Perinatal encephalopathy with hypertension syndrome. What is encephalopathy: symptoms in newborns and children under one year old, treatment methods and prognosis for recovery. Treatment of the acute period

Perinatal encephalopathy in children under one year old, this is a pathology of the infant's brain, which the baby received when he was still in his mother's tummy, as well as in childbirth or in the first days of his life.

A pediatric neurologist observes a child with this diagnosis during the first year of life, prescribes treatment, and controls psychomotor development.

When the child turns one year old, the doctor finally decides whether the child will continue to be observed by a neurologist or whether he can be removed from the register because recovery has come.

What you will learn from this article:

Causes of perinatal encephalopathy

Hypoxia during pregnancy. Hypoxia is a lack of oxygen, which must flow through the umbilical artery to the brain of a developing fetus. The nervous system reacts extremely negatively to hypoxia. Ischemia of the brain tissue develops. Neurons or cells of the brain, as it were, suffocate. Perinatal encephalopathy is therefore also called hypoxic-ischemic.

Hypoxia develops with toxicosis or the threat of abortion. The stress that a young woman endures, work overload. Undesirable factors are acute respiratory diseases, taking various medications, intrauterine infections. And a number of other reasons.

Hypoxia in childbirth and birth trauma. Childbirth can be protracted or, on the contrary, rapid. Both of these are bad. There may be an early discharge of water and a long anhydrous period. Wrapping the umbilical cord around the baby's neck. Birth trauma to the brain or cervical spine can occur.

AT postpartum period the nervous system can suffer due to the incompatibility of the blood of the mother and child in terms of the Rh factor or blood groups, as well as inflammatory diseases.

Assessment of the state of the newborn child on the Apgar Scale

As soon as the baby is born, doctors evaluate his condition on the Apgar Scale. This scale includes several indicators for assessing vital important functions newborn: whether the child immediately and loudly screamed; what color is it skin; rhythmic or not very pulse, what is the respiratory rate and the state of muscle tone.

The best estimate of these indicators immediately after birth and after 5 minutes of life is 8/9 points. Less common is a score of 7/8 points. In these cases, the prognosis for perinatal encephalopathy is always positive. Alas, rarely, but there are newborns whose condition is estimated lower than 7/8 points. These kids need serious rehabilitation treatment in a dedicated hospital.

Psychomotor development of a healthy child up to a year

Each month lived by a child enriches him with new and new psycho-motor skills.

Per month healthy child holds the head for a few seconds when in vertical position. Follows a bright object. His face breaks into a rainbow smile from time to time. But anyway most he sleeps for days. He wakes up only when he is hungry, when his tummy swells and hurts, when he experiences any discomfort.

He has pronounced reflexes of a newborn, and movements in the handles are constrained, tense, muscle tone is increased.

By three to four months, the child already has a vivid reaction of revival when an adult talks to him affectionately. He laughs with might and main, actively moving his arms and legs, often hums. This is how he learns to speak. From the reflexes of the newborn is no longer a trace. He rolls over from his back to his stomach. Pulls up with the head and body when you pull on the handles while trying to sit up. But it's too early for him to sit down.

By 6 months, he knows his loved ones well and is very wary of strangers, he can easily cry. Starts to babble, repeats simple syllables "pa", "ba", "ma". Laughs, picks up toys, pulls in his mouth. Rolls over from tummy to back, trying to get up on all fours.

At 8 months he gets up in bed, and at 10-11 months he takes his first steps. By the age of one, he begins to walk independently, spreading his legs wide for stability, staggering. Already pronounces up to 10 simple words, knows the purpose of many objects. In general, this is a serious little man. And we love him more life!

Symptoms of perinatal encephalopathy

A child with perinatal encephalopathy develops with a moderate delay in psychomotor development. He later begins to hold his head, roll over, sit down, crawl, stand up, walk, talk. The symptoms that he develops can be grouped into several syndromes:

movement disorder syndrome- occurs more often than others. It is manifested by a violation of the formation of muscle tone. If normally, physiological muscle hypertonicity completely disappears by 3 months and movements in the handles become smooth, the child begins to grab toys, transfer them from handle to handle, pulls them into the mouth, then with encephalopathy, muscle hypertonicity persists for a very long time. In the legs, it is manifested by the fact that the child leans on his toes, presses his fingers.

There is also the opposite picture, when the muscles are too relaxed, the tone in them is too low. The arms and legs move weakly, soft as rags. This is myatonic syndrome. Gradually, with repeated courses of massage, muscle tone is also restored.

Hypertension syndrome and an increase in the size of the ventricles of the brain - the appearance of symptoms here is associated with an increase in intracranial pressure. The child has frequent regurgitation, a large fontanel bulges out, he is restless, sleeps poorly. The eyes are turned down and a white strip of the cornea of ​​the eyeball appears at the top - a symptom of Graefe.

There may be mixed forms. Less commonly, syndromes pediatric neurologist also never miss.

What does an ultrasound of the brain tell us?

At the slightest suspicion of the presence of perinatal encephalopathy, each child undergoes an ultrasound examination of the brain, and in some cases, the cervical spine.

Ultrasound can show whether all parts of the brain are correctly formed or not; can reveal the presence of posthypoxic changes in the brain tissue; will show an uneven increase in the ventricles and subarachnoid spaces, the presence of brain cysts, instability of the cervical vertebrae.

Treatment of perinatal encephalopathy in children

Used for treatment drug therapy: nootropic and vasodilator drugs; diuretic drugs; soothing herbs and baths with chamomile, string, motherwort.

Repeated massage courses are widely used. Osteopathy is a gentle option manual therapy. Physiotherapy is often used.

Outcomes of perinatal encephalopathy

In perinatal encephalopathy of hypoxic-ischemic genesis, motor, speech, psycho-intellectual disorders in most cases are completely are being restored. Especially with light and erased forms. By the age of the baby, they are removed from the neurological register and the diagnosis of encephalopathy is canceled.

But the brain of such a child is still weak. The pressures that he experiences in kindergarten, constant colds, stress, schoolwork are too high for him. Therefore, the child gradually decompensates and he complains of restlessness, speech disorders, tics, learning difficulties at school, and headaches.

