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📷 | [Leaving babies one after another] "I was using a camera app for watching" I left my eldest son, XNUMX months old


Photo [Leaving babies one after another] "I was using a camera app for watching" I left my eldest son, XNUMX months old

[Leaving babies one after another] "I was using a camera app for watching" I left my eldest son, XNUMX months old

 
If you write the contents roughly
Pediatricians point out that the effectiveness of the camera is "a condition that you can get it right away."
 

A XNUMX-year-old man and a XNUMX-year-old woman in Sapporo were arrested for leaving their eldest son, who was seven months old, at home for about eight hours. … → Continue reading

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Wikipedia related words

If there is no explanation, there is no corresponding item on Wikipedia.

Pediatrics

Pediatrics(Sorry,English: pediatrics) IsNewbornからpubertyClinical practice and research for (about 15 years old, up to the third grade of junior high school)Medical scienceOne field.

Target age classification

It is divided as follows according to the time after birth.

Nameseason
NewbornLess than 28 days after birth
infant28 days to under 1 year old
An infantFrom 1 year oldprimary schoolPreschool
School children<span>Grade 1-2</span>

After that, according to the classification by "junior high school" or age itself, or according to growthpubertyUse classifications such as.What is puberty?Secondary sex characteristicsPoints from the beginning to the end of.

The age of consultation in pediatrics is generally up to about 15-20 years old, but if you have a chronic illness peculiar to pediatrics even after 20 years old, you are often used in pediatrics for that illness.

History

originallyEnglishof"pediatrics(Pediatrics) "Greek languageof"paidos(Boy) "and"iatros(Doctor) "is derived from the word.

As far as it is generally known, since the beginning of the 19th century, it has been used as a field for medical research on diseases peculiar to children.Internal MedicineIt has a history of development and separation from.

In each country at the beginning of the 20th century学会Has been established as an independent medical field.

CurrentlysurgicalIndependent to handle pediatric diseases from departments other than internal medicinePediatric surgeryThere are also specialized hospitals in Japan that handle pediatric cardiovascular surgery (pediatric cardiovascular surgery), pediatric orthopedics, pediatric ophthalmology, pediatric otolaryngology, and pediatric urology as subdivisions.

Field

Pediatrics is a classification of internal medicine by age group, and inevitably allOrganDisease ofInfectionAnd so on.

As a qualification to represent a pediatric expert, in JapanJapanese Pediatric SocietyCertifying physician,Japanese Society of Pediatrics SpecialistExists.Doctor's licenseOnly those who have a certain level of experience and career in pediatrics are eligible to take the exam and can be obtained by passing the exam.

In addition, there are specialists as subdivisions in genres that require a high degree of specialization in diseases by organ.

As of 2008, the number of pediatric specialists in Japan

  • Japanese Pediatric Neurology Specialist
  • Japanese Society of Pediatric Cardiology Specialist
  • Japanese perinatal and neonatal medical society specialist

Exists.

The genres in pediatrics by cause and organ are introduced below.The classification of genres varies from country to country and from book to book.

Growth and development

Growth and development are similar terms, but development indicates neurological maturity.Development is assessed by neurological findings such as reflexes and movement.Growth is a term that means the maturity of the physique.Parameters such as height, weight, head circumference, and abdominal position are used, but it is considered that there is almost no problem in growth if the weight is about age x 2 + 8 kg for infants to school children, especially in the lower grades.

Reflexes that are recognized and disappear in newborns

It is thought that the purpose of the disappearance of these reflexes is that the disappearance of the reflexes makes the hands and feet dexterous and promotes the development of movement.The following are known as hand reflexes.

Reflection nameAppearance timeMessage
Palm grasp reflexNewborn ~ 4 monthsWhen the palm is pressed, the fingers bend. (Disappears when you hold an object)
Newborn ~ 4 monthsInserting a finger into the mouth causes regular suction movements.Rubbing the corner of the mouth from the upper lip makes the mouth sharp. (Disappears at the time of weaning)
Moro reflexNewborn ~ 4 monthsWhen the head is dropped, both hands are extended and the abducted hand is opened. (Disappears when the neck sits)
Sole grasp reflexNewborn ~ 10 monthsWhen you press on the sole of your foot, your fingers bend. (Disappears when standing)
Babinski reflectionNewborn ~ 2 years oldRubbing the lateral part of the sole causes the hallux to bend dorsiflexively and widen the width of the other toes.

Reflexes that are not seen in newborns and appear with development

It is thought that when they appear, they will be able to turn over and hi-hi.

Reflection nameAppearance timeMessage
Tension cervical reflex1 to 6 monthsWhen the neck is turned sideways, the upper and lower limbs on the same side extend and the opposite side bends. (Disappears when you can turn over)
Landau reflex6 months to 2 years oldWhen the baby is held horizontally and the neck is raised, the trunk and lower limbs are extended, and when the abdomen is bent forward, the trunk and lower limbs are flexed. (Reflection for hi-hi)
Parachute reflex8 months ~ permanentWhen the lifted child is dropped in the hand, the child defensively extends both upper limbs and fingers.

Behavioral development

The Denver II Development Judgment Table is famous.

Coarse exercise (trunk)Fine movement (limbs)言语Social
1 monthsTurn your face to the left or right
3 monthsRaise your face in the prone position, where your neck sits.Bring your hand to your mouth, grab a rattleLaugh aloud, turn to the voice, look afterStare at my mother's face
6 monthsTurn over, sit downHold things from hand to hand, take them with a cloth on your faceRepeat Babbling and BabblingIdentify and shy mothers
10 monthsDo high-high, grab and standPinch with your thumb and index finger, take out the building blocks from the boxWhen you call your name, you turn around and imitateFollow my mother
1Stand alonePut building blocks in the boxDo a bye-bye action by saying two or more meaningful words
1 years 6 monthWalk the stairs when you pull your handScribble to stack two blocksRefers to the part of the body that expresses a wordDrink with a glass
2Walk the stairs, run on level groundStack 4 blocksSpeak two wordsUse a spoon
3Standing on one leg, riding a tricycleWrite a circle, take off your shoes and jacketYou can say the name when you askUse chopsticks, you can wear pajamas
4You can do itWrite a square, you can use scissorsRead your nameHide and seek, rock-paper-scissors
5Skip, stand up and goDraw a triangle and cut over the line with scissorsShiritori can be doneCompete with friends

Medical checkup

A health checkup is one of the services for screening these growths and developments.In the case of Japan, there is a one-month examination, and there are health examinations for three-month, six-month, nine-month, twelve-month, and three-year-old children. The Ameriacan Academy of Pediatrics is characterized by a large number of times such as 1 weeks, 3 month, 6 months, 9 months, 12 months, 3 months, and 2 months.This difference in frequency is thought to be related to the length of hospital stay for normal deliveries.In the United States, the hospitalization period is 1 days for vaginal delivery and 2 days for Caesarean section, but in Japan, the hospitalization period is 4 to 6 days.Therefore, in Japan, there is plenty of time for newborn babies to be examined, and breast milk guidance and jaundice evaluation can be performed.for that reason,Medical checkupIt is said that the number of times can be reduced.Breastfeeding is 1 minutes at a time, 20-8 times daily.Insufficient nutrition often causes babies to cry and fall asleep tired of crying.Eventually, weight gain will be poor.Usually, weight gain after physiological weight loss is 12-20 g / day.Even if a 30% (2300g) weight loss of an average weight of 7g is shown 230-3 days after birth, it should recover within 5 weeks.If this is not the case, there is a high probability that there is a problem with breastfeeding and guidance is needed. After one month, it is too late to evaluate it, and inappropriate breastfeeding often becomes a habit for both mothers and children.In addition, newborns sleep, nourish, excrete, and sleep repeatedly up to 2 weeks after birth, and the reason for crying is easy to understand and deal with, but after 1 weeks, night crying begins.Night crying means crying for 2 hours more than 2 times a week for a total of 3 weeks or more.It happens only between 3 o'clock in the evening and 3 o'clock in the middle of the night, and remedies such as feeding milk, changing diapers, and comforting are invalid. After about a month, mothers are also at risk of developing postpartum depression.In the United States, these instructions are given by health examination, but in Japan, they are often given in the mother's class during childbirth and hospitalization.Diarrhea, vomiting,jaundice, Fever, rash,ConjunctivitisIt is not common to see a medical institution at the time of appearance, and to add new guidance until a one-month examination at other times.The mother's one-month screening also includes a self-assessment table for postpartum depression in Edinburgh as a screening for postpartum depression.

walking

According to the Denver Development Judgment Method, 1% of children will be able to walk well after 5 year and 90 months.If you cannot walk at this time, it will be quite slow to start walking and you will need to see a specialized institution.The same scrutiny is required if there is a delay in sitting, sitting, or holding at the age of 6 in the previous 1 months.In this case, congenital anomalies or pervasive developmental disorders are suspected.In mild mental developmental abnormalities, no intellectual delay is observed during this period, and only muscle weakness is observed, and follow-up is often observed.In this case, it is very difficult to treat the delay and social support is needed.However, the frequency is benign developmental delay called shuffler (Izari child), and then development catches up and normalizes.Children who walk strangely and easily fall even if the time to start walking is normal, specifically, petapeta walking, varus walking (uchiwa walking), valgus walking (sotowa walking), equinus walking, etc. are observed. If you have muscle disease,Cerebral palsy,Ataxia, Skeletal abnormalities may be observed and require close examination.

