The basics of proper nutrition for children under 1 year old, the tasks of a doctor to ensure proper nutrition.
Adaptation (in medieval Latin, adaptatio – adaptation), in biology – the adaptation of living organisms to changing conditions of existence as a result of changes in morphological and physiological characteristics and behavior. Adaptation is also called the habituation process.
Throughout the early childhood period, the child has to adapt to changing nutritional conditions: adaptation to milk nutrition; adaptation to mixtures; adaptation to the introduction of complementary foods; adaptation to the introduction of common table elements.
Immediately after the birth of a child, the supply of glucose through the hemotrophic pathways stops. The transition from hematrophic to dairy nutrition in the early days of life is a complex chain of interrelated processes. Lactotrophic nutrition in the early period of life is the basis for all metabolic processes. Moreover, lactotrophic nutrition, which is an analogue and continuation of hemotrophic nutrition, is a source of substances and stimuli that serve directly for the development and growth of all functional systems of the child’s body. That is why replacing breastfeeding with artificial or mixed feeding can be regarded as a gross interference in the metabolic processes of the newborn’s body, in fact, a metabolic catastrophe.
The next phase in the development of the child’s autonomous nutrition is associated with the introduction of complementary foods. This phase is a complex and rather lengthy adaptation process. Acquaintance of the child with new food takes quite a long time, and normally only by 1.5 – 2 g there is a complete replacement of mother’s milk with ordinary products.
The introduction of complementary foods with an insufficient degree of maturity for intensively growing organs is another metabolic catastrophe with possible adverse consequences. Thus, a child can survive two metabolic disasters: the first when transferred to mixed or artificial feeding, and the second with the early introduction of complementary foods. Criteria for the readiness of children for the introduction of complementary foods are extremely important, and a sufficient length of time for this introduction to ensure optimal metabolic adaptation. There are certain physiological and biochemical substantiations of the most optimal time for the introduction of complementary foods (Table 1).
As can be seen from the data table, it is not advisable to administer complementary foods to a child earlier than 3 to 4 months of life, since before this age he is not physiologically prepared for the assimilation of food other than human milk or its substitutes. Therefore, according to most researchers, the first complementary foods should be introduced in the period from 4 to 6 months of age. However, according to the prevailing practice in Russia, before the introduction of the “main” feeding, children begin to receive fruit juices. In accordance with the feeding scheme approved by the USSR Ministry of Health in 1982 and currently officially operating in Russia, the introduction of fruit juices is recommended from 3 to 4 weeks of age.
However, numerous data (including our own observations) show that children who were injected with juices up to 3 – 4 months showed disruptions of adaptation in the form of intestinal dysfunction (the appearance of “greenery”, mucus in feces, impaired emptying, etc.) , skin rashes, and intestinal dysbiosis developed. There is no need for early introduction of juices, which, like other types of complementary foods, should be introduced no earlier than 4 months.
Specialists working in the field of pediatrics and baby food have three main tasks:
· Pay maximum attention to supporting breastfeeding and ensuring full lactation in mothers;
· To achieve the maximum efficiency of artificial feeding (supplementary feeding and complementary feeding), ensuring adequate growth and development and resistance of children to the action of unfavorable external factors;
· Introduce new products in such a way as not to cause a breakdown of adaptation, “metabolic catastrophe”, and as a result the development of atopic dermatitis.
Preservation and stimulation of lactation.
Natural feeding is a physiological phenomenon for mother and child and therefore cases of true milk deficiency (hypogalactia) are rare. The most responsible for the development of lactation in the mother is the first 3 – 4 months after childbirth. You can recommend the following rules necessary for successful feeding:
· Early attachment of the baby to the breast (in the delivery room);
· Desirable mode of free feeding (at the request of the child);
When introducing complementary foods or supplements, to prevent the extinction of lactation, it is recommended to put the baby to the breast at the end of each feeding;
· If milk is not enough, it is necessary to breastfeed the baby more often. It must be remembered that every drop of mother’s milk is priceless for a nursing baby. However, frequent attachment to the breast can enhance the production of milk in the breast;
· Provide a lactating woman with a balanced diet. The exclusion of many products (fermented milk, meat, fish, vegetables and fruits, protein foods) is not justified;
· Adequate drinking regimen: a nursing woman should drink 150-200 ml of liquid 30 minutes before feeding and 20-30 minutes after feeding. You can drink: compotes, fruit drinks, juices, tea, tea with milk, mineral water without gas. It is undesirable to use: sweet sparkling water, whole cow’s milk. From alcoholic drinks you can: low alcohol or non-alcoholic beer (up to 500.0 per day), a glass of dry wine or champagne (without gas);
· To provide a nursing woman with mental comfort, absence of psychoemotional stress and iatrogenic influences (rash statements of medical workers can significantly reduce lactation);
· Prevention of inflammatory diseases of the mammary gland, for which it is advisable to periodically (1 time in 2 to 3 months) check the milk “for sterility” – microbiological purity, i.e. conduct bacteriological examination of breast milk and therapeutic measures as necessary;
· Prevention of stagnation, for which it is recommended to fully express milk in case of excess. Strained milk can also be used for subsequent feedings;
· The correct interpretation of lactational crises that can occur in any period of lactation and be accompanied by a short-term decrease in lactation and the appearance of anxiety in a child, stool reduction. With adequate measures, lactation is restored within 5-7 days, i.e. a return to the usual lactation regimen occurs, while premature introduction of supplementary feeding can cause inhibition of lactation;
· If breast milk infection is detected, do not stop breastfeeding, but carry out treatment, if possible, without the use of antibiotics;
· If a nursing woman is prescribed antibiotic therapy for some reason, firstly, choose an antibiotic from a special “allowed” list (ampicillin, penicillin, oxacillin, etc.), and secondly, prescribe a prophylactic course of probiotics to the child to reduce the risk of developing him intestinal dysbiosis. As our experience shows, in this case, dysbiosis from the use of antibiotics for the child is almost not threatened;
· Individually decide on the appropriateness of the use of any medication by a nursing woman, if possible, avoid taking them.