Therefore, in the future, the health of the child must be maintained throughout the entire period of childhood. Properly nourish it so that the brain cells receive high-quality nutrients. Give him a neck and back massage twice a year. Follow your posture. Strengthen immunity. If he gets sick too often, try to find a way to stay at home until 5 - 6 years old. Don't forget about vitamins. Be outdoors more often. Play and engage with the child. And love him sincerely! Not for success and achievement! And just because he is the way he is! After all, in the whole wide world he has no one closer to you. Take care of your child, take care of your family and take care of each other.

Perinatal encephalopathy in children is a pathology of the brain of a newborn, which he received during pregnancy with his mother, as well as in childbirth or in the first days of his life. Despite the fact that this pathology is very common, the outcomes are almost always favorable. But this does not mean that it is not necessary to follow the doctor's prescriptions. If you, dear mothers, want your child to develop speech well, to please you with his behavior and to study successfully at school, you need repeated massage courses, symptomatic drug therapy (not always!) And the supervision of an experienced pediatric neurologist.

Perinatal encephalopathy (PEP)

E.S. Bondarenko, V.P. Zykov

Perinatal hypoxic encephalopathy is frequent complication pathology of pregnancy and childbirth and is diagnosed in newborns up to 5% of cases. Perinatal brain damage accounts for more than 60% of the entire pathology of the nervous system childhood, are directly involved in the development of such diseases as cerebral palsy, epilepsy, minimal brain dysfunction.

Risk factors

To recognize the clinical signs of perinatal hypoxia, it is necessary to take into account the risk factors predisposing to its development:

Borderline age of the mother (under 20 and over 35)
Premature placental abruption
placenta previa
Preeclampsia
Premature or late birth
Meconium staining of amniotic fluid
Bradycardia, fetal tachycardia, muffled fetal heart sounds
multiple pregnancy
Long waterless period
maternal diabetes
Any illness of the mother during pregnancy
Maternal use of drugs potentially harmful to the fetus

Among the causes of violations of lung ventilation and blood oxygenation, peripheral and central hypoxia are distinguished. Pathology is involved in peripheral hypoxia respiratory tract or alveolar blood flow, in central hypoxia the basis is a violation of the function of the respiratory center.

Etiology of hypoxia

peripheral

1. Respiratory distress syndrome
2. Aspiration of amniotic fluid
3. Pneumothorax (with birth trauma)
4. Bronchopulmonary dysplasia
5. congenital anomalies(Pierre-Robin syndrome)

Central

1. Low blood pressure in the mother
2. Maternal anemia
3. Arterial hypertension
4. Placental insufficiency
5. Malformations of the brain

Hypoxia leads to a violation of oxidative processes, the development of acidosis, a decrease in the energy balance of the cell, an excess of neurotransmitters, and a violation of the metabolism of glia and neurons. acidosis increases permeability vascular wall with the development of intercellular edema and impaired cerebral hemodynamics. Under conditions of hypoxia, lipid peroxidation is disturbed with the accumulation of aggressive free radicals, hydroperoxides, which have a destructive effect on the membranes of neurons. Ischemic-hemorrhagic disorders of cerebral hemodynamics are the result of severe cerebral hypoxia.
In the antenatal period, the main etiological factor of hypoxia is placental insufficiency. Trophic insufficiency occurs with a violation of absorption and absorption of nutrients through the placenta, a deficiency in the transport of oxygen and carbon dioxide, which is manifested by the syndrome of fetal growth retardation, intrauterine malnutrition, immaturity of the lungs and surfactant. It has been established that a decrease in uteroplacental blood flow is an objective indicator of hypoxic brain damage. Surfactant deficiency and respiratory anoxia are the main pathogenetic factors of cerebral hypoxia in preterm infants and newborns from diabetic mothers. The pathogenesis of surfactant deficiency in newborns is secondary fetal hyperinsulinism, which develops in response to maternal glycemia. Insulin inhibits the synthesis of lecithin, the main element of the surfactant, the lack of which prevents the alveoli from sticking together, which leads to a violation of lung ventilation.
Thus, compensation of gestational diabetes is the prevention of neonatal respiratory distress syndrome and hypoxic encephalopathy. In the neonatal period, the cause of cerebral hypoxia and ischemia may be a pronounced intrapulmonary shunt. Hypoxic cardiopathy of newborns and adrenal insufficiency play a significant role in the pathogenesis of cerebral hypoxia. Hypoglycemia and deficiency of glycogen stores are considered as factors causing increased vulnerability of brain tissue to hypoxia in newborns, especially preterm infants with low body weight.

Morphology of hypoxic encephalopathy

The brain normally absorbs a fifth of the oxygen that enters the body. In young children, the share of the brain in the use of oxygen is almost half, which ensures a high level of metabolism of oxidative processes. Depending on the duration of hypoxia, changes in the brain develop from local edema to necrosis with hemorrhagic impregnation. A number of studies have shown that there is a different sensitivity of brain structures to hypoxia, which depends on the characteristics of metabolism and blood supply. The most sensitive to hypoxia are the Sommer's zone of Ammon's horn and the periventricular area of ​​the adjacent blood supply between the anterior, middle, and posterior cerebral arteries. With a combination of hypoxia and ischemia, foci of necrosis appear in the cortex, thalamus, striatum, and cerebellum. The following stages of morphological hypoxic changes in the brain are distinguished: stage I - edematous-hemorrhagic, stage II - encephalic gliosis, III stage- leukomalacia (necrosis), stage IV - leukomalacia with hemorrhage. The first two stages of acute hypoxia are curable, it is possible to restore the metabolism of neurons and glia, stages III and IV lead to irreversible death of neurons. With antenatal hypoxia, neuronal dystrophy, glia proliferation, sclerosis phenomena, and cystic cavities at the sites of small foci of necrosis are observed.

Clinic of hypoxic encephalopathy

AT clinical picture There are three periods of hypoxic encephalopathy - acute (1st month of a child's life), recovery (from 1 month to 1 year, and in premature immature children up to 2 years) and outcome.

