2015年 · 第53卷第05期

The development of modern neonatal medicine in China mainly began in the 1950s, when neonatal wards were opened in a few hospitals in a few big cities such as Shanghai, Beijing, Tianjin, Nanjing, Hangzhou and Shenyang. In 1963, neonatal transfusion was carried out to treat severe hemolytic disease^[1]。 By the 1970s, neonatal wards were opened, and there was no independent neonatology department. Most newborns were managed by pediatricians. Among pediatric professors and experts, scholars mainly engaged in neonatology include Jin Hanzhen, Feng Shumo, Qin Zhenting, Huang Demin, Song Jie, Huang Zhong, Li Zhuxuan, Xu Zhizhi, He Fuzhen, Guan Xiji, Zhou Qinyu, Zhang Jiaxiang, Hong Wenlan, Ji Xiaocheng, Wu Shengmei, Tang Zeyuan and other professors. Although the development has been slow in these 30 years, it has laid a good foundation for the further development of neonatal medicine in China. Since around 1980, neonatal medicine in China has entered a period of rapid development, and the neonatal mortality rate has dropped significantly, from 5% ~6% in 1950s to 0.9% in 2012^[2]。

Over the past 30 years, neonatal medicine has developed rapidly, which has made great contributions to the progress of health indicators in China. By 2012, our neonatal mortality rate had been reduced from 25/1 000 in 1990 to 9/1 000, achieving the United Nations New Millennium Goal (MG4)^[1]The reduction of infant mortality by two-thirds in 2015, on the basis of 1990, also contributed significantly to the global achievement or approach of this target. The reduction of neonatal mortality is important for the reduction of infant and under-5 mortality. According to the World Health Organization (WHO), premature birth and low birth weight have become the first cause of neonatal death, and respiratory distress syndrome (RDS) is the most common among premature and very low birth weight infants. Correct respiratory management is very important to improve survival rate and reduce complications.

Since its publication in 2004, "Neonatal Frequency Mechanical Ventilation Routine" has played a good role in regulating and leading the treatment of neonatal respiratory failure^[1]。 This routine has been implemented for 10 years. Due to the widespread use of prenatal glucocorticoids and postnatal pulmonary surfactant (PS), and the improvement of neonatal intensive care unit (NICU) management methods, the disease spectrum and severity of neonatal respiratory system have also changed greatly, so the mode of mechanical ventilation has changed accordingly. In the NICU, the frequency of non-invasive mechanical ventilation has increased significantly. For some newborns with severe respiratory diseases, high-frequency ventilation as the remedy or first choice treatment of constant-frequency mechanical ventilation has also achieved good curative effect. Therefore, this routine will be revised and supplemented to the 2004 edition of "Neonatal Frequent Mechanical Ventilation Routine" for the reference of neonatal emergency doctors.

Mechanical ventilation is one of the important methods to treat neonatal respiratory failure. Choosing appropriate ventilation mode and standardized treatment is very important for the clinical prognosis of children. It has been more than 10 years since the publication of "Neonatal Frequency Mechanical Ventilation Routine" in 2004^[1]In 2007, some European neonatologists published the first European guidelines for the management of respiratory distress syndrome (RDS) in premature infants^[2]Two revisions were made in 2010 and 2013, respectively^[3,4]。 2014 American Academy of Pediatrics updated guidelines for respiratory support at birth for premature infants^[5]。 In order to reflect the latest progress in the field of newborns and maintain the advanced and authoritative nature of the routine, in 2015, the Neonatology Group of the Pediatrics Branch of the Chinese Medical Association revised and supplemented the "Neonatal Frequent Mechanical Ventilation Routine", and its interpretation is as follows.

