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


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소아과학의 특징

  • 임신-청소년기

  • 성장과 발달

  • “The child is not a little man”

  • 발육단계


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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


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소아인구의 동태


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영아 사망률


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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


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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


Newborn infant

Newborn Infant


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

FunctionBeforeAfter

  • Temperature UterineBrown fat

  • Gas exchangePlacentaLung

  • WastePlacentaKidney

  • ActivityDo nothingEat and move

  • Energy Maternal glucoseFat & CHO

  • EnvironmentPeace & QuietStress & 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


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1)↑Humidity→ IWL

2)↑Temp & Temp→↑IWL

3) Overhead heater→↑IWL

4) Bililights→↑IWL


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