2012-2013学年上学期--儿童营养与喂养、蛋白质-热能营养不良、营养性维生素D缺乏.doc

右 江 民 族 医 学 院教 案2011至 2012学年上学期课 程 名 称： 儿科学 任 课 教 师： 潘红飞 职 称： 教授 授 课专业及层次：08临本7-10班、全科、心理合班授 课 类 型： 理论课 授 课 日 期： 2011年 10月18、21日 教研室正、副主任或课程负责人审阅意见： 签名： 年 月 日 儿童营养与喂养、蛋白质-热能营养不良、营养性维生素D缺乏一、授课学时：3学时（120分钟）二、教学目的：（一）了解儿童营养素与需要量、能量代谢特征To understand the characters of nutrition requirement and energy metabolism in children.（二）掌握母乳喂养及辅食添加原则To master the breast feeding and principle of food supplementary.（三）了解儿童营养状态的评估To understand the evaluation of nutrition status in children.Understand the etiology and patho-physiology of protein-energy malnutrition.（四）掌握蛋白质-能量营养不良的临床表现Master the clinical manifestation of protein-energy malnutrition.（五）掌握蛋白质-能量营养不良的预防和治疗Master the prevention and treatment of protein-energy malnutrition.（六）了解并发症蛋白质-能量营养不良的Understand the complications of protein-energy malnutrition.（七）了解佝偻病和维生素D 缺乏性手足搐搦的病因和发病机制To understand the etiology and the pathogenesis of rickets and tetany of Vitamin D deficiency.（八）掌握佝偻病和维生素D 缺乏性手足搐搦的临床表现、诊治和预防To master their clinical manifestations ,diagnosis ,treatment and prevention .（九）了解佝偻病和维生素D 缺乏性手足搐搦的鉴别诊断To understand the differential diagnosis三、重点：（一）母乳喂养及辅食添加原则the breast feeding and principle of food supplementary.（二）蛋白质-能量营养不良的临床表现、预防和治疗the clinical manifestation, prevention and treatment of protein-energy malnutrition （三）佝偻病的病因和发病机制he etiology and the pathogenesis of rickets of Vitamin D deficiency.（四）佝偻病和维生素D 缺乏性手足搐搦的临床表现、诊治和预防the clinical manifestations ,diagnosis ,treatment and prevention of rickets and tetany of Vitamin D deficiency. 四、难点：（一）儿童营养素与需要量、能量代谢特征the characters of nutrition requirement and energy metabolism in children.（二）母乳喂养及辅食添加原则the breast feeding and principle of food supplementary.（三）蛋白质-能量营养不良病理生理、临床表现和并发症间的相互关联The relationship between patho-physiology, their clinical manifestation and their complications of protein-energy malnutrition.（四）佝偻病和维生素D 缺乏性手足搐搦的临床表现、诊治和预防The clinical manifestations ,diagnosis ,treatment and prevention of rickets and tetany of Vitamin D deficiency.五、教具或电教设备：多媒体media mix六、自学内容：儿童营养状态的评估七、相关学科知识：生理学、生物化学physiology、biochemistry八、教学法：启发式教育(学)法heuristics lecture九、讲授内容纲要、要求及时间分配小儿营养和喂养（40分）（一）前言-1分钟 （二）小儿营养-10分钟 举例讲解、提问 1.儿童营养需要和能量代谢特征Characters of nutrition requirement and energy metabolism of children. （1）能量Energy: It is necessary for maintaining metabolism of body. Energy needed in children is divided into five divisions.A.基础代谢Basal metabolism.B.食物特殊动力作用Specific dynamic action.C.活动所需Physical activity.D.生长发育Growth and development.E.排泄Fecal loss.In infancy, approximately 50%-60% of the calories are derived from carbohydrate;35%-50% are derived from fat; 10%-15% are derived from protein.儿童能量代谢特征Characters of metabolism in children.A. The ratio for basal metabolism in infants is 10%-15% more than that of adults.B. The energy necessary to build body tissue is specific.C. Energy requirements will increase by growth in children.D. The younger the age, the larger the protein requirement.E. The younger the age, the more the amount of energy 小儿的能量需要，均来源于什么物质呢-图表讲解：2. 营养素Nutrition materials: proteins, fats, carbohydrates, Vitamins and minerals, water and fibers.