Consultation (younger group) on the topic: The variety of diagnostic methods designed to study young children. Methods of objective study of the muscular system. at the III degree, the absence of all reflexes, deep upsets are observed

For citation: Komarova O.N., Khavkin A.I. Algorithm for examination and treatment of children early age with constipation // BC. 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 muscle hypotension - a symptom of various diseases diagnosed in the 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, 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

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Features of examination in pediatrics

The body of a child, especially the first months and years of life, differs in many ways from the body of an adult. Knowledge of the anatomical and physiological characteristics of the child's body is the basis for proper examination, diagnosis, organization of therapeutic measures and care throughout the entire period of childhood.

Examining a child is always more difficult than an adult. Before starting the examination, it is necessary to establish contact with the child and his parents, reassure the patient, and create an atmosphere of mutual trust. Sharp, rude and thoughtless words and actions should be avoided. A calm voice, a light touch soothe a shackled child, help reduce pain, and reduce anxiety in upset parents.

Usually during the conversation, young children remain in the arms of their parents. A school-age child behaves calmly during a conversation; during a survey, he can be involved in a conversation by asking questions. The room where the child is examined should contribute to the creation of a positive emotional mood (bright colors, pictures, comfortable furniture, warmth).

The diagnostic process begins with the collection of an anamnesis, which helps to find out the causes and clinical picture of the disease.

Features of collecting anamnesis in pediatrics are as follows:

In young children, it is impossible to collect an anamnesis, so you have to focus on the complaints of parents, based only on observations of the child;

Older children (who already know how to speak) can express complaints, but they cannot correctly analyze various, painful sensations, give them due importance, associate them with certain “other factors;

The importance of a thorough and detailed clarification (in young children) of the characteristics of the course of pregnancy and childbirth in the mother, the condition of the child in the neonatal period, feeding, caring for the child, physical and neuropsychic development;

Collecting an anamnesis of life and illness, it is necessary to critically evaluate the information received from the mother or from the child, highlight the most important symptoms of the disease., Determine the sequence of their appearance;

Child research methodology

The clinical symptoms of the disease depend on the age and immunological state of the child's body.

In order for the study of the child to be complete, it must be carried out according to a certain scheme. The research methodology for a child differs from the research methodology for an adult. When embarking on an objective study, it is necessary to remember that it is very important to approach the child correctly, to be able to calm him down, distract him, occupy him with a toy or a conversation, since anxiety and excitement greatly complicate, and sometimes simply make it impossible to study. Those. procedures that are unpleasant to the child (for example: examination of the pharynx) or may cause pain should be carried out at the end.

The study of the child consists of questioning and objective research.

When questioned, it turns out: 1) passport data;

2) life history;

3) the history of the development of the disease.

Passport data

In the registration part, you should indicate the age of the child, the exact date of birth, Home address, the number of the children's institution that the child attends, the surname, name, patronymic of the parents and place of work.

Anamnesis of life

The history of life is extremely important for identifying the individual characteristics of the child and for recognizing the present disease, assessing the severity and predicting the course of the disease. The procedure for collecting anamnesis in children:

1. The age of the parents, the state of their health, the presence of hereditary diseases, chronic intoxication, venereal diseases of tuberculosis, alcoholism and other diseases in the family and close relatives.

2. How many pregnancies did the mother have, how did they end. How many births. How many children are currently alive, their age and state of health, Age of deceased children, cause of death.

3. From what pregnancy and childbirth account this child is. State

maternal health during pregnancy and childbirth. Date of delivery, their duration, obstetric intervention.

4. Characteristics of the child during the neonatal period; full-term or not, if possible, find out the cause of prematurity. Cry at birth (weak, loud). Weight and body length at birth. When they put it on the breast, how he took the breast, after how much they fed the child. On what day the rest of the umbilical cord fell off, how did the wound heal with the umbilical cord.

5. Weight of the child at discharge from the hospital (if possible, specify the physiological loss). Physiological jaundice, the time of its manifestation, the degree of its manifestation, duration. On what day was discharged from the hospital.

6. At what age did he start holding his head, turn on his side, sit, crawl, walk. Weight gain in the first year of life and in subsequent years. Time and timing of teething, the order of teething.

7. Neuropsychic development. When he began to smile, walk, recognize his mother, pronounce individual syllables, words, phrases. At what age does she attend a childcare facility? Features of behavior in the children's team, what individual habits. School performance. Additional loads (music, foreign languages, etc.) Sleep, duration of sleep (daytime, nighttime).

8. Feeding. On what feeding was the child in the first year of life. Time of transfer to mixed and artificial feeding. The timing of the introduction of complementary foods. Supplementary food and complementary foods that the child received. Weaning time. Was the diet followed? Nutrition at present.

Appetite. Does he get enough protein food (meat, fish, cottage cheese, milk, eggs), vegetables, fruits, juices. Diet mode, get hot food how many times a day.

9. Material and living conditions. Housing conditions (apartment, private house). Characteristics of the apartment (light, dark, cold, warm, sunny, dry, damp). How often is wet cleaning, airing. Does the child have a separate bed, is there enough linen, clothes for the season. Bathing (regular, no how often). Daily regime. Walk in the air, how many times a day, how many hours a day, systematically, no. Sleep in the air.

10. Transferred diseases. What, at what age, course, severity, Presence of complications, treatment in a hospital, at home.

11. Preventive vaccinations. What diseases is the child vaccinated against? Whether the terms of vaccinations were observed, whether there was a reaction to the vaccination, how it manifested itself.

12. Tuberculin tests (Mantoux reaction), date and results.

13. Allergological history. Allergic reactions and diseases in parents, relatives, in a sick child. Were there manifestations of allergic diathesis and what did they consist of. Food allergies (to which foods). Tolerance of drugs.

14. Hematological history. Transfusion of blood, plasma, gamma globulin and reaction to them.

15. Epidemiological history. Contact with patients with infectious diseases: where (at home, in a children's institution), when, preventive measures in connection with contact.

Similar information.

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

Name	Age two to two years old and six months.	Age from two years and six months. up to three years
Insert the figures into the grooves	Three figurines	Six figurines
Hide the ball in the box	two boxes	four boxes
Disassemble and assemble the pyramid	Of the three rings	Of the four rings
Pick up paired pictures
Pick up colored cubes	Two colors	four colors
Put together a whole picture from parts	Two piece	Of three parts
Get a cart	sliding	Sliding and false
Build with sticks
draw

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.

