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EPA Newsletter/Issue 12/December 2011 EDITORIAL
Consolidating Tasks, Our Continuous Day-Work
Dear Colleagues and Friends,
In the frame of the successful Excellence in Pediatrics latest edition in Istanbul, and with the warm hospitality given by the Turkish Pediatric Association, EPA has held the General Assembly. The normally dense agenda was in this case of particular interest coming from the elections, almost re-elections, thus allowing to continue the tasks that our constitutional short term periods do not often allow us this opportunity. President Prof. Konstantopoulos, Vice President Prof Baranov, Secretary Prof Pettoello-Mantovani, Treasurer Prof Ehrich were all re- elected. Great felicitations for all of them. Professor Laszlo Szabo is quitting us after a long period of continuous and intelligent service. We all are going to miss his judicious interventions, his new department will benefit from the recuperated time. Professor Julije Mestrovic has been elected councilor, he has been collaborating in many important tasks for long time with EPA, may he be welcomed. Only Prof Fugen Cullu and myself were the Council remnants to witness these important issues. This editorial is not trying to compete with the minutes of the GA session, but I am obliged to quote, although briefly, some information related to the ongoing projects: Advisory Groups, Alliance, Educational program all of them are adequately in progress and without doubt will give EPA a greater functionality towards our members national societies or individual.
Newsletter. This is issue 12, thus meaning that NL is 3 three years old, with a reasonable growth velocity and content composition. Since life in the e-literature is fast, then this is probably the moment for thinking about an
adaptation to this spiral of required changes. The first and most important is the incorporation of a co-editor. Juha Halonen, medical writer and PhD with a great experience in this field, has been undertaken this position. The first action consisted in a survey among our members, and after analyzing 603 complete responses, some new newsletter headings will soon be introduced. A practical modification of the cover page has also been agreed, but importantly without losing the identity signs or traits that during the previous years have already identified our publication and made it highly valued. The concept and spirit of a newsletter will be untouched.
Finally it is pertinent to comment on how EPA is required in an important meeting with health authorities to design and carry out programs to increase child health, particularly in areas where improvements are now converging to the European standards. In Tashkent (Uzbekistan) in the past month of November, there was a Round Table on 'Priority actions forachieving Millennium Development Goals 4 and 5 in the European Region'. The meeting, with an intervention on pediatric nutrition, was attended by a majority of Health Ministers of central Asian countries, European representatives, WHO European Region, UNICEF, World Bank, and experts from international organizations such as EPA. It is clear that our Eastern border does not have a definite frontier, and it is also equally clear that our non-colonizing intentions but the fact of intervening there supports the growing respect of our Association.
Manuel Moya Editor of Newsletter
6th EUROPAEDIATRICS CONGRESS
Jointly held with the Royal College of Paediatrics and Child Health 5-8 June 2013, Glasgow, UK, Scottish Exhibition & Conference Centre
The Europaediatrics Congress is the highlight of the activities of the European Paediatric Association (EPA/UNEPSA).
Taking place every two years, this is the flagship event of the EPA/UNEPSA and the meeting point of general paediatricians and paediatric subspecialists not only from Europe but from all over the world.
The Annual RCPCH Conference, addressed to the general paediatrician and the specialist alike, provides a programme that ensures plenty of time for discussion, debate and learning. Prestigious speakers provide updates on key clinical issues and the latest paediatric science through a number of exciting session formats such as the Personal Practice Sessions, the Specialty Group programmes and the Hot topics session.
ANNOUNCEMENT
European Paediatric Association (EPA/UNEPSA)
Join the most extensive paediatric network in Europe!
Since the launch of the individual membership scheme, the European Paediatric Association (EPA/UNEPSA) embraces a constantly increasing number of individual members from all over Europe.
EPA/UNEPSA welcomes all doctors who are certified as paediatricians in Europe and are members of their respective National Paediatric Society/Association participating in EPA/UNEPSA.
By joining EPA/UNEPSA, you gain access to a network of 41 national European associations and open yourself to a new world of opportunities.
Benefits
The individual membership is offered at a privileged 50 Euro annual fee and encompasses a set of benefits that aim to provide value to the wide community of European paediatricians.
