2016年 · 第54卷第03期

Bronchial asthma (hereinafter referred to as asthma) is the most common chronic respiratory diseases in childhood. In the past 20 years, the prevalence of asthma among children under 14 years old in China has shown an obvious upward trend. In 2010, the cumulative prevalence rate of asthma among children under 14 years old in urban areas reached 3.02%, and the prevalence rate in some areas exceeded 7%, which is close to the level of developed countries^[1]。 However, the overall control level of childhood asthma in China is still not ideal^[2], childhood asthma remains an important medical and social problem.

Respiratory diseases are the most common diseases in children, and they are also the main diseases that endanger children's health. The prevention and treatment of children's respiratory diseases is always the important work and responsibility of pediatric workers. Generations of pediatric respiratory workers in China have been making unremitting efforts.

Bronchial asthma (hereinafter referred to as asthma) is the most common chronic airway disease in childhood. In the past 20 years, the prevalence of childhood asthma in China has shown an obvious upward trend. The cumulative prevalence of asthma in urban children under the age of 14 was 1.09% in 1990, 1.97% in 2000 and 3.02% in 2010^[1,2,3]。 Asthma seriously affects children's physical and mental health, and also places a heavy mental and financial burden on families and society. At present, the overall control level of childhood asthma in China is not ideal^[4]This is related to the lack of awareness of the disease among parents of asthmatic children and the uneven standardized management level of clinicians^[5]。 Numerous studies have proved that early intervention and standardized management of childhood asthma are beneficial to control the disease and improve the prognosis. Guidelines for Diagnosis and Prevention of Bronchial Asthma in Children Revised in 2008^[6]It fully embodies the principle of evidence-based medicine and plays an important role in improving the prevention and treatment of childhood asthma in China. Since 2008, new progress has been made in the research of childhood asthma. Based on the 2008 guidelines, this guideline refers to the guidelines for asthma prevention and treatment published abroad in recent years^{[7,8,9,10,11]}And the domestic consensus on asthma diagnosis and treatment^{[12,13,14,15,16]}Draw on new evidence-based medical evidence, and revise it in combination with the important clinical experience of prevention and treatment of childhood asthma in China to make it more practical and operable, and provide guiding suggestions for standardized diagnosis and prevention of childhood asthma.

Child girl, 2 h. Because of "gestational age 30^＋2He was admitted to the pediatric neonatal intensive care unit of Xuzhou Hospital affiliated to Southeast University School of Medicine in 2014. The child was the first and second birth, the youngest twin, and the gestational age at birth was 30^＋2Weeks, her mother did not use glucocorticoids before delivery. She gave birth naturally after emergency delivery in a local hospital, and her amniotic fluid was clear. Postnatal Apgar score unknown, birth weight 1 280 g. After birth, slightly moaning, bruising, progressive aggravation, resuscitation sac support to our hospital sharply. Physical examination: poor response, no sign of anemia. Moaning, bruising, breathing 60 times/min, a little coarse wet rales in both lungs, but no murmur in the heart. Low muscle tone and weak primitive reflex. After admission, the percutaneous oxygen saturation was 75%. After 5 min of bi-level non-invasive positive pressure ventilation, blood gas analysis showed that pH 7.15, oxygen partial pressure 85 mmHg (1 mmHg =0.133 kPa), carbon dioxide partial pressure 55 mmHg, and residual alkali-12.5 mmol/L. The percutaneous oxygen saturation increased to 92%. Chest X-ray showed "respiratory distress syndrome (grade 2)". Bovine pulmonary surfactant 140 mg was administered once by endotracheal intubation, and bi-level noninvasive positive pressure ventilation was continued. The intake amounts for the first 7 days were 60, 80, 100, 120, 130, 140 and 150 ml/ (kg·d), respectively. Blood routine on the second day after birth: white blood cells 15.1×10⁹/L, red blood cells 5.6×10¹²/L, platelets 112.4×10⁹/L, the platelet distribution width was 19%, the average platelet volume was 11.0 fl, and the ratio of large platelets was 41%. On the third day after birth, the hood was changed to inhale oxygen, but when quiet, the heart rate gradually increased to 150 beats/min, the precordial beat was enhanced, and the left margin of the sternum heard a systolic murmur of grade 2/6, and the water pulse could be palpable. Blood type B natriuretic peptide 861 ng/L; Patent ductus arteriosus was confirmed by echocardiography, with a catheter diameter of 2.5 mm, a ratio of left atrial diameter/aortic diameter of 1.9, and pulmonary regurgitation in diastole. Meeting the diagnostic criteria for haemodynamically significant patent ductus arteriosus (hsPDA), acetaminophen suspension was given at 15 mg/kg every 6 hours for a total of 12 doses. There was no significant improvement in PDA symptoms on the 6th day after birth, and re-examination echocardiography confirmed that the ductus arteriosus was still open, with a duct diameter of 2.3 mm; Blood type B natriuretic peptide 884 ng/L; Blood routine: white blood cells 14.1×10⁹/L, red blood cells 5.8×10¹²/L, platelets 84.4×10⁹/L; There were no abnormalities in coagulation function, liver and kidney function and fecal occult blood. Bi-level noninvasive positive pressure ventilation was administered again because the percutaneous oxygen saturation was repeatedly below 90%. According to ref. [1], 20 ml/kg of platelets collected by the machine were infused within 2 h, and furosemide was added once. On the 7th day after birth, the symptoms of PDA were significantly improved, the heart murmur basically disappeared, and the head hood was changed to oxygen inhalation again. On the 8th day after birth, the reexamination of the heart color ultrasound showed that the ductus arteriosus was closed. Blood routine on day 9 after birth: white blood cells 16.10×10⁹/L, red blood cells 4.46×10¹²/L, platelets 340.4×10⁹/L; Blood type B natriuretic peptide 142 ng/L. Cardiac color ultrasound reexamination 6 months after birth showed that the ductus arteriosus did not reopen.

