Pediatrician最新文献

Challenging 'out of hospital' participation in camping and recreational activities has a significant impact on the lives of children with chronic illness and disabilities. Planning these special programs requires attention to resources, population needs, staff training, financing, equipment needs, liability issues and participant selection.

Partial or complete repetitive obstructions of the upper airway during sleep give rise to clinical symptoms associated with heavy, chronic snoring. The number of obstructive sleep apneas during the night may be less important than the repetitive inspiratory increases in upper airway resistance, even if these are associated only with a partial airway collapse. Oxygen saturation may not be severely affected by partial occlusion during nocturnal recording, although clinical symptoms may occur. Esophageal pressure measurements and breathing frequency during sleep are key features in the polygraphic evaluation of prepubertal children. Tonsillectomy and adenoidectomy may be helpful in treating children with small upper airway during sleep. The marked interaction between upper airway adequacy and craniofacial morphology make it critical to evaluate the impact of partial or complete airway occlusion during sleep on facial prognathism. Nasal continuous positive airway pressure is a safe treatment for persistent, partial or complete upper airway occlusion during sleep, but it does not address the mandibular deficiency often seen in symptomatic children. Orthodontic evaluation and treatment may make maxillomandibular surgery unnecessary during the pubertal years.

An increase in the rate of injuries has accompanied the boom in sports participation among children and adolescents. Accurate diagnosis, prompt treatment, and comprehensive rehabilitation are keys to the safe return of the young athlete to sports. Reacquisition of flexibility, strength, and endurance forms the basis of reconditioning. A graded reacclimatization to the demands of the sport allows the athlete to attain the preinjury level of skill. Psychological ramifications of injury such as fear, anger, and depression are to be expected and must be dealt with appropriately.

Disabled teenagers have problems making the transition from adolescence to adulthood. Helping parents, particularly mothers, 'let go' is an important part of the medical management, as is coordinating the complex medical, social, and educational aspects. Issues of bowel and bladder care, sexuality, dating, dressing, and driving must be considered. Role modeling by successful disabled adults and counseling assist in successful transition.

Most studies of adolescent sleep habits show a pattern of decreasing total sleep time, a tendency to delay the timing of sleep, and an increased level of daytime sleepiness. Laboratory tests have shown that adolescents do not have a decreased need for sleep but probably need more sleep than prepubertally. A number of factors affect the development of adolescent sleep patterns. Puberty itself imposes a burden of increased daytime sleepiness with no change in nocturnal sleep. Parental involvement in setting bedtimes wanes, though they become increasingly involved in waking teenagers in the mornings. Curfews and school schedules also affect adolescent sleep patterns, seen most commonly as imposing earlier rise times as the school day begins earlier during the adolescent years. Part-time employment has a significant impact on the sleep patterns of teenagers: those who work more than 20 h each week sleep less, go to bed later, are more sleepy, and drink more caffeine and alcohol. Development of circadian rhythms may also play a role in the phase delay teenagers commonly experience. The primary conclusion is that many adolescents do not get enough sleep. The consequences of the chronic pattern of insufficient sleep are daytime sleepiness, vulnerability to catastrophic accidents, mood and behavior problems, increased vulnerability to drugs and alcohol, and development of major disorders of the sleep/wake cycle. Educational programs hold the promise of improving teenagers' sleep patterns through informing youngsters, parents, and pediatricians about proper sleep hygiene and the risks of poor sleep habits.

Our impulse in medicine is to furnish help and comfort to the human beings who come to us, and to do so by using whatever technology is appropriate. This intuitive feeling is challenged by certain medical ethicists. Their principles, however, must be combined.

The social climate of the past 3 decades has resulted in an increased interest in empowering children to participate in their own health care. Research conducted over the past 18 years by the authors suggests that children are quite competent to enter into programs that are child-centered and family-oriented, whose objectives are to teach children decision making, and to transfer increasing control over decision making related to health matters to the child. These studies indicate that children learn decision-making skills, and apply them quite competently, especially when the scope of decision making is clearly defined. Despite the evolution of programs that have been demonstrated by randomized control trials to effectively reduce the utilization of emergency rooms and hospitals by children with asthma, such programs have not diffused widely, not even into pre-paid health plans. Experience with two such programs indicates that the principle resistance to diffusion derives first from physicians, who are reluctant to share power with adult patients, let alone children, and even some of the parents themselves whose roles are threatened by such efforts.

Philosophical questions are critical to a broader conceptualization of parenting and childhood maltreatment, whether it is neglect or abuse, because they allow a reconsideration of established institutional models and the constitution of alternative approaches. Examining five areas where philosophical discussion may change the conceptual approach of practitioners--epistemology, certainty, causality, ethics and aesthetics--this paper attempts to provide an agenda for future research and experimentation.