• On line access to the Evidence Based Child Health
Journal is a core benefit of individual membership to
our association and we are excited by the prospect of
making such a valuable resource widely available to paediatricians across Europe.
• Our members will enjoy reduced registration fees to Europaediatrics as well as to other events organised by our Association.
• The quarterly e-newsletter aims to be a source of current information relevant to the interests of European paediatricians.
• Finally, our members will find in our new website a valuable tool and resource (access to the members-only section, members'forum and working groups, access to educational programmes, complimentary or privileged prices for additional on-line services, etc.)
Individual membership is offered on an annual basis starting on the 1st January of each year and ending on the 31st of December.
You may apply on line for an individual membership. Please visit our website www.epa-unepsa.org for more details and to fill out a registration form.
We look forward to welcoming all of you in EPA/UNEPSA!
UPDATE IN PAEDIATRIC GENERAL PRACTICE
Is It Possible To Prevent Acute Otitis Media?
An affirmative response after Evidence Based Medicine
Manuel Moya
Vice-President, European Paediatric Association/Nutritional Adviser, International Pediatric Association/ Catedratico y Jefe de Servicio, Professor & Head/Paediatric Department, Universidad Miguel Hernandez,
San Juan, Alicante, Spain/manuel.moya@umh.es
In spite of adequate innate and adaptive immune responses Acute otitis media (AOM) is the most common pediatric bacterial infection in developed countries (83% of children < 3y one episode) and causes significant morbidity, hearing loss and sometimes infection of neighboring bone or central nervous system.
The most frequent bacteria causing AOM are Streptococcus pneumoniae (42%), non-typeable Haemopbilus influenzae (31%) and Moraxella catarrhalis (16%), these are the commoner agents out of the nasopharynx flora. The role of viruses in recurrent AOM as direct agents remains uncertain, in the nasopharynx co-detection of nucleic acids from human rhinoviruses and other respiratory viruses with the commoner bacteria was similar in children suffering from AOM to healthy children.
The primary defects leading to AOM are the Eustachian tube dysfunction and obstruction of the latter because in
children the tubes are shorter, more horizontal and surrounded by enlarged adenoidal tissue. This means viral infections can cause tube inflammation and patency narrowing. The following obstruction impairs the mucociliary clearance with a subsequent accumulation of mucus in the middle ear and a resorption of the air in this space leading to a decreased pressure that pulls bacteria from the nasopharynx which proliferate and give way to AOM. Other favoring factors are low levels of IgA, of defensins, orofacial abnormalities, pollution.
How do we recognize an AOM? First it is important to separate AOM from Otitis media with effusion (OME). In the first case the inflammation of the middle ear appears as acute ear pain (or unexplained irritability in the preverbal child), temperature of 39°C plus a general picture of restlessness, night wakening, cold symptoms and rare cases of balance problems. Otoscopy (atmospheric) slight tympanic
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membrane bulge and probably a slight meniscus or a fluid layer of purulent effusion at the membrane bottom or at its posterior part if lying down. Beware: red tympanic membrane and fever are not specific for AOM and could lead to over diagnosis. Pneumatic otoscopy is useful but not widely used because of the pain it may cause. Conversely ОМЕ shows fluid in the middle ear without signs or symptoms of infection.
Once the diagnosis of AOM is ascertained, most of the current guidelines recommend deferring antimicrobial treatment therapy for 48 hours. This is because before this period spontaneous resolution frequently occurs, but in practice and because of the complications this attitude is not followed and PCPs normally go straight for beta lactam antibiotics. The Centers for Disease Control and Prevention (CDC) stress the importance of appropriate antibiotic use, the over prescription in USA in the last 10 years has decreased by 24% for the most common upper respiratory tract infections but not for AOM. Because of this policy of non over use of antibiotics, prevention is emerging with renewed force.
