MINISTRY OF PUBLIC HEALTH OF UKRAINE O.O. BOGOMOLETS NATIONAL MEDICAL UNIVERSITY
Pediatrics 3rd edition, reprint
Edited by Professor O. Tiazhka
Vinnytsia Nova Knyha 2018
УДК 616-053.2(075) П24 Рекомендовано Міністерством охорони здоров’я України як підручник для англомовних студентів вищих медичних навчальних закладів IV рівня акредитації (протокол № 5 від 28.12.2010 р. засідання науково-методичної Комісії з медицини Міністерства освіти і науки України) Authors: Tiazhka O. V., Pochinok T. V., Antoshkina A. M., Yashchenko Yu. B., Bobrova V. I., Gorobets A. O., Lutay T. I., Mellina T. V., Vinnytska O. P., Minchenko D. O., Pyatnytskyi Yu. S., Vasiukova M. M., Koliubakina L. V., Barzilovich A. D.
Reviewers: The Head of the Pediatric Department No. 4 of the O. O. Bogomolets National Medical University, Professor V. Maydannyk MD, PhD, DSc, Academician of NAMS of Ukraine. The Professor of the Pediatric Department No. 2 of the O. O. Bogomolets National Medical University, Professor S. Krivopustov MD, PhD, DSc. The Head of the Pediatric Department No. 2 of I. Horbachevsky Ternopil State Medical University, Professor G. Pavlyshin MD, PhD, DSc. Translation reviewer: The Head of the Department of Foreign Languages of the O. O. Bogomolets National Medical University, Associate Professor L. Avrakhova
Педіатрія = Pediatrics : textbook / O. V. Tiazhka, T. V. Pochinok, П24 A. M. Antoshkina [et al.] ; edited by O. Tiazhka. – 3rd edition, reprint. – Vinnytsia : Nova Knyha, 2018. – 544 pp. : il. ISBN 978-966-382-690-5 The textbook contains materials on pediatrics within the curriculum for the students of medical faculty, who master pediatrics during IV, V, VI years of study. Each unit contains its current relevance, the aim of the lesson, a list of questions a student is to know after self-training, a list of practical skills a student must acquire having covered the topic. Besides, there are additional materials and educational tests. For the students of medical faculties of higher medical educational establishments of the III–IV levels of accreditation and teachers. УДК 616-053.2(075)
ISBN 978-966-382-690-5
© Authors, 2018 © Nova Knyha, 2018
P ediatrics
Content I. Children’s Prophilactic Medicine .............................................................................................. 5 The contents of the pediatrician’s work at the children’s polyclinic. Vaccinations (Mellina T. V., Gorobetz A. O.) ................................................................................... 5 Diathesis (Tiazhka O. V., Mellina T. V.) ............................................................................................ 16
II. Deficit Diseases of Early Childhood .................................................................................... 24 Rickets (Tiazhka O. V., Mellina T. V.) ................................................................................................ 24 Chronic disorders of nutrition (Tiazhka O. V., Vasiukova M. M.).......................................... 36
III. Neonatology .................................................................................................................................... 50 Newborn period, premature infant’s adaptation, medical care (Yashchenko Yu. B., Koliubakina L. V.) ........................................................................................... 50 Asphyxia (Gorobetz A. O.) ................................................................................................................. 65 Birth trauma (Gorobetz A. O.) ........................................................................................................ 75 Respiratory disorders of newborn (Yashchenko Yu. B., Koliubakina L. V.) ....................... 84 Hemorrhagic disease of newborns (Mellina T. V.)................................................................101 Neonatal jaundices (Gorobetz A. O.) ...........................................................................................109 Infections of the fetus and newborn infant (Yashchenko Yu. B., Koliubakina L. V.).....132 Purulent-septic diseases in infants (Vasiukova M. M.)........................................................151
IV. Blood Diseases .............................................................................................................................163 Anemias (Pochinok T. V., Vinnytska O. P.) .....................................................................................163 Hematoblastoses (Vinnytska O. P., Gorobetz A. O.)...................................................................201 The bleeding (haemostatic) disorders (Vinnytska O. P., Mellina T. V.) ............................219
V. The Respiratory System’s Diseases ....................................................................................230 Pneumonia (Pochinok T. V.) ............................................................................................................230 The acute respiratory viral infections and acute bronchitis in children (Pochinok T. V.) .........................................................................................................245
