소아과학 개론
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소아과학 개론. 삼성서울병원 소아청소년과 장 윤 실. 소아과학의 특징. 임신 - 청소년기 성장과 발달 “The child is not a little man” 발육단계. 소아기의 구분. 출생 전기 (prenatal period) 신생아기 (neonatal period) 생후 4 주간 ( 좁은 의미 생후 1 주간 ) Perinatal period ( 주산기 ): 재태 22 주 - 생후 1 주 사망과 장기 예후 관련 영아기 (infancy) : 1 개월 -1 년 (2 년 )

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소아과학 개론

삼성서울병원 소아청소년과

장 윤 실


소아과학의 특징

  • 임신-청소년기

  • 성장과 발달

  • “The child is not a little man”

  • 발육단계


소아기의 구분

  • 출생 전기 (prenatal period)

  • 신생아기 (neonatal period)

    • 생후 4주간 (좁은 의미 생후 1주간)

    • Perinatal period (주산기): 재태 22주-생후 1주

      • 사망과 장기 예후 관련

  • 영아기 (infancy) : 1개월-1년 (2년)

  • 유아기 (preschool period or early childhood): 2세-5세

  • 학령기 (prepuberal period or late childhood): 6-10세

  • 사춘기(Puberty), 청소년기(Adolescence):11-20세, 개인차

    • 남자: 12-20년

    • 여자: 10-18년




사망의 원인

  • 1세 미만:

    • 주산기 질환-선천개형-미분류-호흡기계

  • 1-4세:

    • 불의의사고-신생물-선천기형-호흡기계

  • 5-9계:

    • 불의의 사고-신생물-신경계질한-타살-선천기형

  • 10-14계:

    • 불의의 사고-신생물-신경계 질환-자살-선천기형

  • 15-19세:

    • 불의의 사고-자살-신생물-신경계질환-순환기질환


성장과 발달

  • 장기별 성장 유형

    • 일반형: 키, 체중 호흡기

      • S자형 : 영아기, 사춘기 급성장

    • 신경형: 뇌, 척수, 시각기, 두위

      • 출생초부터 급성장하여 4세경에 이미 성인 수준

    • 림프형: 가슴샘, 림프절, 편도 등

      • 10-12세 성인의 2배, 이후 퇴축하여 18세경 성인수준

    • 생식형: 생식기, 유방, 음모, 자궁, 전립선

      • 사춘기부터 급성장 16-18세 성인수준



Definition of the newborn
Definition of the Newborn

  • Infants below 28 days of life

  • Transition from dependent fetal period to non-dependent neonatal period

  • Most friable period of whole ages


The fetal to neonatal metabolic transition
The fetal to neonatal metabolic transition

Function Before After

  • Temperature Uterine Brown fat

  • Gas exchange Placenta Lung

  • Waste Placenta Kidney

  • Activity Do nothing Eat and move

  • Energy Maternal glucose Fat & CHO

  • Environment Peace & Quiet Stress & Strain


Succes in transition
Succes in transition

  • Ca. 10% : require some assistance

  • 1% : need extensive resuscitation

  • 90% : transition witout difficulty


Body temperature control
Body Temperature Control

  • Easy to lose heat

    - Relatively large body surface area

    - Poor Insulation

  • Mechanisms of heat loss

    - Convection, Evaporation,

    Radiation, Conduction

  • Cold Stress :

    - Hypoxia, Hypoglycemia, Acidosis


Hematologic values at birth
Hematologic Values at Birth

  • Site of Sampling

    ·Capillary samples higher than venous

    -Especially if prematurity, hypotension, acidosis, anemia

  • Treatment of Umbilical Vessels

    ·Placental vessels contain 75-125 mls blood

    ·Can increase blood volume of newborn by 61%

    ·Placing infant below mother increases placental

    transfusion, completion within 30 sec

  • Blood Volume

    ·Term 85 ml/kg

    ·Preterm 90-105 ml/kg

    ·One month 75 ml/kg


Hemostasis in the newborn
Hemostasis in the Newborn

  • Platelet-vessel interaction

    ·Adhesion-Platelets bind exposed collagen via

    surface glycoprotein lb Von Willebrand

    factor interaction

    ·Aggregation-Platelets activated (by collagen

    binding)and expose fibrinogen binding sites

    (glycoproteins llb-llla)

