コロナウイルス病2019(COVID-19)の状況 by CDC

コロナウイルス病2019(COVID-19)の状況

私のコメント:2020年2月23日付の米国CDCの「コロナウイルス病2019(COVID-19)の状況の概要」https://www.cdc.govを引用して、最新の情報が提供されているので紹介します。

中国の湖北省武漢市で最初に検出された新規(新しい)コロナウイルスによる呼吸器疾患の発生に対応していますが、現在では米国を含む32の場所で検出されています。このウイルスは「SARS-CoV-2」と呼ばれ、それが引き起こす疾病を「コロナウイルス病2019」(「COVID-19」と略されます)と呼んでいます。

2020年1月30日に、WHOの国際保健規制緊急委員会は、発生を「国際的な懸念の公衆衛生上の緊急事態」(PHEIC)と宣言しました。2020年2月23日現在、パンデミックには至っていません。

MERS-CoVとSARS-CoVはどちらも、人々に重篤な病気を引き起こすことが知られています。 COVID-19に関する完全な臨床像は理解されていません。 これまでの報告では、軽度から重度のものがあり、死に至る病気も含まれています。


2020/2/23

無症候性キャリアがCOVID-19の伝播に関係している?

Yan Baiら 中国河南省人民病院の医療画像部門 JAMA Published online February 21, 2020 RESEARCH LETTER: Presumed Asymptomatic Carrier Transmission of COVID-19


中国の安養にあるCOVID-19肺炎の5人の患者の家族クラスターは、発症前に武漢の流行センターから旅行した無症候性の家族と接触していた。一連のイベントは、コロナウイルスが無症候性の保菌者によって感染した可能性が示唆された。

すべての症候性患者は、胸部CTで多発性すりガラス状陰影を有しており、C反応性タンパク質レベルが増加し(1.021.7;正常0.00.4)、リンパ球数は減少していた。

すべての患者は胸部CT画像検査を受けた。 COVID-19核酸のリアルタイム逆転写酵素ポリメラーゼ連鎖反応(RT-PCR)テストは、鼻咽頭スワブ(Novel Coronavirus PCR蛍光診断キット、BioGerm Medical Biotechnology)を使用して実施された。


2020/2/21

SARSとMERSと医療者の感染

SARSは、2002年11月16日、中国広東省で普通とは異なるタイプの肺炎症例が報告されたことをきっかけに、流行が拡大。2003年7月5日にWHOが終息宣言を出すまで東アジアを中心に32の国と地域へ拡大した。WHOに報告された発症者数は8098例、死亡数は774例で、全体の致死率は9.6%と高い。日本では感染者ゼロであった。原因はコロナウイルスであるSARS – CoVと特定された。


MERS(中東呼吸器症候群)は、2012年にアラビア半島で発生したコロナウイルス感染症で、症例の多くは院内感染、もしくは病院スタッフとその家族など濃厚接触者の周辺で起こっています。MERSは2015年と2018年に韓国でアウトブレイク(局地的、一時的な感染症の流行のこと)を起こしたが、これも中東からの帰国者が発端となった院内感染が中心だった。

ヒトコブラクダがMERSコロナウイルスを保有しており、ヒトコブラクダとの濃厚接触がヒトへの感染リスクであると考えられています。ヒト-ヒト感染の効率は高くないと考えられますが、家族間や医療機関における限定的なヒト-ヒト感染(医療関連感染)も報告されています。

今回のCOVID-19では2月7日付で米国医師会誌『JAMA』に掲載された武漢大学中南病院からの経過報告によると、同大学病院にCOVID-19で入院中の患者138人のうち、40人が医療関係者で、17人がすでに他の病気で入院していた患者でした。およそ4割が院内で感染した可能性があります。https://jamanetwork.com/journals/jama/fullarticle/2761044


 2020/2/21

SARS(重症急性呼吸器症候群)に対するWHOガイドライン

From WHO guidelines for the global surveillance of severe acute respiratory syndrome (SARS). Updated recommendations October 2004. 2002年から2003年にかけて流行したSARS(重症急性呼吸器症候群)について、WHOのガイドラインを参考にしながら、今流行中のCOVID-19と対比しながら眺めてみよう。


SARSの致死率は

2003年の流行時のカナダ、中国、香港SAR、シンガポール、ベトナム、米国のデータの分析に基づくと、SARSの致死率は0%から50%以上に及ぶと推定されています。致死率は、年齢層は影響を受け、男性であること、併存疾患の存在も死亡率の上昇に関連しています。


高齢者、小児と妊娠中のSARS

無熱性疾患や細菌性敗血症/肺炎の併発などの非典型的な症状は、高齢者によく見られれます。

根底にある慢性的な疾患と医療施設のより頻繁な使用の両方が、当初考えられなかった院内感染イベントに寄与するようです。

小児集団では、SARSの発生頻度は低く、軽度の病気として観察されます。妊娠中のSARS症例では、妊娠初期の胎児死亡と妊娠後期の母親の死亡率の増加を示唆する報告があります。


SARSの疫学と生態学

2003年3月以降、この症候群について多くのことがわかってきましたが、SARS-CoV感染の疫学とこの疾患の生態学に関する知識は不完全なままです。SARS-CoVの天然の溜池は特定されていませんが、中国南部では、多くの野生生物種-ヒマラヤマスクパームシベット、フェレットアナグマ、およびタヌキが、関連するコロナウイルスによる感染の証拠があります。

香港のアモイガーデンズアパートブロックに住む飼い猫も、SARS-CoVに感染していたことが判明しました。最近では、フェレットと飼い猫が実験的にSARS-CoVに感染すること、以前飼われていた未感染の動物もウイルスに効率的に感染することがわかりました。これらの発見は、この病原体の溜池がさまざまな動物種に関係していることを示しています。

ヤシジャコウネコは、動物から人間への感染に最もよく関連した野生生物種です。ただし、ジャコウネコがSARSのようなコロナウイルスの自然の溜池であるかどうかはまだ証明されていません。


今、最も可能性の高い感染源は実験室!

