美国儿科学会

美国儿科学会

美国儿科学会:关于婴幼儿、儿童和青少年喝果汁的最新推荐

豌豆爸爸 发表了文章 • 7 个评论 • 397 次浏览 • 2017-07-13 09:30 • 来自相关话题

①一岁以下新生儿:不应该喝任何果汁!!!无论什么果汁都不应该去碰,无论什么果汁。
②一岁到三岁的孩子(学步期):每天最多只能喝四个盎司(只有330毫升标准可乐罐的三分之一左右的量!)。
③四到六岁儿童:每天也最多只应该喝下三分之一到二分之一标准可乐罐的量!
④七到十八岁青少年:每天最多只有普通每天早上送到家里的一小瓶牛奶的量!
 
美国儿科学会本文中所提及的『果汁』指的是100%水果汁。
 
本段来自新浪微博 @蕨代霜蛟,为本篇全文的核心概括。

 
摘要

历史上,果汁被儿科医生推荐为维生素C的来源,并且作为健康婴儿和幼儿的额外水源,随着他们的饮食范围扩展到含有较高肾负荷的固体食物。它有时也被推荐用于儿童便秘。果汁作为一种健康的天然维生素来源进行销售,在某些情况下,还作为钙的来源。由于果汁口感好,儿童易于接受。虽然果汁摄入有一些好处,但它也有潜在的危害。果汁中的高含糖量会增加热量消耗和患龋齿的风险。此外,果汁中缺乏蛋白质和纤维会导致体重增加失常(过重或过轻)。儿科医生需要对果汁有足够的了解,以便告知父母和病人如何正确使用。

缩写词:
AAP —美国儿科学会
CYP3A4 —细胞色素 P4503A4

在2008至2013年间,果汁和果汁饮料的销量下降,这可能是由于饮料竞争和日益增长的更健康的食品选择,特别是水果和蔬菜的消费。含有热带水果、茶、运动饮料和能量饮料以及其他组合的饮料,呈现出一系列更新、更时尚的选择。儿童和青少年一直是购买果汁和果汁饮料最多的消费者。健康饮料的选择越来越受欢迎,包括低热量、不含糖的饮料,以及那些来自药草和香料成分的可感知的益处。不幸的是,数据显示,2至18岁的儿童将果汁作为近一半的水果摄入,这样会缺乏膳食纤维和容易导致热量摄入过多。这一比例近年来有所下降。

定义

根据美国食品药品监督管理局(FDA)规定,标签为果汁的产品指的是该产品是100%纯果汁。对于从浓缩液中再造的果汁,标签必须注明该产品是由浓缩物重新制成的。任何饮料,含量小于100%的果汁必须列出果汁产品的百分比,和饮料必须包括一个描述性的词语,如“饮品”、“饮料”或“鸡尾酒”。一般来说,果汁饮料含有10%和99%的果汁,并添加了甜味剂、香料或强化剂,如维生素C或钙。根据FDA的规定,这些成分必须列在标签上。 
果汁成分

水是果汁的主要成分。碳水化合物,包括蔗糖、果糖、葡萄糖和山梨醇,是果汁中排名第二的营养成分。碳水化合物的浓度从11克%(0.44千卡/毫升)到16克%(0.64千卡/毫升)。人乳和标准婴儿配方的碳水化合物的浓度为7克%。

果汁中含有少量的蛋白质和矿物质。有些果汁含有天然的高含量的钾、维生素A和维生素C,此外,一些果汁和果汁饮料添加了维生素C。有些果汁和牛奶具有大致相同的钙含量,但缺乏其他存在于牛奶在中的营养素,如镁和大量的蛋白质。许多这种强化钙的果汁也富含维生素D。果汁中的维生素C和类黄酮可能有长期的健康效果,如降低癌症和心脏病的风险。吃饭的同时饮用含有抗坏血酸的饮料能增加两倍铁的吸收量,这可能对于那些摄入低铁生物利用度食物的儿童来说很重要。

果汁不含脂肪或胆固醇,除非含有果肉,否则也不含纤维。果汁和果汁饮料中的氟化物浓度各有不同。一项研究发现,果汁中的氟化物离子浓度从0.02到2.8 ppm不等。浓缩果汁的氟含量随着复原果汁的水中氟含量变化。

一些制造商专门为婴儿生产果汁。这些果汁不含亚硫酸盐或添加糖,比普通的果汁更贵。

经常被饮用的果汁还包括其他形式。父母经常使用稀释的果汁来治疗便秘或为婴儿和儿童提供补充液体。多达三分之一的青少年喝运动饮料,大约10%至15%的人饮用能量饮料,当儿科医生评估患者的营养摄入情况时应询问这些饮品的使用情况。


与果汁摄取有关的药理学考虑

许多水果(例如葡萄、蓝莓、石榴、苹果)的果汁中含有黄酮类化合物(如柚皮苷、柚皮素、橙皮苷、橙皮苷、柚皮素、槲皮素和山奈酚),它可以减少几种酶和重要的药物转运蛋白的活性。虽然葡萄柚汁的摄入已被证明可以减少肠细胞色素P4503A4(CYP3A4)活性并产生潜在的CYP3A4底物药物(如环孢素、他克莫司、阿托伐他汀、非洛地平、非索非那定,特定的抗逆转录病毒药物)的营养和药物的相互作用(例如,提高生物利用度),但最近的证据表明,柚子汁也可以抑制有机酸转运蛋白活性。除了葡萄柚汁,橘子,苹果所含的黄酮也能减少有机酸转运蛋白OATP2B1活动。虽然葡萄柚汁-CYP3A4底物相互作用和用于产生显著营养药物相互作用的可能性是最充分表征,但是应当注意的是,除了抑制CYP3A4活性,蔓越莓,石榴和蓝莓汁能抑制CYP2C9的酶活性 ,CYP2C9即一种能催化治疗性药物如布洛芬、氟比洛芬、华法林、苯妥英、氟伐他汀和阿米替林的生物转化的细胞色素P450同工酶。 上述任何一种果汁-药物相互作用的临床意义极难根据消化系统的历史情况来预测。
 
在持续时间和幅度较大的相互作用产生的质变是多因素作用的结果,主要包括以下内容:(1)对影响酶或转运蛋白的组成型表达,(2)酶(如CYP2C9)或转运蛋白的显著遗传多态性,(3)不同果汁之间的相对类黄酮的组合物和效力,(4)果汁摄入量和摄入的持续时间(例如,可能需要在成年人中饮用1至2L /天的蔓越莓果汁以产生与华法林的显著相互作用)。在评估潜在的果汁 - 药物相互作用,果汁和药物的联合应用中,其代谢或转运可能是由类黄酮的影响不应该被立即认为是治疗的禁忌症。 必须考虑摄取的果汁的量和类型,表征给定相互作用的具体信息以及服用的药物是否低(如抗逆转录病毒药、钙调磷酸酶抑制剂、钙通道阻滞剂、华法林)或高治疗指数以评估潜在的相互作用。 医师和药剂师之间的协商可以有助于考虑果汁药物相互作用的潜在临床意义。



果汁中碳水化合物的吸收

果汁中的4种主要糖类是蔗糖、葡萄糖、果糖和山梨糖醇。蔗糖是通过存在于小肠上皮中的蔗糖酶水解成两分子的单糖——葡萄糖和果糖。然后,葡萄糖通过活性载体介导的过程在小肠的绒毛边缘被快速吸收。果糖被促进的运输机制通过载体吸收,但不逆浓度梯度。此外,果糖可能被二糖酶相关的转运系统吸收,因为果糖的吸收在葡萄糖存在下更快,当果糖和葡萄糖以等摩尔浓度存在时,发生最大吸收。临床研究显示,当果糖浓度超过葡萄糖(例如苹果和梨汁)时,比这两种糖以相同浓度存在(例如白葡萄汁)时,吸收更快。然而,当以适当的量(10mL / kg体重)提供时,这些不同的果汁也被同样地吸收。梨,苹果,樱桃,杏和李子和无糖食物(例如糖果,口香糖,饮料,冰淇淋)和一些液体药物含有少量的山梨糖醇,山梨糖醇被缓慢的通过被动扩散吸收,因此大部分被摄取的山梨醇未能被吸收。

在小肠中未被吸收的碳水化合物被结肠中的细菌发酵。 这种细菌发酵会产生氢,二氧化碳,甲烷和短链脂肪酸乙酸、丙酸和丁酸。 这些气体和一些脂肪酸中通过结肠上皮被再吸收,并以这种方式,一部分吸收不良的碳水化合物(malabsorbed carbohydrate)可被清除。 未吸收的碳水化合物对胃肠道产生渗透负荷,引起腹泻。

幼儿的腹泻是一种众所周知的良性病症,通常只需从1至4岁的饮食中去除多余的果汁即能产生效果。 然而,在果汁碳水化合物吸收不良,尤其是过量食用时,可导致慢性腹泻、胀气、腹胀、腹痛。 果糖和山梨醇最常见,但特定碳水化合物的比例也可能很重要。 大量摄取果汁可能导致的碳水化合物吸收不良是一些卫生保健提供者推荐用于治疗便秘,尤其是婴幼儿便秘的基础。 北美小儿胃肠病学,肝病学和营养便秘学指南建议利用一些果汁(如西梅脯,梨和苹果汁)中所含的山梨糖醇和其他碳水化合物来帮助增加婴儿粪便的频率和含水量来治疗婴儿便秘。

美国人饮食指南中的果汁相关策略

2015年出版的最新版本的美国人饮食指南的基本前提是,是关注高营养食品。水果是膳食指南中头号关键重点食品。水果与蔬菜一起被推荐提供必需的维生素和矿物质,降低心血管疾病的风险,有可能防止癌症,并抑制摄入过多的热量。例如,每天消耗约1000千卡(取决于体型大小,1-4岁)的儿童每天应该喝约1杯水果,而消费大约2000千卡/天(取决于体型大小,10-18岁)的儿童,每天应消耗约2杯水果。尽管鼓励摄入整个水果,但最多可以以100%果汁(不是水果饮料)的形式提供一半水果。 6盎司的果汁杯等于1杯水果。相比整个水果,果汁没有营养优势。果汁的缺点是缺乏全果的纤维。 果汁的大卡比全果消耗得更快。依靠果汁而不是全果提供每日摄入的水果不能促进与全水果摄入相关的饮食行为。因为最近的研究表明,纯橙汁摄入对成年人有健康益处,但需要进一步的研究来确定儿童和青少年是否可以获得类似的益处。
 
儿科医生通过向儿童患者及其父母提供指导,在儿童健康和营养方面发挥核心作用。儿科医生也可以倡导改变公共政策,特别是在学校里,改善水果和蔬菜的摄入量与促进健康饮食选择的政策相关。开放的评估和适当的饮食习惯的建议,包括食用整个水果而不是果汁,可以帮助促进父母对健康体重增长的支持。尽管与肥胖相关的其他风险因素可能是重要的考虑因素,最近的一项研究表明,对于生育前超重的女性的婴儿和孩子可能需要特别的关注。
 
果汁的微生物安全性

父母需要了解,未经高温消毒的果汁产品可能含有可能对儿童有害的病原体,如大肠杆菌、沙门氏菌属和隐孢子虫属。这些生物与严重的疾病如溶血性尿毒症综合症有关。如果父母选择给予孩子未经高温消毒的果汁产品,则应小心谨慎,并告知这是不安全的做法。市售的未经高压灭菌的果汁必须在标签上注明该产品可能含有有害细菌的警告。这些建议不适用于某些销售模式(例如,“由苹果园、农贸市场、路边摊位或某些果汁酒吧新鲜挤压出售的果汁或苹果酒”[http://www.fda.gov/Food/Resour ... 6.htm]),但是当向儿童提供未经消毒的果汁产品时,家庭应保持警惕。巴氏灭菌的果汁不含微生物,对婴儿,儿童和青少年是安全的。


 
婴儿

美国儿科学会(AAP)建议,在大约6月龄之前,人乳是唯一一种喂养婴儿的营养物质。 对于不能母乳喂养或选择不进行母乳喂养的母亲,可以使用制备好的婴儿配方奶粉作为完整的营养来源。 不需要额外的营养。 没有营养指南建议给6岁以下的婴儿提供果汁。 在饮食中引入固体食物之前提供果汁可能会导致饮食中的果汁取代人乳或婴幼儿配方奶粉,这可能导致蛋白质、脂肪、维生素和矿物质如铁、钙和锌的摄入量减少。儿童营养不良和身材矮小与过多摄入果汁有关。

完全避免在1岁以前的婴儿中使用果汁是最佳的做法。尽管医学上建议给6个月以上的婴儿饮用果汁,但给予婴儿果汁仍需谨慎。 龋齿也与果汁消费有关。牙齿长期暴露于果汁中的糖是造成龋齿的主要原因。 美国儿科学会和美国儿科牙科学会的建议指出,应用杯子向幼儿提供果汁,而不是瓶子,并且婴儿入睡时不能在口中含有盛有果汁的瓶子。 整天允许儿童携带瓶子、容易运输的有盖杯子、开口杯或盒装果汁的做法导致牙齿过度暴露于碳水化合物,这促进了龋齿的形成。

婴儿可被允许吃捣成糊状的整个水果。 1岁以后,可以将果汁用作餐点或小吃的一部分。它不应该在一天中一直被孩子啜饮或当作使一个不安的孩子安静下来的手段。因为婴儿每天摄入<1600千卡,每天4盎司的果汁占推荐日常水果的一半,是绰绰有余的。

关于处理幼儿急性胃肠炎的美国儿科学会实践指数(1996年出版,随后于2001年停止出版)建议,只能使用口服电解质溶液来补充婴儿和幼儿水分,并在整个胃肠炎发作期间继续保持正常饮食。调查显示,许多医疗保健提供者不遵循推荐的腹泻处理流程。与口服电解质溶液(2.5-3g%)相比,果汁(11-16 g%)的高碳水化合物含量可能会超过肠道吸收碳水化合物的能力,导致碳水化合物吸收不良。碳水化合物吸收不良会引起渗透性腹泻,加剧现有的腹泻的严重程度。果汁电解质含量低。钠浓度为1〜3mEq / L。急性腹泻儿童粪便钠浓度为20〜40mEq / L。口服电解质溶液含有40〜45mEq钠/ L。将果汁作为液体损失的替代品,可能会使婴儿发生低钠血症。
 
有人担心,接触橙汁的婴儿可能会增加对橙汁过敏反应的可能性。 一些摄入鲜榨柑橘类果汁的婴儿发生口周皮疹,这有可能是由于酸的化学刺激作用。在一些婴儿身上观察到的腹泻和一些胃肠道症状最有可能归因于碳水化合物吸收不良。 虽然对水果过敏可能发生于生命的早期,但却不常见。
 
幼儿和儿童(1-6岁)
与新生儿的果汁摄入相关的大多数问题也与初学走路的孩子和幼儿有关。果汁和果汁饮料由于口感好极易被这些人群摄入过多。令外,它们便于包装,也可以放在瓶子或可移动的盖杯里,白天随身携带。因为果汁被认为是有营养的,所以父母通常不会限制果汁的摄入。应鼓励刚学走路的孩子和幼儿吃整个水果而非喝果汁。果汁跟苏打水一样会导致机体能量失衡。儿科医生应支持旨在减少果汁摄入的政策,鼓励已经接触果汁的初学走路的孩子和幼儿食用整个水果。这种支持应该包括为妇女、新生儿和儿童制定的特别营养补充计划(WIC),假设这些政策对于无法获得新鲜水果的儿童并没有负面的营养结果(例如总热量不足、食物中缺乏水果)。此外,过多摄入饮料会导致腹泻、营养过剩或营养不良,以及龋齿。用水稀释果汁并不一定会降低果汁对牙齿健康损害的风险。
 
大龄儿童和青少年(7-18岁)

果汁消费表明年龄较大的儿童和青少年营养问题少的原因是他们更少地摄入这些饮料。 尽管如此,果汁摄入量应限制在8盎司/天,是推荐的每日水果的一半。 鼓励消耗整个水果以有利于膳食纤维摄入以及这会花费更长时间消耗相同的千卡热量也很重要的。过量的果汁消耗和由此导致的能量摄入量的增加可能有助于肥胖的发展。 一项研究发现果汁摄入量超过12盎司/天与肥胖有关。然而,其他研究发现,饮用更多量的果汁的儿童比饮用较少果汁的儿童身高更高,BMI更低,还有研究发现果汁摄入和身高变化之间没有关联。最近的一项研究表明,摄入不同种类的100%纯果汁与肥胖无关。但仍需要更多的研究来更好地界定这个关系。
 

 
结论
果汁对1岁以下的婴儿无营养益处。果汁对婴儿和儿童的营养益处不如整个水果,并且在健康和均衡的儿童饮食中并非不可或缺。百分之百的新鲜或重新配制的果汁可以作为1岁以上儿童均衡健康饮食的一部分。但是,水果饮料在营养上并不等同于果汁。果汁不适合治疗脱水或腹泻的治疗。过量的果汁摄入可能与营养不良(营养过剩和营养不良)有关。过量的果汁摄入与腹泻、肠胃气胀、腹部膨胀和龋齿有关。未经消毒的果汁产品可能含有引起严重疾病的病原体,给小孩服用应谨慎。为适当儿童年龄提供的各种果汁不太可能引起任何明显的临床症状。钙强化果汁可作为提供生物可利用的钙的来源,通常也含有维生素D,但缺乏其他存在于母乳、婴儿配方奶粉或牛奶中的其他营养物质。



​建议
除非临床推荐,否则不应将果汁引入12个月月龄前的婴儿饮食中。1至3岁的孩子的果汁摄入量应限制在最多4盎司/天,4至6岁的儿童每天应为4至6盎司/天。对于7至18岁的儿童,果汁摄入量应限制在8盎司或占推荐的每天2至2.5杯水果的1杯果汁。幼儿不应该从瓶子或容易运输的有盖的杯子中获得果汁,这会使他们在整天中容易饮用果汁。幼儿在睡觉时不应该给予果汁。应鼓励孩子吃全果,以满足他们推荐的每日水果摄入量,并应该重视膳食纤维摄入的益处,并且与果汁相比,摄入整个水果时消耗相同千卡的时间要长。家长们应该知道,为了满足流食需求,人乳和/或婴儿配方食品对婴儿和低脂/脱脂奶是足够的,而且对于大龄儿童来说,摄入水就足够了。应极力劝阻婴儿、儿童和青少年摄入未经巴氏消毒的果汁产品。任何儿童服用CYP3A4代谢药物时,应避免使用葡萄柚汁(见上述清单)。在评估营养不良(营养过剩和营养不良)的儿童时,儿科医生应确定所消耗的果汁量。在评估患有慢性腹泻、过度肠胃气胀、腹痛和腹胀的儿童时,儿科医生应确定摄入的果汁量。在评估龋齿的风险时,儿科医生应定期讨论果汁和龋齿之间的关系,并确定果汁的摄入量和摄入形式。儿科医生应该常规地讨论果汁和水果饮品的饮用,并教育年龄较大的儿童,青少年及其父母两者之间的差异。小儿科医师应主张减少幼儿饮食中的果汁,并且在体重异常(过轻或超重)的儿童饮食中去除果汁。儿科医生应支持旨在减少果汁消费的政策,并通过已经接触果汁的幼儿和儿童(例如育儿/幼儿园),包括通过“妇女,婴幼儿特别补充营养计划(WIC)” ,促进整个水果的摄入。 

Lead Authors

Melvin B. Heyman, MD, FAAP
Steven A. Abrams, MD, FAAP
 
中文翻译:Shawnee
本文地址:http://www.wjbb.com/know/1767
原文出处:http://pediatrics.aappublicati ... -0967 查看全部


①一岁以下新生儿:不应该喝任何果汁!!!无论什么果汁都不应该去碰,无论什么果汁。
②一岁到三岁的孩子(学步期):每天最多只能喝四个盎司(只有330毫升标准可乐罐的三分之一左右的量!)。
③四到六岁儿童:每天也最多只应该喝下三分之一到二分之一标准可乐罐的量!
④七到十八岁青少年:每天最多只有普通每天早上送到家里的一小瓶牛奶的量!
 
美国儿科学会本文中所提及的『果汁』指的是100%水果汁。
 
本段来自新浪微博 @蕨代霜蛟,为本篇全文的核心概括。


 
摘要

历史上,果汁被儿科医生推荐为维生素C的来源,并且作为健康婴儿和幼儿的额外水源,随着他们的饮食范围扩展到含有较高肾负荷的固体食物。它有时也被推荐用于儿童便秘。果汁作为一种健康的天然维生素来源进行销售,在某些情况下,还作为钙的来源。由于果汁口感好,儿童易于接受。虽然果汁摄入有一些好处,但它也有潜在的危害。果汁中的高含糖量会增加热量消耗和患龋齿的风险。此外,果汁中缺乏蛋白质和纤维会导致体重增加失常(过重或过轻)。儿科医生需要对果汁有足够的了解,以便告知父母和病人如何正确使用。

缩写词:
AAP —美国儿科学会
CYP3A4 —细胞色素 P4503A4

在2008至2013年间,果汁和果汁饮料的销量下降,这可能是由于饮料竞争和日益增长的更健康的食品选择,特别是水果和蔬菜的消费。含有热带水果、茶、运动饮料和能量饮料以及其他组合的饮料,呈现出一系列更新、更时尚的选择。儿童和青少年一直是购买果汁和果汁饮料最多的消费者。健康饮料的选择越来越受欢迎,包括低热量、不含糖的饮料,以及那些来自药草和香料成分的可感知的益处。不幸的是,数据显示,2至18岁的儿童将果汁作为近一半的水果摄入,这样会缺乏膳食纤维和容易导致热量摄入过多。这一比例近年来有所下降。

定义

根据美国食品药品监督管理局(FDA)规定,标签为果汁的产品指的是该产品是100%纯果汁。对于从浓缩液中再造的果汁,标签必须注明该产品是由浓缩物重新制成的。任何饮料,含量小于100%的果汁必须列出果汁产品的百分比,和饮料必须包括一个描述性的词语,如“饮品”、“饮料”或“鸡尾酒”。一般来说,果汁饮料含有10%和99%的果汁,并添加了甜味剂、香料或强化剂,如维生素C或钙。根据FDA的规定,这些成分必须列在标签上。 
果汁成分

水是果汁的主要成分。碳水化合物,包括蔗糖、果糖、葡萄糖和山梨醇,是果汁中排名第二的营养成分。碳水化合物的浓度从11克%(0.44千卡/毫升)到16克%(0.64千卡/毫升)。人乳和标准婴儿配方的碳水化合物的浓度为7克%。

果汁中含有少量的蛋白质和矿物质。有些果汁含有天然的高含量的钾、维生素A和维生素C,此外,一些果汁和果汁饮料添加了维生素C。有些果汁和牛奶具有大致相同的钙含量,但缺乏其他存在于牛奶在中的营养素,如镁和大量的蛋白质。许多这种强化钙的果汁也富含维生素D。果汁中的维生素C和类黄酮可能有长期的健康效果,如降低癌症和心脏病的风险。吃饭的同时饮用含有抗坏血酸的饮料能增加两倍铁的吸收量,这可能对于那些摄入低铁生物利用度食物的儿童来说很重要。

果汁不含脂肪或胆固醇,除非含有果肉,否则也不含纤维。果汁和果汁饮料中的氟化物浓度各有不同。一项研究发现,果汁中的氟化物离子浓度从0.02到2.8 ppm不等。浓缩果汁的氟含量随着复原果汁的水中氟含量变化。

一些制造商专门为婴儿生产果汁。这些果汁不含亚硫酸盐或添加糖,比普通的果汁更贵。

经常被饮用的果汁还包括其他形式。父母经常使用稀释的果汁来治疗便秘或为婴儿和儿童提供补充液体。多达三分之一的青少年喝运动饮料,大约10%至15%的人饮用能量饮料,当儿科医生评估患者的营养摄入情况时应询问这些饮品的使用情况。


与果汁摄取有关的药理学考虑

许多水果(例如葡萄、蓝莓、石榴、苹果)的果汁中含有黄酮类化合物(如柚皮苷、柚皮素、橙皮苷、橙皮苷、柚皮素、槲皮素和山奈酚),它可以减少几种酶和重要的药物转运蛋白的活性。虽然葡萄柚汁的摄入已被证明可以减少肠细胞色素P4503A4(CYP3A4)活性并产生潜在的CYP3A4底物药物(如环孢素、他克莫司、阿托伐他汀、非洛地平、非索非那定,特定的抗逆转录病毒药物)的营养和药物的相互作用(例如,提高生物利用度),但最近的证据表明,柚子汁也可以抑制有机酸转运蛋白活性。除了葡萄柚汁,橘子,苹果所含的黄酮也能减少有机酸转运蛋白OATP2B1活动。虽然葡萄柚汁-CYP3A4底物相互作用和用于产生显著营养药物相互作用的可能性是最充分表征,但是应当注意的是,除了抑制CYP3A4活性,蔓越莓,石榴和蓝莓汁能抑制CYP2C9的酶活性 ,CYP2C9即一种能催化治疗性药物如布洛芬、氟比洛芬、华法林、苯妥英、氟伐他汀和阿米替林的生物转化的细胞色素P450同工酶。 上述任何一种果汁-药物相互作用的临床意义极难根据消化系统的历史情况来预测。
 
在持续时间和幅度较大的相互作用产生的质变是多因素作用的结果,主要包括以下内容:(1)对影响酶或转运蛋白的组成型表达,(2)酶(如CYP2C9)或转运蛋白的显著遗传多态性,(3)不同果汁之间的相对类黄酮的组合物和效力,(4)果汁摄入量和摄入的持续时间(例如,可能需要在成年人中饮用1至2L /天的蔓越莓果汁以产生与华法林的显著相互作用)。在评估潜在的果汁 - 药物相互作用,果汁和药物的联合应用中,其代谢或转运可能是由类黄酮的影响不应该被立即认为是治疗的禁忌症。 必须考虑摄取的果汁的量和类型,表征给定相互作用的具体信息以及服用的药物是否低(如抗逆转录病毒药、钙调磷酸酶抑制剂、钙通道阻滞剂、华法林)或高治疗指数以评估潜在的相互作用。 医师和药剂师之间的协商可以有助于考虑果汁药物相互作用的潜在临床意义。



果汁中碳水化合物的吸收

果汁中的4种主要糖类是蔗糖、葡萄糖、果糖和山梨糖醇。蔗糖是通过存在于小肠上皮中的蔗糖酶水解成两分子的单糖——葡萄糖和果糖。然后,葡萄糖通过活性载体介导的过程在小肠的绒毛边缘被快速吸收。果糖被促进的运输机制通过载体吸收,但不逆浓度梯度。此外,果糖可能被二糖酶相关的转运系统吸收,因为果糖的吸收在葡萄糖存在下更快,当果糖和葡萄糖以等摩尔浓度存在时,发生最大吸收。临床研究显示,当果糖浓度超过葡萄糖(例如苹果和梨汁)时,比这两种糖以相同浓度存在(例如白葡萄汁)时,吸收更快。然而,当以适当的量(10mL / kg体重)提供时,这些不同的果汁也被同样地吸收。梨,苹果,樱桃,杏和李子和无糖食物(例如糖果,口香糖,饮料,冰淇淋)和一些液体药物含有少量的山梨糖醇,山梨糖醇被缓慢的通过被动扩散吸收,因此大部分被摄取的山梨醇未能被吸收。

在小肠中未被吸收的碳水化合物被结肠中的细菌发酵。 这种细菌发酵会产生氢,二氧化碳,甲烷和短链脂肪酸乙酸、丙酸和丁酸。 这些气体和一些脂肪酸中通过结肠上皮被再吸收,并以这种方式,一部分吸收不良的碳水化合物(malabsorbed carbohydrate)可被清除。 未吸收的碳水化合物对胃肠道产生渗透负荷,引起腹泻。

幼儿的腹泻是一种众所周知的良性病症,通常只需从1至4岁的饮食中去除多余的果汁即能产生效果。 然而,在果汁碳水化合物吸收不良,尤其是过量食用时,可导致慢性腹泻、胀气、腹胀、腹痛。 果糖和山梨醇最常见,但特定碳水化合物的比例也可能很重要。 大量摄取果汁可能导致的碳水化合物吸收不良是一些卫生保健提供者推荐用于治疗便秘,尤其是婴幼儿便秘的基础。 北美小儿胃肠病学,肝病学和营养便秘学指南建议利用一些果汁(如西梅脯,梨和苹果汁)中所含的山梨糖醇和其他碳水化合物来帮助增加婴儿粪便的频率和含水量来治疗婴儿便秘。

美国人饮食指南中的果汁相关策略

2015年出版的最新版本的美国人饮食指南的基本前提是,是关注高营养食品。水果是膳食指南中头号关键重点食品。水果与蔬菜一起被推荐提供必需的维生素和矿物质,降低心血管疾病的风险,有可能防止癌症,并抑制摄入过多的热量。例如,每天消耗约1000千卡(取决于体型大小,1-4岁)的儿童每天应该喝约1杯水果,而消费大约2000千卡/天(取决于体型大小,10-18岁)的儿童,每天应消耗约2杯水果。尽管鼓励摄入整个水果,但最多可以以100%果汁(不是水果饮料)的形式提供一半水果。 6盎司的果汁杯等于1杯水果。相比整个水果,果汁没有营养优势。果汁的缺点是缺乏全果的纤维。 果汁的大卡比全果消耗得更快。依靠果汁而不是全果提供每日摄入的水果不能促进与全水果摄入相关的饮食行为。因为最近的研究表明,纯橙汁摄入对成年人有健康益处,但需要进一步的研究来确定儿童和青少年是否可以获得类似的益处。
 
儿科医生通过向儿童患者及其父母提供指导,在儿童健康和营养方面发挥核心作用。儿科医生也可以倡导改变公共政策,特别是在学校里,改善水果和蔬菜的摄入量与促进健康饮食选择的政策相关。开放的评估和适当的饮食习惯的建议,包括食用整个水果而不是果汁,可以帮助促进父母对健康体重增长的支持。尽管与肥胖相关的其他风险因素可能是重要的考虑因素,最近的一项研究表明,对于生育前超重的女性的婴儿和孩子可能需要特别的关注。
 
果汁的微生物安全性

父母需要了解,未经高温消毒的果汁产品可能含有可能对儿童有害的病原体,如大肠杆菌、沙门氏菌属和隐孢子虫属。这些生物与严重的疾病如溶血性尿毒症综合症有关。如果父母选择给予孩子未经高温消毒的果汁产品,则应小心谨慎,并告知这是不安全的做法。市售的未经高压灭菌的果汁必须在标签上注明该产品可能含有有害细菌的警告。这些建议不适用于某些销售模式(例如,“由苹果园、农贸市场、路边摊位或某些果汁酒吧新鲜挤压出售的果汁或苹果酒”[http://www.fda.gov/Food/Resour ... 6.htm]),但是当向儿童提供未经消毒的果汁产品时,家庭应保持警惕。巴氏灭菌的果汁不含微生物,对婴儿,儿童和青少年是安全的。


 
婴儿

美国儿科学会(AAP)建议,在大约6月龄之前,人乳是唯一一种喂养婴儿的营养物质。 对于不能母乳喂养或选择不进行母乳喂养的母亲,可以使用制备好的婴儿配方奶粉作为完整的营养来源。 不需要额外的营养。 没有营养指南建议给6岁以下的婴儿提供果汁。 在饮食中引入固体食物之前提供果汁可能会导致饮食中的果汁取代人乳或婴幼儿配方奶粉,这可能导致蛋白质、脂肪、维生素和矿物质如铁、钙和锌的摄入量减少。儿童营养不良和身材矮小与过多摄入果汁有关。

完全避免在1岁以前的婴儿中使用果汁是最佳的做法。尽管医学上建议给6个月以上的婴儿饮用果汁,但给予婴儿果汁仍需谨慎。 龋齿也与果汁消费有关。牙齿长期暴露于果汁中的糖是造成龋齿的主要原因。 美国儿科学会和美国儿科牙科学会的建议指出,应用杯子向幼儿提供果汁,而不是瓶子,并且婴儿入睡时不能在口中含有盛有果汁的瓶子。 整天允许儿童携带瓶子、容易运输的有盖杯子、开口杯或盒装果汁的做法导致牙齿过度暴露于碳水化合物,这促进了龋齿的形成。

婴儿可被允许吃捣成糊状的整个水果。 1岁以后,可以将果汁用作餐点或小吃的一部分。它不应该在一天中一直被孩子啜饮或当作使一个不安的孩子安静下来的手段。因为婴儿每天摄入<1600千卡,每天4盎司的果汁占推荐日常水果的一半,是绰绰有余的。

关于处理幼儿急性胃肠炎的美国儿科学会实践指数(1996年出版,随后于2001年停止出版)建议,只能使用口服电解质溶液来补充婴儿和幼儿水分,并在整个胃肠炎发作期间继续保持正常饮食。调查显示,许多医疗保健提供者不遵循推荐的腹泻处理流程。与口服电解质溶液(2.5-3g%)相比,果汁(11-16 g%)的高碳水化合物含量可能会超过肠道吸收碳水化合物的能力,导致碳水化合物吸收不良。碳水化合物吸收不良会引起渗透性腹泻,加剧现有的腹泻的严重程度。果汁电解质含量低。钠浓度为1〜3mEq / L。急性腹泻儿童粪便钠浓度为20〜40mEq / L。口服电解质溶液含有40〜45mEq钠/ L。将果汁作为液体损失的替代品,可能会使婴儿发生低钠血症。
 
有人担心,接触橙汁的婴儿可能会增加对橙汁过敏反应的可能性。 一些摄入鲜榨柑橘类果汁的婴儿发生口周皮疹,这有可能是由于酸的化学刺激作用。在一些婴儿身上观察到的腹泻和一些胃肠道症状最有可能归因于碳水化合物吸收不良。 虽然对水果过敏可能发生于生命的早期,但却不常见。
 
幼儿和儿童(1-6岁)
与新生儿的果汁摄入相关的大多数问题也与初学走路的孩子和幼儿有关。果汁和果汁饮料由于口感好极易被这些人群摄入过多。令外,它们便于包装,也可以放在瓶子或可移动的盖杯里,白天随身携带。因为果汁被认为是有营养的,所以父母通常不会限制果汁的摄入。应鼓励刚学走路的孩子和幼儿吃整个水果而非喝果汁。果汁跟苏打水一样会导致机体能量失衡。儿科医生应支持旨在减少果汁摄入的政策,鼓励已经接触果汁的初学走路的孩子和幼儿食用整个水果。这种支持应该包括为妇女、新生儿和儿童制定的特别营养补充计划(WIC),假设这些政策对于无法获得新鲜水果的儿童并没有负面的营养结果(例如总热量不足、食物中缺乏水果)。此外,过多摄入饮料会导致腹泻、营养过剩或营养不良,以及龋齿。用水稀释果汁并不一定会降低果汁对牙齿健康损害的风险。
 
大龄儿童和青少年(7-18岁)

果汁消费表明年龄较大的儿童和青少年营养问题少的原因是他们更少地摄入这些饮料。 尽管如此,果汁摄入量应限制在8盎司/天,是推荐的每日水果的一半。 鼓励消耗整个水果以有利于膳食纤维摄入以及这会花费更长时间消耗相同的千卡热量也很重要的。过量的果汁消耗和由此导致的能量摄入量的增加可能有助于肥胖的发展。 一项研究发现果汁摄入量超过12盎司/天与肥胖有关。然而,其他研究发现,饮用更多量的果汁的儿童比饮用较少果汁的儿童身高更高,BMI更低,还有研究发现果汁摄入和身高变化之间没有关联。最近的一项研究表明,摄入不同种类的100%纯果汁与肥胖无关。但仍需要更多的研究来更好地界定这个关系。
 

 
结论
  1. 果汁对1岁以下的婴儿无营养益处。
  2. 果汁对婴儿和儿童的营养益处不如整个水果,并且在健康和均衡的儿童饮食中并非不可或缺。
  3. 百分之百的新鲜或重新配制的果汁可以作为1岁以上儿童均衡健康饮食的一部分。但是,水果饮料在营养上并不等同于果汁。
  4. 果汁不适合治疗脱水或腹泻的治疗。
  5. 过量的果汁摄入可能与营养不良(营养过剩和营养不良)有关。
  6. 过量的果汁摄入与腹泻、肠胃气胀、腹部膨胀和龋齿有关。
  7. 未经消毒的果汁产品可能含有引起严重疾病的病原体,给小孩服用应谨慎。
  8. 为适当儿童年龄提供的各种果汁不太可能引起任何明显的临床症状。
  9. 钙强化果汁可作为提供生物可利用的钙的来源,通常也含有维生素D,但缺乏其他存在于母乳、婴儿配方奶粉或牛奶中的其他营养物质。




​建议
  1. 除非临床推荐,否则不应将果汁引入12个月月龄前的婴儿饮食中。1至3岁的孩子的果汁摄入量应限制在最多4盎司/天,4至6岁的儿童每天应为4至6盎司/天。对于7至18岁的儿童,果汁摄入量应限制在8盎司或占推荐的每天2至2.5杯水果的1杯果汁。
  2. 幼儿不应该从瓶子或容易运输的有盖的杯子中获得果汁,这会使他们在整天中容易饮用果汁。幼儿在睡觉时不应该给予果汁。
  3. 应鼓励孩子吃全果,以满足他们推荐的每日水果摄入量,并应该重视膳食纤维摄入的益处,并且与果汁相比,摄入整个水果时消耗相同千卡的时间要长。
  4. 家长们应该知道,为了满足流食需求,人乳和/或婴儿配方食品对婴儿和低脂/脱脂奶是足够的,而且对于大龄儿童来说,摄入水就足够了。
  5. 应极力劝阻婴儿、儿童和青少年摄入未经巴氏消毒的果汁产品。
  6. 任何儿童服用CYP3A4代谢药物时,应避免使用葡萄柚汁(见上述清单)。
  7. 在评估营养不良(营养过剩和营养不良)的儿童时,儿科医生应确定所消耗的果汁量。
  8. 在评估患有慢性腹泻、过度肠胃气胀、腹痛和腹胀的儿童时,儿科医生应确定摄入的果汁量。
  9. 在评估龋齿的风险时,儿科医生应定期讨论果汁和龋齿之间的关系,并确定果汁的摄入量和摄入形式。
  10. 儿科医生应该常规地讨论果汁和水果饮品的饮用,并教育年龄较大的儿童,青少年及其父母两者之间的差异。
  11. 小儿科医师应主张减少幼儿饮食中的果汁,并且在体重异常(过轻或超重)的儿童饮食中去除果汁。
  12. 儿科医生应支持旨在减少果汁消费的政策,并通过已经接触果汁的幼儿和儿童(例如育儿/幼儿园),包括通过“妇女,婴幼儿特别补充营养计划(WIC)” ,促进整个水果的摄入。 


Lead Authors

Melvin B. Heyman, MD, FAAP
Steven A. Abrams, MD, FAAP
 
中文翻译:Shawnee
本文地址:http://www.wjbb.com/know/1767
原文出处:http://pediatrics.aappublicati ... -0967

美国儿科学会:儿童青少年与数字媒体指南

豌豆爸爸 发表了文章 • 2 个评论 • 283 次浏览 • 2016-10-24 09:40 • 来自相关话题

 Abstract

Today’s children and adolescents are immersed in both traditional and new forms of digital media. Research on traditional media, such as television, has identified health concerns and negative outcomes that correlate with the duration and content of viewing. Over the past decade, the use of digital media, including interactive and social media, has grown, and research evidence suggests that these newer media offer both benefits and risks to the health of children and teenagers. Evidence-based benefits identified from the use of digital and social media include early learning, exposure to new ideas and knowledge, increased opportunities for social contact and support, and new opportunities to access health promotion messages and information. Risks of such media include negative health effects on sleep, attention, and learning; a higher incidence of obesity and depression; exposure to inaccurate, inappropriate, or unsafe content and contacts; and compromised privacy and confidentiality. This technical report reviews the literature regarding these opportunities and risks, framed around clinical questions, for children from birth to adulthood. To promote health and wellness in children and adolescents, it is important to maintain adequate physical activity, healthy nutrition, good sleep hygiene, and a nurturing social environment. A healthy Family Media Use Plan (www.healthychildren.org/MediaUsePlan) that is individualized for a specific child, teenager, or family can identify an appropriate balance between screen time/online time and other activities, set boundaries for accessing content, guide displays of personal information, encourage age-appropriate critical thinking and digital literacy, and support open family communication and implementation of consistent rules about media use.
 
Introduction

Today’s generation of children and adolescents are growing up immersed in media, including broadcast and social media. Broadcast media include television and movies. Interactive media include social media and video games in which users can both consume and create content. Interactive media allow information sharing and provide an engaging digital environment that becomes highly personalized.

Media Use Patterns

The most common broadcast medium continues to be TV. A recent study found that TV hours among school-aged children have decreased in the past decade for children younger than 8 years.1 However, among children aged 8 years and older, average daily TV time remains over 2 hours per day.2 TV viewing also has changed over the past decade, with content available via streaming or social media sites, such as YouTube and Netflix.

Overall media use among adolescents has continued to grow over the past decade, aided by the recent increase in mobile phone use among teenagers. Approximately three-quarters of teenagers today own a smartphone,3 which allows access to the Internet, streaming TV/videos, and interactive “apps.” Approximately one-quarter of teenagers describe themselves as “constantly connected” to the Internet.

Social media sites and mobile apps provide platforms for users to create an online identity, communicate with others, and build social networks. At present, 76% of teenagers use at least 1 social media site. Although Facebook remains the most popular social media site,3 teenagers do not typically commit to just 1 social media platform; more than 70% maintain a “social media portfolio” of several selected sites, including Facebook, Twitter, and Instagram.3 Mobile apps provide a breadth of functions, such as photo sharing, games, and video-chatting.

Video games remain very popular among families; 4 of 5 households own a device used to play video games.Boys are the most avid video game players, with 91% of boys reporting having access to a game console and 84% reporting playing video games online or on a cell phone.

Benefits of Media

Both traditional and social media can provide exposure to new ideas and information, raising awareness of current events and issues. Interactive media also can provide opportunities for the promotion of community participation and civic engagement. Students can collaborate with others on assignments and projects on many online media platforms. The use of social media helps families and friends who are separated geographically communicate across the miles.

Social media can enhance access to valuable support networks, which may be particularly helpful for patients with ongoing illnesses, conditions, or disabilities.In 1 study, young adults described the benefits of seeking health information online and through social media, and recognized these channels as useful supplementary sources of information to health care visits.6 Research also supports the use of social media to foster social inclusion among users who may feel excluded or who are seeking a welcoming community: for example, those identifying as lesbian, gay, bisexual, transgender, questioning, or intersex. Finally, social media may be used to enhance wellness and promote healthy behaviors, such as smoking cessation and balanced nutrition.

Risks of Media

A first area of health concern is media use and obesity, and most studies have focused on TV. One study found that the odds of being overweight were almost 5 times greater for adolescents who watch more than 5 hours of TV per day compared with those who watch 0 to 2 hours.9 This study’s findings contributed to recommendations by the American Academy of Pediatrics that children have 2 hours or less of sedentary screen time daily. More recent studies have provided new evidence that watching TV for more than 1.5 hours daily was a risk factor for obesity, but only for children 4 through 9 years of age.10 Increased caloric intake via snacking while watching TV has been shown to be a risk factor for obesity, as is exposure to advertising for high-calorie foods and snacks.Having a TV in the bedroom continues to be associated with the risk of obesity.

Evidence suggests that media use can negatively affect sleep.Studies show that those with higher social media use15 or who sleep with mobile devices in their roomswere at greater risk of sleep disturbances. Exposure to light (particularly blue light) and activity from screens before bed affects melatonin levels and can delay or disrupt sleep.Media use around or after bedtime can disrupt sleep and negatively affect school performance.

Children who overuse online media are at risk of problematic Internet use, and heavy users of video games are at risk of Internet gaming disorder. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,lists both as conditions in need of further research. Symptoms can include a preoccupation with the activity, decreased interest in offline or “real life” relationships, unsuccessful attempts to decrease use, and withdrawal symptoms. The prevalence of problematic Internet use among children and adolescents is between 4% and 8%,21,22 and up to 8.5% of US youth 8 to 18 years of age meet criteria for Internet gaming disorder.

At home, many children and teenagers use entertainment media at the same time that they are engaged in other tasks, such as homework.A growing body of evidence suggests that the use of media while engaged in academic tasks has negative consequences on learning.

Media Influence

Evidence gathered over decades supports links between media exposure and health behaviors among teenagers.The exposure of adolescents through media to alcohol,28,29 tobacco use,30,31 or sexual behaviors is associated with earlier initiation of these behaviors.

Adolescents’ displays on social media frequently include portrayal of health risk behaviors, such as substance use, sexual behaviors, self-injury, or disordered eating.Peer viewers of such content may see these behaviors as normative and desirable.Research from both the United States and the United Kingdom indicates that the major alcohol brands maintain a strong presence on Facebook, Twitter, and YouTube.

Cyberbullying, Sexting, and Online Solicitation

Cyberbullying and traditional bullying overlap, although online bullying presents unique challenges. These challenges include that perpetrators can be anonymous and bully at any time of day, that information can spread online rapidly, and that perpetrator and target roles can be quite fluid in the online world. Cyberbullying can lead to short- and long-term negative social, academic, and health consequences for both the perpetrator and the target. Fortunately, newer studies suggest that interventions that target bullying may reduce cyberbullying.

“Sexting” is commonly defined as the electronic transmission of nude or seminude images as well as sexually explicit text messages. It is estimated that ∼12% of youth aged 10 to 19 years have ever sent a sexual photo to someone else. The Internet also has created opportunities for the exploitation of children by sex offenders through social networking, chat rooms, e-mail, and online games.

Social Media and Mental Health

Research studies have identified both benefits and concerns regarding mental health and social media use. Benefits from the use of social media in moderation include the opportunity for enhanced social support and connection. Research has suggested a U-shaped relationship between Internet use and depression, with increased risks of depression at both the high and low ends of Internet use. One study found that older adolescents who used social media passively (eg, viewing others’ photos) reported declines in life satisfaction, whereas those who interacted with others and posted content did not experience these declines.Thus, in addition to the number of hours an individual spends on social media, a key factor is how social media is used.

Social Media and Privacy

Content that an adolescent chooses to post is shared with others, and the removal of such content once posted may be difficult or impossible. Adolescents vary in their understanding of privacy practices; even those who know how to set privacy settings often don’t believe they will work.Despite efforts by some social media sites to protect privacy or to delete content after it is viewed, privacy violations and unwelcome distribution are always risks.

Parent Media Use and Child Health

Social media can provide positive social experiences, such as opportunities for parents to connect with children via video-chat services. Unfortunately, some parents can be distracted by media and miss important opportunities for emotional connections that are known to improve child health.53,54 One research study found that when a parent turned his or her attention to a mobile device while with a young child, the parent was less likely to talk with the child.Parental engagement is critical in the development of children’s emotional and social development, and these distractions may have short- and long-term negative effects.

Conclusions

The effects of media use are multifactorial and depend on the type of media, the type of use, the amount and extent of use, and the characteristics of the individual child. Children today are growing up in an era of highly personalized media use experiences, so parents must develop personalized media use plans for their children that attend to each child’s age, health, temperament, and developmental stage. Research evidence shows that children and teenagers need adequate sleep, physical activity, and time away from media. Pediatricians can help families develop a Family Media Use Plan (www.HealthyChildren.org/MediaUsePlan) that prioritizes these and other health goals.

