1. Transient state in newborns. 1) Changes in skin.

At birth the skin is covered with whitish greasy material called Vernix Cesseosa. It has a protective value as it contains antibodies that is absorbed by the skin. If not removed it will dry and it will disappear after a few hours. After birth there is redness of the skin which lasts for 1-2 days due to autonomic nerve imbalance. - Edema of the subcutaneous tissue is commonly present and is more evident in eyelids, face, dorsum side of hand, feet and legs. It will disappear after a few days. - Acrocyanosis means peripheral cyanosis of the hands, feet and occasionally circumural area. It is probably caused by venous stasis and not hypoxia. It will disappear after few days. - Mongolian spots: irregular area of blue pigmentation usually present in the sacral and gluteal regions, but may present also at any area of the body as the extremities. They disappear after a few years and have no physiological significance. - Lanugo hair: fine hair characteristic of the new born seen best on the forehead, shoulders, cheeks and back. - Milia: distended sebaceous glands seen as minute white papules on the cheek, nose and chin. They disappear spontaneously in 2-3 weeks. - Capillary hemiangiomas are the most common over the eyelids, forehead and back of the neck. - Skin rashes: newborn skin is the most sensitive to the environmental temperature, clothing and chemicals Most common type of rashes are: (i) erthema toxicum (urticaria neonatarum ) (ii) erythematous sweat rash (iii) vesicular sweat rash. Collection of tiny vesicles on the head and chest of the babies who have been sweating because od the illness or overheating. (iv) seborrhea of the sclap ( cradle cap ) (v) napkin dermatitis ( diaper dermatitis ) It is as cutaneous reaction localized to the area covered by the diaper. 2.Transient hyperthermia. Body temperature is higher than 41C .Starts at 3rd day of life. It will disappear by the 7th-10th day. This due to water and electrolyte abnormalities. Temperature will be normal when breast feeding starts. 3.Transient jaundice in newborns. Start on the 2nd day with increase in conjugated bilirubin and peaks on the 3rd day. It will normalize by 1 2 weeks. 4. Physiological weight loss.
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Most babies loose weight in the first 3 days (less than 10%, if more than 10% considered pathological). Weight loss is due to discharge of meconium and urine, drying if the umbilical cord, loosing of water through skin and respiration. Weight gain will start (25-35gm/day) by the 4th day and progresses thereafter and will regain birth weight by the 7th 10 day. 5. Significance of transient states in newborn. It is the adaptation to the environment. It usually does not appear clinically but if it does, the child should be monitored and the condition should be differentiated from a pathological state. 2)Special features of respiratory system in children. a)Stages of intrauterine development of respiratory system. - Embryonic period:- Begins at about 4th week of gestation,when primitive airways appear as a ventral outpouching on the endodermal epithelium of the foregut. -The outpouching divides into bronchial buds which burrows into the mesenchyme and separates the foregut from the coelomic cavity. -Pseudoglandular period:- Begins around the 6th week to the 16th week of gestation - Lungs resemble an exocrine gland with a thick stroma crossed by narrow ducts lined by an epithelium of tall cells that almost fills up the lumen. - Major airways are already present and are in close association with pulmonary arteries and veins. - Airways continues to branch until entire airway conducting system is formed. -Mucous glands cartilage and smooth muscles are easily distinguished by the end of the 16th week. - Diaphragm is formed. -Canalicular period:- Between 16th and 26th-28th week of gestation. - Epithelial growth predominates over mesenchymal one. - Bronchial tree develops a more tubular appearance.(Distal regions lays the structural foundation of the pulmonary acinus). -Saccular period :- From the 26th 28th week of gestation. - Terminal airways widen and form cylindrical structures known as saccules. - Saccular septation with appearance of secondary crests continues at a rapid rate so that multifaceted structures analogous to the alveoli of
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the mature lung can be seen at the 32nd week. -Alveolar period :- Transition from placental dependence to autonomous gas exchange requires adaptive changes in the lungs. - Changes include:-Production of surfactant in the alveoli. -Transformation of the lungs from a secretory into a gas changing organ. -Establishment of parallel pulmonary and systemic circulation. -Air-liquid interface becomes established in the lungs as soon as the infant takes the first breath of air. -Pulmonary surfactant makes reduction of the surface tension by forming a hydrophobic lipid monolayer at the very surface of the liquid film that lines the air spaces. -Presence is recognized as early as the 24th week of gestation. b)Stages of postnatal development of lungs. -Divided into 2 phases depending on the relative rates of development of the various components of the lungs. a)1st phase:- Extends to the first 18 months of life. - Disporpotionate increase in the surface and volume of compartments involved in gas exchange. -Capillary volume increases more rapidly than airspace volume,and in turn this increases more rapidly than solid tissue volume. - Changes occur through alveolar septation. - Process is active during early pregnancy and may reach completion within the first 2-8 years of life. - New arterial and venous branches develop. b)2nd phase :- All compartments grows more proportionately to each other. - Alveolar and capillary surfaces expand in parallel with somatic growth. c)Special features of different parts of respiratory system in children. -Nose :- small,not fully developed cavities.Mucosal secretion is better than adults.Submucosal membrane only develops by the 8th year of life.Ethmoidal sinus-12yrs. Maxillary-from 2-7 years,Frontal-by 15-20 yrs,Sphenoidal- by 7-15yrs. -Pharynx:- Narrow and small.Lymphopharyngeal circulus isnt developed well.Tonsils are developed by 4-10 yrs and hypertrophy is common in older
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children.Nasopharyngeal tonsils may be enlarged and are known as adenoids. -Larynx:- Has crater form. Soft cartilages. True glottis is narrow till 67yrs.Mucosa is frail nd rich with blood and lymphatic vessels.3rd year- form of larynx is the same in girls and boys.10 years boys have larynx the size of adults. -Trachea :- Almost fully formed at birth.Mucosa is frail,circulation is richer than adults.Soft cartilages.Lumen may be easily narrowed.Grows in length and width according to age. -Bronchi :- Well developed by birth.Mucosa has rich circulation.Right bronchi is shorter and wider than left one.Muscular and elastic fibers are poorly developed in infants.Develop most intensively during the first year. -Lung tissue :- Less airfull,richer circulation and more soft connective tissue in septi of acini.Elastic tissue is poorly developed.Structure of lung is the same as adults. d)Auscultative types of normal breathing in different periods of childhood. -Puerile breathing. -5-7 years -Louder,increased on inspiration and expiration. -This is due to Enlarged amount of interstitial tissue - Short distance between true glottis and place of auscultation - Narrow bronchial lumen -Enlarged elasticity ,thin chest wall,increase vibration. - Less air in lungs After 7 years: -Obstruction Spasm -Hypersecretion of mucous from bronchial wall. e)Special features predisposing to respiratory obstruction. - Decreased amount of smooth muscle in the peripheral airways may result in less support. -Mucous gland hyperplasia in major bronchi favors in increased intraluminal mucous production. -Disproportionately narrow peripheral airways up to 5yrs. results in decreased conductance than in adults and the small children vulnerable to disease affecting the small airways. -Decreased static elastic recoil predisposes to early airways closure during tidal breathing and results in mismatching of ventilation and perfusion and hypoxemia.
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-Highly compliant rib cage and mechanically disadvantageous angle of insertion of diaphragm to rib cage increases diaphragmatic work of breathing. -Decreased number of fatigue resistant skeletal muscle fibres in the diaphragm leaves the diaphragm poorly equipped to maintain high work output. -Deficient collateral ventilation with the pores of Kohn and the Lambert canals deficient in number and sizes. 3. BREAST FEEDING IN INFANTS 1. Contents of breast milk Water: 88%. Protein: 1g/100ml (casein 30% & whey 70%). Rich in Ig, lactoferin & lysozyme which are anti-infective. Fats: 3.5-3.8g/100ml (unsaturated fatty acids 60% & saturated fatty acids 40%). Very rich in lipase enz which helps digestion of triglycerides. Rich in unsaturated essential fatty acids. Their deficiency leads to growth retardation & skin changes. Cholesterol is > amount. This facilitates myelinization of CNS & prevents atherosclerosis later on. -lactose: 7g/100ml. > amounts of lactose helps Ca absorption & provides galactose needed for galactolipids in CNC development. Contain BIFIDUS factor needed for growth of Lactobacilli. Minerals: 0.2g/100ml. Less osmolar load & less renal solute load. No liability to hypertonic dehydration. Better iron absorption. Vitamins : > amount of vitamin A, C, D, E & Niacin. Calories: 67/100ml. 2. Main principles of breast feeding I. Establishment of lactation It is not practical to breast feed the baby for the first few hours after delivery because the mother needs rest to recover from the fatigue of labour & the baby is sleeping practically all the time. After the first 6 hours, the baby should be put to the breast because: Suckling stimulates milk secretion & increases milk supply. Colostrums which are secreted during the first 3-5 days are beneficial to the baby. It is very rich in antibodies especially secretary IgA, rich in macrophages, lactoferin & lysozyme.