With a tendency to a decrease in lactation, it is possible to use such agents as mlecaine, apilak, apilactin, femilak, wrapping the breast with warm cabbage leaf before feeding.
The maximum effectiveness of artificial feeding.
In our opinion, there are three interrelated criteria for the adequacy of breastfeeding:
1. The weight gain of the child is at least 600 g on average for 1 month (counting from the birth weight).
2. The interval between feedings is at least 2.5 hours.
3. The amount of mother’s milk eaten by the child corresponds to the need: 1/5 of the actual weight – up to 1 month; 1/6 – 1/7 of real weight up to 5 – 6 months. The amount of food eaten by a child can be found out by conducting a control weighing, and not once, but during the day (and preferably several days in a row).
If all of the above criteria correspond to the normal above, then the child’s nutrition is adequate, and up to 4–5 months, such a child does not need to change food (introduce supplementary feeding and complementary foods). If there are deviations, then you need to find out whether they are associated with diseases or dysfunctions (including intestinal dysbiosis), or the reason is a lack of breast milk.
If breast milk is not enough to ensure adequate feeding of the baby, the question arises of the introduction of supplementary feeding. The concept of supplementary feeding includes formulas – breast milk substitutes.
Substitutes of breast milk are divided primarily by the degree of their approximation to the composition of breast milk into two large groups: adapted and partially adapted. The adapted substitutes are the closest to human milk in all its components: they have a reduced total protein content compared to cow’s milk (up to 1.4 – 1.6 g / 100 ml), and the protein component is represented by a mixture of casein (the main protein of cow’s milk). milk) and whey proteins (dominant in human milk) in a ratio of 40:60 or 50:50. This is close to their ratio in mature human milk (45:55). Whey proteins in the stomach under the influence of hydrochloric acid form a much more delicate and finely dispersed clot than casein, which provides a larger area of contact with digestive enzymes and, as a result, a higher degree of digestion and assimilation.
The main carbohydrate in most breast milk substitutes is lactose, which has a number of properties that are physiologically important for babies. It promotes the absorption of calcium, has a bifidogenic effect (i.e., the ability to support the growth of bifidobacteria), lowers the pH in the large intestine. Its last two properties are due to the fact that most of the lactose (up to 80%) is not absorbed in the small intestine and enters the large intestine, where it serves as a substrate for B. bifidum and lactobacilli, under the influence of which it is fermented to form lactic acid.
The mixtures that are maximally adapted to human milk in all their components include: Nutrilon (Nutricia, Netherlands), Nan (Nestlé, Switzerland), Humana-1 (Humana, Germany), HiPP-1 (HiPP, Austria), SMA ( White Nutrition Intern., USA), Galia-1 (Danone, France), Semper Baby-1 (Semper, Sweden), Frisolak (Friesland, The Netherlands) and others. Bona and Tutteli mixtures (Nestlé, Finland) are very close to them in composition. ) and Piltti (Valio, Finland), however, not containing taurine and carnitine. A feature of the mixtures Similak (Abbott Laboratories, USA) and Nestogen (Nestlé, Netherlands) is their protein component: unlike all the above adapted mixtures, in which whey proteins predominate, casein dominates in these mixtures, which accounts for 80% of the total protein product. At the same time, casein is subjected to a special treatment that increases its digestibility. The composition of the necessary components of casein formulas is also as close as possible to the composition of human milk. This circumstance, as well as the well-known literature data on the high efficiency of casein formulas in the nutrition of children of the first year of life and at the same time the similarity of blood aminograms of children receiving both types of mixtures, allow us to classify casein formulas as adapted mixtures that can be used in the nutrition of children with the first days of life.