The proband was a 3-year-old female who went to the Department of Pediatrics of Zhuhai Maternal and Child Health Hospital for "dizziness and fatigue for half a year". Physical examination showed anemia face. B-ultrasound examination showed a slightly larger left ventricle and mild tricuspid regurgitation. The liver was enlarged, the oblique diameter of the right lobe of the liver was 9.0 cm, and the length of the liver could be detected under the right costal margin of 2.5 cm. The spleen is slightly larger, with a spleen thickness of 2.9 cm, and a spleen length of 1.9 cm can be detected under the left costal margin. Laboratory tests: hemoglobin (HGB) 80 g/L (reference range: 110-150 g/L), mean red blood cell volume (MCV) 72.6 fl (reference range: 82-95 fl), mean red blood cell hemoglobin content (MCH) 23.9 pg (reference range: 27-31 pg), red blood cell distribution width (RDW) 23.9% (reference range: 10.0%-14.9%), hemoglobin A2 (HbA2) 3.1% (reference range: 1.3%-3.5%), fetal hemoglobin (HbF) 63.1% (reference range:<2%)。 According to its hematological phenotype screening results were microcytic hypochromic anemia with uneven red blood cell size, which was suspected to be intermediate beta-thalassemia. After routine thalassemia genetic diagnosis, only one β-thalassemia heterozygous mutation, namely CD17 (A>T), was found. The genotype results suggested minor beta-thalassemia, which did not match the screening results. With informed consent, the venous blood of the child's grandfather, grandmother, father, mother and younger brother was collected for blood cell, hemoglobin analysis and thalassemia gene testing.

Male, 4 months old, was admitted to hospital in July 2014 due to "repeated abdominal distension, constipation, growth and development retardation after birth". He was the first child and the first child, delivered naturally at full term, with a birth weight of 3 800 g. He had no relevant family history and no hereditary diseases in the family. The parents are in good health, and there is nothing special during pregnancy. Prenatal B-ultrasound at 28 weeks of pregnancy showed that the fetus had a large bladder, right hydronephrosis, and right ureteral dilatation. The external hospital considered the posterior urethral valve, and oligohydramnios at birth. About 24 hours after birth, the fetus was exhausted in 3 days, and it could urinate by itself. After urination, the B-ultrasound reexamination still showed bladder enlargement, no hydronephrosis and ureteral dilatation. Diarrhea twice on 20 days and 30 days after birth, accompanied by vomiting and dehydration in severe cases, and slightly improved after symptomatic treatment. At 56 days, laparotomy in a foreign hospital found severe abdominal adhesions, and intestinal adhesiolysis was performed. Postoperative abdominal distension improved once and reappeared after eating. 90 days after birth, intestinal adhesiolysis + ileal inverted T-stomy was performed again. Intraoperative colon biopsy revealed intestinal ganglion dysplasia, inability to feed normally after operation, repeated sepsis and dehydration, and came to our hospital for further treatment.