Recommendations

Pediatricians

Work with families and schools to promote understanding of the benefits and risks of media.

Promote adherence to guidelines for adequate physical activity and sleep via a Family Media Use Plan (www.HealthyChildren.org/MediaUsePlan).

Advocate for and promote information and training in media literacy.

Be aware of tools to screen for sexting, cyberbullying, problematic Internet use, and Internet gaming disorder.

Families

Develop, consistently follow, and routinely revisit a Family Media Use plan (see the plan from the American Academy of Pediatrics at www.HealthyChildren.org/MediaUsePlan).

Address what type of and how much media are used and what media behaviors are appropriate for each child or teenager, and for parents. Place consistent limits on hours per day of media use as well as types of media used.

Promote that children and adolescents get the recommended amount of daily physical activity (1 hour) and adequate sleep (8–12 hours, depending on age).

Recommend that children not sleep with devices in their bedrooms, including TVs, computers, and smartphones. Avoid exposure to devices or screens for 1 hour before bedtime.

Discourage entertainment media while doing homework.

Designate media-free times together (eg, family dinner) and media-free locations (eg, bedrooms) in homes. Promote activities that are likely to facilitate development and health, including positive parenting activities, such as reading, teaching, talking, and playing together.

Communicate guidelines to other caregivers, such as babysitters or grandparents, so that media rules are followed consistently.

Engage in selecting and co-viewing media with your child, through which your child can use media to learn and be creative, and share these experiences with your family and your community.

Have ongoing communication with children about online citizenship and safety, including treating others with respect online and offline, avoiding cyberbullying and sexting, being wary of online solicitation, and avoiding communications that can compromise personal privacy and safety.

Actively develop a network of trusted adults (eg, aunts, uncles, coaches, etc) who can engage with children through social media and to whom children can turn when they encounter challenges.

Researchers, Governmental Organizations, and Industry

Continue research into the risks and benefits of media.

Prioritize longitudinal and robust study designs, including new methodologies for understanding media exposure and use.

Prioritize interventions including reducing harmful media use and preventing and addressing harmful media experiences.

Inform educators and legislators about research findings so they can develop updated guidelines for safe and productive media use.
 
中文翻译:
本文地址:http://www.wjbb.com/know/1643
原文出处:http://pediatrics.aappublicati ... -2592 查看全部

 Abstract

Today’s children and adolescents are immersed in both traditional and new forms of digital media. Research on traditional media, such as television, has identified health concerns and negative outcomes that correlate with the duration and content of viewing. Over the past decade, the use of digital media, including interactive and social media, has grown, and research evidence suggests that these newer media offer both benefits and risks to the health of children and teenagers. Evidence-based benefits identified from the use of digital and social media include early learning, exposure to new ideas and knowledge, increased opportunities for social contact and support, and new opportunities to access health promotion messages and information. Risks of such media include negative health effects on sleep, attention, and learning; a higher incidence of obesity and depression; exposure to inaccurate, inappropriate, or unsafe content and contacts; and compromised privacy and confidentiality. This technical report reviews the literature regarding these opportunities and risks, framed around clinical questions, for children from birth to adulthood. To promote health and wellness in children and adolescents, it is important to maintain adequate physical activity, healthy nutrition, good sleep hygiene, and a nurturing social environment. A healthy Family Media Use Plan (www.healthychildren.org/MediaUsePlan) that is individualized for a specific child, teenager, or family can identify an appropriate balance between screen time/online time and other activities, set boundaries for accessing content, guide displays of personal information, encourage age-appropriate critical thinking and digital literacy, and support open family communication and implementation of consistent rules about media use.
 
Introduction

Today’s generation of children and adolescents are growing up immersed in media, including broadcast and social media. Broadcast media include television and movies. Interactive media include social media and video games in which users can both consume and create content. Interactive media allow information sharing and provide an engaging digital environment that becomes highly personalized.

Media Use Patterns

The most common broadcast medium continues to be TV. A recent study found that TV hours among school-aged children have decreased in the past decade for children younger than 8 years.1 However, among children aged 8 years and older, average daily TV time remains over 2 hours per day.2 TV viewing also has changed over the past decade, with content available via streaming or social media sites, such as YouTube and Netflix.

Overall media use among adolescents has continued to grow over the past decade, aided by the recent increase in mobile phone use among teenagers. Approximately three-quarters of teenagers today own a smartphone,3 which allows access to the Internet, streaming TV/videos, and interactive “apps.” Approximately one-quarter of teenagers describe themselves as “constantly connected” to the Internet.

Social media sites and mobile apps provide platforms for users to create an online identity, communicate with others, and build social networks. At present, 76% of teenagers use at least 1 social media site. Although Facebook remains the most popular social media site,3 teenagers do not typically commit to just 1 social media platform; more than 70% maintain a “social media portfolio” of several selected sites, including Facebook, Twitter, and Instagram.3 Mobile apps provide a breadth of functions, such as photo sharing, games, and video-chatting.

Video games remain very popular among families; 4 of 5 households own a device used to play video games.Boys are the most avid video game players, with 91% of boys reporting having access to a game console and 84% reporting playing video games online or on a cell phone.

Benefits of Media

Both traditional and social media can provide exposure to new ideas and information, raising awareness of current events and issues. Interactive media also can provide opportunities for the promotion of community participation and civic engagement. Students can collaborate with others on assignments and projects on many online media platforms. The use of social media helps families and friends who are separated geographically communicate across the miles.

Social media can enhance access to valuable support networks, which may be particularly helpful for patients with ongoing illnesses, conditions, or disabilities.In 1 study, young adults described the benefits of seeking health information online and through social media, and recognized these channels as useful supplementary sources of information to health care visits.6 Research also supports the use of social media to foster social inclusion among users who may feel excluded or who are seeking a welcoming community: for example, those identifying as lesbian, gay, bisexual, transgender, questioning, or intersex. Finally, social media may be used to enhance wellness and promote healthy behaviors, such as smoking cessation and balanced nutrition.

Risks of Media

A first area of health concern is media use and obesity, and most studies have focused on TV. One study found that the odds of being overweight were almost 5 times greater for adolescents who watch more than 5 hours of TV per day compared with those who watch 0 to 2 hours.9 This study’s findings contributed to recommendations by the American Academy of Pediatrics that children have 2 hours or less of sedentary screen time daily. More recent studies have provided new evidence that watching TV for more than 1.5 hours daily was a risk factor for obesity, but only for children 4 through 9 years of age.10 Increased caloric intake via snacking while watching TV has been shown to be a risk factor for obesity, as is exposure to advertising for high-calorie foods and snacks.Having a TV in the bedroom continues to be associated with the risk of obesity.

Evidence suggests that media use can negatively affect sleep.Studies show that those with higher social media use15 or who sleep with mobile devices in their roomswere at greater risk of sleep disturbances. Exposure to light (particularly blue light) and activity from screens before bed affects melatonin levels and can delay or disrupt sleep.Media use around or after bedtime can disrupt sleep and negatively affect school performance.

Children who overuse online media are at risk of problematic Internet use, and heavy users of video games are at risk of Internet gaming disorder. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,lists both as conditions in need of further research. Symptoms can include a preoccupation with the activity, decreased interest in offline or “real life” relationships, unsuccessful attempts to decrease use, and withdrawal symptoms. The prevalence of problematic Internet use among children and adolescents is between 4% and 8%,21,22 and up to 8.5% of US youth 8 to 18 years of age meet criteria for Internet gaming disorder.

At home, many children and teenagers use entertainment media at the same time that they are engaged in other tasks, such as homework.A growing body of evidence suggests that the use of media while engaged in academic tasks has negative consequences on learning.

Media Influence

Evidence gathered over decades supports links between media exposure and health behaviors among teenagers.The exposure of adolescents through media to alcohol,28,29 tobacco use,30,31 or sexual behaviors is associated with earlier initiation of these behaviors.

Adolescents’ displays on social media frequently include portrayal of health risk behaviors, such as substance use, sexual behaviors, self-injury, or disordered eating.Peer viewers of such content may see these behaviors as normative and desirable.Research from both the United States and the United Kingdom indicates that the major alcohol brands maintain a strong presence on Facebook, Twitter, and YouTube.

Cyberbullying, Sexting, and Online Solicitation

Cyberbullying and traditional bullying overlap, although online bullying presents unique challenges. These challenges include that perpetrators can be anonymous and bully at any time of day, that information can spread online rapidly, and that perpetrator and target roles can be quite fluid in the online world. Cyberbullying can lead to short- and long-term negative social, academic, and health consequences for both the perpetrator and the target. Fortunately, newer studies suggest that interventions that target bullying may reduce cyberbullying.

“Sexting” is commonly defined as the electronic transmission of nude or seminude images as well as sexually explicit text messages. It is estimated that ∼12% of youth aged 10 to 19 years have ever sent a sexual photo to someone else. The Internet also has created opportunities for the exploitation of children by sex offenders through social networking, chat rooms, e-mail, and online games.

Social Media and Mental Health

Research studies have identified both benefits and concerns regarding mental health and social media use. Benefits from the use of social media in moderation include the opportunity for enhanced social support and connection. Research has suggested a U-shaped relationship between Internet use and depression, with increased risks of depression at both the high and low ends of Internet use. One study found that older adolescents who used social media passively (eg, viewing others’ photos) reported declines in life satisfaction, whereas those who interacted with others and posted content did not experience these declines.Thus, in addition to the number of hours an individual spends on social media, a key factor is how social media is used.

Social Media and Privacy

Content that an adolescent chooses to post is shared with others, and the removal of such content once posted may be difficult or impossible. Adolescents vary in their understanding of privacy practices; even those who know how to set privacy settings often don’t believe they will work.Despite efforts by some social media sites to protect privacy or to delete content after it is viewed, privacy violations and unwelcome distribution are always risks.

Parent Media Use and Child Health

Social media can provide positive social experiences, such as opportunities for parents to connect with children via video-chat services. Unfortunately, some parents can be distracted by media and miss important opportunities for emotional connections that are known to improve child health.53,54 One research study found that when a parent turned his or her attention to a mobile device while with a young child, the parent was less likely to talk with the child.Parental engagement is critical in the development of children’s emotional and social development, and these distractions may have short- and long-term negative effects.

Conclusions

The effects of media use are multifactorial and depend on the type of media, the type of use, the amount and extent of use, and the characteristics of the individual child. Children today are growing up in an era of highly personalized media use experiences, so parents must develop personalized media use plans for their children that attend to each child’s age, health, temperament, and developmental stage. Research evidence shows that children and teenagers need adequate sleep, physical activity, and time away from media. Pediatricians can help families develop a Family Media Use Plan (www.HealthyChildren.org/MediaUsePlan) that prioritizes these and other health goals.

Recommendations

Pediatricians

Work with families and schools to promote understanding of the benefits and risks of media.

Promote adherence to guidelines for adequate physical activity and sleep via a Family Media Use Plan (www.HealthyChildren.org/MediaUsePlan).

Advocate for and promote information and training in media literacy.

Be aware of tools to screen for sexting, cyberbullying, problematic Internet use, and Internet gaming disorder.

Families

Develop, consistently follow, and routinely revisit a Family Media Use plan (see the plan from the American Academy of Pediatrics at www.HealthyChildren.org/MediaUsePlan).

Address what type of and how much media are used and what media behaviors are appropriate for each child or teenager, and for parents. Place consistent limits on hours per day of media use as well as types of media used.

Promote that children and adolescents get the recommended amount of daily physical activity (1 hour) and adequate sleep (8–12 hours, depending on age).

Recommend that children not sleep with devices in their bedrooms, including TVs, computers, and smartphones. Avoid exposure to devices or screens for 1 hour before bedtime.

Discourage entertainment media while doing homework.

Designate media-free times together (eg, family dinner) and media-free locations (eg, bedrooms) in homes. Promote activities that are likely to facilitate development and health, including positive parenting activities, such as reading, teaching, talking, and playing together.

Communicate guidelines to other caregivers, such as babysitters or grandparents, so that media rules are followed consistently.

Engage in selecting and co-viewing media with your child, through which your child can use media to learn and be creative, and share these experiences with your family and your community.

Have ongoing communication with children about online citizenship and safety, including treating others with respect online and offline, avoiding cyberbullying and sexting, being wary of online solicitation, and avoiding communications that can compromise personal privacy and safety.

Actively develop a network of trusted adults (eg, aunts, uncles, coaches, etc) who can engage with children through social media and to whom children can turn when they encounter challenges.

Researchers, Governmental Organizations, and Industry

Continue research into the risks and benefits of media.

Prioritize longitudinal and robust study designs, including new methodologies for understanding media exposure and use.

Prioritize interventions including reducing harmful media use and preventing and addressing harmful media experiences.

Inform educators and legislators about research findings so they can develop updated guidelines for safe and productive media use.
 
中文翻译:
本文地址:http://www.wjbb.com/know/1643
原文出处:http://pediatrics.aappublicati ... -2592

美国儿科学会:媒体与幼儿指南

豌豆爸爸 发表了文章 • 1 个评论 • 322 次浏览 • 2016-10-24 09:28 • 来自相关话题

 Abstract

Infants, toddlers, and preschoolers are now growing up in environments saturated with a variety of traditional and new technologies, which they are adopting at increasing rates. Although there has been much hope for the educational potential of interactive media for young children, accompanied by fears about their overuse during this crucial period of rapid brain development, research in this area still remains limited. This policy statement reviews the existing literature on television, videos, and mobile/interactive technologies; their potential for educational benefit; and related health concerns for young children (0 to 5 years of age). The statement also highlights areas in which pediatric providers can offer specific guidance to families in managing their young children’s media use, not only in terms of content or time limits, but also emphasizing the importance of parent–child shared media use and allowing the child time to take part in other developmentally healthy activities.
 
Introduction

Technologic innovation has transformed media and its role in the lives of infants and young children. More children, even in economically challenged households, are using newer digital technologies, such as interactive and mobile media, on a daily basis1 and continue to be the target of intense marketing. This policy statement addresses the influence of media on the health and development of children from 0 to 5 years of age, a time of critical brain development, building secure relationships, and establishing health behaviors.

Infants and Toddlers

Children younger than 2 years need hands-on exploration and social interaction with trusted caregivers to develop their cognitive, language, motor, and social-emotional skills. Because of their immature symbolic, memory, and attentional skills, infants and toddlers cannot learn from traditional digital media as they do from interactions with caregivers,and they have difficulty transferring that knowledge to their 3-dimensional experience.The chief factor that facilitates toddlers’ learning from commercial media (starting around 15 months of age) is parents watching with them and reteaching the content.

The interactivity of touchscreens enables applications (apps) to identify when a child responds accurately and then tailor its responses, thereby supporting children at their levels of competence. Emerging evidence shows that at 24 months of age, children can learn words from live video-chatting with a responsive adult or from an interactive touchscreen interface that scaffolds the child to choose the relevant answers. Starting at 15 months of age, toddlers can learn novel words from touchscreens in laboratory-based studies but have trouble transferring this knowledge to the 3-dimensional world. However, it should be noted that these experiments used specially designed apps that are not commercially available.

Many parents now use video-chat (eg, Skype, FaceTime) as an interactive media form that facilitates social connection with distant relatives. New evidence shows that infants and toddlers regularly engage in video-chatting, but the same principles regarding need for parental support would apply in order for infants and toddlers to understand what they are seeing.

In summary, for children younger than 2 years, evidence for benefits of media is still limited, adult interaction with the child during media use is crucial, and there continues to be evidence of harm from excessive digital media use, as described later in this statement.

Preschool Media and Learning

Well-designed television programs, such as Sesame Street, can improve cognitive, literacy, and social outcomes for children 3 to 5 years of age and continue to create programming that addresses evolving child health and developmental needs (eg, obesity prevention, resilience). Evaluations of apps from Sesame Workshop and the Public Broadcasting Service (PBS) also have shown efficacy in teaching literacy skills to preschoolers.Unfortunately, most apps parents find under the “educational” category in app stores have no such evidence of efficacy, target only rote academic skills, are not based on established curricula, and use little or no input from developmental specialists or educators. Most apps also generally are not designed for a dual audience (ie, both parent and child). It is important to emphasize to parents that the higher-order thinking skills and executive functions essential for school success, such as task persistence, impulse control, emotion regulation, and creative, flexible thinking, are best taught through unstructured and social (not digital) play,as well as responsive parent–child interactions.

Digital books (also called “eBooks,” books that can be read on a screen) often come with interactive enhancements that, research suggests, may decrease child comprehension of content or parent dialogic reading interactions when visual effects are distracting.Parents should, therefore, be instructed to interact with children during eBook reading, as they would a print book.

Health and Developmental Concerns

Obesity

Heavy media use during preschool years is associated with small but significant increases in BMI,18 may explain disparities in obesity risk in minority children,19 and sets the stage for weight gain later in childhood.Although many studies have used a 2-hour cutoff to examine obesity risk, a recent study of 2-year-olds found that BMI increased for every hour per week of media consumed.It is believed that exposure to food advertising and watching television while eating (which diminishes attention to satiety cues) drives these associations.

Sleep

Increased duration of media exposure and the presence of a television, computer, or mobile device in the bedroom in early childhood have been associated with fewer minutes of sleep per night.

Even infants exposed to screen media in the evening hours show significantly shorter night-time sleep duration than those with no evening screen exposure. Mechanisms underlying this association include arousing content and suppression of endogenous melatonin by blue light emitted from screens.

Child Development

Population-based studies continue to show associations between excessive television viewing in early childhood and cognitive,language,and social/emotional delays, likely secondary to decreases in parent–child interaction when the television is on37 and poorer family functioning in households with high media use. An earlier age of media use onset, greater cumulative hours of media use, and non-PBS content all are significant independent predictors of poor executive functioning in preschoolers.Content is crucial: experimental evidence shows that switching from violent content to educational/prosocial content results in significant improvement in behavioral symptoms, particularly for low-income boys.Notably, the quality of parenting can modify associations between media use and child development: one study found that inappropriate content and inconsistent parenting had cumulative negative effects on low-income preschoolers’ executive function, whereas warm parenting and educational content interacted to produce additive benefits.

Child characteristics also may influence how much media children consume: excessive television viewing is more likely in infants and toddlers with a difficult temperamentor self-regulation problems, and toddlers with social-emotional delays are more likely to be given a mobile device to calm them down.

Parental Media Use

Parents’ background television use distracts from parent–child interactions and child play.Heavy parent use of mobile devices is associated with fewer verbal and nonverbal interactions between parents and children and may be associated with more parent-child conflict. Because parent media use is a strong predictor of child media habits,reducing parental media use and enhancing parent–child interactions may be an important area of behavior change.

Conclusions: Clinical Implications

In summary, multiple developmental and health concerns continue to exist for young children using all forms of digital media to excess. Evidence is sufficient to recommend time limitations on digital media use for children 2 to 5 years to no more than 1 hour per day to allow children ample time to engage in other activities important to their health and development and to establish media viewing habits associated with lower risk of obesity later in life.In addition, encouraging parents to change to educational and prosocial content and engage with their children around technology will allow children to reap the most benefit from what they view.

As digital technologies become more ubiquitous, pediatric providers must guide parents not only on the duration and content of media their child uses, but also on (1) creating unplugged spaces and times in their homes, because devices can now be taken anywhere; (2) the ability of new technologies to be used in social and creative ways; and (3) the importance of not displacing sleep, exercise, play, reading aloud, and social interactions. Realistically, pediatric providers will need to know how to help parents find resources finding appropriate content, tools for monitoring or limiting child use, ideas for play or activities in which to engage rather than digital play, and how parents can limit their own media use (see HealthyChildren.org for examples); each of these can be built into the Family Media Use Plan (see the American Academy of Pediatrics guide to developing a plan at www.healthychildren.org/MediaUsePlan).

Recommendations

Pediatricians

Start the conversation early. Ask parents of infants and young children about family media use, their children’s use habits, and media use locations.

Help families develop a Family Media Use Plan (www.healthychildren.org/MediaUsePlan) with specific guidelines for each child and parent.

Educate parents about brain development in the early years and the importance of hands-on, unstructured, and social play to build language, cognitive, and social-emotional skills.

For children younger than 18 months, discourage use of screen media other than video-chatting.

For parents of children 18 to 24 months of age who want to introduce digital media, advise that they choose high-quality programming/apps and use them together with children, because this is how toddlers learn best. Letting children use media by themselves should be avoided.

Guide parents to resources for finding quality products (eg, Common Sense Media, PBS Kids, Sesame Workshop).

In children older than 2 years, limit media to 1 hour or less per day of high-quality programming. Recommend shared use between parent and child to promote enhanced learning, greater interaction, and limit setting.

Recommend no screens during meals and for 1 hour before bedtime.

Problem-solve with parents facing challenges, such as setting limits, finding alternate activities, and calming children.

Families

Avoid digital media use (except video-chatting) in children younger than 18 to 24 months.

For children ages 18 to 24 months of age, if you want to introduce digital media, choose high-quality programming and use media together with your child. Avoid solo media use in this age group.

Do not feel pressured to introduce technology early; interfaces are so intuitive that children will figure them out quickly once they start using them at home or in school.

For children 2 to 5 years of age, limit screen use to 1 hour per day of high-quality programming, coview with your children, help children understand what they are seeing, and help them apply what they learn to the world around them.

Avoid fast-paced programs (young children do not understand them as well), apps with lots of distracting content, and any violent content.

Turn off televisions and other devices when not in use.

Avoid using media as the only way to calm your child. Although there are intermittent times (eg, medical procedures, airplane flights) when media is useful as a soothing strategy, there is concern that using media as strategy to calm could lead to problems with limit setting or the inability of children to develop their own emotion regulation. Ask your pediatrician for help if needed.

Monitor children’s media content and what apps are used or downloaded. Test apps before the child uses them, play together, and ask the child what he or she thinks about the app.

Keep bedrooms, mealtimes, and parent–child playtimes screen free for children and parents. Parents can set a “do not disturb” option on their phones during these times.

No screens 1 hour before bedtime, and remove devices from bedrooms before bed.

Consult the American Academy of Pediatrics Family Media Use Plan, available at: www.healthychildren.org/MediaUsePlan.

Industry

Work with developmental psychologists and educators to create design interfaces that are appropriate to child developmental abilities, that are not distracting, and that promote shared parent–child media use and application of skills to the real world. Cease making apps for children younger than 18 months until evidence of benefit is demonstrated.

Formally and scientifically evaluate products before making educational claims.

Make high-quality products accessible and affordable to low-income families and in multiple languages.

Eliminate advertising and unhealthy messages on apps. Children at this age cannot differentiate between advertisements and factual information, and therefore, advertising to them is unethical.

Help parents to set limits by stopping auto-advance of videos as the default setting. Develop systems embedded in devices that can help parents monitor and limit media use.
 
中文翻译:
本文地址:http://www.wjbb.com/know/1642
原文出处:http://pediatrics.aappublicati ... -2591 查看全部

 Abstract

Infants, toddlers, and preschoolers are now growing up in environments saturated with a variety of traditional and new technologies, which they are adopting at increasing rates. Although there has been much hope for the educational potential of interactive media for young children, accompanied by fears about their overuse during this crucial period of rapid brain development, research in this area still remains limited. This policy statement reviews the existing literature on television, videos, and mobile/interactive technologies; their potential for educational benefit; and related health concerns for young children (0 to 5 years of age). The statement also highlights areas in which pediatric providers can offer specific guidance to families in managing their young children’s media use, not only in terms of content or time limits, but also emphasizing the importance of parent–child shared media use and allowing the child time to take part in other developmentally healthy activities.
 
Introduction

Technologic innovation has transformed media and its role in the lives of infants and young children. More children, even in economically challenged households, are using newer digital technologies, such as interactive and mobile media, on a daily basis1 and continue to be the target of intense marketing. This policy statement addresses the influence of media on the health and development of children from 0 to 5 years of age, a time of critical brain development, building secure relationships, and establishing health behaviors.

Infants and Toddlers

Children younger than 2 years need hands-on exploration and social interaction with trusted caregivers to develop their cognitive, language, motor, and social-emotional skills. Because of their immature symbolic, memory, and attentional skills, infants and toddlers cannot learn from traditional digital media as they do from interactions with caregivers,and they have difficulty transferring that knowledge to their 3-dimensional experience.The chief factor that facilitates toddlers’ learning from commercial media (starting around 15 months of age) is parents watching with them and reteaching the content.

The interactivity of touchscreens enables applications (apps) to identify when a child responds accurately and then tailor its responses, thereby supporting children at their levels of competence. Emerging evidence shows that at 24 months of age, children can learn words from live video-chatting with a responsive adult or from an interactive touchscreen interface that scaffolds the child to choose the relevant answers. Starting at 15 months of age, toddlers can learn novel words from touchscreens in laboratory-based studies but have trouble transferring this knowledge to the 3-dimensional world. However, it should be noted that these experiments used specially designed apps that are not commercially available.

Many parents now use video-chat (eg, Skype, FaceTime) as an interactive media form that facilitates social connection with distant relatives. New evidence shows that infants and toddlers regularly engage in video-chatting, but the same principles regarding need for parental support would apply in order for infants and toddlers to understand what they are seeing.

In summary, for children younger than 2 years, evidence for benefits of media is still limited, adult interaction with the child during media use is crucial, and there continues to be evidence of harm from excessive digital media use, as described later in this statement.

Preschool Media and Learning

Well-designed television programs, such as Sesame Street, can improve cognitive, literacy, and social outcomes for children 3 to 5 years of age and continue to create programming that addresses evolving child health and developmental needs (eg, obesity prevention, resilience). Evaluations of apps from Sesame Workshop and the Public Broadcasting Service (PBS) also have shown efficacy in teaching literacy skills to preschoolers.Unfortunately, most apps parents find under the “educational” category in app stores have no such evidence of efficacy, target only rote academic skills, are not based on established curricula, and use little or no input from developmental specialists or educators. Most apps also generally are not designed for a dual audience (ie, both parent and child). It is important to emphasize to parents that the higher-order thinking skills and executive functions essential for school success, such as task persistence, impulse control, emotion regulation, and creative, flexible thinking, are best taught through unstructured and social (not digital) play,as well as responsive parent–child interactions.

Digital books (also called “eBooks,” books that can be read on a screen) often come with interactive enhancements that, research suggests, may decrease child comprehension of content or parent dialogic reading interactions when visual effects are distracting.Parents should, therefore, be instructed to interact with children during eBook reading, as they would a print book.

Health and Developmental Concerns

Obesity

Heavy media use during preschool years is associated with small but significant increases in BMI,18 may explain disparities in obesity risk in minority children,19 and sets the stage for weight gain later in childhood.Although many studies have used a 2-hour cutoff to examine obesity risk, a recent study of 2-year-olds found that BMI increased for every hour per week of media consumed.It is believed that exposure to food advertising and watching television while eating (which diminishes attention to satiety cues) drives these associations.

Sleep

Increased duration of media exposure and the presence of a television, computer, or mobile device in the bedroom in early childhood have been associated with fewer minutes of sleep per night.

Even infants exposed to screen media in the evening hours show significantly shorter night-time sleep duration than those with no evening screen exposure. Mechanisms underlying this association include arousing content and suppression of endogenous melatonin by blue light emitted from screens.

Child Development

Population-based studies continue to show associations between excessive television viewing in early childhood and cognitive,language,and social/emotional delays, likely secondary to decreases in parent–child interaction when the television is on37 and poorer family functioning in households with high media use. An earlier age of media use onset, greater cumulative hours of media use, and non-PBS content all are significant independent predictors of poor executive functioning in preschoolers.Content is crucial: experimental evidence shows that switching from violent content to educational/prosocial content results in significant improvement in behavioral symptoms, particularly for low-income boys.Notably, the quality of parenting can modify associations between media use and child development: one study found that inappropriate content and inconsistent parenting had cumulative negative effects on low-income preschoolers’ executive function, whereas warm parenting and educational content interacted to produce additive benefits.

Child characteristics also may influence how much media children consume: excessive television viewing is more likely in infants and toddlers with a difficult temperamentor self-regulation problems, and toddlers with social-emotional delays are more likely to be given a mobile device to calm them down.

Parental Media Use

Parents’ background television use distracts from parent–child interactions and child play.Heavy parent use of mobile devices is associated with fewer verbal and nonverbal interactions between parents and children and may be associated with more parent-child conflict. Because parent media use is a strong predictor of child media habits,reducing parental media use and enhancing parent–child interactions may be an important area of behavior change.

Conclusions: Clinical Implications

In summary, multiple developmental and health concerns continue to exist for young children using all forms of digital media to excess. Evidence is sufficient to recommend time limitations on digital media use for children 2 to 5 years to no more than 1 hour per day to allow children ample time to engage in other activities important to their health and development and to establish media viewing habits associated with lower risk of obesity later in life.In addition, encouraging parents to change to educational and prosocial content and engage with their children around technology will allow children to reap the most benefit from what they view.

As digital technologies become more ubiquitous, pediatric providers must guide parents not only on the duration and content of media their child uses, but also on (1) creating unplugged spaces and times in their homes, because devices can now be taken anywhere; (2) the ability of new technologies to be used in social and creative ways; and (3) the importance of not displacing sleep, exercise, play, reading aloud, and social interactions. Realistically, pediatric providers will need to know how to help parents find resources finding appropriate content, tools for monitoring or limiting child use, ideas for play or activities in which to engage rather than digital play, and how parents can limit their own media use (see HealthyChildren.org for examples); each of these can be built into the Family Media Use Plan (see the American Academy of Pediatrics guide to developing a plan at www.healthychildren.org/MediaUsePlan).

Recommendations

Pediatricians

Start the conversation early. Ask parents of infants and young children about family media use, their children’s use habits, and media use locations.

Help families develop a Family Media Use Plan (www.healthychildren.org/MediaUsePlan) with specific guidelines for each child and parent.

Educate parents about brain development in the early years and the importance of hands-on, unstructured, and social play to build language, cognitive, and social-emotional skills.

For children younger than 18 months, discourage use of screen media other than video-chatting.

For parents of children 18 to 24 months of age who want to introduce digital media, advise that they choose high-quality programming/apps and use them together with children, because this is how toddlers learn best. Letting children use media by themselves should be avoided.

Guide parents to resources for finding quality products (eg, Common Sense Media, PBS Kids, Sesame Workshop).

In children older than 2 years, limit media to 1 hour or less per day of high-quality programming. Recommend shared use between parent and child to promote enhanced learning, greater interaction, and limit setting.

Recommend no screens during meals and for 1 hour before bedtime.

Problem-solve with parents facing challenges, such as setting limits, finding alternate activities, and calming children.

Families

Avoid digital media use (except video-chatting) in children younger than 18 to 24 months.

For children ages 18 to 24 months of age, if you want to introduce digital media, choose high-quality programming and use media together with your child. Avoid solo media use in this age group.

Do not feel pressured to introduce technology early; interfaces are so intuitive that children will figure them out quickly once they start using them at home or in school.

For children 2 to 5 years of age, limit screen use to 1 hour per day of high-quality programming, coview with your children, help children understand what they are seeing, and help them apply what they learn to the world around them.

Avoid fast-paced programs (young children do not understand them as well), apps with lots of distracting content, and any violent content.

Turn off televisions and other devices when not in use.

Avoid using media as the only way to calm your child. Although there are intermittent times (eg, medical procedures, airplane flights) when media is useful as a soothing strategy, there is concern that using media as strategy to calm could lead to problems with limit setting or the inability of children to develop their own emotion regulation. Ask your pediatrician for help if needed.

Monitor children’s media content and what apps are used or downloaded. Test apps before the child uses them, play together, and ask the child what he or she thinks about the app.

Keep bedrooms, mealtimes, and parent–child playtimes screen free for children and parents. Parents can set a “do not disturb” option on their phones during these times.

No screens 1 hour before bedtime, and remove devices from bedrooms before bed.

Consult the American Academy of Pediatrics Family Media Use Plan, available at: www.healthychildren.org/MediaUsePlan.

Industry

Work with developmental psychologists and educators to create design interfaces that are appropriate to child developmental abilities, that are not distracting, and that promote shared parent–child media use and application of skills to the real world. Cease making apps for children younger than 18 months until evidence of benefit is demonstrated.

Formally and scientifically evaluate products before making educational claims.

Make high-quality products accessible and affordable to low-income families and in multiple languages.

Eliminate advertising and unhealthy messages on apps. Children at this age cannot differentiate between advertisements and factual information, and therefore, advertising to them is unethical.

Help parents to set limits by stopping auto-advance of videos as the default setting. Develop systems embedded in devices that can help parents monitor and limit media use.
 
中文翻译:
本文地址:http://www.wjbb.com/know/1642
原文出处:http://pediatrics.aappublicati ... -2591

美国儿科学会:婴儿床床围会增加婴儿死亡风险

豌豆爸爸 发表了文章 • 0 个评论 • 1067 次浏览 • 2015-12-04 09:42 • 来自相关话题

Researchers are calling for a nationwide ban on crib bumpers after finding they are linked to a growing number of infant deaths.

Twenty-three deaths related to crib bumpers were reported to the U.S. Consumer Product Safety Commission (CPSC) from 2006 through 2012, according to the report “Crib Bumpers Continue to Cause Infant Deaths: A Need for a New Preventive Approach.” Eight deaths were reported in each of the three previous seven-year periods.

“Crib bumpers are killing kids,” senior author Bradley T. Thach, M.D., professor emeritus of pediatrics at the Washington University School of Medicine, said in a news release. “Bumpers are more dangerous than we originally thought. The infant deaths we studied could have been prevented if the cribs were empty.”

There were 48 deaths related to crib bumpers from 1985 through 2012, most due to suffocation, according to a review of CPSC data detailed in the report (Scheers NJ, et al. J Pediatr. Nov. 24, 2015, www.sciencedirect.com/science/article/pii/S0022347615012846). In an additional 146 incidents, babies nearly suffocated or choked.

Researchers acknowledged the increase over previous years could be due in part to better reporting to CPSC but also said they believe the actual figures may be higher as they found additional bumper-related deaths when reviewing data from the National Center for the Review and Prevention of Child Deaths.

The Academy, the National Institutes of Health and the Centers for Disease Control and Prevention all recommend against bumpers, but there are no federal regulations regarding their use. Researchers, two of whom previously worked for the CPSC, said that agency would be responsible for instituting a ban, but it has limited resources.

“A ban on crib bumpers would reinforce the message that no soft bedding of any kind should be placed inside a baby's crib,” Dr. Thach said. "There is one sure-fire way to prevent infant deaths from crib bumpers: Don't use them, ever."
 
中文翻译:
本文地址:http://www.wjbb.com/know/1350
原文出处:http://www.aappublications.org ... 20215 查看全部

Researchers are calling for a nationwide ban on crib bumpers after finding they are linked to a growing number of infant deaths.

Twenty-three deaths related to crib bumpers were reported to the U.S. Consumer Product Safety Commission (CPSC) from 2006 through 2012, according to the report “Crib Bumpers Continue to Cause Infant Deaths: A Need for a New Preventive Approach.” Eight deaths were reported in each of the three previous seven-year periods.

“Crib bumpers are killing kids,” senior author Bradley T. Thach, M.D., professor emeritus of pediatrics at the Washington University School of Medicine, said in a news release. “Bumpers are more dangerous than we originally thought. The infant deaths we studied could have been prevented if the cribs were empty.”

There were 48 deaths related to crib bumpers from 1985 through 2012, most due to suffocation, according to a review of CPSC data detailed in the report (Scheers NJ, et al. J Pediatr. Nov. 24, 2015, www.sciencedirect.com/science/article/pii/S0022347615012846). In an additional 146 incidents, babies nearly suffocated or choked.

Researchers acknowledged the increase over previous years could be due in part to better reporting to CPSC but also said they believe the actual figures may be higher as they found additional bumper-related deaths when reviewing data from the National Center for the Review and Prevention of Child Deaths.

The Academy, the National Institutes of Health and the Centers for Disease Control and Prevention all recommend against bumpers, but there are no federal regulations regarding their use. Researchers, two of whom previously worked for the CPSC, said that agency would be responsible for instituting a ban, but it has limited resources.

“A ban on crib bumpers would reinforce the message that no soft bedding of any kind should be placed inside a baby's crib,” Dr. Thach said. "There is one sure-fire way to prevent infant deaths from crib bumpers: Don't use them, ever."
 
中文翻译:
本文地址:http://www.wjbb.com/know/1350
原文出处:http://www.aappublications.org ... 20215

美国儿科研究7大成就,你孩子受益了吗?

红太狼 发表了文章 • 0 个评论 • 655 次浏览 • 2015-05-06 10:20 • 来自相关话题

很多医学观念、技术在今天看起来稀疏平常,但事实上它们是研究人员花费大量心血和精力总结、研发出来的,医生们传播这些观念,使用这些技术,让千千万万的人因此受益,但我们不能忘记默默站在背后的研发人员。

最近,美国儿科学会评出过去40年儿科研究的七大成就,受益于这些成就的不仅仅是美国的孩子,还有世界各地的孩子,因为这些理念和技术也在世界范围内得到广泛推广和使用,我们一起看看是哪些:

一、疫苗接种预防疾病拯救了很多生命

轮状病毒腹泻是导致5岁以下儿童死亡的重要原因之一,B型流感嗜血杆菌(Hib)感染可导致肺炎、脑膜炎、会厌炎等问题。现在轮状病毒和B型流感嗜血杆菌(Hib)感染现在都可以通过疫苗来预防,在美国,轮状病毒疫苗接种使肠胃炎的发生率下降了86%,Hib疫苗接种使Hib感染下降了99%。

二、表面活性剂助早产儿呼吸

早产孩子因为肺发育不成熟,容易出现呼吸窘迫,在没有表面活性剂之前主要靠呼吸机帮助呼吸,但容易出现肺损伤之类并发症,很多孩子因呼吸衰竭死亡。有了表面活性剂后,早产儿能更早的自主呼吸,并发症降低了,死于呼吸窘迫综合征的孩子减少了三分之二。

三、仰卧减少婴儿猝死综合征(SIDS)

研究发现俯卧的婴儿猝死的风险是其它孩子的两倍,根据这一结论,从1994年开始,美国国家儿童健康与发展研究所和儿科学会等机构开始推动“仰卧”运动,每年死于婴儿猝死综合征的孩子从1993年的4700人下降到了2010年的2063人。

四、治愈一种儿童常见癌症

急性淋巴细胞白血病是儿童最常见的癌症,在1975年,15岁以下的孩子5年存活率为60%,15-19岁5年存活率只有28%,那时候确诊白血病往往意味着死亡,在过去的40年里,随着化疗的进步和规范,新确诊病例5年以上存活率达到了90%。

五、预防母婴传播HIV

HIV的危害不用多说,产前,产中,产后母乳喂养均可导致妈妈将HIV传染给孩子,传染率可高达40%,现在通过齐多夫定等药物治疗,母婴传播率降低到不足2%。

六、提高了慢性疾病儿童的预期寿命

镰状细胞病(由于血红蛋白异常导致红细胞呈镰状)和囊肿性纤维病(导致全身多器官囊肿性纤维化,主要是肺部和消化道更易受影响,白种人发病率较高)这样的遗传性疾病,40年前罹患这些疾病预期寿命大约14岁,随着新生儿早期筛查的普及及羟基脲这样的药物的出现,今天这些慢性病患者的预期寿命达40岁以上。

七、安全座椅和安全带救了很多孩子的命

发生车祸时,一岁以内的孩子,使用安全座椅死亡率可下降71%。和只使用安全带相比,1-4岁的孩子使用安全座椅受伤的风险下降54%,4-8岁的孩子风险下降45%。大孩子和成人使用安全带可减少大约50%的死亡和重伤。这些研究成果导致了强制使用安全座椅的法规出台,让死于车祸的儿童显著减少。

这些成就是美国取得的,很多国家很多孩子也受益于这些研究成果,但由于种种原因,这些现成的研究成果在我国并没有得到充分的利用,比如我们国产的轮状病毒疫苗保护率就远低于美国,1岁以内婴儿应该仰卧可能很多儿科医生也不知道,至今儿童安全座椅在国内一线城市的使用率还只有5%,直到今年深圳才开始强制4岁以下儿童乘车使用安全座椅...

了解这些知识,利用好这些技术,本可以让孩子受益、免受伤害。在大环境不能帮孩子充分利用科研成果时,作为家长也可以通过学习,自己做点事情,比如买个安全座椅,给自己孩子增加一份安全保障。
 
本文地址:http://www.wjbb.com/know/1063
原文出处:http://weibo.com/p/1001603839260842160529 查看全部

很多医学观念、技术在今天看起来稀疏平常,但事实上它们是研究人员花费大量心血和精力总结、研发出来的,医生们传播这些观念,使用这些技术,让千千万万的人因此受益,但我们不能忘记默默站在背后的研发人员。

最近,美国儿科学会评出过去40年儿科研究的七大成就,受益于这些成就的不仅仅是美国的孩子,还有世界各地的孩子,因为这些理念和技术也在世界范围内得到广泛推广和使用,我们一起看看是哪些:

一、疫苗接种预防疾病拯救了很多生命

轮状病毒腹泻是导致5岁以下儿童死亡的重要原因之一,B型流感嗜血杆菌(Hib)感染可导致肺炎、脑膜炎、会厌炎等问题。现在轮状病毒和B型流感嗜血杆菌(Hib)感染现在都可以通过疫苗来预防,在美国,轮状病毒疫苗接种使肠胃炎的发生率下降了86%,Hib疫苗接种使Hib感染下降了99%。

二、表面活性剂助早产儿呼吸

早产孩子因为肺发育不成熟,容易出现呼吸窘迫,在没有表面活性剂之前主要靠呼吸机帮助呼吸,但容易出现肺损伤之类并发症,很多孩子因呼吸衰竭死亡。有了表面活性剂后,早产儿能更早的自主呼吸,并发症降低了,死于呼吸窘迫综合征的孩子减少了三分之二。

三、仰卧减少婴儿猝死综合征(SIDS)

研究发现俯卧的婴儿猝死的风险是其它孩子的两倍,根据这一结论,从1994年开始,美国国家儿童健康与发展研究所和儿科学会等机构开始推动“仰卧”运动,每年死于婴儿猝死综合征的孩子从1993年的4700人下降到了2010年的2063人。

四、治愈一种儿童常见癌症

急性淋巴细胞白血病是儿童最常见的癌症,在1975年,15岁以下的孩子5年存活率为60%,15-19岁5年存活率只有28%,那时候确诊白血病往往意味着死亡,在过去的40年里,随着化疗的进步和规范,新确诊病例5年以上存活率达到了90%。

五、预防母婴传播HIV

HIV的危害不用多说,产前,产中,产后母乳喂养均可导致妈妈将HIV传染给孩子,传染率可高达40%,现在通过齐多夫定等药物治疗,母婴传播率降低到不足2%。

六、提高了慢性疾病儿童的预期寿命

镰状细胞病(由于血红蛋白异常导致红细胞呈镰状)和囊肿性纤维病(导致全身多器官囊肿性纤维化,主要是肺部和消化道更易受影响,白种人发病率较高)这样的遗传性疾病,40年前罹患这些疾病预期寿命大约14岁,随着新生儿早期筛查的普及及羟基脲这样的药物的出现,今天这些慢性病患者的预期寿命达40岁以上。

七、安全座椅和安全带救了很多孩子的命

发生车祸时,一岁以内的孩子,使用安全座椅死亡率可下降71%。和只使用安全带相比,1-4岁的孩子使用安全座椅受伤的风险下降54%,4-8岁的孩子风险下降45%。大孩子和成人使用安全带可减少大约50%的死亡和重伤。这些研究成果导致了强制使用安全座椅的法规出台,让死于车祸的儿童显著减少。

这些成就是美国取得的,很多国家很多孩子也受益于这些研究成果,但由于种种原因,这些现成的研究成果在我国并没有得到充分的利用,比如我们国产的轮状病毒疫苗保护率就远低于美国,1岁以内婴儿应该仰卧可能很多儿科医生也不知道,至今儿童安全座椅在国内一线城市的使用率还只有5%,直到今年深圳才开始强制4岁以下儿童乘车使用安全座椅...

了解这些知识,利用好这些技术,本可以让孩子受益、免受伤害。在大环境不能帮孩子充分利用科研成果时,作为家长也可以通过学习,自己做点事情,比如买个安全座椅,给自己孩子增加一份安全保障。
 
本文地址:http://www.wjbb.com/know/1063
原文出处:http://weibo.com/p/1001603839260842160529

美国儿科学会:近40年儿科研究七大成就

红太狼 发表了文章 • 1 个评论 • 1064 次浏览 • 2015-05-01 09:16 • 来自相关话题

Major achievements in pediatric research, often taken for granted, have been made possible with federal funding. A recent congressional briefing hosted by the AAP Committee on Pediatric Research highlighted discoveries from the last 40 years from the perspectives of researchers and families.
 From passenger safety laws to the use of surfactant to rotavirus vaccines, pediatric research innovations over the last four decades have led to life-saving discoveries and policy changes that many take for granted.

Despite the importance of these advancements, researchers don’t always do a good job explaining the impact of their work and how it saves lives, said Tina Cheng, M.D., M.P.H., FAAP, chair of the AAP Committee on Pediatric Research (COPR).
 
That’s one reason the committee hosted a congressional briefing in December to present to lawmakers “7 Great Achievements in Pediatric Research” (see sidebar). Researchers and family members impacted by the research spoke to a standing-room-only crowd, focusing on innovations in the members’ lifetimes.

The topics covered immunizations, pediatric cancer, saving premature infants, preventing HIV transmission from mothers to babies, reducing sudden infant death syndrome (SIDS), increasing life expectancy for children with chronic diseases, and saving lives with car seats and seat belts. Forty years ago some of these discoveries may have seemed like science fiction.
 
To help select the topics, COPR surveyed its members along with the boards of the American Pediatric Society, Academic Pediatric Association, Society for Pediatric Research, Federation of Pediatric Organizations and Association of Medical School Pediatric Department Chairs. The groups, along with the Academy, sponsored the briefing.

“We chose the seven because we felt like they were recent successes and they were successes that would resonate with the public,” said Dr. Cheng, who moderated the briefing.
 
SPEAKING FROM THE HEART

Researchers shared their perspectives, but when family members and young people offered their stories about how research changed their lives, it was even more powerful, said neonatologist Scott Denne, M.D., FAAP, past chair of COPR.

Tokunbo Olaniyan, of Columbia, Md., a young woman whose late mother had sickle cell disease, talked about how grateful she was that her mother lived to be old enough to give birth. Forty years ago, sickle cell patients in the United States typically lived to only about 14 years.
 
College student Vikram Siberry, of Olney, Md., told how a seatbelt saved him during a car accident in high school that took the life of his friend who was behind the wheel.

Dr. Denne also shared how the introduction of surfactant to treat premature babies has affected his professional life.

“The difference is as night-and-day as any intervention has ever been,” he said.

“Before surfactant, our primary tools were the ventilator, and premature babies were born and immediately struggled to breathe,” he told the group. “The ventilator caused substantial damage — major ruptures of the lung — so you had to put in chest tubes. Babies needed to stay on ventilators for prolonged periods. Many babies who left the nursery had significant lung disease, and many babies simply didn’t survive.