II. Technique of feeding Both hands & nipples should be clean. Mother should sit comfortably. Infant is held in a semi recumbent position in the crook of one arm. Nipple is placed well back in the infants mouth. Infants face must not be buried in the breast. Infant should be warm & not wet. The breast is steadied by index & middle fingers of the free hand which should exert gentle pressure to assist the flow of milk. After the feed, the mouth, especially the corners should be wiped. Infant is then held vertically & tapped gently 2-3 times on the back to drive off any air swallowed during feeding. Infant is then placed in bed either lying on its right side @ in the prone position. III. Duration of fed 5-10 minutes on each breast is enough. Never allow > than 20 minutes on both. IV. One breast @ both It is advisable to give both breasts each feed. Consecutive feeds should always begin on alternate breasts, making sure that one breast is properly emptied at each feed. V. Time & regularity of feeding During the first few weeks, the breast is usually given on SELF DEMAND @ 2 hourly. During the first 3 months, the infant should be fed every 3 hours. Later feeding is given 4 hourly. 3. Advantages of breast feeding I. For mother Easy & needs no preparation. Economically, it is the cheapest. Available at any time. Help involution of uterus. Emotional satisfaction. Prolong birth spacing, thus, helping in family planning. II. For infant Natural & perfectly balanced diet.
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Self regulated. Available at any time. Always fresh. At proper temperature. Easy digestion & absorption, so baby sleeps well. Emotional satisfaction. Baby is always with his mother, so she takes better care. Breast fed baby is protected against infections. Breast milk is not allergenic & has anti allergic properties. Rickets is less liable to occur. Iron deficiency anemia is less liable to occur.

4. Main principles of WHO on breast feeding In the absence of contraindications, mothers should suckle their infants immediately after delivary (even if lactation is not present yet). It gives the mothers microorganisms & colostrums with high levels of cellular & humoral anti-infective properties. Besides, stimulation of the areolar area by suckling stimulates prolactin & oxytocin secretion. Mother & newborn must be together in the same room (in the absence of contraindications & if conditions allow this). Healthy newborn infant must not receive any appliance (contraption, device) mimicking breast feeding. Healthy breast fed infants dont need water in addition to breast milk @ formula, even in hot region. Mother should be taught technique of correct breast feeding (@ feeding from a bottle). 5. Methods of calculating of amount of milk I. First 10 days V= n X 70 V= n X 80 V = dairy volume n = the day of life age 70 = if weight <3.2kg 80 = if weight > 3.2 kg Dairy volume decided according to the number of feedings (7) For one feeding: V = 10 X n (n the day of life) 7x a day. On the 10th day, V = 10 X 10 = 100ml per feeding X 7 = 700 ml per day (let it be so till the end of 1sr month)

 Daily volume = 2% weight at birth X n For one feeding, V = 3me X n X weight at birth II. After 10 days Daily volume development upon age & weight: From 2 wk 6 wk : 1/5 from body weight 6 wk 4 mo : 1/6 4 mo 6 mo : 1/7 6 mo 9 mo : 1/8 Method dependent on number of kkal/age/unit of body weight 1st quarter of year - 120 kkal/kg 2nd quarter of year 115 3rd quarter of year 110 4th quarter of year 100 1 liter of breast milk ~ 650-700 kkal / liter. 4) Development and special features of GIT in children. 1. Development of GIT intrauterinally. Anatomic development:By 4 weeks gestation, the primitive foregut is identified By 6 weeks, foregut, midgut, and hindgut divisions are present Hindgut forms a simple tube that rotates counterclockwise around the umbilical artery. This tube elongates quickly and protrudes into the umbilical cord. Peristalsis has been recognized as early as 8 week, but motility is not fully coordinated until near term. At 8 week, the caudal-end becomes continuous with the rectum, which has evolved from cloaca, and at 10 week the bowel rapidly reenters the abdomen. Blood vessels and the nerve supply to the gut are fully developed by 12-13 week. Lymphoid tissue has developed by 20 week. Biochemical development:1) Gastric functional development begins during the second trimester. Gastric acid activity does not begin until after 32 weeks gestation and increases rapidly in the first 24 hours of life. 2) Small intestine functional development also extends into postnatal life. Disaccharides activity sucrase, maltase and isomaltase activity begins by 12 weeks gestation and is at 70% by 34 weeks. Lactase activity remains low until term. ]

2. Special features of esophagus. Normal development:The esophagus begins as a common tubular structure that invaginates to form the esophagus, the pharynx, and the respiratory tree. 3. Special features of stomach. Normal development:The stomach is formed by dilatation of the caudal end of the foregut. Development is complete by 5 weeks gestation. Pyloric musculature of stomach is seen y 3rd month of gestation. Parietal and chief cells appear by 14 week. 4. Special features of intestine. Normal development:The duodenum is formed as the terminal foregut and proximal midgut grow and form a loop. The remainder of the midgut forms jejunum and ileum. Between 5 and 10 weeks gestation, the growing midgut is forced out of the abdominal cavity and into the umbilical cord. The mesentery grows within the loop. By the end of this period, the intestines reenter the abdominal cavity, proceeding cranially to caudally and making a 270-degree rotation. The colon develops from the hindgut and cloaca, which divides into urogenital sinus and rectum by 6 weeks gestation. Set 1 Question 6: Development of hematopoietic system in children 1. Stages of intrauterine blood formation Hematopoietic tissue is derived from the msenchymal layer of the embryo. 1st period Mesoblastic extraembrionic: - Starts at 2-3 weeks of gestation. -Megaloblasts (primitive erythroblasts) are produced. -After yolk sak becomes connected with the systemic circulation, stem cells migrate to the embrio proper and seed future sites of hematopoiesis. - preventantly erythropoiesis.
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2nd period Hepatic: - 5-6 weeks of gestation commences in the liver. - megaloblastic type normoblastic type and differentiated erythroblasts are produced. - Neutrophils and magakaryocyte production begins. - Liver is chief hemopoietic organ til 6th fetal month. After that which functions gradually decline. - Splen 3rd til 5th-7th months, here RBCs, granulocytes and megakaryocytes synthesized. - After 7th month, active syntheis of lymphocytes. - At birth only lymphocytopoiesis occur in spleen. - Lymphocytopoiesis starts from 2nd month of intrauterine life. - Main difference between fetal blood from newborn continues of increase of RBC, Hb and WBC amounts. 3rd Period Bone Marrow Period: - Start in bone marrow at about th-5th fetal month. - By the 6th month bone marrow is chief focus of blood cell production. - Before 6th month, the gestational age many immature blood cells found (erythroblasts, myeloblasts, promyelocytes, myelocytes). - After 6th month prevalence of mature cells normally characteristic. 2. Special Features of intrauterine hematopoiesis. - At birth hematopoietic activity present in most bones. Especially long bones. - Is progressive age, active marrow gradually decrease from distal portion of skeleton. - Age of 16 years- vertebrae, ribs, sternum, skull and pelvis all active sites of blood production. Major requirement for hematopoeisis - Pluripotential hematopoietic stem cells. - Inductive microenvironment. - Stimulatory factors for stem specific cell lines. (erythropoietin, thrombopoietin.) - Nutrients (iron, vit B12, folate, amino acids.) 3. Pecularities of peripheral blood in newborn - Term L= 15-20 x 10 9 / l. (SMTM 30x10 9/I 1st hrs after birth) - [Leukocytosis due to mothers hormonal influence and labor stress]. - Gradually WBC decrease from 7-9 days L= 1012 10 9 /l - Preterm L=10-12 x 10 9/l per year, until they reach adult level. - 3rd year = 8-10x10 9/l
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* ESR after birth 3-7 mm/hr (also due to labor stress) 7-9th day = decrease 1-2mm/hr 2-3 months = increase mm/hr 5 yr = 5-6 mm/hr - Full term normoblast ratio= 5:100 of RBC - Premature ratio= 10:100 of RBC * RBC Newborns (mature and preterm) Er = 5.5- 6 x10 2/l Hb = 195-210 g/l Ht = 0.55 +- 0.66 From 1st day intensive decrease of Er and Hb. To 7-10 day (during 1st month of life) Er = 4.5-5 x 10 12/l Hb = 150-170 g/l - Period of physiologis anemia 1st month of age decrease continues Er = 3-3.5 x10 12/l at 2-3rd month-lowest levels of Er&Hb during life. Hb = 110-140 g/l - If infants is from risk group for anemia or is an unbalanced feeding at this moment time of real anemia (non-physiologic) - During 02 months anisocytosis and polychromatophilia. After 3-4 months increase Er and Hb levels. 4-6 months Er = 3.5 4.5 x 10 12/l Hb = 120-160 g/l - Regeneration of blood in newborns quicker than adults. - Reticulocytes highest in newborns then decrease. - Thrombocyte count constant for all ages 150-300 x 10 5/l 4. Types of hemoglobin in newborns. Type of polypeptide chain 2 2 2 2 2 2 % at birth 60% 40% < 1% % at 12 months < 2% > 95% 2-3 %

1) Hb F (fetal) 2) Hb A 1 (adult) 3) Hb A 2 (adult)

-Hb F is predominant in fetal life; characterized by beng alkali resistant. - Hb A in major adult Hb whose level is reached by 12 month of age.

