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Module 2 diseases of the newborn




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M.GORKY DONETSK NATIONAL MEDICAL UNIVERSITY


DEPARTMENT NO. 2 FOR PEDIATRICS


PRACTICE ACTIVITY GUIDELINES


DISCIPLINE: Pediatrics


Module 2


DISEASES OF THE NEWBORN,

BLOOD DISORDERS AND

DISORDERS OF THE ENDOCRINE SYSTEM

IN CHILDREN.


INTENDED AUDIENCE: 5th - Year Students


FACULTY: Faculty of Medicine for International Students


FACULTY DEPARTMENT:

Department No. 2 for Pediatrics


Donetsk, Ukraine

2009


MODULE 2.

DISEASES OF THE NEWBORN, BLOOD DISORDERS AND DISORDERS OF THE ENDOCRINE SYSTEM IN CHILDREN.


AIMS OF THE MODULE.


To be able:


  1. To determine the etiologic and pathogenetic factors of the diseases of the newborn, hematologic disorders and disorders of the endocrine system in children.

  2. To classify and analyze the typical clinical picture of the diseases of the newborn, hematologic disorders and disorders of the endocrine system in children.

  3. To make the plan of observation and analyze data of laboratory and instrumental investigation at typical course of the diseases of the newborn, hematologic disorders and disorders of the endocrine system in children.

  4. To demonstrate mastering the principles of treatment, rehabilitation and prophylaxis of the diseases of the newborn, hematologic disorders and disorders of the endocrine system in children.

  5. To diagnose and to manage emergency care for children with the diseases of the newborn, hematologic disorders and disorders of the endocrine system.

  6. To carry out the estimation of prognosis at the diseases of the newborn, hematologic disorders and disorders of the endocrine system in children.

  7. To demonstrate mastering the principles of medical ethics and the system of professional seniority in pediatrics.


^ STRUCTURAL MODULES


1. Fetal and neonatal medicine.

1.1. The preterm infant. Characteristic features. Feeding. Nursing.

1.2. Birth asphyxia. Birth trauma. Hypoxic-ischemic encephalopathy.

1.3. Diseases of the respiratory system in infants.

1.4. Hemolytic disease of the newborn. Hemorrhagic disease of the newborn.

1.5. Congenital Infections (TORCH). Bacterial infections in infants.


2. Hematologic disorders in children.

2.1. Anemia in children.

2.2. Hemoblastosis in children.

2.3. Hemorrhagic diseases in children.


3. Disorders of the endocrine system in children.

3.1. Diabetes mellitus in children.

3.2. Comatose conditions in diabetic children.

3.3. Thyroid diseases in children.

3.4. Disorders of hypothalamic-pituitary axis. Adrenal gland dysfunction. Disorders of sexual development in children.

PRACTICE 1

Subject: The preterm infant. Characteristic features. Feeding. Nursing.

Importance of the Subject. Frequency of preterm birth in the last two decades is 5-10% from the general amount of newborns. The neonatal death rate of low birth weight babies is high – 70% general neonatal death. Death of preterm newborns on efficiency of correct medicare, oxygen therapy and prevention of infections.


Aims of the Practice.

Goal to gain knowledge and develop skills in the following: differential diagnosing diseases of preterm newborns and developing a management plan for a child with diseases of preterm newborns.


Skills To Be Mastered

Prerequisite Knowledge and Skills

1. Identify and assess dominant syndrome of diseases of preterm newborns on the basis of complaints, anamnesis and findings of clinical examination.

1.1. Choose from anamnesis information about factors, which predispose to development of diseases of preterm newborns (as explained in the Propaedeutic Pediatrics Course).

1.2. Recognize and evaluate dominant symptoms and sings of diseases of preterm newborns during examination (as explained in the Propaedeutic Pediatrics Course).

2. Make scheme of differential algorithm of diseases of preterm newborns and assess findings.

3. Make differential diagnosis of diseases of preterm newborns.

2. Make a list of appropriate laboratory tests, diagnostic procedures and evaluate their findings (as explained in the Propaedeutic Pediatrics Course).