The high content of mineral salts in cow’s milk, kefir and other non-adapted whole-milk products leads to a significant load on the tubular apparatus of the kidneys, disturbances in the water-electrolyte balance, increased excretion of fats in the form of calcium salts, etc. This is one of the reasons why non-adapted dairy products do not recommend in our country to children of the first 6 – 8 months of life, and in the USA – and throughout the first year. Unadapted dairy products (milk, kefir, etc.) do not correspond to the physiological characteristics of children in the first year of life and should not be included in their diet until 6 – 8 months of age even in very difficult socio-economic conditions.
It should be emphasized that the ingredient and chemical compositions of all modern breast milk substitutes that meet international standards are fairly close to each other. At the same time, there are frequent cases in practice when a child gives pronounced allergic (pseudo-allergic) reactions to one of the most modern adapted mixtures, but tolerates another mixture of the same generation. This indicates the need for maximum individualization of the nutrition of children and the rejection of any ready-made templates and standards when prescribing infant formula to a child. The criterion here can be only the results of careful observation of the child in dynamics and the assessment of his tolerance to a particular product, of course, provided that the doctor has clear ideas about its composition.
The need to expand the baby’s nutrition and supplement mother’s milk (or its substitutes) with other products (complementary foods) is due to the following main factors:
· The need for additional introduction into the body of a growing child of energy and a number of nutrients, the
intake of which only with human milk (or its substitutes), starting from a certain stage of development of infants (usually from 4-6 months), becomes insufficient;
· The appropriateness of training and developing the digestive system of children;
· The need for training and development of the chewing apparatus;
· Expediency of stimulation of intestinal motor activity.
A balanced diet for a child from 6 months to 1 g should include:
3/4 of the total daily volume – protein foods (breast milk, mixtures – substitutes for breast milk, cereals, dairy products);
1/4 of the total daily volume – fiber (vegetables, fruits in the form of mashed potatoes or in another form);
+ 10 ml x age (month) per day – juice;
+ 50.0 per day – cottage cheese;
+ 1/2 yolk 2 – 3 times a week;
+ 50.0 per day of meat or fish.
Ensuring maximum safety when introducing new products, preventing the development of atopic dermatitis.
Adaptation of the child to the introduction of new products is largely due to the normal composition and functioning of the intestinal normoflora. This position follows from the above functions of normoflora and the role of normal biocenosis. Taking into account that the main carbohydrate of breast milk – lactose – is broken down with the active participation of bifidobacteria and lactobacilli, their presence in sufficient quantities is necessary for adaptation to both breast milk and lactose-containing artificial mixtures. The presence of lactose in baby food is the basis of all metabolic processes, so the replacement of milk formulas with lactose-free is not physiological.
Thus, dysbiosis can be the cause of the so-called adaptation diseases, which include the skin reaction to the introduction of new products that occurs in children of the first year of life. This reaction is officially designated as atopic dermatitis, and parents use the term “diathesis”. The appearance of atopic dermatitis on the introduction of supplementary foods or complementary foods is based on the failure of adaptation. In turn, the failure of adaptation caused by dysbiosis or improper administration of a new diet leads to aggravation of dysbiosis, a vicious circle occurs. The result may be persistent intestinal dysbiosis, the development of a deep imbalance and the formation of a chronic disease that can continue for many years to come.
Atopic dermatitis is a chronic recurrent inflammatory skin disease, manifested by intense itching, sympathetic skin reaction, papular rashes and severe lichenification in combination with other signs of atopy.
Among the etiological factors leading to the development of atopic dermatitis, they indicate sensitization to food allergens, especially in childhood. This is due to congenital and acquired disorders of the digestive tract, improper feeding, early introduction of highly allergenic foods into the diet, intestinal dysbiosis, the presence of a high UPF titer, a violation of the cytoprotective barrier, etc., which contributes to the penetration of antigens from the food gruel through the mucous membrane into the internal environment of the body and the formation of sensitization to food.
Food allergy is of the greatest importance in the development of atopic dermatitis in young children, and proteins of cow’s milk, eggs, and fish are causally significant allergens. Accordingly, one of the main postulates of the treatment was the exclusion of a huge number of foods from the child’s diet, which often led to gross metabolic disorders. This issue was actively discussed at the first International Symposium by Gerg Raik (Davos, Switzerland, 1998), where some scientists noted the absence of IgE antibodies in almost half of children with atopic dermatitis. According to our data, the absence of an increase in IgE level in food reactions in children of the first year of life is much more common than its increase. Most likely, the central moment in the development of atopic dermatitis is not just an increase in IgE, but a disturbed regulation of this immunoglobulin. A decrease in the synthesis of interferon gamma, which blocks IgE production, can trigger the development of atopic dermatitis. It was found that the concentration of gamma-interferon in the blood is lower in children at risk who developed atopic dermatitis in the 1st year of life than in children without atopy, although the IgE levels in these children did not differ significantly.
