Pediatri July-Aug 07
09-07-07
17:07
™ÂÏ›‰·1
¶·È‰È·ÙÚÈ΋ ¢ÈÌËÓÈ·›· ¤Î‰ÔÛË Ù˘ EÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ EÙ·ÈÚ›·˜
∆fiÌÔ˜ 70 ñ ∆‡¯Ô˜ 4 ñ πÔ‡ÏÈÔ˜-∞‡ÁÔ˘ÛÙÔ˜ 2007
¶Úfi‰ÚÔ˜ ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜
¶ÂÚȯfiÌÂÓ·
™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹
∞ƒ£ƒ√ ™À¡∆∞•∏™
∂¡¢π∞º∂ƒ√À™∂™ ¶∂ƒπ¶∆ø™∂π™
¢È¢ı˘ÓÙ‹˜ ™‡ÓÙ·Í˘ ∫. ™ÙÂÊ·Ó›‰Ë˜
253 √ ı¿Ó·ÙÔ˜ Ù˘ ËıÈ΋˜ £. ¶ÂÏÂÁÚ›Ó˘
316 ™˘Ó‡·ÚÍË Ó¢ÚÔ‚Ï·ÛÙÒÌ·ÙÔ˜ Î·È ÎÏËÚÔÓÔÌÈ΋˜ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛ˘ π.¶. ¶·Ó·ÁÈÒÙÔ˘, °. §¤Îη, ∞. °·ÚÔ‡ÊË, ∞. ™Ù·ÌÔ˘Ï·Î¿ÙÔ˘, ∂. ¶ÚÂ̤Ù˘, ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜
M¤ÏË ™. ∞Ó‰ÚÔÓ›ÎÔ˘ ¶. ∞˘ÁÔ˘ÛÙ›‰Ô˘-™·‚‚ÔÔ‡ÏÔ˘ A. µ·˙·›Ô˘-°ÂÚ·ÛÈÌ›‰Ë °. µ·ÚÏ¿Ì˘ ∂. °·Ï·Ó¿Î˘ §. £ˆÌ·˝‰Ô˘ ª. ∫·Ó¿ÚÈÔ˘ ∂. ∫·ÙÛ·ÚÔ‡-¶ÂÎÙ·Û›‰Ë A. K·ÙÙ¿Ì˘ ™. K›ÙÛÈÔ˘-∆˙¤ÏË ∞. ¶··‰ÔÔ‡ÏÔ˘ ¡. ¶··‰fiÔ˘ÏÔ˜ ∞. ™È·ÌÔÔ‡ÏÔ˘-ª·˘Ú›‰Ô˘ ª. ∆ÛÔÏÈ¿
∞¡∞™∫O¶∏™∂π™ 257 Persistent vegetative state in children: terminology, aetiology, prognosis and ethical issues v D. Neubauer, S. Grosek, P. Hamilton, M. LoGiudice, D. Matthys, V. Molina, L. Nikolovski, E. Siebke, A. Tenore, F.P. Crawley
320 ™˘ÁÁÂÓ‹˜ ÛÙ¤ÓˆÛË ÚÈÓÈÎÒÓ ÎÔÈÏÔÙ‹ÙˆÓ Î·È ÌÔÓ‹Ú˘ ÎÂÓÙÚÈÎfi˜ ¿Óˆ ÙÔ̤·˜ Ô‰fiÓÙ·˜ Û ÙÚ›· ‚Ú¤ÊË ∞. ∞Ó‰Ú¤Ô˘, ∞. ∫Ô‡ÙÏ·, ∂. ∑¢Á·Ú›‰Ô˘, ∞. ™·ÎÂÏÏ·ÚÔÔ‡ÏÔ˘
266 ∏ ·‡ÍËÛË ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ ÛÙË Û‡Á¯ÚÔÓË ÂÔ¯‹: ÂȉËÌÈÔÏÔÁÈο ‰Â‰Ô̤ӷ Î·È ·ÈÙÈÔÏÔÁ›· ∞. ™ÔÊÈ·ÓÔ‡-∫·ÙÛÔ‡ÏË
325 ™‡Ó‰ÚÔÌÔ Blue Rubber Bleb Nevus Ì ۇÁ¯ÚÔÓË ÚÔÛ‚ÔÏ‹ Ó¢ÚÈÎÔ‡ Î·È ÂÚÂÈÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ª. ∆˙Ô‡ÊË, ¶. ™È¯ÏÈÌ›ÚË, π. ¡¿ÎÔ˘, ª. ∞ÚÁ˘ÚÔÔ‡ÏÔ˘, ∞. ™È·ÌÔÔ‡ÏÔ˘-ª·˘Ú›‰Ô˘ ¶ƒ∞∫∆π∫√ £∂ª∞
ºÈÏÔÏÔÁÈ΋ EÈ̤ÏÂÈ·
272 ªËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜: ÚÔÛٷهÂÈ ÙÂÏÈο Î·È ·fi ÓÂÔϷۛ˜; ¢. ª·Ùı·›Ô˜, ∂. ª·ÓÙ·‰¿Î˘, ¶. §¿ÈÔ˜, ™. ∫·ÎÔχÚ˘, ∞. ÷Ù˙ËÌȯ·‹Ï
∂È̤ÏÂÈ· ÂÏÏËÓÈÎÒÓ ÎÂÈÌ¤ÓˆÓ ∞. µ·ÛÈÏÔÔ‡ÏÔ˘
278 ∞ÓÙÂӉ›ÍÂȘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ∂. ÷Ù˙ˉ¿ÎË, Ã. °È·ÓÓ·ÎÔÔ‡ÏÔ˘
330 ∞ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· ÛÙ· ·È‰È¿ – ıÂڷ¢ÙÈ΋ ÚÔÛ¤ÁÁÈÛË ∆. ∆ÛÈ‚ÈÙ·Ó›‰Ô˘-∫¿ÎÔ˘ÚÔ˘
EÈ̤ÏÂÈ· ·ÁÁÏÈÎÒÓ ÎÂÈÌ¤ÓˆÓ ™. ¡¿ÎÔ˘
∂ƒ∂À¡∏∆π∫∂™ ∂ƒ°∞™π∂™
336 ™À¡∆√ª∞ ¶∞π¢π∞∆ƒπ∫∞ ¡∂∞
285 ∂›‰Ú·ÛË ÙÔ˘ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ˘ÔÛÙ‹ÚÈ͢ ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ∞. ¡ÙÔ˘ÚÓÙÔ‡ÊË, µ. ÃÔϤ‚·˜, §. ∫ÔÓÙÔ‡, ª. ¶·‡ÏÔ˘, ™. ∞Ó‰ÚÔÓ›ÎÔ˘
- ∏ıÈο ˙ËÙ‹Ì·Ù· ÛÙËÓ ÂÚÈÁÂÓÓËÙÈ΋ È·ÙÚÈ΋ - ∆· ηϿ ÙˆÓ ÏÔÈÌÒÍÂˆÓ - √È ‰‡Ô fi„ÂȘ Ù˘ ËÏÈÔÚÔÛÙ·Û›·˜ - º˘Ì·Ù›ˆÛË Î·È ˘ÂÚ·ÙÏ·ÓÙÈΤ˜ Ù‹ÛÂȘ - À¿Ú¯ÂÈ Ï‡ÛÛ· ÛÙËÓ ∂ÏÏ¿‰·;
E¶I™THMONIKE™ EK¢O™EI™ E.¶.E. ¶ÈÂÚ›·˜ 1∞ 144 51 MÂÙ·ÌfiÚʈÛË TËÏ.: 210 87 78 810 Fax: 210 87 78 822
293 ∏ Û˘Ì‚ÔÏ‹ ÂÚÈ‚·ÏÏÔÓÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· ÙÔ˘ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ 1 (™¢1) ∫. ∫·Ú·‚·Ó¿ÎË, ∂. ∆Ûfiη, Ã. ∫·Ú·ÁÈ¿ÓÓË, µ. ¶¤ÙÚÔ˘, ∂. ¶È›‰Ô˘, ª. ªÚÈÛÈÌÈÙ˙‹, ª. ª·˘ÚÈΛԢ, ∫. ∫·ÎϤ·˜, ∞. ¢¿ÎÔ˘-µÔ˘ÙÂÙ¿ÎË
E. °·Ï·Ó¿Î˘ 338 ¡∂∞ ∞¶√ ∆√ ¢π∞¢π∫∆À√
I‰ÈÔÎÙ‹Ù˘
300 ∂ηÙÔÛÙÈ·›Â˜ ı¤ÛÂȘ ÂÚÈ̤ÙÚÔ˘ ̤Û˘ ·È‰ÈÒÓ Ù˘ ∫Ú‹Ù˘ ËÏÈΛ·˜ 3 ¤ˆ˜ 16 ÂÙÒÓ ∂. §ÈÓ·Ú‰¿Î˘, ∫. µ·Ú‰·‚¿˜, ∞. ∫·Ê¿ÙÔ˜
340 ∫§π¡π∫√ ∫√Àπ∑
EΉfiÙ˘ K. °ÚÈ‚¤·˜ ™˘ÓÙÔÓÈÛÙ‹˜ ∂ΉfiÛˆ˜
EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›·© Mȯ·Ï·ÎÔÔ‡ÏÔ˘ 92 Aı‹Ó· 115 28 TËÏ.: 210 7771 140 210 7771 663 Fax: 210 7758 354 e-mail: hps@ath.forthnet.gr EÙ‹ÛÈ· ™˘Ó‰ÚÔÌ‹: 40 € EȉÈ΢fiÌÂÓÔÈ, ºÔÈÙËÙ¤˜: 20 € ∫ˆ‰ÈÎfi˜ ¢È‡ı˘ÓÛ˘ ∂ÔÙ›·˜ ªª∂: 3889
ISSN 0377-2551
308 √ÚÌfiÓ˜ Ô˘ Ú˘ıÌ›˙Ô˘Ó ÙËÓ fiÚÂÍË Î·È ÙÔÓ ÌÂÙ·‚ÔÏÈÛÌfi Û ÚfiˆÚ· ÓÂÔÁÓ¿ ∆. ™È·¯·Ó›‰Ô˘, π. ¶··ÛˆÙËÚ›Ô˘, ª. µÔ˘Ó¿ÙÛÔ˘, ∂. ªËÏ›ÙÛË, ∂. ª¿Ó‰˘Ï·
πÛÙÔÛÂÏ›‰Â˜ ÁÈ· ÌÔ˘ÛÈ΋ ÁÈ· ·È‰È¿ ¡. ¶··‰fiÔ˘ÏÔ˜
°. ¡ÙÈÔ‡‰Ë˜, µ. °ÂˆÚÁÔÔ‡ÏÔ˘, ¡. ª·ÓˆÏ¿ÎË, ¡. ª˘ÚÈÔÎÂÊ·ÏÈÙ¿Î˘ 341 ∂¶π™∆√§∂™ ¶ƒ√™ ∆∏ ™À¡∆∞•∏ ∞. ∞Ó‰Ú¤Ô˘ ™. ¶ÂÙÌÂ˙¿ÎË °.¶. ÃÚÔ‡ÛÔ˜, ª. ∫·Ú¿ÓÙ˙·
Pediatri July-Aug 07
09-07-07
17:07
™ÂÏ›‰·3
Paediatriki Bimonthly Publication of the Greek Paediatric Society
Volume 70 ñ Number 4 ñ July-August 2007
President A. Constantopoulos
Contents
Editorial Board
EDITORIAL COMMENTARY
CASE REPORTS
Editor-in-Chief C. Stefanidis
253 The death of ethics Th. Pelegrinis
316 Coexistence of neuroblastoma and hereditary spherocytosis J.P. Panagiotou, G. Lekka, A. Garoufi, A. Stamoulakatou, E. Premetis, A. Constantopoulos
Members S. Andronikou P. Augoustides-Savvopoulou A. Vazeou-Gerasimidi G. Varlamis ∂. Galanakis L. Thomaidou M. Kanariou ∂. Katsarou-Pectasides A. Kattamis S. Kitsiou-Tzeli ∞. Papadopoulou N. Papadopoulos A. Siamopoulou-Mavridou M. Tsolia Manuscript Editing Greek Editing A. Vasilopoulou English Editing S. Nakou Publisher K. Griveas Publishing Coordinator SCIENTIFIC PUBLICATIONS Ltd 1∞ Pierias St. GR - 144 51, Metamorfossi Tel.: +30 210 87 78 810 Fax: +30 210 87 78 822 Owner Greek Paediatric Society© 92 Michalakopoulou str. GR - 115 28, Athens Tel.: +30 210 7771 140 +30 210 7771 663 Fax: +30 210 7758 354 e-mail: hps@ath.forthnet.gr Annual Subscription All foreign countries: US $ 50
REVIEW ARTICLES 257 Persistent vegetative state in children: terminology, aetiology, prognosis and ethical issues v D. Neubauer, S. Grosek, P. Hamilton, M. LoGiudice, D. Matthys, V. Molina, L. Nikolovski, E. Siebke, A. Tenore, F.P. Crawley 266 The increase of allergic conditions in recent years: epidemiology and causes A. Sofianou-Katsoulis 272 Breastfeeding: does it also protect against neoplasms? D. Matthaios, E. Mantadakis, P. Laios, S. Kakolyris, A. Chatzimihail
320 Congenital nasal pyriform stenosis and single central upper maxillary incisor in three infants A. Andreou, A. Koutla, E. Zeugaridou, A. Sakellaropoulou 325 Blue Rubber Bleb Nevus Syndrome with concurrent neurological and skeletal involvement M. Tzoufi, P. Sihlimiri, I. Nakou, M. Argyropoulou, A. Siamopoulou-Mavridou PRACTICAL ISSUE
278 Contraindications to breastfeeding E. Hatzidaki, C. Giannakopoulou
330 Therapeutic management of childhood atopic dermatitis T. Kakourou
ORIGINAL ARTICLES
336 PAEDIATRIC NEWS IN BRIEF
285 Effect of a supportive program on breastfeeding A. Ntourntoufi, V. Cholevas, L. Kontou, M. Pavlou, S. Andronikou 293 Environmental factors possibly associated with the pathogenesis of diabetes mellitus type 1 (DM1) K. Karavanaki, E. Tsoka, C. Karayianni, V. Petrou, E. Pippidou, M. Brisimitzi, M. Mavrikiou, K. Kakleas, C. Dacou-Voutetakis 300 Waist circumference percentiles of children of Crete aged 3 to 16 years ∂. Linardakis, K. Vardavas, A. Kafatos 308 Hormones regulating the food intake and metabolism of preterm infants T. Siahanidou, I. Papassotiriou, M. Vounatsou, H. Militsi, H. Mandyla
E. Galanakis 338 NEWS FROM THE INTERNET N. Papadopoulos 340 CLINICAL QUIZ G. Dioudis, V. Georgopoulou, M. Manolaki, N. Myriokefalitakis 341 LETTERS TO THE EDITOR A. Andreou S. Petmezaki G.P. Chroussos, M. Karantza
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·5
™À¡∆∞∫∆π∫∏ E¶π∆ƒ√¶∏
EDITORIAL BOARD
¢È¢ı˘ÓÙ‹˜ ™‡ÓÙ·Í˘
Editor-in-Chief
∫ˆÓÛÙ·ÓÙ›ÓÔ˜ ™ÙÂÊ·Ó›‰Ë˜, ∞ı‹Ó·
Constantinos Stefanidis, Athens
∂ȉÈÎÔ› ™˘ÓÙ¿ÎÙ˜
Section Editors
™Ù¤ÏÏ· ∞Ó‰ÚfiÓÈÎÔ˘, ¡ÂÔÁÓÔÏÔÁ›·, πˆ¿ÓÓÈÓ·
Stella Andronikou, Neonatology, Ioannina
¶ÂÚÛÂÊfiÓË ∞˘ÁÔ˘ÛÙ›‰Ô˘-™·‚‚ÔÔ‡ÏÔ˘, MÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù·, £ÂÛÛ·ÏÔÓ›ÎË
Persefoni Avgoustides-Savvopoulou, Metabolic Disorders, Thessaloniki
∞Ó‰ÚÈ·Ó‹ µ·˙·›Ô˘-°ÂÚ·ÛÈÌ›‰Ë, ∂Ó‰ÔÎÚÈÓÔÏÔÁ›·, ∞ı‹Ó·
Andriani Vazaiou-Gerasimidi, Endocrinology, Athens
°ÂÒÚÁÈÔ˜ µ·ÚÏ¿Ì˘, ∫·Ú‰ÈÔÏÔÁ›·, £ÂÛÛ·ÏÔÓ›ÎË
George Varlamis, Cardiology, Thessaloniki
∂ÌÌ·ÓÔ˘‹Ï °·Ï·Ó¿Î˘, ∏ıÈ΋ Î·È ¢ÂÔÓÙÔÏÔÁ›·, ∏Ú¿ÎÏÂÈÔ
Emmanouil Galanakis, Ethics and Deontology, Heraklion
§ˆÚ¤ÙÙ· £ˆÌ·˚‰Ô˘, ∞Ó·Ù˘ÍȷΤ˜ ‰È·Ù·Ú·¯¤˜, ∞ı‹Ó·
Loretta Thomaidou, Developmental Pediatrics, Athens
ª·Ú›· ∫·Ó¿ÚÈÔ˘, ∞ÓÔÛÔÏÔÁ›·, ∞ı‹Ó·
Maria Kanariou, Immunology, Athens
∂˘ÛÙ·ı›· ∫·ÙÛ·ÚÔ‡-¶ÂÎÙ·Û›‰Ë, ¡Â˘ÚÔÏÔÁ›·, ∞ı‹Ó·
Eustathia Katsarou-Pektasides, Neurology, Athens
∞ÓÙÒÓ˘ ∫·ÙÙ¿Ì˘, ∞ÈÌ·ÙÔÏÔÁ›· - OÁÎÔÏÔÁ›·, ∞ı‹Ó·
Antonis Kattamis, Haematology - √ncology, Athens
™ÔÊ›· ∫›ÙÛÈÔ˘-∆˙¤ÏË, °ÂÓÂÙÈ΋, ∞ı‹Ó·
Sophia Kitsiou-Tzeli, Genetics, Athens
∞ÏÂÍ¿Ó‰Ú· ¶··‰ÔÔ‡ÏÔ˘, °·ÛÙÚÂÓÙÂÚÔÏÔÁ›· ¢È·ÙÚÔÊ‹, ∞ı‹Ó·
Alexandra Papadopoulou, Gastroenterology - Nutrition, Athens
¡ÈÎfiÏ·Ô˜ ¶··‰fiÔ˘ÏÔ˜, ∞ÏÏÂÚÁÈÔÏÔÁ›· ¶Ó¢ÌÔÓÔÏÔÁ›·, ∞ı‹Ó·
Nicos Papadopoulos, Allergology - Pneumonology, Athens
∞ÓÙÈÁfiÓË ™È·ÌÔÔ‡ÏÔ˘-ª·˘Ú›‰Ô˘, ƒÂ˘Ì·ÙÔÏÔÁ›·, πˆ¿ÓÓÈÓ·
Antigoni Siamopoulou-Mavridou, Rheumatology, Ioannina
ª·Ú›˙· ∆ÛÔÏÈ¿, §ÔÈ̈ÍÈÔÏÔÁ›·, ∞ı‹Ó·
Marisa Tsolia, Infectious Diseases, Athens
ª¤ÏË Ù˘ ¢ÈÂıÓÔ‡˜ ™˘ÓÙ·ÎÙÈ΋˜ ∂ÈÙÚÔ‹˜ ñ Members of the International Editorial Board Alexis Arzimanoglou, Paris, France
Peter Hoyer, Essen, Germany
Ellis D. Avner, Milwaukee, USA
Jan Janda, Prague, Czech Republic
Swati Bhave, New Delhi, India
Jan Kimpen, Ultrecht, Netherlands
Alberto Bissot, Panama, Panama
Craig B. Langman, Chicago, USA
David Branski, Jerusalem, Israel
John Manis, Boston, USA
Francesco Chiarelli, Chieti, Italy
Manuel Moya, Alicante, Spain
Chok-Wan Chan, Hong Kong, China
Hugh O'Brodovich, Toronto, Canada
Denis Daneman, Toronto, Canada
Ross Petty, Vancouver, Canada
Jochen Ehrich, Hannover, Germany
Willem Proesmans, Leuven, Belgium
Demetrius Ellis, Pittsburgh, USA
Jose Ramet, Antwerp, Belgium
Yoshikatsu Eto, Tokyo, Japan
Alan Sinaiko, Minneapolis, USA
Richard N. Fine, Stony Brook, USA
Nick J. Spencer, Coventry, UK
Margaret C. Fisher, Philadelphia, USA
Alfred Tenore, Udine, Italy
Raif Geha, Boston, USA
Alkis Togias, Bethesda, USA
Adenike Grange, Lagos, Nigeria
Eva Tsalikian, Iowa City, USA
Judith G. Hall, Vancouver, Canada
Catherine Weil-Olivier, Paris, France
Patricia Hamilton, London, UK
Max Zach, Graz, Austria
Enver Hasanoglu, Ankara, Turkey
Johannes Zschocke, Heidelberg, Germany
Christer Holmberg, Helsinki, Finland
v
˘·ÓÈԇϿÛÌ·ˆ· ‰ÂÓ ÌÂϤÙ˜ ‹ÛË ÙÔ˘ ÌËÙ¤Ú·˜ · ÌfiÓÔ Ó·Ì¤ÓÂÚ¤ÂÈ Ô ª∏∆∂™ ˜ Ô˘ ÂÁ¯fiÌÂ˙›ÏË Û : ∞˘Í‹. Ÿˆ˜ ¿ÓıËÌ· Ù· Û˘‰È·ÎÔÓËÏ›· ˜. ∞ÈÌÔÓÈ·. ¡Â%), ÂÊÂÚı› Í›·, ·ÁÓ‰ÚÔÌÔ Ù˜ ·ˆÛÈÓÔÂÙ·È Î˘Î‹˜ ÏÂÈProcef ÙˆÓ 12 ÛÂ Û˘È· ˘„ËÔ‰ËÁ›Â˜ 5 ∂Àƒø ¶∂. ¶√-
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·253
∞ƒ£ƒ√ ™À¡∆∞•∏™
EDITORIAL COMMENTARY
253
O ı¿Ó·ÙÔ˜ Ù˘ ËıÈ΋˜ £. ¶ÂÏÂÁÚ›Ó˘ ¶ÂÚ›ÏË„Ë: ∏ ËıÈ΋ Û‹ÌÂÚ· ‚Ú›ÛÎÂÙ·È Û ÙfiÛÔ ‚·ıÈ¿ ÎÚ›ÛË, ÒÛÙ ӷ ÌÔÚ› Ó· ˘ÔÛÙËÚȯı› fiÙÈ ‚Ú›ÛÎÂÙ·È ÚÔ ÙÔ˘ Ù¤ÏÔ˘˜ Ù˘. ™ÙËÓ ˘fiıÂÛË ·˘Ù‹ Û˘ÓËÁÔÚÔ‡Ó ÙÚÂȘ ΢ڛˆ˜ ÏfiÁÔÈ. ¶ÚÒÙÔÓ, Ë ·ÌÊÈÛ‚‹ÙËÛË Ù˘ ËıÈ΋˜ ÁÏÒÛÛ·˜, ÙÔ ÁÂÁÔÓfi˜ ÂȉÈÎfiÙÂÚ· fiÙÈ, Û‡Ìʈӷ Ì ÔÚÈṲ̂ÓÔ˘˜ ÊÈÏÔÛfiÊÔ˘˜, ı· ÌÔÚÔ‡Û·Ó Ó· ··ÏÂÈÊıÔ‡Ó ·fi ÙË ÁÏÒÛÛ· Ì·˜ ÔÈ ËıÈÎÔ› fiÚÔÈ, ¯ˆÚ›˜ Ó· ·ÏÏÔȈı› ÙÔ ÓfiËÌ· Ù˘. ¢Â‡ÙÂÚÔÓ, Ë ·ÏÌ·Ù҉˘ ÂͤÏÈÍË Ù˘ Ù¯ÓÔÏÔÁ›·˜ Ô˘ ›¯Â ˆ˜ ·ÔÙ¤ÏÂÛÌ· ‚·ÛÈΤ˜ ¤ÓÓÔȘ Ù˘ ËıÈ΋˜ Ó· ÌÔÈ¿˙Ô˘Ó Ó· ÌËÓ ¤¯Ô˘Ó Û‹ÌÂÚ· ÏfiÁÔ ‡·Ú͢. ∆Ú›ÙÔÓ, Ë ·ÌÊÈÛ‚‹ÙËÛË ÙÔ˘ ÊÔÚ¤· Ù˘ ËıÈ΋˜ ˙ˆ‹˜, ‰ËÏ·‰‹ ÙÔ˘ ·˘ÙÔ‡ Ì·˜, ˆ˜ Ì›·˜ ÂÓÈ·›·˜ ˘fiÛÙ·Û˘ Ô˘ ηÙ¢ı‡ÓÂÈ ÙȘ ÛΤ„ÂȘ Î·È ÙȘ Ú¿ÍÂȘ Ì·˜. ∏ ·ÌÊÈÛ‚‹ÙËÛË Ù˘ ËıÈ΋˜ ÂÓÙ¿ÛÛÂÙ·È ÛÙÔ ÁÂÓÈÎfiÙÂÚÔ Ó‡̷ Ù˘ ·Ó·Ó¤ˆÛ˘ ÙÔ˘ ÔÏÈÙÈÛÌÔ‡ Ì·˜ ̤۷ ·fi ÙËÓ Î·Ù¿ÚÁËÛË ÔÚÈÛÌ¤ÓˆÓ ÌÔÚÊÒÓ ÙÔ˘ Î·È ÙËÓ ·ÓÙÈηٿÛÙ·Û‹ ÙÔ˘˜ Ì ¿ÏϘ ÌÔÚʤ˜, fiˆ˜ Û˘Ó¤‚Ë ÛÙËÓ ÂÚ›ÙˆÛË Ù˘ Ì˘ıÔÏÔÁ›·˜ Ô˘ ·fi ¤Ó· ÛËÌÂ›Ô ÎÈ ¤ÂÈÙ· ¤·„ ӷ ·ÔÙÂÏ› ËÁ‹ ‰ËÌÈÔ˘ÚÁ›·˜, ¯ˆÚ›˜ Ó· ·Ó·ÎÔ› Ë ÂÍÂÏÈÎÙÈ΋ ÔÚ›· ÙÔ˘ ÔÏÈÙÈÛÌÔ‡ Ì·˜.
AÏÏËÏÔÁÚ·Ê›·: £ÂÔ‰fiÛ˘ ¶ÂÏÂÁÚ›Ó˘ tpelegr@phil.uoa.gr K·ıËÁËÙ‹˜ ºÈÏÔÛÔÊ›·˜ Î·È ∫ÔÛÌ‹ÙÔÚ·˜ Ù˘ ºÈÏÔÛÔÊÈ΋˜ ™¯ÔÏ‹˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ
§¤ÍÂȘ ÎÏÂȉȿ: ∏ıÈ΋, ÔÏÈÙÈÛÌfi˜, ÁÏÒÛÛ·.
The death of ethics Th. Pelegrinis Abstract: Ethics today is in such a grave crisis, so that one may suppose that it is one step before the end. There are three reasons to support this. First, the questioning of moral language and the fact that according to certain philosophers it is possible to omit moral terms from the language without any change of meaning. Second, the great advancement of technology, due to which basic moral concepts seem to be obsolete. Third, the questioning of the subject of moral life, i.e. the self as a condensed entity which directs our thoughts and actions. The questioning of Ethics is subject to the general attitude of renewing our culture through the rejection of certain forms of it and their substitution with other forms as it happened with mythology. Mythology at a certain time ceased to be a source of creativity without causing a negative effect upon our culture’s progress.
Correspondence: Theodosis Pelegrinis tpelegr@phil.uoa.gr Professor of Philosophy and Dean of the School of Philosophy, University of Athens, Greece
Key words: Ethics, culture, language.
∏ ÂÈÛÙËÌÔÓÈ΋ ¤Ú¢ӷ, Â›Ó·È ÁÂÁÔÓfi˜, ·ÔÙÂÏ› Ì›· ›ÔÓË ‰È·‰Èηۛ·. ¢ÂÓ Â›Ó·È ÌfiÓÔ Ô „˘¯ÈÎfi˜ Î·È ÛˆÌ·ÙÈÎfi˜ ο̷ÙÔ˜, ÛÙÔÓ ÔÔ›Ô ˘Ô‚¿ÏÏÂÙ·È Ô ÂÈÛÙ‹ÌˆÓ ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÓÙ·ÔÎÚÈı› ÛÙȘ ··ÈÙ‹ÛÂȘ ÙÔ˘ ¤ÚÁÔ˘ ÙÔ˘, ·ÏÏ¿ Â›Ó·È ·ÎfiÌË Ë ·ÌÊÈÛ‚‹ÙËÛË Î·È ÔÈ ÚÔËÏ·ÎÈÛÌÔ› Î·È Ë Î·Ù·ÎÚ·˘Á‹ Î·È Ë ¯ÏÂ‡Ë Î·È ÔÈ ‰ÈÒÍÂȘ Ô˘ ˘Ê›ÛٷٷÈ, fiÔÙÂ Û˘Ì‚Â› ÔÈ ·fi„ÂȘ ÙÔ˘ Ó· ÍÂÂÚÓÔ‡Ó Ù· fiÚÈ· Ù˘ ηıÂÛÙË΢›·˜ ·ÓÙ›Ï˄˘ Ù˘ ÎÔÈÓˆÓ›·˜. ∆· ÚÔ‚Ï‹Ì·Ù·, ÂȉÈÎfiÙÂÚ·, Ô˘ ·ÓÙÈÌÂÙˆ›˙ÂÈ Ô ÂÈÛÙ‹ÌˆÓ Î·Ù¿ ÙËÓ ¿ÛÎËÛË ÙÔ˘ ÂÚ¢ÓËÙÈÎÔ‡ ¤ÚÁÔ˘ ÙÔ˘ Â›Ó·È ·ÊÂÓfi˜ ÌÂÓ ÂÛˆÙÂÚÈ΋˜ ٿ͈˜, ·ÊÂÙ¤ÚÔ˘ ‰Â Â͈ÙÂÚÈ΋˜ ʇÛˆ˜. ∂ÛˆÙÂÚÈ΋˜ ٿ͈˜ ÚÔ‚Ï‹Ì·Ù· ÂÓÓÔÒ Ù· ˙ËÙ‹Ì·Ù·, Ù· ÔÔ›· ÚÔ·ÙÔ˘Ó Î·Ù¿ ÙËÓ ÔÚ›· Ù˘ ÂÈÛÙËÌÔÓÈ΋˜ ¤Ú¢ӷ˜. ∆· ÚÔ‚Ï‹Ì·Ù· ·˘Ù¿, ÚÔ‰‹Ïˆ˜, Â›Ó·È Î·Ïԉ¯ԇÌÂÓ· ·fi ÙÔÓ ÂÈÛÙ‹ÌÔÓ·, ·ÊÔ‡, ÂÍ·ÈÙ›·˜ ÙÔ˘˜ ‰ÈηÈÔÏÔÁ›-
Ù·È Ë ·ÚÔ˘Û›· ÙÔ˘ Î·È ·fi ÙËÓ Â›Ï˘Û‹ ÙÔ˘˜ ηٷÍÈÒÓÂÙ·È. ∆· Â͈ÙÂÚÈ΋˜ ʇÛˆ˜ ÚÔ‚Ï‹Ì·Ù·, ÂÍ¿ÏÏÔ˘, ·Ú·¤ÌÔ˘Ó Û fiÏ· ÂΛӷ Ù· ÂÌfi‰È·, Ù· ÔÔ›· ÔÚıÒÓÔÓÙ·È ÌÚÔÛÙ¿ ÛÙÔ ¤ÚÁÔ ÙÔ˘ ÂÈÛÙ‹ÌÔÓ· ·fi ÙÔ ÎÔÈÓˆÓÈÎfi ÂÚÈ‚¿ÏÏÔÓ, ·Ó Û˘Ì‚Â› ÔÈ ·fi„ÂȘ Ô˘ ‰È·Ù˘ÒÓÂÈ ·˘Ùfi˜ Ó· ÌË Û˘Ó¿‰Ô˘Ó ÚÔ˜ ÙȘ ıÚËÛ΢ÙÈΤ˜, ÙȘ ËıÈΤ˜ ηÈ, ÁÂÓÈÎÒ˜, ÙȘ ηıÈÂڈ̤Ó˜ ÂÔÈı‹ÛÂȘ ÙÔ˘ ÎfiÛÌÔ˘. ™Â ·ÓÙ›ıÂÛË ÚÔ˜ Ù· ÂÛˆÙÂÚÈ΋˜ ٿ͈˜ ÚÔ‚Ï‹Ì·Ù·, Ù· ÔÔ›· ¤¯ÂÈ ÙËÓ ‰˘Ó·ÙfiÙËÙ· Ó· ·Ï¤„ÂÈ Î·È, ÂӉ¯Ô̤ӈ˜, Ó· ·ÓÙÈÌÂÙˆ›ÛÂÈ, Ô ÂÈÛÙ‹ÌˆÓ Â›Ó·È ¤ÚÌ·ÈÔ ÙˆÓ Â͈ÙÂÚÈ΋˜ ʇÛˆ˜ ÚÔ‚ÏËÌ¿ÙˆÓ. ∆· ·Ú·‰Â›ÁÌ·Ù·, ÛÙ· ÔÔ›· ÔÈ ÂÈÛÙ‹ÌÔÓ˜ Ï‹ÚˆÛ·Ó ·ÎfiÌË Î·È Ì ÙËÓ ˙ˆ‹ ÙÔ˘˜ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÔÈ ·Ï‹ıÂȘ Ô˘ ‰È·Ù‡ˆÛ·Ó ·¤ÎÏÈÓ·Ó ·fi ÙȘ ÂÔÈı‹ÛÂȘ Ù˘ ÎÔÈÓˆÓ›·˜ ÛÙËÓ ÔÔ›· ·Ó‹Î·Ó, ‰ÂÓ Ï›ԢÓ. √ ∆˙ÔÚÓÙ¿ÓÔ ªÚÔ‡ÓÔ, ·˜ Ô‡ÌÂ, ηٷ‰ÈοÛÙËΠÛÙȘ
∂Ó·ÚÎÙ‹ÚÈ· ÔÌÈÏ›· ÛÙÔ 45Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ, 25-27 M·˝Ô˘ 2007, ™ÈıˆÓ›· ÷ÏÎȉÈ΋˜
¶·È‰È·ÙÚÈ΋ 2007;70:253-256
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·254
254
£. ¶ÂÏÂÁÚ›Ó˘
·Ú¯¤˜ ÙÔ˘ 17Ô˘ ·ÈÒÓ·, ÁÈ·Ù›, ÌÂٷ͇ ¿ÏψÓ, ˘ÔÛÙ‹ÚÈÍ fiÙÈ ÙÔ Û‡Ì·Ó Â›Ó·È ¿ÂÈÚÔ, Ì›· ¿Ô„Ë Ô˘ ‹Ù·Ó ÌÂÓ ·ÏËı‹˜, ·ÏÏ¿ ·ÓÙ›ıÂÙË ÚÔ˜ ÙË ¯ÚÈÛÙÈ·ÓÈ΋ ·Ú¿‰ÔÛË. ™‡Ìʈӷ Ì ÙËÓ ∞Á›· °Ú·Ê‹, ÂȉÈÎfiÙÂÚ·, Ô £Âfi˜ ¤ÊÙÈ·Í ÙÔÓ ÎfiÛÌÔ, ÛÙÔ Î¤ÓÙÚÔ ÙÔ˘ ÔÔ›Ô˘ ÙÔÔı¤ÙËÛ ÙËÓ ÎÔÚˆÓ›‰· Ù˘ ‰ËÌÈÔ˘ÚÁ›·˜ ÙÔ˘, ÙÔÓ ¿ÓıÚˆÔ. ∞Ó, fï˜, ÙÔ Û‡Ì·Ó Â›Ó·È, fiˆ˜ ˘ÔÛÙ‹ÚÈÍÂ Ô ªÚÔ‡ÓÔ, ¿ÂÈÚÔ, ÙfiÙ ‰ÂÓ ˘¿Ú¯ÂÈ ÂÚÈʤÚÂÈ· Ô˘ Ó· ÙÔ ÎÏ›ÓÂÈ Ì¤Û· Ù˘, Î·È Ê˘ÛÈο, ‰ÂÓ ÌÔÚ› Ó· ˘¿Ú¯ÂÈ Î¤ÓÙÚÔ, ÔfiÙÂ Ë ¯ÚÈÛÙÈ·ÓÈ΋ ›ÛÙË ÂÚ› Ù˘ ‰ËÌÈÔ˘ÚÁ›·˜ ÙÔ˘ ÎfiÛÌÔ˘ ·fi ÙÔÓ £Âfi, Ô ÔÔ›Ô˜ ÙÔÔı¤ÙËÛ ÙÔÓ ¿ÓıÚˆÔ ÛÙÔ Î¤ÓÙÚÔ ÙÔ˘ ÎfiÛÌÔ˘, ηı›ÛÙ·Ù·È ¤ˆÏË. √È ·ÓÙȉڿÛÂȘ, ‚¤‚·È·, Ô˘ ÂΉËÏÒıËÎ·Ó Î·È ÂÍ·ÎÔÏÔ˘ıÔ‡Ó Ó· ÂÁ›ÚÔÓÙ·È ÛÙȘ ̤Ú˜ Ì·˜, ÂÓ·ÓÙ›ÔÓ ÙˆÓ ÂÈÛÙËÌfiÓˆÓ ÁÈ· ÙȘ ·fi„ÂȘ ÙÔ˘˜ Ô˘ ‰ÂÓ Û˘Ó¿‰Ô˘Ó ÚÔ˜ ÙȘ ηıÈÂڈ̤Ó˜ ·ÓÙÈÏ‹„ÂȘ Î·È ÙȘ ·ÁȈ̤Ó˜ ·Í›Â˜ Ù˘ ÎÔÈÓˆÓ›·˜ ‰ÂÓ ÂÚÈÔÚ›˙ÔÓÙ·È ÛÙÔ Â‰›Ô Ù˘ ıÚËÛΛ·˜, ·ÏÏ¿ ÂÂÎÙ›ÓÔÓÙ·È, ›Û˘, Û ¿ÏÏÔ˘˜ ÙÔÌ›˜ ÙÔ˘ ÔÏÈÙÈÛÌÔ‡ Ì·˜, fiˆ˜ Ë ËıÈ΋, fiÔ˘ ı· ‹ıÂÏ· Ó· οӈ ÔÚÈṲ̂Ó˜ ÂÈÛËÌ¿ÓÛÂȘ, ÌÈ·˜ Î·È ·Â˘ı‡ÓÔÌ·È Û ·ÎÚÔ·Ù‹ÚÈÔ Î˘Ú›ˆ˜ È·ÙÚÒÓ, ÔÈ ÔÔ›ÔÈ ÓÈÒıÔ˘Ó ÙÔÓ Ì·ÌԇϷ Ù˘ ËıÈ΋˜ Ó· ÙÔ˘˜ ÂÚÈ̤ÓÂÈ ÛÙË ÁˆÓ›·, ¤ÙÔÈÌÔ˜ Ó· ÙÔ˘˜ ÂÈÙÂı›, ·Ó ÂȯÂÈÚ‹ÛÔ˘Ó Ó· ÍÂʇÁÔ˘Ó ·fi ÙȘ ·Ú·‰Â‰Ô̤Ó˜ ·Ú¯¤˜. £· ‹ıÂÏ· Ó· ·Ú·ÙËÚ‹Ûˆ fiÙÈ Ë ËıÈ΋ -¤Ó· ϤÁÌ· ηÓfiÓˆÓ Ô˘ Ú˘ıÌ›˙Ô˘Ó ÙȘ Û¯¤ÛÂȘ ÌÂٷ͇ ÙˆÓ ·ÓıÚÒˆÓ ÛÙÔ˘˜ ÎfiÏÔ˘˜ Ù˘ ÎÔÈÓˆÓ›·˜- ‰ÂÓ Â›Ó·È Û˘Ó˘Ê·Ṳ̂ÓË Ì ÙË Ê‡ÛË ÙÔ˘ ·ÓıÚÒÔ˘, fiˆ˜ ›ӷÈ, ·˜ Ô‡ÌÂ, ÙÔ ¤ÓÛÙÈÎÙÔ Ù˘ ·˘ÙÔÛ˘ÓÙ‹ÚËÛ˘. √ ∞ÚÈÛÙÔÙ¤Ï˘ ϤÂÈ -Î·È ÓÔÌ›˙ˆ fiÙÈ ¤¯ÂÈ ‰›ÎÈÔ- fiÙÈ Ë ËıÈ΋ ·Ú¯›˙ÂÈ ·fi ÂΛ fiÔ˘ ÛÙ·Ì·Ù¿ÂÈ Ë ÊÈÏ›·. ªÂٷ͇ ÙˆÓ Ê›ÏˆÓ ‰ÂÓ Ù›ıÂÙ·È ÙÔ ˙‹ÙËÌ· ·Ó Ú¤ÂÈ ‹ ‰ÂÓ Ú¤ÂÈ Ó· οÓÂÈ Î¿ÙÈ Ô ¤Ó·˜ ·fi ÙÔ˘˜ ‰‡Ô ÁÈ· ÙÔÓ ¿ÏÏÔ ·˘ıfiÚÌËÙ· Î·È ¯ˆÚ›˜ Î·Ó¤Ó·Ó ÂÓ‰ÔÈ·ÛÌfi: Ô Ê›ÏÔ˜ Û οı ÂÚ›ÙˆÛË Ú¿ÙÙÂÈ ÂΛÓÔ Ô˘ ÙÔ˘ ˘·ÁÔÚ‡ÂÈ Ë Û¯¤ÛË Ù˘ ÊÈÏ›·˜ ÙÔ˘ Ì οÔÈÔÓ Û˘Ó¿ÓıÚˆfi ÙÔ˘, ¤ÛÙˆ Î·È ·Ó ͤÚÂÈ fiÙÈ Ë Ú¿ÍË ÙÔ˘ ·˘Ù‹ ·Ú·‚È¿˙ÂÈ Î¿ÔÈ· ıÂÌÂÏÈÒ‰Ë ËıÈ΋ ·Ú¯‹ Ù˘ ÎÔÈÓˆÓ›·˜ fiÔ˘ ˙ÂÈ. ŸÙ·Ó, ÁÈ· Ó· ·Ó·Ê¤Úˆ ÌÈ· ¯·Ú·ÎÙËÚÈÛÙÈ΋ ÂÚ›ÙˆÛË ÊÈÏ›·˜, Ô §·›ÏÈÔ˜, ÌÚÔÛÙ¿ ÛÙÔ˘˜ ƒˆÌ·›Ô˘˜ ˘¿ÙÔ˘˜, ÔÈ ÔÔ›ÔÈ, ÌÂÙ¿ ÙËÓ Î·Ù·‰›ÎË ÙÔ˘ ∆È‚¤ÚÈÔ˘ °Ú¿Î¯Ô˘, ΢ÓËÁÔ‡Û·Ó fiÏÔ˘˜ fiÛÔÈ ‹Ù·Ó Ù˘ ÂÌÈÛÙÔÛ‡Ó˘ ÙÔ˘, ÚÒÙËÛ ÙÔÓ ÛÙÂÓfiÙÂÚÔ Ê›ÏÔ ÙÔ˘, °¿ÈÔ µÏfiÛÈÔ, ÙÈ ı· ÌÔÚÔ‡Û ӷ οÓÂÈ ÁÈ· ¯¿ÚË ÙÔ˘ °Ú¿Î¯Ô˘, ÂΛÓÔ˜ ÙÔ˘ ·¿ÓÙËÛÂ: “∆· ¿ÓÙ·”. “¶Ò˜ Ù· ¿ÓÙ·”, Û˘Ó¤¯ÈÛÂ Ô §·›ÏÈÔ˜, “‰ËÏ·‰‹ ÙÈ; ∞Ó ÛÔ˘ ¤‰ÈÓ ÂÓÙÔÏ‹ Ó· ‚¿ÏÂȘ ʈÙÈ¿ ÛÙÔ˘˜ Ó·Ô‡˜ Ì·˜, ı· ÙÔ ¤Î·Ó˜;”. “¶ÔÙ¤ ‰ÂÓ ı· ÌÔ˘ ¤‰ÈÓ ٤ÙÔÈ· ÂÓÙÔÏ‹”, ·ÔÎÚ›ıËÎÂ Ô µÏfiÛÈÔ˜. “∞Ó, fï˜, ÛÔ˘ ¤‰ÈÓ ٤ÙÔÈ· ÂÓÙÔÏ‹;”, ¤ÌÂÈÓÂ Ô §·›ÏÈÔ˜. “£· ›¯· ˘·ÎÔ‡ÛÂÈ”, ·¿ÓÙËÛÂ Ô µÏfiÛÈÔ˜. ŸÙ·Ó Ë Û¯¤Paediatriki 2007;70:253-256
ÛË ÌÂٷ͇ ‰‡Ô ·ÓıÚÒˆÓ ‰ÂÓ ·ÁÁ›˙ÂÈ Ù· fiÚÈ· Ù˘ ÊÈÏ›·˜, fiÔ˘ Ô ¤Ó·˜ ‰›ÓÂÙ·È ÛÙÔÓ ¿ÏÏÔ ¯ˆÚ›˜ Ó· ˘ÔÏÔÁ›˙ÂÈ Ù›ÔÙÂ, Î·È Ù·˘Ùfi¯ÚÔÓ·, ¿Ó, Û ÂÚ›ÙˆÛË Ô˘ Ô ¤Ó·˜ ÎÏËı› Ó· Ú¿ÍÂÈ Î¿ÙÈ Û ۯ¤ÛË Ì ÙÔÓ ¿ÏÏÔ, ÂΛÓÔ˜ ‰ÈÂÚˆÙËı› ·Ó Ú¤ÂÈ Ó· ÙÔ Î¿ÓÂÈ ‹ fi¯È, ÙfiÙ ̷›ÓÂÈ ÛÙËÓ ˙ˆ‹ ÙÔ˘ Ë ËıÈ΋. ∞Ó, ÏÔÈfiÓ, Ë ËıÈ΋ ‰ÂÓ Â›Ó·È Û˘Ó˘Ê·Ṳ̂ÓË Ì ÙË Ê‡ÛË Ì·˜, ÙfiÙ ÙÔ ÂÚÒÙËÌ· Â›Ó·È Ì‹ˆ˜ ı· ÌÔÚÔ‡Û·Ì ӷ ˙‹ÛÔ˘Ì ¯ˆÚ›˜ ÙËÓ ËıÈ΋. ∫·È fiÙ·Ó Ï¤ˆ “¯ˆÚ›˜ ÙËÓ ËıÈ΋”, ÂÓÓÔÒ ¯ˆÚ›˜ ·Ó·ÊÔÚ¿ Û ηÌÈ¿ ËıÈ΋ ·Ú¯‹ ‹ ·Í›·, Î·È fi¯È ¯ˆÚ›˜ ÙËÓ Ù¿‰Â ËıÈ΋ ·Ú¯‹ ·ÏÏ¿ Ì ÙË ‰Â›Ó· ËıÈ΋ ·Ú¯‹. °È· Ó· ÏÂÈÙÔ˘ÚÁ‹ÛÂÈ ÌÈ· ËıÈ΋ ·Ú¯‹, ¯ÚÂÈ¿˙ÂÙ·È ·ÛÊ·ÏÒ˜ ¯ÚfiÓÔ, ÚÔÎÂÈ̤ÓÔ˘ Ó· ÌÔÚ¤ÛÂÈ Ó· ·ÁȈı› ÛÙË Û˘Ó›‰ËÛË ÙˆÓ ÚÔÛÒˆÓ ÛÙ· ÔÔ›· ·Â˘ı‡ÓÂÙ·È, ÒÛÙ ӷ ‰ËÌÈÔ˘ÚÁËı› Û ·˘Ù¿ Ë ·›ÛıËÛË ÙÔ˘ ηı‹ÎÔÓÙÔ˜, fiÙÈ ‰ËÏ·‰‹ ÔÊ›ÏÔ˘Ó Ó· ÂÓ·ÚÌÔÓÈÛÙÔ‡Ó ÚÔ˜ ÙËÓ ·Ú¯‹ ·˘Ù‹. √È ÂÍÂÏ›ÍÂȘ, fï˜, ÛÙÔÓ ÙÔ̤· Ù˘ È·ÙÚÈ΋˜ ÂȉÈο, Ì¿ÏÈÛÙ·, ηٿ ÙȘ ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜- ÙÚ¤¯Ô˘Ó Ì ÙfiÛË Ù·¯‡ÙËÙ·, ÒÛÙ ӷ Â›Ó·È ·‰‡Ó·ÙÔÓ Ó· Î·Ï˘ÊıÔ‡Ó ·fi ÙȘ ÂοÛÙÔÙ ˘ÊÈÛÙ¿ÌÂÓ˜ ËıÈΤ˜ ·Ú¯¤˜. ∂ÎÙfi˜ ÎÈ ·Ó ı¤ÏÔ˘Ì ÔÈ ÂÎÚfiÛˆÔÈ Ù˘ È·ÙÚÈ΋˜ Ó· ˙Ô˘Ó Û ÌÈ· ·ÙÌfiÛÊ·ÈÚ· ·ÎÔ‡ÛÈ·˜, ¤ÛÙˆ, ˘ÔÎÚÈÛ›·˜ - Ú¿ÁÌ·, ¿ÏψÛÙÂ, Ô˘ ¤¯ˆ ÙËÓ ÂÓÙ‡ˆÛË fiÙÈ Û˘Ì‚·›ÓÂÈ. °È·Ù› ÌÔÚ› ÌÂÓ Ô ÁÈ·ÙÚfi˜, Û‡Ìʈӷ Ì ÙÔÓ fiÚÎÔ ÙÔ˘ πÔÎÚ¿ÙË, ÛÙÔÓ ÔÔ›Ô ‰›‰ÂÈ ›ÛÙÈÓ, Ó· ÔÊ›ÏÂÈ Ó· ‰È‰¿ÛÎÂÈ Î·È Ó· ·ÛΛ ÙËÓ ÂÈÛÙ‹ÌË ÙÔ˘ “¿Ó¢ ÌÈÛıÔ‡ Î·È Í˘ÁÁÚ·Ê‹˜” ‹ Ó· ÌËÓ “Ù¤ÌÓÂÈ”, ·ÏÏ¿ ÛÙËÓ Ú·ÁÌ·ÙÈÎfiÙËÙ· Â›Ó·È ·‰È·ÓfiËÙÔ, Û‹ÌÂÚ·, ¤Ó·˜ ÁÈ·ÙÚfi˜ Ó· ÌËÓ ·Ì›‚ÂÙ·È Î·È Ó· ÌËÓ ·Ú¿ÁÂÈ Û˘ÁÁÚ·ÊÈÎfi ¤ÚÁÔ ‹ ÎÏ¿‰ÔÈ Ù˘ È·ÙÚÈ΋˜, fiˆ˜ Ô ¯ÂÈÚÔ˘ÚÁÈÎfi˜, Ô ÔÚıÔ‰ÈÎfi˜, Ô ÔÊı·ÏÌÔÏÔÁÈÎfi˜ Ó· ··ÈÙÔ‡Ó ·fi ÙÔÓ ÁÈ·ÙÚfi Ó· ÌËÓ “Ù¤ÌÓÂÈ”. ª‹ˆ˜, ÏÔÈfiÓ, Ë Ï‡ÛË ÁÈ· Ó· ÂÈÙÂÏ› ·ÚfiÛÎÔÙ· ηÈ, ηْ ¤ÎÙ·ÛË, ÛˆÛÙ¿ ÙÔ ¤ÚÁÔ ÙÔ˘ Ô ÁÈ·ÙÚfi˜ ı· ‹Ù·Ó Ó· ηٷÚÁËı› Ë ËıÈ΋ - ¯ˆÚ›˜ Ó· ÙÔ ÂÓÓÔÒ ·˘Ùfi ÛÙÔ ÚÔÛ¯¤˜ ̤ÏÏÔÓ, ·ÏÏ¿ Û ‚¿ıÔ˜ ¯ÚfiÓÔ˘; ÿÛˆ˜, Ì¿ÏÈÛÙ·, ·Ú·Î¿ÌÙÔÓÙ·˜ ÛÙȘ ηıËÌÂÚÈÓ¤˜ ˘Ôı¤ÛÂȘ Ì·˜ ÙËÓ ËıÈ΋, Ë ˙ˆ‹ Ì·˜ Ó· ÁÈÓfiÙ·Ó ÈÔ ÂÏ΢ÛÙÈ΋. °È·Ù›, Â›Ó·È ·Ï‹ıÂÈ·, Ë ËıÈ΋ ÁÈ· ‰È¿ÊÔÚÔ˘˜ ÏfiÁÔ˘˜ Ì·˜ Â›Ó·È ÂÓÔ¯ÏËÙÈ΋. ∏ ·ÚÂÙ‹, ·›ÊÓ˘, ÚÔ˜ ÙËÓ ·fiÎÙËÛË Ù˘ ÔÔ›·˜ ·‰È·Ï›و˜ Ì·˜ ÚÔÙÚ¤ÂÈ Ë ËıÈ΋ Î·È ÙÔ Î·ı‹ÎÔÓ Ô˘ ·ÔÚÚ¤ÂÈ ·fi ÙÔ ÌfiÓÈÌÔ ·›ÙËÌ· Ù˘ ·fiÎÙËÛ˘ Ù˘ ·ÚÂÙ‹˜ ··ÈÙÔ‡Ó ·fi Ì·˜ Ó· ı˘ÛÈ¿˙Ô˘Ì οÙÈ ·fi ÙËÓ ˘Á›· Ì·˜ Î·È ÙËÓ Â˘Ù˘¯›· Ì·˜. ∂Ó›ÔÙÂ, Ì¿ÏÈÛÙ·, fiÙ·Ó, fiˆ˜ ϤÂÈ Ô ÔÈËÙ‹˜, Ú¤ÂÈ Ó· ԇ̠ÙÔ ÌÂÁ¿ÏÔ Ó·È ‹ ÙÔ ÌÂÁ¿ÏÔ fi¯È, ÂÓ‰¤¯ÂÙ·È Ë ·ÚÂÙ‹ Î·È ÙÔ Î·ı‹ÎÔÓ Ó· Ì·˜ ÚÔÙÚ¤„Ô˘Ó Ó· ‰È·ÎÈÓ‰˘Ó‡ÛÔ˘ÌÂ Î·È ÙË ˙ˆ‹ Ì·˜ ·ÎfiÌË. ∂›Ó·È ÛÙËÓ Ê‡ÛË Ì·˜ Ó· ı¤ÏÔ˘Ì ӷ ·ÔÏ·Ì‚¿ÓÔ˘Ì ÙË ˙ˆ‹, ÎÈ ·˘Ùfi, ‰˘ÛÙ˘¯Ò˜, ‰ÂÓ Û˘Ì‚·›ÓÂÈ, ÂÓ ÔÏÏÔ›˜, ÂÍ·ÈÙ›·˜ Ù˘ ËıÈ΋˜ Î·È ÙˆÓ ˘Ô¯ÚÂÒÛˆÓ
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·255
255
√ ı¿Ó·ÙÔ˜ Ù˘ ËıÈ΋˜
Ô˘ ·˘Ù‹ Ì·˜ ˘·ÁÔÚ‡ÂÈ. ¢ÂÓ Ì·˜ ·Ú¤ÛÂÈ Ó· Ì·˜ ϤÓ ÙÈ Ú¤ÂÈ Ó· οÓÔ˘ÌÂ, ÔfiÙ οÓÔÓÙ·˜ Ú¿ÁÌ·Ù· Ô˘ Ì·˜ ÂÈ‚¿ÏÏÔÓÙ·È, ·ÈÛı·ÓfiÌ·ÛÙ ‰˘ÛÊÔÚ›·. ªÔÚÔ‡ÌÂ, ‚¤‚·È·, Ó· ·ÁÓÔ‹ÛÔ˘Ì fi,ÙÈ Ì·˜ ϤÓ ˆ˜ ÔÊ›ÏÔ˘Ì ӷ οÓÔ˘ÌÂ. ∞ÏÏ¿, ÙfiÙÂ, ÓÈÒıÔ˘Ì ÂÎÙÂıÂÈ̤ÓÔÈ ·¤Ó·ÓÙÈ ÛÙÔ˘˜ ¿ÏÏÔ˘˜, ˘ÔʤÚÔÓÙ·˜ ¤ÙÛÈ ·fi ÙÔ ‚¿ÚÔ˜ Ù˘ ÂÓÔ¯‹˜, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ·Ì·˘ÚÒÓÂÙ·È Ë ·fiÏ·˘ÛË Ô˘ ÂÈÌfiÓˆ˜ ˙ËÙ¿ÌÂ. ¶ÚÔ˜ ÙÈ, ÏÔÈfiÓ, Ë ‰È·Ù‹ÚËÛË Ù˘ ËıÈ΋˜, Ë ÔÔ›· ÌÔÚ› Ó· ϤÂÈ fiÙÈ Ì·˜ ˘Ô¯ÚÂÒÓÂÈ Ó· ˙ԇ̠̠¤Ó·Ó ÔÚÈṲ̂ÓÔ ÙÚfiÔ ÚÔÎÂÈ̤ÓÔ˘ Ó· Ù‡¯Ô˘Ì ÂÓfi˜ ηχÙÂÚÔ˘ ‚›Ô˘, ·ÏÏ¿ ÛÙËÓ Ú·ÁÌ·ÙÈÎfiÙËÙ· Ì·˜ ÚÔÛʤÚÂÈ ÙË ÌÈ˙¤ÚÈ·; ∫·È Ë ·ÔÚ›· ·˘Ù‹ Á›ÓÂÙ·È ÂÓÙÔÓfiÙÂÚË, Â¿Ó ÛÎÂÊÙԇ̠fiÙÈ Ë ËıÈ΋ ‰ÂÓ ËÁ¿˙ÂÈ ·fi ÙË Ê‡ÛË ÙˆÓ Ú·ÁÌ¿ÙˆÓ. ∞Ó, ȉ›ˆ˜, ›̷ÛÙ ˘Ô¯Úˆ̤ÓÔÈ Ó· Ú˘ıÌ›˙Ô˘Ì ÙË Û˘ÌÂÚÈÊÔÚ¿ Ì·˜ Û‡Ìʈӷ Ì ÙȘ ÂÈÙ·Á¤˜ Ù˘ ËıÈ΋˜, ‰ÂÓ Â›Ó·È ÁÈ·Ù› Ì·˜ ˘Ô‰ÂÈÎÓ‡ÂÙ·È ·˘Ùfi ·fi ÙËÓ ·Ó·ÁηÈfiÙËÙ· ÙˆÓ Ú·ÁÌ¿ÙˆÓ ‹, fiˆ˜ ·Ó¤ÊÂÚ· ÚÔËÁÔ˘Ì¤Óˆ˜, ·fi ÙËÓ ·ÓıÚÒÈÓË Ê‡ÛË Ì·˜, ·ÏÏ¿ ÂÂȉ‹ ‚ÚÂı‹Î·Ì ÂÁÎψ‚ÈṲ̂ÓÔÈ Û ÌÈ· ÁÏÒÛÛ·, ÙËÓ ÔÔ›· ÂÌ›˜ ÂÈÓÔ‹Û·ÌÂ. √È ¿ÓıÚˆÔÈ, Û˘ÁÎÂÎÚÈ̤ӷ, ÁÈ· Ó· ÂÙ‡¯Ô˘Ó Ó· ÂÚÈÔÚ›ÛÔ˘Ó “ÙË ÛÙÚÔ‚ÈÏ›˙Ô˘Û· ÔÏ˘ÏÔÎfiÙËÙ· ÙÔ˘ ÎfiÛÌÔ˘ Û ¤Ó· ÛÎfiÈÌÔ Î·È ¯Ú‹ÛÈÌÔ Û¯‹Ì·”, fiˆ˜ ı· ¤ÏÂÁÂ Ô ¡›ÙÛÂ, ÁÈ· Ó· ÌÔÚ¤ÛÔ˘Ó, ‰ËÏ·‰‹, Ó· ‚¿ÏÔ˘Ó ÙË ¯·Ò‰Ë Ú·ÁÌ·ÙÈÎfiÙËÙ· Û ٿÍË ‰ËÌÈÔ‡ÚÁËÛ·Ó ÙȘ ϤÍÂȘ, ÒÛÙÂ, Ì ‚¿ÛË ·˘Ù¤˜, Ó· ηٷٿÛÛÔ˘Ó Ù· Ú¿ÁÌ·Ù· Û ηÙËÁÔڛ˜, ÒÛÙ ӷ Ù· ͯˆÚ›˙Ô˘Ó ÙÔ ¤Ó· ·fi ÙÔ ¿ÏÏÔ Î·È Ó· Â›Ó·È Û ı¤ÛË, ¤ÙÛÈ, Ó· ÂÈÎÔÈÓˆÓÔ‡Ó ÌÂٷ͇ ÙÔ˘˜. ∆Ô Î·Îfi Ì ÙÔ˘˜ ·ÓıÚÒÔ˘˜ Â›Ó·È fiÙÈ ·fi ¤Ó· ÛËÌÂ›Ô Î·È ÌÂÙ¿ ͤ¯·Û·Ó fiÙÈ ÔÈ Ï¤ÍÂȘ ‰È·‰Ú·Ì·Ù›˙Ô˘Ó ¤Ó·Ó ηı·Ú¿ ÏÂÈÙÔ˘ÚÁÈÎfi ÚfiÏÔ Î·È ›ÛÙ„·Ó ˆ˜ ·˘Ù¤˜ ϤÔÓ Â›Ó·È Ù· ›‰È· Ù· Ú¿ÁÌ·Ù·. ∂Ó ÙÔÈ·‡ÙË ÂÚÈÙÒÛÂÈ, ÔÈ Ï¤ÍÂȘ ÌÔÈ¿˙Ô˘Ó Ó· ÔÚıÒÓÔÓÙ·È ÌÚÔÛÙ¿ Ì·˜ Û·Ó Û˘Ì·Á›˜ fiÁÎÔÈ Ú·ÁÌ¿ÙˆÓ Ô˘ Â›Ó·È ·‰‡Ó·ÙÔÓ Ó· ÙÔ˘˜ ·Ú·Î¿Ì„ÂÈ Î·Ó›˜. ªÂ ·˘Ù‹ ÙËÓ ¤ÓÓÔÈ·, ‰ÒÛ·Ì ÛÙÔ “ηÏfi”, ÛÙÔ “ÛˆÛÙfi”, ÛÙÔ “‰›Î·ÈÔ”, ÛÙÔ “Ú¤ÂÈ” Î·È ÛÙȘ ¿ÏϘ ϤÍÂȘ Ô˘ Û˘ÁÎÚÔÙÔ‡Ó ÙËÓ ÁÏÒÛÛ· Ù˘ ËıÈ΋˜ ÔÓÙÔÏÔÁÈ΋ ˘fiÛÙ·ÛË ‰ËÌÈÔ˘ÚÁÒÓÙ·˜ ÙËÓ ÂÔ›ıËÛË fiÙÈ, ·Ó ÂȯÂÈÚ‹ÛÂÈ Ó· ÙȘ ·ˆı‹ÛÂÈ Î·Ó›˜, ı· Ê¿ÂÈ Ù· ÌÔ‡ÙÚ· ÙÔ˘, fiÙÈ, fiˆ˜ ϤÂÈ ¿ÏÈ Ô ¡›ÙÛÂ, ÛÎÔÓÙ¿ÊÙÔÓÙ·˜ ¿Óˆ ÙÔ˘˜ “ı· Û¿ÛÂÈ ÙÔ fi‰È ÙÔ˘ Ì¿ÏÏÔÓ ·Ú¿ ·˘Ù¤˜”. ∞fi Ù· ̤۷ ÙÔ˘ ÂÚ·Ṳ̂ÓÔ˘ ·ÈÒÓ· -ÂÓÓÔÒ ÙÔ˘ 20Ô‡ ·ÈÒÓ·-, fï˜, ˘‹ÚÍ·Ó ÊÈÏfiÛÔÊÔÈ Ô˘ Âȯ›ÚËÛ·Ó Ó· Ì·˜ ‚Á¿ÏÔ˘Ó ·fi ÙËÓ Ï¿ÓË ·˘Ù‹ ϤÁÔÓÙ·˜ fiÙÈ ÔÈ ËıÈΤ˜ ϤÍÂȘ ‰ÂÓ ·ÔÙÂÏÔ‡Ó ·Í¤ڷÛÙÔ˘˜ ÔÓÙÔÏÔÁÈÎÔ‡˜ fiÁÎÔ˘˜, ·ÏÏ¿ fiÙÈ ı· ÌÔÚÔ‡Û·Ì οÏÏÈÛÙ· Ó· ÌÂÙ·¯ÂÈÚÈÛÙԇ̠ÂÚÈÁڷʤ˜ ·fi ÙȘ Ôԛ˜ Ó· ·Ô˘ÛÈ¿˙Ô˘Ó ÔÈ ËıÈÎÔ› fiÚÔÈ Î·È Ó· ··ÏÏ·ÁÔ‡ÌÂ, ¤ÙÛÈ, ·fi ÙȘ ԯϋÛÂȘ Ô˘ Û˘ÓÂ-
¿ÁÂÙ·È Ë ËıÈ΋. ∞ÓÙ›, ÁÈ· ·Ú¿‰ÂÈÁÌ·, Ó· ÂÈ Î·Ó›˜ ÁÈ· οÔÈÔÓ fiÙÈ Â›Ó·È Î·Ïfi˜ ·Ù¤Ú·˜, ı· ÌÔÚÔ‡ÛÂ, ··Ï›ÊÔÓÙ·˜ ÙÔÓ ˙ËÌÈÔÁfiÓÔ ËıÈÎfi fiÚÔ “ηÏfi˜”, Ó· ·Ú·ÙËÚ‹ÛÂÈ fiÙÈ ÊÚÔÓÙ›˙ÂÈ ÁÈ· Ù· ·È‰È¿ ÙÔ˘ Ó· ÌËÓ ÂÈÓ¿ÓÂ, Ó· ÌÔÚʈıÔ‡Ó, Ó· ÓÈÒıÔ˘Ó ·ÛÊ¿ÏÂÈ·, Î.Ô.Î. √ ·ÂÁÎψ‚ÈÛÌfi˜ Ì·˜ ·fi ÙËÓ ËıÈ΋ ÁÏÒÛÛ· Î·È Ë ·ÂÏ¢ı¤ÚˆÛ‹ Ì·˜ ·fi ÙȘ ·ÚÂÓ¤ÚÁÂȤ˜ Ù˘ ¢ÓÔÔ‡ÓÙ·È ·fi ÙÔ Î·ÈÓÔ‡ÚÈÔ ÂÚÈ‚¿ÏÏÔÓ Ô˘ ‰È·ÌÔÚÊÒÓÂÙ·È ¯¿ÚË ÛÙËÓ ÂͤÏÈÍË Ù˘ ÂÈÛÙ‹Ì˘ Î·È Ù˘ Ù¯ÓÔÏÔÁ›·˜. ∫ÔÚ˘Ê·›· ۇ̂ÔÏ· ÙÔ˘ ËıÈÎÔ‡ ‚›Ô˘ Ì·˜ ˘ÔÓÔ̇ÔÓÙ·È Î·È ÌÔÈ¿˙Ô˘Ó Ó· ηٷÚÚ¤Ô˘Ó Î¿Ùˆ ·fi ÙÔ ‚¿ÚÔ˜ ÙˆÓ ÂÈÛÙËÌÔÓÈÎÒÓ Î·È Ù¯ÓÔÏÔÁÈÎÒÓ ÂÍÂϛ͈Ó. §fiÁÔ˘ ¯¿ÚÈÓ, Ë ¤ÓÓÔÈ· Ù˘ ÌËÙ¤Ú·˜, Ì fiÏË ÙËÓ ËıÈ΋ ·‡Ú· Ô˘ Û¤ÚÓÂÈ Ì·˙› Ù˘, Î·È ÙÔ˘ ·ÁÓÒÛÙÔ˘ ÛÙÚ·ÙÈÒÙË, Ô˘ ÂÎÊÚ¿˙ÂÈ ÙÔ ·‰È·Ú·ÁÌ¿Ù¢ÙÔ ËıÈÎfi ¯Ú¤Ô˜ Ì·˜ ÚÔ˜ ÙËÓ ·ÙÚ›‰· Ì·˜, ÂÌÊ·Ó›˙ÔÓÙ·È Û·Ó Î·Ù¿ÏÔÈ· ÌÈ·˜ ¿ÏÏ˘ ÂÔ¯‹˜. §¤ÁÔÓÙ·˜ “ÌËÙ¤Ú·”, Û˘ÁÎÂÎÚÈ̤ӷ, ÂÓÓÔԇ̠ÙÔ Ï¿ÛÌ· ÂΛÓÔ Ô˘ ·Ú¿ÁÂÈ ˆ¿ÚÈ·, Û˘ÏÏ·Ì‚¿ÓÂÈ, ΢ÔÊÔÚ› ̤۷ ÙÔ˘ ÙÔ ¤Ì‚Ú˘Ô Î·È, ÙÂÏÈο, ÁÂÓÓ¿ÂÈ ÙÔ ·È‰›. ∞fi ÙȘ ÏÂÈÙÔ˘ÚÁ›Â˜ ·˘Ù¤˜ Ù˘ ÌËÙ¤Ú·˜, ˆÛÙfiÛÔ, ÔÈ ÙÚÂȘ -Ë Û‡ÏÏË„Ë, Ë Î˘ÔÊÔÚ›· Î·È Ë Á¤ÓÓËÛË- ¤¯Ô˘Ó ‹‰Ë, ¯¿ÚË ÛÙËÓ ÂͤÏÈÍË Ù˘ ÂÈÛÙ‹Ì˘, ÌÂÙ·ÙÔÈÛÙ› ·fi ÙÔÓ ÂÛˆÙÂÚÈÎfi ÎfiÛÌÔ Ù˘ ÌËÙ¤Ú·˜ Û ¿ÏÏ· ÂÚÈ‚¿ÏÏÔÓÙ·. ¶Ú¿ÁÌ·ÙÈ, Û‹ÌÂÚ· Ë Û‡ÏÏË„Ë ÌÔÚ› Ó· ÂÈÙ¢¯ı› Û ‰ÔÎÈÌ·ÛÙÈÎfi ۈϋӷ, Ë Î˘ÔÊÔÚ›· Ó· Á›ÓÂÈ ÛÙË Ì‹ÙÚ· ÌÈ·˜ ¿ÏÏ˘ Á˘Ó·›Î·˜, Ù˘ ηÏÔ‡ÌÂÓ˘ ‰·ÓÂÈ΋˜ ÌËÙ¤Ú·˜, Î·È Ë Á¤ÓÓËÛË Ó· Û˘ÓÙÂÏÂÛÙ› ·fi ÙË ‰·ÓÂÈ΋ ÌËÙ¤Ú·. ø˜ ÚÔ˜ ÙËÓ ¿ÏÏË ÏÂÈÙÔ˘ÚÁ›· ‰Â, ÙËÓ ·Ú·ÁˆÁ‹ ˆ·Ú›ˆÓ, ÔÈÔ˜ ÌÔÚ› Ó· ·ÔÎÏ›ÛÂÈ fiÙÈ ÛÙÔ Ì¤ÏÏÔÓ Ë ÂÈÛÙ‹ÌË ‰ÂÓ ı· ÌÔÚ› Ó· Ù· ‰ËÌÈÔ˘ÚÁ› Ì Ù¯ÓËÙfi ÙÚfiÔ; ∞Ó¿ÏÔÁÔ˜ Â›Ó·È Î·È Ô ÂÎÊ˘ÏÈÛÌfi˜ Ô˘ ¤¯ÂÈ ˘ÔÛÙ›, ÂÍ·ÈÙ›·˜ Ù˘ ÚÔfi‰Ô˘ Ù˘ ÂÈÛÙ‹Ì˘ Î·È Ù˘ Ù¯ÓÔÏÔÁ›·˜, Ë ¤ÓÓÔÈ· ÙÔ˘ ¿ÁÓˆÛÙÔ˘ ÛÙÚ·ÙÈÒÙË. ∞Ó, ‰ËÏ·‰‹, ÛÙÔ ·ÚÂÏıfiÓ ÌÔÚÔ‡Û·Ì ӷ ÌÈÏ¿Ì ÁÈ· ÙÔÓ ¿ÁÓˆÛÙÔ ÛÙÚ·ÙÈÒÙË Ô˘ ¤ÂÛ ÛÙÔ Â‰›Ô Ù˘ Ì¿¯Ë˜, Û‹ÌÂÚ· ‰ÂÓ ‰ÈηÈÔ‡ÌÂı· Ó· ÙÔ Î¿ÓÔ˘ÌÂ, ÂÂȉ‹, ¯¿ÚË ÛÙËÓ ·Ó¿Ï˘ÛË ÙÔ˘ DN∞ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·Ó·Î·Ï˘Êı› Ë Ù·˘ÙfiÙËÙ· ÙÔ˘ οı ·ÓıÚÒÔ˘. ∞ÏÏ¿, ¤Ú· ·fi ÙËÓ ·ÌÊÈÛ‚‹ÙËÛË ÙˆÓ Û˘Ì‚fiÏˆÓ Ù˘ ËıÈ΋˜ Û˘ÌÂÚÈÊÔÚ¿˜ Ì·˜, Ù›ÓÂÈ Ó· ·Î˘Úˆı› ·ÎfiÌË Î·È Ô ›‰ÈÔ˜ Ô Â·˘Ùfi˜ Ì·˜, ÂΛÓÔ˜ Ô˘ ˘ÔÙ›ıÂÙ·È ˆ˜ Ú¿ÙÙÂÈ Î·È ¯ÚÂÒÓÂÙ·È ÙËÓ ËıÈ΋ ¢ı‡ÓË ÙˆÓ Ú¿ÍÂÒÓ Ì·˜. ¶Ô‡ ˘¿Ú¯ÂÈ, ·Ï‹ıÂÈ·, Ô Â·˘Ùfi˜ Ì·˜ Î·È ÙÈ Â›Ó·È ·˘Ùfi˜; √‡Ù ӷ ÙÔÓ ‰Ô‡ÌÂ, Ô‡Ù ӷ ÙÔÓ ·ÁÁ›ÍÔ˘ÌÂ, Ô‡Ù ӷ ÙÔÓ ·ÓÙÈÏËÊıԇ̠ηı’ ÔÈÔÓ‰‹ÔÙ ¿ÏÏÔ ÙÚfiÔ ÌÔÚÔ‡ÌÂ. ∞ÏÒ˜, ıˆÚԇ̠fiÙÈ ı· Ú¤ÂÈ Ó· ˘¿Ú¯ÂÈ Î¿Ô˘ ‚·ıÈ¿ ̤۷ Ì·˜, ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰ÈηÈÔÏÔÁ‹ÛÔ˘Ì ÙÔÓ ÔÚÁ·ÓˆÌ¤ÓÔ ÙÚfiÔ Ì ÙÔÓ ÔÔ›Ô ÂÓÂÚÁÔ‡ÌÂ. ∫·È Ë ÈÔ ·Ï‹ ÂÓ¤ÚÁÂÈ¿ Ì·˜, ÙÔ ¶·È‰È·ÙÚÈ΋ 2007;70:253-256
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·256
256
£. ¶ÂÏÂÁÚ›Ó˘
Ó· ·ÏÒÛÔ˘ÌÂ, ÁÈ· ·Ú¿‰ÂÈÁÌ·, ÙÔ ¯¤ÚÈ Ì·˜ ÁÈ· Ó· ÌÂÙ·ÎÈÓ‹ÛÔ˘Ì ÛÙÔ ÙÚ·¤˙È ¤Ó· ÛÙ·¯Ùԉԯ›Ô, ··ÈÙ› ¤Ó· Û‡ÓÔÏÔ ÎÈÓ‹ÛÂˆÓ ÙˆÓ Î˘ÙÙ¿ÚˆÓ Ì·˜ Î·È ÙˆÓ Ì˘ÒÓ Ì·˜, ÔÈ Ôԛ˜ Ú¤ÂÈ Ó· ÌÔ˘Ó ÛÙËÓ ÛÂÈÚ¿ Î·È Ó· ÂÓ·ÚÌÔÓÈÛÙÔ‡Ó, ÒÛÙ ӷ ÂÎÏËÚˆı› Ô ÛÎÔfi˜ Ì·˜ - Ë ÌÂٷΛÓËÛË ÙÔ˘ ÛÙ·¯ÙÔ‰Ô¯Â›Ô˘, ÂÓ ÚÔÎÂÈ̤ӈ. ∫¿ÔÈÔ˜, fï˜, ÂÈο˙Ô˘ÌÂ, ¤Ó·˜ Ú˘ıÌÈÛÙ‹˜ ÂÓÙfi˜ Ì·˜, ı· Ú¤ÂÈ Ó· ˘¿Ú¯ÂÈ ÁÈ· Ó· Û˘ÓÙÔÓ›˙ÂÈ ÙȘ ÎÈÓ‹ÛÂȘ Ì·˜, ÒÛÙ ӷ ÌÔÚԇ̠ӷ ÂÈÙÂÏԇ̠ÙȘ Ú¿ÍÂȘ ÛÙȘ Ôԛ˜ ÚÔ‚·›ÓÔ˘ÌÂ. ∞˘Ùfi˜ Ô ÂÛˆÙÂÚÈÎfi˜ Ú˘ıÌÈÛÙ‹˜ Â›Ó·È fi,ÙÈ ÔÓÔÌ¿˙Ô˘Ì “·˘Ùfi” Ì·˜, Ô ÔÔ›Ô˜, ‰ÚÒÓÙ·˜ ·ÓÂÍ¿ÚÙËÙ· ·fi Ù· ̤ÚË ·fi Ù· ÔÔ›· Û˘ÓÙ›ıÂÙ·È, ¤¯ÂÈ ÙËÓ Â˘ı‡ÓË Î·È, ˆ˜ ÂÎ ÙÔ‡ÙÔ˘, Â›Ó·È ˘fiÏÔÁÔ˜ ÁÈ· ÙÔÓ ÙÚfiÔ Ì ÙÔÓ ÔÔ›Ô ÂÓÂÚÁÔ‡ÌÂ Î·È Ú¿ÙÙÔ˘ÌÂ. ∫¿ı ÔÚÁ·ÓˆÌ¤ÓÔ Û‡ÓÔÏÔ, fiˆ˜, ·˜ Ô‡ÌÂ, ¤Ó· ÂÚÁÔÛÙ¿ÛÈÔ ‹ ¤Ó· ÁÚ·Ê›Ô, ‰ÈÔÈÎÂ›Ù·È ·fi οÔÈÔÓ, Ô ÔÔ›Ô˜ ¤¯ÂÈ ÙËÓ ÙÂÏÈ΋ ¢ı‡ÓË ÁÈ· ÙÔÓ ÙÚfiÔ Ì ÙÔÓ ÔÔ›Ô ÂÓÂÚÁÔ‡Ó Ù· ̤ÏË ÙÔ˘ Î·È Â›Ó·È, ÙÂÏÈο, Ô ˘fiÏÔÁÔ˜ ÁÈ· ÙÔ ¤ÚÁÔ Ô˘ ·Ú¿ÁÂÙ·È. øÛÙfiÛÔ, ı· ÌÔÚÔ‡Û·Ó Ó· ÂÈÛËÌ·ÓıÔ‡Ó ÔÚÁ·ÓˆÌ¤Ó· Û‡ÓÔÏ·, Ù· ̤ÏË ÙˆÓ ÔÔ›ˆÓ ÚÔ‚·›ÓÔ˘Ó Û ÔÈΛϘ Û˘ÓÙÔÓÈṲ̂Ó˜ ÂÓ¤ÚÁÂȘ ¯ˆÚ›˜ Ó· ˘¿Ú¯ÂÈ Î·Ó¤Ó·˜ Ú˘ıÌÈÛÙ‹˜. ¶·Ú·‰Â›ÁÌ·ÙÔ˜ ¯¿ÚÈÓ, Ù· ̤ÏË ÌÈ·˜ ·ÔÈΛ·˜ Ì˘ÚÌËÁÎÈÒÓ Î·Ù·Û΢¿˙Ô˘Ó ÛÙȘ ʈÏȤ˜ ÙÔ˘˜ ÛÙÔ¤˜, ÂÍfi‰Ô˘˜ Î·È ¿ÏÏ· Ì˯·ÓÈο ¤ÚÁ·, ‹ Ù· ̤ÏË ÂÓfi˜ ÛÌ‹ÓÔ˘˜ ·Ô‰ËÌËÙÈÎÒÓ Ô˘ÏÈÒÓ ‰È·ÙÚ¤¯Ô˘Ó ÙÂÚ¿ÛÙȘ ·ÔÛÙ¿ÛÂȘ ÂÙÒÓÙ·˜ Û ‰È¿ÊÔÚ· ‡„Ë, ÛÙ·Ì·ÙÒÓÙ·˜ Â‰Ò ÎÈ ÂΛ, ¯ˆÚ›˜, ÙfiÛÔ ÛÙË Ì›· fiÛÔ Î·È ÛÙËÓ ¿ÏÏË ÂÚ›ÙˆÛË, Ó· Ù· ηÙ¢ı‡ÓÂÈ ÛÙȘ ÂÓ¤ÚÁÂȤ˜ ÙÔ˘˜ οÔÈÔ˜ ·Ú¯ËÁfi˜. ∞ÏÒ˜, ÙÔ Î¿ıÂ Ì˘ÚÌ‹ÁÎÈ ÛÙËÓ ·ÔÈΛ· Î·È ÙÔ Î¿ı ̤ÏÔ˜ ÙÔ˘ ÛÌ‹ÓÔ˘˜ ÙˆÓ ·Ô‰ËÌËÙÈÎÒÓ Ô˘ÏÈÒÓ ‰Ú· ‚ϤÔÓÙ·˜ ÙÈ Î¿ÓÂÈ ÙÔ ‰ÈÏ·Ófi ÙÔ˘. ªÂ ·Ó¿ÏÔÁÔ ÙÚfiÔ ı· ÌÔÚÔ‡Û·Ì ӷ ÂÎÏ¿‚Ô˘Ì ÙÔ Î¿ı ·ÓıÚÒÈÓÔ ÔÓ Û·Ó ¤Ó·Ó ÔÚÁ·ÓÈÛÌfi Ô˘
Paediatriki 2007;70:253-256
·ÔÙÂÏÂ›Ù·È ·fi ¯ÈÏÈ¿‰Â˜ ·ÙÙ·Ú· Ô˘ Û˘ÁÎÚÔÙÔ‡ÓÙ·È Û ۇÓÔÏ·, Ù· ÔÔ›· Û˘ÌÂÚÈʤÚÔÓÙ·È ÙÔ Î·ı¤Ó· ÙÔ˘˜ ÎÔÈÙÒÓÙ·˜ Ò˜ ÂÓÂÚÁ› ÙÔ ‰ÈÏ·Ófi ÙÔ˘˜. ∂Ó ÙÔÈ·‡ÙË ÂÚÈÙÒÛÂÈ, ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È Ó· ηٷʇÁÔ˘Ì ÛÙËÓ ˘fiıÂÛË ÙÔ˘ ·˘ÙÔ‡ Ì·˜ ˆ˜ ˘Â‡ı˘ÓÔ˘ ÁÈ· fi,ÙÈ Î¿ÓÔ˘ÌÂ. ¶ÚÔÊ·ÓÒ˜, Û ¤Ó· ÂÚÈ‚¿ÏÏÔÓ, fiÔ˘ ‰ÂÓ ı· ˘¿Ú¯Ô˘Ó ËıÈο ۇ̂ÔÏ·, fiÔ˘ ÔÈ ¿ÓıÚˆÔÈ ‰ÂÓ ı· ÌÂÙ·¯ÂÈÚ›˙ÔÓÙ·È ÙË ÁÏÒÛÛ· Ù˘ ËıÈ΋˜ Î·È ‰ÂÓ ı· ·Â˘ı‡ÓÔÓÙ·È Ô ¤Ó·˜ ÛÙÔÓ ¿ÏÏÔ Û·Ó Ó· ˘¿Ú¯ÂÈ ·fi ›Ûˆ οÔÈÔ˜ Ú˘ıÌÈÛÙ‹˜ ÁÈ· Ó· ·Ó·Ï¿‚ÂÈ ÙËÓ Â˘ı‡ÓË ÁÈ· fiÛ· Ú¿ÙÙÔ˘Ó, Ë ËıÈ΋ ÌÔÚÊ‹ ˙ˆ‹˜ ‰ÂÓ ı· ¤¯ÂÈ Î·ÌÈ¿ ı¤ÛË. ∞˘Ùfi, ‚¤‚·È·, Â’ Ô˘‰ÂÓ› ‰ÂÓ ÛËÌ·›ÓÂÈ fiÙÈ, Â¿Ó Î·È ÂÊfiÛÔÓ Î·Ù·ÚÁËı› Ë ËıÈ΋, ı· ÁÂÌ›ÛÂÈ Ô ÎfiÛÌÔ˜ ·fi ηÎÔÔÈÔ‡˜. √È ¿ÓıÚˆÔÈ ı· Û˘Ó¯›ÛÔ˘Ó Ó· οÓÔ˘Ó Ï›ÁÔ Ôχ Ù· ›‰È· Ú¿ÁÌ·Ù·. ∞ÏÒ˜, ‰ÂÓ ı· ¤¯Ô˘Ó Î·Ó¤Ó·Ó ÏfiÁÔ Ó· Ù· ·ÍÈÔÏÔÁÔ‡Ó ËıÈο fiˆ˜ οÓÔ˘Ó Ì¤¯ÚÈ ÙÒÚ·. ∞˜ ÛÎÂÊÙԇ̠ÌfiÓÔ ÙÔ‡ÙÔ: fiÙ·Ó ¤·„Â Ë Ì˘ıÔÏÔÁ›· Ó· ·ÔÙÂÏ› Û˘ÛÙ·ÙÈÎfi Ù˘ ˙ˆ‹˜ ÙˆÓ ·ÓıÚÒˆÓ, Ù· ‰¤ÓÙÚ·, ÔÈ ı¿Ï·ÛÛ˜, ÔÈ Ï›ÌÓ˜, Ù· ıËÚ›· Î·È fiÏ· Ù· ¿ÏÏ· fiÓÙ· ÁÈ· Ù· ÔÔ›· ÌÈÏÔ‡Û·Ó ÔÈ Ì‡ıÔÈ, ‰ÂÓ ÂÍ·Ê·Ó›ÛÙËηÓ. ™˘Ó¤¯ÈÛ·Ó Ó· ˘¿Ú¯Ô˘Ó fiˆ˜ Î·È ÚÈÓ - ··ÏÏ·Á̤ӷ ·ÏÒ˜ ·fi ÙÔ Ó¤ÊÔ˜ ÙˆÓ Ì˘ıÔÏÔÁÈÎÒÓ ÂÚÈÁÚ·ÊÒÓ. √È fiÔȘ ·Ó·ÊÔÚ¤˜ Ì·˜ Û‹ÌÂÚ· ÛÙÔ˘˜ ̇ıÔ˘˜ Á›ÓÔÓÙ·È, fi¯È, ‚¤‚·È· ÁÈ·Ù› ÙÔ˘˜ ÈÛÙ‡ԢÌÂ, ·ÏÏ¿ ÚÔ˜ Ù¤Ú„Ë Ì·˜. ¶ÔÈÔ˜ ͤÚÂÈ, ÏÔÈfiÓ, Ì‹ˆ˜ ¤ÙÛÈ -·Ó ÔÙ¤ Î·È ÂÊfiÛÔÓ Î·Ù·ÚÁËı› Ë ËıÈ΋- ‰ÂÓ ÁÏÈÙÒÛÔ˘Ó ‰È· ·ÓÙfi˜ ÔÈ ÁÈ·ÙÚÔ› ·fi ¤Ó· ÌÂÁ¿ÏÔ Ì¤ÚÔ˜ ÚÔ‚ÏËÌ¿ÙˆÓ Ô˘ ÙÔ˘˜ ‰ËÌÈÔ˘ÚÁ› Û‹ÌÂÚ· Ë ËıÈ΋ Ì ÙȘ ˘Ô¯ÚÂÒÛÂȘ Ô˘ ÙÔ˘˜ ÂÈ‚¿ÏÏÂÈ, Î·È ÂÌ›˜, ·ÓÙ› ÁÈ· ÙË ÌÈ˙¤ÚÈ· Ô˘ Â‰Ò Î·È ·ÈÒÓ˜ Ì·˜ ÚÔÍÂÓ› Ë ËıÈ΋, ‰ÂÓ ‚ÈÒÓÔ˘Ì ϤÔÓ ÙËÓ ·fiÏ·˘ÛË, ÙËÓ ÔÔ›·, fiˆ˜ ·Ó¤ÊÂÚ· ·Ú·¿Óˆ, ·fi ÙË Ê‡ÛË Ì·˜ ÂÈ˙ËÙԇ̠ÛÙË ˙ˆ‹ Ì·˜.
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·257
REVIEW ARTICLE
∞¡∞™∫√¶∏™∏
257
Persistent vegetative state in children: terminology, aetiology, prognosis and ethical issues v
D. Neubauer, S. Grosek, P. Hamilton, M. LoGiudice, D. Matthys, V. Molina, L. Nikolovski, E. Siebke, A. Tenore, F.P. Crawley Abstract: The vegetative state comprises a group of clinical features of profound brain damage, which appear to demonstrate that the patient is awake but not aware of internal or external environments. The term was introduced to replace others used in the past, such as prolonged coma or coma vigile. Children are in a special position because at certain ages there should be consideration not only of their severe disability or handicap but also of their potential to become conscious. Terminology and definitions that are now quite well delineated are described. The boundaries of the vegetative state are noted and its diagnosis and prognosis are discussed in detail. Finally, ethical considerations are discussed, with regard to the different stances taken in different countries. In the Appendix the results of a short survey of members of the Paediatric section of UEMS (European Union of Medical Specialists)/EAP are summarized on the various attitudes and ethical considerations on persistent vegetative state in children.
Ethics Working Group of the Paediatric Section of the UEMS/European Academy of Paediatrics (formerly CESP) Correspondence: Prof. David Neubauer, david.neubauer@mf.uni-lj.si Department of Child, Adolescent & Developmental Neurology University Children's Hospital, Ljubljana, Slovenia
Key words: End-of-life decisions, children, ethical considerations, euthanasia.
Introduction More than three decades have passed since Professor Bryan Jennett and Professor Fred Plum led the world in understanding the devastating condition of unconsciousness, termed the vegetative state (1). The vegetative state comprises a group of clinical features of profound brain damage that appear to demonstrate that the patient is awake but not aware of internal or external environments. The complexity of its clinical features means that considerable experience is needed to be confident of the diagnosis, and much supportive evidence from a multidisciplinary team experienced in the management of severe brain damage is needed (2). At present neurophysiological assessment and even functional neuroimaging can still play only a supportive rather than a diagnostic or a prognostic role. In spite of concerted attempts to establish clear terminology there is still a relative lack of understanding of the existing nomenclature. Amongst the relatives of brain-damaged persons the term “vegetative” is especially disliked, mainly because of its association with the word “vegetable” (2,3). The term was introduced to replace others used in the past (some of which are still used, although not considered exact), such as prolonged coma or coma vigile (the patients by definition are not in coma), decerebrate dementia, parasomnia, akinetic mutism and apallic syndrome (still preferred and used by German speaking professionals) (2). Confidence in the
diagnosis can sometimes be questioned due to the existence of similar conditions, such as deefferentated state, locked-in syndrome (also coined by Plum and Posner), and especially the minimally conscious state at one end of the spectrum, with brain death at the other. The prognosis was best represented in the paper by the Multi-Society Task Force, which consisted of adult and paediatric neurologists and neurosurgeons, representing five major medical societies in the US (American Academy of Neurology, Child Neurology Society, American Neurology Association, American Association of Neurological Surgeons and the American Academy of Pediatrics) (4,5). Their tables, especially those on the probability of one-year outcomes, of adults and children respectively, are still generally accepted as a basis for decision-making by both medical and legal professionals (6). Finally, there is a huge bulk of literature on ethical issues, especially on reasons for allowing withdrawal of artificially provided hydration and nutrition (AHN), which is still a debated and controversial topic, with very diverse policies in different European countries (7,8). Children are in a special position because at certain ages there should be consideration not only of their severe disability or handicap but also of their potential to become conscious, particularly in the case of severely damaged newborn or preterm infants (9). The basic statements on decision-making in extreme situations have already been laid down by the Royal ¶·È‰È·ÙÚÈ΋ 2007;70:257-265
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·258
258
D. Neubauer et al.
College of Paediatrics (10) and by EAP/the Ethics Working Group (11) (Table 1), which are also used in the recommendations. This paper is an attempt to deal with the terminological, aetiological, prognostic and ethical issues concerning persistent vegetative state and other borderline conditions of consciousness in children and adolescents.
Terminology and definitions Consciousness is a spontaneously occurring state of awareness of oneself and one’s environment and it has two dimensions, wakefulness and awareness (4,5,12). Normal consciousness requires arousals, autonomous brain functions that activate mechanisms to induce the wakeful state, while awareness requires wakefulness (but not vice versa) (13). The disorders of consciousness in children include coma and vegetative state, while the term minimally conscious state (MCS) was introduced to better describe those children and adults who are emerging from a vegetative state, and thus represents a condition “of severely altered consciousness in which minimal but definite behavioural evidence of self or environmental awareness is demonstrated” (12). The diagnostic criteria include simple command following, gestural responses, intelligible verbalization and purposeful behaviour (appropriate smile/cry, vocalization, reaching for objects, touching/holding objects and pursuit eye movements) (14). The term vegetative state can be described as a condition of complete unawareness of the self and the environment, accompanied by preserved sleep-wake cycles with either complete or partial preservation of hypothalamic and brain stem autonomic functions (4,5). The multi-society task force also expressed the view that persistent vegetative state (PVS) was a diagnosis,
while permanent vegetative state was a prognosis. The word persistent usually describes those children and adults who are vegetative for more than one, three or 12 months, according to the aetiology, while permanent describes those who remain vegetative for more than 12 months after traumatic brain injury or more than 3 months after non-traumatic (e.g. anoxicischaemic) brain injury. However, it is now generally agreed that it is preferable to describe the duration and aetiology of the vegetative state rather than to use the terms persistent/permanent (12). The definition of PVS in infants and children includes 10 clinical characteristics that are generally accepted as constituting an operational definition (Table 3). The term coma describes a state of deep, unarousable sustained pathologic unconsciousness with the eyes closed that results from dysfunction of the ascending reticular activating system either in the brainstem or in both cerebral hemispheres (12). Coma usually requires the period of unconsciousness to persist for at least one hour - to distinguish it from other states of transient unconsciousness. Patients in coma lack wakefulness and awareness (patients in vegetative state lack awareness but have retained wakefulness) while the depth of coma can be specified by assessment of brainstem reflexes, breathing pattern, change of pulse and/or respiratory rate to stimulation and stimulus induced non-specific movement (12,15). In comparison, brain death is a permanent absence of all brain functions, including those of the brain stem, and the guidelines for its diagnosis in infants and children are now well established (15). Finally, there are some conditions which should be clearly differentiated from those cited above. Newborn infants cannot be regarded as being in PVS. Even full-term, healthy newborn babies fulfill only five of nine psychological criteria for being conscious. They have perception, record sensory stimulation, can be
Table 1. Considerations on the decision to withhold or withdraw life-supporting treatment in extreme situations (11) 1. Circumstances where life and/or life-supporting treatment are judged as unbearable for the child without the prospect of recovery. 2. One must honestly try to find out the best interest of children. 3. Actual or potential physical or mental disability itself is not a reason to withhold or withdraw life-sustaining treatment. 4. All remedial causes for the child’s condition should be excluded. 5. Available evidence for diagnosis, prognosis and alternative therapy should have been thoroughly explored and discussed. 6. Serious doubts in regarding what is in the best interest of the child should favour supporting the life of the child. 7. Each decision must be made in partnership with the competent child (not relevant in persistent vegetative states), the parents/guardians, the family and the entire health care team. 8. Withholding or withdrawal of life-supporting measures must be coupled with maximal palliative care, including prevention of suffering from hunger, thirst or pain, considering cultural sensitive social and psychosocial support and reflecting religious belief. 9. Paediatricians reject intentional ending of life by administration of a lethal dosage of medication. Treatment to relief suffering that may shorten life as a side-effect is acceptable where the intention of medication is not to end the life of the child. 10.During and after the death bereavement and consulting support should be ensured. Paediatriki 2007;70:257-265
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·259
259
Persistent vegetative state in children
awakened, show emotions and interact socially. However, they have limited long-term memory and cannot speak, and they lack symbolic thinking and free will (9,16).
Aetiological problems and boundaries of persistent vegetative state in children Some of the major neurological conditions that every clinician must be aware of and be able to differentiate from a vegetative state are listed in Table 2. The majority of members of the American Child Neurology Society agreed that the most appropriate statement on childhood PVS is that it “can be diagnosed based on the appropriate clinical neurological examination for age, knowledge of the insult causing brain injury, and appropriate period of observation depending on the age of the patient and nature of the insult” (17). The majority (70%) of child neurologists questioned believed that a diagnosis of PVS could reliably be made in children above two years of age, while before this age, especially below the age of two months, the diagnosis was thought by 16% of child neurologists to be feasible. Some practical and easy approaches can be used to better present the interconnections of different conditions and the boundaries of PVS (Table 4) (15). Diagnosis and prognosis of PVS New polysomnographic techniques, which allow long-term monitoring and even ambulatory recordings in infants and small children, can contribute to the differentiation of sleep/wake stages and thus to assessing some of the higher cortical functions. Regarding the outcome it seems that somatosensory evoked responses are the most sensitive and reliable (15). Classical electroencephalography (EEG) may be supportive of the diagnosis but cannot be diagnostic per se and is still
far from being prognostic (2). New visual functional techniques and especially some of the techniques for cognitive functional assessment in infants and newborns (e.g. visual evoked potentials and cognitive evoked potentials) will in the future permit better understanding and will define the possibility of the infant for sudden focusing and even tracking of objects when possible emergence from the vegetative state is under question. However, the problem remains that there are no tests that can confirm whether the child has any “internal awareness” and whether there exist any abilities to react with others or have any meaningful response to the spoken word. Serial investigations of brain metabolic activity (e.g. measured by positron emission tomography - PET) may potentially be of great value in providing objective criteria confirming the clinical diagnosis of PVS, particularly in small children. However, the restricted availability of this technology, recent statements on the diagnosis of the vegetative state without the need for any radiological or laboratory investigations and the limitations of its interpretation in young children due to low rates of brain metabolic activity and blood flow, all limit its value as a practical diagnostic and/or prognostic tool (6,15). A study made 25 years ago showed very poor outcomes for children in vegetative state following coma as there were only 10 survivors (out of 17 in the series) and only one child became ambulant a year after the initial insult and was moderately mentally retarded (18). The same study also confirmed the notion that children who develop the vegetative state following coma have a poor prognosis, especially when there are early indicators such as decorticate or decerebrate responses, roving eye-movements and spontaneous blinking. More recent studies have shown that the survival rate of PVS children appears to be directly related to age, as the younger children,
Table 2. Definitions of persistent vegetative state in infants and children*
1. Wakefulness without awareness 2. Eyes-open unconsciousness 3. No “voluntary” action/behaviour 4. No “cognitive” response 5. No “voluntary” language 6. Inability to follow commands 7. Spontaneous eye movements but no sustained tracking 8. Intact brainstem reflexes and sleep/wake cycles 9. Spontaneous breathing, chewing and swallowing impaired 10. Bowel and bladder incontinence
Apply (%)
Supportive (%)
Necessary (%)
95 94 91 90 84 83 83 75 75 53
16 33 23 22 29 22 47 53 65 53
84 67 77 78 71 78 53 47 35 47
*Opinion of 250 Child Neurologists (members of American Child Neurology Society) in a study by Ashwal et al (ref. 17) as to which of the listed criteria would apply, be supportive or be necessary as a clinical characteristic for the constitution of the operational guideline of persistent vegetative state (PVS). The data reflect the general opinion that PVS in infants and children is defined as a loss of higher cortical functions rather than the existence of vegetative functions. ¶·È‰È·ÙÚÈ΋ 2007;70:257-265
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·260
260
D. Neubauer et al.
Table 3. Severe disturbances of consciousness and related conditions (adapted from 3,4,5) Condition
Self awareness
Pain & Sleep/wake Motor suffering cycling function
Respiratory function
Brain death Absent
No
Absent
Absent
Coma
Absent
No
Absent
PVS
Absent
No
Intact
No purposeful movements
Minimally conscious state Akinetic mutism
Present but Yes very limited
Intact
Limited
Yes
Intact
Locked-insyndrome
Present
Yes
Intact
Some purposeful movements Moderate limitation of movements Tetraplegia; pseudobulbar palsy;eye movements preserved
None; Spinal reflexes possible No purposeful movements
EEG
Outcome/ recovery
No cerebral No recovery electrical activity/silence Variably Polymorphic Evolves to recovery, depressed delat/theta PVS or death in 2-4 weeks Normal/mildy Polymorphic Depends on depressed theta/delta aetiology (acute traumatic/nontraumatic; degenerative/ metabolic; developmental/ chromosomal) Normal/mildy Polymorphic Recovery unkown, depressed theta/delta probably depends on aetiology (see above) Normal/mildly Slow Recovery unlikely depressed or limited Normal to variably depressed
Normal
Recovery unlikely; remain tetraplegic
EEG=electroencephalogram, PVS=persistent vegetative state
especially those below two months of age, tended to have much shorter survival than children above seven years (mean duration of survival 4.1 vs. 7.4 years respectively) (17). Regarding the aetiology, the longer duration of survival was found in the non-traumatic group of PVS children compared to the traumatic group (8.6 vs. 3.0 years respectively) and perinatal injuries are associated with much shorter survival than those due to developmental/chromosomal abnormalities (4.1 vs. 8.2 years respectively) (19). These findings suggest the possibility that relative sparing of brainstem and hypothalamic functions in the latter group in contrast to the perinatal-insult group (where these structures may be seriously injured) is essential for survival. More recent data suggest that the oneyear outcome is much better after a one month follow-up, compared with a follow-up of three and six months respectively (Table 5) (4-6). Some authorities believe that the estimates of long-term survival by the Task Force Report are too low and that many reported deaths could be the result of decisions to limit lifesustaining measures. There might be a difference between how long these patients could live and how long they do live, as the practice of limiting life-sustaining medical treatment once the vegetative state is declared permanent becomes more widely accepted Paediatriki 2007;70:257-265
(6,7). Finally, a recent paper by Ashwal (15) reports the following probabilities for recovery: 1. After 3 months, children in post-traumatic VS have a 56% chance of regaining consciousness, in contrast to only 3% of children with non-traumatic VS. Good or moderate recovery is expected in 32% of children. 2. After 6 months, children in post-traumatic VS have a 31% chance of recovering consciousness, in contrast to only 3% of children with non-traumatic VS. Good or moderate recovery can be expected in only 11%. 3. VS can thus be considered permanent 12 months after brain trauma or 3 months after nontraumatic brain injury in children. The chance of recovery after this period seems to be exceedingly rare (however, cases of good recovery are well documented even after 12 months of PVS) and is almost always associated with severe disability.
Ethical issues and decisions on withdrawal of artificially provided hydration and nutrition (AHN) When Chalmers wrote on the phenomenology of the conscious mind, he noted: “…when I close my
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·261
261
Persistent vegetative state in children
Table 4. Stepwise approach in evaluation of the unconscious child as proposed by S. Ashwal (adapted from 11, 14) Is the patient conscious? Evidence of sustained or reproducible purposeful response or external stimuli NO absent brainstem function and apnoea YES BRAIN DEATH
NO preserved sleep/wake cycle and eye opening to stimulus or spontaneously NO YES COMA VEGETATIVE STATE
YES preserved functional interactive communication and/or functional use of one or more obejcts NO* YES MINIMALLY vertical eye movements present CONSCIOUS and/or eye blinking STATE YES NO LOCKED-IN EMERGENCE SYNDROME FROM MCS†
* usually preserved: following simple commands and/or gestural or yes/no responses and/or intelligible verbalization and/or purposeful behaviours in response to environmental stimuli (not reflex activity) BUT not able to express preferences † patient has emerged from minimally conscious state (MCS) and may have: mild to severe disability or may become normal
eyes, the whole world disappears and when I open them again, the world appears again” and this is a simplified description of the assessment of consciousness (see Table 3). As Searle stated: “consciousness consists of inner, qualitative, subjective states and processes of sentience or awareness. Consciousness begins when we wake in the morning and continues until we fall asleep again, die, go into coma, or otherwise become ‘unconscious’” (16). However, things become further complicated when other philosophical aspects of consciousness are taken into account, and perhaps its most frequently discussed role involves awareness of the sensory world as well as the awareness of self (including feelings and thoughts) and voluntary control involved in self-regulation (20,21). When the medical professionals and the parents have finally become convinced that the child has reached a (permanent) vegetative state condition, the question of final outcome becomes important, while the ethical decisions should depend on the most reliable prognosis. It is rather impractical to separate discussion of the ethical and legal issues raised by decisions to limit life-prolonging measures for vegetative patients, as the law is largely concerned with ethical principles in particular situations, and doctors and ethicists seek the formal approval of the public or society (represented by the judiciary) for their decisions to limit or stop artificially provided hydration and nutrition (AHN) (22). The appendix presents the variations regarding attitudes about PVS in children in different EU countries according to the results of a short survey on these issues among CESP/EAP members. Despite the fact that there are guidelines to help physicians decide whether certain actions would be
ethical or not, they must also confront the obstacles of personal values, as well as professional, religious and cultural factors. The decision about withdrawing Table 5. The Multi-Society Task Force data (4,5) - conclusions about long-term prognosis are based on review of 754 cases published in the English language literature who were vegetative at one month after an acute insult and from whom one-year outcome was available. The present table includes only children with PVS ( Total: 151, with traumatic injury: 106). The age limit was not defined but most were probably under the age of 16 years One-year outcome of those in vegetative state at 1, 3 and 6 months respectively a) Vegetative state - children after head trauma (n = 106). All figures in %. Outcome At 1 month At 3 months At 6 months died 9 14 14 vegetative 29 30 54 conscious 62 56 32 (independent) (27) (32) (11) b) Vegetative state - children with non-traumatic causes (n = 45). All figures in %. Outcome At 1 month At 3 months At 6 months died 22 3 0 vegetative 65 94 97 conscious 13 3 3 (independent) (6) (0) (0) Children did much better than adults (one-year outcome of those adults in vegetative state at one month: died after trauma 33% and dead due to non-traumatic causes 53%). Also one-year outcome of children in vegetative state at one month revealed that 62%/13% regained consciousness in comparison to adults where these percentages were 52%/15% respectively. The highest independence rate was achieved in head injured children (27%), the lowest in nontraumatic adults (4%) (6). ¶·È‰È·ÙÚÈ΋ 2007;70:257-265
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·262
262
D. Neubauer et al.
AHN and other life-sustaining medical treatment is still associated with a great deal of controversy, especially in paediatric practice. Even when the team in the intensive care unit and the members of the family all agree that it is the right thing to do, there is still sufficient negative professional and public sentiment to make it worth pursuing a judicial order to support such an act (7). Finally, a list is provided of some of the recent examples of practical decision-making and conclusions about treatment regimes in severely ill patients, and especially of the decisions when to withhold or withdraw life-sustaining treatment in children. Recently the Ethics Task Force argued that the word “passive euthanasia” should not be used for withdrawing or withholding life-prolonging treatment that is not providing a benefit to the patient (23) (see also the arguments in the RCPCH document quoted above). However, there are also some rebuttals to this argument, as some believe that professionals should be allowed to employ this term in their discussions of policy and clinical practice (24). Regarding the challenges in end-of-life care in the intensive care units, the recommendation is that the patient must be assured a pain-free death. The patient must be given sufficient analgesia to alleviate pain and distress; if such analgesia hastens death, this “double-effect” should not detract from the primary aim of ensuring comfort (25). Some practical instructions on decision-making about withdrawal of life-sustaining treatment in children are given by Alderson and Nicholson (26). They suggest that the decisions should not be rushed, and should be based on all the evidence available. There should be frequent sharing of information and discussions between all the members of the team, and regular informing and listening to the family, taking into account the child’s interests. Treatment should be withdrawn in a certain sequence (for example, first withdrawal of experimental interventions, then withdrawal of mechanical ventilation, withdrawal of inotropic pressor agents, forgoing antibiotics, forgoing artificial nutrition, including nasogastric tube feeding and decrease of intravenous fluids. Apart from these actions, the physician has a duty to comfort and cherish the child, to prevent and relieve suffering (pain) and to inform and support the family. Once an end-of-life decision has been made, the primary aim is to relieve suffering; pain relief is essential even if it hastens death (allowing the principle of the double effect - that is, associated repression of respiration, if it relieves suffering, is acceptable). If a ventilator is to be switched off, the time should be decided in agreement with the parents and with careful preparation and support. The use of paralyzing agents Paediatriki 2007;70:257-265
should be carefully reconsidered. The care should also continue after the child’s death (10,26). Finally, some advice has been addressed to the family physicians, who are frequently in a position to integrate medical knowledge, individual values and cultural influences into end-of-life care, especially after the Patient SelfDetermination Act was written in response to the Cruzan case (27). This implementation is particularly useful in those cases where a self-decision to end one’s life has been expressed.
Conclusions Thirty years after the term “persistent vegetative state” was first coined by Jennett and Plum it remains the most commonly used term, despite many arguments (more or less substantial) that it should be changed. In addition to the term vegetative state, many authors would like to include aetiological cause and duration. The majority of child neurologists believe that wakefulness without awareness, unconsciousness with the eyes wide open, and absence of voluntary behaviour and language along with lack of cognitive response, are the landmarks of the definition of PVS in children (17). However, such a definition is difficult to be applied in those children who (due to immaturity or disease condition) already demonstrated some of these characteristics before appearance of PVS (9,16). Concerning the aetiological borders, there are not too many problems regarding the distinction of PVS from other similar conditions (refer to Tables 2 and 3), although again in the young age-group they may be questionable and difficult to determine. The Multi-Society Task Force on PVS presented data which gave approximate figures of the long-term (6 and 12 months respectively) outcome of those children who had been at least one month in PVS, due to either traumatic or non-traumatic causes (4,5). The common notion is that children in VS with traumatic brain injury have the best prognosis, as more than half will recover and another half of these will have at least a fair or even a good recovery (4,5,16). Finally but definitely, the most important are the ethical issues related to PVS. The ethics of PVS management rests on some (un)resolved court cases in the recent past. Good clinical practice (28,30) requires a multidisciplinary team (consisting of at least a paediatric intensive care specialist, a child neurologist, a senior registered nurse working in paediatric intensive care unit and a child psychologist) who should first reach an absolute consensus between the members of the team. Thereafter, the team is allowed to sit down with the parents and other relatives to discuss with
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·263
263
Persistent vegetative state in children
them the possibility of withdrawal of AHN in a child who is in PVS. However, there is still an ongoing debate with pro-life representatives about whether such an act is ever justified (“killing or letting die” (6)), regardless of the wishes of the parents. However, some authorities (see an excellent paper on a personal experience by Dr. Richard J. Lin (7)) recommend that: “even if the health-care team and the family of the patient feel it is the ‘right’ thing to do, there is still enough negative professional and public sentiment that it may be worthwhile for a family wishing to withdraw AHN for a loved one to pursue a judicial order supporting their wishes” (7).
Acknowledgements The Working Group acknowledges the particular input and support of Ronald Kurz and Francis Crawley in preparing the present publication, as well as the valuable comments of Janez Primozvicv.
References 1. Jennett B, Plum F. Persistent vegetative state after brain damage. A syndrome in search of a name. Lancet 1972;1: 734-737. 2. Andrews K. The vegetative state-clinical diagnosis. Postgrad Med J 1999;75:321-324. 3. Giacino JT, Zasler ND. Outcome after severe traumatic brain injury: coma, the vegetative state, and the minimally responsive state. J Head Trauma Rehabil 1995;10:40-56. 4. The Multi-Society Task Force on PVS. Medical aspects of the persistent vegetative state (first of two parts). N Engl J Med 1994;330:1499-1508. 5. The Multi-Society Task Force on PVS. Medical aspects of the persistent vegetative state (second of two parts). N Engl J Med 1994;330:1572-1579. 6. Jennett B. The vegetative state. Medical facts, ethical and legal dilemmas. Cambridge: Cambridge University Press; 2002. 7. Lin RJ. Withdrawing life-sustaining medical treatment - a physician's personal reflection. Ment Retard Dev Disabil Res Rev 2003;9:10-15. 8. Harris J. Consent and end of life decisions. J Med Ethics 2003;29:10-15. 9. Lagercrantz H. Should euthanasia be legal? An international survey of neonatal intensive care units staff. Arch Dis Child Fetal Neonatal Ed 2004;89:F2. 10. Royal College of Paediatrics. Withholding or Withdrawing Life-Sustaining Treatment in Children: A Framework for Practice - 2nd edition, 2004: www.rcpch.ac.uk/publications/ recentpublications/witholding.pdf 11. Kurz R, Ethics Working Group of Confederation of the European Specialists of Paediatrics. Decision making in extreme situations involving children: withholding or withdrawal of life supporting treatment in paediatric care. Statement of the ethics working group of the Confederation of the European Specialists of Paediatrics (CESP). Eur J Pediatr 2001;160:214-216.
12. Ashwal S. Medical aspects of the minimally conscious state in children. Brain Dev 2003;25:535-545. 13. Zeman A. Consciousness. Brain 2001;124:1263-1289. 14. Giacino JT, Ashwal S, Childs N, Cranford R, Jennett B, Katz DI, et al. The minimally conscious state: definition and diagnostic criteria. Neurology 2002;58:349-353. 15. Ashwal S. Pediatric vegetative state: epidemiological and clinical issues. NeuroRehabilitation 2004;19:349-360. 16. Searle JR. Consciousness. Annu Rev Neurosci 2000;23: 557-578. 17. Ashwal S, Bale JF, Coulter DL, Eiben R, Garg BP, Hill A, et al. The persistent vegetative state in children: Report of the Child Neurology Society Ethics Committee. Ann Neurol 1992;32:570-576. 18. Gillies JD, Seshia SS. Vegetative state following coma in childhood: evolution and outcome. Dev Med Child Neurol 1980;22:642-648. 19. Ashwal S, Eyman RK, Call TL. Life expectancy of children in a persistent vegetative state. Pediatr Neurol 1994;10:27-33. 20. Posner MI, Rothbart MK. Attention, self-regulation and consciousness. Philos Trans R Soc Lond B Biol Sci 1998;353:1915-1927. 21. Bownds MD. The biology of mind: origins and structures of mind, brain, and consciousness. Maryland: Fitzgerald Science Press, Bethesda;1999. 22. Orentlicher D. From the Office of the General Counsel. The right to die after Cruzan. JAMA 1990;264:2444-2446. 23. Materstvedt LJ, Clark D, Ellershaw J, Forde R, Gravgaard AM, Muller-Busch HC, et al. Euthanasia and physicianassisted suicide: a view from an EACP Ethics Task Force. Palliat Med 2003;17:97-101. 24. Garrard E, Wilkinson S. Passive euthanasia. J Med Ethics 2005;31:64-68. 25. Thompson BT, Cox PN, Antonelli M, Carlet JM, Cassell J, Hill NS, et al. Challenges in end-of-life care in the ICU: statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003: executive summary. Crit Care Med 2004;32:1781-1784. 26. Alderson P, Nicholson R. Deciding when to withhold or withdraw life-sustaining treatment for children. Bull Med Ethics 1997;127:13-20. 27. Crane MK, Wittink M, Doukas DJ. Respecting end-of-life treatment preferences. Am Fam Physician 2005;72:12631268. 28. Trontelj JV. European trends in bioethics: medical research on persons unable to consent. Suppl Clin Neurophysiol 2000;53:457-459. 29. Sauer PJ, Ethics Working Group, Confederation of European Specialists in Paediatrics. Ethical dilemmas in neonatology: recommendations of the Ethics Working Group of the CESP. Eur J Pediatr 2001;160:364-368. 30. Gill D, Ethics Working Group of the Confederation of European Specialists in Paediatrics. Ethical principles and operational guidelines for good clinical practice in paediatric research. Recommendations of the Ethics Working Group of the Confederation of European Specialists in Paediatrics (CESP). Eur J Pediatr 2004;163:53-57.
¶·È‰È·ÙÚÈ΋ 2007;70:257-265
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·264
264
D. Neubauer et al.
Appendix A questionnaire (A) was sent to each of the 35 members and to the observer national delegates to the Paediatric Section of UEMS/European Academy of Paediatrics (formerly CESP). Replies were received from 22 countries and the results are tabulated (B). A. Questionnaire: Bioethics Committees in Europe and dealing with persistent vegetative state (PVS) in children. 1. Is there a National Bioethics Comittee in your country?
yes
no
2. Are the interests of children always represented?
yes
no
3. Does your National Paediatric Society have an Ethics Committee ?
yes
no
4. Are there special guidelines on ethics in paediatric practice ?
yes
no
5. Do local hospitals and universities have ethics committees?
yes
no
6. Do you have a strict definition of PVS? If yes, please answer the following:
yes
no
6a. Do you use the definition below?
yes
no
7. Do you encounter the cases of PVS?
yes
no
8. Would you ever consider withdrawal of artificially provided hydration and nutrition (AHN) in PVS children? If yes, please answer the following:
yes
no
yes
no
yes
no
yes
no
8a. Would you still consider that it may be worthwhile to pursue a judicial order to support such an act? 9. PVS patients do not require any technological support in order to maintain their vital functions and such patients cannot in any way be considered terminal patients, since their condition can be stable and enduring. 10. Do you think that the word “passive euthanasia” should not be used for the withdrawing or withholding of life-prolonging treatment which is not providing a benefit to the patient ?
Paediatriki 2007;70:257-265
Austria Belgium Czech Republic Denmark Former Yugoslav Republic of Macedonia France Georgia Germany Greece Hungary Ireland Israel Italy Luxembourg Netherlands Norway Slovakia Slovenia Sweden Switzerland Turkey United Kingdom of Great Britain and Northern Ireland
Country
N N Y Y Y
Y Y N Y Y Y Y Y N Y Y Y Y Y Y Y N
Y Y Y Y Y
Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N
Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
Y Y Y N Y
Y Y Y Y Y N Y Y N N Y Y Y N Y Y Y
N Y N Y Y
Y Y Y Y Y Y Y Y Y Y Y Y Y / Y Y Y
Y Y / Y Y
Y N N N N Y Y N Y Y Y N Y N Y Y Y
Y Y Y Y N
N Y Y N N N Y N N Y Y N Y N N N Y
N N N Y N
N Y Y / Y N N N N N N / Y N N / Y
/ N N N N
Y N Y / Y Y Y Y Y N N Y Y Y Y Y Y
Y Y Y Y N
Y Y Y Y Y Y Y Y Y N Y N Y N Y Y Y
Y Y Y Y Y
17:08
N Y Y N N N Y Y N Y N Y N N Y N Y
Y N N Y N
09-07-07
N Y Y Y Y N N N N Y N Y N Y N Y Y
Y N N N N
National Interests National Ethical University Strict Common Cases With Judicial PVS not Passive committee of children Paediatric EC guidelines EC definition of PVS drawal order terminal euthanasia paediatric PVS AHN should not be used
B. The tabulated results from the delegates of 22 countries within the Paediatric Section of UEMS/EAP (formerly CESP). Y = yes; N= no; / = no answer
Pediatri July-Aug 07 ™ÂÏ›‰·265
Persistent vegetative state in children
265
¶·È‰È·ÙÚÈ΋ 2007;70:257-265
Pediatri July-Aug 07
09-07-07
266
17:08
™ÂÏ›‰·266
∞¡∞™∫√¶∏™∏
REVIEW ARTICLE
∏ ·‡ÍËÛË ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ ÛÙË Û‡Á¯ÚÔÓË ÂÔ¯‹: ÂȉËÌÈÔÏÔÁÈο ‰Â‰Ô̤ӷ Î·È ·ÈÙÈÔÏÔÁ›· Barnet and Chase Farm Hospitals NHS Trust, London Southampton University, Medical School, United Kingdom AÏÏËÏÔÁÚ·Ê›·: ∞. ™ÔÊÈ·ÓÔ‡-∫·ÙÛÔ‡ÏË katsofkat@hotmail.com ¡ÂfiÊÚÔÓÔ˜ 6, ∆.∫. 161 21, ∞ı‹Ó·
∞. ™ÔÊÈ·ÓÔ‡-∫·ÙÛÔ‡ÏË ¶ÂÚ›ÏË„Ë ∂ÈÛ·ÁˆÁ‹: √È ÂӉ›ÍÂȘ Û¯ÂÙÈο Ì ÙËÓ ·‡ÍËÛË Ù˘ ›وÛ˘ ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ·ı‹ÛÂˆÓ Â›Ó·È Ôχ ÈÛ¯˘Ú¤˜. ¶¤Ú· ·fi Ù· “ÎÏ·ÛÈο” ·ÙÔÈο ÓÔÛ‹Ì·Ù·, ˘¿Ú¯ÂÈ Î·È ¤Ó·˜ ÈηÓfi˜ ·ÚÈıÌfi˜ ·ÏÏÂÚÁÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ, ÂӉ¯Ô̤ӈ˜ ÂÈΛӉ˘ÓˆÓ ÁÈ· ÙË ˙ˆ‹, fiˆ˜ ÔÈ ÙÚÔÊÈΤ˜ ·ÏÏÂÚÁ›Â˜, Ô˘ ϤÔÓ ‰È·ÁÈÁÓÒÛÎÔÓÙ·È Ôχ Û˘¯Ó¿. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ∏ ·Ó·˙‹ÙËÛË ‚È‚ÏÈÔÁÚ·Ê›·˜ ÁÈ· ÙËÓ ·Ó·ÛÎfiËÛË ¤ÁÈÓ ̤ۈ ÙÔ˘ Medline ηıÒ˜ Î·È Ì ÂͤٷÛË Î·ıÂÌ›·˜ ÂÎ ÙˆÓ ·Ó·ÊÔÚÒÓ ÙˆÓ Û¯ÂÙÈÎÒÓ ¿ÚıÚˆÓ. ∞ÔÙÂϤÛÌ·Ù·: ∏ ·‡ÍËÛË ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ·ı‹ÛÂˆÓ ‰È·ÈÛÙÒÓÂÙ·È ·fi ¤Ó·Ó ·ÚÈıÌfi ÌÂÏÂÙÒÓ Ô˘ ·ÂÈÎÔÓ›˙Ô˘Ó ÙËÓ ·˘Í·ÓfiÌÂÓË Â˘·ÈÛıËÙÔÔ›ËÛË ÙˆÓ ‰È·‰Ô¯ÈÎÒÓ ÁÂÓÂÒÓ ¤Ó·ÓÙÈ Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ·ÏÏÂÚÁÈÔÁfiÓˆÓ. π‰È·›ÙÂÚ· ÛÙ· ·È‰È¿ ηٷÁÚ¿ÊÔÓÙ·È ˘„ËÏ¿ ›‰· ÂȉÈÎÒÓ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ ∂ (πgE), ¤Ó·ÓÙÈ ‰È·ÊfiÚˆÓ ·ÏÏÂÚÁÈÔÁfiÓˆÓ. ∏ ·ÏÏ·Á‹ ·˘Ù‹ Û˘Ó‰¤ÂÙ·È Û ÔÏϤ˜ ÌÂϤÙ˜ Ì ÙËÓ “˘fiıÂÛË Ù˘ ˘ÁÈÂÈÓ‹˜” Î·È ÙË ÛÙÚÔÊ‹ ·fi ÙÔÓ ·Ú·‰ÔÛÈ·Îfi ·ÁÚÔÙÈÎfi ÙÚfiÔ ˙ˆ‹˜ Û ¤Ó· “‰˘ÙÈÎÔ‡ Ù‡Ô˘” ÌÔÓÙ¤ÏÔ ˙ˆ‹˜, Ô˘ ›¯Â ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÂÏ¿ÙÙˆÛË Ù˘ ¤ÎıÂÛ˘ Û ÌÈÎÚfi‚È· Î·È ÙȘ ·Ú·ÁfiÌÂÓ˜ ÂÓ‰ÔÙÔ͛Ә. ™Â ·ÓÔÛÈ·Îfi ›‰Ô, ÛÙ· ·ÙÔÈο ¿ÙÔÌ· ÂÈÎÚ·Ù› Ë Ù‡Ô˘ 2 ·ÓÔÛÔÏÔÁÈ΋ ·ÓÙ›‰Ú·ÛË ÙˆÓ ‚ÔËıËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ∆. ™˘ÌÂÚ¿ÛÌ·Ù·: H ·‡ÍËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ·ı‹ÛÂˆÓ Ê·›ÓÂÙ·È fiÙÈ ¿Ú¯ÈÛ ÙË ‰ÂηÂÙ›· ÙÔ˘ 1960 Î·È Û˘Ó¯›ÛÙËΠÛÙȘ ÂfiÌÂÓ˜ ÁÂÓȤ˜. √ ÂÈÔÏ·ÛÌfi˜ ÙÔ˘˜ Ê·›ÓÂÙ·È Ó· Â›Ó·È ˘„ËÏfiÙÂÚÔ˜ ÛÙȘ ·Ó·Ù˘Á̤Ó˜ ¯ÒÚ˜, ÂÓÒ Î·È ÔÈ ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜ Ô˘ ˘ÈÔıÂÙÔ‡Ó ÙÔÓ ‰˘ÙÈÎfi ÙÚfiÔ ˙ˆ‹˜ ·ÎÔÏÔ˘ıÔ‡Ó ·˘Ù‹ ÙËÓ Ù¿ÛË. √ ·ÓÔÛÔÏÔÁÈÎfi˜ Ì˯·ÓÈÛÌfi˜ Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È ÛÙËÓ “˘fiıÂÛË ˘ÁÈÂÈÓ‹˜” ¤¯ÂÈ Á›ÓÂÈ ·ÓÙÈΛÌÂÓÔ ÂÎÙÂٷ̤Ó˘ ¤Ú¢ӷ˜ ηٿ ÙËÓ ÙÂÏÂ˘Ù·›· 15ÂÙ›·. ∏ ÂȉËÌÈÔÏÔÁÈ΋ ‚¿ÛË ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘, ˆÛÙfiÛÔ, ·ÏÏ¿ Î·È ÔÈ Èı·ÓÔ› ÙÚfiÔÈ ÚfiÏ˄˘ ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ Â›Ó·È ÌÂÚÈο ·fi Ù· ·ÓÙÈΛÌÂÓ· Ù˘ Û‡Á¯ÚÔÓ˘ ¤Ú¢ӷ˜.
§¤ÍÂȘ ÎÏÂȉȿ: ∂ȉËÌÈÔÏÔÁ›·, ·ÏÏÂÚÁ›·, ˘ÁÈÂÈÓ‹, ¢·ÈÛıËÙÔÔ›ËÛË.
The increase of allergic conditions in recent years: epidemiology and causes Barnet and Chase Farm Hospitals NHS Trust, London Southampton University Medical School, United Kingdom Correspondence: A. Sofianou-Katsoulis katsofkat@hotmail.com 6, Neofronos St. 161 21, Athens, Greece
A. Sofianou-Katsoulis Abstract Background: There is robust evidence of a rising prevalence of allergic conditions. In many countries the percentages of atopic manifestations have even doubled over a period of fifteen years. Apart from the “classical” atopic conditions, a number of potentially life threatening allergies are very commonly diagnosed, especially food allergies. This is a review of the relevant literature. Methods: The literature search for this review was performed mainly on Medline. Following selection of the relevant papers, a manual search of their references was made. Results: The rise in frequency of allergic conditions has not only been reported by patients and clinicians, but also documented by a number of studies that illustrate the increase in sensitivity to specific allergens between birth cohorts, and the presence of high levels of specific IgEs, particularly in younger populations. This change in population sensitivities has been linked by many studies to the “hygiene hypothesis”, but also to the shift of many traditionally rural societies to a “westernized” life model, resulting in reduced microbial exposure. At the immunological level, atopic individuals exhibit the type 2 response of the helper T cells. Conclusions: The increase in allergic conditions started probably after the 1960s, and seems to be maintained in subsequent birth cohorts. Their prevalence is higher in the developed countries, but developing countries adopting a “westernized” lifestyle follow this trend. The immunological mechanism described in the “hygiene hypothesis” has been investigated extensively in the past 15 years. The epidemiological basis of the increase in allergic conditions and prevention strategies are some of the current research topics.
