The first essential point to be in mind is that the child is not to be treated in the same way as an adult. Children vary far more than adults, both physically and mentally. Each child presents an individual problem; fixed rules cannot be applied. In the treatment of children, the physician’s methods must be flexible and adaptable.
The use of drugs particularly requires much judgement. The possible harm that may result from a given prescription should always be considered.
But good prescriptions are by no means the only objective. The physician who orders the medicine indicated for his little patient, and then dismisses the case from his mind, will find his results frequently disappointing, for details play a large role in the treatment of children.
The parents must be made to understand the results cannot always be immediate. Delicate, nervous children, or those who have serious digestive trouble, may require many months of careful supervision, with little evidence of improvement. The physician, on the other hand, should not permit himself to be too easily encouraged by slow results. Patience and persistence must be combined with a thorough understanding of the problems involved. Without these factors, success in the treatment of children will be difficult to achieve.
Hygiene and sanitation are such familiar subjects that it is only necessary to emphasize their relation to treatment. The patient’s surroundings should be clean, well ordered, and cheerful. This accomplishes not only the obvious purpose of avoiding infection as much as possible, but also reacts beneficially on the child’s mental attitude.
In any infectious disease, extreme care should be taken to prevent spread of the infection. Fresh air and sunlight are valuable disinfectants, and should be used abundantly. Contact with other people should be avoided.
Rest is an important aid, both as a preventive and as a cure. Adequate sleep at night, and a quiet period after dinner, should be insisted upon. A child with fever, however slight, ought to be kept in bed until his temperature becomes normal, sometimes for several days thereafter. This will often avert a serious disease.
An adequate diet is one of the essentials of good health. Its importance in illness is likely to be even greater. Some conditions can be controlled, and many others improved, by changes in diet alone.
In any illness, one of the first considerations is the maintenance of nutrition without causing gastro-intestinal disturbance. Only those foods which are easily assimilated and do not produce distention should be permitted. Fluids should be given liberally, as they dilute toxins and increase elimination. It is advisable to keep the bowels open, if possible, by laxative food such as fruit juices and vegetables. The mineral content of the diet should be adequate. The vitamins should be liberally supplied, particularly vitamin A, as this food factor is thought to build resistance to respiratory infections.
MEDICAL AND NURSING CARE
Nowadays babies are born in a hospital. There the doctor is closer at hand when needed, and he is assisted by interns, nurses, technicians and consultants. A hospital offers all the complicated equipment, like incubators and oxygen tents, to cope with sudden emergencies. All this makes the mother feel very safe and well cared for. The babies are usually in a nursery, where they can be cared for. The babies are usually in a nursery, where they can be efficiently watched and cared for by the nurses. The mother begins taking care of her baby holding him, feeding him. She has the chance to practice these things while she is among experienced people who can explain things to her and help her. She learns about her baby’s hunger patterns, his sleep, his cry, his bowel movements.
When the mother takes her baby home she is visited by a visiting nurse who will show how to make the formula, bathe the baby, diaper him, help her in other practical child-care matters, and follow directions of the doctor.
The way to be sure that your baby is doing well is to have him checked by a doctor regularly. The visits should be once a month in the early months. The doctor will want to weigh and measure the baby to see how he is growing, examine him to see that he is developing well, give him his inoculations. The mother will have five or ten questions that she wants to ask, with her first baby anyway. It’s a good idea to have a little notebook for writing down questions when they come to your mind at home and also for noting developments, such as teething or a rash, that you may want to know the date of later.
There are hundreds of different diseases and injuries such as fever, colds, hoarseness of voice, difficulty in breathing, vomiting, pain, diarrhea, rashes and so on which should always be reported to the doctor immediately.
By far the most important rule is to consult the doctor promptly if a baby or a child looks differently. By this it is meant such signs as unusual paleness, unusual tiredness, unusual drowsiness, lack of interest, unusual irritability, anxiousness, restlessness, prostration.
