超出生体重児に対する早期デキサメサゾン投与の有用性 : National Institute of Child Health and Human Development Neonatal research Network報告 (海外誌掲載論文の和文概要とそれに対するコメント)

Objective: T o de v elop a North American Society for Pediatric Ga str oen te rol og y , He pat olo gy , and Nut ri tio n (N ASP GH AN) and Eu rop ea n Soc ie ty fo r Pe di atr ic Gas tr oen te ro log y , Hep at ol og y , and Nut rit io n (ES PGH AN ) int er nat io nal con se ns us on th e di agn os is an d ma nag em ent of gas tr oes op hag eal refl ux and gas tr oes op hag eal re flu x di sea se in th e ped ia tr ic po pu la tio n. Methods: An international panel of 9 pediatric gastroenterologists and 2 epidemiologists were selected by both societies, which de v eloped these guidelines based on the Delphi principle. Statements were based on systematic literature searches using the best-av ailable e vidence from PubMed, Cumulati ve Index to Nursing and Allied Health Literature, and bibliographies. The committee con v ened in face-to-face meetings 3 times. Consensus was achie v ed for all recommendations through nominal group technique, a structured, quantitati v e method. Articles were e v aluated using the Oxford Centre for Evidence-based Medicine Le vels of Evidence. Using the Oxford Grades of Recommendation, the quality of e vidence of each of the recommendations made by the committee was determined and is summarized in appendices. Results: More than 600 articles were re vie wed for this work. The document provides e vidence-based guidelines for the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population. Conclusions: Th is do cum ent is int end ed to be us ed in dai ly pra cti ce fo r th e de v el op me nt of fut ure cli ni cal pra ct ic e gu ide lin es and as a bas is for cli ni cal tr ia ls . JP GN 49 :49 8 – 54 7, 20 09 . Ke y Wo rd s: Cli nic al pra ct ic e gu id el ine s — Di agn os tic te sts — Ga str oes op hag ea l refl ux (GE R) — Ga str oes op hag ea l refl ux di sea se (GE RD ) — The rap eut ic mod al iti es. # 20 09 by Eu rop ea n Soc ie ty fo r Pe di atr ic Gas tr oen te ro log y , Hep at ol og y , and Nut rit io n and No rt h Am er ica n So ci ety for Pe dia tri c Ga str oen te rol og y , Hep at ol og y , an d Nu tr iti on

/pdf/pediatric-gastroesophageal-reflux-clinical-practice-359og269ui.pdf

Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)

HEALTH AND DEPRIVATION: Inequality and the north

Despite a major decrease in the incidence of sudden infant death syndrome (SIDS) since the American Academy of Pediatrics (AAP) released its recommendation in 1992 that infants be placed for sleep in a nonprone position, this decline has plateaued in recent years. Concurrently, other causes of sudden unexpected infant death occurring during sleep (sleep-related deaths), including suffocation, asphyxia, and entrapment, and ill-defined or unspecified causes of death have increased in incidence, particularly since the AAP published its last statement on SIDS in 2005. It has become increasingly important to address these other causes of sleep-related infant death. Many of the modifiable and nonmodifiable risk factors for SIDS and suffocation are strikingly similar. The AAP, therefore, is expanding its recommendations from being only SIDS-focused to focusing on a safe sleep environment that can reduce the risk of all sleep-related infant deaths including SIDS. The recommendations described in this report include supine positioning, use of a firm sleep surface, breastfeeding, room-sharing without bed-sharing, routine immunization, consideration of a pacifier, and avoidance of soft bedding, overheating, and exposure to tobacco smoke, alcohol, and illicit drugs. The rationale for these recommendations is discussed in detail in this technical report. The recommendations are published in the accompanying "Policy Statement--Sudden Infant Death Syndrome and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment," which is included in this issue (www.pediatrics.org/cgi/doi/10.1542/peds.2011-2220).

SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(07)61662-6.pdf

Sudden infant death syndrome

OBJECTIVE. Prematurely born compared with term born infants are at increased risk of sudden infant death syndrome, particularly if slept prone. The purpose of this work was to test the hypothesis that preterm infants with or without bronchopulmonary dysplasia being prepared for neonatal unit discharge would sleep longer and have less arousals and more central apneas in the prone position. METHODS. This was a prospective observational study in a tertiary NICU. Twenty-four infants (14 with bronchopulmonary dysplasia) with a median gestational age of 27 weeks were studied at a median postconceptional age of 37 weeks. Video polysomnographic recordings of 2-channel electroencephalogram, 2-channel electro-oculogram, nasal airflow, chest and abdominal wall movements, limb movements, electrocardiogram, and oxygen saturation were made in the supine and prone positions, each position maintained for 3 hours. The duration of sleep, sleep efficiency (total sleep time/total recording time), and number and type of apneas, arousals, and awakenings were recorded. RESULTS. Overall, in the prone position, infants slept longer, had greater sleep efficiency (89.5% vs 72.5%), and had more central apneas (median: 5.6 vs 2.2), but fewer obstructive apneas (0.5 vs 0.9). The infants had more awakenings (9.7 vs 3.5) and arousals per hour (13.6 vs 9.0) when supine. There were similar findings in the bronchopulmonary dysplasia infants. CONCLUSIONS. Very prematurely born infants studied before neonatal unit discharge sleep more efficiently with fewer arousals and more central apneas in the prone position, emphasizing the importance of recommending supine sleeping after neonatal unit discharge for prematurely born infants.

