1儿科学总论本科双语(第8版)-2013.9.ppt

,教育经历/工作经历1982198719921995199820012001200420032004Karolinskainstitute2004研究经历/研究方向联系pangyush,儿科学总论PEDIATRICS,授课对象：本科广西医科大学儿科学教研室主讲教师:庞玉生,重点1.儿科学的基础及临床特点2.小儿年龄分期及各期特点3.小儿生长发育的规律4.衡量小儿体格生长的常用指标及计算公式5.小儿营养需要量及婴儿喂养方法6.母乳喂养的优点及牛奶喂养的缺点,难点1.小儿年龄分期及各期特点2.小儿生长发育的规律3.体重的计算公式4.婴儿奶方的计算,Chapter1,GeneralIntroduction,Pediatricsisconcernedwiththehealthofinfants,children,andadolescents;theirgrowthanddevelopment;andtheiropportunitytoachievefullpotentialasadults.,Pediatricsisthestudyofgrowthanddevelopmentofthechildfromgeneticbackgroundandmomentofconceptionthroughadolescence.Itisthescienceandartofprevention,diagnosis,andtreatmentofthediseasesofchildrenfrombirththroughadolescence,whetherthesedisturbancesbephysical,mental,oremotional.,第一节TheTaskandScopeofPediatrics,Researchobjectschildrenfromfetustoadolescents,Researchcontents,(1)Researchtherulesofthechildrensgrowthanddevelopment,andtheirinfluentialfactors,inordertopromotethechildrensphysique,intelligenceandsocialadaptabilityendlessly(2)Researchtherulesofthegenesisanddevelopmentofdiseasesinchildren,andthetheoryandtechnologyofclinicaldiagnoseandtreatment,sothatdegradetheincidenceandmortality，promotehealingrate,Researchcontents,(3)Researchthepreventivemeasuresfordiseases,includingimmunevaccination,screeningforcongenitalgeneticdiseases,andpropagatingeducationaboutscientificknowledge(4)Researchtheprobabilityandspecificmethodsofrehabilitationofdiseasesinchildren.,PurposeofPediatrics,ProtectthehealthofchildPromotethequalityoflife,儿科学三级学科分支respiratorysystem(respiratorymedicine),digestive(gastroenterology),circulatory(cardiology),nervous(neurology),hemotologic(hematology),kidney/renal(nephrology),endocrine(endocrinology),infectious(lemology),emergencymedicineSpecialpediatrics:neonatology,childhealthmedicine,perinatology,Perinatology,perinatalperiod:gestation28Wthedaybeforebirth7d,第二节PediatricCharacteristics,Basiccharacteristics：(1)Differencesinindividual,sexandageNotsuitabletoevaluatehealthconditionormakeaclinicaldiagnosisforapatientwithasinglecriteria,(2)Itisverypowerfulinrecoverycapabilityfordamagewhilesuffereddiseaseinchildren.Aneligiblerehabilitationmakes“halftheworkwithdoubleresult”(3)Itisinferiorinprotection-selfforchild.Itisnecessarytopayattentiontopreventionandhealthcare.,大卫生观,1.Anatomy(1)Theratioofthehead,trunkandextremitieschanged.(2)Thepositionoftheinternalorgansalsochangewhilegrow.