A Modern Approach to the Rehabilitation of Children in the First Years of Life with Functional and Borderline Conditions

The dissertation is devoted to the development and substantiation of modern approaches to the rehabilitation of children in the first years of life who have functional and borderline conditions, including those who experienced intrauterine hypoxia. The efficacy and advisability of the use of substances of natural origin — homeopathic preparations and biologically active complexes — in programs of prevention, treatment, and rehabilitation of this category of patients are investigated. The key areas of the work are dysbiotic disorders of the intestine in children of early and preschool age, phosphorus-calcium metabolism disorders (rickets prevention), and the consequences of posthypoxic ischemic encephalopathy. Clinically substantiated algorithms for diagnosis and therapy using minimally invasive examination methods, aimed at reducing the pharmacological load on the child's organism, are proposed in the work.

The protection of maternal and child health is a priority area designated in the National Program "Children of Russia," as it largely determines the future of the nation (13, 39, 223). Under contemporary socio-economic conditions in Russia, the reduction of state attention to social problems, the sharp limitation of financing for healthcare and medical science, has led to a significant decrease in the number of healthy children: in various regions it ranges from 4 to 10% (13, 236, 251). Over the past five years, the morbidity among newborns has increased by 26.2% (14), among children up to 14 years of age — by 23%, and among adolescents — by 26% (236). The last decade is characterized by substantial shifts in the physical development of children, with a decline in their functional capabilities. The deterioration of children's health has entailed a growing accumulation of negative medico-social consequences. Visceral, metabolic disorders, and nutritional disturbances are severe consequences of diseases of internal organs, congenital malformations, and hereditary abnormalities, the origins of which lie in the perinatal period. In terms of age, these disorders, arising during early childhood, develop in 63.1% of cases by the ages of 10 to 17 (13).

A certain concern is also caused by the constant increase in the number of children belonging to the 2nd health group. According to data from the 2002 All-Russian Dispensary Survey, only 32.1% of children were recognized as healthy (1st health group); 51.7% had functional deviations (2nd health group); 16.2% had chronic diseases (3rd health group). The 2nd health group comprises children at risk who have a predisposition to the development of various diseases, as well as children who have experienced in utero, during birth, or in the first days of life some disease (condition) and who exhibit manifestations of a borderline state (131). By transitional (borderline) states, one should understand conditions reflecting the process of adaptation to new living conditions. In most cases, these conditions are characterized by reversibility. However, they are termed borderline because, although generally physiological for a newborn, under certain conditions they may acquire pathological features and transform into a disease (205).

An analysis of existing methodological approaches to the treatment of most diseases indicates that pharmacotherapy, to this day, constitutes the foundation of comprehensive treatment and rehabilitation programs. Modern medicine is capable of successfully treating a number of serious illnesses. However, to prevent disease and to create an individualized program of prevention and rehabilitation is, unfortunately, not always possible (239). It is also necessary to note that under current conditions the efficacy of pharmacotherapy is not always sufficiently high, and at times an excessive number of medications is prescribed, which is not without consequence for the young patient (6, 4, 3, 45). The economic situation that has developed in the country by the present time, the progressive deterioration of public health, including that of children, have determined one of the directions for the improvement of healthcare and medical science in the Russian Federation as the introduction of low-cost technologies and the development of inpatient-replacing forms of care (12, 13, 14, 39, 40).

Over the past several years, several steps have been taken to rectify the situation: the National Program "Children of Russia" (1993) has been adopted. Since 2003, the sub-program "Healthy Child" has been included in it and is funded. If in the federal budget for 2003, 1.5 billion rubles were allocated in total for the program "Children of Russia," then in 2004 the appropriations for its implementation were increased and amounted to 1.79 billion rubles (251).

In 2001, parliamentary hearings on "The National Strategy for the Protection of Children's Health in Russia and Its Legal Support" were held in Moscow (140). The recommendations of these hearings state that in a civilized society it is necessary to form a special value-based moral and legal practice regarding the best safeguarding of children's interests. At the same time, it was noted that the protection of motherhood and childhood has not yet become a priority direction of contemporary state policy.

The leading task at the present stage should be the development and real implementation of comprehensive programs for the prevention of disability in children, beginning, above all, with the protection of motherhood, since there exists a clear dependence between the features of adaptation of newborns, indicators of their physical development, morbidity in the first year of life, and the state of the mother's health, the presence in her of perinatal risk factors (39, 223). The period of neonatal life and the first year of life deserve particular attention as the most significant and initial periods for determining the child's future health.