Prevention. Probably the most efficient measure is the simplest hand washing may prevent cold and flu with their initial step of Eustachian tubes obstruction. The opportunistic recommendation of conjugated pneumococcal vaccine merits reconsideration, particularly after the initial studies in Holland that did not lend support to the use of conjugate pneumococcal vaccines to prevent recurrent ОМА in unvaccinated toddlers/children. The limited serotypes on the vaccines and the growing rates of Haemophilus or Moraxella probably justify these results. Not to mention the evident serotype replacement such as is the increase of carriers of serotype 19 A with its increased antibiotic resistance
Then new possibilities have been evaluated such as the use of xylitol. Xylitol is a non-fermentable 5-carbon sugar alcohol, well known for its sweetening properties, lower energy content and low glycemic index of 13 and for its caries prevention capacity. In the case of AOM prevention there lies a double mechanism, first, bacterial cell adherence occurs by means of a variety of sugars, xylitol forms a sugarlike structure hindering adherence to nasopharyngeal cells, secondly, this being a non-fermentable sugar as the mono or disaccharides binds to bacteria starving it even in presence of other sugars. Then in conclusion xylitol prevents adherence and growth of Streptococcus pneumoniae, Haemophilus, Moraxella and others as has been documented since 1998 when M. Uhari demonstrated AOM prevention effect when given in syrup or chewing gum, lately it has been recognized that doses should be greater than 3.5 g/day and how in the form of chewing gum it was more effective because chewing and swallowing are also clearing the middle ear.
At this point it Is worth commenting on the important data given by A Azar-pazhoon et al. from Cochrane Acute Respiratory Infections Group. In an Intervention Review they identified four studies with the adequate methods required by an informative randomized controlled trial {RCT), all of them coming from Finland and totalized 3,103 children aged 12 years or younger, where xylitol supplementation was compared to placebo or no treatment to prevent AOM. This article describes perfectly the type of studies, primary
and secondary outcomes plus details related to the search, one of them being Data collection and analysis. Results of the four studies include the issues in young children unable to chew gum, and the older ones doing so (Forest plot) and also the comparison between the different xylitol vehicles. Then the main results are: xylitol chewing gum was superior to xylitol syrup in prevention of AOM in healthy children: Relative Risk (RR) 0.59,95% confidence interval (Cl) 039 to 0.89, then the magnitude of reduction was greater than 41% (1 — RR 0.59).This preventive action did not occur when xylitol was given to children with acute respiratory infections. Preventive effect of xylitol lozenges or syrup was not different in healthy children or with acute respiratory infection. Being the RR < 1,0 and Cl with values lower and higher than 1.0 we can extract from the Plain language summary that a daily dose of 8.4 g of xylitol can prevent acute otitis media in children without acute upper respiratory infections attending day care centers. This is clearly a new opportunity particularly for those who are repeatedly suffering from AOM.
References
1. American Academy of Pediatrics. Subcommittee on management of acute otitis media. Diagnosis and management of acute otitis media. Pediatrics 2004; 113:141-65.
2. Azarpazhooh A., Limeback H., Lawrence H.P., Prakesh-kumar S.S. Xylitol for preventing acute otitis media in children up to 12 years of age. Cochrane Database Syst Rev. 2011 Nov 9;11: CD007095.
3. Centers for Disease Control and Prevention (CDC). Office-related antibiotic prescribing for persons aged ^ 14 years — United States 1993-94 to 2007-08. MMWR Morb Mortal Wkly Rep 2011; 60:1153-6.
4. Cohen R., Levy C., Bonnet E., Thollot F., Boucherat M., Fritzell B. Risk factors for serotype 19A carriage after introduction of 7-valent pneumococcal vaccination. BMC Infect Dis 2011;11: 95-6.
5. Guidelines and Protocols Advisory Committee -Otitis media: Acute otitis media. 2010. http://www. bcguidelines.ca/guideline_otits.html
6. Hoberman A. Paradise J.L., Shaikh N., Greenberg D.P., Kearney D.H., Colborn D.K. Pneumococcal resistance and serotype 19A in Pittsburg-area children with acute otitis media before and after introduction of 7-valent pneumococcal polysaccharide vaccine. Clin Pediatr (Phil) 2011; 50; 114-20.
7. Underwood M., Bakaletz L. innate immunity and the role of defensins in otitis media. Curr Allergy Asthma Rep. 2011; 11: 499-507.
8. Veenhoven R., Bogaert D., Uitervaal C., Brower C., Kiezebrink N. Effect of conjugate pneumococcal vaccine followed by polisaccharidepneumococcal vaccine on recurrent acute media: a randomized study. Lancet 2003; 361: 2189-95.
