2016年 · 第54卷第01期

According to the World Health Organization's Global Action Report on Premature Infants, released in May 2012, premature birth is the leading cause of neonatal death and the second leading cause of death in children under 5 years of age after pneumonia^[1]。 Effective health interventions can reduce the death of premature infants by 2/3, and rational feeding is one of the important and effective interventions. The number of premature babies born in China every year exceeds 10% of the total number of premature babies in the world, ranking second among the countries with the largest number of premature babies in the world^[1]。 Therefore, the nutrition and health of premature infants has become a high-profile medical and social problem.

patent ductus arteriosus (PDA) is a common clinical problem in premature infants. In severe cases, it can adversely affect the circulation of premature infants, inducing congestive heart failure, bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH) and neonatal necrotizin genterocolitis (NEC), which has a great impact on survival and prognosis. The lower the gestational age at birth, the higher the incidence of PDA, and the incidence of PDA in premature infants under 28 weeks at birth was as high as 70%^[1]。 The awareness and research of PDA has gone through the entire process of the development of neonatal intensive care. The first catheter arterial ligation of a premature infant with a birth weight of 1 417 g was reported by DeCanq in 1963. In the 1970s, PDA drug therapy also began clinical application. There are still many controversies on the management of PDA, especially on the definition of hemodynamically significant PDA (hsPDA), the value of PDA intervention, the best time of intervention, the indication of drug intervention, the choice and use of drugs, and the indication of surgery^[2]。 These confusions and controversies reflect the importance of PDA and the high concern of neonatologists, and also show the complexity of PDA management. Due to the numerous clinical influencing factors, the hot issues in PDA management are sorted out.

In recent years, with the continuous improvement of the success rate of premature infants, especially very premature infants in China, further improving their prognosis has become the focus of attention of the industry and the public. Adequate nutritional support is a necessary condition for the growth and health of very (ultra) low birth weight infants. At present, international professional institutions have reached a consensus to actively promote breastfeeding and intensive breastfeeding for premature infants in neonatal intensive care unit (NICU)^[1,2,3]。 In order to further promote and popularize the breastfeeding measures of premature infants in NICU in China and improve the breastfeeding rate of premature infants, the Nutrition Professional Committee of Neonatologists Branch of Chinese Medical Doctors Association, the Breast Milk Bank Group of Child Health Professional Committee of Chinese Medical Doctors Association and the Editorial Committee of Chinese Journal of Pediatrics jointly put forward breastfeeding suggestions for premature infants in NICU suitable for China's national conditions on the basis of summarizing the research results at home and abroad.

pediatric critical care medicine (PCCM) is a medical science that studies the basic, preventive and clinical medical theory and technical methods of severe disease, namely organ dysfunction, in children at all ages, so as to carry out timely and effective treatment. pediatric intensive care unit (PICU) is the practice base and objective subject of PCCM; Its work effect is directly related to the mortality rate and disability rate of children. It is an objective symbol of the overall strength and level of children's medicine, and plays an important role in the national children's medicine development strategy. PICU concentrates critically ill children and high-tech advanced equipment, relying on multi-disciplinary elite team and rigorous and optimized operation plan to realize full-time, holistic and effective monitoring and treatment. It is most necessary to standardize construction according to the principle of system, science and standards. China's children's medical care system construction plan requires PICU to implement corresponding hierarchical construction, that is, to build PICUs at different levels in different levels of administrative regions, and to build a perfect regional children's critical treatment network through an orderly referral system. According to the advanced experience of developed countries and the successful practice in some areas of China, this strategy can indeed take into account the treatment quality of critically ill children and the rational allocation of health resources, and effectively ensure the formation and improvement of comprehensive treatment ability of PCCM. In order to promote the standardized construction and management of PICU and regional children's critical treatment network in China, and to promote the sustainable and healthy development of PCCM in China, this recommendation is specially formulated.

Premature, low birth weight infants are at high risk for growth retardation, infectious diseases, and developmental delays in infancy and childhood, and are the leading cause of death in children under 5 years of age. According to the statistics of the World Health Organization, effective intervention measures can avoid 2/3 of the death of premature infants and reduce the incidence of complications, and rational feeding is one of the important intervention measures. The number of premature infants in China ranks second in the world. With the continuous progress of perinatal medicine and intensive care technology, more and more premature infants with small gestational age and low birth weight can survive, and nutrition management has become one of the important tasks to improve the quality of life of premature infants. In 2009, the editorial board of Chinese journal of pediatrics, the neonatology group and the child health care group of the pediatrics branch of Chinese medical association published "Feeding recommendations for premature/low birth weight infants"^[1]In 2013, the Pediatrics Group of Parenteral and Enteral Nutrition Branch of Chinese Medical Association, the Neonatology Group of Pediatrics Branch of Chinese Medical Association and the Neonatal Surgery Group of Pediatric Surgery Branch of Chinese Medical Association updated the "Clinical Application Guidelines for Neonatal Nutritional Support in China"^[2]To develop standardized enteral and parenteral nutritional support strategies during hospitalization to promote premature infants to achieve normal fetal growth rates and functional status in utero.

