RCRZ (Republican Center for Health Development MD RK)
Version: Clinical Protocols MH RK - 2017

Viral and other refined intestinal infections (A08), diarrhea and gastroenteritis of presumably infectious origin (A09), other bacterial intestinal infections (A04), other salinellase infections (A02), cholera (A00), Shigellosis (A03)

Infectious diseases in children, pediatrics

general information

Short description

Approved
Joint Commission for Medical Services
Ministry of Health of the Republic of Kazakhstan
from "18" August 2017
Protocol No. 26.

Bacterial intestinal infections- This is a group of human infectious diseases with enteral (fecal-oral) mechanism for infection caused by pathogenic (Shigella, Salmonella, etc.) and conventional pathogenic bacteria (protein, Klebsiella, Klostridia, etc.), characterized by preferably damage to the gastrointestinal tract and Manifested by intoxication and diarrhea syndromes.

Input part

Code (s) μb-10:

Classification

Classification :

Diagnostics

Methods, approaches and diagnostic procedures

Diagnostic criteria

Complaints:
· Fever;
· nausea, vomiting;
· Lost;
· stomach ache;
· Liquid stools 3 times or more than a day;
· Meteorism.

WHO and ESPGHAN / ESPID (2008, 2014) criteria (2008, 2014):

Estimation of a fluid deficit in a child for WHO:

The severity of dehydration in percentage of the body weight of the child to the disease

ESPGHAN recommends using a clinical dehydration scale (clinical dehydration scale - CDS), where 0 points - dehydration is missing, from 1 to 4 points - light dehydration, 5-8 points correspond to the dehydration of severe severity.

CLINICAL DEHYDRATION SCALE (CDS):

Laboratory research :
· OAK - leukocytosis, neutrophileenesis, acceleration of ESP;
· Coprogram: the presence of undigested fiber, mucus, leukocytes, erythrocytes, neutral fats;
· Bacteriological examination of vomit mass or washing the stomach and feces is released by pathogenic / conditionally pathogenic flora.

Additional laboratory and instrumental research:
· B / x Blood test: Concentration of electrolytes in serum, urea, creatinine, residual nitrogen, total protein (with dehydration);
· Coagulogram (in DVS syndrome);
· Bacteriological examination of blood and urine - the release of pathogenic / conditionally pathogenic flora;
· RPGA (RING) of blood with specific antigenic diagnosticums - the increase in antibody titers when re-reactions in 4 or more times.
· PCR - determination of DNA of intestinal infections of bacterial etiology.

Indications for consultation of specialists:
· Surgeon consultation - with suspected appendicitis, intestinal obstruction, intestinal invagination.

Diagnostic algorithm:

Differential diagnosis

Differential diagnosis And the rationale for additional research:

Treatment abroad

Treat treatment in Korea, Israel, Germany, USA

Get advice on medical examination

Treatment

Preparations (active substances) used in the treatment

Groups of preparations according to ATX, used in the treatment

Treatment (ambulatory)

Tactics of treatment on an outpatient level

On the outpatient level, the treatment is obtained by children with a light and medium-wing form (children over 36 months) Oki bacterial etiology.
The principles of treatment of patients with OKI includes: mode, rehydration, diet, pathogenetic and symptomatic therapy.
In the event of ineffectiveness of outpatient treatment or its inability, the question of the hospitalization of the child in the profile hospital is considered.

Non-drug treatment:
· Seuming regime (for the entire fever period);
· Diet - depending on the age of the child, its preferences in food and food habits before the start of the disease;
· Children on breastfeeding should be fed up to breast milk so often and so long as they want;
· Children on artificial feeding, continue to feed the usual nutrition for them;
· Children aged 6 months to 2 years - table number 16, from 2 years old and older - table number 4;

Medicia treatment
To relieve hyperthermic syndrome Over 38.5 0 s:
. Paracetamol 10-15 mg / kg with an interval of at least 4 hours, no more than three days through the mouth or PER RECTUM or IBUPROFEN in a dose of 5-10 mg / kg no more than 3 times a day through the mouth.

In diarrhea without dehydration - plan A:
· More often breastfeed and increase the duration of each feed, if the child is extremely breastfeeding, give an additional ORS or pure water in addition to breast milk.
· If a child is on mixed or artificial feeding, give the following fluids in any combination: ACC solution, liquid food (for example, soup, rice decoction) or clean water.
· Explain your mother how much fluid must be given additionally to the usual reception:
· Up to 2 years 50-100 ml after each liquid stool;
· 2 years and older than 100-200 ml after each liquid stool.
· Continue feeding;
· Advise your mother immediately deliver the child to the hospital, if any of the signs listed below will appear:
· Can not drink or suck the chest;
· The child's condition worsens;
· Fever appeared;
· The child has blood in a chair or he drinks badly.

