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Original pediatric doctor Yan, pediatric doctor Yan

When I meet a baby with cough and wheezing, the first thing I think of is bronchiolitis (also called bronchiolitis), especially in winter and spring clinics.

Although bronchiolitis is not strictly pneumonia, it is difficult to manage, which is mainly related to its special lesion location and pathogenic pathogens.

01

bronchiolitis

The bronchioles are located at the end of the bronchi (below ⑤, close to the alveolar ducts), and then down are the alveolar ducts and alveoli.

The respiratory tract of young children (especially infants under one year old) is relatively narrow, and local inflammation and exudation of bronchioles can easily cause lumen blockage, hinder air from entering and leaving alveoli, and even lead to hypoxia and dyspnea in severe cases.

The symptoms of children with bronchiolitis have their own characteristics, so that clinical diagnosis can be made through symptoms and signs.

Early symptoms are mild, such as runny nose, stuffy nose, cough, and some have low fever, just like the common cold.

Different from the common cold, children with bronchiolitis have frequent cough and asthma in about 2-3 days, some have shortness of breath and inspiratory depression, and some have severe dyspnea.

Then there is a long recovery period.

Although most children can recover by themselves (the course of disease is self-limited), some need hospitalization management and even use ventilator because of severe respiratory distress.

Bronchiolitis is mostly caused by virus infection, and there is usually no targeted antiviral drug, so it can only be treated symptomatically, and then the child can carry it by himself.

The main management measures include cleaning nasal secretions, ensuring liquid intake, high-flow oxygen inhalation and auxiliary ventilation when necessary.

Aerosol inhalation of bronchodilators (salbutamol, bricanyl) and corticosteroids (budesonide) has no obvious effect on bronchiolitis, and it is usually not routinely used continuously. Unless it is observed that the symptoms of cough and asthma in children are obviously relieved after atomization inhalation, they can continue, otherwise it is recommended to stop.

It is precisely because the drug treatment of bronchiolitis is limited, so the focus of management is not how to give drugs to children, but to guide parents.

For example, guide parents to care at home, observe the progress of the disease, identify severe cases, and let parents know that the next course of disease may be longer, so they must be psychologically prepared. Otherwise, children will face excessive intervention.

02

Significance of pathogen detection

Respiratory syncytial virus (RSV) is the most common pathogen causing bronchiolitis. In addition, rhinovirus, human metapneumovirus, parainfluenza virus, adenovirus and mycoplasma pneumoniae infection can all cause bronchiolitis.

If the child has typical bronchiolitis symptoms, it is unnecessary to check the pathogen. Because even if the pathogen is known, there is usually no antiviral method. But many times, I will choose to check.

Why check? Mainly to facilitate communication with parents.

For example, cough and asthma in children with bronchiolitis lasts for a long time, which may be several weeks, and has no obvious expected effect on many treatment methods including atomized inhalation. In this case, parents are inevitably anxious.

Parents are anxious and will try their best to control their children’s symptoms. They may take their children to see a doctor repeatedly, and the children will face more medication. In addition, repeated exposure to medical institutions will increase the risk of nosocomial infection.

And a clear result of pathogenic examination (such as detecting a virus) can alleviate parents’ anxiety to a certain extent and facilitate communication between doctors and patients.

Therefore, in the clinic, when a child is suspected of bronchiolitis, I usually suggest a rapid antigen test for nasopharyngeal swab RSV first (RSV is chosen because it is the most likely and the rapid antigen test is very convenient).

If it is positive, inform the parents of the main points of home management, the possibility of facing a longer course of disease, and avoiding the abuse of antibiotics during this period, so that parents can be mentally prepared.

You see, proper auxiliary examination is actually to protect children.

However, RSV is only the most common virus that causes bronchiolitis. At work, children with typical bronchiolitis symptoms will also be encountered, but RSV is negative. How to manage it?

03

A case

Next, share a case. Before sharing, as usual, I would like to thank my parents for their permission.

This 11-month-old baby was the last patient on the afternoon of December 1st. Before coming to my clinic, the course of cough was nearly ten days, and I have been treated twice in other hospitals. In the clinic, the child coughed violently and vomited several times, with obvious asthma, shortness of breath and inspiratory depression, and fever.

Hormones and bronchodilators have been atomized and inhaled at home, and the symptoms are not obviously relieved.

