Analysis in risk factors of respiratory tract infectionin preschool children and construction of nomogram prediction model
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摘要:目的 分析学龄前儿童呼吸道感染的主要危险因素，并建立定量列线图预测模型。方法 采用横断面调查、分层整群随机抽样的方法选择3所幼儿园2 208例学龄前儿童作为研究对象。根据反复呼吸道感染、上呼吸道感染和下呼吸道感染的诊断标准对患者进行诊断。分析学龄前儿童呼吸道感染的主要危险因素。结果 2 208例学龄前儿童共诊断出反复呼吸道感染522例（23.6%），上呼吸道感染265例（12.0%），下呼吸道感染397例（18.0%）。Logistic回归分析显示，哮喘、过敏史、初次使用抗生素年龄 < 6个月、母乳喂养时间 < 6个月和母亲体质量指数（BMI）值每增加3 kg/m2是反复呼吸道感染和下呼吸道感染的主要危险因素，哮喘、过敏史、初次使用抗生素年龄 < 6个月和母亲BMI值每增加3 kg/m2是上呼吸道感染的主要危险因素（P < 0.05）。受试者工作曲线（ROC）分析显示，列线图预测反复呼吸道感染、上呼吸道感染和下呼吸道感染的曲线下面积（AUC）分别为0.865、0.833和0.841（P < 0.05）。结论 学龄前儿童有较高的呼吸道感染发生率，哮喘、过敏史、初次使用抗生素年龄 < 6个月、母乳喂养时间 < 6个月和母亲BMI值每增加3 kg/m2是呼吸道感染和下呼吸道感染的主要危险因素。建立定量列线图模型可以较好指导医师早期识别高危儿童，并进行早期干预。Abstract:Objective To analyze the risk factors of respiratory tract infection in preschool children, and establish a quantitative nomogram prediction model.Methods A cross-sectional survey and stratified cluster random sampling were used to select 2 208 preschool children from 3 kindergartens, and they were diagnosed according to the diagnostic criteria of recurrent respiratory tract infection, upper respiratory tract infection and lower respiratory tract infection. The main risk factors of respiratory tract infection in preschoolers were analyzed.Results In 2 208 preschoolers, there were 522 children (23.6%) with recurrent respiratory tract infection, 265 children(12.0%) with upper respiratory tract infection and 397 children (18.0%) with lower respiratory tract infection. Logistic regression analysis showed that asthma, allergic history, initial use of antibiotics < 6 months, breastfeeding time < 6 months and increase of maternal body mass index (BMI) for every 3 kg/m2 were the main risk factors of recurrent respiratory tract infection and lower respiratory tract infection, while asthma, allergic history, initial use of antibiotics < 6 months and increase of maternal BMI for every 3 kg/m2 were the main risk factors of upper respiratory tract infection(P < 0.05). Receiver Operating Curve (ROC) analysis showed that Area Under Curves (AUC) of nomogram for predicting recurrent respiratory tract infection, upper respiratory tract infection and lower respiratory tract infection were 0.865, 0.833 and 0.841, respectively (P < 0.05).Conclusion Preschool children have a high incidence of respiratory tract infection. Asthma, allergic history, initial use of antibiotic < 6 months and increase of maternal BMI for every 3 kg/m2 are the main risk factors of recurrent respiratory tract infection and lower respiratory tract infection. The establishment of a quantitative nomogram model can better guide clinical physicians to early identify high-risk children and carry out early intervention.
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表 1 呼吸道感染的单因素分析(x±s)[n(%)]