When diarrhea with moderate dehydration - Plan b:
· The volume of the necessary ORS (in ml) can be calculated, multiplying the mass of the child (in kg) by 75.
· Pour the calculated liquid for 4 hours.
· If a child with a hunting solution is drinking an ARC solution and asks for another, you can give more than the recommended amount. Breastfeeding should be continued at the request of the child. Babies on artificial feeding in the first 4 o'clock food is canceled and carried out oral rehydration.
· After 4 hours, re-evaluate the child's condition and determine the status of hydration: if 2 or more signs of moderate dehydration are saved, continue the plan to 4 another 4 hours and give meals by age.
· In the absence of the effect of oral rehydration in the outpatient conditions of the patient, they are sent to inpatient treatment.
· With the substitution goal for the correction of the exocrine lack of pancreatic pancreatin 1000 units / kg / day during meals for 7-10 days.
· For the purpose of etiotropic therapy, Oci: azithromycin on the first day 10 mg / kg, from the second to the fifth day of 5 mg / kg once a day inside;
· Children over six years - Ciprofloxacin 20 mg / kg / day in two intakes within 5-7 days.

List of basic medicines :

Treatment (hospital)

Tactics of treatment at the stationary level
The basis of therapeutic measures at the Oka bacterial etiology is therapy, including: regime, rehydration, diet, means of etiotropic, pathogenetic and symptomatic therapy.

Oral rehydration is carried out in two stages:
· Stage I - in the first 6 hours after the patient's arrival, the water-salt deficiency occurs before the treatment of treatment;
· With dehydration I Art. The volume of the fluid is 40-50 ml / kg, and with dehydration II of Art. - 80-90 ml / kg of body weight in 6 hours;
· II Stage - supporting oral rehydration, which is carried out the entire subsequent period of the disease in the presence of continued loss of fluid and electrolytes. The approximate volume of the solution for supporting rehydration is 80-100 ml / kg body weight per day. The efficiency of oral rehydration is estimated according to the following features: decrease in fluid loss volume; reduce the speed of body weight loss; disappearance of clinical signs of dehydration; normalization of diuresis; Improving the overall condition of the child.

Indications for conducting parenteral rehydration and disintellation:
· Heavy forms of dehydration with signs of hypovolemic shock;
· Infectious-toxic shock;
· Neurotoxicosis;
· Heavy forms of dehydration;
· Combination of precision (either) with severe intoxication;
· Non-corrosive vomiting;
· The inefficiency of oral rehydration for 8 hours with a plan b or the transition of moderate dehydration to severe dehydration.

The program of conducting parenteral rehydration therapy in the first day is based on the calculation of the required amount of fluid and determining the qualitative composition of rehydration solutions. The required volume is calculated as follows:
Total volume (ml) \u003d FP + PP + D, where FP is a daily physiological need for water; PP - pathological losses (with vomiting, liquid chair, perpurement); D is a shortage of fluid that has a child before the start of infusion therapy.
The amount of fluid necessary to compensate for the existing fluid deficit depends on the severity of dehydration and is approximately determined on the basis of body weight deficiency. With an exaccosis of an I degree to compensate for the deficit, 30-50 ml / kg per day is required, with an exicose II of degree - 60-90 ml / kg per day, and with dehydration of the III degree - 100-150 ml / kg per day. The volume of the existing deficit is correcting gradually, only with dehydration of the I degree possible is possible a deficit for one day. For more accurate accounting of pathological losses, careful taking into account all external losses (vomiting, liquid chair) by measuring or weighing them. The replenishment of current pathological losses is carried out with pronounced massive losses every 4-8 hours, with moderate losses - every 12 hours.
The choice of starting solution of infusion therapy is determined by the degree of hemodynamic disorders and the type of dehydration. The pronounced hemodynamic disorders with all types of dehydration are corrected by balanced isosmolar saline salts (saline, solution of ringer, etc.), and if necessary, combined with colloidal solutions. The basic principle of infusion therapy in dehydration syndrome is that refunds of losses must be made of an infusion medium similar to the lost one.
No low-oolar solutions should not be used as a starting solution (5% solutions, low-osmolar polyionic solutions). In this regard, 5% dextrose solutions are most dangerous. First, due to their hyposmolarness; Secondly, glucose utilization is accompanied by the formation of "free" water, which further enhances intracellular hypershydration (danger of brain edema); Thirdly, the adhesion of glucose in fabric hypoperfusion leads to even greater lactate acidosis.

Map of patient surveillance, patient routing:

Non-media treatment[ 1-4 ] :
. Semiating mode (for the entire fever period);
. diet - depending on the age of a child, his preferences in food and food habits before the start of the disease;
. Children on breastfeeding should be fed up with breast milk so often and so long as they want;
. Children on artificial feeding, continue to feed the usual nutrition for them;
. Children aged 6 months to 2 years - table number 16, from 2 years old and older - table number 4;
. Children with lactose insufficiency are prescribed low / lactotic mixtures.

