Federal Clinical Guidelines for Pediatrics Pokory. Clinical guidelines for the provision of medical care to children. Referral of a child to palliative care: ways of making medical decisions

Clinical guidelines for pediatrics were developed by a group of experienced pediatric specialists on behalf of the Minister of Health of the Russian Federation. We recommend that you familiarize yourself with the current version of the document for the application of national recommendations in the daily activities of a pediatrician

We recommend that you familiarize yourself with the current version of the document for the application of national recommendations in the daily activities of a pediatrician.

Download the checklist for the implementation of clinical guidelines.

↯ More articles in the journal

From the article you will learn

On their basis, under the leadership of the Ministry of Health of Russia, criteria for assessing the quality of medical care for specific groups of conditions and diseases of underage patients are being developed.

Main changes for chief medical officers in 2019

Look at the algorithm for implementing clinical recommendations that have been in effect since 2019. It was developed by the experts of the magazine "Deputy Chief Physician". Click on the sections and follow the instructions.

Are the 2019 Federal Clinical Guidelines for Pediatrics mandatory for healthcare providers to apply? In accordance with the Federal Law “On Health Protection”, when providing care to patients, attending physicians are guided by medical standards, procedures and clinical recommendations.

Referral of a child to palliative care: ways of making medical decisions

Order of the Ministry of Health of Russia dated April 14, 2015 No. 193n approved the Procedure for the provision of palliative care to children. The decision to send the child to palliative care should be made by the medical commission of the medical organization.

At the same time, the Procedure does not detail the methodology for selecting pediatric patients for referral to palliative care.

Stratification of patients into certain clinical groups is necessary for proper planning of the scope and nature of palliative care:

Category 1 - life-threatening diseases for which definitive treatment may be feasible but often fails (eg, malignancy, irreversible/malignant heart, liver, and kidney failure);
Category 2 - conditions in which premature death is inevitable, but prolonged intensive treatment can increase the life expectancy of the child and allow him to keep his activity (cystic hypoplasia of the lung / polycystic lung) ...

How to organize palliative care for children

Palliative care for children can be provided by visiting patronage services, palliative care departments, and children's hospices. View convenient tables with indicators and practical experience in the field of pediatric palliative care in the Chief Physician System.

Vaccination of Haemophilus influenzae type b in children
Very long chain fatty acid acyl-CoA dehydrogenase deficiency in children
Immunoprophylaxis of respiratory syncytial virus infection in children
Acute obstructive laryngitis (croup) and epiglottitis in children
Consequences of perinatal lesions of the central nervous system with atonic-astatic syndrome
Consequences of perinatal lesions of the central nervous system with hydrocephalic and hypertension syndromes
Consequences of perinatal lesions of the central nervous system with hyperexcitability syndrome

Pediatrics


Foreword ................................................................ ...............................................
Publication contributors .............................................................. ...............................
.........
Abbreviations ................................................................ ...................................
Allergic rhinitis .................................................................. .........................
Atopic dermatitis................................................ ......................
Bronchial asthma................................................ .........................
Urinary tract infection ............................................................... ....
Fever................................................. .........................................
Fever with no apparent source of infection ..............................................
Nephrotic Syndrome .................................................................. ................
Pneumonia................................................. ......................................
Systemic lupus erythematosus ............................................................... ..........
Febrile convulsions .................................................................. ...................
Epilepsy................................................. ...............................................
Juvenile rheumatoid arthritis .......................................................................
Subject index................................................ ....................

Dear colleagues!

Foreword

You are holding in your hands the first issue of clinical guidelines on childhood diseases, recommended by the Russian Union of Pediatricians. This compilation includes 12 recommendations for the most common childhood diseases, which were developed by leading experts and are intended for pediatricians.

Clinical guidelines describe the doctor's algorithm for diagnosing, treating and preventing diseases and help him quickly make the right clinical decisions. They are designed to introduce the most effective and safe medical technologies (including medicines) into everyday clinical practice, prevent decisions on unreasonable interventions and, thus, contribute to improving the quality of medical care. In addition, clinical guidelines become the fundamental document on the basis of which the system of continuing medical education is built.