In the acute period, according to the severity, there are mild form lesions of the nervous system, reflecting transient disorders of hemolytic dynamics; the form moderate with edematous-hemorrhagic changes, gliosis, single leukomalacias; severe form, characteristic of generalized cerebral edema, multiple leukomalacia and hemorrhages. To determine the severity and severity of violations cerebral circulation the Apgar scale is used.
In the acute period, there are 5 clinical syndromes: increased neuro-reflex excitability, convulsive, hypertensive-hydrocephalic, depression syndrome, coma. Usually there is a combination of several syndromes. feature acute period is the dominance of cerebral disorders without pronounced local symptoms. At mild form Brain damage (Apgar score 6-7 points) is characterized by a syndrome of increased neuro-reflex excitability. The main manifestations of the syndrome are increased spontaneous motor activity, restless superficial sleep, prolongation of the period of active wakefulness, difficulty falling asleep, frequent unmotivated crying, revival of unconditioned congenital reflexes, muscular dystonia, increased knee reflexes, tremor of the limbs and chin. In preterm infants, the syndrome of neuro-reflex excitability in 94% of cases is clinical sign lowering the threshold of convulsive readiness, which is confirmed by electroencephalography (EEG) data. Patients who, according to EEG, have a decrease in the threshold of convulsive readiness, should be considered at risk for convulsive syndrome.

The moderate form of hypoxic encephalopathy (assessed on the Apgar scale 4-6 points) is manifested by hypertensive-hydrocephalic syndrome and depression syndrome.

Hypertension-hydrocephalic syndrome is characterized by an increase in the size of the head by 1–2 cm compared to the norm (or chest circumference), opening of the sagittal suture by more than 0.5 cm, an increase and bulging of the large fontanel. Typical is the brachiocephalic shape of the head with enlarged frontal tubercles or dolichocephalic - with the occiput hanging backwards. Graefe's symptom, "setting sun" symptom, intermittent horizontal nystagmus, descending strabismus are noted. Muscular dystonia is detected, more in distal parts extremities in the form of a symptom of "seal's feet" and "heel piles". In most children, especially in the first days of life, these phenomena are combined with paroxysms of startle, spontaneous Moro reflex, sleep disturbance, Harlequin symptom, general and local cyanosis. The development of hypertensive-hydrocephalic syndrome on the 3rd-5th day of life may be a sign of periventricular hemorrhage. Hypertensive-hydrocephalic syndrome can be isolated, but more often it is combined with a syndrome of depression or a coma syndrome. The syndrome of oppression is manifested by lethargy, physical inactivity, a decrease in spontaneous activity, a general muscular hypotension, hyporeflexia, inhibition of neonatal reflexes, decreased sucking and swallowing reflexes. There are local symptoms in the form of divergent and convergent strabismus, nystagmus, asymmetry and sagging mandible, asymmetry of mimic muscles, bulbar and pseudobulbar symptoms. The syndrome characterizes the course of an acute period of hypoxic encephalopathy and usually disappears at the end of the first month of life. In the acute period, the depression syndrome may be a harbinger of cerebral edema and the development of a coma syndrome.

Coma syndrome is a manifestation of a serious condition of the newborn, according to the Apgar scale, 1-4 points are estimated. In the clinical picture, pronounced lethargy, weakness, muscular hypotension to atony are revealed, congenital reflexes are not detected, the pupils are constricted, the reaction to light is insignificant or absent. No response to painful stimuli, "floating" movements eyeballs, horizontal and vertical nystagmus, tendon reflexes are depressed. Breathing irregular, with frequent apnea, bradycardia, muffled heart sounds, arrhythmic pulse, low blood pressure. There may be seizures with a predominance of the tonic component. serious condition persists for 10-15 days, there are no reflexes of sucking and swallowing. The appearance in the acute period of hydrocephalus with bulging and tension of the large fontanel, divergence of cranial sutures, protrusion of the eyeballs, and rapid head growth indicates intracranial hemorrhage.

Convulsive syndrome in the acute period, as a rule, is combined with a syndrome of depression or coma. Occurs as a result of hypoxic cerebral edema, hypoglycemia, hypomagnesemia, or intracranial hemorrhage. Manifested in the first days of life tonic-clonic or tonic convulsions. Along with this, local clonic convulsions or hemiconvulsions are observed. Convulsive seizures in newborns are characterized by short duration, sudden onset, lack of recurrence patterns and dependence on the state of sleep or wakefulness, feeding regimen and other factors. Convulsions are observed in the form of small-amplitude tremor, short-term respiratory arrest, tonic spasm of the eyeballs by the type of gaze paresis, imitation of the "setting sun" symptom, nystagmus, automatic chewing movements, paroxysms of clonus of the feet, vasomotor reactions. These convulsions in their nature sometimes resemble the spontaneous movements of a child, which makes diagnosis difficult.

The recovery period of hypoxic encephaloratia includes the following syndromes: increased neuro-reflex excitability, hypertensive-hydrocephalic, vegetative-visceral dysfunctions, movement disorders, psychomotor developmental delay, epileptic.

The syndrome of increased neuro-reflex excitability in the recovery period has two variants of the course. With a favorable variant of the course, the disappearance or decrease in the severity of symptoms of increased neuro-reflex excitability is noted within a period of 4-6 months to 1 year. With an unfavorable variant, especially in preterm infants, an epileptic syndrome may develop.

Hypertensive-hydrocephalic syndrome has two variants of the course:

1.hypertensive-hydrocephalic syndrome with a favorable course, in which there is a disappearance of hypertension symptoms with a delay in hydrocephalus;
2. an unfavorable variant of the hypertensive-hydrocephalic syndrome, which is part of the symptom complex of the organic cerebral syndrome.

Outcomes of hypertensive-hydrocephalic syndrome:

1. Normalization of head circumference growth by 6 months.
2. Compensated hydrocephalic syndrome at 8-12 months.
3. Development of hydrocephalus.