I did a rapid RSV antigen test first, and the result was negative.

Although the child has shortness of breath and inspiratory depression, the degree is not serious and the oxygen saturation is still in the normal range.

Although coughing leads to vomiting and affects eating, there is no dehydration;

Although low fever, but the overall state is not bad, willing to interact with others, no symptoms of infection and poisoning;

Most importantly, my mother has a certain ability to observe the changes of diseases. Although she is anxious, she is not particularly anxious.

I evaluate that the child has not reached the indication of hospitalization at present, and there is no clear manifestation of bacterial infection. The high probability is still viral infection. After taking a throat swab sample and doing targeted sequencing, he didn’t prescribe medicine, so he was told to go home for observation and follow up online. I also repeatedly reminded that if the symptoms get worse, I need to be hospitalized.

To tell the truth, when the patient’s family was ready to leave the clinic after the visit, I was really sorry when my mother asked the children to wave goodbye to me. Coming from other places, the total cost of consultation and laboratory test is more than 1,500 yuan. I didn’t prescribe any medicine, and I didn’t know the pathogen. I went home empty-handed, and the future course of my illness is still unclear, which is really worrying.

On the second day, I contacted my parents by phone. The parents reported that they still coughed and vomited, but the frequency was less, my temperature was normal, I could eat something, and my urine volume was normal.

On the afternoon of the third day, targeted sequencing showed that the sample contained high concentration of human metapneumovirus, and cytomegalovirus was detected.

Combined with the symptoms of the child, I think the child is bronchiolitis caused by human metapneumovirus infection. As for the detected cytomegalovirus, it is considered to be carried in the pharynx (previous infection).

Because my home is out of town, I didn’t ask my parents to take her back to the clinic for follow-up, and I kept in touch by phone all the time.

Fortunately, the symptoms behind this child gradually eased, and it was not until mid-December that there was basically no cough, but there was phlegm in the throat from time to time. The total course of disease is more than 3 weeks, which accords with the characteristics of classic bronchiolitis.

04

Human metapneumovirus

Everyone should be unfamiliar with human metapneumovirus, and the doctor’s knowledge is likely to stay at the textbook level, because this pathogen is not checked at ordinary times and there is a lack of perceptual knowledge.

With the targeted sequencing in our outpatient department, many children were found to be infected with this virus. I thought it was a little strange at first, but if you look up the relevant information, you will find that you are rare and strange. I didn’t know it before, but I just didn’t have the ability to test it.

In 2001, Dutch virologist Bernadette G. van den Hoogen and his colleagues isolated a new virus from the respiratory secretions of 28 young children, named human metapneumovirus, hMPV).

HMPV belongs to pneumoviridae. Pneumoviridae is named because its viruses are related to respiratory diseases of people or other animals, and the most famous one is RSV.

HMPV is distributed all over the world, and is often prevalent in winter/spring in temperate regions, overlapping with RSV and flu seasons.

Serological studies show that hMPV has spread for at least 60 years. By the age of five, almost all children in the world have been infected, which is considered to be the common cause of lower respiratory tract infection in children (second only to RSV in some areas).

Although infection is common in early life, reinfection is also common in older children and adults. Reinfection is mostly mild infection, such as common cold symptoms, but the risk of serious diseases will increase when reinfection occurs in immunocompromised people or the elderly.

HMPV may be transmitted by contact with virus-containing secretions, droplets, large aerosol particles or pollutants.

05

Symptom

The symptom characteristics and severity of hMPV are similar to RSV, so I often mistake hMPV infection in children for RSV infection.

Like RSV, the common symptoms of children infected with hMPV are fever, cough, runny nose and stuffy nose, and nearly half of young children may have asthma. A few patients may have acute laryngitis.

If hMPV only affects the upper respiratory tract, the symptoms are like common cold, such as mild fever, runny nose, stuffy nose, sore throat, cough and headache, which usually disappear in about a week.

However, hMPV is not very friendly to children and the elderly, and may spread to the lower respiratory tract. Infants infected with hMPV are prone to bronchiolitis, and the symptoms described in the first part of this paper, "Bronchiolitis", appear.

Some children with hMPV infection need hospitalization because of severe respiratory distress or inability to eat effectively with dehydration.