PREVENTING IRON DEFICIENCY ANAEMIA
The role of follow-on formulae
Many studies have indicated that iron deficiency is common in Britain. It is particularly prevalent in areas of social deprivation, typically inner cities and in children who are members of an ethnic minority group. In 1986 Ehrhardt showed that 28% of Asian children and 12% of Caucasian children admitted to hospital in Bradford were anaemic. A further study completed in 1990 in an inner city practice in Nottingham showed an overall incidence of anaemia of 25%, rising to 39% in Asian children.
The clinical consequences of iron deficiency anaemia are well documented. However, there is growing evidence to suggest that iron has a vital role to play beyond the red blood cell. The non-haematological effects of a lack of iron are not fully understood. Evidence from several studies would suggest that iron deficiency anaemia is associated with behavioural and cognitive changes. If these behavioural changes are related to tissue deficiency and not to haemoglobin concentration, they may be important before iron deficiency has been clinically detected.
The association of iron deficiency during infancy with changes in behavioural development has been shown in at least five independent studies conducted in five separate cultures. All five studies used careful definitions of iron status and included comparison groups without anaemia. All showed that infants with anaemia scored lower on tests of mental development than infants without anaemia; on average 6-14 points lower on the Bayley Scales of Infant Development. Four of the studies showed that anaemic infants’ scores on motor development tests were lower.
In intervention studies, anemic infants treated with iron did not show a significant improvement in the development tests after 1-2 weeks of iron therapy. The potential consequences of these findings have far reaching effects and the need to prevent iron deficiency in early infancy becomes a priority for the health professional. The use of appropriate weaning foods in conjunction with infant formula is widely recommended in the first year. Although the tendency for mothers to keep their infants on infant formula for longer is increasing, some mothers still change their infants to doorstep cow’s milk before the age of 12 months. The 1990 survey indicated that as many as 36% of infants were given cow’s milk as the main drink at nine to ten months. In addition, even if the older infant is maintained on infant formula, it is usual to find low intakes of milk as little as 300-400ml daily. This supplies less than 50% of the infant’s iron requirements. It seems reasonable, therefore, to encourage follow-on formula for infants over six months of age who are on low volumes of infant formula and those infants who have already changed to cow’s milk.
Unfortunately, most follow-on formula is not available on milk tokens, which severely limits its usage. Other than this, it does not appear to have any disadvantages over standard infant formula for infants over the age of six months, and there is little evidence of parents misusing it by giving it to babies below this age. As we concluded in our leader in last month’s Professional Care of Mother and Child, it is probably time to reappraise our thinking on follow-on formulas, as they may be one of the many resources we can use to help prevent iron deficiency.
Follow on formulae – äîïîëíèòåëüíûå ñìåñè
Token – ÿðëûê, èíôîðìàöèÿ î ñîñòàâå
Caucasian: of a proposed human racial classification distinguished by light and brown skin colour and including peoples indigenous (native) to Europe, N. Africa, W. Asia and India.
TELEMEDICINE IN PRACTICE
Telemedicine is defined as the “delivery of health care and sharing of medical knowledge over a distance using telecommunication systems.” The concept of telemedicine is not new. Beyond the use of the telephone, there were numerous attempts to develop telemedicine programs in the 1960’s mostly based on interactive television. The early experience was conceptionally encouraging but suffered inadequate technology. With a few notable exceptions such as the telemetry of medical data in the space program, there was very little advancement of telemedicine in the 1970s and 1980s. Interest in telemedicine has exploded in the 1990s with the development of medical devices suited to capturing images and other data in digital electronic form and the development and installation of high speed, high bandwidth telecommunication systems around the world. Clinical applications of telemedicine are now found in virtually every specialty. Teleradiology is the most common application followed by cardiology, dermatology, psychiatry, emergency medicine, home health care, pathology and oncology. The technological basis and the practical issues are highly variable from one clinical application to another. Teleradiology, including telenuclear medicine, is one of the more well-defined telemedicine services. Techniques have been developed for the acquisition and digitization of images, image compression, image transmission, and image interpretation. The American College of Radiology has promulgated standards for teleradiology, including the requirement for the use of high resolution 2000 x 2000 pixel workstations for the interpretation of plain films. Other elements of the standard address image annotation, patient confidentiality, workstation functionality, cathode ray tube brightness, and image compression. Teleradiology systems are now widely deployed in clinical practice. Applications include providing service from larger to smaller institutions, coverage of outpatient clinics, imaging centers, and nursing homes. Teleradiology is being used in international applications. Unresolved issues in telemedicine include licensure, the development of standards, reimbursement for services, patient confidentiality, and telecommunications infrastructure and cost. A number of states and medical boards have instituted policies and regulations to prevent physicians who are not licensed in the respective state to provide telemedicine services. This is a major impediment to the delivery of telemedicine between state. Telemedicine, including teleradiology, is here to stay and is changing the practice of medicine dramatically. National and international communications networks are being created that enable the sharing of information and knowledge at a distance. Technological barriers are being overcome leaving organizational, legal, financial and special interest issues as the major impediments to the further development of telemedicine and the realization of its benefits.
