Integrated Management of Childhood Illness in family medicine. Putting standards WHO / UNICEF in practice physician of general practitioner family medicine. Maintenance of system documentation. Advising parents.
In the mid 90 -ies of XX century, the World Health Organization (WHO ) and the UN Children’s Fund (UNICEF) has developed a strategy – Integrated Management of Childhood Illness ( IMCI ), which incorporates a number of effective measures to prevent the deaths of children aged 1 week to 5 years to reduce the frequency and severity of disease, and to improve the growth and development of children.
Most deaths among children under 5 years are due to a small number of causes that can be prevented through appropriate interventions.
From 70 % to 90 % of deaths among children under 5 years due to: diseases of the respiratory system ( often pneumonia ), diarrhea , malaria , measles , HIV infection, and neonatal conditions, such as prematurity , asphyxia and infection .
Eating disorders increases the risk of dying from these diseases , more than half of the deaths recorded up to 5 years in children with malnutrition .
IMCI strategy , primarily aimed at helping children with this pathology. Currently, the IMCI strategy implemented more than 100 countries , resulting in reducing child mortality and improving quality of life for children. In 2009 the IMCI strategy adapted and began to take in Ukraine. Today there are computer software training, self-study which allows medical professionals to learn to lead major diseases of childhood using the IMCI clinical guide , you can view videos and photos, perform the necessary exercises to consolidate the knowledge and test your knowledge , and thus significantly reduces the training (www. icatt training.org).
In collaboration with WHO and UNICEF Ukraine Ministry of Health is working on the adaptation and implementation of IMCI in Ukraine . This approach provides a simple and effective methods of prevention and treatment of the main causes of serious childhood diseases , based on facts and observations , rational use and affordable medicines. The approach also includes monitoring of immunization , physical , mental and motor development of the child , parent training for child care , counseling parents on child nutrition and recognition of threatening signs in the case of which you should immediately seek medical attention. This approach is designed to be used on a limited diagnostic equipment, medical equipment selection and clinical procedures , so it is most suitable for rural medicine.
The purpose of IMCI – reducing morbidity, mortality and disability , and improving physical and mental development of children up to 5 years.
IMCI strategy promotes the accurate definition of childhood diseases , provides an integrated management of all significant illnesses , enhances nursing skills counseling , and identifies the need for referral to hospital seriously ill child .
Most pediatric patients with signs and symptoms of several diseases , so the only diagnosis is sometimes impossible or is not correct , and treatment requiring multiple diseases. Therefore, you need an integrated approach to the management of sick children. Paramedic must assess not a single disease, and child health in general ( not cure the disease , and the patient) .
IMCI strategy promotes disease prevention (support breastfeeding , immunization , counseling to improve feeding of infants and children after a year , etc.).
IMCI strategy provides efficient on the following conditions: acute respiratory infections, pneumonia , anemia, diarrhea, ear infections , throat , HIV / AIDS , local bacterial infections , sepsis , meningitis, malnutrition , neonatal jaundice .
IMCI strategy includes a realistic and cost-effective syndromic approach to the management of patients with stage primary care effectiveness is confirmed by evidence-based medicine . Careful and systematic evaluation of the most common and important symptoms and signs provides sufficient information for rational, effective treatment of children. Syndromic approach makes it possible to identify the problem child health , weight status , consistency of care, taking into account the real possibilities of the existing health care system , and allows you to actively involve family members in the provision of health care to the child.
Depending on the age of the child various clinical signs and symptoms with varying degrees of statistical significance , diagnostic sensitivity and specificity. Therefore IMCI manuals are recommendations for the management of patients tactics for the two age categories:
1) Children aged 2 months to 5 years;
2) Children aged 1 week to 2 months.
User IMCI cover almost all of the most frequent and important causes over which the parents of the patient to seek help in the health care setting . If the child is less common disease , or any chronic problem , it is probably in the primary treatment it is necessary to steer a narrow specialist or hospital. The manual does not describe conduct injury , poisoning or other emergency . Given that many sick children showing signs and symptoms of more than one disease , to such patients should be integrated.
Implementation of IMCI strategy improves : the skills of medical personnel in the management of patients by conferral adapted to local conditions to IMCI guidelines and measures for the promotion of their use, the health system required for effective management of the most common and socially important diseases of childhood , practice management of patients children in the family.
Integrated management process consists of the steps you must perform a medical professional to ensure effective management of the disease.
Step 1. Rate . When you receive child clinic doctor evaluates its condition . Asks the mother of conditions that damage the health of the child , then examines child.
Step 2. Classify disease. After review and assessment , the doctor finds that a disease ( if there are several in the child ) needs immediate assistance to referral to hospital , referral to hospital or home treatment after consultation .
Step 3. Identify treatment. After classification of all classes baby doctor determines the specific treatment in a hospital, outpatient or home if there is no serious illness . Have to get advice on treatment and care for a sick child .
Step 4. Treat the child. After visiting the doctor or nurse performing certain procedures according to the situation ; teaches mother to give oral drugs , says diet, drinking regime , care , asked his mother to come to the clinic for re-examination on a particular day .
Step 5. Advises the mother. If a child must be inspected again health worker explains the mother when she is coming again, my mother taught to recognize symptoms that require access to a doctor .
Step 6. Spend the next review. Integrated case management process helps to identify children ieed of re-examination the doctor. This re- evaluated the patient , the emergence of new problems , so treatment is correction .
The main task in this context – to cooperate with the patient ( improved compliance ), because in such cases, often the problem is non-compliance with medical recommendations . Relevant and now the word Abul Faraj Syrian physician who lived in the 13th century : “We three – you , a disease I do. If you will with the disease, you will have two , and I will remain one – you got me win. If you will be with me, we will have two, one disease will – we will win . “
Therefore, at each visit to work with patients. Today proven to improve patient cooperation with a simple dosing regimen , taking drugs added to the life of the patient , the usual domestic affairs.
There is another problem that contributes to the deterioration of compliance with patients , namely, doctors do not always take into account and properly assess the psychological characteristics of a sick child. Moreover , pediatricians work not only with patients but also with his closest family. It should be remembered that the disease often changes the mental state of the patient, which in turn influences the development of the pathological process and the effectiveness of treatment. Success in treatment is largely determined by establishing contacts , understanding and cooperation between the physician , the patient and his family. Do we always do it? Unfortunately , no. Why so ? Establishing good contact with the patient significantly ” interfere with ” the dominance of technology in medicine. Often playing various diagnostic procedures dozens of times over the duration of physician communication with the patient and his family. This situation often allows for good contact with the patient and generates conflicts. In his book ” Uteryannoe èñêóññòâî vrachevanyya ” renowned cardiologist B. Lone quotes that clearly define the position of the patient , “I would not ask a doctor to give me a little more time. I just wish he completely devoted himself to me at least five minutes, I was close to a man , supported not only my body but also the soul , because people have different experience illness ….. “.
Practice proves that the good doctor is always a psychologist , he lacks tact and patience even in dealing with so-called conflict patients. This allows you to set up partnerships between all members of the treatment process and agree on a common program of action that result in accountability disease.
Detailed step by step sequence of actions in the context of IMCI :
Step 1. Rate . Assessment during ambulatory outpatient admission or newborn child involves several important steps that must be performed health professional :
history collection and communication with people who care for the child;
assess the presence of common symptoms of danger;
identify the main symptoms;
assessment of diet ;
assessment of feeding ;
assessment conducted by vaccination ;
assessment of other problems.
As already mentioned, to evaluate the use of only a limited number of clinical symtomiv are carefully selected based on their sensitivity and specificity, as well as taking into account the actual conditions of the first -level health facilities : for children aged 2 months to 5 years – cough or shortness of breath , diarrhea, fever, ear problems , for children aged 1 week to 2 months – a bacterial infection and diarrhea.
Step 2. Classify disease. Based on the evaluation results , grouping the identified symptoms and signs medical professional should classify the child’s illness . This classification is not diagnosed in the traditional sense . It allows you to ” sort ” patients at the primary care indicates the severity of the disease and to determine the tactics subsequent treatment and management of the child. Classification of diseases in the context of IMCI is based on a system of color coding triplets , ” pink ” means that the child should immediately redirect to the hospital , ” yellow ” indicates the need for early outpatient treatment, but ” green” – the need for supportive care at home. If a child has several diseases , each of which is classified by the system of color coding triplets separately.
Step 3. Identify treatment. After classification of all existing diseases medical professional should determine treatment. If it classified as “pink” – direct the child to the hospital , and sent to the hospital should give the child the necessary preparations . If the child needs outpatient treatment (” yellow “) , the manual presents guidelines for the conduct and treatment plan ( with a clearly defined list of essential drugs ), which is the national standard . If serious pathologies not detected ( “green” ) shall advise mother to child care issues at home.
Step 4. Treat the child. After determining the conduct and treatment of child medical professional should perform the necessary actions to meet the identified states. If a child is sent to the hospital , he was prescribed a dose of necessary preparation ( pre- treatment). If the child needs outpatient treatment , he is given the first dose of treatment required . Medical worker teaches mother to care for a child ( right to give medication, food and drink ), and negotiates the next visit . Medical worker also teaches mom to recognize symptoms that indicate the need for urgent appeal for medical help. It is necessary to assess food or breast- feeding, and if any problems , consult mom and eliminate the problem. You also need to consult my mother on zbnerezhennya her own health.
Step 5. Perform the next review. Some childreeed more than one review about this disease. IMCI process helps to identify those children who need extra these reviews. Procedure medical professional when you next visit the child clearly defined in the manual IMCI . During the re-examination of the child again evaluate for new challenges.
As a result, an integrated approach all children who applied to the institution of the first level are divided into three gradations : 1) ” pink ” – children who require hospitalization , and 2) ” yellow ” – children requiring outpatient treatment , and 3) the “green “- children who do not require treatment and observations about the disease.
Outpatient management of children aged 2 months to 5 years.
History taking and communication with my mother . It is important to establish effective communication with her mother or others who care for your child. In order to find out the necessary information about the symptoms of disease or malnutrition and convince my mom to take rational decisions on care and treatment , it is necessary to apply effective communication techniques . The use of such techniques is essential for providing quality care to the child. Take a listen to my mother , show interest , seriously vidnesitsya to her words and problems of the child. Use the skills of verbal and nonverbal communication. Speak clear to the mother tongue . Ask questions , listen to answers to questions and encourage mother to continue the conversation. Mom may need time to think about your question and decide whether the child is given clinical sign. Ask additional questions if the mother is not sure of the answer.
Common signs of danger to routinely check all children .
The child had convulsions during this illness. Seizures caused by a fever are usually not dangerous to the health of the child. However, remember that seizures may be due to meningitis or other life-threatening diseases. At the stage of primary care all children who have had convulsions during this illness are regarded as difficult patients .
A child in a state of lethargic or unconscious . Lack of awareness indicates that a child is seriously ill. Lethargic state – the child is awake , but does not respond adequately to sounds and touch . This condition can be caused by different , usually serious illnesses .
A child caot drink or suck mum. The reasons for this situation may be different. Perhaps the child is very relaxed , or caot swallow. You should not rely solely on the data obtained from the mother. It sposposterihaty as a mother breast-feeding her or liberal .
The child vomiting after taking any food or drink. Vomiting can be a sign of a number of serious diseases. Furthermore, the existence of such a nature vomiting leads to the fact that the child caot take medication or solutions for rehydration.
If a child has one or more general signs of danger , it must be classified as seriously ill (” pink “). Such a child usually needs immediate referral to hospital . Must quickly assess the child’s condition and before administration of the hospital to give the first dose of the drug required (eg , an antibiotic ), and mother – recommendations for its actions during transport (eg give the child small and often drink salt solution for oral rehydration therapy or breast feed ) .
Assessment and classification of symptoms and determine the treatment strategy during the initial review. After checking for general danger signs medical professional should assess the child for the presence of major symptoms .
In basic clinical IMCI manuals are the following four symptoms:
1) cough or shortness of breath;
2) diarrhea;
3) fever ;
4 ) problems with the ear.
The first three symptoms included because they often lead to death. Issues with ear included because they are considered a major cause of childhood disability in low -and middle -income .
Cough or shortness of breath can be a manifestation of pneumonia or severe respiratory infections. After taking into account risk symptoms should ask my mother whether the child has a cough or difficulty breathing , if so, how long the child has seen this symptom .
To assess a sick child with cough or difficult breathing , the following clinical signs:
1 ) the frequency respiration;
2) engaging the bottom of the chest;
3) stridor ;
4) astmoyidne breathing.
All these signs should be assessed when the child is at rest .