The male child was admitted to Xiamen Maternal and Child Health Hospital on January 7, 2012, 53 minutes after birth, shortness of breath and poor crying 53 minutes after birth. Gestational age at birth41^＋3Zhou, delivered by cesarean section due to "intrauterine distress", birth weight 3.54 kg, no premature rupture of membranes, clear amniotic fluid, normal volume, no abnormalities in placenta and umbilical cord, Apgar score 1 min 7, 5 min 8, 10 min 9. After birth, the resuscitation sac was given positive pressure and oxygen resuscitation. His mother's pregnancy is not special. Admission diagnosis "Neonatal pneumonia, mild asphyxia". Physical examination at admission: 60 breaths/min, obvious inspiratory three concave signs were seen, and phlegm sounds were smelled in both lungs. Confidant test was negative. After admission, they were treated with nasal continuous positive airway pressure (NCPAP) support, cefotiam anti-infection, and fasting. Admission chest X-ray showed (Figure 1): Neonatal pneumonia. Blood routine and C-reactive protein (CRP) were normal. After withdrawing NCPAP and changing to nasal tube for oxygen administration at 19 h after birth, the infant developed severe dyspnea and cyanosis, and changed to high-frequency ventilator support. Chest X-ray was re-examined at 25 h after birth (F1-15Figure 2): (1) Right pneumothorax (right lung is compressed by 95%), right pleural effusion to be excluded; (2) Neonatal pneumonia. Closed drainage of the right thoracic cavity was performed, and a large amount of gas and 10 ml of yellow-brown liquid were drained out. Re-examination of chest X-ray showed right pneumothorax absorption, massive emphysema of mediastinum, CRP progressively increased to 82.3 mg/L, accompanied by repeated fever, body temperature 37.9 ℃, meropenem was used to fight infection, CRP gradually decreased to normal, and pleural effusion culture was negative. During this period, attempts were made to withdraw the machine and clamp the drain tube, but failed. The fever appeared again 7 days after birth, and the chest X-ray was re-examined on the 10th day (F1-15Figure 3) showed right pleural effusion, mediastinal emphysema increased than before, right pneumothorax and partial wrapping (right lung was compressed by 80%), and the right thoracic closed drainage tube was replaced, pleural effusion routine: yellow, turbid, nucleated cells 5 500×10⁶/L, leukocyte classification: multinucleated cells 81%, mucin qualitative test positive. Drainage tube end culture: Staphylococcus aureus, susceptible to vancomycin, methicillin-resistant Staphylococcus aureus (MRSA) positive. CRP increased progressively to 81.10 mg/L, and vancomycin combined with moxifloxacin was switched to anti-infection. There was right pyopneumothorax. After thoracic lavage with normal saline, a large amount of colorless liquid was drained from the gastric tube. Esophagography was performed 15 days after birth: patchy contrast medium was seen in the right lower thorax, with a slightly triangular inner edge, and the innermost protrusion was located on the right side of the lower edge of the thoracic 7 vertebral body. A small band-shaped slightly higher density shadow was faintly seen in the space between the thoracic 7 and 8 vertebral bodies connected to the esophagus (F1-15Figure 4F1-15Figure 5), suggesting "esophagopleural fistula". 24 days after birth, "esophageal pleural fistula closure" was performed under general anesthesia. During the operation, a thin short capsular tube at the right posterior of the esophagus communicated with the right thoracic cavity 3 cm above the esophageal hiatus, with a diameter of about 0.6 cm. Premature infant formula was fed nasally 4 days after surgery, and total enteral nutrition was achieved 1 week later. Upper gastrointestinal angiography 13 days after surgery (37 days after birth) showed no leakage of contrast medium into the chest cavity. Esophagography was normal at 5 months after birth (F1-15Figure 6)。