“A daily event was babies dying … multiple chest tubes being placed … a whole host of rooms dedicated for babies who were going to be on ventilators for months. That was the reality before surfactant,” Dr. Denne said.

Today, many babies come off ventilators more quickly, lung damage is significantly less severe and survival rates have increased substantially, he noted.
 
SIDS was addressed by Marian Willinger, Ph.D., director of the research program in SIDS at the Eunice Kennedy Shriver National Institute for Child Health and Human Development. Dr. Willinger, consultant to the AAP Task Force on SIDS, coordinated much of the research efforts on the Back to Sleep campaign. Since 1994, the overall U.S. SIDS rate has declined by more than half as a result of babies being placed on their backs to sleep.

The briefing included graphs and charts on topics such as the progress made in life expectancy for patients with sickle cell anemia and cystic fibrosis. One chart showed the steep drop in perinatally acquired AIDS in the early 1990s with the introduction of an antiretroviral medication.
 
IMPORTANCE OF FUNDING

All of the stories were designed to help lawmakers and others understand the ongoing need for federal research funding.

“It’s very important for the general public to understand how impactful investing in research can and has been,” said Dr. Denne, who said funding should be maintained or better yet, increased.

Although the seven achievements will be no surprise to any pediatrician, Dr. Cheng said they all are taken for granted sometimes and continued investment is needed.

“All of these discoveries were the result of research funding innovation that led to decreased mortality, increased life expectancy, increased quality of life. There are more research discoveries to be made.”
 
7 Great Achievements in Pediatric Research in the Past 40 Years

Preventing disease with life-saving immunizations
 
Diseases like rotavirus and Haemophilus influenzae type b are now preventable due to vaccines.

Saving premature babies by helping them breathe

Deaths from respiratory distress syndrome have been reduced by two-thirds with the introduction of surfactant.

Reducing sudden infant death syndrome (SIDS) with Back to Sleep

SIDS has declined by half due to research and the Back to Sleep campaign.

Curing a common childhood cancer

More than 90% of children with acute lymphocytic leukemia now survive, compared with 57% in the 1970s.

Preventing human immunodeficiency virus (HIV) transmission from mother to baby

Twenty years ago, one in four mothers with HIV transmitted HIV to their babies. Now the transmission rate is less than 2% due to advances in medications given during pregnancy.

Increasing life expectancy for children with chronic diseases

Life expectancy of patients with sickle cell disease or cystic fibrosis has risen from 14 years to more than 40 years.

Saving lives with car seats and seat belts

Research leading to vehicle safety laws has significantly reduced pediatric motor vehicle deaths.
 
AAP评出40年儿科研究七大成就:1.疫苗接种预防疾病。2.表面活性剂助早产儿呼吸。3.仰卧降低婴儿猝死综合征。4.治愈一种儿童常见癌症(急淋白血病存活率从70年代的57%上升到90%)5.阻断HIV母婴传播(降低至<2%)6.提高慢性疾病儿童预期寿命。7.安全座椅和安全带救了很多孩子性命。
 
中文翻译:
本文地址:http://www.wjbb.com/know/1049
原文出处:http://aapnews.aappublications ... .full 查看全部

Major achievements in pediatric research, often taken for granted, have been made possible with federal funding. A recent congressional briefing hosted by the AAP Committee on Pediatric Research highlighted discoveries from the last 40 years from the perspectives of researchers and families.
 From passenger safety laws to the use of surfactant to rotavirus vaccines, pediatric research innovations over the last four decades have led to life-saving discoveries and policy changes that many take for granted.

Despite the importance of these advancements, researchers don’t always do a good job explaining the impact of their work and how it saves lives, said Tina Cheng, M.D., M.P.H., FAAP, chair of the AAP Committee on Pediatric Research (COPR).
 
That’s one reason the committee hosted a congressional briefing in December to present to lawmakers “7 Great Achievements in Pediatric Research” (see sidebar). Researchers and family members impacted by the research spoke to a standing-room-only crowd, focusing on innovations in the members’ lifetimes.

The topics covered immunizations, pediatric cancer, saving premature infants, preventing HIV transmission from mothers to babies, reducing sudden infant death syndrome (SIDS), increasing life expectancy for children with chronic diseases, and saving lives with car seats and seat belts. Forty years ago some of these discoveries may have seemed like science fiction.
 
To help select the topics, COPR surveyed its members along with the boards of the American Pediatric Society, Academic Pediatric Association, Society for Pediatric Research, Federation of Pediatric Organizations and Association of Medical School Pediatric Department Chairs. The groups, along with the Academy, sponsored the briefing.

“We chose the seven because we felt like they were recent successes and they were successes that would resonate with the public,” said Dr. Cheng, who moderated the briefing.
 
SPEAKING FROM THE HEART

Researchers shared their perspectives, but when family members and young people offered their stories about how research changed their lives, it was even more powerful, said neonatologist Scott Denne, M.D., FAAP, past chair of COPR.

Tokunbo Olaniyan, of Columbia, Md., a young woman whose late mother had sickle cell disease, talked about how grateful she was that her mother lived to be old enough to give birth. Forty years ago, sickle cell patients in the United States typically lived to only about 14 years.
 
College student Vikram Siberry, of Olney, Md., told how a seatbelt saved him during a car accident in high school that took the life of his friend who was behind the wheel.

Dr. Denne also shared how the introduction of surfactant to treat premature babies has affected his professional life.

“The difference is as night-and-day as any intervention has ever been,” he said.

“Before surfactant, our primary tools were the ventilator, and premature babies were born and immediately struggled to breathe,” he told the group. “The ventilator caused substantial damage — major ruptures of the lung — so you had to put in chest tubes. Babies needed to stay on ventilators for prolonged periods. Many babies who left the nursery had significant lung disease, and many babies simply didn’t survive.

“A daily event was babies dying … multiple chest tubes being placed … a whole host of rooms dedicated for babies who were going to be on ventilators for months. That was the reality before surfactant,” Dr. Denne said.

Today, many babies come off ventilators more quickly, lung damage is significantly less severe and survival rates have increased substantially, he noted.
 
SIDS was addressed by Marian Willinger, Ph.D., director of the research program in SIDS at the Eunice Kennedy Shriver National Institute for Child Health and Human Development. Dr. Willinger, consultant to the AAP Task Force on SIDS, coordinated much of the research efforts on the Back to Sleep campaign. Since 1994, the overall U.S. SIDS rate has declined by more than half as a result of babies being placed on their backs to sleep.

The briefing included graphs and charts on topics such as the progress made in life expectancy for patients with sickle cell anemia and cystic fibrosis. One chart showed the steep drop in perinatally acquired AIDS in the early 1990s with the introduction of an antiretroviral medication.
 
IMPORTANCE OF FUNDING

All of the stories were designed to help lawmakers and others understand the ongoing need for federal research funding.

“It’s very important for the general public to understand how impactful investing in research can and has been,” said Dr. Denne, who said funding should be maintained or better yet, increased.

Although the seven achievements will be no surprise to any pediatrician, Dr. Cheng said they all are taken for granted sometimes and continued investment is needed.

“All of these discoveries were the result of research funding innovation that led to decreased mortality, increased life expectancy, increased quality of life. There are more research discoveries to be made.”
 
7 Great Achievements in Pediatric Research in the Past 40 Years

Preventing disease with life-saving immunizations
 
Diseases like rotavirus and Haemophilus influenzae type b are now preventable due to vaccines.

Saving premature babies by helping them breathe

Deaths from respiratory distress syndrome have been reduced by two-thirds with the introduction of surfactant.

Reducing sudden infant death syndrome (SIDS) with Back to Sleep

SIDS has declined by half due to research and the Back to Sleep campaign.

Curing a common childhood cancer

More than 90% of children with acute lymphocytic leukemia now survive, compared with 57% in the 1970s.

Preventing human immunodeficiency virus (HIV) transmission from mother to baby

Twenty years ago, one in four mothers with HIV transmitted HIV to their babies. Now the transmission rate is less than 2% due to advances in medications given during pregnancy.

Increasing life expectancy for children with chronic diseases

Life expectancy of patients with sickle cell disease or cystic fibrosis has risen from 14 years to more than 40 years.

Saving lives with car seats and seat belts

Research leading to vehicle safety laws has significantly reduced pediatric motor vehicle deaths.
 
AAP评出40年儿科研究七大成就:1.疫苗接种预防疾病。2.表面活性剂助早产儿呼吸。3.仰卧降低婴儿猝死综合征。4.治愈一种儿童常见癌症(急淋白血病存活率从70年代的57%上升到90%)5.阻断HIV母婴传播(降低至<2%)6.提高慢性疾病儿童预期寿命。7.安全座椅和安全带救了很多孩子性命。
 
中文翻译:
本文地址:http://www.wjbb.com/know/1049
原文出处:http://aapnews.aappublications ... .full

抗生素和儿童上感,家长应该知道什么?

红太狼 发表了文章 • 0 个评论 • 651 次浏览 • 2015-03-31 23:54 • 来自相关话题

很多人反应上篇临床指南太专业,读不懂。这种指南本来就是给医生看的,家长读不懂是正常的。之所以选择找人翻译这篇指南,是因为儿童上呼吸道感染太常见了,很多孩子因为普通感冒而被用了抗菌素,美国也是如此,中国更如此。

既然这个账号的主要读者孩子家长,为充分利用资源,我就把这篇指南把里一些对家长有意义的知识,结合我们的国情解读一下分享给大家。

不要自行给孩子吃抗生素

任何一个药,给孩子吃之前都要分析一下,这个药会会给孩子什么好处,会带来什么坏处。这个分析的基础是对孩子病情有正确的判断,对药物的作用和副作用有充分的了解,如果你对病情判断不清,对药品不了解,就不要随便给孩子吃药,抗生素这样的处方药更是如此。

和其他国家一样,抗菌素在我国也是处方药,但显然管理不那么规范,没有处方上药店也常常能买到,很多家庭都常备着抗生素。孩子一生病家长就心急如焚,胡乱给孩子吃抗生素很常见,总觉得吃点药总比不吃强,也不管是不是细菌感染,也不知道吃的药有什么作用,可能会有什么危害。

上呼吸道感染,大部分是病毒感染引起的,不是细菌感染的话吃抗生素对病情没有任何作用,浪费钱不说,反而可能出现过敏、腹泻等问题,孩子期间接触抗生素还会对健康造成长期影响,导致如炎症性肠病、肥胖、湿疹和哮喘等风险增大。学医这么多年的医生,也经常判断不准,然后用错药,没有医学基础的家长更没法判断准确,用错药更是难免,爱子/女之心+焦虑+无知=害了孩子。

该用抗生素的时候要用

因为抗生素的滥用,有些家长又从一个极端走向了另外一个极端,谈抗生素色变,不管什么情况,哪怕真的细菌感染,医生开的抗生素也不给孩子吃,工作中也常碰到这样的家长。

抗生素虽然有副作用,但自青霉素发明以来,抗生素已拯救了无数人的生命,正如这篇指南里也列举了一些情况,使用正确的话,抗生素是利大于弊的。病情需要用的时候如果不用,就可能延误病情,最后吃亏的还是自己孩子。哪些情况要用,要由医生来决定,不是靠家长自己凭直觉凭感情来决定用不用。

医生乱开药怎么办

抗生素是处方药,应该由医生来决定用不用,但医生滥开抗生素也是不争的事实,正如这篇指南里所说,即便在美国,每年为治疗呼吸系统疾病开出没有治疗意义的抗生素处方达上千万份之多,中国肯定远不止这个数字。

滥用的原因有很多,有客观的也有主观的,有时是病情复杂,很难判断是细菌性还是病毒性感染,有时可能和也医生水平有关,对疾病和药品了解不够深入,当然有时候也是因为医生自己的利益。

任何医学临床指南里对一个药物使用的效益和风险分析,都是从患者角度出发,但在现实里,医生做医疗选择的时候难免也会权衡一下自己的利益。在医患关系紧张的环境下,当自己医疗决策可能影响到自己的人身安全时,为避免漏诊误诊带来的病情延误,医生很可能更愿意选择更积极的治疗,把可疑的细菌感染当细菌感染来治疗,让自己安心一点。另外在我国以药养医的医疗体制下,诊疗费用低廉,医院和医生要靠药品来维持收入,当然也更容易导致药物的滥用。

抗生素自己不能乱吃,上医院遇到医生乱开药,这是患者无法改变的现实,所能做的是找到更值得信任的医院和医生。国内的教材、指南和发达国家相比明显落后,医生学习更新知识途径很有限,这也是我找人翻译这些指南的一个原因,并不是因为什么情怀,而是因为付费阅读有了一些收入,我可以拿部分钱用这种方式回馈大家,同时可以丰富一下这个账号的内容,利人利己。

了解上感相关常识

因为儿童上呼吸道感染很常见,家长经常要面对,所以了解一些相关知识,还是会很有帮助。比如这篇指南里提到的:感冒流鼻涕持续10天以上要考虑鼻窦炎,应该找医生去检查;鼻窦炎诊断不需要常规拍片或者做CT、磁共振;普通感冒、急性支气管炎这些大家经常听到的病等是病毒感染,治疗是以缓解症状为主,不需要用抗生素;阿齐霉素不是治疗任何儿童上呼吸道感染的一线抗生素。等等...了解得越多,自己乱用药的可能性就越低,孩子也更安全。

以上大概是这篇指南对家长们的意义,另外指南里有个总结表,精简得很好,在微博贴过,但制图有点粗糙,重新制图贴在这里,有兴趣的可以看看。



本文地址:http://www.wjbb.com/know/1021
原文出处:http://weibo.com/p/1001593826179411943808 查看全部

很多人反应上篇临床指南太专业,读不懂。这种指南本来就是给医生看的,家长读不懂是正常的。之所以选择找人翻译这篇指南,是因为儿童上呼吸道感染太常见了,很多孩子因为普通感冒而被用了抗菌素,美国也是如此,中国更如此。

既然这个账号的主要读者孩子家长,为充分利用资源,我就把这篇指南把里一些对家长有意义的知识,结合我们的国情解读一下分享给大家。

不要自行给孩子吃抗生素

任何一个药,给孩子吃之前都要分析一下,这个药会会给孩子什么好处,会带来什么坏处。这个分析的基础是对孩子病情有正确的判断,对药物的作用和副作用有充分的了解,如果你对病情判断不清,对药品不了解,就不要随便给孩子吃药,抗生素这样的处方药更是如此。

和其他国家一样,抗菌素在我国也是处方药,但显然管理不那么规范,没有处方上药店也常常能买到,很多家庭都常备着抗生素。孩子一生病家长就心急如焚,胡乱给孩子吃抗生素很常见,总觉得吃点药总比不吃强,也不管是不是细菌感染,也不知道吃的药有什么作用,可能会有什么危害。

上呼吸道感染,大部分是病毒感染引起的,不是细菌感染的话吃抗生素对病情没有任何作用,浪费钱不说,反而可能出现过敏、腹泻等问题,孩子期间接触抗生素还会对健康造成长期影响,导致如炎症性肠病、肥胖、湿疹和哮喘等风险增大。学医这么多年的医生,也经常判断不准,然后用错药,没有医学基础的家长更没法判断准确,用错药更是难免,爱子/女之心+焦虑+无知=害了孩子。

该用抗生素的时候要用

因为抗生素的滥用,有些家长又从一个极端走向了另外一个极端,谈抗生素色变,不管什么情况,哪怕真的细菌感染,医生开的抗生素也不给孩子吃,工作中也常碰到这样的家长。

抗生素虽然有副作用,但自青霉素发明以来,抗生素已拯救了无数人的生命,正如这篇指南里也列举了一些情况,使用正确的话,抗生素是利大于弊的。病情需要用的时候如果不用,就可能延误病情,最后吃亏的还是自己孩子。哪些情况要用,要由医生来决定,不是靠家长自己凭直觉凭感情来决定用不用。

医生乱开药怎么办

抗生素是处方药,应该由医生来决定用不用,但医生滥开抗生素也是不争的事实,正如这篇指南里所说,即便在美国,每年为治疗呼吸系统疾病开出没有治疗意义的抗生素处方达上千万份之多,中国肯定远不止这个数字。

滥用的原因有很多,有客观的也有主观的,有时是病情复杂,很难判断是细菌性还是病毒性感染,有时可能和也医生水平有关,对疾病和药品了解不够深入,当然有时候也是因为医生自己的利益。

任何医学临床指南里对一个药物使用的效益和风险分析,都是从患者角度出发,但在现实里,医生做医疗选择的时候难免也会权衡一下自己的利益。在医患关系紧张的环境下,当自己医疗决策可能影响到自己的人身安全时,为避免漏诊误诊带来的病情延误,医生很可能更愿意选择更积极的治疗,把可疑的细菌感染当细菌感染来治疗,让自己安心一点。另外在我国以药养医的医疗体制下,诊疗费用低廉,医院和医生要靠药品来维持收入,当然也更容易导致药物的滥用。

抗生素自己不能乱吃,上医院遇到医生乱开药,这是患者无法改变的现实,所能做的是找到更值得信任的医院和医生。国内的教材、指南和发达国家相比明显落后,医生学习更新知识途径很有限,这也是我找人翻译这些指南的一个原因,并不是因为什么情怀,而是因为付费阅读有了一些收入,我可以拿部分钱用这种方式回馈大家,同时可以丰富一下这个账号的内容,利人利己。

了解上感相关常识

因为儿童上呼吸道感染很常见,家长经常要面对,所以了解一些相关知识,还是会很有帮助。比如这篇指南里提到的:感冒流鼻涕持续10天以上要考虑鼻窦炎,应该找医生去检查;鼻窦炎诊断不需要常规拍片或者做CT、磁共振;普通感冒、急性支气管炎这些大家经常听到的病等是病毒感染,治疗是以缓解症状为主,不需要用抗生素;阿齐霉素不是治疗任何儿童上呼吸道感染的一线抗生素。等等...了解得越多,自己乱用药的可能性就越低,孩子也更安全。

以上大概是这篇指南对家长们的意义,另外指南里有个总结表,精简得很好,在微博贴过,但制图有点粗糙,重新制图贴在这里,有兴趣的可以看看。



本文地址:http://www.wjbb.com/know/1021
原文出处:http://weibo.com/p/1001593826179411943808

美国儿科学会指南—儿童上呼吸道感染合理使用抗生素原则

红太狼 发表了文章 • 0 个评论 • 1324 次浏览 • 2015-03-27 22:59 • 来自相关话题

Adam L. Hersh, MD, PhD, Mary Anne Jackson, MD, Lauri A. Hicks, DO, and the COMMITTEE ON INFECTIOUS DISEASES

关键词

respiratory tract infections, antibacterial agents

呼吸道感染,抗菌剂

缩写词

AAP—美国儿科学会(American Academy of Pediatrics)

AOM—急性中耳炎(acute otitis media)

GAS—A群链球菌(group A Streptococcus)

NNT—防止1例不良事件发生或得到1例有利结果需要治疗的病例数(number needed to treat)

PTA—扁桃体周围脓肿(peritonsillar abscess)

TM—鼓膜(tympanic membrane)

URI—上呼吸道感染(upper respiratory tract infection)

摘要

大多数上呼吸道感染是由病毒引起,不需要使用抗生素治疗。本临床报告主要介绍了处方抗生素治疗细菌性上呼吸道感染(包括急性中耳炎、急性细菌性鼻窦炎和链球菌性咽炎等)时的策略。本文概述了合理使用抗生素的原则,侧重于运用严格的诊断标准,权衡抗生素治疗的效益和危害,并了解哪些情况不宜使用抗生素。这些原则可用于宣传近期的临床指南,有助于制定本地指南及与患者沟通;也广泛地适用于日常抗生素使用。

《儿科学》Pediatrics 2013;132:1146–1154

引言

在儿科门诊中,超过1/5的患儿会被医生处方抗生素。在美国,医生们每年开具的抗生素处方达近5000万份。1大量资料显示,抗生素处方不当在门诊中十分常见,在治疗病毒导致的上呼吸道感染(URI)时尤其如此。1–3每年,为治疗呼吸系统疾病而开具,却无法提供任何治疗效益的抗生素处方达上千万份之多。1最近的证据表明,广谱抗生素处方有所增加,且频繁发生在无需治疗或适用窄谱抗生素之时。1,2此类抗生素滥用会导致本可以避免的药物相关性不良事件4-6和抗生素耐药性,7,8增加不必要的医疗费用。正在研发中的可治疗抗生素耐药性感染的药物很少,进一步加剧了上述情况。9抗生素耐药性日益严重的健康和经济威胁促使医生合理地处方抗生素,在减少滥用的同时确保处方适当的药物,这也是保障公众健康和患者安全的当务之急。(http://www.cdc.gov/drugresista ... t-2013)。

对于为儿童提供医护服务的门诊医师和其他医务人员而言,每天都需要就是否为存在URI症状的患者处方抗生素做出临床决策。虽然抗生素处方是临床医护的常规组成部分,但合理使用抗生素绝非易事,这是因为病毒性与细菌性URI往往难以区分。本临床报告的主要目的在于提供使用抗生素治疗小儿URI的临床决策原则。需要强调的一点是:临床指南指出,在诊断急性中耳炎(AOM)、急性细菌性鼻窦炎和A群链球菌(GAS)引起的咽炎时,使用严格且经过验证的临床标准十分重要。此外,本文还强调了不适用抗生素的情况(尤其是病毒性呼吸道感染)。考虑到URI十分常见,且大多抗生素处方是为治疗URI而开具,因此,以优化抗生素处方为目的的指南和其他干预措施对此类疾病有较大影响。谨慎应用这些标准将可能减少小儿URI中的抗生素滥用。

抗生素耐药菌的出现和扩散引起了人们的担忧,为此1998年发布了第一版《儿童上呼吸道感染合理使用抗生素原则》(“Principles of Judicious Use of Antimicrobial Agents for Pediatric Upper Respiratory Tract Infections”)。10美国疾病预防控制中心(CDC)与美国儿科学会(APP)合作,力求根据现状更新上述原则。抗生素耐药性仍是重大的公共卫生问题,适当地使用抗生素是保障医疗服务质量的重要目标。虽然2000年7-价肺炎球菌多糖-蛋白结合疫苗(PCV7)的推出使侵袭性肺炎球菌感染发生率的大幅下降,11但由于无相应疫苗的血清型流行率有所增加(以血清型19A,一种常见的抗生素耐药性血清型最为明显),12,13科学家们在2010年推出了13-价肺炎球菌多糖-蛋白结合疫苗(PCV13)。医务人员担心抗生素耐药性是导致人们越来越多地使用广谱抗生素的一个原因。近年来发表了若干高质量的随机对照试验、荟萃分析以及最新或更新后的临床指南,更好地定义了使用抗生素治疗某些特定URI(包括AOM和急性细菌性鼻窦炎)的疗效。14–23与此同时,新出现的证据着重显示了抗生素导致的需要医疗照护的不良事件4-6以及可能危及生命的事件24,25。

本临床报告侧重于几种重要的小儿URI:AOM、急性细菌性鼻窦炎和咽炎,在特定情况下,抗生素可能有益于这些疾病的治疗。这些建议适用于健康的儿童,他们无潜在的内科疾病(如免疫抑制),因此发生严重并发症的风险不大。本报告的目的在于向医务人员介绍应在何种情况下使用最新的建议、指南以及“合理使用抗生素三原则”:(1)确定细菌感染的可能性;(2)权衡抗生素的效益和危害;(3)实施合理的处方策略。

原则一:确定细菌感染的可能性

细菌性URI的临床病史、症状和体征中有许多方面与病毒性感染或非传染病重叠或类似,要做出使用抗生素的合理决策,首先必须确定细菌感染的可能性。当医生确诊病毒感染,并合理地排除并发细菌感染时,不应使用抗生素,因为此时潜在危害远远大于潜在效益。对于AOM、急性细菌性鼻窦炎或咽炎的具体病例,可使用现有的完善且行之有效的严格标准来区分细菌性与非细菌性病因。

急性中耳炎(AOM)

2013年,AAP和美国家庭医师学会(American Academy of Family Physicians)发布了更新后的AOM诊断和治疗临床实践指南。22AOM的定义为:“中耳炎症状和体征的快速发作。”上述体征包括伴有或不伴有红斑的鼓膜(TM)膨出,症状可能包括耳痛、烦躁、耳漏和发热等。诊断AOM往往需要仔细的耳镜检查,以确认存在TM炎性改变。AAP指南建议,在以下任何一种情况下医生都可以确诊AOM:(1)有证据表明存在中耳积液(TM中度到重度膨出);或(2)不能归因于外耳道炎的新发耳漏。如果患儿仅出现轻度TM膨出,但伴有最近发生的耳部疼痛或TM严重红斑,也可以确诊AOM。由于清晰地观察TM可能有困难,且AOM通常是自限性疾病,为了尽量减少抗生素滥用,必须确保诊断的高度准确性。在确诊AOM后,根据疾病的严重程度(严重耳痛,耳痛持续>48小时,或体温≥39°C)、感染的偏侧性(双侧与单侧)、以及年龄(≤23个月和≥24个月)对患者进行分类将有助于合理地使用抗生素。症状严重、双侧受累且年龄较小的患者更可能受益于抗生素。对于年龄稍大、病情不严重且为单侧发病的患者,随访观察是较为合理的处置。

急性细菌性鼻窦炎

AAP23和美国传染病协会(Infectious Diseases Society of America)21近期制定了诊断和治疗急性细菌性鼻窦炎的循证临床指南。该指南支持使用严格的诊断标准来区分细菌性与病毒性URI。具体来说,诊断急性细菌性鼻窦炎应基于如下症状:(1)持续且无好转,(2)恶化,或(3)严重。持续性症状最为常见,包括流涕(任何性质)或持续10天未有好转的日间咳嗽。症状恶化包括恶化或新发发热、日间咳嗽或在典型病毒性URI好转之后流涕。严重症状包括持续发热(体温≥39°C)和流脓涕至少3天。这些临床标准是诊断急性细菌性鼻窦炎的基础。由于许多患有病毒性URI的儿童存在影像学异常,不应常规进行影像学检查。

急性咽炎

咽炎或咽痛可伴有其他非特异性症状,包括咳嗽、鼻塞、发热等。考虑诊断的最重要的因素为:是否是β-溶血性GAS引起。与AOM和急性细菌性鼻窦炎不同,GAS感染可通过实验室化验(快速抗原检测或培养)确诊。26,27评分系统(改良Centor或McIsaac评分28)有助于识别哪些人需要接受测试。存在以下2个或更多特征的患者应接受测试:(1)无咳嗽,(2)扁桃体有渗出物或肿胀,(3)发热史,(4)颈前淋巴结肿胀和触痛,(5)年龄小于15岁。存在URI症状和体征,包括咳嗽、鼻塞、结膜炎、声音嘶哑、腹泻或口咽部病变(溃疡、起泡)的患儿更可能患有病毒性疾病而非GAS感染,不应接受GAS测试。由于3岁以下儿童中风湿热较为罕见,且GAS一般不会引起咽炎,通常不应对他们进行测试。除极少数例外情况(例如,症状明确且与已确诊GAS咽炎的家庭成员有接触)之外,即使患者满足所有上述临床标准,未经测试也不应做出GAS诊断。即使在无症状的儿童中,细菌定植率也可达到15%到20%,这进一步显示了采用适当的临床标准并限制测试的重要性。

普通感冒、非特异性URI、急性咳嗽性疾病和急性支气管炎

普通感冒、非特异性URI、急性咳嗽性疾病和急性支气管炎的症状可能与细菌性URI重叠或相似,可包括咳嗽、鼻塞和咽痛等。总的来说,每年都有数以百万人次因这些病毒性疾病就诊。尤其是急性支气管炎,每年有超过200万人次因这种咳嗽性疾病到儿科就诊,70%以上的情况下医生都会处方抗生素。1AOM、鼻窦炎和咽炎的临床诊断可有助于临床医生排除上述疾病。普通感冒、非特异性URI、急性咳嗽性疾病和急性支气管炎的管理应侧重于缓解症状。不应处方抗生素来治疗这些疾病。

原则二:权衡抗生素的效益与危害

如果发现患者可能是细菌感染,下一步应比较抗生素治疗各种疾病的效益和潜在危害。需要考虑的效益相关预后包括:治愈率,症状减少,并发症和继发病例的预防。危害相关预后包括:抗生素相关性不良事件(如腹痛、腹泻、皮疹等),艰难梭菌性结肠炎,耐药性的产生以及费用等。

AOM效益

自从发布第一版合理使用抗生素原则以来,发表了若干项高质量的随机对照试验和荟萃分析。18–20,29–33总体而言,它们都强调了以下几点:(1)至少有一半的AOM患者无需抗生素治疗就可康复;(2)与安慰剂相比,接受抗生素治疗的儿童更可能康复或加速康复;(3)对于较为年幼,或患有双侧(而非单侧疾病),又或者是症状和体征较为严重的儿童,无抗生素治疗时较难康复。这些观察结果为AOM的治疗建议提供了理论依据。

多项荟萃分析表明,与安慰剂相比,接受抗生素治疗的儿童更容易实现临床症状缓解,防止1例不良事件发生或得到1例有利结果需要治疗的病例数(NNT)为7或8。18,33最近的两项在幼儿中进行、并采用了较严格的诊断标准的随机对照试验表明,与接受安慰剂的儿童相比,接受抗生素治疗的儿童症状评分较优,症状康复更快,且临床失败率(以耳镜检查和症状持续为标准衡量)显著较低,其NNT接近于4。19,20然而,请务必注意,大量关于抗生素治疗AOM效果的研究中,无论接受治疗与否,大多数患者的症状最后都会自发缓解,且不会出现并发症。临床上决定使用抗生素治疗AOM,在某种程度上是因为它们可能有助于预防并发症,如乳突炎等。然而,在上述对照研究和荟萃分析中,抗生素在预防这些罕见但严重的并发症方面并未显示出显著效益。英国对超过100万例AOM发作的观测数据表明,乳突炎(如果发生的话)通常在初次临床就诊时出现。34预防一例乳突炎发作的估算NNT为近5000。34

AAP建议对根据临床诊断标准确诊的AOM患儿行抗生素治疗。对于特定的患儿,尤其是症状不严重、单侧发病的2岁以上儿童,可以考虑观察。

急性细菌性鼻窦炎效益

有关抗生素治疗小儿急性细菌性鼻窦炎疗效的循证评估数量有限,且结果不一。有三项随机对照试验评估了与安慰剂相比,抗生素治疗临床确诊的急性细菌性鼻窦炎患儿的疗效,其中有两项是在1998年版合理使用抗生素原则发布后发表的。14,17,35两项试验的结论表明,在3天和14天后,抗生素组的症状缓解率均较高,14,35但一项研究显示抗生素并不优于安慰剂。17这些研究设计间的重大差异可能是造成其结果不同的一个原因:显示抗生素有益的试验纳入了症状较为严重的患者,并采用了更严格的诊断标准。这强调了临床诊断务必谨慎,因为对于不符合急性细菌性鼻窦炎诊断标准的患者,抗生素无任何临床效益。

抗生素预防化脓性并发症,如眶蜂窝组织炎或颅内脓肿的效益尚未得到证实。个别药效试验的统计学效力不足以证明抗生素对这些罕见并发症的疗效,一项对儿童和成年人随机对照试验的荟萃分析发现,抗生素的使用与并发症的发生率之间无显著相关性。36

AAP建议向存在急性细菌性鼻窦炎的临床特征,尤其是症状严重或有所恶化的患者行抗生素治疗。对于症状持续(>10天)者,可考虑观察加密切随访或抗生素治疗。

GAS咽炎效益

现有研究从症状缓解、传播、预防并发症(如风湿热)等方面评估了抗生素治疗急性咽炎的疗效。五项随机对照研究和一项荟萃分析审查了立即抗生素治疗对症状缓解情况的影响,其中一项于第一版合理使用抗生素原则发布之后完成。37–41这些研究提供了强有力的证据,表明采用抗生素治疗小儿咽炎和已确诊的GAS,可将咽痛、头痛等症状的持续时间缩短约1天。这些效益在短短3天内就十分明显。然而,抗生素治疗对缩短发热时间的效果尚不确定。尽管现有数据有限,但抗生素治疗GAS先证者(index cases)可能会减少水平传播,从而防止继发病例的产生。40,42在大家庭、托儿所、学校和军事环境中,这种效益尤为重要。

从历史上看,处方抗生素治疗GAS咽炎的主要动机是预防风湿热。1975年前在儿童中进行的多项随机对照试验显示,抗生素预防风湿热发作的效益是不治疗的四倍(风湿热在未经治疗的患者中的发生率约为3%)。43虽然近几十年来发生过几次风湿热局部爆发,但在大多数发达国家中其发病率已经大幅度下降。44这种下降的部分原因是诊断识别的改善和抗生素治疗,45但更可能与致风湿病性GAS菌株的流行率下降有关。46

抗生素对于GAS咽炎相关的化脓性并发症,如扁桃体周围脓肿(PTA)、AOM和急性鼻窦炎也有一定的预防作用。一项荟萃分析表明,抗生素治疗可以预防PTA;然而,该分析中的大多数病例都来自1951年的一项研究。43英国一个大型观察队列的数据表明,抗生素治疗可预防PTA的发生,但NNT>4000。47

AAP建议对确诊GAS咽炎的患儿行抗生素治疗。

普通感冒、非特异性URI、急性咳嗽性疾病和急性支气管炎

这些疾病的主要病因是病毒,因此不适用抗生素治疗。由于小儿急性支气管炎的诊断意义尚不确定,相关数据有限。然而,一项大型荟萃分析得出结论:抗生素治疗(包括延迟处方)无益于非特异性咳嗽和感冒患者。48

抗生素治疗的危害

在使用抗生素治疗URI时,考虑其可能造成的危害至关重要。应针对每个病例的具体情况,对潜在危害和潜在效益加以权衡。抗生素相关危害的重要性与以下内容直接相关:(1)评估潜在效益的程度(如,治疗双侧AOM幼儿的效益优于单侧患儿);(2)诊断不确定性的程度。就缓解症状而言,表明抗生素有益于治疗细菌性URI的证据占数量优势。当无法确定URI是否由急性细菌感染引起时,使用抗生素的危害通常会大于效益。采用严格的临床标准来确诊细菌感染有助于将其与小儿非特异性URI和普通感冒相区别。处方抗生素一般无益于治疗非特异性URI和感冒,只可能给这些患儿带来潜在危害。

抗生素是儿童因药物相关不良事件意外就诊的最大原因,每年此类就诊就超过150,000人次,并导致了巨大的潜在发病和费用。4抗生素相关不良事件的程度从轻微(腹泻和皮疹)、严重(Stevens-Johnson综合征)、到危及生命(过敏症或心源性猝死)不等。大多数评估抗生素治疗AOM、鼻窦炎和咽炎效果的临床试验使用的是阿莫西林或阿莫西林-克拉维酸,这些药物仍然是使用抗生素治疗这些疾病时推荐的一线药物。比较抗生素与安慰剂治疗AOM效果的研究表明,在接受治疗的患者中,不良事件(尤其是腹泻和皮疹)率略有增加。两项荟萃分析估算出不良事件率之差约为5%。18,32有两项使用阿莫西林-克拉维酸(以往研究常使用阿莫西林)的近期试验未纳入上述分析。在这两项试验中,接受抗生素治疗的患者的腹泻和皮炎率还要更高。19,20大多数近期进行的表明抗生素治疗鼻窦炎效益的试验中,接受高剂量阿莫西林-克拉维酸治疗的患者中不良事件(定义为皮疹、腹泻、呕吐和腹痛)发生率为44%,相比之下,在安慰剂组中为14%。14

前述不良事件较为常见,但大多数病例都比较轻微。抗生素也可产生严重的过敏反应,如Stevens-Johnson综合征等。25越来越多的证据表明,幼年接触抗生素可能会扰乱肠道及身体其它部位的微生物平衡,从而对健康造成长期不良影响,如炎症性肠病、肥胖、湿疹和哮喘等。49–51最近的一项研究强调了接受阿奇霉素治疗的成年人存在猝死风险,这可能与药物相关性QT间期延长有关。24阿齐霉素并非治疗任何小儿URI的一线抗生素,且它最有可能被不当使用(不能有效地针对引起AOM和鼻窦炎的最常见病原体)。1在过去十年中,住院患儿的艰难梭菌性结肠炎发生率大幅提高。52虽然存在合并症的患儿风险最大,但由于最近抗生素暴露已成为重大风险因素,社区获得性感染也时有发生。53

在个别患者和社区层面上,抗生素暴露与抗生素耐药性的发生间的关联均已得到公认。7,8由于治疗方案有限,抗生素耐药性感染难以治疗,而且在某些病例中,其与临床预后不良相关。54无论在个人和社区层面上,应用严格的诊断标准,在确诊且存在明确的潜在效益时再使用抗生素治疗,对于最大程度地减少抗生素滥用对耐药性的影响至关重要。

原则三:实施合理的处方策略

当有证据表明抗生素的效益时,应从几个方面考虑合理地处方:针对最可能的病原体选择适当的抗生素药物(也要考虑到当地的耐药模式),选择适当的剂量,在满足治疗需要的前提下尽可能地缩短治疗持续时间。此外,医生还应考虑观察和利用延迟处方策略的作用。AOM和急性细菌性鼻窦炎的治疗说明了合理使用抗生素的几个关键环节。由于肺炎链球菌(Streptococcus pneumoniae)是这些疾病最重要的病因,所以传统上建议使用阿莫西林作为一线治疗药物。然而,在某些社区中,细菌性URI中耐阿莫西林的产β-内酰胺酶流感嗜血杆菌(Haemophilus influenzae)的流行率显著增加。55这(从一定程度上)表明,在特定情况下(如症状严重,近期[<6周]抗生素暴露,当地耐阿莫西林流感嗜血杆菌的流行率较高等),应考虑使用阿莫西林-克拉维酸。不过需要务必注意的是,与URI的其他细菌性病因,包括流感嗜血杆菌和莫拉菌属(Moraxella)物种(其自发缓解率较高)相比,肺炎链球菌感染患者中抗生素治疗的效益最大。16由于阿莫西林-克拉维酸比阿莫西林更容易导致不良事件,在大多数情况下,医生可能会选择使用阿莫西林作为第一线药物。

了解当地的流行病学和耐药模式对于适当地选择抗生素尤为重要。肺炎球菌对大环内酯类56和第三代口服头孢菌素57,58耐药率较高,因此这些药物不适合用于治疗大多数疑似细菌性URI的患儿。GAS出现大环内酯类药物耐药性也是一个重大问题,不过一般不会进行药敏试验。

对于AOM和急性细菌性鼻窦炎患儿,考虑观察(也称为“随访观察”或“延迟处方”)的效果,而不是直接行抗生素治疗非常重要。对AOM患者的研究表明,该方法可减少抗生素的使用,患者家庭的接受度良好,而且,辅以密切的随访时,不会造成临床预后恶化。22对于无严重症状且较年长的AOM和鼻窦炎患者,应考虑将观察疗法作为替代性策略。22,23该方法可促进患者及其家属参与共同决策,包括讨论立即进行抗生素治疗相关的潜在效益和风险等。

合理使用抗生素的另一个重要的考虑因素是抗生素暴露的总程度。较短的疗程有可能实现与较长疗程同样的临床效益,同时最大程度地减少了不良事件和产生耐药性的风险,依从性也更好。重要的例子有:阿莫西林治疗GAS咽炎26(每日1次与每日给药2次或3次相比,但每日给药剂量相同,均为50 mg/kg);在患AOM的大龄儿童中行短期疗法(例如,7天与10天相比)。22

结论

本临床报告讨论了合理使用抗生素治疗小儿URI的原则。重点强调了适当的诊断,这是对处方抗生素作出合理决策的基础。尽管本文侧重于特定的几种URI,主要内容亦适用于更广泛和常规的抗生素使用。这些原则可用于促进医师教育,宣传近期的临床指南,协助医生就适当地使用抗生素与患者及其家属沟通,并有助于制定当地的合理使用抗生素指南。

本文版权属于是美国儿科学会及其董事会。所有作者均已和美国儿科学会签署过利益冲突声明,通过董事会审批的程序消除了利益冲突。在制定本出版物的内容时,美国儿科学会不寻求也不接受任何商业介入。

除非在失效时或失效前重新发布、修订或作废,美国儿科学会发布的所有临床报告均在发布 5 年后自动失效。

本报告中提供的指南不作为治疗的唯一准则或医疗护理标准,根据个体的情况作适当变通会更合适。

版权所有 2010 年 美国儿科学会(本翻译文本仅供参考,参考文献可点阅读原文查看)

翻译:@任扶摇

(译者简介:任扶摇,离开分子遗传学科研一线后做起了自由翻译和撰稿人,曾翻译过几十万字的The Lancet, BMJ和NEJM文献和临床指南,并先后为《MIT科技创业》杂志,纽约时报中文网和彭博商业周刊等翻译或撰写编译稿件。)

本文地址:http://www.wjbb.com/know/1020
原文出处:http://weibo.com/p/1001593825089635326039 查看全部

Adam L. Hersh, MD, PhD, Mary Anne Jackson, MD, Lauri A. Hicks, DO, and the COMMITTEE ON INFECTIOUS DISEASES

关键词

respiratory tract infections, antibacterial agents

呼吸道感染,抗菌剂

缩写词

AAP—美国儿科学会(American Academy of Pediatrics)

AOM—急性中耳炎(acute otitis media)

GAS—A群链球菌(group A Streptococcus)

NNT—防止1例不良事件发生或得到1例有利结果需要治疗的病例数(number needed to treat)

PTA—扁桃体周围脓肿(peritonsillar abscess)

TM—鼓膜(tympanic membrane)

URI—上呼吸道感染(upper respiratory tract infection)

摘要

大多数上呼吸道感染是由病毒引起,不需要使用抗生素治疗。本临床报告主要介绍了处方抗生素治疗细菌性上呼吸道感染(包括急性中耳炎、急性细菌性鼻窦炎和链球菌性咽炎等)时的策略。本文概述了合理使用抗生素的原则,侧重于运用严格的诊断标准,权衡抗生素治疗的效益和危害,并了解哪些情况不宜使用抗生素。这些原则可用于宣传近期的临床指南,有助于制定本地指南及与患者沟通;也广泛地适用于日常抗生素使用。

《儿科学》Pediatrics 2013;132:1146–1154

引言

在儿科门诊中,超过1/5的患儿会被医生处方抗生素。在美国,医生们每年开具的抗生素处方达近5000万份。1大量资料显示,抗生素处方不当在门诊中十分常见,在治疗病毒导致的上呼吸道感染(URI)时尤其如此。1–3每年,为治疗呼吸系统疾病而开具,却无法提供任何治疗效益的抗生素处方达上千万份之多。1最近的证据表明,广谱抗生素处方有所增加,且频繁发生在无需治疗或适用窄谱抗生素之时。1,2此类抗生素滥用会导致本可以避免的药物相关性不良事件4-6和抗生素耐药性,7,8增加不必要的医疗费用。正在研发中的可治疗抗生素耐药性感染的药物很少,进一步加剧了上述情况。9抗生素耐药性日益严重的健康和经济威胁促使医生合理地处方抗生素,在减少滥用的同时确保处方适当的药物,这也是保障公众健康和患者安全的当务之急。(http://www.cdc.gov/drugresista ... t-2013)。

对于为儿童提供医护服务的门诊医师和其他医务人员而言,每天都需要就是否为存在URI症状的患者处方抗生素做出临床决策。虽然抗生素处方是临床医护的常规组成部分,但合理使用抗生素绝非易事,这是因为病毒性与细菌性URI往往难以区分。本临床报告的主要目的在于提供使用抗生素治疗小儿URI的临床决策原则。需要强调的一点是:临床指南指出,在诊断急性中耳炎(AOM)、急性细菌性鼻窦炎和A群链球菌(GAS)引起的咽炎时,使用严格且经过验证的临床标准十分重要。此外,本文还强调了不适用抗生素的情况(尤其是病毒性呼吸道感染)。考虑到URI十分常见,且大多抗生素处方是为治疗URI而开具,因此,以优化抗生素处方为目的的指南和其他干预措施对此类疾病有较大影响。谨慎应用这些标准将可能减少小儿URI中的抗生素滥用。

抗生素耐药菌的出现和扩散引起了人们的担忧,为此1998年发布了第一版《儿童上呼吸道感染合理使用抗生素原则》(“Principles of Judicious Use of Antimicrobial Agents for Pediatric Upper Respiratory Tract Infections”)。10美国疾病预防控制中心(CDC)与美国儿科学会(APP)合作,力求根据现状更新上述原则。抗生素耐药性仍是重大的公共卫生问题,适当地使用抗生素是保障医疗服务质量的重要目标。虽然2000年7-价肺炎球菌多糖-蛋白结合疫苗(PCV7)的推出使侵袭性肺炎球菌感染发生率的大幅下降,11但由于无相应疫苗的血清型流行率有所增加(以血清型19A,一种常见的抗生素耐药性血清型最为明显),12,13科学家们在2010年推出了13-价肺炎球菌多糖-蛋白结合疫苗(PCV13)。医务人员担心抗生素耐药性是导致人们越来越多地使用广谱抗生素的一个原因。近年来发表了若干高质量的随机对照试验、荟萃分析以及最新或更新后的临床指南,更好地定义了使用抗生素治疗某些特定URI(包括AOM和急性细菌性鼻窦炎)的疗效。14–23与此同时,新出现的证据着重显示了抗生素导致的需要医疗照护的不良事件4-6以及可能危及生命的事件24,25。

本临床报告侧重于几种重要的小儿URI:AOM、急性细菌性鼻窦炎和咽炎,在特定情况下,抗生素可能有益于这些疾病的治疗。这些建议适用于健康的儿童,他们无潜在的内科疾病(如免疫抑制),因此发生严重并发症的风险不大。本报告的目的在于向医务人员介绍应在何种情况下使用最新的建议、指南以及“合理使用抗生素三原则”:(1)确定细菌感染的可能性;(2)权衡抗生素的效益和危害;(3)实施合理的处方策略。

原则一:确定细菌感染的可能性

细菌性URI的临床病史、症状和体征中有许多方面与病毒性感染或非传染病重叠或类似,要做出使用抗生素的合理决策,首先必须确定细菌感染的可能性。当医生确诊病毒感染,并合理地排除并发细菌感染时,不应使用抗生素,因为此时潜在危害远远大于潜在效益。对于AOM、急性细菌性鼻窦炎或咽炎的具体病例,可使用现有的完善且行之有效的严格标准来区分细菌性与非细菌性病因。

急性中耳炎(AOM)

2013年,AAP和美国家庭医师学会(American Academy of Family Physicians)发布了更新后的AOM诊断和治疗临床实践指南。22AOM的定义为:“中耳炎症状和体征的快速发作。”上述体征包括伴有或不伴有红斑的鼓膜(TM)膨出,症状可能包括耳痛、烦躁、耳漏和发热等。诊断AOM往往需要仔细的耳镜检查,以确认存在TM炎性改变。AAP指南建议,在以下任何一种情况下医生都可以确诊AOM:(1)有证据表明存在中耳积液(TM中度到重度膨出);或(2)不能归因于外耳道炎的新发耳漏。如果患儿仅出现轻度TM膨出,但伴有最近发生的耳部疼痛或TM严重红斑,也可以确诊AOM。由于清晰地观察TM可能有困难,且AOM通常是自限性疾病,为了尽量减少抗生素滥用,必须确保诊断的高度准确性。在确诊AOM后,根据疾病的严重程度(严重耳痛,耳痛持续>48小时,或体温≥39°C)、感染的偏侧性(双侧与单侧)、以及年龄(≤23个月和≥24个月)对患者进行分类将有助于合理地使用抗生素。症状严重、双侧受累且年龄较小的患者更可能受益于抗生素。对于年龄稍大、病情不严重且为单侧发病的患者,随访观察是较为合理的处置。

