REPORTS OF INCIDENCE OF AMS AND HAPE IN CHILDREN
Children at High Altitude: An International Consensus Statement by an Ad Hoc Committee of the International Society for Mountain Medicine, March 12, 2001
關於小兒高海拔肺水腫案例很少. 這篇研究是 2001年發表的
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簡介
每年都有成千上萬的低地兒童平安無事地前往高海拔地區。大多數這些兒科攀登涉及到山區度假勝地的旅行，尤其是在北美和歐洲，還有一小部分涉及到非工業化國家的偏遠高地地區的旅行。此外，越來越多的兒童因父母的職業而搬到高海拔地區與家人一起居住。儘管對大多數人來說，高海拔旅行不會發生意外，但其中一些兒童會出現可能歸因於高海拔暴露，但醫學或科學文獻中幾乎沒有記錄。在這裡，我們概述了可用的案例。本共識聲明涉及兒科人群中嚴重高原病的發生、預防、識別和治療。不幸的是，兒童暴露在高海拔地區的特殊風險很少被研究，許多建議必須從成人數據中推斷出來，並適當考慮生長和發育的影響（Berghold，2000）。
本聲明的目的是為臨床醫生提供有關兒科人群高原旅行建議的信息。通過更好的教育，父母可以就旅行做出明智的決定
如果發生高原反應，他們的孩子可以被賦予檢測高原反應的能力。
上面這張圖照片，將HAPE的部分動畫下來，由數據可以看到，正在發生的HAPE的兒童案例監護人，有一個例子是西藏的
美國報告的報告數量比較多，我猜這兩者之間可能不是機率兩地的醫療與學術風氣不同的
西藏有很多沒被的案例記錄1.1.1。兒童 AMS 的發病率似乎與在成人中觀察到的相同（見表 1；以及 Theis 等，1993；Wu，1994；Yaron 等，1998；Yaron 等，2000）。 1.1.2. 低海拔地區兒童到高海拔地區旅行和高海拔地區兒童從海平面附近旅行返回的 HAPE 的性質和發病率可能不同。與成人相比，低地兒童患 HAPE 的風險可能沒有增加。居住在高海拔地區的兒童比成人更容易患上折返性 HAPE（Marticorena 等，1964；Menon，1965；Scoggin 等，1977；Hultgren 和 Marticorena，1978；Fasules 等，1985）；這些研究涉及高海拔居民重新上升到高海拔，而不是低海拔居民前往高海拔。青藏高原旅行兒童的 HAPE 發生率也與同一組的成人相似（見表 1；Wu，1994）。然而，並發病毒感染可能易患 HAPE（Durmowicz 等，1997），並且這種感染在幼兒中在統計學上更為常見。共識委員會成員報告了兒童 HAPE 個別病例的經驗。
1.1.3. 沒有關於兒童 HACE 發病率的公開信息，文獻中也沒有病例報告。
1.2 兒童急性高原病的危險因素。很少有信息可以概述特別是兒童高原病的風險因素。表 3 包含從一些兒科和一些成人研究中推斷出的高原病的可能風險因素。1.3 急性高原病的症狀和體徵
在兒童中。在所有年齡段（兒童和成人），高原病的症狀都是非特異性的，可能與不相關的變量混淆，例如並發疾病、飲食不當、中毒或與遠程旅行相關的心理因素（Berghold 和 Schaffert，1999）。然而，當與孩子一起上升時，除了考慮針對其他可能的原因進行治療外，明智的做法是假設此類症狀與海拔高度相關並採取適當的措施。
1. 在年齡較大的兒童（0.8 歲）中，假設高原病的表現方式與成人大致相同。
2. 3 歲以下，到任何新環境旅行可能會導致睡眠、食慾、活動和情緒的改變。將單獨旅行引起的行為變化與高原疾病引起的變化區分開來可能很困難。由於
幼兒感知和表達的發展水平存在差異，即使他們會說話，他們也不是高原病症狀的可靠報告者。
症狀可能表現為非特異性行為改變，而不是頭痛或噁心的具體主訴。幼兒急性高山病的典型症狀包括煩躁不安、食慾下降和可能嘔吐、玩耍減少和睡眠困難。這些症狀通常在上升到海拔 4 到 12 小時後開始. 路易斯湖評分的改進版已經
開發出來，用於評估非常年幼兒童的非特異性症狀，並且可能對評估未說話的兒童有用；參見附錄 B（Yaron 等，1998）。然而，目前該評分還沒有被父母或醫生在高海拔兒童管理決策中常規使用進行評估。該分數已被驗證為
父母使用時具有較高的觀察者間一致性，並且它可能有助於對父母進行 AMS 症狀的教育（Yaron 等，2000）。
3. 一些年齡較大的兒童，特別是3-8歲的兒童，以及學習或交流有困難的兒童，也可能對症狀描述不力，導致高原病難以識別。
1.4 預防兒童急性高原病。沒有關於預防兒童高原病的研究；然而，我們假設成人的預防原則也適用於兒童。
1.4.1. 分級上升。緩慢的分級上升，留出適應環境的時間，是有幫助的。已推薦2500米以上每天300米的新生速度和每1000米休息日，但尚不清楚是否更適合兒童或多或少謹慎的建議。與成人相比，關於兒童對海拔的適應情況的數據很少。在一份記錄了兒童心率和動脈血氧飽和度變化的報告中發現，兒童的適應能力至少與成人一樣好，甚至比成人好。
7 至 9 歲的兒童及其成年父母在緩慢的梯度上升過程中（Tuggy 等，2000）。
