Pediatrics as discipline

1. Pediatrics as discipline Department of pediatrics

2. Pediatrics • Pediatrics is aGreek term , whichproceedsfrom two words: • παῖς (pais = child) • ἰατρός (iatros = doctor )

3. History ofpediatrics • • Hippocrates described cephalohematoma, hydrocephalus, diarrhea, strophulus, asthmaand varicella • • Soranus of Ephesus (c. AD 100)described the test for maternalmilk quality appreciation (if the milk drop sticksto the nail, it has sufficientfats, if does not stick – has not fats) • • Galen (c. AD 200) described otitis, pneumonia, prolapseof intestin, rickets. • • Avicenna, (c. AD 990) – tetanos, convulsions, meningitis, omphalitis. • • Avenzoor (c. 1150)performed tracheotomy. • • Hieronymusin 1583 has writen the bookDe Morbus Pusiorum

4. History of pediatrics • In IX century -   Rhazes (Muhammad ibn Zakarīya Rāzi - Persia)has described thechild’s diseases (is considering the father ofpediatrics). •  1530 ThomasPhaer,  Book of the child. • 1852 first hospital in London The Hospital for Sick Children, Great Ormond • Abraham Jacobi, - the founder ofpediatricsinUSA .

5. History of pediatrics • Hôpital des Enfants Malades (French = Hospital for Sick Children), in Paris , june, 1802 • Charité (hospital founded in1710) in Berlin has opened a separately pavilion for children in 1830 • Saint Petersburg  - 1834 • Vienna and  Breslau (Wrocław) - 1837.

6. History of pediatrics • Thomas Sydenham (1624–1689), Hippocrate ofEngland, described scarlet fever, rubella, epilepsy, rickets, fever, scorbutus, chorea whichis known as St. Vitus Dance.

7. History of pediatrics • Edward Jenner (1749–1823) hasvaccinated first time a 8 years boyagainstsmallpox.

9. History of pediatrics • Prof. Mihail Manicatide, born at Giurgiu in 1867, is considered the founder of rumanian scientific school of pediatrics. • He is the author of two treatises of infant medicine for students, appeared in many editions. • Dr. Alfred D. Rusescu, born in 1895 at Bucharest, organized pediatrics and superior medicine studies on modern basis, being the mentor of great professors which developed the pediatrics until our times.

10. History of pediatrics • Faculty of Medicine from Yassy opened its courses at 1 december 1879, but the chair of infantile Clinic appears la 1897. • The chair had as basis the Gregorian Institute founded in 1852, and the clinical base functioned in the infantile section of Epitropia “Holy Spiridon" from Yassy.

11. Pediatrics • Pediatricshasas study object the growing, developmentand pathology of the childfrom the birth until 18 years age.

12. Pediatrics - subspecialities: • preventive pediatrics; • social pediatrics; • neonatology (new-born - 0-28 days); • infantile psychiatry; • cardiology; • pediatricpneumology; • nutritional and metabolism diseases; • oncology; • surgery, orthopedyand pediatrictraumatology.

13. Preventive pediatrics • includesall measures destinedto maintain the healthand to preventthe appearance of disease in children. • It is dividing in :Primary prophylaxis – avoidance ofhealthyindividual taking ill (vaccination, water chlorining)Secondary prophylaxis– recognitionand elimination of disease precursors and the addressing to populationwith increased risk for certain affection. Includes also the diseases complications prevention.Tertiary prophylaxis– has the goal theimprovingorstopping of stillestablished disease complications, avoiding the evolution to invalidity or decease.

14. Primary prophylaxis •   includes 2 types of measures:A) measureapplied tocollectivity B) measureapplied individually

15. Measure applied to collectivity • A) it is realizing through a series of public healthprogramswhich differ from country to country in functionof its development degree.Some programs of public health with central valueare not still universally adopted.Applied measures: - accidents prevention– is difficultand can’t beperformedthrough public education.Prevention of intoxications (detergents, alcohol, mushrooms etc.)prevention ofsuicidesandmurdersprophylaxis of pregnancyin adolescentsprevention of drugs using.