2003年7月以降、SARSが再発する機会が4回ありました。これらのインシデントのうち3つは、実験室のバイオセーフティ違反に起因し、SARSの発症をもたらしました(シンガポール、台北、北京)。

最も最近の事件は、実験室労働者の家族と病院での接触に関与した3世代間の伝染で、9人の症例の集団であり、そのうちの1人は死亡しました。

WHOは、各国に対して、SARS-CoVの培養物を扱ったり、SARS-CoVで実際にまたは潜在的に汚染された臨床検体を保管しているすべての研究所の実験室が、正しいバイオセーフティ手順に従うこと、並びに実験室労働者の病気の適切な監視と調査を実施することを勧告しています。


スーパー・スプレッダーとは

SRASでは、多くの場合、患者一人から1~3人程度への小規模な感染伝播が起こっていたが、中に強い感染力をもつ人、スーパー・スプレッダーの存在が、SARSの拡大を促したとも言われている。

一人の患者から30人以上に感染を広げた事例があった。

このスーパースプレッダーは、糖尿病などの基礎疾患をもち、免疫力の低下のために体内でのウイルスの増殖を抑えきれず、長期間にわたって大量のウイルスを排出し続けていると考えられている。

広東省から香港にSARS コロナウイルスを持ち込んだ第一例の医師が、このスーパー・スプレッダーであった可能性が高いとされている。このスーパー・スプレッダーが香港の国際的なホテルに宿泊して、大量のウイルスを排出し、多くの感染者が発生し、SARS コロナウイルスが世界各地に拡散していく原因になった。

岡田春江著:知っておきたい感染症―21世紀型パンデミックに備える(ちくま新書)から


世界で4千万人が死亡したスペインかぜ

1918 年から1920年に流行したスペインかぜは、全世界で患者数約6億人、死亡数は2,000万から4,000万人に上ったとされています。スペインかぜがヒトにおけるA型インフルエンザウイルスによる流行であることが判明したのは、後になってからです。

日本では1918年の11月に全国的に最初の流行があり、3年間で人口の約半数の2,380万人がかかり、約39万人が死亡したと報告されています。府県別死亡率も載っており、よく見ると、そのピークが発生当初は関西が高いですが、終わりの頃には関東が高くなっています。今回の状況と逆です。(日本におけるスペイン風邪の精密分析、東京健安研セ年報、2005年)

1918年に大流行したスペインかぜ(インフルエンザ)で犠牲者が主に若い健康な成人でした。その理由として、1889年以降に生まれた人々は、1918年に流行したインフルエンザと似た型のウイルスを経験しており、ある程度の免疫があったからだという説があります。(https://natgeo.nikkeibp.co.jp/nng/article/news/14/9190/


2020/2/16

これまでのインフルエンザ・パンデミック

A型インフルエンザウイルスは元来鳥類を中心に保有されていたウイルスです。少しずつその遺伝子が変化し,1957年のアジアインフルエンザと1968年流行の香港型インフルエンザと合わせて3回の大規模のパンデミックが20世紀には起きたことがわかっています。

最近では、2009年にはトリ由来のA型インフルエンザウイルス(H1N1)による流行を経験しています。2018/19年の新型インフルエンザは豚由来のH1N1型インフルエンザによるパンデミックです。

同じH1N1型インフルエンザでも、動物の種類によって宿しているウイルスのタイプが異なり、重症度も異なるようです。幸い、この2回のウイルスでは若年者や小児で重症化する症例は季節性インフルエンザと変わりませんでした。


2020/2/16

超過死亡という新しい概念とは

国立感染症研究所のIASR最新号に、超過死亡の概念が記されている。

インフルエンザの社会的インパクトを評価するにあたって, 重症化の指標として死亡者数が重要である。世界保健機関(WHO)はインフルエンザの流行によってもたらされた死亡の増加を, インフルエンザの「社会的インパクト」の指標とする「超過死亡(excess death, excess mortality)」の概念を提唱している。これは直接的, 間接的を問わず, インフルエンザ流行がなければ回避できたであろう死亡者数を意味する。

これによると1998/99シーズンで超過死亡者数は35,000人を超えているが、2004/05シーズン以降1万人を超えることはなかった。2018/19シーズンは3,276人であり, 直近5シーズンでは3番目と特別に大きな超過死亡が発生したわけではなかった。

IASR Vol. 41, No.2 (No. 480) February 2020


2020/2/16

 

いのちを考える

若葉2020.2.