因素 反复呼吸道感染 上呼吸道感染 下呼吸道感染 无(n=1 686) 有(n=522) 无(n=1 943) 有(n=265) 无(n=1 811) 有(n=397) 性别 男 977(57.9) 290(55.6) 1119(57.6) 148(55.8) 1044(57.6) 223(56.2) 女 709(42.1) 232(44.4) 824(42.4) 117(44.2) 767(42.4) 174(43.8) 年龄 ≤5岁 900(53.4) 328(62.8)* 1059(54.5) 169(63.8)* 1003(55.4) 225(56.7) >5岁 786(46.6) 194(37.2) 884(45.5) 96(36.2) 808(44.6) 172(43.3) 患儿来源 城市 911(54.0) 235(45.0) 1026(52.8) 120(45.3) 979(54.1) 167(42.1) 农村 775(46.0) 287(55.0)* 917(47.2) 145(54.7)* 832(45.9) 230(57.9)* 出生BMI/(kg/m2) 15.4±1.6 15.3±1.4 15.7±1.8 15.0±1.2* 15.3±1.6 15.3±1.4 出生体质量/kg 3.4±0.3 3.5±0.4 3.3±0.4 3.5±0.5 3.4±0.4 3.4±0.3 母乳喂养时间 < 6个月 250(14.8) 108(20.7)* 315(16.2) 43(16.2) 268(14.8) 90(22.7)* ≥6个月 1436(85.2) 414(79.3) 1628(83.8) 222(83.8) 1543(85.2) 307(77.3) 哮喘史 16(0.9) 26(5.0)* 29(1.5) 13(4.9)* 24(1.3) 18(4.5)* 过敏史 460(27.3) 250(47.9)* 593(30.5) 117(44.2)* 544(30.0) 166(41.8)* 睡觉时打鼾 236(14.0) 101(19.3)* 284(14.6) 53(20.0)* 260(14.4) 77(19.4)* 初次使用抗生素年龄 < 6个月 202(12.0) 99(19.0)* 251(12.9) 50(18.9)* 224(12.4) 77(19.4)* ≥6个月 1484(88.0) 423(91.0) 1692(87.1) 215(81.1) 1587(87.6) 320(80.6) 父亲BMI/(kg/m2) 24.1±1.7 25.4±2.2* 24.2±1.6 25.3±1.9* 24.0±1.8 25.5±2.3* 母亲BMI/(kg/m2) 21.3±1.4 22.1±1.6* 21.7±1.5 21.9±1.8 21.1±1.7 22.4±1.9* 妊娠期体质量增加/kg 14.4±2.5 15.3±2.9* 14.6±2.7 14.7±2.8 14.2±2.1 15.5±3.0* 父亲教育水平 大专及以上 1264(75.0) 391(74.9) 1452(74.7) 200(75.5) 1360(75.1) 295(74.3) 高中及以下 422(25.0) 131(25.1) 491(25.3) 62(24.5) 451(24.9) 102(25.7) 母亲教育水平 大专及以上 1240(73.5) 380(72.8) 1431(73.6) 186(70.2) 1303(71.9) 317(79.8) 高中及以下 446(26.5) 142(27.2) 512(26.4) 76(29.8) 508(28.1) 80(20.2) 家庭经济水平 ≥20万元人民币/年 852(50.5) 281(53.8) 989(50.9) 144(54.3) 971(53.6) 162(40.8) < 20万元人民币/年 834(49.5) 241(46.2) 954(49.1) 121(45.7) 840(46.4) 235(59.2)* 妊娠期糖尿病 152(9.0) 83(15.9)* 195(10.0) 40(15.1)* 167(9.2) 68(17.1)* 妊娠期高血压 52(3.1) 16(3.1) 58(3.0) 10(3.8) 56(3.1) 12(3.0) 孕前吸烟史 30(1.8) 10(1.9) 35(1.8) 5(1.9) 32(1.8) 8(2.0) 孕期吸烟史 9(0.5) 3(0.6) 10(0.5) 2(0.9) 10(0.6) 2(0.5) 父亲吸烟史 741(44.0) 234(44.8) 851(43.8) 124(46.8) 785(43.3) 190(47.9) 剖宫产史 735(43.6) 226(43.3) 845(43.5) 116(43.8) 755(41.7) 206(51.9)* BMI: 体质量指数。与无呼吸道感染儿童比较, *P < 0.05。 
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表 2 呼吸道感染的多因素分析
因素 反复呼吸道感染 上呼吸道感染 下呼吸道感染 OR 95%CI P OR 95%CI P OR 95%CI P 调整前 哮喘史 7.45 6.65~8.32 < 0.001 4.85 3.65~5.32 < 0.001 8.03 7.65~8.43 < 0.001 过敏史 2.13 1.56~2.75 < 0.001 2.08 1.55~2.65 < 0.001 2.31 1.63~2.65 < 0.001 初次使用抗生素年龄 < 6个月 1.55 1.16~2.03 < 0.001 1.62 1.23~2.06 < 0.001 1.42 1.12~2.03 < 0.001 母乳喂养时间 < 6个月 1.13 1.02~1.65 0.003 1.08 0.56~1.65 0.234 1.30 1.12~1.69 0.001 母亲BMI值每增加3 kg/m2 1.02 1.00~1.36 0.009 1.03 1.00~1.36 0.016 1.06 1.00~1.63 0.007 妊娠期体质量增加 1.01 0.56~1.54 0.063 1.04 0.45~1.63 0.639 1.08 0.53~1.95 0.098 调整性别、年龄和地区后 哮喘史 8.42 8.01~9.32 < 0.001 5.63 4.67~6.03 < 0.001 7.89 6.69~8.42 < 0.001 过敏史 2.29 1.65~2.75 < 0.001 2.18 1.69~2.75 < 0.001 2.33 1.63~2.98 < 0.001 初次使用抗生素年龄 < 6个月 1.65 1.23~2.03 < 0.001 1.69 1.23~2.12 < 0.001 1.54 1.12~2.34 < 0.001 母乳喂养时间 < 6个月 1.30 1.12~1.76 0.001 1.24 0.63~1.89 0.097 1.42 1.16~2.63 < 0.001 母亲BMI值每增加3 kg/m2 1.13 1.02~1.56 0.003 1.19 1.03~1.59 0.001 1.09 1.00~1.49 0.008 妊娠期体质量增加 1.02 0.36~1.45 0.432 1.05 0.32~1.85 0.639 1.08 0.23~1.54 0.302
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表 3 列线图模型预测效能
感染 AUC 95%CI P 敏感度/% 特异度/% 反复呼吸道感染 0.865 0.812~0.963 0.006 79.8 72.3 上呼吸道感染 0.833 0.801~0.866 0.012 70.5 65.6 下呼吸道感染 0.841 0.806~0.878 0.009 74.2 68.3
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