言语

Four conditions are required for normal language development.First, the vocal and articulatory organs are normal.The development of intelligence for the purposeful use of these organs.There is a suitable place to learn purposeful use.There is no problem with auditory and visual functions. By about 4 months (6 months as a guide), he turns around when his name is called, and laughs aloud when he is an inaniver. By eight months, shyness had begun, and he was speaking a babbling as if he were speaking.The way you make a voice also becomes stronger and weaker. Around 3 months, simple instructional actions will be possible.It reacts to pointing, and when you come, it also acts as if you come high and high. Even if you can say that you are a dad at the age of 8, there are quite a few elements that you cannot be sure of, such as your mother being a dad, but when you reach about 10 year and 1 months, you can express your emotions and express "no" or a bilingual sentence appears. To do. These are often completed at the age of two.

weaning

Breast milk contains immunoglobulins even after the age of one and is excellent in terms of infection protection.There is a culture in child-rearing, and it is difficult to find a medical basis.Since the sucking reflex disappears in about 1 months, it is common to introduce baby food around 4 months from this time.It doesn't matter how long you drink breast milk, but from a nutritional point of view, it is desirable that the main nutrition be provided by baby food other than breast milk by 6 months.There is no problem with graduating by this time.In Pakistan and other countries, they are taking regular curry at 12 months.

excretion

There is also a culture regarding excretion control.In the past, Japan was scarce of substances and promoted the independence of excretion very early.Toilet training used to start from 4 months for stool and 12 months for urine.However, with this method, there were some cases where the diapers dropped out at a certain rate and returned to the use of diapers.Toilet training in the order of night stool, daytime stool, daytime urine, nighttime urine If you start training after 2 years old, 4% at 77 years old and 6% at 91 years old will be able to clean up by themselves become.Training before this is said to be almost unchanged on average.

Neonatal disease

Infant respiratory distress syndrome (RDS)
Infant respiratory distress syndromePulmonary surfactantHappens due to lack ofsyndrome.lungIt is caused by the lack of pulmonary surfactant secreted from type II alveolar epithelial cells, which causes the lungs to collapse due to the surface tension of the alveoli.When the lungs contract at the end of exhalation of breathing, the alveoli lose the surface tension of the alveoli and collapse.When an alveoli collapses, blood flow to the alveoli decreases, surfactant production decreases, and surface tension decreases, creating a vicious cycle.As a symptom, breathe small and frequently so that the lungs do not collapse.Frequent breathing is called tachypnea.Breathe on average with large lungs so that the lungs do not collapse.The stomach is noticeably dented to take more breath from a large state.Breathing while denting your stomach is called depressed breathing.When you exhale so that your lungs do not collapse, close your throat and mouth, and exhale while holding your breath as you would when you moan.Exhaling while holding your breath is called shingin.Due to insufficient oxygenation of the lungsCyanosisCome on.Chest as an examinationRadiographExamination shows a mixture of functioning alveoli and crushed alveoli.This is a characteristic finding of neonatal respiratory distress syndrome.Only the bronchi are highlighted due to the collapse of the alveoliBronchial Torusuke statueMay be visible.Intrapulmonary injection of surfactene is effective for treatment.
Meconium aspiration syndrome (MORE)
Meconium aspiration syndrome occurs by inhaling meconium into the lungs.syndrome.
(,,,,)
Symptoms similar to respiratory urgency syndrome are exhibited 2-3 weeks after birth.

Birth defects / malformations

Malformative syndromeAlso called multiple on one of the bodiesMalformationThe name of the disease is given to each person who has a certain tendency.Most are thought to develop due to genetic problems, and in recent yearsGeneticsMany genes have been elucidated by the progress of.Symptoms are already fixed at birth when the body has finished developing, and there are generally few treatments.For some diseasesBrain surgery-Plastic surgeryThe function and plastic surgery may be corrected by conventional surgery.If you have a strong intelligence or physical disabilityリ ハ ビ リ テ ー シ ョ ンSubject to.

Social due to characteristic appearance and intellectual disability found in many casesDiscriminationI have read many problems from the past because it is easy to be the target of.also,Down syndromeIs relatively frequent and many stories have been made.However, there are certainly, but not all, syndromes with intelligence problems.It is thought that the reason why there are many problems with intelligence is that many genes are involved in the development, differentiation, and metabolism of nerves.Pediatric neurologists are often in charge clinically because of the relatively large impact on intelligence.

In reality, there are many cases for which the name of the disease has not been determined, and there are more than 4000 types for which the name of the disease has been determined.It is thought that about 200 types are recognized by clinical specialists in a relatively large number.The classification is not clearly defined, but it is described separately below.

Infection

The characteristics of pediatric infectious diseases are for adults

  • Many primary infections
  • Immune is immature or special and has the same causemicroorganismBut it can have different symptoms than adults
  • The course is faster and recovers faster than adults

Features such as.InfectionIs one of the most common pediatric outpatients, and its symptoms areFever-cough-Vomiting-diarrheaThere are many things like.

For the causative microorganism (or organism)ウ イ ル ス-BacteriaIs the two major factors,Mycoplasma-rickettsia-Chlamydia-Fungus-ParasiteCan also be mentioned.

Virus infection

Viral infections in children are known to vary seasonally.Febrile convulsions in spring,RhinovirusOrdinary cold, byNorovirusThere are many epidemic vomiting caused by.Bronchial asthma attacks increase during the rainy season, but with itParainfluenza virusCough asthma due to also increases.CoxsackievirusbyHerpangina,rash, AsepticityMeningitis,AdenovirusPharyngoconjunctivitis (Pool fever) Is common in summer.Bronchial asthma attacks increase again in the fall, but are normal with rhinoviruscoldIs also in fashion.In winter, bronchiolitis and rotavirus caused by RS virus, infant vomiting and diarrhea caused by norovirus,influenzaRages.

Colds and viruses

Most patients in pediatricscoldFor viruses that cause (cold, upper respiratory tract inflammation)Coronavirus-RS virus-Adenovirus, parainfluenza virus, rhinovirus, etc. can be mentioned.Some of these are easy to test as described below, but other than that, identification of fine viruses is not important clinically, so identification tests are generally not performed.

Gastroenteritis and virus

Causes of acute gastroenteritis that are common in winterRotavirus-NorovirusThere are many.The latter was noticed in the media for a while, but it has milder symptoms than rotavirus (so no rapid test has been made).

Viruses associated with specific diseases

As a virus associated with a specific diseaseInfluenza virus(influenza),Measles virus(measles,SSPE),Varicella-zoster virus(Varieg,Herpes zoster),Polio virus(Acute poliomyelitis),Mumps virus(Mumps),Hepatitis virus(Hepatitis A, B, C),Herpes simplex virus(Herpes labialis,Herpes encephalitis),Cytomegalovirus(, Infant enteritis),RS virus(Bronchiolitis),Japanese encephalitis virus(Japanese encephalitis),Coxsackievirus(Hand-foot-and-mouth disease,Herpangina,),Enterovirus(Hand-foot-and-mouth disease, Severe compared to Coxsackievirus).

Virus with rapid test

For the causative virus that has received clinical attention and is relatively easy to perform rapid identification tests in hospitals.Influenza virus-RS virus-Rotavirus-AdenovirusCan be mentioned.Each of these viruses has clinical characteristics, test methods have been established, and can be identified in a short time by general hospital tests.

Bacterial infections

Infecting bacteria are about the same as adults.The time of onset and the way of onset may differ from those of adults.

The site of onset can occur in any organ throughout the body, as in adults,Cystitis(Infants),Otitis media(infant),septicemia(Infants) etc. are relatively easy to occur.

Regarding the time of onset, in newbornsE. coli, B-gun hemolytic streptococcal infection, influenza stem bacteria in early childhoodPneumococcusIt is known that there are many infections.Exchange transfusion is very effective in neonatal sepsis.

Children under 3 months often develop sepsis due to bacterial infection and require careful observation.

Correspondence of fever

In the case of children, normal fever is often high, so it is generally considered to be fever at a body temperature of 38 degrees or higher. Below 37.5 degrees, it is almost normal.Differentiated diseases differ greatly depending on the presence or absence of a rash.Kawasaki disease-Rheumatic fever・ YouthRheumatoid arthritisThere is also a child-specific disease with fever accompanied by a rash.If the fever pattern gradually increases while chronotyping, it is considered to be more severe, and if the fever gradually disappears, it is considered to be a healing tendency.Be careful not to judge it as a short-circuited aggravation or healing tendency due to chronotype.An example of how to deal with fever at home is shown.

age対 応
0 to 1 month after birthEven if you think that you are fine and have an appetite, you will be asked to see a doctor.
2 to 3 month after birthIf you're in a good mood, like drinking milk or laughing at ease, don't panic.Visit the outpatient clinic the next day.
4 to 6 month after birthIf you have a fever and no other symptoms, you don't have to panic.It is enough to have an outpatient examination the next day.
After 6 months of ageIf you have a good appetite and mood, don't panic.It is even safer if you have a medical examination the next day or later.

Fever itself is extremely abnormal during the newborn period, and pneumonia / meningitis can lead to death.It is generally considered that fever within 3 months of age requires consultation with a pediatrician.However, after that, in most cases, emergency consultation is not necessary unless it seems to be clearly different from usual.

The fact that you shouldn't take a bath when you have a fever is a story of the time when the bath was outdoors, which is not the case in Japan as of 2009.Basically, it is enough to warm up if you feel chills and cool down when it gets hot.When cooling, head, left and rightDiameterIt is effective to cool the three points of the part.