The state of the gastrointestinal tract plays a significant role in the pathogenesis of reactions to food and atopic dermatitis. The connection of non-atopic eczema with infectious agents, in particular, with staphylococcal, streptococcal infections, fungi of the genus Candida, hemolytic E. coli and other representatives of UPF, has been proved. A study involving 100 outpatients confirmed the prevalence of different types of staphylococci at 88%. In other studies, data have been obtained that the cleavage products of staphylococcal enterotoxin and other microorganisms are highly homologous to the IgE receptor. Significance for skin inflammation may be associated with the attachment of microbial enterotoxins to B-lymphocytes, which stimulates IgE synthesis, causing secondary hypersensitization. In addition, the waste products of microorganisms – toxins can accumulate in the child’s body. They are neutralized by bacteria of the normal flora, and in addition by the pancreas, liver, causing their reactive inflammation, as well as the phenomenon of dysbiosis, which in turn reduces the quality of digestion and affects the breakdown and absorption of vital nutrients.
Very often, inflammatory skin rashes are caused by a violation of intestinal motility (spastic colitis), which leads to severe constipation, and is often a consequence of intestinal dysbiosis. Being in the intestine sometimes for several days, the feces, decomposing, form ammonia, ammonia acids, which in turn also creates endotoxemia syndrome.
A particularly important role in the development and exacerbation of allergic dermatoses is played by the diet. Very often, when single rashes appear on the skin, doctors exclude valuable nutritional components from the child’s diet, without replacing them with anything, which leads to a pronounced violation of all types of metabolism and the functional state of many body systems, which require sufficient amounts of proteins, fats and carbohydrates. Moreover, an exacerbation of the disease is often caused not by the product itself, but by a violation of its splitting and absorption. For the full breakdown and absorption of food, the normoflora of the intestine is again responsible.
The persistence of microbiological disorders in the intestine, along with such factors as hereditary predisposition, disorders of higher nervous activity, autonomic nervous system, disorders of the activity of internal organs, metabolic, neurohumoral, neurovascular disorders, malnutrition, various intoxications, the influence of unfavorable environmental factors leads to a chronic recurrent course atopic dermatitis.
In connection with the above, the importance of preventing allergic problems in early childhood becomes obvious, when the child is especially vulnerable. The basis of such prevention is the correct introduction of new products in order to avoid a breakdown in adaptation and maintain the balance of the intestinal normal flora.
Much has been said about maintaining the balance of the normal flora in the previous chapters of this book. It should be noted the main dates when it is necessary to conduct a planned microbiological study of feces to identify and correct deviations in children of the first year of life:
By 1.5 – 2 months: by this time the first stage of the formation of the biocenosis ends;
By 4 – 5 months: before starting the introduction of complementary foods;
After 6 months (at 7 – 8 months): when many of the complementary foods are introduced, teeth begin to erupt;
· After 1 g: control.
In addition, biocenosis studies are possible after replacing food, taking antibiotics, microbiological correction (not earlier than after 2 to 3 weeks).
The correct introduction of new products is discussed in the next section.
Rules for the introduction of feeding and complementary foods.
The basic principle when introducing any new product is gradual; start with very small doses of new food.
Another important principle of feeding is the stability of basic nutrition. This applies to adapted formulas – breast milk substitutes. If a child receives an adapted mixture as a supplement, it is undesirable to change it to another similar adapted mixture so as not to overload the child’s adaptive capabilities. Supplementation is introduced gradually, and if within 7 to 10 days there is no pronounced deterioration in the child’s condition, the mixture does not need to be changed. In some cases, when the child cannot properly absorb the adapted mixtures, therapeutic nutrition may be temporarily introduced (Frizovoi for constipation and regurgitation; Al-110 for lactase deficiency; hypoallergenic mixtures (Humana-GA) for severe dermatitis, etc. .), which also needs to be introduced as gradually as possible. We consider soy food and hydrolysates to be non-physiological baby food that leads to metabolic dysfunction, therefore we do not recommend such food as a supplement, but, if possible, we recommend replacing it with medicated or adapted formulas. Usually, adaptation disorders are associated with intestinal dysbiosis, and after its correction, it is possible and necessary to gradually switch from medical nutrition to an adapted milk formula.