Rapid breathing ( from 2 to 12 months. – 50 or more in 1 min. , 12 months. 5 years – 40 or more ) – the most sensitive and specific indication for the detection of pneumonia. Engaging the bottom of the chest is an important sign of severe pneumonia. However, remember that the excited state, stuffy nose or sucking chest may cause temporary retraction of the chest. Stridor – hoarse sound to the perfection of the child. Children with stridor at rest tend to obstruction and should be directed to the hospital . The emergence of stridor only when crying or excitement is not the cause of the child to hospital referral . Astmoyidnyy sound that occurs on Vidoz , often caused by asthma . If a child has astmoyidni sounds on Vidoz , the presence or absence of accelerated respiration draw conclusions after conducting a test using fast bronchodilators (if possible). At the stage of primary care do not make differential diagnosis between bronchiolitis and pneumonia.
Based on the above characteristics, children with the disease cough or breathing difficulties can be classified in three categories:
1. Severe pneumonia or very severe disease ( “pink” ) – the child has any general danger sign or involvement of the lower chest wall , or stridor at rest , perhaps , the child has a bacterial infection, life-threatening , you must enter the first dose of antibiotic drug and quickly deliver in a hospital.
2. Pneumonia (” yellow “) – the child has fast breathing , she needs outpatient antibacterial drugs because of the high probability of bacterial pneumonia , with astmoyidnomu breathing aerosol bronchodilators used for 5 days prescribed drugs soften cough; following review – through 2 days , and if a child does not stop coughing for more than 3 weeks to exclude tuberculosis, asthma , or other problem ( if needed, in the hospital ).
3. Cough or cold ( “green” ) – the child does not require antibiotic treatment should be safe remedy for cough relief , recovery – after 1 or 2 weeks, following a review – after 5 days if the child has not stopped coughing for more than 3 weeks, should be excluded tuberculosis, asthma , or other problem ( if needed, in the hospital ).
4. Diarrhea is another symptom that should be routinely checked for each child that asked for help . A child with diarrhea may have the following three potentially deadly disease: 1) acute watery diarrhea ( including cholera ) , 2) the dysentery ( diarrhea, blood ) , and 3) prolonged diarrhea (lasting more than 14 days).
All children with diarrhea should be assessed by : a) signs of dehydration b) duration of diarrhea , and c) the presence of blood in the faeces .
To determine the degree of dehydration used by several clinical characteristics: 1 ) the general condition of the child – depending on the degree of dehydration child with diarrhea may be lethargic / unconscious or disturbing (children who caot be calm ), 2) zapavshi eyes – less reliable sign of dehydration, so in children with severe malnutrition and exhaustion of available eye can always look zapavshymy 3 ) the reaction of the child when he is offered a drink – caot drink (caot recruit the liquid in your mouth and swallow it) , drinking bad ( need assistance ) can swallow liquids only if it is introduced into the mouth, greedily drinking (obviously wants to drink) , and 4) the elasticity of the skin ( skin fold test ) – when released , skinfold straightened very slowly (more than 2 seconds), slow ( fold saved in a brief moment ) is not slow , the child of foul anti-Semitism ( severe malnutrition ) skinfold may be cracking down slowly, even if the child is not dehydrated , the child’s overweight , or swelling of the skin fold can straighten immediately, even if the child is dehydrated .
After assessing the child’s degree of dehydration must figure out how long does diarrhea, and whether blood in stools . This will identify children with prolonged diarrhea or dysentery.
Based on the above clinical signs of disease with diarrhea can be classified into the following categories :
1. Severe dehydration ( “pink” ) – the child has two of the following signs: lethargic / bezsvidomosti , zapavshi eyes , caot drink, skinfold straightened slowly fluid deficit over 10 %, you should immediately start writing fluid intravenously or through a tube in her mouth small portions (oral rehydration ) and quickly steer the hospital.
2. Moderate dehydration (” yellow “) – the child has 2 of these symptoms: anxious / irritable, eyes greedily drinking, skinfold straightened slowly fluid deficit of 5-10% , the child needs to oral rehydration therapy and outpatient treatment following review – 5 days with no improvement.
3. No dehydration ( “green” ) – the child is not sufficient evidence to classify severe or moderate dehydration , fluid deficit does not exceed 5 % , the child should be given more fluids than usual , following a review – after 5 days with no improvement.
Do not routinely prescribe antibiotics for diarrhea , since in most cases the agents are tolerant to them . Antidiarrhoeal products that inhibit intestinal peristalsis should not be given to children. Prolonged diarrhea – an episode of diarrhea with blood in the stool or without , which began as an acute illness and continues 14 days or more , often accompanied by weight loss . It accounts for 15 % of all episodes of diarrhea , causes 30-50% of deaths from diarrhea and almost never occurs in children exclusively breastfed. Diseases of all children who have diarrhea continues for 14 days or more to classify , based on the presence or absence of dehydration:
4. Severe protracted diarrhea ( “pink” ) – the child has any degree of dehydration, it is necessary to begin treatment of dehydration and referred to the hospital .
5. Protracted diarrhea (” yellow “) – the child no signs of dehydration treated as outpatients , give advice on diet, prescribed multivitamins and zinc for 14 days following review – after 5 days.
6. Dysentery (” yellow “) – the child has diarrhea with blood , a sign of invasive intestinal infection , which is about 10% of all episodes of diarrhea in children under 5 years is 15% of all deaths in diarrhea , especially difficult runs with malnutrition , child is prescribed antibiotics, effective against Shigella, the next review – 2 days .
Fever – temperature pidpahvynniy section above 37,5 º C ( rectal – above 38,0 º C) – can be caused by both mild infections , and infections that threaten the life of the child , including malaria, meningitis, typhoid, measles and so on.
A child with a fever should be evaluated on the following criteria:
1) stiff neck – can be a sign of meningitis or other very serious disease ;
2) the risk of contracting malaria and other endemic infections (some recommendations for countries and regions with varying degrees of risk of infection );
3) cold – fever, probably caused by the common cold ;
4 ) the duration of fever – viral infections with fever passes in a few days , fever for more than 5 days indicates the presence of more severe disease (eg, typhoid fever );
5) measles (fever , generalized rash , red eyes , runny nose or cough) – gives high risk of complications even death (pneumonia – 67% , diarrhea – 25%, encephalitis) , disability (blindness , severe malnutrition, neurologic dysfunction) .
Before you classify disease of children with fever , you should check for obvious causes of fever ( ear pain , burns, abscesses , and others. ):
1. Very difficult fibrylne disease ( “pink” ) – the child has any general danger sign and a stiff neck , you must enter the first dose of antibiotics, to prevent hypoglycemia at body temperature 38,5 º C and above give one dose of paracetamol and quickly redirect to the hospital .
2. Chance of bacterial infection (” yellow “) – the child has no general danger signs and stiff neck, stay in the area no risk of malaria, there is no obvious causes of fever (eg , no pneumonia, ear infections or strep throat ), but it is assumed bacterial character, you must assign an antibacterial drug and at body temperature 38,5 º C and above give one dose of paracetamol if the fever continues daily over 5 days , the child should be sent to hospital for further evaluation.
3. Fever ( “green” ) – the child is no general danger signs and stiff neck , and stay in the area no risk of malaria should be at body temperature 38,5 º C and above give one dose of paracetamol, inform the mother of conditions that require immediate repeated appeals , re-examination – in 2 days , and if a fever continues more than 7 days , the child should be sent to hospital for further evaluation.
Issues with ear should check all children approached for help. The child could be ear infection . If you are unable to otoscopy , consider the following clinical signs:
1) painful swelling behind the ear – a sign of mastoiditis , often one-sided process ;
2) earache – an early sign of acute otitis media , manifested by irritability, rubbing his ears ;
3) purulent discharge from the ear , it is necessary to specify their duration.
Based on the above clinical signs of the disease the child may be classified :
1. Mastoidyt ( “pink” ) – should be given the first dose of antibiotics, a single dose of paracetamol and immediately redirect to the hospital .
2. Acute ear infection (” yellow “) – the child has ear pain or purulent discharge from the ear for less than 14 days, you must assign an antibacterial drug for 5 days, give paracetamol for pain , dry ear turundas , re-examination – 5 days .
3. Chronic ear infection (” yellow “) – the child has purulent discharge from the ear for 14 days or more , must be dried ear turundas topical treatment with ear drops for 2 weeks, re-examination – 5 days .
4. No ear infections (” green “) – the child no signs of an ear infection , does not require any special treatment.
Checking the status of nutrition in pediatric patients conducted in order to identify:
1) severe malnutrition ;
2 ) children with low growth due to an unbalanced diet and repeated episodes of infection ( growth arrest );
3) anemia.
In addition to weight for age of the child consider the following clinical signs:
1 ) Types of severe exhaustion – heavy shoulders, buttocks and legs, with clearly protruding ribs ;
2) two feet swelling can be as a result of kvashiorkoru and other diseases ;
3) pale palm – to detect severe anemia, but the specificity of laboratory tests for the diagnosis of anemia is higher.
Based on the above clinical signs of the disease the child may be classified :
1. Severe malnutrition or severe anemia ( “pink” ) – the child has visible severe exhaustion, or edema of both feet, or severe pallor palm , due to the high risk of death should redirect to the hospital .
2. Very low weight ( for age ) or anemia (” yellow “) – revealed changes in child weight ( standard score on the table or scale) or hemoglobin level, whether mild pallor palm , with a very low weight necessary to evaluate the child’s diet and advise mother on these issues , re-examination – in 30 days , with anemia should be given oral iron supplements, re-examination – in 14 days every 6 months is recommended to child deworming .
3. There is a very low weight or no anemia ( “green” ) – in children under 2 years are estimated to have food and advise on issues of nutrition.
Assessment of child nutrition is carried out in all children under 2 years of age and all children whose disease is classified as anemia or very low weight , according to the following criteria:
1 ) the frequency of breast-feeding and night feeding ;
2 ) the types of additional foods or liquids , the frequency of breast- feeding and whether active ;
3) The practice of feeding during this illness.
If any problems with feeding, the mother should give tips to overcome them.
Verification of compliance with immunization schedule is held every sick child, appealed for help. There are situations in which vaccination is absolutely contraindicated in : 1) if the child should immediately redirect to the hospital , and 2) if the child’s primary or secondary immunodeficiency , do not do live vaccines (BCG , measles , polio ) PDTV do if for 3 days after a previous dose of DTP had convulsions or shock.
Assessment of other problems. In each of the major symptoms evaluated and some other common diseases : sepsis , tuberculosis, Conjunctivitis and various other causes fever or severe condition , children with these diseases give the first dose of the drug required and direct the hospital. If there are no indications for emergency hospitalization , it is important to pay attention to the complaints of other mothers , to assess other problems such as skin infections, itchy or swollen lymph nodes , and so on.
Treatment of the child. All children with “pink” classification immediately after the assessment and direct the proper treatment in a hospital. The list of urgent remedial measures before referral to hospital appointment includes antibiotics, vitamin A, paracetamol, tetracycline eye ointment , salt solution for oral rehydration therapy , and prevention of hypoglycaemia through breast milk or sweetened water . If your child has seizures, diazepam or paraldehid used rectally , if seizures continue after ten minutes , give a second dose of diazepam rectally.
In the treatment of a child with ” outpatient ” classification (” yellow ” or ” green “) using a limited number of available basic medicines recommended by national protocols. Always begin treatment with first-line drug . In such cases , along with antibiotics, vitamin A, paracetamol , saline solution for oral rehydration drug use iron protyhlysnyy drug safe agent for the treatment of cough and colds (you caot suppress a cough , breast milk is an effective way to mitigate throat ). If a child aged 2 months to 5 years is a local infection, use of tetracycline eye ointment , dry ear turundas treat ulcers in the mouth with a solution of hentsianvioletu , soften the throat and make it easier to cough through secure means certaiational protocol .
Advising mothers. The success of home treatment depends on how well be performing recommendation. Teaching mothers performed in three stages : Stage 1 – give her information , Stage 2 – show how to implement the recommendations ; Stage 3 – ask the mother to implement the recommendations themselves.
In teaching mothers to:
1 ) use clear words and familiar aids ;
2) praise for what was done correctly and tactfully correct on error ;
3) to provide an opportunity for more practice;
4 ) Encourage the mother to ask clarifying questions and to answer them ;
5) check whether my mother understood the information and whether it is able to implement the recommendations .
Some question mother of a sick child consultations are presented below.
Give advice to continue feeding and increase the amount of fluids during illness. Although during the illness of a child appetite and thirst can be reduced , it is recommended to increase the daily fluid volume , keep regular feeding rate (even if the child does not eat the whole serving).
Teach how to give oral medications or how to treat local infections at home:
1 ) Select a medication and dose for age and weight of the child;
2) Explain to the mother what lies treatments and why it should be carried out ;
3) Demonstrate how to measure a single dose of each drug ;
4) describe the stages of treatment;
5) observe, how to measure a dose of their own ;
6) ask a mother to give one dose a child ;
7) explain in detail how and how many times a day should be given drugs at home;
8) explain why it is necessary to complete treatment strictly defined duration ( not to be canceled before treatment );
9) check how to clear all information.