4. Develop a management plan for a patient with diseases of preterm newborns.


3. Analyze dominant syndromes of diseases of preterm newborns (as explained in the Propaedeutic Pediatrics Course).

4. Prescribe pathogenetic and symptomatic medications and analyze mechanisms of action of main groups of drugs which are used for a treatment of diseases of preterm newborns (as explained in the Medical Drugs Course).


Determination and Providing of Prerequisite Knowledge and Skills.


Questions for Self-Assessment of Prerequisite Knowledge and Skills.


Case 1. Newborn has gestational age of 38 weeks and body weight 2700g. The IUGR was diagnosed. Which factor could entail forming of this pathology?

  1. Fetoplacental insufficiency.

  2. Smoking of pregnant.

  3. Toksicomania of pregnant.

  4. Inferior feed of pregnant.

  5. All is transferred.


Case 2. The preterm newborn 3 days has jaundice. Physiological jaundice was diagnosed. How long does physiological jaundice of preterm newborn last?

  1. 1 week.

  2. 2 weeks.

  3. 3 weeks.

  4. 4 weeks.

  5. 5 weeks.


Case 3. A woman gave birth to full-term newborn. Which gestation age does he have?

  1. 30 weeks.

  2. 32weeks.

  3. 34weeks.

  4. 36weeks.

  5. 38weeks.


Case 4. The preterm newborn, 3-th weeks, has artificial feeding. Which formula will you recommend for feeding of this child?

    1. Nutrilon 1.

    2. Alfare.

    3. Nutrilon Pepti.

    4. Nutrilon Nenatal.

    5. Nestogen.


Answers to the Above Questions.


Case 1. E. Case 2. C. Case 3. E. Case 4. D.


Prerequisite Reading.


1. Manual of Propaedeutic Pediatrics / Nykytyuk S.O., Balatska N.I., Galyash N.B. et al.- Ternopil: TSMO, 2005.- P. 353-434.

2. Pediatry: Guidance aid (O. Tiazhka, O. Vinnitska, T. Zutay and al. – Kyiv.: Medicine, 2007.- P. 71-80.


Practice Overview in Accordance with Aims.


Theory Topics Addressed by the Practice Activities.


  1. Prematurity: definition, classification.

  2. Etiological factors of IUGR. Nursing of low birth weight babies.

  3. Ballard Scores.

  4. Features of preterm newborns thermoregulation. Prevention of hypothermia.

  5. Prevention and treatment of hypoglycemia.

  6. Hyperbilirubinemia of preterm newborns. Complications. Management.

  7. Apnea of preterm newborns. Indications for artificial lungs ventilation.

  8. Stages of nursing of preterm newborns.

  9. Features of management in polyclinic.



Flow Chart Diagram of Preterm Newborns.

(see Appendix 1)


Recommended Reading.


  1. Nelson. Essentials of Pediatrics. – 5-th ed. /[edited by] Richard E. Behrman, Robert M. Kliegman, Hal B. Jenson, Karen J, Marcdante.- Saunders, 2006.- P.301-303.

  2. A Textbook on Pediatrics .- Donetsk, 2007.- Ch.2, P.229-240.


Recommended Sequence of Activities.


Diagnostic Algorithm for Management of Low Birth Weight Babies.

(see Appendix 2)


Case-Study Test Questions.


Case 1. Newborn 1 day. He has thin, red, shiny skin, poor muscle tone, relatively large head, wide sutures and posterior fontanel. Which your conclusion?

  1. Signs of preterm newborns.

  2. Signs of full-term newborns.

  3. Signs of hydrocephalus.

  4. Signs of rickets.

  5. Signs of hypotrophy.


Case 2. Newborn has gestational age of 38 weeks. Signs: skin is pink, pure, and elastic, subcutis and turgor are not changed, two dysembryogenic stigmas are revealed. Body weight – 2700g, growth - 49 cm, head circumference -33 cm, thorax circumference -31сm. The hypoplastic type of IUGR was diagnosed. Select the most informative method of an evaluation of somatometric parameters.

  1. Centile tables.

  2. Weight / growth ratio.

  3. Visual evaluation.

  4. Dysembryogenic stigmas.

  5. Sigmal tables.


Case 3. Newborn from pregnancy proceeded with grave gestosis in second half was born at 41 weeks of gestation with weight of 2400g, growth - 50 cm, head circumference - 34 cm. At examination: skin is non-elastic, subcutis is thin, muscle hypotonia, and neonatal reflexes are reduced. Internal organs are without pathological changes. How to estimate the child?