Syndrome of vegetative-visceral dysfunctions begins to manifest itself after 1 - 1.5 months of life against the background of increased neuro-reflex excitability and hypertensive-hydrocephalic syndrome. In the clinical picture, persistent regurgitation, persistent malnutrition, respiratory rhythm disturbance and apnea, discoloration of the skin, acrocyanosis, tachy- and bradypnoe paroxysms, thermoregulation disorders, dysfunction of the gastrointestinal tract, temporal alopecia are noted.

epileptic syndrome can manifest at any age (as a continuation of convulsions after birth or against the background of a somatic infection). In newborns and infants, it has a so-called age face, that is, convulsive paroxysms imitate those motor abilities that the child has at the time of their appearance.
In newborns and infants (especially premature ones), the convulsive syndrome is characterized by a variety of clinical forms seizures. There are generalized seizures(tonic-clonic, clonic, tonic), abortive, focal, hemiconvulsive, polymorphic seizures, simple and complex absences. The frequency is dominated by polymorphic forms of seizures. In premature infants with perinatal encephalopathy, propulsive and impulsive paroxysms do not occur in isolation, but are observed only as part of polymorphic seizures. The greatest difficulty in diagnosis is represented by abortive and non-convulsive forms of paroxysms.
There is an imitation of unconditioned motor reflexes in the form of paroxysmal manifestations of the neck-tonic symmetrical reflex with head tilt and tonic tension of the arms and legs; neck-tonic asymmetric reflex with a turn of the head to the side and extension of the arm and leg of the same name; the first phase of the Moro reflex with the opening of the handles. There are paroxysms in the form of a spasm of the gaze and nystagmus, an imitation of the "symptom of the setting sun." Often there are bouts of redness and blanching of the skin with increased sweating, sometimes regurgitation. After 3 - 4 months of life, as the ability to hold the head appears, "nods", "klivs" appear, and from 6 - 7 months - "bows" (bending the body back and forth).
Features of convulsive syndrome in premature babies, such as instability clinical manifestations with a predominance of polymorphic convulsions, the presence of abortive forms of seizures, as well as complex absences with imitation of unconditioned reflexes of newborns (the first phase of the Moro reflex, asymmetric neck-tonic reflex) are probably a consequence of the immaturity of brain structures. However, an increase in the frequency of seizures, an increase in the polymorphism of their manifestations, and resistance to anticonvulsant therapy should alert us to the formation of gross organic forms of brain damage.
The polymorphism of attacks, their resistance to therapy is a prognostically unfavorable sign.

Movement Disorder Syndrome is detected from the first weeks of life, may occur with muscle hypotension or hypertension. With the appearance of a syndrome of motor disorders with muscular hypotension, a decrease in spontaneous motor activity, inhibition of tendon reflexes and congenital unconditioned reflexes of newborns are noted. The syndrome of movement disorders with muscular hypotension occurs in isolation, as well as in combination with hypertensive-hydrocephalic syndrome, a syndrome of increased neuro-reflex excitability with a decrease in the threshold of convulsive readiness. The combination of the syndrome of motor disorders and convulsive syndrome is unfavorable.
The increase in muscle hypertension in full-term children, the appearance of handedness focal symptoms should be alarming in terms of the development of cerebral palsy.

Syndrome of delayed psychomotor development begins to appear from 1 - 2 months. In the structure of the syndrome, there is a violation of the reduction of unconditioned congenital reflexes. The neck-tonic symmetrical and asymmetric reflexes, the delay in the formation of rectifying labyrinth chain tonic reflexes acquire a great diagnostic role. If present in the structure this syndrome mental retardation in children month old there is insufficiently stable gaze fixation, short-term tracking with rapid exhaustion. There is no reaction to the mother's voice, auditory concentration. By the age of 2-3 months, there is insufficient animation during communication, the cry is inexpressive, there is no cooing, the children look for the source of the sound with their eyes without turning their heads, a rare, difficult-to-cause smile appears. By six months - they are not actively interested in toys and surrounding objects, they do not react enough to the presence of their mother, the cooing is inactive and short, manipulations with objects are delayed, there is no active attention. If the developmental delay is "tempo", it begins to disappear with proper nursing. This group of children at 4 - 5 months, as it were, "leaps" becomes more active, and mental development ahead of the engine. Emotional reaction to others, interest in toys appear.
Age motor functions begin to be actively compensated after 6 - 7 months and, as a rule, are restored by 1 - 1.5 years. Long-term mental retardation is unfavorable prognostically.

Diagnostics

Examination of the fundus in the acute period of mild hypoxic encephalopathy does not reveal any abnormalities, less often moderate plethora of veins is observed. With a moderate degree, varicose veins, edema, and individual hemorrhages are noted. With a severe degree of damage against the background of a pronounced edema of vasodilation, blurring of the boundaries of the optic nerve head, hemorrhage is noted. In the future, these children may show atrophy of the nipples. optic nerves.
AT cerebrospinal fluid changes are detected when there is intracranial hemorrhage. In these cases, there are fresh and alkaline erythrocytes in the cerebrospinal fluid. After the 7th - 10th day of life, confirmation of the transferred hemorrhage is the presence of macrophages in the cerebrospinal fluid.

Neurosonography- two-dimensional ultrasound examination of the anatomical structures of the brain through the large fontanelle - allows you to establish periventricular hemorrhage, foci of leukomalacia, expansion of the ventricular system - ventriculomegaly. Neurosonography allows for differential diagnosis with brain defects. Signs of brain hypoplasia: an increase in subarachnoid spaces, an expansion of the interhemispheric fissure, ventriculomegaly, an increase in density in the brain parenchyma without a clear differentiation of convolutions, porencephaly. Haloprosencephaly - an increase in one ventricle, shadows, an increase in echo density from the brain stem structures, a decrease in density from the brain parenchyma. Clinical and neurosonographic comparisons revealed a correlation between the number of leukomalacias and neurological outcomes. Multiple leukomalacias in both hemispheres, detected in patients according to neurosonography in the acute period of the disease, are combined with a syndrome of motor disorders and a gross delay in psychomotor development in the recovery period. CT scan of the brain helps to objectify hypoxic changes in brain tissue in the structures of the cerebellum and brainstem, which are not clearly identified with neurosonography.

Electroencephalographic (EEG) the study reveals foci of slow-wave activity, foci of reduction of cortical rhythm, foci of epileptic activity. Great importance An EEG study is used to identify a risk group for convulsive syndrome and diagnose clinically "silent" seizures. An indirect confirmation of the convulsive syndrome, as well as a sign of lowering the threshold of convulsive readiness in patients, is the presence of paroxysmal EEG changes. Repeated seizures can lead to an increase in the severity of paroxysmal activity on the EEG.
From biochemical studies in the acute period, an indicator of the depth of hypoxic disorders is the assessment of acidosis from mixed to severe decompensated metabolic. Increases in severe hypoxia osmotic pressure blood plasma, increases the level of lactate dehydrogenase. Lactate dehydrogenase and other glycolysis enzymes correlate with the severity of the condition of children and reflect the severity of hypoxia in the acute period of perinatal encephalopathy.
X-ray of the lungs is used to diagnose congenital atelectasis, pneumopathy and inflammatory changes lungs.

