The physical development of children and the factors that determine it. Assessment Methods
(in decreasing order of frequency of pathology) are as follows: constitutional, cerebro-endocrine, somatogenic (chronic diseases of various body systems with impaired function of one or another organ), social factors.
In young children, deviations in body weight less or more than 10% of the normative indicators (in the presence of other characteristic signs) are called, respectively hypotrophy and paratrophy. The increase in body weight in children of other ages is more than 14% due to overweight. The main reasons for deviations in body weight of children are alimentary, constitutional, somatogenic, cerebro-endocrine and other factors.
They can manifest as a decrease (microcephaly) or an increase (a common variant is hydrocephalus). The main causes of deviations in the bypass of the chairman are intrauterine brain development disorders, trauma and hypoxia of the brain during childbirth, trauma, infectious diseases and brain tumors in children after birth.
Deviations in the contour of the chest can be both decreasing and increasing. The causes of such disorders are abnormalities in the development of the chest and lungs, diseases of the respiratory system, the degree of physical fitness and muscle development, constitutional features, etc.
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Description of the presentation SEMIOTICS of violations of the physical development of children of different ages according to slides
According to the WHO definition, health is the physical, mental and social well-being
Fundamental criteria for a comprehensive assessment of the child's health Presence or absence of chronic (including congenital) diseases Functional state of organs and systems Resistance and reactivity of the body Level and harmony of physical and neuropsychic development
The term "physical development of a child" refers to the dynamic process of growth (increase in length and weight of the body, individual parts of the body) and biological maturation of the child in a particular period of childhood
The most stable indicator of physical development is body length (height). Body weight, in contrast to length, is a more variable sign, in connection with this, body weight is compared with another body. The circumference of the chest and head is the third mandatory sign for assessing physical development.
Other indicators for in-depth assessment of the morphofunctional state of the body Somatometric - - body length, sitting height, arm, leg length, shoulder width, pelvis; the circumference of the shoulder, thigh, lower leg, abdomen, etc. Somatoscopic - - the shape of the chest, feet, posture, the state of fat deposition, muscles, puberty Functional - - lung capacity, hand compression force, backbone force, stroke volume of the left ventricle, etc.
When assessing physical development, it is now customary to verify biological age or biological maturity, evaluating which in children takes into account somatoscopic and somatometric data, the timing of the appearance of ossification points, the timing of eruption of milk and permanent teeth and their number, the presence and severity of signs of puberty.
The leading indicators of the biological development of children of primary school age are the number of permanent teeth, skeletal maturity, and body length. When assessing the level of biological development of middle-aged and older children, the severity of secondary sexual characteristics, ossification of bones, the nature of growth processes are of greater importance, while body length and the development of the dental system are of lesser importance.
At birth, a healthy full-term newborn has: Body length from 46 to 56 cm (average 50.7 cm in boys and 50.2 cm in girls) Body weight 2700-4000 g (average 3300-3500 g) Head circumference 34 - 36 cm Chest circumference 32 -34 cm
Anthropometric indicators of a newborn child are quite stable, genetic factors at this age have little effect. Therefore, even relatively small deviations from the average statistical indicators, as a rule, indicate a problem in the state of the newborn. In the most severe cases, especially when not only the weight but also the length of the fetus suffers, we have to talk about a delay in the development of the fetus, which is often combined with various malformations.
This delay can be either symmetrical, i.e., with a uniform decrease in body weight and length, which indicates a more severe lesion, or asymmetric. With an asymmetric delay, if the length of the body is pr evaeva ll, we can talk about intrauterine malnutrition. Excess weight is more often characteristic of edematous syndrome or obesity, for example, in children born to mothers with diabetes.
Body length is an indicator characterizing the state of plastic processes in the body. In children of the first year of life, a monthly increase in body length: in the first quarter - - 3 cm in the second - 2.5 cm in the third - 1.5 -2 cm in the fourth - 1 cm The total increase for 1 year is 25 cm. also by the following formula: child 6 months. . has a body length of 66 cm, for each missing month, 2.5 cm is subtracted from this value, for each month after 6, 1.5 cm is added.
Body weight - - reflects the degree of development of internal organs, muscle and bone systems, fatty tissue. Unlike body length, body weight is a fairly labile indicator that reacts relatively quickly and changes under the influence of various causes, both endo- and exogenous. Immediately after birth, the body weight of the child begins to decrease somewhat, i.e., the so-called physiological loss of body weight occurs, which should be approximately 5-6% by the 3-5th day of life, the restoration of body weight should occur by the 7-10th day of life.
These changes in body weight are due to the mechanisms of adaptation of the newborn. After recovery, body weight steadily begins to increase, and the rate of its increase in the first year is higher, the lower the age.
Row. A number of formulas for an approximate calculation of body weight in the first year of life MM body weight (b.t.) can be defined as the sum: mm. . tt. . at birth plus 800 g xx nn , where nn is the number of months. . in during the first half of the year, and 800800 g is the average monthly increase in m. tt. . during the first half of the year. For the second half of life m. tt. . equals: m. tt. . at birth, the pole of the increase m. tt. . for the first half of the year (800 x x 6) plus 400 g x (nn -6) - for the second half of the year, where nn is the age in months, and 400400 g is the average monthly increase in m. tt. . for the second half of the year. . MM. . tt. . a child of 6 months is 8200 g, 800 g is subtracted for each missing month, 400 g is added for each subsequent month. But this formula does not take into account individual fluctuations in body weight at birth, therefore it is less reliable.
The main rule in assessing the increase in body weight: full-term children born with normal body weight, restore it already in the second week double by 4-6 months triple by 1 year
Monitoring changes in head circumference is an integral component of medical control over physical development. This is due to the fact that the circumference of the head also reflects the general laws of the biological development of the child, namely the first (cerebral) type of growth; growth disorders of the skull bones can be a reflection or even the cause of the development of pathological conditions (micro- and hydrocephalus). After birth, the head grows quite rapidly in the first months and years of life and slows down its growth after 5 years.
Approximate head circumference can be estimated using the following formulas: For children under 1 year old: head circumference at birth plus 1.5 cm xx n n for the first half of the year and head circumference plus 0.5 x x nn for the second half of the year. The head circumference of a 6-month-old child is 43 cm, for each missing month we subtract 1.5 cm, for each subsequent month add 0.5 cm or an average of 1 cm per month.
Chest circumference - - is one of the main anthropometric parameters for analyzing changes in the transverse dimensions of the body. The circumference of the chest reflects both the degree of development of the chest, closely correlating with the functional indicators of the respiratory system, and the development of the muscular apparatus of the chest and the subcutaneous fat layer on the chest. . At birth, the circumference of the chest is about 2 cm less than the circumference of the head, and then the rate of expansion of the chest is ahead of the growth of the head, by about 4 months these circumferences are compared, after which the circumference of the chest steadily increases compared to the circumference of the head.
Formulas for an approximate assessment of the rate of development of the chest: For children under 1 year old, the monthly increase in the first half of the year is 2 cm, in the second half of the year - 0.5 cm. The circumference of the chest of a 6-month-old child is 45 cm, for each missing month up to 6 you need to subtract 2 cm, and for each subsequent month after 6 add 0.5 cm.
For children from 2 to 11 5 years old, body length can be calculated by the formula: body length at 8 years old - 130 cm, subtract 7 cm for each missing year, add 5 cm for each exceeding one. Body weight for children from 2 to 12 years old: at 5 years of age, body weight is 19 kg, for each missing year, 2 kg is subtracted, and 3 kg is added for each subsequent year.
Head circumference. At 5 years old - 50 cm, 1 cm is subtracted for each missing year, and 0.6 cm is added for each subsequent year. Chest circumference at the age of 2 to 15 years: up to 10 years 63 cm minus 1.5 cm (10 - nn) where nn is the number of years of a child under 10 years old, over 10 years old - 63 + 3 cm (nn -10).
The physical development of children is influenced by genetic and exogenous factors. The influence of heredity affects mainly after two years of life, and there are two periods when the correlation between the height of parents and children is most significant, this is the age from 2 to 9 years and from 14 to 18 years. At this age, the distribution of body weight relative to body length can vary significantly due to pronounced constitutional features of the physique.
Exogenous factors, in turn, can be divided into intrauterine and postnatal. Intrauterine factors - the state of health of parents, their age, the environmental situation in which parents live, occupational hazards, the course of pregnancy, etc. Postnatal factors - factors that affect the physical development of the child in the course of his life: these are the conditions of nutrition, education, diseases endured by the child, social conditions. So, a moderate nutritional deficiency delays the increase in body weight, but, as a rule, does not affect the length of the body. Longer qualitative and quantitative starvation, unbalanced nutrition with micronutrient deficiencies lead less often not only to a lack of body weight, but also to short stature with a change in body proportions.
