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LECTURE № 11. Modern problems of dysbacteriosis in children. Clinic, diagnosis, treatment

Three phases of microbial colonization of the digestive tract in a child:

1) the first - aseptic, lasting from 10 to 20 hours;

2) the second - the initial settlement of microorganisms, the duration of from 2 to 4 days depending on external environmental factors, the nature of nutrition and time of attachment to the chest;

3) the third - stabilization of microflora (up to 1 month). Intestinal microflora is complex, dynamically

balanced ecosystem. Contains over 500 different types of bacteria. 1 g of feces contains more than 1011 bacteria. The intestinal microflora is subject to frequent violations under the influence of adverse factors. Most of the intestinal microorganisms are the so-called obligate (indigenous) microflora (bifidobacteria, lactobacilli, non-pathogenic E. coli, etc.). 92-95% of the intestinal microflora consists of obligate anaerobes.

The facultative (UE and saprophytic) microflora is not constant, has no significant biological functions, is represented by bacteria - citrobacter, micrococci, proteus, yeast-like fungi, clostridia. The composition of the intestinal microflora is quite individual and is formed in the first days of a child’s life. An important factor in the formation of normal intestinal microflora is natural feeding. Breastmilk contains a large number of substances that contribute to the colonization of the intestine by certain types of microorganisms in certain quantities (staphylococci, etc.). The composition of the intestinal flora of a child after two years is almost the same as that of an adult: the majority are anaerobic, poorly cultivated. The density of bacteria in the stomach, jejunum, ileum, and colon is 1, 10, 100, and 1,000,000, respectively, in 1 ml of intestinal contents.

Functions of the intestinal microflora.

1. Protective:

1) a barrier against microbial contamination (acidic environment, competition of colonies);

2) reduction of mucosal permeability for macromolecules.

2. Immune:

1) synthesis of immune defense factors (lysozyme, complement, properdin);

2) stimulation of the maturation of the lymphoid apparatus of the intestine and the synthesis of Ig;

3) stimulation of phagocyte maturation.

3. Metabolic:

1) synthesis of vitamins of group B;

2) iron metabolism;

3) the exchange of bile acids.

4. Digestive:

1) the breakdown of carbohydrates;

2) synthesis of enzymes;

3) parietal digestion;

4) regulation of absorption;

5) GIT motility stimulation.

Bifidobacteria inhibit the growth of potential pathogens. Restore the normal intestinal flora during antibiotic therapy. Produce B vitamins and folic acid. Reduce the level of urea in the blood. Act as immunomodulators. Reduce cholesterol in the blood. Intestinal dysbiosis is always secondary. It occurs as a result of changes in the internal environment of the intestines, and direct effects on the intestinal microflora. May cause damage to the intestinal epithelium, impaired digestion and absorption, aggravating the already existing adverse changes in the gastrointestinal tract. Changes in the quantitative and qualitative composition of microflora in various parts of the intestine. The appearance of optional strains that are not part of the resident microflora: Proteus, Morganella, Klebsiella, Enterobacter, Citrobacter, Hafma, E. coli with enzymatic deficiency and hemolyzing properties, Pseudomonas. Factors affecting the condition of the gastrointestinal mucosa: diseases that change the internal environment of the intestine (its oxygen content, enzyme composition). Antibiotic therapy (rational and irrational).

Functional disorders of intestinal motility.

1. Immunodeficiency states.

2. The influence of the nature of food on intestinal dysbiosis: food, abundant in carbohydrates, stimulates bifidoflora and leads to an increase in the bacterial mass of the large intestine. Fatty food inhibits bifidobacteria and enterococci, and stimulates the reproduction of bacteroids.

3. A protein diet has virtually no effect on the spectrum and amount of intestinal bacteria.

Causes of changes in the microbiocenosis.