Fever in early infants

Early babiesImmunologyThe system is not complete and is considered to be at high risk of bacterial infection.Oral administration of IgG by breast milk helps prevent infection in early infants.When an early infant has a fever, it is usually a viral infection, but about 10% contains severe infections such as bacterial meningitis and sepsis.Therefore, it is required to see a doctor specializing in pediatrics, but if it is within one month, the effectiveness of various tests is questioned.If the focus of the infection is not clear, it may be indicated for hospitalization. After 1 monthMayo ClinicIt is often sufficient to see a non-specialist based on the Rochster criteria by.

Rochster criteria
  1. Good general condition
  2. There is no particular problem in the past
    1. No history of perinatal antibiotics at birth, no history of treatment for unexplained inferior jaundice
    2. No current or recent antibiotics, no history of hospitalization, no chronic or underlying illness
    3. No long-term obstetric hospitalization history than mother
  3. No signs of infection on skin, soft tissues, bones, joints, ears
  4. Inspection findings
    1. Peripheral blood leukocyte count 5,000 to 15,000 / μL
    2. Number of rod-shaped nuclei <1,500 / μL
    3. Urinary sediment white blood cell count <10 / hpf
    4. Fecal smear white blood cell count <5 / hpf (only for diarrhea cases)

Severe infections are negative when these criteria are met.

Fever in infants

Fever from infants after 3 months to around 3 years old is a very common complaint in the emergency outpatient department.Even if you take careful physical findings, about 30% of the heat source will be unknown.In that case, latent bloodstream, urinary tract infection, latent pneumonia, malignant tumor, or collagen disease may be considered.In particular, the former two require careful examination because they can be treated with antibacterial agents at an early stage.Subclinical bacillemia is the detection of bacteria in blood cultures despite good general condition. It is said that the frequency is high between 3 months and 3 years old.If it is Streptococcus pneumoniae, it will improve naturally, but if it is Haemophilus influenzae, it is said that there is a 90% or higher probability of sepsis or meningitis.If the body temperature is 39 degrees or higher and the white blood cell count is 15,000 / μl or higher, the possibility of latent bloodstream is high.Urinary tract infections are also difficult to detect in boys under 1 year old and girls under 2 years old.Diagnosis can be made by aseptically collecting a urine sample with a catheter or bladder puncture.When the body temperature is 39 degrees or higher and the white blood cell count is 20,000 / μl or higher, no auscultatory noise is observed and there is no sputum.Chest x-rayIn addition, a pathological condition called latent pneumonia, in which infiltration shadows are observed, is also known.In any case, the serious condition is often caused by Streptococcus pneumoniae, and prevention by vaccination is desired.It is also known to use vital signs to determine whether fever is a sign of sepsis.Since these are indicators when the patient is at rest, if they start crying, both the heart rate and the respiratory rate will rise, making it difficult to judge.Changes in heart rate and respiratory rate of +2 SD or more from the normal range are not considered to be caused solely by fever, and the possibility of sepsis is also considered.

ageRespiratory rate ± 2SDRespiratory rate ± 1SDNormal respiratory rate rangeHeart rate ± 2SDHeart rate ± 1SDNormal heart rate range
Birth ~ 3 months10~8020~7030~6040~23065~20590~180
3 to 6 months10~8020~7030~6040~21063~18080~160
6 months to 1 years old10~8017~5525~4540~18060~16080~160
1 to 3 years10~4015~3516~2440~16558~14575~130
3 to 6 years8~3212~2812~2840~14055~12570~110
6 to 10 years8~2410~2414~2030~12045~10560~90

Effect of antipyretic

AntipyreticIs useful for reducing systemic symptoms caused by fever because the fever is reduced.However, the sign of fever, which indicates the severity, improves regardless of the condition, which may be disadvantageous in tracking the course of severe infections.Generally, if fever occurs, the antipyretic agent relieves fever regardless of the pathological condition.Even if you have a fever, there is no merit to take an antipyretic if your general condition is good.Infectious diseases may be prolonged because the rest cannot be maintained due to the antipyretic effect.If fever does not improve even with antipyretics, severe infections may be suspected, but it is difficult to distinguish them by body temperature.The use of antipyretics does not improve the general condition at all, and if the feeling of seriousness continues, the possibility of bacterial meningitis increases.

rash

The differential disease of the rash differs depending on the fever and general condition.AlsovaccineIt depends on the inoculation history.The following classifications are convenient for eruptions.It is easy to understand when observing with a loupe.In rare cases, bleeding spots (bruises) may be mistaken for a rash.LinkList of diseases that cause fever and rashIs also helpful.Various viral infections, heat rash, drug eruption, contact dermatitis, etc. are known as those with good general condition and mild or no fever, and measles and infectious mononucleosis as those with poor general condition. Mononucleosis and Kawasaki disease are known.

Rash patterndisease
ErythemaRoseola,Infectious erythema,Kawasaki disease, SSSS (Staphylococcal burn skin syndrome)
Papulesmeasles,Atopic dermatitis, Cutaneous candidiasis,Molluscum contagiosum(Water Ivo)
BlisterVarieg, Shingles, Hand-foot-and-mouth disease, Herpes labialis
PustuleInfectious impetigo,theory
Whealhives, Allergic reaction
Roseola
It is the first fever after birth of about 6 months to 1 year old (under 2 years old), and it is characteristic that the general condition is good even if it continues for several days. The fever disappears in 3 to 4 days, and a rash appears after sufficient fever reduction.Redness called Nagayama's spots may be observed in two places above the back of the pharynx. It can be affected twice because it is caused by HHV-2 and HHV-6 infections. It is said that HHV-7 is abundant around 2 months and HHV-6 is abundant around 6 year and 1 months.The rash is erythema, and a rash that looks like cherry blossom petals are scattered around the trunk.It has a clean impression compared to other viral rashes.The eruption disappears without leaving any pigmentation in about 6 days.Even idiopathic rashes rarely cause febrile convulsions and encephalitis.It is a benign disease and no cure has been established.Symptomatic treatments such as hydration are sufficient.
measles
Many are over 1 year old. It affects about 10 months, but it is often mild. Measles-rubella combination vaccine is often given at 1 and 5 years old.A rash appears during a biphasic fever and a second fever.It is characteristic that white Koplik's spots are observed on the back of the cheek during the catarrhal period (first fever, rhinitis, conjunctivitis).The rash is a papule and is characterized by starting from the back of the ear, neck, and forehead and spreading to the trunk.Prevention is important because it is a disease that can be fatal due to complications.If contact is made without vaccination, vaccination within 2 days can prevent the disease. Gamma globulin is also effective within 3 days.The incubation period is about 10 days.People under the age of one who are not eligible for vaccination are annoyed. If it is less than 1 months, there is a high possibility that it can be prevented by the immunity of the mother. After 7 months, consider the risk and consider a self-funded vaccine.According to the School Health Law, attendance is suspended for 9 days after the fever is resolved.
Varieg
Mostly in kindergarten children. Voluntary vaccination after 1 year of age.encephalitis・ Inoculation is recommended because it causes cerebellar ataxia.In the familyHerpes zosterThere is a risk of infection if there are patients with.The incubation period is about 2 to 3 weeks, and it is characterized by a mixture of rashes in various states and rapid changes in the rash.The general condition is relatively good.Molluscum contagiosum, early stage of infectious impetigo, diaper rash, exanthema subitum, streptococcal infection, etc. are differentiated.Acyclovir (Zovirax) is a therapeutic drug.Administer 20 mg / kg at a time, 4 times a day for 5 days.If itching is strong, use petrified zinc gastric acid (click) or ointment (underm) locally.Cut your nails to prevent scratching and take a shower to keep your skin clean.Within 72 hours in case of contactLive vaccineAdministration is effective. If you are under 1 year old, it is not applicable.AcyclovirAlso prophylactic administration of.
Infectious impetigo
Very often in hot and humid summer.Heat rashThe epidermis becomes purulent due to trauma such as insect bites.Oral administration of antibacterial drugs is effectiveCefzon, Etc. are used.Furthermore, Linderon VG or the like is also used as a local ointment.
Infectious erythema
Molluscum contagiosum
It is common in infants atopic dermatitis aged 2 to 5 years.
Diaper dermatitis
Pay attention to the wrinkled part of the crotch, and if there is a rash on the wrinkled part, the skinCandidiasisIs.If the wrinkles are normal, there is a high possibility of diaper dermatitis.This is because Candida prefers moisture.It is said that it is difficult to occur with disposable diapers.

Respiratory disease

Since many respiratory diseases are infectious diseases, there are many points that overlap with the above infectious disease items.For infancy, bronchiolitis centered on RS virus, croup and whooping cough for infants, and school childrenMycoplasmaPneumonia is famous.