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5. Changes in leukocyte formula with years.

Mature: - After 1st cross, shift to left gradually disappears. (myeloctyes disappear, amount of metamyelocytes decrease to ~ 1%; band cells decrease approx. 3%). Preterm: - No 1st cross. - Only 2nd cross. - Born with lymphocytosis. Part 1 Question 7 WEANING - its the process of introducing any non-milk food into the infant diet, irrespective of wheather or not breast or bottle feeding continues 1) NECESSITY OF WEANING - to sustain adequate growth, promotes health and normal growth of baby - diet with high amounts of fatty acid, vitamins, and mineral to maintain body maintenance and energy - additional vitamins, minerals and iron - giving infants chewable food helps with development of chewing 2) MICROADDITIONS- TYPE AND TIME - these are given from the age of 3 months, given before macroadditions, in small volumes - given allong with full volume of breast milk/formula -never replace 1 whole feeding 3MONTHS - give small amounts of vit C ( fruit juices, sugar free) - 3-5 drops - carefully observe reaction of infants - if in a week no bad reaction/ allergic rx- we can gradually add volume 4 MONTHS- 30 ml/day 5 MONTHS- 60ml/day
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10-12 MONTHS - 100ml/day - at 4 months, we can also start given child slightly sweetened purred (stewed) apples (better if green) and other fruits (banana mashed with breast milk)- make sure u oderve for reaction 5th month- 50ml/day 6th months- 60ml/day 9-12month- 100ml/day - its safer to give fruits from same climate area oth kinds of microadditions- butter, vege oil,. curds, yogurts

3) RULES OF WEENING - weeaning is divided in to 2 parts microadditions and marcoadditions - microaddition started at 3 months -marcoaddition started at 4.5 or 5th month - additional food is not given before 3-4 months , because ther is no reason of given and may induce GIT problems - microadditions arre given before macroadditions - microadditions are given along with breast/ bottle milk - and never replacing a whole meal - volume and types of food are given depending on child's age -new types of food (non-milk food/ macroadditions) are given before breast/ formula feeding - this is bcoz child is resistant to change and wont eat when not hungry -when infant is use to macroaddition it replaces one meal - when introducing food, it should be in small quantities -- marco/ microadditions are given once a day not at every feeding - weening diet should be varied to cover all vitamins and mineral needs 4) MACROADDITIONS- TYPE AND TIME - its introduced to all infants and is qualitative addition - given food must be introduced only in given infant's age (then intolerance is less common) necessary volume is counted according to child's age -its not given for each feeding but only once a day
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-new type of food (non-milk food) given before breast feeding bcoz infants are conservative and resist change. they wont eat new food if they're not hungry -Start introuducing new food from small quantities (3-5ml) gradually increasing volume(10-15ml/day) and after 7-10 days this new food will replace one whole feeding - 2 weeks later when infant already receives one macroaddition, we begin second macroaddition to replace oth feeding . After this 2 feedings will be non-milk feedings n the rest would be breast/ formula feeding TYPE

1st macroaddition - Powdered infant's cereal / strained foodrice, porridge (4.5-5months) - The first weaning food is semi-sloppy , well mashed, strained / homogenized - this replaces 10 o' clock feeding

2nd macroaddition - mashed vefetables, mashed potato, pwieed carrots, cabbage, turnips (5.5-6 months) - if infant will be ill wilh rickets, anemia, pretesm , constipation, give vegetables as 1st macroaddition and porridge as second macroaddition. - if child has diarrhea, start with porridge and careful when introducing juices - this meals are given in day time at 6 months - weaded yolk ( 1/8)- after 12 months whole yolk per day with curds (cottage cheese) at 7 months - minced meat

3rd macroaddition - kefir+white bread (7.5-8months) - before 7 months cows/ goats milk are not give , may be only small amount in porridge - native fesh milk not given before 12 months - after 8 months -infant does not need breast/formula milk but its better to be stoped only after 1 and a half or 2 years - after 10 months -boiled fish
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- after 12 months - stewed cutlet - infant before 12 months should not be given liver, kidney, or ny other 'inside organs' -contrindicated these feedings are NEVER introduced earlier but can be introduced later if : infant is ill with acute disease with high temperature diarrhea during hot season of the year

5) METHODS OF CALCULATING AMOUNT OF FOOD First 10 days -new born milk volume: 1) V= dairy volume n= day of life V= n x 70 V=n x 80 V/dairy volume is devided according to number of feedings (7) 2) For one feeding : V=10 x n one the 10th day V=10 , 10 = 100ml per feeding x 7 = 700ml per day 3) daily volume = 2% weight at birth x n 4) for one feeding V =3me x n x weight at birth after 10 days - daily volume depends on age and weight from 2 wks- 6wks - 1/5 from body weight 6 wks- 4mths - 1/6 70 is used if weight <3200g 80 is used if weight > 3200g

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4mths- 6moths- 1/7 6mths- 9mths - 1/8 method dependent on number of kkal/age/unit of body weight: - 0-3months- 120kkal/kg - 3-6months- 115kkal/kg - 6-9months- 110kkal/kg 10-12mths - 100kkal/kg 1 liter of breast milk - protein 15g, fat 39g, lactose 74g ( 2nd-3rd week) 0-6months 2,5-3,0 6,5 10-15 7-12months 3-3.5 6 10-14

protein g/kg/day fat sugar/lactose

8. PERIODS OF CHILDHOOD. CHAR OF INTRAUTERINE DVLPT a) Germinal period Moment of ingravidation of ovum and ends with moment of implantation of blastocyts which are formed in mucous membrane of uterus. Duration is 1 week. b) Period of implantation blastocyts implantation in mucous membrane of uterus needs 40 hours united due to medical signs during this period very sensitive to exogenous influence Teratogenic factors factors which disturb intrauterine development; viruses bacteria, toxins chemicals some drugs radiation vibration change in pressure
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During the period of germinal and period of implantation, teratogenic factors cause further incompability. Further development is stopped. Teratogenic factors cause severe chromosome disturbances. c) Embryonal period Duration 3-7weeks Formation of all main internal organs occur All pathology called embryopathy CNS, endocrine not formed yet 3-4 week of gestation critical for growth Classical pathology; Rubella embryopathy - rubella virus, togavidiran group Congenital heart disease Cataract Deafness Born as invalid Should be vaccinated d) Embryofetal duration 2 weeks main characteristic- formation of placenta ( o2, nutrition for fetus) e) Fetal period Is divided in 2;- i) early ii) late i) Early 9th 28th wk of gestation Further differentiation of tissue continues Teratogenic factors dont cause anatomical defects but may cause hypoplasia (abnorm. Working rate), dysplasia ( abnorm. Proportions of layer) to organ. ii) Late 28th 1st registered birth pains During late fetal period, growth continues All main internal storage being formed Surfactant produced in lungs and covers surface of alveolo and superficial tension of alveoli.