BANKING ON CORD BLOOD
Umbilical ‘waste’ is gradually becoming an alternative to bone marrow for transplants.
When H.Baker entered the world on Dec.30, his parents shelled out an extra $1200 to have blood from their son’s umbilical cord collected and processed through a private cord blood bank in California.
They’ll continue to pay about $100 a year to store the frozen extract until their son is 18, on the outside chance that Harrison or an immediate family member might one day need a bone marrow transplant.
Cord blood remains in the umbilical cord and placenta after birth. It contains the same building blocks of the immune system as bone marrow – stem cells that are capable of restoring a damaged blood system and repopulating the body’s red and white blood cells and platelets.
Scientists discovered in 1988 that cord blood, long discarded as medical waste, was the only known substitute for bone marrow transplantation. So far, cord blood has been used to restore bone marrow that’s been ravaged by about 30 different illnesses, including certain cancers, leukemias, blood diseases and immune system disorders.
Harrison’s banked cord blood would be an identical match to his own bone marrow. The boy’s close relatives could also benefit, because the odds of a good match are increased within families.
Cord blood’s overlooked wealth has been called the ultimate in recycling, as research and technology rescue from medical waste a treasure trove of life-giving stem cells. The Harvard Health Letter named umbilical cord blood “recycling” as one of the top 10 medical advances of 1996.
The odds that Harrison will ever need his cord blood could be as long as 1 in 200,000. But a growing number of commercial cord blood banks are flourishing, given life by the fact that if there’s a way to protect children from life’s caprice, parents who can afford a little biological insurance are often eager to pay.
Although the first successful cord blood transplant occurred a decade ago, the opportunity for families to collect and store umbilical cord blood privately has been widely available only since about 1995. Many expectant mothers have never heard of it.
Harrison’s mother was unaware of cord-blood retrieval and his life-saving potential until she read about umbilical cord blood banking in a Dear Abby column about three weeks before her son’s birth. She showed the column to her husband and “it just grabbed them”.
The frozen vials of Harrison’s blood will become his property at age 18. At that point, Harrison could donate the blood to a federally financed cord-blood bank – now few in number – that would make the blood available to anyone in need. Or, Harrison or his parents could continue to pay to store it for themselves or other family members who might be an acceptable match.
Stem cells are the progenitors of all the body’s specialized cells. Previously found only in bone marrow, stem cells contain the essential ingredients for healthy blood and immune systems.
When bone marrow is weakened or destroyed by disease or by chemotherapy and radiation administered to fight disease, the therapy of last resort is a bone marrow transplant.
But there isn’t enough bone marrow available through national and international registries to meet the need. Each year, up to 15,000 people are unable to find a suitable bone marrow donor.
Cord blood transplants are helping meet the demand. So far, about 2,000 cord blood transplants have been performed worldwide, mostly on children. About a quarter of them used cord blood from siblings, while the reminder were from donated cord-blood samples, according to the Cord Blood Donor Foundation, a not-for-profit organization backed by private donations.