  1. Full – term newborn with intrauterine growth retardation.

  2. Preterm newborn.

  3. Immature newborn.

  4. Over-term newborn.

  5. Full – term newborn with normal birth weight.


Case 4. Newborn has birth weight 1200 g., gestational age 29-30 weeks. RDS was diagnosed. Which method of feeding will you choose?

  1. Parenteral nutrition.

  2. Feeding from cup.

  3. Feeding from bottle.

  4. Not to feed.

  5. Brest feeding.


Answers to the above questions.


Case 1. A. Case 2. A. Case 3. A. Case 4. A.


Summary of Activities.


Prior to begin the practice class, the instructor will assess the knowledge and skills of students have mastered, by giving them some test questions to answer. After the pre-practice competence of the students has been found out as appropriate to deal with the subject matter, the students shall proceed to the self-training work under the instructor's guidance. They will interview patients and conduct patients' physical examination themselves in the wards. After that the students will explain data obtained during an objective examination and laboratory tests in the classroom. The instructor will help them identify and assess data that allow to diagnose the appropriate illness. Then the students will prescribe medications for the treatment of this illness. After all the instructor will formulate the conclusions on the subject matter of the Practice and the students shall do the final test work.



Appendix 2.

Diagnostic Algorithm for Management of Low Birth Weight Babies.




PRACTICE 2.

Subject: Birth asphyxia. Birth trauma. Hypoxic-ischemic encephalopathy.


Importance of the Subject. Neonatal asphyxia consequence due to lack of oxygen and/or lack of perfusion from no establishment of satisfactory pulmonary respiration at birth. The term birth trauma is used to denote avoidable and unavoidable mechanical and anoxic trauma, incurred by the infant during labor and delivery. Every year hundreds damaged newborns can died in neonatal period or continue their life as invalids.

Aims of the Practice.

Goal to gain knowledge and develop skills in the following: differential diagnosing neonatal asphyxia, birth trauma and developing a management plan for a child with neonatal asphyxia, birth trauma.


Skills To Be Mastered

Prerequisite Knowledge and Skills

1. Identify and assess dominant syndrome of neonatal asphyxia, birth trauma on the basis of complaints, anamnesis and findings of clinical examination.

1.1. Choose from anamnesis information about factors, which predispose to development of neonatal asphyxia, birth trauma (as explained in the Propaedeutic Pediatrics Course).

1.2. Recognize and evaluate dominant symptoms and sings of neonatal asphyxia, birth trauma (as explained in the Propaedeutic Pediatrics Course).

2. Make scheme of differential algorithm of neonatal asphyxia, birth trauma and assess findings.

3. Make differential diagnoses of neonatal asphyxia, birth trauma.

2. Make a list of appropriate laboratory tests, diagnostic procedures and evaluate their findings (as explained in the Propaedeutic Pediatrics Course).

4. Develop a management plan for a patient with neonatal asphyxia, birth trauma.


3. Analyze dominant syndromes of neonatal asphyxia, birth trauma (as explained in the Propaedeutic Pediatrics Course).

4. Prescribe pathogenetic and symptomatic medications and analyze mechanisms of action of main groups of drugs which are used for a treatment of neonatal asphyxia, birth trauma (as explained in the Medical Drugs Course).


Determination and Providing of Prerequisite Knowledge and Skills.


Questions for Self-Assessment of Prerequisite Knowledge and Skills.


Case 1. There is cephalohematoma at term newborn from the first pregnancy, complicated delivery. How to explain of this pathology?

    1. Asphyxia.

    2. Subperiostal hemorrhage.

    3. Intracranial hemorrhage.

    4. Hydrocephalus.

    5. Meningitis.


Case 2. The newborn has following findings at the first minute of life: hart beat 100 per minute, breathing – 20 per minute.