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• Lecture5 . Children's growth
• Lecture6 . Formation and development of the fetus: 1-10 weeks
• Lecture7 . Formation and development of the fetus: 11-19 weeks
• Lecture8 . Formation and development of the fetus: 20-34th week
• Lecture9 . Formation and development of the fetus: 35-40 weeks
• Lecture 10 . periods of a child's life. Anthropometric studies
• Lecture 11 . Calculation methods and analysis of anthropometric data
• Lecture 12 . The psyche of the child in different periods of his life
• Lecture 13 . The psyche of a child from the second half of life to 12 years
• Lecture 14 . Assessment of the psychomotor development of the child. Neuropsychic development in the 1st year of life
• Lecture 15 . Indicators of psychomotor development of children 2-7 years of age
• Lecture 16 . Formation of the cognitive function of the child
• Lecture 17 . Daily routine for children of different ages
• Lecture 18 . biological rhythm
• Lecture19 . Examination of the cardiovascular system: an objective examination
• Lecture 20 . Limits of absolute dullness of the heart. Auscultation of the heart
• Lecture 21 . Study of pulse and blood pressure
• Lecture 22 . Clinical study of the functional state of the cardiovascular system in children
• Lecture 23 . The structure and function of the child's skin
• Lecture 24 . Examination of the skin and its most important lesions. Cyanosis
• Lecture 25 . Icteric discoloration of the skin. Skin hyperemia. Rash elements
• Lecture 26 . Primary morphological elements: nodule, tubercle, knot, vesicle, bladder, abscess, blister. Secondary morphological elements
• Lecture 27 . Skin research technique
• Lecture 28 . Features of nails and hair in children
• Lecture29 . Basic research methods
• Lecture 30 . Position and constitution of the patient. head examination
• Lecture 31 . Face masks. Examination of the mouth, neck, chest
• Lecture 32 . Examination of the chest and abdomen. Shortness of breath, visible pulsation. Examination of the skin and subcutaneous fat
• Lecture 33 . Inflammatory lesion of the skin. Pathological processes in the subcutaneous tissue. Edema. Inspection of lymph nodes
• Lecture 34 . Examination of the musculoskeletal system
• Lecture 35 . Anthropometry
• Lecture 36 . Thermometry
• Lecture 37 . Kinds and types of fevers
• Lecture 38 . The course and causes of fever. Hypothermia
• Lecture39 . Instrumental-functional research methods
• Lecture 40 . Characteristics of ECG waves and intervals
• Lecture 41 . ECG analysis
• Lecture 42 . The electrical axis of the heart and the diagnostic value of the ECG
• Lecture 43 . Phonocardiography
• Lecture 44 . X-ray examination
• Lecture 45 . Features of X-ray examination of the biliary, urinary and respiratory systems
• Lecture 46 . Contrasting methods. Tomography. Fluorography
• Lecture 47 . Modern radiological research methods. Voiding cystourethrography. X-ray kymography. Electrokymography. X-ray cinematography. X-ray television
• Lecture 48 . Radioisotope research methods
• Lecture49 . Characteristics of the respiratory system of children
• Lecture 50 . Examination of the respiratory system by percussion
• Lecture 51 . Auscultation of the lungs. The severity of the condition of children with damage to the respiratory system. Semiotics of respiratory diseases
• Lecture 52 . Semiotics of acute focal pneumonia and exudative pleurisy
• Lecture 53 . Respiratory failure
• Lecture 54 . The relevance of the problem of caring for patients with respiratory diseases
• Lecture 55 . Caring for patients with respiratory diseases
• Lecture 56 . Hemoptysis and pulmonary hemorrhage. Chest pain
• Lecture 57 . The specifics of the work of the personnel of the pulmonology department
• Lecture 58 . Dyspnea. oxygen therapy
• Lecture59 . Characteristics of the digestive system of children
• Lecture 60 . Examination of the gastrointestinal tract. Collection of anamnesis. Inspection
• Lecture 61 . Palpation of the abdomen
• Lecture 62 . Palpation of the pancreas, liver, gallbladder, spleen
• Lecture 63 . Percussion and auscultation in the study of the digestive organs
• Lecture 64 . Patients with diseases of the circulatory system. Pulse study
• Lecture 65 . Pain in the region of the heart
• Lecture 67 . Observation and care of patients with deficiency
• blood circulation
• Lecture 68 . Examination of the muscular system
• Lecture69 . Examination of the skeletal system
• Lecture 70 . Joint examination. Timing of ossification of the skeleton. Stigmas of dysembryogenesis of the musculoskeletal system
• Lecture 71 . Features of the musculoskeletal system in children
• Lecture 72 . The concept of metabolism
• Lecture 73 . Metabolism in the child's body. Energy consumption and consumption
• Lecture 74 . Basic metabolism in children
• Lecture 75 . Water-salt exchange. Water in the body
• Lecture 76 . salt metabolism
• Lecture 77 . Immunology. Features of the immune system
• Lecture 78 . Single organ of immunity. organs of the immune system. Thymus gland, lymph nodes, spleen, tonsils
• Lecture79 . Bone marrow. The formation of immunity
• Lecture 80 . immune response
• Lecture 81 . Diseases with damage to the immune system
• Lecture 82 . Swiss type immunodeficiency. Wiskott-Aldrich Syndrome. Methods for assessing the immune system
• Lecture 83 . Providing breastfeeding
• Lecture84. Features of the structure of the mammary gland. Breastfeeding technique
• Lecture 85 . Assessment of breastfeeding. Position of the baby at the breast
• Lecture 86 . Breastfeeding
• Lecture 87 . Expression of breast milk
• Lecture 88 . Insufficient mother's milk supply
• Lecture89 . Ways to increase the amount of milk. Feeding low birth weight and sick children
• Lecture 90 . Contraindications to breastfeeding
• Lecture 91 . Rational nutrition of children. Metabolism of proteins and fats
• Lecture 92 . Metabolism of carbohydrates and minerals
• Lecture 93 . Need for vitamins. The principle of the formation of daily rations
• Lecture 94 . Malnutrition
• Lecture 95 . The problem of balanced nutrition
• Lecture 96 . Nutrition for sick children
• Lecture 97 . The nutritional needs of children. Principles of physiological nutrition of children
• Lecture 98 . Floor formation. Clinical signs of congenital pathology of sexual development
• Lecture99 . Methodology for the study of the reproductive system
• Lecture 100 . Precocious sexual development
• Lecture 101 . Development of the organs of the endocrine system. Thyroid and parathyroid glands, thymus, pancreas
• Lecture 102 Thyroid and parathyroid glands, thymus, pancreas
• Lecture 103
• Lecture 104. Testicular and ovarian hormones. Assessment of neuropsychic development. Examination of the thyroid gland and gonads
• Lecture 105
• Lecture 106. Features of the examination of children with endocrine pathology. Collection of anamnesis
• Lecture 107
• Lecture 108
• Lecture 109
• Lecture 110
• Lecture 111
• Lecture 112

Lecture 1. Methodology for the study of a sick child. Anamnesis of life

1. Features of the methodology for examining a child

A comprehensive careful study of a sick child is of great importance for the correct diagnosis of the disease, the appointment of appropriate treatment and the organization of child care. The methodology for examining a child differs from the methodology for examining an adult, especially if it applies to a young child; a number of special methods of objective examination are necessary for a correct assessment of the condition. When examining a patient, it is necessary to adhere to a certain scheme so as not to miss anything significant, important both during questioning and during an objective study.

2. Stages of research of the child

The study of the child is divided into a number of stages:

1) collecting a general history (anamnesis vitae);

2) anamnesis of the disease (anamnesis morbi);

3) an objective study of the present state of the patient (status proeseus);

4) additional studies (laboratory, x-ray, etc.).

The study should end with a diagnosis, treatment and prognosis.

3. Anamnesis of life

Due to the fact that different age periods have certain features of a child's life, the collection of anamnesis at an early age has some features.

So, when highlighting the anamnesis of life in children under 3 years of age, special attention should be paid to the following features:

1) prenatal period;

2) intranatal period;

3) early postnatal periods;

4) life history of young children.

It is necessary to ask the mother in detail about how the child's development proceeded, about the nature of his upbringing, to learn about past diseases, about family diseases, living conditions, about feeding, vaccinations, reactions to them, and the epidemiological environment of the child.