Key words: Allergy, epidemiology, sensitization, hygiene. Paediatriki 2007;70:266-271
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·267
267
∂ȉËÌÈÔÏÔÁ›· ·ÏÏÂÚÁÈÎÒÓ ·ı‹ÛˆÓ
∂ÈÛ·ÁˆÁ‹ ∏ ÚfiÛÊ·ÙË ‚È‚ÏÈÔÁÚ·Ê›· ·Ú¤¯ÂÈ ÈÛ¯˘Ú¤˜ ÂӉ›ÍÂȘ ˆ˜ ÚÔ˜ ÙËÓ ·˘Í·ÓfiÌÂÓË Â›ÙˆÛË ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ·ı‹ÛˆÓ. √È ÎÏ·ÛÈΤ˜ ·ÙÔÈΤ˜ ·ı‹ÛÂȘ, fiˆ˜ ÙÔ ¿ÛıÌ·, ÙÔ ¤Î˙ÂÌ·, Ë ·ÏÏÂÚÁÈ΋ ÚÈÓ›Ùȉ·, ·ÏÏ¿ Î·È ÔÈ ÙÚÔÊÈΤ˜ ·ÏÏÂÚÁ›Â˜ Â›Ó·È Ôχ Û˘¯ÓfiÙÂÚ˜ Û ۯ¤ÛË Ì ÙÔ ·ÚÂÏıfiÓ, ÁÈ· ·Ú¿‰ÂÈÁÌ· Û·Ú¿ÓÙ· ¯ÚfiÓÈ· ÚÈÓ. ∏ ÁˆÁÚ·ÊÈ΋ ›Û˘ ηٷÓÔÌ‹ Ù˘ ›وÛ˘ ‰È·Ê¤ÚÂÈ ÛËÌ·ÓÙÈο Î·È ¤¯ÂÈ È‰È·›ÙÂÚÔ ÂӉȷʤÚÔÓ Ë ·ÔÙ‡ˆÛ‹ Ù˘ ÛÙÔÓ ·ÁÎfiÛÌÈÔ ¯¿ÚÙË, ·fi ÙËÓ ÔÔ›· ÌÔÚÔ‡Ó Ó· ÚÔ·„Ô˘Ó ÛËÌ·ÓÙÈο Û˘ÌÂÚ¿ÛÌ·Ù·, ˆ˜ ÚÔ˜ ÙȘ ·Èٛ˜ Ù˘ ·Ú·ÙËÚÔ‡ÌÂÓ˘ ·‡ÍËÛ˘. √ ÛÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ·Ó·ÛÎfiËÛ˘ Â›Ó·È Ó· ·ÚÔ˘ÛÈ·ÛÙ› Ë Ï¤ÔÓ ÚfiÛÊ·ÙË ‚È‚ÏÈÔÁÚ·Ê›· Ô˘ ·ÊÔÚ¿ ÙËÓ ÂȉËÌÈÔÏÔÁ›· ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ·ı‹ÛÂˆÓ Î·È ÙȘ ·Èٛ˜ ¤Í·ÚÛ˘ ·˘ÙÒÓ. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ∏ ·Ó·˙‹ÙËÛË ‚È‚ÏÈÔÁÚ·Ê›·˜ ÁÈ· ÙË Û˘ÁÁÚ·Ê‹ Ù˘ ·ÚÔ‡Û·˜ ·Ó·ÛÎfiËÛ˘ ¤ÁÈÓ Ì ¤Ú¢ӷ ÛÙË Medline ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÙȘ ϤÍÂȘ ÎÏÂȉȿ “immediate hypersensitivity” OR “hypersensitivity, immediate” OR (“hypersensitivity”) OR “hypersensitivity” OR (“allergy and immunology”) OR (“allergy and immunology” OR Allergy) AND ((“disease outbreaks” [TIAB] NOT Medline[SB]) OR “disease outbreaks” [MeSH Terms] OR Epidemic[Text Word]) AND “humans” [MeSH Terms], Ì ·Ó·˙‹ÙËÛË Û¯ÂÙÈÎÒÓ ·Ó·ÛÎÔ‹ÛÂˆÓ Ù˘ ÙÂÏÂ˘Ù·›·˜ ‰ÂηÂÙ›·˜. √È ·Ó·ÊÔÚ¤˜ ÙˆÓ ¿ÚıÚˆÓ Ô˘ ÎÚ›ıËÎ·Ó Î·Ù¿ÏÏËÏ· ÂÍÂÙ¿ÛıËÎ·Ó Ì›· ÚÔ˜ Ì›· Ì ÛÎÔfi Ó· ‚ÚÂıÔ‡Ó ËÁ¤˜ Ô˘ ‰ÂÓ ÂÌÊ·Ó›˙ÔÓÙ·È ÛÙȘ ËÏÂÎÙÚÔÓÈΤ˜ ‚¿ÛÂȘ ‰Â‰ÔÌ¤ÓˆÓ ‹ Ô˘ ›¯·Ó ‰ËÌÔÛÈ¢ı› ·ÚÎÂÙ¿ ·ÏÈ¿. ∂ȉËÌÈÔÏÔÁ›· ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ·ı‹ÛÂˆÓ ∆· ÂȉËÌÈÔÏÔÁÈο ‰Â‰Ô̤ӷ Ô˘ ˘ÔÛÙËÚ›˙Ô˘Ó ·˘Ùfi Ô˘ Û‹ÌÂÚ· ·ÔηÏÂ›Ù·È “ÂȉËÌ›·” ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ·ı‹ÛÂˆÓ Â›Ó·È Ô˘ÛÈ·ÛÙÈο. ¢ËÌÔÛȇÛÂȘ Ô˘ ÚˆÙÔ¤ÁÈÓ·Ó ÛÙ· ̤۷ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ 1980 ·ÔÂÈÚ¿ıËÎ·Ó Ó· Û˘ÁÎÚ›ÓÔ˘Ó ÙËÓ ÙfiÙ ›وÛË ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ·ı‹ÛÂˆÓ Ì ·ÚfiÌÔÈ· ÛÙÔȯ›· ·fi ÚÔËÁÔ‡ÌÂÓ˜ ‰ÂηÂٛ˜. ¶ÔÏϤ˜ ÌÂϤÙ˜ Ù˘ ÂÔ¯‹˜ η٤‰ÂÈÍ·Ó ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË ÛÙȘ ·ÙÔÈΤ˜ ·ı‹ÛÂȘ, ȉȷ›ÙÂÚ· Û ¯ÒÚ˜ fiˆ˜ Ë ¢·Ó›· Î·È ÙÔ ∏ӈ̤ÓÔ µ·Û›ÏÂÈÔ. √È Û˘ÁÁÚ·Ê›˜ ·¤‰ˆÛ·Ó ÙËÓ ·‡ÍËÛË ·˘Ù‹ ÛÙËÓ ÂÚÈ‚·ÏÏÔÓÙÈ΋ ÌfiÏ˘ÓÛË, ηıÒ˜ Î·È ÛÙËÓ ¤ÎıÂÛË ÛÙ· “ÔÈÎȷο” ·ÏÏÂÚÁÈÔÁfiÓ· (2). ∞Ó¿ÌÂÛ· ÛÙȘ ÌÂϤÙ˜ Ô˘ ηٷ‰ÂÈÎÓ‡Ô˘Ó ÙËÓ ·‡ÍËÛË ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ·ı‹ÛˆÓ, ȉȷ›ÙÂÚË ·Í›· ¤¯Ô˘Ó ·˘Ù¤˜ Ô˘ Û˘ÁÎÚ›ÓÔ˘Ó ÙËÓ Â›ÙˆÛ‹ ÙÔ˘˜ ·Ó¿ÌÂÛ· Û ‰˘Ô ¯ÚÔÓÈΤ˜ ÛÙÈÁ̤˜ ÛÙÔ ·ÚÂÏıfiÓ. ™Â Ì›· ·fi ·˘Ù¤˜, Ë ‰È¿ÁÓˆÛË ÙÔ˘
¿ÛıÌ·ÙÔ˜ ¤ÁÈÓ ‚¿ÛÂÈ ÙˆÓ ·Ó·ÊÂÚfiÌÂÓˆÓ Û˘Ìو̿وÓ, ·ÏÏ¿ Î·È ‚¿ÛÂÈ ‰ÔÎÈÌ·ÛÈÒÓ ÚfiÎÏËÛ˘. ∏ ÌÂϤÙË ·Ó·Ê¤ÚÂÈ ·‡ÍËÛË ÛÙË Û˘¯ÓfiÙËÙ· ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ÛÙË µÚÂÙ·Ó›· ·fi 6 Û 12% ̤۷ Û 15 ¯ÚfiÓÈ·. ∆· ÔÛÔÛÙ¿ ·‡ÍËÛ˘ ‹Ù·Ó ›Û˘ ÂÓÙ˘ˆÛȷο ÁÈ· ÙËÓ ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· (·fi 5 Û 16%) Î·È ÙËÓ ·ÏÏÂÚÁÈ΋ ÚÈÓ›Ùȉ· (·fi 9 Û 15%)(5). ∏ ¤ÎıÂÛË Û¯ÂÙÈο Ì ÙËÓ ·ÚÔ¯‹ ˘ËÚÂÛÈÒÓ ˘Á›·˜ Û ·ÛıÂÓ›˜ Ì ·ÏÏÂÚÁÈο ÓÔÛ‹Ì·Ù·, Ë ÔÔ›· ÂΉfiıËΠ·fi ÙÔ µ·ÛÈÏÈÎfi ∫ÔϤÁÈÔ ÙˆÓ ¶·ıÔÏfiÁˆÓ ∞ÁÁÏ›·˜ ÙÔ 2004, ·Ó·Ê¤ÚÂÈ ¯·Ú·ÎÙËÚÈÛÙÈο Ù· ÂÍ‹˜: Ù· Û˘¯ÓfiÙÂÚ· ·ÏÏÂÚÁÈο ÓÔÛ‹Ì·Ù· ¤¯Ô˘Ó ·˘ÍËı› ÛÙÔ ÙÚÈÏ¿ÛÈÔ Î·Ù¿ Ù· ÙÂÏÂ˘Ù·›· 20 ¯ÚfiÓÈ· ÛÙË µÚÂÙ·Ó›·, ÂÓÒ ÂÚ›Ô˘ ÙÔ ¤Ó· ¤ÌÙÔ ÙÔ˘ ÏËı˘ÛÌÔ‡ ¤¯ÂÈ ·ÔÙ·Óı› Û οÔÈ· Ê¿ÛË Ù˘ ˙ˆ‹˜ ÙÔ˘ Û ÂȉÈÎfi, ÏfiÁˆ οÔÈ·˜ ·ÏÏÂÚÁÈ΋˜ ¿ıËÛ˘ (1,7,18). ∂›Ó·È ·Ï‹ıÂÈ· fiÙÈ Ë ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÂÚ¢ÓÒÓ Ô˘ ηٷÁÚ¿ÊÔ˘Ó ·˘Ù‹ ÙËÓ ·‡ÍËÛË ‚·Û›˙ÔÓÙ·È Û ·ÔÙÂϤÛÌ·Ù· ÂÚˆÙËÌ·ÙÔÏÔÁ›ˆÓ Î·È ÂÔ̤ӈ˜ Û ·Ó·ÊÂÚfiÌÂÓ· Û˘ÌÙÒÌ·Ù·, Ô˘ ÔˆÛ‰‹ÔÙ ÂÓ¤¯Ô˘Ó ˘ÔÎÂÈÌÂÓÈÎfiÙËÙ·. øÛÙfiÛÔ, Û ÌÂÚÈΤ˜ ÌÂϤÙ˜ Ù· Û˘ÌÂÚ¿ÛÌ·Ù· ‚·Û›˙ÔÓÙ·È ÛÙË Û‡ÁÎÚÈÛË ÙˆÓ ÂȤ‰ˆÓ ÙˆÓ ÂȉÈÎÒÓ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ IgE ÙÔ˘ ÔÚÔ‡ ÙˆÓ Û˘ÌÌÂÙ¯fiÓÙˆÓ (4). ™Â Ì›· ·fi ·˘Ù¤˜ ÙȘ ÂÚÁ·Û›Â˜ ¤ÁÈÓ ۇÁÎÚÈÛË ÙˆÓ ÂȤ‰ˆÓ ÙˆÓ ÂȉÈÎÒÓ πgE Ô˘ ÂÍÂÙ¿ÛÙËÎ·Ó Û ÙÚÂȘ ¯ÚÔÓÈΤ˜ ÛÙÈÁ̤˜ Û ‰È¿ÛÙËÌ· 25 ÂÙÒÓ. ¢Â›ÁÌ·Ù· ·›Ì·ÙÔ˜ ÂÏ‹ÊıËÛ·Ó ·fi ÙÚÂȘ ÔÌ¿‰Â˜ ÂıÂÏÔÓÙÒÓ, Ì›· Û οı ¯ÚÔÓÈ΋ ÛÙÈÁÌ‹. ŸÏÔÈ ÔÈ ÂıÂÏÔÓÙ¤˜ ¤¯Ô˘Ó ÙËÓ ›‰È· ËÏÈΛ· Û‹ÌÂÚ·, ÂÓÒ ÔÈ ÔÌ¿‰Â˜ ›¯·Ó ·ÚfiÌÔÈ· ‰ËÌÔÁÚ·ÊÈο Î·È Ê˘ÛÈο ¯·Ú·ÎÙËÚÈÛÙÈο. ∆· ·ÔÙÂϤÛÌ·Ù· ¤‰ÂÈÍ·Ó ÛËÌ·ÓÙÈο ·˘ÍË̤ӷ ›‰· IgE Û ·ʋ Ì ÙË Á‡ÚË ÙˆÓ ‰¤Ó‰ÚˆÓ Î·È ÙˆÓ ·ÁÚÒÓ, ηıÒ˜ Î·È ÙȘ Á¿Ù˜ (8). ∞fi Ù· ·Ú·¿Óˆ ‰È·ÈÛÙÒÓÂÙ·È fiÙÈ Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ·ı‹ÛÂˆÓ ‰ÂÓ ·˘Í¿ÓÂÙ·È ÌfiÓÔ ÛÙȘ ÓÂfiÙÂÚ˜ ÁÂÓȤ˜ ·ÏÏ¿ Î·È Û ·ÓıÚÒÔ˘˜ ÌÂÁ·Ï‡ÙÂÚ˘ ËÏÈΛ·˜, ÂÊfiÛÔÓ ÂÎÙ›ıÂÓÙ·È ÛÙÔÓ Û‡Á¯ÚÔÓÔ ÙÚfiÔ ˙ˆ‹˜, fiˆ˜ ı· ÂÚÈÁÚ·Ê› ·Ú·Î¿Ùˆ (¶›Ó·Î·˜ 1). ™¯ÂÙÈο Ì ٷ ·Ú·¿Óˆ Â›Ó·È Î·È Ù· Â˘Ú‹Ì·Ù· ÙˆÓ Linneberg Î·È Û˘Ó, Ô˘ Û˘Ó¤ÎÚÈÓ·Ó ÌÂÚÈΤ˜ ÁÂÓȤ˜ ˆ˜ ÚÔ˜ ÙËÓ Â˘·ÈÛıËÙÔÔ›ËÛ‹ ÙÔ˘˜ Û ·ÂÚÔ·ÏÏÂÚÁÈÔÁfiÓ· (12). ™ËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ‚Ú¤ıËΠÌÂٷ͇ ÙˆÓ ·ÙfiÌˆÓ Ô˘ ›¯·Ó ÁÂÓÓËı› ÚÈÓ Î·È ÌÂÙ¿ ÙÔ 1960. ∆Ô ‰È¿ÁÚ·ÌÌ· ÛÙËÓ ∂ÈÎfiÓ· 1 ‰Â›¯ÓÂÈ fiÙÈ Ë Â˘·ÈÛıËÙÔÔ›ËÛË ÙÔ˘ ÏËı˘ÛÌÔ‡ Êı›ÓÂÈ ÛÙȘ ·Ï·ÈfiÙÂÚ˜ ÁÂÓȤ˜. ∂›Ó·È ÂӉȷʤÚÔÓ, ˆÛÙfiÛÔ, Î·È Û¯ÂÙÈÎfi Ì ٷ Â˘Ú‹Ì·Ù· ÙˆÓ Law Î·È Û˘Ó. fiÙÈ ÌÂٷ͇ 1990-1998 ·ÎfiÌ· Î·È Ë ÌÂÁ·Ï‡ÙÂÚË ÁÂÓÈ¿ ·ÚÔ˘ÛÈ·˙fiÙ·Ó ÈÔ Â˘·ÈÛıËÙÔÔÈË̤ÓË (12). ÷ڷÎÙËÚÈÛÙÈο Û˘ÌÂÚ¿ÛÌ·Ù· Û¯ÂÙÈο Ì ÙȘ ‰È·ÊÔÚ¤˜ ›وÛ˘ Ù˘ ·ÏÏÂÚÁ›·˜ ÌÂٷ͇ ÙˆÓ ÁÂÓÂÒÓ ¤‰ˆÛÂ Î·È Ë ·ÎfiÏÔ˘ıË ÌÂϤÙË. ™ÙË ÌÂϤÙË ·˘Ù‹ Ô˘ Ú·ÁÌ·ÙÔÔÈ‹ıËΠÛÙË ºÈÏ·Ó‰›· ÂÍÂÙ¿ÛÙËÎ·Ó IgE Û ·ÂÚÔ·ÏÏÂÚÁÈÔÁfiÓ· Î·È Û ÙÚÔÊÈο ·ÏÏÂÚÁÈÔÁfiÓ· ·fi ‰Â›ÁÌ·Ù· ·›Ì·ÙÔ˜ ÂıÂÏÔÓÙÒÓ Ô˘ ›¯·Ó ÁÂÓÓËı› ηٿ ÙȘ ‰ÂηÂٛ˜ ÙÔ˘ 1920, 1940, 1960 Î·È 1990. ∏ ‰È·ÊÔÚ¿ ÛÙË Û˘¯ÓfiÙËÙ· ‰È¿ÁÓˆÛ˘ ¿ÛıÌ·ÙÔ˜ ·fi È·ÙÚfi ‹Ù·Ó ÛÙ·ÙÈÛÙÈÎÒ˜ ÛËÌ·ÓÙÈ΋. ∆· ›‰· IgE ·ÚÔ˘Û›·˙·Ó ·‡ÍËÛË ÛÙȘ ÓÂfiÙÂÚ˜ ÁÂÓȤ˜, Ì ÛËÌ·ÓÙÈΤ˜
¶›Ó·Î·˜ 1. ∞Ó·ÏÔÁ›· ·Ó‰ÚÒÓ Ô˘ ‚Ú¤ıËÎ·Ó ıÂÙÈÎÔ› ÛÙÔ Phadiatop* ¤Ó·ÓÙÈ ÙÚÈÒÓ ·ÏÏÂÚÁÈÔÁfiÓˆÓ, Û ÙÚÂȘ ¯ÚÔÓÈΤ˜ ÛÙÈÁ̤˜. √È ÙÈ̤˜ Â›Ó·È % ÔÛÔÛÙ¿. ¢ËÌÔÛ›Â˘ÛË Î·ÙfiÈÓ ·‰Â›·˜ (8). ∆Ô χÇ Â›¯Â ÙÈÌ‹<0,001 ÁÈ· ÙÔ Phadiatop Î·È ÁÈ· ηı¤Ó· ·fi Ù· 3 ·ÏÏÂÚÁÈÔÁfiÓ· ŒÙÔ˜ 1975-6 1981-2 1996-8 M¤ÛË ·fiÏ˘ÙË ÂÙ‹ÛÈ· ·‡ÍËÛË ÂÈÔÏ·ÛÌÔ‡ (%)
Phadiatop
°Ú·Û›‰È
30 (26-34) 16 (13-19) 33 (29-37) 18 (14-21) 42 (37-46) 27 (23-31) 0,45 (0,17- 0,73) 0,53 (0,30- 0,77)
°‡ÚË ‰¤Ó‰ÚˆÓ
°¿Ù·
5,7 (3,8-8,0) 5,1 (3,3-7,3) 12,6 (9,9-15,8) 0,36 (0,19-0,53)
4,1 (2,6-6,2) 4,5 (2,9-6,6) 10,1 (7,6-13,1) 0,25 (0,13 -0,38)
*™Î‡·ÛÌ· 11 ÎÔÈÓÒÓ ÂÈÛÓÂfiÌÂÓˆÓ ·ÏÏÂÚÁÈÔÁfiÓˆÓ Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ˆ˜ ‰Â›ÎÙ˘ ·ÙÔ›·˜ ¶·È‰È·ÙÚÈ΋ 2007;70:266-271
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·268
268
∞. ™ÔÊÈ·ÓÔ‡-∫·ÙÛÔ‡ÏË
45
∂ÈÔÏ·ÛÌfi˜ (%)
40 35
1990
30
1998
25 20 15 10 5 0 15-22 23-30 31-38 39-46 4754 55-62 63-70 70-77 ∏ÏÈΛ· (¤ÙË)
∂ÈÎfiÓ· 1. ∞ÏÏ·Á‹ ÛÙË Û˘¯ÓfiÙËÙ· ¢·ÈÛıËÙÔÔ›ËÛ˘ ηٿ ËÏÈÎȷ΋ ÔÌ¿‰· ÛÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi ÌÂٷ͇ 1990-1998. ¢ËÌÔÛ›Â˘ÛË Î·ÙfiÈÓ ·‰Â›·˜ (15).
‰È·ÊÔÚ¤˜ ·Ó¿ÌÂÛ· ÛÙ· ÂÚÈÛÛfiÙÂÚ· ˙‡ÁË ÁÂÓÂÒÓ, Û fi,ÙÈ ·ÊÔÚ¿ Ù· ·ÂÚÔ·ÏÏÂÚÁÈÔÁfiÓ·. ∞ÓÙ›ıÂÙ·, ÛÙ· ÙÚÔÊÈο ·ÏÏÂÚÁÈÔÁfiÓ· ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÛÙ· ›‰· IgE ηٷÁÚ¿ÊËΠÌfiÓÔ ÌÂٷ͇ Ù˘ ÁÂÓÈ¿˜ ÙÔ˘ 1920 Î·È ÙÔ˘ 1990. ŒÓ· ·fi Ù· ÛËÌ·ÓÙÈο Â˘Ú‹Ì·Ù· ·˘Ù‹˜ Ù˘ ÌÂϤÙ˘ Â›Ó·È fiÙÈ Ë Â˘·ÈÛıËÙÔÔ›ËÛË Ù˘ ÁÂÓÈ¿˜ ÙÔ˘ 1940 ‰ÂÓ ‰È·Ê¤ÚÂÈ ·fi ·˘Ù‹ ÙÔ˘ 1920. ∂›Ó·È Èı·Ófi ÔÈ Î·Î¤˜ Û˘Óı‹Î˜ ˘ÁÈÂÈÓ‹˜ ηٿ ÙÔÓ 2Ô ¶·ÁÎfiÛÌÈÔ ¶fiÏÂÌÔ Ó· ·Ó¤ÎÔ„·Ó ÚÔÛˆÚÈÓ¿ ÙËÓ ÂͤÏÈÍË ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ·ı‹ÛÂˆÓ (¶›Ó·Î·˜ 2) (9). ∂ÎÙfi˜ fï˜ ·fi ÙË Û˘¯ÓfiÙËÙ·, ¤¯ÂÈ ·ÏÏ¿ÍÂÈ Î·È Ë Ê‡ÛË ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ·ı‹ÛÂˆÓ Ô˘ ÚÔÛ‚¿ÏÏÔ˘Ó ÙÔÓ ÏËı˘ÛÌfi. ∆ÚÔÊÈΤ˜ ·ÏÏÂÚÁ›Â˜ Ô˘ ÂÓ‰¤¯ÂÙ·È Ó· ·Ô‚Ô‡Ó ÂÈΛӉ˘Ó˜ ÁÈ· ÙË ˙ˆ‹, fiˆ˜ Ë ·ÏÏÂÚÁ›· ÛÙÔ˘˜ ÍËÚÔ‡˜ ηÚÔ‡˜, ·Ú·ÙËÚÔ‡ÓÙ·È ÈÔ Û˘¯Ó¿. ∞˘Ùfi ÔÊ›ÏÂÙ·È ÛÙËÓ ÂÈÛ·ÁˆÁ‹ ÛÙËÓ Î·ıËÌÂÚÈÓ‹ ‰È·ÙÚÔÊ‹ ÂÂÍÂÚÁ·ÛÌ¤ÓˆÓ ÙÚÔÊÒÓ Î·ıÒ˜ Î·È Ê·ÁËÙÒÓ ·fi ¯ÒÚ˜ Ù˘ ∞Û›·˜, fiÔ˘ Â›Ó·È Û˘¯ÓfiÙÂÚË Ë ¯Ú‹ÛË ÍËÚÒÓ Î·ÚÒÓ (1,17,18). ŒÓ· ·ÎfiÌË ¯·Ú·ÎÙËÚÈÛÙÈÎfi ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ·ı‹ÛÂˆÓ ÛÙȘ ̤Ú˜ Ì·˜ Â›Ó·È fiÙÈ Ù›ÓÔ˘Ó Ó· ¤¯Ô˘Ó ÔÏ˘Û˘ÛÙËÌ·ÙÈΤ˜ ÂΉËÏÒÛÂȘ: ÔÏÏ¿ ·È‰È¿ Ì ÙÚÔÊÈ΋ ·ÏÏÂÚÁ›·, ÁÈ· ·Ú¿‰ÂÈÁÌ·, ˘ÔʤÚÔ˘Ó ·fi ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· Î·È ‚ÚÔÁ¯ÈÎfi ¿ÛıÌ·, Ù¿ÛË Ô˘ ηٷÁÚ¿ÊÂÙ·È ÛÙËÓ ÙÚ›ÙË Ê¿ÛË Ù˘ ÔÏ˘ÎÂÓÙÚÈ΋˜ ÌÂϤÙ˘ ISAAC (International Study of Asthma and Allergies in Childhood) . ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ·Ú¿ÏÏËÏ· Ì ÙËÓ ÔÏ˘Û˘ÛÙËÌ·ÙÈÎfiÙËÙ· ÛÙȘ ÂΉËÏÒÛÂȘ ÙˆÓ ·ÙÔÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ ÛÙËÓ 3Ë Ê¿ÛË Ù˘ ÌÂϤÙ˘ ·Ú·ÙËÚÂ›Ù·È Î·È Ì›· ·ÏÏ·Á‹ ÛÙËÓ “ÎÏ·ÛÈ΋” ÛÂÈÚ¿ ÂÌÊ¿ÓÈÛ˘ ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ ·Ó¿ ËÏÈΛ·. ∏ ÁÓˆÛÙ‹ ·ÏÏËÏÔ˘¯›· ÂÌÊ¿ÓÈÛ˘ ÙˆÓ ÓÔÛËÌ¿ÙˆÓ ·Ô‰›‰ÂÙ·È ·fi ÙÔÓ fiÚÔ “·ÙÔÈ΋ ·Ú¤Ï·ÛË”- atopic marching (1,18,20). ∞fi Ù· Û˘ÌÂÚ¿ÛÌ·Ù· Ù˘ ÌÂϤÙ˘ ISAAC, Û fiϘ Ù˘
Ê¿Û˘ ‰ÈÂÍ·ÁˆÁ‹˜ Ù˘, ÚÔ·ÙÂÈ fiÙÈ ÔÈ ¯ÒÚ˜ Ì ÙË ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· ·ÏÏÂÚÁÈÒÓ Â›Ó·È ÔÈ ÈÔ ·Ó·Ù˘Á̤Ó˜ ÔÈÎÔÓÔÌÈο Î·È ‚ÈÔÌ˯·ÓÈο, ÂÓÒ ·Ú¿ÏÏËÏ· ÔÈ ÏËı˘ÛÌÔ› ÙÔ˘˜ ÂӉ¯Ô̤ӈ˜ Ó· ¤¯Ô˘Ó ÔÌÔÈfiÙËÙ˜ Î·È Û ÁÂÓÂÙÈÎfi Â›Â‰Ô (∂ÈÎfiÓ· 2)(7, 20). ™ÙËÓ ∂ÏÏ¿‰·, ˆÛÙfiÛÔ, Ë Û˘¯ÓfiÙËÙ¿ ÙÔ˘˜ ·Ú·Ì¤ÓÂÈ Û¯ÂÙÈο ¯·ÌËÏ‹, ·Ó Î·È ·Ó·Ì¤ÓÔÓÙ·È ÓÂÒÙÂÚ· ÛÙÔȯ›· ·fi ÙËÓ ˘fi ÂͤÏÈÍË Â˘Úˆ·˚΋ ÌÂϤÙË Â›ÙˆÛ˘ Ù˘ ÙÚÔÊÈ΋˜ ·ÏÏÂÚÁ›·˜ ∂uropreval. ™Â ÚfiÛÊ·ÙË ‰ËÌÔÛ›Â˘ÛË, ÔÈ ∞ÓıÚ·ÎfiÔ˘ÏÔ˜ Î·È Û˘Ó. ‰ËÌÔÛÈÂ‡Ô˘Ó Ù· ·ÔÙÂϤÛÌ·Ù· ÌÈ·˜ ÌÂϤÙ˘ ÂÈÔÏ·ÛÌÔ‡ ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ÛÙËÓ ÂÚÈÔ¯‹ ÙˆÓ ¶·ÙÚÒÓ. ∏ ηٷÁÚ·Ê‹ ÙÔ˘ ÂÈÔÏ·ÛÌÔ‡ Û ‰È¿ÊÔÚ˜ ¯ÚÔÓÈΤ˜ ÛÙÈÁ̤˜ Ù· ÙÂÏÂ˘Ù·›· 25 ¯ÚfiÓÈ· ÛÙËÓ ÂÚÈÔ¯‹ ‰Â›¯ÓÂÈ fiÙÈ Ù· ÔÛÔÛÙ¿ ¿ÛıÌ·ÙÔ˜ ·˘Í¿ÓÔ˘Ó, ·Ó Î·È Û ¯·ÌËÏfiÙÂÚÔ˘˜ Ú˘ıÌÔ‡˜ Û ۯ¤ÛË Ì ÙÔ ·ÚÂÏıfiÓ (21). ∞ÈÙÈÔÏÔÁÈÎÔ› ·Ú¿ÁÔÓÙ˜ ∆ËÓ ÙÂÏÂ˘Ù·›· 15ÂÙ›· ¤¯Ô˘Ó Á›ÓÂÈ ÔÏϤ˜ ÚÔÛ¿ıÂȘ Ó· ÂÚÌËÓ¢Ù› Ë ·Ú·ÙËÚÔ‡ÌÂÓË ·‡ÍËÛË ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ·ı‹ÛˆÓ. Œ¯Ô˘Ó ‰È·Ù˘ˆı› ÔÈΛϘ “ıˆڛ˜” Î·È “˘Ôı¤ÛÂȘ”, Ô˘ Û ÔÏϤ˜ ÂÚÈÙÒÛÂȘ Û˘ÌÏËÚÒÓÔ˘Ó Ë Ì›· ÙËÓ ¿ÏÏË. ∏ “˘fiıÂÛË Ù˘ ˘ÁÈÂÈÓ‹˜” ‰È·Ù˘ÒıËΠÙÔ 1989 ·fi ÙÔÓ David Strachan. H ÌÂϤÙË ÙÔ˘ ¤‰ÂÈÍ fiÙÈ ÂÓ‰¤¯ÂÙ·È Ô ÏfiÁÔ˜ ÁÈ· ÙËÓ ·‡ÍËÛË ÙˆÓ ·ÙÔÈÎÒÓ ·ı‹ÛÂˆÓ Ó· Â›Ó·È Ë Ì›ˆÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ·È‰ÈÒÓ ÛÙȘ ÔÈÎÔÁ¤ÓÂȘ, ·ÏÏ¿ Î·È Ë ‚ÂÏÙ›ˆÛË ÙˆÓ Û˘ÓıËÎÒÓ ˘ÁÈÂÈÓ‹˜ ̤۷ ÛÙÔ Û›ÙÈ. ™˘ÁÎÂÎÚÈ̤ӷ, ÚԤ΢„ fiÙÈ Ë Â›ÙˆÛË Ù˘ ·ÏÏÂÚÁÈ΋˜ ÚÈÓ›Ùȉ·˜ Â›Ó·È ·ÓÙÈÛÙÚfiʈ˜ ·Ó¿ÏÔÁË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ·È‰ÈÒÓ ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· Î·È ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ÌÂÁ·Ï‡ÙÂÚˆÓ ·‰ÂÚÊÒÓ (3). ™·Ó Û˘Ó¤¯ÂÈ· Ù˘ ·Ú·¿Óˆ ˘fiıÂÛ˘ ¤¯ÂÈ ‚ÚÂı› fiÙÈ Ë ·ÏÏ·Á‹ ÛÙË ÌÈÎÚԂȷ΋ ¯ÏˆÚ›‰· ÙÔ˘ ÂÓÙ¤ÚÔ˘ ‰ËÌÈÔ˘ÚÁ› ·ÏÏÂÚÁÈ΋ ÚԉȿıÂÛË, ÏfiÁˆ Ù˘ ÌÂȈ̤Ó˘ ηٷӿψÛ˘ ÌË ·ÛÙÂÚȈ̤ÓÔ˘ Á¿Ï·ÙÔ˜ Î·È ÏfiÁˆ ÙÔ˘ Û‡Á¯ÚÔÓÔ˘ ÙÚfiÔ˘ ‰È·ÙÚÔÊ‹˜ - ‰›·ÈÙ˜ ÔÏ˘ÂÂÍÂÚÁ·ÛÌ¤ÓˆÓ ÙÚÔÊÒÓ, Ùˆ¯¤˜ ÛÂ Ê˘ÙÈΤ˜ ›Ó˜. ™ÙË ‰È·Ù·Ú·¯‹ ›Û˘ Ù˘ ¯ÏˆÚ›‰·˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘ Û˘Ì‚¿ÏÏÂÈ Ë ÌÂȈ̤ÓË ¤ÎıÂÛË Û ÌÈÎÚÔ‚È·ÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Î·È Ù· ÚÔ˚fiÓÙ· ÙÔ˘˜, fiˆ˜ ›Û˘ Î·È Ë Î·Ù¿¯ÚËÛË ÙˆÓ ·ÓÙÈ‚ÈÔÙÈÎÒÓ (11). °È· ÙÔÓ ÏfiÁÔ ·˘Ùfi, ÂÍÂÙ¿ÛÙËÎÂ Ô ÚfiÏÔ˜ ÙˆÓ ÚÔ‚ÈÔÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÛÙË ‰È·ÙÚÔÊ‹, Ì ÛÎÔfi ÙËÓ ÂÏ¿ÙÙˆÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ ÙˆÓ ·ÙÔÈÎÒÓ ·ı‹ÛÂˆÓ (19). ∆· ·ÔÙÂϤÛÌ·Ù· Â›Ó·È ÔÚȷο ˘¤Ú ÙÔ˘ ÚfiÏÔ˘ ÙˆÓ ÚÔ‚ÈÔÙÈÎÒÓ Î·È ÔˆÛ‰‹ÔÙ ¯Ú‹˙Ô˘Ó ÂÚ·ÈÙ¤Úˆ ¤Ú¢ӷ˜. ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ‰ÂÓ ÈÛ¯‡ÂÈ Ô ÈÛ¯˘ÚÈÛÌfi˜ fiÙÈ ÔÈ Î·Î¤˜ Û˘Óı‹Î˜ ˘ÁÈÂÈÓ‹˜ ÚÔÛÙ·ÙÂ‡Ô˘Ó ¿ÓÙ· ·fi ÙËÓ ·Ó¿Ù˘ÍË ·ÙÔ›·˜. ∞ÓÙÈı¤Ùˆ˜, ÂÚÈÙÒÛÂȘ, fiˆ˜ ÁÈ· ·Ú¿‰ÂÈÁÌ· Ë Ïԛ̈ÍË ·fi ÙÔÓ ·Ó·Ó¢ÛÙÈÎfi Û˘Á΢ÙÈ·Îfi Èfi (RSV), Úԉȷı¤ÙÔ˘Ó ÁÈ· ·Ó¿Ù˘ÍË ¿ÛıÌ·ÙÔ˜. ∏ ÈÔ ÛˆÛÙ‹ ‰È·Ù‡ˆÛË Â›Ó·È fiÙÈ Ô ·Ú·‰ÔÛÈ·Îfi˜ ·ÁÚÔÙÈÎfi˜ ÙÚfiÔ˜ ˙ˆ‹˜ ÚÔÛٷهÂÈ ·fi ÙËÓ ·Ó¿Ù˘ÍË ·ÙÔ›·˜. ™Â ¤Ó· “·ÁÚÔÙÈÎfi” ÂÚÈ‚¿ÏÏÔÓ, Ë ¤ÎıÂÛË Û Gram ·ÚÓËÙÈο ‚·ÎÙ‹ÚÈ· Ô‰ËÁ› ÛÙËÓ ¤ÎıÂÛË ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ ۈϋӷ Û ‚·ÎÙËÚȷ΋ ÂÓ‰ÔÙÔÍ›ÓË. ∏
¶›Ó·Î·˜ 2. ∂ÈÔÏ·ÛÌfi˜ (%) -Ì 95% ‰È¿ÛÙËÌ· ‚‚·ÈfiÙËÙ·˜ - ¿ÛıÌ·ÙÔ˜, ·ÏÏÂÚÁ›·˜ ÛÙËÓ ÚˆÙ½ÓË Á¿Ï·ÎÙÔ˜ ·ÁÂÏ¿‰Ô˜ Î·È ·ÓȯÓ‡ÛÈÌˆÓ ÂȉÈÎÒÓ IgE Û ¿ÙÔÌ· Ô˘ ÂÎÚÔÛˆÔ‡Ó ÙȘ ÁÂÓȤ˜ ÙÔ˘ 1990, 1963-66, 1943-46 Î·È 1923-26. ¢ËÌÔÛ›Â˘ÛË Î·ÙfiÈÓ ·‰Â›·˜ (9) ∏ÏÈÎȷΤ˜ ÔÌ¿‰Â˜ ÕÛıÌ· ÀÂÚ¢·ÈÛıËÛ›· ÛÙÔ Á¿Ï· ∂ȉÈΤ˜ ·ÓÔÛÔÛÊ·ÈÚ›Ó˜ πgE ÛÙÔ Á¿Ï· Paediatriki 2007;70:266-271
1990 7 ÂÙÒÓ, n=100
1963-67 27 ÂÙÒÓ, n=100
1943-46 47 ÂÙÒÓ, n=100
1923-26 67 ÂÙÒÓ, n=100
10 (4,9-17,7) 14 (7,9-22,4) 9 (4,2-16,4)
1 (0,03-5,5) 10 (4,9-17,6) 4,4 (1,2-10,8)
1 (0,03-5,5) 14 (8-22,6) 1 (0,03-5,5)
5 (1,6-11) 13 (7,1-21) 7,1 (2,9-14)
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·269
269
∂ȉËÌÈÔÏÔÁ›· ·ÏÏÂÚÁÈÎÒÓ ·ı‹ÛˆÓ
∂ÈÔÏ·ÛÌfi˜ ¿ÛıÌ·ÙÔ˜ ÙÔ˘˜ ÙÂÏÂ˘Ù·›Ô˘˜ 12 Ì‹Ó˜
8,0% 3,4%
1,2%
∂ÈÔÏ·ÛÌfi˜ 3,6% ÂÎ˙¤Ì·ÙÔ˜ 1,3% ÙÔ˘˜ ÙÂÏÂ˘Ù·›Ô˘˜ 12 Ì‹Ó˜
1,3% ∂ÈÔÏ·ÛÌfi˜ ÚÈÓ›Ùȉ·˜ ÙÔ˘˜ ÙÂÏÂ˘Ù·›Ô˘˜ 12 Ì‹Ó˜
★
≥9%
◆
6-9%
●
3-6%
■
<3%
7,5%
∂ÈÎfiÓ· 2. ¶·ÁÎfiÛÌÈÔ˜ ¯¿ÚÙ˘ Ù˘ ηٷÓÔÌ‹˜ ÙÔ˘ ÂÙ‹ÛÈÔ˘ ÂÈÔÏ·ÛÌÔ‡ Û ÙÔ˘Ï¿¯ÈÛÙÔÓ ‰‡Ô ·fi ÙȘ ÙÚÂȘ ·ÙÔÈΤ˜ ·ı‹ÛÂȘ. ∫·Ù·ÁÚ¿ÊÂÙ·È Â›Û˘ Ë ·Ó·ÏÔÁ›· ÙˆÓ ·È‰ÈÒÓ Ì οÔÈ· ÙÔ˘Ï¿¯ÈÛÙÔÓ ·fi ÙȘ ÎÔÈÓ¤˜ ·ÙÔÈΤ˜ ·ı‹ÛÂȘ. ¢ËÌÔÛ›Â˘ÛË Î·ÙfiÈÓ ·‰Â›·˜ (7).
ÂÓ‰ÔÙÔÍ›ÓË ·˘Ù‹ Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ ÂÈ‚›ˆÛË Î·È ˆÚ›Ì·ÓÛË ÙˆÓ ·ÓÙÈÁÔÓÔ·ÚÔ˘ÛÈ·ÛÙÈÎÒÓ ‰ÂÓ‰ÚÈÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ. ø˜ Û˘Ó¤ÂÈ· ÙˆÓ ·Ú·¿Óˆ, Ù· ‰ÂÓ‰ÚÈÙÈο ·ÙÙ·Ú· ·Ó·Ù‡ÛÛÔ˘Ó ˘Ô‰Ô¯Â›˜ ∆LR (toll-like receptors) Ô˘ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ ·Ó¿Ù˘ÍË ÌË ·ÏÏÂÚÁÈ΋˜ ·ÓÔÛÔÏÔÁÈ΋˜ ·¿ÓÙËÛ˘. ∞˘Ùfi Û˘Ì‚·›ÓÂÈ Ì ÙËÓ ·Ú·ÁˆÁ‹ ηٿÏÏËÏˆÓ Î˘Ù·ÚÔÎÈÓÒÓ (πL-12, INF-Á) Î·È ÙËÓ ÂÈÎÚ¿ÙËÛË ÙˆÓ Î˘ÙÙ¿ÚˆÓ Th1 (16). ¢ÂÓ ˘¿Ú¯ÂÈ ·ÌÊÈ‚ÔÏ›· Î·È ¤¯ÂÈ ·Ô‰Âȯı› Î·È ·fi Û¯ÂÙÈ΋ ÌÂϤÙË ÛÙË ¢·Ó›· fiÙÈ Ë ÌÂٷΛÓËÛË ÙˆÓ ÏËı˘ÛÌÒÓ ÛÙȘ ÌÂÁ¿Ï˜ fiÏÂȘ Ô‰ËÁ› ÛÙËÓ ·ÒÏÂÈ· Ù˘ “·ÓÔÛÔÏÔÁÈ΋˜ ·ÓÔ¯‹˜” ÛÙ· ·ÏÏÂÚÁÈÔÁfiÓ·. ∞˘Ùfi Û˘Ì‚·›ÓÂÈ ÁÈ·Ù› Ë ¤ÎıÂÛË ÙˆÓ ·ÓıÚÒˆÓ Û ·ÏÏÂÚÁÈÔÁfiÓ·, .¯. Á‡ÚË, Â›Ó·È Ôχ ÌÈÎÚfiÙÂÚË, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ¯¿ÓÔ˘Ó ÙËÓ ·ÓÔÛÔÏÔÁÈ΋ ·ÓÔ¯‹ ÙÔ˘˜ Û ·˘Ù¿ Î·È Ó· ¢·ÈÛıËÙÔÔÈÔ‡ÓÙ·È. ™ÙËÓ ·ÓÔÛÔıÂڷ›·, ·ÓÙÈı¤Ùˆ˜, Ë ·Â˘·ÈÛıËÙÔÔ›ËÛË ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ÙËÓ ·˘Í·ÓfiÌÂÓË ¤ÎıÂÛË Û οÔÈÔ ·ÏÏÂÚÁÈÔÁfiÓÔ. ∞˘Ùfi˜ Â›Ó·È Ô ÏfiÁÔ˜ Ô˘ Ë Û˘ÁÎÂÎÚÈ̤ÓË ÌÂϤÙË ÔÓfiÌ·Û ÙËÓ ·Ú·¿Óˆ ‰È·‰Èηۛ· ·Ó¿Ù˘Í˘ ·ÏÏÂÚÁÈÒÓ ÏfiÁˆ ·ÛÙÈÎÔÔ›ËÛ˘, “·ÓÙ›ÛÙÚÔÊË ÂÚ›ÙˆÛË ·ÓÔÛÔıÂڷ›·˜” (15). ∆Ô ·Ú¿‰ÂÈÁÌ· Ù˘ ÚÒËÓ ∞Ó·ÙÔÏÈ΋˜ °ÂÚÌ·Ó›·˜ ¤¯ÂÈ ¯ÚËÛÈÌÔÔÈËı› ›Û˘ ·fi ÔÏÏÔ‡˜ ÂÚ¢ÓËÙ¤˜. √ ÏfiÁÔ˜ Â›Ó·È fiÙÈ Ë Âӈ̤ÓË °ÂÚÌ·Ó›· ·ÔÙÂÏÂ›Ù·È ·fi ‰‡Ô ÁÂÓÂÙÈο ·ÚfiÌÔÈÔ˘˜ ÏËı˘ÛÌÔ‡˜, Ô˘ fï˜ ÂÎÙ¤ıËÎ·Ó Û ·ÏÏÂÚÁÈÔÁfiÓ· Û ‰È·ÊÔÚÂÙÈÎfi ‚·ıÌfi ÚÈÓ ·fi ÙËÓ ÂÓÔÔ›ËÛË. √ ‚·ıÌfi˜ Ù˘ ¢·ÈÛıËÙÔÔ›ËÛ˘ Ô˘ ÂÎÙÈÌ‹ıËΠ·fi ‰ÂÚÌ·-
ÙÈΤ˜ ‰ÔÎÈ̷ۛ˜ Ó˘ÁÌÔ‡ (skin prick tests) ‹Ù·Ó ¯·ÌËÏfiÙÂÚÔ˜ ÛÙËÓ ∞Ó·ÙÔÏÈ΋ Û ۇÁÎÚÈÛË Ì ÙË ¢˘ÙÈ΋ °ÂÚÌ·Ó›·. ∞fi ÙËÓ ¿ÏÏË ÌÂÚÈ¿, Ë Â›ÙˆÛË Ù˘ ·ÏÏÂÚÁÈ΋˜ ÚÈÓ›Ùȉ·˜, ·Ú·ÙËÚÂ›Ù·È ·˘ÍË̤ÓË Û fiÏÂȘ Ù˘ ∞Ó·ÙÔÏÈ΋˜ °ÂÚÌ·Ó›·˜ ̤۷ Û ϛÁ· ¯ÚfiÓÈ· ÌÂÙ¿ ÙËÓ ÂÓÔÔ›ËÛË. ∞˘Ùfi Èı·ÓfiÓ Ó· ÔÊ›ÏÂÙ·È ÛÙÔÓ ÈÔ “‰˘ÙÈÎfi” ÙÚfiÔ ˙ˆ‹˜ Ô˘ ˘ÈÔıÂÙ‹ıËΠ(6). ªÂϤÙ˜ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙË ‰ÂηÂÙ›· ÙÔ˘ 1990 ˆÛÙfiÛÔ, ‰ÂÓ ‰Â›¯ÓÔ˘Ó ‰È·ÊÔÚ¤˜ ÛÙËÓ Â›ÙˆÛË .¯. ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ‹ ÛÙËÓ Â˘·ÈÛıËÙÔÔ›ËÛË ÙÔ˘ ÏËı˘ÛÌÔ‡ ‚¿ÛÂÈ ÙˆÓ ÙÈÌÒÓ IgE. ¶·ÚfiÌÔÈ· ·ÔÙÂϤÛÌ·Ù· ÚÔ¤Ú¯ÔÓÙ·È ·fi ÌÂϤÙ˜ ÛÙËÓ πÙ·Ï›·, ÙËÓ ∂Ï‚ÂÙ›· Î·È ÙËÓ ∞˘ÛÙÚ·Ï›·. ∏ ÂÍ‹ÁËÛË Ô˘ ‰›ÓÂÙ·È Â›Ó·È fiÙÈ ÂӉ¯Ô̤ӈ˜ Ë ·‡ÍËÛË ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ÂΉËÏÒÛÂˆÓ Ó· ¤¯ÂÈ ÊÙ¿ÛÂÈ Û ¤Ó· “Ï·Ùfi” (13,20, 22, 23). ™ÙÔ Î˘ÙÙ·ÚÈÎfi ›‰Ô, Ë ˘fiıÂÛË “˘ÁÈÂÈÓ‹˜” ÌÔÚ› Ó· ÂÍËÁËı› ·fi ÙËÓ ·ÒÏÂÈ· Ù˘ ¯ÚfiÓÈ·˜ ÌÈÎÚԂȷ΋˜ ‰È¤ÁÂÚÛ˘ ÛÙ· ·ÙÙ·Ú· Ù˘ ÂÁÁÂÓÔ‡˜ ·ÓÔÛ›·˜, ̤ۈ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ TLR. OÈ toll-like receptors Â›Ó·È ˘Ô‰Ô¯Â›˜ (̤¯ÚÈ ÛÙÈÁÌ‹˜ ¤¯Ô˘Ó ·Ó·Î·Ï˘Êı› ÙÔ˘Ï¿¯ÈÛÙÔÓ 10) ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÙˆÓ ‰ÂÓ‰ÚÈÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·ıÒ˜ Î·È ÙˆÓ ¡∫ (natural killer) ΢ÙÙ¿ÚˆÓ. √È ˘Ô‰Ô¯Â›˜ ·˘ÙÔ› ·ÏÏËÏÂȉÚÔ‡Ó Ì ‰È¿ÊÔÚ· ÙÌ‹Ì·Ù· ÙˆÓ ‚·ÎÙËÚ›ˆÓ Î·È ÙˆÓ ÈÒÓ Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È ÛÙÔ ·ÓÔÛÔÔÈËÙÈÎfi Û‡ÛÙËÌ·. ∞Ó¿ÏÔÁ· Ì ÙÔÓ Ù‡Ô ÙÔ˘ ˘Ô‰Ô¯¤· ·ÏÏ¿ Î·È ÙÔ ÙÌ‹Ì· ÙÔ˘ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡ Ô˘ ·ÚÔ˘ÛÈ¿¶·È‰È·ÙÚÈ΋ 2007;70:266-271
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·270
270
∞. ™ÔÊÈ·ÓÔ‡-∫·ÙÛÔ‡ÏË
˙ÂÙ·È ÚÔ·ÙÂÈ Î·È Ë ·Ó¿ÏÔÁË ·ÓÔÛÔÏÔÁÈ΋ ·¿ÓÙËÛË, Ô˘ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ Â›‰Ô˜ ÙˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ Ô˘ ÂÎÎÚ›ÓÔÓÙ·È. ∏ ÂÏ¿ÙÙˆÛË ÙÔ˘ ÌÈÎÚÔ‚È·ÎÔ‡ ÊÔÚÙ›Ô˘ Û˘Ó¿ÁÂÙ·È ÂÓ›Û¯˘ÛË Ù˘ ·ÓÔÛÔÏÔÁÈ΋˜ Ì¿ÏÏÔÓ ·¿ÓÙËÛ˘ ̤ۈ ÙˆÓ ‚ÔËıËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Th2, Ô˘ ¢ı‡ÓÔÓÙ·È Î˘Ú›ˆ˜ ÁÈ· ÙȘ ·ÏÏÂÚÁÈΤ˜ ·ÓÙȉڿÛÂȘ, ·Ú¿ Ù˘ ∆h1 ·¿ÓÙËÛ˘. √ Ì˯·ÓÈÛÌfi˜ Ì ÙÔÓ ÔÔ›Ô ÚÔ·ÙÂÈ ·˘Ù‹ Ë “·ÓÈÛÔÚÚÔ›·” ˘¤Ú Ù˘ ∆h2 ·¿ÓÙËÛ˘ ‰ÂÓ ¤¯ÂÈ ‰È¢ÎÚÈÓÈÛÙ›. ¶Èı·ÓfiÓ Ó· Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ˘ÂÚ·Ú·ÁˆÁ‹˜ ∆h2 ΢ÙÙ·ÚÔÎÈÓÒÓ ‹ ÌÂȈ̤Ó˘ ‰È¤ÁÂÚÛ˘ ÙˆÓ “Ú˘ıÌÈÛÙÈÎÒÓ” ∆ ΢ÙÙ¿ÚˆÓ (10). ∏ ·¿ÓÙËÛË Th2 Â›Ó·È Ô˘ÛÈ·ÛÙÈο ·ÏÏÂÚÁÈ΋ ·¿ÓÙËÛË ÙÔ˘ ·ÓÔÛÔÏÔÁÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Û ¤Ó·Ó “·ıÒÔ ÂÈÛ‚ÔϤ·”, ÙÔ ·ÏÏÂÚÁÈÔÁfiÓÔ, Î·È Â›Ó·È ·ÚfiÌÔÈ· Ì ÙËÓ ·¿ÓÙËÛË Ô˘ ı· ›¯·Ì ÌÂÙ¿ ÙËÓ ÂÈÛ‚ÔÏ‹ ÂÓfi˜ ·Ú·Û›ÙÔ˘ ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi. ™ÙȘ ‰˘ÙÈΤ˜ ÎÔÈӈӛ˜ Ê·›ÓÂÙ·È fiÙÈ Ë ·¿ÓÙËÛË ·˘Ù‹ ÂÓÂÚÁÔÔÈÂ›Ù·È ·fi ÎÔÈÓ¿ ·ÏÏÂÚÁÈÔÁfiÓ· Î·È ·˘Ùfi Û˘Ì‚·›ÓÂÈ, Èı·Ófiٷٷ, ÏfiÁˆ ¤ÏÏÂȄ˘ ÈηÓÔ‡ ·ÓÔÛÔÚÚ˘ıÌÈÛÙÈÎÔ‡ ÊÔÚÙ›Ô˘ ·Ú·Û›ÙˆÓ ÛÙȘ Û˘Óı‹Î˜ ‚ÂÏÙȈ̤Ó˘ ˘ÁÈÂÈÓ‹˜. ∞˘Ùfi˜ Â›Ó·È Ô ÏfiÁÔ˜ Ô˘ Ù· ·Ú¿ÛÈÙ· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ·fi ÔÚÈṲ̂Ó˜ ÌÂϤÙ˜ ÛÙËÓ ÚÔÛ¿ıÂÈ· ·Ó·ÛÙÚÔÊ‹˜ Ù˘ ·ÏÏÂÚÁÈ΋˜ ÚԉȿıÂÛ˘ ÔÚÈÛÌ¤ÓˆÓ ·ÙfiÌˆÓ (14). ™Â ¿ÏϘ ÌÂϤÙ˜, ¤Ó· Ì˘ÎÔ‚·ÎÙËÚ›‰ÈÔ, ÙÔ ª.vaccae, ¯ÔÚËÁ‹ıËΠ۠ÌÈÎÚ¤˜ ÔÛfiÙËÙ˜ Ì ÙË ÌÔÚÊ‹ ·ÓÔÛÔıÂڷ›·˜, ÚÈÓ ÙËÓ ¤Ó·ÚÍË Ù˘ ¤Í·ÚÛ˘ Ù˘ ·ÏÏÂÚÁÈ΋˜ ÚÈÓ›Ùȉ·˜ Û ÌÈ· ÚÔÛ¿ıÂÈ· ÂϤÁ¯Ô˘ ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ (16). ∆· ·ÔÙÂϤÛÌ·Ù· ·˘ÙÒÓ ÙˆÓ ÂÚ¢ÓÒÓ Â›Ó·È Û Ôχ ÚÒÈÌÔ ÛÙ¿‰ÈÔ, fï˜ ‰È·Ê·›ÓÂÙ·È fiÙÈ ›Ûˆ˜ Ë ˘fiıÂÛË Ù˘ ˘ÁÈÂÈÓ‹˜ ‰ËÌÈÔ˘ÚÁ‹ÛÂÈ Ó¤Â˜ ÛÙÚ·ÙËÁÈΤ˜ ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ ·Ú·ÙËÚÔ‡ÌÂÓ˘ ·‡ÍËÛ˘ ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ·ı‹ÛˆÓ.
™˘Ì¤Ú·ÛÌ· ∆· ÎÏ·ÛÈο ·ÏÏÂÚÁÈο ÓÔÛ‹Ì·Ù· ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·‡ÍËÛË Ô˘ ηٷ‰ÂÈÎÓ‡ÂÙ·È ·fi ÔÏ˘ÎÂÓÙÚÈΤ˜ ÌÂϤÙ˜ Ô˘ ‰ÈÂÍ¿ÁÔÓÙ·È Û ·ÁÎfiÛÌÈÔ Â›Â‰Ô. √È ·Ó·Ù˘Á̤Ó˜ ¯ÒÚ˜ ‚Ú›ÛÎÔÓÙ·È ÛÙËÓ ÎÔÚ˘Ê‹ ÙˆÓ ·˘ÍËÙÈÎÒÓ Ù¿ÛˆÓ, ·ÏÏ¿ Î·È ÔÈ ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜ Ô˘ ·ÎÔÏÔ˘ıÔ‡Ó ÙÔ ‰˘ÙÈÎfi ÌÔÓÙ¤ÏÔ ˙ˆ‹˜ ·ÎÔÏÔ˘ıÔ‡Ó Ì ÛËÌ·ÓÙÈο ÔÛÔÛÙ¿. ¢È·ÊÔÚ¤˜ ÛÙ· ÔÛÔÛÙ¿ ÂΉ‹ÏˆÛ˘ ‰ÂÓ ·Ú·ÙËÚÔ‡ÓÙ·È ÌfiÓÔ ÛÙ· ·È‰È¿ ·Ó¿ÌÂÛ· ÛÙȘ ‰ÂηÂٛ˜. ∞‡ÍËÛË ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ·ı‹ÛÂˆÓ ÛÙËÓ ÂÔ¯‹ Ì·˜ ·Ú·ÙËÚÂ›Ù·È Î·È ÛÙÔÓ ÂÓ‹ÏÈÎÔ ÏËı˘ÛÌfi. ∆Ô ¿ÏÏÔ ÛËÌ·ÓÙÈÎfi ¯·Ú·ÎÙËÚÈÛÙÈÎfi ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ ÛÙȘ ̤Ú˜ Ì·˜ Â›Ó·È Ë “ÔÏ˘Û˘ÛÙËÌ·ÙÈÎfiÙËÙ·” Ì ÙËÓ ÔÔ›· ÂΉËÏÒÓÔÓÙ·È. √È ·Èٛ˜ Ô˘ ¤¯Ô˘Ó Ô‰ËÁ‹ÛÂÈ ÛÙËÓ ·‡ÍËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ·ı‹ÛÂˆÓ ÛÙȘ ̤Ú˜ Ì·˜ Â›Ó·È ·ÎfiÌ· ·ÓÙÈΛÌÂÓÔ ¤Ú¢ӷ˜. ∏ “˘fiıÂÛË ˘ÁÈÂÈÓ‹˜” ¯ÚËÛÈÌÔÔÈÂ›Ù·È Â˘Ú¤ˆ˜ ˆ˜ ÌÔÓÙ¤ÏÔ ÁÈ· ÙËÓ ÂÚ·ÈÙ¤Úˆ ÌÂϤÙË ÙÔ˘˜ Û ÂȉËÌÈÔÏÔÁÈÎfi Î·È ·ÓÔÛÔÏÔÁÈÎfi ›‰Ô, Ì ÂӉȷʤÚÔÓÙ· ·ÔÙÂϤÛÌ·Ù· ˆ˜ ÚÔ˜ ÙÔÓ ÚfiÏÔ ÙˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ, ÙˆÓ ‰È·ÊfiÚˆÓ ˘Ô‰Ô¯¤ˆÓ Î·È ÙÔ˘ ÌÈÎÚÔ‚È·ÎÔ‡ ÊÔÚÙ›Ô˘, ÛÙÔ ÔÔ›Ô ÂÎÙ›ıÂÓÙ·È ‰È¿ÊÔÚÔÈ ÏËı˘ÛÌÔ›. ∂›Ó·È ÛËÌ·ÓÙÈÎfi ÔÈ ·ÛıÂÓ›˜ Ì ·ÏÏÂÚÁ›Â˜ Ó· ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È ·fi È·ÙÚÔ‡˜ ÂÍÂȉÈÎÂ˘Ì¤ÓÔ˘˜ ÛÙËÓ ·Ú·ÎÔÏÔ‡ıËÛ‹ ÙÔ˘˜, ÌÈ·˜ Î·È ÛÙȘ ̤Ú˜ Ì·˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Û˘Ó‹ıˆ˜ ‚·Ú‡ÙÂÚ˜ ÂΉËÏÒÛÂȘ, Û Paediatriki 2007;70:266-271
ÔÏÏ¿ Û˘ÛÙ‹Ì·Ù·. ∂Ô̤ӈ˜, ¯ÚÂÈ¿˙ÔÓÙ·È ÚÔÛÂÎÙÈ΋ ‰ÈÂÚ‡ÓËÛË Î·È ÂÍ·ÙÔÌÈÎÂ˘Ì¤ÓË ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Royal College of Physicians. Allergy: the unmet need: A blueprint for better patient care. Report of a working party. London:RCP, 2003. 2. Wüthrich B. Epidemiology of the allergic diseases: are they really on the increase? Int Arch Allergy Appl Immunol 1989;90 (Suppl 3):S3-S10. 3. Strachan DP. Hay fever, hygiene and household size. BMJ 1989;299:1259-1260. 4. Nakagomi T, Itaya H, Tominaga T, Yamaki M, Hisamatsu S, Nakagomi O. Is atopy increasing? Lancet 1994;343: 121-122. 5. Burr ML, Butland BK, King S, Vaughan-Williams E. Changes in asthma prevalence: two surveys 15 years apart. Arch Dis Child, 1989;64:1452-1456. 6. von Mutius E. The rising trends in asthma and allergic disease. Clin Exp Allergy 1998;28 (5 suppl):S45-S49. 7. The International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis and atopic eczema: ISAAC. Lancet 1998;351: 1220-1221. 8. Law M, Morris JK, Wald N, Luczynska C, Burney P. Changes in atopy over a quarter of a century, based on cross sectional data at three time periods. BMJ 2005;330: 1187-1188. 9. Isolauri E, Huure A, Salminen S, Impivaara O. The allergy epidemic extends beyond the past few decades. Clin Exp Allergy 2004;34:1007-1010. 10. Romagnani S. The increased prevalence of allergy and the hygiene hypothesis: missing immune deviation, reduced immune suppression, or both? Immunology 2004;112: 352-363. 11. Schmidt WP. Model of the epidemic of childhood atopy. Med Sci Monit 2004;10:HY5-9. 12. Linneberg A, Nielsen NH, Madsen F, FrÔ/lund L, Dirksen A, JÔ/rgensen T. Is the increase in allergic respiratory disease caused by a cohort effect? Clin Exp Allergy 2002;32: 1702-1705. 13. Zollner IK, Weiland SK, Piechotowski I, Gabrio T, von Mutius E, Link B, et al. No increase in the prevalence of asthma, allergies, and atopic sensitisation among children in Germany:1992-2001. Thorax 2005;60:545-548. 14. Falcone FH, Pritchard DI. Parasite role reversal: worms on trial. Trends Parasitol 2005;21:157-160. 15. Linneberg A. Hypothesis: urbanization and the allergy epidemic-a reverse case of immunotherapy? Allergy 2005; 60:538-539. 16. Matricaldi PM, Bonini S. Mimicking microbial ‘education’ of the immune system: a strategy to revert the epidemic trend of atopy and allergic asthma? Respir Res 2000;1: 129-132. 17. Ewan PW, Durham SR. NHS allergy services in the UK: proposals to improve allergy care. Clin Med 2002;2: 122-127. 18. Royal College of Physicians. Containing the allergy epidemic: summary and recommendations of a new report
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·271
271
∂ȉËÌÈÔÏÔÁ›· ·ÏÏÂÚÁÈÎÒÓ ·ı‹ÛˆÓ
from the Royal College of Physicians. Clin Exp Allergy 2004;34:515-517. 19. ∫alliomaki M, Salminen S, Arvilommi H, Kero P, Koskinen P, Isolauri E. Probiotics in primary prevention of atopic disease: a randomised placebo-controlled trial. Lancet 2001; 357(9262):1076-1079. 20. Asher MI, Montefort S, Björkstén B, Lai CK, Strachan DP, Weiland SK, et al. Worldwide time trends in the prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and eczema in childhood: ISAAC Phases One and Three
repeat multicountry cross-sectional surveys. Lancet 2006; 368:733-743. 21. Anthracopoulos ªµ, Liolios ∂, Panagiotakos DB, Triantou ∫, Priftis ∫¡. Prevalence of asthma among schoolchildren in Patras, Greece: four questionnaire surveys during 19782003. Arch Dis Child 2007;92;209-212. 22. Russel G. The childhood asthma epidemic. Thorax 2006; 61:276-278. 23. ∂der W, Ege MJ, von Mutius E. The asthma epidemic. N Engl J Med 2006;355:2226-2235.
Quiz 1. À„ËÏfiÙÂÚÔ˜ ÂÙ‹ÛÈÔ˜ ÂÈÔÏ·ÛÌfi˜ Û ÙÔ˘Ï¿¯ÈÛÙÔÓ ‰‡Ô ·ÙÔÈΤ˜ ·ı‹ÛÂȘ Ù·˘Ùfi¯ÚÔÓ· Û˘Ó·ÓٿٷÈ: ·. ™Â ¯ÒÚ˜ Ù˘ ¡ÔÙÈÔ·Ó·ÙÔÏÈ΋˜ ∞Û›·˜ ‚. ™ÙË ª. µÚÂÙ·Ó›· Á. ™Â ¯ÒÚ˜ Ù˘ ∫ÂÓÙÚÈ΋˜ ∂˘ÚÒ˘ ‰. ™ÙËÓ ∂ÏÏ¿‰· 2. ¶ÔÈ· ·fi ÙȘ ·Ú·Î¿Ùˆ ‰È·Ù˘ÒÛÂȘ ‰ÂÓ Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÙ·È ÛÙËÓ “˘fiıÂÛË Ù˘ ˘ÁÈÂÈÓ‹˜”; ·. ∏ Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ·ı‹ÛÂˆÓ ÛÙȘ ̤Ú˜ Ì·˜ ÔÊ›ÏÂÙ·È ÛÙË ‚ÂÏÙ›ˆÛË ÙˆÓ Û˘ÓıËÎÒÓ ˘ÁÈÂÈÓ‹˜ ÛÙÔ ÔÈÎÈ·Îfi ÂÚÈ‚¿ÏÏÔÓ ‚. ∏ ›وÛË Ù˘ ·ÏÏÂÚÁÈ΋˜ ÚÈÓ›Ùȉ·˜ ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· Â›Ó·È ·ÓÙÈÛÙÚfiʈ˜ ·Ó¿ÏÔÁË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ·È‰ÈÒÓ Î·È Ù˘ ÛÂÈÚ¿˜ Á¤ÓÓËÛ˘ Á. ∏ ·‡ÍËÛË ÙˆÓ ·ÏÏÂÚÁÈÒÓ ÔÊ›ÏÂÙ·È ÌÂٷ͇ ¿ÏÏˆÓ Û ÂÚÈ‚·ÏÏÔÓÙÈÎÔ‡˜ Î·È ÎÏÈÌ·ÙÔÏÔÁÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ‰. ∆Ô ·ÛÙÈÎÔÔÈË̤ÓÔ ÌÔÓÙ¤ÏÔ ˙ˆ‹˜ Î·È ‰È·ÙÚÔÊ‹˜ Û˘Ì‚¿ÏÏÂÈ Â›Û˘ ÛÙËÓ ·‡ÍËÛË ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ·ı‹ÛÂˆÓ 3. ™ÙÔ ÎÏ·ÛÈÎfi ÌÔÓÙ¤ÏÔ “·ÙÔÈ΋˜ ·Ú¤Ï·Û˘” (atopic marching), Ë ·ÏÏËÏÔ˘¯›· ÂÌÊ¿ÓÈÛ˘ ÙˆÓ ·ÙÔÈÎÒÓ ·ı‹ÛÂˆÓ Â›Ó·È: ·. ∆ÚÔÊÈΤ˜ ·ÏÏÂÚÁ›Â˜-¤Î˙ÂÌ·-¿ÛıÌ·-·ÏÏÂÚÁÈ΋ ÚÈÓ›Ùȉ· ‚. ŒÎ˙ÂÌ·-ÙÚÔÊÈΤ˜ ·ÏÏÂÚÁ›Â˜-¿ÛıÌ·-·ÏÏÂÚÁÈ΋ ÚÈÓ›Ùȉ· Á. ŒÎ˙ÂÌ·-¿ÛıÌ·-ÙÚÔÊÈΤ˜ ·ÏÏÂÚÁ›Â˜-·ÏÏÂÚÁÈ΋ ÚÈÓ›Ùȉ· ‰. ∞ÏÏÂÚÁÈ΋ ÚÈÓ›Ùȉ·-¤Î˙ÂÌ·-¿ÛıÌ·-ÙÚÔÊÈΤ˜ ·ÏÏÂÚÁ›Â˜ 4. √È ·Ú·Î¿Ùˆ ΢ÙÙ·ÚÔΛÓ˜ ¯·Ú·ÎÙËÚ›˙Ô˘Ó ÙËÓ Ù‡Ô˘ Th2 ·ÓÔÛÔÏÔÁÈ΋ ·¿ÓÙËÛË Ô˘ ¢ı‡ÓÂÙ·È ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ·ÏÏÂÚÁÈÎÒÓ ÂΉËÏÒÛˆÓ, ÂÎÙfi˜ ·fi ÙËÓ: ·. INF- Á ‚. IL-4 Á. IL-5 ‰. IL-13 5. ∞‡ÍËÛË ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ·ı‹ÛÂˆÓ ·Ú·ÙËÚ›ٷÈ: ·. ™Â ¯ÒÚ˜ Ô˘ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ˘ÈÔı¤ÙËÛ·Ó ÙÔ “‰˘ÙÈÎfi” ÌÔÓÙ¤ÏÔ ˙ˆ‹˜ ‚. ™Â ÌÂÁ·Ï‡ÙÂÚÔ ‚·ıÌfi ÛÙÔ˘˜ ÓÂfiÙÂÚÔ˘˜ Û ۯ¤ÛË Ì ÙÔ˘˜ ÈÔ ËÏÈÎȈ̤ÓÔ˘˜ Á. ™Â ·ÓıÚÒÔ˘˜ ÌÂÁ·Ï‡ÙÂÚ˘ ËÏÈΛ·˜ Û ۇÁÎÚÈÛË Ì ÙȘ ÚÔ¯ˆÚË̤Ó˜ ËÏÈ˘ Û ÚÔËÁÔ‡ÌÂÓ˜ ‰ÂηÂٛ˜ ‰. ™Â fiϘ ÙȘ ·Ú·¿Óˆ ÂÚÈÙÒÛÂȘ
√È ÛˆÛÙ¤˜ ··ÓÙ‹ÛÂȘ ÛÙË ÛÂÏ›‰· 292 ¶·È‰È·ÙÚÈ΋ 2007;70:266-271
Pediatri July-Aug 07
09-07-07
272
1 ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌÈ·ÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ ∞ÏÂÍ·Ó‰ÚÔ‡ÔÏ˘ 2 ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞ÈÌ·ÙÔÏÔÁ›·˜ - √ÁÎÔÏÔÁ›·˜, ¶·ÓÂÈÛÙËÌÈ·ÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ ∏Ú·ÎÏ›Ԣ 3 ∫ÏÈÓÈ΋ ¶·ıÔÏÔÁÈ΋˜ √ÁÎÔÏÔÁ›·˜, ¶·ÓÂÈÛÙËÌÈ·ÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ ∞ÏÂÍ·Ó‰ÚÔ‡ÔÏ˘ AÏÏËÏÔÁÚ·Ê›·: ¶·Ó·ÁÈÒÙ˘ §¿ÈÔ˜ panoslaios@gmail.com ª·˘ÚÔÎÔÚ‰¿ÙÔ˘ 15 ∆.∫. 681 00, ∞ÏÂÍ·Ó‰ÚÔ‡ÔÏË
17:08
™ÂÏ›‰·272
∞¡∞™∫√¶∏™∏
REVIEW ARTICLE
ªËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜: ÚÔÛٷهÂÈ ÙÂÏÈο Î·È ·fi ÓÂÔϷۛ˜; ¢. ª·Ùı·›Ô˜3, ∂. ª·ÓÙ·‰¿Î˘2, ¶. §¿ÈÔ˜1, ™. ∫·ÎÔχÚ˘3, ∞. ÷Ù˙ËÌȯ·‹Ï1 ¶ÂÚ›ÏË„Ë: ∆Ô ÌËÙÚÈÎfi Á¿Ï· ÂÚȤ¯ÂÈ Ô˘Û›Â˜ Ô˘ ÚÔÛÙ·ÙÂ‡Ô˘Ó ÙÔ ‚Ú¤ÊÔ˜ ·fi ÏÔÈÌÒÍÂȘ Î·È ‚ÔËıÔ‡Ó ÛÙËÓ ˆÚ›Ì·ÓÛË ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜. ∂Âȉ‹ Ë √§§, Ë Û˘¯ÓfiÙÂÚË ÓÂÔÏ·Û›· ÛÙ· ·È‰È¿ ÌÔÚ› Ó· Û¯ÂÙ›˙ÂÙ·È Ì ηı˘ÛÙÂÚË̤ÓË ¤ÎıÂÛË Û ÎÔÈÓ¤˜ ÏÔÈÌÒÍÂȘ, ˘¿Ú¯ÂÈ Ë ¿Ô„Ë fiÙÈ Ô ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ ı· ÌÔÚÔ‡Û ӷ ÌÂÙ·‚¿ÏÂÈ ÙËÓ Â›ÙˆÛ‹ Ù˘ ̤ۈ ÚÔʇϷ͢ ·fi ÎÔÈÓ¤˜ ÏÔÈÌÒÍÂȘ. ¶ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰ÈÂÚ¢ӋÛÔ˘Ì ·Ó fiÓÙˆ˜ Ô ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ ·ÛΛ ÚÔÛٷ٢ÙÈ΋ ›‰Ú·ÛË ¤Ó·ÓÙÈ Ù˘ √§§, ·ÏÏ¿ Î·È ¿ÏÏˆÓ ÓÂÔÏ·ÛÈÒÓ Ù˘ ·È‰È΋˜ Î·È ÂÓ‹ÏÈ΢ ˙ˆ‹˜, ÚÔ‚‹Î·Ì Û ·Ó·ÛÎfiËÛË ÌÂÏÂÙÒÓ Ô˘ ‰ËÌÔÛȇÙËÎ·Ó ÛÙËÓ Medline ÌÂٷ͇ 1948-2006, ηıÒ˜ Î·È ÙˆÓ ‚È‚ÏÈÔÁÚ·ÊÈÎÒÓ ÙÔ˘˜ ·Ó·ÊÔÚÒÓ. ∏ Û˘ÓÙÚÈÙÈ΋ ÏÂÈÔ„ËÊ›· ÙˆÓ Û¯ÂÙÈÎÒÓ ÌÂÏÂÙÒÓ Â›Ó·È ÌÂϤÙ˜ ·Ú·Ù‹ÚËÛ˘ ·ÛıÂÓÒÓ-Ì·ÚÙ‡ÚˆÓ, ·ÚÎÂÙ¤˜ Ì ÌÈÎÚfi ·ÚÈıÌfi ·ÛıÂÓÒÓ, ÂÓÒ Û ÔÏϤ˜ ‰ÂÓ ˘¿Ú¯ÂÈ Â·Ú΋˜ ¤ÏÂÁ¯Ô˜ ÁÈ· Û˘Ó˘¿Ú¯Ô˘Û˜ ÌÂÙ·‚ÏËÙ¤˜. ¢‡Ô ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÌÂÙ··Ó·Ï‡ÛÂȘ ÙˆÓ ·Ú·¿Óˆ ÌÂÏÂÙÒÓ ·Ó·Ê¤ÚÔ˘Ó fiÙÈ Ë ·‡ÍËÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ÌËÙ¤ÚˆÓ Ô˘ ıËÏ¿˙Ô˘Ó ı· ÌÔÚÔ‡Û ÛÙËÓ Î·Ï‡ÙÂÚË ÂÚ›ÙˆÛË Ó· ÌÂÈÒÛÂÈ ÙÔÓ ·ÚÈıÌfi Ó¤ˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ ÔÍ›·˜ Ï¢¯·ÈÌ›·˜ ‹ ÏÂÌÊÒÌ·ÙÔ˜ ÛÙ· ·È‰È¿ ηٿ 5%, ÂÓÒ ıÂÙÈ΋ ›‰Ú·ÛË ÛÙÔ˘˜ ÂÓ‹ÏÈΘ ‚Ú¤ıËΠÌfiÓÔ ÁÈ· ÙÔÓ ÚÔÂÌÌËÓÔ·˘ÛÈ·Îfi ηÚΛÓÔ ÙÔ˘ Ì·ÛÙÔ‡. ™˘ÌÂÚ·ÛÌ·ÙÈο, ··ÈÙÔ‡ÓÙ·È Î·Ï‡ÙÂÚ· ۯ‰ȷṲ̂Ó˜, Ì·ÎÚÔ¯ÚfiÓȘ, ÚÔÔÙÈΤ˜ ÌÂϤÙ˜ ÛÙÔ Ì¤ÏÏÔÓ, Ô˘ Ó· Ï·Ì‚¿ÓÔ˘Ó ˘fi„Ë ‰È¿ÊÔÚÔ˘˜ ÂÈ̤ÚÔ˘˜ ·Ú¿ÁÔÓÙ˜, ÒÛÙ ӷ ‰È¢ÎÚÈÓÈÛÙ› Ï‹Úˆ˜ Ù˘¯fiÓ Â›‰Ú·ÛË ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ÛÙËÓ ·Ó¿Ù˘ÍË ÓÂÔÏ·ÛÈÒÓ. ∞Ó Ù· ·ÔÙÂϤÛÌ·Ù· ·fi ÙȘ ÌÂϤÙ˜ ·˘Ù¤˜ Â›Ó·È ıÂÙÈο, ÔÈ ·È‰›·ÙÚÔÈ ·ÏÏ¿ Î·È Ë ÎÔÈÓˆÓ›· ÁÂÓÈÎfiÙÂÚ· ı· ¤¯Ô˘Ó ¤Ó· ·ÎfiÌ· Âȯ›ÚËÌ· ÁÈ· Ó· ÚÔˆı‹ÛÔ˘Ó ÂÓÂÚÁ¿ ÙÔÓ ÌËÙÚÈÎfi ıËÏ·ÛÌfi.
§¤ÍÂȘ ÎÏÂȉȿ: ªËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜, ηÚΛÓÔ˜, ·ÓıÚÒÈÓÔ Á¿Ï·, Ï¢¯·ÈÌ›·, ·Ó·ÛÎfiËÛË.
1 Paediatric Department, Alexandroupoli University Hospital 2 Paediatric Haematology Oncology Department, Herakleion University Hospital 3 Internal Oncology Department, Alexandroupoli University Hospital Correspondence: Panagiotis Laios panoslaios@gmail.com 15, Mavrokordatou St. 681 00, Alexandroupoli, Greece
µreastfeeding: does it also protect against neoplasms? D. Matthaios3, E. Mantadakis2, P.Laios1, S. Kakolyris3, A. Chatzimihail1 Abstract: Human milk contains substances that protect infants against infections and help the maturation of the immune system. Since acute lymphatic leukaemia (ALL), the most common paediatric neoplasm, has been related to delayed exposure to common infections, the opinion has been expressed that breastfeeding could modify its incidence by offering protection against these infections. In order to clarify whether breastfeeding is indeed protective against ALL and other forms of neoplasia in children and adults, a review was made of Medline-indexed papers published between 1948 and 2006, and their references. The vast majority of relevant studies were observational case-control studies, several of which concerned small numbers of patients, and many did not correct adequately for confounding variables. Two published metanalyses of these studies suggest that increasing the number of women who breastfeed could at best decrease the incidence of acute leukaemia and lymphoma in children by 5%, while a protective role for adults was seen only for premenopausal breast cancer. In conclusion, better-planned long-term, prospective studies are required, with control for confounding variables, in order to define the role, if any, of breastfeeding in the development of malignancies. If these studies provide positive indications of a protective role, then paediatricians and society will have another reason for actively promoting breastfeeding.
Key words: Breastfeeding, cancer, human milk, leukaemia, review.
™˘ÓÙÔÌÔÁڷʛ˜ ALL HAMLET √§§ ∫¡™
Acute Lymphoblastic Leukemia Human Alpha-Lactalbumin Made LEthal to Tumor cells √Í›· §ÂÌÊÔ‚Ï·ÛÙÈ΋ §Â˘¯·ÈÌ›· ∫ÂÓÙÚÈÎfi ¡Â˘ÚÈÎfi ™‡ÛÙËÌ·
∂ÈÛ·ÁˆÁ‹ ∏ ¢ÓÔ˚΋ ›‰Ú·ÛË ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·Paediatriki 2007;70:272-277
ÛÌÔ‡ ÛÙËÓ ÚfiÏË„Ë Ù˘ ÂÌÊ¿ÓÈÛ˘ ÓÔÛËÌ¿ÙˆÓ ÙfiÛÔ ÛÙË ‚ÚÂÊÈ΋ fiÛÔ Î·È ÛÙËÓ ·È‰È΋ ËÏÈΛ· ¤¯ÂÈ ·Ô‰Âȯı› ·fi ‰È¿ÊÔÚ˜ ÌÂϤÙ˜ (1). O ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ Â›Ó·È ·Ô‰Â‰ÂÈÁ̤ÓÔ fiÙÈ ÚÔÛٷهÂÈ ·fi ÏÔÈÌÒÍÂȘ ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡, ˆÙ›Ùȉ˜, ÏÔÈÌÒÍÂȘ ÙÔ˘ ηÙÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡, ÓÂÎÚˆÙÈ΋ ÂÓÙÂÚÔÎÔÏ›Ùȉ·, ¤Î˙ÂÌ·, ‰ÈÂÈÛ‰˘ÙÈΤ˜ ÏÔÈÌÒÍÂȘ (ÌÈÎÚÔ‚È·È̛˜,
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·273
273
ªËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ Î·È ÓÂÔϷۛ˜
ÌËÓÈÁÁ›Ùȉ˜) Î·È Ô˘ÚÔÏÔÈÌÒÍÂȘ (2-10). ∆· ÓÂÔÁÓ¿ Ô˘ ıËÏ¿˙Ô˘Ó ÂÌÊ·Ó›˙Ô˘Ó Â›Û˘ ·˘ÍË̤ÓË ·ÓÙÈۈ̷ÙÈ΋ ·¿ÓÙËÛË Û ÂÌ‚fiÏÈ· Î·È ÌÂÁ·Ï‡ÙÂÚÔ ı‡ÌÔ ·‰¤Ó· (11,12), ÂÓÒ Ù· ‚Ú¤ÊË Ô˘ ıËÏ¿˙Ô˘Ó ÁÈ· ‰È¿ÛÙËÌ· ÌÂÁ·Ï‡ÙÂÚÔ ·fi 6 Ì‹Ó˜ ¤¯Ô˘Ó ÌÈÎÚfiÙÂÚË ıÓËÙfiÙËÙ· Î·È ıÓËÛÈÌfiÙËÙ· Û ۯ¤ÛË Ì ·˘Ù¿ Ô˘ ‰ÂÓ ıËÏ¿˙Ô˘Ó (13). ∆Ô ÌËÙÚÈÎfi Á¿Ï· ·Ú¤¯ÂÈ ÚÔÛÙ·Û›· ¤Ó·ÓÙÈ ÙˆÓ ÌÈÎÚÔ‚È·ÎÒÓ ÏÔÈÌÒ͈Ó, ̤ۈ ÙˆÓ ·ÓÙÈۈ̿وÓ, ÏÈȉ›ˆÓ, ÁÏ˘ÎÔÚˆÙÂ˚ÓÒÓ Î·È ¿ÏÏˆÓ ÚˆÙÂ˚ÓÒÓ Ô˘ ÂÚȤ¯ÂÈ (14-16). ¶·Ú¿ÏÏËÏ·, ÛÙÔ ÌËÙÚÈÎfi Á¿Ï· ¤¯Ô˘Ó ‚ÚÂı› ÔÚÌfiÓ˜, ΢ÙÙ·ÚÔΛÓ˜ Î·È ¤Ó˙˘Ì· Ô˘ ‰È·‰Ú·Ì·Ù›˙Ô˘Ó ÛËÌ·ÓÙÈÎfi ·ÓÔÛÔÙÚÔÔÔÈËÙÈÎfi ÚfiÏÔ ÛÙËÓ ˆÚ›Ì·ÓÛË ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÙÔ˘ ‚Ú¤ÊÔ˘˜ (17). ™‡Ìʈӷ Ì ̛· ÌÂϤÙË, ÙÔ ÌËÙÚÈÎfi Á¿Ï· ÂÚȤ¯ÂÈ Ï‹ıÔ˜ ·Ú·ÁfiÓÙˆÓ, ÔÏÏÔ› ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ ‰ÂÓ ¤¯Ô˘Ó ·ÎfiÌ· Ù·˘ÙÔÔÈËı› Î·È ÔÈ ÔÔ›ÔÈ ‰ÚÔ˘Ó Û ÂÏ¿¯ÈÛÙ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ Î·È Û˘¯Ó¿ Û˘ÓÂÚÁÈο (5). ∏ ‰ÈÂÚ‡ÓËÛË Ô˘ÛÈÒÓ, fiˆ˜ ÙÔ Û‡ÌÏÂÁÌ· HAMLET, Ô˘ ÚÔ·ÙÂÈ ·fi ÙÔ ÌËÙÚÈÎfi Á¿Ï· Î·È ¤¯ÂÈ È‰ÈfiÙËÙ˜ ÂÈÏÂÎÙÈ΋˜ ηٷÛÙÚÔÊ‹˜ ÙˆÓ Î·ÚÎÈÓÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Ì¤Ûˆ ·ÁˆÁ‹˜ Ù˘ ·fiÙˆÛ˘, ·ÔÙÂÏ› ·ÓÙÈΛÌÂÓÔ ÌÂϤÙ˘ (18-20). ∆Ô ›‰ÈÔ ÈÛ¯‡ÂÈ Î·È ÁÈ· ÙËÓ Â›‰Ú·ÛË ÙÔ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÙÔ˜ ÛÙËÓ ÚfiÏË„Ë ¯ÚfiÓÈˆÓ ÓÔÛËÌ¿ÙˆÓ, fiˆ˜ Ë ·¯˘Û·ÚΛ· Î·È Ô Û·Î¯·Ú҉˘ ‰È·‚‹Ù˘, ÙfiÛÔ ÛÙ· ·È‰È¿ fiÛÔ Î·È ÛÙÔ˘˜ ÂÓ‹ÏÈΘ (1). ∆ÂÏÂ˘Ù·›·, Ô ÚfiÏÔ˜ ÙÔ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÙÔ˜ ÛÙËÓ ÚfiÏË„Ë ‰È·ÊfiÚˆÓ ÌÔÚÊÒÓ ÓÂÔÏ·Û›·˜ ·ÔÙÂÏ› ·ÓÙÈΛÌÂÓÔ ÌÂϤÙ˘. ™ÙËÓ ·ÚÔ‡Û· Û‡ÓÙÔÌË ·Ó·ÛÎfiËÛË ‰ÈÂÚ¢ÓÒÓÙ·È ÔÈ Èı·Ó¤˜ ÂȉڿÛÂȘ ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ÛÙËÓ ÚfiÏË„Ë ‰È·ÊfiÚˆÓ ÓÂÔÏ·ÛÈÒÓ ÙfiÛÔ ÛÙËÓ ·È‰È΋ fiÛÔ Î·È ÛÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹. °È· ÙÔÓ ÛÎÔfi ·˘Ùfi, Ú·ÁÌ·ÙÔÔÈ‹ıËΠ·Ó·ÛÎfiËÛË ÌÂÏÂÙÒÓ Ô˘ ‰ËÌÔÛȇÙËÎ·Ó ÛÙËÓ Medline ÌÂٷ͇ 1948-2006 Î·È ÙˆÓ ·Ó·ÊÔÚÒÓ ÙÔ˘˜. ™˘ÓÔÏÈο, ¤ÁÈÓ ·Ó·ÛÎfiËÛË 41 ÂÚÁ·ÛÈÒÓ Ô˘ Ú·ÁÌ·Ù‡ÔÓÙ·È ÙË Û¯¤ÛË ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ Î·È ÂÌÊ¿ÓÈÛ˘ ÓÂÔÏ·ÛÈÒÓ, ÔÈ 26 Û ·È‰È¿ Î·È ÔÈ 15 Û ÂÓ‹ÏÈΘ (21-60). √È ÂÚÁ·Û›Â˜ ·˘Ù¤˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Û ‰‡Ô ÌÂٷӷχÛÂȘ Ô˘ ÔÏÔÎÏËÚÒıËÎ·Ó ·fi ÙËÓ ›‰È· ÔÌ¿‰· ÂÚ¢ÓËÙÒÓ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ÙÔ˘ Bristol Î·È ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ St. George ÙÔ˘ §ÔÓ‰›ÓÔ˘ (61,62). ¶ÚÈÓ ·Ó·ÊÂÚıÔ‡ÌÂ, fï˜, ÛÙ· ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ, ·˜ Û˘˙ËÙ‹ÛÔ˘Ì ÂÓ Ù¿¯ÂÈ ÙȘ ·fi„ÂȘ ÁÈ· ÙËÓ ·ıÔÁ¤ÓÂÛË Ù˘ √§§, Ù˘ Û˘¯ÓfiÙÂÚ˘ ·È‰È·ÙÚÈ΋˜ ÓÂÔÏ·Û›·˜.
∞ÈÙÈÔ·ıÔÁ¤ÓÂÛË ·È‰ÈÎÒÓ Ï¢¯·ÈÌÈÒÓ ∞Ó Î·È Ù· ·›ÙÈ· Ù˘ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜ ÌÂÏÂÙÔ‡ÓÙ·È ¿Óˆ ·fi ÌÈÛfi ·ÈÒÓ·, ‰ÂÓ ¤¯Ô˘Ó ·ÎfiÌ· ‰È¢ÎÚÈÓÈÛÙ›. ∂›Ó·È fï˜ ۷ʤ˜ fiÙÈ Ë ·È‰È΋ Ï¢-
¯·ÈÌ›· ·ÔÙÂÏ› ÔÏ˘·Ú·ÁÔÓÙÈ΋ ÓfiÛÔ. ∂ȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ ·Ú¤¯Ô˘Ó ¤ÌÌÂÛ˜ ÂӉ›ÍÂȘ fiÙÈ Ë ÔÍ›· Ï¢¯·ÈÌ›· ÙˆÓ ·È‰ÈÒÓ ¤¯ÂÈ ÂÌ‚Ú˘˚΋ ÚԤϢÛË, ·ÚfiÏÔ Ô˘ Ì›· Ù¤ÙÔÈ· Û˘Û¯¤ÙÈÛË Â›Ó·È ÈÔ ÂÌÊ·Ó‹˜ ÁÈ· ÙËÓ ÔÍ›· Ì˘ÂÏÔÁÂÓ‹ Ï¢¯·ÈÌ›· ÙˆÓ ‚ÚÂÊÒÓ ·Ú¿ ÁÈ· ÙËÓ √§§ ÙˆÓ ‚ÚÂÊÒÓ ‹ ÙˆÓ ·È‰ÈÒÓ. °ÂÓÂÙÈΤ˜ ·ÓˆÌ·Ï›Â˜, fiˆ˜ ÙÔ Û‡Ó‰ÚÔÌÔ Down, ÙÔ Û‡Ó‰ÚÔÌÔ Bloom, Ë ·Ó·ÈÌ›· Fanconi, Ë ·Ù·Í›·-ÙËÏ·ÁÁÂÈÂÎÙ·Û›·, ·ÏÏ¿ Î·È Ë ¤ÎıÂÛË Û ÈÔÓ›˙Ô˘Û· ·ÎÙÈÓÔ‚ÔÏ›·, ·ÎfiÌ· Î·È Î·Ù¿ ÙËÓ ÂÓ‰ÔÌ‹ÙÚÈÔ ˙ˆ‹, ηıÒ˜ Î·È Ë ¯Ú‹ÛË ¯ËÌÈÎÒÓ, Ê·ÚÌ¿ÎˆÓ ‹ ¯ËÌÂÈÔıÂڷ›·˜ Û¯ÂÙ›˙ÔÓÙ·È Ì ·˘ÍË̤ÓË Â›ÙˆÛË ·È‰È΋˜ Ï¢¯·ÈÌ›·˜. ∂ÓÙÔ‡ÙÔȘ, ÙÔ ÔÛÔÛÙfi Ù˘ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜ Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÁÓˆÛÙÔ‡˜ ηÚÎÈÓÔÁfiÓÔ˘˜ ·Ú¿ÁÔÓÙ˜ ‹ ÎÏËÚÔÓÔÌÔ‡ÌÂÓ˜ ÁÂÓÂÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ Â›Ó·È <5% (63). ∏ Èı·Ó‹ Û˘Û¯¤ÙÈÛË ·È‰ÈÎÒÓ Ï¢¯·ÈÌÈÒÓ Ì ÏÔÈÌÒÍÂȘ Î·È ·ÛÙ˘ÊÈÏ›· ·ÔÙÂÏ› ·ÓÙÈΛÌÂÓÔ ÌÂϤÙ˘ ÙÔ˘ Kinlen Â‰Ò Î·È ‰ÂηÂٛ˜ (64-67). ª¿ÏÈÛÙ·, ˘¿Ú¯ÂÈ Ë ¿Ô„Ë fiÙÈ Ù· ˘„ËÏ¿ ÔÛÔÛÙ¿ ıÓËÙfiÙËÙ·˜ ·fi Ï¢¯·È̛˜ ÛÙ· ·È‰È¿ ηٿ ÙȘ ‰ÂηÂٛ˜ ÙÔ˘ 1950 Î·È 1960 ÛÙËÓ ∂ÏÏ¿‰· Î·È ÙËÓ πÙ·Ï›· Û¯ÂÙ›˙ÔÓÙ·Ó Ì ÙËÓ ÂÛˆÙÂÚÈ΋ ÌÂÙ·Ó¿ÛÙ¢ÛË ·fi ·ÁÚÔÙÈΤ˜ Û ·ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ Ô˘ ÂÈÎÚ·ÙÔ‡Û ÙËÓ ÂÚ›Ô‰Ô ÂΛÓË (67). ∆· ‰Â‰Ô̤ӷ ÈÔÁÂÓÔ‡˜ ηÚÎÈÓÔÁ¤ÓÂÛ˘ Î·È Ï¢¯·ÈÌÈÔÁ¤ÓÂÛ˘ ÛÙÔ˘˜ ·ÓıÚÒÔ˘˜ Â›Ó·È ÔÏÏ¿ (68,69), ·ÏÏ¿ ‰ÂÓ Û¯ÂÙ›˙ÔÓÙ·È ¿ÌÂÛ· Ì ÙÔÓ ·È‰ÈÎfi ηÚΛÓÔ, Ì ÂÍ·›ÚÂÛË ÙÔ ÂÓ‰ËÌÈÎÔ‡ Ù‡Ô˘ ϤÌʈ̷ Burkitt Ô˘ Â›Ó·È ÂÍ·ÈÚÂÙÈο Û˘¯Ófi ÛÙËÓ ∞ÊÚÈ΋ Î·È ·Ô‰Â‰ÂÈÁ̤ӷ Û¯ÂÙ›˙ÂÙ·È Ì ÙÔÓ Èfi Epstein Barr (69), ·ÏÏ¿ Î·È ÙÔ Ë·ÙÔ΢ÙÙ·ÚÈÎfi ηÚΛӈ̷ Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙÔÓ Èfi Ù˘ Ë·Ù›Ùȉ·˜ µ (70). ∞ÈÙÈÔÏÔÁÈ΋ Û˘Û¯¤ÙÈÛË ÛÙÔ˘˜ ÂÓ‹ÏÈΘ ˘¿Ú¯ÂÈ Î·È ÌÂٷ͇ ÙÔ˘ ÈÔ‡ Ù˘ Ë·Ù›Ùȉ·˜ C Î·È ÙˆÓ Û¿ÓÈˆÓ ÌË Hodgkin ÏÂÌÊˆÌ¿ÙˆÓ ÙÔ˘ ‹·ÙÔ˜ (71). √ ‚ÚÂÙ·Ófi˜ ·ÓÔÛÔÏfiÁÔ˜ Mel Greaves ‰È·Ù‡ˆÛ ÙËÓ ¿Ô„Ë fiÙÈ Ë ÎÔÈÓ‹ √§§ µ-΢ÙÙ·ÚÈ΋˜ ÚÔ¤Ï¢Û˘, Ë ÈÔ Û˘¯Ó‹ ÌÔÚÊ‹ Ï¢¯·ÈÌ›·˜ ÙˆÓ ·È‰ÈÒÓ, Â›Ó·È ·ÔÙ¤ÏÂÛÌ· Ì›·˜ ·ÓÒÌ·Ï˘ ‹ ηı˘ÛÙÂÚË̤Ó˘ ·¿ÓÙËÛ˘ ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Û ÎÔÈÓ¤˜ ÏÔÈÌÒÍÂȘ Î·È fi¯È ·ÔÙ¤ÏÂÛÌ· Ï¢¯·ÈÌÈÔÁ¤ÓÂÛ˘ ·fi ¤Ó·Ó Û˘ÁÎÂÎÚÈ̤ÓÔ ÏÔÈÌÔÁfiÓÔ ·Ú¿ÁÔÓÙ·, Ô˘ Ô‡Ùˆ˜ ‹ ¿Ïψ˜ Ô˘‰¤ÔÙ ¤¯ÂÈ Ù·˘ÙÔÔÈËı› (63,72-74). ŒÓ· ·Ú¯ÈÎfi Ù˘¯·›Ô Û˘Ì‚¿Ó ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ‰È·›ÚÂÛ˘ ÙˆÓ Úfi‰ÚÔÌˆÓ µ ΢ÙÙ¿ÚˆÓ ÚÈÓ ‹ ÌÂÙ¿ ÙË Á¤ÓÓËÛË ·ÎÔÏÔ˘ıÂ›Ù·È ·fi ¤Ó· ‰Â‡ÙÂÚÔ Û˘Ì‚¿Ó ÛÙÔÓ ÌÂÙ·ÏÏ·Á̤ÓÔ ÎÏÒÓÔ, ˆ˜ ·ÔÙ¤ÏÂÛÌ· ηı˘ÛÙÂÚË̤Ó˘ ‹ ˘ÂÚ‚ÔÏÈο ·ÓÒÌ·Ï˘ ·ÓoÛÔÏÔÁÈ΋˜ ‰È¤ÁÂÚÛ˘ ηٿ ÙËÓ Â͈̋ÙÚÈÔ ˙ˆ‹, ÌÂ Û˘Ó·ÎfiÏÔ˘ıË ÂÌÊ¿ÓÈÛË Ï¢¯·ÈÌ›·˜. ∆Ô ÚfiÙ˘Ô Î·È Ë ¯ÚÔÓÈ΋ ÛÙÈÁÌ‹ ÙˆÓ ÌË ÂȉÈÎÒÓ ÏÔÈÌÒÍÂˆÓ Â›Ó·È Èı·Ófiٷٷ ÔÈ ¶·È‰È·ÙÚÈ΋ 2007;70:272-277
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·274
274
¢. ª·Ùı·›Ô˜ Î·È Û˘Ó.
ϤÔÓ ÛËÌ·ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË Ï¢¯·ÈÌ›·˜. ¶Ú¿ÁÌ·ÙÈ, ÂȉËÌÈÔÏÔÁÈΤ˜ ¤Ú¢Ó˜ ‰È·›ÛÙˆÛ·Ó fiÙÈ ·È‰È¿ ̠Ϣ¯·ÈÌ›· ‰ÂÓ Â›¯·Ó ÂÎÙÂı› ηٿ ÙËÓ ÚÒÈÌË ‚ÚÂÊÈ΋ ËÏÈΛ· Û ÎÔÈÓ¤˜ ÏÔÈÌÒÍÂȘ Û ۯ¤ÛË Ì ÔÌ¿‰· ÂϤÁ¯Ô˘. ∏ ·˘ÍË̤ÓË Â›ÙˆÛË Ù˘ ÓfiÛÔ˘ Û ÂÚÈÛÛfiÙÂÚÔ ·Ó·Ù˘Á̤Ó˜ ÎÔÈӈӛ˜ Û˘Ì‚·‰›˙ÂÈ Ì ÙË ıˆڛ· ·˘Ù‹ (63,72-74). ∏ Û˘ÏÏÔÁ‹ ·›Ì·ÙÔ˜ ÓÂÔÁÓÒÓ Û οÚÙ˜ Guthrie Á›ÓÂÙ·È ·Ú·‰ÔÛȷο ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ÎÏËÚÔÓÔÌÔ‡ÌÂÓˆÓ ‰È·Ù·Ú·¯ÒÓ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡, fiˆ˜ Ë Ê·ÈÓ˘ÏÎÂÙÔÓÔ˘Ú›·, ·ÏÏ¿ Û˘Ì‚¿ÏÏÂÈ Î·È ÛÙË ‰ÈÂÚ‡ÓËÛË ¿ÏÏˆÓ ÁÂÓÂÙÈÎÒÓ ·ÏÏ·ÁÒÓ Ô˘ Û˘Ì‚·›ÓÔ˘Ó Î·Ù¿ ÙËÓ ÂÓ‰ÔÌ‹ÙÚÈÔ ˙ˆ‹. ∏ ÁÂÓÂÙÈ΋ Ù·˘ÙÔÔ›ËÛË Û ٤ÙÔȘ οÚÙ˜ Ù˘ ÎÚ˘ÙÈ΋˜ ÌÂÙ¿ÏÏ·Í˘ TEL-AML1, Ù˘ Û˘¯ÓfiÙÂÚ˘ ›ÎÙËÙ˘ ÌÔÚȷ΋˜ ·ÓˆÌ·Ï›·˜ ·È‰ÈÒÓ Ì √§§, ÂÓÈÛ¯‡ÂÈ ÙËÓ ·Ú·¿Óˆ ıˆڛ· (72,75,76). ¶·ÚfiÏÔ Ô˘ ‰ÂÓ ˘¿Ú¯Ô˘Ó ·ÎfiÌ· ·ÚÎÂÙ¿ ‰Â‰Ô̤ӷ, Â›Ó·È Ôχ Èı·Ófi fiÙÈ Ôχ ÂÚÈÛÛfiÙÂÚ· ÓÂÔÁÓ¿ ʤÚÔ˘Ó ÙË ÌÂÙ¿ÏÏ·ÍË TEL-AML1 ·fi fiÛ· ÙÂÏÈο ı· ·Ó·Ù‡ÍÔ˘Ó ÎÔÈÓ‹ √§§, οÙÈ Ô˘ ÛËÌ·›ÓÂÈ fiÙÈ Ë ÌÂÙ¿ÏÏ·ÍË ·˘Ù‹ ·fi ÌfiÓË Ù˘ ‰ÂÓ ·ÚΛ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË Ï¢¯·ÈÌ›·˜, ·ÏÏ¿ fiÙÈ ¤Ó· ‰Â‡ÙÂÚÔ ÁÂÁÔÓfi˜, Èı·ÓfiÓ Ë ·ÒÏÂÈ· ÙÔ˘ ‰Â‡ÙÂÚÔ˘ ÁÔÓȉ›Ô˘ TEL Â›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË Ù˘ ÎÔÈÓ‹˜ √§§ ÛÙËÓ ·È‰È΋ ËÏÈΛ· (72). ∞Ó Ë ıˆڛ· ÙÔ˘ Greaves Â›Ó·È ÛˆÛÙ‹, ÙfiÙ ÔÙȉ‹ÔÙ ÚÔÛٷهÂÈ ÙÔ ·È‰› ·fi ÎÔÈÓ¤˜ ÏÔÈÌÒÍÂȘ ‹ ‚ÔËı¿ÂÈ ÙË ÛˆÛÙ‹ ˆÚ›Ì·ÓÛË ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ı· ÌÔÚÔ‡Û ӷ ÌÂÈÒÛÂÈ ÙËÓ Â›ÙˆÛË Ù˘ Ï¢¯·ÈÌ›·˜, Ì›·˜ ÓfiÛÔ˘ Ô˘ ηٿ ÙÔÓ Greaves ÌÔÚ› Ó· ·ÔÙÂÏ› ÙÔ Ù›ÌËÌ· Ù˘ ÔÈÎÔÓÔÌÈ΋˜ ·Ó¿Ù˘Í˘ ÙˆÓ ·ÓıÚÒÈÓˆÓ ÎÔÈÓˆÓÈÒÓ (63,72-74). °È· ÙÔ˘˜ ·Ú·¿Óˆ ÏfiÁÔ˘˜ ÂÚÂ˘Ó¿Ù·È Ë ı¤ÛË ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ÛÙËÓ ÚfiÏË„Ë ÓÂÔÏ·ÛÈÒÓ ÙÔ˘ ·ÈÌÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ηıÒ˜ Â›Ó·È ÁÓˆÛÙfi fiÙÈ ÙÔ ÌËÙÚÈÎfi Á¿Ï· ÂÚȤ¯ÂÈ ÔÈΛÏÔ˘˜ ·ÓÙÈÌÈÎÚÔ‚È·ÎÔ‡˜, ·ÓÙÈÊÏÂÁÌÔÓÒ‰ÂȘ Î·È ·ÓÔÛÔÙÚÔÔÔÈËÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ÚÔÛÙ·ÙÂ‡Ô˘Ó ·fi ÏÔÈÌÒÍÂȘ. ∂ȉÈÎfiÙÂÚ·, fiˆ˜ ‹‰Ë ·Ó·Ê¤ÚıËΠÛÙËÓ ÂÈÛ·ÁˆÁ‹, ÙÔ ÌËÙÚÈÎfi Á¿Ï· ÌÔÚ› Ó· ÌÂÈÒÛÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ·Ó¿Ù˘Í˘ ÏÔÈÌÒÍÂˆÓ ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ Î·È ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ηٿ ÙË ÓÂÔÁÓÈ΋ Î·È ÌÂÙ¤ÂÈÙ· ˙ˆ‹ ÙÔ˘ ·È‰ÈÔ‡, ̤ۈ ÌÂÙ·ÊÔÚ¿˜ ÌËÙÚÈÎÒÓ ·ÓÙÈۈ̿وÓ, Ì·ÎÚÔÊ¿ÁˆÓ Î·È ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Ô˘ ˘¿Ú¯Ô˘Ó ηٷگ‹Ó ÛÙÔ ÚˆÙfiÁ·Ï· Î·È ÌÂÙ¤ÂÈÙ· ÛÙÔ ÒÚÈÌÔ ÌËÙÚÈÎfi Á¿Ï·. ∞˜ ‰Ô‡Ì fï˜ ÂÚÈÏËÙÈο Ù· ˘¿Ú¯ÔÓÙ· ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ Û¯ÂÙÈο Ì ÙËÓ Â›‰Ú·ÛË ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ÛÙËÓ ·Ó¿Ù˘ÍË ·È‰È΋˜ Ï¢¯·ÈÌ›·˜, ·ÏÏ¿ Î·È ÁÂÓÈÎfiÙÂÚ· ÓÂÔÏ·ÛÈÒÓ Ù˘ ·È‰È΋˜ Î·È ÂÓ‹ÏÈ΢ ˙ˆ‹˜. Paediatriki 2007;70:272-277
ªËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ Î·È ÓÂÔϷۛ˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ¶ÚÈÓ ÙÔ 2006, ‰ËÌÔÛȇıËÎ·Ó Û˘ÓÔÏÈο 26 ÌÂϤÙ˜ Ô˘ Ú·ÁÌ·Ù‡ÔÓÙ·È ÙËÓ Â›‰Ú·ÛË ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ÛÙËÓ ÂÌÊ¿ÓÈÛË ÓÂÔÏ·ÛÈÒÓ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ Î·È Ô˘ ÂÚȤ¯Ô˘Ó ·Ó·ÏÔÁ›· Èı·ÓÔÙ‹ÙˆÓ (odds ratio) ÛÙË ÛÙ·ÙÈÛÙÈ΋ ÙÔ˘˜ ·Ó¿Ï˘ÛË (21-46). √È ÌÂϤÙ˜ ·˘Ù¤˜ Û˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó Û ̛· ÌÂÙ··Ó¿Ï˘ÛË Ô˘ ¤ÁÈÓ ÙËÓ ›‰È· ¯ÚÔÓÈ¿, ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰Ôı› ·¿ÓÙËÛË ÛÙÔ ÂÚÒÙËÌ· Ù˘ ÂӉ¯fiÌÂÓ˘ ›‰Ú·Û˘ ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ÛÙËÓ ÂÌÊ¿ÓÈÛË ÓÂÔÏ·ÛÈÒÓ Î·Ù¿ ÙËÓ ·È‰È΋ ËÏÈΛ· (61). √È 24 ·fi ·˘Ù¤˜ ‹Ù·Ó ÌÂϤÙ˜ ·Ú·Ù‹ÚËÛ˘ ·ÛıÂÓÒÓ-Ì·ÚÙ‡ÚˆÓ (observational, case-control studies) (21-23,25-28,30-46) Î·È ÌfiÏȘ ‰‡Ô ‹Ù·Ó ÌÂϤÙ˜ ÎÔfiÚÙ˘ (cohort studies) (24,29). ™ÙȘ 6 ÌÂÏÂÙ‹ıËÎÂ Ë Â›‰Ú·ÛË ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ÛÙȘ Ï¢¯·È̛˜ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ (21,27,33,35,37,42), ÛÙȘ 2 ÛÙȘ Ï¢¯·È̛˜ Î·È Ù· ÏÂÌÊÒÌ·Ù· Hodgkin (46) Î·È ÌË Hodgkin (43), ÛÙȘ 5 ÛÙËÓ √§§ ÌfiÓÔ (22,24,31,38, 45), ÛÙȘ 7 ÛÙȘ ·È‰ÈΤ˜ ÓÂÔϷۛ˜ ÁÂÓÈÎfiÙÂÚ· (13,25,28,34,36,39,44), ÂÓÒ Û Í¯ˆÚÈÛÙ¤˜ ÌÂϤÙ˜ ÂÍÂÙ¿ÛÙËÎ·Ó ÙÔ Ó¢ÚÔ‚Ï¿Ûو̷ (30), ÔÈ ÓÂÔϷۛ˜ ÙÔ˘ ∫¡™ (27), ÔÈ fiÁÎÔÈ ·fi ·Ú¯¤ÁÔÓ· ÁÂÓÓËÙÈο ·ÙÙ·Ú· (26), ÔÈ Ó·ÓÈÎÔ› ÔÛÙÈÎÔ› fiÁÎÔÈ (32) Î·È ÙÔ Ï¤Ìʈ̷ Hodgkin (41). √È ÙÚÂȘ ÌÂÁ·Ï‡ÙÂÚ˜ Î·È ÛÙ·ÙÈÛÙÈο ÏËÚ¤ÛÙÂÚ˜ ÌÂϤÙ˜ ‹Ù·Ó ÂΛÓË ÙÔ˘ ·ÌÂÚÈηÓÈÎÔ‡ Children’s Cancer Group Ì >2.500 ·È‰È¿ Ì ηÚΛÓÔ (33), Ë ‚ÚÂÙ·ÓÈ΋ ÌÂϤÙË U∫ Childhood Cancer Ì >3.000 ·È‰È¿ Ì ηÚΛÓÔ (28) Î·È Ù¤ÏÔ˜ Ë ÌÂϤÙË Ù˘ √ÍÊfiډ˘ (Oxford Survey of Childhood Cancers) Ì >3.000 ·È‰È¿ Ì ηÚΛÓÔ (34). ™Â fiϘ ۯ‰fiÓ ÙȘ ÌÂϤÙ˜ ˘‹Ú¯Â ‰ÈfiÚıˆÛË ÁÈ· ÌÂÙ·‚ÏËÙ¤˜, fiˆ˜ Ë ÌËÙÚÈ΋ ËÏÈΛ· Î·È ÙÔ Ê‡ÏÔ, ·ÏÏ¿ ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ Ô ¤ÏÂÁ¯Ô˜ ÁÈ· ÌÂÙ·‚ÏËÙ¤˜ Ô˘ Èı·ÓfiÓ ÂËÚ¿˙Ô˘Ó ÙËÓ Â›ÙˆÛË Î·ÚΛÓÔ˘, fiˆ˜ Ë ÎÔÈÓˆÓÈ΋ Ù¿ÍË, Ë ‰È·ÌÔÓ‹, Ô ‚·ıÌfi˜ ·ÛÙÈÎÔÔ›ËÛ˘, Ë ÌËÙÚÈ΋ Âη›‰Â˘ÛË, ÙÔ ÂÈÛfi‰ËÌ·, ÙÔ Ì¤ÁÂıÔ˜ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ (·ÚÈıÌfi˜ ·È‰ÈÒÓ) Î·È Ë ¤ÎıÂÛË Û ¯ËÌÈο, ηÓfi ‹ ·ÏÎÔfiÏ, Ô›ÎÈÏ Ôχ ·fi ÌÂϤÙË Û ÌÂϤÙË. ∂›Û˘, Ë Ì¤ıÔ‰Ô˜ ÂÎÙ›ÌËÛ˘ ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ Ô›ÎÈÏ ÌÂٷ͇ ηْ ȉ›·Ó Û˘Ó¤ÓÙ¢Í˘ ÙˆÓ ÌËÙ¤ÚˆÓ Ì ÙÔÓ ÂÚ¢ÓËÙ‹ (25,28,29,31,34,35,39,43,44, 46), ÙËÏÂʈÓÈÎÒÓ Û˘ÓÂÓÙ‡ÍÂˆÓ Ì ÙÔÓ ÂÚ¢ÓËÙ‹ (30,41), ·Ó·ÛÎfiËÛ˘ È·ÙÚÈÎÒÓ ÈÛÙÔÚÈÎÒÓ (23,36), Î·È Û˘ÌÏ‹ÚˆÛ˘ ÂÚˆÙËÌ·ÙÔÏÔÁ›ˆÓ Ô˘ Ù·¯˘‰ÚÔÌ‹ıËÎ·Ó ÛÙÔ˘˜ ÁÔÓ›˜ (38,45). ∏ ÌÂÙ··Ó¿Ï˘ÛË ¤‰ÂÈÍ fiÙÈ ·È‰È¿ Ô˘ ı‹Ï·Û·Ó ‰È¤ÙÚ¯·Ó ÌÈÎÚfiÙÂÚÔ Î›Ó‰˘ÓÔ Ó· ·Ó·Ù‡ÍÔ˘Ó √§§ ηٿ 9% (95% fiÚÈ· ÂÌÈÛÙÔÛ‡Ó˘ 2-16%), ϤÌʈ̷ Hodgkin ηٿ 24% (95% fiÚÈ· ÂÌÈÛÙÔÛ‡Ó˘ 3-40%) Î·È Ó¢ÚÔ‚Ï¿Ûو̷ ηٿ 41% (95% fiÚÈ· ÂÌÈÛÙÔÛ‡Ó˘ 22-56%) Ì ÌÈÎÚÔ‡ ‚·ıÌÔ‡ ÂÙÂÚÔÁ¤ÓÂÈ· ·Ó¿ÌÂÛ·
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·275
275
ªËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ Î·È ÓÂÔϷۛ˜
ÛÙȘ ÌÂϤÙ˜ (61). ŸÌˆ˜, fiˆ˜ ‹‰Ë ·Ó·Ê¤ÚıËÎÂ, Ù· ·ÔÙÂϤÛÌ·Ù· ÁÈ· ÙÔ Ï¤Ìʈ̷ Hodgkin Î·È ÙÔ Ó¢ÚÔ‚Ï¿Ûو̷ ÚÔ¤Ú¯ÔÓÙ·Ó ·fi ‰‡Ô ÌfiÓÔ ÌÂϤÙ˜ (41,30), οÙÈ Ô˘ ÛËÌ·›ÓÂÈ fiÙÈ Ë Û˘Û¯¤ÙÈÛË ·˘Ù‹ Ú¤ÂÈ Ó· ÂȂ‚·Èˆı› ÛÙÔ Ì¤ÏÏÔÓ Î·È ·fi ¿ÏϘ ÂÚÁ·Û›Â˜. ∫·Ì›· ›‰Ú·ÛË ‰ÂÓ Ê¿ÓËΠӷ ¤¯ÂÈ Ô ıËÏ·ÛÌfi˜ ÛÙËÓ ·Ó¿Ù˘ÍË ÔÍ›·˜ Ì˘ÂÏÔÁÂÓÔ‡˜ Ï¢¯·ÈÌ›·˜, ÓÂÔÏ·ÛÈÒÓ ÙÔ˘ ∫¡™, fiÁÎˆÓ ·fi ·Ú¯¤ÁÔÓ· ÁÂÓÓËÙÈο ·ÙÙ·Ú· Î·È ÔÛÙÈÎÒÓ ‹ ¿ÏÏˆÓ Û˘Ì·ÁÒÓ fiÁΈÓ. ∏ ÂÎÙ›ÌËÛË ÙˆÓ ‚ÚÂÙ·ÓÒÓ ÂÚ¢ÓËÙÒÓ ‹Ù·Ó fiÙÈ Ë ·‡ÍËÛË ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡, ‰ËÏ·‰‹ ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ÌËÙ¤ÚˆÓ Ô˘ ıËÏ¿˙Ô˘Ó ‹ ¿Ïψ˜ ÙÔ˘ ÂÈÔÏ·ÛÌÔ‡ ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ·fi 50% Û 100% ı· ÌÔÚÔ‡Û ÛÙËÓ Î·Ï‡ÙÂÚË ÂÚ›ÙˆÛË Ó· ÌÂÈÒÛÂÈ ÙÔÓ ·ÚÈıÌfi Ó¤ˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ ÔÍ›·˜ Ï¢¯·ÈÌ›·˜ ‹ ÏÂÌÊÒÌ·ÙÔ˜ ÛÙ· ·È‰È¿ ηٿ 5% (61).
ªËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ Î·È ÓÂÔϷۛ˜ ÌÂÙ¿ ÙËÓ ÂÓËÏÈΛˆÛË H ›‰Ú·ÛË ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ÛÙËÓ ·Ó¿Ù˘ÍË ÓÂÔÏ·ÛÈÒÓ ÛÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹ ¤¯ÂÈ ÌÂÏÂÙËı› ·ÚÎÂÙ¿, fiˆ˜ Ê·›ÓÂÙ·È ·fi ÙË ‰ËÌÔÛ›Â˘ÛË ·ÚÎÂÙÒÓ ÌÂÏÂÙÒÓ Ô˘ Ú·ÁÌ·Ù‡ÔÓÙ·È ÙÔ ı¤Ì· (47-60,62). ∏ ÈÔ ÚfiÛÊ·ÙË ·fi ·˘Ù¤˜, ÁÓˆÛÙ‹ Î·È ˆ˜ ÌÂϤÙË Boyd Orr ·ÊÔÚ¿ 4.999 ¿ÙÔÌ· Ô˘ ¤Ï·‚·Ó ·Ú¯Èο ̤ÚÔ˜ ÛÙË ÌÂϤÙË Î·Ù¿ ÙËÓ ÂÚ›Ô‰Ô 1937-1939 Û ËÏÈΛ· 0-19 ÂÙÒÓ, ηٿ ÙË ‰È¿ÚÎÂÈ· ‰ËÏ·‰‹ Ù˘ ·È‰È΋˜ Î·È ÂÊË‚È΋˜ ËÏÈΛ·˜ (62). °È· 4.379 ·fi ·˘ÙÔ‡˜, ‰ËÏ·‰‹ ÙÔ 88% ÂÚ›Ô˘ ÙˆÓ ·ÛıÂÓÒÓ ˘‹Ú¯·Ó ‰È·ı¤ÛÈÌ· ÛÙÔȯ›· fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ·Ó¿Ù˘ÍË ÓÂÔÏ·ÛÈÒÓ ·fi ÙÔ 1948 ˆ˜ ÙÔ 2003. ÃÚËÛÈÌÔÔÈÒÓÙ·˜ ·Ó·ÏÔÁ›Â˜ ÎÈÓ‰‡ÓÔ˘ (hazard ratios), ÔÈ ÂÚ¢ÓËÙ¤˜ Ù˘ ÌÂϤÙ˘ ‰ÂÓ ‰È·›ÛÙˆÛ·Ó ÚÔÛٷ٢ÙÈ΋ ›‰Ú·ÛË ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ÛÙËÓ ·Ó¿Ù˘ÍË Î·ÚΛÓÔ˘ ÛÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹ (·Ó·ÏÔÁ›· ÎÈÓ‰‡ÓÔ˘ 1,07, 95% fiÚÈ· ÂÌÈÛÙÔÛ‡Ó˘ 0,89-1,28). √È ÓÂÔϷۛ˜ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ‹Ù·Ó Ô Î·ÚΛÓÔ˜ Ì·ÛÙÔ‡, ÚÔÛÙ¿ÙË, ÛÙÔÌ¿¯Ô˘ Î·È Ô ÔÚıÔÎÔÏÈÎfi˜ ηÚΛÓÔ˜ (62). ™ÙËÓ ›‰È· ‰ËÌÔÛ›Â˘ÛË, ÔÈ ÂÚ¢ÓËÙ¤˜ ÚÔ¤‚ËÛ·Ó Î·È Û ̛· ÌÂÙ··Ó¿Ï˘ÛË ÙˆÓ 14 ÚÔÁÂÓ¤ÛÙÂÚˆÓ ÌÂÏÂÙÒÓ Ô˘ ·Û¯ÔÏ‹ıËÎ·Ó Ì ÙÔ ı¤Ì· -Î·È ÔÈ Ôԛ˜ ÛÙËÓ ÏÂÈÔÓfiÙËÙ¿ ÙÔ˘˜ ‹Ù·Ó ÌÂϤÙ˜ ·Ú·Ù‹ÚËÛ˘ ·ÛıÂÓÒÓ-Ì·ÚÙ‡ÚˆÓ- Î·È Î·Ù¤‰ÂÈÍ·Ó fiÙÈ Ô ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ ÚÔÛٷهÂÈ ·fi ÙÔÓ ÚÔÂÌÌËÓÔ·˘ÛÈ·Îfi ηÚΛÓÔ ÙÔ˘ Ì·ÛÙÔ‡ (Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ 0,88, 95% fiÚÈ· ÂÌÈÛÙÔÛ‡Ó˘ 0,79-0,98), ·ÏÏ¿ fi¯È ·fi ÙÔÓ ÌÂÙÂÌÌËÓÔ·˘ÛÈ·Îfi ηÚΛÓÔ ÙÔ˘ Ì·ÛÙÔ‡ ‹ ¿ÏÏÔ˘˜ ηÚΛÓÔ˘˜ Ù˘ ÂÓ‹ÏÈ΢ ˙ˆ‹˜ (62). ∞fi ÙȘ ÌÂϤÙ˜ Ô˘ Û˘ÌÂÚȤϷ‚Â Ë ÌÂÙ··Ó¿Ï˘ÛË ÙˆÓ Martin Î·È Û˘Ó. (62), ÔÈ ÂÙ¿ ÂÚÈÏ¿Ì‚·Ó·Ó ¿Óˆ ·fi 500 ·ÛıÂÓ›˜ Ì ηÚΛÓÔ (49-51,53,54,56,58) Ì ÌÂÁ·Ï‡ÙÂÚË ÙË ÌÂϤÙË ÙˆÓ Titus-Ernstoff Î·È Û˘Ó. Ô˘ ÂÚÈÏ¿Ì‚·Ó 4.008 ·ÛıÂÓ›˜ Ì ‰È¿ÊÔÚ˜ ÓÂÔϷۛ˜ (49). ™ÙÔÓ
·ÓÙ›Ô‰·, ÔÈ ·Ï·ÈfiÙÂÚ˜ ÌÂϤÙ˜ ÙˆÓ Tokuhata Î·È Û˘Ó. Û ·ÔÁfiÓÔ˘˜ Á˘Ó·ÈÎÒÓ Ì ηÚΛÓÔ ÙÔ˘ Ì·ÛÙÔ‡ (52) Î·È ÙˆÓ Henderson Î·È Û˘Ó. Û¯ÂÙÈο Ì ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÂÌÊ¿ÓÈÛË Î·ÚΛÓÔ˘ ÙˆÓ fiÚ¯ÂˆÓ Û Ó·ÚÔ‡˜ ÂÓ‹ÏÈΘ (59) ÂÚÈÏ¿Ì‚·Ó·Ó <80 ·ÛıÂÓ›˜ Î·È ÂÔ̤ӈ˜ ÂÏ¿¯ÈÛÙË ÛÙ·ÙÈÛÙÈ΋ ÈÛ¯‡. °ÂÓÈÎfiÙÂÚ·, Û¯ÔÏÈ¿˙ÔÓÙ·˜ Ù· ‰Â‰Ô̤ӷ ÙfiÛÔ ÁÈ· ÙȘ ·È‰È·ÙÚÈΤ˜ ÓÂÔϷۛ˜ fiÛÔ Î·È ÁÈ· ·˘Ù¤˜ ÙˆÓ ÂÓËϛΈÓ, Â›Ó·È Èı·Ófi Ù˘¯fiÓ Û¯ÂÙÈ΋ Ì›ˆÛË Ù˘ ›وÛ˘ Û ۯ¤ÛË Ì ÙÔÓ ÌËÙÚÈÎfi ıËÏ·ÛÌfi Ó· Â›Ó·È ·ÔÙ¤ÏÂÛÌ· fi¯È ·˘ÙÔ‡ ηı’ ·˘ÙÔ‡ ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡, ·ÏÏ¿ ÌÂÙ·‚ÏËÙÒÓ Ô˘ ‰ÂÓ ÂϤÁ¯ıËÎ·Ó ‹ Î·È ·ÔÙ¤ÏÂÛÌ· ÂÈÛ·ÁˆÁ‹˜ ÚÔηٷϋ„ÂˆÓ (bias) ˘¤Ú ÙÔ˘ ıËÏ·ÛÌÔ‡. ∞ÎfiÌ· fï˜ Î·È ·Ó Ô ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ Â›Ó·È fiÓÙˆ˜ ÚÔÛٷ٢ÙÈÎfi˜ ¤Ó·ÓÙÈ ÓÂÔÏ·ÛÈÒÓ, Ë ÚÔÛٷ٢ÙÈ΋ ÙÔ˘ ›‰Ú·ÛË Â›Ó·È Ì¿ÏÏÔÓ ÌÈÎÚ‹ Î·È fi¯È ÛËÌ·ÓÙÈ΋ ÛÂ Â›Â‰Ô ÚfiÏ˄˘ ÙÔ˘ ηÚΛÓÔ˘.
™˘ÌÂÚ¿ÛÌ·Ù· ™˘ÌÂÚ·ÛÌ·ÙÈο, Ô ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜, ÂÎÙfi˜ ÙˆÓ Î·ıÈÂÚˆÌ¤ÓˆÓ ıÂÙÈÎÒÓ ÂȉڿÛÂÒÓ ÙÔ˘ ˆ˜ ÚÔ˜ ÙËÓ ÚfiÏË„Ë ‰È·ÊfiÚˆÓ ÓÔÛËÌ¿ÙˆÓ Î·È ÙË Ì›ˆÛË Ù˘ ‚ÚÂÊÈ΋˜ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÛÈÌfiÙËÙ·˜, Ê·›ÓÂÙ·È fiÙÈ ›Ûˆ˜ ÚÔÛٷهÂÈ Î·È ·fi ÙËÓ ÂÌÊ¿ÓÈÛË ‰È·ÊfiÚˆÓ ÓÂÔÏ·ÛÈÒÓ, ΢ڛˆ˜ Ù˘ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜ Î·È ÙÔ˘ ÚÔÂÌÌËÓÔ·˘ÛÈ·ÎÔ‡ ηÚΛÓÔ˘ ÙÔ˘ Ì·ÛÙÔ‡. ∏ ÂӉ¯fiÌÂÓË fï˜, ÚÔÛٷ٢ÙÈ΋ ›‰Ú·Û‹ ÙÔ˘ Ê·›ÓÂÙ·È Ó· Â›Ó·È ‹È· Î·È ‰ÂÓ ·Ó·‰ÂÈÎÓ‡ÂÙ·È Û fiϘ ÙȘ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÌÂϤÙ˜. √È ÙÂÏÂ˘Ù·›Â˜ Â›Ó·È Û˘Ó‹ıˆ˜ ÌÂϤÙ˜ ·Ú·Ù‹ÚËÛ˘ ·ÛıÂÓÒÓ-Ì·ÚÙ‡ÚˆÓ, Ô˘ Û˘¯Ó¿ ‰ÂÓ ÂϤÁ¯Ô˘Ó ·ÚÎÒ˜ ÁÈ· Û˘Ó˘¿Ú¯Ô˘Û˜ ÌÂÙ·‚ÏËÙ¤˜. ∂›Ó·È ۷ʤ˜ fiÙÈ ÛÙÔ Ì¤ÏÏÔÓ ··ÈÙÔ‡ÓÙ·È Î·Ï‡ÙÂÚ· ۯ‰ȷṲ̂Ó˜, Ì·ÎÚÔ¯ÚfiÓȘ, ÚÔÔÙÈΤ˜ ÌÂϤÙ˜ Ô˘ Ó· Ï·Ì‚¿ÓÔ˘Ó ˘fi„Ë ‰È¿ÊÔÚÔ˘˜ Û˘Ó˘¿Ú¯ÔÓÙ˜ ·Ú¿ÁÔÓÙ˜ Î·È Ó· ‰›ÓÔ˘Ó ¤ÌÊ·ÛË ÛÙËÓ ¤Ó·ÚÍË, ·ÔÎÏÂÈÛÙÈÎfiÙËÙ· Î·È ‰È¿ÚÎÂÈ· ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡, ÒÛÙ ٷ Û˘ÌÂÚ¿ÛÌ·Ù· Ó· Â›Ó·È Ï¤ÔÓ Â˘Ú¤ˆ˜ ·Ô‰ÂÎÙ¿. ÕÏψÛÙÂ, Ë Î·ÚÎÈÓÔÁ¤ÓÂÛË Â›Ó·È ¤Ó· ÔÏ˘·Ú·ÁÔÓÙÈÎfi Î·È ÂÍ·ÈÚÂÙÈο ÔχÏÔÎÔ Ê·ÈÓfiÌÂÓÔ, ÙÔ˘ ÔÔ›Ô˘ ÙÔÓ Ì˯·ÓÈÛÌfi ÌfiÏȘ ÚfiÛÊ·Ù· ·Ú¯›˙Ô˘Ì ӷ ·Ó·Î·Ï‡ÙÔ˘ÌÂ. ∞Ó Ù· ·ÔÙÂϤÛÌ·Ù· ·fi ÙȘ Ӥ˜, ηχÙÂÚ· ۯ‰ȷṲ̂Ó˜ ÌÂϤÙ˜ Ô˘ ·ÊÔÚÔ‡Ó ÙËÓ ·Í›· ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ˆ˜ ÚÔ˜ ÙËÓ ÚfiÏË„Ë ÙÔ˘ ηÚΛÓÔ˘ Â›Ó·È ıÂÙÈο, ÔÈ ·È‰›·ÙÚÔÈ ·ÏÏ¿ Î·È Ë ÎÔÈÓˆÓ›· ÁÂÓÈÎfiÙÂÚ· ı· ¤¯Ô˘Ó ¤Ó· ·ÎfiÌ· Âȯ›ÚËÌ· ÁÈ· Ó· ÚÔˆı‹ÛÔ˘Ó ÂÓÂÚÁ¿ ÙÔÓ ÌËÙÚÈÎfi ıËÏ·ÛÌfi. µÈ‚ÏÈÔÁÚ·Ê›· 1. Department of Health and Human Services. HHS Blueprint for Action on Breastfeeding. Washington, DC: Office on Women’s Health; 2000 www.4woman.gov/Breastfeeding/bluprntbk2.pdf. ¶·È‰È·ÙÚÈ΋ 2007;70:272-277
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·276
276
¢. ª·Ùı·›Ô˜ Î·È Û˘Ó.
2. Morrow AL, Ruiz-Palacios GM, Altaye M, Jiang X, Guerrero ML, Meinzen-Derr JK, et al. Human milk oligosaccharides are associated with protection against diarrhea in breast-fed infants. J Pediatr 2004;145:297-303. 3. Newburg DS, Ruiz-Palacios GM, Altaye M, Chaturvedi P, Meinzen-Derr J, Guerrero Mde L, et al. Innate protection conferred by fucosylated oligosaccharides of human milk against diarrhea in breastfed infants. Glycobiology 2004;14:253-263. 4. Duncan B, Ey J, Holberg CJ, Wright AL, Martinez FD, Taussig LM. Exclusive breast-feeding for at least 4 months protects against otitis media. Pediatrics 1993;91:867-872. 5. Duffy LC, Faden H, Wasielewski R, Wolf J, Krystofik D. Exclusive breastfeeding protects against bacterial colonization and day care exposure to otitis media. Pediatrics 1997;100:E7. 6. Chantry CJ, Howard CR, Auinger P. Full breastfeeding duration and associated decrease in respiratory tract infection in US children. Pediatrics 2006;117:425-432. 7. Updegrove K. Necrotizing enterocolitis: the evidence for use of human milk in prevention and treatment. J Hum Lact 2004;20:335-339. 8. Marild S, Hansson S, Jodal U, Oden A, Svedberg K. Protective effect of breastfeeding against urinary tract infection. Acta Paediatr 2004;93:164-168. 9. Gessner BD, Ussery XT, Parkinson AJ, Breiman RF. Risk factors for invasive disease caused by Streptococcus pneumoniae among Alaska native children younger than two years of age. Pediatr Infect Dis J 1995;14:123-128. 10. Kull I, Bohme M, Wahlgren CF, Nordvall L, Pershagen G, Wickman M. Breast-feeding reduces the risk for childhood eczema. J Allergy Clin Immunol 2005;116:657-661. 11. Hanson LA. Human milk and host defence: immediate and long-term effects. Acta Paediatr Suppl 1999;88:42-46. 12. Hasselbalch H, Jeppesen DL, Engelmann MD, Michaelsen KF, Nielsen MB. Decreased thymus size in formula-fed infants compared with breastfed infants. Acta Paediatr 1996; 85:1029-1032. 13. Golding J, Emmett PM, Rogers IS. Breast feeding and infant mortality. Early Hum Dev 1997;49 Suppl:S143-S155. 14. Hanson LA. Breastfeeding provides passive and likely long-lasting active immunity. Ann Allergy Asthma Immunol 1998;81:523-533. 15. Newburg DS. Innate immunity and human milk. J Nutr 2005;135:1308-1312. 16. Butler JE. Immunologic aspects of breast feeding, antiinfectious activity of breast milk. Semin Perinatol 1979;3: 255-270. 17. Oddy WH, Kendall GE, Blair E, De Klerk NH, Stanley FJ, Landau LI, et al. Breast feeding and cognitive development in childhood: a prospective birth cohort study. Paediatr Perinat Epidemiol 2003;17:81-90. 18. Svensson M, Duringer C, Hallgren O, Mossberg AK, Hakansson A, Linse S, et al. Hamlet--a complex from human milk that induces apoptosis in tumor cells but spares healthy cells. Adv Exp Med Biol 2002;503:125-132. 19. Gustafsson L, Hallgren O, Mossberg AK, Pettersson J, Fischer W, Aronsson A, et al. HAMLET kills tumor cells by apoptosis: structure, cellular mechanisms, and therapy. J Nutr 2005;135:1299-1303. 20. Hallgren O, Gustafsson L, Irjala H, Selivanova G, Orrenius S, Svanborg C. HAMLET triggers apoptosis but tumor cell Paediatriki 2007;70:272-277
21.
22.
23.
24.
25.
26.
27.
28. 29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
death is independent of caspases, Bcl-2 and p53. Apoptosis 2006;11:221-233. Jourdan-Da Silva N, Perel Y, Mechinaud F, Plouvier E, Gandemer V, Lutz P, et al. Infectious diseases in the first year of life, perinatal characteristics and childhood acute leukaemia. Br J Cancer 2004;90:139-145. Infante-Rivard C, Fortier I, Olson E. Markers of infection, breast-feeding and childhood acute lymphoblastic leukaemia. Br J Cancer 2000;83:1559-1564. McKinney PA, Juszczak E, Findlay E, Smith K, Thomson CS. Pre- and perinatal risk factors for childhood leukaemia and other malignancies: a Scottish case control study. Br J Cancer 1999;80:1844-1851. Murray L, McCarron P, Bailie K, Middleton R, Davey Smith G, Dempsey S, et al. Association of early life factors and acute lymphoblastic leukaemia in childhood: historical cohort study. Br J Cancer 2002;86:356-361. Hartley AL, Birch JM, McKinney PA, Blair V, Teare MD, Carrette J, et al. The Inter-Regional Epidemiological Study of Childhood Cancer (IRESCC): past medical history in children with cancer. J Epidemiol Community Health 1988;42:235-242. Shu XO, Nesbit ME, Buckley JD, Krailo MD, Robinson LL. An exploratory analysis of risk factors for childhood malignant germ-cell tumors: report from the Childrens Cancer Group (Canada, United States). Cancer Causes Control 1995;6:187-198. Schuz J, Kaletsch U, Kaatsch P, Meinert R, Michaelis J. Risk factors for pediatric tumors of the central nervous system: results from a German population-based casecontrol study. Med Pediatr Oncol 2001;36:274-282. UK Childhood Cancer Study Investigators. Breastfeeding and childhood cancer. Br J Cancer 2001;85:1685-1694. Golding J, Paterson M, Kinlen LJ. Factors associated with childhood cancer in a national cohort study. Br J Cancer 1990;62:304-308. Daniels JL, Olshan AF, Pollock BH, Shah NR, Stram DO. Breast-feeding and neuroblastoma, USA and Canada. Cancer Causes Control 2002;13:401-405. Dockerty JD, Skegg DC, Elwood JM, Herbison GP, Becroft DM, Lewis ME. Infections, vaccinations, and the risk of childhood leukaemia. Br J Cancer 1999;80:1483-1489. Frentzel-Beyme R, Becher H, Salzer-Kuntschik M, Kotz R, Salzer M. Factors affecting the incident juvenile bone tumors in an Austrian case-control study. Cancer Detect Prev 2004;28:159-169. Shu XO, Linet MS, Steinbuch M, Wen WQ, Buckley JD, Neglia JP, et al. Breast-feeding and risk of childhood acute leukemia. J Natl Cancer Inst 1999;91:1765-1772. Lancashire RJ, Sorahan T; OSCC. Breastfeeding and childhood cancer risks: OSCC data. Br J Cancer 2003;88:10351037. Perrillat F, Clavel J, Jaussent I, Baruchel A, Leverger G, Nelken B, et al. Breast-feeding, fetal loss and childhood acute leukaemia. Eur J Pediatr 2002;161:235-237. Hardell L, Dreifaldt AC. Breast-feeding duration and the risk of malignant diseases in childhood in Sweden. Eur J Clin Nutr 2001;55:179-185. Bener A, Denic S, Galadari S. Longer breast-feeding and protection against childhood leukaemia and lymphomas. Eur J Cancer 2001;37:234-238. Rosenbaum PF, Buck GM, Brecher ML. Breastfeeding and
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·277
277
ªËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ Î·È ÓÂÔϷۛ˜
39.