Medical treatment:
To relieve hyperthermic syndrome, over 38.5 ° C is assigned:
· Paracetamol 10-15 mg / kg with an interval of at least 4 hours, not more than three days through the mouth or Per Rectum;
· or
· Ibuprofen at a dose of 5-10 mg / kg no more than 3 times a day through the mouth;

In diarrhea without dehydration - Plan A, with moderate dehydration - Plan B.

With severe dehydration - Plan in: in / in liquid to a child<12 мес. 30 мл/кг в течение 1 часа, затем введите 70 мл/кг за 5 часов. Если ребенок ≥ 12 мес. в/в за 30 мин 30 мл/кг, затем 70 мл/кг за 2,5 часа. Повторяйте оценку через каждые 15-30 мин. Если статус гидратации не улучшается, увеличьте скорость капельного введения жидкостей. Также давайте растворы ОРС (около 5 мл/кг/ч) как только ребенок сможет пить: обычно через 3-4 ч (младенцы) или 1-2 ч (дети более старшего возраста). Повторно оцените состояние младенца через 6 ч, а ребенка старше одного года - через 3 ч. Определите степень обезвоживания. Затем выберите соответствующий план (А, Б или В) для продолжения лечения.

For the purpose of disinfecting therapy, intravenous infusion at the rate of 30 - 50 ml / kg / day with the inclusion of solutions:
· 10% dextrose (10-15 ml / kg);
· 0.9% sodium chloride (10-15 ml / kg);
· Ringer (10-15 ml / kg).

With the substitution goal for the correction of the exocrine lack of pancreatic pancreatin 1000 U / kg / day during meals for 7-10 days.
Antibacterial drugs are prescribed in age dosages, taking into account the etiology of the Oka. When choosing an antibacterial drug, the severity of the disease is taken into account, the age of the child, the presence of concomitant pathology and complications. If the temperature in a patient with confirmed Oci is not reduced within 46-72 hours, alternative methods of antimicrobial drugs should be considered.

Ethiotropic antibacterial therapy[ 1-5 ] :

· Azitromycin on the first day 10 mg / kg, from the second to the fifth day of 5 mg / kg once a day inside;
· Children over six years old Ciprofloxacin 20-30 mg / kg / day in two intakes within 5-7 days;
· Ceftriaxone 50-75 mg / kg per day in / m or V / B, to one gram - once a day, more than one gram - twice a day. Course of treatment 5-7 days; or
· Cefotaxim 50-100 mg / kg per day in / m or W / in, in two or three receptions. Course of treatment 5-7 days; or
· Amicacin 10-15 mg / kg per day in / m or V / in two receptions. Course of treatment 5-7 days; or
· Cefuroxime 50-100 mg / kg per day in / m or in / in two or three receptions. Course of treatment 5-7 days.

List of basic medicines[1- 5 ,11-18 ]:

Hospitalization

Indications for hospitalization indicating the type of hospitalization

Indications for planned hospitalization: not

Indications for emergency hospitalization:
· Children with severe and medigative forms (up to 36 months) viral gastroenteritis;
· All forms of the disease in children under the age of two months;
· Forms of a disease with severe dehydration regardless of the age of the child;
· Spending diarrhea with dehydration of either degree;
· Chronic forms of dysentery (with exacerbation);
· Heated premorbide background (presence, chronic diseases, etc.);
· Fever\u003e 38 ° С for children<3 месяцев или> 390 C for children from 3 to 36 months;
· Pronounced diarrheal syndrome (frequent and significant chair);
· Stubborn (repeated) vomiting;
· Lack of effect from oral rehydration;
· No effect of outpatient treatment for 48 hours;
· Clinical symptom complex of heavy infectious disease with hemodynamic disorder, insufficiency of the function of organs;
· Epidemiological testimony (children from "closed" institutions with a round-the-clock stay, from large families, etc.);
· Cases of the disease in medical organizations, boarding schools, orphanages, children's homes, sanatoriums, boarding schools for the elderly and disabled, summer recreational organizations, holiday homes;
· The inability to ensure proper home care (social problems).

