based cross-sectional study design and quantitative research were performed to collect data for this study. The structured-questionnaire included a children’s version of “healthy life style” and a parents’ version of “healthy life style”. The questionnaire consisted of health parameters, environmental factors, and energy balance-related behaviors developed by Gau et al. (2013). Body height, body weight, waist-circumference and triceps skinfold were measured. BMI was calculated based on the continuous growth curve data of children and adolescents published by Chen and Chang (2010). This study used the median (50th) as the standard and subtracted the BMI of children with CHD to obtain the adjusted median BMI. The adjusted median BMI was divided into BMI < 50th and BMI ≥ 50th groups to understand these two groups of children with CHD in terms of energy balance-related behaviors and the difference between related factors. Data were collected at a medical center in northern Taiwan from the outpatient clinics of pediatric cardiology and pediatric wards from June 3, 2014 to October 31, 2014. The study included 7-12-year-old children with mild and moderate-to-severe CHD, and their parents. The inclusion criteria were as follows: (1) Children with mild CHD diagnosed by a cardiologist (ventricular septal defect [VSD], atrial septal defect [ASD], or patent ductus arteriosus [PDA]). (2) Children with moderate-to-severe CHD (tetralogy of Fallot [TOF], transposition of great arteries [TGA] or endocardial cushion defect [ECD]), and their parents. (3) Children and their parents who could understand Chinese and had agreed to participate in interviews and questionnaires. The data were analyzed by the Software R version 3.1.3 to version descriptive and inferential statistical analysis and regression models were used for predictive analysis. Results: A total of 123 child-parent groups participated, of which 97 cases comprised the study group. A total of 72 children with mild CHD (ASD, VSD, or PDA) and their parents and 25 children with moderate-to-severe CHD (TOF, TGA, or ECD) and their parents were included. Thus, a response rate of 78.86% was achieved. The average age of participants was 9.73 ± 1.49 years, and 53.61% (n = 52) were boys and 46.39% (n = 45) were girls. In all, 19.6% (n = 19) had BMI < 15th and 14.43% (n = 14) had BMI ≥ 85th. More children with mild CHD were found to be overweight and obese than those in the moderate-to-severe CHD. However, the number of underweight children was higher in the moderate-to-severe CHD than the mild CHD. The average adjusted median of BMI (50th) was -0.09 ± 3.61 kg/m2. This showed that school-aged children with CHD had BMI below the normal average. Water intake is significant in children with normal heart size and borderline BMI. With respect to energy balance-related behaviors, children with mild congenital heart disease have higher consumption of yogurt, Yakult, high-fat snacks, and crackers than do children with moderate-to -severe congenital heart disease. No significant difference was found in physical activity relative time and sedentary behaviors, but the number was significantly lower in children with moderate-to -severe than in those with mild congenital heart disease. In a comprehensive investigation of health status, generalized additive models (GAM) analysis of the associations between environment factors, energy balance-related behaviors and the children’s body mass index was performed. Considering the interaction between the independent and dependent variables, model 4 is the best predictor and explained a total variance of 73.49%. The variables which were significantly positive were: health states and interaction of water intake, heart enlargement and interaction of water, aspirin use, being aware of active habits, being aware of dietary habits, parents’ BMI, father’s education level (senior high school), mothers being working professionals, snacking at midnight and indulging in sedentary activities. Significant negative variables were: being diagnosed with moderate-to-severe CHD, borderline heart size, suffering from asthma, parental education level (junior high school), transporting children to and from school and intake of fruits and vegetables. Conclusion: Besides receiving treatment for congenital heart disease, patients encounter numerous challenges in their daily lives, and nursing care must be both comprehensive and persistent. The predictions of this study can help medical personnel understand the possible factors that affect the body mass index of children with congenital heart disease, including their own disease, their family and social environment, and their own behavior related to energy balance. The predictive factors identified in this study can provide suggestions for children who are at risk of becoming overweight or obese and their appropriate care. For children with body mass indexes that are too low, nutritionists or other professionals can be consulted for cross-team health guidance. Clinics and schools can provide consistent and coherent care for accurate treatment for children with congenital heart disease, and promote healthier lifestyles for children.