01-绪论+生长发育+儿童保健

Introduction曹励之

Physicalandemotionalhealthofinfants、children、andadolescents；theirgrowthanddevelopment；theirdiseaseprevention;andtreatment.Development、Prevention、Clinicpediatrics

Perinatology(围生医学)、Neonatology(新生儿学)、Adolescentmedicine(青春期医学)

Principles:protectchildren’shealth,improvethelifequalityPediatrics(儿科学)Threedifferences:individual,ageandsexGoodrecoveryabilityWeakselfprotectionCharacteristicsPediatricsisnottheminiatureofinternalmedicineDifferentdevelopmentregulationsindifferentagesDifferentnormaldataaboutphysiologyandbiochemistryindifferentagesImmunesystemisnotasperfectasadult’sBiggerwaterandnutritionrequirementDifferentpathologicalchangesbetweenadultandchildrenSinglechildpolicy(China)ChildrenClinicalManifestationandDiagnosisInfectiveDiseasesChildrenSevereCan’tbelimitedmultisysteminvolvementNeonateNotspecificLosingdefinitelocationDosebeingconnectedwithdifferentagesTreatingtheprimaryandthecomplicationsNursingandsupportingChangingquicklyGoodcapacityofrestoreLesssequelae(后遗症)thanthatofadultexceptnervoussystemEmphasizeguardingofyounger,weaknessandcriticallyillTreatmentandPrognosisMonitoringofperinatalperiodPlannedimmunization

Fourofthemostordinarydisease(malnutrition,anemia,diarrheaandpneumonia)Preventingtheadultdisease(obesity,hypertension,diabetesorcoronaryheartdisease)Prevention

GOBIGrowth,Oralrehydration,Breastfeeding,ImmunizationIMCI(integratedmanagementofchildhoodillness)Pneumonia(19%)Diarrhea(18%)Malaria(8%)Measles(4%)HIV/AIDS(3%)Neonataldiseases(37%):preterm,asphyxia,infection

Principlesofchildren’shealthcareInfectiousdiseasesMentalproblemsinchildrenPreventionofadultdiseasesinchildrenAccidentalinjuryinchildrenEnvironmentalpollutionAdolescentmedicineandothersubjects’immersionintothePediatricsGeneticdiagnosisandpreventionofchildren’sdiseasesChallengesandfuturesFetalperiodFromfertilizationtothebirthofthebabyStagesofDevelopment(First)

StagesofDevelopment(Second)

Newbornperiod

Fromumbilicalcordligationto28thday(Earlynewbornperiodisyoungerthan7days)BadabilityofadjustingandadaptingHighmorbidityandmortality

Importanceofhealthprotection,nursingandplannedimmunizationPerinatalperiod:from28weeksofpregnancyto7thdayafterbirthPerinatal

mortality(死亡率)isanimportantguidelineofjudgingdevelopingdegreeofonecountry.CharacteristicMouthSkinApgarscoreMother/infantbinding(roomingin)RuleoutcongenitalgeneticandmetabolicdiseasesFunctionanalysisNurseatbirthImmunizationshouldbepostponedifthechildhasanacutefebrileillness.Prematurebabiescanbeimmunizedfollowingtherecommendedscheduleaccordingtochronologicalage,i.e.immunizationshouldnotbepostponed.ContraindicationsBeingtreatedwithchemotherapyorradiotherapyformalignantdiseaseOnimmunosuppressivetreatmentafterorganorbonemarrowtransplant.Onhigh-dosesystemicsteroids.Withimpairedcell-mediatedimmunity,e.g.severecombinedimmunodeficiencysyndromeorDiGeorgesyndrome.LivevaccinesarecontraindicatedinimmunocompromisedchildrenStagesofDevelopment(Third)

Infancyperiod

Afterdeliveryto1yearold

Characteristic

RapidestperiodofgrowthLargerrequirementofnutritionandenergyToomuch:obesity,diarrheaDeficiency:anemia,malnutrition

BreastmilkPlannedimmunization

Susceptivetotheinfectiousdiseaseinthelatter6monthsPhysicalexamination:age<6months:everymonthage>6months:every2-3monthsStagesofDevelopment(Fourth)Toddler’sageFrom1yearto3yearsCharacteristicFasterintelligencedevelopmentElementaryeducationPoorerabilityofidentifyingdangerThunderboltinjuryChangingoffoodMalnutrition,disordersofdigestionImmunedeficiencyBeingapttoinfectivediseasePhysicalexamination:every6months