About 2 ½ years ago, the National Heart, Lung and Blood Institute, part of the National Institutes of Health, began a five-year, $30 million study on the effectiveness of cord-blood transplants from unrelated donors. Scientists hope that the work will help advance a national cord-blood registry.
The study is gathering evidence on the appropriate dose of cord-blood cells needed for patients of different weights. Because there is only a small amount of blood contained in the umbilical cord, the sample is often insufficient to treat someone who weighs more than about 110 pounds, according to Dr. S.Y., a hematologist, oncologist and medical director of the bone-marrow transplant program at Virginia Commonwealth University’s Medical College of Virginia.
However, while cord blood contains a lower volume of stem cells than the amount available from bone marrow donors, the cells are more concentrated and adaptable. The ‘naïve’ cells have not yet committed to specific tasks, as they have in an adult bone marrow donor. So cord blood from unrelated donors doesn’t have to match as specifically as unrelated bone marrow.
The young cells also are less likely to trigger a potentially lethal immune system reaction known as graft-vs.-host disease, which causes the donor cells to attack the recipient’s tissue. That has fueled hope that cord blood transplants could make a big difference for minorities who are underrepresented in bone marrow donor pools.
For now, though, there are government-financed cord-blood collection and storage programs at only a handful of U.S. medical teaching centers. Cord-blood donation for public use, meaning that it is available to any patient who needs a transplant, is unavailable in most communities. The National Marrow Donor Program, which maintains a national registry of bone-marrow donors, is also collecting data for a cord-blood registry.
So far, only about 15000 to 20000 cord blood samples are publicly available, Yanovich said. By comparison, more than 3 million people have signed up to donate their bone marrow if it’s needed to save a life.
“If we don’t find a bone-marrow donor in the registry, we pursue the cord blood,” said Yanovich.
Building a cord-blood collection and storage program is an expensive proposition, and the federal government has not yet committed itself to a nationwide effort that would collect, test, preserve, and store umbilical cords. However, the Cord Blood Donor Foundation, a not-for-profit group, is building an ethnically balanced stem cell bank through private donations.
While government input is limited, the Nov.26 issue of the New England Journal of Medicine reported that 562 cord-blood transplants had been performed with cord blood banked at government expense at the New York Blood Center. The article showed that the procedure can be effective even when the donor is unrelated and does not have a complete antigen match. Antigens are part of every cell, and they’re capable of stimulating an immune response. So blood is typed according to antigens, a critical consideration in all types of transplants, to help prevent the foreign substance from attacking its host.
The big breakthrough in cord-blood transplantation occurred in October 1988, when a Paris doctor performed the first cord-blood transplant on a 6-year-old American boy, Matthew Farrow. Matthew was at the end of his options after a lengthy international bone-marrow search had failed to turn up a suitable match. He was losing his battle against a genetic blood disease called Fanconi’s anemia, which usually kills its victims by age 12.
That’s when Matthew’s parents decided to conceive their third child a little ahead of schedule, in hopes that the infant’s bone marrow would be an acceptable match for their dying son. Doctors knew that if the infant’s bone marrow matched Matthew’s, so would her umbilical cord blood.
In utero tests showed that it did, and little Dorothy Farrow helped save her brother’s life soon after her birth.
Seven years later, there was still no sign of the deadly disease, and a new era in cord-blood transplantation was under way.
Since September 1997, the University of Virginia Medical Center has performed six cord-blood transplants from unrelated donors. Three died from infections after the transplant – a not-uncommon outcome whenever one’s damaged bone marrow is destroyed so healthy stem cells can take root.
Some scientists criticize commercial banks, saying they prey on the fears of protective parents.
“They’re just basically using a scare tactic,” Yanovich said. “I think they’re playing with the fear just to make more money.”
Because the likelihood is so remote that a particular child will require a transplant, Yanovich thinks cord blood should be collected and distributed for the public good, “saved for everybody.”
J.Kurtzberg of Duke University, an early pioneer in cord blood transplant, agrees that very few children whose cord blood is stored at private banks will ever need it.