9. Wiertsema S.P., Chidlow G.R., Kirkham L.A., Corscad-den K.J., Mowe E.N., Vijayasekaran S. High detection rates of nucleic acids of a wide range of respiratory viruses in the nasopharynx and the middle ear of children with a history of recurrent acute otitis media. J Med Virol 2011; 83: 2008-17.
NEWS FROM AROUND THE CONTINENT
16th Congress of the European Union for School and University Health and Medicine. Moscow, Russia on 9-11th June 2011 Brief review from Union of pediatricians of Russia
For the first time in the history of Russia, on the 9-11th of June 2011 in Moscow the 16th Congress of the European Union for School and University Health and Medicine «EUSUHM-2011 «was held.
The motto of the Congress was: Education and health from childhood to adult life. Organizers of EUSUHM-2011: The European Union for school and University medicine (EUSUHM), Union of pediatricians of Russia (UPR) (www.pediatr-russia.ru), Russian Ministry of health and social development, Russian society for school and university medicine.
The Congress was attended by 1197 experts from 22 countries (Belarus, Belgium, Great Britain, Hungary, Denmark, Germany, India, Spain, Italy, Kyrgyzstan, China, Moldova, Netherlands, United Arab Emirates, Russia, Slovenia, Ukraine, Croatia, Finland, Sweden, Switzerland and Estonia). 119 reports were presented. At the poster alley 98 reports were also demonstrated.
The Scientific program included a discussion of the following issues:
1. Preserving and improving the health of pupils, students of educational institutions, promoting a healthy lifestyle.
2. Physical health of preschool children, schoolchildren and students.
3. Healthy nutrition and physical activity of schoolchildren.
4. Neuro-psychological, cognitive development and health of preschool children, pupils and students.
5. Reproductive health of children, adolescents and youth.
6. Clinics, youth friendly.
7. Vaccination in children, adolescents and young adults.
8. Physical health of students: early detection of abnormalities, affecting the learning process, and its prevention.
9. Career counseling and assistance in choosing the profession.
10. Children with disabilities: medical-psychological and social rehabilitation.
11. International Classification of Functioning, work incapacity and health — the version for children and youth (ICF CY).
12. The role of school nurses in child healthcare.
13. Strengthening the role of parents in children's healthcare.
14. Use of new technologies in the pediatric healthcare system.
15. Medical and psychological support for young sportsmen.
Leading specialists from WHO, IPA, EPA, EUSUHM, UPR took part in the plenary sessions dedicated to the more actual issues of school medicine and whole pediatrics: challenges and future projects for preschool, school and university healthcare, control tobacco in children and adolescents, early identification of developmental problems, etc.
The results of all discussions and sharing the experience were following:
Despite the fact that we live in different systems (social, educational, etc.), formulation and review of medical and psycho-pedagogical problems of education in children, adolescents and students is actual and timely in all countries.
We need to continue our united activities directed on health promotion (school, universities, kindergarten, nursery schools, community) for providing psychical, mental and sexual welfare for children and youth, formation of healthy life style for children in the World.
INTERNATIONAL SYMPOSIUM: The National Model of Maternity and Childhood Health Protection in Uzbekistan: Healthy Mother-Healthy Child
This symposium was held in Tashkent last November under the initiative of the President of Uzbekistan Mr. I Karimov. It encompassed three main sessions: A Round Table with the ministries of Health and international organizations concerned with health in children, a Main session on the Uzbek model 'Healthy mother — healthy child' with the intervention of the President, WHO General Director and the Minister of
Health, these were followed by the contributions from different representatives to this plan and finally a third session dealing with specific aspects of child health. On this occasion the Vice President Prof Manuel Moya was representing EPA and was intervening in the three sessions respectively with an analysis of the European variations concerning the neonatal and post neonatal screening, newborn transport and nutrition.
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Centennial Congress Scientific Report
1. Approach of the Scientific Program
The subjects discussed in the Congress, were considered from a different perspective in comparison with subjects discussed in the other Pediatric National Congresses or in the heart of our Society. We wanted to focus on the aspect that «surrounds» diseases and not in their clinical description.
This approach allowed us to observe multiple factors that are present in Pediatrics and that are usually hidden from our daily work; this also opened up the path to the interaction of similar disciplines, which are closely connected with medicine.
