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Vol 14, No 5
Vol 14, No 5 October 2018 ISSN 1708-8569
Review articles
Original articles
Pediatric clinical practice guidelines in China: still a long way to go
  Jie Chen
  [Abstract] [Full Text] [PDF]  
Review articles:
Chinese guidelines for the assessment and provision of nutrition support therapy in critically ill children
  Xue-Mei Zhu, Su-Yun Qian, Guo-Ping Lu, Feng Xu, Ying Wang, Chun-Feng Liu, Xiao-Xu Ren, Yu-Cai Zhang, Heng-Miao Gao, Tao Zhou, Hong-Xing Dang, Chong-Fan Zhang, Yi-Min Zhu
Background: This document represents the first evidence-based guidelines to describe best practices in nutrition therapy in critically ill children (> 1 month and < 18 years), who are expected to require a length of stay more than 2 or 3 days in a Pediatric Intensive Care Unit admitting medical patients domain.
Methods: A total of 25,673 articles were scanned for relevance. After careful review, 88 studies appeared to answer the preidentified questions for the guidelines. We used the grading of recommendations, assessment, development and evaluation criteria to adjust the evidence grade based on the quality of design and execution of each study.
Results: The guidelines emphasise the importance of nutritional assessment, particularly the detection of malnourished patients. Indirect calorimetry (IC) is recommended to estimate energy expenditure and there is a creative value in energy expenditure, 50 kcal/kg/day for children aged 1-8 years during acute phase if IC is unfeasible. Enteral nutrition (EN) and early enteral nutrition remain the preferred routes for nutrient delivery. A minimum protein intake of 1.5 g/kg/day is suggested for this patient population. The role of supplemental parenteral nutrition (PN) has been highlighted in patients with low nutritional risk, and a delayed approach appears to be beneficial in this group of patients. Immune-enhancing cannot be currently recommended neither in EN nor PN.
Conclusion: Overall, the pediatric critically ill population is heterogeneous, and an individualized nutrition support with the aim of improving clinical outcomes is necessary and important.
  [Abstract] [Full Text] [PDF]  
Chinese clinical practice guidelines for acute infectious diarrhea in children
  Jie Chen, Chao-Min Wan, Si-Tang Gong, Feng Fang, Mei Sun, Yuan Qian, Ying Huang, Bao-Xi Wang, Chun-Di Xu, Li-Yan Ye, Mei Dong, Yu Jin, Zhi-Hua Huang, Qin-Bing Wu, Chao-Min Zhu, You-Hong Fang, Qi-Rong Zhu, Yong-Sui Dong
Background: The guidelines addressed the evidence-based indications for the management of children with acute infectious diarrhea in Chinese pediatric population.
Data sources: The experts group of evidence development put forward clinical problems, collects evidence, forms preliminary recommendations, and then uses open-ended discussions to form recommendations. The literature review was done for developing this guideline in databases including PubMed, Cochrane, EMBASE, China Biomedical Database, and Chinese Journal Full-text Database up to June 2013. Search the topic ¡°acute diarrhea¡± or ¡°enteritis¡± and ¡°adolescent¡± or ¡°child¡± or ¡°Pediatric patient¡± or ¡°Baby¡± or ¡°Infant¡±.
Results: For the treatment of mild, moderate dehydration, hypotonic oral rehydration solutions (ORS) are strongly recommended. Intravenous (IV) rehydration is recommended for severe dehydration, with a mixture of alkali-containing dextrose sodium solution. Nasogastric feeding tube rehydration is used for children with severe dehydration without IV infusion conditions with ORS solution. Regular feeding should resume as soon as possible after oral rehydration or IV rehydration. The lactose-free diet can shorten the diarrhea duration. Zinc supplements are recommended in children with acute infectious diarrhea. Saccharomyces boulardii and Lactobacillus Rhamnus are recommended to be used in acute watery diarrhea. Saccharomyces boulardii is recommended in children with antibiotic-associated diarrhea as well. Montmorillonite and Racecadotril (acetorphan) can improve the symptoms of diarrhea or shorten the course of acute watery diarrhea. Antibiotics are recommended with dysenteric-like diarrhea, suspected cholera with severe dehydration, immunodeficiency, and premature delivery children with chronic underlying disease; otherwise, antibiotics are not recommended.