1. How do you estimate frequency of hart beat?

  1. Bradycardia.

  2. Tachycardia.

  3. Norm.





2. How do you estimate frequency of breathing?

  1. Bradypnea.

  2. Tachypnea.

  3. Norm.






Case 3. The newborn at 36 hours of age develops hypotension, bradycardia, cyanosis, tense anterior fontanel. The most appropriate diagnostic test is:

  1. Echocardiography.

  2. Serum coagulation profile.

  3. Neurosonography.

  4. Electrocardiography.

  5. Complete blood count.


Case 4. The newborn has Apgar Score at first minute – 2 balls. Artificial respiration was marked. Which drugs are prescribed a child?

  1. Cytostatic drugs.

  2. Vitamins.

  3. Corticosteroids.

  4. Sedative.

  5. Drugs for normalization of oxidation-reduction processes.


Answers to the Above Questions.


Case 1. B. Case 2.1. A. Case 2.2. A. Case 3. C.

Case 4. E.


Prerequisite Reading.


  1. Manual of Propaedeutic Pediatrics / Nykytyuk S.O., Balatska N.I., Galyash N.B. et al.- Ternopil: TSMO, 2005.- P. 353-434.

  2. Pediatry: Guidance aid (O. Tiazhka, O. Vinnitska, T. Zutay and al. – Kyiv.: Medicine, 2007.- P. 53-61.


Practice Overview in Accordance with Aims.


Theory Topics Addressed by the Practice Activities.


  1. Criteria of asphyxia.

  2. Pathogenesis of asphyxia.

  3. Apgar Score.

  4. Neonatal resuscitation (A,B,C,D – resuscitation).

  5. Birth injury. Etiology.

  6. Soft-tissues injuries.

  7. Birth injury of peripheral nerves.

  8. Differential diagnosis of intracranial hemorrhages.


Flow Chart Diagramme of Neonatal Asphyxia.

(see Appendix 1).


Recommended Reading.


  1. Nelson. Essentials of Pediatrics. – 5-th ed. /[edited by] Richard E. Behrman, Robert M. Kliegman, Hal B. Jenson, Karen J, Marcdante.- Saunders, 2006.- P.323-325.

  2. A Textbook on Pediatrics .- Donetsk, 2007.- Ch.2, P.213-223.


Recommended Sequence of Activities.


Management Algorithm for Neonatal Resuscitation.

(see Appendix 2).


Case-Study Test Questions.


Case 1. There is cephalohematoma at term newborn born from the first pregnancy, complicated delivery. It has appeared jaundice since 2nd day, changes in neurological status since 3rd day - nystagmus, Grefe symptom.  Urine and stool are yellow. Group of blood of the mother A(II) Rh+, child’s - A(II) Rh+. Bilirubin level at third day  - 258 mcmol/l (indirect). How to explain the jaundice?

  1. Atresia of bile ducts.

  2. Physiological jaundice.

  3. Haemolytic disease of newborn.

  4. Fetal hepatitis.

  5. Cranial haemorrhage.


Case 2. A newborn has the following findings at 5 minutes of life: hart beat 130 per minute, cyanosis hands and feet, good muscle tone, strong cry and grimace. This infant’s Apgar Score is:

    1. 6.

    2. 7.

    3. 8.

    4. 9.

    5. 10.


Case 3. Baby girl was born by vaginal delivery. His birth weight was 3900 g. There were difficulties in delivery of the shoulder. The baby does not move the arm freely at the left side. There is tenderness in the left supraclavicular region. The most likely diagnosis is:

  1. Dushen’s - Erb’s paralysis.

  2. Desherin’s - Klumke paralysis.

  3. Fracture of left claviculae.

  4. Fracture of humerus.

  5. Upper paraparesis.


Case 4. The child was born from ІІ pregnancy at the woman of 35 years which suffers from hypertonic disease. Delivery ІІ, amniotic fluid contents meconium. Umbilical cord was wound round the neck. Apgar score on 1 minute - 2 balls. The breathing is not present. The newborn requires primary reanimation. Which operation carries out earlier?

  1. Suck out the mucus and tracheal contents under the visual control.

  2. Artificial lung ventilation with bag and mask.

  3. Artificial lung ventilation through intubation.

  4. Inhalation of 100 % oxygen.

  5. Catheterization of umbilical vein.


Answers to the above questions.


Case 1. E. Case 2. C. Case 3. C. Case 4. A.


Summary of Activities.


