儿科保健和小儿营养

PRIMARY OF CHILD CARE AND INFANT FEEDING Routine immunization Schedules, contraindications and reactions Breast feeding Advantages and contraindications Comparison of human and cows milk Technique of breast feeding and artificial feeding Emphases of This Lesson Children and adolescents represent a big group of whole population It is most vulnerable population! A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. 健康是指生理、心理及社会适应三 个方面全部良好的一种状况，而不 仅仅是指没有生病或者体质健壮 HEALTHWHO What is the difference of Pediatrics from most other medical specialties ? What is the key points in pediatric history taking and examination ? The childs age late fetus:29-40w embryo:0-12w Fetus middle fetus:13-28w Infant period (0y) Perinatal stage: 28w of fetus-1w of life Newborn: 0-28ds Toddler period (1-2y) Preschool period- young child (3-5y) School age period - old child (6-11y) Puberty teenager, adolescent PRIMARY OF CHILD CARE Primary of child care comprises efforts to avert rather than to cure disease and disability preventive medicine has been subdivided into primary, secondary and tertiary prevention fetus pre-schoolinfanttoddlerschoolpuberty Secondary Prevention Preventive Pediatrics Primary Prevention Tertiary prevention Primary Prevention Nutrition Immunizations Hand washing Parenting education Improvement of the environment Primary Prevention Community Primary Prevention Several measures to prevent disease at the community level have had enormous effects on childhood morbidity and mortality,accidents, homicide and nonfatal injuries Primary Prevention in the Pediatricians Office to foster the smooth, normal development of the child from infancy to adulthood to help ensure that each child achieves adult life as physically, intellectually, and emotionally intact as possible Primary Prevention Basic requirement for almost every successful primary preventive measure in pediatrics is understanding the cause pathogenesis natural history of disease Secondary Prevention Physical examination Growth measurements Disease screening tests Secondary Prevention involves the recognition and elimination of the precursors of disease and includes many screening programs such as those for elevated blood lead levels efforts designed to identify and reverse disease in its early stages such as a screening program for scoliosis in adolescents Tertiary Prevention Prevention of further disabilities due to chronic disorders Prevention acute problems in chronic disorders Regular monitoring of patient status Tertiary Prevention includes measures intended to ameliorate or arrest the disabilities arising from established disease physiotherapy to prevent contractures in patients with chronic neurologic disorders Knowledge of the natural history of the disease and of the means to recognize and treat it are necessary Definition of the cause is not essential In Contrast for Secondary or Tertiary Prevention Prenatal Period Sometime during the 3rd trimester about any of their problems or concerns Care in the newborn nursery The proposed schedule of visits Planned immunizations Desirability of breast feeding Living arrangements for the baby May be available at home during the 1st wk or 2 after birth. Newborn Care Physical examination within 24 hr after birth Prophylaxis for ophthalmia neonatorum Single intramuscular dose of a vitamin K preparation A test for PKU should be done and T4 measured 10 to 15 ml of cord blood should be collected at birth and saved in the refrigerator, for 7 days for typing, Coombs testing, and other tests if needed Newborn Care Follow-up First routine follow-up visit depends on the status of the infant and the experience of the parents. An office visit at 3-4 wk after birth ensures that feeding is going well provides answers to questions that have arisen identifies and solves minor problems reassures the parents. Routine Immunization The schedule for immunization is that recommended for routine protection of children by the Committee on Infectious Diseases of the World Public Health Service For prevention of seven diseases in China Routine Immunization 12/ 100,000 incidence of measles in China,2003 What is Routine Immunization? Implies the “regular” delivery, i.e., known schedule Part of a larger plan Not time limited Goal to provide needed vaccines to all eligible persons and to successive birth cohorts The Schedule for Vaccine Immunization in China Onset ageHBVBCGOPVDPTMV 24hr1 0 mo1 1 mo2 2 mo1 3 mo21 4 mo32 5 mo3 6 mo3 8 mo1 9 mo 18 mo42 PV poliomyelitis vaccine OPV:Oral Poliomyelitis Vaccine, a live, attenuated trivalent polio vaccine IVP: an inactivated (killed) trivalent polio vaccine A full course of either vaccine protects the recipient against paralytic poliomyelitis almost without exception The 1st dose of OPV should be given at approximately 2 mo of age and the 2nd 1 mo later. PV poliomyelitis vaccine 3rd dose at 4 mo of age is recommended ,close to the areas of high endemicity of poliomyelitis An additional dose:18 mo of age and another prior to school entry. Ordinarily started at 3 mo of age Two additional doses are given at 1-2 mo intervals DPT and Td(diphtheria) should be given intramuscularly, preferably in the anterolateral thigh in young infants and either in the thigh or the deltoid in older children. DPT Diphtheria Pertussis Tetanus Vaccine MMR（MV） measles-mumps-rubella（measles ） vaccine A live attenuated vaccine Be administered at 8 mo of age in China Reactions to Vaccine Local swelling and tenderness at the site of injection Slight fever Irritability Neurologic reactions Transient rashes Influenza A (H1N1) Vaccine CONTRAINDICATIONS Hypersensitivity to eggs, neomycin, or polymyxin, or life-threatening reaction to previous influenza vaccination. WARNINGS AND PRECAUTIONS If Guillain-Barr Syndrome (GBS) has occurred within 6 weeks of previous influenza vaccination, the decision to give Influenza A (H1N1) Vaccine should be based on careful consideration of the potential benefits and risks. Immunocompromised persons may have a diminished immune response to Influenza A (H1N1) Vaccine. Contraindications to Vaccine Pregnancy Immunocompromised / immunodeficiency Therapeutic immunosuppression An acute febrile illness Delayed Immunization Infants more than 2 mo but less than 14 mo of age without any immunization should be started on the same sequence of immunizations and intervals between doses as those recommended for young infants. Children 14 mo-7 yr of age who have received no immunizations should receive DPT, OPV, and a tuberculin test at the 1st visit. All children should receive a dose of Td in early adolescence. When immunization is delayed, questions arise about the simultaneous administration of multiple antigens, such as giving DTP, OPV, and MMR at the initial visit. In all situations it should be borne in mind that an interval of at least 1 mo should be allowed between doses of the same or different vaccines when they are not given simultaneously. FEEDING OF INFANTS Successful infant feeding requires cooperative functioning between the mother and her baby Prompt establishment of comfortable, satisfying feeding practices contributes greatly to the infants and mothers emotional well-being Feeding time should be pleasurable for both mother and child FEEDING OF INFANTS Feedings should be initiated to maintain normal metabolism and growth during the transition from fetal to extrauterine life Promote maternal-infant bonding Decrease the risks of hypoglycemia, hyperkalemia, hyperbilirubinemia, and azotemia Normal activity Alertness Suck Cry FEEDING OF INFANTS More mistakes are made by feeding the infant too much than too little The schedule of initial feeding in a hospital is less important than the principle of unhurried beginning and patient assistance and support for the mother FEEDING OF INFANTS Suggestions The infant is taken to the mother for the 1st feeding at 10 A.M. or 6 P.M. Subsequent formula or breast feedings are given every 3-4 hr/day and night by the mother. Artificially fed infants should receive sterile water for the 1st feeding. since regurgitation and aspiration of this liquid are less likely to cause significant irritation of the respiratory tract The emptying time of the infants stomach may vary from 1-4 or more hr. Most healthy bottle-fed infants will want 6-9 feedings/24 hr by the end of the 1st wk of life. FEEDING OF INFANTS Suggestions Term infants:rapidly increase their intake from 30 ml to 80-90 ml every 3- 4 hr prior to discharge at 4-5 days of life. Feeding well:the infant is no longer losing weight by 5-7 days and is gaining weight by 12-14 days. Many will not want a late evening feeding between 4 and 8 mo of age and will be satisfied with 3 meals a day by 9-12 mo. It is important to establish that babies cry for reasons other than hunger and need not be fed every time they cry Sick infants are often uninterested in food The habit of offering frequent, small feedings or of holding and feeding to pacify all crying should not be cultivated BREAST FEEDING Breast feeding continues to have practical and psychologic advantages that should be considered when the mother selects the method for feeding Human milk is the most appropriate of all available milks for the human infant since it is uniquely adapted to his or her needs BREAST FEEDING Colostrum The secretion of the breasts during the latter part of pregnancy and for the 2-4 days after delivery a deep lemon yellow color, alkaline, and its specific gravity is 1.040-1.060.The total amount of colostrums secreted daily is 10-40 ml. Human or cow colostrum contains several times as much protein as mature breast milk and more minerals but less carbohydrate and fat. Human colostrum also contains some unique immunologic factors. After the first few days of lactation, colostrum is replaced by secretion of a transitional form of milk which gradually assumes the characteristics of mature breast milk by the 3rd or 4th wk. BREAST FEEDING Colostrum Human milk late in pregnancy and early after birth contains more protein, calcium, and other minerals than later during nursing. ColostrumMature milk earlylate Fat Protein lactose BREAST FEEDING Advantages Breast milk is the natural food for pull-term infants during 1st months of life. always readily available at the proper temperature and no time is required in preparation fresh and free of contaminating bacteria so that the chances of gastrointestinal disturbances are lessened BREAST FEEDING Advantages Allergy and intolerance to cows milk are responsible for significant disturbances and feeding difficulties not seen in breast-fed infants diarrhea, intestinal bleeding, and occult melena ,“Spitting up,“ colic, and atopic eczema are less common in infants receiving human milk BREAST FEEDING Advantages Human milk contains bacterial and viral antibodies, including relatively high concentrations of secretory IgA antibodies Less respiratory and gastrointestinal diseases in breast-fed infants Breast-fed infants of mothers with high antipoliomyelitis titers are relatively resistant to infection by the attenuated live poliomyelitis vaccine viruses BREAST FEEDING Advantages The growth of the mumps, influenza, vaccinia, and Japanese B encephalitis viruses can be inhibited by substances in human milk These ingested antibodies from human colostrum and milk may afford local gastrointestinal immunity against organisms that enter the body via this route. Macrophages are normally present in human colostrum and milk and may have the ability to synthesize complement, lysozyme, and lactoferrin. Breast milk is also a source of lactoferrin, the iron- binding whey protein BREAST FEEDING Advantages The stool of the breast-fed infant has a lower pH than that of the infant fed cows milk, and its bacterial content is predominantly