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Table of contents

1. The structure and organization of the work of the children's polyclinic (Pediatric department. The structure of the children's city polyclinic)
2. Supervision of healthy children. Antenatal protection of the fetus
3. neonatal period. Patronage for a newborn. First patronage for a newborn. Second patronage for a newborn. Third patronage for a newborn. Features of monitoring and rehabilitation of premature and post-term newborns
4. Groups at risk of health disorders. Schools for future parents
5. Observation of the child in the postnatal period
6. Observation of children of the early childhood period
7. Supervision of children of preschool age in the clinic
8. Observation of school-age children in the clinic. The work of a pediatrician in a school
9. Immunoprophylaxis
10. Rehabilitation of children after illness. Disability (Disability. Rehabilitation process)
11. Rehabilitation of gastroenterological patients (Esophagitis. Gastritis. Duodenitis, gastroduodenitis. Enteritis, colitis (enterocolitis). Pancreatitis. Diseases of the biliary system. Chronic hepatitis. Establishment of disability for children with diseases of the digestive system)
12. Rehabilitation of children with metabolic diseases (Hypotrophy. Obesity. Diathesis. Rickets. Spasmophilia)
13. Rehabilitation of children with diseases of the cardiovascular system (Congenital heart defects. Congenital carditis. Acquired carditis. Rheumatism. Heart failure. Arterial hypertension. Arterial hypotension. Hemorrhagic vasculitis (Schonlein-Henoch disease). Nodular periarteritis. Disability of children with diseases of the circulatory organs)
14. Rehabilitation of children with juvenile rheumatoid arthritis
15. Rehabilitation of children with diseases of the urinary system (Acute glomerulonephritis. Chronic glomerulonephritis. Rapidly progressive glomerulonephritis. Pyelonephritis. Urinary tract infection. Interstitial nephritis. Urolithiasis. Disability of children with diseases of the urinary system)
16. Rehabilitation of children with blood diseases (Iron deficiency anemia. Protein deficiency anemia. Vitamin deficiency anemia. Hemolytic anemia. Hemophilia. Thrombocytopenic purpura. Leukemia. Disability of children with blood diseases)
17. Rehabilitation of children with diseases of the respiratory system (Bronchitis. Chronic pneumonia. Acute pneumonia. Alveolitis. Bronchial asthma. Disability of children with diseases of the respiratory system)

LECTURE No. 1. Structure and organization of the work of a children's clinic

Outpatient care for the children's population occupies a leading position in the general health care system and is carried out with the help of a wide network of children's polyclinics and polyclinic departments.

The children's polyclinic is a state institution. It can be an independent institution or be part of a children's city hospital, citywide or central district hospital.

The children's city polyclinic provides medical and preventive care to children from birth to 14 years old inclusive. The provision of medical care is carried out directly in the clinic, at home, in preschool institutions and schools.

The children's polyclinic performs the functions of organizing and conducting a set of preventive measures (dynamic medical supervision of children of various age groups, the frequency of their comprehensive examinations by doctors of narrow specialties); medical consultative care at home and in the clinic; rehabilitation with the use of sanatorium and resort treatment at the respective resorts, medical and preventive care in preschool institutions and schools; carrying out anti-epidemic measures and vaccination immunoprophylaxis.

The categorization of a children's polyclinic is determined by the number of children served, which is updated annually by a census conducted by district patronage nurses.

Currently, there are 5 categories of children's polyclinics, depending on the planned number of visits per day: the first category - 800 visits; the second category - 700 visits; the third category - 500 visits; fourth category - 300 visits; fifth category - 150 visits.

The structure of the children's polyclinic should include such departments as pediatric, specialized care, medical rehabilitation, pediatric department for providing medical care in organized groups.

1. Pediatric department

Provides medical and preventive care to children both in the clinic and at home. This system creates optimal opportunities for continuous monitoring of children by the same doctor and nurse, makes it possible to accurately assess the development and health of the child in dynamics, taking into account the conditions in which he lives and is brought up. The work of the department is based on the district principle.

At the medical site, the number of children from birth to 15 years old should not exceed 800. For their service, 1 position of a pediatrician and 1,5 positions of a nurse are provided.

The main figure providing medical care to children in the polyclinic, despite a significant increase in the volume of specialized care, is the local pediatrician.

The goals of the local pediatrician: to achieve a reduction in morbidity and mortality in children of all ages; to carry out activities aimed at creating optimal conditions for the physical, mental, sexual and immunological development of the child, to carry out specific and non-specific prevention.

Tasks of the local pediatrician:

1) ensuring contacts and continuity in work with doctors of the antenatal clinic for monitoring pregnant women, especially those at risk;

2) visiting newborns in the first 3 days after discharge from the maternity hospital, as well as monitoring the patronage of newborns by the district nurse;

3) reception of healthy children in the clinic, assessment of their physical and mental development, appointment, depending on the age and condition of the child, of a regimen, rational nutrition, recommendations for specific and non-specific prevention of rickets, malnutrition, obesity, anemia;

4) organization at home and in the clinic of preventive monitoring of children, especially of early and preschool age; as necessary, sending them for laboratory research and consultation of other specialists;

5) drawing up a plan of vaccination work and monitoring its implementation together with the district nurse, dynamic monitoring of healthy and sick children, implementing, together with other specialists, the rehabilitation of registered children, analyzing the effectiveness of dynamic monitoring;

6) organizing the examination and rehabilitation of children before they enter preschool institutions and schools;

7) visits to the parents of children at home in case of their illness, the provision of drug and physiotherapy care, exercise therapy, if necessary, active monitoring of the patient at home until his recovery, hospitalization or permission to visit the clinic;

8) sending children for treatment to a hospital, if necessary, taking all measures for emergency hospitalization of the patient;

9) informing the management of the polyclinic about cases when, for some reason, a seriously ill child remains non-hospitalized;

10) timely and in the prescribed manner informing about the detection of an infectious disease or suspicion of it, comprehensive prevention of infectious diseases;

11) selection and appropriate accounting of children in need of sanatorium and resort treatment for health reasons.

The doctor and nurse working at the pediatric site conduct planned health education work with the child's parents, promote a healthy lifestyle, explain the harm of alcoholism and smoking in families.

Each polyclinic usually organizes the work of the most necessary specialists: an otolaryngologist, a surgeon, an oculist, a neuropathologist, a cardiorheumatologist, and a dentist.

More narrow specialists, such as an orthopedist, urologist, nephrologist, endocrinologist, doctor of functional diagnostics, are introduced into the staff of one of the children's polyclinics of the district and serve all the children of the administrative territory.

Medical specialists should build their work in close contact with pediatricians and accept patients mainly in their areas.

Certain types of specialized medical care for children are provided in dispensaries: psycho-neurological, dermatological, oncological, anti-tuberculosis, deaf and speech therapy, - in the states of which positions of children's doctors are provided.

Also, the composition of the children's clinic must necessarily include a department of medical rehabilitation, containing rooms for physiotherapy, physiotherapy exercises, and massage. The main contingent of patients in the rehabilitation department are children with diseases of the respiratory system, nervous system, musculoskeletal system, and ENT. Patients are referred to this department by heads of structural subdivisions of healthcare institutions. Reception and selection of patients are carried out by the medical consultative rehabilitation commission of the polyclinic. Patients are admitted to the department after stopping the acute period of the disease or its exacerbation, as well as disabled people with an individual rehabilitation program.

Tasks of the Department of Medical Rehabilitation:

1) a peculiar formation of an individual program of rehabilitation and the use of rehabilitation means and methods;

2) implementation of an individual rehabilitation program for the disabled and sick;

3) the use of a complex of all necessary methods and means of rehabilitation;

4) conducting explanatory work among the population and sick children about the means and methods of restoring and strengthening health.

Pediatric department for the provision of medical care in organized groups

Pediatric departments have been established in preschool institutions and schools to provide medical and preventive care to children. Their tasks include monitoring sanitary and hygienic conditions, the regime of educational work and labor education, protecting the health of children and reducing their morbidity, improving their physical education and hardening in preschool institutions and schools. Employees of such departments conduct scheduled preventive examinations in kindergartens and schools. Doctors of children's educational institutions carry out dispensary observation of sick children, are engaged in their rehabilitation: they control the alternation of classes and rest, nutrition and physical education of preschoolers and schoolchildren. They provide medical assistance to children attending kindergartens and schools.

2. The structure of the children's city polyclinic

In a children's city polyclinic, there should be provided: a filter with a separate entrance, an isolation room with a box (at least two), a reception desk, a wardrobe, offices (pediatricians, doctors of narrow specialties, medical diagnostics, first-aid appointments, for raising a healthy child, X-ray, physiotherapy, procedural, vaccination, physiotherapy, massage, social and legal assistance, statistics), laboratory, administrative part, other auxiliary premises.

In the clinic, in places convenient for viewing (halls, corridors), it is necessary to hang out colorfully designed posters, stands informing about the development and principles of raising a healthy child, preventing diseases, visual impairment, hearing impairment, musculoskeletal system and other topics.

A special stand should contain up-to-date information on cases of infectious diseases and quarantine periods in preschool institutions and schools, which allows you to quickly implement anti-epidemic measures.

The registry is an important structural link both in organizing services for children in the polyclinic and in providing them with medical care at home. The main task of the registry is to ensure the mutually coordinated activities of all departments.

On weekends and holidays, doctors on duty work at the polyclinic, who conduct outpatient appointments and provide home calls. The number of doctors on duty depends on the number of children in the area of ​​the polyclinic and the workload on these days; on Saturdays, receptions of specialist doctors are organized, and, if possible, procedural, vaccination, physiotherapy and other rooms work. To eliminate queues at the registry office and for the convenience of the population on the day of admission to the clinic, there is a preliminary appointment with doctors for all days of the week by phone, early issuance of coupons indicating the date and hour of appearance, as well as preliminary self-registration for an appointment.

In the latter case, a folder with self-recording sheets for a certain day is created for each doctor. Each line of the sheet contains the hours and minutes of the reception. When self-recording, parents choose the most convenient time for them and enter the child's passport information.

Doctor's house calls, transmitted by phone, during a personal visit to the registry or in the order of self-recording, are entered in the doctor's house call record book, separate for each section. When accepting a call to the house, the registrar necessarily specifies the patient's condition, main complaints, body temperature. He immediately informs the district pediatrician about cases of a serious condition, in the absence of the latter - to the head of the outpatient department or the head of the outpatient clinic.

Parents should know that a doctor should be called to the house in case of an acute infectious disease or suspicion of it, in a serious condition of the patient, in case of a primary disease, on an asset per child discharged from the hospital, in the presence of contact with an infectious patient.

The first aid room is an independent structural unit and reports to the senior nurse of the polyclinic.

Children and their parents turn to it for control feeding, treatment of microtraumas, issuance of certificates of the epidemiological situation at the place of residence, drawing up extracts from development histories and referrals for various types of research before determining children in preschool institutions or when entering school, leaving for children's sanatoriums and summer health facilities.

Anthropometric measurements, determination of body temperature and blood pressure in children before examination by a pediatrician are also carried out in the first aid room.

The office of a healthy child - a structural subdivision of the children's polyclinic - plays the role of a methodological center for preventive work among young children.

The main task of the healthy child's office is to teach young mothers theoretical knowledge and practical skills on care, upbringing, developmental features of healthy children of early and preschool age. For an office, it is advisable to have a bed for a young child with a set of bedding; the simplest arena; baby stroller; changing table; medical scales; stadiometer; children's table; high chair for children; a glass cabinet for baby care items (in which medical thermometers and for measuring the temperature of water and air are laid out on the shelves, a rubber bulb, jars for cotton wool and pipettes, a gas tube, vaseline oil, potassium permanganate, an alcohol solution of brilliant green, boric acid in powder , baby cream, bottle of 30-100 ml for water, nipples for feeding and drinking; baby soap), a locker for baby clothes with folded undershirts, flannel diapers (100 X 120 cm), cotton (same size), diapers, scarf , bonnet, sliders; toy cabinet, baby food sample cabinet; baby bath.

Of the visual aids, stands are needed that contain information about the nutrition and regimen of a pregnant woman and a nursing mother, prevention of hypogalactia, prenatal care, daily routine, indicators of physical development, age-related massage and gymnastics complexes, methods of hardening children in the first three years of life.

In the office of a healthy child, local pediatricians receive healthy children of the first year of life. Here it is advisable to organize group appointments for children of the same age or with the same deviations in health. The district nurse invites 3-4 children for one time (with a short interval).

When the doctor accepts the second child, the nurse of the office teaches the mother of the first examined baby how to massage and gymnastics, gives her instructions, and the district nurse prepares the next patient for the reception.

After receiving the last of the children invited for a group examination, the doctor conducts a conversation with mothers about the upbringing of children of this age or with this type of deviation in health.

The office is working on the prevention of rickets. In the classroom, parents get acquainted with the anatomical and physiological characteristics of the body of a one-year-old child, changes in his psychophysiological development.

The pediatric office is placed in a room isolated from noise with sufficient lighting, good ventilation and uniform air temperature (not lower than 20-22 ° C). The office is equipped with a table for the doctor, chairs, a changing table for examining young children and a couch for examining older children, a sink with hot and cold water, a height meter, and baby scales. It should have a small table for medical instruments, a spatula, a centimeter tape, toys.

Currently, among low-income and socially disadvantaged families, the primary task for a pediatrician is to conduct preventive conversations about hygiene standards and rules of care, as well as raising children of different age groups.

The most relevant topics of sanitary propaganda for the local pediatrician, depending on the age of the child:

1) rules for care, rational feeding, a set of measures for hardening, prevention of rickets - for parents with infants;

2) observance of the daily routine, methods of hardening measures, prevention of acute respiratory diseases, specific prevention of childhood infections - for parents of children of younger and older toddlers;

3) instilling personal hygiene skills, hardening methods and hygienic gymnastics, prevention of acute childhood infections, allergic and infectious-allergic diseases, childhood injuries - for parents with children of preschool age;

4) prevention of postural disorders, myopia, rheumatism and other infectious-allergic diseases, neuroses, issues of sexual education - for parents with school-age children, teachers and schoolchildren themselves. The effectiveness of health education is enhanced by the use of visual aids, as well as by providing parents with specially selected literature for self-study.

In sanitary-educational work on hygienic education, the organization of schools for young mothers, fatherhood schools, public universities for parents at preschool institutions is widely practiced.

Particular attention in matters of hygienic discipline should be given to children who have already suffered serious illnesses and are in remission.

Dieting, limiting physical activity, physiotherapy exercises and moderate hardening procedures prevent relapses. In these cases, one should not neglect conversations with the child himself, explaining to him the need for these temporary measures, preventing unforeseen psychological breakdowns.

LECTURE No. 2. Observation of healthy children. Antenatal protection of the fetus

All healthy children are subject to medical supervision. Its main goals are to identify premorbid deviations in the health of the child and conduct timely rehabilitation.

The order and frequency of medical examinations are provided for by the current orders and methodological recommendations of the Ministry of Health and depend on the age of the child.

If the child belongs to the I group of health, then observation in accordance with the presented scheme is considered sufficient. If the child belongs to the II, III, IV or V group, then he needs rehabilitation.

The effectiveness of the work of a district doctor with a healthy child is assessed annually in terms of physical, nervous and mental development, resistance and reactivity of the body, the functional state of the main organs and systems, the presence or absence of chronic diseases (including congenital and hereditary).

Antenatal protection of the fetus

After the pregnant woman is registered in the antenatal clinic, the information is transferred by phone to the children's clinic and recorded in a special journal.

The first prenatal care for a pregnant woman is carried out by the district nurse of the children's polyclinic. The purpose of patronage is to collect an anamnesis and instruct the expectant mother.

When taking an anamnesis, it is necessary to pay attention to 3 groups of prenatal risk factors:

1) socio-biological;

2) obstetric-gynecological (including complications of pregnancy and the condition of the fetus);

3) extragenital diseases of the mother.

To assess the degree of risk, a scale of significance of prenatal risk factors is used.

The high-risk group includes pregnant women with a total assessment of prenatal risk factors of 10 points or more, medium risk - 5-9 points, low - up to 4 points. Over time, the low-risk group, as a rule, decreases by childbirth, while the middle and high-risk group increases. It is also necessary to pay attention to heredity, the moral and psychological climate in the family, to find out whether this pregnancy is desirable or accidental.

The briefing deals with healthy lifestyle issues and the possibility of reducing the identified risk factors. The nurse invites future parents to the "School of a young mother", which operates in the department of a healthy child.

The information received and these recommendations are carefully recorded in the history of the child's development (f. No. 112) under the heading "First prenatal care". The district doctor gets acquainted with the results of patronage, if necessary, visits a pregnant woman at home. Together with an obstetrician-gynecologist and a district therapist, he takes part in attracting the administration at the place of work to improve working conditions, organizes legal advice from a lawyer, and gives recommendations on improving diet and health improvement.

The second antenatal care is carried out at the 31-38th week of pregnancy by the district nurse. Its main goals are to verify the implementation of previously given recommendations, re-evaluate risk factors and prepare for the postpartum period.

When collecting an anamnesis, the nurse re-evaluates prenatal risk factors, clarifies information about heredity and the moral and psychological climate in the family, readiness to raise a child.

The briefing includes questions such as:

1) breastfeeding (advantages over artificial feeding, preparation of the mammary glands, prevention of mastitis and hypogalactia);

2) organization of a zone for servicing a child (a place for dressing and swaddling, clean clothes and linen, bathing, a first-aid kit for children, a crib - a sleeping area where a newborn can be safely placed);

3) acquisition of a dowry for a newborn;

4) purchase of a first aid kit for mother and child, which should contain: sterile cotton wool and bandages, baby powder and cream, potassium permanganate, 5% iodine solution, furatsilin tablets, vaseline oil, 1% aqueous solution of brilliant green, rubber heating pad , children's enema No. 3, gas tube, thermometer for measuring body temperature and water thermometer, pipettes;

5) information about the phone numbers of the polyclinic and pediatric emergency care;

6) conversations with the expectant mother and other family members, preparing for the birth of the child.

Information and recommendations are recorded in the history of the development of the child (f. No. 112) under the heading "Second prenatal patronage."

LECTURE № 3. Neonatal period. Patronage for a newborn

After the newborn is discharged from the maternity hospital, information is transferred by telephone to the children's clinic, where the full name of the mother, the address and date of birth of the child are recorded in the newborn visit log. During the first three days after discharge from the maternity hospital, the district doctor and nurse perform the first patronage of the newborn. Children with risk factors, congenital anomalies and diseases, premature or overdue children, as well as the first child in the family, should be examined on the first day after discharge from the maternity hospital.

1. First patronage for a newborn

An anamnesis is collected to identify and clarify risk factors, an objective examination of the child, instructions to the mother and paperwork (form No. 112).

Anamnesis includes the collection of social, biological and genealogical information. The parameters of the social anamnesis are: the completeness of the family and the psychological climate in it, housing conditions, material security, the level of sanitary and hygienic conditions for caring for the child and the apartment, lifestyle. The biological history covers the features of the antenatal period, the state of health of the mother and child, the genealogical history - the state of health of parents and relatives (at least 3 generations). The mother gives the doctor the exchange card received upon discharge from the maternity hospital. It contains information about pregnancy and childbirth, the condition of the child at birth (Apgar score), the main parameters of physical development (body weight, body length, head and chest circumference), health group and risk group.

Objective examination

An objective examination is carried out by systems. Congenital malformations, symptoms of intrauterine infection and purulent-septic diseases, birth trauma should not go unnoticed.

The skin of a newborn should be pink, clean and velvety. Changes in the color of the skin (cyanosis, icterus, earthy shade and pallor) require a special examination. Sweating and diaper rash indicate care defects. Turgor and elasticity of the skin matter. With pustules on the skin, purulent discharge from the umbilical wound or hyperemia around the navel, it is necessary to send the child to the hospital for examination and treatment.

The posture of the newborn may be physiological or pathological (posture "frog", "pointing dog"). In a physiological posture, the tone of the flexors of the arms and legs predominates ("embryonic" posture). Forced position indicates pathology.

The head of a newborn is rounded. Sometimes it may have a cephalohematoma (subperiosteal hemorrhage as a result of a birth injury). The size of the large fontanel ranges from 1 to 3 cm in medians. The small fontanel in most newborns is closed. The bulging of the fontanel above the level of the bones of the skull, the suffering facial expression indicate an increase in intracranial pressure (with hydrocephalus, meningitis, cerebral hemorrhage). Such a child should be observed by a neurologist.

When examining the eyes, the pupils should be symmetrical, with a lively reaction to light. Nystagmus, a symptom of the "setting sun" usually indicate a severe pathology of the central nervous system and the need to consult a neurologist. Underdeveloped and low-lying auricles can be combined with congenital malformations of the internal organs and deafness. When examining the pharynx, pay attention to the soft and hard palate to identify a hidden cleft and arcuate configuration. The frenulum of the tongue may be shortened, and if this leads to a violation of the act of sucking, its surgical correction is necessary.

The chest is actively involved in the act of breathing, it is symmetrical. Pay attention to the frequency and nature of breathing, percussion and auscultation data during examination of the lungs and heart. It should be remembered that congenital heart defects occupy the first place among other congenital malformations. Their first manifestation may be a coarse murmur detected on auscultation for the first time in the neonatal period. With auscultation of wheezing in the lungs, the child needs to be examined in a hospital. It should be remembered that percussion data in a newborn are more reliable than auscultation data, since due to the thin chest, breathing is well carried out from one half of the chest to the other, which makes it difficult to fix weakened breathing.

The abdomen is palpated counterclockwise. The edge of the liver can normally be lower than the costal arch by 1-2 cm. When palpation of pathological formations, the child should be sent for an ultrasound scan of the abdominal organs.

The genitals should be shaped according to the sex and age of the child.

Limbs. The legs, bent at the hip joints at an angle of 90 °, can be retracted until they completely touch the table surface. With a congenital dislocation of the hip, a dull click will be heard. Paralysis of ErbaDuchen and Dejerine Klumpke indicate a birth traumatic injury to the brachial plexus.

The nervous system and mental development are assessed by observing the child and communicating with him - by activity, look, and the severity of unconditioned reflexes. The reflexes of the greatest diagnostic significance are: sucking, searching, grasping, crawling, protective, support and automatic walking, Babkin's reflex. Tendon reflexes, their symmetry, muscle tone are determined.

briefing

Parental briefing deals with child care, feeding and upbringing.

Recommendations for care. Cleanliness is important for the health of a newborn. The crib should be placed in a bright place in the room, but not in a draft. The newborn is placed in the crib on its side, without a pillow. The air temperature is maintained at 20-22 °C.

Bathing is done daily in a special baby bath, which is not used for washing diapers or baby clothes. Duration of bathing - 10 min.

You can bathe your baby in the morning or in the evening. The best time is in the evening, before the last feeding, as this improves the baby's nighttime sleep. Before bathing in the first 2 weeks, the bath should be scalded with boiling water. A newborn should be bathed in boiled water until the umbilical wound has healed. Water temperature 37-38 °C. Water is poured into the bath so that it covers the bottom. It is good to add decoctions of herbs (sequence, chamomile) to the water. The child should be gradually immersed in water, wrapped in a diaper, so as not to cause anxiety. With one hand they support the head of the child, and with the other they wash him.

For washing it is convenient to use an individual soft sponge. Soap is used 2 times a week, only for children. After bathing, the child is laid face down on the palm, clasping the chest, and rinsed with water from a jug. Then you should dry the skin of the child with a towel, while making blotting movements. It is especially important that the skin folds are dry.

They are treated with baby cream, powder or boiled sunflower oil. Each mother chooses her own skin care products for the child. The area of ​​the umbilical wound is treated with a solution of brilliant green or a 5% solution of potassium permanganate, or a 5% solution of iodine.

Morning toilet - every morning after the first feeding, the child is washed with a cotton swab moistened with warm boiled water, eyes - from the outer corner to the inner, with a separate swab for each eye. The nose is cleaned with cotton turundas moistened with vaseline oil.

Swaddling is an important aspect of newborn care. Recommend free and wide swaddling. For free swaddling, the child is put on a vest with sewn-in sleeves. Legs are wrapped in a blanket. The chest remains free, which facilitates breathing and serves as a prevention of lung diseases. For wide swaddling between the thighs, an additional diaper is laid, due to which the thighs remain in a state of dilution, which contributes to the reduction of the femoral head into the acetabulum and is a conservative treatment for congenital hip dislocation.

Walks in the fresh air should begin immediately after discharge from the maternity hospital. The first time the duration of the walk is 5 minutes at a temperature not lower than -10 °C. In order to adapt to the environment, the duration of walks is increased gradually, adding 5 minutes daily. Walking is contraindicated in case of illness of the child. They should be resumed after recovery, gradually increasing the duration.

Proper feeding of the newborn ensures its timely harmonious development and forms immunity. Attaching the baby to the breast immediately after birth stimulates lactopoiesis. It is necessary to explain to the mother the advantages of breastfeeding and to recommend breastfeeding at the request of the child during the period of lactation. When breastfeeding, a very important emotional contact is established between mother and child, which favorably affects the psycho-emotional state of the mother and the formation of the child's personality. It is necessary to alternate feeding with each mammary gland. To determine the amount of milk eaten by a child, control weighing is used.

Before feeding, the mother should put on a scarf, wash her hands with soap and express one drop of milk. Most often, difficulties in breastfeeding are due to the irregular shape of the nipples, their cracks. To improve the shape, gently pull the nipples for 2-3 minutes 3-4 times a day. For the treatment of cracks, 1-5% synthomycin liniment, 0,2% furatsilin ointment, calendula ointment can be used. After using these products, before feeding the baby, the breast should be thoroughly washed with warm water and baby soap.

Sometimes breastfeeding is contraindicated. This may be due to the condition of the mother or child. Contraindications to breastfeeding by the mother include kidney, heart failure, malignant tumors, severe blood diseases, severe infectious diseases (such as tuberculosis, meningitis, diphtheria, tetanus, etc.).

The child is not applied to the breast in case of severe intracranial birth trauma, respiratory, heart failure, deep prematurity with the absence of sucking and swallowing reflexes, hemolytic disease of the newborn (if antibodies in high titer are found in the mother's milk), hereditary metabolic disorders (phenylketonuria, galactosemia, etc. .). All these conditions are absolute contraindications. Maternal mastitis is a relative contraindication. With the serous nature of inflammation, feeding from a healthy mammary gland is allowed. With purulent mastitis, breastfeeding stops completely.

Sometimes there is a decrease or cessation of lactation in the mother. Hypogalactia can be primary and secondary. Primary hypogalactia is caused by neurohormonal disorders, therefore hormones are prescribed for the development of lactation: lactin 70-100 units. intramuscularly 1-2 times a day for 5-6 days; oxytocin 1,5-2 units. (0,3-0,4 ml) intramuscularly 2-3 times a day daily for 3 days, pituitrin 2,5 units. (0,5 ml) 1-2 times a day intramuscularly for 5-6 days. Secondary hypogalactia is more common. Its occurrence is promoted by insufficient sleep, malnutrition, violation of the rules of breastfeeding, taking medications (antibiotics, diuretics, barbiturates, furazolidone, etc.). Treatment of secondary hypogalactia consists in eliminating its causes. To stimulate lactopoiesis, vitamins (A, B12, B6 C, PP), apilac (0,01 g 3 times a day under the tongue for 10-15 days), dry brewer's yeast (1-2 g 3 times a day inside 10 -15 days), use phytotherapeutic agents (hawthorn, lemon balm, strawberry leaves, oregano herb, dill). If it is impossible to restore lactation, then it is necessary to provide the child with donor human milk. Women's milk collection points have been set up at dairy kitchens. The donor woman must be healthy and clean.

In the absence of women's milk, its substitutes can be prescribed - mixtures adapted to women's milk. Unadapted simple mixtures have now lost their value.

Upbringing. From the very beginning, mutual understanding is established between parents and the child with the help of specific signals, a unique form of relationship is formed - attachment. A newborn child has the ability to withstand the adverse effects of a new environment and selectively respond to certain stimuli. The mental structure of the personality of a newborn, the individual characteristics of temperament are visible from the first days of life ("difficult child", "easy child"). The variability of the child's behavior is due to changes in his emerging consciousness. Breastfeeding plays an important role in the upbringing of a small person. A child who is breastfed feels protected, needed, desired. In conditions of positive mental contact, children grow more obedient.

From the first days of life, the baby needs the correct daily routine (alternation in time of basic physiological needs: sleep, wakefulness, nutrition, walking, hygiene and hardening measures). This contributes to the formation of a certain rhythm of life. Children develop a reflex for a while, a dynamic stereotype of behavior is formed, biological rhythms are established, which provides them with a calm and quick falling asleep, good appetite, and active behavior during wakefulness. Children who live according to the established rhythm do not need additional sedation (rocking, carrying, using a pacifier).

In the future, such a child easily gets used to the daily routine. This teaches him to be organized and makes life easier for him and his parents. The correct mode of the day should not be imposing. A child can be taught better and faster if you adapt to the level of his mental development, individual biological rhythm, taking into account the physical condition and individual mental characteristics. Deviations from the regime for 30 minutes or, in extreme cases, for 1 hour are allowed.