小儿每月需能量和需水量表年龄 能量（Kcal/kgd） 水（ml/ kgd）1岁 110 15013岁 100 12546岁 90 10079岁 80 751012岁 70 751315岁 60 501619岁 50 50成人 4045 4050（三）小儿喂养-29分钟 1. 母乳喂养Breast feeding -举例讲解、提问、示图 （1）母乳成分及其分泌量The components and quantity of breast feeding.A. Colostrum: first 4 days postpartum, 250-500ml/dB. Transitional milk: 5-10 days postpartumC. Mature milk: 11 days-9 monthsD. Late milk: 10 months later.（2）母乳喂养的优点The advantages of breast feedingA. Decreasing mortality rate of infants.B. Decreasing incidence rate of infants.C. Reducing the rate of malnutrition.D. Cheap, convenience, free of bacteria.E. Promoting the affection between the mother and the infant.F. Others.（3）母乳喂养的方法The ways of breast feedingA.Giving breast feeding half an hour after delivery if both mother and baby are health.B.Giving breast feeding in terms of requirement of infant, the mother and the baby live in the same room.C. Weaning Time 10-12 months postpartum.母乳与牛乳成分的比较成份(100g) 母乳 牛乳蛋白质(g) 0.9 3.3酪蛋白 0.4 2.7白蛋白 0.4 0.4不饱和脂肪酸( % ) 8.0 2.0乳糖(g) 7.0 4.8矿物质(mg) 200.0 800.0钙 34.0 117.0磷 15.0 92.0免疫成分 丰富 缺乏（4）母乳喂养注意事项Breast feeding announcements（5）母乳喂养禁忌Breast feeding contraindication。 2.人工喂养Artificial feeding-举例讲解、提问（1） Cows milk（2） Goats milk（3） Milk substitutes：for example：formula milk.3. Partial breast feeding. 4.辅食的添加Supplementary food adding. （1）目的Purpose Supplemental nutrition materialPrepare for the weaningDevelop the good habit of diet(2) 原则Principle from few to multiple, from thin to dense, from delicate to rude, from one kind to several kinds, giving the supplementary food to children with good health.(3) 添加顺序Subsequence.辅食的添加的顺序月龄 添加的辅食13个月 鲜果汁、青菜水 鱼肝油制剂46个月 米糊、乳儿糕、烂粥 蛋黄、鱼泥、豆腐、动物血 菜泥、水果泥79个月 烂面、烤馒头片、饼干 鱼、蛋、肝泥1012个月 稠粥、软饭、挂面、馒头、面包 碎菜、碎肉、油、豆制品4. 幼儿喂养Feeding during the toddlers age. 1. 充足的能量及优质蛋白Sufficient energy and good quality protein.2. 细软够熟切碎之食物Small、soft、overripe and minced foods3. 每日三餐二点心Three meals and two snacks a day.4. 禁食花生米、黄豆、瓜子等以免误吸入气管Dont eat peanut、bean、melon seeds, etc. to avoid them entering windpipe .（四）营养状况评价-自学 蛋白质-热能营养不良（40分）（一）概述(overview)- -1分钟-导语引起注意，时讲明教学目的 （二）定义(definition) - 2分钟 Definition: Protein-energy malnutrition is the nutrition deficiency because of energy and protein . It is common below 3 years old. The clinical manifestations: initiated with failure to gain weight, followed by loss of weight, decrease and disappearance of subcutaneous fat and disorders of multiple organs and tissues.（三）病因 (etiology)-5分钟 举例讲解，贯穿国内外研究进展与争论，同时联系病例进行医德教育 （1）热卡摄入不足Inadequate calorie intake.（2）消化吸收障碍Insufficient digestion and absorption.（3）需要量增加Requirements increasing.（4）消耗增加Consumption increasing.（四）病理生理（Pathophysiologiy）-7分钟注意各科间、各系统间的联系，融会贯通进行讲授 营养不良病理生理、临床表现以及并发症之间的关系1. 代谢异常Metabolism abnormality.(问题与提问：在重度营养不良时，组织消耗，细胞分解，细胞内钾移至细胞外，使血钾浓度维持在正常水平，当补液纠酸后，细胞外钾又回到细胞内，低血钾症又可能出现，故治疗时应注意补钾。)2. 多器官、组织障碍Disorder of multiple organs and tissues.（五）临床表现(clinical manifestation)- 10分钟举例讲解 体重不增到体重减轻Failure to gain weight followed by loss of weight.顺序为The order of decrease or disappearance of subcutaneous fat：腹部Abdomen 躯干trunk 臀部 buttock 四肢extremities 面部 face.最后为多器官障碍The disorder of multiple organs.