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VI. The Cardiovascular System’s Diseases............................................................................266 Acute rheumatic fever in children (Pochinok T. V.)...............................................................266 Non-rheumatic carditis in the children (Pochinok T. V.).....................................................281 The disorders of heart rhythm in the children (Vasiukova M. M.)..................................292 Congenital heart diseases (Pochinok T. V.)...............................................................................321 Diffuse diseases of the connective tissue (Pochinok T. V.).................................................354
VII. The Digestive System’s Diseases.......................................................................................364 Functional disorders (Gorobetz A. O., Bobrova V. I., Minchenko D. O.).................................364 Chronic gastritis and gastroduodenitis in children (Gorobetz A. O., Bobrova V. I.)......374 Gallbladder dysfunctions (Gorobetz A. O., Bobrova V. I.).......................................................386 Celiac disease (Gorobetz A. O., Bobrova V. I.)..............................................................................403 VIII. Nephrology..................................................................................................................................435 Glomerulonephritis (Lutay T. I., Mellina T. V.)...........................................................................435 Pyelonephritis (Lutay T. I., Gorobetz A. O.).................................................................................450
IX. The Endocrine System’s Diseases......................................................................................467 Diabetes mellitus (Antoshkina A. M., Gorobetz A. O.)...............................................................467 Thyroid gland diseases (Antoshkina A. M.)...............................................................................489
X. Allergic Diseases...........................................................................................................................502 The most common allergic diseases (Pyatnytskyi Yu. S., Mellina T. V).............................502 Bronchial asthma (Pyatnytskyi Yu. S., Mellina T. V)..................................................................511 Appendices (Barzilovich A. D.)..........................................................................................................529 Appendix 1..........................................................................................................................................529 Appendix 2 .........................................................................................................................................534 Appendix 3 .........................................................................................................................................537 Appendix 4 .........................................................................................................................................541
LIST of AUTORS....................................................................................................................................542
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I. Children’s Prophilactic Medicine The contents of the pediatrician’s work at the children’s polyclinic. Vaccinations The child’s health state complex evaluation. The health level of each child is the main index of the Health care system measurements effectiveness. The health is not just the absence of diseases and injuries, but it is also harmonious neurologic-and-behavioral and physical development, normal functioning of all organs and systems, absence of diseases, sufficient ability of adaptation to unusual environmental conditions and resistance to unsuitable influences.
The state of the child’s health is examined with the help of main criteria estimated during each prophylactic inspection of decreeted age groups. The next signs are taken into account: 1. Deviations in ante-, intra-, early postnatal periods. 2. Neurologic-and-behavioral and physical development level and harmoniousness. 3. Main organs and systems functional state. 4. Resistance and reactivity of the organism. 5. Chronic and concomitant pathology availability or absence.
The complex evaluation makes it possible to form the groups joining the children with the same state of health taking into account all the indexes mentioned above. Group I — healthy children with all systems functional development normal indexes who are ailing 3 and less times a year and have normal neurologic-and-behavioral and physical development and no significant deviations in anamnesis.
Group II — the group of risk: y subgroup A — the children with risk factors from biological and sociological anamnesis data; • subgroup B — the children with functional deviations, primary changes in physical and neurologic-and-behavioral development, frequently ailing but having no chronic diseases.
Groups III, IV, V — the children with chronic diseases: Group III — the state of compensation: seldom exacerbations of chronic diseases, seldom acute diseases, normal level of the organism’s functions.
