Consultation (younger group) on the topic: The variety of diagnostic methods designed to study young children. which is the child? Features of development in early childhood. Growth disturbances may be observed in the disease

The method of objective examination of the child

An objective examination of the child begins with an assessment of the general condition. There are: good condition (only in relation to healthy children), satisfactory, moderate, severe and extremely severe.

After that, they proceed to assess the position of the child in bed: active, passive or forced. Under the active position is understood the position of the child, when he can take any position in bed, perform active movements. They speak of a passive position if the patient without outside help cannot change his position. And, finally, if the child takes some special position to alleviate his condition (the pose of a pointing dog with meningitis, sitting position, resting his hands on his knees, with an attack of bronchial asthma), then the position is assessed as forced. Restriction of the regimen according to therapeutic indications is not evidence of the patient's passive position.

Assessment of the child's consciousness- clear, somnolent, or stuporous (a state of stupor, soporous, reaction only to strong irritation). With loss of consciousness, they speak of a coma, it is rational to determine the degree of coma. In coma of the 1st degree (mild coma) - there is no consciousness and voluntary movements, corneal and corneal reflexes are preserved, the 2nd degree is characterized by a lack of consciousness, areflexia (only sluggish pupillary reflexes are preserved), respiratory rhythm disorders are often observed. With a coma of the 3rd degree, there is a lack of all reflexes, deep respiratory and circulatory disorders, cyanosis and hypothermia.

In parallel, the child's mood is noted (smooth, calm, upbeat, excited, unstable), his reaction and contact with others, interest in toys.

Survey methodology by systems

Skin and subcutaneous tissue.

Objective methods of skin examination are: inspection, palpation, examination of vascular fragility and determination of dermographism.

Inspection . A thorough examination of the child's skin can only be done in good light. The child must be completely undressed. Since older children are shy at the same time, it is advisable to expose the child gradually, as needed. Particular attention should be paid to the armpits, skin folds, circumference anus where diaper rash and other skin manifestations most often occur.

First of all, you should pay attention to the color of the skin and visible mucous membranes, and then to the blood supply, expansion of the veins and venous capillaries, the presence of rashes, hemorrhages, scars, hair growth. The normal color of a baby's skin is pink. However, with pathology, pallor or redness of the skin, jaundice, cyanosis, an earthy or earthy-gray tint is possible. It is also necessary to pay attention to other skin changes: the expansion of the skin venous network in the interscapular region (in the upper back), in the upper chest, on the head and in the abdomen. In the presence of a rash, the following elements are distinguished:

Roseola- a speck of pale pink, red, purple-red or purple in size from a point to 5 mm. The shape is rounded or irregular, the edges are clear or blurry; does not protrude above the level of the skin. When the skin is stretched, it disappears; when released, it reappears. Multiple roseolas 1-2 mm in size are usually described as a small punctate rash.

Spot- has the same color as roseola, size from 5 to 20 mm, does not protrude above the level of the skin. The shape of the spot is most often irregular. The spot disappears with pressure on the skin, after the cessation of pressure it appears in the same place again. Multiple spots 5-10 mm in size are described as a small-spotted rash. Spots 10-20 mm in size form a large-spotted rash.

Erythema- Extensive areas of hyperemic skin of red, purple-red or purple color. Spots larger than 20 mm, tending to merge, should be considered as erythema.

Hemorrhage- hemorrhages in the skin. Hemorrhages have the appearance of dots or spots of various sizes and shapes that do not disappear when the skin is stretched. The color is initially red, purple or violet, then, as the hemorrhage resolves, becomes yellow-green, and finally yellow. Pinpoint hemorrhages are called petechiae. Multiple hemorrhages round shape 2 to 5 mm in size are described as purpura. Irregularly shaped hemorrhages larger than 5 mm - ecchymosis. Hemorrhages can be superimposed on other elements of the rash. In such cases, one speaks of a petechial transformation of roseola, spots, papules, etc.

Papule- slightly elevated above the level of the skin, which is often well defined by touch. Has a flat or domed surface. Size from 1 to 20 mm. The shape and color are the same as those of roseola and spots. Papules often leave behind pigmentation and flaking of the skin.

Often, in a routine clinical examination of a sick child, it is very difficult or even impossible to distinguish roseolas and spots from papules. On the other hand, the same patient may have roseola and papules at the same time, or spots and papules. In such cases, it is appropriate to describe the rash as roseolopapular or maculopapular. Thus, the size of papules is also indicated at the same time: roseolo-papules have a size of up to 5 mm, maculo-papules from 5 to 20 mm.

tubercle- an element that is clinically similar to a papule, but differs from the latter in that when the tubercle is felt, the infiltrate in the skin is always clearly defined. In addition, tubercles, unlike papules, undergo necrosis during reverse development, often form ulcers and leave behind a scar or skin atrophy.

Knot- is a delimited seal that goes deep into the skin, often rises above the surface of the skin, has a size of up to 6-8-10 cm or more.

Blister- usually arises quickly and disappears quickly, leaving no trace behind. It rises above the level of the skin, has a round or oval shape, size from a few mm to 10-15-20 cm or more. Color from white to pale pink or light red, often accompanied by itching.

bubble- cavity element with a size of 1 to 5 mm. The vesicle is filled with transparent serous or bloody contents, it can shrink and give a transparent or brown-colored crust. If its cover is opened, then erosion is formed - a wetting surface of pink or red color limited by the size of the bubble. In the case of accumulation in the bubble of a large number of leukocytes, it turns into an abscess-pustule. A group of vesicles located on acutely inflamed skin is called herpes.

Bubble- a formation similar to a bubble, but larger than 5 mm (up to 10-15 cm and more).

It is also necessary to pay attention to the presence of pigmented and depigmented areas, peeling, elements of exudative diathesis, milk crusts on the cheeks, gneiss on the scalp and eyebrows, in addition to scratching, prickly heat, scars, etc.

When examining the scalp, pay attention to baldness, especially on the back of the head, sufficiency or thinning of the hairline, local hair loss, stiffness and brittleness, features of hair growth in the sacral-lumbar region, scalloped hair growth on the head, an abundance of vellus and coarser vegetation on the forehead, abundant vegetation on the limbs and back. You should examine the condition of the nails on the hands and feet, pay attention to their shape (watch glasses, brittleness, fungal infections, etc.).

It is necessary to examine additionally visible mucous membranes of the lower eyelid and oral cavity, note the degree of their blood supply and changes in the mucous membranes (pallor, cyanosis, hyperemia). Detailed examination of the oral cavity and pharynx, as an unpleasant procedure for a child early age, should be postponed to the very end of an objective study.

The obtained visual data must be supplemented by palpation. The doctor's hands should be clean, warm and dry. Palpation should be superficial, it should be carried out gently and not cause pain to the child, especially at the site of inflammatory infiltrates, in which there are inevitably unpleasant and often painful sensations. Carefully monitor the child's facial expressions, distract the child's attention from the examination by talking.

With the help of palpation, the thickness and elasticity, moisture, and temperature of the skin are determined.

In order to determine the thickness and elasticity of the skin, it is necessary to capture the skin (without the subcutaneous layer) in a small fold with a large and index fingers right hand, then remove the fingers. If the fold straightens out immediately, as soon as the fingers are taken away, then the skin is considered to be of normal elasticity; if the fold does not straighten out immediately, but gradually, then such skin elasticity is considered reduced. It is easier to capture the skin in a fold where there is little subcutaneous fat layer - on the back of the hand, on the elbow bend. The elasticity of the skin can also be determined on the abdomen and chest. Of particular importance is the determination of skin elasticity in young children.

Humidity is determined by stroking the skin with the doctor's fingers on symmetrical areas of the body: on the chest, torso, in the armpits and groin areas, on the limbs, including the palms and soles, especially in prepubertal children, on the back of the head - in infants. Normally, moderate moisture of the skin is determined by palpation, and in pathology there may be dryness, high humidity and increased sweating.

Feeling determines the temperature of the skin. The skin temperature may be elevated or decreased depending on the general body temperature, but there may be a local increase or decrease in temperature. So, for example, a local increase in temperature is easy to determine in the area of ​​​​inflamed joints, and cold extremities with vasospasm, with damage to the central and peripheral nervous system.