The leading regime factor is the feeding of the child. Feeding on demand is carried out during the adaptation period in order to establish the optimal feeding regimen for mother and child. The subsequent transition to feeding according to the regimen should be gradual. The criterion for a correctly chosen regimen is the state of health of the child, primarily the functions of the central nervous system. In conditions of impaired adaptation, the child becomes capricious, whiny and irritable.

In accordance with the feeding regime, other regimes are formed: sleep and wakefulness, walks, tempering and hygiene measures.

At the first visit of a newborn, it is necessary to tell the mother about conditions that require urgent medical attention, and to tell where to go for help with illnesses.

Document processing

Information about the content of the first patronage for a newborn is recorded in the history of the child's development (form No. 112) under the heading "First patronage for a newborn". The entry is made according to the scheme: anamnesis, objective examination data, diagnosis indicating the health group and risk group, recommendations for care, feeding and education. If the child belongs to II-V health groups, then recommendations should be given for rehabilitation in accordance with the risk group or nosological form of the disease.

2. Second patronage for a newborn

The second patronage for the newborn is carried out on the 14th day of the child's life. Its purpose is to re-examine the newborn by organs and systems to determine the state of health, monitor the implementation of recommendations, answer questions from the mother in connection with the problems that have arisen, and provide instruction.

When collecting an anamnesis, it is necessary to find out the issues of feeding, daily routine, and behavior of the newborn.

Objective examination

An objective examination is carried out in stages. It should be treated no less carefully than during the first patronage, since a pathology that has not manifested itself earlier can be detected at this age.

It is necessary to evaluate how the child is gaining weight. If there are regurgitation, then the mother should be explained that children under 1 year old have physiological insufficiency in the work of the sphincter apparatus of the gastrointestinal tract. When swallowing air during feeding, the child should be held vertically for 10 minutes after feeding. If regurgitation is persistent, constant, there is vomiting in a fountain, the child is not gaining weight well, then it must be examined in a hospital.

From the age of two weeks, children may experience cramping abdominal pain (colic), which is due to the adaptation of the gastrointestinal tract to new living conditions. This is manifested by the sudden anxiety of the child.

The mother is obliged to report such symptoms to the local doctor, who evaluates whether these changes are functional abnormalities or are due to organic pathology.

briefing

The mother should be reminded of the importance of massage and gymnastics for the newborn. Massage and gymnastics are connected to hardening and recreational activities.

The main methods of massage are stroking, rubbing, kneading, tapping, vibration. At the initial stages, the massage should be light; of all the techniques, stroking is used mainly, as it helps to relax the muscles. During the massage, the mass of the baby grows faster. A lethargic child becomes more alive and active, an excitable child falls asleep faster, his sleep becomes deeper and longer.

Massage is carried out with clean, warm, dry hands. They start from the face: the forehead is stroked from the center outward with the thumbs of the right and left hands. The cheeks are massaged from the nose to the ear and from the center of the upper lip to the ear, then from the chin to the ear. The limb massage is carried out from the distal end to the proximal one from the outer and inner sides. When massaging the back, stroking movements are carried out with the palms from top to bottom and the back of the hand from bottom to top. When massaging the chest, the ends of the fingers are moved along the intercostal spaces from the sternum to the sides, without pressing on the ribs. Massage of the abdomen is carried out clockwise, it is necessary to spare the liver area and not touch the genitals. Lastly, the feet and palms are massaged.

If during the procedure the child is naughty and cries, you need to interrupt it and calm the baby. Massage from 2-3 weeks of age should be alternated with laying the baby on the stomach to strengthen the muscles of the back, abdomen and limbs. Laying out is done for 2-3 minutes before feeding.

The use of special exercises in the neonatal period will help the child control his body. Since the hypertonicity of the flexor muscles predominates in the newborn, it is necessary to help them relax. Movements should be performed slowly, rhythmically and smoothly. Gymnastics is carried out during wakefulness, when the child is in a good mood. Exercises are done by playing with the baby, while the mother should smile, talk affectionately with him or sing a song.

First exercise: the child lies on his back, the mother allows him to grab his thumbs with his hands, then spreads the newborn's arms to the sides and brings them together, crossing them on his chest. The exercise helps to relax the muscles of the chest and shoulder girdle.

The second exercise: the child lies on his back, the mother raises his arms above his head and lowers him down through the sides. Exercise relaxes the muscles of the shoulder girdle, upper limbs.

The third exercise: the child lies on his back, the mother takes him by the shins and gently bends his knees to his stomach, then unbends his legs. Exercise relaxes the muscles of the legs, helps the child free the intestines from gases.

The fourth exercise: the child lies on his stomach, the mother props up the child's feet with her hands, this makes the baby straighten his legs and crawl forward (reflex crawling). Exercise promotes the development of the muscles of the legs, arms and back.

For the upbringing and development of the visual concentration of the newborn, toys are hung above the crib at a distance of 40-50 cm from the face.

The first toys after discharge from the maternity hospital can be 2-3 large balls of bright color, hung over the crib alternately every 2-3 days. This contributes to the development of the visual analyzer and creates a joyful mood in the child.

Patronage data are recorded in the history of the child's development (f. No. 112) under the heading "Second patronage for a newborn".

3. Third patronage for a newborn

The third patronage for a newborn is carried out on the 21st day of the child's life. Its goals are to monitor the dynamics of the state of health and developmental conditions of the newborn, feeding, conduct sanitary and educational work, and treat identified developmental abnormalities.

Objective examination

When examining a newborn, it is necessary to pay attention to his behavior, well-being, reaction to the environment. In dynamics, indicators of body weight, height, head circumference, chest, the state of the large fontanel are evaluated.

On the oral mucosa there may be thrush with defects in child care. A newborn in the third week of life can already fix his gaze, respond with positive emotions to an affectionate appeal to him.

The skin is normally elastic, velvety, pink, clean. In the presence of pustules, treatment at home is necessary with a satisfactory condition of the child and the possibility of good care.

In a state of moderate severity or an unfavorable sanitary and cultural level in the family, the district doctor gives a referral for examination and treatment in a hospital.

The umbilical region should be epithelialized by the 21st day of the child's life. With purulent discharge from the umbilical wound, hyperemia around the navel, the child should be sent to the hospital.

To determine the condition of the newborn, the doctor re-evaluates the unconditioned physiological reflexes (Babkin, sucking, grasping, automatic gait, crawling), performs percussion and auscultation of the lungs, heart, and palpation of the abdomen.

briefing

Then the doctor clarifies in a conversation with the mother the nature of the physiological functions of the child, gives recommendations on feeding and caring for the newborn, and answers questions that she had during the third week of the child's life.

During the third patronage, you should tell your mother about rickets in children and prepare her for the need to prevent this disease, inform her about the importance of ultraviolet rays, vitamin D for the life of the body and write out a prescription for purchasing an oil solution of vitamin D at a pharmacy in a prophylactic dose of 450 IU / day.

It is necessary to talk about deficiency anemia in children, the importance of breastfeeding and the prevention of anemia. The doctor discusses with the mother the issues of hardening the child's body and strengthening its resistance, introduces the method of teaching swimming.

At the end of the conversation, the district doctor invites the mother and child to an appointment at the clinic when the baby is one month old, brings to the attention of the schedule of work of the district doctor and specialists, and informs about the day of a healthy child.

The data obtained are recorded in the history of the child's development (f. No. 112) under the heading "Third Patronage for the Newborn".

By the end of the neonatal period, the district doctor must make a forecast of the child's health for the first year of life. Some children of risk groups can be removed from dispensary observation and from the second month they can be observed in the same way as healthy children. If there are deviations in the state of health and development of the child, it is necessary to conduct an in-depth examination with the involvement of specialists, to make a correction in the tactics of recreational activities.

4. Features of observation and rehabilitation of premature and post-term newborns

All premature and post-term newborns are at risk. They require increased attention of the local doctor: the first patronage for them is carried out the next day after discharge from the maternity hospital or hospital (departments of the I and II stages of nursing), as they need special care due to their weakness.

When collecting an anamnesis, it is necessary, if possible, to establish the etiological factors that led to the birth of a premature or overdue child, since the volume of rehabilitation measures depends on this.

An objective examination should be aware of the functional characteristics of premature babies. On the part of the nervous system, a syndrome of depression, a weak cry, a decrease in muscle tone, physiological reflexes, and imperfection of thermoregulation are characteristic.

When assessing the state of the respiratory system, lability of the respiratory rate (35-80 per 1 min), uneven depth of breathing, weakened breathing during auscultation over the area of ​​atelectasis, and apnea attacks can be detected. The heart rate is also variable and can vary between 140-180 beats per minute.

Vascular dystonia is noted. The immaturity of the respiratory and circulatory organs leads to an insufficient supply of oxygen to the child's body, as a result of which his condition worsens even more.

Caring for premature babies is an extremely difficult task. To preserve their vital activity, it is necessary to create special conditions for care and feeding.

The air temperature in the apartment should be in the range of 24-26 ° C (since premature babies cool quickly), the baby should be swaddled quickly in pre-warmed diapers. Cooling of a premature baby can occur with prolonged lying in wet diapers. After bathing, the child is wrapped in a heated towel. A sign of hypothermia is a cold nose. Due to the imperfection of thermoregulation, overheating of a premature baby can easily occur. Then drops of sweat appear on the forehead and at the root of the nose.

Feeding premature babies presents significant challenges. Due to the small capacity of the stomach, such children are recommended to feed often in small portions. For a premature baby, breastfeeding is especially important, since the secretion of its own digestive enzymes is not enough. Breastfeeding compensates for the low level of humoral immunity of the premature and nonspecific protective factors. The risk of developing anemia of prematurity with breastfeeding is lower. For their artificial feeding, adapted mixtures can be used.

Given the immaturity of the nervous system, a premature baby should be protected from strong external stimuli: loud music, screams, bright light. You should talk more and pick up a premature baby, which contributes to his mental development. Sensory stimulation plays a huge role in neurological and physical maturation. However, it is necessary to remember the rapid fatigue of premature babies.

For the prevention of respiratory diseases, given the tendency of such children to stagnation, it is necessary to change the position of a premature baby in the crib more often.

The child should be picked up slowly, because due to vascular dystonia, when the position of the child's body changes, a violation of the blood supply to the brain can easily develop.

All premature babies are examined by a neuropathologist, otolaryngologist, ophthalmologist in the first month of life. If violations of the central nervous system, musculoskeletal system, hearing, visual impairment are detected, premature babies are under the supervision of a specialist of the appropriate profile.

Nursing of a premature baby after discharge from the hospital is carried out in accordance with an individual rehabilitation program, which depends on the identification of risk factors for the development of pathology. Premature newborns belong to the II group of health. Strict adherence to medical recommendations and close contact with the family are necessary. Most often, premature babies are characterized by a lag in physical and neuropsychic development, neurological diseases that lead to disability (cerebral palsy, hydrocephalus, epilepsy, deafness); long-term consequences are mental and personality defects. Unfavorable outcomes (disability and death) in some cases are due to the low socioeconomic status of the family, lack of attention to the child, and improper upbringing.

Among postterm newborns, morbidity and mortality are also significantly higher than among full-term infants. They often have asphyxia, birth trauma of the central nervous system, aspiration syndrome, pyoderma, acute respiratory diseases, mental retardation, a tendency to overweight, viscerovegetative disorders (irritability, regurgitation, constipation, dyskinesia of the gastrointestinal tract).

The rehabilitation program, as in premature babies, is compiled on an individual basis in accordance with the identified risk factors.

Taking into account the propensity of post-term newborns to overweight, it is recommended to increase the number of feedings (7 instead of 6), but reduce the single amount of food in the first months of life. With severe dryness of the skin, its peeling, hygienic baths, softening and nourishing the skin, have a good effect. To do this, rye or wheat bran, potato starch (50-100 g per 10 l of water) are added to the water. Baby soap for dry skin can be used no more than 2 times a week. In connection with the dysfunction of the nervous system, a protective regimen is prescribed. They give recommendations on the development of motor skills and education, taking into account the physiological characteristics of premature and post-term newborns.

LECTURE No. 4. Risk groups for health disorders. Schools for future parents

Pregnant women of the increased risk group for the birth of children with health problems:

1) pregnant women under the age of 20 and nulliparous over 30 years;

2) weighing less than 45 kg and more than 91 kg;

3) having more than 5 pregnancies;

4) with threats of premature birth or with a post-term pregnancy, or with toxicosis;

5) with multiple pregnancy;

6) with a burdened obstetric history (abortion, miscarriage, stillbirth, narrow pelvis, uterine malformations, uterine scar);

7) with extragenital pathology;

8) with social risk factors (single, large families, poor living conditions);

9) whose work is associated with occupational hazards;

10) with bad habits;

11) who had acute infections during pregnancy;

12) with Rh-negative blood, especially during the 2nd and subsequent pregnancy;

13) students of universities and other educational institutions;

14) with hereditary diseases in parents and relatives.

Medical documents issued during the observation of a pregnant woman:

1) sheet of the unborn child;

2) insert "Antenatal care";

3) drawing up a genetic map;

4) school for future parents.

The organization of the school for future parents includes:

1) registration in the children's clinic of the future parental couple;

2) collection of passport data and registration of information about the state of health of future parents and their relatives, the presence or absence of bad habits, occupational hazards, the course of pregnancy, social and living conditions, etc.;

3) involvement of future parents in school according to the adopted curriculum.

The place of organization of the school for future parents is the office of a healthy child in a polyclinic.

Goals, objectives, work program of the school for young parents

The goal of the school for young parents is to involve future parents in a conscious and full participation in the upbringing of a healthy child.

The task of the school for young parents is to expand the knowledge of parents on raising a healthy child through health education:

1) teaching parents how to care for a newborn child;

2) training in the method of natural feeding;

3) training in daily routines;

4) teaching methods of physical education (organization of bathing, gymnastics, massage, tempering procedures);

5) preparation of the mammary glands of the mother for feeding the newborn;

6) conducting antenatal prophylaxis of hypogalactia;

7) promotion of natural feeding;

8) recommendations on the daily routine and nutrition of a pregnant and lactating mother;

9) recommendations to future parents on organizing a healthy lifestyle;

10) recommendations for the prevention of health disorders of young parents;

11) measures to improve the health of future parents;

12) recommendation of relevant literature, issuance of leaflets, watching videos.

The program of work of the school of future parents includes the following points.

1. Measures to improve the health of expectant mothers and fathers:

1) registration of girls in the service region;

2) rehabilitation of girls who are registered with a dispensary for any disease, including treatment in day hospitals and sanatorium treatment;

3) rehabilitation of young and future parents of chronic foci of infection;

4) involvement of girls in classes at the school of future parents;

5) giving a course of lectures to young parents on a specific program;

6) improving the quality and efficiency of monitoring socially disadvantaged families;

7) conducting an analysis of the quality of medical examination of girls, boys (young parents) with a report at dispatch meetings.

2. Activities to train young parents in the skills of caring for a newborn:

1) conducting preventive classes with future parents in the office of a healthy child for the care of newborns and small children;

2) teaching young parents to conduct age-related complexes of massage and gymnastics;

3) training young parents in the technology of preparing baby food;

4) recommendations for young parents on organizing a home microstadium;

5) improvement of children from risk groups for ENT diseases and orthopedic pathology.

3. Forecasting the health of the unborn child and organizing preventive measures in accordance with the risk group. Forecasting and prevention of diseases is carried out in 3 stages.

The first stage - the forecast is built by the consultant of the medical genetic consultation before the young people enter into marriage. The risk of having children with hereditary and endocrine pathology is discussed.

The second stage is the antenatal prognosis, which is made by an obstetrician-gynecologist, therapist, pediatrician and is carried out from the moment the pregnant woman is registered in the antenatal clinic.

The third stage is postnatal prognosis and prevention of child diseases by a neonatologist and pediatrician.

Children's disease risk groups (health group II):

1) with the risk of a violation of the state during the period of social adaptation and with the risk of increased incidence of acute respiratory viral infections;

2) with the risk of developing CNS pathology;

3) with the risk of anemia, rickets, dystrophy;

4) with the risk of developing congenital malformations of organs and systems;

5) with the risk of purulent-septic diseases in the neonatal period;

6) with the risk of allergic diseases;

7) newborn social risk groups (children from socially disadvantaged families, single-parent, large families, with a low level of material support).

Risk factors for morbidity in children

Risk factors for health disorders during the period of social adaptation and the risk of increased incidence of acute respiratory viral infections:

1) the age of the mother is over 30 years;

2) mother's bad habits;

3) extragenital pathology of the mother;

4) pathology of pregnancy and childbirth;

5) toxoplasmosis and other latent infections in the mother and fetus;

6) acute infections of the mother at the end of pregnancy and during childbirth;

7) asphyxia of a newborn;

8) prematurity;

9) large fruit;

10) unsatisfactory living conditions;

11) III, IV, V groups of child health. Risk factors for the development of pathology:

1) mother's bad habits;

2) extragenital pathology of the mother;

3) SARS and other bacterial infections, especially transferred at the end of pregnancy and in childbirth;

4) mental retardation of the mother;

5) miscarriages in anamnesis, stillbirths, multiple pregnancy, birth of children with low or large weight, infertility;

6) occupational hazards;

7) mother's age up to 16 years and over 40 years;

8) pathology of pregnancy and childbirth;

9) narrow pelvis;

10) toxicosis of the first half of pregnancy;

11) polyhydramnios;

12) pathology of the placenta;

13) intrauterine fetal hypoxia;

14) 4th pregnancy and more;

15) the period between previous and present births is 1 year or less;

16) weakness of labor activity;

17) premature detachment of the placenta;

18) use of obstetric methods of childbirth;

19) entanglement of the umbilical cord;

20) immunological incompatibility of blood of mother and fetus;

21) prematurity;

22) asphyxia of a newborn;

23) the child's body weight is 4 kg or more;

24) children with a stigmatization level of 5 points or more. Risk factors for the development of rickets, anemia, dystrophy:

1) heart defects in the mother and other extragenital pathology;

2) endocrine diseases (diabetes mellitus, thyroid disease, obesity);

3) anemia in the mother;

4) congenital malformations;

5) the age of the mother is over 30;

6) childbirth from the 4th pregnancy and more;

7) the period of time between previous births and the onset of this pregnancy is a year or less;

8) drug therapy during pregnancy;

9) toxicosis of the first and second half of pregnancy;

10) poor nutrition of a pregnant woman;

11) bad habits in a pregnant woman;

12) fetal hypotrophy;

13) prematurity;

14) twin children;

15) weight at birth 4 kg or more;

16) anticonvulsant therapy in newborns;

17) persistent jaundice in newborns;

18) early artificial feeding;

19) infectious and inflammatory diseases of the child;

20) children with unstable stool.

Risk factors for congenital malformations in children:

1) pathology of pregnancy;

2) the use of drugs during pregnancy;

3) endocrine diseases of a pregnant woman;

4) the age of the mother is over 30;

5) mother's bad habits;

6) rubella transferred during pregnancy or contact with a patient with rubella;

7) toxoplasmosis and other infections in the mother;

8) SARS and other infections in the first trimester of pregnancy. Risk factors for the development of pyoinflammatory diseases in the neonatal period:

1) chronic pyelonephritis and other inflammatory diseases in the mother;

2) acute infections at the end of pregnancy and childbirth;

3) rubella during pregnancy;

4) inflammatory diseases of the genitals in the mother;

5) a long waterless period. Risk factors for allergic diseases:

1) toxoplasmosis in the mother;

2) chronic bronchopulmonary diseases of the mother;

3) neurodermatitis, urticaria, angioedema in the mother;

4) food and other allergies in the mother;

5) miscarriages in history;

6) occupational hazards;

7) toxicosis of the first and second half of pregnancy;

8) the threat of miscarriage;

9) taking medications during pregnancy;

10) transfusion of blood and blood substitutes during pregnancy and childbirth.

Newborn social risk groups:

1) children from socially disadvantaged families;

2) children from incomplete families;

3) children from large families;

4) children from families with a low level of material security;

5) children whose parents are students;

6) children from families of refugees, migrants;

7) children from families of conscripts;

8) children from families with poor living conditions.

LECTURE No. 5. Observation of the child in the postnatal period

In the first year of life, the local doctor monthly examines the child in the clinic. The examination includes the collection of anamnesis, an objective examination, instruction and registration of information in the history of the child's development (form No. 112).

When collecting an anamnesis, it is necessary to pay attention to the psychological climate in the family after the birth of the child, issues of feeding, care and upbringing.

Objective examination

During an objective examination, physical development is assessed by the method of centile characteristics, neuropsychic development along the lines of development. Particular attention should be paid to the proportionality and harmony of development, the formation of motor activity.

A systematic review is underway. When examining the skin in children with an allergic predisposition, persistent diaper rash can be detected, and from 2-3 months - atopic dermatitis. On the oral mucosa with poor care, weakened immunological protection, there are thrush (whitish plaques), aphthous stomatitis.

The small fontanel usually closes in the second month of life, the large fontanel - by 16 months. Unconditioned reflexes gradually disappear by 3 months of age. Cooing and babbling by 4-6 months acquires an emotional coloring (requirement, discontent), by the first year the child can speak simple words.

In the first year of life, congenital malformations of the internal organs that did not manifest themselves in the neonatal period can be detected.

These are congenital malformations of the heart, kidneys, central nervous system, digestive organs, lungs, hereditary metabolic disorders. If noise is detected in the heart area, it is necessary to appoint a consultation with a cardiologist, ultrasound, ECG, FCG. Among congenital heart defects, an open ductus arteriosus, atrial or ventricular septal defect are more common than others.

Abdominal examination often reveals an umbilical hernia. In boys, when examining the genitals, dropsy of the testicle can be detected, which disappears in many by the end of the first year of life. By 3 months of age, the child should be examined by an orthopedist to rule out congenital dislocation of the hip.

briefing

Instructing parents concerns the issues of feeding, child care, education.

Feeding plays an important role in a child's development. During the first year of life, the child must receive breast milk.

In extreme cases, adapted milk formulas can be an alternative to it. However, by 5-6 months, when the growing needs of the child can no longer be met by an increase in the amount of breast milk or formula, complementary foods are introduced.

To adapt the child's gastrointestinal tract to a new type of food, complementary foods are introduced gradually over 2 weeks, starting with 5-10 ml and increasing its amount daily so that one feeding with breast milk is replaced by a new type of food. The next two weeks, the diet does not change.

At 6-7 months, a second complementary food is introduced, replacing it with another feeding with breast milk. The introduction of the second complementary foods is carried out according to the same rules.

Complementary foods are a higher quality food than breast milk. It should be given before breastfeeding, while the baby is hungry.

You should not prescribe complementary foods at an earlier date, as this may contribute to the further development of gastrointestinal diseases. Currently, there is a significant increase in erosive and ulcerative lesions of the stomach, duodenum.

By the time complementary foods are introduced, the baby's digestive organs should be sufficiently mature.

Rational feeding in the postnatal period is important for the harmonious development of children. Children from large (3 or more children) and low-income families are entitled to free provision of milk formulas and other food products.

The necessary food for the child is prescribed by the doctor. The prescription indicates the full name of the child, his age, the full name of the doctor, the date the prescription was issued. In the prescription part, a one-time amount of the product and the number of packages are noted, in the signature - the method of use. Prescriptions are issued on a special form with a polyclinic stamp. The doctor's signature on the prescription is supplemented by a seal.

Care instructions

Creating proper hygienic conditions for the child in the family, maintaining cleanliness prevent the occurrence of diseases and allow the child to adapt faster.

Clothing. From the 2-3rd month, during wakefulness, instead of diapers, the child is put on sliders, in which he freely moves his legs.

When walking in cold weather, you should wear overalls. Shoes before the child began to walk should be soft. The child's clothing should be made from natural, not synthetic fibers.

Skin and mucosal care. Up to 6 months, the child should be bathed every day, from 6 months to a year - every other day. To clean the child's mouth after eating, you need to give him boiled water to drink.

After teething, they must be cleaned. First, soft gauze should be used for this.

Every day after the first feeding, a morning toilet is carried out - the child's face is washed, the nasal passages and ears are cleaned. In the evening, after a hygienic bath, the skin folds are thoroughly blotted with a dry towel and treated with baby cream or powder.

The child's dishes should be thoroughly washed and boiled. Toys must be kept clean. Linen after washing should be ironed with a hot iron.

An important role in the upbringing of a child is played by a rationally constructed daily routine, which takes into account the physiological capabilities of the baby and contributes to the active life of all its organs and systems.

It is an alternation in the time of feeding, sleep and wakefulness in accordance with the physiological capabilities of the child.

Properly selected daily routine helps the formation of the mental component of the child's personality. The unpredictability of behavior is replaced by the regularity of requirements already by the age of 2 months. Timely reasonable satisfaction of the needs of the child develops attachment to parents, which manifests itself from the age of 3 months.

Wake time should be used for physical and mental development. For the purpose of harmonious physical development, special sets of exercises have been developed. Such activities are carried out by the mother with the child. It is better that they are performed at the same time of day and accompanied by positive emotions.

At the age of 1-2 months, it is recommended: massage of the hands and feet (stroking), reflex extension of the toes, massage of the abdomen and chest, reflex extension of the back, laying on the stomach and massage of the back, reflex crawling, dancing (supporting the child in an upright position, you should encourage him to a short stop with his feet, lifting him from the table).

At the age of 2-3 months, they recommend: reflex flexion and extension of the toes, massage of the hands and crossing of the arms, massage of the legs and sliding of the feet (lying on the back, sliding the feet back and forth on the surface of the table), massage of the abdomen, half-turns of the torso to the right and left, transition to a sitting position (cannot be performed with congenital dislocation of the hip), transfer to a standing position, massage of the back and abduction of the shoulders back, reflex crawling, reflex arching of the back (lying on the stomach, grab the child’s legs in the area of ​​the ankle joints with one hand, bring the other hand under chest, lift the baby above the table, he will reflexively bend his back).

At the age of 3-4 months, the main task of the gymnastic complex is the development of turns from the back to the stomach, the development of the muscles of the limbs and torso.

To do this, use hand massage (stroking, rubbing), alternately bending the arms in front of the chest, leg massage (rubbing), leg bending, leg massage (kneading), stepping (lying on your back with bent legs, stepping on the table with small steps), raising the legs , massage of the abdomen, transition to a sitting position, turning from back to stomach, back massage, reflex crawling, arching the back when lifting a child above the table, dancing.

At the age of 4-5 months, they carry out: spreading the arms to the sides, massage the legs - ring-shaped rubbing, alternate extension of the legs, alternate straightening of the arms, spreading the legs to the sides (lying on the back, grab the child’s straight legs by the shins and spread them apart, slightly lifting above the table, then bring them together), standing stroking massage (from the tips of the toes along the back surface to the ankle joint), circular movements of the legs (bring the hips to the stomach and spread them wide apart, then return to the starting position), massage the abdomen, transition in a sitting position, turning from back to stomach, back massage (kneading), back bending, crawling with sipping after a toy, reflex bending of the body (lying on its side, lift the child above the table, supporting him with one hand at his side, with the other taking his feet) .

At the age of 5 to 6 months, they carry out: hand massage (kneading), arm extension, leg massage (kneading), raising legs, abducting bent legs to the sides, foot massage (patting on the plantar side of the toes), bicycle exercise, massage back (kicking), crawling after a toy, moving to a sitting position, reflex flexion of the body forward when raising the back above the table from a supine position, tense arching (grab the child’s legs in the ankle joints with the left hand, bring the right hand under the back, lift the child by the legs up, without delaying in this position, lower the legs down, with the right hand help the baby move to a sitting position).

At the age of 6 to 8 months, they carry out: circular movements of the feet, alternately raising the legs, arching the back, massage the abdomen (pinching), turning on the back (lying on the stomach, take the child by the shins and help him roll over onto his back and back), back massage (patting), sitting down by straightened arms, moving the arms to the sides and raising them up, playing with the ball (encourage the child to reach for it with the body turning in different directions).

At the age of 8 to 10 months, it is recommended: flexion and extension of the arms (holding on to the rings), lowering the straight legs to the sides (grabbing both legs of the child, raise the straight legs up and lower to the side until they touch the table with the rotation of the pelvis, repeat in the other direction ), back massage (rubbing), getting on all fours (putting your hand under the baby’s tummy), emphasis on hands (standing on all fours, supporting the hips), abdominal massage (patting), moving to a sitting position (holding a finger), standing on legs, standing ball play, walking with support behind the torso.

At the age of 11 to 12 months, it is recommended: bending the torso with raising the chest from a prone position, bending the torso with raising the legs. It is necessary to encourage the child to walk on all fours (moving the toy), to carry out the "walking on his hands" exercise, to bend the body (lying on his back, with one hand to hold the child's legs in the ankle joints, with the other to raise the lower back, prompting to bend the back with support on the shoulders), independently move to a sitting position, stand up while sipping hands, walk independently, squat, walk with a toy and holding on to a chair.

The physical and mental development of the child are closely interrelated. In the central nervous system, the centers of motor activity of the hands and speech are located nearby.

Therefore, massage of the palms, small movements of the fingers (first passive flexion and extension, then work with the designer, mosaic, music lessons) contribute to the development of speech centers in the child.

From the first days of life, it is necessary to talk with the child. The semantic meanings of words are acquired not by themselves, but as a result of many days of repetition. By 7 months, the child begins to understand the names of the surrounding objects, the names of people, willingly repeats the game of "patties", laughs when playing "goat". By 9-10 months, he remembers his name, performs the commands "give", "on", "get up", "throw" and others, by 1 year he speaks simple words.