Likewise, the special characteristics of the event, which were closely related to the fact that we were commemorating the 100 years of history of our Society, lead us to the organization of a special structure in other aspects. The idea was to create a meeting where several subjects had a look to the past, that is to say retrospective — in order to emphasize the difficulties, achievements, failures as well as remembering our teachers who guided us and where our role models; a look to the present — pointing out the advances but also the main problems, especially the ones in the social field, the inequities of care, the contradictions in ethics and the multiple difficulties in the practice of our profession.
Finally the subjects also had to have a look to the near future so as to stress the aspects that have the most chances to benefit the health of the population and to emphasize the increasing moral dilemmas that we will have to face.
As we have already pointed out, in order to build up this program, having the same point of view with the lectures and people participating in the scientific sessions was essential. These persons showed their enthusiasm with the agenda at all times and helped in its construction. We also had the possibility to count with the assistance of professionals of other disciplines such as anthropology, sociology and, in a lesser degree; philosophy.
2. Activities
Conferences
We held 36 conferences, of which 60% were in charge of the foreign lecturers. As an indicator of compliance of the
aforementioned approach, a 75% of the conferences tackled aspects that go beyond the field of medicine.
Sessions
86 sessions, where different subjects were raised, were held, and its majority was carried out by the Committees, the Sub commissions, and the Tasks Groups of the Sociedad Argentina de Pediatria.
Panels
38 Panels with the participation of experts were carried out. Their modality consisted of questions, which had tobeon-topic but could refer to any aspect of interest, and answers.
Among the scientific activities we also included the tribute to Dr. Carlos Gianantonio, the most important figure in Argentinean Pediatrics, through the display of three videos of his conferences.
This tribute had an enormous impact and also awakened a remarkable expectation, as a result the conference rooms where the videos were displayed could not handle the amount of people who gathered there, and thus many pediatricians missed the tribute. As a consequence and also because of the request made by the Scientific Committee, the videos were uploaded to the webpage of the Society and are now available to everyone.
Conclusions
In our opinion, there was a very good chance that with the Congress's approach we achieved several goals that will surely allow us to have a different perspective regarding the different aspects involved in the practice of Pediatrics.
To have the chance to take look of what we did, what we do nowadays and the need of an interdisciplinary Pediatrics, will surely be motive to make a deep reflexion and with any luck this may help us give a better care to health in the period of life which takes place from the birth of a child up to his adulthood.
Dr. Jose Maria Ceriani Cernadas Dra. Margarita Ramonet
CALENDAR OF EVENTS
EPA-UNEPSA MEETINGS
EPA/UNEPSA 2012 Spring Workshop & Schools
27-28 April 2012, Alicante, Spain
6th Europaediatrics Congress jointly held with the Royal College of Paediatrics and Child Health
5-8 June 2013, Glasgow, UK
MEMBER SOCIETIES' MEETINGS
Royal College of Paediatrics and Child Health Annual Conference 2012
22-24 May 2012, Glasgow, United Kingdom
48th National Turkish Pediatric Association Congress
May 2012 (exact date TBC), Antalya, Turkey
50th Pan-Hellenic Paediatric Conference —
Hellenic Paediatric Society
1-3 June 2012, Ioannina, Greece
OTHER PAEDIATRIC MEETINGS IN EUROPE
3rd congress of European Confederation of Primary Care Paediatricians (ECPCP): «Paediatrics yesterday, today, tomorrow, here and elsewhere»
22-24 June 2012, Strasbourg — France
34th UMEMPS Congress