急性细菌性鼻窦炎

AAP23和美国传染病协会(Infectious Diseases Society of America)21近期制定了诊断和治疗急性细菌性鼻窦炎的循证临床指南。该指南支持使用严格的诊断标准来区分细菌性与病毒性URI。具体来说,诊断急性细菌性鼻窦炎应基于如下症状:(1)持续且无好转,(2)恶化,或(3)严重。持续性症状最为常见,包括流涕(任何性质)或持续10天未有好转的日间咳嗽。症状恶化包括恶化或新发发热、日间咳嗽或在典型病毒性URI好转之后流涕。严重症状包括持续发热(体温≥39°C)和流脓涕至少3天。这些临床标准是诊断急性细菌性鼻窦炎的基础。由于许多患有病毒性URI的儿童存在影像学异常,不应常规进行影像学检查。

急性咽炎

咽炎或咽痛可伴有其他非特异性症状,包括咳嗽、鼻塞、发热等。考虑诊断的最重要的因素为:是否是β-溶血性GAS引起。与AOM和急性细菌性鼻窦炎不同,GAS感染可通过实验室化验(快速抗原检测或培养)确诊。26,27评分系统(改良Centor或McIsaac评分28)有助于识别哪些人需要接受测试。存在以下2个或更多特征的患者应接受测试:(1)无咳嗽,(2)扁桃体有渗出物或肿胀,(3)发热史,(4)颈前淋巴结肿胀和触痛,(5)年龄小于15岁。存在URI症状和体征,包括咳嗽、鼻塞、结膜炎、声音嘶哑、腹泻或口咽部病变(溃疡、起泡)的患儿更可能患有病毒性疾病而非GAS感染,不应接受GAS测试。由于3岁以下儿童中风湿热较为罕见,且GAS一般不会引起咽炎,通常不应对他们进行测试。除极少数例外情况(例如,症状明确且与已确诊GAS咽炎的家庭成员有接触)之外,即使患者满足所有上述临床标准,未经测试也不应做出GAS诊断。即使在无症状的儿童中,细菌定植率也可达到15%到20%,这进一步显示了采用适当的临床标准并限制测试的重要性。

普通感冒、非特异性URI、急性咳嗽性疾病和急性支气管炎

普通感冒、非特异性URI、急性咳嗽性疾病和急性支气管炎的症状可能与细菌性URI重叠或相似,可包括咳嗽、鼻塞和咽痛等。总的来说,每年都有数以百万人次因这些病毒性疾病就诊。尤其是急性支气管炎,每年有超过200万人次因这种咳嗽性疾病到儿科就诊,70%以上的情况下医生都会处方抗生素。1AOM、鼻窦炎和咽炎的临床诊断可有助于临床医生排除上述疾病。普通感冒、非特异性URI、急性咳嗽性疾病和急性支气管炎的管理应侧重于缓解症状。不应处方抗生素来治疗这些疾病。

原则二:权衡抗生素的效益与危害

如果发现患者可能是细菌感染,下一步应比较抗生素治疗各种疾病的效益和潜在危害。需要考虑的效益相关预后包括:治愈率,症状减少,并发症和继发病例的预防。危害相关预后包括:抗生素相关性不良事件(如腹痛、腹泻、皮疹等),艰难梭菌性结肠炎,耐药性的产生以及费用等。

AOM效益

自从发布第一版合理使用抗生素原则以来,发表了若干项高质量的随机对照试验和荟萃分析。18–20,29–33总体而言,它们都强调了以下几点:(1)至少有一半的AOM患者无需抗生素治疗就可康复;(2)与安慰剂相比,接受抗生素治疗的儿童更可能康复或加速康复;(3)对于较为年幼,或患有双侧(而非单侧疾病),又或者是症状和体征较为严重的儿童,无抗生素治疗时较难康复。这些观察结果为AOM的治疗建议提供了理论依据。

多项荟萃分析表明,与安慰剂相比,接受抗生素治疗的儿童更容易实现临床症状缓解,防止1例不良事件发生或得到1例有利结果需要治疗的病例数(NNT)为7或8。18,33最近的两项在幼儿中进行、并采用了较严格的诊断标准的随机对照试验表明,与接受安慰剂的儿童相比,接受抗生素治疗的儿童症状评分较优,症状康复更快,且临床失败率(以耳镜检查和症状持续为标准衡量)显著较低,其NNT接近于4。19,20然而,请务必注意,大量关于抗生素治疗AOM效果的研究中,无论接受治疗与否,大多数患者的症状最后都会自发缓解,且不会出现并发症。临床上决定使用抗生素治疗AOM,在某种程度上是因为它们可能有助于预防并发症,如乳突炎等。然而,在上述对照研究和荟萃分析中,抗生素在预防这些罕见但严重的并发症方面并未显示出显著效益。英国对超过100万例AOM发作的观测数据表明,乳突炎(如果发生的话)通常在初次临床就诊时出现。34预防一例乳突炎发作的估算NNT为近5000。34

AAP建议对根据临床诊断标准确诊的AOM患儿行抗生素治疗。对于特定的患儿,尤其是症状不严重、单侧发病的2岁以上儿童,可以考虑观察。

急性细菌性鼻窦炎效益

有关抗生素治疗小儿急性细菌性鼻窦炎疗效的循证评估数量有限,且结果不一。有三项随机对照试验评估了与安慰剂相比,抗生素治疗临床确诊的急性细菌性鼻窦炎患儿的疗效,其中有两项是在1998年版合理使用抗生素原则发布后发表的。14,17,35两项试验的结论表明,在3天和14天后,抗生素组的症状缓解率均较高,14,35但一项研究显示抗生素并不优于安慰剂。17这些研究设计间的重大差异可能是造成其结果不同的一个原因:显示抗生素有益的试验纳入了症状较为严重的患者,并采用了更严格的诊断标准。这强调了临床诊断务必谨慎,因为对于不符合急性细菌性鼻窦炎诊断标准的患者,抗生素无任何临床效益。

抗生素预防化脓性并发症,如眶蜂窝组织炎或颅内脓肿的效益尚未得到证实。个别药效试验的统计学效力不足以证明抗生素对这些罕见并发症的疗效,一项对儿童和成年人随机对照试验的荟萃分析发现,抗生素的使用与并发症的发生率之间无显著相关性。36

AAP建议向存在急性细菌性鼻窦炎的临床特征,尤其是症状严重或有所恶化的患者行抗生素治疗。对于症状持续(>10天)者,可考虑观察加密切随访或抗生素治疗。

GAS咽炎效益

现有研究从症状缓解、传播、预防并发症(如风湿热)等方面评估了抗生素治疗急性咽炎的疗效。五项随机对照研究和一项荟萃分析审查了立即抗生素治疗对症状缓解情况的影响,其中一项于第一版合理使用抗生素原则发布之后完成。37–41这些研究提供了强有力的证据,表明采用抗生素治疗小儿咽炎和已确诊的GAS,可将咽痛、头痛等症状的持续时间缩短约1天。这些效益在短短3天内就十分明显。然而,抗生素治疗对缩短发热时间的效果尚不确定。尽管现有数据有限,但抗生素治疗GAS先证者(index cases)可能会减少水平传播,从而防止继发病例的产生。40,42在大家庭、托儿所、学校和军事环境中,这种效益尤为重要。

从历史上看,处方抗生素治疗GAS咽炎的主要动机是预防风湿热。1975年前在儿童中进行的多项随机对照试验显示,抗生素预防风湿热发作的效益是不治疗的四倍(风湿热在未经治疗的患者中的发生率约为3%)。43虽然近几十年来发生过几次风湿热局部爆发,但在大多数发达国家中其发病率已经大幅度下降。44这种下降的部分原因是诊断识别的改善和抗生素治疗,45但更可能与致风湿病性GAS菌株的流行率下降有关。46

抗生素对于GAS咽炎相关的化脓性并发症,如扁桃体周围脓肿(PTA)、AOM和急性鼻窦炎也有一定的预防作用。一项荟萃分析表明,抗生素治疗可以预防PTA;然而,该分析中的大多数病例都来自1951年的一项研究。43英国一个大型观察队列的数据表明,抗生素治疗可预防PTA的发生,但NNT>4000。47

AAP建议对确诊GAS咽炎的患儿行抗生素治疗。

普通感冒、非特异性URI、急性咳嗽性疾病和急性支气管炎

这些疾病的主要病因是病毒,因此不适用抗生素治疗。由于小儿急性支气管炎的诊断意义尚不确定,相关数据有限。然而,一项大型荟萃分析得出结论:抗生素治疗(包括延迟处方)无益于非特异性咳嗽和感冒患者。48

抗生素治疗的危害

在使用抗生素治疗URI时,考虑其可能造成的危害至关重要。应针对每个病例的具体情况,对潜在危害和潜在效益加以权衡。抗生素相关危害的重要性与以下内容直接相关:(1)评估潜在效益的程度(如,治疗双侧AOM幼儿的效益优于单侧患儿);(2)诊断不确定性的程度。就缓解症状而言,表明抗生素有益于治疗细菌性URI的证据占数量优势。当无法确定URI是否由急性细菌感染引起时,使用抗生素的危害通常会大于效益。采用严格的临床标准来确诊细菌感染有助于将其与小儿非特异性URI和普通感冒相区别。处方抗生素一般无益于治疗非特异性URI和感冒,只可能给这些患儿带来潜在危害。

抗生素是儿童因药物相关不良事件意外就诊的最大原因,每年此类就诊就超过150,000人次,并导致了巨大的潜在发病和费用。4抗生素相关不良事件的程度从轻微(腹泻和皮疹)、严重(Stevens-Johnson综合征)、到危及生命(过敏症或心源性猝死)不等。大多数评估抗生素治疗AOM、鼻窦炎和咽炎效果的临床试验使用的是阿莫西林或阿莫西林-克拉维酸,这些药物仍然是使用抗生素治疗这些疾病时推荐的一线药物。比较抗生素与安慰剂治疗AOM效果的研究表明,在接受治疗的患者中,不良事件(尤其是腹泻和皮疹)率略有增加。两项荟萃分析估算出不良事件率之差约为5%。18,32有两项使用阿莫西林-克拉维酸(以往研究常使用阿莫西林)的近期试验未纳入上述分析。在这两项试验中,接受抗生素治疗的患者的腹泻和皮炎率还要更高。19,20大多数近期进行的表明抗生素治疗鼻窦炎效益的试验中,接受高剂量阿莫西林-克拉维酸治疗的患者中不良事件(定义为皮疹、腹泻、呕吐和腹痛)发生率为44%,相比之下,在安慰剂组中为14%。14

前述不良事件较为常见,但大多数病例都比较轻微。抗生素也可产生严重的过敏反应,如Stevens-Johnson综合征等。25越来越多的证据表明,幼年接触抗生素可能会扰乱肠道及身体其它部位的微生物平衡,从而对健康造成长期不良影响,如炎症性肠病、肥胖、湿疹和哮喘等。49–51最近的一项研究强调了接受阿奇霉素治疗的成年人存在猝死风险,这可能与药物相关性QT间期延长有关。24阿齐霉素并非治疗任何小儿URI的一线抗生素,且它最有可能被不当使用(不能有效地针对引起AOM和鼻窦炎的最常见病原体)。1在过去十年中,住院患儿的艰难梭菌性结肠炎发生率大幅提高。52虽然存在合并症的患儿风险最大,但由于最近抗生素暴露已成为重大风险因素,社区获得性感染也时有发生。53

在个别患者和社区层面上,抗生素暴露与抗生素耐药性的发生间的关联均已得到公认。7,8由于治疗方案有限,抗生素耐药性感染难以治疗,而且在某些病例中,其与临床预后不良相关。54无论在个人和社区层面上,应用严格的诊断标准,在确诊且存在明确的潜在效益时再使用抗生素治疗,对于最大程度地减少抗生素滥用对耐药性的影响至关重要。

原则三:实施合理的处方策略

当有证据表明抗生素的效益时,应从几个方面考虑合理地处方:针对最可能的病原体选择适当的抗生素药物(也要考虑到当地的耐药模式),选择适当的剂量,在满足治疗需要的前提下尽可能地缩短治疗持续时间。此外,医生还应考虑观察和利用延迟处方策略的作用。AOM和急性细菌性鼻窦炎的治疗说明了合理使用抗生素的几个关键环节。由于肺炎链球菌(Streptococcus pneumoniae)是这些疾病最重要的病因,所以传统上建议使用阿莫西林作为一线治疗药物。然而,在某些社区中,细菌性URI中耐阿莫西林的产β-内酰胺酶流感嗜血杆菌(Haemophilus influenzae)的流行率显著增加。55这(从一定程度上)表明,在特定情况下(如症状严重,近期[<6周]抗生素暴露,当地耐阿莫西林流感嗜血杆菌的流行率较高等),应考虑使用阿莫西林-克拉维酸。不过需要务必注意的是,与URI的其他细菌性病因,包括流感嗜血杆菌和莫拉菌属(Moraxella)物种(其自发缓解率较高)相比,肺炎链球菌感染患者中抗生素治疗的效益最大。16由于阿莫西林-克拉维酸比阿莫西林更容易导致不良事件,在大多数情况下,医生可能会选择使用阿莫西林作为第一线药物。

了解当地的流行病学和耐药模式对于适当地选择抗生素尤为重要。肺炎球菌对大环内酯类56和第三代口服头孢菌素57,58耐药率较高,因此这些药物不适合用于治疗大多数疑似细菌性URI的患儿。GAS出现大环内酯类药物耐药性也是一个重大问题,不过一般不会进行药敏试验。

对于AOM和急性细菌性鼻窦炎患儿,考虑观察(也称为“随访观察”或“延迟处方”)的效果,而不是直接行抗生素治疗非常重要。对AOM患者的研究表明,该方法可减少抗生素的使用,患者家庭的接受度良好,而且,辅以密切的随访时,不会造成临床预后恶化。22对于无严重症状且较年长的AOM和鼻窦炎患者,应考虑将观察疗法作为替代性策略。22,23该方法可促进患者及其家属参与共同决策,包括讨论立即进行抗生素治疗相关的潜在效益和风险等。

合理使用抗生素的另一个重要的考虑因素是抗生素暴露的总程度。较短的疗程有可能实现与较长疗程同样的临床效益,同时最大程度地减少了不良事件和产生耐药性的风险,依从性也更好。重要的例子有:阿莫西林治疗GAS咽炎26(每日1次与每日给药2次或3次相比,但每日给药剂量相同,均为50 mg/kg);在患AOM的大龄儿童中行短期疗法(例如,7天与10天相比)。22

结论

本临床报告讨论了合理使用抗生素治疗小儿URI的原则。重点强调了适当的诊断,这是对处方抗生素作出合理决策的基础。尽管本文侧重于特定的几种URI,主要内容亦适用于更广泛和常规的抗生素使用。这些原则可用于促进医师教育,宣传近期的临床指南,协助医生就适当地使用抗生素与患者及其家属沟通,并有助于制定当地的合理使用抗生素指南。

本文版权属于是美国儿科学会及其董事会。所有作者均已和美国儿科学会签署过利益冲突声明,通过董事会审批的程序消除了利益冲突。在制定本出版物的内容时,美国儿科学会不寻求也不接受任何商业介入。

除非在失效时或失效前重新发布、修订或作废,美国儿科学会发布的所有临床报告均在发布 5 年后自动失效。

本报告中提供的指南不作为治疗的唯一准则或医疗护理标准,根据个体的情况作适当变通会更合适。

版权所有 2010 年 美国儿科学会(本翻译文本仅供参考,参考文献可点阅读原文查看)

翻译:@任扶摇

(译者简介:任扶摇,离开分子遗传学科研一线后做起了自由翻译和撰稿人,曾翻译过几十万字的The Lancet, BMJ和NEJM文献和临床指南,并先后为《MIT科技创业》杂志,纽约时报中文网和彭博商业周刊等翻译或撰写编译稿件。)

本文地址:http://www.wjbb.com/know/1020
原文出处:http://weibo.com/p/1001593825089635326039

美国儿科学会政策声明:维护和改善幼儿的口腔健康

豌豆爸爸 发表了文章 • 0 个评论 • 361 次浏览 • 2015-02-04 11:26 • 来自相关话题

Abstract
Oral health is an integral part of the overall health of children. Dental caries is a common and chronic disease process with significant short- and long-term consequences. The prevalence of dental caries for the youngest of children has not decreased over the past decade, despite improvements for older children. As health care professionals responsible for the overall health of children, pediatricians frequently confront morbidity associated with dental caries. Because the youngest children visit the pediatrician more often than they visit the dentist, it is important that pediatricians be knowledgeable about the disease process of dental caries, prevention of the disease, and interventions available to the pediatrician and the family to maintain and restore health.

Introduction
Dental caries is the most common chronic disease of childhood. Twenty-four percent of US children 2 to 4 years of age, 53% of children 6 to 8 years of age, and 56% of 15-year-olds have caries experience (ie, untreated dental caries, filled teeth, teeth missing as a result of dental caries). For children 5 to 19 years of age, children from poor and racial or ethnic minority families have higher rates of untreated dental caries than do their peers from nonpoor and nonminority families. For some age groups, the incidence of dental caries has decreased or stayed the same, but for the youngest children, it has increased. Among 6- to 8-year-olds and 15-year-olds, caries experience and untreated dental decay remained mostly unchanged between 1988–1994 and 1999–2004. In children 2 to 4 years of age, the caries experience increased significantly, from 19% to 24%, during that same time period. The increase in the caries experience and untreated caries was statistically significant in children from poor families.

The Etiology and Pathogenesis of Dental Caries
A dynamic process takes place at the surface of the tooth that involves constant demineralization and remineralization of the tooth enamel (the caries balance). Multiple factors affect that dynamic process and can be manipulated in ways that tip the balance toward disease (demineralization) or health (remineralization). These factors include bacteria, sugar, saliva, and fluoride. Because these factors can be manipulated, it is possible for pediatricians and families to prevent, halt, or even reverse the disease process.

Different oral structures and tissues have different and distinct microbial communities (microbiomes). The oral microbiome at the surface of the tooth is referred to as dental plaque. During the disease process of dental caries, bacteria that are aciduric and acidogenic predominate in the dental plaque. Streptococcus mutans is most strongly associated with dental caries, although other bacterial species have these capabilities and thus can also be pathogenic. When environmental factors make it possible to select for these pathogenic bacteria in dental plaque, the disease process begins.

A key environmental factor that allows for selection and proliferation of these pathogenic bacteria is dietary sugar intake. Because these pathogenic bacteria have the ability to ferment sugars, produce acid, and decrease the pH of the dental plaque, they make possible the selection of other aciduric, acidogenic bacteria that will contribute to disease. As more bacteria produce more acid, the pH at the surface of the tooth decreases. This process causes the demineralization of the tooth enamel. Unimpeded, these long periods of low pH and demineralization will result in cavitation.

Saliva is an important factor in buffering the low pH and bringing these demineralization pressures back to a balance with remineralization. In addition to acting as a buffering agent, saliva also flushes the oral cavity of food particles and provides an environment rich in calcium and phosphate to aid in remineralization. When salivary flow is impeded, the pH is able to decrease to a lower level, tipping the scales toward demineralization (disease); in addition, the time it takes to buffer back to a normal pH is longer.

Another important factor that can affect the balance of demineralization and remineralization is fluoride. More in-depth reviews of fluoride are available elsewhere. It is important, however, for pediatricians and other child health care providers to understand how fluoride influences the caries balance. Fluoride has 3 key effects on the caries balance: (1) inhibition of demineralization at the tooth surface; (2) enhancement of remineralization, which results in a more acid-resistant tooth surface; and (3) inhibition of bacterial enzymes. The primary effect of fluoride is topical, via fluoridated toothpastes, mouth rinses, and varnishes, although there is still value in systemic fluoride exposures via fluoridated water and supplements.

Preventive Strategies

Caries Risk Assessment

Ideally, primary prevention efforts will anticipate and prevent caries before the first sign of disease. Preventive strategies for this multifactorial, chronic disease require a comprehensive and multifocal approach that begins with caries risk assessment. Assessing each child’s risk of caries and tailoring preventive strategies to specific risk factors are necessary for maintaining and improving oral health. There is no single test that takes into consideration all risk factors and accurately predicts an individual's susceptibility to caries. However, pediatricians can conduct an excellent risk assessment for caries by focusing on the key risk factors for dental caries that are associated with diet, bacteria, saliva, and status of the teeth (both current status and previous caries experience). The American Academy of Pediatrics (AAP)/Bright Futures Oral Health Risk Assessment Tool can be found at http://www2.aap.org/oralhealth ... html.

Sugars (but not sugar substitutes) are a critical risk factor in the development of caries. The risk of caries is greatest if sugars are consumed at high frequency and are in a form that remains in the mouth for long periods of time. Thus, key behaviors that place a child at high risk of caries include continual bottle/sippy cup use (especially with fluids other than water), sleeping with a bottle (especially with fluids other than water), frequent between-meal snacks of sugars/cooked starch/sugared beverages, and frequent intake of sugared medications.

Early acquisition of S mutans is a major risk factor for early childhood caries and future caries experience. Strong evidence demonstrates that mothers are a primary source of S mutans colonization for their children. Thus, an important factor associated with caries risk in young children is the recent or current presence of active dental decay in the primary caregiver. Prevention, diagnosis, and treatment of oral diseases are highly beneficial, can be undertaken, and should be encouraged during pregnancy with no additional fetal or maternal risk compared with the risk of not providing care. The most important and predictive risk factor for caries, however, is previous caries experience. This finding is not surprising, considering that the factors which initiated the disease process often continue to exist over time.

Other caries risk factors are associated with salivary flow and the status of the teeth. Diseases (eg, diabetes mellitus, Sjögren's syndrome, cystic fibrosis) and medications (eg, antihistamines, anticonvulsants, antidepressants) that result in xerostomia (decreased salivary flow) reduce the availability of saliva to buffer the acid produced by pathogenic bacteria, thus enhancing their ability to cause damage to the teeth. In addition, the teeth of preterm infants, which frequently have enamel defects, are at increased susceptibility for disease. Older children who have deep pits and fissures in their molars are also at increased susceptibility for disease.

Anticipatory Guidance
With a clear understanding of the etiology of dental caries and the risk factors that lead to and facilitate the spread of this disease, pediatricians can target anticipatory guidance to assist families in preventing it. Because the disease of dental caries is multifocal, the anticipatory guidance should also be multifocal. Pediatricians should concentrate their anticipatory guidance on topics that can affect the risk of disease.

Dietary Counseling
Because sugar intake is such an important risk factor for dental caries, pediatricians can incorporate anticipatory guidance associated with preventing dental caries into discussions with families about dietary habits and nutritional intake. Pediatricians should counsel parents and caregivers on the importance of reducing the frequency of exposure to sugars in foods and drinks. To decrease the risk of dental caries and ensure the best possible health and developmental outcomes, pediatricians should recommend that parents do the following:

•Exclusively breastfeed infants for 6 months and continue breastfeeding as complementary foods are introduced for 1 year or longer, as mutually desired by mother and infant.

•Discourage putting a child to bed with a bottle. Establish a bedtime routine conducive to optimal oral health (eg, brush, book, and bed).

•Wean from a bottle by 1 year of age.

•Limit sugary foods and drinks to mealtimes.

•Avoid carbonated, sugared beverages and juice drinks that are not 100% juice.

•Limit the intake of 100% fruit juice to no more than 4 to 6 oz per day.

•Encourage children to drink only water between meals, preferably fluoridated tap water.

•Foster eating patterns that are consistent with guidelines from the US Department of Agriculture.

Oral Hygiene
The value of good oral hygiene lies in controlling the levels and activity of disease-causing bacteria in the oral cavity and delivering fluoride to the surface of the tooth. It is important to remember that pathogenic bacteria can be passed from caregiver to child. Thus, anticipatory guidance for both parent and child is important. Key anticipatory guidance points regarding oral hygiene are as follows:

•Parents/caregivers should be encouraged to model and maintain good oral hygiene and a relationship with their own dental provider.

•Parents/caregivers, especially those with significant history of dental decay, should be cautioned to avoid sharing with their child items that have been in their own mouths.

•The child’s teeth should be brushed twice a day as soon as the teeth erupt with a smear or a grain-of-rice–sized amount of fluoridated toothpaste. After the third birthday, a pea-sized amount should be used.

•Parents/caregivers should help/supervise a child brushing his or her teeth until mastery is obtained, usually at around 8 years of age.

Fluoride
The delivery of fluoride to the teeth includes community-based options (water fluoridation), self-administered modalities (fluoride toothpaste and supplements), and professional applications (fluoride varnish). Each of these delivery mechanisms is useful in preventing dental caries.

Water fluoridation is a community-based intervention that optimizes the level of fluoride in drinking water, resulting in preeruptive and posteruptive protection of the teeth.19 Water fluoridation is a cost-effective means of preventing dental caries, with the lifetime cost per person equaling less than the cost of 1 dental restoration. Most bottled waters do not contain an adequate amount of fluoride.

Fluoride toothpaste is an important way to deliver fluoride to the surface of the tooth. Fluoride toothpaste has been shown to be effective in reducing dental caries in both primary and permanent teeth. It is important to limit the amount of toothpaste used to a smear or a grain-of-rice–sized amount for young children and no more than a pea-sized amount for children older than 3 years. Fluoride supplements should be prescribed for children whose primary source of drinking water is deficient in fluoride.

Fluoride varnish is a professionally applied, sticky resin of highly concentrated fluoride. Two or more applications of fluoride varnish per year are effective in preventing caries in children at high risk of all ages. In most states, pediatricians can apply and be paid for application of fluoride varnish to the teeth of young children. Application of fluoride varnish is even more effective when coupled with counseling. The US Preventive Services Task Force recently published a new recommendation that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption (B recommendation). More details and recommendations on fluoride can be found in the AAP clinical report “Fluoride Use in Caries Prevention in the Primary Care Setting.”

Other Important Anticipatory Guidance Topics
A frequent topic of discussion with parents is nonnutritive oral habits, such as use of pacifiers and thumb sucking. AAP policy states that parents consider offering a pacifier at naptime and bedtime because of a protective effect of pacifiers on the incidence of sudden infant death syndrome after the first month of life.27 Both finger- and pacifier-sucking habits will only cause problems with dental structures if they go on for a long period of time. Evaluation by a dentist is indicated for nonnutritive sucking habits that continue beyond 3 years of age.28

Dental injuries are common. Twenty-five percent of all schoolchildren experience some form of dental trauma. Pediatricians can help prevent such trauma by encouraging parents to cover sharp corners of household furnishings at the level of walking toddlers, recommend use of car safety seats, and be aware of electrical cord risk for mouth injury. Pediatricians can also encourage mouthguard use during sports activities in which there is a significant risk of orofacial injury.More information on dental trauma is available in the AAP clinical report “Management of Dental Trauma in a Primary Care Setting.”

Collaboration With Dental Providers
The AAP, the American Academy of Pediatric Dentistry, the American Dental Association, and the American Association of Public Health Dentistry all recommend a dental visit for children by 1 year of age. Although pediatricians have the opportunity to provide early assessment of risk for dental caries and anticipatory guidance to prevent disease, it is also important that children establish a dental home. A dental home is the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way.

Unfortunately, little is known about pediatric health care providers’ dental referral behaviors and patterns. Although 1 study found that children 2 to 5 years of age who received a recommendation from their health care provider to visit the dentist were more likely to have a dental visit, the US Preventive Services Task Force found no study that evaluated the effects of referral by a primary care clinician to a dentist on caries incidence. It is also noteworthy that preschool-aged children covered by Medicaid who had an early preventive dental visit by 1 year of age were more likely to use subsequent preventive services and to have lower dental expenses.

With early referral to a dental provider, there is an opportunity to maintain good oral health, prevent disease, and treat disease early. Establishing such collaborative relationships between physicians and dentists at the community level is essential for increasing access to dental care for all children and improving their oral and overall health.

Conclusions
Oral health is an integral part of the overall health and well-being of children. A pediatrician who is familiar with the science of dental caries, capable of assessing caries risk, comfortable with applying various strategies of prevention and intervention, and connected to dental resources can contribute considerably to the health of his or her patients. This policy statement, in conjunction with the oral health recommendations of the third edition of the AAP's Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, serves as a resource for pediatricians and other pediatric primary care providers to be knowledgeable about addressing dental caries. Because dental caries is such a common and consequential disease process in the pediatric population, it is essential that pediatricians include oral health in their daily practice of pediatrics.

Suggestions for Pediatricians

1.Administer an oral health risk assessment periodically to all children.

2.Include anticipatory guidance for oral health as an integral part of comprehensive patient counseling.

3.Counsel parents/caregivers and patients to reduce the frequency of exposure to sugars in foods and drinks.

4.Encourage parents/caregivers to brush a child’s teeth as soon as teeth erupt with a smear or a grain-of-rice–sized amount of fluoride toothpaste and a pea-sized amount at 3 years of age.

5.Advise parents/caregivers to monitor brushing until 8 years of age.

6.Refer to the AAP clinical report, “Fluoride Use in Caries Prevention in the Primary Care Setting,” for fluoride administration and supplementation decisions.

7.Build and maintain collaborative relationships with local dentists.

8.Recommend that every child has a dental home by 1 year of age.

中文翻译:
本文地址:http://www.wjbb.com/know/932
原文出处:http://pediatrics.aappublicati ... .full 查看全部

Abstract
Oral health is an integral part of the overall health of children. Dental caries is a common and chronic disease process with significant short- and long-term consequences. The prevalence of dental caries for the youngest of children has not decreased over the past decade, despite improvements for older children. As health care professionals responsible for the overall health of children, pediatricians frequently confront morbidity associated with dental caries. Because the youngest children visit the pediatrician more often than they visit the dentist, it is important that pediatricians be knowledgeable about the disease process of dental caries, prevention of the disease, and interventions available to the pediatrician and the family to maintain and restore health.

Introduction
Dental caries is the most common chronic disease of childhood. Twenty-four percent of US children 2 to 4 years of age, 53% of children 6 to 8 years of age, and 56% of 15-year-olds have caries experience (ie, untreated dental caries, filled teeth, teeth missing as a result of dental caries). For children 5 to 19 years of age, children from poor and racial or ethnic minority families have higher rates of untreated dental caries than do their peers from nonpoor and nonminority families. For some age groups, the incidence of dental caries has decreased or stayed the same, but for the youngest children, it has increased. Among 6- to 8-year-olds and 15-year-olds, caries experience and untreated dental decay remained mostly unchanged between 1988–1994 and 1999–2004. In children 2 to 4 years of age, the caries experience increased significantly, from 19% to 24%, during that same time period. The increase in the caries experience and untreated caries was statistically significant in children from poor families.

The Etiology and Pathogenesis of Dental Caries
A dynamic process takes place at the surface of the tooth that involves constant demineralization and remineralization of the tooth enamel (the caries balance). Multiple factors affect that dynamic process and can be manipulated in ways that tip the balance toward disease (demineralization) or health (remineralization). These factors include bacteria, sugar, saliva, and fluoride. Because these factors can be manipulated, it is possible for pediatricians and families to prevent, halt, or even reverse the disease process.

Different oral structures and tissues have different and distinct microbial communities (microbiomes). The oral microbiome at the surface of the tooth is referred to as dental plaque. During the disease process of dental caries, bacteria that are aciduric and acidogenic predominate in the dental plaque. Streptococcus mutans is most strongly associated with dental caries, although other bacterial species have these capabilities and thus can also be pathogenic. When environmental factors make it possible to select for these pathogenic bacteria in dental plaque, the disease process begins.

A key environmental factor that allows for selection and proliferation of these pathogenic bacteria is dietary sugar intake. Because these pathogenic bacteria have the ability to ferment sugars, produce acid, and decrease the pH of the dental plaque, they make possible the selection of other aciduric, acidogenic bacteria that will contribute to disease. As more bacteria produce more acid, the pH at the surface of the tooth decreases. This process causes the demineralization of the tooth enamel. Unimpeded, these long periods of low pH and demineralization will result in cavitation.

Saliva is an important factor in buffering the low pH and bringing these demineralization pressures back to a balance with remineralization. In addition to acting as a buffering agent, saliva also flushes the oral cavity of food particles and provides an environment rich in calcium and phosphate to aid in remineralization. When salivary flow is impeded, the pH is able to decrease to a lower level, tipping the scales toward demineralization (disease); in addition, the time it takes to buffer back to a normal pH is longer.

Another important factor that can affect the balance of demineralization and remineralization is fluoride. More in-depth reviews of fluoride are available elsewhere. It is important, however, for pediatricians and other child health care providers to understand how fluoride influences the caries balance. Fluoride has 3 key effects on the caries balance: (1) inhibition of demineralization at the tooth surface; (2) enhancement of remineralization, which results in a more acid-resistant tooth surface; and (3) inhibition of bacterial enzymes. The primary effect of fluoride is topical, via fluoridated toothpastes, mouth rinses, and varnishes, although there is still value in systemic fluoride exposures via fluoridated water and supplements.

Preventive Strategies

Caries Risk Assessment

Ideally, primary prevention efforts will anticipate and prevent caries before the first sign of disease. Preventive strategies for this multifactorial, chronic disease require a comprehensive and multifocal approach that begins with caries risk assessment. Assessing each child’s risk of caries and tailoring preventive strategies to specific risk factors are necessary for maintaining and improving oral health. There is no single test that takes into consideration all risk factors and accurately predicts an individual's susceptibility to caries. However, pediatricians can conduct an excellent risk assessment for caries by focusing on the key risk factors for dental caries that are associated with diet, bacteria, saliva, and status of the teeth (both current status and previous caries experience). The American Academy of Pediatrics (AAP)/Bright Futures Oral Health Risk Assessment Tool can be found at http://www2.aap.org/oralhealth ... html.

Sugars (but not sugar substitutes) are a critical risk factor in the development of caries. The risk of caries is greatest if sugars are consumed at high frequency and are in a form that remains in the mouth for long periods of time. Thus, key behaviors that place a child at high risk of caries include continual bottle/sippy cup use (especially with fluids other than water), sleeping with a bottle (especially with fluids other than water), frequent between-meal snacks of sugars/cooked starch/sugared beverages, and frequent intake of sugared medications.

Early acquisition of S mutans is a major risk factor for early childhood caries and future caries experience. Strong evidence demonstrates that mothers are a primary source of S mutans colonization for their children. Thus, an important factor associated with caries risk in young children is the recent or current presence of active dental decay in the primary caregiver. Prevention, diagnosis, and treatment of oral diseases are highly beneficial, can be undertaken, and should be encouraged during pregnancy with no additional fetal or maternal risk compared with the risk of not providing care. The most important and predictive risk factor for caries, however, is previous caries experience. This finding is not surprising, considering that the factors which initiated the disease process often continue to exist over time.

Other caries risk factors are associated with salivary flow and the status of the teeth. Diseases (eg, diabetes mellitus, Sjögren's syndrome, cystic fibrosis) and medications (eg, antihistamines, anticonvulsants, antidepressants) that result in xerostomia (decreased salivary flow) reduce the availability of saliva to buffer the acid produced by pathogenic bacteria, thus enhancing their ability to cause damage to the teeth. In addition, the teeth of preterm infants, which frequently have enamel defects, are at increased susceptibility for disease. Older children who have deep pits and fissures in their molars are also at increased susceptibility for disease.

Anticipatory Guidance
With a clear understanding of the etiology of dental caries and the risk factors that lead to and facilitate the spread of this disease, pediatricians can target anticipatory guidance to assist families in preventing it. Because the disease of dental caries is multifocal, the anticipatory guidance should also be multifocal. Pediatricians should concentrate their anticipatory guidance on topics that can affect the risk of disease.

Dietary Counseling
Because sugar intake is such an important risk factor for dental caries, pediatricians can incorporate anticipatory guidance associated with preventing dental caries into discussions with families about dietary habits and nutritional intake. Pediatricians should counsel parents and caregivers on the importance of reducing the frequency of exposure to sugars in foods and drinks. To decrease the risk of dental caries and ensure the best possible health and developmental outcomes, pediatricians should recommend that parents do the following:

•Exclusively breastfeed infants for 6 months and continue breastfeeding as complementary foods are introduced for 1 year or longer, as mutually desired by mother and infant.

•Discourage putting a child to bed with a bottle. Establish a bedtime routine conducive to optimal oral health (eg, brush, book, and bed).

•Wean from a bottle by 1 year of age.

•Limit sugary foods and drinks to mealtimes.

•Avoid carbonated, sugared beverages and juice drinks that are not 100% juice.

•Limit the intake of 100% fruit juice to no more than 4 to 6 oz per day.

•Encourage children to drink only water between meals, preferably fluoridated tap water.

•Foster eating patterns that are consistent with guidelines from the US Department of Agriculture.

Oral Hygiene
The value of good oral hygiene lies in controlling the levels and activity of disease-causing bacteria in the oral cavity and delivering fluoride to the surface of the tooth. It is important to remember that pathogenic bacteria can be passed from caregiver to child. Thus, anticipatory guidance for both parent and child is important. Key anticipatory guidance points regarding oral hygiene are as follows:

•Parents/caregivers should be encouraged to model and maintain good oral hygiene and a relationship with their own dental provider.

•Parents/caregivers, especially those with significant history of dental decay, should be cautioned to avoid sharing with their child items that have been in their own mouths.

•The child’s teeth should be brushed twice a day as soon as the teeth erupt with a smear or a grain-of-rice–sized amount of fluoridated toothpaste. After the third birthday, a pea-sized amount should be used.

•Parents/caregivers should help/supervise a child brushing his or her teeth until mastery is obtained, usually at around 8 years of age.

Fluoride
The delivery of fluoride to the teeth includes community-based options (water fluoridation), self-administered modalities (fluoride toothpaste and supplements), and professional applications (fluoride varnish). Each of these delivery mechanisms is useful in preventing dental caries.

Water fluoridation is a community-based intervention that optimizes the level of fluoride in drinking water, resulting in preeruptive and posteruptive protection of the teeth.19 Water fluoridation is a cost-effective means of preventing dental caries, with the lifetime cost per person equaling less than the cost of 1 dental restoration. Most bottled waters do not contain an adequate amount of fluoride.

Fluoride toothpaste is an important way to deliver fluoride to the surface of the tooth. Fluoride toothpaste has been shown to be effective in reducing dental caries in both primary and permanent teeth. It is important to limit the amount of toothpaste used to a smear or a grain-of-rice–sized amount for young children and no more than a pea-sized amount for children older than 3 years. Fluoride supplements should be prescribed for children whose primary source of drinking water is deficient in fluoride.

Fluoride varnish is a professionally applied, sticky resin of highly concentrated fluoride. Two or more applications of fluoride varnish per year are effective in preventing caries in children at high risk of all ages. In most states, pediatricians can apply and be paid for application of fluoride varnish to the teeth of young children. Application of fluoride varnish is even more effective when coupled with counseling. The US Preventive Services Task Force recently published a new recommendation that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption (B recommendation). More details and recommendations on fluoride can be found in the AAP clinical report “Fluoride Use in Caries Prevention in the Primary Care Setting.”

Other Important Anticipatory Guidance Topics
A frequent topic of discussion with parents is nonnutritive oral habits, such as use of pacifiers and thumb sucking. AAP policy states that parents consider offering a pacifier at naptime and bedtime because of a protective effect of pacifiers on the incidence of sudden infant death syndrome after the first month of life.27 Both finger- and pacifier-sucking habits will only cause problems with dental structures if they go on for a long period of time. Evaluation by a dentist is indicated for nonnutritive sucking habits that continue beyond 3 years of age.28

Dental injuries are common. Twenty-five percent of all schoolchildren experience some form of dental trauma. Pediatricians can help prevent such trauma by encouraging parents to cover sharp corners of household furnishings at the level of walking toddlers, recommend use of car safety seats, and be aware of electrical cord risk for mouth injury. Pediatricians can also encourage mouthguard use during sports activities in which there is a significant risk of orofacial injury.More information on dental trauma is available in the AAP clinical report “Management of Dental Trauma in a Primary Care Setting.”

Collaboration With Dental Providers
The AAP, the American Academy of Pediatric Dentistry, the American Dental Association, and the American Association of Public Health Dentistry all recommend a dental visit for children by 1 year of age. Although pediatricians have the opportunity to provide early assessment of risk for dental caries and anticipatory guidance to prevent disease, it is also important that children establish a dental home. A dental home is the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way.

Unfortunately, little is known about pediatric health care providers’ dental referral behaviors and patterns. Although 1 study found that children 2 to 5 years of age who received a recommendation from their health care provider to visit the dentist were more likely to have a dental visit, the US Preventive Services Task Force found no study that evaluated the effects of referral by a primary care clinician to a dentist on caries incidence. It is also noteworthy that preschool-aged children covered by Medicaid who had an early preventive dental visit by 1 year of age were more likely to use subsequent preventive services and to have lower dental expenses.

With early referral to a dental provider, there is an opportunity to maintain good oral health, prevent disease, and treat disease early. Establishing such collaborative relationships between physicians and dentists at the community level is essential for increasing access to dental care for all children and improving their oral and overall health.

Conclusions
Oral health is an integral part of the overall health and well-being of children. A pediatrician who is familiar with the science of dental caries, capable of assessing caries risk, comfortable with applying various strategies of prevention and intervention, and connected to dental resources can contribute considerably to the health of his or her patients. This policy statement, in conjunction with the oral health recommendations of the third edition of the AAP's Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, serves as a resource for pediatricians and other pediatric primary care providers to be knowledgeable about addressing dental caries. Because dental caries is such a common and consequential disease process in the pediatric population, it is essential that pediatricians include oral health in their daily practice of pediatrics.

Suggestions for Pediatricians

1.Administer an oral health risk assessment periodically to all children.

2.Include anticipatory guidance for oral health as an integral part of comprehensive patient counseling.

3.Counsel parents/caregivers and patients to reduce the frequency of exposure to sugars in foods and drinks.

4.Encourage parents/caregivers to brush a child’s teeth as soon as teeth erupt with a smear or a grain-of-rice–sized amount of fluoride toothpaste and a pea-sized amount at 3 years of age.

5.Advise parents/caregivers to monitor brushing until 8 years of age.

6.Refer to the AAP clinical report, “Fluoride Use in Caries Prevention in the Primary Care Setting,” for fluoride administration and supplementation decisions.

7.Build and maintain collaborative relationships with local dentists.

8.Recommend that every child has a dental home by 1 year of age.

中文翻译:
本文地址:http://www.wjbb.com/know/932
原文出处:http://pediatrics.aappublicati ... .full

美国儿科学会:研究显示有29%的高中生吸过电子香烟

灰太狼 发表了文章 • 1 个评论 • 1068 次浏览 • 2015-01-10 21:58 • 来自相关话题

全国数据表明青少年使用电子香烟正每年稳定增长。对夏威夷高中生一项新的研究发现,29%的高中生吸过电子香烟,明显高于之前预测。此研究《青少年只吸电子香烟与即吸电子香烟又吸香烟的风险因素》发表于2015年1月的《儿科学期刊》(网上发表于12月15日)。

该研究在2013年调查了夏威夷的1941名高中生。学生们报告了他们使用电子烟、烟、酒精和大麻的情况,以及药物滥用的相关社会心理因素,比如父母支持、学术参与、同伴抽烟和寻求刺激行为。研究者发现17%的学生报告只吸电子烟,12%的学生既吸电子烟也吸香烟,3%的学生只吸香烟。吸电子烟的学生,比起既吸电子烟又吸香烟的学生,社会心理风险因素更少。

研究者们认为,这使得电子香烟更可能将中等风险的青少年吸引去抽烟,而这些青少年本不会那么容易受到影响去抽烟的。

中文翻译:晴天绿海
本文地址:http://www.wjbb.com/know/922
原文出处:http://www.aap.org/en-us/about ... .aspx
原文下载:http://pediatrics.aappublicati ... -0760 查看全部


全国数据表明青少年使用电子香烟正每年稳定增长。对夏威夷高中生一项新的研究发现,29%的高中生吸过电子香烟,明显高于之前预测。此研究《青少年只吸电子香烟与即吸电子香烟又吸香烟的风险因素》发表于2015年1月的《儿科学期刊》(网上发表于12月15日)。

该研究在2013年调查了夏威夷的1941名高中生。学生们报告了他们使用电子烟、烟、酒精和大麻的情况,以及药物滥用的相关社会心理因素,比如父母支持、学术参与、同伴抽烟和寻求刺激行为。研究者发现17%的学生报告只吸电子烟,12%的学生既吸电子烟也吸香烟,3%的学生只吸香烟。吸电子烟的学生,比起既吸电子烟又吸香烟的学生,社会心理风险因素更少。

研究者们认为,这使得电子香烟更可能将中等风险的青少年吸引去抽烟,而这些青少年本不会那么容易受到影响去抽烟的。

中文翻译:晴天绿海
本文地址:http://www.wjbb.com/know/922
原文出处:http://www.aap.org/en-us/about ... .aspx
原文下载:http://pediatrics.aappublicati ... -0760

美国儿科学会政策指南:2014–2015年度儿童流感疫苗预防控制建议

豌豆爸爸 发表了文章 • 1 个评论 • 1250 次浏览 • 2014-09-23 11:00 • 来自相关话题

美国儿科学会政策指南:2014–2015年度儿童流感疫苗预防控制建议

这个指南的目的是针对儿童流行性感冒的预防治疗中对于季节性流感疫苗和抗病毒药物日常使用的建议进行更新。美国儿科学会向6月龄及以上的所有人,包括儿童和青少年在内,推荐年度季节性流行性感冒免疫。在2014-2015年度季节性感冒来临之际,强调以下几点:

1、2014-2015年度的流感病毒结构和2013-2014年度是一样的;
2、2014-2015年度,美国提供三价和四价流感疫苗;
3、年度通用流感免疫可使用三价或四价的流感疫苗(无偏好);
4、2-8岁的健康儿童,若无鼻内流感疫苗禁忌症和注意事项,推荐接种减毒活流感疫苗(LAIV)。如果减毒活流感疫苗缺货的话,可接种灭活流感疫苗(IIV),不应该为等待减毒活流感疫苗到货而推迟接种疫苗;
5、6月龄-8岁儿童的流感疫苗剂量管理反映了疫苗菌株与上季度相比没有变化;

如同以往,儿科医生、护士和其他所有的卫生保健人员都应该接种流感疫苗,扩大流感疫苗的使用并加强感染控制措施的实施。此外,当出现临床流感感染时,儿科医生应立即辨别,并能够快速进行抗病毒治疗,以减少发病率和死亡率。

中文翻译:2009401030135
本文地址:http://www.wjbb.com/know/558
原文出处:http://pediatrics.aappublicati ... -2413 查看全部


美国儿科学会政策指南:2014–2015年度儿童流感疫苗预防控制建议

这个指南的目的是针对儿童流行性感冒的预防治疗中对于季节性流感疫苗和抗病毒药物日常使用的建议进行更新。美国儿科学会向6月龄及以上的所有人,包括儿童和青少年在内,推荐年度季节性流行性感冒免疫。在2014-2015年度季节性感冒来临之际,强调以下几点:

1、2014-2015年度的流感病毒结构和2013-2014年度是一样的;
2、2014-2015年度,美国提供三价和四价流感疫苗;
3、年度通用流感免疫可使用三价或四价的流感疫苗(无偏好);
4、2-8岁的健康儿童,若无鼻内流感疫苗禁忌症和注意事项,推荐接种减毒活流感疫苗(LAIV)。如果减毒活流感疫苗缺货的话,可接种灭活流感疫苗(IIV),不应该为等待减毒活流感疫苗到货而推迟接种疫苗;
5、6月龄-8岁儿童的流感疫苗剂量管理反映了疫苗菌株与上季度相比没有变化;

如同以往,儿科医生、护士和其他所有的卫生保健人员都应该接种流感疫苗,扩大流感疫苗的使用并加强感染控制措施的实施。此外,当出现临床流感感染时,儿科医生应立即辨别,并能够快速进行抗病毒治疗,以减少发病率和死亡率。

中文翻译:2009401030135
本文地址:http://www.wjbb.com/know/558
原文出处:http://pediatrics.aappublicati ... -2413

辅食添加指南和6-12月龄食谱

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癫痫发作、惊厥以及癫痫

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《美国儿科学会育儿百科》第33章 皮肤:疥疮

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美国儿科学会更新婴儿猝死综合征(SIDS)的预防建议

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《美国儿科学会育儿百科》第34章 孩子的睡眠:让睡眠同步

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《美国儿科学会育儿百科》第34章 孩子的睡眠

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美国儿科学会:哺乳期用药

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美国儿科学会:纯母乳喂养的持续时间

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美国儿科学会:母乳喂养的经济效益

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美国儿科学会:母乳喂养对母亲的作用

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美国儿科学会:关于婴幼儿、儿童和青少年喝果汁的最新推荐

豌豆爸爸 发表了文章 • 7 个评论 • 397 次浏览 • 2017-07-13 09:30 • 来自相关话题

①一岁以下新生儿:不应该喝任何果汁!!!无论什么果汁都不应该去碰,无论什么果汁。
②一岁到三岁的孩子(学步期):每天最多只能喝四个盎司(只有330毫升标准可乐罐的三分之一左右的量!)。
③四到六岁儿童:每天也最多只应该喝下三分之一到二分之一标准可乐罐的量!
④七到十八岁青少年:每天最多只有普通每天早上送到家里的一小瓶牛奶的量!
 