第一节课下课（六）临床分型及分度(clinical types and degrees) -3分钟 （图示讲解） Classification according to either energy or protein deficiencyA. MarasmusB. EdemaC. IntermediaMarasmus could be divided into different degrees according to the loss of weight and others.A. Below 3years old, it is divided into three degrees：mild, mid, severe.B. Above 3 years old, it is divided into two degrees：mild and severe.3岁以下小儿营养不良（消瘦型）特点轻度中度重度体重低于正常均值15-25%25-40%40%腹壁皮褶厚度0.8-0.4cm30203030皮下脂肪减少明显减少或近消失减少明显减少或近消失消瘦轻微严重轻微严重精神萎靡、呆滞轻微明显或严重轻微明显皮肤颜色及弹性苍白、弹性差苍白明显、弹性很差苍白、弹性差苍白明显、弹性很差（七）并发症(complication) -2分钟-举例讲解 （1） 贫血Anemia（2） 维生素缺乏症Vitamins deficiency（3） 感染Infections（4） S自发性低血糖pontaneous hypoglycemia（5） 水电解质混乱Disorder of water and electrolyte（八）诊断(diagnosis) -2分钟 It is more common below 3 years old.History：feeding history.Clinical manifestation.Laboratory examination：IGF-1, PAB etc.（九）治疗（treatment）-4分钟 （1） Get rid of causes（2） Adjust diet（3） Facilitate digestion（4） Treat complications（5） Others: nutrition support treatment热卡供应： 轻度：6080kcal/kgd 120180 kcal/kgd。 中、重度：4055 kcal/kgd 120180 kcal/kgd。蛋白质供应：1.52.0g/kgd 3.04.5 g/kgd。食物选择：乳制品，豆浆、蛋类、肝泥、肉末、鲜鱼粉等。食物供给方式：尽量口服，若不能口服者，可予以鼻饲、静脉营养等。（十）.预防（prevention） -4分钟 Reasonable feeding, to advocate breast feeding.Reasonable regime.Prevent and treat diseases, correct deformity.Monitoring the growth and development.营养性维生素D缺乏（40分）1营养性维生素D缺乏病的概述（包括临床病历导入和提问）-1分钟（启发式讲授）Definition of rickets of Vitamin D deficiency.2维生素D的来源和生理功能The source and physiologic function of Vitamin D -3分钟图示讲解3维生素D缺乏病的病因Etiology of rickets of Vitamin D deficiency.-8分钟 （启发式讲授）日光照射不足：最主要的病因维生素D摄入不足食物中钙、磷含量过低或比例不当维生素D的需要量增大 疾病影响及其他如围生期Vit D不足、药物影响等；（结合病例提问1-2名同学）4维生素D 缺乏性手足搐搦的发病机制Pathogenesis of rickets and tetany of Vitamin D deficiency. -2分钟图示讲解5维生素D缺乏性佝偻病的临床表现The clinical manifestations of rickets of Vitamin D deficiency.结合发病机制讲解营养性维生素D缺乏性佝偻病的临床表现中各期临床、生化、X线特点主要表现为生长中的骨骼改变，肌肉松弛和非特异性神经精神症状，临床上分为初期、活动期、恢复期、后遗症期。-12分钟图示、列表格讲解营养性维生素D缺乏性佝偻病临床四期的特点初 期激 期恢复期后遗症期发病年龄3月左右3月多2岁症状非特异性神经精神症状骨骼改变和运动机能发育迟缓症状减轻或接近消失症状消失体征枕秃生长发育最快部位骨骼改变，肌肉松弛血钙正常或稍低稍降低数天内恢复正常正常血磷浓度明显降低同上正常Ca+ P乘积30406个月1岁脊柱后突侧突学坐后骨盆扁平6维生素D 缺乏性手足搐搦的诊断Diagnosis of rickets and tetany of Vitamin D deficiency.-1分钟 7维生素D缺乏性佝偻病的鉴别诊断Differentia l diagnosis of rickets of Vitamin D deficiency -1分钟图示讲解8维生素D缺乏性佝偻病的治疗和预防Treatment and prevention of rickets of Vitamin D deficiency.-3分钟 （启发式讲授）治疗目的：控制活动期，防止骨骼畸形和复发对活动期的患儿，VitD剂量2000-4000UI/d，视临床症状和X-线改善情况于一个月后改为预防量对有并发症者或无法口服者可肌注VitD3一次，量为20-30万IU，3个月后改为口服预防量。预防：一般VitD每日需要量为400IU/天，至2岁。9. 维生素D 缺乏性手足搐搦的诱因The evoked reason of tetany of Vit D deficiency. -1分钟10. 维生素D 缺乏性手足搐搦的临床表现和诊断The clinical manifestations and Diagnosis of tetany of Vitamin D deficiency.-5分钟图示讲解（启发式讲授）主要临床表现为惊厥，喉痉挛和手足搐搦，常伴程度不等的佝偻病表现。典型发作：a. convulsionb. carpopedal spasmc. laryngeal spasm三种症状中以无热惊厥为最常见。隐匿型(Latent tetany)：在不发作时，可引发以下神经肌肉兴奋的体征。a. Chvostecks sign(facial phenomenon)b. Trosseau signc. Peroneal sign诊断diagnosis婴幼儿突发无热惊厥，且反复发作，发作后神志清醒无神经系统体征者，应首先考虑本症。若于冬末春初发病，母乳期有肌肉抽搐等缺钙史，小儿为人工喂养，极少户外活动，未服鱼肝油等病史，或已有佝偻病症状及体征者，均有助于诊断、检查血总钙1.881.75mmol/L，或钙离子1.0mmol/L即可确诊。11维生素D 缺乏性手足搐搦的鉴别诊断Differentia l diagnosis of tetany of Vitamin D deficiency -1分钟（启发式讲授）(1)低血糖(2)婴儿痉挛症(3)低血镁症(4)中枢神经系统感染(5)急性喉炎（简要讨论）12维生素D 缺乏性手足搐搦的治疗Treatment of tetany