昨年暮れのある日、体調を崩し、外出も控えていた。所在無げにしていたところ、うっすらと埃を被った本棚に、「般若心経」(新井満著)を見つけた。その横には、瀬戸内寂聴さんの「般若心経」も並んで置かれていた。
いずれも2005年頃の発行で、大学を定年退官し、こども病院にいた頃であろう。なぜこの時期にこれらの本を手にしたか定かな記憶はないが、人生の折り返し点を迎え、手にとってみたのであろう。瀬戸内寂聴さんの「般若心経」は半分ほど読んだところに栞が挟まれたままになっていた。

「般若心経」は本文266文字からなる経文であり、天台宗の開祖最澄、真言宗の開祖空海によって伝来した仏教であり、宗派を問わず詠まれている。「色即是空」、「空即是色」は大変有名な文言であるが、解ったような、解らないような話である。

新井満氏の「般若心経」
新井満氏の「般若心経」は70頁ほどの小冊子であり、一気に通読できる。『無数のいのちが寄り集って、あなたといういのちを成している』という文言に惹きつけられた。

あなたを産んでくれたのは父と母だ。
その父にも、また父と母がいて、
その母にも、また父と母がいる。
その父と母にも、さらにまた父と母がいる。
あなたから十代前までさかのぼるならば、
あなたにつながる父と母は千人以上になる。
さらに二十代前までさかのぼるならば、
父と母の数は百万人を超える。
即ち、無数のいのちが寄り集まって、
あなたという命を成しているのだ。その中の
わずか一つのいのちが欠けたとしても、
あなたといういのちは成りたたない。

お彼岸には、先祖代々の墓前で、手を合わせているが、これまで自分がこれほどまでに多数のいのちの集合体とは思ってもみなかった。この世に生を受けた私たち一人ひとりは、障害の有無にかかわらず代々引き継がれてきた唯一無二の大切な存在なのだ。

我が国には、障害者の日常生活及び社会生活を総合的に支援するための「障害者総合支援法」が平成25年4月に成立した。「地域社会における共生の実現」という言葉も盛り込まれた。

ところが、平成28年には、障害者は生きる権利がないという理由で19人の障害者を刺し殺した相模原障害者施設殺傷事件が、さらに、平成30年には、政府中央省庁の8割にあたる行政機関で、3,460人の障害者雇用が水増しされていた問題が発覚し、政府要人の障害者への不用意な発言も相次いでいる。

超格差社会にある日本では、障害者に対する差別的発言や姿勢が、以前よりも目立ってきたように思える。新型出生前診断(NIPT)もいのちの選別という大きな問題を抱えている。科学技術の進歩と人間の幸せとは何か、医師として、小児科医として考え続けたい。

令和2年2月  傘寿を迎えて

 

Child Rearing in the Age of Artificial Intelligence (AI)

Discovering the Intriguing Abilities of Babies,
Nurturing Them to be Warm-hearted Children

Hajime Nakamura, M.D.

Index

Introduction

Chapter 1   The intriguing abilities of babies

Chapter 2   Human brain development as seen from cognitive and brain science

Chapter 3   Nurturing them to be warm-hearted children

Chapter 4    Toward a society “living together” with handicapped children

Chapter 5   In the age of AI, what happens to child rearing?

Afterword

Introduction

The advancement of brain science has given us the ability to observe the structures of the human brain in minute details, as well as their functions, such that we can now think about children’s psychomotor development by linking it to the development of their brains. This has resulted in the finding that the problems of delinquencies, crimes and suicides committed by pubescent children are related to how they spend the period from infancy to school age.

The most important in child rearing is to plant the ability of trust others people in a baby’s brain. The learning of a baby is mediated by an “emotion of enjoyment” that is brought to both a mother and her child through staring at one another, smiling, and imitating facial expressions. This evolves into a sense of trust in people, turning the child into a sensitive adult.

Today, the world is about to rush into the age of artificial intelligence (AI). The deep-learning functions of an AI are based on artificial neural networks constructed by mimicking the workings of a human brain. What has been learned or thought by the AI becomes etched as memories.

The development of early AIs proceeded by modeling the process of development in human babies; now, we have reached an era in which chess and Go masters are defeated by AIs. Sometimes, an AI will exhibit capabilities that are superior to the intelligence of an adult.

Before long, an era will probably come, in which AI robots will be asked to help raise children. If they are to help raise our children, we will have to foster the AI robots to become full of “care” and “warm-heartedness”, just like Astro Boy, the child robot depicted by the cartoonist Osamu Tezuka.

But before that, it seems even more important to re-evaluate whether the child rearing we humans are performing ourselves today is appropriate.

I am dedicating this book to Mr. Kenzo Kassai, whom I admire and for whose deep love and teachings of children I am grateful.

In preparing this book, I would like to express my heartfelt thanks to Mr. Takemasa Kawashima for helping with the English version of the manuscript, Ms. Emi Nagao for creating the figures, and Mr. Koichi Kanbara for the design.

February 2020

Hajime Nakamura, M.D.

Pediatrician, Professor Emeritus of Kobe University

 

Chapter 1. The intriguing abilities of babies

  1. The fantastic learning abilities of children’s brain

Babies stare incessantly at what is happening in their surroundings. The fantastic learning abilities of babies appear to lie in this observing eye.

When babies encounter a scene that is different from what they normally see, they look as if they were mystified. When someone is behaving strangely, a baby will interpret that there may be something wrong in this person’s behavior.

Children are quite cautious towards a behavior that they have never experienced themselves; this is something that feels justified.

We humans are characterized by a longer childhood than any other animal species.