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Group IV — the state of subcompensation: frequent (3–4 times a year) exacerbations of chronic diseases, frequent acute diseases (4 times a year and more), worsening of the functional state of different systems. Group V — the state of decompensation: significant functional deviations (pathologic changes of the organism; frequent and severe exacerbations of chronic diseases; frequent acute diseases; the level of physical and neurologic-and-behavioral development is corresponding or backward). To get the first impression about the initial level of health of the child a complex evaluation is carried out during the first visit to the child at his home after the discharge from the maternity house The health level evaluation of children of the first two years of life is carried out each 3 months; for children of the third year of life it is carried out once in six months. In case there are more than one diagnose, the group is estimated in accordance with the main one. In the process of observing the child, the group may be changed dependently on the health state dynamics. Children of I group of health are to be examined in usual terms estimated for prophylactic examinations of adults. Children of II group are to be under special attention of pediatricians as prophylactic and treatment measurements may contribute to removing these patients to I group of health. Children of II group are examined and sanitated in accordance with an individual plan which is composed in conformity with the chronic pathology forming risk degree, expression of functional deviations and resistance degree. Children of III, IV and V group are under pediatricians and specialists observation in accordance with “Methodical recommendations on the prophylactic medical examination of “children’s population” and have to receive necessary treatment dependently on the availability of one or other pathology.
The main principles of prophylactic medical examination of children
The main method of prophylaxis in pediatrics is prophylactic medical examination of healthy children. Up to 1997 all children under the age of 15 years had been observed by pediatricians. Nowadays all children from the birth till the age of 18 years are observed by children’s doctors. In prophylactic medical examination the child’s health complex evaluation with the group of health estimation is carried out. According to the received results the value and the character of treatment and sanitating measurements for children with revealed pathology or the tendency to it are estimated. In modern conditions the prophylactic medical examination is the basic form of children’s polyclinics work. The prophylactic medical examination is carried out in accordance with the age of the child and the child’s diseases as well. The following contingents of children’s population are subjected to the prophylactic medical examination by the district pediatrician: 6
yy all children in the neonatal period (every month); yy children of the first year of life (every 3 months); yy children from the groups of risk; yy children elder than 1 year who don’t attend any pre-school establishments (every 6 months); • children with chronic diseases (together with specialists). The prophylactic medical examination of the children’s population includes the following measurements: 1) regular medical examinations with the carrying out of laboratory and instrumental investigations estimated value; 2) evaluation and estimation of the health state in order to reveal the children who have any factors of risk; 3) final examination of sick children who need it with the use of all modern diagnostic methods; 4) detecting of the diseases on early stages with the following carrying out of necessary treatment-sanitating measurements complex and the children’s health state dynamical observation.
The district pediatrician is responsible for all stages of prophylactic medical examination carried out. Each child subjected to prophylactic medical examination has his own “Prophylactic medical examination control card” (the form № 030/u). Besides signal functions (prophylactic medical examinations attending control) carrying out it also reflects the information about the health state of children of different groups of age. This information helps the pediatrician in prophylactic medical examination carrying out, observing the terms of examination and emergency treatment-sanitating measurements. The control card should be first of all an operative document in doctor’s work.