Advises on problems breastfeeding (if applicable): based on the outstanding issues and give advice on child nutrition during and after illness. The right way is : to promote breastfeeding (exclusive breastfeeding – up to 6 months) to introduce a child under the age foods , foods rich in energy and nutrients , to comply with disease frequency of feeding , referral to a child , do not use a bottle to feed children of all ages .
Inform and discuss in what cases should be re- contact the institution : a) the appearance of signs should immediately seek help , and b ) when will the next visit to monitor the disease , and c) when planning a healthy child visit or visit for vaccination.
The following observations. In some diseases required repeated visits to the health facility for follow-up , the purpose of which – the evaluation of disease, efficacy , emergence of new problems. If your next visit revealed new problems , the child needs to complete evaluation: please check the availability of the common signs of danger and see all the main symptoms, and evaluate the status of child nutrition . If a child is not a new disease, evaluate the child in accordance with the recommendations and , if necessary, continue treatment. If a child has a few problems and his condition worsens , or if the child is drawn several times with a chronic pathology, treatment which is ineffective , its govern the hospital.
Outpatient management of children from 1 week to 2 months
Assessment and classification of symptoms and determine the treatment strategy during the initial review. Having a serious illness or local bacterial infection evaluate the most informative on the following criteria:
1 ) refusal to feed ;
2) seizures (for this disease );
3) rapid breathing (more than 60 in one minute) ;
4) significant involvement of the chest;
5 ) motion only after stimulation / absence of independent movements ( this symptom is used instead of symptoms in infants ‘ lethargic / unconscious “);
6) fever ( axillary temperature above 37,5 º C or rectal above 38,0 º C) or hypothermia ( axillary temperature below 35,5 º C below rectal 36,0 º C);
7) redness around the umbilical wound or discharge of pus from it;
8) pustules on the skin.
Based on the above clinical signs of disease of newborns can be classified into the following categories :
1. Very severe disease ( “pink” ) – the child has any of the following symptoms: refusal to eat , seizures, rapid breathing , significant involvement of the chest, fever / hypothermia , the movement only after stimulation / absence of independent movements, you must enter the first dose antibacterial drug intramuscularly , to prevent hypoglycemia , quickly steer in the hospital, advise mother as a baby warm during transport.
2. Local bacterial infection (” yellow “) – the child has redness around the umbilical wound or discharge of pus from it, or pustules on the skin , to give an oral antibacterial drug to treat mom to teach local infection and care for a child, the following observation – in 2 days.
3. Severe disease or local bacterial infection is unlikely (” green “) – the child has no symptoms of a serious illness or local bacterial infection teach my mother how to care for your child.
Jaundice – frequent diseases in infants , it is evaluated on the following criteria: time of occurrence , localization – yellowness palm and soles.
Based on the above clinical signs , the condition of newborns can be classified in the following categories:
1. Severe jaundice ( “pink” ) – a newborn jaundice is any location that occurs before the age of 24 hours, or jaundice palm and feet at any age , it is necessary to prevent hypoglycemia , quickly steer in the hospital, have to consult as baby warm during transport.
2. Jaundice (” yellow “) – in the newborn has jaundice that occurred at the age of 24 hours, and palm and feet are not yellow ; Consult mother to care for the child, in which case go for help , if the child is over 14 days to guide in hospital for examination , re-examination – in 1 day.
3. No jaundice ( “green” ) – No jaundice in the newborn ; Consult mother to care for the child.
Diarrhea . All sick newborns need to check for the presence of diarrhea. However, the evaluation of thirst by drinking liquid offerings is not a reliable way , as a sign ” drinking is bad ” is not used in infants as features to classify the degree of dehydration. All infants with prolonged diarrhea or blood in the stool should redirect to the hospital .
Feeding problems or low weight infants evaluated on the following criteria:
frequency of breast-feeding , night feeding ;
for other foods or liquids , the frequency of their use;
practice during the feeding of the disease ;
weight for age.
The estimation process is the same as for older children. If a child has difficulty feeding or breastfeeding it 8 times / day, if it gets more food or liquid, or it ‘s low weight for age , in this case, the newborn should assess breastfeeding on the following criteria : 1) the accuracy application of the newborn to the breast , and 2) the effectiveness of sucking ( sucking slowly with small breaks ), and 3 ) the presence of ulcers or white bumped in the mouth (thrush ). Based on the above clinical signs , the condition of newborns can be classified in the following categories:
1. Feeding problem or low weight (” yellow “) – is a newborn problems such as poor latch to the breast or ineffective sucking or frequency of breast-feeding at least 8 times / day, or for other food or liquid other than breast milk or low weight for age, or thrush (ulcers / White ran in the mouth) , and should consult his mother about each feeding problems , teach the proper application to breast feeding treatment , care , and if the newborn receives other foods or drinks should give advice to mothers often breastfeed , reduce the amount of other foods or beverages , and feed the baby from a cup , with thrush should teach the mother how to treat the disease at home, re-examination about the problems with feeding – 2 days later , at the low weight – after 14 days.
2. No problems feeding ( “green” ) – in the newborn is not low weight for age and no signs of inadequate feeding.
Assessment of vaccination in newborns is the same as in older children .
Assessment of other problems in newborns performed as in older children . If you found a potentially dangerous problem, or if the first level health facility caot provide assistance newborn , a child should redirect to the hospital . If there are no grounds for immediate hospitalization, need to pay attention to the complaints of other mothers and to assess other problems in the newborn.
Treatment of newborn. The list of urgent remedial measures before referral to hospital include: first dose of antibiotic drug intramuscularly or orally , transporting newborn in warm conditions, prevention of hypoglycemia through breast milk or sweetened water , frequent introduction of salt solution for oral rehydration on the way to hospital. When outpatient treatment choices newborn antibacterial drug and its dosage differ from recommended for children older . Treatment and prevention of hypoglycemia diarrhea in infants is the same as in older children. The first dose of drugs the child should always receive medical facility.
Advising mothers should include the following highlights: learning how to give oral medicines or how to treat local infections, learning proper latch to the breast , practical assistance in apposition baby to the breast , advice on the use of other foods and liquids ( often advise to breastfeed , so once and for as long as he wants newborn, day and night, during illness and when the baby is healthy, reducing the number of feedings of breast milk substitutes ) discuss the reasons for which you should immediately seek help, and the next time you visit. Advise immediately contact the institution if the newborn is any of the following symptoms: bad suckles , the condition worsened, appeared fever, rapid breathing , shortness of breath, blood in the stool .
The following observations of the child. For repeat visits for follow-up is recommended for children whose conditions are classified as a local bacterial infection (including yeast ) and feeding problem or low weight. If a child is not a new problem , assess the child in accordance with the instructions , use about signs of a child in order to choose the right treatment, spend a cure.
HIV infection
HIV- infected woman can give birth to a child as not infected with HIV and infected . Infection can occur in utero (ie during pregnancy) , during birth or during breastfeeding breast milk. All children born to HIV-infected mothers to 18 months determined antibodies to HIV ( the question is , whether his own or maternal antibodies ).
Antibodies – immunoglobulins are proteins , which are produced by the immune system against various bacteria and viruses , including HIV. During pregnancy in HIV- infected women in the smallest molecule of protein ( immunoglobulin G) cross the placenta to the fetus. The presence of antibodies to HIV in the child born to HIV- infected mothers, to 18 months does not indicate that the child is infected. The disappearance of antibodies to HIV in the child after 18 months suggests that it is not infected. Save antibodies in children after 18 months confirms the diagnosis of HIV infection, because these antibodies the immune system produces has a child who is infected with HIV. If an HIV-infected woman will feed your baby is not infected ver-
it ‘s milk , it can become infected during breastfeeding at any time feeding. Therefore, refusal of feeding breast milk – a very important component of prevention of HIV transmission from mother to child.
Clinical surveillance of HIV -infected children is :
• dispensary units Ukrainian and regional (city ) Center for Prevention and Control of AIDS.
• Cabinet infectious diseases ( Keys ) clinics in the community of patients.
• In the absence of the latter – and district pediatricians and infectious disease specialist children’s hospitals.
Clinical supervision of minors (under 18 ) is carried out with the consent of their legal representatives who may be present during the examination of the patient .
Basic principles of clinical supervision
Voluntary – clinical supervision is carried out on a voluntary basis.
Privacy – the right patient ( his family ) diagnosis secrecy ( non-disclosure of HIV infection to minimize the number of people aware of the fact of infection).
Availability – maximum proximity of all types of medical care to the person.
Versatility – a wide range of medical care , which is done on an outpatient basis .
The main tasks of clinical supervision for HIV- infected children
• Provision of comprehensive treatment and preventive care .
• Timely detection of signs of disease progression.
• Prevention of opportunistic infections are factors of progression of HIV infection.
• Advising relatives of child care and nutrition.
• Psychological support and assistance in social adaptation.
The order of clinical supervision
1. Children born to HIV-infected mothers, to clarify their HIV status
Clinical examination : a review by a pediatrician during the first month of life – every 2 weeks , and then during the first year of life per month, after 12 months to clarify the status of HIV – 1 every 2-3 months. During each clinical examination pediatrician for measurement of body weight and growth of the child , in children younger than 2 years as measured by the sight of the head. Based on the results of anthropometry in the history of child doctor builds curves of body weight , height and head circumference . During each clinical examination doctor how nervous and mental development of children ( children in the first 3 years of life in accordance with the tables of motor and psy-
hichnyh skills ).
During each inspection record the physician in medical records ( card) :
• skin and mucous membranes;
• the size of the lymph nodes;
• Dimensions BTE salivary glands;
• respiratory, cardiovascular and digestive system , central nervous system (CNS );
• size of the liver and spleen ;
In medical records are written down carried diseases, fever , episodes of vomiting , depression emptying, increased bleeding , have been reported in children between inspections , and so on.
Laboratory examination
• expanded blood count 1 every 1-3 months
• control the degree of immunosuppression at 1 and 4 months, then to refine HIV status based on the presence of clinical indicators
• The level of immunoglobulins – 1 every 6 months
• ALT / AST, thymol test – one every 3-6 months
• X-ray of the chest – if indicated
• Neurosonography – 1 every 6 months
• tests to clarify the child’s HIV status : HIV DNA PCR – under 48 hours – 4 months, the detection of antibodies to HIV – at the age of 18 months.
Clinical supervision involves vaccination in accordance with the calendar of vaccinations for HIV- infected children , prevention of pneumocystis pneumonia 4-6 weeks to 1 year or exclusion of HIV, the annual Mantoux test .
2. The order of clinical supervision for children with confirmed HIV status
Clinical examination
Each survey pediatrician or infectious children :
• Measurement of body weight and height
• Head circumference measurements in children up to 2 years
• Assessment of neuropsychological development
assessment of the skin and mucous surfaces
• assessment of lymph nodes
• determination of BTE salivary glands
• Assessment of respiratory, cardiovascular system , gastrointestinal tract and central nervous system
• determining the size of the liver and spleen
Required laboratory tests
• complete blood count ( s counting the number of lymphocytes , platelets, hematocrit )
• urinalysis
• biochemistry (bilirubin , ALT , AST , glucose, total protein and protein fractions )
• The level of CD4 + T cells ( 1 every 3-6 months. Based on clinical , shown
abilities are recorded )
• viral load (if applicable)
The need for additional examination and consultation determines pediatrician .
Mantoux test is done to all HIV – infected children, regardless of the stage of HIV infection, 1 held every 6 months.
The frequency of clinical supervision for children with HIV infection
The frequency of supervision of a pediatrician and laboratory tests depends on the stage of HIV infection and the clinical situation :
I stage HIV infection ( WHO classification , 2002):
• Review pediatrician 1 every 3 – 6 months
• Laboratory examination – 1 every 6 months
II stage HIV infection ( WHO classification , 2002):
• Review pediatrician – 1 in every 3 months
• Survey – 1 every 3 – 6 months
• the detection of severe immunosuppression (level of CD4 + < 15%) – re-examination after 1 month
Stage III HIV infection ( WHO classification , 2002):
• Review pediatrician – 1 time per month
• supervision of the pediatrician frequency as the frequency of laboratory and instrumental examination depends on the clinical situation
• In case of opportunistic infections indicated inpatient treatment to achieve remission
IMCI strategy aimed at improving the quality of care at the primary level. It facilitates proper outpatient management stereotyping children and behavior in health care relationships in the family. This approach is aimed , first, to determine the main symptom ( syndrome ) and severity of condition, which further defines the optimal tactics and treatment. Integrated assessment is an signifies our strong , consistent examination of the child with regard to complaints made by parents, and with their active detection on the basis of simple questions and objective clinical signs. The list of symptoms used in IMCI , was determined by a large number of studies conducted by experts from WHO for 30 years in different countries based on the principles of evidence-based medicine. As a result, an integrated approach all children who applied to the primary care medical facility , divided into three gradations : 1) “pink” – children requiring hospitalization , and 2) ” yellow ” – children requiring outpatient treatment , and 3) “green” – children who do not require treatment and observation about this disease. The existing conditions of assistance at primary health care with limited diagnostic and therapeutic possibilities of this approach is realistic and effective , it enables rapid decision , which significantly reduces the risk of death and disability in children aged 1 week to 5 years.