Traditionally, clinical guidelines have been developed by medical professional communities. For example, in the USA, these are the American Academy of Pediatrics, the Society of Pediatric Neurologists, and the National Institute of Child Health. In the European Union - the British Thoracic Society, the French Association of Pediatricians, the European Respiratory Society, etc. In Russia - the Union of Pediatricians of Russia, the All-Russian Scientific Society of Cardiology, the Russian Respiratory Society, etc.

The most famous pediatric doctors with extensive experience in clinical and research work, who own the international methodology for developing clinical recommendations, were involved in writing the articles.

The development of guidelines for pediatrics has its own characteristics. For ethical reasons, conducting clinical trials is particularly difficult in children. All drugs, including those used in pediatrics, can bring both benefits and potential harm (risks). Therefore, when describing the medical treatment of children in order to improve its safety, age restrictions on the use of drugs, the features of their use in pediatric practice are given in detail, and possible risks (even insufficiently proven ones) associated with their use are described.

Clinical guidelines for pediatrics will be updated regularly (at least once every 2 years), the electronic version of the guidelines will be available on CD. The second issue will be published in 2006 and will contain about 10 new clinical guidelines. At the same time, more detailed guidelines for individual diseases and a guide to medicines used in pediatrics are being prepared.

I am sure that the clinical guidelines developed by the Union of Pediatricians of Russia will be useful in your work and will help improve the quality of medical care for your patients.

The developers of recommendations invite readers to cooperate. Comments, criticisms, questions and wishes can be sent to the address: 119828, Moscow, st. Malaya Pirogovskaya, 1a, GEOTAR-Media Publishing Group (e-mail address: [email protected]).

PARTICIPANTS OF THE EDITION

Members of the publication

Chief Editor

A.A. Baranov, Dr. honey. sciences, prof., acad. RAMS

Responsible editor

L.S. Namazova, Dr. honey. sciences, prof.

allergic rhinitis

I.I. Balabolkin, Dr. honey. Sciences, prof., corresponding member. RAMS (reviewer) M.R. Bogomilsky, Dr. honey. Sciences, prof., corresponding member. RAMS (reviewer) N.I. Voznesenskaya, Ph.D. honey. Sciences O.V. Karneeva, Ph.D. honey. Sciences I.V. Ryleeva, Dr. med. Sciences

Atopic dermatitis

L.S. Namazova, Dr. honey. sciences, prof. SOUTH. Levina, Ph.D. honey. Sciences A.G. Surkov K.E. Efendieva, Ph.D. honey. Sciences

I.I. Balabolkin, Dr. honey. Sciences, prof., corresponding member. RAMS (reviewer) T.E. Borovik, Dr. honey. sciences, prof.

N.I. Voznesenskaya, Ph.D. honey. Sciences L.F. Kaznacheeva, Dr. honey. sciences, prof. L.P. Mazitova, Ph.D. honey. Sciences I.V. Ryleeva, Dr. med. Sciences G.V. Yatsyk, dr. honey. sciences, prof.

Bronchial asthma

L.S. Namazova, Dr. honey. sciences, prof. L.M. Ogorodova, Dr. honey. sciences, prof. SOUTH. Levina, Ph.D. honey. Sciences A.G. Surkov K.E. Efendieva, Ph.D. honey. Sciences

I.I. Balabolkin, Dr. honey. Sciences, prof., corresponding member. RAMS (reviewer) N.I. Voznesenskaya, Ph.D. honey. Sciences N.A. Geppe, dr. honey. sciences, prof. (reviewer)

D.S. Korostovtsev, Dr. honey. sciences, prof. F.I. Petrovsky, Ph.D. honey. Sciences I.V. Ryleeva, Dr. med. Sciences I.V. Sidorenko, Ph.D. honey. Sciences Yu.S. Smolkin, Dr. honey. Sciences

A.A. Cheburkin, Dr. honey. sciences, prof.

urinary tract infection

Fever

Fever with no apparent source of infection

VC. Tatochenko, Dr. honey. sciences, prof.

nephrotic syndrome

A.N. Tsygin, Dr. honey. sciences, prof. O.V. Komarova, Ph.D. honey. Sciences T.V. Sergeeva, Dr. honey. sciences, prof. A.G. Timofeeva, Ph.D. honey. Sciences O.V. Chumakova, Dr. honey. Sciences

Pneumonia

VC. Tatochenko, Dr. honey. sciences, prof.

G.A. Samsygin, Dr. honey. sciences, prof. (reviewer) A.I. Sinopalnikov, Dr. honey. sciences, prof. (reviewer)