Conclusion: The principles of the most controversial treatments with of acute infectious disease are reaching to a consensus in China.
  [Abstract] [Full Text] [PDF]  
Chinese guidelines for the diagnosis and treatment of hand, foot and mouth disease (2018 edition)
  Xing-Wang Li, Xin Ni, Su-Yun Qian, Quan Wang, Rong-Meng Jiang, Wen-Bo Xu, Yu-Cai Zhang, Guang-Jun Yu, Qiang Chen, Yun-Xiao Shang, Cheng-Song Zhao, Hui Yu, Ting Zhang, Gang Liu, Hui-Ling Deng, Jie Gao, Xian-Gui Ran, Qiao-Zhi Yang, Bian-Li Xu, Xue-Yong Huang, Xing-Dong Wu, Yi-Xiao Bao, Yi-Ping Chen, Zhi-Hai Chen, Qing-Quan Liu, Guo-Ping Lu, Chun-Feng Liu, Rong-Bing Wang, Guo-Liang Zhang, Fang Gu, Hong-Mei Xu, Ying Li, Tao Yang
Background: Hand, foot, and mouth disease (HFMD) is a common infectious disease in childhood caused by an enterovirus (EV), and which is principally seen in children under 5 years of age. To promote diagnostic awareness and effective treatments, to further standardize and strengthen the clinical management and to reduce the mortality of HFMD, the guidelines for diagnosis and treatment have been developed.
Methods: National Health Commission of China assembled an expert committee for a revision of the guidelines. The committee included 33 members who are specialized in diagnosis and treatment of HFMD.
Results: Early recognition of severe cases is utmost important in diagnosis and treatment of patients with HFMD. The key to diagnosis and treatment of severe cases lies in the timely and accurate recognition of stages 2 and 3 of HFMD, in order to stop progression to stage 4. Clinicians should particularly pay attention to those EV-A71 cases in children aged less than 3 years, and those with disease duration less than 3 days. The following indicators should alert the clinician of possible deterioration and impending critical disease: (1) persistent hyperthermia; (2) involvement of nervous system; (3) worsening respiratory rate and rhythm; (4) circulatory dysfunction; (5) elevated peripheral WBC count; (6) elevated blood glucose and (7) elevated blood lactic acid. For treatment, most mild cases can be treated as outpatients. Patients should be isolated to avoid cross-infection. Intense treatment modalities should be given for those severe cases.
Conclusion: The guidelines can provide systematic guidance on the diagnosis and management of HFMD.
  [Abstract] [Full Text] [PDF]  
Original articles:
Elevated serum neopterin levels in children with functional constipation: association with systemic proinflammatory cytokines
  Ceren Cıralı, Emel Ulusoy, Tuncay Kume, Nur Arslan
Background: Functional constipation is a clinical problem with an incompletely understood etiology. Functional bowel diseases have been shown to be related to inflammation in many studies in adults. In this study, we aimed to evaluate leukocytes, C-reactive protein, proinflammatory and anti-inflammatory cytokines, and neopterin levels in children with functional constipation.
Methods: Seventy-six children with constipation and 71 healthy controls (mean age 7.12 ¡À 3.46 years and 7.32 ¡À 4.33 years, respectively, P = 0.991) were included in the study. Leukocytes, C-reactive protein, interleukin (IL)-1¦Â, IL-6, IL-10, IL-12, tumor necrosis factor-alpha (TNF-¦Á) and neopterin levels were assessed in patients and healthy controls. Parameters were measured in the serum using enzyme-linked immunosorbent assay methods.
Results: Mean IL-6 (20.31 ¡À 12.05 vs. 16.2 ¡À 10.25 pg/mL, respectively, P = 0.003), IL-12 (181.42 ¡À 133.45 vs.