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 Alveioli doesnt collapse May be open for new inspiration In absence of sulfactant, alveoli collapse after inspiration. Clinically will be neonate respi distress, Xray differs athelectosis in lung, Treatment endothelial tube Infectios agents cause typical clinical change. Pathology called fetopathy
Part 1 Question 9. 9. Morpho-functional special features of newborns 1) Def. of full-term newborn. -Delivery at 37-41 week of gestation 2) Pecularities of full term newborn -infant posture is characterized byflexionof all extremities -the motor activity is primarily flexor -muscle tone of flexor is increased -the infant allows extension of the knee to approximately 80 degrees -sleep and waking pattern are well developed at term -clonus may be seen in the lower extremities by sudden dorsi flexion of the foot with the knee partially flexed -The deep tendon reflexes are readily elicited in most term infants - cant fix their eyes. More time spend in sleeping -after unwrapped they stretch themselves, have usual posture with bent legs n hands drawn to the trunk, n cant hold head 3) Name the main transient states in newborn -physiologic weight loss -physiologic jaundice -physiologic hyperthermia -physiologic anemia -physiologic erythema -physiologic constipation, diarrhea, vomiting 4) Transient hyperthermia -it starts t 3rd day and disappear at 7-10th day. These appear due to fluid n electrolytes abnormalities. After starting breast feeding it becomes normal. 5) Changes in weight in neonates -children loss weight after born due to: a) Discharge of meconium n urine b) Drying of umbilical cord c) Loosing of water through skin n lung during respiration 18

3rd-4th day of life child has minimum weight. 7th-8th day child regain weight. Premature infants regain weight on 16th-21st day Physiological weight loss should not exceed 6-8% of childs birth weight. If >10% - pathological weight loss Part 1 Question 10. 10.Main regularities of neuro-psychological of children 1.)Neuro-psychological state of new born? o Their movements are uncoordinated,athetoid. o They cant hold head o Tone of bending muscles r elevated o Newborns have several unconditioned reflexes,they r divided into 3 groups:1. the group of automatisms 2. transient rudimentary reflexes,disappering with age 3. reflexes,appering only after birth. 2.)Unconditioned reflexes of new born? o Newborns have several unconditioned reflexes,they r divided into 3 groups:1. the group of automatisms 2. transient rudimentary reflexes,disappering with age 3. reflexes,appering only after birth. o The 1st group includes corneal,conjunctival,pharengeal,swallowing,tendinous reflexes of extremeties,orbitoeyelidal reflexes o The 2nd group includes oral segmental automatisms(sucking,searching,lip and palmomouth reflexes) spinal segmental automatisms(ggrasping reflex,moro reflex.,reflex of support,reflex of automatic gait,reflex of creeping,halants and peres reflex),posture reflex (labyrinthine symmetrical and un symmetrical cervical reflexes). o The last group is formed by the labyrinthine reflexes,simple and chain and trunk reflexes. 3.)Rules of evaluation of reflexes in newborns? o Should be conducted in comfortable for child conditions in warm, welllightened room on smooth half-tough surface. o Child must be awake,dry and not hungry 4.)Neuro-psychological development development during the 1st year of life? 19

o Motor milestones:1. 2 mths-raises the chin when prone 2. 3mths-holds the head erect 3. 4mths-rolls from prone to supine 4. 5mths-rolls fr supine to prone 5. 6mths-remains sitting when put so 6. 7mths-sits alone 7. 8mths-creeps 8. 9mths-stands supported 9. 10mths-walks supported 10. 11mths-stands alone 11. 12mths-attemps to walk alone. o Sensory-motor(fine motor) milestones:1. 4mths-plays with rattle in his hands but cannot pick it up if it drops. 2. 5mths-he can grasp an object voluntarily and racks objects to mouth. 3. 6mths-transfer rattle from hand to hand. 4. 10mths-can pick up small objects. 5. 12mths-mouthing should stop and begins to throw objects to floor o Language:1. 2mths:-very mild sounds 2. 4mths:-laughs 3. 7mths:-m-m sounds 4. 10mths:-one word with meaning 5. 12mths:-2-3 words with meaning o Personal-social:1. 4-6 weeks:-social smile 2. 5mths:-recognizes mother 3. 12mths:-coorperation in dressing 5.)Neuro-psychological development development during early childhood? o Motor milestones:1. 15mths:-walks alone 2. 24mths:-runs alone o Sensory-motor(fine motor) milestones:1. 15mths:-tower 2 cubes o Language:1. 24mths:-joints 2-3 words in sentences o Personal-social:20

1. 18mths:-sphincter control by day 2. 24mths:-sphincter control by dat and night and asks for toilet by day 3. 3years:-feeds self well

11. ASPHYXIA IN NEWBORNS a) Etiology Inadequate oxygenation of maternal blood Low maternal blood pressure as a result in hypotension Inadequate relaxation of the uterus Premature separation of the placanta; placanta previa Impedence to the circulation of blood thru the umbilical cord Uterine vessel vasoconstriction Placental insuff. From numerous causes ( maternal toxemia, postmaturity diabetes, preterm gestation) Multiple gestation Abnormal position of child Blood group, sensitization Congenital malformations Vaginal bleeding Extremes in maternal age (<20, >35)

b) Apgar score Apgar evaluation is a rapid scoring system which helps in assessing the oxygenation, ventilation and degree of asphyxia in a uniform manner. It is perfomed at1 and 5 mins after birth. 5 signs are examined and assigned a score of 0,1,2. the apgar score is obtained by adding all individual scores. sign 1) Heart rate 2) respi. Effort 3) muscle tone 4) reflex irritability ( catheter in nose) 5) skin color 0 Flaccid No response Blue, pale 1 <100 beats/min Weak cry, irregular Some flexion Grimace, sluggish Body pink, extremities blue 2 >100beats/min Strong cry, regular Well flexed Cough/ sneeze Pink all over

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c) Classification i. (8-19) good oxygenation ii. Mild asphyxia (6-7) Heart Rate(2), resp effort(1-2), muscle tone(1-2), reflex(1-2), skin(1) Infant goof prognosis, initially will be depressed Hyper alertness, which resolves in 1-2 days, no focal signs

iii.

Mod. Asphyxia/ blue asphyxia(4-5) Heart rate (2), resp. effort( 0-1), muscle tone(1), reflex irritability(1), skin(0-1). Infant very depressed, prolonged period of hyper alertness, hyper reflex, gen, seizures in 12-24hr after episode of .prognosis variable severe asphyxia/ white asphyxia(0-3) heart rate (1), resp effort(0), ,muscle tone(0-1), reflex irritability(0), skin color(0-1) coma, intractable seizures, cerebral edema, intracranial hemorrhage, infant more depressed as cerebral edema develops

iv.

d) clinics Depending on level of asphyxia e) treatment Follow the ABCD:A- airways i. anticipation anticipate high risk situations by history of pregnancy, labor and delivery ii. maintenance of body heat infant dried and provided with radiant heat
22

iii.

establishment of airway clear mouth, nose, pharynx of meconium by suction. Place head in extended position iv. tactile stimulation if no brathing, use gentle flicking of feet and rubbing of back all process should not take more than 20 sec. B- Breathing i. ventilation adequate, but heart rate 100/min- use supplemental O2 to HR or skin color ii. ventilation inadequate, HR 100/min mech ventilation positive pressure ventilation (PPV), 90-100% O2 using face mask contra indicated to diaphragmatic hernia use of endotracheal intubation besides face mask in case of diaphragmatic hernia C- Circulation Circulation and external cardiac massage Chest compression necessary if Asystole present Peripheral pulses not palpable No improvement of bradycard by artifi venti Chest compression with 2 fingers Btwn middle and lower 3rd of sternum If cardiac massage performed with face mask mech ventilation use stomach probe for decompression Pulse 80/min stop ext card massage and continue mech venti Pulse between 60-80 continue mech venti and chest compression HR 80/min or asystole present continue chest compression and mech venti and medications administered D- Drugs i. Epiniphrine 0.1-0.3 ml/kg of 1:10,000 solt (1.0 ml of 0.1% Epiniphrine +10.0 ml of saline (0.9% NaCl take 1.0 ml of this solt Indications: HR 80/min During asystole Expected effect: 30 secs after admin HR 80/min. other meds should nt be admin, chest compression stopped, mech venti continued
23

ii. volume expanders saline, albumin (5%), ringer lactate Indications: given 10-20ml/kg thru umbilical vein. Dose given 5-10 mins hypovolemia weak pulse pallor BP No/ poor effect of performing resuscitation Effect: Tissue perfusion Normalization of HR BP iii.
iv.

sodium bicarbonate 4% solt., .(05 mEq/ml) dose: 2-4 ml/kg (1-2 mEq/kg) of 4% solt should be given slowly (2ml/kg/min, or 1mEq/kg/min) ( at least 2 mins) into the umbilical vein nalaxone for poor spontaneous respi effort, secondary to maternal narcotic usage during labor. Given subcutaneously, IM, IV, intratracheal route

12. Hemolytic disease of newborn. 1) Etiopathogenesis Etioligy a) Allergy / anphylactoid purpura -Hypersensitivity vasculitis involving blood vessels of skin, joints, gut and kidneys -Preceded by history of upper respiratory tract infection. -Hypersensitivity due to virus Ag-Ab complex. b) Idiopathic thrombocytopenic purpura -Due to autoimmune process (antibodies against platelets). c) Hemophilia - Deficiency / functional abnormality of factor VIII. 2) Classification. Hemorrhagic disorders: a) Bleeding disorders I) Platelet disorders Decrease in number( Thrombocytopenia) (1) Hereditary thrombocytopenia (2)Acquired Thrombocytopenia -Idiopathic thrombocytopenic purpura(ITP)