1.4.2. 通常應避免使用藥物預防來幫助兒童適應環境，因為在大多數情況下緩慢上升可達到相同的效果，並最大限度地減少兒童不必要的藥物使用。在極少數情況下，當快速上升不可避免時，可能需要使用乙酰唑胺幫助兒童適應環境。已知先前對 AMS 易感的兒童可能會受益於預防以幫助適應環境。乙酰唑胺確實會出現副作用，例如感覺異常、皮疹和可能的脫水；因此不應鼓勵使用。磺胺過敏是使用乙酰唑胺的禁忌症。
1.4.3. 教育。兒童及其照顧者應在高原旅行（2500 米以上）之前熟悉高原病的症狀及其管理。父母還應該了解他們的孩子在旅行期間的反應，無論海拔如何，以便能夠將高海拔疾病與簡單的
旅行症狀區分開來。
1.4.4. 應急預案。前往偏遠海拔地區的所有團體在出行前應制定應急預案，以確保必要時疏散該黨的患病成員。應急計劃的一部分應包括提供通信以促進疏散。如果孩子正在前往高海拔地區，應該可以立即（數小時內）下降或獲得氧氣。當下降需要數天或需要在下降前進一步上升時，應避免在海拔高度逗留。
1.4.5. 團體旅遊。學校探險是年齡較大的兒童的一種流行教育體驗。計劃學校團體遠征到（睡眠）海拔 2500 米以上的組織必須規劃一個允許分級上升、休息日、輕鬆下降以及在生病時靈活的行程的組織。遠征前 p5。醫療和疏散保險（適用於所有旅行者）。
1.5 兒童急性高原病的治療。沒有關於治療兒童急性高原病的研究。然而，遵循表 4 中概述的適當兒科藥物劑量的成人治療流程似乎是合適的。 在管理患有急性高山病的兒童時要更加謹慎，並且在症狀出現後更早下降可能比實際情況更謹慎對於成年人來說，因為兒童期 AMS 的自然病程沒有得到很好的表徵。在可能的情況下，下降時應盡量少用力，這可能會加劇症狀，並且在下降過程中應在可行的情況下抱起孩子。
2.有症狀的高原肺動脈高壓
有症狀的高原肺動脈高壓 (SHAPH) 包括肺動脈高壓的急性加重以及亞急性嬰兒高山病 (SIMS) 或高原心髒病綜合徵。
在與並發病毒感染相關的生活或旅行到高海拔地區的嬰兒中觀察到肺動脈壓力急劇增加（Susan Niermeyer，未發表的觀察結果）。治療的重點是給氧和下降。SHAPH 的亞急性形式幾乎只發生在持續暴露於 3000 m 以上海拔 1 個月以上的低海拔嬰兒（1 歲以下）（Wu 和 Liu，1955；Khoury 和 Hawes，1963；Sui 等人） ., 1988; Wu, 1994)。SHAPH 的風險可能存在種族差異。中國嬰兒的發病率為 1%
3050 到 5188 m (Wu, 1994)。在這種情況下，嬰兒會出現缺氧性肺動脈高壓和隨之而來的右心室心力衰竭。表現始於進食不良、嗜睡和出汗。之後，呼吸困難、紫紺、咳嗽、煩躁、失眠、肝腫大、水腫、少尿等心力衰竭的跡象可能會變得明顯。管理不同於急性高山病的管理應包括以下內容：
1. 評估每個孩子的既往病史。
2. 對父母、工作人員和孩子進行關於高原疾病和其他探險健康危害的教育。
3. 對工作人員進行野外急救培訓並準備合適的急救箱。
4. 應急和疏散計劃，包括緊急情況下的通訊方式。
5. 醫療和疏散保險（適用
於所有旅行者）。
1.5 兒童急性高原病的治療。
沒有關於治療兒童急性高原病的研究。然而，遵循表 4 中概述的
適當兒科藥物劑量的成人治療流程似乎是合適的。在管理患有急性高山病的兒童時要更加謹慎，並且在症狀出現後更早下降可能比實際情況更謹慎對於成年人來說，因為兒童期 AMS 的自然病程沒有得到很好的表徵。在可能的情況下，下降應該涉及最小的勞累，這可能會加劇症狀，並且在下降過程中，應在可行的情況下攜帶兒童。
2. 症狀性高原肺動脈高壓
症狀性高原肺動脈高壓（SHAPH）包括肺動脈高壓急性加重以及亞急性嬰兒高山病（SIMS）或高原心髒病綜合徵。在與並發病毒感染相關的生活或旅行到高海拔地區的嬰兒中觀察到肺動脈壓力急劇增加（Susan Niermeyer，未發表的觀察結果）。
治療的重點是給氧和下降。
SHAPH 的亞急性形式幾乎只發生在低海拔血統的嬰兒（1 歲以下）中暴露在海拔超過 3000 米的地方超過1 個月（Wu 和 Liu，1955；Khoury 和Hawes，1963；Sui 等，1988；Wu，1994）。有可能在SHAPH的危險種族差異。
在3050 至 5188 米的中國嬰兒中，發病率為 1% （Wu，1994）。在這種情況下，嬰兒會出現缺氧性肺動脈高壓和隨之而來的右心室心力衰竭。表現始於進食不良、嗜睡和出汗。之後，呼吸困難、紫紺、咳嗽、煩躁、失眠、肝腫大、水腫、少尿等心力衰竭的跡象可能會變得明顯。管理不同於急性高山病，其目的是控制充血性心力衰竭和逆轉肺動脈高壓。
治療包括吸氧、藥物利尿和緊急下降。
3. 嬰兒猝死綜合徵 (SIDS)由於存在相互矛盾的報告，目前尚不清楚暴露於高海拔是否會增加 SIDS 的風險（Barkin 等，1981；Getts 和 Hill，1982；Kohlendorfer 等，1998）。俯臥位是海拔和海平面的重要輔助因素（Kohlendorfer 等，1998）。與在海平面上一樣，嬰兒總是仰臥睡覺並避免被動接觸煙草煙霧可以降低 SIDS的風險（Wisborg 等，2000）。關聯的可能性需要仔細考慮與年幼（1 歲）嬰兒一起上升到海拔高度。還有一個理論上的風險和一些證據表明暴露於高海拔地區可能會干擾出生後的正常呼吸適應（Niermeyer，1997 年；Parkins 等，1998 年）。
4. 寒冷暴露
嬰兒和幼兒由於表面積與體積之比很大，因此特別容易受到寒冷的影響。在遠足期間必須被抱起的孩子不會通過肌肉活動產生熱量，並且有體溫過低的風險。足夠的衣服對於防止痛苦、體溫過低和凍傷至關重要。委員會了解到一些四肢凍傷的案例，包括那些需要截肢的案例（未發表的意見，S. Kriemler；未發表的意見，JA Litch）。