美国儿科学会本文中所提及的『果汁』指的是100%水果汁。
 
本段来自新浪微博 @蕨代霜蛟,为本篇全文的核心概括。

 
摘要

历史上,果汁被儿科医生推荐为维生素C的来源,并且作为健康婴儿和幼儿的额外水源,随着他们的饮食范围扩展到含有较高肾负荷的固体食物。它有时也被推荐用于儿童便秘。果汁作为一种健康的天然维生素来源进行销售,在某些情况下,还作为钙的来源。由于果汁口感好,儿童易于接受。虽然果汁摄入有一些好处,但它也有潜在的危害。果汁中的高含糖量会增加热量消耗和患龋齿的风险。此外,果汁中缺乏蛋白质和纤维会导致体重增加失常(过重或过轻)。儿科医生需要对果汁有足够的了解,以便告知父母和病人如何正确使用。

缩写词:
AAP —美国儿科学会
CYP3A4 —细胞色素 P4503A4

在2008至2013年间,果汁和果汁饮料的销量下降,这可能是由于饮料竞争和日益增长的更健康的食品选择,特别是水果和蔬菜的消费。含有热带水果、茶、运动饮料和能量饮料以及其他组合的饮料,呈现出一系列更新、更时尚的选择。儿童和青少年一直是购买果汁和果汁饮料最多的消费者。健康饮料的选择越来越受欢迎,包括低热量、不含糖的饮料,以及那些来自药草和香料成分的可感知的益处。不幸的是,数据显示,2至18岁的儿童将果汁作为近一半的水果摄入,这样会缺乏膳食纤维和容易导致热量摄入过多。这一比例近年来有所下降。

定义

根据美国食品药品监督管理局(FDA)规定,标签为果汁的产品指的是该产品是100%纯果汁。对于从浓缩液中再造的果汁,标签必须注明该产品是由浓缩物重新制成的。任何饮料,含量小于100%的果汁必须列出果汁产品的百分比,和饮料必须包括一个描述性的词语,如“饮品”、“饮料”或“鸡尾酒”。一般来说,果汁饮料含有10%和99%的果汁,并添加了甜味剂、香料或强化剂,如维生素C或钙。根据FDA的规定,这些成分必须列在标签上。 
果汁成分

水是果汁的主要成分。碳水化合物,包括蔗糖、果糖、葡萄糖和山梨醇,是果汁中排名第二的营养成分。碳水化合物的浓度从11克%(0.44千卡/毫升)到16克%(0.64千卡/毫升)。人乳和标准婴儿配方的碳水化合物的浓度为7克%。

果汁中含有少量的蛋白质和矿物质。有些果汁含有天然的高含量的钾、维生素A和维生素C,此外,一些果汁和果汁饮料添加了维生素C。有些果汁和牛奶具有大致相同的钙含量,但缺乏其他存在于牛奶在中的营养素,如镁和大量的蛋白质。许多这种强化钙的果汁也富含维生素D。果汁中的维生素C和类黄酮可能有长期的健康效果,如降低癌症和心脏病的风险。吃饭的同时饮用含有抗坏血酸的饮料能增加两倍铁的吸收量,这可能对于那些摄入低铁生物利用度食物的儿童来说很重要。

果汁不含脂肪或胆固醇,除非含有果肉,否则也不含纤维。果汁和果汁饮料中的氟化物浓度各有不同。一项研究发现,果汁中的氟化物离子浓度从0.02到2.8 ppm不等。浓缩果汁的氟含量随着复原果汁的水中氟含量变化。

一些制造商专门为婴儿生产果汁。这些果汁不含亚硫酸盐或添加糖,比普通的果汁更贵。

经常被饮用的果汁还包括其他形式。父母经常使用稀释的果汁来治疗便秘或为婴儿和儿童提供补充液体。多达三分之一的青少年喝运动饮料,大约10%至15%的人饮用能量饮料,当儿科医生评估患者的营养摄入情况时应询问这些饮品的使用情况。


与果汁摄取有关的药理学考虑

许多水果(例如葡萄、蓝莓、石榴、苹果)的果汁中含有黄酮类化合物(如柚皮苷、柚皮素、橙皮苷、橙皮苷、柚皮素、槲皮素和山奈酚),它可以减少几种酶和重要的药物转运蛋白的活性。虽然葡萄柚汁的摄入已被证明可以减少肠细胞色素P4503A4(CYP3A4)活性并产生潜在的CYP3A4底物药物(如环孢素、他克莫司、阿托伐他汀、非洛地平、非索非那定,特定的抗逆转录病毒药物)的营养和药物的相互作用(例如,提高生物利用度),但最近的证据表明,柚子汁也可以抑制有机酸转运蛋白活性。除了葡萄柚汁,橘子,苹果所含的黄酮也能减少有机酸转运蛋白OATP2B1活动。虽然葡萄柚汁-CYP3A4底物相互作用和用于产生显著营养药物相互作用的可能性是最充分表征,但是应当注意的是,除了抑制CYP3A4活性,蔓越莓,石榴和蓝莓汁能抑制CYP2C9的酶活性 ,CYP2C9即一种能催化治疗性药物如布洛芬、氟比洛芬、华法林、苯妥英、氟伐他汀和阿米替林的生物转化的细胞色素P450同工酶。 上述任何一种果汁-药物相互作用的临床意义极难根据消化系统的历史情况来预测。
 
在持续时间和幅度较大的相互作用产生的质变是多因素作用的结果,主要包括以下内容:(1)对影响酶或转运蛋白的组成型表达,(2)酶(如CYP2C9)或转运蛋白的显著遗传多态性,(3)不同果汁之间的相对类黄酮的组合物和效力,(4)果汁摄入量和摄入的持续时间(例如,可能需要在成年人中饮用1至2L /天的蔓越莓果汁以产生与华法林的显著相互作用)。在评估潜在的果汁 - 药物相互作用,果汁和药物的联合应用中,其代谢或转运可能是由类黄酮的影响不应该被立即认为是治疗的禁忌症。 必须考虑摄取的果汁的量和类型,表征给定相互作用的具体信息以及服用的药物是否低(如抗逆转录病毒药、钙调磷酸酶抑制剂、钙通道阻滞剂、华法林)或高治疗指数以评估潜在的相互作用。 医师和药剂师之间的协商可以有助于考虑果汁药物相互作用的潜在临床意义。



果汁中碳水化合物的吸收

果汁中的4种主要糖类是蔗糖、葡萄糖、果糖和山梨糖醇。蔗糖是通过存在于小肠上皮中的蔗糖酶水解成两分子的单糖——葡萄糖和果糖。然后,葡萄糖通过活性载体介导的过程在小肠的绒毛边缘被快速吸收。果糖被促进的运输机制通过载体吸收,但不逆浓度梯度。此外,果糖可能被二糖酶相关的转运系统吸收,因为果糖的吸收在葡萄糖存在下更快,当果糖和葡萄糖以等摩尔浓度存在时,发生最大吸收。临床研究显示,当果糖浓度超过葡萄糖(例如苹果和梨汁)时,比这两种糖以相同浓度存在(例如白葡萄汁)时,吸收更快。然而,当以适当的量(10mL / kg体重)提供时,这些不同的果汁也被同样地吸收。梨,苹果,樱桃,杏和李子和无糖食物(例如糖果,口香糖,饮料,冰淇淋)和一些液体药物含有少量的山梨糖醇,山梨糖醇被缓慢的通过被动扩散吸收,因此大部分被摄取的山梨醇未能被吸收。

在小肠中未被吸收的碳水化合物被结肠中的细菌发酵。 这种细菌发酵会产生氢,二氧化碳,甲烷和短链脂肪酸乙酸、丙酸和丁酸。 这些气体和一些脂肪酸中通过结肠上皮被再吸收,并以这种方式,一部分吸收不良的碳水化合物(malabsorbed carbohydrate)可被清除。 未吸收的碳水化合物对胃肠道产生渗透负荷,引起腹泻。

幼儿的腹泻是一种众所周知的良性病症,通常只需从1至4岁的饮食中去除多余的果汁即能产生效果。 然而,在果汁碳水化合物吸收不良,尤其是过量食用时,可导致慢性腹泻、胀气、腹胀、腹痛。 果糖和山梨醇最常见,但特定碳水化合物的比例也可能很重要。 大量摄取果汁可能导致的碳水化合物吸收不良是一些卫生保健提供者推荐用于治疗便秘,尤其是婴幼儿便秘的基础。 北美小儿胃肠病学,肝病学和营养便秘学指南建议利用一些果汁(如西梅脯,梨和苹果汁)中所含的山梨糖醇和其他碳水化合物来帮助增加婴儿粪便的频率和含水量来治疗婴儿便秘。

美国人饮食指南中的果汁相关策略

2015年出版的最新版本的美国人饮食指南的基本前提是,是关注高营养食品。水果是膳食指南中头号关键重点食品。水果与蔬菜一起被推荐提供必需的维生素和矿物质,降低心血管疾病的风险,有可能防止癌症,并抑制摄入过多的热量。例如,每天消耗约1000千卡(取决于体型大小,1-4岁)的儿童每天应该喝约1杯水果,而消费大约2000千卡/天(取决于体型大小,10-18岁)的儿童,每天应消耗约2杯水果。尽管鼓励摄入整个水果,但最多可以以100%果汁(不是水果饮料)的形式提供一半水果。 6盎司的果汁杯等于1杯水果。相比整个水果,果汁没有营养优势。果汁的缺点是缺乏全果的纤维。 果汁的大卡比全果消耗得更快。依靠果汁而不是全果提供每日摄入的水果不能促进与全水果摄入相关的饮食行为。因为最近的研究表明,纯橙汁摄入对成年人有健康益处,但需要进一步的研究来确定儿童和青少年是否可以获得类似的益处。
 
儿科医生通过向儿童患者及其父母提供指导,在儿童健康和营养方面发挥核心作用。儿科医生也可以倡导改变公共政策,特别是在学校里,改善水果和蔬菜的摄入量与促进健康饮食选择的政策相关。开放的评估和适当的饮食习惯的建议,包括食用整个水果而不是果汁,可以帮助促进父母对健康体重增长的支持。尽管与肥胖相关的其他风险因素可能是重要的考虑因素,最近的一项研究表明,对于生育前超重的女性的婴儿和孩子可能需要特别的关注。
 
果汁的微生物安全性

父母需要了解,未经高温消毒的果汁产品可能含有可能对儿童有害的病原体,如大肠杆菌、沙门氏菌属和隐孢子虫属。这些生物与严重的疾病如溶血性尿毒症综合症有关。如果父母选择给予孩子未经高温消毒的果汁产品,则应小心谨慎,并告知这是不安全的做法。市售的未经高压灭菌的果汁必须在标签上注明该产品可能含有有害细菌的警告。这些建议不适用于某些销售模式(例如,“由苹果园、农贸市场、路边摊位或某些果汁酒吧新鲜挤压出售的果汁或苹果酒”[http://www.fda.gov/Food/Resour ... 6.htm]),但是当向儿童提供未经消毒的果汁产品时,家庭应保持警惕。巴氏灭菌的果汁不含微生物,对婴儿,儿童和青少年是安全的。


 
婴儿

美国儿科学会(AAP)建议,在大约6月龄之前,人乳是唯一一种喂养婴儿的营养物质。 对于不能母乳喂养或选择不进行母乳喂养的母亲,可以使用制备好的婴儿配方奶粉作为完整的营养来源。 不需要额外的营养。 没有营养指南建议给6岁以下的婴儿提供果汁。 在饮食中引入固体食物之前提供果汁可能会导致饮食中的果汁取代人乳或婴幼儿配方奶粉,这可能导致蛋白质、脂肪、维生素和矿物质如铁、钙和锌的摄入量减少。儿童营养不良和身材矮小与过多摄入果汁有关。

完全避免在1岁以前的婴儿中使用果汁是最佳的做法。尽管医学上建议给6个月以上的婴儿饮用果汁,但给予婴儿果汁仍需谨慎。 龋齿也与果汁消费有关。牙齿长期暴露于果汁中的糖是造成龋齿的主要原因。 美国儿科学会和美国儿科牙科学会的建议指出,应用杯子向幼儿提供果汁,而不是瓶子,并且婴儿入睡时不能在口中含有盛有果汁的瓶子。 整天允许儿童携带瓶子、容易运输的有盖杯子、开口杯或盒装果汁的做法导致牙齿过度暴露于碳水化合物,这促进了龋齿的形成。

婴儿可被允许吃捣成糊状的整个水果。 1岁以后,可以将果汁用作餐点或小吃的一部分。它不应该在一天中一直被孩子啜饮或当作使一个不安的孩子安静下来的手段。因为婴儿每天摄入<1600千卡,每天4盎司的果汁占推荐日常水果的一半,是绰绰有余的。

关于处理幼儿急性胃肠炎的美国儿科学会实践指数(1996年出版,随后于2001年停止出版)建议,只能使用口服电解质溶液来补充婴儿和幼儿水分,并在整个胃肠炎发作期间继续保持正常饮食。调查显示,许多医疗保健提供者不遵循推荐的腹泻处理流程。与口服电解质溶液(2.5-3g%)相比,果汁(11-16 g%)的高碳水化合物含量可能会超过肠道吸收碳水化合物的能力,导致碳水化合物吸收不良。碳水化合物吸收不良会引起渗透性腹泻,加剧现有的腹泻的严重程度。果汁电解质含量低。钠浓度为1〜3mEq / L。急性腹泻儿童粪便钠浓度为20〜40mEq / L。口服电解质溶液含有40〜45mEq钠/ L。将果汁作为液体损失的替代品,可能会使婴儿发生低钠血症。
 
有人担心,接触橙汁的婴儿可能会增加对橙汁过敏反应的可能性。 一些摄入鲜榨柑橘类果汁的婴儿发生口周皮疹,这有可能是由于酸的化学刺激作用。在一些婴儿身上观察到的腹泻和一些胃肠道症状最有可能归因于碳水化合物吸收不良。 虽然对水果过敏可能发生于生命的早期,但却不常见。
 
幼儿和儿童(1-6岁)
与新生儿的果汁摄入相关的大多数问题也与初学走路的孩子和幼儿有关。果汁和果汁饮料由于口感好极易被这些人群摄入过多。令外,它们便于包装,也可以放在瓶子或可移动的盖杯里,白天随身携带。因为果汁被认为是有营养的,所以父母通常不会限制果汁的摄入。应鼓励刚学走路的孩子和幼儿吃整个水果而非喝果汁。果汁跟苏打水一样会导致机体能量失衡。儿科医生应支持旨在减少果汁摄入的政策,鼓励已经接触果汁的初学走路的孩子和幼儿食用整个水果。这种支持应该包括为妇女、新生儿和儿童制定的特别营养补充计划(WIC),假设这些政策对于无法获得新鲜水果的儿童并没有负面的营养结果(例如总热量不足、食物中缺乏水果)。此外,过多摄入饮料会导致腹泻、营养过剩或营养不良,以及龋齿。用水稀释果汁并不一定会降低果汁对牙齿健康损害的风险。
 
大龄儿童和青少年(7-18岁)

果汁消费表明年龄较大的儿童和青少年营养问题少的原因是他们更少地摄入这些饮料。 尽管如此,果汁摄入量应限制在8盎司/天,是推荐的每日水果的一半。 鼓励消耗整个水果以有利于膳食纤维摄入以及这会花费更长时间消耗相同的千卡热量也很重要的。过量的果汁消耗和由此导致的能量摄入量的增加可能有助于肥胖的发展。 一项研究发现果汁摄入量超过12盎司/天与肥胖有关。然而,其他研究发现,饮用更多量的果汁的儿童比饮用较少果汁的儿童身高更高,BMI更低,还有研究发现果汁摄入和身高变化之间没有关联。最近的一项研究表明,摄入不同种类的100%纯果汁与肥胖无关。但仍需要更多的研究来更好地界定这个关系。
 

 
结论
果汁对1岁以下的婴儿无营养益处。果汁对婴儿和儿童的营养益处不如整个水果,并且在健康和均衡的儿童饮食中并非不可或缺。百分之百的新鲜或重新配制的果汁可以作为1岁以上儿童均衡健康饮食的一部分。但是,水果饮料在营养上并不等同于果汁。果汁不适合治疗脱水或腹泻的治疗。过量的果汁摄入可能与营养不良(营养过剩和营养不良)有关。过量的果汁摄入与腹泻、肠胃气胀、腹部膨胀和龋齿有关。未经消毒的果汁产品可能含有引起严重疾病的病原体,给小孩服用应谨慎。为适当儿童年龄提供的各种果汁不太可能引起任何明显的临床症状。钙强化果汁可作为提供生物可利用的钙的来源,通常也含有维生素D,但缺乏其他存在于母乳、婴儿配方奶粉或牛奶中的其他营养物质。



​建议
除非临床推荐,否则不应将果汁引入12个月月龄前的婴儿饮食中。1至3岁的孩子的果汁摄入量应限制在最多4盎司/天,4至6岁的儿童每天应为4至6盎司/天。对于7至18岁的儿童,果汁摄入量应限制在8盎司或占推荐的每天2至2.5杯水果的1杯果汁。幼儿不应该从瓶子或容易运输的有盖的杯子中获得果汁,这会使他们在整天中容易饮用果汁。幼儿在睡觉时不应该给予果汁。应鼓励孩子吃全果,以满足他们推荐的每日水果摄入量,并应该重视膳食纤维摄入的益处,并且与果汁相比,摄入整个水果时消耗相同千卡的时间要长。家长们应该知道,为了满足流食需求,人乳和/或婴儿配方食品对婴儿和低脂/脱脂奶是足够的,而且对于大龄儿童来说,摄入水就足够了。应极力劝阻婴儿、儿童和青少年摄入未经巴氏消毒的果汁产品。任何儿童服用CYP3A4代谢药物时,应避免使用葡萄柚汁(见上述清单)。在评估营养不良(营养过剩和营养不良)的儿童时,儿科医生应确定所消耗的果汁量。在评估患有慢性腹泻、过度肠胃气胀、腹痛和腹胀的儿童时,儿科医生应确定摄入的果汁量。在评估龋齿的风险时,儿科医生应定期讨论果汁和龋齿之间的关系,并确定果汁的摄入量和摄入形式。儿科医生应该常规地讨论果汁和水果饮品的饮用,并教育年龄较大的儿童,青少年及其父母两者之间的差异。小儿科医师应主张减少幼儿饮食中的果汁,并且在体重异常(过轻或超重)的儿童饮食中去除果汁。儿科医生应支持旨在减少果汁消费的政策,并通过已经接触果汁的幼儿和儿童(例如育儿/幼儿园),包括通过“妇女,婴幼儿特别补充营养计划(WIC)” ,促进整个水果的摄入。 

Lead Authors

Melvin B. Heyman, MD, FAAP
Steven A. Abrams, MD, FAAP
 
中文翻译:Shawnee
本文地址:http://www.wjbb.com/know/1767
原文出处:http://pediatrics.aappublicati ... -0967 查看全部


①一岁以下新生儿:不应该喝任何果汁!!!无论什么果汁都不应该去碰,无论什么果汁。
②一岁到三岁的孩子(学步期):每天最多只能喝四个盎司(只有330毫升标准可乐罐的三分之一左右的量!)。
③四到六岁儿童:每天也最多只应该喝下三分之一到二分之一标准可乐罐的量!
④七到十八岁青少年:每天最多只有普通每天早上送到家里的一小瓶牛奶的量!
 
美国儿科学会本文中所提及的『果汁』指的是100%水果汁。
 
本段来自新浪微博 @蕨代霜蛟,为本篇全文的核心概括。


 
摘要

历史上,果汁被儿科医生推荐为维生素C的来源,并且作为健康婴儿和幼儿的额外水源,随着他们的饮食范围扩展到含有较高肾负荷的固体食物。它有时也被推荐用于儿童便秘。果汁作为一种健康的天然维生素来源进行销售,在某些情况下,还作为钙的来源。由于果汁口感好,儿童易于接受。虽然果汁摄入有一些好处,但它也有潜在的危害。果汁中的高含糖量会增加热量消耗和患龋齿的风险。此外,果汁中缺乏蛋白质和纤维会导致体重增加失常(过重或过轻)。儿科医生需要对果汁有足够的了解,以便告知父母和病人如何正确使用。

缩写词:
AAP —美国儿科学会
CYP3A4 —细胞色素 P4503A4

在2008至2013年间,果汁和果汁饮料的销量下降,这可能是由于饮料竞争和日益增长的更健康的食品选择,特别是水果和蔬菜的消费。含有热带水果、茶、运动饮料和能量饮料以及其他组合的饮料,呈现出一系列更新、更时尚的选择。儿童和青少年一直是购买果汁和果汁饮料最多的消费者。健康饮料的选择越来越受欢迎,包括低热量、不含糖的饮料,以及那些来自药草和香料成分的可感知的益处。不幸的是,数据显示,2至18岁的儿童将果汁作为近一半的水果摄入,这样会缺乏膳食纤维和容易导致热量摄入过多。这一比例近年来有所下降。

定义

根据美国食品药品监督管理局(FDA)规定,标签为果汁的产品指的是该产品是100%纯果汁。对于从浓缩液中再造的果汁,标签必须注明该产品是由浓缩物重新制成的。任何饮料,含量小于100%的果汁必须列出果汁产品的百分比,和饮料必须包括一个描述性的词语,如“饮品”、“饮料”或“鸡尾酒”。一般来说,果汁饮料含有10%和99%的果汁,并添加了甜味剂、香料或强化剂,如维生素C或钙。根据FDA的规定,这些成分必须列在标签上。 
果汁成分

水是果汁的主要成分。碳水化合物,包括蔗糖、果糖、葡萄糖和山梨醇,是果汁中排名第二的营养成分。碳水化合物的浓度从11克%(0.44千卡/毫升)到16克%(0.64千卡/毫升)。人乳和标准婴儿配方的碳水化合物的浓度为7克%。

果汁中含有少量的蛋白质和矿物质。有些果汁含有天然的高含量的钾、维生素A和维生素C,此外,一些果汁和果汁饮料添加了维生素C。有些果汁和牛奶具有大致相同的钙含量,但缺乏其他存在于牛奶在中的营养素,如镁和大量的蛋白质。许多这种强化钙的果汁也富含维生素D。果汁中的维生素C和类黄酮可能有长期的健康效果,如降低癌症和心脏病的风险。吃饭的同时饮用含有抗坏血酸的饮料能增加两倍铁的吸收量,这可能对于那些摄入低铁生物利用度食物的儿童来说很重要。

果汁不含脂肪或胆固醇,除非含有果肉,否则也不含纤维。果汁和果汁饮料中的氟化物浓度各有不同。一项研究发现,果汁中的氟化物离子浓度从0.02到2.8 ppm不等。浓缩果汁的氟含量随着复原果汁的水中氟含量变化。

一些制造商专门为婴儿生产果汁。这些果汁不含亚硫酸盐或添加糖,比普通的果汁更贵。

经常被饮用的果汁还包括其他形式。父母经常使用稀释的果汁来治疗便秘或为婴儿和儿童提供补充液体。多达三分之一的青少年喝运动饮料,大约10%至15%的人饮用能量饮料,当儿科医生评估患者的营养摄入情况时应询问这些饮品的使用情况。


与果汁摄取有关的药理学考虑

许多水果(例如葡萄、蓝莓、石榴、苹果)的果汁中含有黄酮类化合物(如柚皮苷、柚皮素、橙皮苷、橙皮苷、柚皮素、槲皮素和山奈酚),它可以减少几种酶和重要的药物转运蛋白的活性。虽然葡萄柚汁的摄入已被证明可以减少肠细胞色素P4503A4(CYP3A4)活性并产生潜在的CYP3A4底物药物(如环孢素、他克莫司、阿托伐他汀、非洛地平、非索非那定,特定的抗逆转录病毒药物)的营养和药物的相互作用(例如,提高生物利用度),但最近的证据表明,柚子汁也可以抑制有机酸转运蛋白活性。除了葡萄柚汁,橘子,苹果所含的黄酮也能减少有机酸转运蛋白OATP2B1活动。虽然葡萄柚汁-CYP3A4底物相互作用和用于产生显著营养药物相互作用的可能性是最充分表征,但是应当注意的是,除了抑制CYP3A4活性,蔓越莓,石榴和蓝莓汁能抑制CYP2C9的酶活性 ,CYP2C9即一种能催化治疗性药物如布洛芬、氟比洛芬、华法林、苯妥英、氟伐他汀和阿米替林的生物转化的细胞色素P450同工酶。 上述任何一种果汁-药物相互作用的临床意义极难根据消化系统的历史情况来预测。
 
在持续时间和幅度较大的相互作用产生的质变是多因素作用的结果,主要包括以下内容:(1)对影响酶或转运蛋白的组成型表达,(2)酶(如CYP2C9)或转运蛋白的显著遗传多态性,(3)不同果汁之间的相对类黄酮的组合物和效力,(4)果汁摄入量和摄入的持续时间(例如,可能需要在成年人中饮用1至2L /天的蔓越莓果汁以产生与华法林的显著相互作用)。在评估潜在的果汁 - 药物相互作用,果汁和药物的联合应用中,其代谢或转运可能是由类黄酮的影响不应该被立即认为是治疗的禁忌症。 必须考虑摄取的果汁的量和类型,表征给定相互作用的具体信息以及服用的药物是否低(如抗逆转录病毒药、钙调磷酸酶抑制剂、钙通道阻滞剂、华法林)或高治疗指数以评估潜在的相互作用。 医师和药剂师之间的协商可以有助于考虑果汁药物相互作用的潜在临床意义。



果汁中碳水化合物的吸收

果汁中的4种主要糖类是蔗糖、葡萄糖、果糖和山梨糖醇。蔗糖是通过存在于小肠上皮中的蔗糖酶水解成两分子的单糖——葡萄糖和果糖。然后,葡萄糖通过活性载体介导的过程在小肠的绒毛边缘被快速吸收。果糖被促进的运输机制通过载体吸收,但不逆浓度梯度。此外,果糖可能被二糖酶相关的转运系统吸收,因为果糖的吸收在葡萄糖存在下更快,当果糖和葡萄糖以等摩尔浓度存在时,发生最大吸收。临床研究显示,当果糖浓度超过葡萄糖(例如苹果和梨汁)时,比这两种糖以相同浓度存在(例如白葡萄汁)时,吸收更快。然而,当以适当的量(10mL / kg体重)提供时,这些不同的果汁也被同样地吸收。梨,苹果,樱桃,杏和李子和无糖食物(例如糖果,口香糖,饮料,冰淇淋)和一些液体药物含有少量的山梨糖醇,山梨糖醇被缓慢的通过被动扩散吸收,因此大部分被摄取的山梨醇未能被吸收。

在小肠中未被吸收的碳水化合物被结肠中的细菌发酵。 这种细菌发酵会产生氢,二氧化碳,甲烷和短链脂肪酸乙酸、丙酸和丁酸。 这些气体和一些脂肪酸中通过结肠上皮被再吸收,并以这种方式,一部分吸收不良的碳水化合物(malabsorbed carbohydrate)可被清除。 未吸收的碳水化合物对胃肠道产生渗透负荷,引起腹泻。

幼儿的腹泻是一种众所周知的良性病症,通常只需从1至4岁的饮食中去除多余的果汁即能产生效果。 然而,在果汁碳水化合物吸收不良,尤其是过量食用时,可导致慢性腹泻、胀气、腹胀、腹痛。 果糖和山梨醇最常见,但特定碳水化合物的比例也可能很重要。 大量摄取果汁可能导致的碳水化合物吸收不良是一些卫生保健提供者推荐用于治疗便秘,尤其是婴幼儿便秘的基础。 北美小儿胃肠病学,肝病学和营养便秘学指南建议利用一些果汁(如西梅脯,梨和苹果汁)中所含的山梨糖醇和其他碳水化合物来帮助增加婴儿粪便的频率和含水量来治疗婴儿便秘。

美国人饮食指南中的果汁相关策略

2015年出版的最新版本的美国人饮食指南的基本前提是,是关注高营养食品。水果是膳食指南中头号关键重点食品。水果与蔬菜一起被推荐提供必需的维生素和矿物质,降低心血管疾病的风险,有可能防止癌症,并抑制摄入过多的热量。例如,每天消耗约1000千卡(取决于体型大小,1-4岁)的儿童每天应该喝约1杯水果,而消费大约2000千卡/天(取决于体型大小,10-18岁)的儿童,每天应消耗约2杯水果。尽管鼓励摄入整个水果,但最多可以以100%果汁(不是水果饮料)的形式提供一半水果。 6盎司的果汁杯等于1杯水果。相比整个水果,果汁没有营养优势。果汁的缺点是缺乏全果的纤维。 果汁的大卡比全果消耗得更快。依靠果汁而不是全果提供每日摄入的水果不能促进与全水果摄入相关的饮食行为。因为最近的研究表明,纯橙汁摄入对成年人有健康益处,但需要进一步的研究来确定儿童和青少年是否可以获得类似的益处。
 
儿科医生通过向儿童患者及其父母提供指导,在儿童健康和营养方面发挥核心作用。儿科医生也可以倡导改变公共政策,特别是在学校里,改善水果和蔬菜的摄入量与促进健康饮食选择的政策相关。开放的评估和适当的饮食习惯的建议,包括食用整个水果而不是果汁,可以帮助促进父母对健康体重增长的支持。尽管与肥胖相关的其他风险因素可能是重要的考虑因素,最近的一项研究表明,对于生育前超重的女性的婴儿和孩子可能需要特别的关注。
 
果汁的微生物安全性

父母需要了解,未经高温消毒的果汁产品可能含有可能对儿童有害的病原体,如大肠杆菌、沙门氏菌属和隐孢子虫属。这些生物与严重的疾病如溶血性尿毒症综合症有关。如果父母选择给予孩子未经高温消毒的果汁产品,则应小心谨慎,并告知这是不安全的做法。市售的未经高压灭菌的果汁必须在标签上注明该产品可能含有有害细菌的警告。这些建议不适用于某些销售模式(例如,“由苹果园、农贸市场、路边摊位或某些果汁酒吧新鲜挤压出售的果汁或苹果酒”[http://www.fda.gov/Food/Resour ... 6.htm]),但是当向儿童提供未经消毒的果汁产品时,家庭应保持警惕。巴氏灭菌的果汁不含微生物,对婴儿,儿童和青少年是安全的。


 
婴儿

美国儿科学会(AAP)建议,在大约6月龄之前,人乳是唯一一种喂养婴儿的营养物质。 对于不能母乳喂养或选择不进行母乳喂养的母亲,可以使用制备好的婴儿配方奶粉作为完整的营养来源。 不需要额外的营养。 没有营养指南建议给6岁以下的婴儿提供果汁。 在饮食中引入固体食物之前提供果汁可能会导致饮食中的果汁取代人乳或婴幼儿配方奶粉,这可能导致蛋白质、脂肪、维生素和矿物质如铁、钙和锌的摄入量减少。儿童营养不良和身材矮小与过多摄入果汁有关。

完全避免在1岁以前的婴儿中使用果汁是最佳的做法。尽管医学上建议给6个月以上的婴儿饮用果汁,但给予婴儿果汁仍需谨慎。 龋齿也与果汁消费有关。牙齿长期暴露于果汁中的糖是造成龋齿的主要原因。 美国儿科学会和美国儿科牙科学会的建议指出,应用杯子向幼儿提供果汁,而不是瓶子,并且婴儿入睡时不能在口中含有盛有果汁的瓶子。 整天允许儿童携带瓶子、容易运输的有盖杯子、开口杯或盒装果汁的做法导致牙齿过度暴露于碳水化合物,这促进了龋齿的形成。

婴儿可被允许吃捣成糊状的整个水果。 1岁以后,可以将果汁用作餐点或小吃的一部分。它不应该在一天中一直被孩子啜饮或当作使一个不安的孩子安静下来的手段。因为婴儿每天摄入<1600千卡,每天4盎司的果汁占推荐日常水果的一半,是绰绰有余的。

关于处理幼儿急性胃肠炎的美国儿科学会实践指数(1996年出版,随后于2001年停止出版)建议,只能使用口服电解质溶液来补充婴儿和幼儿水分,并在整个胃肠炎发作期间继续保持正常饮食。调查显示,许多医疗保健提供者不遵循推荐的腹泻处理流程。与口服电解质溶液(2.5-3g%)相比,果汁(11-16 g%)的高碳水化合物含量可能会超过肠道吸收碳水化合物的能力,导致碳水化合物吸收不良。碳水化合物吸收不良会引起渗透性腹泻,加剧现有的腹泻的严重程度。果汁电解质含量低。钠浓度为1〜3mEq / L。急性腹泻儿童粪便钠浓度为20〜40mEq / L。口服电解质溶液含有40〜45mEq钠/ L。将果汁作为液体损失的替代品,可能会使婴儿发生低钠血症。
 
有人担心,接触橙汁的婴儿可能会增加对橙汁过敏反应的可能性。 一些摄入鲜榨柑橘类果汁的婴儿发生口周皮疹,这有可能是由于酸的化学刺激作用。在一些婴儿身上观察到的腹泻和一些胃肠道症状最有可能归因于碳水化合物吸收不良。 虽然对水果过敏可能发生于生命的早期,但却不常见。
 
幼儿和儿童(1-6岁)
与新生儿的果汁摄入相关的大多数问题也与初学走路的孩子和幼儿有关。果汁和果汁饮料由于口感好极易被这些人群摄入过多。令外,它们便于包装,也可以放在瓶子或可移动的盖杯里,白天随身携带。因为果汁被认为是有营养的,所以父母通常不会限制果汁的摄入。应鼓励刚学走路的孩子和幼儿吃整个水果而非喝果汁。果汁跟苏打水一样会导致机体能量失衡。儿科医生应支持旨在减少果汁摄入的政策,鼓励已经接触果汁的初学走路的孩子和幼儿食用整个水果。这种支持应该包括为妇女、新生儿和儿童制定的特别营养补充计划(WIC),假设这些政策对于无法获得新鲜水果的儿童并没有负面的营养结果(例如总热量不足、食物中缺乏水果)。此外,过多摄入饮料会导致腹泻、营养过剩或营养不良,以及龋齿。用水稀释果汁并不一定会降低果汁对牙齿健康损害的风险。
 
大龄儿童和青少年(7-18岁)

果汁消费表明年龄较大的儿童和青少年营养问题少的原因是他们更少地摄入这些饮料。 尽管如此,果汁摄入量应限制在8盎司/天,是推荐的每日水果的一半。 鼓励消耗整个水果以有利于膳食纤维摄入以及这会花费更长时间消耗相同的千卡热量也很重要的。过量的果汁消耗和由此导致的能量摄入量的增加可能有助于肥胖的发展。 一项研究发现果汁摄入量超过12盎司/天与肥胖有关。然而,其他研究发现,饮用更多量的果汁的儿童比饮用较少果汁的儿童身高更高,BMI更低,还有研究发现果汁摄入和身高变化之间没有关联。最近的一项研究表明,摄入不同种类的100%纯果汁与肥胖无关。但仍需要更多的研究来更好地界定这个关系。
 

 
结论
  1. 果汁对1岁以下的婴儿无营养益处。
  2. 果汁对婴儿和儿童的营养益处不如整个水果,并且在健康和均衡的儿童饮食中并非不可或缺。
  3. 百分之百的新鲜或重新配制的果汁可以作为1岁以上儿童均衡健康饮食的一部分。但是,水果饮料在营养上并不等同于果汁。
  4. 果汁不适合治疗脱水或腹泻的治疗。
  5. 过量的果汁摄入可能与营养不良(营养过剩和营养不良)有关。
  6. 过量的果汁摄入与腹泻、肠胃气胀、腹部膨胀和龋齿有关。
  7. 未经消毒的果汁产品可能含有引起严重疾病的病原体,给小孩服用应谨慎。
  8. 为适当儿童年龄提供的各种果汁不太可能引起任何明显的临床症状。
  9. 钙强化果汁可作为提供生物可利用的钙的来源,通常也含有维生素D,但缺乏其他存在于母乳、婴儿配方奶粉或牛奶中的其他营养物质。




​建议
  1. 除非临床推荐,否则不应将果汁引入12个月月龄前的婴儿饮食中。1至3岁的孩子的果汁摄入量应限制在最多4盎司/天,4至6岁的儿童每天应为4至6盎司/天。对于7至18岁的儿童,果汁摄入量应限制在8盎司或占推荐的每天2至2.5杯水果的1杯果汁。
  2. 幼儿不应该从瓶子或容易运输的有盖的杯子中获得果汁,这会使他们在整天中容易饮用果汁。幼儿在睡觉时不应该给予果汁。
  3. 应鼓励孩子吃全果,以满足他们推荐的每日水果摄入量,并应该重视膳食纤维摄入的益处,并且与果汁相比,摄入整个水果时消耗相同千卡的时间要长。
  4. 家长们应该知道,为了满足流食需求,人乳和/或婴儿配方食品对婴儿和低脂/脱脂奶是足够的,而且对于大龄儿童来说,摄入水就足够了。
  5. 应极力劝阻婴儿、儿童和青少年摄入未经巴氏消毒的果汁产品。
  6. 任何儿童服用CYP3A4代谢药物时,应避免使用葡萄柚汁(见上述清单)。
  7. 在评估营养不良(营养过剩和营养不良)的儿童时,儿科医生应确定所消耗的果汁量。
  8. 在评估患有慢性腹泻、过度肠胃气胀、腹痛和腹胀的儿童时,儿科医生应确定摄入的果汁量。
  9. 在评估龋齿的风险时,儿科医生应定期讨论果汁和龋齿之间的关系,并确定果汁的摄入量和摄入形式。
  10. 儿科医生应该常规地讨论果汁和水果饮品的饮用,并教育年龄较大的儿童,青少年及其父母两者之间的差异。
  11. 小儿科医师应主张减少幼儿饮食中的果汁,并且在体重异常(过轻或超重)的儿童饮食中去除果汁。
  12. 儿科医生应支持旨在减少果汁消费的政策,并通过已经接触果汁的幼儿和儿童(例如育儿/幼儿园),包括通过“妇女,婴幼儿特别补充营养计划(WIC)” ,促进整个水果的摄入。 


Lead Authors

Melvin B. Heyman, MD, FAAP
Steven A. Abrams, MD, FAAP
 
中文翻译:Shawnee
本文地址:http://www.wjbb.com/know/1767
原文出处:http://pediatrics.aappublicati ... -0967

美国儿科学会:儿童青少年与数字媒体指南

豌豆爸爸 发表了文章 • 2 个评论 • 283 次浏览 • 2016-10-24 09:40 • 来自相关话题

 Abstract

Today’s children and adolescents are immersed in both traditional and new forms of digital media. Research on traditional media, such as television, has identified health concerns and negative outcomes that correlate with the duration and content of viewing. Over the past decade, the use of digital media, including interactive and social media, has grown, and research evidence suggests that these newer media offer both benefits and risks to the health of children and teenagers. Evidence-based benefits identified from the use of digital and social media include early learning, exposure to new ideas and knowledge, increased opportunities for social contact and support, and new opportunities to access health promotion messages and information. Risks of such media include negative health effects on sleep, attention, and learning; a higher incidence of obesity and depression; exposure to inaccurate, inappropriate, or unsafe content and contacts; and compromised privacy and confidentiality. This technical report reviews the literature regarding these opportunities and risks, framed around clinical questions, for children from birth to adulthood. To promote health and wellness in children and adolescents, it is important to maintain adequate physical activity, healthy nutrition, good sleep hygiene, and a nurturing social environment. A healthy Family Media Use Plan (www.healthychildren.org/MediaUsePlan) that is individualized for a specific child, teenager, or family can identify an appropriate balance between screen time/online time and other activities, set boundaries for accessing content, guide displays of personal information, encourage age-appropriate critical thinking and digital literacy, and support open family communication and implementation of consistent rules about media use.
 
Introduction

Today’s generation of children and adolescents are growing up immersed in media, including broadcast and social media. Broadcast media include television and movies. Interactive media include social media and video games in which users can both consume and create content. Interactive media allow information sharing and provide an engaging digital environment that becomes highly personalized.

Media Use Patterns

The most common broadcast medium continues to be TV. A recent study found that TV hours among school-aged children have decreased in the past decade for children younger than 8 years.1 However, among children aged 8 years and older, average daily TV time remains over 2 hours per day.2 TV viewing also has changed over the past decade, with content available via streaming or social media sites, such as YouTube and Netflix.

Overall media use among adolescents has continued to grow over the past decade, aided by the recent increase in mobile phone use among teenagers. Approximately three-quarters of teenagers today own a smartphone,3 which allows access to the Internet, streaming TV/videos, and interactive “apps.” Approximately one-quarter of teenagers describe themselves as “constantly connected” to the Internet.

Social media sites and mobile apps provide platforms for users to create an online identity, communicate with others, and build social networks. At present, 76% of teenagers use at least 1 social media site. Although Facebook remains the most popular social media site,3 teenagers do not typically commit to just 1 social media platform; more than 70% maintain a “social media portfolio” of several selected sites, including Facebook, Twitter, and Instagram.3 Mobile apps provide a breadth of functions, such as photo sharing, games, and video-chatting.

Video games remain very popular among families; 4 of 5 households own a device used to play video games.Boys are the most avid video game players, with 91% of boys reporting having access to a game console and 84% reporting playing video games online or on a cell phone.

Benefits of Media

Both traditional and social media can provide exposure to new ideas and information, raising awareness of current events and issues. Interactive media also can provide opportunities for the promotion of community participation and civic engagement. Students can collaborate with others on assignments and projects on many online media platforms. The use of social media helps families and friends who are separated geographically communicate across the miles.

Social media can enhance access to valuable support networks, which may be particularly helpful for patients with ongoing illnesses, conditions, or disabilities.In 1 study, young adults described the benefits of seeking health information online and through social media, and recognized these channels as useful supplementary sources of information to health care visits.6 Research also supports the use of social media to foster social inclusion among users who may feel excluded or who are seeking a welcoming community: for example, those identifying as lesbian, gay, bisexual, transgender, questioning, or intersex. Finally, social media may be used to enhance wellness and promote healthy behaviors, such as smoking cessation and balanced nutrition.

Risks of Media

A first area of health concern is media use and obesity, and most studies have focused on TV. One study found that the odds of being overweight were almost 5 times greater for adolescents who watch more than 5 hours of TV per day compared with those who watch 0 to 2 hours.9 This study’s findings contributed to recommendations by the American Academy of Pediatrics that children have 2 hours or less of sedentary screen time daily. More recent studies have provided new evidence that watching TV for more than 1.5 hours daily was a risk factor for obesity, but only for children 4 through 9 years of age.10 Increased caloric intake via snacking while watching TV has been shown to be a risk factor for obesity, as is exposure to advertising for high-calorie foods and snacks.Having a TV in the bedroom continues to be associated with the risk of obesity.

Evidence suggests that media use can negatively affect sleep.Studies show that those with higher social media use15 or who sleep with mobile devices in their roomswere at greater risk of sleep disturbances. Exposure to light (particularly blue light) and activity from screens before bed affects melatonin levels and can delay or disrupt sleep.Media use around or after bedtime can disrupt sleep and negatively affect school performance.

Children who overuse online media are at risk of problematic Internet use, and heavy users of video games are at risk of Internet gaming disorder. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,lists both as conditions in need of further research. Symptoms can include a preoccupation with the activity, decreased interest in offline or “real life” relationships, unsuccessful attempts to decrease use, and withdrawal symptoms. The prevalence of problematic Internet use among children and adolescents is between 4% and 8%,21,22 and up to 8.5% of US youth 8 to 18 years of age meet criteria for Internet gaming disorder.

At home, many children and teenagers use entertainment media at the same time that they are engaged in other tasks, such as homework.A growing body of evidence suggests that the use of media while engaged in academic tasks has negative consequences on learning.

Media Influence

Evidence gathered over decades supports links between media exposure and health behaviors among teenagers.The exposure of adolescents through media to alcohol,28,29 tobacco use,30,31 or sexual behaviors is associated with earlier initiation of these behaviors.

Adolescents’ displays on social media frequently include portrayal of health risk behaviors, such as substance use, sexual behaviors, self-injury, or disordered eating.Peer viewers of such content may see these behaviors as normative and desirable.Research from both the United States and the United Kingdom indicates that the major alcohol brands maintain a strong presence on Facebook, Twitter, and YouTube.

Cyberbullying, Sexting, and Online Solicitation

Cyberbullying and traditional bullying overlap, although online bullying presents unique challenges. These challenges include that perpetrators can be anonymous and bully at any time of day, that information can spread online rapidly, and that perpetrator and target roles can be quite fluid in the online world. Cyberbullying can lead to short- and long-term negative social, academic, and health consequences for both the perpetrator and the target. Fortunately, newer studies suggest that interventions that target bullying may reduce cyberbullying.

“Sexting” is commonly defined as the electronic transmission of nude or seminude images as well as sexually explicit text messages. It is estimated that ∼12% of youth aged 10 to 19 years have ever sent a sexual photo to someone else. The Internet also has created opportunities for the exploitation of children by sex offenders through social networking, chat rooms, e-mail, and online games.