23-26 September 2012, Kos, Greece
Excellence in Paediatrics 2012
28 November — 1 December 2012, Madrid-Spain
Excellence in Child Mental Health 2012
28 November — 1 December 2012, Madrid-Spain
INFORMATION
List of member countries and links to societies'websites
Albania
Albanian Paediatric Society Armenia
Armenian Association of Paediatrics Austria
Oesterrechische Gesellschaft fur Kinder- und Jugendheilkunde (OEGKJ)
Belgium
Societe Belge de Pediatrie/
Belgische Vereiniging voor Kindergeneeskunde
Bosnia and Herzegovina
Paediatric Society of Bosnia and Herzegovina
Bulgaria
Bulgarian Paediatric Association Croatia
Croatian Paediatric Society Cyprus
Cypriot Paediatric Society Czech Republic
Czech National Paediatric Society Denmark
Dansk Paediatrisc Selskab Estonia
Estonian Paediatric Association Finland
Finnish Paediatric Society France
Societe Francaise de Pediatrie
Georgia
Georgian Paediatric Association Germany
Deutsche Gesellschaft fur Kinder-und Jugendmedizin (DGKJ)
Greece
Hellenic Paediatric Society Hungary
Hungarian Paediatric Association Ireland
Royal College of Physicians of Ireland/ Faculty of Paediatrics
Israel
Israeli Paediatric Association Italy
Societa Italiana di Pediatria Societa Italiana di Ricerca Pediatria
Latvia
Latvijas Pediatru Asociacija Lithuania
Lithuanian Paediatric Society Luxembourg
Societe Luxembourgeoise de Pediatrie Macedonia
Paediatric Society of Macedonia Moldova
Moldovan Paediatric Society
The Netherlands
Nederlandse Vereninging voor Kindergeneeskunde
Poland
PolskieTowarzystwo Pediatryczne Portugal
Sociedade Portuguesa de Pediatria Romania
Societatea Romana de Pediatrie Societatea Romana de Pediatrie Sociala
Russia
The Union of Paediatricians of Russia
Serbia and Montenegro
Paediatric Association of Serbia and Montenegro
Slovakia
Slovenska Paediatricka Spolocnost Slovenia
Slovenian Paediatric Society Spain
Asociacion Espahola de Pediatria Sweden
Svenska Barnlakarforeningen Switzerland
Societe Suisse de Pediatrie/ Schweizerische Gesellschaft fur Padiatrie
Turkey
Turk Pediatri Kurumu Ukraine
Ukraine Paediatric Association United Kingdom
Royal College of Paediatrics and Child Health
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Газета Европейской педиатрическом ассоциации, 12-й выпуск 6-Й КОНГРЕСС EUROPAEDIATRICS
проводится совместно с Королевским колледжем педиатрии и детского здоровья 5-8 июня 2013 г. в Глазго, Соединенное Королевство, Шотландский выставочный конференц-центр
Конгресс ЕигоресНаиюв — главное событие в деятельности Европейской педиатрической ассоциации (EPA/UNEPSA), проводится один раз в два года. На его заседаниях отмечают работы лучших педиатров не только Европы, но и всего мира.
В программе ежегодной конференции RCPCH, адресованной как педиатрам общего профиля, так и предста-
вителям педиатрических субспециальностей, отводится много времени для обсуждений, дебатов и обучения. Известные докладчики представляют новые данные по ключевым вопросам и последним достижениям педиатрической науки на таких заседаниях, как персональные практические сессии, специальные групповые программы и заседания по актуальным вопросам.
НОВОСТИ В общей педиатрическом ПРАКТИКЕ
Можно ли предупредить острый средний отит
Мануэль Мойя
Вице-президент Европейской педиатрической ассоциации, Советник по питанию Международной ассоциации педиатров Catedratico у Jefe de Servicio, профессор и руководитель, детское отделение. Университет Мигеля Эрнандеса, Сан-Хуан, Аликанте, Испания. E-mail: manuel.moya@umh.es
Острый средний отит (acute otitis media, AOM) является не только одной из самых распространенных бактериальных инфекций у детей в развитых странах (83% детей младше 3 лет), но также причиной довольно высокой смертности, потери слуха; иногда инфекция поражает соседние кости или центральную нервную систему.
Чаще всего АОМ вызывают Streptococcus pneumoniae, (42%), нетипируемые Haemophilus inluenzae (31%) и Moraxella catarrhalis (16%), т. е. наиболее характерные для микрофлоры носоглотки бактерии. Роль вирусов при рецидивирующих АОМ как непосредственных агентов остается неясной.