V.F. Uchaikin, Dr. honey. sciences, prof., acad. RAMS (reviewer)

Systemic lupus erythematosus

N.S. Podchernyaeva, Dr. honey. sciences, prof. O.A. Solntseva

Members of the publication

Febrile convulsions

O.I. Maslova, Dr. honey. sciences, prof. V.M. Studenikin, Dr. honey. sciences, prof. L.M. Kuzinkova, Dr. honey. Sciences

Epilepsy

O.I. Maslova, Dr. honey. sciences, prof. V.M. Studenikin, Dr. honey. sciences, prof.

Juvenile rheumatoid arthritis

E.I. Alekseeva, Dr. honey. sciences, prof. T.M. Bzarova, Ph.D. honey. Sciences I.P. Nikishina, Dr. honey. sciences, prof.

M.K. Soboleva, Dr. honey. sciences, prof. (reviewer) M.Yu. Shcherbakova, Dr. honey. sciences, prof. (reviewer)

Project Managers

G.E. Ulumbekova, President of the GEOTAR-Media Publishing Group, Executive Director of the Association of Medical Societies for Quality K.I. Saitkulov, Director of New Projects, GEOTARMEDIA Publishing Group

CREATION METHODOLOGY AND QUALITY ASSURANCE PROGRAM

This publication is the first issue of Russian clinical guidelines on childhood diseases. The aim of the project is to provide the practitioner with recommendations for the prevention, diagnosis and treatment of the most common childhood illnesses.

Why are clinical guidelines needed? Because in the conditions of the explosive growth of medical information, the number of diagnostic and therapeutic interventions, the doctor must spend a lot of time and have special skills to search, analyze and apply this information in practice. When compiling clinical guidelines, these steps have already been completed by the developers.

High-quality clinical recommendations are created according to a specific methodology that guarantees their up-to-dateness, reliability, generalization of the best world experience and knowledge, applicability in practice and ease of use. This is the advantage of clinical recommendations over traditional sources of information (textbooks, monographs, guidelines).

A set of international requirements for clinical guidelines was developed in 2003 by specialists from the UK, Canada, Germany, France, Finland and other countries. Among them are the AGREE1 clinical guidelines quality assessment tool, the SIGN 502 clinical guidelines development methodology, etc.

We bring to your attention a description of the requirements and activities that were used in the preparation of this publication.

1. Concept and project management

A management team consisting of project managers and an administrator was created to work on the project.

To develop the concept and the project management system, the project managers held many consultations with domestic and foreign specialists (epidemiologists, economists and healthcare organizers, medical information search specialists, representatives of insurance companies, industry representatives - manufacturers of medicines, medical equipment, heads of professional societies, leading developers of clinical

1 Appraisal of Guidelines for Research and Evaluation - Clinical Guideline Quality Assessment Tool, http://www.agreecollaboration.org/

2 Scottish Intercollegiate Guidelines Network - Scottish Intercollegiate Guidelines Development Organization

Creation methodology and quality assurance program

recommendations, practitioners). Reviews of the first translated edition of clinical guidelines based on evidence-based medicine (Clinical guidelines for general practitioners. - M.: GEOTAR-MED, 2004) are analyzed.

As a result, the concept of the project was developed, stages were formulated, their sequence and deadlines, requirements for stages and performers; approved instructions and methods of control.

General: prescribing effective interventions, avoiding unnecessary interventions, reducing the number of medical errors, improving the quality of medical care

Specific - see the "Treatment Goals" section of the clinical guidelines.

3. Audience

Intended for pediatricians, internists, medical specialists (eg allergists, neurologists), interns, residents, senior students.

The compilers and editors assessed the feasibility of the recommendations in pediatric practice in Russia.

Choice of diseases and syndromes. In the first issue, the diseases and syndromes most frequently encountered in the practice of a pediatrician were selected. The final list was approved by the editor-in-chief of the publication.

4. Stages of development

Creation of a management system, concepts, selection of topics, creation of a development team, literature search, formulation of recommendations and their ranking in terms of reliability, examination, editing and independent review, publication, distribution, implementation.

6. Applicability to groups of patients

The group of patients to which these recommendations apply (gender, age, disease severity, comorbidities) is clearly defined.