The male child was transferred to the neonatal intensive care unit from the obstetrics department of the Third Hospital of Peking University on June 24, 2014, 10 minutes after birth, mainly due to "dyspnea for 10 minutes". It is the first birth of her mother's second child, gestational age 24^＋6Zhou, due to her mother's severe preeclampsia, delivered vaginally. After birth, wheezing breathing, whole body blue, no response, Apgar score 1 min 3 points, tracheal intubation T-piece resuscitation device pressurized oxygen, 5 min 6 points, 10 min 9 points. There were no abnormalities in umbilical cord, placenta and amniotic fluid. Physical examination: body temperature 35.4 ℃, heart rate 96 beats/min, 20 breaths/min, blood pressure 49/22 mmHg (1 mmHg =0.133 kPa), body weight 610 g, body length 30 cm, head circumference 22 cm. Super immature appearance, weak reaction, purple skin color, tender and shiny skin, flat and soft anterior fontanel, poor spontaneous breathing, perioral cyanosis, positive triple concave sign. The breathing sounds of both lungs were thick, and a moderate amount of fine wet rales could be heard. There was no abnormality in the physical examination of heart and abdomen. The limbs are cool, and the capillary refill time is 3~4 s. The muscle tone was hypotonic and none of the primitive reflexes were elicited. extremely preterm infant (EPI) and ultra low birth weight infant were admitted to hospital.

A 2-year-old child was seen in our hospital in September 2013 because she "found vulvar discharge for more than 40 days and aggravated for more than 10 days". The child had yellow-green vulvar discharge without obvious inducement more than 40 days ago, no fever, noisy crying, frequent urination, noisy crying and diarrhea during urination, and good appetite. More than 10 days ago, vulvar discharge increased, sometimes with pale bloody discharge, and no other complaints of discomfort. For further diagnosis and treatment, we went to our hospital. Deny the history of foreign body insertion into the vagina, deny the history of trauma, sexual assault and major disease.

The child is a male, 9 years and 5 months old, Tibetan, from Ganzi Prefecture, Sichuan Province. I went to our hospital in September 2014 because of "general pain accompanied by walking mass for more than 1 month". More than a month ago, the child had right thigh pain without obvious trigger, which was needle-like pain, and the pain was unbearable. A 2 cm ×3 cm mass appeared at the pain area, and the surrounding mass was red and swollen. There was no discomfort such as vomiting, diarrhea, joint pain and rash. The mass lasted for 1 to 2 days and then disappeared, and the pain was relieved. After the right thigh mass disappeared, the right calf mass appeared later. The size did not change significantly compared with before, and it was still accompanied by pain. It disappeared after 1 to 2 days, and the pain was relieved. In the past 1 month, the mass has traveled all over the body, and up to 2 masses can appear at the same time. During the course of the disease, mental and food appetite were acceptable, no obvious abnormalities in urine and bowel movements were found, and no obvious weight decrease was seen. The local hospital checked for hydatid IgG positive, abdominal B-ultrasound showed peritoneal effusion, and was diagnosed as "parasitic infection". After treatment (specific medication unknown), the mass did not disappear, and the pain was not obviously relieved, so I came to our hospital for treatment. The child has been in good health, has a history of eating raw beef and mutton, has no history of eating aquatic foods such as crabs, has no history of allergic diseases, and denies a history of skin trauma.

Neonatal hypoxic-ischemic encephalopathy (HIE) is the main cause of neonatal death and childhood disability^[1]。 Except that mild hypothermia can improve the prognosis of children with moderate HIE, there is no recognized effective treatment^[2,3]。 Although early use of mild hypothermia therapy has gradually become the standard treatment for HIE in some countries, more than 40% of children have neurological disorders or even death after receiving mild hypothermia therapy^[4,5]。 Therefore, exploring the methods of treating HIE has become a hot topic in recent years. Compared with stem cells from other sources, cord blood stem cells have the characteristics of easy collection, low risk, strong cell proliferation ability and low immunogenicity. More and more studies have been carried out on animal models of nerve injury by cord blood cell transplantation, and animal experiments have shown that cord blood transplantation can improve the prognosis of animals with hypoxic-ischemic brain injury^{[6,7,8,9,10,11]}。 The progress of umbilical cord blood transplantation in the treatment of neonatal HIE is reviewed.