Young children are characterized by high motor activity, which is a stimulator of osteogenesis and cartilage growth. However, physical mobility should be adequate for the age of the child. For example, excessive vertical load when lifting weights leads to the opposite effect - inhibition of growth. The physical development of children is influenced not only by proper wakefulness, but also by sleep, since it is during sleep that all the main metabolic changes that determine the growth of the child's skeleton are carried out (and growth hormone is released during sleep).
In young children, especially in the first year of life, there is a close interdependence of physical and neuropsychic development. The absence or lack of positive, as well as an excess of negative emotions affects the physical condition, and can be one of the causes of growth disorders. Climatic and geographical conditions are environmental factors that affect growth and development. For example, there was an acceleration of growth in the spring, deceleration in the autumn-winter period. Hot climates and high mountains inhibit growth, but can accelerate the maturation of children.
In the postnatal period, endocrine regulation of growth is of great importance. Growth-promoting hormones are pituitary growth hormone, thyroid hormones, and insulin. . Growth hormone stimulates chondrogenesis, while thyroid hormones have a greater effect on osteogenesis. The influence of STH has relatively little effect on the growth of a child up to 2-3 years old and is especially large in the period from 7 to 10 years. The greatest growth effect of thyroxin is determined in the first 5 years of life, and then in the prepubertal and pubertal periods. Thyroxine stimulates osteogenic activity and increased bone maturation. Androgens, acting in the prepubertal and pubertal periods, enhance the development of muscle tissue, endochondral ossification and chondroplastic bone growth. The action of androgens as growth stimulants is short-lived.
Throughout childhood, the rate of growth of children is not the same. The phase of intensive growth and primary increase in body weight continues until 4 years of age. The most pronounced increase in body weight. Normally eating children acquire rounded shapes. The first phase of rapid growth (stretching) - - age from 5 to 8 years. Body weight increases proportionally, but lags behind body length indicators. The second phase - - weight gain - - age from 9 to 13 years. Body weight increases faster than body length. The second phase of rapid growth is between 13 and 16 years. Growth stops in girls at about 17 years of age, and in boys at 19 years of age.
Changes in body length with age are characterized by varying degrees of elongation of various body segments. So the height of the head increases only 2 times, the length of the body - 3 times, and the length of the lower limbs - 5 times. The most dynamic changes are in two segments - the upper part of the face and the length of the leg. The growth rate has a pronounced craniocaudal gradient, in which the lower segments of the body grow faster than the upper ones. For example, the foot grows faster than the lower leg, and the lower leg faster than the hip, this affects the proportions of the body. In practice, various indices of development proportionality are often used.
The most widespread is the definition of the relationship between the upper and lower body segments (Chulitskaya IIII index). In addition to changes in the ratios between body lengths, age-related changes in proportions also significantly affect the ratios between body length and various transverse dimensions (for example, chest circumference and body length - Erisman index) -) - Chulitskoll Index II (shoulder circumference, tibia and body length) . A decrease in the index confirms the child's malnutrition. When using various indices, the idea of the degree of harmony of the child's physique is significantly refined.
In practical work, the physical development of a child is usually assessed by comparing his individual indicators with age standards. . Currently, the centile method is used for this purpose, which is easy to work with, since when using centile tables or graphs, calculations are excluded. Two-dimensional centile scales "body length - body weight", "body length - chest circumference", in which body weight and chest circumference are calculated for the proper body length, make it possible to judge the harmony of development. Physical development is considered harmonious, in which body weight and chest circumference correspond to body length, i.e. fall into the 25th -75th centile. With disharmonious physical development, these indicators lag behind due (10 -25 - 10 -3) or exceed them (75 -90 - 90 -97) due to increased fat deposition.
Currently, a comprehensive scheme for assessing the physical development of children is being increasingly used. It involves both the biological level and the morphofunctional state of the organism. The physical development of children is assessed in the following sequence: first, the correspondence of the calendar age to the level of biological development, which corresponds to the calendar age, is determined if most of the indicators of biological development are in the middle age range (M 11). If the indicators of biological development lag behind the calendar age or are ahead of it, this indicates a delay (retardation) or acceleration (acceleration) of the rate of biological development.
Then anthropometric and functional indicators are evaluated. To evaluate the former, the centile method is used and functional indicators, as already noted, are compared with age standards. Functional indicators in children with harmonious development range from M 11 to M 22 or more. In children with disharmonious and sharply disharmonious physical development, these indicators are usually below the age norm. Somatograms are also used to assess anthropometric indicators.
Modern anthropometric indicators in young people in the period of completion of growth are much higher than they were 100 years ago. This process, which has been called acceleration and has been observed over the past 100 years, has affected mainly young groups of the population in developed and prosperous countries. Acceleration is most pronounced in urban children and among the more affluent segments of the population. The known causes of acceleration are good and more nutritious nutrition, a varied set of stimuli (sports, travel, communication), and a decrease in the frequency of infectious diseases that retard the development of the child.
Acceleration is considered as the result of a complex interaction of exo- and endogenous factors: genotype change due to large migration of the population and the emergence of mixed marriages, changed nature of aa nutrition, clinical conditions, scientific and technological progress aa and its impact on the environment. Acceleration was noted in all age groups, starting from prenatal. ZZ and the last 40-50 years - - the body length of newborns has increased by 1-2 cm, children 2 years old - by 4-5 cm. The average height of 15-year-old children has become 20 cm more over 100 years. strength, accelerated the period of biological maturation. .
There are harmonious and disharmonious types of acceleration. The first includes children whose anthropometric indicators and biological maturity are higher than those for this age group. The second group includes children who have increased body growth in length without accelerating sexual development or early puberty without increasing growth in length.
But if earlier the process of acceleration was considered only as a positive phenomenon, then in recent years there is information about a more frequent disproportion in the development of individual body systems in such children, especially neuroendocrine, cardiovascular. According to numerous publications, the process of acceleration in economically developed countries is currently slowing down. There is no reason to believe that in the future a significant decrease in the age of puberty is expected, as well as an increase in body length above the norm of average height that has been established for millennia.
If we talk about the assessment of indicators of body length, then low growth is growth below the average, for a given age, values \u200b\u200bmore than 22, or below the third percentile, which corresponds to a deviation from them by 10%. Dwarf growth: growth rates are below average by 3 and respectively below 0.5 percentile. Large growth, macrosomia: growth rates exceed the average by 1-3, or are above the 97th percentile. Gigantic growth, gigantism: growth rates exceed the average by more than 3. .
About 3% 3% of children and young men are classified as undersized. Most of them are somatically quite healthy. They can show psychic vulnerability when it comes to their short stature. Short stature may be due to family, constitutional factors, when both parents or at least one of them are short. Constitutional alal dwarf growth is always associated with a specific pathology of genes or chromosomes, regardless of whether this can be confirmed by scientific methods or not.
Causes of pathological short stature: Primary short stature with low birth weight Secondary short stature due to metabolic disorders (including pathology of the endocrine glands), which appear only after birth Growth disorders associated mainly with the development of long tubular bones
Two. Two main groups of short stature and: and: Proportional low growth with general slow development. At the same time, age-related physiological proportions are preserved (the ratio of the size of the head to the body, limbs). In a newborn, the ratio of the length of the head and body corresponds to 1: 4, at the age of 6 years - 1: 5, by 12 years - 1: 7, in adults - 1: 8. Disproportionate low growth usually occurs with isolated disorders in the most active growth zones. Normal ratios between the sizes of the head, torso and limbs are violated.
The most common causes of proportional short stature Constitutional (familial) short stature. This group includes healthy children of healthy parents, whose growth is below average. Such children remain below their peers. Weight and length of the body at birth may be normal and, and, ossification of the skeleton (the appearance of ossification nuclei) occurs at the usual time. The level of growth hormone in the blood is normal.
The most common causes of proportionate short stature Initial short stature. The frequency of the phenomenon is determined by the prevalence of short stature in previous generations and preferential marriages between people of short stature. Its signs already at birth are low indicators of body weight and length. The child is born with all signs of maturity, pregnancy usually has a normal duration. The proportions of the body in children are observed, the ossification of the skeleton and mental development, as well as the puberty period, proceed normally, which makes it possible to exclude the pathology of metabolic processes.
The most common causes of proportionate short stature Alimentary short stature. The causes of alimentary short stature are either malnutrition or a violation of the absorption of nutrients. . The most adverse effect is the lack of proteins. These children are particularly susceptible to infectious diseases.
Consequences of quantitative and qualitative malnutrition Anorexia in severe mental or physical disorders. Diabetes mellitus, difficult to compensate and regulate. Mauriat's syndrome kk aa (diabetes mellitus, short stature, hepatomegaly, congestion in the portal vein system, obesity, chronic acetonuria, hypercholesterolemia). Diabetes insipidus. Short stature is a consequence of a metabolic disorder due to a lack of antidiuretic hormone (adiuretin). At the same time, there is almost always a lesion of the anterior pituitary gland (growth hormone) and lily of the hypothalamus (vegetative centers). .
