Comprehensive assessment of the health status of children. health groups. National. Comprehensive assessment of the child's health status

Comprehensive Assessment health status of children

To assess the health of children and adolescents, it is necessary to use at least four criteria, namely: 1) the presence or absence of chronic diseases at the time of examination; 2) the level of achieved physical and neuropsychic development and the degree of its harmony; 3) the level of functioning of the main body systems; 4) the degree of body resistance adverse effects.

From a hygienic point of view most attention deserves a health assessment based on the totality of all four characteristics.

These goals are met by the method of comprehensive assessment and distribution of children and adolescents into health groups.

In accordance with the proposed scheme, children and adolescents, depending on the totality of health indicators, are divided into five groups.

_First group. - these are persons who do not have chronic diseases, who did not get sick or rarely got sick during the observation period and who have normal, age-appropriate physical and neurological mental development(health, no deviations).

_second group. are children and adolescents who do not suffer from chronic diseases, but have functional and morphological abnormalities, as well as often (4 times a year or more) or long-term (more than 25 days for one disease) sick (health with functional abnormalities and reduced resistance).

_Third group. unites people with chronic diseases or congenital pathology in a state of compensation, with rare and not severe exacerbations of a chronic disease, without pronounced violation general well-being(patients in a state of compensation).

_to the fourth group. include persons with chronic diseases, birth defects development in a state of subcompensation, with impairments general condition and well-being after an exacerbation, with a protracted period of convalescence after acute intercurrent diseases (patients in a state of subcomplexation).

_to the fifth group. include patients with severe diseases in a state of decomplexation and with significantly reduced functionality (patients in a state of decomplexation). As a rule, such patients do not attend general institutions for children and adolescents and are not covered by mass examinations.

Children and adolescents classified as different groups health, need a differentiated approach in the development of a complex of therapeutic and preventive measures. For persons belonging to the first health group, educational, labor and sports activities are organized without any restrictions in accordance with the existing programs of the educational process. A pediatrician or a therapist of a teenage office conducts a preventive examination at the usual (scheduled) time. At the same time, medical appointments consist of the usual general health measures that have a training effect on the body.

Children and adolescents in the second health group (sometimes called the risk group) require more attention from doctors. The fact is that this contingent needs a complex of recreational activities, the timely implementation of which is most effective in preventing the development chronic pathology in children's and adolescence. Of particular importance are hygienic recommendations for increasing the body's resistance by non-specific means: optimal physical activity, hardening natural factors nature, rational mode days, additional fortification of food.

Children and adolescents assigned to the third group, fourth and fifth health groups are under dispensary observation by doctors of various specialties in accordance with the existing methodological recommendations for medical examination of the child population.

Patients receive the necessary therapeutic and preventive care, due to the presence of one or another form of pathology and a decrease in complexation. In children's and teenage institutions, a sparing day regimen is created for them, the duration of rest and night sleep is lengthened, the volume and intensity are limited. physical activity and others. If necessary, patients with chronic diseases or those with congenital malformations are sent to a special children's and adolescent institutions, where, taking into account the characteristics of the pathology, treatment and education are purposefully carried out.

Basic principles for organizing medical examinations of children and adolescents, determining the degree of functional readiness of children to enter school

The state of health of children and adolescents depends on the organization of their medical support. The most common form is in which medical care is mainly concentrated in the hands of the district pediatrician (in a polyclinic, at home), and preventive care(in the conditions of a kindergarten, school) is assigned to doctors working in children's institutions.

One of the main links in the chain of various preventive measures is dispensary observation health status of preschoolers, schoolchildren and adolescents. A large amount of work on the medical examination of children attending preschool institutions, schools, is carried out by the medical personnel of these institutions (pediatrician and nurse). It is they who mainly exercise control over the dynamics of the state of health of preschoolers and schoolchildren, organize the rehabilitation of children (in the conditions of these educational institutions). An important element of control is periodic mandatory medical examinations of children and adolescents. The results of these examinations allow not only to assess the level of health of each child (taking into account all criteria) and children's team in general, but also serve as the basis for evaluating the effectiveness of ongoing medical and health-improving and hygienic measures.