40.
41.
42.
43. 44. 45.
46.
47.
48.
49.
50.
51.
52. 53.
54.
55.
childhood acute lymphoblastic leukaemia. Paediatr Perinatal Epidemiol 2000;14:A26. Smulevich VB, Solionova LG, Belyakova SV. Parental occupation and other factors and cancer risk in children: I. Study methodology and non-occupational factors. Int J Cancer 1999;83:712-717. Schuz J, Kaletsch U, Meinert R, Kaatsch P, Michaelis J. Association of childhood leukaemia with factors related to the immune system. Br J Cancer 1999;80:585-590. Grufferman S, Davis MK, Ambinder RF, Shugart YY, Gilchrist GS, Brecher ML. A protective effect of breastfeeding on risk of Hodgkin’s disease in children. Paediatr Perinat Epidemiol 1998;12:A13. Petridou E, Trichopoulos D, Kalapothaki V, Pourtsidis A, Kogevinas M, Kalmanti M, et al. The risk profile of childhood leukaemia in Greece: a nationwide case-control study. Br J Cancer 1997;76:1241-1247. Magnani C, Pastore G, Terracini B. Infant feeding and childhood cancer. Lancet 1988;2:1136. Davis MK, Savitz DA, Graubard BI. Infant feeding and childhood cancer. Lancet 1988;2:365-368. van Duijn CM, van Steensel-Moll HA, van der Does-vd Berg, van Wering ER, van Zanen GE, Valkenburg HA, et al. Infant feeding and childhood cancer. Lancet 1988;2: 796-797. Shu XO, Clemens J, Zheng W, Ying DM, Ji BT, Jin F. Infant breastfeeding and the risk of childhood lymphoma and leukaemia. Int J Epidemiol 1995;24:27-32. Coupland CA, Forman D, Chilvers CE, Davey G, Pike MC, Oliver RT. Maternal risk factors for testicular cancer: a population-based case-control study (UK). Cancer Causes Control 2004;15:277-283. Wingard DL, Criqui MH, Edelstein SL, Tucker J, Tomlinson-Keasey C, Schwartz JE, et al. Is breast-feeding in infancy associated with adult longevity? Am J Public Health 1994;84:1458-1462. Michels KB, Trichopoulos D, Rosner BA, Hunter DJ, Colditz GA, Hankinson SE, et al. Being breastfed in infancy and breast cancer incidence in adult life: results from the two nurses’ health studies. Am J Epidemiol 2001;153: 275-283. Sanderson M, Williams MA, Daling JR, Holt VL, Malone KE, Self SG, et al. Maternal factors and breast cancer risk among young women. Paediatr Perinat Epidemiol 1998; 12:397-407. Titus-Ernstoff L, Egan KM, Newcomb PA, Baron JA, Stampfer M, Greenberg ER, et al. Exposure to breast milk in infancy and adult breast cancer risk. J Natl Cancer Inst 1998;90:921-924. Tokuhata GK. Morbidity and mortality among offspring of breast cancer mothers. Am J Epidemiol 1969;89:139-153. Weiss HA, Potischman NA, Brinton LA, Brogan D, Coates RJ, Gammon MD, et al. Prenatal and perinatal risk factors for breast cancer in young women. Epidemiology 1997;8: 181-187. Freudenheim JL, Marshall JR, Graham S, Laughlin R, Vena JE, Bandera E, et al. Exposure to breastmilk in infancy and the risk of breast cancer. Epidemiology 1994;5:324-331. Ekbom A, Hsieh CC, Trichopoulos D, Yen YY, Petridou E, Adami HO. Breast-feeding and breast cancer in the offspring. Br J Cancer 1993;67:842-845.
56. Brinton LA, Hoover R, Fraumeni JF Jr. Reproductive factors in the aetiology of breast cancer. Br J Cancer 1983;47: 757-762. 57. Henderson BE, Powell D, Rosario I, Keys C, Hanisch R, Young M, et al. An epidemiologic study of breast cancer. J Natl Cancer Inst 1974;53:609-614. 58. Bucalossi P, Veronesi U. Some observations on cancer of the breast in mothers and daughters. Br J Cancer 1957;11:337-347. 59. Henderson BE, Benton B, Jing J, Yu MC, Pike MC. Risk factors for cancer of the testis in young men. Int J Cancer 1979;23:598-602. 60. Penrose LS, MacKenzie HJ, Karn MN. A genetical study of human mammary cancer. Br J Cancer 1948;2:168-176. 61. Martin RM, Gunnell D, Owen CG, Smith GD. Breastfeeding and childhood cancer: A systematic review with metaanalysis. Int J Cancer 2005;117:1020-1031. 62. Martin RM, Middleton N, Gunnell D, Owen CG, Smith GD. Breast-feeding and cancer: the Boyd Orr cohort and a systematic review with meta-analysis. J Natl Cancer Inst 2005;97:1446-1457. 63. Greaves M. Infection, immune responses and the aetiology of childhood leukaemia. Nat Rev Cancer 2006;6:193-203. 64. Kinlen LJ. Epidemiological evidence for an infective basis in childhood leukaemia. Br J Cancer 1995;71:1-5. 65. Kinlen LJ, Balkwill A. Infective cause of childhood leukaemia and wartime population mixing in Orkney and Shetland, UK. Lancet 2001;357:858. 66. Kinlen LJ. Infection and childhood leukemia. Cancer Causes Control 1998;9:237-239. 67. Kinlen LJ, Petridou E. Childhood leukemia and rural population movements: Greece, Italy, and other countries. Cancer Causes Control 1995;6:445-450. 68. Hjelle B. Human T-cell leukemia/lymphoma viruses. Life cycle, pathogenicity, epidemiology, and diagnosis. Arch Pathol Lab Med 1991;115:440-450. 69. Hammerschmidt W, Sugden B. Epstein-Barr virus sustains Burkitt’s lymphomas and Hodgkin’s disease. Trends Mol Med 2004;10:331-336. 70. Park NH, Song IH, Chung YH. Chronic hepatitis B in hepatocarcinogenesis. Postgrad Med J 2006;82:507-515. 71. Pozzato G, Mazzaro C, Santini G, Burrone O. Hepatitis C virus and non-Hodgkin's lymphomas. Leuk Lymphoma 1996;22:53-60. 72. Greaves M. Molecular genetics, natural history and the demise of childhood leukaemia. Eur J Cancer 1999;35: 1941-1953. 73. Greaves MF. Aetiology of acute leukaemia. Lancet 1997; 349:344-349. 74. Greaves M. Science, medicine and the future: childhood leukaemia. BMJ 2002;324:283-287. 75. Gale KB, Ford AM, Repp R, Borkhardt A, Keller C, Eden OB, et al. Backtracking leukemia to birth: identification of clonotypic gene fusion sequences in neonatal blood spots. Proc Natl Acad Sci USA 1997;94:13950-13954. 76. Wiemels JL, Cazzaniga G, Daniotti M, Eden OB, Addison GM, Masera G, et al. Prenatal origin of acute lymphoblastic leukaemia in children. Lancet 1999;354:1499-1503.
¶·È‰È·ÙÚÈ΋ 2007;70:272-277
Pediatri July-Aug 07
09-07-07
278
17:08
™ÂÏ›‰·278
∞¡∞™∫√¶∏™∏
REVIEW ARTICLE
∞ÓÙÂӉ›ÍÂȘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ¡ÂÔÁÓÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘ AÏÏËÏÔÁÚ·Ê›·: ÃÚÈÛÙ›Ó· °È·ÓÓ·ÎÔÔ‡ÏÔ˘ ekibolos@med.uoc.gr, hritsa@yahoo.gr ∞ÙÏ·ÓÙ›‰Ô˜ 37, ∆.∫. 71 305, ∏Ú¿ÎÏÂÈÔ ∫Ú‹Ù˘
∂. ÷Ù˙ˉ¿ÎË, Ã. °È·ÓÓ·ÎÔÔ‡ÏÔ˘ ¶ÂÚ›ÏË„Ë: ∆Ô ÌËÙÚÈÎfi Á¿Ï· ·ÔÙÂÏ› ÙËÓ È‰·ÓÈÎfiÙÂÚË ÙÚÔÊ‹ ÁÈ· Ù· ‚Ú¤ÊË. √ ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ ÌÂÈÒÓÂÈ ÙËÓ Â›ÙˆÛË Î·È ÙË ÛÔ‚·ÚfiÙËÙ· ÔÏÏÒÓ ÏÔÈÌÒ͈Ó, fiˆ˜ ‚·ÎÙËÚȷ΋ ÌËÓÈÁÁ›Ùȉ·, ÛË„·ÈÌ›·, Á·ÛÙÚÂÓÙÂÚ›Ùȉ·, ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ÓÂÎÚˆÙÈ΋ ÂÓÙÂÚÔÎÔÏ›Ùȉ·, ̤ÛË ˆÙ›Ùȉ·, Ô˘ÚÔÏԛ̈ÍË, Î·È fi„ÈÌË ÛË„·ÈÌ›·, Û ÚfiˆÚ· Î·È ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿, ·ÏÏ¿ Î·È ÙË ‚ÚÂÊÈ΋ ıÓËÛÈÌfiÙËÙ·. ŸÛÔÓ ·ÊÔÚ¿ ÛÙË ÌËÙ¤Ú·, ÂÚÈÔÚ›˙ÂÈ ÙËÓ ·ÒÏÂÈ· ·›Ì·ÙÔ˜ ÌÂÙ¿ ÙÔÓ ÙÔÎÂÙfi, ‚ÔËı¿ÂÈ ÛÙËÓ ·ÔηٿÛÙ·ÛË Ù˘ ·ÈÛıËÙÈ΋˜ ÙÔ˘ ÛÒÌ·ÙÔ˜, ÂÓÒ ¤¯ÂÈ ·Ú·ÙËÚËı› fiÙÈ ÔÈ ıËÏ¿˙Ô˘Û˜ ÌËÙ¤Ú˜ ¤¯Ô˘Ó ÌÂȈ̤ÓË Â›ÙˆÛË Î·Ù·ÁÌ¿ÙˆÓ ÙÔ˘ ÈÛ¯›Ô˘ Î·È ÔÛÙÂÔfiÚˆÛ˘ ηٿ ÙË ÌÂÙÂÌÌËÓÔ·˘Ûȷ΋ ÂÚ›Ô‰Ô Î·È ÌÈÎÚfiÙÂÚ˜ Èı·ÓfiÙËÙ˜ ·Ó¿Ù˘Í˘ ηÚΛÓÔ˘ Ì·ÛÙÔ‡ Î·È ˆÔıËÎÒÓ. øÛÙfiÛÔ, ˘¿Ú¯Ô˘Ó Î·È ÂÚÈÙÒÛÂȘ Ô˘ Ë ˘Á›· ÙÔ˘ ‚Ú¤ÊÔ˘˜ ‹ Ù˘ ÌËÙ¤Ú·˜ ÙÔ˘ ‰ËÌÈÔ˘ÚÁÔ‡Ó ÂÚˆÙËÌ·ÙÈο Û¯ÂÙÈο Ì ÙËÓ ·ÛÊ¿ÏÂÈ· ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡. ∞ÓÙ¤Ó‰ÂÈÍË ÁÈ· ÌËÙÚÈÎfi ıËÏ·ÛÌfi ·ÔÙÂÏ› ÙÔ Û‡Ó‰ÚÔÌÔ Â›ÎÙËÙ˘ ·ÓÔÛÔ·Ó¿ÚÎÂÈ·˜ ÛÙȘ ·Ó·Ù˘Á̤Ó˜ ¯ÒÚ˜, fiÔ˘ Ë ¯ÔÚ‹ÁËÛË ÙÚÔÔÔÈË̤ÓÔ˘ Á¿Ï·ÎÙÔ˜ ·ÁÂÏ¿‰·˜ Â›Ó·È ÂÊÈÎÙ‹ Î·È ‰È·ı¤ÛÈÌË, Ë ¯Ú‹ÛË Ú·‰ÈÔ˚ÛÔÙfiˆÓ ÁÈ· ‰È·ÁÓˆÛÙÈÎÔ‡˜ ‹ ıÂڷ¢ÙÈÎÔ‡˜ ÛÎÔÔ‡˜ ÁÈ· fiÛÔ ‰È¿ÛÙËÌ· ·ÂÎÎÚ›ÓÂÙ·È ÙÔ Ú·‰ÈÔ˚ÛfiÙÔÔ ÛÙÔ ÌËÙÚÈÎfi Á¿Ï·, Ë ¯Ú‹ÛË Ó·ÚΈÙÈÎÒÓ Ô˘ÛÈÒÓ, ·ÓÙÈÌÂÙ·‚ÔÏÈÙÒÓ ‹ ¯ËÌÂÈÔıÂڷ¢ÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Î·È Ê·Ú̷΢ÙÈÎÒÓ Û΢·ÛÌ¿ÙˆÓ ·fi ÙË ÌËÙ¤Ú· fiˆ˜ ÌÂÙÚÔÓȉ·˙fiÏË, ÎÏÈÓÙ·Ì˘Î›ÓË, ¯ÏˆÚ·ÌÊ·ÈÓÈÎfiÏË, οÔÈˆÓ ‚-·Ó·ÛÙÔϤˆÓ Î·È „˘¯ÔÙÚfiˆÓ. ∏ Ë·Ù›Ùȉ· µ ÂÊfiÛÔÓ ¯ÔÚËÁËı› ˘ÂÚ¿ÓÔÛË Á-ÛÊ·ÈÚ›ÓË, Î·È ÌÈ· ‰fiÛË ÂÌ‚ÔÏ›Ô˘, ‰ÂÓ ·ÔÙÂÏ› ·ÓÙ¤Ó‰ÂÈÍË ÁÈ· ÙÔÓ ÌËÙÚÈÎfi ıËÏ·ÛÌfi. ∏ Ïԛ̈ÍË ·fi ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi ‰ÂÓ ·ÔÙÂÏ› ·ÓÙ¤Ó‰ÂÈÍË, Â¿Ó Ë ÔÚÔÌÂÙ·ÙÚÔ‹ ‰ÂÓ Â›Ó·È ÚfiÛÊ·ÙË Î·È ÙÔ ÓÂÔÁÓfi Â›Ó·È ÙÂÏÂÈfiÌËÓÔ. ∂¿Ó Ë ÌËÙ¤Ú· ¤¯ÂÈ ÂÓÂÚÁfi Ê˘Ì·Ù›ˆÛË, ÙÔ ÓÂÔÁÓfi Ù˘ ·ÔÌ·ÎÚ‡ÓÂÙ·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙÔÓ ÙÔÎÂÙfi. ∆Ô Á¿Ï· Ù˘ ÌËÙ¤Ú·˜ ÌÔÚ› Ó· ¯ÔÚËÁÂ›Ù·È ÛÙÔ ÓÂÔÁÓfi ÂÎÙfi˜ Î·È Â¿Ó ˘¿Ú¯ÂÈ Ê˘Ì·ÙÈ҉˘ Ì·ÛÙ›Ùȉ·. §¤ÍÂȘ ÎÏÂȉȿ: ªËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜, ÔʤÏË, ·ÓÙÂӉ›ÍÂȘ.
Contraindications to breastfeeding Neonatology Department, University of Crete, Greece Correspondence: Christina Giannakopoulou ekibolos@med.uoc.gr, hritsa@yahoo.gr 37, Atlantidos St., 71 305, Herakleion, Crete, Greece
E. Hatzidaki, C. Giannakopoulou Abstract: Maternal breast milk is the ideal nutrient for infants. There is strong evidence that breastfeeding decreases the incidence and severity of a wide range of infectious diseases, including bacterial meningitis, bacteraemia, diarrhoea, respiratory tract infection, necrotizing enterocolitis, otitis media, urinary tract infection and late onset sepsis in preterm infants, as well as reducing infant mortality. Benefits for the mother include decreased postpartum bleeding, earlier return to pre-pregnancy weight, decreased risk of breast and ovarian cancer, and lowered risk of hip fractures and osteoporosis in the postmenopausal period. However, there are situations where maternal or neonatal health may be under threat as far as breastfeeding safety is concerned. Breastfeeding is contraindicated for mothers who are infected with human immunodeficiency virus in developed countries where formula preparation is safe, for mothers who are receiving diagnostic or therapeutic radioactive isotopes or who have been exposed to radioactive materials as long as radioactivity is present in their milk, and for mothers who are using narcotics or being administered antimetabolites, chemotherapeutic agents or certain other medications such as metronidazole, clindamycin, chloramphenicol, some beta-blocking agents and psychotropic drugs. Hepatitis B is not a contraindication to breastfeeding when the infant has received hepatitis B immunoglobulin and the first dose of vaccine soon after birth. Cytomegalovirus infection is not a contraindication to breastfeeding if the conversion is not recent and the infant is full term. Separation of infants immediately after birth is appropriate if their mothers are suffering from active tuberculosis. The only contraindication to using breast milk is when the mother has tuberculosis mastitis. Key words: Breastfeeding, benefits, contraindications.
Paediatriki 2007;70:278-284
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·279
279
∞ÓÙÂӉ›ÍÂȘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡
∂ÈÛ·ÁˆÁ‹ ∆Ô ÌËÙÚÈÎfi Á¿Ï· ·ÔÙÂÏ› ·Ó·ÌÊÈÛ‚‹ÙËÙ· ÙËÓ È‰·ÓÈÎfiÙÂÚË ÙÚÔÊ‹ ÁÈ· ÙÔ ‚Ú¤ÊÔ˜ Î·È ·fi ÙfiÙ Ԣ ÙÔ Á¤ÓÔ˜ ÙˆÓ ·ÓıÚÒˆÓ ÂÌÊ·Ó›ÛÙËΠÛÙË ÁË ·ÔÙ¤ÏÂÛ ÙËÓ ·ÔÎÏÂÈÛÙÈ΋ ÙÚÔÊ‹ ÁÈ· ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ Ù˘ ˙ˆ‹˜. ¶ÂÚȤ¯ÂÈ fiÏ· Ù· ··Ú·›ÙËÙ· ıÚÂÙÈο Û˘ÛÙ·ÙÈο Û ȉ·ÓÈ΋ ·Ó·ÏÔÁ›· ÁÈ· ÙË ÛˆÛÙ‹ ·Ó¿Ù˘ÍË ÙÔ˘ ‚Ú¤ÊÔ˘˜. ∂›Ó·È ¤Ó· ‰˘Ó·ÌÈÎfi Î·È fi¯È ÛÙ·ÙÈÎfi ÚÔ˚fiÓ Ì ϋıÔ˜ ΢ÙÙ¿ÚˆÓ, ·ÓÙÈۈ̿وÓ, ·˘ÍËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Î·È ¿ÏÏˆÓ ÂÓÂÚÁÒÓ ‚ÈÔÏÔÁÈÎÒÓ ÛÙÔȯ›ˆÓ Ô˘ ‚ÔËıÔ‡Ó ÛÙËÓ ¿Ì˘Ó· Î·È ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ Ó¤Ô˘ ÔÚÁ·ÓÈÛÌÔ‡ (1,2). √ ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜, Û‡Ìʈӷ Ì ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ·Ó·ÊÔÚ¤˜, Ê·›ÓÂÙ·È fiÙÈ ÌÂÈÒÓÂÈ ÙË ‚ÚÂÊÈ΋ ıÓËÛÈÌfiÙËÙ· (3), ÙËÓ Â›ÙˆÛË Î·È ÙË ÛÔ‚·ÚfiÙËÙ· ÔÏÏÒÓ ÏÔÈÌÒÍÂˆÓ fiˆ˜ ‚·ÎÙËÚȷ΋ ÌËÓÈÁÁ›Ùȉ· (4), ÛË„·ÈÌ›· (5), Á·ÛÙÚÂÓÙÂÚ›Ùȉ· (6,7), ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (8-10), ÓÂÎÚˆÙÈ΋ ÂÓÙÂÚÔÎÔÏ›Ùȉ· (11), ̤ÛË ˆÙ›Ùȉ· (12), Ô˘ÚÔÏԛ̈ÍË (13), Î·È fi„ÈÌË ÛË„·ÈÌ›·, Û ÚfiˆÚ· Î·È ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ (14). ∫¿ÔÈÔÈ ÂÚ¢ÓËÙ¤˜ ·Ó·Ê¤ÚÔ˘Ó ÌÂȈ̤ÓË Â›ÙˆÛË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘ (15,16), ÙÔ˘ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ π Î·È ππ (17,18), ÙˆÓ ÏÂÌʈ̿وÓ, Ù˘ Ï¢¯·ÈÌ›·˜, Ù˘ ÓfiÛÔ˘ Hodgkin (19), Ù˘ ·¯˘Û·ÚΛ·˜ (20-22), Ù˘ ˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›·˜ (23) Î·È ÙÔ˘ ¿ÛıÌ·ÙÔ˜ (24) Û ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ Î·È ÂÓ‹ÏÈΘ Ô˘ ı‹Ï·Û·Ó ηٿ ÙË ‚ÚÂÊÈ΋ ËÏÈΛ· Û ۯ¤ÛË Ì ¿ÙÔÌ· Ô˘ ‰ÂÓ ı‹Ï·Û·Ó. Œ¯ÂÈ Â›Û˘ ·Ó·ÊÂÚı› fiÙÈ Ô ıËÏ·ÛÌfi˜ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÂÏ·ÊÚ¿ ˘ÂÚÔ¯‹ ÛÙËÓ Â›‰ÔÛË Û ‰ÔÎÈ̷ۛ˜ ÓÔËÙÈÎÔ‡ ÂȤ‰Ô˘ (25), ÂÓÒ ¤¯ÂÈ ·Ú·ÙËÚËı› fiÙÈ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÂÒ‰˘ÓˆÓ ‰È·‰ÈηÛÈÒÓ fiˆ˜ ·ÈÌÔÏË„›· ·fi ÙË Ù¤ÚÓ· ÙÔ˘ ÓÂÔÁÓÔ‡ ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô ÚÔ˘Ù›Ó·˜ ·Ú¤¯ÂÈ ·Ó·ÏÁËÛ›· ÛÙÔ ÓÂÔÁÓfi (26). √ ıËÏ·ÛÌfi˜ ·Ú¤¯ÂÈ Â›Û˘, ÛËÌ·ÓÙÈο ÔʤÏË ÛÙË ÌËÙ¤Ú·. ¶ÂÚÈÔÚ›˙ÂÈ ÙËÓ ·ÒÏÂÈ· ·›Ì·ÙÔ˜ ÌÂÙ¿ ÙÔÓ ÙÔÎÂÙfi Î·È ‚ÔËı¿ÂÈ ÙË Ì‹ÙÚ· Ó· ·ӤÏıÂÈ ÁÚ‹ÁÔÚ· ÛÙËÓ ·Ú¯È΋ Ù˘ ÌÔÚÊ‹ (27). µÔËı¿ÂÈ ÛÙË ÁÚËÁÔÚfiÙÂÚË Î·Ù·Ó¿ÏˆÛË Ï›Ô˘˜ Î·È ÛÙËÓ ·ÔηٿÛÙ·ÛË Ù˘ ·ÈÛıËÙÈ΋˜ ÙÔ˘ ÛÒÌ·ÙÔ˜ Î·È ÙÔ˘ ÛÙ‹ıÔ˘˜ (28), ÂÓÒ ¤¯ÂÈ ·Ú·ÙËÚËı› fiÙÈ ÔÈ ıËÏ¿˙Ô˘Û˜ ÌËÙ¤Ú˜ ¤¯Ô˘Ó ηχÙÂÚË ÔÛÙÈ΋ ˘ÎÓfiÙËÙ·, ÌÂȈ̤ÓË Â›ÙˆÛË Î·Ù·ÁÌ¿ÙˆÓ ÙÔ˘ ÈÛ¯›Ô˘ Î·È ÔÛÙÂÔfiÚˆÛ˘ ηٿ ÙË ÌÂÙÂÌÌËÓÔ·˘Ûȷ΋ ÂÚ›Ô‰Ô (29) Î·È ÌÈÎÚfiÙÂÚ˜ Èı·ÓfiÙËÙ˜ ·Ó¿Ù˘Í˘ ηÚΛÓÔ˘ Ì·ÛÙÔ‡ Î·È ˆÔıËÎÒÓ (30). øÛÙfiÛÔ, ˘¿Ú¯Ô˘Ó Î·È ÂÚÈÙÒÛÂȘ Ô˘ Ë Ê˘ÛÈ΋ ηٿÛÙ·ÛË Î·È Ë ˘Á›· ÙÔ˘ ‚Ú¤ÊÔ˘˜ ‹ Ù˘ ÌËÙ¤Ú·˜ ÙÔ˘, ‰ËÌÈÔ˘ÚÁÔ‡Ó Î¿ÔÈ· ÂÚˆÙËÌ·ÙÈο ÙfiÛÔ fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ·ÛÊ¿ÏÂÈ·, ·ÏÏ¿ Î·È ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ÛÙÔ ‚Ú¤ÊÔ˜. ∆fiÙÂ, fiˆ˜ Â›Ó·È ÏÔÁÈÎfi, ··ÈÙÂ›Ù·È ÚÔÛÂÎÙÈ΋ ÂÎÙ›ÌËÛË ÙˆÓ ÎÈÓ‰‡ÓˆÓ Ô˘ Ù˘¯fiÓ ·ÔÚÚ¤Ô˘Ó ·fi
ÙË ¯Ú‹ÛË ÙÔ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÎÙÔ˜, Û ۯ¤ÛË Ì ÙÔ ·Ó·ÌÂÓfiÌÂÓÔ fiÊÂÏÔ˜. ™ÎÔfi˜ Ù˘ ·Ó·ÛÎfiËÛ˘ ·˘Ù‹˜ Â›Ó·È Ó· ·ÚÔ˘ÛÈ·ÛÙÔ‡Ó ÔÈ ÙÚ¤¯Ô˘Û˜ ·ÓÙÈÏ‹„ÂȘ Û¯ÂÙÈο Ì ÙȘ Û˘¯ÓfiÙÂÚ˜ ·fi ÙȘ ·ÓÙÂӉ›ÍÂȘ ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡.
§ÔÈÌÒÍÂȘ Ù˘ ÌËÙ¤Ú·˜ §ÔÈÌÒ‰Ë ÓÔÛ‹Ì·Ù· Ù˘ ÌËÙ¤Ú·˜ Á›ÓÔÓÙ·È Ôχ Û˘¯Ó¿ ·Èٛ˜ ÚÔ‚ÏËÌ·ÙÈÛÌÔ‡ ÁÈ· ÙÔÓ ÂӉ¯fiÌÂÓÔ Î›Ó‰˘ÓÔ ÁÈ· ÙÔ ÓÂÔÁÓfi Î·È ÙÔ ‚Ú¤ÊÔ˜, Ô˘ ·ÔÚÚ¤ÂÈ ·fi ÙË Û˘Ó¤¯ÈÛË ÙÔ˘ ıËÏ·ÛÌÔ‡. ™Â ÔÏϤ˜ ÂÚÈÙÒÛÂȘ, ÙÔ ÓÂÔÁÓfi ¤¯ÂÈ ‹‰Ë ÂÎÙÂı› ÛÙÔÓ ÏÔÈÌÒ‰Ë ·Ú¿ÁÔÓÙ·. ¢È·ÎÔ‹ ÙÔ˘ ıËÏ·ÛÌÔ‡ ηٿ ÙË Ê¿ÛË Ô˘ ·ÓÙÈÛÒÌ·Ù· Î·È ·ÓÔÛÔÚ˘ıÌÈÛÙÈΤ˜ Ô˘Û›Â˜ ÂÎÎÚ›ÓÔÓÙ·È ÛÙÔ ÌËÙÚÈÎfi Á¿Ï· Î·È ÚÔÛÙ·ÙÂ‡Ô˘Ó ÙÔ ‚Ú¤ÊÔ˜ ·fi ÙË Ïԛ̈ÍË ‹ ÂÚÈÔÚ›˙Ô˘Ó ÙË ÛÔ‚·ÚfiÙËÙ· ÙˆÓ Û˘Ìو̿وÓ, Â¿Ó Ë Ïԛ̈ÍË ¤¯ÂÈ ‹‰Ë ÂÁηٷÛÙ·ı›, Ì¿ÏÏÔÓ ‰ÂÓ ˆÊÂÏ›. To ÎÔÈÓfi ÎÚ˘ÔÏfiÁËÌ· Â›Ó·È ·fi Ù· ηχÙÂÚ· ·Ú·‰Â›ÁÌ·Ù· ÓfiÛÔ˘ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÔÔ›·˜ Â›Ó·È ÚÔÙÈÌfiÙÂÚË Ë Û˘Ó¤¯ÈÛË ÙÔ˘ ıËÏ·ÛÌÔ‡. §ÔÈÌÒÍÂȘ ÙÔ˘ Ô˘ÚÔÔÈÔÁÂÓÓËÙÈÎÔ‡ Î·È ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Ù˘ ÌËÙ¤Ú·˜ ‰ÂÓ ÂÎı¤ÙÔ˘Ó ÙÔ ‚Ú¤ÊÔ˜ Û ΛӉ˘ÓÔ, ÂÎÙfi˜ ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ô˘ ¤¯ÂÈ ÂÁηٷÛÙ·ı› ÛË„·ÈÌ›· (31,32). ™‡Ó‰ÚÔÌÔ Â›ÎÙËÙ˘ ·ÓÔÛÔ·Ó¿ÚÎÂÈ·˜ √ Èfi˜ ·ÓȯÓ‡ÂÙ·È ÛÙÔ ÌËÙÚÈÎfi Á¿Ï· Î·È ÌÂÙ·‰›‰ÂÙ·È ÛÙÔ ÓÂÔÁÓfi Ì ÙÔÓ ıËÏ·ÛÌfi. ™ÙȘ ·Ó·Ù˘Á̤Ó˜ ¯ÒÚ˜, fiÔ˘ ˘¿Ú¯Ô˘Ó ‡ÎÔÏ· ‰È·ı¤ÛÈ̘ ËÁ¤˜ Ù¯ÓËÙ‹˜ ‰È·ÙÚÔÊ‹˜, Û˘ÓÈÛÙ¿Ù·È Ë ·ÔÊ˘Á‹ ÙÔ˘ ıËÏ·ÛÌÔ‡, ÂÓÒ ÁÈ· ÙȘ ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜ ÂÎÙÈÌ¿Ù·È Ô Î›Ó‰˘ÓÔ˜ Ô˘ ·ÔÚÚ¤ÂÈ ·fi ÙË Û›ÙÈÛË ·fi ¿ÏϘ ËÁ¤˜ Î·È Ì¿ÏÏÔÓ ÂÓı·ÚÚ‡ÓÔÓÙ·È ÔÈ ÌËÙ¤Ú˜, ÂÊfiÛÔÓ ‚¤‚·È· Ë Ê˘ÛÈ΋ ÙÔ˘˜ ηٿÛÙ·ÛË ÙÔ ÂÈÙÚ¤ÂÈ, Ó· ıËÏ¿ÛÔ˘Ó Ù· ‚Ú¤ÊË ÙÔ˘˜ (2,31,33). §Ô›ÌˆÍË ·fi ·Ú‚Ô˚fi µ19 ¢ÂÓ ˘¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ ÌÂÙ¿‰ÔÛ˘ ÙÔ˘ ÈÔ‡ ·fi ÙÔ ·ÓıÚÒÈÓÔ ÌËÙÚÈÎfi Á¿Ï·, ·Ó Î·È ¤¯ÂÈ ·ÓȯÓ¢Ù› Û Á¿Ï· ÔÓÙÈÎÔ‡. ¢ÂÓ ÚÔÙ›ÓÂÙ·È Ë ‰È·ÎÔ‹ ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ (31). §Ô›ÌˆÍË ·fi ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi √ Èfi˜ ·ÓȯÓ‡ÂÙ·È ÛÙÔ ÌËÙÚÈÎfi Á¿Ï·. ∏ ‰È·Ï·ÎÔ˘ÓÙȷ΋ ÌÂÙ·ÊÔÚ¿ ÌËÙÚÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Î·Ù¿ ÙÔ˘ ÈÔ‡, ÚÔÛٷهÂÈ Ù· ÙÂÏÂÈfiÌËÓ· ‚Ú¤ÊË ÔÚÔıÂÙÈÎÒÓ ÌËÙ¤ÚˆÓ. ªÂÙ¿ ÙË Á¤ÓÓËÛË, ¤ÎıÂÛË ÛÙÔÓ Èfi ‚ÚÂÊÒÓ Ô˘ ‰ÂÓ ‰È·ı¤ÙÔ˘Ó Ù· ÂȉÈο ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ÙÔ˘ ÈÔ‡, fiˆ˜ ÚfiˆÚ· ÓÂÔÁÓ¿ Î·È ‚Ú¤ÊË ÔÚÔ·ÚÓËÙÈÎÒÓ ÌËÙ¤ÚˆÓ, ÌÔÚ› Ó· ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÂΉ‹ÏˆÛË ÛÔ‚·Ú‹˜ ÓfiÛÔ˘. £ËÏ¿˙ÔÓÙ· ‚Ú¤ÊË ÔÚÔıÂÙÈÎÒÓ ÌËÙ¤ÚˆÓ ÌÔÚ› Ó· ÂΉËÏÒÛÔ˘Ó Û˘Ìو̷ÙÈ΋ ÓfiÛÔ, Â¿Ó Ë ÔÚÔÌÂÙ·ÙÚÔ‹ Á›ÓÂÈ Î·Ù¿ ¶·È‰È·ÙÚÈ΋ 2007;70:278-284
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·280
280
∂. ÷Ù˙ˉ¿ÎË, Ã. °È·ÓÓ·ÎÔÔ‡ÏÔ˘
ÙËÓ ÂÚ›Ô‰Ô Ù˘ Á·ÏÔ˘¯›·˜. ∏ Ïԛ̈ÍË ·fi ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi ‰ÂÓ ·ÔÙÂÏ› ·ÓÙ¤Ó‰ÂÈÍË, Â¿Ó Ë ÔÚÔÌÂÙ·ÙÚÔ‹ ‰ÂÓ ¤ÁÈÓ ηٿ ÙËÓ ÂÚ›Ô‰Ô Ù˘ Á·ÏÔ˘¯›·˜ Î·È ÙÔ ÓÂÔÁÓfi Â›Ó·È ÙÂÏÂÈfiÌËÓÔ. øÛÙfiÛÔ, ‰ÂÓ ÈÛ¯‡ÂÈ ÙÔ ›‰ÈÔ ÁÈ· Ù· Ôχ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÚfiˆÚ· ÓÂÔÁÓ¿ ÔÚÔıÂÙÈÎÒÓ ÌËÙ¤ÚˆÓ. ∏ ·fiÊ·ÛË ÁÈ· ÙË ¯ÔÚ‹ÁËÛË ÌËÙÚÈÎÔ‡ Á¿Ï·ÎÙÔ˜ ı· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ÌÂÙ¿ ·fi ÚÔÛÂÎÙÈ΋ ÂÎÙ›ÌËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÌÂÙ¿‰ÔÛ˘ Ù˘ ÓfiÛÔ˘, Û ۯ¤ÛË Ì ÙÔ fiÊÂÏÔ˜ ÁÈ· ÙÔ ÓÂÔÁÓfi ·fi ÙÔÓ ÌËÙÚÈÎfi ıËÏ·ÛÌfi. ∂›Ó·È ÁÓˆÛÙfi fiÙÈ Î·Ù¿„˘ÍË ‹ ·ÛÙÂÚ›ˆÛË ÙÔ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÎÙÔ˜ ÂÚÈÔÚ›˙ÂÈ ÛËÌ·ÓÙÈο ÙÔ È˚Îfi ÊÔÚÙ›Ô ÙÔ˘ ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚Ô‡ (2,31,34,35). §Ô›ÌˆÍË ·fi ÙÔÓ Èfi ÙÔ˘ ·ÏÔ‡ ¤ÚËÙ· ŒÓ· ˘ÁȤ˜ ÓÂÔÁÓfi Ô˘ ÁÂÓÓ‹ıËΠ·fi ÌËÙ¤Ú· Ì Ïԛ̈ÍË ·fi ÙÔÓ Èfi ÌÔÚ› Ó· ıËÏ¿ÛÂÈ, ÂÎÙfi˜ ·fi ÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ˘¿Ú¯ÂÈ ÂÓÂÚÁfi˜ ‚Ï¿‚Ë ÛÙÔÓ Ì·ÛÙfi Ù˘ ÌËÙ¤Ú·˜ ÙÔ˘. ™ÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ˘¿Ú¯ÂÈ ÂÓÂÚÁfi˜ ‚Ï¿‚Ë ÛÙÔÓ Ì·ÛÙfi, Ô ıËÏ·ÛÌfi˜ Ú¤ÂÈ Ó· ‰È·ÎfiÙÂÙ·È Ì¤¯ÚÈ Ë ‚Ï¿‚Ë Ó· ÂÍ·Ê·ÓÈÛÙ› (2,31,32,34,36,37). §Ô›ÌˆÍË ·fi ÙÔÓ Èfi Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜ ™ÙÔ ÌËÙÚÈÎfi Á¿Ï· ·ÓȯÓ‡ÔÓÙ·È ÙfiÛÔ ÙÔ DNA ÙÔ˘ ÈÔ‡, fiÛÔ Î·È ·ÓÙÈÛÒÌ·Ù· ÂÓ·ÓÙ›ÔÓ ÙÔ˘. ™ÙȘ ÂÚÈÙÒÛÂȘ ÂΛӘ Ô˘ Ë ÌËÙ¤Ú· ÂÌÊ·Ó›ÛÂÈ ÙË ÓfiÛÔ, Ô Î›Ó‰˘ÓÔ˜ ÌÂÙ¿‰ÔÛ˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙË ÛÙÂÓ‹ ·ʋ Î·È Â›Ó·È ›‰ÈÔ˜ ÁÈ· ÙÔ ‚Ú¤ÊÔ˜ Ô˘ ıËÏ¿˙ÂÈ ·ÏÏ¿ Î·È ÁÈ· ·˘Ùfi Ô˘ ÛÈÙ›˙ÂÙ·È Ì ÙÚÔÔÔÈË̤ÓÔ Á¿Ï· ·ÁÂÏ¿‰·˜. ∞ÔÌ·ÎÚ‡ÓÔ˘Ì ÏÔÈfiÓ ÙÔ ÓÂÔÁÓfi ÁÈ· fiÛÔ ‰È¿ÛÙËÌ· Ë ÌËÙ¤Ú· ÌÂÙ·‰›‰ÂÈ ÙË ÓfiÛÔ, ·Ó Î·È Ë ·ÔÌ¿ÎÚ˘ÓÛË ÌÔÚ› Ó· ÌËÓ ¤¯ÂÈ È‰È·›ÙÂÚÔ ÓfiËÌ·, ηıÒ˜ ÙÔ ÓÂÔÁÓfi ¤¯ÂÈ ÂÎÙÂı› ÛÙË ÓfiÛÔ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÚÔ‰ÚÔÌÈÎÔ‡ ÛÙ·‰›Ô˘. ∆Ô Á¿Ï· Ù˘ ÌËÙ¤Ú·˜ ÌÔÚ› Ó· ¯ÔÚËÁÂ›Ù·È ÛÙÔ ‚Ú¤ÊÔ˜, ÂÎÙfi˜ Â¿Ó ˘¿Ú¯Ô˘Ó ‰ÂÚÌ·ÙÈΤ˜ ‚Ï¿‚˜ ÛÙÔÓ Ì·ÛÙfi. ∏ ÌËÙ¤Ú· ÌÔÚ› Ó· ıËÏ¿ÛÂÈ ÙÔ ÌˆÚfi Ù˘, fiÙ·Ó ‰ÂÓ ¤¯Ô˘Ó ÂÌÊ·ÓÈÛÙ› Ӥ˜ ‚Ï¿‚˜ ÁÈ· 72 ÒÚ˜, ÂÓÒ ÔÈ ˘¿Ú¯Ô˘Û˜ ¤¯Ô˘Ó ÂÊÂÏÎȉÔÔÈËı›, Û˘Ó‹ıˆ˜ 6 Ì 10 ̤Ú˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË ÙÔ˘ ÂÍ·Óı‹Ì·ÙÔ˜ (31,32). ∏·Ù›Ùȉ˜ ∏·Ù›Ùȉ· ∞. ªÂÙ¿‰ÔÛË ÙÔ˘ ÈÔ‡ ·fi ÙÔ ÌËÙÚÈÎfi Á¿Ï· ¤¯ÂÈ ·Ó·ÊÂÚı› Û ̛· ÂÚ›ÙˆÛË. øÛÙfiÛÔ, ‰ÂÓ Â›Ó·È ‚¤‚·ÈÔ fiÛÔ Û˘¯Ó¿ Ô Èfi˜ Ù˘ Ë·Ù›Ùȉ·˜ ∞ ÌÔÚ› Ó· ·ÔÌÔÓˆı› ÛÙÔ ÌËÙÚÈÎfi Á¿Ï·. ∏ ¤ÎıÂÛË ÙÔ˘ ‚Ú¤ÊÔ˘˜ ÛÙÔÓ Èfi Û˘Ó‹ıˆ˜ ¤¯ÂÈ ‹‰Ë ÚÔËÁËı› Ù˘ ‰È·ÁÓˆÛÙÈ΋˜ ÂȂ‚·›ˆÛ˘ Ù˘ ÓfiÛÔ˘ ÛÙË ÌËÙ¤Ú·. ¢ÂÓ ˘¿Ú¯ÂÈ ÏfiÁÔ˜ ‰È·ÎÔ‹˜ ÙÔ˘ ıËÏ·ÛÌÔ‡. ™ÙË ÌËÙ¤Ú· Û˘ÓÈÛÙ¿Ù·È ÙÔ ÚÔÛÂÎÙÈÎfi χÛÈÌÔ ÙˆÓ ¯ÂÚÈÒÓ Î·È Ë ÛˆÛÙ‹ ˘ÁÈÂÈÓ‹, ÁÂÓÈÎfiÙÂÚ·, Î·È ÂÓı·ÚÚ‡ÓÂÙ·È Ó· ıËÏ¿ÛÂÈ ÙÔ ÓÂÔÁÓfi Ù˘ (31,32,34,37). Paediatriki 2007;70:278-284
∏·Ù›Ùȉ· µ. √ Èfi˜ Ù˘ Ë·Ù›Ùȉ·˜ µ ÚÔηÏ› ÙË Û˘¯ÓfiÙÂÚË Î·È ÛÔ‚·ÚfiÙÂÚË ÂÚÈÁÂÓÓËÙÈ΋ Ïԛ̈ÍË. ∆Ô ·ÓÙÈÁfiÓÔ ÙÔ˘ ÈÔ‡ ·ÓȯÓ‡ÂÙ·È ÛÙÔ ÌËÙÚÈÎfi Á¿Ï·. ∆Ô È˚Îfi ÊÔÚÙ›Ô fï˜ Â›Ó·È ÌÈÎÚfi Î·È ‰ÂÓ ¤¯ÂÈ ·Ô‰Âȯı› ÌÂÙ¿‰ÔÛË ÙÔ˘ ÈÔ‡ ·fi ÙÔ ÌËÙÚÈÎfi Á¿Ï·. ¢ÂÓ Û˘ÓÈÛÙ¿Ù·È ·ÔÊ˘Á‹ ÙÔ˘ ıËÏ·ÛÌÔ‡ ÂÊfiÛÔÓ ¤¯ÂÈ ÚÔËÁËı› Û˘Ó‰˘·Ṳ̂ÓË ÂÓÂÚÁËÙÈ΋ Î·È ·ıËÙÈ΋ ·ÓÔÛÔÔ›ËÛË Ì ˘ÂÚ¿ÓÔÛË Á-ÛÊ·ÈÚ›ÓË Î·È Ì›· ‰fiÛË ÂÌ‚ÔÏ›Ô˘ (31,32,34,37). ∏·Ù›Ùȉ· C. √ Èfi˜ Ù˘ Ë·Ù›Ùȉ·˜ C ÌÂÙ·‰›‰ÂÙ·È Ì ÙËÓ ·ÚÂÓÙÂÚÈ΋ Ô‰fi. ∏ ÌÂÙ¿‰ÔÛË ÙÔ˘ ÈÔ‡ Ì ÙÔÓ ıËÏ·ÛÌfi ‰ÂÓ ¤¯ÂÈ ·Ô‰ÂȯÙ›. ∏ ı¤ÛË ÙÔ˘ Center for Disease Control and Prevention ÙˆÓ ∏¶∞ Â›Ó·È fiÙÈ Ë Ïԛ̈ÍË ·fi ÙÔÓ Èfi Ù˘ Ë·Ù›Ùȉ·˜ C ‰ÂÓ ·ÔÙÂÏ› ·ÓÙ¤Ó‰ÂÈÍË ÁÈ· ÙÔÓ ÌËÙÚÈÎfi ıËÏ·ÛÌfi, ÂÎÙfi˜ ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ô˘ Û˘Ó˘¿Ú¯ÂÈ Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ·. øÛÙfiÛÔ ÈÛÙ‡ÂÙ·È fiÙÈ ıËϤ˜ Ì χÛË Û˘Ó¯›·˜ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ ‹ ıËϤ˜ Ô˘ ·ÈÌÔÚÚ·ÁÔ‡Ó ÌÔÚ› Ó· ·˘Í‹ÛÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ÌÂÙ¿‰ÔÛ˘ (31,32,34,35,37). ∞ÓÂÍ¿ÚÙËÙ· ·fi ÙÔÓ ·ÈÙÈÔÏÔÁÈÎfi ·Ú¿ÁÔÓÙ· Ù˘ Ë·Ù›Ùȉ·˜ A, B, ‹ C, Ô ıˆÚËÙÈÎfi˜ ΛӉ˘ÓÔ˜ ÌÂÙ¿‰ÔÛ˘ ·fi ÙÔ ÌËÙÚÈÎfi Á¿Ï· ı· Ú¤ÂÈ Ó· Û˘˙ËÙÂ›Ù·È Ì ÙÔ˘˜ ÁÔÓ›˜, ÔÈ ÔÔ›ÔÈ ı· Ú¤ÂÈ Ó· ·ÔÊ·Û›˙Ô˘Ó ÁÈ· ÙÔ Â›‰Ô˜ Ù˘ ‰È·ÙÚÔÊ‹˜ ÙÔ˘ ·È‰ÈÔ‡ ÙÔ˘˜ (31). §Ô›ÌˆÍË ·fi ¯Ï·Ì‡‰È· ∂ȉÈΤ˜ πgA ·ÓÔÛÔÛÊ·ÈÚ›Ó˜ ¤¯Ô˘Ó ·ÓȯÓ¢Ù› ÛÙÔ ‡·Ú Î·È ÛÙÔ ÌËÙÚÈÎfi Á¿Ï·. ¢ÂÓ ˘¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ ÁÈ· ÂӉ¯fiÌÂÓË ÌÂÙ¿‰ÔÛË Ù˘ ÓfiÛÔ˘ ·fi ÙÔÓ ÌËÙÚÈÎfi ıËÏ·ÛÌfi (31). §ÈÛÙÂÚ›ˆÛË ¢ÂÓ ˘¿Ú¯Ô˘Ó ·Ó·ÊÔÚ¤˜ Ô˘ Ó· ÂÓÔ¯ÔÔÈÔ‡Ó ÙÔ ÌËÙÚÈÎfi Á¿Ï· Û·Ó ËÁ‹ ÌÂÙ¿‰ÔÛ˘ Ù˘ ÏÈÛÙ¤ÚÈ·˜. ∆Ô ÌËÙÚÈÎfi Á¿Ï· ıˆÚÂ›Ù·È Î·Ù¿ÏÏËÏË ÙÚÔÊ‹ ÁÈ· ÙÔ ‚Ú¤ÊÔ˜ ˘fi ÙËÓ ÚÔ¸fiıÂÛË fiÙÈ ÁÈ· ÙË ıÂڷ›· Ù˘ ÌËÙ¤Ú·˜ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ·ÓÙÈÌÈÎÚÔ‚È·ÎÔ› ·Ú¿ÁÔÓÙ˜ Ô˘ ÂÈÙÚ¤ÔÓÙ·È Î·Ù¿ ÙÔÓ ıËÏ·ÛÌfi (31). °ÔÓÔÎÎÔÎÈ΋ Ïԛ̈ÍË ¢ÂÓ ˘¿Ú¯ÂÈ Î›Ó‰˘ÓÔ˜ ÌÂÙ¿‰ÔÛ˘ Ù˘ ÓfiÛÔ˘ ·fi ÙÔ ÌËÙÚÈÎfi Á¿Ï· (31). ™‡ÊÈÏË ¢ÂÓ ˘¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ ÁÈ· ÂӉ¯fiÌÂÓË ÌÂÙ¿‰ÔÛË Ù˘ ÓfiÛÔ˘ Ì ÙÔÓ ıËÏ·ÛÌfi, ÂÎÙfi˜ ·Ó ˘¿Ú¯Ô˘Ó ÂÓÙÔÈṲ̂Ó˜ ‚Ï¿‚˜ ÛÙÔ Ì·ÛÙfi ‹ ÙË ıËÏ‹, ÔfiÙÂ Ô ıËÏ·ÛÌfi˜ Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È, ̤¯ÚÈ Ë ÌËÙ¤Ú· Ó· ¿ÚÂÈ ıÂڷ›· Î·È Ó· ˘Ô¯ˆÚ‹ÛÔ˘Ó ÔÈ ‚Ï¿‚˜ (31). ∆ÔÍÔÏ¿Û̈ÛË ªÂÙ¿‰ÔÛË Ù˘ ÓfiÛÔ˘ ·fi ÙÔÓ ÌËÙÚÈÎfi ıËÏ·ÛÌfi ‰ÂÓ ¤¯ÂÈ ÙÂÎÌËÚȈı›. √È ıËÏ¿˙Ô˘Û˜ ÌËÙ¤Ú˜
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·281
281
ªËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ Î·È ÓÂÔϷۛ˜
ÚÔÛʤÚÔ˘Ó ÛÙ· ÓÂÔÁÓ¿ ÙÔ˘˜ ÂȉÈο ·ÓÙÈÛÒÌ·Ù· Ì ÙÔ Á¿Ï· ÙÔ˘˜. ¢ÂÓ ˘¿Ú¯ÂÈ ÏÔÈfiÓ Î·Ì›· ·ÓÙ¤Ó‰ÂÈÍË ÁÈ· ÙÔÓ ÌËÙÚÈÎfi ıËÏ·ÛÌfi (31,37). º˘Ì·Ù›ˆÛË ™ÙȘ ÂÚÈÙÒÛÂȘ ÂΛӘ Ô˘ ˘¿Ú¯ÂÈ ÌfiÓÔ ıÂÙÈ΋ ‰ÂÚÌ·ÙÈ΋ ‰ÔÎÈÌ·Û›· Ê˘Ì·Ù›Ó˘, Ô ıËÏ·ÛÌfi˜ Û˘ÓÈÛÙ¿Ù·È ·ÓÂÈʇϷÎÙ·. ∂¿Ó Ë ÌËÙ¤Ú· ¤¯ÂÈ ÂÓÂÚÁ‹ ÓfiÛÔ, ÙÔ ÓÂÔÁÓfi ·ÔÌ·ÎÚ‡ÓÂÙ·È ·fi ÙË ÌËÙ¤Ú· ÙÔ˘ ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙÔÓ ÙÔÎÂÙfi. ∆Ô Ì˘ÎÔ‚·ÎÙËÚ›‰ÈÔ Ù˘ Ê˘Ì·Ù›ˆÛ˘ ‰ÂÓ ·ÔÌÔÓÒÓÂÙ·È ÛÙÔ ÌËÙÚÈÎfi Á¿Ï·. ∏ ÌËÙ¤Ú· ÌÔÚ› Ó· ·Ê·ÈÚ› ÙÔ Á¿Ï· Ù˘ Ì ·ÓÙÏ›· Î·È Ó· ¯ÔÚËÁÂ›Ù·È ÛÙÔ ÓÂÔÁÓfi Ù˘ ·fi ¿ÏÏÔ ¿ÙÔÌÔ. ∏ ÌfiÓË ·ÓÙ¤Ó‰ÂÈÍË ¯ÔÚ‹ÁËÛ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÎÙÔ˜ Â›Ó·È Ë Ê˘Ì·ÙÈ҉˘ Ì·ÛÙ›Ùȉ· Ù˘ ÌËÙ¤Ú·˜. ™ÙËÓ ÂÈÏÔÁ‹ Ù˘ ·ÓÙÈÊ˘Ì·ÙÈ΋˜ ·ÁˆÁ‹˜ ÛÙË ÌËÙ¤Ú· Ï·Ì‚¿ÓÂÙ·È ˘fi„Ë Ë ÂӉ¯fiÌÂÓË ·¤ÎÎÚÈÛË ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÛÙÔ ÌËÙÚÈÎfi Á¿Ï· Î·È ÔÈ ÂȉڿÛÂȘ ÛÙËÓ ˘Á›· ÙÔ˘ ÓÂÔÁÓÔ‡. ∏ ·ÔÌ¿ÎÚ˘ÓÛË ÙÔ˘ ÓÂÔÁÓÔ‡ ÂÊ·ÚÌfi˙ÂÙ·È Ì¤¯ÚÈ Ó· ·Ô‰Âȯı› fiÙÈ Ë ÌËÙ¤Ú· ‰ÂÓ ÌÂÙ·‰›‰ÂÈ ÙË ÓfiÛÔ (31,32,35,37).
¡ÔÛ‹Ì·Ù· ÌÂÙ·‚ÔÏÈÛÌÔ‡ °·Ï·ÎÙÔ˙·ÈÌ›· ∏ Á·Ï·ÎÙÔ˙·ÈÌ›· Â›Ó·È ÌÈ· ÓfiÛÔ˜ Ô˘ ÔÊ›ÏÂÙ·È Û ·Ó¿ÚÎÂÈ· ÙÔ˘ ÂÓ˙‡ÌÔ˘ galactose-1-phosphate uridyl transferase. ™ÙËÓ ÎÏ·ÛÈ΋ Ù˘ ÌÔÚÊ‹ Ë ¤ÏÏÂÈ„Ë ÙÔ˘ ÂÓ˙‡ÌÔ˘ Â›Ó·È Ï‹Ú˘ Î·È ÙÔ ÓÂÔÁÓfi ‰ÂÓ ÌÔÚ› Ó· ·Ó¯Ù› ÙËÓ ·ÚÔ˘Û›· Á·Ï·ÎÙfi˙˘ ÛÙË ‰›·ÈÙ¿ ÙÔ˘, ÂÔ̤ӈ˜ Ô ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ ‰ÂÓ Â›Ó·È ·ÓÂÎÙfi˜ Î·È ‰ÂÓ ÂÈÙÚ¤ÂÙ·È. À¿Ú¯Ô˘Ó fï˜ Î·È ÌÔÚʤ˜ fiÔ˘ Ë ·Ó¿ÚÎÂÈ· ÙÔ˘ ÂÓ˙‡ÌÔ˘ ‰ÂÓ Â›Ó·È Ï‹Ú˘ Î·È Î¿ÔÈ· ÔÛfiÙËÙ· Á·Ï·ÎÙfi˙˘ ÌÔÚ› Ó· Â›Ó·È ·ÓÂÎÙ‹ ·fi ÙÔ ÓÂÔÁÓfi, ÔfiÙÂ Î·È ÙÔ Á¿Ï· Ù˘ ÌËÙ¤Ú·˜ ÙÔ˘ ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› ÁÈ· Ó· ηχ„ÂÈ ÙÌ‹Ì· ÙˆÓ ‰È·ÙÚÔÊÈÎÒÓ ÙÔ˘ ·Ó·ÁÎÒÓ (2,31,32,37). º·ÈÓ˘ÏÎÂÙÔÓÔ˘Ú›· ∏ Ê·ÈÓ˘ÏÎÂÙÔÓÔ˘Ú›· ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ‰˘Û·ÓÂÍ›· ÛÙË Ê·ÈÓ˘Ï·Ï·Ó›ÓË. ∆Ô ÌËÙÚÈÎfi Á¿Ï· Â›Ó·È ÁÓˆÛÙfi fiÙÈ ÂÚȤ¯ÂÈ ÌÈÎÚ¿ ÔÛ¿ Ê·ÈÓ˘Ï·Ï·Ó›Ó˘. ∏ ÚÔÛÊÔÚ¿ οÔÈˆÓ ÔÛÔÙ‹ÙˆÓ ÌËÙÚÈÎÔ‡ Á¿Ï·ÎÙÔ˜ Î·È Ë ÚÔÛı‹ÎË ÂȉÈÎÔ‡ Á¿Ï·ÙÔ˜ ÂχıÂÚÔ˘ Û ʷÈÓ˘Ï·Ï·Ó›ÓË ˆ˜ Û˘ÌÏËڈ̷ÙÈ΋ ‰È·ÙÚÔÊ‹ Â›Ó·È Ë È‰·ÓÈÎfiÙÂÚË Ï‡ÛË (32,37). ¡fiÛÔ˜ Wilson ™ÙȘ ÂÚÈÙÒÛÂȘ Ô˘ Ë ÌËÙ¤Ú· ¿Û¯ÂÈ ·fi ÓfiÛÔ ÙÔ˘ Wilson Ô˘ ÛÙË ÏÂÈÔ„ËÊ›· ÙˆÓ ÂÚÈÙÒÛÂˆÓ ‚Ú›ÛÎÂÙ·È ˘fi ıÂڷ›· Ì ÂÓÈÎÈÏÏ·Ì›ÓË, Ô ıËÏ·ÛÌfi˜ ‰ÂÓ ÂÈÙÚ¤ÂÙ·È. ∏ ÂÓÈÎÈÏÏ·Ì›ÓË ·ÂÎÎÚ›ÓÂÙ·È ·fi ÙÔ ÌËÙÚÈÎfi Á¿Ï· Î·È ÂÎÙfi˜ ·fi ÙÔÓ ¯·ÏÎfi, ‰ÂÛ̇ÂÈ ÙÔ Ì·ÁÓ‹ÛÈÔ Î·È ÙÔÓ Û›‰ËÚÔ (32).
™˘Ó‹ıÂȘ Ù˘ ıËÏ¿˙Ô˘Û·˜ ÌËÙ¤Ú·˜ ¢ÈÔÚıˆÙÈΤ˜ ÂÂÌ‚¿ÛÂȘ ÙÔ˘ ÛÙ‹ıÔ˘˜ Ì ÛÈÏÈÎfiÓË ∞ÔÙÂÏ› ÌÈ· Û˘Ó‹ıË Ù·ÎÙÈ΋ ÛÙȘ ∏¶∞ fiÔ˘ ·Ó·Ê¤ÚÔÓÙ·È ÂÚÈÛÛfiÙÂÚ˜ ·fi 200.000 ÂÂÌ‚¿ÛÂȘ ÂÙËÛ›ˆ˜, Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·. √È ÂÚÈÛÛfiÙÂÚ˜ ·fi ·˘Ù¤˜ Â›Ó·È Û ¤Ê˂˜ Î·È Ó·ڤ˜ ÂÓ‹ÏÈΘ Á˘Ó·›Î˜. ™‡Ìʈӷ Ì ÙËÓ ∞ÌÂÚÈηÓÈ΋ ∞η‰ËÌ›· ¶·È‰È·ÙÚÈ΋˜ ‰ÂÓ ·ÔÙÂÏ› ·ÓÙ¤Ó‰ÂÈÍË ÁÈ· ÙÔÓ ÌËÙÚÈÎfi ıËÏ·ÛÌfi (38). øÛÙfiÛÔ, ¤¯Ô˘Ó ‰ËÌÈÔ˘ÚÁËı› ÂÚˆÙËÌ·ÙÈο, ηıÒ˜ ‰ÂÓ ˘¿Ú¯Ô˘Ó ·ÚÎÂÙ¤˜ ÌÂϤÙ˜ Ô˘ Ó· ÙÂÎÌËÚÈÒÓÔ˘Ó ÙËÓ ·ÛÊ¿ÏÂÈ· ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ (39). ¢È·ÈÙËÙÈΤ˜ Û˘Ó‹ıÂȘ ∏ ÌËÙ¤Ú· Ì ÙÔ Á¿Ï· Ù˘ ηχÙÂÈ ÙȘ ‰È·ÙÚÔÊÈΤ˜ ·Ó¿ÁΘ ÙÔ˘ ‚Ú¤ÊÔ˘˜ Ù˘, ·Ú¤¯ÔÓÙ¿˜ ÙÔ˘ fiÏ· Ù· ··Ú·›ÙËÙ· ıÚÂÙÈο Û˘ÛÙ·ÙÈο, fiˆ˜ ÚˆÙ½Ó˜, Ï›Ë, ˘‰·Ù¿ÓıڷΘ, ‚Èٷ̛Ә, ȯÓÔÛÙÔȯ›· ÛÙË ÛˆÛÙ‹ ·Ó·ÏÔÁ›· ÁÈ· ÙËÓ ÔÌ·Ï‹ ÙÔ˘ ·Ó¿Ù˘ÍË. À¿Ú¯Ô˘Ó fï˜ ÂÚÈÙÒÛÂȘ ÌËÙ¤ÚˆÓ Ô˘ Ë ‰È·ÙÚÔÊ‹ ÙÔ˘˜ Â›Ó·È ÚÔÛ·ÚÌÔṲ̂ÓË, fi¯È Û‡Ìʈӷ Ì ÙȘ ·Ó¿ÁΘ ÙÔ˘˜, ·ÏÏ¿ Û‡Ìʈӷ Ì ÔÏÈÙÈÛÌÈΤ˜ ‹ ÚÔÛˆÈΤ˜ ÂÔÈı‹ÛÂȘ. ÃÔÚÙÔÊ·Á›·, ·ÔÊ˘Á‹ Á·Ï·ÎÙÔÎÔÌÈÎÒÓ ÚÔ˚fiÓÙˆÓ, ˘ÔıÂÚÌȉÈ΋ ‰È·ÙÚÔÊ‹, Â›Ó·È ÌÂÚÈΤ˜ ·fi ·˘Ù¤˜ ÙȘ ηÙËÁÔڛ˜ ‰È·ÈÙËÙÈ΋˜ Û˘ÌÂÚÈÊÔÚ¿˜. √È ÌËÙ¤Ú˜ ÂÓËÌÂÚÒÓÔÓÙ·È ÁÈ· ÙËÓ ÂӉ¯fiÌÂÓË ‰È·ÈÙËÙÈ΋ ·Ó¿ÚÎÂÈ¿ ÙÔ˘˜ Î·È ÂÓı·ÚÚ‡ÓÔÓÙ·È Ó· ·›ÚÓÔ˘Ó Û˘ÌÏËÚÒÌ·Ù· ‰È·ÙÚÔÊ‹˜ Ì ÛÙfi¯Ô ÙËÓ ÂÍ·ÛÊ¿ÏÈÛË ÏËÚ¤ÛÙÂÚ˘ ‰È·ÙÚÔÊÈ΋˜ ¿ÚÎÂÈ·˜ ÛÙÔ ‚Ú¤ÊÔ˜ ÙÔ˘˜ (32,37). ∫¿ÓÈÛÌ· ∆Ô Î¿ÓÈÛÌ· Ù˘ ÌËÙ¤Ú·˜ ‰ÂÓ ·ÔÙÂÏ› ·ÓÙ¤Ó‰ÂÈÍË ÁÈ· ÙÔÓ ıËÏ·ÛÌfi, ˆÛÙfiÛÔ Ë ÌËÙ¤Ú· Ú¤ÂÈ Ó· ÂÓı·ÚÚ‡ÓÂÙ·È Ó· ÌËÓ Î·Ó›˙ÂÈ ÛÙÔ ÂÚÈ‚¿ÏÏÔÓ ÙÔ˘ ÛÈÙÈÔ‡ Î·È Ó· ηٷ‚¿ÏÂÈ Î¿ı ‰˘Ó·Ù‹ ÚÔÛ¿ıÂÈ· Ó· ‰È·Îfi„ÂÈ ÙÔ Î¿ÓÈÛÌ· fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ ÈÔ Û‡ÓÙÔÌ· (2,38). ∞ÏÎÔfiÏ √È ıËÏ¿˙Ô˘Û˜ ÌËÙ¤Ú˜ Ú¤ÂÈ Ó· ·ÔʇÁÔ˘Ó ÙË Ï‹„Ë ·ÏÎÔÔÏÔ‡¯ˆÓ ÔÙÒÓ, ÂÂȉ‹ ÙÔ ·ÏÎÔfiÏ Û˘ÁÎÂÓÙÚÒÓÂÙ·È ÛÙÔ ÌËÙÚÈÎfi Á¿Ï· Î·È Ë ¯Ú‹ÛË ÙÔ˘ ·Ó·ÛÙ¤ÏÏÂÈ ÙËÓ ·Ú·ÁˆÁ‹ ÌËÙÚÈÎÔ‡ Á¿Ï·ÎÙÔ˜. ¶ÂÚÈÛÙ·Ûȷ΋ Ï‹„Ë ÂÓfi˜ ÌÈÎÚÔ‡ ·ÏÎÔÔÏÔ‡¯Ô˘ ÔÙÔ‡ Â›Ó·È ·Ô‰ÂÎÙ‹, ·ÏÏ¿ Ô ıËÏ·ÛÌfi˜ Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È ÁÈ· 2 ÒÚ˜ ÌÂÙ¿ ·fi ÙË Ï‹„Ë ÙÔ˘ (2,40). ÃÚ‹ÛË Ó·ÚΈÙÈÎÒÓ Ô˘ÛÈÒÓ ∏ ¯Ú‹ÛË ·fi ÙË ÌËÙ¤Ú· Ó·ÚΈÙÈÎÒÓ Ô˘ÛÈÒÓ ·ÔÙÂÏ› ·ÓÙ¤Ó‰ÂÈÍË ÁÈ· ıËÏ·ÛÌfi (2). ¶·È‰È·ÙÚÈ΋ 2007;70:278-284
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·282
282
∂. ÷Ù˙ˉ¿ÎË, Ã. °È·ÓÓ·ÎÔÔ‡ÏÔ˘
ŒÎıÂÛË ÛÂ Ê˘ÙÔÊ¿Ú̷η Î·È ·Ú·ÛÈÙÔÎÙfiÓ· ™Â ÂÚÈÙÒÛÂȘ ·Û˘Ó‹ıÈÛÙ· ˘„ËÏ‹˜ ÂÚÈ‚·ÏÏÔÓÙÈ΋˜ ÊfiÚÙÈÛ˘ ÔÈ ÌËÙ¤Ú˜ Â›Ó·È ‰˘ÓËÙÈο Û ΛӉ˘ÓÔ. ∫¿ı ÂÚ›ÙˆÛË ÌÂÏÂÙ¿Ù·È Ì ÚÔÛÔ¯‹ (32). ŒÎıÂÛË Û ‚·Ú¤· ̤ٷÏÏ· Œ¯ÂÈ ·Ó·ÊÂÚı› ¤ÎıÂÛË ‚ÚÂÊÒÓ Û ‚·Ú¤· ̤ٷÏÏ· fiˆ˜ ÌfiÏ˘‚‰Ô, ˘‰Ú¿ÚÁ˘ÚÔ, ·ÚÛÂÓÈÎfi, Î·È Î¿‰ÌÈÔ. ∏ ¤ÎıÂÛË ·˘Ù‹ ÌÔÚ› Ó· Û¯ÂÙ›˙ÂÙ·È Ì ÙË ‰È·ı¤ÛÈÌË ·ÚÔ¯‹ ÓÂÚÔ‡ Ù˘ Û˘ÁÎÂÎÚÈ̤Ó˘ ÂÚÈÔ¯‹˜, ÙÔ Á¿Ï· ·ÁÂÏ¿‰·˜ ·ÏÏ¿ Î·È ÙÔ ÙÚÔÔÔÈË̤ÓÔ Á¿Ï· ·ÁÂÏ¿‰·˜. øÛÙfiÛÔ Ë ¤ÎıÂÛË ÁÈ· Ù· ÓÂÔÁÓ¿ Ô˘ ÛÈÙ›˙ÔÓÙ·È Ì ÌËÙÚÈÎfi Á¿Ï· Â›Ó·È ÂÚÈÔÚÈṲ̂ÓË Û ۯ¤ÛË Ì ÙË Û›ÙÈÛË Ì ÙÚÔÔÔÈË̤ÓÔ Á¿Ï· ·ÁÂÏ¿‰·˜, ·ÎfiÌ· Î·È Û ÁˆÁÚ·ÊÈΤ˜ ÂÚÈÔ¯¤˜ Ô˘ ˘¿Ú¯Ô˘Ó ˘„ËÏ¿ ›‰· ÙÔ˘ ÌÂÙ¿ÏÏÔ˘ (32,37). ªfiÏ˘‚‰Ô˜: √ ÌfiÏ˘‚‰Ô˜ ‰È¤Ú¯ÂÙ·È ÙÔÓ Ï·ÎÔ‡ÓÙ·, Î·È ·ÂÎÎÚ›ÓÂÙ·È Î·È ÛÙÔ ÌËÙÚÈÎfi Á¿Ï·. ∂¿Ó Ù· ›‰· ÙÔ˘ ÌÔχ‚‰Ô˘ ÛÙË ÌËÙ¤Ú· Â›Ó·È ÌÈÎÚfiÙÂÚ· ÙˆÓ 40 Ìg/dl, Ô ıËÏ·ÛÌfi˜ ıˆÚÂ›Ù·È ·ÛÊ·Ï‹˜. ∏ ÁÂÓÈÎfiÙÂÚË ÛÙÚ·ÙËÁÈ΋ fiÛÔÓ ·ÊÔÚ¿ ÙÔÓ ıËÏ·ÛÌfi ÛÙȘ ÂÚÈÙÒÛÂȘ ¤ÎıÂÛ˘ Û ‚·Ú¤· ̤ٷÏÏ· ÂÍ·ÚÙ¿Ù·È ¿ÌÂÛ· ·fi ÙÔ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi Â›Â‰Ô Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ Î·È ÙË ‰˘Ó·ÙfiÙËÙ¿ Ù˘ Ó· ¯ÔÚËÁ‹ÛÂÈ ÛÙÔ ÓÂÔÁÓfi ÙÚÔÔÔÈË̤ÓÔ Á¿Ï· ·ÁÂÏ¿‰·˜. ™Â ÌÂÚÈΤ˜ ÂÚÈÙÒÛÂȘ Ë ÂÚÈ‚·ÏÏÔÓÙÈ΋ ÊfiÚÙÈÛË Â›Ó·È ÌÂÁ¿ÏË Î·È ÙÔ Ù¯ÓËÙ¿ ·Ú·Û΢·˙fiÌÂÓÔ Á¿Ï· ÂÎı¤ÙÂÈ ÙÔ ‚Ú¤ÊÔ˜ Û ÌÂÁ·Ï‡ÙÂÚ· ÔÛ¿ ÌÂÙ¿ÏÏÔ˘ Û ۯ¤ÛË Ì ÙÔ ÌËÙÚÈÎfi (32,37). À‰Ú¿ÚÁ˘ÚÔ˜: ŒÎıÂÛË Û ˘‰Ú¿ÚÁ˘ÚÔ ¤¯ÂÈ ·Ó·ÊÂÚı› Û ԉÔÓÙÈ·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜ Î·È Ô‰ÔÓÙÈ¿ÙÚÔ˘˜, Î·È ÌÂÙ¿ ·fi ηٷӿψÛË ÌÔÏ˘ÛÌ¤ÓˆÓ ı·Ï·ÛÛÈÓÒÓ Î·È „·ÚÈÒÓ. ªÂϤÙ˜ Ô˘ ‰ÈÂÓÂÚÁ‹ıËÎ·Ó ÛÙ· ÓËÛÈ¿ ™Â¸¯¤ÏϘ Û ·È‰È¿ Ô˘ ÂÎÙ¤ıËÎ·Ó ÛÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ Ì¤Ù·ÏÏÔ ÌÂÙ¿ ·fi ηٷӿψÛË ÌÔÏ˘ÛÌ¤ÓˆÓ „·ÚÈÒÓ, ‰ÂÓ ‰È·ÈÛÙÒıËΠΛӉ˘ÓÔ˜ ·fi ÙËÓ ÂÈϤÔÓ ¤ÎıÂÛË Û ÌËÙÚÈÎfi Á¿Ï·. ∏ Ó¢ÚÔ·Ó·Ù˘Íȷ΋ ÂͤÏÈÍË ÙˆÓ ·È‰ÈÒÓ Ô˘ ı‹Ï·˙·Ó ‹Ù·Ó ηχÙÂÚË Û ۯ¤ÛË Ì ·˘Ù¿ Ô˘ ÛÈÙ›ÛÙËÎ·Ó Ì Ù¯ÓËÙ‹ ‰È·ÙÚÔÊ‹ (32,37). ∫¿‰ÌÈÔ: ∆Ô Î¿‰ÌÈÔ Â›Ó·È ÁÓˆÛÙfi fiÙÈ ‰È¤Ú¯ÂÙ·È ÙÔÓ Ï·ÎÔ‡ÓÙ·. ŒÎıÂÛË ¤¯ÂÈ ·Ó·ÊÂÚı› Û ‚ÈÔÌ˯·ÓÈΤ˜ ÂÚÈÔ¯¤˜ Î·È Û ‚·Ú›˜ ηÓÈÛÙ¤˜. ∆Ô ¤Ì‚Ú˘Ô ¤¯ÂÈ ‹‰Ë ÂÎÙÂı› ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘. ∏ ÌËÙ¤Ú· ı· Ú¤ÂÈ Ó· ÂÓËÌÂÚÒÓÂÙ·È ÁÈ· ÙÔÓ ÂӉ¯fiÌÂÓÔ Î›Ó‰˘ÓÔ ·fi ÙË ¯ÔÚ‹ÁËÛË ÌËÙÚÈÎÔ‡ Á¿Ï·ÙÔ˜ ÛÙÔ ‚Ú¤ÊÔ˜ Ù˘ Û ۯ¤ÛË Ì ÙÔ fiÊÂÏÔ˜ Î·È Ó· ·ÔÊ·Û›˙ÂÈ. ªÂÚÈÎÔ› ÚÔÙ›ÓÔ˘Ó ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÙÔ˘ ÌÂÙ¿ÏÏÔ˘ ÛÙÔ ·›Ì· Ù˘ ıËÏ¿˙Ô˘Û·˜ fiÙ·Ó Ë ¤ÎıÂÛË Â›Ó·È ·Û˘Ó‹ıÈÛÙ· ÛËÌ·ÓÙÈ΋ (32,37). ƒ·‰ÈÔÓÔ˘ÎÏÂÔÙ›‰È·: ∏ ÂÚÈ‚·ÏÏÔÓÙÈ΋ ¤ÎıÂÛË Û ڷ‰ÈÔÓÔ˘ÎÏÂÔÙ›‰È· ¤¯ÂÈ ··Û¯ÔÏ‹ÛÂÈ Â› ‰ÂηÂٛ˜ ÙÔ˘˜ ÂÚ¢ÓËÙ¤˜. øÛÙfiÛÔ, ÚÔÛÂÎÙÈΤ˜ ÂÎÙÈÌ‹ÛÂȘ Paediatriki 2007;70:278-284
ηٿ ÙË ‰È¿ÚÎÂÈ· ˘ÚËÓÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ ·ÔÎ¿Ï˘„·Ó, fiÙÈ Ù· ›‰· ÙÔ˘ ÛÙÚÔÓÙ›Ô˘ (strontium 90) ÛÙÔ ÌËÙÚÈÎfi Á¿Ï· Â›Ó·È ÌÈÎÚfiÙÂÚ· ·fi ·˘Ù¿ Ô˘ ˘¿Ú¯Ô˘Ó ÛÙÔ ÙÚÔÔÔÈË̤ÓÔ Á¿Ï· ·ÁÂÏ¿‰·˜, ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰·˜ Î·È ÛÙÔ ÓÂÚfi (32,37).
§‹„Ë Ê·Ú̷΢ÙÈÎÒÓ Ô˘ÛÈÒÓ ·fi ÙË ÌËÙ¤Ú· ¶ÔÏϤ˜ ÌËÙ¤Ú˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ Ïԯ›·˜ ¯ÚËÛÈÌÔÔÈÔ‡Ó ‰È¿ÊÔÚ· Ê·Ú̷΢ÙÈο Û΢¿ÛÌ·Ù·. ∏ ÁÓÒÛË Ù˘ Ê·ÚÌ·ÎÔÎÈÓËÙÈ΋˜ Î·È Ù˘ ‚ÈԉȷıÂÛÈÌfiÙËÙ·˜ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÛÙË ÌËÙ¤Ú· Î·È ÛÙÔ ÓÂÔÁÓfi, Î·È ÙˆÓ ÂӉ¯fiÌÂÓˆÓ ÂȉڿÛÂˆÓ ÛÙËÓ ˘Á›· ÙÔ˘˜, Â›Ó·È ÚˆÙÂ‡Ô˘Û·˜ ÛËÌ·Û›·˜. À¿Ú¯Ô˘Ó οÔȘ ÂÚÈÙÒÛÂȘ Ô˘ Ë ¯ÔÚ‹ÁËÛË ÙÔ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÙÔ˜ ‰ÂÓ Â›Ó·È ·ÛÊ·Ï‹˜. °È· Ó· ÚÔÙ›ÓÔ˘Ì ÙË Û˘Ó¤¯ÈÛË ‹ ÙË ‰È·ÎÔ‹ ÙÔ˘ ıËÏ·ÛÌÔ‡, Â›Ó·È ··Ú·›ÙËÙÔ Ó· Û˘ÓÂÎÙÈÌ‹ÛÔ˘Ì ÔÏÏÔ‡˜ ·Ú¿ÁÔÓÙ˜, fiˆ˜ Ë ·Ó·ÁηÈfiÙËÙ· Ù˘ ¯ÔÚ‹ÁËÛ˘ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ ÛÙË ÌËÙ¤Ú·, Ë ‰˘Ó·ÙfiÙËÙ· ·ÓÙÈηٿÛÙ·Û‹˜ ÙÔ˘ Ì Û΢¿ÛÌ·Ù· Ô˘ ·ÂÎÎÚ›ÓÔÓÙ·È ÛÙÔ ÌËÙÚÈÎfi Á¿Ï· Û ÌÈÎÚfiÙÂÚ˜ ÔÛfiÙËÙ˜ Î·È Ë Ú‡ıÌÈÛË ÙˆÓ ÌÂÛԉȷÛÙËÌ¿ÙˆÓ ¯ÔÚ‹ÁËÛ˘, ¤ÙÛÈ ÒÛÙÂ Ë Ì¤ÁÈÛÙË Û˘ÁΤÓÙÚˆÛË ÛÙÔ Ï¿ÛÌ· Ó· ·¤¯ÂÈ ¯ÚÔÓÈο ηٿ ÙÔ ‰˘Ó·ÙfiÓ ÂÚÈÛÛfiÙÂÚÔ ·fi ÙËÓ ÒÚ· ÙˆÓ ÁÂ˘Ì¿ÙˆÓ ÙÔ˘ ‚Ú¤ÊÔ˘˜. À¿Ú¯Ô˘Ó ÂÚÈÙÒÛÂȘ fiˆ˜, Ï‹„Ë ·Ó·ÈÛıËÛ›·˜ ‹ Ú·‰ÈÔÊ·ÚÌ¿ÎˆÓ ÁÈ· ‰È·ÁÓˆÛÙÈÎÔ‡˜ ÏfiÁÔ˘˜, ηٿ ÙȘ Ôԛ˜ ÌÔÚ› Ó· ‰È·ÎÔ› ÚÔÛˆÚÈÓ¿ Ô ıËÏ·ÛÌfi˜ Î·È ÛÙË Û˘Ó¤¯ÂÈ· Ë ÌËÙ¤Ú· Ó· ıËÏ¿˙ÂÈ ÙÔ ‚Ú¤ÊÔ˜ Ù˘ ¯ˆÚ›˜ Úfi‚ÏËÌ· (36,38,41). ™ËÌ·ÓÙÈ΋ ›Û˘ ·Ú¿ÌÂÙÚÔ ·ÔÙÂÏ› Î·È Ë ËÏÈΛ· ÙÔ˘ ‚Ú¤ÊÔ˘˜ Ô˘ ıËÏ¿˙ÂÈ. ∆Ô ÓÂÔÁÓfi Î·È ÙÔ ÌÈÎÚfi ‚Ú¤ÊÔ˜ Â›Ó·È ÈÔ Â˘·›ÛıËÙÔ ·fi ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ‚Ú¤ÊÔ˜ ÂÍ·ÈÙ›·˜ Ù˘ ·ÓˆÚÈÌfiÙËÙ·˜ ÙfiÛÔ ÙˆÓ Ì˯·ÓÈÛÌÒÓ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÙˆÓ Ê·ÚÌ¿ÎˆÓ ÛÙÔ ‹·Ú, fiÛÔ Î·È Ù˘ ÓÂÊÚÈ΋˜ ·¤ÎÎÚÈÛ˘ (41). ∏ ¯Ú‹ÛË ·ÓÙÈÓÂÔÏ·ÛÌ·ÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ·fi ÙË ÌËÙ¤Ú· Î·È Ë ¤ÎıÂÛË ÙÔ˘ ‚Ú¤ÊÔ˘˜ Û ·ÓÙÈÓÂÔÏ·ÛÌ·ÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÛÙË Ê¿ÛË Ô˘ Ë ·Ó¿Ù˘ÍË ÙˆÓ ÈÛÙÒÓ ÙÔ˘ Â›Ó·È Ù·¯‡Ù·ÙË Û›ÁÔ˘Ú· ÚÔ‚ÏËÌ·Ù›˙ÂÈ. ∞Ó Î·È ‰ÂÓ ˘¿Ú¯Ô˘Ó ÌÂϤÙ˜ Ô˘ Ó· ÙÂÎÌËÚÈÒÓÔ˘Ó Î˘ÙÙ·ÚÈ΋ ‹ ÔÚÁ·ÓÈ΋ ‚Ï¿‚Ë, Ô ıËÏ·ÛÌfi˜ Û ·˘Ù¤˜ ÙȘ ÂÚÈÙÒÛÂȘ Ô˘ Ë ÌËÙ¤Ú· Â›Ó·È ˘fi ·ÁˆÁ‹ Ì ·ÓÙÈÌÂÙ·‚Ôϛ٘ ‹ ¯ËÌÂÈÔıÂڷ¢ÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, ·ÓÙÂӉ›ÎÓ˘Ù·È. ∏ ¯Ú‹ÛË Ú·‰ÈÔ˚ÛÔÙfiˆÓ ÁÈ· ‰È·ÁÓˆÛÙÈÎÔ‡˜ ‹ ıÂڷ¢ÙÈÎÔ‡˜ ÛÎÔÔ‡˜ ·ÔÙÂÏ› ·ÓÙ¤Ó‰ÂÈÍË ÁÈ· ıËÏ·ÛÌfi ÁÈ· fiÛÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ·ÂÎÎÚ›ÓÂÙ·È ÙÔ Ú·‰ÈÔ˚ÛfiÙÔÔ ÛÙÔ ÌËÙÚÈÎfi Á¿Ï· (2,38,41). ∏ ¯Ú‹ÛË Ù˘ ·ÛÈÚ›Ó˘ ·fi ÙË ıËÏ¿˙Ô˘Û· Ú¤ÂÈ Ó· Á›ÓÂÙ·È Ì ÚÔÛÔ¯‹. ªÔÚ› Ó· ÚÔηϤÛÂÈ ‰È·Ù·Ú·¯‹ ÛÙË ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ, ·ÈÌÔÚÚ·ÁÈ΋ ‰È¿ıÂÛË Î·È ÌÂÙ·‚ÔÏÈ΋ ÔͤˆÛË. ¶ÚÔÙ›ÓÂÙ·È ÛÙȘ ÌËÙ¤Ú˜ Ô˘ ıËÏ¿˙Ô˘Ó Ù· ÓÂÔÁÓ¿ ‹ Ù· Ôχ ÌÈÎÚ¿ ‚Ú¤ÊË ÙÔ˘˜ ηÈ
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·283
283
∞ÓÙÂӉ›ÍÂȘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡
¯ÚÂÈ¿˙ÔÓÙ·È ·ÓÙÈÊÏÂÁÌÔÓÒ‰ÂȘ ·Ú¿ÁÔÓÙ˜, Ó· ·›ÚÓÔ˘Ó È‚Ô˘ÚÔ˘Ê¤ÓË ‹ Ó·ÚÔͤÓË (38,41,42). ∏ ¯Ú‹ÛË ‚-·Ó·ÛÙÔϤˆÓ ·fi ÙË ÌËÙ¤Ú· ¤¯ÂÈ Û˘Û¯ÂÙÈÛı› Ì ˘fiÙ·ÛË, ‚Ú·‰˘Î·Ú‰›· Î·È Ù·¯‡ÓÔÈ· Û ÌÈÎÚ¿ ‚Ú¤ÊË. ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ Ë ÛÔÙ·ÏfiÏË Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È, Ë ·ÙÂÓÔÏfiÏË Ó· ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ì ÚÔÛÔ¯‹Ø Ë Ï·‚ÂÙ·ÏfiÏË Î·È Ë ÚÔÚ·ÓÔÏfiÏË Â›Ó·È ÁÂÓÈο Û˘Ì‚·Ù¤˜ Ì ÙÔÓ ıËÏ·ÛÌfi Ì ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Î·È ÙÔ˘ ηډȷÎÔ‡ Ú˘ıÌÔ‡ ÙÔ˘ ‚Ú¤ÊÔ˘˜ (38,41,42). ∏ ¯Ú‹ÛË ¯ÏˆÚ·ÌÊÂÓÈÎfiÏ˘ Ú¤ÂÈ Ó· ‰È·ÎfiÙÂÙ·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡, ÂÍ·ÈÙ›·˜ ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÙÔÍÈÎfiÙËÙ·˜ ÛÙÔÓ Ì˘ÂÏfi ÙˆÓ ÔÛÙÒÓ. ¶ÚÔÙ›ÓÂÙ·È ·Ó·ÌÔÓ‹ 24 ˆÚÒÓ ·fi ÙËÓ ÙÂÏÂ˘Ù·›· ‰fiÛË ÚÈÓ ÙËÓ ¤Ó·ÚÍË ÙÔ˘ ıËÏ·ÛÌÔ‡. ∫·È ÁÈ· ÙË ¯Ú‹ÛË Ù˘ ÎÏÈÓÙ·Ì˘Î›Ó˘ ÚÔÙ›ÓÂÙ·È ·ÔÊ˘Á‹ ηٿ ÙÔÓ ıËÏ·ÛÌfi. ¶ÚÔÙ›ÓÂÙ·È ·Ó·ÌÔÓ‹ 24 ˆÚÒÓ ·fi ÙËÓ ÙÂÏÂ˘Ù·›· ‰fiÛË ÚÈÓ ÙËÓ ¤Ó·ÚÍË ÙÔ˘ ıËÏ·ÛÌÔ‡. ∞Ó¿ÏÔÁË Ô‰ËÁ›· ·ÔÊ˘Á‹˜ ÈÛ¯‡ÂÈ Î·È ÁÈ· ÙË ÌÂÙÚÔÓȉ·˙fiÏË Ì ÚÔÙÂÈÓfiÌÂÓÔ ‰È¿ÛÙËÌ· ·ÔÊ˘Á‹˜ ÙȘ 12 Ì 24 ÒÚ˜ (42). ∞Ó ¤Ó· ‚Ú¤ÊÔ˜ ¤¯ÂÈ ¤ÏÏÂÈ„Ë G6PD, Ë ¯Ú‹ÛË ·fi ÙË ÌËÙ¤Ú· ÙÔ˘ Ó·ÏȉÈÍÈÎÔ‡ ÔͤԘ, ÓÈÙÚÔÊÔ˘Ú·ÓÙÔ˝Ó˘, Î·È ÛÔ˘ÏÊÔÓ·ÌȉÒÓ Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È (34). ∆· „˘¯ÔÙÚfi· Ê·Ú̷΢ÙÈο Û΢¿ÛÌ·Ù· ·ÂÎÎÚ›ÓÔÓÙ·È ÛÙÔ ÌËÙÚÈÎfi Á¿Ï·. ∏ Û˘ÁΤÓÙÚˆÛ‹ ÙÔ˘˜ ÌÔÚ› Ó· Â›Ó·È ¯·ÌËÏ‹ ·ÏÏ¿ Ô ¯ÚfiÓÔ˜ ËÌÈ˙ˆ‹˜ Â›Ó·È ÌÂÁ¿ÏÔ˜. ∏ ¯Ú‹ÛË ÙÔ˘˜ ·fi ÙË ıËÏ¿˙Ô˘Û· ÌËÙ¤Ú· ¤¯ÂÈ Û˘Û¯ÂÙÈÛı› Ì ¿ÏÏÔÙ ¿ÏϘ Û˘Ó¤ÂȘ ÁÈ· ÙÔÓ ÂÁΤʷÏÔ ÙˆÓ ‚ÚÂÊÒÓ, Ô˘ fiˆ˜ Â›Ó·È ÁÓˆÛÙfi ·Ó·Ù‡ÛÛÂÙ·È Ì ÁÚ‹ÁÔÚÔ˘˜ Ú˘ıÌÔ‡˜. ∏ ·fiÊ·ÛË ÁÈ· ÙË ¯ÔÚ‹ÁËÛË ‹ fi¯È ÌËÙÚÈÎÔ‡ Á¿Ï·ÙÔ˜ ı· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ÌÂÙ¿ ·fi ÂÎÙÂÓ‹ Î·È ÏÂÙÔÌÂÚ‹ Û˘˙‹ÙËÛË ÌÂٷ͇ ÙÔ˘ ıÂÚ¿ÔÓÙÔ˜ ÁÈ·ÙÚÔ‡ Î·È Ù˘ ÌËÙ¤Ú·˜, Û¯ÂÙÈο Ì ÙȘ ÂӉ¯fiÌÂÓ˜ Û˘Ó¤ÂȘ ÁÈ· ÙÔ ÓÂÔÁÓfi Û ۯ¤ÛË Ì ÙÔ fiÊÂÏÔ˜ ·fi ÙË ¯Ú‹ÛË ÙÔ˘. °ÂÓÈÎfiÙÂÚ·, ÔÈ Î·Ù¢ı˘ÓÙ‹ÚȘ ÁÚ·Ì̤˜ ÚÔÙ›ÓÔ˘Ó ÙËÓ ·ÔÊ˘Á‹ ÙÔ˘ ıËÏ·ÛÌÔ‡ Û ϋıÔ˜ Ù¤ÙÔÈˆÓ Û΢·ÛÌ¿ÙˆÓ (38,41). √È Î·Ù¿ÏÔÁÔÈ ÙˆÓ Ê·Ú̷΢ÙÈÎÒÓ Ô˘ÛÈÒÓ Î·È Û΢·ÛÌ¿ÙˆÓ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÛÙËÓ Î·ıËÌÂÚÈÓ‹ ¿ÛÎËÛË Ù˘ È·ÙÚÈ΋˜ Â›Ó·È ÌÂÁ¿ÏÔÈ. ∫¿ı ÚÔÛ¿ıÂÈ· ·Ó·ÊÔÚ¿˜ Û ηıÂÌ›· Û˘ÁÎÂÎÚÈ̤ÓË Ê·Ú̷΢ÙÈ΋ Ô˘Û›·, ı· ··ÈÙÔ‡Û ÌÂÁ¿ÏË ¤ÎÙ·ÛË Î·È ı· ͤÊ¢Á ÂӉ¯Ô̤ӈ˜ ·fi ÙÔÓ ÛÎÔfi ·˘Ù‹˜ Ù˘ ·Ó·ÛÎfiËÛ˘. ∏ ¢·ÈÛıËÙÔÔ›ËÛË ÙÔ˘ ÎÏÈÓÈÎÔ‡, Ë ·Ó·˙‹ÙËÛË Û‡Á¯ÚÔÓˆÓ ÏËÚÔÊÔÚÈÒÓ ·fi ÙÔ ‰È·‰›ÎÙ˘Ô, ‹ ·fi ηٿ ÙÔ ‰˘Ó·ÙfiÓ ÈÔ ÚfiÛÊ·Ù˜ ·Ó·ÊÔÚ¤˜, Û¯ÂÙÈο Ì ÙË ‰˘Ó·ÙfiÙËÙ· ¯Ú‹Û˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ Ê·Ú̷΢ÙÈÎÔ‡ Û΢¿ÛÌ·ÙÔ˜, Ë Û˘ÓÂÎÙ›ÌËÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ Ô˘ ÚԷӷʤÚıËÎ·Ó Î·È Ô Û‚·ÛÌfi˜ Ù˘ ˘Á›·˜ ÙfiÛÔ Ù˘ ÌËÙ¤Ú·˜ fiÛÔ Î·È ÙÔ˘ ÓÂÔÁÓÔ‡ Ù˘, Â›Ó·È Î·ıÔÚÈÛÙÈ΋˜ ÛËÌ·Û›·˜ ÁÈ· ÙË Ï‹„Ë
·ÔÊ¿ÛÂˆÓ fiÛÔÓ ·ÊÔÚ¿ ÙË Û˘Ó¤¯ÈÛË ‹ ÙË ‰È·ÎÔ‹ ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ (2,36,38,41). ™ÙȘ Û‡Á¯ÚÔÓ˜ ÎÔÈӈӛ˜ ¤¯Ô˘Ó ¤ÏıÂÈ ÛËÌ·ÓÙÈΤ˜ ÙÚÔÔÔÈ‹ÛÂȘ ÛÙË ‰ÔÌ‹ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜. ∏ Á˘Ó·›Î· ¤¯ÂÈ ·ÏÏ¿ÍÂÈ ÙÚfiÔ ˙ˆ‹˜, Û˘ÌÌÂÙ¤¯ÂÈ ÂÓÂÚÁ¿ ÛÙËÓ ÂÍ·ÛÊ¿ÏÈÛË ‚ÈÔÙÈÎÒÓ fiÚˆÓ, ·Ô˘ÛÈ¿˙ÂÈ ·ÚÎÂÙ¤˜ ÒÚ˜ ·fi ÙÔ Û›ÙÈ Î·È ÙË ÊÚÔÓÙ›‰· ÙÔ˘ ÓÂÔÁ¤ÓÓËÙÔ˘ ·Ó·Ï·Ì‚¿ÓÂÈ Ôχ Û˘¯Ó¿ ÙÚ›ÙÔ ÚfiÛˆÔ. ∏ ¯ÚËÛÈÌÔÔ›ËÛË Ù˘ Ù¯ÓËÙ‹˜ ‰È·ÙÚÔÊ‹˜ Û˘¯Ó¿ ·ÔÙÂÏ› ÙËÓ Â‡ÎÔÏË Ï‡ÛË. ∆· ÏÂÔÓÂÎÙ‹Ì·Ù· ÙÔ˘ ıËÏ·ÛÌÔ‡ ÁÈ· ÙË ÌËÙ¤Ú·, ÙÔ ÓÂÔÁÓfi, ÙÔ ‚Ú¤ÊÔ˜ Î·È ÙÔÓ ¿ÓıÚˆÔ ÁÂÓÈÎfiÙÂÚ·, Â›Ó·È ÔÏÏ¿ Î·È ÛËÌ·ÓÙÈο. √È ÂÚÈÙÒÛÂȘ Ô˘ Ô ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ ‰ÂÓ Â›Ó·È ·ÛÊ·Ï‹˜ ‰ÂÓ Â›Ó·È ÔÏϤ˜, ·ÏÏ¿ Ô Î¿ı ÎÏÈÓÈÎfi˜ Ô˘ ·Û¯ÔÏÂ›Ù·È Ì ÓÂÔÁÓ¿ Î·È ‚Ú¤ÊË Ú¤ÂÈ Ó· Â›Ó·È ÂÓ‹ÌÂÚÔ˜. ∆ËÓ ÙÂÏÈ΋ ·fiÊ·ÛË ı· ¿ÚÂÈ Ì·˙› Ì ÙÔ˘˜ ÁÔÓ›˜, ·ÊÔ‡ ÙÔ˘˜ ÂÎı¤ÛÂÈ ÙÔ˘˜ ÎÈÓ‰‡ÓÔ˘˜ Ô˘ ·ÔÚÚ¤Ô˘Ó ·fi ÙË ¯Ú‹ÛË ÙÔ˘ ÌËÙÚÈÎÔ‡ Á¿Ï·ÙÔ˜ ÁÈ· ÙÔ ÓÂÔÁÓfi ÙÔ˘˜, ¿ÓÙ· Ì ÁÓÒÌÔÓ· ÙÔÓ Û‚·ÛÌfi Ù˘ ˘Á›·˜ Ù˘ ÌËÙ¤Ú·˜ Î·È ÙÔ˘ ÓÂÔÁÓÔ‡. ÃÚ¤Ô˜ ÙˆÓ ˘ËÚÂÛÈÒÓ ˘Á›·˜, ·ÏÏ¿ Î·È Ù˘ ÎÔÈÓˆÓ›·˜ ÁÂÓÈÎfiÙÂÚ·, Â›Ó·È Ë ÚÔ·ÁˆÁ‹ ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡. √ ÛÙfi¯Ô˜ ÛÙȘ ·Ó·Ù˘Á̤Ó˜ ¯ÒÚ˜ ÁÈ· ÙÔ 2010 Â›Ó·È Ó· ÊÙ¿ÛÂÈ ÙÔ ÔÛÔÛÙfi ÙˆÓ ‚ÚÂÊÒÓ Ô˘ ıËÏ¿˙Ô˘Ó ÙÔ˘Ï¿¯ÈÛÙÔÓ ÙÔ 75%, ÂÎÂ›ÓˆÓ Ô˘ ıËÏ¿˙Ô˘Ó ÁÈ· ÂÚÈÛÛfiÙÂÚÔ ·fi 6 Ì‹Ó˜ ÙÔ 50%, ÂÓÒ ·˘ÙÒÓ Ô˘ ıËÏ¿˙Ô˘Ó ÁÈ· ¤Ó· ¯ÚfiÓÔ ÙÔ 25% (2).
µÈ‚ÏÈÔÁÚ·Ê›· 1. Breastfeeding and the use of human milk. American Academy of Pediatrics. Work group on breastfeeding. Pediatrics 1997;100:1035-1039. 2. Gartner LM, Morton J, Lawrence RA, Naylor AJ, O’Hare D, Schanler RJ et al. Breastfeeding and the use of human milk. American Academy of Pediatrics. Work group on breastfeeding. Pediatrics 2005;115:496-506. 3. Chen A, Rogan WJ. Breastfeeding and the risk of postneonatal death in the United States. Pediatrics 2004;113:e435-439. 4. Cochi SL, Fleming DW, Hightower AW, Limpakarnjanarat K, Facklam RR, Smith JD et al. Primary invasive Haemophilus influenzae type b disease: a population-based assessment of risk factors. J Pediatr 1986;108:887-896. 5. Takala AK, Eskola J, Palmgren J, Ronnberg PR, Kela E, Rekola P et al. Risk factors of invasive Haemophilus influenzae type b disease among children in Finland. J Pediatr 1989;115:694-701. 6. Kramer MS, Guo T, Platt RW, Sevkovskaya Z, Dzikovich I, Collet JP, et al. Infant growth and health outcomes associated with 3 compared with 6 mo of exclusive breastfeeding. Am J Clin Nutr 2003;78:291-295. 7. Bhandari N, Bahl R, Mazumdar S, Martines J, Black RE, Bhan MK; Infant Feeding Study Group. Effect of community-based promotion of exclusive breastfeeding on diarrhoeal illness and growth: a cluster randomized controlled trial. Lancet 2003;361:1418-1423. 8. Blaymore Bier JA, Oliver T, Ferguson A, Vohr BR. Human ¶·È‰È·ÙÚÈ΋ 2007;70:278-284
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·284
284
∂. ÷Ù˙ˉ¿ÎË, Ã. °È·ÓÓ·ÎÔÔ‡ÏÔ˘
9.
10.
11. 12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
milk reduces outpatient upper respiratory symptoms in premature infants during their first year of life. J Perinatol 2002;22:354-359. Bachrach VR, Schwarz E, Bachrach LR. Breastfeeding and the risk of hospitalization for respiratory disease in infancy: a meta-analysis. Arch Pediatr Adolesc Med 2003;157: 237-243. Oddy WH, Sly PD, de Klerk NH, Landau LI, Kendall GE, Holt PG, et al. Breast feeding and respiratory morbididy in infancy: a birth cohort study. Arch Dis Child 2003;88: 224-228. Lucas A, Cole TJ. Breast milk and neonatal necrotising enterocolitis. Lancet 1990;336:1519-1523. Aniansson G, Alm B, Andersson B, Hakansson A, Larsson P, Nylen O, et al. A prospective cohort study on breastfeeding and otitis media in Swedish infants. Pediatr Infect Dis J 1994;13:183-188. Marild S, Hansson S, Jodal U, Oden A, Svedberg K. Protective effect of breastfeeding against urinary tract infection. Acta Paediatr 2004;93:164-168. Schanler RJ, Shulman RJ, Lau C. Feeding strategies for premature infants: beneficial outcomes of feeding fortified human milk versus preterm formula. Pediatrics 1999;103:1150-1157. Alm B, Wennergren G, Norvenius SG, Skjaerven R, Lagercrant H, Helweg-Larsen K, et al. Breast feeding and the sudden infant death in Scandinavia, 1992-95. Arch Dis Child 2002;86:400-402. McVea KL, Turner PD, Peppler DK. The role of brestfeeding in sudden infant death syndrome. J Hum Lact 2000;16:13-20. Kostraba JN, Cruickshanks KJ, Lawler-Heavner J, Jobim LF, Rewers MJ, Gay EC, et al. Early exposure to cow’s milk and solid foods in infancy, genetic predisposition, and risk of IDDM. Diabetes 1993;42:288-295. Pettitt DJ, Forman MR, Hanson RL, Knowler WC, Bennett PH. Breastfeeding and the incidence of non-insulindependent diabetes mellitus in Pima Indians. Lancet 1997;350:166-168. Davis MK. Review of the evidence for an association between infant feeding and childhood cancer. Int J Cancer Suppl 1998;11:29-33. Armstrong J, Reilly JJ, Child Health Information Team. Breastfeeding and lowering the risk of childhood obesity. Lancet 2002;359:2003-2004. Grummer-Strawn LM, Mei Z. Centers for Disease Control and Prevention Pediatric Nutrition Surveillance System. Does breastfeeding protect against pediatric overweight? Analysis of longitudinal data from the Centers for Disease Control and Prevention Pediatric Nutrition Surveillance System. Pediatrics 2004;113:e81-86. Krebs NF, Jacobson MS. American Academy of Pediatrics, Committee on Nutrition. Prevention of pediatric overweight and obesity. Pediatrics 2003;112:424-430. Owen CG, Whincup PH, Odoki K, Gilg JA, Cook DG. Infant feeding and blood cholesterol: a study in adolescents and a systematic review. Pediatrics 2002;110:597-608. Gdalevich M, Mimouni D, Mimouni M. Breast-feeding
Paediatriki 2007;70:278-284
25. 26. 27.
28.
29.
30.
31. 32.
33.
34.
35.
36. 37.
38.
39. 40. 41. 42.
and the risk of bronchial asthma in childhood: a systematic review with meta-analysis of prospective studies. J Pediatr 2001;139:261-266. Reynolds A. Breastfeeding and brain development. Pediatr Clin North Am 2001;48:159-171. Labbok MH. Effects of breastfeeding on the mother. Pediatr Clin North Am 2001;48:143-158. Chua S, Arulkumaran S, Lim I, Selamat N, Ratnam SS. Influence of breastfeeding and nipple stimulation on postpartum uterine activity. Br J Obstet Gynaecol 1994; 101:804-805. Dewey KG, Heinig MJ, Nommsen LA. Maternal weightloss patterns during prolonged lactation. Am J Clin Nutr 1993;58:162-166. Cumming RG, Klineberg RJ. Breastfeeding and other reproductive factors and the risk of hip fractures in elderly women. Int J Epidemiol 1993;22:684-691. Rosenblatt KA, Thomas DB. Lactation and the risk of epithelial ovarian cancer. The WHO Collaborative Study of Neoplasia and Steroid Contraceptives. Int J Epidemiol 1993;22:192-197. Lawrence RM, Lawrence RA. Breast milk and infection. Clin Perinatol 2004;31:501-528. Lawrence RM, Lawrence RA. Given the benefits of breastfeeding, what contraindications exist? Pediatr Clin North Am 2001;48:235-251. Read JS; American Academy of Pediatrics Committee on Pediatric AIDS. Human milk, breastfeeding, and transmission of human immunodeficiency virus type 1 in the United States. American Academy of Pediatrics, Committee on Pediatric AIDS. Pediatrics 2003;112: 1196-1205. American Academy of Pediatrics. Human milk. In: Pickering LK, editors. Red Book: 2003 Report of the Committee on Infectious Diseases. 26th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2003. p.117. Hamprecht K, Maschmann J, Vochem M, Dietz K, Speer CP, Jahn G. Epidemiology of transmission of cytomegalovirus from mother to preterm infant by breastfeeding. Lancet 2001;357:513-518. Powers NG, Slusser W. Breastfeeding update. 2: Clinical lactation management. Pediatr Rev 1997;18:147-161. Lawrence RA, Howard CR. Given the benefits of breastfeeding, are there any contraindications? Clin Perinatol 1999;26:479-490. American Academy of Pediatrics. Committee on Drugs. Transfer of drugs and other chemicals into human milk. Pediatrics 2001;108:776-789. Lee JH, Zuckerman D. Silicon, silicone, and breast implants. Pediatrics 2002; 110:1030. Anderson PO. Alcohol and breastfeeding. J Hum Lact 1995; 11:321-323. Berlin CM, Briggs GG. Drugs and chemicals in human milk. Semin Fetal Neonatal Med 2005;10:149-159. Gomella TL. Effects of drugs and substances on lactation and breast-feeding. In: Neonatology: Management, procedures, on-call problems, diseases and drugs. 5th ed. USA: Lange medical books/McGraw-Hill; 2004. p. 644.
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·285
∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞
ORIGINAL ARTICLE
285
∂›‰Ú·ÛË ÙÔ˘ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ˘ÔÛÙ‹ÚÈ͢ ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ∞. ¡ÙÔ˘ÚÓÙÔ‡ÊË1, µ. ÃÔϤ‚·˜3, §. ∫ÔÓÙÔ‡2, ª. ¶·‡ÏÔ˘1, ™. ∞Ó‰ÚÔÓ›ÎÔ˘1 ¶ÂÚ›ÏË„Ë ∂ÈÛ·ÁˆÁ‹: ∏ Û˘¯ÓfiÙËÙ· ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ (ª£) ηٿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙË ª·È¢ÙÈ΋ ∫ÏÈÓÈ΋ (ª∫) ÙÔ˘ ¶·ÓÂÈÛÙËÌÈ·ÎÔ‡ °ÂÓÈÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ πˆ·ÓÓ›ÓˆÓ (¶°¡π) ÂÎÙÈÌ‹ıËΠ·fi ÚÔËÁÔ‡ÌÂÓË ÌÂϤÙË ˆ˜ Û¯ÂÙÈο ¯·ÌËÏ‹. ∞fi ÙÔÓ π·ÓÔ˘¿ÚÈÔ ÙÔ˘ 1998 ÂÊ·ÚÌfiÛÙËΠÂÓÙ·ÙÈÎfi ÚfiÁÚ·ÌÌ· ÂÓ›Û¯˘Û˘ Î·È ÚÔÒıËÛ˘ ÙÔ˘ ª£. ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ó· ÂÎÙÈÌËı› Ë Â›‰Ú·ÛË ÙÔ˘ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ˘ÔÛÙ‹ÚÈ͢ ÙÔ˘ ª£ ÛÙË Û˘¯ÓfiÙËÙ· ÙÔ˘ ª£ ηٿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙÔ ÓÔÛÔÎÔÌÂ›Ô Î·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÚÒÙÔ˘ ¯ÚfiÓÔ˘ ˙ˆ‹˜ ÙÔ˘ ‚Ú¤ÊÔ˘˜. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ∞fi ÙÔÓ π·ÓÔ˘¿ÚÈÔ ¤ˆ˜ ÙÔÓ ¢ÂΤ̂ÚÈÔ ÙÔ˘ 1999 ÌÂÏÂÙ‹ıËÎ·Ó ÚÔ‰ÚÔÌÈο 878 ˙¢Á¿ÚÈ· (ÌËÙ¤Ú· – ÓÂÔÁÓfi), ˆ˜ ÚÔ˜ ÙË ‰È·ÙÚÔÊ‹ ÙÔ˘ ‚Ú¤ÊÔ˘˜ (ª£ ‹ Ù¯ÓËÙ‹ ‰È·ÙÚÔÊ‹) Î·È ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ı· ÌÔÚÔ‡Û·Ó Ó· ÙËÓ ÂËÚ¿ÛÔ˘Ó. ∏ ‰È¿ÚÎÂÈ· ÙÔ˘ ıËÏ·ÛÌÔ‡ ÂÎÙÈÌ‹ıËΠÌÂÙ¿ ·fi ÙËÏÂʈÓÈ΋ ÂÈÎÔÈÓˆÓ›·. ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Û˘ÁÎÚ›ıËÎ·Ó Ì ÂΛӷ ·ÚfiÌÔÈ·˜ ÚÔËÁÔ‡ÌÂÓ˘ ÌÂϤÙ˘, Ô˘ ›¯Â Á›ÓÂÈ ÚÈÓ ÙËÓ ·Ú¤Ì‚·ÛË, ηٿ ÙÔ ¤ÙÔ˜ 1997. ∞ÔÙÂϤÛÌ·Ù·: ªÂÙ¿ ÙËÓ ·Ú¤Ì‚·ÛË, Ë Û˘¯ÓfiÙËÙ· ÙÔ˘ ª£ ηٿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙË ª∫ (3Ë Ì 7Ë Ë̤ڷ ÌÂÙ¿ ÙÔÓ ÙÔÎÂÙfi) ·˘Í‹ıËΠÁÈ· ÙÔÓ Û˘ÓÔÏÈÎfi ª£ ·fi 81,9% Û 87% (p<0,01) Î·È ÁÈ· ÙÔÓ ·ÔÎÏÂÈÛÙÈÎfi ª£ ·fi 38,6% Û 71% (p<0,001). ™ËÌ·ÓÙÈ΋ ›‰Ú·ÛË ÙÔ˘ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ÛÙËÓ ·‡ÍËÛË ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ Î·È ·ÔÎÏÂÈÛÙÈÎÔ‡ ıËÏ·ÛÌÔ‡ ·Ú·ÙËÚ‹ıËΠÛÙ· ÓÂÔÁÓ¿ Ì ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ (µ°) ≥2,5 kg, ÛÙ· ÎÔÚ›ÙÛÈ·, ÛÙ· ÓÂÔÁÓ¿ Ô˘ ÁÂÓÓ‹ıËÎ·Ó ÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÙÔÎÂÙfi (º∆) Î·È ÛÙ· ÓÂÔÁÓ¿ ÙˆÓ ÌËÙ¤ÚˆÓ ÌÂÁ·Ï‡ÙÂÚ˘ ËÏÈΛ·˜ Î·È Ì ÂÌÂÈÚ›· ª£ ·fi ÚÔËÁÔ‡ÌÂÓ· ·È‰È¿. ∏ ‰È¿ÚÎÂÈ· ÙÔ˘ ª£ (Û˘ÓÔÏÈÎÔ‡ Î·È ·ÔÎÏÂÈÛÙÈÎÔ‡) ≥6 Ì‹Ó˜ ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÌÂÁ·Ï‡ÙÂÚË (p<0,001) ÌÂÙ¿ ÙËÓ ·Ú¤Ì‚·ÛË. ™˘ÌÂÚ¿ÛÌ·Ù·: ∏ ˘ÔÛÙ‹ÚÈÍË ÙÔ˘ ıËÏ·ÛÌÔ‡ ηٿ ÙȘ ÚÒÙ˜ Ë̤Ú˜ ·fi ÙÔÓ ÙÔÎÂÙfi ‚ÔËı¿ÂÈ ÛËÌ·ÓÙÈο ÛÙËÓ ÂÁηٿÛÙ·ÛË ÙÔ˘ ·ÔÎÏÂÈÛÙÈÎÔ‡ ª£, Î·È ÛÙË ÌÂÁ·Ï‡ÙÂÚË ‰È¿ÚÎÂÈ· ÙÔ˘ ıËÏ·ÛÌÔ‡.
1 ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ ¡ÔÛËÏ›·˜ ¡ÂÔÁÓÒÓ, 2 ª·È¢ÙÈ΋ ∫ÏÈÓÈ΋, ¶·ÓÂÈÛÙËÌÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô πˆ·ÓÓ›ÓˆÓ 3 ∂ÚÁ·ÛÙ‹ÚÈÔ ÙÔ˘ ∆Ô̤· ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡, π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ πˆ·ÓÓ›ÓˆÓ. AÏÏËÏÔÁÚ·Ê›·: ∞Á·ı‹ ¡ÙÔ˘ÚÓÙÔ‡ÊË dourdufi@otenet.gr ¶·ÓÂÈÛÙ‹ÌÈÔ πˆ·ÓÓ›ÓˆÓ π·ÙÚÈ΋ ™¯ÔÏ‹ ∆Ô̤·˜ ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ ∆·¯. £˘Ú. 1186 ∆.∫. 451 10, πˆ¿ÓÓÈÓ·
§¤ÍÂȘ ÎÏÂȉȿ: ªËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜, Ú·ÎÙÈΤ˜ ª£.
Effect of a supportive program on breastfeeding A. Ntourntoufi1, V. Cholevas3, L. Kontou2, M. Pavlou1, S. Andronikou1 Abstract Background: The rate of breastfeeding (BF) at discharge from the maternity ward at the University Hospital of Ioannina was estimated to be relatively low in a previous study. From January 1998, BF was actively supported for all neonates delivered at the maternity ward. The aim of the study was to evaluate the effect of a supportive program on the rate of initiation and duration of BF, at discharge from the maternity ward and during the first year of life. Methods: From January to December 1999, 878 mother-infant couples were studied prospectively regarding the type of feeding of the infant (BF or bottle feeding) and the factors that could have an influence on it. The duration of BF was evaluated by telephone contact. The results of this study were compared to those of a previous similar study which was conducted before the intervention, during the year 1997. Results: The rate of BF at discharge from the maternity ward (3rd to 7th day after delivery) increased after intervention from 81.9% to 87% for overall BF (p<0.01), and from 38.6% to 71% for exclusive BF (p<0.001). Significant increase of overall and exclusive BF after intervention was noticed in infants with birth weight ≥2.5kg, in girls, in infants born by normal vaginal delivery, in multiparous mothers and mothers of a more mature age. The duration of BF (overall and exclusive) ≥6 months was significantly higher after intervention (p<0.001). Conclusion: BF policies applied constantly in the maternity ward seem to increase the overall and exclusive BF and the duration of BF ≥6 months.
1 Neonatal Intensive Care Unit 2 Maternity Clinic, University General Hospital of Ioannina 3 Child Health Department Laboratory, University of Ioannina Medical School Correspondence: Agathi Ntourntoufi dourdufi@otenet.gr University of Ioannina Medical School Child Health Department PO Box 1186 451 10, Ioannina, Greece
Key words: Breastfeeding rate, maternity ward routines.
¶·È‰È·ÙÚÈ΋ 2007;70:285-292
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·286
286
∞. ¡ÙÔ˘ÚÓÙÔ‡ÊË Î·È Û˘Ó.
™˘ÓÙÔÌÔÁڷʛ˜ ª£ ª∫ ¶°¡π ∏∫ µ° º∆ ∞∂ ∫∆
ªËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ ª·È¢ÙÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô πˆ·ÓÓ›ÓˆÓ ∏ÏÈΛ· ·ËÛ˘ µ¿ÚÔ˜ Á¤ÓÓËÛ˘ º˘ÛÈÔÏÔÁÈÎfi˜ ÙÔÎÂÙfi˜ ∞Ó·ÚÚÔÊËÙÈ΋ ÂÌ‚Ú˘Ô˘ÏΛ· ∫·ÈÛ·ÚÈ΋ ÙÔÌ‹
∂ÈÛ·ÁˆÁ‹ ∂ÎÙÂٷ̤ÓË ¤Ú¢ӷ ‰Â›¯ÓÂÈ fiÙÈ ÔÈ Î·ıËÌÂÚÈÓ¤˜ Ú·ÎÙÈΤ˜ Ô˘ ·ÎÔÏÔ˘ıÔ‡ÓÙ·È ÛÙȘ ª∫ ¤¯Ô˘Ó ÌÂÁ¿ÏË ÛËÌ·Û›· ÁÈ· ÙËÓ ÂÁηٿÛÙ·ÛË Î·È ÙË Ì·ÎÚÔ¯ÚfiÓÈ· ¤Î‚·ÛË ÙÔ˘ ª£ (1). ™ÙȘ ÛηӉÈÓ·‚ÈΤ˜ ¯ÒÚ˜, Ë Û˘¯ÓfiÙËÙ· ÙÔ˘ ª£ Â›Ó·È ÌÂÁ¿ÏË (>95%) Û ۇÁÎÚÈÛË Ì ÂΛÓË Û ¿ÏϘ Â˘Úˆ·˚Τ˜ ¯ÒÚ˜ (24). ∞˘Ùfi Ê·›ÓÂÙ·È ˆ˜ ÔÊ›ÏÂÙ·È Î˘Ú›ˆ˜ ÛÙȘ ·ÏÏ·Á¤˜ ÙˆÓ Ú·ÎÙÈÎÒÓ ÛÙȘ ª∫ (4). ¶ÔÏÏÔ› ·Ú¿ÁÔÓÙ˜ Ê·›ÓÂÙ·È ˆ˜ ÂËÚ¿˙Ô˘Ó ÙËÓ ¤Ó·ÚÍË Î·È ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ª£. √ÚÈṲ̂ÓÔÈ ·fi ·˘ÙÔ‡˜ ÌÔÚÔ‡Ó ‰˘ÓËÙÈο Ó· ÙÚÔÔÔÈËıÔ‡Ó, fiˆ˜ Ë ÊÚÔÓÙ›‰· ÙÔ˘ ÓÂÔÁÓÔ‡ ÛÙËÓ ·›ıÔ˘Û· ÙÔÎÂÙÔ‡ Î·È ÛÙË ª∫ (4). ∏ Û˘¯ÓfiÙËÙ· ¤Ó·Ú͢ ÙÔ˘ ª£ ÛÙË ª∫ ÙÔ˘ ¶°¡π ›¯Â ÂÎÙÈÌËı› ηٿ ÙÔ ¤ÙÔ˜ 1997, Û ÚÔËÁÔ‡ÌÂÓË ÌÂϤÙË (ÌË ‰ËÌÔÛÈÂ˘Ì¤Ó· ÛÙÔȯ›·). ∞Ó Î·È Ë Û˘¯ÓfiÙËÙ· ÙÔ˘ ª£ (Û˘ÓÔÏÈÎfi˜ ª£, ·ÔÎÏÂÈÛÙÈÎfi˜ Î·È ÌÈÎÙfi˜) ηٿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙË ª∫ (3Ë Ì 7Ë Ì¤Ú· ÌÂÙ¿ ÙÔÓ ÙÔÎÂÙfi) ‹Ù·Ó ÈηÓÔÔÈËÙÈ΋ (81,9%), Ë Û˘¯ÓfiÙËÙ· ÙÔ˘ ·ÔÎÏÂÈÛÙÈÎÔ‡ ıËÏ·ÛÌÔ‡ ‹Ù·Ó ¯·ÌËÏ‹ (38,6%). ∞fi ÙÔ ¤ÙÔ˜ 1998 Î·È ÌÂÙ¿ ¤ÁÈÓ ÚÔÛ¿ıÂÈ· ÂÓÙ·ÙÈ΋˜ ˘ÔÛÙ‹ÚÈ͢ ÙˆÓ ÌËÙ¤ÚˆÓ, ÒÛÙ ӷ ηٷʤÚÔ˘Ó Ó· ıËÏ¿ÛÔ˘Ó ÙÔ ÓÂÔÁÓfi ÙÔ˘˜. ™ÎÔfi˜ ·˘Ù‹˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ó· ÂÎÙÈÌËıÔ‡Ó Ù· ·ÔÙÂϤÛÌ·Ù· ÙÔ˘ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ÚÔÒıËÛ˘ Î·È ˘ÔÛÙ‹ÚÈ͢ ÙÔ˘ ª£ Ô˘ ÂÊ·ÚÌfiÛÙËΠÛÙÔ ¶°¡π, Û˘ÁÎÚ›ÓÔÓÙ¿˜ Ù· Ì ÂΛӷ ÚÔËÁÔ‡ÌÂÓ˘ ÌÂϤÙ˘ Ô˘ ‰ÈÂÍ‹¯ıË Î·Ù¿ ÙÔ ¤ÙÔ˜ 1997, fiÔ˘ ‰ÂÓ ˘‹Ú¯Â Ù·ÎÙÈ΋ ÂȉÈ΋˜ ÔÏÈÙÈ΋˜ ÁÈ· ÙËÓ ˘ÔÛÙ‹ÚÈÍË ÙÔ˘ ª£. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ∆ÔÓ √ÎÙÒ‚ÚÈÔ ÙÔ˘ 1997, ¤Ó·˜ ÓÂÔÁÓÔÏfiÁÔ˜ Î·È ‰‡Ô Ì·›Â˜ ÙÔ˘ ¶°¡π ·Ú·ÎÔÏÔ‡ıËÛ·Ó ÙÔ ÚfiÁÚ·ÌÌ· Âη›‰Â˘Û˘ ÙÔ˘ ª£ ÛÙÔ ¡ÔÛÔÎÔÌÂ›Ô ŒÏÂÓ· µÂÓÈ˙¤ÏÔ˘. ∞fi ÙÔÓ π·ÓÔ˘¿ÚÈÔ ÙÔ˘ 1998, Ô ª£ ˘ÔÛÙËÚ›¯ıËΠÂÓÙ·ÙÈο ÁÈ· fiÏ· Ù· ÓÂÔÁÓ¿ Ô˘ ÁÂÓÓ‹ıËÎ·Ó ÛÙÔ ¶°¡π. ∏ ·Ú¤Ì‚·ÛË ·ÔÙÂÏÔ‡ÓÙ·Ó ·fi ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙˆÓ “¢¤Î· µËÌ¿ÙˆÓ ÁÈ· ∂ÈÙ˘¯‹ £ËÏ·ÛÌfi” (5). ŒÌÊ·ÛË ‰fiıËΠÛÙËÓ ÙÔÔı¤ÙËÛË ÙÔ˘ ÓÂÔÁÓÔ‡ ÛÙÔ ÛÙ‹ıÔ˜ Ù˘ ÌËÙ¤Ú·˜ ÙÔ˘ ÂÓÙfi˜ ÌÈÛ‹˜ Ì ̛· ÒÚ· ·fi ÙÔÓ ÙÔÎÂÙfi, ÛÙË Û˘Ó¯‹ ·Ú·ÌÔÓ‹ ÙÔ˘ ÓÂÔÁÓÔ‡ ‰›Ï· ÛÙË ÌËÙ¤Ú· ÙÔ˘ (rooming in), ÛÙË ‚Ô‹ıÂÈ· ÙˆÓ ÌËÙ¤ÚˆÓ ÁÈ· ÙË ÛˆÛÙ‹ ÙÔÔı¤ÙËÛË ÙÔ˘ ̈ÚÔ‡ ÙÔ˘˜ ÛÙÔ ÛÙ‹ıÔ˜, Î·È ÛÙËÓ Ú·ÎÙÈ΋ ÙÔ˘ ıËÏ·ÛÌÔ‡ ÁÂÓÈο (Ô‰ËÁ›Â˜ ÚÔÊÔÚÈΤ˜ Î·È ÁÚ·Ù¤˜). Paediatriki 2007;70:285-292
∏ ÂÍ·ÙÔÌÈÎÂ˘Ì¤ÓË ‚Ô‹ıÂÈ· Î·È Ë ˘ÔÛÙ‹ÚÈÍË ÙˆÓ ÌËÙ¤ÚˆÓ ÁÈÓfiÙ·Ó ·fi ÙÔ ÚÔÛˆÈÎfi Ù˘ ª∫ fiÛÔ Û˘¯Ó¿ ¯ÚÂÈ·˙fiÙ·Ó Ì¤¯ÚÈ ÙËÓ ÂÁηٿÛÙ·ÛË ÙÔ˘ ıËÏ·ÛÌÔ‡. ∂›Û˘, ÛÙ· Ï·›ÛÈ· ÙˆÓ Â͈ÙÂÚÈÎÒÓ È·ÙÚ›ˆÓ Ù˘ ¡ÂÔÁÓÔÏÔÁÈ΋˜ ∫ÏÈÓÈ΋˜, ÙËÚ‹ıËÎÂ Û˘Ì‚Ô˘Ï¢ÙÈÎfi È·ÙÚÂ›Ô ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙˆÓ ‚ÚÂÊÒÓ Ô˘ ı‹Ï·˙·Ó, Ô˘ Ú·ÁÌ·ÙÔÔÈÔ‡ÓÙ·Ó ‰‡Ô ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰·. ™Â ÚÔËÁÔ‡ÌÂÓË ÌÂϤÙË ¤ÁÈÓ ·Ó·‰ÚÔÌÈο ·Ó¿Ï˘ÛË 829 ÈÛÙÔÚÈÎÒÓ ÓÂÔÁÓÒÓ Ô˘ ÁÂÓÓ‹ıËÎ·Ó ÛÙË ª∫ ÙÔ˘ ¶°¡π ÌÂٷ͇ 1-1-97 Î·È 31-12-97, ÂÚ›Ô‰Ô Î·Ù¿ ÙËÓ ÔÔ›· ‰ÂÓ ˘‹Ú¯Â ÂȉÈ΋ ˘ÔÛÙ‹ÚÈÍË ÙÔ˘ ª£. ªÂÙ¿ ÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ·Ú¤Ì‚·Û˘, ÌÂÏÂÙ‹ıËÎ·Ó ÚÔÔÙÈο 878 ÓÂÔÁÓ¿ Ô˘ ÁÂÓÓ‹ıËÎ·Ó ·fi 1-1-1999 ¤ˆ˜ 31-12-1999. ∏ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ‚ÚÂÊÒÓ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ‹Ù·Ó ÙÂÏÂÈfiÌËÓ· Ì ËÏÈΛ· ·ËÛ˘ (∏∫) ≥37 ‚‰ÔÌ¿‰ˆÓ. ∫·Ù¿ ÙËÓ ÚÒÙË ÂÚ›Ô‰Ô (1997), 17 ‚Ú¤ÊË Â›¯·Ó ∏∫ 36 ‚‰ÔÌ¿‰ˆÓ, ¤Ó· ‹Ù·Ó 35 ‚‰ÔÌ¿‰ˆÓ Î·È 6 ·fi ·˘Ù¿ ›¯·Ó µ° <2,5 kg. ∫·Ù¿ ÙË ‰Â‡ÙÂÚË ÂÚ›Ô‰Ô (1999), 20 ‹Ù·Ó 36 ‚‰ÔÌ¿‰ˆÓ ∏∫ Î·È ¤Ó· 35 ‚‰ÔÌ¿‰ˆÓ. √ÎÙÒ ·fi ·˘Ù¿ ›¯·Ó µ° <2,5 kg. √ ¯ÚfiÓÔ˜ ·Ú·ÌÔÓ‹˜ ÛÙË ª∫ ÙˆÓ ÌËÙ¤ÚˆÓ Ô˘ ›¯·Ó ÁÂÓÓ‹ÛÂÈ Ì º∆ ‹Ù·Ó 3 Ì 4 Ë̤Ú˜ Î·È ÂÎÂ›ÓˆÓ Ô˘ ›¯·Ó ÁÂÓÓ‹ÛÂÈ Ì ∫∆ 5 ¤ˆ˜ 7 Ë̤Ú˜. ŸÏ· Ù· ÓÂÔÁÓ¿ ÂÍÂÙ¿˙ÔÓÙ·Ó ·fi ÓÂÔÁÓÔÏfiÁÔ ÚÈÓ ÙËÓ ¤ÍÔ‰fi ÙÔ˘˜ ·fi ÙË ª∫. °È· οı ÓÂÔÁÓfi ηٷÁÚ¿ÊËÎÂ Ô Ù‡Ô˜ Ù˘ ‰È·ÙÚÔÊ‹˜ ÙÔ˘, ·ÔÎÏÂÈÛÙÈÎfi˜ ‹ ÌÈÎÙfi˜ (ª£ Î·È Û˘Ìϋڈ̷) ‹ Ù¯ÓËÙ‹ ‰È·ÙÚÔÊ‹, ηٿ ÙËÓ ¤ÍÔ‰fi ÙÔ˘ ·fi ÙË ª∫. ∂›Û˘ ηٷÁÚ¿ÊËÎ·Ó ‰È¿ÊÔÚÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ÌÔÚ› Ó· Û¯ÂÙ›˙ÔÓÙ·È Î·È Ó· ÂËÚ¿˙Ô˘Ó ÙÔÓ ÙÚfiÔ ‰È·ÙÚÔÊ‹˜ ÙˆÓ ÓÂÔÁÓÒÓ, fiˆ˜ ÙÔ Ê‡ÏÔ ÙÔ˘ ÓÂÔÁÓÔ‡ Î·È ÙÔ µ° (<2,5 kg, 2,5 - 3,0 kg, >3,0 kg), Ô ÙÚfiÔ˜ Á¤ÓÓËÛ˘ (º∆, ∞∂, ∫∆), Ô ÙfiÎÔ˜ Ù˘ ÌËÙ¤Ú·˜ Î·È Ë ËÏÈΛ· Ù˘ (<20, 20-30, 31-40, >40 ÂÙÒÓ) Î·È ÙÔ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi Â›Â‰Ô Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜, fiÔ˘ Ë Ù¿ÍË π ·Ó·Ê¤ÚÂÙ·È Û ·ÓÂȉ›Î¢ÙÔ˘˜ ÂÚÁ¿Ù˜, Ë Ù¿ÍË ππ Û ÂÍÂȉÈÎÂ˘Ì¤ÓÔ˘˜ ÂÚÁ¿Ù˜ Î·È Ù¯ӛÙ˜, Ë Ù¿ÍË πππ Û ·fiÊÔÈÙÔ˘˜ ·ÓÒÙÂÚˆÓ Û¯ÔÏÒÓ Î·È Ë Ù¿ÍË IV Û ·fiÊÔÈÙÔ˘˜ ·ÓÂÈÛÙËÌ›Ô˘ (6). ŒÁÈÓ ۇÁÎÚÈÛË fiÏˆÓ ÙˆÓ ·Ú·¿Óˆ ·Ú·ÁfiÓÙˆÓ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÂÚÈfi‰ˆÓ Ô˘ ÌÂÏÂÙ‹ıËηÓ, ÚÈÓ ÙËÓ ·Ú¤Ì‚·ÛË (1997) Î·È ÌÂÙ¿ ·fi ·˘Ù‹Ó (1999). ∏ ‰È¿ÚÎÂÈ· ÙÔ˘ ıËÏ·ÛÌÔ‡ ÂÎÙÈÌ‹ıËÎÂ, ÌÂÙ¿ ·fi ÙËÏÂʈÓÈ΋ ÂÈÎÔÈÓˆÓ›· Ì ÙË ÌËÙ¤Ú·, 6 Î·È 12 Ì‹Ó˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË ÙÔ˘ ̈ÚÔ‡ Ù˘. √ÚÈÛÌÔ›: ∞ÔÎÏÂÈÛÙÈÎfi˜ ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜: ÛËÌ·›ÓÂÈ fiÙÈ ÙÔ ÌˆÚfi ÛÈÙ›˙ÂÙ·È ÌfiÓÔ Ì ÌËÙÚÈÎfi Á¿Ï· ·fi ÙË ÌËÙ¤Ú· ÙÔ˘ ‹ Ì›· ÙÚÔÊfi, ‹ ÌËÙÚÈÎfi Á¿Ï· Ô˘ ¤¯ÂÈ Û˘ÏÏÂÁ›, Î·È Î·Ì›· ¿ÏÏË ÛÙÂÚ¿ ‹ ˘ÁÚ‹ ÙÚÔÊ‹. ™˘ÓÔÏÈÎfi˜ ıËÏ·ÛÌfi˜: ÂÚÈÏ·Ì‚¿ÓÂÈ ÙË Û›ÙÈÛË ÙÔ˘ ̈ÚÔ‡ Ì ÌËÙÚÈÎfi Á¿Ï·, ›Ù ·ÔÎÏÂÈÛÙÈο ›Ù ÛÂ Û˘Ó‰˘·ÛÌfi Ì ¯ÔÚ‹ÁËÛË Û˘ÌÏËÚÒÌ·ÙÔ˜ ÙÚÔÔÔÈË̤ÓÔ˘ Á¿Ï·ÙÔ˜. ªÈÎÙ‹ ‰È·ÙÚÔÊ‹: Û›ÙÈÛË ÙÔ˘ ‚Ú¤ÊÔ˘˜ Ì ÌËÙÚÈÎfi Á¿Ï· ·ÏÏ¿ Î·È Û˘Ìϋڈ̷ Ì ÙÚÔÔÔÈË̤ÓÔ Á¿Ï·. ∆¯ÓËÙ‹ ‰È·ÙÚÔÊ‹: Û›ÙÈÛË ÙÔ˘ ‚Ú¤ÊÔ˘˜ ·ÔÎÏÂÈÛÙÈο Ì ÙÚÔÔÔÈË̤ÓÔ Á¿Ï· ·ÁÂÏ¿‰Ô˜. ™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË: ∏ ÂÎÙ›ÌËÛË ÙˆÓ ‰È·ÊfiÚˆÓ ·Ú·ÁfiÓÙˆÓ ¤ÁÈÓ Ì ·Ó¿Ï˘ÛË ¯2. ™˘Û¯¤ÙÈÛË ¤ÁÈÓ ÁÈ· οı ÂÚ›Ô‰Ô ÌÂٷ͇ ÙˆÓ ÔÌ¿‰ˆÓ ÁÈ· Ó· ÂÎÙÈÌËı› Ë Â›‰Ú·ÛË ÙˆÓ ‰È·ÊfiÚˆÓ ·Ú·Ì¤ÙÚˆÓ ÛÙË Û˘¯ÓfiÙËÙ· ÙÔ˘ ıËÏ·ÛÌÔ‡. ™˘Û¯¤ÙÈÛË ¤ÁÈÓ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÂÚÈfi‰ˆÓ, ÚÈÓ Î·È ÌÂÙ¿ ÙËÓ ·Ú¤Ì‚·ÛË, ÁÈ· Ó· ÂÎÙÈÌËı› Ë Â›‰Ú·ÛË ÙÔ˘ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ÚÔÒıËÛ˘ ÙÔ˘ ıËÏ·ÛÌÔ‡ Î·È ÙˆÓ ·Ú·ÁfiÓÙˆÓ Ô˘ ı· ÌÔÚÔ‡Û·Ó Ó· ÂËÚ¿ÛÔ˘Ó ÙÔÓ ª£.