Acute laryngitis (croup)

CroupIs also called acute laryngitis or acute subvocal laryngitis, and is one of the pediatric emergency diseases.Long time agodiphtheriaHowever, the spread of vaccines has dramatically reduced the number of diphtheria-induced croups.acuteRespiratory tract infectionIt is a syndrome that presents with a dog-like cough, hoarseness, and dyspnea associated with the disease, and most of them are viral.In the case of Haemophilus influenzae, it tends to become serious.Very often from 6 months to 6 years old.AuscultationThe upper stridor (stridor) is an important finding to suspect upper airway stenosis.Conversely, if it is wheezing, it is an obstruction of the lower respiratory tract.Weasing sounds HYUXNUMX during both inspiration and exhalation, and the strongest point is the chest, while Strider hears HYUXNUMX only in the inspiration, and the strongest point is in the neck.Also, if you open it and breathe frequently, the strider will be easier to hear.Care should be taken as airway stenosis may further progress and become more serious if the patient is made to cry violently or excited.Tongue depressorPharyngeal examination usingX-rayThere have also been reports of cases of respiratory arrest caused by photography.Severity is often determined from the clinical manifestations.

severityInuho-sama coughResting inspiratory wheezingDepressed breathing at restOther
MildSometimesNone ~ SlightNone ~ Slight
ModerateoftenEasy listeningclearNo excitement
SevereoftenRemarkable, sometimes accompanied by expiratory wheezingSignificantExcited state
Imminent respiratory failureYes (sometimes inconspicuous)Yes, sometimes weakenedYes (sometimes inconspicuous)Decreased consciousness, cyanosis

Above moderateア ド レ ナ リ ンThere is an indication for inhalation.The optimal inhalation amount is 1000-fold diluted adrenaline 0.5 ml / kg and the maximum amount is 5 ml.Although the reaction is immediate, the effect disappears in 2 hours, so it is necessary to re-evaluate the electrocardiogram and oxygen saturation after 2 hours under monitoring.As soon as the symptoms improve with adrenaline inhalationsteroidIf you take this medicine, the effect of steroids will appear when the effect of adrenaline disappears.Regardless of severityDexamethasoneA single dose of 0.6 mg / kg, maximum dose of 10 mg is standard.If oral administration is difficult, 2 mg may be inhaled.Intubation may be performed due to respiratory failure.There is no active indication for antibacterial drugs because most of them are viral infections.

Acute epiglottitis

Acute inflammatory swelling that occurs in the posterior skull.It is a completely different condition from croup because it appears as a symptom of severe bacterial infection caused by Haemophilus influenzae. It tends to occur more often in infants aged 2 to 7 years.Difficulty breathing・ Hypersalivation, depressed breathing, muffled voice, and sitting breathing are typical symptoms.It is often accompanied by dysphagia and dysphagia.For early diagnosis, it is common to distinguish infants who complain of odynophagia and dysphagia when the symptoms of upper respiratory tract inflammation are the only symptoms and the findings of the pharynx and tonsils are poor.Anxiety, pharyngeal irritation, or lying on the supine position may cause sudden upper airway obstruction, leading to suffocation.Procedures such as intraoral observation, venous line retention, and supine position should be avoided until the airway is ready.If you are diagnosed with epiglottitis, in principle, you will be hospitalized and do not hesitate to secure an airway such as endotracheal intubation.

Childhood asthma

Bronchial asthmaGINA 2006, a guideline for adults, and JPGL 2005, a guideline for childhood asthma, are known.Early spring and early autumn are the best times for seizures. The onset is often 3 to 5 years old. Inhalation of β2 agonists and systemic administration of steroids are the basics.AminophyllineIncluding side effects such as vomiting, it is difficult to adjust the blood concentration, and it becomes reluctant in consideration of safety and convenience.Inhalation is performed with an inhaler (quantitative dew inhaler and dry powder inhaler)NebulizerInhalation by is known.The amount of inhaled drug is generally unchanged, whether in children or adults.This is because the more you grow, the better you tend to inhale, and the more drug you reach the peripheral airways.Factors that influence nebulizer treatment include respiratory patterns, mouth breathing or nasal breathing, the degree of airway narrowing lesions, and the presence of artificial airways.

Acute pharyngitis / acute tonsillitis

Basically an adult acuteSore throatIs similar to.StreptococcusIf byRheumatic fever,Acute glomerulonephritisThere are complications such as.Administration of bicillin is effective in preventing rheumatic fever.AdenovirusbyPharyngoconjunctivitis,CoxsackievirusbyHerpanginaEtc. are famous.Herpangina is common in infants and school children with summer colds and is characterized by fever and enanthem.Petechiae may occur early.Sore throat and hypersalivation are noted.

Acute bronchiolitis

It is a disease characterized by expiratory wheezing that occurs frequently in winter, and more than 50% of themRS virusAnd thenParainfluenza virusMostly due to. It is especially common in babies up to 6 months, and up to 2 years is the predominant age.The causes are mainly bronchiolar-level edema, exfoliated substances such as epithelial cells, and excess mucus, and it is thought that bronchospasm is less involved.The clinical picture resembles an asthma attack,coldIt is often difficult to distinguish it from the first asthma attack triggered by.It is said that childhood asthma is predominantly 3 to 5 years old and is common in early spring and early autumn, but it is difficult to distinguish it by itself.It is often observed that administration of bronchodilators sometimes improves wheezing, but oxygenation and the like are poorly improved.Although adrenaline is said to improve symptoms in the short term, it is not recommended to use it for a long period of time because it is said that it does not shorten the length of hospital stay or illness.As a treatment strategy for this disease, easy inhalation therapy should be avoided, and supportive therapies such as oxygen administration, humidification, respiratory physiotherapy, infusion therapy, and artificial ventilation therapy should be considered mainly. The AAP has proposed guidelines, but they have not been organized as of 2008.As a treatment, it tends to improve in about 3 days, and it is generally cured in about 3 days.Inpatient indications for appropriate supportive care are important in treatment policy.Hospitalization may be due to ventilatory / oxygenation disorders due to acute bronchiolitis or apnea.Ventilation / oxygenation disorders have a risk factor of hospitalization such as oxygen saturation of less than 95%, respiratory rate of 45 / min or more, and less than 6 months of age.Within 2 months of age for apnea,acidosisThe presence of,AtelectasisIs a risk factor for hospitalization.Findings such as how the milk is drunk are also helpful.

pneumonia

In the field of pediatrics, depending on agepneumoniaThe most common causative organism can be estimated.Haemophilus influenzae type b in the United StatesvaccineAnd the introduction of the pneumococcal vaccine has been successful in preventing childhood pneumonia.

NameseasonPneumonia-prone bacillus
NewbornLess than 28 days after birthGroup B hemolytic streptococcus,E. coli, Staphylococcus
infant28 days to under 1 year oldStaphylococcus, Streptococcus pneumoniae
An infantFrom 1 year oldprimary schoolPreschoolStreptococcus pneumoniae,Haemophilus influenzae
School children<span>Grade 1-2</span>Mycoplasma, Pneumococcus

Treatment differs depending on the causative microorganism, but in the case of general bacteria, administration of antibacterial agents can be discontinued in about 3 to 7 days.

Digestive disease

Childhood abdominal pain

Pediatricstomach acheAs the cause of the emergency outpatient frequencyConstipation,Acute Gastroenteritis(Cold syndrome with upper respiratory tract inflammation accompanied by diarrhea and vomiting), psychogenic vomiting, cyclic vomiting syndrome (periodic vomiting, self-poisoning), intussusception, appendicitis, and allergic vasculitis are known. ..In particular, intussusception, appendicitis, and allergic vasculitis are urgent diseases that cause abdominal pain in children.

Acute constipation

It is said to occur after the age of two.Acute constipation often causes severe abdominal pain.You may cry or have a pale face.He complains of suffering so much that he suspects a serious illness, but in many cases water intake is maintained.Since the abdominal wall is thin in children, it is easier to diagnose constipation by abdominal examination than in adults.In the lower left abdomenTumorI often touch the stool mass.If you find a stool mass on an X-ray, you can make a diagnosis, but as a diagnostic treatmentIntestineOften do. As a guideline for the amount of 50% glycerin enema used, it is 1 to 2 ml / kg.

ageGE usage
Infants of about 5 kg5-10ml
An infant10-30ml
School children (lower grades)30-60ml

Is a guideline amount.In recent years, many mothers have never undergone an enema and may need guidance.Most of the failures are that the drug solution leaks out of the anus due to the shallow insertion.Therefore, when inserting it, be gentle and take the courage to insert it deeply.olive oilUse lubricating oil, insert it as far back as possible, and hold it down for a few minutes.If you pour the drug solution vigorously, it may cause liquid leakage, so pour the drug solution moderately and slowly.Also, if the chemical solution is used while it is cold, it may cause liquid leakage, so if it is used by warming it to a temperature close to body temperature with warm water, there will be less leakage.Be sure to check the properties of the stool after defecation.It is a rabbit fecal stool, and if the subjective symptoms improve, the treatment is successful.Contraindications for enemasUlcerative colitisSince it is a case of organic disease such as, there is no problem even if it is performed in most cases.Also, unlike the use of other laxatives, there is no dependence.

Chronic constipation

慢性便秘症の場合は食事や排便訓練など生活習慣の改善で9割程度は改善するといわれている。処方としては1日1回3〜5mg(5〜10滴)やラクツロースシロップ(学童以降はあまり用いない)1日3回0.5〜2mg/kgなどが多い。朝に排便習慣をつける、ウォッシュレットを利用した肛門刺激、3歳以上では排便がなくとも毎朝10分程度トイレに座らせる、食物繊維を多くとる、うんちが出たら褒めるといったトレーニングで改善する場合がほとんどである

Acute Gastroenteritis

Symptoms such as fever, vomiting, diarrhea, and abdominal pain are typical.It is characterized by a large number of variations such as no fever and only vomiting, but the symptoms gradually complete, and diarrhea and fever are often accompanied.Nausea suppositories and purinperan syrup are often used to prevent nausea.If repeated, there is a possibility of psychogenic vomiting and self-poisoning, but it is often treated as acute gastroenteritis at the first visit.

Psychogenic vomiting

In adults, it corresponds to irritable bowel syndrome (IBS).Suspected if there are frequent bowel movements and abdominal pain in school children and above.Herbal medicine・ Drugs such as ・ are used.