During this period, as they are always under the protection of adults, children only need to learn about their surrounding environment. The brain is constituted in such a way that what is learned during childhood becomes useful for the first time when children reach adulthood.

  1. Child rearing begins with “eye-contact”

The basis of child rearing lies in “eye-contact”.

Here, “eye-contact “does not merely mean that a set of eyes meets another set of eyes.

By staring at each other or through a smile, an “emotion of enjoyment” is communicated back-and-forth between a mother and her child, which is why we call this “eye-contact”.

It is important to nurture children in such a manner that this native faculty as humans is not lost.

If a child is raised in such a manner as to share an action with other people through “eye-contact” from infancy, the child’s communication skills as a human being can increase, and warm interpersonal relationships could be built, even after becoming an adult.

  1. A baby’s smile heals people’s mind

If you smile at a baby, even soon after birth, the baby’s facial expression will relax.

While childcare books describe that babies start smiling when they are one to two months old, the starting time is different depending on how surrounding adults are involved with the baby.

If a mother always faces her baby while smiling and talking, in response to the mother’s smile, the baby starts smiling early.

A baby will return the smile to anyone whose eyes meet the baby’s, not just to the parents.

A baby’s smile is the best form of compassion, which heals people’s mind.

  1. Babies communicate by imitating facial expressions

A baby, even soon after birth, can imitate facial expressions of other people, sticking out the tongue or opening and closing the mouth, as if they were reflected in a mirror.

It is thought that, since a baby cannot survive from the time of birth without the help of a mother, the act of imitating facial expressions was natively given in order to draw the mother’s attention.

The communication between a mother and her child through facial expressions, such as staring at one another, smiling, and imitating facial expressions, brings an “emotion of enjoyment” to both the mother and her child.

  1. The eyesight of babies develops rapidly until they are one year old

In the first month after birth, babies have discerning abilities in the dark that are largely indifferent from those of an adult’s eyes; however, in well-lit areas, they cannot clearly recognize a subject, and their interpretation appears to be based only on contours.

At three to four months after birth, the visual cortex in the cerebrum develops, such that they stare firmly at a facing person, and their facial expressions are also enriched.

At about nine months after birth, if a facing person’s gaze is turned toward a third party, a baby can track this gaze and superpose the baby’s own gaze in a “conjugate gaze”.

Further on, at beyond ten months after birth, “social referencing” becomes active, which is to glance at the facing person to seek confirmation, as in “I could do it!” or “It’s fine like this!”

A manner of interaction that is adapted to the developmental stage of the baby is important.

  1. A conversation with a baby starts with “Baby talk”

A mom speaks to her baby using her own prosody, in which her voice rises in pitch and has inflections, regardless of whether it is done consciously or not.

This is called motherese, or “Baby talk”.

The mom realized naturally that, even soon after birth, a newborn could hear well, and knew what to do so that her baby responds well.

Children who grow up while listening often to songs appear to memorize words early on. Speaking by using inflections is effective for memorization into the baby’s brain.

There is no need to hold back just because you are tone-deaf. Speak slowly to your baby with ample inflections.

  1. The bond between a mother and a child comes from the pheromones in breast milk

Babies can distinguish whether the smell of breast milk is that from their own respective mothers, or that from another person.

The human body odor is related to a difference in “pheromones”. Babies appear to distinguish the smell of breast milk between that from their respective mothers and that from another person, based on the differences in terms of pheromones in the breast milk.

The smell of breast milk is said to be helpful in relieving stress in newborns.

There is a scientific paper reporting that, when sampling blood from newborns, there was less stress when the babies smelled their respective mother’s breast milk than when they smelled another person’s breast milk.

While the sense of smell is the most primitive function among the five senses, the most effective at healing is the sense of smell.

  1. The smell of the amniotic fluid is similar to that of breast milk

Immediately after birth, a baby will attempt to climb the mother’s body to suck on her nipple.

This is because the breast milk has a smell that is shared with the amniotic fluid.

In addition to the amniotic fluid and breast milk, sweat, saliva and secretions from sebaceous glands, which are related to body odors, have a healing effect, and help in relieving stress.

In response to vanillin, which is the main ingredient of the vanilla aroma used in ice creams, babies exhibit similar responses to those shown in response to the amniotic fluid. Perhaps, vanilla ice cream is loved, not only by children, but also by adults, because it reminds them of the mother, and heals their mind.

The smell is important for maintaining human relationships.

  1. Oxytocin increases the ability to trust others

“Trust” is indispensable for establishing a smooth human relationship.

Recently, a scientific paper has been released, describing that the ingestion of oxytocin, a type of hormone, greatly improved the ability of an individual to trust other people.

Oxytocin has been known for a very long time to have uterotonic action in mothers after giving birth.

An increase of oxytocin in the maternal body after giving birth is also involved in forming an attachment between a mother and her child.

What a baby should acquire in the first year after birth is the “fundamental ability to trust people”. If a child manages to attain this fundamental sense of trust, the child will continue to develop steadily thereafter.

  1. People have an inherent ability to empathize

The ability to feel other people’s joy and pain as if they were one’s own, that is, empathy, is an ability that people possess inherently.

If someone is crying, a newborn will follow and cry, and when hearing a good mood in a voice or laughter, the baby will look happy.

A two-year-old child can even comfort a discouraged friend or parent.

Children respond very sensitively to inhumane actions and unjust behaviors.