1. Lesions of the gastrointestinal tract of infectious and non-infectious nature.

2. Acute infections of extra-intestinal localization.

3. Chronic inflammatory and allergic diseases.

4. Leukemia and other malignant processes.

5. Postradiation syndrome.

6. The use of cytostatics and antibiotics.

Classification of dysbiosis.

Stage I - reducing the number and level of activity of bifidobacteria and lactobacilli. Changes in aerobic flora.

Stage II - an increase or a sharp decrease in E. coli. The appearance of defective strains of E. coli and atypical types of enterobacteria.

Stage III - high titers of opportunistic microflora associations. A sharp decrease in bifidobacteria and lactobacilli or suppression of their activity.

Stage IV - a sharp decrease in bifidobacteria and lactobacilli or suppression of their activity. Pronounced imbalance of microflora. High titers of bacteria of the genus Proteus, Pseudomonas aeruginosa, clostridia.

The clinical picture of intestinal dysbiosis: liquid or unstable chair with an admixture of mucus, greenery, or with undigested food particles. Less commonly - constipation, regurgitation, vomiting, flatulence, rumbling along intestinal loops. Abdominal pain (inconsistent). Thrush, furred tongue; hyperemia around the anus. Anorexia, poor weight gain.

Clinical forms of dysbiosis.

1. Compensated (latent compensated): violation of the normal composition of microflora. Clinical symptoms are absent.

2. Subcompensated (local subcompensated): disruption of the normal composition of microflora, symptoms of intestinal inflammation with intoxication and bacteremia.

3. Decompensated (generalized decompensated): the appearance of metastatic inflammatory foci, intoxication and bacteremia, the development of sepsis and septicemia.

Survey plan and diagnosis of dysbiosis: hemogram, advanced coprogram, cyto-program, bacteriological examination of feces, pH of feces; sugar curve, trypsin activity, biochemical blood test; elimination tests (exclusion of gluten, dairy products, sweet vegetables and fruits); determination of sweat chlorides, ultrasound of the abdominal organs.

Indications for the study of intestinal microflora (for dysbacteriosis):

1) intestinal dysfunction after the use of antibacterial drugs;

2) a prolonged period of recovery after OCI;

3) chronic intestinal disorders without isolating pathogenic bacteria;

4) food allergies;

5) chronic diseases of the digestive tract in combination with flatulence, diarrhea and constipation;

6) irritable bowel syndrome.

Stages of dysbacteriosis correction:

1) diet therapy;

2) normalization of intestinal microflora;

3) adsorption and elimination of toxic products from the intestine;

4) restoration of normal digestion;

5) arresting intestinal motility disorders;

6) correction of the immune status;

7) normalization of metabolism.

Diet therapy with persistent constipation and the absence of pronounced pain syndrome.

Diet number 3 - stimulating intestinal peristalsis.

1. Low-fat boiled meat, fish; buckwheat, rice or oatmeal; unleavened cottage cheese, white stale bread, pasta and vermicelli.

2. Add bran to food, wholemeal bread.

3. Fruit juices, honey, sweet dishes, carbonated drinks, vegetables, salty foods, cold foods, white wines and highly mineralized mineral waters (Arzni, Essentuki No. 17).

Diet therapy for diarrhea.


1. White stale bread and crackers made from it, dry biscuits.

2. Mucous rice and oat soups; rice, oatmeal and semolina; fresh cottage cheese, dishes from boiled vegetables; omelets, soft-boiled egg; jelly, mousse and juice from quince, pear, dogwood, carrot, black currant and blueberry.

3. Warm and hot dishes, strong tea, cocoa, natural red wines.

Forbidden: fatty foods, raw fruits, milk, wheat and barley porridge.

Limited to: plant fiber and sugar (no more than 40 grams per day).

Diet therapy for fermentation dyspepsia (pronounced flatulence; profuse, frothy, sour stools).


1. Increasing the amount of protein products in boiled form (meat, fish).

2. Unconcentrated broths, ear, omelette, boiled or baked potatoes.

Using cloves, bay leaf, pepper.