(3)Therulesofgrowthanddevelopmentmustbeknown.,2.Function：Thenormalvalueofphysiologyandbiochemistryisdifferentindifferentage.heartrate,respirationrate,bloodpressureandtestvalueofserumandotherbodyfluid,3.PathologyPneumococcalinfection4.Immunitynonspecificimmunity，humoralimmunityandcytoimmunity：immaturesIgA、IgG:lower5.Psychology：goodplasticityGoodpersonalityandbehaviorneedtobetrained,Infant:bronchopneumonia,Adult:lobarpneumonia,respiratorytractanddigestivetractinfection,6、疾病种类(spectrumofdisease)(1)Verydifferentaboutthespectrumofdiseasebetweenchildrenandadult.cardiovasculardiseases:Leukemia:childhood:acutelymphoblasticleukemiaadulthood:granulocyticleukemia(2)Inchildhood:,Childhood:congenital,Adulthood:coronary,newborn:congenital,Infant:infectious,7、临床表现(clinicalmanifestation),不典型，变化快（atypical,changeable）（1）年幼体弱儿：对疾病反应差，体温不升、不哭、纳呆、表情淡漠，且无明显定位症状和体征（2）婴幼儿：易患急性感染性疾病，且易扩散，发展快，来势凶险,8、诊断(diagnosis),儿童表述有困难且不准确全面准确体检非常重要，有时甚至是关键注意发病年龄和季节，以及流行病学不同年龄儿童检验正常值常不同,9、治疗(treatment)强调综合治疗（combinedtherapy)重视主要疾病的治疗，不忽视并发症的治疗药物治疗，护理和支持疗法supportivecare药物剂量(dosage)体重或体表面积surfacearea重视液体出入量和液体疗法,10、预后(prognosis)：来势凶猛，恢复也较快较少转成慢性或留下后遗症早期诊断和治疗特别重要11、预防（prevention)计划免疫plannedimmunization,第三节小儿年龄分期,1.Fetalperiodfromeggfertilizedtobabyborn40Winall（fetalage,gestationage,embryonicperiod）harmfulfactorsimpaireddevelopment（abortion,anomaly,dysplasia）Protectmother，protectfetus,2.NeonatalperiodFromthemomentligaturingtheumbilicalcordtothedaybefore28thdayafterbirthParasiticlifeindependentlivingAdaptabilityisimmaturityHighmorbidityandmortalitybirthinjury,infection,abnormity,3.InfantperiodFrombirthtothetimebefore1yearGrowanddeveloprapidlyNeedmorenutritivematerialDigestivefunctionimperfectDigestionandnutritioneasilydisorderedImmunefunctionimmatureEasytohaveinfectiousdiseasesandtransmissiblediseases,4.ToddlersageFrom1yeartothetimebefore3yearsGrowanddevelopslowerthanbeforeIntelligencedeveloprapidlyContactoutsideworldmoreExercisemorePoorlyidentifydangerprotection-selfEmergentdamageincidenceisveryhigh,5.PreschoolageFrom3yearsto6-7yearsGrowanddevelopslowlyIntelligencedevelopsrapidlymoreContactwidelywithchildrenandsocietyKnowledgeexpandsSelf-careabilityandsocialintercourseabilitybuildup,6.SchoolageFrom67years（primaryschool）tothetimebeforeadolescence(male13,female12)GrowanddevelopslowlyBesidesgenitalsystem,alllikesadultIntelligencedevelopmentspeedupmature,7.AdolescenceFrom10yrsto20yrsThetimewhenpubertyonsetsandendsongirlisearlier2yrsthanthatonboyGrowanddevelopspeedupagainThatisso-called“secondpeak”pubertyspurtGenitalsystemdevelopsrapidlyandtrendtobemature,青春期Adolescence男:13至20岁女:11至18岁个体相差2-4岁,古代儿科学Ancientpediatrics-中医儿科（2400多年前）,第四节我国儿科学的发展与展望Developmentandoutlook,近代儿科学（20世纪初期）1937年成立中华医学会儿科分会40年代各大城市开始普设儿科1943诸福棠教授主编实用儿科学问世1957、1964、1973、1985、1995、2002再版,现代儿科学（20世纪中期新中国成立后）传染病发病率大幅下降，婴儿死亡率逐年下降1960年宣布消灭天花1994年无脊髓灰质炎50年代开创中西医结合儿科70年代后期成立儿科学各专业学组80年代成立儿童医院、儿