Even middle and high school students who turn to bullying and delinquency have the ability to empathize engraved in the back of their brains.

  1. The soul of the three-year-old lasts till one hundred

There is an ancient proverb in Japan that says “the soul of the three-year-old lasts till one hundred”, meaning that the child-rearing environment until three years of age has a tremendous influence on the mental development of the child.

Such an expression is not unique to Japan, and similar proverbs exist everywhere around the world.

In English-speaking countries, “what is learned in the cradle is carried to the grave”.

In Jordan, an Islamic state, a saying in Arabic has it that “what is learned in youth is carved in stone”.

In China, “when you look at a three-year-old, you see how the child will turn out when old”.

Regardless of language, religion, and culture, the importance of the child-rearing environment until three years of age is an awareness that is shared worldwide.

Chapter 2. Human brain development as seen from cognitive brain science

  1. The weight of the Human brain and the development of neural networks

The weight of the human brain is about 400 g at birth, doubles in six months thereafter, and nearly triples at the age of three and later. It takes until after 20 years of age to become complete, weighing around 1,300 g.

The human brain exerts various functions through neural networks, in which neurons (brain nerve cells) are connected to one another through projections.

Using a device called MRI, we can observe a child’s brain and learn about the extent of development of its neural networks.

The change in the brain weight matches approximately the development of the neural networks, and this change is greatest between about six moths to about three years after birth.

Figure 1. Cerebral surface image (left) and middle section image (right) of the human brain

Figure 2. Human brain development, cerebral limbic system vs. prefrontal cortex

  1. The development of the brain reflects evolution

The cerebral cortex of humans has a layer of gray matter where nerve cells are present, and a layer of cerebral white matter where nervous fibers are gathered; in addition, a region called the cerebral limbic system exists deeper inside the cerebrum.

The cerebral limbic system is involved in the manifestation of emotions, motivation, memory and autonomic nervous activities: it is the center of life-support and instinctive behaviors.

The cerebral limbic system is one of the most ancient parts of the brain in evolutionary terms, which begins to develop early in the human brain. At puberty, it matures straight away under the strong influences from hormones.

This development of cerebral limbic system, which matures relatively early, is drawing a lot of attention given its relationship to the sensitivity and the mental development of a child in infancy, but there is still much to be learned.

  1. The development of the cerebral cortex differs from area to area

In the cerebral cortex, the layer of gray matter in the primary sensory and motor area for sensing and responding to light, sound, smell, taste, and feel, develops most quickly, and is almost complete during infancy.

The area called the prefrontal cortex exists in the anterior part of the cerebral cortex, which is responsible for thinking, such as concentration, planning, and analysis, that is, higher order brain functions. This prefrontal cortex has an inhibitory action against impulsive human behaviors.

While the prefrontal cortex begins to function at the ages of four to five, it matures only past twenty years of age.

Why are teens prone to behaving dangerously? The mismatch between the maturation period of the limbic system, which causes a teen that has reached adolescence to behave emotionally, and the maturation period of the prefrontal cortex, which causes restrained actions to be taken, may be interpreted as being the cause.

  1. The brain of an infant has plasticity

If a human neuron remains unused until the age of about three, it is removed to reduce waste in a process called “pruning”, so that frameworks are formed efficiently in the brain.

It was considered that inadequate nursing in infancy left tremendous damages to lifelong physical and mental development, which were irreparable later. However, research data that would overturn such a conventional idea were released.

An important delay in development was observed in two- to three-year-old infants who spent time in an extremely horrible environment of a Romanian orphanage in the period of Ceausescu’s regime. However, when they were moved to a British nursery and patiently educated, the children could gradually regain a normal development.

While there certainly is a critical period for child development, that is, a period most suitable for development, there is absolutely no reason to give up even if this period is over.

For the brain of an infant has plasticity.

  1. The development of emotions requires the five senses.

The development of the five senses, namely, sight, hearing, touch, smell, and taste, is essential for the development of emotions.

The critical period to acquire these is in early childhood.

Early education is not about achieving early what can be done even after reaching adulthood: it is about what can only be acquired in infancy, and the most important is to cultivate the five senses.

Languages that have been learned by the age of three can be spoken fluently, but this will become difficult after that period. In this regard, absolute pitch identification is said to be similar.

  1. The sensitive mind dwells in the limbic system

While cognitive abilities such as arithmetic, literacy, and knowledge can be taught, there are no textbooks for non-cognitive abilities, such as emotion and sensibility.

It is the people surrounding the child, who cultivate sensitivity in the mind of the child.

Words and attitudes from family members, and from friends and teachers at the nursery school, are baked as sensibilities in the limbic system deep inside the child’s brain.

We should “listen to”, “answer”, and “praise”, the questions asked by a child. In this way, the child will grow up to be a sensitive adult.

  1. Cherish the wonderful learning ability of children

Recently, teens have been immensely successful in the worlds of games such as chess and Go, and sports.

The mothers of all these young people say with one voice that there was no coercion from the parents, and that, in their early childhood, the children had an interest of their own in these activities, and independently expressed their wish to practice them.

We believe that the experience of successes through their own efforts has stimulated the limbic system in the children’s brains, increased their motivation for learning as an emotion of enjoyment, and fostered their strength to persevere tenaciously (grit) and the flexibility that allows one to handle stress (resilience).