Social Media and Mental Health

Research studies have identified both benefits and concerns regarding mental health and social media use. Benefits from the use of social media in moderation include the opportunity for enhanced social support and connection. Research has suggested a U-shaped relationship between Internet use and depression, with increased risks of depression at both the high and low ends of Internet use. One study found that older adolescents who used social media passively (eg, viewing others’ photos) reported declines in life satisfaction, whereas those who interacted with others and posted content did not experience these declines.Thus, in addition to the number of hours an individual spends on social media, a key factor is how social media is used.

Social Media and Privacy

Content that an adolescent chooses to post is shared with others, and the removal of such content once posted may be difficult or impossible. Adolescents vary in their understanding of privacy practices; even those who know how to set privacy settings often don’t believe they will work.Despite efforts by some social media sites to protect privacy or to delete content after it is viewed, privacy violations and unwelcome distribution are always risks.

Parent Media Use and Child Health

Social media can provide positive social experiences, such as opportunities for parents to connect with children via video-chat services. Unfortunately, some parents can be distracted by media and miss important opportunities for emotional connections that are known to improve child health.53,54 One research study found that when a parent turned his or her attention to a mobile device while with a young child, the parent was less likely to talk with the child.Parental engagement is critical in the development of children’s emotional and social development, and these distractions may have short- and long-term negative effects.

Conclusions

The effects of media use are multifactorial and depend on the type of media, the type of use, the amount and extent of use, and the characteristics of the individual child. Children today are growing up in an era of highly personalized media use experiences, so parents must develop personalized media use plans for their children that attend to each child’s age, health, temperament, and developmental stage. Research evidence shows that children and teenagers need adequate sleep, physical activity, and time away from media. Pediatricians can help families develop a Family Media Use Plan (www.HealthyChildren.org/MediaUsePlan) that prioritizes these and other health goals.

Recommendations

Pediatricians

Work with families and schools to promote understanding of the benefits and risks of media.

Promote adherence to guidelines for adequate physical activity and sleep via a Family Media Use Plan (www.HealthyChildren.org/MediaUsePlan).

Advocate for and promote information and training in media literacy.

Be aware of tools to screen for sexting, cyberbullying, problematic Internet use, and Internet gaming disorder.

Families

Develop, consistently follow, and routinely revisit a Family Media Use plan (see the plan from the American Academy of Pediatrics at www.HealthyChildren.org/MediaUsePlan).

Address what type of and how much media are used and what media behaviors are appropriate for each child or teenager, and for parents. Place consistent limits on hours per day of media use as well as types of media used.

Promote that children and adolescents get the recommended amount of daily physical activity (1 hour) and adequate sleep (8–12 hours, depending on age).

Recommend that children not sleep with devices in their bedrooms, including TVs, computers, and smartphones. Avoid exposure to devices or screens for 1 hour before bedtime.

Discourage entertainment media while doing homework.

Designate media-free times together (eg, family dinner) and media-free locations (eg, bedrooms) in homes. Promote activities that are likely to facilitate development and health, including positive parenting activities, such as reading, teaching, talking, and playing together.

Communicate guidelines to other caregivers, such as babysitters or grandparents, so that media rules are followed consistently.

Engage in selecting and co-viewing media with your child, through which your child can use media to learn and be creative, and share these experiences with your family and your community.

Have ongoing communication with children about online citizenship and safety, including treating others with respect online and offline, avoiding cyberbullying and sexting, being wary of online solicitation, and avoiding communications that can compromise personal privacy and safety.

Actively develop a network of trusted adults (eg, aunts, uncles, coaches, etc) who can engage with children through social media and to whom children can turn when they encounter challenges.

Researchers, Governmental Organizations, and Industry

Continue research into the risks and benefits of media.

Prioritize longitudinal and robust study designs, including new methodologies for understanding media exposure and use.

Prioritize interventions including reducing harmful media use and preventing and addressing harmful media experiences.

Inform educators and legislators about research findings so they can develop updated guidelines for safe and productive media use.
 
中文翻译:
本文地址:http://www.wjbb.com/know/1643
原文出处:http://pediatrics.aappublicati ... -2592 查看全部

 Abstract

Today’s children and adolescents are immersed in both traditional and new forms of digital media. Research on traditional media, such as television, has identified health concerns and negative outcomes that correlate with the duration and content of viewing. Over the past decade, the use of digital media, including interactive and social media, has grown, and research evidence suggests that these newer media offer both benefits and risks to the health of children and teenagers. Evidence-based benefits identified from the use of digital and social media include early learning, exposure to new ideas and knowledge, increased opportunities for social contact and support, and new opportunities to access health promotion messages and information. Risks of such media include negative health effects on sleep, attention, and learning; a higher incidence of obesity and depression; exposure to inaccurate, inappropriate, or unsafe content and contacts; and compromised privacy and confidentiality. This technical report reviews the literature regarding these opportunities and risks, framed around clinical questions, for children from birth to adulthood. To promote health and wellness in children and adolescents, it is important to maintain adequate physical activity, healthy nutrition, good sleep hygiene, and a nurturing social environment. A healthy Family Media Use Plan (www.healthychildren.org/MediaUsePlan) that is individualized for a specific child, teenager, or family can identify an appropriate balance between screen time/online time and other activities, set boundaries for accessing content, guide displays of personal information, encourage age-appropriate critical thinking and digital literacy, and support open family communication and implementation of consistent rules about media use.
 
Introduction

Today’s generation of children and adolescents are growing up immersed in media, including broadcast and social media. Broadcast media include television and movies. Interactive media include social media and video games in which users can both consume and create content. Interactive media allow information sharing and provide an engaging digital environment that becomes highly personalized.

Media Use Patterns

The most common broadcast medium continues to be TV. A recent study found that TV hours among school-aged children have decreased in the past decade for children younger than 8 years.1 However, among children aged 8 years and older, average daily TV time remains over 2 hours per day.2 TV viewing also has changed over the past decade, with content available via streaming or social media sites, such as YouTube and Netflix.

Overall media use among adolescents has continued to grow over the past decade, aided by the recent increase in mobile phone use among teenagers. Approximately three-quarters of teenagers today own a smartphone,3 which allows access to the Internet, streaming TV/videos, and interactive “apps.” Approximately one-quarter of teenagers describe themselves as “constantly connected” to the Internet.

Social media sites and mobile apps provide platforms for users to create an online identity, communicate with others, and build social networks. At present, 76% of teenagers use at least 1 social media site. Although Facebook remains the most popular social media site,3 teenagers do not typically commit to just 1 social media platform; more than 70% maintain a “social media portfolio” of several selected sites, including Facebook, Twitter, and Instagram.3 Mobile apps provide a breadth of functions, such as photo sharing, games, and video-chatting.

Video games remain very popular among families; 4 of 5 households own a device used to play video games.Boys are the most avid video game players, with 91% of boys reporting having access to a game console and 84% reporting playing video games online or on a cell phone.

Benefits of Media

Both traditional and social media can provide exposure to new ideas and information, raising awareness of current events and issues. Interactive media also can provide opportunities for the promotion of community participation and civic engagement. Students can collaborate with others on assignments and projects on many online media platforms. The use of social media helps families and friends who are separated geographically communicate across the miles.

Social media can enhance access to valuable support networks, which may be particularly helpful for patients with ongoing illnesses, conditions, or disabilities.In 1 study, young adults described the benefits of seeking health information online and through social media, and recognized these channels as useful supplementary sources of information to health care visits.6 Research also supports the use of social media to foster social inclusion among users who may feel excluded or who are seeking a welcoming community: for example, those identifying as lesbian, gay, bisexual, transgender, questioning, or intersex. Finally, social media may be used to enhance wellness and promote healthy behaviors, such as smoking cessation and balanced nutrition.

Risks of Media

A first area of health concern is media use and obesity, and most studies have focused on TV. One study found that the odds of being overweight were almost 5 times greater for adolescents who watch more than 5 hours of TV per day compared with those who watch 0 to 2 hours.9 This study’s findings contributed to recommendations by the American Academy of Pediatrics that children have 2 hours or less of sedentary screen time daily. More recent studies have provided new evidence that watching TV for more than 1.5 hours daily was a risk factor for obesity, but only for children 4 through 9 years of age.10 Increased caloric intake via snacking while watching TV has been shown to be a risk factor for obesity, as is exposure to advertising for high-calorie foods and snacks.Having a TV in the bedroom continues to be associated with the risk of obesity.

Evidence suggests that media use can negatively affect sleep.Studies show that those with higher social media use15 or who sleep with mobile devices in their roomswere at greater risk of sleep disturbances. Exposure to light (particularly blue light) and activity from screens before bed affects melatonin levels and can delay or disrupt sleep.Media use around or after bedtime can disrupt sleep and negatively affect school performance.

Children who overuse online media are at risk of problematic Internet use, and heavy users of video games are at risk of Internet gaming disorder. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,lists both as conditions in need of further research. Symptoms can include a preoccupation with the activity, decreased interest in offline or “real life” relationships, unsuccessful attempts to decrease use, and withdrawal symptoms. The prevalence of problematic Internet use among children and adolescents is between 4% and 8%,21,22 and up to 8.5% of US youth 8 to 18 years of age meet criteria for Internet gaming disorder.

At home, many children and teenagers use entertainment media at the same time that they are engaged in other tasks, such as homework.A growing body of evidence suggests that the use of media while engaged in academic tasks has negative consequences on learning.

Media Influence

Evidence gathered over decades supports links between media exposure and health behaviors among teenagers.The exposure of adolescents through media to alcohol,28,29 tobacco use,30,31 or sexual behaviors is associated with earlier initiation of these behaviors.

Adolescents’ displays on social media frequently include portrayal of health risk behaviors, such as substance use, sexual behaviors, self-injury, or disordered eating.Peer viewers of such content may see these behaviors as normative and desirable.Research from both the United States and the United Kingdom indicates that the major alcohol brands maintain a strong presence on Facebook, Twitter, and YouTube.

Cyberbullying, Sexting, and Online Solicitation

Cyberbullying and traditional bullying overlap, although online bullying presents unique challenges. These challenges include that perpetrators can be anonymous and bully at any time of day, that information can spread online rapidly, and that perpetrator and target roles can be quite fluid in the online world. Cyberbullying can lead to short- and long-term negative social, academic, and health consequences for both the perpetrator and the target. Fortunately, newer studies suggest that interventions that target bullying may reduce cyberbullying.

“Sexting” is commonly defined as the electronic transmission of nude or seminude images as well as sexually explicit text messages. It is estimated that ∼12% of youth aged 10 to 19 years have ever sent a sexual photo to someone else. The Internet also has created opportunities for the exploitation of children by sex offenders through social networking, chat rooms, e-mail, and online games.

Social Media and Mental Health

Research studies have identified both benefits and concerns regarding mental health and social media use. Benefits from the use of social media in moderation include the opportunity for enhanced social support and connection. Research has suggested a U-shaped relationship between Internet use and depression, with increased risks of depression at both the high and low ends of Internet use. One study found that older adolescents who used social media passively (eg, viewing others’ photos) reported declines in life satisfaction, whereas those who interacted with others and posted content did not experience these declines.Thus, in addition to the number of hours an individual spends on social media, a key factor is how social media is used.

Social Media and Privacy

Content that an adolescent chooses to post is shared with others, and the removal of such content once posted may be difficult or impossible. Adolescents vary in their understanding of privacy practices; even those who know how to set privacy settings often don’t believe they will work.Despite efforts by some social media sites to protect privacy or to delete content after it is viewed, privacy violations and unwelcome distribution are always risks.

Parent Media Use and Child Health

Social media can provide positive social experiences, such as opportunities for parents to connect with children via video-chat services. Unfortunately, some parents can be distracted by media and miss important opportunities for emotional connections that are known to improve child health.53,54 One research study found that when a parent turned his or her attention to a mobile device while with a young child, the parent was less likely to talk with the child.Parental engagement is critical in the development of children’s emotional and social development, and these distractions may have short- and long-term negative effects.

Conclusions

The effects of media use are multifactorial and depend on the type of media, the type of use, the amount and extent of use, and the characteristics of the individual child. Children today are growing up in an era of highly personalized media use experiences, so parents must develop personalized media use plans for their children that attend to each child’s age, health, temperament, and developmental stage. Research evidence shows that children and teenagers need adequate sleep, physical activity, and time away from media. Pediatricians can help families develop a Family Media Use Plan (www.HealthyChildren.org/MediaUsePlan) that prioritizes these and other health goals.

Recommendations

Pediatricians

Work with families and schools to promote understanding of the benefits and risks of media.

Promote adherence to guidelines for adequate physical activity and sleep via a Family Media Use Plan (www.HealthyChildren.org/MediaUsePlan).

Advocate for and promote information and training in media literacy.

Be aware of tools to screen for sexting, cyberbullying, problematic Internet use, and Internet gaming disorder.

Families

Develop, consistently follow, and routinely revisit a Family Media Use plan (see the plan from the American Academy of Pediatrics at www.HealthyChildren.org/MediaUsePlan).

Address what type of and how much media are used and what media behaviors are appropriate for each child or teenager, and for parents. Place consistent limits on hours per day of media use as well as types of media used.

Promote that children and adolescents get the recommended amount of daily physical activity (1 hour) and adequate sleep (8–12 hours, depending on age).

Recommend that children not sleep with devices in their bedrooms, including TVs, computers, and smartphones. Avoid exposure to devices or screens for 1 hour before bedtime.

Discourage entertainment media while doing homework.

Designate media-free times together (eg, family dinner) and media-free locations (eg, bedrooms) in homes. Promote activities that are likely to facilitate development and health, including positive parenting activities, such as reading, teaching, talking, and playing together.

Communicate guidelines to other caregivers, such as babysitters or grandparents, so that media rules are followed consistently.

Engage in selecting and co-viewing media with your child, through which your child can use media to learn and be creative, and share these experiences with your family and your community.

Have ongoing communication with children about online citizenship and safety, including treating others with respect online and offline, avoiding cyberbullying and sexting, being wary of online solicitation, and avoiding communications that can compromise personal privacy and safety.

Actively develop a network of trusted adults (eg, aunts, uncles, coaches, etc) who can engage with children through social media and to whom children can turn when they encounter challenges.

Researchers, Governmental Organizations, and Industry

Continue research into the risks and benefits of media.

Prioritize longitudinal and robust study designs, including new methodologies for understanding media exposure and use.

Prioritize interventions including reducing harmful media use and preventing and addressing harmful media experiences.

Inform educators and legislators about research findings so they can develop updated guidelines for safe and productive media use.
 
中文翻译:
本文地址:http://www.wjbb.com/know/1643
原文出处:http://pediatrics.aappublicati ... -2592

美国儿科学会:媒体与幼儿指南

豌豆爸爸 发表了文章 • 1 个评论 • 322 次浏览 • 2016-10-24 09:28 • 来自相关话题

 Abstract

Infants, toddlers, and preschoolers are now growing up in environments saturated with a variety of traditional and new technologies, which they are adopting at increasing rates. Although there has been much hope for the educational potential of interactive media for young children, accompanied by fears about their overuse during this crucial period of rapid brain development, research in this area still remains limited. This policy statement reviews the existing literature on television, videos, and mobile/interactive technologies; their potential for educational benefit; and related health concerns for young children (0 to 5 years of age). The statement also highlights areas in which pediatric providers can offer specific guidance to families in managing their young children’s media use, not only in terms of content or time limits, but also emphasizing the importance of parent–child shared media use and allowing the child time to take part in other developmentally healthy activities.
 
Introduction

Technologic innovation has transformed media and its role in the lives of infants and young children. More children, even in economically challenged households, are using newer digital technologies, such as interactive and mobile media, on a daily basis1 and continue to be the target of intense marketing. This policy statement addresses the influence of media on the health and development of children from 0 to 5 years of age, a time of critical brain development, building secure relationships, and establishing health behaviors.

Infants and Toddlers

Children younger than 2 years need hands-on exploration and social interaction with trusted caregivers to develop their cognitive, language, motor, and social-emotional skills. Because of their immature symbolic, memory, and attentional skills, infants and toddlers cannot learn from traditional digital media as they do from interactions with caregivers,and they have difficulty transferring that knowledge to their 3-dimensional experience.The chief factor that facilitates toddlers’ learning from commercial media (starting around 15 months of age) is parents watching with them and reteaching the content.

The interactivity of touchscreens enables applications (apps) to identify when a child responds accurately and then tailor its responses, thereby supporting children at their levels of competence. Emerging evidence shows that at 24 months of age, children can learn words from live video-chatting with a responsive adult or from an interactive touchscreen interface that scaffolds the child to choose the relevant answers. Starting at 15 months of age, toddlers can learn novel words from touchscreens in laboratory-based studies but have trouble transferring this knowledge to the 3-dimensional world. However, it should be noted that these experiments used specially designed apps that are not commercially available.

Many parents now use video-chat (eg, Skype, FaceTime) as an interactive media form that facilitates social connection with distant relatives. New evidence shows that infants and toddlers regularly engage in video-chatting, but the same principles regarding need for parental support would apply in order for infants and toddlers to understand what they are seeing.

In summary, for children younger than 2 years, evidence for benefits of media is still limited, adult interaction with the child during media use is crucial, and there continues to be evidence of harm from excessive digital media use, as described later in this statement.

Preschool Media and Learning

Well-designed television programs, such as Sesame Street, can improve cognitive, literacy, and social outcomes for children 3 to 5 years of age and continue to create programming that addresses evolving child health and developmental needs (eg, obesity prevention, resilience). Evaluations of apps from Sesame Workshop and the Public Broadcasting Service (PBS) also have shown efficacy in teaching literacy skills to preschoolers.Unfortunately, most apps parents find under the “educational” category in app stores have no such evidence of efficacy, target only rote academic skills, are not based on established curricula, and use little or no input from developmental specialists or educators. Most apps also generally are not designed for a dual audience (ie, both parent and child). It is important to emphasize to parents that the higher-order thinking skills and executive functions essential for school success, such as task persistence, impulse control, emotion regulation, and creative, flexible thinking, are best taught through unstructured and social (not digital) play,as well as responsive parent–child interactions.

Digital books (also called “eBooks,” books that can be read on a screen) often come with interactive enhancements that, research suggests, may decrease child comprehension of content or parent dialogic reading interactions when visual effects are distracting.Parents should, therefore, be instructed to interact with children during eBook reading, as they would a print book.

Health and Developmental Concerns

Obesity

Heavy media use during preschool years is associated with small but significant increases in BMI,18 may explain disparities in obesity risk in minority children,19 and sets the stage for weight gain later in childhood.Although many studies have used a 2-hour cutoff to examine obesity risk, a recent study of 2-year-olds found that BMI increased for every hour per week of media consumed.It is believed that exposure to food advertising and watching television while eating (which diminishes attention to satiety cues) drives these associations.

Sleep

Increased duration of media exposure and the presence of a television, computer, or mobile device in the bedroom in early childhood have been associated with fewer minutes of sleep per night.

Even infants exposed to screen media in the evening hours show significantly shorter night-time sleep duration than those with no evening screen exposure. Mechanisms underlying this association include arousing content and suppression of endogenous melatonin by blue light emitted from screens.

Child Development

Population-based studies continue to show associations between excessive television viewing in early childhood and cognitive,language,and social/emotional delays, likely secondary to decreases in parent–child interaction when the television is on37 and poorer family functioning in households with high media use. An earlier age of media use onset, greater cumulative hours of media use, and non-PBS content all are significant independent predictors of poor executive functioning in preschoolers.Content is crucial: experimental evidence shows that switching from violent content to educational/prosocial content results in significant improvement in behavioral symptoms, particularly for low-income boys.Notably, the quality of parenting can modify associations between media use and child development: one study found that inappropriate content and inconsistent parenting had cumulative negative effects on low-income preschoolers’ executive function, whereas warm parenting and educational content interacted to produce additive benefits.

Child characteristics also may influence how much media children consume: excessive television viewing is more likely in infants and toddlers with a difficult temperamentor self-regulation problems, and toddlers with social-emotional delays are more likely to be given a mobile device to calm them down.

Parental Media Use

Parents’ background television use distracts from parent–child interactions and child play.Heavy parent use of mobile devices is associated with fewer verbal and nonverbal interactions between parents and children and may be associated with more parent-child conflict. Because parent media use is a strong predictor of child media habits,reducing parental media use and enhancing parent–child interactions may be an important area of behavior change.

Conclusions: Clinical Implications

In summary, multiple developmental and health concerns continue to exist for young children using all forms of digital media to excess. Evidence is sufficient to recommend time limitations on digital media use for children 2 to 5 years to no more than 1 hour per day to allow children ample time to engage in other activities important to their health and development and to establish media viewing habits associated with lower risk of obesity later in life.In addition, encouraging parents to change to educational and prosocial content and engage with their children around technology will allow children to reap the most benefit from what they view.

As digital technologies become more ubiquitous, pediatric providers must guide parents not only on the duration and content of media their child uses, but also on (1) creating unplugged spaces and times in their homes, because devices can now be taken anywhere; (2) the ability of new technologies to be used in social and creative ways; and (3) the importance of not displacing sleep, exercise, play, reading aloud, and social interactions. Realistically, pediatric providers will need to know how to help parents find resources finding appropriate content, tools for monitoring or limiting child use, ideas for play or activities in which to engage rather than digital play, and how parents can limit their own media use (see HealthyChildren.org for examples); each of these can be built into the Family Media Use Plan (see the American Academy of Pediatrics guide to developing a plan at www.healthychildren.org/MediaUsePlan).

Recommendations

Pediatricians

Start the conversation early. Ask parents of infants and young children about family media use, their children’s use habits, and media use locations.

Help families develop a Family Media Use Plan (www.healthychildren.org/MediaUsePlan) with specific guidelines for each child and parent.

Educate parents about brain development in the early years and the importance of hands-on, unstructured, and social play to build language, cognitive, and social-emotional skills.

For children younger than 18 months, discourage use of screen media other than video-chatting.

For parents of children 18 to 24 months of age who want to introduce digital media, advise that they choose high-quality programming/apps and use them together with children, because this is how toddlers learn best. Letting children use media by themselves should be avoided.

Guide parents to resources for finding quality products (eg, Common Sense Media, PBS Kids, Sesame Workshop).

In children older than 2 years, limit media to 1 hour or less per day of high-quality programming. Recommend shared use between parent and child to promote enhanced learning, greater interaction, and limit setting.

Recommend no screens during meals and for 1 hour before bedtime.

Problem-solve with parents facing challenges, such as setting limits, finding alternate activities, and calming children.

Families

Avoid digital media use (except video-chatting) in children younger than 18 to 24 months.

For children ages 18 to 24 months of age, if you want to introduce digital media, choose high-quality programming and use media together with your child. Avoid solo media use in this age group.

Do not feel pressured to introduce technology early; interfaces are so intuitive that children will figure them out quickly once they start using them at home or in school.

For children 2 to 5 years of age, limit screen use to 1 hour per day of high-quality programming, coview with your children, help children understand what they are seeing, and help them apply what they learn to the world around them.

Avoid fast-paced programs (young children do not understand them as well), apps with lots of distracting content, and any violent content.

Turn off televisions and other devices when not in use.

Avoid using media as the only way to calm your child. Although there are intermittent times (eg, medical procedures, airplane flights) when media is useful as a soothing strategy, there is concern that using media as strategy to calm could lead to problems with limit setting or the inability of children to develop their own emotion regulation. Ask your pediatrician for help if needed.

Monitor children’s media content and what apps are used or downloaded. Test apps before the child uses them, play together, and ask the child what he or she thinks about the app.

Keep bedrooms, mealtimes, and parent–child playtimes screen free for children and parents. Parents can set a “do not disturb” option on their phones during these times.

No screens 1 hour before bedtime, and remove devices from bedrooms before bed.

Consult the American Academy of Pediatrics Family Media Use Plan, available at: www.healthychildren.org/MediaUsePlan.

Industry

Work with developmental psychologists and educators to create design interfaces that are appropriate to child developmental abilities, that are not distracting, and that promote shared parent–child media use and application of skills to the real world. Cease making apps for children younger than 18 months until evidence of benefit is demonstrated.

Formally and scientifically evaluate products before making educational claims.

Make high-quality products accessible and affordable to low-income families and in multiple languages.

Eliminate advertising and unhealthy messages on apps. Children at this age cannot differentiate between advertisements and factual information, and therefore, advertising to them is unethical.

Help parents to set limits by stopping auto-advance of videos as the default setting. Develop systems embedded in devices that can help parents monitor and limit media use.
 
中文翻译:
本文地址:http://www.wjbb.com/know/1642
原文出处:http://pediatrics.aappublicati ... -2591 查看全部

 Abstract

Infants, toddlers, and preschoolers are now growing up in environments saturated with a variety of traditional and new technologies, which they are adopting at increasing rates. Although there has been much hope for the educational potential of interactive media for young children, accompanied by fears about their overuse during this crucial period of rapid brain development, research in this area still remains limited. This policy statement reviews the existing literature on television, videos, and mobile/interactive technologies; their potential for educational benefit; and related health concerns for young children (0 to 5 years of age). The statement also highlights areas in which pediatric providers can offer specific guidance to families in managing their young children’s media use, not only in terms of content or time limits, but also emphasizing the importance of parent–child shared media use and allowing the child time to take part in other developmentally healthy activities.
 
Introduction

Technologic innovation has transformed media and its role in the lives of infants and young children. More children, even in economically challenged households, are using newer digital technologies, such as interactive and mobile media, on a daily basis1 and continue to be the target of intense marketing. This policy statement addresses the influence of media on the health and development of children from 0 to 5 years of age, a time of critical brain development, building secure relationships, and establishing health behaviors.

Infants and Toddlers

Children younger than 2 years need hands-on exploration and social interaction with trusted caregivers to develop their cognitive, language, motor, and social-emotional skills. Because of their immature symbolic, memory, and attentional skills, infants and toddlers cannot learn from traditional digital media as they do from interactions with caregivers,and they have difficulty transferring that knowledge to their 3-dimensional experience.The chief factor that facilitates toddlers’ learning from commercial media (starting around 15 months of age) is parents watching with them and reteaching the content.

The interactivity of touchscreens enables applications (apps) to identify when a child responds accurately and then tailor its responses, thereby supporting children at their levels of competence. Emerging evidence shows that at 24 months of age, children can learn words from live video-chatting with a responsive adult or from an interactive touchscreen interface that scaffolds the child to choose the relevant answers. Starting at 15 months of age, toddlers can learn novel words from touchscreens in laboratory-based studies but have trouble transferring this knowledge to the 3-dimensional world. However, it should be noted that these experiments used specially designed apps that are not commercially available.

Many parents now use video-chat (eg, Skype, FaceTime) as an interactive media form that facilitates social connection with distant relatives. New evidence shows that infants and toddlers regularly engage in video-chatting, but the same principles regarding need for parental support would apply in order for infants and toddlers to understand what they are seeing.

In summary, for children younger than 2 years, evidence for benefits of media is still limited, adult interaction with the child during media use is crucial, and there continues to be evidence of harm from excessive digital media use, as described later in this statement.

Preschool Media and Learning

Well-designed television programs, such as Sesame Street, can improve cognitive, literacy, and social outcomes for children 3 to 5 years of age and continue to create programming that addresses evolving child health and developmental needs (eg, obesity prevention, resilience). Evaluations of apps from Sesame Workshop and the Public Broadcasting Service (PBS) also have shown efficacy in teaching literacy skills to preschoolers.Unfortunately, most apps parents find under the “educational” category in app stores have no such evidence of efficacy, target only rote academic skills, are not based on established curricula, and use little or no input from developmental specialists or educators. Most apps also generally are not designed for a dual audience (ie, both parent and child). It is important to emphasize to parents that the higher-order thinking skills and executive functions essential for school success, such as task persistence, impulse control, emotion regulation, and creative, flexible thinking, are best taught through unstructured and social (not digital) play,as well as responsive parent–child interactions.

Digital books (also called “eBooks,” books that can be read on a screen) often come with interactive enhancements that, research suggests, may decrease child comprehension of content or parent dialogic reading interactions when visual effects are distracting.Parents should, therefore, be instructed to interact with children during eBook reading, as they would a print book.

Health and Developmental Concerns

Obesity

Heavy media use during preschool years is associated with small but significant increases in BMI,18 may explain disparities in obesity risk in minority children,19 and sets the stage for weight gain later in childhood.Although many studies have used a 2-hour cutoff to examine obesity risk, a recent study of 2-year-olds found that BMI increased for every hour per week of media consumed.It is believed that exposure to food advertising and watching television while eating (which diminishes attention to satiety cues) drives these associations.

Sleep

Increased duration of media exposure and the presence of a television, computer, or mobile device in the bedroom in early childhood have been associated with fewer minutes of sleep per night.

Even infants exposed to screen media in the evening hours show significantly shorter night-time sleep duration than those with no evening screen exposure. Mechanisms underlying this association include arousing content and suppression of endogenous melatonin by blue light emitted from screens.

Child Development

Population-based studies continue to show associations between excessive television viewing in early childhood and cognitive,language,and social/emotional delays, likely secondary to decreases in parent–child interaction when the television is on37 and poorer family functioning in households with high media use. An earlier age of media use onset, greater cumulative hours of media use, and non-PBS content all are significant independent predictors of poor executive functioning in preschoolers.Content is crucial: experimental evidence shows that switching from violent content to educational/prosocial content results in significant improvement in behavioral symptoms, particularly for low-income boys.Notably, the quality of parenting can modify associations between media use and child development: one study found that inappropriate content and inconsistent parenting had cumulative negative effects on low-income preschoolers’ executive function, whereas warm parenting and educational content interacted to produce additive benefits.

Child characteristics also may influence how much media children consume: excessive television viewing is more likely in infants and toddlers with a difficult temperamentor self-regulation problems, and toddlers with social-emotional delays are more likely to be given a mobile device to calm them down.

Parental Media Use

Parents’ background television use distracts from parent–child interactions and child play.Heavy parent use of mobile devices is associated with fewer verbal and nonverbal interactions between parents and children and may be associated with more parent-child conflict. Because parent media use is a strong predictor of child media habits,reducing parental media use and enhancing parent–child interactions may be an important area of behavior change.

Conclusions: Clinical Implications

In summary, multiple developmental and health concerns continue to exist for young children using all forms of digital media to excess. Evidence is sufficient to recommend time limitations on digital media use for children 2 to 5 years to no more than 1 hour per day to allow children ample time to engage in other activities important to their health and development and to establish media viewing habits associated with lower risk of obesity later in life.In addition, encouraging parents to change to educational and prosocial content and engage with their children around technology will allow children to reap the most benefit from what they view.

As digital technologies become more ubiquitous, pediatric providers must guide parents not only on the duration and content of media their child uses, but also on (1) creating unplugged spaces and times in their homes, because devices can now be taken anywhere; (2) the ability of new technologies to be used in social and creative ways; and (3) the importance of not displacing sleep, exercise, play, reading aloud, and social interactions. Realistically, pediatric providers will need to know how to help parents find resources finding appropriate content, tools for monitoring or limiting child use, ideas for play or activities in which to engage rather than digital play, and how parents can limit their own media use (see HealthyChildren.org for examples); each of these can be built into the Family Media Use Plan (see the American Academy of Pediatrics guide to developing a plan at www.healthychildren.org/MediaUsePlan).

Recommendations

Pediatricians

Start the conversation early. Ask parents of infants and young children about family media use, their children’s use habits, and media use locations.

Help families develop a Family Media Use Plan (www.healthychildren.org/MediaUsePlan) with specific guidelines for each child and parent.

Educate parents about brain development in the early years and the importance of hands-on, unstructured, and social play to build language, cognitive, and social-emotional skills.

For children younger than 18 months, discourage use of screen media other than video-chatting.

For parents of children 18 to 24 months of age who want to introduce digital media, advise that they choose high-quality programming/apps and use them together with children, because this is how toddlers learn best. Letting children use media by themselves should be avoided.

Guide parents to resources for finding quality products (eg, Common Sense Media, PBS Kids, Sesame Workshop).

In children older than 2 years, limit media to 1 hour or less per day of high-quality programming. Recommend shared use between parent and child to promote enhanced learning, greater interaction, and limit setting.

Recommend no screens during meals and for 1 hour before bedtime.

Problem-solve with parents facing challenges, such as setting limits, finding alternate activities, and calming children.

Families

Avoid digital media use (except video-chatting) in children younger than 18 to 24 months.

For children ages 18 to 24 months of age, if you want to introduce digital media, choose high-quality programming and use media together with your child. Avoid solo media use in this age group.

Do not feel pressured to introduce technology early; interfaces are so intuitive that children will figure them out quickly once they start using them at home or in school.

For children 2 to 5 years of age, limit screen use to 1 hour per day of high-quality programming, coview with your children, help children understand what they are seeing, and help them apply what they learn to the world around them.

Avoid fast-paced programs (young children do not understand them as well), apps with lots of distracting content, and any violent content.

Turn off televisions and other devices when not in use.

Avoid using media as the only way to calm your child. Although there are intermittent times (eg, medical procedures, airplane flights) when media is useful as a soothing strategy, there is concern that using media as strategy to calm could lead to problems with limit setting or the inability of children to develop their own emotion regulation. Ask your pediatrician for help if needed.

Monitor children’s media content and what apps are used or downloaded. Test apps before the child uses them, play together, and ask the child what he or she thinks about the app.

Keep bedrooms, mealtimes, and parent–child playtimes screen free for children and parents. Parents can set a “do not disturb” option on their phones during these times.

No screens 1 hour before bedtime, and remove devices from bedrooms before bed.

Consult the American Academy of Pediatrics Family Media Use Plan, available at: www.healthychildren.org/MediaUsePlan.

Industry

Work with developmental psychologists and educators to create design interfaces that are appropriate to child developmental abilities, that are not distracting, and that promote shared parent–child media use and application of skills to the real world. Cease making apps for children younger than 18 months until evidence of benefit is demonstrated.

Formally and scientifically evaluate products before making educational claims.

Make high-quality products accessible and affordable to low-income families and in multiple languages.

Eliminate advertising and unhealthy messages on apps. Children at this age cannot differentiate between advertisements and factual information, and therefore, advertising to them is unethical.

Help parents to set limits by stopping auto-advance of videos as the default setting. Develop systems embedded in devices that can help parents monitor and limit media use.
 
中文翻译:
本文地址:http://www.wjbb.com/know/1642
原文出处:http://pediatrics.aappublicati ... -2591

美国儿科学会:婴儿床床围会增加婴儿死亡风险

豌豆爸爸 发表了文章 • 0 个评论 • 1067 次浏览 • 2015-12-04 09:42 • 来自相关话题

Researchers are calling for a nationwide ban on crib bumpers after finding they are linked to a growing number of infant deaths.

Twenty-three deaths related to crib bumpers were reported to the U.S. Consumer Product Safety Commission (CPSC) from 2006 through 2012, according to the report “Crib Bumpers Continue to Cause Infant Deaths: A Need for a New Preventive Approach.” Eight deaths were reported in each of the three previous seven-year periods.

“Crib bumpers are killing kids,” senior author Bradley T. Thach, M.D., professor emeritus of pediatrics at the Washington University School of Medicine, said in a news release. “Bumpers are more dangerous than we originally thought. The infant deaths we studied could have been prevented if the cribs were empty.”

There were 48 deaths related to crib bumpers from 1985 through 2012, most due to suffocation, according to a review of CPSC data detailed in the report (Scheers NJ, et al. J Pediatr. Nov. 24, 2015, www.sciencedirect.com/science/article/pii/S0022347615012846). In an additional 146 incidents, babies nearly suffocated or choked.

Researchers acknowledged the increase over previous years could be due in part to better reporting to CPSC but also said they believe the actual figures may be higher as they found additional bumper-related deaths when reviewing data from the National Center for the Review and Prevention of Child Deaths.

The Academy, the National Institutes of Health and the Centers for Disease Control and Prevention all recommend against bumpers, but there are no federal regulations regarding their use. Researchers, two of whom previously worked for the CPSC, said that agency would be responsible for instituting a ban, but it has limited resources.

“A ban on crib bumpers would reinforce the message that no soft bedding of any kind should be placed inside a baby's crib,” Dr. Thach said. "There is one sure-fire way to prevent infant deaths from crib bumpers: Don't use them, ever."
 
中文翻译:
本文地址:http://www.wjbb.com/know/1350
原文出处:http://www.aappublications.org ... 20215 查看全部

Researchers are calling for a nationwide ban on crib bumpers after finding they are linked to a growing number of infant deaths.

Twenty-three deaths related to crib bumpers were reported to the U.S. Consumer Product Safety Commission (CPSC) from 2006 through 2012, according to the report “Crib Bumpers Continue to Cause Infant Deaths: A Need for a New Preventive Approach.” Eight deaths were reported in each of the three previous seven-year periods.

“Crib bumpers are killing kids,” senior author Bradley T. Thach, M.D., professor emeritus of pediatrics at the Washington University School of Medicine, said in a news release. “Bumpers are more dangerous than we originally thought. The infant deaths we studied could have been prevented if the cribs were empty.”

There were 48 deaths related to crib bumpers from 1985 through 2012, most due to suffocation, according to a review of CPSC data detailed in the report (Scheers NJ, et al. J Pediatr. Nov. 24, 2015, www.sciencedirect.com/science/article/pii/S0022347615012846). In an additional 146 incidents, babies nearly suffocated or choked.

Researchers acknowledged the increase over previous years could be due in part to better reporting to CPSC but also said they believe the actual figures may be higher as they found additional bumper-related deaths when reviewing data from the National Center for the Review and Prevention of Child Deaths.

The Academy, the National Institutes of Health and the Centers for Disease Control and Prevention all recommend against bumpers, but there are no federal regulations regarding their use. Researchers, two of whom previously worked for the CPSC, said that agency would be responsible for instituting a ban, but it has limited resources.

“A ban on crib bumpers would reinforce the message that no soft bedding of any kind should be placed inside a baby's crib,” Dr. Thach said. "There is one sure-fire way to prevent infant deaths from crib bumpers: Don't use them, ever."
 
中文翻译:
本文地址:http://www.wjbb.com/know/1350
原文出处:http://www.aappublications.org ... 20215

美国儿科研究7大成就,你孩子受益了吗?

红太狼 发表了文章 • 0 个评论 • 655 次浏览 • 2015-05-06 10:20 • 来自相关话题

很多医学观念、技术在今天看起来稀疏平常,但事实上它们是研究人员花费大量心血和精力总结、研发出来的,医生们传播这些观念,使用这些技术,让千千万万的人因此受益,但我们不能忘记默默站在背后的研发人员。

最近,美国儿科学会评出过去40年儿科研究的七大成就,受益于这些成就的不仅仅是美国的孩子,还有世界各地的孩子,因为这些理念和技术也在世界范围内得到广泛推广和使用,我们一起看看是哪些:

一、疫苗接种预防疾病拯救了很多生命

轮状病毒腹泻是导致5岁以下儿童死亡的重要原因之一,B型流感嗜血杆菌(Hib)感染可导致肺炎、脑膜炎、会厌炎等问题。现在轮状病毒和B型流感嗜血杆菌(Hib)感染现在都可以通过疫苗来预防,在美国,轮状病毒疫苗接种使肠胃炎的发生率下降了86%,Hib疫苗接种使Hib感染下降了99%。

二、表面活性剂助早产儿呼吸

早产孩子因为肺发育不成熟,容易出现呼吸窘迫,在没有表面活性剂之前主要靠呼吸机帮助呼吸,但容易出现肺损伤之类并发症,很多孩子因呼吸衰竭死亡。有了表面活性剂后,早产儿能更早的自主呼吸,并发症降低了,死于呼吸窘迫综合征的孩子减少了三分之二。

三、仰卧减少婴儿猝死综合征(SIDS)

研究发现俯卧的婴儿猝死的风险是其它孩子的两倍,根据这一结论,从1994年开始,美国国家儿童健康与发展研究所和儿科学会等机构开始推动“仰卧”运动,每年死于婴儿猝死综合征的孩子从1993年的4700人下降到了2010年的2063人。

四、治愈一种儿童常见癌症

急性淋巴细胞白血病是儿童最常见的癌症,在1975年,15岁以下的孩子5年存活率为60%,15-19岁5年存活率只有28%,那时候确诊白血病往往意味着死亡,在过去的40年里,随着化疗的进步和规范,新确诊病例5年以上存活率达到了90%。

五、预防母婴传播HIV

HIV的危害不用多说,产前,产中,产后母乳喂养均可导致妈妈将HIV传染给孩子,传染率可高达40%,现在通过齐多夫定等药物治疗,母婴传播率降低到不足2%。

六、提高了慢性疾病儿童的预期寿命

镰状细胞病(由于血红蛋白异常导致红细胞呈镰状)和囊肿性纤维病(导致全身多器官囊肿性纤维化,主要是肺部和消化道更易受影响,白种人发病率较高)这样的遗传性疾病,40年前罹患这些疾病预期寿命大约14岁,随着新生儿早期筛查的普及及羟基脲这样的药物的出现,今天这些慢性病患者的预期寿命达40岁以上。

七、安全座椅和安全带救了很多孩子的命

发生车祸时,一岁以内的孩子,使用安全座椅死亡率可下降71%。和只使用安全带相比,1-4岁的孩子使用安全座椅受伤的风险下降54%,4-8岁的孩子风险下降45%。大孩子和成人使用安全带可减少大约50%的死亡和重伤。这些研究成果导致了强制使用安全座椅的法规出台,让死于车祸的儿童显著减少。

这些成就是美国取得的,很多国家很多孩子也受益于这些研究成果,但由于种种原因,这些现成的研究成果在我国并没有得到充分的利用,比如我们国产的轮状病毒疫苗保护率就远低于美国,1岁以内婴儿应该仰卧可能很多儿科医生也不知道,至今儿童安全座椅在国内一线城市的使用率还只有5%,直到今年深圳才开始强制4岁以下儿童乘车使用安全座椅...

了解这些知识,利用好这些技术,本可以让孩子受益、免受伤害。在大环境不能帮孩子充分利用科研成果时,作为家长也可以通过学习,自己做点事情,比如买个安全座椅,给自己孩子增加一份安全保障。
 
本文地址:http://www.wjbb.com/know/1063
原文出处:http://weibo.com/p/1001603839260842160529 查看全部

很多医学观念、技术在今天看起来稀疏平常,但事实上它们是研究人员花费大量心血和精力总结、研发出来的,医生们传播这些观念,使用这些技术,让千千万万的人因此受益,但我们不能忘记默默站在背后的研发人员。

最近,美国儿科学会评出过去40年儿科研究的七大成就,受益于这些成就的不仅仅是美国的孩子,还有世界各地的孩子,因为这些理念和技术也在世界范围内得到广泛推广和使用,我们一起看看是哪些:

一、疫苗接种预防疾病拯救了很多生命

轮状病毒腹泻是导致5岁以下儿童死亡的重要原因之一,B型流感嗜血杆菌(Hib)感染可导致肺炎、脑膜炎、会厌炎等问题。现在轮状病毒和B型流感嗜血杆菌(Hib)感染现在都可以通过疫苗来预防,在美国,轮状病毒疫苗接种使肠胃炎的发生率下降了86%,Hib疫苗接种使Hib感染下降了99%。

二、表面活性剂助早产儿呼吸

早产孩子因为肺发育不成熟,容易出现呼吸窘迫,在没有表面活性剂之前主要靠呼吸机帮助呼吸,但容易出现肺损伤之类并发症,很多孩子因呼吸衰竭死亡。有了表面活性剂后,早产儿能更早的自主呼吸,并发症降低了,死于呼吸窘迫综合征的孩子减少了三分之二。

三、仰卧减少婴儿猝死综合征(SIDS)

研究发现俯卧的婴儿猝死的风险是其它孩子的两倍,根据这一结论,从1994年开始,美国国家儿童健康与发展研究所和儿科学会等机构开始推动“仰卧”运动,每年死于婴儿猝死综合征的孩子从1993年的4700人下降到了2010年的2063人。

四、治愈一种儿童常见癌症

急性淋巴细胞白血病是儿童最常见的癌症,在1975年,15岁以下的孩子5年存活率为60%,15-19岁5年存活率只有28%,那时候确诊白血病往往意味着死亡,在过去的40年里,随着化疗的进步和规范,新确诊病例5年以上存活率达到了90%。

五、预防母婴传播HIV

HIV的危害不用多说,产前,产中,产后母乳喂养均可导致妈妈将HIV传染给孩子,传染率可高达40%,现在通过齐多夫定等药物治疗,母婴传播率降低到不足2%。

六、提高了慢性疾病儿童的预期寿命

镰状细胞病(由于血红蛋白异常导致红细胞呈镰状)和囊肿性纤维病(导致全身多器官囊肿性纤维化,主要是肺部和消化道更易受影响,白种人发病率较高)这样的遗传性疾病,40年前罹患这些疾病预期寿命大约14岁,随着新生儿早期筛查的普及及羟基脲这样的药物的出现,今天这些慢性病患者的预期寿命达40岁以上。

七、安全座椅和安全带救了很多孩子的命

发生车祸时,一岁以内的孩子,使用安全座椅死亡率可下降71%。和只使用安全带相比,1-4岁的孩子使用安全座椅受伤的风险下降54%,4-8岁的孩子风险下降45%。大孩子和成人使用安全带可减少大约50%的死亡和重伤。这些研究成果导致了强制使用安全座椅的法规出台,让死于车祸的儿童显著减少。

这些成就是美国取得的,很多国家很多孩子也受益于这些研究成果,但由于种种原因,这些现成的研究成果在我国并没有得到充分的利用,比如我们国产的轮状病毒疫苗保护率就远低于美国,1岁以内婴儿应该仰卧可能很多儿科医生也不知道,至今儿童安全座椅在国内一线城市的使用率还只有5%,直到今年深圳才开始强制4岁以下儿童乘车使用安全座椅...

了解这些知识,利用好这些技术,本可以让孩子受益、免受伤害。在大环境不能帮孩子充分利用科研成果时,作为家长也可以通过学习,自己做点事情,比如买个安全座椅,给自己孩子增加一份安全保障。
 
本文地址:http://www.wjbb.com/know/1063
原文出处:http://weibo.com/p/1001603839260842160529

美国儿科学会:近40年儿科研究七大成就

红太狼 发表了文章 • 1 个评论 • 1064 次浏览 • 2015-05-01 09:16 • 来自相关话题

Major achievements in pediatric research, often taken for granted, have been made possible with federal funding. A recent congressional briefing hosted by the AAP Committee on Pediatric Research highlighted discoveries from the last 40 years from the perspectives of researchers and families.
 From passenger safety laws to the use of surfactant to rotavirus vaccines, pediatric research innovations over the last four decades have led to life-saving discoveries and policy changes that many take for granted.

Despite the importance of these advancements, researchers don’t always do a good job explaining the impact of their work and how it saves lives, said Tina Cheng, M.D., M.P.H., FAAP, chair of the AAP Committee on Pediatric Research (COPR).
 
That’s one reason the committee hosted a congressional briefing in December to present to lawmakers “7 Great Achievements in Pediatric Research” (see sidebar). Researchers and family members impacted by the research spoke to a standing-room-only crowd, focusing on innovations in the members’ lifetimes.

