DYNAMICS OF CLINICAL-CHEMISTRY VALUES UNDER THE HEMOLYTIC DISEASE OF THE NEWBORNS
Nadezhda Liavina
Master's Degree Student, Kuban State University,
Russia, Krasnodar
Nina Ulitina
Associate Professor, Candidate of Biological Sciences, Kuban State University,
Russia, Krasnodar
Irina Sysoeva
managerress, Regional Affiliated Hospital №2,
Russia, Krasnodar
ANNOTATION
The article is devoted to the current problem of obstetrics and neonatology, in particular hemolytic disease of the newborn. The blood of 162 newborns was studied, the levels of bilirubin, hemoglobin and reticulocytes were determined using automatic analyzers Cobas Integra 400 plus and Sysmex 21N. As a result of the study, it was revealed that reticulocytosis, hyperbilirubinemia and anemia are observed in all forms of hemolytic disease of the newborn.
ABSTRACT
The article is devoted to the up to date topical issue concerning obstetrics and neonatology: hemolytic disease of the newborn. blood examination of 162 newborns is carried out; the level determination of bilirubin, hemoglobin and reticulocytes is performed by automatic analyzers Cobas Integra 400 plus and Sysmex 21N. As a result of research it has been found that reticulocytosis, hyperbilirubinemia and anemia are present in all forms of the hemolytic disease of the newborn.
Keywords: hemolytic disease of the newborn; hyperbilirubinemia; reticulocytosis; rhesus conflict.
keywords: hemolytic disease of the newborn; hyperbilirubinemia; reticulocytosis; rhesus incompatibility.
Purpose of the study- to identify clinical and biochemical blood parameters that change with various forms of hemolytic disease of the newborn.
Research material- cord and venous blood of newborns.
Research methods: photometric and non-cyanide hemoglobin method.
Laboratory studies were performed on automatic analyzers Cobas Integra 400 plus, ABL 800 FLEX and Sysmex 21 N.
During the last decade, neonatal morbidity has increased from 2,425 per 10,000 live births in 2004 to 6,022.6 in 2014. An analysis of the nature of morbidity and the structure of early neonatal mortality shows that such causes as neonatal infection, pathology due to inadequate assistance in childbirth have ceased to be the leading causes of morbidity and mortality in newborns. Currently, a special role is given to the significance of fetal pathology, which subsequently leads to a violation or impossibility of adapting the newborn to extrauterine life. In 2014, the structure of the causes of infant mortality consisted mainly (69%) of the pathology of the perinatal period and congenital anomalies. A great influence on the structure of neonatal morbidity and mortality is exerted by hemolytic disease of the newborn and fetus, a disease of newborns caused by an immunological conflict due to incompatibility of the blood of the mother and fetus for erythrocyte antigens. The detection of cases of hemolytic disease of the newborn in Russia over the past five years has not shown a downward trend, amounting to 87.0 per 10,000 live births in 2014 (88.7 per 10,000 live births in 2004).
Among the diseases of newborns, hemolytic disease occupies a special place. Having various clinical manifestations, the pathology is characterized by an intense increase in the level of conjugated bilirubin, which leads to damage to the central nervous system and other organs, as well as to permanent disability or death. In Russia in 2014, hemolytic disease of the newborn was diagnosed in 0.9% of newborns. Currently, significant progress has been made in the treatment of icteric forms of hemolytic disease of the newborn (HDN), but this, unfortunately, does not apply to the edematous form of HDN that develops as a result of the Rh conflict. One of the main activities of modern medicine is to reduce not only perinatal mortality, but also perinatal morbidity. These indicators are affected by cases of hemolytic disease of the fetus and newborn. Despite the good knowledge of the causes of the development of hemolytic disease of the newborn, significant difficulties in its treatment still exist. The developed tactics for the treatment of hemolytic disease in the postnatal period is more aimed at eliminating hyperbilirubinemia and preventing possible encephalopathy. The rational use of conservative treatment led to a decrease in the cases of exchange transfusion in newborns with hemolytic disease, but could not completely eliminate the need for exchange transfusion in HDN.
Results and discussion
In the course of the study, 162 newborns were examined, of which the experimental group consisted of 142 newborns with hemolytic disease: 27 (19%) with Rh-conflict and 115 (81%) with incompatibility for antigens of the ABO system, and 20 newborns of the neonatal department represented the control group .
During the observation, the following laboratory parameters were analyzed: the level of total bilirubin, the level of hemoglobin, the number of erythrocytes and reticulocytes.
In all newborns with hemolytic disease, the concentration of total bilirubin in the blood serum was determined in the first hours after birth (from the umbilical cord vein) and in dynamics at least twice a day until it began to decrease (with the calculation of the rate of increase in the concentration of bilirubin in the blood). In the first five days of life, newborns were examined daily to determine the level of hemoglobin and count the number of erythrocytes and reticulocytes.
The results of the examination of newborns in the first hours of life with Rh-conflict HDN are shown in Table 1.
Table 1.
Laboratory parameters of newborns diagnosed with HDN with Rh-incompatibility (at birth)
|
Laboratory indicators |
Severity of HDN |
Age norms |
||
|
moderate |
||||
|
Hemoglobin (g/l) |
||||
|
Reticulocyte count |
||||
Studies have shown that Rh-conflict TTH in 63% of cases had a severe course (in 17 out of 27). Moderate severity of the disease was diagnosed in 23% of cases (6) and mild in 14% (4).
Rh-conflict HDN is characterized by early onset of hyperbilirubinemia. According to our observations, in 22 out of 27 cases, the appearance of icteric coloration of the skin is noted in the first 24 hours of life, including in 15 infants - in the first 6 hours. In ABO-THN, jaundice was diagnosed in 17 out of 115 newborns in the first 6 hours of life.
The indicators of red blood of newborns at birth (hemoglobin, erythrocytes) correspond to age norms. Reticulocytosis (more than 43%) was detected in moderate and severe hemolytic disease of the newborn with Rh incompatibility.
The results of the examination of newborns in the first hours of life with hemolytic disease according to the ABO system are shown in Table 2.
Table 2.
Laboratory indicators of newborns with a diagnosis of HDN according to the ABO system (at birth)
|
Laboratory indicators |
Severity of HDN |
Age norms |
||
|
moderate |
||||
|
Hemoglobin (g/l) |
||||
|
Number of erythrocytes (10 12/l) |
||||
|
Reticulocyte count |
||||
|
Cord blood bilirubin level (µmol/l) |
||||
|
Hourly increase in bilirubin levels in the first 12 hours after birth (µmol/l) |
||||
During the implementation of the conflict on antigens of the ABO system, a mild form of the disease was diagnosed in 49 newborns (42.6%) out of 115, moderate - in 44 (38.3%) and severe - in 22 (19.1%). In the implementation of hemolytic conflict for antigens of the ABO system, a mild form of hemolytic disease is more often diagnosed. The conflict on antigens of the ABO system is characterized by the appearance of jaundice at the end of the first day of a child's life - in 89 cases out of 115. The indicators of the red blood of newborns at birth (hemoglobin, erythrocytes) correspond to age norms. Reticulocytosis (more than 43%) was detected in moderate and severe hemolytic disease of the newborn.
Severe TTH more often developed in case of a conflict on the antigens of the Rhesus system (63.0%) than in the case of a conflict on the antigens of the ABO system (39.0%). In newborns, hemolytic disease with incompatibility for antigens of the ABO system predominates (81%) over Rhesus conflict (19%). The most important symptom characterizing HDN is hyperbilirubinemia. It is detected at different times both in infants with Rh-conflict HDN and in ABO system conflict. Jaundice in newborns appears primarily on the face, most noticeable in the nose and nasolabial triangle. At the beginning of the illness, the face of the infant is always more icteric than the body. This is due to the thin skin on the face, the presence of developed subcutaneous fat and better blood supply to tissues in this area. The development and course of HDN has its own patterns: the conflict is realized in newborns already from the first pregnancy with a conflict according to the ABO system or from a second one with an Rhesus conflict. The severity of Rh-conflict HDN directly depends on the titer of maternal Rh antibodies and the match between the blood groups of the mother and the newborn. The most important sign that characterizes the various forms of HDN is jaundice. With Rh-conflict hemolytic disease in 55% of newborns, its early appearance was noted, in the first 6 hours of life. Early onset of jaundice, in the first 6 hours of life, is diagnosed more often in Rh-conflict TTH (55.6%) than in ABO-THTH (14.8%). With ABO-THN, jaundice was detected in 77.3% of the observed patients at the end of the first day of life. In 84.3% of cases, hyperbilirubinemia, which appeared early and increased in intensity, was the only clinical sign (monosymptom) of HDN.
conclusions
Based on the results of the observation, the following conclusions can be drawn:
- in all forms of hemolytic disease of the newborn, reticulocytosis, anemia and hyperbilirubinemia are observed;
- for Rh-conflict hemolytic disease of the newborn, a reduced level of erythrocytes is characteristic, due to their increased decay, and an intensive increase in bilirubin in the first 12 hours after birth, which very often leads to a replacement blood transfusion;
- for hemolytic disease of the newborn according to the ABO system, the following is characteristic: the number of erythrocytes within the age norms and the increase in bilirubin, which requires treatment with phototherapy, but does not require a replacement blood transfusion;
- Relative diagnostic significance in various forms of hemolytic disease of the newborn is the determination of the level of bilirubin and its hourly increase in the first 12 hours after birth.
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Principles of organization of pathology departments
newborns.
2. Intracranial birth injury: risk factors,
causes, main clinical
symptoms of hemodynamic disorders of the brain and
hemorrhages. Modern methods of examination
children (ophthalmoscopy of the fundus, radiography,
computed tomography, MRI, electromyography,
ultrasound, thermal imaging
diagnosis, lumbar puncture).
3. Asphyxia. Risk factors, causes. Complex method
resuscitation. Prevention of secondary asphyxia.
4. Hemolytic disease of the newborn: causes,
pathogenesis, clinical forms, symptoms,
severity criteria, laboratory diagnostics.
5. Sepsis: etiology, routes of infection, clinical forms
(septicemia, septicopyemia), clinical
manifestations, laboratory diagnostics, care,
principles of treatment.
neonatal period
Neonatal period - from ligation of the umbilical cordup to 28 days - the period of adaptation to extrauterine
life.
Enteral nutrition begins
characterized by intensive development
analyzers, the formation of conditioned reflexes,
the emergence of emotional and tactile
contact with mother.
A newborn baby sleeps a lot, usually
wakes up hungry or uncomfortable.
Newborn child
A full-term newborn is born inperiod from 38 to 42 weeks. intrauterine
development.
Premature - born at term
pregnancy from 22 to 37 weeks. with body weight
2500g or less and 45cm or less in length.
Postterm - a child born after
42 weeks pregnant
Order of the Ministry of Health of Ukraine dated 04.04.2005_ No. _152__ Protocol for medical supervision of a healthy new born child
Order of the Ministry of Health of Ukrainedate _04.04.2005_ № _152__
Protocol
medical supervision of a healthy newborn
child
Current principles of perinatal care
based on the WHO concept of how the physiological
vagity monitoring
for a child with obezhennyam medical vtruchan without
proper testimony.
Health care protocol
new born child, broken up with a method
I will become healthy children, zastosuvannya
modern effective technologies of physiological
watch over the new people, practical help
medical personnel are welcome.
perinatal period
continues from the 22nd week of gestation, includes the intranatal period and the first 7 dayslife.
Perinatal mortality is the number
stillborn (children born
dead with a gestational age of more than 22 weeks) and
number of deaths in the first week of life
(6 days 23 hours and 59 minutes) per 1000 births
alive and dead. The perinatal management program includes
medical and socio-psychological support
women in ante, intra- and post-natal periods.
Analyze family, obstetric and genetic history,
socio-economic status, nutrition, physical
activity.
The condition of the pregnant woman and the degree of risk are assessed;
blood type, Rh factor, hemoglobin and hematocrit are determined.
If a pregnant woman belongs to a risk group for
isoimmunization (Rh-negative blood type, obstetric
history), testing for isoimmune antibodies is performed.
According to the indications, an examination is carried out in order to identify
TORCH infections (toxoplasmosis, other viruses, rubella,
cytomegalovirus, herpes) and sexually transmitted infections
(testing for syphilis, hepatitis B in our country
necessarily).
Study of the level of serum alpha-fetoprotein in the mother
Study of the level of serum alpha-fetoprotein in the motheris mandatory in economically developed
countries. Elevated levels of alpha-fetoprotein
in the second trimester of pregnancy (16-17 weeks)
be with neural tube malformations,
is the basis for further
antenatal examination (ultrasonography II
level, amniocentesis with concentration determination
alpha-fetoprotein and activity
acetylcholinesterase in amniotic fluid
up to 90-95% accuracy verify the diagnosis of defects
neural tube.
The main tasks of the regional perinatal center:
1. Diagnosticsand therapy of perinatal problems of any degree
difficulties (both children and mothers).
2. Round-the-clock advisory assistance to institutions with
lower level of perinatological activity.
3. Transportation of newborns and pregnant women from these
institutions.
4. Summarizing the experience of perinatal management of pregnant women and
high-risk newborns.
5. Development and implementation of new perinatal technologies.
6. Control and analysis of the work of perinatal institutions with less
level of treatment and diagnostic capabilities.
7. Education of students, interns, postgraduate
improvement of doctors, midwives and nurses.
8. Release of audio and video materials.
9. Coordination of activities and management of the entire system
Healthy term newborn
SIGNSNORMAL PARAMETERS
Heart rate
100-160 per min.
Breathing rate
30-60 per min.
Color of the skin
movements
pink,
No
central cyanosis
Active
Muscle tone
satisfactory
Temperature
newborn
36.5-37.5 C Criteria for
estimates
0 points
Skin coloration
cover
Pink body color
pallor or
and blue color
cyanosis (bluish
limbs
coloring)
(acrocyanosis)
Everything pink color
body and limbs
Heart rate in 1 minute
Missing
<100
>100
reflex
excitability
(baby reaction
for introduction
nasal catheter)
Does not react
The reaction is weak
expressed (grimace,
motion)
Reaction in the form
movement, coughing,
sneezing, loud
cry
Muscle tone
Missing,
limbs
hang down
reduced, some
bending
limbs
Active
movements
Breath
Missing
Irregular, cry
weak
Normal, scream
loud
1 point
2 points
Apgar score
The sum of 8-10 points -satisfactory condition
newborn
7-6 points - the state of the average
severity - mild asphyxia
5-4 points - severe condition -
moderate asphyxia ("blue")
3-1 point - extremely serious condition -
severe asphyxia ("white")
0 points - stillborn
Necessary additional examinations of the newborn
LaboratoryInstrumental (if possible)
Neurosonography (if available)
Complete blood count: hemoglobin,
clinical symptoms
erythrocytes, hematocrit, platelets, encephalopathies, and
newborns with body weight
leukocyte formula
birth<1500 г)
blood glucose
General urine analysis
Blood electrolytes (K, Na, Ca)
X-ray of the chest organs
cells (in the presence of respiratory
disorders)
Echocardiography, ECG (with
the presence of physical changes
from the side of the heart, disorders
heart rate, increase
heart size)
Sechovin and creatinine 5
Gas warehouse and acid-lubric
6
EEG (if seizures are present)
The term "birth trauma" refers to violations of the integrity of the tissues and organs of the child that occur during childbirth.