5. 陽光照射
高海拔地區雪和較薄的大氣層的反射使太陽紫外線輻射灼傷的風險比海平面高。如果暴露在過多的陽光下，兒童比成人更容易被灼傷。需要適當的防曬霜（UVA 和 B，SPF 30 美元，在日曬前塗抹）、帽子和長袖以及護目鏡，以防止曬傷或雪盲。
6. 帶孩子在高海拔環境中旅行時需要考慮的其他因素 帶孩子旅行對父母和孩子來說都是非常有益的。對於很多帶著孩子上學的家長來說山上，這次旅行是一個遠離日常活動的放鬆機會。但是，應考慮許多因素，這些因素可能會改善兒童和父母對此類旅行的享受（Berghold 和 Moravec，1994 年）。
1.無聊。幼兒的注意力通常很短，並且在相對較短的距離旅行後很容易感到無聊。應謹慎選擇刺激性的行程。
2.身體能力。已經估計了幼兒（在海平面）可能行走的距離（Gentile 和 Kennedy，1991），但這些估計只能用作可以針對每個兒童進行調整的指導方針。應該強調的是，孩子們應該只走他們想要走的路。
3. 食物。一些年幼的孩子可能對環境變化的適應能力很差，拒絕不熟悉的食物。在可能的情況下，在高海拔旅行之前嘗試食物是有幫助的。確保充足的食物和液體攝入很重要。
4. 衛生。在偏遠的徒步旅行中，對於試圖為孩子保持適當衛生的父母來說，帶著年幼的嬰兒旅行可能會特別緊張。
5. 並發疾病。腸胃炎在兒童旅行者中可能並不比在成人中更常見。兒童更容易出現嚴重的、危及生命的胃腸炎脫水，因此每個醫療包都應包含製作安全口服補液溶液的用品。
7. 已有疾病的兒童患有某些潛在慢性疾病的兒童患慢性病惡化或與海拔直接相關的疾病（如 HAPE）的風險可能會增加。幾乎沒有數據可用於確定特定疾病的風險，例如囊性纖維化或早產兒慢性肺病（支氣管肺發育不良）。然而，通過首先了解與高原有關的疾病發展的已知風險因素，然後評估每個孩子的狀況如何在缺氧環境中影響他或她的心肺生理，就有可能確定發展為高原相關疾病的相對風險。高海拔並發症。例如，兩者都相對缺乏增加分鐘高原通氣和肺血管過度灌注，例如在沒有肺動脈的個體中看到的，是發生 HAPE 的危險因素（Matsuzawa 等，1989；Selland 等，1993；Sebbane 等，1997） . 因此，合乎邏輯地認為，先天性心臟缺陷導致肺血管床過度灌注的兒童，例如心房和室間隔缺損、單側肺動脈缺如和動脈導管未閉，會增加發展的風險。與高原有關的疾病，如 HAPE。同樣，患有繼發於早產或囊性纖維化的嚴重肺部疾病且海平面 PaCO2 水平升高的兒童在受到海拔高度壓力時可能無法增加他們的每分鐘通氣量，因此有在海拔高度生病的風險。患有唐氏綜合症的兒童發生阻塞性呼吸暫停和換氣不足以及導致肺血流量增加的先天性心臟缺陷的發生率很高。
患有非心肺疾病的兒童在高海拔地區患病的風險也可能增加，這取決於疾病對高海拔壓力的反應。例如，一名繼發於腎上腺生殖器綜合徵的皮質醇缺乏症兒童在中等海拔地區發展為 HAPE，兩名最近完成化療的癌症兒童也是如此（未發表的觀察，AG Durmowicz）。不再接受藥物治療的兒童可能會在低至 2700 m 的地方出現新發或複發性癲癇發作（未發表的觀察，PH Hackett）。此外，患有鐮狀細胞性貧血的兒童在高海拔地區發生鐮狀細胞危象的風險似乎更高（Mahony 和 Githens，1979 年）。
最重要的是，如果父母決定帶著患有慢性疾病的孩子到高海拔地區旅行，則必須制定特殊計劃以確保充足的物資和緊急疏散。這可能意味著限制前往更發達的海拔目的地的旅行，而不是孤立的偏遠地區旅行。
8. 關於帶孩子爬山的特殊注意事項的聲明
1 沒有關於孩子爬山的絕對安全高度的數據。
2. 海拔2500米以上，尤其是2500米以上的睡眠，有患急性高原病的風險。
3. 並發疾病可能會增加患高原病的風險。
4. 長期（數週）暴露於高原缺氧對整體生長以及大腦和心肺發育的影響尚不清楚。
8.1 旅行地點。前往工業化國家的山區和滑雪勝地的高海拔地區可以輕鬆快速地獲得醫療服務，應與在偏遠山區和無法獲得高水平醫療技術的地區進行遠程旅行不同。
1. 工業化國家的山地旅遊景點和滑雪場大多位於3000米以下，大部分遊客會在3000米以下睡覺。
在這個海拔高度，急性高山病很常見，嚴重高山病的風險可能很小。一旦被識別，在大多數情況下，可以通過氧氣和/或下降來有效控制高原病。在旅遊活動（乘坐纜車、山路旅行和滑雪旅行）期間上升到海拔高度高於度假村位置，大約 4000 m，通常很短（小時）並且可能帶來最小的額外風險。步行或騎馬在 3000 米以上的長途旅行應緩慢分級和謹慎上升，以減少高原病的可能性。
2. 在無法快速獲得醫療服務的偏遠山區進行攀登時應更加謹慎。睡眠海拔等於或低於 3000 米的攀登，患嚴重高原病的風險較低；但是當發生 HAPE 或 HACE 時，管理可能比發達地區更困難。在這種情況下，較高的攀登應採用緩慢分級的攀登、休息（適應）日和仔細的應急計劃。
8.2 孩子的年齡
1. 高原病在無法報告典型的高山病症狀的兒童（3 歲）中尤其難以識別。同樣，一些 3 至 8 歲的兒童可能擅長報告症狀，但對於這個年齡段的年幼兒童和學習困難的兒童，他們在表達急性高原病症狀的經歷方面表現不佳，則需要格外小心。年齡較大的兒童（0.8 歲）通常已達到報告這些症狀所需的發育水平。
2. 很多沒有語言的孩子到北美山脈3000米的度假村旅行沒有並發症，但更高的攀登和偏遠地區的攀登需要格外小心。
3. 對於出生後最初幾周和幾個月的嬰兒，可能存在一些額外的理論擔憂，即暴露於 2500m 以上超過幾個小時可能會影響正常的呼吸模式（Parkins 等，1998）。
