Pediatrician最新文献

The aggressive use of multiple therapeutic modalities has led to a significant increase in the number of survivors of childhood malignancy. These forms of cancer therapy have important effects on multiple organ systems. This review article evaluates the long-term effect of therapy on the reproductive potential of both boys and girls. While alkylating agents have been shown to cause a 50% reduction in the fertility potential of boys, they have almost no adverse effect in girls. Other chemotherapeutic agents and combinations of chemotherapeutic agents have also been shown to cause a greater reduction in the reproductive potential of girls than boys. Radiation produces severe dose-related gonadal damage in both boys and girls. The effect of Hodgkin's disease, leukemia and their therapies are evaluated. Despite the known mutagenic potential of some forms of cancer therapy there has not been an increased frequency of congenital abnormalities in the offspring of survivors of childhood cancer. The use of oophoropexy and other forms of prophylactic therapy to limit toxicity are also considered.

Intelligence and academic achievement testing of long-term survivors of childhood cancer reveal a high incidence of memory deficits, visual-spatial skill impairment, and attention deficit disorders. While the results of various studies must be interpreted carefully, the data available identify CNS irradiation and the toxic synergism of CNS irradiation and intrathecal chemotherapy as primary etiologic factors in the neuropsychologic sequelae of curative therapy. Early education intervention is mandatory to identify survivors of childhood cancer who require assistance in overcoming intellectual disabilities.

Atopic dermatitis is common and causes sleep loss, a disfiguring appearance, an unpleasant odour, teasing, short stature and restriction of career choice in severe cases. There are no drugs which control the scratching; distraction, keeping the nails short and smooth, and the use of mittens at night are all helpful. The sedative action of the older H1 antihistamines makes them useful if scratching prevents a child from falling asleep. Emollients are useful for the associated skin dryness. The least potent topical steroids should be used sparingly to avoid the main hazards of skin atrophy, systemic absorption and growth stunting. Bacterial skin infection with Staphylococcus aureus and sometimes beta-haemolytic streptococci is common and is best treated with oral antibiotics. Herpes simplex virus skin infection is also common; the initial infection occasionally causes a lethal (if untreated) illness. Allergy to house dust mites, pet animals, pollen and food can worsen dermatitis in some cases. There is no test however, which can be used to predict those patients who will respond to avoidance measures, so that management tends to be based on empirical trials of antigen avoidance. Seborrheic dermatitis is a common disorder that usually occurs in the first months of infancy. Findings consist of greasy yellow scales on the scalp (most simply treated with an emollient) and well-demarcated erythematous patches in the diaper area that spread to other areas such as the axillae and neck (usually requiring topical steroids). Some cases go on to develop atopic dermatitis, but many others, although florid, resolve spontaneously.

Erythema multiforme minor is an acute, self-limited cutaneous or mucocutaneous disorder. Although it most commonly afflicts young adults, it is also frequently seen in children. An antecedent infection with herpes simplex virus is often the precipitating factor. Recent studies detailing the usual clinical course and histologic features of erythema multiforme minor, together with investigative studies examining potential pathomechanisms, have begun to provide a clearer picture of this disease process such that a more rational approach to therapy is now possible.

The infant and preschool child with asthma present a unique challenge to the physician responsible for their medical care. Asthma is common in childhood, and estimates of its prevalence in infants and children below the age of 2 years range from 5 to 10%. Despite significant medical advances in the treatment of acute asthma and in the maintenance therapy of the stable asthmatic, reports indicate that morbidity from asthma is on the increase. A clear understanding of the pathophysiologic mechanisms involved, and the array of management possibilities will allow the physician to develop a therapeutic strategy which is suitable for the child and family. With an organized rational approach, the management of the young asthmatic can be a rewarding and pleasant experience for the child, family and physician.

Asthma remains a major cause of morbidity and an occasional cause of mortality in children despite greatly increased knowledge of its pathophysiology and newer improved medications. Management of asthma requires consideration of the two components of airway obstruction, spasm of bronchial smooth muscle and inflammation resulting in mucosal edema and mucous secretions. The pharmacologic alternatives include medications that relax bronchial smooth muscle, prevent the release of mediators that induce bronchospasm and inflammation and anti-inflammatory corticosteroids that can reverse or prevent the inflammatory component of asthma. Therapeutic decisions in asthma also require consideration of the clinical pattern of disease which can be classified as intermittent, seasonal allergic or chronic. Therapeutic strategies for the use of pharmacologic agents include intervention measures for reversal of acute symptoms and maintenance measures to prevent symptoms. While all patients need available intervention measures to reverse acute symptoms when present, only those patients with prolonged periods of symptomatology, i.e. seasonal allergic or chronic, require pharmacologic agent for maintenance therapy. When evaluation identifies environmental factors as clinically important precipitants of asthma, appropriate environmental manipulation offers a potentially useful nonpharmacologic approach to therapy. The use of injections of allergenic extracts in selected patients with appropriate inhalant allergen sensitivity offers an immunologic approach for decreasing symptoms in patients with a predominant inhalant allergic component to their disease. Success in the treatment of asthma requires careful consideration of health care delivery. Available measures, when appropriately delivered to the patients when needed, have been convincingly demonstrated to greatly decrease morbidity.

During the last decade, research on the behavioral aspects of childhood asthma has focussed on three goals: (1) learning how families manage asthma at home and use health care services; (2) identifying specific problems they encounter in managing asthma, and (3) developing and evaluating educational programs to teach families to overcome these problems and to manage asthma effectively in the home environment. This paper will describe the research findings on the problems families face in managing asthma, review the available and evaluated health education programs that have been developed to solve them and suggest strategies for physicians and other health care providers to incorporate health education into routine office care for asthma.

Vascular nevi occur in up to 70% of infants. The term includes hemangiomas, of which the majority involute, and vascular malformations, such as port wine stains which tend to persist. The appearance, and in some cases rapid growth of the lesion, may be alarming to the parents and may cause great distress to the patient. In rare cases systemic involvement and associated abnormalities may be life threatening or permanently disabling. Correct diagnosis of the type of lesion is vital to know the prognosis of the lesion, the likelihood of complications and whether investigations and treatment are indicated.

Nocturnal enuresis is a common, largely inherited condition wherein children involuntarily pass urine while asleep. What is inherited appears to be a mild maturational delay that expresses itself partly in terms of growth and development and primarily in terms of diminished urinary control. Drugs are the most frequently used treatment but the recent literature shows that they are inappropriate as a primary treatment because of potential risks to child health and/or questionable long-term effectiveness. Effective treatment requires the specific teaching of continence skills, and several behavioral methods suitable to that purpose are described in this paper.