If classes with a child are irregular or they are not given due importance, but only feed the child and take care of him, then the baby’s mental lag in mental development and educational neglect will soon be discovered.

The main emotions of the child are associated with the desire for independence. Already in the second half of life, negativism and the spirit of contradiction appear. This may be the refusal of passive feeding from a spoon or an unwillingness to sit on the potty.

You should use the desire for independence for learning. The child himself should remove food from the spoon with his lips, and from 6-7 months you should give the spoon in his hands, helping with this.

Even in the first half of life, the child should be taught to the potty. To do this, if he woke up dry, you need to hold the baby over the pot.

It is necessary to seat the child on a warm pot. It is important to teach your child to wash their hands before feeding. Accustoming to neatness is possible if the child is ready for this. The readiness of the child is indicated by the desire to please parents, imitate adults, the desire for independence and the adequate development of motor skills.

For the safety of the child and the prevention of injuries, it is advisable to have a playpen, high sides in a crib, use plugs for sockets, a special table with a chair. A home first aid kit with medicines, small, piercing and cutting objects should be removed in a place inaccessible to the child.

Hardening is carried out in conjunction with physical and mental education. The main factors are air, water and sun.

Hardening with air begins from the first days of a child's life during swaddling, airing, walking. In good summer weather, the child should be outside all day long. Babies fall asleep easily in the fresh air.

Water procedures are dosed by temperature and time. The effect of cold water on the skin contributes to the narrowing of the capillaries. Then their expansion occurs (the phase of active hyperemia). With prolonged exposure to cold, the capillary tone drops significantly, the skin becomes cyanotic, the number of heartbeats slows down, which is important to consider when monitoring hardening procedures.

The main methods of hardening with water are rubbing, dousing, showering and swimming. Hardening should begin with rubbing. Separate parts of the body are wiped with a flannel mitten soaked in water, then rubbed with a dry terry towel. Pouring is carried out from a jug. The shower affects the child's body by the difference in water temperature and massaging effect. When hardening with a shower and dousing, the water temperature can be reduced gradually or use a contrast method.

The best time to start learning to swim is 3-4 weeks of age, until the child's innate swimming reflex has faded. During training, the ability to stay on the water and hold your breath is maintained for a long time. Training is carried out by parents with the help of a polyclinic methodologist and under the supervision of a local doctor. The child must complete the program in five steps. The first stage - every day for a month they develop the ability to flounder in warm water (37 ° C). Classes are held 1 hour before feeding, their duration is 10-15 minutes. At the second stage, classes last 2 months, at which time various swimming devices are mastered. The third stage is carried out within 2 months, classes are extended to 40-45 minutes. The child masters swimming movements with arms and legs. The fourth stage is carried out in the second half of life. Its duration is 3 months, the goal is to teach independent swimming. In the fifth stage, swimming becomes a child's need. By the end of the first year of life, parents bring the baby to the pool of the children's clinic 2-3 times a week. Children involved in swimming are less likely to get sick, they have a faster physical and neuropsychic development.

Sunbathing is usually carried out after the child is accustomed to air baths. The duration of the procedure is increased gradually from 5 minutes to 30-40 minutes. After a sunbath, the child is poured over from a jug, the water temperature is 20-22 °C. When walking, the child's face should be open to the sun's rays.

Stage epicrisis

In the first year of a child's life, every 3 months in the history of development (f. No. 112), a milestone epicrisis is drawn up. Scheme of a stage epicrisis

1. Anamnesis (biological, genealogical, social and information for the previous period).

2. Metric data, including anthropometry, parameters of neuropsychic development (leading lines by age).

3. Objective data that combine the somatic state, behavioral reactions of the child.

4. Conclusion, which reflects the assessment of the level of physical development for a given age period, the level of neuropsychic development (development group), diagnosis, health group, risk group and recommendations - medical and pedagogical. Thus, the milestone epicrisis is a unified form that allows you to assess the child's condition, predict its development and make recommendations.

The anthropometric data of the child is evaluated by the method of centile characteristics and marked on the left side of the record.

A staged epicrisis allows assessing the child's condition in dynamics, determining the effectiveness of ongoing recreational activities and identifying risk factors in the early stages of pathology development.

LECTURE No. 6. Observation of children of the early childhood period

In early childhood, the health of the child is monitored by the local doctor and the pediatrician of the preschool institution (DDU), if the child attends a children's group. In the second year of life, the doctor examines the child once a quarter, in the third year of life - once every six months. Examinations are carried out in the office of the district doctor of the children's polyclinic or in the doctor's office in the kindergarten.

When collecting an anamnesis, it is necessary to pay attention to the data of previous examinations, past diseases, childhood infections, information about vaccinations, allergic anamnesis, heredity, developmental abnormalities identified earlier. It is necessary to clarify the features of the child's behavioral reactions, the degree of his emotionality in relation to the surrounding reality, the level of physical and mental development.

An objective examination is carried out systematically. Particular attention is paid to the condition of the nasopharynx, since many children at this age often suffer from respiratory diseases with a protracted and recurrent course. The degree of hyperplasia and friability of the tonsils, nasal congestion, the presence of adenoids (the child breathes through the mouth) are revealed. At this age, children often have otitis media, which is due to the anatomical and physiological features of the structure of the ENT organs. You should pay attention to the order of teething and their number, caries can be detected.

When examining the legs, pay attention to the configuration of the arch of the foot to identify clubfoot. Fat pads under the arch of the feet, which are normal during the first years of life, give the impression of flat feet.

The presence of noise over the region of the heart may be due to age-related features (the chest develops faster than the growth of the cardiovascular system occurs) or pathology (CHD, carditis). Therefore, in each case, the doctor differentiates physiological and organic noise, if necessary, prescribes an additional examination.

When auscultating the lungs in children aged 3 to XNUMX years, puerile (close to hard) breathing is heard, which is due to the anatomical and physiological characteristics of the bronchopulmonary system.

When palpating the abdomen, it is necessary to remember the suggestibility of the child. If you persistently ask him about pain sensations, then the child can answer in the affirmative or negatively, depending on the intonation of the doctor's voice, without evaluating the true sensations. Therefore, by palpating the abdomen, the doctor distracts the child, tells him interesting stories. With soreness, the child will involuntarily change his facial expression.

Examination of the genital organs is carried out in each patient, and adrenogenital syndrome in boys can be detected - dropsy of the testicles, etc. If an adrenogenital syndrome is suspected, an endocrinologist is consulted. With dropsy of the testicles, surgical intervention is indicated by the age of 2.

Given the negativism in the behavior of children aged 1 to 3 years, for a proper examination, you should establish a positive emotional contact with the child. Assessing neuropsychic development, the doctor pays attention to speech. At 1 year old, the child speaks simple words, and by 2-3 years old - sentences. At the request of the doctor, the child shows his eyes, mouth, fingers. Considering objects, the baby asks questions: "What is this?", "Why?", "When?", "Where?" At this age, children memorize simple verses and melodies well.

In the second year of life, the child begins to draw, by the age of two he adds blocks, plays hide and seek. Emotional experiences are improved: joy, resentment, love, fear. Easy suggestibility and obedience of the child are favorable for education.

Parenting is mainly concerned with the upbringing of the child.

You should accustom him to neatness: wash your face in the morning and evening, brush your teeth, wash your hands before eating, comb your hair, make your bed. You should teach your child to perform household chores - water indoor flowers, wipe dust.

With irritability, which at this age is due to the desire to defend independence, if there are no serious disorders, it is necessary to distract the child or not pay attention to his behavior.

If you refuse to eat, do not force feed. To meet the daily requirement, 0,5 liters of milk, 30 g (2 tablespoons) of fruit juice or a slice of fruit, 60 g of iron-containing products, multivitamins are sufficient.

Gymnastics continues in early childhood. In the second year of life, the child trains in walking, in the third year running and jumping are connected. In summer, exercises can be done outdoors, in the shade.

At the age of 12-14 months, the child takes the first independent steps, you can encourage this by beckoning the child with a bright toy.

It is recommended to squat while holding on to the hoop, crawl through the hoop, crawl under obstacles set at a height of 30-35 cm, followed by straightening the body to get a toy placed on a chair 40-45 cm high, flexion and extension of the torso, sitting on your knees at adult, ball rolling (sitting on the floor with legs wide apart), climbing on an object, squatting, throwing a ball, lifting legs, walking independently and with assistance.

At the age of 14 to 18 months, it is recommended: walking along the path (35-40 cm wide, 2 m long), stepping over sticks (two sticks are placed at a distance of 25-30 cm), tossing a big ball, climbing over an obstacle, walking on an inclined plane, climbing a ladder, throwing small balls alternately with each hand, the game of "catching up".

At the age of 1,5 to 2 years, they recommend walking on an inclined plane, shifting cubes, crawling on all fours, climbing a ladder, throwing small balls at a target, running after a toy, playing a horse (fixing the reins on the child’s shoulders).

At the age of 2 to 2,5 years, the child is offered walking and running after an adult, walking on the board (at a height of 15-20 cm, maintaining balance), push-ups on the hands (lying on the mat), clapping in front of him and above his head (in the position standing), exercise "sit down, lie down", circular movements of "winding thread" (hands, arms bent at a right angle, fingers clenched into a fist), climbing a ladder, throwing balls at a target, walking (raising knees high).

At the age of 2,5-3 years, the child is offered walking on toes (with arms spread apart), walking on a log, raising straightened legs (lying on a rug), crossing arms, tilting the torso.

The training of the body by hardening continues. The duration of hardening with air increases to 1 hour: at an air temperature of at least 22 ° C in the shade. Swimming is widely used. The kindergartens have swimming pools where children can swim all year round. In summer, swimming in open water is allowed at an air temperature of 22 °C. Stay under the rays of the sun in the summer lasts from 5 to 10 minutes 2-3 times a day.

After examining the child and talking with the parents, an entry is made in the history of the child's development (form No. 112) according to the previous scheme: physical development is assessed by the method of centile characteristics, mental development along the lines of development.

Preparing a child for admission to kindergarten

Most parents register their child in a children's team at the age of 2-3 years. It should be borne in mind that admission to a kindergarten leads to a certain breakdown of the psychological and dynamic stereotype (there is a separation of the baby from the mother, contacts with unfamiliar children). This leads to a violation of the adaptation of the child, which is manifested by a disorder of sleep, appetite, and increased excitability.

A failure in adaptation contributes to a decrease in immunological reactivity, which, under the conditions of new contacts, leads to infection and disease. The most common are acute respiratory diseases.

Recurrent infectious diseases lead to immunodeficiency states and a vicious circle develops. Therefore, the child must be carefully prepared for admission to the kindergarten. The result is considered good if adaptation occurs within a month. Special training of a child in preschool begins at the postnatal age.

It is especially active during the last 3 months before visiting the children's team. The district doctor and nurse carry out such work in accordance with the recovery plan and taking into account individual characteristics. Be sure to take into account the level of physical and neuropsychic development of the child, the frequency of acute respiratory diseases throughout the year, the presence of chronic foci of infections, congenital anomalies, allergic reactions and other diseases.

When preparing a child for admission to a kindergarten, he must be taught to communicate with new people. The child must eat and sleep on his own. The regime of the day is as close as possible to the regime of the day in the younger nursery group. Activities for general preparation relate to issues of care, physical and neuropsychic development, upbringing, hardening of the child. Special training is a plan of rehabilitation measures in relation to the state of health of a given child. Not later than one month before admission to the kindergarten, the necessary age-related preventive vaccinations must be made. If a child falls ill before going to a kindergarten, then he can visit the kindergarten no earlier than 2 weeks after clinical recovery.

Data from anamnesis, examination, rehabilitation, information about vaccinations are recorded in the history of the child's development (form No. 112). In the direction to the kindergarten, the passport data of the child, his home address, the number and address of the children's clinic are indicated. An extract from the history of the child's development is attached to the referral, which notes the features of the course of pregnancy and childbirth of the mother, the dynamics of the physical and mental development of the child, allergic anamnesis, preventive vaccinations and reactions to them, previous diseases, contacts with infectious patients, the need for further special health measures.

Work on adaptation continues in the kindergarten. The teacher should be warned about the meeting with a new child and prepare the children of the kindergarten group for it. You can accept no more than 3 children per week and no more than 20 children in 1,5 months in a group. The educator clarifies with the parents the features of the regime that was at home, the child's established habits, the way of going to bed, favorite toys, the diminutive name that the child was called at home. You should maintain emotional contact with the child, you can not forcibly involve him in the game.

The entire adaptation period is divided into 3 stages: acute, subacute and compensation period. In the acute period, the emotional state changes, behavior is disturbed, sleep and appetite worsen, vegetative and hormonal changes occur. In the subacute period, the child actively learns a new environment, the biorhythms of various organs and systems are restored. Appetite normalizes faster, then sleep and emotions, and only then - the game and speech. During the period of compensation, systems and organs work in concert, which is manifested by positive emotions and balanced behavior.

According to the degree of severity, adaptation is light, moderate and severe. With mild adaptation, disturbances in behavior, appetite, sleep, communication, and speech activity last no more than a month. During the same period, functional deviations are normalized, diseases do not occur. With adaptation of moderate severity, the changes are more pronounced.

Sleep, appetite and motor activity are restored within a month, and speech activity - within two months. Functional deviations are expressed more clearly. ARI develops. Severe adaptation is noted for a significant duration - from 2 to 6 months, it can occur in two versions - recurrent acute respiratory infections or a neurotic state. Severe adaptation is a predictive test of a child's behavior in stressful situations, inappropriate behavior occurs in 90% of cases, such children are often registered with a psychoneurologist. Full adaptation of their state of health occurs in 1,5-2 years.

In a family where a child in the third year of life communicated only with close relatives, it is difficult to achieve the optimal level of age socialization. It is necessary not to protect the child from social adaptation, but purposefully form and train adaptive capabilities, without which it is impossible to behave adequately in different social situations.

For better adaptation in kindergarten, it is recommended to leave the child for a shortened day in the first week and allow the mother to be with the child in the group. The results of the course of the adaptation period are analyzed quarterly by the medical and pedagogical staff of the kindergarten for the current correction of the general and special scheme of adaptation measures.

The work of a pediatrician in a preschool institution

When a child enters a preschool, there must be documents: an extract from the history of the development of the child (detailed epicrisis), a certificate of the absence of contacts with infectious patients. On the first day after the initial examination, to ensure adaptation, the doctor prescribes a sparing regimen and food close to home for the child. The frequency of observation during the period of adaptation of children under 3 years old is at least 1 time in 5-6 days, 3-7 years old - once every 10-20 days (with an entry in the history of development, f. No. 112). The adaptation period can be considered completed when the child's behavior becomes adequate: good sleep, appetite appear, the incidence is not higher than that of peers. At the end of the adaptation period, the doctor writes down an epicrisis indicating a plan for further observation.

In his work, the pediatrician of the kindergarten is guided by orders, instructions and orders of higher health authorities and officials. A preschool doctor observes a dispensary group of sick children. He also examines children for suspected acute illness.

The doctor of the preschool institution organizes medical control over the nutrition of children, their physical development and hardening, conducts sanitary and educational work on the prevention of injuries, and maintains medical records. In special cases, the doctor of the preschool institution reports to the head of the preschool department of the polyclinic on the state of health of children, their morbidity, and measures taken to prevent it. The doctor is obliged to constantly work on improving his qualifications, conduct consultations for medical and educational personnel, and conduct health education work with parents.

The main sanitary and hygienic requirements for kindergartens are: the norm of usable area per child is 4 sq. m; natural light factor for a group room of at least 1,5%; relative air humidity 30-60%. Optimal aeration is achieved with cross-ventilation in the absence of children during the day 5 times. Wet cleaning of the premises is carried out 2 times a day, general cleaning and change of bed linen - once a week. Of great importance is the selection of furniture according to age, body size.

Children receive four meals a day differentiated, in accordance with age. Three age tables are prepared for them (from one year to 1,5 years; from 1,5 to 3 years; from 3 to 6 years). The portion size for children 5-6 years old is larger than for 3-4 years old. All children undergo fortification of food. A ten-day menu is used for the summer-autumn and winter-spring periods, separately for children of early and preschool age. You should have a card file of dishes indicating the set and quantity of products, the volume of servings, the chemical composition and calorie content. A cumulative statement is maintained, in which the head nurse enters the daily amount of food received in one day by one child. At the end of 7-10 days, the average number of products per child per day, chemical composition, calorie content, and the ratio of ingredients are calculated. The doctor gets acquainted with the results of the analysis and writes down the summary in the accumulative statement. When taking samples from ready-made meals, the doctor daily monitors the state of the catering unit, compliance with the rules of culinary processing, cooking technology, rules for storing and selling products, processing kitchen utensils and utensils.

Scheduled preventive examinations of children are carried out: for children 2-3 years old once a quarter, over 3 years old - once every six months. In-depth examinations of the pediatrician with the involvement of other specialists are carried out once a year (specialists go to the kindergarten). During an in-depth examination of children aged 4 years and older, the functional indicators of VC, the force of squeezing the hand, pulse and respiration rate, and blood pressure are assessed. Children with identified pathologies are sent with their parents to the polyclinic, where they receive recommendations for rehabilitation and treatment, and rehabilitation is carried out in a kindergarten.

Often and long-term ill children, as well as all healthy children, are hardened in kindergartens (air, solar, water procedures). The basic rules of hardening: gradualness, regularity, individual accounting, adequacy of the load. Of the methods of hardening in kindergartens, walking barefoot along the path of health, sunbathing, UVI in winter (individual, group), hardening with water (contrasting dousing of the feet and legs, washing, rinsing the mouth) are widely used. To improve metabolic processes, often ill children receive a freshly prepared yeast drink, a rosehip broth.

The doctor of the kindergarten carries out anti-relapse and health-improving measures. To increase the body's defenses, Eleutherococcus tincture, Echinacea, Estifan are prescribed. Sanitize the nasopharynx (UVI and UHF for tonsils for children over 3 years old, inhalation of elecampane, calendula, eucalyptus, rinsing the throat with solutions of sage, gourd, chamomile, tincture of calendula, eucalyptus, propolis - 1 tsp per glass of water, irrigation of the throat with inhalipt 2 times per day for 5-7 days), prescribe vitamins, aloe. Ribomunil has a good effect. In an epidemically unfavorable period (autumn and spring), endonasal interferon, oxolinic ointment, thymalin, dibazol orally in microdoses are indicated. During the rehabilitation period after acute respiratory diseases, a sparing regimen is prescribed for 20 days.

At the end of the year, the effectiveness of recovery, the health group should be assessed. A sanatorium group for weakened, often ill children can be organized in a kindergarten. The number of children in these groups up to 2 years old - 10 people, from 2 to 3 years old - 15, over 3 years old - 20 children. Duration of stay in a sanatorium group - up to a year. At this time, the child retains a place in the main group.

Improving the system of preschool education makes it possible to improve the health of children and creates the prerequisites for teaching children at school.

LECTURE No. 7. Observation of preschool children in the clinic

Starting from preschool age, the child is observed by the local doctor once a year. When visiting a kindergarten, supervision is carried out by the pediatrician of this institution. In case of detection of deviations in the health of the child, they are sent for examination to the clinic.

Throughout the preschool period, the child is preparing to enter school.

During medical examinations, the district pediatrician evaluates the physical and mental development of the child, conducts a systematic examination, and also plans medical and educational activities.

To assess the physical development, the anthropometric data of the child are studied. Special attention should be paid to the development of the spine, timely detection of postural disorders, assessment of the development of muscles that perform fine differentiated movements, such as modeling, drawing, sewing. In addition, it is necessary to assess the general condition of the musculoskeletal and ligamentous apparatus, since only with its sufficient development is it possible to actively work vital organ systems - blood circulation, respiration, metabolism.

When assessing mental development, it is necessary to pay attention to the child's intellectual abilities, such as speech, memory, the desire to know the world around him, the ability to control his behavior and form relationships with adults and peers. Also take into account the level of attention and thinking.

When conducting a system-by-system examination, attention is paid to the state of the nasopharynx, palatine tonsils, which, if enlarged, are a reservoir of persistent viral and bacterial infection, cause sensitization, intoxication, and, with significant growth, hypoxia of various organs and tissues.

During this period, milk teeth are replaced by permanent ones. At the age of 5 years, the lower permanent incisors erupt, at 6 years old - the upper ones, at 5-8 years old - large molars. The skeletal system of children is richer in cartilage than adults.

The formation of physiological curves of the spine in the cervical, thoracic and lumbar regions continues throughout the entire preschool age. Incorrect body position in bed and when sitting at the table leads to a slight violation of posture. Uncomfortable shoes interfere with the correct formation of the arch of the child's foot.

In children of primary preschool age (4-5 years old), the extensor muscles are underdeveloped. As a result, the child often takes the wrong posture: head down, shoulders drawn together, stooped back. From this it follows that for the correct formation of posture, the state of the bone and muscle systems is important.

Posture is the habitual position of the body when sitting, standing and walking.

Characteristic features of the posture of a preschooler:

1) the head is tilted forward;

2) the shoulder girdle is displaced anteriorly, does not protrude beyond the level of the chest;

3) the line of the chest smoothly passes into the line of the abdomen, which protrudes by 1-2 cm;

4) the curves of the spine are weakly expressed;

5) the angle of inclination of the pelvis is small.

Posture is formed in the preschool period and is fixed at school age.

One of the main patterns in this period is the uneven development and maturation of individual organs and systems (large muscles are better developed and smaller ones are worse), irregular breathing, pulse lability due to imperfection of nervous regulation, dyskinesia of the gastrointestinal tract, a change in the tone of the autonomic nervous system from the predominance of sympathetic to dominance of the parasympathetic division.

At preschool age, there is a rapid improvement of motor skills, which leads to a large need for oxygen in the child's body.

Under the influence of stress factors, the imperfection of the neurohumoral regulation of cardiac activity, respiration with an increased need for oxygen easily leads to functional and then organic changes. On the part of the gastrointestinal tract, this is manifested by recurrent abdominal pain due to spasm or hypotension of smooth muscles.

In each case, in the presence of complaints and identified deviations, age-related changes should be differentiated from organic pathology.

When briefing parents, it is necessary to pay attention to a wide range of issues, mainly related to the upbringing of the child.

Education at this age is of particular importance, as the child is preparing for school. This requires significant changes in neuropsychic development, improvement of motor skills and hardening, strengthening of immunological reactivity.

For proper mental development, independence should be cultivated and the feeling of attachment to parents should be reduced if it is too developed in a child. Preparing for school, the child must painlessly part with his mother. It is necessary to develop in him the ability to control his desires, to behave in a balanced manner, to overcome the feeling of fear and separation. It is necessary to form the child's ability for collective games, communication with peers.

It is necessary to develop the cognitive abilities of the child: he must know his address, have an idea about the world around him, about his native land. By age 4, the question "Why?" is replaced by the question "What should I do?" By this age, the child is ready for independent reading. It is necessary to train the child's memory, increase vocabulary, the ability to formulate one's thoughts.

To do this, you need to teach your child poems, songs, retell what they read. Watching violent television programs makes children aggressive, so they should not watch all programs uncontrollably.

For the development of motor skills and cognitive abilities, it is necessary to take children with you on hikes, teach your child to skate, bike, ski. It is also necessary to train the small muscles of the hands so that the child can draw a circle, a straight line, a variety of geometric shapes, little men.

During classes, it is necessary to monitor the posture of the child and strengthen the muscles that hold the spine in the correct position.

With the development of motor activity, it is necessary to use more and more morning exercises, collective outdoor games.

Morning exercises include walking, running, upper and lower waist exercises. It is better to exercise outdoors.

Outdoor games (volleyball, tennis, basketball) bring up endurance and discipline in children. From the age of 5-6 years, children attend sports sections (gymnastics, acrobatic, figure skating, swimming); modern or ballroom dancing.

You should teach the child to be neat: wash yourself in the morning, treat your clothes carefully, clean up after yourself after the game, wash your hands before eating, use a handkerchief, eat carefully.

It is necessary to instill in the child a sense of responsibility for their health, to explain to him the need to comply with the rules of the road.

The role of hardening in the preschool period is great, since the sensitivity to cooling remains high. At this age, a conscious understanding of the need for hardening is important to maintain one's health.

At preschool age, a specific immune response to antigenic stimulation is formed. In frequently and long-term ill children, the formation of immunological reactivity is delayed and transient immune deficiency develops. In the absence of the effect of general medical recreational activities, treatment with ribomunil should be carried out.

Determining the degree of functional readiness of children to enter school

The medical criteria for school maturity include a comprehensive assessment of the state of health (level of biological development, morbidity for the previous period, psychophysiological criteria). When issuing a medical opinion on readiness for learning, medical indications for postponing the education of children of 6 years of age should be taken into account.

Determination of the psychophysiological readiness of children to enter school is carried out in September-October of the year preceding the start of education.

The Medical Pedagogical Commission, which includes a psychologist, a pediatrician, and a teacher, identifies children who are not ready for learning.

Such children need special training, the effectiveness of which is determined in February-March of the year of admission to school during a repeated psychophysiological examination.

Psychophysiologically immature children stay for another year in kindergarten (in the kindergarten preparatory group). If the child has not previously attended kindergarten, he is assigned to a preparatory group for a year. The final decision of the medical and pedagogical commission is drawn up before the start of the academic year (in July-August).

Readiness of the child for school is considered at three levels.

The first level is morphofunctional (physical development, resistance, neurodynamic properties, development of speech, muscles, performance).

The second level is mental readiness (perception, memory, thinking, imagination).

The third level is personal readiness (attitude towards school, educational activities, peers and adults, the ability to build relationships, learn and implement moral standards).

Determination of psychophysiological maturity is carried out according to special diagnostic programs. They include a variety of tests that are constantly being improved and updated.

The modern diagnostic program includes an awareness questionnaire: full name, address, addition of phrases of the started sentence, motivational readiness (attitude towards school). They use tests in pictures, children are invited to play a game.

When conducting psychological research, they also evaluate the development of speech (stories from pictures), the level of self-regulation (according to various game methods), motor skills of the hand, and the level of physical fitness.

As a result of the survey, children are identified with a high level of psychophysiological development, with an average level (insufficient development of motivation and volitional qualities) and with a low level.

The further program of preparing the child for school is carried out by the teacher of the kindergarten group in a differentiated manner depending on the results of the survey. If necessary, specialists participate in the preparation of the child: a speech therapist, a psychologist, a pediatrician.

LECTURE No. 8. Observation of school-age children in the clinic. The work of a pediatrician in a school

The school period is divided into junior school period (6-9 years old), middle school period (10-14 years old) and adolescence period (15-17 years old). A pediatrician works with junior and middle school age, and an adolescent doctor works with adolescents. However, the greatest continuity in work can be achieved when the child is observed by one (family) doctor.

Examination of school-age children is carried out during scheduled examinations with the invitation of specialists in accordance with the scheme of dynamic observation of healthy children. For a more thorough history taking, more frequent interviews of children should be conducted. Pay attention to past illnesses, behavioral patterns, rates of physical and mental development.

When examining organs and systems, the most attention is paid to the condition of the skin (there may be acne), the condition of the teeth (caries). It is necessary to assess the posture of the child and identify its violations in the early stages, and timely correction of visual impairment is also important.

Middle and senior school age is a period of significant hormonal changes in the body of a teenager, the period of puberty, which affects the state of all organs and systems. Diseases such as obesity, hypothalamic syndrome, vegetovascular dystonia, hypertensive and hypotensive conditions should be promptly identified and treated. This pathology often appears against the background of existing chronic foci of infection in the nasopharynx, biliary and urinary tract. It is necessary to assess the correct (in accordance with the sex and age of the child) development of secondary sexual characteristics.

To assess physical development, anthropometric data and motor skills are taken into account - the ability to jump on one leg, stand with eyes closed, perform precise movements - write, sculpt, draw; at primary school age - to tie shoelaces.

When evaluating neuropsychic development, academic performance, behavioral characteristics at school and at home, development of speech, memory, and independence in thinking are taken into account.

A system-by-system examination during puberty should be carried out especially carefully, since at this age, against the background of hormonal changes, adaptation often fails, which can cause changes in various organs and systems. It is mandatory for all children to assess the state of the thyroid gland, lymph nodes, respiratory organs, blood circulation, digestion and urination. Recommendations are made based on the survey data.

At school age, they relate mainly to educational moments. It is necessary to teach the child to take care of his health by cultivating hygiene skills (morning and evening toilet, keeping clothes clean, washing hands before eating). In middle and senior school age, the child should be able to dress himself according to the weather, as well as distinguish what clothes should be worn at home, in the theater, school, for walks. An understanding of the need for proper nutrition should be developed so that the child can independently warm up and cook several dishes, eat regularly in accordance with the daily regimen throughout the day, evenly distributing the load on the digestive organs.

Recommendations for caring for a child include organizing a workplace for the learning process with good lighting and a comfortable position for correct posture. For physical education, you should purchase a sports suit and comfortable sports shoes.

