儿童支气管哮喘与母孕期及新生儿期相关影响因素分析

目的 分析儿童支气管哮喘在母孕期及新生儿期的影响因素,为早期防治儿童哮喘提供依据。方法 选择306例哮喘患儿(哮喘组)和250例正常儿童(对照组),对所有儿童母孕期和新生儿期的临床资料进行调查。结果 单因素分析显示哮喘组与对照组在孕期使用抗生素、新生儿期使用抗生素、新生儿期服用益生菌、早产、剖宫产、低出生体重、母乳喂养方面比较差异有统计学意义(P0.05)。多因素logistic回归分析显示,孕期使用抗生素(OR=3.908,95%CI:1.277~11.962)、新生儿期使用抗生素(OR=24.154,95%CI:7.864~74.183)、早产(OR=8.535,95%CI:2.733~26.652)及剖宫产(OR=4.588,95%CI:2.887~7.291)为儿童哮喘的独立危险因素;而新生儿期服用益生菌(OR=0.014,95%CI:0.004~0.046)及母乳喂养6个月(OR=0.161,95%CI:0.103~0.253)为儿童哮喘的保护因素。结论 孕期减少抗生素的使用、减少剖宫产、新生儿期避免滥用抗生素、尽量母乳喂养、尽早添加益生菌可对儿童哮喘起到一定的早期预防作用。     

Cocaine use in pregnancy in Amsterdam

To study the effects of cocaine use in pregnancy in Amsterdam, clinical data on cocaine-using pregnant women ( n = 21) and their offspring ( n = 23) were obtained retrospectively (1987–1994) at the Academic Medical Center, Amsterdam. Infants exposed to cocaine had a median gestational age of 39 weeks and a median birth weight of 3090 g. There were six preterm infants, two small-for-gestational-age infants and five infants with a small head circumference. Three infants had a congenital malformation. One infant (Potter's syndrome) died shortly before birth. One infant had congenital syphilis, four had intracerebral abnormalities on ultrasound and four had abnormal neurologic symptoms in the neonatal period. One infant died after 21 days of life. At follow-up four infants showed abnormal development. In 12 of the 23 infants (52%), one or more possible effects of cocaine were found.     

Neonatal outcome in hypertensive disorders of pregnancy

Background

Hypertensive disorders in pregnancy account for increased perinatal morbidity and mortality when compared to uneventful gestations.

Aims

To analyze perinatal outcome of pregnancies complicated by different kinds of hypertension to uncomplicated pregnancies in a series of Italian women and to compare our data with series from other countries.

Study design

The sample was divided into four groups of hypertensive women: chronic hypertension (CH), gestational hypertension (GH), preeclampsia (PE), and chronic hypertension complicated by preeclampsia (CHPE). One thousand normal pregnancies served as controls.

Subjects

Neonatal features of the offspring of 965 Italian women with hypertension in pregnancy were evaluated.

Measures

Gestational age, birthweight and the rate of small for gestational age were the outcomes. Perinatal asphyxia and mortality were also assessed.

Results

Gestational age, the mean of birth weight and birth percentile were significantly lower in all groups with hypertensive complications when compared with controls. The rate of very early preterm delivery (< 32 weeks) was 7.8% in CH, 5.9% in GH, 21.2% in PE and 37.2% in CHPE while it was to 1.2% in the control group. The rate of SGA was globally 16.2% in CH, 22.8% in GH, 50.7% in PE, 37.2% in CHPE and 5% in controls. The rate of SGA in PE was much higher than reported in series from other countries.

Conclusion

Comparing our data with those reported from other countries, it is evident that the rate of fetal growth restriction in PE we found in our center, is significantly higher even in the presence of a global lower incidence of PE.     