7. Developers

Authors-compilers (practitioners with experience in clinical work and writing scientific articles, who know English and have computer skills), chief editors of sections (leading domestic experts, chief specialists of the Ministry of Health and Social Development of the Russian Federation, heads of leading research institutions, professional societies, heads of departments), scientific editors and independent reviewers (professional staff of educational and academic institutions), editors of a publishing house (practitioners with experience in writing scientific articles, who know English, have computer skills, with at least 5 years of experience in a publishing house ) and project managers (experience in managing projects with a large number of participants with a limited time frame, knowledge of the methodology for creating clinical recommendations).

8. Developer training

Several training seminars were held on the principles of evidence-based medicine and the methodology for developing clinical guidelines.

All specialists were provided with a description of the project, the format of the article, instructions for compiling a clinical recommendation, sources of information and instructions for their use, an example of a clinical recommendation.

With all developers, the project manager and responsible editors maintained continuous communication by phone and e-mail in order to resolve operational issues.

9. Independence

The opinion of the developers does not depend on the manufacturers of medicines and medical equipment.

The instructions for compilers indicated the need to confirm the effectiveness (benefit / harm) of interventions in independent sources of information (see paragraph 10), the inadmissibility of mentioning any commercial names. The international (non-commercial) names of medicines are given, which were checked by the editors of the publishing house according to the State Register of Medicines (as of summer 2005).

10. Sources of information and instructions for their use

Approved sources of information for the development of clinical guidelines.

Creation methodology and quality assurance program

Dear colleagues!

In accordance with the Federal Law of December 25, 2018 No. 489-FZ “On Amendments to Article 40 of the Federal Law “On Compulsory Medical Insurance in the Russian Federation” and the Federal Law “On the Basics of Protecting the Health of Citizens in the Russian Federation” on clinical recommendations » Clinical guidelines are currently defined as a document containing structured information based on scientific evidence on prevention, diagnosis, treatment and rehabilitation.

This Federal Law defines a transitional period until December 31, 2021, necessary for the revision and approval of clinical recommendations in accordance with the norms introduced by the bill. The approved clinical guidelines will contain parameters that reflect the correct choice of diagnostic and treatment methods based on the principles of evidence-based medicine. The application of clinical recommendations will allow medical workers to determine the tactics of managing a patient with a specific nosology at all stages of medical care.

Clinical guidelines will be used as the basis for developing other documents regulating the process of providing medical care, including standards and procedures for providing medical care, as well as criteria for assessing the quality of medical care. Thus, at the end of the transition period, an integral system for managing the quality of medical care will be created, based on clinical recommendations that take into account the best world practices.

The Ministry of Health of the Russian Federation issued a number of orders regulating the work on the development of clinical guidelines:

Order of the Ministry of Health of Russia dated February 28, 2019 No. 101n "On approval of the criteria for the formation of a list of diseases, conditions (groups of diseases, conditions) for which clinical recommendations are developed." Currently, this list is posted on the website of the Ministry of Health of the Russian Federation https://www.rosminzdrav.ru/poleznye-resursy/nauchno-prakticheskiy-sovet;
Order of the Ministry of Health of Russia dated February 28, 2019 No. 102n “On Approval of the Regulations on the Scientific and Practical Council of the Ministry of Health of the Russian Federation”;
Order of the Ministry of Health of Russia dated February 28, 2019 No. 103n “On approval of the procedure and terms for the development of clinical recommendations, their revision, the standard form of clinical recommendations and the requirements for their structure, composition and scientific validity of the information included in clinical recommendations”;
Order of the Ministry of Health of Russia dated February 28, 2019 No. 104n "On approval of the procedure and terms for the approval and approval of clinical recommendations, the criteria for the scientific and practical council to decide on the approval, rejection or referral for revision of clinical recommendations or the decision to revise them."

According to the order of the Ministry of Health of Russia dated February 28, 2019 No. 103n “Medical professional non-profit organizations develop draft clinical recommendations and organize their public discussion, including with the participation of scientific organizations, educational organizations of higher education, medical organizations, medical professional non-profit organizations, their associations (unions ) specified in Part 5 of Article 76 of Federal Law N 323-FZ, as well as by posting it on the Internet information and telecommunications network.