The term "birth trauma" refers toviolations of the integrity of tissues and organs
baby that occurs during childbirth.
Perinatal hypoxia and asphyxia often
associated with birth trauma.
Intracranial birth injury
These are brain disorders that occur duringtime of birth due to mechanical
damage to the skull and its contents,
cause compression of the brain, swelling of tissues and, as
usually hemorrhage.
Perinatal brain damage
Intracranial hemorrhage (ICH).There are subdural, epidural,
subarachnoid, peri- and
intraventricular, parenchymal,
intracerebellar and other ICHs.
The frequency of intracranial hemorrhage
very variable. Among the full-term she
is 1:1000, in preterm infants with
body weight less than 1500 g reaches 50%.
Predisposing factors:
discrepancy between the size of the fetal head andbirth canal, fast or swift
childbirth, improper imposition of obstetric
abdominal forceps, vacuum extraction of the fetus,
delivery by caesarean section,
chronic intrauterine hypoxia.
Birth trauma of the brain and hypoxia
pathogenetically related to each other and how
usually combined. Ratio
traumatic and non-traumatic
hemorrhages in the brain and its soft membranes
is 1:10.
Clinic
ClinicThe most typical manifestation of any
intracranial hemorrhages are:
1) sudden deterioration in general condition
child with the development of various options
depression syndrome with intermittent
emerging signs of hyperexcitability;
2) change in the nature of the cry;
3) bulging of a large fontanel or its
voltage,
4) abnormal movements of the eyeballs;
5) violations of thermoregulation (hypo- or
hyperthermia);
Clinic
Clinic6) vegetative-visceral disorders (regurgitation,
pathological loss of body weight, flatulence,
unstable stool, tachypnea, tachycardia,
peripheral circulatory disorders);
7) pseudobulbar and movement disorders;
convulsions;
8) progressive posthemorrhagic anemia;
9) acidosis, hyperbilirubgnemia and others
metabolic disorders;
10) accession of somatic diseases
(meningitis, sepsis, pneumonia, cardiovascular
and adrenal insufficiency, etc.).
Subarachnoid hemorrhages
occur as a result of violations of the integritymeningeal vessels. Their most common localization
- parietotemporal region of the cerebral hemispheres and
cerebellum. Blood, settling on the membranes of the brain, causes
their aseptic inflammation and further leads to
cicatricial-atrophic changes in the brain and its
shells, impaired liquorodynamics.
Clinical manifestations of SAH: either immediately after
birth, or after a few days appear
signs of general arousal, anxiety,
"brain" cry, sleep inversion, children lie with wide
open eyes, face alert or
anxiety, increased motor activity due to
hyperesthesia, muscle tone and congenital reflexes.
Risk Factors for Intracranial Birth Injury
macrosomia,prematurity,
postmaturity,
developmental anomalies
intrauterine viral and mycoplasmal
fetal infections (the latter as a result of
vascular lesions and frequent lesions
brain),
pathology of the birth canal of the mother
(infantilism, long-term consequences of rickets,
rigidity). The frequency of IVH in newborns with body weight less than
1000 g exceeds 60%.
The frequency of IVH in newborns with a body weight greater than
1000 g fluctuates between 20-60%.
Of all IVH, 90% develop in the first hour of life!!!
Rice. 1 Hemorrhage in subependymal
matrix in a premature baby with the term gestation
less than 28 tyzh.
Clinical manifestations of intracranial birth trauma
sudden deterioration in the child's condition with developmentvarious variants of the syndrome of depression of the central
nervous system, which sometimes passes into
excitation; change in the nature of the cry;
bulging fontanel;
abnormal eye movements
violation of thermoregulation (hypo- or hyperthermia)
vegetative-visceral disorders; pseudobulbar and
movement disorder;
muscle spasms
progressive post-hemorrhagic anemia,
metabolic disorders; accession
somatic diseases,
Diagnostics
it is necessary to determine the degree of severity,nature of the course of the disease, localization of injury
brain and leading neurological
syndromes. In the presence of intracranial
hematomas indicate presumed
localization.
It is necessary to analyze clinical anamnestic data, pay attention to
neurological symptoms that
appear on the 3rd-4th day of life and are stored in
further.
Diagnostics
The study of cerebrospinal fluid is carried outwith severe intracranial hypertension,
repeated convulsions (characterized by the presence
erythrocytes over 1000/µl, increased
protein content).
Conduct an examination of the fundus, use
neurosonography, computed tomography,
echoencephalography, if fractures are suspected
skull bones - craniography.
Additionally, the level is determined
glucose in serum and cerebrospinal
fluid (diagnostic criterion is
decrease in the ratio of glucose in
cerebrospinal fluid and blood up to 0.4).
Diagnosis
possible when taking into account the complex of anamnestic (coursepregnancy and childbirth, childbirth benefits, medication
mother's therapy during pregnancy and childbirth, etc.),
analysis of the dynamics of the clinical picture in a child and assessment
results of such diagnostic methods:
- neurosonography - ultrasound scanning of the head
brain through a large fontanel. This method is highly
informative, non-invasive, not burdened by radiation exposure and
gives an image of various structures of the brain;
- computed tomography of the brain - allows you to analyze
both the state of the bones of the skull and the brain parenchyma;
- nuclear magnetic resonance and emission tomography allows to detect pathological changes in the brain,
to distinguish between white and gray matter of the brain and
clarify the degree of myelination (maturity) of various areas
brain;
- electroencephalography (EEG).
Treatment
Provide maximum peace, gentleswaddling and performing various procedures;
"Temperature protection" - the child is placed in
kuvez, where the temperature is 30-33 ° C.
Start breastfeeding with expressed milk
12-24 hours after birth depending on
the severity of the condition. To the breast of the child's mother
apply only after reduction of acute
symptoms of intracranial hemorrhage.
In the complex of therapeutic measures
leading is dehydration,
antihemorrhagic and sedative therapy. Monitoring of key parameters
vital functions: blood pressure and pulse, respiration numbers,
body temperature, etc.
Speedy recovery of normal
airway patency and adequate
lung ventilation.
maintaining adequate brain perfusion;
correction of pathological acidosis and other
biochemical indicators (hypoglycemia,
hypocalcemia, etc.); systematic delivery to
brain energy in the form of a 10% glucose solution.
Prevention and early treatment of intrauterine
hypoxia and asphyxia of the newborn.
Treatment of a convulsive syndrome
In the presence of convulsions, immediately determine the contentblood glucose. If this indicator<2,6 ммоль / л, медленно
bolus inject 10% glucose solution at the rate of 2 ml/kg per
for 5-10 minutes, then switch to continuous administration
10% glucose solution at the rate of 6-8 mg / kg / min. After 30
minutes to re-determine the level of glucose in the blood:
if starting blood sugar > 2.6 mmol/L or if
after correction of hypoglycemia, convulsions did not disappear, enter
phenobarbital, and in its absence - phenytoin.
Phenobarbital is administered intravenously or orally (after
enteral nutrition) at a loading dose of 20 mg/kg for 5
minutes.
In the absence or ineffectiveness of phenobarbital and
phenytoin, as well as, if possible, long-term
artificial ventilation of the lungs and the presence
qualified professionals, you can use:
diazepam lidocaine -;
thiopental - Correct laboratory-confirmed
violations by supporting:
blood glucose level in the range of 2.8-5.5
mmol/l;
the level of total calcium - 1.75-2.73 mmol / l;
sodium level - 134-146 mmol / l;
potassium level - 3.0-7.0 mmol / l.
Perinatal injuries of the spinal cord and brachial plexus
forced increase in the distance between the shoulders andthe base of the skull, which happens when pulling the head with
fixed hangers and pull by the hangers with
fixed head (breech presentation) and
excessive rotation (with facial presentation). In the moment
the birth of such children often used superimposition
tongs, hand aids.
Pathogenesis:
1. Damage to the spine
2. Hemorrhages in the spinal cord and its membranes
3. Ischemia in the region of the vertebral arteries due to stenosis,
spasm or occlusion of them
4. Damage to the intervertebral discs
5. Damage to the cervical roots and brachial plexus
Clinic
With trauma to the cervical spinepain syndrome is noted
change in the position of the child, sharp crying;
possible - fixed torticollis,
short or long neck
bruising, lack of sweat, dry skin
over the site of injury.
In case of damage to the upper cervical segments (C1-C4)
lethargy, adynamia, diffusemuscle hypotension, hypothermia,
arterial hypotension, hypo- or
areflexia, paralysis of movements, SDR; at
change in the position of the child - strengthening
respiratory disorders up to apnea.
Characteristic are the delay
urination or urinary incontinence, posture
frogs", spastic torticollis, symptoms
lesions III, VI, VII, IX, X pairs of cranial nerves.
Paresis and paralysis of Duchenne-Erb
- develop with damage to the spinal cord at the levelC5-C6 or brachial plexus.
Clinic: the affected limb is brought to
torso, extended at the elbow joint, turned
inward, rotated at the shoulder joint, pronated
in the forearm, the hand is in palmar flexion and turned
back and out. The head is often tilted. Neck seems
short with a large number of transverse folds.
The rotation of the head is due to the presence of spastic or
traumatic torticollis. Passive movements in
paretic limbs are painless; reflexes
Moreau, Babkina, prehensile reduced, tendinous
reflex is absent.
Fetal hypoxia
is a pathological conditionwhich lies intrauterine deficiency
oxygen.
risk factors for the development of antenatal
fetal hypoxia are:
delayed pregnancy,
long-term (more than 4 weeks) gestosis of pregnant women,
multiple pregnancy,
threatened miscarriage,
pregnancy diabetes,
bleeding, somatic and infectious
diseases in the 1st trimester of pregnancy,
smoking and other types of drug addiction
pregnant.
Under acute asphyxia
newborn imply the absencegas exchange in the lungs after the birth of a child, i.e.
choking with other signs
live births as a result of exposure
intranatal factors (oxygen deficiency,
accumulation of carbon dioxide and unoxidized
products of cellular metabolism). Asphyxia,
developed against the backdrop of chronic
intrauterine hypoxia is asphyxia
newborn, developed antenatally in
conditions of placental insufficiency.
The main risk factors for the development of intrapartum fetal asphyxia:
- C-section; pelvic, gluteal and other abnormalpresentation of the fetus;
- premature and delayed childbirth;
- anhydrous interval of 10 hours;
- rapid labor - less than 4 hours in primiparas and less
2 hours in multiparous;
- placenta previa or premature detachment,
rupture of the uterus;
- use of obstetric forceps 11 other aids in childbirth
mother (shock, etc.);
- disorders of the placental-fetal (umbilical cord)
blood circulation with tight entanglement, true knots, etc.;
- diseases of the heart, lungs and brain in the fetus, abnormal frequency
fetal heartbeat;
- meconium in the amniotic fluid and its aspiration;
narcotic analgesics administered 4 hours or less before
the birth of a child.
Classification of asphyxia of the newborn
depending on the severity of the conditionchild at birth, allocate:
1. Asphyxia of moderate severity (moderate) 4-6 points in the first minute, by the fifth - 8-10
points
2. Severe asphyxia - 0-3 points on a scale
Apgar at the 1st minute, by the 5th - less than 7 points
Clinic of moderate moderate severity of asphyxia:
the condition of the child at birth of moderate severity,the child is lethargic, but there is spontaneous
motor activity, reaction to examination and
irritation is weak. Physiological reflexes
the newborn is oppressed. The cry is short
unemotional. The skin is cyanotic, but
when oxygenated, they quickly turn pink, often at the same time
remains acrocyanosis. Poi auscultation is heard
tachycardia, muffled heart sounds or
increased sonority. Breathing after prolonged sleep apnea
rhythmic, with sighs. Characterized by repeated
apnea. hyperexcitability,
small-scale hand tremor, frequent regurgitation,
hyperesthesia
For severe asphyxia:
general condition at birth severe or veryheavy. Physiological reflexes practically
are not called. With active oxygenation (often with
ventilator) the possibility remains
restore skin color to pink. tones
hearts are often deaf, may appear
systolic murmur. With very severe
the state of the clinic can correspond
hypoxic shock - skin is pale with sallow
tint, symptom of "white spot" 3 seconds and
more, low blood pressure, spontaneous breathing
absent, no response to examination and pain
irritation, areflexia, muscle atony,
closed eyes, sluggish pupillary response to light or
lack of response
Treatment
Primary resuscitation systemnewborns developed by the American
the Heart Association and the American
Academy of Pediatrics. Main stages
resuscitation is called "ABC - krokami."
Main stages:
A. ensuring the patency of the respiratory
ways (Airways);
B. stimulation or restoration of breathing
(breathing);
C. maintaining blood circulation
(Circulation).
Jaundice
- visual manifestation of hyperbilirubinemia,which is noted in full-term at the level
bilirubin 85 µmol/l, in premature babies more than 120 µmol/l.
Neonatal jaundice (jaundice of the newborn)
Appearance of a visible yellow colorskin, sclera and/or mucous membranes
membranes of the child due to
increased levels of bilirubin in
newborn blood. Early jaundice - appears before 36 hours of a child's life.
Jaundice that appears in the first 24 hours is always a sign
pathology.
"Physiological" jaundice, appears after 36 hours
life of the child and is characterized by an increase in the level
total bilirubin is not higher than 205 µmol/l. Such jaundice
more often due to developmental and metabolic features
newborn during this period of life. "Physiological"
jaundice can be either uncomplicated or complicated
course, and therefore requires careful monitoring of
the condition of the child.
Complicated "physiological" jaundice is a physiological
jaundice, the course of which may be accompanied by a change
child's condition.
Prolonged (protracted) jaundice, which is determined
after 14 days of life in a full-term newborn and after
21 days of life in a premature baby.
Late jaundice that appears after 7 days of life
newborn. This jaundice always requires careful
examinations.
Physiological jaundice
Physiological jaundice (hyperbilirubinemia)
Develops 2-3 days after birthDuration on average 8-12 days
Hyperbilirubinemia develops in everyone
newborns in the first days of life, however
yellowness of the skin is noted only in 60-70%. Bilirubin concentration (later
referred to as B) in the blood serum in the first days of life
increases at a rate of 1.7-2.6 µmol/l/h and
reaches 3-4 days on average 103-137 µmol/l (B in
cord blood serum is 26-34
µmol/l).
Increased total and indirect bilirubin
Pathogenetic classification of neonatal jaundice
jaundice caused byadvanced education
bilirubin
(unconjugated
hyperbilirubinemia)
A. hemolytic causes
Hemolytic disease of the fetus and
newborn with isoimmunization according to:
Rh factor, ABO system
other antigens
Increased hemolysis due to
taking medication
Hereditary hemolytic
anemia.