8.3 海拔高度暴露的長度
1. 3000 m 以上的長時間（0.1 天）或需要在 3000 m 以上的睡眠會增加急性高山病的風險，應謹慎進行緩慢梯度上升、內置休息日和應急計劃.
2. 如果孩子因父母的職業而在海拔 2500 米以上旅行並且預計將在高海拔地區長期居住，則應按照第 1.4 節所述進行緩慢的分級上升。對於計劃永久居住在高海拔地區的嬰兒（1 歲），由於 3000 m 以上的 SIMS 風險很小，一些權威機構建議將上升到高海拔地區推遲到一歲以後。如果要避免父母分離，這通常是不切實際的。因此，在爬升前仔細體格檢查和初步適應高海拔後，應密切跟踪嬰兒的生長百分位；脈搏血氧飽和度可能有用，尤其是在睡眠期間，應定期監測心電圖以了解右心室肥厚的發展。
9. 結論
如果準備充分，帶孩子的野外旅行對父母和照顧者來說是一種有益的體驗。上升到海拔為這種荒野旅行增加了額外的維度，必須仔細考慮。不幸的是，直接指導的數據很少，但考慮到一些兒科研究和成人數據的推斷，為安全實踐提供了一個框架。這裡描述的共識觀點提供了保守的建議，應該對需要帶孩子爬高海拔的醫生有幫助。
INTRODUCTION
EACH YEAR MANY THOUSANDS of lowland children travel to high altitude uneventfully. The majority of these pediatric ascents involve trips to mountain resorts, especially in North America and Europe, and a smaller proportion involve journeys to remote highland areas in nonindustrialized nations. In addition, an increasing number of children are moving to reside with their families at high altitude as a result of parental occupation. Although altitude travel is without incident for most, some of these children develop symptoms that may be
attributed to altitude exposure, but there has been little documentation in the medical or scientific literature. Here we outline cases where available. This consensus statement is concerned with the incidence, prevention, recognition, and treatment of serious altitude illness in the pediatric population. Unfortunately, the particular risks of exposure of children to high altitude have been little studied and much of the advice
must necessarily be extrapolated from adult data with due consideration of the influence of growth and development (Berghold, 2000).
The aim of this statement is to offer information for clinicians providing advice concerning altitude travel in the pediatric population. Through better education, parents can make informed decisions regarding travel ith
their children and can be empowered to detect altitude illness, should it occur.
1994年, 看名字應該是大陸的研究, 西藏海拔 4550, 收入 465位小孩及 5335 位成人, AMS機率 34%, 跟大人 38.2% 差不多, 小兒 HAPE 1.5%, 跟大人 1.27% 也差不多.
科羅拉多的數據, 海拔 2835公尺, 3488 公尺, 3109公尺, 海拔比西藏低很多, 所以成人與小兒都沒有罹患HAPE的案例
上面這張圖太大, 將HAPE的部分裁剪下來, 由數據可以看到, 發生HAPE的兒童案例不多, 有一例是西藏的報告
美國的報告數量比較多, 我猜這之間差異可能不是發生機率, 而是兩地的醫療水準與學術風氣不同
1.1.1. The incidence of AMS in children seems to be the same as that observed in adults (see Table 1; and Theis et al., 1993; Wu, 1994; Yaron et al., 1998; Yaron et al., 2000).