16. Pediatrics – in Republic of Moldova creation ofabilitiesforphysical and neuropsychical health state assessmentin children and adolescents • careand alimentation of healthy and sick child • organizationandcarrying outof prophylactic, sanitaro-antiepidemicaland medical measuresat home and in preschool and school institutions

17. Pediatrics – in Republic of Moldova • Correct diagnosis of acute and chronic diseases on the base of anamnesis, clinicalandparaclinical examination, conformable to WHO diseases classification • appreciationofinvestigationsand treatment volume after national standards of RM • According toemergency care to childrenatstageshome - FDC - hospital • assimilatingof correct dispensary control ofhealthy and sick children.

18. Goal of discipline:  Studyof child’s physiologic and pathologic changes, knowledge of child’s diseases evolution, diagnosis, treatmentandprophylaxis, development ofclinical reasoning and medical synthesis – defining elementsin the training of eachphysician.

19. Objectives of forming: • To appreciate the state of physical and neuropsychical development, to determine thegroups of health and risk in children; • To perform the collection of anamnesis and objective clinical examination of children, interpretation of collected data; • To argue the prescribingandinterpretation of laboratory investigations and paraclinical examinationin dependence of basic pathology and national standards; • To possess the general medical manoeuvres in diverse pathologies of the child;

20. Objectives of forming: • Enteralandparenteral alimentation; • gastric washing, performingof evacuator and medicamentous enemas, urinary bladder catheterization; • Determining of pulse, arterial pressure, respiration rate; • Interpretation ofradiologic, ultrasonographic, ECG data, general laboratory, microbiologic,biochemical, immunologic investigations; • To determine the tacticsof medical conduct in the cases of emergencies: shock, coma, acute respiratory and cardiac failure, crisis of bronchial asthma, accidental poisonings, traumas, insect bites, sinking.

21. Childhood periods • There are evidencing the following periods: • · new-born period (4 weeks); • · suckling period (until 1 year); • · period of milk teeth (from 1 until 6-7 yrs); • · period of big childhood (from 8 until 11 yrs); • · period of sexual maturation (12-17 yrs).

22. Period of new-born • It constitutesthe period to extrauterine life adaptation, inwhicha series of characteristic phenomena have place, for example: physiologic icterus, physiologic weight loss, genital crise etc. • Durationof new-born period is considered untilthe age of 30 days (so-the first month of life).

23. Period of suckling • This period, which lasts from 1 month until 1 year, ischaracterizedby very active growing. • The period of suckling has the most rapid period of growing, not spread in another periods. In this period, also, thepsychomotory developmentof suckling is in permanent progress, especially due to continuous development of nervous system.

24. Examination of suckling

25. Period of infant (little child) • After 1 year age, the child isnot still considered suckling baby, he walks alone, speaks, becomes active. The growing in height and weight is less accentuated. • This period includes the age between 1 and 3 yrs.Inthis period the surrounding conditions organization is very important. • Correct infant follow-up, good conduced education workcontributesto assimilationof first hygienic skillsand of elementary education rules.

26. Preschool period • It occurs between 3 and 7 yrs, the age in which the child’s mind intensively developsdue tomore complex developmentof central nervous system. • Assimilation of knowledge about surrounding world increases continuously, in report with development of attention, spirit ofobservation, memory. • The child becomes more independent, due tocontinuous development of thesefunctions.

27. School period • The growing rhythm is more lent at this period beginning (incomparisonto preschool age), for to its endto accelerate, at the same timewith pubertyappearance. • Gradually, the exterior aspect of pupilgets near to that of adult. Due to central nervous system maturation, the pupilhas more complex psychic activity, which allowsto assimilate variousandample knowledge.

28. SEMEIOLOGY semeion – sign logos – science, speech Semeiologyis the fundamental basisofdiagnosis which can beestablishedon the basis of anamnestic datawhichorientates, of clinical datawhichsubstantiateand oflaboratory data which confirm it. • Semeiology – interpretation ofdifferent diseases signs having the goalto establish more correctly and more rapidly the diagnosis. • Semeiologyuses symptoms, signs, syndromesand also paraclinical investigationswhich must be aimed for diagnosis confirmation.

