Traditional medicine

Clinical guidelines for pediatrics pdf. Clinical guidelines for providing medical care to children

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

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

Download the clinical guidelines compliance checklist.

↯ More articles in the magazine

From the article you will learn

Based on them, under the leadership of the Russian Ministry of Health, criteria for assessing the quality of medical care for specific groups of conditions and diseases of minor patients are being developed.

Main changes for medical officers in 2019

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

Are the 2019 federal clinical guidelines for pediatrics mandatory for use by medical institutions? In accordance with the Federal Law “On Health Protection,” attending physicians, when providing care to patients, are guided by medical standards, procedures and clinical recommendations.

Referring a child for palliative care: ways to make medical decisions

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

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

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

Category 1 - life-threatening diseases for which radical treatment may be feasible but often fails (eg, malignancy, irreversible/malignant cardiac, hepatic and renal failure);
Category 2 - conditions in which premature death is inevitable, but long-term intensive treatment can increase the child's life expectancy and maintain his activity (cystic pulmonary hypoplasia/polycystic pulmonary disease)...

How to organize palliative care for children

Visiting patronage services, palliative care departments, and children's hospices can provide palliative care to children. Look at convenient tables with indicators and practical developments in the field of children's palliative care in the Chief Physician System.

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

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

Download the clinical guidelines compliance checklist.

↯ More articles in the magazine

From the article you will learn

Main changes for medical officers in 2019

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

Referring a child for palliative care: ways to make medical decisions

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

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

Category 1 - life-threatening diseases for which radical treatment may be feasible but often fails (eg, malignancy, irreversible/malignant cardiac, hepatic and renal failure);
Category 2 - conditions in which premature death is inevitable, but long-term intensive treatment can increase the child's life expectancy and maintain his activity (cystic pulmonary hypoplasia/polycystic pulmonary disease)...

How to organize palliative care for children

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

Pediatrics


Preface........................................................ .......................................
Publication contributors........................................................ ............................
.........
Abbreviations......................................................... ...................................
Allergic rhinitis................................................... ...........................
Atopic dermatitis................................................... ......................
Bronchial asthma................................................ ...........................
Urinary tract infection................................................................... ....
Fever................................................. ...........................................
Fever without visible source of infection....................................................
Nephrotic syndrome................................................................... ................
Pneumonia................................................. ......................................
Systemic lupus erythematosus.................................................... ..........
Febrile seizures................................................... ....................
Epilepsy................................................. .......................................
Juvenile rheumatoid arthritis.................................................................
Subject index................................................... ....................

Dear colleagues!

Preface

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

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

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

The most famous pediatric doctors with extensive experience in clinical and research work and knowledge of the international methodology for developing clinical guidelines were involved in writing the articles.

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

Clinical recommendations for pediatrics will be regularly updated (at least once every 2 years), and an electronic version of the recommendations will be available on CDs. The second issue will be published in 2006 and will contain approximately 10 new clinical recommendations. At the same time, more detailed guidelines on individual diseases and a reference book of medications used in pediatrics are being prepared.

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

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

PUBLICATION PARTICIPANTS

Publication participants

Editor-in-Chief

A.A. Baranov, Dr. honey. Sciences, prof., academician RAMS

Executive Editor

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

Allergic rhinitis

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

Atopic dermatitis

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

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

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

Bronchial asthma

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

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

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

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

Urinary tract infection

Fever

Fever without visible source of infection

V.K. Tatochenko, Dr. honey. sciences, prof.

Nephrotic syndrome

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

Pneumonia

V.K. Tatochenko, Dr. honey. sciences, prof.

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

V.F. Uchaikin, Dr. honey. Sciences, prof., academician RAMS (reviewer)

Systemic lupus erythematosus

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

Publication participants

Febrile seizures

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

Epilepsy

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

Juvenile rheumatoid arthritis

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

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

Project Managers

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

CREATION METHODOLOGY AND QUALITY ASSURANCE PROGRAM

This publication is the first release of Russian clinical guidelines on childhood diseases. The goal of the project is to provide practicing physicians with recommendations for the prevention, diagnosis and treatment of the most common childhood diseases.

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

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

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

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

1. Concept and project management

To work on the project, a management group was created consisting of project managers and an administrator.

To develop the concept and project management system, the project managers held many consultations with domestic and foreign experts (epidemiologists, economists and health care managers, specialists in the field of medical information retrieval, representatives of insurance companies, industry representatives - manufacturers of medicines, medical equipment, heads of professional societies, leading developers of clinical re-

1 Appraisal of Guidelines for Research and Evaluation - Tool for assessing the quality of clinical guidelines, http://www.agreecollaboration.org/

2 Scottish Intercollegiate Guidelines Network - Scottish intercollegiate organization for the development of clinical guidelines

Creation methodology and quality assurance program

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

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

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

For specific ones, see the “Treatment Goals” section of the clinical guidelines.

3. Audience

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

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

Selection of diseases and syndromes. The first issue selected diseases and syndromes that are most often encountered in the practice of pediatricians. The final list was approved by the editor-in-chief of the publication.

4. Development stages

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

6. Applicability to patient groups

The group of patients to whom these recommendations apply (gender, age, severity of the disease, concomitant diseases) is clearly defined.

7. Developers

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

8. Developer training

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

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

The project manager and responsible editors maintained continuous contact with all developers by phone and email in order to resolve operational issues.

9. Independence

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

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

10. Sources of information and instructions for their use

Sources of information for the development of clinical recommendations have been approved.