According to the order of the Ministry of Health of Russia No. 102n dated February 28, 2019, after the development of clinical recommendations, they will be further considered by the Scientific and Practical Council of the Ministry of Health of Russia and approved, rejected or sent for revision in accordance with the terms and criteria regulated by the order of the Ministry of Health of Russia 104n.

With a positive decision of the Scientific and Practical Council of the Ministry of Health of Russia, clinical recommendations are approved by professional non-profit organizations.

In connection with the above, we would like to inform you that the Union of Pediatricians of Russia, a medical professional non-profit organization, has begun developing clinical guidelines for diseases, conditions (groups of diseases, conditions) included in the List for which clinical guidelines should be developed/updated. .

We also inform you that the formation of working groups will be carried out in cooperation with medical professional non-profit organizations in the relevant fields and will include, among other things, specialists providing medical care to patients of the adult age category.

The Union of Pediatricians of Russia widely involves professional communities, as well as scientific, educational organizations and the public, in the development of clinical recommendations.

President of the Union of Pediatricians of Russia,
Chief freelance pediatric specialist in preventive medicine of the Ministry of Health of Russia,
acad. RAS L.S. Namazova-Baranova

Honorary President of the Union of Pediatricians of Russia,
Chief freelance specialist pediatrician of the Ministry of Health of Russia,
acad. RAS A.A. Baranov

Vaccination of Haemophilus influenzae type b in children
Vaccination of diseases caused by the human papillomavirus
Vaccination of pneumococcal infection in children
Vaccination of rotavirus infection in children
Very long chain fatty acid acyl-CoA dehydrogenase deficiency in children
Immunoprophylaxis of meningococcal infection in children

We recommend that you familiarize yourself with the current version of the document for the application of national recommendations in the daily activities of a pediatrician.

Download the checklist for the implementation of clinical guidelines.

↯ More articles in the journal

From the article you will learn

Main changes for chief medical officers in 2019

Look at the algorithm for implementing clinical recommendations that have been in effect since 2019. It was developed by the experts of the magazine "Deputy Chief Physician". Click on the sections and follow the instructions.

Referral of a child to palliative care: ways of making medical decisions

At the same time, the Procedure does not detail the methodology for selecting pediatric patients for referral to palliative care.

Stratification of patients into certain clinical groups is necessary for proper planning of the scope and nature of palliative care:

Category 1 - life-threatening diseases for which definitive treatment may be feasible but often fails (eg, malignancy, irreversible/malignant heart, liver, and kidney failure);
Category 2 - conditions in which premature death is inevitable, but prolonged intensive treatment can increase the life expectancy of the child and allow him to keep his activity (cystic hypoplasia of the lung / polycystic lung) ...

How to organize palliative care for children

Vaccination of Haemophilus influenzae type b in children
Very long chain fatty acid acyl-CoA dehydrogenase deficiency in children
Immunoprophylaxis of respiratory syncytial virus infection in children
Acute obstructive laryngitis (croup) and epiglottitis in children
Consequences of perinatal lesions of the central nervous system with atonic-astatic syndrome
Consequences of perinatal lesions of the central nervous system with hydrocephalic and hypertension syndromes
Consequences of perinatal lesions of the central nervous system with hyperexcitability syndrome

Due to the large number of SARS, I decided to lay out recommendations for their treatment, a friend gave them to me today (she is a pediatrician). Here's the text, with some abbreviations:

MEDICAL CARE FOR CHILDREN WITH ACUTE RESPIRATORY VIRAL INFECTION (ACCUTE NASOPHARYNGITIS)

Chief Freelance

specialist pediatrician

Ministry of Health of Russia

Academician of the Russian Academy of Sciences

A.A. Baranov

Chief Freelance

infectious diseases specialist

diseases in children

Ministry of Health of Russia

Yu.V. Lobzin

These clinical guidelines were developed by the professional association of pediatricians, the Union of Pediatricians of Russia, updated and agreed with the chief freelance specialist in infectious diseases in children of the Ministry of Health of Russia in September 2014, reviewed, approved at the XVIII Congress of Pediatricians of Russia "Actual Problems of Pediatrics" on February 14, 2015.