B. non-hemolytic causes:
hemorrhages
Polycythemia
Enhanced enterohepatic
circulating bilirubin (fine atresia)
intestines; pyloric stenosis; disease
Hirschsprung;
jaundice caused by
reduced
conjugation
bilirubin
(mostly neocon
jugated
hyperbilirubinemia)
jaundice caused by
reduced excretion
bilirubin
(mainly with
elevated straight
bilirubin fraction)
1. Crigler-Najjar disease type 1 and 2
2. Gilbert's syndrome
3. Hypothyroidism
4. Jaundice
newborns,
located on
breastfeeding
breastfeeding
Hepatocellular
diseases:
toxic
infectious
metabolic
bile thickening syndrome
Obstruction of the outflow of bile
(biliary atresia):
extrahepatic
intrahepatic
Risk factors affecting bilirubin levels and severity of jaundice
prematurityHemorrhage (cephalohematoma, hemorrhage
skin)
Malnutrition, frequent vomiting
Sudden weight loss in a child
Having a generalized infection
Incompatibility between the blood of mother and child
group and Rh factor
Hereditary hemolytic anemia or
hemolytic disease
Procedure for clinical examination and assessment of jaundice
Color of the skinCheck for jaundice
skin staining should be carried out,
when the child is completely undressed,
condition of sufficient (optimally
daylight) lighting. For this
light pressure on the skin
child to the level of subcutaneous tissue.
Prevalence of icteric discoloration of the skin
jaundice first appears on the face, withsubsequent distribution across
towards the limbs of the child,
reflecting the degree of increase in the level of bilirubin
in blood serum.
An alternative to using visual
evaluation can be level determination
skin bilirubin by transcutaneous
bilirubinometry (TKB)
Basic principles of examination and treatment of a newborn with jaundice
Newborn with bilirubin levelcord blood more than 50 µmol/l
It is necessary to redefine the general
serum bilirubin (OBS) no later than
than 4 hours after birth and calculate
hourly increase in bilirubin. V
further it is recommended to
laboratory examination according to
clinical condition of the child.
Newborn with early or "dangerous" jaundice
Newborn with early or "dangerous"jaundice
Phototherapy should be started immediately
Simultaneously with the start of phototherapy
take a blood sample to determine OPS Total bilirubin in blood serum
If, at the time of the birth of a child,
blood type, Rh affiliation and direct
Coombs test was not determined, should
conduct research data
Recommended level determination
hemoglobin, hematocrit, as well as counting
erythrocyte and reticulocyte counts
Phototherapy for neonatal jaundice
Phototherapy is the mosteffective method to reduce the level
bilirubin in newborns
neonatal jaundice. timely and
properly administered phototherapy
reduces the need for replacement
blood transfusion up to 4% and reduces
the likelihood of complications
neonatal jaundice.
Hemolytic disease of the newborn (HDN)
Cause of hemolytic diseasenewborns are most often
Rh incompatibility or ABO
(group) blood of mother and child, or
other erythrocyte antigens.
Jaundice in HDN is the result of increased
erythrocyte hemolysis,
hyperbilirubinemia with
unconjugated bilirubin.
Clinical forms of HDN:
The icteric form is the most common. Shemanifested by icteric discoloration of the skin and
mucous membranes.
Anemic form occurs in 10-20% of newborns
and is manifested by pallor, low hemoglobin levels
(<120 г / л) и гематокрита (<40%) при рождении.
The edematous form (hydrops foetalis) is severe
manifestation of the disease and has a high percentage
lethality. Almost always associated with
incompatibility of the blood of the mother and child according to the Rh factor. Manifested by generalized edema and
anemia at birth.
In a mixed form, symptoms 2 or 3 are combined
the forms described above.
Mandatory examinations:
1. Determination of the child's blood type andRh accessories (if it was not
previously defined)
2. Determination of the level of total bilirubin in
blood serum
3. Determination of hourly level gain
bilirubin
4. Determination of the direct Coombs test
5. Complete blood count with counting
erythrocytes, hemoglobin, hematocrit,
parts of reticulocytes
Coombs reaction -
Coombs reaction -antiglobulin test to determine
incomplete anti-erythrocyte antibodies. Test
Coombs is used to detect antibodies to
Rh factor in pregnant women and
determination of hemolytic anemia in
newborn children with Rh incompatibility, leading to the destruction
erythrocytes. The fundamentals of the method are described in 1908
the year of Moreshi, in 1945 - Coombs, Muran
and Race, later called
"Coombs reaction".
Diagnosis Criteria
The birth of a child with generalizededema and anemia (hemoglobin<120 г / л и
hematocrit<40%)
The appearance of icteric coloration of the skin
child 1 day after birth and
positive Coombs test. General level
serum bilirubin corresponds to the level
performing an exchange transfusion
The appearance of pale skin coloration in 1 day and
laboratory confirmation of anemia
(hemoglobin<135 г / л и гематокрита <40%), а
also increased levels of reticulocytes
Purulent-inflammatory diseases of the skin and subcutaneous tissue
Vesiculopustulosis is a diseasepredominantly staphylococcal nature,
manifests itself already in the middle of the early
neonatal period and is characterized
inflammation of the mouths of the eccrine sweat glands.
The main symptoms of the disease are
small superficial vesicles up to
several millimeters in diameter
filled first with transparent, and then
cloudy content. most loved
their location is the skin of the buttocks,
hips, natural folds and head.
The course of the disease is benign.
Omphalitis
bacterial inflammation of the bottom of the umbilical wound, umbilicalrings, subcutaneous tissue around the umbilical ring and
umbilical vessels.
The disease usually begins at the end of the early neonatal period.
period when purulent discharge from the umbilical
wounds, hyperemia and swelling of the umbilical ring, infiltration
subcutaneous tissue around the navel, vasodilation
anterior abdominal wall, red streaks (lymphangitis).
The general condition of the child is disturbed, he becomes lethargic, ill
breastfeeding, spitting up, weight gain decreases.
Body temperature rises, sometimes to febrile. In analysis
blood leukocytosis with a shift to the left, an increase in ESR. Possible
metastatic infections and generalization of the process.
An umbilical ulcer occurs as a complication of a bacterial
inflammation of the navel or omphalitis. umbilical wound is covered
serous-purulent or purulent discharge. General state
the child in the first days of the disease may not be disturbed,
further there is a syndrome of intoxication.
neonatal sepsis
Sepsis - is a bacterial infectionwith primary (entrance gate) and secondary
(arising in a metastatic way) focus, from
which constantly or periodically into the bloodstream
microorganisms enter and cause severe
manifestations of the disease.
This is a bacterial infection that develops in the first
90 days of life. Its manifestations are varied and
include decreased spontaneous activity,
sucking energy, apnea, bradycardia,
temperature instability, respiratory
insufficiency, vomiting, diarrhea, abdominal enlargement,
restlessness, convulsions and jaundice.
early sepsis
early sepsisusually the result
neonatal infection during
childbirth. In over 50% of early
sepsis clinical manifestations
develop within 6 hours after
birth, and within 72 hours - at
most patients. Late
neonatal sepsis infection often
comes from the environment.
Neonatal sepsis - etiology
Group B streptococci and gram-negative
intestinal microorganisms cause 70% of early
sepsis. When cultured from the vagina and rectum in
women by the time of delivery in 30% can be identified
colonization of the GHS. Massiveness of colonization
determines the degree of risk of microorganism invasion,
which is 40 times higher with massive colonization.
Although only 1 in 100 newborns
colonized GBS develops invasive
disease, more than 50% of them develop
disease in the first 6 hours of life.
Non-typable strains of Haemophilus influenzae all
are more likely to cause sepsis in
newborns, especially premature ones. Other Gram-negative intestinal
rods and gram-positive
microorganisms - Listeria monocytogenes,
enterococci, group D streptococci, alphahemolytic streptococci and staphylococci
cause most of the other cases.
Streptococcus pneumoniae H.
influenzae type b and, less commonly, Neisseria meningitidis.
Asymptomatic gonorrhea occurs in 5-10%
pregnancies, so N. gonorrhoeae also
may be the causative agent of neonatal
sepsis. Staphylococci cause 30-50% of late
neonatal sepsis, most often in
association with the use of intravascular
devices. Isolation of Enterobactercloacae £
Sakazakii from blood or cerebrospinal fluid
suggests food contamination. At
outbreaks of nosocomial pneumonia
or sepsis caused by Pseudomonas
aeruginosa suggest contamination
equipment for IVL. Candida sp become more and more important
causes of late
sepsis developing in 12-13%
very low birth weight infants
birth.
Some viral infections can
appear as early or late
neonatal sepsis.
Early manifestations
often non-specific and obliterated and do not differ independing on etiology.
Especially often there is a decrease in spontaneous
activity, sucking energy, apnea,
bradycardia, temperature instability.
Fever is noted only in 10-50%, however
if persists usually indicates
infectious disease. Other manifestations
include respiratory failure
neurological disorders, jaundice, vomiting,
diarrhea and an enlarged abdomen. About availability
anaerobic infection often indicates
unpleasant putrid smell of amniotic
fluids at birth.
Septicopyemia
Occurs with febrile hecticfever
pronounced symptoms of intoxication,
weight loss
there are local multiple
purulent lesions: purulent
peritonitis, purulent meningitis, osteomyelitis and
arthritis, otitis, phlegmon of various areas,
pleurisy and lung abscesses, etc.
hemorrhagic syndrome
Septicemia
The clinical form of sepsis, in whichthe patient has pronounced symptoms
increasing bacterial toxicity
in the absence of foci of purulent inflammation.
A large number of microbes in
blood, multiplying rapidly,
hematogenously deposited in tissues in
not enough to
local purulent foci formed. In most neonates with early sepsis,
caused by GBS, the disease is manifested by respiratory
insufficiency that is difficult to distinguish from a disease
hyaline membranes.
Skin redness, discharge or bleeding from
umbilical wound in the absence of hemorrhagic diathesis
suggest omphalitis.
Coma, convulsions, opisthotonus, or bulging fontanel
suggest meningitis or brain abscess.
Decreased spontaneous limb movements and
edema, erythema, and localized fever or
joint pain indicates
osteomyelitis or purulent arthritis.
Unexplained bloating may indicate peritonitis or necrotizing ulcerative enterocolitis.
umbilical sepsis
Occurs most often. entrance gateinfection is the umbilical wound. infection
can occur during cord processing and from
beginning of demarcation of the umbilical cord stump to complete
epithelialization of the umbilical wound (usually from 2-3 to 10-12
days, and when processing the rest of the umbilical cord metal
bracket - up to 5-6 days).
The primary septic focus is rarely solitary in
umbilical fossa, more often foci are found in different
combinations: in the umbilical arteries and fossa or in the umbilical
vein and arteries.
Umbilical sepsis can occur in the form of
septicemia, and in the form of septicopyemia. Metastases
with umbilical sepsis: purulent peritonitis, purulent
meningitis, osteomyelitis and arthritis, phlegmon of various
areas, pleurisy and lung abscesses.
Early diagnosis
In neonates with suspected sepsis andthose whose mothers allegedly had
place chorioamnionitis, as soon as possible
complete blood count should be taken
counting the leukocyte formula and number
platelets, blood and urine cultures,
perform a lumbar puncture if
allows the condition of the child. In the presence of
respiratory system symptoms
x-ray required
chest organs. Diagnosis
confirmed by isolation of the pathogen
bacteriological method.
Neonatal sepsis - isolation of the pathogen
If the child has several foci of purulentinfection and at the same time severe toxicosis diagnosis
sepsis is usually not difficult. Exact
diagnosis is possible after detection
pathogen in blood culture. Diagnostic value
has a bacteriological examination of pus, cerebrospinal fluid,
urine, pharyngeal mucus, stool, punctate or smear from any
possible primary foci of sepsis or its
metastases. All crops should preferably be done before the start
antibiotic therapy with mandatory use
media for the isolation of gram-negative microbes and
anaerobic flora. Blood must be cultured
less than three times in an amount of at least 1 ml and in
ratio for sowing 1:10. The inoculated medium should
be immediately placed in the thermostat.
Urine analysis and cultures
Urine must be obtained bycatheterization or suprapubic puncture rather than
with urine collection bags. Though
are of diagnostic value only
urine culture results, detection of more than 5
leukocytes in the field of view with a large
increase in centrifuged urine or
any number of microorganisms in fresh
uncentrifuged urine, stained
Grama, is preliminary
evidence of a urinary tract infection
systems
Other tests to check for infection and inflammation
Counter immunoelectrophoresis and latex agglutination reactions make it possible to detect antigens in biologicalliquids; they can be used when
antibiotic therapy makes culture results
unreliable. They can also detect capsular
GBS polysaccharide antigen, E. coli K1, N. Meningitidis type B,
S. pneumoniae, H. influenzae type b.
Acute phase indicators are proteins produced by
liver under the influence of IL-1 in the presence of inflammation.
The most significant are tests for quantitative
determination of C-reactive protein. concentration 1
mg/dL gives false positive and
false negative results 10%. The increase in C-reactive protein occurs during the day with a peak on the 2nd-3rd
day and decreases to the sensitivity of the pathogen and
localization of the source of infection.
Treatment
Urgent hospitalization in a separate boxspecialized department.
Should the baby be breastfed or
expressed breast milk.
Detoxification infusion therapy,
which is often started as a parenteral
nutrition and at the same time carried out with the aim of
correction of water and electrolyte disorders
metabolism and acid-base status.
Antibiotics for sepsis in newborns
Antibiotics for sepsisnewborns
Before results
antibiograms are used
combinations of ampicillin with
aminoglycosides or cephalosporins with
carbenicillin, aminoglycosides.
One of the antibiotics is administered intravenously.
Antibiotics are changed every 7-10 days.
Antibiotics can be changed as
only the pathogen will be isolated. Prevention - strict adherence
sanitary epidemiological regime in obstetrics
institutions, departments of newborns
city hospitals.
After discharge from the hospital - follow-up
in the clinic for three years
pediatrician, neurologist and others
specialists, depending on the nature
the course of the disease.
"The role of the nurse in the care of newborns with jaundice"
Analysis of the incidence of hyperbilirubinemia in newborns in 2006 according to the maternity hospital No. 20 of the City Clinical Hospital No. 1 named after. N.I. Pirogova
Cause of hemolytic jaundice among term and preterm infants
Using the main treatments for hemolytic disease of the newborn
Analysis of the medical history of a newborn child
Mother: Natalya Pavlovna Zhuravleva, born on 08/24/82, was admitted on 10/20/2006.
Obstetric diagnosis at admission: 2 spontaneous premature births at 34 weeks. Was not registered.
Obstetric history:
- 1 pregnancy - 2002, delivery on time, girl 3300 gr, discharged on the 3rd day.
- 2 pregnancy - 2003, medical abortion without complications.
- 3rd pregnancy - real -2006, not registered, not examined. Didn't do an ultrasound.
- On October 20, 2006, at 13:00, a girl was born, weight 2040, height 42 cm. Apgar score 7-7 points. Oxygen was given in the delivery room for 2 minutes. The waters are green, indicating the presence of an infection. The child was born without asphyxia. The condition at birth is moderate, the cry is squeaky, the tone is increased.
