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LECTURE No. 11. Current problems of dysbiosis in children. Clinic, diagnosis, treatment



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

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

2) the second - the initial colonization by microorganisms, the duration from 2 to 4 days, depending on external environmental factors, the nature of nutrition and the time of application to the breast;

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. Intestinal microflora is prone to frequent disturbances 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.). At 92-95% of the intestinal microflora consists of obligate anaerobes.

The optional (UP and saprophytic) microflora is inconstant, has no significant biological functions, is represented by bacteria - cytrobacters, micrococci, protea, 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. Breast milk 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 practically the same as that of an adult: the majority are anaerobes that are difficult to cultivate. The density of bacteria in the stomach, jejunum, ileum, and colon is 1, 10, 100, and 1,000,000 thousand, respectively, in 1 ml of intestinal contents.

Functions of intestinal microflora.

1. Protective:

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

2) a decrease in the permeability of the mucous membrane for macromolecules.

2. Immune:

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

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

3) stimulation of maturation of phagocytes.

3. Metabolic:

1) synthesis of B vitamins;

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) stimulation of gastrointestinal motility.

Bifidobacteria inhibit the growth of potential pathogens. Restore the normal intestinal flora during antibiotic therapy. B vitamins and folic acid are produced. Reduce the level of urea in the blood. Act as immunomodulators. Lower blood cholesterol. Intestinal dysbiosis is always secondary. There is a consequence of changes in the internal environment of the intestine, and a direct effect on the intestinal microflora. It can lead to damage to the intestinal epithelium, disruption of the processes of digestion and absorption, exacerbating 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 hemolytic properties, Pseudomonas. Factors affecting the state of the gastrointestinal mucosa: diseases that change the internal environment of the intestine (oxygen content in it, enzyme composition). Antibiotic therapy (rational and irrational).

Functional disorders of intestinal motility.

1. Immunodeficiency conditions.

2. The influence of the nature of food on intestinal dysbiosis: food rich in carbohydrates stimulates bifidoflora and leads to an increase in the bacterial mass of the large intestine. Fatty foods inhibit bifidobacteria and enterococci, and stimulate the growth of bacteroids.

3. Protein diet practically does not affect the spectrum and number of intestinal bacteria.

Causes of changes in microbiocenosis.

1. Gastrointestinal tract lesions of an infectious and non-infectious nature.

2. Acute infections of extraintestinal localization.

3. Chronic inflammatory and allergic diseases.

4. Leukemia and other malignant processes.

5. Post-radiation syndrome.

6. The use of cytostatics and antibiotics.

Classification of dysbiosis.

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

Stage II - an increase or sharp decrease in E. coli. The appearance of inferior strains of E. coli and atypical species of enterobacteria.

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

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

Clinical picture of intestinal dysbiosis: loose or unstable stool with an admixture of mucus, greens, or particles of undigested food. Less commonly, constipation, regurgitation, vomiting, flatulence, rumbling along the intestinal loops. Abdominal pain (intermittent). Thrush, coated tongue; hyperemia around the anus. Anorexia, poor increase in body weight.

Clinical forms of dysbiosis.

1. Compensated (latent compensated): violation of the normal composition of microflora. There are no clinical symptoms.

2. Subcompensated (local subcompensated): violation 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.

Examination plan and diagnosis of dysbiosis: hemogram, expanded coprogram, cytocoprogram, 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 cavity.

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

1) intestinal dysfunction after the use of antibacterial drugs;

2) the prolonged period of convalescence after OCI;

3) chronic intestinal disorders without isolation of pathogenic bacteria;

4) food allergy;

5) chronic gastrointestinal diseases in combination with flatulence, diarrhea and constipation;

6) irritable bowel syndrome.

Stages of correction of dysbiosis:

1) diet therapy;

2) normalization of intestinal microflora;

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

4) restoration of normal digestion;

5) stopping intestinal motility disorders;

6) correction of the immune status;

7) normalization of metabolism.

Diet therapy for persistent constipation and the absence of severe pain.

Diet No. 3 - stimulating intestinal motility.

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

2. Add bran food, wholemeal bread to food.

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

Diet therapy for diarrhea.

Recommended.

1. White stale bread and crackers from it, dry cookies.

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, blackcurrant and blueberry.

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

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

Limited: plant fiber and sugar (not more than 40 g per day).

Diet therapy for fermentative dyspepsia (severe flatulence; copious, foamy, sour stools).

Recommended.

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

2. Unconcentrated broths, ear, scrambled eggs, boiled or baked potatoes.

3.
Use of cloves, bay leaf, pepper.

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

milk and vegetable fiber - for 1-2 weeks.

Diet therapy for putrefactive dyspepsia (frequent headaches, signs of intoxication, moderate flatulence, cramping and pain in the distal intestine).

Recommended.

1. The first 2 days - hunger (broth of wild rose, weakly sweet tea).

2. From the 3rd day - dry cookies, crackers made of white bread. From day 5-6, rice porridge on the water and dairy products.

3. In the future, a vegetable diet.

Forbidden: protein foods and coarse fiber.