29. Symptoms – have subjective character, being relatedby patient, are variable in different cases, after perceptionmode and not alwaysare objective (fever, headache, insomnia, astenia, hiccups, dyspnea etc.) • Signs – objective manifestations produced by disease, observed by patient and completed by physician throughproper feelings(e.g. murmur, rale, dullness etc.) • Syndrome–group of symptomsandsignswhichexpressesa pathologic state, whichhave acommon physiopathologicmechanism; allowby their sum the orientation to certain diagnosis; forelucidatingorconfirmation the complementary investigations as possible aimed are performing. Conclusion resulted fromsigns and symptoms analysis andconfirmationbyanalysesguide us to the diagnosis which could be also a syndrome.

30. The health – is defined by WHO as „ a state of completephysical, mental and social good andnotconsistsonlyfromdisease or inflammation absence” • The diseaseis defined in different mode but afterRumanian medical dictionary represents: „ deviationfrom health state duetosome internal medium modifications orexternal medium agents action” or „ isadeviationor turning off from normal withundesirable consequences on personal comfort and social activity”. • Acute disease – ashort duration episodeat the end of which the patient takes again his normal activity. • Chronic disease– a long duration disease whichgenerates permanent, partialor total incapacity, there is an organic orfunctional alterationwhich obligates the patientto modify his normal life mode and which persistsmore long time.

31. Teguments • At birth, the epidermisis very thin and the smallest irritation produceslesionswhich very easily are infecting. • New-born has the skin coveredby protector fat layer (named vernix caseosa), after removal of which thefine epidermis, by pink color, appears. • The skin has the protection role of organs which it covers, of body constant temperature maintaining; has, also, the respiration function, which in children is very important.

32. Teguments • Subcutaneous layer of fat is not completely formed at birth, and is developing gradually: • It appears first of all on face, after that on superior and inferior members, thoraxand after all on abdomen (in the age around 45 days).

33. Skin fold • It has in suckling babies the thickness by 1,5-2 cm. This fat layer (cellular, subcutaneous tissue) has the role of protection, role in the thermoregulation mechanism, role of nutritive reserveandofdiverse organs supporting. • In healthy child, the teguments palpation givesa special sensation of resistance to pressing.

34. Teguments of suckling baby • In healthy breast fed suckling they are white-pink, velvet-like, in artificially fed they are more pale. • The thickening of epidermis horny layer and basal cells pigment appearance begin, the chromatoforming cells develop, the resistance to infections and physico-chemical agents increases. • Dermis is maturating, the dermal papillae are multiplying, the capillaries become longer.

35. Teguments of suckling baby • are elastic, skin fold returns immediately to initial form; • in dehydration states the fold returns slowly or is persistent.

36. Sebaceous glands • good developed at birth, have sometimes an excess of secretion which determines the appearance of seborrheic dermatitis at the head skin level.

37. Sweat glands • Begin to develop in 2-3 months age and in 2 yrs when the corresponding nervous centers are maturating achieve their integral functional activity.

38. Hair • During growing they change the color. • During the puberty installation as part of secondary sexual characters the facial, axillar, anterior thoracic, pubian, on external part of members hair growing appear.

39. Suckling skin surface • It is bigin report to his corporal weight and decreases with the age. • Skin surfaceis calculating after Lassabliere formula: • Skin s. =T 2x0,92 • Specific skin surface represents thereportbetweenskin surface and corporal weight: • Skin s. (in cm 2)/W(kg) • ­  in n.b. specific skin surface = 660 cm 2/kg body;  • ­  in 1 yearspecific skin surface = 420 cm 2/kg body;  • ­  in adult specific skin surface = 220 cm 2/kg body.

40. Cellular subcutaneous tissue • Good represented in new-born on the face, continues to develop on superior, inferior members, thorax and still at 6 weeks on abdomen. • In malnutrition states its disappearance occurs in the inverse order of its appearance: • abdomen, thorax, inferior members, superior members, and at the end - on face (Bichat pads disappearanse).