К развитию АОМ приводит дисфункция евстахиевой трубы и ее последующая обструкция, чему способствуют анатомические особенности: у детей трубы короче, расположены более горизонтально и окружены разросшейся аденоидной тканью. Вирусные инфекции, вызы-
вающие воспаление трубы, приводят к ее явному сужению. Последующая обструкция ухудшает мукоцилиарный клиренс с дальнейшей аккумуляцией слизи в среднем ухе и резорбцией воздуха в этом пространстве, что ведет к понижению давления и «затягиванию» бактерий из носоглотки, которые пролиферируют и приводят к АОМ. Другими благоприятствующими развитию болезни факторами являются низкий уровень иммуноглобулина (Ig) A, аномалии развития челюстно-лицевой области, загрязнение и т. п.
Как мы распознаем АОМ?
Во-первых, важно различать АОМ и острый отит с гноетечением (otitis media with effusion, ОМЕ). В первом случае воспаление проявляется острой болью в ухе (непонятной раздражительностью ребенка, не умеющего говорить), высокой температурой (39°С), беспокойством, отсутстви-
ем сна ночью, ознобом и в редких случаях нарушением равновесия. При отоскопии барабанная перепонка слегка выпячивается и образует небольшой мениск, или наблюдается небольшой слой жидкости на дне перепонки или в ее задней части. Необходимо быть внимательным: красная барабанная перепонка и высокая температура нетипичны для АОМ! Полезно провести пневматическую отоскопию, но она не находит широкого применения из-за болезненности процедуры. И, наоборот, при ОМЕ может появиться жидкость в среднем ухе без симптомов инфекции.
После установления диагноза большинство современных руководств рекомендует проведение отсроченного антибактериального лечения через 48 ч: часто в течение этого периода происходит спонтанное разрешение болезни. На практике из-за возникающих осложнений это положение обычно не выполняется, используются бета-лактамные антибиотики. Центры контроля и профилактики заболеваний подчеркивают важность правильного использования антибиотиков. В США за последние 10 лет при лечении наиболее распространенных инфекций верхних дыхательных путей стали выписывать на 24% меньше антибиотиков. В отношении АОМ такая ситуация связана с политикой не переусердствовать с антибиотиками: профилактика вновь набирает силу.
Профилактика. Очевидно, что наиболее эффективной мерой, как правило, является простейшая: например, мытье рук способно предупредить простуду и грипп, а также развитие обструкции евстахиевых труб. Альтернативные рекомендации по использованию конъюгированных пневмококковых вакцин целесообразно пересмотреть, особенно после публикации результатов исследований в Голландии, продемонстрировавших неэффективность данных вакцин для профилактики рецидивов АОМ у непривитых детей младшего возраста. Это обусловлено ограниченным количеством серотипов пневмококка в вакцинах, увеличением этиологической значимости Haemophilus и Moraxella, а также, увеличением носительства серотипа 19А наряду с повышением его устойчивости к антибиотикам.
Были оценены новые возможности профилактики, в частности, использование ксилита. Ксилит — неферментируемый многоатомный 5-углеродный спирт (сахарный спирт), известный своими подслащивающими свойствами; обладает низкой калорийностью и низким гликемическим индексом равным 13, а также способностью предупреждать развитие кариеса. В основе профи-
лактики АОМ лежит двойной механизм: 1 — поскольку прикрепление бактериальных клеток к клеткам носоглотки происходит с помощью различных сахаров, ксилит, являясь сахароподобным соединением, затрудняет этот процесс, 2 — ксилит, являясь неферментируемым веществом, также как моно- или дисахариды связывается с бактериями, которые «голодают» даже в присутствии других сахаров, что приводит к их гибели. Ксилит оказывает подобное действие на Streptococcus pneumoniae, Haemophilus, Moraxella и другие бактерии, что было зафиксировано в 1998 г., когда M. Uhari показал эффект предупреждения АОМ у детей при помощи сиропа или жевательной резинки с ксилитом. Позднее было признано, что доза ксилита должна превышать 35 г/день, и что жевательная резинка более эффективна, поскольку жевание и глотание также способствуют очищению среднего уха.