In particular, the following points need to be emphasized:

1) which child is in a row, what pregnancy was born from, how the pregnancies proceeded and how they ended (miscarriage, stillborn and premature babies, abortions);

2) how the pregnancy proceeded (toxicosis of the first or second half of pregnancy - nausea, vomiting, edema, hypertension, nephropathy, eclampsia, past viral infections), whether the mother used maternity leave;

3) how the birth proceeded, on what day and with what weight the child was discharged home;

4) diseases in the neonatal period. The presence of jaundice, birth injuries, other diseases;

5) physical and psychomotor development of the child;

6) the behavior of the child at home and in the team: attitude towards other children and adults;

7) features of sleep, its duration;

8) general features of feeding in the first year of life (natural, artificial, mixed);

9) timing of teething;

10) past illnesses;

11) prophylactic vaccinations - against tuberculosis (TSB), poliomyelitis, staphylococcus, measles, mumps, rubella. reaction to vaccinations. Characterization of tuberculin samples;

12) contact with infectious patients;

13) Was the child treated in a hospital?

Life history of older children

When collecting an anamnesis of older children, it is necessary to ask about the living conditions of the family, the profession of parents, the home environment, the room in which the child lives, etc.

The following information is specified:

1) which is the child? Features of development in early childhood;

the behavior of the child at home and in the team, for schoolchildren - academic performance. What subjects do you prefer?

2) previous diseases and surgical interventions;

3) prophylactic vaccinations and tuberculin tests;

4) the sexual development of the child (the timing of the appearance of secondary sexual characteristics).

An addition to the life history is a family history, therefore, along with the passport data of the parents, they find out:

1) the state of health of parents and close relatives. The presence in the family of infectious, mental, nervous, endocrine, allergic diseases, occupational hazards, smoking, alcoholism;

2) a family tree, starting with a sick child to grandparents, to brothers and sisters horizontally;

3) assessment of material and living conditions.

Lecture 2. History of the disease. Objective examination of the child

1. Medical history

After a general questioning about the child, they proceed to collecting an anamnesis of the disease. It should be borne in mind that the signs of the disease are not always detected immediately, more often they are established gradually, over several hours or days. It is necessary to be able to establish the early signs of the disease and identify the main, leading ones from them. It is necessary to find out when and how the disease began, what preceded it, what was the body temperature and how it changed in the future, whether there was a rash, what home, drug and non-drug remedies were used for treatment. It is necessary to pay attention to the complaints of parents, to clarify each complaint by additional questions. Specify the time when complaints appeared, the circumstances under which they arose, how the disease proceeded from the moment it began. Additionally, they ask about the possible pathology of all organs and systems. They are interested in what kind of general manifestations of the disease were noted (fever, chills, sleep disturbance, appetite, mood changes). When examining a child, it is necessary to observe certain conditions that contribute to a more complete receipt of information and at the same time the least traumatic to the child. The room where the study is carried out should be warm, without drafts, with natural light. Noise is important. Inspection is carried out in the presence of parents. The pediatrician needs to find contact with the parents and the child. The doctor's hands should be warm. It is unacceptable to wear bright jewelry and use cosmetics with persistent odors.

2. An objective examination of the child. General state

An objective examination of the child begins with a determination of his general condition, which can be mild, moderate, severe, extremely severe. A satisfactory condition is said when there are no signs of intoxication or they are insignificant, there are no functional disorders of the body. At the same time, the child has a clear mind and active behavior. The state of moderate severity is characterized by distinct signs of intoxication, the presence of functional disorders of the body systems. In a serious condition, various stages of impaired consciousness, intoxication syndrome, decompensation of the physiological systems of the body are revealed. An extremely serious condition is characterized by the appearance of signs that threaten the life of the child. In addition, the child's well-being is noted, which is his subjective feeling, mood (smooth, calm, excited, unstable), reaction to examination - adequate, inadequate. The first thing the doctor should not forget about when starting an objective examination is to approach the child correctly and calm him down. Crying, anxiety of the child make it difficult and may even make it impossible to study. Therefore, if the doctor finds the child sleeping, he should not wake him up, but ask the mother, try to get as much data as possible by examination during sleep.

3. Position of the child

First of all, you need to pay attention to the position of the child. A healthy infant lies on its back during sleep, arms bent at the elbows, pressed to the body, fingers clenched into fists. Children who have come out of infancy do not take any specific position during sleep. Only in some diseases do children take the position characteristic of this disease. So, with meningitis, the child usually lies on his side, his legs are bent at the knees and pressed to his stomach, with a large effusion into the pleural cavity, he lies on his sore side. Distinguish the active position of the child, in which he occupies a relaxed position. In a passive position, the child cannot change position without assistance. A forced position is a position that a child takes to alleviate the condition.

4. State of consciousness

It is important to assess the state of consciousness. It can be clear, doubtful, soporous.

With a clear mind, the child is oriented in time and space.

With somnolent consciousness, the reaction to the environment is reduced. The child reacts to strong irritation by crying, answers questions sluggishly.

In the soporous state, there is no reaction to the environment, but the reaction to painful stimuli is preserved.

With a significant degree of inhibition of the cerebral cortex, loss of consciousness occurs - coma.

There are 3 degrees of coma:

1) I degree - easy. There is no consciousness and voluntary movements, corneal and corneal reflexes are preserved;

2) II degree is characterized by lack of consciousness, areflexia (pupil reflexes are preserved), respiratory distress is often observed;

3) at the III degree, the absence of all reflexes, deep disorders of the respiratory rhythm are observed.

If consciousness is lost, then it is necessary to pay attention to the width of the pupils and the presence of a reaction to light. Wide pupils that do not react to light are one of the symptoms of deep depression of the central nervous system. In such patients, it is imperative to check the pain reaction and reflexes from the larynx and pharynx, which allow you to determine the depth of the coma.

Lecture 3. Features of a general examination. Objective research methods

1. Deviations from the normal anatomical structure

During a general examination, attention is drawn to congenital deviations of the outer parts of the body from the normal anatomical structure of the body.

There are 4 groups of deviations:

1) background features;

2) informative features;

3) specific features;

4) signs of congenital malformations.

Background signs are small developmental deviations associated with genetic pathology.

Informative signs are associated with a specific genetic syndrome.

Specific signs are characteristic of a particular genetic pathology.

Signs (dysmorphia) in congenital malformations that are not typical for genetic pathologies.

Groups 1 and 2 are combined as signs of stigma. More than 5 - 6 stigmas, especially of group II, can be regarded as the probability of a deviation in the development of internal organs. A number of features are a reflection of the normal genetic development of this family.

2. Description of the stigmas

Stigmas on examination are described by parts of the body.

Head.

Changes in the shape of the head, flat nape, overhanging forehead, high, low hair growth at the back of the head. There are microcephaly (decrease in the size of the skull), macrocephaly (increase in the size of the skull). Along with this, the child has large saphenous veins on the head, divergence of the sutures of the skull, bulging of the fontanel. When examining the face, there may be a curvature of the nose, fusion of the eyebrows along the bridge of the nose (synophrysis), excessive development and protrusion of the upper jaw, or, conversely, a decrease in the size of the lower jaw. When examining the eyes, a section of the eyes is distinguished, an increase in all sizes of the eyeballs, the presence of an epicanthus - a vertical semilunar skin fold. Attention is drawn to the color and shape of the iris. The presence of a defect in the iris is called a coloboma.

When examining the ears, pay attention to their location; for this, a horizontal line is conditionally drawn connecting the corners of the eyes. If the lower part of the ear tragus is located above this line, they speak of low-lying ears. If higher - about the high location of the ears. In addition, any deviations in the shape of the ears are noted - incremented lobes, deformed ears, ears of different sizes, double tragus, anomalies in the development of curls. The teeth may be sparse. The irregular shape and position of the teeth also matter. The neck and torso may have a different shape, various anomalies, incorrect location of the navel, hernia.