The teenager's room should be clean and comfortable. You should not use bright red irritating colors for interior decoration, it is better to observe calm and tonic tones - green, yellow. Further development of cognitive functions is necessary. When teaching, the type of higher nervous activity of the child is necessarily taken into account. Children with a balanced type easily master new educational material, get tired and get sick less. Children with an excited type are unbalanced, they quickly grasp the educational material, but do not master it to the end. Patient and persistent work is required to develop the ability to hold attention and inhibit excitement. The progress of these children is uneven. Children with an inhibitory type of higher nervous activity need to be explained again, but the material they understand is firmly retained. With an inert type, inhibitory and excitable processes are weak, children get tired quickly, study weakly, often get sick and need a sparing regimen.

By the age of 8, a child can focus on many aspects, phenomena, discover a hierarchy, think logically, and understand the point of view of others. By the age of 12, abstract thinking develops, the ability to make hypotheses. It is necessary, revealing the child's abilities, to determine the right direction in choosing a specialty. In the period from 6 to 12 years, the child should be taught to independently prepare lessons, instill in him a sense of responsibility for the accurate and conscientious completion of homework, and develop interest in cognitive activities.

In these matters, the coordinated activity of parents and teachers is necessary. At this age, the consciousness of one's goal in life and ways to achieve it begins.

During the school period, the children's team breaks up into groups. An important event in the life of a child is the appearance of a friend. The growing influence of peers can challenge family values.

Rejection of inhibitions usually precedes a child's ability to make intelligent decisions. The role of parents in preventing rash acts is great and can be performed in conditions of maintaining psychological contact with the child.

The correct attitude of parents to the sexual education of the student is necessary. Such education is carried out in the form of unobtrusive conversations that arise by chance as the child shows interest.

In middle and high school age, a child should know about the structure of male and female genital organs, conception and fertilization, sexual relationships, methods of contraception, sexually transmitted diseases and AIDS. You should not impose such topics for conversations on the child, but you must always be ready to give the correct answer to the questions that interest him.

The child is brought up with a negative attitude towards smoking, alcoholism and drug addiction, supporting negative emotions for bad habits.

This is opposed to a healthy lifestyle, orienting the child on the importance of maintaining his own health. Education of a healthy lifestyle cannot be carried out by order.

They bring up and consolidate in the child a healthy interest in physical exercises in the fresh air, hobbies for sports, books, travel, organized leisure activities in their free time.

Puberty is accompanied by a transient immunodeficiency state. At this age, you should actively continue hardening procedures, observe the daily regimen to exclude physical and psychological overload, take multivitamins in spring and autumn, sanitize chronic foci of infection in a timely manner (it is recommended to rinse the tonsils daily with decoctions of gourd, eucalyptus, sage, chamomile, calendula, yarrow, bark). oak).

Prevention of obesity, psychoneurosis, thyroid dysfunction should be carried out in a timely manner. Early diagnosis of gynecological pathology in girls, its treatment in the initial stages are important.

At school age, the improvement of motor functions continues. Physical exercises for speed (speed running, fast games, dressing, undressing, etc.) at 6-9 years old contribute to the development of high-speed processes in mental activity.

The work of a pediatrician at school

The school doctor works under the guidance and supervision of the head of the preschool department of the polyclinic. The responsibilities of a pediatrician include:

1) timely medical examinations of children with a conclusion on the state of health, determination of a medical group for physical education and drawing up a plan of medical and recreational activities;

2) based on the analysis of medical examinations, the preparation of an action plan to improve the health of schoolchildren, which is considered by the pedagogical council, is approved by the head physician of the polyclinic and the director of the school;

3) implementation of medical control over physical education at school, working hours, labor training, catering, sanitary and anti-epidemic measures;

4) carrying out work on the professional orientation of schoolchildren, taking into account their state of health, preparing materials for the commission on exempting students from transfer and final exams;

5) outpatient reception at school, provision of medical care to those in need;

6) carrying out sanitary and educational work, prevention of injuries and their accounting;

7) observation of dispensary patients, their recovery;

8) timely informing school leaders about the health status of schoolchildren;

9) improving their professional qualifications.

The medical staff of the school is part of the staff of the children's polyclinic. The doctor is also a member of the pedagogical council of the school, he is obliged to draw up the current curriculum of work, which is approved by the head doctor of the children's polyclinic.

LECTURE No. 9. Immunoprophylaxis

The introduction of active immunization means into the practice of children's healthcare has led to a significant decrease in the incidence of infectious diseases in children. Currently, vaccinations against tuberculosis, diphtheria, tetanus, whooping cough, poliomyelitis, measles, mumps, hepatitis B, rubella and other epidemiological indications are being vaccinated. Means of active immunization against acute respiratory diseases (ribomunil, polyoxidonium) are used. The first clinical trials of prophylactic vaccinations against chickenpox are underway.

1. Organization and conduct of preventive vaccinations

Currently, vaccination work in the clinic is organized and carried out in accordance with the order, which approved the calendar of preventive vaccinations, instructions on the tactics of immunization, the main provisions on the organization and conduct of preventive vaccinations, a list of medical contraindications to immunization, the procedure for registering information about complications from vaccinations .

Preventive vaccinations should be carried out at the time set by the calendar. In case of their violation, the simultaneous administration of several vaccines is allowed, but in different parts of the body and with separate syringes.

With separate vaccinations, the minimum interval should be at least a month. If the vaccination against hepatitis B is not carried out on the same day as other vaccinations, then the interval between their administration is not regulated.

In the event of acute diseases, including acute respiratory viral infections and acute intestinal infections, or exacerbation of chronic, routine immunization is postponed until the symptoms of the disease disappear.

Preventive vaccinations are carried out in appropriately equipped vaccination rooms in polyclinics or other premises with strict observance of sanitary and hygienic requirements.

By decision of the health authorities, preventive vaccinations can be carried out at the place of work (study) of the vaccinated or at home.

The vaccination room of the polyclinic should consist of rooms for vaccination and storage of a vaccination card file and have a refrigerator for storing vaccination preparations, a cabinet for tools and a set of medicines for emergency and anti-shock therapy, bixes with sterile material, a changing table or a medical couch, a table for preparing vaccination preparations , table for storing medical records. The office should have instructions for the use of vaccinations and a reminder for emergency care.

Vaccinations against tuberculosis and Mantoux testing should be carried out in a separate room, and in its absence - on a special table, on allocated days and hours.

To avoid contamination, it is forbidden to combine vaccinations against tuberculosis with vaccinations against other infections. It is forbidden to carry out vaccinations against tuberculosis and the Mantoux test at home.

The head of the medical institution is responsible for setting up vaccination work, appoints medical workers responsible for planning and implementing preventive vaccinations with a clear definition of their functional responsibilities.

Preventive vaccinations are carried out by medical workers trained in the rules of vaccination technique and emergency care.

Health workers are required to notify parents in advance about the day of preventive vaccinations. All persons to be vaccinated should be examined by a doctor or paramedic, taking into account the anamnesis (previous diseases, allergic reactions to vaccinations, drugs, food).

Immediately before vaccination, the child is examined and body temperature is measured to exclude an acute illness.

After the vaccination, medical supervision should be provided for him.

Vaccinations and tuberculin diagnostics are carried out with syringes and needles for single use only. For immunization, vaccines approved for use in Russia are used.

The medical staff of the vaccination room is responsible for the completeness and correctness of the vaccination documentation.

A record of the vaccination performed is made in the working journal of the vaccination room, the history of the development of the child, the card of preventive vaccinations, the medical record of the child attending the children's institution, the register of preventive vaccinations. After vaccination and revaccination against tuberculosis, after 1, 3, 6, 12 months, the nature of the papule, scar, and the state of regional lymph nodes are recorded.

The record indicates the name of the drug, the country of manufacture, dose, series, control number, expiration date, information about local and general reactions to the vaccine, complications, and the timing of their development.

If a post-vaccination reaction occurs, it is necessary to immediately notify the head of the medical institution, if a complication develops, send an emergency notification to the territorial center of epidemiology. The fact of refusal of vaccinations is recorded in medical documents with a note that the medical worker has given explanations about the consequences of the refusal, signed by the citizen and the medical worker.

Essential Vaccines

The first vaccination is carried out within 24 hours after the birth of the child. This is a Hepatitis B immunization. EngerixV Recombinant Yeast Liquid Vaccine is a sterile suspension containing genetically engineered purified Hepatitis B Major Surface Antigen (HBS Ag).

A surface antigen gene has been isolated from the hepatitis B virus and incorporated into yeast.

As a result of the reproduction of yeast cells and the purification of the surface antigen, the HBS Ag vaccine was obtained, spontaneously transforming into spherical particles with a diameter of 20 nm, containing non-glycosylated HBS Ag polypeptides and a lipid matrix of phospholipids, which have the properties of natural HBS Ag. The preservative is thiomersal. Three times the introduction of "EngerixV" leads to the formation of specific antibodies and prevents the development of hepatitis B in 95-98% of those vaccinated.

The vaccine is administered intramuscularly into the deltoid muscle region of older children or into the anterolateral thigh region in newborns and young children.

As an exception, in patients with thrombocytopenia and other diseases of the blood coagulation system, the vaccine can be administered subcutaneously.

It is not recommended to administer the vaccine intramuscularly in the gluteal region, as well as subcutaneously and intradermally, as this can lead to a low immune response. It is strictly forbidden to administer the vaccine intravenously. A single dose of the drug for newborns and children under 10 years old is 10 mcg (0,5 ml), for children over 10 years old - 20 mcg (1 ml).

The second vaccination is carried out at the age of 1 month, the third - at 5 months, simultaneously with DTP and OPV. Premature babies weighing less than 2 kg are vaccinated from two months with similar intervals between vaccinations.

Primary vaccination against tuberculosis is carried out for newborns on the 3rd-4th day of life. The BCG vaccine is live dried bacteria of the BCG vaccine strain No. 1. One inoculation dose - 0,05 mg BCG - is dissolved in 0,1 ml of the solvent, injected intradermally at the border of the upper and middle thirds of the outer surface of the left shoulder.

Premature babies weighing less than 2 kg, as well as children not vaccinated in the maternity hospital due to medical contraindications, are vaccinated at the clinic with the BCGM vaccine. Children older than two months, not vaccinated during the neonatal period, are vaccinated in the clinic after a tuberculin test with a negative result.

Children are vaccinated again if 2 years after vaccination and a year after revaccination they have not developed a post-vaccination scar and the Mantoux reaction is negative.

At the age of 7 years, children who have a negative reaction to the Mantoux test are subject to revaccination. The interval between the Mantoux test and revaccination should be at least 3 days and not more than 2 weeks.

Persons with positive and doubtful reactions to the Mantoux test, as well as those who had complications from previous injections of BCG and BCGM, are not subject to immunization.

Vaccination against poliomyelitis is carried out with a live polio oral vaccine containing attenuated strains of human poliomyelitis virus of three immunological types (I, II, III). The vaccine is available in the form of a solution and sweets.

Vaccination is carried out from three months three times with an interval between vaccinations of a month, revaccination - at 18 months, 24 months and 7 years once.

In the presence of inactivated polio vaccine, the first vaccination in the vaccine cycle at the age of 3 months is carried out with IPV, and the 2 subsequent ones with OPV. Before entering school, a child must receive 5 vaccinations (3 in the first year of life and 2 in the second).

In the case when the child was previously vaccinated according to an individual scheme, the minimum interval between the completed vaccination and revaccinations should be at least 6 months. Co-administration of oral polio vaccine with all vaccines is not excluded.

Vaccine-associated paralytic poliomyelitis occurs within 4 to 30 days, in contact persons - from 4 to 75 days, in persons with immunodeficiency, these terms may be different.

All contact (vaccinated and unvaccinated) children should receive OPV when dealing with a patient with wild poliomyelitis caused by wild poliovirus.

Fully vaccinated people are given 1 dose of OPV, for unvaccinated people, the introduction is carried out according to the full scheme, for partially vaccinated people - up to the number of vaccinations set by the calendar.

Vaccinations against diphtheria, whooping cough, tetanus are carried out with the DPT vaccine (adsorbed pertussis-diphtheria-tetanus vaccine), which consists of a mixture of phase I pertussis microbes killed with formalin or merthiolite, purified and concentrated diphtheria and tetanus toxoids adsorbed on aluminum hydroxide.

The DTP vaccination course consists of three intramuscular injections of the drug (0,5 ml each) with an interval of a month. Shortening intervals is not allowed.

If it is necessary to lengthen the intervals after the 1st or 2nd vaccination for more than a month, the next vaccination should be carried out as soon as possible, determined by the state of health of the child, but not exceeding 6 months. In exceptional cases, intervals may be extended up to 12 months.

Inoculations with DTP vaccine are carried out simultaneously with immunization against polio. Revaccination is carried out once every 18 months. Vaccinations against whooping cough are done from 3 months to 4 years. Children with contraindications to DTP are vaccinated with ADSanatoxin according to the scheme: vaccination - at 3 and 4 months, revaccination after 9-12 months.

If, after three or two DPT vaccinations, the child has had whooping cough, then the DPT vaccination course is considered complete. In the first case, revaccination is carried out with ADS at 18 months, in the second - after 9-12 months.

If a child has received only one DTP vaccination, he is subject to a second DTP vaccination with a booster in 9-12 months.

In the event of post-vaccination complications for the first DTP vaccination, the second is carried out with ADSanatoxin, if for the second - vaccination is considered complete, if for the third - ADS revaccination is carried out after 12-18 months.

In case of violation of the immunization regimen against diphtheria and tetanus, the intervals between vaccine injections should be: between vaccination and revaccination - 9-12 months, between the first and second revaccinations - at least 4 years, between the second and third, third and fourth revaccinations - at least 4 years, between subsequent revaccinations - at least 10 years.

For emergency prevention of whooping cough in unvaccinated children, normal human immunoglobulin is used twice with an interval of 24 hours in a single dose of 3 ml as early as possible, vaccination is not carried out. Effective chemoprophylaxis with erythromycin (40-50 mg/kg/day) for 14 days.

The second revaccination (6 years) is carried out with ADSantitoxin once, the third (11 years) - with ADSantatoxin once. Children over 6 years of age, not previously vaccinated, are vaccinated with ADSManatoxin: 2 vaccinations with an interval of a month, revaccination is carried out once after 9-12 months. ADSManatoxin consists of a mixture of concentrated and purified diphtheria and tetanus toxoids with a reduced content of antigens adsorbed on aluminum hydroxide.

Persons who have been in contact with a patient with diphtheria are subject to vaccination with ADSM (ADM) - toxoid at a dose of 0,5 ml, if the last vaccination was more than 5 years ago. Persons who are unvaccinated and with an unknown vaccination history are vaccinated twice with an interval of a month.

Trimovax vaccine for the prevention of measles, mumps and rubella contains live attenuated measles, mumps and rubella viruses, is available in lyophilized form, water for injection is used as a solvent. Children are vaccinated at 12 months by subcutaneous or intramuscular injection.

At the age of 6, revaccination is carried out with a complex vaccine, in cases where the child did not have any of the indicated infections or monovaccines according to the calendar, if he had had at least one of them.

Monovaccines are administered simultaneously in different parts of the body or at intervals of a month. The Trimovax vaccine may be administered simultaneously with any other vaccine, except for BCG and BCG.

In contact with a measles patient who is not ill and unvaccinated, a live measles vaccine is administered in the first 3 days. If there are contraindications to vaccination and children under 12 months of age, normal human immunoglobulin is administered at a dose of 1,5 ml or 3,0 ml.

In case of contact with a patient with epidparotitis, the ZhPV vaccination is carried out no later than 72 hours from the moment of contact with a sick and unvaccinated person.

Contraindications to prophylactic vaccinations

A contraindication to all vaccinations is a complication of the previous dose of the drug - allergic edema that developed within 24 hours after vaccination, immediate anaphylactic reactions, encephalitis, convulsions.

Vaccinations are contraindicated in children with immunodeficiency, immunosuppression, malignant neoplasms.

There are additional contraindications for individual vaccines: BCG is contraindicated in premature babies weighing less than 2 kg, with regional lymphadenitis, regional abscess, keloid scar after a previous vaccination, history of tuberculous sepsis, generalized BCG infection (which developed 1-12 months after immunization), children who are infected with or have a history of tuberculosis.

There are no absolute contraindications for OPV. For DTP, contraindications are progressive diseases of the nervous system, uncontrolled epilepsy, infantile spasms, progressive encephalopathy.

There are no absolute contraindications for ADS, ADSM, AD and AS, for ZhKV, ZHPV, Trimovax - an anaphylactic reaction to aminoglycosides and egg protein, for a monovaccine against rubella - an anaphylactic reaction to aminoglycosides, for a vaccine against hepatitis B - hypersensitivity to yeast and other components of the vaccine.

A relative contraindication is an acute disease or an exacerbation of a chronic one.

In this case, routine vaccination is postponed until the symptoms disappear.

The following are not a contraindication to vaccination: perinatal encephalopathy, bronchial asthma, hay fever, drug allergy, eczema, dermatoses, anemia, cerebral palsy, Down syndrome, upper respiratory tract infections and diarrhea at temperatures below 38 ° C, chronic diseases of the heart, lungs, liver and kidneys , thymus enlargement, congenital malformations, treatment with antibiotics or small doses of corticosteroids, dysbacteriosis, tuberculin Mantoux test without functional manifestations, history of prematurity, malnutrition, hemolytic disease of the newborn, hyaline membrane disease, convulsions (including epilepsy, sepsis in family members), allergies in relatives, sudden death in the family, Mantoux tuberculin test and tuberculosis infection in family members.

Post-vaccination reactions and complications

Post-vaccination reactions are changes in the functional state of the body that do not go beyond the physiological norm.

A strong general reaction consists in an increase in body temperature above 40 ° C, a strong local reaction in the appearance of an infiltrate at the injection site with a diameter of more than 8 cm or an infiltrate in the presence of lymphangitis with lymphadenitis.

A post-vaccination complication is a pathological condition of the body that develops after vaccination and, in its manifestations, goes beyond the physiological norm.

Complications include:

1) anaphylactic shock on DTP, ATP, ZhKV, which occurs within 24 hours after the introduction of the vaccine;

2) collaptoid state on DPT after 5-7 days from the introduction of the vaccine;

3) encephalopathy (impaired cerebral functions of the central nervous system, generalized or focal increase in intracranial pressure, impaired consciousness for more than 6 hours, convulsions, slow waves on the EEG) for the introduction of DTP, ATP in terms of 3 to 7 days;

4) residual convulsive state (an episode of convulsions at a temperature below 39 ° C, if they were absent before and repeated after vaccination) on DTP, ATP, ADM for a period of 3 days;

5) paralytic poliomyelitis on OPV up to 30 days in a vaccinated person, up to 6 months and later in an immunodeficient person, up to 75 days in a contact person;

6) after vaccination with tuberculosis - lymphadenitis, regional abscess, keloid scar and other complications that have arisen during the year;

7) chronic arthritis on "Trimovax", rubella vaccine within 42 days;

8) neuritis of the brachial nerve to DPT, DTP, AS, ADSM and other vaccines in terms of 2 to 28 days;

9) thrombocytopenic purpura on ZhKV, "Trivaktsina", rubella vaccine in a period of 7 to 30 days. Febrile convulsions, fontanelle bulging, shrill

crying, prolonged crying can be observed with encephalopathy, but by themselves are not sufficient to make a diagnosis of complications from vaccination.

The main principles of the treatment of post-vaccination reactions and complications are the fight against hyperthermia, detoxification, the use of desensitizing drugs, anticonvulsant and dehydration therapy, the treatment of intercurrent infections and exacerbated chronic diseases, symptomatic therapy.

In case of anaphylactic shock, medical assistance should be provided immediately. It consists in stopping the administration of the drug, giving the patient a horizontal position (on his side), warming him up, administering intramuscularly antihistamines, intravenous glucocorticoids, oxygen therapy, symptomatic therapy (administration of cardiac, diuretic, anticonvulsants, etc.). After removing from anaphylactic shock, the child is immediately hospitalized.

If a complication is detected after immunization or if it is suspected, the doctor (paramedic) is obliged to notify the head physician of the medical institution about this. The chief physician ensures the hospitalization of the patient in a hospital, sending an emergency notice.

The territorial center of epidemiology registers complications for vaccination with a specification of the clinical diagnosis, a laboratory study of the material obtained from the patient sends information to the regional center of epidemiology.

LECTURE No. 10. Rehabilitation of children after illness. Disability

Manifestations of the disease are considered at three levels: organ, organism and social.

At the organ level, the disease manifests itself in the form of morphological changes that lead to dysfunction of an organ or organ system. At the organismal level, the disease is characterized by limited life activity.

At the social level, the disease leads to social inferiority, due to the limitation of life, a person is not able to fulfill his usual role in life in accordance with age.

According to the definition of WHO experts, the criteria for vital activity are:

1) orientation;

2) communication;

3) self-service;

4) movement;

5) engaging in labor activity;

6) control over their behavior;

7) training.

Life restriction is characterized by the absence of one or a combination of several of these criteria. The assessment of vital activity criteria in children requires taking into account the age capabilities of the child.

Restriction of the child's life activity is expressed in the complete or partial loss of the ability to carry out orientation, communication, movement, self-service, control of one's behavior, as well as in the loss of the opportunity to engage in labor activities, such as playing, studying.

The restriction of the child's life activity is determined by a violation of functions and is divided into three degrees: sharp (I degree), significant (II degree), pronounced (III degree).

The state of functions is characterized by functional class (FC):

0 - no dysfunction;

1 - there are slight dysfunctions (no more than 25%), fully compensated;

2 - moderate dysfunctions (from 25% to 50%), partially compensated to a moderate degree;

3 - significant dysfunctions (from 51% to 75%), poorly compensated;

4 - pronounced and complete (over 75%) dysfunctions, not compensated.

1. Disability

Disability in a child is a state of persistent social maladjustment caused by the limitation of his life activity due to a violation of the functions of organs or their systems.

WHO experts have developed survival criteria that characterize disability:

1) orientation in the surrounding world;

2) physical independence;

3) mobility;

4) communication;

5) classes;

6) economic independence.

There are four degrees of limitation of survival criteria: insignificant, moderate, significant, sharp.

A minor degree is characterized by the possibility of complete compensation of the corresponding criterion when using assistive devices or with constant medication, as well as with a periodic disorder of this criterion.

A moderate degree is defined in cases of achieving partial compensation when using assistive devices or medications. A significant degree is observed in cases where the help of others is needed. A sharp degree of limitation requires constant assistance in a special institution. Thus, it can be concluded that a disabled person is a person who needs social assistance and protection in connection with the restriction of his life activity due to the presence of any physical or mental disabilities.

Disability from childhood is established in cases where disability due to illness or injury occurred before the age of 16, and for students - before 18 years. The CEC issues a conclusion, which is an official document certifying the period and cause of disability, and also draws up an individual rehabilitation program, which indicates the specific volumes and types of medical, professional, and social rehabilitation of a disabled child.

An individual rehabilitation program is a document binding on the relevant state bodies, enterprises, institutions and organizations, regardless of their form of ownership.

The reason for the establishment of disability is not the disease or injury itself, but their consequences. The consequences can manifest themselves in the form of violations of any mental, physiological or anatomical structure or function, which in turn leads to a limitation in the life and social insufficiency of the child.

In chronic somatic diseases, the formation of various life restrictions is possible. In such cases, the issue of establishing disability in children is considered only after examination in a specialized hospital by specialists from children's medical institutions, when social maladaptation becomes persistent, despite the treatment and rehabilitation carried out.

For children, disability is established without specifying the group and reason for a certain period, which may fit into one of the following time frames: from 6 months to 2 years; for 2 years, 5 years, until the age of 16.

The period for which disability is established depends on the reversibility of the functional disorders caused by the disease, injury or defect, as well as the possibilities of social adaptation, and in other words, on the clinical prognosis and the rehabilitation potential of the child's body.

2. Rehabilitation process

Rehabilitation is the complete elimination of pathological changes in the child's body that caused the disease, and ensuring its further harmonious development. Rehabilitation differs from treatment in that it helps the patient to restore normal life activity in accordance with his age. Goals of rehabilitation:

1) restoration of functions;

2) social rehabilitation;

3) professional activity, and in children - the ability to learn.

There are medical, social and labor rehabilitation.

Medical rehabilitation provides a staged treatment from the onset of the disease to the full restoration of health. Its tasks are to restore and compensate for the functional capabilities of the body.

To do this, with the help of psychotherapy, it is necessary to form an adequate attitude of the child to the disease, give him the necessary training, orient the disabled person or the patient with the help of psychological methods to restore health through their own training efforts, restore lost functions and learning abilities.

Social rehabilitation ensures the organization of a day regimen appropriate for the age and lifestyle of the child, rules for the care of close family members or the relevant staff of preschool or school institutions.

This type of rehabilitation forms in the child a conscious attitude towards himself in case of illness, a positive perception of the family and society. Social rehabilitation is aimed at providing social assistance and services for adaptation to the social sphere, providing auxiliary technical means, home care, material assistance, and, if necessary, education and training in specialized institutions.

Occupational rehabilitation consists in preparing the child for the learning process, mastering the school curriculum or the program of a preschool institution, providing funds for education, career guidance, and vocational training.

Rehabilitation stages

Early rehabilitation involves improving the results of treatment, restoring the functionality of the diseased organ and body. It is carried out in the period of acute manifestations of the disease in a hospital or clinic, that is, this is the clinical stage of rehabilitation. It is the preparation of the whole organism for the next stage.

Late rehabilitation, or the sanatorium stage, consists in the complete elimination of pathological changes, the restoration of the possibility of the child's physical and mental activity, taking into account his individual abilities.

This type of rehabilitation can be carried out in a local sanatorium or clinic using the factors of sanatorium treatment.

Factors of rehabilitation of the sanatorium stage:

1) sparing training mode of motor activity;

2) exercise therapy;

3) massage;

4) curative pedagogy;

5) nutrition;

6) intake of mineral water;

7) physiotherapeutic effects;

8) sanitation of foci of infection;

9) continuation of the treatment prescribed in the hospital.

A gentle training regimen is selected individually depending on the child's capabilities with a gradual expansion of the load.

Therapeutic exercise is of great importance in all diseases.

Under its influence, oxidative processes in the body increase, and overall metabolism improves.

Physical exercise has a regulatory effect on vascular tone.

At the same time, blood flow and lymph outflow are accelerated, and therefore congestion in the liver, spleen and skin is reduced. At the same time, the hemoglobin content and the number of red blood cells increase in the blood, and the phagocytic function of the blood increases.

Physical exercises have a positive effect on the emotional tone of the child, improve his mood, make him more active, sociable.

Exercise therapy should be carried out simultaneously with massage, which is one of the types of passive gymnastics.

As a rule, the technique of general massage is used.

Therapeutic pedagogy provides psychological rehabilitation, increases the ability to mental stress.

The nutrition of a sick child should be complete, should provide the need for food ingredients, as well as calories in accordance with age. Spicy, fried, canned foods and extractives are excluded from the diet.

Food should be varied, include dishes of vegetable and animal origin, contain vegetable fats and pork fat, as they are sources of unsaturated fatty acids.

Mineral water. Bottled mineral water can be used for drinking. Take it 30-40 minutes before meals, 4-5 ml / kg 3 times a day for 3-4 weeks. In the treatment of intestinal diseases, mineral water is taken cold.

The chemical components of mineral waters, absorbed through the mucous membrane of the gastrointestinal tract, directly affect metabolic processes, the pH of digestive juices, as well as enzymatic activity.

After 15-30 minutes after ingestion of water, stimulation of gastric secretion is observed, the functions of the liver and pancreas are activated.

Bicarbonate waters normalize the motor and secretory functions of the digestive tract, reduce the effects of dyspepsia, thin and help remove pathological mucus from the mucous membrane of the stomach, respiratory and urinary tract, and normalize the acid-base balance.

Sodium chloride waters stimulate metabolic processes, have a choleretic effect, stimulate the secretion of the stomach, intestines and pancreas. Calcium chloride waters reduce the permeability of cell membranes, reduce bleeding, and have a beneficial effect on the growth of bone tissue and teeth.

Sulfate ions in combination with calcium cations have an anti-inflammatory effect and thicken the vascular wall. Magnesium ions affect the secretion of bile. Iodine and bromine ions normalize the function of the central nervous system and thyroid gland.

Arsenic waters actively influence the energy potential of cells and their overall resistance.

Silicon has anti-inflammatory, antitoxic and analgesic properties. Fluoride strengthens the tissues of the teeth. The use of mineral water for drinking can be repeated 6 months after the completed course at the sanatorium stage of rehabilitation.

Physiotherapeutic methods of treatment are selected taking into account the clinical manifestations of the disease, tolerability and effectiveness in this patient. In this case, electrical procedures can be used.

Under the influence of electric currents, a complex complex of both local and general body reactions occurs in the form of changes in blood circulation, metabolism, tissue trophism in a diseased organ, and others, which contributes to the disappearance of the inflammatory process.

For therapeutic purposes, electrotherapy methods include galvanization, pulsed electrotherapy, and high-frequency electrotherapy.

Sanitation of foci of chronic infection is carried out at all stages of rehabilitation by conservative methods, but at the sanatorium stage, surgical methods can also be used against the background of appropriate drug treatment.

Drug treatment and prevention of relapses continue in accordance with the developed treatment regimen in the hospital.

The sanatorium stage of rehabilitation is of decisive importance in the complete elimination of the disease.

Each specialized department should have this stage of rehabilitation, where highly qualified specialists of the specified profile work.