To study the fragility of the skin vessels, it is necessary to apply a rubber bandage or tourniquet on the lower third of the child's shoulder for 2-3 minutes. With increased fragility of the vessels after removing the tourniquet, in place of it, as well as in the elbow and on the forearm, small hemorrhages appear. You can also capture skin fold, better on the front or side of the chest with the thumb and forefinger of the right and left hands and squeeze the fold or make a pinch. If a bruise appears at the pinch site, then the fragility of the vessels is considered increased.

The study of dermographism is carried out by passing from top to bottom with the back of the index finger of the right hand or the handle of the hammer over the skin of the chest and abdomen. After some time, a white (white dermographism) or red (red dermographism) strip appears at the site of mechanical irritation of the skin. Not only the type of dermographism is noted, but also the speed of its appearance and disappearance.

Examination of the subcutaneous fat layer.

Some idea of ​​the quantity and distribution of the subcutaneous fat layer can be obtained from a general examination of the child, however, the final judgment about his condition is made only after palpation.

To assess the subcutaneous fat layer, a somewhat deeper palpation is required than when examining the skin - with the thumb and forefinger of the right hand, not only the skin, but also the subcutaneous tissue is captured in the fold. The thickness of the subcutaneous fat layer should be determined not in one area, but in various places (on the chest - between the nipple and the sternum, on the abdomen - at the level of the navel, on the back - under the shoulder blades, on the limbs - on the outer surface of the thigh and shoulder , on the face - in the cheek area), since in pathological cases the deposition of fat in different places turns out to be unequal. Depending on the thickness of the subcutaneous fat layer, one speaks of normal, excessive and insufficient fat deposition. Attention is drawn to the uniform (throughout the body) or uneven distribution of the subcutaneous fat layer.

During palpation, attention should also be paid to the quality of the subcutaneous fat layer, its consistency. In some cases, the subcutaneous fat layer becomes dense, and the seal may be limited to individual areas - scleroderma. Seal can capture all or almost all of the subcutaneous tissue - sclerema. Along with compaction, swelling of the subcutaneous fat layer can also be observed - sclerema (puffiness differs from compaction in that in the first case, when pressed, a recess is formed, which levels out quite quickly, in the second case, a hole does not form when pressed).

Attention should be paid to the presence of edema and its distribution (on the eyelids, face, limbs, general edema - anasarca or localized). To determine the presence of edema in the lower extremities, it is necessary to press the index finger of the right hand in the shin area above the tibia. If pressure results in an impression that disappears gradually, then this is swelling of the subcutaneous tissue; in the event that the impression disappears immediately, then they speak of mucous edema. In a healthy child, depression does not form. Determination of soft tissue turgor is carried out by squeezing the skin and all soft tissues on the thumb and forefinger of the right hand. inner surface hips and shoulders, with a feeling of resistance or elasticity, called turgor, being perceived. If in young children the turgor of soft tissues is reduced, then when they are squeezed, a feeling of lethargy and flabbiness is determined.

Examination of peripheral lymph nodes.

The study of peripheral lymph nodes is performed using inspection and palpation, and the main method of examination should be considered palpation, which requires a certain skill.

With the index and middle fingers of both hands symmetrically, trying to press the palpable lymph nodes to a more thick fabric(muscular, bone), probe the lymph nodes located in the subcutaneous tissue. Palpation is carried out in the following order: it is advisable to start from the occipital lymph nodes, going further forward and down, feeling behind the ear lymph nodes - on the mastoid process, submandibular - at the angle of the lower jaw, chin - one on each side, anterior cervical - along the anterior edge of the sternum - clavicular-nipple muscles, posterior cervical - behind the sternocleidomastoid muscle, supraclavicular - in the supraclavicular fossae, subclavian - in the subclavian fossae, axillary - in the armpits, ulnar - in the groove of the biceps muscle at the elbow and above, thoracic - at the lower edge pectoralis major muscle, inguinal - in the inguinal regions.

The chin, axillary and elbow lymph nodes are the most difficult to palpate. Mental lymph nodes are felt with light movements of the fingers from back to front near the midline of the chin region. To find the axillary lymph nodes, you need to insert your fingers as deep as possible into the armpit and from there, move your fingers down along the chest. Elbow nodes are palpated as follows: capturing the lower third of the forearm of the opposite arm of the subject with the hand, they bend the child’s arm at the elbow joint and then probe with the index and middle fingers of the other hand with longitudinal sliding movements at the level of the elbow and slightly higher.

If it was possible to probe the lymph nodes, then it is necessary to note the following features: number (many, few, single), size (preferably in mm or cm), consistency (soft, elastic, dense), mobility, relation to neighboring nodes (palpable in isolation or soldered in bags), relation to surrounding tissues, skin and subcutaneous tissue (soldered or not), sensitivity to palpation (painful or not).

It is also necessary to examine the pharyngeal lymphatic ring of Pirogov-Valdeira. To do this, using a spatula, open the child's mouth wide and examine the palatine tonsils located between the arches and the lingual lymph nodes located in the root of the tongue (form the so-called lingual tonsil). Pay attention to the size of the tonsils, the presence of raids.

The nasopharyngeal tonsils are located behind the choanae. Difficulty in nasal breathing can indicate their growth (adenoids) - the child snores at night, speech becomes nasal, hearing decreases. Characteristically adenoid face: languid expression, thick lips, open mouth. Nasopharyngeal tonsils are available for examination with a cleft palate, in other cases, if their enlargement is suspected, an additional examination is applied by palpation with the index finger (usually by an ENT doctor).

Study of the muscular system.

When examining the muscular system, it is necessary to note the degree of development or mass of muscles, their tone, strength, volume and nature of movements.

Muscle tone is determined by passive flexion and extension of the upper and lower extremities. According to the degree of resistance that occurs during passive movements, as well as the consistency of muscle tissue, determined by touch, the muscle tone is judged. Normally, the mass and tone of muscles in symmetrical areas should be the same. It is possible to increase (hypertension) and decrease (hypotension) tone.

Muscle strength in older children is examined using a dynamometer. In children younger age muscle strength is determined only approximately, by the subjective feeling of the necessary resistance to one or another movement of the child.

Study of the osteoarticular system.

Objective research skeletal system performed by inspection, palpation, measurement and, if necessary, radiography.

The skeletal system is examined sequentially in the following order: first the head (skull), then the trunk (ore cell and spine), upper and lower limbs.

Inspection of the head determines its size and shape. However, a more accurate idea of ​​​​the size of the head is given by measuring with a centimeter tape (see somatometric research technique), pay attention to whether the size of the head is increased (macrocephaly) or, conversely, reduced (microcephaly).

On examination, pay attention to the shape of the skull. Normally, the shape of the skull is rounded, and in case of pathology it can be square, tower, etc.

Palpation examines fontanelles, sutures, as well as the density of the bones themselves. Feeling is done with both hands, putting the thumbs on the forehead, palms on the temporal regions, the middle and index fingers examine the parietal bones, the occipital region, sutures, fontanelles. Pay attention to whether there is a softening of the bones, especially in the neck (craniotabes), bone defects, less often a significant hardening of the bones of the skull.

When palpating a large fontanel, it is necessary, first of all, to determine the size of the fontanel. The distance is measured between two opposite sides of the fontanel, not diagonally (it is difficult to decide where the suture ends and the fontanel begins). The edges of the fontanel are carefully felt, attention is drawn to whether they are soft, pliable, serrated, late or early closing, protrusion or retraction. You should feel and evaluate the condition of the seams: is there any compliance or divergence.

When examining the chest, pay attention to its shape. Normally, in a newborn, the chest has a funnel-shaped shape, and with age it flattens somewhat and by school age takes the final shape - a truncated cone. Pay attention to the presence of a "chicken" breast, Harrison's groove (retraction at the site of attachment of the diaphragm), a heart hump, a "shoemaker's" chest, a funnel-shaped chest. On palpation, it is noted whether there is a thickening at the border of the bone and cartilaginous parts of the ribs (a consequence of excessive formation of osteoid tissue) - rachitic rosary.

When examining the spine, you should pay attention to whether there is a curvature to the side (scoliosis), forward (lordosis), back (kyphosis). In the case of scoliosis, when examining a child from the front, one can notice that one shoulder is higher than the other and one arm is closer to the body than the other.