The topics covered immunizations, pediatric cancer, saving premature infants, preventing HIV transmission from mothers to babies, reducing sudden infant death syndrome (SIDS), increasing life expectancy for children with chronic diseases, and saving lives with car seats and seat belts. Forty years ago some of these discoveries may have seemed like science fiction.
 
To help select the topics, COPR surveyed its members along with the boards of the American Pediatric Society, Academic Pediatric Association, Society for Pediatric Research, Federation of Pediatric Organizations and Association of Medical School Pediatric Department Chairs. The groups, along with the Academy, sponsored the briefing.

“We chose the seven because we felt like they were recent successes and they were successes that would resonate with the public,” said Dr. Cheng, who moderated the briefing.
 
SPEAKING FROM THE HEART

Researchers shared their perspectives, but when family members and young people offered their stories about how research changed their lives, it was even more powerful, said neonatologist Scott Denne, M.D., FAAP, past chair of COPR.

Tokunbo Olaniyan, of Columbia, Md., a young woman whose late mother had sickle cell disease, talked about how grateful she was that her mother lived to be old enough to give birth. Forty years ago, sickle cell patients in the United States typically lived to only about 14 years.
 
College student Vikram Siberry, of Olney, Md., told how a seatbelt saved him during a car accident in high school that took the life of his friend who was behind the wheel.

Dr. Denne also shared how the introduction of surfactant to treat premature babies has affected his professional life.

“The difference is as night-and-day as any intervention has ever been,” he said.

“Before surfactant, our primary tools were the ventilator, and premature babies were born and immediately struggled to breathe,” he told the group. “The ventilator caused substantial damage — major ruptures of the lung — so you had to put in chest tubes. Babies needed to stay on ventilators for prolonged periods. Many babies who left the nursery had significant lung disease, and many babies simply didn’t survive.

“A daily event was babies dying … multiple chest tubes being placed … a whole host of rooms dedicated for babies who were going to be on ventilators for months. That was the reality before surfactant,” Dr. Denne said.

Today, many babies come off ventilators more quickly, lung damage is significantly less severe and survival rates have increased substantially, he noted.
 
SIDS was addressed by Marian Willinger, Ph.D., director of the research program in SIDS at the Eunice Kennedy Shriver National Institute for Child Health and Human Development. Dr. Willinger, consultant to the AAP Task Force on SIDS, coordinated much of the research efforts on the Back to Sleep campaign. Since 1994, the overall U.S. SIDS rate has declined by more than half as a result of babies being placed on their backs to sleep.

The briefing included graphs and charts on topics such as the progress made in life expectancy for patients with sickle cell anemia and cystic fibrosis. One chart showed the steep drop in perinatally acquired AIDS in the early 1990s with the introduction of an antiretroviral medication.
 
IMPORTANCE OF FUNDING

All of the stories were designed to help lawmakers and others understand the ongoing need for federal research funding.

“It’s very important for the general public to understand how impactful investing in research can and has been,” said Dr. Denne, who said funding should be maintained or better yet, increased.

Although the seven achievements will be no surprise to any pediatrician, Dr. Cheng said they all are taken for granted sometimes and continued investment is needed.

“All of these discoveries were the result of research funding innovation that led to decreased mortality, increased life expectancy, increased quality of life. There are more research discoveries to be made.”
 
7 Great Achievements in Pediatric Research in the Past 40 Years

Preventing disease with life-saving immunizations
 
Diseases like rotavirus and Haemophilus influenzae type b are now preventable due to vaccines.

Saving premature babies by helping them breathe

Deaths from respiratory distress syndrome have been reduced by two-thirds with the introduction of surfactant.

Reducing sudden infant death syndrome (SIDS) with Back to Sleep

SIDS has declined by half due to research and the Back to Sleep campaign.

Curing a common childhood cancer

More than 90% of children with acute lymphocytic leukemia now survive, compared with 57% in the 1970s.

Preventing human immunodeficiency virus (HIV) transmission from mother to baby

Twenty years ago, one in four mothers with HIV transmitted HIV to their babies. Now the transmission rate is less than 2% due to advances in medications given during pregnancy.

Increasing life expectancy for children with chronic diseases

Life expectancy of patients with sickle cell disease or cystic fibrosis has risen from 14 years to more than 40 years.

Saving lives with car seats and seat belts

Research leading to vehicle safety laws has significantly reduced pediatric motor vehicle deaths.
 
AAP评出40年儿科研究七大成就:1.疫苗接种预防疾病。2.表面活性剂助早产儿呼吸。3.仰卧降低婴儿猝死综合征。4.治愈一种儿童常见癌症(急淋白血病存活率从70年代的57%上升到90%)5.阻断HIV母婴传播(降低至<2%)6.提高慢性疾病儿童预期寿命。7.安全座椅和安全带救了很多孩子性命。
 
中文翻译:
本文地址:http://www.wjbb.com/know/1049
原文出处:http://aapnews.aappublications ... .full 查看全部

Major achievements in pediatric research, often taken for granted, have been made possible with federal funding. A recent congressional briefing hosted by the AAP Committee on Pediatric Research highlighted discoveries from the last 40 years from the perspectives of researchers and families.
 From passenger safety laws to the use of surfactant to rotavirus vaccines, pediatric research innovations over the last four decades have led to life-saving discoveries and policy changes that many take for granted.

Despite the importance of these advancements, researchers don’t always do a good job explaining the impact of their work and how it saves lives, said Tina Cheng, M.D., M.P.H., FAAP, chair of the AAP Committee on Pediatric Research (COPR).
 
That’s one reason the committee hosted a congressional briefing in December to present to lawmakers “7 Great Achievements in Pediatric Research” (see sidebar). Researchers and family members impacted by the research spoke to a standing-room-only crowd, focusing on innovations in the members’ lifetimes.

The topics covered immunizations, pediatric cancer, saving premature infants, preventing HIV transmission from mothers to babies, reducing sudden infant death syndrome (SIDS), increasing life expectancy for children with chronic diseases, and saving lives with car seats and seat belts. Forty years ago some of these discoveries may have seemed like science fiction.
 
To help select the topics, COPR surveyed its members along with the boards of the American Pediatric Society, Academic Pediatric Association, Society for Pediatric Research, Federation of Pediatric Organizations and Association of Medical School Pediatric Department Chairs. The groups, along with the Academy, sponsored the briefing.

“We chose the seven because we felt like they were recent successes and they were successes that would resonate with the public,” said Dr. Cheng, who moderated the briefing.
 
SPEAKING FROM THE HEART

Researchers shared their perspectives, but when family members and young people offered their stories about how research changed their lives, it was even more powerful, said neonatologist Scott Denne, M.D., FAAP, past chair of COPR.

Tokunbo Olaniyan, of Columbia, Md., a young woman whose late mother had sickle cell disease, talked about how grateful she was that her mother lived to be old enough to give birth. Forty years ago, sickle cell patients in the United States typically lived to only about 14 years.
 
College student Vikram Siberry, of Olney, Md., told how a seatbelt saved him during a car accident in high school that took the life of his friend who was behind the wheel.

Dr. Denne also shared how the introduction of surfactant to treat premature babies has affected his professional life.

“The difference is as night-and-day as any intervention has ever been,” he said.

“Before surfactant, our primary tools were the ventilator, and premature babies were born and immediately struggled to breathe,” he told the group. “The ventilator caused substantial damage — major ruptures of the lung — so you had to put in chest tubes. Babies needed to stay on ventilators for prolonged periods. Many babies who left the nursery had significant lung disease, and many babies simply didn’t survive.

“A daily event was babies dying … multiple chest tubes being placed … a whole host of rooms dedicated for babies who were going to be on ventilators for months. That was the reality before surfactant,” Dr. Denne said.

Today, many babies come off ventilators more quickly, lung damage is significantly less severe and survival rates have increased substantially, he noted.
 
SIDS was addressed by Marian Willinger, Ph.D., director of the research program in SIDS at the Eunice Kennedy Shriver National Institute for Child Health and Human Development. Dr. Willinger, consultant to the AAP Task Force on SIDS, coordinated much of the research efforts on the Back to Sleep campaign. Since 1994, the overall U.S. SIDS rate has declined by more than half as a result of babies being placed on their backs to sleep.

The briefing included graphs and charts on topics such as the progress made in life expectancy for patients with sickle cell anemia and cystic fibrosis. One chart showed the steep drop in perinatally acquired AIDS in the early 1990s with the introduction of an antiretroviral medication.
 
IMPORTANCE OF FUNDING

All of the stories were designed to help lawmakers and others understand the ongoing need for federal research funding.

“It’s very important for the general public to understand how impactful investing in research can and has been,” said Dr. Denne, who said funding should be maintained or better yet, increased.

Although the seven achievements will be no surprise to any pediatrician, Dr. Cheng said they all are taken for granted sometimes and continued investment is needed.

“All of these discoveries were the result of research funding innovation that led to decreased mortality, increased life expectancy, increased quality of life. There are more research discoveries to be made.”
 
7 Great Achievements in Pediatric Research in the Past 40 Years

Preventing disease with life-saving immunizations
 
Diseases like rotavirus and Haemophilus influenzae type b are now preventable due to vaccines.

Saving premature babies by helping them breathe

Deaths from respiratory distress syndrome have been reduced by two-thirds with the introduction of surfactant.

Reducing sudden infant death syndrome (SIDS) with Back to Sleep

SIDS has declined by half due to research and the Back to Sleep campaign.

Curing a common childhood cancer

More than 90% of children with acute lymphocytic leukemia now survive, compared with 57% in the 1970s.

Preventing human immunodeficiency virus (HIV) transmission from mother to baby

Twenty years ago, one in four mothers with HIV transmitted HIV to their babies. Now the transmission rate is less than 2% due to advances in medications given during pregnancy.

Increasing life expectancy for children with chronic diseases

Life expectancy of patients with sickle cell disease or cystic fibrosis has risen from 14 years to more than 40 years.

Saving lives with car seats and seat belts

Research leading to vehicle safety laws has significantly reduced pediatric motor vehicle deaths.
 
AAP评出40年儿科研究七大成就:1.疫苗接种预防疾病。2.表面活性剂助早产儿呼吸。3.仰卧降低婴儿猝死综合征。4.治愈一种儿童常见癌症(急淋白血病存活率从70年代的57%上升到90%)5.阻断HIV母婴传播(降低至<2%)6.提高慢性疾病儿童预期寿命。7.安全座椅和安全带救了很多孩子性命。
 
中文翻译:
本文地址:http://www.wjbb.com/know/1049
原文出处:http://aapnews.aappublications ... .full

抗生素和儿童上感,家长应该知道什么?

红太狼 发表了文章 • 0 个评论 • 651 次浏览 • 2015-03-31 23:54 • 来自相关话题

很多人反应上篇临床指南太专业,读不懂。这种指南本来就是给医生看的,家长读不懂是正常的。之所以选择找人翻译这篇指南,是因为儿童上呼吸道感染太常见了,很多孩子因为普通感冒而被用了抗菌素,美国也是如此,中国更如此。

既然这个账号的主要读者孩子家长,为充分利用资源,我就把这篇指南把里一些对家长有意义的知识,结合我们的国情解读一下分享给大家。

不要自行给孩子吃抗生素

任何一个药,给孩子吃之前都要分析一下,这个药会会给孩子什么好处,会带来什么坏处。这个分析的基础是对孩子病情有正确的判断,对药物的作用和副作用有充分的了解,如果你对病情判断不清,对药品不了解,就不要随便给孩子吃药,抗生素这样的处方药更是如此。

和其他国家一样,抗菌素在我国也是处方药,但显然管理不那么规范,没有处方上药店也常常能买到,很多家庭都常备着抗生素。孩子一生病家长就心急如焚,胡乱给孩子吃抗生素很常见,总觉得吃点药总比不吃强,也不管是不是细菌感染,也不知道吃的药有什么作用,可能会有什么危害。

上呼吸道感染,大部分是病毒感染引起的,不是细菌感染的话吃抗生素对病情没有任何作用,浪费钱不说,反而可能出现过敏、腹泻等问题,孩子期间接触抗生素还会对健康造成长期影响,导致如炎症性肠病、肥胖、湿疹和哮喘等风险增大。学医这么多年的医生,也经常判断不准,然后用错药,没有医学基础的家长更没法判断准确,用错药更是难免,爱子/女之心+焦虑+无知=害了孩子。

该用抗生素的时候要用

因为抗生素的滥用,有些家长又从一个极端走向了另外一个极端,谈抗生素色变,不管什么情况,哪怕真的细菌感染,医生开的抗生素也不给孩子吃,工作中也常碰到这样的家长。

抗生素虽然有副作用,但自青霉素发明以来,抗生素已拯救了无数人的生命,正如这篇指南里也列举了一些情况,使用正确的话,抗生素是利大于弊的。病情需要用的时候如果不用,就可能延误病情,最后吃亏的还是自己孩子。哪些情况要用,要由医生来决定,不是靠家长自己凭直觉凭感情来决定用不用。

医生乱开药怎么办

抗生素是处方药,应该由医生来决定用不用,但医生滥开抗生素也是不争的事实,正如这篇指南里所说,即便在美国,每年为治疗呼吸系统疾病开出没有治疗意义的抗生素处方达上千万份之多,中国肯定远不止这个数字。

滥用的原因有很多,有客观的也有主观的,有时是病情复杂,很难判断是细菌性还是病毒性感染,有时可能和也医生水平有关,对疾病和药品了解不够深入,当然有时候也是因为医生自己的利益。

任何医学临床指南里对一个药物使用的效益和风险分析,都是从患者角度出发,但在现实里,医生做医疗选择的时候难免也会权衡一下自己的利益。在医患关系紧张的环境下,当自己医疗决策可能影响到自己的人身安全时,为避免漏诊误诊带来的病情延误,医生很可能更愿意选择更积极的治疗,把可疑的细菌感染当细菌感染来治疗,让自己安心一点。另外在我国以药养医的医疗体制下,诊疗费用低廉,医院和医生要靠药品来维持收入,当然也更容易导致药物的滥用。

抗生素自己不能乱吃,上医院遇到医生乱开药,这是患者无法改变的现实,所能做的是找到更值得信任的医院和医生。国内的教材、指南和发达国家相比明显落后,医生学习更新知识途径很有限,这也是我找人翻译这些指南的一个原因,并不是因为什么情怀,而是因为付费阅读有了一些收入,我可以拿部分钱用这种方式回馈大家,同时可以丰富一下这个账号的内容,利人利己。

了解上感相关常识

因为儿童上呼吸道感染很常见,家长经常要面对,所以了解一些相关知识,还是会很有帮助。比如这篇指南里提到的:感冒流鼻涕持续10天以上要考虑鼻窦炎,应该找医生去检查;鼻窦炎诊断不需要常规拍片或者做CT、磁共振;普通感冒、急性支气管炎这些大家经常听到的病等是病毒感染,治疗是以缓解症状为主,不需要用抗生素;阿齐霉素不是治疗任何儿童上呼吸道感染的一线抗生素。等等...了解得越多,自己乱用药的可能性就越低,孩子也更安全。

以上大概是这篇指南对家长们的意义,另外指南里有个总结表,精简得很好,在微博贴过,但制图有点粗糙,重新制图贴在这里,有兴趣的可以看看。



本文地址:http://www.wjbb.com/know/1021
原文出处:http://weibo.com/p/1001593826179411943808 查看全部

很多人反应上篇临床指南太专业,读不懂。这种指南本来就是给医生看的,家长读不懂是正常的。之所以选择找人翻译这篇指南,是因为儿童上呼吸道感染太常见了,很多孩子因为普通感冒而被用了抗菌素,美国也是如此,中国更如此。

既然这个账号的主要读者孩子家长,为充分利用资源,我就把这篇指南把里一些对家长有意义的知识,结合我们的国情解读一下分享给大家。

不要自行给孩子吃抗生素

任何一个药,给孩子吃之前都要分析一下,这个药会会给孩子什么好处,会带来什么坏处。这个分析的基础是对孩子病情有正确的判断,对药物的作用和副作用有充分的了解,如果你对病情判断不清,对药品不了解,就不要随便给孩子吃药,抗生素这样的处方药更是如此。

和其他国家一样,抗菌素在我国也是处方药,但显然管理不那么规范,没有处方上药店也常常能买到,很多家庭都常备着抗生素。孩子一生病家长就心急如焚,胡乱给孩子吃抗生素很常见,总觉得吃点药总比不吃强,也不管是不是细菌感染,也不知道吃的药有什么作用,可能会有什么危害。

上呼吸道感染,大部分是病毒感染引起的,不是细菌感染的话吃抗生素对病情没有任何作用,浪费钱不说,反而可能出现过敏、腹泻等问题,孩子期间接触抗生素还会对健康造成长期影响,导致如炎症性肠病、肥胖、湿疹和哮喘等风险增大。学医这么多年的医生,也经常判断不准,然后用错药,没有医学基础的家长更没法判断准确,用错药更是难免,爱子/女之心+焦虑+无知=害了孩子。

该用抗生素的时候要用

因为抗生素的滥用,有些家长又从一个极端走向了另外一个极端,谈抗生素色变,不管什么情况,哪怕真的细菌感染,医生开的抗生素也不给孩子吃,工作中也常碰到这样的家长。

抗生素虽然有副作用,但自青霉素发明以来,抗生素已拯救了无数人的生命,正如这篇指南里也列举了一些情况,使用正确的话,抗生素是利大于弊的。病情需要用的时候如果不用,就可能延误病情,最后吃亏的还是自己孩子。哪些情况要用,要由医生来决定,不是靠家长自己凭直觉凭感情来决定用不用。

医生乱开药怎么办

抗生素是处方药,应该由医生来决定用不用,但医生滥开抗生素也是不争的事实,正如这篇指南里所说,即便在美国,每年为治疗呼吸系统疾病开出没有治疗意义的抗生素处方达上千万份之多,中国肯定远不止这个数字。

滥用的原因有很多,有客观的也有主观的,有时是病情复杂,很难判断是细菌性还是病毒性感染,有时可能和也医生水平有关,对疾病和药品了解不够深入,当然有时候也是因为医生自己的利益。

任何医学临床指南里对一个药物使用的效益和风险分析,都是从患者角度出发,但在现实里,医生做医疗选择的时候难免也会权衡一下自己的利益。在医患关系紧张的环境下,当自己医疗决策可能影响到自己的人身安全时,为避免漏诊误诊带来的病情延误,医生很可能更愿意选择更积极的治疗,把可疑的细菌感染当细菌感染来治疗,让自己安心一点。另外在我国以药养医的医疗体制下,诊疗费用低廉,医院和医生要靠药品来维持收入,当然也更容易导致药物的滥用。

抗生素自己不能乱吃,上医院遇到医生乱开药,这是患者无法改变的现实,所能做的是找到更值得信任的医院和医生。国内的教材、指南和发达国家相比明显落后,医生学习更新知识途径很有限,这也是我找人翻译这些指南的一个原因,并不是因为什么情怀,而是因为付费阅读有了一些收入,我可以拿部分钱用这种方式回馈大家,同时可以丰富一下这个账号的内容,利人利己。

了解上感相关常识

因为儿童上呼吸道感染很常见,家长经常要面对,所以了解一些相关知识,还是会很有帮助。比如这篇指南里提到的:感冒流鼻涕持续10天以上要考虑鼻窦炎,应该找医生去检查;鼻窦炎诊断不需要常规拍片或者做CT、磁共振;普通感冒、急性支气管炎这些大家经常听到的病等是病毒感染,治疗是以缓解症状为主,不需要用抗生素;阿齐霉素不是治疗任何儿童上呼吸道感染的一线抗生素。等等...了解得越多,自己乱用药的可能性就越低,孩子也更安全。

以上大概是这篇指南对家长们的意义,另外指南里有个总结表,精简得很好,在微博贴过,但制图有点粗糙,重新制图贴在这里,有兴趣的可以看看。



本文地址:http://www.wjbb.com/know/1021
原文出处:http://weibo.com/p/1001593826179411943808

美国儿科学会指南—儿童上呼吸道感染合理使用抗生素原则

红太狼 发表了文章 • 0 个评论 • 1324 次浏览 • 2015-03-27 22:59 • 来自相关话题

Adam L. Hersh, MD, PhD, Mary Anne Jackson, MD, Lauri A. Hicks, DO, and the COMMITTEE ON INFECTIOUS DISEASES

关键词

respiratory tract infections, antibacterial agents

呼吸道感染,抗菌剂

缩写词

AAP—美国儿科学会(American Academy of Pediatrics)

AOM—急性中耳炎(acute otitis media)

GAS—A群链球菌(group A Streptococcus)

NNT—防止1例不良事件发生或得到1例有利结果需要治疗的病例数(number needed to treat)

PTA—扁桃体周围脓肿(peritonsillar abscess)

TM—鼓膜(tympanic membrane)

URI—上呼吸道感染(upper respiratory tract infection)

摘要

大多数上呼吸道感染是由病毒引起,不需要使用抗生素治疗。本临床报告主要介绍了处方抗生素治疗细菌性上呼吸道感染(包括急性中耳炎、急性细菌性鼻窦炎和链球菌性咽炎等)时的策略。本文概述了合理使用抗生素的原则,侧重于运用严格的诊断标准,权衡抗生素治疗的效益和危害,并了解哪些情况不宜使用抗生素。这些原则可用于宣传近期的临床指南,有助于制定本地指南及与患者沟通;也广泛地适用于日常抗生素使用。

《儿科学》Pediatrics 2013;132:1146–1154

引言

在儿科门诊中,超过1/5的患儿会被医生处方抗生素。在美国,医生们每年开具的抗生素处方达近5000万份。1大量资料显示,抗生素处方不当在门诊中十分常见,在治疗病毒导致的上呼吸道感染(URI)时尤其如此。1–3每年,为治疗呼吸系统疾病而开具,却无法提供任何治疗效益的抗生素处方达上千万份之多。1最近的证据表明,广谱抗生素处方有所增加,且频繁发生在无需治疗或适用窄谱抗生素之时。1,2此类抗生素滥用会导致本可以避免的药物相关性不良事件4-6和抗生素耐药性,7,8增加不必要的医疗费用。正在研发中的可治疗抗生素耐药性感染的药物很少,进一步加剧了上述情况。9抗生素耐药性日益严重的健康和经济威胁促使医生合理地处方抗生素,在减少滥用的同时确保处方适当的药物,这也是保障公众健康和患者安全的当务之急。(http://www.cdc.gov/drugresista ... t-2013)。

对于为儿童提供医护服务的门诊医师和其他医务人员而言,每天都需要就是否为存在URI症状的患者处方抗生素做出临床决策。虽然抗生素处方是临床医护的常规组成部分,但合理使用抗生素绝非易事,这是因为病毒性与细菌性URI往往难以区分。本临床报告的主要目的在于提供使用抗生素治疗小儿URI的临床决策原则。需要强调的一点是:临床指南指出,在诊断急性中耳炎(AOM)、急性细菌性鼻窦炎和A群链球菌(GAS)引起的咽炎时,使用严格且经过验证的临床标准十分重要。此外,本文还强调了不适用抗生素的情况(尤其是病毒性呼吸道感染)。考虑到URI十分常见,且大多抗生素处方是为治疗URI而开具,因此,以优化抗生素处方为目的的指南和其他干预措施对此类疾病有较大影响。谨慎应用这些标准将可能减少小儿URI中的抗生素滥用。

抗生素耐药菌的出现和扩散引起了人们的担忧,为此1998年发布了第一版《儿童上呼吸道感染合理使用抗生素原则》(“Principles of Judicious Use of Antimicrobial Agents for Pediatric Upper Respiratory Tract Infections”)。10美国疾病预防控制中心(CDC)与美国儿科学会(APP)合作,力求根据现状更新上述原则。抗生素耐药性仍是重大的公共卫生问题,适当地使用抗生素是保障医疗服务质量的重要目标。虽然2000年7-价肺炎球菌多糖-蛋白结合疫苗(PCV7)的推出使侵袭性肺炎球菌感染发生率的大幅下降,11但由于无相应疫苗的血清型流行率有所增加(以血清型19A,一种常见的抗生素耐药性血清型最为明显),12,13科学家们在2010年推出了13-价肺炎球菌多糖-蛋白结合疫苗(PCV13)。医务人员担心抗生素耐药性是导致人们越来越多地使用广谱抗生素的一个原因。近年来发表了若干高质量的随机对照试验、荟萃分析以及最新或更新后的临床指南,更好地定义了使用抗生素治疗某些特定URI(包括AOM和急性细菌性鼻窦炎)的疗效。14–23与此同时,新出现的证据着重显示了抗生素导致的需要医疗照护的不良事件4-6以及可能危及生命的事件24,25。

本临床报告侧重于几种重要的小儿URI:AOM、急性细菌性鼻窦炎和咽炎,在特定情况下,抗生素可能有益于这些疾病的治疗。这些建议适用于健康的儿童,他们无潜在的内科疾病(如免疫抑制),因此发生严重并发症的风险不大。本报告的目的在于向医务人员介绍应在何种情况下使用最新的建议、指南以及“合理使用抗生素三原则”:(1)确定细菌感染的可能性;(2)权衡抗生素的效益和危害;(3)实施合理的处方策略。

原则一:确定细菌感染的可能性

细菌性URI的临床病史、症状和体征中有许多方面与病毒性感染或非传染病重叠或类似,要做出使用抗生素的合理决策,首先必须确定细菌感染的可能性。当医生确诊病毒感染,并合理地排除并发细菌感染时,不应使用抗生素,因为此时潜在危害远远大于潜在效益。对于AOM、急性细菌性鼻窦炎或咽炎的具体病例,可使用现有的完善且行之有效的严格标准来区分细菌性与非细菌性病因。

急性中耳炎(AOM)

2013年,AAP和美国家庭医师学会(American Academy of Family Physicians)发布了更新后的AOM诊断和治疗临床实践指南。22AOM的定义为:“中耳炎症状和体征的快速发作。”上述体征包括伴有或不伴有红斑的鼓膜(TM)膨出,症状可能包括耳痛、烦躁、耳漏和发热等。诊断AOM往往需要仔细的耳镜检查,以确认存在TM炎性改变。AAP指南建议,在以下任何一种情况下医生都可以确诊AOM:(1)有证据表明存在中耳积液(TM中度到重度膨出);或(2)不能归因于外耳道炎的新发耳漏。如果患儿仅出现轻度TM膨出,但伴有最近发生的耳部疼痛或TM严重红斑,也可以确诊AOM。由于清晰地观察TM可能有困难,且AOM通常是自限性疾病,为了尽量减少抗生素滥用,必须确保诊断的高度准确性。在确诊AOM后,根据疾病的严重程度(严重耳痛,耳痛持续>48小时,或体温≥39°C)、感染的偏侧性(双侧与单侧)、以及年龄(≤23个月和≥24个月)对患者进行分类将有助于合理地使用抗生素。症状严重、双侧受累且年龄较小的患者更可能受益于抗生素。对于年龄稍大、病情不严重且为单侧发病的患者,随访观察是较为合理的处置。

急性细菌性鼻窦炎

AAP23和美国传染病协会(Infectious Diseases Society of America)21近期制定了诊断和治疗急性细菌性鼻窦炎的循证临床指南。该指南支持使用严格的诊断标准来区分细菌性与病毒性URI。具体来说,诊断急性细菌性鼻窦炎应基于如下症状:(1)持续且无好转,(2)恶化,或(3)严重。持续性症状最为常见,包括流涕(任何性质)或持续10天未有好转的日间咳嗽。症状恶化包括恶化或新发发热、日间咳嗽或在典型病毒性URI好转之后流涕。严重症状包括持续发热(体温≥39°C)和流脓涕至少3天。这些临床标准是诊断急性细菌性鼻窦炎的基础。由于许多患有病毒性URI的儿童存在影像学异常,不应常规进行影像学检查。

急性咽炎

咽炎或咽痛可伴有其他非特异性症状,包括咳嗽、鼻塞、发热等。考虑诊断的最重要的因素为:是否是β-溶血性GAS引起。与AOM和急性细菌性鼻窦炎不同,GAS感染可通过实验室化验(快速抗原检测或培养)确诊。26,27评分系统(改良Centor或McIsaac评分28)有助于识别哪些人需要接受测试。存在以下2个或更多特征的患者应接受测试:(1)无咳嗽,(2)扁桃体有渗出物或肿胀,(3)发热史,(4)颈前淋巴结肿胀和触痛,(5)年龄小于15岁。存在URI症状和体征,包括咳嗽、鼻塞、结膜炎、声音嘶哑、腹泻或口咽部病变(溃疡、起泡)的患儿更可能患有病毒性疾病而非GAS感染,不应接受GAS测试。由于3岁以下儿童中风湿热较为罕见,且GAS一般不会引起咽炎,通常不应对他们进行测试。除极少数例外情况(例如,症状明确且与已确诊GAS咽炎的家庭成员有接触)之外,即使患者满足所有上述临床标准,未经测试也不应做出GAS诊断。即使在无症状的儿童中,细菌定植率也可达到15%到20%,这进一步显示了采用适当的临床标准并限制测试的重要性。

普通感冒、非特异性URI、急性咳嗽性疾病和急性支气管炎

普通感冒、非特异性URI、急性咳嗽性疾病和急性支气管炎的症状可能与细菌性URI重叠或相似,可包括咳嗽、鼻塞和咽痛等。总的来说,每年都有数以百万人次因这些病毒性疾病就诊。尤其是急性支气管炎,每年有超过200万人次因这种咳嗽性疾病到儿科就诊,70%以上的情况下医生都会处方抗生素。1AOM、鼻窦炎和咽炎的临床诊断可有助于临床医生排除上述疾病。普通感冒、非特异性URI、急性咳嗽性疾病和急性支气管炎的管理应侧重于缓解症状。不应处方抗生素来治疗这些疾病。

原则二:权衡抗生素的效益与危害

如果发现患者可能是细菌感染,下一步应比较抗生素治疗各种疾病的效益和潜在危害。需要考虑的效益相关预后包括:治愈率,症状减少,并发症和继发病例的预防。危害相关预后包括:抗生素相关性不良事件(如腹痛、腹泻、皮疹等),艰难梭菌性结肠炎,耐药性的产生以及费用等。

AOM效益

自从发布第一版合理使用抗生素原则以来,发表了若干项高质量的随机对照试验和荟萃分析。18–20,29–33总体而言,它们都强调了以下几点:(1)至少有一半的AOM患者无需抗生素治疗就可康复;(2)与安慰剂相比,接受抗生素治疗的儿童更可能康复或加速康复;(3)对于较为年幼,或患有双侧(而非单侧疾病),又或者是症状和体征较为严重的儿童,无抗生素治疗时较难康复。这些观察结果为AOM的治疗建议提供了理论依据。

多项荟萃分析表明,与安慰剂相比,接受抗生素治疗的儿童更容易实现临床症状缓解,防止1例不良事件发生或得到1例有利结果需要治疗的病例数(NNT)为7或8。18,33最近的两项在幼儿中进行、并采用了较严格的诊断标准的随机对照试验表明,与接受安慰剂的儿童相比,接受抗生素治疗的儿童症状评分较优,症状康复更快,且临床失败率(以耳镜检查和症状持续为标准衡量)显著较低,其NNT接近于4。19,20然而,请务必注意,大量关于抗生素治疗AOM效果的研究中,无论接受治疗与否,大多数患者的症状最后都会自发缓解,且不会出现并发症。临床上决定使用抗生素治疗AOM,在某种程度上是因为它们可能有助于预防并发症,如乳突炎等。然而,在上述对照研究和荟萃分析中,抗生素在预防这些罕见但严重的并发症方面并未显示出显著效益。英国对超过100万例AOM发作的观测数据表明,乳突炎(如果发生的话)通常在初次临床就诊时出现。34预防一例乳突炎发作的估算NNT为近5000。34

AAP建议对根据临床诊断标准确诊的AOM患儿行抗生素治疗。对于特定的患儿,尤其是症状不严重、单侧发病的2岁以上儿童,可以考虑观察。

急性细菌性鼻窦炎效益

有关抗生素治疗小儿急性细菌性鼻窦炎疗效的循证评估数量有限,且结果不一。有三项随机对照试验评估了与安慰剂相比,抗生素治疗临床确诊的急性细菌性鼻窦炎患儿的疗效,其中有两项是在1998年版合理使用抗生素原则发布后发表的。14,17,35两项试验的结论表明,在3天和14天后,抗生素组的症状缓解率均较高,14,35但一项研究显示抗生素并不优于安慰剂。17这些研究设计间的重大差异可能是造成其结果不同的一个原因:显示抗生素有益的试验纳入了症状较为严重的患者,并采用了更严格的诊断标准。这强调了临床诊断务必谨慎,因为对于不符合急性细菌性鼻窦炎诊断标准的患者,抗生素无任何临床效益。

抗生素预防化脓性并发症,如眶蜂窝组织炎或颅内脓肿的效益尚未得到证实。个别药效试验的统计学效力不足以证明抗生素对这些罕见并发症的疗效,一项对儿童和成年人随机对照试验的荟萃分析发现,抗生素的使用与并发症的发生率之间无显著相关性。36

AAP建议向存在急性细菌性鼻窦炎的临床特征,尤其是症状严重或有所恶化的患者行抗生素治疗。对于症状持续(>10天)者,可考虑观察加密切随访或抗生素治疗。

GAS咽炎效益

现有研究从症状缓解、传播、预防并发症(如风湿热)等方面评估了抗生素治疗急性咽炎的疗效。五项随机对照研究和一项荟萃分析审查了立即抗生素治疗对症状缓解情况的影响,其中一项于第一版合理使用抗生素原则发布之后完成。37–41这些研究提供了强有力的证据,表明采用抗生素治疗小儿咽炎和已确诊的GAS,可将咽痛、头痛等症状的持续时间缩短约1天。这些效益在短短3天内就十分明显。然而,抗生素治疗对缩短发热时间的效果尚不确定。尽管现有数据有限,但抗生素治疗GAS先证者(index cases)可能会减少水平传播,从而防止继发病例的产生。40,42在大家庭、托儿所、学校和军事环境中,这种效益尤为重要。

从历史上看,处方抗生素治疗GAS咽炎的主要动机是预防风湿热。1975年前在儿童中进行的多项随机对照试验显示,抗生素预防风湿热发作的效益是不治疗的四倍(风湿热在未经治疗的患者中的发生率约为3%)。43虽然近几十年来发生过几次风湿热局部爆发,但在大多数发达国家中其发病率已经大幅度下降。44这种下降的部分原因是诊断识别的改善和抗生素治疗,45但更可能与致风湿病性GAS菌株的流行率下降有关。46

抗生素对于GAS咽炎相关的化脓性并发症,如扁桃体周围脓肿(PTA)、AOM和急性鼻窦炎也有一定的预防作用。一项荟萃分析表明,抗生素治疗可以预防PTA;然而,该分析中的大多数病例都来自1951年的一项研究。43英国一个大型观察队列的数据表明,抗生素治疗可预防PTA的发生,但NNT>4000。47

AAP建议对确诊GAS咽炎的患儿行抗生素治疗。

普通感冒、非特异性URI、急性咳嗽性疾病和急性支气管炎

这些疾病的主要病因是病毒,因此不适用抗生素治疗。由于小儿急性支气管炎的诊断意义尚不确定,相关数据有限。然而,一项大型荟萃分析得出结论:抗生素治疗(包括延迟处方)无益于非特异性咳嗽和感冒患者。48

抗生素治疗的危害

在使用抗生素治疗URI时,考虑其可能造成的危害至关重要。应针对每个病例的具体情况,对潜在危害和潜在效益加以权衡。抗生素相关危害的重要性与以下内容直接相关:(1)评估潜在效益的程度(如,治疗双侧AOM幼儿的效益优于单侧患儿);(2)诊断不确定性的程度。就缓解症状而言,表明抗生素有益于治疗细菌性URI的证据占数量优势。当无法确定URI是否由急性细菌感染引起时,使用抗生素的危害通常会大于效益。采用严格的临床标准来确诊细菌感染有助于将其与小儿非特异性URI和普通感冒相区别。处方抗生素一般无益于治疗非特异性URI和感冒,只可能给这些患儿带来潜在危害。

抗生素是儿童因药物相关不良事件意外就诊的最大原因,每年此类就诊就超过150,000人次,并导致了巨大的潜在发病和费用。4抗生素相关不良事件的程度从轻微(腹泻和皮疹)、严重(Stevens-Johnson综合征)、到危及生命(过敏症或心源性猝死)不等。大多数评估抗生素治疗AOM、鼻窦炎和咽炎效果的临床试验使用的是阿莫西林或阿莫西林-克拉维酸,这些药物仍然是使用抗生素治疗这些疾病时推荐的一线药物。比较抗生素与安慰剂治疗AOM效果的研究表明,在接受治疗的患者中,不良事件(尤其是腹泻和皮疹)率略有增加。两项荟萃分析估算出不良事件率之差约为5%。18,32有两项使用阿莫西林-克拉维酸(以往研究常使用阿莫西林)的近期试验未纳入上述分析。在这两项试验中,接受抗生素治疗的患者的腹泻和皮炎率还要更高。19,20大多数近期进行的表明抗生素治疗鼻窦炎效益的试验中,接受高剂量阿莫西林-克拉维酸治疗的患者中不良事件(定义为皮疹、腹泻、呕吐和腹痛)发生率为44%,相比之下,在安慰剂组中为14%。14

前述不良事件较为常见,但大多数病例都比较轻微。抗生素也可产生严重的过敏反应,如Stevens-Johnson综合征等。25越来越多的证据表明,幼年接触抗生素可能会扰乱肠道及身体其它部位的微生物平衡,从而对健康造成长期不良影响,如炎症性肠病、肥胖、湿疹和哮喘等。49–51最近的一项研究强调了接受阿奇霉素治疗的成年人存在猝死风险,这可能与药物相关性QT间期延长有关。24阿齐霉素并非治疗任何小儿URI的一线抗生素,且它最有可能被不当使用(不能有效地针对引起AOM和鼻窦炎的最常见病原体)。1在过去十年中,住院患儿的艰难梭菌性结肠炎发生率大幅提高。52虽然存在合并症的患儿风险最大,但由于最近抗生素暴露已成为重大风险因素,社区获得性感染也时有发生。53

在个别患者和社区层面上,抗生素暴露与抗生素耐药性的发生间的关联均已得到公认。7,8由于治疗方案有限,抗生素耐药性感染难以治疗,而且在某些病例中,其与临床预后不良相关。54无论在个人和社区层面上,应用严格的诊断标准,在确诊且存在明确的潜在效益时再使用抗生素治疗,对于最大程度地减少抗生素滥用对耐药性的影响至关重要。

原则三:实施合理的处方策略

当有证据表明抗生素的效益时,应从几个方面考虑合理地处方:针对最可能的病原体选择适当的抗生素药物(也要考虑到当地的耐药模式),选择适当的剂量,在满足治疗需要的前提下尽可能地缩短治疗持续时间。此外,医生还应考虑观察和利用延迟处方策略的作用。AOM和急性细菌性鼻窦炎的治疗说明了合理使用抗生素的几个关键环节。由于肺炎链球菌(Streptococcus pneumoniae)是这些疾病最重要的病因,所以传统上建议使用阿莫西林作为一线治疗药物。然而,在某些社区中,细菌性URI中耐阿莫西林的产β-内酰胺酶流感嗜血杆菌(Haemophilus influenzae)的流行率显著增加。55这(从一定程度上)表明,在特定情况下(如症状严重,近期[<6周]抗生素暴露,当地耐阿莫西林流感嗜血杆菌的流行率较高等),应考虑使用阿莫西林-克拉维酸。不过需要务必注意的是,与URI的其他细菌性病因,包括流感嗜血杆菌和莫拉菌属(Moraxella)物种(其自发缓解率较高)相比,肺炎链球菌感染患者中抗生素治疗的效益最大。16由于阿莫西林-克拉维酸比阿莫西林更容易导致不良事件,在大多数情况下,医生可能会选择使用阿莫西林作为第一线药物。

了解当地的流行病学和耐药模式对于适当地选择抗生素尤为重要。肺炎球菌对大环内酯类56和第三代口服头孢菌素57,58耐药率较高,因此这些药物不适合用于治疗大多数疑似细菌性URI的患儿。GAS出现大环内酯类药物耐药性也是一个重大问题,不过一般不会进行药敏试验。

对于AOM和急性细菌性鼻窦炎患儿,考虑观察(也称为“随访观察”或“延迟处方”)的效果,而不是直接行抗生素治疗非常重要。对AOM患者的研究表明,该方法可减少抗生素的使用,患者家庭的接受度良好,而且,辅以密切的随访时,不会造成临床预后恶化。22对于无严重症状且较年长的AOM和鼻窦炎患者,应考虑将观察疗法作为替代性策略。22,23该方法可促进患者及其家属参与共同决策,包括讨论立即进行抗生素治疗相关的潜在效益和风险等。

合理使用抗生素的另一个重要的考虑因素是抗生素暴露的总程度。较短的疗程有可能实现与较长疗程同样的临床效益,同时最大程度地减少了不良事件和产生耐药性的风险,依从性也更好。重要的例子有:阿莫西林治疗GAS咽炎26(每日1次与每日给药2次或3次相比,但每日给药剂量相同,均为50 mg/kg);在患AOM的大龄儿童中行短期疗法(例如,7天与10天相比)。22

结论

本临床报告讨论了合理使用抗生素治疗小儿URI的原则。重点强调了适当的诊断,这是对处方抗生素作出合理决策的基础。尽管本文侧重于特定的几种URI,主要内容亦适用于更广泛和常规的抗生素使用。这些原则可用于促进医师教育,宣传近期的临床指南,协助医生就适当地使用抗生素与患者及其家属沟通,并有助于制定当地的合理使用抗生素指南。

本文版权属于是美国儿科学会及其董事会。所有作者均已和美国儿科学会签署过利益冲突声明,通过董事会审批的程序消除了利益冲突。在制定本出版物的内容时,美国儿科学会不寻求也不接受任何商业介入。

除非在失效时或失效前重新发布、修订或作废,美国儿科学会发布的所有临床报告均在发布 5 年后自动失效。

本报告中提供的指南不作为治疗的唯一准则或医疗护理标准,根据个体的情况作适当变通会更合适。

版权所有 2010 年 美国儿科学会(本翻译文本仅供参考,参考文献可点阅读原文查看)

翻译:@任扶摇

(译者简介:任扶摇,离开分子遗传学科研一线后做起了自由翻译和撰稿人,曾翻译过几十万字的The Lancet, BMJ和NEJM文献和临床指南,并先后为《MIT科技创业》杂志,纽约时报中文网和彭博商业周刊等翻译或撰写编译稿件。)

本文地址:http://www.wjbb.com/know/1020
原文出处:http://weibo.com/p/1001593825089635326039 查看全部

Adam L. Hersh, MD, PhD, Mary Anne Jackson, MD, Lauri A. Hicks, DO, and the COMMITTEE ON INFECTIOUS DISEASES

关键词

respiratory tract infections, antibacterial agents

呼吸道感染,抗菌剂

缩写词

AAP—美国儿科学会(American Academy of Pediatrics)

AOM—急性中耳炎(acute otitis media)

GAS—A群链球菌(group A Streptococcus)

NNT—防止1例不良事件发生或得到1例有利结果需要治疗的病例数(number needed to treat)

PTA—扁桃体周围脓肿(peritonsillar abscess)

TM—鼓膜(tympanic membrane)

URI—上呼吸道感染(upper respiratory tract infection)

摘要

大多数上呼吸道感染是由病毒引起,不需要使用抗生素治疗。本临床报告主要介绍了处方抗生素治疗细菌性上呼吸道感染(包括急性中耳炎、急性细菌性鼻窦炎和链球菌性咽炎等)时的策略。本文概述了合理使用抗生素的原则,侧重于运用严格的诊断标准,权衡抗生素治疗的效益和危害,并了解哪些情况不宜使用抗生素。这些原则可用于宣传近期的临床指南,有助于制定本地指南及与患者沟通;也广泛地适用于日常抗生素使用。

《儿科学》Pediatrics 2013;132:1146–1154

引言

在儿科门诊中,超过1/5的患儿会被医生处方抗生素。在美国,医生们每年开具的抗生素处方达近5000万份。1大量资料显示,抗生素处方不当在门诊中十分常见,在治疗病毒导致的上呼吸道感染(URI)时尤其如此。1–3每年,为治疗呼吸系统疾病而开具,却无法提供任何治疗效益的抗生素处方达上千万份之多。1最近的证据表明,广谱抗生素处方有所增加,且频繁发生在无需治疗或适用窄谱抗生素之时。1,2此类抗生素滥用会导致本可以避免的药物相关性不良事件4-6和抗生素耐药性,7,8增加不必要的医疗费用。正在研发中的可治疗抗生素耐药性感染的药物很少,进一步加剧了上述情况。9抗生素耐药性日益严重的健康和经济威胁促使医生合理地处方抗生素,在减少滥用的同时确保处方适当的药物,这也是保障公众健康和患者安全的当务之急。(http://www.cdc.gov/drugresista ... t-2013)。

对于为儿童提供医护服务的门诊医师和其他医务人员而言,每天都需要就是否为存在URI症状的患者处方抗生素做出临床决策。虽然抗生素处方是临床医护的常规组成部分,但合理使用抗生素绝非易事,这是因为病毒性与细菌性URI往往难以区分。本临床报告的主要目的在于提供使用抗生素治疗小儿URI的临床决策原则。需要强调的一点是:临床指南指出,在诊断急性中耳炎(AOM)、急性细菌性鼻窦炎和A群链球菌(GAS)引起的咽炎时,使用严格且经过验证的临床标准十分重要。此外,本文还强调了不适用抗生素的情况(尤其是病毒性呼吸道感染)。考虑到URI十分常见,且大多抗生素处方是为治疗URI而开具,因此,以优化抗生素处方为目的的指南和其他干预措施对此类疾病有较大影响。谨慎应用这些标准将可能减少小儿URI中的抗生素滥用。

抗生素耐药菌的出现和扩散引起了人们的担忧,为此1998年发布了第一版《儿童上呼吸道感染合理使用抗生素原则》(“Principles of Judicious Use of Antimicrobial Agents for Pediatric Upper Respiratory Tract Infections”)。10美国疾病预防控制中心(CDC)与美国儿科学会(APP)合作,力求根据现状更新上述原则。抗生素耐药性仍是重大的公共卫生问题,适当地使用抗生素是保障医疗服务质量的重要目标。虽然2000年7-价肺炎球菌多糖-蛋白结合疫苗(PCV7)的推出使侵袭性肺炎球菌感染发生率的大幅下降,11但由于无相应疫苗的血清型流行率有所增加(以血清型19A,一种常见的抗生素耐药性血清型最为明显),12,13科学家们在2010年推出了13-价肺炎球菌多糖-蛋白结合疫苗(PCV13)。医务人员担心抗生素耐药性是导致人们越来越多地使用广谱抗生素的一个原因。近年来发表了若干高质量的随机对照试验、荟萃分析以及最新或更新后的临床指南,更好地定义了使用抗生素治疗某些特定URI(包括AOM和急性细菌性鼻窦炎)的疗效。14–23与此同时,新出现的证据着重显示了抗生素导致的需要医疗照护的不良事件4-6以及可能危及生命的事件24,25。