Creation methodology and quality assurance program

Dear colleagues!

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

This Federal Law defines a transition period until December 31, 2021, necessary for the revision and approval of clinical recommendations in accordance with the standards introduced by the bill. Approved clinical recommendations will contain parameters reflecting the correct choice of diagnostic and treatment methods based on the principles of evidence-based medicine. The use of clinical recommendations will allow medical professionals to determine the tactics for managing a patient with a specific nosology at all stages of medical care.

Clinical recommendations will be used as the basis for the development of other documents regulating the process of providing medical care, including standards and procedures for providing medical care, as well as criteria for assessing the quality of medical care. Thus, at the end of the transition period, a comprehensive quality management system for medical care will be created, based on clinical recommendations that take into account the best global practices.

The Ministry of Health of the Russian Federation has issued a number of orders regulating the work on the formation of clinical recommendations:

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

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

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

If the scientific and practical council of the Russian Ministry of Health makes a positive decision, clinical recommendations are approved by professional non-profit organizations.

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

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

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

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

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

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

Due to the large number of ARVIs, I decided to post recommendations for their treatment; a friend gave them to me today (she is a pediatrician). Here is the text with slight abbreviations:

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

Chief freelancer

pediatrician specialist

Ministry of Health of Russia

Academician of the Russian Academy of Sciences

A.A. Baranov

Chief freelancer

infectious disease specialist

diseases in children

Ministry of Health of Russia

Yu.V.Lobzin

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

Composition of the working group: acad. RAS Baranov A.A., corresponding member. RAS Namazova-Baranova L.S., acad. RAS Yu.V. Lobzin, prof., doctor of medical sciences A.N. Uskov, Doctor of Medical Sciences, Prof., Tatochenko V.K., Doctor of Medical Sciences Bakradze M.D., Ph.D. Vishneva E.A., Ph.D. Selimzyanova L.R., Ph.D. Polyakova A.S.

DEFINITION

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

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

Acute nasopharyngitis is diagnosed when there is an acute runny nose and/or cough, while influenza and lesions of other localizations are excluded:

 acute otitis media (corresponding complaints, otoscopy);

 acute tonsillitis (predominant involvement of the tonsils, plaque);

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

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

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

EPIDEMIOLOGY

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

ETIOLOGY

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

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

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

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

PATHOGENESIS

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

The assumption is that with any viral infection, the bacterial flora is activated (“viral-bacterial etiology of acute respiratory infections” based, for example, on the presence of leukocytosis in the patient) not confirmed by practice: in most patients, ARVI proceeds smoothly without the use of antibiotics. Bacterial complications of ARVI occur rarely (1-5% of cases). As a rule, they are already present on the 1st-2nd days of illness; in later periods they occur most often as a result of superinfection. One should keep in mind streptococcal pharyngitis, which may not be accompanied by the classic “sore throat”; the bright, “scarlet” color of the palatine arches and especially the back wall of the pharynx may indicate a streptococcal infection. In such cases, a rapid diagnostic test can help. It is also necessary to remember about “silent” pneumonia, which is difficult to identify clinically (especially if the patient is not percussed).

CLASSIFICATION

Nasopharyngitis can be divided according to severity depending on the level of temperature and the severity of general nonspecific symptoms.

CLINICAL PICTURE

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

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

COMPLICATIONS

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

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

Painful “clicks” in younger patients and a feeling of “stuffiness” in the ear in older children are a consequence of dysfunction of the auditory tube due to a viral infection, caused by changes in pressure in the middle ear cavity, which can lead to the development of acute otitis media.

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

DIAGNOSTIC EXAMINATION

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

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

Indications for chest x-ray are:

Maintaining febrile temperature for more than 3 days,

Detection of the above high levels of inflammatory markers,

The appearance of physical symptoms of pneumonia (see FKR on the management of pneumonia in children).

It should be remembered that the detection of increased bronchovascular pattern and shadows of the roots of the lungs and increased airiness in the images are not an indication for antibacterial therapy.

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

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

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

TREATMENT

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

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

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

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

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

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

Cough relief: since in case of nasopharyngitis the cough is most often caused by irritation of the larynx by flowing secretions, toileting the nose is the most effective method for its relief. Cough associated with a “sore throat” due to inflammation of the mucous membrane of the pharynx or its drying out when breathing through the nose is eliminated warm sweet drink(2C) or, after 6 years, by using lozenges or lozenges containing antiseptics (2C).

Antitussives, expectorants, mucolytics, including numerous patented preparations with various herbal remedies, are not indicated for “colds” due to ineffectiveness (2C), which has been proven in randomized studies.

Steam and aerosol inhalations have shown no effect in randomized trials and are not recommended by the World Health Organization (WHO) for the treatment of “colds” (2B).

Antihistamines, which have atropine-like effects, have not been shown to be effective in reducing runny nose and nasal congestion in randomized trials (2C).

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

MANAGEMENT OF CHILDREN

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

Hospitalization is required in severe cases and the development of complications.

PREVENTION

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

Hardening protects against infection with a small dose of infection and probably contributes to a milder course of ARVI.

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

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

OUTCOMES AND PROGNOSIS

As stated above, ARVI, in the absence of bacterial complications, is fleeting, although it can leave symptoms such as discharge from the nasal passages and cough for 1-2 weeks. The opinion that acute respiratory viral infections, especially frequent ones, lead to the development of “secondary immunodeficiency” is unfounded.