41. Clinical assessment of suckling nutrition state • Measurement of thoracic (normal 1-1,5 cm) and abdominal (1,5-2 cm) skin fold thickness, • Presence of adductors folds on thigh internal part • presence of turgor (resistance which we feel at pressure taking between fingers the tissues on the external part of thigh; • in malnutrition – the disappearance of cellular subcutaneous tissue • turgor is diminished; sometimes is pasty in suckling babies excessively fed with floury products).

42. Clinical assessment of suckling baby nutrition state • More precise assessment of nutrition state is realizing calculating: • ponderal index(PI), • perimeter of medium arm (MAP), • Nutritional index (NI) and • body Mass Index - BMI.

43. EXAMENATION OF TEGUMENTS, MUCOSAE ANDDERIVATES • COLOR OF TEGUMENTS • Pallor:there ismore open color of tegumentsand mucosae andappears in the case of superficialcirculation reducing, in vasoconstrictionorappears more frequently in anemias. • - iron deficient anemia – waxy or chalk pallor • In hemolytic and megaloblastic anemia –yellowish, like to wheat straw. • In chronic leukemia and CRF – agrey-sallow color appears • In bacterial infectiousendocarditis – pallor isby milk coffee type • Redness :appearsthroughaccentuated vasodilatationor circulatory oxihemoglobin quantity increasing (polyglobulia) • After exposure to increased temperature or in febrile states, after physical effort, in neuro-vegetative dystonia,in carbon oxide intoxication, in primaryor secondary polyglobulias.

44. Cyanosis (kianos):there is a bluish – violet colorof skin and mucosaeand appears due to reduced hemoglobin increasingat the level of small vessels in certain areas. • True cyanosis: in conditions of reduced hemoglobin absolute quantity increasing. In capillaries (over 5 g /100 ml of blood). It appears more at extremities and depends from some factors: - volumeof skin and mucous capillaries, thickness and transparence of cutaneo-mucous layer (best observed on ears lobes, cheek bones, lips and nail bed). -skin pigmentation (in black race or other skin hyperpigmentations) itis better seen on palms or conjunctival mucosa -associationwith other pigments in the same time, for ex. with jaundice -concentration of Hemoglobin in blood, appearing more rapidly in polyglobuliathan in anemia • False cyanosis appears in: -intoxication with carbon oxide (carboxyhemoglobinemia), which has a bluish color with carmine tint -polycytemia vera, when the cyanosis has red-violet aspect

45. -methemoglobinemia and sulphhemoglobinemia (intoxication with nitrites, nitrotoluene, benzene etc) -argiria – deposition of silver salts in teguments, giving abluish-grey colouring In the cyanosis appearance the absolutelevel of redused Hemoglobin has importance. La anemics, especially at values ↓5 g. /100 ml bloodthe cyanosiscan’t be distinguished. • CENTRAL CYANOSIS: is due to insufficient saturation of arterial blood with oxygen, which leads to reduced Hemoglobin absolutelevel increasingin arterial blood over limit value of 5 g/100 ml. This cyanosis is generalized and involves both tegumentsand mucosae, the temperaturebeing not decreased;there is so-called warm cyanosis Causes of centraltype cyanosis: • Respiratory causes: -affectionswhich reducethe circulation bed: massive pneumonias, bronchopneumonias, miliarTBC, extended pulmonary fibroses, massivepleuresies, pneumothorax, fibrothorax, kypho-scoliotic thorax, etc. - Affections which produce the respiratory pathways obstruction: laryngo-tracheal diseases, tumorswhich compress respiratory pathways, bronchial asthma, chronic broncho - pulmonal obstructive diseases, etc.