When examining the upper limbs, attention is paid to the presence of shortening of the humerus, thickening in the area of ​​the epiphyses of the radius (bracelets) and diaphyses of the phalanges (strings of pearls). When examining the lower extremities, attention should be paid to whether there is shortening of the hips, X-shaped or O-shaped curvature of the limbs, flat feet.

Joints should be carefully examined by inspection, palpation and measurement. It is necessary to determine the shape of the joint, determine whether there are deformations, check the range of motion, mobility and pain in the joints. Feeling reveals the skin temperature in the joints. The size of the joint is determined by a centimeter tape (the circumferences of both joints are measured at the same level).

Assessment methodology physical development .

Assessment of physical development is especially important in childhood. To assess physical development, in addition to measuring length and weight, it is necessary to determine the circumferences of the head, chest, body proportions and calculate a number of indices. Comparison of the data obtained with standard values ​​for a given age or the results of empirical formulas allows an objective assessment of the physical development of a given child. An objective assessment of physical development in older children is impossible without assessing the degree of sexual development.

Measuring the length of children up to a year.

The measurement is carried out with a special stadiometer in the form of a wide board 80 cm long and 40 cm wide. On one side of the board there is a centimeter scale, at its beginning there is a fixed bar, at the end of the scale there is a movable transverse bar, easily moving along the scale. The order of measurement: the child is measured in a supine position - it fits in such a way that the head tightly touches the top of the head to the transverse fixed bar of the stadiometer. The head is set in a position in which the lower edge of the orbit and the upper edge of the ear tragus are in the same vertical plane. The assistant or mother firmly fixes the head. The child's legs should be straightened by lightly pressing the child's knees with the left hand, with the right hand bring the movable bar of the height meter tightly to the heels, bending the foot to a right angle. The distance between the movable and fixed bars will correspond to the length of the child.

Length measurement for older children.

The measurement is made in a standing position by a stadiometer, which is a wooden board 2 m 10 cm long, 8-10 cm wide and 5-7 cm thick, installed vertically on a wooden platform 75 * 50 cm in size. 2 division scales in cm are applied on the vertical scale ; one (right) - for standing length, the other (left) - sitting. A planchette 20 cm long slides along it. At a level of 40 cm from the floor, a folding bench is attached to a vertical board to measure the length of a sitting.

Measurement procedure: the child is placed on the platform of the height meter with his back to the vertical stand in a natural, straightened position, touching the vertical stand with his heels, buttocks, interscapular region, arms lowered, head is set in a position in which the lower edge of the orbit and the upper edge of the ear tragus are in the same horizontal planes. The movable bar is applied to the head without pressure. The measurement of young children (from 1 to 3 years old) is carried out with the same height meter, only a folding bench is used instead of the lower platform and the reading is carried out on a scale on the left. The installation of the head and body is the same as when measuring older children.

At the same time, when measuring the length, the height of the child's head is determined (the distance between the top of the head and the most prominent part of the chin) and the relationship between head height and height is checked. It is judged if it is age appropriate. The midpoint of the body is found, for this the length is divided in half and a line is drawn at the level of the half-length figure.

For citation: Komarova O.N., Khavkin A.I. Algorithm for the examination and treatment of young children with constipation // RMJ. 2016. №6. pp. 358-360

The article presents an algorithm for the examination and treatment of young children with constipation

For citation. Komarova O.N., Khavkin A.I. Algorithm for the examination and treatment of young children with constipation // RMJ. 2016. No. 6. S. 358–360.