Information

Sources and literature

1. Meeting Protocols of the Joint Commission on the Quality of Medical Services MD RK, 2017
   1. 1) Roberg M.Kliegman, Bonita F.Stanton, Joseph W.ST.Geme, Nina F.Schoor / Nelson Textbook of Pediatrics. Twentieth Edition. International Edition.// ELSEVIER-2016, Vol. 2-TH. 2) Passkin V.F., Nisevich N.I., Shamshieva O.V. Infectious diseases in children: textbook - Moscow, Gootar Media, 2011 - 688 p. 3) Treatment of diarrhea. Tutorial for doctors and other categories of senior health workers: World Health Organization, 2006 4) Providing inpatient assistance to children (WHO management to maintain the most common diseases in the primary level hospitals, adapted to the terms of the Republic of Kazakhstan) 2016. 450 s. Evrop. 5) Farthing M., Salam M., Lindberg G. et al. Acute Diarrhea in Adults and Children: A Global Perspective. World Gastroenterology Organization, 2012 // www.worldgastroenterology.org/ 6) WORLD Gastroenterology Organization (WGO). WGO Practice Guideline: Acute Diarrhea. Munich, Germany: World Gastroenterology ORGANISATION (WGO); 2008 mar.28p. 7) Implementation of new recommendations on clinical management of diarrhea. Guide for decision-making and software managers. Top 2012.// www.euro.who.int/__data/assets/pdf_file/0007/../9244594218r.pdf. 8) National Collaborating Center for Women "S and Children" S Health. DIARRHOEA AND VOMITING IN CHILDREN. Diarrhoea and vomiting Caused by GastroenTis: Diagnosis, Assessment and Management in Children Young Than 5 Years. London (UK): National Institute for Health and Clinical Excellence (NICE); 2009 Apr 9) CENTERS FOR DISEASE CONTROL AND PREVENTION. Salmonella Senftenberg Infections, Serbia. Emerging Infectious Diseases 2010; 16 (5): 893-894. 10) Majowicz SE, Musto J, Scallan E, Angulo FJ, Kirk M, O'Brien SJ, et al.; International Collaboration On Enteric Disese 'Burden of Illness' Studies. The Global Burden of Nontyphoidal Salmonella Gastroenteritis. CLIN INFECT DIS. 2010; 50: 882-9. http://dx.doi.org/ 10.1086 / 650733 11) Petrovska L, Mather Ae, Abuun M, Branchu P, Harris SR, Connor T, et al. MicroEvolution of Monophasic Salmonella Typhimurium During Epidemic, United Kingdom, 2005-2010. Emerg Infect Dis. 2016; 22: 617-24. http://dx.doi.org/10.3201/ EID2204.150531 12) Samuel J. Bloomfield, Jackie Benschop, Patrick J. Biggs, Jonathan C. Marshall, David T.S. Hayman, Philip E. Carter, Anne C. Midwinter, Alison E. Mather, Nigel P. Frenchlu J, Sun L, Fang L, Yang F, Mo Y, Lao J, et al. Genomic Analysis of Salmonella Enterica Serovar Typhimurium DT160 Associated with A 14-Year Outbreak, New Zealand, 1998-2012 Emerging Infectious Diseases www.cdc.gov/eid vol. 23, No. 6, June 2017 13) G. Gigante, G. Caracciolo, M. Campanale, V. Cesario, G. Gasbarrini, G. Cammarota, A. Gasbarrini Ospedale Gemelli, Rome, Italy; Fondazione Italiana Ricerca in Medicina, Rome, Italy Gelatine Tannate Reduces Antibiotics Associated Side-Effects of Anti-Helicobacter Pylori First- Line Therapy Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 14) Gelatin Tannate for Treating Acute Gastroenteritis: A Systematic Review Center for Reviews and Dissemination Original Author (s): Ruszczynski M, Urbanska M and Szajewska H Annals of Gastroenterology, 2014, 27 (2), 121-124 15) Esteban Carretero J , Durbán Reguera F, López-Argüeta Ál - Varez S, López Montes J. A Comparative Analysis Of Response to Ors (Oral Rehydration Solution) VS. Ors + Gelatin Tannate in Two Cohorts of Pediatric Patients with Acute Diarrhea. REV ESP Enferm Dig 2009; 101: 41-49. 16) a large reference book of medicines / ed. L. E. Ziganshina, V. K. Lepakhina, V. I. Petrova, R. W. Habrieva. - M.: Gootar Media, 2011. - 3344 from 17) BNF for Children 2014-2015 18) Order of the Minister of National Economy of the Republic of Kazakhstan dated March 12, 2015 No. 194. Registered at the Ministry of Justice of the Republic of Kazakhstan on April 16, 2015 No. 10741 Approval of the sanitary rules "Sanitary - epidemiological requirements for the organization and conduct of sanitary - anti-epidemic (preventive) measures to prevent infectious diseases"