Effect of Prone and Supine Position on Sleep, Apneas, and Arousal in Preterm Infants

Concerns regarding gastroesophageal reflux (GER) and associated apnea episodes result in some practitioners having convalescent, prematurely born infants sleep in the prone position. We have tested the hypothesis that such infants would not suffer from clinically important acid GER or associated apnea episodes more in the supine compared with the prone position. Lower esophageal pH was measured and videopolysomnographic recordings of nasal airflow, chest and abdominal wall movements, electrocardiographic activity, and oxygen saturation were made on two successive days of 21 premature infants (median gestational age 28 wk) at a median postmenstrual age (PMA) of 36 wk. On each day, the infants were studied prone and supine. The acid reflux index was higher in the supine compared with the prone position (median 3% versus 0%, p = 0.002), but was low in both positions. The number of obstructive apnea episodes per hour was higher in the supine position (p = 0.008). There were, however, no statistically significant correlations between the amount of acid GER and the number of either obstructive or total apnea episodes in either the supine or prone position. Supine compared with prone sleeping neither increases clinically important acid GER nor obstructive apnea episodes associated with acid GER in asymptomatic, convalescent, prematurely born infants.

/pdf/acid-gastroesophageal-reflux-in-convalescent-preterm-infants-167s8cz46u.pdf

Acid gastroesophageal reflux in convalescent preterm infants: effect of posture and relationship to apnea.

“New” bronchopulmonary dysplasia (BPD) has been suggested to be a maldevelopment sequence with reduced alveolarisation of the lungs; affected infants then would be predicted to have low lung volumes. The aim of this study was to test that hypothesis by comparing the lung volumes of infants who had had mild-moderate BPD with those without BPD of similar postmenstrual age. Lung volumes of 17 infants who had mild-moderate BPD (oxygen dependent beyond 28 days, but not past term) (BPD infants) were compared to those of 17 infants without BPD (non-BPD infants). All were born at less than 33 weeks of gestation and studied at postmenstrual ages of 33 to 39 weeks. Lung volume was assessed by measurement of functional residual capacity (FRC). The BPD infants had lower lung volumes (median 19.1 ml/kg) than the non-BPD infants (median 26.5 ml/kg) (p=0.0001). The BPD compared to the non-BPD infants were of greater postnatal age (p=0.0003), born at a lower gestational age (p=0.0001) and of lighter birthweight (p=0.0001). Regression analysis, however, demonstrated that lung volume was significantly related to BPD status (p=0.005), independently of postnatal age, birthweight and gestational age. It is concluded that the lower lung volumes of the infants who had had mild-moderate BPD support the hypothesis that new BPD is associated with poor alveolarisation.

Lung volumes in infants who had mild to moderate bronchopulmonary dysplasia.

Background: Term newborns can compensate fully for an imposed dead space (tube breathing) by increasing their minute ventilation. Objective: To test the hypothesis that infants of smoking mothers would have an impaired response to tube breathing. Design: Prospective study. Setting: Perinatal service. Patients: Fourteen infants of smoking and 24 infants of non-smoking mothers (median postnatal age 37 (11–85) hours and 26 (10–120) hours respectively) were studied. Interventions: Breath by breath minute volume was measured at baseline and when a dead space of 4.4 ml/kg was incorporated into the breathing circuit. Main outcome measures: The maximum minute ventilation during tube breathing was determined and the time constant of the response calculated. Results: The time constant of the infants of smoking mothers was longer than that of the infants of non-smoking mothers (median (range) 37.3 (22.2–70.2) v 26.2 (13.8–51.0) seconds, p  =  0.016). Regression analysis showed that maternal smoking status was related to the time constant independently of birth weight, gestational or postnatal age, or sex (p  =  0.018). Conclusions: Intrauterine exposure to smoking is associated with a dampened response to tube breathing.

https://fn.bmj.com/content/fetalneonatal/90/4/F316.full.pdf

Dampened ventilatory response to added dead space in newborns of smoking mothers.

Rationale: Infants of mothers who smoked (S) or substance misused (SM) during pregnancy have an increased risk of sudden infant death syndrome (SIDS).Objectives: To test the hypothesis that infants of S and SM mothers compared with infants of non–substance-misusing, nonsmoking mothers (control subjects) would have a reduced ventilatory response to hypercarbia and that any reduction would be greater in the SM infants.Methods: Infants were assessed before maternity/neonatal unit discharge. Maternal and infant urine samples were obtained and tested for cotinine, cannabinoids, opiates, amphetamines, methadone, cocaine, and benzodiazepines.Measurements and Main Results: Respiratory flow and Vt were measured using a pneumotachograph inserted into a face mask placed over the infant’s mouth and nose. The ventilatory responses to three levels of inspired carbon dioxide (0 [baseline], 2, and 4% CO2) were assessed. Twenty-three SM, 34 S, and 22 control infants were assessed. The birth weight of the control subjects ...

Ravindra Bhat

Papers

Effect of Prone and Supine Position on Sleep, Apneas, and Arousal in Preterm Infants

Acid gastroesophageal reflux in convalescent preterm infants: effect of posture and relationship to apnea.

Lung volumes in infants who had mild to moderate bronchopulmonary dysplasia.

Dampened ventilatory response to added dead space in newborns of smoking mothers.

Ventilatory Response to Hypercarbia in Newborns of Smoking and Substance-Misusing Mothers