Self-addiction

It is said that many people are 4 to 5 years old.It is a disease that repeats severe vomiting and the cause is unknown.Urinary ketone bodies are positive.NormalInfusionTo deal with it.

Vomiting in children

In adults, vomiting caused by infections and ulcers in the gastrointestinal tract is the most common, but in children, other diseases are also differentiated.Congenital intestinal atresia can occur with abnormal bowel rotation and can occur with the annular pancreas.Treatment requires scrutiny of the cause.Scrutiny of other malformations may also be important in these disorders.

Onset timediseaseVomitingImage findings
Immediately after birthCongenital esophageal atresiaFoam-likecoil up sign
Birth hours to 1 weekBiliarymicrocolon Many niveau
Birth hours to 1 weekImperforate anusInverted position shooting without rectal thermometer
Birth hours to 1 weekHirschsprung's diseasemegacolon caliber change narrow segment
Birth a few weeksHypertrophic pyloric stenosisFountain-like vomitingstring sign umbrella sign showlder sign
A few months to 2 years oldIntussusceptionBile, yellow vomitusCrab claw, target sign

Diarrhea in children

Because loose stools are normal for newborns and infantsdiarrheaEven if it is sued, it is necessary to doubt from the judgment of the parents.Therefore, if diarrhea is the main complaint, instruct to bring a diaper.PoopYou should confirm the properties of.The characteristics of stools of newborns and infants are that the absorption of nutrients is active and that the function of the intestinal mucosa is underdeveloped.Intestinal juice,bileThere is a lot of secretion such as, so what you eat may come out as it is.In addition, since the rhythm of defecation is established by school age, the number of defecations per day is large at the beginning.The number of bowel movements per day decreases after the first few months of life.On the other hand, if you are a school child or older and have frequent bowel movements or abdominal pain,Irritable bowel syndromeThere is a possibility of.

Describes normal stools from newborns to infants.Normally, it is soft and often has no shape.In the case of breastfeeding, the younger the age, the softer the stool and the slightly sour odor.It is characteristic that the stool will soak into the diaper.In the case of milk nutrition, the hardness varies and is usually darker than that of breast milk stool.Pathological stools are stools that soak into diapers, but they are often clearly different from usual stools, such as blood contamination.It is morbid if defecation is observed 7 to 8 times a day, that is, every 2 to 3 hours.Typical abnormal stools are pure white or pure red.White stools are often infected with rotavirus from winter to early spring.Biliary atresiaCan be considered in.Norovirus infection may be accompanied by vomiting.Strawberry jelly-like stools with intussusception and spot-like bleeding of bacterial enteritis are famous as red stools.However, the frequency is the highest in tomato and watermelon residues.After the establishment of solid stool, the same treatment as for adults is sufficient.DiarrheaAcute GastroenteritisMostly due to.When did diarrhea begin, what is the nature of diarrhea, such as frequency, condition, and odor?Maybe you have diarrhea such as meals (prone to occur with oils such as grilled meat and Chinese) and drinks (prone to occur with ionized drinking water), or you have symptoms other than diarrhea such as fever, nausea, vomiting, impaired consciousness, and weight loss. It becomes important whether there are similar symptoms around.Weight loss is very important as the degree of dehydration. If the weight loss is 2 to 3%, it can be treated outpatiently, but if it is 6% or more, hospitalization is required. If it is 7% or more, it is highly dehydrated and it is a serious condition.Infusions are often used to treat mild dehydration that can be treated outpatiently.More detailsInfusionchecking ...

WeightInfusion rate
10kg100ml / hr
10~20kg200ml / hr
20~30kg300ml / hr

In the outpatient department, if diuresis is not obtained after administration for 2 hours, consider hospitalization.In recent years, treatment is often performed with ORS.Solita T3 granules have a very good electrolyte balance, but they have a bad taste and are difficult to handle.Aqualite and aquabalance are said to have a relatively good taste in ORS.Vocalisette for children can also be used for treatment.If it is Pocari Sweat for adults, dilute it with water and use it.However, keep in mind that electrolyte supplementation will be small when treated with Pocari Sweat.It is recommended that you avoid eating foods that are high in fiber.Specifically, udon, toast, potatoes, satoimo, tofu, stewed vegetables (especially carrots and pumpkins are well-balanced in terms of nutrition and digestion), and apples, bananas, white peaches, etc. are said to be preferable in small amounts. ..If you have nausea, give water frequently in small doses (50 ml as a guide) when the nausea subsides.In principle, antidiarrhea is not used for diarrhea that is thought to be caused by an infectious disease. In particular, antidiarrhea is contraindicated for less than 6 months and contraindicated for children under 2 years of age.When using lopemin, use 0.04 to 0.08 / kg / day for 3 minutes, and the number of days is short.BioferminIntestinal regulators such asConsider the use of antibiotics if bacterial diarrhea is strongly suspected, such as in an episode of food poisoning.ProofIf there is, the use of Chinese herbal medicine is also effective.Goreisan(Gorei-san) is often used.

ageWuling San Wan usage
Less than 1 age1/4 of the adult amount
1-3 years1/3 of the adult amount
Less than 7 age1/2 of the adult amount
Less than 12 age2/3 of the adult amount

Goreisan isPlain hot waterDissolve in and boil in the microwave to cool and take.In rare cases, the intestine may be enema.

Child-specific digestive disorders

Even in the field of pediatrics, many gastrointestinal diseases are curative with surgical treatment.

Acute appendicitis

Acute appendicitisIs characterized by persistent abdominal pain.Since the appendix is ​​controlled by Th9-11, referred pain occurs around the navel at first, and it moves to right lower abdominal pain within a few hours.In some cases, there is no fever.Blood tests often do not change within 12 hours of onset.If you can't walk because of pain, you are seriously ill.If the Blumberg sign, heel drop test, or Kenken test is positive, consider the possibility of surgery.Since the omentum is underdeveloped in children, it is difficult for the omentum to relieve the symptoms.Poor fixation of the appendix may cause flank pain and back pain.Antibacterial agents are generally administered in surgical facilities because it is difficult to follow up due to symptoms.If in doubt, it is one of the pediatric emergency diseases that requires follow-up on the same day.

Intussusception (ICD-10: K56.1)

Intussusception(Chojuseki, English: intussusception, invasion) IsIntestinesIs a disease that enters the intestines themselves.It is characterized by abdominal pain, vomiting and bloody stools (strawberry jelly-like).Bloody stools are often unclear, but enema may result in bloody stools. Mostly from 6 months to 2 years old, and after that, if the symptoms are similar polyp And Meckel's diverticulum,Malignant lymphomaConsider the existence of underlying diseases such as.ButcolonOften drawn to.In the intestinespolypIf there is something wrong withanusThe intestines on the sidePeristaltic movementIt is caused by swallowing the intestine with abnormalities.I was pushed into the anal side intestine of the same diameter as myselfmouthBlood does not reach the side intestines,NecrosisI have something to do.The anal side intestine repeats peristalsis every 2 to 3 hours and tries to forcefully descend the oral side intestine, so cry every 2 to 3 hours.I'm tired while I'm not crying.Defecation stops because the intestines are blocked.A rare disease called intussusception is also known.It mainly affects infants, with typical symptoms such as abdominal pain and bloody stools, and only with impaired consciousness, often with sepsis.MisdiagnosisWill be done. The symptom that an empty part appears in the lower right abdomen () is famous.It is known that the ileocecal region in the lower right abdomen is pulled into the ascending colon, so that the ileocecal region that should have been there disappears from the lower right abdomen and feels empty.Abdominal ultrasonography shows a target sign named because the double-looking intestine looks like a bow and arrow, and a cow's eye sign named because it looks like a cow's eye.High-pressure enema and manual reduction are known as treatments.Intussusception encephalopathy also quickly improves the state of consciousness when the intussusception is reduced.

Congenital hypertrophic pyloric stenosis (ICD-10: Q40.0)

Congenital hypertrophic pyloric stenosis(Stenosis) isstomachIs the exit ofpylorusA disease in which the tissues around the body grow.The enlargement of the tissue is called thickening.Thickened tissue narrows the pylorus.Narrowing is called stenosis.Metabolic because it spits acidic gastric fluidAlkalosisbecome.MultifactorHeredityIt is suggested that this is hereditary.saliva,foodStops passing through the stenosis and spits out from around the first few weeks of life.gall bladderGet out ofbileIs green, but the gallbladder is on the anal side of the stomach and the exit of the stomach is narrowed. In this disease, the vomitus is not green.Blood tests show metabolic alkalosis. Low because it loses gastric acid, which is HClcrawlBlood, highBicarbonate ionBlood (high HCO)3-Blood).Abdominal ultrasonography shows an owl's eye sign.X-rayIn fluoroscopy, the pyloric part becomes thin and tubular, and the pyloric canal is recognized.It is also called a string sign because it looks like a thin thread.Surgical treatment is used as treatment.Surgery is a pyloromyotomy.The prognosis is good.

Hirschsprung's disease (ICD-10: Q43.1)

Hirschsprung's disease(Hirschsprung's disease) is a disease in which the nerves that cause peristalsis in the intestine are damaged.The nerves that cause peristalsis in the intestinesAuerbach's plexusSay.Since the intestines do not peristaltic, food flows back and spits green vomitus mixed with bile.Vomiting green vomiting mixed with bile is called bile vomiting.Also admits stubborn constipation.