Members of the working group: acad. RAS Baranov A.A., corresponding member. RAS Namazova-Baranova L.S., acad. RAS Yu.V. Lobzin, Prof., MD A.N. Uskov, d.m.s., prof., Tatochenko V.K., d.m.s. Bakradze M.D., Ph.D. Vishneva E.A., Ph.D. Selimzyanova L.R., Ph.D. Polyakova A.S.

DEFINITION

Acute respiratory viral infection (ARVI) is an acute, in most cases, self-limiting infection of the respiratory tract, causing upper respiratory catarrh syndrome (URI - upper respiratory infection) in the English literature), occurring with fever, runny nose, sneezing, cough, sore throat , a violation of the general condition of varying severity.

The term “ARVI” should be avoided as a diagnosis, using the term “acute nasopharyngitis” (the term “common cold” is used in the English literature), since ARVI pathogens also cause laryngitis (croup), tonsillitis, bronchitis, bronchiolitis, which should be indicated in diagnosis. In detail, these syndromes are considered separately (see FKR for the management of children with acute tonsillitis and stenosing laryngotracheitis (croup).

Acute nasopharyngitis is diagnosed with an acute runny nose and / or cough, while excluding influenza and lesions of other localization:

 acute otitis media (corresponding complaints, otoscopy);

 acute tonsillitis (mainly involvement of palatine tonsils, raids);

 bacterial sinusitis (edema, hyperemia of the soft tissues of the face, orbits, and other symptoms);

 damage to the lower respiratory tract (increased or difficult breathing, obstruction, retraction of the compliant parts of the chest, shortening of percussion sound, wheezing in the lungs);

In the absence of these signs, a viral lesion of only the upper respiratory tract is likely (ARVI - rhinitis, nasopharyngitis, pharyngitis), often accompanied by conjunctivitis. The sign of "red eyes" is easy to assess and, at the same time, very specific for excluding bacterial infection, not inferior in diagnostic value to laboratory markers of inflammation.

EPIDEMIOLOGY

ARVI is the most common human infection: children aged 0-5 years suffer, on average, 6-8 episodes of ARVI per year, in kindergartens the incidence is especially high in the 1st-2nd year of visit - 10-15% higher than in unorganized children, but at school the latter get sick more often. The incidence is highest in the period from September to April and is (recorded) 87-91 thousand per 100 thousand population. Among frequently ill children, many have an allergic predisposition and / or bronchial hyperreactivity, which leads to a more pronounced manifestation of even a mild respiratory infection.

ETIOLOGY

ARVI is caused by about 200 viruses, most often rhinoviruses with more than 100 serotypes, as well as RS virus, parainfluenza viruses, adenoviruses, bocavirus, metapneumovirus, coronaviruses. Some non-polio enteroviruses can cause similar manifestations. Rhino-, adeno- and enteroviruses cause persistent immunity, which does not exclude infection with other serotypes; RS-, corona- and parainfluenza viruses do not leave stable immunity.

The spread of viruses occurs most often by self-inoculation on the nasal mucosa or conjunctiva from hands contaminated by contact with the patient (handshake!) or with virus-infected surfaces (rhinovirus persists on them for up to a day).

Another way - airborne- when inhaling particles of an aerosol containing a virus, or when larger drops get on the mucous membranes in close contact with the patient.

The incubation period for most viruses is 24-72 hours. Isolation of viruses by patients is maximum on the 3rd day after infection, sharply decreases by the 5th day; mild shedding of the virus can persist for up to 2 weeks.

PATHOGENESIS

Symptoms of nasopharyngitis are the result not so much of the damaging effect of the virus as the reaction of the innate immune system. Affected epithelial cells secrete cytokines, incl. interleukin 8 (IL 8), the amount of which correlates both with the degree of involvement of polynuclears in the submucosal layer and epithelium, and the severity of symptoms. An increase in nasal secretion is associated with an increase in vascular permeability, the number of leukocytes in it can increase 100-fold, changing its color from transparent to white-yellow (accumulation of leukocytes) or greenish (peroxidase) - there is no reason to consider a change in the color of the secret as a sign of a bacterial infection. Coronaviruses leave the cells of the nasal epithelium intact, the cytopathic effect is inherent in adenoviruses and influenza viruses.