The skin is dry in a lubricant soaked in "greens". The umbilical cord is imbibed with "green".
Diagnosis: partial atelectasis. PP CNS of mixed genesis. VUI. implementation risk. Chronic intrauterine hypoxia. Prematurity - 34-35 weeks.
From 15-05 the state of the child with negative dynamics due to the development of respiratory failure.
In order to improve metabolic processes and microcirculation, infusion therapy is carried out.
From 15-50, the condition worsens to very severe in respiratory failure. Absolute dependence on oxygen. In the lungs, breathing is weakened in all lung fields. Skin with an icteric tint.
Conclusion: RDS. Lung atelectasis PP CNS excitation syndrome of mixed genesis. VUI. The risk of HDN according to Rh - factor (the mother has 2 blood group, Rh (-)). Prematurity 34 weeks. Chronic intrauterine hypoxia.
Started artificial ventilation.
At 4:00 pm, 1 dose of Curosurf was administered.
16-15. With an antihypoxic purpose, sodium oxybutyrate 20% - 2.0 ml was intravenously prescribed.
According to the analyzes - an increase in bilirubin to 211 microns / l, which is critical. Risk of HDN. The blood was sent for an express test to determine the Rh factor.
21-00. The condition is very serious. The jaundice of the skin intensified. According to the analysis: bilirubin - 211 µmol / l, hemoglobin - 146 g / l, leukocytes - 61 * 109, glucose - 3.7 mmol / l.
Considering the anamnesis, the severity of the condition, tissue hypoxia, jaundice visible "by eye", high bilirubin numbers, a decrease in hemoglobin levels, high leukocytosis, the diagnosis is made: "THBN. Generalized intrauterine infection without a clear focus of localization. PP CNS infectious-hypoxic genesis. arousal syndrome. Lung atelectasis. Prematurity 34 weeks.
Given the high numbers of bilirubin, a clinically significant jaundice is indicated for PZK surgery.
- 21-30. Received hemacon erythromass 0 (1) Rh (-) 200, 0 from 20.10. donor Androsov E.V. No. 22998-31786, plasma C3-160.0 dated February 28. - donor E.S. Baryshnikova No. 339382-3001. Tests were carried out for group Rh - compatibility of the child's serum and the donor's blood. Blood group and Rh - factor compatible.
- 22-00. Operation ZPK.
Conducted catheterization of the umbilical vein. Fixation of the catheter in the stump of the umbilical cord with a ligature, to the skin - with adhesive tape.
20 ml of the child's blood was withdrawn, then 20 ml of erythromass and 10 ml of plasma were alternately injected. After every 10 ml of infusate, 10 ml of the child's blood was removed. After 100 ml of the injected media, 1.0 ml of a 10% solution of calcium gluconate was injected into the vein.
A total of 200 ml of erythromass 0 (1) Rh (-) was introduced. 90 ml of plasma.
270 ml of the child's blood was withdrawn (20 ml of erythromass was injected for anemia).
Operation without complications. Finished at 23-40.
Tactics of a nurse in exchange transfusion.
Preparing for the operation:
- - m / s sterile dresses;
- - prepares 3 test tubes to determine the level of bilirubin;
- - prepares 10% calcium gluconate (to neutralize sodium citrate, which is contained in donated blood);
- - prepares an antibiotic, which is administered at the end of the procedure to prevent bacterial complications;
- - fills 2 systems with erythrocyte mass and plasma;
- - prepares a container for disinfection of the withdrawn blood;
- - covers a sterile table with sterile material;
- - warms the blood up to 28 C;
- - aspirates the contents from the child's stomach;
- - makes a cleansing enema, swaddles in sterile underwear, leaving the front wall of the abdomen open;
- - lays on prepared heating pads (or in a pitcher).
During the operation:
- - delivers syringes with blood and plasma, calcium;
- - washes syringes;
- - assists the doctor;
- - monitors body temperature and basic vital functions.
After an exchange transfusion:
- - sends blood tubes to the laboratory;
- - collects urine for general analysis;
- - monitors the general condition of the child;
- - carries out phototherapy;
- - carries out infusion therapy according to the doctor's prescription;
- - according to the doctor's prescription, he organizes a laboratory examination of a sick child: determination of the level of bilirubin immediately after the ZPK and after 12 hours, examination of the urine test after the operation, determination of the level of glucose in the blood 1-3 hours after the operation.
- 3-50. Severe condition. The skin is icteric.
- 7-00. Severe condition. Skin is icteric. White Spot Syndrome 1-2 sec.
Continuous phototherapy is carried out.
For phototherapy, an AMEDA light fiber lamp is used.
The procedure is carried out in order to reduce the toxicity of indirect bilirubin, due to the formation of an isomer that is soluble in water. The session time is 3 hours with 2 hour intervals.
Preparation for the phototherapy procedure:
- - the nurse puts on the child light-protective glasses,
- - a diaper closes the genitals;
- - checks the operation of the equipment.
During the procedure:
- - the nurse protects the child from overheating. To do this, she regularly monitors body temperature, the general condition of the body.
- - a nurse conducts dehydration prophylaxis. To do this, she must control the drinking regime (10-15 ml of liquid per 1 kg of mass per day), assess the condition of the skin, mucous membranes.
- - control over the appearance of side effects of phototherapy: diarrhea with green stools, transient rash on the skin, "bronze child" syndrome (blood serum, urine, skin are stained), etc.
- 21.10.06. The child's condition is serious. Skin is icteric. Organs without deterioration.
For further treatment, she is transferred to the neonatal pathology department of the Children's Clinical Hospital No. 1.
- 1. The nurse's knowledge of the first symptoms of diseases accompanied by hyperbilirubinemia will help in the nursing diagnosis of this group.
- 2. Knowledge of the technique of invasive procedures, phototherapy, etc. will allow organizing nursing care at every stage of nursing newborns.
- 3. Knowledge of the features of the manipulations will allow you to identify side effects in the early stages of their occurrence and possibly prevent the development of complications.
MINISTRY OF HEALTH OF THE CHELYABINSK REGION
STATE BUDGET PROFESSIONAL
EDUCATIONAL INSTITUTION
"SATKINSKY MEDICAL COLLEGE"
Research
The role of a nurse in organizing the prevention of morbidity in children of the first year of life on the example of a children's clinic in the city of Satka
Specialty: 34. 02. 01 Nursing
Full-time form of education
Student: Akhmetyanov Ruslan Danisovich
Group 41 "s"
Head: Vasilyeva Asya Toirovna
___________________________________________
«____» _______________________________ 2016
Admitted to the defense: Final qualifying work
"__" ________ 20__ is protected with a rating of "____________"
Deputy Director for SD "_____" ____________________ 20__
Chairman of the SEC ________________
I.A. Sevostyanova
Satka 2016
| INTRODUCTION……………………………………………………………..…... | |
| Chapter 1. Theoretical aspects in the study of prevention morbidity in children of the first year of life 1.1. Dispensary observation of healthy children of the first years of life……………………………………………………………….…. 1.2. Preventive reception of a healthy child…………………..…… 1.3. Monitoring of newborns from risk groups during first year of life………………………………………………………... 1.4. The role of the nurse in newborn care children……………………………………………………………………………. 1.5. Vaccination of children of the first year of life…………. Chapter 2. Empirical study of the role of the nurse in Organizations for the prevention of morbidity in children of the first year of life on the example of the children's polyclinic in Satka 2.1. Analysis of the work of the children's polyclinic in Satka……………………….. 2.2. Clinical examination of children of the first year of life in the clinic Satka………………………………………………………………………. 2.3. The work of a nurse in a vaccination room…………..………………. 2.4. The role of the nurse in newborn care children of Satka…………………………………………………….…………. | |
| CONCLUSION………………………………………………….………… | |
| …………………… | |
| APPS…………………………………………………………… |
INTRODUCTION
The first year of a child's life is an important and difficult period. It was at this time that the foundation was laid, the basis for the physical development of the baby, and hence his future health.
The relevance of this topic is that early childhood is decisive both in the overall development of the child and in the formation of his health. Therefore, the health of children in the future largely depends on the effectiveness of preventive measures carried out in this age period.
The role of a nurse in the organization of preventive measures for the incidence of children in the first year of life is to examine children: conducting anthropometry; psychometry, early referral of the child to specialists, laboratory and instrumental studies, determined by order No. 307 of the Ministry of Health and Social Development of Russia dated April 28, 2007 "On the standard for dispensary (preventive) observation of a child during the first year of life."
During patronage visits at home, he controls the correctness of the procedures. All data obtained during such visits are recorded in the child's developmental history. It is important that gymnastics and massage are carried out systematically with a gradual complication of exercises and massage techniques.
The purpose of the work. To analyze the role of a nurse in the prevention of morbidity in children of the first year of life using the example of a children's clinic in the city of Satka.
Research objectives:
The study of theoretical material on this topic.
2 Analysis of the main indicators of the medical activities of the children's clinic for the period from 2013 to 2015.
3 Studying the role of a nurse in organizing the prevention of morbidity in children of the first year of life on the example of a children's clinic in the city of Satka.
Object of study. Children of the first year of life.
Subject of study. The role of the nurse in the organization of preventive measures for the incidence of children in the first year of life.
Research methods:
1 work with documentation;
2 analytical;
3 statistical;
4 math.
Hypothesis: The nurse plays a huge role in organizing preventive measures for the incidence of children in the first year of life.
The practical significance of the study. The research materials can be used in the study of PM. 02. Participation in medical diagnostic and rehabilitation processes. MDC 02.01.5 Nursing in pediatrics.
Work structure. The work is made of 46 pages of printed text, consists of an introduction, 2 chapters, conclusion, 26 sources, 2 tables and 6 diagrams.
1 Theoretical aspects in the study of the prevention of morbidity in children of the first year of life
Prevention - ( prophylactic- protective) a complex of various kinds of measures aimed at preventing a phenomenon and / or eliminating risk factors.
Dispensary observation of healthy children of the first year of life
Dispensary supervision of a district nurse: 1 visit at home once a month, with mandatory monitoring of visits after preventive vaccinations.
The frequency of examinations by specialists: a pediatrician in the first month of life at least 3 times, subsequently at least 1 time per month.
Inspection by narrow specialists:
– at 1 year neuropathologist, ophthalmologist, orthopedist;
- twice (1 trimester and 12 months);
- examination by ENT, dentist at 12 months.
Laboratory diagnostic examination:
– urinalysis for PKU 2x;
- CBC, urinalysis at 3 months (before vaccination) and at 12 months.
Surveillance Performance Indicators:
- good monthly weight gain;
- good adaptation of the child to new living conditions;
- normal physical and neuropsychic development and a decrease in the level of morbidity.
During preventive examinations, the following is monitored:
- for the regime of the day;
- feeding a child;
- performing a massage;
- hardening measures;
During an objective examination, special attention is paid to:
- body weight and height;
- circumference of the head and chest;
- assessment of neuropsychic and physical development;
- teething;
– property of bite;
- behavior;
- the condition of the skin, musculoskeletal system, internal organs;
- a trace reaction from BCG vaccination;
- the presence of congenital diseases, developmental anomalies.
Additional methods of examination: anthropometry 1 time per month, clinical analysis of blood and urine by the 3rd month of life and at 1 year.
Based on the data of objective and additional research methods, the doctor gives a comprehensive assessment of the state of health, including an assessment of physical and neuropsychic development, behavior, the presence or absence of functional or organic deviations from the norm, determines the health group, if necessary, the risk group for developing the disease and prescribes a set of preventive measures. and recreational activities.
The main preventive and health measures:
- organization of rational feeding;
- Sufficient exposure to fresh air;
- massage;
- gymnastics tempering procedures;
- tasks of education;
– specific prevention of rickets;
– prevention of anemia;
– treatment of the identified pathology.
Criteria for the effectiveness of clinical examination: indicators of neuropsychic and physical development, behavior, clinical examination data, frequency of diseases.
Depending on the state of health, children can be classified into the following groups:
- To 1st health group- healthy children with normal physical and mental development, without anatomical defects, functional and morphofunctional abnormalities;
– to 2nd health group- children who do not have chronic diseases, but have some functional and morphofunctional disorders. This group also includes convalescents, especially those who have had severe and moderate infectious diseases, children with general retardation of physical development without endocrine pathology (short stature, lag in biological development), children with underweight or overweight, children often and long-term ill with acute respiratory diseases, children with the consequences of injuries or operations while maintaining the corresponding functions;
- To 3rd health group- children suffering from chronic diseases in the stage of clinical remission, with rare exacerbations, with preserved or compensated functional capabilities, in the absence of complications of the underlying disease. In addition, this group includes children with physical disabilities, the consequences of injuries and operations, provided that the corresponding functions are compensated. The degree of compensation should not limit the possibility of education or work of the child;
- To 4th health group- children suffering from chronic diseases in the active stage and the stage of unstable clinical remission with frequent exacerbations, with preserved or compensated functional capabilities or incomplete compensation of functional capabilities; with chronic diseases in remission, but with limited functionality. The group also includes children with physical disabilities, the consequences of injuries and operations with incomplete compensation of the corresponding functions, which to a certain extent limits the child's ability to study or work;
- To 5th health group- children suffering from severe chronic diseases, with rare clinical remissions, with frequent exacerbations, continuously relapsing course, with severe decompensation of the body's functional capabilities, the presence of complications of the underlying disease, requiring constant therapy. This group also includes children with physical disabilities, the consequences of injuries and operations with a pronounced violation of the compensation of the corresponding functions and a significant limitation of the possibility of learning or working.
In the process of observing a child, his health group may change depending on the dynamics of his state of health.
1.2 Prophylactic reception of a healthy child
1 Organization of sanitary and hygienic care for the child (microclimate of the room, quantity and quality of ventilation, lighting, organization of the place of sleep and wakefulness, walks, clothing, personal hygiene).
Mothers need to be explained that non-compliance with sanitary and hygienic care for a child can adversely affect the child's health, physical and mental development. In the history of development, the doctor fixes the shortcomings in the care of the child, gives appropriate prescriptions for their correction.
2 Organization of the mode of life and nutrition according to age. Often the mother's complaints about the child's poor appetite, increased or decreased excitability, indifference, tearfulness are not associated with any organic changes, but are the result of improper organization of the sleep and wakefulness regimen, feeding regimen.
You need to know that up to 9 months there should be the following sequence: sleep, feeding, wakefulness, which corresponds to the anatomical and physiological needs of the child. After 9 months, this sequence changes due to the lengthening of the segments of wakefulness, namely, wakefulness, feeding, sleep. During the first year of life, the time of active wakefulness increases from several minutes to 3 hours, the duration of sleep per day decreases from 18 to 14 hours. An arbitrary increase in the period of wakefulness can cause negative emotions, capriciousness, and increased excitability in a child.
3 Organization of rational feeding and nutrition is one of the main tasks of a general pediatrician. At each appointment or home visit, the doctor exercises strict control over the compliance of the feeding received by the child with his physiological needs for basic food ingredients. This is especially true for children born with a weight of up to 2500 and more than 4000 g. They need more frequent calculations of nutrition by ingredients and calories, as they can easily develop malnutrition.