The late 20th century was a period of reassessment of the attitude toward the use of methods of traditional folk medicine for therapeutic purposes: reflexotherapy, manual therapy, and phytotherapy, homeopathy, and homotoxicology. The popularity of traditional medicine is constantly growing (1, 67, 69, 91, 93, 97). On the one hand, a number of economists regard this process as a means of reducing healthcare expenditures (Serebryakov S.O., 2000; Agadzhanyan I.A., 1997). On the other hand, this form of therapy allows for an approach to treatment from the position of the organism as a whole and, as a rule, takes into account the individual characteristics of patients (23, 67, 69, 91, 93, 97, 139). Natural biologically active substances, in contrast to synthetic preparations, are more naturally incorporated into the metabolism of the human body, exerting no undesirable side effects, but rather producing regulatory, tonic, and immunomodulatory actions (69, 91, 93, 97, 139, 262, 282, 384). The particular interest in pediatrics is due to the fact that in treatment, substances of natural origin are used in small doses and according to individual indications, which, compared with generally accepted methods of treatment, are characterized by a milder (gentler) load on the organism (91, 93).

Fundamental medical-biological investigations conducted in our country and abroad over the past 10-15 years have provided scientific substantiation for the various positive effects of the use of biocomplexes and homeopathic medicinal preparations and have created the necessary prerequisites for their broader application in medical practice. However, works substantiating, from the position of evidence-based medicine and using objective methods of investigation, the use of substances of natural origin in children in the first years of life with functional and borderline conditions are insufficient. Moreover, there are no works in which algorithms for the prescription of these preparations in children of the 2nd health group, particularly those who have experienced perinatal pathology, are presented.

All of the above has determined the OBJECTIVE of our investigation: to study the efficacy and advisability, as well as to develop methods and algorithms for the use of substances of natural origin in the prevention, treatment, and rehabilitation of children in the first years of life with the most commonly encountered borderline and functional conditions.

Based on the stated objective, the following TASKS were formulated:

1. To conduct a multifactor analysis of the state of health of children of early and preschool age with an aggravated perinatal history and their mothers in contemporary conditions.

2. To determine the prevalence of dysbiotic disorders of the intestine in children in the first years of life and the features of their clinical-laboratory presentation.

3. To evaluate the significance of biochemical parameters of feces (volatile fatty acids and their isoforms) and the level of secretory immunoglobulin A in coprofiltrates for a comprehensive assessment of the efficacy of correction of intestinal dysbiosis.

4. To develop a comprehensive program for the correction of dysbiotic disorders of the intestine in children in the first years of life using substances of natural origin and to evaluate its efficacy.

5. To study the clinical-laboratory efficacy of the complex preparation Hepel in treatment and rehabilitation programs in premature infants.

6. To identify the features of the course of phosphorus-calcium metabolism disorders in children in the first year of life under contemporary conditions, and to develop a new approach to the prevention of these disorders.

7. To establish the features of the clinical manifestations of posthypoxic ischemic encephalopathy. On this basis, to develop an algorithm for the use of the complex preparation Traumel S and to evaluate its clinical efficacy in children in the first year of life with hemoliquordynamic distension who experienced acute and chronic intrauterine hypoxia.

8. To evaluate the efficacy of the use of the complex preparation Cerebrum-Compositum in rehabilitation programs in children with manifestations of posthypoxic ischemic encephalopathy and minimal brain dysfunction.

SCIENTIFIC NOVELTY. For the first time, from the position of evidence-based medicine, on the basis of clinical, biochemical, microbiological, immunological, and comprehensive ultrasonic examination data, the advisability of including homeopathic preparations and biologically active complexes in programs of prevention, treatment, and rehabilitation of children in the first years of life with functional and borderline conditions has been substantiated.

For the first time, the content of volatile fatty acids and their isoforms in the feces of premature infants has been studied, and the level of secretory immunoglobulin A in coprofiltrates in children of early and preschool age has been established.

The advisability of using the determination of volatile fatty acid levels and secretory immunoglobulin A in coprofiltrates in children for assessing the degree of dysbiotic disorders in the composition of intestinal microflora and determining the efficacy of their correction has been demonstrated.

As a result of the conducted investigations, the clinical-microbiological features of the course of dysbioses in children of early age have been identified, and a comprehensive program for the correction of this condition has been proposed.

For the first time, differentiated approaches to the prevention of phosphorus-calcium metabolism disorders in children of early age using substances of natural and plant origin have been determined. The insufficient efficacy of modern rickets prevention programs using vitamin D has been established. Criteria for evaluating the efficacy of rickets prevention measures in children using non-invasive research methods in outpatient settings have been developed.

