目的:探讨地区级早期高危儿系统管理的模式,评估其可行性及效果。方法:建立“家庭-社区-防保所-医院”四位一体的高危儿系统管理模式,对出院高危儿进行建档、筛查、随访、转诊、咨询及指导、脑性瘫痪确诊及实施早期干预等。结果:系统管理后1年与前1年比较,高危儿筛查率、转诊率、接诊率、脑性瘫痪确诊数均有明显提高(P<0.05)。系统管理后1年,半年随访率为70.96%,1年随访率为39.95%。确诊脑性瘫痪75例,其中74例得到规范治疗,治愈25例,康复率达到33.78%。结论:建立区级高危儿系统管理中心,通过多单位及多学科协作,并结合家庭式的干预模式,是提高高危儿系统管理率,减少脑性瘫痪发生率的可行且有效的管理模式。 OBJECTIVE: To explore the mode of management of early-stage high-risk infants in district level and evaluate its feasibility and effectiveness. Methods: To establish a “family-community-prevention and treatment-hospital” four-in-one system for managing high-risk infants, documenting, screening, follow-up, referral, counseling and guidance of high-risk discharged children, and diagnosis of cerebral palsy And implement early intervention. Results: Compared with the previous one year after system management, the screening rate, referral rate, admissions rate and cerebral palsy of high risk children were significantly increased (P <0.05). One year after system management, the half-year follow-up rate was 70.96% and the one-year follow-up rate was 39.95%. 75 cases of cerebral palsy diagnosed, of which 74 cases were standardized treatment, 25 cases were cured, the recovery rate reached 33.78%. Conclusion: The establishment of district-level high-risk infant system management center is a feasible and effective management mode to improve the management rate of high-risk children and reduce the incidence of cerebral palsy through multi-unit and multidisciplinary collaboration combined with family-based intervention mode.