135.6 ¡À 83.67 pg/mL, respectively, P = 0.018) and neopterin levels (2.08 ¡À 1.12 vs. 1.52 ¡À 1.02 pg/mL, respectively, P = 0.001) were significantly higher in constipated children than healthy controls. Leukocyte and thrombocyte counts, C-reactive protein, and IL-1¦Â, IL-10 and TNF-¦Á levels did not show any difference between the two groups.
Conclusions: In this study, IL-6, IL-12 and neopterin levels of constipated patients were found to be higher than those of controls. These results indicate the presence of subclinical inflammation in children with functional constipation.
  [Abstract] [Full Text] [PDF]  
Health correlates, addictive behaviors, and peer victimization among adolescents in China
  Qi-Qi Chen, Meng-Tong Chen, Yu-Hong Zhu, Ko Ling Chan, Patrick Ip
Background: Peer victimization has been recognized as a common social problem affecting children and adolescents in all parts of the world. This study aims to examine the prevalence of different types of peer victimization and to evaluate the associations between peer victimization and health correlates.
Methods: Using a large population sample of 18,341 adolescents aged 15-17 years from 6 cities in China, this study estimated the prevalence of different types of peer victimization, addictive behaviors, and health-related variables with self-administrated questionnaires. A three-phase logistical regression analysis was conducted to investigate the associations between peer victimization and addictive behaviors as well as health-related factors among adolescents.
Results: A total of 42.9% of the surveyed Chinese adolescents have been bullied by peers, with boys reporting higher rate on overt victimization (36.9%) and girls on relational forms (33.9%). School environment (34.7%) was the most frequent scene of peer violence, followed by neighborhood, family, and internet. Addictive behaviors except substance abuse were found related to higher possibility of peer victimization (aOR 1.21-1.73, P < 0.001). Peer victimization was significantly associated with more depressive symptoms, post-traumatic stress disorder symptoms, and suicide ideation and deliberate self-harm (aOR 1.05-2.27, P < 0.001), and poorer self-esteem and health-related quality of life (aOR 0.95-0.97, P < 0.001).
Conclusion: Possible explanations of the associations found in this study are discussed and implications for future services are raised.
  [Abstract] [Full Text] [PDF]  
Associations of non-high-density lipoprotein cholesterol with metabolic syndrome and its components in Korean children and adolescents: the Korea National Health and Nutrition Examination Surveys 2008¨C2014
  Yong Min Kim, So Hyun Kim, Young Suk Shim
Background: In this study, we aimed to investigate the relationship between single-gender Korean references for non-high-density lipoprotein cholesterol (non-HDL-C) and metabolic syndrome (MetS) in childhood.
Methods: A total of 5742 Korean children aged 10-18 years who participated in a national survey were included. The subjects were classified into three groups based on single-gender non-HDL-C levels as follows: < 120 mg/dL (desirable), ¡Ý 120 and < 150 mg/dL (borderline high), and ¡Ý 150 mg/dL (high).
Results: Males in the borderline high non-HDL-C group had odds ratios (ORs) of 2.86 (95% confidence interval, 2.30-3.56) for elevated triglycerides (TG), 1.73 (1.08-1.79) for reduced high-density lipoprotein cholesterol (HDL-C) and 1.73 (1.08-2.78) for MetS compared with males in the desirable non-HDL-C group after adjusting for covariates. Males in the high non-HDL-C group had ORs of 1.65 (1.14-2.41) for elevated blood pressure (BP), 6.21 (4.27-9.05) for elevated TG, and 3.29 (1.49-7.26) for MetS compared with males in the desirable non-HDL-C group. Females in the borderline high non-HDL-C group had ORs of 3.03 (2.43-3.76) for elevated TG, 1.63 (1.13-2.35) for reduced HDL-C, and 4.53 (2.47-8.31) for MetS compared with females in the desirable non-HDL-C group. Females in the high non-HDL-C group had ORs of 1.43 (1.00-2.04) for elevated BP, 6.36 (4.45-9.08) for elevated TG, and 7.64 (3.65-15.96) for MetS compared with females in the desirable non-HDL-C group.