∞ÔÙÂϤÛÌ·Ù· ™ÙÔÓ ¶›Ó·Î· 1 Ê·›ÓÔÓÙ·È ÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·287
287
¶ÚÔÒıËÛË ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡
Û¯ÂÙ›˙ÔÓÙ·È Ì ٷ ‚Ú¤ÊË Î·È Ô˘ ı· ÌÔÚÔ‡Û·Ó Ó· ¤¯Ô˘Ó οÔÈ· ›‰Ú·ÛË ÛÙÔÓ ÙÚfiÔ ‰È·ÙÚÔÊ‹˜ ÙÔ˘˜ ηٿ ÙËÓ ¤ÍÔ‰fi ÙÔ˘˜ ·fi ÙË ª∫, ÁÈ· ÙȘ ‰‡Ô ÂÚÈfi‰Ô˘˜ 1997 Î·È 1999. ∆Ô 1999, 87% ÙˆÓ ÓÂÔÁÓÒÓ ı‹Ï·˙·Ó ηٿ ÙËÓ ¤ÍÔ‰fi ÙÔ˘˜ ·fi ÙË ª∫ Û˘ÁÎÚÈÙÈο Ì 81,9% ÙÔ 1997 (p<0,01). ∆Ô ÔÛÔÛÙfi ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ÛÈÙ›˙ÔÓÙ·Ó ·ÔÎÏÂÈÛÙÈο Ì ÌËÙÚÈÎfi Á¿Ï· ‹Ù·Ó 71% Î·È 38,6% ·ÓÙ›ÛÙÔȯ· ÁÈ· Ù· ¤ÙË 1999 Î·È 1997 (p<0,001). ∏ ·‡ÍËÛË ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ Î·È Î˘Ú›ˆ˜ Ë ·‡ÍËÛË ÙÔ˘ ·ÔÎÏÂÈÛÙÈÎÔ‡ ª£ ÙËÓ ÂÚ›Ô‰Ô ÌÂÙ¿ ÙËÓ ·Ú¤Ì‚·ÛË ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ (¶›Ó·Î·˜ 1). º·›ÓÂÙ·È ˆ˜ Ë ·‡ÍËÛË ÙÔ˘ ª£ ÛÙ· ÎÔÚ›ÙÛÈ· ‹Ù·Ó ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚË ÁÈ· ÙÔÓ Û˘ÓÔÏÈÎfi Î·È ÙÔÓ ·ÔÎÏÂÈÛÙÈÎfi ª£ (p<0,05 Î·È p<0,001, ·ÓÙ›ÛÙÔȯ·) Û˘ÁÎÚÈÙÈο Ì ٷ ·ÁfiÚÈ·, ηٿ ÙËÓ ÂÚ›Ô‰Ô ÌÂÙ¿ ÙËÓ ·Ú¤Ì‚·ÛË. ∆Ô µ° Ê·›ÓÂÙ·È Ó· ηıÔÚ›˙ÂÈ ÙÔÓ Ù‡Ô Û›ÙÈÛ˘ Î·È ·˘Ùfi˜ Ô ·Ú¿ÁÔÓÙ·˜ ·Ú·Ì¤ÓÂÈ ÛÙ·ıÂÚfi˜ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÂÚÈfi‰ˆÓ. À¿Ú¯ÂÈ ÌÈ· ·‡ÍËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ ÙÔ˘ ª£ Û ۯ¤ÛË Ì ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ µ° ·fi <2,5 kg ¤ˆ˜ >3 kg. ∆· ÓÂÔÁÓ¿ Ì µ° <2,5 kg ıËÏ¿˙Ô˘Ó ÏÈÁfiÙÂÚÔ ·fi ÂΛӷ Ì µ° >2,5 kg (p<0,05 ÚÈÓ Î·È p<0,01 ÌÂÙ¿ ÙËÓ ·Ú¤Ì‚·ÛË). ∆Ô ÌÈÎÚfiÙÂÚÔ µ° Ê·›ÓÂÙ·È ˆ˜ ÂËÚ¿˙ÂÈ ·ÚÓËÙÈο ÙËÓ ¤Ó·ÚÍË ÙÔ˘ ª£ Î·È Î˘Ú›ˆ˜ ÙÔ˘ ·ÔÎÏÂÈÛÙÈÎÔ‡ ª£. ∆· ÓÂÔÁÓ¿ Ì µ° ≥2,5 kg ıËÏ¿˙Ô˘Ó Ì ÌÂÁ·Ï‡ÙÂÚË Û˘-
¯ÓfiÙËÙ· ·fi ÂΛӷ Ì ÌÈÎÚfiÙÂÚÔ µ°. ∆Ô ÚfiÁÚ·ÌÌ· ˘ÔÛÙ‹ÚÈ͢ ÙÔ˘ ıËÏ·ÛÌÔ‡ ‚Ô‹ıËÛ ÛËÌ·ÓÙÈο ÛÙËÓ ·‡ÍËÛË ÙÔ˘ ª£ ÌfiÓÔ ÛÙ· ÓÂÔÁÓ¿ Ì µ° ≥2,5 kg (p<0,05 Î·È p<0,001 ÁÈ· ÙÔÓ Û˘ÓÔÏÈÎfi Î·È ·ÔÎÏÂÈÛÙÈÎfi ª£, ·ÓÙ›ÛÙÔȯ·) (¶›Ó·Î·˜ 1). √ ¶›Ó·Î·˜ 2 ‰Â›¯ÓÂÈ ÙÔ˘˜ ÌËÙÚÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ‰È·ÙÚÔÊ‹ ÙÔ˘ ÓÂÔÁÓÔ‡ ηٿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙË ª∫. ¶ÚÈÓ ÙËÓ ·Ú¤Ì‚·ÛË, Ù· ÓÂÔÁÓ¿ Ô˘ ÁÂÓÓÈÔ‡ÓÙ·Ó Ì º∆ Î·È ÂΛӷ Ô˘ ÁÂÓÓÈÔ‡ÓÙ·Ó Ì ∫∆ ı‹Ï·˙·Ó Û ·ÚfiÌÔÈ· ÔÛÔÛÙ¿ (83,6% Î·È 84,5% ·ÓÙ›ÛÙÔȯ·), ÂÓÒ ÂΛӷ Ô˘ ÁÂÓÓÈÔ‡ÓÙ·Ó Ì ∞∂ ı‹Ï·˙·Ó ÏÈÁfiÙÂÚÔ Û˘¯Ó¿ (72,3%, p<0,01). ªÂÙ¿ ÙËÓ ·Ú¤Ì‚·ÛË, Ô Û˘ÓÔÏÈÎfi˜ ª£ ·˘Í‹ıËΠ۠88,6%, 91% Î·È 80,5% ·ÓÙ›ÛÙÔȯ· ÁÈ· Ù· ÓÂÔÁÓ¿ Ô˘ ÁÂÓÓ‹ıËÎ·Ó Ì º∆, ∞∂ Î·È ∫∆, ·ÓÙ›ÛÙÔȯ·. ∆· ÓÂÔÁÓ¿ Ô˘ ÁÂÓÓÈÔ‡ÓÙ·È Ì ∫∆ Ê·›ÓÂÙ·È fiÙÈ ıËÏ¿˙Ô˘Ó ÛËÌ·ÓÙÈο ÏÈÁfiÙÂÚÔ (p<0,05), Û ۯ¤ÛË Ì ÙȘ 2 ¿ÏϘ ÔÌ¿‰Â˜, ÌÂÙ¿ ÙËÓ ·Ú¤Ì‚·ÛË. ∂›Û˘, Ô ·ÔÎÏÂÈÛÙÈÎfi˜ ª£ ·˘Í‹ıËΠÛËÌ·ÓÙÈο ÌÂÙ¿ ÙËÓ ·Ú¤Ì‚·ÛË Î·È ÛÙȘ 3 ÔÌ¿‰Â˜ ÙÔÎÂÙÔ‡ (p<0,001), ·Ó Î·È ÛÙËÓ ÔÌ¿‰· Ù˘ ∫∆ Ë Û˘¯ÓfiÙËÙ· ·ÔÎÏÂÈÛÙÈÎÔ‡ ıËÏ·ÛÌÔ‡ ‹Ù·Ó ÌÈÎÚfiÙÂÚË Û ۯ¤ÛË Ì ÙȘ ¿ÏϘ ‰‡Ô ÔÌ¿‰Â˜. ∏ ‡·ÚÍË ÚÔËÁÔ‡ÌÂÓÔ˘ ·È‰ÈÔ‡ Ù˘ ÌËÙ¤Ú·˜ Ô˘ ¤¯ÂÈ ıËÏ¿ÛÂÈ ÂËÚ¿˙ÂÈ ıÂÙÈο ÙÔÓ ª£. ∆Ô 1997, Ô ·ÚÈıÌfi˜ ÚÔËÁÔ‡ÌÂÓˆÓ ·È‰ÈÒÓ ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ‰ÂÓ Ê·›ÓÂÙ·È Ó· ›¯Â ÛËÌ·ÓÙÈ΋ ›‰Ú·ÛË
¶›Ó·Î·˜ 1. ™˘¯ÓfiÙËÙ· ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ (ª£) (Û˘ÓÔÏÈÎfi˜, ·ÔÎÏÂÈÛÙÈÎfi˜ Î·È ÌÈÎÙfi˜) ηٿ ÙËÓ ¤ÍÔ‰Ô ÙÔ˘ ÓÂÔÁÓÔ‡ ·fi ÙË ª∫, ÚÈÓ (1997) Î·È ÌÂÙ¿ (1999) ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ·Ú¤Ì‚·Û˘ ÁÈ· ÙËÓ ÂÓ›Û¯˘ÛË ÙÔ˘ ª£ Î·È Û‡ÁÎÚÈÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔ ÓÂÔÁÓfi (ʇÏÔ Î·È ‚¿ÚÔ˜ Á¤ÓÓËÛ˘) Î·È Ô˘ ı· ÌÔÚÔ‡Û·Ó Ó· ÂËÚ¿ÛÔ˘Ó ÙÔÓ ÙÚfiÔ Û›ÙÈÛ˘ (ÂÓÙfi˜ οı ÂÚÈfi‰Ô˘ Î·È ÌÂٷ͇ ÙˆÓ ‰‡Ô ÂÚÈfi‰ˆÓ) ∆ÚfiÔ˜ Û›ÙÈÛ˘
™˘ÓÔÏÈÎfi˜ ª£
∞ÚÈıÌfi˜ ÓÂÔÁÓÒÓ (%) ∞ÁfiÚÈ º‡ÏÔ ∫ÔÚ›ÙÛÈ µ¿ÚÔ˜ Á¤ÓÓËÛ˘ (Kg)
<2,5 2,5-3 >3
™‡ÓÔÏÔ N 1997: 929 1999: 878 1997: 460 1999: 442 1997: 469 1999: 436 1997: 6 1999: 8 1997: 236 1999: 216 1997: 687 1999: 654
760 (81,9)** 764 (87,0)Á 371 (80,5) 374 (84,6) 389 (83,0)** 390 (89,4)· 3 (50,0)Á 4 (57,1)Â 183 (77,7)Á,* 185 (85,6)Â 574 (83,4)Á,* 576 (88,1)Â
∞ÔÎÏÂÈÛÙÈÎfi˜ ªÈÎÙfi˜ (ª£+ ª£ Ù¯ÓËÙ‹ ‰È·ÙÚÔÊ‹) 359 (38,6)*** 623 (71,0) 187 (40,7)*** 277 (62,6)‚ 172 (36,7)** 327 (75,0)‚ 1 (16,7)‰ 1 (14,2)˙ 80 (34,2)‰,*** 148 (68,5)˙ 278 (40,5)‰,*** 442 (67,6)˙
401 (43,2) 141 (16,0) 184 (40,1) 97 (21,9) 217 (46,3) 63 (14,4) 2 (33,3) 3 (42,9) 103 (43,5) 37 (17,1) 296 (43,1) 134 (15,3)
∆¯ÓËÙ‹ ‰È·ÙÚÔÊ‹ 169 (18,0) 114(13,0) 89 (19,4) 68 (15,4) 80 (17,1) 46 (10,4) 3 (50,0) 4 (42,8) 53 (22,3) 31 (14,4) 113(16,6) 78 (11,9)
·,Á,‰
p<0,05, Â,˙ p<0,01 Î·È ‚ p<0,001: ∆È̤˜ p, ¯2, ÁÈ· ÙȘ ÔÌ¿‰Â˜ ‰È·ÊfiÚˆÓ ÙÚfiˆÓ Û›ÙÈÛ˘ Î·È ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÓÂÔÁÓÒÓ, ÙÔ Ê‡ÏÔ Î·È ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ÂÓÙfi˜ Ù˘ οı ÂÚÈfi‰Ô˘ Ù˘ ÌÂϤÙ˘. ·&‚ : ÛËÌ·ÓÙÈÎfiÙËÙ· ÌÂٷ͇ ÙˆÓ ‰‡Ô Ê‡ÏˆÓ Î·Ù¿ ÙËÓ ÂÚ›Ô‰Ô ÌÂÙ¿ ÙËÓ ·Ú¤Ì‚·ÛË ÁÈ· ÙÔÓ Û˘ÓÔÏÈÎfi (·) Î·È ÙÔÓ ·ÔÎÏÂÈÛÙÈÎfi (‚) ª£. Á&‰ : ÛËÌ·ÓÙÈÎfiÙËÙ· ÌÂٷ͇ ÙˆÓ 3 ÔÌ¿‰ˆÓ ÙÔ˘ µ° ÚÈÓ ÙËÓ ·Ú¤Ì‚·ÛË (1997) ÁÈ· ÙÔÓ Û˘ÓÔÏÈÎfi (Á) Î·È ÙÔÓ ·ÔÎÏÂÈÛÙÈÎfi (‰) ª£ Â&˙ : ÛËÌ·ÓÙÈÎfiÙËÙ· ÌÂٷ͇ ÙˆÓ 3 ÔÌ¿‰ˆÓ ÙÔ˘ µ° ÌÂÙ¿ ÙËÓ ·Ú¤Ì‚·ÛË (1999) ÁÈ· ÙÔÓ Û˘ÓÔÏÈÎfi (Â) Î·È ÙÔÓ ·ÔÎÏÂÈÛÙÈÎfi (˙) ª£ * p<0,05, ** p<0,01, ***p<0,001: ™ËÌ·ÓÙÈÎfiÙËÙ· ÌÂٷ͇ ÙˆÓ ‰‡Ô ÂÚÈfi‰ˆÓ Ù˘ ÌÂϤÙ˘ ÁÈ· ÙÔ˘˜ ‰È¿ÊÔÚÔ˘˜ ·Ú¿ÁÔÓÙ˜, fiÛÔÓ ·ÊÔÚ¿ ÙÔÓ Û˘ÓÔÏÈÎfi Î·È ÙÔÓ ·ÔÎÏÂÈÛÙÈÎfi ª£. ¶·È‰È·ÙÚÈ΋ 2007;70:285-292
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·288
288
∞. ¡ÙÔ˘ÚÓÙÔ‡ÊË Î·È Û˘Ó.
100% 90%
™˘ÓÔÏÈÎfi˜ ª£
80%
∞ÔÎÏÂÈÛÙÈÎfi˜ ª£
70%
¶ÚÈÓ ÙËÓ ·Ú¤Ì‚·ÛË ªÂÙ¿ ÙËÓ ·Ú¤Ì‚·ÛË
60%
¶ÚÈÓ ÙËÓ ·Ú¤Ì‚·ÛË 50% ªÂÙ¿ ÙËÓ ·Ú¤Ì‚·ÛË 40% 30% 20% 10% 0 1Ë Â‚‰ÔÌ¿‰·
1Ô˜ Ì‹Ó·˜
2Ô˜ Ì‹Ó·˜
3Ô˜ Ì‹Ó·˜
4-6 Ì‹Ó˜
>6 Ì‹Ó˜
∂ÈÎfiÓ· 1. ¶ÔÛÔÛÙfi ÙˆÓ ‚ÚÂÊÒÓ Ô˘ ıËÏ¿˙Ô˘Ó (·ÔÎÏÂÈÛÙÈÎfi˜ Î·È Û˘ÓÔÏÈÎfi˜ ª£) ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÚÒÙÔ˘ ¯ÚfiÓÔ˘ ˙ˆ‹˜, ÚÈÓ Î·È ÌÂÙ¿ ÙËÓ ·Ú¤Ì‚·ÛË. p<0,01 ·fi ÙËÓ 1Ë Â‚‰ÔÌ¿‰· ˆ˜ ÙÔÓ 2Ô Ì‹Ó· ÁÈ· ÙÔÓ Û˘ÓÔÏÈÎfi ª£. p<0,001 ·fi ÙÔÓ 3Ô Ì‹Ó· Î·È ÌÂÙ¿ ÙÔÓ 6Ô Ì‹Ó· ÁÈ· ÙÔ Û˘ÓÔÏÈÎfi ª£ Î·È ·fi ÙËÓ 1Ë Â‚‰ÔÌ¿‰· ˆ˜ ÌÂÙ¿ ÙÔÓ 6Ô Ì‹Ó· ÁÈ· ÙÔÓ ·ÔÎÏÂÈÛÙÈÎfi ª£.
¶›Ó·Î·˜ 2. ¶·Ú¿ÁÔÓÙ˜ Û¯ÂÙÈ˙fiÌÂÓÔÈ Ì ÙË ÌËÙ¤Ú· (Ù‡Ô˜ ÙÔÎÂÙÔ‡, ·ÚÈıÌfi˜ ÙfiÎÔ˘ ÌËÙ¤Ú·˜, ËÏÈΛ· ÌËÙ¤Ú·˜) ı· ÌÔÚÔ‡Û·Ó Ó· ÂËÚ¿ÛÔ˘Ó ÙË Û˘¯ÓfiÙËÙ· ÙÔ˘ ª£ (Û˘ÓÔÏÈÎfi˜, ·ÔÎÏÂÈÛÙÈÎfi˜ Î·È ÌÈÎÙfi˜) ηٿ ÙËÓ ¤ÍÔ‰Ô ÙÔ˘ ÓÂÔÁÓÔ‡ ·fi ÙË ª∫, ÚÈÓ (1997) Î·È ÌÂÙ¿ (1999) ÙËÓ ·Ú¤Ì‚·ÛË, ÂÓÙfi˜ οı ÂÚÈfi‰Ô˘ Î·È ÌÂٷ͇ ÙˆÓ ‰‡Ô ÂÚÈfi‰ˆÓ ∆ÚfiÔ˜ Û›ÙÈÛ˘
∆ÔÎÂÙfi˜ (%)
™˘ÓÔÏÈÎfi˜ ª£ º∆ ∞∂ ∫∆
∆fiÎÔ˜ ÌËÙ¤Ú·˜ (%)
I II III
∏ÏÈΛ· ÌËÙ¤Ú·˜ (¤ÙË)
<20 20-29 30-39 > 40
‚,Á,‰,˙
™‡ÓÔÏÔ N 1997: 709 1999: 647 1997: 148 1999: 67 1997: 71 1999: 164 1997: 468 1999: 414 1997: 346 1999: 346 1997: 115 1999: 118 1997: 31 1999: 18 1997: 633 1999: 473 1997: 252 1999: 375 1997: 11 1999: 12
593 (83,6)·,** 573 (88,6)‚ 107 (72,3)·,** 61 (91,0)‚ 60 (84,5)· 132 (80,5)‚ 396 (84,6) 350 (84,5)‰ 270 (78,0)*** 306 (88,4)‰ 94 (81,7)** 110 (93,2)‰ 29 (93,6)* 12 (66,6)Ë 526 (83,1) 402 (85,0)Ë 196 (77,8)*** 339 (90,4)Ë 8 (72,7) 7 (58,3)Ë
∞ÔÎÏÂÈÛÙÈÎfi˜ ªÈÎÙfi˜ (ª£+ ª£ Ù¯ÓËÙ‹ ‰È·ÙÚÔÊ‹) 281 (39,6)Á,*** 441 (68,1) 53 (35,8)Á,*** 47 (70,2) 25 (35,2)Á,*** 105 (64,0) 166 (35,5)Â,*** 256 (61,8)˙ 136 (39,3)Â,*** 243 (70,2)˙ 57 (49,6)Â,** 84 (71,0)˙ 15 (48,4)* 10 (55,5)ı 242 (38,2)*** 316 (66,8)ı 98 (38,9)*** 258 (68,8)ı 4 (36,4) 5 (41,7)ı
312 (44,0) 132 (20,4) 54 (36,5) 14 (20,8) 35 (49,3) 27 (16,5) 230 (49,2) 94 (22,7) 134 (38,7) 63 (18,2) 37 (32,2) 26 (22,0) 14 (45,2) 2 (1,1) 284 (44,9) 86 (18,2) 98 (38,9) 81 (21,6) 4 (36,4) 2 (16,6)
∆¯ÓËÙ‹ ‰È·ÙÚÔÊ‹ 116(16,4) 74 (11,4) 41 (27,7) 6 (8,9) 11 (15,5) 32 (19,5) 89 (19,4) 64 (15,5) 80 (17,1) 40 (11,6) 21 (18,3) 8 (6,7) 2(6,5) 6 (33,3) 107 (16,9) 71 (15,0) 56 (22,2) 36 (9,6) 3 (27,3) 5 (41,6)
p<0,05, ·,Â,ı p<0,01 Î·È Ë p<0,001: ™ËÌ·ÓÙÈÎfiÙËÙ· ÌÂٷ͇ ÙˆÓ ÔÌ¿‰ˆÓ ÁÈ· οı ·Ú¿ÁÔÓÙ· ηٿ ÙËÓ ›‰È· ÂÚ›Ô‰Ô Ù˘ ÌÂϤÙ˘ * p<0,05, **p<0,01, ***p<0,001: ™ËÌ·ÓÙÈÎfiÙËÙ· ÌÂٷ͇ ÙˆÓ ‰‡Ô ÂÚÈfi‰ˆÓ, ÁÈ· ÙÔ˘˜ ‰È¿ÊÔÚÔ˘˜ ·Ú¿ÁÔÓÙ˜. Paediatriki 2007;70:285-292
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·289
289
¶ÚÔÒıËÛË ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡
¶›Ó·Î·˜ 3. ™˘¯ÓfiÙËÙ· ª£ (Û˘ÓÔÏÈÎfi˜, ·ÔÎÏÂÈÛÙÈÎfi˜ Î·È ÌÈÎÙfi˜) ηٿ ÙËÓ ¤ÍÔ‰Ô ÙÔ˘ ÓÂÔÁÓÔ‡ ·fi ÙË ª∫, Û ۯ¤ÛË Ì ÙÔ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi Â›Â‰Ô Î·Ù¿ ÙȘ ‰‡Ô ÂÚÈfi‰Ô˘˜ Ù˘ ÌÂϤÙ˘ ÚÈÓ (1997) Î·È ÌÂÙ¿ (1999) ÙËÓ ·Ú¤Ì‚·ÛË ∆ÚfiÔ˜ Û›ÙÈÛ˘
∆¿ÍË (N, %)
™˘ÓÔÏÈÎfi˜ ª£ I II III IV
™‡ÓÔÏÔ N 1997: 193 1999: 154 1997: 288 1999: 352 1997: 219 1999: 189 1997: 216 1999: 183
154 (79,8) 133 (86,4) 233 (80,9) 300 (85,2) 176 (80,4) 165 (87,3) 186 (86,1) 159 (86,9)
∞ÔÎÏÂÈÛÙÈÎfi˜ ªÈÎÙfi˜ (ª£+ ª£ Ù¯ÓËÙ‹ ‰È·ÙÚÔÊ‹) 72 (37,3)* 109 (70,8) 118 (41,0)* 219 (62,2) 81 (37,0)* 136 (72,0) 80 (37,0)* 115 (62,8)
82 (42,5) 24 (15,6) 115 (40,0) 81 (23,0) 95 (43,4) 29 (15,3) 106(49,1) 44 (24,0)
∆¯ÓËÙ‹ ‰È·ÙÚÔÊ‹ 39 (20,2) 21 (13,6) 55 (19,1) 52 (14,8) 43 (19,6) 24 (12,7) 30 (13,9) 24 (13,1)
*
p<0,001: ™ËÌ·ÓÙÈÎfiÙËÙ· ÌÂٷ͇ ÙˆÓ 2 ÂÚÈfi‰ˆÓ Ù˘ ÌÂϤÙ˘. ∆¿ÍË I: ·ÓÂȉ›Î¢ÙÔÈ ÂÚÁ¿Ù˜, ∆¿ÍË II: ÂȉÈÎÂ˘Ì¤ÓÔÈ ÂÚÁ¿Ù˜ Î·È Ù¯ӛÙ˜, ∆¿ÍË III: ·fiÊÔÈÙÔÈ ·ÓÒÙÂÚˆÓ Û¯ÔÏÒÓ, ∆¿ÍË IV: ·fiÊÔÈÙÔÈ ·ÓÂÈÛÙËÌ›Ô˘.
ÛÙÔÓ Û˘ÓÔÏÈÎfi ª£, ·ÏÏ¿ ·˘Í‹ıËΠÛËÌ·ÓÙÈο Ë Û˘¯ÓfiÙËÙ· ÙÔ˘ ·ÔÎÏÂÈÛÙÈÎÔ‡ ª£ (p<0,01). ªÂÙ¿ ÙËÓ ·Ú¤Ì‚·ÛË, Ê·›ÓÂÙ·È fiÙÈ fiÛÔ ·˘Í¿ÓÂÙ·È Ô ·ÚÈıÌfi˜ ÙˆÓ ·È‰ÈÒÓ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ Ô˘ ¤¯Ô˘Ó ıËÏ¿ÛÂÈ, ·˘Í¿ÓÂÙ·È Ô Û˘ÓÔÏÈÎfi˜ Î·È Ô ·ÔÎÏÂÈÛÙÈÎfi˜ ª£ (p<0,05). ∏ ·Ú¤Ì‚·ÛË ·‡ÍËÛ ÛËÌ·ÓÙÈο ÙÔÓ Û˘ÓÔÏÈÎfi ª£ ÛÙȘ ÌËÙ¤Ú˜ Ì 2 Î·È 3 ‹ ÂÚÈÛÛfiÙÂÚ· ·È‰È¿ (p<0,001 Î·È p<0,01, ·ÓÙ›ÛÙÔȯ·). ∏ ›‰Ú·ÛË ÛÙËÓ ·‡ÍËÛË ÙÔ˘ ·ÔÎÏÂÈÛÙÈÎÔ‡ ª£ ‹Ù·Ó ÈÔ ÛËÌ·ÓÙÈ΋ ÛÙȘ ÌËÙ¤Ú˜ Ì 1 Î·È 2 ·È‰È¿ (p<0,001) Î·È ÏÈÁfiÙÂÚÔ ÛËÌ·ÓÙÈ΋ Û ÂΛӘ Ì 3 ‹ ÂÚÈÛÛfiÙÂÚ· ·È‰È¿ (p<0,01). ∏ ËÏÈΛ· Ù˘ ÌËÙ¤Ú·˜ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ÂËÚ¿˙ÂÈ ÙÔÓ ª£ ÚÈÓ ÙËÓ ·Ú¤Ì‚·ÛË. ªÂÙ¿ ÙËÓ ·Ú¤Ì‚·ÛË, Ô ª£ (Û˘ÓÔÏÈÎfi˜ Î·È ·ÔÎÏÂÈÛÙÈÎfi˜) ·˘Í¿ÓÂÈ Ì ÙËÓ ËÏÈΛ· Ù˘ ÌËÙ¤Ú·˜ (p<0,001). ªËÙ¤Ú˜ ËÏÈΛ·˜ >40 ÂÙÒÓ ıËÏ¿˙Ô˘Ó ÏÈÁfiÙÂÚÔ Û˘¯Ó¿ Î·È ÚÈÓ Î·È ÌÂÙ¿ ÙËÓ ·Ú¤Ì‚·ÛË. ∏ ›‰Ú·ÛË Ù˘ ·Ú¤Ì‚·Û˘ ÛÙË Û˘¯ÓfiÙËÙ· ÙÔ˘ ·ÔÎÏÂÈÛÙÈÎÔ‡ ª£ ‹Ù·Ó ÛËÌ·ÓÙÈÎfiÙÂÚË ÛÙȘ ËÏÈ˘ 20-29 Î·È 30-39 ÂÙÒÓ (p<0,001). ∏ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈ΋ ηٿÛÙ·ÛË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ‰ÂÓ ÂËÚ¤·Û ÙË Û˘¯ÓfiÙËÙ· ÙÔ˘ ª£ Î·È ·˘Ùfi ‰ÂÓ ‰È¤ÊÂÚ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÂÚÈfi‰ˆÓ. ∏ ‰È¿ÚÎÂÈ· ÙÔ˘ ıËÏ·ÛÌÔ‡ ÚÈÓ Î·È ÌÂÙ¿ ÙËÓ ·Ú¤Ì‚·ÛË Ê·›ÓÂÙ·È ÛÙËÓ ∂ÈÎfiÓ· 1. ∏ ‰È¿ÚÎÂÈ· ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ıËÏ·ÛÌÔ‡ ÛÙËÓ ÚÒÙË ÂÚ›Ô‰Ô ‰Â›¯ÓÂÈ ÌÈ· ÚÔԉ¢ÙÈ΋ ÂÏ¿ÙÙˆÛË ·fi 81,3% ÙËÓ 1Ë Â‚‰ÔÌ¿‰· ÛÙÔ 40% ÌÂٷ͇ ÙÔ˘ 4Ô˘ Î·È 6Ô˘ Ì‹Ó· Î·È ÛÙÔ 22,6% ÌÂÙ¿ ÙÔÓ 6Ô Ì‹Ó·, ÂÓÒ Ô ·ÔÎÏÂÈÛÙÈÎfi˜ ıËÏ·ÛÌfi˜ ¤ÊÙÂÈ ·fi 39% ÛÙÔ 18,8% Î·È 9% ÛÙȘ ›‰È˜ ÂÚÈfi‰Ô˘˜. ªÂÙ¿ ÙËÓ ·Ú¤Ì‚·ÛË, Ù· ÔÛÔÛÙ¿ Û˘ÓÔÏÈÎÔ‡ ª£ Â›Ó·È 84,4%, 64,9% Î·È 44,4% ÛÙÔ Ù¤ÏÔ˜ Ù˘ 1˘ ‚‰ÔÌ¿‰·˜, ηٿ ÙÔÓ 4Ô Ì 6Ô
Ì‹Ó· Î·È ÌÂÙ¿ ÙÔÓ 6Ô Ì‹Ó· ·ÓÙ›ÛÙÔȯ·, ÂÓÒ ÙÔ˘ ·ÔÎÏÂÈÛÙÈÎÔ‡ ıËÏ·ÛÌÔ‡ 61,8%, 42,8% Î·È 29,1% (∂ÈÎfiÓ· 1). ∏ ·‡ÍËÛË Ù˘ ‰È¿ÚÎÂÈ·˜ ÙÔ˘ ª£ (Û˘ÓÔÏÈÎÔ‡ Î·È ·ÔÎÏÂÈÛÙÈÎÔ‡) ηٿ ≥6 Ì‹Ó˜ Â›Ó·È ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ (p<0,001) ÌÂÙ¿ ÙËÓ ·Ú¤Ì‚·ÛË.
™˘˙‹ÙËÛË ªÂÙ¿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ˘ÔÛÙ‹ÚÈ͢ Î·È ÂÓ›Û¯˘Û˘ ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ÌÂÙ¿ ÙÔÓ ÙÔÎÂÙfi Î·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·Ú·ÌÔÓ‹˜ ÙˆÓ ÌËÙ¤ÚˆÓ Î·È ÙˆÓ ÓÂÔÁÓÒÓ ÙÔ˘˜ ÛÙË ª∫ ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ, ·Ú·ÙËÚ‹ıËΠÌÈ· ·‡ÍËÛË ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ª£ ·fi 81,9% ÛÙÔ 87%, ·ÏÏ¿ ΢ڛˆ˜ ÌÈ· ·‡ÍËÛË ÙÔ˘ ·ÔÎÏÂÈÛÙÈÎÔ‡ ıËÏ·ÛÌÔ‡ Ô˘ ۯ‰fiÓ ‰ÈÏ·ÛÈ¿ÛÙËΠ·fi 38,6% ÙÔ 1997, ÚÈÓ ÙËÓ ·Ú¤Ì‚·ÛË, ÛÙÔ 71% ÙÔ 1999 (¶›Ó·Î·˜ 1). ŒÙÛÈ, ÙÔ ÔÛÔÛÙfi ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ‰ÂÓ ¤·ÈÚÓ·Ó Î·ıfiÏÔ˘ ÙÚÔÔÔÈË̤ÓÔ Á¿Ï· ηٿ ÙËÓ ¤ÍÔ‰fi ÙÔ˘˜ ·fi ÙË ª∫ ÂÏ·ÙÙÒıËΠۯ‰fiÓ ÛÙÔ ÌÈÛfi. ªÂÏÂÙÒÓÙ·˜ ÙË Û˘¯ÓfiÙËÙ· ÙÔ˘ ª£ ÙÔ 1997, ‚Ú¤ıËΠfiÙÈ ÂÓÒ ¤Ó· ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ÙˆÓ ÌËÙ¤ÚˆÓ Â›¯·Ó ÛÎÔfi Ó· ıËÏ¿ÛÔ˘Ó Î·È ÍÂΛӷÁ·Ó ª£, ÌfiÓÔ ÙÔ ¤Ó· ÙÚ›ÙÔ Û¯Â‰fiÓ ·˘ÙÒÓ, ηٿÊÂÚ·Ó Ó· ıËÏ¿ÛÔ˘Ó ·ÔÎÏÂÈÛÙÈο ηٿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙË ª∫. º·›ÓÂÙ·È ˆ˜ Ë ·fiÊ·ÛË Ù˘ ÌËÙ¤Ú·˜ Ó· ıËÏ¿ÛÂÈ ·fi ÌfiÓË Ù˘ ‰ÂÓ Â·ÚΛ ÁÈ· Ó· ÂÙ‡¯ÂÈ Ô ÛÙfi¯Ô˜. °È· ÙËÓ ÂÁηٿÛÙ·ÛË ÙÔ˘ ª£ Â›Ó·È ·Ó·Áη›Â˜ ÛˆÛÙ¤˜ Ô‰ËÁ›Â˜ Î·È ˘ÔÛÙ‹ÚÈÍË ÙˆÓ ÌËÙ¤ÚˆÓ ·fi ÙÔ ÚÔÛˆÈÎfi ˘Á›·˜ Ù˘ ª∫ (ÓÂÔÁÓÔÏfiÁÔÈ, ·È‰›·ÙÚÔÈ, Ì·›Â˜, ÓÔÛËχÙÚȘ) (7). ™ÙȘ ÛηӉÈÓ·‚ÈΤ˜ ¯ÒÚ˜, Ë ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ ÙÔ˘ ª£ ÂÈÙ‡¯ıËΠÌÂÙ¿ ·fi ·Ú¤Ì‚·ÛË ÛÙȘ Ú·ÎÙÈΤ˜ ÙˆÓ ª∫ Î·È Î˘Ú›ˆ˜ ÙË ¶·È‰È·ÙÚÈ΋ 2007;70:285-292
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·290
290
∞. ¡ÙÔ˘ÚÓÙÔ‡ÊË Î·È Û˘Ó.
Û˘Ó¯‹ ·ʋ ÌËÙ¤Ú·˜ - ÓÂÔÁÓÔ‡ Î·È ÙËÓ ·ÚÔ¯‹ ÚÔÛˆÈ΋˜ ÂÍ·ÙÔÌÈÎÂ˘Ì¤Ó˘ ‚Ô‹ıÂÈ·˜ Û οı ÌËÙ¤Ú· ÁÈ· ÙËÓ ÂÁηٿÛÙ·ÛË ÙÔ˘ ª£ (4). √ ÛÙfi¯Ô˜ Ù˘ ·Ú¤Ì‚·Û˘ ÁÈ· ÂÓ›Û¯˘ÛË ÙÔ˘ ª£ ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ‹Ù·Ó Ó· ·˘ÍËı› fi¯È ÌfiÓÔ Ë Û˘¯ÓfiÙËÙ· ÙÔ˘ ª£ Û˘ÓÔÏÈο ·ÏÏ¿ Î·È ÂΛÓË ÙÔ˘ ·ÔÎÏÂÈÛÙÈÎÔ‡ ª£ Ô˘ ‹Ù·Ó Ôχ ¯·ÌËÏ‹ Û ۯ¤ÛË Ì ¿ÏϘ Â˘Úˆ·˚Τ˜ ¯ÒÚ˜ Î·È Î˘Ú›ˆ˜ ÙȘ ÛηӉÈÓ·‚ÈΤ˜ ¯ÒÚ˜ (2). ¶ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜ (1) ¤‰ÂÈÍ·Ó fiÙÈ Ô ·ÔÎÏÂÈÛÙÈÎfi˜ ª£ ηٿ ÙËÓ ÚÒÙË Â‚‰ÔÌ¿‰· ˙ˆ‹˜ ›¯Â ÛËÌ·ÓÙÈ΋ ›‰Ú·ÛË ÛÙË Û˘ÓÔÏÈ΋ ‰È¿ÚÎÂÈ· ÙÔ˘ ıËÏ·ÛÌÔ‡. ŒÙÛÈ, Ë Â›Ù¢ÍË Ù˘ ÛËÌ·ÓÙÈ΋˜ ·‡ÍËÛ˘ ÙÔ˘ ·ÔÎÏÂÈÛÙÈÎÔ‡ ª£ ηٿ ÙËÓ ÚÒÙË Â‚‰ÔÌ¿‰· ˙ˆ‹˜ Ê·›ÓÂÙ·È ˆ˜ Â›Ó·È ÛËÌ·ÓÙÈÎfi ÁÂÁÔÓfi˜ ÁÈ· ÙË Û˘¯ÓfiÙËÙ· ÙÔ˘ ª£ ÛÙËÓ ÂÚÈÔ¯‹ Ù˘ µ¢ ∂ÏÏ¿‰·˜, Ï·Ì‚¿ÓÔÓÙ·˜ ˘fi„Ë fiÙÈ ¿Óˆ ·fi ÙÔ 50% ÙˆÓ ÙÔÎÂÙÒÓ Á›ÓÔÓÙ·È ÛÙÔ ¶°¡π. ∆Ô ÁÂÁÔÓfi˜ fiÙÈ Ë ·ÚÔ¯‹ ‚Ô‹ıÂÈ·˜ ÛÙȘ ÌËÙ¤Ú˜ ηٿ ÙȘ ÚÒÙ˜ ‚‰ÔÌ¿‰Â˜ ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ Î·Ï‡ÙÂÚË ÂÈÙ˘¯›· ÙÔ˘ ª£ ÌÂÁ·Ï‡ÙÂÚ˘ ‰È¿ÚÎÂÈ·˜ ·Ó·Ê¤ÚÂÙ·È Î·È Û ¿ÏϘ ÌÂϤÙ˜ (8-10). ™ÙË ÌÂϤÙË ÙˆÓ Ahluwalia Î·È Û˘Ó. Û˘ÌÂÚ·›ÓÂÙ·È fiÙÈ “Ë ÛÙÚ·ÙËÁÈ΋ Ì ٷ ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù· Â›Ó·È Ë ·ÚÔ¯‹ ‚Ô‹ıÂÈ·˜ Î·È Ë Î·ıÔ‰‹ÁËÛË Ô˘ ·Ú¤¯ÂÙ·È ÛÙȘ ÌËÙ¤Ú˜ Ï›ÁÔ ÌÂÙ¿ ÙÔÓ ÙÔÎÂÙfi ÛÙÔ ÓÔÛÔÎÔÌ›Ԕ (11). √È Ú·ÎÙÈΤ˜ Ô‰ËÁ›Â˜ Ô˘ ‰›ÓÔÓÙ·È ÛÙȘ ÌËÙ¤Ú˜ ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙÔÓ ÙÔÎÂÙfi ÌÔÚ› Ó· ÙÔ˘˜ ÚÔÛʤÚÔ˘Ó ÙËÓ Î·Ù¿ÏÏËÏË ‚Ô‹ıÂÈ· ÁÈ· ÙÔÓ ÂÈÙ˘¯‹ ıËÏ·ÛÌfi ÙÔ˘ ̈ÚÔ‡ ÙÔ˘˜. ∏ ·‡ÍËÛË ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ Î·È ÙÔ˘ ·ÔÎÏÂÈÛÙÈÎÔ‡ ª£ Ì ÙËÓ ·Ú¤Ì‚·ÛË ÂÓ›Û¯˘Û˘ ÙÔ˘ ª£ ÛÙË ª∫ Û˘ÌʈÓ› Î·È Ì ¿ÏϘ ·Ó·ÊÔÚ¤˜ ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· fiÙÈ Ë Âη›‰Â˘ÛË Î·È Ë ˘ÔÛÙ‹ÚÈÍË Û¯ÂÙ›˙ÔÓÙ·È Ì ·‡ÍËÛË Ù˘ ¤Ó·Ú͢ ÙÔ˘ ª£ (11-13). ªÈ· ÌÂϤÙË ·fi ÙËÓ ∆Ô˘ÚΛ· ¤‰ÂÈÍ ˘„ËÏfiÙÂÚË Û˘¯ÓfiÙËÙ· ·ÔÎÏÂÈÛÙÈÎÔ‡ ª£ ÛÙËÓ ÔÌ¿‰· ·Ú¤Ì‚·Û˘ Û ۯ¤ÛË Ì ÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘ (14). ∂›Û˘, ÔÈ Kurinij Î·È Û˘Ó. ¤‰ÂÈÍ·Ó fiÙÈ Ë ÔÏÈÙÈ΋ ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ ÂËÚ¿˙ÂÈ ÙËÓ Èı·ÓfiÙËÙ· Ô˘ ¤¯ÂÈ ÌÈ· ÌËÙ¤Ú· Ó· ıËÏ¿ÛÂÈ ·ÔÎÏÂÈÛÙÈο ÙÔ ÌˆÚfi Ù˘ (15). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, fiˆ˜ Î·È Û ¿ÏϘ ÌÂϤÙ˜ (16-18), Ù· ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÓÂÔÁÓ¿ (<2,5 kg) ›¯·Ó ÏÈÁfiÙÂÚ˜ Èı·ÓfiÙËÙ˜ Ó· ıËÏ¿ÛÔ˘Ó (p<0,05) Û ۯ¤ÛË Ì ÂΛӷ ÌÂÁ·Ï‡ÙÂÚÔ˘ µ° (>2,5 kg). ∏ Û˘¯ÓfiÙËÙ· ª£ ‹Ù·Ó ÂÚ›Ô˘ 50% ÛÙ· <2,5 kg Î·È >80% ÛÙ· ÌÂÁ·Ï‡ÙÂÚÔ˘ µ° (>2,5 kg) ÓÂÔÁÓ¿. ∆Ô ÚfiÁÚ·ÌÌ· ˘ÔÛÙ‹ÚÈ͢ ÙÔ˘ ª£ ‰ÂÓ ÂËÚ¤·Û ÛËÌ·ÓÙÈο ÙË Û˘¯ÓfiÙËÙ· ª£ ÙˆÓ ÓÂÔÁÓÒÓ Ì ¯·ÌËÏfi µ° (·‡ÍËÛË ·fi ÙÔ 50% ÛÙÔ 57,1%). ª›· ·fi ÙȘ Èı·Ó¤˜ ·Èٛ˜ Ù˘ ÌÈÎÚfiÙÂÚ˘ Û˘¯ÓfiÙËÙ·˜ ª£ ÛÙ· ÓÂÔÁÓ¿ Ì µ° <2,5 kg Â›Ó·È Ë Û¯ÂÙÈ΋ ·ÓˆÚÈÌfiÙËÙ¿ ÙÔ˘˜ (35-36 ‚‰ÔÌ¿‰Â˜) Û ۯ¤ÛË Ì Paediatriki 2007;70:285-292
Ù· ÌÂÁ·Ï‡ÙÂÚ· ÓÂÔÁÓ¿, ÌÂÁ·Ï‡ÙÂÚ˘ ∏∫ Î·È Â›Û˘ Ë ÌÂÁ·Ï‡ÙÂÚË ·‚‚·ÈfiÙËÙ· Ù˘ ÌËÙ¤Ú·˜ fiÛÔÓ ·ÊÔÚ¿ ÙËÓ Â¿ÚÎÂÈ· ÙÔ˘ Á¿Ï·Ùfi˜ Ù˘, fiˆ˜ ·Ó·Ê¤ÚÔ˘Ó Î·È ÔÈ Barros Î·È Û˘Ó. (18). √È Rajan Î·È Û˘Ó. ›Û˘ ·Ó·Ê¤ÚÔ˘Ó fiÙÈ Ù· ÓÂÔÁÓ¿ Ì µ° >2,5 kg ¤¯Ô˘Ó ÌÂÁ·Ï‡ÙÂÚ˜ Èı·ÓfiÙËÙ˜ Ó· ıËÏ¿ÛÔ˘Ó ·ÔÎÏÂÈÛÙÈο ·’ fiÙÈ ÂΛӷ Ì µ° <2,5 kg (19). ∏ ›‰Ú·ÛË ÙÔ˘ Ù‡Ô˘ ÙÔ˘ ÙÔÎÂÙÔ‡ ÛÙËÓ ÂÈÙ˘¯›· ÙÔ˘ ª£ ¤¯ÂÈ ·Ó·ÊÂÚı› Û ÔÏϤ˜ ÌÂϤÙ˜ (2022). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, Ë ∞∂ Î·È Ë ∫∆ Ê·›ÓÂÙ·È ˆ˜ ¤¯Ô˘Ó ·ÚÓËÙÈ΋ ›‰Ú·ÛË ÛÙÔÓ ª£. ∏ ·Ú¤Ì‚·ÛË ˘ÔÛÙ‹ÚÈ͢ ÙÔ˘ ıËÏ·ÛÌÔ‡ ‚Ô‹ıËÛ ÙȘ ÌËÙ¤Ú˜ Ó· ÂÙ‡¯Ô˘Ó ÙÔÓ ª£ (p<0,01) ÌfiÓÔ ÛÙËÓ ÔÌ¿‰· ÂΛÓË Ô˘ Á¤ÓÓËÛ Ì ∞∂ Î·È fi¯È Ì ∫∆. ∏ ·‡ÍËÛË ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ª£ (p<0,05) ‹Ù·Ó ÏÈÁfiÙÂÚÔ ÛËÌ·ÓÙÈ΋ ÛÙ· ̈ڿ Ô˘ ÁÂÓÓ‹ıËÎ·Ó Ì ∫∆, Û ۯ¤ÛË Ì ÂΛӷ Ô˘ ÁÂÓÓ‹ıËÎ·Ó Ì º∆ ‹ ∞∂, ÌÂÙ¿ ÙËÓ ·Ú¤Ì‚·ÛË. ∏ ·‡ÍËÛË ÙÔ˘ ·ÔÎÏÂÈÛÙÈÎÔ‡ ıËÏ·ÛÌÔ‡ ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Î·È ÛÙȘ ÙÚÂȘ ÔÌ¿‰Â˜ ÌÂÙ¿ ÙËÓ ·Ú¤Ì‚·ÛË (p<0,001). √È Victora Î·È Û˘Ó. Û‡ÁÎÚÈÓ·Ó ÙÔÓ ÙÚfiÔ Û›ÙÈÛ˘ Û ‚Ú¤ÊË Ô˘ ÁÂÓÓ‹ıËÎ·Ó Ì º∆ Î·È Ì ∫∆ (20). ™ÙË ÌÂϤÙË ÙÔ˘˜, Ô Ù‡Ô˜ ÙÔ˘ ÙÔÎÂÙÔ‡ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ÂËÚ¿˙ÂÈ ÙËÓ ¤Ó·ÚÍË ÙÔ˘ ª£, ÂÓÙÔ‡ÙÔȘ Ë ‰È¿ÚÎÂÈ· ÙÔ˘ ª£ ‹Ù·Ó ÛËÌ·ÓÙÈο ÌÈÎÚfiÙÂÚË ÛÙ· ̈ڿ Ô˘ ›¯·Ó ÁÂÓÓËı› Ì ∫∆. ∫·È Û ¿ÏϘ ÌÂϤÙ˜ ·Ó·Ê¤ÚÂÙ·È Â›‰Ú·ÛË ÙÔ˘ ›‰Ô˘˜ ÙÔ˘ ÙÔÎÂÙÔ‡ ÛÙÔÓ ÙÚfiÔ Û›ÙÈÛ˘ ÙÔ˘ ‚Ú¤ÊÔ˘˜ (21,22). ¶Èı·ÓfiÓ Ë ·ÈÙ›· Ù˘ ÌÈÎÚfiÙÂÚ˘ Û˘¯ÓfiÙËÙ·˜ ª£ ÛÙ· ‚Ú¤ÊË Ô˘ ÁÂÓÓÈÔ‡ÓÙ·È Ì ∫∆ Â›Ó·È Ë Î·ı˘ÛÙÂÚË̤ÓË ÙÔÔı¤ÙËÛË ÙÔ˘ ̈ÚÔ‡ ÛÙÔ ÛÙ‹ıÔ˜ Ù˘ ÌËÙ¤Ú·˜ ÙÔ˘, Ô˘ ‰‡ÛÎÔÏ· ÂËÚ¿˙ÂÙ·È ·fi ·Ú¤Ì‚·ÛË. √ ÙfiÎÔ˜ Ù˘ ÌËÙ¤Ú·˜ ‹ Ô ·ÚÈıÌfi˜ ·È‰ÈÒÓ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ÂËÚ¿˙ÂÈ ÛËÌ·ÓÙÈο ÙË Û˘¯ÓfiÙËÙ· ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ª£, ·Ó Î·È Ë Û˘¯ÓfiÙËÙ· ÙÔ˘ ·ÔÎÏÂÈÛÙÈÎÔ‡ ª£ ·˘Í·ÓfiÙ·Ó ·Ú¿ÏÏËÏ· Ì ÙËÓ ·‡ÍËÛË ÙÔ˘ ·ÚÈıÌÔ‡ ·È‰ÈÒÓ ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ÙÔ 1997. ªÂÙ¿ ÙËÓ ·Ú¤Ì‚·ÛË ˘‹Ú¯Â ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË Î·È ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ Î·È ÙÔ˘ ·ÔÎÏÂÈÛÙÈÎÔ‡ ª£ (p<0,05). À¿Ú¯ÂÈ ‰È¯ÔÁӈ̛· ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· fiÛÔÓ ·ÊÔÚ¿ ÙËÓ Â›‰Ú·ÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ·È‰ÈÒÓ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ÛÙË Û˘¯ÓfiÙËÙ· ÙÔ˘ ª£. ™Â Ì›· ÌÂϤÙË ·fi ÙÔ ¶ÂÚÔ‡, Ë ‡·ÚÍË Ó¤ˆÓ ·È‰ÈÒÓ ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· Û¯ÂÙÈ˙fiÙ·Ó ıÂÙÈο Ì ÙËÓ Â›ÙˆÛË ÙÔ˘ ª£ Î·È ÙË ‰È¿ÚÎÂÈ¿ ÙÔ˘ (23). ª›· ÌÂϤÙË ·fi ÙËÓ ∞ÁÁÏ›· ÙÔ 1990 ‰Â›¯ÓÂÈ fiÙÈ ÙÔ ÚÒÙÔ ·È‰› Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ıËÏ¿˙ÂÈ Ì ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· Û ۯ¤ÛË Ì ÙÔ ‰Â‡ÙÂÚÔ Î·È Ù· ÂfiÌÂÓ· ·È‰È¿ (24). ™ÙË ÌÂϤÙË ÙˆÓ Victora Î·È Û˘Ó. ·Ó·Ê¤ÚÂÙ·È fiÙÈ Ù· ·È‰È¿ ÌËÙ¤ÚˆÓ Ô˘ ›¯·Ó ıËÏ¿ÛÂÈ ¤Ó· ÚÔËÁÔ‡ÌÂÓÔ ·È‰› ›¯·Ó ÂÚÈÛÛfiÙÂÚ˜ Èı·ÓfiÙËÙ˜ Ó· ıËÏ¿ÛÔ˘Ó (20). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÙÔ ÚfiÁÚ·ÌÌ· ÂÓ›Û¯˘Û˘ ÙÔ˘ ıËÏ·ÛÌÔ‡
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·291
291
¶ÚÔÒıËÛË ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡
‹Ù·Ó ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈÎfi ÁÈ· ÙȘ ÌËÙ¤Ú˜ Ô˘ ›¯·Ó ÚÔËÁÔ‡ÌÂÓË ÂÌÂÈÚ›· ıËÏ·ÛÌÔ‡. ∏ ËÏÈΛ· Ù˘ ÌËÙ¤Ú·˜ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ÂËÚ¿˙ÂÈ ÙÔÓ ª£ ÚÈÓ ÙËÓ ·Ú¤Ì‚·ÛË. ªÂÙ¿ ÙËÓ ·Ú¤Ì‚·ÛË, ÙÔ 1999, Ù· ·ÔÙÂϤÛÌ·Ù· ‰Â›¯ÓÔ˘Ó fiÙÈ Ô ª£ ·˘Í¿ÓÂÈ ·Ú¿ÏÏËÏ· Ì ÙËÓ ËÏÈΛ· Ù˘ ÌËÙ¤Ú·˜ ˆ˜ ÙËÓ ËÏÈΛ· ÙˆÓ 40 ÂÙÒÓ. ™Â ÌËÙ¤Ú˜ ÌÂÁ·Ï‡ÙÂÚ˘ ËÏÈΛ·˜ (>40 ÂÙÒÓ), Ë ·Ú¤Ì‚·ÛË ‰ÂÓ ‰Â›¯ÓÂÈ Ó· ¤¯ÂÈ Î¿ÔÈ· ›‰Ú·ÛË, ·Ó Î·È Ô ·ÚÈıÌfi˜ ÙˆÓ ÌËÙ¤ÚˆÓ ·˘Ù‹˜ Ù˘ ËÏÈΛ·˜ ‹Ù·Ó Ôχ ÌÈÎÚfi˜. ¶·ÚfiÌÔÈ· ·ÔÙÂϤÛÌ·Ù· ·Ó·Ê¤ÚÔÓÙ·È Î·È Û ¿ÏϘ ÌÂϤÙ˜ (21,23). ∏ ÌÈÎÚfiÙÂÚË ËÏÈΛ· Ù˘ ÌËÙ¤Ú·˜ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ÂËÚ¿˙ÂÈ ÙË Û˘¯ÓfiÙËÙ· Î·È ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ª£, fiˆ˜ ·Ó·Ê¤ÚÂÙ·È Û ÌÂϤÙË ·fi ÙË ¢·Ó›· (25), ·ÓÙ›ıÂÙ· Ì ¿ÏϘ ÌÂϤÙ˜ (24). √È ‰È·ÊÔÚ¤˜ ·˘Ù¤˜ ÌÔÚ› Ó· ÔÊ›ÏÔÓÙ·È fi¯È ÛÙËÓ ËÏÈΛ· ·ÏÏ¿ Û ÂıÓÈΤ˜ Î·È ÎÔÈÓˆÓÈΤ˜ ‰È·ÊÔÚ¤˜. ∏ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈ΋ ηٿÛÙ·ÛË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜, ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ‰ÂÓ ‰Â›¯ÓÂÈ Ó· ÂËÚ¿˙ÂÈ ÙË Û˘¯ÓfiÙËÙ· ÙÔ˘ ª£, fiˆ˜ ·Ó·Ê¤ÚÂÙ·È Î·È Û ¿ÏϘ Â˘Úˆ·˚Τ˜ ÌÂϤÙ˜ (25,26). ™ÙȘ ‰˘ÙÈΤ˜ ‚ÈÔÌ˯·ÓÔÔÈË̤Ó˜ ¯ÒÚ˜, Â›Ó·È ÎÔÈÓfi Ê·ÈÓfiÌÂÓÔ ÌËÙ¤Ú˜ ˘„ËÏfiÙÂÚˆÓ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎÒÓ Ù¿ÍˆÓ, Ì ÌÂÁ·Ï‡ÙÂÚË ÌfiÚʈÛË, Ó· ıËÏ¿˙Ô˘Ó Û˘¯ÓfiÙÂÚ· Î·È ÁÈ· ÌÂÁ·Ï‡ÙÂÚÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ·fi ÙȘ Á˘Ó·›Î˜ ¯·ÌËÏfiÙÂÚˆÓ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎÒÓ ÂȤ‰ˆÓ. ∆Ô ·ÓÙ›ıÂÙÔ ·Ú·ÙËÚÂ›Ù·È ÛÙȘ ÂÚÈÔ¯¤˜ ˘fi ·Ó¿Ù˘ÍË, fiÔ˘ ÔÈ ÌËÙ¤Ú˜ ¯·ÌËÏfiÙÂÚˆÓ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎÒÓ ÛÙڈ̿وÓ, Ì ÌÈÎÚfiÙÂÚË ÌfiÚʈÛË, ıËÏ¿˙Ô˘Ó ÂÚÈÛÛfiÙÂÚÔ (21-23). ∞˘Ù‹ Ë ‰È·ÊÔÚ¿ ‰Â›¯ÓÂÈ fiÙÈ ÔÈ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎÔ› ·Ú¿ÁÔÓÙ˜ ‰‡Ó·ÓÙ·È Ó· ÂËÚ¿ÛÔ˘Ó ÛËÌ·ÓÙÈο ÙÔÓ ª£ (27). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ‰ÂÓ ·Ú·ÙËÚ‹ıËΠÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÌÂٷ͇ ÙˆÓ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎÒÓ Ù¿ÍˆÓ, ·Ó Î·È Ê·›ÓÂÙ·È fiÙÈ ÔÈ ÌËÙ¤Ú˜ Ì ÌÂÁ·Ï‡ÙÂÚË ÌfiÚʈÛË ÍÂÎÈÓÔ‡Ó Ó· ıËÏ¿˙Ô˘Ó Ì ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ·, ·ÏÏ¿ ÂΛӘ Ì ÌÈÎÚfiÙÂÚË ÌfiÚʈÛË ıËÏ¿˙Ô˘Ó ÁÈ· ÌÂÁ·Ï‡ÙÂÚÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·. ∆Ô ÚfiÁÚ·ÌÌ· ˘ÔÛÙ‹ÚÈ͢ ÙÔ˘ ª£ ›¯Â Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·‡ÍËÛË fi¯È ÌfiÓÔ Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ ¤Ó·Ú͢ ÙÔ˘ ª£ ·ÏÏ¿ Î·È Ù˘ ‰È¿ÚÎÂÈ¿˜ ÙÔ˘. ∫·Ù¿ ÙËÓ ÂÚ›Ô‰Ô ÌÂÙ¿ ÙËÓ ·Ú¤Ì‚·ÛË, Ë Û˘¯ÓfiÙËÙ· ÙÔ˘ ª£ ‹Ù·Ó 64,9% Î·È ÙÔ˘ ·ÔÎÏÂÈÛÙÈÎÔ‡ ª£ ‹Ù·Ó 42,8% ÌÂٷ͇ ÙÔ˘ 4Ô˘ - 6Ô˘ Ì‹Ó·, Û˘¯ÓfiÙËÙ· Ô˘ ÏËÛÈ¿˙ÂÈ ÙÔ˘˜ ÛÙfi¯Ô˘˜ ÙÔ˘ “Healthy People” ÁÈ· ÙÔ 2000 (28). √ ·ÔÎÏÂÈÛÙÈÎfi˜ ıËÏ·ÛÌfi˜ ηٿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙËÓ ª∫ ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ Ì·˜ ‹Ù·Ó ¯·ÌËÏfi˜ (38,6%) ÚÔ Ù˘ ·Ú¤Ì‚·Û˘, ÂÓÒ ÌÂÙ¿ ·fi ÙËÓ ˘ÔÛÙ‹ÚÈÍË Î·È ÙËÓ Î·ıÔ‰‹ÁËÛË ÙˆÓ ÌËÙ¤ÚˆÓ ·fi ÙÔ ÓÔÛËÏ¢ÙÈÎfi ÚÔÛˆÈÎfi Ù˘ ª∫ ·fi ÙËÓ ·›ıÔ˘Û· ÙÔÎÂÙÔ‡ Î·È Î·Ù¿ ÙȘ ÚÒÙ˜ ̤Ú˜ ˙ˆ‹˜ ÂÈÙ‡¯ıËΠÌÈ· ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË (71%). ∏ ˘ÔÛÙ‹-
ÚÈÍË Î·È Ë ÂÓı¿ÚÚ˘ÓÛË ÙˆÓ ÌËÙ¤ÚˆÓ Ó· ıËÏ¿ÛÔ˘Ó ÛÙËÓ ÚÒÈÌË ÌÂÙ·ÁÂÓÓËÙÈ΋ ÂÚ›Ô‰Ô Ê·›ÓÂÙ·È Î·ıÔÚÈÛÙÈ΋ ÁÈ· ÙËÓ ÂÁηٿÛÙ·ÛË Î·È ÂÔ̤ӈ˜ ÁÈ· ÙË Ì·ÎÚÔ¯ÚfiÓÈ· ‰È¿ÚÎÂÈ· ÙÔ˘ ıËÏ·ÛÌÔ‡. ∆· “ÊÈÏÈο ÚÔ˜ Ù· ‚Ú¤ÊË” ÓÔÛÔÎÔÌ›· ¤¯Ô˘Ó Û·Ó ÛÙfi¯Ô ÙËÓ ˘ÔÛÙ‹ÚÈÍË ÙˆÓ ÌËÙ¤ÚˆÓ Î·È ÙˆÓ ‚ÚÂÊÒÓ ÙÔ˘˜ ÁÈ· ıËÏ·ÛÌfi ·ÔÎÏÂÈÛÙÈο Î·È ÁÈ· Ì·ÎÚfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· (5,29). ∂ÈϤÔÓ, Ë Û˘Ó¯‹˜ ·ʋ ÙˆÓ ÌËÙ¤ÚˆÓ Ì ¿ÙÔÌ· ÂȉÈο ÂÎ·È‰Â˘Ì¤Ó· ÛÙÔÓ ª£ Â›Ó·È ÛËÌ·ÓÙÈ΋ ÁÈ· ÙË ‰È·Ù‹ÚËÛË ÙÔ˘ ª£.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Powers NG, Naylor AJ, Wester RA. Hospital policies: crucial to breastfeeding success. Semin Perinatol 1994;18:517-524. 2. Zetterstrom R. Breastfeeding and infant-mother interaction. Acta Paediatr 1999;88 (Suppl. 430):1-6. 3. Giovannini M, Banderali G, Agostoni C, Silano M, Radaelli G, Riva E. Epidemiology of breastfeeding in Italy. Acta Paediatr 1999;88 (Suppl 430):19-22. 4. Heiberg Endresen E, Helsing E. Changes in breastfeeding practices in Norwegian maternity wards: national surveys 1973, 1982 and 1991. Acta Paediatr 1995;84:719-724. 5. WHO/UNICEF. Protecting, promoting and supporting breastfeeding: the special role of maternity services. Joint WHO/ UNICEF statement. Geneva: WHO, 1989. 6. Galanakis E. Infant and mother in Epirus: the first 6 months after birth. [MD Thesis]. Ioannina: University of Ioannina Greece;1993. 7. Salariya EM, Easton PM, Carter JI. Duration of breastfeeding after early initiation and frequent feeding. Lancet 1978;2:1141-1143. 8. Pechlivani F, Vassilakou T, Sarafidou J, Zachou T, Anastasiou CA, Sidossis LS. Prevalence and determinants of exclusive breastfeeding during hospital stay in the area of Athens, Greece. Acta Paediatr 2005;94:928-934. 9. Jones DA, West RR. Lactation nurse increases duration of breast feeding. Arch Dis Child 1985;60:772-774. 10. Cunnigham WE, Segree W. Breast feeding promotion in an urban and a rural Jamaican hospital. Soc Sci Med 1990;30:341-348. 11. Ahluwalia IB, Tessaro I, Grummer-Strawn LM, MacGowan C, Benton-Davis S. Georgia’s breastfeeding promotion program for low-income women. Pediatrics 2000;105:E85. 12. Grossman LK, Harter C, Sachs L, Kay A. The effect of postpartum lactation counseling on the duration of breastfeeding in low-income women. Am J Dis Child 1990;144: 471-474. 13. Leff EW, Schriefer J, Hagan JF, DeMarco PA. Improving breastfeeding support: a community health improvement project. Jt Comm J Qual Improv 1995;21:521-529. 14. Neyzi O, Güleçyüz M, Dinçer Z, Olgun P, Kutluay T, Uzel N, et al. An educational intervention on promotion of breast feeding complemented by continuing support. Pediatr Perinat Epidemiol 1991;5:299-303. 15. Kurinij N, Shiono PH. Early formula supplementation of breast-feeding. Pediatrics 1991;88:745-750. 16. Kramer MS, Chalmers B, Hodnett ED, Serkovskaya Z, Dzikovich I, Shapiro S, et al. Promotion of Breastfeeding Intervention Trial (PROBIT): a randomized trial in the Republic of Belarus. JAMA 2001;285:413-420. ¶·È‰È·ÙÚÈ΋ 2007;70:285-292
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·292
292
∞. ¡ÙÔ˘ÚÓÙÔ‡ÊË Î·È Û˘Ó.
17. Rogers IS, Emmett PM, Golding J. The incidence and duration of breast feeding. Early Hum Dev 1997;49:S46-S74. 18. Barros FC, Victora CG, Vaughan JP, Smith PG. Birth weight and duration of breast-feeding: are the beneficial effects of human milk being overestimated? Pediatrics 1986;78:656-661. 19. Rajan L, Oakley A. Infant feeding practice in mothers at risk of low birth weight delivery. Midwifery 1990;6:18-27. 20. Victora CG, Huttly SR, Barros FC Vaughan JP. Breast feeding duration in consecutive offspring: a prospective study from southern Brazil. Acta Paediatr 1992;81:12-14. 21. Grantham-McGregor SM, Back EH. Breast feeding in Kingston, Jamaica. Arch Dis Child 1970;45:404-409. 22. Landman JP, Shaw-Lyon V. Breast-feeding in decline in Kingston, Jamaica, 1973. West Indian Med J 1976;25:43-57. 23. Elo IT, Grummer-Strawn LM. Changes in breastfeeding initiation and duration in Peru, 1977-1986. Soc Biol 1993;40:224-243. 24. White A, Freeth S, O’ Brien M. Infant feeding. London: HMSO, 1992.
25. Weile B, Rubin DH, Krasilnikoff PA, Kuo HS, Jekel JF. Infant feeding patterns during the first year of life in Denmark: factors associated with the discontinuation of breast-feeding. J Clin Epidemiol 1990;43:1305-1311. 26. van den Boom SA, Kimber AC, Morgan JB. Type of milk feeding in infants and young children up to 19 months of age in three socio-economic groups in Madrid. Acta Paediatr 1993;82:1017-1023. 27. World Health Organization, Contemporary patterns of breastfeeding. Report on the WHO collaboration study on breastfeeding. Geneva WHO, 1981. 28. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: Government Printing Office, 1990:379-80. 29. Philipp BL, Merewood A. The Baby-Friendly way: the best breastfeeding start. Pediatr Clin North Am 2004;51: 761-783.
™ˆÛÙ¤˜ ··ÓÙ‹ÛÂȘ ÙÔ˘ Quiz ÁÈ· ÙÔ ¿ÚıÚÔ “∏ ·‡ÍËÛË ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ ÛÙË Û‡Á¯ÚÔÓË ÂÔ¯‹: ÂȉËÌÈÔÏÔÁÈο ‰Â‰Ô̤ӷ Î·È ·ÈÙÈÔÏÔÁ›·” 1. À„ËÏfiÙÂÚÔ˜ ÂÙ‹ÛÈÔ˜ ÂÈÔÏ·ÛÌfi˜ Û ÙÔ˘Ï¿¯ÈÛÙÔÓ ‰‡Ô ·ÙÔÈΤ˜ ·ı‹ÛÂȘ Ù·˘Ùfi¯ÚÔÓ· Û˘Ó·ÓٿٷÈ: ‚. ™ÙË ª. µÚÂÙ·Ó›· 2. ¶ÔÈ· ·fi ÙȘ ·Ú·Î¿Ùˆ ‰È·Ù˘ÒÛÂȘ ‰ÂÓ Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÙ·È ÛÙËÓ “˘fiıÂÛË Ù˘ ˘ÁÈÂÈÓ‹˜”; Á. ∏ ·‡ÍËÛË ÙˆÓ ·ÏÏÂÚÁÈÒÓ ÔÊ›ÏÂÙ·È ÌÂٷ͇ ¿ÏÏˆÓ Û ÂÚÈ‚·ÏÏÔÓÙÈÎÔ‡˜ Î·È ÎÏÈÌ·ÙÔÏÔÁÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ 3. ™ÙÔ ÎÏ·ÛÈÎfi ÌÔÓÙ¤ÏÔ “·ÙÔÈ΋˜ ·Ú¤Ï·Û˘” (atopic marching), Ë ·ÏÏËÏÔ˘¯›· ÂÌÊ¿ÓÈÛ˘ ÙˆÓ ·ÙÔÈÎÒÓ ·ı‹ÛÂˆÓ Â›Ó·È: ‚. ŒÎ˙ÂÌ·-ÙÚÔÊÈΤ˜ ·ÏÏÂÚÁ›Â˜-¿ÛıÌ·-·ÏÏÂÚÁÈ΋ ÚÈÓ›Ùȉ· 4. √È ·Ú·Î¿Ùˆ ΢ÙÙ·ÚÔΛÓ˜ ¯·Ú·ÎÙËÚ›˙Ô˘Ó ÙËÓ Ù‡Ô˘ Th2 ·ÓÔÛÔÏÔÁÈ΋ ·¿ÓÙËÛË Ô˘ ¢ı‡ÓÂÙ·È ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ·ÏÏÂÚÁÈÎÒÓ ÂΉËÏÒÛˆÓ, ÂÎÙfi˜ ·fi ÙËÓ: ·. INF- Á 5. ∞‡ÍËÛË ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ·ı‹ÛÂˆÓ ·Ú·ÙËÚ›ٷÈ: ‰. ™Â fiϘ ÙȘ ·Ú·¿Óˆ ÂÚÈÙÒÛÂȘ (Û ¯ÒÚ˜ Ô˘ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ˘ÈÔı¤ÙËÛ·Ó ÙÔ “‰˘ÙÈÎfi” ÌÔÓÙ¤ÏÔ ˙ˆ‹˜, Û ÌÂÁ·Ï‡ÙÂÚÔ ‚·ıÌfi ÛÙÔ˘˜ ÓÂfiÙÂÚÔ˘˜ Û ۯ¤ÛË Ì ÙÔ˘˜ ÈÔ ËÏÈÎȈ̤ÓÔ˘˜, ηıÒ˜ Î·È Û ·ÓıÚÒÔ˘˜ ÌÂÁ·Ï‡ÙÂÚ˘ ËÏÈΛ·˜ Û ۇÁÎÚÈÛË Ì ÙȘ ÚÔ¯ˆÚË̤Ó˜ ËÏÈ˘ Û ÚÔËÁÔ‡ÌÂÓ˜ ‰ÂηÂٛ˜)
Paediatriki 2007;70:285-292
Pediatri July-Aug 07
09-07-07
∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞
17:08
™ÂÏ›‰·293
ORIGINAL ARTICLE
293
∏ Û˘Ì‚ÔÏ‹ ÂÚÈ‚·ÏÏÔÓÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· ÙÔ˘ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ 1 (™¢1) ∫. ∫·Ú·‚·Ó¿ÎË3, ∂. ∆Ûfiη2, Ã. ∫·Ú·ÁÈ¿ÓÓË3, µ. ¶¤ÙÚÔ˘1, ∂. ¶È›‰Ô˘2, ª. ªÚÈÛÈÌÈÙ˙‹2, ª. ª·˘ÚÈΛԢ2, ∫. ∫·ÎϤ·˜3, ∞. ¢¿ÎÔ˘-µÔ˘ÙÂÙ¿ÎË1 ¶ÂÚ›ÏË„Ë ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ªÂÏÂÙ‹Û·Ì 106 ·È‰È¿ Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ 1 (™¢1) Ì ̤ÛË ËÏÈΛ· 11,73 ¤ÙË, ηıÒ˜ Î·È 150 Ì¿ÚÙ˘Ú˜ Ì ·ÓÙ›ÛÙÔÈ¯Ë ËÏÈΛ· Î·È Ê‡ÏÔ, Ì ÛÎÔfi Ó· ÂÎÙÈÌ‹ÛÔ˘Ì ÙËÓ Â›‰Ú·ÛË ÂÚÈ‚·ÏÏÔÓÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÛÙËÓ ÂΉ‹ÏˆÛË ÙÔ˘ ™¢1, ·Ó¿ÏÔÁ· Ì ÙËÓ ÎÔÈÓˆÓÈ΋ Ù¿ÍË. √È ÁÔÓ›˜ Û˘ÌÏ‹ÚˆÛ·Ó ÂÚˆÙËÌ·ÙÔÏfiÁÈ· Ô˘ ·ÊÔÚÔ‡Û·Ó ÙËÓ Âη›‰Â˘ÛË Î·È ÙÔ Â¿ÁÁÂÏÌ¿ ÙÔ˘˜, ηıÒ˜ Î·È ÙÔ ·ÙÔÌÈÎfi ÈÛÙÔÚÈÎfi ÙˆÓ ·È‰ÈÒÓ fiÛÔÓ ·ÊÔÚ¿ ÙÔÓ ıËÏ·ÛÌfi, ηıÒ˜ Î·È ÙË Û˘¯ÓfiÙËÙ· ÈÔÁÂÓÒÓ ÏÔÈÌÒ͈Ó, ÂÌ‚ÔÏÈ·ÛÌÒÓ Î·È ·ÏÏÂÚÁÈÎÒÓ ·ÓÙȉڿÛˆÓ. ∞ÔÙÂϤÛÌ·Ù·: ∆· ·È‰È¿ ÙˆÓ Î·ÙÒÙÂÚˆÓ ÎÔÈÓˆÓÈÎÒÓ Ù¿ÍÂˆÓ ÂÌÊ¿ÓÈ˙·Ó ˘„ËÏfiÙÂÚÔ Î›Ó‰˘ÓÔ ÂΉ‹ÏˆÛ˘ ™¢1, ·fi ÂΛӷ Ù˘ ̤Û˘ Î·È ·ÓÒÙÂÚ˘ ÎÔÈÓˆÓÈ΋˜ Ù¿Í˘ (OR = 0,16, 95% CI: (0,03, 0,80)). ∏ ÂΉ‹ÏˆÛË Î¿ı ·ÏÏÂÚÁÈ΋˜ ·ÓÙ›‰Ú·Û˘ (OR=0,06; 95% CI: (0,01, 0,23)), ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ ÎÔÈÓˆÓÈ΋ Ù¿ÍË, ηıÒ˜ Î·È Ô ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ (OR=0,45, 95% CI: (0,27, 0,77)) ‰ÚÔ‡Û·Ó ÚÔÛٷ٢ÙÈο ÛÙËÓ ÂΉ‹ÏˆÛË ™¢1. ∫·Ù¿ ÙËÓ ·Ó¿Ï˘ÛË Ù˘ ÔÏÏ·Ï‹˜ ÏÔÁÈÛÙÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘, Ë ÂΉ‹ÏˆÛË Û˘ÌÙˆÌ¿ÙˆÓ ·ÏÏÂÚÁ›·˜ (OR=0,10,95% CI: (0,03, 0,40)), Ë ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÈÔÁÂÓÒÓ ÏÔÈÌÒÍÂˆÓ (OR=0,11, 95% CI: (0,02, 0,50)), ȉȷ›ÙÂÚ· ηٿ Ù· ‰˘Ô ÚÒÙ· ¯ÚfiÓÈ· ˙ˆ‹˜, ηıÒ˜ Î·È Ë ÚԤϢÛË ·fi ÙȘ ·ÓÒÙÂÚ˜ ÎÔÈÓˆÓÈΤ˜ Ù¿ÍÂȘ (OR=0,16, 95% CI: (0,03, 0,80)) ‰ÚÔ‡Û·Ó ÚÔÛٷ٢ÙÈο ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË ™¢1. ™˘ÌÂÚ¿ÛÌ·Ù·: ™Ù· ·È‰È¿ Ì ™¢1 Ù˘ ÌÂϤÙ˘ Ì·˜, Ë ·ÚÔ˘Û›· ·ÏÏÂÚÁÈÎÒÓ ÂΉËÏÒÛˆÓ, Ô ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜, ÔÈ Û˘¯Ó¤˜ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ, ȉȷ›ÙÂÚ· ηٿ Ù· ‰‡Ô ÚÒÙ· ¯ÚfiÓÈ· ˙ˆ‹˜, ηıÒ˜ Î·È Ë ÚԤϢÛË ·fi ÙË ÌÂÛ·›· Î·È ÙËÓ ·ÓÒÙÂÚË ÎÔÈÓˆÓÈ΋ Ù¿ÍË ‰ÚÔ‡Û·Ó ÚÔÛٷ٢ÙÈο ÛÙËÓ ÂΉ‹ÏˆÛË ™¢1.
1 ∂Ó‰ÔÎÚÈÓÔÏÔÁÈÎfi ∆Ì‹Ì·, ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” 2 µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” ∞ıËÓÒÓ 3 ¢È·‚ËÙÔÏÔÁÈÎfi π·ÙÚ›Ô, µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶&∞ ∫˘ÚÈ·ÎÔ‡” AÏÏËÏÔÁÚ·Ê›·: ∫˘Úȷ΋ ∫·Ú·‚·Ó¿ÎË kakarav2@yahoo.gr µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶&∞ ∫˘ÚÈ·ÎÔ‡” £Ë‚ÒÓ Î·È §Â‚·‰Â›·˜, ∆.∫. 115 27, ∞ı‹Ó·
§¤ÍÂȘ ÎÏÂȉȿ: πÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ, ÂÌ‚ÔÏÈ·ÛÌfi˜ Ì MMR, ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜, ·ÏÏÂÚÁ›Â˜, ÎÔÈÓˆÓÈ΋ Ù¿ÍË, ·ıÔÁ¤ÓÂÈ· ™¢1.
∂nvironmental factors possibly associated with the pathogenesis of diabetes mellitus type 1 (DM1) K. Karavanaki3, E. Tsoka2, C. Karayianni3, V. Petrou1, E. Pippidou2, M. Brisimitzi2, M. Mavrikiou2, K. Kakleas3, C. Dacou-Voutetakis1 Abstract Methods: We studied 106 children with type 1 diabetes mellitus (DM1) with a median age of 11.73 years and 150 controls with similar age and sex distribution, with the aim to assess the potential associations between environmental factors and the development of DM1, stratified by social class. The parents completed questionnaires on their education and occupation and on their children’s personal history of breastfeeding, allergic symptoms and viral infections. Results: Children of the lower classes had a higher risk of DM1 compared to children of the middle or upper social classes (OR = 0.16, 95% CI: (0.03, 0.80)). The occurrence of any assessed allergic symptoms (OR=0.06; 95% CI: (0.01, 0.23)), irrespectively of social class, as well as breastfeeding (OR=0.45, 95% CI: (0.27, 0.77)) were protective of DM1 presentation. According to the multiple logistic regression analysis, the presence of allergic symptoms (OR=0.10, 95% CI: (0.03,0.40)), the increased frequency of infections (OR=0.11, 95% CI: (0.02,0.50)), especially during the first 2 years of life and the origin from upper and middle social classes (OR=0.16, 95% CI: (0.03,0.80)), were protective of DM1 presentation. Conclusion: In the children with DM1 of our study, the presence of allergic symptoms, breastfeeding, frequent viral infections and originating from a middle or upper social class had a protective effect on DM1 presentation.
1 Department of Endocrinology, First Department of Paediatrics of the University of Athens, “Aghia Sofia” Children’s Hospital 2 Second Department of Paediatrics, “Aghia Sofia” Children’s Hospital 3 Diabetic Clinic, Second Department of Paediatrics of the University of Athens, “P. & A. Kyriakou” Children’s Hospital Correspondence: Kyriaki Karavanaki, kakarav2@yahoo.gr 2nd Paediatric Clinic of the University of Athens, “P. & A. Kyriakou” Children’s Hospital ∆hivon and Levadeias St., 115 27, Athens, Greece
Key words: Viral infections, MMR vaccination, breastfeeding, allergies, social class, DM1 pathogenesis.
¶·È‰È·ÙÚÈ΋ 2007;70:293-299
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·294
294
∫. ∫·Ú·‚·Ó¿ÎË Î·È Û˘Ó.
∂ÈÛ·ÁˆÁ‹ √ ۷ί·Ú҉˘ ‰È·‚‹Ù˘ Ù‡Ô˘ 1 (™¢1) ÔÊ›ÏÂÙ·È Û ·˘ÙÔ¿ÓÔÛË Î·Ù·ÛÙÚÔÊ‹ ÙˆÓ ‚-΢ÙÙ¿ÚˆÓ ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜ Û ÁÂÓÂÙÈο ÚԉȷÙÂıÂÈ̤ӷ ¿ÙÔÌ·. £ÂˆÚÂ›Ù·È fiÙÈ Ë ·˘ÙÔ¿ÓÔÛË ‰È·‰Èηۛ· ¿ÁÂÙ·È ·fi ÔÚÈṲ̂ÓÔ˘˜ ÂÚÈ‚·ÏÏÔÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, fiˆ˜ Ë ÌÈÎÚ‹ ‰È¿ÚÎÂÈ· ·ÔÎÏÂÈÛÙÈÎÔ‡ ıËÏ·ÛÌÔ‡ Î·È Ë ÚÒÈÌË ¤ÎıÂÛË Û ڈÙ½Ó˜ Á¿Ï·ÎÙÔ˜ ·ÁÂÏ¿‰Ô˜ Î·È ‰ËÌËÙÚȷο ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ· (1), Ë ÌÂÁ¿ÏË ËÏÈΛ· Ù˘ ÌËÙ¤Ú·˜ (2) Î·È ÙÔ ¯·ÌËÏfi ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi Â›Â‰Ô (3). √È ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ ÌÔÚ› Ó· ıˆÚËıÔ‡Ó ÂÈÙ·¯˘ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ù˘ ·˘ÙÔ¿ÓÔÛ˘ ηٷÛÙÚÔÊ‹˜ ÙˆÓ ‚-΢ÙÙ¿ÚˆÓ (4). ∞ÓÙ›ıÂÙ·, Û‡Ìʈӷ Ì ÙËÓ ˘fiıÂÛË Ù˘ ˘ÁÈÂÈÓ‹˜ (hygiene hypothesis), Ë ÌÂȈ̤ÓË ¤ÎıÂÛË Û ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜, ˆ˜ Û˘Ó¤ÂÈ· ÙˆÓ ‚ÂÏÙÈˆÌ¤ÓˆÓ Û˘ÓıËÎÒÓ ‰È·‚›ˆÛ˘, Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ·ÏÏÂÚÁÈÎÒÓ Î·È ·˘ÙÔ¿ÓÔÛˆÓ ÓÔÛËÌ¿ÙˆÓ (5). ∆ÂÏÂ˘Ù·›·, Û‡Ìʈӷ Ì ÙËÓ ˘fiıÂÛË Ù˘ ÂÈÙ¿¯˘ÓÛ˘ (accelerator hypothesis), Èı·ÓÔÏÔÁÂ›Ù·È Ë Û˘¯ÓfiÙÂÚË ¤Ó·ÚÍË ÙÔ˘ ™¢1 ‹ ™¢2 Û ¿ÙÔÌ· Ì ·˘ÍË̤ÓÔ ÛˆÌ·ÙÈÎfi ‚¿ÚÔ˜ ηٿ ÙË ‚ÚÂÊÈ΋ ËÏÈΛ· Î·È ÔÈ ‰‡Ô ·˘Ù¤˜ ÌÔÚʤ˜ ‰È·‚‹ÙË ·Ô‰›‰ÔÓÙ·È Û ÂÓÈ·›· ‰È·Ù·Ú·¯‹ Ù˘ ·ÓÙ›ÛÙ·Û˘ ÛÙËÓ ÈÓÛÔ˘Ï›ÓË (6). √ ÛÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ó· ‰ÈÂÚ¢ӋÛÂÈ ÙÔÓ ÚfiÏÔ Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ÂÚÈ‚·ÏÏÔÓÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ, ÔÈ ÔÔ›ÔÈ Èı·ÓÒ˜ Û˘ÌÌÂÙ¤¯Ô˘Ó ÛÙËÓ ·ıÔÁ¤ÓÂÈ· ÙÔ˘ ™¢1. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ∏ ÌÂϤÙË Û˘ÌÂÚȤϷ‚ fiÏ· Ù· ·È‰È¿ ËÏÈΛ·˜ 3,5 -14,9 ÂÙÒÓ, ÛÙ· ÔÔ›· ‰È·ÁÓÒÛıËΠ™¢1 ÛÙËÓ ∂ÏÏ¿‰· ÙÔ 1992. ∏ ÂÈÎÔÈÓˆÓ›· Ì fiÏ· Ù· ·È‰È·ÙÚÈο ÓÔÛÔÎÔÌ›· (ȉȈÙÈο ‹ ‰ËÌfiÛÈ·) Ù˘ ∂ÏÏ¿‰·˜ ¤ÁÈÓ Ì ÂÈÛÙÔϤ˜ Î·È Ì ÙËÏÂʈÓÈ΋ ÂÈÎÔÈÓˆÓ›·, ÙfiÛÔ ÚÈÓ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÌÂϤÙ˘, fiÛÔ Î·È ÌÂÙ¿ ÙËÓ ÔÏÔÎÏ‹ÚˆÛË ÙÔ˘ 12Ô˘ Ì‹Ó· Ù˘ ÌÂϤÙ˘. ∂ÈÚfiÛıÂÙ·, ÂÈÛÙÔϤ˜ ÂÛÙ¿ÏËÛ·Ó Û fiÏÔ˘˜ ÙÔ˘˜ È·ÙÚÔ‡˜ Ì ÂÍÂȉ›Î¢ÛË ÛÙÔ ™¢, Û ÂÓ‰ÔÎÚÈÓÔÏfiÁÔ˘˜ Ô˘ ·Ú·ÎÔÏÔ˘ıÔ‡Ó ·È‰È¿ Ì ™¢1 ÛÙËÓ ∂ÏÏ¿‰·, ηıÒ˜ Î·È Û fiÏÔ˘˜ ÙÔ˘˜ ·È‰È¿ÙÚÔ˘˜ (7). ªÂ ÙÔÓ ÙÚfiÔ ·˘Ùfi ÂÓÙÔ›Û·Ì ÛÙËÓ ∂ÏÏ¿‰·, ηٿ ÙÔ ¤ÙÔ˜ 1992, 106 ·È‰È¿ Ì ÚfiÛÊ·ÙË ‰È¿ÁÓˆÛË ™¢1. √ ÏËı˘ÛÌfi˜ ÙˆÓ Ì·ÚÙ‡ÚˆÓ ÂÚÈÏ¿Ì‚·Ó 150 ·È‰È¿ Ì ·Ó¿ÏÔÁË ËÏÈΛ· Î·È Ê‡ÏÔ. ∆· ·È‰È¿ ·˘Ù¿ ÓÔÛËχıËÎ·Ó ÁÈ· ÚÔÛˆÚÈÓfi Úfi‚ÏËÌ· (΋ÏË, ÔÍ›· ÛΈÏËÎÔÂȉ›Ùȉ·, Ó¢ÌÔÓ›·, Á·ÛÙÚÂÓÙÂÚ›Ùȉ·, ÎÏ) Î·È ‰ÂÓ ¤·Û¯·Ó ·fi ¯ÚfiÓÈÔ ÓfiÛËÌ·. ∞fi ÙËÓ ÔÌ¿‰· ÙˆÓ Ì·ÚÙ‡ÚˆÓ ÂÍ·ÈÚ¤ıËÎ·Ó ·È‰È¿ Ô˘ ÓÔÛËχÔÓÙ·Ó ÛÙȘ ·È‰È·ÙÚÈΤ˜ ÎÏÈÓÈΤ˜ ÏfiÁˆ ÎÚ›ÛÂˆÓ ¿ÛıÌ·ÙÔ˜ ‹ ¿ÏÏˆÓ ·ÏÏÂÚÁÈÎÒÓ ·ÓÙȉڿÛˆÓ, ‰ÈfiÙÈ ¤¯ÂÈ ·Ó·ÊÂÚı› fiÙÈ Ë ‡·ÚÍË ·ÏÏÂÚÁÈÒÓ ·ÓÙ·ÁˆÓ›˙ÂÙ·È ÙËÓ ÂÌÊ¿ÓÈÛË ·˘ÙÔ¿ÓÔÛˆÓ ÓÔÛËÌ¿ÙˆÓ (8). √È ÁÔÓ›˜ ÙˆÓ ·È‰ÈÒÓ Ì ™¢1 Î·È ÙˆÓ Ì·ÚÙ‡ÚˆÓ ·¿ÓÙËÛ·Ó ÛÂ Û˘ÁÎÂÎÚÈ̤ÓÔ ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ. √È ÂÚˆÙ‹ÛÂȘ Î·È ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜ ÂÙ¤ıËÛ·Ó ·fi ·È‰›·ÙÚÔ Ì ÂÍÂȉ›Î¢ÛË ÛÙÔ ™¢1 Î·È ÔÈ ··ÓÙ‹ÛÂȘ Û˘ÌÏËÚÒıËÎ·Ó ·fi ÙÔÓ ›‰ÈÔ ÛÙÔ ¤ÓÙ˘Ô ÙÔ˘ ÂÚˆÙËÌ·ÙÔÏÔÁ›Ô˘. ∂ȉÈÎfiÙÂÚ·, fiÛÔÓ ·ÊÔÚ¿ ÙÔ ÈÛÙÔÚÈÎfi ÙˆÓ ÂÌ‚ÔÏÈ·ÛÌÒÓ, Ô È·ÙÚfi˜ ¤Ï·‚ ÙȘ ÏËÚÔÊÔڛ˜ Û¯ÂÙÈο Ì ÙÔ Â›‰Ô˜, ÙÔÓ ·ÚÈıÌfi ‰fiÛÂˆÓ Î·È ÙËÓ ËÏÈΛ· ÙˆÓ ÂÌ‚ÔÏÈ·ÛÌÒÓ ·fi ÙÔ ‚È‚ÏÈ¿ÚÈÔ ÀÁ›·˜ ÙˆÓ ·È‰ÈÒÓ. Paediatriki 2007;70:293-299
∆Ô ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ ÂÚÈÏ¿Ì‚·Ó ÙȘ ÂÍ‹˜ ÏËÚÔÊÔڛ˜: ·) ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈο Î·È ÔÈÎÔÁÂÓÂȷο ¯·Ú·ÎÙËÚÈÛÙÈο (ËÏÈΛ· ÁÔÓ¤ˆÓ, ÌfiÚʈÛË, ·ÁÁÂÏÌ·ÙÈ΋ Î·È ÔÈÎÔÁÂÓÂȷ΋ ηٿÛÙ·ÛË, ·ÚÈıÌfi˜ ·‰ÂÚÊÒÓ), ‚) ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi (‰È·‚‹Ù˘, ˘¤ÚÙ·ÛË, ηډȷÁÁÂȷΤ˜ Î·È ·ÓÔÛÔÏÔÁÈΤ˜ ·ı‹ÛÂȘ), Á) ·ÙÔÌÈÎfi ·Ó·ÌÓËÛÙÈÎfi: 1. ™˘¯ÓfiÙËÙ· ÏÔÈÌÒ͈Ó, fiÔ˘ Û˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó: ∞. §ÔÈÌÒ‰Ë ÓÔÛ‹Ì·Ù· Ì ·ıÔÁÓˆÌÔÓÈ΋ ÎÏÈÓÈ΋ ÂÈÎfiÓ· (·ÓÂÌ¢ÏÔÁÈ¿) ‹ ÙÂÎÌËÚȈ̤ӷ Ì ·ÓÙÈۈ̷ÙÈÎfi ¤ÏÂÁ¯Ô, fiˆ˜ Ë Ïԛ̈ÍË ·fi ÈÔ‡˜ ÂÚ˘ıÚ¿˜, ·ÚˆÙ›Ùȉ·˜, Epstein Barr (EBV) Î·È Î˘ÙÙ·ÚÔÌÂÁ·ÏÔÈfi (CMV). µ. ∫ÔÈÓ¤˜ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ, fiˆ˜ ÔÈ ÏÔÈÌÒÍÂȘ ·fi ÈÔ‡˜ ÙÔ˘ ·ÓÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ‹ ÙÔ˘ ÂÓÙ¤ÚÔ˘ (9). √È ÈÔ› Ô˘ ıˆÚÔ‡ÓÙ·È ˆ˜ ÔÈ ÈÔ Èı·ÓÔ› ÁÈ· ÙËÓ ÚfiÎÏËÛË ÎÔÈÓÒÓ ÈÔÁÂÓÒÓ ÏÔÈÌÒÍÂˆÓ Â›Ó·È ÔÈ ÚÈÓÔ˚Ô›, ÔÈ Rota-ÈÔ› Î·È ÔÈ ÈÔ› Ù˘ Áڛ˘ Î·È Ù˘ ·Ú·Áڛ˘, ÁÈ· ÙÔ˘˜ ÔÔ›Ô˘˜ ‰ÂÓ ˘¿Ú¯ÂÈ ·ıËÙÈ΋ ·ÓÔÛÔÔ›ËÛË (9). ∞ÓÙ›ıÂÙ·, ÏÔÈÌÒÍÂȘ Ô˘ ÚÔÏ·Ì‚¿ÓÔÓÙ·È Ì ٷ ÂÌ‚fiÏÈ·, fiˆ˜ Ë ÈÏ·Ú¿, Ë ·ÚˆÙ›Ùȉ·, Ë ÂÚ˘ıÚ¿, Ë ·ÓÂÌ¢ÏÔÁÈ¿ Î·È Ô ÎÔÎ·Ù˘ Â›Ó·È ÂÍ·ÈÚÂÙÈο ÌÔÏ˘ÛÌ·ÙÈΤ˜ Î·È ÌÂÙ·‰›‰ÔÓÙ·È Â‡ÎÔÏ· (8). ∏ Û˘¯ÓfiÙËÙ· ÙˆÓ ÏÔÈÌÒÍÂˆÓ Î·ıÔÚ›ÛÙËΠˆ˜ ÂÍ‹˜: ·Ô˘Û›· ÏÔÈÌÒ͈Ó: ≤ 2/¤ÙÔ˜, Û¿ÓȘ: 2-5/¤ÙÔ˜, Û˘¯Ó¤˜:> 5/¤ÙÔ˜. 2. ∆‡Ô˜ Î·È ËÏÈΛ· ·ÓÔÛÔÔ›ËÛ˘ Ì ˙ÒÓÙ˜ ÂÍ·ÛıÂÓË̤ÓÔ˘˜ ÈÔ‡˜, ‰ËÏ·‰‹ ÂÌ‚ÔÏÈ·ÛÌfi˜ ¤Ó·ÓÙÈ ÈÏ·Ú¿˜-ÂÚ˘ıÚ¿˜·ÚˆÙ›Ùȉ·˜ (MMR). 3. πÛÙÔÚÈÎfi ·ÏÏÂÚÁÈÎÒÓ ·ÓÙȉڿÛÂˆÓ (Ù‡Ô˜ Î·È Û˘¯ÓfiÙËÙ· ÂÂÈÛÔ‰›ˆÓ). √ ·È‰›·ÙÚÔ˜ Ì ÂÍÂȉ›Î¢ÛË ÛÙÔ ™¢1 η٤ÁÚ·Ê ÙËÓ ·ÎÚÈ‚‹ ·¿ÓÙËÛË ÙÔ˘ ÁÔÓ¤· ÛÙȘ ÂÚˆÙ‹ÛÂȘ “¶·ÚÔ˘ÛÈ¿˙ÂÈ ÙÔ ·È‰› Û·˜ ·ÏÏÂÚÁÈΤ˜ ·ÓÙȉڿÛÂȘ; ∂¿Ó Ó·È, ÂÚÈÁÚ¿„Ù ÙȘ. ¶fiÛÔ Û˘¯Ó¿ ÙȘ ·ÚÔ˘ÛÈ¿˙ÂÈ Î·È ·fi ÔÈ· ËÏÈΛ·; ÃÚÂÈ¿ÛıËΠÓÔÛËÏ›· Û ÓÔÛÔÎÔÌÂ›Ô ÁÈ· ÙÔ ÏfiÁÔ ·˘Ùfi;”. ™ÙË Û˘Ó¤¯ÂÈ·, ÔÈ ·ÛıÂÓ›˜ ηٷٿ¯ıËÎ·Ó ÛÙȘ ‰È¿ÊÔÚ˜ ηÙËÁÔڛ˜ ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ·ÓÙȉڿÛÂˆÓ (¿ÛıÌ·, ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ·, ÎÓ›‰ˆÛË, ·ÁÁÂÈÔÓÂ˘ÚˆÙÈÎfi Ô›‰ËÌ·, ÂÈÂÊ˘Î›Ùȉ·, ÚÈÓ›Ùȉ·, ÙÚÔÊÈ΋ ·ÏÏÂÚÁ›· Î·È Ê·Ú̷΢ÙÈ΋ ·ÏÏÂÚÁ›·) Ì ‚¿ÛË ÙȘ ··ÓÙ‹ÛÂȘ, ÛÂ Û˘ÓÂÚÁ·Û›· Ì ·ÏÏÂÚÁÈÔÏfiÁÔ ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ. 4. ™˘¯ÓfiÙËÙ· Î·È ‰È¿ÚÎÂÈ· ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡. ªÂıÔ‰ÔÏÔÁ›· ™ÙË ªÂÁ¿ÏË µÚÂÙ·Ó›· Î·È Û ¿ÏϘ ¯ÒÚ˜, Ë Â·ÁÁÂÏÌ·ÙÈ΋ ÎÔÈÓˆÓÈ΋ Ù¿ÍË ‰È·ÈÚÂ›Ù·È Û ¤ÍÈ ÔÌ¿‰Â˜: ·ÁÁÂÏÌ·ÙÈ΋ ··Û¯fiÏËÛË (I), ‰ÈÔÈÎËÙÈ΋ Î·È Ù¯ÓÈ΋ ··Û¯fiÏËÛË (II), ÂȉÈÎÂ˘Ì¤ÓË ··Û¯fiÏËÛË (III), ËÌÈ-ÂȉÈÎÂ˘Ì¤ÓË ¯ÂÈÚˆÓ·ÎÙÈ΋ ··Û¯fiÏËÛË (IV) Î·È ·ÓÂȉ›Î¢ÙË ¯ÂÈÚˆÓ·ÎÙÈ΋ ··Û¯fiÏËÛË (V) (10). ™ÙË ÌÂϤÙË Ì·˜, Ë ÂÎÙ›ÌËÛË Ù˘ ÎÔÈÓˆÓÈ΋˜ Ù¿Í˘ ÙˆÓ ÁÔÓ¤ˆÓ ‚·Û›ÛÙËΠÛÙÔ ÌÔÚʈÙÈÎfi Î·È Â·ÁÁÂÏÌ·ÙÈÎfi Â›Â‰Ô Î·È ÙˆÓ ‰˘Ô ÁÔÓ¤ˆÓ Ù·˘Ùfi¯ÚÔÓ·. ™˘ÁÎÂÎÚÈ̤ӷ, Â¿Ó Î·È ÔÈ ‰˘Ô ÁÔÓ›˜ ›¯·Ó Ï¿‚ÂÈ ·ÓÒÙÂÚË ‹ ·ÓÒÙ·ÙË Âη›‰Â˘ÛË Î·È ·Ó‹Î·Ó ÛÙËÓ Â·ÁÁÂÏÌ·ÙÈ΋ ηÙËÁÔÚ›· I ‹ II, ÙfiÙÂ Ë ÎÔÈÓˆÓÈ΋ Ù¿ÍË ¯·Ú·ÎÙËÚÈ˙fiÙ·Ó ˆ˜ “∞ÓÒÙÂÚË”. ™ÙËÓ ÂÚ›ÙˆÛË Ô˘ Î·È ÔÈ ‰˘Ô ÁÔÓ›˜ ‹Ù·Ó ̤¯ÚÈ ·fiÊÔÈÙÔÈ ÙÔ˘ §˘Î›Ԣ Î·È ·Ó‹Î·Ó ÛÙËÓ Â·ÁÁÂÏÌ·ÙÈ΋ ηÙËÁÔÚ›· III, IV ‹ V, ÙfiÙÂ Ë ÎÔÈÓˆÓÈ΋ Ù¿ÍË ¯·Ú·ÎÙËÚÈ˙fiÙ·Ó ˆ˜ “∫·ÙÒÙÂÚË”. ∏ “ª¤ÛË” ÎÔÈÓˆÓÈ΋ Ù¿ÍË ÂÚÈÏ¿Ì‚·Ó fiϘ ÙȘ ˘fiÏÔȘ ÂÚÈÙÒÛÂȘ. ™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ∏ ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ¤ÁÈÓ Ì ÙÔ ÛÙ·ÙÈÛÙÈÎfi ÚfiÁÚ·ÌÌ· Stata 8. ∆· ¯·Ú·ÎÙËÚÈÛÙÈο ÁÓˆÚ›ÛÌ·Ù· ÙˆÓ ‰ÂÈÁÌ¿ÙˆÓ Û˘ÁÎÚ›ıËÎ·Ó ÌÂٷ͇ ·ÛıÂÓÒÓ Î·È Ì·ÚÙ‡ÚˆÓ Ì ÙË ‰ÔÎÈÌ·Û›· x2,
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·295
295
¶ÂÚÈ‚·ÏÏÔÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Î·È ·ıÔÁ¤ÓÂÈ· ÙÔ˘ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ 1
ÂÎÙfi˜ ·fi ÙËÓ ËÏÈΛ·, ÁÈ· ÙËÓ ÔÔ›· ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë ÌË·Ú·ÌÂÙÚÈ΋ ‰ÔÎÈÌ·Û›· Mann-Whitney U Test. ∏ ÌÔÓÔ·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË ÂÚÈÂÏ¿Ì‚·Ó ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÙÔ˘ Û¯ÂÙÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ (Ôdds ratio) ÂÌÊ¿ÓÈÛ˘ ™¢1 ÁÈ· οı ÌÂÙ·‚ÏËÙ‹ ͯˆÚÈÛÙ¿. ™Â ‰Â‡ÙÂÚË Ê¿ÛË, ÔÈ ›‰È˜ Û˘Û¯ÂÙ›ÛÂȘ ÂÍÂÙ¿ÛıËÎ·Ó ÌÂÌÔӈ̤ӷ ÁÈ· ÙË ÌÂÛ·›·/·ÓÒÙÂÚË Î·È ÙËÓ Î·ÙÒÙÂÚË ÎÔÈÓˆÓÈ΋ Ù¿ÍË. ªÂ ÙËÓ ·Ó¿Ï˘ÛË Ù˘ ÔÏÏ·Ï‹˜ ÏÔÁÈÛÙÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ ÂÎÙÈÌ‹ıËÎÂ Ë ·ÏÏËÏ›‰Ú·ÛË ÙˆÓ ·ÓˆÙ¤ÚˆÓ ÌÔÓÔÌÂÙ·‚ÏËÙÒÓ ÛÙËÓ ÂΉ‹ÏˆÛË ™¢1, Î·È Â›Û˘ ‰È·ÈÛÙÒıËÎÂ Â¿Ó ·˘Ù‹ Ë Û˘Û¯¤ÙÈÛË ÙÚÔÔÔÈÔ‡Ù·Ó ·fi ÙËÓ ÎÔÈÓˆÓÈ΋ Ù¿ÍË.
∞ÔÙÂϤÛÌ·Ù· A. ∫·Ù·ÓÔÌ‹ ˆ˜ ÚÔ˜ ÙÔ Ê‡ÏÔ Î·È ÙËÓ ËÏÈΛ· ∏ ÌÂϤÙË ÂÚȤϷ‚ 106 ·È‰È¿ (55,7% ·ÁfiÚÈ· Î·È 44,3% ÎÔÚ›ÙÛÈ·) Ì ÚfiÛÊ·Ù· ‰È·ÁÓˆÛı¤ÓÙ· ™¢1 (Û ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÂÓfi˜ ÌËÓfi˜ ·fi ÙË ‰È¿ÁÓˆÛË) Î·È 150 Ì¿ÚÙ˘Ú˜ (55,3% ·ÁfiÚÈ· Î·È 44,7% ÎÔÚ›ÙÛÈ·), Ì ·Ó¿ÏÔÁË ËÏÈΛ· Î·È Ê‡ÏÔ. ∏ ËÏÈΛ· ÙˆÓ ·È‰ÈÒÓ Î·Ù¿ ÙË ‰È¿ÁÓˆÛË ÙÔ˘ ‰È·‚‹ÙË Î˘Ì·ÈÓfiÙ·Ó ·fi Ù· 3,5 ¤ˆ˜ Ù· 14,9 ¤ÙË (‰È¿ÌÂÛÔ˜ ÙÈÌ‹=11,7) Î·È ‰ÂÓ ‰È¤ÊÂÚ ÛËÌ·ÓÙÈο ·fi ÙËÓ ËÏÈΛ· ÂͤٷÛ˘ ÙˆÓ Ì·ÚÙ‡ÚˆÓ. B. ªÔÚʈÙÈÎfi Â›Â‰Ô ÙˆÓ ÁÔÓ¤ˆÓ, ·ÁÁÂÏÌ·ÙÈ΋ Î·È ÎÔÈÓˆÓÈ΋ Ù¿ÍË √È ·Ù¤Ú˜ ÙˆÓ ·È‰ÈÒÓ Ì ™¢1 ‰ÂÓ ‰È¤ÊÂÚ·Ó ÛËÌ·ÓÙÈο ·fi ÂΛÓÔ˘˜ ÙˆÓ Ì·ÚÙ‡ÚˆÓ, ˆ˜ ÚÔ˜ ÙÔ ÌÔÚʈÙÈÎfi ›‰Ô, ÙËÓ Â·ÁÁÂÏÌ·ÙÈ΋ Î·È ÙËÓ ÎÔÈÓˆÓÈ΋ Ù¿ÍË. ∞ÓÙ›ıÂÙ·, ÔÈ ÌËÙ¤Ú˜ ÙˆÓ ·È‰ÈÒÓ Ì ™¢1 ÂÌÊ¿ÓÈ˙·Ó ÈÔ Û˘¯Ó¿ ¯·ÌËÏfiÙÂÚÔ ÌÔÚʈÙÈÎfi Â›Â‰Ô (‚·ÛÈ΋ Î·È ‰Â˘ÙÂÚÔ‚¿ıÌÈ· Âη›‰Â˘ÛË) (p<0,001), ·Û¯ÔÏÔ‡ÓÙ·Ó Û ˘„ËÏfiÙÂÚÔ ÔÛÔÛÙfi Ì ٷ ÔÈÎȷο (75%) Î·È ·Ó‹Î·Ó ÛÙËÓ Î·ÙÒÙÂÚË ÎÔÈÓˆÓÈ΋ Ù¿ÍË Û ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi (92,1%), Û˘ÁÎÚÈÙÈο Ì ÂΛӘ ÙˆÓ Ì·ÚÙ‡ÚˆÓ, ·ÓÙ›ÛÙÔȯ· (ÔÈÎȷο: 57,7%, p=0,022, ÎÔÈÓˆÓÈ΋ Ù¿ÍË: 75,3%, p=0,001). √ ηıÔÚÈÛÌfi˜ Ù˘ ÔÈÎÔÁÂÓÂȷ΋˜ ÎÔÈÓˆÓÈ΋˜ Ù¿Í˘ ‚·Û›ÛÙËΠÙfiÛÔ ÛÙËÓ ·ÙÚÈ΋, fiÛÔ Î·È ÛÙË ÌËÙÚÈ΋ ÎÔÈÓˆÓÈ΋ Ù¿ÍË. ¶·Ú·ÙËÚ‹ıËΠfiÙÈ Ë Û˘¯ÓfiÙËÙ· Ù˘ ηÙÒÙÂÚ˘ ÎÔÈÓˆÓÈ΋˜ Ù¿Í˘ ‹Ù·Ó ÔÚȷο ˘„ËÏfiÙÂÚË ÛÙ· ·È‰È¿ Ì ‰È·‚‹ÙË (46,2%),
Û˘ÁÎÚÈÓfiÌÂÓË Ì ÂΛÓË ÙˆÓ Ì·ÚÙ‡ÚˆÓ (34,9%) (p=0,07) (¶›Ó·Î·˜ 1). °. ªÔÓÔ·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË ∏ ÔÌ¿‰· ÙˆÓ ·È‰ÈÒÓ Ì ™¢1 Û˘ÁÎÚ›ıËΠ̠ÙËÓ ÔÌ¿‰· ÙˆÓ Ì·ÚÙ‡ÚˆÓ, ˆ˜ ÚÔ˜ ÙÔ ÈÛÙÔÚÈÎfi ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡, ÎÔÈÓÒÓ ÈÔÁÂÓÒÓ ÏÔÈÌÒ͈Ó, ÂÌ‚ÔÏÈ·ÛÌÔ‡ Ì MMR Î·È ÙÔ ÈÛÙÔÚÈÎfi ·ÏÏÂÚÁÈÎÒÓ Û˘ÌÙˆÌ¿ÙˆÓ (¶›Ó·Î·˜ 2). ∂ÎÙÈÌ‹ıËΠ›Û˘ Ë ‰È·ÊÔÚÔÔ›ËÛË ÙˆÓ ·Ú·¿Óˆ Û¯¤ÛÂˆÓ ·Ó¿ÏÔÁ· Ì ÙËÓ ÎÔÈÓˆÓÈ΋ Ù¿ÍË ÙˆÓ ÁÔÓ¤ˆÓ. ∞fi ÙËÓ ÌÔÓÔ·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË ‰È·ÈÛÙÒÛ·Ì fiÙÈ ÙÔ ÈÛÙÔÚÈÎfi ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ ÂÌÊ·Ó›˙ÂÈ ÚÔÛٷ٢ÙÈ΋ ›‰Ú·ÛË ¤Ó·ÓÙÈ ÙÔ˘ ™¢1 ·) ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ ·È‰ÈÒÓ Ì ™¢1 (¶›Ó·Î·˜ 2, OR = 0,45, p = 0,003), ‚) ÛÙ· ·È‰È¿ Ù˘ ̤Û˘ Î·È ·ÓÒÙÂÚ˘ ÎÔÈÓˆÓÈ΋˜ Ù¿Í˘ (OR=0,35, p=0,004), ·ÏÏ¿ fi¯È Û ÂΛӷ Ù˘ ηÙÒÙÂÚ˘ ÎÔÈÓˆÓÈ΋˜ Ù¿Í˘. ∂ÈϤÔÓ, Ë ÌÂÁ·Ï‡ÙÂÚË ‰È¿ÚÎÂÈ· ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ Û¯ÂÙÈ˙fiÙ·Ó Ì ¯·ÌËÏfiÙÂÚÔ Î›Ó‰˘ÓÔ ÂΉ‹ÏˆÛ˘ ™¢1 ÛÙË Û˘ÓÔÏÈ΋ ÔÌ¿‰· ·È‰ÈÒÓ Ì ™¢1 (¶›Ó·Î·˜ 2, OR=0,89, p=0,032), ·ÏÏ¿ fi¯È ÛÙȘ ÂÈ̤ÚÔ˘˜ ÎÔÈÓˆÓÈΤ˜ Ù¿ÍÂȘ. ¢È·ÈÛÙÒıËΠ·ÚÓËÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ Ù˘ ·ÚÔ˘Û›·˜ ÏÔÈÌÒÍÂˆÓ Î·È ÙÔ˘ ™¢1 (¶›Ó·Î·˜ 2, OR=0,51, p=0,020). √ ÚÔÛٷ٢ÙÈÎfi˜ ÚfiÏÔ˜ ÙˆÓ ÏÔÈÌÒÍÂˆÓ ‰È·ÈÛÙÒıËΠ›Û˘ ÁÈ· Ù· ·È‰È¿ Ì ™¢1 Ù˘ ηÙÒÙÂÚ˘ ÎÔÈÓˆÓÈ΋˜ Ù¿Í˘ (OR=0,35, p=0,026), ·ÏÏ¿ fi¯È ÁÈ· ÂΛӷ Ù˘ ̤Û˘ Î·È ·ÓÒÙÂÚ˘ ÎÔÈÓˆÓÈ΋˜ Ù¿Í˘. ∂ȉÈÎfiÙÂÚ·, ÔÈ ‚·ÎÙËÚȷΤ˜ ÏÔÈÌÒÍÂȘ ‰ÂÓ Û¯ÂÙ›˙ÔÓÙ·Ó Û ÛËÌ·ÓÙÈÎfi ‚·ıÌfi Ì ÙËÓ ÂÌÊ¿ÓÈÛË ™¢1 Ô‡Ù ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ ·È‰ÈÒÓ Ì ™¢1 (¶›Ó·Î·˜ 2), Ô‡Ù ÛÙȘ ÂÈ̤ÚÔ˘˜ ÎÔÈÓˆÓÈΤ˜ Ù¿ÍÂȘ. ∞ÓÙ›ıÂÙ·, Ë ·ÚÔ˘Û›· ÈÔÁÂÓÒÓ ÏÔÈÌÒÍÂˆÓ ÂËÚ¤·˙ ÛËÌ·ÓÙÈο ÙËÓ ÂΉ‹ÏˆÛË ÙÔ˘ ™¢1 ·) ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ ·È‰ÈÒÓ Ì ™¢1 (¶›Ó·Î·˜ 2, OR = 0,47, p=0,011) Î·È ‚) Û ÂΛӷ Ù˘ ηÙÒÙÂÚ˘ ÎÔÈÓˆÓÈ΋˜ Ù¿Í˘ (OR=0,30, p=0,014). ŸÛÔÓ ·ÊÔÚ¿ ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Ù˘ ÚÒÙ˘ ÂÌÊ¿ÓÈÛ˘ ÙˆÓ ÈÔÁÂÓÒÓ ÏÔÈÌÒ͈Ó, ÔÈ ÏÔÈÌÒÍÂȘ Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·Ó Î˘Ú›ˆ˜ ÛÙ· ‰˘Ô ÚÒÙ· ¯ÚfiÓÈ· Ù˘ ˙ˆ‹˜ (¶›Ó·Î·˜ 2, OR=0,33, p=0,005) ‹ Î·È ·ÚÁfiÙÂÚ· (OR=0,53, p=0,053), ‰ÚÔ‡Û·Ó ÚÔÛٷ٢ÙÈο ¤Ó·ÓÙÈ Ù˘ ÂΉ‹ÏˆÛ˘ ÙÔ˘ ™¢1.
¶›Ó·Î·˜ 1. ∆·ÍÈÓfiÌËÛË ·Ó¿ÏÔÁ· Ì ÙËÓ ÎÔÈÓˆÓÈ΋ Ù¿ÍË ÙˆÓ ÁÔÓ¤ˆÓ ¶·ÙÚÈ΋ ÎÔÈÓˆÓÈ΋ Ù¿ÍË ¶·È‰È¿ Ì ‰È·‚‹ÙË ª¿ÚÙ˘Ú˜ N = 106 (%) N = 146 (%) ∫·ÙÒÙÂÚË ∞ÓÒÙÂÚË
49 (46,23) 57 (53,77) p-value = 0,211
56 (38,36) 90 (61,64) p-value = 0,001
∫ÔÈÓˆÓÈ΋ Ù¿ÍË ÙˆÓ ÁÔÓ¤ˆÓ ªËÙÚÈ΋ ÎÔÈÓˆÓÈ΋ Ù¿ÍË ¶·È‰È¿ Ì ‰È·‚‹ÙË ª¿ÚÙ˘Ú˜ N = 88 (%) N = 146 (%) 81 (92,05) 7 (7,95) p-value = 0,070
110 (75,34) 36 (24,66)
√ÈÎÔÁÂÓÂȷ΋ ÎÔÈÓˆÓÈ΋ Ù¿ÍË ¶·È‰È¿ Ì ‰È·‚‹ÙË ª¿ÚÙ˘Ú˜ N = 106 (%) N = 146 (%) 49 (46,23) 57 (53,77)*
51 (34,93) 95 (65,07)*
* ∏ ÔÈÎÔÁÂÓÂȷ΋ ÎÔÈÓˆÓÈ΋ Ù¿ÍË ¤¯ÂÈ ÔÚÈÛı› Ì ÙÚ›· ›‰· ‚·ÛÈ˙fiÌÂÓË ÛÙȘ ÎÔÈÓˆÓÈΤ˜ Ù¿ÍÂȘ ÙÔ˘ ·Ù¤Ú· Î·È Ù˘ ÌËÙ¤Ú·˜: ηÙÒÙÂÚË, ̤ÛË, ·ÓÒÙÂÚË. ∂‰Ò Ë Ì¤ÛË Î·È Ë ·ÓÒÙÂÚË ÎÔÈÓˆÓÈ΋ Ù¿ÍË Û˘ÁÎÚ›ÓÔÓÙ·È Ì ÙËÓ Î·ÙÒÙÂÚË ÎÔÈÓˆÓÈ΋ Ù¿ÍË ¶·È‰È·ÙÚÈ΋ 2007;70:293-299
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·296
296
∫. ∫·Ú·‚·Ó¿ÎË Î·È Û˘Ó.
¶›Ó·Î·˜ 2. ªÔÓÔ·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË: Ë Â›‰Ú·ÛË ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡, ÙˆÓ ·ÏÏÂÚÁÈÎÒÓ ·ÓÙȉڿÛˆÓ, ÙˆÓ ÈÔÁÂÓÒÓ ÏÔÈÌÒÍÂˆÓ Î·È ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Ì MMR ÛÙËÓ ÂΉ‹ÏˆÛË ÙÔ˘ ™¢1 N (ÂÚÈÙÒÛÂȘ / ¶·È‰È¿ Ì ̿ÚÙ˘Ú˜) ‰È·‚‹ÙË (%) ªËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ ªËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ ¢È¿ÚÎÂÈ· ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ (Û ̋Ó˜)*
ª¿ÚÙ˘Ú˜ (%)
OR (95% CI)
p-value
103/150 96/140
53 (51,46) 0 (0, 8)
105 (70,00) 1 (0, 8)
0,45 (0,27, 0,77) 0,89 (0,79, 0,99)**
0,003 0,032
106/99
57 (53,77)
69 (69,70)
0,51 (0,28, 0,91)
0,020
106/99
49 (46,23) 8 (7,55)
64 (64,65) 5 (5,05)
0,47 (0,26, 0,85) 0,98 (0,29, 3,29)
0,011 0,973
¶ÂÚ›Ô‰Ô˜ Ù˘ ˙ˆ‹˜ Ì ÙËÓ ÚÒÙË ¤ÎıÂÛË ÛÙȘ ÏÔÈÌÒÍÂȘ ¶ÚÒÙ· 2 ¤ÙË ˙ˆ‹˜ 106/99 ∞ÚÁfiÙÂÚ·
17 (16,04) 48 (45,28)
28 (28,28) 49 (49,49)
0,33 (0,14, 0,75) 0,53 (0,27, 1,02)
0,005 0,053
™˘¯ÓfiÙËÙ· ÏÔÈÌÒÍÂˆÓ (2 ÊÔÚ¤˜ / ¤ÙÔ˜) ¤Ó·ÓÙÈ (< 2 ÊÔÚ¤˜/ ¤ÙÔ˜)
75/94
15 (20,00)
52 (55,32)
0,20 (0,10, 0,43)
<0,001
∂Ì‚ÔÏÈ·ÛÌfi˜ ∂Ì‚ÔÏÈ·ÛÌfi˜ Ì MMR ∏ÏÈΛ· ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Ì MMR*
106/97 51/92
51 (48,11) 1,5 (1,0, 4,0)
∞ÏÏÂÚÁÈΤ˜ ·ÓÙȉڿÛÂȘ ∞ÏÏÂÚÁ›Â˜
90/36
34 (37,38)
§ÔÈÌÒÍÂȘ §ÔÈÌÒÍÂȘ ∂›‰Ô˜ ÏÔÈÌÒÍÂˆÓ πÔÁÂÓ›˜ µ·ÎÙËÚȷΤ˜
92 (94,85) 0,05 (0,02, 0,16) <0,001 1.3 (1,2, 3,9) 1,59 (1,01, 2,50)** 0,046 33 (91,67)
0,06 (0,01, 0,23)
<0,001
* Œ¯Ô˘Ó ·Ó·ÊÂÚı› ÔÈ ‰È¿ÌÂÛ˜ ÙÈ̤˜ Î·È Ù· ·ÓÙ›ÛÙÔȯ· ÂÓ‰ÔÙÂÙ·ÚÙËÌÔÚȷο ‡ÚË. ** OR ηٿ ÌÈ· ÌÔÓ¿‰· ·˘Í¿ÓÂÙ·È ÛÙËÓ “¤ÎıÂÛË”.
∏ Û˘Û¯¤ÙÈÛË ·˘Ù‹ ·Ú¤ÌÂÈÓ ÛËÌ·ÓÙÈ΋ ÁÈ· Ù· ·È‰È¿ Ì ™¢1 Ù˘ ηÙÒÙÂÚ˘ ÎÔÈÓˆÓÈ΋˜ Ù¿Í˘, ·ÏÏ¿ fi¯È ÁÈ· ÂΛӷ Ù˘ ̤Û˘ Î·È ·ÓÒÙÂÚ˘ ÎÔÈÓˆÓÈ΋˜ Ù¿Í˘. ∞Ó·ÊÔÚÈο Ì ÙË Û˘¯ÓfiÙËÙ· ÙˆÓ ÈÔÁÂÓÒÓ ÏÔÈÌÒ͈Ó, Ë ·ÚÔ˘Û›· ‰˘Ô ‹ ÂÚÈÛÛÔÙ¤ÚˆÓ ÏÔÈÌÒ͈Ó/¤ÙÔ˜ Û¯ÂÙÈ˙fiÙ·Ó Ì ÌÈÎÚfiÙÂÚÔ Î›Ó‰˘ÓÔ ÂΉ‹ÏˆÛ˘ ™¢1, Û˘ÁÎÚÈÙÈο Ì ÙËÓ ÂÌÊ¿ÓÈÛË ÏÈÁfiÙÂÚˆÓ ·fi ‰‡Ô ÏÔÈÌÒÍÂˆÓ ÙÔÓ ¯ÚfiÓÔ (¶›Ó·Î·˜ 2, OR=0,20, p<0,001). ∏ ·Ú·¿Óˆ Û˘Û¯¤ÙÈÛË ·Ú¤ÌÂÈÓ ÛËÌ·ÓÙÈ΋ Î·È ÛÙȘ ÂÈ̤ÚÔ˘˜ ÎÔÈÓˆÓÈΤ˜ Ù¿ÍÂȘ. √ ÂÌ‚ÔÏÈ·ÛÌfi˜ Ì MMR ›Û˘ ·Ô‰Â›¯ıËΠfiÙÈ ‰Ú· ÚÔÛٷ٢ÙÈο ¤Ó·ÓÙÈ Ù˘ ÂΉ‹ÏˆÛ˘ ™¢1, ÙfiÛÔ ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ ·È‰ÈÒÓ (¶›Ó·Î·˜ 2, OR=0,05, p<0,001) fiÛÔ Î·È ÛÙȘ ÂÈ̤ÚÔ˘˜ ÎÔÈÓˆÓÈΤ˜ Ù¿ÍÂȘ. ∆· ·È‰È¿ Ì ™¢1 ÂÌ‚ÔÏÈ¿ÛıËÎ·Ó Ì MMR Û ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚË ËÏÈΛ· Û˘ÁÎÚÈÙÈο Ì ÙÔ˘˜ Ì¿ÚÙ˘Ú˜ (¶›Ó·Î·˜ 2, OR=1,59, p=0,046). ∏ ‰È·ÊÔÚ¿ ·˘Ù‹ ‰ÂÓ ‹Ù·Ó ÛËÌ·ÓÙÈ΋ ÛÙȘ ÂÈ̤ÚÔ˘˜ ÎÔÈÓˆÓÈΤ˜ Ù¿ÍÂȘ. ∏ ÂÌÊ¿ÓÈÛË ·ÏÏÂÚÁÈÎÒÓ ·ÓÙȉڿÛÂˆÓ ÁÂÓÈο ‰ÚÔ‡Û ÚÔÛٷ٢ÙÈο ÛÙËÓ ÂΉ‹ÏˆÛË ÙÔ˘ ™¢1 (OR=0,06, p<0,001)(¶›Ó·Î·˜ 2). ∏ Û˘Û¯¤ÙÈÛË ·˘Ù‹ ‰ÂÓ ‰È·ÊÔÚÔÔÈ‹ıËΠÛÙȘ ÂÈ̤ÚÔ˘˜ ÎÔÈÓˆÓÈΤ˜ Ù¿ÍÂȘ (ηÙÒÙÂÚË: OR=0,08, p=0,06, ·ÓÒÙÂÚË Î·È Ì¤ÛË Ù¿ÍË: OR=0,05, p<0,001). Paediatriki 2007;70:293-299
¢. ∞Ó¿Ï˘ÛË ÔÏÏ·Ï‹˜ ÏÔÁÈÛÙÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ ™ÙÔ ÌÔÓÙ¤ÏÔ ÔÏÏ·Ï‹˜ ÏÔÁÈÛÙÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ Û˘ÌÌÂÙ›¯·Ó ÔÈ ·ÎfiÏÔ˘ı˜ ·Ú¿ÌÂÙÚÔÈ Ô˘ Û¯ÂÙ›˙ÔÓÙ·Ó ÛËÌ·ÓÙÈο Ì ÙËÓ ÂΉ‹ÏˆÛË ÙÔ˘ ™¢1 ηٿ ÙËÓ ÌÔÓÔ·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË (Û˘¯ÓfiÙËÙ· ÙˆÓ ÈÔÁÂÓÒÓ ÏÔÈÌÒÍÂˆÓ Î·È ÂÚ›Ô‰Ô˜ ˙ˆ‹˜ Ô˘ ¤ÁÈÓÂ Ë ÚÒÙË ¤ÎıÂÛË Û ·˘Ù¤˜, Û˘¯ÓfiÙËÙ· ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Ì MMR, ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ Î·È ÎÔÈÓˆÓÈ΋ Ù¿ÍË) (¶›Ó·Î·˜ 3), Ì ÛÎÔfi Ó· ÌÂÏÂÙËı› Ë ·ÏÏËÏ›‰Ú·Û‹ ÙÔ˘˜ ÛÙËÓ ÂΉ‹ÏˆÛË ÙÔ˘ ™¢1. ∏ ÔÏ˘·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË ÂȂ‚·›ˆÛ ÙÔÓ ÚÔÛٷ٢ÙÈÎfi ÚfiÏÔ Ù˘ ·ÚÔ˘Û›·˜ ·ÏÏÂÚÁÈÎÒÓ ·ÓÙȉڿÛÂˆÓ ÛÙËÓ ÂΉ‹ÏˆÛË ÙÔ˘ ™¢1 (OR=0,10, 95% CI: (0,03, 0,40)). ∂›Û˘, Ë ·ÚÔ˘Û›· ÈÔÁÂÓÒÓ ÏÔÈÌÒ͈Ó, ›Ù ηٿ Ù· ‰‡Ô ÚÒÙ· ¯ÚfiÓÈ· ˙ˆ‹˜ (OR=0,08, 95% CI: (0,01, 0,93)), ›Ù ·ÚÁfiÙÂÚ· (OR=0,07, 95% CI: (0,07, 0,70)) ‰È·‰Ú·Ì·Ù›˙ÂÈ ÚÔÛٷ٢ÙÈÎfi ÚfiÏÔ ÛÙËÓ ÂΉ‹ÏˆÛË ÙÔ˘ ™¢1. ∂ÈÚfiÛıÂÙ·, Ë ÂΉ‹ÏˆÛË ‰‡Ô ‹ ÂÚÈÛÛfiÙÂÚˆÓ ÏÔÈÌÒ͈Ó/¯ÚfiÓÔ Û¯ÂÙ›˙ÂÙ·È Ì ÌÂȈ̤ÓÔ Î›Ó‰˘ÓÔ ÂΉ‹ÏˆÛ˘ ™¢1, Û˘ÁÎÚÈÙÈο Ì ÙËÓ ÂΉ‹ÏˆÛË ÏÈÁfiÙÂÚˆÓ ·fi ‰‡Ô ÏÔÈÌÒÍÂˆÓ ÙÔÓ ¯ÚfiÓÔ (OR=0,11, 95% CI: (0,02, 0,50)). ∂›Û˘, Ù· ·È‰È¿ Ù˘ ηÙÒÙÂÚ˘ ÎÔÈÓˆÓÈ΋˜ Ù¿Í˘ ÂÌÊ·Ó›˙Ô˘Ó ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ÂΉ‹ÏˆÛ˘ ™¢1, Û˘ÁÎÚÈÓfiÌÂÓ·
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·297
297
¶ÂÚÈ‚·ÏÏÔÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Î·È ·ıÔÁ¤ÓÂÈ· ÙÔ˘ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ 1
¶›Ó·Î·˜ 3. ∞Ó¿Ï˘ÛË Ù˘ ÔÏÏ·Ï‹˜ ÏÔÁÈÛÙÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ ˆ˜ ÚÔ˜ ÙËÓ ·ÏÏËÏ›‰Ú·ÛË ‰È·ÊfiÚˆÓ ·Ú·ÁfiÓÙˆÓ ÛÙËÓ ÂΉ‹ÏˆÛË ÙÔ˘ ™¢1
∞ÏÏÂÚÁÈΤ˜ ÂΉËÏÒÛÂȘ ¶ÂÚ›Ô‰Ô˜ Ù˘ ˙ˆ‹˜ ηٿ ÙËÓ ÚÒÙË ¤ÎıÂÛË ÛÙȘ ÏÔÈÌÒÍÂȘ ™˘¯ÓfiÙËÙ· ÏÔÈÌÒÍÂˆÓ ( 2 ÊÔÚ¤˜ / ¤ÙÔ˜ ¤Ó·ÓÙÈ < 2ÊÔÚ¤˜/¤ÙÔ˜) ∫ÔÈÓˆÓÈ΋ Ù¿ÍË (̤ÛË & ·ÓÒÙÂÚË ¤Ó·ÓÙÈ Î·ÙÒÙÂÚ˘)
Ì ÂΛӷ Ù˘ ̤Û˘ Î·È ·ÓÒÙÂÚ˘ ÎÔÈÓˆÓÈ΋˜ Ù¿Í˘ (OR = 0,16, 95% CI: (0,03, 0,80)). ™ÙËÓ ·Ó¿Ï˘ÛË Ù˘ ÔÏÏ·Ï‹˜ ÏÔÁÈÛÙÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘, Ë Â›‰Ú·ÛË ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ Î·È ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Ì MMR ‰ÂÓ Û˘Ó¤‚·Ï·Ó ÛËÌ·ÓÙÈο ÛÙËÓ ÂÌÊ¿ÓÈÛË ÙÔ˘ ™¢1.