Rules for the organization of rational feeding and nutrition:
– support, encourage and maintain breastfeeding as long as possible;
- timely transfer the child to mixed or artificial feeding with a lack of breast milk and the inability to receive donor milk;
- in a timely manner, taking into account the age, type of feeding, individual characteristics of the child, introduce juices, fruit purees, supplementary foods, complementary foods into the diet;
Supplementation should be given after breastfeeding and not from a spoon, but from a horn with a nipple. This is explained by the fact that in the first 3-4 months of the child, the act of sucking is physiological, which maintains the excitability of the food center. Spoon-feeding causes a decrease in the excitability of this center, a mismatch in the rhythm of sucking and swallowing, which leads to rapid fatigue of the child, and possibly refusal to eat.
Complementary foods are usually given from 4-5 months at the beginning of feeding with a high excitability of the food center. It is advisable to give it from a spoon in order to teach the child to remove food with his lips and gradually master the skills of chewing.
- periodically (up to 3 months monthly, and then once every 3 months) calculate the chemical composition of the food actually received by the child in order to make an appropriate correction if necessary;
- Correctly organize the method of feeding.
When introducing supplementary feeding, the child must be held in her arms, as with breastfeeding. When introducing complementary foods, the child should be held in his arms, sitting in an upright position.
Failure to follow the feeding methodology often leads to malnutrition in children. If an infant during a monthly examination according to the rate of increase in body weight and length corresponds to normal indicators, and is also healthy, then the nutrition received by the child should be considered rational. Therefore, he is in optimal feeding conditions.
4 Organization of physical education of the child. It has a positive effect on the body as a whole:
- increases the activity of non-specific body defense factors (lysozyme, complement components, etc.) and thereby increases resistance to viral and bacterial infection;
– improves blood supply, especially to the periphery;
- improves metabolism and thereby the utilization of food products;
- regulates the processes of excitation and inhibition;
- increases the activity of the adrenal glands (increases the production of corticosteroids);
- regulates the activity of the endocrine system;
- improves the functioning of the brain and all internal organs.
Physical education of children up to the 1st year of life includes: massage, gymnastics and kinesiotherapy (laying the child on the stomach in each period of wakefulness for the development of independent movements).
It is very important that gymnastics and massage are carried out systematically, with a gradual complication of exercises and massage techniques. If the control over the conduct of massage and gymnastics is insufficient on the part of the doctor and nurse, if the attention of parents on the great importance of physical education is not fixed at receptions, then, naturally, their effectiveness is significantly reduced.
To organize kinesiotherapy, it is necessary to have a wooden track on the floor and maintain a comfortable air temperature in the room.
The nurse needs to teach the mother how to carry out hardening procedures using air baths, organizing sleep on the street, on the balcony, bathing 2 times a day with wiping the body with a damp towel, and then dousing with a gradual decrease in temperature.
5 Organization of neuropsychic development of the child. It goes in close contact with physical development and is one of the components of health. Violation or lag in physical development often leads to a delay in neuropsychic development. In a child who is often ill, physically weakened, the formation of conditioned reflexes, various skills is delayed, it is difficult to evoke joy.
A pediatrician must take into account the mutual influence of physical and neuropsychic development and create favorable conditions for their development. It must be remembered that the theme of development and the sequence in the formation of various movements, skills, and speech in children of the 1st year of life depend not only on their individual characteristics, but also on the impact on the child of adults caring for children, as well as on the environment. environment. Monitoring the dynamics of the neuropsychic development of young children. Assessment of neuropsychic development (NPD) in young children is carried out according to specially developed development standards on time: in the first year of life - monthly, in the second year - 1 time per quarter, in the third year - 1 time per six months, on days, close to the child's birthday. Medical workers: a district pediatrician or a nurse, or a nurse (paramedic) of the office of a healthy child, diagnose CPD in accordance with the recommendations, according to certain indicators - lines of development. If the development of the child does not correspond to the age, then it is checked according to the indicators of the previous or subsequent age periods.
Methodology for determining the level of neuropsychic development of children in the first year of life.
In the 1st year of life, the following lines of neuropsychic development are controlled:
Up to 6 months:
- development of visual orienting reactions;
- development of auditory orienting reactions;
- development of positive emotions;
- development of general orienting reactions;
- development of hand movements;
- development of skills.
From 6 months to 1 year:
- sensory development;
- development of general movements;
- development of actions with objects;
- development of the preparatory stages of active speech;
– development of preparatory stages of speech understanding;
- development of skills.
The development of all skills and abilities in the first year of life is closely related to the level of development of the analyzers. The most significant among them are visual, auditory, tactile and proprioceptive analyzers.
For a child up to 3 months, the timely occurrence of visual and sound concentration is very important, as well as the development of the following positive emotions: a smile and a revival complex.
At the age of 3 to 6 months, it is important to develop visual and auditory differentiations with the ability to find the source of sound, the formation of grasping movements of the hand (taking a toy from the hands of an adult and from different positions), cooing, babble (the beginning of speech development).
At the age of 6 to 9 months, the leading is the development of crawling, imitation in the pronunciation of sounds and syllables, the formation of simple connections between objects and words denoting them.
At the age of 9-12 months, the most significant are the development of understanding of adult speech, the formation of the first simple words, the development of primary actions with objects and independent walking. No less important than sensory development is movement development.
The mother should be informed what movements and at what age to teach the child. From the first days and weeks of life, during periods of wakefulness, the arms and legs of the child should be free; before each feeding, it must be laid out on the stomach, developing the ability to raise and hold the head. Such free movements of the head strengthen the muscles of the neck and back, the correct bend of the spine is formed, and the blood circulation of the brain improves. If the family has conditions for maintaining a comfortable temperature for an undressed child, it is advisable to lay it out on a wooden track on the floor during the wakefulness period for the development of crawling and body sensation in space. In the future, all these movements must be continued to develop, putting toys on the track so that the child can capture them and / or purposefully move towards them. From time to time (but not too often) the child must be picked up, giving him an upright position. This stimulates holding the head, fixing the gaze on the faces of the mother, father and other relatives and friends.
From 3 months, special attention is paid to the development of hand movements, from 4 months it is necessary to teach the child to grab a free toy, by 6 months - to roll over from his stomach to his back.
In the second half of the year, it is necessary to learn to crawl, and by 8 months - to sit and sit, stand up and step over in a crib or playpen. With such a sequence of development of movements, a child by 12 months masters the ability to walk independently.
1.3 Follow-up of newborns at risk in
during the first year of life
Risk groups for young children:
- children at risk for the development of CNS pathology (having undergone perinatal CNS damage);
- children at risk for anemia, WDN, convalescents of anemia;
- children at risk of developing chronic eating disorders;
- children with constitutional anomalies;
- children suffering from rickets 1, 2 degrees;
- children born with a large body weight ("large fetus");
- children who have undergone purulent-inflammatory diseases, intrauterine infection;
- often and long-term ill children;
– children from priority families.
Principles of observation of children from risk groups:
– identification of leading risk factors. Definition of monitoring tasks (prevention of the development of pathological conditions and diseases);
– preventive examinations by a pediatrician and doctors of other specialties (duration and frequency);
– laboratory-diagnostic, instrumental studies;
- features of preventive examinations, preventive and therapeutic measures (nutrition, regimen, massage, gymnastics, non-drug and drug rehabilitation);
– criteria for the effectiveness of observation;
- the observation plan is reflected in the form 112-y.
– examination by a pediatrician at 1 month of life at least 5 times, in the future
monthly;
– examination by a neurologist at 2 months (not later), then quarterly;
– examination by the head of the polyclinic department at the 3rd month, mandatory for each child’s illness at the 1st year;
- strict control of the pediatrician over the size of the head, neurological status, level of mental and physical development;
- preventive vaccinations strictly according to an individual plan and only with the permission of a neurologist;
- upon reaching 1 year, in the absence of pathology from the central nervous system, the child can be removed from the dispensary (f.30).
- examination daily for 10 days after discharge from the maternity hospital, then on the 20th day and at 1 month, up to a year monthly;
- strict control over the condition of the skin and umbilical wound;
- early laboratory tests (blood, urine) at 1 month and 3 months, after each disease;
- measures for the prevention, early detection and treatment of dysbacteriosis;
- in the absence of symptoms of intrauterine infection, they are removed from the register (f. 30) at the age of 3 months.
- examination by a pediatrician at 1 month of life at least 4 times, then monthly;
– examination by the head of the clinic no later than 3 months;
- the struggle for natural feeding, strict control over weight gain, the fight against hypogalactia. A balanced diet, taking into account the weight of the child;
– examination by an endocrinologist at least 2 times in the 1st year of life (in the 1st quarter and at 12 months). Before the appointment with the endocrinologist, a blood test
on an empty stomach for sugar;
- dispensary observation for 1 year, in the absence of pathology, the account is taken (form 30) at the age of 12 months.
- examination by a pediatrician 4 times at 1 month of life, then monthly;
- urinalysis at 1 month, then 1 time per quarter and after each disease;
- consultation of specialists in the early stages at the slightest suspicion of a pathology (cardiologist, surgeon);
- dispensary observation for 1 year, in the absence of pathology, they are deregistered (form 30) at the age of 12 months.
- strict control over the quality of child care, nutrition, weight gain, neuropsychic development;
- Mandatory hospitalization for any disease;
– participation of the head of the polyclinic in the preventive monitoring of this group of children;
- earlier registration in the kindergarten (in the second year) preferably with a round-the-clock stay;
- control of the district nurse over the actual place of residence of the child.
A child of the 1st year of life is characterized by a number of features that do not occur at an older age:
– fast pace of physical and neuropsychic development;
- the need for sensory impressions and motor activity;
- immobility of the child, "sensory hunger" lead to a developmental delay;
- the interdependence of physical and neuropsychic development;
- emotional impoverishment, lack of impressions, insufficient motor activity lead to a delay in neuropsychic and physical development;
– low resistance to weather and environmental impacts and various diseases;
- a very large dependence of the development of the child on the mother (parents, guardians). A characteristic feature of this period of the child's life is the transformation of the child from a helpless creature into a person with character and certain personality traits.
There is no such period in the life of an older age that in 12 months a healthy child triples its weight and grows by 25-30 cm, i.e. it is during the 1st year of life that the growth and development of the child proceeds at a very rapid pace.
The functional speech system is also rapidly developing. The child masters the intonation of the language in which he is spoken to; cooing, babbling, the first syllables, words appear. He begins to understand the speech of adults communicating with him.
The child gradually develops skills and abilities: the ability to drink from a mug, cup, eat food from a spoon, eat bread or crackers; the first elements of the skill of cleanliness.
The emotional sphere of the child expands significantly, and he adequately responds to changing circumstances: crying, laughing, smiling, whimpering, interest in surrounding objects and actions, etc. In this regard, it is necessary to properly organize control over the development of the child and his state of health in order to notice deviations in mental and motor development as early as possible and plan recreational activities that ensure the prevention of various diseases.
1.4 The role of the nurse in newborn care
Patronage of a newborn child during the first month of life is carried out by a pediatrician and a pediatric nurse.
The overall goal of patronages is to create a program for the rehabilitation of the child.
Specific goals:
- assess the socio-economic conditions of the family;
Develop a mother's education program aimed at meeting the vital needs of the child. During the first patronage, the nurse talks to the mother, clarifies the course of pregnancy and childbirth, studies the discharge summary, clarifies the family's anxieties and problems associated with the birth of a child.
The nurse pays attention to the conditions of the baby's stay, gives recommendations on caring for the baby.
The nurse examines the child, examines the skin and mucous membranes, evaluates reflexes. Looks at the activity of sucking and the nature of feeding. Also draws attention to the crying of the child, breathing. Palpates the tummy and examines the large fontanel, umbilical wound.
The nurse learns about the mother's well-being, somatic and mental health and lactation, the nature of nutrition, and examines the mammary glands. During the primary patronage, the mother is given recommendations for protecting her health: daytime rest, varied food, enhanced drinking regimen, personal hygiene (daily shower or wash body to the waist, change bra daily, wash hands after coming from the street, before swaddling and feeding child, etc.).
The nurse teaches the mother the daily regimen and nutrition to improve lactation, proper feeding of the child, caring for him, the method of feeding, convinces parents of the need to regularly see a doctor and follow all his recommendations. Teaches mother and all family members the technology of psycho-emotional communication with the child. For successful communication with a child, it is necessary to know the level of his age needs and communication opportunities.
Newborns up to 1 month like:
- suck;
- listen to repeated soft sounds;
- focus on movement and light;
- to be on the hands, especially when he is lulled.
The task of parents is to provide the child with the opportunity to listen to their conversations and singing, soft music, feel their hands, feel bodily communication, especially during feeding. Mother's advice: even if the baby is bottle-fed, it is necessary to take him in your arms during feeding.
The main indicators of the correct psycho-emotional development of a newborn after discharge from the hospital:
- responds positively to stroking;
- spontaneously smiles;
- calms down when picked up;
- holds his gaze for a short period of time during feeding.
The nurse should teach the correct implementation of daily manipulations for the baby:
- treatment of the umbilical wound;
- bathing a child
- washing;
- nail care.
It is enough to treat the umbilical wound once a day, after an evening bath. Do not strive to do this at every opportunity: this way you will rip off the crusts that form on the wound too often, which will not speed up, but only complicate and delay healing.
The purpose of such patronage is to assist the mother in organizing and conducting care for the newborn. It is important to teach her to properly perform manipulations for caring for a child. During the primary care of a newborn, the nurse receives a number of specific instructions from the doctor on the specifics of monitoring this child.
Bathing should be a daily routine for your baby. Firstly, the baby's skin is thin, and metabolic and excretory processes and skin respiration are much more active in it. Therefore, it must be cleaned regularly. Secondly, bathing is extremely useful as a hardening method.
Wash your baby after every stool and when changing the diaper. It is most convenient to wash the baby under running water, so that the water flows from front to back. If for some reason water is not available (on a walk, in a clinic), you can use wet baby wipes.
In the morning, the baby can be washed right on the changing table. Wipe the baby's face and eyes with a cotton swab dipped in boiled water. There must be a separate swab for each eye. Direct movements from the outer corner of the eye to the inner.
If the child's breathing is difficult. To do this, it is more convenient to use a cotton turunda (wick). Carefully, with twisting movements, we introduce it into the nostril. If there are a lot of dry crusts in the nose, turunda can be moistened in oil (vaseline or vegetable). From these manipulations, the baby can sneeze, which will simplify the task.
A child's ears should only be cleaned when wax is visible at the mouth of the ear canal. Do not do this too often: the more sulfur is removed, the faster it starts to be produced. When cleaning the ears, in no case should you penetrate the ear canal deeper than 5 mm. There are even special cotton swabs with limiters for this.
Nails should be cut as they grow so that the baby does not scratch himself or you. Use baby nail scissors that have extensions at the tips. Nails should be cut straight, without rounding the corners, so as not to stimulate their growth and ingrowth into the skin. This concludes the primary patronage of the newborn.
At the second patronage, the nurse checks the correctness of the procedures.