According to statistics, in children's gastroenterological practice, constipation is the most common cause visits to a doctor and ranges from 25 to 40% of all cases, while about half of the observed patients are young children. Children most commonly affected by constipation are artificial feeding.
How to diagnose constipation? Most often, parents go to the doctor with complaints for infrequent and/or painful and/or difficult bowel movements in children. Indeed, the diagnosis of "constipation" in the first year of a child's life is completely clinical and is established on the basis of an anamnesis and complaints from the patient's parents. The main criteria for the diagnosis of constipation are rare, painful, difficult defecation or incomplete bowel movements occurring within 2 weeks. and more, which are significant reasons health disorders of the child.
Initially, we will determine the "norms" of stool frequency. In infants who are exclusively breastfeeding, the frequency of stools can vary from what we are used to - after each feeding - up to once every 3-4 weeks. Infrequent bowel movements (oligofecalia) in newborns are associated with more complete absorption of food. This condition is interpreted as "pseudo-constipation". At the same time, the nature of the stool has a mushy or liquid consistency, and only in 1.1% of cases is a dense stool observed. Most authors believe that in this situation, in the absence of regurgitation, vomiting, abdominal wall tension or other gastrointestinal symptoms, with normal increase child in weight, correction is not required. As a rule, the frequency of emptying increases with the introduction of complementary foods. But our opinion: it is necessary to carry out corrective measures in order to achieve a bowel movement at least once every 2-3 days. The frequency of stool in a child on artificial feeding should be at least 1 time per day, and with the introduction of complementary foods at 4-6 months. frequency of 1-2 times a day is considered normal. Decreased bowel movements are treated as constipation.
In identifying the causes of constipation, correctly assembled anamnesis. In a conversation with parents, it is necessary to find out when constipation began and what events preceded this. For example, constipation due to dehydration stool characteristic of acute febrile conditions on the background of febrile temperature and severe sweating, as well as after suffering intestinal infection such as dysentery. When appointed drug therapy drugs such as antispasmodics, M-anticholinergics, calcium channel blockers, muscle relaxants, anticonvulsants, iron preparations, there is a decrease in stool frequency.
Common cause of constipation in babies- undernutrition. Insufficient milk intake is more common in breastfeeding. Lack of nutrition can be associated, firstly, with hypogalactia in the mother, and secondly, for example, in children with anomalies of the facial skeleton, with defects in the oral cavity, or with the general weakness of the child. Also, the cause of underfeeding is persistent regurgitation and vomiting. In addition, constipation is also often noted in children with infantile anorexia or nutritional underdevelopment. The formation of these conditions is based on violations of the “mother-child” relationship, when mothers take little interest in their children, do not monitor their receipt of the required amount of nutrition during feeding. Malnutrition can be diagnosed in a child by scanty, viscous consistency and dark-colored stools, as well as by oliguria and malnutrition, which develop due to insufficient fluid intake and nutrients. In such a situation, it is important to evaluate general state child, the degree of dehydration and malnutrition and make a correction.
Constipation is observed in children with a change in nutrition: when transferring from breastfeeding to artificial feeding, as well as with the introduction of complementary foods. Constipation leads to inadequate, excessive intake of calcium salts with food, for example, with cottage cheese, consumed in larger quantities than recommended. Calcium soaps formed in the intestines are not absorbed and cause hard stools. A similar situation is also noted with an excess of vitamin D.
It is important to clarify the presence of a concomitant disease for constipation for correct and timely correction. Thus, constipation often occurs in patients with food allergies. In particular, the relationship between allergy to proteins cow's milk with constipation. Constipation develops due to the occurrence of local areas of spasm and edema in the intestine as a result of the production of inflammatory mediators under the influence of an allergen. In 10% of children, lactase deficiency occurs with constipation due to intestinal spasm caused by the acidic pH of the contents of the colon.
The cause of constipation can be muscular hypotension - a symptom of various diseases diagnosed in early childhood, primarily rickets or hypothyroidism, less often L-carnitine deficiency. The main symptoms of L-carnitine deficiency, in addition to muscle hypotension and constipation, are regurgitation, delayed physical development.
In the presence of a persistent progressive nature of constipation and the absence of independent defecation, with an increase in the abdomen, palpable fecal stones lagging behind the pace of physical development, it is necessary to exclude organic pathology:
congenital anomalies colon (eg, Hirschsprung's disease, dolichocolon, dolichosigma, duplication of the colon, megacolon, mobile caecum, mobile sigma, splanchnoptosis);
congenital anomalies of the rectum and anus (fistulous forms of anus atresia, congenital strictures of the anus and rectum);
neuromuscular disorders (hypoganglionosis, inflammatory neuropathy and degenerative leiomyopathy);
mechanical obstruction in the intestine (inflammatory adhesions, tumors, enlarged lymph nodes).
When analyzing complaints, it is important to clarify how long after birth the discharge of meconium was observed. Delayed passage of meconium more than 48 hours after birth may indicate Hirschsprung disease or cystic fibrosis. To confirm Hirschsprung's disease, it is sufficient to perform irrigography in frontal and lateral projections. The pictures usually clearly show a zone of persistent narrowing in the distal colon (aganglionosis zone) with expansion and impaired emptying of its more proximal sections. In addition, the diagnosis is confirmed after studying a transmural biopsy taken operatively from the intestine. The absence of nerve ganglia in the biopsy, as well as a high level of acetylcholinesterase, confirms the diagnosis of Hirschsprung's disease, which requires surgical treatment.
It is important to note that in 90–95% of cases, there is no organic cause of constipation in a child. The most common constipation is functional in nature, which is formed in young children due to the immaturity of the central and peripheral neuroregulation, leading to impaired motor and secretory functions. gastrointestinal tract(GIT). The immaturity of neuromuscular transmission is due to weak myelination of nerve trunks and insufficiency of mediators in interneuronal and neuromuscular synapses.
For a more informed diagnosis, one should rely on the Rome III criteria, according to which constipation can be a manifestation the following types functional disorders: difficulty defecation in newborns (dyschesia - G6) and functional constipation in children from birth to 4 years (G7).
In the presence of difficult defecation, accompanied by strong straining, groaning and crying, infantile dyschezia should be suspected, the formation of which is based on the immaturity of the pathways of the lumbosacral nerve plexus, as well as the inability of the child to coordinately strain the abdominal muscles and at the same time relax the muscles pelvic floor. The process of defecation gives the child anxiety, while the stool has a soft character, after defecation, the child, as a rule, calms down. Dyschezia is noted from the 1st to the 10th week of a child's life.
Quite often, in the practice of a pediatrician, there are situations when the stool frequency corresponds to the norm, but the stool is dense, fragmented, in a meager amount, parents describe it as "sheep's" feces. These are signs of incomplete emptying of the bowels and, accordingly, constipation.
The presence of blood on the surface of the feces indicates irritation of the intestine or an anal fissure in a child, which, as a rule, is a consequence of injury to the intestinal mucosa with dense feces.
Thus, when collecting complaints and anamnesis, it is necessary to find out the frequency and nature of bowel movements, the duration of constipation, the method of feeding, allergic anamnesis, and collect information about comorbidities and medications taken.
At examination the child should evaluate the weight and height indicators, the position of the anus, the anal reflex, pay attention to the increase in the abdomen, the identification of feces in the intestine during palpation, and conduct a digital rectal examination. The presence of pigmentation, hair growth in the lumbosacral region, depression in the sacral spine, anus dystopia, anomalies of the gluteal cleft, the absence of an anal reflex indicate the need to exclude the organic cause of constipation.
Additional Research conducted to determine the cause of constipation. Clinical analysis of blood, urine, coprogram, fecal analysis for eggs of worms, ultrasound of organs are performed abdominal cavity. According to the indications, a survey radiography of the gastrointestinal tract, irrigoscopy, radiography and / or MRI examination of the lumbosacral spine (clarification of malformations of the spinal cord), sigmoidoscopy, colonoscopy, allergy examination, hormonal profile study (hormones thyroid gland), electroencephalography, a study to exclude disaccharidase deficiency, celiac disease (suspicion arises only when the child receives gluten-containing foods). If necessary, consultations of specialist doctors are carried out: a neurologist, an endocrinologist, a surgeon, a geneticist.
It should be noted that the accumulated clinical experience usually allows only with a well-collected history and a thorough examination of the child to exclude the organic cause of constipation. There is no need to conduct a complex set of examinations and laboratory research before starting treatment. Only in cases with anxiety clinical symptoms or in the absence of improvement against the background of ongoing conventional therapy, further studies are indicated.
anxiety symptoms requiring clarification of the surgical, infectious pathology, inflammatory bowel diseases, are: unmotivated weight loss, fever, vomiting of bile, the appearance of blood in the stool (in the absence of anal fissures), muscle tension of the anterior abdominal wall and pain on palpation, changes in clinical analysis blood (anemia, leukocytosis, increased ESR) and biochemical analysis blood.
aim treatment constipation in children is the restoration of the normal consistency of the intestinal contents and its passage through the colon.
Used to correct constipation A complex approach with diet therapy, if necessary - drug therapy and mechanical bowel movements. When identifying concomitant disease its correct correction is important, which will help resolve constipation (for example, in the presence of rickets, an adequate dose of vitamin D is selected, etc.).
The main way to correct constipation in early childhood is diet therapy. Main and important rule- keep breastfeeding as long as possible. In children who are breastfed, the composition should be adjusted mother's milk, which in many cases is achieved by optimizing the mother's diet. In particular, it is known that the fat composition breast milk and mother's diet are identical. Therefore, it is advisable to include in the diet of mothers vegetable oils that stimulate motor activity intestines, as well as foods high in dietary fiber (vegetables, fruits, cereals, wholemeal bread, etc.).
If a breastfed child is allergic to cow's milk proteins, the nursing mother is prescribed a hypoallergenic diet with the exclusion of milk and dairy products, and a formula-fed child is given specialized semi-elemental or elemental mixtures (based on a complete hydrolyzate of protein and amino acids, respectively).
For a formula-fed child, the mixture is selected individually, since it is important to assess the clinical symptoms in the aggregate. So, for example, with a combination of constipation and regurgitation, it is recommended to prescribe mixtures containing gluten from carob beans, which increase the viscosity of mixtures and have an antireflux and laxative effect.
In patients with constipation, mixtures containing a modified fat component have proven themselves well: supplemented with beta-palmitate or not containing palm oil as the main source of fat in a mixture of oils. It is known that approximately 70% of palmitic acid in breast milk is associated with the central carbon atom in the glycerol molecule, i.e., it is in the sn-2 position, while in standard mixtures palmitic acid is located mainly in the edge positions - sn-1 and sn- 3 . Differences in the position of palmitic acid in the triglyceride molecule in breast milk and vegetable oils is a major factor in the differences in digestion and absorption of certain ingredients in breast milk and infant formula. The ester bonds connecting palmitic acid to the backbone of the glycerol molecule in the marginal positions are easily hydrolyzed by pancreatic lipase in the intestine. The released palmitic acid forms insoluble complexes with calcium in infant formula - calcium soaps that are not absorbed in the intestines, but are excreted with the stool, changing its characteristics: the stool becomes more dense and bowel emptying occurs at a lower frequency. In addition, along with insoluble calcium soaps, the body loses calcium and an important energy donor - palmitic acid. The exact opposite is the situation when palmitic acid is connected to glycerol in the middle position. Fatty acids with no affinity for calcium are released from the lateral positions of the triglyceride, and palmitic acid in the form of monoglyceride is well absorbed.
Thus, altering the fat component of formulas, such as omitting the combination of palm oil, the source of palmitic acid at the sn-1 and sn-3 positions, or adding palmitic acid at the sn-2 position, may improve stool characteristics to softer and frequent, increase calcium retention and preserve the energy component of the mixture. This has been clinically supported, for example, in a meta-analysis of 13 studies comparing fat and calcium absorption, stool calcium excretion, and intestinal dyspepsia of three types of infant formula: palm oil based, beta palmitate based, and palm oil free.
It was confirmed that the absorption of these nutrients is higher (p<0,01), экскреция кальция со стулом ниже (p<0,01), а минеральная плотность костей (BMD) и содержание минеральных веществ в костной ткани (BMC – bone mineral content) выше у младенцев, получавших смеси с высокой долей бета-пальмитата и смеси без пальмового масла, нежели у младенцев, получавших смеси на основе пальмового масла. При этом стул был значимо мягче, а частота его выше при вскармливании смесями с бета-пальмитатом и смесями без пальмового масла (p < 0,01) .
For patients with colic and constipation, it is advisable to prescribe mixtures based on partial protein hydrolyzate (“Comfort” mixtures), in which, as a rule, the amount of lactose is reduced, and the fatty component does not contain palm oil. The effectiveness of mixtures based on partially hydrolyzed protein in constipation has been evaluated in clinical studies.
A recent study in 209 healthy full-term infants aged 0-8 days (4 months nursing) aimed to compare infant growth rates fed with two partial whey protein hydrolysate formulas with and without palm oil, and to compare gastrointestinal tolerance of these mixtures. The results obtained show the normative growth rates when fed with both mixtures. Differences were noted in stool density, which was significantly less in the group of infants who received formula without palm oil (Similac Comfort).
Another randomized, controlled, double-blind study conducted by M. W. Borschel's group was to evaluate gastrointestinal tolerance and bone mineralization in 89 healthy term infants treated with one of two whey partial hydrolysate formulas differing in fat composition. To determine the mineralization of bone tissue, children underwent dual-energy x-ray absorptiometry. Growth and weight gain and growth rates did not differ between the test formula and control formula groups. Throughout the study, stool firmness was statistically significantly softer in the group of infants who received formula without palm oil. By the 84th day of the study, the BMC was significantly higher in the group of children who received the formula without palm oil (Similak Comfort).
Thus, the results of the conducted studies show an improvement in the characteristics of the stool in children with the use of mixtures based on partially hydrolyzed protein without palm oil. These results are consistent with those of Y. Vandenplas et al.: Whey protein hydrolyzate formulas enriched with prebiotics and/or probiotics, and containing beta-palmitate in the fat composition or not containing palm oil, have a beneficial effect on functional constipation.
In the absence or insufficient effect of diet therapy for a child with constipation, drug correction is recommended. It is very important before the start of the main therapy, if there are feces in the intestine, to free the intestines from them with the help of cleansing enemas or suppositories with glycerin. In the treatment of dyschezia, as well as with incomplete emptying of the rectum, local stimulation of the anus with microclysters with water / glycerin or suppositories with glycerin is effective.
In the case of a dense stool, oral use of osmotic laxatives is possible: lactulose solution (from birth), polyethylene glycol (from 6 months). It is important to note that lactulose not only promotes softening of feces and emptying the intestines, but also has the properties of a prebiotic, being a substrate for bifidobacteria and lactobacilli, which, metabolizing lactulose, produce short-chain fatty acids (acetic, propionic, butyric, etc.).
As additional means in the treatment of constipation, motility regulators can be considered - drugs that have a prokinetic or antispasmodic effect. The use of mineral oils to soften stools in young children is dangerous due to the risk of developing aspiration pneumonia.
Drug correction is indicated for patients with constipation that accompanies the underlying pathology, and treatment in this situation is carried out jointly by a gastroenterologist and doctors of other specialties.