“The public bank, in contrast, makes units available to anyone who matches,” she said in a recent article in the Duke University Research Magazine. “It seems to be a better use of resources.”
Generally speaking, hepatitis is any inflammation of the liver. Although it is often caused by a virus, other causes may include alcohol, medications and that have a harmful effect on the liver, toxins, or autoimmune disorders.
In total, there are at least 7 known viral hepatitis strains: A,B,C,D,E,F, and G. Of these viral forms, hepatitis C may be the leading infectious cause of chronic liver disease in the Western world, affecting more than 170 million people worldwide. Hepatitis A, which is not blood-borne, and hepatitis B, which is blood-borne, are also very widespread. Only these viral forms of hepatitis, including hepatitis C, can be spread directly from one person to another.
Examples of nonviral forms of hepatitis include alcoholic hepatitis (caused by excessive drinking), toxic/drug induced hepatitis (caused by inhaling or swallowing certain toxins or medications such as acetaminophen), and autoimmune hepatitis (which occurs when the body Ts immune system attacks its own liver cells).
About Hepatitis A
Hepatitis A, often abbreviated as HAV (hepatitis A virus), is extremely prevalent (widespread) in the U.S. population. In fact, 1 out of 3 Americans has been infected at some point. However, most people who are infected with hepatitis A recover completely without treatment and, once the infection has subsided, develop lifelong immunity to the disease.
Hepatitis A is transmitted primarily by the fecal-to-oral route through contaminated food or water, or because of poor hygiene habits. Hepatitis A can also be contracted by eating shellfish from contaminated water sources. In the U.S., people who live in communities with high rates of hepatitis A infection are considered at risk for contracting the disease.
People who are infected with hepatitis A generally develop flu-like symptoms, such as low-grade fever, aches, and mild abdominal pain within 10 to 40 days after exposure. In some individuals, these flu-like symptoms can be followed by jaundice (a yellowing of the eyes and skin). Hepatitis A is an acute condition and most people clear the virus on their own without treatment. However, in fewer than 1% of cases, severe acute infections may lead to liver failure and to a need for liver transplantation. Hepatitis A does not lead to the development of chronic hepatitis, cirrhosis, or liver cancer.
A vaccine is available to protect against hepatitis A. It is recommended for anyone who may be going to an area where there are increased rates of hepatitis A, including Mexico, Central America, Sub-Saharan Africa, Southeast Asia, and the Middle East. The vaccine is also recommended for people who might become seriously ill if they are infected with the virus.
Hepatitis A can be avoided by washing hands with warm water and soap, particularly after using the toilet or changing diapers, and before preparing and eating food. Good hygiene practices are particularly important for anyone who works with food.
About Hepatitis B.
Hepatitis B, often abbreviated as HBV (hepatitis B virus), is transmitted through blood or blood products, through sexual contact, or from mother to child during pregnancy or childbirth.
In the U.S. an estimated 1.25 million people are infected with hepatitis B. According to the U.S. Centers for Disease Control and Prevention (CDC), about 30% of people who are infected with HBV do not have any symptoms of the disease. Others may experience flu-like symptoms, including low-grade fever, aches, and mild abdominal pain.
Although individuals with healthy immune systems usually recover from HBV after about 6 months, 5% to 10% of those who are infected develop the chronic (long-term) form of the disease. Often those with long-term infection have no symptoms, or they may suffer from fatigue, malaise and periods of jaundice. If left untreated these individuals may be at risk for serious complications of liver damage such as cirrhosis, liver failure or liver cancer.
A highly effective vaccine has been developed to help protect against hepatitis B. Currently, the CDC is supporting a universal childhood vaccination program with the goal of eliminating the spread of hepatitis B altogether. In addition, the vaccine is recommended for adults who are at a higher risk for contracting hepatitis B due to their occupations (eg. Healthcare workers and emergency medical personnel), lifestyle choices or health conditions.
Hepatitis B can be prevented by carefully cleaning up blood and blood products, practicing safe sex, and not sharing needles, razors, or other personal care items (such as toothbrushes and nail clippers) that might come into contact with blood. To help prevent mother-to-child transmission, all pregnant women should be tested for the hepatitis B virus. Newborns of mothers who test positive can be vaccinated against the condition and receive other precautionary treatments.