Medical examination of children aged 5-6 years has special meaning to prepare the child for school, as it allows not only to timely identify deviations in the state of his health, but also to carry out the most complete recovery.

Primary education program, application active method generally corresponds to the age capabilities of a six-year-old child. At the same time, some first-graders do not adapt well to school conditions. This is because many children with perfectly normal intelligence do not have sufficient functional readiness for school. As special studies have shown, "unprepared" for school are children with a lag in biological age, with certain diseases or functional abnormalities, with insufficient development of psychophysiological functions that are most associated with educational activities.

Most children who do not have sufficient functional readiness for school do not cope with the requirements curriculum and school routine. The unpreparedness of children for school adversely affects their performance, academic performance and health.

Thus, according to the Institute of Hygiene and Prevention of Diseases among Children and Adolescents, more than 50% of children admitted to school do not have "school" maturity, while studying in the first grade, their health deteriorated both due to functional abnormalities and due to deterioration of the course or the emergence of new chronic diseases.

Therefore, there is a need for a thorough timely diagnosis of the degree of readiness of each child before entering school. This diagnosis is based on the results of a comprehensive medical research and special study, which determines the level of development of "school-necessary" functions.

All children who, upon reaching the decreed age, will enter school, in September-October of the year preceding admission, undergo the first in-depth examination. An in-depth medical examination (scheduled medical examination) is carried out in a kindergarten or children's clinic by a pediatrician, otolaryngologist, ophthalmologist, neuropsychiatrist, orthopedic surgeon, dentist. At the same time, the pediatrician's doctor preschool or a children's polyclinic, a psychophysiological examination of all children is carried out. The results of the first in-depth medical and psychophysiological examination of children are recorded in medical card child development.

Children with deviations in the state of health are prescribed a complex of therapeutic and recreational measures. Preschoolers who have a lag in the development of school-required functions (motor skills, speech) are assigned a set of exercises to correct them. Therapeutic and recreational activities are carried out by doctors of the children's clinic. Classes to eliminate defects in sound pronunciation are conducted by a speech therapist.

Exercises or activities to develop motor skills (drawing, modeling, playing with small designers, etc.) can be done by educators kindergarten or parents.

The district pediatrician or the doctor of the preschool institution controls the implementation of the prescribed activities.

Repeated medical checkup children, including a psychophysiological examination, is carried out in April-May by the same specialists as during the first examination.

When conducting a re-examination, a final decision is made on the readiness of the child for school. Children who have deviations in the state of health, are lagging behind in biological development and have not reached school maturity are considered not ready for learning. The conclusion about the readiness for school is entered in the medical record of the child's development. There are medical indications for postponing the admission to school of children of six years of age (Appendix N 1).

School maturity is understood as such a level of development of a number of physiological systems or even individual functions that ensures that students fulfill all the requirements set by the school without compromising health and normal development.

The study of indicators of a number of functions in children in comparison with academic performance, working capacity, fatigue, educational activity and health dynamics in the first grade made it possible to select psychophysiological criteria by which one can indirectly judge the degree of functional readiness of children for schooling.

It includes 6 indicators (criteria) of health.

I. The study of risk factors in the genealogical, biological and social history. Hereditary diseases are identified, a family pedigree (genetics) is compiled, the health of the father and mother before conception, maternal toxicosis, maternal illness, occupational hazards, viral infections, duration of labor, bad habits parents, diseases of the child in the neonatal period, in infancy and the first 3-4 years, the nature of feeding, hardening, the psychological climate in the family (in a bad climate - neurosis), material and living conditions.

II. The physical development of a child is a dynamic process of growth (increase in body length and weight, development of individual parts of the body) and biological maturation in a particular period of childhood.

The definition of physical development includes

1. Measurement and evaluation of growth is carried out according to centile normative tables (whether growth corresponds to age).

2. Measurement of body weight and assessment (according to two-centile tables of correspondence of weight to the height of the child).

3. Measurement of chest circumference and assessment (according to norms).

4. Physique:

The length of the torso, arms, legs, circumference, limbs;

The condition of the p / w layer;

Development of the muscular system;

The development of the bones of the spine;

Foot development (plantometry);

Development chest(the form);

5. sexual development(determined by the number of erupted permanent teeth, length and weight of the body, the development of secondary sexual characteristics).