™˘˙‹ÙËÛË ∏ ·ÚÔ‡Û· ÌÂϤÙË ·ÚÔ˘ÛÈ¿˙ÂÈ ÛÙÔȯ›· Û¯ÂÙÈο Ì ÙÔÓ ÚfiÏÔ ÙˆÓ ÈÔÁÂÓÒÓ ÏÔÈÌÒ͈Ó, ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Ì ˙ÒÓÙ˜ ÂÍ·ÛıÂÓË̤ÓÔ˘˜ ÈÔ‡˜, ÙÔ˘ ÌËÙÚÈÎÔ‡ ıËÏ·ÛÌÔ‡ Î·È Ù˘ ·ÚÔ˘Û›·˜ ·ÏÏÂÚÁÈÒÓ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· ÙÔ˘ ™¢1. ∞fi ÙÔ˘˜ ÂÚÈ‚·ÏÏÔÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, ÔÚÈṲ̂ÓÔÈ ÈÔ› (Coxsackie, Echo, Rota, CMV, ∂Ú˘ıÚ¿˜ Î·È ¶·ÚˆÙ›Ùȉ·˜) ¤¯ÂÈ ıˆÚËı› fiÙÈ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ ·ıÔÁ¤ÓÂÈ· ÙÔ˘ ™¢1 (11,12). ªÂÚÈΤ˜ ÌÂϤÙ˜ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ ÔÈ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ ·ÔÙÂÏÔ‡Ó Èı·ÓÔ‡˜ ·ÈÙÈÔÏÔÁÈÎÔ‡˜ ‹ ÂÈÙ·¯˘ÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÂÌÊ¿ÓÈÛ˘ ÙÔ˘ ™¢1 (13,14). ∞ÓÙ›ıÂÙ·, Ë ˘fiıÂÛË Ù˘ ˘ÁÈÂÈÓ‹˜ (5) ˘ÔÛÙËÚ›˙ÂÈ fiÙÈ ÙÔ ˘„ËÏfi ‚ÈÔÙÈÎfi Â›Â‰Ô Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÌÂȈ̤ÓË ¤ÎıÂÛË Û ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ‡˜ Î·È Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÂΉ‹ÏˆÛ˘ ·ÏÏÂÚÁÈÒÓ Î·È ·˘ÙÔ¿ÓÔÛˆÓ ÓÔÛËÌ¿ÙˆÓ ÛÙËÓ ·È‰È΋ ËÏÈΛ·. ∂›Û˘, Ë ıˆڛ· ·˘Ù‹ ˘ÔÛÙËÚ›˙ÂÈ ˆ˜ Ô ÌÂȈ̤ÓÔ˜ ·ÓÔÛÔÏÔÁÈÎfi˜ ÂÚÂıÈÛÌfi˜ ÙÔ˘ ·Ó·Ù˘ÛÛfiÌÂÓÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (ȉȷ›ÙÂÚ· ηٿ Ù· ‰‡Ô ÚÒÙ· ¯ÚfiÓÈ· ˙ˆ‹˜), ÙÔ Î¿ÓÂÈ ÈÔ Â˘¿ÏˆÙÔ ÛÙË ÌÂÙ¤ÂÈÙ· ¤ÎıÂÛË ÛÙÔ˘˜ ÏÔÈÌÔÁfiÓÔ˘˜ ·Ú¿ÁÔÓÙ˜, ÁÂÁÔÓfi˜ Ô˘ ÂӉ¯Ô̤ӈ˜ ÂÈÛ‡‰ÂÈ ÙËÓ ÂÌÊ¿ÓÈÛË ™¢1 Î·È ·ÏÏÂÚÁÈÒÓ (15,16). ¶Ú¿ÁÌ·ÙÈ, Ù· ·È‰È¿ Ì ‰È·‚‹ÙË Ù˘ ÌÂϤÙ˘ Ì·˜ ÂÌÊ¿ÓÈ˙·Ó ÏÈÁfiÙÂÚÔ Û˘¯Ó¿ ÎÔÈÓ¤˜ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ Û˘ÁÎÚÈÙÈο Ì ÙÔ˘˜ Ì¿ÚÙ˘Ú˜, ȉȷ›ÙÂÚ· ηٿ Ù· ‰‡Ô ÚÒÙ· ¯ÚfiÓÈ· ˙ˆ‹˜ Î·È ÙÔ ÁÂÁÔÓfi˜ ·˘Ùfi ‹Ù·Ó ÈÔ ¤Î‰ËÏÔ ÛÙȘ ηÙÒÙÂÚ˜ ÎÔÈÓˆÓÈΤ˜ Ù¿ÍÂȘ. ¶ÔÈΛϷ ‰Â‰Ô̤ӷ ˘Ê›ÛÙ·ÓÙ·È ÁÈ· ÙË Û˘Û¯¤ÙÈÛË ÙˆÓ ÂÌ‚ÔÏ›ˆÓ Î·È Ù˘ ÂΉ‹ÏˆÛ˘ ™¢1 ÛÙ· ·È‰È¿. ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ (17,18) ıˆÚÔ‡Ó ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi Ì MMR ˆ˜ ÚÔÛٷ٢ÙÈÎfi ·Ú¿ÁÔÓÙ· ¤Ó·ÓÙÈ ÏÔÈÌÒÍÂˆÓ Ô˘ Èı·ÓfiÓ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ÂΉ‹Ïˆ-
¶ÚÒÙ· 2 ¤ÙË ˙ˆ‹˜ ∞ÚÁfiÙÂÚ·
OR
95% CI
p-value
0,10 0,08 0,07
(0,03, 0,40) (0,01, 0,93) (0,07, 0,70)
0,001 0,043 0,024
0,11
(0,02, 0,50)
0,004
0,16
(0,03, 0,80)
0,026
ÛË ™¢1. ™ÙË ÌÂϤÙË Ì·˜, ÛÙ· ·È‰È¿ Ì ‰È·‚‹ÙË ‰È·ÈÛÙÒıËΠÌÂȈ̤ÓË Û˘¯ÓfiÙËÙ· ÂÌ‚ÔÏÈ·ÛÌÔ‡ Ì MMR Î·È ÌÂÁ·Ï‡ÙÂÚË ËÏÈΛ· ÂÌ‚ÔÏÈ·ÛÌÔ‡, Û˘ÁÎÚÈÙÈο Ì ÙÔ˘˜ Ì¿ÚÙ˘Ú˜. ∆· ‰Â‰Ô̤ӷ ·˘Ù¿ Èı·ÓfiÓ ˘Ô‰ËÏÒÓÔ˘Ó fiÙÈ Ë ÌÂȈ̤ÓË ‹ Î·È Î·ı˘ÛÙÂÚË̤ÓË ‰È¤ÁÂÚÛË ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Úԉȷı¤ÙÂÈ ÛÙËÓ ÂΉ‹ÏˆÛË ÙÔ˘ ™¢1 Î·È Û˘ÌʈÓÔ‡Ó Ì ÙËÓ ˘fiıÂÛË Ù˘ ˘ÁÈÂÈÓ‹˜ (5,19). ∏ Û¯¤ÛË ÌÂٷ͇ ·ÙÔ›·˜ Î·È ·˘ÙÔ·ÓÔÛ›·˜ Â›Ó·È ·ÌÊÈÏÂÁfiÌÂÓË. ∫·Ù¿ ÙËÓ ıˆڛ· ÙÔ˘ Th1/Th2 ·Ú·‰Â›ÁÌ·ÙÔ˜ (20,21), Ù· ∆2 ‚ÔËıËÙÈο ÏÂÌÊÔ·ÙÙ·Ú· (∆h2) ¢ԉÒÓÔ˘Ó ÙËÓ ·Ú·ÁˆÁ‹ IgE ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ, ̤ۈ Ù˘ ·ÂÏ¢ı¤ÚˆÛ˘ ΢ÙÙ·ÚÔÎÈÓÒÓ, ÂÓÒ Ù· ∆1 ‚ÔËıËÙÈο ÏÂÌÊÔ·ÙÙ·Ú· (Th1) ÙËÓ ÂÚÈÔÚ›˙Ô˘Ó Î·È ÚÔ¿ÁÔ˘Ó ÙËÓ ÂÌÊ¿ÓÈÛË ·˘ÙÔ·ÓfiÛˆÓ ÓÔÛËÌ¿ÙˆÓ, fiˆ˜ Ô ™¢1 (22). ∫·Ù¿ Û˘Ó¤ÂÈ·, Û ÂÚÈÙÒÛÂȘ ·˘ÙÔ¿ÓÔÛˆÓ ·ı‹ÛˆÓ, Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ∆h2 ·ÏÏÂÚÁÈÎÒÓ ·ı‹ÛÂˆÓ Â›Ó·È ÌÂȈ̤ÓË. ¶Ú¿ÁÌ·ÙÈ, ¤¯ÂÈ ·Ó·ÊÂÚı› fiÙÈ Ù· ·È‰È¿ Ì ™¢1 ÂÌÊ·Ó›˙Ô˘Ó ÌÂȈ̤ÓÔ Î›Ó‰˘ÓÔ ÁÈ· ÂΉ‹ÏˆÛË ·ÙÔÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ (8) Î·È Ù· ·È‰È¿ Ì ·ÙÔÈÎfi ¤Î˙ÂÌ· ¤¯Ô˘Ó ÌÂȈ̤ÓÔ Î›Ó‰˘ÓÔ ÁÈ· ÂΉ‹ÏˆÛË ™¢1, ÁÂÁÔÓfi˜ Ô˘ ‰Â›¯ÓÂÈ fiÙÈ Ô Ù‡Ô˜ ·˘Ùfi˜ Ù˘ ·ÙÔÈ΋˜ ·ÓÙ›‰Ú·Û˘ ›Ûˆ˜ ·Ú¤¯ÂÈ ÌÂÚÈ΋ ÚÔÛÙ·Û›· ¤Ó·ÓÙÈ ÙÔ˘ ™¢1 (23). ∆· Â˘Ú‹Ì·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Û˘ÌʈÓÔ‡Ó Ì ÙȘ ·Ú·¿Óˆ ÌÂϤÙ˜, ·ÊÔ‡ ‰È·ÈÛÙÒÛ·Ì ÌÂȈ̤ÓË Û˘¯ÓfiÙËÙ· ·ÏÏÂÚÁÈÒÓ Û ·È‰È¿ Ì ™¢1, Û˘ÁÎÚÈÙÈο Ì ÙÔ˘˜ Ì¿ÚÙ˘Ú˜. ∞ÓÙ›ıÂÙ·, ¿ÏϘ ÌÂϤÙ˜ (24) ·Ó·Ê¤ÚÔ˘Ó fiÙÈ Ë Û˘¯ÓfiÙËÙ· ÙÔ˘ ¿ÛıÌ·ÙÔ˜ ‹Ù·Ó ·˘ÍË̤ÓË Û ·È‰È¿ Ì ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù·, fiˆ˜ Ô ™¢1 Î·È Ë ÎÔÈÏÈÔοÎË, Û ۇÁÎÚÈÛË Ì ÂΛÓË ÛÙ· Ê˘ÛÈÔÏÔÁÈο ·È‰È¿. ™ÙȘ ·ÓÙÈÎÚÔ˘fiÌÂÓ˜ ·fi„ÂȘ ¿Óˆ ÛÙÔ ı¤Ì· Ù˘ Èı·Ó‹˜ Û˘Ó‡·Ú͢ ‹ fi¯È ·ÙÔ›·˜ Î·È ·˘ÙÔ·ÓÔÛ›·˜, ÔÈ Huang Î·È Û˘Ó. (25) ÚÔÙ›ÓÔ˘Ó ÙËÓ ÂÚÌËÓ›· fiÙÈ Ë ·ÓÔÛÔÏÔÁÈ΋ ·¿ÓÙËÛË Ù‡Ô˘ Th2 ·Ú¯›˙ÂÈ ÓˆÚ›˜ ÛÙËÓ ·È‰È΋ ËÏÈΛ·, ÚÔ¿ÁÔÓÙ·˜ ÙËÓ ÂÌÊ¿ÓÈÛË ·ÏÏÂÚÁÈÒÓ Î·È ÛÙ·Ì·Ù¿ Û οÔÈ· ¯ÚÔÓÈ΋ ÛÙÈÁÌ‹. ∞ÓÙ›ıÂÙ·, Ë Th1 ·¿ÓÙËÛË Â›Ó·È Ì›· Ì·ÎÚ¿ ‰È·‰Èηۛ·, Ô˘ ‰È·ÚΛ ·fi Ì‹Ó˜ ¤ˆ˜ Î·È 10 ¯ÚfiÓÈ·, ˆ˜ ÙËÓ Ï‹ÚË Î·Ù·ÛÙÚÔÊ‹ ÙÔ˘ ÔÚÁ¿ÓÔ˘-ÛÙfi¯Ô˘ (fiˆ˜ Ù· ‚·ÙÙ·Ú· ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜). ŸÙ·Ó Ë ‰È·‰Èηۛ· ·˘Ù‹ ¶·È‰È·ÙÚÈ΋ 2007;70:293-299
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·298
298
∫. ∫·Ú·‚·Ó¿ÎË Î·È Û˘Ó.
ÔÏÔÎÏËÚˆı›, ÌÔÚ› Ó· ÂÓÂÚÁÔÔÈËı› Ë Th2 ·¿ÓÙËÛË Ô‰ËÁÒÓÙ·˜ Û ÂÌÊ¿ÓÈÛË ·ÏÏÂÚÁÈÒÓ. √ ÚfiÏÔ˜ Ù˘ ¤Ó·Ú͢ Ï‹„˘ ͤÓ˘ ÙÚÔÊ‹˜ ·fi ÙÔ ‚Ú¤ÊÔ˜ ˆ˜ ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ™¢1 ‹ ™¢2 ÛÙË ÌÂÙ¤ÂÈÙ· ˙ˆ‹ Â›Ó·È ·ÌÊÈÏÂÁfiÌÂÓÔ˜ (26). Œ¯ÂÈ ·Ô‰ÂȯÙ› fiÙÈ Ë ˘ÁÈÂÈÓ‹ Î·È Ë ËÌÈ-·ÔÛÙÂÈڈ̤ÓË ‰È·ÙÚÔÊ‹ ηٿ ÙËÓ ÚÒÙË ‚ÚÂÊÈ΋ ËÏÈΛ· (27) ÙÚÔÔÔÈ› ÙÔÓ ·ÔÈÎÈÛÌfi ÙÔ˘ ÂÓÙ¤ÚÔ˘ Ì ‚·ÎÙËÚ›‰È· Î·È ÚÔÛٷهÂÈ ·fi ÙËÓ ÂÌÊ¿ÓÈÛË ·ÏÏÂÚÁÈÒÓ Î·È ·˘ÙÔ·ÓÔÛ›·˜. ∞ÓÙ›ıÂÙ·, Ë ÚÒÈÌË ¤ÎıÂÛË ÛÙȘ ÚˆÙ½Ó˜ ÙÔ˘ Á¿Ï·ÙÔ˜ ·ÁÂÏ¿‰·˜ (1) Î·È ÛÙ· ‰ËÌËÙÚȷο, ηıÒ˜ Î·È ÙÔ ·˘ÍË̤ÓÔ ‚¿ÚÔ˜ ηٿ ÙË ‚ÚÂÊÈ΋ ËÏÈΛ· (6) ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› ˆ˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ™¢1. ∂Ô̤ӈ˜, Èı·ÓÔÏÔÁÂ›Ù·È fiÙÈ Â›Ó·È ‰˘Ó·Ùfi Ó· “ÂϤÁÍÔ˘Ì”, ̤ۈ Ù˘ ‰È·ÙÚÔÊÈ΋˜ ·Ú¤Ì‚·Û˘, ÙËÓ ·˘ÙÔ·ÓÔÛ›· ¤Ó·ÓÙÈ ÙˆÓ ‚-΢ÙÙ¿ÚˆÓ, Ì ÙÔÓ ·ÔÎÏÂÈÛÙÈÎfi Î·È ·Ú·ÙÂٷ̤ÓÔ ÌËÙÚÈÎfi ıËÏ·ÛÌfi (28). ∏ ÚÔÛٷ٢ÙÈ΋ ‰Ú¿ÛË ÙÔ˘ ıËÏ·ÛÌÔ‡ ÛÙËÓ ÂÌÊ¿ÓÈÛË ÙÔ˘ ™¢1 ¤¯ÂÈ ·Ô‰Âȯı› Î·È ÛÙË ÌÂϤÙË Ì·˜ ÛÙ· ·È‰È¿ Ì ‰È·‚‹ÙË, Î·È È‰È·›ÙÂÚ· Û ÂΛӷ ÙˆÓ ·ÓÒÙÂÚˆÓ ÎÔÈÓˆÓÈÎÒÓ Ù¿ÍˆÓ. ø˜ ÌÂÈÔÓ¤ÎÙËÌ· Ù˘ ÌÂϤÙ˘ Ì·˜ ÌÔÚ› Ó· ıˆÚËı› fiÙÈ Ë ÔÌ¿‰· ÙˆÓ Ì·ÚÙ‡ÚˆÓ ÂÚȤϷ‚ ·È‰È¿ Ô˘ ÓÔÛËχıËÎ·Ó Ì Ô͇ ·È‰È·ÙÚÈÎfi Úfi‚ÏËÌ· (Á·ÛÙÚÂÓÙÂÚ›Ùȉ·). ŸÌˆ˜, ÈÛÙ‡ԢÌ fiÙÈ Ë ÂÈÏÔÁ‹ ·˘ÙÒÓ ÙˆÓ Ì·ÚÙ‡ÚˆÓ ‰ÂÓ ÂËÚ¤·Û ÙËÓ ·ÍÈÔÈÛÙ›· ÙÔ˘˜ ÛÙËÓ ·¿ÓÙËÛË ÙÔ˘ ÂÚˆÙËÌ·ÙÔÏÔÁ›Ô˘ Ù˘ ÌÂϤÙ˘. ™˘ÌÂÚ·ÛÌ·ÙÈο, ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ‰È·ÈÛÙÒıËΠfiÙÈ Û ̛· ÔÌ¿‰· ·È‰ÈÒÓ Ì ÚfiÛÊ·Ù· ‰È·ÁÓˆṲ̂ÓÔ ™¢1, Ë ·ÚÔ˘Û›· Û˘¯ÓÒÓ ÈÔÁÂÓÒÓ ÏÔÈÌÒÍÂˆÓ Î·Ù¿ Ù· 2 ÚÒÙ· ¯ÚfiÓÈ· ˙ˆ‹˜, Ô ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜, Ë ·ÚÔ˘Û›· ·ÏÏÂÚÁÈÎÒÓ ·ÓÙȉڿÛˆÓ, ηıÒ˜ Î·È Ë ÚԤϢÛË ·fi ÙȘ ·ÓÒÙÂÚ˜ ÎÔÈÓˆÓÈΤ˜ Ù¿ÍÂȘ ‹Ù·Ó ·Ú¿ÁÔÓÙ˜ ÚÔÛٷ٢ÙÈÎÔ› ÛÙËÓ ÂÌÊ¿ÓÈÛË ™¢1. √È ÎÏÈÓÈΤ˜ ·˘Ù¤˜ ·Ú·ÙËÚ‹ÛÂȘ Ô‰ËÁÔ‡Ó ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ ÎÔÈÓÔ› ÂÚÈ‚·ÏÏÔÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ (fiˆ˜ ÌÂȈ̤ÓÔ˜ ·ÓÔÛÔÏÔÁÈÎfi˜ ÂÚÂıÈÛÌfi˜ ηٿ Ù· ÚÒÙ· ¯ÚfiÓÈ· ˙ˆ‹˜) ÚÔ¿ÁÔ˘Ó ÙËÓ ÂΉ‹ÏˆÛË ·ÙÔ›·˜ Î·È ·˘ÙÔ·ÓÔÛ›·˜. ŸÌˆ˜, Â›Ó·È Èı·Ófi Ë ·ÏÏËÏ›‰Ú·ÛË ÌÂٷ͇ Ù˘ Th1 Î·È Th2 ·ÓÔÛÔÏÔÁÈ΋˜ ·¿ÓÙËÛ˘ Ó· ‰Ú· ÚÔÛٷ٢ÙÈο ÛÙËÓ ÂÌÊ¿ÓÈÛË ™¢1.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Knip M, Akerblom HK. Early nutrition and later diabetes risk. Adv Exp Med Biol 2005;569:142-150. 2. Bingley PJ, Douek IF, Rogers CA, Gale EA. Influence of maternal age at delivery and birth order on risk of type 1 diabetes in childhood: prospective population based family study. Bart's-Oxford Study Group. BMJ 2000;321:420-424. 3. Sepa A, Wahlberg J, Vaarala O, Frodi A, Ludvigsson J. Psychological stress may induce diabetes-related autoimmunity in infancy. Diabetes Care 2005;28:290-295. 4. Vlajinac H, Sipeticã S, Marinkovicã J, Bjekicã M, Kocev N, SaPaediatriki 2007;70:293-299
5. 6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
jicã S. The Belgrade childhood diabetes study - comparison of children with type 1 diabetes with their siblings. Paediatr Perinat Epidemiol 2006;20:238-243. Kolb H, Elliott RB. Increasing incidence of IDDM a consequence of improved hygiene? Diabetologia 1994;37:729. Kibirige M, Metcalf B, Renuka R, Wilkin TJ. Testing the accelerator hypothesis: the relationship between body mass and age at diagnosis of type 1 diabetes. Diabetes Care 2003; 26:2865-2870. Dacou-Voutetakis C, Karavanaki K, Tsoka-Gennatas H. National data on the epidemiology of IDDM in Greece. Cases diagnosed in 1992. Hellenic Epidemiology Study Group. Diabetes Care 1995;18:552-554. Cardwell CR, Shields MD, Carson DJ, Patterson CC. A meta-analysis of the association between childhood type 1 diabetes and atopic disease. Diabetes Care. 2003;26:25682574. Dingle J∏, Badger GF, Jordan WS Jr. Illness in the Home: A Study of 25,000 Illnesses in a Group of Cleveland Families. Cleveland, OH: Press of Western Reserve University;1964:398. Butland BK, Strachan DP, Lewis S, Bynner J, Butler N, Britton J. Investigation into the increase in hay fever and eczema at age 16 observed between the 1958 and 1970 British birth cohorts. BMJ 1997;315:717-721. Moya-Suri V, Schlosser M, Zimmermann K, Rjasanowski I, Gürtler L, Mentel R. Enterovirus RNA sequences in sera of schoolchildren in the general population and their association with type 1-diabetes-associated autoantibodies. J Med Microbiol 2005;54:879-883. Salminen K, Sadeharju K, Lonnrot M, Vahasalo P, Kupila A, Korhonen S, et al. Enterovirus infections are associated with the induction of beta-cell autoimmunity in a prospective birth cohort study. J Med Virol 2003;69:91-98. Hindersson M, Elshebani A, Orn A, Tuvemo T, Frisk G. Simultaneous type 1 diabetes onset in mother and son coincident with an enteroviral infection. J Clin Virol 2005;33: 158-167. Otonkoski T, Roivainen M, Vaarala O, Dinesen B, Leipälä JA, Hovi T, et al. Neonatal Type I diabetes associated with maternal echovirus 6 infection: a case report. Diabetologia 2000;43(10):1235-1238. Marshall AL, Chetwynd A, Morris JA, Placzek M, Smith C, Olabi A, et al. Type 1 diabetes mellitus in childhood: a matched case control study in Lancashire and Cumbria, UK. Diabet Med 2004;21:1035-1040. Viskari H, Ludvigsson J, Uibo R, Salur L, Marciulionyte D, Hermann R, et al. Relationship between the incidence of type 1 diabetes and enterovirus infections in different European populations: results from the EPIVIR project. J Med Virol 2004;72:610-617. Hyöty H, Hiltunen M, Reunanen A, Leinikki P, Vesikari T, Lounamaa R, et al. Decline of mumps antibodies in type 1 (insulin-dependent) diabetic children and a plateau in the rising incidence of type 1 diabetes after introduction of the mumps-measles-rubella vaccine in Finland. Childhood Diabetes in Finland Study Group. Diabetologia 1993;36: 1303-1308. Altobelli E, Petrocelli R, Verrotti A, Valenti M. Infections and risk of type I diabetes in childhood: a population-based case-control study. Eur J Epidemiol 2003;18:425-430. DeStefano F, Mullooly JP, Okoro CA, Chen RT, Marcy
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·299
299
¶ÂÚÈ‚·ÏÏÔÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Î·È ·ıÔÁ¤ÓÂÈ· ÙÔ˘ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ 1
20. 21. 22.
23.
24.
SM, Ward JI, et al. Childhood vaccinations, vaccination timing, and risk of type 1 diabetes mellitus. Pediatrics 2001; 108:E112. Roep BO. The role of T-cells in the pathogenesis of Type 1 diabetes: from cause to cure. Diabetologia 2003;46:305-321. Mallia P, Johnston SL. Respiratory viruses: do they protect from or induce asthma? Allergy 2002;57:1118-1129. Offit PA, Hackett CJ. Addressing parents’ concerns: do vaccines cause allergic or autoimmune diseases? Pediatrics 2003;111:653-659. Sheikh A, Smeeth L, Hubbard R. There is no evidence of an inverse relationship between TH2-mediated atopy and TH1-mediated autoimmune disorders: Lack of support for the hygiene hypothesis. J Allergy Clin Immunol 2003; 111:131-135. ∫ero J, Gissler M, Hemminki E, Isolauri E. Could TH1 and
25. 26.
27. 28.
TH2 diseases coexist? Evaluation of asthma incidence in children with coeliac disease, type 1 diabetes or rheumatoid arthritis: a register study. J Allergy Clin Immunol 2001;108:781-783. Huang SW. Is the “hygiene hypothesis” being challenged? J Allergy Clin Immunol 2003;112:461-462. Hummel M, Füchtenbusch M, Schenker M, Ziegler AG. No major association of breast-feeding, vaccinations, and childhood viral diseases with early islet autoimmunity in the German BABYDIAB Study. Diabetes Care 2000;23:969-974. Tedeschi A, Airaghi L. Common risk factors in type 1 diabetes and asthma. Lancet 2001;357:1622. Akerblom HK, Virtanen SM, Ilonen J, Savilahti E, Vaarala O, Reunanen A, et al. Dietary manipulation of beta cell autoimmunity in infants at increased risk of type 1 diabetes: a pilot study. Diabetologia 2005;48:829-837.
¶·È‰È·ÙÚÈ΋ 2007;70:293-299
Pediatri July-Aug 07
09-07-07
300
17:08
™ÂÏ›‰·300
∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞
ORIGINAL ARTICLE
∂ηÙÔÛÙÈ·›Â˜ ı¤ÛÂȘ ÂÚÈ̤ÙÚÔ˘ ̤Û˘ ·È‰ÈÒÓ Ù˘ ∫Ú‹Ù˘ ËÏÈΛ·˜ 3 ¤ˆ˜ 16 ÂÙÒÓ ¶·ÓÂÈÛÙ‹ÌÈÔ ∫Ú‹Ù˘, ∆Ì‹Ì· π·ÙÚÈ΋˜, ∆Ô̤·˜ ∫ÔÈÓˆÓÈ΋˜ π·ÙÚÈ΋˜, ∫ÏÈÓÈ΋ ¶ÚÔÏËÙÈ΋˜ π·ÙÚÈ΋˜ Î·È ¢È·ÙÚÔÊ‹˜, ∏Ú¿ÎÏÂÈÔ ∫Ú‹Ù˘ AÏÏËÏÔÁÚ·Ê›·: EÌÌ·ÓÔ˘‹Ï §ÈÓ·Ú‰¿Î˘ linman@med.uoc.gr ¢È·ÛÙ·‡ÚˆÛË µÔ‡Ù˜ – ™Ù·˘Ú¿ÎÈ· ∆.∫. 71 003, ∆.£. 2208 ∏Ú¿ÎÏÂÈÔ ∫Ú‹Ù˘
∂. §ÈÓ·Ú‰¿Î˘, ∫. µ·Ú‰·‚¿˜, ∞. ∫·Ê¿ÙÔ˜ ¶ÂÚ›ÏË„Ë ∂ÈÛ·ÁˆÁ‹: ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ô ˘ÔÏÔÁÈÛÌfi˜ ÂηÙÔÛÙÈ·›ˆÓ ı¤ÛÂˆÓ (∂£) Î·È Ë ‰ËÌÈÔ˘ÚÁ›· Î·Ì˘ÏÒÓ ÂÚÈ̤ÙÚÔ˘ ̤Û˘ (¶ª) ·È‰ÈÒÓ Î·È ÂÊ‹‚ˆÓ Ù˘ ∫Ú‹Ù˘. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ™ÙË ÌÂϤÙË Û˘ÌÌÂÙ›¯·Ó 5.321 ·È‰È¿ - 2.643 ·ÁfiÚÈ· Î·È 2.678 ÎÔÚ›ÙÛÈ·, ËÏÈΛ·˜ 2,516,5 ÂÙÒÓ, Î·È ‰ÈÂÓÂÚÁ‹ıËÎ·Ó 7.538 ÌÂÙÚ‹ÛÂȘ ¶ª. √È ÌÂÙÚ‹ÛÂȘ ·˘Ù¤˜ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÂÙ¿ ÌÂϤÙ˜ Ô˘ ‰ÈÂÍ‹¯ıËÛ·Ó ÌÂٷ͇ 1992-2005 Û ·ÓÙÈÚÔÛˆÂ˘ÙÈο ‰Â›ÁÌ·Ù· ·È‰ÈÒÓ, ·fi ÙËÓ ∫ÏÈÓÈ΋ ¶ÚÔÏËÙÈ΋˜ π·ÙÚÈ΋˜ Î·È ¢È·ÙÚÔÊ‹˜, Ù˘ π·ÙÚÈ΋˜ ™¯ÔÏ‹˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘. OÈ ÂÍÔÌ·Ï˘Ṳ̂Ó˜ ∂£ Ù˘ ¶ª ˘ÔÏÔÁ›ÛÙËÎ·Ó Ì ÙË ¯Ú‹ÛË ÔÏ˘ˆÓ˘ÌÈÎÒÓ ÌÔÓ٤ψÓ, ÂÓÒ ¤ÁÈÓ ۇÁÎÚÈÛË Ù˘ ¶ª ÙˆÓ ·È‰ÈÒÓ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Ì ÌÂÙÚ‹ÛÂȘ ¿ÏÏˆÓ ‰ÈÂıÓÒÓ ÌÂÏÂÙÒÓ. ∞ÔÙÂϤÛÌ·Ù·: ∏ ¶ª ˘ÔÏÔÁ›ÛÙËΠ·Ó¿ ʇÏÔ Î·È ËÏÈΛ· ηıÒ˜ Î·È ÔÈ ÂÍÔÌ·Ï˘Ṳ̂Ó˜ ∂£: 5Ë, 10Ë, 25Ë, 50‹, 75Ë, 85Ë, 90‹ Î·È 95Ë. ™˘ÁÎÚÈÙÈο, ‚Ú¤ıËΠfiÙÈ Ù· ·È‰È¿ Î·È ÔÈ ¤ÊË‚ÔÈ Ù˘ ∫Ú‹Ù˘ ¤¯Ô˘Ó, ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ËÏÈ˘, ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚË ¶ª ·fi Ù· ·È‰È¿ Î·È ÙÔ˘˜ ÂÊ‹‚Ô˘˜ Ù˘ ∫‡ÚÔ˘ Î·È ÙˆÓ ∏¶∞ (p<0,05), Î·È Û fiϘ ÙȘ ËÏÈ˘ ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚ˜ ̤Û˜ ÙÈ̤˜ ·fi Ù· ·È‰È¿ Ù˘ √ÏÏ·Ó‰›·˜, Ù˘ ª. µÚÂÙ·Ó›·˜, Ù˘ ∞˘ÛÙÚ·Ï›·˜ Î·È ÙÔ˘ ∫·Ó·‰¿. øÛÙfiÛÔ, ‰ÂÓ ‰È¤ÊÂÚ·Ó ÛËÌ·ÓÙÈο (p>0,05) ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ËÏÈ˘ ·fi Ù· ·È‰È¿ Ù˘ πÛ·Ó›·˜, ÂÓÒ Û fiϘ ÙȘ ËÏÈ˘ ›¯·Ó ÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚ˜ ÙÈ̤˜ ¶ª (50‹ ∂£) ·fi Ù· ·È‰È¿ Ù˘ πÙ·Ï›·˜ (p<0,001). ™˘ÌÂÚ¿ÛÌ·Ù·: ∏ ¯Ú‹ÛË ÙˆÓ ∂£ Ù˘ ¶ª ·ÔÙÂÏ› ¯Ú‹ÛÈÌÔ Î·È ·ÍÈfiÈÛÙÔ ÂÚÁ·ÏÂ›Ô ÁÈ· ÁÔÓ›˜ Î·È ·È‰›·ÙÚÔ˘˜, ÂÓÒ Ë ¶ª ηٷ‰ÂÈÎÓ‡ÂÈ ÙÔ ÛÔ‚·Úfi Úfi‚ÏËÌ· Ù˘ ·È‰È΋˜ ÎÂÓÙÚÈ΋˜ ·¯˘Û·ÚΛ·˜ ÛÙ· ·È‰È¿ Ù˘ ∫Ú‹Ù˘.
§¤ÍÂȘ ÎÏÂȉȿ: ¶·È‰È¿, ÂÚ›ÌÂÙÚÔ˜ ̤Û˘, ÎÂÓÙÚÈ΋ ·¯˘Û·ÚΛ·, ÂηÙÔÛÙÈ·›Â˜ ı¤ÛÂȘ.
Waist circumference percentiles of children of Crete aged 3 to 16 years University of Crete, Faculty of Medicine Department of Social Medicine, Division of Preventive Medicine and Nutrition, Heraklion, Crete, Greece Correspondence: Emmanouil Linardakis linman@med.uoc.gr Voutes-Stavrakia Junction 71 003, PO Box.: 2208 Heraklion, Crete, Greece
E. Linardakis, K. Vardavas, A. Kafatos Abstract Background: The aim of this study was to estimate percentiles and growth curves of the waist circumference (WC) in children and adolescents of Crete, Greece. Methods: WC measurements were recorded for 5,321 subjects, 2,643 boys and 2,678 girls, aged 2.5 to 16.5 years, on whom a total of 7,538 were made. These measurements were derived from seven studies conducted between 1992 and 2005, on representative samples of children and adolescents in Crete, by the Preventive Medicine and Nutrition Clinic of the University of Crete. Smoothed percentiles of WC were estimated using polynomial models. The WC distribution was compared with that reported in other countries. Results: The age-sex specific descriptive characteristics and the smoothed percentiles of the 5th, 10th, 25th, 50th, 75th, 85th, 90th and 95th place were estimated. The mean WC of children and adolescents in this study in most age groups was found to be higher than that of children from Cyprus and the U.S (p<0.05) and higher in all age groups than that of children from the Netherlands, the U.K, Australia and Canada. The WC of the Cretan children did not differ significantly from that of Spanish children in most age groups but was lower (50th percentiles) in all age groups compared to Italian children (p<0.001). Conclusions: WC percentiles can be a useful and reliable tool for use by parents and paediatricians. The use of WC percentiles confirms that childhood central obesity is a major health problem in Crete.
Key words: Children, waist circumference, central obesity, percentiles.
™˘ÓÙÔÌÔÁڷʛ˜ ¶M ∂£ Paediatriki 2007;70:300-307
¶ÂÚ›ÌÂÙÚÔ˜ ª¤Û˘ ∂ηÙÔÛÙÈ·›· £¤ÛË
¢ª™ IOTF
¢Â›ÎÙ˘ ª¿˙·˜ ™ÒÌ·ÙÔ˜ International Obesity Task Force
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·301
301
∂ηÙÔÛÙÈ·›Â˜ ı¤ÛÂȘ ÂÚÈ̤ÙÚÔ˘ ̤Û˘ ·È‰ÈÒÓ
∂ÈÛ·ÁˆÁ‹ ∏ ¤Ó·ÚÍË Ù˘ ÂȉËÌÈ΋˜ ¤Í·ÚÛ˘ Ù˘ ·¯˘Û·ÚΛ·˜ ¯ÚÔÓÔÏÔÁÂ›Ù·È ·fi ÙȘ ·Ú¯¤˜ ÙÔ˘ 1960 ÁÈ· ÙÔ˘˜ ÂÓ‹ÏÈΘ Î·È ÙÔ˘ 1980 ÁÈ· Ù· ·È‰È¿ Î·È ÙÔ˘˜ ÂÊ‹‚Ô˘˜ (1,2). Œ¯Ô˘Ó ˆÛÙfiÛÔ ·Ó·Ù˘¯ı› ‰È¿ÊÔÚÔÈ ‰Â›ÎÙ˜ ̤ÙÚËÛ˘ Ù˘ ·¯˘Û·ÚΛ·˜ Î·È ¯ÚËÛÈÌÔÔÈËı› ÙfiÛÔ ÁÈ· ÙËÓ Î·Ù·ÁÚ·Ê‹ Ù˘ fiÛÔ Î·È ÁÈ· ÙË ‰È·¯ÚÔÓÈ΋ Î·È ‰È·ÔÏÈÙÈÛÌÈ΋ Û‡ÁÎÚÈÛË ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘. ¶ÔÏϤ˜ ÌÂϤÙ˜ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ¤¯Ô˘Ó ·Ó·‰Â›ÍÂÈ ÙÔÓ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ Ù˘ ̤ÙÚËÛ˘ Ù˘ ÂÚÈ̤ÙÚÔ˘ ̤Û˘ (¶ª) ˆ˜ ‰Â›ÎÙË ÎÂÓÙÚÈ΋˜ ·¯˘Û·ÚΛ·˜ ÙfiÛÔ ÛÙÔÓ ÂÓ‹ÏÈÎÔ fiÛÔ Î·È ÛÙÔÓ ·È‰ÈÎfi ÏËı˘ÛÌfi (3-11). ∏ ̤ÙÚËÛË Ù˘ ¶ª Û ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜ ·ÔÙÂÏ› ·ÍÈfiÈÛÙÔ ÚÔÁÓˆÛÙÈÎfi ‰Â›ÎÙË, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ¿ÏÏÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘, ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË Î·Ù¿ ÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹ ηډȷÁÁÂÈ·ÎÒÓ Î·È ¿ÏÏˆÓ ¯ÚfiÓÈˆÓ ÓÔÛËÌ¿ÙˆÓ (3-6). ∏ ¶ª ·È‰ÈÒÓ Î·È ÂÓËÏ›ÎˆÓ ·ÔÙÂÏ› ›Û˘ Ì›· ·fi ÙȘ ¤ÓÙÂ Û˘ÓÈÛÙÒÛ˜ ÙÔ˘ ÌÂÙ·‚ÔÏÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ (6-11). ∏ ·˘ÍË̤ÓË ÂÓ·fiıÂÛË ÎÔÈÏÈ·ÎÔ‡ Ï›Ô˘˜ Û˘Óԉ‡ÂÙ·È ·fi ·˘ÍË̤ÓË ·ÓÙ›ÛÙ·ÛË ÛÙË ‰Ú¿ÛË Ù˘ ÈÓÛÔ˘Ï›Ó˘ Î·È ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË Û·Î¯·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ 2. ∏ Û‡ÓıÂÛË Â›Û˘ ÙÔ˘ ÎÔÈÏÈ·ÎÔ‡ Ï›Ô˘˜ Û ÏÈ·Ú¿ Ôͤ· Â›Ó·È ‰˘ÛÌÂÓ¤ÛÙÂÚË ¤Ó·ÓÙÈ ÙÔ˘ ÁÏÔ˘ÙÈ·›Ô˘ (5). ∏ ̤ÙÚËÛË Ù˘ ¶ª ˆ˜ ‰Â›ÎÙË ÎÂÓÙÚÈ΋˜ ·¯˘Û·ÚΛ·˜ Â›Ó·È ·Ï‹, Ë Èı·ÓfiÙËÙ· ÛÊ¿ÏÌ·ÙÔ˜ ÛÙË ‰È·‰Èηۛ· ̤ÙÚËÛ˘ ÌÈÎÚ‹ Î·È Ë Î·ıȤڈۋ Ù˘ ÛÙËÓ Î·ıËÌÂÚÈÓ‹ ·È‰È·ÙÚÈ΋ ÎÏÈÓÈ΋ ÂͤٷÛË Ê·›ÓÂÙ·È ÂȂ‚ÏË̤ÓË. ∏ ·ÚÔ‡Û· ÌÂϤÙË ÛÙԯ‡ÂÈ ÛÙÔ Ó· Ù·ÍÈÓÔÌ‹ÛÂÈ ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜ Û ÂηÙÔÛÙÈ·›Â˜ ı¤ÛÂȘ (∂£), ÒÛÙ ӷ ˘¿Ú¯ÂÈ ¤Ó· ̤ÙÚÔ Û‡ÁÎÚÈÛ˘ ÛÙËÓ Î·ıËÌÂÚÈÓ‹ ·È‰È·ÙÚÈ΋ ÂͤٷÛË, ηıÒ˜ Î·È ‚·ÛÈο ‰Â‰Ô̤ӷ Û‡ÁÎÚÈÛ˘ ÁÈ· ÌÂÏÏÔÓÙÈ΋ ·ÍÈÔÏfiÁËÛË ÙÔ˘ ÂÈÔÏ·ÛÌÔ‡ Ù˘ ÎÂÓÙÚÈ΋˜ ·¯˘Û·ÚΛ·˜. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ¶ÂÚÈÔ¯‹ ÌÂϤÙ˘ ∏ ÌÂϤÙË Ú·ÁÌ·ÙÔÔÈ‹ıËΠ۠·È‰È¿ Î·È ÂÊ‹‚Ô˘˜ Ù˘ ∫Ú‹Ù˘ Ô˘ Û˘ÌÌÂÙ›¯·Ó Û ÌÂϤÙ˜ Ù˘ ∫ÏÈÓÈ΋˜ ¶ÚÔÏËÙÈ΋˜ π·ÙÚÈ΋˜ Î·È ¢È·ÙÚÔÊ‹˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘. ∏ ∫Ú‹ÙË ‰È·ÈÚÂ›Ù·È Û ٤ÛÛÂÚȘ ÓÔÌÔ‡˜, ÂÎÙ›ÓÂÙ·È Û 8.335 km2, Ì ÌfiÓÈÌÔ ÏËı˘ÛÌfi 594.368 ηÙÔ›ÎÔ˘˜ (·ÔÁÚ·Ê‹ 2001), ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ 142.880 ‹ 24% Â›Ó·È <19 ÂÙÒÓ. ∆Ô 42% ÙÔ˘ ÏËı˘ÛÌÔ‡ Â›Ó·È ·ÁÚÔÙÈÎfi˜, ÙÔ 46% ·ÛÙÈÎfi˜ Î·È ÙÔ 12% ËÌÈ·ÛÙÈÎfi˜. ¶ÏËı˘ÛÌfi˜ ÌÂϤÙ˘ °È· ÙË ÌÂϤÙË ÂÈϤ¯ıËÎ·Ó Î·È ÂÏ‹ÊıËÛ·Ó ·fi fiϘ ۯ‰fiÓ Ù˘ ÂÚÈÔ¯¤˜ Ù˘ ∫Ú‹Ù˘ (∂ÈÎfiÓ· 1) 5.321 ·È‰È¿ Î·È ¤ÊË‚ÔÈ - 2.643 ·ÁfiÚÈ· Î·È 2.678 ÎÔÚ›ÙÛÈ·, ËÏÈΛ·˜ 2,5-16,5 ÂÙÒÓ, ÙˆÓ ÔÔ›ˆÓ ÌÂÙÚ‹ıËÎÂ Ë ¶ª. ∆· ·È‰È¿ Î·È ÔÈ ¤ÊË‚ÔÈ
Û˘ÌÌÂÙ›¯·Ó Û ·ÓÙÈÚÔÛˆÂ˘ÙÈο ‰Â›ÁÌ·Ù· ·È‰ÈÎÒÓ Î·È ÂÊË‚ÈÎÒÓ ÏËı˘ÛÌÒÓ ÂÙ¿ ‰È·¯ÚÔÓÈÎÒÓ Î·È Û˘Á¯ÚÔÓÈÎÒÓ ÌÂÏÂÙÒÓ (¶›Ó·Î·˜ 1) Ô˘ ‰ÈÂÍ‹¯ıËÛ·Ó ·fi ÙËÓ ∫ÏÈÓÈ΋ ¶ÚÔÏËÙÈ΋˜ π·ÙÚÈ΋˜ Î·È ¢È·ÙÚÔÊ‹˜, Ù˘ π·ÙÚÈ΋˜ ™¯ÔÏ‹˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘. √È ÌÂϤÙ˜ ·˘Ù¤˜ Ô˘ ‰ÈÂÍ‹¯ıËÛ·Ó ÌÂٷ͇ ÙˆÓ ÂÙÒÓ 1992 Î·È 2005, ·ÊÔÚÔ‡Û·Ó ¶ÚÔÁÚ¿ÌÌ·Ù· ∞ÁˆÁ‹˜ Î·È ¶ÚÔ·ÁˆÁ‹˜ Ù˘ ÀÁ›·˜ ÁÈ· ÙË ÛˆÌ·ÙÈ΋ ·Ó¿Ù˘ÍË Î·È ÙËÓ ÚfiÏË„Ë ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘. ∏ ÂÈÏÔÁ‹ ÙˆÓ ·È‰ÈÒÓ ÛÙȘ ÂÙ¿ ÌÂϤÙ˜ ‹Ù·Ó Ù˘¯·›· ÔÏ˘ÛÙ·‰È·Î‹. ∞ÊÔ‡ ÂÈϤ¯ıËÎ·Ó Ù˘¯·›· ÔÈ ÂÚÈÔ¯¤˜ ÌÂϤÙ˘ (·ÛÙÈΤ˜, ËÌÈ·ÛÙÈΤ˜ Î·È ·ÁÚÔÙÈΤ˜) Î·È ÂÓ Û˘Ó¯›· Ù· Û¯ÔÏ›· ÙˆÓ ÂÚÈÔ¯ÒÓ, Û˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó fiÏ· Ù· ·È‰È¿ ÙˆÓ Û¯ÔÏ›ˆÓ. ¶ÂÚÈÛÛfiÙÂÚ˜ ÏÂÙÔ̤ÚÂȘ ˆÛÙfiÛÔ ·Ó·Ê¤ÚÔÓÙ·È Û ÚÔËÁÔ‡ÌÂÓ˜ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÂÚÁ·Û›Â˜ ÙˆÓ ÌÂÏÂÙÒÓ (12-20). ∂›Û˘, ÔÈ ÂÍÂÙ¿ÛÂȘ ÙˆÓ ·È‰ÈÒÓ ¤ÁÈÓ·Ó ÛÙÔÓ ¯ÒÚÔ ÙˆÓ Û¯ÔÏ›ˆÓ ÙÔ˘˜ ηÙfiÈÓ ¤ÁÎÚÈÛ˘ ÙˆÓ ÚÔÁÚ·ÌÌ¿ÙˆÓ Î·È ÙˆÓ ÂÍÂÙ¿ÛÂÒÓ ÙÔ˘˜ ·fi ÙÔ ÀÔ˘ÚÁÂ›Ô ¶·È‰Â›·˜, ÂÓÒ ÁÈ· ÙË Û˘ÌÌÂÙÔ¯‹ ÙÔ˘˜ ÚÔËÁ‹ıËΠÏÂÙÔÌÂÚ‹˜ ÂÓË̤ڈÛË Î·È ÂÓ˘fiÁÚ·ÊË Û˘ÁηٿıÂÛË ÙˆÓ ÁÔÓ¤ˆÓ. ¶ÚÔËÁ‹ıËΠ·ÎfiÌË ¤ÁÎÚÈÛË ÙˆÓ ÌÂÏÂÙÒÓ ·fi ÙËÓ ÂÈÙÚÔ‹ ∏ıÈ΋˜ Î·È ¢ÂÔÓÙÔÏÔÁ›·˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘. ª¤ÙÚËÛË ¶ÂÚÈ̤ÙÚÔ˘ ª¤Û˘ ∏ ̤ÙÚËÛË Ù˘ ¶ª ¤ÁÈÓ ¯ˆÚ›˜ ÚÔ‡¯·, Û ÂηÙÔÛÙ¿, Ì ϷÛÙÈ΋ ÌÂÙÚÈ΋ Ù·ÈÓ›·, οوıÂÓ ÙÔ˘ Ï¢ÚÈÎÔ‡ ÙfiÍÔ˘ ÛÙÔ Ì¤ÛÔ Ù˘ ·fiÛÙ·Û˘ ÌÂٷ͇ Ï¢ÚÈÎÔ‡ ÙfiÍÔ˘ Î·È Ï·ÁÔÓ›Ô˘ ·ÎÚÔÏÔÊ›·˜ (∂ÈÎfiÓ· 2). ™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ∏ ·Ó¿Ï˘ÛË ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ¤ÁÈÓ Ì ÙË ¯Ú‹ÛË ÙÔ˘ ÚÔÁÚ¿ÌÌ·ÙÔ˜ SPSS 13.0. ™ÙÔÓ ˘ÔÏÔÁÈÛÌfi ÙˆÓ ∂£ Ù˘ ¶ª, ηıÒ˜ Î·È ÛÙË ÁÚ·ÊÈ΋ ·ÂÈÎfiÓÈÛË ÙˆÓ Î·Ì˘ÏÒÓ ÙÔ˘˜, ˘ÔÏÔÁ›ÛÙËÎ·Ó ÔÈ ËÏÈ˘ Û ‰È·ÛÙ‹Ì·Ù· ËÏÈÎÈ·ÎÒÓ ÔÌ¿‰ˆÓ. ™˘ÁÎÂÎÚÈ̤ӷ, Ë ËÏÈΛ· ÙˆÓ 3 ÂÙÒÓ ·ÊÔÚ¿ ÙÔ ‰È¿ÛÙËÌ· ·fi 2,5 ¤ˆ˜ 3,4 ¤ÙË, ÙˆÓ 4 ÙÔ ‰È¿ÛÙËÌ· ·fi 3,5 ¤ˆ˜ 4,4 ¤ÙË, Î.Ô.Î. ¶ÔÏ˘ˆÓ˘ÌÈο ÌÔÓ٤Ϸ ÚÔÛ·ÚÌÔÁ‹˜ Áã ‚·ıÌÔ‡ (cubic models) (21,22) ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÁÈ· ÙËÓ ÂÍÔÌ¿Ï˘ÓÛË ÙˆÓ ÙÈÌÒÓ ÙˆÓ ·‰ÚÒÓ ∂£, Ù· ÔÔ›· ¤‰ˆÛ·Ó Û˘ÓÙÂÏÂÛÙ¤˜ ÚÔÛ·ÚÌÔÁ‹˜ (R2) ÌÂÁ·Ï‡ÙÂÚÔ˘˜ ÙÔ˘ 98%. ªÂ ÙË Ì¤ıÔ‰Ô ÂϤÁ¯Ô˘ Student ·ÏÔ‡ ‰Â›ÁÌ·ÙÔ˜ (One sample t test) ¤ÁÈÓ ۇÁÎÚÈÛË ÙˆÓ Ì¤ÛˆÓ ÙÈÌÒÓ Ù˘ ¶ª ÙˆÓ ·È‰ÈÒÓ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Ì ÂΛӘ ¿ÏÏˆÓ ÂÚ¢ÓÒÓ (22-30), ÂÓÒ ·Ó··Ú·ÛÙ¿ıËÎ·Ó ÁÚ·ÊÈο ÔÈ 90¤˜ ∂£ ÙˆÓ ÌÂÏÂÙÒÓ ·˘ÙÒÓ (·fi ÙË ÌÂϤÙË ÙˆÓ Fredriks et al, 2005 (23) ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÔÈ ÙÈ̤˜ Ù˘ +2SD). ∏ ÂÈÏÔÁ‹ Ù˘ 90‹˜ ∂£ Ù˘ ¶ª ·ÊÔÚ¿ ÙË ¯Ú‹ÛË Ù˘ ˆ˜ fiÚÈÔ Î·ıÔÚÈÛÌÔ‡ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ - ·¯‡Û·ÚÎˆÓ ·È‰ÈÒÓ Î·È ÂÊ‹‚ˆÓ.
¡. ÷ӛˆÓ ¡. ƒÂı‡ÌÓÔ˘ ¢È·¯ÚÔÓÈΤ˜ ÌÂϤÙ˜
™‡Á¯ÚÔÓ˜ ÌÂϤÙ˜
¡. ∏Ú·ÎÏ›Ԣ ¡. §·ÛÈı›Ô˘
∂ÈÎfiÓ· 1. ÿÚÙ˘ Ù˘ ∫Ú‹Ù˘. √È Î‡ÎÏÔÈ ‰Â›¯ÓÔ˘Ó ÙȘ ÂÚÈÔ¯¤˜ ·fi ÙȘ Ôԛ˜ ÚÔ¤Ú¯ÔÓÙ·È Ù· ·È‰È¿ Î·È ÔÈ ¤ÊË‚ÔÈ Ù˘ ÌÂϤÙ˘. ¶·È‰È·ÙÚÈ΋ 2007;70:300-307
Paediatriki 2007;70:300-307
™˘Á¯ÚÔÓÈ΋ ™˘Á¯ÚÔÓÈ΋ ™˘Á¯ÚÔÓÈ΋ ¢È·¯ÚÔÓÈ΋
¶ÚfiÁÚ·ÌÌ· ¶ÚÔ·ÁˆÁ‹˜ Ù˘ ÀÁ›·˜ (¢‹ÌÔ˜ ƒÔ‡‚·)
¶ÚfiÁÚ·ÌÌ· ÕıÏËÛ˘ Î·È ¢È·ÙÚÔÊ‹˜
¶ÚfiÁÚ·ÌÌ· ¶ÚÔ·ÁˆÁ‹˜ Ù˘ ÀÁ›·˜ (¶·È‰ÈÎÔ› ™Ù·ıÌÔ› ∏Ú·ÎÏ›Ԣ)
¶ÚfiÁÚ·ÌÌ· ∂Î·È‰Â˘ÙÈ΋˜ ¶·Ú¤Ì‚·Û˘
¶·È‰ÈÎÔ› ™Ù·ıÌÔ› ∏Ú·ÎÏ›Ԣ
™¯ÔÏ›· ¢‹ÌˆÓ ∏Ú·ÎÏ›Ԣ, ∆˘Ï›ÛÔ˘ Î·È ÃÂÚÛÔÓ‹ÛÔ˘
¡ËÈ·ÁˆÁ›Ô, ¢ËÌÔÙÈÎfi Î·È °˘ÌÓ¿ÛÈÔ ¢‹ÌÔ˘ ƒÔ‡‚· ∏Ú·ÎÏ›Ԣ
¢ËÌÔÙÈο ™¯ÔÏ›· ¢‹ÌÔ˘ ∞Á. ¡ÈÎÔÏ¿Ô˘
1Ë ÂͤÙ. - 2004/05 ¡ËÈ·ÁˆÁ›· fiÏˆÓ ÙˆÓ ¢‹ÌˆÓ Î·È ∫ÔÈÓÔÙ‹ÙˆÓ ÙÔ˘ ¡ÔÌÔ‡ ÷ӛˆÓ
2004
2003-04
2001
2000
4,0-7,0
2,5-6,1
2,8-16,5
4,0-15,3
8,1-13,8
10,0-16,5
9,2-16,5
13,6-16,5
10,2-13,1
7,6-9,9
864
73
382
92
173
215
373
292
408
241
621
∞fi ÙÔÓ ¡ÔÌfi §·ÛÈı›Ô˘ ÂÈϤ¯ıËÎÂ Î·È Û˘ÌÌÂÙ›¯Â ·ÓÙÈÚÔÛˆÂ˘ÙÈÎfi ‰Â›ÁÌ· ÙˆÓ ·È‰ÈÒÓ ÛÙȘ ÎÏÈÓÈΤ˜ ÂÍÂÙ¿ÛÂȘ ÌfiÓÔ Î·Ù¿ ÙËÓ ÚÒÙË Ì¤ÙÚËÛË (1992-93) Î·È ·ÔÙÂÏÔ‡ÓÙ·Ó ·fi 109 ·ÁfiÚÈ· Î·È 111 ÎÔÚ›ÙÛÈ· * ™ÙȘ ‰È·¯ÚÔÓÈΤ˜ ÌÂϤÙ˜ ˘‹Ú¯·Ó ·È‰È¿ Ô˘ ÂÓÙ¿¯ıËÎ·Ó Û ·˘Ù¤˜ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ Â·Ó·Ï·Ì‚·ÓfiÌÂÓˆÓ ÂÍÂÙ¿ÛˆÓ
2.678
3.804
∫·Ê¿ÙÔ˜ Î·È Û˘Ó, 2005 [20]
∞‰ËÌÔÛ›Â˘Ù· ™ÙÔȯ›·
§ÈÓ·Ú‰¿Î˘ ª, 2005 [19]
ªÔÛ¯·Ó‰Ú¤· Î·È Û˘Ó, 2003 [18]
∞‰ËÌÔÛ›Â˘Ù· ™ÙÔȯ›·
¶·È‰·ÁˆÁÈÎfi πÓÛÙÈÙÔ‡ÙÔ [17]
Moschandreas et al, 2003 [16]
Kafatos et al, 2005 [15]
Manios et al, 2002 [14]
Manios et al, 1999 [13]
∫·Ê¿ÙÔ˜ Î·È Û˘Ó, 1998 [12]
µÈ‚ÏÈÔÁÚ·Ê›·
302
†
*
833
45
426
99
175
258
430
322
409
233
574
ªÂÙÚ‹ÛÂȘ ∞ÁfiÚÈ· ∫ÔÚ›ÙÛÈ·
2.643
™˘Á¯ÚÔÓÈ΋
¶ÚfiÁÚ·ÌÌ· ¶ÚÔ·ÁˆÁ‹˜ Ù˘ ÀÁ›·˜ (¢‹ÌÔ˜ ∞Á. ¡ÈÎÔÏ¿Ô˘)
-//-
2Ë ÂͤÙ. - 2000
°˘ÌÓ¿ÛÈ· - §‡ÎÂÈ· ¡ÔÌÒÓ ∏Ú·ÎÏ›Ԣ, ƒÂı‡ÌÓÔ˘ Î·È Ã·Ó›ˆÓ
4Ë ÂͤÙ. - 2002 ¢ËÌÔÙÈο Î·È °˘ÌÓ¿ÛÈ· ¡ÔÌÒÓ ∏Ú·ÎÏ›Ԣ, ƒÂı‡ÌÓÔ˘ Î·È §·ÛÈı›Ô˘
¢ËÌÔÙÈο ™¯ÔÏ›· ¡ÔÌÒÓ ∏Ú·ÎÏ›Ԣ, ƒÂı‡ÌÓÔ˘ Î·È Ã·Ó›ˆÓ
3Ë ÂͤÙ. - 1998
1Ë ÂͤÙ. - 1999
¢ËÌÔÙÈο ™¯ÔÏ›· ¡ÔÌÒÓ ∏Ú·ÎÏ›Ԣ, ƒÂı‡ÌÓÔ˘ Î·È Ã·Ó›ˆÓ
2Ë ÂͤÙ. - 1995
5,0-8,5
∏ÏÈΛ· (¤ÙË)
™‡ÓÔÏÔ ·È‰ÈÒÓ
¢È·¯ÚÔÓÈ΋
¶ÚfiÁÚ·ÌÌ· ∂Î·È‰Â˘ÙÈ΋˜ ¶·Ú¤Ì‚·Û˘
¢ËÌÔÙÈο ™¯ÔÏ›· ¡ÔÌÒÓ ∏Ú·ÎÏ›Ԣ, ƒÂı‡ÌÓÔ˘, ÷ӛˆÓ Î·È §·ÛÈı›Ô˘†
1Ë ÂͤÙ. - 1992
ÃÒÚÔ˜ ÌÂϤÙ˘
17:08
3.734
¢È·¯ÚÔÓÈ΋
¶ÚfiÁÚ·ÌÌ· ∂Î·È‰Â˘ÙÈ΋˜ ¶·Ú¤Ì‚·Û˘
ŒÙÔ˜ ∂ͤٷÛ˘
09-07-07
™‡ÓÔÏÔ ÌÂÙÚ‹ÛˆÓ
∂›‰Ô˜
ªÂϤÙË ¶ÚfiÁÚ·ÌÌ·
¶›Ó·Î·˜ 1. ™˘Á¯ÚÔÓÈΤ˜ Î·È ‰È·¯ÚÔÓÈΤ˜ ÌÂϤÙ˜ - ÚÔÁÚ¿ÌÌ·Ù· ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘ Ô˘ Û˘ÌÌÂÙ›¯·Ó ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÁÈ· ÙÔÓ ˘ÔÏÔÁÈÛÌfi ÙˆÓ ÂηÙÔÛÙÈ·›ˆÓ ı¤ÛÂˆÓ Ù˘ ÂÚÈ̤ÙÚÔ˘ ̤Û˘ 5.321 ·È‰ÈÒÓ Ù˘ ∫Ú‹Ù˘, ËÏÈΛ·˜ 2,5 ¤ˆ˜ 16,5 ÂÙÒÓ, Ì 7.538 ÌÂÙÚ‹ÛÂȘ
Pediatri July-Aug 07 ™ÂÏ›‰·302
∂. §ÈÓ·Ú‰¿Î˘ Î·È Û˘Ó.
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·303
303
∂ηÙÔÛÙÈ·›Â˜ ı¤ÛÂȘ ÂÚÈ̤ÙÚÔ˘ ̤Û˘ ·È‰ÈÒÓ
∂ÈÎfiÓ· 2. ™¯ËÌ·ÙÈ΋ ·ÂÈÎfiÓÈÛË Ì¤ÙÚËÛ˘ ÂÚÈ̤ÙÚÔ˘ ̤Û˘.
∞ÔÙÂϤÛÌ·Ù· √È ·Ó¿ ËÏÈΛ· Î·È Ê‡ÏÔ Ì¤Û˜ ÙÈ̤˜ Î·È Ù˘ÈΤ˜ ·ÔÎÏ›ÛÂȘ Ù˘ ¶ª ÙˆÓ ·È‰ÈÒÓ Î·È ÙˆÓ ÂÊ‹‚ˆÓ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 2. ™ÙÔÓ ¶›Ó·Î· 3 ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÔÈ ÂȉÈΤ˜ ·Ó¿ ʇÏÔ Î·È ËÏÈΛ· ÂÍÔÌ·Ï˘Ṳ̂Ó˜ ∂£ Ù˘ ¶ª. √È ∂£ ·ÊÔÚÔ‡Ó ÙËÓ 5Ë, 10Ë, 25Ë, 50‹, 75Ë, 85Ë, 90‹ Î·È 95Ë ∂£ Ì ÙË ÁÚ·ÊÈ΋ ÙÔ˘˜ ·ÂÈÎfiÓÈÛË Ó· ·ÚÔ˘ÛÈ¿˙ÂÙ·È ÛÙËÓ ∂ÈÎfiÓ· 3. ™ÙÔÓ ¶›Ó·Î· 4 ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÔÈ ·Ó¿ ʇÏÔ Î·È ËÏÈΛ· ̤Û˜ Î·È ‰È¿ÌÂÛ˜ ÙÈ̤˜ Ù˘ ¶ª, Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Û ۇÁÎÚÈÛË Ì ÂΛӘ ÌÂÏÂÙÒÓ ¿ÏÏˆÓ ¯ˆÚÒÓ. Ÿˆ˜ Ê·›ÓÂÙ·È, Ù· ·È‰È¿ Ù˘ ∫Ú‹Ù˘ ¤¯Ô˘Ó ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ËÏÈ˘ ÛËÌ·ÓÙÈο (p<0,05) ˘„ËÏfiÙ¶›Ó·Î·˜ 2. ¶ÂÚ›ÌÂÙÚÔ˜ ̤Û˘ 7.538 ÌÂÙÚ‹ÛÂˆÓ 5.321 ·È‰ÈÒÓ Ù˘ ∫Ú‹Ù˘ ∏ÏÈΛ· (¤ÙË)† 3 4 5 6 7 8 9 10 11 12 13 14 15 16 #
∞ÁfiÚÈ· ¡ ª¤ÛË ÙÈÌ‹ (∆∞)# 44 96 421 872 213 113 220 170 384 427 84 156 357 177
50,5 (3,9)* 54,0 (4,9) 55,1 (5,9) 56,3 (7,1) 56,8 (6,3) 59,7 (6,4) 62,6 (8,4) 68,1 (9,9) 71,4 (10,7) 71,6 (10,6) 72,5 (9,7) 76,9 (10,8) 78,2 (10,4) 81,8 (12,9)
∫ÔÚ›ÙÛÈ· ¡ ª¤ÛË ÙÈÌ‹ (∆∞) 33 99 389 834 181 108 213 173 414 417 113 192 457 181
52,2 (3,9) 52,8 (4,5) 54,7 (5,4) 55,1 (6,0) 55,1 (5,7) 59,9 (8,2) 61,7 (8,9) 66,2 (9,2) 68,6 (9,7) 69,2 (9,8) 69,5 (9,2) 71,8 (7,9) 71,8 (8,0) 72,7 (9,1)
∆∞: Ù˘È΋ ·fiÎÏÈÛË † ∏ ËÏÈΛ· ·ÊÔÚ¿ ËÏÈÎȷΤ˜ ÔÌ¿‰Â˜: Ù· 3 ¤ÙË ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ·È‰È¿ ËÏÈΛ·˜ 2,5-3,4 ¯ÚfiÓˆÓ Î.Ô.Î. * √È ÙÈ̤˜ Â›Ó·È Û ÂηÙÔÛÙ¿ (cm)
™˘˙‹ÙËÛË ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ˘ÔÏÔÁ›ÛÙËÎ·Ó Î·È ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ∂£ Ù˘ ¶ª ÁÈ· ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜ Ù˘ ∫Ú‹Ù˘. ∆· ·È‰È¿ Î·È ÔÈ ¤ÊË‚ÔÈ Ù˘ ∫Ú‹Ù˘ ‚Ú¤ıËÎ·Ó Ó· ¤¯Ô˘Ó ·fi ÙȘ ˘„ËÏfiÙÂÚ˜ ÙÈ̤˜ ÎÂÓÙÚÈ΋˜ ·¯˘Û·ÚΛ·˜, Ì ÂÍ·›ÚÂÛË ·Ó¿ÏÔÁ˘ ËÏÈΛ·˜ ·È‰È¿ Ù˘ πÙ·Ï›·˜. √È ÂÚÈÛÛfiÙÂÚ˜ ·fi ÙȘ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÌÂϤÙ˜ ÙˆÓ ¯ˆÚÒÓ ∫‡ÚÔ˘, πÙ·Ï›·˜, πÛ·Ó›·˜, ª. µÚÂÙ·Ó›·˜, 110 ¶ÂÚ›ÌÂÙÚÔ˜ ª¤Û˘ (cm)
∆ÔÔı¤ÙËÛË ÛÙÔ ‡„Ô˜ ÙÔ˘ ÔÌÊ·ÏÔ‡
Ú˜ ̤Û˜ ÙÈ̤˜ ¶ª Û ۯ¤ÛË Ì ٷ ·ÓÙ›ÛÙÔȯ˘ ËÏÈΛ·˜ ·È‰È¿ Ù˘ ∫‡ÚÔ˘ Î·È ÙˆÓ ∏¶∞, ÂÓÒ Û fiϘ ÙȘ ËÏÈ˘ ¤¯Ô˘Ó ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚ˜ ̤Û˜ ÙÈ̤˜ ·fi Ù· ·È‰È¿ Ù˘ √ÏÏ·Ó‰›·˜, Ù˘ ª. µÚÂÙ·Ó›·˜, Ù˘ ∞˘ÛÙÚ·Ï›·˜ Î·È ÙÔ˘ ∫·Ó·‰¿. ∂›Û˘, ‰ÂÓ ‰È·Ê¤ÚÔ˘Ó ÛËÌ·ÓÙÈο ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ËÏÈ˘ ·fi Ù· ·È‰È¿ Ù˘ πÛ·Ó›·˜ (p>0,05), ÂÓÒ ¤¯Ô˘Ó ÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚ˜ ÙÈ̤˜ ¶ª (50‹ ∂£) ·fi ÂΛӷ Ù˘ πÙ·Ï›·˜ (p<0,001). ∆¤ÏÔ˜, ÛÙËÓ ∂ÈÎfiÓ· 4 ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ì¤Ûˆ ÁÚ·ÊÈÎÒÓ Ù· fiÚÈ· Ù˘ 90‹˜ ∂£ Ù˘ ¶ª ÁÈ· ÙȘ ÚÔ·Ó·ÊÂÚı›Û˜ ¯ÒÚ˜. ∆· ·È‰È¿ Ù˘ πÙ·Ï›·˜ Ê·›ÓÔÓÙ·È Ó· ¤¯Ô˘Ó ÙËÓ ˘„ËÏfiÙÂÚË 90‹ ∂£ Î·È Ù· ·È‰È¿ Ù˘ ª. µÚÂÙ·Ó›·˜ ÙË ¯·ÌËÏfiÙÂÚË, ÂÓÒ ÂΛӷ Ù˘ ∫Ú‹Ù˘ ¤¯Ô˘Ó ۯ‰fiÓ ·ÚfiÌÔÈ· 90‹ ∂£ ÌfiÓÔ Ì ٷ ·È‰È¿ ÙˆÓ ∏¶∞.
95 90 85 75
·ÁfiÚÈ·
100 90 80
50 25 10 5
70 60 50 40
3
4
5
6
7
8 9 10 11 12 13 14 15 16 ∏ÏÈΛ· (¤ÙË)
100 ¶ÂÚ›ÌÂÙÚÔ˜ ª¤Û˘ (cm)
ªÂٷ͇ Ï¢ÚÈÎÔ‡ ÙfiÍÔ˘ Î·È Ï·ÁÔÓ›Ô˘
ÎÔÚ›ÙÛÈ·
90
95 90 85 75 50 25 10 5
80 70 60 50 40
3
4
5
6
7
8 9 10 11 12 13 14 15 16 ∏ÏÈΛ· (¤ÙË)
∂ÈÎfiÓ· 3. ∫·Ì‡Ï˜ ÂηÙÔÛÙÈ·›ˆÓ ı¤ÛÂˆÓ ÂÚÈ̤ÙÚÔ˘ ̤Û˘. ¶·È‰È·ÙÚÈ΋ 2007;70:300-307
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·304
304
∂. §ÈÓ·Ú‰¿Î˘ Î·È Û˘Ó.
¶›Ó·Î·˜ 3. ∆È̤˜ ÂÍÔÌ·Ï˘ÛÌ¤ÓˆÓ ÂηÙÔÛÙÈ·›ˆÓ ı¤ÛÂˆÓ ÂÚÈ̤ÙÚÔ˘ ̤Û˘ 7.538 ÌÂÙÚ‹ÛÂˆÓ 5.321 ·È‰ÈÒÓ Ù˘ ∫Ú‹Ù˘ ∏ÏÈΛ· (¤ÙË) ∞ÁfiÚÈ· 3 4 5 6 7 8 9 10 11 12 13 14 15 16 ∫ÔÚ›ÙÛÈ· 3 4 5 6 7 8 9 10 11 12 13 14 15 16
5Ë
10Ë
25Ë
50‹
75Ë
85Ë
90‹
95Ë
45,4 46,3 47,3 48,6 50,0 51,5 53,2 54,9 56,8 58,8 60,9 63,0 65,2 67,4
46,8 47,6 48,6 49,8 51,3 52,8 54,6 56,5 58,5 60,6 62,8 65,1 67,5 69,9
49,0 49,8 50,8 52,2 53,8 55,6 57,5 59,6 61,8 64,1 66,3 68,5 70,7 72,7
51,3 52,0 53,2 54,8 56,8 59,1 61,6 64,2 66,8 69,4 71,9 74,1 76,1 77,8
53,1 54,3 56,2 58,6 61,5 64,7 68,1 71,6 75,0 78,2 81,1 83,6 85,5 86,8
55,3 56,9 59,0 61,8 64,9 68,3 71,9 75,7 79,4 83,0 86,4 89,4 92,1 94,2
56,3 58,5 61,2 64,3 67,7 71,3 75,1 79,0 82,9 86,6 90,2 93,6 96,6 99,1
59,1 62,1 65,3 68,6 72,2 75,8 79,5 83,3 87,1 90,9 94,6 98,4 102,0 105,6
46,3 46,3 46,6 47,3 48,4 49,8 51,3 53,0 54,8 56,5 58,2 59,8 61,1 62,2
47,4 47,4 47,7 48,5 49,7 51,3 53,0 54,9 56,8 58,6 60,3 61,7 62,8 63,4
49,8 49,8 49,9 50,7 52,1 53,9 56,0 58,2 60,4 62,5 64,3 65,6 66,4 66,4
52,2 52,2 52,9 54,3 56,2 58,4 60,7 63,2 65,5 67,5 69,2 70,3 70,7 70,7
55,2 55,3 56,4 58,3 60,8 63,7 66,8 69,8 72,6 74,9 76,5 77,2 76,8 75,1
55,7 57,1 59,2 61,8 64,8 68,0 71,2 74,3 77,0 79,2 80,7 81,4 81,0 79,5
56,7 58,5 61,0 64,0 67,3 70,7 74,2 77,4 80,2 82,5 84,1 84,7 84,2 82,5
60,5 62,2 64,8 67,8 71,3 75,0 78,6 82,1 85,2 87,8 89,6 90,5 90,3 88,7
√ÏÏ·Ó‰›·˜, ∞˘ÛÙÚ·Ï›·˜, ∫·Ó·‰¿ Î·È ∏¶∞ (22-29), Ô˘ ·ÊÔÚÔ‡Ó ÂÚÁ·Û›Â˜ ˘ÔÏÔÁÈÛÌÔ‡ ∂£ Ù˘ ¶ª, ·ÔÙÂÏÔ‡Ó Û˘Á¯ÚÔÓÈΤ˜ ÌÂϤÙ˜ Î·È ¤¯Ô˘Ó ‰ÈÂÍ·¯ı› Û ‰È·ÛÙ‹Ì·Ù· ‰È¿ÚÎÂÈ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ ‰‡Ô ÂÙÒÓ. øÛÙfiÛÔ, Ë ·fi ÎÔÈÓÔ‡ ¯Ú‹ÛË ‰È·¯ÚÔÓÈÎÒÓ Î·È Û˘Á¯ÚÔÓÈÎÒÓ ÌÂÏÂÙÒÓ ÁÈ· ÙË ‰ËÌÈÔ˘ÚÁ›· ∂£ Î·Ì˘ÏÒÓ ·Ó¿Ù˘Í˘ Ô˘ ηχÙÔ˘Ó Â›Û˘ ÌÂÁ·Ï‡ÙÂÚ· ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù· ¤¯ÂÈ ‹‰Ë ÂÊ·ÚÌÔÛÙ› Û ∏¶∞ Î·È ª. µÚÂÙ·Ó›· (30,31). ∏ ¶ª Â›Ó·È ·Ï‹ Î·È Â‡ÎÔÏË ÛÙË Ì¤ÙÚËÛ‹ Ù˘ ·ÏÏ¿ Î·È ÌÂÁ¿Ï˘ ÛÔ˘‰·ÈfiÙËÙ·˜, ηıÒ˜ Â›Ó·È ‰Â›ÎÙ˘ ÎÂÓÙÚÈ΋˜ ·¯˘Û·ÚΛ·˜. √È Mamalakis Î·È Û˘Ó. (5), ¤‰ÂÈÍ·Ó fiÙÈ Ë Û‡ÓıÂÛË Û ÏÈ·Ú¿ Ôͤ· ÙÔ˘ ÎÔÈÏÈ·ÎÔ‡ ˘Ô‰fiÚÈÔ˘ Ï›Ô˘˜ Â›Ó·È ÛËÌ·ÓÙÈο ‰˘ÛÌÂÓ¤ÛÙÂÚË ÙÔ˘ ÁÏÔ˘ÙÈ·›Ô˘ (˘„ËÏfiÙÂÚ· ›‰· ÎÔÚÂÛÌ¤ÓˆÓ Î·È trans ÏÈ·ÚÒÓ ÔͤˆÓ Î·È ¯·ÌËÏfiÙÂÚ· ÌÔÓÔ·ÎfiÚÂÛÙˆÓ Î·È ÔÏ˘·ÎfiÚÂÛÙˆÓ) Î·È Û¯ÂÙ›˙ÂÙ·È Â›Û˘ ηχÙÂÚ· Ì ٷ ÏÈ›‰È· ÔÚÔ‡ ·›Ì·ÙÔ˜. ∂ÈϤÔÓ, Ë ÎÂÓÙÚÈ΋ ·¯˘Û·ÚΛ· ·ÔÙÂÏ› ¤Ó·Ó ·fi ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÙÔ˘ ÌÂÙ·‚ÔÏÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ (611). √È Moreno Î·È Û˘Ó. (11), ·Ó·Ê¤ÚÔ˘Ó fiÙÈ Ë ¶ª ˆ˜ ‰Â›ÎÙ˘ ·¯˘Û·ÚΛ·˜ ·ÔÙÂÏ› Û ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜ ηχÙÂÚÔ ÚÔÁÓˆÛÙÈÎfi ‰Â›ÎÙË ÙÔ˘ ÌÂÙ·Paediatriki 2007;70:300-307
‚ÔÏÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘, ·fi fi,ÙÈ Ô ‰Â›ÎÙ˘ Ì¿˙·˜ ÛÒÌ·ÙÔ˜ (¢ª™) ‹ ÙÔ ¿¯Ô˜ ÙˆÓ ‰ÂÚÌ·ÙÈÎÒÓ Ù˘¯ÒÓ. °È· ÙËÓ ·˘Í·ÓfiÌÂÓË Û˘¯ÓfiÙËÙ· Ù˘ ·¯˘Û·ÚΛ·˜ Î·È ÙÔ˘ ÌÂÙ·‚ÔÏÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ ÛÙ· ·È‰È¿ Î·È ÛÙÔ˘˜ ÂÊ‹‚Ô˘˜ ¢ı‡ÓÔÓÙ·È Î˘Ú›ˆ˜ Ë ¤ÏÏÂÈ„Ë ÛˆÌ·ÙÈ΋˜ ¿ÛÎËÛ˘, Ë Î·Î‹ ‰È·ÙÚÔÊ‹ Î·È ÙÔ stress, Ô˘ Ô‰ËÁÔ‡Ó Û ·ÔÚÚ‡ıÌÈÛË ÙÔ˘ ¿ÍÔÓ· ˘Ôı·Ï¿ÌÔ˘˘fiÊ˘Û˘-ÂÈÓÂÊÚȉ›ˆÓ (32). ∏ ÎÂÓÙÚÈ΋ ·¯˘Û·ÚΛ· Û¯ÂÙ›˙ÂÙ·È Ì ·ÓÙ›ÛÙ·ÛË ÛÙË ‰Ú¿ÛË Ù˘ ÈÓÛÔ˘Ï›Ó˘, ·‡ÍËÛË ÙˆÓ ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ, Ì›ˆÛË Ù˘ HDL ¯ÔÏËÛÙÂÚfiÏ˘ Î·È ·‡ÍËÛË ÙÔ˘ ۷ί¿ÚÔ˘. ™Ô˘‰·›Ô ÚfiÏÔ Â›Û˘ Ê·›ÓÂÙ·È ˆ˜ ¤¯ÂÈ Ë ÔÚÌÔÓÈ΋ ‰Ú¿ÛË Ù˘ ÏÂÙ›Ó˘, ηıÒ˜ ¤¯ÂÈ ‚ÚÂı› Û ·È‰È¿ Î·È ÂÓ‹ÏÈΘ Ó· Û¯ÂÙ›˙ÂÙ·È Ì ÙÔ˘˜ ·Ú·¿Óˆ ·Ú¿ÁÔÓÙ˜ Î·È È‰È·›ÙÂÚ· Ì ÙËÓ ÎÂÓÙÚÈ΋ ·¯˘Û·ÚΛ· Ô˘ Ô‰ËÁ› Û ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ 2 (33-35). ™Â 1.209 ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜ Ù˘ ∫Ú‹Ù˘ ËÏÈΛ·˜ 3-18 ÂÙÒÓ (19), ‚Ú¤ıËÎ·Ó 48 ·È‰È¿ (3,9%) Ì ÙÚÂȘ ‹ ÂÚÈÛÛfiÙÂÚ˜ Û˘ÓÈÛÙÒÛ˜ ÌÂÙ·‚ÔÏÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘, ÂÎ ÙˆÓ ÔÔ›ˆÓ ÙÔ 62% ›¯·Ó ÎÂÓÙÚÈ΋ ·¯˘Û·ÚΛ· (¶ª>90‹ ∂£). ™ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·È‰ÈÒÓ, ÙÔ 8,5% ‚Ú¤ıËΠ̠ÎÂÓÙÚÈ΋ ·¯˘Û·ÚΛ·, ÂÓÒ, Ì ‚¿ÛË ÙÔÓ ¢ª™ (fiÚÈ· International Obesity Task Force - IOTF)
†
55,6 58,1 58,8 62,1 65,4 66,1 67,0 66,4 68,1 69,5 68,5
52,2 52,8 54,7 55,1 55,1 59,9 61,7 66,2 68,6 69,2 69,5 71,8 71,8 72,7
49,7 51,2 52,1 53,3 54,8 56,5 58,2 59,9 61,8 63,9 66,1 68,2 70,3 72,3 49,2 50,6 51,3 52,5 54,0 55,7 57,3 59,0 60,6 62,4 64,1 65,6 66,8 67,9
0,038 <0,001 <0,001 <0,001 0,100 0,926 0,118 <0,001 <0,001 <0,001 0,020 <0,001 <0,001 <0,001 <0,001 0,001 <0,001 0,681 <0,001 0,150 0,099 <0,001 <0,001 <0,001 0,127 0,004 0,666 0,081
M.T.
<0,001 <0,001 <0,001 <0,001 0,011 <0,001 <0,001 <0,001 <0,001 <0,001 <0,001 <0,001 <0,001 <0,001
0,200 <0,001 <0,001 <0,001 <0,001 <0,001 <0,001 <0,001 <0,001 <0,001 <0,001 <0,001 <0,001 <0,001
p-value
0,160 0,236 0,119 0,275 <0,001 <0,001 <0,001 0,073 <0,001
54,9 0,372 56,6 0,001 59,0 0,234 61,4 0,611 64,1 0,03 64,9 <0,001 65,3 <0,001 67,3 0,011 66,8 <0,001 -
56,0 57,3 60,6 63,2 65,4 68,0 68,0 70,6 72,8 -
M.T. p-value
πÛ·Ó›· (25)
51,3 52,2 54,4 55,3 56,8 58,0 60,0 61,6 63,6 64,7 64,9 66,2
52,3 52,7 54,6 55,7 58,1 59,6 61,5 63,8 66,4 68,7 70,8 71,8
M.T.
<0,001 <0,001 0,107 <0,001 <0,001 <0,001 <0,001 <0,001 <0,001 <0,001 <0,001 <0,001
<0,001 <0,001 <0,001 <0,001 <0,001 <0,001 <0,001 <0,001 <0,001 <0,001 <0,001 <0,001
p-value
ª. µÚÂÙ·Ó›·, 1990 (24)
55,6 57,3 59,1 61,0 62,3 64,6 66,8 68,2 69,8 -
55,9 58,1 60,2 61,3 64,6 66,6 69,4 71,3 73,2 -
0,235 0,001 <0,001 <0,001 <0,001 <0,001 0,002 <0,001 <0,001
0,041 0,011 <0,001 <0,001 <0,001 <0,001 0,004 <0,001 <0,001
M.T. p-value
∞˘ÛÙÚ·Ï›·, 1985 (26)
63,0 66,5 69,0 71,0 76,0 77,0 82,0 85,0 -
61,0 64,0 67,0 69,0 72,0 75,0 80,0 82,0 -
<0,001 <0,001 <0,001 <0,001 <0,001 <0,001 <0,001 <0,001
<0,001 <0,001 <0,001 <0,001 <0,001 <0,001 <0,001 <0,001
¢È¿ÌÂÛÔ˜ p-value
πÙ·Ï›· (30)
One sample Student test √È Ì¤Û˜ ÙÈ̤˜ ‰fiıËÎ·Ó ÌÂÙ¿ ·fi ÚÔÛˆÈ΋ ÂÈÎÔÈÓˆÓ›·, ÂÓÒ ÔÈ ∂£ ‰ËÌÔÛȇÔÓÙ·È ÛÙÔ Obes. Res. 2001. * ∆È̤˜ ÙˆÓ Â˘Úˆ-·ÌÂÚÈηÓÒÓ. ##M.T.: ª¤ÛË ∆ÈÌ‹
49,3 51,2 53,1 55,0 56,9 58,8 60,7 62,5 64,4 66,3 68,2 70,1 72,0 73,9
49,2 51,3 53,3 55,4 57,5 59,6 61,7 63,7 65,8 67,9 70,0 72,1 74,1 76,2
¢È¿ÌÂÛÔ˜ p-value
√ÏÏ·Ó‰›·, 1996 (23)
60,9 62,5 64,8 65,9 68,3 67,9
63,3 65,8 66,5 69,7 72,5 73,6
<0,001 <0,001 <0,001 <0,001 <0,001 <0,001
<0,001 <0,001 <0,001 <0,001 <0,001 <0,001
M.T. p-value
∫·Ó·‰¿˜, 1981 (29)
17:08
0,014 <0,001 0,150 0,523 0,252 <0,001 <0,001 <0,001 <0,001 <0,001 <0,001
55,6 0,002 57,6 0,068 60,4 0,218 62,8 0,701 66,5 0,034 66,9 <0,001 69,1 <0,001 71,4 0,291 75,9 0,262 75,2 <0,001 78,7 0,002
50,5 54,0 55,1 56,3 56,8 59,7 62,6 68,1 71,4 71,6 72,5 76,9 78,2 81,8
M.T. p-value
M.T. ##
∏¶∞, 1988-94* (27)
09-07-07
#
∞ÁfiÚÈ· 3 4 5 6 7 8 9 10 11 12 13 14 15 16 ∫ÔÚ›ÙÛÈ· 3 4 5 6 7 8 9 10 11 12 13 14 15 16
∏ÏÈΛ· (¤ÙË)
∫‡ÚÔ˜, 1999 † (22)
¶·ÚÔ‡Û· ÌÂϤÙË
¶›Ó·Î·˜ 4. ™‡ÁÎÚÈÛË Ì¤ÛˆÓ ÙÈÌÒÓ Ù˘ ÂÚÈ̤ÙÚÔ˘ ̤Û˘ ·È‰ÈÒÓ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Î·È ÌÂÏÂÙÒÓ ¿ÏÏˆÓ ¯ˆÚÒÓ
Pediatri July-Aug 07 ™ÂÏ›‰·305
∂ηÙÔÛÙÈ·›Â˜ ı¤ÛÂȘ ÂÚÈ̤ÙÚÔ˘ ̤Û˘ ·È‰ÈÒÓ
305
¶·È‰È·ÙÚÈ΋ 2007;70:300-307
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·306
306
∂. §ÈÓ·Ú‰¿Î˘ Î·È Û˘Ó.
√ÏÏ·Ó‰›· ∫·Ó·‰¿˜ ∞˘ÛÙÚ·Ï›· ª. µÚÂÙ·Ó›·
3
4
5
6
7
8 9 10 11 12 13 14 15 16 ∏ÏÈΛ· (¤ÙË)
100 95 ÎÔÚ›ÙÛÈ· 90 85 80 75 70 65 60 55 50 3 4 5 6
πÙ·Ï›· ∏¶∞
¶ÂÚ›ÌÂÙÚÔ˜ ª¤Û˘ (cm)
∫Ú‹ÙË πÙ·Ï›· ∏¶∞ ∫‡ÚÔ˜
·ÁfiÚÈ·
¶ÂÚ›ÌÂÙÚÔ˜ ª¤Û˘ (cm)
100 95 90 85 80 75 70 65 60 55 50
√ÏÏ·Ó‰›· ∫Ú‹ÙË ∞˘ÛÙÚ·Ï›· ∞˘ÛÙÚ·Ï›· ∫‡ÚÔ˜ ∫·Ó·‰¿˜ ª. µÚÂÙ·Ó›· ª. µÚÂÙ·Ó›·
7
8 9 10 11 12 13 14 15 16 ∏ÏÈΛ· (¤ÙË)
∂ÈÎfiÓ· 4. ™¯ËÌ·ÙÈ΋ Û‡ÁÎÚÈÛË Î·Ì˘ÏÒÓ 90˘ ÂηÙÔÛÙÈ·›·˜ ı¤Û˘ ‹/Î·È +2SD Ù˘ ÂÚÈ̤ÙÚÔ˘ ̤Û˘ ·È‰ÈÒÓ ‰È·ÊfiÚˆÓ ÌÂÏÂÙÒÓ.
(2), ÙÔ ÔÛÔÛÙfi ÙˆÓ ·¯‡Û·ÚÎˆÓ ·È‰ÈÒÓ ‹Ù·Ó 9,9%. ∏ ‰È·ÊÔÚ¿ ·˘Ù‹ ÔÊ›ÏÂÙ·È Î·Ù¿ ·ÚÈÔ ÏfiÁÔ ÛÙËÓ Î·Ù·ÓÔÌ‹ ÙÔ˘ Ï›Ô˘˜ ÛÙÔ ÛÒÌ· (ÎÂÓÙÚÈο ‹ ÂÚÈÊÂÚÂȷο) Î·È ÛÙÔ fiÙÈ Ù· fiÚÈ· ÙÔ˘ IOTF ‰ÂÓ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ·È‰È¿ ·fi ÙËÓ ∂ÏÏ¿‰· Î·È ÙËÓ ∫Ú‹ÙË. £· Ú¤ÂÈ, ÂÔ̤ӈ˜, ÛÙȘ ÌÂϤÙ˜ Ô˘ ·ÊÔÚÔ‡Ó ÙË ÛˆÌ·ÙÈ΋ ·Ó¿Ù˘ÍË ÙˆÓ ·È‰ÈÒÓ, ÙË ÌÂÙ·‚ÔÏ‹ ÙˆÓ ÛˆÌ·ÙÔÌÂÙÚ‹ÛÂÒÓ ÙÔ˘˜ ·ÏÏ¿ Î·È ÙÔÓ ˘ÔÏÔÁÈÛÌfi ∂£ Î·È ÙËÓ Î·Ù·Û΢‹ Î·Ì˘ÏÒÓ ·Ó¿Ù˘Í˘, Ó· Ï·Ì‚¿ÓÔÓÙ·È ˘fi„Ë ÎÔÈÓˆÓÈÎÔ›, ÔÏÈÙÈÛÌÈÎÔ›, ÂÚÈ‚·ÏÏÔÓÙÈÎÔ› Î·È ‚ÈÔÏÔÁÈÎÔ› ·Ú¿ÁÔÓÙ˜ (1,36). ∞fi ÙË Û‡ÁÎÚÈÛË Ù˘ ¶ª ÙˆÓ ·È‰ÈÒÓ Ù˘ ∫Ú‹Ù˘ Ì ·È‰È¿ ¿ÏÏˆÓ ¯ˆÚÒÓ Î·È ·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ô Î·ıÔÚÈÛÌfi˜ ÙˆÓ ËÏÈÎÈ·ÎÒÓ ÔÌ¿‰ˆÓ ‰È¤ÊÂÚ ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ, ‰È·ÈÛÙÒıËΠfiÙÈ Ù· ·È‰È¿ Ù˘ ∫Ú‹Ù˘ ¤¯Ô˘Ó ÌÂÁ·Ï‡ÙÂÚË ¶ª Û ۇÁÎÚÈÛË Ì ·È‰È¿ ¿ÏÏˆÓ ¯ˆÚÒÓ, Ì ÌÔÓ·‰È΋ ÂÍ·›ÚÂÛË ÂΛӷ Ù˘ πÙ·Ï›·˜. ∞˘Ùfi ÙÂÎÌËÚÈÒÓÂÙ·È Î·È ·fi ÙÔ ˘„ËÏfi ÔÛÔÛÙfi ÙˆÓ ˘¤Ú‚·ÚˆÓ Î·È ·¯‡Û·ÚÎˆÓ ·È‰ÈÒÓ Ù˘ ∫Ú‹Ù˘ Ô˘ Ì ‚¿ÛË ÙÔÓ ¢ª™ (fiÚÈ· IOTF) ·Ó¤Ú¯ÂÙ·È Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÛÙÔ 33,1% (19). ™ÙËÓ πÙ·Ï›·, ·ÓÙ›ÛÙÔȯ·, ÙÔ ÔÛÔÛÙfi ˘¤Ú‚·ÚˆÓ Î·È ·¯‡Û·ÚÎˆÓ ·È‰ÈÒÓ ‚Ú¤ıËΠ˘„ËÏfiÙÂÚÔ, ÊÙ¿ÓÔÓÙ·˜ ÙÔ 36%, ÂÓÒ ·ÎÔÏÔ˘ıÔ‡Ó Ô ∫·Ó·‰¿˜ Ì 30%, Ë πÛ·Ó›· Ì 27%, ÔÈ ∏¶∞ Ì 25,6% (ÙÔ 198894) Î·È Ë ª. µÚÂÙ·Ó›· Ì 20% (2). ¢˘ÛÙ˘¯Ò˜, Ë ¤ÏÏÂÈ„Ë ‰ËÌÔÛÈÂ˘Ì¤ÓˆÓ ‰Â‰ÔÌ¤ÓˆÓ ∂£ Ù˘ ¶ª ·È‰ÈÒÓ Î·È ÂÊ‹‚ˆÓ ·fi ¿ÏϘ ÂÚÈÔ¯¤˜ Ù˘ ∂ÏÏ¿‰·˜, ηıÈÛÙÔ‡Ó ·‰‡Ó·ÙË ÙË Û‡ÁÎÚÈÛË Ì ·È‰È¿ ¿ÏÏˆÓ ÂÚÈÔ¯ÒÓ. ∂ÈϤÔÓ, ÏfiÁˆ ¤Í·ÚÛ˘ Ù˘ ·¯˘Û·ÚΛ·˜ ηٿ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, ‰ÂÓ ‰‡Ó·Ù·È Ó· ÂÏÂÁ¯ı› Ë ÏËı˘ÛÌȷ΋ Ù¿ÛË (secular trend) ÙÔ˘ ·È‰ÈÎÔ‡ ÏËı˘ÛÌÔ‡ Û ۯ¤ÛË Ì ÙËÓ ¶ª. °È’ ·˘Ùfi Ô ˘ÔÏÔÁÈÛÌfi˜ ∂£ Ù˘ ¶ª ·È‰ÈÒÓ Î·È ÂÊ‹‚ˆÓ Ù˘ ∫Ú‹Ù˘, ¤¯ÂÈ È‰È·›ÙÂÚË ÛÔ˘‰·ÈfiÙËÙ·, ÒÛÙ ÌÂÏÏÔÓÙÈο Ó· ˘¿ÚÍÂÈ Ì¤ÙÚÔ Û‡ÁÎÚÈÛ˘ ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô ‰È·¯ÚÔÓÈÎÒÓ ·ÏÏ·ÁÒÓ. Paediatriki 2007;70:300-307
°ÂÓÈο, Â›Ó·È ·Ó·Áη›· Ë ‰ÈÂÍ·ÁˆÁ‹ ÌÂϤÙ˘ Û ÂıÓÈÎfi Â›Â‰Ô Ì ÙË Ï‹„Ë ·ÓÙÈÚÔÛˆÂ˘ÙÈÎÔ‡ ÂıÓÈÎÔ‡ ‰Â›ÁÌ·ÙÔ˜ ·È‰ÈÒÓ fiÏˆÓ ÙˆÓ ËÏÈÎÈÒÓ, ÚÔÎÂÈ̤ÓÔ˘ Ó· ˘ÔÏÔÁÈÛıÔ‡Ó Î·È Ó· ‰ËÌÈÔ˘ÚÁËıÔ‡Ó ∂£ Î·È Î·Ì‡Ï˜ ¶ª. ¶·Ú¿ÏÏËÏ·, ÂÎÙfi˜ ·fi ÙËÓ ÂÎÙ›ÌËÛË ÙÔ˘ ÂȤ‰Ô˘ ˘Á›·˜, ıÚ¤„˘ Î·È ·Ó¿Ù˘Í˘, ÔÈ ∂£ Ù˘ ¶ª ÌÔÚÔ‡Ó Ó· ÂÓۈ̷وıÔ‡Ó Î·È ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ Î·Ì˘ÏÒÓ ·Ó¿Ù˘Í˘ ÙÔ˘ ‚È‚ÏÈ·Ú›Ô˘ ˘Á›·˜ ÙˆÓ ·È‰ÈÒÓ, ÒÛÙ ӷ ·ÔÙÂÏÔ‡Ó ¤Ó· ÔÏÔÎÏËڈ̤ÓÔ Î·È Û‡Á¯ÚÔÓÔ ÂÚÁ·ÏÂ›Ô ÁÈ· ÙÔÓ ¤ÏÏËÓ· ·È‰›·ÙÚÔ Î·È ÁÔÓÈfi.
XÚËÌ·ÙÔ‰fiÙËÛË ∏ ¯ÚËÌ·ÙÔ‰fiÙËÛË ÙˆÓ ¶ÚÔÁÚ·ÌÌ¿ÙˆÓ ∞ÁˆÁ‹˜ Î·È ¶ÚÔ·ÁˆÁ‹˜ Ù˘ ÀÁ›·˜ ÙˆÓ ·È‰ÈÒÓ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ ¤ÁÈÓ ·fi ÙË Friesland Hellas, Î·È ÂÎÂ›ÓˆÓ Ô˘ ·ÊÔÚÔ‡Û·Ó ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜, ·fi ÙË °ÂÓÈ΋ °Ú·ÌÌ·Ù›· ∞ıÏËÙÈÛÌÔ‡, ÙÔ ÀÔ˘ÚÁÂ›Ô ¶·È‰Â›·˜ Î·È £ÚËÛÎÂ˘Ì¿ÙˆÓ, ÙÔ ¶·È‰·ÁˆÁÈÎfi πÓÛÙÈÙÔ‡ÙÔ, ÙȘ ‰ËÌÔÙÈΤ˜ ·˘ÙÔ‰ÈÔÈ΋ÛÂȘ ÙˆÓ ¢‹ÌˆÓ ∞Á. ¡ÈÎÔÏ¿Ô˘, ƒÔ‡‚·, ÃÂÚÛÔÓ‹ÛÔ˘, ∏Ú·ÎÏ›Ԣ Î·È Ã·Ó›ˆÓ, ηıÒ˜ Î·È ÙË ¡Ô̷گȷ΋ ∞˘ÙÔ‰ÈÔ›ÎËÛË Ã·Ó›ˆÓ.
∂˘¯·ÚÈÛٛ˜ ∂˘¯·ÚÈÛÙԇ̠ıÂÚÌ¿ ÁÈ· ÙËÓ ÔÏÔÎÏ‹ÚˆÛË Ù˘ ÌÂϤÙ˘ ÙÔ˘˜ Û˘ÓÂÚÁ¿Ù˜: ÃÚ‹ÛÙÔ Ã·Ù˙‹, ∂ÈÚ‹ÓË ª¿ÚηÙ˙Ë, πˆ¿ÓÓ· ªÔÛ¯·Ó‰Ú¤·, ªÈ¯¿ÏË ∫˘ÚȷοÎË, ™ÔÊ›· ºÏÔ˘Ú‹, ª·Ú›· ªÈÙÛÒÚË, πˆ¿ÓÓ· ∞ÔÛÙÔÏ¿ÎË, ºÚfiÛˆ ªÂÚ‚·Ó¿ÎË, Caroline Codrington, ∞ϛӷ ¶··‰¿ÎË, ∫·ÙÂÚ›Ó· ™·ÚÚ‹, ª˘ÚˆÓ›· §·ÓÙ˙Ô˘Ú¿ÎË Î·È ·fi ÙËÓ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ °ÂÓÈÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ ÷ӛˆÓ ÙÔ˘˜ ¢ËÌ‹ÙÚË ∞ı·Ó·ÛfiÔ˘ÏÔ Î·È ∂˘·ÁÁÂÏ›· ª·ÏˆÌÂÓ¿ÎË. ∂›Û˘, ·ÔÙÂÏÂÛÌ·ÙÈο Û˘Ó¤‚·Ï·Ó ÙÔ π·ÙÚÔÎÔÈÓˆÓÈÎfi ∫¤ÓÙÚÔ Î·È Ë ¢È‡ı˘ÓÛË ¶ÚˆÙÔ‚¿ıÌÈ·˜ ∂η›‰Â˘Û˘ ÙÔ˘ ¡ÔÌÔ‡ ÷ӛˆÓ.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Cole TJ. The secular trend in human physical growth: a biological view. Econ Hum Biol 2003;1:161-168. 2. Lobstein T, Baur L, Uauy R; IASO International Obesity Taskforce. Obesity in children and young people: a crisis in public health. Obes Rev 2004;1 (Suppl 5):4-104.
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·307
307
∂ηÙÔÛÙÈ·›Â˜ ı¤ÛÂȘ ÂÚÈ̤ÙÚÔ˘ ̤Û˘ ·È‰ÈÒÓ
3. Savva SC, Tornaritis M, Savva ME, Kourides Y, Panagi A, Silikiotou N, et al. Waist circumference and waist-toheight ratio are better predictors of cardiovascular disease risk factors in children than body mass index. Int J Obes Relat Metab Disord 2000;24:1453-1458. 4. Maffeis C, Pietrobelli A, Grezzani A, Provera S, Tato L. Waist circumference and cardiovascular risk factors in prepubertal children. Obes Res 2001;9:179-187. 5. Mamalakis G, Kafatos A, Manios Y, Kalogeropoulos N, Andrikopoulos N. Abdominal vs buttock adipose fat: relationships with children's serum lipid levels. Eur J Clin Nutr 2002; 56:1081-1086. 6. Hirschler V, Aranda C, Calcagno Mde L, Maccalini G, Jadzinsky M. Can waist circumference identify children with the metabolic syndrome? Arch Pediatr Adolesc Med 2005;159:740-744. 7. Cruz M, Goran M. The metabolic syndrome in children and adolescents. Curr Diab Rep 2004;453-462. 8. Jessup A, Harrell J. The Metabolic Syndrome: Look for It in Children and Adolescents, Too! Clin Diabetes 2005;23: 26-32. 9. Duncan GE, Li SM, Zhou XH. Prevalence and trends of a metabolic syndrome phenotype among U.S. adolescents, 1999-2000. Diabetes Care 2004;27:2438-2443. 10. Grundy S, Becker D, Clark LT, Cooper RS, Denke MA, Howard J, et al. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) Final Report. Circulation 2002;106:3143-3420. 11. Moreno LA, Pineda I, Rodriguez G, Fleta J, Sarria A, Bueno M. Waist circumference for the screening of the metabolic syndrome in children. Acta Paediatr 2002;91: 1307-1312. 12. ∫·Ê¿ÙÔ˜ ∞, ª·ÓÈfi˜ °, ÷Ù˙‹˜ Ã, ªÔÛ¯·Ó‰Ú¤· π, ª·ÏˆÌÂÓ¿ÎË ∂, ∞ı·Ó·ÛfiÔ˘ÏÔ˜ ¢, et al. ∞ÍÈÔÏfiÁËÛË ÚÔÁÚ¿ÌÌ·ÙÔ˜ “∞ÁˆÁ‹˜ ÀÁ›·˜” ÌÂÙ¿ ·fi ÙÚ›· ¯ÚfiÓÈ· ÂÎ·È‰Â˘ÙÈ΋˜ ·Ú¤Ì‚·Û˘ ÛÙ· ‰ËÌÔÙÈο Û¯ÔÏ›· Ù˘ ∫Ú‹Ù˘. ¶·È‰È·ÙÚÈ΋ 1998;61:483-497. 13. Manios Y, Moschandreas J, Hatzis C, Kafatos A. Evaluation of a health and nutrition education program in primary school children of Crete over a three-year period. Prev Med 1999;28:149-159. 14. Manios Y, Moschandreas J, Hatzis C, Kafatos A. Health and nutrition education in primary schools of Crete: changes in chronic disease risk factors following a 6-year intervention program. Br J Nutr 2002;88:315-324. 15. Kafatos A, Codrington CA, Linardakis M. Obesity in childhood: The Greek experience. World Rev Nutr Diet 2005;94:27-35. 16. Moschandreas JA, Kafatos A. Calcium intake in relation to diet and health indicators in Cretan primary and high school pupils, Greece. Int J Vitam Nutr Res 2002;72: 264-277. 17. ¶·È‰·ÁˆÁÈÎfi πÓÛÙÈÙÔ‡ÙÔ - ŒÚÁÔ ™∂¶¶∂, “ ŒÎıÂÛË ¶·ÚÔ˘Û›·Û˘ ∆ˆÓ ∞ÔÙÂÏÂÛÌ¿ÙˆÓ ∆ˆÓ ¶ÂÈÚ·Ì·ÙÈÎÒÓ ¶ÚÔÁÚ·ÌÌ¿ÙˆÓ”, ∞ı‹Ó·, ∑¿ÂÈÔ ª¤Á·ÚÔ, 7-9 ºÂ‚ 2000. 18. ªÔÛ¯·Ó‰Ú¤· I, ÷Ù˙‹˜ X, ª·ÌÌ¿˜ I, ªÂÚÙÛÈ¿˜ °, §ÈÓ·Ú‰¿Î˘ ª, ∫˘Úȷο΢ ª, et al. ¢Â›ÎÙ˜ ·¯˘Û·ÚΛ·˜ Î·È ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Û ·È‰È¿ ·ÁÚÔÙÈ΋˜ ÔÚÂÈÓ‹˜ ÂÚÈÔ¯‹˜ Ù˘ ∫Ú‹Ù˘. ¶·È‰È·ÙÚÈ΋ 2003;66:264-277. 19. §ÈÓ·Ú‰¿Î˘ ª. ™˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ÌÂÙ·‚ÔÏÈÎÔ‡ Û˘Ó-
20.
21.
22.
23.
24.
25.
26.
27.
28.
29. 30.
31.
32.
33. 34.
35.
36.
‰ÚfiÌÔ˘ Û ·È‰ÈÎfi, ÂÊË‚ÈÎfi Î·È ÂÓ‹ÏÈÎÔ ÏËı˘ÛÌfi Ù˘ ∫Ú‹Ù˘ Û ۯ¤ÛË Ì ÙË ‰È·ÙÚÔÊ‹ ÙÔ˘˜. [ªÂÙ·Ù˘¯È·Î‹ ÂÚÁ·Û›·]. ∏Ú¿ÎÏÂÈÔ: ¶·ÓÂÈÛÙ‹ÌÈÔ ∫Ú‹Ù˘; 2005, Webpage: http//:mph.med.uoc.gr/ dissertation_catalog.htms ∫·Ê¿ÙÔ˜ ∞, ÷Ù˙‹˜ Ã, §ÈÓ·Ú‰¿Î˘ ª, ∞ı·Ó·ÛfiÔ˘ÏÔ˜ ¢, §ÈÔÓ‹˜ Ã, ª·ÏˆÌÂÓ¿ÎË ∂, et al. ∞ıËÚÔÁfiÓÔÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Û ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ ÙÔ˘ ÓÔÌÔ‡ ÷ӛˆÓ. ¶·È‰È·ÙÚÈ΋ 2006;70:97-106. §ÈÓ·Ú‰¿Î˘ ª, ªÔÛ¯·Ó‰Ú¤· I, ∫·Ê¿ÙÔ˜ ∞. ∫·Ì‡Ï˜ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘ ·È‰ÈÒÓ ‚ÚÂÊÈ΋˜ Î·È ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ Ù˘ ∫Ú‹Ù˘ Ô˘ ÚԤ΢„·Ó ·fi ‰È·¯ÚÔÓÈ΋ ·Ú·ÎÔÏÔ‡ıËÛ‹ ÙÔ˘˜. ¶·È‰È·ÙÚÈ΋ 2000;63:391-407. Savva SC, Kourides Y, Tornaritis M, Epiphaniou-Savva M, Tafouna P, Kafatos A. Reference growth curves for cypriot children 6 to 17 years of age. Obes Res 2001;9:754-762. Fredriks AM, van Buuren S, Fekkes M, Verloove-Vanhorick SP, Wit JM. Are age references for waist circumference, hip circumference and waist-hip ratio in Dutch children useful in clinical practice? Eur J Pediatr 2005;164: 216-222. McCarthy HD, Jarrett KV, Crawley HF. The development of waist circumference percentiles in British children aged 5.0-16.9 y. Eur J Clin Nutr 2001;55:902-907. Moreno LA, Fleta J, Mur L, Rodriquez G, Sarria A, Bueno M. Waist circumference values in Spanish children--gender related differences. Eur J Clin Nutr 1999;53:429-433. Eisenmann JC. Waist circumference percentiles for 7- to 15-year-old Australian children. Acta Paediatr 2005;94: 1182-1185. Fernandez JR, Redden DT, Pietrobelli A, Allison DB. Waist circumference percentiles in nationally representative samples of African-American, European-American, and Mexican-American children and adolescents. J Pediatr 2004;145:439-444. Katzmarzyk PT. Waist circumference percentiles for Canadian youth 11-18y of age. Eur J Clin Nutr 2004;58: 1011-1015. Zannolli R, Morgese G. Waist percentiles: a simple test for atherogenic disease? Acta Paediatr 1996;85:1368-1369. Kuczmarski RJ, Ogden CL, Guo SS, Grummer-Strawn LM, Flegal KM, Mei Z, et al. 2000 CDC Growth Charts for the United States: methods and development. Vital Health Stat 2002;11:1-190. Cameron N. British growth charts for height and weight with recommendations concerning their use in auxological assessment. Ann Hum Biol 2002;29:1-10. Eisenmann JC. Secular trends in variables associated with the metabolic syndrome of North American children and adolescents: a review and synthesis. Am J Hum Biol 2003;15: 786-794. Moran O, Phillip M. Leptin: obesity, diabetes and other peripheral effects--a review. Pediatr Diabetes 2003;4:101-109. Mendoza-Nunez VM, Garcia-Sanchez A, Sanchez-Rodriguez M, Galvan-Duarte RE, Fonseca-Yerena ME. Overweight, waist circumference, age, gender, and insulin resistance as risk factors for hyperleptinemia. Obes Res 2002;10: 253-259. Johnson MS, Huang TT, Figueroa-Colon R, Dwyer JH, Goran MI. Influence of leptin on changes in body fat during growth in African American and white children. Obes Res 2001;9:593-598. ∫·Ê¿ÙÔ˜ ∞. ∫·Ì‡Ï˜ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘ ·È‰ÈÒÓ Ù˘ ¯ÒÚ·˜ Ì·˜. ¶·È‰È·ÙÚÈ΋ 2007;70:70-74. ¶·È‰È·ÙÚÈ΋ 2007;70:300-307
Pediatri July-Aug 07
09-07-07
308
17:08
™ÂÏ›‰·308
∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞
ORIGINAL ARTICLE
√ÚÌfiÓ˜ Ô˘ Ú˘ıÌ›˙Ô˘Ó ÙËÓ fiÚÂÍË Î·È ÙÔÓ ÌÂÙ·‚ÔÏÈÛÌfi Û ÚfiˆÚ· ÓÂÔÁÓ¿ 1 ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·Ó/Ì›Ô˘ ∞ıËÓÒÓ, 2 µÈÔ¯ËÌÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” AÏÏËÏÔÁÚ·Ê›·: ∆¿ÓÈ· ™È·¯·Ó›‰Ô˘ neonat5@paidon-agiasofia.gr ªÔÓ¿‰· ¡ÂÔÁÓÒÓ, ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·Ó/Ì›Ô˘ ∞ıËÓÒÓ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” £Ë‚ÒÓ & §Â‚·‰Â›·˜ ∆.∫. 115 27, ∞ı‹Ó·
∆. ™È·¯·Ó›‰Ô˘1, π. ¶··ÛˆÙËÚ›Ô˘2, ª. µÔ˘Ó¿ÙÛÔ˘2, ∂. ªËÏ›ÙÛË2, ∂. ª¿Ó‰˘Ï·1 ¶ÂÚ›ÏË„Ë ∂ÈÛ·ÁˆÁ‹: ∏ ·Ó¿Ù˘ÍË Î·È ıÚ¤„Ë Î·Ù¿ ÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ÌÂÙ¤ÂÈÙ· ˘Á›· ‹ ÂÌÊ¿ÓÈÛË ÓÔÛËÌ¿ÙˆÓ ÊıÔÚ¿˜. ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ·˘Ù‹˜ ‹Ù·Ó Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜, Û ÚfiˆÚ· ÓÂÔÁÓ¿, ÙˆÓ ÂȤ‰ˆÓ ÔÚÌÔÓÒÓ Ô˘ ÌÂÙ¤¯Ô˘Ó ÛÙËÓ ÚfiÛÏË„Ë ÙÚÔÊ‹˜ Î·È ÙÔÓ ÌÂÙ·‚ÔÏÈÛÌfi, ·ÏÏ¿ Î·È Ë ·Ó·˙‹ÙËÛË Ù˘ ÌÂٷ͇ ÙÔ˘˜ Û¯¤Û˘, ηıÒ˜ Î·È Ù˘ Û˘Û¯¤ÙÈÛ‹˜ ÙÔ˘˜ Ì ÙȘ ۈ̷ÙÔÌÂÙÚÈΤ˜ ·Ú·Ì¤ÙÚÔ˘˜ ÙˆÓ ·È‰ÈÒÓ Î·È ÙÔÓ Ú˘ıÌfi ·‡ÍËÛ˘ ÙÔ˘ ۈ̷ÙÈÎÔ‡ ‚¿ÚÔ˘˜. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ∆· ›‰· ÔÏÈÎÔ‡ ÂÙȉ›Ô˘ ÀÀ (ƒÀÀ), ƒÀÀ3-36, ÁÎÚÂÏ›Ó˘, ÈÓÛÔ˘Ï›Ó˘, ÏÂÙ›Ó˘ Î·È ·‰ÈÔÓÂÎÙ›Ó˘ ÚÔÛ‰ÈÔÚ›ÛÙËÎ·Ó ÛÙÔÓ ÔÚfi 62 ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ, ËÏÈΛ·˜ ·ËÛ˘ 32,0±2,1 ‚‰ÔÌ¿‰ˆÓ, Û ËÏÈΛ· 40±14 Ë̤Ú˜ ˙ˆ‹˜, ηıÒ˜ Î·È 15 ÙÂÏÂÈfiÌËÓˆÓ ÓÂÔÁÓÒÓ ·Ó¿ÏÔÁ˘ ËÏÈΛ·˜ Î·È Ê‡ÏÔ˘. ŸÏ· Ù· ÓÂÔÁÓ¿ ÛÈÙ›ÛÙËÎ·Ó Ì ÙÚÔÔÔÈË̤ÓÔ Á¿Ï·. ∞ÔÙÂϤÛÌ·Ù·: ∆· ›‰· ƒÀÀ, ƒÀÀ3-36 Î·È ÁÎÚÂÏ›Ó˘ ‹Ù·Ó ˘„ËÏfiÙÂÚ· ÛÙ· ÚfiˆÚ· ·fi Ù· ÙÂÏÂÈfiÌËÓ· (p<0,001 ÁÈ· fiϘ ÙȘ ‰È·ÊÔÚ¤˜), Ù˘ ·‰ÈÔÓÂÎÙ›Ó˘ ‹Ù·Ó ¯·ÌËÏfiÙÂÚ· (p<0,01), ÂÓÒ Ù· ›‰· ÏÂÙ›Ó˘ Î·È ÈÓÛÔ˘Ï›Ó˘ ‰ÂÓ ‰È¤ÊÂÚ·Ó. øÛÙfiÛÔ, ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿, ÌÂÙ¿ ·fi ‰ÈfiÚıˆÛË ÁÈ· ÙÔ ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜, Ù· ›‰· Ù˘ ·‰ÈÔÓÂÎÙ›Ó˘ ‹Ù·Ó ˘„ËÏfiÙÂÚ· (p=0,02) Î·È Ù˘ ÈÓÛÔ˘Ï›Ó˘ ¤ÙÂÈÓ·Ó Ó· Â›Ó·È ˘„ËÏfiÙÂÚ· (p=0,07) ·fi ·˘Ù¿ ÙˆÓ ÙÂÏÂÈfiÌËÓˆÓ. ∆· ›‰· ƒÀÀ Î·È ƒÀÀ3-36 ÛÙÔÓ ÔÚfi ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ Û˘Û¯ÂÙ›ÛıËÎ·Ó ıÂÙÈο Ì ٷ ›‰· ÁÎÚÂÏ›Ó˘ (r=0,33, p=0,009 Î·È r=0,30, p=0,01, ·ÓÙ›ÛÙÔȯ·) Î·È ÈÓÛÔ˘Ï›Ó˘ (r=0,37, p=0,003 Î·È r=0,38, p=0,003, ·ÓÙ›ÛÙÔȯ·). ¢È·ÈÛÙÒıËΠ·ÚÓËÙÈ΋ Û˘Û¯¤ÙÈÛË ÙÔ˘ ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜ ÙˆÓ ÚÔÒÚˆÓ Ì ÙÔ ƒÀÀ (r=-0,44, p<0,001), ÙÔ ƒÀÀ3-36 (r=-0,33, p=0,01) Î·È ÙËÓ ÈÓÛÔ˘Ï›ÓË (r=-0,43, p<0,01), ·ÏÏ¿ ıÂÙÈ΋ Ì ÙËÓ ·‰ÈÔÓÂÎÙ›ÓË (r=0,28, p=0,02). ∆· ›‰· ÏÂÙ›Ó˘ Û˘Û¯ÂÙ›ÛÙËÎ·Ó ·ÚÓËÙÈο (r=-0,27, p<0,05) Î·È Ù˘ ·‰ÈÔÓÂÎÙ›Ó˘ ıÂÙÈο (r=0,26, p<0,05) Ì ÙÔÓ Ú˘ıÌfi ·‡ÍËÛ˘ ‚¿ÚÔ˘˜ ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ. ªÂ ÙË Ì¤ıÔ‰Ô Ù˘ ÔÏÏ·Ï‹˜ ÂÍ¿ÚÙËÛ˘ ‰È·ÈÛÙÒıËΠfiÙÈ Ë ‰È·ÙÚÔÊ‹ Ì Á¿Ï· Ô˘ ÂÚÈ›¯Â LCPUFAs ÂËÚ¤·Û ıÂÙÈο Ù· ›‰· Ù˘ ·‰ÈÔÓÂÎÙ›Ó˘ (‚=0,28, p=0,03). ™˘ÌÂÚ¿ÛÌ·Ù·: ™˘ÌÂÚ·›ÓÂÙ·È fiÙÈ Ù· ÚfiˆÚ· ‚Ú¤ÊË ‰ÂÓ ÌÂÈÔÓÂÎÙÔ‡Ó ˆ˜ ÚÔ˜ ÙË Û‡ÓıÂÛË/¤ÎÎÚÈÛË ÙˆÓ ÔÚÌÔÓÒÓ Ô˘ Û˘ÌÌÂÙ¤¯Ô˘Ó ÛÙËÓ ·‡ÍËÛË Î·È ÙÔÓ ÌÂÙ·‚ÔÏÈÛÌfi, ˆÛÙfiÛÔ Ô ‚ÈÔÏÔÁÈÎfi˜ ÚfiÏÔ˜ ÙˆÓ ÔÚÌÔÓÒÓ ·˘ÙÒÓ ¯ÚÂÈ¿˙ÂÙ·È ÂÚ·ÈÙ¤Úˆ ‰ÈÂÚ‡ÓËÛË.
§¤ÍÂȘ ÎÏÂȉȿ: ¶ÂÙ›‰ÈÔ ÀÀ, ÁÎÚÂÏ›ÓË, ÏÂÙ›ÓË, ·‰ÈÔÓÂÎÙ›ÓË, ÓÂÔÁÓ¿.
Hormones regulating the food intake and metabolism of preterm infants 1 First Department of Paediatrics, University of Athens 2 Biochemistry Laboratory, “Aghia Sophia” Hospital, Athens, Greece
Correspondence: Tania Siahanidou neonat5@paidon-agiasofia.gr Neonatal Unit, First Department of Paediatrics, University of Athens “Aghia Sophia” Children’s Hospital Thivon & Levadias St 115 27, Athens, Greece
Paediatriki 2007;70:308-315
T. Siahanidou1, I. Papassotiriou2, M. Vounatsou2, H. Militsi2, H. Mandyla1 Abstract Background: Growth and nutrition in the neonatal period have been linked with health and disease in later life. The aim of this study was to determine in preterm infants the circulating levels of hormones implicated in the regulation of food intake and metabolism, and to examine their interrelation and correlations with anthropometric parameters and weight gain. Methods: Serum levels of total peptide YY (PYY), PYY3-36, ghrelin, insulin, leptin and adiponectin were determined in 62 preterm infants (gestational age 32.0±2.1 weeks) at 40±14 days of life, and in 15 full term infants of a comparable postnatal age and gender. All the infants were formula fed. Results: In the preterm infants, the levels of PYY, PYY3-36 and ghrelin were significantly higher than in the full term infants (p<0.001 for all), adiponectin levels were lower (p<0.01) and there was no difference in leptin and insulin levels between the two groups. However, after correction for body weight, serum adiponectin levels were significantly higher (p=0.02) and insulin levels tended to be higher (p=0.07) in preterm than in full term infants. In the preterm infants, serum PYY and PYY3-36 levels were positively correlated with serum ghrelin (r=0.33, p=0.009 and r=0.30, p=0.01, respectively) and insulin levels (r=0.37, p=0.003 and r=0.38, p=0.003, respectively). PYY, PYY3-36 and insulin levels correlated negatively (r=-0.44, p<0.001; r=-0.33, p=0.01 and r=-0.43, p<0.01, respectively), and adiponectin levels positively
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·309
√ÚÌfiÓ˜ Ô˘ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ fiÚÂÍË Î·È ÙoÓ ÌÂÙ·‚ÔÏÈÛÌfi
309
(r=0.28, p=0.02), with the body weight, while leptin levels correlated negatively (r=-0.27, p<0.05) and adiponectin levels positively (r=0.26, p<0.05) with the growth rate. In multiple regression analysis, feeding with a formula containing LCPUFAs was an independent predictor of the serum adiponectin level (‚=0.28, p=0.03). Conclusions: Preterm infants are not defective in the synthesis/secretion of the hormones implicated in the regulation of growth and metabolism; however the physiological role of these hormones needs to be further elucidated.
Key words: Peptide YY, ghrelin, leptin, adiponectin, neonates.
∂ÈÛ·ÁˆÁ‹ ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ÓÂÔÁÓ¿ Ì ¯·ÌËÏfi ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ¤¯Ô˘Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ Ó· ÂÌÊ·Ó›ÛÔ˘Ó Î·Ú‰È·ÁÁÂȷο ÓÔÛ‹Ì·Ù· Î·È ÌÂÙ·‚ÔÏÈÎfi Û‡Ó‰ÚÔÌÔ (˘¤ÚÙ·ÛË, ˘ÂÚÏÈȉ·ÈÌ›·, ·ÓÙÔ¯‹ ÛÙËÓ ÈÓÛÔ˘Ï›ÓË Î·È Û·Î¯·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ 2) ηٿ ÙËÓ ÂÓ‹ÏÈÎÔ ˙ˆ‹ (1). ŸÌˆ˜, ˘¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ fiÙÈ Î·È Ù· ÚfiˆÚ· ÓÂÔÁÓ¿ ¤¯Ô˘Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ Ó· ÂÌÊ·Ó›ÛÔ˘Ó ÓÔÛ‹Ì·Ù· ÊıÔÚ¿˜ ·ÚÁfiÙÂÚ·, ·ÓÂÍ·Úًو˜ ·Ó ÙÔ ‚¿ÚÔ˜ ÙÔ˘˜ ηٿ ÙË Á¤ÓÓËÛË ‹Ù·Ó ¯·ÌËÏfi ‹ ηÓÔÓÈÎfi ÁÈ· ÙË ‰È¿ÚÎÂÈ· ·ËÛ˘ (2). ∂ÈϤÔÓ, Ë ‰È·ÙÚÔÊ‹, Ë ·Ó¿Ù˘ÍË Î·È Ë ıÚ¤„Ë Î·Ù¿ ÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ÌÂÙ¤ÂÈÙ· ηϋ ÂͤÏÈÍË ‹ ÙËÓ ÂÌÊ¿ÓÈÛË ÓÔÛËÌ¿ÙˆÓ ÊıÔÚ¿˜ (3-5). ∞fi Ù· ÂÙ›‰È· Ô˘ ¤¯Ô˘Ó ̤¯ÚÈ Û‹ÌÂÚ· ·Ó·ÁÓˆÚÈÛı› fiÙÈ Ú˘ıÌ›˙Ô˘Ó ÙËÓ ÚfiÛÏË„Ë ÙÚÔÊ‹˜ Î·È ÙÔ ÈÛÔ˙‡ÁÈÔ ÂÓ¤ÚÁÂÈ·˜, ÙÔ ÂÙ›‰ÈÔ ÀÀ (ƒÀÀ) ÂÎÎÚ›ÓÂÙ·È Î˘Ú›ˆ˜ ·fi ÂÓ‰ÔÎÚÈÓÈο ·ÙÙ·Ú· ÙÔ˘ ÏÂÙÔ‡ Î·È ÙÔ˘ ·¯¤Ô˜ ÂÓÙ¤ÚÔ˘ Î·È ÔÈ Î‡ÚÈÔÈ ÈÛfiÙ˘Ô› ÙÔ˘ Â›Ó·È ÙÔ ƒÀÀ1-36 Î·È ÙÔ ƒÀÀ3-36. ∏ ¯ÔÚ‹ÁËÛË ÙÔ˘ ƒÀÀ1-36 Û ÂÈÚ·Ì·Ùfi˙ˆ· ·ÛΛ ÔÚÂÍÈÔÁfiÓÔ ‰Ú¿ÛË Ì¤Ûˆ ÙˆÓ À1 ˘Ô‰Ô¯¤ˆÓ ÙÔ˘ ˘Ôı·Ï¿ÌÔ˘ Î·È ·ÓÔÚÂÍÈÔÁfiÓÔ ‰Ú¿ÛË Ì¤Ûˆ ÙˆÓ À2 ˘Ô‰Ô¯¤ˆÓ, ÂÓÒ Ë ¯ÔÚ‹ÁËÛË ÙÔ˘ ƒÀÀ3-36 ¤¯ÂÈ ÌfiÓÔÓ ·ÓÔÚÂÍÈÔÁfiÓÔ ‰Ú¿ÛË Ì¤Ûˆ ÙˆÓ À2 ˘Ô‰Ô¯¤ˆÓ Î·È ·Ó·ÛÙ¤ÏÏÂÈ ÙËÓ ·‡ÍËÛË ÙÔ˘ ۈ̷ÙÈÎÔ‡ ‚¿ÚÔ˘˜ (6,7). ∏ ÁÎÚÂÏ›ÓË ·Ú¿ÁÂÙ·È Î˘Ú›ˆ˜ ·fi ·ÙÙ·Ú· ÙÔ˘ ÛÙÔÌ¿¯Ô˘ Î·È ·ÛΛ ÔÚÂÍÈÔÁfiÓÔ ‰Ú¿ÛË Ì¤Ûˆ ‰È¤ÁÂÚÛ˘ ÙˆÓ À1 ˘Ô‰Ô¯¤ˆÓ ÙÔ˘ ˘Ôı·Ï¿ÌÔ˘. ∏ ¯ÚfiÓÈ· ¯ÔÚ‹ÁËÛ‹ Ù˘ Û ÂÈÚ·Ì·Ùfi˙ˆ· Ô‰ËÁ› Û ·‡ÍËÛË ÙÔ˘ ۈ̷ÙÈÎÔ‡ ‚¿ÚÔ˘˜ ̤ۈ ·‡ÍËÛ˘ Ù˘ ÚÔÛÏ·Ì‚·ÓfiÌÂÓ˘ ÙÚÔÊ‹˜ ·ÏÏ¿ ηÈ, ÂӉ¯Ô̤ӈ˜, ̤ۈ ÂÏ¿ÙÙˆÛ˘ Ù˘ ÔÍ›‰ˆÛ˘ ÙÔ˘ Ï›Ô˘˜ Î·È Ì›ˆÛ˘ Ù˘ ηٷӿψÛ˘ ÂÓ¤ÚÁÂÈ·˜ (8). ∏ ÏÂÙ›ÓË ·Ú¿ÁÂÙ·È ·fi ÙÔÓ ÏÈÒ‰Ë ÈÛÙfi ηÈ, ̤ۈ Ù˘ ÎÂÓÙÚÈ΋˜ ‰Ú¿Û˘ Ù˘ Û ·ÙÙ·Ú· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, ÂÚÈÔÚ›˙ÂÈ ÙËÓ ÚfiÛÏË„Ë ÙÚÔÊ‹˜ Î·È ·ÚÂÌ‚·›ÓÂÈ ÛÙÔÓ ÌÂÙ·‚ÔÏÈÛÌfi ·Ó·ÛÙ¤ÏÏÔÓÙ·˜ ÙË ÓÂÔÁÏ˘ÎÔÁ¤ÓÂÛË (9). ∆· ›‰¿ Ù˘ ÛÙÔÓ ÔÚfi Â›Ó·È ·˘ÍË̤ӷ Û ¿ÙÔÌ·
Ì ·¯˘Û·ÚΛ· Î·È ÌÂÙ·‚ÔÏÈÎfi Û‡Ó‰ÚÔÌÔ, ÏfiÁˆ ·Ó¿Ù˘Í˘ ·ÓÙÔ¯‹˜. ∏ ÈÓÛÔ˘Ï›ÓË, ÂÎÙfi˜ ·fi ÙÔÓ ÁÓˆÛÙfi Ù˘ ÚfiÏÔ ÛÙËÓ ÔÌÔÈÔÛÙ·Û›· Ù˘ ÁÏ˘Îfi˙˘, ¤¯ÂÈ ÎÂÓÙÚÈ΋ ‰Ú¿ÛË, Û˘ÓÂÚÁÈ΋ Ì ·˘Ù‹ Ù˘ ÏÂÙ›Ó˘, ÛÙË Ú‡ıÌÈÛË Ù˘ ÚfiÛÏ˄˘ ÙÚÔÊ‹˜ Î·È ÛÙÔ ÈÛÔ˙‡ÁÈÔ ÂÓ¤ÚÁÂÈ·˜ (9). ∆¤ÏÔ˜, Ë ·‰ÈÔÓÂÎÙ›ÓË ·Ú¿ÁÂÙ·È ·fi ÙÔÓ ÏÈÒ‰Ë ÈÛÙfi Î·È ·˘Í¿ÓÂÈ ÙËÓ Â˘·ÈÛıËÛ›· ÙˆÓ ÈÛÙÒÓ ÛÙËÓ ÈÓÛÔ˘Ï›ÓË, ÚÔÛٷهÔÓÙ·˜ ·fi ÙËÓ ·Ó¿Ù˘ÍË ·ÓÙÔ¯‹˜ ÛÙËÓ ÈÓÛÔ˘Ï›ÓË Î·È ·fi ÙËÓ ÂÌÊ¿ÓÈÛË ÌÂÙ·‚ÔÏÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ (10). ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ·˘Ù‹˜ ‹Ù·Ó Ó· ÚÔÛ‰ÈÔÚÈÛÙÔ‡Ó Ù· ›‰· ÔÏÈÎÔ‡ ƒÀÀ, ƒÀÀ3-36, ÁÎÚÂÏ›Ó˘, ÈÓÛÔ˘Ï›Ó˘, ÏÂÙ›Ó˘ Î·È ·‰ÈÔÓÂÎÙ›Ó˘ ÛÙÔÓ ÔÚfi ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ ÂÚ› ÙÔ Ù¤ÏÔ˜ ÙÔ˘ 1Ô˘ Ì‹Ó· ˙ˆ‹˜ ÙÔ˘˜ Î·È Ó· ·Ó·˙ËÙËı› Ë ÌÂٷ͇ ÙÔ˘˜ Û¯¤ÛË, ηıÒ˜ Î·È Ë Û˘Û¯¤ÙÈÛ‹ ÙÔ˘˜ Ì ÙȘ ۈ̷ÙÔÌÂÙÚÈΤ˜ ·Ú·Ì¤ÙÚÔ˘˜ ÙˆÓ ·È‰ÈÒÓ, ÙËÓ ÚfiÛÏË„Ë ÙÚÔÊ‹˜ Î·È ÙÔÓ Ú˘ıÌfi ·‡ÍËÛ˘ ÙÔ˘ ‚¿ÚÔ˘˜.
ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ªÂÏÂÙ‹ıËÎ·Ó 62 ÚfiˆÚ· ÓÂÔÁÓ¿ (ÎÔÚ›ÙÛÈ·/·ÁfiÚÈ· 34/28), ËÏÈΛ·˜ ·ËÛ˘ 32,0±2,1 ‚‰ÔÌ¿‰ˆÓ Î·È ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ 1542±275 g, Ô˘ ÓÔÛËχÙËÎ·Ó ÛÙË ªÔÓ¿‰· Ì·˜. ™ÙË ÌÂϤÙË ÂÚÈÂÏ‹ÊıËÛ·Ó ÓÂÔÁÓ¿ Ô˘ 1) ‰ÂÓ ÂÌÊ¿ÓÈ˙·Ó Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜, 2) ‰ÂÓ Â›¯·Ó ÛËÌ·ÓÙÈ΋ ÓÔÛËÚfiÙËÙ· (ÓÂÎÚˆÙÈ΋ ÂÓÙÂÚÔÎÔÏ›Ùȉ·, ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈ΋ ‰˘ÛÏ·Û›·, ÂÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›· ÛÙ·‰›Ô˘ >1 ηٿ Volpe) ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÓÔÛËÏ›·˜ ÙÔ˘˜, 3) ‰ÂÓ ÂÌÊ¿ÓÈÛ·Ó Ïԛ̈ÍË Î·Ù¿ ÙȘ 10 ÙÔ˘Ï¿¯ÈÛÙÔÓ ÙÂÏÂ˘Ù·›Â˜ Ë̤Ú˜ ÓÔÛËÏ›·˜ Î·È 4) ÛÈÙ›ÛÙËÎ·Ó ·ÔÎÏÂÈÛÙÈο Ì ÙÚÔÔÔÈË̤ÓÔ Á¿Ï·. ∏ ËÏÈΛ· ·ËÛ˘ ˘ÔÏÔÁ›ÛÙËΠ‚¿ÛÂÈ Ù˘ ÙÂÏÂ˘Ù·›·˜ ¤ÌÌËÓ˘ Ú‡Û˘, ÙˆÓ Â˘ÚËÌ¿ÙˆÓ ÙÔ˘ ÂÌ‚Ú˘˚ÎÔ‡ ˘ÂÚ˯ÔÁÚ·Ê‹Ì·ÙÔ˜ Î·È Ù˘ ÎÏÈÓÈ΋˜ ÂͤٷÛ˘ ÙÔ˘ ÓÂÔÁÓÔ‡. ø˜ ÏÈÔ‚·Ú‹ ÁÈ· ÙË ‰È¿ÚÎÂÈ· ·ËÛ˘ ÔÚ›ÛÙËÎ·Ó Ù· ÓÂÔÁÓ¿ Ì ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ <-2 SD ÁÈ· ÙËÓ ËÏÈΛ· ·ËÛ˘ Î·È ÙÔ Ê‡ÏÔ. ∂Ù¿ ·fi Ù· 62 ÚfiˆÚ· ‹Ù·Ó ÏÈÔ‚·Ú‹ (11,3%). ŸÏ· Ù· ÓÂÔÁÓ¿ ÛÈÙ›ÛÙËÎ·Ó Ì ÙÔ ›‰ÈÔ ÙÚÔÔÔÈË̤ÓÔ Á¿Ï· (S-26, Wyeth Nutritional, Ireland). ∏ ÂÙ·ÈÚ›· ·Ú·ÁˆÁ‹˜ ÂÈÛ‹Á·Á ÛÙËÓ ·ÁÔÚ¿ Á¿Ï· Ì ÙËÓ ›‰È· ÂˆÓ˘Ì›·, ÙÔ ÔÔ›Ô ÂÚÈ›¯Â ÔÏ˘·ÎfiÚÂÛÙ· ÏÈ·Ú¿ Ôͤ· Ôχ Ì·ÎÚ¿˜ ·Ï‡ÛÔ˘ (LCPUFAs), ·Ú·¯È‰ÔÓÈÎfi (97 mg/100g ÛÎfiÓ˘ Á¿Ï·ÎÙÔ˜) Î·È ÂÈÎÔÛȉ˘ÔÂÍ·ÓÔ˚Îfi ¶·È‰È·ÙÚÈ΋ 2007;70:308-315
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·310
310
∆. ™È·¯·Ó›‰Ô˘ Î·È Û˘Ó.
(56 mg/100 g ÛÎfiÓ˘ Á¿Ï·ÎÙÔ˜), fï˜ ‰ÂÓ ‰È¤ÊÂÚ ˆ˜ ÚÔ˜ ÙË ÏÔÈ‹ Û‡ÓıÂÛ‹ ÙÔ˘ ·fi ÙÔ ÚÔËÁÔ‡ÌÂÓÔ Á¿Ï·, Ô‡Ù ˆ˜ ÚÔ˜ ÙËÓ ÂÚÈÂÎÙÈÎfiÙËÙ¿ ÙÔ˘ Û ıÂÚÌ›‰Â˜ (67 Kcal/100 ml Á¿Ï·ÎÙÔ˜). ∂ÓÓ¤· ·fi Ù· 62 ÚfiˆÚ· ÛÈÙ›ÛÙËÎ·Ó Ì ÙÔ Á¿Ï· Ô˘ ‹Ù·Ó ÂÌÏÔ˘ÙÈṲ̂ÓÔ Ì LCPUFAs. ∏ ËÏÈΛ· ·ËÛ˘, ÙÔ Ê‡ÏÔ Î·È Ù· ۈ̷ÙÔÌÂÙÚÈο ηٿ ÙË Á¤ÓÓËÛË ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ Ô˘ ÛÈÙ›ÛÙËÎ·Ó Ì Á¿Ï· Ô˘ ÂÚÈ›¯Â LCPUFAs ‰ÂÓ ‰È¤ÊÂÚ·Ó ·fi Ù· ·ÓÙ›ÛÙÔȯ· ÙˆÓ ˘ÔÏÔ›ˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ. ∆· ÓÂÔÁÓ¿ ÛÈÙ›ÛÙËÎ·Ó ·Ú¯Èο Ì ÚÈÓÔÁ·ÛÙÚÈÎfi ηıÂÙ‹Ú· Î·È ÛÙË Û˘Ó¤¯ÂÈ· Ì ı‹Ï·ÛÙÚÔ Î¿ı 3 ÒÚ˜. ŒÁÈÓ ηٷÁÚ·Ê‹ Ù˘ ÚÔÛÏ·Ì‚·ÓfiÌÂÓ˘ ÔÛfiÙËÙ·˜ Á¿Ï·ÙÔ˜ Î·È ˘ÔÏÔÁ›ÛÙËÎÂ Ë ÚfiÛÏË„Ë ıÂÚÌ›‰ˆÓ/∫g*/24ˆÚÔ Î·Ù¿ ÙËÓ ÙÂÏÂ˘Ù·›· ‚‰ÔÌ¿‰· ÚÈÓ ÙËÓ ¤ÍÔ‰Ô. ∆· ÓÂÔÁÓ¿ ˙˘Á›˙ÔÓÙ·Ó Î·ıËÌÂÚÈÓ¿ ÛÙËÓ ›‰È· ËÏÂÎÙÚÔÓÈ΋ ˙˘Á·ÚÈ¿. ∆Ô Ì‹ÎÔ˜ ÛÒÌ·ÙÔ˜ Î·È Ë ÂÚ›ÌÂÙÚÔ˜ ÎÂÊ·Ï‹˜ ÙÔ˘˜ ÌÂÙÚÈfiÙ·Ó ·Ó¿ ‚‰ÔÌ¿‰· ·fi ÙÔÓ ›‰ÈÔ ÂÚ¢ÓËÙ‹. ∂ÎÙÈÌ‹ıËÎÂ Ë ·fiÎÏÈÛË ÙÔ˘ ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜ ·fi ÙÔ Ì¤ÛÔ Ê˘ÛÈÔÏÔÁÈÎfi ÁÈ· ÙËÓ ËÏÈΛ· Î·È ÙÔ Ê‡ÏÔ (z-score) Ì ηٿÏÏËÏÔ ÚfiÁÚ·ÌÌ· (http://www.biomedcentral.com). YÔÏÔÁ›ÛÙËÎÂ Ô Ú˘ıÌfi˜ ·‡ÍËÛ˘ ÙÔ˘ ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜ (g/Kg*/24ˆÚÔ), ηıÒ˜ Î·È Ô ‰Â›ÎÙ˘ Ì¿˙·˜ ÛÒÌ·ÙÔ˜ (BMI). ∫·Ù¿ ÙËÓ Ë̤ڷ Ù˘ ÂÍfi‰Ô˘ ÙÔ˘˜ ·fi ÙÔ ÙÌ‹Ì· ÓÂÔÁÓÒÓ, Ù· ÓÂÔÁÓ¿ ˘Ô‚Ï‹ıËÎ·Ó Û ·ÈÌÔÏË„›· ÁÈ· ÙÔÓ Û˘Ó‹ıË ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô Î·È ÂÈϤÔÓ ÁÈ· ÙË Ì¤ÙÚËÛË ÙˆÓ ÂȤ‰ˆÓ ÔÏÈÎÔ‡ ƒÀÀ, ƒÀÀ3-36, ÁÎÚÂÏ›Ó˘, ÈÓÛÔ˘Ï›Ó˘, ÏÂÙ›Ó˘ Î·È ·‰ÈÔÓÂÎÙ›Ó˘ ÛÙÔÓ ÔÚfi. ∏ ̤ÛË ËÏÈΛ· ÙÔ˘˜ ηٿ ÙËÓ ·ÈÌÔÏË„›· ‹Ù·Ó 40±14 Ë̤Ú˜ ˙ˆ‹˜. ∏ ̤ÙÚËÛË ÙˆÓ ÂȤ‰ˆÓ ÔÏÈÎÔ‡ ƒÀÀ Î·È ƒÀÀ3-36 ¤ÁÈÓ Ì RIA (Linco Research), fiˆ˜ Î·È Ù˘ ÁÎÚÂÏ›Ó˘ (Phoenix Pharmaceuticals) Î·È Ù˘ ·‰ÈÔÓÂÎÙ›Ó˘ (Linco Research). H ÏÂÙ›ÓË ÚÔÛ‰ÈÔÚ›ÛÙËΠ̠ELISA (Diagnostic Systems Laboratories, USA). ∏ ÂÏ¿¯ÈÛÙË ·ÓȯÓ‡ÛÈÌË Û˘ÁΤÓÙÚˆÛË Î·È Ô ÂÓ‰Ô- Î·È ‰È·- ·Ó·Ï˘ÙÈÎfi˜ Û˘ÓÙÂÏÂÛÙ‹˜ ÌÂÙ·‚ÏËÙfiÙËÙ·˜ ÙˆÓ ¯ÚËÛÈÌÔÔÈËı¤ÓÙˆÓ ÂÌÔÚÈÎÒÓ Û˘Û΢·ÛÈÒÓ (kits) ‹Ù·Ó 10 pg/ml, 4,5% Î·È 6,5% ·ÓÙ›ÛÙÔȯ· ÁÈ· ÙÔ ÔÏÈÎfi PYY, 20 pg/ml, 7% Î·È 6,4% ·ÓÙ›ÛÙÔȯ· ÁÈ· ÙÔ PYY3-36, 12 pg/ml, 5,5% Î·È 2,1% ·ÓÙ›ÛÙÔȯ· ÁÈ· ÙË ÁÎÚÂÏ›ÓË, 1 Ìg/ml, 7% Î·È 6% ·ÓÙ›ÛÙÔȯ· ÁÈ· ÙËÓ ·‰ÈÔÓÂÎÙ›ÓË Î·È 0,05 Ìg/L, 3,2% Î·È 4% ·ÓÙ›ÛÙÔȯ· ÁÈ· ÙË ÏÂÙ›ÓË. ∏ ̤ÙÚËÛË Ù˘ ÈÓÛÔ˘Ï›Ó˘ ¤ÁÈÓ Ì ÙË Ì¤ıÔ‰Ô Ù˘ ¯ËÌÂÈÔʈٷ‡ÁÂÈ·˜ Û ·˘ÙfiÌ·ÙÔ ·Ó·Ï˘Ù‹ (ASC:180, Bayer Diagnostics Corp.). °È· ÙË Û‡ÁÎÚÈÛË ÙˆÓ ÂȤ‰ˆÓ ÙˆÓ ÔÚÌÔÓÒÓ, ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ˆ˜ ÔÌ¿‰· ·Ó·ÊÔÚ¿˜ 15 ˘ÁÈ‹ ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿, ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ 3200±498 g, Ô˘ ›¯·Ó ·ÚfiÌÔÈ· ËÏÈΛ· (36±15 Ë̤Ú˜ ˙ˆ‹˜) Î·È Ê‡ÏÔ (ÎÔÚ›ÙÛÈ·/·ÁfiÚÈ· 9/6) Ì ٷ ÚfiˆÚ· Î·È ÛÈÙ›ÛÙËÎ·Ó ·fi ÙË Á¤ÓÓËÛË Ì ÙÔ ›‰ÈÔ ÙÚÔÔÔÈË̤ÓÔ Á¿Ï· (S-26, Wyeth) ¯ˆÚ›˜ LCPUFAs. ∏ ÌÂϤÙË ÂÁÎÚ›ıËΠ·fi ÙËÓ ∂ÈÙÚÔ‹ ∏ıÈ΋˜ Î·È ¢ÂÔÓÙÔÏÔÁ›·˜ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ Î·È Ï‹ÊıËΠ¤ÁÁÚ·ÊË Û˘ÁηٿıÂÛË ÙˆÓ ÁÔÓ¤ˆÓ ÙˆÓ ·È‰ÈÒÓ Ô˘ ÌÂÏÂÙ‹ıËηÓ. ∆· ·ÔÙÂϤÛÌ·Ù· ÂÎÊÚ¿ÛÙËÎ·Ó ˆ˜ ̤ÛË ÙÈÌ‹±SD, Ì ÂÍ·›ÚÂÛË ÙËÓ ÈÓÛÔ˘Ï›ÓË Î·È ÙË ÏÂÙ›ÓË, ÙˆÓ ÔÔ›ˆÓ Ù· ›‰· ÂÎÊÚ¿ÛÙËÎ·Ó ˆ˜ ‡ÚÔ˜ Î·È ‰È¿ÌÂÛË ÙÈÌ‹, ÏfiÁˆ ÌË Î·ÓÔÓÈ΋˜ ηٷÓÔÌ‹˜. ∏ ηٷÓÔÌ‹ ÙˆÓ ÙÈÌÒÓ ÙÔ˘ ÔÏÈÎÔ‡ PYY, ÙÔ˘ PYY3-36 Î·È Ù˘ ·‰ÈÔÓÂÎÙ›Ó˘ ‹Ù·Ó ηÓÔÓÈ΋. °È· ÙË Û‡ÁÎÚÈÛË ÙˆÓ ÔÌ¿‰ˆÓ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÔÈ ‰ÔÎÈ̷ۛ˜ ttest Î·È Mann-Whitney U-test. ∏ ·Ó·˙‹ÙËÛË ÙˆÓ Û˘Û¯ÂÙ›ÛÂˆÓ ¤ÁÈÓ Ì ÌÂıfi‰Ô˘˜ ·Ï‹˜ Û˘Û¯¤ÙÈÛ˘ (correlation analysis), ·Ï‹˜ ÂÍ¿ÚÙËÛ˘ (regression analysis) Î·È ÔÏÏ·Ï‹˜ ÂÍ¿ÚÙËÛ˘ (multiple regression analysis). °È· ÙË ÌÂϤÙË ÙˆÓ Û˘Û¯ÂÙ›ÛÂˆÓ ¤ÁÈÓ ÏÔÁ·Ú›ıÌËÛË ÙˆÓ ÙÈÌÒÓ ÙˆÓ ÔÚÌÔÓÒÓ Ô˘ ‰ÂÓ Â›¯·Ó ηÓÔÓÈ΋ ηٷÓÔÌ‹. Paediatriki 2007;70:308-315
∞ÔÙÂϤÛÌ·Ù· ∆· ۈ̷ÙÔÌÂÙÚÈο ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ Î·Ù¿ ÙËÓ ¤ÍÔ‰fi ÙÔ˘˜ ·fi ÙË ªÔÓ¿‰· ¡ÂÔÁÓÒÓ, ηıÒ˜ Î·È ÙˆÓ ÙÂÏÂÈfiÌËÓˆÓ ÓÂÔÁÓÒÓ, Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ™Ù· ÚfiˆÚ· ÓÂÔÁÓ¿, Ë ·fiÎÏÈÛË ÙÔ˘ ‚¿ÚÔ˘˜ ÙÔ˘˜ ·fi ÙÔ Ì¤ÛÔ Ê˘ÛÈÔÏÔÁÈÎfi ÁÈ· ÙËÓ ËÏÈΛ· Î·È ÙÔ Ê‡ÏÔ (z-score) ηٿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙË ªÔÓ¿‰· ¡ÂÔÁÓÒÓ ‹Ù·Ó ·ÚÓËÙÈ΋ (-2,0±0,4). ∂›Û˘, ÙÔ ÈÛÔ˙‡ÁÈÔ ÙÔ˘ ۈ̷ÙÈÎÔ‡ ÙÔ˘˜ ‚¿ÚÔ˘˜ ‹Ù·Ó ·ÚÓËÙÈÎfi, ‰ÈfiÙÈ Ë ‰È·ÊÔÚ¿ ÙÔ˘ z-score ÙÔ˘ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ·fi ÙÔ zscore ÙÔ˘ ‚¿ÚÔ˘˜ ÙÔ˘˜ ηٿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙË ªÔÓ¿‰· (¢z-score ‚¿ÚÔ˘˜) ‹Ù·Ó ·ÚÓËÙÈ΋ (-0,92±0,72, ¶›Ó·Î·˜ 1), ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙÔ˘ ˘„ËÏÔ‡ ÔÛÔÛÙÔ‡ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ Ì ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜ <-2 SD ηٿ ÙËÓ ¤ÍÔ‰Ô (63%) ¤Ó·ÓÙÈ ÌÈÎÚfiÙÂÚÔ˘ ÔÛÔÛÙÔ‡ ηٿ ÙË Á¤ÓÓËÛË (11,3%). ∏ ÔÛfiÙËÙ· ÙÔ˘ ÚÔÛÏ·Ì‚·ÓfiÌÂÓÔ˘ Á¿Ï·ÙÔ˜/∫g*/24ˆÚÔ ‰ÂÓ ‰È¤ÊÂÚÂ, Î·È ÂÔ̤ӈ˜ Ô‡Ù ÙÔ ÔÛfi ıÂÚÌ›‰ˆÓ/∫g*/24ˆÚÔ ÌÂٷ͇ ÚfiˆÚˆÓ Î·È ÙÂÏÂÈfiÌËÓˆÓ ÓÂÔÁÓÒÓ (156±20 Î·È 155±27 Kcal/Kg/24ˆÚÔ, ·ÓÙ›ÛÙÔȯ·). ∆· ›‰· ÔÏÈÎÔ‡ ƒÀÀ, ƒÀÀ3-36 Î·È ÁÎÚÂÏ›Ó˘, ‹Ù·Ó ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚ· ÛÙ· ÚfiˆÚ· ·fi Ù· ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿. ∆· ›‰· ·‰ÈÔÓÂÎÙ›Ó˘ ‹Ù·Ó ÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚ· ÛÙ· ÚfiˆÚ· Î·È ‰ÂÓ ‰È¤ÊÂÚ·Ó Ù· ›‰· ÈÓÛÔ˘Ï›Ó˘ Î·È ÏÂÙ›Ó˘ ÌÂٷ͇ ÚfiˆÚˆÓ Î·È ÙÂÏÂÈfiÌËÓˆÓ. øÛÙfiÛÔ, ÌÂÙ¿ ·fi ‰ÈfiÚıˆÛË ÁÈ· ÙÔ ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜, Ù· ›‰· ·‰ÈÔÓÂÎÙ›Ó˘ ‹Ù·Ó ˘„ËÏfiÙÂÚ· ÛÙ· ÚfiˆÚ· ·fi Ù· ÙÂÏÂÈfiÌËÓ·, ÂÓÒ Ë ‰È·ÊÔÚ¿ ˆ˜ ÚÔ˜ Ù· ›‰· ÈÓÛÔ˘Ï›Ó˘ ¤ÙÂÈÓ ӷ Â›Ó·È ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ (p=0,07) (¶›Ó·Î·˜ 2). ™Ù· ÚfiˆÚ· ÓÂÔÁÓ¿, Ù· ›‰· ƒÀÀ3-36 ·ÔÙÂÏÔ‡Û·Ó ÙÔ 48% ÙˆÓ Î˘ÎÏÔÊÔÚÔ‡ÓÙˆÓ ÂȤ‰ˆÓ ÔÏÈÎÔ‡ ƒÀÀ, ÔÛÔÛÙfi ·ÚfiÌÔÈÔ Ì ·˘Ùfi ÙˆÓ ÙÂÏÂÈfiÌËÓˆÓ (42%), Ë ‰Â Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ƒÀÀ Î·È ƒÀÀ3-36 ‹Ù·Ó ıÂÙÈ΋ (r=0,82, p<0,01). ∆· ›‰· ƒÀÀ, ηıÒ˜ Î·È ƒÀÀ3-36, Û˘Û¯ÂÙ›ÛıËÎ·Ó ıÂÙÈο Ì ٷ ›‰· ÁÎÚÂÏ›Ó˘ (r=0,33, p=0,009, ∂ÈÎfiÓ· 1∞, Î·È r=0,30, p=0,01, ·ÓÙ›ÛÙÔȯ·) Î·È ÈÓÛÔ˘Ï›Ó˘ (r=0,37, p=0,003, ∂ÈÎfiÓ· 1µ, Î·È r=0,38, p=0,003, ·ÓÙ›ÛÙÔȯ·). ¶›Ó·Î·˜ 1. ™ˆÌ·ÙÔÌÂÙÚÈΤ˜ ·Ú¿ÌÂÙÚÔÈ ÙˆÓ ·È‰ÈÒÓ Ù˘ ÌÂϤÙ˘ ¶ÚfiˆÚ· ∆ÂÏÂÈfiÌËÓ· (n=62) (n=15) ∏ÏÈΛ· Â͈̋ÙÚÈ·˜ ˙ˆ‹˜ (Ë̤Ú˜) 40±14 µ¿ÚÔ˜ ÛÒÌ·ÙÔ˜ (g) 2269±162** ª‹ÎÔ˜ ÛÒÌ·ÙÔ˜ (cm) 46,7±0,7** ¶ÂÚ›ÌÂÙÚÔ˜ ÎÂÊ·Ï‹˜ (cm) 33,2±1,0** ¢z-score ‚¿ÚÔ˘˜# -0,92±0,72**
36±15 3835±706 54,3±3,3 36,7±1,6 -0,15±0,63
# ¢È·ÊÔÚ¿ z-score ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ·fi ÙÔ z-score ÙÔ˘ ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜ ηٿ ÙËÓ ·ÈÌÔÏË„›· **p≤0,01 Û˘ÁÎÚÈÙÈο Ì ٷ ÙÂÏÂÈfiÌËÓ·
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·311
311
√ÚÌfiÓ˜ Ô˘ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ fiÚÂÍË Î·È ÙoÓ ÌÂÙ·‚ÔÏÈÛÌfi
1600
A
A 1400
¶ÂÙ›‰ÈÔ ÀÀ (pg/ml)
OÏÈÎfi ÂÙ›‰ÈÔ ÀÀ ÔÚÔ‡ (pg/ml)
1600
1200 1000 800 600 400 400
1400 1200 1000 800 600
500
600
700
800
900
1000
400 1800
1100
2000
°ÎÚÂÏ›ÓË ÔÚÔ‡ (pg/ml) 1600
2400
2600
2800
1,4
B
B
1,2
1400
log ÈÓÛÔ˘Ï›ÓË (mU/L)
OÏÈÎfi ÂÙ›‰ÈÔ ÀÀ ÔÚÔ‡ (pg/ml)
2200
B¿ÚÔ˜ ÛÒÌ·ÙÔ˜ (g)
1200 1000 800
1,0 ,8 ,6 ,4 ,2
600
0,0 400 -,2
0,0
,2
,4
,6
,8
1,0
1,2
-,2 1800
1,4
Log ÈÓÛÔ˘Ï›ÓË ÔÚÔ‡ (mU/L)
2000
2200
2400
2600
2800
B¿ÚÔ˜ ÛÒÌ·ÙÔ˜ (g)
∂ÈÎfiÓ· 1. ™˘Û¯¤ÙÈÛË ÙˆÓ ÂȤ‰ˆÓ ÔÏÈÎÔ‡ ƒÀÀ ÔÚÔ‡ Û ÚfiˆÚ· ÓÂÔÁÓ¿ Ì ∞) Ù· ›‰· ÁÎÚÂÏ›Ó˘ (r=0,33, p=0,009, µ) Ù· ›‰· ÈÓÛÔ˘Ï›Ó˘ (r=0,37, p=0,003).
∂ÈÎfiÓ· 2. ™˘Û¯¤ÙÈÛË ÙˆÓ ÂȤ‰ˆÓ ∞) ÔÏÈÎÔ‡ ƒÀÀ ÔÚÔ‡ (r=-0,44, p<0,001) Î·È µ) ÈÓÛÔ˘Ï›Ó˘ ÔÚÔ‡ (r=-0,43, p<0,01) Ì ÙÔ ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ.
¢È·ÈÛÙÒıËΠ·ÚÓËÙÈ΋ Û˘Û¯¤ÙÈÛË ÙˆÓ ÂȤ‰ˆÓ ƒÀÀ, ηıÒ˜ Î·È ƒÀÀ3-36, Ì ÙÔ ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜ ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ (r=-0,44, p<0,001, ∂ÈÎfiÓ· 2∞, Î·È r=-0,33, p=0,01, ·ÓÙ›ÛÙÔȯ·) Î·È Ì ÙÔÓ µªπ (r=-0,46, p<0,001 Î·È r=-0,38, p<0,01, ·ÓÙ›ÛÙÔȯ·). ∂›Û˘, Ù· ›‰· ÈÓÛÔ˘Ï›Ó˘ Û˘Û¯ÂÙ›ÛıËÎ·Ó ·ÚÓËÙÈο Ì ÙÔ ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜ ÙˆÓ Úfiˆ-
ÚˆÓ ÓÂÔÁÓÒÓ (r=-0,43, p<0,01, ∂ÈÎfiÓ· 2µ) Î·È Ì ÙÔÓ µªπ (r=-0,52, p<0,01). ¢ÂÓ ‰È·ÈÛÙÒıËΠÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË ÙˆÓ ÂȤ‰ˆÓ ÁÎÚÂÏ›Ó˘ Î·È ÏÂÙ›Ó˘ ÔÚÔ‡ Ì ÙȘ ۈ̷ÙÔÌÂÙÚÈΤ˜ ·Ú·Ì¤ÙÚÔ˘˜ ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ Î·Ù¿ ÙË Á¤ÓÓËÛË ‹ ÙËÓ ¤ÍÔ‰Ô ·fi ÙË ªÔÓ¿‰·. ∆· ›‰· ÏÂÙ›Ó˘ Û˘Û¯ÂÙ›ÛıËÎ·Ó ·ÚÓËÙÈο Ì ÙÔÓ Ú˘ıÌfi ·‡ÍËÛ˘
¶›Ó·Î·˜ 2. ∂›Â‰· ÔÚÌÔÓÒÓ ÛÙÔÓ ÔÚfi ÙˆÓ ·È‰ÈÒÓ Ù˘ ÌÂϤÙ˘
√ÏÈÎfi ƒÀÀ (pg/ml) ƒÀÀ3-36 (pg/ml) °ÎÚÂÏ›ÓË (pg/ml) πÓÛÔ˘Ï›ÓË (mU/L) πÓÛÔ˘Ï›ÓË/Kg* (mU/L/∫g*) §ÂÙ›ÓË (Ìg/L) ∞‰ÈÔÓÂÎÙ›ÓË (Ìg/ml) ∞‰ÈÔÓÂÎÙ›ÓË/Kg*(Ìg/ml/Kg*)
¶ÚfiˆÚ· (n=62)
∆ÂÏÂÈfiÌËÓ· (n=15)
1126±215 544±157 721±98 0,7-22,2 (‰È¿ÌÂÛË 2,3) 0,3-9,7 (‰È¿ÌÂÛË 1,0) 0,1-15,6 (‰È¿ÌÂÛË 1,2) 40±15 18,0±6,8
825±234 350±114 602±93 0,5-10,6 (‰È¿ÌÂÛË 3,1) 0,1-3,4 (‰È¿ÌÂÛË 0,7) 0,1-9,7 (‰È¿ÌÂÛË 1,2) 53±16 14,1±4,8
p <0,001 <0,001 <0,001 >0,05 0,07 >0,05 <0,01 0,02 ¶·È‰È·ÙÚÈ΋ 2007;70:308-315
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·312
312
∆. ™È·¯·Ó›‰Ô˘ Î·È Û˘Ó.
Log ÏÂÙ›Ó˘ ÔÚÔ‡ (Ìg/L)
1,5 1,0 ,5 0,0 -, 5 -1,0 -1,5 0
3
6
9
12
15
18
21
24
27
30
∞‡ÍËÛË ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜ (g/Kg/24ˆÚÔ) ∂ÈÎfiÓ· 3. ™˘Û¯¤ÙÈÛË ÙˆÓ ÂȤ‰ˆÓ ÏÂÙ›Ó˘ ÔÚÔ‡ Ì ÙÔÓ Ú˘ıÌfi ·‡ÍËÛ˘ ÙÔ˘ ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜ ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ (r=-0,27, p<0,05).
·‰ÈÔÓÂÎÙ›ÓË ÔÚÔ‡ ‡ (Ìg/ml)
100 ∞ 80 60 40 20 0 -3,0
-2,5
-2,0
-1,5
-1,0
-,5
z-score ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜
·‰ÈÔÓÂÎÙ›ÓË ÔÚÔ‡ ‡ (Ìg/ml)
100 µ 80 60 40 20 0 0
5
10
15
20
25
30
∞‡ÍËÛË ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜ (g/Kg/24ˆÚÔ) ∂ÈÎfiÓ· 4. ™˘Û¯¤ÙÈÛË ÙˆÓ ÂȤ‰ˆÓ ·‰ÈÔÓÂÎÙ›Ó˘ ÔÚÔ‡ Ì ∞) ÙÔ z-score ÙÔ˘ ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜ ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ (r=0,28, p=0,02) Î·È µ) ÙÔÓ Ú˘ıÌfi ·‡ÍËÛ˘ ‚¿ÚÔ˘˜ (r=0,26, p<0,05). Paediatriki 2007;70:308-315
‚¿ÚÔ˘˜ ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ (r=-0,27, p<0,05, ∂ÈÎfiÓ· 3). ¢È·ÈÛÙÒıËΠÛËÌ·ÓÙÈ΋ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË ÙˆÓ ÂȤ‰ˆÓ ·‰ÈÔÓÂÎÙ›Ó˘ ÔÚÔ‡ Ì ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ (r=0,31, p<0,05), ÙÔ zscore ÙÔ˘ ‚¿ÚÔ˘˜ ÙÔ˘˜ ηٿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙË ªÔÓ¿‰· (r=0,28, p=0,02, ∂ÈÎfiÓ· 4∞) Î·È ÙÔÓ Ú˘ıÌfi ·‡ÍËÛ˘ ÙÔ˘ ۈ̷ÙÈÎÔ‡ ÙÔ˘˜ ‚¿ÚÔ˘˜ (r=0,26, p<0,05, ∂ÈÎfiÓ· 4µ). ªÂ ÙË Ì¤ıÔ‰Ô Ù˘ ·Ï‹˜ ÂÍ¿ÚÙËÛ˘ ‰È·ÈÛÙÒıËΠfiÙÈ Ë Á¤ÓÓËÛË Ì ‚¿ÚÔ˜ <-2SD (ÏÈÔ‚·Ú‹ ÁÈ· ÙË ‰È¿ÚÎÂÈ· ·ËÛ˘ ÓÂÔÁÓ¿) Î·È Ë ‡·ÚÍË ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜ <-2SD ηٿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙË ªÔÓ¿‰· (οو ·fi Ù· Ê˘ÛÈÔÏÔÁÈο fiÚÈ·) ÂËÚ¤·Û·Ó ·ÚÓËÙÈο Ù· ›‰· ·‰ÈÔÓÂÎÙ›Ó˘ (‚=-0,26, p<0,05 Î·È ‚=-0,25, p<0,05, ·ÓÙ›ÛÙÔȯ·), ÂÓÒ Ë ‰È·ÙÚÔÊ‹ Ì ÙÚÔÔÔÈË̤ÓÔ Á¿Ï· Ô˘ ÂÚÈ›¯Â LCPUFAs Ù· ÂËÚ¤·Û ıÂÙÈο (‚=0,28, p=0,02). ªÂ ÙË Ì¤ıÔ‰Ô Ù˘ ÔÏÏ·Ï‹˜ ÂÍ¿ÚÙËÛ˘ ‰È·ÈÛÙÒıËΠfiÙÈ Ë ‰È·ÙÚÔÊ‹ Ì Á¿Ï· ÂÌÏÔ˘ÙÈṲ̂ÓÔ Ì LCPUFAs, ÙÔ ¯·ÌËÏfi ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ÁÈ· ÙË ‰È¿ÚÎÂÈ· ·ËÛ˘ (ÏÈÔ‚·Ú‹ ÓÂÔÁÓ¿) Î·È Ô Ú˘ıÌfi˜ ·‡ÍËÛ˘ ‚¿ÚÔ˘˜ Û˘Û¯ÂÙ›ÛıËÎ·Ó ·ÓÂÍ¿ÚÙËÙ· Ì ٷ ›‰· ·‰ÈÔÓÂÎÙ›Ó˘ (¶›Ó·Î·˜ 3). ¶ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰ÈÂÚ¢ÓËı› ÂÚ·ÈÙ¤Úˆ Ë Û˘Û¯¤ÙÈÛË Ù˘ ·‰ÈÔÓÂÎÙ›Ó˘ Ì ÙÔÓ Ú˘ıÌfi ·‡ÍËÛ˘ ‚¿ÚÔ˘˜, ·Ó·˙ËÙ‹ıËÎ·Ó Î·È ¿ÏÏÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ËÌÂÚ‹ÛÈ· ÚfiÛÏË„Ë ‚¿ÚÔ˘˜ ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿. ∂ÎÙfi˜ Ù˘ ·‰ÈÔÓÂÎÙ›Ó˘ Î·È Ù˘ ÏÂÙ›Ó˘ (Ë ÔÔ›· ‹‰Ë ·Ó·Ê¤ÚıËΠfiÙÈ Û˘Û¯ÂÙ›˙ÂÙ·È ·ÚÓËÙÈο Ì ÙËÓ ÚfiÛÏË„Ë ‚¿ÚÔ˘˜), ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ Î·È ÙÔ Ì‹ÎÔ˜ ÛÒÌ·ÙÔ˜ ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ Û˘Û¯ÂÙ›ÛıËÎ·Ó ·ÚÓËÙÈο (r=-0,27, p<0,05 Î·È r=-0,36, p=0,02, ·ÓÙ›ÛÙÔȯ·), ÂÓÒ Ë ËÌÂÚ‹ÛÈ· ÚfiÛÏË„Ë ıÂÚÌ›‰ˆÓ Û˘Û¯ÂÙ›ÛıËΠıÂÙÈο Ì ÙÔÓ Ú˘ıÌfi ·‡ÍËÛ˘ ÙÔ˘ ‚¿ÚÔ˘˜ ÙÔ˘˜ (r=0,53, p<0,001). ªÂ ÙË Ì¤ıÔ‰Ô Ù˘ ÔÏÏ·Ï‹˜ ÂÍ¿ÚÙËÛ˘ ‰È·ÈÛÙÒıËΠfiÙÈ Ë ÚfiÛÏË„Ë ıÂÚÌ›‰ˆÓ Î·È Ù· ›‰· ·‰ÈÔÓÂÎÙ›Ó˘ ‹Ù·Ó ÔÈ ÌfiÓÔÈ ·ÓÂÍ¿ÚÙËÙÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¤·Û·Ó ÙÔÓ Ú˘ıÌfi ·‡ÍËÛ˘ ‚¿ÚÔ˘˜ (¶›Ó·Î·˜ 4). ¢ÂÓ ‰È·ÈÛÙÒıËÎÂ Û˘Û¯¤ÙÈÛË ÙˆÓ ÂȤ‰ˆÓ ÙˆÓ ÔÚÌÔÓÒÓ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó Ì ÙËÓ ÔÛfiÙËÙ· Ù˘ ÚÔÛÏ·Ì‚·ÓfiÌÂÓ˘ ÙÚÔÊ‹˜ Î·È ÙÔ ÔÛfi ÙˆÓ ıÂÚÌ›‰ˆÓ.
™˘˙‹ÙËÛË ∏ ÌÂϤÙË ·˘Ù‹ ¤‰ÂÈÍ fiÙÈ Ù· ÚfiˆÚ· ÓÂÔÁÓ¿, ÂÚ› ÙÔ Ù¤ÏÔ˜ ÙÔ˘ 1Ô˘ Ì‹Ó· ˙ˆ‹˜ ÙÔ˘˜, ¤¯Ô˘Ó ˘„ËÏfiÙÂÚ· ›‰· ÔÏÈÎÔ‡ ƒÀÀ, ƒÀÀ3-36 Î·È ÁÎÚÂÏ›Ó˘, Û˘ÁÎÚ›ÛÈÌ· ›‰· ÈÓÛÔ˘Ï›Ó˘ Î·È ÏÂÙ›Ó˘, Î·È ¯·ÌËÏfiÙÂÚ· ›‰· ·‰ÈÔÓÂÎÙ›Ó˘ ÔÚÔ‡ ·fi ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ ·ÚfiÌÔÈ·˜ ËÏÈΛ·˜ Î·È Ê‡ÏÔ˘. ∆Ô ÔÏÈÎfi ƒÀÀ Ô˘ ΢ÎÏÔÊÔÚ› ÛÙÔÓ ÔÚfi ·ÔÙÂÏ›ٷÈ, ÂÚ›Ô˘ ηٿ ÙÔ ‹ÌÈÛ˘, ·fi ÙÔ ƒÀÀ3-36, fiˆ˜ Î·È ÛÙÔ˘˜ ÂÓ‹ÏÈΘ (11). ∞’ fiÛÔ ÁÓˆÚ›˙Ô˘ÌÂ, ·˘Ù‹ ›ӷÈ
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·313
313
√ÚÌfiÓ˜ Ô˘ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ fiÚÂÍË Î·È ÙoÓ ÌÂÙ·‚ÔÏÈÛÌfi
¶›Ó·Î·˜ 3. ¶·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó Ù· ›‰· ·‰ÈÔÓÂÎÙ›Ó˘ ÔÚÔ‡ ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿ (r2 ÙÔ˘ ÌÔÓÙ¤ÏÔ˘=0,25, p=0,006) ∞ÓÂÍ¿ÚÙËÙ˜ ÌÂÙ·‚ÏËÙ¤˜ µ¿ÚÔ˜ Á¤ÓÓËÛ˘ <-2 SD (ÏÈÔ‚·Ú‹ ÁÈ· ÙË ‰È¿ÚÎÂÈ· ·ËÛ˘) z-score ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜ ηٿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙË ªÔÓ¿‰· ƒ˘ıÌfi˜ ·‡ÍËÛ˘ ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜ (g/Kg/24ˆÚÔ) ™›ÙÈÛË Ì Á¿Ï· Ô˘ ÂÚÈ›¯Â LCPUFAs
‚
p
-0,28 -0,006 0,27 0,28
0,04 0,96 0,03 0,03
∂Í·ÚÙË̤ÓË ÌÂÙ·‚ÏËÙ‹: ›‰· ·‰ÈÔÓÂÎÙ›Ó˘ ÔÚÔ‡ ‚, Û˘ÓÙÂÏÂÛÙ‹˜ Û˘Û¯¤ÙÈÛ˘
Ë ÚÒÙË ÌÂϤÙË Î·Ù¿ ÙËÓ ÔÔ›· ÚÔÛ‰ÈÔÚ›ÛÙËÎ·Ó Û˘Á¯ÚfiÓˆ˜ ÛÙÔÓ ÔÚfi ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ ·˘Ù¤˜ ÔÈ ÔÚÌfiÓ˜ Î·È ·Ó·˙ËÙ‹ıËÎÂ Ë ÌÂٷ͇ ÙÔ˘˜ Û¯¤ÛË, ηıÒ˜ Î·È Ë Û¯¤ÛË ÙÔ˘˜ Ì ÙËÓ ÚfiÛÏË„Ë ÙÚÔÊ‹˜ Î·È Ì ·Ú·Ì¤ÙÚÔ˘˜ ·‡ÍËÛ˘. ∏ Û‡ÓıÂÛË ‹/Î·È ¤ÎÎÚÈÛË ÙÔ˘ ƒÀÀ (ÔÏÈÎÔ‡ Î·È ƒÀÀ3-36) Î·È Ù˘ ÁÎÚÂÏ›Ó˘ Ú˘ıÌ›˙ÔÓÙ·È ·fi ‰È¿ÊÔÚÔ˘˜ ·Ú¿ÁÔÓÙ˜, ÛÙÔ˘˜ ÔÔ›Ô˘˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ù· ıÚÂÙÈο Û˘ÛÙ·ÙÈο (ÚˆÙ½ÓË, ϛԘ, ˘‰·Ù¿ÓıڷΘ), ÙÔ ÔÛfi ıÂÚÌ›‰ˆÓ, ÙÔ ¯ÔÏÈÓÂÚÁÈÎfi Û‡ÛÙËÌ· (Ë ‰È¤ÁÂÚÛË ¯ÔÏÈÓÂÚÁÈÎÒÓ ÈÓÒÓ ÙÔ˘ Ó¢ÌÔÓÔÁ·ÛÙÚÈÎÔ‡ Ô‰ËÁ› Û ¤ÎÎÚÈÛË PYY Î·È ÁÎÚÂÏ›Ó˘), ÔÈ ÔÚÌfiÓ˜ (Á·ÛÙÚ›ÓË, ÈÓÛÔ˘Ï›ÓË, ¯ÔÏÔ΢ÛÙÔÎÈÓ›ÓË, Á·ÛÙÚÈÎfi ·Ó·ÛÙ·ÏÙÈÎfi ÂÙ›‰ÈÔ, ·˘ÍËÙÈ΋ ÔÚÌfiÓË, ۈ̷ÙÔÛÙ·Ù›ÓË, ÏÂÙ›ÓË, ÁÏ˘ÎÔÎÔÚÙÈÎÔÂȉ‹, Î.·.) Î·È ÔÈ ·˘ÍËÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ (IGF-1, TGF-·, ÂȉÂÚÌÈÎfi˜ ·˘ÍËÙÈÎfi˜ ·Ú¿ÁˆÓ, Î.¿.) (12-14). ∏ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ƒÀÀ, ÁÎÚÂÏ›Ó˘ Î·È ÈÓÛÔ˘Ï›Ó˘ ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿ Ù˘ ÌÂϤÙ˘ Ì·˜ ˘Ô‰ËÏÒÓÂÈ fiÙÈ ÂӉ¯Ô̤ӈ˜ ˘¿Ú¯ÂÈ ·ÏÏËÏÔÚÚ‡ıÌÈÛË Ù˘ ¤ÎÎÚÈÛ˘ ÙˆÓ ÂÙȉ›ˆÓ ·˘ÙÒÓ ‹ Ë ¤ÎÎÚÈÛ‹ ÙÔ˘˜ ˘fiÎÂÈÙ·È Û ÎÔÈÓ‹ Ú‡ıÌÈÛË. ∞Ó Î·È ÙÔ ·›ÙÈÔ Ô˘ ¢ı‡ÓÂÙ·È ÁÈ· Ù· ˘„ËÏfiÙÂÚ· ›‰· ƒÀÀ Î·È ÁÎÚÂÏ›Ó˘ ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿ Ô˘ ÌÂÏÂÙ‹Û·Ì ‰ÂÓ Â›Ó·È ÁÓˆÛÙfi, Â›Ó·È ·ÍÈÔÛËÌ›ˆÙÔ fiÙÈ Ù· ·˘ÍË̤ӷ ›‰· ÁÎÚÂÏ›Ó˘ ÛÙÔÓ ÔÚfi ·ÔÙÂÏÔ‡Ó ÛÙ·ıÂÚfi ‡ÚËÌ· Û ηٷÛÙ¿ÛÂȘ Ô˘ Û˘Óԉ‡ÔÓÙ·È ·fi ·ÚÓËÙÈÎfi ÈÛÔ˙‡ÁÈÔ ÂÓ¤ÚÁÂÈ·˜ ‹ ·ÒÏÂÈ· ‚¿ÚÔ˘˜, .¯. Ó¢ÚÔÁÂÓ‹˜ ·ÓÔÚÂÍ›·, η¯ÂÍ›· ÏfiÁˆ ηډÈÔ¿ıÂÈ·˜ ‹ ηÚΛÓÔ˘, Î.· (15,16). ÀÔ¶›Ó·Î·˜ 4. ¶·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙÔ Ú˘ıÌfi ·‡ÍËÛ˘ ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜ ÙˆÓ ÚÔÒÚˆÓ (r2 ÙÔ˘ ÌÔÓÙ¤ÏÔ˘=0,48, p=0,001) ∞ÓÂÍ¿ÚÙËÙ˜ ÌÂÙ·‚ÏËÙ¤˜ µ¿ÚÔ˜ Á¤ÓÓËÛ˘ ª‹ÎÔ˜ ÛÒÌ·ÙÔ˜ ¶ÚfiÛÏË„Ë ıÂÚÌ›‰ˆÓ/Kg/24ˆÚÔ ∂›Â‰· ÏÂÙ›Ó˘ ÔÚÔ‡ ∂›Â‰· ·‰ÈÔÓÂÎÙ›Ó˘ ÔÚÔ‡
‚
p
0,08 -0,23 0,46 -0,11 0,30
0,56 0,12 0,003 0,41 0,03
∂Í·ÚÙË̤ÓË ÌÂÙ·‚ÏËÙ‹: ·‡ÍËÛË ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜ (g/Kg/24ˆÚÔ) ‚, Û˘ÓÙÂÏÂÛÙ‹˜ Û˘Û¯¤ÙÈÛ˘
ÛÙËÚ›˙ÂÙ·È fiÙÈ Ë ÁÎÚÂÏ›ÓË ·˘Í¿ÓÂÙ·È ÛÙȘ ηٷÛÙ¿ÛÂȘ ·˘Ù¤˜ ÚÔÎÂÈ̤ÓÔ˘ Ó· ·Û΋ÛÂÈ ·ÓÙÈÛÙ·ıÌÈÛÙÈ΋ ‰Ú¿ÛË Ì¤Ûˆ Ù˘ ıÂÙÈ΋˜ ›‰Ú·Û‹˜ Ù˘ ÛÙËÓ fiÚÂÍË Î·È ÛÙËÓ ·‡ÍËÛË ÙÔ˘ ÏÈÒ‰Ô˘˜ ÈÛÙÔ‡. Œ¯Ô˘Ó ›Û˘ ·Ó·ÊÂÚı› ·˘ÍË̤ӷ ›‰· ƒÀÀ Û ηٷÛÙ¿ÛÂȘ Ì ·ÚÓËÙÈÎfi ÈÛÔ˙‡ÁÈÔ ÂÓ¤ÚÁÂÈ·˜ Î·È ·ÒÏÂÈ· ‚¿ÚÔ˘˜, ·Ó Î·È Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ Ï›ÁˆÓ ̤¯ÚÈ Û‹ÌÂÚ· ÌÂÏÂÙÒÓ Â›Ó·È ·ÓÙÈÎÚÔ˘fiÌÂÓ· (15,17). ∞ÚÓËÙÈÎfi ÈÛÔ˙‡ÁÈÔ ÛˆÌ·ÙÈÎÔ‡ ‚¿ÚÔ˘˜ ·Ú·ÙËÚ‹ıËΠÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿ Ù˘ ÌÂϤÙ˘ Ì·˜ Î·È ÂÈϤÔÓ, Ë Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙˆÓ ÂȤ‰ˆÓ ƒÀÀ Î·È ÙÔ˘ ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜ ‹ ÙÔ˘ BMI ‹Ù·Ó ·ÚÓËÙÈ΋. ∏ ‰È·›ÛÙˆÛË fiÙÈ Ù· ›‰· ÈÓÛÔ˘Ï›Ó˘ ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿ Ô˘ ÌÂÏÂÙ‹Û·Ì ¤ÙÂÈÓ·Ó Ó· Â›Ó·È ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚ· ·fi ·˘Ù¿ ÙˆÓ ÙÂÏÂÈfiÌËÓˆÓ ÌÂÙ¿ ·fi ‰ÈfiÚıˆÛË ÁÈ· ÙÔ ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ·ÚÓËÙÈ΋ Û˘Û¯¤ÙÈÛË Ù˘ ÈÓÛÔ˘Ï›Ó˘ Ì ÙÔ ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜ ÙˆÓ ÚfiˆÚˆÓ Î·È ÙËÓ ·Ô˘Û›· ¯·ÌËÏfiÙÂÚˆÓ ÂȤ‰ˆÓ ÏÂÙ›Ó˘ ÛÙ· ÚfiˆÚ· Û˘ÁÎÚÈÙÈο Ì ٷ ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿, Â›Ó·È ÂӉ¯Ô̤ӈ˜ ÂÓ‰ÂÈÎÙÈ΋ ÂÓfi˜ ÚÔÁÚ·ÌÌ·ÙÈÛÌÔ‡ Ô˘ ·ÊÔÚ¿ ÛÙË ÌÂÙ¤ÂÈÙ· ÂÌÊ¿ÓÈÛË ·ÓÙÔ¯‹˜ ÛÙËÓ ÈÓÛÔ˘Ï›ÓË Î·È ÙË ÏÂÙ›ÓË Û ·È‰È¿ Ô˘ ÁÂÓÓ‹ıËÎ·Ó ÚfiˆÚ· ‹ Ì ¯·ÌËÏfi ‚¿ÚÔ˜ (2,18). ∆· ›‰· ·‰ÈÔÓÂÎÙ›Ó˘ ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿ Ù˘ ÌÂϤÙ˘ Ì·˜, ·Ó Î·È ¯·ÌËÏfiÙÂÚ· ·fi ·˘Ù¿ ÙˆÓ ÙÂÏÂÈfiÌËÓˆÓ, ‹Ù·Ó ˘„ËÏfiÙÂÚ· ·fi ÂΛӷ ÙˆÓ ÙÂÏÂÈfiÌËÓˆÓ ÌÂÙ¿ ·fi ‰ÈfiÚıˆÛË ÁÈ· ÙÔ ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜, ·ÏÏ¿ Î·È ·fi Ù· ›‰· Ô˘ ¤¯Ô˘Ó ·Ó·ÊÂÚı› Û ÌÂÁ¿Ï· ·È‰È¿ Î·È ÂÓ‹ÏÈΘ (19). ∆· ˘„ËÏ¿ ›‰· ·‰ÈÔÓÂÎÙ›Ó˘ ηٿ ÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· Î·È Ë ıÂÙÈ΋ Û˘Û¯¤ÙÈÛ‹ ÙÔ˘˜ Ì ÙÔ ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜ Û˘ÌʈÓÔ‡Ó Ì ٷ ·ÔÙÂϤÛÌ·Ù· ÚÔËÁÔ‡ÌÂÓˆÓ ÌÂÏÂÙÒÓ Û ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ (19,20). ∂ÓÒ Û ÌÂÁ¿Ï· ·È‰È¿ Î·È ÂÓ‹ÏÈΘ, fiÛÔ ÌÂÁ·Ï‡ÙÂÚÔ Â›Ó·È ÙÔ ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜ Î·È Ë Ì¿˙· ÙÔ˘ ÏÈÒ‰Ô˘˜ ÈÛÙÔ‡, ÙfiÛÔ ¯·ÌËÏfiÙÂÚ· Â›Ó·È Ù· ›‰· ·‰ÈÔÓÂÎÙ›Ó˘ (10,21), ÙÔ‡ÙÔ ‰ÂÓ Û˘Ì‚·›ÓÂÈ Û ÓÂÔÁÓ¿, ‰ÈfiÙÈ ÂӉ¯Ô̤ӈ˜ ‰ÂÓ ¤¯Ô˘Ó ·ÎfiÌË ·Ó·Ù˘¯ı› ÔÈ Ì˯·ÓÈÛÌÔ› Ô˘ ·Ó·ÛÙ¤ÏÏÔ˘Ó ÙËÓ ·Ú·ÁˆÁ‹ ·‰ÈÔÓÂÎÙ›Ó˘, ΢ڛˆ˜ ÏfiÁˆ ‰È·ÊÔÚÂÙÈ΋˜ Û‡ÓıÂÛ˘ Î·È Î·Ù·ÓÔÌ‹˜ ÙÔ˘ ÏÈÒ‰Ô˘˜ ÈÛÙÔ‡ .¯. ÌÈÎÚ¿-·ÓÒÚÈÌ· ÏÈÔ·ÙÙ·Ú·, ¶·È‰È·ÙÚÈ΋ 2007;70:308-315
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·314
314
∆. ™È·¯·Ó›‰Ô˘ Î·È Û˘Ó.
‡·ÚÍË Ê·ÈÔ‡ Ï›Ô˘˜, ·ÚÔ˘Û›· Ï›Ô˘˜ ΢ڛˆ˜ ÛÙÔÓ ˘Ô‰fiÚÈÔ ÈÛÙfi Î·È fi¯È ÂÓ‰ÔÎÔÈÏȷο ÛÙ· ÓÂÔÁÓ¿, Û˘ÁÎÚÈÙÈο Ì ÌÂÁ¿Ï· ·È‰È¿ Î·È ÂÓ‹ÏÈΘ (20). ∏ ÌÂϤÙË Ì·˜ ¤‰ÂÈÍ fiÙÈ ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿, Ô Ú˘ıÌfi˜ ·‡ÍËÛ˘ ‚¿ÚÔ˘˜ ·ÔÙÂÏ› ·Ú¿ÁÔÓÙ· Ô˘ ÂËÚ¿˙ÂÈ ıÂÙÈο Ù· ›‰· ·‰ÈÔÓÂÎÙ›Ó˘ (¶›Ó·Î·˜ 3). ∆Ô‡ÙÔ ÂӉ¯Ô̤ӈ˜ ÔÊ›ÏÂÙ·È Û ¿ÏÏÔ˘˜ ·Ú¿ÁÔÓÙ˜, .¯. IGF-1, ·˘ÍËÙÈ΋ ÔÚÌfiÓË, Î.·., ÔÈ ÔÔ›ÔÈ ·ÊÂÓfi˜ ÂȉÚÔ‡Ó ıÂÙÈο ÛÙËÓ ·‡ÍËÛË Î·È ·ÊÂÙ¤ÚÔ˘ ¿ÁÔ˘Ó ÙË Û‡ÓıÂÛË Ù˘ ·‰ÈÔÓÂÎÙ›Ó˘ (22). ∞ÏÏ¿ Î·È ·ÓÙ›ÛÙÚÔÊ·, Ë ·‰ÈÔÓÂÎÙ›ÓË ‚Ú¤ıËΠfiÙÈ ·ÔÙÂÏ› ·Ú¿ÁÔÓÙ· Ô˘ ÂËÚ¿˙ÂÈ ÙÔÓ Ú˘ıÌfi ·‡ÍËÛ˘ (¶›Ó·Î·˜ 4), ÂӉ¯Ô̤ӈ˜ Ì ¿ÌÂÛË ‰Ú¿ÛË ‹/Î·È ·˘Í¿ÓÔÓÙ·˜ ÙËÓ Â˘·ÈÛıËÛ›· ÙˆÓ ÈÛÙÒÓ Û ÔÚÌfiÓ˜ Ô˘ ‰ÈÂÁ›ÚÔ˘Ó ÙËÓ ·‡ÍËÛË, .¯. ÈÓÛÔ˘Ï›ÓË Î·È IGF (23). ∞Ó Î·È Â›Ó·È ÌÈÎÚfi˜ Ô ·ÚÈıÌfi˜ ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ Ô˘ ÛÈÙ›ÛÙËÎ·Ó Ì Á¿Ï· Ô˘ ÂÚÈ›¯Â LCPUFAs, Ë ıÂÙÈ΋ ›‰Ú·ÛË ÙˆÓ LCPUFAs ÛÙ· ›‰· ·‰ÈÔÓÂÎÙ›Ó˘ ·ÔÙÂÏ›, ηٿ ÙË ÁÓÒÌË Ì·˜, ÛËÌ·ÓÙÈÎfi ‡ÚËÌ· Î·È ·Ó·Ê¤ÚÂÙ·È ÁÈ· ÚÒÙË ÊÔÚ¿ ÛÙÔÓ ¿ÓıÚˆÔ. ª¤¯ÚÈ Û‹ÌÂÚ·, ÂÏ¿¯ÈÛÙ˜ ÌÂϤÙ˜, ÔÈ Ôԛ˜ Ú·ÁÌ·ÙÔÔÈ‹ıËÎ·Ó ÌfiÓÔ Û ÂÈÚ·Ì·Ùfi˙ˆ·, ¤‰ÂÈÍ·Ó fiÙÈ Ë ‰È·ÙÚÔÊ‹ Ô˘ ÂÚȤ¯ÂÈ LCPUFAs, Û˘ÁÎÂÎÚÈ̤ӷ ÂÈÎÔÛÈÂÓÙ·ÓÔ˚Îfi (20:5, n-3) Î·È ÂÈÎÔÛȉ˘ÔÂÍ·ÓÔ˚Îfi (22:6, n-3), ÚÔηÏ› ·‡ÍËÛË ÙˆÓ ÂȤ‰ˆÓ ·‰ÈÔÓÂÎÙ›Ó˘, Èı·Ófiٷٷ ̤ۈ ‰È¤ÁÂÚÛ˘ Ù˘ Û‡ÓıÂÛ˘ ‹/Î·È ¤ÎÎÚÈÛ‹˜ Ù˘ ·fi Ù· ÏÈÔ·ÙÙ·Ú· (24). ∂›Û˘, fiˆ˜ ηٷ‰Â›¯ıËΠ۠ÂÈÚ·Ì·Ùfi˙ˆ·, ‰›·ÈÙ· ÏÔ‡ÛÈ· Û LCPUFAs ηٿ ÙËÓ ÂÚÈÁÂÓÓËÙÈ΋ ÂÚ›Ô‰Ô Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ ÚfiÏË„Ë ÙÔ˘ ÌÂÙ·‚ÔÏÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ ηٿ ÙËÓ ÂÓ‹ÏÈÎÔ ˙ˆ‹ (3). ∆Ô ÁÂÁÔÓfi˜ ·˘Ùfi ÌÔÚ› Ó· ÂÚÌËÓ‡ÛÂÈ ÙËÓ ˆÊ¤ÏÈÌË ‰Ú¿ÛË ÙˆÓ LCPUFAs ηٿ Ù˘ ·ÓÙ›ÛÙ·Û˘ ÛÙËÓ ÈÓÛÔ˘Ï›ÓË, ηıÒ˜ Î·È ÙË ÌÈÎÚfiÙÂÚË Û˘¯ÓfiÙËÙ· ·¯˘Û·ÚΛ·˜, ·ÓÙÔ¯‹˜ ÛÙËÓ ÈÓÛÔ˘Ï›ÓË, ۷ί·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË Ù‡Ô˘ 2, ˘¤ÚÙ·Û˘ Î·È ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘ ηٿ ÙËÓ ÂÓ‹ÏÈÎÔ ˙ˆ‹ Û ·È‰È¿ Ô˘ ÛÈÙ›ÛÙËÎ·Ó Î·Ù¿ ÙË ‚ÚÂÊÈ΋ ËÏÈΛ· Ì ÌËÙÚÈÎfi Á¿Ï·, ÙÔ ÔÔ›Ô Â›Ó·È ÁÓˆÛÙfi fiÙÈ Â›Ó·È ÏÔ‡ÛÈÔ Û LCPUFAs (3). ÃÚÂÈ¿˙ÂÙ·È Ó· ‰ÈÂÚ¢ÓËı› ·Ó Ô ÂÌÏÔ˘ÙÈÛÌfi˜ ÙÔ˘ ÙÚÔÔÔÈË̤ÓÔ˘ Á¿Ï·ÙÔ˜ Ì LCPUFAs ÁÈ· ÙË ‰È·ÙÚÔÊ‹ ÚfiˆÚˆÓ ‹ ÙÂÏÂÈfiÌËÓˆÓ ÓÂÔÁÓÒÓ Ô˘ ‰ÂÓ ıËÏ¿˙Ô˘Ó ı· ›¯Â ·ÚfiÌÔÈ· ¢ÂÚÁÂÙÈο ·ÔÙÂϤÛÌ·Ù·. ¢ÂÓ ‰È·ÈÛÙÒıËÎÂ Û˘Û¯¤ÙÈÛË ÙˆÓ ÔÚÌÔÓÒÓ Ô˘ ÌÂÏÂÙ‹Û·Ì Ì ÙËÓ ÔÛfiÙËÙ· Ù˘ ÚÔÛÏ·Ì‚·ÓfiÌÂÓ˘ ÙÚÔÊ‹˜ Î·È ÙÔ ÔÛfi ÙˆÓ ıÂÚÌ›‰ˆÓ. ∂›Û˘, Ì ÂÍ·›ÚÂÛË ÙË ÏÂÙ›ÓË Î·È ÙËÓ ·‰ÈÔÓÂÎÙ›ÓË, ‰ÂÓ ‰È·ÈÛÙÒıËÎÂ Û˘Û¯¤ÙÈÛË ÙˆÓ ÂȤ‰ˆÓ ÙˆÓ ˘ÔÏÔ›ˆÓ ÔÚÌÔÓÒÓ Ì ÙÔÓ Ú˘ıÌfi ·‡ÍËÛ˘ ÙÔ˘ ‚¿ÚÔ˘˜ ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ. ŸÌˆ˜, Ú¤ÂÈ Ó· ÏËÊı› ˘fi„Ë fiÙÈ ÔÈ Ì˯·ÓÈÛÌÔ› Ô˘ Ú˘ıÌ›˙Ô˘Ó ÙËÓ ÚfiÛÏË„Ë ÙÚÔÊ‹˜ Î·È ÙÔ ÈÛÔ˙‡ÁÈÔ ÛˆÌ·ÙÈÎÔ‡ ‚¿ÚÔ˘˜ Â›Ó·È ÔχÏÔÎÔÈ Î·È fiÙÈ Ë ·ÏÏËÏ›‰Ú·ÛË ‰È·ÊfiPaediatriki 2007;70:308-315
ÚˆÓ ÔÚÌÔÓÒÓ Î·È ·Ú·ÁfiÓÙˆÓ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÂÈÛÎÈ¿˙ÂÈ ÙË Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙˆÓ ÔÚÌÔÓÒÓ Ô˘ ÌÂÏÂÙ‹Û·ÌÂ Î·È Ù˘ ÔÛfiÙËÙ·˜ Ù˘ ÚÔÛÏ·Ì‚·ÓfiÌÂÓ˘ ÙÚÔÊ‹˜ ‹ ÙÔ˘ Ú˘ıÌÔ‡ ·‡ÍËÛ˘. ∂Í¿ÏÏÔ˘, Ô ‚ÈÔÏÔÁÈÎfi˜ ÚfiÏÔ˜ ÙˆÓ ˘fi ÌÂϤÙË ÔÚÌÔÓÒÓ ‰ÂÓ ¤¯ÂÈ Ï‹Úˆ˜ ‰È¢ÎÚÈÓÈÛÙ› ηÈ, fiˆ˜ ˘ÔÛÙËÚ›˙ÂÙ·È Û ¿ÏϘ ÌÂϤÙ˜ (25), ‰ÂÓ ·ÔÎÏ›ÂÙ·È Ó· Â›Ó·È ‰È·ÊÔÚÂÙÈÎfi˜ ‹ ÂÚÈÛÛfiÙÂÚÔ Û‡ÓıÂÙÔ˜ ·fi ·˘ÙfiÓ Ô˘ ̤¯ÚÈ Û‹ÌÂÚ· ÁÓˆÚ›˙Ô˘ÌÂ. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ù· ÚfiˆÚ· ÓÂÔÁÓ¿ ‰ÂÓ ÌÂÈÔÓÂÎÙÔ‡Ó Û˘ÁÎÚÈÙÈο Ì ٷ ÙÂÏÂÈfiÌËÓ· ˆ˜ ÚÔ˜ ÙË Û‡ÓıÂÛË/¤ÎÎÚÈÛË ÔÚÌÔÓÒÓ Ô˘ ıˆÚÂ›Ù·È fiÙÈ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ·‡ÍËÛË Î·È ÙÔÓ ÌÂÙ·‚ÔÏÈÛÌfi. ∞Ó Î·È Ô ‚ÈÔÏÔÁÈÎfi˜ ÚfiÏÔ˜ ÙˆÓ ÔÚÌÔÓÒÓ ·˘ÙÒÓ ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿ ̤ÏÏÂÈ Ó· ‰È¢ÎÚÈÓÈÛÙ› ÂÚ·ÈÙ¤Úˆ, ·fi Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘ Ì·˜ ÚÔ·ÙÔ˘Ó ÂӉ›ÍÂȘ fiÙÈ ÔÈ ‰È·Ù·Ú·¯¤˜ Ô˘ ‰È·ÈÛÙÒÓÔÓÙ·È Û ·È‰È¿ Ô˘ ÁÂÓÓ‹ıËÎ·Ó ÚfiˆÚ· ‹ Ì ¯·ÌËÏfi ‚¿ÚÔ˜ (1,2,18) ÂӉ¯Ô̤ӈ˜ ÍÂÎÈÓÔ‡Ó Ôχ ÓˆÚ›˜, ·fi ÙË ÓÂÔÁÓÈ΋ ËÏÈΛ·. ∏ ·‰ÈÔÓÂÎÙ›ÓË Ê·›ÓÂÙ·È fiÙÈ ·›˙ÂÈ ÚfiÏÔ ÛÙËÓ ·‡ÍËÛË.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Barker DJ. The fetal and infant origins of adult disease. BMJ 1990;301:1111. 2. Hofman PL, Regan F, Jackson WE, Jefferies C, Knight DB, Robinson EM, et al. Premature birth and later insulin resistance. N Engl J Med 2004;351:2179-2186. 3. Das UN. Pathophysiology of metabolic syndrome X and its links to the perinatal period. Nutrition 2005;21:762-773. 4. Barker DJ, Osmond C, Forsen TJ, Kajantie E, Eriksson JG. Trajectories of growth among children who have coronary events as adults. N Engl J Med 2005;353:1802-1809. 5. Singhal A, Lucas A. Early origins of cardiovascular disease: is there a unifying hypothesis? Lancet 2004;363:1642-1645. 6. Batterham RL, Cowley MA, Small CJ, Herzog H, Cohen MA, Dakin CL, et al. Gut hormone PYY(3-36) physiologically inhibits food intake. Nature 2002;418:650-654. 7. Chelikani PK, Haver AC, Reidelberger RD. Intravenous infusion of peptide YY(3-36) potently inhibits food intake in rats. Endocrinology 2005;146:879-888. 8. Neary NM, Small CJ, Bloom SR. Gut and mind. Gut 2003; 52:918-921. 9. Broberger C. Brain regulation of food intake and appetite: molecules and networks. J Intern Med 2005;258:301-327. 10. Nedv›dkovaã J, Smitka K, Kopskyã V, Hainer V. Adiponectin, an adipocyte-derived protein. Physiol Res 2005;54;133-140. 11. Grandt D, Schimiczek M, Beglinger C, Layer P, Goebell H, Eysselein VE, et al. Two molecular forms of peptide YY (PYY) are abundant in human blood: characterization of a radioimmunoassay recognizing PYY 1-36 and PYY 3-36. Regul Pept 1994;51:151-159. 12. Onaga T, Zabielski R, Kato S. Multiple regulation of peptide YY secretion in the digestive tract. Peptides 2002;23: 279-290. 13. Erdmann J, Lippl F, Schusdziarra V. Differential effect of protein and fat on plasma ghrelin levels in man. Regul Pept 2003;116:101-107.
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·315
315
√ÚÌfiÓ˜ Ô˘ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ fiÚÂÍË Î·È ÙoÓ ÌÂÙ·‚ÔÏÈÛÌfi
14. Lippl F, Kircher F, Erdmann J, Allescher HD, Schusdziarra V. Effect of GIP, GLP-1, insulin and gastrin on ghrelin release in the isolated rat stomach. Regul Pept 2004;119:93-98. 15. Stock S, Leichner P, Wong AC, Ghatei MA, Kieffer TJ, Bloom SR, et al. Ghrelin, peptide YY, glucose-dependent insulinotropic polypeptide, and hunger responses to a mixed meal in anorexic, obese and control female adolescents. J Clin Endocrinol Metab 2005;90:2161-2168. 16. Shimizu Y, Nagaya N, Isobe T, Imazu M, Okumura H, Hosoda H, et al. Increased plasma ghrelin level in lung cancer cachexia. Clin Cancer Res 2003;9:774-778. 17. Misra M, Miller KK, Tsai P, Gallagher K, Lin A, Lee N, et al. Elevated peptide YY levels in adolescent girls with anorexia nervosa. J Clin Endocrinol Metab 2006;91:1027-1033. 18. Singhal A, Farooqi IS, O’Rahilly S, Cole TJ, Fewtrell M, Lucas A. Early nutrition and leptin concentrations in later life. Am J Clin Nutr 2002;75:993-999. 19. Kotani Y, Yokota I, Kitamura S, Matsuda J, Naito E, Kuroda Y. Plasma adiponectin levels in newborns are higher than those in adults and positively correlated with birth weight. Clin Endocrinol 2004;61:418-423.
20. Dunger D, Ong K. Abundance of adiponectin in the newborn. Clin Endocrinol 2004;61:416-417. 21. Stefan N, Bunt JC, Salbe AD, Funahashi T, Matsuzawa Y, Tataranni PA. Plasma adiponectin concentrations in children: relationships with obesity and insulinemia. J Clin Endocrinol Metab 2002;87:4652-4656. 22. Halleux CM, Takahashi M, Delporte ML, Detry R, Funahashi T, Matsuzawa Y, et al. Secretion of adiponectin and regulation of apM1 gene expression in human visceral adipose tissue. Biochem Biophys Res Commun 2001;288: 1102-1107. 23. Fu Y, Luo N, Klein RL, Garvey WT. Adiponectin promotes adipocyte differentiation, insulin sensitivity, and lipid accumulation. J Lipid Res 2005;46:1369-1379. 24. Flachs P, Mohamed-Ali V, Horakova O, Rossmeisl M, Hosseinzadeh-Attar MJ, Hensler M, et al. Polyunsaturated fatty acids of marine origin induce adiponectin in mice fed a high-fat diet. Diabetologia 2006;49:394-397. 25. Degen L, Oesch S, Casanova M, Graf S, Ketterer S, Drewe J, et al. Effect of peptide YY3-36 on food intake in humans. Gastroenterology 2005;129:1430-1436.
¶·È‰È·ÙÚÈ΋ 2007;70:308-315
Pediatri July-Aug 07
09-07-07
316
17:08
™ÂÏ›‰·316
∂¡¢π∞º∂ƒ√À™∞ ¶∂ƒπ¶∆ø™∏
CASE REPORT
™˘Ó‡·ÚÍË Ó¢ÚÔ‚Ï·ÛÙÒÌ·ÙÔ˜ Î·È ÎÏËÚÔÓÔÌÈ΋˜ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛ˘ 1 ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¡ÔÛÔÎÔÌ›Ԣ ™¿ÚÙ˘ 2 µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙ‹ÌÈÔ˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡” 3 ∞ÈÌ·ÙÔÏÔÁÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” AÏÏËÏÔÁÚ·Ê›·: πˆ¿ÓÓ˘ ¶. ¶·Ó·ÁÈÒÙÔ˘ gpp@hospspa.gr ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¡ÔÛÔÎÔÌ›Ԣ ™¿ÚÙ˘
π.¶. ¶·Ó·ÁÈÒÙÔ˘1, °. §¤Îη2, ∞. °·ÚÔ‡ÊË2, ∞. ™Ù·ÌÔ˘Ï·Î¿ÙÔ˘3, ∂. ¶ÚÂ̤Ù˘3, ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜2 ¶ÂÚ›ÏË„Ë: ∆Ô Ó¢ÚÔ‚Ï¿Ûو̷ Û˘ÓÈÛÙ¿ ÙÔÓ Û˘¯ÓfiÙÂÚÔ Â͈ÎÚ·ÓÈ·Îfi Û˘Ì·Á‹ ηÎÔ‹ıË fiÁÎÔ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜, ÂÎÚÔÛˆÒÓÙ·˜ ÙÔ 8-10% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ Î·ÎÔËıÒÓ ÓÔÛËÌ¿ÙˆÓ ÛÙ· ·È‰È¿. ¶ÚÔ¤Ú¯ÂÙ·È ·fi Ù· ·ÙÙ·Ú· ÙÔ˘ Û˘Ì·ıËÙÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Î·È Ë ÚÔ‚ÔÏ‹ ÙÔ˘ ÔÈΛÏÏÂÈ ÂÍ·ÚÙÒÌÂÓË ·fi ÙËÓ ÚˆÙÔ·ı‹ ÂÓÙfiÈÛË Î·È ÙÔ ÛÙ¿‰ÈÔ ÙÔ˘ fiÁÎÔ˘. ∏ ·Ó·ÈÌ›· ‰ÂÓ ·ÔÙÂÏ› Û‡ÓËı˜ ‡ÚËÌ· ÙÔ˘ Ó¢ÚÔ‚Ï·ÛÙÒÌ·ÙÔ˜ Î·È ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È Û ‰È‹ıËÛË ÙÔ˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ, ·ÈÌÔÚÚ·Á›· ÙÔ˘ fiÁÎÔ˘ ‹ ·˘ÙÔ¿ÓÔÛË ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›·. ∏ ÎÏËÚÔÓÔÌÈ΋ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛË Â›Ó·È ¤Ó· Û¯ÂÙÈο Û˘¯Ófi ·ÈÌ·ÙÔÏÔÁÈÎfi ÓfiÛËÌ· Ù˘ Ï¢΋˜ Ê˘Ï‹˜, Ô˘ ÚÔ‚¿ÏÏÂÈ Ì ·Ó·ÈÌ›·, ›ÎÙÂÚÔ, ÛÏËÓÔÌÂÁ·Ï›·. ∏ ÙÚÈ¿‰· ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Û ¿ÏÏÔ˘˜ ·ÛıÂÓ›˜ ÂÎÊÚ¿˙ÂÙ·È Ï‹Úˆ˜ Î·È Û ¿ÏÏÔ˘˜ Ë ˘fiÓÔÈ· Î·È ‰È¿ÁÓˆÛË ÙÔ˘ ÓÔÛ‹Ì·ÙÔ˜ ÚÔ·ÙÂÈ ÛÂ Ù˘¯·›Ô ·ÈÌ·ÙÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô. ªfiÓÔ ÙÔ 1/3 ÙˆÓ ÂÚÈÙÒÛÂˆÓ ‰È·ÁÈÁÓÒÛÎÂÙ·È Î·Ù¿ ÙÔÓ 1Ô ¯ÚfiÓÔ ˙ˆ‹˜. ∏ ÎÏËÚÔÓÔÌÈ΋ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛË ‰ÂÓ Û˘Óԉ‡ÂÙ·È ·fi ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ηÎÔËıÒÓ ÓÔÛËÌ¿ÙˆÓ. Œ¯Ô˘Ó ÂÚÈÁÚ·Ê› ÌÂÌÔӈ̤Ó˜ ÂÚÈÙÒÛÂȘ Û˘Ó‡·Ú͢ Ì ·ÈÌ·ÙÔÏÔÁÈΤ˜ ηÎÔ‹ıÂȘ, fiˆ˜ ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ ·Ó·ÈÌ›·, Î·È ·ÎfiÌË ÏÈÁfiÙÂÚ˜ ÌÂ Û˘Ì·Á›˜ fiÁÎÔ˘˜. ™˘Ó‡·ÚÍË ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛ˘ Î·È Ó¢ÚÔ‚Ï·ÛÙÒÌ·ÙÔ˜ ‰ÂÓ ¤¯ÂÈ Ì¤¯ÚÈ ÙÒÚ· ÂÚÈÁÚ·Ê›, fiˆ˜ ·˘Ùfi ÚÔ·ÙÂÈ ·fi ÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›·, ·Ó Î·È Ë Û˘¯ÓfiÙËÙ· ηıÂÌ›·˜ ·fi ÙȘ ‰‡Ô ηٷÛÙ¿ÛÂȘ ‰ÂÓ Â›Ó·È Î·È ÙfiÛÔ Û¿ÓÈ·. ¶ÂÚÈÁÚ¿ÊÂÙ·È ı‹Ï˘ ‚Ú¤ÊÔ˜ 2,5 ÌËÓÒÓ Ì ·Ó·ÈÌ›· Î·È ÌfiÚʈ̷ ·ÚÈÛÙÂÚÔ‡ ÂÈÓÂÊÚȉ›Ô˘ Ô˘ ·ÓÙÈÛÙÔȯԇÛ Û Ó¢ÚÔ‚Ï¿Ûو̷. ∏ ·Ó·ÈÌ›· ‹Ù·Ó ÙÔ ÚÔ¤¯ÔÓ Û‡Ìو̷ Î·È ‰ÂÓ ÔÊÂÈÏfiÙ·Ó ÛÙÔ Ó¢ÚÔ‚Ï¿Ûو̷ ·ÏÏ¿ Û ÎÏËÚÔÓÔÌÈ΋ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛË Ô˘ ÎÏËÚÔÓÔÌ‹ıËΠ̠˘ÔÏÂÈfiÌÂÓÔ ÛˆÌ·ÙÈÎfi ÁÔÓ›‰ÈÔ, fiˆ˜ ·Ô‰Â›¯ıËΠ·fi ÙÔÓ ¤ÏÂÁ¯Ô ÙÔ˘ ‚Ú¤ÊÔ˘˜ Î·È ÙˆÓ ÁÔÓ¤ˆÓ ÙÔ˘.
§¤ÍÂȘ ÎÏÂȉȿ: ¡Â˘ÚÔ‚Ï¿Ûو̷, ÎÏËÚÔÓÔÌÈ΋ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛË, ·Ó·ÈÌ›·, ‚Ú¤ÊÔ˜.
Coexistence of neuroblastoma and hereditary spherocytosis 1 Paediatric Department, Sparta Hospital 2 2nd Paediatric Department, University of Athens, “P. & A. Kyriakou” Children’s Hospital 3 Haematology Lab, “Aghia Sophia” Children’s Hospital Correspondence: John P. Panagiotou gpp@hospspa.gr Paediatric Clinic Sparta Hospital, Greece
J.P. Panagiotou1, G. Lekka2, A. Garoufi2, A. Stamoulakatou3, E. Premetis3, A. Constantopoulos2 Abstract: Neuroblastoma is the most common extracranial solid tumour of childhood, accounting for 810% of all childhood cancers. It originates from neural crest cells of the sympathetic nervous system and its clinical presentation depends on the primary tumour site and the extension of the disease. Anaemia is not a common feature of neuroblastoma, but when present it may be due to bone marrow metastasis, tumor haemorrhage or autoimmune haemolytic anaemia. Hereditary spherocytosis is a relatively common haematologic disease in Caucasian populations. Its cardinal symptoms are anaemia, jaundice, and splenomegaly, which may all be present, but some patients are asymptomatic and the disease is detected on routine examination. Only one third of cases are diagnosed during the first year of life. Hereditary spherocytosis is not associated with an increased risk of malignancies. Rarely, coexistence of spherocytosis with blood cancers, such as acute lymphoblastic leukaemia, has been reported and even less frequently with solid tumours. To the knowledge of the authors, coexistence of spherocytosis and neuroblastoma has never been described, even though neither condition is rare. The case is described of an infant girl, aged 2.5 months, who presented with anaemia as the primary symptom, and who had a mass in the left adrenal gland, found to be neuroblastoma. The cause of the anaemia was hereditary spherocytosis, transmitted as an autosomal recessive trait, as confirmed by the laboratory investigation of the infant and her parents. Key words: Neuroblastoma, hereditary spherocytosis, anaemia, infant.
∂ÈÛ·ÁˆÁ‹ ∆Ô Ó¢ÚÔ‚Ï¿Ûو̷ ·Ó‹ÎÂÈ ÛÙ· ηÎÔ‹ıË ÓÔÛ‹Ì·Ù· Î·È ÚÔ¤Ú¯ÂÙ·È ·fi Ù· ·ÙÙ·Ú· ÙÔ˘ Û˘Ì·ıËÙÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∏ Û˘¯ÓfiÙËÙ¿ ÙÔ˘ Â›Ó·È ÂÚ›Ô˘ 1:10.000 ·È‰È¿ Î·È ÂÎÚÔۈ› ÙÔ 8-10% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ Î·ÎÔËıÒÓ ÓÔPaediatriki 2007;70:316-319
ÛËÌ¿ÙˆÓ ÛÙ· ·È‰È¿. ™˘Ó‹ıˆ˜ ·ÊÔÚ¿ ·È‰È¿ οو ÙˆÓ 5 ÂÙÒÓ (50% οو ÙˆÓ 2 ÂÙÒÓ, 1/3 οو ÙÔ˘ 1 ÂÙfi˜) Î·È ··ÓÙ¿Ù·È Û˘¯ÓfiÙÂÚ· ÛÙ· ·ÁfiÚÈ·. ™Â ÌÂÚÈΤ˜ ÂÚÈÙÒÛÂȘ, Ô fiÁÎÔ˜ ·Ú¯›˙ÂÈ Ó· Û¯ËÌ·Ù›˙ÂÙ·È ÂÓ‰ÔÌËÙÚ›ˆ˜ Î·È ÌÔÚ› Ó· ‰È·ÁÓˆÛı› Ì ÙÔ ÂÌ‚Ú˘˚Îfi ˘ÂÚ˯ÔÁÚ¿ÊËÌ·.
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·317
317
¡Â˘ÚÔ‚Ï¿Ûو̷ Î·È ÎÏËÚÔÓÔÌÈ΋ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛË
™ÙË ‚ÚÂÊÈ΋ ËÏÈΛ·, ·ÔÙÂÏ› ÙÔÓ Û˘¯ÓfiÙÂÚÔ Û˘Ì·Á‹ fiÁÎÔ. ™Ù· 2/3 ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÍÂÎÈÓ¿ÂÈ ·fi ÙËÓ ÎÔÈÏÈ¿ Î·È ÙÔ 65% ·˘ÙÒÓ ·fi Ù· ÂÈÓÂÊÚ›‰È·. ªÔÚ› Ó· ÂÌÊ·Ó›˙ÂÈ Û˘ÌÙÒÌ·Ù· Ô˘ ÌÔÈ¿˙Ô˘Ó Ì ÔÔÈ·‰‹ÔÙ ¿ÏÏË ÓfiÛÔ, fiˆ˜ ‰È¿ÚÚÔȘ, ·ÓÔÚÂÍ›·, ÔÛÙÈο ¿ÏÁË ‹ Ó· ‰È·ÁÓˆÛı› ÛÂ Ù˘¯·›Ô ÎÏÈÓÈÎfi ‹ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô. ∏ ·Ó·ÈÌ›· ‰ÂÓ Â›Ó·È Û˘¯Ó‹ ÂΉ‹ÏˆÛË ÙÔ˘ Ó¢ÚÔ‚Ï·ÛÙÒÌ·ÙÔ˜ Î·È Û˘Ó‹ıˆ˜ ·ÎÔÏÔ˘ı› ÙË ¯ËÌÂÈÔıÂڷ›· (1-4). ∏ ÎÏËÚÔÓÔÌÈ΋ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛË Â›Ó·È ¤Ó· Û¯ÂÙÈο Û˘¯Ófi ·ÈÌ·ÙÔÏÔÁÈÎfi ÓfiÛËÌ· Ô˘ ÔÊ›ÏÂÙ·È Û ¤ÏÏÂÈÌÌ· ÙÔ˘ ÚˆÙÂ˚ÓÈÎÔ‡ ÂÚ˘ıÚÔ΢ÙÙ·ÚÈÎÔ‡ ÛÎÂÏÂÙÔ‡. ∆Ô ·ÔÙ¤ÏÂÛÌ· Ù˘ ‚Ï¿‚˘ ·˘Ù‹˜ Â›Ó·È Ù· ÂÚ˘ıÚ¿ ·ÈÌÔÛÊ·›ÚÈ· Ó· Ï·Ì‚¿ÓÔ˘Ó ÛÊ·ÈÚÈÎfi Û¯‹Ì·, Ó· Á›ÓÔÓÙ·È ‰‡ÛηÌÙ· (·˘ÍË̤ÓË Â˘ıÚ·˘ÛÙfiÙËÙ·) Î·È Ó· ηٷÛÙÚ¤ÊÔÓÙ·È Î·ıÒ˜ ‰È¤Ú¯ÔÓÙ·È ·fi Ù· ÙÚȯÔÂȉ‹ ·ÁÁ›· Ù˘ Û˘ÛÙËÌ·ÙÈ΋˜ ΢ÎÏÔÊÔÚ›·˜ Î·È Î˘Ú›ˆ˜ ÙÔ˘ ÛÏ‹Ó·. ∏ ›وۋ Ù˘ ÛÙË µfiÚÂÈ· ∂˘ÚÒË Â›Ó·È Û¯Â‰fiÓ 1:2000. ∏ ‰È¿ÁÓˆÛË ÌÔÚ› Ó· ÙÂı› ÛÙË ÓÂÔÁÓÈ΋, ÛÙË ‚ÚÂÊÈ΋ ‹ Û ÌÂÁ·Ï‡ÙÂÚË ËÏÈΛ·. ™ÙËÓ ÚÒÈÌË ‚ÚÂÊÈ΋ ËÏÈΛ· ÌÔÚ› Ó· ÚÔ‚¿ÏÂÈ Ì Ôχ ‚·Ú‡ Ê·ÈÓfiÙ˘Ô, ·ÎfiÌË Î·È Û ·ÛıÂÓ›˜ Ô˘ ·ÚÁfiÙÂÚ· ÂÌÊ·Ó›˙Ô˘Ó ‹È˜ ‹ ̤ÙÚÈ·˜ ‚·Ú‡ÙËÙ·˜ ÌÔÚʤ˜ Ù˘ ÓfiÛÔ˘ (5-7). ¶ÂÚÈÁÚ¿ÊÂÙ·È ‚Ú¤ÊÔ˜ ı‹Ï˘ ËÏÈΛ·˜ 2,5 ÌËÓÒÓ Ì Ó¢ÚÔ‚Ï¿Ûو̷ Î·È ÎÏËÚÔÓÔÌÈ΋ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛË, ‰‡Ô ÓÔÛÔÏÔÁÈΤ˜ ÔÓÙfiÙËÙ˜, Ë Û˘Ó‡·ÚÍË ÙˆÓ ÔÔ›ˆÓ ‰ÂÓ ¤¯ÂÈ ÂÚÈÁÚ·Ê› ̤¯ÚÈ Û‹ÌÂÚ· ÛÙËÓ ÂÏÏËÓÈ΋ ‹ ÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›·.
¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ £‹Ï˘ ‚Ú¤ÊÔ˜ 2,5 ÌËÓÒÓ ÂÈÛ‹¯ıË ÛÙËÓ ÎÏÈÓÈ΋ ÁÈ· ¤ÏÂÁ¯Ô ·Ó·ÈÌ›·˜. ∂›Ó·È ÙÔ ‰Â‡ÙÂÚÔ ·È‰› Ê·ÈÓÔÙ˘Èο ˘ÁÈÒÓ ÁÔÓ¤ˆÓ, Ô˘ ÁÂÓÓ‹ıËΠÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÙÔÎÂÙfi ÌÂÙ¿ ·fi ÙÂÏÂÈfiÌËÓË Ê˘ÛÈÔÏÔÁÈ΋ ·ËÛË Î·È Ì ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ 3390 g. ∆Ô ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ·Ó·Ê¤ÚÂÙ·È ÂχıÂÚÔ. ™Â ËÏÈΛ· 1,5 ÌËÓÒÓ ÓÔÛËχıËΠÁÈ· ‚ÚÔÁ¯ÈÔÏ›Ùȉ·, fiÔ˘ Î·È ‰È·ÈÛÙÒıËΠ·Ó·ÈÌ›· (Hb:8,8gr/dl, ∏t:24,5% ), Ë ÔÔ›· ÌÂÙ¿ ·fi 15 Ë̤Ú˜ ÂȉÂÈÓÒıËΠ(Hb:7,4gr/dl, ∏t:20,5%) Î·È ÂÈÛ‹¯ıË ÁÈ· ÂÚ·ÈÙ¤Úˆ ¤ÏÂÁ¯Ô. ∫·Ù¿ ÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË ‰È·ÈÛÙÒıËÎ·Ó ˆ¯ÚfiÙËÙ· Î·È „ËÏ·ÊËÙfi ÌfiÚʈ̷ ÛÙÔ ·ÚÈÛÙÂÚfi ˘Ô¯fiÓ‰ÚÈÔ, ÛÎÏËÚ‹˜ Û‡ÛÙ·Û˘, ·ÓÒ‰˘ÓÔ, ÎÈÓËÙfi, Ô˘ ‰ÂÓ Ê·ÈÓfiÙ·Ó Ó· ÂÍÔÚÌ¿Ù·È ·fi ÙÔÓ ÛÏ‹Ó·. ∏ ÏÔÈ‹ ηٿ Û˘ÛÙ‹Ì·Ù· ÂͤٷÛË ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋. ∏ ·Ó·ÈÌ›· ÙÔ˘ ‚Ú¤ÊÔ˘˜, Ì ‚¿ÛË Ù· ÌÔÚÊÔÏÔÁÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ÂÚ˘ıÚÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ, ‰ËÏ·‰‹ ·ÓÈÛÔ΢ÙÙ¿ÚˆÛË, ÌÈÎÚÔ΢ÙÙ¿ÚˆÛË, ÔÏ˘¯ÚˆÌ·ÙÔÊÈÏ›· Î·È ¤ÓÙÔÓË ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛË, ÙËÓ ·‡ÍËÛË ÙˆÓ ¢∂∫ (¢∂∫:9,04%, ‰ÈÔÚıˆÌ¤Ó· ¢∂∫:5,97%), ÙË ÌÈÎÚÔ‡ ‚·ıÌÔ‡ ¤ÌÌÂÛË ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›· (1,7mg/dl) Î·È ÙȘ ·ÚÓËÙÈΤ˜ ‰ÔÎÈ̷ۛ˜ Coombs,
Ù·ÍÈÓÔÌ‹ıËΠÛÙËÓ ÔÌ¿‰· ÙˆÓ ÌË ¿ÓÔÛˆÓ ·ÈÌÔÏ˘ÙÈÎÒÓ ·Ó·ÈÌÈÒÓ, Ì Èı·ÓfiÙÂÚË ‰È¿ÁÓˆÛË ÙËÓ ÎÏËÚÔÓÔÌÈ΋ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛË. ™ÙÔÓ ·ÂÈÎÔÓÈÛÙÈÎfi ¤ÏÂÁ¯Ô Ô˘ ·ÎÔÏÔ‡ıËÛ (˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜, ˘ÔÏÔÁÈÛÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÎÔÈÏ›·˜, ÛÈÓıËÚÔÁÚ¿ÊËÌ· Ì ÛÂÛËÌ·Ṳ̂ÓË ÌÂÙ·-Ȉ‰Ô-‚ÂÓ˙˘Ï-ÁÔ˘·Óȉ›ÓË (MIµG)) ‰È·ÈÛÙÒıËΠÛÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ÚfiÛıÈÔ˘ ·Ú·ÓÂÊÚÈÎÔ‡ ¯ÒÚÔ˘ ¢ÌÂÁ¤ı˘ ¯ˆÚÔηٷÎÙËÙÈ΋ ÂÍÂÚÁ·Û›· ̤ÁÈÛÙ˘ ‰È·Ì¤ÙÚÔ˘ 6 cm, Ì ÌÔÚÊÔÏÔÁÈο ¯·Ú·ÎÙËÚÈÛÙÈο Û˘Ì‚·Ù¿ Ì Ó¢ÚÔ‚Ï¿Ûو̷. ∞ÎÔÏÔ‡ıËÛ ÂÎÙÂٷ̤ÓÔ˜ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÚÔ˜ ÂȂ‚·›ˆÛË Ù˘ ‰È¿ÁÓˆÛ˘ Î·È ÛÙ·‰ÈÔÔ›ËÛË ÙÔ˘ ÓÔÛ‹Ì·ÙÔ˜. ªÂ ÙÔÓ ·Ú·ÎÏÈÓÈÎfi ¤ÏÂÁ¯Ô ‰ÂÓ ‰È·ÈÛÙÒıËÎ·Ó ·ÔÌ·ÎÚ˘Ṳ̂Ó˜ ÌÂÙ·ÛÙ¿ÛÂȘ. ∞ÎÔÏÔ‡ıËÛ ϋÚ˘ ¯ÂÈÚÔ˘ÚÁÈ΋ ÂÍ·›ÚÂÛË ÙÔ˘ ÚˆÙÔ·ıÔ‡˜ fiÁÎÔ˘. ∏ ·ıÔÏÔÁÔ·Ó·ÙÔÌÈ΋ ¤ÎıÂÛË ÂȂ‚·›ˆÛ ÙË ‰È¿ÁÓˆÛË ÙÔ˘ Ó¢ÚÔ‚Ï·ÛÙÒÌ·ÙÔ˜, ·ıÔÏÔÁÔ·Ó·ÙÔÌÈÎÔ‡ ÛÙ·‰›Ô˘ π, Î·È ÙÔ ‚Ú¤ÊÔ˜ ·Ú·¤ÌÊıËΠÛÙÔ √ÁÎÔÏÔÁÈÎfi ∆Ì‹Ì· ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ ÁÈ· ÂÚ·ÈÙ¤Úˆ ·ÓÙÈÌÂÙÒÈÛË. ªÂÙ¿ ÙËÓ ÔÏÔÎÏ‹ÚˆÛË Ù˘ ıÂڷ›·˜ ‰ÈÂÓÂÚÁ‹ıËΠϋÚ˘ ·ÈÌ·ÙÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÛÙÔ ‚Ú¤ÊÔ˜ Î·È Û fiÏË ÙËÓ ÔÈÎÔÁ¤ÓÂÈ·. ™ÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ ÚˆÙÂ˚ÓÒÓ Ù˘ ÌÂÌ‚Ú¿Ó˘ ÙˆÓ ÂÚ˘ıÚÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ ‰ÂÓ ‚Ú¤ıËΠη̛· ÔÛÔÙÈ΋ ‹ ÔÈÔÙÈ΋ ‰È·Ù·Ú·¯‹ ÙˆÓ ÚˆÙÂ˚ÓÒÓ. ™ÙË ‰ÔÎÈÌ·Û›· ÔÛ̈ÙÈ΋˜ ·ÓÙ›ÛÙ·Û˘ ÂÚ˘ıÚÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ Ì ‰È¿Ï˘Ì· NaCl 5 g/l ‰È·ÈÛÙÒıËΠχÛË ÛÙÔ 39% ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÙÔ˘ ‚Ú¤ÊÔ˘˜ Î·È ÛÙÔ 8,5% ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÙÔ˘ ·Ù¤Ú· (ÊÙ 0-5%), ÂÓÒ Û ‰È¿Ï˘Ì· NaCl 5,5 g/l ‰È·ÈÛÙÒıËΠχÛË ÛÙÔ 1,9% ÙˆÓ Î˘ÙÙ¿ÚˆÓ Ù˘ ÌËÙ¤Ú·˜ (ÊÙ 0%). ∆· ·ÔÙÂϤÛÌ·Ù· ÙÔ˘ ÂϤÁ¯Ô˘ ¤ıÂÛ·Ó ÙË ‰È¿ÁÓˆÛË Ù˘ ÎÏËÚÔÓÔÌÈ΋˜ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛ˘ Ì ۈ̷ÙÈÎfi ˘ÔÏÂÈfiÌÂÓÔ Ù‡Ô ÌÂÙ·‚›‚·Û˘.
™˘˙‹ÙËÛË ∆Ô Ó¢ÚÔ‚Ï¿Ûو̷ ·Ó‹ÎÂÈ ÛÙÔ˘˜ ηÎÔ‹ıÂȘ fiÁÎÔ˘˜ ÙÔ˘ Û˘Ì·ıËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Î·È ·ÓÙÈÚÔۈ‡ÂÈ ÙÔ 8-10% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ Î·ÎÔËıÒÓ ÓÔÛËÌ¿ÙˆÓ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜. ∂ȉÈÎfiÙÂÚ· fï˜, ÁÈ· ÙË ‚ÚÂÊÈ΋ ËÏÈΛ· ·ÔÙÂÏ› ÙÔÓ Û˘¯ÓfiÙÂÚÔ Û˘Ì·Á‹ fiÁÎÔ (2). ∏ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÔÈΛÏÏÂÈ ÛËÌ·ÓÙÈο Î·È ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ÂÓÙfiÈÛË Î·È ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ fiÁÎÔ˘. ™Â ÂÚ›Ô˘ 2/3 ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÂÓÙÔ›˙ÂÙ·È ÛÙËÓ ÎÔÈÏÈ¿ ÌÂ Û˘¯ÓfiÙÂÚË ÂÓÙfiÈÛË Ù· ÂÈÓÂÊÚ›‰È· Î·È ÎÏÈÓÈο ·ÚÔ˘ÛÈ¿˙ÂÙ·È Ì ‰ÈfiÁΈÛË ÎÔÈÏ›·˜, Ë ÔÔ›· Û˘¯Ó¿ ·Ó·Î·Ï‡ÙÂÙ·È Ù˘¯·›· ·fi ÙÔ˘˜ ÁÔÓ›˜ ‹ Ì „ËÏ·ÊËÙ‹ Ì¿˙· Ô˘ ·ÔηχÙÂÙ·È ÛÂ Ù˘¯·›· ÎÏÈÓÈ΋ ÂͤٷÛË ·fi ÙÔÓ ·È‰›·ÙÚÔ. ™Â ÂÚ›ÙˆÛË Ô˘ ˘¿Ú¯Ô˘Ó ‰ÈËı‹ÛÂȘ Î·È ¿ÏÏˆÓ ÔÚÁ¿ÓˆÓ, Ë ÓfiÛÔ˜ ÌÔÚ› Ó· ÚÔ‚¿ÏÂÈ Ì ·Ó¿ÏÔÁË ÎÏÈÓÈ΋ Û˘Ìو̷ÙÔÏÔÁ›·, fiˆ˜ ·Ó·ÈÌ›·, ·Ó ¤¯ÂÈ ¶·È‰È·ÙÚÈ΋ 2007;70:316-319
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·318
318
π.¶. ¶·Ó·ÁÈÒÙÔ˘ Î·È Û˘Ó.
‰ÈËıËı› Ô Ì˘ÂÏfi˜ ÙˆÓ ÔÛÙÒÓ, Ë·ÙÔÌÂÁ·Ï›· Û ÂÓÙfiÈÛË Ù˘ ÓfiÛÔ˘ ÛÙÔ ‹·Ú, ÎÏ (1,4,8). ™ÙËÓ ÂÚ›ÙˆÛË Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È, ÙÔ Ó¢ÚÔ‚Ï¿Ûو̷ ·ÔηχÊıËÎÂ Ù˘¯·›· ηٿ ÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË ÙÔ˘ ·È‰ÈÔ‡ Ô˘ ¤ÁÈÓ ÏfiÁˆ ·Ó·ÈÌ›·˜. ∞Ú¯Èο, ÙÔ „ËÏ·ÊËÙfi ÌfiÚʈ̷ Ô˘ ÂÓÙÔ›ÛıËΠÛÙËÓ ˘ÔÛÏËÓÈ΋ ÂÚÈÔ¯‹, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ˘¿Ú¯Ô˘Û· ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›·, ıˆڋıËÎÂ Û·Ó Èı·Ó‹ ÂÍˆÌ˘ÂÏÈ΋ ÂÛÙ›· ·ÈÌÔÔ›ËÛ˘. ™Â ·ÁfiÚÈ 9 ÂÙÒÓ Ì ÎÏËÚÔÓÔÌÈ΋ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛË ¤¯ÂÈ ÂÚÈÁÚ·Ê› ÂÍˆÌ˘ÂÏÈ΋ ·ÈÌÔÔ›ËÛË, ˘Ô‰˘fiÌÂÓË Ì¿˙· ÙˆÓ ÂÈÓÂÊÚȉ›ˆÓ, Ë ÔÔ›· ·ÔηχÊıËΠÛÙÔÓ ˘ÂÚ˯ÔÁÚ·ÊÈÎfi ¤ÏÂÁ¯Ô Ù˘ ÎÔÈÏ›·˜ Ô˘ ¤ÁÈÓ ÏfiÁˆ ÈÎÙ¤ÚÔ˘, ÂÓÒ Ë ÔÚÈÛÙÈ΋ ‰È¿ÁÓˆÛË Ù¤ıËΠ̠ÙÔÓ ·ÂÈÎÔÓÈÛÙÈÎfi ¤ÏÂÁ¯Ô Î·È ÙËÓ ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË ÙÔ˘ ÌÔÚÊÒÌ·ÙÔ˜ (9). ™ÙË ‰È΋ Ì·˜ ÂÚ›ÙˆÛË, Ù· ·ÂÈÎÔÓÈÛÙÈο Â˘Ú‹Ì·Ù· Ì·˜ ÚÔÛ·Ó·ÙfiÏÈÛ·Ó ÚÔ˜ ÙËÓ Èı·Ó‹ ‰È¿ÁÓˆÛË ÙÔ˘ Ó¢ÚÔ‚Ï·ÛÙÒÌ·ÙÔ˜, ÁÂÁÔÓfi˜ Ô˘ ÂÓÈÛ¯‡ıËΠ·fi ÙËÓ ·Ó‡ÚÂÛË ·˘ÍËÌ¤ÓˆÓ ÂȤ‰ˆÓ ‚·ÓÈÏÌ·Ó‰ÂÏÈÎÔ‡ (VMA) Î·È ÔÌÔ‚·ÏÈÓÈÎÔ‡ ÔͤԘ (HVA) ÛÙ· Ô‡Ú· Î·È ÙÂÏÈο ÂȂ‚·ÈÒıËΠ̠ÙËÓ ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË ÙÔ˘ ÚˆÙÔ·ıÔ‡˜ fiÁÎÔ˘. °ÂÓÈο, ÛÙË ‰È¿ÁÓˆÛË ÙÔ˘ Ó¢ÚÔ‚Ï·ÛÙÒÌ·ÙÔ˜ Û˘Ì‚¿ÏÏÔ˘Ó Ù· ·ÂÈÎÔÓÈÛÙÈο Â˘Ú‹Ì·Ù· Î·È ÔÈ ‚ÈÔ¯ËÌÈÎÔ› ‰Â›ÎÙ˜. ∞fi ÙÔ˘˜ ‚ÈÔ¯ËÌÈÎÔ‡˜ ‰Â›ÎÙ˜, ÛËÌ·ÓÙÈ΋ ‰È·ÁÓˆÛÙÈ΋ ·Í›· ¤¯Ô˘Ó Ù· ·˘ÍË̤ӷ ›‰· ÙˆÓ ÌÂÙ·‚ÔÏÈÙÒÓ ÙˆÓ Î·Ù¯ÔÏ·ÌÈÓÒÓ, VMA Î·È HVA, ÛÙ· Ô‡Ú· ÙˆÓ ·ÛıÂÓÒÓ, Ô˘ ‚Ú›ÛÎÔÓÙ·È ·˘ÍË̤ӷ Û ¿Óˆ ·fi 90% ÙˆÓ ÂÚÈÙÒÛˆÓ. ∞fi ÙÔÓ ·ÂÈÎÔÓÈÛÙÈÎfi ¤ÏÂÁ¯Ô, Ë ÈÔ ÂȉÈ΋ ÂͤٷÛË Â›Ó·È ÙÔ ÔÏfiÛˆÌÔ ÛÈÓıËÚÔÁÚ¿ÊËÌ· Ì MIBG, ·Ó Î·È ¿ÏϘ ·ÂÈÎÔÓÈÛÙÈΤ˜ ̤ıÔ‰ÔÈ, fiˆ˜ Ë ·Ï‹ ·ÎÙÈÓÔÁÚ·Ê›·, ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· Î·È Ë ˘ÔÏÔÁÈÛÙÈ΋ ÙÔÌÔÁÚ·Ê›·, ÚÔÛʤÚÔ˘Ó ÛËÌ·ÓÙÈ΋ ‚Ô‹ıÂÈ· (1). ∏ ÔÚÈÛÙÈ΋ ‰È¿ÁÓˆÛË Ù›ıÂÙ·È ·fi ÙËÓ ÈÛÙÔÏÔÁÈ΋ ÌÂϤÙË ÈÛÙÈÎÒÓ ‰ÂÈÁÌ¿ÙˆÓ ÙÔ˘ fiÁÎÔ˘, ‹ ·fi ÙÔ Û˘Ó‰˘·ÛÌfi ‰È‹ıËÛ˘ ÙÔ˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ Î·È ·˘ÍËÌ¤ÓˆÓ ÂȤ‰ˆÓ VMA Î·È HVA (3). ∏ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÓÔÛ‹Ì·ÙÔ˜ ÂÚÈÏ·Ì‚¿ÓÂÈ Û˘Ó‰˘·ÛÌfi ¯ÂÈÚÔ˘ÚÁÈ΋˜ ÂÍ·›ÚÂÛ˘, ¯ËÌÂÈÔıÂڷ›·˜ Î·È ·ÎÙÈÓÔıÂڷ›·˜. ™Â ÂÚÈÛÙ·ÙÈο Ì ‰˘ÛÌÂÓ‹ ÚfiÁÓˆÛË (ÛÙ¿‰ÈÔ IV, ˘ÔÙÚÔ‹ ÓfiÛÔ˘) ÌÔÚ› Ó· ÂȯÂÈÚËı› ·˘ÙfiÏÔÁË ÌÂÙ·ÌfiÛ¯Â˘ÛË ·Ú¯¤ÁÔÓˆÓ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ (1). ∏ ·Ó·ÈÌ›· Û ·È‰È¿ Ì ηÎÔ‹ıË ÓÔÛ‹Ì·Ù· Â›Ó·È ·ÚÎÂÙ¿ Û˘¯Ó‹ Î·È ÌÔÚ› Ó· Û¯ÂÙ›˙ÂÙ·È Ì ÙË ‰È‹ıËÛË ÙÔ˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ ·fi ηÎÔ‹ıË Î‡ÙÙ·Ú·, ÙË ¯ËÌÂÈÔıÂڷ›· Î·È ·ÎÙÈÓÔıÂڷ›· ‹/Î·È ÙËÓ ÔÍ›· ·ÒÏÂÈ· ·›Ì·ÙÔ˜. ∆· ÔÛÔÛÙ¿ ·Ó·ÈÌ›·˜ Â›Ó·È Û·ÊÒ˜ ÌÂÁ·Ï‡ÙÂÚ· ÛÙȘ ηÎÔ‹ıÂȘ Ì ‰È‹ıËÛË ÙÔ˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ (Ï¢¯·ÈÌ›·, ϤÌʈ̷, Ó¢ÚÔ‚Ï¿Ûو̷ ÛÙ·‰›Ô˘ 3-4), Û˘ÁÎÚÈÓfiÌÂÓ· Ì ¿ÏÏÔ˘˜ Ù‡Ô˘˜ ηÚΛÓÔ˘. ∏ ·Ó·ÈÌ›· Û fiϘ ·˘Ù¤˜ ÙȘ ÂÚÈÙÒÛÂȘ ›Paediatriki 2007;70:316-319
Ó·È Î·Ù¿ ηÓfiÓ· ÔÚıfi¯ÚˆÌË - ÔÚıÔ΢ÙÙ·ÚÈ΋, ÔÊÂÈÏfiÌÂÓË Û ·Ó·Ú΋ ·Ú·ÁˆÁ‹ ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÓ. ∏ ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›· Ô˘ Û˘Ó‰˘¿˙ÂÙ·È Ì ηÎÔ‹ıË ÓÔÛ‹Ì·Ù· ··ÓÙ¿Ù·È Î˘Ú›ˆ˜ Û ÏÂÌÊÒÌ·Ù·, Î·È ¤¯ÂÈ ¯·Ú·ÎÙËÚÈÛÙÈο ¿ÓÔÛÔ˘ Ù‡Ô˘ ·ÈÌÔÏ˘ÙÈ΋˜ ·Ó·ÈÌ›·˜ (10). ∆Ô È‰È·›ÙÂÚÔ ÛÙÔÈ¯Â›Ô Ù˘ ÂÚ›ÙˆÛ˘ Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È Â›Ó·È fiÙÈ Ë ·Ó·ÈÌ›· ‰ÂÓ Û˘Û¯ÂÙÈ˙fiÙ·Ó Ì ÙÔ Ó¢ÚÔ‚Ï¿Ûو̷, ·ÏÏ¿ ÔÊÂÈÏfiÙ·Ó Û ÌË ¿ÓÔÛÔ˘ Ù‡Ô˘ ·ÈÌfiÏ˘ÛË Î·È ÂȉÈÎfiÙÂÚ· ÛÙËÓ ÎÏËÚÔÓÔÌÈ΋ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛË, fiˆ˜ ÚԤ΢„ ·fi ÙÔÓ ÂÚ·ÈÙ¤Úˆ ¤ÏÂÁ¯Ô. ∏ ÎÏËÚÔÓÔÌÈ΋ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛË ·ÔÙÂÏ› ·ÈÌ·ÙÔÏÔÁÈÎfi ÓfiÛËÌ· Ô˘ ηٿ ηÓfiÓ· ÌÂÙ·‚È‚¿˙ÂÙ·È Ì ۈ̷ÙÈÎfi ÂÈÎÚ·ÙËÙÈÎfi (~75%), Û·ÓÈfiÙÂÚ· Ì ۈ̷ÙÈÎfi ˘ÔÏÂÈfiÌÂÓÔ ÁÔÓ›‰ÈÔ (~25%), ÂÓÒ ÌÈÎÚfi ÌfiÓÔ ÔÛÔÛÙfi ·ÊÔÚ¿ Ӥ˜ ÌÂÙ·ÏÏ¿ÍÂȘ. √Ê›ÏÂÙ·È Û ¤ÏÏÂÈÌÌ· ÙÔ˘ ÚˆÙÂ˚ÓÈÎÔ‡ ÂÚ˘ıÚÔ΢ÙÙ·ÚÈÎÔ‡ ÛÎÂÏÂÙÔ‡, Ô˘ ÌÔÚ› Ó· ·ÊÔÚ¿ ÔÛÔÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ ÙˆÓ ÚˆÙÂ˚ÓÒÓ ÛÂÎÙÚ›Ó˘, ·Á΢ڛÓ˘, ÚˆÙ½Ó˘ 3 ‹ ÚˆÙ½Ó˘ 4,2, Î·È Ô‰ËÁ› Û ÛÊ·ÈÚÈÎfi Û¯‹Ì· ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÓ (5). ∏ ÂÏ·Ùو̤ÓË Â˘Î·Ì„›· ÙˆÓ ÛÊ·ÈÚÔ΢ÙÙ·ÚÈÎÒÓ ÂÚ˘ıÚÔ΢ÙÙ¿ÚˆÓ ÚÔηÏ› ÙËÓ ÚfiˆÚË Î·Ù·ÛÙÚÔÊ‹ ÙÔ˘˜ ÛÙÔÓ ÛÏ‹Ó·. ∏ ‚·Ú‡ÙËÙ· Ù˘ ÓfiÛÔ˘ ÔÈΛÏÏÂÈ ·fi ·Û˘Ìو̷ÙÈ΋ ¤ˆ˜ ‚·ÚÈ¿ ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›· Ì ÛÏËÓÔÌÂÁ·Ï›· Î·È Û˘¯Ó¤˜ ÌÂÙ·ÁÁ›ÛÂȘ. ∏ ‰È¿ÁÓˆÛË Ù˘ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛ˘ Ù›ıÂÙ·È ·fi (5,6): 1) ÙËÓ ‡·ÚÍË ÛÙÔ Â›¯ÚÈÛÌ· ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÓ Û ÔÛÔÛÙfi ¿Óˆ ·fi 15-20%, 2) ÙË ‰ÔÎÈÌ·Û›· ÔÛ̈ÙÈ΋˜ ·ÓÙ›ÛÙ·Û˘ ÂÚ˘ıÚÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ (¤ÎıÂÛË Û ˘fiÙÔÓÔ ‰È¿Ï˘Ì· NaCl Ô‰ËÁ› Û ٷ¯‡ÙÂÚË Ï‡ÛË ÙˆÓ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÓ), Î·È 3) ÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ ÚˆÙÂ˚ÓÒÓ Ù˘ ÌÂÌ‚Ú¿Ó˘ ÙˆÓ ÂÚ˘ıÚÒÓ (ËÏÂÎÙÚÔÊfiÚËÛË Á¤Ï˘ ÁÈ· Ù·˘ÙÔÔ›ËÛË Ù˘ ÂȉÈ΋˜ ÚˆÙÂ˚ÓÈ΋˜ ·ÓˆÌ·Ï›·˜). ªÂ ÙË ‰ÔÎÈÌ·Û›· ÔÛ̈ÙÈ΋˜ ·ÓÙ›ÛÙ·Û˘ ÂÚ˘ıÚÒÓ ÂȂ‚·ÈÒıËÎÂ Ë ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛË ÛÙÔ ‚Ú¤ÊÔ˜ Î·È Ë ÂÙÂÚÔ˙˘ÁˆÙ›· ÛÙÔ˘˜ ÁÔÓ›˜. ¡· ÛËÌÂȈı› fiÙÈ ÙÔ ÁÂÁÔÓfi˜ Ù˘ ÌË Î·Ù·ÁÚ·Ê‹˜ ¢ÚËÌ¿ÙˆÓ ·fi ÙËÓ ·Ó¿Ï˘ÛË ÚˆÙÂ˚ÓÒÓ Ù˘ ÌÂÌ‚Ú¿Ó˘, fiˆ˜ Û˘Ó¤‚Ë ÛÙËÓ ÂÚ›ÙˆÛË Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È, ‰ÂÓ ·ÔÎÏ›ÂÈ ÙÔ ÓfiÛËÌ·, Î·È ÙfiÙÂ Ë ‰È¿ÁÓˆÛË Ù›ıÂÙ·È ·fi ÙË ‰ÔÎÈÌ·Û›· ÔÛ̈ÙÈ΋˜ ·ÓÙ›ÛÙ·Û˘ ÂÚ˘ıÚÒÓ Î·È ÙË ÌÔÚÊÔÏÔÁ›· ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜ Û ¿Û¯ÔÓÙ· Î·È ÁÔÓ›˜. ∏ Û˘Ó‡·ÚÍË ÛÊ·ÈÚÔ΢ÙÙ·ÚÈ΋˜ ·Ó·ÈÌ›·˜ Î·È Ó¢ÚÔ‚Ï·ÛÙÒÌ·ÙÔ˜ Ê·›ÓÂÙ·È Ó· ·ÔÙÂÏ› ÂÍ·ÈÚÂÙÈο Û¿ÓÈÔ Û˘Ó‰˘·ÛÌfi, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ‰ÂÓ ¤¯ÂÈ ÂÚÈÁÚ·Ê› ¿ÏÏÔ ·Ó¿ÏÔÁÔ ÂÚÈÛÙ·ÙÈÎfi ÛÙËÓ ÚÔÛÈÙ‹ Û ̷˜ ‰ÈÂıÓ‹ Î·È ÂÏÏËÓÈ΋ ‚È‚ÏÈÔÁÚ·Ê›·. ∞ÎfiÌË, ·ÛıÂÓ›˜ ÌÂ Û˘ÁÁÂÓ‹ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛË ‰ÂÓ Ê·›ÓÂÙ·È Ó· ÂÌÊ·Ó›˙Ô˘Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ·ÈÌ·ÙÔÏÔÁÈ΋˜ ‹ ¿ÏÏ˘ ηÎÔ‹ıÂÈ·˜, ·ÊÔ‡ ¤¯Ô˘Ó ·Ó·ÊÂÚı›
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·319
319
¡Â˘ÚÔ‚Ï¿Ûو̷ Î·È ÎÏËÚÔÓÔÌÈ΋ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛË
ÌÂÌÔӈ̤Ó˜ ÌfiÓÔ ÂÚÈÙÒÛÂȘ Û˘Ó‰˘·ÛÌÔ‡ Ù˘ .¯. Ì ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›·, ÌÂ Ì˘ÂÏÔ‰˘ÛÏ·ÛÙÈÎfi Û‡Ó‰ÚÔÌÔ ‹ Ì ÔÏÏ·ÏÔ‡Ó Ì˘¤ÏˆÌ· (11). Œ¯ÂÈ Â›Û˘ ·Ó·ÊÂÚı› ÌÂÙ·ÙÚÔ‹ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÂÚ˘ıÚÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ Û ÛÊ·ÈÚÔ·ÙÙ·Ú·, ÌÂÙ¿ ·fi ÂÒ·ÛË Ì ηÎÔ‹ıË Î‡ÙÙ·Ú·, ÚÔÊ·ÓÒ˜ ·fi ÙËÓ Â›‰Ú·ÛË Ô˘ ¿ÛÎËÛ·Ó ¿Óˆ ÙÔ˘˜ Ù· ηÎÔ‹ıË Î‡ÙÙ·Ú·, ¯ˆÚ›˜ fï˜ Ó· ÌÔÚ› Ó· ·ÈÙÈÔÏÔÁËı› ·˘Ùfi ÙÔ Ê·ÈÓfiÌÂÓÔ (12). ∆¤ÏÔ˜, Û˘Ó‡·ÚÍË Û˘ÁÁÂÓÔ‡˜ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛ˘ Ì ηÏÔ‹ıÂȘ fiÁÎÔ˘˜, fiˆ˜ ·Ì·ÚÙÒÌ·Ù· ÛÏËÓfi˜, ÂÛٛ˜ ÂÍˆÌ˘ÂÏÈ΋˜ ·ÈÌÔÔ›ËÛ˘ Î·È Ì˘ÂÏÔÏ›ˆÌ·, ·Ó·Ê¤ÚÔÓÙ·È Û˘¯ÓfiÙÂÚ· (9). ¶Èı·ÓÒ˜, ÛÙÔ Ì¤ÏÏÔÓ, ÂÊfiÛÔÓ ˘¿ÚÍÔ˘Ó ¿ÏÏ· ·Ó¿ÏÔÁ· ÂÚÈÛÙ·ÙÈο, Ó· ‰È¢ÎÚÈÓÈÛı› ·Ó Ë Û˘Ó‡·ÚÍË ÙˆÓ ‰‡Ô ·˘ÙÒÓ ‰È·ÊÔÚÂÙÈÎÒÓ ÓÔÛÔÏÔÁÈÎÒÓ ÔÓÙÔًوÓ, Ì›·˜ ·ÈÌ·ÙÔÏÔÁÈ΋˜ Î·È ÂÓfi˜ Û˘Ì·ÁÔ‡˜ fiÁÎÔ˘ (ÎÏËÚÔÓÔÌÈ΋ ÛÊ·ÈÚÔ΢ÙÙ¿ÚˆÛË-Ó¢ÚÔ‚Ï¿Ûو̷), ‹Ù·Ó Ù˘¯·›· ‹ ·Ó ˘¿Ú¯ÂÈ Î¿ÔÈÔ˜ ÎÔÈÓfi˜ ·ıÔÁÂÓÂÙÈÎfi˜ Ì˯·ÓÈÛÌfi˜.
3.
4. 5. 6.
7. 8.
9.
10. 11.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Caron H, Pearson A. Neuroblastoma. In: Voute PA, Kalifaand C, Barett A (editors). Cancer in children: Clinical management. 4th ed. Oxford University Press;1997. p 274-291. 2. Stiller CA, Draper GJ. The epidemiology of cancer in chil-
12.
dren. In: Voute PA, Kalifaand C, Barett A (editors). Cancer in children: Clinical management. 4th ed. Oxford University Press;1997. p 1-20. Golden CB, Feusner JH. Malignant abdominal masses in children: quick guide to evaluation and diagnosis. Pediatr Clin North Am 2002;49:1369-1392. Chandler JC, Gauderer MW. The neonate with an abdominal mass. Pediatr Clin North Am 2004;51:979-997. Packman CH. The spherocytic haemolytic anaemias. Br J Haematol 2001;112:888-899. Bolton-Maggs PH. The diagnosis and management of hereditary spherocytosis. Baillieres Best Pract Res Clin Haematol 2000;13:327-342. Segel GB, Hirsh MG, Feif SA. Managing anemia in pediatric office practice : Part 1. Pediatr Rev 2002;23:75-84. Michon J. Incidence of anemia in pediatric cancer patients in Europe: results of a large, international survey. Med Pediatr Oncol 2002;39:448-450. Calhoun SK, Murphy RC, Shariati N, Jacir N, Bergman K. Extramedullary hematopoiesis in a child with hereditary spherocytosis: an uncommon cause of an adrenal mass. Pediatr Radiol 2001;31:879-881. Ruggiero A, Riccardi R. Interventions for anemia in pediatric cancer patients. Med Pediatr Oncol 2002;39:451-454. Martinez-Climent JA, Lopez- Andreu JA, Ferris-Tortajada J, Perez-Sirvent ML, Castel-Sanchez V. Acute lymphoblastic leukaemia in a child with hereditary spherocytosis. Eur J Pediatr 1995;154:753-754. Chaimoff C, Fishman P, Hart J, Djaldetti M. Transformation of erythrocytes to spherocytes following incubation with malignant cells. J Submicrosc Cytol 1985;17:465-468.
¶·È‰È·ÙÚÈ΋ 2007;70:316-319
Pediatri July-Aug 07
09-07-07
320
17:08
™ÂÏ›‰·320
∂¡¢π∞º∂ƒ√À™∞ ¶∂ƒπ¶∆ø™∏
CASE REPORT
™˘ÁÁÂÓ‹˜ ÛÙ¤ÓˆÛË ÚÈÓÈÎÒÓ ÎÔÈÏÔÙ‹ÙˆÓ Î·È ÌÔÓ‹Ú˘ ÎÂÓÙÚÈÎfi˜ ¿Óˆ ÙÔ̤·˜ Ô‰fiÓÙ·˜ Û ÙÚ›· ‚Ú¤ÊË ¡ÂÔÁÓÔÏÔÁÈÎfi ∆Ì‹Ì· ∂™À, °¶¡ “πÔÎÚ¿ÙÂÈÔ”, £ÂÛÛ·ÏÔÓ›ÎË AÏÏËÏÔÁÚ·Ê›·: ∞ϤͷӉÚÔ˜ ∞Ó‰Ú¤Ô˘ aalex@the.forthnet.gr ÃÂÈ̈ӛ‰Ô˘ 15, ∫·Ï·Ì·ÚÈ¿ T.K. 551 33, £ÂÛÛ·ÏÔÓ›ÎË
∞. ∞Ó‰Ú¤Ô˘, ∞. ∫Ô‡ÙÏ·, ∂. ∑¢Á·Ú›‰Ô˘, A. ™·ÎÂÏÏ·ÚÔÔ‡ÏÔ˘ ¶ÂÚ›ÏË„Ë: ¶ÂÚÈÁÚ¿ÊÔÓÙ·È ÙÚ›· ‚Ú¤ÊË ÌÂ Û˘ÁÁÂÓ‹ ÛÙ¤ÓˆÛË ·ÈÔÂȉԇ˜ ÙÚ‹Ì·ÙÔ˜ (™™∞∆) Î·È ÌÔÓ‹ÚË ÎÂÓÙÚÈÎfi ¿Óˆ ÙÔ̤· Ô‰fiÓÙ· (ª∫∞∆√). √ ª∫∞∆√ Û ÓÂÔÁÓ¿ Ì ™™AT ·ÔÙÂÏ› ¤Ó·Ó ηϿ ÙÂÎÌËÚȈ̤ÓÔ, Û¿ÓÈÔ Û˘Ó‰˘·ÛÌfi Ô˘ ÂÚÈÁÚ¿ÊËΠÂÎÙÂÓÒ˜ ÙË ‰ÂηÂÙ›· ÙÔ˘ 1980. ∏ ‰È¿ÁÓˆÛË Ù˘ ™™∞∆ Ù¤ıËΠÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· ‚·ÛÈṲ̂ÓË ÛÙ· ÎÏÈÓÈο Â˘Ú‹Ì·Ù· Ù˘ ıÔÚ˘‚Ò‰Ô˘˜, Û˘Ú›ÙÙÔ˘Û·˜ ÚÈÓÈ΋˜ ·Ó·ÓÔ‹˜ Î·È Ù˘ ·‰˘Ó·Ì›·˜ ‰Èfi‰Ô˘ ÚÈÓÔÁ·ÛÙÚÈÎÔ‡ ηıÂÙ‹Ú· ÌÂÁ¤ıÔ˘˜ Fr 8. ∏ ÂȂ‚·›ˆÛË ¤ÁÈÓ Ì ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ¿Óˆ ÁÓ¿ıÔ˘. ∏ ‡·ÚÍË ª∫∞∆√ ‰È·ÁÓÒÛıËΠ̠·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ¿Óˆ ÁÓ¿ıÔ˘ ÛÙ· 2 ÂÚÈÛÙ·ÙÈο ηٿ ÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· Î·È ÛÙÔ ¿ÏÏÔ ÎÏÈÓÈο, Û ËÏÈΛ· 10 ÌËÓÒÓ. ŒÓ· ÓÂÔÁÓfi ›¯Â ÔÏϷϤ˜ Ì›˙ÔÓ˜ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ˘fi ÌÔÚÊ‹ Û˘Ó‰ÚfiÌÔ˘ Ì ˘Ô-˘ÔÊ˘ÛÈÛÌfi, ·ÙÚËÛ›· ÚˆÎÙÔ‡, ÎÚ˘„ÔÚ¯›·, ÌÈÎÚfi ¤Ô˜, ıÔψً ˘ÂÚÒ· Î·È ÓÂÊÚÈΤ˜ ·ÓˆÌ·Ï›Â˜. ∆· ¿ÏÏ· ‰‡Ô ›¯·Ó ‹È· Û˘ÓÔ‰¿ ÚÔ‚Ï‹Ì·Ù·, fiˆ˜ ·ÚÔ‰È΋ ‰˘ÛÊ·Á›· Î·È Î·ı˘ÛÙ¤ÚËÛË ÛˆÌ·ÙÈ΋˜ ·Ó¿Ù˘Í˘. ™˘˙ËÙÂ›Ù·È Ë Û¯¤ÛË Ô˘ ¤¯Ô˘Ó ÔÈ ·ÓˆÌ·Ï›Â˜ ·˘Ù¤˜ Ì ÛÔ‚·Ú¤˜ ·ı‹ÛÂȘ, fiˆ˜ Ë ÔÏÔÚÔÛÂÁÎÂÊ·Ï›·, Ô ˘Ô-˘ÔÊ˘ÛÈÛÌfi˜ Î·È ÙÔ ÎÔÓÙfi ·Ó¿ÛÙËÌ·. §¤ÍÂȘ ÎÏÂȉȿ: ™˘ÁÁÂÓ‹˜ ÛÙ¤ÓˆÛË ÚÈÓÈÎÒÓ ÎÔÈÏÔًوÓ, Û˘ÁÁÂÓ‹˜ ÛÙ¤ÓˆÛË ·ÈÔÂȉԇ˜ ÙÚ‹Ì·ÙÔ˜, ÌÔÓ‹Ú˘ ÎÂÓÙÚÈÎfi˜ ¿Óˆ ÙÔ̤·˜ Ô‰fiÓÙ·˜.
Congenital nasal pyriform stenosis and single central upper maxillary incisor in three infants Neonatology Department ¡∏π, Hippokration General Hospital, Thessaloniki, Greece Correspondence: Alexandros Andreou aalex@the.forthnet.gr 15, Chimonidou St, Kalamaria 551 33, Thessaloniki, Greece
A. Andreou, A. Koutla, E. Zeugaridou, A. Sakellaropoulou Abstract: Three neonates with congenital nasal pyriform stenosis (CNPS) and a single central maxillary incisor (SCMI) are described. SCMI in neonates with CNPS comprises a well documented but rare combination that was extensively described in the 1980s. The diagnosis of CNPS was made in infancy, based on the clinical findings of noisy, wheezing nasal breathing and the inability of passage of a rhinogastric tube size Fr 8. SCMI was diagnosed in infancy in two of the neonates by computer tomography (CT) scanning of upper maxilla, and in the third on the basis of clinical findings at the 10th month of age. One neonate had associated multiple major congenital abnormalities in the form of a syndrome, with hypopituitarism, anal atresia, cryptorchidism, small penis, high arched palate and renal malformations. The other two had mild coexisting problems, such as transient dysphagia and developmental retardation. The relationship between CNPS and SCMI and severe abnormalities, such as holoprosencephaly, hypopituitarism and short stature are discussed.
Key words: Congenital nasal stenosis, congenital nasal pyriform stenosis, single central upper maxillary incisor.
∂ÈÛ·ÁˆÁ‹ √ ÌÔÓ‹Ú˘ ÎÂÓÙÚÈÎfi˜ ¿Óˆ ÙÔ̤·˜ Ô‰fiÓÙ·˜ (ª∫∞∆√) Û ÓÂÔÁÓ¿ ÌÂ Û˘ÁÁÂÓ‹ ÛÙ¤ÓˆÛË ÚÈÓÈÎÒÓ ÎÔÈÏÔÙ‹ÙˆÓ (™™ƒ∫) ·ÔÙÂÏ› ¤Ó·Ó ηϿ ÙÂÎÌËÚȈ̤ÓÔ, Û¿ÓÈÔ Û˘Ó‰˘·ÛÌfi Ô˘ ÂÚÈÁÚ¿ÊËΠÂÎÙÂÓÒ˜ ÙË ‰ÂηÂÙ›· ÙÔ˘ 1980 (1). ∏ ™™ƒ∫ Û˘Óԉ¢fiÙ·Ó Ì ª∫∞∆√ Û ÔÛÔÛÙfi 60%-70% (2-4), ÂÓÒ Û ·ÛıÂÓ›˜ Ì ª∫∞∆√ Ë ·ÚÔ˘Û›· οÔÈ·˜ ÌÔÚÊ‹˜ ™™ƒ∫ Â›Ó·È ÛÙ·ıÂÚfi ‡ÚËÌ· (5). ªÂÌÔӈ̤ӷ ‹ ÛÂ Û˘Ó‰˘·ÛÌÔ‡˜, Ë ™™ƒ∫ Î·È Ô ª∫∞∆√ ÌÔÚ› Ó· Û˘Ó‰¤ÔÓÙ·È ÌÂ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ·fi ¿ÏÏ· Û˘ÛÙ‹Ì·Ù·, ÁÓˆÛÙ¿ Paediatriki 2007;70:320-324
Û‡Ó‰ÚÔÌ· Î·È ¯ÚˆÌÔÛˆÌÈΤ˜ ·ÓˆÌ·Ï›Â˜ ‹ Ó· ··ÓÙÔ‡Ó Û ηٿ Ù· ¿ÏÏ· Ê˘ÛÈÔÏÔÁÈο ¿ÙÔÌ· (6). ªÔÚ› ›Û˘, Ó· ·ÔÙÂÏÔ‡Ó ÙȘ ÌÔÓ·‰ÈΤ˜ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ÔÏÔÚÔÛÂÁÎÂÊ·Ï›·˜, ˘Ô-˘ÔÊ˘ÛÈÛÌÔ‡ Î·È Î·ı˘ÛÙ¤ÚËÛ˘ Ù˘ ·Ó¿Ù˘Í˘ ηٿ ÙË ‚ÚÂÊÈ΋ ËÏÈΛ· (6,7). ¶ÂÚÈÁÚ¿ÊÔ˘Ì ÙÚ›· ÓÂÔÁÓ¿ Ì ™™∞∆ Î·È ª∫∞∆√ ÁÈ· Ó· ÙÔÓÈÛı› Ë Û·ÓÈfiÙËÙ· Î·È Ë ÛËÌ·Û›· Ù˘ ‰È¿ÁÓˆÛ˘ ηٿ ÙË ÓÂÔÁÓÈ΋ ËÏÈΛ·.