46. 2. Cardiac causes: • left cardiac failure, mitro-aorticvalvulopathies, cardiomyopathies, disorders of rhythm and conductibility. • congenital complexe cardiopathieswhich canbe installing at birth, persisting all life – blue disease. • Potent ductus arteriosus • arterio-venous fistulasof great and middle vessels, with veno-arterial shunt after aneurismasor on small vessels, in hereditary telangiectasia. 3. Mixt causes: cardiac and respiratory. The chronic cor pulmonalein which the right heart failure consecutively some broncho - pulmonal affection appearing, is typically. • PERIPHERAL CYANOSIS:isdeterminedby vasoconstrictionfollowed byblood circulation speed slowing in a peripheral area, which leads to increased oxygen extraction by tissuesfrom arterial blood. -Generalized cyanosis:appears after exposure to cold or in congestive cardiac failure, when the cutaneous compensatory vasoconstrictionis associated. It is more pronounced on the limbs which are cold and in the right and congestive cardiac failure the edemas can appear.

47. -Localized cyanosis– appearsin venous or arterial trunks obstructions and is strictly localized at corresponding area. If the obstacle is in superior vena cava thecyanosisof cephalic extremity, of superior members, of neck and of thorax superior part appears(cyanosisin pelerinewith or without edema). Disorders of pigmentation: -Hypomelanosesare characterized by melanic pigment decreasing or absence. The albinism characterized byabsence of pigment in skin, hairand eyes and vitiligo characterizedbylight color with hyperpigmented contour spotsappearance take part from this group. -Hypermelanosesappearthrough numeric increasing of melanic cellsand their overloading with pigment and are due to hormonal causes: chronic insufficiencyof suprarenal glands (Addison disease), hyperthyroidism (Basedow disease). Ephelides- small brown – redish spots on cheeks, shoulders, back, dorsal part of hands appearthroughpigmentation of skin under the form of frecklesand have familial and constitutional character. -Icterusis the yellow colouring of the skin, mucosae and scleresdeterminedby theirimpregnation with bilirubin when it has increased values in blood (over normal value by1mg at 100 ml of blood).

48. Tegumentsin children Hyperpigmentation Hyperpigmentation

49. CUTANEOUS LESIONS: • Macula: smooth spot, by pink or redish color, with small dimensions (under 1cm diameter) which not exceeds tegumentar plane and appears in erruptive infectious diseases such as measles, rubella, typhoid fever. • Papule:asmall, round prominenceon skin, with the diameter under 0,5 cm, palpable; appears in scarlet fever, urticaria • Noduleis a dermic or hypodermic formation byvaried dimensions, palpable, whichappears in xantomatosis, lipomatosis, erythema nodosa. • Vesicleis araised above the surrounding skin plane, under 1cmdiameter, fluid-filled lesion whichappearsin varicella, herpesZoster. • Bullais a vesiclewith purulent content whichappearsin acnea, variola, impetigo. • Cystis asoft, raised, encapsulated lesion filled with semisolid or liquid contents. • Crustshave depositsof solidified exudateson tegument surface which appear in the evolution of herpes, zone Zoster oras consequence of erosions, ulcerations oratthe level ofcutaneous eczema. • Cicatrixappearsafterskin plagues healing where the fibrous tissue is developing. • Fissuresaredeep linear defects of the skin below its basal membrane level. • Erosionis a superficial defect of the skin.

50. Ulceris a deep defect of the skin below its basal membrane level. • Gangrenais a necrosis of tissueand underlying stratum which can suprainfect becoming fetide. • Scaris a change in the skin secondary to some injury or inflammation. Sites may be erythematous, hypopigmented or hypertrophic depending on their age or character. Sites on hair-bearing areas may be characterized by destruction of hair follicles. • Atrophyis an acquired loss of substance. In the skin, this may appear as a depression with intact epidermis (i.e., loss of dermal or subcutaneous tissue) or as sites of shiny, delicate, wrinkled lesions (i.e., epidermal atrophy). Vascular lesions at the skin level: • Petechiae: are hemorrhagic spotsby small dimensions (< 1cm) by round or oval form which appear on skin or mucosae. • Ecchymoses:are hemorrhagic dermo-hypodermic spots more than 1cm. • Telangiectasies:aresmall vessels dilatations on the skin or mucosae which appear in hypovitaminoses B, cirrhosis.