Installation on the fact that with any viral infection, the bacterial flora is activated (“viral-bacterial etiology of acute respiratory infections” based, for example, on the presence of leukocytosis in a patient) not supported by practice: in most patients, ARVI flows smoothly without the use of antibiotics. Bacterial complications of SARS occur rarely (1-5% of patients). As a rule, they are already present on the 1-2nd day of illness; in later periods they occur most often due to superinfection. It should be borne in mind streptococcal pharyngitis, which may not be accompanied by the classic "tonsillitis with raids"; bright, "scarlet" color of the palatine arches and especially the posterior pharyngeal wall may indicate a streptococcal infection. In such cases, a rapid diagnostic test can help. It is also necessary to remember about "silent" pneumonia, which is difficult to identify clinically (especially if the patient is not percussed).

CLASSIFICATION

The division of nasopharyngitis according to severity is possible depending on the level of temperature and the severity of general non-specific symptoms.

CLINICAL PICTURE

It varies widely, manifestations of viral infections of various etiologies overlap each other. In infants, fever is common, discharge from the nasal passages, sometimes there is anxiety, difficulty feeding and falling asleep. In older children, typical manifestations are: runny nose, difficulty in nasal breathing (peak on the 3rd day, duration up to 6-7 days), in 1/3-1/2 patients - sneezing and/or cough (peak on the 1st day , the average duration is 6-8 days), less often - a headache (20% on the 1st and 15% - up to the 4th day). In a number of children, after suffering from ARVI, some symptoms, such as coughing, can persist up to the 10th day and even longer.

The vast majority of patients have normal or subfebrile temperature, and among those hospitalized, febrile fever is more often detected, which in 82% of patients decreases on the 2-3rd day of illness; for a longer time (up to 5-7 days), febrile condition lasts with influenza and adenovirus infection. The persistence of this temperature for more than 3 days (in the absence of signs of influenza or adenovirus infection) should be alert for a bacterial infection. A repeated rise in temperature after a short-term improvement may indicate the same, although more often it is a sign of superinfection.

COMPLICATIONS

Complications of nasopharyngitis are observed infrequently, are associated with the addition of a bacterial infection and are manifested by the following symptoms:

Persistence of nasal congestion for more than 10-14 days, deterioration after improvement, pain in the face may indicate the development of bacterial sinusitis;

Painful “clicks” in younger patients, a feeling of “congestion” in the ear in older children is a consequence of the dysfunction of the auditory tube during a viral infection, due to a change in pressure in the middle ear cavity, which can lead to the development of acute otitis media.

ARVI and, especially, influenza predispose (the more often the younger the child) to infection of the lungs, primarily with pneumococcus with the development of pneumonia. In addition, a respiratory infection is a trigger for exacerbation of chronic diseases, most often bronchial asthma and urinary tract infections.

DIAGNOSTIC EXAMINATION

Examination of a patient with nasopharyngitis aims to identify bacterial foci that are not determined by clinical methods. Urinalysis (including using test strips on an outpatient basis) is mandatory in all febrile children, because. 5-10% of infants and young children with urinary tract infection also have viral co-infection with clinical signs of SARS.

A blood test is justified with more pronounced general symptoms. Leukopenia, characteristic of influenza and enterovirus infections, is usually absent in other acute respiratory viral infections, in which in 1/3 of cases leukocytosis reaches a level of 10-15∙109/l and even higher. Such figures in themselves cannot justify the prescription of antibiotics, but may be a reason to search for a bacterial focus, first of all, “silent” pneumonia, in relation to which the prognostic value (PPR) of leukocytosis > 15∙109/l reaches 88%, and CRP > 30 mg/l - almost 100%. But in children of the first 2-3 months of life and with acute respiratory viral infections, leukocytosis can reach 20 ∙109 / l or more.

Indications for chest radiography are:

Preservation of febrile temperature for more than 3 days,

Identification of the above high levels of inflammatory markers,

Appearance of physical symptoms of pneumonia (see FCR for the management of pneumonia in children).

It should be remembered that the detection in the pictures of an increase in the bronchovascular pattern and the shadow of the roots of the lungs, an increase in airiness are not an indication for antibiotic therapy.

Otoscopy is a routine method and is indicated for all patients with symptoms of nasopharyngitis.

X-ray of the paranasal sinuses for patients with ARVI in the acute period (the first 10-12 days) is not indicated - it often reveals inflammation of the sinuses caused by the virus, which resolves spontaneously within 2 weeks.