Assessment of physical development:

Age appropriate;

Lagging behind in physical development;

advance in physical development.

III. Determination of the level of neuropsychic development, taking into account age (according to the tables, all the skills, indicators that a child has at this age and that he has are compared according to the tables). In addition, they evaluate mental health : emotions, mood (up to 2-6 years), sleep, appetite, personality traits, negative habits.

Age appropriate;

Lags behind in neuropsychic development;

Ahead of neuropsychic development.

IV. resistance. She is considered:

High - number acute diseases 0-3 times a year;

Reduced - the number of acute diseases per year 4-7 times;

Sharply reduced - the number of acute diseases per year is more than 8.

Normal quantity acute illnesses per year:

Healthy

1 year - up to 4 diseases;

2-3 years - up to 6 diseases;

4 years - up to 5 diseases;

5-6 years - up to 4 diseases;

older than 6 years - up to 3 diseases.

Frequently ill children (FIC)

1 year - 4 or more times;

2-3 years - 6 or more times;

4 years - 5 or more times;

5-6 years - 4 or more times;

older than 6 years - 3 or more times.

To determine resistance (immunity) by the number of SARS, the resistance index (IR) is used

IR (%) = number of SARS cases x 100 number of months of life since the onset of ARVI recurrence

Example. A 2-year-old child had 6 acute respiratory viral infections in 12 months

IR = 6/12 x 100 = 50%

If IR \u003d 33-40% - relative to FBI;

If IR = 41-50 - frequently ill children;

If IR = 51% or more - very often ill children.

V. Functional state of organs and systems. Evaluated heart rate, respiratory rate, blood pressure, Hb and Er, VC, minute blood volume.

Grade functional state:

Normal (functional indicators are equal to the norm);

Deteriorated (1 or more indicators on the verge of normal and pathological);

Poor (functional indicators differ sharply from the norm).

VI. The presence of chronic diseases or congenital malformations. Evaluation: “healthy”, “border condition”, “sick”. When assessing the state of health, all 6 criteria (indicators) of health are used simultaneously. None of the criteria taken separately can characterize the condition of the child as a whole. As a result of a comprehensive assessment, children are divided into 3 groups for health reasons:

group 1 - healthy children with normal development, normal functions and immunity;

Health group 2 - healthy, but having functional and some morphological abnormalities, reduced body resistance;

Group 3 - children, sick chronic diseases, in a state of compensation, subcompensation (4) and decompensation (5).

Currently, the distribution of children by health groups is carried out on the basis of the Instructions for a comprehensive assessment of the health status of children, approved. Order of the Ministry of Health of Russia dated December 30, 2003 No. 621. In accordance with this document, the system for a comprehensive assessment of the health status of each child is still based on four basic criteria:

• - presence or absence functional disorders and (or) chronic diseases (taking into account the clinical variant and the phase of the course of the pathological process);
• - the level of the functional state of the main body systems;
• - the degree of resistance of the body to adverse external influences;
• - level development and its degree of harmony.

Depending on the state of health, children can be classified into the following groups:

to the 1st health group - healthy children with normal physical and mental development, without anatomical defects, functional and morphofunctional deviations;

to the 2nd health group - children who do not have chronic diseases, but have some functional and morphofunctional disorders. also in this group includes convalescents *, especially those who have undergone severe and moderate infectious diseases, children with a general delay in physical development without endocrine pathology(short stature, developmental delay), children who are underweight or overweight bodies, children often and for a long time ill with acute respiratory diseases, children with the consequences of injuries or operations while maintaining the corresponding functions;

to the 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 the 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 functionality or incomplete compensation functionality; 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 the 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.

According to the Health Committee of St. Petersburg, only 12% of children aged 0 to 17 years are recognized as healthy (1st health group), from 56 to 73% have functional abnormalities (2nd health group), on average 26 % - chronic diseases (3rd health group). Children of the 4th-5th groups make up 1-2%. Similar situation with slight fluctuations can be traced throughout Russia. Unfortunately, in adolescence, almost every third child has a chronic pathology and, accordingly, the 3rd health group.