Literature

1. Khavkin A.I. Correction of functional constipation in children // Ros. Bulletin of Perinatology and Pediatrics. 2012. Vol. 4 (1). pp. 127–130.
2. North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Evaluation and treatment of constipation in children: summary of updated recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition // J Pediatr Gastroenterol Nutr. Sep 2006. Vol. 43(3). R. 405–407.
3. Tunc V.T., Camurdan A.D., Ilhan M.N., Sahin F., Beyazova U. Factors associated with defecation patterns in 0–24-month-old children // Eur J Pediatr. 2008 Vol. 167. R. 1357-1362.
4. El-Hodhod M.A., Younis N.T., Zaitoun Y.A., Daoud S.D. Cow "s milk allergy related pediatric constipation: appropriate time of milk tolerance // Pediatr Allergy Immunol. Mar 2010. Vol. 21 (2 Pt 2). E407-412.
5. Weaver L.T., Steiner H. The bowel habit of young children // Arch Dis Child. 1984 Vol. 59. R. 649–652.
6. Khavkin A.I., Belmer S.V., Gorelov A.V., Zvyagin A.A. Diagnosis and treatment of functional constipation in children // Questions of children's dietology. 2013. V. 11. No. 16. S. 51–58.
7. Lyonyushkin A.I., Komissarov I.A. Pediatric coloproctology. Guide for doctors. St. Petersburg: SPbGPMA, 2008, pp. 279–313.
8. Hyman P.E., Milla P.J., Benninga M.A. et al. Childhood Functional Gastrointestinal Disorders: neonate/toddler // Gastroenterology. 2006 Vol. 130(5). R. 1519–1526.
9. National program for optimizing the feeding of children in the first year of life. Approved at the XVI Congress of Pediatricians of Russia (February 2009). M., 2010. 68 p.
10. Nelson S.E., Frantz J.A., Ziegler E.E. Absorption of fat and calcium by infants fed a milk-based formula containing palm olein // J Am Coll Nutr. 1998 Vol. 17 (4). R. 327–332.
11. Yu Z., Han S., Zhu C., Sun Q., Guo X. Effects of infant formula containing palm oil on the nutrient absorption and defecation in infants: a meta-analysis // Zhonghua Er Ke Za Zhi. 2009 Vol. 47(12). R. 904–910.
12. Hyman P.E., Milla P.J., Benninga M.A. et al. Childhood functional gastrointestinal disorders: neonate/toddler // Gastroenterology. 2006 Vol. 130. R. 1519-1526.
13. Borschel M.W., Choe Y.S., Kajzer J.A. Growth of Healthy Term Infants Fed Partially Hydrolyzed Whey-Based Infant Formula: A Randomized, Blinded, Controlled Trial // Clin Pediatr published online. Julу 2014. Vol. 8.
14. Borschel M.W., Groh-Wargo S., Brabec B. et al. Tolerance, Bone Mineral Content, and Serum Vitamin D Concentration of Term Infants Fed Partially Hydrolyzed Whey-based Infant Formula // The Open Nutrition J. 2012. Vol. 6. 71–79.
15. Vandenplas Y., Cruchet S., Faure C. et al. When should we use partially hydrolysed formulae for frequent gastrointestinal symptoms and allergy prevention? // Acta Pediatrica. July 2014. Vol. 103 (Issue 7). R. 689–695.

The presented technique involves the examination of the child along the main lines of development: social, physical, cognitive.

The purpose of the psychological and pedagogical examination is to identify the individual level of formation of the main lines of development of the child of the third year of life. The survey is aimed at identifying the current level of development of the child (independent performance of tasks) and the zone of its proximal development (the child's ability to complete tasks with the help of an adult).

The main method of study in the course of an individual examination is the observation of children in the course of their activities.

Social development. The study of social development includes establishing the nature of the interaction and communication of the child with adults; determination of the level of formation of self-service skills; features of behavior and emotional-volitional sphere. Social development is determined in the course of a conversation with the child's parents.

Child's means of communication: expressive-mimic (smile, look, gestures, etc.); subject-effective (stretching various objects to an adult, expressing protest, etc.); speech means of communication (statements, questions).

Characteristics of contacts between a child and an adult: establishes contact easily and quickly; selective contact; formal contact; does not make contact.

Features of behavior and emotional-volitional sphere: active (passive); active (inert); not aggressive (aggressive) towards other children; prevailing mood (cheerful, calm, irritable, unstable, sharp mood swings).

Features of the character of the child: calm, passive, cheerful, smiling, irritable, angry, stubborn, lethargic, often (rarely) crying, conflict, etc.

Skills in life (to be specified in conversation with parents): eats independently with a spoon; eats with someone's help; feeds an adult; sucks a bottle; drinks independently from a cup; drinks with someone's help; watered by an adult; dresses independently; a little help from an adult is required; dressed by an adult; the skill of neatness is formed (he uses the toilet on his own); the skill of neatness is not formed (does not ask to use the toilet in a timely manner).

To understand whether the baby is able to establish contact with a new adult and cooperate with him, he is offered the task “Catch the ball” (you will need a groove and a ball).

Conducting a survey: the teacher puts the ball on the groove and asks the child: “Catch the ball!” Then the adult turns the groove and asks the baby to roll the ball along the groove: “Roll the ball!” Roll the ball four times.

Teaching a child to act: if the child does not catch the ball, the adult shows him two or three times how to do it.

Evaluation of the child's actions: ready to complete the task; understands verbal instructions; wants to cooperate (play) with an adult; how it relates to the game; result.

If the child does not cope with the task "Catch the ball", he is offered an easier task, intended for children of the second year of life, "Bring the ball".

Conducting a survey: an adult rolls the ball across the carpet past the child and asks: "Bring the ball." The game is repeated two or three times.