Conclusion: Our results suggest that, in a Korean population, a non-HDL-C level of 120 mg/dL for males and 150 mg/dL for females is the threshold between borderline high and high risk for MetS.
  [Abstract] [Full Text] [PDF]  
High incidence of maternal vitamin B12 deficiency detected by newborn screening: first results from a study for the evaluation of 26 additional target disorders for the German newborn screening panel
  Gwendolyn Gramer, Junmin Fang-Hoffmann, Patrik Feyh, Glynis Klinke, Peter Monostori, J¨¹rgen G. Okun, Georg F. Hoffmann
Background: Newborn screening (NBS) in Germany currently includes 15 target disorders. Recent diagnostic improvements suggest an extension of the screening panel.
Methods: Since August 2016, a prospective study evaluating 26 additional target disorders (25 metabolic disorders and vitamin B12-deficiency) in addition to the German screening panel is performed at the Newborn Screening Center Heidelberg. First-tier results from tandem-MS screening are complemented by second-tier strategies for 15 of the additional target disorders. NBS results of seven patients diagnosed symptomatically with one of the additional target disorders by selective screening since August 2016 are retrospectively evaluated.
Results: Over a 13-month period, 68,418 children participated in the study. Second-tier analyses were performed in 5.4% of samples. Only 59 (0.1%) of study participants had abnormal screening results for one of the additional target disorders. Target disorders from the study panel were confirmed in 12 children: 1 3-hydroxy-3-methylglutaryl coenzyme A (CoA)-lyase deficiency, 1 citrullinemia type I, 1 multiple acyl-CoA dehydrogenase-deficiency, 1 methylenetetrahydrofolate reductase-deficiency, and 8 children with maternal vitamin B12-deficiency. In addition, six of seven patients diagnosed symptomatically outside the study with one of the target disorders would have been identified by the study strategy in their NBS sample.
Conclusions: Within 13 months, the study ¡°Newborn Screening 2020¡± identified additional 12 children with treatable conditions while only marginally increasing the recall rate by 0.1%. Maternal vitamin B12-deficiency was the most frequent finding. Even more children could benefit from screening for the additional target disorders by extending the NBS panel for Germany and/or other countries.
  [Abstract] [Full Text] [PDF]  
Determinants for asthma control, quality of life and use of complementary and alternative medicine in asthmatic pediatric patients in four cities
  Kam Lun Hon, Yan Min Bao, Kate C. Chan, Kin Wai Chau, Rong-Shan Chen, Kun Tat Gary Cheok, Wa Keung Chiu, Li Deng, Chun-Hui He, Kin Mui Ieong, Jeng Sum C. Kung, Ping Lam, Shu Yan David Lam, Qun Ui Lee, So Lun Lee, Ting Fan Leung, Theresa N. H. Leung, Lei Shi, Ka Ka Siu, Wei-Ping Tan, Maggie Haitian Wang, Tak Wai Wong, Bao-Jing Wu, Ada Y. F. Yip, Yue-Jie Zheng, Daniel K. Ng
Background: Asthma is a significant chronic health problem worldwide. Management aims at disease control by reducing functional impairment and exacerbations and improving quality of life (QoL). We report a multi-center study to survey asthma control and QoL in four cities in the Pearl River Delta.
Methods: The conjoint survey involved ten Hong Kong pediatric hospitals/units, two Shenzhen hospitals, two Macau hospitals, and two Guangzhou hospitals on asthma control (using Asthma Control Test) and QoL (Pediatric Allergic Disease Quality of Life Questionnaire, PADQLQ). Acceptability of a treatment is graded as very good/good/fair/poor.