1.1.2. The nature and incidence of HAPE may differ between children resident at low altitude who travel to high altitude and those resident at high altitude who return from travels near sea level. Lowland children probably have no increased risk of HAPE compared to adults.
Children resident at high altitude are more likely than adults to develop reentry HAPE (Marticorena et al., 1964; Menon, 1965; Scoggin et al., 1977; Hultgren and Marticorena, 1978; Fasules et al., 1985); these studies involved high altitude residents reascending to altitude, rather than low altitude residents journeying to high altitude. The incidence of HAPE in children traveling on the Tibetan plateau was also found similar to adults among the same group (see Table 1; and Wu, 1994). However, intercurrent viral infections may predispose to HAPE (Durmowicz et al., 1997), and such infections are statistically more frequent among young children. Members of the consensus committee report experience of individual cases of HAPE in children.
1.1.3. There is no published information about the incidence of HACE in children and no case reports in the literature.
1.2 Risk factors for acute altitude illness in children. Very little information is available that outlines risk factors for altitude illness specifically in children. Table 3 contains possible risk factors for altitude illness inferred from a few pediatric and some adult studies. 1.3 Symptoms and signs of acute altitude illness
in children. At all ages (children and adults) the symptoms of altitude illness are nonspecific and can be confused with unrelated variables, such as intercurrent illness, dietary indiscretion, intoxication, or psychological factors associated with remote travel (Berghold and Schaffert, 1999). However, when ascending with children, it is wise to assume that such symptoms are altitude related and to take appropriate action, in addition to considering treatment for other possible causes.
1. In older children (.8 years), it is assumed that altitude illness will present in much the same way as it does in adults.
2. Under 3 years of age, travel to any new environment may result in alterations of sleep, appetite, activity, and mood. Differentiating behavioral changes caused by travel alone from changes caused by altitude illness can be difficult. Because of variability in the developmental level of perception and expression in young
children, they are not reliable reporters of symptoms of altitude illness even when they can talk.
Symptoms may appear as nonspecific behavioral changes, rather than specific complaints of headache or nausea. The typical symptoms of acute mountain sickness in very young children include increased fussiness, decreased appetite and possibly vomiting, decreased playfulness, and difficulty sleeping. These symptoms usually begin 4 to 12 hours after ascent to altitude. A modification of the Lake Louise score has been
developed that assesses the nonspecific symptoms in very young children and may prove useful in the evaluation of preverbal children; see Appendix B (Yaron et al., 1998). However, at present this score has not been evaluated for routine use by parents or physicians in making decisions about the management of children at high altitude. The score has been validated as having high interobserver agreement when
used by parents, and it may be helpful in educating parents about the symptoms of AMS (Yaron et al., 2000).
3. Some older children, particularly those in the age range from 3 to 8 years, and children with learning or communication difficulties may also be poor at describing their symptoms, making altitude illness difficult to recognize.
1.4 Prevention of acute altitude illness in children. There are no studies concerning the prevention of altitude illness in children; however, we assume that prevention principles in adults are also appropriate for children.
1.4.1. Graded ascent. Slow graded ascent, allowing time for acclimatization, is helpful. Anascent rate of 300 m per day above 2500 m and a rest day every 1000 m has been recommended, but it is not clear whether a more or less cautious recommendation is more appropriate for children. There are few data on how well children acclimatize to altitude in comparison to adults. Children were found to acclimatize at least as well if not better than adults in one report that recorded the change in heart rate and arterial oxygen saturation of
children 7 to 9 years of age and their adult parents during a slow graded ascent (Tuggy et al., 2000).
1.4.2. Drug prophylaxis to aid acclimatization in childhood usually should be avoided, as slower ascent achieves the same effect in most cases and minimizes the unnecessary use of drugs in childhood. In rare cases, when a rapid ascent is unavoidable, use of acetazolamide to aid acclimatization might be warranted in a child. Children with known previous susceptibility to AMS may benefit from prophylaxis to aid in acclimatization. Side effects do occur with acetazolamide, such as paresthesiae, skin rashes, and possible dehydration; thus use should not be encouraged. Sulfa allergy is a contraindication to acetazolamide use.
1.4.3. Education. Children and their carers should be acquainted with the symptoms of altitude illness and its management prior to altitude travel (above 2500 m). Parents should also know their children’s reactions during travel, irrespective of altitude, to be capable of differentiating high altitude illness from simple
travel symptoms.
1.4.4. Emergency plan. An emergency contingency plan should be made by all groups traveling to a remote altitude location prior to travel so as to ensure evacuation of a sick member of the party if necessary. Part of the emergency plan should include provision of communications to facilitate evacuation. If a child is traveling to altitude, descent or access to oxygen should be possible immediately (within hours). Altitude sojourns when descent takes days or requires further ascent, prior to descent, should be avoided.
1.4.5. Group travel. School expeditions are a popular educational experience for older children. It is essential that organizations planning school group expeditions to (sleeping) altitudes above 2500 m plan an itinerary that allows graded ascent, rest days, easy descent, and a flexible itinerary in case of illness. Preexpedition p5. Medical and evacuation insurance (applies to all travelers).
1.5 Treatment of acute altitude illness in children. There are no studies of treatment of acute altitude illness in children. However, it seems appropriate to follow adult treatment algorithms with appropriate pediatric drug dosages as outlined below in Table 4. It may be prudent to be more cautious in managing children with acute mountain sickness and descend earlier after the onset of symptoms than would be the case for an adult, because the natural history of AMS in childhood is not well characterized. Descent, when possible, should involve minimal exertion, which might exacerbate symptoms, and the child should be carried where practical during descent.