There is reason to believe that human biological evolution in recent decades has lagged behind the evolution of the environment. Therefore, most children are born with adaptation disorders or significant prerequisites for such disorders (dysbiosis,
which appears at an early age in most children). Therefore, children of the first year need to introduce new products much more carefully than in previous generations. A more careful introduction of supplementary feeding or complementary foods will not harm the child in any way, and there will be no lack of nutrients and vitamins. At the same time, the careful introduction of a new product will minimize the risk of developing atopic dermatitis and other disruptions in adaptation in a child.
Even if the baby is substantially deficient in breast milk, the gradual feeding is justified and the risk of malnutrition is potentially less dangerous than the risk of failure to adapt. Our experience shows that children who were supplemented with supplementary foods or feeding were immediately administered in large numbers, in most cases had more pronounced disorders of the intestinal biocenosis, accompanied by functional decompensation, including manifestations of atopic dermatitis than children to whom new nutrition was introduced gradually.
THE LESS THAN THE INITIAL DOSE OF THE NEW PRODUCT IS, THE SLOWER IT IS INCREASED, THE LESS THERE IS THE LOWER THE PROBABILITY OF ATOPIC DERMATITIS.
This rule can be illustrated by a physical education example. In order not to “rip” the muscles, but to effectively “pump up”, you need to gradually increase the load. This also applies to the work of the pancreas, the immune system and other adaptation mechanisms. At the same time, one must not forget that in a child during the first months of life, these mechanisms are underdeveloped and the load must be adequate. The younger the child is, the more carefully any new product is introduced.
A NEW PRODUCT IS PLEASED TO BE INTRODUCED AT THE END OF FEEDING, IF POSSIBLE MIXING WITH THE HABITUAL FOOD.
New products are introduced into those feedings in which it is planned to use them in the future. Dokorm (adapted mixture – a substitute for breast milk) can be administered several times a day, and any kind of complementary foods is administered only once a day. In this case, a physical culture analogy can also be applied: during physical training, the muscles are first “warmed up”, and only then they are given a load. Enzymatic systems, the intestines also need to “warm up”, begin to work actively, digesting familiar food. The introduction of a new product at the end of feeding will not catch the baby’s body by surprise, in addition, it will be easier for the baby to get used to new taste sensations. When the amount of a new product reaches 30.0 – 50.0 (with the correct introduction – by 7 – 10 days), and the child adapts to this product, you can give such a product at the beginning of feeding.
After the child has eaten the usual food, a new product should be dripped into the mouth from a pipette or given on the tip of a teaspoon or mixed with the “last spoon” of the usual food. Day after day, the portion of the product increases.
ENTER NO MORE THAN ONE NEW PRODUCT IN 7 – 10 DAYS.
It takes time to adapt to a new product: at least one week. Adaptation is better if it is adaptation to one impact. If at the peak of adaptation to one effect a new effect occurs that requires adaptation, then this can lead to a breakdown. This applies not only to nutrition: it is undesirable to introduce new products 3 days before or 3 days after vaccinations, in the first week of teething, during acute respiratory infections and other acute diseases, as well as in the first 10-14 days of corrective measures for intestinal dysbiosis . In addition to facilitating adaptation, compliance with this condition provides information on the individual tolerance of the introduced new product.
TO EVALUATE THE COURSE OF ADAPTATION AND INDIVIDUAL TOLERANCE OF A NEW PRODUCT ON CHANGES IN THE CHAIR, SKIN, BEHAVIOR AND FEELING OF THE CHILD.
First you need to evaluate the initial state according to these criteria before introducing a new product. When starting to introduce a new product with micro doses, evaluate the changes. If deterioration from the initial state is noted (the appearance or intensification of skin rashes; changes in stool: impaired emptying, thinning, the appearance of mucus or “green”; anxiety or regurgitation), and if these disorders are mild, you do not need to cancel the administered product immediately: you can time (2 – 4 days) to continue giving this product without increasing the portion. Thus, the digestive systems can adapt, which will be manifested by a return to the original state, in which case the gradual introduction of a new product can be continued. If the manifestations of the failure of adaptation are pronounced, or after deterioration there is no return to the initial state, the new product is canceled. After canceling the product that caused the adaptation to fail, for some time (up to 1 week) it is advisable not to introduce other new products, and then continue the introduction of complementary foods. You can return to the product that did not fit the child after 3 – 4 weeks, introducing it again gradually.
It is very important to follow these guidelines when you first try to introduce new products. In the future, the child’s adaptive capabilities are enhanced, and new products can be introduced at a faster pace, but, as before, with caution.
These rules may seem unnecessarily strict, however, in our opinion, caution and even reinsurance when introducing new products to a child under 1 g will not hurt. There will not be much harm if the introduction of complementary foods is delayed, all the same, the child will receive all the food components he needs for development. And the risk of failure of adaptation with the subsequent development of intestinal dysbiosis and atopic dermatitis with inaccurate introduction of new products in children of the first year of life increases many times.