Results: Good asthma control was only reported in 80% subjects in Hong Kong, but higher in sister cities (85-94%, P < 0.001). Allergic rhinitis, ¡°incense burning¡±, and ¡°smoker in family¡± were prevalent among the four cities. Logistic regression showed better control of asthma was associated with better PADQLQ (B = − 0.029, P < 0.001), better acceptability of bronchodilator (B = − 1.488, P = 0.025), negatively with ¡°smoker in family¡± (B = − 0.83, P = 0.015) and various PADQLQ domains. Conversely, worse PADQLQ was associated with allergic rhinitis severity (B = 4.77, P < 0.001), poor control of asthma (B = 7.56, P < 0.001), increased frequency of traditional Chinese medicine use (B = 1.7, P < 0.05), increased frequency of bronchodilator usage (B = 1.05, P < 0.05), ¡°smoker in family¡± (B = 4.05, P < 0.05), and incense burning at home (B = 3.9, P < 0.05).
Conclusions: There are some clinical and cultural differences among the four southern Chinese cities within the Guangdong province. This study identifies potentially modifiable environmental and treatment factors associated with poor asthma control and QoL for health-care interventions. Having a smoker in the family is independently associated with poor asthma control and QoL.
  [Abstract] [Full Text] [PDF]  
The availability of probiotics and donor human milk is associated with improved survival in very preterm infants
  Janet Sharpe, Mandy Way, Pieter J. Koorts, Mark W. Davies
Background: To determine whether the introduction of pasteurized donor human milk and probiotics for infants born < 32 weeks gestational age or < 1500 g birthweight is associated with a reduction in mortality and the incidence of necrotising enterocolitis (NEC) and sepsis.
Methods: We performed a retrospective analysis of two cohorts: before and after the introduction of probiotics and pasteurized donor human milk. Univariate analysis of primary and secondary outcomes was performed; variables impacting outcomes were assessed using multivariate logistic regression.
Results: There were 1791 infants: 1334 in the pre-donor milk/probiotic cohort and 457 in the post-donor milk/probiotic cohort. On univariate analysis, mortality (7.6 vs. 2.4%, P < 0.001) and incidence of sepsis (6.2 vs. 3.5%, P = 0.028) were statistically significantly lower in the post-donor milk/probiotic group. NEC (2.8 vs. 1.5%, P = 0.14) and non-NEC associated gastrointestinal perforation (1.6 vs. 0.4%, P = 0.052) were lower in the post-donor milk/probiotics cohort, but these were not statistically significant. The difference in mortality remained statistically significant on multivariate analysis in the post-donor milk/probiotic cohort compared to those in the pre-donor milk/probiotic cohort (odds ratio 0.31, 95% confidence interval 0.16-0.61). The decrease in the incidence of NEC was consistent with previous observational studies but the difference was not statistically significant.
Conclusion: The availability of probiotics and pasteurised donor human milk is associated with a reduction in mortality in very preterm infants.
  [Abstract] [Full Text] [PDF]  
Clinical features of postinfectious bronchiolitis obliterans in children undergoing long-term nebulization treatment
  Xiao-Mei Zhang, Ai-Zhen Lu, Hao-Wei Yang, Li-Ling Qian, Li-Bo Wang, Xiao-Bo Zhang
Background: Limited data are available in relation to the clinical features of PIBO undergoing prolonged nebulization treatment with budesonide, terbutaline and ipratropium bromide. This retrospective study aimed to outline the features of clinical, high-resolution computed tomography (HRCT) and pulmonary function test (PFT) of PIBO, undergoing maintenance therapy utilizing a triple nebulization treatment and to determine the factors associated with prognosis.
Methods: Children diagnosed with PIBO were followed up between April 2014 and March 2017. The clinical features after maintenance nebulization treatment for 12 months were thereafter summarized.
Results: Thirty patients, 21 boys and 9 girls, were enrolled in the study. The median age of patients was 17.4 months, with a range between 3.0 and 33 months. Persistent coughing and wheezing were detected whilst wheezing and crackles were the common manifestations presented. HRCT scans revealed patchy ground and glass opacity, while PFT showed fixed airway obstruction in all patients. Four patients were lost during follow-up. After treatment, the clinical symptoms were improved greatly in all patients (P < 0.01). The mean increase in the percentage of TPEF%TE and VPEF%VE were improved greatly (P < 0.01). Images of the HRCT scan indicated marked improvements in 18 patients (81.8%) in comparison with scans obtained pre-treatment.