Vaccinal prevention of infectious diseases in children The last 10 years are characterized by the increased number of the socalled guided infections — diphtheria, pertussis, rubella, epidemic parotiditis (mumps), tuberculosis. These infections tend to have severe course and severe complications leading to disability (for instance, poliomyelitis). Vaccinal prevention (Table 1.1) is the most effective and economically substantiated way of decreasing the number of infectious diseases in children. There are a number of contraindications for prophylactic immunization (Table 1.2) wich are usually caused by allergic reactions of various origin. Even if there are no contraindicatios the doctor should examine the child carefully before the procedure and continue careful observation during vaccination to prevernt the development of local or general postvaccination reaction (Table 1.3; 1.4) 7
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3 months, 3 times
Against pertussis, diphtheria and tetanus (APDT)
12–15 months
Against rubella
0 (12 hours of life), 3 months, 5 months
12–15 months
Against parotiditis
Against hepatits B
12–15 months
Against rubeola
Against diphtheria and tetanus
3 months, 3 times
3–5 day of life
The term of vaccination start
Against poliomyelitis
Against tuberculosis
The list of infections
15 years – girls
15 years – boys
6 years
18 months – APDT
18 months
7 years
I
6 years – ADT
3 years
14 years
II
11 years – ADT-m
6 years
III
14 years – ADT-m
14 years
IV
The term of revaccination
Table 1.1. The prophylactic immunization’ calendar
18 years – ADT-m
V
Vaccine against hepatitis is prescribed to newborns in the dose of 0.5 ml
Vaccination and revaccination is taking disposably
The second vaccination is taken by ADT-anatoxin in the dose of 0.5 ml. The third and all other revaccinations are taken by ADTM-anatoxin
Immunization is taking by APDT-vaccine 3 times with an interval for 1 month among each vaccination in the dose of 0.5 ml. APDT-vaccine is used till 3 years 11 months and 29 days
Vaccinations are taking 3 times with an interval for 1 month among each time
Vaccination and revaccination is taking disposably. Children with a negative Mantoux test are subjected to revaccination in 7 and 14 years
The notes
Table 1.2. The list of contraindications for prophylactic immunization Vaccine
Contraindications
All vaccines and anatoxins
Severe complications from preliminary dose such as anaphylactic shock. Allergic reaction to any of vaccine’s components. Progressive diseases of nervous tissue, hydrocephaly and hydrocephalic syndrome in the stage of decompensation; epilepsy, epileptic syndrome with convultions no more than 2 times a month. Anemia with a level of hemoglobin equaled 80 g/l (prophylactic immunization is taken after hemoglobin’s level increasing)
All live vaccines
Congenital combined immunodeficiencies, primary hypogammaglobulinemia (vaccine’s introduction is contraindicated in selective Ig A and Ig M immunodeficiencies, hemoblastosis, malignant neoplasms, AIDS, pregnancy
BCG
Newborn’s body weight less than 2000 g, in prematurity of the II degree (body weight 1500–1999 g). Vaccination is not taken before the age of 1 month. Complications in previous immunization (lymphadenitis, keloid cicatrix, osteomyelitis, generalized BCG-infection, tuberculosis infection)
Vaccine against poliomyelitis
It is recommended immunization by inactivated poliomyelitic vaccine for children who has some contraindications for a live vaccines’ introduction and also for their family members
The list of possible complications, which arise in prophylactic immunization’ taking A. Anaphylactic shock. B. Generalized rash (eruption), polymorphocellular erythema, Lyell’s syndrome. C. Encephalitis, encephalopathy, polyradiculoneuritis, mononeuritis, meningitis. D. Acute miocarditis, acute nephritis, thrombocytopenic purpura, agranulocytosis, hypoplastic anemia, systemic diseases of connective tissue. E. Complications after BCG-vaccination, lymphadenitis, regional abscess, keloid cicatrix, osteomyelitis. Table 1.3. The character and evaluation of general and local reaction for immunization A general reaction
An appraisal of intensity Mild
Temperature increasing To 37.5
Clinical symptoms General weakness, headache, vertigo, nausea, catarrhal
A local reaction
Infiltration size To 2.5 cm
Other local manifestations Hyperemia without infiltration
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A general reaction An appraisal of intensity
Temperature increasing
Clinical symptoms