Impact of maternal work outside the home during pregnancy on neonatal outcome

The impact of mothers' work during pregnancy upon neonatal outcome has not been fully elucidated. A study of maternal health habits and neonatal outcome conducted from 1977 to 1979 at Boston City Hospital assessed the effects of paid work outside the home during pregnancy, particularly third trimester work in a standing position, upon duration of gestation and intrauterine growth, while controlling for potentially confounding variables. Postpartum, 1,690 low-income women were interviewed to provide detailed information on their sociodemographic and health characteristics. Of the 1,507 women whose work status during pregnancy could be classified, 55% did not perform paid work outside the home or attend school, 7% worked into the third trimester in a standing position, and 38% had other work histories or attended school. Infants were examined according to a standard protocol by pediatricians blind to mothers' work history. There was no significant relationship between the mothers' work history during pregnancy and the infants' length of gestation, weight, or head circumference at birth, when confounding variables were controlled statistically by multiple regression analyses. However, women who worked in a standing position into the third trimester delivered infants who were longer than infants born either to mothers with other work histories or to mothers who did not work or attend school. Healthy women with uncomplicated low-risk pregnancies who feel well enough to attend school or work during pregnancy, even in a job requiring some standing, may do so without fear that their infant will suffer shortened gestation or impaired intrauterine growth.     

Medication use during pregnancy and the risk of childhood cancer in the offspring

The young age at onset of many cancers in childhood has led to investigations on maternal exposures during pregnancy. Data from a population-based case-control study in Germany (1992–1997) that included 1,867 cases and 2,057 controls was used to investigate this question. Maternal use of vitamin, folate or iron supplementation was associated with a reduced risk of non-Hodgkin lymphoma and tumors and, less clearly, with leukemia, but not with CNS tumors. An increased risk of neuroblastoma was associated most markedly with diuretics and other antihypertensives, but also with vitamin, folate or iron supplementation. No associations were seen with pain relievers, antinauseants or cold medications, nor with delivery by Caesarian section. The strengths of this study are its population base, the large number of cases and the inclusion of different case groups to identify disease specificity of associations. The limitation of this study is an exposure assessment relying on maternal self-reports. In conclusion, these data indicate a potential influence of some maternal medication during pregnancy on the risk of childhood cancer in the offspring; however, no clear picture is seen. Sponsored by the Federal Ministry for the Environment, Nuclear Safety, and Nature Protection.     

Alcohol and substance abuse identified during pregnancy: maternal morbidity, child morbidity and welfare interventions

Aim: To study the relations between postnatal maternal morbidity, child morbidity and welfare interventions in families with prenatal alcohol or substance abuse. Methods: A register‐based longitudinal retrospective cohort study. The exposed cohort included 638 children born to 524 women followed‐up during pregnancy for alcohol or substance abuse 1992–2001. Non‐exposed children (n = 1914) born to control women were matched for maternal age, parity, number of foetuses, month of birth and delivery hospital of the index child. Perinatal and follow‐up data of both cohorts were collected from national registers until 2007. Results: Postnatal maternal abuse‐related healthcare utilization and use of medication were associated with child out‐of‐home care. Significant differences were in particular observed in the categories of maternal mental and behavioural disorders caused by psychoactive substance use as well as injury and poisoning. Maternal inpatient care for mental and behavioural disorders peaked at the time of child out‐of‐home care. Maternal abuse‐related healthcare utilization was associated with early child healthcare utilization and use of medication for mental and behavioural disorders. These associations were largely explained by the association with child out‐of‐home care. Conclusions: Postnatal maternal abuse‐related morbidity is associated with significant early child morbidity, use of medication and timing of out‐of‐home care.     

Management of women who use drugs during pregnancy

Substance abuse in pregnancy is associated with significant maternal and fetal morbidity. The complication for care is that the mother is the cause of the problem that potentially harms not only herself but also her unborn child. The abuse is further complicated by the associated legal, social and environmental problems. The aim for the obstetrician is to provide a non-judgemental, supportive environment to minimise the risk, not only during pregnancy and the neonatal period, but also in the long term. To achieve this, caregivers need to be multidisciplinary and tolerant of the mother's problem. The aim of antenatal care is to reduce risk, which does not mean that the mother must abstain from drug use. The aim is to keep her within the care system and encourage her to take responsibility for her situation. No-one should be turned away or denied help as, ultimately, this is harmful to the mother and her baby. To provide this care, the obstetrician needs support from midwives, addiction counsellors, social workers, neonatologists, health visitors and general practitioners. Whereas the healthcare structure in the UK lends itself to this approach, this is not the case in other parts of the world. However, programmes of comprehensive antenatal care do not universally improve the health of the mother and the outcome of her pregnancy. The specifics of the care provided are probably less important than the quality of the care given and the degree of engagement of the individual. This chapter outlines the problems and potential solutions with reference to the service in Leeds in the UK.     