The objectives of an integrated approach to the management of the child. Fact-based syndromic approach can be used to determine:
• The problem of health , which can be a child
• The severity of the child
• Actions that you can take to help your child
What is the ” integration “?
Clinical evaluation and treatment
-Knowledge and skills for those who care for a child
Opportunities , structure and functions of the health system
The role of health care in integrating
– The decision to change the system of the child
– Adapt management of integrated management to local conditions
– Organization of training
– Provide medical institution optimal medical therapy
– Decision on the system of admission
Integration in the ” Clinical evaluation and treatment”
-Assessment of signs in a child, then classification of “disease”
– Classification indicates the severity of the disease and determine the place where the child will be treating .
– Treatment should be carried out as soon as carried out “classification “. At all stages of care must be continuity of action medical professionals.
A general assessment of the child: estimated availability of four general danger signs ( three questions : Can a child drink or suck the breasts? Whether the child is vomiting? Whether seizures ? And Review: lethargy or lack of consciousness) , the availability of the main symptoms disease (cough , diarrhea , fever, sore throat and ear , changes in the skin , etc.), measures the weight and height of the child, is deposited on the charts and vaccination status is assessed , the assessment of anemia, child nutrition and counseling tactics follow-up and required treatment.
Integration in the ” knowledge and skills of people who care “
Parents need to be trained medical professional on how to monitor and evaluate the condition of the child , that should be responsible for the child along with the medical professional. Parents need to be trained to provide treatment and care for the child at her home.
Society and parents should trust the decision of the medical officer and the medical officer should know that it is designed to assist parents in addressing the health problems of the child. Requirements for quality medical recommendations – reduce mortality and improve health results – ensuring best practice at all levels – real – can be implemented at the appropriate level of care – cost effective – the best results with minimal additional investment – suitable for medical – adapted to local conditions and capacities of health systems – scientific evidence.
The problem of diagnosis of infectious and non-infectious diseases in pediatrics there for many centuries, from the time of Hippocrates , Galen and Ibn Sina , who in his writings describe some of the symptoms of various diseases of childhood. Since the XIX century, when Pediatrics in a separate science papers on the diagnosis of childhood diseases , it became more and more. Significant progress this medical discipline made through the works of local pediatricians who have made a significant contribution to the development of pediatrics as a science and the development of criteria for the diagnosis of diseases of childhood. The emergence in recent years, many algorithms for clinical diagnosis had to solve all the difficulties at diagnosis in children. However, still the analysis of medical institutions at various levels are regularly incidents as hypo -and overdiagnosis of various diseases , setting incorrect diagnoses underestimation of the severity of the patients , their failure to provide timely and appropriate care. These medical errors sometimes become the cause of death of children from diseases with timely diagnosis and adequate therapy can be classified as fully treatable .
Development of integrated approaches to the diagnosis of diseases of childhood, to assess the severity of the patient and to choose the optimal set of therapeutic agents , their practical implementation in health care would significantly increase the effectiveness of health care for children. Due to this very important and timely developed and translated into Russian guidelines for the management ( Supervision) inpatients ” Integrated Management of Childhood Illness ” ( IMCI ) for children with a serious infection or severe malnutrition developed by WHO ( WHO). The first guide devoted to the diagnosis in ambulatory practice. The first defects in the organization of care for children , aimed at hospitalization may occur at the stage of execution history , ie in the waiting room . Related they usually underestimate the severity of the patients if necessary waiting their turn and their failure to provide adequate emergency care. The first section of the IMCI guide devoted to this problem – sorting urgent assessment and immediate treatment. Sort by severity of condition required for all children before any administrative procedures , ie the registration and processing history , so all staff receiving units must be trained in the basics sorting to identify patients ieed of urgent attention .
By pressing classified attributes, for which there is international consensus :
• Difficulty breathing , severe respiratory distress
• Central cyanosis
• Signs of shock ( the filling capillary nail bed – more than 3 seconds , weak rapid pulse )
• Coma or convulsions
• Severe dehydration ( lethargy , sunken eyes , slow smoothing skin folds ).
Children with at least one of these signs require immediate treatment to prevent death. In the absence of signs of immediate searches of children with so-called Priority signs – symptoms that indicate a high risk of death :
• Visible severe depletion
• Age – less than 2 months
• Swelling of both feet
• Cutting pale palms
• lethargic state , constant irritability and anxiety
• Severe burns
• Any respiratory distress
• A child immediately sent to the hospital with other medical institution.
The presence of one or more attributes listed below require priority attention in the waiting room . Status of these children should be evaluated immediately to determine the required further examination and treatment. In the absence of both emergency and priority signs children can be served in the waiting room to a general queue. Emergency treatments that can be claimed in the waiting room :
• Measures to eliminate foreign body airway
• Oxygen
• Child Care unconscious (prevention of aspiration ), including trauma
• Intravenous infusion in shock with severe malnutrition and dehydration in
• Introduction of anticonvulsants for seizures
• Combating hyperthermia.
After the required types of emergency treatment required of all employees receiving department conducted re- assessment of the child’s diagnosis and treatment of underlying problem. Instructions and patterns of action in emergency situations suggested in the manual IMCI give sufficient knowledge to provide emergency care in hospitals first level.
Examination and observation for several hours facilitated by the presence of the emergency department in the waiting room . A significant number of children after first-aid can be allowed to go home without hospitalization, treatment that reduces and eliminates the problems associated with being in the hospital ( nosocomial infection violation of their traditional way of life, etc. ). Unfortunately , this form of assistance to Ukraine was developed, leading to excessive hospitalization.
In decreasing order of probabilities listed a list of diseases for the child that is unconscious : meningitis, febrile convulsions, hypoglycemia, head injury , poisoning , shock, encephalopathy with acute glomerulonephritis , diabetic ketoacidosis , cerebral malaria. Please be aware of the most characteristic symptoms and laboratory diagnostic data that can clarify the diagnosis .
For children in the first two months of life causes impaired consciousness or convulsions differ significantly from those of their elders. This – birth trauma / asphyxia newborns ( occurring in the first 2-3 days of life ), intracranial hemorrhage , hemolytic disease of newborn , neonatal meningitis .
Much of the guide is devoted to the differential diagnosis of cough and respiratory failure . For the duration of cough is divided into short – “acute ” and “chronic ” ( more than 3-4 weeks). Causes of acute cough in children vary with cough or difficulty breathing with wheezing and asthma in those who coughs against wheezing . Undoubtedly , the most common cause of acute cough beginning with asthmatic component should be considered as acute respiratory infection (ARI ) and acute bronchitis , which is , according to the WHO , the reason for hospitalization. In Ukraine to date still hospitalized children with acute respiratory infections and bronchitis , so remember these causes coughing needed. Another common cause of cough is pneumonia . Pneumonia – first among causes of cough without bronchospasm , while among the causes of pneumonia, asthmatic breathing is in last place . Indeed, for the development of pneumonia uncharacteristic bronchospasm , moreover , marked bronchial obstruction is likely to exclude the diagnosis of pneumonia. Among the causes of coughing or wheezing without bronchospasm appear as severe anemia, heart failure, foreign body in the bronchi , tuberculosis, whooping cough. The latter two infections , however, are diagnosed more often in the later stages of the disease , as a cause of chronic cough.
In children, the first two months of life, cough and / or shortness of breath cause very different diseases. This – respiratory distress syndrome ( hyaline membrane disease ) , sepsis , meningitis , pneumonia.
The main reason astmoidnoho breathing in children – asthma . Other diseases that occur with symptoms of bronchospasm , it should be noted obstructive bronchitis, bronchiolitis , foreign body in the bronchi. One option respiratory failure is its difficulty in inhaling. Such symptoms usually occurs during respiratory viral infections ( stenosing laryngotracheitis parahrypoznoyi or influenza etiology) . If the child has stridor at birth , and in the background increases PDG only , cause – congenital abnormality or immaturity of the cartilage of the larynx. However, remember that stridoroznym breath arises when rare nowadays diseases – diphtheria, epihlotyti , foreign body at the level of the vocal cords.
Diagnostic series for children with chronic cough is large enough. Besides those already mentioned tuberculosis and whooping cough , asthma , and foreign body in the bronchi it include chronic nonspecific lung disease (chronic pneumonia, bronchiectasis) , cystic fibrosis , malformations of the bronchi and lungs , primary immunodeficiency , HIV infection . Often prolonged cough in a child stored on the chronic foci of infection in the nasopharynx , causing leaking mucus and secretions in the trachea and bronchi , and as a result – cough ( prolonged duration of sinusitis, acute adenoiditis , back rhinitis) .
The next symptom is a common cause for hospitalization – fever. Search Diagnostic children with hyperthermia should be carried out in several directions. All children can be divided into groups : patients with localized signs of infection, children with rashes on the skin and a group with fever without apparent foci of infection.
The most simple diagnosis of fever in children with localized features.
It can be ARI with catarrhal symptoms , pneumonia with cough and typical physical symptoms of meningitis, meningeal signs and bulging fontanelles , otitis media with flushed and fixed eardrum , mastoiditis , arthritis or osteomyelitis with local pain and local swelling and hyperemia, retropharyngeal abscess asymmetry of the tonsils and trismus , infection of skin and soft tissue ( cellulitis, erysipelas, pyoderma ).
When fever with a rash should think about “children ” infections – measles, chicken pox, rubella, scarlet fever. If the first three infections occurring relatively easy and in most cases do not require spetsialnoyiterapiyi (except for the appointment of Acyclovir in severe varicella ), the early diagnosis of scarlet fever ( pronounced farynhotonzylit the reaction of lymph nodes, typical changes of the mucosa, throat swab for hemolytic streptococcus ) and destination protystreptokokovyh antibiotics fundamentally important for the prevention of late complications poststreptokokkovyh .
More often hyperthermia with rashes on the skin is caused by a variety of viral infections : enterovirus , parovirusna , herpes -type 6 , Epstein- Bar , which are characterized by transient rash , it is easy systemic disorders ineffective antibiotic therapy. Meningococcal disease runs with petechial and / or hemorrhagic rash , clinical shock and other alarming symptoms. In recent years, Ukraine is rarely diagnosed typhoid , swivel, typhus, hemorrhagic fever , but for them it must be remembered in the differential diagnosis of children with fever, skin rash.
Additional difficulties in the diagnosis of fever in children with rashes on the skin may occur when the cause of their drug allergies started in response to the treatment. Re- appointment of analgesics increases the probability of joining medical dermatitis that can change the clinical picture. Purpose aminopenicillins in infectious mononucleosis often leads to severe dermatitis , because their purpose with this infection should be recognized invalid.
There is no doubt that the introduction of an integrated approach to diagnosis and management of hospitalized children, especially in hospitals first level ( central district hospitals ) will increase the efficiency of care. A similar approach to therapy in pediatric patients also benefit the work of medical institutions, medical reduce stress and reduce the length of stay of children in hospital.
The hardest thing is diagnostic search for fever without localized signs. The most common cause of this condition – urinary tract infection. For children in the first months of life, a serious condition and fever may be signs of septicemia . No specific symptoms may occur early as typhoid , malaria , fevers with HIV infection . When fever in children with central venous catheter should be aware of the possibility catheter -associated infections. Special mention should be in the diagnosis of diseases occurring with prolonged fever (more than 7 days). Along with undiagnosed and therefore untreated bacterial infections such banal as pneumonia, urinary tract infection , salmonellosis, cause prolonged fever , often without localized signs may be infective endocarditis, abscesses (liver, retroperitoneal , kidney ), miliary tuberculosis, brucellosis, leishmaniasis , malaria . In infectious diseases continued fever may cause the cancer and ONCOHEMATOLOGICAL , diffuse connective tissue diseases (rheumatoid arthritis, systemic lupus erythematosus , etc.) , Kawasaki disease .
The differential diagnosis of prolonged hyperthermia possible only with the laboratory bacteriological, immunological and biochemical bases, which, unfortunately , there is not in all hospitals of the first level . However, knowledge of all possible spectrum of pathologies occurring with prolonged fever, pediatricians will quickly orient and guide the patient to the appropriate medical facility .