Education: if the child does not go for the ball, the adult takes the ball himself and gives it to the child. After the child has held the ball in his hands, the adult asks to roll the ball: "Roll the ball."

Evaluation of the child's actions: ready to complete the task; understands verbal instructions; how it relates to cooperation (accepts the game or refuses to play).

Physical development. In order to study the level of formation of the main movements, sets of exercises for children 2-3 years old are offered, as well as special series of tasks for young children (1.5 - 2 years old). Each series consists of 5 exercises of varying difficulty.

In the process of examining physical development, the level of formation of such basic movements of the child as walking, running, jumping, etc. is determined.

Due to the fact that many children entering the short stay group do not speak or speak insufficiently, all tasks are given to the child in verbal and non-verbal form: during the examination, the teacher should use natural gestures.

When starting the examination, it is important to remember that the child can be stubborn, negativistic, refuse the proposed tasks. Therefore, the methodology provides for the use of various ways to encourage the child to fulfill them. If the child begins to interact with an adult, but refuses to perform any specific task, do not force him.

If the baby does not want to act, another pedagogical technique should be used: you need to complete the task together with a peer from the group. The teacher invites a peer and invites the children to complete the task in turn. In such a situation, as a rule, they attract an active child who can quickly establish contact with others.

It should be emphasized that the specialist starts the examination only when a friendly, trusting relationship is established between him and the baby.

If the child easily comes into contact with an adult and willingly focuses on the task, but cannot complete it on his own or does it incorrectly, training is carried out. The methodology provides for the use of fixed types of assistance - display, imitation, joint actions. After helping the baby is always given the opportunity to complete the task on their own.

In the process of examining physical development, attention is drawn to the contact of the child (the desire to cooperate with an adult), his activity. There is an emotional response to encouragement or comments, the ability to detect the fallacy of one's own actions, and interest in the result of the activity.

For the examination you need: a log, three skittles, two ropes, a cord, a hoop, a box 10 cm high; long stick; a board raised at one end above the floor by 15-20 cm.

Exercises for kids 2 -2.5 years:

• 1. Walking in a given direction.
• 2. Running after an adult in a given direction.
• 3. Climbing over a log.
• 4. Jumping in place on two legs.
• 5. Walking on a cord laid straight.

Exercises for children 2.5-3 years old:

• 1. Walking with obstacles.
• 2. Crawling on all fours.
• 3. Jumping over a rope placed on the floor.
• 4. Running between two lines (you can't step on the lines).
• 5. Walking on a cord laid in a zigzag.

Additional exercises

Exercises for children 1.5 -2 years old, and

for children 2 -2.5 years old who failed tasks corresponding to their age:

• 1. Walking in a straight line.
• 2. Crawling through a hoop.
• 3. Climbing with the help of an adult onto a 10 cm high box turned upside down.
• 4. Stepping over a stick, a rope laid on the floor.
• 5. Walking on the board, one end raised 15-20 cm above the floor, and descending from it.

Evaluation of the child's actions: ready to perform the task, performs tasks with the help of an adult (showing, imitation, joint actions), the ability to complete the task after training, the result.

cognitive development. Psychological and pedagogical examination of cognitive development involves identifying the level of sensory development: practical orientation to the form, size, color; perception of a subject image, a holistic perception of a subject picture; development of visual thinking. An important direction in the examination of the child is the study of the level of development in the child of objective actions - correlative and instrumental, as well as the prerequisites for designing and drawing.

Children are offered tasks taking into account their age: one series of tasks is designed for children from two years to two years and six months, the other - for children from two years and six months to three years (Table 1).

Let us consider in detail the methodology for examining the cognitive development of children.

Insert the figures into the grooves (Seguin's board).

The task is aimed at identifying the level of formation of the child's orientation to the form. Normally, the child acts by trial method.

Equipment: a wooden (or plastic) board with three slots - round, triangular, square or with six slots - round, square, rectangular, semicircular, triangular and hexagonal, with six flat geometric shapes, the bases of each of which correspond to the shape of one of the slots.

Conducting a survey: the teacher shows the child a board, draws his attention to the figures and takes them out in turn. Then he invites the child to insert these figures into the slots: "Insert all the figures into your slots."

Education: is carried out if the child does not understand what needs to be done, tries to insert the figure with the help of force, i.e. does not take into account the shape of the slot. The teacher shows slowly how to insert the figures into the slots, using the trial method: “Here is the figure. We will try to insert it into this slot. She doesn't fit here. Let's try another one. This is where it fits." After the explanation, the child is given the opportunity to act independently. If he fails, we must work with him. Then he is again given the opportunity to complete the task on his own.

Table 1

Tasks aimed at cognitive development

Evaluation of the child's actions: ready to complete the task, understands the verbal instruction, acts purposefully, performs tasks independently or after training; the method of completing the task - the trial method, chaotic actions, joint actions with an adult; what is the learning ability during the diagnostic examination; result.

Hide the ball in the box. The task is aimed at identifying the child's orientation to the value, the presence of correlative actions. Normally, the child acts by trial method.

Equipment: 2 (3) square-shaped boxes of different sizes of the same color with corresponding lids; 2 (3) balls, different in size, but the same in color.

Conducting a survey: 2 (3) boxes, different in size, and covers for them, located at some distance from the boxes, are placed in front of the child. The teacher puts a large ball in a large box, and a small ball in a small box and asks the child to cover the boxes with lids, hide the balls. At the same time, the child is not explained which cover to take. The task is for the child to guess which lid to close the corresponding box.

Education: if the child chooses the lids incorrectly, the adult shows and explains: we close the large box with a large lid, and a small box with a small lid. After training, the child is asked to complete the task on their own.

Evaluation of the child's actions: ready to perform the task, understands the verbal instruction; methods of execution - the method of trials, the presence of correlative actions, chaotic actions, joint actions with an adult; what is the learning ability during the diagnostic examination; result.

Disassemble and assemble the pyramid. The task is aimed at identifying the level of development of the child's practical orientation to the value, the presence of correlative actions, the definition of the leading hand, the consistency of the actions of both hands, the purposefulness of actions.

Equipment: pyramid of 3 (4) rings.

Conducting a survey: the teacher offers the child to disassemble the pyramid. If the child does not start the task, the adult dismantles the pyramid himself and invites the child to assemble it.

Education: if the child does not start the task, the adult begins to give him rings one at a time, each time showing with a gesture that the rings need to be put on the rod, then he offers to complete the task on his own.

Evaluation of the child's actions: ready to complete the task, takes into account the size of the rings; learning, attitude to activity, result.

Pick up paired pictures. The task is aimed at identifying the level of development of the child's visual perception of subject pictures, understanding the gesture instructions.

Equipment: two (four) pairs of subject pictures.

Conducting a survey: two subject pictures are placed in front of the child. Exactly the same pair of pictures is in the hands of an adult. The psychologist shows with a pointing gesture that he and the child have the same pictures. Then the adult closes his pictures, takes out one of them and, showing it to the child, asks to show the same one.

Education: if the child does not complete the task, then they show him how to correlate paired pictures: “I have the same one as yours”, while the teacher uses a pointing gesture.

Evaluation of the child's actions: ready to complete the task, makes a choice, understands the gestures of the teacher; learning, attitude to their work.

Pick up colored cubes. The task is aimed at highlighting color as a sign, at distinguishing and naming colors.

Equipment: colored cubes - 2 red, 2 yellow (2 white), 2 green, 2 blue (four colors).

Conducting a survey: 2 (4) colored cubes are placed in front of the child and asked to show the same one as in the adult’s hand: “Take the same cube as mine.” Then the teacher asks to show: “Show me where

Education: if the child does not distinguish colors, then the teacher teaches him. In those cases when a child distinguishes colors, but does not distinguish them by name, he is taught to distinguish two colors by name, while repeating the name of the color two or three times. After training, the independent performance of the task is again checked.

Evaluation of the child's actions: ready to complete the task, does the child compare colors, recognizes them by name, does he know the name of the color; the teacher fixes the verbal accompaniment of actions; attitude towards their activities; result.

Fold the cut picture. The task is aimed at identifying the level of development of a holistic perception of a subject image.

Equipment: subject pictures (2 identical), one of which is cut into two (three) parts.