Let's move away from the dry language of documents and explain that the first health group includes children who do not have deviations in their state of health. Unless sometimes they suffer from respiratory diseases. Unfortunately, there are almost no such practically healthy children on the territory of the Russian Federation.

The second group of health includes children with any functional changes, most often associated with uneven growth and development. For example, functional systolic heart murmurs, biliary dyskinesia, posture disorder, deficiency or excess of body weight of the 1st degree. This is the transition period between health and disease. A child with a second health group must be examined and treated so that the disease does not become chronic.

The third health group consists of children with chronic diseases in the stage of compensation. The most common diseases are chronic pyelonephritis without kidney failure, chronic gastroduodenitis, chronic tonsillitis and etc.

The fourth health group includes children with chronic diseases in the stage of subcompensation. For example, a child has a congenital malformation of the kidneys - hydronephrosis, and against its background there is a decrease in kidney function, or the child bronchial asthma during an attack with impaired respiratory function, rheumatoid arthritis with limited function of the joints, etc.

The fifth health group includes children suffering from chronic diseases in the stage of decompensation. As a rule, these are children with handicapped health.

A careful study of regulatory legal acts makes it clear that the concept of "health group" is more statistical than medical and allows you to assess the health status of any patient based on the totality of data. Evaluation criteria for health groups are taken into account when conducting the All-Russian clinical examination of children and adolescents, when compiling annual reports of any healthcare institution, etc.

Note(*):

Decompensation - disorders of the body's activity that occur when its adaptive mechanisms are unable to compensate for the disorders caused by the disease.

Remission-period of flow chronic illness a person characterized by the weakening or disappearance of its signs.

Convalescent - a patient in the recovery stage.

The main indicator of the effectiveness of measures to protect the health of children is the level of health of each child.

Health is not only the absence of disease and injury, but also the harmonious physical and neuropsychic development, normal functioning of all organs and systems, absence of diseases, sufficient ability to adapt to unusual environmental conditions, resistance to adverse effects.

The state of health of the child is examined using the main criteria determined during each preventive examination of the decreed ages. The following signs are taken into account:

1. Deviations in ante-, intra-, early postnatal periods.

2. The level and harmony of physical and neuropsychic development.

3. Functional state of the main organs and systems.

4. Resistance and reactivity of the organism.

5. Presence or absence of chronic (including congenital) pathology.

A comprehensive assessment allows you to form groups that bring together children with the same state of health, taking into account all the above indicators.

Group I — healthy children with normal indicators functional development of all systems that rarely get sick (up to 3 times a year) with normal physical and neuropsychic development, without significant deviations in history.

II group - risk group:

subgroup A - children with risk factors according to biological and social history;

subgroup B - children with functional abnormalities, with initial changes in physical and neuropsychic development, who often get sick, but do not have chronic diseases.

III, IV and V groups - children with chronic diseases:

III group — state of compensation: rare exacerbations of chronic diseases, rare acute diseases, normal level of body functions;

Group IV — state of subcompensation: frequent (3-4 times a year) exacerbations of chronic diseases, frequent acute diseases (4 times a year or more), deterioration of the functional state various systems organism;

In the group - a state of decompensation: significant functional deviations ( pathological changes organism; frequent severe exacerbations chronic diseases, frequent acute diseases, the level of physical and neuropsychic development corresponds to age or lags behind it).

Comprehensive assessment of the child's health status carried out at the initial visit of the child after discharge from the hospital to get an idea of ​​​​the initial level of health status. In the future, the assessment of the health status of children of the 1st and 2nd years of life is carried out quarterly, children of the 3rd year - at the end of each six months. With several diagnoses, a health group is established with the underlying disease. In the process of monitoring a child, the health group may change depending on the dynamics of the level of health status.

Children of the I health group should be observed at the usual times established for preventive examinations healthy. For them, preventive, educational and general health measures are carried out.