Consequences of quantitative and qualitative malnutrition Insufficient nutrition with homelessness, neglect of children, as a manifestation of severe hospitalism (not only in orphanages, but also in some families), with kwashiorkor associated with a chronic lack of protein in food. Frequent vomiting on the basis of psychogenic disorders or as a result of anatomical anomalies (stenosis of the esophagus or duodenum 12, diaphragmatic hernia, Hirschsprung's disease, PUD of the stomach and duodenum 12). Digestive disorders (maldigestion), including cystic fibrosis and other diseases. Malabsorption (malabsorption), partial or complete after extensive resection of the small intestine, prpr and Crohn's disease, celiac disease, etc.
The most common causes of proportional short stature Short stature in the last three groups of causes is combined into the concept of short stature of intestinal origin. . Low growth due to hypoxia. . It occurs in chronic diseases of the lungs and respiratory tract, heart disease, chronic severe anemia (children attract attention with pallor and constant cyanosis or cyanosis when moving). They suffer from shortness of breath, have a chronic cough, fingers in the form of drumsticks.
The most common causes of proportional short stature Short stature in violation of puberty: hypogonadal hypogonadism, late puberty Frohlich's adiposogenital dystrophy ovarian dysgenesis (Shereshevsky-Turner syndrome)
Low growth on the basis of cerebral and hormonal pathology. . Cerebral causes: : slow-growing brain tumors residual effects of stem encephalitis, tuberculous meningoencephalitis and neurosyphilis microcyphalia, hydrocephalus alcoholic embryopathy
Hormonal pathology Pituitary stunting caused by hypofunction of the anterior pituitary gland, primarily by GH deficiency, and very significant (growth begins to slow down from the age of 2, dwarf growth is formed by the end of school age) Hypothesis and rheosis Important features Struma, myxedema, delayed ossification of the skeleton, dementia
Low disproportionate growth Chondrodystrophy (achondroplasia, chondrodysplasia). Predominantly hereditary pathology of cartilage cells, manifested by a violation of the growth of long tubular bones and the base of the skull. Imperfect osteogenesis. The disease is based on hereditary inferiority of osteoblasts, leading to increased bone fragility with minimal causes and shortening of the limbs precisely because of multiple fractures.
Low disproportionate growth of Mucopolysaccharidosis. . Malformations of the spine. A decrease in the size of the body with a normal length of the limbs is characteristic. Vitamin D - - pp-resistant forms of rickets (rickets-like diseases). . Hereditary hypophosphatasia (Ratban's syndrome). Cystinosis (Abdergalden-Fanconi disease). Rachitic change of bones and short stature.
High growth High initial growth. As a rule, there is a family predisposition to high growth. In many previous generations, a significant number of tall people are noted, as in cases of primordial short stature. Arachnodactyly (Marfan's syndrome) - - hereditary (autosomal dominant) widespread mesodermal dysplasia: tall stature, thin long bones, a pronounced picture of leptosomal asthenia, long hands and feet, often chest deformity, general muscular hypotension. Often ectopia of the lens and dilatation of the aorta.
High growth Pituitary gigantism (eosinophilic adenoma of the anterior pituitary gland in children). Adults have acromegaly. Children are tall and slender. High growth at early puberty (early puberty is a strong stimulus to growth, but this is temporary, and then growth stops). Chromosomal aberrations. Klinefelter's syndrome (XXY - chromosomopathy) with primary underdevelopment of the testicles. Heller-Nelson syndrome. Syndrome HUU, XXXXY.
Deviation in magnification m. tt. . Hypotrophy - reduced body weight. Eutrophy is a condition in which an increase in body weight and an increase in body length do not go beyond the limits of physiological ratios (i.e., this is a state of normal nutrition). Dystrophy is a condition in children whose body weight is 15-20% lower than normal. They attract the attention of thinness, thin limbs, poor development of muscles and subcutaneous fat. Atrophy is the condition of a child whose body weight is 30% below the average or below the 3rd percentile.
Constitutional factors Prematurity, newborns with intrauterine dystrophy (other points are also important - embryopathies, chromosomal abnormalities). . Asthenic physique. (Children are usually healthy.) Marfan's syndrome. . Progressive lipodystrophy.
Exogenous factors Improper low-calorie nutrition. . Wrong care. . Severe (subacute and chronic) infections.
Lesions associated with impaired metabolic processes Malignant tumors. . DCDC PP spastic type. . Cirrhosis of the liver. . Nephrosis (mainly nephronephritis). . Long-term cytostatic therapy. . Chronic renal failure. . Galactosemia.
Chronic digestive disorders Cystic fibrosis, celiac disease, with malabsorption syndrome, pancreatic insufficiency in chronic pancreatitis, hepatitis, congenital lipase deficiency, Shwachman's syndrome - exocrine pancreatic insufficiency, accompanied by neutropenia, thrombocytopenia and short stature. . Malabsorption due to allergy to cow's milk or soy proteins. .
Chronic digestive disorders Malabsorption of monosaccharides, disaccharides. . Congenital insufficiency of enterokinase. . Tryptophan malabsorption (Hartnup syndrome). . Enteropathic acrodermatitis (impaired absorption of zinc). .
Excess body weight Excess should be considered body weight (taking into account body length) 15%15% higher than the average, which exceeds 97 percentiles. . With obesity, body weight exceeds the average for a given age by 25% or more. .
Causes of overweight Constitutional factors. Unreasonable high-calorie nutrition (excess of proteins, carbohydrates, fats and fluids). Unfavorable mental and social conditions that most strongly affect children in a state of depression, as well as resigned and weak-willed children with weak self-consciousness, and the feeble-minded. Cerebral diseases. Diencephalic or diencephalic-pituitary obesity, adiposogenital dystrophy.
Causes of overweight Endocrine disorders: hypothyroidism, hypercortisolism, Cushing's syndrome. Primary metabolic disorders: type II glycogenosis, Mauriat's syndrome kk a a (diabetes mellitus). Obesity in other syndromes: PP and wick's syndrome; Prader-Willi syndrome; Ahlstrom-Halgren syndrome (obesity + blindness + retinal dystrophy), reduced glucose tolerance with the development of diabetes mellitus, hearing loss due to damage to the inner ear.
The physical development of the child. Assessment of physical development. Semiotics of violations.
Features of writing a medical history in pediatrics.
Methodological development for students
Specialty: medicine
Academic discipline: pediatrics
Head Department: Professor Griganov V.I.
Astrakhan - 2009
Seminar topic: "Physical development of the child. Assessment of physical development. Semiotics of disorders. Peculiarities of writing a medical history in pediatrics"
Goals:
Educational
Emphasize the importance of the section on physical development in the work of a pediatrician;
Solve complex deontological problems that arise in relationships with a sick child, parents, middle and junior medical staff, colleagues.
Educational
To teach the methodology of anthropometric measurements in children of different ages.
To teach to evaluate the height and weight of the body, head circumference, chest circumference of children of different ages.
To teach to evaluate the physical development of children of different ages according to formulas and tables.
Evaluate the data of laboratory research, functional and instrumental methods of research of children with this pathology.
Know the classifications of the most common diseases of this pathology
Make plans for the treatment and prevention of diseases of this pathology in children of different ages
Independent work of students
Extracurricular
The student must know the basics of physical development, which the student learns independently from the textbook.
Classroom - analysis of the topic by questions
Educational and methodological materials for students:
1. Folder "Teaching aids for students"
2. Educational tasks for independent work in pediatrics. Under the editorship of prof. V.I. Griganova Suprun S.V., Murzova O.A., Suprun O.I., Shvechikhina E.R. Astrakhan: AGMA.-2009
3. Anthropometric assessment of the physical development of children. Suprun O.I., Chelnokov M.M., Murzova O.A., Suprun S.V. Astrakhan: AGMA.-2009
4. Chronic eating disorders in children. Shvechikhina E.R., Suprun S.V. Astrakhan: AGMA.-2009
5. Methodological manual for writing a medical history for students of the medical faculty Miroshnikova E.M. Astrakhan: 2009
6. Some aspects of the physical development of children in normal and pathological conditions. Stroykova T.R., Griganov V.I. Astrakhan: ASMA.-2009
1. Vidal's Handbook. Medicines in Russia. http://www.vidal.ru/
2. Electronic pharmacological guide for doctors http://medi.ru/
3. "Pediatrics" Journal named after G.N. Speransky http://www.pediatriajournal.ru/about.html
4. All-Russian medical portal http://bibliomed.ru/
5. Website of the Astrakhan State Medical Academy
http://agma.astranet.ru/
6. Internet portal "ConsultantPlus" - the legislation of the Russian Federation: Fundamentals of the legislation of the Russian Federation on the protection of the health of citizens. http://base.consultant.ru/cons/cgi/online.cgi?req=doc;base=LAW;n=58254
7. Website of the Union of Pediatricians of Russia: Guidelines http://www.pediatr-russia.ru/news/recomend/
8. Russian medical server http://www.rusmedserv.com/
Questions to control the level of assimilation of educational material
1. Classification of periods of childhood.
2. Functional characteristics of each age period of childhood and features of pathology.
3. The concept of physical development.
4. The main indicators of the physical development of children, their stability and lability.
5. Factors affecting the growth of the child.
6. Physiological laws of growth growth in different age periods.
7. Reasons for possible changes in body weight.
8. Physiological laws of weight gain.
9. Formulas for calculating the length and weight of the body, the circumference of the head and chest of a child of different ages.