Conducting a survey: the teacher shows the child two (three) parts of the cut picture and asks to fold the whole picture: "Make the whole picture."

Education: in those cases when the child cannot correctly connect the parts of the picture, the adult shows the whole picture and asks to make the same from the parts. If after that the child does not cope with the task, the adult himself superimposes one part of the split picture on the whole and asks the child to add another. Then he invites the child to complete the task on their own.

Evaluation of the child's actions: ready to complete the task, in what way it performs - on its own, after training; relation to the result; result.

Get the trolley (sliding ribbon). The task is aimed at identifying the level of development of visual-effective thinking, the ability to use an auxiliary tool (ribbon).

Equipment: for a child aged 2 years to 2 years 6 months. - a cart with a ring, a ribbon through the prose ring; for a child aged 2 years 6 months. up to 3 years - next to the sliding ribbon - false.

Conducting a survey: in front of the child at the other end of the table is a cart that he cannot reach with his hand. In the reach of his hand are two ends of the ribbon, which are separated by 50 cm. The child is asked to get the cart. If the child pulls on only one end of the string, the cart stays in place. The task is for the child to guess to pull the trolley by both ends of the ribbon (connect both ends, or pull both ends of the ribbon with both hands).

Education: the child himself, by trial and error, completes the task.

Evaluation of the child's actions: if the child pulls at both ends, then a high level of performance is noted. If the child pulls first at one end of the ribbon, then he should be given the opportunity to try again, but this is already a lower level of performance. An adult behind the screen threads the ribbon through the ring and, having removed the screen, offers the child to get the cart. If the child does not guess to use the ribbon, then this is assessed as a failure to complete the task; the attitude of the child to the result is also recorded, the result itself is evaluated.

Build with sticks("hammer" or "house"). The task is aimed at identifying the level of development of a holistic perception, the child's ability to act by imitation, display.

Equipment: four or six flat sticks of the same color.

Conducting a survey: in front of the child, they build a “hammer” or “house” figure from sticks and ask him to do the same: “Build the same hammer.”

Education: if the child cannot complete the display task, he is asked to complete the imitation task: “Look and do as I do.” After training, the child is again offered to build a "hammer".

Evaluation of the child's actions: ready to complete the task, the nature of the action is noted - by imitation, display; learning ability, attitude to the result is assessed; result.

draw(path or house). The task is aimed at understanding the speech instruction, identifying the child's readiness to create a subject drawing, as well as determining the leading hand, the consistency of the actions of the hands, attitudes towards the result, the result.

Equipment: pencil, paper.

Conducting a survey: the child is given a sheet of paper, a pencil and asked to draw: "Draw a path (house)."

Training is not provided.

Evaluation of the child's actions: Does the child understand verbal instructions? whether he performs specific actions with a pencil; drawing analysis - scribbling, deliberate scribbling, subject drawing; attitude towards drawing; result.

The development of speech. Speech examination includes the study of the child's understanding of oral speech addressed to him and the determination of the state of his active speech. For these purposes, first of all, observations are made of children during the entire survey. Special assignments are also offered.

In the course of an individual examination, it is found out how many words denoting objects and actions the child knows, that is, vocabulary, the level of formed ™ phonemic hearing, the ability to follow verbal instructions of varying complexity.

Show picture. The task is aimed at studying the child's vocabulary (nouns, verbs).

Equipment: pictures depicting objects well known to the child: a doll, a ball, a bear, a spinning top; plate, teapot, cup, spoon; car, train, bus, plane; apple, orange, tomato, cucumber. Pictures showing the action: the girl gets dressed, the boy washes; the boy is skating, the mother is bathing the baby; children build a garage, children play ball; the girl drinks, the doctor gives the boy medicine.

Conducting a survey: 2-4 pictures are laid out in front of the child and they are offered to show one of them. For example: "Show me where the top (doll, bear) is." If the child chooses the right picture, the teacher

asks to say what is depicted on it. If the kid cannot choose the picture correctly, the adult does it himself, names the object and asks the kid to repeat.

Another example. The teacher asks the child: “Show me where the girl dresses. What is the girl doing? If the child does not answer, the teacher himself says: “The girl is getting dressed,” and asks the child to repeat the phrase.

At the same time, the teacher fixes the child's ability to name objects (actions) with sound, syllable, onomatopoeia, word or gesture; the presence of phrasal speech (understandable or obscure to others) is noted.

Complete the task. The task is aimed at identifying the child's ability to perform verbal instructions of varying complexity, as well as understanding simple prepositions. (on, in, under) the level of formation of phrasal speech.

Equipment: box; toys - nesting doll, dog, car, doll, red and yellow cubes, ball.

Conducting a survey: the child is offered to perform the following actions: clap your hands; raise a hand; put a matryoshka on box; hide the ball under table; take a doll for yourself, and give the teacher a red cube.

After each action performed, the teacher asks the child to say what he did: “Tell me, where did you hide the nesting doll?”, “What did you give me? What did you take?" etc.

If the child does not follow the instructions, the adult should repeat it. Repeat tasks should not be more than three times.

fixed performing actions in accordance with verbal instructions.

During the examination, the state of the child's speech is clarified, while it is noted whether he uses sentences consisting of three words, whether he uses adjectives and pronouns, whether he uses sentences consisting of one or two words; does he use easy words (beep) or complete, pronounces certain words correctly (for example, car), whether he names objects and actions at the moment of strong interest; whether he uses facilitated words at the moment of physical activity, surprise, joy.

Assessment of the child's speech development: ready to complete the task, how it relates to the task - whether he understands the verbal instruction, whether there is independent speech, whether he can repeat the phrase, words, babble words, sounds, lack of active speech after an adult.

The results of the psychological and pedagogical examination of children with organic lesions of the central nervous system

Many years of experience in conducting a psychological and pedagogical examination of young children using the presented methods allows us to determine the main parameters (indicators) of the main lines of development: the child's readiness to interact and cooperate with an adult; formation of basic movements; acceptance of the task, ways of performing (on their own or with the help of an adult), learning ability in the process of psychological and pedagogical examination, the presence of imitative ability, interest in the result. In accordance with these parameters, children of the third year of life with organic lesions of the central nervous system can be divided into three groups.

To the first group include children who are lagging behind the age norm in some main lines of development. The child of this group is interested in cooperation with an adult; he has a readiness to establish contact with a new adult, he takes the initiative in communication; eats on his own, dresses with the help of an adult, he has a neatness skill. In most cases, physical exercises are performed by imitation in accordance with the age norm. Tasks related to cognitive development, performs after training. At the same time, he learns well, is interested in cooperation with an adult, shows interest in the result of his activity; there is an interest in deliberate scribbling, there is an imitative ability. He understands elementary instructions addressed to him, uses a pointing gesture, uses separate words in active speech.

To the second group include children who lag behind the age norm in all main lines of development. The child is inactive and has little initiative in communicating with a new adult; when performing household procedures, he needs the help of an adult, the skill of neatness is not formed. Physical development below the age norm: performs only that part of the tasks that are designed for young children, does not imitate the actions of an adult. He cannot cope with tasks related to cognitive development on his own, and after training he performs only some of them, as a rule, together with an adult. When trying to complete tasks on his own, he has chaotic movements, there is no imitative ability. The child has no interest in drawing on paper, he does not use a pencil for its intended purpose, he cannot independently build a figure out of sticks even after training. The understanding of the speech addressed to him is limited, he acts only on the instructions made by the gesture, in active speech babble words or individual sounds are noted.

To the third group include children who have a significant lag behind the age norm in all main lines of development. The child does not show interest in an adult, is not proactive in communicating with a new adult; when performing household procedures, he always needs the help of an adult, the skill of neatness is not formed. He does not perform tasks aimed at physical development, since most often he does not understand the task assigned to him; his general movements are awkward, tense, he hardly switches to new movements, his balance is poorly maintained. Tasks aimed at cognitive abilities, does not independently perform. When trying to fulfill them independently, he acts chaotically and inadequately with objects: he takes toys in his mouth, knocks, throws, i.e. the child does not understand what to do. He has no orientation to the conditions of the task, there are no purposeful actions. The child adequately acts only in conjunction with an adult (the hand of an adult holds the hand of a baby), he has no imitative ability. Shows no interest in productive activities (scribing on paper, building with sticks). The understanding of speech is very limited, in active speech there are only individual sounds.