Diagnostic number of children with prolonged fever should be supplemented with Munchausen syndrome where the child usually lasted for 10-14 years at simulating hyperthermia to address some of their internal problems , causing numerous unnecessary pediatricians study.
There is an integrated approach to the diagnosis of chronic diarrhea and eating disorders, as reflected in the user IMCI . A very important recommendation of WHO not to use antibiotics for non-invasive and invasive mild diarrhea. But we caot , in particular , totally agree with the direction of IMCI that increased intracranial pressure is an absolute contraindication for lumbar puncture . This symptom – one of the most frequent in meningitis . In the presence of hypertension liquor are requested to follow certain precautions when puncture – slow discharge a small amount of cerebrospinal fluid , further horizontal position of the child to prevent herniation of the cerebellum into the foramen magnum .
Diarrhea is a leading cause of infant morbidity and mortality in developing countries and an important cause of malnutrition. In 2003, deaths from diarrhea 1.87 million children under the age of 5 years. Eight out of 10 of these deaths occur in the first years of life. In developed countries, children up to 3 years on average 3 times a year there is diarrhea. Exploring the past 3 decades has revealed many previously unknown organisms that cause diarrhea. These include: rotaviruses (15-25 %) , bacteria : – different strains of E. Coli ( enteropathogenic locally adhesive 30%, diffuse adhesion , enteroinvazyvni , enterohemorahichni ); – Shigella (10-15%), Campylobacter jejuni (5-15%); – Vibrio cholerae; – Salmonella (1-5%), the simplest – Yiardia duodenalis ( to 100 %), entameba histolytica, cryptosporiclium (5-15%). Most deaths diarrhea specifies different levels of dehydration in children. Dehydration of the organism against acute diarrhea of any disease and any age , except in severe forms , may safely and effectively treat 90% of cases by oral rehydration . Glucose and some salts are part of the mix called oral rehydration salts ( ORS ), they are dissolved in water to obtain a solution of the PRS , which is absorbed in the small intestine desired volume, depending on the level of loss of fluid and electrolytes. Solutions of the new ORS recommended by WHO with low osmolarity can reduce by 33% the need for conducting secondary IV infusion , 30% lower occurrence of vomiting and stool frequency by 20%. Important during illness feeding of children is against malnutrition in children. This is especially observed in refractory and bloody diarrhea.
Clinical management of children with diarrhea include:
– Conducting oral rehydration
– Continued feeding of children
– Use of antimicrobial drugs in severe diarrhea.
Guidelines recent years, WHO recommended ORS with reduced osmolarity and addition of zinc salt solutions .
Definition: diarrhea is a rare and unusual excretion of watery feces , no less than 3 times in 24 hours. What matters more is not the multiplicity and nature of excrement, their consistency .
Clinical forms of diarrheal disease .
For the treatment of diarrhea is essential definition of the clinical form of the disease at the first examination of the child. Laboratory studies are not necessary.
There are four clinical forms.
– Acute watery diarrhea (including cholera ), lasts for several hours or days – the main danger of dehydration, weight loss.
– Acute bloody diarrhea, dysentery often – the main risk destroying the integrity of the intestinal mucosa , septic condition, malnutrition and possible dehydration.
– Refractory diarrhea that lasts 14 days or more – danger – severe malnutrition and infection without involving damage to the gastrointestinal tract.
– Diarrhea against malnutrition in severe form , the risk – systemic infection, dehydration , heart failure , deficiency of vitamins and minerals.
Dehydration – a process in which there is increased loss of water and electrolytes, bicarbonates . Moisture loss from the body occurs when frequent vomiting, sweating , urinating and breathing. Dehydration occurs when these losses are not adequately replenished , and there is a shortage of water and electrolytes.
The degree of dehydration is defined by symptoms that reflect the number of lost fluids : the initial stages of these features are not visible. The average degree of dehydration: thirst, restlessness, irritability , decreased skin turgor , sunken eyes , drawn fontanelle ( in infants ). Severe dehydration: there are signs of hypovolemic shock – a change of consciousness , low urine output , cold limbs , weak rapid pulse, low blood pressure and cyanosis. Malnutrition . Loss of fluid and electrolytes in diarrhea , even with adequate refill it , do not rule out malnutrition in children . When diarrhea reduces the amount of food consumed is reduced absorbability of nutrients , although the need for them rises sharply , leading to weight loss and stop its growth. The initial decrease in supply increases with diarrhea.
In these cases, the WHO recommends:
– Continue to give your child foods rich iutrients as during and after diarrhea
– Provide nutrition according to the age when he is healthy.
zinc
As a result of randomized controlled trials in the enrichment of food with zinc , it was found that zinc supplementation at 10-20 mg per day significantly reduces the severity and duration of diarrhea in children under 5 years by 10-14 days of 2-3 months. It is known that zinc plays an important role in the formation metalofermentiv , polirybosom , cell membranes , taking part in the growth and reproduction of cells and the immune system.
Use of antimicrobial and antidiarrhoeal drugs. The use of antimicrobials should be differentiated , that take into account the clinical form of diarrhea and antibiotic sensitivity to agents that cause diarrhea. Bloody diarrhea due to dysentery or shigellosis, cholera , requires the appointment of antibacterial agents , and against diarrhea caused by Cryptosporidium rotavirusomi and has no effect with antibiotics . Assessment of children suffering from diarrhea.
It consists of the study of history , functional test , including the following questions and survey methods . The mother of the child should determine : the presence of blood in the stool , duration of diarrhea, number of watery bowel movements per day , the number of fluids – vomit , presence of fever , cough , cramps , cases of measles , the practice of feeding to the onset of the disease , the kind and the amount of adopted fluid medications, immunization history . Methods for studying the overall survey: evaluation of the general condition, the activity of the child, his restlessness, irritability. Lethargy or unconscious. Sunken eyes . How sick drinking : refuse , eagerly drinking, not drinking. Study of skin turgor : is the skin fold of two fingers and there is a straightening : fast, slow, very slow (> 2 sec). Study chair child:
Is there mucus in the stool and blood ? Are there signs of decrease in supply? Rate ratio of body weight to age and growth of the map physical development. Is the child coughing ? Count the respiratory rate, comparable to the norm. Review of the chest may reveal involvement of the chest in the intercostal spaces . The study of body temperature. Fever can be due to :
– Severe forms of dehydration
– Pneumonia Malaria
– Infections of the gastro – intestinal tract.
Determination of the degree of dehydration and the choice of treatment plan .
Signs of dehydration will , if the child is active, sunken eyes , drinking normally, no thirst . The average degree of dehydration is defined with signs – anxiety child sunken eyes , drinking eagerly . Severe dehydration – when a sick child is inhibited , sunken eyes , drinking does not.
The plan prevention and treatment of dehydration.
With no signs of dehydration treatment recommended in the home to prevent dehydration and reduced meals. With some signs of dehydratioecessary treatment – oral rehydration .
If signs of severe dehydration intravenous rehydration .
Evaluation deficit fluid intake .
Determination of drying to do with the specification of body weight and age.
Calculation based on the degree of dehydration do, knowing about fluid deficit as a percentage relative to body weight. With no signs of dehydration may be fluid deficit of 5 % of body weight. The volume of fluid should be at the rate of not less than 50 ml per 1 kg of body weight of the child , that weighs 5 kg, the recovery amount is 250 ml. In moderate dehydration deficit to approximately 10% of body weight , so restoring the volume rate of 50-100 ml per 1 kg of weight. If dehydration is severe shortage of more than 10 %, so updating should not be less than 100 ml per 1 kg of weight.
In assessing the general condition of the child is also important to diagnose other important issues:
diagnosis of dysentery concerns the detection of impurities of blood in the stool.
Refractory diarrhea – a diarrhea for 14 days, which does not tend to improve . The diagnosis of malnutrition is put in the presence of edema in the extremities, muscle atrophy and with obvious signs of cachexia.
The diagnosis of severe infection not related to the gastrointestinal tract , placed under the sign of pneumonia or sepsis – a fever, lethargy , heart failure , requiring immediate hospitalization.
Adoption of good communications – principles of effective counseling
When communicating with his mother and other family members is important to use effective communication skills . There are 6 basic skills used to communicate effectively , to use non-verbal communication ;
ask ‘open’ questions;
response and gesture , expressing the same concern ;
reflect the mother’s words ;
show compassion , empathy ( empathy );
avoid the use of estimating words.
Use non-verbal communication – health care professional should be at the meeting to look at the mother rather than the side, as she may feel that her absently listening. Of particular importance are the following kinds of dumb behavior: facial expression , posture , eye contact .
Asking “open” questions – before starting a conversation with her mother, to ask her a few questions . It is important to ask questions so as to invoke the mother on openness and thereby obtain the necessary information. It should be striving to ask questions that require detailed answers . Respond and gesture , expressing the same interest – to show the mother that her listen attentively interested in her answer , there are several possible methods: gestures , such as eye , nod your head, smile or simple emotional expressions .
Display mother’s words – sometimes mothers given a lot of questions . In response to each question , a woman can say less and less. In this case, it is useful to repeat the words , it shows that you understand the woman.
Show compassion , empathy ( empathy ) – it is important to show that you understand the feelings of the mother. The words she expresses her feelings and it is important to respond to it in a way to show that uu hear and you understand her feelings. It is important to have always felt your interest .
Avoid using estimating the words: ” true “, ” false “, ” good”, “bad “, ” sufficient “, ” likely “, etc. . If the health care worker often uses these words in a conversation , she may think that she is doing something wrong.
There are four main stages in advising the mother to child care :
ask and listen to his mother in order to identify possible problems and know that the mother is doing for child care ;
praise the mother for what she was doing right ;
mother to give advice on how to care for your child at home;
check out how to have a clear explanation.
Keeping a sick child at the age of 1 week – 2 months
SMPS / B_____________ Age______________ Weight____________ Temperature____________
Complaints___________________First visit_______ Repeated vizyt____________
Please rate (circle circle ) Classification
^ Assess the likely bacterial infection
– Have the child convulsion ?
– BF per min. ____
Repeat with increased ________ Tachypnea ?
o
or is difficult to breathe
o
whether blowing nose wings
o
whether grants ( listen)
o
whether a bulging fontanel ( examination and palpation )
o
Do spreading redness and leaves the skin
o
fever more than 37.5 or less than 35.5 hypothermia
o
pustules on the skin. They are many and significant ?
o
Lethargy or lack of awareness.
o
Movement of the child. Less than normal ?
^ ARE IN CHILD diarrhea ?
– How long? ___ days
– Is there blood in the stools?
Tak____ Ni______
o
The general condition .
Is lethargy or lack consciousness?
Tired or galling ?
o
Take your fingers fold leather belly . It crushes
Very slowly (longer than 2 seconds )
o
slowly
CHECK OR feeding problems with low weight
– Are there any problems with feeding ? Yes No
– Does breastfeeding ? Yes No
– If so, how many times in 24 hours ? ___ times
– Is usually a child receives any other food or drink? Yes No
If so – how often
– What used to feed your baby ? o
weigh –
o
Determine whether weight age –
Poor ___ Very poor_____
QUALITY PROBLEMS IF FOUND feeding . DO feed the baby at least 8 times a day. OR get another food or drink , DO LOW WEIGHT FOR AGE AND NO OTHER FOR IMMEDIATE direction shown in the hospital
Rate feeding breast – feeding or breast-feeding for the last hour?
If the child is not fed for the last hour – ask the mother to put the child to the breast. Watch the process 4 min.
o
or the right latch to the breast ? To do this, watch the :
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chin touches the chest yes no
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mouth wide open yes no
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lower lip very detailed yes no
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more areola above the mouth than below it yes no
no application at all bad application of good attachment
o
or baby sucks effectively ( slow deep sucking / swallowing, sometimes – pause)
does not suck entirely ineffective suckling effectively suckling
see if there are layers of white or mouth ulcer
Assess vaccination status
The next vaccination date ____
treatment
The following overview
Vaccination is now
Keeping a sick child aged 2 months – 5 years
SMPS / B_____________ Age______________ Weight____________ Temperature____________
Complaints_________________First visit_______ Repeated visit____________
Please rate (circle circle ) Classification
^ RISK ASSESSMENT OF GENERAL FEATURES
Caot drink or suck on the breast constantly vomiting Seizures lethargy lack of awareness
^ ARE IN CHILD respiratory distress or cough ? YES NO
– How long? ___ days
– BF per min. ____
Repeat with increased ________ Tachypnea ?
o
Review – involving the chest
o
Listen and behold – stridor
^ ARE IN CHILD diarrhea ?
– How long? ___ days
– Is there blood in the stools?
Yes____ No______
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The general condition .
Is lethargy or lack consciousness?