The hands and feet may also have various deviations:

1) transverse fold of the palm;

2) long "spider fingers" - arachnodactyly;

3) shortening of the fingers due to the development of the phalanges - bradydactyly.

Attention is drawn to the color of the skin, the presence of pigmented areas, large birthmarks, excessive local hair growth. If the child does not have a genetic pathology, then we can talk about the presence of adverse effects during the laying of organs and tissues. In addition to examining the skin, attention is drawn to the color of the skin, the presence of a rash, which, with appropriate data, makes it possible to diagnose various infectious diseases. The presence of blue coloration of the lips and face makes one suspect a circulatory disorder, heart defects. Next, attention is drawn to the nature of the cough, breathing. Frequent, "groaning" breathing with flaring of the nostrils, a short cough suggest pneumonia. The calm state of the child during sleep is a favorable moment for counting the pulse and breathing.

3. Features of the inspection

If the child is awake, everything that could cause him anxiety should be avoided during the examination. When examining a child, he should be occupied with a toy, a playful conversation. The behavior of the doctor depends on the age of the child. Young children should be immediately undressed and examined in the crib, on the changing table, or on the mother's lap. Preschool children can also be undressed all at once, or undressed gradually as you explore. The doctor should not forget to examine the child's legs. All research should be done in such a way that it causes the least possible disturbance to the child. Each child requires an individual approach, the success of the study depends on the experience and skill of the doctor. The study must be carried out in a certain order, moving from one organ to another. In the study of children, the accepted order is very often violated, because the mood of the child has to be taken into account, and mainly because those organs, the study of which can cause pain, should generally be put aside. Inspection of the pharynx, as the most unpleasant procedure, is also performed at the end of the study.

4. Objective research methods

When examining a child, methods of palpation, percussion and auscultation are used.

The palpation method is a palpation method based on temperature and other types of sensitivity of the palmar part of the hand. Basically, this method examines the skin, subcutaneous tissue, muscles, lymph nodes of the respiratory, cardiovascular system, and abdominal organs.

Distinguish superficial palpation and deep.

To detect a large amount of free fluid in the abdominal cavity, superficial palpation is used. Sometimes penetrating palpation is used, for this one finger is pressed on one area.

The percussion method is based on the impact on the surface of the body, which causes vibrations that can be heard.

The method of auscultation is based on the fixation of natural sound vibrations that occur during the activity of the body. Most often, auscultation is performed with a stethophonendoscope.

sick child clinical trial

The hands of the doctor and the stethophonendoscope should be warm and clean. In order to maintain contact, you can allow the child to play with this instrument so that it does not cause fear.

Since young children really like to play "telephone" and they know this subject, you can explain to them that the listening tube is a telephone.

Lecture 4. Additional methods of examination. Diagnostics

1. Laboratory and instrumental examination methods

In addition to objective, there are instrumental and laboratory examinations.

Laboratory methods include clinical, immunological and biochemical blood tests, urine, feces, cerebrospinal and pleural fluids.

Instrumental methods include X-ray, electrocardiographic, endoscopic, ultrasound, radioisotope, computed tomography, magnetic resonance imaging, positron emission tomography.

The results of the history taking, examination and examination of the child make it possible to assess the state of health, correctly diagnose if the child has a disease.

2. Diagnosis

When making a diagnosis, take into account:

1) collection of an anamnesis of the disease, an anamnesis of life;

2) objective examination of the patient;

3) instrumental methods of examination;

4) additional methods;

5) councils, consultations;

6) diagnosis.

Types of diagnostics:

a) direct type;

b) methodical type.

The direct type is as follows: based on a symptom, a doctor conducts a series of studies that are relevant to this symptom, for example, when providing emergency care. It can lead to a number of errors due to the one-sidedness of the research.

The methodical type is more thorough, since the main complaints, anamnesis are taken into account, all organs are examined.

3. Classification of diagnoses:

1) by the method of constructing a straight line (by analogy): differential, complete, by observation, by the results of treatment;

2) by the time of detection: early, late, retrospective, postmortem;

3) according to the degree of validity: preliminary, final, questionable.

There may be an intuitive or inductive diagnosis.

4. Forecast

Prognosis is a reasonable guess about what will happen to the patient.

The forecast may be:

1) good;

2) bad;

3) doubtful;

4) very bad;

5) foreshadowing death.

The possibility of medical error must be taken into account.

1. Genealogical method

The genealogical method reveals the patterns of inheritance of traits within the boundaries of one family. Therefore, it is called the family tree method.

Analysis of the family tree allows you to establish the type of inheritance of a given hereditary disease or any other signs. Sometimes it becomes necessary to analyze several pedigrees of families where the same hereditary disease is present, and process the data obtained using specific mathematical genetic methods in order to establish the type of inheritance of the disease. The design of the family tree is carried out by a special designation. In the family tree, each generation is marked with a Roman numeral, and each person with an Arabic one. A family tree, starting with a sick child, to grandparents upwards vertically and to siblings horizontally. If necessary, the scope of the genealogical survey can be expanded. It is desirable that the obtained data be reflected in the genetic map.

2. Population-genetic method

The population-genetic method reveals the patterns of the spread of hereditary traits and diseases in large groups of the population, considering peoples on a large scale. Based on the law of J. Garan and V. Weiberg, the gene frequency of a given trait or hereditary disease is determined in certain areas and at certain periods of time.

3. Cytogenetic method

The cytogenetic method allows you to study heredity at the cellular level, i.e. chromosome research. Peripheral blood lymphocyte cultures have received the widest use for chromosomal diagnostics.

4. Ontogenetic method

The ontogenetic method makes it possible to study the manifestations of a gene in ontogeny. They are the science of genetics.

In medical genetics, various methods of clinical research are widely used to establish an accurate diagnosis.

Lecture 5

1. Growth as a biological process

Growth is a biological process in a child's body. It is inherent in the period of childhood and includes a change in the mass and shape of the body, the physiological functions of the body and its biological maturation. Growth begins with the fertilization of the egg and ends with the transformation into a mature organism. Growth is a quantitative process in which body length and weight increase. Growth rate, body weight gain, sequence and increase in various body parts, maturation of organs and systems at each age stage are programmed by hereditary mechanisms and, under optimal environmental conditions, follow certain patterns. However, adverse factors, especially in the prenatal period and in early childhood, can disrupt the development of children, sometimes causing irreversible changes. The term "physical development" is understood as a dynamic process of growth (increase in body length and weight, development of various parts of the body) and the biological maturation of a child in a particular period of childhood. Efficiency and reserve of physical strength are formed during the development of static and motor functions. The normal growth of the body is carried out by the mutual action of hormonal factors, an adequate response of the tissue and their sensitivity in providing nutrients and energy.

2. Periods of growth

There are several periods of growth, which have their own characteristics in relation to its nature, speed and influence from internal and external influences.

The prenatal period (from 0 to 280 days) is divided into:

1) germinative - 0-14 days;

2) embryo - from the 14th day to 9 weeks;

3) fetus - from 9 weeks to birth.

A premature baby - from the 27th to the 37th gestational week, birth on average after 280 days, the neonatal period - the first 4 weeks after birth, the chest period - the first year of life.

Early childhood - from 1 year to 3 years, preschool age - 3 - 6 years, school age - 7-14 years.

Pubertal period: girls - 10 - 12 years old, boys - 12 - 14 years old, youth - from 14 to 18 years old.

3. Growth factors

genetic factors.