Children of the II group of health deserve closer attention of pediatricians, since preventive and therapeutic measures can contribute to the transition of children from this group to group I. Children of this group are observed and healed by individual plan, which is compiled in accordance with the degree of risk of developing chronic pathology, the severity of functional abnormalities and the degree of resistance.

Children of III, IV and V groups are under the supervision of pediatricians and specialists in accordance with " methodological recommendations on the conduct of medical examination of the child population "and should receive necessary treatment depending on the presence of a particular pathology.

A comprehensive assessment of the health status of children includes:

Assessment of the child's health level according to certain criteria;

Determination of the health group;

Factors affecting a child's health are divided into two groups: 1) determining (or causing) health; 2) characterizing health. The first group includes genealogical, biological and social factors, the second - physical and neuropsychic development, the level of the functional state of the body, resistance to infections, the presence or absence of chronic diseases or malformations.

The first component of health is the presence or absence of deviations in early ontogeny, including genealogical, biological, social anamnesis.

In the identification of ontogenetic deviations, an important place is given to the genealogical history (compilation of the family tree of the child's family). It is important that a woman and a man be examined in a medical genetic institution.

Biological history (perinatal ontogenesis): it is necessary to carefully collect information about ante-, intra- and postnatal periods the life of the child and the factors that adversely affect their course.

Social history (family composition, parental education, budget and living conditions, psychological attitudes of the family) is collected in order to determine the conditions that especially affect the neuropsychic development of the child.

The second component of health is the level of physical development: it is determined by the control of physical development. The physical development of the child (especially early age) is a very sensitive sign of a state of health, which changes quite quickly under the influence of various conditions. Signs of physical development depend both on inherited features and on a complex complex social conditions(see. Physical development).

The third component of health - the level of neuropsychic development - has great importance, since the development of the higher nervous system depends on it. The general level of neuropsychic development of the child is characterized by the level of individual mental functions, which reflects the degree of maturation of the CNS. When evaluating general level neuropsychic development of children under the age of 3 should be guided by generally accepted indicators normal level along the main lines of neuropsychic development, among which significant and informative indicators of each of them are highlighted (see Neuropsychic development).

In young children, indicators of behavior and mood are also assessed. Indicators of behavior include mood (cheerful, calm, irritable, depressed, unstable); falling asleep (slow, calm, fast, restless); sleep (deep, calm, restless, in duration - normal, shorter, longer); appetite (good, unstable, bad, selective attitude to food); the nature of wakefulness (active, passive, variable active); individual characteristics (contact, shy, touchy, easily tiring, aggressive, initiative, etc.).

When evaluating the mood, the following features are noted: 1) cheerful, cheerful: a positive attitude towards the environment (processes), actively plays with interest, is friendly, reactions are emotionally colored, often (adequately) smiles, laughs, willingly contacts with others; 2) calm: has a positive attitude towards the environment, calm, active, reactions are less emotionally colored, shows little feeling of joy, less contacts on their own initiative with others; 3) irritable, agitated: inadequately related to the environment. It may be inactive or its activity is unstable, there are effective outbursts of excitement, anger, screaming; 4) depressed mood: lethargic, inactive, passive, non-contact, away from conflicts, closed, sad, can cry quietly, for a long time; 5) unstable mood: can be cheerful, laugh and cry quickly, enter into conflicts and be closed, rather quickly moves from one mood to another.

The fourth component of health is the functional state of organs and their systems. The level of the functional state of the body is determined by the frequency of heart contractions and respiration, blood pressure, laboratory data. Complete Analysis clinical, laboratory and instrumental research allows you to objectively assess the state of health of the child.

The fifth component of health is the degree of resistance of the body to adverse effects, which manifests itself in susceptibility to diseases. Absence (never sick during the year - health index) or rare (episodic ill 1-2-3 times during the year) acute diseases indicate good resistance, frequent incidence (4 times or more during the year) - about worsened or bad.

The sixth component of health is the presence or absence of chronic diseases. Detected by the pediatrician during each scheduled inspection, as well as by specialist doctors, if necessary and within certain time limits established by the current recommendations for medical examination of the child population.

All components are closely interconnected and allow us to give a qualitative assessment of the child's health with the definition of a health group. It is customary to distinguish 5 health groups (Table 9).