Prior to begin the practice class, the instructor will assess the knowledge and skills of students have mastered, by giving them some test questions to answer. After the pre-practice competence of the students has been found out as appropriate to deal with the subject matter, the students shall proceed to the self-training work under the instructor's guidance. They will interview patients and conduct patients' physical examination themselves in the wards. After that the students will explain data obtained during an objective examination and laboratory tests in the classroom. The instructor will help them identify and assess data that allow to diagnose the appropriate illness. Then the students will prescribe medications for the treatment of this illness. After all the instructor will formulate the conclusions on the subject matter of the Practice and the students shall do the final test work.


Appendix 1.


Flow Chart Diagramme of Neonatal Asphyxia.
Differential diagnosis

Congenital hart failure



Anamnesis

Asphyxia

Secondary

Acid – alkaline state

Blood test

Neurosonographia

TORCH - infections

Acute adrenal insufficiency

A, B, C, D resuscitation

Primary



Appendix 2


Management Algorithm for Neonatal Resuscitation.




PRACTICE 3.

Subject: Diseases of the respiratory system in infants.


Importance of the Subject. The most critical and immediate physiologic change required of the neonate is onset breathing. Diseases of respiratory system in newborns are inflammatory and noninflammatory. They are accompanied respiratory insufficiency. It is syndrome of respiratory disorders (SDR) or respiratory distress.


Aims of the Practice.

Goal to gain knowledge and develop skills in the following: differential diagnosing diseases of respiratory system in newborns and developing a management plan for a child with diseases of respiratory system in newborns.


Skills To Be Mastered

Prerequisite Knowledge and Skills

1. Identify and assess dominant syndrome of diseases of respiratory system in newborns on the basis of complaints, anamnesis and findings of clinical examination.

1.1. Choose from anamnesis information about factors, which predispose to development of diseases of respiratory system in newborns (as explained in the Propaedeutic Pediatrics Course).

1.2. Recognize and evaluate dominant symptoms and sings of diseases of respiratory system in newborns during examination (as explained in the Propaedeutic Pediatrics Course).

2. Make scheme of differential algorithm of diseases of respiratory system in newborns and assess findings.

3. Make differential diagnoses of diseases of respiratory system in newborns.

2. Make a list of appropriate laboratory tests, diagnostic procedures and evaluate their findings (as explained in the Propaedeutic Pediatrics Course).

4. Develop a management plan for a patient with diseases of respiratory system in newborns.


3. Analyze dominant syndromes of diseases of respiratory system in newborns (as explained in the Propaedeutic Pediatrics Course).

4. Prescribe pathogenetic and symptomatic medications and analyze mechanisms of action of main groups of drugs which are used for a treatment of diseases of respiratory system in newborns (as explained in the Medical Drugs Course).



Determination and Providing of Prerequisite Knowledge and Skills.


Questions for Self-Assessment of Prerequisite Knowledge and Skills.


Case 1. The preterm newborn has surfactant deficiency. Which pathological changes will register in lungs of this infant?

  1. Edema.

  2. Atelectasis.

  3. Emphysema.

  4. Bronchospasm.

  5. Lymphostasis.


Case 2. The preterm newborn has breathing of type of “swings”. Breathing of type of “swings” is:

  1. Retraction of xifoid appendix at inspiration.

  2. Retraction of xifoid appendix at expiration.

  3. Intercostal retraction inspiration.

  4. Intercostal retraction expiration.

  5. Periodic apnea.


Case 3. The initial examination of preterm newborn revealed bilateral reticulogranular pattern and air bronchogram at chest X-ray. Chest X-ray is typical for:

  1. Pneumotorax.

  2. RDS.

  3. Pneumonia.

  4. Atelectasis.

  5. Aspiration syndrome.


Case 4. The patient is a 10-hour-old newborn. A hyaline membrane disease was diagnosed. Which pathogenic drugs will help to compensate a surfactant deficiency?

  1. Antibiotics.

  2. Vitamins.

  3. Synthetic substitutes of surfactant.

  4. Solution of glucose.

  5. Corticosteroids.


Answers to the Above Questions.


Case 1. B. Case 2. A. Case 3. B. Case 4. C.


Prerequisite Reading.


  1. Manual of Propaedeutic Pediatrics / Nykytyuk S.O., Balatska N.I., Galyash N.B. et al.- Ternopil: TSMO, 2005. - P. 353-396.