Effects of maternal cigarette smoking and cocaine use in pregnancy on fetal response to vibroacoustic stimulation and habituation

Background: Cigarette smoking and cocaine use in pregnancy are common in the US and both are risk factors for sudden infant death syndrome (SIDS). Although the cause of SIDS is not known, one postulated mechanism involves abnormalities of arousal and arousal regulation. Cigarette smoking and cocaine use may cause deficits of arousal. Many believe arousal deficits occur prenatally. Aims: The aim of this study was to assess the effects of cigarette smoke and cocaine exposure during pregnancy on measures of fetal arousal and arousal competency: 1) the fetal response to vibroacoustic stimulation (VAS) and 2) habituation to VAS. Hypothesis: Maternal cigarette smoking and cocaine use in pregnancy are associated with altered arousal and arousal regulation in the fetus. Methods: Three groups of mother-fetal dyads were enrolled: 1) cigarette smokers (n = 54), 2) cocaine users (n = 30), and 3) controls (n = 60). One hundred eight fetuses were tested at 29-31 wk gestation, 119 at 32-35 wk, and 118 at 36+ wk. The fetal response to VAS was assessed using real-time ultrasound and a paradigm of arousal responsiveness. Responders were tested with repeated VAS to assess habituation. Also, the quality of fetal reactivity to repeated stimuli was assessed as a measure of arousal and arousal regulation competence (Behavioral Reactivity Scale). Results: The control group had a larger proportion of fetuses who were too active to initiate testing ("too active to test") (p = 0.013); the proportion of fetuses too active to test decreased with increasing gestational age. The majority of the fetuses who could be tested responded to the initial VAS, and there were no group differences. The proportion of fetuses that habituated and the rate of habituation did not differ between the groups. Behavioral reactivity did not differ between groups.

Conclusions: The original hypotheses were not confirmed. However, the chosen assessment paradigms may have lacked sensitivity. The proportion of fetuses that were "too active to test" decreased with gestational age. The control group had a larger proportion of fetuses that were "too active to test" compared with the exposure groups. We speculate that these findings indicate that prenatal exposure to these neuroteratogens may have produced an acceleration of the behavioral response to vibroacoustic stimulation.     

小儿脑性瘫痪母亲妊娠期危险因素的Meta分析

目的：探讨小儿脑性瘫痪母亲妊娠期的主要危险因素,为今后防治工作提供依据。方法：以“小儿脑性瘫痪”“妊娠期”“危险因素”和“病例对照”等为检索词,收集1998~2011年关于小儿脑性瘫痪发病危险因素的研究文献,应用Meta分析的固定效应模型及Dersimonion-Laird随机效应模型,综合定量评价小儿脑瘫妊娠期相关危险因素的作用。结果：共18篇文献纳入研究,累计病例11050例,对照15941例。小儿脑瘫妊娠期危险因素的多因素分析结果如下:孕母高龄(≥35岁)（OR=4.172,95%CI：1.670~10.426,P0.05)、妊娠高血压综合征（OR=4.096,95%CI：2.246~7.469,P0.05)、父亲吸烟（OR=2.376,95%CI：0.801~7.049,P>0.05)。结论：孕母高龄(≥35岁)、多胎妊娠、母孕早期用药、有害环境、孕母反复阴道流血、妊娠高血压综合征是小儿脑性瘫痪发病的母亲妊娠期主要危险因素。     

Risk of stillbirth in relation to maternal haemoglobin concentration during pregnancy

The authors determined the association between maternal haemoglobin concentration measured at <28 weeks' gestation and late fetal death at >or=28 weeks' gestation (stillbirth). Data were derived from the National Maternal and Infant Health Survey--a nationally representative survey of US deliveries in 1988. Analysis was restricted to women with a singleton live birth (n = 4,199) or a stillbirth (n = 1,375) for whom maternal prenatal care, haemoglobin, smoking status and gestational age data were available. Haemoglobin concentrations during first and second trimesters, respectively, were classified as mild (10.0 to <11.0 and 9.5 to <10.5 g dL(-1)) or moderate (9.0 to <10.0 and 8.5 to <9.5 g dL(-1)) anaemia, or high haemoglobin (>or=14.6 g dL(-1) in either trimester). Hazard ratios (HR) and 95% confidence intervals (CI) for stillbirth were derived from discrete proportional hazards regression models after adjusting for confounders. Stillbirth was not associated with mild anaemia or high haemoglobin in either the first or second trimester of pregnancy. Moderate anaemia measured before 28 weeks' gestation was significantly associated with an increased risk of stillbirth among non-black women (adjusted HR: 4.4; 95% CI: 1.02, 19.01). Moderate anaemia was not associated with stillbirths among black women. Further investigation regarding causal mechanisms for this association is warranted.     