2. Symptomatic high altitude pulmonary hypertension
Symptomatic high altitude pulmonary hypertension (SHAPH) includes acute exacerbations of pulmonary hypertension as well as the syndrome of subacute infantile mountain sickness (SIMS) or high altitude heart disease.
Acute increases in pulmonary artery pressure have been observed in infants living or traveling to high altitude in association with intercurrent viral infections (Susan Niermeyer, unpublished observation). Treatment focuses on oxygen administration and descent. The subacute form of SHAPH occurs almost exclusively in infants (under 1 year of age) of lowaltitude ancestry who are continuously exposed to altitudes over 3000 m for more than 1 month (Wu and Liu, 1955; Khoury and Hawes, 1963; Sui et al., 1988; Wu, 1994). There may be ethnic differences in the risk of SHAPH. Incidence was 1% among Chinese infants at
3050 to 5188 m (Wu, 1994). In this condition, infants develop hypoxic pulmonary hypertension and consequent right ventricular cardiac failure. The presentation begins with poor feeding, lethargy, and sweating. Later, signs of heart failure such as dyspnea, cyanosis, cough, irritability, insomnia, hepatomegaly, edema, and oliguria may become apparent. Management is different from acute mountain sicknesslanning should include the following:
1. Assessment of past medical history for each child.
2. Education of parents, staff, and children about altitude illness and other expedition health hazards.
3. Wilderness first aid training for staff members and preparation of an appropriate first aid kit.
4. Emergency and evacuation planning, including means of communication in an emergency.
5. Medical and evacuation insurance (applies
to all travelers).
1.5 Treatment of acute altitude illness in children.
There are no studies of treatment of acute altitude illness in children. However, it seems appropriate to follow adult treatment algorithms
with appropriate pediatric drug dosages as
outlined below in Table 4.
It may be prudent to be more cautious in
managing children with acute mountain sickness and descend earlier after the onset of
symptoms than would be the case for an adult,
because the natural history of AMS in childhood is not well characterized. Descent, when
possible, should involve minimal exertion,
which might exacerbate symptoms, and the
child should be carried where practical during
descent.
2. Symptomatic high altitude pulmonary
hypertension
Symptomatic high altitude pulmonary hypertension (SHAPH) includes acute exacerbations of pulmonary hypertension as well as the
syndrome of subacute infantile mountain sickness (SIMS) or high altitude heart disease.
Acute increases in pulmonary artery pressure
have been observed in infants living or traveling to high altitude in association with intercurrent viral infections (Susan Niermeyer, unpublished observation). Treatment focuses on
oxygen administration and descent. The subacute form of SHAPH occurs almost exclusively in infants (under 1 year of age) of lowaltitude ancestry who are continuously
exposed to altitudes over 3000 m for more than
1 month (Wu and Liu, 1955; Khoury and
Hawes, 1963; Sui et al., 1988; Wu, 1994). There
may be ethnic differences in the risk of SHAPH.
Incidence was 1% among Chinese infants at
3050 to 5188 m (Wu, 1994). In this condition,
infants develop hypoxic pulmonary hypertension and consequent right ventricular cardiac
failure. The presentation begins with poor feeding, lethargy, and sweating. Later, signs of
heart failure such as dyspnea, cyanosis, cough,
irritability, insomnia, hepatomegaly, edema,
and oliguria may become apparent. Management is different from acute mountain sickness and is directed at control of congestive cardiac failure and reversal of pulmonary hypertension.
Treatment consists of administration of oxygen, pharmacologic diuresis, and urgent descent.
3. Sudden infant death syndrome (SIDS)
It is unclear whether exposure to high altitude invokes an increased risk of SIDS as there are conflicting reports (Barkin et al., 1981; Getts and Hill, 1982; Kohlendorfer et al., 1998). The prone sleeping position is an important cofactor at altitude as well as at sea level (Kohlendorfer et al., 1998). As at sea level, the risk of
SIDS may be reduced by always laying the infant to sleep on the back and avoiding passive exposure to tobacco smoke (Wisborg et al., 2000). The possibility of an association warrants careful consideration of an ascent to altitude with a young (, 1 year old) infant. There is also a theoretical risk and some evidence that
exposure to altitude may interfere with the normal respiratory adaptation that occurs following birth (Niermeyer, 1997; Parkins et al., 1998).
4. Cold exposure
Infants and small children are particularly vulnerable to the effects of cold because of their large surface area to volume ratio. The child who has to be carried during a hike is not generating heat through muscle activity and is at risk of hypothermia. Adequate clothing is essential to prevent misery, hypothermia, and frostbite. The committee is aware of a number of cases of frostbite of extremities, including those necessitating amputations (unpublished observations, S. Kriemler; unpublished observations, J.A. Litch).
5. Sun exposure
Reflection from snow and a thinner atmospheric layer at high altitude make the risk ofsolar ultraviolet radiation burns more likely than at sea level. Children are more likely to burn than adults if exposed to excess sun. Appropriate sun-block creams (UVA and B, SPF $ 30, applied before sun exposure), hats and
longsleeves, and goggles are required to prevent sunburn or snowblindness.
6. Other factors to consider when traveling in the altitude environment with children Traveling with children can be very rewarding for both parents and children alike. For many parents who carry their children into the
mountains, the trip is an opportunity to relax away from their normal daily activities. However, a number of factors should be considered that may improve the enjoyment of such travel for the children and parents (Berghold and Moravec, 1994).
1. Boredom. Young children typically have a short attention span and will easily become bored after traveling relatively short distances. A stimulating itinerary should be carefully chosen.