Tired or galling ?
o
Zapavshi eyes
o
Take your fingers fold leather belly . It crushes
Very slowly (longer than 2 seconds )
o
slowly
^ ARE IN CHILD FEVER (temperature 37.5 and above) YES NO
Assessment of risk of malaria high low
– How long? ___ days
– If more than 7 days – if every day was ?
– Whether the child Cree for last three months ?
– Evaluate stiff neck
– Are there any discharge from the nose
^ SYMPTOMS measles
– generalized rash
– one: cough , rhinitis , conjunctivitis
If you had measles now or three months ago o
overview mouth – ulcers
o
– If any – are deep and widespread ?
o
Eclipse corneal
^ Is there a problem with CHILD ear YES NO
– Pain in the ear ?
– Discharge from ear?
– How long? ___ days
– Look that stands out from the ear
– The palpable seal behind the ear
^ CHECK OR feeding problems with low weight
o
Evaluation pronounced depletion
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Pale hands
expressed moderate
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Edema of both feet
o
Compliance weight age
Poor ___ Very poor_____
ASSESSMENT In case, when feeding is anemia , very low weight or age less than 2 years
– Does breastfeeding ? Yes No
– If so, how many times in 24 hours ? ___ times
– Does breastfeeding at night? Yes No
– Is usually a child receives any other food or drink? Yes No
if so – what
How many times a day times ___
Applying for nursing
If very low weight –
How much and how oduyut child who feeds the child
Has feeding during illness and how
Problems with feeding
Assess vaccination status
The next vaccination date ____
treatment
The following overview
Advice as to whether or when to again seek medical advice immediately
Vaccination is now
Tips for feeding
Pediatric Respiratory Failure
Pediatric respiratory failure develops when the rate of gas exchange between the atmosphere and blood is unable to match the body’s metabolic demands. It is diagnosed when the patient’s respiratory system loses the ability to provide sufficient oxygen to the blood, and hypoxemia develops, or when the patient is unable to adequately ventilate, and hypercarbia and hypoxemia develop.
Management of acute respiratory failure begins with supporting the patient, followed by determining and treating the underlying etiology. While supporting the respiratory system and ensuring adequate gas exchange in the blood, the clinician should initiate an intervention specifically defined to correct the underlying condition.
Pathophysiology
Hypoxemia, defined as a decreased level of oxygen in the blood, is caused by one of the following abnormalities:
- Mismatch between alveolar ventilation (V) and pulmonary perfusion (Q)
- Intrapulmonary shunt
- Hypoventilation
- Abnormal diffusion of gases at the alveolar-capillary interface
- Reduction in inspired oxygen concentration
- Increased venous desaturation with cardiac dysfunction plus one or more of the above 5 factors
Hypoxemia is to be distinguished from hypoxia, defined as a decreased level of oxygen in the tissues. These 2 conditions may be closely related and may or may not coexist, but they are not synonymous.
Ventilation-perfusion mismatch, intrapulmonary shunt, and hypoventilation
The 3 most important abnormalities in gas exchange that lead to respiratory failure are V/Q mismatch, intrapulmonary shunt, and hypoventilation.
The V/Q ratio determines the adequacy of gas exchange in the lung. When alveolar ventilation matches pulmonary blood flow, CO2 is eliminated and the blood becomes fully saturated with oxygen. In the normal lung, gravitational forces affect the V/Q ratio. When a person stands, the V/Q is greater than 1 at the apex of the lung (ventilation exceeds perfusion) and less than 1 at the base (less ventilation with more perfusion). In the overall healthy lung, the V/Q ratio is assumed to be ideal and equals 1.
A mismatch between ventilation and perfusion is the most common cause of hypoxemia. When the V/Q ratio is less than 1 throughout the lung, arterial hypoxemia results. As V/Q mismatch worsens, the minute ventilation increases producing either a low or normal arterial partial pressure of CO2 (PaCO2). The hypoxemia caused by low V/Q areas is responsive to supplemental oxygen administration. The more severe the V/Q imbalance, the higher the concentration of inspired oxygen is needed to raise the arterial partial pressure of oxygen (PaO2).
In the extreme case when the V/Q ratio equals 0, pulmonary blood flow does not participate in gas exchange because the perfused lung unit receives no ventilation (V=0). This condition is intrapulmonary shunting and is calculated by comparing the oxygen contents in arterial blood, mixed venous blood, and pulmonary capillary blood (see Workup).
In healthy people, the percentage of intrapulmonary shunt is less than 10%. When the intrapulmonary shunt is greater than 30%, resultant hypoxemia does not improve with supplemental oxygenation because the shunted blood does not come in contact with the high oxygen content in the alveoli. Instead, treatment consists of recruiting and maximizing lung volume with positive pressure. PaO2 continues to fall proportionately as the shunt increases.
In contrast, PaCO2 remains constant because of a compensatory increase in minute ventilation until the shunt fraction exceeds 50%. The protective reflex that reduces the degree of intrapulmonary shunting is hypoxic pulmonary vasoconstriction (HPV); alveolar hypoxia leads to vasoconstriction of the perfusing vessel. This partially corrects the regional V/Q mismatch by improving PaO2 at the expense of increasing pulmonary vascular resistance.
When ventilation is in excess of capillary blood flow, the V/Q ratio is greater than 1. At the extreme, areas of ventilated lung receive no perfusion, and the V/Q ratio approaches infinity (Q=0). This extreme condition is referred to as alveolar dead-space ventilation. In addition to alveolar dead space, anatomic dead space represents the volume of air in conducting airways that cannot participate in gas exchange.
Combined, the alveolar and anatomic dead-space volumes are referred to as physiologic dead space, which normally accounts for 30% of total ventilation. Increased dead-space ventilation results in hypoxemia and hypercapnia. This increase can be caused by decreased pulmonary perfusion due to hypotension, pulmonary embolus, or alveolar overdistention during mechanical ventilation. The ratio of dead-space to tidal-gas volume can be calculated on the basis of the difference between CO2 in arterial blood and in exhaled gas (see Workup).
Under steady-state conditions, PaCO2 is directly proportional to CO2 production (VCO2) and inversely proportional to alveolar ventilation (VA), as follows: PaCO2 = VCO2 X (k/VA), where k is a constant = 0.863.
Therefore, when VA decreases or VCO2 increases, PaCO2 increases. With alveolar hypoventilation, hypoxemia is predicted by using the alveolar gas equation, but the alveolar-arterial gradient remains normal (see Workup).
Another way to approach respiratory failure is based on 2 patterns of blood-gas abnormalities. Type I respiratory failure results from poor matching of pulmonary ventilation to perfusion; this leads to noncardiac mixing of venous blood with arterial blood. As a result, type I respiratory failure is characterized by arterial hypoxemia with normal or low arterial CO2.
Type II respiratory failure results from inadequate alveolar ventilation in relation to physiologic needs and is characterized by arterial hypercarbia and hypoxemia. Type II respiratory failure occurs when a disease or injury imposes a load on a child’s respiratory system that is greater than the power available to do the respiratory work. In this scenario, the hypoxemia is proportional to the hypercarbia.
A wide array of diseases can cause respiratory failure. Therefore, the physician must identify the affected area in the respiratory system that contributes to the respiratory failure. Identification can be achieved by dividing the respiratory system into 3 anatomic parts: (1) the extrathoracic airway, (2) the lungs responsible for gas exchange, and (3) the respiratory pump that ventilates the lung and that includes the nervous system, thorax, and respiratory muscles.
In general, diseases that affect the anatomic components of the lung result in regions of low or absent V/Q ratios, initially leading to type I (or hypoxemic) respiratory failure. In contrast, diseases of the extrathoracic airway and respiratory pump result in a respiratory power-load imbalance and type II respiratory failure. Hypercarbia due to alveolar hypoventilation is the hallmark of diseases involving the respiratory pump.
Pediatric considerations
The frequency of acute respiratory failure is higher in infants and young children than in adults, for several reasons. This difference can be explained by defining anatomic compartments and their developmental differences in pediatric patients that influence susceptibility to acute respiratory failure. Neonates present a unique susceptibility to respiratory failure, both resulting from and/or complicated by issues related to prematurity and transition from intrauterine to extrauterine life.
Extrathoracic airway differences
The area extending from the nose through the nasopharynx, oropharynx, and larynx to the subglottic region of the trachea constitutes the extrathoracic airway. This area differs in pediatric versus adult patients in 8 respects, as follows:
1. Neonates and infants are obligate nasal breathers until the age of 2-6 months because of the proximity of the epiglottis to the nasopharynx. Nasal congestion can lead to clinically significant distress in this age group.
2. The airway is small; this is one of the primary differences in infants and children younger than 8 years compared with older patients.
3. Infants and young children have a large tongue that fills a small oropharynx.
4. Infants and young children have a cephalic larynx. The larynx is opposite vertebrae C3-4 in children versus C6-7 in adults.
5. The epiglottis is larger and more horizontal to the pharyngeal wall in children than in adults. The cephalic larynx and large epiglottis can make laryngoscopy challenging.
6. Infants and young children have a narrow subglottic area. In children, the subglottic area is cone shaped, with the narrowest area at the cricoid ring. A small amount of subglottic edema can lead to clinically significant narrowing, increased airway resistance, and increased work of breathing. Adolescents and adults have a cylindrical airway that is narrowest at the glottic opening.
7. In slightly older children, adenoidal and tonsillar lymphoid tissue is prominent and can contribute to airway obstruction.
8. Uncorrected congenital anatomic abnormalities (eg, cleft palate, Pierre Robin sequence) or acquired abnormalities (eg, subglottic stenosis, laryngomalacia/tracheomalacia) may cause inspiratory obstruction.
Intrathoracic airway differences
The intrathoracic airways and lung include the conducting airways and alveoli, the interstitia, the pleura, the lung lymphatics, and the pulmonary circulation. There are 6 noteworthy differences between children and adults in this area, as follows:
1. Infants and young children have fewer alveoli than do adults. The number dramatically increases during childhood, from approximately 20 million at birth to 300 million by 8 years of age. Therefore, infants and young children have a relatively small area for gas exchange.
2. The alveolus is small. Alveolar size increases from 150-180 to 250-300 µm during childhood.
3. Collateral ventilation is not fully developed; therefore, atelectasis is more common in children than in adults. During childhood, anatomic channels form to provide collateral ventilation to alveoli. These pathways are between adjacent alveoli (pores of Kohn), bronchiole and alveoli (Lambert channel), and adjacent bronchioles. This important feature allows alveoli to participate in gas exchange even in the presence of an obstructed distal airway.
4. Smaller intrathoracic airways are more easily obstructed than larger ones. With age, the airways enlarge in diameter and length.
5. Infants and young children have relatively little cartilaginous support of the airways. As cartilaginous support increases, dynamic compression during high expiratory flow rates is prevented.
6. Residual alveolar damage from chronic lung disease of prematurity or bronchopulmonary dysplasia decreases pulmonary compliance.
Respiratory pump differences
The respiratory pump includes the nervous system with central control (ie, cerebrum, brainstem, spinal cord, peripheral nerves), respiratory muscles, and chest wall. The following 5 features mark the difference between the pediatric and adult population:
1. The respiratory center is immature in infants and young children and leads to irregular respirations and an increased risk of apnea.
2. The ribs are horizontally oriented. During inspiration, a decreased volume is displaced, and the capacity to increase tidal volume is limited compared with that in older individuals.
3. The small surface area for the interaction between the diaphragm and thorax limits displacing volume in the vertical direction.
4. The musculature is not fully developed. The slow-twitch fatigue-resistant muscle fibers in the infant are underdeveloped.
5. The soft compliant chest wall provides little opposition to the deflating tendency of the lungs. This leads to a lower functional residual capacity in pediatric patients than in adults, a volume that approaches the pediatric alveolus critical closing volume.
Etiology
The most common reasons for respiratory failure in the pediatric population can be divided by anatomic compartments, as follows.