Normal intrauterine and postnatal growth is genetically programmed. Various genetically determined diseases, as well as constitutional bone diseases, amino acid metabolism disorders and others, proceed with growth disorders. The genes that control the growth of an organism are distributed on many chromosomes. Birth weight is also due to genetic factors in approximately 38% of cases, in other cases, external factors such as the state of health and nutrition of the mother, the order of pregnancy, the age of the mother and other factors matter. It should be noted that the genes that control the growth rate are independent of the genes that control the final growth.

Hormonal factors.

For the growth and development of the child's body, the endocrine system is important, which, in cooperation with the skeletal system, ensures the growth of the body. The main growth hormone is somatotropin, which controls the secretion of complex neural and hormonal substances that have a stimulating or inhibitory effect. Many hormones play a role in growth, including insulin, thyroid hormones, corticosteroids, androgens, estrogens, parathyroid hormone, and vitamin D.

Other growth factors.

Other growth factors include nutrition and chronic diseases.

Nutrition.

The value of proper and rational nutrition for the growth of the body is associated with protein, mineral, vitamin components, as well as with the caloric composition of food. The most common growth retardation in children is protein starvation. The first sign of this is stunting and weight gain, especially vulnerable in the thoracic, fetal and pubertal ages, when there is a maximum growth rate. In addition to protein deficiency, it is important to distribute calories between proteins, fats and carbohydrates, which should be adequate for age. Mineral substances such as zinc, iron and calcium, as well as vitamins C, A, D are also important for the growth of the child's body.

Chronic diseases.

Growth disturbances may occur in liver disease, chronic renal failure, cardiac anomalies, chronic lung disease, and severe anemia.

4. Growth during different periods of childhood

Prenatal (gestational) period.

In the prenatal period, which covers the time from fertilization of the egg to birth, the most intensive growth of the body is observed. After fertilization, cell division occurs and cell differentiation completely ends during the 16th gestational week. By week 28, the degree of differentiation is sufficient for possible extrauterine life. During the 9 week embryonic period, the developing embryo quickly transforms from a cell mass into a miniature human body. During this period, growth, tissue and cellular differentiation of organs and tissues are carried out.

Lecture 6. Formation and development of the fetus: 1-10 weeks

Week 1st.

In fact, she hasn't gotten pregnant yet. But obstetricians consider the gestational age and the due date from the first day of the last menstruation, since the egg begins to mature in the ovary, preparing for the upcoming fertilization. After fertilization, which occurs on the 10th - 16th day from the onset of menstruation, the egg continues its development.

Week 2

Fertilization occurs - the fusion of male and female germ cells, as a result of which the set of chromosomes inherent in man is restored, and a qualitatively new cell is formed - a zygote (a fertilized egg, or a single-celled embryo). In the process of fertilization, 3 phases are distinguished:

1 - interaction and convergence of gametes (sperm and egg);

2 - contact interaction and activation of the egg;

3 - the entry of the sperm into the egg and subsequent fusion.

The nuclei of the male and female germ cells unite. Thus, the zygote acquires the genes inherited from both parents. Each section of the fertilized egg will give rise to a specific structure of the embryo. The sex of the unborn child depends on the sex chromosomes. When an egg cell fuses with a sperm cell carrying an X chromosome, a girl is born, and when a sperm cell carries a Y chromosome, a boy is born. Thus, the sex of the child depends on the sex chromosomes of the father.

Week 3

By the end of the first day after fertilization, the crushing of the human embryo begins. It lasts 3-4 days. During the first days, it happens slowly. The first division is completed after 30 hours. After 40 hours, 4 cells are formed. At this time, the embryo moves along the oviduct (fallopian tube) to the uterus. Starting from the 3rd day, crushing is faster. The nutrition of the embryo is carried out due to the small reserves of yolk in the egg. After 5-5.5 days, the fetal egg enters the uterus. By this time, it increases in size and consists of 107 cells. Then, within 2 days, the embryo is free in the uterine cavity, and from the 7th day after fertilization, the introduction of the embryo into the uterine wall begins.

Week 4th.

The introduction of the embryo into the uterus lasts about 40 hours. In this case, the embryo is completely immersed in the tissues of the uterine mucosa. This period is the first critical period in the development of the embryo. From the 7th to the 14th day, extra-embryonic organs are actively formed, providing the necessary conditions for the development of the embryo.

Week 5th.

On the 14-15th day after fertilization, all germ layers are laid, from which all organs and tissues of the fetus will be formed in the future. By the 17th day, the fetus begins to feed on the mother's blood, the laying of the rudiments of the main organs continues. Vessels of the embryo begin to communicate with the vessels of extra-embryonic organs. Starting from the 20th - 21st day, the body of the embryo separates from the extraembryonic organs and the final formation of the rudiments occurs. At the beginning of the 5th week of pregnancy, the first laying of the heart appears, and hematopoiesis begins inside the primary blood vessels - blood stem cells are formed, from which all blood cells develop in the future. Sex glands begin to form, primary germ cells appear. The thyroid gland begins to develop. The laying of the liver occurs. The embryo is only 1.5 mm long. From the 18th to the 60th day after fertilization, the fetus is most sensitive to the action of harmful factors.

Week 6

The embryo has a length of 4-5 mm, there are rudiments of arms and legs. He can already stretch and turn his head, move his arms and legs. The laying of the spleen and bone marrow occurs. The rudiments of the stomach, large intestine, larynx, trachea and lungs of the fetus appear. The formation of the neural tube ends by the 28th day after fertilization. There is a laying of the pituitary gland - the central regulatory link of the endocrine system. The division of the gonads into male and female begins. The egg begins to form. The thymus gland is laid. In case of its underdevelopment in children, cellular immune responses are disrupted, resulting in purulent infections.

Week 7th.

The fetal liver becomes the center of hematopoiesis. The development of the small intestine and adrenal glands begins. The brain is rapidly developing. Reflex motor reactions of the fetus to stimuli occur in the early stages of development. At the 8th week, irritation of the near-oral region of the face causes the neck to flex in the opposite direction, which leads to the removal of the stimulated surface of the head from the stimulus - an elementary protective reflex. When irritation is applied to the skin of the fetus, rapid movement of the arms and torso can be observed. With more severe skin irritation, a common reaction often occurs, which is based on the simultaneous contraction of the flexor and extensor muscles.

Week 8

The length of the embryo is 22 - 24 mm. The outer ear is already visible on the head. Most of the organs are already formed, and in the future only their growth occurs. Bones and joints are actively developing. There is a separation of the finger phalanges. Bones and joints are actively developing. There is a process of formation of the upper lip.

Week 9

The cerebellum is formed in the brain. The first bookmarks of lymph nodes appear. The middle layer of the adrenal glands develops. In the lungs, the rudiments of the bronchi appear in the form of short, even tubes. The division of the ovaries in female fetuses begins.

Week 10

The baby is already moving, can make hand movements to the head, face, mouth, opening, closing the mouth, swallowing. There is sensitivity of the skin of the genital area. The pancreas in the fetus is formed on the 3rd month. Insulin regulates all types of metabolism, but in the fetus it mainly increases the permeability of cell membranes for amino acids. Milk teeth begin to develop. In the erythrocytes of the fetus, various substances appear that determine the blood type. From this moment, the features of the further development of the fetus begin to form, depending on the blood group.

Lecture 7. Formation and development of the fetus: 11-19 weeks

Week 11th.