2. Physical ability. Estimates of distances that young children might be expected to walk (at sea level) have been made (Gentile and Kennedy, 1991), but these should only be used as guidelines that may be adjusted for each individual child. It should be emphasized that children should only walk as long as they want to.
3. Food. Some young children may be very poorly adaptable to changes in circumstances and refuse unfamiliar food. It is helpful to try foods out prior to altitude travel when possible. It is important to ensure an adequate food and liquid intake.
4. Hygiene. In remote treks, traveling with young infants may be particularly stressful for parents trying to maintain appropriate hygiene for their child.
5. Intercurrent illness. Gastroenteritis is probably no more common among child travelers than among adults. Children are more prone to develop severe, life-threatening dehydration with gastroenteritis, and supplies to make a safe oral rehydration solution should be part of every medical kit.
7. Children with preexisting illness
Children with certain underlying chronic medical conditions may be at increased risk of developing either an exacerbation of their chronic illness or an illness directly related to altitude, such as HAPE. Few to no data exist for determining the risk for specific medical conditions such as cystic fibrosis or chronic lung disease of prematurity (bronchopulmonary dysplasia). However, by first possessing a knowledge of known risk factors for the development of altitude-related illnesses and then assessing how each individual child’s condition may affect his or her cardiopulmonary physiology in a hypoxic environment, it may be possible to determine the relative risk of developing complications at altitude. For instance, both a relative lack of increased minute
ventilation at altitude and pulmonary vascular overperfusion, such as is seen in individuals who lack a pulmonary artery, are risk factors for the development of HAPE (Matsuzawa et al., 1989; Selland et al., 1993; Sebbane et al., 1997).
Therefore, it is logical to believe that children with congenital heart defects resulting in overperfusion of the pulmonary vascular bed, such as atrial and ventricular septal defects, unilateral absence of a pulmonary artery, and patent ductus arteriosus, would be at increased risk for the development of altitude-related illnesses like HAPE. Similarly, children who have significant lung disease secondary to premature birth or cystic fibrosis and have elevated PaCO2 levels at sea level may not be able to increase their minute ventilation when stressed by altitude and thus be at risk for illness at altitude. Children with Down syndrome have a high incidence of both obstructive apnea and hypoventilation, as well as congenital heart defects resulting in increased pulmonary blood flow. Perhaps these physiologic abnormalities contributed to the development of HAPE in children with Down syndrome at relatively low altitudes (Durmowicz, Pediatrics 2001, in press).
Children with noncardiopulmonary disorders may also be at increased risk for the development of illness at altitude depending on how the disorder responds to the stresses of al-titude. For instance, a child with cortisol deficiency secondary to adrenogenital syndrome developed HAPE at moderate altitude, as did two children with cancer who had recently finished chemotherapy (unpublished observations, A.G. Durmowicz). New onset or recurrent seizures in children who are no longer on medication may occur at as low as 2700 m (unpublished observation, P.H. Hackett). In addition, children with sickle cell anemia appear to be at increased risk for sickling crises at altitude (Mahony and Githens, 1979).
Above all, if parents decide to travel to altitude with children with chronic medical conditions, special planning to ensure adequate supplies and for expedient evacuation is essential. This likely means limiting travels to
more developed altitude destinations, rather than isolated backcountry trips.
8. Statement on special considerations for ascent to altitude with children
1 There are no data about safe absolute altitudes for ascent in children.
2. The risk of acute altitude illness is for ascents above about 2500 m, particularly sleeping above 2500 m.
3. Intercurrent illness might increase the risk of altitude illness.
4. Effects of longer-term (weeks) exposure to altitude hypoxia on overall growth and brain and cardiopulmonary development are unknown.
8.1 Location of travel. Travel to high altitude in mountain and ski resorts in industrialized countries with easy and rapid access to medical care should be considered differently from remote travel in isolated mountain ranges and areas without access to a high level of medical sophistication.
1. Most mountain tourist sites and ski resorts in industrialized countries are located at or below about 3000 m, and a majority of travelers to these sites will sleep at about 3000 m or less.
Acute mountain sickness is common at this altitude, and there is probably a small risk of serious altitude illness. Once recognized, altitude illness is effectively managed with oxygenand/or descent in most cases. Ascents during tourist activities (cable car rides, travel on mountain roads, and ski trips) to altitudes
higher than the resort location, about 4000 m, are usually brief (hours) and probably carry minimal additional risk. Longer trips above 3000 m on foot or horseback should be undertaken with slow graded and cautious ascent to reduce the possibility of altitude illness.
2. Ascents made in remote mountain locations without rapid access to medical care should be undertaken with greater caution. Ascents with sleeping altitudes at or below 3000 m carry a low risk of serious altitude illness; but when HAPE or HACE occurs, management can be more difficult than in developed areas.
Higher ascents in this context should be undertaken with slow-graded ascent, rest (acclimatization) days, and careful emergency planning.
8.2 Age of the child
1. Altitude illness is especially difficult to recognize in preverbal children (,3 years), who cannot report classic symptoms of mountain sickness. Similarly, some children from 3 to 8 years may be good at reporting symptoms, but extra caution is required for the younger children in this age range and for children with
learning difficulties who will be poor at expressing their experience of symptoms of acute altitude illness. Older children (.8 years) have usually reached the developmental level necessary to report these symptoms.
2. Many preverbal children travel to resorts at 3000 m in North American mountain ranges without complications, but extra caution is required for higher ascents and for ascents in remote areas.