Treatment of the acute period

In the acute period, timely correction of respiratory distress syndrome and adequate ventilation of the lungs are necessary. In preterm infants, colfosceryl palmitate 5 ml/kg is administered endotracheally. The use of surfactant analogues leads to a significant regression neurological syndromes hypoxic encephalopathy.

Correction of homeostasis and hypovolemia: fresh frozen plasma 5 - 10 ml / kg, 10% albumin 5 - 10 ml / kg, reopoliglyukin 7 - 10 ml / kg, gemodez 10 ml / kg.
Decreased vascular permeability: 12.5% ​​solution of etamsylate intramuscularly or intravenously, 1% vikasol 0.1 ml / kg.
Metabolic and antioxidant therapy: piracetam 50 mg/kg, 10% glucose 10 ml/kg, actovegin intravenously, 5% vitamin E 0.1 ml per day. Soybean oil is used as an antioxidant 2-3 ml for 4-6 days on the skin of the abdomen.
Vascular Therapy: vinpocetine 1mg/kg intravenously.
Dehydration therapy: hydrocortisone 3-10 mg/kg, prednisolone 1-2 mg/kg, 25% magnesium sulfate 0.2 ml/kg.
Improvement of tissue metabolism of the heart muscle: cocarboxylase 8 mg/kg, ATP 10 mg/kg.
Anticonvulsant therapy: diazepam 1mg/kg IM or IV, GHB 50mg/kg, barbiturates, when benzodiazepines are not effective, 5mg/kg.
Treatment recovery period
Treatment of the recovery period is carried out according to the syndromological principle.

In the syndrome of increased neuro-reflex excitability with manifestations of vegetative-visceral dysfunctions, sedatives: diazepam 0.001 g 2 times a day, tazepam 0.001 g 2 times a day, a mixture with citral - a solution of citral 2.0, magnesium sulfate 3.0, 10% glucose solution 200.0 - a teaspoon 3 times a day; from 2 months of age, a soothing cocktail of herbs (valerian root, motherwort, sage) is prescribed, 1 teaspoon 3 times a day.
With pronounced manifestations of the hypertensive-hydrocephalic syndrome, acetazolamide is used at a dose of 0.02 g / kg per day once according to the scheme: 3 days - intake, 1 day break, course from 3 weeks to 1 - 1.5 months with panangin.
With the syndrome of movement disorders: vitamin B6 5 mg, vitamin B1 2 mg, ATP 0.5 ml 10-12 injections, pyritinol 10-20 drops per 1 kg of body weight 2 times a day in the morning for 1-3 months. Massage. Physiotherapy mothers are trained in rehabilitation skills.
With the syndrome of delayed psychomotor development: piracetam 30 - 50 mg / kg in 3 divided doses, pyritinol. From 6 months cerebrolysin 0.5 ml No. 20 (contraindicated in convulsive syndrome), vitamins B6, B1. Gamma-aminobutyric acid 0.06 g 2-3 times a day.
With convulsive syndrome: sodium valproate 20 - 50 mg / kg, clonazepam up to 1 - 2 mg per day, phenobarbital 1 - 2 mg / kg. For resistant seizures, lamotrigine 1–2 mg/kg.
Surgical treatment is used for combined periventricular hemorrhages and the development of posthemorrhagic hydrocephalus, ventricular shunting is performed.
Therapeutic measures are further individualized depending on the outcome of the process. By the age of one, most mature children with the appearance of verticalization and speech functions can reveal the outcomes of perinatal hypoxic encephalopathy. Recovery occurs in 15-20% of children. Frequent consequences of the transferred encephalopathy are minimal brain dysfunction, hydrocephalic syndrome. The most severe outcomes are cerebral palsy and epilepsy.

Undoubtedly, advances in perinatal medicine, adequate management of childbirth and the acute period of hypoxic encephalopathy will reduce the neuropsychiatric outcomes of the disease.

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One of the most terrible diseases is encephalopathy in children, which can have both a congenital form (perinatal) and acquired during life. The disease itself is a diffuse disorder of the brain, which in children manifests itself in an accelerated form of development.

Consequences of encephalopathy in babies

As it became known only recently, the perinatal form of the disease in newborns can be inherited. However, this information is unspecified. The symptoms in the youngest children are not as pronounced as in adults, and therefore it is rarely possible to diagnose the disease in time and take measures to eliminate it. The most terrible consequence of encephalopathy in newborns is the lack of supply of nutrients to the brain (for example, when the bilirubin form of encephalopathy sets in). As a result, nerve cells acquire signs of dystrophy, die off, due to which important departments and functions of the body stop developing.

Treatment should also be aimed at eliminating swelling of the brain. It is the increase in the size of the brain that leads to an increase in the head in children whose skull has not yet formed to the proper degree. Consequences - hydrocephalus, Down's syndrome, cerebral palsy, and this is not the whole list, there may be unspecified cause anomalies.

Types of encephalopathy

The children's form of the disease is no different from the adult one according to the classification - encephalopathy can be congenital hereditary or developed in the mother's womb, so to speak, perinatal and acquired due to the influence of harmful factors on the brain area. Symptoms of both forms of encephalopathy in newborns or adult children converge.

The disease can lead not only to non-compliance with the diet during pregnancy, but also to birth trauma - such cases of residual encephalopathy occupy about 8-10% of all registered cases.

The children's nervous system is very unstable and tender, especially when receiving craniocerebral injuries, there is a risk of developing consequences even some time after treatment has been provided. Compare: if a child can get a concussion just from jumping high altitude or sudden braking while running, what can cause a rupture of the vessel?

Discirculatory or toxic

This form of brain disease differs from the residual one in that it can cause organic changes in neurons due to the action of vascular diseases or the ingress of toxins into the blood. This may be affected by an unspecified cause, or it will happen due to the fault of the following factors:

  • vascular insufficiency.
  • Arterial or venous aneurysms.
  • Blood diseases - toxicoplasmosis, leukemia, bilirubin deficiency or an overestimated rate, etc.
  • Viruses and infectious diseases - from jaundice (Botkin's disease) to hepatitis, influenza with complications, pneumonia.
  • Diseases of other organs, etc.