Information

Organizational aspects of the Protocol

List of protocol developers:
1) Efendiyev Imdate Musa Ogly - Candidate of Medical Sciences, Head of the Department of Children's Infectious Diseases and Phthisiology, RGP on PVV "State Medical University of Families."
2) Baheeva Dynagool Ayapbekovna - Doctor of Medical Sciences, Associate Professor, Head of the Department of Children's Infectious Diseases, Astana Medical University JSC.
3) Kuttyukuanova Galia Gabdullaevna - Doctor of Medical Sciences, Professor, Professor of the Department of Children's Infectious, RSP Diseases on the Kazakh National Medical University. S.D. Asphendiyarova.
4) Davrdariani Hatun Georgievna - Candidate of Medical Sciences, Associate Professor of the Department of Children's Infectious Diseases, RSP on PVV "Karaganda State Medical University".
5) Zhumagaliyeva Galina Dautovna - Candidate of Medical Sciences, Associate Professor Head of Children's Infections, RSP on PFV "West Kazakhstan State University. Marat Ozapanova. "
6) Majitov Talgat Mansurovich - Doctor of Medical Sciences, Professor, Professor of the Department clinical pharmacology, JSC "Astana Medical University".
7) Komsheva Kumuscul Abdullayevna - Candidate of Medical Sciences, Associate Professor of the Department of Children's Infectious Diseases, RGP on PVV "Kazakh National Medical University. S.D. Asphendiyarova. "
8) Alshynbekova Gulsharbat Canhagatovna - Candidate of Medical Sciences, I.O.professor of the Department of Children's Infectious Diseases, RGP on PKV "Karaganda State Medical University".

Indication for the absence of conflict of interest:not .

Reviewers:
1) Kosherova Bakhyt Nurgaliyevna - Doctor of Medical Sciences, Professor RGP on PFV "Karaganda State Medical University" Vice Rector for clinical work and continuous professional development, professor of the Department of Infectious Diseases.

Note Protocol Review Conditions:revision of the Protocol 5 years after its publication and from the date of its entry into force or in the presence of new methods with the level of evidence.

Attached files

Attention!

• By self-medication, you can apply irreparable harm to your health.
• The information posted on the MedElement website and in MEDElement mobile applications, "Lekar Pro", "Dariger Pro", "Diseases: Therapist's Directory", cannot and should not replace a full-time doctor consultation. Be sure to contact medical facilities in the presence of any diseases or disturbing symptoms.
• The choice of medicines and their dosages should be stated with a specialist. Only a doctor can prescribe the necessary medicine and its dosage, taking into account the disease and the state of the patient's body.
• Website MedElement and Mobile Applications "MedElement (Medleylement)", "Lekar Pro", "Dariger Pro", "Diseases: Directory of Therapist" are exclusively information and reference resources. The information posted on this site should not be used for unauthorized changes to the doctor's prescriptions.
• The editorial office of MedElement is not responsible for any damage to health or material damage resulting from the use of this site.

Citation:Guarino A., Lo Vecchio A., Zakharova I.N., Sugan N.G., Israilbekova I.B. Tactics of children with acute gastroenteritis on chipboard: Implementing international recommendations in pediatrician practical // RMG. 2014. №21. Pp. 1483.

Acute gastroenteritis (OGE) occupies an important place in the structure of pathology in childhood, yielding in frequency and economic damage to only acute respiratory diseases and influenza.

In 2008, the European School of Children's Gastroenterologists, Hepatologists and Nutriciologists (ESPGHAN) (ESPID) (ESPID) (ESPID) (ESPID) published guidelines for children with OGE, including data on epidemiology, etiology, diagnosis and treatment of this pathology. This guide is updated in 2014 on the basis of these evidence-based medicine accumulated in recent years (Table 1).
Definition. OGE - a liquefied (liquid or unformed) chair and / or an increase in the frequency of the chair (more than 3 defecates in 24 hours), in combination or without fever or vomiting. At the same time, the change in the contestation of the chair is a clearer diarrhea indicator than the frequency of the chair, especially in the first months of the child's life. The duration of acute diarrhea should not be more than 7 days. You can talk about the prolonged course of gastroenteritis with more than 7 diarrhea durability, but less than 14 days.

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An important aspect of the etiological structure of the OCI in children is currently the change of dominant pathogens with bacterial for viral, among which the most significant is rotavirus infection. In the Resolution of the Chief State Sanitary Doctor of the Russian Federation G. G. Onishchenko dated 19.03.2010 No. 21 "On the prevention of acute intestinal infections" it was said: "Growth In recent years, indicators of the incidence of OKI, caused by the established bacterial and viral pathogens in the Russian Federation, is mainly due to Rotavirus infection, the incidence levels of which for the period 1999-2009. Grew almost 7 times. The proportion of said nosology in the structure of OCI increased from 1.4% to 7.0%. The most affected contingent at rotavirus infection is children under 14, constituting about 90% in the structure of pathology. " This fact determines the revision of the main therapeutic approaches in the Oka in children, in particular the correction of dehydration syndrome.