This is likely the result of both a development of the prefrontal cortex which begins to function for the first time at the ages of four to five, and a more effective utilization of the creative exploration abilities and the flexible learning abilities that have been nurtured by the child up to that point.

This was certainly helped by the parents who provided a suitable environment for the children to learn through their own experiences, and have been watching over them.

Chapter 3. Nurturing them to be warm-hearted children

  1. Breastfeeding is wonderful

A baby held in the mother’s arms takes a mouthful of nipple and drinks the milk while staring at her face, or sometimes with slightly open eyes. This sight of happy-looking mother and child can induce happiness even in strangers around them.

You can actually feel that breastfeeding creates the bond between a mother and her child, which encompasses the mother’s love for her child, and the child’s sense of trust and security towards the mother.

Among the children that have been breast-fed until about three months after birth, the number of cases in which the breast-feeding is interrupted once the mother goes back to work is not small.

While the number of work places with a nursery room is on the rise recently, they are still very limited.  Although breastfeeding during the day is difficult, lactating in the morning and in the evening will allow the supply of breast milk to continue.

Even if you must go to work, do not give up: continue to breastfeed.

  1. “No!” is a banned word in child rearing

Even babies that do not yet understand language will retract their hands in a hurry upon hearing the prohibiting word “No!”

The babies are merely retracting their hands because they are simply afraid.

If people keep repeating “No!”, fear will be imprinted in the babies’ brain.

It is possible that, by the time these babies are grown up, they are adults who attempt to solve everything by force.

Before saying “No!”, take a breath.

  1. Don’t say “it’s not OK because these are the rules”

While “laws and regulations must be complied with”, it is not true that “solely complying with the laws and regulations is sufficient”. If a mere compliance with the laws and regulations were to be promoted, confusion and inconsistencies will arise in a society.

A country that is governed by the rule of law while being incapable of autonomy without the laws is not an ideal human society.

In the upbringing of a child, stop restraining the child high-handedly by saying “it’s not OK because these are the rules”.

Instead of saying “it’s not OK because these are the rules” regarding an action, provide an explanation, as in “it’s not OK because it annoys other people”.

You must not educate a child while thinking that “solely complying with the laws and regulations is to be right”.

  1. An angry mother is a scary mother; yet, she’s kind

Children wake up to their ego at about one-and-a-half years old, and heavily demand affection of the parents. If a child’s demand for the mother’s affection is excessive, the mother might be driven close to losing her patience, to the point of thinking “I don’t want this child anymore”.

In such a moment, the mother might use such words of rejection as “you’re not mommy’s child”.

After being extremely angry, hug your child more affectionately than usual.

Then, for the child, “mommy is scary when she’s angry, but mommy is kind. I love my mommy”.

A stronger resonance will arise between the hearts of the parent and the child.

  1. When child rearing becomes a worry, send a tweet

When tired of child rearing, a socially skilled mother does not worry alone, and talks with her friends by phone or by e-mail, to calm her feelings.

A mother who is not so good at socializing may be worrying alone, without being able to solve a small worry of child rearing.

When you are tired of child rearing, muttering loudly by yourself is fine, and posting a few lines in Twitter is also fine.

In response to your tweet, advices may come from your followers, and from people experienced in child rearing.

If you have the time, share your experience with a novice mother in trouble, through a gentle tweet, as a follower.

  1. Neglect and indifference hurt most

In Japan, where the birth rate is declining, suicide among young people is on the rise. This may be related to “child abuse” and “bullying”, which have been increasing steadily in recent years.

The number of consultation cases about child abuses brought into child guidance centers throughout Japan has exceeded 100,000, a 3-fold increase in the past 5 years. Of note among these are increases in psychological abuses and neglect.

What characterizes neglect and indifference, which leave no evidence, is that they are difficult for other people to notice. Repeated neglect and indifference are etched as injuries to the heart of a child, and their effects will carry on throughout the child’s life.

It is important for each adult to be more interested in and talk with the children around us.

  1. Gently hold back the raised hand

Abuse against children is happening repeatedly all over Japan.

Recently, there have been more and more infants brought to our Emergency Clinic for Children due to a bruise to the head.

Among the bruises to the head of an infant are those caused by physical abuse. A “severe shaking” or a “hit”, even once, will cause serious brain damages.

Things do not go readily the way the parents intend, even with their own adorable child. When things did not go the way they intended, there was a build-up of stress, and the parents found themselves raising their hands unintentionally.

If someone were there to hold back that raised hand from behind, the matter could have been handled without becoming serious.

  1. A child always praised is good at praising others

Probably no one becomes angry when praised by other people.

A person who is good at praising others will skillfully find something that another person is likely to be delighted by, and praise the other person.

If a child is continuously given goals that are difficult to achieve, there are less opportunities for the child to hear words of praise.

If you set a goal that children can reach with little effort, the children will hear the words of praise more often.

What give the child confidence are the positive feelings from the parents.

  1. Do not force your two-year-old child to obey

After two years, children awaken to their ego and enter the first rebellious phase.

Parents approach their children believing it is for the benefit of their children’s health and development. However children cannot understand what the parents are thinking. It is past three years of age that children are capable of understanding their parents’ feelings.

If you try to force your child to obey during this first rebellious phase, you risk implanting a distrust of people in the child’s brain, which may lead to delinquency and violence when the child enters puberty.

The feelings of your child will shift while you are taking a deep breath.