When introducing complementary foods, it is desirable to give preference to ready-made baby food, adapted or partially adapted. Addiction to such products occurs more smoothly than to products of their own preparation. In turn, when adaptation to “canned” nutrition has occurred, it will be easier for a child to adapt to non-adapted products. Baby food does not contain preservatives and other harmful additives, enriched with vitamins, balanced in composition, but you can be sure of this only by purchasing it in specialized stores or baby food departments.
In some cases, the recommendations on the timing of administration indicated on the packaging of baby food (especially for juices and mashed potatoes) do not correspond to physiological capabilities (see table. 1). Regardless of the recommendations of the company, the manufacturer of baby food, you must remember that the introduction of any complementary foods is undesirable up to 4 – 5 months, and such products as cottage cheese, meat, fish – up to 6 – 7 months.
It should be borne in mind that in addition to the individual intolerance of certain products, the child may not like the taste of the food. In this case, the child will spit new food or refuse it. We believe that forcing a child to eat by force is wrong. You can use any of the ways that your child likes the food (for example, add fructose) or refuse this product (maybe temporarily, and then the child will treat this product differently).
If there is an intolerance to a particular product, you can find a replacement for it among similar ones. But if adaptation dysfunctions accompany the introduction of almost any complementary food product or a whole group of products is not digested (for example, dairy products, including lactose-containing mixtures), then, most likely, this is not a matter of nutrition, but of internal problems leading to disadaptation syndrome. Most often, according to our observations, dysbiosis is such a problem. Correction of microecological disorders leads to the restoration of the child’s normal adaptation to nutrition.
Cases from our practice can serve as illustrations for this section:
Egor T., 4 months. Diagnosis: atopic dermatitis. From the anamnesis it is known that almost immediately after birth, the baby was breast-fed: the Tutteli mixture was introduced, the mixture was introduced quickly (the first portion was 50.0; after 3 days, all feedings were replaced with this mixture). At the age of 1 month (by this time the child had been receiving the Tutteli mixture for 3 weeks), the child developed rashes on the face, and then all over the body, in connection with which the district pediatrician recommended replacing the milk formula with soy food. This replacement was carried out in 1 day. The manifestations of dermatitis at first decreased, but then a wave-like course began: pronounced exacerbations and incomplete short-term remissions alternated regardless of external influences. The food did not change anymore. The child was sent to the CDC MNIIEM named after G.N. Gabrichevsky for microbiological examination of feces and treatment.
In the study of biocenosis, the following results were obtained: the total amount of E. coli – 300 million / g, bifidobacteria – less than 107, lactobacilli – less than 105, UPF was not detected. These results are interpreted as intestinal dysbiosis (type I) 3 degrees.
Recommended: euflorins – L and B in a therapeutic dosage, course – 1 month, mezim-forte with gradual cancellation, starting from 1/2 tab 3 times a day – 3 weeks, instrumentation – 5 days. All drugs are prescribed from the first day of treatment. On nutrition, it is recommended: for the first 2 weeks of treatment, do not change anything (leave soybean nutrition, do not introduce complementary foods), then gradually replace soybean nutrition with milk formula, after completing the treatment, gradually introduce complementary foods.
In the course of treatment, the rashes gradually disappeared, the parents replaced the soy food with milk formula (Tutteli), then they introduced complementary foods without any problems. The normalization of the state was stable, and later the child had no rashes. In control studies of intestinal biocenosis, there were no violations of more than 1 degree.
Comment: as a result of a sharp introduction of supplementary feeding, the child suffered a failure of adaptation, which caused microbiological disorders (impaired adhesion of normoflora), aggravated by the fact of the absence of natural feeding. For some time the condition was clinically compensated, then decompensation occurred. The introduction of soybean nutrition could aggravate microecological disturbances, as a result of this – violation of the barrier function of the gastrointestinal tract. The process has acquired a wave-like course typical for atopic dermatitis, which does not depend on nutrition and other external influences. The fact that dermatitis did not disappear due to soy nutrition shows that the problem was not intolerance to milk protein or lactose. This is also evidenced by the problem-free administration of dairy products after the treatment of dysbiosis. The introduction of new products according to our rules prevented a new breakdown in adaptation and the development of dysbiosis, which allowed the child’s body to develop physiologically. Also, this case characterizes an increase in adaptive abilities with age (the same mixture caused (albeit with the wrong introduction) a breakdown in adaptation at 1 month, but was introduced without problems at an older age).
Ivan S., 3 months. Diagnosis: atopic dermatitis. Eruptions in the form of crusts, hyperemia and oozing on the cheeks, behind the ears, on the arms and legs. The study of biocenosis was not carried out according to the method of R.V. Epstein-Litvak and F.L.Vilshanskaya: the total number of Escherichia coli is 6×108; hemolytic Escherichia coli – 4×105; coccal flora (enterococci) 5×106; Staphylococcus aureus 3×105; bifidobacteria – 109, lactobacilli – 107.