Forbidden: honey, jam, candy, watermelons, bananas, grapes,

milk and vegetable fiber - for 1-2 weeks.

Diet therapy for putrid dyspepsia (frequent headaches, signs of intoxication, moderate flatulence, spasms and pain in the distal intestines).


1. The first 2 days - hunger (dogrose broth, weakly sweet tea).

2. From the 3rd day - dry biscuits, bread crumbs from white bread. From the 5th-6th day, rice porridge in water and fermented milk products.

3. In the future - vegetable diet.

Forbidden: protein food and coarse fiber.

Limited to: fats.

Antibacterial drugs: non-imbalanced microbial flora in the intestines - intrix - a combination of 3 antiseptics from the group of 8-hydroxyquinolones, effective against pathogenic bacteria and fungi. Nifuroxazide is effective against gram-positive cocci and gram-negative (Salmonella, Shigella and Proteus) bacteria. Entero-pedic contains streptomycin, bacitracin, etc. Dpendan containing furazolidone and metronidazole.

Biological active substances are used to improve the function and regulation of the GIT microbiocenosis, prevention and treatment: dietary supplements, functional nutrition, probiotics, prebiotics, synbiotics, bacteriophages, biotherapeutic agents.

Dietary supplements are natural nutrients: vitamins, minerals, proteins, enzymes, herbal products.

Requirements for dietary supplements that must contain one or more nutritional components: vitamins, minerals, herbs or other plants, amino acids. Do not intend to be used as the main ordinary food or the only source of food. They are used only as an addition to the basic diet in order to increase the daily intake of certain nutritional components. Functional food should be understood as ready-for-sale food products to which biological products are added. Functional nutrition is defined as a modified food product that provides improved health more optimally than the original product. Functional nutrition includes antioxidants, carotenoids, digestive enzymes, yogurts and dairy products with the addition of pro-and prebiotics. Mixtures containing pre- and probiotics (fermented milk products, NAN fermented milk with bifidobacteria, NAN 6-12 months with bifidobacteria). Mixes with the addition of polysaccharide thickeners (for example, Frisovom). Acidobif is a dietary supplement for children over 1 year old with lactase deficiency, milk protein intolerance and intestinal dysbiosis, containing lacto-and bifidobacteria. Eugalan Forte is a dietary supplement for adults and children over 3 years old, containing bifidobacteria and lactulose.

Probiotics - preparations based on microorganisms (lyophilized powders containing bifidobacteria and lactobacilli). Probiotics are drugs and foods that contain substances of microbial and non-microbial origin. With the natural method of administration, they have a favorable effect on the physiological functions and biochemical reactions of the organism through the optimization of its microecological status. Probiotics (eubiotics) are live, weakened strains of microorganisms: more often bifidobacteria, less often yeast, which, based on the term “probiotic,” are normal inhabitants of the intestine of a healthy person. Microorganisms that are part of probiotics, are found in large quantities, non-pathogenic, non-toxic, retain viability when passing through the gastrointestinal tract and during storage. Current requirements for probiotics: natural origin, resistance to gastric acid and bile, the ability to colonize the intestines, antagonism to pathogenic bacteria. Confirmed clinical effect. Indications for use of probiotics: diarrhea associated with antibiotics, infectious diarrhea, prevention of diarrhea, irritable bowel syndrome, gastrointestinal allergy syndrome, inflammatory diseases.

Probiotics - drugs, mono- and polycomponent drugs: bifidumbacterin, lactobacterin, bifikol, colibacterin, primadophilus, floradophilus, bifinorm, subamin, bifidine, bifilin, biobacton, bifillong, linex, biofractolact, bacterisubtil. Combined preparations: bifiform, bifizil, acipol, bifacid, bifidumbacterin-forte, fermented milk eubiotics bifidok, bifikefir, lactofidus.

