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

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

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

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

3) third - stabilization of microflora (up to 1 month). The intestinal microflora is a complex, dynamically balanced ecosystem. Contains more than 500 different types of bacteria. 1 g of feces contains more than 1011 bacteria. Intestinal microflora is subject to frequent disturbances under the influence of unfavorable factors. Most of the intestinal microorganisms are the so-called obligate (indigenous) microflora (bifidobacteria, lactobacilli, non-pathogenic Escherichia coli, etc.). 92-95% of the intestinal microflora consists of obligate anaerobes.

Facultative (UP and saprophytic) microflora is unstable, has no significant biological functions, and is represented by bacteria - Citrobacter, Micrococcus, Proteus, yeast-like fungi, Clostridia. The composition of the intestinal microflora is quite individual and is formed in the first days of a child’s life. An important factor in the formation of normal intestinal microflora is natural feeding. Human milk contains a large amount of substances that contribute to the colonization of the intestines by certain types of microorganisms in certain quantities (staphylococci, etc.). The composition of the intestinal flora of a child after two years is practically no different from 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 respectively 1, 10, 100 and 1 thousand in 000 ml of intestinal contents.

Functions of the intestinal microflora.

1. Protective:

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

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 the maturation of the lymphoid apparatus of the intestine and the synthesis of Ig;

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 normal intestinal flora during antibiotic therapy. Produce B vitamins and folic acid. Reduces urea levels in the blood. Act as immunomodulators. Reduce blood cholesterol levels. Intestinal dysbiosis is always secondary. It occurs as a consequence of changes in the internal environment of the intestine, as well as 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 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 facultative strains that are not part of the resident microflora: Proteus, Morganella, Klebsiella, Enterobacter, Citrobacter, Hafnia, E. coli with enzymatic deficiency and hemolyzing properties, Pseudomonas. Factors influencing the state of the gastrointestinal mucosa: diseases that change the internal environment of the intestine (oxygen content, enzyme composition). Antibiotic therapy (rational and irrational).

Functional disorders of intestinal motility.

1. Immunodeficiency states.

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

3. A protein diet has virtually no effect on the range and number of intestinal bacteria.

Causes of microbiocenosis changes.

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

2. Acute infections of extraintestinal localization.

3. Chronic inflammatory and allergic diseases

4. Leukemias and other malignant processes.

5. Post-radiation syndrome.

6. The use of cytostatics and antibiotics. Classification of dysbacteriosis.

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

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

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

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

Clinical picture of intestinal dysbiosis: loose or unstable stools mixed with mucus, greens, or particles of undigested food. Less commonly - constipation, regurgitation, vomiting, flatulence, rumbling along the intestinal loops. Abdominal pain (not constant) Thrush, coated tongue; hyperemia around the anus. Anorexia, poor weight gain. Clinical forms of dysbacteriosis.

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

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

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

Examination plan and diagnosis of dysbiosis: hemogram, extended coprogram, cytocoprogram, bacteriological examination of stool, stool pH; sugar curve, trypsin activity, biochemical blood test; elimination tests (exclusion of gluten, dairy products, sweet vegetables and fruits); determination of sweat chlorides, ultrasound of the abdominal organs.

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

1) intestinal dysfunction after the use of antibacterial drugs;

2) prolonged period of convalescence after OKA;

3) chronic intestinal disorders without isolation of pathogenic bacteria;

4) food allergy;

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

6) irritable bowel syndrome. Stages of correction of dysbacteriosis:

1) diet therapy;

2) normalization of intestinal microflora;

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

4) restoration of normal digestion;

5) relief of 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 number 3 - stimulating intestinal motility.

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

2. Adding bran to food, wholemeal bread.

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

Diet therapy for diarrhea. Recommended.

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

2. Slimy rice and oatmeal soups; rice, oatmeal and semolina porridge; fresh cottage cheese, dishes from boiled vegetables; omelettes, soft-boiled eggs; jellies, mousses and juices from quince, pear, dogwood, carrots, black currants and blueberries.

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

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

Limited: vegetable fiber and sugar (no more than 40 g per day).

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

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

2. Non-concentrated broths, fish soup, scrambled eggs, boiled or baked potatoes.

3. Using cloves, bay leaves, pepper. Prohibited: 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, spasms and pain in the distal intestines). Recommended.

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

2. From the 3rd day - dry cookies, white bread crackers. From the 5th-6th day, rice porridge with water and fermented milk products.

3. In the future - a vegetable diet. Prohibited: protein foods and coarse fiber. Limit: fats.

Antibacterial drugs: do not disturb the balance of microbial flora in the intestines - 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. Enterosediv contains streptomycin, bacitracin, etc. Dpendan, containing furazolidone and metronidazole.

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

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

Requirements for dietary supplements that must contain one or more nutritional components: vitamins, minerals, herbs or other plants, amino acids. Not intended to be used as a staple food or sole source of nutrition. They are used only as a supplement to the main diet in order to increase the daily intake of certain nutritional components. Functional nutrition should be understood as food products ready for sale to which biological products have been added. Functional food is defined as a modified food that provides better health benefits than the original food. Functional foods include antioxidants, carotenoids, digestive enzymes, yoghurts and dairy products with added pro- and prebiotics. Mixtures containing pre- and probiotics (fermented milk products, fermented milk NAN with bifidobacteria, NAN 6-12 months with bifidobacteria). Mixtures with the addition of polysaccharide thickeners (for example, Frisov). Acidobeef is a food supplement for children over 1 year of age with lactase deficiency, milk protein intolerance and intestinal dysbiosis, containing lacto- and bifidobacteria. Eugalan forte is a food supplement for adults and children over 3 years old, containing bifidobacteria and lactulose.