The greatest interest in this case is the anamnesis. The rash appeared on the cheeks and behind the ears at 1 month, a few days after the start of the introduction of the fermented milk supplement “Agu”. First, hyperemia of the cheeks appeared, then the rash began to crack and get wet, then similar phenomena appeared on the skin of the arms and legs. We linked the appearance of atopic dermatitis and dysbiosis with a sharp and, in our opinion, untimely introduction of complementary foods.
Recommendations:
15pt; TEXT-INDENT: -14.15pt; TEXT-ALIGN: justify “> 1. Cancellation of “Agu” (at 6 months “Agu”, as planned, was introduced again, carefully, in compliance with our recommendations outlined above – the introduction passed without any breakdowns in adaptation), gradually the fermented milk mixture was replaced with an adapted milk mixture (Frisolak ).
2. Prescribed enzymes – abomin according to the scheme: 1st week: 1 tab x 3 times a day; 2nd week: 1/2 tab 3 times a day; 3rd week: 1/4 tab 3 times a day; 4th week: 1/8 tab 3 times a day.
3. Ketotifen 1/4 tab 2 times a day – 30 days (necessary to interrupt the inadequate immune response of the still unformed immune system of an infant).
4. Correction of dysbiosis – KIP 1 bottle in the morning 30 minutes before meals – 5 days, bifidumbacterin and acylact 5 doses 1 time per day in the evening 30 minutes before meals – 15 days (probiotics are prescribed with a supporting purpose).
5. Externally: celestoderm with haramycin 1 time per day, in a thin layer, only for rashes. Lubricate daily, but not more than 10 days in a row, until the skin manifestations disappear. Lubricate the face only until the itching and weeping disappear (2 – 3 days). In addition to the hormonal ointment, apply Radevit and Tsindol.
6. Bathe with baby foam for bath with chamomile (for example, Penaten, Bubchen), treat the skin with baby cream with vitamin E.
7. Carefully follow the recommendations for the introduction of complementary foods.
All treatment was started simultaneously. The effect was received in the first week. In the control analysis of the intestinal microflora (after 60 days from the start of treatment), UPF was not detected, autoflora was within normal limits. Atopic dermatitis finally disappeared after 2 weeks and did not appear in a long follow-up (up to 1 g).
Evgeniya V., 4 months. Diagnosis: atopic dermatitis. The rash appeared from 3 months, when the child was on mixed feeding (breast milk more than 2/3 of the daily volume and the “HiPP – 1” mixture). Supplementation was introduced at 2.5 months. Feeding is gradual.
Revealed intestinal dysbiosis: the total amount of Escherichia coli – 300 million / g; lactose-negative enterobacteriaceae – 75% (Klebsiella, E. aerogenes), hemolyzing Escherichia coli – 33%; bifidobacteria – less than 107, lactobacilli – 105 (intestinal dysbiosis grade 3).
Recommended: do not change food (leave the same mixture and breast-feed as much as possible); to correct dysbacteriosis: instrumentation – 10 days, combined pyobacteriophage – 7 days (inside and rectally), primadofilus – 1 month + after the course of the bacteriophage euflorin – L and euflorin – B, 5 doses each 1 time per day – 20 days, mezim – forte with a gradual dose reduction – 3 weeks. It is also recommended not to introduce complementary foods until the end of treatment.
After the treatment course, the rashes disappeared and did not resume anymore, the effect was persistent (more than 1 g), no dysbacteriosis was detected in the control study, the introduction of complementary foods according to our scheme did not cause any deterioration in the condition of the baby, up to 1 g the baby received breast milk.
Commentary: This case illustrates that in atopic dermatitis associated with intestinal dysbiosis, it makes no sense to refuse breastfeeding and adapted milk formulas, since the dermatitis is not caused by nutrition. In this case, other factors were the cause of dysbiosis, dysbiosis could cause a violation of adaptation to nutrition (including breast milk and adapted formulas), and correction of dysbiosis led to the normalization of the child’s adaptation to nutrition, which made it possible to introduce complementary foods without problems.