1.5 Vaccination of children in the first year of life
Infectious diseases are very common in children, sometimes they can be severe, give complications.
The purpose of immunization is the formation of specific immunity to an infectious disease by artificially creating an infectious process, which in most cases proceeds without manifestations or in a mild form. Every child can and should be vaccinated, parents only need to contact a pediatrician in a timely manner. If any individual characteristics of the child's body are identified, the doctor draws up an individual plan for examining the child, his medical preparation for subsequent vaccination.
In accordance with the order of the Ministry of Health of Russia No. 125n dated March 21, 2014 "On approval of the national calendar of preventive vaccinations and the calendar of preventive vaccinations according to epidemic indications":
The implementation of this order can significantly modernize vaccination in Russia, because:
1 Mandatory vaccination of children, starting from 2 months of life, against pneumococcal infection has been introduced.
2 The list of contingents subject to vaccination against various infections has been expanded.
3 The list of infections and the list of contingents subject to vaccination according to the Calendar of preventive vaccinations according to epidemic indications has been expanded. According to the Federal Law of September 17, 1998 No.
N 157 - Federal Law "On Immunoprophylaxis of Infectious Diseases" regions can finance programs for the vaccination of hemophilic, pneumococcal, rotavirus infections, and chicken pox.
To organize and conduct vaccinations, a medical institution must have a license for the relevant type of activity issued by the territorial (city, regional, regional) health authority and a room (vaccination room) that meets the requirements of SPiN 2.08.02-89.
Vaccination is a mandatory state measure for the prevention of infectious diseases. Structural changes in the current economic and demographic situation in the country, the growing international consolidation in the implementation of programs for the elimination and eradication of infections lead to increased requirements for immunoprophylaxis.
Thus, the role of a nurse in the organization of preventive measures, the incidence of children in the first year of life is to examine children: conducting anthropometry; psychometry, early referral of the child to specialists, laboratory and instrumental studies, determined by order No. 307 of the Ministry of Health and Social Development of Russia dated April 28, 2007 "On the standard for dispensary (preventive) observation of a child during the first year of life."
The nurse conducts psychological preparation of the child for vaccination.
2. The role of a nurse in organizing the prevention of morbidity in children of the first year of life on the example
children's polyclinic of the city of Satka
2.1 Clinical examination of children of the first year of life in the children's polyclinic of the city of Satka
Statistical data on medical examination of children of the first year of life were obtained from the Central Children's Polyclinic No. 1 in Satka.
For three years, 2,331 children (children of the first year of life) underwent medical examinations, of which 792 children underwent medical examinations in 2013, which accounted for 34% of the total number of those who underwent medical examinations for the year.
In 2014, 764 children underwent medical examinations, which accounted for 32.8% of the total number of those who underwent medical examinations for the year.
In 2015, 775 children underwent medical examinations, which accounted for 33.2% of the total number of those who underwent medical examinations for the year. The number of examined children in 2015 decreased by 0.8% compared to 2013.
Table 1
Clinical examination of children of the first year of life
| Children of the first year of life | Number of people examined | Distribution by health groups |
| Group 1 - 369 (46.6%) Group 2 - 256 (32.4%) Group 3 - 117 (14.7%) Group 4 - 29 (3.8%) Group 5 - 21 (2.5%) |
||
| Group 1 - 233 (30.4%) Group 2 - 383 (50.3%) Group 3 - 99 (12.9%) Group 4 - 22 (2.8%) Group 5 - 27 (3.6%) |
||
| Group 1 - 294 (37.9%) Group 2 - 359 (46.3%) Group 3 - 75 (9.5%) Group 4 - 16 (2%) Group 5 - 32 (4.1%) |
In 2013, the number of examined children was higher by 1.2% than in 2014 and by 0.8% than in 2015 (Figure 1).
Figure 1 - The share ratio of the number of examined
children of the first year of life for 2013 - 2015
Of the total number of children examined in 2013 (792 children), 369 children of the first year of life were with the first health group, which amounted to 46.6%. With the second group 256 children of the first year of life, which amounted to 32.4%. From the third group 117 children of the first year of life, which amounted to 14.7%, from the fourth group 29 children of the first year of life, which amounted to 3.8% and from the fifth group 21 children, which amounted to 2.5% (Fig. 2).
Figure 2 - Share ratio by health groups
for 2013 among children of the first year of life
Figure 3 - Share ratio by health groups
for 2014 among children of the first year of life
Of the total number of children examined in 2014 (764 children) with the first health group, there were 233 children of the first year of life, which amounted to 30.4%. With the second group 383 children of the first year of life, which amounted to 50.3%. From the third group 99 children of the first year of life, which accounted for 12.9%, from the fourth group 22 children of the first year of life, which amounted to 2.8% and from the fifth group 27 children, which amounted to 3.6%.
Of the examined children of the first year of life in 2014, there were 19.9% more children with the second group than with the first group, by 37.4% than with the third group, by 47.5% than with the fourth group and by 46 .7% than with the fifth (Fig.3).
Of the total number of children examined in 2015 (775 children) with the first health group, there were 294 children of the first year of life, which amounted to 37.9%. With the second group 359 children of the first year of life, which amounted to 46.3%. With the third group 74 children of the first year of life, which amounted to 9.5%, with the fourth 16 children of the first year of life, which amounted to 2% and with the fifth group 32 children, which amounted to 4.1%.
Figure 4 - Share ratio by health groups
for 2015 among children of the first year of life
Of the examined children of the first year of life in 2015, there were 8.4% more children with the second group than with the first group, by 36.8% than with the third group, by 44.3% than with the fourth group and by 42 .2% than with the fifth group (Fig. 4).
Figure - 5 Share ratio by health groups
From 2013 to 2015 among children of the first year of life
– with the second group 42.7%;
– with the third group 12.4%;
– with the fourth group 3%;
- with the fifth group 3.5%.
From 2013 to 2015, the number of children with the 5th group increased by 13.7 compared to 2013 (Fig. 5).
– carrying out anthropometry;
– psychometrics;
- early referral of the child to specialists;
2.3. The work of a nurse in the vaccination room
One of the main directions in the activities of the polyclinic in prevention is to increase the literacy of the population in matters of immunoprophylaxis and the formation of an understanding of the importance of vaccines for health.
Preventive vaccinations are the main measure in the fight against many infectious diseases in children, which radically affect the epidemic process.
The Cabinet of Immunoprophylaxis currently serves:
– child population aged 0-15 years;
- adolescent population 15-18 years old.
Preventive vaccinations are planned in the “Vaccinal Prevention” office on a monthly basis, reports on the implementation of the preventive vaccination plan are also received here and entered into a computer database. Vaccines are stored in the refrigerator, the sales deadlines and the cold chain are respected.
table 2
Implementation of the immunization plan for children of the first year of life
| Name of vaccinations | Done | Done | Done |
| diphtheria tetanus | |||
| poliomyelitis | |||
| rubella mumps | |||
| tuberculosis | |||
| Viral Hepatitis B | |||
| pneumococcal infection | |||
| Haemophilus influenzae | |||
For three years, 31836 vaccinations were made for children of the first year of life, in 2013 10288 vaccinations, which is 32.3% of all vaccinated children of the first year of life per year. In 2014, 9920 vaccinations, which is 31.1% of all vaccinated children in the first year of life per year. In 2015, there were 11,630 vaccinations, which is 36.6% of all vaccinated children in the first year of life per year. From this we can conclude that the number of vaccinated children is increasing every year. Since 2013, it has increased by 4.3% compared to 2015 (Figure 6).
Figure - 6 Proportion of the number of vaccinated children under 1 year of age
The work of a nurse in the vaccination room in Satka
The nurse checks the number of vaccine vials for the workday, controls the temperature in the refrigerator, and notes readings in a journal.
The nurse conducts psychological preparation of the child for vaccination. In the history of development, it records the doctor's admission to vaccination, the intervals between vaccinations and their compliance with the individual vaccination calendar. Registers the vaccination in the vaccination card (form No. 063 / y), the register of preventive vaccinations (form No. 064 / y) and in the history of the child's development (form No. 112 / y) or in the child's individual card (form No. 026 /y). Performs vaccinations and gives advice to parents on child care.
The nurse receives vaccinations and medicines. Responsible for the use and culling of bacterial preparations. Observes the rules for storing vaccines during immunization and the rules for processing vaccination tools. Responsible for the sanitary and hygienic regime of the vaccination room.
During the working day, she destroys all remaining vaccine in open vials, writes down in the registration book the amount of vaccine used and sums up (number of doses left), checks and records the temperature of refrigerators.
Every month, the nurse prepares a report on vaccination work.
1 Organization of labor in accordance with this instruction, hourly work schedule.
Organization of the treatment room according to the standard.
Compliance with the requirements for labeling medical supplies.
4 Accurate and timely maintenance of medical records. Timely submission of a report on the performed manipulations for the month, half year, year.
5 Preparing the office for work.
6 Proficiency in the methods of carrying out preventive, therapeutic, diagnostic, sanitary and hygienic procedures, manipulations and their high-quality, modern implementation.
7 Strict observance of blood sampling technology for all types of laboratory tests.
8 Timely and correct transportation of the test material to the laboratory departments.
9 Timely notification to the attending physician about the complications from the manipulation, about the patient's refusal to perform the manipulation.
10 Ensuring the availability and completeness of the first aid kit for emergency care, the provision of emergency first aid.
11 Carrying out control of the sterility of the received material and medical instruments, compliance with the terms of storage of sterile products.
12 Regular and timely medical examination, examination for RW, HbSAg, HIV - infection, carriage of pathogenic staphylococcus aureus.
13 Ensuring good order and. sanitation of the treatment room.
14 Timely discharge and receipt from the main honey. nurses necessary for the work of medicines, tools, systems, alcohol, honey. tools, medical items destination.
15 Ensuring the correct accounting, storage and use of medicines, alcohol, honey. tools, medical items destination.
16 Carrying out a dignity. lumen work on health promotion and disease prevention, promotion of healthy lifestyles.
17 Continuous improvement of the professional level of knowledge, skills and abilities. Timely improvement.
The conclusion of the study.
Of the examined children of the first year of life in 2013, there were 14.2% more children with the first group than with the second group, by 31.9% than with the third group, by 42.8% than with the fourth group and by 43 .8% than from the fifth.
For three years of children of the first year of life:
- with 1 health group was 38.4%;
– with the second group 42.7%;
– with the third group 12.4%;
– with the fourth group 3%;
- with the fifth group 3.5%.
2.4 The role of the nurse in newborn care
children of the city of Satka
The senior nurse of the children's polyclinic in Satka, having received information about the discharge of the baby from the maternity hospital, on the same day enters the data into the register of newborns; she fills in the history of the development of the newborn, pastes prenatal care inserts into it, transfers the history of development to the registry or directly to the district nurse.
The first patronage for a newborn is performed 1-2 days after discharge from the hospital; Discharged premature babies with symptoms of perinatal and congenital pathology are visited by a nurse and a district doctor on the day of discharge. If this day falls on weekends or holidays, such children are visited by a pediatrician on duty.
General purpose of patronages:
– create a program for the rehabilitation of the child;
- assess the health status of the child;
- evaluate the health status of the mother;
– assess the socio-economic conditions of the family.
CONCLUSION
The protection of children's health in our country is one of the priority tasks, since there is no greater value than human health, which is an indicator of the well-being of society.
Particular attention belongs to preventive and health-improving measures that contribute to the reduction of morbidity.
The nurse teaches the mother the daily regimen and nutrition to improve lactation, proper feeding of the child, caring for him, the method of feeding, convinces parents of the need to regularly see a doctor and follow all his recommendations. Gives recommendations on the physical and neuropsychic education of the child, massage, hardening, development of hygiene skills, prevention of rickets. Teaches mother and all family members the technology of psycho-emotional communication with the child.
The nurse teaches the correct implementation of daily manipulations for the baby:
- treatment of the umbilical wound;
- bathing a child
- washing;
- treatment of the nose, ears, eyes;
- nail care.
All nurses at the Satka children's polyclinic do their job well. Competently explain the rules of caring for children of the first year of life.
The vaccination nurse conducts psychological preparation of the child for vaccination. In the history of development, it records the doctor's admission to vaccination, the intervals between vaccinations and their compliance with the individual vaccination calendar.
Registers the vaccination in the vaccination card (form No. 063 / y), the register of preventive vaccinations (form No. 064 / y) and in the history of the child's development (form No. 112 / y) or in the child's individual card (form No. 026 /y). Performs vaccinations and gives advice to parents on child care.
For three years, 2331 children (children of the first year of life) underwent medical examination. The number of examined children in 2015 decreased by 0.8% compared to 2013.
In 2013, the number of examined children was higher by 1.2% than in 2014 and by 0.8% than in 2015.
Of the examined children of the first year of life in 2013, there were 14.2% more children with the first group than with the second group, by 31.9% than with the third group, by 42.8% than with the fourth group and by 43 .8% than from the fifth.
Of the examined children of the first year of life in 2014, there were 19.9% more children with the second group than with the first group, by 37.4% than with the third group, by 47.5% than with the fourth group and by 46 .7% than with the fifth.
Of the examined children of the first year of life in 2015, there were 8.4% more children with the second group than with the first group, by 36.8% than with the third group, by 44.3% than with the fourth group and by 42 .2% than with the fifth group.
For three years of children of the first year of life:
- with 1 health group was 38.4%;
– with the second group 42.7%;
– with the third group 12.4%;
– with the fourth group 3%;
- with the fifth group 3.5%.
From 2013 to 2015, the number of children with the 5th group increased by 13.7 compared to 2013.
For three years, 31836 vaccinations were made for children of the first year of life, in 2013 10288 vaccinations, which is 32.3% of all vaccinated children of the first year of life per year. In 2014, 9920 vaccinations, which is 31.1% of all vaccinated children in the first year of life per year. In 2015, there were 11,630 vaccinations, which is 36.6% of all vaccinated children in the first year of life per year. From this we can conclude that the number of vaccinated children is increasing every year. Since 2013, it has increased by 4.3% compared to 2015.
Basic principles of immunoprophylaxis:
– mass character, availability, timeliness, efficiency;
– Mandatory vaccination against vaccine-preventable diseases;
- an individual approach to the vaccination of children;
- safety during preventive vaccinations;
- Free vaccinations.
The role of the nurse in organizing the medical examination of children in the first year of life is to examine children:
– carrying out anthropometry;
– psychometrics;
- early referral of the child to specialists;
– referral to laboratory and instrumental studies.
One of the main sections of the work of a pediatric nurse is the hygienic education of family members, especially young parents, teaching them how to raise a healthy child, which involves individual lessons, taking into account the cultural and general educational level of the family, the psychological climate and many other factors. At each pediatric site, an annual plan for sanitary and educational work with the population should be drawn up, in accordance with which the pediatrician and the nurse systematically organize lectures and conversations.
LIST OF USED SOURCES
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13. Nikitin, B.P. Steps of creativity or educational games. – M.: Enlightenment, 2009. – 160 p.