Congenital esophageal atresia (ICD-10: Q39)

Congenital esophageal atresia(Sensation) is a disease in which the esophagus is naturally closed.Often the mouth side of the closed esophagustracheaBecause it is connected to, the lungs are mixed with air and vomiting foamy vomiting.Vomiting foamed vomiting is called foamy vomiting.Conversely, the anal side of the closed esophagus is connected to the stomach, so stomach acid enters the lungs from the stomach.pneumoniaWake up.Surgical treatment is used as treatment.

Biliary atresia (ICD-10: Q44.4)

Biliary atresiaIs a condition similar to neonatal hepatitis, but the prognosis is extremely poor, and it is a disease for which living-donor liver transplantation is indicated.Both have a pathogenic mechanism of persistent jaundice during the neonatal period.

Biliary atresiaNeonatal hepatitis
conceptObstructive jaundice due to inflammatory extrahepatic biliary obstructionOnset in newborns and infants, unknown cause
prognosisPoor, hepatic ductal anastomosis or as soon as possible within 60 days of age
(English edition)(Kasai surgery) required
Naturally lighten
EpidemiologyMostly for girlsMostly for boys
Gray-white stoolVery manySometimes admitted (mostly blue)
Stool Schmit reactionSometimes admitAdmit
LAPRise over 500 IUMild rise
Lipoprotein XAdmitI will not admit it
Duodenal fluid collectionDo not recognize bileRecognize bile

Congenital biliary dilatation (ICD-10: Q44.5)

Congenital biliary dilatation(Formerly congenital biliary dilatation) develops before the age of five.It is noticed by abdominal pain, abdominal mass, and jaundice caused by cholangitis.fromCholangiocarcinoma-Gallbladder cancerBecause of the risk of complications, cystectomy and hepatic jejunostomy are performed.

Liver disease

As with the term physiological jaundice in newborns, the appearance of jaundice is normal.This is understood from the physiological characteristics of newborns.Most of the fetal liver is due to immature liver function during the fetal periodGlucuronic acid conjugationDo not do.During the fetal period, hyperbilirubinemia is prevented by passing unconjugated bilirubin to the maternal blood in the placenta.After birth, it is thought that physiological jaundice occurs due to the combination of the production of bilirubin by the decomposition of HbF and the immaturity of liver function.Jaundice is caused by hyperbilirubinemia because bilirubin turns yellow when tissue is deposited.Bilirubin in particularElastic fibersDue to its high affinity with, it deposits on tissues rich in elastic fibers such as skin, sclera, and blood vessels.Since it has a particularly high affinity with the sclera, jaundice screening is performed by the color of the bulbar conjunctiva.In addition, since yellow dyeing shows tissue deposition to the last, it fluctuates later than the data of blood biochemistry.Bilirubin tissue deposits other than skinBasal gangliaKernicterus (bilirubin encephalopathy) due to the deposition of kernicterus is famous.This is one of the non-conjugated bilirubinsalbuminUnbound bilirubin that is not bound to is deposited.It is a disease that occurs in newborns and does not drink milk.Moro reflexIt starts with symptoms such as disappearance and causes convulsions and opisthotonus.Experience shows that this is extremely rare unless T-Bil exceeds 25 mg / dL, so it is unlikely to occur with today's management techniques.

Neonatal jaundice

NewbornJaundice seen in.High as a pathological conditionBilirubinDue to blood flow.BilirubinIndirect bilirubinとDirect bilirubinThere are two of blood.There are two ways to classify newborn jaundice, one is by the time when jaundice is seen and the other is by the pathological condition of jaundice.If you divide it according to the time, it can be divided into three.High when divided by pathologyIndirect bilirubinBlood / highDirect bilirubinIt can be divided into two types: blood.Early-onset jaundice is jaundice that occurs within 2 hours after birth, physiological jaundice is jaundice that occurs about 24 days to 2 weeks after birth, and persistent jaundice is jaundice that occurs more than 2 weeks after birth.

Timing \ PathologyIndirect (non-conjugated) bilirubinDirect (conjugated) bilirubin
Early departuresepticemia
Persistent vegetative,Congenital biliary atresia

Treatment includes phototherapy, plasma exchange, etc. as symptomatic treatment.

Phototherapy
In the blood by shining a ray of lightBilirubinIt is a treatment method that decomposes.Light rays promote excretion from urine.It should be noted that this treatment method can be used only for the purpose of lowering unconjugated bilirubin, and is contraindicated because it causes high conjugated bilirubin.Adaptation is indicated when the total bilirubin value exceeds 17.
By exchanging the antibody in the blood and the red blood cells bound to the antibody, severe jaundice (neoplastic hemolytic disease = incompatibility between mother and baby) is treated radically.An indwelling catheter is inserted into the radial artery, phlebotomy is performed from there, and exchange transfusion is performed by injecting twice as much exchange blood as whole blood into the peripheral vein.
Plasmapheresis
Kernicterus is indicated when the total bilirubin level exceeds 20.
Although this treatment, which has been started for about 30 years, is more effective than exchange transfusion, it has only recently attracted attention, and the frequency of exchange transfusion has decreased significantly.However, the Ministry of Health, Labor and Welfare has not approved insurance coverage.

Constitutional jaundice

Unconjugated bilirubin is taken up by hepatocytes, undergoes glucuronidation in hepatocytes, and is excreted in the intrahepatic bile duct.It is called a disease in which the function of the enzyme required for the process is reduced or the enzyme itself is deficient.

Obstacle processsick
CaptureGilbert's Syndrome
HugCrigler-Najard Syndrome
excretionDubin-Johnson Syndrome,Rotor syndrome
Gilbert's Syndrome(Gilbert's Syndrome)
Gilbert's Syndrome is one of the syndromes that presents with jaundice.I don't read it as Gilbert.Reported by Dr. Gilbert of France.Gilbert's syndrome includes many diseases because it is a syndrome of indirect bilirubin-dominant jaundice in adults.
Crigler-Najard Syndrome(Crigler-Najjar syndrome, UDP-glucuronosyltransferase deficiency, UDP-glucuronosyltransferase deficiency)
Crigler-Najard Syndrome is a deficiency of uridine diphosphate glucuronide transferase. Type I is a complete deficiency, severe and poor prognosis. Type II is a partial deficiency, mild and has a good prognosis.Glucuronic acid conjugationFrom failureIndirect bilirubinRise and nuclearjaundiceIndicates.

Renal urinary system

Heart disease

Heart disease in children is a congenital heart malformation (Mind malformation), It is roughly classified into acquired diseases.Arrhythmias can be either congenital or acquired.

Admit to adultsAngina,Myocardial infarctionRarely exists.Kawasaki diseaseOf the aftereffectscoronary arteryMyocardial infarction due to aneurysm is important.

Mind malformation

The incidence is about 1%.From birthCyanosisIt is divided into a cyanotic type cardiac malformation that develops and a non-cyanotic type that does not develop.The principle of cyanosis is that it returns from the whole body to the heart.Oxygen saturationIt is caused by the fact that low blood is ejected to the whole body as it is (right-to-left shunt) without passing through the lungs due to malformation.

Symptoms are cyanosis,Heart murmurOften found by.Confirmation is done by echocardiography and cardiac catheterization (contrast examination).Since it is completely different from adult heart disease, complex heart malformations are often diagnosed and treated by pediatric cardiologists who specialize in the heart.

Although some symptoms can be alleviated by oral medication in mild cases, most complicated and severe cases are treated by surgery.

The classification of cardiac malformations is shown below.It is often admitted that multiple of these are merged.

Ventricular septal defectIs the most common.Other than thatAtrial septal defect,Patent ductus arteriosus,Tetralogy of Fallot,,,Complete transposition of large vessels,Corrected transposition of the great arteries,Double outlet right ventricle,Total anomalous pulmonary venous return,,,,,,,Mitral regurgitation,,,,,, etc.Often, multiple heart malformations are combined.

Acquired diseasesHypertrophic cardiomyopathy,Dilated cardiomyopathy,Myocarditis,Heart tamponade, Coronary aneurysm due to sequelae of Kawasaki disease, isolated myocardial densification disorder, etc.

arrhythmiaIt is,Atrial fibrillation,Atrial flutter,Ventricular tachycardia,Ventricular fibrillationSome of them are easy to develop even in adults, and as a disease with a large congenital factorLong QT syndrome,Brugada syndrome,WPW syndromeAnd so on.

Myocarditis
PediatricMyocarditisAre widespread, from asymptomatic to suddenly shocking.In many cases, prior infection symptoms such as upper respiratory tract inflammation and gastrointestinal symptoms are observed.Fulminant myocarditis is a pediatric emergency disease similar to bacterial meningitis and acute epiglottitis because the prognosis varies greatly depending on the course of treatment on an hourly basis.Tachycardia and arrhythmia due to conduction disorders that cannot be explained by an increase in body temperature may occur.Myocarditis is especially considered when cardiovascular abnormalities are suspected due to syncope and arrhythmia is found, even though no electrocardiographic abnormalities have been pointed out.Since rapid deterioration may be observed, treatment at a tertiary medical facility is recommended.

Immunodeficiency

Allergies

In childrenAllergiesDiseases are frequent, and as a general practice, there are many allergies following infectious diseases such as the common cold.

In children,ImmunologyOften become allergic as they mature.The incidence is high, but it often improves spontaneously as the patient grows.In asthma, 7% of infants are in remission by adulthood.

AllergiesBronchial asthma,Atopic dermatitis,allergic rhinitis(Hay fever) is listed as one of the three major allergies.others,hives・ There are such things.If food causes asthma symptoms or urticariaFood allergyCalled.