Limited to: fats.

Antibacterial drugs: non-equilibrium microbial flora in the intestine - Intetrix - 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. Enterosedive contains streptomycin, bacitracin, etc. Dpendan containing furazolidone and metronidazole.

Biological active substances are used to improve the function and regulation of the digestive tract 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 nutrient components: vitamins, minerals, herbs or other plants, amino acids. Not intended for use as the main ordinary food or sole source of nutrition. They are used only as an addition to the main diet in order to increase the daily intake of certain nutritional components. Functional nutrition should be understood as ready-for-sale food products in which biological products are added. Functional nutrition is defined as a modified food product that provides better 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, NAS fermented with bifidobacteria, NAS 6-12 months with bifidobacteria). Mixtures with the addition of thickening polysaccharides (for example, Frisovom). Acidobif is a food supplement for children over 1 year old with lactase deficiency, milk protein intolerance and intestinal dysbiosis, containing lactobacilli 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 beneficial effect on the physiological functions and biochemical reactions of the body through the optimization of its microecological status. Probiotics (eubiotics) are live, attenuated strains of microorganisms: more often bifidobacteria, less often yeast, which, based on the term “probiotic”, refers to normal inhabitants of the intestines of a healthy person. The microorganisms that make up the probiotics are contained in large quantities, non-pathogenic, non-toxic, retain viability during passage through the gastrointestinal tract and during storage. Current requirements for probiotics: natural origin, resistance to the action of acids of gastric juice and bile, the ability to colonize the intestines, antagonism to pathogenic bacteria. Confirmed clinical effect. Indications for use of probiotics: diarrhea associated with taking antibiotics, infectious diarrhea, prevention of diarrhea, irritable bowel syndrome, gastrointestinal syndrome in case of allergies, inflammatory diseases.

Probiotics - preparations, mono- and multicomponent preparations: bifidumbacterin, lactobacterin, bificol, colibacterin, primadofilus, fluradofilus, bifinorm, subamine, bifidin, bifilin, biobactone, bifilong, linex, biofructolact, bactis. Combined preparations: bifiform, bifizil, acipol, bifacid, bifidumbacterin forte, sour-milk eubiotics, bifidoc, bifikefir, lactofidus.

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

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

Lactulose is a synthetic disaccharide not found in nature.

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

Synbiotics are a mixture of probiotics and prebiotics that improve the survival and engraftment of live bacterial supplements in the intestines and selectively stimulate the growth and activation of indigenous bacteria metabolism. Examples of synbiotics: bifidumbacterin forte, bifilis, lactofidus, nutrolin B, vitamins and other biotherapeutic agents - contain substances and (or) living microorganisms that have therapeutic properties. The microorganisms used as biotherapeutic preparations include: Lactobacillus acidophilus, L. plantarum, L. casei, L. bulgaricus; Bifidobacterium longum, Enterococcus faecium. Probiotics are not considered therapeutic agents until clinical studies have proven their effectiveness. Biotherapeutic agents - preparations of bifidumbacterin, lactobacterin, coli-bacterin, primadofilius, enterol, bactisubtil. Hilak forte - drops, calcium pantothenate and pamba.

Enterosorbents - Smecta, Bilignin, Tannacomp, Polysorb, Polyphepan, Espumisan. Assign with correction of compensated dysbiosis. Probiotics containing bifidumbacteria can be prescribed to children from birth. Clinical effectiveness is assessed 10 days after the end of therapy, microbiological - after 1 month. The number of bifidotherapy courses is 1-3. With a decrease in the number of lactobacilli, linex, acipol and lactobacterin, acylact are used. Acid-forming preparations are recommended - prebiotics that do not contain live bacteria: normase or hilak-fort (together with bifidopreparations). You can use lysozyme, bifilis. Correction of subcompensated dysbiosis involves the appointment

3-4 courses of combined multicomponent preparations - bifidobacteria and lacto-containing probiotics. Combination therapy with normase or hilak-fort is recommended only with a normal content of lactobacilli. In addition to lysozyme, CIP (complex immunoglobulin preparation) can be used. In the absence of a sufficient effect, chlorophyllipt can be used; sporobacterin, biosporin (or their analogue, bactisubtil). Correction of decompensated dysbiosis is a short-term (3–7 days) administration of sorbents (carbolen, carbolong, vaulen, microsorb P, polyphepan, lignin, smecta). The use of 3–6 courses of bifidobacteria and lacto-containing probiotics. With developed immunodeficiency, immune preparations (interferon or reaferon, leukinferon, levamisole, etc.), enzyme preparations (mesim-forte, panzinorm, festal, pancytrate, creon) are prescribed for 1-3 weeks. With septic manifestations - the use of antibacterial therapy against the background of probiotics (with selective contamination - non-absorbable drugs, with secondary extraintestinal foci - resorptive drugs) - ercefuril, furazolidone, aminoglycosides, erythromycin, macrolides, metronidazole; antifungal drugs.
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LECTURE No. 11. Current problems of dysbiosis in children. Clinic, diagnosis, treatment

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