Routine virological and / or bacteriological examination of all patients does not make sense, because. does not affect the choice of treatment, with the exception of a rapid test for influenza in high-fever children and a rapid test for streptococcus in tonsillitis.

TREATMENT

ARVI is the most common reason for the use of various drugs and procedures, most often unnecessary with unproven action, often causing side effects. Therefore, it is very important to explain to parents the benign nature of the disease and tell them how long the symptoms are expected to last, as well as to convince them that minimal interventions are sufficient.

Antiviral therapy, which is absolutely justified for influenza, is less effective for ARVI and is not required in most cases. It is possible to prescribe interferon-alpha (ATC code: L03AB05) no later than the 1-2nd day of illness, however, there is no reliable evidence of its effectiveness. It may be justified to administer it in the form of nasal drops - 1-2 drops 3-4 times a day, rectal suppositories are also used ( interferon alpha-2b) within 2-5 days:

Newborns: gestational age<34 недель 150 000 МЕ трижды в день, >34 weeks up to 150,000 IU twice a day;

Children aged 1 month to 7 years - 150,000 IU twice a day;

Children over 7 years old - 500,000 IU twice a day.

umifenovir (ATC code: J05AX13): children 2-6 years old 0.05, 6-12 years old - 0.1, >12 years old - 0.2 g 4 times a day,

Cough relief: since coughing in nasopharyngitis is most often caused by irritation of the larynx with a flowing secret, nasal toilet - the most effective method of stopping it. Cough associated with a "sore throat" due to inflammation of the pharyngeal mucosa or its drying out when breathing through the nose is eliminated warm sweet drink(2C) or, after 6 years, using lozenges or lozenges containing antiseptics (2C).

Antitussives, expectorants, mucolytics, including numerous proprietary preparations with various herbal remedies, are not indicated for the "cold" due to inefficiency (2C), which has been proven in randomized trials.

Steam and aerosol inhalations have not shown any effect in randomized trials and are not recommended by the World Health Organization (WHO) for the treatment of the "cold" (2B) .

Atropine-like antihistamines have not been shown in randomized trials to reduce runny nose and nasal congestion (2C).

Taking vitamin C (200 mg/day) from the onset of ARVI does not affect the course (2B).

MANAGEMENT OF CHILDREN

Semi-bed mode with a quick transition to the general after the temperature drops. A re-examination is necessary if the temperature persists for more than 3 days or the condition worsens.

Hospitalization is required in case of severe course and development of complications.

PREVENTION

Controlling the transmission of infection - thorough hand washing after contact with the patient, is of paramount importance. Wearing masks is also important. cleaning surfaces around the patient, in kindergartens - rapid isolation of sick children, compliance with the ventilation regime and the duration of walks.

Hardening protects against infection with a small dose of infection and probably contributes to an easier course of SARS.

Vaccination. Although there are no vaccines against respiratory viruses yet, annual influenza vaccination from the age of 6 months. reduces the incidence of SARS. In children of the first year of life from risk groups (prematurity, bronchopulmonary dysplasia (FKR for the provision of medical care to children with BPD), congenital heart defects (CHD), neuromuscular disorders), palivizumab is used to prevent RS-virus infection in the autumn-winter season - i.v. m, at a dose of 15 mg / kg monthly - from 3 to 5 injections

Reliable evidence of a decrease in respiratory morbidity under the influence of immunomodulators ( taktivin, inosine pranobex, etc.), herbal preparations or vitamin C - no.

OUTCOMES AND FORECAST

As indicated above, SARS, in the absence of bacterial complications, are transient, although they can leave symptoms such as discharge from the nasal passages and cough for 1-2 weeks. The opinion that SARS, especially frequent ones, lead to the development of "secondary immunodeficiency" is unfounded.

Federal Clinical Guidelines for Pediatrics Pokory. ﻿ Clinical guidelines for the provision of medical care to children. Referral of a child to palliative care: ways of making medical decisions

Main changes for chief medical officers in 2019

Referral of a child to palliative care: ways of making medical decisions

How to organize palliative care for children

Main changes for chief medical officers in 2019

Referral of a child to palliative care: ways of making medical decisions

How to organize palliative care for children

Federal Clinical Guidelines for Pediatrics Pokory. Clinical guidelines for the provision of medical care to children. Referral of a child to palliative care: ways of making medical decisions