Signs of encephalopathy begin to appear in children with sleep disorders: the child does not fall asleep well, is naughty. His perception worsens, the psyche suffers. All these are symptoms of the so-called pseudoneurasthenic syndrome. Dizziness and unsteadiness when walking are connected to it, problems with blood pressure, failure of the brain to perform the work of the organs of hearing or vision. Since the children's nervous system is quite fragile, sudden mood swings can occur - tearfulness, increased activity or consequences of epileptic encephalopathy in children.

If treatment is not prescribed on time, perinatal or other encephalopathy that is not specified during the diagnosis process will lead to more detrimental abnormalities in the brain. The stagnation of consciousness will acquire a permanent character, for children it is like being in prostration. Frequent fainting, asymmetry of tendon reflexes, increased muscle tone in newborns and older children are possible. Finally, symptoms will often manifest as vegetative-vascular dystonia and lability. As for emotional state, it is joined by the deterioration of attention and memory in children.

Perinatal

Another form of brain disease in the form of encephalopathy, which appears either in the last 12 weeks of pregnancy or during childbirth. The reason may be as unspecified - stress, trauma, poor nutrition, and the specific disease suffered future mother. For example, anemia or pneumonia.

To prevent encephalopathy in newborns, it is recommended to monitor your diet, walk on fresh air and completely relieve yourself of stress. You should also be careful with the use of coffee, chocolate, especially alcohol and cigarettes - even passive smoking provokes such an ailment as perinatal or a form of residual brain encephalopathy in newborn babies. By the way, even if the disease could not be avoided (birth trauma), treatment in the first weeks of life is quite easy, and the chances of completely getting rid of the consequences by 12 months of life are 90-95%.

Bilirubin

This form of cerebral encephalopathy occurs due to hemolytic disease, which is caused by incompatibility of blood types in mothers and children. If bilirubin, which has not been processed by the liver, is elevated in the blood - above 0.1-0.2 grams per 1 liter, then it leads to toxic poisoning, that is, to admission hazardous substances to the area of ​​the brain.

Bilirubin encephalopathy disease can be caused by causes of jaundice:

  • Sepsis.
  • birth trauma or injuries received during the life of children.
  • Toxoplasmosis.
  • Tendency to diabetes mother.
  • Heredity in children.
  • Unfinished treatment of intrauterine jaundice.

Symptoms or what happens as a result of damage to the brain, its subcortical nuclei, cerebellum: metabolism in tissues is disturbed, which leads to an inevitable drop in immunity and failure of body functions, as with later residual encephalopathy in children.

The clinical picture breaks down the symptoms into three phases:

  1. There are signs of food poisoning, such as weakness, nausea, decreased skeletal muscle tone. However conventional treatment does not help from poisoning: babies retain frequent regurgitation possible refusal to eat.
  2. There are symptoms that are present in nuclear jaundice - bent joints, hands clenched into a fist. The neck is painfully bent, bilirubin encephalopathy can lead to an increase in body temperature and even a breakdown in breathing.
  3. There comes a kind of false effect, which actually says that the treatment does not give results. Usually, a short-term improvement is replaced by a return of symptoms in an enhanced form - to cerebral palsy, a mask-like face, overstrain of the back muscles, rolling the iris over the eyelid.

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Treatment of the disease

Each doctor will advise you to start a complex of preventive and curative measures already at the appearance primary symptoms encephalopathy. So, in addition to drugs, it is prescribed special diet, in which you need to exclude to the maximum the consumption of table salt, polyunsaturated fats, cholesterol, chocolate. Instead, consume more iodine-containing foods, vitamins and ascorbic acid.

Neurologist, website editor

Often in medical records newborn children, you can see the abbreviation PEP, which frightens young mothers. The term "perinatal encephalopathy" itself was proposed in 1976 and comes from four Greek words: the prefix "peri" - located near, with something, "natus" - birth, "pathos" - disease and "enkefalos" - brain.

The perinatal period is the time from 28 weeks of pregnancy to the seventh day after birth (up to 28 days in premature babies), and encephalopathy is a term that refers to various pathologies of the brain.

Thus, PEP is a kind of collective diagnosis for designating neurological disorders in newborns, and the specific symptoms, causes and severity of this condition may be different.

AT international classification exist different kinds encephalopathy, their names indicate the cause of the onset of the disease (for example, hypoxic or diabetic encephalopathy), but there is no perinatal form, since this term only indicates the time interval for the onset of disorders.

In recent years, domestic pediatric neurologists are also increasingly using other diagnoses, such as perinatal asphyxia and hypoxic-ischemic encephalopathy.

The intrauterine development of the brain and the nervous system as a whole is influenced by various adverse factors in particular maternal health and environment.

Complications can also occur during childbirth.

  1. Hypoxia. When a child in the womb or during childbirth lacks oxygen, all body systems suffer, but above all the brain. The cause of hypoxia may be chronic diseases mothers, infections, incompatibility by blood group or Rh factor, age, bad habits, polyhydramnios, malformations, dysfunctional pregnancy, unsuccessful birth, and many others.
  2. Birth injury, causing hypoxic or mechanical injuries (fractures, deformities, hemorrhages). Can cause injury: weak labor activity, quick delivery, poor fetal position or obstetrician error.
  3. Toxic lesions. This group of causes is associated with bad habits and the intake of toxic substances during pregnancy (alcohol, drugs, some medicines), as well as with the influence of the environment (radiation, industrial waste in air and water, salts of heavy metals).
  4. Maternal infections- acute and chronic. The greatest danger is the infection of a woman during the bearing of a child, since in this case the risk of infection of the fetus is very high. For example, toxoplasmosis, herpes, rubella, syphilis rarely cause symptoms in the fetus. infectious disease, but are the cause of serious disorders in the development of the brain and other organs.
  5. Developmental and metabolic disorders. These can be congenital diseases of both the mother and the child, prematurity of the fetus, malformations. Often the cause of PEP is severe in the first months of pregnancy or preeclampsia in the latter.