Dehydration syndrome is a leading pathogenetic factor with oki in children, causing the severity of the disease. Therefore, special significance for practical health care is acquired by the efficiency and correctness of the dehydration degree of dehydration in a child, a patient Oci. N. V. Vorotntseva, V. V. Maleeva, V. I. Pokrovsky according to the assessment of the severity of dehydration on the basis of the assessment of the acute loss of body weight of the patient preserve their relevance to the present: Exicosis of the I degree corresponds to a loss of up to 5% of body weight, which It makes up to 50 ml / kg of liquid, the degree of exicose - the loss of 6-10% of the body weight (60-100 ml / kg), the exicose of the degree III is the loss of more than 10% of the body weight (110-150 ml / kg). Dehydration with loss of body weight more than 20% is not compatible with life. However, in relation to pediatric practice, determining the child's body mass deficit against the background of the disease is not always possible due to the intensive growth of children, therefore the assessment of the degree of dehydration is carried out on the basis of clinical data. In this regard, the recommendations of the European Society of Pediatrics, Gastroenterologists and Nutritions (European Society For Paediatric Gastroenterology Hepatology and Nutrition, Espghan) from 2014 were currently widespread. However, they provide a clinical assessment only external view, the states of the eyeballs and mucous membranes, as well as the presence of tears in a child. A more complete clinical scale M. H. Gorelick further comprises determining the time of capillary reperfusion (normally no more than 2 seconds), reduction of diuresis, main hemodynamic parameters (frequency and tilling of the pulse) and respiratory disruption indicators. There are other scales of clinical assessment of dehydration severity. However, the significance of each of the symptoms of monitoring in clinical practice may not always be high enough, especially with an exicose I degree, which makes them most applicable in the exicosis of the II degree (Table 1).

When the ocoms in children prevail the isotonic type of dehydration, characterized by proportional loss of fluid and electrolytes, primarily sodium. At the same time, there is no change in the osmotic pressure of water in intracellular and extracellular spaces, which makes it difficult to determine the laboratory methods.

Objectivating the diagnosis of dehydration severity in children is possible using an algorithm that includes clinical (increasing the time of capillary reperfusion, determined by the clinically dryness of the mucous membranes), anamnous (severity of diarrhea and vomiting), instrumental (evaluation of humidity of the skin) and laboratory (deficiency of buffer bases of blood serum ) Data.

Also one of important aspects Pathogenesis, which is natural for the Oka of any etiology, is the development of disorders of the microflora of the gastrointestinal tract (gastrointestinal tract). It was previously shown that with dysentery of the zone in 67.8-85.1% of patients, with salmonellosis - in 95.1%, yersiniosis - in 94.9%, rotavirus infection - in 37.2-62.8% of violations of The sides of the tract microflora are pronounced.

Destabilization of the microbiocenosis GTS Against the background of the infectious process leads to a decrease in the colonization resistance of microflora, increase the severity of inflammatory reactions on the part of the intestinal mucosa and reduce the pace of reparative processes in the intestine, which leads to the exacerbation of intoxication syndrome due to the release of toxins not only pathogenic pathogens, but also representatives Conditional pathogenic microflora (UPB), whose share with OCI increases.

The main pathogenetic aspects of Oka are justified and therapeutic approaches - rehydration and probiotic therapy, from timeliness and adequacy of the appointment of which depend on the duration of the disease and its outcomes.

With the development of dehydration, the basic principle of conducting such patients is the rapid reimbursement of losses of fluid and salts, as well as an increase in the buffer capacity of the blood. It is generally recognized that in pediatric practice should be preferred to oral rehydration, as less traumatic and more physiological for the child. The international practice of applying oral rehydration at the skills was widely used since the 70s of the 20th century, and its inclusion in the standards of patients's maintenance allowed to reduce the number of hospitalization cases by 50-60% and significantly, by 40-50%, reduce children's mortality. However, the first recommendations that can be attributed to rehydration therapy and include the appointment of rice beam, coconut juice and carrot soup belong to the period more than 2500 years ago and belong to the ancient Indian doctor Sushruta. In 1874, in France, Dr. Luton was substantiated the appointment of additional water for the treatment of children, patients with Oka. For the first time, a solution, which included glucose, sodium and chlorine, proposed to use Dr. Robert A. Phillips, after opening the mechanism for the potentization of the absorption glucose in the intestine of sodium and potassium ions. In our country in the 30s-50s of the 20th century, the development of methods of rehydration therapy of Oki M. S. Maslov (1928, 1945, 1955), V. I. Morava (1937), V. E. Balaban (1937) was carried out. The basic principles of oral rehydration, the composition of solutions and methods for organizing assistance to patients with Oki in our country were developed by the Central Research Institute of Epidemiology under the leadership of V. I. Pokrovsky.

The general therapeutic approach to oral rehydration provides for the early appointment of rehydration solutions and is carried out in two stages:

• 1st stage - replenishment of losses that occurred until the appeal medical help. The total amount of liquid 50-80 ml / kg is prescribed for 6 hours;
• The 2nd stage is a supporting rehydration, the task of which is to replenish the current losses of the liquid during the Oka. On a day, 80-100 ml / kg of fluid is prescribed. The duration of the second stage of oral rehydration continues until the recovery or appearance of indications for parenteral dehydration correction.