Secondary prevention, or rehabilitation treatment, at the outpatient stage of rehabilitation is a complex of therapeutic and educational activities aimed at restoring or compensating for morphological and functional changes in the child's body resulting from a disease or injury, as well as the mental status of the patient, and ensures complete restoration of health, the return of the child to his usual living conditions.

At this stage, stable compensation of impaired functions, complete physical, mental and social adaptation should be achieved.

Spa treatment is used at the polyclinic stage of rehabilitation.

Resort rehabilitation is carried out at the respective resorts or in specialized summer camps for children, where potent resort factors and hardening are used, which the child can endure if there is a sufficient supply of strength.

Therefore, the timing of the resort treatment is determined for each nosological form individually, but not earlier than 6 months after the sanatorium stage of treatment.

The goals of outpatient rehabilitation are complete recovery, prevention of chronic pathology and disability of children or compensation for functional changes in the child's body resulting from the disease, as well as restoration of the patient's mental status in order to return him to his usual way of life as soon as possible.

Resort rehabilitation provides for the prevention of recurrence of the disease. The potent resort rehabilitation factors include: balneotherapy, mud therapy, light therapy, hardening. Exercise therapy, physiotherapy, and curative pedagogy are also used.

Balneotherapy - the use of natural (natural) water sources or artificially prepared mineral waters for external use.

Balneotherapy includes bathing and swimming in the pool, general and local baths, baths, baths of natural mineral waters and their artificially prepared analogues, as well as internal use of mineral water (oral intake, gastric and intestinal lavage, inhalations).

Organic compounds in mineral waters (substances such as humins, bitumens, naphthenic acids, phenol-containing compounds) determine its bactericidal and biostimulating properties. According to the pH value, mineral waters are divided into acidic (pH 3,5-6,8), neutral (pH 6,8-7,2) and alkaline (pH 7,2-8,5 and higher).

According to the predominance of ions, they are called sodium chloride, sodium bicarbonate. Mineral baths have a thermal, mechanical, chemical effect on the body.

The biologically active substances contained in the bath act on the skin and, penetrating through it, are included in metabolic processes.

Baths with a water temperature of 35-37 ° C are prescribed for children after 1-2 days, as they cause fatigue. Baths are contraindicated for weakened children.

Mud therapy is the use of natural organomineral colloidal formations (peloids) containing active substances (salts, gases, biostimulants) that have the properties of heat carriers.

Muds have a thermal, mechanical and chemical effect, provide a gradual release of heat, causing active hyperemia not only of the skin, but also of deeply located tissues and organs, improving their blood circulation.

Mechanical action improves hemodynamics.

The chemical factor in the action of mud is due to the presence of biologically active substances in them that act directly on the skin and penetrate into the circulating blood (volatile, hormone-like substances, antibiotic compounds, organic acids, etc.), activate bioenergetic and enzymatic processes.

Muds can be applied in the form of a general overlay on the whole body, excluding the head, neck, heart area, and local procedures ("trousers", "underpants", "gloves", "boots", etc.). The mud temperature can be between 37°C and 46°C.

After applying the mud, rest for one or two days is required. Pelotherapy is contraindicated for young children and weakened children.

At preschool and school age, the time of procedures is reduced compared to adults, but the indications for the appointment of mud are the same as for adults.

Light therapy (phototherapy) is the use of electromagnetic oscillations of the optical range (light) for therapeutic purposes. The absorbed energy has a biological effect.

When light energy is absorbed by atoms and molecules of body tissues, it is converted into thermal and chemical energy, which provide photobiological effects, they depend on the type of light (infrared, ultraviolet).

Infrared and visible light - electromagnetic oscillations with a wavelength from 400 microns to 760 nm. These rays penetrate to a depth of 1 cm and are called thermal (or caloric). Visible light - electromagnetic oscillations with a wavelength from

760 to 400 nm.

Infrared and visible rays, when absorbed, give similar effects in the tissues of the body, they are constantly acting environmental factors.

An increase in tissue temperature in the affected area leads to an improvement in blood circulation, a change in vascular permeability, an increase in metabolic processes, an increase in phagocytosis, and pain relief.

When exposed to these rays on the reflexogenic zones, the spasm of the smooth muscles of the internal organs decreases, their functions improve, and biologically active substances are formed.

These rays have an anti-inflammatory effect. Rays with a wavelength of 450-460 nm destroy the water-insoluble bilirubin molecule, and the resulting photobilirubin dissolves in water and is excreted from the body with urine and bile.

Ultraviolet radiation - electromagnetic vibrations with a wavelength of 180 to 400 nm. They are characterized by low penetrating ability, are absorbed by the surface layers of the skin, cause photochemical processes in it, as a result of which biologically active substances (histamine, acetylcholine, prostaglandins, etc.) are released, the activity of peroxidase, histaminase, tyrosinase and other enzymes increases.

There is an improvement in the functions of organs and systems, endocrine glands and immunity, the formation of vitamin D, and the processes of pigment formation are stimulated.

Under the influence of UV rays, erythema is formed, 4-12 hours after irradiation, necrosis and necrobiosis of epithelial cells occurs, followed by peeling of the skin. Uferitema has a bactericidal, desensitizing effect. UV rays actively influence all types of metabolism, improve the processes of higher nervous activity.

Large doses of UV radiation reduce the tone of the SAS, and small doses stimulate not only the SAS, but also the pituitary gland, activate the function of the cortical layer of the adrenal glands, the thyroid and gonads, the heart, lungs, and the digestive system. UV irradiation has found wide application in the treatment of various diseases.

Laser therapy is the use of low-energy laser radiation for therapeutic purposes (light amplification by stimulated radiation).

The depth of laser radiation does not exceed a few millimeters, it irritates the skin receptors. There are degranulation of mast cells, proliferation of fibroblasts, and intensification of trophoregenerative processes.

The stimulating effect of the laser is manifested with short-term exposure (up to 3 minutes).

Low-energy laser radiation affects the endocrine glands, in particular, it activates the functions of the adrenal glands and the thyroid gland.

At the same time, the number of erythrocytes and reticulocytes increases, there is an increase in the mitotic activity of bone marrow cells, the activity of respiratory enzymes and the formation of ATP, humoral protective factors (interferon, lysozyme, complement), and phagocytic activity are stimulated. Laser therapy has found wide application in various inflammatory diseases.

At the resort stage of rehabilitation, ultrasound, magnetotherapy, exercise therapy, massage, hardening procedures are also used. Walking tours, close tourism, outdoor games without participation in competitions are shown.

Resort rehabilitation is always a complex effect of all resort factors. They should be selected individually for each child, depending on the age and state of health, as well as his reaction.

In chronically occurring processes, the use of resort factors in combination with etiotropic treatment is recommended.

Tertiary prevention provides for rehabilitation aimed at reducing the factors and conditions that lead to disability, as well as enabling people with disabilities to achieve social integration.

Rehabilitation at this level aims to help the disabled person achieve optimal physical, intellectual, mental and social performance and support him by providing the means to change his life and expand his independence.

This is not only the training of the disabled to adapt to the environment, but also the intervention in their immediate environment, society as a whole.

LECTURE No. 11. Rehabilitation of gastroenterological patients

1. Esophagitis

Esophagitis is an inflammatory disease of the esophageal wall, characterized by pain that is more pronounced during the passage of food. Predisposing factors are various aggressive effects on the mucosa: burns, chemicals, esophageal reflux, as well as prolonged mechanical effects (tube feeding, repeated EFGS, foreign bodies, etc.) and a decrease in the protective mechanisms of the esophagus in eating disorders, polyhypovitaminosis.

The causative agents of the disease are more often Helicobacter pylori and herpetic infections.

Isolated esophagitis (without damage to other digestive organs) is characterized by changes in the mucous membrane, determined endoscopically. According to international criteria for the severity of inflammation, four degrees of damage to the esophagus are distinguished:

I degree - one or more erythematous stripes on the mucosa with exudate or sometimes erosions on the surface;

II degree - merged edematous erythematous stripes, but not closed in a circle (with the presence of erosion);

III degree - the entire mucosa of the esophagus in the lower third looks edematous, erythematous with erosions;

IV degree - ulceration of the mucosa with (or without) the formation of stricture, metaplasia of the epithelium, cicatricial changes, shortening of the esophagus. Neutrophilic infiltration indicates an acute process, lymphocytic plasma - a chronic one.

Early rehabilitation is aimed at preventing the development of complications such as bleeding, scarring, strictures, changes in the relief of the esophageal mucosa. It provides for the elimination of predisposing factors, active etiological and pathogenetic treatment, a diet within the first table with the additional administration of vitamins, lysozyme, which improve the regeneration of damaged esophageal mucosa.

Etiological agents are prescribed (erythromycin 20 mg / kg per day, metronidazole 0,25 g 2 times a day); cytoprotectors (denol); H2histamine blockers (cimetidine 25 mg/kg per day in 2 doses per day).

Psychotherapy is indicated and, if necessary, psychotropic drugs are used (Elenium 0,005 g per reception, Seduxen 2,5-5 mg - a single dose, motherwort tincture 1 drop for 1 year of life).

Late rehabilitation is carried out in a local sanatorium or in a clinic using all methods of sanatorium treatment. Rational nutrition, mineral water of low and medium mineralization, heated to 38-39 ° C at the rate of 3-4 ml / kg 30 minutes before meals 3 times a day, are prescribed, psychotherapy, exercise therapy are carried out, pulsed currents of low frequency are prescribed according to the electrosleep method.

Rehabilitation treatment in the clinic includes hardening of children and prevention of relapses. In this case, sedatives, therapeutic pedagogy, coniferous baths, exercise therapy, walking and sleeping in the air, SMT (sinusoidal modulated currents to the epigastric region) are used.

6 months after the completed sanatorium stage of rehabilitation, the child can continue rehabilitation at the resort or use resort rehabilitation factors in a polyclinic.

Further rehabilitation treatment in a polyclinic continues, if necessary, after the spa treatment. General strengthening and hardening measures are prescribed.

Rehabilitation monitoring or dynamic monitoring is carried out until deregistration. At the same time, the terms for anti-relapse treatment in a hospital are determined.

The frequency of observation: after inpatient treatment, when conducting sanatorium treatment in a polyclinic, it is necessary to see a doctor every 10 days, when conducting rehabilitation treatment - 1 time per year; when using spa treatment - 1 time per week, subsequently - 1 time in 6 months. The child is removed from the register 2 years after the spa treatment.

Observations of other specialists (dentist, otolaryngologist) are carried out once a year, the rest - according to indications.

Laboratory and instrumental examination is carried out at the stationary stage of rehabilitation, at the sanatorium stage, at the stage of rehabilitation treatment - once a year until deregistration (blood test, EFGDS, intraesophageal pHmetry are performed).

The follow-up period for I and II degrees of inflammation is 2 years, for III and IV degrees - 3 years in the absence of clinical manifestations of the disease after the last exacerbation.

2. Gastritis

Gastritis is an inflammatory disease of the stomach wall, characterized by abdominal pain and dyspeptic disorders.

The etiological factor is more often Helicobacter pylori infection, but it can be Salmonella, Yersinia, rotovirus infections.

Predispose to the development of gastritis emotional lability (conflicts in the family, school, some kind of disaster, stressful situations), malnutrition, allergic processes. With the elimination of the pathogen and predisposing factors of the disease, the function of the organ can be restored; then one speaks of an acute process.

Long-term persistence of the pathogen or the action of a predisposing factor leads to a persistent dysfunction, as a rule, to a chronic process. FC is determined by the degree of inflammation activity.

Based on the Sydney classification, gastritis is divided into acute and chronic.

In acute gastritis, according to the severity of neutrophilic infiltration, three degrees of activity of the process are distinguished, in chronic gastritis - according to the level of lymphocytic-plasmic infiltration - four.

Depending on the degree of activity, the prevalence of the inflammatory process, antral, fundic gastritis and pangastritis are distinguished.

3. Duodenitis, gastroduodenitis

The etiology, predisposing factors are the same as in gastritis. According to the prevalence of the inflammatory process, it is divided into limited (bulbitis) and widespread, involving other parts of the duodenum. The degree of activity of the process is determined in the same way as with gastritis.

Early rehabilitation should be aimed at normalizing mental disorders through psychotherapy, which is also carried out at other stages of rehabilitation, since the disease itself can also cause a neurotic state.

Psychological rehabilitation consists in overcoming mental reactions, gaining psychological comfort, eliminating the conditions of neuroticism.

At the same time, in addition to etiological treatment (antibiotics, metronidazole preparations), it is necessary to strengthen the mechanisms of sanogenesis. (biotransformation - biochemical defense of the body) to increase the resistance of the mucous membrane of the stomach and duodenum by regulating the pro- and antioxidant properties of gastric juice, use dietary factors.

Rational nutrition is shown - products with a high content of biotransformation enzymes, vitamins C, group B are recommended. Electrophoresis of novocaine, papaverine, sedatives are recommended.

With increased acidity of gastric juice, antacids, anti-inflammatory drugs (vikalin, vikair), histamine H2 receptor blockers - ranitidine hydrochloride 0,1 g 2 times a day are prescribed.

Of the non-selective blockers of dopamine receptors, cerucal is used at a dose of 5-10 mg 30 minutes before meals 3 times a day.

Late rehabilitation is carried out in a clinic or sanatorium using all the factors of sanatorium treatment.

Mineral water can be bottled sodium chloride or bicarbonate chloride, 3-4 ml / kg (single dose), heated to 38-39 ° C, 3 times a day.

Against the background of factors of sanatorium treatment, late rehabilitation provides for the rehabilitation of foci of chronic infection. If necessary, medical treatment is carried out according to the scheme developed at an early stage of rehabilitation. Rosehip oil, pentoxyl 0,15-0,3 g 3 times a day are also used; riboxin 0,1-0,2 g orally 3 times a day, gastrofarm 0,5 g 3 times; carnitine 20% solution, 1 tsp. 1-2 times a day; electrosleep, exercise therapy, massage, therapeutic pedagogy.

Secondary prevention is carried out in a polyclinic using resort rehabilitation factors that contribute to the complete elimination of the disease and its exacerbations, as well as hardening of the child's body.

Dynamic observation of children with chronic gastritis, gastroduodenitis is carried out up to 4 years in the absence of complaints and signs of illness.

Patients are removed from the register when the functions of the stomach and duodenum are fully restored.

Stomach ulcer and duodenal ulcer

This is an inflammatory disease that occurs with ulceration of the mucous membrane of the stomach and duodenum.

Helicobacteriosis infection is detected in 100% of patients. The predisposing factors are the same as for gastritis. Early rehabilitation includes:

1) etiological treatment: erythromycin, cefazolin, amoxicillin, metronidazole, bismuth preparations;

2) antisecretory agents: Mholinolytics - non-selective (atropine, platifillin, metacin); selective (gastrocepin, pirencepin);

3) H2histamine receptor blockers: cimetidine, ranitidine, famotidine, nizatidine, roxatidine;

4) antacids: magnesium oxide, calcium carbonate, almagel, phosphalugel;

5) increasing the resistance of the mucous membrane of the stomach and duodenum: stimulating mucus formation (carbenoxolone, enprostil, Cytotec), cytoprotectors that form a protective film (denol, sucralrat, smecta), enveloping (vikalin, vikair);

6) agents that normalize the motor function of the stomach and duodenum: cerucal, regnal;

7) antispasmodics: noshpa, papaverine;

8) reparants: solcoseryl, sea buckthorn oil, gastrofarm;

9) sedatives;

10) tranquilizers.

A balanced diet enriched with lysozyme and vitamins is also important.

All this therapy is carried out at the hospital stage, which leads to the restoration of the function of the stomach.

Late rehabilitation is carried out in a local sanatorium, where psychotherapy, curative pedagogy continue, children receive good nutrition, drink mineral water. For oral administration, sulfate calcium-magnesium-sodium, bicarbonate-sulfate, sodium-calcium waters are used, starting from 1,5-2 ml / kg during the first week, then they switch to the full dose (3-5 ml / kg) 30-60 minutes before meals, in a heated up to 38-39 °C for 3-4 weeks. Other methods of sanatorium rehabilitation are used (physiotherapy, exercise therapy), but more carefully than with gastritis.

Rehabilitation treatment - secondary prevention is carried out in the clinic, a full-fledged diet, a sparing regimen are prescribed, according to indications - sedatives, adaptogens: tincture of ginseng 1 drop per 1 year of life, tincture of Eleutherococcus.

6 months after the completed sanatorium treatment, a spa treatment is indicated, which consists in the repeated appointment of mineral water for drinking and mineral baths, physiotherapy, mud applications on the stomach area. Of great importance are therapeutic pedagogy, exercise therapy, tempering procedures such as dousing, showering, bathing, staying in the fresh air, walking.

Dynamic observation. After the rehabilitation, children suffering from peptic ulcer should be observed by a doctor once a quarter, and with stable remission - 1 times a year with hospitalization for examination and anti-relapse therapy 2-1 times a year.

Necessary examination methods: blood and urine analysis 2 times a year, coprogram - 1 time per quarter, EGD, intragastric pHmetry, fractional gastric sounding, ultrasound of the abdominal organs. Children are removed from the dispensary if there is a complete clinical endoscopic remission for at least 5 years.

4. Enteritis, colitis (enterocolitis)

It is an inflammatory disease of the wall of the small and large intestines, characterized by abdominal pain and diarrheal syndrome.

Chronic colitis, enterocolitis are most often associated with acute infections.

In this case, the pathogen that caused the disease has already lost its significance, and intestinal dysfunctions are supported by those morphological changes that remain after the infection.

The main clinical symptoms are abdominal pain, bloating and rumbling, impaired intestinal motility (constipation, diarrhea or constipation). Pain during the period of remission of the disease may be absent, and intestinal dysfunctions persist, which requires restorative treatment.

In addition, irritability, tearfulness, depressed mood, vascular dystonia syndrome, and a tendency to spasms of smooth muscles are typical for these patients.

Early rehabilitation consists in the organization of nutrition, corresponding to the possibilities of assimilation of food, psychotherapy, the use of electrophoresis with novocaine for pain, the use of astringents, enveloping, adsorbing agents. With nonspecific ulcerative colitis, psychotherapy, sedatives, salazopyridazine 30-60 mg / kg per day for 2 doses, then 10-20 mg / kg per day, prednisone in severe forms of the disease are indicated. Metronidazole 0,2 g is used - 2-3 times; intestopan 1-2 tablets per day, nevigramon 60 mg/kg per day in 4 divided doses. In the absence of effect, azothiaprine 3-5 mg/kg per day is used, then 1-2 mg/kg per day; cyclosporine 4 mg/kg per day in 2 divided doses.

Antibacterial drugs are used simultaneously with lactobacterin, bifidumbacterin. Microclysters with sea buckthorn oil, solcoseryl are used.

At the stage of late rehabilitation, in addition to psychotherapy and therapeutic pedagogy, mineral waters, physiotherapeutic factors, physiotherapy exercises are used, it is necessary to normalize the motor function of the intestine.

Drinking mineral water with enterocolitis, accompanied by an increase in the motor function of the intestine and diarrhea, should be prescribed in small quantities (1-2 ml / kg) with a temperature of 46-44 ° C. With the disappearance of diarrheal phenomena, they switch to the usual dose (4-5 ml / kg).

With the phenomena of intestinal stasis and constipation, the water should be at room temperature. Mineral waters of low or medium mineralization are used with a predominance of hydrocarbonate, sulfate, calcium ions, weakly carbonic or not containing carbonic acid.

The motor activity of the colon is enhanced by more mineralized and cold waters containing magnesium ions and sulfates. Intestinal stasis is eliminated by intestinal washing with mineral water. 5-6 procedures are prescribed every other day. Intestinal lavage is contraindicated in acute processes in the intestines, ulcerative colitis, intestinal bleeding, polyps, rectal prolapse.

physiotherapy factors. Inductothermia is considered the most effective at a dosage until a slight warmth is felt on the abdomen, the duration of exposure is 10-15 minutes, the number is 8-10 procedures. It is also recommended a low-thermal dosage for 10-12 minutes, 8-10 procedures are carried out every other day. UHF is effective, the duration of the procedure is 15 minutes, 10-12 procedures every other day.

Light therapy (UV irradiation, laser radiation) has a good effect. With the help of special light guides, the area of ​​the rectum is irradiated (daily, 10-12 procedures for 10 minutes).

The appointment of physiotherapeutic procedures for patients with exacerbations of enterocolitis or colitis and extensive erosive and ulcerative processes is contraindicated.

At the stage of secondary prevention, resort treatment factors are widely used, among which one of the most powerful is mud therapy.

It is believed that it has an anti-inflammatory effect, improves bowel function. Assign applications of silt, peat or sapropelic mud on the abdomen for 15-20 minutes every other day, 8-10 procedures.

Muds increase the reactivity of the body, trigger mechanisms that ensure the cleansing of the body from the pathogenic flora weakened by antibiotics. Such treatment can be prescribed 6 months after the exacerbation.

Spa treatment can be carried out at a resort or in a summer holiday camp, since a favorable environment, positive emotions, the influence of landscape and climate have a beneficial effect on the condition of patients.

The use of medications increases the effectiveness of resort factors and, according to a number of authors, is appropriate.

The same therapeutic effect as "clean" mud is given by electro-mud procedures, they are better tolerated. Mud electrophoresis is prescribed for 12-15 minutes, 8-10 procedures every other day.

Spa treatment is contraindicated for patients with tuberculous lesions of the intestine, with polyps, intestinal bleeding and suspected intestinal tumors.

Further dynamic observation is carried out in the clinic. Observation at the pediatrician is shown 2 times a year, then during the period of stable remission - 1 time per year. Laboratory examination at the stage of rehabilitation treatment is carried out once every 1 months and includes a general blood test, urine, coprogram and fecal occult blood analysis, determination of protein and protein fractions of blood. The patient is removed from the register 6 years after the exacerbation in the absence of signs of the disease.

5. Pancreatitis

Pancreatitis is an inflammatory disease of the pancreas. Most often, pancreatitis occurs with infectious diseases, such as mumps, herpes infection. A predisposing factor is a violation of the outflow of pancreatic juice in the presence of stones in the Versungian duct or obstructions in the Vater papilla (spasm or stenosis of the sphincter of Oddi).

In these cases, there is an increase in pressure in the ductal system of the gland, favorable conditions are created for the development of the etiological factor and the activation of enzymes in the gland itself, which leads to subsequent autolysis of its tissue with vascular damage and the development of edema of the gland.

In the development of chronic pancreatitis, a long-term persistence of pathogens or the action of a predisposing factor that contributes to stagnation of the juice with subsequent stretching of the ducts, the development of a discrepancy between the activity of pancreatic enzymes and their inhibitors can play a role.

Early rehabilitation is aimed at eliminating the factors of violation of the outflow of pancreatic juice, as well as reducing inflammation, which leads to an improvement in the function and blood supply of the gland.

In the presence of pain, antispasmodics, peripheral Mholinolytics, myotropic drugs, narcotic analgesics, aminofillin are prescribed. It is advisable to carry out electrophoresis of novocaine solution using a sparing method, when the strength and duration of exposure are reduced.

Inductothermia and UHF can be used, but in an athermic dose, with a duration of exposure of 5-8 minutes, every other day, taking into account the clinical manifestations of pancreatitis.

Rational nutrition with partial parenteral nutrition is prescribed. Alkaline drinking, vitamins C, A, E, group B, infusion therapy are shown; enterosorbents; intravenous administration of anti-enzymes (kontrykal 20-000 IU / day).

To reduce the exocrine function of the gland, peritol is prescribed 2-4 mg 3 times a day orally, histamine H2 receptor blockers. Etiological treatment for herpes infection is carried out with Virolex 10 mg/kg (single dose).

Late rehabilitation is carried out in a local sanatorium or in a polyclinic using the factors of sanatorium treatment. Rational nutrition, mineral waters of low and medium mineralization are shown.

The most effective are waters containing magnesium and calcium ions. They stimulate the secretion of pancreatic juice and normalize the activity of enzymes in it. Water must first be heated to 38-39 ° C and taken 1 hour before meals, the course of treatment is 21 days.

Secondary prevention with the use of spa treatment is carried out in the remission phase. Spa treatment is carried out in a clinic or resort 6 months after the completed sanatorium stage of rehabilitation. It is possible to carry out spa rehabilitation in a holiday camp using bottled mineral water, mud (carefully) and other factors of spa treatment.

Spa treatment is contraindicated in patients with stenosing papillitis and impaired patency of the pancreatic ducts.

Dynamic observation. In the first year after the spa stage, the pediatrician observes the patient once a month, then 1 times a year. Laboratory studies (blood test, coprogram, determination of urine amylase) in the first year are carried out 2 time in 1 months, then 3 times a year, glucose tolerance test for insulin content - 2 time per year; Ultrasound of the pancreas - 1 time per year; duodenal sounding to determine the function of the pancreas - according to indications. Tissue antibodies are determined once a year.

Children are not removed from dispensary registration.

6. Diseases of the biliary system

Diseases of the biliary system in children, as a rule, are of microbial origin. A predisposing factor is a violation of the outflow of bile, which develops with biliary dyskinesia.

Dyskinesias can be associated with dysfunction of the sphincter apparatus, blockage of the ducts or their compression. Subsequently, the presence of an inflammatory process in the ducts may be accompanied by a violation of the outflow of bile.

The contractility of the gallbladder is also important.

Clinical studies have shown that chronic cholecystocholangitis occurs in two forms: simple and immunocomplex.

The simple form occurs in 70% of patients, manifests itself in all children with abdominal pain (in the right hypochondrium, epigastrium, navel) of various nature, duration, often paroxysmal, sometimes intermittent, dull.

The pain syndrome is usually accompanied by dyspeptic disorders (nausea, belching, unstable stools, constipation). An important symptom is an enlarged liver associated with bile stasis.

As a rule, there are positive symptoms of Ortner (pain with an oblique blow to the right costal arch), Murphy (sharp pain on inspiration with deep palpation in the right hypochondrium - sometimes the breath is even interrupted by pain), Kera (pain at the point of the gallbladder, aggravated at the moment inhalation), phrenicussymptom (symptom of Georgievsky Mussi - pain on pressure between the legs of the right sternocleidomastoid muscle), Pekarsky (pain on pressure on the xiphoid process), Boas (pain on pressure to the right of the VIII thoracic vertebra), muscle resistance in the right hypochondrium, etc.

After the elimination of the pain attack, these symptoms may not be detected. The well-being of children with this form is not disturbed.

There are no symptoms of chronic intoxication and changes in other organs. Physical development corresponds to age. In some children, the main symptom of the disease is an enlarged liver without pain. Only a comprehensive examination can diagnose cholecystocholangitis.

The immunocomplex form occurs in 30% of patients and is characterized by symptoms of chronic intoxication: pallor, blue under the eyes, headaches, irritability, fatigue, sleep disturbance, appetite, often subfebrile temperature, sweating, some lag in physical development, etc. Local symptoms are the same , as in the simple form.

All patients in this group have changes in the cardiovascular system, manifested by the expansion of the boundaries of the heart, muffled tones, systolic murmur, heart rhythm disturbances, and changes in blood pressure. An electrocardiographic study recorded muscle changes, rhythm disturbances.

When rheography of the aorta and pulmonary artery, changes in the contractility of the myocardium and the structure of the systole of both the right and left ventricles are determined.

When rheography of the liver, there is a violation of its blood circulation, characterized by a decrease in arterial and venous blood flow, more pronounced in children 7-10 years old.

On the part of the digestive organs, there may be functional changes in the stomach and duodenum, less often - gastritis, duodenitis, sometimes reactive pancreatitis and reactive hepatitis. Some patients have transient albuminuria. All children of this group have circulating immune complexes in their blood.

Early rehabilitation of patients with cholecystitis, cholecystocholangitis is to improve the function of the biliary system.

For this purpose, the causes that led to the violation of the outflow of bile are eliminated, and cholekinetics (cholecystokinin, magnesium sulfate, egg yolks), cholelithin and cholespasmolytics (atropine sulfate, belladonna extract), ganglioblockers (gangleron, dicolin, benzohexonium) are prescribed.

When painful symptoms subside, drugs that stimulate bile formation are used: true (decholin, holosas, cholenzim, allochol, nikodin, oxofenamide, tsikvalon, sandy immortelle grass, bitter rhubarb root, strawberry leaves) and hydrocholeretics (sodium salicylate, valerian preparations, etc.).

Polyalcohols (sorbitol, mannitol, xylitol) have cholekinetic and choleretic properties. Antibacterial therapy is carried out.

Of the physiotherapeutic measures during the period of acute manifestations of the disease, only electrophoresis (magnesium sulfate, papaverine, novocaine) is prescribed for the gallbladder area.

Late rehabilitation provides for treatment in a local sanatorium using mineral water of low and medium mineralization and other factors of sanatorium treatment, continuation of antibacterial therapy according to the scheme developed in the hospital.

Secondary prevention is carried out in a polyclinic using the factors of spa treatment or in a resort.

One of the most effective resort factors is mud therapy.

It has a positive effect on the functional state of the gallbladder, as well as an analgesic, anti-inflammatory effect.

Applications of silt, sapropel, peat mud are applied to the area of ​​the right hypochondrium at a temperature of 40-44 °C. At the same time, other factors of the spa rehabilitation of a tempering nature are prescribed.

The period of dynamic observation with a simple form of the disease can be limited to two years, with an immunocomplex - three.