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-Secondary to other disease(e.g.leukemia, hypersplenism ) Defective platelet function. (1)Hereditary (2)Acquired (drugs: aspirin, uremia, malignancies and ) II) Vascular disorders Hereditary (e.g.- hemorrhagic teleangioectasia) Acquired: (a) Nutritional disorders: Scurvy (b) Allergic: Anaphylactoid purpura(HenochScholiens) (c) Septicemia: Meningococcemia (d) Whooping cough b) Coagulation disorders Hereditary (e.g. Hemophilia) Acquired (e.g. DIC, liver disease, Hemorrhagic disease of new born) 3. Clinical signs and symptoms. (I)Anaphyalctoid purpura Usually in children inn the range of 2 8 years of age and more males are affected than females. Skin rash: occurs in 100% of cases -Recurrent attack of urticaria and maculopapular rash which changes to petechial and purpuric rash in all cases. - Distribution: mainly in the lower limbs and buttocks, trunk, face (seldom). - Sometimes erythema multiforum and angoinuerotic edema. Abdominal manifestations: occurs in 65% of cases. => they result from petechial hemorrhagic and / or edema in bowel wall. - severe abdominal pain, vomiting is common also and occasionally associated with hematemesis, melena or occult blood in stools may also be present. - most common complication is intussuseption. Arthalgia and / or arthritis : occurd in 65% of cases. - May be mono- or polyarthritis. - Ankle and knee joint are the most common, joint finding resemble rheumatic arthritis (transitory, affects mainly big joints which becomes swollen and tender but no cardiac manihestations). Renal manifestation: occurs in 20% of cases.

25

-cl. Pict. Resemble ac. Streptococcal glomerulonephritis (hypertension, edema, oligouria and hematouria leukocytouria) - serum complement is normal. - some cases may progress to renal failure. CNS manifestations: not common. - facial nerve palsy, convulsions, hemiparesis and coma. - most cases have been attributed to hypertensive encephalopathy. (II)Idiopathic Thrombocytic Purpura.(ITP) There are 2 types: acute(90%) and chronic(10%). It is the most common type of thrombocytic purpura. It is characterized by: Short life span of platelets. Normal number of megakaryocytes in the bone marrow. Absence of primary disease. Normal sized spleen. Acute:-mostly in children. -Self limited. -acute onset of spontaneous or induced bleeding commonly in children ( petechia, purpura, ecchymosis and sometimes subcutaneous hematoma). -less commonly=> bleeding from mucous membrane( hematouria, GIT bleeding, gum bleeding and epistaxis) -rarely intracranial bleeding. Chronic:-mostly in adults -it is diagnosed if disease persist for more than 6 months. (III)Hemophilia A: it is due to factor VIII (antihemophilic globulin) defiency. In neonates: intracranial hemorrhage Usually diagnosed when there is prolonged bleeding after circumsion. In early infancy: excessive bruising and intramuscular hematoma results from minor trauma. In childhood: epistaxis, GIT bleeding, hematuria, intraocular bleeding Hemarthosis (most characteristic)may cause limping and psuedoarthrosis of an extremety. Intracranial hemorrhage and bleeding into the neck 4. Diagnosis
26

H-Ss Purpura Laboratory: 25% patient tourniquet test positive Occult blood in stool Normal platelet numbers and function. Normal bleeding time. Normal clotting test Normal serum complement Other test: occult blood in stool US in abdomen for intussusception Urine analysis and liver function test Renal function test ( follow up 1 year after recovery) X-ray. ITP Laboratory: Hess test positive Thrombocytopenia(<40000/mm3 ) BT increase CT normal Clot retraction increase Bone marrow: megakaryocytes normal , some show little productive activity Atypical :=> lymphadenopathy, hepatosplenomegaly, anemia, neotropenia / Neutrophilia => bone marrow aspirate necessary to exclude leukemia Hemophilia A Laboratory: CT increase (3-4 min) BT normal Increased PTT ( phase I of coagulation cascade) Normal PT Functional assay: Factor VIII decrease. 5. Treatment Hemophilia A General: avoid severe injury Encourage nonviolent exercise (swimming). Avoid IM injection and aspirin Regular dental hygiene and regular dental exam. Avoid surgery if possible, if needed do replacement therapy in hospital with lab facilities for monitoring therapy response.
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Local measures: Bleeding arrest fro small wounds=> pressure, immobilization and cold compress. Cant cathetherize but can puncture urinary bladder. Replacement therapy: to prevent life threatening hemorrhage by increase plasma Factor VIII to maintain hemostasis. Products used fresh frozen plasma( 10-15 ml/ kg/ 12hrs) {has risk of hepatits, cryoprecipitate (also has risk of hepatitis), Factor VIII concentrate=> 250-1500 IU/ in 25ml, has risk of AIDS and hepatitis). ITP a) Acute:Vary according severity: only bruise ( absent mucosal or severe hemorrhage): no traetment Severe or mucosal bleeding: Prednisone( 2mg/kg/day for 2 weewks), IV Ig (400mg/kg/day for 5 days). Life threatening bleeding: severe headache with neuron signs with any patient with severe thrombocytopenia treat as emergency, do CT for brain, give massive dose platelets plus high dose of methylprednisolone plus IV Ig plus emergency splenectomy plus crainiotomy. b) Chronic: splenectomy ( can avoid by repeated therapy with IV Ig, cytotoxic drug {cyclophosphamide}) Spontaneous recovery after many years possible. Indication for ac treatment: severe thrombocytopenia , repeated mucosal bleeding, older children with menorrhagia. H-Ss purpura Sympthomatic treatment: to control joint and abdominal manisfestation. i) analgasics( colic abdominal pain) ii) Prednisone (2mg/ ky/ day), insevere case plus CNS manifestation.
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iii) NSAIDs : Ibuprofen iv) Antacids, proton pump inhibitors, H2 blockers vi) Heparin ( 1 tab has 5mg) complication: 1 ) infection give ab => amoxycylin 2 ) renal failure and intusuception manage accordingly. 13)The main regularities of weight and height changes during the first year of life. a)Physical state of a newborn. -Weight is not constant,it rapidly answers to all internal and external factors. -Full term newborn = 2500 to 4000gm -Newborn with body weight less than 2500gm are considered prematures. -Newborn with body weight more than 4000gms are considered large newborns. b)Physiological weight loss. -Most babies lose weight in the first 3 days (less than 10%). -Weight gain (25-35gm/day) starts by the 4th day and progresses onwards. -Underfeeding is considered in infants with excessive weight loss. -By 7th to 10th day of life most full term baby regain weight -These weight loss is due to perspiration - Drying from skin - Drying from umbilical cord - Discharge of urine and meconium - The first 2 days,child is unable to take large amount of milk c)Pathological weight loss. -Long regain of losses -Loss is larger than 10% of body weight. -They need medical correction and medical observation. d)Further changes in weight during the first year. -Full term babies has weight from 2500-4000gms. -1st month increase by 600gm. -2nd and 3rd month 800gm. -Each month after tht 50gms lesser than the previous.Ex:4th month -750gm, 5th month -700gms.. and so on. e)Changes in height during the first year. -Length of mature newborn is between 46-56cm.
29

-Length of premature babies is less than 45cm. -During first few days of life,length may decrease bcoz of the disappearance of birth tumour on the childs head in the first 2 days. -First 3 months-length increases 3cm per month. -2nd quarter 2.5 cm per month -3rd quarter 1.5-2.0cm per month. -Last 3 months of the 1st yr 1cm per month. -General increase is about 25cm for the first year.