StagesofDevelopment(Fifth)Preschoolage

From3yearsto6-7yearsCharacteristicSlower

growthMorematuredevelopmentofintelligence

plasticityculture(可塑性培养)Trainingofgoodhabitandindependentability(sleeping,eating,stool,healthhabit)Preventionofinfectiousdiseasesandaccidents(learnselfprotection119,110,120)

Moreimmunedisease

StagesofDevelopment(Sixth)Schoolage

From6-7yearsto12-14yearsCharacteristic

Physicalgrowthbeingsimilarasadult’sExceptgenitalsystem

Comprehensivedevelopmentofthemorals,intelligenceandbodiesLowermorbidityCultivationofthesanitationhabitStagesofDevelopment(Seventh)

Adolescence

Girl：11-12y~17-18yBoy：13-14y~18-20yCharacteristicThesecondpeakofdevelopmentandgrowth.Thepeakdevelopmentofthegenitalsystem-healthcareTheinstabilityofneuroendocrinesystem-psychology;behavior;spiritScientificbreeding:newbornsandinfantsSuitablebreeding:laterstagesEarlyeducation:infantsandtoddlersInjuryprevention:toddlers,pre-schoolsandschoolagesPsychiatriceducation:pre-schools,schoolagesandpubertySexeducation:schoolagesandpubertyHealthCareGrowthandDevelopmentGrowth

MorphologicalgrowthoforgansandsystemsQuantitativechangeDevelopment

Differentiationandmaturefunctionofcells,organizationsandorgansQualitativechangeDefinitionContinuedprocessandsegmentalRulesUnbalancedevelopmentofsystemsandorgans抬头（3m）Generalrules(First):Up→Down独坐（6-8m）扶站（9-11m）独走（13-15m）

独坐持物（12月）翻身（6-7个月）Generalrules(Second):

Near→Far探身取物（6个月）Generalrules(Third):Careless→Careful

单手持物（9个月）Generalrules(Fourth):Easy→Complex

Generalrules(Fifth):Low→High-grade

IndividualDifference

InfluencingFactorsInheritanceSexNutritionDiseasePregnancyEnvironmentPhysiqueDevelopmentWeight

Totalweightofallorgans,systemsandliquidinbodyReflectingconditionsofgrowthandnutritionCalculatingthedoseofdrugandtransfusionWeightofbirth

Boy:3.3±0.4kg

Girl:3.2±0.4kgNormalweightloss

Weightlossduringthefirst10days(3to9percent)

Twopeaks

Frombirthto6months

~3m:700~800g/m

4~6m:500~600g/m7~12m:300~400g/mAdolescence

4~5kg/y×2~3y

AgesWeight(kg)Increasedweight（kg）

1～12yAges×2＋83m6±12m9±24m12±Birth33/(0~3月)13/(3~12月)233/(1~2岁)Growthonweight<6mW：Watbirth（Kg）+m×0.7（Kg）7~12mW：6（Kg）+m×0.25（Kg）2y~pre-puberty：age×2（Kg）+7(or8)（Kg）or3~12m：[age（m）+9]/2(Kg)1~6y：age（y）×2+8（Kg）7~12y：[age（y）×7-5]/2(Kg)W=weight;m=months;y=yearsEquilibriumStandingHeightLengthfromthetopofheadtothebottomoffoot<3y:Lyingonback(recumbentlength)Atbirth

：50cm1y：75cm2y：87cm2~12y：age×7+70cm(75)

TwoPeaksofHeightInfants

Thefirst3monthsIncreasing11~12cm

Adolescence

PeakheightvelocityPHA(生长高峰)TwotimesofchildperiodspeedLasting2-3yearsGirlsbeinghigherthanboysParsSuperiorandParsInferiorAtBirth

ParsSuperior(0.60)>

ParsInferior(0.40)(上部量)(下部量)12yearsold

ParsSuperior=ParsInferiorSittingHeightHeightfromthetopofheadtohucklebonetuber

Representingthedevelopmentofskullandspine

<3y:Crown-rumplengthwhenlyingonbackFingerDistanceDistancebetweentwomiddlefingerswhentwoarmslyingatlevelRepresentingthedevelopmentoflongboneoftheupperlimbsNormal:<height