Collagen disease

Also commonly found in adultsRheumatoid arthritis(Or in children),Systemic lupus erythematosus(SLE),Scleroderma,Polyarteritis nodosa,Antiphospholipid antibody syndrome,Sjogren's syndrome,Behcet's diseaseEtc. can also occur in childhood.Collagen disease that is relatively specific to childrenRheumatic fever,Vasculitis syndrome,Vascular purpura(Allergic purpura),Kawasaki diseaseAnd so on.

Allergic purpura
Allergic purpuraIs typically a child aged 3 to 10 years oldRespiratory tract infectionAfter 10 to 30 days, gastrointestinal symptoms (abdominal pain, sometimes intussusception), joint symptoms, purpura (capillary disorders, sometimes ulceration), edema, and nephritis about 2 weeks later. , Proteinuria, hematuria.It is just a disorder of the blood vessel wall, and the bleeding timeplateletThe number, coagulation time, and platelet count are within the normal range.The concept is mainly systemic small blood vesselsVasculitisThe skin symptoms, abdominal symptoms, and joint symptoms are considered to be trias.teethPathologyTypicallyIgA nephropathyIs the same as. Symptoms of renal inflammation appear in 20% to 60% of cases, and in some cases renal failure gradually progresses.dialysisIs required.It is thought that specific treatment is necessary for cases with severe abdominal pain / arthralgia and cases with progressive renal inflammation, but in other cases, specific treatment is not necessary because it resolves spontaneously within 4 weeks. Has been done.
Treatment of abdominal pain and joint pain
Symptoms such as edema, abdominal pain, vomiting, bloody stool, and melena due to gastrointestinal vasculitis are observed.In severe cases require intestinal rest.BuscopanAntispasmodic drugs such as NSAIDs and drugs such as NSAIDs may be used on fasting and infusion.In the case of treatment resistance, it is said that prednisolone is effective in alleviating abdominal pain and arthralgia by starting with 1 to 2 mg / kg / day and gradually reducing the dose.
Treatment of pyelonephritis
Symptoms of renal inflammation appear in 20% to 60% of cases, but 30% of them are in remission within half a year, and about 60% are in remission even if they are prolonged.Only 1-2% require dialysis, but it is the leading cause of dialysis induction under the age of 18.Treatment is not required for hematuria alone or for mild (0.5 g / day or less) proteinuria.If proteinuria persistsAntiplatelet drug,ACE inhibitorTo use. Proteinuria of 1g / day or more persists,Nephrotic syndromeIn cases of hypertension and decreased renal function, treatment is performed with a focus on steroids.MethylprednisoloneThere are methods such as pulse therapy (100 to 250 mg / day for 3 days) and post-therapy prednisolone 1 mg / kg / day, but depending on the result of renal biopsy, an immunosuppressive drug may be used in combination, so it is performed at a specialized facility. It is desirable to be treated.The acute phase is reversible, but the chronic phase makes the disorder irreversible.
Kawasaki disease
Kawasaki diseaseIs a systemic vasculitis of unknown cause, and is said to be common in infants and boys under 4 years old. Changes such as erythema formation centered on the BCG inoculation site are not included in the main symptoms of Kawasaki disease, but are specific findings.Skin symptoms vary from those associated with mild redness to those with blistering, crusting, and ulceration.
Rheumatic fever

Endocrine disease

Hematopoietic device

All blood cells are born from the bone marrow in the bone.Hematopoietic stem cells in it are the source of all blood cells.That hematopoiesisStem cellsHowever, it divides and partly differentiates.When it becomes a megakaryocyte, its nucleus comes out and becomes a platelet, a lymphoblast becomes a B cell, and when it is educated in the thymus, it becomes a T cell.Monoblasts become macrophages (macrophages), myelocytes become neutrophils, and erythroblasts become erythrocytes.Among them, neutrophils, T cells, B cells, macrophages, basophils, and eosinophils are called leukocytes.

In childhood cancer, it is a malignant tumor of the hematopoietic organ.leukemiaIs often seen.The most common type of leukemia is acute lymphocytic leukemia (ALL), and conversely, chronic lymphocytic leukemia (CML) is rarely seen.

Idiopathic thrombocytopenic purpura (ITP)

In children, bleeding symptoms such as sudden purpura and epistaxis typically appear after prior infection, often leading to diagnosis.In children, the incidence is 3 to 7 per 2 per year, which is a rare disease.There are two types, acute type and chronic type, which improve within half a year.In the case of children, more than 80% are acute types that heal spontaneously within 6 months, and half of the chronic cases progress within a few years.Gastrointestinal bleeding and intracranial hemorrhage, which are considered to be serious bleeding, often occur within the first few days of the onset of illness. Serious bleeding is observed in about 1%, but the most serious intracranial hemorrhage is about 0.2%.Treatment is intravenous immune globulin (IVIg) or steroids.IVIg is considered to be the fastest and first choice in terms of platelet count recovery.Select IVIg if severe bleeding is present, and consider steroid and platelet transfusions if life-threatening.If the platelet count exceeds 30,000 / μl, the risk of serious bleeding is significantly reduced.However, these treatments are not treatments that cure ITP itself, but treatments that restore platelet counts, and there is a possibility of recurrence due to treatment interruption.

According to the guidelines of the ITP Committee of the Japanese Society of Pediatric Hematology

  • Have bleeding symptoms.
  • In peripheral blood, a decrease of 100,000 / μl or less is observed only in platelets.
  • The bone marrow presents with characteristic ITP findings.This is because the bone marrow megakaryocyte count is not normal or has increased.MegakaryocyteSome of them are immature, both erythroblasts and granulocytes are normal in number, and the granulocyte / erythrocyte (M / E) ratio is normal and totally orthoplastic. Can be given.
  • Being able to rule out various diseases that can cause thrombocytopenia.

These are the diagnostic criteria for ITP.Bone marrow aspiration is required to confirm this criterion.However, the benefit of bone marrow aspiration is to prevent oversight of other diseases such as acute leukemia, and the probability of overlooking leukemia without bone marrow aspiration is less than 1%.It is considered sufficient to perform bone marrow aspiration only when there is an abnormality in the number or morphology of red blood cells or white blood cells, when considering the administration of adrenal steroids, and when high-dose IVIg administration is ineffective.

Disseminated intravascular coagulation (DIC)

Disseminated intravascular coagulation Treatment of (DIC) includes anticoagulant therapy, protease inhibitors, replacement therapy, ATIII,Protein CCan be given.Anticoagulant therapies include heparin (UFH) and low molecular weight heparin (LMWH, fragmin, etc.).Heparin binds to ATIII and inactivates Xa and thrombin, but small molecule heparin has a large anti-Xa activity / antithrombin activity ratio and is said to have a low risk of bleeding.Therefore, small molecule heparin tends to have a better prognosis in terms of survival rate.Known protease inhibitors include gabexate mesylate (GM, FOY, etc.) and nafamostat mesylate (NM, fusan). For GM, the DIC score improves, but there is no data that improves mortality.Replacement therapy includes replacement of coagulation factors and platelets by FFP transfusion.It is said that it is effective when the fibrinolytic hyperfibrinolysis type is accompanied by bleeding symptoms, but the fibrinolytic suppression type rarely causes bleeding symptoms, and there is a cautious opinion. If ATIII is 70 or less, replenishment is considered meaningful.

Neuromuscular disease (Child Neurology (Study))

There are many types of neuromuscular diseases in the pediatrics department, and in general, hundreds of types of diseases are targeted even if it is said that clinical knowledge is necessary at the base hospital at the prefecture level.More specialized knowledge is required of doctors.Therefore relatively quicklyPediatric Neurology-Neurology PediatricsIt has become independent under the name of the department (Tottori University (Showa 46), Okayama University (Showa 54), etc.).The disease classification among neuromuscular diseases is not clearly defined, but it can be roughly divided into the following genres.The above malformative syndromes are often treated clinically by pediatric neurologists as specialists.

Epilepsy, paroxysmal disease

Epilepsy(,), (: There are two types, Paniotopolos type and Gasteau type), (,),Epileptic spasms(West syndrome(Almost synonymous with) is seen relatively frequently.It is often found in babies who have a fever higher than that.Febrile convulsionsCauses seizures but is different from epilepsy.Cry and attract() Is not epilepsy.

Febrile convulsions

Infection / immune disorders in the central nervous system

Meningitis,Brain abscess,Acute encephalitis,Acute encephalopathy,ADEM,Multiple sclerosis,MyelitisSuch.Relatively talked aboutInfluenza encephalopathyIs an acute encephalopathy caused by influenza.The side effects of Tamiflu and influenza encephalopathy are completely different.

Meningitis

Neurocutaneous syndrome (nevus)

Neurodegenerative disease due to inborn errors of metabolism

Each of them contains a lot of diseases, but it is complicated, so only the classification is described below.Glycogen storage disease,,,Lysosome disease,Mucopolysaccharidosis, (,) ,,,Mitochondrial disease,Spinocerebellar degeneration,,Such.

Cerebrovascular disease

As a child-specific diseaseMoyamoya disease··and so on.

Brain tumor

Tumors that develop in children and adults are very different.

Cerebral palsy

Cerebral palsy is a disease in which the brain causes impaired voluntary movements. It is divided into ,,,.There are many misunderstandings such as cerebral palsy = mental retardation, but the definition is an abnormality of voluntary movement, not intelligence.In the athetosis type, there is a disease head in the basal ganglia, and there are many cases of motor disorders without intellectual impairment caused by strong jaundice in the neonatal period.