14. CLINICO-FUNCTIONAL FEATURES OF NEWBORNS 1. Height and weigh in full-term newborns and prematures I. Height Full term newborn: 46 56 cm. Prematures : <45 cm. II. Weight Full term newborn: 2.5 4 kg. Prematures : <2.5 kg. 2. Neuro-psychological state of neonates I. Group of stable automatism Corneal, conjunctival, pharyngeal swallowing & carotid reflexes. Tendon reflexes of extremities. Orbido eyelid reflexes. II. Transient rudimentary reflexes Oral segment : Sucking, searching, lip & palmo mouth reflexes. Spinal segment : Grasping reflex, Moro reflex, reflex of support, reflex of automatic gait, creeping reflex, Barbinsky reflex, Halants reflex, Peres reflex. III. Reflexes appearing only after birth Labyrinth reflex. Simple & chain cervical & trunk reflexes. 3. Apgar score
30

Sign Score (0) Score (1) Score (2) 1. Heart rate Absent Below 100 Over 100 2. Respiratory rate Absent Slow, irregular Good crying 3. Reflex irritability Absent Sluggish responseCough @ sneeze 4. Muscle tone Lost Some flexion of Active motion extremities 5. Colour Blue @ paleBody is pink, Completely pink extremities are blue 4. Assessment of neonate at the delivery room Apgar score at 1 minute helps in assessment of the general condition of the newborn & in detecting the method of resuscitation needed. If the score; 8-10 : Normal infant. If the score; 4-7 : Mild moderate depression. Assure patency of airway. Gentle skin stimulation. If no improvement, ventilate by bag & mask. If still deteriorating & pulse rate decreasing, proceed to endotracheal intubation. If the score; <4 : Severely depressed. Assure patency of airway. Ventilate by bag & mask (AMBU) at a rate 40/min. If heart rate is still below 60/min, start external cardiac massage (120X/min). If the heart is still slow, colour poor & perfusion poor, start IV medications via an umbilical catheter. If respiratory failure persists, transfer the baby to the ICU for mechanical ventilation. 5. Routine care of a neonate at the delivery room Infant should be suspended with head downwards immediately after delivery until the mouth, pharynx & nose have been cleared of fluid, mucous, blood & amniotic fluid by gravity. Infant is received by the pediatrician in a dry sterile warm blanket. Gentle suction of the mouth & pharynx using soft rubber catheter is done. Stomach should be aspirated by a nasogastric tube.

31

 Infant is kept with head tilted downwards at an angle of 30 degrees to allow drainage from the respiratory tract. 15) Main regularities of height changing throughout childhood. 1. Height in full-term newborns and prematures. Mature newborn: - between 46-56 cm Premature newborn: - less than 45 cm 2. Changes in height during the 1st year of life. During 1st day of life, length may decrease slightly due to disappearance of birth tumor on child head in fist 2 days. Then, length always increases. During 1st 3 month of life, length increase for 3 cm per month. During the 2nd quarter, it increase 2.5 cm per month During the 3rd quarter, it increase 1.5-2 cm per month During last 3 month of 1sr year, it increase 1 cm per month. ** Generally, height increase 25cm for 1st year of life. 3. Height acceleration periods. 1st height acceleration period:Boys 4-5 years old Girls after 6 years old Then, growth rate become slower and has its minimum at :Boys 9 years old Girls 8 years old Then, a short stabilization period until:Boys 13 years old Girls 9 years old Then, 2nd height acceleration period begins:Boys 47-48 cm Girls 37-38 cm According to Tanners data, children stop grow in length at:Boys 18 years old Girls 16 years old 4. Hormonal regulation of height during childhood. Hormones promoting growth are:1) Somatotropic hormone of pituitary body 1 It promotes chondrogenesis. 2 It is important from 7-11 years of life 2) Hormones of thyroid gland 1 It influence osteogenesis
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2 Thyroxin has main influence on growth till 5 year of life. Then, during prepubertal & pubertal period 3) Insulin 4) Androgens 1 Has brief activity 2 Active during prepubertal and pubertal periods 3 After pubertal acceleration, it promotes discontinuance of growth 5. Contemporary methods of height evaluation. Formulas for approximate counting of height in diff periods of childhood:For children from 2 till 15 years :- 8 year old child has height 130 cm So, for each missing year subtract 7 cm, And for each extra year plus 5 cm.
16)Special features of skeleton and muscle system in children 1. Types of Osteogenesis 12345Type 1 osteogenesis imperfecta(mild) Type 2 osteogenesis imperfecta(perinatal lethal) Type 3 osteogenesis imperfecta(progressive deforming) Type 4 osteogenesis imperfecta(moderately severe) Type 5 osteogenesis imperfecta( hyperplastic callus)

2. Intrauterine Osteogenesis

3. Pecularites of skeleton in children The Osseous maturation(Bone age) It is determined by x ray on the hemiskeleton for the following data: a) the number and size of the epiphyseal centers b) the size , shape density and sharpness of outline of the ends of bones c) the distance separating epiphysis and metaphysic or the degree of fusion between these two elements. The ossification centres present in the full term baby at birth are: Distal end of femur, proximal end of tibia, the head of humerus, the calceneous, the talus and the cuboid

33

An xray on the hands and wrist can help in assessing osseous maturation instead of xray on hemiskeleton. The carpal centers are not present at birth but appear at about 2 months of age. Two carpal centers are present at one year of age, and in general one additional carpal center appear each year, so that seven centers are present at the age of 6 yrs. The metacarpal and phalangeal epiphyseal centers appear in the 3rd year. The distal radial epiphysis is present by the end of 1st year. The distal ulnar epiphysis appear at 6-8 yrs(in girls) and 7-10yrs(in boys) The bone age as calculated fro xray should be compared witth the true age( chronological age) of the patient: If the bone is less than chronological age , this is called delayed bone age which occurs in condition of growth retardation as congenital hypothyroidism and hypopituitarism. Advanced bone age occurs in condition as congenital adrenal hyperplasia, and hyperthyroidism. See also Nelson page 37 4. Order of deciduos teeth eruption Maxillary Central incissor Lateral incissor Canine First molar Second molar Mandibular Central incissor Lateral incissor canine First molar Second molar Eruption 7 1/2 months 8months 16-12 months 12-16 months 20-30 months Eruption 6 months 7 months 16- 20 months 12-16 months 20-30 months

5. Eruption of permanent teeth The secondary teeth begins to erupt when the child is about 7-8 years of age. The top teeth should overlap the bottom teeth all the way around the mouth and the child should bite down on the back teeth Maxillary Central incissor Lateral incissor canine First premolar Second premolar First molar Second molar Third molar Eruption 7-8 yrs 8-9yrs 11-12 yrs 10-12yrs 10-12yrs 6-7yrs 12-13yrs 17-21yrs 34

Mandibular Central incissor Lateral incissor canine First premolar Second premolar First molar Second molar Third molar

Eruption 6-7yrs 7-8 yrs 9-10yrs 10-12yrs 11-12yrs 6-7yrs 11-13yrs 17-21yrs

17. Periods of Childhoos: Postnatal life 1. Neonatal 28days (Path, Circulation, respiration, diff. birth injuries 1) Early includes 1st week of birth 2) Late includes next 3 weeks of childs life. Main characteristics: Adaptation of child to new condition of life. - Sterile, stable temperature in contrast which Ag, decrease T. - Thermoregulation must start, immune system start to protect child from foreign Ag. - Contamination which microbial flora occurs. - All nutrients in uterine period but after birth gas exchange (Pulmsystemic circulation) must be established and intrauterine communicans such as foramen ovale, ductuc arteriosus and ductus venosus must stop. Enteral nutrition with digestion and abs in GIT - Excretory system must function. - Characterised by physiological phenomena due to diff levels of function of diff system for adaption. 2. Infantile Period aft neonatal and ends at 1 yr of life. - Characterised by most intensice physical growth. - H x 2, W x 3. - Function activity of GIT low, thus nutrition should be easily digested and conc in small amount. - Breast milk can supply amount till 4-5 months of life. - Secretory portion of Ig A (for mucous membrane) - Bone is fragile - Incomplete digested product can lead to intoxication, allergy - Immunity during 1st year of life provided by maternal factors. (Breast Milk, placenta) - During 1st 6 months (GIT disease predominant)
35

- but 2nd half, decreased (upper respiratory infection etc (clinics > sever due to w/o own immunity thus start vaccination). - Most intensice development of motor function. - After 1st year, eruption of teeth start. - Manifestation of congenital diseases occurs. 3 Early Childhood 2nd, 3rd years of life Physiological Selfishness - Physical growth less intensive - By end of 2nd year of life, eruption of 20 desideus teeth complete. 2nd year most intensive development of coordination 3rd year intensive development of speech/language skills - unable to play so children left at home at this time. Periods of Lost Possibility: - Upper respiratory viral infection predominant. - Individual features of cha is formed. 4 Preschool 4 (6-7yrs) - Characterised by 1st most considerable height acceleration. - Improvement of memory, development of coordination of small muscles of hand (draw small details and write). - by end of thus period, immune system mature thus respiratory infection decreased. - Sexual distinction appears. 5 Schoolhood 1) Early (6-7) 11yrs - 1st sexual distinction in growth appears (grow earlier but less potential) In girls fatty tissue. In boys muscular. - Intensive intellectual development 2) Late/Adolescence (11-18years) - Sexual maturation which arise with changes of function of sexual gland and vegetative NS. - problems in psychological development. - Disturbance of maturation, endocrine disease. QUESTION 18 (PART1) CHANGES IN WEIGHT THROUGHOUT CHILDHOOD 1. WEIGHT IN FULL-TERM NEONATES AND PREMATURES Full term neonates weigh = 2500-4000gm
36

