General questions of treatment of endocrine diseases in children

June 13, 2018 03:15 | Disease Treatment
The use of hormones for the treatment of various diseases has been known since ancient times. As early as 382-322 years. BC this was indicated in the works of Aristotle and in the papyrus of Eber( 23-79 BC).Numerous indications of the use of "medicines" of animal origin indicate that this was done in accordance with the level of knowledge of that time, that is, purely empirically. Along with the development of medicine, hormone therapy has also evolved - from the use of individual endocrine glands to treat and administer hormones.

The use of hormones began in the early XX century after the release of adrenaline, adrenotropic hormones and, finally, steroid hormones.

Since then, hormone therapy has become a pharmacological basis. This in many ways contributed, in turn, to the development of clinical endocrinology as a separate clinical specialty.

Investigations in the field of methods for isolating and obtaining purified hormones, and in particular determining the properties of hormones and their effect on the body as a whole, new studies on the interaction of hormonal and nervous factors - all this led to a significant expansion of the scope of hormones.

Currently, hormones are widely used in the therapy of not only endocrine, but also non-endocrine diseases.

A huge influence on the therapy of a number of diseases was provided by the isolation of steroid hormones and the realization of their synthesis in relatively large quantities. Steroid therapy has literally revolutionized the treatment of a number of diseases in adults.

The use of hormone therapy in pediatrics was somewhat slower. There have been only separate attempts to apply hormones for the treatment of mainly endocrine diseases in children( substitution therapy).

One of the first organ preparations used in pediatrics was thyroid medications with myxedema. AA Kisel is one of the pioneers of this type of therapy.

A great contribution to the elucidation of the role of individual hormones in a number of diseases in children was made by VI Molchanov.60 years ago he conducted clinical-experimental studies on the role of adrenal glands in the pathogenesis of toxic diphtheria, which he published in 1909 as a monograph, which were exceptional in interest and importance for scientific and practical pediatrics. Adrenals and their changes in diphtheria still pay attention in domestic and foreign literature, because Molchanov convincingly proved the connection between adrenal changes and a number of severe cardiovascular disorders in toxic diphtheria.

He also proposed a technique for studying the content of adrenaline in the blood in children.

The study of the role of hormones was further developed in the works of VI Molchanov and his school, devoted to the study of the clinic of disorders of growth and development in children. In fact, these are the only works of that time for children's endocrine pathology, not only in the domestic, but also in the foreign press.

A significant contribution to the development of hormonal therapy in children was made by GN Speransky, Yu. F. Dombrovskaya, OD Sokolova-Ponomareva, RL Hamburg, DD Sokolov, and others.

At present, hormonotherapy has takenone of the important places in the therapy of childhood diseases. Every year, the use of hormones takes an increasing scale in the treatment of non-endocrine diseases in young children. This was largely facilitated by the production of cortisone, prednisone, prednisolone, etc., the appearance of anabolic steroids and their successful use in the treatment of many diseases.

The widespread introduction of hormonal therapy in pediatrics has a very favorable effect on the results of treatment of many diseases.

However, hormonal therapy should be used in children's practice according to strict indications. It should be borne in mind that hormone therapy often has many negative aspects;there are certain indications and contraindications to hormone therapy in children. It is necessary to know well and necessarily take into account the possibility of side effects with hormone therapy on a growing organism.

The main feature of endocrine diseases in children is the impact of these diseases on the growth and development of the child's body.

Unlike adults, all the symptoms of endocrine diseases in children are closely associated with disruption of growth processes( from easy delay to complete cessation) or rapid growth. The development of the nervous system is also closely related to the hormonal function. With many endocrine diseases, there are clear violations in the development of the child's psyche.

Endocrine diseases in children often lead to significant violations of sexual development in the direction of hypogonadism, as well as significant hypergonadism. Often a pediatric endocrinologist has to meet with signs of heterosexual development.

Treatment of endocrine diseases in children is a complex task that requires the competence of a number of specialists: pediatric endocrinologist, urologist, gynecologist, ophthalmologist, psychiatrist, neurologist, surgeon.

In a number of cases, only an integrated approach of many specialists can provide a correct solution to the question of the tactics of treating an endocrine patient.

In the treatment of endocrine diseases in children, the issues of medical examination are of great importance.

In the treatment of endocrine diseases in children, it is important not only the proper administration of a hormonal drug. Often, general health improvement measures( improvement of sanitary conditions and sanitary and hygienic conditions), proper nutrition, often special therapeutic nutrition, adherence to the regime are of great therapeutic importance.

The use of sex hormone drugs in childhood often causes pediatricians many questions.

The main manifestation of the effect of sex hormones on the body is the development of secondary sexual characteristics: the formation of features of the structure of the figure inherent in this sex;the development of axillary trunks and pubic region, men - an increase in the growth of mustache and beard, in women - the mammary glands. Male sex hormones, in addition, contribute to the development of muscles, cartilage of the larynx( which, in turn, causes a decrease in the tone of the voice), the growth of the penis. Female sex hormones cause an increase in the size of the vagina, the uterus, the appearance of menstruation.

In addition, sex hormones promote the maturation of the skeleton, speeding up the closure of the "growth zones" of the tubular bones.