Стоит прокомментировать важные данные, представленные A. Azarpazhoon и др. из Группы острых респираторных инфекций (Cochrane). В обзоре было представлено четыре информативных рандомизированных контролируемых исследования (РКИ), выполненных в Финляндии, которые включили 3 103 детей в возрасте ^ 12 лет. Сравнивались группы с использованием ксилита и плацебо, а также группы, где не проводилось лечение с целью профилактики АОМ. В статье описаны типы исследований, первичные и вторичные результаты, детали дизайна, в частности сбор и анализ данных. Результаты всех четырех исследований включали данные о детях младшего и более старшего возрастов, в зависимости от наличия или отсутствия умения жевать ксилитсодержащий продукт. Сравнивались также различные способы транспорта ксилита. По результатам исследования, жевательная резинка с ксилитом признана более эффективным средством профилактики АОМ по сравнению с сиропом у здоровых детей: относительный риск (RR) 0,59; 95% доверительный интервал (CI) 0,39-0,89; величина снижения более 41% (1 — RR 0,59). Данное превентивное средство не работает, если ксилит используется при развившихся острых респираторных инфекциях. Если RR < 1,0 и величины CI больше или меньше 1,0, мы можем сделать вывод, что ежедневная доза ксилита 84 г способна предотвратить острый отит среднего уха у детей без острых инфекций верхних дыхательных путей, проходящих лечение в дневных стационарах. Это новая перспектива, особенно для тех, кто страдает рецидивирующим АОМ.
НОВОСТИ СО ВСЕГО КОНТИНЕНТА
16-й конгресс Европейского союза школьной и университетской медицины и здоровья Москва, Россия, 9-11 июня 2011 г. Краткий обзор от Союза педиатров России
Впервые в истории России с 9 по 11 июня 2011 г. цине «ЕизинМ-2011». Девиз конгресса: «Образование в Москве проходил 16-й конгресс Европейского союза и здоровье с детства до взрослой жизни». Организаторы по школьному и университетскому здоровью и меди- ЕивинМ-2011: Европейский Союз школьной и уни-
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ПЕДИАТРИЧЕСКАЯ ФАРМАКОЛОГИЯ /2012/ ТОМ 9/ № 2
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верситетской медицины (ЕивинМ), Союз педиатров России (СПР) (www.peCiatr-russia.ru), Министерство здравоохранения и социального развития РФ, Российское общество школьной и университетской медицины.
В работе конгресса приняли участие 1197 специалистов из 22 стран мира: Беларуси, Бельгии, Великобритании, Венгрии, Дании, Германии, Индии, Испании, Италии, Кыргызстана, Китая, Молдовы, Нидерландов, Объединенных Арабских Эмиратов, России, Словении, Украины, Хорватии, Финляндии, Швеции, Швейцарии и Эстонии. Представлено 119 докладов, в постерной сессии — 98 докладов.
Ведущие специалисты ВОЗ, 1РА, ЕРА, EUSUHM, Союза педиатров России приняли участие в пленарных заседаниях, посвященных наиболее актуальным вопросам школьной медицины и педиатрии в целом: проблемы
и будущие проекты в области школьного и университетского здравоохранения; борьба с курением среди детей и подростков, раннее выявление проблем физического и психического развития и т. п.
Сделаны некоторые обобщения по результатам дискуссий и обмена опытом:
• несмотря на то, что мы живем в разных системах (социальных, образовательных и т. д.), анализ медицинских и психолого-педагогических проблем образования у детей, подростков и студентов актуальны и своевременны во всех странах;
• необходимо продолжать совместные мероприятия, направленные на укрепление здоровья (в школах, университетах, детских садах, яслях, сообществах), формирование здорового образа жизни для обеспечения физического, психического и сексуального благополучия детей и молодежи.
МЕЖДУНАРОДНЫЙ СИМПОЗИУМ Национальная модель защиты здоровья матери и ребенка в Узбекистане: «Здоровая мать — здоровое дитя»
Симпозиум проведен в Ташкенте в ноябре прошлого года по инициативе Президента Республики Узбекистан г-на И. Каримова. Симпозиум состоял из трех основных заседаний: Круглого стола совместно с министерствами здравоохранения и международными организациями, посвященного здоровью детей; основного заседания, посвященного узбекской модели «Здоровая мать — здоровое дитя» с участием
Президента, Генерального директора ВОЗ и министра здравоохранения; заседания, касавшегося конкретных аспектов детского здоровья. В связи с этим вицепрезидент профессор Manuel Moya, представитель EPA, принял участие во всех заседаниях с анализом европейских вариантов, касающихся неонатального и пост-неонатального скрининга, транспортировки и питания новорожденного.
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