  2. Pediatry: Guidance aid (O. Tiazhka, O. Vinnitska, T. Zutay and al. – Kyiv.: Medicine, 2007.- P. 37-107.


Practice Overview in Accordance with Aims.


Theory Topics Addressed by the Practice Activities.


  1. Risk factors for RDS. Surfactant system of lungs. Prenatal prevention of RDS.

  2. Assessing the severity of respiratory insufficiency in RDS. Silverman and Downes Retraction Scores.

  3. Clinical and chest X-ray presentation of RDS.

  4. Treatment of RDS. Surfactant therapy.

  5. Pneumonias at newborns. Etiology. Classification.

  6. Risk factors for pneumonias at newborns. Pathogenesis.

  7. The features of pneumonias of newborns.

  8. Treatment of pneumonias of newborns.


Flow Chart Diagramme of Respiratory Distress Syndrome.

(see Appendix 1).


Recommended Reading.


  1. Nelson. Essentials of Pediatrics. – 5-th ed. /[edited by] Richard E. Behrman, Robert M. Kliegman, Hal B. Jenson, Karen J, Marcdante.- Saunders, 2006.- P.304-305.

  2. A Textbook on Pediatrics .- Donetsk, 2007.- Ch.2, p.241-249.


Recommended Sequence of Activities.


Diagnostic Algorithm for Pneumonia of Newborns.

(see Appendix 2)


Case-Study Test Questions.


Case 1. The chest X-ray examination of preterm newborn revealed a diffuse atelectasises. Which possible reason of this pathology?

  1. Pneumonia.

  2. Bronchial asthma.

  3. Bronchiolitis.

  4. Deficiency of surfactant.

  5. Tuberculosis.


Case 2. Newborn has birth weight of 2000g. Gestational age - 30 weeks. In three hours after birth it has appeared dyspnoea, acrocyanosis. RR - 80 per 1 min, expiratory murmurs, HR - 186 per 1 min. There is shortening of sound under lung percussion, crepitation under auscultation. The doctor has suspected a respiratory distress-syndrome. Which investigation will confirm the diagnosis?

  1. X-ray examination of chest.

  2. Analysis of blood.

  3. Evaluation on a Silverman score.

  4. Evaluation on an Apgar score.

  5. Electrocardiography.



Case 3. The child of 2 days which was born on the 34th week of  gestation with weight 2200g, Apgar score 6 balls has respiratory disorders as retraction of xiphisternum and intercostal interspaces, movement of nares in breathing. There are no changes at percussion, at auscultation - moist variable rales at both hemithoraxes. The congenital reflexes are normal. Acrocyanosis. Indicate the most probable cause of respiratory disorder.

  1. Primary lung atelectasis.

  2. Hyalinic membrane disease.

  3. Birth trauma.

  4. Congenital pneumonia.

  5. Aspiration syndrome.


Case 4. The 1-hours old 32-weeks-gestational age newborn develops progressing cyanosis, grunting, flaring, retraction. The chest X-ray reveals a ground glasses-air bronchogram pattern. The most appropriate therapy is:

  1. Oral indomethacin.

  2. Intravenous dexamethasone.

  3. Intramuscular vitamin E.

  4. Endotracheal surfactant.

  5. Intravenous sodium bicarbonate.


Answers to the above questions.


Case 1. D. Case 2. A. Case 3. B. Case 4. D.


Summary of Activities.


Prior to begin the practice class, the instructor will assess the knowledge and skills of students have mastered, by giving them some test questions to answer. After the pre-practice competence of the students has been found out as appropriate to deal with the subject matter, the students shall proceed to the self-training work under the instructor's guidance. They will interview patients and conduct patients' physical examination themselves in the wards. After that the students will explain data obtained during an objective examination and laboratory tests in the classroom. The instructor will help them identify and assess data that allow to diagnose the appropriate illness. Then the students will prescribe medications for the treatment of this illness. After all the instructor will formulate the conclusions on the subject matter of the Practice and the students shall do the final test work.


Appendix 1.


Flow Chart Diagramme of Respiratory Distress Syndrome.

Anamnesis

Clinical signs

  1   2   3   4   5   6

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