10. Methodology for assessing the physical development of the child according to centile tables.
11. Calculation of the surface of the child's body.
12. Change in body proportions with age.
13. Methods for assessing the proportionality of the child's development.
14. Determination of the degree of prematurity of the child.
15. Definition of the concept of intrauterine malnutrition and the causes of the development of this pathology.
16. Determination of the degree of intrauterine malnutrition by weight and length of the body of the newborn.
17. Anatomical and functional signs of full-term and prematurity.
18. The concept of malnutrition, paratrophy, hypostature, their clinical characteristics.
19. Degrees of malnutrition, paratrophy, obesity.
PLAN - CHRONOCARD
| № | EPATS LESSONS | FUNDS | ACTIVITIES OF THE TEACHER | STUDENT ACTIVITIES | TIME |
| 1. | ORGANIZATIONAL STAGE | Magazine | Notes the presence of students, draws attention to the appearance of the student, communicates the topic and purpose of the lesson | listen | min |
| 2. | Control of the initial level of knowledge | Tests | Questions students on the topic orally or distributes tests, checks tests against standards | Answer verbally or in writing | min |
| 3. | MAIN STAGE | Emphasizes the relevance of the topic under study. Based on the definition of the initial knowledge, the correction of the knowledge necessary for the independent work of the student at the bedside of the patient is carried out, shows the methodology for studying the organs of the system under study | Listen, watch | min | |
| 4. | Sick children | The teacher distributes 1 patient for 2 students | Students independently clarify complaints, clarify anamnesis, examine children, record the results of the examination in the educational medical history | min | |
| 5. | Folder "Methodological development on the topic" (for students) | Controls students | Make a brief conclusion according to the examination and analyzes of the patient. | min | |
| 6. | The final stage | Sick children | The teacher, together with the students, selectively examines 1-2 patients, corrects the results of the examination and description, paying attention to the clinical significance of various symptoms and syndromes, as well as laboratory research, functional and instrumental research methods. | Report, demonstrate the examined patient. Discuss the results of the examination, the semiotics of the identified symptoms and syndromes of lesions of this organ system | min |
| 7. | Tests, tasks | Answers students' questions and discusses answers with them | Solve several situational problems | min | |
| 8. | Magazine | The teacher evaluates the activities of students in the classroom. Emphasizes the main questions to be studied on the next topic. | listen | min |
ANNOTATION
GROWTH
The most stable indicator of physical development is the growth of the child. It determines the absolute length of the body and, accordingly, the increase in the size of the body, the development, maturation of its organs and systems, the formation of functions in a given period of time.
Throughout the life of a child, the growth process proceeds unevenly, sometimes intensifying, sometimes slowing down. Anthropometric indicators are assessed mainly by 2 methods: parametric or sigmal and non-parametric - centile. The parametric scale includes the arithmetic mean (“norm”) and deviations from it, measured by the value of sigma (standard deviation). Centile tables show the quantitative boundaries of a trait in a certain proportion or percentage (centile) of children of a given age and gender. Values are taken as normal values - in the intervals of the 25th-50th-75th centile (it is desirable to evaluate at the 50th centile) (see Table of changes in the height and weight of a child from 0 to a year:: Table 1 and Table 2).
The greatest growth energy falls on the first quarter of the year (Table A). In full-term newborns, growth ranges from 46 to 60 cm. On average, 48-52 cm, but 50-52 cm are considered adaptive indicators of growth. This means that adaptation in the prenatal period occurred not only at the organismal level, but also at the organ level and enzymatic.
Table A. Increase in height and body weight in children of the first year of life
| Age, months | Increase in height per month, see | Increase in growth over the past period, see | Monthly weight gain, gr. | Weight gain for the past period, gr. |
| 2,5 | 11,5 | |||
| 2,5 | ||||
| 2,5 | 16,5 | |||
| 19,5 | ||||
| 21,5 | ||||
| 23,5 | ||||
| 1-1,5 | 24,5-25 | |||
| 1-1,5 | 25,5-26 | |||
| 1-1,5 | 26,5-27 |
During the first year, the child adds an average of 25 cm in height, so that by the year his height is on average 75-76 cm. With the correct development of the child, the monthly increase in height can vary within ± 1 cm, however, by 6 months and by the year these fluctuations growth should not exceed 1 cm.
Growth reflects the features of plastic processes occurring in the human body. Hence the importance of quality nutrition, especially the content in it of a sufficient amount of a balanced high-grade protein component and B vitamins, as well as A, D, E. Of course, the "gold standard" of optimal nutrition for children under 1 year old is human milk. Deficiency of certain nutritional components selectively disrupts the growth processes in children. These include vitamin A, zinc, iodine. Stunting can be caused by various chronic diseases.
Measurements of the height of a child in the first year of life are made on a horizontal stadiometer. Measurements are made by 2 people. The measurer is on the right side of the child. The assistant holds the child's head in a horizontal position so that the upper edge of the tragus of the ear and the lower edge of the orbit are in the same plane perpendicular to the stadiometer board. The top of the head should touch the vertical fixed bar. The child's arms are extended along the body. Measuring with light pressure on the knees of the child with his left hand, he holds his legs in a straightened position, and with his right hand moves the movable bar of the height meter tightly to the plantar side of the feet, bent at a right angle.
BODY MASS
Unlike height, body weight is a rather labile indicator that reacts relatively quickly and changes under the influence of a variety of reasons. Particularly intensive weight gain occurs in the first quarter of the year. The body weight of full-term newborns ranges from 2600g to 4000g and averages 3-3.5 kg. However, the adaptive body weight is 3250-3650 grams. Normally, in most children, by the 3rd-5th day of life, a “physiological” loss in weight of up to 5% is noted. This is due to the greater loss of water with insufficient milk supply. Recovery of physiological weight loss occurs by a maximum of 2 weeks.
The dynamics of body weight is characterized by a greater increase in the first 6 months of life and less by the end of the first year. The body weight of a child doubles by 4.5 months, triples by a year, despite the fact that this indicator can change and depends on nutrition, previous diseases, etc. The energy of increasing body weight gradually weakens with each month of life.
To determine body weight at the age of one year, it is better to use Table. 3.
Based on this table, the weight gain of a child for each subsequent month of life can be calculated by subtracting 50 grams from the increase of the previous month (but only after the 3rd month), or by the formula: X \u003d 800-50 x n, where 50 is the child adds 50 g less in body weight for each subsequent month of life, after the 3rd month; n is the number of months of a child's life minus three.
For example, in the tenth month of life, a child adds 800-(50x7) = 450g in weight.
There is another opinion that the average monthly increase in body weight in the first half of life is 800g, in the second half - 400g. However, it should be emphasized that the calculation according to the data given in Table. 3 is considered preferable (more physiological). Data on the assessment of body weight in relation to height (body length) for boys and girls in centile intervals are given in Table. 4 and 5.
On average, by one year, the body weight of a child is 10-10.5 kg. The increase in body weight in infants is not always characterized by such a pattern. It depends on the individual characteristics of the child and a number of external factors. Children with an initial low body weight give relatively large monthly weight gains and it doubles and triples earlier than in larger children. Formula-fed babies immediately after birth double their body weight about a month later than breast-fed babies. Body weight is a labile indicator, especially in a young child, and can change under the influence of various conditions sometimes during the day. Therefore, body weight is an indicator of the current state of the body, in contrast to height, which does not immediately change under the influence of various conditions and is a more constant and stable indicator. A deviation of body weight from the norm up to 10% is not considered a pathology, however, a pediatrician should analyze this loss.
PROPORTIONALITY OF DEVELOPMENT
When assessing the physical development of a child, it is necessary to know the correct relationship between body weight and height. The weight-height indicator (MCI) is understood as the ratio of mass to height, i.e. what is the mass per 1 cm of body length. Normal in newborns (MCI) is 60-75 g.