For now, be satisfied with your child’s development.

  1. Until when are people in a rebellious phase?

People are believed to undergo a rebellious phase twice.

The first time is around two to three years of age. The first rebellious phase is called “the terrible twos”.

The second time is around the ages of twelve to fifteen, which corresponds exactly to adolescence. The child rejects or ignores whatever a parent says, is strongly self-assertive, and will not apologize honestly even after doing something wrong.

Both phases are periods during which the body and the brain develop and grow rapidly. Children who have awakened to their ego struggle without knowing how to get in touch adequately with the parents and the people in their surroundings, and end up in a rebellious attitude.

We pediatricians tell the parents that “rebellion is a testimony of the growth of the child; watch over your child with room for rejoicing”. Alas, parents are quite hard to convince.

Chapter 4. Toward a society “living together” with handicapped children

  1. What is a child with developmental disabilities like?

Children with developmental disabilities refers to children with a mental handicap to a mild degree, if at all, who have problems in their abilities to communicate with people. It is an umbrella term for disorders such as learning disability (LD), attention-deficit/hyperactivity disorder (ADHD), and high-functioning pervasive developmental disorder. The cause is a congenital defect in the neurogenesis and the development of the brain.

Children with problems such as restlessness and strong fixation are difficult to understand, obviously for the people in their surroundings, but also for their parents. The children struggle with stricter parental discipline and stricter life-style guidance from the teachers, which are forced upon them.

However, in children with developmental disabilities, only a specific function is affected, and most of their functions are normal or more than normal.

Rather than just trying to fix the shortcomings of the children, it is important to figure out the fields in which the children excel, and extend these abilities.

  1. The importance of living together with children who have developmental disabilities

The “Act on Support for Persons with Developmental Disabilities” has been implemented in April 2005 in Japan.

Its purpose is the precise framing and understanding of problematic developmental behaviors in children with developmental disabilities, to organize a living environment that surrounds the children.

When a handicapped child is brought up together with school children without disabilities, various stimuli encourage the development of handicapped child.

At the same time, children without disabilities learn since childhood about having a handicapped child nearby, and can be expected to grow up into adults with a mind that is considerate of handicapped people.

  1. Adults with developmental disabilities have become a social problem

Developmental disabilities, which so far have been a problem only in children, have become a problem in adults today.

In the past, there were many workplaces where people could work by themselves, such that someone who is not good at communicating with others could work.

In the modern society, starting with the service industry, the proportion occupied by the tertiary sector of industry is high, which has been gradually limiting the places where they could work, affecting them enormously. It is predicted that this trend will be reinforced increasingly in the future.

Instead of turning the negative aspects of disabled people into problems, one should seek ways to utilize their strengths adequately.

From here on, instead of a management based on efficiency-dominated principles that pursue only profits, creating various workplaces adapted to the abilities of the workers is important.

  1. The joy of living together with disabled people through sports

The 6th Japanese Disabled Persons Sports Competition was held in Kobe in October 2006, welcoming the Crown Prince.

There were the energetic activities by the players who had various disabilities, the work of the volunteers who supported them, and the enthusiastic encouragements from the crowd. This was an enormous, deeply moving ring, in which I participated as part of the audience.

At the sight of the people with various disabilities, such as motor dysfunction, mental handicap, and hearing disorder, competing lively with bright, worry-free smiles, the entire stadium was bursting with the joy of “living together”.

The opportunities to feel the joy of “living together” with disabled people should be increased, not only through sports, but also in daily life.

Then, we would be grateful for our own lives, share our hopes and dreams with our friends, and realize a compassionate society.

  1. Children with disabilities exhibit a “spark of life” using their entire body

In the “Village of Happiness” of Kobe city, there is a living facility for children with severe mental and physical handicap named “Nikoniko House Medical Welfare Center”.

The “spark of life” exhibited by the smile or the entire body of the handicapped children bless the family members and the facility staff in their surroundings with tremendous hope and happiness of “living”.

Most people from the city probably know very little about the actual conditions in the facility for people with disabilities.

I would like to spread in the society the image of the users, their families, and staff, spending time together so cheerfully and lively.

Chapter 5. In the age of AI, what happens to child rearing?

  1. The age of AI is here

Japan has started road-testing autonomous car driving by artificial intelligence (AI).

Starting with home appliances, people are surrounded with products that have on-board AI (internet of things, or IoT), which are being released one after another.

In the United States, cloud-based speech recognition services have already begun. When spoken to, a speech recognition service software for smartphones, which are already commercially available, will immediately give you directions or let you know the location of a material, etc.

When my granddaughter asked, “are you a robot?”, I was surprised that a reply came back from the smartphone in a slightly displeased voice: “I have a heart too!” It was almost an illusion that an actual person was answering.

  1. Pet robots are extremely popular with children

In our pediatric outpatient clinic, there is a Japanese-made pet robot called “PARO”, which is covered with a white artificial fur and shaped to look like a seal.

PARO is very popular with children. In particular, if autistic children begin to play with PARO, they will not leave the place easily at all.

PARO moves the eyelids, neck, foreflippers, and hind flippers realistically like the actual animal, and also squeaks adorably. PARO reacts when you call its name.

PARO is intelligent, has feelings, and does not like rough treatments. Its personality changes according to how people interact with it. PARO also has the ability to learn the actions of its owner.