Acquired extrathoracic airway causes include the following:
- Infections (eg, retropharyngeal abscess, Ludwig angina, laryngotracheobronchitis, bacterial tracheitis, peritonsillar abscess)
- Trauma (eg, postextubation croup, thermal burns, foreign-body aspiration)
- Other (eg, hypertrophic tonsils and adenoid)
Congenital extrathoracic airway causes include the following:
- Subglottic stenosis
- Subglottic web or cyst
- Laryngomalacia
- Tracheomalacia
- Vascular ring
- Cystic hygroma
- Craniofacial anomalies
Intrathoracic airway and lung causes include the following:
- Acute respiratory distress syndrome (ARDS)
- Asthma
- Aspiration
- Bronchiolitis
- Bronchomalacia
- Left-sided valvular abnormalities
- Pulmonary contusion
- Near drowning
- Pneumonia
- Pulmonary edema
- Pulmonary embolus
- Sepsis
Respiratory pump causes include the following:
- Diaphragm eventration
- Diaphragmatic hernia
- Flail chest
- Kyphoscoliosis
- Duchenne muscular dystrophy
- Guillain-Barré syndrome
- Infant botulism
- Myasthenia gravis
- Spinal cord trauma
- Spinal muscular atrophy (SMA)
Central control causes include the following:
- CNS infection
- Drug overdose
- Sleep apnea
- Stroke
- Traumatic brain injury
Prognosis
The prognosis depends on the underlying etiology leading to acute respiratory failure. It can be good when the respiratory failure is an acute event that is not associated with prolonged hypoxemia (eg, in the case of a seizure or intoxication). It may be fair to poor when a new process is associated with chronic respiratory failure secondary to a neuromuscular disease or thoracic deformity or in the case of warm hypoxia exceeding 10-20 minutes. This may herald the need for long-term mechanical ventilation.
The prognosis can vary when respiratory failure is associated with a chronic disease with acute exacerbations. Acute respiratory failure remains an important cause of morbidity and mortality in children. Cardiac arrests in children frequently result from respiratory failure. In 2000, data from the National Center for Health Statistics listed respiratory illnesses as one of the top 10 causes of pediatric mortality. Respiratory failure may be the sign of an irreversible progressive disease that leads to death (eg, idiopathic pulmonary hypertension).
History
Consideration of the questions that follow can help guide the history in a patient with possible respiratory failure.
Does the patient have factors that increase the risk for respiratory failure? Factors may include any of the following:
- Young age
- Premature birth
- Immunodeficiency
- Chronic pulmonary, cardiac, or neuromuscular disease (eg, cystic fibrosis, bronchopulmonary dysplasia, unrepaired congenital heart disease, spinal muscular atrophy [SMA])
- Anatomic abnormalities
Does the patient have a cough, rhinorrhea, or other symptoms of an upper respiratory tract infection? These manifestations may help in defining an etiology.
Does the patient have a fever or signs of sepsis? Several infections can lead to respiratory failure because of a systemic inflammatory response, pulmonary edema, or acute respiratory distress syndrome (ARDS) or because of a power-load imbalance secondary to increased oxygen consumption. Epiglottitis from Haemophilus influenzae infection, although decreased in recent years owing to widespread immunization, is a classic cause of obstructive respiratory failure in infants and children.
How long have the symptoms been present? The natural course of a respiratory illness must be considered. Respiratory syncytial virus (RSV) infections, for example, frequently worsen over the initial 3-5 days before improvement occurs.
Does the patient have any pain? Pain can suggest pleuritis or foreign-body aspiration.
Does the patient have a possible or known exposure to sedatives (eg, benzodiazepines, tricyclic antidepressants, narcotics) or has he or she recently undergone a procedure that used general anesthesia? This could suggest hypoventilation.
Does the patient have symptoms of neuromuscular weakness or paralysis? What is the distribution of weakness and duration of symptoms to narrow the differential diagnosis? Bulbar dysfunction suggests myasthenia gravis. Distal weakness that progresses upward suggests Guillain-Barré syndrome. Apnea associated with a traumatic injury suggests a cervical spinal cord injury.
Does the patient have a history suggestive of a stroke or seizure?
Does the patient have a history of headaches? With chronic hypercapnia, headaches typically occur at nighttime or upon the patient’s awakening in the morning.
Physical Examination
During the physical examination, the clinician should avoid interfering with the patient’s mechanisms for compensation. Children often find the most advantageous position for breathing, which can be a helpful diagnostic clue for the astute clinician.
Children with respiratory distress commonly sit up and lean forward to improve leverage for the accessory muscles and to allow for easy diaphragmatic movement. Children with epiglottitis sit upright with their necks extended and heads forward while drooling and breathing through their mouths. Making a child lie down or making him or her cry during the simplest examination can precipitate acute respiratory failure.
The clinician should observe whether the patient appears well or sick, and should look for central or peripheral cyanosis.
The respiratory rate and quality can provide diagnostic information, and they should be assessed with attention to age-specific norms for each particular patient. Bradypnea is most often observed in central control abnormalities. Slow and large tidal volume breaths also minimize turbulence and resistance in significant extrathoracic airway obstruction (eg, epiglottitis). The fast and shallow breathing of tachypnea is most efficient in intrathoracic airway obstruction. It decreases dynamic compliance of the lung.
Auscultation provides information about the symmetry and quality of air movement. Evaluate the patient for stridor (an inspiratory sound), wheezing (an expiratory sound), crackles, and decreased breath sounds (eg, alveolar consolidation, pleural effusion).
Grunting is an expiratory sound made by infants as they exhale against a closed glottis. It is an attempt to increase functional residual capacity and lung volume. This is done in order to raise functional residual capacity above the critical closing volume and to avoid alveolar collapse. This physical finding represents impending respiratory failure and should not be overlooked.
Assess for accessory muscle use and nasal flaring. Suprasternal and intercostal retractions are present when high negative pleural pressures are required to overcome airway obstruction or stiff lungs.
Evaluate for paradoxical movement of the chest wall. In the presence of abnormalities of the pulmonary pump, paradoxical chest-wall movement occurs because of instability of the chest wall associated with absent intercostal muscle use. As the diaphragm contracts and pushes abdominal contents out, the chest wall retracts inward instead of expanding normally. Termed abdominal breathing, this, however, may be a normal compensatory pattern for a very young infant with chronic lung disease or decreased chest wall compliance.
Tachycardia and hypertension may occur secondary to increased circulatory catecholamine levels. A gallop is suggestive of myocardial dysfunction leading to respiratory failure. Age-specific bradycardia associated with decreased or shallow breathing and desaturations noted via pulse oximeter is ominous and indicates the need for emergent positive-pressure ventilation.
Peripheral vasoconstriction may develop secondary to respiratory acidosis and/or hypoxia.
Patients may be lethargic, irritable, anxious, or unable to concentrate. The inability to breathe comfortably creates anxiety, and superimposed hypoxemia and hypercapnia accentuates any restlessness and agitation. Increased agitation may indicate a general worsening of the patient’s condition.
Diagnostic Considerations
Problems to be considered in the differential diagnosis of pediatric respiratory failure include the following:
- Guillain-Barré syndrome
- Ludwig angina
- Neuromuscular disorders (eg, Duchenne muscular dystrophy or spinal muscular atrophy [SMA] type 1)
- Pulmonary embolus
- Spinal cord injury
- Tracheal foreign bodies
- Transverse myelitis, cervical or high thoracic
- Vascular slings
Differential Diagnoses
- Aspiration Syndromes
- Congenital Central Hypoventilation Syndrome
- Congenital Diaphragmatic Hernia Imaging
- Genetics of Asphyxiating Thoracic Dystrophy (Jeune Syndrome)
- Imaging in Bronchopulmonary Dysplasia
- Laryngomalacia
- Neonatal Sepsis
- Pediatric Subglottis Stenosis Surgery
- Physical Child Abuse
- Respiratory Syncytial Virus (RSV) Infection
Approach Considerations
Arterial blood gas (ABG) measurement can be used to define acute respiratory failure. Arbitrary definitions include a partial pressure of CO2 (PaCO2) greater than 50 mm Hg, a partial pressure of oxygen (PaO2) less than 60 mm Hg, or arterial oxygen saturation less than 90%. An elevated serum bicarbonate level suggests metabolic compensation for chronic hypercapnia.
A complete blood count (CBC) may be helpful. Polycythemia suggests chronic hypoxemia.
Electrolyte abnormalities can contribute to weakness; hypokalemia, hypocalcemia, and hypophosphatemia can impair muscle contraction.
Calculate the alveolar-arterial oxygen difference ([A-a]DO2), which is the difference between the alveolar PAO2 and the arterial PaO2. This value is an index of the efficiency of gas exchange by the lungs.
The alveolar gas equation is used to calculate the PAO2 on the basis of the relationship between the pressure of oxygen in inspired gas (PiO2), the PaCO2, and the respiratory quotient (RQ), as follows: PAO2 = FiO2 (Pb – PH 2O) – (PaCO2/RQ).
PiO2 is a function of the fractional concentration of inspired oxygen (FiO2), the barometric pressure (Pb), and the partial pressure of water vapor (PH 2O) in humidified air.
RQ is the ratio of the volume of carbon dioxide expired to the volume of oxygen consumed by an organism. The body normally produces approximately 200 mL of carbon dioxide per minute and consumes approximately 250 mL of oxygen per minute; therefore, RQ is 0.8. Different fuel sources produce different RQ values: the RQ for carbohydrates is 1; protein is 0.8; and fat is 0.7.
In children, (A-a)DO2 is normally 5-10 and reflects venous admixture from anatomic right-to-left shunts, which include the bronchial circulation, thebesian veins, and small arteriovenous anastomoses in the lung.
The PaO2/FiO2 ratio is a commonly used indicator of gas exchange. A PaO2/FiO2 less than 200 is correlated with a shunt fraction greater than 20%. For ventilated patients, a similar calculation is called the oxygen index, calculated by (PaO2 x FiO2/mean airway pressure) x 100. These numbers are used to quickly communicate the severity of respiratory failure and can provide some diagnostic and therapeutic guidance (eg, when to start inhaled nitric oxide).
Imaging studies may include plain radiography or computed tomography (CT), or magnetic resonance imaging (MRI) scans. Fluoroscopy is valuable to evaluate the movement of the diaphragms and dynamic obstructive lesions of both the extrathoracic and intrathoracic airway. Ventilation/perfusion (V/Q) scanning can predict a probability of V/Q mismatch secondary to a pulmonary embolism.
Imaging Studies
Radiography
Lateral and anteroposterior (AP) radiographs of the neck can reveal a radiopaque foreign body or soft-tissue structures encroaching on the lumen of the airway, such as in acute epiglottitis.
Chest radiographs may yield helpful findings (see examples in the images below).
Bilateral airspace infiltrates on chest radiograph film secondary to acute respiratory distress syndrome that resulted in respiratory failure
.
Extensive left-lung pneumonia caused respiratory failure; the mechanism of hypoxia is intrapulmonary shunting.
Evaluate for abnormalities that require immediate intervention (eg, malpositioned endotracheal tube, pneumothorax).
Common findings associated with respiratory failure include the following:
- Focal or diffuse pulmonary disease (eg, pneumonia, ARDS)
- Bilateral hyperinflation (eg, asthma)
- Asymmetric lung expansion suggesting a bronchial obstruction
- Pleural effusion
- Cardiomegaly
If hypoxemia is present but the chest radiograph is clear, this finding could suggest cyanotic congenital heart disease, pulmonary hypertension, or pulmonary emboli.
CT and MRI
Chest CT scanning can be performed when sophisticated diagnostic images are needed. It can further define radiopacities due to vascular, pleural, interstitial, or airway lesions.
Airway CT scanning, MRI, and/or angiography can be used to differentiate deep-tissue structures, bone lesions, and vascular abnormalities.
Other Pulmonary Function Tests
Useful information may be provided by determination of dead-space volume to tidal gas volume (VD/VT) and determination of the intrapulmonary shunt fraction (Qs/Qt).
Determination of dead-space volume to tidal gas volume
VD/VT is based on the difference between PaCO2 and the CO2 in exhaled gas (PeCO2). PeCO2 is measured by collecting expired gas in a large collection bag and using an infrared CO2 analyzer to measure the PCO2 in a sample of gas.
In a normal lung, the capillary blood equilibrates fully with alveolar gas; therefore, the PeCO2 approximates the PaCO2. As VD/VT increases, the PeCO2 falls below PaCO2.
Reference range VD/VT is approximately 0.30.
VD/VT = (PaCO2 – PeCO2)/PaCO2
Determination of the intrapulmonary shunt fraction
Qs/Qt is the ratio of shunted flow (Qs) to the total flow or cardiac output (Qt). It is derived by the relationship between the oxygen content in arterial blood (CaO2), mixed venous blood (CvO2), and pulmonary capillary blood (CcO2) while breathing FiO2 that equals 1.
Arterial oxygen content (in mL O2/dL) = [1.34 mL O2/g hemoglobin × hemoglobin (in g/dL) × SpO2] + [PaO2 (in mm Hg) × 0.003 mL O2/dL/mm Hg].
Directly measuring pulmonary capillary blood (CcO2) is difficult; therefore, CcO2 is assumed to be 100% when FiO2 equals 1.
The normal intrapulmonary shunt is less than 10%.
Qs/Qt = (CcO2 – CaO2)/(CcO2 – CvO2)
Bronchoalveolar Lavage and Lung Biopsy
Bronchoalveolar lavage (BAL) is performed to identify a specific infectious pulmonary pathogen; bacterial, viral, and acid-fast bacillus (AFB) cultures and silver stains can be performed. BAL can also be performed to isolate lipid-laden macrophages (suggestive of recurrent aspiration) or pulmonary hemorrhage.