In addition to height and body weight, correct body proportions are important for assessing physical development. It is known that the circumference of the chest in full-term babies is less than the circumference of the head at birth. Head circumference in full-term children varies within a fairly wide range - from 33.5 to 37.5 cm, on average it is 35 cm. When analyzing these digital indicators, one should take into account the height and weight of the child's body, as well as the ratio of the head circumference to the circumference of the chest . When comparing, it should be borne in mind that at birth the head should not exceed the chest circumference by more than 2 cm. In the future, it is necessary to focus on the growth rate of the head circumference. In the first 3-5 months, the monthly increase is 1.0-1.5 cm, and then 0.5-0.7 cm. By the year, the head circumference increases by 10-12 cm and reaches 46-47-48 cm (on average 47 cm).
In a child born with adaptive indicators of height and body weight, the head circumference is about 36 cm. During the first 3 months of life, the head circumference should “grow” by 4 cm (that is, at 3 months - 40 cm). Over the next 3 months, the head circumference increases by another 3 cm and becomes 43 cm by 6 months, and 46-48 cm by the year. The size of a large fontanel at birth should not exceed 2.5x3 cm, 3x3 cm.
The circumference of the head is measured with the centimeter tape position at the back at the level of the occiput, and in front - above the eyebrows.
To characterize the physical development of a child, a correct assessment of the characteristics of his chest is of great importance, since the vital activity of the internal organs largely depends on the shape and size of the latter. The increase in chest circumference occurs most intensively in the first year of life, especially in the first 6 months.
In a newborn, the circumference of the chest is 33-35 cm. The monthly increase in the first year of life averages 1.5-2 cm per month. By the year, the circumference of the chest increases by 15-20 cm, after which the growth energy decreases and the circumference of the chest increases on average by 3 cm by preschool age, and by 1-2 cm per year in preschool age.
For an individual assessment of the physical development of the child, it is important to know the periods of intersection of the circumference of the head and chest. In healthy children, this decussation occurs at about 3-4 months, and in children who have at 5-7 months. the cross has not come, you need to take into account and analyze the dynamics of the development of the chest and head in them. An earlier crossover may indicate developing microcephaly, so it is necessary to monitor the timing of the closure of the large fontanel. A large fontanel should overgrow by the end of the first year in 80% of children, in other children - by 1.5 years. The anteroposterior size of the chest in most full-term newborns is less than or equal to the transverse diameter. Already during the first year of life, the transverse diameter begins to prevail over the anteroposterior and the shape of the chest flattens.
STATIC FUNCTIONS
Static functions are evaluated taking into account the pace of motor development of the child. These are various motor skills of the child. It is necessary to take into account the ability of a child at a certain age to hold his head, make movements with his hands (feeling an object, grasping, holding a toy in one hand, performing various actions), the appearance of dynamic functions (turning from back to stomach and from stomach to back, pulling up, crawling, sitting down stand up, walk, run).
At 2 months, the child holds his head well,
at 3 months - turns well from back to stomach,
at 5.5-6 months - turns well from stomach to back,
at 6 months - sits if he was planted,
at 7.5 months, (when the child learns to crawl well) - sits down by himself,
at 9 months - well worth it,
at 10 months - walks around the arena, holding on with his hand,
by 12 months - walks independently.
The development of static functions is facilitated by various sets of exercises for children: from 1 to 3 months; from 3 to 6 months; 6 to 9 months; from 9 to 12 months.
Etiology of malnutrition
Exogenous (external) factors:
· Nutritional factors
v quantitative underfeeding : more often with natural feeding (hypogalactia, low content of proteins and fats in breast milk, "sluggish" suckers)
v quality underfeeding: more often with artificial feeding, especially with unadapted mixtures (milk, kefir), with untimely introduction of complementary foods
· infectious factors(frequent acute respiratory infections, intestinal infections, pyelonephritis, sepsis, etc.)
· Toxic ( may be with acute and persistent infections, poisoning, chronic alcoholism and other substance abuse in the mother)
· Deprivation ( defects in care, upbringing, especially in the so-called "refusal" children)
Mixed
Endogenous (internal) factors: Related
Malformations (CNS, respiratory organs, gastrointestinal tract)
Chromosomal and gene defects, including those with congenital immunodeficiencies
Endocrine disorders (hypothyroidism, pituitary dwarfism, adrenogenital syndrome)
Anomalies in constitutions
Enzyme pathologies (disaccharidase deficiency, celiac disease, exudative enteropathy, cystic fibrosis, etc.)
Primary metabolic disorders (phenylketonuria, homocystinuria, etc., xanthomatosis)
Acquired diseases of the internal organs.
PATHOGENESIS OF HYPOTROPHY
As a result of underfeeding, the secretory and motor functions of the gastrointestinal tract decrease, in particular:
Decreased acidity of gastric juice;
the content of enzymes in pancreatic juice decreases;
Decreased enzymatic activity of the intestine;
cavitary and membrane digestion is disturbed;
dysbacteriosis develops.
With malnutrition, metabolic disorders always occur. In addition, liver functions are impaired, for example, antitoxic, prothrombin-forming. Pronounced biochemical changes occur:
· hypoproteinemia;
· hypolipidemia;
· hypoglycemia;
hypercholesterolemia with an increase in the content of free fatty acids.
Violated water and mineral exchanges, which together leads to metabolic acidosis and endogenous toxicosis. Violation primarily of protein metabolism contributes to the development of immune deficiency, primarily humoral, and then cellular immunity.
Malnutrition also leads to disorders of the central nervous system function, impaired formation of conditioned reflexes; in severe cases - to a delay in the mental development of the child.
Thus, with malnutrition, the utilization of nutrients (primarily protein) in the intestine is disrupted, all types of metabolism are disrupted, immunity is suppressed.
CLINIC OF HYPOTROPHY
According to the severity of the disease, 3 degrees of malnutrition are distinguished.
I degree: the subcutaneous fat layer is thinned on the trunk and abdomen. Reduced muscle tone and skin turgor. Body weight deficit 11-20%. The Chulitskaya index has been reduced to 20-11. Psychomotor development is somewhat delayed, but does not lag behind significantly in the future.
II degree: the subcutaneous fat layer is significantly thinned or absent on the trunk and abdomen, reduced on the limbs. Body weight deficit 21-30%. Chulitskaya index lowered to 10-0. Moderately impaired food tolerance - reduced appetite, flattened weight curve. Psychomotor development lags behind age norms, and in the future, the intellectual potential of the child decreases.
III degree: the subcutaneous fat layer is absent, it disappears last on the face, in the area of Bish's lumps. Chulitskaya index 0 or negative. Deficit of body weight more than 30%. Reduced tissue turgor and muscle tone, muscle atrophy. Significantly behind the physical and psychomotor development. Food tolerance is impaired - appetite is absent or perverted, flatulence, constipation or unstable stools are disturbing, the weight curve is reduced. Disturbed metabolism. Anemia, hypoproteinemia with edema are possible. The frequency and severity of infections that are prone to generalization are increasing.
The formation of the nervous and endocrine systems is disrupted, which in the long term reduces the intellectual potential of the child.
TREATMENT OF HYPOTROPHY
1. BASIC THERAPY
Mode: lengthening sleep, maximum limitation of painful manipulations, fresh air, sunbathing, ambient temperature of at least 23-24 degrees
Etiological treatment: rehabilitation of infections, correction of deprivation, compensation of impaired functions in case of defects and diseases of internal organs
Diet (principles: stages, rejuvenation, individuality):
Staged:
stages of feeding
1. clarification of food tolerance,
2. transitional
3. stage of enhanced nutrition
nutritional rejuvenation principle:- products and mixtures are used for feeding younger children, the number of feedings is increased, the volume of each feeding is reduced.
selected individually: - the content of the stages depends on the degree of malnutrition, that is, on the condition of the child,
2. Medical treatment
A. Replacement therapy:
Enzyme preparations (mezim-forte, kreon, etc.)
Vitamins (C, B1, B6, A)
Macro- and microelemental correction (preparations Fe, Zn, etc.)
Immunological drugs (immunoglobulins, plasma, KIPs, interferons)
Probiotics (lactobacterin in the first months of life, Nutrolin with vitamins gr. B, in the second half of the year bifidum-bacterin, bifidum-bacterin forte, bifiform - baby, bifilis, hilak-forte, lineks)
Glucocorticosteroids, thyroxine, DOX, etc. (with severe forms of malnutrition - alimentary insanity)
B. Metabolic agents:
Hormonal anabolics - 0.5-1.0 mg / kg per day once a week (nerobol, retabolil - with sufficient protein intake in the child's body)
Non-hormonal anabolics (orotate K, and others in courses of 2-3 weeks)
B. Stimulants:
General stimulants (apilac, ginseng, massage, UV radiation, etc.)