Lung diseases of various causes and respiratory failure are common diseases in newborns, and they are also the first cause of hospitalization and death^[1]Therefore, the research on the diagnosis and treatment of neonatal lung diseases has always been the key topic of neonatal medicine. For a long time, the diagnosis and differential diagnosis of lung diseases mainly rely on traditional chest X-ray and CT examination, and it has even been regarded as the "gold standard" for the diagnosis of many lung diseases and has become an indispensable imaging examination method in clinical practice. However, chest X-ray and CT examination have obvious limitations: it is difficult for severe children to make timely diagnosis because they are not suitable for moving, and may delay their condition or even cause serious consequences; It is difficult to check at any time and is inconvenient for dynamic observation, and may lead to missed diagnosis or misdiagnosis of some diseases, especially when the condition suddenly changes and examination is particularly needed. Radiation injury is difficult to avoid completely, especially chest CT scan radiation is more harmful, which has a potential high risk of DNA damage and cancer^[2]。 Because radiation damage is more sensitive to cells in the differentiation stage, it may cause greater potential harm to newborns and premature infants in the rapid development stage. Especially those severely ill newborns and immature premature infants in the neonatal intensive care unit (NICU) are frequently exposed to radiation due to lung disease or other diseases that need to be excluded, and it is difficult to estimate the cumulative dose of active and passive radiation injury suffered during hospitalization. Therefore, it is urgent to actively find alternative and reliable examination and diagnosis methods suitable for neonatal clinical application.

Preterm birth is the leading cause of perinatal complications and even death. Due to the improvement of health and medical conditions and the development of pediatric intensive care, the survival rate of premature infants increases, but premature birth will involve later developing tissues and organs, including the nervous system and lungs, and cause intraventricular hemorrhage, necrotizing enterocolitis and bronchopulmonary dysplasia (BPD). Surviving premature infants are prone to long-term health problems, which seriously affect the children's quality of life and bring a heavy burden to their families and society^[1]。 The new advances in genetic analysis of BPD at home and abroad are reviewed.

Klebsiella pneumoniae (Klebsiella pneumoniae, KP), an opportunistic pathogen, is one of the common pathogens causing community-acquired infections and nosocomial infections, showing a global epidemic trend. Carbapenene antibiotics are often the last choice when controlling KP infection. However, with the widespread use of carbapenem antibiotics in recent years, carbapenem-resistant Klebsiella pneumoniae (carbapenem-resistantKlebsiella pneumoniaeCRKP) gradually emerged and became widespread, and CRKP was repeatedly detected in children with ventilator-associated pneumonia and other types of infection in intensive care units (PICUs). CRKP infection is difficult to control and has a high mortality rate, which has become an independent risk factor for hospital death^[1]。 The infection status and treatment progress of CRKP are reviewed.

brain injury in premature infants (BIPI) is the primary cause of cognitive dysfunction and cerebral palsy in premature infants, which seriously affects the quality of life of premature infants, and also brings a heavy burden to families and society^[1]。 In the past 20 years, with the further improvement of the treatment level of premature infants, the survival rate of ultra-premature infants has increased significantly (50% ~70%), and the accompanying neurodevelopmental disorders have also increased significantly. Numerous studies have shown that at least 1 in 4 survivors develop cerebral palsy, and the incidence of neurodysplasia is more than 50%^[2]。 The etiology of BIPI is very complex and the mechanism is not very clear. Various pathological changes can lead to neurodevelopmental disorders in premature infants. According to the pathogenesis, it can be divided into two types: hemorrhagic injury and ischemia-hypoxic injury. The former is mainly germinal stroma-intraventricular hemorrhage, while the latter is periventricular leukomalacia (PVL). The incidence of BIPI was negatively correlated with gestational age at birth. It is speculated that the immature development of cerebral vascular structure and the imperfect regulation mechanism of cerebral blood flow in premature infants may be the pathological basis of BIPI. neurovascular unit (NVU) refers to a system composed of neurons, glia and blood vessels, including neurons, astrocytes, microglia, vascular endothelial cells, vascular pericytes, basement membrane and extracellular matrix. The interaction between these components maintains the normal physiological function of neurons and the repair after injury. Vascular neurofactors are a large class of cytokines that can act on NVU, promote angiogenesis, regulate vascular remodeling and blood-brain barrier permeability, regulate nerve cell metabolism and promote nerve cell regeneration. These vascular neurofactors act on NVU in different ways, regulate its structure and function, and play an important role in maintaining normal physiological function of neurons and repair after injury. This paper reviews the recent advances in cerebrovascular development of premature infants and the protective mechanism of vascular neurofactors against NVU in BIPI.

Therapeutic studies in the field of pediatrics are mainly non-randomized clinical trials or observational studies. The main reason is that the feasibility of randomized controlled studies in pediatrics is limited. If you participate in the study, there is a 50% chance of being assigned to the control group, and parents will definitely have doubts. In view of this, Zelen's design may be a good solution, which not only retains the advantages of randomization, ensures good comparability between groups, but also takes into account the wishes of the parents of the children, and has good feasibility.