Health group I includes healthy children with normal indicators of the functional state of organs and systems, rarely ill, with normal physical and neuropsychic development, without deviations in history, without chronic diseases.

Health group II - healthy children, but already having certain functional abnormalities, initial changes in physical and neuropsychic development, with an unfavorable anamnesis, often ill, but without symptoms of chronic diseases. Young children who have only risk factors in ontogenesis are allocated to group IIA. The main reasons why healthy young children are classified as health group II are: 1) deviations in physical development (lagging behind body weight from height or exceeding 1.1-25); 2) lag of neuropsychic development by no more than 1 month in children of the first year of life, by 1 quarter - by the 2nd year and by half a year - by the 3rd year of life; 3) frequent morbidity (4 times a year or more); 4) functional changes in the cardiovascular system (presence of noise of a functional nature, tachycardia) and nervous systems(increased excitability, bad dream, motor disinhibition, restless wakefulness, instability of appetite); 5) the initial degree of anemia (decrease in hemoglobin level within 1.1-25, which corresponds to the lower limit of the norm); 6) rickets of the 1st degree ( subacute course); 7) the threat of malnutrition or the initial degree of malnutrition (lagging body weight by 10-15%); eight) exudative diathesis with moderately expressed intermittent manifestations, allergic predisposition; 9) adenoids of the 1st degree; 10) hypertrophy of the tonsils of the 1st-2nd degree; 11) deviations in the early history: gestosis of pregnant women, "Rh-negative" mother's affiliation, mother's diseases (rheumatism, congenital heart disease, hypertonic disease, diabetes, anemia, chronic alcoholism, schizophrenia, etc.
); 11) delayed pregnancy; 12) complications in childbirth: prolonged labor with a long anhydrous period, asphyxia, birth injury without neurological symptoms; 13) the condition and diseases of the child during the neonatal period: large fruit, disease of the navel, pneumonia, transferred in the first month of life, etc .; 14) prematurity; 15) pylorospasm (without malnutrition); 16) the state of convalescence after acute gastric and other infectious diseases.

Health group III includes children with long-term diseases, congenital malformations in the stage of compensation:

1) congenital heart disease in the stage of compensation;

2) birth trauma with residual effects neurological symptoms;

3) hemolytic disease;

4) exudative diathesis with significantly pronounced skin manifestations in the form of eczema (rare exacerbations);

5) anemia (decreased hemoglobin level to 85 g/l);

6) rickets of the 2-3rd degree;

7) malnutrition of the 2nd degree (lag in body weight up to 21-30%);

8) phenylketonuria;

9) pyloric stenosis, pylorospasm with malnutrition;

10) umbilical hernia, requiring surgical intervention(before surgery);

11) congenital stridor without croup;

12) dental caries (subcompensated form);

13) chronic tonsillitis (simple form);

14) chronic otitis media(rare exacerbations);

15) chronic hepatitis, gastritis, duodenitis, etc. (rare exacerbations);

16) presence physical handicaps and congenital pathology (congenital torticollis, congenital dislocation hip joints, congenital pathology of the urinary system, etc.).

To the IV group of health include children with the same diseases, but in the stage of subcompensation.

Health group V - children with chronic diseases in the stage of decompensation, disabled people who at the time of the study are in the hospital or on bed rest at home. A refined scheme for assessing health groups in children with the identification of several risk groups according to Yu.E. Veltishchev is given in table. ten.

Thus, a healthy child is considered to be a child who is harmoniously physically and psychomotorly developed in accordance with age, ethnic and environmental characteristics, rarely gets sick (no more than 3 times a year), does not have anamnestic (including genetic and antenatal) and objective data that could would be prerequisites for the formation of diseases.

An assessment of the state of health by groups with several diagnoses in a child is given according to the most basic and severe of them. At each subsequent examination at the decreed time, there is a change in the state of the child's health, for example, a transition from II to I health group (in case of improvement) or to III and IV (in case of deterioration). Timely medical examination and rehabilitation of children of the II health group impede the development pathological conditions with the transition to III group health.

Table 9. Scheme of distribution of young children by health groups