A local reaction Infiltration size
Other local manifestations
effects in nasopharynx, conjunctivitis, rash and other clinical manifestations of different intensity Mean
37.6–38.5
All signed above manifestations of a mean severity degree
2.6–5 cm
Infiltration with lymphadenitis without lymphangoitis
Hard
38.6 and higher
Severe manifestations
More than 5 cm
Infiltration with lymphadenitis and lymphangoitis
Emergency protection from anaphylactic shock Anaphylactic shock is one of the most dangerous and severe manifestations of allergy. It often happens in children with allergic diseases. An emergency cover includes the next: A. Doctor must stop allergen’s entrance to organism. In intramuscular introduction of allergen, a tourniquet should be placed on for 25–30 min, the place of injection should be injected by 1 % solution of adrenaline hydrochloride or 1 % solution of mezatone, diluted in 3–5 ml of isotonic solution of sodium chloride. B. Oxygenotherapy. C. Subcutaneus introduction of 0.2–0.5 ml of 1 % solution of adrenaline hydrochloride every 10–15 min until taking a child out of shock. D. Intravenous introduction of 10 % solution of calcium chloride or calcium gluconate (1 ml for 1 year of life), antihistamine preparations (benadryl, promethazine, suprastine, pipolphen) in the doses recommended for the given age. E. Glucocorticoid hormones — hydrocortisone, prednisolone (2–5 mg for 1 kg of weight for prednisolone). F. In bronchospasm — bronchial spasmolytics (aminophylline, allupent, novodrine). G. In acute obstructive respiratory failure — to eliminate the mucus from respiratory tracts, to preserve the falling back of the tongue and to remove this complication if it has already happened. H. During arterial hypotension — intravenous drip-feed introduction of noradrena line hydrotartratis or mezatone. I. Intravenous stream introduction of corglicone, celanide, strophantine in isotonic solution of sodium chloride. 10
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APDT, ADT
BCG
Vaccine
During first two days after the vaccination
General: body temperature rising with no acute disorder of the child’s general state
First two days
Acute general: body temperature rising more than 38.6
Encephalopathy: cerebral functions’ disorder, intracranial pressure rising (uninterrupted loud cry in children)
Collaptoid state: muscular tonus reduction, sudden paleness, vertigo, sleepiness, cardiovascular and respiratory insufficiency
During first two days
During first two days
General: body temperature rising up to 38.6 with no acute disorder of the child’s general state
Acute local: soft tissues’ edema more than 5 cm, infiltration 2 cm.
Local: hyperemia of skin, infiltration up to 2 cm
Allergic complications: angioneurotic Quincke’s edema, nettle rush, exacerbation of allergic diseases In some cases — system reactions like anaphylactic shock
Subcutaneous cold tuberculous abscesses (the breach of introductive technique) Superficial ulcer (the breach of introductive technique) Regional lymphadenitis Keloid cicatrix Osteomyelitis Generalized BCG-infection
Complications
During first two days
Acute general: never happens
5–7 weeks after the vaccination
4–6 weeks after the vaccination
Term after introduction
Acute local: soft tissues’ edema more than 20 mm, infiltration 10 mm
Local: infiltration 5–10 mm
Reaction
Table 1.4. The terms of main postvaccinal reactions and complications development
7 days
7 days
24 hours
10 days
5–12 months 1–1.5 months 1–1.5 months
1–2 months
1–2 months
1–2 months
Term after introduction
12 Term after introduction
On 6–12th day, duration — 1–3 days Toxic complications: body temperature rising more than 38.6, manifestation of intoxication, acute catarrhal effects, rush
Acute general: body temperature rising more than 38.5, catarrhal effects in nasopharynx, conjunctivitis, appetites reduce, general weakness, headache, sometimes — rush
Acute miocarditis
First 1–3 days
Local: hyperemia and edema of tissues
6–11 days, duration — up to 30 days
6–11 days, duration — 3–5 days
10–15 days
Allergic complications: polymorph rush, angioneurotic Quincke’s edema, arthralgias In some cases — system reactions like anaphylactic shock Encephalopathy: convulsions, intracranial pressure rising, consciousness’ disorders. In some cases — encephalitis
Complications
LMV
Term after introduction
consciousness’ disorders, convulsions, 7 days pathologic reflexes, extremities’ 3 days paresises In some cases -encephalitis Residual state: appearing of convulsions in body temperature lower Up to 30 days than 39.0 in case if they were absent in anamnesis and took place during 1 year after vaccination Acute miocarditis, acute nephritis, aseptic (serous) meningitis (quite rare)