The 9-month-old child was admitted to the hospital mainly for "intermittent fever, cough, wheezing for 30 days and rash for 19 days". 30 days before admission, the child developed low fever, cough (a little phlegm in the throat) and wheezing. He went to a local hospital. The chest X-ray showed a patchy shadow in the upper lobe of the left lung, so he was hospitalized in the local hospital and diagnosed as "bronchiolitis". He was given anti-infective treatment such as ceftizole for 7 days, and the child improved and was discharged. Twenty-one days before admission, the child had repeated intermittent fever, with a peak body temperature of 40 ℃ and no chills. He was hospitalized again in a local hospital and given intravenous infusion of cephalosporin antibiotics. 19 days before admission, a miliary reddish rash appeared all over the body, without scratching, and gradually merged into tablets. Then, cephalosporin antibiotics were stopped, and fosfomycin, ribavirin, meropenem were given successively to anti-infection, gamma globulin supportive treatment, dexamethasone anti-inflammatory treatment, etc. The child's body temperature was normal and the rash disappeared; Six days before admission, the child's rash increased again, and fever appeared again, with the highest body temperature of 38.8℃ (the rash increased significantly during the fever period). In order to seek further diagnosis and treatment, he came to our hospital for treatment, and the outpatient clinic was admitted to our department with "pneumonia". The child came from the onset of the disease, with good spirits, poor appetite, no obvious change in weight, and no abnormal appearance of urine and stool.

The 27-h-old child was admitted to the First Hospital of Jilin University in June 2015 due to fever for 15 h. The child was the first birth, first delivery, full-term cesarean section, birth weight 4.0 kg, normal amniotic fluid and placenta, and denied the history of intrauterine distress and postnatal asphyxia. The child went to the local hospital 10 h after birth due to vomiting and crying. Considering the existence of colic, he was given homemade anisodamine tablets and intestinal probiotic mixed powder for oral administration. The doctor's advice was 1/3 pack each time (each containing 5 mg of anisodamine tablets). The parents took 3 packs by mistake. After 2 h, the child developed fever (body temperature was not measured). After 2 h, the child took 3 packs of the above preparations orally again 7 h before admission (20 h after birth). After 2 h, the child's body temperature reached 40.1℃, accompanied by full flushing. During the course of the disease, there were no convulsions and disturbances of consciousness, no dyspnea and skin blues, no diarrhea, and oliguria 12 h before admission (15 h after birth). The mother was healthy during pregnancy and did not take any medication. Physical examination at admission: body temperature 39.5 ℃, heart rate 155 beats/min, breathing 56 beats/min, slight irritability, crying, face flushing, and no rash all over the body. Bilateral pupils of equal size, 4 mm in diameter, normal response to light, normal auscultation of both lungs, hypercardiac sounds, no murmur or additional cardiac sounds, abdominal swelling, no enlargement of liver and spleen, extremely weak intestinal sounds, and bladder palpable above the pubic symphysis. The muscle tone and primitive reflex of the extremities were normal. Laboratory tests: normal blood routine; CRP 20 mg/L; Myocardial enzymes: creatine kinase 584 (normal value: 25-200) U/L, creatine kinase isoenzyme 67.7 (normal value: 0-25) U/L, lactate dehydrogenase 597 (normal value: 135-226) U/L, α-hydroxybutyrate dehydrogenase 474 (normal value: 78-182) U/L; Liver function: aspartate transferase 56.6 (normal value: 15-40) U/L, the remainder normal; Normal kidney function; Rapid screening of toxic drugs (mass spectrometry): anisodamine was detected in whole blood. Electrocardiogram: sinus tachycardia; Abdominal X-ray: intestinal dilatation; Abdominal color ultrasound: pneumatosis in the intestinal lumen and highly filled bladder.

A 3-year-old 8-month-old male was admitted to the hospital on August 2, 2012 due to "cervical lymph node enlargement found for 15 months". Fifteen months ago, the child went to a local hospital for "acute upper respiratory tract infection". Physical examination found that the cervical lymph nodes and spleen were enlarged, and blood routine showed that the white blood cell count, hemoglobin and platelet count were all decreased, and Mycobacterium tuberculosis antibody and protein chip were all negative. Blood biochemistry showed normal liver function, lactate dehydrogenase and C-reactive protein, cervical lymph node puncture showed lymph node reactive hyperplasia, and bone marrow puncture showed proliferative anemia. Considering the diagnosis of lymphadenitis, anti-infective treatment (specific medication unknown) was given for more than half a month, but the effect was not good. For further diagnosis and treatment, we went to our hospital.

Acute respiratory distress syndrome (ARDS) is a common severe disease in pediatric intensive care unit (PICU), and mechanical ventilation is still one of the important treatments for ARDS. Commonly used standard ventilation modes include volume-controlled ventilation, pressure-controlled ventilation, etc. Small tidal volume lung protection strategy is advocated. High frequency oscillatory ventilation (HFOV) is widely used in pediatrics. In recent years, airway pressure release ventilation (APRV) has also been used in the treatment of ARDS in children. The principle, parameter setting and clinical application of APRV in children are reviewed.

Juvenile idiopathic arthritis (JIA) refers to a group of arthritic diseases with an onset age of less than 16 years and a course of more than 6 weeks. It is one of the most common chronic immune system diseases in children. The International Federation of Rheumatology (ILAR) classifies JIA into seven subtypes based on clinical presentation, course of disease, prognosis, and response to treatment with condition-ameliorating drugs (DMARDs). Pro-inflammatory cytokines such as interleukin 1 β (IL-1 β), IL-6, tumor necrosis factor α (TNF-α), IL-17 and IL-23 play an important role in the pathogenesis of JIA, and inhibiting its activity becomes an important part of treatment; Different pathogenesis of various subtypes determines different responses to biological agents^[1]。

One principle that can be followed in the statistical analysis of clinical studies is the intention-to-treat (ITT) analysis principle, which includes all randomized subjects and analyzes them according to the results of randomization grouping, even if some patients do not strictly follow the randomization grouping to receive treatment during the study. However, it is difficult to strictly implement the principle of ITT analysis due to loss of follow-up and other reasons in actual work, so the statistical analysis data sets of clinical trials are divided into full analysis set (FAS), per-protocol set (PPS) and safety set (SS).