Prematures Large newborns

= < 2500gm = > 4000gm

2. PHYSIOLOGICAL WEIGHT LOSS Immediately after birth, child's eight is decreased. This is called Physiological weight loss - All these changes are due to adaptation of newborn to extrauterine life - Its heighest on the 3rd day and by the 7 /10th day infants regain their birth weights ( baby is able to intake small quantity of milk) - Infants should start to grow at approximately 30gm/day during first month - 14-16 days for preterms neonates to regain weight 3 main reason of weight loss: - loss of water through skin and lungs through respiration(7075%) - discharge of meconium - drying up of umbilical cord 3. PATHOLOGICAL WEIGHT LOSS long regaining of these looses and loss more than 10% is pathological and needs medical correction - effects usually preterm neonates, child with congenital heart disease, chronic gut or respiratory disorders Also knows as failure to thrive. Its causes are: Non-organic causes: - feeding problems: insufficient milk, wrong technique - maternal stress: inadequate food consumed, lack awareness of how much to consume, tense, poorly feeding child, - lack of stimulation and under-nutrition ( no demand for food) Organic causes: - inability to feed : mechanical plate(cleft palate), lack of coordination( cerebral plasty) - poor retention of food ( vomiting, gastro- esophageal reflux) - illness induced anorexia ( cystic fibrosis, congenital heart disease, ) - impaired nutritional reabsorption ( coeliac disease, malignancy) - metabolic ( hypothyroidism, congenital adrenal hyperplasia
37

organic acid disorders) miscellaneous ( chromosomal disorders, infections)

4. CHANGES IN WEIGHT DURING 1ST YEAR OF LIFE The first month weight gian = 600 gm 2nd month weight gain = 800gm 3rd month weight gain =800gm 4th month weight gain = 750gm 5th month weight gain = 700 gm and every month after than child gains 50gm less ( -50gm from previous month weight gain) 5) CONTEMPORARY METHODS OF WEIGHT EVALUATION 19) Feeding Of Infants. 1. Types of feeding. There are 3 main types of feeding: (i) Breastfeeding-Amount of breast milk is more than 80% of daily volume of nutrition. (ii) Formula feeding/Artificial feeding-Amount of breast milk is less than 20% or one-fifth of daily volume. (iii) Intermediate type of feeding (Combined feeding)-Amount of breastmilk is more than 20% but less than 80%. 2. Advantages of breast feeding. You can divide this into 2 categories. (i) Advantages for the Mother: 1. Easy, needs no preparation. 2. Economically, its the cheapest food. Its actually free. 3. Available at any time. 4. Helps involution of uterus. 5. Emotional satisfaction of mother and baby. 6. Lower incidence rate of breast cancer for those women who breast feed their babies.
(ii)

Advantages for the Infant:

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1. Natural, perfectly balanced diet to suit nutritional needs of infant. 2. Self-regulated. 3. Available at any time. 4. Always fresh. 5. At proper temperature. 6. Easy digestion and absorption, so baby sleeps and thrives well. 7. Emotional satisfaction. 8. Baby is always with mother, so it is taken better care of. 9. Non-allergenic and anti-allergenic properties of breast milk: Infants exclusively fed on human milk are less liable to allergic diseases such as: Infantile eczema, allergic rhinitis, allergic gastroenteropathy..etc. which can be caused by animal milk. Secretory IgA in human milk has a blocking effect preventing absorption of foreign proteins macromolecules from the GIT of newborn. 10. Rickets is less liable to occur in breast fed infants due to: Breast milk contains double the amount of vitamin D present in cows milk. Suitable Ca/p ratio helps better absorption of both. No loss of Ca in stools in form of insoluble Ca palmitate. 11. Fe deficiency anemia is less liable to occur at age 6-12 months(mo): Fe content is 1.5X more than that of cows milk. Better absorption of iron due to the presence of facilitating factors in breast milk like: vitamin C and E, larger amounts of Cu and the acidic medium of gut of the breast fed baby. No Fe loss in stools in contrast to formula fed babies which may suffer from repeated microhemorrhages of GIT. 12. Lower renal solute as the minerals in human milk are only th 1/4 of that in cows milk. 13. Lower incidence of malocclusion of teeth later on. 14. Less liability of contamination of milk by insecticides, pesticides, soil fertilizers (particularly NITRATES) and preservatives. 15. Breast fed baby is protected against infections: Anti-infective properties of breast milkBreast milk protects against gastroenteritis, necrotizing enterocolitis, otitis media, epidemic infectious diarrhea in newborn and gram - septicemia of newborn. The anti-infective properties are as follows:
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A)

Humoral factors:

1. Antibodies: breast milk and colostrums are very rich in immunoglobulins which give antibacterial, antiviral and antitoxic properties. Eg. (i) Secretory IgA Most IMPORTANT and acts as antiseptic intestinal paint on mucous membranes of infant. (ii) IgG, IgM,IgD are also present in lesser amounts. 2. Lysozyme: bacteriolytic against enterobacteriaceae and gram + bacteria. 3. Lactoperoxidase: bacteria killing enzyme. 4. Lactoferrin: it is an Fe binding protein present in human milk in an unsaturated form. It has bacteriostatic properties by depriving the bacteria from the Fe necessary for their growth. It is also effective against C.albicans. 5. Antistaphylococcal factor: present in lipid fraction of milk. 6. Interferon: protects against some neonatal viral infections. Eg. Herpes. 7. Bifidus factor: A mucopolysaccharide present in human milk and facilitating the growth of Lactobacillus bifidus which forms 99.8% of bacterial flora of the intestine of breast fed infants. Lactobacilli appear to have an intestinal guardian function, particularly in inhibiting the growth of undesirable, possibly harmful organisms as pathogenic E.coli. B) Cellular factors: Human milk is a live fluid containing up to 4 000 000 cells/ml of colostrums or early milk during the 1st few weeks of life. These cells assist in repelling infection in infants GIT. Most of them originate Peyers patches in mothers intestine, circulate in her blood to reach mammary gland, secreted with milk and ingested by infant and implants in his Peyers patches. These cells include: 1. Macrophages: they phagocytose and kill bacteria and fungi. They secrete lysozyme, lactoferrin and complement. 2. Lymphocytes: include B and T cells. B cells secrete antibodies particularly IgA, while T cells are concerned with cell mediated immunity. 3. Epithelial cells.

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C) Miscellaneous factors: 1. Cleanliness and lack of opportunity of contamination of breast milk. 2. Closeness and restricted micro-environment between mother and baby. 3. Low pH of the intestinal contents of breast fed babies offers a remarkable resistance to infection with enterobactericeae. 3. WHO declaration on breast feeding. PLEASE REFER TO QUESTION 3 OF FINAL EXAM FIRST QUESTIONS. ITS THE SAME THING. I PROMISE.
4.

Microadditions.

Given earlier than macroadditions. From age 3 mo, in small volumes, plus to the full volume of breast milk or formula, and never replace 1 whole feeding ( in comparison with macroadditions ) At 3 months, introduce small volumes of vit. C-containing fruit juices ( preferably sugar free ). Better if home prepared. Start from 3-5 drops and observe reaction. If during the week, no bad reactions-this means no intolerance or allergy to this type of food. Gradually add volume: 4 mo-30 ml/d, 5 mo-60 ml, 10-12 mo100 ml/day. From 4 mo, introduce slightly sweetened pureed (stewed) apple (better if green) and other fruits (banana mashed with breast milk or formula). Look at reaction. 5 mo-50 ml/d, 6 mo-60, 9-12 mo-100 ml/day. More examples of microadditions: --mashed fruit --butter, vegetable oil --curds, yoghurt 5. Types of macro-feeding up. st 1 macroaddition: ( 4.5-5 months ): Powdered instant cereal OR strained food like rice, oatmeal, porridge, semolina porridge, buckwheat porridge is given. Food must be semi-sloppy in nature, homogenized or strained. Itll begin with 5%, later 7-8 months ( 8% ), 10 months ( 10% ).
41

Replace it as 10 oclock feeding.