Secondary cholecystocholangitis should be monitored constantly if there was no surgical correction. Laboratory and instrumental studies (blood test, ultrasound of the gallbladder, duodenal sounding) are carried out once a year.

7. Chronic hepatitis

Chronic hepatitis in children in most cases is a consequence of previous viral hepatitis or is a primary chronic anicteric viral hepatitis. It develops with prolonged persistence of the virus with the formation of immune complexes that damage hepatocytes. The classification of chronic hepatitis (CH), adopted at the World Congress of Hepatologists in 1994 in Los Angeles, is presented in the following form.

HG form:

1) chronic viral hepatitis, indicating the virus that caused it (B, e, C, G, F) or it is noted that the virus has not been identified;

2) autoimmune hepatitis;

3) chronic toxic or drug-induced hepatitis.

HCG activity:

I - minimal (increase in the normal level of ALT activity up to 3 times);

II - moderate (AlT activity in blood serum increased up to 10 times);

III - severe (ALT level is more than 10 times higher than normal); inactive hepatitis.

HCG stages:

I - mild periportal fibrosis;

II - moderate fibrosis with portoportal septa;

III - severe fibrosis with portocentral septa;

IV - violation of the lobular structure;

V - the formation of cirrhosis of the liver.

Phases of virus development:

1) replication;

2) integration.

Early rehabilitation involves improving liver function at the hospital stage of treatment, when there are complaints of weakness, malaise, tearfulness, deviations in liver function tests, changes in blood biochemical parameters (dysproteinemia, bilirubinemia, increased enzyme activity).

Etiological and pathogenetic treatment is shown, the main attention is paid to the regimen (sick leave) and diet (table No. 5), anti-inflammatory and antitoxic therapy. Etiotropic treatment is prescribed (ribavirin, acyclovir), sterferons; prednisolone 1-2 mg/kg per day; eufillin 2,4% solution - 2-4 mg / kg per day; trental 1,5-2 mg/kg per day; thymalin 0,2 mg/kg; cytochrome C 0,25% solution intramuscularly; adsorbent - cholestyramine 5-10 g per day before meals.

To improve blood circulation in the liver, it is recommended to use magnetic fields on the liver area. However, this procedure is carried out carefully, in the stage of reducing inflammatory-necrotic processes. The motor mode gradually increases, exercise therapy is used.

Late rehabilitation of children with hepatitis is carried out by methods of sanatorium rehabilitation in a polyclinic or sanatorium. This stage corresponds to the stage of attenuation of the activity of the process, which is characterized by the absence of complaints, but there is an increase in the size of the liver without an increase in the spleen, slight deviations in liver function tests.

In this case, all the factors of spa treatment are used, including mineral waters containing bicarbonates, sulfates, chlorine and magnesium.

Water is drunk hot (42-44 °C) at the rate of 4-5 ml/kg 3 times a day. If necessary, treatment with prednisolone, interferon is carried out.

Bilignin 5-10 g before meals, bile acids, methionine, actovegin (solcoseryl) 5-10 ml / kg per day, lipoic acid, anabolic steroids are used.

Rehabilitation treatment in the clinic is carried out by a district doctor, immunomodulatory therapy (hardening) is carried out. Vitamins are prescribed in age dosages, cytochrome C, choleretic agents for 1 week every month.

Excluded physical and mental stress. Physical education classes are held according to a sparing program, the regime is general.

Further dynamic monitoring is carried out once a quarter, then 1 times a year (planned hospitalization and anti-relapse rehabilitation).

General and biochemical blood tests are examined, serological markers of all hepatitis viruses are determined, liver ultrasound is performed 2 times a year, liver biopsy according to indications, liver function tests (transaminase, bilirubin, RPHA with tissue diagnosticum). Patients are removed from the register 5 years after recovery.

8. Establishment of disability for children with diseases of the digestive system

There are the following terms of disability:

1) for a period of 6 months to 2 years - with a complicated course of gastric ulcer and duodenal ulcer;

2) for a period of 2 to 5 years - for diseases, pathological conditions, malformations of the gastrointestinal tract, liver, biliary tract, cirrhosis of the liver, chronic hepatitis, continuously recurrent ulcerative process, terminal ileitis. Clinical characteristics: persistent pronounced violations of the digestive or liver functions;

3) for a period of 5 years - for diseases, injuries, malformations of the esophagus, gastrointestinal tract (after total resection of the stomach or 2/3 of the small intestine, chronic intestinal adhesive obstruction with multiple fistulas, obstruction of the esophagus with and without gastrostomy, artificial esophagus, celiac disease ). Clinical characteristics: persistent pronounced disorders of the digestive function, persistent severe fecal incontinence, fecal fistulas that are not amenable to surgical correction or are not subject to surgical treatment in terms of time;

4) for a period up to the age of 16 - with cirrhosis of the liver, chronic hepatitis with severe activity, persistent irreversible liver dysfunction in congenital, hereditary, acquired diseases.

LECTURE No. 12. Rehabilitation of children with metabolic diseases

1. Hypotrophy

Hypotrophy - protein-calorie deficiency, characterized by weight loss, growth and developmental disorders of the child.

Hypotrophy can be congenital (caused by intrauterine growth retardation) and acquired.

Hypotrophy is the main diagnosis if it develops as a result of feeding disorders, improper care, past diseases. In the presence of the underlying disease (malformation, hereditary and acquired diseases), malnutrition is considered as a syndrome.

According to clinical manifestations, malnutrition is divided into cachectic and edematous, according to severity - into I, II, III degrees, hypostatura is separately distinguished. Hypostatura can be considered as a manifestation of malnutrition of II-III degrees, but with a small amount of subcutaneous fat remaining, with a uniform lagging of the child in length and body weight.

The degree of malnutrition is determined not only by the deficit of body length and weight, but also by clinical manifestations, such as pallor, dryness and degenerative changes in the skin, absence or swelling of subcutaneous fat, acidosis, signs of metabolic disorders, functional disorders of internal organs and the central nervous system, decreased resistance to any influence of the external environment, the manifestation of polyhypovitaminosis.

Early rehabilitation is carried out in parallel with treatment and ensures the restoration of the child's vital signs in accordance with age. FC corresponds to the degree of malnutrition, RP is assessed by the general condition of the child. Rehabilitation provides for the organization of a rational daily routine, proper care, classes and games that cause positive emotions. When the cause of malnutrition is eliminated and diet therapy is carried out, it is necessary to restore the secretion and motor activity of the gastrointestinal tract, which is achieved by diet, the use of choleretic drugs and, for a short time, replacement therapy with digestive juices and enzymes, as well as dietary supplements with lysozyme and bifidobacterin.

In order to improve metabolic processes, alternation of therapeutic and hygienic baths, ultraviolet irradiation are prescribed. Stimulating therapy is carried out by the introduction of uglobulin, apilac, dibazole, metacin, a 20% solution of carnitine chloride (1 drop per 1 kg of body weight 2 times a day). Older children are shown ginseng, aloe. Elenium, glutamic acid, neuroleptics are used to improve the functional activity of the nervous system.

Late rehabilitation is carried out in the clinic and at home, subject to sufficient heat, proper hygiene, and fresh air. General massage is of great importance. It increases the emotional tone and activity of the child, while improving appetite and general condition. Weakened children are given a stroking massage, very gently and lightly for 2-3 minutes 2-3 times a day. In the future, the duration of the procedure increases. Simultaneously with stroking, rubbing and kneading are carried out.

Rehabilitation treatment includes a combination of massage and gymnastics, starting with simple exercises, then gymnastics takes a dominant place, complemented by massage. These procedures are prescribed 1,5-2 hours after eating. Continued ultraviolet exposure. Hardening procedures are gradually introduced: rubbing, dousing with water, outdoor games that do not tire the child.

Dynamic observation is necessary during the year with the elimination of predisposing factors. Inspection of children of the first year is carried out monthly, in subsequent ages - 1 time per quarter.

2. Obesity

Obesity (paratrophy) is a chronic eating disorder characterized by excessive accumulation of fat, accompanied by a disorder in the growth and development of the child.

According to the level of excess body weight, there are 4 degrees of obesity:

I degree - excess weight from the average age by 10-29%;

II degree - 30-49%;

III degree - 50-99%;

IV degree - more than 100%.

Early rehabilitation is carried out simultaneously with the elimination of the cause and the organization of rational feeding, the method of increasing the activity of the child and the use of water procedures and physiotherapy exercises.

The complex of physical therapy exercises depends on the child's ability and gradually moves from light physical exercises to more difficult ones.

Due to the ease of development of relapses of obesity, those types of physiotherapy exercises that can be carried out for a long time and provide a stable therapeutic effect (swimming, gymnastics) are valuable.

Late rehabilitation is carried out in a local sanatorium, summer camp or in a clinic. With a rational diet, the main physical activity is running (3 times a day along a track 500-1500 m long, depending on age).

It matters to reduce the duration of sleep (only during the holidays). At school, it is desirable to organize special classes for children with obesity and include additional lessons of physiotherapy exercises for them.

Rehabilitation treatment in a polyclinic provides for the organization of rational nutrition, psychotherapy, dosed physical activity.

Dynamic observation. Obese children in the first year of life are examined by a pediatrician once a month, in the second year of life - once a quarter, then 1 times a year. An endocrinologist and a neuropathologist examine obese children once a year, other specialists - according to indications.

During dynamic monitoring, the weight and length of the body are monitored, the general condition of the child, the dynamics of sexual development, the level of sugar in the blood and urine, total lipids, cholesterol (3 blood lipoproteins - once a year, with obesity of III-IV degrees - 2 times a year) .

In the presence of endocrine disorders, a study of TSH, STH is performed. Observation of the endocrinologist is carried out monthly.

3. Diathesis

Exudative catarrhal diathesis is an age-specific dysmetabolic reaction characterized by infiltrative desquamative processes in the skin and mucous membranes. This is not an allergic disease, but diathesis, manifested by greasy scales on the skin of the scalp, eyebrows ("gneiss"), a "milky crust" on the cheeks (redness and peeling), dense nodules on the skin, peeling of the mucous membranes ("geographic tongue"). Children are prone to diseases of the upper respiratory tract, diaper rash. They are pasty, have excessive body weight.

Early rehabilitation is carried out simultaneously with symptomatic treatment by normalizing water and mineral metabolism and CBS under the control of biochemical studies, as well as eliminating hypovitaminosis and functional adrenal insufficiency.

Late rehabilitation and rehabilitation treatment consists in the organization of rational feeding with the addition of dietary supplements and vitamins, as well as digestive enzymes (in case of stool disorder).

Dynamic observation is carried out in the same way as in healthy children.

Lymphatic hypoplastic diathesis is a generalized increase in lymphatic formations against the background of a decrease in the functions of the adrenal glands, mainly their chromophin apparatus.

As a result of a decrease in the synthesis of catecholamines and glucocorticoids with a relatively sufficient formation of mineralocorticoids, hyperplasia of the lymphatic tissue, retention of sodium, chlorides, and water in the body occur. Children are pasty, pale, lethargic, tissue turgor is lowered, muscles are poorly developed. Lymph nodes, thymus gland, spleen are enlarged. With strong exogenous and endogenous stimuli, fainting, collapse, and death develop. Death is sudden, in which no anatomical signs of the disease are detected.

Early rehabilitation is aimed at normalizing the functions of the adrenal glands, which is achieved by prescribing ascorbic acid, improving blood circulation in them as a result of physiotherapeutic effects (ultrasound, thermal procedures). With a sharp increase in lymph nodes (bronchopulmonary, mesenteric), thymus, short-term glucocorticoids and ACTH are indicated.

Late rehabilitation and rehabilitation treatment are carried out in a polyclinic using a balanced diet with dietary supplements, the appointment of courses of adaptogens, vitamins, dibazol, pentoxyl in age dosages.

Nervous-arthritic diathesis is a disorder of purine metabolism, manifested by the precipitation of uric acid crystals in the tissues of the joints and other organs, characterized by pain and increased nervous excitability.

The manifestations of this diathesis are very polymorphic, different in different children, which is associated with the degree of violation of the severity of purine metabolism.

The main symptom is indomitable vomiting, accompanied by abdominal pain, the smell of acetone from the mouth as a result of ketoacidosis. More often it occurs with the use of fatty foods and foods low in carbohydrates. At the same time, an acetone crisis develops. It can last 1-2 days. Due to frequent vomiting, exsicosis develops. Older children complain of headache, joint pain. They often have stones in the gallbladder or renal pelvis.

Early rehabilitation is carried out against the background of treatment and ensures the normalization of metabolic disorders. With vomiting, acidosis and dehydration are fought. Allopurinol, which reduces the synthesis of uric acid, vitamins are used.

Late rehabilitation consists in hardening the child - constant gymnastics, sports, and exposure to fresh air are necessary.

Alkaline mineral waters are prescribed. In food limit fat, meat, fish. Products containing purine bases and caffeine are excluded (liver, brains, kidneys, herring, spinach, sorrel, cocoa, chocolate, etc.).

Rehabilitation treatment in a polyclinic provides for rational feeding.

Dynamic observation is carried out in the same way as in a healthy child.

4. Rickets

Rickets (hypovitaminosis D) is characterized by a violation of mineral (mainly calcium phosphate) metabolism, manifested by insufficient mineralization of bones, dysfunction of the muscular, nervous systems and internal organs.

Clinical manifestations of rickets are polymorphic.

Early rehabilitation is carried out simultaneously with vitamin D treatment and is aimed at eliminating functional disorders of organs and systems and improving the synthesis and metabolism of vitamin D in the child's body. For this purpose, long-wave ultraviolet spectrum is used. In the initial period of the disease and with rickets of the first degree, UVR is used, starting with 1/4 of the biodose, followed by (every 2 exposures) increasing it by 1/4 of the biodose. By the end of the course of treatment, the dose is adjusted to 2-3 biodoses, irradiating the front and back surfaces of the body.

With rickets II-III degree, an accelerated irradiation scheme is used: they start with 1 / 4-1 / 3 biodose, increase doses more quickly - after 1 or 2 irradiations by the value of the initial dose, bringing up to 2 biodoses on the body surface.

Late rehabilitation is carried out against the background of ongoing treatment of rickets with vitamin D and citrates. Apply massage and therapeutic exercises. They have a beneficial effect on metabolism, improve blood circulation, respiration, and gas exchange. Especially indicated for hypophosphatemic and mixed variants of rickets. Hydrotherapy is used with a gradual transition from warm, indifferent douche temperatures to cool ones. Salt baths are used with sea or ordinary table salt at the rate of 100 g of salt per 10 liters of water. The temperature of the first bath is 38 °C, the duration is 3-8 minutes, after every 2-3 baths the duration of the procedure is increased by 1 minute. In total, the course of treatment requires 12-15 baths every other day. Coniferous baths are recommended for restless children.

Mud therapy is prescribed for children with impaired static functions, with muscle hypotension.

These children can use inductotherapy on their feet in a low-thermal dosage. Electrophoresis of a solution of proserin in a dilution of 1: 2000 is shown with the electrode located in the lumbosacral region, the second (forked) - on the calf muscles.

The duration of the procedure is 10 minutes, 12-15 procedures are performed per course. During the period of convalescence of rickets, calcium chloride electrophoresis is used.

Recovery treatment. 1 month after the first course of UVR is completed, a second course of treatment can be carried out. Further restorative treatment and dynamic monitoring are carried out as a prevention of rickets with a frequency of observation corresponding to healthy children.

5. Spasmophilia

Spasmophilia is a disease of children characterized by increased neuromuscular excitability, convulsive syndrome due to a decrease in the content of ionized calcium in the blood against the background of alkalosis.

There are hidden and explicit spasmophilia. Latent spasmophilia is manifested by symptoms of increased excitability of the neuromuscular apparatus, diagnosed by the presence of specially identified symptoms (Khvostek, Trousseau, Maslova, Lust). Signs of explicit spasmophilia are laryngospasm, carpopedal spasm, eclampsia.

Early rehabilitation is carried out against the background of the treatment of spasmophilia with calcium preparations, anticonvulsants (with an explicit form) and the normalization of feeding. UVR is used to improve the synthesis of vitamin D in the skin, starting from 1/8 dose to 1,5 biodose, which increase gradually, as in rickets.

Late rehabilitation begins with the disappearance of the main symptoms of overt spasmophilia. Dibazol, pentoxyl, glutamic acid in age dosages, vitamins of group B are prescribed. General massage, gymnastics, outdoor exposure are shown.

Rehabilitation treatment in a polyclinic provides for rational feeding, the appointment of prophylactic doses of vitamin D.

Dynamic observation is carried out with the same frequency of examinations as in healthy children.

LECTURE No. 13. Rehabilitation of children with diseases of the cardiovascular system

1. Congenital heart defects

Congenital heart defects (CHD) - the presence of certain defects in the development of the heart and great vessels that have arisen as a result of exposure to the embryo and fetus of various harmful factors during pregnancy (such as diseases, drug use, alcoholism, smoking, occupational hazards, etc.). ). In the structure of the disease, the phase of adaptation, the phase of relative compensation, and the terminal phase are distinguished.

In early rehabilitation, surgical care is a radical method, but even after it, changes in the functions of the cardiovascular system persist for a long time. The main tasks are to improve and train the functions of the cardiovascular system, sanitize foci of chronic infection, and increase the body's resistance. Physical therapy matters.

Children who do not have complaints and shortness of breath during normal games can do exercise therapy with a gradual increase in load.

Patients with complaints of fatigue and shortness of breath with little physical exertion receive a gradual expansion of the motor regimen. Riboxin 0,2 g 2 times a day, cocarboxylase 0,025-0,05 g 1 time a day, vitamins are shown.

Late rehabilitation is carried out in a local sanatorium using exercise therapy, a gradual expansion of the motor regimen, hydrotherapy and other factors of sanatorium rehabilitation. Climatorehabilitation includes a long stay of children in the air, which improves the nonspecific resistance of the body.

Rehabilitation treatment in the clinic provides for hardening of the child's body using the factors of resort rehabilitation. At the same time, exercise therapy is important in the form of individual or small group classes, walks. Hydrotherapy is widely used: coniferous, oxygen, chloride, sodium, iodine-bromine, carbon dioxide baths according to a sparing method. Other factors of resort rehabilitation are also applied.

Further dynamic monitoring in the conservative management of children with congenital heart defects is aimed at maintaining compensation and preventing decompensation of cardiac activity.

Children with defects, accompanied by both enrichment and depletion of the small circle, as well as depletion of the systemic circulation, are observed once a month in the first year of life; in the second year - 1 time in 1 months; in the future - 2-2 times a year. With the development of complications, as well as after operations according to an individual schedule, 3-1 times a year they are hospitalized for clinical rehabilitation.

Dynamic monitoring is carried out by a pediatrician, a cardiologist, an ENT doctor and a dentist, they examine children 2 times a year, other specialists - according to indications.

Sanitation of foci of infection, careful treatment of intercurrent diseases are necessary at all stages of rehabilitation. Unoperated children remain on the register permanently, after the operation - 1-2 years.

2. Congenital carditis

Early congenital carditis occurs before the 7th month of fetal development. Its mandatory morphological substrate is fibroelastosis or elastofibrosis of the endo- and myocardium.

Late congenital carditis develops in the fetus after the 7th month of gestation without fibroelastosis and elastofibrosis.

The diagnosis of congenital carditis is considered reliable if the symptoms of heart damage are detected in utero or in the first days after birth without previous intercurrent disease or with a history of maternal illness during pregnancy.

Early rehabilitation provides for the prevention of the development of heart failure. Non-steroidal anti-inflammatory drugs, drugs that improve myocardial trophism, as well as UVR with an individually selected biodose are prescribed.

The skin is irradiated with separate fields (along the spine, lumbosacral, upper thoracic, lower thoracic fields), electric sleep is shown at a low pulse frequency, general massage, exercise therapy with a gradual increase in the number of exercises.

Late rehabilitation at the stage of sanatorium treatment is carried out with an individual approach to the choice of rehabilitation factors.

All the same factors as at the stage of early rehabilitation are important with a freer choice of loads. Sanitation of foci of infection is carried out. Climatic rehabilitation is widely used.

Rehabilitation treatment in a polyclinic provides for hardening of children. For this purpose, resort treatment factors are used.

Hydrotherapy is widely used. Assign warm fresh or coniferous baths at a water temperature of 36-37 ° C, dousing, rubbing, showers, bathing in water sources, exercise therapy, walking on flat terrain.

Further dynamic monitoring is carried out with early carditis constantly, with late carditis - within 5 years after the disappearance of signs of the disease. Examinations by a pediatrician in the first year are carried out 2 times a month, by a cardiologist - 1 time in 2-3 months; lordoctor, dentist - 2 times a year. Laboratory and instrumental studies are done 2 times a year during hospitalization for clinical rehabilitation and diagnosis clarification.

3. Acquired carditis

Non-rheumatic carditis is an inflammatory lesion predominantly of the myocardium, which develops against the background of an immunological deficiency of the body.

Acute non-rheumatic carditis manifests itself against the background or 1-2 weeks after suffering any infectious disease, characterized by carditis with damage (or without damage) to the conduction system of the heart. Based on the classification, the course of carditis can be acute, subacute or chronic; clinical manifestations differ in mild, moderate and severe forms of the disease.

Subacute carditis is more common in older children. They can be initially subacute, when signs of heart failure gradually increase. For subacute carditis, all manifestations of acute are typical, but they are persistent.

Chronic carditis is also more common in older children. It can be primary chronic, it is detected during a routine examination of children or when signs of heart failure appear. Chronic carditis can be formed against the background of acute and subacute carditis. More often it proceeds without complaints of the patient.

Early rehabilitation provides for the prevention of heart failure, which is achieved by etiological and pathogenetic treatment, elimination of predisposing factors and foci of chronic infection. Corticosteroid drugs and derivatives of quinolonic acids are prescribed.

At this stage of rehabilitation, timely expansion of the regimen to a training one, exercise therapy under the control of the state, changes in the heart, positive dynamics of the disease and laboratory and instrumental indicators are important.

Late rehabilitation is carried out using sanatorium rehabilitation methods in a polyclinic or in a local sanatorium of a cardiological profile, where the restoration of the functional capabilities of the heart is achieved by using all the methods of sanatorium rehabilitation in a complex (therapeutic pedagogy, regimen, exercise therapy, diet).

The purpose of this stage of rehabilitation is the prevention of complications of carditis (cardiosclerosis, myocardial hypertrophy, conduction disorders; lesions of the valvular apparatus, constrictive myopericarditis, thromboembolic syndrome).

Rehabilitation treatment in the clinic provides for the prevention of relapses. It is carried out by the hardening method using the factors of spa treatment in a clinic or at a resort.

These rehabilitation methods are used in the absence of signs of circulatory failure. After the spa treatment, rehabilitation treatment continues according to an individually designed program.

Dynamic observation and examination are carried out in the process of rehabilitation. Observation is carried out by a pediatrician and a cardiologist once every 1 months - in the first year, then 2 times a year. A lorvrach and a dentist also examine the child 2 times a year, other specialists - according to indications. Twice a year, patients are hospitalized for examination and clinical rehabilitation. Patients are removed from the register 2-2 years after the disappearance of all signs of the disease, and children with chronic carditis are monitored constantly.

4. Rheumatism

Rheumatism is an immunopathological process that develops mainly in the connective tissue of blood vessels and the heart due to infection /? - hemolytic group A streptococcus. In most children with rheumatism, recovery occurs, but with prolonged and massive streptococcal infection, chronic rheumatic disease develops with a tendency to recurrence of rheumatic heart disease.

Early rehabilitation is aimed at restoring the functions of the affected organs, taking into account the activity of the process. Assign antirheumatic treatment (penicillin, non-steroidal anti-inflammatory drugs, steroid hormones in severe forms of the disease, vitamins C, A, E), protective regimen, psychotherapy.

UVR is used in an erythemal dosage with an individually selected biodose. With polyarthritis, erythema is localized in the area of ​​\uXNUMXb\uXNUMXbthe joints; if the phenomena of polyarthritis are absent, then exposure to UV rays is carried out on reflex-segmental zones.

Contraindications for UVI are hemorrhagic syndrome, heart defects with circulatory failure. Calcium electrophoresis is used according to the method of general influence of Vermel, which helps to equalize the ratio of blood electrolytes, improve the tone of the heart muscle, and reduce vascular permeability.

Electrosleep is recommended at a low frequency of impulses, which improves the psycho-emotional state. With chorea, warm fresh or coniferous baths are used in alternation with electrosleep. When stabilizing the activity of rheumatism, physiotherapy exercises are prescribed.

Late rehabilitation is carried out in local cardiological sanatoriums in the active phase of rheumatism with and without heart disease.

In the sanatorium, against the background of treatment, the whole complex of sanatorium rehabilitation factors is used, the foci of infection are sanitized. Sanatorium rehabilitation provides for the complete recovery of the child.

Rehabilitation treatment is carried out in the clinic in order to prevent recurrence of the disease with constant year-round bicillin prophylaxis. In 8-12 months after the end of the acute period, in the absence of signs of activity and circulatory insufficiency, spa treatment is indicated. It can be carried out in resorts, in holiday camps of a resort type, in a clinic. At the same time, natural factors, mineral waters, therapeutic mud, exercise therapy, hardening procedures are used.

Further dynamic monitoring of children with rheumatism is carried out by the local pediatrician and cardio-rheumatologist for 2 years quarterly, and then 2 times a year. Examination by a lorvrach and a dentist is necessary 2 times a year, by other specialists - according to indications. Twice a year, children under dynamic observation can be hospitalized for examination, diagnosis clarification and clinical rehabilitation. Bicillinoprophylaxis is carried out for 3-5 years.

The criteria for the effectiveness of rehabilitation are the absence of repeated attacks and the formation of heart disease, adaptation to physical activity.

5. Heart failure

Heart failure is the loss of the ability of the heart to provide the hemodynamics necessary for the normal functioning of the body.

Heart failure is the result of a violation of the contractile function of the myocardium. Depending on the severity of heart failure, 4 functional classes are distinguished.

Early rehabilitation is carried out simultaneously with treatment at the hospital stage by eliminating the cause of the disease, organizing the regimen and nutrition within table No. 10, prescribing cardiac glycosides, dopamine, cardiotrophic drugs, diuretics, vasodilators.

Late rehabilitation (sanatorium stage) - carried out in a local sanatorium or in a clinic. The motor mode is regulated, exercise therapy is prescribed in accordance with the general condition of the patient.

Continues taking drugs that improve metabolic processes in the myocardium (cocarboxylase, riboxin, ATP, B vitamins). Sanitation of foci of infection, medical pedagogy are being carried out. It is recommended that the patient stay outdoors.

Restorative rehabilitation is carried out in a polyclinic with the subsequent use of spa treatment, where the motor regimen is expanded, hardening, nutrition in accordance with the possibilities of digestion and absorption of food (table No. 5), outdoor walks, medical pedagogy.

Dynamic observation in the first year is carried out monthly. The cardiologist examines the child every 2-3 months, in the second year - once a quarter, then once every 5 months.

Twice a year the child can be hospitalized for examination and rehabilitation. Laboratory and instrumental studies are required 2 times a year (general analysis and biochemical blood test, ECG, FCG, ultrasound of the heart), functional tests - according to indications. Children who have had heart failure are not removed from the register.

6. Arterial hypertension

Primary arterial hypertension (hypertension) is a disease characterized by a persistent increase in blood pressure.

With the clinical characteristics of primary arterial hypertension in children, the following stages must be observed.

Stage IA - transient increase in systolic pressure up to 130-150 mm Hg. Art. at normal diastolic pressure.

K stage - labile systolic hypertension within 130-150 mm Hg. Art., in some cases, increased diastolic pressure up to 80 mm Hg. Art. There are complaints of headache, tachycardia.

11A stage - systolic pressure reaches 160-180 mm Hg. Art., diastolic - 90 mm Hg. Art., there are signs of left ventricular hypertrophy, frequent complaints of headache, ringing in the ears;

Stage 11B is characterized by a persistent increase in blood pressure. There may be hypertensive crises that proceed according to the sympathoadrenal type, characterized by a sharp headache, decreased vision, and vomiting.

Patients are excited, shivering in all body and other vegetative symptoms are noted. The crisis lasts from several minutes to several hours.

Stage III does not occur in children.

Early rehabilitation is carried out simultaneously with treatment. Physical therapy, walks in the air, therapeutic baths - coniferous, oxygen, chloride, sodium (sodium chloride concentration - 10 g / l), iodine-bromine are prescribed.

Medicinal electrophoresis with magnesium sulfate, bromine, aminophylline on the collar zone, galvanization according to the reflex-segmental technique are used.

Inhalations of aerosols of dibazol, obzidan, etc. are recommended. Electric sleep, sinusoidal modulated currents (SMT) are used.

Late rehabilitation is carried out in a local sanatorium, where all the factors of sanatorium rehabilitation are used. Physical factors are assigned in turn, taking into account the individual characteristics of the cardiovascular and nervous systems.

Restorative rehabilitation aims to eliminate predisposing factors. A diet, psychotherapy, physical education are prescribed, the daily routine is adjusted. Spa treatment is shown in the conditions of a holiday camp.

Dynamic monitoring is carried out for 2-3 years by a local doctor and a cardiologist once a quarter with the right to hospitalization for examination and rehabilitation 2 times a year.