  • Normal platelet cts, but decreased platelet aggregation in newborns

  • Bleeding time normal (modified template of lvy bleeding time device)


Hemostasis in the newborn1
Hemostasis in the Newborn

  • Procoaqulant System

    ·Coagulation proteins synthesized by fetus

    ·Coagulation proteins do not cross placenta

    ·Appear by 10 weeks, increase t/o gestation

    ·Fibrinogen conc. slighly lower at birth

    ·Normal levels of V, VIII, and vWF

    ·"Physiologically" low levels of vit K

    dependent factors II, VII, IX and X


Circulation anatomy fetal vs neonatal
Circulation anatomyFetal vs Neonatal

Placental Circulation

Ductus Arteriosus

Ductus Venosus

Foramen Ovale

Pulmonary Vasculature

Myocardium


Fetal circulation
FETAL CIRCULATION

Normal Anatomy


Placental circulation interruption of flow
PLACENTAL CIRCULATIONinterruption of flow

Immediate Decrease in Pre-load

Immediate Increase in After-load


Ductus venosus
DUCTUS VENOSUS

Mechanism of Closure not

well understood

Probably Passive


Ductus arteriosus
DUCTUS ARTERIOSUS

  • Functional Closure at 10-15 hr.

  • Constriction of Media due to O2

  • Obliteration may take weeks

  • Effect of Vasoactive Substances

    - less well defined


Pulmonary vasculature fetal
PULMONARY VASCULATUREFetal

  • Very High PVR Early in Gestation

  • Progressive Rise in PAP

  • Rise in QP (3-10%) thru gestation


Pulmonary vasculature newborn
PULMONARY VASCULATURENewborn

  • Increased media:lumen Ratio

  • Immediate Rapid Fall in PVR

  • Slower Further Fall in PVR


Foramen ovale
FORAMEN OVALE

Passive Closure due to

increased left atrial flow

and resultant increase

in pressure


Myocardium immature
MYOCARDIUM Immature

  • Myocyte division only in fetus

    and early newborn

  • Smaller percentage of contractile

    proteins and mitochondria


Physiology fetal vs neonatal
PHYSIOLOGYFetal vs Neonatal

  • Pressure

  • Flow

  • Resistance

  • Contractility


Resistance changes
RESISTANCE CHANGES

  • Decrease in PVR

  • Increase in SVR


Pressure changes
PRESSURE CHANGES

  • Decrease in PAP due to

    decrease in PVR

  • Increase in LAP due to

    increase in PBF


Flow changes
FLOW CHANGES

  • PDA flow changes to L to R

  • FO flow changes to Lto R

    and dimishes rapidly


Contractility
CONTRACTILITY

  • Immature Myocardium

  • High Resting Tension

  • Diminished Active Response


Myocardial mechanics immature vs mature
MYOCARDIAL MECHANICSImmature vs Mature

  • Contractile Proteins

  • Energy Utilization

  • Calcium Metabolism


Myocardial mechanics
MYOCARDIAL MECHANICS

  • Contractile Proteins

  • Myosin Heavy Chain*

  • Myosin Light Chain

  • Actin

  • Tropomyosin*

  • Troponin C

  • Troponin I*

  • Troponin T*


Myocardial mechanics contractile proteins
MYOCARDIAL MECHANICSContractile Proteins

  • Troponin I - inhibits Actin-

    Myosin interactions

  • Troponin T- binds troponin

    complex to thin fillament


Myocardial mechanics immature
MYOCARDIAL MECHANICSImmature

  • Myofibril number:

    fetus < newborn < adult

  • ATPase increases with maturation

  • ATPase determines velocity of

    muscle shortening


Myocardial mechanics energy utilization
MYOCARDIAL MECHANICSEnergy Utilization

  • Mitochondria are major source of

    high energy phosphate

  • Decreased number of MC in

    immature myocardium

  • Relative lack of enzyme for FFA

    transport into MC


Myocardial mechanics calcium metabolism
MYOCARDIAL MECHANICSCalcium Metabolism

  • SR poorly formed in immature

  • Ca uptake by SR is depressed

  • Function of SR increases with

    maturation


Summary anatomy
SUMMARYAnatomy

  • Changes re-route blood

  • Flow to adapt to extra-uterine

    environment


Summary physiology
SUMMARYPhysiology

  • Changes (most notably in PVR)

    permit the circulation to sustain

    life as maturation progresses


Summary myocardial mechanics
SUMMARYMyocardial Mechanics

Adaptation to extra-uterine condition is more gradual, probably because of the cellular and molecular processes involved