Immunostimulating (tactivin, thymogen, immunal, methyluracil, dibazol, sodium nucleinate, pentoxyl)
D. Symptomatic remedies
A. Non-organ specific
Cytomac 0.5-1.0 ml / kg intravenously (improves the intensity of tissue respiration, microcirculation)
· Coenzyme Q 2 mg/kg drip up to 1.0 ml per day (improves redox processes and energy potential of cells)
Actovegin up to 1.0 ml intramuscularly or intravenously (activates cellular metabolism, replenishes energy resources in tissues)
Potassium orotate ¼ tab-1 tab at night for at least 3-4 weeks (anabolic effect)
Akti-5 ½-1 teaspoon of syrup 2-3 times a day (anabolic effect)
Limontar up to 1 ½ tablets per day, dissolved in water or juice (increases appetite, anabolic effect)
Biotredin 2 mg/kg per day up to 1 ½ tablets per day (normalizes metabolic processes)
Kogitum up to 2 ampoules per day (10 ml in an ampoule) enterally (general stimulating effect)
Apilak ½ -1 suppository 2-3 times a day for 2-3 weeks
B. Organ-specific:
Essentiale up to 6 capsules per day (antioxidant, antihypoxant, improves liver tissue metabolism)
Karsil and LIV-52
Nootropil 50-100 mg/day
Glycine up to 100 mg/day
Semax 1-3 drops intranasally daily or every other day
Riboxin 1-2 tablets per day
HYPOSTATURE
A variant of dystrophy with a more or less uniform lag of the child in height and body weight with satisfactory fatness.
The hypostasis is usually
stage recovery from severe malnutrition occurring with growth deficiency, since the child usually gains weight faster.
Possibility of hypostatus unbalanced diet, the predominance of carbohydrates with a deficiency of other ingredients.
· It happens constitutional hypostatura (small parents), with neuro-arthritic diathesis.
Sometimes a consequence endocrine pathology (pituitary dwarfism).
・To be excluded endogenous nature of the hypostatura (on background of congenital and acquired pathology).
HYPOSTATURE CLINIC
The child proportionally lags behind in height, weight, intelligence, timing of teething, i.e. the biological age of the child lags behind the calendar. There are trophic disorders and signs of polyhypovitaminosis, dysproteinemia, decreased absorption of fat in the intestine, aminoaciduria.
DIAGNOSIS
is established on the basis of clinical and anthropometric data.
TREATMENT
is carried out at home according to the same principles as with hypotrophy of the II degree. It is very important to eliminate the causative factor.
PARATROPHY
Chronic eating disorder with a predominance of body weight with a relatively normal growth of the child.
The most common causes of paratrophy are:
refeeding the child
a diet high in carbohydrates or protein
Improper nutrition of a pregnant woman with an excess of carbohydrates, fats, with a lack of vitamins, minerals
The hereditary-constitutional factor.
CLINIC OF PARATROPHY
There are 3 degrees of paratrophy.
· 1 degree: an increase in body weight compared to the average norm by 10-20%;
· 2nd degree:- by 20-30%;
· 3rd degree:- by 30-40%.
Excess body weight appears more often at 3-5 months of age. Children have manifestations of rickets, exudative diathesis, often find an increase in the thymus gland. In the anamnesis, such patients often note the presence of asphyxia, intracranial injury in the perinatal period. During the examination, various disorders of carbohydrate, protein or fat metabolism are found.
Carbohydrate eating disorder such as paratrophy.
Carbohydrate overfeeding is possible even in a child who is breastfed, with disordered nutrition, the introduction of a large amount of sweet tea, apple or juice with a lot of sugar to the child.
Improper nutrition contributes to the deposition of excess fat in the subcutaneous fat and leads to water retention in the body. The child looks obese, pasty, with flabby tissue turgor. Anthropometric indicators may correspond to above average or high physical development.
An excess of carbohydrates can further lead to the depletion of the enzymatic capacity of the gastrointestinal tract and to an increase in fermentation processes. The chair becomes liquid, frothy, dark in color, acid reaction. Develop a lack of vitamin B1, acidosis. The child, as it were, turns from “well-fed” into a hypotrophic, pale, lethargic, with a sharply reduced tissue turgor. As a result of a sharply reduced immunity, he often begins to get sick with ARVI, pneumonia and other diseases.
Protein malnutrition such as paratrophy.
Overfeeding with protein is possible:
· in the first half with early introduction (2-3 months) of whole cow or goat milk.
· In the second half the cause of protein overfeeding may be the excessive introduction of cottage cheese, protein enpit, the use of adapted dry mixes in a higher concentration or diluted with milk instead of water.
With an excess introduction of protein, it is first well digested, and the child gains weight well. However, with the depletion of the enzymatic ability of the gastrointestinal tract, its splitting by putrefactive intestinal microflora increases. The stool becomes dense, dry, whitish in color, alkaline, with a putrid odor, containing a large amount of calcium and magnesium soaps. The body accumulates intermediate products of protein metabolism (azotemia). Due to intoxication and azotemia, appetite decreases, the child loses weight. Anemia develops. Children with a protein eating disorder are less likely to get sick than those with a carbohydrate eating disorder, but suffer from kidney pathology somewhat more often.
Treatment is aimed primarily at correcting nutrition.
ENDOGENIC FACTORS
Endogenous causes depend on the effect that the endocrine glands have on the increase in height and body weight.
In the earliest period, this influence comes from the thymus gland, from the end of the first year of life - from the thyroid gland and from 3-4 years old - from the pituitary gland. The level of hormones involved in the growth process and the sensitivity of tissues to their action is determined by the genotype. Growth-promoting hormones are pituitary growth hormone (GH), thyroid hormones, and insulin. STH stimulates chondrogenesis, and thyroid hormones have a greater effect on osteogenesis.
EXOGENOUS FACTORS
Exogenous factors are those conditions in which the child falls after birth.
This is primarily nutrition (plastic and energy material). Quantitatively and qualitatively, malnutrition first of all inhibits the growth of body weight, and then growth.
Climatic and geographical conditions
The growth of the child is affected by movements that increase bone growth, increase metabolism
To assess the physical development of children under 1 year old, it is better to use the following indicators:
2. body weight;
3. Proportionality of development (head circumference; chest circumference, some anthropometric indices);
4. Static functions (motor skills of the child);
5. Timely eruption of milk teeth (in children under 2 years old).
The main criteria for the physical development of children of different ages:
Body mass
body length
Head circumference
Body proportions: physique, posture
GROWTH
The most stable indicator of physical development is the growth of the child.
The highest growth rate is observed in the first three months of a child's life.
In full-term births, growth ranges from 46 to 60 cm. On average, -48-52 cm, but 50-52 cm are considered adaptive indicators of growth.
During the first year, the child adds an average of 25 cm in height, so that by the year his height averages 75-76 cm.
In the second year of life, the child will grow by 12-13 cm, in the third - 7-8 cm.
BODY MASS
Unlike height, body weight is a rather labile indicator that reacts relatively quickly and changes under the influence of a variety of reasons.
Particularly intensive weight gain occurs in the first quarter of the year. The body weight of full-term newborns ranges from 2600 to 4000 g and is on average 3-3.5 kg. However, the adaptive body weight is 3250-3650 grams.
Normally, most children have a "physiological" weight loss of up to 5-8% by the 3-5th day of life. This is due to the greater loss of water with insufficient milk supply. Recovery of physiological weight loss occurs on days 3-5 by a maximum of 2 weeks.
BODY MASS
The dynamics of body weight is characterized by a greater increase in the first 6 months of life and less by the end of the first year.
The body weight of a child doubles by 4.5 months, triples by a year, despite the fact that this indicator can change and depends on nutrition, previous diseases, etc. The energy of increasing body weight gradually weakens with each month of life.
Monthly weight gain in children under one year old
Chest circumference
In a newborn, the circumference of the chest is 33-35 cm. The monthly increase in the first year of life averages 1.5-2 cm per month.
By the year, the circumference of the chest increases by 15-20 cm, after which the growth energy decreases and the circumference of the chest increases on average by 3 cm by preschool age, and by 1-2 cm per year in preschool age.
CENTILE TABLES
Two-dimensional centile scales - "body length - body weight", "body length - chest circumference", in which the values of body weight and chest circumference are calculated for the proper body length, make it possible to judge the harmony of development.
Usually, the 3rd, 10th, 25th, 50th, 75th, 90th, 97th centiles are used to characterize the sample.
3rd centile - this is the value of the indicator, less than which it is observed in 3% of the sample members; the value of the indicator is less than the 10th centile - in 10% of the sample members, etc. The gaps between centiles are called centile corridors. Allocate 7 centile corridors
Indicators included:
in the 4th-5th corridors (25th-75th centiles), should be considered average,
in the 3rd (10-25th centile) - below average,
in the 2nd (3rd-10th centile) - low,
in the 1st (up to the 3rd centile) - very low,
in the 6th (75-90th centile) - above average,
in the 7th (90-97th centile) - high,
in the 8th (above the 97th centile) - very high.
