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Emergency Medical Services for Children

The overwhelming majority of the 27 million children who present annually for emergency care in the United States are seen at community hospital emergency departments (EDs). Visits to children's hospital EDs account for just 10% of initial emergency care encounters. This distribution suggests that the greatest opportunity to optimize care for acutely ill or injured pediatric patients, on a population basis, occurs broadly as part of…

Complementary Therapies and Integrative Medicine

Integrative medicine focuses on promoting physical, mental, emotional, spiritual, social, and educational well-being in the context of a medical home in a healthy family and community. The foundations of integrative medicine are health-promoting practices such as optimal nutrition and dietary supplements to prevent deficiencies, avoidance of addictive substances (e.g., nicotine, illicit drugs), physical activity, adequate sleep, a healthy environment, and supportive social relationships. Evidence-based complementary therapies…

Poisoning

Poisoning is the leading cause of injury-related death in the United States, surpassing that from motor vehicle crashes. Most these deaths are unintentional (i.e., not suicide). In adolescents, poisoning is the 3rd leading cause of injury-related death. Of the >2 million human poisoning exposures reported annually to the National Poison Data Systems (NPDS) of the American Association of Poison Control Centers (AAPCC), approximately 50% occur in…

Pediatric Pain Management

Pain is both a sensory and an emotional experience. When unrecognized and undertreated, pain extracts a significant physiologic, biochemical, and psychological toll on both the child and the family. Many disease processes and most interventional diagnostic or treatment procedures in pediatrics are associated with pain. Similarly, traumatic, developmental, cognitive, psychological, and social experiences can also trigger and maintain chronic pain. Definition and Categories of Pain The…

Anesthesia and Perioperative Care

The continuum of anesthesia includes varying degrees of sedation (i.e., mild, moderate, or deep) and general anesthesia. All forms of sedation are characterized by some preservation of purposeful movement (see Chapter 75 ), whereas general anesthesia is defined by the complete loss of consciousness. Potent pharmacologic agents are required to suppress the perception and physiologic response to noxious stimuli. Perioperatively, the anesthesiologist is responsible for providing…

Principles of Drug Therapy

The clinical pharmacology of a given drug reflects a multifaceted set of properties that pertain to not only the disposition and action of drugs, but also the response (e.g., adverse effects, therapeutic effects, therapeutic outcomes) to their administration or use. The 3 most important facets of clinical pharmacology are pharmacokinetics, pharmacodynamics, and pharmacogenomics. Pharmacokinetics describes the movement of a drug throughout the body and the concentrations…

Pediatric Pharmacogenetics, Pharmacogenomics, and Pharmacoproteomics

Interindividual variability in the response to similar doses of a given medication is an inherent characteristic of both adult and pediatric populations. Pharmacogenetics , the role of genetic factors in drug disposition and response, has resulted in many examples of how variations in human genes can lead to interindividual differences in pharmacokinetics and drug response at the level of individual patients. Pharmacogenetic variability contributes to the…

Deficit Therapy

Dehydration, most often caused by gastroenteritis, is a common problem in children. Most cases can be managed with oral rehydration (see Chapter 366 ). Even children with mild to moderate hyponatremic or hypernatremic dehydration can be managed with oral rehydration. Clinical Manifestations The 1st step in caring for the child with dehydration is to assess the degree of dehydration ( Table 70.1 ), which dictates both…

Maintenance and Replacement Therapy

Maintenance intravenous (IV) fluids are used in a child who cannot be fed enterally. Along with maintenance fluids, children may require concurrent replacement fluids if they have continued excessive losses, as may occur with drainage from a nasogastric (NG) tube or with high urine output because of nephrogenic diabetes insipidus. If dehydration is present, the patient also needs to receive deficit replacement (see Chapter 70 ).…

Electrolyte and Acid-Base Disorders

Composition of Body Fluids Larry A. Greenbaum Keywords total body water fluid compartments edema intracellular fluid extracellular fluid osmolality hyperglycemia pseudohyponatremia point-of-care testing Total Body Water Total body water (TBW) as a percentage of body weight varies with age ( Fig. 68.1 ). The fetus has very high TBW, which gradually decreases to approximately 75% of birthweight for a term infant. Premature infants have higher TBW than…

Vitamin K Deficiency

Vitamin K is necessary for the synthesis of clotting factors II, VII, IX, and X; deficiency of vitamin K can result in clinically significant bleeding. Vitamin K deficiency typically affects infants, who experience a transient deficiency related to inadequate intake, or patients of any age who have decreased vitamin K absorption. Mild vitamin K deficiency can affect long-term bone and vascular health (see Chapters 124.4 and…

Vitamin E Deficiency

Vitamin E is a fat-soluble vitamin and functions as an antioxidant, but its precise biochemical functions are not known. Vitamin E deficiency can cause hemolysis or neurologic manifestations and occurs in premature infants, in patients with malabsorption, and in an autosomal recessive disorder affecting vitamin E transport. Because of its role as an antioxidant, there is considerable research on vitamin E supplementation in chronic illnesses. Pathogenesis…

Vitamin D Deficiency (Rickets) and Excess

Rickets Bone consists of a protein matrix called osteoid and a mineral phase, principally composed of calcium and phosphate, mostly in the form of hydroxyapatite . Osteomalacia occurs with inadequate mineralization of bone osteoid in children and adults. Rickets is a disease of growing bone caused by unmineralized matrix at the growth plates in children only before fusion of the epiphyses. Because growth plate cartilage and…

Vitamin C (Ascorbic Acid) Deficiency and Excess

Vitamin C is important for synthesis of collagen at the level of hydroxylation of lysine and proline in precollagen. It is also involved in neurotransmitter metabolism (conversion of dopamine to norepinephrine and tryptophan to serotonin), cholesterol metabolism (conversion of cholesterol to steroid hormones and bile acids), and the biosynthesis of carnitine. Vitamin C functions to maintain the iron and copper atoms, cofactors of the metalloenzymes, in…

Vitamin B Complex Deficiencies and Excess

Vitamin B complex includes a number of water-soluble nutrients, including thiamine (vitamin B 1 ), riboflavin (B 2 ), niacin (B 3 ), pyridoxine (B 6 ), folate, cobalamin (B 12 ), biotin, and pantothenic acid. Choline and inositol are also considered part of the B complex and are important for normal body functions, but specific deficiency syndromes have not been attributed to a lack of…

Vitamin A Deficiencies and Excess

Overview of Vitamin A Vitamin A is a fat-soluble micronutrient that cannot be synthesized de novo by mammals; thus it is an obligatory dietary factor. The term vitamin A is generally used to refer to a group of compounds that possess the biologic activity of all- trans retinol ( Fig. 61.1 ). As a fat-soluble micronutrient, vitamin A is recognized as being essential for all vertebrates…

Overweight and Obesity

Epidemiology Obesity is an important pediatric public health problem associated with risk of complications in childhood and increased morbidity and mortality throughout adult life. Obesity is now linked to more deaths than underweight. In 2014, according to the World Health Organization (WHO), more than 1.9 billion persons ≥20 yr old were overweight or obese. In the United States, 37% of adults are obese, and 35% are overweight.…