Infection control basic principles
Infection Control - Basic Principles

  • Exclude ill personnel/visitors

    (often the source)

    - Respiratory Infection (RSV common)

    - Skin Infection

    - Diarhea

    - Fever

    - Cold Sores (Herpes Labialis)

  • Orient to Universal Precautions & Isolation Procedures

  • The usual problem is Poor Handwashing!


Handwashing
Handwashing

◆ 2 minute scurb at beginning of day

◆ 15 second wash before and after touching any patient

◆ A void self-contamination - touching eyes, face, nose, mouth, phone, other, objects not exclusive to the patient


Clothing
Clothing

◆Clean scrub suit or gown when holding newborn

◆Hats. shoe covers, masks not routinely required


Renal response to sodium load
Renal Response to Sodium Load

  • Normal adult renal response to Na load is to increase Na excretion.

  • Newborn kidney able to respond to Na load but, not as well as adult.

    - proximal tubule decreases FRN

    - but distal nephron increases Na reabsorption

    more than adult

    - net result is less Na excretion in newborn

    than adult

  • Preterm infant < 36 weeks responds better to Na load than term infant


Excretion of k in neonate
Excretion of K in Neonate

  • Mechanisms qualitatively similar in immature and mature kidney

  • Newborn cannot excrete K load as well as adult

    ↓K secretory ability of distal nephron

    ↓Distal Na-K-ATPase activity

    ?↓response to aldosterone

    ↓distal H2O & Na delivery (due to low GFR)

    permeability characteristics of cell membranes


Response to h 2 o load
Response to H2O Load

  • Newborns do not respond as well as adults to H2O load

    - Low GFR

  • Newborn can produce very dilute urine (50 mosm/L)

  • Fetus can and does produce dilute urine


Neonatal concentrating ability
Neonatal Concentrating Ability

  • Neonate cannot concentrate urine

    as well as adult

    Adult maximum 1200 - 1400 mosm/L

    Newborn maximum 600 - 700 mosm/L


Renal glucose handling
Renal Glucose Handling

  • Glucose usually reabsorbed completely in proximal tubule

  • Maximum glucose reabsorption (TmG) lower in newborn than adult kidney

  • However, TmG/GFR equivalent in both groups

  • Renal threshold for glucose (level of plasma glucose at which glucose is excreted) lower in newborn than adult.


Glucose threshold
Glucose threshold

  • Glucose excreted at lower plasma glucose in younger animal

  • Thus newborn especially preterm infant more likely to spill glucose

  • Thus newborn prone to osmotic diuresis

  • Thus solute & H2O excretion increases & H2O intake requirements increase when glucose excreted.


Changes in body h 2 o with development
Changes in Body H2O with Development

  • TBW (as % body weight) falls with development mostly in fetal, neonatal and early infant period.

  • Fall in TBW due to fall in ECF.


Fluid balance
FLUID BALANCE

  • Fluid Balance = Intake - Output

  • Output -Urine

    -GI

    -Skin

    -Lungs


Factors affecting iwl in neonates
FACTORS AFFECTING IWL IN NEONATES

  • Environmental Factors

    Humidity

    Temperature

    Incubator vs Overhead Heater

    Bililights


Factors affecting iwl in neonates1
FACTORS AFFECTING IWL IN NEONATES

  • Infant Factors

    - Minute ventilation (VE)

    - Body surface area

    - Skin thickness

    - Gestational Age

    - Postnatal Age


1 ve iwl 2 bsa iwl 3 skin thickness iwl 4 g a iwl 5 postnatal age iwl
1) ↑ VE →↑IWL2)↑BSA→↑IWL3)↑Skin Thickness → IWL4)↑G.A.→ IWL 5)↑Postnatal Age → IWL


1)↑Humidity→ IWL

2)↑Temp & Temp→↑IWL

3) Overhead heater→↑IWL

4) Bililights→↑IWL


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