Insulin dependent diabetes in pregnancy: Impact of maternal blood glucose control on the offspring

Definition of optimal glycaemic control in diabetic pregnancy may still be debated. Measures of glucose control (based on 4–6 daily glucose and frequent HbA_1c values) were recorded in two series of diabetic pregnancies; one multicentre study (n= 92, 1979–82), and one study from our own institution (n= 113, 1983–85). The average pregnancy glucose levels were 5.9 mmol/L (third trimester only) and 6.5 mmol/L (all trimesters), respectively. Discriminant analysis (including pregnancy glucose, HbA_1c, gestational age, diabetes duration and hypertension) revealed that gestational age only (first series) and gestational age and HbA_1c independently of each other (second series) were significantly associated with the occurrence of severe neonatal morbidity present among 30 and 16.8% of the infants, respectively. The overall outcome was favourable. The findings of no perinatal mortality, normal premature delivery rate (8.9%) and a very low rate of severe maternal hypoglycaemia (4.4%) in series two support the feasibility of a strict but individualized management programme.     

A longitudinal study on the effects of maternal smoking and secondhand smoke exposure during pregnancy on neonatal neurobehavior

Maternal smoking during pregnancy is one of the most modifiable causes of morbidity and mortality for both pregnant women and their fetuses. The long-term effects of prenatal exposure to smoke on child behavior and development have been the subject of more extensive research than have the short-term effects. Therefore, the aim of this work is to examine the effects of smoke exposure during pregnancy on neonatal behavior, including in our study a group of mothers exposed to secondhand smoke. The behavior of 282 healthy full-term newborns was assessed using the Neonatal Behavior Assessment Scale (NBAS) at 48-72 h of life. Sixty-two mothers smoked during pregnancy (no mother smoked more than 15 cig/day) and 17 were exposed to secondhand smoke. After adjusting for socio-demographic and obstetric factors, both newborns whose mothers smoked and those whose mothers were exposed to secondhand smoke showed significantly lower scores in the habituation cluster than non-smoking mothers. Exposure to secondhand smoke was also related to lower motor system cluster scores as well as some supplementary items and the newborns of smoking mothers showed significantly lower scores in the state regulation cluster and in some items of the state organization cluster than the newborns of non-smoking mothers. We conclude that active and passive smoking during pregnancy affects several aspects of neurobehavioral development, regardless of socio-demographic, obstetric and pediatric factors.     

Long-term impact of maternal substance use during pregnancy and extrauterine environmental adversity: stress hormone levels of preadolescent children

Prenatal cocaine exposure (PCE) is associated with blunted stress responsivity within the extrauterine environment. This study investigated the association between PCE and diurnal salivary cortisol levels in preadolescent children characterized by high biological and/or social risk (n = 725). Saliva samples were collected at their home. Analyses revealed no group differences in basal evening or morning cortisol levels; however, children with higher degrees of PCE exhibited blunted overnight increases in cortisol, controlling for additional risk factors. Race and caregiver depression were also associated with diurnal cortisol patterns. Although repeated PCE may contribute to alterations in the normal or expected stress response later in life, sociodemographic and environmental factors are likewise important in understanding hormone physiology, especially as more time elapses from the PCE. Anticipating the potential long-term medical, developmental, or behavioral effects of an altered ability to mount a normal protective cortisol stress response is essential in optimizing the outcomes of children with PCE.     