7. Arterial hypotension

Arterial hypotension is diagnosed with a decrease in blood pressure in school-age children below 90/48 mm Hg. Art. It is characterized by dizziness, headache, palpitations, weakness, and sometimes fainting.

The main criterion for diagnosis is the result of measuring blood pressure.

Early rehabilitation is carried out against the background of treatment. Physical factors are used to improve the functional state of the nervous and cardiovascular systems: electrosleep, drug electrophoresis, massage, exercise therapy. Rehabilitation of children after fainting begins with a galvanic collar according to Shcherbak. Apply electrophoresis of calcium, mezaton on the collar zone.

Late rehabilitation is carried out in a local sanatorium, where all the factors of sanatorium rehabilitation are important. Oxygen, pearl, chloride, sodium and other baths are used with a water temperature of 35-36 ° C, which stimulate the function of the sympathetic nervous system, increase the contractile activity of the myocardium, and have a tonic effect on the central nervous system. Of great importance are exercise therapy, massage.

Restorative rehabilitation is carried out by the method of hardening, the use of resort treatment factors.

Dynamic observation is carried out by the district doctor together with the cardiologist for 2-3 years or more when examined once a quarter, with a full clinical examination 1 times a year. The criteria for recovery are the normalization of blood pressure, favorable reactions to functional tests.

8. Hemorrhagic vasculitis (Schonlein-Henoch disease)

Hemorrhagic vasculitis is a systemic disease of the walls of microvessels as a result of damage to them by immune complexes.

The diagnostic criterion is hemorrhagic syndrome, which determines the clinical variant of the disease: skin, articular, abdominal, renal, mixed (cutaneous-articular-renal-abdominal).

FC is determined by the severity of the hemorrhagic syndrome, RP - by the general condition of the patient.

Early rehabilitation, which improves vascular function, includes the appointment of antiplatelet agents (curantyl, trental, indomethacin), heparin, as well as the organization of a regimen (bed), fortified rational nutrition, and psychotherapy.

Late rehabilitation is carried out through the gradual use of the factors of sanatorium rehabilitation (therapeutic pedagogy, outdoor walks, calm games, exercise therapy). Electric sleep is prescribed, foci of infection are sanitized.

Restorative rehabilitation - secondary prevention is carried out by hardening, using individually selected factors of resort rehabilitation (balneotherapy, walks, exercise therapy, health path, hobby classes).

Dynamic observation is carried out by the local doctor for 5 years during examination 2 times a year in a hospital. In the presence of renal syndrome, the same observation is carried out as with glomerulonephritis.

9. Nodular periarteritis

Periarteritis nodosa is a systemic inflammatory disease of the arteries, predominantly of small and medium caliber, characterized by ischemia of the corresponding zones of the organs (up to infarcts and necrosis).

Diagnostic criteria are focal (in various organs) pain syndrome, arterial hypertension, fever, weight loss, sweating, the presence of nodules on the skin, polymorphism of complaints.

Early rehabilitation is carried out simultaneously with treatment (prednisolone 2 mg/kg per day, non-steroidal anti-inflammatory drugs, antihypertensive drugs are prescribed), it provides for the improvement of the functions of the affected vessels.

Electrophoresis with drugs can be used at the site of ischemia. It is necessary to treat intercurrent diseases and foci of chronic infection.

Late rehabilitation begins after the manifestations of the disease subside and the signs of process activity decrease. All factors of sanatorium rehabilitation are used.

Psychotherapy and therapeutic pedagogy matter, food should contain vitamins, microelements, biologically active additives. Assign exercise therapy, massage, water treatments (baths, showers), therapeutic sleep, stay in the fresh air, games without physical activity.

Restorative rehabilitation is carried out for a long time. Hardening procedures, exercise therapy, massage are used. With the disappearance of signs of activity of the inflammatory process, factors of resort treatment are used to completely eliminate residual effects after ischemia, heart attacks, thrombosis, gangrene. Rehabilitation is carried out with an individual selection of procedures, regimen, and therapeutic pedagogy.

Dynamic observation is carried out constantly by the local doctor and cardiologist with a frequency and a complete examination at least 2 times a year.

This is possible during the hospitalization of the patient for rehabilitation and clinical examination in order to clarify the diagnosis. Laboratory and instrumental studies at all stages of rehabilitation and dynamic monitoring are the same: they determine the general blood test, C reactive protein, the blood levels of immunoglobulins G, M, E. Timely diagnosis and treatment of intercurrent diseases in order to prevent relapse are very important. Remissions are long (up to 10 years).

10. Disability of children with diseases of the circulatory system

Disability for children from 6 months to 2 years is not established.

1. Disability for a period of 2 years is established with hemorrhagic vasculitis.

Clinical characteristics: a combination of two or more syndromes with a disease course of more than 2 months, annual exacerbations. The following diseases are also taken into account: pathological conditions of the cardiovascular system, congenital and acquired defects of the heart and large vessels (inoperable and not subject to surgical intervention until a certain age), conditions after surgery on the heart and large vessels, heart rhythm disturbances, including after implantation of pacemakers .

2. Disability for up to 5 years is established in case of heart failure.

Clinical characteristics: congestive heart failure II-III degrees and more or chronic severe hypoxemia.

3. Disability for a period up to the age of 16 is established for diseases, pathological conditions, congenital and acquired heart defects, inoperable patients with circulatory disorders of the II degree, with malignant hypertension.

LECTURE No. 14. Rehabilitation of children with juvenile rheumatoid arthritis

1. Juvenile rheumatoid arthritis

Juvenile rheumatoid arthritis (JRA) is an immunopathological process with systemic joint damage.

Early rehabilitation is carried out in a hospital. Biogenic stimulants are prescribed - apilac, anabolic hormones. Against the background of treatment, physical factors are used: UV rays on the affected area of ​​the joints (the affected joints are irradiated in turn, but not more than two large or a group of small joints) after 2-3 days. In case of trophic disorders, the skin of the collar or lumbosacral zone is irradiated. Effective UHF electric field on the joints. Apply massage, exercise therapy, novocaine electrophoresis on the joints.

Late rehabilitation is carried out in a local sanatorium or clinic. Microwave therapy, ultrasound on the joints, diadynamic currents on the joints and reflexogenic zones are used. Other factors of sanatorium treatment are also applied. Particular attention is paid to exercise therapy, massage.

Rehabilitation treatment uses resort treatment factors, among which thermal procedures (paraffin, ozocerite, hot sand, mud) and other factors (close tourism, outdoor games, dances) predominate. With restriction of movements in the joints, mechanotherapy, exercise therapy, massage, balneotherapy in the form of chloride, radon baths are indicated.

Orthopedic care started at the stage of early rehabilitation, movement treatment continues at the stage of rehabilitation treatment.

At all stages of rehabilitation, it is necessary to carry out sanitation of foci of infection, timely treatment of intercurrent diseases.

Dynamic observation is carried out within 5 years after the exacerbation of the disease by the local doctor and orthopedist (if necessary). The frequency of observation is once a quarter. A complete examination and clarification of the diagnosis are carried out in stationary conditions 2 times a year.

2. Systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is an immunopathological connective tissue disease characterized by a predominant lesion of the nuclei of cellular structures by universal capillaritis.

Early rehabilitation begins from the moment the diagnosis is established; its goal is to reduce the activity of the pathological process, which is achieved by the appointment of glucocorticoids and cytostatics, good nutrition with the addition of dietary supplements.

Late rehabilitation is a sanatorium stage. Maintenance therapy with glucocorticoids prescribed in the hospital is carried out, and all individually selected factors of sanatorium rehabilitation are used. Sanitize foci of chronic infection. Set the daily routine corresponding to the age of the child, with an increase in the number of hours of sleep. Complete nutrition is required. Medical pedagogy is of great importance. It is necessary to take into account the presence of lesions of internal organs.

During rehabilitation treatment, constant hardening is carried out, factors of spa treatment are carefully used, but only in the same climatic zone (it is necessary to avoid sunlight, hypothermia, overheating). Physical activity without fatigue is recommended; dosed health path and outdoor games.

Dynamic observation is carried out continuously until the transfer of the child to the polyclinic for adults. The local doctor observes the patient once a quarter. Twice a year, the child is hospitalized for a complete examination and diagnosis in the dynamics of rehabilitation.

3. Systemic sclerosis

Systemic sclerosis (scleroderma) is a connective tissue disease with a predominant lesion of collagen, characterized by fibrous-sclerotic processes in the affected organs and tissues.

Early rehabilitation begins after diagnosis and is consistent with treatment. Means that improve microcirculation, anti-inflammatory drugs and glucocorticoids are prescribed. With insufficient effect, cytostatics are prescribed (leukeran 0,1-0,2 mg / kg per day), D-penicillamine 1,2-2 g / day, unithiol - 0,05-0,1 2 times a day, angiotrophin 1 ml. Electrophoresis with hyaluronidase, lidase is used. Showing complamin 0,1 g 2 times a day, aloe extract, ATP; vasodilators.

Late rehabilitation - after discharge from the hospital, the treatment prescribed in the hospital continues in maintenance doses. It is better to carry it out in a local sanatorium, using all the factors of sanatorium treatment with their individual selection.

Of great importance are massage, exercise therapy, nutrition with the mandatory appointment of dietary supplements. The mode provides for an increase in hours of sleep. It is important to carry out timely rehabilitation of foci of infection and the prevention of other diseases.

With restorative treatment (secondary prevention), predisposing factors are eliminated, children are hardened. When stabilizing the process, the factors of resort treatment (balneo-mud therapy) are widely used.

Dynamic monitoring is carried out constantly. Examinations by the local doctor and, if necessary, by other specialists (depending on the affected organs) are carried out once a quarter. Twice a year, the child can be hospitalized for a complete clinical examination, diagnosis and rehabilitation.

4. Dermatomyositis

Dermatomyositis is a systemic connective tissue disease with a primary lesion of muscles and skin.

Early rehabilitation is carried out after the diagnosis of the disease is established and is consistent with the treatment. Corticosteroids, non-steroidal anti-inflammatory drugs, ATP, vitamins are prescribed. As a result of treatment, the function of the affected organs improves. Physiotherapy in the acute period is contraindicated (except for electrophoresis of drugs). Exercise therapy and massage should be prescribed immediately after the pain syndrome has decreased.

Late rehabilitation is carried out after discharge from the hospital using all the factors of sanatorium rehabilitation and simultaneous treatment (prevention) of calcifications, contractures. Supportive drug therapy prescribed in the hospital is carried out. Nutrition is of great importance (complete proteins of animal origin, dietary supplements are recommended).

Rehabilitation is being carried out actively. Rehabilitation of calcifications, contractures, supporting anti-relapse treatment, and hardening continue. The factors of resort treatment or the stay of children in resorts with the use of balneotherapy, exercise therapy, massage, mechanotherapy are used. Medical pedagogy and psychotherapy are important.

Dispensary supervision is carried out constantly. It is necessary to exclude insolation, hypothermia, physical and mental overwork. Children should constantly engage in exercise therapy, have extra days of rest (not attend school), good nutrition, extra hours of sleep. Supervision of the local doctor is carried out constantly.

Patients are examined depending on the presence of residual effects once a month or quarter, 2 times a year they are hospitalized for clinical examination, diagnosis clarification and the need for anti-relapse treatment.

5. Disability of children with systemic connective tissue diseases

Disability for a period of 6 months to 2 years is established in pathological conditions caused by diffuse lesions of the connective tissue with a high degree of process activity for more than 3 months and annual exacerbations.

LECTURE No. 15. Rehabilitation of children with diseases of the urinary system

1. Acute glomerulonephritis

Acute glomerulonephritis is an inflammatory disease of the kidneys of an immunopathological nature with a predominant lesion of the renal glomeruli and involvement of the renal tubules, interstitial tissue, and vessels in the process.

Diagnostic criteria: pain in the lumbar region, decrease in the amount of urine, pallor of the skin, edema, increased blood pressure, intoxication, urinary syndrome (oliguria, proteinuria, hematuria, cylindruria), changes in the blood (increased urea, creatinine, potassium, magnesium), change in cholesterol levels, anemia, accelerated ESR, there may be eosinophilia.

Early rehabilitation is a successful treatment of an acute process in a hospital. In order to improve kidney function, bed rest, diet, drugs that improve renal blood flow (curantil, eufillin), electrophoresis with a 1% solution of nicotinic acid or heparin are prescribed.

Late rehabilitation includes a sanatorium stage, which is carried out in a polyclinic or in a local sanatorium. The previously prescribed therapy, diet within table No. 7, physiotherapy, exercise therapy, sanitation of foci of chronic infection and treatment of concomitant diseases continue.

A therapeutic regimen is shown with limitation of physical activity and the inclusion of morning exercises according to an individual plan, exercise therapy, games, and music lessons. A day break is recommended.

It is necessary to provide for the child's stay in the fresh air, but protect him from cooling. Avoid excessive insolation, active sports, avoid contact with aggressive liquids and organic solvents.

Diet matters a lot. It should be complete, taking into account the age of the patient. Physiological norms of protein, fats and carbohydrates are prescribed with the inclusion of complete proteins (such as boiled meat, fish, liver, cottage cheese, eggs), unsaturated fatty acids (vegetable oil), vitamins (vegetables, fruits). The diet is kept hypochlorite (0,05-0,1 g/kg of salt per day) for at least 6 months. Extractive substances, essential oils, smoked meats, spicy seasonings, spices are excluded from the diet.

Physiotherapy occupies an important place in sanatorium treatment. Paraffin applications are applied to the lumbar region. To eliminate renal ischemia, novocaine electrophoresis is used on the lumbar region. To reduce vasospasm, electrophoresis of a 2-4% solution of magnesium sulfate is indicated.

Expanding blood vessels, increasing diuresis, magnesium has a positive effect on the course of the disease and the patient's well-being. Also shown are irradiations of the lumbar region with solar lamps or infrared rays. In order to desensitize the body, reduce inflammation in the kidneys, calcium electrophoresis is used (especially in patients with severe hematuria). At the stage of sanatorium treatment, an important role is given to therapeutic pedagogy and psychotherapy.

Rehabilitation treatment, or secondary prevention, is carried out in a polyclinic using the factors of spa treatment or at a resort. However, treatment at the resort is indicated for children with no signs of exacerbation of the process in the kidneys during the year.

At the stage of spa treatment, children are hardened using all methods of spa treatment: balneotherapy (water temperature 37-38 °C), mud applications, and climatotherapy; rehabilitation of chronic foci of infection.

Dynamic observation is carried out within 5 years after the acute process. The child is observed by a pediatrician and a nephrologist. Inspection is carried out once a quarter for the 1st year, thereafter - 2 times a year.

A complete examination is carried out 2 times a year at the time of hospitalization for rehabilitation and includes a study of urine, blood, a biochemical blood test (urea, creatinine, CRP, total protein and fractions, cholesterol, electrolytes are determined), blood pressure measurement, Zimnitsky test, determination of the clearance of endogenous creatinine, kidney ultrasound, fundus examination.

2. Chronic glomerulonephritis

Chronic glomerulonephritis is a long-term diffuse inflammatory disease of the glomerular apparatus of the kidneys, leading to sclerosis of the parenchyma of the organ and renal failure, occurring in a hematuric, edematous proteinuric (nephrotic) or mixed form.

Diagnostic criteria: hypertension, edema, hematuria of varying severity, proteinuria, cylindruria, dysproteinemia, impaired renal function of varying degrees.

Early rehabilitation is an inpatient treatment of an exacerbation of the disease using bed rest, rational nutrition, anti-inflammatory therapy, hormones, cytostatics, antisclerotic drugs, anticoagulants and antiaggregants.

Late rehabilitation - treatment in a local sanatorium or sanatorium treatment in a polyclinic. The goals of sanatorium rehabilitation are the continuation of maintenance therapy started in the hospital, the correction of the regimen and diet, taking into account the form, stage of the disease, the degree of renal dysfunction, sanitation of foci of infection, prevention of intercurrent diseases, hardening.

A sparing regime is recommended with the exclusion of physical and mental stress, additional daytime rest, and an additional day off per week is introduced for schoolchildren. It is necessary to avoid cooling, contact with infectious patients. After discharge from the hospital, the child should be at home for 1-1,5 months so that adaptation to the usual regimen takes place gradually.

The diet depends on the clinical form of the disease. In the hematuric form of chronic glomerulonephritis, the diet is hyperchloride, complete with a maximum content of vitamins. With a nephrotic form, it is necessary to slightly increase the amount of protein and include foods rich in potassium salts (raisins, dried apricots, prunes, baked potatoes) in the diet.

The purpose of physical factors is limited. Very carefully, you can carry out thermal procedures (electric light baths, irradiation of the lumbar region with a solar lamp or a lamp for infrared rays, heated sand). Inductothermy of the kidney area is recommended.

In the preuremic and uremic period (in the absence of heart failure and cerebrovascular accidents), coniferous baths are used, in the presence of skin itching, starch baths with a water temperature of 37-38 ° C are used.

Rehabilitation treatment, or secondary prevention, is carrying out hardening procedures in a clinic or at a resort using balneo-mud therapy, exercise therapy, and climatotherapy. Children in the inactive phase of the disease, with impaired renal function no more than I degree, a year after the exacerbation of the disease, are subject to resort rehabilitation.

Children with nephrotic form of glomerulonephritis are treated in a dry and hot climate in the summer. In such a climate, the increased release of water through the skin leads to a decrease in diuresis, as a result, conditions are created for the release of more concentrated urine.

Under the influence of heat, dry air, skin perspiration increases, peripheral vessels expand, which reflexively expands the vessels of the kidneys and improves renal circulation. This has a positive effect on kidney function. With an interval of a month, 1-2-month courses of kidney collection are shown.

Dynamic observation. The local doctor observes the child at least once every 1,5-2 months. Nephrologist consultations are carried out as needed. Children are not removed from the dispensary. Scope of research: general and AddisKakovsky urinalysis, Zimnitsky test, general and biochemical blood tests, total protein, fractions, urea, creatinine, cholesterol, electrolytes, CRP, sialic acid, determination of endogenous creatinine clearance, ultrasound of the kidneys, radiography according to indications.

3. Rapidly progressive glomerulonephritis

Rapidly progressive (malignant) glomerulonephritis is a disease characterized by the rapid development of renal failure.

Diagnostic criteria: increasing severity of clinical manifestations of glomerulonephritis, the development of renal failure, the symptoms of which are rapidly progressing.

Early rehabilitation consists in the immediate hospitalization of children with suspected acute glomerulonephritis, strict adherence to all doctor's prescriptions, which in many cases prevent the rapid progression of the disease.

Of great importance are strict adherence to bed rest, the exclusion of physical and neuropsychic stress, hypothermia, especially in adolescent children. Anticoagulants and antiaggregants are used in complex therapy to improve kidney function.

Late rehabilitation at the stage of sanatorium treatment is the stabilization of the inflammatory process, a sparing regime, good nutrition with the inclusion of dietary supplements, restorative treatment, sanitation of chronic foci of infection.

Late rehabilitation lasts for a long time, since spa treatment is allowed only in the absence of kidney failure.

Dynamic observation is carried out for 5 years. The volume of examinations is the same as for glomerulonephritis.

4. ​​Pyelonephritis

Pyelonephritis is a microbial inflammatory process in the pelvicalyceal system and tubulointerstitial tissue of the kidneys. Classification By pathogenesis:

1) primary pyelonephritis;

2) secondary pyelonephritis:

a) obstructive, with anatomical anomalies of the urinary system;

b) with disembryogenesis of the kidneys;

c) with dysmetabolic nephropathies. With the flow:

1) acute pyelonephritis;

2) chronic pyelonephritis:

a) manifest recurrent form;

b) latent form.

By period:

1) exacerbation (active);

2) reverse development of symptoms (partial remission);

3) remission (clinical laboratory). By kidney function:

1) without impaired renal function;

2) with impaired renal function;

3) chronic renal failure.

Diagnostic criteria: intoxication, fever, dysuria, pain in the lumbar region, leukocyturia, bacteriuria, microhematuria, changes in the blood (accelerated ESR, leukocytosis, neutrophilia).

Early rehabilitation is the successful treatment of a child during the period of acute manifestations of the disease using a protective regimen, rational nutrition, rational antibiotic therapy, taking into account the sensitivity of the microflora, the properties of the drug and the reactivity of the macroorganism, the acidity of the urine, the allergic mood of the body.

Late rehabilitation takes place in a local sanatorium or clinic. Sanatorium treatment has a general strengthening effect, increases immunological reactivity, and has a positive effect on the child's psyche.

Intermittent (10 days of each month) antibiotic therapy continues while taking biologics and choleretic agents.

An important condition is to ensure regular outflow of urine (urination at least once every 3 hours), the functioning of the intestines.

The state of the genitourinary organs is monitored, constipation is prevented, and helminthiasis is treated. Medicinal herbs are widely used.

When carrying out herbal medicine, one should take into account the properties of herbs to have an anti-inflammatory effect (bearberry, celandine, St. kidneys).

With hypertension and atony of the urinary tract, as well as to improve renal blood flow, you can use a decoction of oats.

Phytotherapy is recommended between courses of antimicrobials. The appointment of herbs with different effects is substantiated. It is recommended to change herbal infusions every 10-12 days. During the period of taking herbal diuretics, it is necessary to include foods rich in potassium in the diet (raisins, dried apricots, baked potatoes, fresh carrots). It is necessary to increase the drinking regimen by 20-30% to replenish fluids, prescribe decoctions of dried apricots, rose hips, dried fruits, lingonberry or cranberry juice.

The child is on a sparing regime with the exception of great physical exertion, sports competitions. Physical education classes are shown in a special group, hygienic gymnastics is mandatory in the morning. Swimming is prohibited. Sanitize chronic foci of infection.

The diet includes a complete balanced diet with protein intake in the first half of the day and a sufficient introduction of liquid in the form of fruit drinks, juices, mineral waters (Borjomi, Slavyanovskaya, Smirnovskaya, Naftusya, etc.). Food should contain the maximum amount of vitamins, complete proteins. To train the kidneys and create unfavorable environmental conditions for microorganisms, it is recommended to alternate, after 5-7 days, plant foods that alkalize urine and protein foods that acidify.

Salt restriction is recommended only in the presence of hypertension. Foods rich in extractive substances, spices, marinades, smoked sausages, canned food, and spices are excluded from the diet for the entire period of dispensary observation. In chronic pyelonephritis, therapy aimed at increasing the protective properties of the body is of great importance.

Physiotherapeutic procedures have found wide application in the rehabilitation of children with pyelonephritis. Sodium chloride baths are recommended. It should be remembered that balneotherapy of patients with pyelonephritis requires careful monitoring of the observance of a favorable microclimate in the hydropathic and rest room in order to avoid hypothermia. Medicinal electrophoresis of a 1% solution of furadonin, urosulfan, UHF, microwave on the kidney area, diathermy, paraffin, ozokerite or mud applications on the lumbar region are recommended.

In pyelonephritis, accompanied by hypotension of the pelvicalyceal system and ureters, sinusoidal modulated currents (SMT) are used to increase the tone of smooth muscles and the upper urinary tract, improve the excretory function of the kidneys and reduce diastolic blood pressure.

The appointment of physiotherapy must be approached individually, taking into account the physiological state of the kidneys and urinary tract. Contraindications are impaired renal function, the presence of cicatricial narrowing, urolithiasis.

Rehabilitation treatment, or secondary prevention, is carried out in a polyclinic and at a resort. Spa treatment is indicated for children who do not have signs of renal failure, or for patients with only grade I renal failure.

At the stage of spa treatment, hardening procedures, mineral, coniferous, air, sun baths, therapeutic mud, exercise therapy, and thermal procedures are widely used. It is recommended to take low-mineralized mineral waters (you can use bottled ones).

Dynamic observation is carried out within 5 years after acute pyelonephritis and constantly - with chronic pyelonephritis.

Required amount of research: general and Nechiporenko urinalysis, general and biochemical blood tests (urea, creatinine, total protein and fractions, CRP, electrolytes are determined), bacteriological examination of urine, ultrasound of the kidneys, X-ray examination and examination of the fundus according to indications.

5. Urinary tract infection

Urinary tract infection - infection of the organs of the urinary system without a special indication of the level of damage to the urinary tract, leading to the appearance of neutrophilic leukocyturia and bacteriuria.

Diagnostic criteria: there may be fever, dysuric phenomena, pain syndrome, urinary syndrome.

Early rehabilitation at the stage of inpatient treatment includes bed rest, diet, drinking plenty of fluids, taking antispasmodics, sitz baths, herbal medicine.

Late rehabilitation takes place in a clinic or in a local sanatorium.

A sparing regimen with limited physical activity, a diet with the exclusion of products that irritate the urinary tract (extractive and pungent substances) are shown. To increase diuresis and better flushing of the urinary tract, drink plenty of water (tea with sugar and vitamin juices). It is advisable to use mineral waters.

From physiotherapy, thermal procedures, UHF, microwave, electrophoresis with anti-inflammatory drugs on the area of ​​the bladder, pelvis are shown. In chronic cystitis, installations with tomycin, collargol, protargol are recommended. Measures are being taken to prevent intestinal dysfunction, helminthiases, and the state of the genital organs is monitored.

Rehabilitation treatment, or secondary prevention, includes the use of spa treatments. Of great importance are hardening with the appointment of therapeutic mud, balneotherapy, air and sunbathing; intake of mineral waters.

Dynamic observation is carried out within 1 year after the transferred process. Examinations are carried out the same as for pyelonephritis.

6. Interstitial nephritis

Interstitial nephritis - inflammation of the connective tissue of the kidneys with involvement in the process of tubules, blood and lymphatic vessels, renal stroma.

Clinical picture: abdominal pain, increased blood pressure, leukocyturia, microhematuria, oliguria, hyperoxaluria.

Early rehabilitation includes rational nutrition, taking membrane stabilizers (vitamins A, E), agents that improve tissue trophism, anti-sclerotic drugs.

Late rehabilitation is a sanatorium stage using all the factors of sanatorium treatment. A rational regimen, diet, physiotherapy procedures (microwave, electrophoresis with novocaine, nicotinic acid on the lumbar region) are recommended. It is advisable to prescribe medicinal herbs (collection according to Kovaleva). Sanitation of chronic foci of infection is being carried out.

Rehabilitation treatment includes hardening, spa rehabilitation, exercise therapy, gymnastics, herbal medicine courses (lingonberries, strawberries, phytolysin).

Dynamic observation after an acute process is carried out for 3 years, with a chronic one - constantly. Scope of research: blood and urine tests, Zimnitsky test, daily excretion of salts in urine, biochemical blood test (urea, creatinine, CRP, proteinogram, ionogram are determined); creatinine clearance, ultrasound.

7. Urolithiasis

Urolithiasis is a disease of the kidneys and urinary system caused by the presence of stones.

Diagnostic criteria: pain in the abdomen or side, hematuria, dysuria, repeated urinary tract infections.

Early rehabilitation provides for rational nutrition, taking into account the type of stone, taking antispasmodics, analgesics.

Late rehabilitation is carried out in a polyclinic or in a local sanatorium. A sparing regimen, restriction of physical activity, diet therapy aimed at maximizing the reduction in urine of salts that made up the stone, increasing diuresis due to the additional administration of liquid, highly fortified food are shown; herbal medicine using dill seeds, licorice root, parsley, celandine, wild strawberries, horsetail, birch leaf, wild rose.

It is necessary to prevent helminthiases, monitor the condition of the genital organs, intestines, sanitize chronic foci of infection.

During rehabilitation treatment, or secondary prevention, resort methods of treatment, diet, various methods of hardening, balneotherapy, vitamin therapy are used (vitamins A, groups B, E are shown).

Dynamic monitoring is carried out for 5 years. The scope of examinations: blood analysis, urine analysis, Zimnitsky, AddisKakovsky test, determination of urea, residual nitrogen, ultrasound of the kidneys, excretory urography, bacteriological examination of urine according to indications.

8. Disability of children with diseases of the urinary system

1. Disability for children with kidney pathology for a period of 6 months to 2 years is determined with persistent, pronounced impairment of kidney function, a high degree of activity of the pathological process in the renal tissue.

2. Disability for a period of 2 to 5 years is determined with sclerosing, sluggish, therapy-resistant variants of glomerulonephritis, confirmed by the results of a kidney biopsy or examination in a specialized hospital.

Clinical characteristics: nephrotic syndrome, therapy-resistant hypertension, high degree of activity of the nephrotic process.

3. Disability for a period of 5 years is determined for diseases, injuries and malformations of the urinary tract; partial or complete aplasia of organs.

4. Disability before the age of 16 is determined for kidney diseases, including hereditary pathological conditions, malformations of the kidneys and urinary organs with chronic renal failure and malignant hypertension, diabetes insipidus syndrome, renal diabetes insipidus.

LECTURE No. 16. Rehabilitation of children with blood diseases

1. Iron deficiency anemia

Iron deficiency anemia is a hypochromic anemia that develops as a result of iron deficiency in the body.

Diagnostic criteria: pallor of the skin and mucous membranes, trophic disorders, taste perversion, a decrease in the concentration of hemoglobin in the blood, a color index.

Early rehabilitation is reduced to the successful treatment of the disease, the appropriate regimen, a diet with the introduction of foods rich in iron and vitamins, drug therapy, and the treatment of helminthiasis.