06

Severe risk

The risk of severe illness and hospitalization is significantly increased in the following groups:

Premature infants (gestational age ≤36 weeks)

Low birth weight infants (birth weight less than 2500g)

Infants under 1 year old

Chronic lung diseases (especially bronchopulmonary dysplasia)

Abnormal anatomical structure of airway

Congenital heart disease (with significant hemodynamic abnormalities)

Immune hypofunction

Nervous system diseases

Children with these high-risk factors need special attention, because their risk of adverse outcomes is significantly increased.

07

Treatment

Symptomatic treatment.

Use antipyretics to relieve discomfort caused by fever.

Clean nasal secretions to make children more comfortable and easy to eat and sleep.

Ensure liquid and energy intake and avoid dehydration.

Respiratory support: oxygen, assisted breathing.

Antiviral treatment.

Ribavirin and other antiviral drugs have been shown to be active against hMPV in vitro. However, there is no clinical data about the effect of ribavirin or other antiviral drugs on hMPV infection.

Therefore, antiviral drugs are not recommended for people infected with hMPV.

08

Epidemic vaccine

At present, there is no approved hMPV vaccine.

Moderna, an American pharmaceutical company, has developed a candidate vaccine against hMPV and conducted clinical trials.

As of October 2019, the candidate vaccine has passed the first phase of clinical trials. It is reported that the vaccine is well tolerated at all dosage levels within two months, and it stimulates immune response and produces neutralizing antibodies.

09

Total knot

Whether it is RSV, hMPV, or bronchiolitis caused by Boca virus, rhinovirus and parainfluenza virus, there is no difference in our management principles.

If you have the conditions to check, you can check the cause and find out hMPV, so don’t worry too much; If there is no condition to check, it can be diagnosed by symptoms and managed according to bronchiolitis.

The focus of management is still home care and observing the progress of the disease.

Original title: "Cough, asthma and fever, thought it was RSV infection, the result was human metapneumovirus, what should I do?" 》

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　　At the 14th Beijing International Finance Expo, more than 150 Chinese and foreign financial institutions gathered to show the latest achievements in financial risk prevention and control, smart financial services and inclusive finance innovation. Spring light photo (people’s vision)

　　In the process of expanding financial openness, China has also actively initiated the establishment of international financial institutions such as the Asian Infrastructure Investment Bank. The picture shows the headquarters building of the AIIB in Beijing Financial Street. Xinhua News Agency reporter Wu Kaixiang photo

　　Financial opening will directly serve the economic and trade exchanges between China and overseas. The picture shows a busy scene in Chongqing Central Station of China Railway Lianji at Chongqing Railway Port on May 7 this year. Photo by Sun Kaifang (People’s Vision)

　　Not long ago, Guo Shuqing, President of China Banking and Insurance Regulatory Commission, China, said that on the basis of in-depth study and evaluation, 12 new measures to expand the opening up of the banking and insurance industries will be introduced in the near future. In recent days, people from all walks of life have been paying more and more attention to the opening up of China’s financial industry. Insiders pointed out that China’s new round of measures to expand the opening of banking and insurance industry not only responded to the concerns of foreign financial institutions, but also met the needs of China’s own economic and financial development.

　　These opening measures are not only conducive to enriching market players, stimulating market vitality, but also improving the management level and competitiveness of the financial industry; It is also conducive to learning from international advanced concepts and experiences, expanding product and service innovation, and increasing effective financial supply, which embodies the meaning of China’s economic development towards high quality.

　　Foreign investment in China "has a bigger door and a wider road"

　　— — Expanding financial openness will help improve the business space and convenience of foreign-funded institutions in China.

　　In early May, a message released by the State Administration of Foreign Exchange aroused widespread concern. This information shows that since the beginning of this year, the State Administration of Foreign Exchange has approved a total of 13 qualified foreign institutional investors (QFII) with a total investment quota of 4.74 billion US dollars, exceeding the total amount approved in 2018; A total of 12 RMB qualified foreign institutional investors (RQFII) were approved to invest a total of 24 billion yuan, exceeding half of the total amount approved in 2018. This means that the door for foreign capital to enter China is getting wider and wider.