If PARO were to evolve further, it may work as an “emotional counselor” for those contemporary people who are not good at communicating with others.

  1. The development of a baby’s brain serves as a model for the development of AI robots

We have reached an era in which Go masters are defeated by AIs. The abilities exerted by AIs outperform those enabled by a baby’s intelligence, and sometimes by an adult’s intelligence.

Human brain nerve cells are connected to each other by lines called synapses, which allows us to learn and think about various things. An AI is a set of artificial neural networks created by mimicking the human brain.

In humans, if neurons are not being used, they disappear through a phenomenon called “pruning”, whereas an AI’s neural networks will keep on accumulating. Humans are no match for AI robots which keep creating and accumulating new neural networks.

I remember nostalgically when, thirty years ago, robotics researchers used to come frequently to our nursery to observe the behavioral development of the babies.

  1. The voice is important to get along with AI

A human voice can convey many types of information to another person.

With your eyes closed, listening to the other person’s voice is enough to learn about the person’s emotions, and even health condition.

The eyes also tell many things to the other person, but the voice reflects someone’s intention more richly and more accurately.

What you are hearing usually as your voice is a combination of both the vibrations of the air coming from your ears, and the vibrations in the nostrils and the throat mediated by bone conduction. Your own voice that you are hearing yourself is different from your voice that other people are hearing. This can be well understood by listening to a record of your own voice.

In order to get along with AIs, learning to speak with a voice that conveys your thoughts and feelings correctly to your listener will become important.

  1. Let’s also give AI robots a warm heart

In the human society, bullying is happening somewhere everyday.

There is bullying not only among children but also in the adult world. Countries are incessantly in conflicts.

From a historical perspective, in a war, even the nicest person can become someone who commits unbelievably horrible acts.

Regarding this point, AIs must not imitate humans.

As depicted by Osamu Tezuka in Astro Boy, I wish for the AI robots to continue to have a warm heart.

  1. The beginning of a new family life with the addition of AI

In the near future, once the sensor functions are improved for the five senses (sight, hearing, touch, smell, and taste), there is the possibility that AIs evolve to have the same intelligence as humans.

Then, the AIs might become members of the human society.

In order for the human beings and the AIs to get along, the humans and the AIs have to nurture the ability to communicate one another since childhood.

If a human child is not constantly kind to an AI, the AI may end up hating the human child and retaliate.

A child with developmental disabilities cannot interact well with people in the human society, but may do well if living together with an AI.

At school, a new class will start, to learn how to foster a friendship with an AI.

Let’s begin a new family life together with an AI.

Afterword

In May 2017, I was blessed with the opportunity to publish “The Baby’s Four Seasons”, followed by “Enjoying Child Rearing Even More” in December of the same year. Both were collections of essays related to child rearing, which I had been writing in series over more than a decade.

In the middle of editing the second book, “Enjoying Child Rearing Even More”, I received news of Mr. Kenzo Kassai’s  passing. It occurred to me that many of the contents included in these essays were written continuations of the topics discussed at the Aprica Childcare Institute chaired by Mr. Kenzo Kassai.

Founded in 1970 by three people, namely, Dr. Jushichiro Naito, pediatrician, Mr. Osamu Tezuka, cartoonist, and Mr. Kenzo Kassai, has been expanding a “Movement to Nurture Warmheartedness”. Through child rearing, not only within Japan, but also internationally, exchanges have been taking place, in particular, active research exchanges with China regarding child rearing.

I have been added to the members of the institute since 1995, the year of the Great Hanshin Awaji Earthquake. Until then, I would constantly discuss about the problems of child rearing with my fellow pediatricians, but I had almost no opportunity to discuss the matters with people other than maternal and child health personnels. However, representatives from a variety of professions, such as business people, lawyers, and members of the press, were participants in this institute, and I was greatly impressed to see them tackling the problems of children seriously before my own eyes.

Not only activities within Japan, but also frequent international conferences have been held, such that the institute has become a place where the many like-minded people who support this movement gather from all over the world, particularly from China and the U.S.

In the beginning of the 21st Century, the U.S.-China-Japan International Academic Conference for Happiness of Babies took place three times on Awaji Island, Hyogo Prefecture. Many people participated, starting with Ms. Wu Beiqiu, who has been active in and outside China, Dr. Hu Qingli, M.D., and others, Dr. Louis Z. Cooper, Past President of the American Academy of Pediatrics, Dr. Robert J. Bigge, and others, from the U.S., and Dr. Noboru Kobayashi, pediatrician, Dr. Hiroshi Nishida, neonatologist, and Dr. Shoichi Sakamoto, obstetrician, from Japan.

I have been able to feel strongly that “to protect the children” is a desire shared by the entirety of humanity even if the countries, races, and cultures are different.

I would feel fortunate if could forward this desire through this book, even a little.

In preparing this book, I would like to express my heartfelt thanks to Prof. Satoshi Takada and Prof. Hisahide Nishio of Kobe University, for providing invaluable advice, Takuji Harada, Mr. Gu Zhenshen, and Ms. Keiko Kawasaki, of the Aprica Childcare Institute, for the supply of materials, Ms. Ayumi Tanidawa, of Hyogo Prefecture Preventive Medical Association, and Ms. Yoko Oka, of the Kobe Shimbun General Publication Center, for help in the publication process, and Ms. Yuko Kurokawa, President of ACBroadband Co., LTD.