In an intubated patient, samples can be obtained blindly or bronchoscopically.
BAL is indicated in critically ill children to guide antimicrobial therapy and in children whose conditions have deteriorated during therapy.
Lung biopsy may be indicated if BAL does not reveal a pathogen, especially in immunocompromised hosts; it can identify Aspergillus species or Pneumocystis jiroveci. Lung biopsy is also helpful in the diagnosis of sarcoidosis and other granulomatous conditions.
Other Tests
Electromyography (EMG) or nerve conduction testing can help determine the etiology for neuromuscular weakness leading to respiratory pump failure.
Fiberoptic and rigid bronchoscopy can be performed to assess large and small airways for anatomic abnormalities or foreign bodies.
Nasal airflow tracings coupled with chest-movement recordings (pneumograms) have a specific role in identifying sleep-associated extrathoracic airway obstruction and respiratory control abnormalities.
Thoracentesis is used in patients with pleural effusions, to check the cell count and protein level to determine whether pleural fluid is an exudate or transudate. Other pleural fluid studies include measurement of triglycerides, to determine whether the effusion is chylous, and bacterial and acid-fast bacterial (AFB) cultures. Cytology is used to evaluate for malignant effusions.
Test of respiratory mechanics and lung-volume measurements are most beneficial in following the progression of disease and the effects of treatment over time. Many infants and children cannot cooperate with traditional pulmonary function measurements. Many contemporary pediatric ventilators incorporate sophisticated sensors and software that measure inhaled and exhaled breaths and can display pulmonary flow loops and other pulmonary parametrics. This provides valuable information regarding real-time, as well as trended, pulmonary dynamics.
Approach Considerations
Management of acute respiratory failure begins with a determination of the underlying etiology. While supporting the respiratory system and ensuring adequate oxygen delivery to the tissues, initiate an intervention specifically defined to correct the underlying condition. For example, a patient with status asthmaticus is given supplemental oxygen to treat hypoxemia, but corticosteroids and beta-agonist drugs are also given to treat the underlying pathology.
Extrathoracic airway support
For partial upper-airway obstruction (eg, from anesthesia or acute tonsillitis), place a nasopharyngeal airway to provide a passageway for air.[1] An oropharyngeal airway can be used temporarily in the unconscious patient.
For extrathoracic airway obstruction, such as croup, the following measures may be helpful:
- Inspired humidity to liquefy secretions
- Heliox (helium and oxygen gas mixture) to decrease work of breathing
- Racemic epinephrine 2.25%, an aerosolized vasoconstrictor
- Systemic corticosteroids to decrease airway edema
Heliox has a helium concentration of 60-80% and thus has a density lower than that of air; it improves breathing by reducing turbulent airflow through a narrowed area. A limiting factor in the use of Heliox is that it typically contains oxygen in the same concentration as room air, and some patients may require higher concentrations of oxygen.
Consultations
Consultations may be indicated with the following:
- Neurologist for neuromuscular weakness evaluation
- Cardiologist if left-sided valvar obstruction or cardiomyopathy is suspected
- Pulmonologist for chronic pulmonary diseases
- Otorhinolaryngologist for evaluation of foreign-body aspiration or anatomic abnormality
Tracheal Intubation
Endotracheal intubation is occasionally needed to maintain airway patency in certain cases (eg, epiglottitis, thermal burns to the airway, severe croup). In general, uncuffed tubes are used in children younger than 8 years because the subglottic trachea surrounded by the cricoid cartilage is the narrowest part of the pediatric airway.
Ieonates and infants younger than 6 months, an endotracheal tube with an inner diameter (ID) of 3.5-4 mm is appropriate. In infants aged 6-12 months, a tube with a 4-4.5 mm ID is appropriate. Weight is the traditional guide to determine appropriate endotracheal tube size in infants and children, and many emergency departments have a color-coded emergency equipment cart organized by weight for easy access. A useful bedside or field guideline for appropriate endotracheal tube size is approximately the size of the patient’s fifth finger.
In children older than 1 year, the following formula can be used: Tube size (ID in millimeters) = (age in years + 16)/4
The mnemonic MSOAPP can be used to remember the preparation essential for a safe tracheal intubation procedure, as follows:
- M – Monitors (heart rate, blood pressure, pulse oximetry, capnography for CO2 detection)
- S – Suction and catheters
- O – Oxygenation with a bag-valve mask
- A – Apparatus (laryngoscope, endotracheal tubes appropriate for the patient’s age and a half-size smaller and larger, stylets, oral airways)
- P – Pharmacy (medications for amnesia and paralysis)
- P = People (respiratory therapist, nurse, a skilled set of hands)
In adults, confirming proper sizing is accomplished by allowing the breathing circuit pressure to rise until air leaking around the tube can be auscultated, ideally approximately 15-18 cm water; the endotracheal tube cuff is then inflated. In infants and children, there is no cuff, and it is not uncommon to require pressures much higher than 18 cm water to provide adequate ventilatory support. Therefore, it is important to place the proper-diameter endotracheal tube to optimize ventilatory support. Radiographic confirmation should always be obtained, with the distal tip ideally positioned midway between the thoracic inlet and the carina.
Lung and Respiratory Pump Support
Oxygen therapy
The initial treatment for hypoxemia is to provide supplemental oxygen. High-flow (>15 L/min) oxygen delivery systems include a Venturi-type device that places an adjustable aperture lateral to the stream of oxygen. Oxygen is mixed with entrained room air, and the amount of air is adjusted by varying the aperture size. The oxygen hoods and tents also supply high gas flows.
Low-flow (< 6 L/min) oxygen delivery systems include the nasal cannula and simple face mask.
Humidified high-flow nasal cannula therapy
Although no single universally accepted definition is available for what constitutes humidified high-flow nasal cannula (HHFNC) therapy ieonates, a widely used and reasonable definition is optimally warmed (body temperature) and humidified respiratory gases delivered by nasal cannula at flow rates of 2-8 L/min.[2]
In 2004, the US Food and Drug Administration (FDA) approved a device specifically for the provision of HHFNC ieonates: Vapotherm 2000i (Vapotherm, Inc, Stevensville, MD). This devices delivered molecular vapor with 95-100% relative humidity at body temperature through nasal cannula at flow rates between 5-40 L/min.
In August 2005, the Centers for Disease Control and Prevention (CDC) was notified of a Ralstonia species outbreak among pediatric patients receiving supplemental oxygen therapy with the Vapotherm 2000i. It was recalled from the market but has subsequently been reintroduced.[3]
Following the withdrawal of Vapotherm from the market, many individual neonatal and pediatric centers put together their own systems for delivery of HHFNC using the basic components of a humidifier, respiratory circuit, adapter, and nasal cannula.
Limited evidence is available to support the specific role, efficacy, and safety of HHFNC. The available evidence suggests that HHFNC provides inconsistent and relatively unpredictable positive airway pressure but may be effective in the treatment of some neonatal respiratory conditions while being more user-friendly for caregivers and better tolerated by infants and toddlers than conventional CPAP.[4, 5]
Continuous positive airway pressure
Continuous positive airway pressure (CPAP) may be indicated if lung disease results in severe oxygenation abnormalities such that an FiO2 greater than 0.3 is needed to maintain a PaO2 greater than 60 mm Hg.
CPAP in pressures from 3-10 cm water is applied to increase lung volume and may redistribute pulmonary edema fluid from the alveoli to the interstitium.
CPAP enhances ventilation to areas with low V/Q ratios and improves respiratory mechanics.
If a high concentration of FiO2 is needed and if the patient does not tolerate even short periods of discontinued airway pressure, positive-pressure ventilation should be administered.
Noninvasive positive-pressure ventilation (NPPV)
Noninvasive positive-pressure ventilation (NPPV) refers to assisted ventilation provided with nasal prongs or a face mask instead of an endotracheal or tracheostomy tube. This therapy can be administered to decrease the work of breathing and to provide adequate gas exchange.
NPPV can be given by using a volume ventilator, a pressure-controlled ventilator, or a device for bilevel positive airway pressure (BIPAP or bilevel ventilator) (see the image below).
A device only recently made commercially widely available is the RAM cannula, which was developed by a clinician at the Children’s Hospital of Los Angeles. This device provides the comfort and ease of a nasal cannula and, when attached to a ventilator circuit, can deliver true noninvasive positive-pressure ventilation in both the conventional mode and the high-frequency mode. Currently, it is the only device that has this capability.
A Bilevel positive airway pressure support machine is shown here. This could be used in spontaneous mode or timed mode (backup rate could be set).
Inspiratory pressure support is a ventilator modality in which increased circuited pressure during inspiration boosts the patient’s effort. However, the patient’s effort, as reflected by sensitive measurement of the circuit gas flow, triggers both the beginning and end of the inspiratory phase of the mechanical cycle.
Potential drawbacks of noninvasive ventilation include inappropriate delay of the start of mechanical ventilation via endotracheal tube.[6] In addition, gastric distention can occur, with possible pulmonary aspiration.
The severity of the patient’s disease limits the use of this technique. Prolonged wearing of the facial interface can lead to nasal congestion, facial reddening, eye irritation, or ulceration of the nasal bridge. If periodic relief from the face mask or nasal prongs is unavailable for several days, tracheal intubation is necessary and safer.
5.2. Theoretical questions to studies.
1.What major clinical symptoms of pneumonia in children?
1.
What are the major clinical symptoms of various degrees of dehydration in children?
2.
What are the major clinical symptoms of bacterial infection (in children up to 2 months )?
3.
What are the major clinical symptoms of infectious ear damage in children?
4.
What are the major clinical symptoms of severe anemia in children?
5.
Assessment of feeding or underweight in children during the first two years of life .
6.
Differential diagnosis of hyperthermia. Treatment of hyperthermia.
7.
Clinical management of children with diarrhea.
8.
Principles of effective counseling of parents.
1.
5.3. Materials for self-control.
A. Review Questions .
1.
What is IMCI strategy
2.
leading causes of infant and perinatal mortality in the world and in Ukraine
3.
objectives , principles, components and target population IMCI strategy
4.
important aspects of the effect of medicine on a child’s health in Ukraine
5.
comparative analysis of the “standard ” approach to the management of patients with IMCI
6.
explain the ” integral ” aspect of IMCI
7.
classification approaches for cough and shortness of breath for IMCI
8.
classification approaches for dehydration for IMCI
9.
classification approaches for probable bacterial infection (in children up to 2 months ) in IMCI
10.
classification approaches to problems feeding or underweight for IMCI
11.
classification approaches to hyperthermia for IMCI
12.
classification approaches to anemia and malnutrition for IMCI
13.
immediate assessment of the child for signs of IMCI
14.
assess the priority of the child for signs of IMCI
15.
Differential diagnosis of hyperthermia in children with IMCI
16.
tactics of children with diarrhea for IMCI
17.
principles of effective counseling of parents
Suggested Reading
General
1.
Handbook YVBDV ( Yntehryrovannoe Doing disease Children’s age ) Vsemyrnaya Organization of Health , Department of Health and development , child and teenager ( SUN ), 2000 , 202 p.
2.
Orders MoH Ukraine “On Improving outpatient care to children in Ukraine “, “On the improvement of care for children teens “, and protocols in the fields of ” Pediatrics ” and others. Ministry of Health of Ukraine . – Kyiv , 2005 – 414 p.
3.
Nelson textbook 18th Edition by Robert M. Kliegman, MD, Richard E. Behrman, MD, Hal B. Jenson, MD and Bonita F. Stanton, MD. Publisher : SAUNDERS
4.
Integrated Management of Childhood Illness strategy as a modern primary health care for children
AP Volosovets , SP Kryvopustov , National Medical University. AA Bogomoltsa , Kyiv
Magazine ” child health ” 1 (10) 2008 / Clinical lecture
5.
Sazawal S., Black R.E. Meta-analysis of intervention trials on case management of pneumonia in community settings / / Lancet. – 1992. – 340 ( 8818 ). – 528-533 .
Learn more
6.
Tests of Pediatrics / Ed. Corr. Medical Sciences of Ukraine , Professor. VG Maidannyk . – Kyiv, 2007.-429 p.
7.
http://www.who.int/child-adolescent-health/integr.htm
8.
Pocket book of hospital care for children: Guidelines for the management of common illnesses with limited resources. http://www.who.int/child-adolescent health / publications / CHILD_HEALTH / PB.htm
9.
Serious childhood problems in countries with limited resources. http://www.who.int/child-adolescent-health/New_Publications/CHILD_HEALTH/ISBN_92_4_156269_2.pdf
10.
http://www.un.org/millenniumgoals
11.
http://www.un.org/russian/goals/