Prebiotics are indigestible food ingredients that promote the selective stimulation of growth and metabolic activity of one or more groups of bacteria (lactobacilli, bifidobacteria) in the colon. In order for a food component to be classified as a prebiotic, it should not be hydrolyzed by enzymes and absorbed in the upper GI tract. Prebiotic should be a selective substrate for bifidobacteria and lactobacilli. Prebiotics: fructo-oligosaccharides, galacto-oligosaccharides (in dairy products, cornflakes, cereals, bread, onions, chicory, garlic, bananas, and many others).

Galacto-oligosaccharides are found in breast and cow's milk. Inulin is found in tubers and roots of dahlias, artichokes and dandelions.

Lactulose is a synthetic disaccharide not found in nature.

Prebiotics = drugs: hilak-forte (a concentrate of metabolic products of normal microflora) - inhibits the growth of pathogens and restores the biological environment. Calcium Pantothenate helps to increase the biomass of bifidobacteria. Pamba (para-aminobenzoic acid) promotes the growth of normal microflora. Lysozyme has mucolytic and bifidogenic properties, it is active against gram-positive cocci.

Synbiotics are a mixture of probiotics and prebiotics that improve the survival and survival in the intestines of live bacterial supplements and selectively stimulate the growth and activation of the metabolism of indigenous bacteria. Examples of synbiotics: bifidumbacterin-forte, bifiliz, lactofidus, nutrolin B, vit and other biotherapeutic agents - contain substances and (or) live microorganisms with therapeutic properties. Microorganisms that are used as biotherapeutic drugs include: Lactobacillus acidophilus, L. plantarum, L. casei, L. bulgaricus; Bifidobacterium longum, Enterococcus faecium. Probiotics are not considered a therapeutic agent until clinical trials prove their effectiveness. Biotherapeutic agents - drugs bifidumbacterin, lactobacterin, coli-bacterin, primadophilus, enterol, baktisubtil. Hilak Forte - drops, calcium pantothenate and pampa.

Enterosorbents - smecta, bilignin, tannacomp, polysorb, polyphepanum, espumizan. Assign with the correction of compensated dysbacteriosis. Children from birth can be assigned probiotics containing bifidumbacteria. Clinical efficacy is evaluated 10 days after the end of therapy, microbiological - after 1 month. The number of courses of bifidotherapy - 1-3. With a decrease in the number of lactobacilli - Linex, Acipol and Lactobacterin, Acylact are used. Acid-forming drugs are recommended - prebiotics that do not contain live bacteria: normase or hilak-forte (along with bifid preparations). You can use lysozyme, bifiliz. Correction of subcompensated dysbacteriosis provides for the appointment

3-4 courses of combined multicomponent preparations - bifidobacteria and lactic probiotics. Combination therapy with normase or hilak-forte is recommended only with normal lactobacillus levels. In addition to lysozyme, can be used KIP (complex immunoglobulin drug). In the absence of sufficient effect, chlorophyllipt can be used; sporobacterin, biosporin (or their analogue is baktisubtil). Correction of decompensated dysbacteriosis is a short-term (3-7 days) prescription of sorbents (carbol, carbolong, waulen, micro sorb P, polyphepan, lignin, smect). Use of 3–6 courses of bifidobacteria and lactic probiotics. When immunodeficiency develops, immune preparations are prescribed (interferon or reaferon, leukinferon, levamisole, etc.), enzyme preparations (mezim-forte, panzinorm, festal, pancytrate, creon) for 1–3 weeks. With septic manifestations - use of antibiotic therapy on the background of probiotics (with selective contamination - nonabsorbable drugs, with secondary extraintestinal foci - resorptive drugs) - ercefuril, furazolidone, aminoglycosides, erythromycin, macrolides, metronidazole; antifungal drugs.
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LECTURE № 11. Modern problems of dysbacteriosis in children. Clinic, diagnosis, treatment

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