　　"China’s determination to open wider to the outside world and a series of reform measures it is promoting have made China’s financial market more and more attractive to foreign investment. China’s stock market and bond market have been included in several global important indexes one after another, which also makes foreign capital have a strong allocation demand for China’s financial market. In the first quarter, overseas institutions bought a net of US$ 19.4 billion in Chinese stocks and US$ 9.5 billion in Chinese bonds, a substantial increase compared with the same period last year and the fourth quarter. The State Administration of Foreign Exchange will continue to actively support the expansion of the financial market to the outside world, meet the expanding investment needs of overseas investors in China’s financial market, and attract long-term global capital to enter China’s financial market. " The relevant person in charge of the State Administration of Foreign Exchange said.

　　Beyond the implementation level, 12 new initiatives issued by China Banking and Insurance Regulatory Commission, China, have attracted more attention. Specifically, these measures mainly include: canceling the upper limit of the shareholding ratio of a single Chinese bank and a single foreign bank to Chinese commercial banks at the same time; Cancel the total assets requirement of $10 billion for foreign banks to set up foreign-funded corporate banks in China and $20 billion for foreign banks to set up branches in China; Cancel the $1 billion total assets requirement for overseas financial institutions to invest in trust companies; Allow overseas financial institutions to invest in foreign-funded insurance companies in China; Allow foreign insurance group companies to invest in the establishment of insurance institutions; At the same time, relax the access policy for Chinese and foreign financial institutions to invest in the establishment of consumer finance companies; Cancel the approval of foreign banks to start RMB business, and allow foreign banks to operate RMB business when they start business.

　　Xiao Yuanqi, spokesperson of China Banking and Insurance Regulatory Commission, China, said that the 12 new opening-up measures are aimed at further improving the foreign investment and business environment in the financial sector and stimulating the vitality of foreign investment in the development of China’s financial industry. "For example, if the relevant restrictions on the ratio of foreign shares are abolished, foreign investors can freely choose to operate in China by means of equity participation, joint venture or sole proprietorship, so as to further promote fair competition between Chinese and foreign investors. For another example, canceling the quantitative access requirements for institutions such as total assets and comprehensively evaluating the qualifications of applicants with more prudent conditions can attract more high-quality foreign-funded institutions with professional characteristics, which will help to further enrich financial market players and improve the supply of financial services. In addition, measures to expand the scope of foreign-funded business will further expand the space for foreign-funded institutions to operate in China and enhance their operational convenience. "

　　Ceng Gang, deputy director of the National Finance and Development Laboratory, believes that the new opening policy is the implementation and deepening of the general direction and policy principles of financial opening in the previous stage. "For example, at the same time, the upper limit of the shareholding ratio of foreign banks to Chinese commercial banks is cancelled, which reflects the consistency standard of foreign capital and Chinese capital; For another example, canceling the approval of foreign banks to start RMB business and allowing foreign banks to operate RMB business when they start business is also a manifestation of promoting more full competition in the market. " Ceng Gang said.

　　The "catfish effect" will expand.

　　— — The entry of "small but beautiful" and "small but refined" foreign capital will make China’s financial system more balanced.

　　The impact of the new round of financial opening policy is undoubtedly enormous. It is understood that at present, the banking and insurance industry in China has formed a multi-ownership structure of state-owned, private and foreign capital. Among them, private capital has accounted for 43%, 56%, 83% and 49% of the total share capital of joint-stock banks, city commercial banks, rural commercial banks and insurance companies respectively. Foreign banks and foreign insurance companies account for 1.64% and 6.36% of assets in China.

　　Guo Shuqing pointed out that financial management departments adhere to internal and external consistency, treat all domestic and foreign entities fairly and equally, and cooperate and compete under the same rules to form a win-win situation. He said that by further opening up and building a fair and consistent market environment, it will be more conducive to the full competition of banking and insurance institutions, optimize the shareholding structure, standardize shareholder behavior, and form a reasonable and diverse market system.

　　Take "allowing overseas financial institutions to invest in foreign-funded insurance companies in China" as an example. Before liberalization, the overseas shareholders of foreign-funded insurance companies should be insurance companies; After liberalization, allowing qualified non-insurance financial institutions to hold shares in foreign-funded insurance companies can enrich the types of shareholders and sources of funds of foreign-funded insurance companies. "At present, China insurance market has introduced six foreign insurance brokerage companies. Cancelling the requirements of relevant business years and total assets will help encourage and guide high-quality foreign-funded insurance brokerage companies with significant late-comer advantages to enter the China market, and help China deepen exchanges and cooperation with advanced international counterparts. " Xiao Yuanqi said.