14. Order No. 307 of the Ministry of Health and Social Development of Russia dated April 28, 2007 “On the standard for dispensary (preventive) observation of a child during the first year of life”.
15. Order of the Ministry of Health of Russia No. 125n dated March 21, 2014 « On the approval of the national calendar of preventive vaccinations and the calendar of preventive vaccinations according to epidemic indications.
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APPS
Annex 1
Criteria for evaluating the effectiveness of preventive work
– Coverage of prenatal care for pregnant women;
– Patronage coverage of children of the first year of life;
- Completeness of coverage of preventive examinations of children (at least 95% of the total number of children of the corresponding age subject to preventive examinations; in the first year of a child's life - 100% at 1 month, 3 months, 6 months, 9 months, 12 months. );
– Complete coverage of preventive vaccinations in accordance with the National Calendar (at least 95% of the total number of children subject to vaccination);
- The share of the number of children in the first year of life who are breastfed (at 3 months - at least 80%, at 6 months - at least 50%, at 9 months - at least 30%);
– It is carried out on the first day after discharge from the hospital (in the first three days, if the newborn is healthy);
- Clarify and evaluate the social, genealogical and biological history, using the data of the mother's survey, prenatal patronage and information from the newborn's exchange card (f-113-u);
– Issues and problems of feeding a newborn;
– Objective examination of the newborn;
– Conclusion on the diagnosis, health group and risk group;
– Medical examination plan for the first month;
– Prevention of hypogalactia, vitamin and micronutrient deficiencies, nutrition of a nursing woman;
– Maximum observance of the principle of professional ethics, internal culture, friendliness and solemnity of the situation.
Newborn baby care
Order of the Ministry of Health and Social Development of the Russian Federation of April 28, 2007 No. 307 “On the standard for dispensary (preventive) observation of a child during the first year of life
– Patronage of the district pediatrician on the 14th and 21st day of life, according to indications (health group) on the 10th, 14th, 21st day of life;
– Patronage of a nurse at least 2 times a week;
– During the first month of life, medical care for children is provided by a pediatrician and specialists of a children's clinic only at home;
– Commission examination at 1 month of life in a polyclinic (neurologist, pediatric surgeon, orthopedic traumatologist, ophthalmologist, pediatrician, head of the pediatric department, audiological screening, ultrasound of the hip joints);
– Assessment of physical development based on anthropometric indicators, neuropsychic development, determination of a health group, identification of risk groups;
– Dispensary observation plan during the first year of life.
Observation of children in the first year of life Order of the Ministry of Health and Social Development of the Russian Federation dated April 28, 2007 No. 307 “On the standard for dispensary (preventive) observation of a child during the first year of life:
- Pediatrician - monthly: assessment of anamnesis, identification of risk groups, prognosis of health status, risk orientation, assessment of information from the previous period, physical development, neuropsychic development, resistance assessment, diagnosis and assessment of the functional state of the body, conclusion on health status, recommendations.
- Neurologist - 3, 6, 12 months, pediatric dentist and pediatric surgeon - 9 and 12 months, orthopedist, ophthalmologist, otolaryngologist - 12 months, pediatric gynecologist - up to 3 months and 12 months for girls.
– Statement for dispensary registration and observation according to the registration form No. 030-u.
Laboratory and instrumental studies:
- At the age of 1 month - audiological screening and ultrasound of the hip joints;
- At 3 months - a blood and urine test, at 12 months - a blood and urine test, ECG;
- In risk groups - additionally at 1 month and 9 months, a blood and urine test, at 9 months, an ECG.
Newborn health groups
Group 1 - healthy children (having no deviations in the state of health and risk factors).
2 Group - depending on the number and direction of risk factors, as well as on their potential or actual implementation, is divided into options: A and B.
Group 3 - the presence of a chronic disease in the stage of compensation.
4 and 5 Groups - by analogy with the corresponding groups of older children.
At the end of the neonatal period, it passes into the health group of young children (Order No. 621).
Appendix 2
The procedure for carrying out preventive vaccinations for citizens within the framework of the national calendar of preventive vaccinations
1 Preventive vaccinations within the framework of the national calendar of preventive vaccinations are carried out for citizens in medical organizations if such organizations have a license that provides for the performance of works (services) for vaccination (carrying out preventive vaccinations).
2 Vaccination is carried out by medical workers who have been trained in the use of immunobiological drugs for the immunoprophylaxis of infectious diseases, the organization of vaccination, vaccination techniques, as well as in the provision of medical care in an emergency or urgent form.
3 Vaccination and revaccination within the framework of the national calendar of preventive vaccinations are carried out with immunobiological medicinal products for the immunoprophylaxis of infectious diseases, registered in accordance with the Russian Federation, according to the instructions for their use.
4 Before carrying out preventive vaccination, the person to be vaccinated, or his legal representative, is explained the need for immunoprophylaxis of infectious diseases, possible post-vaccination reactions and complications, as well as the consequences of refusing to carry out preventive vaccination, and an informed voluntary consent to medical intervention is issued in accordance with the requirements of the Federal Law of 21 November 2011 N 323-FZ "On the basics of protecting the health of citizens in the Russian Federation."
5 All persons who are to be vaccinated must first be examined by a doctor (paramedic).
6 When changing the timing of vaccination, it is carried out according to the schemes provided for by the national calendar of preventive vaccinations and in accordance with the instructions for the use of immunobiological drugs for the immunoprophylaxis of infectious diseases. It is allowed to administer vaccines (except vaccines for the prevention of tuberculosis) used within the framework of the national immunization calendar, on the same day with different syringes to different parts of the body.
7 Vaccination of children for whom immunoprophylaxis against pneumococcal infection was not started in the first 6 months of life is carried out twice with an interval between vaccinations of at least 2 months.
8 Vaccination of children born to mothers with HIV infection is carried out within the framework of the national calendar of preventive vaccinations in accordance with the instructions for the use of immunobiological drugs for the immunoprophylaxis of infectious diseases. When vaccinating such children, the following are taken into account: HIV - the child's status, type of vaccine, immune status indicators, the child's age, concomitant diseases.
9 Revaccination of children against tuberculosis born to mothers with HIV infection and who received three-stage chemoprophylaxis of HIV transmission from mother to child (during pregnancy, childbirth and in the neonatal period) is carried out in the maternity hospital with vaccines for the prevention of tuberculosis (for gentle primary vaccination). In children with HIV infection, as well as when HIV nucleic acids are detected in children by molecular methods, revaccination against tuberculosis is not carried out.
10 Vaccination with live vaccines within the framework of the national immunization calendar (with the exception of vaccines for the prevention of tuberculosis) is carried out for children with HIV infection with the 1st and 2nd immune categories (no immunodeficiency or moderate immunodeficiency).
11 If the diagnosis of HIV infection is excluded, children born to mothers with HIV infection are vaccinated with live vaccines without prior immunological examination.
12 Toxoids, killed and recombinant vaccines are administered to all children born to mothers with HIV infection as part of the national preventive vaccination schedule. For children with HIV infection, these immunobiological drugs for the immunoprophylaxis of infectious diseases are administered in the absence of severe and severe immunodeficiency.
13 When vaccinating the population, vaccines containing antigens that are relevant to the Russian Federation are used to ensure maximum effectiveness of immunization.
14 When vaccinating against hepatitis B in children of the first year of life, against influenza of children from 6 months of age studying in general educational institutions, pregnant women, vaccines that do not contain preservatives are used.
Perinatal pathology in Russia: level, structure of morbidity
L.P. Sukhanov
(Part of the chapter "Dynamics of health indicators of born offspring and perinatal demography in Russia in 1991-2002" of the book by L.P. Sukhanova Perinatal problems of reproduction of the Russian population in the transition period. M., "Canon + Rehabilitation", 2006 272 p.)
The main indicators of the health of the born offspring are the level of prematurity in the population, morbidity and parameters of physical development.
prematurity associated primarily with the incidence of pregnant women, has a negative impact on the physical development of children in subsequent periods of their lives and inevitably contributes to the growth of not only perinatal morbidity and mortality, but also disability.
The growth of prematurity among newborns in Russia is noted by numerous studies and statistical indicators. At the same time, it is emphasized that, firstly, the frequency of diseases and complications in premature infants is higher than in full-term ones (respiratory distress syndrome, hyperbilirubinemia, anemia of prematurity, infectious diseases, etc.), and secondly, that pathology in of a premature baby has its own characteristics, accompanied by severe disorders of metabolic processes and immune disorders, which determines the maximum "contribution" of premature babies to perinatal and infant mortality, as well as childhood disability.
According to the data of statistical form No. 32, during the analyzed period, the number of premature births increased from 5.55% in 1991 to 5.76% in 2002 - with uneven growth over the years (the maximum value of the indicator in 1998 was 6.53%) .
An analysis of the rate of prematurity among newborns in comparison with the number of births with low body weight (Fig. 37) in the federal districts of Russia, carried out according to statistical form No. 32, revealed that the highest level of prematurity among live births, as well as the number of low birth weight children, are observed in the Siberian and Far Eastern Federal District, and the minimum number of premature and underweight children is observed in the Southern Federal District, which is consistent with the data of the analysis of the structure of born children by body weight given earlier.
Figure 37. The ratio of the proportion of premature and "low birth weight" newborns (in % of live births) by federal districts of Russia in 2002
Characteristically, in the Central Federal District, the only one in the country, the level of prematurity (5.59%) exceeded the number of those born with low body weight (5.41%), while the figures in Russia were 5.76 and 5.99%, respectively.
Analysis newborn morbidity
in Russia over the past 12 years revealed a progressive steady increase in the overall incidence rate by 2.3 times - from 173.7‰ in 1991 to 399.4 in 2002 (Table 16, Fig. 38), mainly due to an increase in the number sick full-term children (from 147.5‰ in 1991 to 364.0‰ in 2002), or 2.5 times.
The incidence of premature babies increased by 1.6 times over the same years (from 619.4 to 978.1‰), which is shown in Fig. 3.
The increase in the incidence of newborns occurred mainly due to intrauterine hypoxia and asphyxia at birth (from 61.9‰ in 1991 to 170.9‰ in 2002, or 2.8 times), as well as slowing down the growth and malnutrition of newborns, the level of which increased from 23.6‰ in 1991 to 88.9‰ in 2002, or 3.8 times. In third place in terms of morbidity in newborns is neonatal jaundice, recorded in statistical form No. 32 only since 1999; its frequency was 69.0‰ in 2002.
Figure 38. Dynamics of the incidence rate of newborns in Russia (full-term and premature, per 1000 births of the corresponding gestational age) in 1991-2002
In terms of the growth rate of the prevalence of pathology in newborns during the analyzed years (from 1991 to 2002), hematological disorders are in first place (5.2 times), growth retardation and malnutrition (congenital malnutrition) are in second place (3.8 times), on the third - intrauterine hypoxia and asphyxia at birth (2.8). Next comes intrauterine infection (2.7 times), birth trauma (1.6 times) and congenital developmental anomalies (1.6 times).
Table 16. The incidence of newborns in Russia in 1991-2002 (per 1000 live births)
|
Diseases |
1991 |
1992 |
1993 |
1994 |
1995 |
1996 |
1997 |
1998 |
1999 |
2000 |
2001 |
2002 |
2002/1991 |
|
General morbidity |
173,7 |
202,6 |
234,7 |
263,5 |
285,2 |
312,9 |
338,7 |
356,5 |
393,4 |
399,4 |
229,9 |
||
|
Got sick full-term |
147,5 |
174,3 |
233,1 |
253,5 |
281,2 |
307,7 |
349,3 |
345,1 |
357,1 |
246,8 |
|||
|
Sick premature |
619,4 |
661,8 |
697,3 |
774,9 |
797,4 |
809,3 |
824,1 |
867,5 |
932,5 |
981,6 |
978,1 |
157,9 |
|
|
congenital anomalies |
18,8 |
20,5 |
22,8 |
24,4 |
25,74 |
27,85 |
29,63 |
30,22 |
29,34 |
29,43 |
30,32 |
29,67 |
157,8 |
|
Slow growth, malnutrition |
23,6 |
32,2 |
39,6 |
46,4 |
52,2 |
61,35 |
67,92 |
78,75 |
81,43 |
85,87 |
88,87 |
376,6 |
|
|
Birth injury |
26,3 |
27,9 |
27,6 |
31,5 |
32.5 |
32,7 |
31,6 |
31,3 |
41,7 |
41,1 |
42,6 |
41,9 |
159,3 |
|
including intracranial |
8,74 |
7,37 |
6,75 |
3,06 |
2,15 |
1,67 |
|||||||
|
Hypoxia intrauterine and birth asphyxia |
61,9 |
78,7 |
96,2 |
113,9 |
127,3 |
143,49 |
158,12 |
171,79 |
175,54 |
176,28 |
169,21 |
170,94 |
276,2 |
|
Respiratory distress syndrome |
14,4 |
15,6 |
17,8 |
18,8 |
19,8 |
21,29 |
21,4 |
22,48 |
17,39 |
18,06 |
17,81 |
18,67 |
129,7 |
|
including RDS in term infants |
7,21 |
7,75 |
9,07 |
8,43 |
9,49 |
5,73 |
6,26 |
5,86 |
6,15 |
120,6 |
|||
|
Intrauterine infections |
10,65 |
10,5 |
13,2 |
16,03 |
19,19 |
23,4 |
23,43 |
25,01 |
24,55 |
24,25 |
24,03 |
||
|
Incl. sepsis |
0,33 |
0,28 |
0,32 |
0,40 |
0,34 |
0,41 |
0,42 |
0,42 |
0,59 |
0,50 |
0,44 |
0,35 |
106,1 |
|
Hemolytic disease of the newborn |
6,10 |
6,20 |
6,60 |
7,00 |
7,53 |
8,02 |
8,56 |
10,35 |
9,32 |
8,89 |
8,41 |
8,68 |
142,3 |
|
Hematological disorders |
2,26 |
3,33 |
4,10 |
5,90 |
6,59 |
8,27 |
9,06 |
9,31 |
10,00 |
10,44 |
11,30 |
11,78 |
521,2 |
|
neonatal jaundice |
47,31 |
55,49 |
61,58 |
68,99 |
145,8 |
||||||||
|
TRANSFERRED NEWBORN |
6,17 |
6,64 |
7,31 |
7,99 |
8,17 |
8,72 |
9,17 |
9,11 |
9,28 |
9,01 |
9,11 |
8,89 |
144,1 |
Such a significant increase in the prevalence of hypoxia and malnutrition in newborn children in the last decade (Fig. 39) is an inevitable result of the growth of extragenital and obstetric pathology in pregnant women, against which placental insufficiency develops and, as a consequence of the latter, intrauterine growth retardation of the fetus.