central nervous system (CNS) infection in children is a rare disease that can lead to death and serious disability in children. Objective detection of brain-specific protein levels in body fluids can help to judge the degree of brain injury, monitor the disease progression, evaluate the treatment effect and guide the follow-up rehabilitation treatment. S100B protein has been widely studied as a very important brain-specific protein^[1]Which has the following characteristics: (1) high distribution specificity: the vast majority are distributed in glial cells and Schwann cells; (2) the content in normal human body is extremely low and relatively stable; (3) It is conducive to early judgment of brain injury: S100B protein is elevated in the early stage of brain injury, and its half-life is short^[2]； (4) Convenient detection: samples from various sources (cerebrospinal fluid, blood, amniotic fluid and urine, etc.) can be quantitatively detected by simple immunological methods; (5) Stable properties: the sample is stable from room temperature to – 70 ℃ within 48 h of collection, and it will not degrade by freezing^[3]。 The research progress of S100B protein and its application in childhood CNS infectious diseases is summarized as follows.

postural orthostatic tachycardia syndrome (POTS) is the most common cause of orthostatic intolerance (OI) in children^[1], manifested by chronic OI symptoms and abnormal increase in heart rate after upright position, and some children may have syncope attacks. 1993 Schondorf and Low^[2]The concept of POTS was put forward, and the disease has become a hot spot in the research of functional cardiovascular diseases in children in recent years. The diagnosis of POTS in children is mostly carried out according to the criteria of adults. The diagnostic criteria of adult POTS are generally considered to be: chronic OI symptoms, heart rate increase>30 beats/min within 10 minutes from recumbent position to upright position, or heart rate>120 beats/min, without orthostatic hypotension (decreased blood pressure<20/10 mmHg, 1 mmHg =0.133 kPa), And excluding cardiovascular organic diseases and other states affecting the autonomic nervous system, such as anemia, drugs and other factors^[3]。 In recent years, some scholars believe that the diagnostic criterion of POTS in children should set the increasing value of heart rate at 40 beats/min in upright position^[4,5,6,7]。 In fact, POTS in children is not a single disease, but a group of diseases with diverse causes and similar clinical manifestations. At present, the mainstream pathogenesis theories include vascular endothelial dysfunction leading to hypervasodilation, hypovolemia, autonomic dysfunction, abnormal Bezold-Jarisch reflex mechanism, muscle pump dysfunction, viral infection, norepinephrine transporter mutation, etc., involving vascular, nervous, muscular, endocrine and other multi-system lesions^[3,8]。 Among the above pathogenesis, vascular endothelial dysfunction leads to hypervasodilation, which has attracted widespread attention^[8,9]。 The researchers believe that some children with POTS have abnormal vascular endothelial function, and their peripheral blood vessels are abnormally relaxed, resulting in a further reduction of the return blood volume on the basis of the upright position, which causes the sympathetic nerves to be over-excited and cause clinical symptoms^[10]。 As a vasoconstrictor, midodrine hydrochloride has been used in the treatment of POTS in children in recent years, and has achieved certain curative effects. This article reviews the clinical research progress of midodrine hydrochloride in the treatment of POTS in children.

Professor Jin Hanzhen is a famous pediatric expert in China and one of the main founders of neonatal medicine in China. Professor Jin Hanzhen, whose ancestral home is Shaoxing, Zhejiang Province, was admitted to National Shanghai Medical College in 1939. After graduating in 1945, he worked in the Department of Pediatrics of China Red Cross Hospital (now Huashan Hospital of Fudan University). In 1952, he participated in the establishment of Pediatric Hospital Affiliated to Shanghai First Medical College (now Pediatric Hospital Affiliated to Fudan University), and has been working in Pediatric Hospital since then. In 2014, the Chinese Medical Association awarded Professor Jin Hanzhen the "Lifetime Achievement Award of Chinese Pediatricians", and the Chinese Medical Doctors Association awarded her the "Special Contribution Award of Chinese Neonatologists". 2015 marks the 70th anniversary of Professor Kim Han-jin's career in pediatrics.

ROC is drawn with sensitivity (true positive rate) as ordinate and 1-specificity (false positive rate) as abscissa. It is generally believed that the more left convex ROC is, the higher its diagnostic value. The area under the curve (AUC) can judge the efficacy of the diagnostic test. If the AUC is>0.5, and the statistical test is meaningful, it can indicate that the diagnostic test has certain diagnostic value.