2nd macroaddition: ( 5.5-6 months ): Mashed vegetables potato, carrot, cabbage, turnip with little milk and vegetable oil. If infants have rickets, low-weight or pre-term anemia, replace 2nd addition to 1st. If child has diarrhea, its better to start off with porridge. Must be given in daytime. 6 mo: Egg yolk, 1/8, after 12 mo whole yolks or curd. 7 mo: Minced meat 8 mo: Meat balls ( stewed ). 10 mo: Boiled fish After 12 mo: Cutlets allowed. If infants are < 12 mo, NEVER give fish liver, broths, kidney, basically inside organs are contraindicated. 3rd macroaddition: ( 7.5-8 months ) Kefir and white bread. Best variant to continue breast-feeding until 1, 1.5-2 years. Part 1 Question 20 20. Acute bronchiolitis in children 1) Etiology - respiratory syncytial virus - para influenza virus - adeno-virus -mycoplasma 2) Clinics - Age 1st 2years of life, peak at 6month -Season winter n early spring a) Mild resp. tract infection (mid-upper) -rhinitis - low grade fever -cough - Irritability b) Development of resp. distress - Paroxysmal wheezing - feeding becomes difficult - cough - low grade fever -dyspnoea - irritability ( due to hypoxia) c) Objective examination
42

- grunting - acting ala nasi - cyanosis

- tachypnoea (60-80/min) - dehydration

3) Diagnosis 1. Chest examination a) Inspection - hyper inflated chest - tachypnoea - Prolonged expiration - intercostals, subcostal retraction 2. Palpation - tactile vocal fremitus decrease - palpable ronchi 3. Percussion - hyper resonance on both lungs 4. Auscultation - decrease air entry - long expiration - vesicular breathing - general wheezing Heart sound rapid, weak Heart failure with gallop rhythm can occur Liver, spleen palpable below arch( due to depression of diaphragm due to hyperinflation) Liver enlarged due to heart failure

4) Treatment - Hospitalization - humidified oxygen - IV fluid- if acidosis presentNaHCO3 added to infusion - Position infant at 30-40degree sitting + neck slightly extended - Antiviral Riba virin (virazole) inhalation for 3-5days - monoclonal antibodies - mechanical ventilators - gluco corticosteroid decrease complication 5) Complications - Pneumonia - Respiratory failure - Emphysema - Cor pulmonale

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22)Special features of urinary tract in children. a)Intrauterine development of urinary tract -morphogenesis begins 1st trimester of pregnancy, it develop until 36th week of gestation -during this time , kidney pass following stages: a)pronephron -appears at end of 3rd weeks of gestation -requires dorsal part of head of embryo for further development - this part not significant and it disappears b)mesonephron -appear at 4th week of gestation -kidney is not appeared -pelvis is appear -only tubes are formed c)metanephron -appears at 5th weeks of gestation -from mesodermal layers. -kidney forms at 7th week -kedney ascends and rotates 90 degree and all nephrons continues development until 36 weeks b)Postnatal development of urinary tract -kidneys excreate urine into amniotic fluid : 10 ml/kg -by birth time , morphological and functional develop is not completed -kidney located T11 or T12 to L 4 -by 2nd year of life , all these topographic features of kidney disappear -urethra is wide and hypotonic coz muscle fiber are poorly developed c)special features of kidneys -kidney has tubular structure -prirenal fat layers are poorly developed , so kidneys are mobile and may develop nephroptosis -cortical layers develop in sufficiently but number of glomerulas are the same as in adults -structures not the same as adults -juxterglomerular system not developes -morphological maturation is completed by 3-5 years -functional maturity reaches by 7-8 years -GFR reaches adult level at 2 years of age -concentration ability is 2 times lower than adults -urethra is wide & hypotonic because muscular fibres are poorly developed. d)Special features of urine bladder -neonatal bladder is located higher than adults -has oval form -capacity is 50 ml -has RBC and protein in urine and it is physiological -no. of urinatory / days = 20-25 times e)Methods of renal function investigation -biochemical analysis creatine and urea -zimnetsky test -daily taken 8 portion of urine and check specific gravity at every 3 hrs .find concentration ability of kidney -reberg test to find tubular reabsorption ( >98ml/min) GFR (80 100 ml /min ) -nitchiparenk test WBC cont , RBC and casts in 1ml of urine -creatine clearance test

23. Artificial Feeding in Infants. 1. Definition of artificial or formula feeding.

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It is a supply substitute to normal breast milk, a modified animal milk that promote growth and normal health of a baby and near as possible normal to baby put on breast. 2. Indication. 1.All contraindications to breast feeding i) mother dangerous: psychiatric, useless (drug addict, death bed) ii) infant allergy, congenital anomaly: cleft palate metabolic: PKU, hemolytic disease( e.g. => ITP ) 2. death of mother 3. insuffiency of breast milk ( mother not produce enough) 4. Twins ( not enough milk => milk not enough to satisfy ) 5. mother employment 6. institutions: nurseries 7. Metabolic disease: PKU, galactocemia 3. Classification. a) types of formula feed: i) substitute, ii) mixed - complementary - supplementary b) according to content of milk: i) humanized milk: vegetable (e.g. => soy ) cow ( can be American, European ) buffalo ii) modified special milk: Isomil, Iofenalac iii) acidified milk formula c) according to forms: dry liquid 4. Methods of calculation of amount of formula feed. I) age less than 10 days - V = ml/d (Total volume per day) - n = age in days -Weight of child can be >3200g or <3200g - if weight is >3200g use 80 denominator , if weight is <3200g use 70 denominator - number of feeding is usually 7 times. 1) V = n x 70 = total volume for 1 day @ V = n x 80 = total volume for 1 day V / 7 = volume for 1 feed (ml / feed / day) 2) V = 10 x n = volume for 1 feed
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V x 7 = volume for 1 day 3) Daily volume (ml / day ) = 2% birth weight x n 4) 1 feed (V) = 3ml x n x birth weight II) age more than 10 days. 1) Volume (age + weght) for mature babies i)2 6 wk=> 1/5 x body weight ii)6wks 4mth => 1/6 x body weight iii) 4 6 mth => 1/7 x body weight iv) 6 -9 mth=> 1/8 x body weight Energy needed for premature and ill babies 25 kkal/kg X 5x for 4days 50kkal/kg X 10X for 10 days Day 14 = 100 kkal/ kg Day 21 = 120 kkal/ kg Day 30 = 135 kkal/kg Use 130 135 kkal/kg upto 2nd quarter 2nd quarter = 115 120 kkal/ kg III) Energy needed for mature babies. 1st mth = 120 kkal/kg 2nd mth = 115 kkal/kg 3rd mth = 110 kkal/kg 4th mth = 100-105 kkal/kg IV) Daily rate of food - 0 2 mth = 7-8 feeds per day , with 3-2.5hrs between feed - 2 6 mth = 6 7 feeds per day, with 3.5 3 hrs - 6 1yr = 5 6 feeds per day, with 4 hrs between meals - >1yr = 4 5 times, with 5.5 6 hrs between meals. 5. Criteria for adequacies for feeding. 1. Infant calm and satisfied after feed. 2. Infant sleep well 2 3 hrs after feed. 3. normal stool motion ( semiform, mustard yellow, soft, acidic odour and frequent ) with no constipation. 4. Normal urine amount. 5. Normal weight gain ( estimate by weight chart, test weight and test feed) Set 1: Question 24 Failure to Thrive

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1) Etiology: Prenatal: - Maternal: - Severe malnutrition - Severe infections - HT - Pre-eclampsia - Excessive exercises - Abnormal uterus - Hyperpyrexia - Low socioeconomic conditions - Placental - Placental abruption - Low lying placenta - Placental infarction - Abnormal insertion of cord - Fetal - Multiple gestation - Chromosomal disorders - Intrauterine infections - Genetically small size Postnatal: - Poverty - Sucking disorders bad teat of bottle, lips abnormality blocked nose or palate. - Vomitting due to pyloris stenosis or gastroesophageal refluxes - Skin disorders eczema, burns - GIT hemorrhage. - Kidney diseases DM, nephrotic syndrome. - Failure to supply sufficient calories due to poverty, usual dietary beliefs. - Failure to ingest sufficient calories due to anatomical structure abnormalities, cardiac, pulmo, CNS disorders. Interactive prob is parents and child. - Failure to utilize adequate calories due to GIT diseases, renal endocrine, metabolic, infectious, cardiac disorders, cystic fibrosis. 2- Classification Gomes classification: 1st degree 10-24% below expected birth with for age
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2nd degree 25-39% 3rd degree - >39% Russian Classification: 1st degree 10-20% 2nd degree 20-30% 3rd degree - >30% 3 Clinical Signs In Mild phase (10-20% below expect) - Skin folds 2-3mm - Irritability - Immune reaction normal or slightly decreased - Psychomotor develop is norml - Hyperactivity - Infant is hungry - Hypotonus of muscles - Slow rate of weight gain

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