Irina Yu., 7 months Diagnosis: atopic dermatitis, gastrointestinal dysfunction, intestinal dysbiosis. From the anamnesis it is known that at 3 months, when the child was only breastfed, it was recommended to gradually introduce apple juice, and then applesauce. Shortly afterwards, the child developed rashes on his cheeks. The local pediatrician associated the appearance of dermatitis with intolerance to breast milk (in addition, there were epidermal staphylococci in the amount of 600 CFU in each breast). The doctor categorically stated that mother’s milk is harmful to the baby, after which lactation decreased sharply. Parents were forced to sharply introduce an artificial mixture (“Nan”). The dermatitis got worse and more common. After that, several more milk and sour milk mixtures were tried, the child’s condition progressively worsened. As a result, the child was transferred to soybean nutrition, in addition, all types of complementary foods were excluded. After switching to soy food (at 4.5 months), the child’s bowel movement was disturbed: there was no spontaneous emptying, the stool became thick, gray-green. At the same time, the child became very restless, and dermatitis was widespread (almost all of the skin), with a tendency to oozing. After 3 weeks, the child was transferred to a protein hydrolyzate mixture (Frisopep). Nevertheless, there was no improvement, in addition, the child became more anxious, put on weight worse. By the age of 7 months, the child received “Frizopep”, not a single food product, was lagging behind in physical development, he had severe atopic dermatitis with weeping, lack of independent bowel movement, and by this time not a single preventive vaccination was given.
In a microbiological study, pronounced intestinal dysbiosis (grades 3 – 4) was noted: the absence of normal flora, the presence of UPF up to 100% (including S. aureus), as well as fungi of the genus Candida – 106.
Comment: This is an example of iatrogenicity. The introduction of complementary foods was unjustifiably early, when the child was not functionally ready for this, which led to a breakdown in adaptation. This breakdown was misinterpreted, and harsh statements about the dangers of mother’s milk (although this is completely untrue) led to the loss of lactation due to psychological stress. Then the principle of stability of basic nutrition was violated, which aggravated the syndrome of adaptation disorder. Further, another medical error was made: the introduction of non-physiological nutrition was recommended, which not only exacerbated the problems, but also led to the emergence of new components related to the non-receipt of the necessary food components for the child. Severe dysbiosis most likely developed as a result of a deep metabolic imbalance that arose due to impaired adaptation to nutrition and malnutrition. Dysbacteriosis, in turn, exacerbated the imbalance and impaired adaptation.
Recommendations:
1. Before treatment, gradually introduce adapted milk formulas instead of the hydrolyzate: Frizolak and Frizovoy (therapeutic mixture recommended for constipation). Replace in 5 – 7 days. (The recommendation to normalize nutrition first seems to us a prerequisite for the restoration of normal flora, at the same time, the replacement of nutrition should not cause another failure of adaptation, so it should be carried out gradually).
2. Carry out a course of treatment: KIP – 10 days, combined pyobacteriophage – 7 days (inside and rectally) and nystatin – 7 days at age-specific dosages, mezim-forte – 3 weeks with a gradual dose reduction, ketotifen 1/4 tab 2 times a day – 1 month, enterosgel – 7 days (to bind UPF decay products resulting from the action of bacteriophage and nystatin). After the end of the bacteriophage course, connect euflorins at 10 doses per day – 1 month.
3. After 3 weeks from the start of treatment, vaccinate (Tetracoccus vaccine is recommended), adding suprastin to the treatment 3 days before vaccination, 1/4 tab 2 times a day – 7 days.
4. After 3 – 5 days after vaccination, start the introduction of complementary foods, observing all the requirements of gradualness and adaptation.
As expected, replacing the hydrolyzate with adapted mixtures did not lead to a worsening of the condition (although there was no improvement before the start of treatment either). During treatment, a wave-like course was noted: sometimes better, sometimes worse (which was also expected). After 3 weeks from the start of treatment, the severity of dermatitis significantly decreased, the child became calmer, gained good weight (+1200.0), but constipation persisted. As recommended, a prophylactic vaccination was made with the Tetracoccus vaccine; 3 days after the vaccination, a short-term exacerbation of dermatitis was noted, but it quickly passed. At the end of the treatment, the introduction of complementary foods began, which occurred without sharp deterioration. After the introduction of a sufficient amount of puree, the child recovered independent bowel movement. 1 month after the end of treatment, the child continued to have moderate dermatitis (peeling, slight hyperemia on the cheeks; in other places, the skin is clean), the child emptied normally, reached age-related levels of physical development, and was calm.
In the control study (1 month after the end of treatment), the following indicators were noted: the total number of E. coli – 160 million / g; bifidobacteria – 108; lactobacilli – less than 105; the total amount of UPF is 33%. The fact that the final restoration of the biocenosis did not occur did not surprise us, since after a pronounced and sufficiently long imbalance, rarely one course is enough for a complete recovery and normalization of all functions.
Supportive treatment was recommended, including: primadofilus – 1 month, euflorin – L, 5 doses per day – 20 days, CIP – 5 days, repeated course of mezim-forte. After this course, the rashes on the skin finally disappeared, and in the next microbiological study the result obtained corresponded to the norms. The child normally assimilated any product, including dairy products. The effect was lasting.