本临床报告侧重于几种重要的小儿URI:AOM、急性细菌性鼻窦炎和咽炎,在特定情况下,抗生素可能有益于这些疾病的治疗。这些建议适用于健康的儿童,他们无潜在的内科疾病(如免疫抑制),因此发生严重并发症的风险不大。本报告的目的在于向医务人员介绍应在何种情况下使用最新的建议、指南以及“合理使用抗生素三原则”:(1)确定细菌感染的可能性;(2)权衡抗生素的效益和危害;(3)实施合理的处方策略。

原则一:确定细菌感染的可能性

细菌性URI的临床病史、症状和体征中有许多方面与病毒性感染或非传染病重叠或类似,要做出使用抗生素的合理决策,首先必须确定细菌感染的可能性。当医生确诊病毒感染,并合理地排除并发细菌感染时,不应使用抗生素,因为此时潜在危害远远大于潜在效益。对于AOM、急性细菌性鼻窦炎或咽炎的具体病例,可使用现有的完善且行之有效的严格标准来区分细菌性与非细菌性病因。

急性中耳炎(AOM)

2013年,AAP和美国家庭医师学会(American Academy of Family Physicians)发布了更新后的AOM诊断和治疗临床实践指南。22AOM的定义为:“中耳炎症状和体征的快速发作。”上述体征包括伴有或不伴有红斑的鼓膜(TM)膨出,症状可能包括耳痛、烦躁、耳漏和发热等。诊断AOM往往需要仔细的耳镜检查,以确认存在TM炎性改变。AAP指南建议,在以下任何一种情况下医生都可以确诊AOM:(1)有证据表明存在中耳积液(TM中度到重度膨出);或(2)不能归因于外耳道炎的新发耳漏。如果患儿仅出现轻度TM膨出,但伴有最近发生的耳部疼痛或TM严重红斑,也可以确诊AOM。由于清晰地观察TM可能有困难,且AOM通常是自限性疾病,为了尽量减少抗生素滥用,必须确保诊断的高度准确性。在确诊AOM后,根据疾病的严重程度(严重耳痛,耳痛持续>48小时,或体温≥39°C)、感染的偏侧性(双侧与单侧)、以及年龄(≤23个月和≥24个月)对患者进行分类将有助于合理地使用抗生素。症状严重、双侧受累且年龄较小的患者更可能受益于抗生素。对于年龄稍大、病情不严重且为单侧发病的患者,随访观察是较为合理的处置。

急性细菌性鼻窦炎

AAP23和美国传染病协会(Infectious Diseases Society of America)21近期制定了诊断和治疗急性细菌性鼻窦炎的循证临床指南。该指南支持使用严格的诊断标准来区分细菌性与病毒性URI。具体来说,诊断急性细菌性鼻窦炎应基于如下症状:(1)持续且无好转,(2)恶化,或(3)严重。持续性症状最为常见,包括流涕(任何性质)或持续10天未有好转的日间咳嗽。症状恶化包括恶化或新发发热、日间咳嗽或在典型病毒性URI好转之后流涕。严重症状包括持续发热(体温≥39°C)和流脓涕至少3天。这些临床标准是诊断急性细菌性鼻窦炎的基础。由于许多患有病毒性URI的儿童存在影像学异常,不应常规进行影像学检查。

急性咽炎

咽炎或咽痛可伴有其他非特异性症状,包括咳嗽、鼻塞、发热等。考虑诊断的最重要的因素为:是否是β-溶血性GAS引起。与AOM和急性细菌性鼻窦炎不同,GAS感染可通过实验室化验(快速抗原检测或培养)确诊。26,27评分系统(改良Centor或McIsaac评分28)有助于识别哪些人需要接受测试。存在以下2个或更多特征的患者应接受测试:(1)无咳嗽,(2)扁桃体有渗出物或肿胀,(3)发热史,(4)颈前淋巴结肿胀和触痛,(5)年龄小于15岁。存在URI症状和体征,包括咳嗽、鼻塞、结膜炎、声音嘶哑、腹泻或口咽部病变(溃疡、起泡)的患儿更可能患有病毒性疾病而非GAS感染,不应接受GAS测试。由于3岁以下儿童中风湿热较为罕见,且GAS一般不会引起咽炎,通常不应对他们进行测试。除极少数例外情况(例如,症状明确且与已确诊GAS咽炎的家庭成员有接触)之外,即使患者满足所有上述临床标准,未经测试也不应做出GAS诊断。即使在无症状的儿童中,细菌定植率也可达到15%到20%,这进一步显示了采用适当的临床标准并限制测试的重要性。

普通感冒、非特异性URI、急性咳嗽性疾病和急性支气管炎

普通感冒、非特异性URI、急性咳嗽性疾病和急性支气管炎的症状可能与细菌性URI重叠或相似,可包括咳嗽、鼻塞和咽痛等。总的来说,每年都有数以百万人次因这些病毒性疾病就诊。尤其是急性支气管炎,每年有超过200万人次因这种咳嗽性疾病到儿科就诊,70%以上的情况下医生都会处方抗生素。1AOM、鼻窦炎和咽炎的临床诊断可有助于临床医生排除上述疾病。普通感冒、非特异性URI、急性咳嗽性疾病和急性支气管炎的管理应侧重于缓解症状。不应处方抗生素来治疗这些疾病。

原则二:权衡抗生素的效益与危害

如果发现患者可能是细菌感染,下一步应比较抗生素治疗各种疾病的效益和潜在危害。需要考虑的效益相关预后包括:治愈率,症状减少,并发症和继发病例的预防。危害相关预后包括:抗生素相关性不良事件(如腹痛、腹泻、皮疹等),艰难梭菌性结肠炎,耐药性的产生以及费用等。

AOM效益

自从发布第一版合理使用抗生素原则以来,发表了若干项高质量的随机对照试验和荟萃分析。18–20,29–33总体而言,它们都强调了以下几点:(1)至少有一半的AOM患者无需抗生素治疗就可康复;(2)与安慰剂相比,接受抗生素治疗的儿童更可能康复或加速康复;(3)对于较为年幼,或患有双侧(而非单侧疾病),又或者是症状和体征较为严重的儿童,无抗生素治疗时较难康复。这些观察结果为AOM的治疗建议提供了理论依据。

多项荟萃分析表明,与安慰剂相比,接受抗生素治疗的儿童更容易实现临床症状缓解,防止1例不良事件发生或得到1例有利结果需要治疗的病例数(NNT)为7或8。18,33最近的两项在幼儿中进行、并采用了较严格的诊断标准的随机对照试验表明,与接受安慰剂的儿童相比,接受抗生素治疗的儿童症状评分较优,症状康复更快,且临床失败率(以耳镜检查和症状持续为标准衡量)显著较低,其NNT接近于4。19,20然而,请务必注意,大量关于抗生素治疗AOM效果的研究中,无论接受治疗与否,大多数患者的症状最后都会自发缓解,且不会出现并发症。临床上决定使用抗生素治疗AOM,在某种程度上是因为它们可能有助于预防并发症,如乳突炎等。然而,在上述对照研究和荟萃分析中,抗生素在预防这些罕见但严重的并发症方面并未显示出显著效益。英国对超过100万例AOM发作的观测数据表明,乳突炎(如果发生的话)通常在初次临床就诊时出现。34预防一例乳突炎发作的估算NNT为近5000。34

AAP建议对根据临床诊断标准确诊的AOM患儿行抗生素治疗。对于特定的患儿,尤其是症状不严重、单侧发病的2岁以上儿童,可以考虑观察。

急性细菌性鼻窦炎效益

有关抗生素治疗小儿急性细菌性鼻窦炎疗效的循证评估数量有限,且结果不一。有三项随机对照试验评估了与安慰剂相比,抗生素治疗临床确诊的急性细菌性鼻窦炎患儿的疗效,其中有两项是在1998年版合理使用抗生素原则发布后发表的。14,17,35两项试验的结论表明,在3天和14天后,抗生素组的症状缓解率均较高,14,35但一项研究显示抗生素并不优于安慰剂。17这些研究设计间的重大差异可能是造成其结果不同的一个原因:显示抗生素有益的试验纳入了症状较为严重的患者,并采用了更严格的诊断标准。这强调了临床诊断务必谨慎,因为对于不符合急性细菌性鼻窦炎诊断标准的患者,抗生素无任何临床效益。

抗生素预防化脓性并发症,如眶蜂窝组织炎或颅内脓肿的效益尚未得到证实。个别药效试验的统计学效力不足以证明抗生素对这些罕见并发症的疗效,一项对儿童和成年人随机对照试验的荟萃分析发现,抗生素的使用与并发症的发生率之间无显著相关性。36

AAP建议向存在急性细菌性鼻窦炎的临床特征,尤其是症状严重或有所恶化的患者行抗生素治疗。对于症状持续(>10天)者,可考虑观察加密切随访或抗生素治疗。

GAS咽炎效益

现有研究从症状缓解、传播、预防并发症(如风湿热)等方面评估了抗生素治疗急性咽炎的疗效。五项随机对照研究和一项荟萃分析审查了立即抗生素治疗对症状缓解情况的影响,其中一项于第一版合理使用抗生素原则发布之后完成。37–41这些研究提供了强有力的证据,表明采用抗生素治疗小儿咽炎和已确诊的GAS,可将咽痛、头痛等症状的持续时间缩短约1天。这些效益在短短3天内就十分明显。然而,抗生素治疗对缩短发热时间的效果尚不确定。尽管现有数据有限,但抗生素治疗GAS先证者(index cases)可能会减少水平传播,从而防止继发病例的产生。40,42在大家庭、托儿所、学校和军事环境中,这种效益尤为重要。

从历史上看,处方抗生素治疗GAS咽炎的主要动机是预防风湿热。1975年前在儿童中进行的多项随机对照试验显示,抗生素预防风湿热发作的效益是不治疗的四倍(风湿热在未经治疗的患者中的发生率约为3%)。43虽然近几十年来发生过几次风湿热局部爆发,但在大多数发达国家中其发病率已经大幅度下降。44这种下降的部分原因是诊断识别的改善和抗生素治疗,45但更可能与致风湿病性GAS菌株的流行率下降有关。46

抗生素对于GAS咽炎相关的化脓性并发症,如扁桃体周围脓肿(PTA)、AOM和急性鼻窦炎也有一定的预防作用。一项荟萃分析表明,抗生素治疗可以预防PTA;然而,该分析中的大多数病例都来自1951年的一项研究。43英国一个大型观察队列的数据表明,抗生素治疗可预防PTA的发生,但NNT>4000。47

AAP建议对确诊GAS咽炎的患儿行抗生素治疗。

普通感冒、非特异性URI、急性咳嗽性疾病和急性支气管炎

这些疾病的主要病因是病毒,因此不适用抗生素治疗。由于小儿急性支气管炎的诊断意义尚不确定,相关数据有限。然而,一项大型荟萃分析得出结论:抗生素治疗(包括延迟处方)无益于非特异性咳嗽和感冒患者。48

抗生素治疗的危害

在使用抗生素治疗URI时,考虑其可能造成的危害至关重要。应针对每个病例的具体情况,对潜在危害和潜在效益加以权衡。抗生素相关危害的重要性与以下内容直接相关:(1)评估潜在效益的程度(如,治疗双侧AOM幼儿的效益优于单侧患儿);(2)诊断不确定性的程度。就缓解症状而言,表明抗生素有益于治疗细菌性URI的证据占数量优势。当无法确定URI是否由急性细菌感染引起时,使用抗生素的危害通常会大于效益。采用严格的临床标准来确诊细菌感染有助于将其与小儿非特异性URI和普通感冒相区别。处方抗生素一般无益于治疗非特异性URI和感冒,只可能给这些患儿带来潜在危害。

抗生素是儿童因药物相关不良事件意外就诊的最大原因,每年此类就诊就超过150,000人次,并导致了巨大的潜在发病和费用。4抗生素相关不良事件的程度从轻微(腹泻和皮疹)、严重(Stevens-Johnson综合征)、到危及生命(过敏症或心源性猝死)不等。大多数评估抗生素治疗AOM、鼻窦炎和咽炎效果的临床试验使用的是阿莫西林或阿莫西林-克拉维酸,这些药物仍然是使用抗生素治疗这些疾病时推荐的一线药物。比较抗生素与安慰剂治疗AOM效果的研究表明,在接受治疗的患者中,不良事件(尤其是腹泻和皮疹)率略有增加。两项荟萃分析估算出不良事件率之差约为5%。18,32有两项使用阿莫西林-克拉维酸(以往研究常使用阿莫西林)的近期试验未纳入上述分析。在这两项试验中,接受抗生素治疗的患者的腹泻和皮炎率还要更高。19,20大多数近期进行的表明抗生素治疗鼻窦炎效益的试验中,接受高剂量阿莫西林-克拉维酸治疗的患者中不良事件(定义为皮疹、腹泻、呕吐和腹痛)发生率为44%,相比之下,在安慰剂组中为14%。14

前述不良事件较为常见,但大多数病例都比较轻微。抗生素也可产生严重的过敏反应,如Stevens-Johnson综合征等。25越来越多的证据表明,幼年接触抗生素可能会扰乱肠道及身体其它部位的微生物平衡,从而对健康造成长期不良影响,如炎症性肠病、肥胖、湿疹和哮喘等。49–51最近的一项研究强调了接受阿奇霉素治疗的成年人存在猝死风险,这可能与药物相关性QT间期延长有关。24阿齐霉素并非治疗任何小儿URI的一线抗生素,且它最有可能被不当使用(不能有效地针对引起AOM和鼻窦炎的最常见病原体)。1在过去十年中,住院患儿的艰难梭菌性结肠炎发生率大幅提高。52虽然存在合并症的患儿风险最大,但由于最近抗生素暴露已成为重大风险因素,社区获得性感染也时有发生。53

在个别患者和社区层面上,抗生素暴露与抗生素耐药性的发生间的关联均已得到公认。7,8由于治疗方案有限,抗生素耐药性感染难以治疗,而且在某些病例中,其与临床预后不良相关。54无论在个人和社区层面上,应用严格的诊断标准,在确诊且存在明确的潜在效益时再使用抗生素治疗,对于最大程度地减少抗生素滥用对耐药性的影响至关重要。

原则三:实施合理的处方策略

当有证据表明抗生素的效益时,应从几个方面考虑合理地处方:针对最可能的病原体选择适当的抗生素药物(也要考虑到当地的耐药模式),选择适当的剂量,在满足治疗需要的前提下尽可能地缩短治疗持续时间。此外,医生还应考虑观察和利用延迟处方策略的作用。AOM和急性细菌性鼻窦炎的治疗说明了合理使用抗生素的几个关键环节。由于肺炎链球菌(Streptococcus pneumoniae)是这些疾病最重要的病因,所以传统上建议使用阿莫西林作为一线治疗药物。然而,在某些社区中,细菌性URI中耐阿莫西林的产β-内酰胺酶流感嗜血杆菌(Haemophilus influenzae)的流行率显著增加。55这(从一定程度上)表明,在特定情况下(如症状严重,近期[<6周]抗生素暴露,当地耐阿莫西林流感嗜血杆菌的流行率较高等),应考虑使用阿莫西林-克拉维酸。不过需要务必注意的是,与URI的其他细菌性病因,包括流感嗜血杆菌和莫拉菌属(Moraxella)物种(其自发缓解率较高)相比,肺炎链球菌感染患者中抗生素治疗的效益最大。16由于阿莫西林-克拉维酸比阿莫西林更容易导致不良事件,在大多数情况下,医生可能会选择使用阿莫西林作为第一线药物。

了解当地的流行病学和耐药模式对于适当地选择抗生素尤为重要。肺炎球菌对大环内酯类56和第三代口服头孢菌素57,58耐药率较高,因此这些药物不适合用于治疗大多数疑似细菌性URI的患儿。GAS出现大环内酯类药物耐药性也是一个重大问题,不过一般不会进行药敏试验。

对于AOM和急性细菌性鼻窦炎患儿,考虑观察(也称为“随访观察”或“延迟处方”)的效果,而不是直接行抗生素治疗非常重要。对AOM患者的研究表明,该方法可减少抗生素的使用,患者家庭的接受度良好,而且,辅以密切的随访时,不会造成临床预后恶化。22对于无严重症状且较年长的AOM和鼻窦炎患者,应考虑将观察疗法作为替代性策略。22,23该方法可促进患者及其家属参与共同决策,包括讨论立即进行抗生素治疗相关的潜在效益和风险等。

合理使用抗生素的另一个重要的考虑因素是抗生素暴露的总程度。较短的疗程有可能实现与较长疗程同样的临床效益,同时最大程度地减少了不良事件和产生耐药性的风险,依从性也更好。重要的例子有:阿莫西林治疗GAS咽炎26(每日1次与每日给药2次或3次相比,但每日给药剂量相同,均为50 mg/kg);在患AOM的大龄儿童中行短期疗法(例如,7天与10天相比)。22

结论

本临床报告讨论了合理使用抗生素治疗小儿URI的原则。重点强调了适当的诊断,这是对处方抗生素作出合理决策的基础。尽管本文侧重于特定的几种URI,主要内容亦适用于更广泛和常规的抗生素使用。这些原则可用于促进医师教育,宣传近期的临床指南,协助医生就适当地使用抗生素与患者及其家属沟通,并有助于制定当地的合理使用抗生素指南。

本文版权属于是美国儿科学会及其董事会。所有作者均已和美国儿科学会签署过利益冲突声明,通过董事会审批的程序消除了利益冲突。在制定本出版物的内容时,美国儿科学会不寻求也不接受任何商业介入。

除非在失效时或失效前重新发布、修订或作废,美国儿科学会发布的所有临床报告均在发布 5 年后自动失效。

本报告中提供的指南不作为治疗的唯一准则或医疗护理标准,根据个体的情况作适当变通会更合适。

版权所有 2010 年 美国儿科学会(本翻译文本仅供参考,参考文献可点阅读原文查看)

翻译:@任扶摇

(译者简介:任扶摇,离开分子遗传学科研一线后做起了自由翻译和撰稿人,曾翻译过几十万字的The Lancet, BMJ和NEJM文献和临床指南,并先后为《MIT科技创业》杂志,纽约时报中文网和彭博商业周刊等翻译或撰写编译稿件。)

本文地址:http://www.wjbb.com/know/1020
原文出处:http://weibo.com/p/1001593825089635326039

美国儿科学会政策声明:维护和改善幼儿的口腔健康

豌豆爸爸 发表了文章 • 0 个评论 • 361 次浏览 • 2015-02-04 11:26 • 来自相关话题

Abstract
Oral health is an integral part of the overall health of children. Dental caries is a common and chronic disease process with significant short- and long-term consequences. The prevalence of dental caries for the youngest of children has not decreased over the past decade, despite improvements for older children. As health care professionals responsible for the overall health of children, pediatricians frequently confront morbidity associated with dental caries. Because the youngest children visit the pediatrician more often than they visit the dentist, it is important that pediatricians be knowledgeable about the disease process of dental caries, prevention of the disease, and interventions available to the pediatrician and the family to maintain and restore health.

Introduction
Dental caries is the most common chronic disease of childhood. Twenty-four percent of US children 2 to 4 years of age, 53% of children 6 to 8 years of age, and 56% of 15-year-olds have caries experience (ie, untreated dental caries, filled teeth, teeth missing as a result of dental caries). For children 5 to 19 years of age, children from poor and racial or ethnic minority families have higher rates of untreated dental caries than do their peers from nonpoor and nonminority families. For some age groups, the incidence of dental caries has decreased or stayed the same, but for the youngest children, it has increased. Among 6- to 8-year-olds and 15-year-olds, caries experience and untreated dental decay remained mostly unchanged between 1988–1994 and 1999–2004. In children 2 to 4 years of age, the caries experience increased significantly, from 19% to 24%, during that same time period. The increase in the caries experience and untreated caries was statistically significant in children from poor families.

The Etiology and Pathogenesis of Dental Caries
A dynamic process takes place at the surface of the tooth that involves constant demineralization and remineralization of the tooth enamel (the caries balance). Multiple factors affect that dynamic process and can be manipulated in ways that tip the balance toward disease (demineralization) or health (remineralization). These factors include bacteria, sugar, saliva, and fluoride. Because these factors can be manipulated, it is possible for pediatricians and families to prevent, halt, or even reverse the disease process.

Different oral structures and tissues have different and distinct microbial communities (microbiomes). The oral microbiome at the surface of the tooth is referred to as dental plaque. During the disease process of dental caries, bacteria that are aciduric and acidogenic predominate in the dental plaque. Streptococcus mutans is most strongly associated with dental caries, although other bacterial species have these capabilities and thus can also be pathogenic. When environmental factors make it possible to select for these pathogenic bacteria in dental plaque, the disease process begins.

A key environmental factor that allows for selection and proliferation of these pathogenic bacteria is dietary sugar intake. Because these pathogenic bacteria have the ability to ferment sugars, produce acid, and decrease the pH of the dental plaque, they make possible the selection of other aciduric, acidogenic bacteria that will contribute to disease. As more bacteria produce more acid, the pH at the surface of the tooth decreases. This process causes the demineralization of the tooth enamel. Unimpeded, these long periods of low pH and demineralization will result in cavitation.

Saliva is an important factor in buffering the low pH and bringing these demineralization pressures back to a balance with remineralization. In addition to acting as a buffering agent, saliva also flushes the oral cavity of food particles and provides an environment rich in calcium and phosphate to aid in remineralization. When salivary flow is impeded, the pH is able to decrease to a lower level, tipping the scales toward demineralization (disease); in addition, the time it takes to buffer back to a normal pH is longer.

Another important factor that can affect the balance of demineralization and remineralization is fluoride. More in-depth reviews of fluoride are available elsewhere. It is important, however, for pediatricians and other child health care providers to understand how fluoride influences the caries balance. Fluoride has 3 key effects on the caries balance: (1) inhibition of demineralization at the tooth surface; (2) enhancement of remineralization, which results in a more acid-resistant tooth surface; and (3) inhibition of bacterial enzymes. The primary effect of fluoride is topical, via fluoridated toothpastes, mouth rinses, and varnishes, although there is still value in systemic fluoride exposures via fluoridated water and supplements.

Preventive Strategies

Caries Risk Assessment

Ideally, primary prevention efforts will anticipate and prevent caries before the first sign of disease. Preventive strategies for this multifactorial, chronic disease require a comprehensive and multifocal approach that begins with caries risk assessment. Assessing each child’s risk of caries and tailoring preventive strategies to specific risk factors are necessary for maintaining and improving oral health. There is no single test that takes into consideration all risk factors and accurately predicts an individual's susceptibility to caries. However, pediatricians can conduct an excellent risk assessment for caries by focusing on the key risk factors for dental caries that are associated with diet, bacteria, saliva, and status of the teeth (both current status and previous caries experience). The American Academy of Pediatrics (AAP)/Bright Futures Oral Health Risk Assessment Tool can be found at http://www2.aap.org/oralhealth ... html.

Sugars (but not sugar substitutes) are a critical risk factor in the development of caries. The risk of caries is greatest if sugars are consumed at high frequency and are in a form that remains in the mouth for long periods of time. Thus, key behaviors that place a child at high risk of caries include continual bottle/sippy cup use (especially with fluids other than water), sleeping with a bottle (especially with fluids other than water), frequent between-meal snacks of sugars/cooked starch/sugared beverages, and frequent intake of sugared medications.

Early acquisition of S mutans is a major risk factor for early childhood caries and future caries experience. Strong evidence demonstrates that mothers are a primary source of S mutans colonization for their children. Thus, an important factor associated with caries risk in young children is the recent or current presence of active dental decay in the primary caregiver. Prevention, diagnosis, and treatment of oral diseases are highly beneficial, can be undertaken, and should be encouraged during pregnancy with no additional fetal or maternal risk compared with the risk of not providing care. The most important and predictive risk factor for caries, however, is previous caries experience. This finding is not surprising, considering that the factors which initiated the disease process often continue to exist over time.

Other caries risk factors are associated with salivary flow and the status of the teeth. Diseases (eg, diabetes mellitus, Sjögren's syndrome, cystic fibrosis) and medications (eg, antihistamines, anticonvulsants, antidepressants) that result in xerostomia (decreased salivary flow) reduce the availability of saliva to buffer the acid produced by pathogenic bacteria, thus enhancing their ability to cause damage to the teeth. In addition, the teeth of preterm infants, which frequently have enamel defects, are at increased susceptibility for disease. Older children who have deep pits and fissures in their molars are also at increased susceptibility for disease.

Anticipatory Guidance
With a clear understanding of the etiology of dental caries and the risk factors that lead to and facilitate the spread of this disease, pediatricians can target anticipatory guidance to assist families in preventing it. Because the disease of dental caries is multifocal, the anticipatory guidance should also be multifocal. Pediatricians should concentrate their anticipatory guidance on topics that can affect the risk of disease.

Dietary Counseling
Because sugar intake is such an important risk factor for dental caries, pediatricians can incorporate anticipatory guidance associated with preventing dental caries into discussions with families about dietary habits and nutritional intake. Pediatricians should counsel parents and caregivers on the importance of reducing the frequency of exposure to sugars in foods and drinks. To decrease the risk of dental caries and ensure the best possible health and developmental outcomes, pediatricians should recommend that parents do the following:

•Exclusively breastfeed infants for 6 months and continue breastfeeding as complementary foods are introduced for 1 year or longer, as mutually desired by mother and infant.

•Discourage putting a child to bed with a bottle. Establish a bedtime routine conducive to optimal oral health (eg, brush, book, and bed).

•Wean from a bottle by 1 year of age.

•Limit sugary foods and drinks to mealtimes.

•Avoid carbonated, sugared beverages and juice drinks that are not 100% juice.

•Limit the intake of 100% fruit juice to no more than 4 to 6 oz per day.

•Encourage children to drink only water between meals, preferably fluoridated tap water.

•Foster eating patterns that are consistent with guidelines from the US Department of Agriculture.

Oral Hygiene
The value of good oral hygiene lies in controlling the levels and activity of disease-causing bacteria in the oral cavity and delivering fluoride to the surface of the tooth. It is important to remember that pathogenic bacteria can be passed from caregiver to child. Thus, anticipatory guidance for both parent and child is important. Key anticipatory guidance points regarding oral hygiene are as follows:

•Parents/caregivers should be encouraged to model and maintain good oral hygiene and a relationship with their own dental provider.

•Parents/caregivers, especially those with significant history of dental decay, should be cautioned to avoid sharing with their child items that have been in their own mouths.

•The child’s teeth should be brushed twice a day as soon as the teeth erupt with a smear or a grain-of-rice–sized amount of fluoridated toothpaste. After the third birthday, a pea-sized amount should be used.

•Parents/caregivers should help/supervise a child brushing his or her teeth until mastery is obtained, usually at around 8 years of age.

Fluoride
The delivery of fluoride to the teeth includes community-based options (water fluoridation), self-administered modalities (fluoride toothpaste and supplements), and professional applications (fluoride varnish). Each of these delivery mechanisms is useful in preventing dental caries.

Water fluoridation is a community-based intervention that optimizes the level of fluoride in drinking water, resulting in preeruptive and posteruptive protection of the teeth.19 Water fluoridation is a cost-effective means of preventing dental caries, with the lifetime cost per person equaling less than the cost of 1 dental restoration. Most bottled waters do not contain an adequate amount of fluoride.

Fluoride toothpaste is an important way to deliver fluoride to the surface of the tooth. Fluoride toothpaste has been shown to be effective in reducing dental caries in both primary and permanent teeth. It is important to limit the amount of toothpaste used to a smear or a grain-of-rice–sized amount for young children and no more than a pea-sized amount for children older than 3 years. Fluoride supplements should be prescribed for children whose primary source of drinking water is deficient in fluoride.

Fluoride varnish is a professionally applied, sticky resin of highly concentrated fluoride. Two or more applications of fluoride varnish per year are effective in preventing caries in children at high risk of all ages. In most states, pediatricians can apply and be paid for application of fluoride varnish to the teeth of young children. Application of fluoride varnish is even more effective when coupled with counseling. The US Preventive Services Task Force recently published a new recommendation that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption (B recommendation). More details and recommendations on fluoride can be found in the AAP clinical report “Fluoride Use in Caries Prevention in the Primary Care Setting.”

Other Important Anticipatory Guidance Topics
A frequent topic of discussion with parents is nonnutritive oral habits, such as use of pacifiers and thumb sucking. AAP policy states that parents consider offering a pacifier at naptime and bedtime because of a protective effect of pacifiers on the incidence of sudden infant death syndrome after the first month of life.27 Both finger- and pacifier-sucking habits will only cause problems with dental structures if they go on for a long period of time. Evaluation by a dentist is indicated for nonnutritive sucking habits that continue beyond 3 years of age.28

Dental injuries are common. Twenty-five percent of all schoolchildren experience some form of dental trauma. Pediatricians can help prevent such trauma by encouraging parents to cover sharp corners of household furnishings at the level of walking toddlers, recommend use of car safety seats, and be aware of electrical cord risk for mouth injury. Pediatricians can also encourage mouthguard use during sports activities in which there is a significant risk of orofacial injury.More information on dental trauma is available in the AAP clinical report “Management of Dental Trauma in a Primary Care Setting.”

Collaboration With Dental Providers
The AAP, the American Academy of Pediatric Dentistry, the American Dental Association, and the American Association of Public Health Dentistry all recommend a dental visit for children by 1 year of age. Although pediatricians have the opportunity to provide early assessment of risk for dental caries and anticipatory guidance to prevent disease, it is also important that children establish a dental home. A dental home is the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way.

Unfortunately, little is known about pediatric health care providers’ dental referral behaviors and patterns. Although 1 study found that children 2 to 5 years of age who received a recommendation from their health care provider to visit the dentist were more likely to have a dental visit, the US Preventive Services Task Force found no study that evaluated the effects of referral by a primary care clinician to a dentist on caries incidence. It is also noteworthy that preschool-aged children covered by Medicaid who had an early preventive dental visit by 1 year of age were more likely to use subsequent preventive services and to have lower dental expenses.

With early referral to a dental provider, there is an opportunity to maintain good oral health, prevent disease, and treat disease early. Establishing such collaborative relationships between physicians and dentists at the community level is essential for increasing access to dental care for all children and improving their oral and overall health.

Conclusions
Oral health is an integral part of the overall health and well-being of children. A pediatrician who is familiar with the science of dental caries, capable of assessing caries risk, comfortable with applying various strategies of prevention and intervention, and connected to dental resources can contribute considerably to the health of his or her patients. This policy statement, in conjunction with the oral health recommendations of the third edition of the AAP's Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, serves as a resource for pediatricians and other pediatric primary care providers to be knowledgeable about addressing dental caries. Because dental caries is such a common and consequential disease process in the pediatric population, it is essential that pediatricians include oral health in their daily practice of pediatrics.

Suggestions for Pediatricians

1.Administer an oral health risk assessment periodically to all children.

2.Include anticipatory guidance for oral health as an integral part of comprehensive patient counseling.

3.Counsel parents/caregivers and patients to reduce the frequency of exposure to sugars in foods and drinks.

4.Encourage parents/caregivers to brush a child’s teeth as soon as teeth erupt with a smear or a grain-of-rice–sized amount of fluoride toothpaste and a pea-sized amount at 3 years of age.

5.Advise parents/caregivers to monitor brushing until 8 years of age.

6.Refer to the AAP clinical report, “Fluoride Use in Caries Prevention in the Primary Care Setting,” for fluoride administration and supplementation decisions.

7.Build and maintain collaborative relationships with local dentists.

8.Recommend that every child has a dental home by 1 year of age.

中文翻译:
本文地址:http://www.wjbb.com/know/932
原文出处:http://pediatrics.aappublicati ... .full 查看全部

Abstract
Oral health is an integral part of the overall health of children. Dental caries is a common and chronic disease process with significant short- and long-term consequences. The prevalence of dental caries for the youngest of children has not decreased over the past decade, despite improvements for older children. As health care professionals responsible for the overall health of children, pediatricians frequently confront morbidity associated with dental caries. Because the youngest children visit the pediatrician more often than they visit the dentist, it is important that pediatricians be knowledgeable about the disease process of dental caries, prevention of the disease, and interventions available to the pediatrician and the family to maintain and restore health.

Introduction
Dental caries is the most common chronic disease of childhood. Twenty-four percent of US children 2 to 4 years of age, 53% of children 6 to 8 years of age, and 56% of 15-year-olds have caries experience (ie, untreated dental caries, filled teeth, teeth missing as a result of dental caries). For children 5 to 19 years of age, children from poor and racial or ethnic minority families have higher rates of untreated dental caries than do their peers from nonpoor and nonminority families. For some age groups, the incidence of dental caries has decreased or stayed the same, but for the youngest children, it has increased. Among 6- to 8-year-olds and 15-year-olds, caries experience and untreated dental decay remained mostly unchanged between 1988–1994 and 1999–2004. In children 2 to 4 years of age, the caries experience increased significantly, from 19% to 24%, during that same time period. The increase in the caries experience and untreated caries was statistically significant in children from poor families.

The Etiology and Pathogenesis of Dental Caries
A dynamic process takes place at the surface of the tooth that involves constant demineralization and remineralization of the tooth enamel (the caries balance). Multiple factors affect that dynamic process and can be manipulated in ways that tip the balance toward disease (demineralization) or health (remineralization). These factors include bacteria, sugar, saliva, and fluoride. Because these factors can be manipulated, it is possible for pediatricians and families to prevent, halt, or even reverse the disease process.

Different oral structures and tissues have different and distinct microbial communities (microbiomes). The oral microbiome at the surface of the tooth is referred to as dental plaque. During the disease process of dental caries, bacteria that are aciduric and acidogenic predominate in the dental plaque. Streptococcus mutans is most strongly associated with dental caries, although other bacterial species have these capabilities and thus can also be pathogenic. When environmental factors make it possible to select for these pathogenic bacteria in dental plaque, the disease process begins.

A key environmental factor that allows for selection and proliferation of these pathogenic bacteria is dietary sugar intake. Because these pathogenic bacteria have the ability to ferment sugars, produce acid, and decrease the pH of the dental plaque, they make possible the selection of other aciduric, acidogenic bacteria that will contribute to disease. As more bacteria produce more acid, the pH at the surface of the tooth decreases. This process causes the demineralization of the tooth enamel. Unimpeded, these long periods of low pH and demineralization will result in cavitation.

Saliva is an important factor in buffering the low pH and bringing these demineralization pressures back to a balance with remineralization. In addition to acting as a buffering agent, saliva also flushes the oral cavity of food particles and provides an environment rich in calcium and phosphate to aid in remineralization. When salivary flow is impeded, the pH is able to decrease to a lower level, tipping the scales toward demineralization (disease); in addition, the time it takes to buffer back to a normal pH is longer.

Another important factor that can affect the balance of demineralization and remineralization is fluoride. More in-depth reviews of fluoride are available elsewhere. It is important, however, for pediatricians and other child health care providers to understand how fluoride influences the caries balance. Fluoride has 3 key effects on the caries balance: (1) inhibition of demineralization at the tooth surface; (2) enhancement of remineralization, which results in a more acid-resistant tooth surface; and (3) inhibition of bacterial enzymes. The primary effect of fluoride is topical, via fluoridated toothpastes, mouth rinses, and varnishes, although there is still value in systemic fluoride exposures via fluoridated water and supplements.

Preventive Strategies

Caries Risk Assessment

Ideally, primary prevention efforts will anticipate and prevent caries before the first sign of disease. Preventive strategies for this multifactorial, chronic disease require a comprehensive and multifocal approach that begins with caries risk assessment. Assessing each child’s risk of caries and tailoring preventive strategies to specific risk factors are necessary for maintaining and improving oral health. There is no single test that takes into consideration all risk factors and accurately predicts an individual's susceptibility to caries. However, pediatricians can conduct an excellent risk assessment for caries by focusing on the key risk factors for dental caries that are associated with diet, bacteria, saliva, and status of the teeth (both current status and previous caries experience). The American Academy of Pediatrics (AAP)/Bright Futures Oral Health Risk Assessment Tool can be found at http://www2.aap.org/oralhealth ... html.

Sugars (but not sugar substitutes) are a critical risk factor in the development of caries. The risk of caries is greatest if sugars are consumed at high frequency and are in a form that remains in the mouth for long periods of time. Thus, key behaviors that place a child at high risk of caries include continual bottle/sippy cup use (especially with fluids other than water), sleeping with a bottle (especially with fluids other than water), frequent between-meal snacks of sugars/cooked starch/sugared beverages, and frequent intake of sugared medications.

Early acquisition of S mutans is a major risk factor for early childhood caries and future caries experience. Strong evidence demonstrates that mothers are a primary source of S mutans colonization for their children. Thus, an important factor associated with caries risk in young children is the recent or current presence of active dental decay in the primary caregiver. Prevention, diagnosis, and treatment of oral diseases are highly beneficial, can be undertaken, and should be encouraged during pregnancy with no additional fetal or maternal risk compared with the risk of not providing care. The most important and predictive risk factor for caries, however, is previous caries experience. This finding is not surprising, considering that the factors which initiated the disease process often continue to exist over time.

Other caries risk factors are associated with salivary flow and the status of the teeth. Diseases (eg, diabetes mellitus, Sjögren's syndrome, cystic fibrosis) and medications (eg, antihistamines, anticonvulsants, antidepressants) that result in xerostomia (decreased salivary flow) reduce the availability of saliva to buffer the acid produced by pathogenic bacteria, thus enhancing their ability to cause damage to the teeth. In addition, the teeth of preterm infants, which frequently have enamel defects, are at increased susceptibility for disease. Older children who have deep pits and fissures in their molars are also at increased susceptibility for disease.

Anticipatory Guidance
With a clear understanding of the etiology of dental caries and the risk factors that lead to and facilitate the spread of this disease, pediatricians can target anticipatory guidance to assist families in preventing it. Because the disease of dental caries is multifocal, the anticipatory guidance should also be multifocal. Pediatricians should concentrate their anticipatory guidance on topics that can affect the risk of disease.

Dietary Counseling
Because sugar intake is such an important risk factor for dental caries, pediatricians can incorporate anticipatory guidance associated with preventing dental caries into discussions with families about dietary habits and nutritional intake. Pediatricians should counsel parents and caregivers on the importance of reducing the frequency of exposure to sugars in foods and drinks. To decrease the risk of dental caries and ensure the best possible health and developmental outcomes, pediatricians should recommend that parents do the following:

•Exclusively breastfeed infants for 6 months and continue breastfeeding as complementary foods are introduced for 1 year or longer, as mutually desired by mother and infant.

•Discourage putting a child to bed with a bottle. Establish a bedtime routine conducive to optimal oral health (eg, brush, book, and bed).

•Wean from a bottle by 1 year of age.

•Limit sugary foods and drinks to mealtimes.

•Avoid carbonated, sugared beverages and juice drinks that are not 100% juice.

•Limit the intake of 100% fruit juice to no more than 4 to 6 oz per day.

•Encourage children to drink only water between meals, preferably fluoridated tap water.

•Foster eating patterns that are consistent with guidelines from the US Department of Agriculture.

Oral Hygiene
The value of good oral hygiene lies in controlling the levels and activity of disease-causing bacteria in the oral cavity and delivering fluoride to the surface of the tooth. It is important to remember that pathogenic bacteria can be passed from caregiver to child. Thus, anticipatory guidance for both parent and child is important. Key anticipatory guidance points regarding oral hygiene are as follows:

•Parents/caregivers should be encouraged to model and maintain good oral hygiene and a relationship with their own dental provider.

•Parents/caregivers, especially those with significant history of dental decay, should be cautioned to avoid sharing with their child items that have been in their own mouths.

•The child’s teeth should be brushed twice a day as soon as the teeth erupt with a smear or a grain-of-rice–sized amount of fluoridated toothpaste. After the third birthday, a pea-sized amount should be used.

•Parents/caregivers should help/supervise a child brushing his or her teeth until mastery is obtained, usually at around 8 years of age.

Fluoride
The delivery of fluoride to the teeth includes community-based options (water fluoridation), self-administered modalities (fluoride toothpaste and supplements), and professional applications (fluoride varnish). Each of these delivery mechanisms is useful in preventing dental caries.

Water fluoridation is a community-based intervention that optimizes the level of fluoride in drinking water, resulting in preeruptive and posteruptive protection of the teeth.19 Water fluoridation is a cost-effective means of preventing dental caries, with the lifetime cost per person equaling less than the cost of 1 dental restoration. Most bottled waters do not contain an adequate amount of fluoride.

Fluoride toothpaste is an important way to deliver fluoride to the surface of the tooth. Fluoride toothpaste has been shown to be effective in reducing dental caries in both primary and permanent teeth. It is important to limit the amount of toothpaste used to a smear or a grain-of-rice–sized amount for young children and no more than a pea-sized amount for children older than 3 years. Fluoride supplements should be prescribed for children whose primary source of drinking water is deficient in fluoride.

Fluoride varnish is a professionally applied, sticky resin of highly concentrated fluoride. Two or more applications of fluoride varnish per year are effective in preventing caries in children at high risk of all ages. In most states, pediatricians can apply and be paid for application of fluoride varnish to the teeth of young children. Application of fluoride varnish is even more effective when coupled with counseling. The US Preventive Services Task Force recently published a new recommendation that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption (B recommendation). More details and recommendations on fluoride can be found in the AAP clinical report “Fluoride Use in Caries Prevention in the Primary Care Setting.”

Other Important Anticipatory Guidance Topics
A frequent topic of discussion with parents is nonnutritive oral habits, such as use of pacifiers and thumb sucking. AAP policy states that parents consider offering a pacifier at naptime and bedtime because of a protective effect of pacifiers on the incidence of sudden infant death syndrome after the first month of life.27 Both finger- and pacifier-sucking habits will only cause problems with dental structures if they go on for a long period of time. Evaluation by a dentist is indicated for nonnutritive sucking habits that continue beyond 3 years of age.28

Dental injuries are common. Twenty-five percent of all schoolchildren experience some form of dental trauma. Pediatricians can help prevent such trauma by encouraging parents to cover sharp corners of household furnishings at the level of walking toddlers, recommend use of car safety seats, and be aware of electrical cord risk for mouth injury. Pediatricians can also encourage mouthguard use during sports activities in which there is a significant risk of orofacial injury.More information on dental trauma is available in the AAP clinical report “Management of Dental Trauma in a Primary Care Setting.”

Collaboration With Dental Providers
The AAP, the American Academy of Pediatric Dentistry, the American Dental Association, and the American Association of Public Health Dentistry all recommend a dental visit for children by 1 year of age. Although pediatricians have the opportunity to provide early assessment of risk for dental caries and anticipatory guidance to prevent disease, it is also important that children establish a dental home. A dental home is the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way.

Unfortunately, little is known about pediatric health care providers’ dental referral behaviors and patterns. Although 1 study found that children 2 to 5 years of age who received a recommendation from their health care provider to visit the dentist were more likely to have a dental visit, the US Preventive Services Task Force found no study that evaluated the effects of referral by a primary care clinician to a dentist on caries incidence. It is also noteworthy that preschool-aged children covered by Medicaid who had an early preventive dental visit by 1 year of age were more likely to use subsequent preventive services and to have lower dental expenses.

With early referral to a dental provider, there is an opportunity to maintain good oral health, prevent disease, and treat disease early. Establishing such collaborative relationships between physicians and dentists at the community level is essential for increasing access to dental care for all children and improving their oral and overall health.

Conclusions
Oral health is an integral part of the overall health and well-being of children. A pediatrician who is familiar with the science of dental caries, capable of assessing caries risk, comfortable with applying various strategies of prevention and intervention, and connected to dental resources can contribute considerably to the health of his or her patients. This policy statement, in conjunction with the oral health recommendations of the third edition of the AAP's Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, serves as a resource for pediatricians and other pediatric primary care providers to be knowledgeable about addressing dental caries. Because dental caries is such a common and consequential disease process in the pediatric population, it is essential that pediatricians include oral health in their daily practice of pediatrics.

Suggestions for Pediatricians

1.Administer an oral health risk assessment periodically to all children.

2.Include anticipatory guidance for oral health as an integral part of comprehensive patient counseling.

3.Counsel parents/caregivers and patients to reduce the frequency of exposure to sugars in foods and drinks.

4.Encourage parents/caregivers to brush a child’s teeth as soon as teeth erupt with a smear or a grain-of-rice–sized amount of fluoride toothpaste and a pea-sized amount at 3 years of age.

5.Advise parents/caregivers to monitor brushing until 8 years of age.

6.Refer to the AAP clinical report, “Fluoride Use in Caries Prevention in the Primary Care Setting,” for fluoride administration and supplementation decisions.

7.Build and maintain collaborative relationships with local dentists.

8.Recommend that every child has a dental home by 1 year of age.

中文翻译:
本文地址:http://www.wjbb.com/know/932
原文出处:http://pediatrics.aappublicati ... .full

美国儿科学会:研究显示有29%的高中生吸过电子香烟

灰太狼 发表了文章 • 1 个评论 • 1068 次浏览 • 2015-01-10 21:58 • 来自相关话题

全国数据表明青少年使用电子香烟正每年稳定增长。对夏威夷高中生一项新的研究发现,29%的高中生吸过电子香烟,明显高于之前预测。此研究《青少年只吸电子香烟与即吸电子香烟又吸香烟的风险因素》发表于2015年1月的《儿科学期刊》(网上发表于12月15日)。

该研究在2013年调查了夏威夷的1941名高中生。学生们报告了他们使用电子烟、烟、酒精和大麻的情况,以及药物滥用的相关社会心理因素,比如父母支持、学术参与、同伴抽烟和寻求刺激行为。研究者发现17%的学生报告只吸电子烟,12%的学生既吸电子烟也吸香烟,3%的学生只吸香烟。吸电子烟的学生,比起既吸电子烟又吸香烟的学生,社会心理风险因素更少。

研究者们认为,这使得电子香烟更可能将中等风险的青少年吸引去抽烟,而这些青少年本不会那么容易受到影响去抽烟的。

中文翻译:晴天绿海
本文地址:http://www.wjbb.com/know/922
原文出处:http://www.aap.org/en-us/about ... .aspx
原文下载:http://pediatrics.aappublicati ... -0760 查看全部


全国数据表明青少年使用电子香烟正每年稳定增长。对夏威夷高中生一项新的研究发现,29%的高中生吸过电子香烟,明显高于之前预测。此研究《青少年只吸电子香烟与即吸电子香烟又吸香烟的风险因素》发表于2015年1月的《儿科学期刊》(网上发表于12月15日)。

该研究在2013年调查了夏威夷的1941名高中生。学生们报告了他们使用电子烟、烟、酒精和大麻的情况,以及药物滥用的相关社会心理因素,比如父母支持、学术参与、同伴抽烟和寻求刺激行为。研究者发现17%的学生报告只吸电子烟,12%的学生既吸电子烟也吸香烟,3%的学生只吸香烟。吸电子烟的学生,比起既吸电子烟又吸香烟的学生,社会心理风险因素更少。

研究者们认为,这使得电子香烟更可能将中等风险的青少年吸引去抽烟,而这些青少年本不会那么容易受到影响去抽烟的。

中文翻译:晴天绿海
本文地址:http://www.wjbb.com/know/922
原文出处:http://www.aap.org/en-us/about ... .aspx
原文下载:http://pediatrics.aappublicati ... -0760
美国儿科学会是一个由53000名从事于保障婴幼儿和青少年体格、精神和社会生活健康的儿科医生、儿科医学专家和小儿内外科学者组成的组织。该学会拥有全面快捷的信息,是美国儿童养育及儿童健康的权威机构,并是美国及世界最具影响力的儿科研究学会。