Early diagnosis and correction of developmental problems. The first year of a child's life Arkhipova Elena Filippovna

Examination of children of the first year of life

In the process of working with children of the first year of life, special attention should be paid to the prevention of deviations in their development. For this purpose, when examining children from the first weeks of life, the following methods and techniques are used: observation of babies during the wakefulness period, conversations with medical personnel, study of medical records, psychological and pedagogical observation of children in the pre-speech period, a comparative analysis of their psychomotor and speech development.

Such an examination, which is complex in nature, makes it possible to identify pathological features in the pre-speech development of children, including children with the consequences of perinatal damage to the central nervous system (CNS PPP), to identify the structure of the disorder and determine ways of correction.

Such work with children is carried out from an early age, since pathological features in their development appear from birth and prevent the further correct formation of speech and mental activity.

In the process of examining children of the first year of life, special attention is paid to the following areas of work.

The study of anamnestic data. When analyzing the anamnestic data, the following are taken into account: the course of pregnancy, the condition of the child at birth, the characteristics of crying, the presence and nature of asphyxia (Apgar score). Particular attention is drawn to the congenital unconditioned oral reflexes that provide the possibility of sucking and swallowing. The time of appearance of orienting reactions to visual and sound stimuli, the moment of appearance and the nature of a smile are taken into account.

The study of the motor development of the child. Together with a neuropathologist, the child's motor abilities are examined: the presence of pathological tonic reflexes and their distribution to the muscles of the tongue and eyes; the ability to hold the head, which is necessary for the development of orienting-cognitive activity; the ability to turn, sit, which also expands the possibilities of knowing the world around, contributes to the development of objective activity and contact.

Particular attention is paid to the development of the muscles of the hand, the position of the first finger, the possibility of visual-motor coordination, manipulative and objective activity (which affects the development of speech). Together with the doctor, the general muscle tone of the child, the nature of hyperkinesis (pathological, sudden involuntary movements in various muscle groups), seizures are determined, and the child's ability to lean on his legs and walk is also revealed.

The study of the state of the speech apparatus. The presence of pathology in the structure of the articulatory apparatus is noted. Together with the doctor, the state of the tone of the muscles of the articulation apparatus, the distribution of tension during emotional stress, the features of the movement of the lips and tongue are examined. The state of oral reflexes, oral synkinesis (involuntary accompanying movements that occur only with voluntary movements), the nature of hyperkinesis are determined. Watching the child in the process of feeding, the features of eating are noted: sucking and swallowing. The nature of the voice, cry and breathing are taken into account.

The study of the voice and pre-speech activity of the child. When examining the pre-speech level of development, the speech therapist notes the nature of the child's cry, its intonation-expressive coloring and communicative function. It establishes the presence, nature and time of the appearance of an intoned voice used by the child as a means of communication. Watching the child, it is necessary to note the time of appearance cooing, features of its development from spontaneous vocalization to self-imitation and reciprocal cooing.

Let us give examples of methods for identifying possible voice reactions of a child.

Detection technique

The situation is provocative or natural. The child lies on his back, calm.

1) An adult leans over the child, keeping a distance of 25-30 cm from his eyes. Focuses the child's attention on his face, gently pronounces words and sounds for 2-3 minutes.

2) Only observation is carried out, without the use of means of influence.

3) Observations alternate with repeated pronunciation of vowels for 8-10 minutes.

If the child has babble it is necessary to determine the stage of its development (stages I, II, III according to V. I. Beltyukov - see p. 65).

Detection technique

The situation is natural. The child is awake. An adult watches him for 30 minutes.

1) Roll call with the child.

2) The adult repeats the syllables that are in the child's babbling.

3) The situation is provocative. An adult, sitting in front of the child, emotionally addresses him and clearly, with short pauses, pronounces the syllables that the child had previously pronounced himself. The exercise is carried out for 30 seconds.

4) The adult clearly pronounces syllables with short pauses that are not in the child's babbling.

If the child has first words determine the time of their appearance and the nature of amorphous words-sentences.

Detection technique

The situation is natural or provocative.

1) An adult offers the child toys that he played repeatedly and watches him play.

2) An adult can invite the child to name the toy: “What (who) is this?”

3) An adult sits in front of the child and pronounces syllables (in various combinations) with different intonations that the baby has not previously uttered.

4) An adult tries to interest the child in a toy and asks: “What (who) is this?”

Psychological and pedagogical examination is aimed at studying the state of orienting reactions in children in the first weeks of life and orienting-cognitive activity in children during the first months of life. During the examination, sensory functions are studied: visual and auditory perception, attention to adult speech and the level of development of the initial understanding of speech.

Let us give an example of a technique for identifying visual orienting reactions.

Detection technique

The situation is provoking. The child lies on his back.

1) An adult holds a toy (a rattle with a ball 5-10 cm in diameter) at a distance of 40-50 cm from the child's face and moves it either to the right or to the left by 20-30 cm (2-3 times).

2) An adult, attracting the attention of a child, swings the toy, talks to him, then leaning towards the baby, then moving away from him. Having caused concentration, the adult remains motionless or holds the toy at a height of 40–50 cm from the child's eyes.

3) An adult causes the child to focus on an object (bright toy), moving it to the side by 20 cm, and then stops the object at a height of 50–70 cm from the baby’s eyes.

4) Familiar and unfamiliar adults talk to the child in turn. The exercise is carried out for 1.5–2 minutes.

There are many diagnostic methods designed to study young children, for example, the methods of H. M. Aksarina, K.L. Pechora, G.V. Pantyukhina, E.L. Frucht, L. T. Zhurby, O. V. Timonina, E. M. Mastyukova, E.A. Strebeleva.

As the basic methods for diagnosing the psychomotor development of infants suffering from CNS PPP, we can recommend the methods of G.V. Pantyukhina, G.L. Pechory, E.L. Frucht (1983), O.V. Bazhenova (1986), Yu.A. Lisichkina (2004), M. Griffiths (2000), M.L. Dunaikina (2001). To assess the nature, degree of disorders, development prognosis, and determine the corrective focus of measures, a qualitative clinical analysis of deviations in psychomotor development is required. For this purpose, the methods of L. T. Zhurba, E. N. Mastyukova and E. D. Aingorn (1981) are used.

As an example, we give the Griffiths psychomotor development test (translated by E. S. Keshishyan, 2000), which is used for screening examinations of children (see table 2).

table 2

Griffiths psychomotor development test

The assessment of the psychomotor development of the child is made in points, which are then compared with the points determined by the standards (see table 3).

Table 3

Summary table of scores

Let us give an example of a quantitative analysis of the results of an examination of a child at the age of one year.

According to the results of a screening examination, a child at the age of one year scored: motor skills - 17 points; social adaptation - 16 points; hearing and speech - 13 points; eyes and hands - 19 points; ability to play - 20 points. The total amount is 85 points out of 150–155 possible (see table 3). Thus, a one-year-old child in terms of motor development corresponds to a seven-month-old child; by the level of social adaptation - a six-month-old child; on the development of hearing and speech - a five-month-old child; eyes and hands - a seven-month-old child; ability to play - an eight-month-old child.

As a result, the graph of the level of psychomotor development of a child at the age of one year will look like this.

Examination parameters: 1. Motor skills. 2. Social adaptation. 3. Hearing and speech. 4. Eyes and hands. 5. Ability to play.

Analyzing the results obtained during the examination of a child at the age of one year, and comparing them with the conditional norm, one can note a lag in psychomotor development for all functions for 6 months. In fact, a child of one year corresponds to a six-month-old child. The revealed features in the psychomotor development of the child are indications for its deeper study in the medical, psychological and pedagogical terms.

During such an examination, it is possible to identify children of the "risk group" and plan a corrective regimen aimed at stimulating certain functions, as well as include psychological and pedagogical support. If the lag increases with age, for example, at 8 months the child gains only 60 points instead of 100 points, which corresponds to the level of development of a six-month-old child, then a deeper examination and, possibly, corrective and developmental measures are needed. It is also necessary to study the conditions for raising an infant, his somatic condition, etc.

For a deeper examination of children, the methods of O. V. Bazhenova (1986), M. L. Dunaykin (2001) and others should be used.