Probiotics are preparations based on microorganisms (lyophilized powders containing bifidobacteria and lactobacilli). Probiotics are drugs and food products that contain substances of microbial and non-microbial origin. When administered naturally, they have a beneficial effect on the physiological functions and biochemical reactions of the body through optimization of its microecological status. Probiotics (eubiotics) are live, weakened strains of microorganisms: more often bifido-lactobacteria, less often yeast, which, based on the term “probiotic,” refer to the normal inhabitants of the intestines of a healthy person. The microorganisms that make up probiotics are contained in large quantities, are non-pathogenic, non-toxic, and remain viable when passing through the gastrointestinal tract and during storage. Modern requirements for probiotics: natural origin, resistance to gastric acid and bile, ability to colonize the intestines, antagonism to pathogenic bacteria. Confirmed clinical effect. Indications for the use of probiotics: diarrhea associated with antibiotics, infectious diarrhea, prevention of diarrhea, irritable bowel syndrome, gastrointestinal syndrome due to allergies, inflammatory diseases.

Probiotics - preparations, mono- and multicomponent preparations: bifidumbacterin, lactobacterin, bificol, colibacterin, primadophilus, floradophilus, bifinorm, subamin, bifidin, bifilin, biobacton, bifilong, linex, biofructolact, bactisubtil. Combined drugs: bifiform, bifi-zil, acipol, bifacid, bifidumbacterin-forte, fermented milk eubiotics bifidoc, bifikefir, lactofidus.

Prebiotics are indigestible food ingredients that help selectively stimulate the growth and metabolic activity of one or more groups of bacteria (lactobacteria, bifidobacteria) in the colon. For a food component to be classified as a prebiotic, it must not be hydrolyzed by enzymes and absorbed in the upper gastrointestinal tract. The prebiotic must be a selective substrate for bifidobacteria and lactobacilli. Prebiotic substances: 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) - suppresses the growth of pathogens and restores the biological environment. Calcium pantothenate helps increase the biomass of bifidobacteria. Pamba (para-aminobenzoic acid) promotes the growth of normal microflora. Lysozyme has mucolytic and bifidogenic properties and is active against gram-positive cocci.

Synbiotics are a mixture of probiotics and prebiotics that improve the survival and engraftment of living bacterial additives in the intestines and selectively stimulate the growth and activation of metabolism of indigenous bacteria. Examples of synbiotics: bifidumbacterin-forte, bifiliz, lactofidus, nutrolin B, vita and other biotherapeutic agents - contain substances and (or) living microorganisms that have therapeutic properties. Microorganisms used as biotherapeutic drugs include: Lactobacillus acidophilus, L. plantarum, L. casei, L. bulgaricus; Bifidobacterium longum, Enterococcus faecium. Probiotics are not considered therapeutic agents until clinical trials demonstrate their effectiveness. Biotherapeutic agents - drugs bifidumbacterin, lactobacterin, colibacterin, primadophilus, enterol, bactisubtil. Hilak forte - drops, calcium pantothenate and pamba.

Enterosorbents - smecta, bilignin, tannacomp, polysorb, polyphepan, espumizan. Prescribed for the correction of compensated dysbacteriosis. Children from birth can be prescribed probiotics containing bifidumbacteria. Clinical effectiveness is assessed 10 days after the end of therapy, microbiological - after 1 month. The number of bifidotherapy courses is 1-3. When the number of lactobacilli decreases, Linex, Acipol and Lactobacterin, Acylact are used. Acid-forming drugs are recommended - prebiotics that do not contain live bacteria: normase or hilak-forte (together with bifid drugs). You can use lysozyme, bifiliz. Correction of sub-compensated dysbiosis involves prescribing 3-4 courses of combined multicomponent drugs - bifido- and lactose-containing probiotics. Combination therapy with normase or hilak-forte is recommended only if the lactobacilli count is normal. In addition to lysozyme, CIP (complex immunoglobulin preparation) can be used. If there is no sufficient effect, chlorophyllipt can be used; sporobacterin, biosporin (or their analogue - bactisubtil). Correction of decompensated dysbiosis is a short-term (3-7 days) prescription of sorbents (carbolene, carbolong, vaulen, microsorb P, polyphepan, lignin, smecta). Use of 3-6 courses of bifido- and lacto-containing probiotics. If immunodeficiency has developed, immune drugs (interferon or reaferon, leukinferon, levamisole, etc.), enzyme preparations (mezim-forte, panzinorm, festal, pancitrate, creon) are prescribed for 1-3 weeks. For septic manifestations - the use of antibacterial therapy against the background of probiotics (for selective contamination - non-absorbable drugs, for secondary extraintestinal foci - resorptive drugs) - ercefuril, furazolidone aminoglycosides, erythromycin, macrolides, metronidazole; antifungal drugs.

Author: Pavlova N.V.

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