These factors can cause various types of disease. The most common are the following:

  • hemorrhagic form caused by hemorrhages in the brain;
  • ischemic, caused by problems with blood supply and oxygen supply to brain tissues;
  • dysmetabolic is a pathology of metabolism in tissues.


Symptoms and prognosis

Immediately after birth, the child's well-being is assessed on a ten-point basis, which takes into account the heartbeat, breathing rates, muscle tone, skin color, and reflexes. Scores 8/9 and 7/8 are obtained by healthy newborns without signs of perinatal encephalopathy.

According to studies, the severity and prognosis of the disease can be correlated with the scores obtained:

  • 6-7 points - a mild degree of violations, in 96-100% of cases recovery without the need drug treatment and without further consequences;
  • 4-5 points - the average degree, in 20-30% of cases leads to pathologies of the nervous system;
  • 0-3 points - severe degree, most often leads to serious violations of the functioning of the brain.

Doctors distinguish three stages of encephalopathy - acute (during the first month of life), recovery (up to six months), late recovery (up to 2 years) and a period of residual effects.

Neonatologists and obstetricians talk about encephalopathy if a child under the age of one month has the following syndromes:

  1. Syndrome of depression of the nervous system. It is characterized by lethargy, decreased muscle tone, reflexes, consciousness. Occurs in children with medium degree the severity of the disease.
  2. coma syndrome. The child is lethargic, sometimes to such an extent that there is no motor activity. Inhibited cardiac activity, breathing. The main reflexes (search, sucking, swallowing) are absent. This syndrome occurs due to hemorrhage, asphyxia during childbirth or cerebral edema and leads to the need to place the child in intensive care with the connection of an artificial respiration apparatus.
  3. Increased neuro-reflex excitability. Anxiety, trembling, causeless frequent crying, similar to hysterical, bad dream, arms and legs. Premature babies are more likely to have seizures, for example, when high temperature up to development. This syndrome is observed in mild forms of PEP.
  4. Convulsive syndrome. Unmotivated paroxysmal movements of the head and limbs, tension of the arms and legs, shuddering, twitching.
  5. Hypertension-hydrocephalic syndrome. It is characterized by an increase in the amount of cerebrospinal fluid and an increase in intracranial pressure. At the same time, the head circumference grows faster than the norm (more than 1 cm weekly), the size of the large fontanel also does not correspond to age. The child's sleep becomes restless, there is a monotonous prolonged crying, regurgitation, head tilting and fontanelle bulging, as well as a characteristic trembling of the eyeballs.

During the recovery period, perinatal encephalopathy is accompanied by symptoms:

  1. Convulsive syndrome.
  2. Syndrome of increased neuro-reflex excitability.
  3. Syndrome of vegetative-visceral changes. In a child, due to the pathological functioning of the autonomic nervous system, there is a delay in weight gain, regurgitation, disturbances in the rhythm of breathing and thermoregulation, changes in the functioning of the stomach and intestines, and “marbling” of the skin.
  4. Hypertension-hydrocephalic syndrome.
  5. Syndrome of movement disorders. Normally, in a child up to a month, the limbs are half-bent, but easily unbent, and then immediately return to their original position. If the muscles are flaccid or so tense that it is impossible to straighten the legs and arms, then the cause is a reduced or increased tone. In addition, the movements of the limbs must be symmetrical. All this interferes with normal physical activity and purposeful movements.
  6. Syndrome of delayed psychomotor development. A child later than the norm begins to raise his head, roll over, sit, walk, smile, and so on.

About 20–30% of children diagnosed with PEP recover completely, in other cases, complications develop, depending on the severity of the disease, the completeness and timeliness of treatment.

Perinatal encephalopathy can lead to the following consequences:

  • syndrome and attention deficit;
  • delayed speech and mental development, brain dysfunction;
  • epilepsy;
  • cerebral palsy (infantile cerebral palsy);
  • oligophrenia;
  • progressive hydrocephalus;
  • vegetative dystonia.

Diagnostics

Perinatal encephalopathy is diagnosed by a pediatrician and a pediatric neurologist based on the data of the examination, tests and examinations of the child, as well as information about pregnancy, childbirth and the health of the mother.

The most effective and modern diagnostic methods are the following:

  1. Neurosonography (NSG) is an ultrasound examination of the brain through the fontanelle to detect intracranial damage and the state of brain tissues.
  2. Electroencephalogram (EEG) - registers the electrical potentials of the brain and is of particular value in the diagnosis of PEP with convulsive syndrome. Also, using this method, you can establish the asymmetry of the cerebral hemispheres and the degree of delay in their development.
  3. Dopplerography to assess blood flow in the tissues of the brain and neck, narrowing or blockage of blood vessels.
  4. Video monitoring. Video recording is used to establish spontaneous movements.
  5. Electroneuromyography (ENMG) - electrical stimulation of the nerve to determine the violation of the interaction of nerves and muscles.
  6. Positron emission tomography (PET), based on the introduction into the body of a radioactive tracer, which accumulates in tissues with the most intensive metabolism. It is used to assess metabolism and blood flow in various departments and brain tissues.
  7. Magnetic resonance imaging (MRI) - research internal organs using magnetic fields.
  8. Computed tomography (CT) is a series of X-ray images to create a complete picture of all brain tissues. This study makes it possible to clarify hypoxic disorders that are not clearly identified in NSH.

NSG and EEG are the most informative and most often used for diagnosis. AT without fail the child should be sent to an ophthalmologist for examination of the fundus, the condition of the optic nerves and the establishment of congenital disorders.

It is worth noting that, according to various sources, in Russia, perinatal encephalopathy is diagnosed in 30–70% of newborns, while according to foreign studies, only about 5% of children really suffer from this disease. There is overdiagnosis.

The reasons for this may be non-compliance with the standards of examination (for example, the diagnosis of hyperexcitability in a child examined in a cold room strangers), referring to the pathology of transient phenomena (for example, throwing up limbs) or ordinary signals of needs (crying).

Treatment

The central nervous system of newborns is plastic, capable of development and recovery, so the treatment of encephalopathy should be started as early as possible. It depends on the severity of the disease and specific symptoms.