Reaction
APDT, ADT
Vaccine
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From 3rd to 10th day
General: body temperature rising up to 37.5, slight hyperemia of fauces, running nose, appetite reduce, abdominal ache Painless enlargement of salivary glands
General: short-lived worsening of general condition, low grade fever
Local: hyperemia, pain, cutaneous swelling, itch, lump in the place of introduction
1–3 days
1–4 days
7–14 days, duration — no more than 1–2 days
General: body temperature rising, rush, lymphatic nodes enlargement
Vaccine against hepatitis B
1–3 days
Local: hyperemia
Vaccination against rubella
2–3 days
Bowel dysfunction
3 days, duration — 42 days
First 1–3 days
Term after introduction
Local: hyperemia
Reaction
LVS
LPV
Vaccine
10 days 24 hours 7–14 days 14–30 days 14–30 days
7–30 days 7–60 days after immunization of vaccinated persons 10 days
The 5th–21st day
7–15 days
7–15 days
1–16 days
Term after introduction
Allergic: Quincke’s edema, serum Up to 30 days sickness with arthritis and skin reactions (erythema, erythema nodosum, etc.) development Anaphylactic reactions 24 hours In some cases –— myalgia, peripheral Up to 30 days neuropathy, facial paralysis, Guillain — Barre syndrome, optic neuritis
Allergic complications: nettle rush In some cases – anaphylactic shock Encephalopathy: convulsions, connected with hyperthermia Acute arthralgia, acute polyarthritis Transitoric polyneuropathy
Vaccinoassociated poliomyelitis: flabby paresis of extremities (mainly the lower ones): in vaccinated persons in contact persons Allergic complications: rush, Quincke’s edema (quite rare)
Allergic complications: nettle rush, angioneurotic Quincke’s edema Encephalopathy: convulsions, consciousness’ disorders. Toxic complications: high temperature (more than 38.5), vomiting, abdominal ache Serous meningitis on the background of hyperthermia
Complications
Vaccinations’ main complications treatment Ethiotropic therapy is used only in some complications after BCG introduction. Taking into account vaccinal strain specific influence on mycobacteria, one of antituberculous drugs is prescribed (isoniazid dosing 10 mg per 1 kg of body weight in a day, phthivazid — 30 mg per 1 kg of body weight in a day, PASA (paraaminosalicylic acid) — 20 mg per 1 kg of body weight in a day, streptomycin — 20 mg per 1 kg of body weight in a day intramuscularly. 10 % phthivazid liniment and 20 % liniment with PASA are used for local application in ulcers). Encephalitic syndrome. Dehydration is used (15–20 % solution of mannitol dosing 1–1.5 mg per 1 kg of body weight, lasix — 1–3 mg per 1 kg of body weight in a day in 2–3 doses intramuscularly or intravenously with the next changing into acetazolamide (0.125–0.25 g per os). Spastic syndrome. Diazepam is used intramuscularly or intravenously on 10 % glucose solution dosing 0.05 mg per 1 kg of body weight; phenobarbital — under the age of 1 year — 1 mg per 1 kg of body weight, elder than 1 year — 10 mg per 1 year of life separately or combined with definin in equal quantity. 25 % solution of magnium sulfate is used dosing 0.2 ml per 1 kg of body weight intramuscularly. In case if mentioned measures have no effectiveness sodium oxybutyrat dosing 50–100 mg per 1 kg of body weight with 20–30 ml of 5 % glucose solution is introduced intravenously. In allergic reactions and complications antihistaminic drugs in age doses are used (perorally or parenterally). In severe cases of allergic complications prednisolone and dexamethasone are used dependently on severity of complication. Measurements on anaphylactic shock treatment are described in the next topic.
Vaccination of children who had reaction in previous immunization carrying out
Continuation of vaccines introduction is contraindicated to those who had severe reactions or complications on the previous dose. As their appearance is more often connected with pertussis’ component introduction, so the next buster-dose is introduced with ADT-anatoxin; live vaccines (ОPV, LMV, LPV) are contraindicated to these children. Quite often allergic complications may develop as an answer on vaccines’ first dose introduction. In this case the next immunization should be carried out at the in-patient department and antihistaminic drugs or corticosteroids are to be prescribed 2–3 days before on the background of hypoallergenic diet.