3. For infants in the first few weeks and months of life, there may be some additional theoretical concerns that exposure to over 2500m for more than a few hours may affect normal respiratory patterns (Parkins et al., 1998).
8.3 Length of altitude exposure
1. Ascents higher than 3000 m that are prolonged (.1 day) or require sleeping above 3000m increase the risk of acute mountain sicknessand should be undertaken cautiously with slow graded ascent, built-in rest days, and emergency planning.
2. In circumstances where the child is traveling above 2500-m altitude because of parental occupation and prolonged altitude residence is anticipated, slow graded ascent as described in Section 1.4 should be undertaken. For infants (,1 year) planning to reside permanently at altitude, some authorities recommend delaying ascent to altitude until beyond the first year of life because of the slight risk of SIMS above 3000 m. This is usually impractical if parental separation is to be avoided. Therefore, after a careful physical exam before ascent and initial acclimatization to high altitude, the infant should be followed closely with respect to
growth percentiles; pulse oximetry may be useful, especially during sleep, and the ECG should be monitored periodically for the development of right ventricular hypertrophy.
9. Conclusion
Wilderness travel with children is a rewarding experience for parents and carers when undertaken with adequate preparation. Ascent to altitude adds an extra dimension to such wilderness travel and must be carefully considered. Unfortunately, there are few data to direct guidance, but consideration of a few pediatric studies and extrapolation from adult data provide a framework for safe practice. The consensus view described here provides conservative recommendations that should be helpful for physicians who are required to offer advice about ascent to high altitude with children.
第二篇參考資料 What is high-altitude pulmonary edema in children?(連結在此)
這一篇論文是美國科羅拉多兒童醫院發表的. 剛稍微搜尋一下該醫院的背景, 裡面的醫師看起來都很厲害
Gwendolyn Kerby, MD Pulmonology - Pediatric
Oren Kupfer, MD Pulmonology - Pediatric, Pediatrics
Steve Abman, MD Pulmonology - Pediatric, Pediatrics
Stephen Hawkins, MD Pulmonology - Pediatric, Pediatrics, Sleep Medicine
什麼是小兒高海拔肺水腫?
肺水腫患者, 肺部會充斥液體, 通常發生在高海拔, 但少數在中海拔發病
患者會呼吸困難, 一開始乾咳, 隨病情嚴重會出現痰液, 也可能會咳血, 患者氧氣濃度通常很低.
What is high-altitude pulmonary edema in children?
High-altitude pulmonary edema (HAPE) is a condition in which a child's lungs fill with fluid at high elevation (or rarely, moderate elevation). Children complain of trouble breathing, and they have a cough that starts out dry and becomes wet. They may also cough up blood. Their oxygen levels are also low.
在這裡直接將HAPE分三種(uptodate說兩種, 不含小兒高海拔肺水腫)
There are three types of HAPE:
上面兩種, "典型HAPE"與"再返HAPE"(不知道怎麼翻譯比較好), 在uptodate 上面有介紹,
Classic HAPE occurs in children who live at a lower elevation and develop symptoms after traveling to high elevation.
Re-entry HAPE occurs in children who live at high elevation, travel to low elevation and then develop symptoms after they return home.
High-altitude resident pulmonary edema (HARPE) occurs in children who live at high elevation and develop symptoms without a change in elevation.
HAPE can happen more than once in many children. At Children's Hospital Colorado, we have vast experience helping children who are affected by altitude and can provide helpful advice on preventing it in the future.
What causes high-altitude pulmonary edema?
There is less oxygen at high altitude, which causes blood vessels in the lungs to constrict or tighten. This leads to fluid leaking into the lungs.
Who gets high-altitude pulmonary edema?
HAPE appears to run in some families and is more common in males before puberty. Children with certain underlying heart or lung conditions, such as obstructive sleep apnea, pulmonary hypertension, atrial septal defect and ventricular septal defect, are more likely to develop HAPE. Respiratory infections often trigger HAPE in children.
What are the signs and symptoms of high-altitude pulmonary edema?
Children may have one or more of the following signs and symptoms:
Cough that starts out dry and becomes wet
Coughing up blood
Shortness of breath
Blue or purple lips
What tests are used to diagnose high-altitude pulmonary edema?
Typically, we do a chest X-ray to confirm pulmonary edema and to evaluate for other lung diseases. A pediatric chest X-ray is a test that provides a picture of a child's heart, lungs and bones in the chest. Less commonly, a chest ultrasound may be done at some of our locations. A chest ultrasound uses sound waves to produce pictures of the inside of the chest.
How do we diagnose high-altitude pulmonary edema in children?
Our providers diagnose a child with HAPE when they have signs and symptoms of pulmonary edema and they have had a recent change to high elevation, or they live at a high elevation and then develop symptoms.
How is high-altitude pulmonary edema treated?
We treat HAPE by giving your child supplemental oxygen and/or moving them to a lower elevation. Sometimes medicines can help lower blood pressure in the blood vessels of the lungs. It is also important that we evaluate your child for any underlying heart disease. Our experts in high-altitude pulmonary edema can help determine if your child needs any additional testing or treatments.
Prevention of HAPE includes a slow ascent to high elevation, using oxygen during sleep at home and/or medicines.
Why choose Children's Colorado for treatment of high-altitude pulmonary edema?
Our Breathing Institute and Heart Institute are among the best at what they do and have multiple experts who can treat high-altitude pulmonary edema. We have pediatric pulmonologists and pediatric cardiologists who have specialized expertise in treating high-altitude pulmonary edema. These pediatric specialists often partner together to take care of children with HAPE, ensuring they receive the most complete care. We also conduct ongoing research to better understand HAPE.