　　According to Dong Ximiao, vice president of Chongyang Financial Research Institute of China Renmin University, the launch of a new round of opening-up measures in the financial industry will help to introduce small and medium-sized foreign financial institutions with characteristics and advantages, improve the unbalanced domestic financial institution system, promote more cooperation between domestic and foreign small and medium-sized financial institutions in terms of equity, business and products, and also help finance to better serve private small and micro enterprises.

　　"Previously, the foreign capital introduced by China was basically a top-level large-scale well-known foreign-funded institution. The cancellation of scale restrictions is conducive to the relatively small scale of foreign capital introduction, especially the better development, ‘ Small and beautiful ’ 、‘ Small but refined ’ Small and medium-sized foreign capital entered China. The introduction of these small and medium-sized foreign-funded institutions, on the one hand, is conducive to the enrichment of the main level of the financial industry in opening up to the outside world, and improves the unbalanced state of China’s financial system; On the other hand, it is conducive to the formation of ‘ Catfish effect ’ To promote full competition in the financial industry, so that private enterprises and small and micro enterprises in the real economy can get more support. " Dong Ximiao told reporters.

　　Peng Zhiwei, director of the Department of International Economics and Trade of Nankai University, pointed out in an interview with this reporter that a direct effect of China’s new round of measures to expand financial openness is to promote competition in the domestic financial industry and improve the efficiency of the financial market in allocating factors and resources. "Today, China’s economy is seeking higher quality development, so the financial industry should also carry out supply-side reform. At this time, further opening up the financial sector is obviously conducive to promoting reform and accelerating the upgrading of China’s financial industry. "

　　Quickly add whip to "enter the competition"

　　— — The new action of financial opening to the outside world has better responded to the real needs and concerns of foreign capital.

　　Swiss bank’s shareholding in UBS Securities increased to 51%, achieving absolute control; Jordan Arab Bank and Morocco Foreign Trade Bank successfully set up Shanghai branch; Allianz (China) Insurance was approved to build and became the first foreign insurance holding company in China; S&P was allowed to enter China’s credit rating market; American Express initiated the establishment of a joint venture company in China, and the application for preparing a bank card clearing institution has been examined and approved … … With the last round of financial opening, foreign financial institutions are more and more actively deploying the China market.

　　Nowadays, the new round of financial opening policy has obviously further increased China’s attractiveness to overseas financial institutions. Dbs group said that the implementation of the open policy has enabled foreign banks to have a more level playing field in China. After more reforms, DBS Bank is more willing to invest in China and expand its business in China. Morgan Stanley predicts that with the increase of China A-share market in MSCI Emerging Markets Index, the proportion of foreign investors holding China A-shares will increase from 2.6% to about 10% within 10 years, which is expected to bring hundreds of billions of dollars into China capital market every year.

　　As the largest foreign-funded property insurance company in China market, AXA Tianping will be 100% wholly owned by French AXA, and it is the first wholly foreign-funded company among the top 20 property insurance companies in China. In recent years, the continuous opening of China’s financial industry, especially the rapid growth of the insurance industry, has strengthened AXA Tianping’s confidence in expanding the layout of the China market.

　　Wei Zewei, Executive Chairman and CEO of AXA China, said that insurance regulators are promoting market liberalization and providing foreign investors with the same level of market access as domestic enterprises, and positive changes can be seen everywhere. "We have always been full of confidence in the China market and believe that the China market has great growth potential. Now we have become a leading foreign-funded life insurance and property insurance company in China. In the future, AXA Tianping will continue to devote itself to serving the China market and further deepen the insurance industry to provide more humanized services, so as to ‘ Quality ’ Win. "

　　"According to the data of the Ministry of Commerce, in the first quarter, 9,616 foreign-invested enterprises were newly established nationwide, and the actual use of foreign capital was 242.28 billion yuan, a year-on-year increase of 6.5%; In March, the actually used foreign capital increased by 8% year-on-year. Among them, high-tech manufacturing and high-tech service industries have increased substantially, and the investment in China by economies such as the United States, Japan, South Korea and the European Union has increased rapidly. A large number of foreign investments in China also show that the new situation of economic development requires China to provide more diversified, more open and more effective financial services. Expanding financial openness is obviously beneficial to the development of this open economy. It can be said that the new round of financial opening-up measures has better responded to the actual needs and concerns of foreign investment. " Peng Zhiwei said. (Our reporter Wang Junling.)