Self-control questions A. The main line of the district pediatrician work. 14
B. The main principles of prophylactic medical examination of children with chronic diseases. C. Contraindications to immunization. D. Possible local and general reactions on immunization, the terms of appearance on different vaccines. E. The terms of appearance possible complications on different vaccinations, emergency. F. Working out an individual immunization calendar for certain child with the breach of vaccination terms and without it. G. Treatment of children in postvaccinal reactions and complications appearance.
Tests 1. The child, 1 year old, came to the district doctor reception 1 month after treatment of obstructive bronchitis, respiratory insufficiency of degree I–II at the in-patient department. During 5 days he received prednisolone dosing 1 mg per 1 kg of body weight in a day. What is the tactics of immunization? A. LMV should be immediately carried out. B. LMV should be carried out 2 weeks later. C. LMV should be carried out 3 months later. D. LMV should be carried out 6 months later.
2. “Bruton’s agammaglobulinemia” was diagnosed in 7 months old child. What vaccines can be used for immunization? A. APDT. B. BCG. C. Against measles. D. Against epidemic parotiditis. E. Poliomyelitis inactivated vaccine. 3. To what age is APDT vaccine used for immunization? A. To 2 years 11 months and 29 days. B. To 3 years 11 months and 29 days. C. To 4 years 11 months and 29 days. D. To 5 years 11 months and 29 days.
4. 6 years old child had been vaccinated with BCG on the 5th day of life at the delivery house. No one of following vaccinations were carried out. What is the plan of immunization? A. APDT three times. B. ADT two times. C. Vaccines against measles and epidemic parotiditis. 15
D. ADT-m 4 times. E. Vaccines against measles, rubella and epidemic parotiditis.
5. 16 years old child is not vaccinated. He came to pediatrician’s reception for solving the problem of immunization. Contraindications are excluded. What is the plan of vaccinations against diphtheria? A. APDT three times. B. ADT two times. C. AD 2 times. D. ADT-m 2 times. E. ADT-m 3 times.
Tasks 1. The child, 6.5 months old, born from physiological pregnancy and normal delivery. The parents are healthy. Breast feed. Smiles, seats without support, pronounces separate syllables, tries to creep. Objective examination of the child has detected no pathology. How often does the district doctor have to carry out an active examination of the child under the age of 1 year? A. Once a week. B. Once in a month. C. Twice in a month. D. Once in 2 months. E. Once in 3 months.
Diathesis Diathesis’ study lies in a basis of prophylactic medicine. Early diagnosing of diathesis (prenosologic stages) makes it possible to approach in health forming timely, identically and differentiated, enables abilitation’s carrying out, rehabilitative measures’ prescription and, therefore, diseases’ primary prophylaxis. Medical rehabilitation — lost or damaged functions’ reproduction or compensation.
Modern notion of diathesis Diathesis is not a disease. It is the peculiarity of organism’s functioning — the constitution, which causes the tendency to certain diseases’ development and peculiarities of their course as well. These deviations from normal phenotype manifest itself as 16
unstable balance of immune, metabolic, neuroendocrinal homeostasis. This instability is closely connected with age peculiarities and process of tissues’, organs’, enzymatic systems’ maturation and differentiation. In diathesis’ forming the leading role belongs to polygenic inherited factors; the influence of negative fetal factors (such as gestosis, virus-and-bacterial diseases, menace of fetus wastage) is of significant importance as well. According to IDC-10, 15 of 17 human diseases’ classes (except traumas and poisonings) have inherited tendency. It means that there are as many diathesis as diseases’ classes; for instance there are described atopic, autoallergenic, pneumonic, encephalitic, intestinal-ulceric diathesis and others. It has been historically formed that the most researched are the following three types of diathesis: allergic, lymphatic and neuroarthritic (or urine acid diathesis) ones. Allergic diathesis (AD) is organism’s prenosologic stage with minimal transit manifestations; it is the readiness for allergic reactions and diseases resulted by inherited, congenital peculiarities of immunity, neurovegetative homeostasis and metabolism. Children with AD have a tendency to development of allergic diseases (bronchial asthma, skin and digestive system allergic diseases, Quincke’s edema, anaphylactic shock, etc.). Diagnostic criteria of AD: yy inherited tendency to allergy (allergic reactions and diseases in relatives); yy allergic reactions in child (with mild course or transit) on food-stuffs, drugs, vaccines, chemical substances, insects’ bites, etc.; yy repeated acute obstructive bronchitis and stenosis of larynx; yy “geographic tongue”; yy frequent episodes of fluid excrements with no changes of general habitus; yy eosinophilia in blood and secrets (nasal mucous, saliva, sputum); yy increased level of IgE, deficit of IgA and T-lymphocytes; • decreasing of blood histaminopexia level, increased histamine and acetylcholine sensitivity.