Figure 39. Dynamics of the frequency of intrauterine hypoxia, congenital anomalies and growth retardation in newborns in 1991-2002 (per 1000)
At the same time, it is important to note that the frequency of growth retardation and malnutrition of newborns (Fig. 39) continues to progressively increase in recent years, which confirms the situation about the continuing serious ill health of the reproduced offspring. It should be emphasized that we are talking about an objective criterion - the weight and height indicators of newborns, not subject to possible erroneous or subjective interpretation. Data on an increase in the frequency of growth retardation and malnutrition of newborns are consistent with the data presented above on changes in the structure of children by body weight - a decrease in the number of large and an increase in low birth weight newborns during the analyzed period. In turn, congenital trophic disorders and previous prenatal hypoxia and asphyxia at birth are the main background condition and the cause of the child's development of neurological and somatic pathology in the future.
Figure 40. Dynamics of the frequency of birth trauma, including intracranial, in Russia in 1991-2002 (per 1000)
One of the main problems of perinatology is the birth trauma of the fetus and newborn, which is of great medical and social importance, since the heart injury of children largely determines perinatal mortality and childhood disability. During the analyzed period in Russia, there has been an increase in the frequency of birth trauma in newborns (by 1.6 times) due to the so-called "other" birth trauma (Fig. 40), while the frequency of intracranial birth trauma has sharply decreased from 9.3‰ to 1.67‰; Such dynamics may be due, on the one hand, to a change in the tactics of labor management (an increase in the frequency of abdominal delivery), and, on the other hand, to a change in the statistical accounting of this pathology since 1999, when fractures of the clavicle and cephalohematomas began to be included in the heading "birth trauma". This led to the observed increase over the past 4 years in the frequency of all birth trauma (due to the "other") to the level of 41.1-42.6‰, which certainly indicates an insufficient level of obstetric care in the obstetric hospital. So, today, every 25th child born has a traumatic injury during childbirth.
It should be noted that in recent years in Russia, against the background of a sharp decrease in the frequency of intracranial birth trauma (2.2 times from 1998 to 1999), there has been an equally sharp (2.3 times) increase in mortality from this pathology - from 6.17% in 1998 to 14.3% in 1999 (Figure 41). Among full-term children, mortality increased from 5.9% in 1991 to 11.5% in 2003, and among premature babies - from 26.4% to 33.2% (!) Over the same years, with a sharp rise in mortality in 1999 year with a decrease in the incidence rate also indicates a change in diagnostic approaches for this pathology. Nevertheless, such a high level of mortality, especially in premature babies, puts the problem of birth trauma in newborns in first place among obstetric problems in modern Russia.
Figure 41. Mortality of newborns from intracranial birth trauma in the dynamics of 1991-2003 (per 100 cases)
Extremely unfavorable is the increase in the frequency of neonatal jaundice in Russia - from 47.3‰ in 1999 (from which their registration began) by 1.5 times in three years. This pathology is typical for premature babies and newborns with morphofunctional immaturity, and the increase in its prevalence is consistent with the data on the continuing high level of prematurity and intrauterine growth retardation. In addition, hypoxic damage to hepatocytes contributes to impaired bilirubin conjugation in a newborn, and thus, an increase in the frequency of neonatal jaundice is naturally associated with an increase in the frequency of intrauterine hypoxia and asphyxia at birth. In an increase in the incidence of jaundice in newborns, one cannot exclude the influence of such a factor as an increase in the frequency of induced ("programmed") births, as well as prenatal caesarean section, in which delivery is performed under conditions of incomplete morphofunctional maturity of the enzyme systems of the fetal body, in particular, the liver transferase system.
The significance of the growth of neonatal jaundice is increasing due to the recent increase in the population of mental retardation of children and the pathology of the nervous system, since bilirubin encephalopathy as a result of severe forms of neonatal jaundice is accompanied by significant neurological disorders. At the same time, the lack of the ability to objectively control the level of hyperbilirubinemia in jaundice in many obstetric hospitals in the country (some of which do not have laboratories at all) may be the reason for the development of this pathology in newborns.
Figure 42. The frequency of hemolytic disease of the newborn (HDN) and hematological disorders in newborns in Russia in 1991-2002, per 1000
The growth in the country of hemolytic disease of newborns by 1.4 times in 2002 in comparison with 1991 (Fig. 42) can also cause an increase in the incidence of bilirubin encephalopathy in newborns. The presented figure shows an increase in the incidence of hemolytic disease in newborns, which was also most pronounced in 1998-1999.
When discussing the problem of hemolytic disease with Rh incompatibility, it is necessary to note the unfavorable trend of a decrease in recent years in Russia in specific immunoprophylaxis of Rh conflict in Rh-negative women, which is largely due to economic factors - the high cost of anti-Rh globulin, as indicated by V.M. Sidelnikov.
The frequency of respiratory distress syndrome increased during the analyzed period from 14.4‰ to 18.7‰, while the change in the statistical registration of this nosological form since 1999 had a significant impact on its dynamics (Fig. 43). However, even under this condition, the growth of this pathology in newborns, including full-term children, characterizes the increase in the degree of morphofunctional immaturity, i.e. that background pathology, which is not taken into account independently, but is clearly detected by indirect signs (growth of conjugative jaundice, respiratory distress syndrome in full-term children).
Figure 43. Dynamics of respiratory distress syndrome (RDS) in newborns in 1991-2002 and RDS in full-term children (per 1000 of the corresponding population)
The frequency of infectious pathology specific to the perinatal period (Fig. 44) increased in newborns in 2002 in comparison with 1991 by 2.7 times and amounted to 24.0‰, which to a certain extent could be explained by an improvement in the detection of infections. However, the increase in septic morbidity among newborns, consistent with the increase in septic complications in parturients/parturient women (the maximum value of the indicator for both women and children in 1999), allows us to regard the increase in congenital infectious pathology in newborns as true.
Figure 44. Dynamics of the frequency of perinatal infections (diagram, left scale) and sepsis (graph, right scale) in newborns in Russia in 1991-2002, per 1000
In 2002, the structure of the incidence of newborns in Russia is presented as follows: in the 1st place - hypoxia, in the second - malnutrition, in the third - neonatal jaundice, in the fourth - birth trauma, in the fifth - developmental anomalies.
Noting the particular importance of congenital anomalies (malformations) and chromosomal disorders, which, although they are in fifth place in terms of the frequency of neonatal pathology, are extremely important because they cause severe pathology and disability in children, measures for prenatal diagnosis of congenital and hereditary pathology are of paramount importance. . In Russia, there is an increase in congenital anomalies in newborns from 18.8‰ in 1991 to 29.7‰ in 2002, or 1.6 times. The population frequency of malformations averages from 3% to 7%, and this pathology causes more than 20% of childhood morbidity and mortality and is detected in every fourth death in the perinatal period. At the same time, it was shown that with a good organization of prenatal diagnosis, it is possible to reduce the birth of children with congenital pathology by 30%.
Statistical data and numerous studies convincingly show how big the role of congenital malformations (CM) in the structure of morbidity and mortality in children is. Malformations cause more than 20% of infant mortality (an increase of up to 23.5% in 2002 among all dead children under the age of one in Russia). The population frequency of congenital malformations averages from 3% to 7%, and among stillborns reaches 11-18%. At the same time, there is a pattern: the lower the PS level, the higher the frequency of congenital malformations. Thus, according to the Scientific Center for Obstetrics, Gynecology and Perinatology of the Russian Academy of Medical Sciences, a decrease in PS to 4‰-7‰ was accompanied by a sharp increase (from 14% to 39%) in the proportion of malformations among dead fetuses and newborns.
The prevalence of congenital anomalies among newborns in the dynamics of 1991-2002 is shown in fig. 45.
Figure 45. Dynamics of the frequency of congenital anomalies in newborns in Russia in 1991-2002 (per 1000 births)
As can be seen from Table. 17, in the context of the federal districts of Russia, the maximum incidence rate of newborns was noted in the Siberian Federal District, mainly due to full-term children. In this district, the maximum rate of hypoxia, malnutrition, and respiratory disorders, incl. respiratory distress syndrome of full-term infants, which characterizes a high degree of morphofunctional immaturity among newborns.
Table 17. Morbidity in newborns by federal districts of Russia in 2002 (per 1000)
|
RUSSIA |
Central Federal District |
Northwestern Federal District |
Southern Federal District |
Privolzhsky Federal District |
Ural Federal District |
Siberian Federal District |
Far Eastern Federal District |
|
|
General morbidity |
||||||||
|
term |
||||||||
|
premature |
||||||||
|
Hypotrophy |
||||||||
|
Birth injury |
||||||||
|
Incl. Cheka |
||||||||
|
hypoxia |
||||||||
|
Respiratory disorders |
||||||||
|
Incl. RDS |
||||||||
|
of which RDS-premature |
||||||||
|
RDS-term |
||||||||
|
congenital pneumonia |
||||||||
|
infections, specific |
||||||||
|
Incl. sepsis |
||||||||
|
Hematological disorders |
||||||||
|
Jaundice neonatal |
||||||||
|
congenital anomalies |
An extremely high level of growth retardation and malnutrition (malnutrition) of newborns (every ninth - tenth child born in the Volga, Ural and Siberian Federal Districts) and jaundice (every tenth - twelfth) determines the high incidence of older children in these territories.
The high frequency of birth trauma in the Siberian District (48.3‰ compared to 41.9‰ in Russia) and intracranial birth injury in the Southern Federal District (1.7 times higher than the national figure) characterizes the low quality of obstetric services in these areas. The maximum level of infectious pathology of newborns was noted in the Far Eastern Federal District, 1.4 times higher than in Russia as a whole, and septic complications are most often observed in the Volga Federal District. The highest level of neonatal jaundice was also noted there - 95.1‰, with 69‰ in Russia.
The maximum frequency of congenital anomalies in the Central Federal District - 42.2‰ (1.4 times higher than the national level) dictates the need to study the causes and eliminate the factors that cause congenital malformations of the fetus, as well as take the necessary measures to improve the quality of prenatal diagnosis of this pathology.
According to the growth in the incidence of newborns in Russia, there is an increase in the number of newborns transferred from an obstetric hospital to the departments of pathology of newborns and the second stage of nursing from 6.2% in 1991 to 8.9% in 2002.
A natural consequence of an increase in the incidence of newborns is an increase in the number of chronic pathologies in children, up to severe health disorders, with limited life activity. The role of perinatal pathology as a cause of childhood disability is determined by different authors in 60-80%. Congenital and hereditary pathologies, prematurity, extremely low birth weight, intrauterine infections (cytomegalovirus, herpetic infection, toxoplasmosis, rubella, bacterial infections) occupy a significant share among the causes contributing to the disability of children; the authors note that in terms of prognosis, meningitis and septic conditions are especially unfavorable clinical forms.
It is noted that the quality of perinatal care, as well as rehabilitation measures at the stage of treatment of chronic diseases, are often fundamental in the formation of a disabling pathology. Kamaev I.A., Pozdnyakova M.K. et al. note that due to the steady increase in the number of disabled children in Russia, the expediency of timely and high-quality prediction of disability at an early and preschool age is obvious. Based on a mathematical analysis of the significance of various factors (family living conditions, the health of parents, the course of pregnancy and childbirth, the child's condition after birth), the authors developed a prognostic table that makes it possible to quantify the risk of a child developing disability due to diseases of the nervous system, mental sphere, congenital anomalies ; the values of prognostic coefficients of the studied factors and their informative value were determined. Among the significant risk factors for the fetus and newborn, the main risk factors were intrauterine growth retardation (IUGR); prematurity and immaturity; hypotrophy; hemolytic disease of the newborn; neurological disorders in the neonatal period; purulent-septic diseases in a child.
Pointing to the interconnectedness of the problems of perinatal obstetrics with pediatric, demographic and social problems, the authors emphasize that the fight against pregnancy pathology that causes impaired growth and development of the fetus (somatic diseases, infection, miscarriage) is most effective at the stage of preconception preparation.
The real factor in the prevention of severe disabling diseases in a child is the early detection and adequate treatment of perinatal pathology, and above all placental insufficiency, intrauterine hypoxia, intrauterine growth retardation, urogenital infections, which play an important role in CNS damage and the formation of fetal abnormalities.
Sharapova O.V., notes that one of the leading causes of neonatal and infant mortality is still congenital anomalies and hereditary diseases; In this regard, according to the author, prenatal diagnosis of malformations and timely elimination of fetuses with this pathology are of great importance.
In order to implement measures to improve prenatal diagnosis aimed at preventing and early detection of congenital and hereditary pathologies in the fetus, increase the efficiency of this work and ensure interaction in the activities of obstetrician-gynecologists and medical geneticists, an order of the Ministry of Health of Russia dated December 28, 2000 No. 457 "On improving prenatal diagnosis and prevention of hereditary and congenital diseases in children.
Prenatal diagnosis of congenital malformations, designed for active prevention of the birth of children with developmental anomalies by terminating pregnancy, includes ultrasound examination of pregnant women, determination of alpha-fetoprotein, estriol, human chorionic gonadotropin, 17-hydroxyprogesterone in the mother's blood serum and determination of the fetal karyotype by chorion cells in women over 35 years old.
It has been proven that with a good organization of prenatal diagnosis, it is possible to reduce the birth of children with severe congenital pathology by 30%. Noting the need for antenatal prevention of congenital pathology, V.I. Kulakov notes that for all its high cost (the cost of one amniocentesis procedure with chorion cell biopsy and karyotype determination is about 200-250 US dollars), it is more cost-effective than the cost of maintaining a disabled child with severe chromosomal pathology.
1 - Baranov A.A., Albitsky V.Yu. Social and organizational problems of pediatrics. Selected essays. - M. - 2003. - 511s.
2 - Sidelnikova V.M. Miscarriage. - M.: Medicine, 1986. -176s.
3 - Barashnev Yu.I. Perinatal neurology. M. Science. -2001.- 638 p.; Baranov A.A., Albitsky V.Yu. Social and organizational problems of pediatrics. Selected essays. - M. - 2003. - 511s.; Bockeria L.A., Stupakov I.N., Zaichenko N.M., Gudkova R.G. Congenital anomalies (malformations) in the Russian Federation // Children's Hospital, - 2003. - No. 1. - C7-14.
4 - Kulakov V.I., Barashnev Yu.I. Modern biomedical technologies in reproductive and perinatal medicine: prospects, moral, ethical and legal problems. // Russian Bulletin of Perinatology and Pediatrics. - 2002. No. 6. -p.4-10.
5 - Ibid.
6 - Ibid.
7 - Kagramanov A.I. Comprehensive assessment of the consequences of diseases and causes of disability in the child population: Abstract of the thesis. diss. cand. honey. Sciences. - M., 1996. - 24 p.
8 - Kulakov V.I., Barashnev Yu.I. Modern biomedical technologies in reproductive and perinatal medicine: prospects, moral, ethical and legal problems. // Russian Bulletin of Perinatology and Pediatrics. - 2002. No. 6. -p.4-10; Ignatieva R.K., Marchenko S.G., Shungarova Z.Kh. Regionalization and improvement of perinatal care. /Materials of the IV Congress of the Russian Association of Perinatal Medicine Specialists. - M., 2002. - c. 63-65.
9 - Kulakov V.I., Barashnev Yu.I. Modern biomedical technologies in reproductive and perinatal medicine: prospects, moral, ethical and legal problems. // Russian Bulletin of Perinatology and Pediatrics. - 2002. No. 6. -p.4-10