ALLERGIC MANIFESTATIONS IN CHILDREN
Within recent years numerous apparently diverse conditions such as asthma, hayfever, eczema, urticaria, migraine and other minor affections have been shown to have a similar etiologic basis, a hypersensitivity on the part of the sufferer to many usually harmless articles commonly encountered in his diet or environment. To this group of diseases the term ‘allergic’ has been applied; the individuals manifesting such an exaggerated susceptibility to substances innocuous to normal persons in the amounts commonly encountered are said to be ‘allergic’ to those articles; and the agents giving rise to those reactions in such apparently minute doses are termed ‘allergens’. When we analyse the origin of these allergic responses we find that they arise in one of two ways: either as a definite inheritance of a predisposition to manifest specific hypersensitiveness, or acquired as the result of tissue damage or excessive irritation.
Though the allergic tendency is prenatal in origin the actual manifestations and causative allergens generally depend upon postnatal factors. The site and type of reaction are frequently consequent upon some local strain or injury, and selectivity of the allergen generally follows repeated or continuous contact with some factor of diet or environment.
Allergic diseases have several characteristics in common the determination of which proves of the utmost importance in diagnosis. They are essentially periodic in nature with apparent intervals of freedom. The symptoms frequently have their onset at night or are most distressing during those hours.
With the exception of hayfever the different manifestations have their maximum onset during childhood or adolescence, and each manifestation appears to have definite sex and seasonal variations. In addition, allergic conditions are definitely affected by varied states of health of the sufferer, by intercurrent diseases, such as fever, exanthemata or climatological factors, locality, altitude or environment.
Varied manifestations of disease in childhood have been shown to fall into the allergic category. The commoner of these include such respiratory symptoms as recurrent bronchitis and asthma; such cutaneous eruption as eczema, flexural pruritis, urticaria including the popular and giant types, and purpura; such abdominal conditions as food-upsets, colic and recurrent vomiting, hayfever, migraine, enuresis and reactions to therapeutic serums and physical agents
Much can be done to prevent the development of allergic symptoms in children, especially children of allergic parents. The homes should be as free from dust and allergens as possible. New foods should be tried one at a time, at least a week apart, to see if symptoms occur. Asthmatic children should be guided away from dusty occupations. Exposure to colds should be minimized. Psychosomatic factors, if present, should be given proper attention.
The hemophilias are a group of inherited disorders characterized by decreased clotting factor activity, with prolonged and often spontaneous bleeding. Hemophilia A, or classic hemophilia, is by far the most common form of disease and results from subnormal factor VIII activity. Until recently it was thought that factor VIII was absent., but it is now recognized that material identified antigenically as factor VIII is present, although procoagulant activity is reduced. It is currently believed that factor VIII has two components. Measuring each component independently permits detection of carriers, as well as a clear delineation from von Willebrand’s disease. In the latter, procoagulant activity is present disproportionate to the amount of protein antigen, and platelet abnormalities are present as well. Hemophilia B (Christmas disease) results from deficient factor IX activity. Both hemophilias A and B are sex-linked disorders; however, the mutation rate for hemophilia A is said to be upward of 25%, one of the highest known in human disease, von Willebrand’s disease is autosomally transmitted and thus affects both sexes equally.
For reasons that remain unclear, hemophilia is rarely manifested on the first day of life, even after a difficult delivery. Factor VIII does not cross the placenta, yet the newborn with hemophilia does not experience increased bruising or unusually severe cephalhematomas. Even after circumcision, 75% of affected neonates have only mild or no bleeding; a complication from the procedure implies severe disease, defined as less than 1% normal activity. The first few months of life are usually a benign period during which the only clinical clues to the diagnosis may be exaggerated bruising from contact with crib slats. When walking – and falling – begins, excessive bruising and bleeding, particularly of the lip and tongue, are noted. Ecchymoses and soft-tissue bleeding remain common in childhood.