Late rehabilitation provides for a regimen with sufficient physical activity, maximum exposure to fresh air, balanced nutrition, massage, gymnastics, rehabilitation of chronic infection foci, treatment of diseases accompanied by impaired intestinal absorption, bleeding, and helminthiasis therapy.

A diet is prescribed using foods rich in iron (such as meat, tongue, liver, eggs, tangerines, apricots, apples, dried fruits, nuts, peas, buckwheat, oatmeal).

Dairy products should be kept to a minimum as iron absorption from them is difficult.

It is also necessary to significantly limit flour products, since the phytin contained in them makes it difficult for the absorption of iron. A maintenance dose (half the therapeutic dose) of iron preparations is recommended until serum iron levels normalize.

Secondary prevention includes rational feeding, prevention of colds and gastrointestinal diseases, detection and treatment of helminthiasis, dysbacteriosis, hypovitaminosis, allergic diseases, and various hardening methods.

Dynamic observation is necessary within 6 months. The scope of examinations: a general blood test, a biochemical study (bilirubin, iron-binding capacity of serum, serum iron, proteinogram are determined); Analysis of urine.

2. Protein deficiency anemia

Protein deficiency anemia is an anemia that develops as a result of a dietary deficiency of animal proteins.

Diagnostic criteria: pallor, pastosity, decrease in hemoglobin and red blood cells with a normal color index.

Early rehabilitation includes the correct regimen, physical education, massage, diet in accordance with age, sufficient exposure to fresh air, sanitation of foci of infection, treatment of helminthiasis, and normalization of the functions of the gastrointestinal tract.

Secondary prevention provides for rational feeding, hardening, prevention of infectious (including gastrointestinal) diseases, dysbacteriosis.

Dynamic observation is carried out within 6 months. Examinations: general blood test, biochemical (proteinogram, bilirubin, serum iron are determined), urinalysis.

3. Vitamin deficiency anemia

Vitamin deficiency anemia develops as a result of a lack of vitamin B12 and folic acid, vitamin E.

Diagnostic criteria: pallor of the skin and mucous membranes, glossitis, detection of megaloblasts, a decrease in hemoglobin in the blood; color index greater than 1,0; erythrocytes with Jolly bodies.

Early rehabilitation consists in correcting the diet (vitamin B12 is found in meat, eggs, cheese, milk, folic acid in fresh vegetables (tomatoes, spinach), a lot of it in yeast, as well as in meat, liver), eliminating the causes that caused anemia, prescribing vitamins.

With late rehabilitation, an active motor mode, massage, good nutrition, treatment of helminthiasis, sanitation of foci of chronic infection are indicated.

Secondary prevention includes a balanced diet, various hardening methods, sufficient physical activity, prevention of colds and intestinal infections.

Dynamic observation is carried out within 6 months. The scope of examinations: determination of protein and its fractions, bilirubin, serum iron, ionogram, general blood and urine analysis.

4. Hemolytic anemia

Hemolytic anemia - anemia resulting from increased destruction of red blood cells.

Diagnostic criteria: pallor, yellowness of the skin and mucous membranes, splenomegaly, a decrease in erythrocytes and hemoglobin with a normal color index, defective erythrocytes, reticulocytosis.

Early rehabilitation is a successful treatment for an exacerbation of the disease.

Late rehabilitation is carried out in a polyclinic or a local sanatorium and is reduced to the prevention of hemolytic crises, which are most often provoked by intercurrent infection.

A rational regimen, gymnastics are necessary, but with the exception of large physical exertion, sudden movements, shaking, carrying weights, playing sports. Exercise therapy, physical education in a special group, morning exercises, sufficient exposure to fresh air are shown.

It is recommended to take vitamins, herbal medicine (calendula, dill seeds, birch leaves, cudweed, juniper, chamomile, strawberries, corn stigmas, horsetail, sand immortelle are recommended), good nutrition, rehabilitation of foci of chronic infection.

Secondary prevention includes a sparing regimen, diet, active treatment and prevention of acute infectious diseases, chronic diseases of the gastrointestinal tract and sanitation of focal infection, the use of all types of hardening, genetic counseling for hereditary hemolytic anemia.

Dynamic monitoring is carried out constantly. Examinations: general blood test, determination of the shape and osmotic stability of erythrocytes, reticulocytes, biochemical blood test (bilirubin and protein fractions, proteinogram), urinalysis, abdominal ultrasound.

5. Hemophilia

Hemophilia is a hereditary disease characterized by a sharply slow blood clotting and increased bleeding due to a lack of certain blood clotting factors.

Diagnostic criteria: repeated episodes of hematoma-type bleeding, hemorrhages in the joints, nosebleeds, prolongation of blood clotting time, low levels of coagulation factors VIII, IX, XI.

Early rehabilitation is a successful treatment of an exacerbation of the disease in a hospital using replacement therapy, vitamins.

Late rehabilitation is carried out in a local sanatorium or clinic.

A sparing regimen is recommended, all sports associated with jumping, falling, hitting, including cycling, are prohibited.

The child is exempt from physical education at school, exercise therapy is indicated, as this increases the level of factor VIII, general and joint massage.

Nutrition should correspond to physiological needs. Phytotherapy is shown (a decoction of oregano and hareslip intoxicating).

It is very important that the child has regular (at least 4 times a year) dental cleaning, as this significantly reduces the number of bleeding episodes due to tooth extractions and caries. Sanitation of chronic foci of infection is carried out, physiotherapeutic treatment of the joints is indicated (phonophoresis with hydrocortisone, lidase).

Secondary prevention consists in adherence to the regimen, prevention of limb injuries, a full diet, hardening, psychological, social adaptation and career guidance (the exclusion of labor that requires heavy physical exertion).

Dynamic monitoring is carried out constantly. Scope of examinations: blood test, coagulogram, urinalysis, feces with the definition of occult blood.

6. Thrombocytopenic purpura

Thrombocytopenic purpura is a disease characterized by a tendency to bleeding due to thrombocytopenia.

Classification

With the flow:

1) acute (lasting less than 6 months);

2) chronic:

a) with rare relapses;

b) with frequent relapses;

c) continuously recurring. By period:

1) exacerbation (crisis);

2) clinical remission (lack of bleeding with persistent thrombocytopenia);

3) clinical hematological remission. According to the clinical picture:

1) "dry" purpura (there is only skin hemorrhagic syndrome);

2) "wet" purpura (purpura in combination with bleeding).

Diagnostic criteria: hemorrhagic syndrome; characterized by polymorphism, polychromy of hemorrhage, bleeding, a decrease in the level of platelets in the blood.

Early rehabilitation - treatment of the disease in a hospital using drugs that improve the adhesive and aggregative properties of platelets (such as epsilon aminocaproic acid, adroxon, dicynone, calcium pantothenate).

Late rehabilitation is carried out in a polyclinic or a local sanatorium. Children are shown a sparing regimen, exercise therapy, a diet with the exception of allergenic foods, canned food, it is recommended to keep a food diary. Include peanuts, spinach, dill, nettle in the diet. Sanitation of foci of infection, deworming, prevention of infectious diseases, and the fight against dysbacteriosis are carried out, since all these factors can provoke an exacerbation of the process.

Within 3-6 months after discharge from the hospital, it is advisable to use hemostatic herbal preparations in combination with alternating two-week courses of drugs that stimulate the adhesive aggregation function of platelets, choleretic agents.

The hemostatic collection includes yarrow, shepherd's purse, nettle, intoxicating hare lip, St. John's wort, wild strawberry (plants and berries), water pepper, corn stigmas, wild rose.

Secondary prevention comes down to following a hypoallergic diet, various hardening procedures, active treatment and prevention of infectious diseases.

In the treatment of children, it is necessary to avoid the appointment of acetylsalicylic acid, analgin, carbenicillin, nitrofuran drugs, UHF and UVR, which disrupt platelet function. Contraindicated physical education in the general group, hyperinsolation.

Within 3-5 years, climate change is inappropriate.

During recovery, dynamic monitoring of the child is carried out for 2 years, in the chronic course of the disease - constantly. The scope of examinations: complete blood count, determination of the duration of bleeding, coagulogram, general urinalysis.

7. Leukemia

Leukemia is a group of malignant tumors arising from hematopoietic cells.

Diagnostic criteria: hemorrhagic, hepatolienal syndrome, generalized enlargement of lymph nodes; changes in the peripheral blood: the presence of leukemic cells, changes in the myelogram.

Early rehabilitation - timely detection of the disease and active treatment in the hospital.

Late rehabilitation is carried out at the stage of sanatorium treatment. The mode is determined by the patient's condition and his hematological data.

The diet should be high-calorie with a protein content 1,5 times higher than the norm, enriched with vitamins and minerals.

When used in the treatment of glucocorticoids, the diet is enriched with foods containing a large amount of potassium and calcium. Fried foods, marinades, smoked meats, extractives are not recommended. Dairy products are shown.

Animal fats are limited. Products that have the properties of non-specific sorbents are recommended (carrots, plums, sea buckthorn, black currants, cherries, legumes, pumpkins, zucchini, melons).

Courses of complexes of vitamins A, E, C, B1, B6 are prescribed in therapeutic doses for a month 4-6 times a year.

Medicines that increase the number of leukocytes are recommended (Eleutherococcus extract, sodium nucleinate, dibazol, pentoxyl, metacil). It is necessary to control the processes of digestion and assimilation of food, the activity of the liver and pancreas.

Sanitation of foci of infection, prevention of infectious diseases are carried out. Psychological and social adaptation and rehabilitation play an important role.

Secondary prevention is reduced to the exclusion of physical and mental stress in children, a full diet, hardening. Children are exempted from physical education, in the spring and winter period, it is better to study according to the school curriculum at home. It is necessary to protect the child from contact with infectious patients.

Climate change is not recommended.

Dynamic monitoring is carried out constantly. Scope of research: general blood test at least 1 time in 2 weeks with platelet and reticulocyte count, biochemical blood test (bilirubin, proteinogram, alanine and aspartic transaminases, urea, creatinine, alkaline phosphatase are determined), urinalysis, abdominal ultrasound.

8. Disability of children with blood diseases

1. Disability of children with blood diseases for a period of 6 months to 2 years is established with hematological conditions that occur with hemorrhagic vasculitis with a duration of more than 2 months and annual exacerbations.

2. Disability for a period of 2 to 5 years is established for hereditary and acquired blood diseases.

Clinical characteristics: at least 1 crisis during the year with a decrease in hemoglobin less than 100 g / l.

3. Disability for 5 years is established for acute leukemia, lymphogranulomatosis.

Clinical characteristics: from the moment of diagnosis to the age of 16.

4. One-time disability is established for hematosarcomas (lymphosarcoma, etc.), malignant histiocytosis, hemoglobinosis; hereditary and acquired hypo- and aplastic conditions of hematopoiesis (hemoglobin below 100 g / l, platelets below 100 in 000 mm1, leukocytes - 3 in 4000 mm1); hemophilia A, B, C, deficiency of V, VII coagulation factors, rare types of coagulation, von Willebrand disease, Glanzmann's thrombasthenia, hereditary and congenital thrombocytopathies from the moment of diagnosis; chronic thrombocytopenic purpura, regardless of splenectomy, with a continuously relapsing course with severe hemorrhagic crises, platelet count 2 or less in 50 mm000; chronic leukemia, myeloid leukemia.

LECTURE No. 17. Rehabilitation of children with diseases of the respiratory system

The goals of the rehabilitation of children with diseases of the respiratory system are to reduce the classes of functional disorders to complete restoration of functions in acute and recurrent diseases and to stabilize minimal disorders in chronic pathology.

Children's pulmonology sanatoriums can be considered as a sanatorium (late rehabilitation) and as a resort (rehabilitation treatment), depending on the patient's condition and the methods of rehabilitation being carried out.

A separate issue in the problem of rehabilitation of children with respiratory diseases is immunorehabilitation - one of the main links, especially in recurrent and chronic pathology.

With early rehabilitation, we can only talk about immunotherapy, but not about immunocorrection. In the period of late rehabilitation, immunocorrective therapy is planned and fully performed during rehabilitation treatment.

The main principles of immunorehabilitation treatment are:

1) justification of a stable immunodeficiency state;

2) the consistent use of immunocorrective drugs, starting with the activation of the expression of receptors of those lymphocytes that represent the greatest defect in the structure of the pathological response;

3) it is desirable to select drugs for corrective therapy in the in vitro system;

4) the use of a combination of drugs with different mechanisms of action;

5) the appointment of membrane-stabilizing drugs upon reaching clinical and immunological remission;

6) carrying out immunorehabilitation is most effective with a normal balance of the functions of the endocrine and central nervous systems.

A short list of drugs and methods of influencing the immune system

Tmimetic preparations include: thymalin, Taktivin, thymogen, thymosin - extracts from the thymus gland of newborn calves; vitamin A, carnitine chloride, levamisole hydrochloride salt.

It is possible to influence the function of T cells with ultrasound in the area of ​​the projection of the thymus gland, with infrared rays.

Vmimetics include splenin, berlopentin, myelopid, prosplen, IRS19, immunal, bronchomunal, ribomunal, etc.

The function of B-lymphocytes can be influenced by ultrasound on the projection of the sternum and spleen, semi-chromatic laser, EHF therapy, UVI in reflex zones.

Vitamin B15, sodium nucleinate, phosphaden, methyluracil, dibazol, phytosplat, infusions and tinctures of adaptogenic plants, autohemoserotherapy, thermal procedures on the solar plexus area, reflexology, etc. have an immunomodulatory effect.

1. Bronchitis

Bronchitis is an inflammatory disease of the bronchi of various etiologies (infectious, allergic, physicochemical).

Criteria for diagnosis: cough, dry and various wet rales, x-ray - the absence of infiltrative or focal changes in the lung tissue; bilateral strengthening of the pulmonary pattern and roots of the lungs can be observed.

Acute bronchitis is bronchitis that occurs without signs of bronchial obstruction.

Early rehabilitation includes drug treatment, started at the first manifestations of bronchitis, leading to an improvement in bronchial function. To improve the general condition, adaptogenic preparations, vitamins, microelements are used. At this stage, exercise therapy, breathing exercises, iontophoresis with anti-inflammatory action are prescribed.

Late rehabilitation is carried out in a local sanatorium or in a clinic using all the factors of sanatorium treatment, breathing exercises, exercise therapy are prescribed. Vaccination is carried out with ribomunzh, bronchomunal, etc.

Rehabilitation treatment includes exercise therapy (training regimen), the appointment of membrane-stabilizing drugs, reparants.

Correction of immunodeficiency is carried out during its stabilization, herbal medicine, health paths, hardening procedures.

Dynamic observation is carried out by the local doctor during the year. A month after the completed treatment, physical methods of research, general clinical tests, and determination of the parameters of the immune status are carried out.

Acute obstructive bronchitis, bronchiolitis - acute bronchitis, occurring with bronchial obstruction syndrome. For bronchiolitis, respiratory failure and an abundance of small bubbling rales are characteristic; for obstructive bronchitis - wheezing.

Acute obliterating bronchiolitis is a serious disease of a viral or immunopathological nature, leading to obliteration of bronchioles and arterioles.

Early rehabilitation - against the background of etiological treatment, secretolytic, bronchodilator, expectorant drugs are prescribed, unloading the pulmonary circulation, restoring microcirculation of the bronchial mucosa and submucosa, reparants, vitamin therapy. Respiratory gymnastics, exercise therapy, iontophoresis of medicinal substances are used.

Late rehabilitation - factors of sanatorium treatment, methods of restoring bronchial trophism are used, correction of immunity is carried out, stimulating immunotherapy.

Rehabilitation treatment - for the prevention of relapses, immunomodulators, adaptogens are prescribed. Training breathing exercises and other factors of spa treatment and hardening are shown.

Dynamic observation is carried out by the local doctor together with the pulmonologist. Inspection is carried out once a quarter with a study of the function of external respiration. Lorvrach examines 2 times a year. Sanitation of foci of chronic infection is being carried out. The duration of observation is one year.

Recurrent bronchitis - bronchitis without obstruction, episodes of which are repeated 2-3 times within 1-2 years against the background of acute respiratory viral infections. Episodes of bronchitis are characterized by the duration of clinical manifestations (2 weeks or more).

Recurrent obstructive bronchitis - obstructive bronchitis, episodes of which are repeated in young children against the background of acute respiratory viral infections. Unlike bronchial asthma, obstruction is not paroxysmal in nature and is not associated with exposure to non-infectious allergens.

Occasionally, repeated episodes of obstruction are associated with chronic food aspiration. In some children, recurrent obstructive bronchitis is the debut of bronchial asthma (risk groups: children with signs of allergy in a personal or family history, as well as with three or more episodes of obstruction).

Early rehabilitation - against the background of etiological treatment, interferonogenic anti-inflammatory drugs, bronchodilators, secretolytic agents, expectorants, protective and training regimen are prescribed. They improve circulation at the level of the pulmonary circulation, carry out physiotherapy with an anti-inflammatory effect.

Late rehabilitation - all factors of sanatorium treatment are prescribed. Immunotherapy is carried out with adaptogens of plant and animal origin. Antibacterial drugs, prolonged methylxanthines, immunomodulation, vitamin therapy, microelements, enzymes with a substitution purpose, exercise therapy, and massage are used.

Rehabilitation treatment - vaccination with preparations is prescribed - extracts from bacteria, hardening, physical procedures, inhibitors of allergic inflammation. The child is allowed full educational and physical activity.

Dynamic observation: the district doctor examines the child once a quarter, the lor doctor - 2 times a year. Additional studies: conduct allergic tests, examine the function of external respiration (determine peak expiratory speed). Patients are removed from the register in the absence of clinical and laboratory abnormalities within 3 years.

Chronic bronchitis, bronchiolitis, chronic pneumonia in childhood are more often manifestations of other chronic lung diseases. As independent diseases, they are chronic respiratory inflammatory lesions of the bronchi, lung tissue, occurring with repeated exacerbations; are diagnosed with the exclusion of pulmonary and mixed forms of cystic fibrosis, ciliary dyskinesia syndrome and other hereditary lung diseases.

Criteria for diagnosis: productive cough, persistent various-sized moist rales in the lungs (for several months) in the presence of 2-3 exacerbations of the disease per year for 2 years.

Chronic bronchiolitis (with obliteration) is a disease that is a consequence of acute obliterating bronchiolitis, the morphological substrate of which is the obliteration of bronchioles and arterioles of one or more sections of the lungs, leading to impaired pulmonary blood flow and the development of emphysema.

Syndrome of a unilateral supertransparent lung (the so-called McLeod syndrome) is a special case of this disease, which is manifested by shortness of breath and other signs of respiratory failure of varying severity, the presence of persistent fine bubbling wheezing.

Diagnostic criteria: characteristic clinical findings in the presence of radiological signs of increased transparency of the lung tissue and a sharp decrease in pulmonary blood flow in the affected parts of the lungs during scintigraphy.

2. Chronic pneumonia

Chronic pneumonia is a chronic inflammatory non-specific process, which basically contains irreversible morphological changes in the form of bronchial deformation and pneumosclerosis in one or some segments, accompanied by recurrent inflammation in the bronchi, as well as lung tissue.

Most often, chronic pneumonia develops as a result of incomplete cure of acute pneumonia, atelectasis of various origins, the consequences of a foreign body entering the bronchi.

Diagnostic criteria: the presence of characteristic clinical symptoms of varying severity, cough with sputum, stable localized wheezing in the lungs, recurrent exacerbations. X-ray revealed signs of limited pneumosclerosis, bronchography - deformation and expansion of the bronchi in the lesion.

Early rehabilitation - during exacerbation, antibacterial drugs, secretolytic and expectorant drugs, bronchodilators, postural drainage, exercise therapy, breathing exercises, vitamin therapy, reparants, general and chest massage are prescribed, physical activity is recommended. Physiotherapy includes high-frequency electrotherapy, inhalation of mucolytic agents.

Late rehabilitation is carried out at the sanatorium stage. All factors of sanatorium rehabilitation, microelement therapy, phytotherapy, general massage, high-frequency methods not used at the first stage of rehabilitation, galvanization of the lungs and drug electrophoresis are used.

Rehabilitation treatment - immunocorrective therapy is used; biologics to eliminate intestinal dysbiosis, drugs that restore tissue trophism, immunomodulation by physical factors of influence, resort rehabilitation.

Dynamic observation of children with chronic bronchopulmonary diseases is carried out constantly by the local doctor and pulmonologist, examination - once a quarter. A complete clinical and laboratory-instrumental examination is indicated 2 times a year during hospitalization of children. The child needs constant exercise therapy, hardening procedures.

3. Acute pneumonia

Acute pneumonia is an acute inflammatory lung disease. Pneumonia can be caused by bacterial, viral, rickettsial, chlamydial, mycoplasmal, parasitic pathogens, some chemical influences, and allergic factors.

Diagnostic criteria: violation of the general condition, fever, cough, shortness of breath of varying severity and characteristic physical changes. X-ray confirmation is based on the detection of focal infiltrative changes in the lungs.

According to morphological forms, focal, segmental, focal-draining, croupous and interstitial pneumonia are distinguished. Interstitial pneumonia is detected in pneumocystosis, sepsis and some other diseases.

The form of the disease can be mild, moderate and severe, which is manifested by neurotoxicosis or infectious toxic shock.

The course of the disease is often acute, sometimes protracted.

Protracted pneumonia is diagnosed in the absence of resolution of the pneumonic process within 6 weeks to 8 months from the onset of the disease; this should be an occasion to search for possible causes of such a flow.

When pneumonia recurs (with the exclusion of re- and superinfection), it is necessary to examine the child for the presence of cystic fibrosis, immunodeficiency, chronic food aspiration, etc.

Pneumonia can be uncomplicated or complicated. The main complications are: inpneumatic pleurisy, metapneumatic pleurisy, pulmonary destruction, lung abscess, pneumothorax, pyopneumothorax.

The formulation of a complete diagnosis should include, along with the indicated parameters, data on the localization of the pneumonic process (lung, lobe, segment, focal, interstitial), time from the onset of the disease, and information on the specified (if possible) or suspected etiology.

Early rehabilitation - against the background of etiological treatment, secretolytic agents, substitution immunotherapy, exercise therapy, breathing exercises, immunomodulatory treatment with adaptogens are used.

With late rehabilitation, sanatorium factors, vitamin therapy are used, if possible, infectious allergies are eliminated.

General massage and chest massage, vaccination against opportunistic flora (bronchomunal, immunal, bronchovacs, etc. are prescribed), elimination of dysbacteriosis are shown.

At the stage of rehabilitation treatment, elimination of dysbacteriosis, sanitation of foci of chronic infection are carried out, resort rehabilitation factors, and hardening are used.

Dynamic observation is carried out by the district doctor, examining children under the age of 3 years 2 times a quarter, older than 3 years - once a quarter, lor doctor - 2 times a year. Once a year, an x-ray of the lungs is performed, the function of external respiration is assessed, and foci of infection are sanitized; tempering procedures are shown. The duration of observation is one year.

4. Alveolitis

Exogenous allergic alveolitis is an immunopathological disease caused by inhalation of organic dust containing various antigens, and manifested by diffuse damage to the alveolar and interstitial tissue of the lung, followed by the development of pneumofibrosis.

Diagnosis criteria: acute, subacute or chronic lung disease, accompanied by cough, diffuse crepitating and small bubbling rales, shortness of breath, restrictive and obstructive ventilation disorders in the presence of indications of contact with a causally significant allergen. Radiologically it is characterized by diffuse infiltrative and interstitial changes.

Toxic fibrosing alveolitis is a disease caused by the toxic effect of chemicals, as well as certain drugs on the lung tissue.

The diagnostic criteria are the same as for allergic alveolitis, if there is evidence of contact with the relevant chemical agents or drugs.

Idiopathic fibrosing alveolitis is a primary chronic disease of unknown etiology with the localization of the main pathological process in the interstitium of the lung, which, progressing, leads to diffuse pulmonary fibrosis.

Diagnostic criteria: a steadily progressive disease, accompanied by shortness of breath, cough, restrictive ventilation disorders, development of cor pulmonale in the absence of indications of etiological factors characteristic of other types of alveolitis.

Early rehabilitation - for all alveolitis, antihistamines, glucocorticoids, tissue respiration enzymes, inhibitors of allergy mediators, vitamins, microelements, a protective regime for contacts with allergens and chemical agents are prescribed.

Late rehabilitation, or the sanatorium stage, is carried out in a clinic or sanatorium using all the factors of sanatorium treatment. Antimediators, membrane stabilizing agents, histamine, histoglobulan, antiallergic globulin, exercise therapy, massage, oxygen aerosol therapy are prescribed.

Rehabilitation treatment is aimed at general strengthening of the body, hardening. Resort factors of rehabilitation are used.

Dynamic observation is carried out by the local doctor and the allergist during the examination once a quarter. The survey is carried out 2 times a year.

5. Bronchial asthma

Bronchial asthma is a disease characterized by reversible bronchial obstruction, the pathogenetic basis of which is allergic inflammation of the respiratory tract. As a rule, bronchial hyperreactivity is noted, in typical cases - periodic occurrence of attacks with impaired bronchial patency as a result of their spasm, mucosal edema and mucus hypersecretion.

Bronchial asthma also occurs in the form of asthmatic bronchitis without typical attacks, spasmodic cough, asthma of physical exertion.

Diagnostic criteria: asthma attacks, status asthmaticus, asthmatic bronchitis, spasmodic coughing attacks, accompanied by acute lung distention and difficulty in exhalation. X-ray during an attack, swelling of the lungs is observed, against the background of which an increase in the bronchovascular pattern is often detected.

Allocate atopic and non-atopic forms of bronchial asthma. In childhood, the atopic form of the disease predominates.

Periods of the disease: exacerbation, remission. Along with causally significant allergens, non-specific factors such as respiratory viral infection, air and residential air pollution, physical activity, neuro- and psychogenic effects, certain drugs, chemicals (for example, acetylsalicylic acid) provoke an exacerbation.

By severity, asthma is divided into mild, moderate and severe. When assessing the severity, along with the criteria of international consensus, one should also take into account the patient's condition in the non-attack period, the presence of functional changes in the external respiratory apparatus and the cardiovascular system.

Complications: lung atelectasis, pneumothorax, mediastinal emphysema, cor pulmonale, pulmonary emphysema (if the latter two are present, other chronic obstructive pulmonary diseases, which are a more common cause of these complications, must be excluded).

It also does not consider lung damage in a number of systemic and hereditary diseases (such as Kartanger's syndrome, ciliary dyskinesia, immunodeficiency states, cystic fibrosis, lung damage in systemic lupus erythematosus, rheumatoid arthritis, lung and pleural tumors, etc.).

Within the framework of this classification, like any other, as new data are accumulated, further in-depth characterization of the clinical manifestations of lung disease in children is possible.

Early rehabilitation provides for the relief of an attack, the appointment of antimediators (ketofen, ketotifen, zaditen, ketasma - early age 1/4 tablet 2 times 1-2 months, the rest 1/2 tablet 2 times 1-2 months; terfenadine - up to 3 years, 15 mg 2 times a day, older children - 30 mg 2 times a day, 14-16 years old - 60 mg 2 times a day for a month; Zyrtec - 2 mg 1 time a day for 10-14 days for children under 3 years old , older children - 3-5 mg, course up to 10-14 days); inhibitors of inflammatory mediators are combined with prolonged theophyllines (up to 3 years - 1 / 4 tablets 2 times a day, older children - 1 / 4-1 / 2 tablets 2 times a day, if necessary - up to a month).

Late rehabilitation - the use of intal in capsules and aerosol; sodium nedocromil aerosol (1-2 breaths 2 times a day for 6 weeks or more), autoserotherapy against the background of other factors of sanatorium treatment with the use of breathing exercises (according to Buteyko, etc.), specific hyposensitization.

At the stage of rehabilitation treatment, correction of immunological disorders, membrane stabilization, rehabilitation with histoglobulin, lysates of leukocytes, autolymphocytes are carried out. Resort factors of rehabilitation, transition to physical activity, exercise therapy are used.

Dispensary observation is carried out until the age of 15. Examinations of the local doctor and allergist after the attack period are carried out once a quarter, with a stable remission - 2 times a year. Promotion is underway.

6. Disability of children with diseases of the respiratory system

Disability for a period of 6 months to 2 years is not established.

1. Disability for a period of 2 years is established for congenital and acquired diseases of the respiratory organs (including the condition after lung resection).

Clinical characteristics: persistent respiratory failure of II degree or more or severe and frequent attacks of bronchial asthma (4 or more per year).

2. Disability for a period of 5 years is not established.

3. Disability for a period up to the age of 16 is established once for diseases, pathological conditions and malformations of the respiratory organs that are not subject to surgical treatment, with symptoms of respiratory failure of the II degree and heart failure; hormone-dependent bronchial asthma; pulmonary heart failure III degree.

Medical rehabilitation (tertiary prevention) is carried out through health care organized by the health authorities at the place of residence of disabled children, as well as children in stationary institutions.

The objectives of the medical rehabilitation of people with disabilities since childhood are to improve or stabilize the criteria for survival and life (orientation in the environment, physical independence, mobility of communication, ability to engage in activities; economic independence, prevention of the transition of dysfunctions into physical and other defects that prevent a disabled person from participating in society). Disabled people are guaranteed qualified free medical care at the expense of the budget in state medical institutions.

Authors: Drozdov A.A., Drozdova M.V.

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