Physical development is harmonious, in which body weight and chest circumference correspond to body length, that is, they fall into the 4th-5th centile corridors (25th-75th centiles).
Physical development is considered disharmonious, in which body weight and chest circumference lag behind due (3rd corridor, 10-25th centile) or more than due (6th corridor, 75-90th centile) due to increased fat deposition.
Anomalies in one or more determinants of sex formation can lead to both anatomical and functional deviations from the “norm” and various clinical forms of sexual differentiation disorders. The type of violations of sexual differentiation depends on the causes and time of its occurrence in ontogeny.
In the early stages of embryogenesis, changes in the chromosome set, for example, 45 XO - Shereshevsky-Turner syndrome (ICD-X code - Q96), or dysfunction of sex chromosomes can lead to gonadal agenesis, i.e., to the development of an organism without gonads. In the future, the formation of a female phenotype with pronounced hypogonadism occurs.
The syndrome of gonadal bisexuality (true hermaphroditism - Q99 - according to ICD-X) is also attributed to the same period of violations of gonadal differentiation, when
differentiation of both zones of the sexual anlage (testicles and ovary). In most patients with this pathology, a female (46 XX) karyotype is determined, less often a male (46 XY) karyotype. According to some authors, a mixed gonad occurs in an embryo with mosaicism for the HY antigen.
The result of chromosomal aberrations, gene mutations (Q97 - other abnormalities of sex chromosomes, female phenotype, Q98 - other abnormalities of sex chromosomes, male phenotype according to ICD-X) may be the appearance of gonadal dysgenesis. Dysgenetic testicles do not fully regress the Müllerian ducts and normal masculinization of the external genitalia, which contributes to the development of derivatives of the paramesonephric ducts (uterus, fallopian tubes, upper third of the vagina) and manifests itself already at birth in the bisexual structure of the external genitalia (sex uncertainty and pseudohermaphroditism - Q56 according to ICD-X). Ovarian dysgenesis syndrome with a normal female karyotype and phenotype can manifest itself only in the pubertal period with more or less pronounced hypogonadism (congenital ovarian anomalies - Q50
according to ICD-X).
Violation of the normal formation of the male external genitalia contributes to the insufficient activating effect of testosterone produced by both the fetal testicles and the adrenal glands. For example, the syndrome of incomplete masculinization (false male hermaphroditism), in which in patients with male genetic and gonadal sex, an intersex structure of the external genitalia is detected: a split scrotum, urethral hypospadias, underdevelopment of the penis. In the ICD-X, these diseases are represented by the headings Q54 - hypospadias and Q55 - other congenital anomalies of the male genital organs.
In the complete absence (monorchism) or aplasia of the testis, code Q55.0 ICD-X is used. In postnatal life, diseases or conditions accompanied by the death of the ovaries (testicles), with a normal karyotype, the structure of the internal and external genitalia, are manifested in the pubertal period by the absence of secondary sexual characteristics and, accordingly, reproductive ability.
Congenital dysfunction of the adrenal cortex (adrenogenital disorders - E25 - according to ICD-X) is the most common cause of virilization of girls at an early age (manifestations of any male androgen-dependent signs). This is a hereditary
levitation associated with a violation of the biosynthesis of glucocorticoids even in the prenatal period due to a congenital deficiency of a number of adrenal enzyme systems (“congenital error of metabolism”). A low level of cortisol in the blood, according to the feedback principle, leads to increased secretion of adrenocorticotropic hormone (ACTH) by the pituitary gland and, consequently, to hyperplasia of the adrenal cortex, mainly the reticular zone, where hormones are intensively produced, the synthesis of which is not disturbed (mainly androgens). This leads even in the prenatal period to the masculinization of the external genitalia in girls (female pseudohermaphroditism), and in postnatal life it manifests itself in the heterosexual structure of the genitals.
During intrauterine formation of the male sex, it is necessary to single out the phase of descending of the testicles into the scrotum (22-32 weeks), which occurs under the influence of both hormonal and mechanical factors. Undescended testicle(s) is called cryptorchidism (unilateral or bilateral) and is coded as Q53.
False puberty. Differential diagnosis requires a state of false puberty, which is caused by diseases with an increase in the production of sex hormones, independent of the gonadotropic function of the pituitary gland. Hyperplasia of the endocrine glands or tumors that produce hormonally active substances can cause the development of secondary sexual characteristics. At the same time, the gonads remain in an infantile state, neither spermatogenesis nor ovulation occurs, i.e., a violation of the sequence of puberty occurs.
Gonadal false sexual development is a relatively rare pathology. In boys, this is due to a tumor growing from the interstitial Leydig cells in the testis. In such cases, children grow faster, they are more muscular, the external genitalia quickly increase in size, hair appears, voice mutation. After removal of the tumor, false virilization stops. In girls, isosexual false puberty is most often associated with a tumor in the ovarian granule cells that produces estrogens. The first symptom of this condition is often irregular anovulatory menstrual flow or isolated thelarche (development of the mammary glands) in the absence (or slight severity) of genital hair. In such cases, the ICD-X code depends on the nature of the tumor.
The basis of false sexual development that accompanies the pathology of the adrenal glands (congenital adrenogenital syndrome - code E25 ICD-X) is an increased production of androgens. A distinct formation of secondary sexual characteristics is noted only in boys (the testicles always remain underdeveloped), and in girls, manifestations of virilization cause a picture of heterosexual pseudopuberty.
Iatrogenic false puberty can occur with long-term use of glucocorticoids, anabolic sex hormones.
To designate disorders of sexual development associated with any pathological process, use the appropriate ICD-X coding. In the primary diagnosis of an unspecified disorder of sexual development, the code E30.9 is used.
Precocious puberty (PPR)(pubertas praecox)- an extensive group of diseases, different in etiology, pathogenesis, clinical manifestations and prognosis, which are united by the appearance of one or a number of secondary sexual characteristics caused by the effect of sex hormones on the body before physiological puberty.
In clinical practice, the diagnosis of such a condition is resorted to when secondary sexual characteristics appear in boys up to 9.5-10 years old, in girls - up to 8-9 years old, or the appearance of menarche up to 10 years old.
True PPR- all forms pubertas praecox, which are based on increased production of gonadotropic and, accordingly, gonadal hormones. The formation of hormonal correlations in such cases repeats the features of the formation of hypothalamic-pituitary-gonadal relationships in healthy adolescents, only at an earlier time. Puberty always follows an isosexual pattern.
Cerebral PPR. The cause of true PPR, as a rule, is associated with one or another cerebral pathology. These can be tumors, consequences of antenatal pathology, neuroinfections, cranial injuries. For example, precocious puberty caused by hyperfunction of the pituitary gland is designated by the code E22.8 ICD-X.
Idiopathic (constitutional) PPR. In addition to the cerebral, there is also an idiopathic (constitutional) form
true PPR, when there are no obvious disorders from the side of the central nervous system. Constitutional PPR is more often registered in girls. Premature formation of menstrual function is designated by code E30.1 ICD-X (premature menstruation), and premature enlargement of the mammary glands by code E30.8 ICD-X (other disorders of puberty). In idiopathic forms of true PPR, under the influence of increased production of gonadotropins, somatic sexual maturity can occur very early. Great psychological difficulties are associated with perfect spermatogenesis or the ability to become pregnant, on the one hand, and mental infantilism and social immaturity, on the other. Despite the similarity of external manifestations, the physical and sexual development of such children has a number of features that make it possible to reject the point of view on PPR as "normal puberty at an abnormally early time." With the initial manifestations of PPR, children, as a rule, are ahead of their peers in physical development. Subsequently, due to the early closure of the epiphyses, short stature is formed. Features of sexual development in the constitutional form of PPR in girls include possible violations of the stages of the appearance of estrogen- and androgen-dependent secondary sexual characteristics: delayed or weakly expressed sexual hair growth compared to the development of the mammary glands, internal and external genitalia. This obviously reflects the autonomy of the maturation of the hypothalamic-pituitary-gonadal (gonadarch) system in the immature adrenarche system, which probably begins to function at the usual time. There is a certain feature in the shape of the mammary glands. Their increase is mainly due to the growth of glandular tissue without a preliminary change in the areola. With a fully formed mammary gland, the areola and nipple remain "childish" - pale colored, flat (obviously due to a violation of the normal action of estrogens, prolactin and gonadotropins on the breast tissue). Menarche as the climax of puberty does not depend on the development of other sexual characteristics, sometimes being the first symptom of PPR. Menstruation can come quite regularly with the prepubertal development of the genitals and uterus, possibly due to an increase in the receptor sensitivity of the endometrial tissue to estrogenic influence.