科研究所、PICU、NICU90年代基因诊断、基因治疗,我国儿童死亡率的变化,我国儿童死亡率与其他国家的比较,儿科医学教育迅速发展1950年中华儿科杂志创刊1960年第一本高等医药院校教材儿科学出版1978年儿科学硕士、博士、博士后培养重视儿科学继续教育我国儿科医师6万名儿内科、儿外科、儿童保健,Outlookin21centuryReducemorbidityandmortalityProtectchildrenshealth，improvelifesqualityPayattentiontochildrensrehabilitationPreventionduringchildrenforadultdiseasesIntegratedmanagementofchildhoodillness(IMCI)Genediagnosisandgenetherapy,中华人民共和国母婴保健法中国儿童发展纲要20112020儿童保健工作是发展社会生产力的一种投资儿童是祖国的未来儿童健康是一生健康的基础儿童强则祖国强，儿童健康则家庭国家健康儿科医师相对不足全国6万多，广西2000多,Chapter2GrowthandDevelopment,生长（growth)指儿童身体各器官、系统的长大，有相应的测量值，即有量的变化。生长是发育的物质基础。发育（development)指细胞、组织、器官的分化与功能成熟，是质的变化。,1.生长发育是连续性的、有阶段性的过程生后第一个生长高峰第二年后生长减慢青春期第二个生长高峰,二个生长高峰,第一节生长发育规律,2.各系统器官发育不平衡,3.生长发育的个体差异individualvariation受遗传和环境的影响生长“轨迹”不同,鄂州高矮兄弟“武大”潘熙春22岁1.33m“武二”潘熙明19岁1.96m,4.生长发育的一般规律由上到下：抬头抬胸坐、立、行由近到远：从臂到手，从腿到脚由粗到细：全掌抓握手指拾取由简单到复杂：画直线画圈、图形由低级到高级：看、听、感觉事物认识事物记忆、思维、分析、判断,第二节影响生长发育的因素,一、遗传因素(geneticfactors)Thetrajectory,characteristics,potentialortendencyofthegrowthanddevelopmentduringchild,aredeterminedbyparentsgeneticfactors.Alsoitisdeeplydeterminedbyethnicandfamilialgeneticinformation.,二、环境因素（environmentalfactors)营养(nutrition)疾病(diseases)母亲情况(mothersstatus)家庭和社会环境(familyandsocialenvironment),一、体格生长常用指标(generalindex)体重、身高（长）、坐高（顶臀长）头围、胸围、上臂围、皮下脂肪,第三节体格生长,（一）体重的增长（bodyweight）Totalweightoforgans,systemsandbodyfluidsEasytomeasureaccuratelyAsensitiveindextoevaluatechildgrowthandnutritionalstatusCalculatedosageandquantityofintravenoustransfusionwithweightinpediatricclinic,二、出生至青春前期的体格生长规律(growthbeforepuberty),1.生后第一年体重增长最快，是生长的第一个高峰期；青春期前随年龄增加:先快后慢、再趋于稳定。2.非匀速增长过程:生后第一年内前3个月体重增长后9个月体重增长。3.生理性体重下降：生后一周内如奶量摄入不足，加之水分丢失、胎粪排出,体重增长的规律,3/(03月),1,3/(312月),2,3,3/(12岁),2kg/年,体重的增长,关于体重估计公式：生后12月体重（kg）=10生后112岁体重（kg）=年龄（岁）28公式可用于药量和补液计算，不能用于体格发育的评价。因为体重的增长是一个非匀速的过程，尤其是小婴儿；同时其增长也受遗传、环境影响，因此存在个体差异。,（二）身材的增长Growthonstature,-身高bodyheight,-身长bodylength,2岁至青春前期年龄（岁）7755cm/y,6163cm,1113cm/(03月),85cm,1012cm/(12岁),1113cm/(312月),75cm,12月,身高的增长（bodylength）,坐高（顶臀长）Sittingheight,-顶臀长crown-rumplength,头顶到坐骨结节的长度，反映头颅和脊柱的增长,-坐高,（年龄-1）,头胸围生长曲线,cm,（五）上臂围的增长upperarmcircumference,代表肌肉、骨骼、皮下脂肪和皮肤的生长1岁内增长迅速，之后减缓左上臂围筛查15岁营养状况nutritionalstatus（1）13.5cm，营养良好（eutrophy）（2）12.513.5cm，营养中等（secondary）（3）2yr5565%oftotalenergy80%or40disadvantageforhealthDeficient：athrepsy,lowerbodyweight,growthretardationExcessive：obesity、dentalnecrosis,ENERGYPRODUCED,06m45%50%712m35%40%,优质goodquality提高利用率,(三）Micronutrient1.MineralsMacroelement：calcium,sodium,phosphor,potassiumConstitutebodycomponent,Regulatenervousandmuscleexcitability,(2)Microelement：Essentialtraceelement：iodine,zinc,selenium,copper,molybdenum,chrome,cobalt,ferrum，magnesiumActivefactorsforenzymeandvitaminHormonalactionNucleicacidmetabolism,2、VitaminFat-solublevitamins：A,D,E,KWater-solubevitamins：B,CEasilydeficient：A,D,C,B1,（四）Otherfood1.dietaryfiber：Solubility：reducetoabsorbfattyacidandcholesterolInsolubility：increasethevolumeofstoolandpromotetoexcretestool2.Water:infant100150ml/kg.ddecrease25ml/kg.devery3yrs,二、小儿消化系统的发育与营养关系GastroentericDevelopmentandNutrition（一）消化酶的成熟与宏量营养素的消化、吸收,1.蛋白质Protein（1）胃蛋白酶pepsin3月后活性增加18月时达成人水平（2）胰蛋白酶trypsin1月已达成人水平,2.脂肪吸收:胃酸分泌（Pepticacidsecretion）消化：胃脂肪酶(HGL)胰脂酶（Pancreaticlipase）：新生儿期几乎无法测定2岁后达成人水平母乳的脂肪酶:补偿胰脂酶不足肠脂酶（Entericlipase）：生后不足,3.糖类双糖Disaccharidases胎儿3月后所有双糖酶出现胎儿8月:蔗糖、麦芽糖酶活性达最高足月:出生乳糖酶活性高多糖（淀粉Starch）唾液腺淀粉酶salivaryamylase:胰淀粉酶pancreaticamylase:3月后逐渐增高2岁达成人水平小肠-淀粉酶-amylase:,小结Summary婴儿消化功能的成熟也同样遵循发育不平衡的规律和逐渐成熟的过程,婴儿消化蛋白质能力强，可满足生后生长需要。婴儿胃脂酶、母乳中的脂肪酶可代偿胰脂肪酶的不足婴儿早期对单、双糖的消化能力较好，对多糖消化较差。婴儿食物选择应符合发育成熟总规律，不宜过早添加固体食物，特别是淀粉类、鸡蛋等。,（二）进食技能的发育1.食物接受的模式发展2.挤压反射（Extrusionreflex）新生儿至34月挤压反射3.咀嚼(chewing、mastication),出生具有的一种最基本的进食动作,解剖特点吸吮口腔小舌短而宽（舌系带固定）颊脂肪垫唇肌发育好,觅食反射Rootingreflex,吸吮Sucking,舌,软腭,吞咽发育有效吞咽,软腭,食物团块,口腔,吞咽（swallow),感觉发育：味、嗅、视,后天咀嚼行为的学习,敏感期：46月,动作发育：可坐，手到口,口腔刺激:萌牙,训练婴儿7月左右咬嚼指状食物、从杯咂水;9月学用勺自喂；1岁断离奶瓶。,均有利于儿童口腔发育成熟,第二节Infantfeeding,一、Feedingofbreastmilk（一）人乳的特点characteristics1.营养丰富，生物效价高必需氨基酸比例适宜-酪蛋白，含磷少，凝块小乳清蛋白为主，促进糖蛋白形成酪：清1：4易消化吸收宏量营养素产能比例适宜婴儿很少过敏,母乳牛乳理想标准CHO(g)6.941%5.029%40%50%FAT(g)3.750%4.052%50%PRO(g)1.59%3.319%11%E(kcal/dl)6769,宏量营养素产能比（100ml）,乙型乳糖含量丰富，利于脑发育及肠道益生菌生长，有利钙吸收不饱和脂肪酸较多，利于脑发育，必需脂肪酸为主，脂肪酶多电解质浓度低、蛋白质分子小，适宜婴儿肾发育水平；钙、铁、锌吸收率高，Ca:P=2:1维生素D、K含量低,2.生物作用Biologicalaction（1）缓冲力小：不影响胃酸，利于酶发挥作用lessbuffering：notinfluencegastricacid（2）含不可替代的免疫成分，可增强婴儿免疫力SIgA丰富免疫活性细胞immunocyte乳铁蛋白lactoferrin溶菌酶lysozyme双歧因子bifidusfactor低聚糖oligose（3）生长调节因子growthregulator:taurine,3Otherseconomicconvenientsavetime,labor-savingsuitabletemperaturebaby-motheremotionmentalhealthuterinecontractionformother,（二）CompositionofHumanmilk1.各期人乳的变化Foremilk:Afterparturition45days，secretoryvolumeisfew(1545ml/d)Interimmilk:5day14days,secretoryvolumegraduallyincrease，morefat.Maturemilk:14days,secretoryvolumeincrease，lessprotein.,1.Protein2.Fat3.Carbohydrate4.Vitamin5.Mineral6.Immunity(1)Immunoglobulin(2)Lactoferrin(3)Lysozyme(4)Cellular:macrophages,初乳过渡乳成熟乳PRO22.515.611.5FAT28.543.732.6CHO75.977.475.0矿物质3.082.412.06Ca0.330.290.35P5,各期母乳成分变化(g/L),IIIIII,ProFat17.127.755.1,2.哺乳过程乳汁成分的变化（g/L）,（三）建立良好的母乳喂养方法1.Prepareantepartum2.Protectmammarypapilla3.SetupanormalbreastfeedingBeginearly：afterbirth15min2hFeeddependinguprequirement4.Keepmilksecretion,5.Masterperfectfeedingskill6.Motherishappy,InfantFeeding:Breastfeeding,Disadvantageofbreastfeeding,（四）不宜哺乳的情况HIV感染的母亲乳母患