In addition to spontaneous movements, fetal movements appear in response to external influences, for example, when the mother laughs or coughs. Sensitivity of the skin of the palms appears. The fetus has a grasping reaction. The sense of smell develops, which occurs when the amniotic fluid is washed by the oral, nasal cavity and pharynx of the fetus. The fetus smells the food taken by the mother. A different fetal reaction to decaffeinated and decaffeinated coffee and to alcohol has been described. In addition, a sudden change in diet after childbirth can cause difficulties with breastfeeding, as the newborn remembers the smells that he felt in utero. The formation of the fetal cardiovascular system is completed. Under the influence of unfavorable factors on the mother during the formation of the cardiovascular system, heart or vascular defects may occur. The fetal kidney begins to function at the 11th - 12th week of pregnancy.

Week 12

Fruit length 6 - 7 cm.

It is already possible to distinguish fingers from toes, nails are visible. The rudiments of hair, glands and nails are laid in the skin. The external genitalia appear. By the 12th week, the thymus resembles a mature organ. The thyroid gland is already formed and capable of synthesizing iodotyrosine. Thyroid hormones regulate metabolism and ensure the growth, development and specialization of tissues, including the central nervous system, therefore, with reduced thyroid function, growth retardation is observed due to metabolic inhibition. Leukocytes appear in the blood of the fetus.

Week 13

All 20 teeth are formed. The pancreas begins to produce insulin. In the male fetus, the development of the prostate gland (prostate) begins. Sex cells actively multiply in female fetuses.

Week 14

The fetus reacts to the following substances: lactic, citric acids, urea, amino acids, proteins and salts. Swallowing movements are maximal in response to sweet, minimal - to sour and bitter. Fetal movements - in full (spontaneous, with periods of activity and rest). There are movements of the lower jaw. The handles interact with other parts of the body and with the umbilical cord. There are taste sensations. One of the forms of spontaneous activity of the fetal muscles appears - respiratory movements. The frequency of respiratory movements is high - 40 - 70 per minute. Sex cells continue to actively multiply in female fetuses. By the time of birth, their number progressively decreases and is about 4 - 5% of the original. The total number of germ cells at the time of birth is about 300,000 - 400,000.

Week 15th.

Hormones play an exceptional role at all stages of prenatal development of the body. Up to 2 - 3 months, the fetus develops under the influence of the mother's hormones that pass through the placenta (steroid hormones), as well as placental hormones. Then the fetus's own hormones begin to be produced. The production of hormones in a newborn is very small, but this deficiency is compensated by the mother's hormones that come with breast milk.

Week 16

At the end of the 16th week, the coccyx-parietal size of the fetus (the length from the head to the pelvic end in a bent state) is 12 cm, its weight is 110 g. When examining the external genitalia, the sex of the fetus can be determined. The mother's voice and music are able to reach the uterine cavity. There is a reaction to sounds, although the formation of the ear is completed at 24 weeks. Apparently, sound vibrations are perceived with the help of skin and bone structures. The fetus may gain weight in response to listening to certain music. Fetal erythrocytes contain fetal hemoglobin, which has a high affinity for oxygen, which is important for providing the fetus with oxygen, since in this case hemoglobin saturation with oxygen is better. Adult hemoglobin begins to be synthesized in the fetus from the 16th week and at the 8th month it is only about 10%, by the time of birth - about 30%, and by 4-5 months of a child's life, fetal hemoglobin is almost completely replaced by adult hemoglobin . Fetal hemoglobin (0.1 - 2%) is preserved in adults. In the fetus, especially in recent months, the saturation of blood hemoglobin with oxygen is reduced. As a result, a compensatory reaction occurs - the number of erythrocytes in the blood increases and the content of hemoglobin in it increases.

Week 17th.

There is skin sensitivity of the abdomen and buttocks. The formation of all departments of the conduction system of the heart, which ensure its automatic work, is being completed. The formation of the uterus in the female fetus ends. The rudiments of milk teeth begin to be covered with dentin (the main tissue of the tooth). The laying of permanent teeth takes place. The bud of a permanent tooth is located behind each bud of a milk tooth.

Week 18

The size of the fetus is 20 - 22 cm, weight 250 g. Multiparous women begin to feel fetal movement, which is a manifestation of spontaneous activity of the fetal muscles - periodic phase contractions of the extensor muscles, which are common. Movement is usually felt 4-8 times per hour. The frequency of movements increases when the blood of the mother, and consequently the fetus, is depleted of nutrients and oxygen. In the process of fetal motor activity, the activity of the heart increases, blood pressure rises, blood flow accelerates throughout the body and through the placenta, which leads to an increase in oxygen and nutrients in the blood. The motor activity of the fetus contributes to the development of its muscles and brain.

Week 19

The size of the fetus is 24 cm, weight 280 - 300 g. The urine formed has a reduced density, its amount is small: at 5 months - 2.2 ml / h, and by birth - 26.7 ml / h. Since the formed urine is excreted into the amniotic fluid, the excretory function is performed by the placenta. Most of the end products of fetal metabolism, toxic to it and subject to excretion, pass into the mother's blood through the placental membrane. Thus, the placenta performs not only respiratory, nutritional, but also excretory functions for the fetus.

Lecture 8. Formation and development of the fetus: 20-34 weeks

Week 20

The fetus weighs a little over 300 g. The length of the fetus is already 25 - 26 cm. The skin becomes less transparent, the whole body is covered with soft fluffy hair and a cheese-like lubricant. You can see some hair on the head. In the intestines, the original feces - meconium - begin to form. The eyes are still closed, but the fetus is well oriented in the uterine cavity. For example, twins and twins are able to find each other's face and hold hands. Primiparous women begin to feel the fetal movement, which is a manifestation of the spontaneous activity of the fetal muscles - periodic phase contractions of the extensor muscles. Movement is usually felt 4-8 times per hour. The frequency of movements increases when the blood of the mother, and consequently the fetus, is depleted of nutrients and oxygen. In the process of fetal motor activity, the activity of the heart increases, blood pressure rises, blood flow accelerates throughout the body and through the placenta, which leads to an increase in oxygen and nutrients in the blood. The motor activity of the fetus contributes to the development of its muscles and brain. The heart rate of the fetus in the second half of pregnancy is 130 - 150 beats per minute.

Week 21st.

The fetus weighs a little more than 400 g. In the rudiment of milk teeth, the deposition of calcareous salts begins and the final formation of the main tooth tissue. Enamel formation occurs somewhat later.

Week 22

The fetus weighs about 500 g, the length of the fetus is 26 - 28 cm. Between the 5th and 7th month, if there are male hormones in the blood of the fetus, the hypothalamus develops according to the male type, in their absence - according to the female.

Week 23rd.

The fetus weighs a little over 500 g, the length of the fetus is 28 cm. The ability to dream appears - for the first time, a phase of REM sleep is observed, determined by eye movements.

Week 24th.

The fetus weighs about 600 g. The characteristic folding of the skin with subcutaneous fatty tissue is determined. You can usually see eyebrows and eyelashes. The total number of nerve cells in the central nervous system reaches the highest value. A fetus born at this time will try to breathe, but is not yet viable. He can survive only if he is in special conditions, the presence of artificial ventilation of the lungs and intensive care.

Week 25th.

The length of the fetus is 30 cm. The fetus weighs about 650 g. The process of development of alveolar ducts and alveoli begins in the lungs. The bone marrow develops intensively. By this time, the bone marrow begins to function as the main hematopoietic organ.

Week 26th.

The length of the fetus is about 30 - 32 cm. Body weight 600 - 800 g. Eyes open for the first time. The fetus is able to respond with increased heart rate to the illumination of the anterior abdominal wall of the mother. The structures responsible for the central regulation of respiration reach sufficient maturity. This ensures that they can be immediately included in the work after the birth of the child. Such a fetus can be born alive, perform extrauterine respiratory movements and survive if kept in a special incubator.