Unusual:>height1~2cmHeadCircumferenceAtbirth：33~34cm1y：46cm(thefirst3m=later９m＝６cm)2y：48cm5y：50cm15y：54~58cmChestCircumferenceAtbirth

：32cm＜headcircumference1~2cm1y：＝HeadCircumference

＞１y：＞HeadCircumference

AgeCC（cm）comparingwithHC（cm）ChestcircumferenceAtbirth32<1～21y

46equal>1y

HC+（age-1）>（age-1）CC=chestcircumference,HC=headcircumferenceGrowthcurveofCCandHCcmUpperArmCircumference

＜５y:Reflectingchildren’snutritionconditions

＞13.5cm：Fine

12.5~13.5cm：Medium

＜12.5cm：Malnutrition

ProportionofBody

Proportionoftheheadandheight:infants(1/4)-----adults(1/8)WeightbyStature（体形匀称）

Weight-For-Height（身高的体重）

ChestCircumference/Height（身高胸围指数）

EMI/age（年龄的体块指数）

Trunk-LegRation（身材匀称)SittingHeight/StandingHeight.Atbirth:0.67→14years:0.53SpanandStandingHeight常用的统计学表示方法

+2SD-2SD均值离差法P3rd

P50thP97th百分位法界值点的选择（cut-offpoint）（1）均值离差法：±2SD（2）百分位法：P3rd～

P97thX测量值的表示（1）表格（2）生长曲线

生长曲线评价结果表示均值离差法：百分位法：等级法三分法下（异常）

中上(异常）五分法下（异常）中下

中中上上（异常）p3rdp25th

p50thp75thp97th

-2SD-1SD

1SD2SDXGrowthandDevelopmentofSystemsClosingofbonesuturesandfontanellesAreaAtbirthClosedage1.5~2cm≦18m0.5cm1~2mPalpable3~4mBonegap

PosteriorFontanelleFrontalFontanelle

SpinaldevelopmentAgeActivityMusclesSpinalcurve3mLifthead颈后肌颈曲（颈部脊柱前凸）6mSit腰肌胸曲（胸部脊柱后凸）12mWalk下肢肌腰曲（腰部脊柱前凸）7~8m:PrimaryTeethappears2y:DeciduousTeeth=moon’sage–(4~6)Itisunusualifnoteethat1year.2.5y:CompletedThefirstmolarat6y，thesecondat12y，thethirdafter18y.Teeth

SensoryandPerceptual,BehavioralDevelopmentDevelopmentofBrainweight

Brainweightweight%Adultbrainweight%Birth350g10%~12%25%6m600~700g50%12m60%2~3y75%4~5y80%~90%Adult1500g2%~3%Developmentofbrainfunction：Getclosedtotheadult’slevel:3yrsoldObtainadult’sfullfunctions:8yrsoldCongenitalunconditionedreflex紧张性颈反射握持反射爬行反射踏步反射拥抱反射Summary

Developmentofmorphologyisearlierthanthefunctioninthecerebralcortex；

Lowerexcitementincerebralcortexandhigherinsubcorticalcenter；

Unconditionedreflex；

Incompletemyelinizationofnervefibers

SensoryandPerceptualDevelopment

Abilityof

obtaininginformationfromenvironmentthroughsensororgans

andisessentialtootherareas’development.Newborns

Thebestfocusdistanceis20cm.Eyesandheadsarecapableoffollowingthefocusedobjects.Distinctionofsizeandshapeisalsopossible.听感知的发育皮肤感觉的发育SkinsensationSensePerceptionDevelopment

SenseofTaste（味觉）

Atbirth:Rathermatureoftaste4~5months:Keyperiodofdevelopment

SensePerceptionDevelopment

SenseofSmell（嗅觉）

Atbirth:Lookingfornippleswhensmellingmilk’staste3~4m:Differentiationodor

7~8m:Responsetosweet-smellSensePerceptionDevelopment

TactileSensation

（触觉）

Newbornsareverysensitiveinmultipleareas2～3y

Distinctproperty5～6y

Distinctobjectsofdifferentsizeandweight

SenseofpainNewbornsarenotsensitivetothepainbecauseofincompletemyelinizationofnervefiberswhichwillbeimprovedafter2months.MotorDevelopment