Conclusions: Our data suggest a potential role of long-term nebulization treatment of budesonide, terbutaline, ipratropium bromide on PIBO, due to its efficacy as indicated in the improved clinical symptoms, pulmonary functions and CT manifestations identified in the children. New prospective and controlled studies are required to confirm this proposition.
  [Abstract] [Full Text] [PDF]  
Phlegmonous appendicitis in children is characterized by eosinophilia in white blood cell counts
  Maximiliane I. Minderjahn, Dag Schadlich, Josephine Radtke, Karin Rothe, Marc Reismann
Background: Phlegmonous and complicated appendicitis represent independent entities depending on hereditary immunological mechanisms. However, clinically there are no means to distinguish uncomplicated phlegmonous from complicated mappendicitis. The ability to distinguish these two forms of appendicitis is relevant as current attempts are to treat both forms of the disease differently. The aim of the present study was to investigate differences in white blood cell counts (WBCs) in these conditions to identify areas of interest for future molecular studies.
Methods: White blood cell counts of patients aged between 7 and 14 years who underwent appendectomy from January 2008 to June 2016 were investigated with special reference to particular cellular subpopulations.
Results: A total of 647 children were included in the study. Within distinct inflammatory patterns, significant eosinophilia and basophilia were found in phlegmonous inflammation compared with complicated inflammation (0.11 ¡À 0.19 ¡Á 109/L vs. 0.046 ¡À 0.104 ¡Á 109/L, P < 0.0001, and 0.033 ¡À 0.031 ¡Á 109/L vs. 0.028 ¡À 0.024 ¡Á 109/L, P < 0.001).
Conclusions: Compared with complicated disease, phlegmonous appendicitis seems to depend primarily on eosinophil inflammation. This observation is stable over time and indicates a direction for investigation of underlying genetic prerequisites.
  [Abstract] [Full Text] [PDF]  
Surgical outcome after complete repair of tetralogy of Fallot with absent pulmonary valve: comparison between bovine jugular vein-valved conduit and monocusp-valve patch
  En-Shi Wang, Xue-Song Fan, Li Xiang, Shou-Jun Li, Hao Zhang
Background: The prognosis of tetralogy of Fallot with absent pulmonary valve (TOF/APV) without operation is poor. We evaluated the surgical outcome of TOF/APV in a single center.
Methods: Twenty-two TOF/APV patients underwent complete surgical correction in our hospital. Right ventricular outflow tract reconstruction was performed using bovine jugular vein (BJV)-valved conduit implantation (n = 10), homograft-valved conduit implantation (n = 2), or monocusp-valve patch (n = 10). Health-related quality of life (QOL) was evaluated during follow-up.
Results: The overall survival at 5 and 10 years was 86.4 ¡À 7.3% (confidence interval 69.4-97.2%). The survival rates were significantly different between patients with and without bronchial stenosis (40 and 100%, P = 0.0003, log-rank test). The survival of patients aged > 6 months was higher than those ¡Ü 6 months (100 vs. 40%, P = 0.0003, log-rank test). Patients with BJV-valved conduits had higher systolic gradients from the right ventricle to the pulmonary artery (RV-PA) compared to those with monocusp-valve patches. BJV-valved conduit implantation was a risk factor for post-operative pulmonary-valve stenosis. The QOL score for patients with BJV-valved conduits was lower than those with monocusp-valve patches (P < 0.05). No reoperation was performed during follow-up.
Conclusions: Bronchial stenosis and lower age (¡Ü 6 months) were the main factors influencing post-operative survival. The use of a BJV-valved conduit was a main reason for RV-PA restenosis; thus, the use of a BJV-valved conduit may increase the need for repeat intervention and decrease the post-operative quality of life.
  [Abstract] [Full Text] [PDF]  
World Journal of Pediatric Surgery
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