Impact of maternal influenza vaccination during pregnancy on the incidence of acute respiratory illness visits among infants

OBJECTIVE: To determine whether influenza vaccination of pregnant women prevents visits for respiratory illness in their infants born during the influenza season. DESIGN: Retrospective matched cohort study. SETTING: Four managed care organizations in the United States. Patients A total of 41 129 infants (3160 and 37 969 born to vaccinated and unvaccinated mothers, respectively) born between 1995 and 2001. Main Exposure Maternal influenza vaccination. Infants were considered exposed if their gestational age at birth was at least 30 weeks, if the time from maternal vaccination to birth was at least 28 days, and if they were exposed to at least 14 days of the influenza season. MAIN OUTCOME MEASURES: Incidence of acute respiratory illnesses (outpatient, emergency department, and inpatient settings combined) and incident rate ratios (IRRs) for infants exposed and unexposed to maternal vaccination during the following 4 periods: peak influenza, respiratory syncytial virus predominant, periseasonal, and summer weeks. The time to the first acute respiratory illness during peak influenza weeks was also assessed. RESULTS: During the peak influenza weeks, infant visit rates were 15.4 and 17.1 per 100 person-months for exposed and unexposed infants, respectively (IRR, 0.90; 95% confidence interval, 0.80-1.02). Adjusted IRRs for the 4 periods found a protective effect of infant female sex, whereas Medicaid status and maternal high-risk status increased infant visit rates. Maternal influenza vaccination did not reduce visit rates during any of the 4 time periods (IRR for peak influenza season, 0.96; 95% confidence interval, 0.86-1.07) and did not delay the onset of first respiratory illness. CONCLUSION: We were unable to demonstrate that maternal influenza vaccination reduces respiratory illness visit rates among their infants.     

Impact of sustained neuromuscular blockade on outcome of mechanically ventilated children

Background: Neuromuscular blocking agents (NMBA) are commonly administered to critically ill children in pediatric intensive care units (PICU) in the USA and Europe. Although NMBA are frequently used in PICU patients, their role in the PICU setting has not yet been clearly defined. The aim of this study was to describe the sustained administration of NMBA and its impact on outcome of PICU patients. Methods: A 3‐year retrospective cohort study was conducted to compare mechanically‐ventilated patients who received NMBA for at least 12 h with patients who did not (control group). Results: A total of 317 consecutive patients were ventilated over 3473 days. Patients were similar in age, weight and severity scores. Thirty‐four children (10.7%) received NMBA. Compared with controls, the neuromuscular blockade (NMB) group had a longer duration of mechanical ventilation (13.7 vs 5.5 days, P= 0.000), longer PICU stay (20 vs 11 days, P= 0.000) and increased occurrence of ventilator‐associated pneumonia (6.6 vs 4.1/1000 ventilator days, P= 0.010). The NMB use was not associated with higher mortality (8.8% vs 17.6%, P= 0.287) or longer hospital stay (30.5 vs 23 days, P= 0.117). Conclusion: Although the use of NMBA was not associated with greater mortality, we found that sustained use of NMBA is associated with prolonged mechanical ventilation, longer PICU stay and higher incidence of ventilator‐associated pneumonia when compared with controls. Larger studies are necessary to confirm these findings.     

Cracking the whip on childhood mortality – role of the specialized neonatal unit in Eritrea

Health care services in developing countries are being challenged by high childhood mortality rates. Although there have been tremendous strides made in reducing infant mortality rates largely due to vaccinations and improved standards of living, a lot remains to be done to reduce neonatal mortality. Achievement of the Millennium Development Goal (MDG) number 4 on childhood mortality will remain unattainable in most developing countries unless purpose based interventions targeted at reducing neonatal mortality are instituted. This viewpoint is based on the experiences gained in Eritrea, a country that gained independence less than twenty years ago following a protracted war that left a trail of destruction of infrastructure in general and health facilities in particular. War that broke out with Ethiopia less than 10 years into its independence and border conflicts followed by a no peace no war stalemate situation aggravated by frequent droughts have continued to throttle economic recovery, reconstruction and rehabilitative efforts. The population is estimated at 3.5 million comprising of nine ethnic groups who speak different languages. The country has a surface area of 124 000 km² which shares borders with Sudan, Ethiopia, Djibouti and the Red Sea.
Conclusion: Attainment of the MDG number 4 on reduction of childhood mortality can be achieved by addressing morbidities of the neonate where the bottle neck currently appears to be sited.