of the lacto-bacillus group in contrast to a preponderance of the coliform group in artificially fed infants. Human milk contains a “growth factor“ which facilitates intestinal colonization by Lactobacillus bifidus. The intestinal flora of infants fed human milk may protect them against infections caused by some species of E. coli. BREAST FEEDING Advantages Milk from the mother whose diet is quantitatively adequate and properly balanced will supply the necessary nutrients, with the possible exception of vitamin D after several months and fluoride. Iron stores are sufficient for the 1st 6-9 mo in term infants. The iron of human milk is well absorbed by the infant; breast-fed infants may not require supplemental iron during the 1st yr, but their diets should be supplemented after 6 mo of age by the addition of cereal and meat or by administration of one of the ferrous iron preparations. Human milk contains sufficient vitamin C for the infants needs, provided the mothers intake is adequate. BREAST FEEDING Psychologic Advantages The mother is gaining both a feeling of being essential and a sense of accomplishment The infant is afforded a close and comfortable physical relationship with the mother Breast feeding offers increased opportunity for close sensual contact between mother and infant studies suggest that early, and intimate tactile and visual contact are important in determining the quality of attachment and mothering which is provided the infant. BREAST FEEDING Technique The infant should be hungry at feeding time, and held in a comfortable, semisitting position for his or her enjoyment and for facilitation of eructation without vomiting The mother must be comfortable and completely at ease. The baby is supported comfortably with the face held close to the mothers breast by one arm and hand while the other hand supports the breast so that the nipple is easily accessible to the infants mouth and yet does not obstruct the infants nasal breathing. The babys lips should be expected to engage considerable areola as well as nipple. BREAST FEEDING Technique The normal infant is equipped with several reflexes, which are designed to make him a successful feeder from the breast. The most obvious of these reflexes are those concerned with the actual getting of food-rooting, sucking, swallowing, and satiety reflexes.if the infant is not hungry, he or she will not search for the nipple or suck. At the end of the nursing period the infant should be held erect over the mothers shoulder or on her lap to eructate swallowed air,to facilitate emptying of the stomach into the intestines and to lessen the chances of regurgitation. BREAST FEEDING Contraindications For the average, healthy, full-term infant there are no disadvantages to breast feeding, provided the mothers milk supply is ample and her diet contains sufficient amounts of protein and vitamins. Infrequently, allergens to which the infant is sensitized may be conveyed in the milk. In such instances an attempt should be made to find the specific allergen and to remove it from the mothers diet; its presence rarely is a valid reason for weaning the baby. BREAST FEEDING Contraindications For the mother, there are few contraindications to breast feeding: Markedly inverted nipples Mastitis Acute infection in the mother Septicemia, nephritis, eclampsia, profuse hemorrhage, active tuberculosis, typhoid fever, and malaria are permanent contraindications to nursing Chronic poor nutrition, debility, severe neuroses, and postpartum psychoses What is the signs for the milk supply is sufficient? sleeps 2-4 hr gains weight adequately Three possibilities for the mother unable to produce sufficient milk: errors in feeding technique responsible for the infants inadequate progress; remediable maternal factors related to diet, rest, or emotional distress; physical disturbances in the infant that interfere with eating or with gain in weight. Determination of Adequacy of Milk Supply BREAST FEEDING other announcements Low birth weight infants who are too weak to suck or those who tire before an adequate volume is ingested may be given human milk by gavage. Many such infants have thrived. Human breast milk has also been advocated in the management of necrotizing enterocolitis . The low vitamin K content of human milk may contribute to hemorrhagic disease of the newborn. Administration of 1 mg of vitamin K1 parenterally at birth is recommended for all infants, especially for those who will be breast-fed. For the normal and healthy baby who is getting insufficient breast milk, artificial feeding may be offered either immediately after or in place of one or more breast feedings. An attempt should first be made to increase the supply of breast milk. Any of the milk formulas may be offered in amounts sufficient to satisfy the baby Supplementary Feedings Weaning Usually at 6-12mo of age Weaning should be initiated by substituting whole cows milk by bottle or cup for part of a breast feeding, and subsequently for all of a breast feeding Supplementary Feedings Formula Feedings Commercial formulas are modified from a cows milk base with protein and ash reduced to levels near those of human milk to decrease osmolality and renal excretory load The saturated fat of cows milk is replaced with some unsaturated vegetable fatty acids, and vitamins are added. The concentration of lactose is lower in cows milk Low birth weight infants particularly may benefit from the increased cystine of lactoproteins Technique of Artificial Feedings The mother and infant in a comfortable position, unhurried, and free from distractions. The temperature may be tested by dropping milk on the wrist. The nipple holes should be of such size that milk will drop slowly. Technique of Artificial Feedings Spitting up occurs more often in the artificially fed than in the breast-fed infant. Aspiration of this milk is less l