Week 27th.

The length of the fetus is 33 - 35 cm. The body weight is 900 - 1000 g. The lungs of the fetus are not an organ of external respiration, but they are not collapsed. The alveoli and bronchi are filled with fluid that is produced by the alveoli. The presence of fluid in the lungs contributes to their development, as they are in a straightened state. External respiration of the fetus is carried out with the help of the placenta, which receives mixed blood from the abdominal aorta through the umbilical arteries. In the placenta, gas exchange takes place between the blood of the fetus and the blood of the mother. Fetal respiratory movements do not provide gas exchange, but they contribute to the development of the lungs, respiratory muscles and blood circulation of the fetus, increasing blood flow to the heart due to the periodic occurrence of negative pressure in the chest cavity.

Week 28

The length of the fetus is 35 cm, weight 1000 - 1100 g. Subcutaneous fatty tissue is poorly developed. The skin is wrinkled. The thin skin of red color is covered with cheese-like grease. Pronounced development of vellus hair covering the whole body. The cartilages of the nose and ears are soft. The nails do not reach the end of the toes and hands. In boys, the testicles are not lowered into the scrotum; in girls, the small labia are not covered by the large ones. Eyes open. The pupillary membrane disappears from the eyes. In case of premature birth in this period, a newborn without concomitant pathology with careful professional care can survive. During childbirth in this period, the cry of the child already repeats the voice characteristics of the mother, which indicates the intrauterine perception of the mother's speech by the fetus.

Week 29

Fruit length 35 cm, weight 1100 g. Thin red skin covered with cheese-like grease. In the event of a premature birth at this time, a newborn without concomitant disorders with careful professional care can survive.

Week 30th.

The length of the fetus is 35 - 37 cm, weight 1200 g. The structure of the cerebral cortex reaches a high degree of development by the end of the prenatal period of development, which is associated with its intensive functioning. 2 - 3 months before birth, the fetus, reacting with distinct movements to a sudden sound irritation, with the repetition of a sound, gradually reduces the motor reaction, and then completely stops movement. If, after this, other stimuli are presented, including other sounds, then the fetal motor reaction can be observed again. Thus, in the second half of prenatal development, the functions of the cortex should already be defined as tentative-exploratory.

Week 31st.

The fruit reaches a length of 40 - 42 cm and a weight of about 1500 - 1700 g. The surface of the skin is still red and wrinkled. Dreams, manifested by the REM phase, occupy the entire time of sleep. If preterm birth occurs, the newborn usually survives with appropriate care.

...

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Diagnosis of young children

DIAGNOSTICS OF EARLY CHILDREN(1-3 YEARS)

Diagnostics cognitive development

The study fixes the understanding of the instructions, speed, accuracy of execution, the adequacy of the action, interest, acceptance of help, orientation towards the result, learning ability, reaction to success.

color gnosis(4 colors : red, blue, yellow, green)

Regulations:

difference from 1.5-2 years;

choice by name - in 2-3 years;

independence of the name - in 2.5-3 years.

Stimulus material: color sets of didactic games "Butterflies and wings", "Fish and tails", "Flower and petal", "Socks and mittens", "Leaves", etc.

Instruction example:

1) "put a petal of a suitable color for each flower";

2) "show me where the red is (blue, yellow, green) petal";

3) "Name the color of this flower."

Other tasks are presented in the same way.

Regulations:

comparison - from 1.5-2 years;

choice by name - at 2 years;

independence of the name - in 3 years.

Stimulus material: circle (ball, square (dice, rectangle (brick, triangle) (roof) two sets of four primary colors.

Instruction example:

1) "give me the same" (shape and color match);

2) "show me where the cube is";

3) "name the form."

subject gnosis

Stimulus material: 10-12 cards showing familiar objects (lotto for kids).

Instruction:

1) "show me where it's drawn.";

2) "what is drawn?" or "what is it?"

Regulations:

At 1.5-2 years old, 4-5 pictures are called.

At 2.5 years old, they name many objects from groups: toys, dishes, clothes, furniture.

At 3 years old, children know and name all objects, their properties and qualities; some generalizing words are formed in the passive dictionary. concepts: toys, clothes, furniture, shoes.

Method "Select by sample" (paired pictures)

Stimulus material: six pairs of identical subject pictures.

Regulations:

choice from two monk cards - at 2 years old;

choice of four pictures - at 3 years old.

For children older than 4 years, the technique is presented if they cannot cope with the classification.

constructive praxis (method "Cut pictures")

Stimulus material: pictures cut into two and three parts with different cut configurations.

Regulations:

split picture of two fragments - at 2.5-3 years;

cut picture of three fragments - at 3 - 3.5 years.

Analysis of results:

1) perform purposeful actions;

2) connects the parts without analyzing the resulting whole;

3) application with turns;

4) visual ratio of parts without attachment.

Imitation construction (the method is offered to children 2.5-3 years old)

Stimulus material: cubes, rectangular bars (bricks, triangular prisms (roof, hemispheres of different colors.

Analysis of results:

1) imitation of the external manipulations of an adult without taking into account the shape, size and spatial relationships (what forchildren 3 years is inadequate);

2) imitation of manipulations, taking into account the shape, size and spatial arrangement;

3) comparison and correction of errors;

4) accurate reproduction of the arrangement of figures without errors and corrections;

5) sample self-analysis and reproduction.

Spatial Gnosis

Stimulus material: small toys and pictures packed in a box.

Instruction example:

"Put the bear near the box", "Put it in the box", "Put it on the box", "Hide the picture under the box", "Get it out from under the box", "Show me where the top is (bottom)", "Walk straight (back)".

Regulations:

2.5-3 years - children understand prepositional case constructions; make mistakes in 1-2 tasks, are easily corrected;

3.5-4 years - perform all tasks.

Diagnostics ways of activity.

Pyramid folding. Folding nesting dolls

Stimulus material: a pyramid of four and six rings with a cap.

Regulations:

remove the rings from the pyramid - at 1 year;

collect a pyramid without taking into account the diameter of the rings - in 1.5-2.5 years;

they assemble a pyramid taking into account the diameter of the rings and setting the result without samples and trying on - in 3-3.5 years; visual correlation work.

Analysis of results:

1) non-specific manipulative actions (the child knocks on the table, brings it to his ear, rattles, takes it in his mouth, etc.). These actions are inadequate;

2) simple manipulation (specific manipulation);

3) a power test (for example, a child puts a small nesting doll into the lower part of a large one and vice versa, while using force (presses, not taking into account the properties of the object);

4) purposeful trial (the child notices mistakes, corrects them and finds the right way to solve them);

5) trying on (the child still cannot correlate objects at a distance and brings them to each other, noticing the discrepancy, changes them);

6) visual ratio (the child immediately correctly solves the problem, visually correlating the elements).

Children 3 years old with safe intelligence can work with visual correlation, it is acceptable to try on or a purposeful test. Lack of these methods by 3 years testifies about mental deficiencies. Up to 2.5 years it is legal to use force.

Method "Inserts" ("Misochki")

Stimulus material: seven cylindrical or square cups (liners) different sizes of four primary colors.