According to current modern approaches, it is recommended that the use of finished forms of solutions balanced by electrolyte composition and osmolarity (75 MEKV / L sodium and 75 MEKV / L glucose and osmolarity 245 mosm / l) are recommended, with the value of the osmolarity of solutions recommended for pediatric Applications are paid great importance.

At the dawn of the introduction of the method into routine clinical practice in 1970, the World Health Organization recommended that the compositions with general osmolarity 311 mmol / l are recommended for oral rehydration. Despite their effectiveness in the correction of dehydration, the main disadvantage of these basic solutions was the lack of a positive effect on the diarrhea syndrome. One of the achievements proposed in 2004 of WHO was to reduce osmolarity of solutions for oral rehydration to 245 mmol / l, and sodium concentrations up to 75 mmol / l and glucose to 75 mmol / l. The principal difference of hyposmolar formulas for oral rehydration is that in previous solutions, osmolarity was higher compared to blood plasma, which did not contribute to a decrease in the volume of carte masses during diarrhea and could lead to the development of hypernatremia. In 2001, Seokyung Hahn was made by a metaanalysis of 15 randomized clinical studies conducted in various countries of the world, which showed that the use of solutions for oral rehydration with reduced osmolarity optimizes the absorption of water and electrolytes in the intestine to a greater extent than the use of hyperosmolar solutions, while There were no cases of clinically significant hyponatremia, except in cases of cholera.

It was also shown that this type of solutions reduces the need for infusion therapy, reduces the severity of diarrheal syndrome and vomiting and reduces the volume of solutions in the oral rehydration carried out, which is an important advantage for pediatrics.

It should be borne in mind that the correction of dehydration should be carried out using and nonsense solutions, among which preference should be given to drinking water (not mineral!), It is possible to use pectin-containing decoction (apple compote without sugar, carrot-rice decoction). The ratio of glucose-gas solutions and drinking water should be 1: 1 with a water diarrhea, 2: 1 with pronounced vomiting, 1: 2 with invasive diarrhea.

Heavy forms of Oka, lack of effect from oral rehydration or the presence of abundant vomiting, swelling, development of functional (acute) renal failure are indications for conducting parenteral rehydration, which can be carried out using one of the modern domestic solutions - a 1.5% solution of sodium sodium sodium, which has proved its effectiveness in intensive therapy for these states.

The pathogenetic substantiation of the need to use probiotic drugs at the Oka does not cause doubts both in the domestic and foreign literature. Probiotic therapy is recommended to prescribe in comprehensive starting therapy regardless of the etiology of the disease and in as early as possible. These drugs are also shown to all patients in the reconnaissance period in order to restore microbiocenosis parameters. Their use in children in children is not only pathogenetically reasonable, but also refers to high level Estimates - A - in accordance with the principles of evidence-based medicine. This fact was confirmed in 2010 by the results of metahanalya, which included the results of 63 randomized controlled clinical studies. It has been shown that the use of probiotics reliably reduces the duration of the diarrhea on average by 24.76 hours and reduces the frequency of the chair, while these drugs are characterized by a high security profile.

One of the pathogenetic mechanisms to recommend probiotics at the Oka is their positive effect on the mucine layer of the gastrointestinal mucosa. Against the background of the infectious process, a change in the physical characteristics of this barrier is observed - a decrease in viscosity due to the destruction of disulfide bonds between cysteine \u200b\u200bbridges of the superstructure of this gel, which can lead to translocation of microorganisms from the intestinal lumen in the tissue. These processes are developing under the action of pathogenic microorganisms that have appropriate pathogenic factors in the form of enzymes that destroy mucus (neuraminidase, hyaluronidase, mucinase). Long, including in the post-infectious period, change physical properties The mucin layer leads to the risk of developing inflammatory bowel diseases. Microorganisms related to components normal microflora The tract of the person, as well as the products of their exchange, have a potentiary effect on the state of the mucin layer through a variety of mechanisms, including genetic.

A modern look at therapy with probiotics involves a strain-specific approach, which includes the establishment in clinical studies of therapeutic effects characteristic of certain genetically certified strains and their further use, taking into account the strain-specific properties of probiotics in various clinical situations.

In relation to acute intestinal infections in children working group ESPGHAN In 2014, based on the analysis of published systematic reviews and results of randomized clinical research, including placebo-controlled, published a memorandum in which all probiotic strains were divided into probiotics with a positive recommendation, with negative recommendations and probiotics with insufficient evidence of their effectiveness. To the recommended strains (despite the low level of evidence in the opinion of experts) for the therapy of the eye in children were attributed Lactobacillus GG, Saccharomyces Boulardii, Lactobacillus Reuteri Strain DSM 17938 (source strain ATCC 55730), as well as thermally inactivated strain Lactobacillus Acidophilus LB.Formally to probiotics as living microorganisms with specified useful properties can not be available, but it has shown its effectiveness in acute infectious gastroenteritis.