The advisability of using the biocomplex "Children's Sea Calcium" in children in the first year of life for the correction of phosphorus-calcium metabolism disorders has been scientifically substantiated.

On the basis of longitudinal observation and data from comprehensive ultrasonic investigation (neurosonography, Dopplerography of cerebral vessels), the phased development of structural and vascular changes in the central nervous system has been established, and a differentiated approach to the prescription of complex homeopathic preparations for the prevention and treatment of hemoviscoplastic disorders in children of early age who experienced intrauterine hypoxia has been developed; the clinical-instrumental efficacy of this form of therapy has been demonstrated.

For the first time, the necessity of conducting, in children of early age who experienced acute and/or chronic intrauterine hypoxia, in addition to neurosonography, Doppler mapping of cerebral vessels has been substantiated, which allows for early diagnosis and timely treatment of the consequences of posthypoxic ischemic encephalopathy.

The conducted investigation has made it possible to clarify the features of the clinical manifestations of the aforementioned laboratory and instrumental research methods for intestinal dysbiosis, rickets, and posthypoxic ischemic encephalopathy in children of early and preschool age at the present stage, as well as to determine new opportunities in the prevention and treatment of these conditions.

PRACTICAL SIGNIFICANCE AND IMPLEMENTATION OF THE RESEARCH RESULTS. The practical significance of the work is determined by the fact that it presents the features of the clinical course of intestinal dysbiosis, rickets, and the consequences of posthypoxic ischemic encephalopathy in children of early and preschool age at the present stage.

Qualitatively new approaches to the diagnosis, prevention, and treatment of these conditions using substances of natural origin have been presented.

Criteria for evaluating the efficacy of the proposed program using non-invasive research methods, which are neither costly nor difficult to perform, have been developed and can therefore be used in the primary healthcare link.

The implementation of the obtained results in the work of pediatric departments of polyclinics and hospitals has made it possible to optimize care for children in the first years of life who experienced intrauterine hypoxia, suffer from intestinal dysbiosis, and have phosphorus-calcium metabolism disorders, while simultaneously reducing the pharmacological load on the child's organism.

The advisability of using traditional methods in rehabilitation and treatment programs for children of early and preschool age has been established.

The research results have been reported at 27 congresses, meetings, symposia, and conferences of republican and local significance, including at the 8th and 9th Congresses of Russian Pediatricians (1998, 2001); the Moscow International Homeopathic Conference (2001); the 8th Congress of Russian Pediatricians (2003); the "Man and Medicine" congresses in 2002 and 2005; the 57th International Congress of the Homeopathic League (2002); the 1st and 2nd Russian Congresses of Pediatric Infectiousists (2002, 2003); the 2nd All-Russian Congress of Pediatric Allergology (2003), and others, in 11 cities — Moscow, St. Petersburg, Baku, Voronezh, Yaroslavl, Kostroma, Saratov, Krasnodar, Kaluga, Penza, and Cheboksary.

The research results and practical recommendations derived from them have been implemented in the practical work of DIB No. 4, DKB No. 38 of the Federal Management of Medbioextrem under the Ministry of Health of the Russian Federation, Izmailovskaya DKB No. 3, children's polyclinic No. 103, children's polyclinic No. 80 of the Southern Administrative Okrug, and are also used in the educational process at the departments of hospital pediatrics of the Moscow Faculty with a Course of Postgraduate Medical Education (headed by Professor L.I. Ilyenko) and the Department of Children's Diseases No. 3 (headed by Professor V.F. Demin) of RGMU.

PUBLICATIONS. Fifty-seven scientific works on the dissertation topic have been published, including 2 informational letters approved by the Department of Healthcare of Moscow and the Chief Pediatrician of Moscow, corresponding member of RAMN Professor A.A. Rumyantsev; 2 textbooks approved by the Methodological Association for Medical and Pharmaceutical Education of Russian Universities, and 1 physician's guide approved by the chairman of the section of the Academic Council of the Ministry of Health of Russia on epidemiology, infectious diseases, and virology, academician of RAMN Professor V.I. Pokrovsky.

The results of the work formed the basis of materials that received Diploma Laureate awards of RGMU in 1996 and 2004, and were included in the project "Healthy Child — Moscow, Russia, and the Whole World!", which was awarded the Gold Quality Mark "Russian Brand" in 2003. The author holds Author's Certificate No. 1743607 for the invention "Method of Prevention of Intestinal Dysbacteriosis in Newborns" dated March 5, 1990.