Lifthead2m

Lifthead3m

Stable4m

Verystable,freelyrotationRollover1~2m侧卧至仰卧4~5月仰卧至侧卧6~8月仰卧至俯卧1~2mNewborn6~8mWalk、Run、Jump6月扶站9~12月扶物走1岁独走几步1.5~2岁跑2岁双足跳3~4.5岁独足跳

大运动发育

二抬liftshead十站standsalone

四翻rollsover周岁走walksalone

六坐sits二岁跑runswell

八爬creeps三岁独足跳hopsFineMotorDevelopment三玩手playshands一岁乱画scribbles五抓graspsobject二岁折纸foldspaper七换手passesobject三岁搭桥buildsbridge九月对指picksupwiththumb-indexfingerSpeechandLanguageDevelopment

ConditionsoflingualdevelopmentHearing

CNSPronouncingorgans

|||Acceptance

Understandingandexpression

pronunciationAdvancedconditions：Adequatelanguage

Environmentalirritation1~6m

Pronouncesinglesyllable7~11m

Pronouncerepeatedsyllables10~13m

Say:“mom”1~3y

Sayvocabularies,simplesentencesandsingshortsongs4~5y

Saycompoundsentencesandsingnurseryrhyme7~24m

lingualinterpret2~3y

lingualexpressionSuspiciousdelayed14m

problemswithsingleword24m

problemsofcombining2words30m

difficultiesofspeakingsimplesentencesScreeningstandard24m

Vocabulary<30

——Disability

Vocabulary<50

——Suspicious个人-社会能力的发育（Personal—SocialSkill）

personal—socialskill

二笑smileresponsively

六认生shywithstrangers

九月做再见wavebye-bye

一岁示需要indicatewants

二岁做游戏playinteractivegames

三岁会穿衣putonT-shirtListstheworryingsignsatagesgivenAgeDevelopmentalsign6-8weeksAsymmetricalMoroExcessheadlagNovisualfixation/followingNostartleorquieteningtosoundNoresponsivesmiling8monthsPersistingprimitivereflexesNotweightbearingonlegsNotreachingoutfortoysNotfixingonsmallobjectsNotvocalizing10monthsUnabletositunsupported1yearShowingahandpreferenceNotrespondingtoownname18monthsNotwalkingNopincergripPersistenceofcasting3yearsInaccurateuseofaspoonNotspeakinginsentencesUnabletounderstandsimplecommandsUnabletousethetoiletaloneNotinteractingwithotherchildrenNeverReflexDevelopment(Ⅰ)Appearsatbirthandneverdisappears

Cornealreflex(角膜反射)

Conjunctivalreflex(结膜反射)Papillaryreflex(瞳孔反射)

Pharyngealreflex(吞咽反射)NeverReflexDevelopment(Ⅱ)Appearsatbirthbutdisappearsat3~4monthsRootingreflex（觅食反射）

Suckingreflex（吸吮反射）

Graspingreflex（握持反射）

Embracereflex（拥抱反射）NeverReflexDevelopment(Ⅲ)Notexistatbirthbutappearsgraduallyandbestableat1year

Abdominalreflex（腹壁反射）

Cremastericreflex（提睾反射）

Tendonjerk（腱反射）PathologicReflex<4monthsKernigsign(+)<2yearsBarbinskisign(+)TheSongofGrowthandDevelopment

一哭二笑三伊呀四月哈哈望妈妈五抓六坐握足玩七翻八爬九叫爸十站对指十二走看图说话在十八两岁能用勺吃饭喜怒分明命令发三岁学穿鞋和袜长成大娃别娇他PsychologicaldevelopmentBeginningofthecognitionprocessAlternativereactionstoenvironmentandstimulationUnconsciousattentionConsciousattentionThestabilityoftheattentionAttention

Nerveactionprocessthatdepositingand“readingout”theinformationFeelingmemoryTemporarymemory

repeatedrecognition

repeated

reproduce

MechanicalmemoryConsciousmemoryLogicalmemoryMemoryLong