Analysis of results:

1) non-specific manipulations (use of insert for purposes other than intended; inappropriate actions);

2) specific manipulations (cognitive);

3) power test (action by force, without taking into account the properties and size of the insert);

4) chaotic test (intermediate way of performing a task, when trial and force actions are combined);

5) purposeful trial (self-correction of errors with finding the final solution);

6) trying on (determining the inconsistency of the liners by bringing them to each other;

7) visual correlation (correct decision based only on

visual analysis);

Up to 2.5 years, a power test is possible. By the age of 3, a visual ratio is formed, a purposeful test or trying on is acceptable. Non-specific manipulations in activity by 2.5-3 years testify about the decline of intellectual development.

Taking into account the methods of activity is important for determining the level of mental development of the child. If a child achieves results using lower methods than age, one should evaluate learning ability or draw a conclusion about a certain form of mental development disorder. High learning ability, i.e. a quick transition from a low method to a higher one, evidence for the child. Lack of learning ability and exercise capacity, as well as a result-oriented attitude, can be associated with a violation of both the emotional-volitional and cognitive spheres.

Method "Mailbox" ("Box of Forms") (L. A. Wenger, G. L. Vygodskaya, E. I. Leonhard)

Stimulus material: a wooden box or plastic box with five slots - semicircular, triangular, rectangular, square, hexagonal and ten three-dimensional geometric shapes.

Analysis of results:

up to 3 years, a power test is allowed;

at 3 years and older, purposeful tests with elements of visual correlation appear.

The child acts by force, i.e., pushes the figure into the first slot that comes across or into the one into which the adult lowered the previous figure. samples:

the child goes from hole to hole, trying to push a figure into each of them; trying on: the child begins to focus on the shape of the slot and the figure. At the same time, he still cannot correlate the forms visually at a distance, therefore he applies the figure to a slit that is similar, from his point of view. So, a hexagon is often applied to a square, then immediately transferred to the desired slot, a semicircle to a triangle, and vice versa. With this method, there are also difficulties with the reversal of a triangle and a semicircle. visual correlation: the child visually correlates the shape of the slot and the figure and always lowers the figure into the desired slot; in this case, the figures are rotated in advance, in the air.

Tasks with household items (according to O. V. Bazhenova)

stimulus material and study: the child is presented with an appropriate household item with a request to perform a certain action with it.

Regulations:

15 months - brings a spoon to his mouth, drinks well from a cup himself, can

take a pill out of the bottle, draw scribbles with a pencil, show interest in a book;

18 months - removes mittens, socks, leafing through a book, turning it over

at the same time 2-3 pages, pointing to pictures, eats thick food with a spoon on their own. Able to reproduce actions often observed in life; if, in front of a child, a toy is hidden under one of two identical objects, and then the objects are swapped, he finds

a toy in a new place;

2 years old - starts the spinning top, inserts the key into the keyhole, turns the door handle, presses the bell button, feeds and cradles the doll, drives the car, leafs through the book - each page separately, puts on socks, shoes, panties, plays a number of logically connected

actions;

2.5 years - imitates a large number of actions of adults with household items, in the game acts in an interconnected and sequential manner (wakes up the doll, dresses it, feeds it, takes it for a walk, etc.). He dresses independently, but still does not know how to tie shoelaces, fasten buttons;

3 years - imitates a large number of actions of adults with household items, plays a role in the game, dresses independently, fastens buttons, ties shoelaces with a little help from an adult.

Game development diagnostics.

Children are encouraged to play with familiar toys.

Analysis of the level of development games:

2) manipulation with objects - up to 2 years;

3) procedural game actions - from 2 years (for example, carries a car, dresses and undresses a doll, etc.);

4) procedural game with design elements - from 2-3 years (for example, loads a car with cubes, rolls a doll, etc.);

5) story game - by 3 years.

Diagnostics motor development.

General motor skills.

Static and dynamic coordination are determined by the following parameters:

1 year - independent walking;

1.5-2 years - climbs and descends the stairs, holding on to the handrail; steps over an obstacle on the floor; stands on a bench 20 cm from the floor;

2.5 years - bounces, simultaneously separating both legs from the ground, with support; jumps over several obstacles; bends over an object;

3 years - climbs up the stairs in 10 steps 12-15 cm high, alternately puts his feet on each step; jumps on two legs without support, stands on one leg for 10 s with open eyes.

Simultaneity of movements: on the sides of the box are large buttons or coins in denominations of 20 rubles. three on each side. On a signal, the child must simultaneously take a coin with both hands from each side and put it into the box. Speed ​​is not taken into account. The test is considered failed if the hands move at different times.

Distinctness of movements: a 3-year-old child is invited to hit the table hard with a percussion hammer. The presence is noted (or absence) synkenesium.

Fine finger movements

The degree of differentiation of movements and the possibility of actions with small objects are assessed.

Regulations:

2 years - repeat strokes, draw circles;

2.5-3 years old - draw straight lines, circles according to the show; can draw a person - "cephalopod".

oral praxis:

lips (pull out lips with a tube, stretch into a smile);

cheeks (inflate and retract cheeks);

tongue (put the tongue on the lower lip, lick the upper lip, make a “slide” out of the tongue).

The presence of deviation of the tongue, asymmetry of the grin testify about neurological symptoms. Strength is noted (strong, weak, volume (whether movements are brought to an end, switchability (fast, slow) oral movements.

Memory research

Run a series from memory instructions: get up, open the door, sit down at the table, open the box, take a pencil.

Regulations:

1.5 years - perform 3 actions;

2 years - perform 3-4 actions;

3 years - perform 5 actions.

The game "What has changed - what has not become"

The child is presented with four pictures, which he names. Then the child is asked to turn away, and the experimenter removes one of the pictures and replaces the other or swaps them. Asks the child to find changes.

Failure to complete the task testifies about the difficulties at the stage of reproduction.

Attention research

Method "Visual dictation"

Stimulus material: three tables of 16 cells, where familiar pictures are drawn (out of order).

Regulations:

For children 2-2,5 years - find two repeating pictures;

For children 3-4 years old - find two repeating pictures;

For children 5 years - looking for pictures in a table.

Instruction: "Here, on the plate, there are pictures. Look and close all the same (e.g. houses). As fast as possible. But make no mistake."

Analysis of results:

speed of execution of one table - 1.5 minutes.

Attention disorders:

1) increased distractibility (impaired concentration);

2) attention generalization (dependence of attention on external influences);

3) "stuck" attention (impaired switchability, poor ability to move from one object to another;

4) limited attention span (inability to perceive at the moment the required amount of information).

When studying the emotional-volitional sphere and behavior are taken into account: contact, duration of concentration of attention, emotional background of mood, reaction to encouragement and censure, presence or absence of motor disinhibition.

1. Contact:

a) light, quick contact;

b) superficial;

c) contact is established with difficulty;

d) leaves contact;

e) protest reaction.

2. Attention:

a) gaze fixes (does not fix);

b) stable (unstable);

c) with good switchability from one subject to another;

d) "jamming";

e) with the phenomena of generalization.

3. Mood background:

a) normal;

b) slightly elevated (reduced);

c) euphoric;

d) depressive;

e) contrasting.

4. Reaction to encouragement and censure:

a) adequate;

b) indifferent;

c) with an increase (decrease) performance;

d) adjustment of activities;

e) no reaction;

f) refusing to act when censured;

g) aggressive reaction to censure;

h) disorganization of activities.

The results of the study are entered into the map with numerical designations in accordance with diagnostic level and age of the subject. Before starting a psychological study, a complete anamnestic information and social characteristics of the family are collected. When drawing up the conclusion, the interpretation of the state of deviant development on the basis of a qualitative analysis of the results is systematized only according to the nosological principle. Accordingly, recommendations are given on sending the child to one or another type of children's educational institution.