Muscle disease

Muscle disease gradually destroys musclesMuscular dystrophy, Affected from the distal limbs (forearm, lower leg)Distal muscular myopathy,Myotonia syndrome(Etc.), I have a problem with my strength by natureCongenital myopathyAmong the muscle diseases, the above-mentioned metabolic diseases (glycogen storage diseases), endocrine disorders, and mitochondrial diseases also overlap.It also causes muscle atrophy due to nerves.Spinal muscular atrophy(SMA),Amyotrophic lateral sclerosis, Hereditary motor / sensory neuropathy, etc. are also included depending on the division (often included in the following peripheral neuropathy).Relatively talked aboutDuchenne muscular dystrophy(DMD) Is classified as muscular dystrophy as the name suggests.

Peripheral neuropathy

Spinal muscular atrophy,Guillain-Barre syndrome,,Such.

Child and adolescent psychiatry

manyMental illnessOnset in child and adolescence[1]According to WHO, about 20% of children and adolescents in the world have mental illness / problems.[2].

Pediatric neoplasm

Unlike adults, there are many non-epithelial sarcomas as neoplasms in children, and it is often suggested that they are associated with congenital anomalies such as Down's syndrome.Of particular importance isNeuroblastoma-Hepatoblastoma・ It is a child-specific disease such as nephroblastoma and retinal blast type.others,Brain tumor-Acute lymphocytic leukemia-TeratomaAnd testicular abscesses.Retinoblastoma TheRb geneIs involved and often develops before the age of two.Teratomas often occur on the midline, and bone lesions are unlikely to occur.It tends to occur in the sacrum, gonads, retroperitoneum, and mediastinum.Testicular abscesses often occur with painless swelling of the scrotum between the ages of 2 and 1.Brain tumorUnder 1 year old and over 10 years old occur on the tent, and in the range from 1 year old to 10 years old, it is more common under the tent.This is because there are many cerebellar developmental tumors such as astrocytomas and medulloblastomas.

Abdominal mass

Since there are so many age-specific diseases in childhood, it is not desirable to increase the differentiation unnecessarily, but for the sake of simplicity, the causative diseases of the abdominal mass are summarized.It is a very important field because it includes neuroblastoma, hepatoblastoma, and nephroblastoma.

PartOrgandisease
upper abdomenstomachHypertrophic pyloric stenosis, gastric stenosis, air swallowing
liverHepatoblastoma, liver cancer, hepatitis, hepatic hemangioma, glycogen storage disease, accumulation disease, biliary atresia
spleenInfectious disease, cirrhosis, biliary atresia
PancreasPancreatic cyst, chronic pancreatitis, tumor
Biliary systemBiliary dilatation, cholelithiasis, cholecystitis
Mid abdomenIntestinesIntussusception, double intestinal tract, mesenteric cyst, lymphoma, Crohn's disease
Abdominal wallUrachal cyst, umbilical cyst
MesenteryLymphadenitis, lymphoma
Blood vesselaneurysm
Lower abdomenbladderGiant bladder, urinary retention
IntestinesConstipation, dysphoria, Hirschsprung's disease, lymphoma, enterocolitis, Crohn's disease
uterusWater uterine vagina, pregnancy
OvaryCyst
Lateral abdomenKidneyHydronephrosis, renal cyst, nephroblastoma
Adrenal glandNeuroblastoma, hematoma
OtherWhole abdomenIntraperitoneal abscess

We will summarize the particularly famous hepatoblastoma, nephroblastoma, and neuroblastoma.

Hepatic blastomaNeuroblastomaRenal blastoma
Occurrence siteHepatocytesAdrenal medulla, sympathetic ganglia, etc.Renal tubule
Predominant ageThere is a peak in 1-year-old children, and it is common in menOnset by 3 yearsOnset by 5 years
Physical findingsIrregular surface mass on the right hypochondriumA mass with irregular surface on the left abdomen that exceeds the midlineA tumor with a smooth surface on the left abdomen that does not exceed the midline
Characteristic inspectionAFP is a markerUrinary VMA, HVA, serum NSE marker, X-ray calcificationMalformations of the urinary tract, external genitals, and iris

Neuroblastoma

NeuroblastomaIs the largest prognostic factor with the largest number of MYCN copies. The prognosis is poor in cases amplified 10 times or more.Other DNA ploidy is diploid or low tetraploid. The cases of 2q, 4q, and 1q defects have a poor prognosis.The prognosis is good if the age at the time of discovery is less than 14 year, but the prognosis is poor if the age is 17 year or older.

International stagingMessage
1Complete gross resection for localized tumor.No lymph node metastasis.
2ALocalized tumor with gross non-complete resection, no lymph node metastasis.
2BLocalized tumor with gross or non-complete resection, no ipsilateral lymph node metastasis.
3Unresectable unilateral tumor with infiltration beyond the median.Alternatively, it is a unilateral localized tumor with contralateral lymph node metastasis.Or a midline tumor with bilateral infiltration and bilateral lymph node metastasis.
4Distant metastasis and multi-organ dissemination are observed.

Acute leukemia

Current status of medical practice

Adult OfInternal MedicineSimilarly, in the case of a child's illness, it is the first medical treatment subject to be examined, but the rapid progress of the declining birthrate and aging population, the large number of applicants compared to other clinical departments, and the targeting of children. Aspiring to be a pediatrician because of the heavy burden on workDoctorHas decreased, and some have become a social problem (see:Lack of doctors).New graduate medical students who wish to become pediatricians often witness the rigors of work while undergoing clinical training and are often converted.

Pediatricians often find it most painful in pediatric workOn dutyIt is a business.Night visits at emergency hospitals in the city are most often pediatric.Until recently, most hospitals had a small number of pediatric on-duty doctors.In recent years, reviews have begun, and in order to reduce the burden on pediatricians, intern doctors before deciding on internal medicine or departments often provide medical care.but,Kawasaki disease-Intussusception-BronchiolitisIn many cases, pediatric-specific diseases cannot be diagnosed or treated unless a pediatrician is a specialist, and since the person does not complain, the pediatrician needs a unique feeling based on experience. There are also voices who question today's situation, which may be seen by pediatricians and physicians.

Patients admitted to pediatricsCompulsory educationThere are many age groups who need cancer, and basic education will be insufficient for diseases such as childhood cancer that require a long treatment period.For this reason, some hospitals have set up an elementary school branch in the hospital to temporarily transfer to another hospital and provide in-hospital education (see details).Hospital classSee item).

Source

[How to use footnotes]
  1. ^ Fit Mind, Fit Job --From Evidence to Practice in Mental Health and Work (Report). OECD. (2015-03). P. 40. two:10.1787 / 9789264228283-en. 
  2. ^ 10 FACTS ON MENTAL HEALTH --Mental health: a state of well-being (Report). WHO. (2014-08). http://www.who.int/features/factfiles/mental_health/en/. 

References

Related item

外部 リンク

efficacy

efficacy(Kou) is the effect obtained by the action of a certain substance.MedicineThose that obtain the effect by taking or applying, such asSpalikebathing,Drinking fountainThere are cases where the effect is obtained.The effect of medicinesEffectivenessAlso called (Yukosei).

Efficacy in hot springs

The effect in hot springs isHot springIt has been known to people for a long time as represented by.As mentioned above, its effects can be roughly divided into two types: bathing and drinking hot springs.In addition, there are not only beneficial effects for the human body but also adverse effects, and those that are beneficial are called indications and those that have adverse effects are called contraindications.

Efficacy often depends on the quality of the hot spring.They areHot spring analysis reportDescribed as an indication or contraindication.As a general rule, the hot spring analysis report describes the efficacy based on the quality of the spring.However, the effects that have been handed down to hot springs for a long time can also be determined as the effects after receiving the advice of a specialist.These things1983To the Environment Agency (currentlyMinistry of the Environment) Is based on the "Criteria for determining indications for hot springs".1983The standards stipulated in the above have been revised since 2007, and discussions have begun on revisions.2008Will be revised to.

It should be noted that the efficacy does not guarantee the effect to everyone, but is just a guide.

Effectiveness in medicine

Effectiveness in medicine is an intervention (eg, an intervention).Drug,Medical equipment,Surgical procedure,public healthThe above intervention) is the ability (or therapeutic effect) to make a beneficial change.[1]..Often compared to other interventions available to establish the effectiveness of one intervention[2]..Specifically, efficacy means that the drug is "when tested in ideal circumstances, such as in tightly controlled clinical trials."placeboWhether it shows health benefits to or other interventions "[3]..These studies focus on key parameters to show statistical differences between the placebo and intervention groups.This type of comparison is "descriptive"Randomized controlled trialsCalled, "practical" trials are used to establish the effectiveness of interventions for non-specific parameters.[Source required].

Related item

Source

  1. ^ “3.11 --Mental Health Services Research”. Comprehensive Clinical Psychology. Oxford: Pergamon. (January 1998). Pp. 225–241. two:10.1016 / b0080-4270 (73) 00275-3. ISBN 978-0-08-042707-2 
  2. ^ Nursing research: generating and assessing evidence for nursing practice (Tenth ed.). Philadelphia. (December 2015). ISBN 9781496300232. OCLC 919860667 
  3. ^ Thaul, Susan (2012-06-25) (CRS Report for Congress). How FDA Approves Drugs and Regulates Their Safety and Effectiveness (CRS 7-5700, R41983). Washington, DC: Congressional Research Service (CRS). P. 4. https://fas.org/sgp/crs/misc/R41983.pdf 

 

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