Porridges should be made in water, curds and yolk are to be introduced by the age of one year; juices and puree should be made of green apples only. Broths should be excluded. Chocolate, honey, nuts, caviare, crabs, crowfish and other obligate allergens are to be excluded from elder children’s menu. If these products are bore well, they should be taken in small quantities. Rehabilitation of children with AD. 1. Hypoallergenic feeding of pregnant woman, suckling mother and child from the moment of birth, especially in case of tendency to allergic reactions in the family. yy child’s hypoallergenic diet: early and long breast-feeding, in case of necessity — adapted soya formulas or cow milk proteins’ hydrolyzate; porridges
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2. 3.
4.
5.
6. 7. 8.
should be prepared in water; curds and yolk are to be introduced at the end of the first year of life; juices and puree should be made of green apples only, broths and fish are to be excluded. Obligate allergens are to be excluded from menu of elder children; they are: chocolate, honey, nuts, caviare, sea products, red or brightly orange fruit and vegetables. Hypoallergenic conditions of life (regular damp clearing up and airing of the flat; avoiding woolen carpets, blankets and dresses, domestic animals and birds, aerosol cosmetic substances, household chemical goods, smoking in the flat). Early recognizing and sanation of chronic inflammation niduses as it contributes to partial elimination of infectious allergens. General health-improving measures (rational age regimen, physical training, tempering). Prophylactic immunization’s carrying out in accordance to individual plan (all immunizations should be carried out after differentiate preparation of each child, taking into account allergic manifestations in anamnesis. Preparation for immunization includes prescription of antihistaminic drugs, vitamins A and E, enzymatic drugs and other medicines dependently on child’s peculiarities on the background of hypoallergenic conditions of life and hypoallergenic diet. Unmedicamental measures (speleotherapy, remedial gymnastics). Schoolchildren’s professional orientation taking into consideration ethiology of disease. Medicamental rehabiliation: eliminative measures; specifically excluding of food-stuffs, which cause individual food intolerance (for their detecting the food diary is kept); antihistaminic drugs (cetrin, loratadin, telfast, tavegil, etc.); vitamins A and E, Ca2+drugs, preparations of licorice’s root; gastroenterologic examination, prescription of enzymatic drugs and probyotics in case of necessity.
Lymphatic diathesis (LD). It is a condition, which is characterized by lymphatic tissue hyperplasia, endocrinic system dysfunction with decreased adaptation for environmental action, hypoimmune manifestations. Instead of term “lymphatic diathesis” it was previously used “lymphohypoplastic” one. It is explained by the fact that in modern conditions preponderate majority of children with this type of diathesis doesn’t have hypoplasia of internal organs (epinephros, heart, aorta, kidneys) as it was considered to be at the beginning of XIX century. At about only one third of these children epinephros, thymus reticuloepithelial apparatus, thyroid and sexual glands, heart and aorta’s hypoplasia may be found. However most children have hypo- or dysfunction of internal organs. According to our data, the frequency of LD makes 10–15 %. Children with LD have a tendency to frequent virus-and-bacterial diseases, early formation of chronic niduses of inflammation, especially in respirator tract. Children with this diathesis have insufficiency of immunity’s cellular and humoral mechanisms, endocrinic system dysfunction, specifically morphofunctional (or functional only) insufficiency of epinephros. It is accompanied by glucocorticoids and catechol18