Lactobacillus Reuteri DSM. 17938 is one of the most studied strains. This microorganism refers to the authentic for the human body - it is found in breast milk of man, inhabits in a colon of a person, is found in oral cavity, stomach, small intestine, vagina. In the intestines of man Lactobacillus Reuteri. produces an antimicrobial substance - "Reetterin", oppressing growth Escherichia.sPP. ., SalmonellasPP. ., ShigellasPP. ., Proteus.sPP. ., Pseudomonas.sPP. ., Clostridium.sPP. . and staphylococcussPP. . , as well as some yeast and viruses.

Strain Lactobacillus Reuteri DSM. 17938 Sustainable to the following antimicrobial means (Joint reception of probiotics is possible Lactobacillus Reuteri Protectis With these means): amoxicillin, ampicillin, augmentin, dyloxicillin, oxacillin, penicillin G, phenoxymethylpenicillin, cefuroxime, cephalotin, vancomycin, doxycycline, tetracycline, fusidic acid, ciprofloxacin, enrofloxacin, nylideglic acid, metronidazole. Lactobacillus Reuteri DSM. 17938 is sensitive to cefotaxim, neomycin, streptomycin, clarithromycin, erythromycin, roxitromycin, clindamycin, chloramphenicol, rifampicin, iminem, linesolid, virginiaminemicin.

Wherein Lactobacillus Reuteri DSM. 17938 is characterized by a good security profile, which is confirmed by the Food and Agricultural Organization of the UN (Food and Agriculture ORGANIZATION OF THE UNITED NATIONS, FAO) and WHO in 2002

Clinical efficacy Lactobacillus Reuteri DSM. 17938 is shown in functional colic in children of the first year of life, as part of complex eradication therapy H. Rylori.-Infection, prevention of antibiotic associated diarrhea, metabolic syndrome, in therapy of allergic diseases. The effectiveness of this strain is confirmed in 163 clinical studies in 14,000 patients, of which 114 - randomized, double / blind or blind placebo-controlled studies, 47 - open studies, 56 studies were carried out among 7,300 children 0-3 years of life.

However, the clinical effects of this strain at Oci were the most well studied, which was the reason for its inclusion in ESPGHAN Recommendation. So, in a multicenter randomized by a blind clinical study conducted among hospitalized with acute gastroenteritis children who received traditional therapy with or without 1 × 10 8 Lactobacillus Reuteri DSM. 17938 for 5 days, it was shown that the purpose of this probio strain reduces the duration of diarrhea after 24 and 48 h (50% in the main group against 5% in the comparison group, P< 0,001) и 72 ч (69% против 11%, р < 0,001), позволяет уменьшить сроки госпитализации (4,31 ± 1,3 дня против 5,46 ± 1,77 дня, р < 0,001) и снизить вероятность развития затяжного характера диареи (17% в группе сравнения и ни одного пациента в основной группе) . Аналогичные данные были получены и в других исследованиях .

Considering the above, it can be concluded that at present in the Russian Federation, the only low-lit-andary glucosolesale rehydration solution containing Lactobacillus Reuteri DSM. 17938, is a biogo oss (biologically active additive). This solution has a therapeutic effect on two main pathogenetic areas - to correlate both dehydration and disorders of the microbiocenosis during the children in children. It is important to emphasize that, in addition to glucose, salts and probiotics, the biogo ORS contains a zinc that has a positive effect on water absorption, which will also potentiate the processes of immunological protection and participates in the regeneration processes.

In terms of composition and osmolarity, the combination of salts Biogi ORS complies with the recommendations of the European society of pediatricians, gastroenterologists and nutritionists, as well as WHO and UNICEF on oral rehydration at light and middle degrees of dehydration (Table 2).

The effectiveness of this combination is Lactobacillus Reuteri DSM. 17938 and solutions for oral rehydration - was confirmed in a prospective placebo-controlled study, where a decrease in 84% of children with dehydration for the second day of receiving this combination was shown.

Thus, combination therapy with a probiotic and low-grade solution for oral rehydration (biogo ORS) in children without age limitations is not only pathogenetically substantiated, which has proven its undoubted efficiency and safety in controlled clinical studies, but also the most promising direction in the treatment of acute diarches of any etiology, Significantly reduced polypragmazia.

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A. A. Plovenia 1, candidate of Medical Sciences
A. V. Gorelov,doctor of Medical Sciences, Professor, Corresponding Member of the Russian Academy of Sciences