Syndrome of delayed puberty diagnosed in the absence of secondary sexual characteristics in adolescents after 13.5 years and in girls in the absence of menstruation by 15 years and older. Clinically and pathogenetically, this is a heterogeneous group of developmental disorders of the reproductive system. We can talk about three main mechanisms underlying the delay in sexual development:
Late maturation of the hypothalamic-pituitary-gonadal system;
Late maturation of germ cell receptors interacting with gonadotropins;
Low sensitivity of the tissues of the external genitalia to the effects of sex hormones.
The reasons for delayed sexual development include the pathology of pregnancy and childbirth, adverse conditions for the early development of the child, starvation, obesity, chronic somatic and infectious diseases, endocrinopathies, and CNS lesions. The delay in sexual development can go both in parallel with the delay in physical and mental maturation, and disharmoniously with the discrepancy in the rates of growth and development.
We must not forget about the possibility of having a constitutionally determined "delayed puberty" (ICD-X code - E30.0: delayed puberty). In this case, as a rule, children noticeably lag behind their peers in physical development; but in the future, both growth and puberty are normal. Obviously, adolescents who do not have any signs of puberty two years or more after the average time for the appearance of these signs in the population cannot be ignored.
In case of violation of stereotypes of gender-role behavior, the following ICD-X headings are used: F64 - gender identity disorders; F65 - disorders of sexual preference; F66 - Psychological and behavioral disorders associated with sexual development and orientation.
- a group of diseases of various etiologies, accompanied by a deviation in the indicators of the child's physical development from age norms. It is more often manifested by growth retardation, diseases leading to accelerated growth are much less common. Growth disorders in children are almost always accompanied by symptoms from the cardiovascular system and the gastrointestinal tract (depending on the etiology). An assessment of physical development is carried out on the basis of specially designed tables, as well as complex laboratory diagnostics. Treatment is etiotropic, hormone replacement therapy, neurosurgical and other operations are used.
General information
Growth disorders in children are accompanied by a huge number of various endocrine and somatic diseases. Difficulties in timely diagnosis and expensive hormonal therapy put the problem of the physical development of the child in one of the first places in pediatrics. In addition, diseases of this group have a direct impact on the demographic situation in the future. Of particular danger are intrauterine growth retardation and congenital endocrine pathologies, in which timely correction is practically impossible, and for this reason the child remains undersized. Growth disorders in children can, to a certain extent, reduce the quality of life of an already adult person, and also often affect fertility in the future.
Causes and classification of growth disorders in children
Some diseases are associated with endocrine disorders. These may be pathologies of somatotropin metabolism, its insufficient or excessive formation, or a change in the sensitivity of peripheral receptors to this hormone. Disorders of growth hormone metabolism can be caused by tumors of the hypothalamic-pituitary region, genetic defects of any enzymes involved in the formation of somatotropin, etc. In addition, growth disorders in children occur with pathologies of the metabolism of other hormones, in particular, thyroid hormones, adrenal glands, sex hormones, and some central hormones such as ACTH and releasing factors.
Some somatic pathologies can also cause growth disorders in children. First of all, this is a group of skeletal dysplasia and chromosomal diseases, accompanied by short stature. Pathologies of the kidneys, liver and gastrointestinal tract are also sometimes accompanied by growth retardation. This is usually due to malnutrition (irrational diet, starvation) or food absorption. At the same time, the liver indirectly participates in the growth process of the child, since it is here, under the influence of somatotropic hormone, that insulin-like growth factors are formed that directly affect target cells, triggering anabolic reactions.
There are two main principles on the basis of which all nosologies are divided into subgroups. The first principle is quantitative, in this case one speaks of either growth retardation or premature and accelerated growth. The second principle is related to the causes of pathologies. In accordance with it, growth disorders of endocrine and somatic genesis are distinguished. In the structure of general morbidity, the latter subgroup significantly prevails. In addition, growth disorders in children include some hereditary forms of pathology, for example, family short stature.
Symptoms of growth disorders in children
It is worth noting that growth retardation is much more common than accelerated growth and development. In the case of intrauterine growth retardation, immediately after the birth of a child, one can notice that the parameters of his physical development to one degree or another lag behind the norm. However, more often it is possible to suspect growth disorders in children from about 3-4 years old, when it is possible to trace the dynamics of growth. As a rule, from now on, the lag is determined not only by the pediatrician, but also by the baby's parents. This can be a proportional growth retardation (the trunk and limbs evenly lag behind in size from the age norm) and a disproportionate shape (the limbs are either short or long in relation to the body).
Chromosomal syndromes, in the clinic of which there are growth disorders in children, are also manifested by specific changes in appearance (for example, Down syndrome or). Additional symptoms are characteristic of all somatic diseases that affect the physical development of the child. With malformations of the cardiovascular system, cyanosis of the skin and other signs are detected, violations are confirmed by ECG data. Pathologies of the gastrointestinal tract are accompanied by dyspeptic symptoms, changes in stool, bloating and other symptoms.
As for endocrine diseases, growth disorders in children are also not their only manifestation. If the changes are related to growth hormone produced by the pituitary gland, growth rates will deviate markedly from age norms, unlike other diseases in which this may not be so obvious. Insufficiency of the hormonal function of the thyroid gland, in addition to short stature, is manifested by the characteristic lethargy of the child, low blood pressure and bradycardia, with hyperfunction of the gland, the symptoms are opposite, growth is accelerated.
Sex hormones to some extent potentiate the physical development of the child. They are involved in the formation of ossification nuclei and the closure of growth zones in the epiphyses of bones at the end of puberty. Thus, congenital and acquired diseases of the adrenal glands, as well as defects in the metabolism of sex hormones, inevitably lead to growth disorders in children. In some cases, growth retardation may be associated with severe psycho-emotional stress. In addition, constitutional features also play a role in physical development. These children usually have a family history of growth retardation, more often on the paternal side.
Diagnosis of growth disorders in children
There are certain standards that a pediatrician is guided by when assessing the physical development of a child, in particular, centile tables containing quantitative boundaries for height, weight and other indicators for children of different ages. If the patient's indicators for one or two years go beyond the limits indicated for a specific age, we can talk about acceleration or delay in physical development. Compliance with a certain column of centile tables for the purpose of diagnosing growth disorders in children is always evaluated over several years.
Algorithms have been developed on the basis of which differential diagnosis of the causes of growth disorders in children is carried out. The need for them arises due to the fact that the study of the function of the pituitary gland is expensive and represents a serious burden on the child's body, therefore, it is performed only according to strict indications. At the initial stage, any somatic pathologies that can cause growth disorders in children are excluded.
ECG and EchoCG diagnostics are performed to assess the state of the cardiovascular system. Pathologies of the gastrointestinal tract are diagnosed on the basis of the results of a biochemical blood test, abdominal ultrasound and X-ray examination (according to indications).
Next, a laboratory study of the function of the thyroid and other peripheral glands is performed, since it is technically easier to examine the peripheral glands than the central ones. Determine the level of thyroxine, glucocorticoids, sex hormones. This allows you to detect a possible decrease or increase in the function of any of these endocrine glands and start appropriate therapy. If the child has no abnormalities, screening for deficiency or excess of somatotropic hormone and insulin-like growth factors is carried out. In addition to laboratory diagnostics, at this stage, bone age is determined (R-gram of the hand and wrist joint), MRI of the child's brain, and a karyotype study.
If there is a suspicion of growth disorders in children associated with the metabolism of somatotropin, a single measurement of the level of its basal secretion is performed, as well as several stimulation tests. Growth hormone deficiency is confirmed at stimulated secretion levels below 7 ng/mL. A concentration of 7-10 ng / ml indicates a partial deficiency of somatotropin. This result usually speaks in favor of a point mutation in the growth hormone gene. Along with this, the concentrations of prolactin and thyroid-stimulating hormone are determined, since with some tumors and genetic mutations there is a multiple insufficiency of pituitary hormones. The tests are highly informative and allow the doctor to decide on the tactics of treatment.
Treatment and prognosis of growth disorders in children
Etiotropic therapy of diseases is carried out. If growth disorders in children are associated with hormonal causes, hormone replacement therapy is prescribed, or hormone antagonists are used, which are synthesized in excess. For the treatment of somatotropic insufficiency, synthetic somatotropin is used. Most hormone-producing tumors can be removed surgically. As a rule, relapses of such neoplasms are rare. Growth disorders in children with somatic diseases are corrected according to indications, however, in most cases, the treatment of the underlying disease leads to the normalization of physical development. All children must be prescribed a complete diet and vitamin therapy.
The prognosis is often favorable. In most cases, it is possible to compensate for the insufficiency of somatotropic and other hormones. One of the most important factors for successful treatment is the timely diagnosis of growth disorders in children, and it is very often impossible due to the weak severity of deviations from the norm or the presence of other, more dangerous symptoms. The slightest delay in the therapeutic correction of physical development can lead to a sharp decrease in the body's sensitivity to treatment. In addition, some causes of growth disorders in children, such as chromosomal disorders, cannot be eliminated.