Sex hormones necessary for the correct formation of a developing organism normally begin to be produced in the body of the child with entry into pubertal age( from 10-12 years in girls, from 12-13 years in boys).Therefore, their use with a therapeutic purpose before this age is not shown.

The use of sex hormones can be of the nature of "substitution therapy" or be prescribed to stimulate the function of the sex glands.

Substitution therapy is performed when there are no own sex glands( castration, agonadism, anarchism) or there is no hope for restoration of their function( deep atrophy after the transferred infections, intoxications).Substitution therapy should be carried out continuously, starting with puberty and throughout the whole adult age. At boys it is carried out continuously, dosages are selected individually. To achieve a good development of secondary sexual characteristics, higher dosages are initially required. After achieving the desired results, it is possible to switch to maintenance therapy in slightly smaller doses, depending on the individual characteristics of the organism, its sensitivity to hormonal drugs.

In girls, it should be cyclic, imitating the normal cycles of women. At the beginning of treatment, only estrogens are usually applied in cycles of 20 days with a break between cycles of 10 days, in gradually increasing dosages. When a sufficient development of secondary sexual characteristics and the appearance of induced menstruation can be achieved, one can proceed to normal therapy by adding the hormone of the yellow body to the phase of the simulated cycle. Overdose of estrogens can be expressed in the appearance of mastopathy, uterine bleeding. In such cases, treatment should not be canceled, it is only necessary to reduce the dosage of estrogens, having selected them individually.

Stimulation therapy is carried out in those cases when the function of their own sex glands is somewhat reduced, the sexual development slightly lags behind the age norm. However, it should be done with caution, minimal doses and no more than 2-3 consecutive courses, remembering that an overdose of injected sex hormones can cause oppression of the gonadotropic function of the pituitary gland and thus will not improve the function of your own sex glands, but can finally stop it.

Regulatory therapy is performed in girls with juvenile bleeding. The best results are obtained in such cases by cyclic administration of the hormones of the yellow body for 4-5 courses in a row. Indication for the continuation of treatment is the resumption of bleeding after discontinuation of the drug. Side effects of the hormone of the yellow body does not cause.

And, finally, the use of radiation therapy. Radiation treatment of children with endocrine diseases occupies a significant place in the overall complex of therapeutic measures. The object of radiation exposure are endocrine glands, affected by a tumor, inflammatory or dystrophic process.

Most often remote methods of therapy are used: X-ray therapy and gamma-therapy, more rarely - radiation and high-energy radiation. In this case, it is always necessary to take into account the strong biological effect of penetrating radiation and the high sensitivity of the growing organism to it. As is known, ionizing radiation has a biological effect on all tissues of the body. The basis is a damaging effect, which affects one or another degree of disruption of the function and structure of living tissues. The task of the attending physician is to direct the effect of ionizing radiation on the pathological tissue and protect all neighboring healthy tissues from destruction by all measures of protection. The injurious effect of radiation treatment methods in a child is higher than that of adults, and this places a great responsibility on the doctor. At present, the opportunity has been obtained to irradiate the pathological focus in any dose necessary for each specific case without noticeable changes on the skin. To a lesser extent, shaking deeply located organs and tissues is achieved. At the same time, responsibility is greatly increased and constant monitoring of the doctor for the patient is required. The doctor must take into consideration the reaction of the sick child comprehensively.

The solution of technical, physical and dosimetric problems allowed to more successfully study the radiobiological problems associated with radiation therapy, and closer approach to the implementation of its main principle - to irradiate only the pathological focus with minimal impact on surrounding normal organs and tissues, given their low tolerance. These issues are especially important in pediatrics. With the use of all modern achievements in physics and radiobiology, radiation treatment is a highly effective method.

The successes of radiation treatment of endocrine patients are unquestionable, however, the questions of methodology, the magnitude of the dose, need to be clarified.

When selecting the method of irradiation of a pathological focus, it is necessary to take into account its dimensions, depth of occurrence, anatomical and topographical features of the given area, as well as the physical characteristics of the radiation used and the features of its absorption by individual tissues. The increase in the relative deep doses due to the increase in the size of the irradiated field can not be used because of the increase in the secondary radiation. A technique has been developed for irradiating a pathological focus from several skin fields, i.e., multi-field cross-irradiation, but it does not always provide the desired energy distribution in pathological and healthy tissues due to inadequate centering upon irradiation. In some cases, the way out of these difficulties is found by using rotational( mobile) radiation, during which the source of radiation or the patient moves. With this method, a deep dose of radiation is greatly increased.

Taking into account the peculiarities of the reactions of the growing organism to the radiation effect and the long-term consequences of radiation therapy in children, it is necessary to approach the appointment of both single and total doses of radiation very responsibly. Radiation therapy in a child should be carried out under the supervision of a thorough study of the reactions to irradiation. In the appointment of a single dose, the intervals between exposures and the total dose, individual indications must be taken into account.

The high sensitivity of a growing organism to ionizing radiation obliges to reduce the irradiation of a child in every possible way. This is possible with combined methods of treatment. At present, the combination of surgical and radiotherapy is most widely used in children. Children undergoing radiation treatment need vitamin therapy, a complex of general and local activities( see the relevant sections of the book).

Radiation therapy in children suffering from tumors( especially malignant) is undoubtedly shown. Widely testified to the radiation treatment of interstitial-pituitary diseases( acromegaly, Itenko-Cushing's disease, etc.).
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