¶ÂÚ›ÙˆÛË 1Ë ¡ÂÔÁÓfi, ·ÁfiÚÈ, ‰Â‡ÙÂÚÔ ·È‰› Ê·ÈÓÔÌÂÓÈο ˘ÁÈÒÓ ÁÔÓ¤ˆÓ Ô˘ ‰ÂÓ Â›¯·Ó Û˘ÁÁ¤ÓÂÈ· ÌÂٷ͇
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·321
321
™˘ÁÁÂÓ‹˜ ÛÙ¤ÓˆÛË ÚÈÓÈÎÒÓ ÎÔÈÏÔÙ‹ÙˆÓ Î·È ÌÔÓ‹Ú˘ ÎÂÓÙÚÈÎfi˜ ¿Óˆ ÙÔ̤·˜ Ô‰fiÓÙ·˜
ÙÔ˘˜, ÌÂٷʤÚıËΠÛÙËÓ ÎÏÈÓÈ΋ Ì·˜ ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË ÏfiÁˆ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜. °ÂÓÓ‹ıËΠ·fi 24¯ÚÔÓË ÌËÙ¤Ú· ÌÂÙ¿ ·fi ÔÌ·Ï‹ ÂÁ΢ÌÔÛ‡ÓË 39 ‚‰ÔÌ¿‰ˆÓ. ∆Ô ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ‹Ù·Ó ·ÚÓËÙÈÎfi ÁÈ· ˘ÔÛÌ›·, ÌÔÓ‹ÚË ÎÂÓÙÚÈÎfi ÙÔ̤· Ô‰fiÓÙ·, ·ÓˆÌ·Ï›Â˜ ÙÔ˘ ÚÔÛÒÔ˘ ‹ ¿ÏϘ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜. H ‚·ıÌÔÏÔÁ›· Apgar ‹Ù·Ó 9 ÛÙÔ 1Ô Î·È 5Ô ÏÂÙfi. ∆Ô µ° ‹Ù·Ó 3700 g, ÙÔ ª™ 54 cm Î·È Ë ¶∫ 36 cm. ∏ Ê˘ÛÈ΋ ÂͤٷÛË ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ¤‰ÂÈÍ 60 ·Ó·ÓÔ¤˜ ÛÙÔ ÏÂÙfi, ̤ÙÚȘ ÂÈÛÔÏΤ˜ ÌÂÛÔÏ¢ڛˆÓ Î·È ıÔÚ˘‚Ò‰Ë ÚÈÓÈ΋, ÂÈÛÓ¢ÛÙÈ΋ Î·È ÂÎÓ¢ÛÙÈ΋ ·Ó·ÓÔ‹. À‹Ú¯·Ó ·˘ÍË̤Ó˜ ÂÎÎÚ›ÛÂȘ Î·È ÛÙȘ ‰‡Ô ÚÈÓÈΤ˜ ÎÔÈÏfiÙËÙ˜ Î·È ·‰˘Ó·Ì›· ‰Èfi‰Ô˘ ÚÈÓÔÁ·ÛÙÚÈÎÔ‡ ηıÂÙ‹Ú· ÌÂÁ¤ıÔ˘˜ Fr 8 ‰È·Ì¤ÛÔ˘ Î·È ÙˆÓ ‰‡Ô ÚÈÓÈÎÒÓ ÎÔÈÏÔًوÓ. ∏ ÂͤٷÛË Ù˘ ÛÙÔÌ·ÙÈ΋˜ ÎÔÈÏfiÙËÙ·˜ ¤‰ÂÈÍ ÛÙÂÓ‹, ıÔψً ˘ÂÚÒ·. √È fiÚ¯ÂȘ ‰ÂÓ ‹Ù·Ó „ËÏ·ÊËÙÔ› ÛÙÔ fiÛ¯ÂÔ, Ô‡Ù ÛÙÔ˘˜ ‚Ô˘‚ˆÓÈÎÔ‡˜ fiÚÔ˘˜. ∆Ô Ì¤ÁÂıÔ˜ ÙÔ˘ ¤Ô˘˜ ‹Ù·Ó 1,5 cm Î·È ‹Ù·Ó ÌÈÎÚfiÙÂÚÔ ·fi ÙË 10Ë ∂ηÙÔÛÙÈ·›· £¤ÛË (∂£). À‹Ú¯Â ·ÙÚËÛ›· ÙÔ˘ ÚˆÎÙÔ‡. ∏ ÏÔÈ‹ Ê˘ÛÈ΋ ÂͤٷÛË ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋. √ Û˘Ó‹ı˘ ÂÚÁ·ÛÙËÚÈ·Îfi˜ Î·È ‚ÈÔ¯ËÌÈÎfi˜ ¤ÏÂÁ¯Ô˜ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜. ∏ ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ· ‚ÂÏÙÈÒıËΠ̠ÙËÓ ÙÔÔı¤ÙËÛË ÂÓfi˜ ÛÙÔÌ·ÙÈÎÔ‡ ·ÂÚ·ÁˆÁÔ‡. ∆ËÓ 3Ë Ë̤ڷ ˙ˆ‹˜ ‰ÈÂÓÂÚÁ‹ıËΠÎÔÏÔÛÙÔÌ›·. ∏ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ÙˆÓ ÚÈÓÈÎÒÓ ÎÔÈÏÔÙ‹ÙˆÓ Î·È Ù˘ ¿Óˆ ÁÓ¿ıÔ˘ ¤‰ÂÈÍÂ Û˘ÁÁÂÓ‹ ÛÙ¤ÓˆÛË ÛÙÔ ·ÈÔÂȉ¤˜ ÙÚ‹Ì· Î·È ª∫∞∆√ (∂ÈÎfiÓ· 1). ∏ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ¤‰ÂÈÍ ˘ÔÏ·Û›· Ù˘ ˘fiÊ˘Û˘, ¯ˆÚ›˜ ÛÙÔȯ›· ÔÏÔÚÔÛÂÁÎÂÊ·Ï›·˜. √ ˘ÂÚ˯ÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ù˘ ÎÔÈÏȷ΋˜ ¯ÒÚ·˜ ¤‰ÂÈÍ ‰ÈÏ·ÛÈ·ÛÌfi Ù˘ ÓÂÊÚÈ΋˜ ˘¤ÏÔ˘ ¿Ìʈ Î·È ¤Ó·Ó ÂÈÎÔ˘ÚÈÎfi ÛÏ‹Ó·, Ô˘ÚÈ·›· ÛÙÔÓ Ê˘ÛÈÔÏÔÁÈÎfi. ∆Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜, Ô ·ÎÙÈÓÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÙÔ˘ ÛÎÂÏÂÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Î·È Ù· ÔÙÈο Î·È ·ÎÔ˘ÛÙÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο. √ ηڢfiÙ˘Ô˜ ‹Ù·Ó ¿ÚÚÂÓÔ˜, 46ÃÀ. ∏ ™™∞∆ ·ÓÙÈÌÂÙˆ›ÛÙËΠ̠ÙËÓ ÙÔÔı¤ÙËÛË ÚÈÓÈÎÒÓ ÛˆÏËÓ·Ú›ˆÓ ¿Ìʈ ÁÈ· 2 Ì‹Ó˜. ™ÙË ‰È¿ÚÎÂÈ· 2 ¯ÚfiÓˆÓ ·Ú·ÎÔÏÔ‡ıËÛ˘, ÙÔ µ™, ÙÔ ª™ Î·È Ë ¶∫ ·Ú¤ÌÂÓ·Ó Î¿Ùˆ ·fi ÙË 10Ë ∂£. √È fiÚ¯ÂȘ ›¯·Ó η٤ÏıÂÈ ÛÙÔÓ ‚Ô˘‚ˆÓÈÎfi fiÚÔ, ÂÓÒ ÙÔ Ì‹ÎÔ˜ ÙÔ˘ ¤Ô˘˜ ·Ú¤ÌÂÈÓ οو ·fi ÙË 10Ë ∂£. ∏ „˘¯ÔÎÈÓËÙÈ΋ ·Ó¿Ù˘ÍË Î·Ù¿ Denver ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋. √ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ˘fiÊ˘Û˘ Û ËÏÈΛ· 2 ÂÙÒÓ ¤‰ÂÈÍ ·Ó¿ÚÎÂÈ· Ù˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ (›‰· ÛÙ· 0 ÏÂÙ¿: 0,36 ng/ml, ÛÙ· 60 ÏÂÙ¿: 0,48 ng/ml, ÛÙ· 90 ÏÂÙ¿: 0,44 ng/ml, Î·È ÛÙ· 120 ÏÂÙ¿: 0,4 ng/ml), Ù˘ ı˘Ï·ÎÈÔÙÚfiÔ˘ (FSH: 0) Î·È Ù˘ ˆ¯ÚÈÓÔÙÚfiÔ˘ ÔÚÌfiÓ˘ (LH: 0). ∂Ï·Ùو̤ӷ ‹Ù·Ó Î·È Ù· ›‰· ÔÏÈ΋˜ ı˘-
∂ÈÎfiÓ· 1. ™˘ÁÁÂÓ‹˜ ÛÙ¤ÓˆÛË ·ÈÔÂȉԇ˜ ÙÚ‹Ì·ÙÔ˜ Î·È ÌÔÓ‹Ú˘ ÎÂÓÙÚÈÎfi˜ ÙÔ̤·˜ Ô‰fiÓÙ·˜ ÛÙËÓ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ÙˆÓ ÚÈÓÈÎÒÓ ÎÔÈÏÔÙ‹ÙˆÓ Î·È Ù˘ ¿Óˆ ÁÓ¿ıÔ˘ ÛÙËÓ 1Ë ÂÚ›ÙˆÛË.
ÚÔ͛Ӣ (∆4: 2,78 mg/dl), ÔÏÈ΋˜ ÙÚÈ-Ȉ‰Ôı˘ÚÔÓ›Ó˘ (∆3: 51,6 ng/dl), ÂχıÂÚ˘ ∆4 (FT4: 0,51 ng/dl) Î·È ÂχıÂÚ˘ ∆3 (F∆3: 1,07 pg/dl). ∆· ›‰· Ù˘ ÊÏÔÈÔÙÚfiÔ˘ (ACTH) Î·È ı˘ÚÂÔÙÚfiÔ˘ ÔÚÌfiÓ˘ (TSH), ηıÒ˜ Î·È Ù˘ ÎÔÚÙÈ˙fiÏ˘ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο.
¶ÂÚ›ÙˆÛË 2Ë ¡ÂÔÁÓfi, ÎÔÚ›ÙÛÈ, ÙÚ›ÙÔ ·È‰› Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜, ÌÂٷʤÚıËΠÛÙËÓ ÎÏÈÓÈ΋ Ì·˜ Û ËÏÈΛ· 16 ËÌÂÚÒÓ, ÏfiÁˆ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ Î·È ÛÙ¤ÓˆÛ˘ ÙˆÓ ÚÈÓÈÎÒÓ ÎÔÈÏÔÙ‹ÙˆÓ ¿Ìʈ. ∏ ÌËÙ¤Ú·, 32 ÂÙÒÓ, ¤·Û¯Â ·fi ÛÎÏ‹Ú˘ÓÛË Î·Ù¿ Ͽη˜ Î·È ‰ÂÓ Â›¯Â Û˘ÁÁ¤ÓÂÈ· Ì ÙÔÓ Î·ıfiÏ· ˘ÁÈ‹ ·Ù¤Ú·. ¢ÂÓ ·Ó·Ê¤ÚÔÓÙ·È Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ÛÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÂÚÈ‚¿ÏÏÔÓ. ∆Ô Ì·È¢ÙÈÎfi ÈÛÙÔÚÈÎfi ‹Ù·Ó ÂχıÂÚÔ. ∏ ·ËÛË ÂÚ·ÙÒıËΠÙËÓ 37Ë Â‚‰ÔÌ¿‰·, Ì ηÈÛ·ÚÈ΋ ÙÔÌ‹ ÏfiÁˆ ÚÔËÁËı›۷˜. ∆Ô ÓÂÔÁÓfi ¤ÎÏ·„ ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË Î·È Ï›Á˜ ÒÚ˜ ·ÚÁfiÙÂÚ· ÂÌÊ¿ÓÈÛ ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ· Î·È ÂÈÛÓ¢ÛÙÈÎfi Û˘ÚÈÁÌfi. ∏ ÂÈÛ·ÁˆÁ‹ ÚÈÓÈÎÔ‡ ηıÂÙ‹Ú· ÌÂÁ¤ıÔ˘˜ Fr 6 Û ·ÌÊfiÙÂÚ˜ ÙȘ ÚÈÓÈΤ˜ ÎÔÈÏfiÙËÙ˜ ‰ÂÓ ‹Ù·Ó ‰˘Ó·Ù‹. §fiÁˆ Âȉ›ӈÛ˘ Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ ÙÔ ÓÂÔÁÓfi ÌÂٷʤÚıËΠÛÙËÓ ÎÏÈÓÈ΋ Ì·˜. ∫·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹, Ù· ۈ̷ÙÔÌÂÙÚÈο ¯·Ú·ÎÙËÚÈÛÙÈο ‹Ù·Ó µ° 2890 g, ª™ 48 cm Î·È ¶∫ 33,5 cm. ∂ÈÛÎÔÈο, ÙÔ ¯ÚÒÌ· ‹Ù·Ó Úfi‰ÈÓÔ, ÔÈ ·Ó·ÓÔ¤˜ ‹Ù·Ó 70 ÙÔ ÏÂÙfi Î·È ˘‹Ú¯Â ·Ó·¤Ù·ÛË ÚÈÓÈÎÒÓ ÙÂÚ˘Á›ˆÓ. ∞ÎÚÔ·ÛÙÈο, ˘‹Ú¯Â ÂÈÛÓ¢ÛÙÈÎfi˜ Û˘ÚÈÁÌfi˜. ¢ÂÓ ‹Ù·Ó ‰˘Ó·Ù‹ Ë ‰›Ô‰Ô˜ ÚÈÓÔÁ·ÛÙÚÈÎÔ‡ ηıÂÙ‹Ú· ÌÂÁ¤ıÔ˘˜ Fr 8 ‰È·Ì¤ÛÔ˘ ÙˆÓ ‰‡Ô ÚÈÓÈÎÒÓ ÎÔÈÏÔًوÓ. H ÂͤٷÛË ÙˆÓ ÏÔÈÒÓ Û˘ÛÙËÌ¿ÙˆÓ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋. ∆ËÓ 6Ë Ë̤ڷ ˙ˆ‹˜, ÏfiÁˆ Âȉ›ӈÛ˘ ¶·È‰È·ÙÚÈ΋ 2007;70:320-324
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·322
322
∞. ∞Ó‰Ú¤Ô˘ Î·È Û˘Ó.
Ϥ˜ Ì ÎËÚ›· ÌÂÁ¤ıÔ˘˜ Fr 7, 8 Î·È 9. §fiÁˆ ‰˘ÛÊ·Á›·˜, Ë Û›ÙÈÛË ÁÈÓfiÙ·Ó Ì ÚÈÓÔÁ·ÛÙÚÈÎfi ۈϋӷ ÁÈ· 8 Ë̤Ú˜. ™Â ËÏÈΛ· 1 ÌËÓfi˜ ÂÍ‹Ïı Ì µ™ 3240 g (3Ë-10Ë ∂£), ¶∫ 36 cm (50Ë-75Ë ∂£), Î·È ª™ 48 cm (10Ë ∂£). ™Â ËÏÈΛ· 3 ÌËÓÒÓ Ô ¤ÏÂÁ¯Ô˜ ÁÈ· ∆4, ∆3, ∆SH, ÎÔÚÙÈ˙fiÏË ÔÚÔ‡ Î·È ·˘ÍËÙÈ΋ ÔÚÌfiÓË ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜. ∆Ô ·ÌÈÓfiÁÚ·ÌÌ· ÔÚÔ‡, Ô‡ÚˆÓ Î·È Ù· ÔÚÁ·ÓÈο Ôͤ· Ô‡ÚˆÓ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο. √ ˘ÂÚ˯ÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ù˘ ÎÔÈÏÈ¿˜ Î·È ÔÈ ˆÙÔ·ÎÔ˘ÛÙÈΤ˜ ÂÎÔ̤˜ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈΤ˜. ∏ ·ÍÔÓÈ΋ Î·È Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈΤ˜. ™ÙÔÓ Â·Ó¤ÏÂÁ¯Ô Û ËÏÈΛ· 10,5 ÌËÓÒÓ ¤ÁÈÓ ·ÓÙÈÏËÙ‹, ÂÈÛÎÔÈο, Ë ‡·ÚÍË ª∫∞∆√. ™Â ËÏÈΛ· 25 ÌËÓÒÓ, ÙÔ µ™ ‹Ù·Ó 9700g (3Ë -10Ë ∂£), ÙÔ ª™ 76,5 cm (3Ë ∂£) Î·È Ë ¶∫ 46,5 cm (10Ë - 50Ë ∂£). ∏ „˘¯ÔÎÈÓËÙÈ΋ ·Ó¿Ù˘ÍË ÙÔ˘ ‚Ú¤ÊÔ˘˜ Ì ÙË ‰ÔÎÈÌ·Û›· Denver ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋. ∂ÈÎfiÓ· 2. ™˘ÁÁÂÓ‹˜ ÛÙ¤ÓˆÛË ·ÈÔÂȉԇ˜ ÙÚ‹Ì·ÙÔ˜ ÛÙËÓ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ÙˆÓ ÚÈÓÈÎÒÓ ÎÔÈÏÔÙ‹ÙˆÓ ÛÙË 2Ë ÂÚ›ÙˆÛË.
∂ÈÎfiÓ· 3. ™˘ÁÁÂÓ‹˜ ÛÙ¤ÓˆÛË ·ÈÔÂȉԇ˜ ÙÚ‹Ì·ÙÔ˜ Î·È ÌÔÓ‹Ú˘ ÎÂÓÙÚÈÎfi˜ ÙÔ̤·˜ Ô‰fiÓÙ·˜ ÛÙËÓ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ÙˆÓ ÚÈÓÈÎÒÓ ÎÔÈÏÔÙ‹ÙˆÓ Î·È Ù˘ ¿Óˆ ÁÓ¿ıÔ˘ ÛÙËÓ 3Ë ÂÚ›ÙˆÛË.
Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜, ÙÔ ÓÂÔÁÓfi ‰È·ÛˆÏËÓÒıËÎÂ Î·È ÙÔÔıÂÙ‹ıËΠÛÂ Û˘Ó¯‹ ıÂÙÈ΋ ›ÂÛË ·ÂÚ·ÁˆÁÒÓ ÁÈ· 2 Ë̤Ú˜. √ Û˘Ó‹ı˘ ·ÈÌ·ÙÔÏÔÁÈÎfi˜ Î·È ‚ÈÔ¯ËÌÈÎfi˜ ¤ÏÂÁ¯Ô˜ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜. ∏ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ÙˆÓ ÚÈÓÈÎÒÓ ÎÔÈÏÔÙ‹ÙˆÓ ¤‰ÂÈÍ ÛÙ¤ÓˆÛË ÛÙÔ ·ÈÔÂȉ¤˜ ÙÚ‹Ì· ¿Ìʈ (∂ÈÎfiÓ· 2). ∞ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ¿Óˆ ÁÓ¿ıÔ˘ ÁÈ· ÙËÓ ‡·ÚÍË ª∫∞∆√ ‰ÂÓ Ú·ÁÌ·ÙÔÔÈ‹ıËΠÁÈ· Ù¯ÓÈÎÔ‡˜ ÏfiÁÔ˘˜. ∏ ·Ï‹ ·ÎÙÈÓÔÁÚ·Ê›· ¿Óˆ ÁÓ¿ıÔ˘ ‰ÂÓ ÛÎÈ·ÁÚ¿ÊËÛ ¢ÎÚÈÓÒ˜ ÙȘ Ô‰ÔÓÙÈΤ˜ Ú›˙˜ Î·È ‰ÂÓ ‹Ù·Ó ‰È·ÁÓˆÛÙÈ΋ ÁÈ· ‡·ÚÍË ‹ ÌË ª∫∞∆√. ∏ ™™∞∆ ·ÓÙÈÌÂÙˆ›ÛÙËΠ̠‰È·ÛÙÔPaediatriki 2007;70:320-324
¶ÂÚ›ÙˆÛË 3Ë ¡ÂÔÁÓfi, ÎÔÚ›ÙÛÈ, 1Ô ·È‰› Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜, ÌÂٷʤÚıËΠÛÙËÓ ÎÏÈÓÈ΋ Ì·˜ ÙÔ 2Ô 24ˆÚÔ ˙ˆ‹˜, ÏfiÁˆ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ Î·È ÌÂÁ¿Ï˘ ÛÙ¤ÓˆÛ˘ ÙˆÓ ÚÈÓÈÎÒÓ ÎÔÈÏÔÙ‹ÙˆÓ ¿Ìʈ. ∏ ÌËÙ¤Ú·, 30 ÂÙÒÓ, Î·È Ô ·Ù¤Ú·˜, 37 ÂÙÒÓ, ‹Ù·Ó Ê·ÈÓÔÌÂÓÈο ˘ÁÈ›˜ Î·È ‰ÂÓ Â›¯·Ó Û˘ÁÁ¤ÓÂÈ· ÌÂٷ͇ ÙÔ˘˜. ¢ÂÓ ·Ó·Ê¤ÚÔÓÙ·È ¿ÙÔÌ· ÌÂ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ÛÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÂÚÈ‚¿ÏÏÔÓ. ∏ ·ËÛË ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋ Î·È ÂÚ·ÙÒıËΠÙËÓ 39Ë Â‚‰ÔÌ¿‰·, Ì ÛÈ··. ∏ ‚·ıÌÔÏÔÁ›· Apgar ‹Ù·Ó 9 ÛÙÔ 1Ô Î·È 5Ô ÏÂÙfi. ∆Ô ÓÂÔÁÓfi ÂÌÊ¿ÓÈÛ ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË ¤ÓÙÔÓË ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ·, ÂÈÛÓ¢ÛÙÈÎfi Û˘ÚÈÁÌfi Î·È Ì¤ÙÚȘ ÂÈÛÔÏΤ˜ ÌÂÛÔÏ¢ڛˆÓ. ŒÁÈÓ ·Ú¯Èο ÚÔÛ¿ıÂÈ· ÂÈÛfi‰Ô˘ ÚÈÓÔÁ·ÛÙÚÈÎÔ‡ ηıÂÙ‹Ú· ÌÂÁ¤ıÔ˘˜ Fr 8 ·ÌÊÔÙÂÚfiÏ¢ڷ, Ë ÔÔ›· ·¤Ù˘¯Â. ÃÔÚËÁ‹ıËΠÔ͢ÁfiÓÔ Ì ̿Ûη ÁÈ· Ì›· Ë̤ڷ Î·È ÙË 2Ë Ë̤ڷ ˙ˆ‹˜ ÏfiÁˆ Âȉ›ӈÛ˘ Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ ‰È·ÛˆÏËÓÒıËÎÂ Î·È ‰È·ÎÔÌ›ÛÙËΠÛÙËÓ ÎÏÈÓÈ΋ Ì·˜. ∫·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹, Ù· ۈ̷ÙÔÌÂÙÚÈο ¯·Ú·ÎÙËÚÈÛÙÈο ‹Ù·Ó µ° 3150 g (25Ë -50Ë ∂£), ¶∫ 34 cm (50Ë ∂£)Î·È ª™ 50 cm (50Ë -75Ë ∂£). ∏ ·fiÛÙ·ÛË ÌÂٷ͇ ÙˆÓ ¤Íˆ ηÓıÒÓ ‹Ù·Ó 5,1 cm (3Ë ∂£), ÌÂٷ͇ ÙˆÓ ¤Ûˆ ηÓıÒÓ 1,7cm (3Ë ∂£) Î·È ÌÂٷ͇ ÙˆÓ ÎÔÚÒÓ 3,1 cm (<3Ë ∂£). ∏ ÂͤٷÛË ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÙÔ˘ ‰È·ÛˆÏËӈ̤ÓÔ˘ ÓÂÔÁÓÔ‡ ¤‰ÂÈÍ ÚÈÓÈ΋ Û˘ÌÊfiÚËÛË Î·È ¤ÎÎÚÈÌ· ¿Ìʈ. ∆· ÏÔÈ¿ Û˘ÛÙ‹Ì·Ù· ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο. ∆Ô ÓÂÔÁÓfi Ù¤ıËΠ۠ÂÓ‰ÔÙÚ·¯Âȷ΋ ÂÊ·ÚÌÔÁ‹ Û˘Ó¯ԇ˜ ıÂÙÈ΋˜ ›ÂÛ˘ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ ÁÈ· 6 Ë̤Ú˜ Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÙÔÔıÂÙ‹ıËΠ·ÂÚ·ÁˆÁfi˜ ÁÈ· 3 Ë̤Ú˜. À‹Ú¯Â ‰˘Û¯¤ÚÂÈ· ÛÙË Û›ÙÈÛË Î·È ÙËÓ Î·Ù¿ÔÛË. √ Û˘Ó‹ı˘ ·ÈÌ·ÙÔÏÔÁÈÎfi˜ Î·È ‚ÈÔ¯ËÌÈÎfi˜ ¤ÏÂÁ¯Ô˜
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·323
323
™˘ÁÁÂÓ‹˜ ÛÙ¤ÓˆÛË ÚÈÓÈÎÒÓ ÎÔÈÏÔÙ‹ÙˆÓ Î·È ÌÔÓ‹Ú˘ ÎÂÓÙÚÈÎfi˜ ¿Óˆ ÙÔ̤·˜ Ô‰fiÓÙ·˜
‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜. ∏ ·ÎÙÈÓÔÁÚ·Ê›· ıÒÚ·ÎÔ˜, ηıÒ˜ Î·È Ô ˘ÂÚ˯ÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ù˘ ηډȿ˜ Î·È ÙˆÓ ÓÂÊÚÒÓ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜. ∏ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ¿Óˆ ÁÓ¿ıÔ˘ Î·È ÚÈÓÈÎÒÓ ÎÔÈÏÔÙ‹ÙˆÓ ·ÔÎ¿Ï˘„ ™™∞∆ Î·È ‡·ÚÍË ª∫∞∆√ (∂ÈÎfiÓ· 3). ∆Ô Â‡ÚÔ˜ ÙˆÓ ÚÈÓÈÎÒÓ ¯Ô·ÓÒÓ ÛÙÔ ‡„Ô˜ ÙÔ˘ ·ÈÔÂȉԇ˜ ÎfiÏÔ˘ ‹Ù·Ó 3,6 mm Î·È 4,8 mm ·ÓÙ›ÛÙÔȯ· (º.∆. 13,4 mm). ∏ ‚˘ıÔÛÎfiËÛË Î·È Ù· ·ÎÔ˘ÛÙÈο ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο. ∂Í‹Ïı Û ËÏÈΛ· ÂÓfi˜ ÌËÓfi˜ Ì ‹ÈÔ ÂÈÛÓ¢ÛÙÈÎfi Û˘ÚÈÁÌfi. ™Â ËÏÈΛ· ÙÚÈÒÓ ÌËÓÒÓ Ë Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋.
™˘˙‹ÙËÛË ∏ ‡·ÚÍË ª∫∞∆√ ·Ó·Ê¤ÚıËΠÁÈ· ÚÒÙË ÊÔÚ¿ ÙÔ 1958 ·fi ÙÔÓ Scott (8). H Û‡Ó‰ÂÛË ÙÔ˘ ª∫∞∆√ Ì ÙË ™™ƒ∫ ·Ó·ÁÓˆÚ›ÛıËΠ·fi ÙÔ˘˜ Arlis Î·È Û˘Ó. ÙÔ 1992 (5,9). À¿Ú¯Ô˘Ó ÙÚÂȘ Ù‡ÔÈ ™™ƒ∫ ·Ó¿ÏÔÁ· Ì ÙËÓ ·Ó·ÙÔÌÈ΋ ı¤ÛË Ù˘ ÛÙ¤ÓˆÛ˘ Î·È fiÏÔÈ ÙÔ˘˜ ÌÔÚ› Ó· Û˘Ó‰˘¿˙ÔÓÙ·È Ì ª∫∞∆√. ∂›Ó·È Ë ·ÙÚËÛ›· ÙˆÓ Ô›ÛıÈˆÓ ÚÈÓÈÎÒÓ ¯Ô·ÓÒÓ, Ë ÌÂÛÔÚÈÓÈ΋ ÛÙ¤ÓˆÛË Î·È Ë ÚfiÛÊ·Ù· ·Ó·ÁÓˆÚÈÛı›۷ ÛÙ¤ÓˆÛË ÙÔ˘ ·ÈÔÂȉԇ˜ ÙÚ‹Ì·ÙÔ˜ (1). ∆Ô ·ÈÔÂȉ¤˜ ÙÚ‹Ì· Â›Ó·È ÙÔ ÛÙÂÓfiÙÂÚÔ ÔÛÙ¤ÈÓÔ ÙÌ‹Ì· Ù˘ ÚÈÓÈ΋˜ ÎÔÈÏfiÙËÙ·˜ Î·È ‹Ù·Ó Ë ·ÈÙ›· ™™ƒ∫ Î·È ÛÙȘ ÙÚÂȘ ÂÚÈÙÒÛÂȘ Ô˘ ÂÚÈÁÚ¿ÊËηÓ. ∏ ÛÙ¤ÓˆÛ‹ ÙÔ˘ ıˆÚÂ›Ù·È fiÙÈ ÔÊ›ÏÂÙ·È Û ˘ÂÚ·Ó¿Ù˘ÍË Ù˘ ¿Óˆ ÁÓ¿ıÔ˘ ηٿ ÙËÓ ÂÌ‚Ú˘ÔÁ¤ÓÂÛË (5). ∫Ï·ÛÈο, Ë ·‰˘Ó·Ì›· ‰Èfi‰Ô˘ ÚÈÓÔÁ·ÛÙÚÈÎÔ‡ ηıÂÙ‹Ú· ÌÂÁ¤ıÔ˘˜ Fr 8 ı¤ÙÂÈ ÙËÓ ˘Ô„›· ÁÈ· ÔÛÙ¤ÈÓË ÚÈÓÈ΋ ·fiÊÚ·ÍË, fiˆ˜ ÛÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ÂÚÈÁÚ¿ÊÔÓÙ·È. ∏ ™™∞∆ ıˆÚÂ›Ù·È ·Û˘Ó‹ı˘ ·ÈÙ›· ÚÈÓÈ΋˜ ·fiÊڷ͢ ÛÙ· ÓÂÔÁÓ¿ Î·È ÛÙ· ·È‰È¿, Èı·ÓfiÓ fï˜, Ó· Â›Ó·È ÈÔ Û˘¯Ó‹ (3) Î·È ÚÔηÏ› fiÌÔÈ· ÎÏÈÓÈο ÛËÌ›· Ì ÙËÓ ·ÙÚËÛ›· ÙˆÓ ÚÈÓÈÎÒÓ ¯Ô·ÓÒÓ (10). ∏ ÛÔ‚·ÚfiÙËÙ· ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÔÈΛÏÏÂÈ ·Ó¿ÏÔÁ· Ì ÙÔÓ ‚·ıÌfi Ù˘ ·fiÊڷ͢ Î·È ÂΉËÏÒÓÂÙ·È Ì ÚÈÓÈ΋ Û˘ÌÊfiÚËÛË, Û˘ÚÈÁÌfi, ΢ÎÏÈο ÂÂÈÛfi‰È· ΢¿ÓˆÛ˘ Î·È ·ÂÈÏËÙÈΤ˜ ÁÈ· ÙË ˙ˆ‹ ηٷÛÙ¿ÛÂȘ. ∏ ‡·ÚÍË ª∫∞∆√ Á›ÓÂÙ·È Û˘Ó‹ıˆ˜ ·ÓÙÈÏËÙ‹ ηٿ ÙË ‚ÚÂÊÈ΋ ËÏÈΛ· ÌÂÙ¿ ÙËÓ ·Ó·ÙÔÏ‹ ÙˆÓ ÓÂÔÁÈÏÒÓ Ô‰fiÓÙˆÓ, fiˆ˜ Ë 2Ë ÂÚ›ÙˆÛË. ∏ ˘fiÓÔÈ· ‡·Ú͢ ª∫∞∆√ ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ· Ù›ıÂÙ·È fiÙ·Ó ˘¿Ú¯ÂÈ ™™ƒ∫ Î·È Ë ‰È¿ÁÓˆÛË ‚·Û›˙ÂÙ·È ÛÙËÓ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ¿Óˆ ÁÓ¿ıÔ˘, fiˆ˜ Û˘Ó¤‚Ë ÛÙËÓ 1Ë Î·È 3Ë ÂÚ›ÙˆÛË. ™ÙË 2Ë ÂÚ›ÙˆÛË ÏfiÁˆ Ù¯ÓÈÎÔ‡ Έχ̷ÙÔ˜ ‰ÂÓ ¤ÁÈÓ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ¿Óˆ ÁÓ¿ıÔ˘ Î·È Ë ·Ï‹ ·ÎÙÈÓÔÁÚ·Ê›· ¿Óˆ ÁÓ¿ıÔ˘ ‰ÂÓ ‹Ù·Ó ‰È·ÁÓˆÛÙÈ΋ ÏfiÁˆ Î·È Ù˘ ÌË Î·Ï‹˜ ·Û‚ÂÛÙÔÔ›ËÛ˘ ÙˆÓ Ô‰fiÓÙˆÓ Û ·˘Ù‹ ÙËÓ ËÏÈΛ·. ∏ ™™ƒ∫ Î·È Ô ª∫∞∆√ ÌÂÌÔӈ̤ӷ ‹ ÛÂ Û˘Ó‰˘·ÛÌfi ¤¯Ô˘Ó ·Ó·ÊÂÚı› Û·Ó ÌÂÌÔӈ̤ӷ Â˘Ú‹Ì·-
Ù· Û ʷÈÓÔÌÂÓÈο ˘ÁÈ›˜ ·ÛıÂÓ›˜. ™ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ Û˘Ó‰¤ÔÓÙ·È Ì ¿ÏϘ Û˘ÁÁÂÓ›˜ Î·È ¯ÚˆÌÔÛˆÌÈΤ˜ ·ÓˆÌ·Ï›Â˜ ‹ ÁÓˆÛÙ¿ Û‡Ó‰ÚÔÌ· (6). °È· ÙÔÓ ¤ÏÂÁ¯Ô Û˘ÓÔ‰ÒÓ ·ÓˆÌ·ÏÈÒÓ ı· Ú¤ÂÈ Ó· ‰ÈÂÓÂÚÁÂ›Ù·È Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, ¯ÚˆÌÔÛˆÌÈ΋ ·Ó¿Ï˘ÛË, ¤ÏÂÁ¯Ô˜ Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ˘fiÊ˘Û˘, ÔÚÌÔÓÈÎfi˜ ¤ÏÂÁ¯Ô˜ Î·È ¤ÏÂÁ¯Ô˜ ÙˆÓ ËÏÂÎÙÚÔÏ˘ÙÒÓ. ∏ ™™ƒ∫ Â›Ó·È Û˘¯Ófi Î·È Î·Ù¿ ÔÚÈṲ̂ÓÔ˘˜ (5) ÛÙ·ıÂÚfi ‡ÚËÌ· Û ª∫∞∆√ (2,3,5,9). ∏ ™™∞∆ ¤¯ÂÈ ·Ó·ÊÂÚı› fiÙÈ Û˘Óԉ‡ÂÙ·È ·fi ª∫∞∆√ Û ÔÛÔÛÙfi 60%-70% (2,4). ∫·ıÒ˜ Ë ™™ƒ∫ ‰È·ÁÈÁÓÒÛÎÂÙ·È Î˘Ú›ˆ˜ ÛÙË ÓÂÔÁÓÈ΋ ËÏÈΛ·, ÌÔÚ› Ó· ıˆÚËı› ˆ˜ ÛÙÔÈ¯Â›Ô ÁÈ· ÙË ‰È¿ÁÓˆÛË ÙÔ˘ ª∫∞∆√, ÚÈÓ ÙËÓ ·Ó·ÙÔÏ‹ ÙˆÓ ÓÂÔÁÈÏÒÓ Ô‰fiÓÙˆÓ. ™Â οı ÓÂÔÁÓfi Ì ˘Ô„›· ™™ƒ∫ ı· Ú¤ÂÈ Ó· ‰ÈÂÓÂÚÁÂ›Ù·È ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ÙÔ˘ ÚÔÛÒÔ˘, ·fi ÙËÓ ˘ÂÚÒ· ̤¯ÚÈ ÙË ÌÂÛfiÙËÙ· ÙÔ˘ ÔÊı·ÏÌÈÎÔ‡ ÎfiÁ¯Ô˘ (10,11) ÁÈ· ‰È¿ÁÓˆÛË Î·È ÂÓÙÔÈÛÌfi Ù˘ ÚÈÓÈ΋˜ ·fiÊڷ͢ Î·È ÙÔ˘ ª∫∞∆√. ∆Ô ÎÔÓÙfi ·Ó¿ÛÙËÌ· Â›Ó·È ¤Ó· ·fi Ù· ÚÒÙ· Â˘Ú‹Ì·Ù· Ô˘ Û˘Ó‰˘¿ÛÙËÎ·Ó Ì ™™ƒ∫ Î·È ª∫∞∆√ (2,5,9). ∏ 1Ë Î·È 2Ë ÂÚ›ÙˆÛË ·ÚÔ˘Û›·Û·Ó ÛËÌ·ÓÙÈ΋ ηı˘ÛÙ¤ÚËÛË Ù˘ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘ Î·È ‰˘ÛÙÚÔÊ›·. ™ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ, Ë ·ÈÙÈÔÏÔÁ›· Â›Ó·È Ë ·Ó¿ÚÎÂÈ· Ù˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘. ∞fi Ù· ‰‡Ô ÂÚÈÛÙ·ÙÈο Ì·˜ Ì ÎÔÓÙfi ·Ó¿ÛÙËÌ·, Ô ¤Ó·˜ ·ÛıÂÓ‹˜ ›¯Â ·Ó¿ÚÎÂÈ· ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ Î·È ˘Ô-˘ÔÊ˘ÛÈÛÌfi. ∏ ™™∞∆ Î·È Ô ª∫∞∆√ ·ÔÙÂÏÔ‡Ó ·ÓˆÌ·Ï›Â˜ Ù˘ ̤Û˘ ÁÚ·ÌÌ‹˜ Î·È ÌÔÚ› ·fi ÌfiÓ˜ ÙÔ˘˜ Ó· Â›Ó·È ÔÈ ÌÔÓ·‰ÈΤ˜ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ÔÏÔÚÔÛÂÁÎÂÊ·Ï›·˜ (7). ªÈÎÚfi ÔÛÔÛÙfi ·ÛıÂÓÒÓ Ì ÔÏÔÚÔÛÂÁÎÂÊ·Ï›· ÌÔÚ› Ó· ¤¯ÂÈ Ê˘ÛÈÔÏÔÁÈÎfi ÚÔÛˆÂ›Ô ‹ ‹È˜, ÂÏ¿¯ÈÛÙ˜ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ, fiˆ˜ ™™ƒ∫, ª∫∞∆√, ˘ÔÛÌ›· Î·È ˘ÔÙËÏÔÚÈÛÌfi (7). Œ¯ÂÈ ·Ó·ÊÂÚı› fiÙÈ ™™∞∆ Î·È ™ª∞∆√ ÌÔÚ› Ó· Û˘Ó˘¿Ú¯Ô˘Ó Ì ˘ÔÙËÏÔÚÈÛÌfi, ›ÌÔÓË ÚÈÓÈ΋ Û˘ÌÊfiÚËÛË, ‰˘ÛÎÔϛ˜ ÛÙË Û›ÙÈÛË, fiˆ˜ ÛÙË 2Ë Î·È 3Ë ÂÚ›ÙˆÛË, ‹ Ì ÌÈÎÚfi ¤Ô˜ Î·È ÎÚ˘„ÔÚ¯›·, fiˆ˜ ÛÙËÓ 1Ë ÂÚ›ÙˆÛË (6). √ ÚÒÙÔ˜ ·ÛıÂÓ‹˜ Ì·˜ ·ÚÔ˘Û›·˙ ›Û˘ ·ÙÚËÛ›· ÙÔ˘ ÚˆÎÙÔ‡ Î·È ÓÂÊÚÈΤ˜ ·ÓˆÌ·Ï›Â˜. √ Û˘Ó‰˘·ÛÌfi˜ ·˘ÙÒÓ ÙˆÓ ·ÓˆÌ·ÏÈÒÓ ¤¯ÂÈ Û¿ÓÈ· ·Ó·ÊÂÚı› ÛÙÔ Û‡Ó‰ÚÔÌÔ VACTREL (6). √ ·ÛıÂÓ‹˜ Ì·˜ ‰ÂÓ Â›¯Â Ù· ¿ÏÏ· ¯·Ú·ÎÙËÚÈÛÙÈο Â˘Ú‹Ì·Ù· ·˘ÙÔ‡ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘, fï˜, ÙÔ Û‡ÓÔÏÔ ÙˆÓ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ ÙÔ˘ Èı·ÓÔÏÔÁ› ÙËÓ ‡·ÚÍË Û˘Ó‰ÚfiÌÔ˘. ∏ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ™™∞∆ ‚·Û›˙ÂÙ·È ÛÙË ÛÔ‚·ÚfiÙËÙ· ÙˆÓ Û˘Ìو̿وÓ. ÕÌÂÛË ‰È·ÛˆÏ‹ÓˆÛË Ù˘ ÙÚ·¯Â›·˜ Î·È ·ÂÚÈÛÌfi˜ ··ÈÙÂ›Ù·È Û˘¯Ó¿ ÙȘ ÚÒÙ˜ Ë̤Ú˜ ˙ˆ‹˜, ηıÒ˜ Ù· ÓÂÔÁÓ¿ ·Ó·Ó¤Ô˘Ó ˘Ô¯ÚˆÙÈο ·fi ÙË Ì‡ÙË. ™Â ‰‡Ô ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ Ì·˜ ¶·È‰È·ÙÚÈ΋ 2007;70:320-324
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·324
324
∞. ∞Ó‰Ú¤Ô˘ Î·È Û˘Ó.
¯ÚÂÈ¿ÛıËΠ·Ú¯Èο ‰È·ÛˆÏ‹ÓˆÛË Ù˘ ÙÚ·¯Â›·˜ ÁÈ· ·ÂÚÈÛÌfi. ∆ÔÈ΋ ıÂڷ›· Î·È ÚÈÓÈÎÔ› ηıÂÙ‹Ú˜ ÂÊ·ÚÌfi˙ÔÓÙ·È Û ‹È˜ ÂÚÈÙÒÛÂȘ (3,12). ∫·È ÔÈ ÙÚÂȘ ÂÚÈÙÒÛÂȘ Ì·˜ ·ÓÙÈÌÂÙˆ›ÛıËÎ·Ó Û˘ÓÙËÚËÙÈο Ì ÙÔÔı¤ÙËÛË ÚÈÓÈÎÒÓ Î·ıÂÙ‹ÚˆÓ Î·È ·ÂÚ·ÁˆÁÒÓ. ÃÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÂÊ·ÚÌfi˙ÂÙ·È Û ·ÛıÂÓ›˜ Ì ¿ÓÔÈ· ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ‡ÓÔ˘, ·ÓÂÈÏËÌ̤Ó˜ ‰È·ÛˆÏËÓÒÛÂȘ, ·ÔÙ˘¯›· ·ÔۈϋӈÛ˘, ‰˘ÛÎÔÏ›· Û›ÙÈÛ˘ Ô˘ Û˘Óԉ‡ÂÙ·È ·fi ΢¿ÓˆÛË, ÌË ·ÓÙ·fiÎÚÈÛË ÛÙË ¯ÔÚ‹ÁËÛË Û˘Ó¯ԇ˜ ıÂÙÈ΋˜ ›ÂÛ˘ ÛÙÔ˘˜ ·ÂÚ·ÁˆÁÔ‡˜ Î·È fiÙ·Ó ˘¿Ú¯ÂÈ ·ÔÙ˘¯›· Ù˘ Û˘ÓÙËÚËÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ ÁÈ· ¿Óˆ ·fi 10-15 Ë̤Ú˜ (3). ∆¤ÏÔ˜, Â›Ó·È ‰˘Ó·Ù‹ Î·È ÚÔÁÂÓÓËÙÈ΋ ‰È¿ÁÓˆÛË Ì ˘ÂÚ˯ÔÁÚ¿ÊËÌ· Û ËÏÈΛ· ·ËÛ˘ 18-22 ‚‰ÔÌ¿‰ˆÓ (13).
5.
6.
7.
8. 9.
10.
BÈ‚ÏÈÔÁÚ·Ê›· 1. Brown OE, Myer CM 3rd, Manning SC. Congenital nasal pyriform aperture stenosis. Laryngoscope 1989;99:86-91. 2. Lo FS, Lee ÀJ, Lin SP, Shen EY, Huang JK, Lee KS. Solitary maxillary central incisor and congenital nasal pyriform aperture stenosis. Eur J Pediatr 1998;157:39-44. 3. Van Den Abbeele T, Triglia JM, Francois M, Narcy P. Congenital nasal pyriform aperture stenosis: diagnosis and management of 20 cases. Ann Otol Rhinol Laryngol 2001;110:70-75. 4. Huang J∫, Cheng SJ, Lin JC, Sheu CY. Congenital nasal
Paediatriki 2007;70:320-324
11.
12.
13.
pyriform aperture stenosis and single central maxillary incisor: CT and MRI findings. Clin Imaging 1998;22:393-397. Hall R∫, Bankier ∞, Aldred ªJ, Kan K, Lucas JO, Perks AG. Solitary median maxillary central incisor, short stature, choanal atresia/ midnasal stenosis (SMMCI) syndrome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:651-662. Nanni L, Ming JE, Du À, Hall RK, Aldred M, Bankier A, et al. SHH mutation is associated with solitary median maxillary central incisor: a study of 13 patients and review of the literature. Am J Med Genet 2001;102:1-10. Hattori H, Okuno T, Momoi T, Kataoka K, Mikawa H, Shiota K. Single central maxillary incisor and holoprosencephaly. Am J Med Genet 1987;28:483-487. Scott DC. Absence of upper central incisor. Brit Dent J 1958;104:247-248. Arlis H, Ward RF. Congenital nasal pyriform aperture stenosis. Isolated abnormality vs developmental field defect. Arch Otolaryngol Head Neck Surg 1992;118:989-991. Royal SA, Hedlund GL, Wiatrak µJ. Single central maxillary incisor with nasal pyriform aperture stenosis-CT diagnosis prior to tooth eruption. Pediatr Radiol 1999;29:357-359. Huang JK, Cheng SJ, Yang CC, Yun CH, Shih SL. Congenital nasal pyriform aperture stenosis and single central maxillary incisor: preoperative evaluation with three-dimensional computed tomography. J Formos Med Assoc 2004;103:37-40. Lee JJ, Bent JP, Ward RF. Congenital nasal pyriform aperture stenosis: non-surgical management and long-term analysis. Int J Pediatr Otorhinolaryngol 2001;60:167-171. Hall R. Solitary median maxillary central incisor (SMMCI) syndrome. Orphanet J Rare Dis 2006;1:12.
Pediatri July-Aug 07
09-07-07
17:08
™ÂÏ›‰·325
∂¡¢π∞º∂ƒ√À™∞ ¶∂ƒπ¶∆ø™∏
CASE REPORT
325
™‡Ó‰ÚÔÌÔ Blue Rubber Bleb Nevus Ì ۇÁ¯ÚÔÓË ÚÔÛ‚ÔÏ‹ Ó¢ÚÈÎÔ‡ Î·È ÂÚÂÈÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ª. ∆˙Ô‡ÊË1, ¶. ™È¯ÏÈÌ›ÚË1, π. ¡¿ÎÔ˘1, ª. ∞ÚÁ˘ÚÔÔ‡ÏÔ˘2, ∞. ™È·ÌÔÔ‡ÏÔ˘ - ª·˘Ú›‰Ô˘1 ¶ÂÚ›ÏË„Ë: ∆Ô Û‡Ó‰ÚÔÌÔ Blue Rubber Bleb Nevus (BRBN) ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÊÏ‚ÈΤ˜ ‰˘ÛϷۛ˜, Ô˘ ·ÊÔÚÔ‡Ó Î˘Ú›ˆ˜ ÙÔ ‰¤ÚÌ· Î·È ÙoÓ Á·ÛÙÚÂÓÙÂÚÈÎfi ۈϋӷ. ¶ÈÔ Û¿ÓÈ· Â›Ó·È Ë ÚÔÛ‚ÔÏ‹ ÙÔ˘ Ó¢ÚÈÎÔ‡ Î·È ÙÔ˘ ÂÚÂÈÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∆Ô Û‡Ó‰ÚÔÌÔ ·˘Ùfi Â›Ó·È Û¿ÓÈÔ, ·ÊÔ‡ ¤ˆ˜ Û‹ÌÂÚ· ¤¯Ô˘Ó ‰ËÌÔÛÈ¢ı› ÏÈÁfiÙÂÚ˜ ·fi 200 ÂÚÈÙÒÛÂȘ. ∆· ·ÈÌ·ÁÁÂÈÒÌ·Ù· ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ ‰È·ÈÛÙÒÓÔÓÙ·È ÛÙË Á¤ÓÓËÛË Î·È ÂȉÂÈÓÒÓÔÓÙ·È Ì ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ÛÒÌ·ÙÔ˜, ÚÔηÏÒÓÙ·˜ ·ÈÛıËÙÈο ΢ڛˆ˜ ÚÔ‚Ï‹Ì·Ù·, ÂÓÒ Ù· ·ÓÙ›ÛÙÔȯ· ÚÔ‚Ï‹Ì·Ù· ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ ۈϋӷ ÌÔÚÔ‡Ó Ó· ÂÌÊ·ÓÈÛÙÔ‡Ó Û ÌÂÁ·Ï‡ÙÂÚË ËÏÈΛ·. ∞Ó ·ÈÌÔÚÚ·Á‹ÛÔ˘Ó, ÚÔηÏÔ‡Ó ¯ÚfiÓÈ· ·Ó·ÈÌ›·, ‹ ÌÔÚ› Ó· ¤¯Ô˘Ó ÂÈÏÔΤ˜, fiˆ˜ Ú‹ÍË, Û˘ÛÙÚÔÊ‹ ÂÓÙ¤ÚÔ˘ Î·È ÂÁÎÔÏ·ÛÌfi. ∂›Û˘, ÌÔÚ› Ó· ÚÔÛ‚ÏËıÔ‡Ó Î·È ¿ÏÏ· fiÚÁ·Ó·. ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ÂÓfi˜ ·ÁÔÚÈÔ‡ ËÏÈΛ·˜ 13 ÂÙÒÓ, Ì ۇӉÚÔÌÔ BRBN, Ì ÔÏϤ˜ ÓÔÛËÏ›˜, ÙÔ˘ ÔÔ›Ô˘ Ë ·Ú·ÎÔÏÔ‡ıËÛË ÍÂΛÓËÛ ·fi ÙË ÓÂÔÁÓÈ΋ ËÏÈΛ·. ¶·ÚÔ˘ÛÈ¿˙ÂÈ ÔÏϷϤ˜ ·ÁÁÂȷΤ˜ ‰˘ÛϷۛ˜ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ Î·È ÙˆÓ ‚ÏÂÓÓÔÁfiÓˆÓ, ÂÓÒ ÔÈ ·ÓÙ›ÛÙÔȯ˜ ‰˘ÛϷۛ˜ ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ ۈϋӷ ÂΉËÏÒıËÎ·Ó Ì ¯ÚfiÓÈ· ·Ó·ÈÌ›· Î·È ÂÈÏÂÔÂÈÏÂ˚Îfi ÂÁÎÔÏ·ÛÌfi. ∞ÍÈÔÛËÌ›ˆÙË Â›Ó·È Ë ÂÎÙÂٷ̤ÓË ÚÔÛ‚ÔÏ‹ ÙÔ˘ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, Ì ·ÈÌ·ÁÁ›ˆÌ· ÛÙÔÓ ·ÚÈÛÙÂÚfi ÈÓÈ·Îfi ÏÔ‚fi, Ô˘ ›¯Â ÚÔηϤÛÂÈ ˆ˜ ÂÈÏÔ΋ ·ÁÁÂÈ·Îfi ÂÁÎÂÊ·ÏÈÎfi ÂÂÈÛfi‰ÈÔ Î·È Ì ·ÈÌ·ÁÁÂÈÒÌ·Ù· ·Ú·ÛÔÓ‰˘ÏÈο, Ù· ÔÔ›· Ȥ˙Ô˘Ó ÙÔÓ ÓˆÙÈ·›Ô Ì˘ÂÏfi. √ ·ÛıÂÓ‹˜ ·ÚÔ˘ÛÈ¿˙ÂÈ ·ÓıÂÎÙÈΤ˜, Û‡ÓıÂÙ˜ ÂÛÙȷΤ˜ Î·È ÁÂÓÈÎÂ˘Ì¤Ó˜ ÂÈÏËÙÈΤ˜ ÎÚ›ÛÂȘ Î·È ¿Û¯ÂÈ ·fi ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË. ∆¤ÏÔ˜, ·fi ÙË Á¤ÓÓËÛ‹ ÙÔ˘, ÂÌÊ·Ó›˙ÂÈ ÔÏϷϤ˜ ÛÎÂÏÂÙÈΤ˜ ·ÓˆÌ·Ï›Â˜. ™ÙË ‰È·ı¤ÛÈÌË ‚È‚ÏÈÔÁÚ·Ê›·, ·˘Ù‹ Â›Ó·È Ë ÚÒÙË ÂÚ›ÙˆÛË Ù·˘Ùfi¯ÚÔÓ˘ ÚÔÛ‚ÔÏ‹˜ ÙÔ˘ Ó¢ÚÈÎÔ‡ Î·È ÙÔ˘ ÂÚÂÈÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜.
1 ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ¶·ÓÂÈÛÙËÌÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô πˆ·ÓÓ›ÓˆÓ 2 ∞ÎÙÈÓÔÏÔÁÈÎfi ∆Ì‹Ì·, ¶·ÓÂÈÛÙËÌÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô πˆ·ÓÓ›ÓˆÓ AÏÏËÏÔÁÚ·Ê›·: ªÂÚfiË ∆˙Ô‡ÊË mtzoufi@uoi.gr ∆Ô̤·˜ ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ πˆ·ÓÓ›ÓˆÓ, ∆.£. 1186 ∆.∫. 45110, πˆ¿ÓÓÈÓ·
§¤ÍÂȘ ÎÏÂȉȿ: BRBNS, Ó¢ÚÈÎfi Û‡ÛÙËÌ·, ÂÚÂÈÛÙÈÎfi Û‡ÛÙËÌ·.
Blue Rubber Bleb Nevus Syndrome with concurrent neurological and skeletal involvement M. Tzoufi1, P. Sihlimiri1, I. Nakou1, M. Argyropoulou2, A. Siamopoulou - Mavridou1 Abstract: The blue rubber bleb nevus syndrome (BRBNS) consists of venous malformations affecting the skin and gastrointestinal tract. It is less common for the nervous and the skeletal systems to be involved. This syndrome is rare, as descriptions of less than 200 cases have been published. The skin haemangiomata are present at birth and deteriorate as the body grows, causing mainly cosmetic problems. Haemangiomata of the gastrointestinal tract may appear later in life and can bleed, causing chronic anaemia, or present with complications such as rupture, intestinal torsion and intussusception. Other organs may also be involved. The case of a 13 year-old boy with BRBNS is described, who was monitored since birth, and had multiple hospitalizations. He presented with multiple nevi of the skin and mucous membranes, and gastrointestinal tract lesions, which caused anaemia and ileoileic intussusception. This boy’s nervous system was significantly affected, with a haemangioma of the left occipital lobe, which caused a stroke, and multiple paravertebral haemangiomata causing pressure symptoms. He suffers from complex partial and generalized epileptic seizures and cerebral palsy. Multiple skeletal anomalies have also been present from birth. This is the first case of BRBNS in the available literature describing concurrent neurological and skeletal involvement.
1 Paediatric Department, University General Hospital of Ioannina, Ioannina 2 Radiology Department, University General Hospital of Ioannina, Ioannina Correspondence: Meropi Tzoufi mtzoufi@uoi.gr Department of Child Health University of Ioannina, Medical School, PO Box: 1186 GR 45110, Ioannina, Greece
Key words: BRBNS, nervous system, skeletal involvement.
∂ÈÛ·ÁˆÁ‹ ∆Ô Blue Rubber Bleb Nevus ™‡Ó‰ÚÔÌÔ (BRBN) Â›Ó·È ÌÈ· Û¿ÓÈ· ÔÓÙfiÙËÙ·, Ë ÔÔ›· ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ·ÁÁÂȷΤ˜ ·ÓˆÌ·Ï›Â˜ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ Î·È ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ ۈϋӷ. √ G. Gascoven ÛËÌ›ˆÛ ÚÒÙÔ˜ ÙË Û¯¤ÛË ÙˆÓ
ÊÏ‚ÈÎÒÓ ·ÓˆÌ·ÏÈÒÓ Î·È Ù˘ ·ÈÌÔÚÚ·Á›·˜ ·fi ÙÔ Á·ÛÙÚÂÓÙÂÚÈÎfi Û‡ÛÙËÌ·, ÙÔ 1860 (1). ™¯Â‰fiÓ ¤Ó·Ó ·ÈÒÓ· ·ÚÁfiÙÂÚ·, ÙÔ 1958, Ô William Bennet Bean, ÔÓfiÌ·Û ٷ ¯·Ú·ÎÙËÚÈÛÙÈο ·ÁÁ›· “Blue rubber bleb nevus”, ÂÍ·ÈÙ›·˜ ÙÔ˘ ¯ÚÒÌ·ÙÔ˜, Ù˘ ˘Ê‹˜ Î·È ÙÔ˘ Û¯‹Ì·Ùfi˜ ÙÔ˘˜ (2). ¶·È‰È·ÙÚÈ΋ 2007;70:325-329
Pediatri July-Aug 07
09-07-07
17:09
™ÂÏ›‰·326
326
ª. ∆˙Ô‡ÊË Î·È Û˘Ó.
°È’ ·˘Ùfi ÙÔÓ ÏfiÁÔ, ÙÔ BRBNS ·Ó·Ê¤ÚÂÙ·È ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· Î·È ˆ˜ Û‡Ó‰ÚÔÌÔ Bean’s.
¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ¶·ÚÔ˘ÛÈ¿˙ÂÙ·È Ë ÂÚ›ÙˆÛË ÂÓfi˜ ‰ÂηÙÚÈ¿¯ÚÔÓÔ˘ ·ÁÔÚÈÔ‡, ÙÔ ÔÔ›Ô ÁÂÓÓ‹ıËΠ·fi ÙÂÙ·ÚÙÔÙfiÎÔ ÌËÙ¤Ú·, ÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÙÔÎÂÙfi, ÙÂÏÂÈfiÌËÓÔ Î·È Ì ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ 3.500 g. ∆Ô 6Ô ·È‰› Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ¿Û¯ÂÈ ·fi Ó¢ÚÔ˚ӈ̿وÛË Ù‡Ô˘ 1, ÂÓÒ Ù· ˘fiÏÔÈ· ̤ÏË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ Â›Ó·È ˘ÁÈ‹. ∞̤ۈ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË, ÓÔÛËχÙËΠÛÙË ÓÂÔÁÓÈ΋ ÌÔÓ¿‰· ÂÍ·ÈÙ›·˜ ÂÚÈÁÂÓÓËÙÈ΋˜ ·ÛÊ˘Í›·˜ Î·È Ïԛ̈͢. ™ÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË ‰È·ÈÛÙÒıËηÓ: ·) ÔÏÏ·Ï¿ ·ÈÌ·ÁÁÂÈÒÌ·Ù· ‰¤ÚÌ·ÙÔ˜ (¿Óˆ ‚ϤʷÚÔ, ÙÂÚ‡ÁÈÔ ÙÔ˘ ·˘ÙÈÔ‡, οو ÁÓ¿ıÔÈ, ¿Óˆ Î·È Î¿Ùˆ ¿ÎÚ·, Ï¿ÙË), ηıÒ˜ Î·È ·ÈÌ·ÁÁÂÈÒÌ·Ù· ÛÙ· ԇϷ Î·È ÙÔ ‚ÏÂÓÓÔÁfiÓo ÙˆÓ ¯ÂÈϤˆÓ, ‚) ÔÏϷϤ˜ ÛÎÂÏÂÙÈΤ˜ ·ÓˆÌ·Ï›Â˜ (ÛÎÔÏ›ˆÛË, ıÒڷη˜ ˘Ô‰ËÌ·ÙÔÔÈÒÓ, Û˘ÁÁÂÓ¤˜ ÂÍ¿ÚıÚËÌ· ·ÚÈÛÙÂÚÔ‡ ÈÛ¯›Ô˘, ηٿÁÌ·Ù· ‰ÂÍÈÔ‡ Î·È ·ÚÈÛÙÂÚÔ‡ ÈÛ¯›Ô˘, ÂÍ¿ÚıÚËÌ· Î·È ÛÙȘ ‰‡Ô ηٿ ÁfiÓ˘ ·ÚıÚÒÛÂȘ Î·È ·ÌÊÔÙÂÚfiÏ¢ÚË Ú·È‚Ô˚ÔÔ‰›·), Á) ‚·Ï·ÓÈÎfi˜ ˘ÔÛ·‰›· Î·È ÎÚ˘„ÔÚ¯›· ¿Ìʈ, ‰) ÎÈÓËÙÈΤ˜ Î·È ·ÈÛıËÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ ÛÙ· οو ¿ÎÚ· (·Ô˘Û›· ·ÓÙ›‰Ú·Û˘ ÛÙÔÓ fiÓÔ, ÙÔ ˙ÂÛÙfi Î·È ÙÔ ÎÚ‡Ô), ·ÎÚ¿ÙÂÈ· Ô‡ÚˆÓ Î·È ·Ô˘Û›· ÎÔÈÏÈ·ÎÒÓ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎÒÓ (∂ÈÎfiÓ˜ 1,2). ™Â ËÏÈΛ· ‰‡Ô ÌËÓÒÓ, ÛÙÔÓ ÂÓ‰ÔÛÎÔÈÎfi ¤ÏÂÁ¯Ô ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ‰È·ÈÛÙÒıËÎ·Ó ÔÏÏ·Ï¿ ·ÈÌ·ÁÁÂÈÒÌ·Ù· Û fiÏÔ ÙÔ Ì‹ÎÔ˜ ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ ۈϋӷ Î·È ¤ÙÛÈ ¤ÁÈÓÂ Ë ‰È¿ÁÓˆÛË ÙÔ˘ BRBNS. √ ÏÔÈfi˜ ·ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ¤‰ÂÈÍÂ: ·) ·ÈÌ·ÁÁ›ˆÌ· ÛÙÔÓ ·ÚÈÛÙÂÚfi ÈÓÈ·Îfi ÏÔ‚fi, ÌÂÁ¤ıÔ˘˜ 2 cm, ‚) ·ÈÌ·ÁÁ›ˆÌ· Û ·ʋ Ì ÙÔÓ ‰ÂÍÈfi ÓÂÊÚfi, Ô˘ ÂÂÎÙÂÈÓfiÙ·Ó ÛÙË ÛÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË, Á) ÙÂÚ¿ÛÙÈÔ ·ÈÌ·ÁÁ›ˆÌ· ÛÙËÓ ÔÈÛıÔÂÚÈÙÔÓ·˚΋ ¯ÒÚ· Û ·ʋ Ì ÙÔ ‰ÂÍÈfi ÂÈÓÂÊÚ›‰ÈÔ, ‰) ˘ÔÏ·ÛÙÈÎfi-‰˘ÛÏ·ÛÙÈÎfi ÓÂÊÚfi Î·È Â) Ó¢ÚÔÁÂÓ‹ ·ÛÙË ˘ÔÙÔÓÈÎÔ‡ Ù‡Ô˘. ™Â ËÏÈΛ· 2 ÌËÓÒÓ Ú·ÁÌ·ÙÔÔÈ‹ıËΠ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË Ì ÌÂÚÈ΋ ÂÎÙÔÌ‹ ÙÔ˘ ·ÈÌ·ÁÁÂÈÒÌ·ÙÔ˜, ÙÔ ÔÔ›Ô ÂÚ¯fiÙ·Ó Û ·ʋ Ì ÙÔ ‰ÂÍÈfi ÂÈÓÂÊÚ›‰ÈÔ. ™ÙËÓ ›‰È· ËÏÈΛ·, ηٿ ÙË Ó¢ÚÔÏÔÁÈ΋ ÂͤٷÛË ‰È·ÈÛÙÒıËÎÂ Û˘ÁÁÂÓ‹˜ ·Ú·ÏËÁ›·. ™Â ËÏÈΛ· 3 ÂÙÒÓ, Ë ÂÎÙ›ÌËÛË Ù˘ ÓÔËÙÈ΋˜ ÙÔ˘ ÏÂÈÙÔ˘ÚÁ›·˜ Ì ÂȉÈο ·Ó·Ù˘Íȷο ÙÂÛÙ (Denver ππ Î·È Early Language Milestone) ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋. ™Â ËÏÈΛ· 4 ÂÙÒÓ, ÂÈÛ‹¯ıË ÛÙËÓ ÎÏÈÓÈ΋ Ì·˜ Ì ÛÔ‚·Ú¤˜ ËÏÂÎÙÚÔÏ˘ÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ Û ËÌÈ-Έ̷ÙÒ‰Ë Î·Ù¿ÛÙ·ÛË, ÛÙËÓ ÔÔ›· ·Ú¤ÌÂÈÓ ÁÈ· ÙÚ›· ÙÔ˘Ï¿¯ÈÛÙÔÓ 24ˆÚ·. ∆fiÙ ·ÚÔ˘Û›·ÛÂ Î·È Â·ÓÂÈÏËÌ̤ӷ ÂÂÈÛfi‰È· ÂÛÙÈ·ÎÒÓ Û·ÛÌÒÓ Ì ‰Â˘ÙÂÚÔPaediatriki 2007;70:325-329
∂ÈÎfiÓ· 1. √ ·ÛıÂÓ‹˜.
∂ÈÎfiÓ· 2. ¢ÂÚÌ·ÙÈΤ˜ Î·È ÛÎÂÏÂÙÈΤ˜ ·ÓˆÌ·Ï›Â˜.
·ı‹ ÁÂӛ΢ÛË (‰È¿ÚÎÂÈ·˜ ≤30 min). AÂÈÎÔÓÈÛÙÈο, ÛÙËÓ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘, ‰È·ÈÛÙÒıËΠÂÈÌ‹Î˘ ˘fi˘ÎÓË ÂÚÈÔ¯‹, ÛÙÔÓ ÌÂوȷ›Ô, ‚ÚÂÁÌ·ÙÈÎfi Î·È ÈÓÈ·Îfi ÏÔ‚fi, Ì ·ۂÂÛÙÒÛÂȘ. ™ÙÔ Ï·›ÛÈÔ Ù˘ Ù·ÎÙÈ΋˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙÔ˘ ·ÛıÂÓÔ‡˜ ÌÂÙ¿ ·fi ‰‡Ô Ì‹Ó˜, ‰È·ÈÛÙÒıËΠËÌÈÏËÁ›· ‰ÂÍÈÔ‡ ¿Óˆ ¿ÎÚÔ˘, ÛÔ‚·Ú‹ ‰È·Ù·Ú·¯‹ ÔÌÈÏ›·˜, ‹È· ¤ÎÙˆÛË Ù˘ ÓÔËÌÔÛ‡Ó˘ Î·È ‰È·Ù·Ú·¯¤˜ Û˘ÌÂÚÈÊÔÚ¿˜. ∂ÈϤÔÓ, 6 Ì‹Ó˜ ·ÚÁfiÙÂÚ·, ·ÚÔ˘Û›·Û ÚÔԉ¢ÙÈο, Ôχ Û˘¯Ó¤˜, Û‡ÓıÂÙ˜ ÂÛÙȷΤ˜ ÎÚ›ÛÂȘ (>10-15 ËÌÂÚËÛ›ˆ˜) ÌÈÎÚ‹˜ ‰È¿ÚÎÂÈ·˜ Î·È Û·ÓÈfiÙÂÚ· ÁÂÓÈÎÂ˘Ì¤Ó˜, ÌÂÁ¿Ï˘ ‰È¿ÚÎÂÈ·˜ (status epilepticus). ∞ÓÙÈÌÂÙˆ›ÛıËΠ̠ÔÏÏ·Ï‹ Î·È ÌÂÙ·‚·ÏÏfiÌÂÓË ·ÓÙÈÛ·Û̈‰È΋ Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹, Ì ÌÂÚÈ΋ ÂÈÙ˘¯›· (Ú‡ıÌÈÛË Î·Ù¿ 75%). ™Â ËÏÈΛ· 6,5 ÂÙÒÓ, ·ÚÔ˘Û›·ÛÂ Û˘ÌÙÒÌ·Ù· ÂÓÙÂÚÈ΋˜ ·fiÊڷ͢. ∆¤ıËÎÂ Ë ‰È¿ÁÓˆÛË ÙÔ˘
Pediatri July-Aug 07
09-07-07
17:09
™ÂÏ›‰·327
327
™‡Ó‰ÚÔÌÔ Blue Rubber Bleb Nevus
ÂÈÏÂÔÂÈÏÂ˚ÎÔ‡ ÂÁÎÔÏ·ÛÌÔ‡, Ô ÔÔ›Ô˜ ÔÊÂÈÏfiÙ·Ó Û ÌÂÁ¿ÏÔ ·ÈÌ·ÁÁ›ˆÌ· ÛÙËÓ ÂÚÈÔ¯‹ Î·È ÙÔ ÔÔ›Ô ·Ê·ÈÚ¤ıËΠ¯ÂÈÚÔ˘ÚÁÈο. ∂ÈϤÔÓ, ÂÂȉ‹ Û˘Ó¤¯È˙ ӷ ·ÚÔ˘ÛÈ¿˙ÂÈ Û˘¯Ó¤˜ ÂÈÏËÙÈΤ˜ ÎÚ›ÛÂȘ, ¤ÁÈÓ ̷ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘ (MRI), ÛÙËÓ ÔÔ›· ‰È·ÈÛÙÒıËΠÂÎÙÂٷ̤ÓË ‚Ï¿‚Ë Ì·ÎÚÔ΢ÛÙÈ΋˜ ÂÁÎÂÊ·ÏÔÌ·Ï¿Î˘ÓÛ˘ ÛÙÔ ·ÚÈÛÙÂÚfi ÂÁÎÂÊ·ÏÈÎfi ËÌÈÛÊ·›ÚÈÔ, Ë ÔÔ›· ÚÔηÏÔ‡Û ¤ÏÍË Ù˘ Û‡ÛÙÔȯ˘ Ï¿ÁÈ·˜ ÎÔÈÏ›·˜, ÚÔÊ·ÓÒ˜ ·fiÙÔÎÔ˜ ÙÔ˘ ıÚÔÌ‚ˆÙÈÎÔ‡ ·ÁÁÂÈ·ÎÔ‡ ÂÁÎÂÊ·ÏÈÎÔ‡ ÂÂÈÛÔ‰›Ô˘, Ô˘ ›¯Â ˘ÔÛÙ› ÛÙËÓ ËÏÈΛ· ÙˆÓ 4 ÂÙÒÓ . ™Â ËÏÈΛ· 12 ÂÙÒÓ, ‰È·ÈÛÙÒıËΠÁÈ· ÚÒÙË ÊÔÚ¿ „ËÏ·ÊËÙ‹ ÂÒ‰˘ÓË Ì¿˙· ÛÙÔÓ ·˘¯¤Ó·. ∏ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· (MRI) ·˘¯ÂÓÈ΋˜ ÌÔ›Ú·˜ ·ÔÎ¿Ï˘„ ¤Ó· ÌÂÁ¿ÏÔ Î·È ·ÚÎÂÙ¿ ÌÈÎÚfiÙÂÚ· ·ÈÌ·ÁÁÂÈÒÌ·Ù· ÛÙËÓ ·˘¯ÂÓÈ΋ ÂÚÈÔ¯‹ (∂ÈÎfiÓ· 3), ÂÓÒ Ë Â·Ó·ÏËÙÈ΋ MRI ÂÁÎÂÊ¿ÏÔ˘ ‹Ù·Ó ¯ˆÚ›˜ Ô˘ÛÈ·ÛÙÈ΋ ÌÂÙ·‚ÔÏ‹. ™Â ËÏÈΛ· 13 ÂÙÒÓ, ÂÂȉ‹ Û˘Ó¤¯È˙ ӷ ·ÚÔ˘ÛÈ¿˙ÂÈ Û˘¯Ó¤˜ ÂÈÏËÙÈΤ˜ ÎÚ›ÛÂȘ, ÚÔԉ¢ÙÈο ÂȉÂÈÓÔ‡ÌÂÓ˜, ¤ÁÈÓÂ Î·È ‰Â‡ÙÂÚË Â·Ó·ÏËÙÈ΋ MRI ÂÁÎÂÊ¿ÏÔ˘, fiÔ˘ ‰È·ÈÛÙÒıËÎ·Ó ÔÈ ›‰È˜ ‚Ï¿‚˜ Ù˘ ÂÁÎÂÊ·ÏÔÌ·Ï¿Î˘ÓÛ˘ ÛÙÔ ·ÚÈÛÙÂÚfi ÂÁÎÂÊ·ÏÈÎfi ËÌÈÛÊ·›ÚÈÔ (∂ÈÎfiÓ· 4), ηıÒ˜ Î·È ‹È· ·ÙÚÔÊ›· ÙÔ˘ Û‡ÛÙÔÈ¯Ô˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ÛΤÏÔ˘˜ Î·È ÙÔ˘ ·ÓÙ›ÛÙÔÈ¯Ô˘ ËÌÈÛÊ·ÈÚ›Ô˘ Ù˘ ·ÚÂÁÎÂÊ·Ï›‰·˜. ™ÙË ‰È¿ÚÎÂÈ· Ù˘ Ì·ÎÚfi¯ÚÔÓ˘ ·Ú·ÎÔÏÔ‡ıËÛ‹˜ ÙÔ˘, ÂÈÛ‹¯ıË ÔÏϤ˜ ÊÔÚ¤˜ Û ÓÔÛÔÎÔÌÂ›Ô ÂÍ·ÈÙ›·˜ ÛÔ‚·ÚÒÓ ÏÔÈÌÒÍÂˆÓ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Î·È ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ÔÈ Ôԛ˜ Î·È ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó ·ÔÙÂÏÂÛÌ·ÙÈο. √È ÂÚÁ·ÛÙËÚȷΤ˜ ÂÍÂÙ¿ÛÂȘ, Û˘Ó¯›˙Ô˘Ó Ó· ‰Â›¯ÓÔ˘Ó ÛÙ·ıÂÚ‹ Î·È ÂÌ̤ÓÔ˘Û· ÛȉËÚÔÂÓÈ΋ ·Ó·ÈÌ›·, ηıÒ˜ Î·È ÛÙ·ıÂÚ‹ ÌÈÎÚÔÛÎÔÈ΋ ·Ô‚ÔÏ‹ ·›Ì·ÙÔ˜ ÛÙ· ÎfiÚ·Ó·. ÃÚÂÈ¿ÛÙËΠӷ ÌÂÙ·ÁÁÈÛÙ› 3 ÊÔÚ¤˜ Î·È Û˘Ó¯›˙ÂÙ·È Ë ¯ÔÚ‹ÁËÛË Ûȉ‹ÚÔ˘ Î·È Ë Û˘ÌÏËڈ̷ÙÈ΋ ‰È·ÙÚÔÊ‹. ∆¤ÏÔ˜, ·Ú·ÎÔÏÔ˘ıÂ›Ù·È Ì ٷÎÙÈÎfi ÎÏÈÓÈÎfi Î·È ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô.
™˘˙‹ÙËÛË To µRBNS ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ·ÁÁÂȷΤ˜ ·ÓˆÌ·Ï›Â˜ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ Î·È ¿ÏÏˆÓ ÔÚÁ¿ÓˆÓ. ∂›Ó·È ÌÈ· Û¿ÓÈ· ÔÓÙfiÙËÙ·, ·ÊÔ‡ ·fi ÙËÓ ·Ú¯È΋ ÂÚÈÁÚ·Ê‹ ÙÔ˘ ÙÔ 1958 (2), ¤¯Ô˘Ó ‰ËÌÔÛÈ¢ı› ÏÈÁfiÙÂÚ˜ ·fi 200 ÂÚÈÙÒÛÂȘ, ΢ڛˆ˜ ۠ϢÎÔ‡˜ Î·È π¿ˆÓ˜, ÂÓÒ ÌfiÓÔÓ ÙÚÂȘ ·ÛıÂÓ›˜ ·Ó‹ÎÔ˘Ó ÛÙË Ì·‡ÚË Ê˘Ï‹. √È ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ‰È·ÈÛÙÒÓÔÓÙ·È Î·Ù¿ ÙË Á¤ÓÓËÛË ‹ ÛÙ· ÚÒÙ· ¯ÚfiÓÈ· ˙ˆ‹˜, ÂÓÒ Û˘¯Ó¿ ÔÈ ‚Ï¿‚˜ Â›Ó·È ·ÚÔ‡Û˜ Î·È ·fi ÙËÓ ÂÓ‰ÔÌ‹ÙÚÈÔ ˙ˆ‹. ∂Ï¿¯ÈÛÙ˜ ÂÚÈÙÒÛÂȘ ‰È·ÁÓÒÛÙËÎ·Ó ÛÙËÓ ÂÓ‹ÏÈÎÔ ˙ˆ‹ (3). ∆Ô Û‡Ó‰ÚÔÌÔ ÂÌÊ·Ó›˙ÂÙ·È Î·È ÛÙ· ‰‡Ô ʇϷ. √È ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ Â›Ó·È ÛÔÚ·‰ÈΤ˜, ·Ó
∂ÈÎfiÓ· 3. MRI ·˘¯ÂÓÈ΋˜ ÌÔ›Ú·˜: ·ÈÌ·ÁÁÂÈÒÌ·Ù· ·˘¯ÂÓÈ΋˜ ÂÚÈÔ¯‹˜.
∂ÈÎfiÓ· 4. MRI ÂÁÎÂÊ¿ÏÔ˘: ÂÎÙÂٷ̤ÓË ‚Ï¿‚Ë Ì·ÎÚÔ΢ÛÙÈ΋˜ ÂÁÎÂÊ·ÏÔÌ·Ï¿Î˘ÓÛ˘ ÛÙÔ ·ÚÈÛÙÂÚfi ÂÁÎÂÊ·ÏÈÎfi ËÌÈÛÊ·›ÚÈÔ.
Î·È ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› Î·È Î¿ÔȘ Ô˘ ÎÏËÚÔÓÔÌÔ‡ÓÙ·È Ì ÙÔÓ ·˘Ùoۈ̷ÙÈÎfi ÂÈÎÚ·ÙÔ‡ÓÙ· ¯·Ú·ÎÙ‹Ú·, ÔÊÂÈÏfiÌÂÓ˜ Û ÁÔÓ›‰ÈÔ Ô˘ ‰ڿ˙ÂÙ·È ¶·È‰È·ÙÚÈ΋ 2007;70:325-329
Pediatri July-Aug 07
09-07-07
17:09
™ÂÏ›‰·328
328
ª. ∆˙Ô‡ÊË Î·È Û˘Ó.
ÛÙÔ 9p ¯ÚˆÌfiۈ̷ (4). ¡ÂfiÙÂÚ· ‰Â‰Ô̤ӷ ‰›ÓÔ˘Ó ÂÚÈÛÛfiÙÂÚ˜ ÏËÚÔÊÔڛ˜ Û¯ÂÙÈο Ì ÙÔÓ ÙÚfiÔ ÁÂÓÂÙÈ΋˜ ÌÂÙ·‚›‚·Û˘ ·˘ÙÒÓ ÙˆÓ ·ÁÁÂÈ·ÎÒÓ ·ÓˆÌ·ÏÈÒÓ (5). ∆· Â˘Ú‹Ì·Ù· ÛÙÔ BRBNS ‰È·ÎÚ›ÓÔÓÙ·È Û ‰ÂÚÌ·ÙÈΤ˜ Î·È Â͈‰ÂÚÌ·ÙÈΤ˜ ·ÓˆÌ·Ï›Â˜. √È ‰ÂÚÌ·ÙÈΤ˜ ·ÓˆÌ·Ï›Â˜ Â›Ó·È Û˘Ó‹ıˆ˜ ÔÏϷϤ˜ Î·È ‰È·Ê¤ÚÔ˘Ó Û ̤ÁÂıÔ˜, ·fi Ï›Á· ¯ÈÏÈÔÛÙ¿ ̤¯ÚÈ ·ÚÎÂÙ¿ ÂηÙÔÛÙ¿ Û ‰È¿ÌÂÙÚÔ. ªÔÚ› Ó· Â›Ó·È Â˘·›ÛıËÙ˜ ÛÙËÓ „ËÏ¿ÊËÛË Î·È Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ˘ÂÚȉڈۛ·. ™·ÓÈfiٷٷ ·ÈÌÔÚÚ·ÁÔ‡Ó, ÂÎÙfi˜ ·Ó ÙÚ·˘Ì·ÙÈÛÙÔ‡Ó. ªÂ ÙËÓ ¿ÚÔ‰Ô Ù˘ ËÏÈΛ·˜ ·Ú·ÙËÚÂ›Ù·È ·‡ÍËÛË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ Î·È ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ·ÁÁÂÈ·ÎÒÓ ‰˘ÛÏ·ÛÈÒÓ . º·›ÓÂÙ·È fiÙÈ ÙÔ BRBNS ÂȉÂÈÓÒÓÂÙ·È Ì ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ÛÒÌ·ÙÔ˜ Î·È ÌfiÓÔ Û·ÓÈfiٷٷ ‚ÂÏÙÈÒÓÂÙ·È, ÂÓÒ ÂÚÈÁÚ¿ÊÔÓÙ·È Î·È ÂÚÈÙÒÛÂȘ ·ÓÂÌÊ¿ÓÈÛ˘ ÙˆÓ “·ÈÌ·ÁÂȈ̿وӔ ÌÂÙ¿ ·fi ¯ÂÈÚÔ˘ÚÁÈ΋ ÂÍ·›ÚÂÛË (3). Œ¯Ô˘Ó ·Ó·ÊÂÚı› ÙÚÂȘ Ù‡ÔÈ ·ÁÁÂÈ·ÎÒÓ ‰ÂÚÌ·ÙÈÎÒÓ ·ÓˆÌ·ÏÈÒÓ: ·) Ê˘Û·Ï›‰Â˜ ÌÏÂ, ÂÏ·ÛÙÈΤ˜, ÁÂÌ¿Ù˜ Ì ·›Ì· (blue rubber bleb), Ì Ï›· ‹ Ú˘ÙȉˆÌ¤ÓË ÂÈÊ¿ÓÂÈ·, Ô˘ ˘Ô¯ˆÚÔ‡Ó Î·È Í·Ó·ÁÂÌ›˙Ô˘Ó ÁÚ‹ÁÔÚ·, fiÙ·Ó ·ÛÎËı› ›ÂÛË, ‚) ÌÂÁ¿Ï˜ ‰‡ÛÌÔÚʘ ÊÏ‚ÈΤ˜ ·ÓˆÌ·Ï›Â˜, Ô˘ ÌÔÚ› Ó· ȤÛÔ˘Ó ˙ˆÙÈο fiÚÁ·Ó· Î·È Á) ÌÏ ·ÓÒ̷Ϙ Ì¿˙˜. ∞Ó Î·È ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙÔ‡Ó ÔÔ˘‰‹ÔÙÂ, ÂÓÙÔ›˙ÔÓÙ·È Î˘Ú›ˆ˜ ÛÙ· ¿Óˆ ¿ÎÚ·, ÙÔÓ ÎÔÚÌfi Î·È ÙÔ ÂÚ›ÓÂÔ. ∞ÈÌ·ÁÁÂÈÒÌ·Ù· ÛÙ· οو ¿ÎÚ· Â›Ó·È ·Û˘Ó‹ıÈÛÙ· ηÈ, fiÙ·Ó ˘¿Ú¯Ô˘Ó, Û˘Óԉ‡ÔÓÙ·È ·fi ·ÍÈÔÛËÌ›ˆÙ˜ ‰È·Ù·Ú·¯¤˜ (6). ∆· “·ÈÌ·ÁÁÂÈÒÌ·Ù·” ÛÙÔÓ Á·ÛÙÚÂÓÙÂÚÈÎfi ۈϋӷ (·fi ÙÔ ÛÙfiÌ· ˆ˜ ÙÔ ÔÚıfi, ÌÂ Û˘¯ÓfiÙÂÚË ÂÓÙfiÈÛË ÛÙÔ ÏÂÙfi ¤ÓÙÂÚÔ) ‰È·ÈÛÙÒÓÔÓÙ·È Û fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Ì BRBNS. øÛÙfiÛÔ, Ù· “·ÈÌ·ÁÁÂÈÒÌ·Ù·” ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙÔ‡Ó Û ÌÂÁ·Ï‡ÙÂÚË ËÏÈΛ· (ÂÊ˂›· ‹ Î·È ·ÚÁfiÙÂÚ·) Î·È fi¯È ·fi ÙË Á¤ÓÓËÛË, fiˆ˜ Û˘Ì‚·›ÓÂÈ Ì ÙȘ ·ÓÙ›ÛÙÔȯ˜ ‚Ï¿‚˜ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜. ™Â ·ÓÙ›ıÂÛË Ì ÙȘ ‰ÂÚÌ·ÙÈΤ˜ ‚Ï¿‚˜, ÔÈ ÊÏ‚ÈΤ˜ ·ÓˆÌ·Ï›Â˜ ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ ۈϋӷ ·ÈÌÔÚÚ·ÁÔ‡Ó Û˘¯Ó¿. ªÔÚ› Ó· ˘ÔÛÙÔ‡Ó Ú‹ÍË ·˘ÙfiÌ·Ù· Î·È Ó· ÚÔηϤÛÔ˘Ó ÔÍ›· ÛÔ‚·Ú‹ ·ÈÌÔÚÚ·Á›· Î·È ı¿Ó·ÙÔ. ™˘Ó‹ıˆ˜ fï˜, Ë ·ÈÌÔÚÚ·Á›· Â›Ó·È ·ÚÁ‹, ÌÈÎÚ‹ Î·È ¯ÚfiÓÈ·, ¤¯ÔÓÙ·˜ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÛȉËÚÔÂÓÈ΋ ·Ó·ÈÌ›·. ∂Ó›ÔÙÂ, ÔÈ ÊÏ‚ÈΤ˜ ·ÓˆÌ·Ï›Â˜ ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡, ¢ı‡ÓÔÓÙ·È ÁÈ· ÂÈÏÔΤ˜ fiˆ˜ ÂÈÏÂfi, Û˘ÛÙÚÔÊ‹ ‹ ÂÁÎÔÏ·ÛÌfi (7). √ ·ÛıÂÓ‹˜ Ì·˜ ·ÔÙÂÏ› ·ÓÙÈÚÔÛˆÂ˘ÙÈ΋ ÂÚ›ÙˆÛË, ·ÊÔ‡ ·ÚÔ˘ÛÈ¿˙ÂÈ Ù˘ÈΤ˜ ‰ÂÚÌ·ÙÈΤ˜ ‚Ï¿‚˜, ÛȉËÚÔÂÓÈ΋ ·Ó·ÈÌ›· Ì ıÂÙÈ΋ ªayer ÎÔÚ¿ÓˆÓ Î·È ÂÂÈÛfi‰ÈÔ ÂÁÎÔÏ·ÛÌÔ‡. √È ÔÚıÔ‰ÈΤ˜ ·ÓˆÌ·Ï›Â˜ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Î˘ÚÙÒÛÂȘ ÙˆÓ ÔÛÙÒÓ, ·ıÔÏÔÁÈο ηٿÁÌ·Ù·, ·ÚıÚÈΤ˜ ‚Ï¿‚˜ Î·È ˘ÂÚ·Ó¿Ù˘ÍË Paediatriki 2007;70:325-329
ÙˆÓ ÔÛÙÒÓ (6,8). √È ÔÛÙÈΤ˜ ‚Ï¿‚˜ ÚÔ·ÙÔ˘Ó ˆ˜ ·ÔÙ¤ÏÂÛÌ· Ù˘ ·ÛÎÔ‡ÌÂÓ˘ ›ÂÛ˘ ·fi ÙȘ ·Ú·Î›ÌÂÓ˜ ÊÏ‚ÈΤ˜ ‚Ï¿‚˜. µÏ¿‚˜ ÛÙËÓ ·Ú·Î›ÌÂÓË ÙˆÓ ÛÔÓ‰‡ÏˆÓ ÂÚÈÔ¯‹ ÌÔÚ› Ó· ÚÔηϤÛÔ˘Ó ›ÂÛË ÛÙË ÛÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË Î·È Î·ı›˙ËÛË ÙˆÓ ÛÔÓ‰‡ÏˆÓ, ÂÓÒ Â›Ó·È Èı·Ófi Ó· ÂÎÙ›ÓÔÓÙ·È ÛÙ· ÌÂÛÔÛÔÓ‰‡ÏÈ· ‰È·ÛÙ‹Ì·Ù·, ÂËÚ¿˙ÔÓÙ·˜ ÙËÓ ÎÈÓËÙÈÎfiÙËÙ· Î·È ÙËÓ ·ÈÛıËÙÈÎfiÙËÙ·. √ ·ÛıÂÓ‹˜ Ì·˜ ·ÚÔ˘Û›·˙ ·ıÔÏÔÁÈο ηٿÁÌ·Ù· ·fi ÙË Á¤ÓÓËÛ‹ ÙÔ˘, ·ÚıÚÈΤ˜ ‚Ï¿‚˜ (Û˘ÁÁÂÓ‹ ‰˘ÛÏ·Û›· ÈÛ¯›Ô˘) Î·È ›ÂÛË ÛÙË ÛÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË, ÌÂ Û˘ÓÔ‰fi ·Ú·ÏËÁ›·. ™ÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›·, ˘¿Ú¯Ô˘Ó ¿ÏÏ· 14 ÂÚÈÛÙ·ÙÈο Ì ÙÔ Û‡Ó‰ÚÔÌÔ Î·È Û˘ÓÔ‰¤˜ ÔÚıo‰ÈΤ˜ ·ÓˆÌ·Ï›Â˜ (6,8). ÷ڷÎÙËÚÈÛÙÈΤ˜ ‚Ï¿‚˜ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÛÙÔ ‹·Ú, ÙÔÓ ÛÏ‹Ó·, ÙÔ ÂÚÈÙfiÓ·ÈÔ, ÙÔ˘˜ Ó‡ÌÔÓ˜, ÙËÓ ÙÚ·¯Â›·, ÙÔ˘˜ ÛÎÂÏÂÙÈÎÔ‡˜ ̇˜, Ù· Ì¿ÙÈ·, ÙË ¯ÔÏˉfi¯Ô ·ÛÙË, ÙÔ ¤Ô˜, ÙȘ ·ÚˆÙ›‰Â˜ Î·È ÙÔ ∫ÂÓÙÚÈÎfi ¡Â˘ÚÈÎfi ™‡ÛÙËÌ· (∫¡™) (3,7,8). ∞Ó Î·È ·ÚÎÂÙÔ› ÂÚ¢ÓËÙ¤˜ ¤¯Ô˘Ó ·Ó·Ê¤ÚÂÈ Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ∫¡™ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ, ÔÚÈṲ̂Ó˜ ·fi ÙȘ ‰È·ÁÓÒÛÂȘ ‰ÂÓ ‹Ù·Ó Û·Ê›˜. H ÚÒÙË ÙÂÎÌËÚȈ̤ÓË ÂÚÈÁÚ·Ê‹ ¤ÁÈÓ ÙÔ 1978 ·fi ÙÔ˘˜ Waybright et al (9), Û ·ÛıÂÓ‹ Ô˘ ·ÚÔ˘Û›·˙ ÂÛÙÈ·ÎÔ‡˜ Û·ÛÌÔ‡˜ Î·È Ó¢ÚÔÏÔÁÈο ÛËÌ›·, ÂÍ·ÈÙ›·˜ ıÚÔÌ‚ÒÛˆ˜ Ù˘ ÊϤ‚·˜ ÙÔ˘ °·ÏËÓÔ‡, ÂÓÒ Î·È ÔÏÏ¿ ¿ÏÏ· ·ÈÌ·ÁÁÂÈÒÌ·Ù· ‹Ù·Ó ›Û˘ ıÚÔÌ‚ˆÌ¤Ó·. ∆· ÂÛÙȷο Ó¢ÚÔÏÔÁÈο ÛËÌ›· Ê·›ÓÂÙ·È fiÙÈ ÔÊ›ÏÔÓÙ·È Û ıÚfiÌ‚ˆÛË ÙˆÓ ·ÁÁÂÈ·ÎÒÓ ‰˘ÛÏ·ÛÈÒÓ. √È ‰˘ÛϷۛ˜ ·˘Ù¤˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ıÚfiÌ‚ˆÛË ÏfiÁˆ ¯·ÌËÏ‹˜ ÚÔ‹˜ ·›Ì·ÙÔ˜, fiˆ˜ ·Ô‰ÂÈÎÓ‡ÂÙ·È ·fi ÙËÓ ÂÓ·fiıÂÛË ·ÈÌÔÛȉËÚ›Ó˘ ÛÙÔ˘˜ ÂÚÈ‚¿ÏÏÔÓÙ˜ ÈÛÙÔ‡˜ Î·È ÙËÓ ·Û‚ÂÛÙÔÔ›ËÛ‹ ÙÔ˘˜. ∂ÎÙfi˜ ·fi ÙȘ ÊÏ‚ÈΤ˜ ‰˘ÛϷۛ˜, Û ·ÛıÂÓ›˜ Ì BRBNS ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÛÔÓ‰˘ÏÈο ·ÈÌ·ÁÁÂÈÒÌ·Ù· Ô˘ ÚÔηÏÔ‡Ó ›ÂÛË ÛÙË ÛÔÓ‰˘ÏÈ΋ ÛÙ‹ÏË, ÁÈÁ·ÓÙÈ·›Ô ÊÏ‚ÈÎfi ·ÁÁ›ˆÌ·, ¿ÓÔÈ· Û¯ÂÙÈ˙fiÌÂÓË Ì ÙË ¯ÚfiÓÈ· ÂÓ‰·ÁÁÂȷ΋ ‰È·ÛÔÚ¿ ıÚfiÌ‚ˆÓ, ÔÏÏ·Ï¿ ÂÁÎÂÊ·ÏÈο ·ÁÁÂȷο ¤ÌÊÚ·ÎÙ·, ηıÒ˜ Î·È ·ÚÙËÚÈÔÊÏ‚҉˜ Û˘Ú›ÁÁÈÔ (10). √È ·Ú·ÎÏÈÓÈΤ˜ ̤ıÔ‰ÔÈ Ô˘ ¯ÚËÛÈÌÂ‡Ô˘Ó ÛÙË ‰È¿ÁÓˆÛË ÙÔ˘ BRBNS Â›Ó·È ÂÍÂÙ¿ÛÂȘ ·›Ì·ÙÔ˜, ÁÂÓÈ΋ Ô‡ÚˆÓ (ÁÈ· ‡·ÚÍË ·ÈÌ·ÙÔ˘Ú›·˜), Mayer ÎÔÚ¿ÓˆÓ, ÂÓ‰ÔÛÎÔÈΤ˜ ̤ıÔ‰ÔÈ Î·È MRI ÂÁÎÂÊ¿ÏÔ˘, Ë ÔÔ›· ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÙÂÏÂ˘Ù·›· ÁÈ· ÙËÓ ·Ó‡ÚÂÛË ·Û˘Ìو̷ÙÈÎÒÓ ·Û¯fiÓÙˆÓ, ÌÂÏÒÓ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ÙÔ˘ ¿Û¯ÔÓÙÔ˜ (11). ∞ÔÙÂÏÂÛÌ·ÙÈ΋ ıÂڷ›· ÁÈ· ÙÔ˘˜ ¿Û¯ÔÓÙ˜ ·fi BRBNS ‰ÂÓ ˘¿Ú¯ÂÈ. ∏ ·Ó·ÈÌ›· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Ì ÙË ¯ÔÚ‹ÁËÛË Ûȉ‹ÚÔ˘ Î·È Ì ÌÂÙ·ÁÁ›ÛÂȘ. ∏ ¯ÂÈÚÔ˘ÚÁÈ΋ ıÂڷ›· ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ Ì¤ÁÂıÔ˜, ÙÔÓ ·ÚÈıÌfi, ÙËÓ ÂÓÙfiÈÛË Î·È Ù· Û˘ÌÙÒÌ·Ù· ÙÔ˘ ·ÛıÂÓÔ‡˜. √È ÂÊ·ÚÌÔṲ̂Ó˜ ̤ıÔ‰ÔÈ ÁÈ· ıÂڷ›·
Pediatri July-Aug 07
09-07-07
17:09
™ÂÏ›‰·329
329
™‡Ó‰ÚÔÌÔ Blue Rubber Bleb Nevus
Â›Ó·È ¯ÂÈÚÔ˘ÚÁÈ΋ ÂÍ·›ÚÂÛË ÌÂÌÔÓˆÌ¤ÓˆÓ ‚Ï·‚ÒÓ, ¯ÂÈÚÔ˘ÚÁÈ΋ ÂÎÙÔÌ‹ ÙÌ‹Ì·ÙÔ˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘ ‹ ÂȉÈΤ˜ ÂÓ‰ÔÛÎÔÈΤ˜ ıÂڷ›˜ Ì Laser. √È ÔÚıÔ‰ÈΤ˜ ·ÓˆÌ·Ï›Â˜ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Ì ‰ÈÔÚıˆÙÈΤ˜ ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ. ∞Ó ÔÈ ‚Ï¿‚˜ ÚÔηÏÔ‡Ó ÁÈÁ·ÓÙÈÛÌfi, Ô ·ÎÚˆÙËÚÈ·ÛÌfi˜ Â›Ó·È Èı·ÓfiÙÂÚ· Ë Î·Ï‡ÙÂÚË ıÂڷ›· (6). ∏ ÚfiÁÓˆÛË ÔÈΛÏÂÈ Î·È ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ¤ÎÙ·ÛË Ù˘ Û˘ÌÌÂÙÔ¯‹˜ ÙˆÓ ÂÛˆÙÂÚÈÎÒÓ ÔÚÁ¿ÓˆÓ, ÂÓÒ Ë Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ∫¡™, fiÙ·Ó ˘¿Ú¯ÂÈ, Ô‰ËÁ› Û ̛· ¯ÚfiÓÈ·, ‚Ú·‰¤ˆ˜ ÂȉÂÈÓÔ‡ÌÂÓË ÔÚ›·, ÏfiÁˆ ÙˆÓ ÂÈÏËÙÈÎÒÓ ÎÚ›ÛÂˆÓ (11,12). √ ·ÛıÂÓ‹˜ Ô˘ ÂÚÈÁÚ¿„·Ì ·ÚÔ˘ÛÈ¿˙ÂÈ È‰È·›ÙÂÚÔ ÂӉȷʤÚÔÓ, ÁÈ·Ù› ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· ·Ó·Ê¤ÚÔÓÙ·È ÌfiÓÔ ‰‡Ô ÂÚÈÙÒÛÂȘ ·È‰ÈÒÓ Ì ÚÔÛ‚ÔÏ‹ ÙÔ˘ ∫¡™, Ì ÚÒÙÔ Û‡Ìو̷ ÙËÓ ÂÌÊ¿ÓÈÛË ÂÛÙÈ·ÎÒÓ ÂÈÏËÙÈÎÒÓ ÎÚ›ÛÂˆÓ ÛÙË ÓÂÔÁÓÈ΋ Î·È ‚ÚÂÊÈ΋ ËÏÈΛ·, Ì ηϋ ‹ ÌÂÚÈ΋ ·ÓÙ·fiÎÚÈÛË ÛÙË Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ Î·È ·Ó·Ù˘Íȷ΋ ÂÈ‚Ú¿‰˘ÓÛË (11,12). ∂›Û˘, ÚÔ¯ˆÚÒÓÙ·˜ Û ·Ó·ÛÎfiËÛË Ù˘ ‰È·ı¤ÛÈÌ˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ ‰ÂÓ ˘¿Ú¯ÂÈ ¿ÏÏË Î·Ù·ÁÂÁÚ·Ì̤ÓË ÂÚ›ÙˆÛË ·È‰ÈÔ‡ Ì BRBN Û‡Ó‰ÚÔÌÔ, Ì ٷ˘Ùfi¯ÚÔÓË ÚÔÛ‚ÔÏ‹ ÙÔ˘ ∫¡™, ÙÔ˘ ÓˆÙÈ·›Ô˘ Ì˘ÂÏÔ‡ Î·È ÙÔ˘ ÂÚÂÈÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜.
BÈ‚ÏÈÔÁÚ·Ê›· 1. Gascoyen CG. Case of nevus involving the parotid gland and causing death frouffocation: nevi of viscera. Trans Path Soc Lond 1860;11:267. 2. Bean WB. Blue rubber bleb naevi of the skin and gastrointestinal tract. In: Thomas CC, editor. Vascular spiders and related lesions of the skin. Spring-field, IL: Charles Thomas, 1958:178-185.
3. ¡ahmWK, Moise S, Eichenfield LF, Paller AS, Nathanson L, Malicki D, et al. Venous malformations in blue rubber bleb nevus syndrome: variable onset of presentation. J Am Acad Dermatol. 2004;50 (Suppl 5):S101-106. 4. Gallione CJ, Pasyk KA, Boon LM, Lennon F, Johnson DW, Helmbold EA et al. A gene for familial venous malformations maps to chromosome 9 in a second large kindred. J Med Genet 1995;32:197-199. 5. Chen DH, Lipe HP, Qin Z, Bird TD. Cerebral cavernous malformation: novel mutation in a Chinese family an evidence for heterogeneity. J Neurol Sci 2002;196:91-96. 6. ªcCarthy JC, Goldberg MJ, Zimbler S. Orthopaedic dysfunction in blue rubber-bleb nevus syndrome. J Bone Joint Surg Am 1982;64:280-283. 7. Dobru D, Seuchea N, Dorin M, Careianu V. Blue rubber bleb nevus syndrome: case report and literature review. Rom J Gastroenterol 2004;13:237-240. 8. Kassarjian A, Fishman SJ, Fox VL, Burrows PE. Imaging characteristics of blue rubber bleb nevus syndrome. Am J Roentgenol 2003;181:1041-1048. 9. Waybright EA, Selhorst JB, Rosenblum WI, Suter CG. Blue rubber bleb nevus syndrome with CNS involvement and thrombosis of a vein of galen malformation. Ann Neurol 1978;3:464-467. 10. Carvalho S, Barbosa V, Santos N, Machado E. Blue rubber-bleb nevus syndrome: report of a familiar case with a dural arteriovenous fistula. Am J Neuroradiol 2003;24: 1916-1918. 11. Kim SJ. Blue rubber bleb nevus syndrome with central nervous system involvement. Pediatric Neurol 2000;22: 410-412. 12. Eiris-Punal J, Picon-Cotos M, Viso-Lorenzo A, CastroGago M. Epileptic disorder as the first neurologic manifestation of blue rubber bleb nevus syndrome. J Child Neurol 2002;17:219-222.
¶·È‰È·ÙÚÈ΋ 2007;70:325-329
Pediatri July-Aug 07
09-07-07
330
17:09
™ÂÏ›‰·330
¶ƒ∞∫∆π∫√ £∂ª∞
PRACTICAL ISSUE
∞ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· ÛÙ· ·È‰È¿ - ıÂڷ¢ÙÈ΋ ÚÔÛ¤ÁÁÈÛË ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ
∆. ∆ÛÈ‚ÈÙ·Ó›‰Ô˘ - ∫¿ÎÔ˘ÚÔ˘
AÏÏËÏÔÁÚ·Ê›·: ∆¿ÏÈ· ∆ÛÈ‚ÈÙ·Ó›‰Ô˘-∫¿ÎÔ˘ÚÔ˘ kakst@otenet.gr ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·Ó/Ì›Ô˘ ∞ıËÓÒÓ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” £Ë‚ÒÓ & ¶··‰È·Ì·ÓÙÔÔ‡ÏÔ˘, ∆.∫. 115 27, ∞ı‹Ó·
¶ÂÚ›ÏË„Ë: ∏ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·È‰ÈÒÓ Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· (∞¢) ‰ÂÓ ÛÙËÚ›˙ÂÙ·È ÌfiÓÔ ÛÙË ÁÓÒÛË, ·ÏÏ¿ Î·È ÛÙËÓ Ù¤¯ÓË ÙÔ˘ ¯ÂÈÚÈÛÌÔ‡ ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ‰¤ÚÌ·ÙÔ˜. ª›· ·fi ÙȘ ÛÔ˘‰·ÈfiÙÂÚ˜ ·Ú·Ì¤ÙÚÔ˘˜ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ·È‰ÈÒÓ Ì ∞¢ Â›Ó·È Ë Âη›‰Â˘ÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È Ù˘ ÔÈÎÔÁ¤ÓÂÈ¿˜ ÙÔ˘, fiÛÔÓ ·ÊÔÚ¿ ÙË Ê‡ÛË Î·È ÙËÓ ÔÚ›· Ù˘ ÓfiÛÔ˘, ÙËÓ ·ÔÊ˘Á‹ ÂÎÏ˘ÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ, ÙË ÛˆÛÙ‹ ÂÓ˘‰¿ÙˆÛË ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ Î·È ÙËÓ ÂȉÈ΋ ıÂڷ›·. ∏ Û˘˙‹ÙËÛË Ì ÙÔ ·È‰› Î·È ÙÔ˘˜ ÁÔÓ›˜ ÁÈ· ÙÔÓ ÙÚfiÔ ‰Ú¿Û˘, ÙË Ì¤ıÔ‰Ô ÂÊ·ÚÌÔÁ‹˜ Î·È ÙËÓ ·ÛÊ¿ÏÂÈ· ÙˆÓ ÙÔÈÎÒÓ Û΢·ÛÌ¿ÙˆÓ ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ Î·Ï‡ÙÂÚË Û˘ÌÌfiÚʈÛË Î·È ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ÓfiÛÔ˘. ∏ ‰È·Ù‹ÚËÛË ·Î¤Ú·ÈÔ˘ ÂȉÂÚÌȉÈÎÔ‡ ÊÚ·ÁÌÔ‡ ·ÔÙÂÏ› ÛËÌ·ÓÙÈ΋ ·Ú¿ÌÂÙÚÔ ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ ∞¢, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Ë ÍËÚÔ‰ÂÚÌ›· ÂÈÙÚ¤ÂÈ ÙËÓ Â›ÛÔ‰Ô ÂÚÂıÈÛÙÈÎÒÓ Ô˘ÛÈÒÓ ÛÙÔ ‰¤ÚÌ· Ì ·ÔÙ¤ÏÂÛÌ· ÙË ‰ËÌÈÔ˘ÚÁ›· ÊÏÂÁÌÔÓ‹˜ Î·È ÙËÓ ¤Í·ÚÛË Ù˘ ÓfiÛÔ˘. ∆· ÙÔÈο ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ ·ÔÙÂÏÔ‡Ó ıÂڷ›· ÚÒÙ˘ ÁÚ·ÌÌ‹˜. ŸÙ·Ó ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÛˆÛÙ¿, ÂÏ·¯ÈÛÙÔÔÈÂ›Ù·È Ë Èı·ÓfiÙËÙ· ˘ÔÙÚÔ‹˜, Ù·¯˘Ê˘Ï·Í›·˜ Î·È ÂÌÊ¿ÓÈÛ˘ ¿ÏÏˆÓ ÙÔÈÎÒÓ Î·È Û˘ÛÙËÌ·ÙÈÎÒÓ ·ÚÂÓÂÚÁÂÈÒÓ. √È ÙÔÈÎÔ› ·Ó·ÛÙÔÏ›˜ Ù˘ ηÏÛÈÓ¢ڛÓ˘ ÂӉ›ÎÓ˘ÓÙ·È ÁÈ· ·È‰È¿ Ì ̤ÙÚÈ· ‹ ÛÔ‚·Ú‹ ∞¢. ™Â ÛÔ‚·Ú‹ ¤Í·ÚÛË Ù˘ ∞¢ Û˘ÓÈÛÙÒÓÙ·È ÙÔÈο ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ Î·È fiÙ·Ó ˘¿ÚÍÂÈ ‚ÂÏÙ›ˆÛË ÂÊ·ÚÌfi˙ÂÙ·È ÙÔÈÎfi˜ ·Ó·ÛÙÔϤ·˜ Ù˘ ηÏÛÈÓ¢ڛÓ˘ ̯ÚÈ ÙËÓ Ï‹ÚË ‡ÊÂÛË ÙˆÓ Û˘Ìو̿وÓ. ™Â ÂÚ›ÙˆÛË ˘ÔÙÚÔ‹˜ ÂÊ·ÚÌfi˙ÂÙ·È ¿ÌÂÛ· ÙÔÈÎfi˜ ·Ó·ÛÙÔϤ·˜ Ù˘ ηÏÛÈÓ¢ڛÓ˘. ŒÙÛÈ, Ë ¯Ú‹ÛË ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ ÂÚÈÔÚ›˙ÂÙ·È ÌfiÓÔ ÛÙȘ Ê¿ÛÂȘ ¤ÓÙÔÓ˘ ¤Í·ÚÛ˘ Ù˘ ∞¢. ∆· ·ÓÙÈ˚ÛÙ·ÌÈÓÈο ¯ÔÚËÁÔ‡ÓÙ·È Û˘ÛÙËÌ·ÙÈο ÁÈ· ÙËÓ ·ÓÙÈÎÓËÛÌÒ‰Ë Î·È ËÚÂÌÈÛÙÈ΋ ÙÔ˘˜ ‰Ú¿ÛË. ∏ ¯Ú‹ÛË ÙÔÈÎÔ‡ ·ÓÙÈ‚ÈÔÙÈÎÔ‡ ¤¯ÂÈ ÛÙfi¯Ô ÙËÓ ÂÏ¿ÙÙˆÛË ÙÔ˘ ÛÙ·Ê˘ÏÔÎÔÎÎÈÎÔ‡ ÊÔÚÙ›Ô˘ ‹ ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Ïԛ̈͢.
§¤ÍÂȘ ÎÏÂȉȿ: ∞ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ·, ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, ÙÔÈÎÔ› ·Ó·ÛÙÔÏ›˜ ηÏÛÈÓ¢ڛÓ˘, ·ÓÙÈ˚ÛÙ·ÌÈÓÈο, ·ÓÙÈ‚ÈÔÙÈο.
Therapeutic management of childhood atopic dermatitis First Paediatric Department of the University of Athens, Greece Correspondence: Talia Kakourou kakst@otenet.gr First Department of Paediatrics of the University of Athens “Aghia Sofia” Children’s Hospital Thivon & Papadiamantopoulou St. 115 27, Athens, Greece
T. Kakourou Abstract: The management of children with Atopic Dermatitis (AD) is as much based on knowledge, as it is an art form. One of the most important aspects in the management of AD is education of the patient and his/her family regarding the nature and course of the disease, the avoidance of trigger factors, the proper hydration of the skin and the specific treatment. Explanation and discussion with the patient and the parents about the mode of action, the methods of application and the safety of topical preparations may achieve higher compliance and better control of the disease. The maintenance of an intact skin barrier is particularly important because xerosis allows the entry of antigens, which causes irritation of the skin and disease exacerbations. Topical corticosteroids (TCS) are first-line treatment for AD and when used properly, they minimize the possibility of rebound, tachyphylaxis, as well as topical and systemic side effects. Topical Calcineurin Inhibitors (TCI) are reserved for children with moderate and severe AD providing effective long-term disease control. It is suggested that a major flare should be managed with TCS and, when the inflammation subsides, TCI should be applied until the skin becomes clear. If the first sign reoccurs, TCI therapy should be restarted. Antihistamines are used for their sedative and antipruritic action and anti-infectious agents are used in order to reduce the staphylococcal burden or to treat an infection.
Key words: Atopic dermatitis, corticosteroids, topical calcineurin inhibitors, antihistamines, antibiotics.
∂ÈÛ·ÁˆÁ‹ ∏ ›وÛË Ù˘ ·ÙÔÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜ (∞¢) Û ·È‰È¿ ÛÙËÓ ∂˘ÚÒË Â›Ó·È ÂÚ›Ô˘ 15% (1). ∏ Û˘¯ÓfiÙËÙ· ÙˆÓ È·ÙÚÈÎÒÓ ÂÈÛΤ„ÂˆÓ ÁÈ· ∞¢ Û ·È‰Ô‰ÂÚÌ·ÙÔÏÔÁÈÎfi È·ÙÚÂ›Ô Î·Ù¿ ÙÔ˘˜ ¯ÂÈÌÂÚÈÓÔ‡˜ Ì‹Ó˜ Â›Ó·È 25,2% (ÚÔÛˆÈ΋ ÂÌÂÈÚ›·). ∂›Û˘, ÁÈ·ÙÚÔ› ¿ÏÏˆÓ ÂȉÈÎÔÙ‹Paediatriki 2007;70:330-335
ÙˆÓ, fiˆ˜ ·È‰›·ÙÚÔÈ, ‰ÂÚÌ·ÙÔÏfiÁÔÈ, ·ÏÏÂÚÁÈÔÏfiÁÔÈ, ÂÍÂÙ¿˙Ô˘Ó Î·ıËÌÂÚÈÓ¿ ·È‰È¿ Ì ∞¢ Î·È ¤ÙÛÈ ÂӉȷʤÚÔÓÙ·È ÁÈ· ÙË ÓfiÛÔ (2). ∏ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ∞¢, fiˆ˜ Î·È Î¿ı ‰ÂÚÌ·ÙÔÏÔÁÈÎÔ‡ ÓÔÛ‹Ì·ÙÔ˜, ‰ÂÓ ÛÙËÚ›˙ÂÙ·È ÌfiÓÔ ÛÙË ÁÓÒÛË ·ÏÏ¿ ÂÍ›ÛÔ˘ Î·È ÛÙËÓ Ù¤¯ÓË ÙÔ˘ ¯ÂÈÚÈÛÌÔ‡ ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ‰¤ÚÌ·ÙÔ˜. ŒÙÛÈ, ÛÙËÓ ·ÚÔ‡Û·
Pediatri July-Aug 07
09-07-07
17:09
™ÂÏ›‰·331
331
∞ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· – ıÂڷ›·
ÂÈÛ‹ÁËÛË, Ë Û˘ÁÁڷʤ·˜ ‰ÂÓ ı· ·ÚÔ˘ÛÈ¿ÛÂÈ ÙȘ ÙÂÏÂ˘Ù·›Â˜ ηÙ¢ı˘ÓÙ‹ÚȘ Ô‰ËÁ›Â˜ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ∞¢, ·ÏÏ¿ ÙȘ Ô‰ËÁ›Â˜ ·˘Ù¤˜ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙË ‰È΋ Ù˘ “Ù¤¯ÓË”, fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÓÔÛ‹Ì·ÙÔ˜. ∂η›‰Â˘ÛË ª›· ·fi ÙȘ ÛÔ˘‰·ÈfiÙÂÚ˜ ·Ú·Ì¤ÙÚÔ˘˜ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ·È‰ÈÒÓ Ì ∞¢ Â›Ó·È Ë Âη›‰Â˘ÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È Ù˘ ÔÈÎÔÁ¤ÓÂÈ¿˜ ÙÔ˘, fiÛÔÓ ·ÊÔÚ¿ ÙË Ê‡ÛË Î·È ÙËÓ ÔÚ›· Ù˘ ÓfiÛÔ˘, ÙËÓ ·ÔÊ˘Á‹ ÂÎÏ˘ÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ, ÙË ÛˆÛÙ‹ ÂÓ˘‰¿ÙˆÛË ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ Î·È ÙËÓ ÂȉÈ΋ ıÂڷ›·. ŒÙÛÈ, ÛÙËÓ ÚÒÙË Â›ÛÎÂ„Ë ‰›ÓÂÙ·È fiÛÔ˜ ¯ÚfiÓÔ˜ ¯ÚÂÈ¿˙ÂÙ·È ÁÈ· Ó· ηٷÓÔ‹ÛÔ˘Ó ÔÈ ÁÔÓ›˜ Î·È ÙÔ ·È‰› fiÙÈ Ë ÚԉȿıÂÛË ÁÈ· ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· ‚Ú›ÛÎÂÙ·È ÛÙ· ÁÔÓ›‰È¿ Ì·˜, fiÙÈ Ë ÓfiÛÔ˜ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·Ô ˘Ê¤ÛÂȘ Î·È ÂÍ¿ÚÛÂȘ, fiÙÈ ÔÈΛÏÔÈ ·Ú¿ÁÔÓÙ˜ (.¯. ·Î·Ù¿ÏÏËÏÔ ÓÙ‡ÛÈÌÔ, ÌÈÎÚfi‚È·, „˘¯ÔÏÔÁÈÎfi ÛÙÚ˜) Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ ¤Ó·ÚÍË Î·È ÔÚ›· Ù˘ ÓfiÛÔ˘ Î·È fiÙÈ ÙÂÏÈο ¢ÂÏÈÛÙԇ̠fiÙÈ ÙÔ ·È‰› ÌÂÁ·ÏÒÓÔÓÙ·˜ ı· ··ÏÏ·Á› ·fi ÙÔ Úfi‚ÏËÌ¿ ÙÔ˘. ∂›Ó·È Ôχ ÛËÌ·ÓÙÈÎfi ÔÈ ÁÔÓ›˜ Ó· ÌËÓ ·ÈÛı¿ÓÔÓÙ·È ¤ÓÔ¯ÔÈ, ÂÂȉ‹ ÙÔ ·È‰› ÙÔ˘˜ ¿Û¯ÂÈ ·fi ∞¢. ¶ÚÔÏËÙÈο ̤ÙÚ· ∆o ˙ÂÛÙfi ÓÂÚfi ÚÔηÏ› ˘ÂÚ·ÈÌ›· Î·È ÂȉÂÈÓÒÓÂÈ ÙÔ ¤Î˙ÂÌ·, ÁÈ’ ·˘Ùfi ÙÔ ÓÂÚfi ÙÔ˘ Ì¿ÓÈÔ˘ Ú¤ÂÈ Ó· Â›Ó·È ¯ÏÈ·Úfi (33-34oC). ∂›Û˘, ÙÔ ÎÔÈÓfi Û·Ô‡ÓÈ ÂȉÂÈÓÒÓÂÈ ÙÔ ‹‰Ë ÍËÚfi ‰¤ÚÌ· ÙÔ˘ ·ÙÔÈÎÔ‡ ·È‰ÈÔ‡, ÁÈ’ ·˘Ùfi Ú¤ÂÈ Ó· ¯ÚËÛÈÌÔÔÈÂ›Ù·È ˘ÔηٿÛÙ·ÙÔ Û·Ô˘ÓÈÔ‡ ‹ ÂȉÈÎfi Ï¿‰È (bath oil) ÛÙÔ ÓÂÚfi ÙÔ˘ Ì¿ÓÈÔ˘. ∆Ô ‰¤ÚÌ· ı· Ú¤ÂÈ Ó· ÛÎÔ˘›˙ÂÙ·È Ù·ÌÔÓ·ÚÈÛÙ¿ Î·È fi¯È Ì ÙÚ›„ÈÌÔ, ÙÔ Ì¿ÓÈÔ ÙÔ˘ ·È‰ÈÔ‡ Ó· Â›Ó·È Î·ıËÌÂÚÈÓfi Î·È ÔÈ Ì·Ï·ÎÙÈΤ˜ Ô˘Û›Â˜ Ó· ÂÊ·ÚÌfi˙ÔÓÙ·È ÙfiÛÔ Û˘¯Ó¿, ÒÛÙ ÙÔ ‰¤ÚÌ· ÙÔ˘ ·È‰ÈÔ‡ Ó· ‰È·ÙËÚÂ›Ù·È “‚ÂÏÔ‡‰ÈÓÔ”. ∂›Ó·È ÚÔÙÈÌfiÙÂÚÔ Ó· ÂÊ·ÚÌfi˙ÔÓÙ·È Û ӈfi ‰¤ÚÌ·, ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙÔ Ì¿ÓÈÔ, ÁÈ· ηχÙÂÚÔ ·ÔÙ¤ÏÂÛÌ·. √È ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ÂȉÂÚÌȉÈÎÔ‡ ÊÚ·ÁÌÔ‡ ÙÔ˘ ·ÙÔÈÎÔ‡ ‰¤ÚÌ·ÙÔ˜ ÂÈÙÚ¤Ô˘Ó ÙË ‰È·‰ÂÚÌÈ΋ ·ÒÏÂÈ· ÓÂÚÔ‡ Ô˘ Ô‰ËÁ› Û ÍËÚfiÙËÙ· ÙÔ˘ ‰¤ÚÌ·ÙÔ˜, ·Ú¿ÏÏËÏ· fï˜ ÂÈÙÚ¤Ô˘Ó Î·È ÙËÓ Â›ÛÔ‰Ô ÂÚÂıÈÛÙÈÎÒÓ Ô˘ÛÈÒÓ ·Ô ÙÔ ÂÚÈ‚¿ÏÏÔÓ ÛÙÔ ‰¤ÚÌ· Ì ·ÔÙ¤ÏÂÛÌ· ÙË ‰ËÌÈÔ˘ÚÁ›· ÊÏÂÁÌÔÓ‹˜. ∂Ô̤ӈ˜, Ë ‰ÈfiÚıˆÛË ÙÔ˘ ÂȉÂÚÌȉÈÎÔ‡ ÊÚ·ÁÌÔ‡ ·ÔÙÂÏ› ‚·ÛÈÎfi ̤ÙÚÔ ÚfiÏ˄˘ ÙÔ˘ ÂÎ˙¤Ì·ÙÔ˜ (∂ÈÎfiÓ· 1). ÀÔÏÔÁ›˙ÂÙ·È fiÙÈ ÁÈ· ÛˆÛÙ‹ ÂÓ˘‰¿ÙˆÛË ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ ÂÓfi˜ ÌÈÎÚÔ‡ ·È‰ÈÔ‡ ··ÈÙÔ‡ÓÙ·È 150-200 g Ì·Ï·ÎÙÈ΋˜ Ô˘Û›·˜ ‚‰ÔÌ·‰È·›ˆ˜, ÂÓÒ ÁÈ· ÂÓ‹ÏÈη 500 g. ¢˘ÛÙ˘¯Ò˜, Ù· ˘ÔηٿÛٷٷ Û·Ô˘ÓÈÔ‡ Î·È Ù· Ì·Ï·ÎÙÈο Û΢¿ÛÌ·Ù· ‰ÂÓ Û˘ÓÙ·ÁÔÁÚ·ÊÔ‡ÓÙ·È ·fi Ù· Ù·Ì›· Î·È Â›Ó·È ·ÚÎÂÙ¿ ‰··ÓËÚ¿. ŒÙÛÈ,
ÚÔÙ›ÓÂÙ·È Ó· Û˘ÓÙ·ÁÔÁÚ·ÊÔ‡ÓÙ·È 2-3 ˘ÔηٿÛٷٷ Û·Ô˘ÓÈÔ‡, bath oils Î·È Ì·Ï·ÎÙÈΤ˜ Îڤ̘/ ·ÏÔÈʤ˜, ÒÛÙ ÔÈ ÁÔÓ›˜ Î·È ÙÔ ·È‰› Ó· ¤¯Ô˘Ó ÙË ‰˘Ó·ÙfiÙËÙ· Ó· ÂÈϤÍÔ˘Ó ÙÔ ÂÚÈÛÛfiÙÂÚÔ ·ÔÙÂÏÂÛÌ·ÙÈÎfi, ÎÔÛÌËÙÈο ·Ô‰ÂÎÙfi Î·È ÔÈÎÔÓÔÌÈο Û‡ÌÊÔÚÔ Û¯‹Ì· ÂÚÈÔ›ËÛ˘ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜. ∆· Ó‡¯È· Ú¤ÂÈ Ó· Îfi‚ÔÓÙ·È Û˘¯Ó¿, Ù· ÚÔ‡¯· Ó· Â›Ó·È ‚·Ì‚·ÎÂÚ¿, ¯·Ï·Ú¿ Î·È ¿ÓÂÙ· Î·È Ù· ÎÏÈÓÔÛοÛÌ·Ù· Ó· Â›Ó·È Â›Û˘ ‚·Ì‚·ÎÂÚ¿ Î·È Ó· ϤÓÔÓÙ·È Û ıÂÚÌÔÎÚ·Û›· >55ÔC ·Ó¿ ‚‰ÔÌ¿‰·. ¡· ÚÔÙÈÌÔ‡ÓÙ·È ·ÔÚÚ˘·ÓÙÈο Û ˘ÁÚ‹ ÌÔÚÊ‹ Î·È Ó· ·ÔʇÁÂÙ·È ÙÔ Ì·Ï·ÎÙÈÎfi, ÁÈ·Ù› ·Ú·Ì¤ÓÂÈ ÛÙȘ ›Ó˜ ÙˆÓ ÚÔ‡¯ˆÓ Î·È ÌÔÚ› Ó· ÂÚÂı›ÛÂÈ ÙÔ ‰¤ÚÌ·. ∏ ¤ÎıÂÛË Û ÔÈÎȷ΋ ÛÎfiÓË, Á‡ÚË, ÙÚ›¯ˆÌ· ˙ÒˆÓ Î·È Î·Ófi Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È. ŒÙÛÈ, ÙÔ ˘ÓÔ‰ˆÌ¿ÙÈÔ ÙÔ˘ ·ÙÔÈÎÔ‡ ·È‰ÈÔ‡ Ú¤ÂÈ Ó· Â›Ó·È ÏÈÙfi ¯ˆÚ›˜ ÌÈÎÚÔ·ÓÙÈΛÌÂÓ· Ô˘ ‰ÂÓ Ï¤ÓÔÓÙ·È ‹ ¯·ÏÈ¿ Ì ·¯‡ ¤ÏÔ˜. ∆Ô ¿ÙˆÌ· Ú¤ÂÈ Ó· ÛÎÔ˘›˙ÂÙ·È Ì ËÏÂÎÙÚÈ΋ ÛÎÔ‡· ηıËÌÂÚÈÓ¿ Î·È Ù· ¤ÈÏ· Ó· ÍÂÛÎÔÓ›˙ÔÓÙ·È Ì ‚ÚÂÁÌÂÓÔ ·Ó› ‰‡Ô ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰·, Ù· ·È¯Ó›‰È· Ó· ϤÓÔÓÙ·È Î¿ı 10 Ë̤Ú˜, ÂÓÒ Ù· ÏÔ˘ÏÔ‡‰È· ÛÙÔÓ ÂÛˆÙÂÚÈÎfi ¯ÒÚÔ ÙÔ˘ ÛÈÙÈÔ‡ Â›Ó·È ÚÔÙÈÌfiÙÂÚÔ Ó· ·ÔʇÁÔÓÙ·È, fiˆ˜ Î·È Ë Â·Ê‹ Ì ÙÚȯˆÙ¿ ηÙÔÈΛ‰È· ˙Ò·, Ì ÙËÓ ÚÔ¸fiıÂÛË fiÙÈ ÙÔ ÙÂÏÂ˘Ù·›Ô ‰ÂÓ ÂËÚ¿˙ÂÈ Û˘Ó·ÈÛıËÌ·ÙÈο ÙÔ ·È‰›. ∏ ıÂÚÌÔÎÚ·Û›· ÛÙÔ Û›ÙÈ ÙÔ˘˜ ¯ÂÈÌÂÚÈÓÔ‡˜ Ì‹Ó˜ ‰ÂÓ ı· Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÂÈ ÙÔ˘˜ 18ÔC, ÂÓÒ ı· Ú¤ÂÈ Ó· ˘¿Ú¯ÂÈ Ì¤ÙÚÈ· ˘ÁÚ·Û›·. ∆Ô ÙÂÏÂ˘Ù·›Ô ÂÍ·ÛÊ·Ï›˙ÂÙ·È Â¿Ó ˘¿Ú¯ÂÈ ÌÒÏ Ì ÓÂÚfi ÛÙÔ ‰ˆÌ¿ÙÈÔ. √ ÌËÙÚÈÎfi˜ ıËÏ·ÛÌfi˜ Û˘ÓÈÛÙ¿Ù·È ÙÔ˘Ï¿¯ÈÛÙÔ Ì¤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÌËÓÒÓ, Ì ÙȘ ÛÙÂÚ¤˜ ÙÚÔʤ˜ Ó· ÂÈÛ¿ÁÔÓÙ·È ÚÔԉ¢ÙÈο ·Ô ÙÔÓ 7Ô Ì‹Ó· (Ì›· ηÈÓÔ‡ÚÁÈ· ÙÚÔÊ‹ ·Ó¿ ‚‰ÔÌ¿‰·), ÒÛÙ ӷ Á›ÓÂÙ·È ¤ÁηÈÚË ·Ó·ÁÓÒÚÈÛË Ù˘¯fiÓ ÙÚÔÊÈ΋˜ ·ÏÏÂÚÁ›·˜. ∂ÎÙfi˜ ·fi Ù· Û˘ÓÙËÚËÙÈο Î·È ÙȘ ¯ÚˆÛÙÈΤ˜ Ô˘ Ú¤ÂÈ Ó· ·ÔʇÁÔÓÙ·È, Ù· ·È‰È¿ Ú¤ÂÈ Ó· ¤¯Ô˘Ó ÂχıÂÚÔ ‰È·ÈÙÔÏfiÁÈÔ. ¢È·ÈÙËÙÈÎÔ› ¯ÂÈÚÈÛÌÔ› ‹/Î·È ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÂӉ›ÎÓ˘ÓÙ·È fiÙ·Ó ÙÔ ÈÛÙÔÚÈÎfi ÙÔ˘ ·È‰ÈÔ‡ ı¤ÙÂÈ ÈÛ¯˘Ú¤˜ ˘Ô„›Â˜ ÁÈ· ·ÏÏÂÚÁ›· ÛÂ Û˘ÁÎÂÎÚÈ̤ÓË ÙÚÔÊ‹ ‹ fiÙ·Ó ÙÔ ¤Î˙ÂÌ· ‰ÂÓ ·ÓÙ·ÔÎÚ›ÓÂÙ·È ÛÙËÓ Î·Ù¿ÏÏËÏË ıÂڷ¢ÙÈ΋ ·ÁˆÁ‹. ∆Ô ÂÌ‚fiÏÈÔ Ù˘ ÈÏ·Ú¿˜ Â›Ó·È ·ÛʷϤ˜ Û ÂÚÈÙÒÛÂȘ ·ÏÏÂÚÁ›·˜ ÛÙÔ ·˘Áfi (3).
£Âڷ›· ∆ÔÈο ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ √È ÁÔÓ›˜ ‰È‰¿ÛÎÔÓÙ·È fiÙÈ ·) ÛÙË ‰ÂÚÌ·ÙÔÏÔÁ›· ÈÛ¯‡ÂÈ ÙÔ ·Í›ˆÌ· “˘ÁÚfi ÛÙÔ ˘ÁÚfi Î·È ÍËÚfi ÛÙÔ ÍËÚfi” Î·È fiÙÈ ‚) Ë Ï¤ÍË ¤Î˙ÂÌ· ÚÔ¤Ú¯ÂÙ·È ·fi ÙÔ Ú‹Ì· ˙¤ˆ (‚Ú¿˙ˆ). ∂Ô̤ӈ˜ ÂÎ˙ÂÌ·ÙÈΤ˜ ‚Ï¿‚˜ Ô˘ Â›Ó·È ˘ÁÚ¤˜ Î·È ÔÚÔÚÚÔÔ‡Ó ÌÔÚ› Ó· ˘Ô‰ËÏÒÓÔ˘Ó ·Ï¿ ¤Î˙ÂÌ· ÛÙËÓ ÔÍ›· ÙÔ˘ Ê¿ÛË, ·ÏÏ¿ Î·È ÂΉ‹ÏˆÛË Ïԛ̈͢. ŒÙÛÈ, ¶·È‰È·ÙÚÈ΋ 2007;70:330-335
Pediatri July-Aug 07
09-07-07
17:09
™ÂÏ›‰·332
332
∆. ∆ÛÈ‚ÈÙ·Ó›‰Ô˘-∫¿ÎÔ˘ÚÔ˘
∞) √È ‚Ï¿‚˜ Ô˘ Â›Ó·È ˘ÁÚ¤˜ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È ·Ú¯Èο Ì ÂÈı¤Ì·Ù· ‹ „ÂηÛÌÔ‡˜ Ì NaCl 0,9%, ̤¯ÚȘ fiÙÔ˘ ÙÔ ‰¤ÚÌ· ÛÙ·Ì·Ù‹ÛÂÈ Ó· ÔÚÔÚÚÔ›. ∞˘Ùfi ÂÈÙ˘Á¯¿ÓÂÙ·È Û 1-3 24ˆÚ·. ™ÙË Û˘Ó¤¯ÂÈ·, ÂÊ·ÚÌfi˙ÂÙ·È ÙÔÈÎfi ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ¤˜ (‹È·˜ ÈÛ¯‡Ô˜ Û ÚfiÛˆÔ Î·È ÁÂÓÓËÙÈο fiÚÁ·Ó· ÁÈ· ‚Ú¤ÊË ¤ˆ˜ ¤ÍÈ ÌËÓÒÓ, ̤ÙÚÈ·˜ ÈÛ¯‡Ô˜ ÁÈ· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿) Û ۯ‹Ì· ÚÔԉ¢ÙÈ΋˜ Ì›ˆÛ˘. °È· ·Ú¿‰ÂÈÁÌ·, ÂÊ·ÚÌfi˙ÂÙ·È ˘‰ÚÔÎÔÚÙÈ˙fiÓË 1% ÙÚÂȘ ÊÔÚ¤˜ ËÌÂÚËÛ›ˆ˜ (Úˆ› - ÌÂÛË̤ÚÈ - ‚Ú¿‰˘) ̤¯ÚÈ Ó· ˘¿ÚÍÂÈ ‚ÂÏÙ›ˆÛË (ÏÈÁfiÙÂÚÔ ÂÚ‡ıËÌ· Î·È ÎÓËÛÌfi˜), .¯. ÁÈ· 3 Ë̤Ú˜. ™ÙË Û˘Ó¤¯ÂÈ·, ÂÊ·ÚÌfi˙ÂÙ·È ‰‡Ô ÊÔÚ¤˜ ËÌÂÚËÛ›ˆ˜ (Úˆ›-‚Ú¿‰˘) ÁÈ· 3 Ë̤Ú˜, Î·È Ì›· ÊÔÚ¿ ËÌÂÚËÛ›ˆ˜ (Úˆ›) ÁÈ· ¿ÏϘ 3 Ë̤Ú˜. ∞ÎfiÌË Î·È Û‹ÌÂÚ·, Ì ÙËÓ Î·ÈÓÔ‡ÚÁÈ· ÁÂÓÈ¿ ÙˆÓ ÙÔÈÎÒÓ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ (.¯. fluticasone propionate, mometasone furoate) Ô˘ ¤¯Ô˘Ó Ì·ÎÚ‡ ¯ÚfiÓÔ ‰Ú¿Û˘ (·ÚΛ Ë Â¿ÏÂÈ„Ë Ì›· ÊÔÚ¿ ÙËÓ Ë̤ڷ) Î·È ÏÈÁfiÙÂÚ˜ ·ÚÂÓ¤ÚÁÂȘ (ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó Î·ıËÌÂÚÈÓ¿ ÁÈ· ¤Ó·Ó Ì‹Ó· Ì ·ÛÊ¿ÏÂÈ·) (4,5), Â›Ó·È ÚÔÙÈÌfiÙÂÚÔ ÙÔ Û¯‹Ì· ÚÔԉ¢ÙÈ΋˜ Ì›ˆÛ˘ (‰‡Ô ÊÔÚ¤˜ ËÌÂÚËÛ›ˆ˜ .¯. 5 Ë̤Ú˜, Î·È ÛÙË Û˘Ó¤¯ÂÈ· Ì›· ÊÔÚ¿ ËÌÂÚËÛ›ˆ˜ ÁÈ· 5 Ë̤Ú˜). ∂›Ó·È Ôχ ÛËÌ·ÓÙÈÎfi ÔÈ ÁÔÓ›˜ Ó· ηٷÓÔÔ‡Ó ÙË ‰È·ÊÔÚ¿ ¯Ú‹Û˘ Ì·Ï·ÎÙÈÎÔ‡ Û΢¿ÛÌ·ÙÔ˜ Î·È ÛˆÛÙ‹˜ ¯Ú‹Û˘ ÙÔÈÎÔ‡ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉԇ˜. ™ËÌÂÈÒÓÂÙ·È fiÙÈ fiÙ·Ó ÙÔ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ¤˜ ÂÊ·ÚÌfi˙ÂÙ·È Ì›· ÊÔÚ¿ ËÌÂÚËÛ›ˆ˜, Â›Ó·È ÚÔÙÈÌfiÙÂÚÔ Ë ÂÊ·ÚÌÔÁ‹ Ó· Á›ÓÂÙ·È ÙÔ Úˆ› Î·È fi¯È ÙÔ ‚Ú¿‰˘ ÁÈ· Ó· ÂÏ·¯ÈÛÙÔÔÈÂ›Ù·È Ë Èı·ÓfiÙËÙ· ηٷÛÙÔÏ‹˜ ÙÔ˘ ¿ÍÔÓ· ˘Ôı¿Ï·ÌÔ˜- ˘fiÊ˘ÛË- ÂÈÓÂÊÚ›‰È·. ∏ ‰È·ÏÂ›Ô˘Û· ¯Ú‹ÛË ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ ÂÏ·¯ÈÛÙÔÔÈ› ÙËÓ Èı·ÓfiÙËÙ· ˘ÔÙÚÔ‹˜, Ù·¯˘Ê˘Ï·Í›·˜ (·ÓÔ¯‹˜ ÛÙ· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹) Î·È ÙËÓ ÂÌÊ¿ÓÈÛË ¿ÏÏˆÓ ÙÔÈÎÒÓ Î·È Û˘ÛÙËÌ·ÙÈÎÒÓ ·ÚÂÓÂÚÁÂÈÒÓ. ™‡Ìʈӷ Ì ÙËÓ ÂÌÂÈÚ›· ÌÔ˘, Ë ¯Ú‹ÛË Ê˘ÛÈÔÏÔÁÈÎÔ‡ ÔÚÔ‡ ÛÙÔ ¤Î˙ÂÌ· Ô˘ Â›Ó·È ˘ÁÚfi, ÂÏ·ÙÙÒÓÂÈ ÙÔÓ ¯ÚfiÓÔ ¯ÔÚ‹ÁËÛ˘ ÙÔÈÎÔ‡ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉԇ˜. ∞Ú¯Èο Û˘ÓÈÛÙÔ‡Û·Ì ·oÛÙ·Á̤ÓÔ ÓÂÚfi ·ÓÙ› ÁÈ· Ê˘ÛÈÔÏÔÁÈÎfi ÔÚfi Ì ÙÔ ·ÈÙÈÔÏÔÁÈÎfi fiÙÈ ÙÔ ·Ï·ÙÔ‡¯Ô ‰È¿Ï˘Ì· ı· ÂÚ¤ıÈ˙ ÙÔ ¿Û¯ÔÓ ‰¤ÚÌ·, fï˜ ‰È·ÈÛÙÒıËΠfiÙÈ ¤¯ÂÈ ·ÎÚÈ‚Ò˜ Ù· ·ÓÙ›ıÂÙ· ·ÔÙÂϤÛÌ·Ù·. ∆ÔÈο ·ÓÙÈ‚ÈÔÙÈο / ·ÓÙÈ‚ÈÔÙÈο Ì ÙË Û˘ÛÙËÌ·ÙÈ΋ Ô‰fi µ) ∂¿Ó ÔÈ ÂÎ˙ÂÌ·ÙÈΤ˜ ‚Ï¿‚˜ ÂÍ·ÎÔÏÔ˘ıÔ‡Ó Î·È Â›Ó·È ˘ÁÚ¤˜ ÌÂÙ¿ ·Ô 5 Ë̤Ú˜ „ÂηÛÌÒÓ ÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÔÚfi Î·È ÙÔ ·È‰› ηٿ Ù· ¿ÏÏ· Â›Ó·È Î·Ï¿, ÙfiÙ ÚÔÛÙ›ıÂÙ·È ÙÔÈÎfi ·ÓÙÈ‚ÈÔÙÈÎfi Ì ÛÙfi¯Ô Ó· ÂÏ·ÙÙˆı› ÙÔ ÛÙ·Ê˘ÏÔÎÔÎÎÈÎfi ÊÔÚÙ›Ô ‹ Ó· ·ÓÙÈÌÂÙˆÈÛı› Èı·Ó‹ Ïԛ̈ÍË (6). ŸÙ·Ó ÔÈ ‚Ï¿‚˜ ÛÙ·Ì·Ù‹ÛÔ˘Ó Ó· ÔÚÔÚÚÔÔ‡Ó, Ú¿ÁÌ· Ô˘ ÂÈÙ˘Á¯¿ÓÂPaediatriki 2007;70:330-335
∂ÈÎfiÓ· 1. •ËÚÔ‰ÂÚÌ›· Û ÎÔÚ›ÙÛÈ Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ·.
∂ÈÎfiÓ· 2. ∞ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· Û ‚Ú¤ÊÔ˜. √È ‚Ï¿‚˜ Â›Ó·È ÍËÚ¤˜.
∂ÈÎfiÓ· 3. √È ÂÎ˙ÂÌ·ÙÈΤ˜ ‚Ï¿‚˜ Â›Ó·È ˘ÁÚ¤˜ ηٷ ÙfiÔ˘˜ ÌÂÙ¿ ·Ô 5‹ÌÂÚË ·ÁˆÁ‹ ÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÔÚfi ÔfiÙ ı· ÚÔÛÙÂı› ·ÓÙÈ‚›ˆÛË ÙÔÈο.
Pediatri July-Aug 07
09-07-07
17:09
™ÂÏ›‰·333
333
∞ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· – ıÂڷ›·
Ù·È Û˘Ó‹ıˆ˜ ÌÂÙ¿ ·Ô 2-3 Ë̤Ú˜ ÙÔÈ΋˜ ·ÓÙÈ‚ÈÔÙÈ΋˜ ıÂڷ›·˜, Û˘ÓÈÛÙ¿Ù·È Îڤ̷ ÙÔÈÎÔ‡ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉԇ˜/ ·ÓÙÈ‚ÈÔÙÈÎÔ‡ Û ۯ‹Ì· ÚÔԉ¢ÙÈ΋˜ Ì›ˆÛ˘. °) ∂·Ó ÔÈ ÂÎ˙ÂÌ·ÙÈΤ˜ ‚Ï¿‚˜ ÂÍ·ÎÔÏÔ˘ıÔ‡Ó Ó· Â›Ó·È ˘ÁÚ¤˜ ÌÂÙ¿ ·Ô 5 Ë̤Ú˜ ÙÔÈ΋˜ ·ÓÙÈ‚ÈÔÙÈ΋˜ ·ÁˆÁ‹˜ ‹ Â¿Ó ÙÔ ¤ÎÎÚÈÌ· Â›Ó·È ÔÚÔ˘Ò‰Â˜, ˘¿Ú¯Ô˘Ó ÊÏ˘ÎÙ·ÈÓ›‰È· ‹ ¿ÏÏ· Û˘ÌÙÒÌ·Ù·, ¯ÔÚËÁÂ›Ù·È ·ÓÙÈ‚ÈÔÙÈÎfi ·Ô ÙÔ ÛÙfiÌ· ‹, Ôχ Û¿ÓÈ·, ÂÓ‰ÔÊÏ‚›ˆ˜ (∂ÈÎfiÓ˜ 2-6).
∂ÈÎfiÓ· 4. ∞ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· Û ·È‰› Û¯ÔÏÈ΋˜ ËÏÈΛ·˜. √È ‚Ï¿‚˜ ¯·Ú·ÎÙËÚÈÛÙÈο ÂÓÙÔ›˙ÔÓÙ·È ÛÙȘ ¤Ûˆ ÂÈÊ¿ÓÂȘ ÙˆÓ ¿ÎÚˆÓ Î·È ÙÔÓ ÎÔÚÌfi.
∂ÈÎfiÓ· 5. §ÂȯËÓÔÔÈË̤Ó˜ ÂÎ˙ÂÌ·ÙÈΤ˜ ‚Ï¿‚˜ Û ¤ÊË‚Ô.
∂ÈÎfiÓ· 6. ŒÎ˙ÂÌ· ÛÙȘ ¤Ûˆ ÂÈÊ¿ÓÂȘ ÙˆÓ ‰·ÎÙ‡ÏˆÓ (‰˘ÛȉڈÛÈÎfi) Ì ÔÚÔ˘Ò‰Â˜ ¤ÎÎÚÈÌ· ·fi 10Ë̤ÚÔ˘, ·Ú¿ ÙËÓ ÙÔÈ΋ ·ÓÙÈ‚ÈÔÙÈ΋ ·ÁˆÁ‹. £· ‰Ôı› ·ÓÙÈÛÙ·Ê˘ÏÔÎÔÎÎÈÎfi ·fi ÙÔ ÛÙfiÌ·.
∆ÔÈÎÔ› ·Ó·ÛÙÔÏ›˜ Ù˘ ηÏÛÈÓ¢ڛÓ˘ ™ÙËÓ ÂÚ›ÙˆÛË Û˘¯ÓÒÓ ˘ÔÙÚÔÒÓ ‹ ÂÎÙÂÙ·Ì¤ÓˆÓ Î·È Â›ÌÔÓˆÓ ÂÎ˙ÂÌ·ÙÈÎÒÓ ‚Ï·‚ÒÓ Ô˘ Ú·ÎÙÈο ÂÎÊÚ¿˙ÔÓÙ·È Ì ÂÊ·ÚÌÔÁ‹ ÙÔÈÎÒÓ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ >10 ̤Ú˜/ Ì‹Ó· ÛÙÔ ÚfiÛˆÔ Î·È >15 ̤Ú˜/ Ì‹Ó· ÛÙÔ ÛÒÌ· ‹/Î·È ¯Ú‹ÛË ÎÔÚÙÈÎÔÛÙÂÚÔÂȉԇ˜ >15gr/Ì‹Ó· Û ‚Ú¤ÊÔ˜ Î·È >30gr/Ì‹Ó· Û ÌÂÁ·Ï‡ÙÂÚÔ ·È‰›, ÙfiÙ ÚÔÛÙ›ıÂÙ·È Î·È ÙÔÈÎfi˜ ·Ó·ÛÙÔϤ·˜ Ù˘ ηÏÛÈÓ¢ڛÓ˘ (tacrolimus, pimecrolimus) (3) . ™ËÌÂÈÒÓÂÙ·È fiÙÈ ÙÔ tacrolimus ΢ÎÏÔÊÔÚ› ˆ˜ ·ÏÔÈÊ‹ Î·È ÙÔ pimecrolimus Ì ÙË ÌÔÚÊ‹ Îڤ̷˜. ∏ ·ÓÙÈÊÏÂÁÌÔÓ҉˘ ‰Ú¿ÛË ÙÔ˘ tacrolimus 0,1% Â›Ó·È ·ÚfiÌÔÈ· Ì ÂΛÓË ÂÓfi˜ ̤ÙÚÈ·˜ ÈÛ¯‡Ô˜ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉԇ˜, ÂÓÒ ÙÔ pimecrolimus 1% Â›Ó·È ËÈfiÙÂÚÔ (7-9). ∏ ÂÁÎÂÎÚÈ̤ÓË ËÏÈΛ· ¯ÔÚ‹ÁËÛ˘ ·Ó·ÛÙÔϤ· Ù˘ ηÏÛÈÓ¢ڛÓ˘ Û ·È‰È¿ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË ÙˆÓ ‰‡Ô ÂÙÒÓ. ∂¿Ó ¤Ó· ·È‰› ÏËÚ› Ù· ÎÚÈÙ‹ÚÈ· ¯Ú‹Û˘ ÙÔÈÎÔ‡ ·Ó·ÛÙÔϤ· ηÏÛÈÓ¢ڛÓ˘, ÙfiÙ ÛÙË Ê¿ÛË Ô˘ ÙÔ ÙÔÈÎfi ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ¤˜ ¯ÔÚËÁÂ›Ù·È ÌfiÓÔ ÙÔ Úˆ›, Ô ·Ó·ÛÙÔϤ·˜ Ù˘ ηÏÛÈÓ¢ڛÓ˘ ÂÊ·ÚÌfi˙ÂÙ·È ÙÔ ‚Ú¿‰˘ Î·È fiÙ·Ó Á›ÓÂÈ ‰È·ÎÔ‹ ÙÔ˘ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉԇ˜, ÙfiÙ ÂÊ·ÚÌfi˙ÂÙ·È Úˆ›- ‚Ú¿‰˘ ̤¯ÚÈ Ï‹ÚÔ˘˜ ˘Ô¯ÒÚËÛ˘ ÙˆÓ Û˘Ìو̿وÓ. ™Â ¤Ó·ÚÍË ˘ÔÙÚÔ‹˜ (‹ÈÔ ÂÚ‡ıËÌ·, ÎÓËÛÌfi˜) ÂÊ·ÚÌfi˙ÂÙ·È ÙÔÈÎfi˜ ·Ó·ÛÙÔϤ·˜ ηÏÛÈÓ¢ڛÓ˘, ‰‡Ô ÊÔÚ¤˜ ËÌÂÚËÛ›ˆ˜ Î·È Á›ÓÂÙ·È ·fiÙÔÌË ‰È·ÎÔ‹ fiÙ·Ó ˘Ô¯ˆÚ‹ÛÔ˘Ó Ù· Û˘ÌÙÒÌ·Ù·. ŸÙ·Ó ÔÈ ·Ó·ÛÙÔÏ›˜ Ù˘ ηÏÛÈÓ¢ڛÓ˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ¤ÁηÈÚ·, ÌÂÈÒÓÔ˘Ó ÙË ‚·Ú‡ÙËÙ·, ÂÈÌË·ÓÔ˘Ó ÙÔÓ ¯ÚfiÓÔ ÌÂٷ͇ ÙˆÓ ÂÍ¿ÚÛÂˆÓ Î·È ‚ÂÏÙÈÒÓÔ˘Ó Û˘ÓÔÏÈο ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ÓfiÛÔ˘. ŒÙÛÈ, Ë ¯Ú‹ÛË ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ ÂÚÈÔÚ›˙ÂÙ·È ÌfiÓÔ ÛÙȘ Ê¿ÛÂȘ ¤ÓÙÔÓ˘ ¤Í·ÚÛ˘ ÙÔ˘ ÂÎ˙¤Ì·ÙÔ˜. ªÂϤÙ˜ Ì pimecrolimus Û ‚Ú¤ÊË ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ, fiÙ·Ó ¯ÚËÛÈÌÔÔÈÂ›Ù·È Î·Ù¿ ÙËÓ ¤Ó·ÚÍË ÙˆÓ Û˘Ìو̿وÓ, ÌÔÚ› Ó· ·ÔÙÚ¤„ÂÈ ¤Í·ÚÛË Ù˘ ÓfiÛÔ˘ ÁÈ· ‰È¿ÛÙËÌ· ̤¯ÚÈ Î·È 12 Ì‹Ó˜ (10). ∞ÓÙÈ˚ÛÙ·ÌÈÓÈο ∞ÓÙÈ˚ÛÙ·ÌÈÓÈο ¯ÔÚËÁÔ‡ÓÙ·È Û˘ÛÙËÌ·ÙÈο ÁÈ· ÙËÓ ·ÓÙÈÎÓËÛÌÒ‰Ë Î·È ËÚÂÌÈÛÙÈ΋ ÙÔ˘˜ ‰Ú¿ÛË. ŒÙÛÈ, ¶·È‰È·ÙÚÈ΋ 2007;70:330-335
Pediatri July-Aug 07
09-07-07
17:09
™ÂÏ›‰·334
334
∆. ∆ÛÈ‚ÈÙ·Ó›‰Ô˘-∫¿ÎÔ˘ÚÔ˘
ÚÔÙÈÌÒÓÙ·È Ù· ÚÒÙ˘ ÁÂÓÈ¿˜ ·ÓÙÈ˚ÛÙ·ÌÈÓÈο Ô˘ ÏËÚÔ‡Ó ÙȘ ·ÓˆÙ¤Úˆ ȉÈfiÙËÙ˜. √˘‰¤ÔÙ fï˜ ÂÊ·ÚÌfi˙ÔÓÙ·È ÙÔÈο, ÁÈ·Ù› ¢·ÈÛıËÙÔÔÈÔ‡Ó ÙÔ ‰¤ÚÌ· (3). ∂˘Ú¤ˆ˜ Û˘ÓÙ·ÁÔÁÚ·ÊÂ›Ù·È Ë ˘‰ÚÔ͢˙›ÓË. ™ËÌÂÈÒÓÂÙ·È fiÙÈ Ô Ì¤ÛÔ˜ ¯ÚfiÓÔ˜ ˘Ô‰ÈÏ·ÛÈ·ÛÌÔ‡ Ù˘ ˘‰ÚÔ͢˙›Ó˘ ÛÙ· ·È‰È¿ Â›Ó·È 7,1±2,3 ÒÚ˜ Ì ‡ÚÔ˜ 4 ÒÚ˜ ÛÙ· ‚Ú¤ÊË ËÏÈΛ·˜ 12 ÌËÓÒÓ Î·È 11 ÒÚ˜ ÛÙ· ·È‰È¿ 14 ¯ÚÔÓÒÓ (11). ŒÙÛÈ, ÛÙ· ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ Ë ˘‰ÚÔ͢˙›ÓË ¯ÔÚËÁÂ›Ù·È 3 ÊÔÚ¤˜ ËÌÂÚËÛ›ˆ˜, ÒÛÙ ӷ ÂÈÙ˘Á¯¿ÓÔÓÙ·È ÛÙ·ıÂÚ¿ ıÂڷ¢ÙÈο ›‰· ÛÙÔ ·›Ì·. ÃÔÚËÁÂ›Ù·È ·Ú¯Èο ¯·ÌËÏ‹ ‰fiÛË ˘‰ÚÔ͢˙›Ó˘ (1mg/kg/24ˆÚÔ) Î·È ÔÈ ÁÔÓ›˜ ÌÔÚ› ÚÔԉ¢ÙÈο Ó· ‰ÈÏ·ÛÈ¿ÛÔ˘Ó ‹ Î·È Ó· ÙÚÈÏ·ÛÈ¿ÛÔ˘Ó ÙËÓ 24ˆÚË ‰fiÛË ¯ˆÚ›˜ Ó· ˙ËÙ‹ÛÔ˘Ó ÙË Û˘Ó‰ÚÔÌ‹ ÙÔ˘ ÁÈ·ÙÚÔ‡ ÙÔ˘˜. ∂¿Ó ÙÔ ·È‰› ÂÍ·ÎÔÏÔ˘ı› Î·È ¤¯ÂÈ ÎÓËÛÌfi Û fiÏË ÙË ‰È¿ÚÎÂÈ· Ù˘ Ë̤ڷ˜, ·˘Í¿ÓÔ˘Ó Î·È ÙȘ ÙÚÂȘ ‰fiÛÂȘ, ÂÓÒ Â¿Ó ¤¯ÂÈ ÎÓËÛÌfi ÛÂ Û˘ÁÎÂÎÚÈ̤ÓË ÂÚ›Ô‰Ô Ù˘ Ë̤ڷ˜, ÁÈ· ·Ú¿‰ÂÈÁÌ· ÙÔ ‚Ú¿‰˘, ÙfiÙ ·˘Í¿ÓÔ˘Ó ÙË ‚Ú·‰ÈÓ‹ ‰fiÛË ÌfiÓÔ. ∏ ˘‰ÚÔ͢˙›ÓË ¯ÔÚËÁÂ›Ù·È ÁÈ· ¤ÓÙ Ë̤Ú˜ ÂÈϤÔÓ, ÌÂÙ¿ ÙËÓ ˘Ô¯ÒÚËÛË ÙÔ˘ ÎÓËÛÌÔ‡. ªÂ ÙÔ ·ÓˆÙ¤Úˆ Û¯‹Ì· ıÂڷ›·˜, Ë ‰fiÛË Ù˘ ˘‰ÚÔ͢˙›Ó˘ fi¯È ÌfiÓÔ ÂÍ·ÙÔÌÈ·ÂÙ·È ·ÏÏ¿ ‰È·Ê¤ÚÂÈ ÛÙÔ ›‰ÈÔ ÙÔ ·È‰› οı ÊÔÚ¿, ·Ó¿ÏÔÁ· Ì ÙË ‚·Ú‡ÙËÙ· Ù˘ ˘ÔÙÚÔ‹˜. ∂ÈϤÔÓ, Ë ‰È·ÏÂ›Ô˘Û· ¯ÔÚ‹ÁËÛË ·ÓÙÈ˚ÛÙ·ÌÈÓÈÎÔ‡ ÂÏ·ÙÙÒÓÂÈ ÙËÓ Èı·ÓfiÙËÙ· Ù·¯˘Ê˘Ï·Í›·˜ Î·È ¿ÏÏˆÓ Û˘ÛÙËÌ·ÙÈÎÒÓ ·ÚÂÓÂÚÁÂÈÒÓ.
∂ÈÎfiÓ· 7. ¶ÔÏϷϤ˜ ‚Ï¿‚˜ ÌÔÏ˘ÛÌ·ÙÈ΋˜ ÙÂÚÌ›ÓıÔ˘ Û ·È‰› Ì ÍËÚÔ‰ÂÚÌ›·- ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ·.
∞ÓÙÈ-ÈÈ΋ ·ÁˆÁ‹ √È ·ÛıÂÓ›˜ Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· Â›Ó·È ÂÈÚÚ›˜ Û ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ (·Ïfi˜ ¤Ú˘, ÌÔÏ˘ÛÌ·ÙÈ΋ Ù¤ÚÌÈÓıÔ˜, Ì˘ÚÌËÁÎȤ˜) (∂ÈÎfiÓ˜ 7-9). √È ÁÔÓ›˜ Ú¤ÂÈ Ó· Â›Ó·È Â˘·ÈÛıËÙÔÔÈË̤ÓÔÈ Î·È Ó· ÂÈÛΤÙÔÓÙ·È ÙÔÓ ·È‰›·ÙÚfi ÙÔ˘˜ ÌfiÏȘ ·ÓÙÈÏËÊıÔ‡Ó ÔÈ·‰‹ÔÙ ·Û˘Ó‹ıË ‰ÂÚÌ·ÙÈ΋ ‚Ï¿‚Ë (12). ™˘ÛÙËÌ·ÙÈ΋ ·ÓÙÈÊÏÂÁÌÔÓ҉˘ ·ÁˆÁ‹ ∏ Û˘ÛÙËÌ·ÙÈ΋ ·ÓÙÈÊÏÂÁÌÔÓ҉˘ ·ÁˆÁ‹ (.¯. ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ¤˜, ΢ÎÏÔÛÔÚ›ÓË, ·˙·ıÈÔÚ›ÓË) ÂÚÈÔÚ›˙ÂÙ·È Û ›ÌÔÓ˜, ÛÔ‚·Ú¤˜ Î·È ·ÓıÂÎÙÈΤ˜ ÛÙËÓ ÙÔÈ΋ ·ÁˆÁ‹ ÂÚÈÙÒÛÂȘ ·ÙÔÈÎÔ‡ ÂÎ˙¤Ì·ÙÔ˜ (3,13). ™ÙË ¯ÒÚ· Ì·˜, Ù· ÂÚÈÛÛfiÙÂÚ· ·È‰È¿ Ì ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· ¤¯Ô˘Ó ‹È· ‹ ̤ÙÚÈ·˜ ‚·Ú‡ÙËÙ·˜ ÓfiÛÔ. ∞˘Ùfi Èı·ÓÒ˜ ÔÊ›ÏÂÙ·È ÛÙȘ ÎÏÈÌ·ÙÔÏÔÁÈΤ˜ Û˘Óı‹Î˜, ÙÔÓ ÙÚfiÔ ‰È·‚›ˆÛ˘ Î·È ÙË ‰È·ÙÚÔÊ‹ (ÌÂÛÔÁÂȷ΋ ‰›·ÈÙ·).
™˘Ì¤Ú·ÛÌ· ∏ ·ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· Â›Ó·È ¯ÚfiÓÈ· ÓfiÛÔ˜ Ô˘ Paediatriki 2007;70:330-335
∂ÈÎfiÓ· 8. µÏ¿‚˜ ·ÏÔ‡ ¤ÚËÙ·.
∂ÈÎfiÓ· 9. √̷Ϥ˜ Ì˘ÚÌËÁÎȤ˜.
Pediatri July-Aug 07
09-07-07
17:09
™ÂÏ›‰·335
335
∞ÙÔÈ΋ ‰ÂÚÌ·Ù›Ùȉ· – ıÂڷ›·
¯·Ú·ÎÙËÚ›˙ÂÙ·È ·Ô ÂÍ¿ÚÛÂȘ Î·È ˘Ê¤ÛÂȘ. ∂›Ó·È ÂÔ̤ӈ˜ ÛËÌ·ÓÙÈÎfi ÙÔ ·È‰› Î·È Ë ÔÈÎÔÁ¤ÓÂÈ¿ ÙÔ˘ Ó· ÂÎ·È‰Â˘ıÔ‡Ó ÒÛÙ ӷ ·ÓÙÈÌÂÙˆ›˙Ô˘Ó Û ÌÂÁ¿ÏÔ ‚·ıÌfi ÙË ÓfiÛÔ ÌfiÓÔÈ ÙÔ˘˜, Ó· ˙ËÙÔ‡Ó ¿ÌÂÛ· È·ÙÚÈ΋ ‚Ô‹ıÂÈ· fiÙ·Ó ¤¯Ô˘Ó Ó· ·ÓÙÈÌÂÙˆ›ÛÔ˘Ó Î¿ÙÈ ·Û‡ÓËı˜, Ó· ·Ú·ÎÔÏÔ˘ıÔ‡ÓÙ·È Û ٷÎÙÈο ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù· ·Ô ÂȉÈÎfi Î·È Î˘Ú›ˆ˜ Ó· ¤¯Ô˘Ó ¿ÌÂÛË ÚfiÛ‚·ÛË ÛÙÔÓ ·È‰›·ÙÚÔ ÙÔ˘˜, fiÔÙÂ Î·È fiÙ·Ó ÙÔ ÎÚ›ÓÔ˘Ó ··Ú·›ÙËÙÔ.
6.
7. 8.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Schultz Larsen F, Diepgen T, Svensson A. The occurrence of atopic dermatitis in north Europe: an international questionnaire study. J Am Acad Dermatol 1996;34:760-764. 2. Barbarot S, Beauchet A, Zaid S, Lacour JP, Groupe de Recherche Clinique en Dermatologie Pédiatrique. The management of atopic dermatitis in children by dermatologists, paediatricians, general practitioners and allergologists: a national survey on practice patterns. Ann Dermatol Venereol 2005;132:283-295. 3. Darsow U, Lubbe J, Taieb A. Seidenari S, Wollenberg A, Calza AM, et al. Position paper on diagnosis and treatment of atopic dermatitis. J Eur Acad Dermatol Venereol 2005;19: 286-295. 4. Friedlander SF, Hebert AA, Allen DB, Fluticasone Pediatrics Safety Study Group. Safety of fluticasone propionate cream 0.05% for the treatment of severe and extensive atopic dermatitis in children as young as 3 months. J Am Acad Dermatol 2002;46:387-393. 5. Lebwohl M. A comparison of once-daily application of
9.
10.
11.
12.
13.
mometasone furoate 0.1% cream compared with twicedaily hydrocortisone valerate 0.2% cream in pediatric atopic dermatitis patients who failed to respond to hydrocortisone: mometasone furoate study group. Int J Dermatol 1999;38:604-606. Lever R, Hadley K, Downey D, Mackie R. Staphylococcal colonization in atopic dermatitis and the effect of topical mupirocin therapy. Br J Dermatol 1988;119:189-198. Abramovits W. Atopic dermatitis. J Am Acad Dermatol 2005;53 (1 Suppl):S86-93. Paller A, Eichenfield LF, Leung DY, Stewart D, Appell M. A 12-week study of tacrolimus ointment for the treatment of atopic dermatitis in pediatric patients. J Am Acad Dermatol 2001;44 (1 Suppl):S47-S57. Eichenfield LF, Lucky AW, Boguniewicz M, Langley RG, Cherill R, Marshall K. Safety and efficacy of pimecrolimus (ASM 981) cream 1% in the treatment of mild and moderate atopic dermatitis in children and adolescents. J Am Acad Dermatol 2002;46:495-504. Kapp A, Papp K, Bingham A, Folster-Holst R, Ortonne JP, Potter PC, et al. Long-term management of atopic dermatitis in infants with topical pimecrolimus, a nonsteroid antiinflammatory drug. J Allergy Clin Immunol 2002;110: 277-284. Simons FE, Simons KJ, Becker AB, Haydey RP. Pharmacokinetics and antipruritic effects of hydroxyzine in children with atopic dermatitis. J Pediatr 1984;104:123-127. Wollenberg A, Wetzel S, Burgdorf WH, Haas J. Viral infections in atopic dermatitis: pathogenic aspects and clinical management. J Allergy Clin Immunol 2003;112:667-674. Dohil MA, Eichenfield LF. A treatment approach for atopic dermatitis. Pediatr Ann 2005;34:201-210.
¶·È‰È·ÙÚÈ΋ 2007;70:330-335
Pediatri July-Aug 07
09-07-07
17:09
™ÂÏ›‰·336
336
™À¡∆√ª∞ ¶∞π¢π∞∆ƒπ∫∞ ¡∂∞
AÏÏËÏÔÁÚ·Ê›·: ∂ÌÌ·ÓÔ˘‹Ï °·Ï·Ó¿Î˘ egalanak@med.uoc.gr ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘
∂ÌÌ·ÓÔ˘‹Ï °·Ï·Ó¿Î˘
∏ıÈο ˙ËÙ‹Ì·Ù· ÛÙËÓ ÂÚÈÁÂÓÓËÙÈ΋ È·ÙÚÈ΋ ™ÙÔ ·ÚfiÓ Ù‡¯Ô˜ Ù˘ “¶·È‰È·ÙÚÈ΋˜” ÊÈÏÔÍÂÓÔ‡ÓÙ·È Ë ÂÓ·ÚÎÙ‹ÚÈ· ÔÌÈÏ›· ÛÙÔ ÊÂÙÈÓfi 45Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ (£ÂÔ‰fiÛ˘ ¶ÂÏÂÁÚ›Ó˘. √ ı¿Ó·ÙÔ˜ Ù˘ ËıÈ΋˜) Î·È Ë ·Ó·ÛÎfiËÛË ÙˆÓ Neubauer Î·È Û˘Ó. (Ethics Working Group, UEMS/European Academy of Paediatrics) ÁÈ· ËıÈο ˙ËÙ‹Ì·Ù· Ô˘ Û˘Ó‰¤ÔÓÙ·È Ì ÙË ÊÚÔÓÙ›‰· ÙÔ˘ ·È‰ÈÔ‡ Û ÎÒÌ·. ∆· ËıÈο ˙ËÙ‹Ì·Ù· ÛÙËÓ ·È‰È·ÙÚÈ΋ Î·È ÙËÓ ÂÚÈÁÂÓÓËÙÈ΋ È·ÙÚÈ΋ Â›Ó·È ÔÏÏ¿ Î·È ·Î·ÓıÒ‰Ë. ¶Ôχ ÚfiÛÊ·Ù· ÛËÌÂÈÒıËÎ·Ó ¤ÓÙÔÓ˜ ·ÓÙÈ·Ú·ı¤ÛÂȘ ÁÈ· ˙ËÙ‹Ì·Ù· ‰È·ÎÔ‹˜ Ù˘ ·ËÛ˘ ÛÙȘ ∏¶∞ Î·È ÛÙËÓ ∂ÏÏ¿‰·. ™ÙȘ ∏¶∞, ÙÔ ∞ÓÒÙ·ÙÔ ¢ÈηÛÙ‹ÚÈÔ (Supreme Court, 18 ∞ÚÈÏ›Ô˘ 2007) ÁÓˆÌÔ‰fiÙËÛ (ÏÂÈÔ„ËÊ›· 5 ÚÔ˜ 4) ηٿ Ù˘ ‰È·ÎÔ‹˜ Ù˘ ÚÔ¯ˆÚË̤Ó˘ ·ËÛ˘, ·ÎfiÌË ÎÈ ·Ó Û˘ÓÙÚ¤¯Ô˘Ó È·ÙÚÈΤ˜ ÂӉ›ÍÂȘ (Ì ÂÍ·›ÚÂÛË ÙËÓ ·ÂÈÏ‹ ÁÈ· ÙË ˙ˆ‹ Ù˘ ÂÁ·Ԣ). H È·ÙÚÈ΋ ·ÓÙ›‰Ú·ÛË ˘‹ÚÍ ¿ÌÂÛË, ÙÔ ∞ÌÂÚÈηÓÈÎfi ∫ÔϤÁÈÔ ª·ÈÂ˘Ù‹ÚˆÓ Î·È °˘Ó·ÈÎÔÏfiÁˆÓ ¯·Ú·ÎÙ‹ÚÈÛ ÙËÓ ·fiÊ·ÛË “ÂÔÓ›‰ÈÛÙË Î·È ·‰È·ÓfiËÙË” Î·È ÙÔ New Engl J Med ÊÈÏÔͤÓËÛ 4 ΛÌÂÓ· ÛÙȘ ÊÂȉˆÏ¤˜ ÛÂÏ›‰Â˜ ÙÔ˘ (24 ª·˝Ô˘ 2007;356:2195, 2125, 2128, 2201) Ì ‰ËÎÙÈΤ˜ ÂÎÊÚ¿ÛÂȘ ÁÈ· ÓÔÌÈÎÔ‡˜ Î·È ‰ÈηÛÙÈÎÔ‡˜ Ô˘ ·ÚÂÌ‚·›ÓÔ˘Ó ÛÙËÓ Î·ıËÌÂÚÈÓ‹ È·ÙÚÈ΋ Ú·ÎÙÈ΋ Î·È “·ÛÎÔ‡Ó È·ÙÚÈ΋ ¯ˆÚ›˜ ¿‰ÂÈ· ¿ÛÎËÛ˘”. ™ÙËÓ ∂ÏÏ¿‰·, Ë ∂ıÓÈ΋ ∂ÈÙÚÔ‹ µÈÔËıÈ΋˜ ‰È·Ù‡ˆÛ (29 ª·ÚÙ›Ô˘ 2007, Ì ÌÂÈÔ„ËÊ›· ÂÓfi˜ ̤ÏÔ˘˜) ηÙ¢ı‡ÓÛÂȘ ÁÈ· ˙ËÙ‹Ì·Ù· ÚÔÁÂÓÓËÙÈ΋˜ ‰È¿ÁÓˆÛ˘ (www.bioethics.gr). ∂ÎÊÚ¿ÛÂȘ fiˆ˜ “Ë ∂ÈÙÚÔ‹ ıˆÚ› ‰ÈηÈÔÏÔÁË̤ÓË ÙËÓ ÂÈÏÔÁ‹ ÂÌ‚Ú‡Ô˘, ˆ˜ ÁÂÓÈ΋ ‰˘Ó·ÙfiÙËÙ· ÙˆÓ ˘Ô„ËÊ›ˆÓ ÁÔÓ¤ˆÓ…”, Î·È “Ë ·Ô‰Ô¯‹ Ù˘ Á¤ÓÓËÛ˘ ·È‰ÈÒÓ Ì ÛÔ‚·Ú¤˜ ‚Ï¿‚˜ ÛÙËÓ ˘Á›· ÙÔ˘˜, fiÛÔ Î·È ·Ó ı· ÌÔÚÔ‡Û ӷ ‰ÈηÈÔÏÔÁËı› Û ÂÓÙÂÏÒ˜ ·ÎÚ·›Â˜ ÂÚÈÙÒÛÂȘ…, ηٿ ηÓfiÓ· ÂϤÁ¯ÂÙ·È ËıÈο” ÂÈÎÚ›ıËÎ·Ó ·fi ÙËÓ ∂ÎÎÏËÛ›· (16 ª·˝Ô˘ 2007, www.ecclesia.gr/ greek/holysynod): “Ë ∂ÎÎÏËÛ›· Ì·˜ ηٷ‰Èο˙ÂÈ ·˘ÙfiÓ ÙÔÓ ÎÚ˘ÙÔ-Ú·ÙÛÈÛÌfi, ÙÈÌ¿ ÙÔ ·Á·ıfi Ù˘ ˙ˆ‹˜ ˆ˜ ÈÂÚfi Ì˘ÛÙ‹ÚÈÔ ·ÎfiÌË Î·È Ì¤Û· ·fi ·Ó·Ëڛ˜, ·Ù¤ÏÂȘ ‹ ÛÔ‚·Paediatriki 2007;70:336-337
Ú¤˜ ·Ûı¤ÓÂȘ…” Î·È “Ô fiÓÔ˜ ÁÂÓÓ¿ ÙËÓ ·Á¿Ë Î·È fi¯È Ë Î·ÏÔ¤Ú·ÛË ÙÔ˘ ¢ÁÔÓÈÎÔ‡ ۯ‰ȷÛÌÔ‡”. ∞ÓÙÈ·Ú·ı¤ÛÂȘ Û ˙ËÙ‹Ì·Ù· È·ÙÚÈ΋˜ ËıÈ΋˜ ÛËÌÂÈÒÓÔÓÙ·È Î·È Û ¿ÏϘ ¯ÒÚ˜, Î·È Â›Ó·È Â˘ÚfiÛ‰ÂÎÙ˜ Î·È ÁfiÓÈ̘. ∞˘Ùfi Ô˘ ͯˆÚ›˙ÂÈ ÛÙËÓ ÂÏÏËÓÈ΋ ÂÚ›ÙˆÛË Â›Ó·È Ë ÛȈ‹ ÙˆÓ ÂÏÏ‹ÓˆÓ È·ÙÚÒÓ. ∆· ηϿ ÙˆÓ ÏÔÈÌÒÍÂˆÓ ∏ ·ÙÔ›· ¤¯ÂÈ ·˘ÍËı› ÙÂÏÂ˘Ù·›· ÛÙȘ ‰˘ÙÈΤ˜ ÎÔÈӈӛ˜, ·ÏÏ¿ ÙÔ ÁÈ·Ù› ·Ú·Ì¤ÓÂÈ ·‰È¢ÎÚ›ÓÈÛÙÔ. ªÈ· ÂÚÌËÓ¢ÙÈ΋ ˘fiıÂÛË, ÁÓˆÛÙ‹ ˆ˜ “˘fiıÂÛË Ù˘ ˘ÁÈÂÈÓ‹˜” (hygiene hypothesis) ÚÂۂ‡ÂÈ fiÙÈ Ë ÚÒÈÌË ¤ÎıÂÛË Û ÏÔÈÌÒÍÂȘ (fiˆ˜ Ë·Ù›Ùȉ· ∞, ÂÏÈÎÔ‚·ÎÙËÚ›‰ÈÔ ˘ÏˆÚÔ‡, ÙÔÍfiÏ·ÛÌ·, ¤ÏÌÈÓı˜) Âȉڿ ¢ÂÚÁÂÙÈο ÛÙÔ ·ÓÔÛÔÔÈËÙÈÎfi Û‡ÛÙËÌ· ·ÔÙÚ¤ÔÓÙ·˜ ÙËÓ ÂÌÊ¿ÓÈÛË ·ÙÔ›·˜ - ¿Ú· Ù· ·È‰È¿ ¯ˆÚ›˜ ÔÏϤ˜ ÏÔÈÌÒÍÂȘ ı· Â›Ó·È ÈÔ ·ÙÔÈο. ¶ÚfiÛÊ·ÙË ÌÂϤÙË ·fi ÙË °ÂÚÌ·Ó›· (J Epidemiol Community Health 2007;61:638) Ì 3347 ·È‰È¿ ¤‰ÂÈÍ fiÙÈ fiÛÔ ÈÔ Û˘¯Ófi˜ Ô ·ÔÈÎÈÛÌfi˜ Ì Helicobacter pylori, ÙfiÛÔ ÏÈÁfiÙÂÚÔ Û˘¯Ófi ÙÔ ¤Î˙ÂÌ· (OR=0,31, p=0,006). √ÌÔ›ˆ˜, ÂÚÁ·Û›· ·fi ÙȘ ∏¶∞ (Arch Intern Med 2007;167:821) Ì 7663 ÂÓ‹ÏÈΘ η٤ÏËÍ fiÙÈ fiÛÔ ÈÔ Û˘¯Ófi˜ Ô ·ÔÈÎÈÛÌfi˜ Ì cagA(+) ÛÙÂϤ¯Ë H pylori, ÙfiÛÔ ÏÈÁfiÙÂÚÔ Û˘¯Ófi ÙÔ ¿ÛıÌ· (ȉȷ›ÙÂÚ· ÚÈÓ Ù· 15 ¤ÙË ˙ˆ‹˜, OR=0,63, 95% CI 0,43-0,93), Ë ·ÏÏÂÚÁÈ΋ ÚÈÓ›Ùȉ·, Ù· ·ÏÏÂÚÁÈο Û˘ÌÙÒÌ·Ù· Î·È Ë ‰ÂÚÌ·ÙÈ΋ ¢·ÈÛıËÙÔÔ›ËÛË Û Á‡ÚË Î·È Ì‡ÎËÙ˜. ∞ӷʤÚÂÙ·È ÏÔÈfiÓ fiÙÈ o ¯ÚfiÓÈÔ˜ ÂÚÂıÈÛÌfi˜ ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ÏÂÌÊÈÎÔ‡ ÈÛÙÔ‡ ·fi ÙÔ H. pylori ÂÓ‰¤¯ÂÙ·È Ó· ¢ԉÒÓÂÈ ÙËÓ ˆÚ›Ì·ÓÛË Ù˘ ·ÓÔÛ›·˜. ∏ Ïԛ̈ÍË H. pylori Û˘Ó‹ıˆ˜ Û˘Ì‚·›ÓÂÈ Î·Ù¿ ÙËÓ ÚÒÙË ‰ÂηÂÙ›· Ù˘ ˙ˆ‹˜ Î·È ¤¯ÂÈ ÌÂȈı› ÛÙȘ ‚ÈÔÌ˯·ÓÈΤ˜ ¯ÒÚ˜. ™Â ÌÈ· ÌÈÎÚfiÙÂÚ˘ Îϛ̷η˜ ÌÂϤÙË ·fi ÙËÓ ∆Ô˘ÚΛ· (J Trop Ped 2007; ˘fi ‰ËÌÔÛ›Â˘ÛË) ‰ÂÓ ÂȂ‚·ÈÒıËΠ·˘Ù‹ Ë Û¯¤ÛË. ∏ Ôχ ÂӉȷʤÚÔ˘Û· “˘fiıÂÛË Ù˘ ˘ÁÈÂÈÓ‹˜” Û˘˙ËÙÂ›Ù·È ·fi ÙË ‰ÂηÂÙ›· ÙÔ˘ 1980, ¿ÏÏÔÙ ÂÚÈÛÛfiÙÂÚÔ Î·È ¿ÏÏÔÙ ÏÈÁfiÙÂÚÔ, ˆÛÙfiÛÔ ·Ú·Ì¤ÓÂÈ ˘fiıÂÛË. ¶ÂÚÈÛÛfiÙÂÚ· ÁÈ· ÙËÓ “˘fiıÂÛË Ù˘ ˘ÁÈÂÈÓ‹˜” ÛÙÔ ·ÚfiÓ Ù‡¯Ô˜ Ù˘
Pediatri July-Aug 07
09-07-07
17:09
™ÂÏ›‰·337
PAEDIATRIC NEWS IN BRIEF ¶·È‰È·ÙÚÈ΋˜, ÛÙËÓ ·Ó·ÛÎfiËÛË ™ÔÊÈ·ÓÔ‡-∫·ÙÛÔ‡ÏË Î·È ÛÙË ÌÂϤÙË ∫·Ú·‚·Ó¿ÎË Î·È Û˘Ó, fiÔ˘ ÔÈ Û˘¯Ó¤˜ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ ÛÙ· ‰˘Ô ÚÒÙ· ¤ÙË ˙ˆ‹˜ ʤÚÔÓÙ·È Ó· ‰ÚÔ˘Ó ÚÔÛٷ٢ÙÈο ÛÙËÓ ÂΉ‹ÏˆÛË Û·Î¯·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ 1. √È ‰˘Ô fi„ÂȘ Ù˘ ËÏÈÔÚÔÛÙ·Û›·˜ ∏ ˘ÂÚÈ҉˘ ·ÎÙÈÓÔ‚ÔÏ›· Â›Ó·È Î·ÚÎÈÓÔÁfiÓÔ˜ Î·È Ë ˘ÂÚ‚ÔÏÈ΋ ¤ÎıÂÛË ÛÙÔÓ ‹ÏÈÔ Â›Ó·È ÂÈΛӉ˘ÓË ÁÈ· fiÏÔ˘˜ - Ôχ ÂÚÈÛÛfiÙÂÚÔ ÁÈ· Ù· ÌÈÎÚ¿ ·È‰È¿. ∞fi ÙËÓ ¿ÏÏË fï˜, Ë ËÏȷ΋ ·ÎÙÈÓÔ‚ÔÏ›· ¢ԉÒÓÂÈ ÙË Û‡ÓıÂÛË Ù˘ ‚ÈÙ·Ì›Ó˘ D Î·È Ë ˘ÂÚ‚ÔÏÈ΋ ·ÔÊ˘Á‹ Ù˘ ¤ÎıÂÛ˘ Ê·›ÓÂÙ·È Ó· ÌËÓ Â›Ó·È ¿Û¯ÂÙË Ì ÙËÓ ÚfiÛÊ·ÙË Â·ÓÂÌÊ¿ÓÈÛË Ù˘ Ú·¯›Ùȉ·˜ ·ÎfiÌË Î·È Û ËÏÈfiÏÔ˘ÛÙ˜ ¯ÒÚ˜ (Am Fam Physician 2006;74:619: “Ë Ú·¯›Ùȉ· ‰ÂÓ Â›Ó·È ÓfiÛÔ˜ ÙÔ˘ ·ÚÂÏıfiÓÙÔ˜”, Î·È J Clin Invest 2006 116:2062: “Ë ÓÂÎÚ·Ó¿ÛÙ·ÛË Ù˘ ·Ó¿ÚÎÂÈ·˜ ‚ÈÙ·Ì›Ó˘ D Î·È Ù˘ Ú·¯›Ùȉ·˜”). ∆Ô Úfi‚ÏËÌ· Ì ÙÔÓ ‹ÏÈÔ Â›Ó·È fiÙÈ ÙÔ ·ÛʷϤ˜ fiÚÈÔ ¤ÎıÂÛ˘ ·Ú·Ì¤ÓÂÈ ¿ÁÓˆÛÙÔ (Med J Aust 2006;185:268). ∞fi ÙËÓ ·ÓÂÈÛÙËÌȷ΋ ·È‰È·ÙÚÈ΋ ÎÏÈÓÈ΋ ÙÔ˘ ∏Ú·ÎÏ›Ԣ ¤Ú·Û·Ó ÙË ÊÂÙÈÓ‹ ¿ÓÔÈÍË 3 ‚Ú¤ÊË Ì ڷ¯›Ùȉ· - fiÏ· ‰È¤ÌÂÓ·Ó ÛÙË ÓfiÙÈ· ∫Ú‹ÙË, fiÔ˘ Ë ËÏÈÔÊ¿ÓÂÈ· Â›Ó·È ·˘ÙÔÓfiËÙË. ŸÏ˜ ÔÈ ¤ÁÎ˘Â˜ ÎÈ fiÏ· Ù· ‚Ú¤ÊË (Î·È Ì¿ÏÈÛÙ· Ù· ÌÂÏ·¯ÚÈÓ¿ ¿ÙÔÌ·) Ô˘ ‰ÂÓ ÂÎÙ›ıÂÓÙ·È ÛÙÔÓ ‹ÏÈÔ Ê·›ÓÂÙ·È fiÙÈ ¯ÚÂÈ¿˙ÔÓÙ·È Û˘ÌÏËڈ̷ÙÈ΋ ‚ÈÙ·Ì›ÓË D. º˘Ì·Ù›ˆÛË Î·È ˘ÂÚ·ÙÏ·ÓÙÈΤ˜ Ù‹ÛÂȘ ™ÙȘ 29 ª·˝Ô˘ 2007, ¿Ó‰Ú·˜ 32 ÂÙÒÓ Ì ÂÍ·ÈÚÂÙÈο ·ÓıÂÎÙÈ΋ Ê˘Ì·Ù›ˆÛË (extensively drugresistant tuberculosis, XDR TB) Ù¤ıËΠ۠ηڷÓÙ›Ó· ÛÙȘ ∏¶∞ Ì ÓÔÛËÏ›· ˘fi ÊÚÔ‡ÚËÛË (CNN, BBC Î·È in.gr 30 ª·˝Ô˘ 2007, ‰ÂÏÙ›· Ù‡Ô˘ CDC 2 Î·È 8 πÔ˘Ó›Ô˘ 2007). ◊Ù·Ó Ë ÚÒÙË ÊÔÚ¿ ÌÂÙ¿ ·fi 44 ¤ÙË Ô˘ ÂÊ·ÚÌfiÛıËΠ٤ÙÔÈ· ηڷÓÙ›Ó· ÛÙȘ ∏¶∞, Ë ÚÔËÁÔ‡ÌÂÓË ‹Ù·Ó ÙÔ 1963 Î·È ·ÊÔÚÔ‡Û ÎÚÔ‡ÛÌ· ¢ÏÔÁÈ¿˜. √ ·ÛıÂÓ‹˜ ›¯Â Ù·Íȉ¤„ÂÈ Ôχ ÚfiÛÊ·Ù· Û ∂˘ÚÒË (Î·È ∂ÏÏ¿‰·, 14-21 ª·˝Ô˘) Ì ‰‡Ô ˘ÂÚ·ÙÏ·ÓÙÈΤ˜ Ù‹ÛÂȘ: ∞ÙÏ¿ÓÙ·-¶·Ú›ÛÈ Î·È ¶Ú¿Á·-ªfiÓÙÚÂ·Ï (12 Î·È 24 ª·˝Ô˘). ∏ ÌÔÏ˘ÛÌ·ÙÈÎfiÙËÙ¿ ÙÔ˘ ıˆڋıËΠ¯·ÌËÏ‹, ˆÛÙfiÛÔ ÙÔ CDC Û˘Ó¤ÛÙËÛ ¤ÏÂÁ¯Ô ÁÈ· Ù· ÏËÚÒÌ·Ù· ÙˆÓ ·ÂÚÔÛηÊÒÓ Î·È ÁÈ· fiÏÔ˘˜ ÙÔ˘˜ Û˘ÓÂÈ‚¿Ù˜ (Î·È Ì¿ÏÈÛÙ· fiÛÔ˘˜ οıÔÓÙ·Ó ÛÙËÓ ›‰È· ÛÂÈÚ¿ ‹ ‰‡Ô ÛÂÈÚ¤˜ ÌÚÔÛÙ¿ Î·È ‰˘Ô ÛÂÈÚ¤˜ ›Ûˆ). ∏ Û‡ÛÙ·ÛË ·ÊÔÚÔ‡Û ÙȘ ˘ÂÚ·ÙÏ·ÓÙÈΤ˜ Î·È fi¯È ÙȘ Â˘Úˆ·˚Τ˜ Ù‹ÛÂȘ ÏfiÁˆ ÙÔ˘ ÌÂÁ·Ï‡ÙÂÚÔ˘ ¯ÚfiÓÔ˘ ¤ÎıÂÛ˘. ∞fi ÙÔ˘˜ 274 Ôϛ٘ ∏¶∞ ÂÓÙÔ›ÛıËÎ·Ó ÁÚ‹ÁÔÚ· ÔÈ 255. ∞fi ÙȘ 25 ª·˝Ô˘ ÙÔ ı¤Ì· Û˘ÓÙfiÓÈÛÂ Ë ¶·-
337
ÁÎfiÛÌÈ· √ÚÁ¿ÓˆÛË ÀÁ›·˜. ∂ÓËÌÂÚÒıËÎ·Ó ÔÈ ¯ÒÚ˜ Ì Ôϛ٘-Û˘ÓÂÈ‚¿Ù˜ Î·È ÔÈ ¯ÒÚ˜ ·fi fiÔ˘ ¤Ú·ÛÂ Ô ·ÛıÂÓ‹˜. ™ÙËÓ ∂˘ÚÒË ÂΉfiıËΠԉËÁ›· ÎÔÈÓ‹˜ ÔÏÈÙÈ΋˜ Ù˘ ∂˘Úˆ·˚΋˜ ŒÓˆÛ˘ Î·È ÛÙËÓ ∂ÏÏ¿‰· Ù¤ıËΠ۠ÂÊ·ÚÌÔÁ‹ ÙÔ Û¯¤‰ÈÔ “¶ÂÚÛ¤·˜”. ŒÓ·˜ ŒÏÏËÓ·˜ Û˘ÓÂÈ‚¿Ù˘ ÛÙËÓ Ù‹ÛË ∞ÙÏ¿ÓÙ·¶·Ú›ÛÈ ‚Ú¤ıËÎÂ Î·È ÂϤÁ¯ıËÎÂ. ™ÙȘ ∏¶∞, Ë XDR ∆µ ¤¯ÂÈ ‰È·ÁÓˆÛı› Û 49 ·ÓıÚÒÔ˘˜ ·fi ÙÔ 1993 ¤ˆ˜ ÙÔ 2006, ·ÏÏ¿ Â›Ó·È Ôχ ÈÔ Û˘¯Ó‹ (Î·È Û˘Ó‹ıˆ˜ ı·Ó·ÙËÊfiÚ·) Û ¿ÏϘ ¯ÒÚ˜. ∏ ·ÓÙÈÌÂÙÒÈÛË Î¿ı ÎÚÔ‡ÛÌ·ÙÔ˜ ÛÙȘ ∏¶∞ ÎÔÛÙ›˙ÂÈ ÂÚ› Ù· $500.000 (ú400.000). À¿Ú¯ÂÈ Ï‡ÛÛ· ÛÙËÓ ∂ÏÏ¿‰·; Ÿ¯È Û¿ÓÈ· ¯ÚÂÈ¿˙ÂÙ·È Ó· ‰ÒÛÔ˘Ì ԉËÁ›Â˜ ÁÈ· ·È‰È¿ Ì ‰‹ÁÌ·Ù· (‹ Èı·Ó¿ ‰‹ÁÌ·Ù· ‹ ¿ÏÏË Â·Ê‹) ·fi Û΢ÏÈ¿ ‹ (Û·ÓÈfiÙÂÚ·) ·ÏÂÔ‡‰Â˜, Ó˘¯ÙÂÚ›‰Â˜ ‹ ¿ÏÏ· ¿ÁÚÈ· ˙Ò·. ∏ χÛÛ· Â›Ó·È ÙÔ ÏÔÈÌ҉˜ ÓfiÛËÌ· Ì ÙË ÌÂÁ·Ï‡ÙÂÚË ıÓËÙfiÙËÙ· (100%), ‰ÂÓ ¤¯ÂÈ ıÂڷ›·, Î·È Ë ÌÔÈÚ·›· ηٿÏËÍË Â›Ó·È ı¤Ì· ËÌÂÚÒÓ ÌÂÙ¿ ÙËÓ ÂΉ‹ÏˆÛË ÙˆÓ ÎÏÈÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ (Ë ÌÔÓ·‰È΋ ÂÍ·›ÚÂÛË, Û 15ÂÙ¤˜ ÎÔÚ›ÙÛÈ, ÂÚÈÁÚ¿ÊÂÙ·È ÛÙÔ New Engl J Med 2005;352:2508). ∂›Ó·È ÁÓˆÛÙ‹ Ë ·Í›· Ù˘ ÚÔʇϷ͢ (ÂÚÈÔ›ËÛË ÙÚ·‡Ì·ÙÔ˜, ÂȉÈ΋ ·ÓÔÛÔÛÊ·ÈÚ›ÓË, ÂÌ‚fiÏÈÔ) ÌÂÙ¿ ÙËÓ ¤ÎıÂÛË Î·È ÚÈÓ ÙȘ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ. ŸÌˆ˜, Ë Ï‡ÛÛ· ÛÙÔÓ ¿ÓıÚˆÔ Â›Ó·È Ôχ Û¿ÓÈ· ηÈ, ·fi ÙËÓ ¿ÏÏË, ÙÔ ·Ó·ÌÓËÛÙÈÎfi Â›Ó·È Û˘¯Ó¿ ·Û·Ê¤˜ ‹ ÙÔ ÛÎ˘Ï› Â›Ó·È ·‰¤ÛÔÙÔ Î·È ‰ÂÓ ÌÔÚ› Ó· ·Ú·ÎÔÏÔ˘ıËı›. ¢˘Ô ÚfiÛÊ·Ù· ÎÚÔ‡ÛÌ·Ù· ÛÙȘ ∏¶∞ (MMWR 2007;56:361) ·ÊÔÚÔ‡Û·Ó ·ÁfiÚÈ 11 ÂÙÒÓ Ì ‰‹ÁÌ· ·fi ÛÎ˘Ï› ÚÔ 2ÂÙ›·˜ Î·È ÎÔÚ›ÙÛÈ ËÏÈΛ·˜ 10 ÂÙÒÓ Ì ‰‹ÁÌ· ·fi Ó˘¯ÙÂÚ›‰· ÚÔ 3Ì‹ÓÔ˘. ∆· ·È‰È¿ ‰ÂÓ Â›¯·Ó ¿ÚÂÈ ÚÔÊ˘Ï·ÎÙÈ΋ ·ÁˆÁ‹ Î·È Î·Ù¤ÏËÍ·Ó, ÌÔÏÔÓfiÙÈ ·ÓÙÈÌÂÙˆ›ÛıËÎ·Ó Ì ÙËÓ ÈÔ ÂÓÙ·ÙÈ΋ Î·È ÙÂÎÌËÚȈ̤ÓË ·ÁˆÁ‹. ™ÙȘ ∏¶∞ ·Ó·Ê¤ÚÔÓÙ·È 3 ÂÚ›Ô˘ ÎÚÔ‡ÛÌ·Ù· ÂÙËÛ›ˆ˜. À¿Ú¯ÂÈ Ï‡ÛÛ· ÛÙËÓ ∂ÏÏ¿‰·; ∏ ¿ÌÂÛË ‰‹ÏˆÛË ÙˆÓ ÎÚÔ˘ÛÌ¿ÙˆÓ Â›Ó·È (ıˆÚËÙÈÎÒ˜ ÙÔ˘Ï¿¯ÈÛÙÔÓ) ˘Ô¯ÚˆÙÈ΋ ÛÙË ¯ÒÚ· Ì·˜ Î·È Ì ÙËÓ ÙÚ·ÁÈ΋ ÙÔ˘˜ ηٿÏËÍË, ‰ÂÓ ı· ÂÚÓÔ‡Û·Ó ··Ú·Ù‹ÚËÙ·. ∞fi ÌÈ· ÂÈÛÎfiËÛË ÙˆÓ ‰ËÌÔÛÈÂ˘Ì¤ÓˆÓ ‰ÂÏÙ›ˆÓ Ù˘ ∂™À∂, Ù˘ PubMed Î·È Ù˘ iatrotek on-line ÚÔ·ÙÂÈ fiÙÈ ‰ÂÓ ¤¯ÂÈ ·Ó·ÊÂÚı› ·ÓıÚÒÈÓÔ ÎÚÔ‡ÛÌ· ÛÙËÓ ∂ÏÏ¿‰· ·fi ÙË ‰ÂηÂÙ›· ÙÔ˘ 1970. øÛÙfiÛÔ, ÛÙË ‰ÂηÂÙ›· 1951-1960 ›¯·Ó ·Ó·ÊÂÚı› 53 ı·Ó·ÙËÊfiÚ· ·ÓıÚÒÈÓ· ÎÚÔ‡ÛÌ·Ù· (Parassitologia 1988;30:93).
¶·È‰È·ÙÚÈ΋ 2007;70:336-337
Pediatri July-Aug 07
09-07-07
17:09
™ÂÏ›‰·338
338
¡∂∞ ∞¶√ ∆√ ¢π∞¢π∫∆À√
µ’ ¶·È‰È·ÙÚÈ΋ ¶·ÓÂÈÛÙËÌȷ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó·
¡ÈÎfiÏ·Ô˜ ¶··‰fiÔ˘ÏÔ˜, ¶·È‰›·ÙÚÔ˜, ∞ÏÏÂÚÁÈÔÏfiÁÔ˜
AÏÏËÏÔÁÚ·Ê›·: ¡ÈÎfiÏ·Ô˜ ¶··‰fiÔ˘ÏÔ˜ npg@allergy.gr
πÛÙÔÛÂÏ›‰Â˜ ÁÈ· ÌÔ˘ÛÈ΋ ÁÈ· ·È‰È¿ ∏ ÌÔ˘ÛÈ΋ ·ÔÙÂÏ› ·Ó·ÌÊ›‚ÔÏ· ·Ó·fiÛ·ÛÙÔ ÎÔÌÌ¿ÙÈ Ù˘ Û˘ÓÔÏÈ΋˜ ÌÔÚʈÙÈ΋˜ Âη›‰Â˘Û˘ ÙˆÓ ·È‰ÈÒÓ ·fi ÙËÓ ‚ÚÂÊÈ΋ ÙÔ˘˜ ÎÈfiÏ·˜ ËÏÈΛ·. ¶ÔÏϤ˜ ÂÈÛÙËÌÔÓÈΤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ηٷϋÍÂÈ ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ Ë ÌÔ˘ÛÈ΋ „˘¯·ÁˆÁ›· ÙˆÓ ·È‰ÈÒÓ Û˘Ì‚¿ÏÏÂÈ ÛÙË ‰È·ÌfiÚʈÛË ÙÔ˘ ¯·Ú·ÎÙ‹Ú· ÙÔ˘˜ ηıÒ˜ Î·È ÛÙÔÓ ÌÂÙ¤ÂÈÙ· ·ÁÁÂÏÌ·ÙÈÎfi ÙÔ˘˜ ÚÔÛ·Ó·ÙÔÏÈÛÌfi, fiÙ·Ó ·˘Ù‹ ·ÔÎÙ¿ Ù·ÎÙÈÎfi Î·È ÔÚÁ·ÓˆÌ¤ÓÔ ¯·Ú·ÎÙ‹Ú·. ∞Ó¿ÌÂÛ· Û ̛· ÏËıÒÚ· ‰˘Ó·ÙÔًوÓ, ÙÔ ‰È·‰›ÎÙ˘Ô ÚÔÛʤÚÂÈ Î·È ÂΛÓË Ù˘ ÌÔ˘ÛÈ΋˜ Âη›‰Â˘Û˘, ÚÔÛÂÏ·ÔÓÙ·˜ ÙËÓ ÚÔÛÔ¯‹ fi¯È ÌfiÓÔ ÙˆÓ ·È‰ÈÒÓ Î·È ÙˆÓ ÂÊ‹‚ˆÓ, ·ÏÏ¿ Î·È ÙˆÓ ÁÔÓ¤ˆÓ ‹ Î·È ÙˆÓ ‰·ÛοψÓ.
ªÔ˘ÛÈ΋ Âη›‰Â˘ÛË ÁÈ· ·È‰È¿ - http://www.music4kids.com/meyc/ Music Education for Young Children, a resource for teachers and parents, Â›Ó·È Ô Ù›ÙÏÔ˜ Ù˘ ÚÒÙ˘ ÈÛÙÔÛÂÏ›‰·˜ Ô˘ Ì ȉȷ›ÙÂÚË Â˘ÎÔÏ›· ÌÔÚ› Ó· ‚ÚÂÈ Î¿ÔÈÔ˜ ÛÙÔ ‰È·‰›ÎÙ˘Ô. ∞Ï‹, Ì ÏÈÙ¿ ·È‰Èο Û¯¤‰È· Ó· ÎÔÛÌÔ‡Ó ÙÔÓ “¯ÒÚÔ” Ù˘, Ë ÛÂÏ›‰· ·˘Ù‹ Â͢ËÚÂÙ› Ì ϷΈÓÈÎfi ÙÚfiÔ ÙÔÓ ÏfiÁÔ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘. ª›· ÛÙ‹ÏË ·ÚÈÛÙÂÚ¿ Ô‰ËÁ› ÙÔÓ ÂÈÛΤÙË ÛÙ· η›ÚÈ· links Ù˘, ñ Books, Periodicals, Catalogs ñ Music Curricula ñ Songs and Music Games ñ Teaching Ideas ñ Musical Development ñ Music and the Brain ñ Professional Organizations ÂÓÒ ˘¿Ú¯Ô˘Ó ÂÚ·ÈÙ¤Úˆ ÏÂÈÙÔ˘ÚÁ›Â˜ fiˆ˜ ‰˘Ó·ÙfiÙËÙ· register Û Discussion Forum, ÛÙÔ ÔÔ›Ô Ô ÂοÛÙÔÙ ÁÔÓ¤·˜ ‹ ‰¿ÛηÏÔ˜ ÌÔÚ› Ó· ·ÓÙ·ÏÏ¿ÍÂÈ È‰¤Â˜ Î·È Ó· ·Ó·Ù‡ÍÂÈ ‰È¿ÏÔÁÔ Û¯ÂÙÈο Ì ÙÔ ı¤Ì·.
ªÔ˘ÛÈ΋ Û‡ÓıÂÛË - http://www.creatingmusic.com/ A˘Ù‹ Ë ÈÛÙÔÛÂÏ›‰· ·Ó·Ê¤ÚÂÙ·È ÂÚÈÛÛfiÙÂÚÔ Û ·È‰È¿ Ô˘ ‹‰Ë ¤¯Ô˘Ó ÂÈÛ¯ˆÚ‹ÛÂÈ Ì ÙÔÓ ¤Ó· ‹ Ì ÙÔÓ ¿ÏÏÔ ÙÚfiÔ ÛÙÔÓ ¯ÒÚÔ Ù˘ ÌÔ˘ÛÈ΋˜ Âη›‰Â˘Û˘. ¶ÂÚÈÛÛfiÙÂÚÔ ÂÍÂȉÈÎÂ˘Ì¤ÓË ÏÔÈfiÓ ·ÏÏ¿ ¯ˆÚ›˜ Ó· ·ÔÎÏ›ÂÈ ÙÔÓ ÂÈÚ·Ì·ÙÈÛÌfi ÙˆÓ ·È‰ÈÒÓ ÛÙË ÌÔ˘ÛÈ΋ Û‡ÓıÂÛË, Ë ÈÛÙÔÛÂÏ›‰· ·Ú¤¯ÂÈ ¤Ó· on line ‰ËÌÈÔ˘ÚÁÈÎfi ÌÔ˘ÛÈÎfi ÂÚÈ‚¿ÏÏÔÓ ÁÈ· ·È‰È¿ fiÏˆÓ ÙˆÓ ËÏÈÎÈÒÓ. ªÔÚÔ‡Ó Ó· Û˘Óı¤ÛÔ˘Ó, Ó· Û¯ËÌ·Ù›ÛÔ˘Ó ÌÔ˘ÛÈο puzzles ·ÏÏ¿ Î·È Ó· ·Û¯ÔÏËıÔ‡Ó Ì ·È‰Èο ·È¯Ó›‰È·. |
Paediatriki 2007;70:338-339
Pediatri July-Aug 07
09-07-07
17:09
™ÂÏ›‰·339
NEWS FROM THE INTERNET
339
∫Ï·ÛÈ΋ ÌÔ˘ÛÈ΋ ÁÈ· ·È‰È¿ - http://www.classicsforkids.com/ ∏ ÈÛÙÔÛÂÏ›‰· ·˘Ù‹ ÂÈÛ¿ÁÂÈ Ì ¢¯¿ÚÈÛÙÔ ÙÚfiÔ Ù· ·È‰È¿ ÛÙÔÓ ¯ÒÚÔ ÂÓfi˜ ˘„ËÏÔ‡ Î·È È‰È·›ÙÂÚÔ˘ ›‰Ô˘˜ ÌÔ˘ÛÈ΋˜. ¶ÚfiÎÂÈÙ·È ÁÈ· ÙËÓ ÎÏ·ÛÈ΋ ÌÔ˘ÛÈ΋. ∆Ô ÏÔ‡ÛÈÔ ÂÚȯfiÌÂÓÔ ·ÚÔ˘ÛÈ¿˙ÂÙ·È Ì ¤ÓÙÔÓ· ¯ÚÒÌ·Ù· Î·È ÁÚ·ÊÈο, ÂÓÒ Ôχ ‡ÎÔÏ· ·Ó·Î·Ï‡ÙÂÈ Î·Ó›˜ fiÙÈ ÚfiÎÂÈÙ·È ÁÈ· Ì›· ÈÛÙÔÛÂÏ›‰· Ì ÔÏϤ˜ Ú·ÎÙÈΤ˜ ÂÊ·ÚÌÔÁ¤˜ Î·È ÏÈÁfiÙÂÚ˜ ıˆÚËÙÈΤ˜ ·Ó·Ï‡ÛÂȘ. ∆· ·È‰È¿ ¤¯Ô˘Ó ÙË ‰˘Ó·ÙfiÙËÙ· Ó· ·ÎÔ‡ÛÔ˘Ó ‰ˆÚÂ¿Ó ÎÏ·ÛÈ΋ ÌÔ˘ÛÈ΋, Ë ÔÔ›· ·Ó·‚·ıÌ›˙ÂÙ·È Û ‚‰ÔÌ·‰È·›· ‚¿ÛË. ∆· ‚‹Ì·Ù· ÁÈ· ÙËÓ ¤Ó·ÚÍË Ù˘ ÂÊ·ÚÌÔÁ‹˜ Â›Ó·È ·Ï¿, ÂÓÒ ·ÎÔÏÔ˘ıÔ‡Ó Quiz Ì ÂÚˆÙ‹ÛÂȘ Û¯ÂÙÈο Ì ÙÔÓ ÂοÛÙÔÙ ÎÏ·ÛÈÎfi Û˘Óı¤ÙË. ∂Ê·ÚÌÔÁ¤˜ fiˆ˜ ÌÔ˘ÛÈÎfi ÏÂÍÈÎfi, ·ÎÚfi·ÛË ÁÈ· Ôχ ÌÈÎÚ¿ ·È‰È¿, ηıÒ˜ Î·È ÏÔ‡ÛÈ· ·Ú¯Â›· Ì ‚ÈÔÁÚ·ÊÈο ÛÙÔȯ›· ÙˆÓ Û˘ÓıÂÙÒÓ, events Î·È ·È¯Ó›‰È· Â›Ó·È ÌÂÚÈο ÌfiÓÔ ·fi Ù· ÂÚȯfiÌÂÓ· ÙÔ˘.
Children’s music - http://www.childrensmusic.org/ ∏ ÛÂÏ›‰· ¤¯ÂÈ Û·Ê‹ ‰È·¯ˆÚÈÛÙÈο fiÚÈ· Ù˘ ıÂÌ·ÙÔÏÔÁ›·˜ Ù˘, Ì ÙÔÌ›˜ Ô˘ ·Â˘ı‡ÓÔÓÙ·È ÛÙÔ˘˜ ÁÔÓ›˜, ÛÙ· ·È‰È¿, ÛÙÔ˘˜ ‰·ÛοÏÔ˘˜, ηıÒ˜ Î·È ·Ú¯Â›Ô Ì ÏËıÒÚ· ÌÔ˘ÛÈÎÒÓ ÂÎÙÂÏÂÛÙÒÓ. ∏ ÈÛÙÔÛÂÏ›‰· ·Ú¤¯ÂÈ ÚfiÛ‚·ÛË Î·È ÛÙ· Children's Music Web Awards 2007, ‚Ú·‚›· Ô˘ ÂÈϤÁÔÓÙ·È Î·È ·ÔÓ¤ÌÔÓÙ·È ·ÔÎÏÂÈÛÙÈο ·fi Ù· ·È‰È¿. ∞ӷʤÚÔÓÙ·È ·ÎfiÌË ‰Ú·ÛÙËÚÈfiÙËÙ˜ Û¯ÂÙÈΤ˜ Ì ÊÈÏ·ÓıÚˆÈΤ˜ ÂΉËÏÒÛÂȘ, fiˆ˜ Ë ‰ÈÔÚÁ¿ÓˆÛË ÎÔÓÛ¤ÚÙˆÓ Û ·È‰Èο ÓÔÛÔÎÔÌ›·. µ·ÛÈ΋ Âȉ›ˆÍË ÙÔ˘ ‰È·‰ÈÎÙ˘·ÎÔ‡ ·˘ÙÔ‡ ¯ÒÚÔ˘ Â›Ó·È Ë Ì‡ËÛË ÙˆÓ ·È‰ÈÒÓ ÛÙÔÓ ¯ÒÚÔ ÙÔ˘ Ú·‰ÈÔÊÒÓÔ˘, ÛÙÔÓ ÔÔ›Ô ÂÈÛ¤Ú¯ÔÓÙ·È Â‡ÎÔÏ· Ì ÙËÓ ¤Ó·ÚÍË Ì›·˜ ·Ï‹˜ ÂÊ·ÚÌÔÁ‹˜.
¶·È‰È·ÙÚÈ΋ 2007;70:338-339
Pediatri July-Aug 07
09-07-07
17:09
™ÂÏ›‰·340
340
∫§π¡π∫√ ∫√Àπ∑
1 ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ 2 µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ¶ÂÓÙ¤Ï˘
°. ¡ÙÈÔ‡‰Ë˜1, µ. °ÂˆÚÁÔÔ‡ÏÔ˘1, ¡. ª·ÓˆÏ¿ÎË2, ¡. ª˘ÚÈÔÎÂÊ·ÏÈÙ¿Î˘1
AÏÏËÏÔÁÚ·Ê›·: µ·ÛÈÏÈ΋ °ÂˆÚÁÔÔ‡ÏÔ˘ villy_pedi@yahoo.gr ∞ÈÏÈ·ÓÔ‡ 29 ∆.∫. 112 54, ∫¿Ùˆ ¶·Ù‹ÛÈ· ∞ı‹Ó·
µÚ¤ÊÔ˜ ı‹Ï˘, ËÏÈΛ·˜ 3 ÌËÓÒÓ, ·ÚÔ˘Û›·Û ÂȉÂÈÓÔ‡ÌÂÓË ˆ¯ÚfiÙËÙ· Î·È ·ÓÔÚÂÍ›· ·fi 15Ë̤ÚÔ˘ Î·È ÌÂÙˆÚÈÛÌfi ÎÔÈÏ›·˜ ·fi 7Ë̤ÚÔ˘. ∆Ô ·ÙÔÌÈÎfi Î·È ÙÔ ÎÏËÚÔÓÔÌÈÎfi ÈÛÙÔÚÈÎfi ·Ó·Ê¤ÚÔÓÙ·È ÂχıÂÚ·. ∆· ˘ÂÚ˯ÔÁÚ·Ê‹Ì·Ù· ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙÔ˘ ΢‹Ì·ÙÔ˜ ·Ó·Ê¤ÚÔÓÙ·È ¯ˆÚ›˜ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ∏ ۈ̷ÙÈ΋ ·‡ÍËÛË Î·È Ë „˘¯ÔÎÈÓËÙÈ΋ ÂͤÏÈÍË ÙÔ˘ ‚Ú¤ÊÔ˘˜ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈΤ˜. ∫·Ù¿ ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË ‰È·ÈÛÙÒıËΠÎÔÈÏȷ΋ Ì¿˙· ÛÎÏËÚ‹˜ Û‡ÛÙ·Û˘, Ô˘ ηٷϿ̂·Ó ÙÔ ‰ÂÍÈfi ˘Ô¯fiÓ‰ÚÈÔ Î·È ÂÂÎÙÂÈÓfiÙ·Ó ÛÙÔ ÂÈÁ¿ÛÙÚÈÔ. ∞fi Ù· ÏÔÈ¿ Û˘ÛÙ‹Ì·Ù· ‰ÂÓ ÚԤ΢„ οÙÈ ·ıÔÏÔÁÈÎfi. ∏ ÁÂÓÈ΋ ·›Ì·ÙÔ˜ Î·È Ô ‚ÈÔ¯ËÌÈÎfi˜ ¤ÏÂÁ¯Ô˜ (ÁÏ˘Îfi˙Ë, Ô˘Ú›·, ÎÚ·ÙÈÓ›ÓË, SGOT, SGPT, ÁGT, ALP, LDH, ËÏÂÎÙÚÔχÙ˜, pH) ‰ÂÓ ¤‰ÂÈÍ·Ó ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ∆Ô ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜ ¤‰ÂÈÍ ÌfiÚʈ̷ ÂÙÂÚÔÁÂÓÔ‡˜ ˯ԉÔÌ‹˜, ÙÔ˘Ï¿¯ÈÛÙÔÓ 10 cm, Ì ‰È¿Û·ÚÙ˜ ÌÈÎÚÔ·ÔÙÈÙ·ÓÒÛÂȘ, Ô˘ ·ÚÂÎÙfiÈ˙ ÙÔÓ ·ÚÈÛÙÂÚfi ÏÔ‚fi ÙÔ˘ ‹·ÙÔ˜, ÙÔÓ ÛÙfiÌ·¯Ô ηÈ, ÚÔ˜ Ù· ›Ûˆ, ÙËÓ Î¿Ùˆ ÎÔ›ÏË ÊϤ‚· Î·È ÙËÓ ·ÔÚÙ‹. √ ‰ÂÍÈfi˜ ÏÔ‚fi˜ ÙÔ˘ ‹·ÙÔ˜ ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚÔ˜ ηٿ 3,5 cm, ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ˘Ê‹, ÂÓÒ Ô ·ÚÈÛÙÂÚfi˜ ‰ÂÓ ‹Ù·Ó ‰˘Ó·ÙfiÓ Ó· ·ÂÈÎÔÓÈÛÙ›. ∆· ˘fiÏÔÈ· ÂÓ‰ÔÎÔÈÏȷο fiÚÁ·Ó· ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο. √ ¤ÏÂÁ¯Ô˜ ËÎÙÈÎfiÙËÙ·˜, Ë ÁÂÓÈ΋ Ô‡ÚˆÓ Î·È Ë
·ÎÙÈÓÔÁÚ·Ê›· ıÒÚ·ÎÔ˜ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο. √ ˘fiÏÔÈÔ˜ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ‰ÂÓ ¤‰ÂÈÍ ·ıÔÏÔÁÈο ÛÙÔȯ›· (·-ÂÌ‚Ú˘˚΋ ÚˆÙ½ÓË, ÊÂÚÚÈÙ›ÓË, ¿ÌÂÛÔ˜-¤ÌÌÂÛÔ˜ Coombs, VMA Î·È HVA Ô‡ÚˆÓ 24ÒÚÔ˘). ∆Ô Ì˘ÂÏfiÁÚ·ÌÌ· ¤‰ÂÈÍ ÂÈÎfiÓ· ·ÓÙ›‰Ú·Û˘ Ì˘ÂÏÔ‡ ÛÂ Û˘ÛÙËÌ·ÙÈ΋ ‹ ¯ÚfiÓÈ· ÓfiÛÔ ÂÍˆÌ˘ÂÏÈ΋˜ ÂÓÙfiÈÛ˘. ∆Ô ·È‰› ˘Ô‚Ï‹ıËΠ۠CT ÎÔÈÏ›·˜, fiÔ˘ ‰È·ÈÛÙÒıËΠÂÙÂÚÔÁÂÓ‹˜ Ì¿˙· ÛÙÔÓ ·ÚÈÛÙÂÚfi ÏÔ‚fi ÙÔ˘ ‹·ÙÔ˜ (ÙÌ‹Ì· ππ), ‰È·ÛÙ¿ÛÂˆÓ 10Ã10,5Ã6 cm, Ì ·ÔÙÈÙ·ÓÒÛÂȘ, Û·Ê‹ fiÚÈ·, ¤ÓÙÔÓË ÂÚÈÊÂÚÈ΋ ÚfiÛÏË„Ë ÛÎÈ·ÁÚ·ÊÈÎÔ‡ Î·È ÎÂÓÙÚÈΤ˜ Ù‹ÍÂȘ (∂ÈÎfiÓ· 1). ∏ Ì¿˙· ÚÔηÏÔ‡Û ÈÂÛÙÈο Ê·ÈÓfiÌÂÓ· ÛÙÔÓ ÛÏ‹Ó· Î·È ÙÔÓ ·ÚÈÛÙÂÚfi ÓÂÊÚfi, ¯ˆÚ›˜ Ó· Ù· ‰ÈËı›. ∆· ˘fiÏÔÈ· fiÚÁ·Ó· ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο. ∞ÎÔÏÔ‡ıËÛ·Ó ÂÚ¢ÓËÙÈ΋ Ï··ÚÔÙÔÌ›·, ‚ÈÔ„›· ‹·ÙÔ˜, ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË Î·È ·ÓÔÛÔ˚ÛÙÔ¯ËÌÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜.
¶Èı·Ó¤˜ ‰È·ÁÓÒÛÂȘ: 1. ™ËÚ·ÁÁ҉˜ ·ÈÌ·ÁÁ›ˆÌ· 2. ∏·ÙÔ‚Ï¿Ûو̷ 3. ªÂÛÂÁ¯˘Ì·ÙÈÎfi ·Ì¿Úو̷ 4. ™‡Ó‰ÚÔÌÔ Kasabach-Merritt 5. µÚÂÊÈÎfi Ë·ÙÈÎfi ·ÈÌ·ÁÁÂÈÔÂÓ‰ÔıËÏ›ˆÌ· (µ∏∞)
∂ÈÎfiÓ· 1. ÀÔÏÔÁÈÛÙÈ΋ ÙÔÌÔÁÚ·Ê›· ‡ÛÙÂÚ· ·fi ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË ÛÎÈ·ÁÚ·ÊÈÎÔ‡. ∂ÙÂÚÔÁÂÓ‹˜ Ì¿˙· ÛÙÔÓ ·ÚÈÛÙÂÚfi ÏÔ‚fi ÙÔ˘ ‹·ÙÔ˜, Ì ·ÔÙÈÙ·ÓÒÛÂȘ Î·È Û·Ê‹ fiÚÈ·.
∏ ·¿ÓÙËÛË ·ÎÔÏÔ˘ı› ÛÙË ÛÂÏ›‰· 344 Paediatriki 2007;70:340,344
Pediatri July-Aug 07
09-07-07
17:09
™ÂÏ›‰·341
∂¶π™∆√§∂™ ¶ƒ√™ ∆∏ ™À¡∆∞•∏
LETTERS TO THE EDITOR
341
¶ÚÔ˜ ÙËÓ ∂ÈÙÚÔ‹ ™‡ÓÙ·Í˘ Ù˘ “¶·È‰È·ÙÚÈ΋˜” ™¯ÂÙÈο Ì ÙËÓ ÂÈÛ‹ÁËÛË Ù˘ ∂ÏÏËÓÈ΋˜ ¡ÂÔÁÓÔÏÔÁÈ΋˜ ∂Ù·ÈÚ›·˜ ÁÈ· ¯ÔÚ‹ÁËÛË Synagis ÁÈ· ÚfiÏË„Ë ÓfiÛÔ˘ ·fi ·Ó·Ó¢ÛÙÈÎfi Û˘Á΢ÙÈ·Îfi Èfi ∞ÍÈfiÙÈÌ ·ÚÈ ¢È¢ı˘ÓÙ¿, ™Â ÚfiÛÊ·ÙÔ Ù‡¯Ô˜ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡ ‰ËÌÔÛȇıËÎ·Ó Û˘ÛÙ¿ÛÂȘ Ù˘ ∂ÏÏËÓÈ΋˜ ¡ÂÔÁÓÔÏÔÁÈ΋˜ ∂Ù·ÈÚ›·˜ (∂¡∂) (› ÚÔ‰ڛ·˜ Î. ª. •¿ÓıÔ˘) ÁÈ· ¯ÔÚ‹ÁËÛË ÙÔ˘ Synagis ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ ÓfiÛÔ˘ ·fi ÙÔÓ ·Ó·Ó¢ÛÙÈÎfi Û˘Á΢ÙÈ·Îfi Èfi (RSV) (1). ∆Ô ¿ÚıÚÔ ·˘Ùfi Â›Ó·È Ô˘ÛÈ·ÛÙÈο ÌÈ· ·ÎÚÈ‚‹˜ ÌÂÙ¿ÊÚ·ÛË Û˘ÛÙ¿ÛÂˆÓ Ô˘ ÚÔÙ›ÓÔ˘Ó ÂÙ·ÈÚ›˜ ¿ÏÏˆÓ ÎÚ·ÙÒÓ ÁÈ· ÙȘ ¯ÒÚ˜ ÙÔ˘˜. ∞˘Ùfi Â›Ó·È Î·ıfiÏ· ÛÎfiÈÌÔ ·fi ÙË ÛÙÈÁÌ‹ Ô˘ ‰ÂÓ ˘¿Ú¯Ô˘Ó ÌÂϤÙ˜ ÁÈ· ÙÔ ·Ú·¿Óˆ ı¤Ì· ÛÙÔÓ ÂÏÏ·‰ÈÎfi ¯ÒÚÔ. ∆Ô ÌfiÓÔ ÛËÌÂ›Ô Ô˘ ÌÔÚ› Ó· ‰È·Ê¤ÚÂÈ ·fi ¯ÒÚ· Û ¯ÒÚ· Â›Ó·È ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÂÌÊ¿ÓÈÛ˘ ÙÔ˘ RSV, fiˆ˜ ·Ó·Ê¤ÚÂÙ·È Î·È ÛÙÔ ¿ÚıÚÔ. ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ, ·Ó·Ê¤ÚÂÙ·È fiÙÈ: “ÛÙËÓ ∂ÏÏ¿‰· (Ô RSV) ÂÌÊ·Ó›˙ÂÙ·È Î˘Ú›ˆ˜ ÌÂٷ͇ ¡ÔÂÌ‚Ú›Ô˘ Î·È ª·ÚÙ›Ô˘” (1). ŸÌˆ˜, Ô˘ıÂÓ¿ ÛÙÔ Î›ÌÂÓÔ ‰ÂÓ ·Ó·Ê¤ÚÂÙ·È ÂÏÏËÓÈ΋ ÌÂϤÙË Â›Ù οÔÈÔ ¿ÏÏÔ ÛÙÔÈ¯Â›Ô ·fi ÙÔ ÔÔ›Ô Ó· ÚÔ·ÙÂÈ ·˘Ùfi ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÂÌÊ¿ÓÈÛ˘ ÙÔ˘ RSV ÛÙËÓ ∂ÏÏ¿‰·. ¶·Ú·ı¤Ùˆ ‰‡Ô ÂȉËÌÈÔÏÔÁÈο ‰Â‰Ô̤ӷ ·fi ÙÔÓ ÂÏÏ·‰ÈÎfi ¯ÒÚÔ Ô˘ ‰Â›¯ÓÔ˘Ó fiÙÈ ÙÔ ·Ó·ÊÂÚfiÌÂÓÔ ·fi ÙËÓ ∂¡∂ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Â›Ó·È ÂÛÊ·Ï̤ÓÔ: 1. ¶·ÓÂÏÏ‹ÓÈ· ÂȉËÌÈÔÏÔÁÈ΋ ÌÂϤÙË, ‰ËÌÔÛÈÂ˘Ì¤ÓË ÙÔ 2002, Ô˘ ‰ÂÓ ·Ó·Ê¤ÚÂÙ·È ÛÙÔ ¿ÚıÚÔ Ù˘ ∂¡∂ ‰Â›¯ÓÂÈ fiÙÈ Ë Ïԛ̈ÍË ·fi RSV Â›Ó·È ÈÔ Û˘¯Ó‹ ÙÔÓ ∞Ú›ÏÈÔ ·fi ÙÔÓ ¡Ô¤Ì‚ÚÈÔ Î·È ÙÔÓ ¢ÂΤ̂ÚÈÔ Î·È ÂÍ›ÛÔ˘ Û˘¯Ó‹ Ì ÙÔÓ π·ÓÔ˘¿ÚÈÔ. ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ, ÔÛÔÛÙfi 7,9-11,3% ÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ ÛËÌÂÈÒÓÔÓÙ·È ÙÔÓ ∞Ú›ÏÈÔ Î·È 0,3-4,6% ÙÔÓ ª¿ÈÔ (2), ÂÓÒ ÙÔÓ ¡Ô¤Ì‚ÚÈÔ ÛËÌÂÈÒÓÔÓÙ·È 1,9% Î·È ÙÔÓ ¢ÂΤ̂ÚÈÔ 9,8% (2). ™Ù· ÙÂÏÂ˘Ù·›· 10 ¯ÚfiÓÈ· ÓÔÛËχıËÎ·Ó ÛÙËÓ ª∂¡¡, fiÔ˘ ÚÔ˝ÛÙ·Ì·È, 47 ‚Ú¤ÊË Ì ‚ÚÔÁ¯ÈÔÏ›Ùȉ· (ÛÙË ÏÂÈÔÓfiÙËÙ· ·fi RSV) Î·È Ë Êı›ÓÔ˘Û· ·ÚÈıÌËÙÈ΋ ηٷÓÔÌ‹ ÙÔ˘˜ ·Ó¿ Ì‹Ó· ‹Ù·Ó: ∞Ú›ÏÈÔ˜ 12, ºÂ‚ÚÔ˘¿ÚÈÔ˜ 11, ª¿ÚÙÈÔ˜ 8, π·ÓÔ˘¿ÚÈÔ˜ 6, ª¿ÈÔ˜ 5, πÔ‡ÓÈÔ˜ 2 Î·È ·fi ¤Ó· ÙÔ˘˜ Ì‹Ó˜ √ÎÙÒ‚ÚÈÔ, ¡Ô¤Ì‚ÚÈÔ Î·È ¢ÂΤ̂ÚÈÔ. ¶·ÚfiÙÈ Ô ÌÈÎÚfi˜ ·ÚÈıÌfi˜ ·˘ÙÒÓ ÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ Î·È Ë ÂÈÏÂÎÙÈÎfiÙËÙ¿ ÙÔ˘˜ ‰ÂÓ ÂÈÙÚ¤Ô˘Ó ÙËÓ ÂÍ·ÁˆÁ‹ ·ÛÊ·ÏÒÓ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ, ÂÓÙÔ‡ÙÔȘ ·Ú¤¯ÂÙ·È Ì›· ¤Ó‰ÂÈÍË ÁÈ· ÙÔ˘˜ Ì‹Ó˜ ηٿ ÙÔ˘˜ ÔÔ›Ô˘˜ ÛËÌÂÈÒÓÔÓÙ·È ‚·ÚȤ˜ ÏÔÈÌÒÍÂȘ ·fi RSV Ô˘ ¯Ú‹˙Ô˘Ó ÓÔÛËÏ›·˜ ÛÙË ª∂¡¡. ŸÏ· Ù· ‚Ú¤ÊË ¯ÚÂÈ¿ÛÙËÎ·Ó Ô͢ÁfiÓÔ Î·È 26 ·fi Ù· 47 ¯ÚÂÈ¿ÛıËÎ·Ó Ì˯·ÓÈ΋ ˘ÔÛÙ‹ÚÈÍË Ù˘ ·Ó·ÓÔ‹˜. ∞fi Ù· ·Ú·¿Óˆ Á›ÓÂÙ·È Û·Ê¤˜ fiÙÈ Ë ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô˜ ÂÌÊ¿ÓÈÛ˘ ÙÔ˘ RSV, ÙËÓ ÔÔ›· ·Ó·Ê¤ÚÂÈ Ë ∂¡∂, ‰ÂÓ ÈÛ¯‡ÂÈ ÁÈ· Ù· ÂȉËÌÈÔÏÔÁÈο ‰Â‰Ô̤ӷ Ù˘ ∂ÏÏ¿‰·˜. ∫·Ù¿ ÙÔ˘˜ Ì‹Ó˜ ∞Ú›ÏÈÔ Î·È ª¿ÈÔ Î·Ù·ÁÚ¿ÊÔÓÙ·È ·ÚÎÂÙ¿ ÂÚÈÛÙ·ÙÈο, ÂÚÈÛÛfiÙÂÚ· ·fi fi,ÙÈ ÙÔÓ ¡Ô¤Ì‚ÚÈÔ Î·È ÙÔÓ ¢ÂΤ̂ÚÈÔ. √ÚÈṲ̂ӷ Ù·Ì›·, ‚·ÛÈ˙fiÌÂÓ· ÛÙËÓ ·ÙÂÎÌËÚ›ˆÙË Ô‰ËÁ›· Ù˘ ∂¡∂ fiÙÈ Ô RSV ÂÌÊ·Ó›˙ÂÙ·È ÛÙËÓ ∂ÏÏ¿‰· ηٿ ÙÔ˘˜ Ì‹Ó˜ ÌÂٷ͇ ¡ÔÂÌ‚Ú›Ô˘ Î·È ª·ÚÙ›Ô˘, ·ÚÓÔ‡ÓÙ·È Ó· ¯ÔÚËÁ‹ÛÔ˘Ó Synagis ÙÔÓ ∞Ú›ÏÈÔ Î·È ÙÔÓ ª¿ÈÔ Ì fi,ÙÈ ·˘Ùfi Û˘Ó¿ÁÂÙ·È ÁÈ· ÙËÓ ˘Á›· ÓÂÔÁÓÒÓ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘. £· ·Ú·Î·ÏÔ‡Û· fiÏÔ˘˜ ÙÔ˘˜ ·È‰È¿ÙÚÔ˘˜ Î·È Ù· Ù·Ì›· Ó· Ï¿‚Ô˘Ó ˘fi„Ë Ù· ÛÙÔȯ›· ·˘Ù¿. ∂›Û˘, Ì ·ÊÔÚÌ‹ ÙÔ Úfi‚ÏËÌ· ·˘Ùfi ı· ‹Ù·Ó ÛÎfiÈÌÔ ÔÈ Û˘ÛÙ¿ÛÂȘ ÙˆÓ ∂Ù·ÈÚÂÈÒÓ ÀÔÂȉÈÎÔÙ‹ÙˆÓ Ó· ‚·Û›˙ÔÓÙ·È Û ÙÂÎÌËÚȈ̤Ó˜ ·fi„ÂȘ ÔÌ¿‰·˜ ÂȉÈÎÒÓ. ªÂ ÂÎÙ›ÌËÛË ∞. ∞Ó‰Ú¤Ô˘ ¢È¢ı˘ÓÙ‹˜ ¡ÂÔÁÓÔÏÔÁÈÎÔ‡ ∆Ì‹Ì·ÙÔ˜ ∂™À πÔÎÚ¿ÙÂÈÔ °¡£
µÈ‚ÏÈÔÁÚ·Ê›· 1. ∂ÏÏËÓÈ΋ ¡ÂÔÁÓÔÏÔÁÈ΋ ∂Ù·ÈÚ›· (EÈ̤ÏÂÈ· ™. ¶ÂÙÌÂ˙¿ÎË). ∂ÈÛ‹ÁËÛË ÁÈ· ¯ÔÚ‹ÁËÛË Synagis ÁÈ· ÚfiÏË„Ë ÓfiÛÔ˘ ·fi ·Ó·Ó¢ÛÙÈÎfi Û˘Á΢ÙÈ·Îfi Èfi (RSV). ¶·È‰È·ÙÚÈ΋ 2006;69:69-71. 2. Constantopoulos AG, Kafetzis DA, Syrogiannopoulos GA, Roilides EJ, Malaka-Zafiriou EE, Sbyrakis SS, et al. Burden of respiratory syncytial viral infections on pediatric hospitals: a two-year prospective epidemiological study. Eur J Clin Microbiol Infect Dis 2002;21:102-107.
¶·È‰È·ÙÚÈ΋ 2007;70:341-343
Pediatri July-Aug 07
342
09-07-07
17:09
™ÂÏ›‰·342
∂¶π™∆√§∂™ ¶ƒ√™ ∆∏ ™À¡∆∞•∏
LETTERS TO THE EDITOR
¶ÚÔ˜ ÙËÓ ∂ÈÙÚÔ‹ ™‡ÓÙ·Í˘ Ù˘ “¶·È‰È·ÙÚÈ΋˜” ∞ÍÈfiÙÈÌ ·ÚÈ ¢È¢ı˘ÓÙ¿, ™¯ÂÙÈο Ì ÙËÓ ÂÈÛÙÔÏ‹ ÙÔ˘ ΢ڛԢ ∞Ó‰Ú¤Ô˘, Ô˘ ·Ó·Ê¤ÚÂÙ·È ÛÙȘ Û˘ÛÙ¿ÛÂȘ Ù˘ ∂ÏÏËÓÈ΋˜ ¡ÂÔÁÓÔÏÔÁÈ΋˜ ∂Ù·ÈÚ›·˜ (∂¡∂) ÁÈ· ÙË ¯ÔÚ‹ÁËÛË ÙÔ˘ Synagis (1), ı· ‹ıÂÏ· Ó· ··ÓÙ‹Ûˆ Ù· ÂÍ‹˜: 1. √ÚıÒ˜ ÙÔÓ›˙ÂÙ·È ÛÙËÓ ÂÈÛÙÔÏ‹ fiÙÈ ÔÈ Û˘ÛÙ¿ÛÂȘ ËÁ¿˙Ô˘Ó ·fi ÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›·, ÁÂÁÔÓfi˜ Ô˘ ·Ó·Ê¤ÚÂÙ·È Î·È ÛÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ ¿ÚıÚÔ˘. ∫‡ÚÈ· ËÁ‹ ·ÔÙÂÏÔ‡Ó ÔÈ Û˘ÛÙ¿ÛÂȘ Ù˘ ∞ÌÂÚÈηÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ ∂Ù·ÈÚ›·˜ (2), ÛÙËÓ ÔÔ›· Î·È ·Ó·Ê¤ÚÔÓÙ·È ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ ¿ÏÏˆÓ ¯ˆÚÒÓ. 2. √ÚıÒ˜ ›Û˘ ·Ó·Ê¤ÚÂÙ·È fiÙÈ Ë ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô˜ Û˘¯ÓfiÙÂÚ˘ ›وÛ˘ Ù˘ Ïԛ̈͢ ·fi ·Ó·Ó¢ÛÙÈÎfi Û˘Á΢ÙÈ·Îfi Èfi (RSV) ‰È·Ê¤ÚÂÈ ·fi ¯ÒÚ· Û ¯ÒÚ·. ∆Ô ÛÙÔÈ¯Â›Ô ·˘Ùfi ÂÏ‹ÊıË ˘fi„Ë Î·È ¯ˆÚ›˜ ·ÌÊÈ‚ÔÏ›· ÛÙËÓ ∂ÏÏ¿‰· Â›Ó·È ‰È·ÊÔÚÂÙÈÎfi (3), fiˆ˜ ·Ó·Ê¤ÚÂÙ·È Î·È ÛÙȘ Û˘ÛÙ¿ÛÂȘ (1). ∂›Û˘, Ù· ‰Â‰Ô̤ӷ ·˘Ù¿ ·Ó·Ê¤ÚıËÎ·Ó ÂÎÙÂÓÒ˜ ÛÙËÓ ÔÌÈÏ›· ÌÔ˘ ÛÙÔ ™˘ÌfiÛÈÔ ÙÔ˘ 1Ô˘ ™˘Ó‰ڛԢ Ù˘ ∂¡∂ (∞Ú›ÏÈÔ˜ 2006). 3. ªÂÙ¿ ·fi Û˘ÏÏÔÁ‹ ÛÙÔȯ›ˆÓ ·fi ªÔÓ¿‰Â˜ ∂ÓÙ·ÙÈ΋˜ £Âڷ›·˜ ¡ÂÔÁÓÒÓ ‰È·ÈÛÙÒıËΠfiÙÈ ÂÚÈÛÙ·ÙÈο Ì ‚ÚÔÁ¯ÈÔÏ›Ùȉ· ·fi RSV ηٷÁÚ¿ÊËÎ·Ó Î·È ÙÔÓ ª¿ÈÔ. ∆· Â˘Ú‹Ì·Ù· ·˘Ù¿ ·Ó·ÎÔÈÓÒıËÎ·Ó ÛÙÔ 44Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ (∞Ó·ÙÔÏ›ÙÔ˘ º. Î·È Û˘Ó. Î·È °È·ÓÓ¿ÎË ¶. Î·È Û˘Ó.). 4. ∆Ô Ó¤Ô ¢ÈÔÈÎËÙÈÎfi ™˘Ì‚Ô‡ÏÈÔ Ù˘ ∂¡∂ Ì ٷ ‰Â‰Ô̤ӷ ·˘Ù¿ ¤Î·Ó ÂÈÛ‹ÁËÛË ÚÔ˜ ÙÔ ÀÔ˘ÚÁÂ›Ô ÀÁ›·˜ Î·È ∫ÔÈÓˆÓÈ΋˜ ∞ÏÏËÏÂÁÁ‡Ë˜, Ì ·ÔÙ¤ÏÂÛÌ· Ó· Á›ÓÂÈ ·Ô‰ÂÎÙ‹ Ë ·Ú¿Ù·ÛË ÙÔ˘ ¯ÚfiÓÔ˘ ¯ÔÚ‹ÁËÛ˘ ÙÔ˘ Synagis Î·È Î·Ù¿ ÙÔÓ ∞Ú›ÏÈÔ, ÒÛÙ ӷ Î·Ï˘ÊıÔ‡Ó Ù· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÓÂÔÁÓ¿ Î·È ÙÔÓ ª¿ÈÔ. 5. ŒÁÈÓ ÂÓË̤ڈÛË ÙˆÓ ∆·Ì›ˆÓ Î·È ·Ó·ÁÓÒÚÈÛË ÙÔ˘ ÂÈϤÔÓ ÎfiÛÙÔ˘˜ ¯ÔÚ‹ÁËÛ˘ ÙÔ˘ Synagis Î·È ÙÔÓ ∞Ú›ÏÈÔ. 6. Œ¯ÂÈ ÂÙÔÈÌ·Ûı› ΛÌÂÓÔ Ì ·Ó¿ÏÔÁÔ ÂÚȯfiÌÂÓÔ ÁÈ· ηٷ¯ÒÚÈÛË ÛÙËÓ ÈÛÙÔÛÂÏ›‰· Ù˘ ∂¡∂. 7. ∂ÈÛ˘Ó¿ÙÔÓÙ·È ·ÓÙ›ÁÚ·Ê· Ù˘ ÂÈÛ‹ÁËÛ˘ ÚÔ˜ ÙÔÓ ÀÔ˘ÚÁfi ÀÁ›·˜ Î·È ∫ÔÈÓˆÓÈ΋˜ ∞ÏÏËÏÂÁÁ‡Ë˜ ηıÒ˜ Î·È ÙÔ˘ ÎÂÈ̤ÓÔ˘ ÁÈ· ÙËÓ Î·Ù·¯ÒÚÈÛË ÛÙËÓ ÈÛÙÔÛÂÏ›‰· Ù˘ ∂¡∂. ∂˘¯·ÚÈÛÙԇ̠Ôχ ÙÔÓ Î‡ÚÈÔ ∞Ó‰Ú¤Ô˘ ÁÈ· Ù· Û¯fiÏÈ¿ ÙÔ˘ Î·È ÁÈ· ÙËÓ Â˘Î·ÈÚ›· Ô˘ Ì·˜ ÚÔÛ¤ÊÂÚ ӷ ·Ó·ÊÂÚıԇ̠ÛÙȘ ÂÓ¤ÚÁÂȘ Ù˘ ∂¡∂ ÁÈ· ÙÔ ı¤Ì· ·˘Ùfi. ªÂ ÂÎÙ›ÌËÛË Î·È Û˘Ó·‰ÂÏÊÈÎÔ‡˜ ¯·ÈÚÂÙÈÛÌÔ‡˜, ™ÔÊ›· ¶ÂÙÌÂ˙¿ÎË ¶·È‰›·ÙÚÔ˜ ¡ÂÔÁÓÔÏfiÁÔ˜ ¢È¢ı‡ÓÙÚÈ· ª∂¡¡ “ªËÙ¤Ú·”
µÈ‚ÏÈÔÁÚ·Ê›· 1. ∂ÏÏËÓÈ΋ ¡ÂÔÁÓÔÏÔÁÈ΋ ∂Ù·ÈÚ›· (EÈ̤ÏÂÈ· ™. ¶ÂÙÌÂ˙¿ÎË). ∂ÈÛ‹ÁËÛË ÁÈ· ¯ÔÚ‹ÁËÛË Synagis ÁÈ· ÚfiÏË„Ë ÓfiÛÔ˘ ·fi ·Ó·Ó¢ÛÙÈÎfi Û˘Á΢ÙÈ·Îfi Èfi (RSV). ¶·È‰È·ÙÚÈ΋ 2006;69:69-71. 2. American Academy of Pediatrics Committee on Infectious Diseases and Committee of Fetus and Newborn. Prevention of respiratory syncytial virus infections: indications for the use of palivizumab and update on the use of RSV-IGIV. Pediatrics 1998;102:1211-1216. 3. Constantopoulos AG, Kafetzis DA, Syrogiannopoulos GA, Roilides EJ, Malaka-Zafiriou EE, Sbyrakis SS, et al. Burden of respiratory syncytial viral infections on pediatric hospitals: a two-year prospective epidemiological study. Eur J Clin Microbiol Infect Dis 2002;21:102-107.
Paediatriki 2007;70:341-343
Pediatri July-Aug 07
09-07-07
17:09
™ÂÏ›‰·343
∂¶π™∆√§∂™ ¶ƒ√™ ∆∏ ™À¡∆∞•∏
LETTERS TO THE EDITOR
343
∞Á·ËÙÔ› ·ÚÈÔÈ, ∂›Ì·ÛÙ ÛÙËÓ Â˘¯¿ÚÈÛÙË ı¤ÛË Ó· Û·˜ ÂÓËÌÂÚÒÛÔ˘Ì fiÙÈ ÙÔ ∫¤ÓÙÚÔ ¶ÚfiÏ˄˘ Î·È ÀÁ›·˜ ÙˆÓ ∂Ê‹‚ˆÓ (∫∂.¶.À.∂.-“º›ÏÔÈ ∂Ê‹‚ˆÓ”) Ù˘ ∞ã ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, Û˘ÌÏ‹ÚˆÛ ‰‡Ô ¯ÚfiÓÈ· ÂÈÙ˘¯Ô‡˜ ÏÂÈÙÔ˘ÚÁ›·˜. ∏ ·ÓÔ‰È΋ ÔÚ›· ÙÔ˘ ÚÒÙÔ˘ ∫¤ÓÙÚÔ˘ ÁÈ· ÂÊ‹‚Ô˘˜ Û˘Ó¯›˙ÂÙ·È, ÌÂÙÚÒÓÙ·˜ ̤¯ÚÈ Û‹ÌÂÚ· 600 ÂÊ‹‚Ô˘˜ Î·È ÔÏÏÔ‡˜ ÁÔÓ›˜ Ô˘ ¤Ï·‚·Ó ÛËÌ·ÓÙÈ΋ ‚Ô‹ıÂÈ· Î·È ÛÙ‹ÚÈÍË Û ı¤Ì·Ù· Ô˘ ÙÔ˘˜ ··Û¯ÔÏÔ‡Û·Ó. ∆Ô ∫∂.¶.À.∂. ‰¤¯ÂÙ·È ÂÊ‹‚Ô˘˜ 11-18 ÂÙÒÓ Î·È ÙȘ ÔÈÎÔÁ¤ÓÂȤ˜ ÙÔ˘˜, Û ÒÚ˜ Û˘Ì‚·Ù¤˜ Ì ÙȘ ‰Ú·ÛÙËÚÈfiÙËÙ˜ Ù˘ ÂÊË‚È΋˜ ËÏÈΛ·˜ Î·È ÔÈ ˘ËÚÂۛ˜ Ô˘ ·Ú¤¯ÔÓÙ·È Â›Ó·È: 1. ™˘Ì‚Ô˘Ï¢ÙÈ΋ Î·È ÚÔÏËÙÈ΋ ·ÁˆÁ‹ ˘Á›·˜, 2. ¢È·ÁÓˆÛÙÈ΋ Î·È ıÂڷ¢ÙÈ΋ ‚Ô‹ıÂÈ· Û ÂÊ‹‚Ô˘˜ Ì ÔÚÁ·ÓÈο ‹ „˘¯ÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù·, 3. ∂ÓË̤ڈÛË ÙˆÓ ÁÔÓ¤ˆÓ ÁÈ· ÙË Û˘ÌÂÚÈÊÔÚ¿ Î·È ÙȘ ȉȷÈÙÂÚfiÙËÙ˜ ÙˆÓ ÂÊ‹‚ˆÓ. √È ·Ó¿ÁΘ ÙˆÓ ÂÊ‹‚ˆÓ ηχÙÔÓÙ·È ·fi Ù· ·Ú·Î¿Ùˆ ÂȉÈο ÙÌ‹Ì·Ù· : ñ ∞ÁˆÁ‹˜ ÀÁ›·˜ ñ ¢È·ÙÚÔÊ‹˜-ÕÛÎËÛ˘ ñ ∂Ó‰ÔÎÚÈÓÔÏÔÁ›·˜ ñ °˘Ó·ÈÎÔÏÔÁ›·˜ ñ ¢ÂÚÌ·ÙÔÏÔÁ›·˜ ñ ∞ÏÏÂÚÁÈÔÏÔÁ›·˜ ñ ¡Â˘ÚÔÏÔÁ›·˜ ñ æ˘¯È·ÙÚÈ΋˜ ñ æ˘¯ÔÏÔÁÈ΋˜ ˘ÔÛÙ‹ÚÈ͢ (·ÙÔÌÈ΋ ˘ÔÛÙ‹ÚÈÍË ‹ ÔÌ¿‰· ÂÊ‹‚ˆÓ) ÎÏ. ¶·Ú¿ÏÏËÏ· ˘¿Ú¯ÂÈ Û˘ÓÂÚÁ·Û›· Î·È Ì ¿ÏϘ ÂȉÈÎfiÙËÙ˜, ·Ó¿ÏÔÁ· Ì ÙȘ ·Ó¿ÁΘ ÙˆÓ ÂÊ‹‚ˆÓ. ∏ ÂÊ˂›· Â›Ó·È ÌÈ· ËÏÈΛ· Ì ÔÏϤ˜ ‰˘ÛÎÔϛ˜ ÛÙËÓ ·Ó¿Ù˘ÍË ÙˆÓ ‰È·ÚÔÛˆÈÎÒÓ Û¯¤ÛˆÓ. ø˜ ÂÎ ÙÔ‡ÙÔ˘, Ë ÂÈÏÔÁ‹ ÙˆÓ ÂȉÈÎÒÓ ÙÔ˘ ∫¤ÓÙÚÔ˘ Ì·˜, Ì ÎÚÈÙ‹ÚÈÔ ÙËÓ Î·Ù¿ÏÏËÏË ÁÓÒÛË Î·È ÂÌÂÈÚ›· ηıÒ˜ Î·È Ë Ù‹ÚËÛË ·fiÏ˘Ù˘ ¯Â̇ıÂÈ·˜ ·fi ÏÂ˘Ú¿˜ ÙÔ˘˜, ‚ÔËı¿ÂÈ ÛÙËÓ ÂÏ¿ÙÙˆÛË ÙˆÓ ‰˘ÛÎÔÏÈÒÓ Ù˘ ÂÈÎÔÈÓˆÓ›·˜ È·ÙÚÔ‡-ÂÊ‹‚Ô˘. ™ÙÔ ∫∂.¶.À.∂. ηٿ ÙËÓ ÚÒÙË Â›ÛÎÂ„Ë ÙÔ˘ ÂÊ‹‚Ô˘ Ú·ÁÌ·ÙÔÔÈÂ›Ù·È Ô ‚·ÛÈÎfi˜ ÔÚÁ·ÓÈÎfi˜ ¤ÏÂÁ¯Ô˜ ηıÒ˜ Î·È Û˘˙‹ÙËÛË Ô˘ ·ÊÔÚ¿ ÛÙËÓ „˘¯ÔÎÔÈÓˆÓÈ΋ ÙÔ˘ ·Ó¿Ù˘ÍË Î·È Û˘ÌÂÚÈÊÔÚ¿, ÚÔÛʤÚÔÓÙ¿˜ ÙÔ˘ ¤ÙÛÈ Ù· ηٿÏÏËÏ· ÂÊfi‰È· ÁÈ· ÛˆÛÙ¤˜ ÂÈÏÔÁ¤˜ Î·È ·ÔÊ¿ÛÂȘ Ô˘ ı· ηıÔÚ›ÛÔ˘Ó ÙËÓ ÔÚ›· ÙÔ˘ ÚÔ˜ ÙËÓ ÂÓËÏÈΛˆÛË. °È· ÏËÚÔÊÔڛ˜ Î·È Ú·ÓÙ‚ԇ ÔÈ ¤ÊË‚ÔÈ ‹ Î·È ÔÈ ÔÈÎÔÁ¤ÓÂȤ˜ ÙÔ˘˜ ÌÔÚÔ‡Ó Ó· ηÏÔ‡Ó ÛÙÔ 210 746 74 54 ηıËÌÂÚÈÓ¿ 10.00-14.30 ‹ ÛÙÔ 210 746 74 52 15.00-17.00. ªÂ ÙÈÌ‹, √ ¢È¢ı˘ÓÙ‹˜ °ÂÒÚÁÈÔ˜ ¶. ÃÚÔ‡ÛÔ˜ ∫·ıËÁËÙ‹˜-¢È¢ı˘ÓÙ‹˜ ∞ã ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ
∏ ∂ÈÛÙËÌÔÓÈ΋ À‡ı˘ÓË ∫·Ú¿ÓÙ˙· ª·Ú›· ¶·È‰›·ÙÚÔ˜-∂Ó‰ÔÎÚÈÓÔÏfiÁÔ˜
¶·È‰È·ÙÚÈ΋ 2007;70:341-343
Pediatri July-Aug 07
09-07-07
344
17:09
™ÂÏ›‰·344
CLINICAL QUIZ
∫ÏÈÓÈÎfi QUIZ ∞¶∞¡∆∏™∏ ∏ ‰È¿ÁÓˆÛË ‹Ù·Ó ‚ÚÂÊÈÎfi Ë·ÙÈÎfi ·ÈÌ·ÁÁÂÈÔÂÓ‰ÔıËÏ›ˆÌ· (µ∏∞). √È Ë·ÙÈÎÔ› fiÁÎÔÈ ÛÙ· ·È‰È¿ Â›Ó·È Û¿ÓÈÔÈ (2-3% ÙˆÓ fiÁΈÓ) (1). ∆Ô µ∏∞ Â›Ó·È Ô ÙÚ›ÙÔ˜ ÈÔ Û˘¯Ófi˜ fiÁÎÔ˜ ‹·ÙÔ˜ ÛÙ· ·È‰È¿ (12%) Î·È Ô ÈÔ Û˘¯Ófi˜ ηÏÔ‹ı˘ ·ÁÁÂÈ·Îfi˜ fiÁÎÔ˜ ‹·ÙÔ˜ ÛÙ· ‚Ú¤ÊË, Ô ÔÔ›Ô˜ fï˜ ÌÔÚ› Ó· ÂÍ·ÏÏ·Á› Û ۿÚΈ̷ (2,3). √È ÂÚÈÛÛfiÙÂÚÔÈ fiÁÎÔÈ ·˘Í¿ÓÔ˘Ó Û ̤ÁÂıÔ˜ ηٿ ÙÔ ÚÒÙÔ ¤ÙÔ˜ Ù˘ ˙ˆ‹˜ Î·È Û˘Ó‹ıˆ˜ ˘ÔÛÙÚ¤ÊÔ˘Ó Ì¤¯ÚÈ ÙÔ ‰Â‡ÙÂÚÔ (3,4). ∏ ‚Ï¿‚Ë ÌÔÚ› Ó· Â›Ó·È ÌÔÓ‹Ú˘ ‹ ÔÏ˘ÂÛÙȷ΋ (5). √ ÌÔÓ‹Ú˘ fiÁÎÔ˜ Â›Ó·È Û·ÊÒ˜ ÂÚÈÁÂÁÚ·Ì̤ÓÔ˜, ¯ˆÚ›˜ ο„·, Ì ‰È¿ÌÂÙÚÔ 0,2 ¤ˆ˜ 15 cm (6). Œ¯Ô˘Ó ·Ó·ÁÓˆÚÈÛÙ› ‰‡Ô Ù‡ÔÈ µ∏∞. ™ÙÔÓ Ù‡Ô π, ÙÔ ÌfiÚʈ̷ ·ÚÔ˘ÛÈ¿˙ÂÈ Û˘¯Ó¿ ·ÔÙÈÙ·ÓÒÛÂȘ, Ì ÔÏÏ·Ï¿ ÌÈÎÚ¿ ·ÁÁ›· Ì ·ÓÒÚÈÌ· ÂÓ‰ÔıËÏȷο ·ÙÙ·Ú· Î·È Û¯ÈÛÌÔÂȉ›˜ ¯ÒÚÔ˘˜, ÛÙÔ˘˜ ÔÔ›Ô˘˜ ÂÁÎψ‚›˙ÔÓÙ·È ¯ÔÏËÊfiÚ· ·ÁÁ›·. ™ÙÔÓ Ù‡Ô ππ, Ù· ÂÓ‰ÔıËÏȷο ·ÙÙ·Ú· ÙˆÓ ·ÁÁ›ˆÓ ÙÔ˘ ÌÔÚÊÒÌ·ÙÔ˜ ÂÌÊ·Ó›˙ÔÓÙ·È ÂÚÈÛÛfiÙÂÚÔ ·‰È·ÊÔÚÔÔ›ËÙ·, ¯ˆÚ›˜ ÛÙÚÒÌ· ¯ÔÏËÊfiÚˆÓ ·ÁÁ›ˆÓ (7,8). ∆Ô µ∏∞ ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ·È‰ÈÔ‡ ‹Ù·Ó Ù‡Ô˘ π. √ fiÁÎÔ˜ ÌÔÚ› Ó· Â›Ó·È ·Û˘Ìو̷ÙÈÎfi˜, Û˘¯Ó¿ fï˜ ÚÔ‚¿ÏÏÂÈ Ì ˷ÙÔÌÂÁ·Ï›·, ÌÂÙˆÚÈÛÌfi ÎÔÈÏ›·˜ ‹ „ËÏ·ÊËÙ‹ Ì¿˙·. ªÔÚ› Ó· ˘¿Ú¯Ô˘Ó ÂÎÙÂٷ̤Ó˜ ·ÚÙËÚÈÔÊÏ‚҉ÂȘ ÂÈÎÔÈӈӛ˜, ÔÈ Ôԛ˜ ÚÔηÏÔ‡Ó ·˘ÍË̤Ó˜ ÂÚÈÊÂÚÈΤ˜ ·ÓÙÈÛÙ¿ÛÂȘ Î·È Û˘ÌÊÔÚËÙÈ΋ ηډȷ΋ ·Ó¿ÚÎÂÈ· Ì ˘„ËÏ‹ ·ÚÔ¯‹, ÌÈÎÚÔ·ÁÁÂÈÔ·ıËÙÈ΋ ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›· Î·È ıÚÔÌ‚Ô΢ÙÙ·ÚÔÂÓ›·, ÏfiÁˆ ηٷÛÙÚÔÊ‹˜ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ ÂÓÙfi˜ ÙÔ˘ fiÁÎÔ˘. ™ÙÔ 50% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Û˘Ó˘¿Ú¯ÂÈ ÂȉÂÚÌȉÈÎfi ·ÈÌ·ÁÁ›ˆÌ·. ªÔÚ› Ó· Û˘Ó˘¿Ú¯Ô˘Ó ›ÎÙÂÚÔ˜, ÛÙ·ÛÈÌfiÙËÙ· ‚¿ÚÔ˘˜, ÂÓÙÂÚÈ΋ ·fiÊÚ·ÍË, ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ·, ·ÈÌÔÂÚÈÙfiÓ·ÈÔ Î·È shock, ÏfiÁˆ ڋ͢ ÙÔ˘ fiÁÎÔ˘ (5,8,9). ∏ ‰È¿ÁÓˆÛË ‚·Û›˙ÂÙ·È ÛÙ· Â˘Ú‹Ì·Ù· ÙÔ˘ ·ÂÈÎÔÓÈÛÙÈÎÔ‡ ÂϤÁ¯Ô˘ Î·È ÛÙËÓ ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË. ™Â ÂÚÈÙÒÛÂȘ µ∏∞ Ì ·ÚÙËÚÈÔÊÏ‚҉ÂȘ ÂÈÎÔÈӈӛ˜, Ù· ‰È·ÙÂٷ̤ӷ ·ÁÁ›· Ì ·˘ÍË̤ÓË ÚÔ‹ ·›Ì·ÙÔ˜ ‰›ÓÔ˘Ó Ù˘È΋ ÂÈÎfiÓ· ÛÙÔ Doppler. ªÂ ÙËÓ CT Î·È ÙËÓ MRI ÎÔÈÏ›·˜ ηıÔÚ›˙ÔÓÙ·È Ù· ·ÎÚÈ‚‹ ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ Ì¿˙·˜, ÙÔ Ì¤ÁÂıÔ˜, Ë ÔÌÔÈÔÁ¤ÓÂÈ· ‹ Ë ÂÙÂÚÔÁ¤ÓÂÈ· ·˘Ù‹˜, Ë ‡·ÚÍË ·ÈÌÔÚÚ·ÁÈÒÓ, ÓÂÎÚÒÛˆÓ, ÈÓÒÛÂˆÓ ‹ ·ÔÙÈÙ·ÓÒÛÂˆÓ Î·È Ë ‰È‹ıËÛË ‹ Ë ·ÚÂÎÙfiÈÛË ·Ú·Î›ÌÂÓˆÓ ÔÚÁ¿ÓˆÓ (4,5). ¢È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ı· Á›ÓÂÈ ·fi ÙÔ ÛËÚ·ÁÁ҉˜ ·ÈÌ·ÁÁ›ˆÌ·, ÙÔ Ë·ÙÔ‚Ï¿Ûو̷ Î·È ÙÔ ÌÂÛÂÁ¯˘Ì·ÙÈÎfi ·Ì¿Úو̷. ∆Ô ÚÒÙÔ ··ÓÙ¿Ù·È Paediatriki 2007;70:340,344
Û ÌÂÁ·Ï‡ÙÂÚË ËÏÈΛ· Î·È ÛÙÔ ÛÒÌ· Û˘Ó˘¿Ú¯Ô˘Ó Î·È ¿ÏÏ· ·ÈÌ·ÁÁÂÈÒÌ·Ù·, ÂÓÒ ÙÔ ‰Â‡ÙÂÚÔ Â›Ó·È Î·ÎÔ‹ı˘ fiÁÎÔ˜, Ô˘ ··ÓÙ¿Ù·È Û ËÏÈΛ· ÌÈÎÚfiÙÂÚË ÙˆÓ 5 ÂÙÒÓ. ∆¤ÏÔ˜, ÙÔ ÌÂÛÂÁ¯˘Ì·ÙÈÎfi ·Ì¿Úو̷ Â›Ó·È Î˘ÛÙÈ΋˜ ˘Ê‹˜ Î·È ÚÔ‚¿ÏÏÂÈ Ì ˘ÚÂÙfi, ÌÂÙˆÚÈÛÌfi, Â̤ÙÔ˘˜ Î·È ‰˘ÛÎÔÈÏÈfiÙËÙ· (4). ™Â ·È‰È¿ Ì ·Û˘Ìو̷ÙÈÎfi µ∏∞ ‰ÂÓ ··ÈÙÂ›Ù·È ıÂڷ›·, ÂÓÒ, fiÙ·Ó ˘¿Ú¯Ô˘Ó Û˘ÌÙÒÌ·Ù·, Ë ·ÓÙÈÌÂÙÒÈÛË ÂÚÈÏ·Ì‚¿ÓÂÈ ÙË ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ Î·È ·-ÈÓÙÂÚÊÂÚfiÓ˘. ™Â ·ÛıÂÓ›˜ ÛÙÔ˘˜ ÔÔ›Ô˘˜ ·ÔÙ˘Á¯¿ÓÂÈ Ë Û˘ÓÙËÚËÙÈ΋ ·ÁˆÁ‹, ÚÔÙ›ÓÂÙ·È ÂÌ‚ÔÏÈÛÌfi˜ ‹ ·ÔϛӈÛË Ù˘ Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜. √È ÌÔÓ‹ÚÂȘ Û˘Ìو̷ÙÈÎÔ› fiÁÎÔÈ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Ì ¯ÂÈÚÔ˘ÚÁÈ΋ ÂÍ·›ÚÂÛË, fiˆ˜ ¤ÁÈÓ ÛÙÔ ‚Ú¤ÊÔ˜ Ô˘ ÂÚÈÁÚ¿„·ÌÂ, Û ÂȉÈÎfi ΤÓÙÚÔ ÙÔ˘ Â͈ÙÂÚÈÎÔ‡. ™ÙËÓ ÂÚ›ÙˆÛË Ô˘ ÔÈ ˘fiÏÔȘ ̤ıÔ‰ÔÈ ·ÔÙ‡¯Ô˘Ó, Û˘ÓÈÛÙ¿Ù·È Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ (5,9).
µÈ‚ÏÈÔÁÚ·Ê›· 1. Parker BR. The hepatobiliary system. In: Silverman FN, Kuhn JP, eds. Caffey’s pediatric x-ray diagnosis: an integrating imaging approach. 9th ed. St. Louis, Mo: Mosby; 1993. 915-969. 2. Mortelé KJ, Vanzieleghem B, Mortelé B, Benoit Y, Ros PR. Solitary hepatic infantile hemangioendothelioma: dynamic gadolinium-enhanced MR imaging findings. Eur Radiol 2002;12:862-865. 3. Sty JR, Wells RG, Starshak RJ, Gregg DC. The hepatobiliary system. In: Sty JR, Wells RG, Starshak RJ, Gregg DC (eds). Diagnostic imaging of infants and children. Gaithersburg, Md: Aspen Publishers;1992. 247-293. 4. Rajendran VR, Manoj B. Giant infantile hemangioendothelioma liver in a two month old baby with a normal identical twin- a case report. Calicut Med J 2004;2:E6. 5. Konus √L, Ozdemir H, Onal B, Isik S. Infantile hepatic hemangioendothelioma: findings in the liver with spectral and color Doppler Sonography. Gazi Med J 1999;10:156-160. 6. Horton KM, Bluemke DA, Hruban RH, Soyer P, Fishman EK. CT and MR imaging of benign hepatic and biliary tumors. Radiographics 1999;19:431-451. 7. Dehner LP, Ishak KG. Vascular tumors of the liver in infants and children. A study of 30 cases and review of the literature. Arch Pathol 1971;92:101-111. 8. Zenge JP, Fenton L, Lovell MA, Grover TR. Case report: infantile hemangioendothelioma. Curr Opin Pediatr 2002;14:99-102. 9. Swischuk LE. Abnormalities of the liver. In: Swischuk LE, eds. Imaging of the newborn, infant, and young child. 4th ed. Baltimore: Md: Williams & Wilkins; 1997. 501-521.
Pediatri July-Aug 07
09-07-07
17:09
™ÂÏ›‰·345
¶ƒ√™∂Ã∏ ™À¡∂¢ƒπ∞
xiii
24-25 ∞˘ÁÔ‡ÛÙÔ˘ 2007
3Ô ¢ÈÂıÓ¤˜ ™˘Ó¤‰ÚÈÔ ¡ÔÛËÏ¢ÙÒÓ ¶·È‰È·ÙÚÈ΋˜ ª¤Á·ÚÔ ªÔ˘ÛÈ΋˜ ∞ıËÓÒÓ AC&C International Tel.: 210 6889100 Fax: 210 6844777 E-mail: pn2007@acnc.gr Website: www.pediatricnursing2007.com
∞ı‹Ó·
25-30 ∞˘ÁÔ‡ÛÙÔ˘ 2007
25th International Congress of Pediatrics ª¤Á·ÚÔ ªÔ˘ÛÈ΋˜ ∞ıËÓÒÓ ¶ÏËÚÔÊÔڛ˜: ∞C&C International Tel.: 210 68 89 100 Fax: 210 68 44 777 E-mail: icp2007@acnc.gr Website: www.icp2007.gr
∞ı‹Ó·
31 ∞˘ÁÔ‡ÛÙÔ˘ 4 ™ÂÙÂÌ‚Ú›Ô˘ 2007
14th Congress of the International Pediatric Nephrology Association Blaguss Congress Bureau Tel.: +36 1 374 7030, Fax: +36 1 312 1582 E-mail: info@blaguss-congress.hu Website: www.blaguss-congress.hu
µÔ˘‰·¤ÛÙË, √˘ÁÁ·Ú›·
5-6 ™ÂÙÂÌ‚Ú›Ô˘ 2007
3rd International Multi-disciplinary symposium on Congenital Malformations in Fetus and Child Contact: Dr Liana Beni-Adani Tel.: 972 524 262 057 Fax: 972 36 973 451 E-mail: lianabenia@gmail.com
Jerusalem, Israel
9-12 ™ÂÙÂÌ‚Ú›Ô˘ 2007
2nd World Congress of the World Federation of Associations of Pediatric Surgeons Contact: General Secretariat, Uniline Exhibitions S.A, Av. Cfirdoba 632, 11th floor, (C1054AAS) Buenos Aires, Argentina Tel.: 541 143 225 707 E-mail : pedsurg2007@uniline.com.ar
Buenos Aires, Argentina
9-13 ™ÂÙÂÌ‚Ú›Ô˘ 2007
8th World Congress of Perinatal Medicine Contact: MCA Events - Roberto Caflisch Tel.: 39 0 234 934 404 Fax: 39 0 234 934 397 E-mail: caflisch@mcaevents.org
Florence, Italy
13-14 ™ÂÙÂÌ‚Ú›Ô˘ 2007
European Society for Social Pediatrics and Child Health Annual Meeting Contact: Dr. Stella Tsitoura Dept of Social Pediatrics Aglaia Kyriakou Children's Hospital 18, Mesogeion Avenue Athens, Greece E-mail: socmed@otenet.gr Website: www.essop.org
Trieste, Italy
Pediatri July-Aug 07
09-07-07
17:09
™ÂÏ›‰·346
xiv
14-16 ™ÂÙÂÌ‚Ú›Ô˘ 2007
European Society for Paediatric Haematology & Immunology 2007 Athens Hilton ¶ÏËÚÔÊÔڛ˜: Triaena Tours & Congress S.A 15, Mesogion Avenue, 115 26 Athens, Greece ∆ËÏ.: 210 74 99 372 / 304 / 300 Fax: 210 77 13 795 E-mail: congress@triaenatours.gr Website: www.esphi2007-athens.gr
∞ı‹Ó·
21 - 23 ™ÂÙÂÌ‚Ú›Ô˘ 2007
™ÂÌÈÓ¿ÚÈÔ ∂ÍÂȉÈÎÂ˘Ì¤Ó˘ ÀÔÛÙ‹ÚÈ͢ Ù˘ ∑ˆ‹˜ ÛÙ· ¶·È‰È¿ (APLS) ∆Ì‹Ì· π·ÙÚÈ΋˜, ¶·ÓÂÈÛÙ‹ÌÈÔ ∫Ú‹Ù˘ ¶ÏËÚÔÊÔڛ˜: ª.∂.£.¶. ¶·.°.¡.∏. ∆ËÏ.: 2810 392447 Fax: 2810 392652 ∂-mail: julietaperezg@hotmail.com
∏Ú¿ÎÏÂÈÔ, ∫Ú‹Ù˘
21-23 ™ÂÙÂÌ‚Ú›Ô˘ 2007
2Ë ∂ÈÛÙËÌÔÓÈ΋ ™˘Ó¿ÓÙËÛË ∂ÏÏËÓÈ΋˜ ∞η‰ËÌ›·˜ ¶·È‰È·ÙÚÈ΋˜ Aldemar Olympian Village Resort ¶ÏËÚÔÊÔڛ˜: FIRSTEVENT ∆ËÏ.: 210 8228950 Fax: 210 8228901 E-mail: info@firstevent.gr
™Î·Êȉȿ ∏Ï›·˜
21-23 ™ÂÙÂÌ‚Ú›Ô˘ 2007
3rd ESH-EHA Conference on Focus on Paediatric Haematology and Oncology Contact: Conference Secretariat: European School of Haematology (ESH), Centre Hayem, Hôpital Saint-Louis, 1, av. Claude Vellefaux Cedex 10, 75475 Paris Tel.: 33 142 066 540 Fax: 33 142 060 587 E-mail: ghyslaine_lebougault@paris7.jussieu.fr
Sestri Levante, Italy
26-29 ™ÂÙÂÌ‚Ú›Ô˘ 2007
The 7th Congress of the European Pediatric Neurology Society Contact: Flap Tour Tel.: 90-3-124-540-000 Fax: 90-3-124-540-001 E-mail: epns2007@flaptour.com.tr Website: www.epns2007.org
Kuçadasi, Turkey
18-22 √ÎÙˆ‚Ú›Ô˘ 2007
19th International Congress of Pediatrics Contact: Dr GhR Walizadeh, Dr A Habibolahi Tel.: 982 166 428 998 Fax: 982 166 923 054 E-mail: pedcong@tums.ac.ir
Tehran, Iran