If the brain dysfunction is mild or moderate, the child remains on home treatment. In this case, use:

  • individual mode, calm atmosphere in the house, balanced nutrition, lack of stress;
  • assistance of correctional teachers, psychologists, speech therapists with alalia and dysarthria
  • massage and physiotherapy for normalization of tone, development of motor functions and coordination of movements
  • physiotherapy;
  • phytotherapy (various sedative fees and herbs to normalize water-salt metabolism).

With severe motor, nervous disorders, delayed child development and other AED syndromes, drugs are used. The doctor prescribes drugs, as well as other methods of treatment, based on the manifestations of the disease:

  1. At movement disorders most often prescribed dibazol and galantamine. With increased muscle tone - Baclofen and Mydocalm to reduce it. These drugs are introduced into the body, including using electrophoresis. Massage is also used special exercises, physiotherapy.
  2. If PEP is accompanied by a convulsive syndrome, anticonvulsant drugs are prescribed by the doctor. With convulsions, physiotherapy and massage are contraindicated.
  3. Delayed psychomotor development is a reason for prescribing drugs to stimulate brain activity, increasing blood circulation in it. These are Actovegin, Pantogam, Nootropil and others.
  4. With hypertension-hydrocephalic syndrome, phytotherapy is used, and in severe cases- Diakarb to accelerate the outflow of cerebrospinal fluid. Sometimes a part of the cerebrospinal fluid is removed through a puncture of the fontanel.

For the treatment of PEP of any severity, B vitamins are prescribed, since they are necessary for normal development and functioning of the nervous system. In many cases, swimming, salt baths, or herbal preparations, osteopathy.

Perinatal encephalopathy is one of the most common diagnoses of pediatric neurologists. This is due to the fact that PEP is a collective term denoting disorders of the child's brain in the perinatal period, which have various reasons including maternal health, pregnancy, lack of congenital diseases, complications during childbirth, ecology and other circumstances.

Symptoms can be different, relating to disorders of the nerves, muscles, internal organs, metabolism, therefore, for an accurate diagnosis, the doctor must not only examine the child, but also collect the entire anamnesis regarding the health of the mother and father, complications during pregnancy, labor activity, as well as appoint additional examinations.

Encephalopathy is a non-inflammatory disease of the brain, in which its tissue changes, as a result of which its main functions are violated. Pathology can be congenital and acquired.

Congenital perinatal encephalopathy in children suggests that they have various pathologies of the nervous system that have arisen during their prenatal development during childbirth or immediately after birth. The diagnosis is very serious, requiring medical intervention, a fairly long course of treatment and vigilant attention from parents.

Since a child acquires perinatal encephalopathy at the very beginning of his life, attentive parents may notice some deviations from the first days of his life. Over time, they will intensify, grow and will distinguish a sick baby from other, healthy babies. The disease covers a fairly wide range of manifestations of nervous disorders and pathologies. Doctors distinguish from them a number of the most typical, basic symptoms of perinatal encephalopathy in children.

In infancy:

  • weak or very late cry at the birth of a baby;
  • heart problems;
  • lack of sucking reflexes;
  • anxiety;
  • frequent, hysterical crying;
  • excessive lethargy or increased muscle tone;
  • inadequate reactions to sound and light;
  • reflex shudders;
  • bulging eyes, strabismus;
  • tilting the head;
  • frequent regurgitation during meals and after meals (read more why);
  • sleep disorders.

At an older age, you can note:

  • disorders of memory and consciousness;
  • inactivity, lack of initiative, apathy towards everything;
  • permanent;
  • depression;
  • fatigue, distraction, irritability, tearfulness, general weakness, poor sleep, lack of appetite;
  • dizziness;
  • vagueness of thought;
  • narrowed circle of interests;
  • verbosity;

The problem with perinatal encephalopathy in children is that the disease borders too closely on many other similar diseases of the central nervous system. Parents may miss the first signs due to their ignorance. Even if the child often lags behind in mental and mental development from his peers, parents hope that over time he will catch up with them. But with severe forms of congenital encephalopathy, this is almost impossible. At timely handling to the doctor and the correct diagnosis, therapy is prescribed depending on the form and severity of the disease.

Types of disease

A child can be diagnosed with various forms of the disease, of which there are quite a lot. The classification is based on the genesis (origin) of brain disorders. The most common types of encephalopathy are:

  • posthypoxic perinatal- due to lack of oxygen, even during fetal development or during childbirth;
  • hypoxic-ischemic- brain damage caused not only by oxygen deficiency, but also by a serious violation of cerebral circulation;
  • transient- transient disturbances in the blood circulation of the brain, which can manifest itself in a short loss of consciousness, temporary visual impairment, speech impairment, weakness in different parts of the body, numbness, muscle tingling.

Each of these types differs not only in special symptoms, but also requires a certain treatment.

Treatment Methods

Treatment of perinatal encephalopathy in children is long-term. The doctor tries to take into account the severity and duration of the disease, the age of the child, concomitant diseases. Therapy is carried out on an outpatient basis or in a hospital, at the discretion of the doctor. Usually two or three courses of therapy are required within a year - it all depends on the severity of the encephalopathy. The main methods of treatment are:

  • drug therapy (analgesics, NSAIDs, hormones);
  • blockades (injections);
  • metabolic, antioxidant, vascular therapy;
  • manual therapy (articular, muscular, radicular technique);
  • physiotherapy (SMT, UHF);
  • osteopathy;
  • therapeutic exercises (well-known exercise therapy);
  • surgical treatment;
  • acupuncture (reflexology);
  • herbal medicine: treatment with herbs minimizes the negative effects of encephalopathy in children - herbal teas from knotweed, dandelion, plantain, clover, knotweed, mint, sweet clover, lingonberry, St. heavy or late consequences encephalopathy (including oligophrenia);
  • aromatherapy in such cases also comes to the rescue: they improve the condition of sick children essential oils ginger, chamomile, geranium, lavender, rosemary;
  • stem cell treatment.

Specified therapeutic actions and methods are applied depending on the causes, symptoms and severity of the manifestations of the disease in the child. Regular medical supervision helps to minimize dangerous consequences for the health of children, which can overtake already in adulthood.

Consequences of perinatal encephalopathy in adulthood

Many adult neurological ailments come from childhood. Doctors say that their cause is untreated congenital encephalopathy. The consequences can be very diverse:

  • early osteochondrosis;
  • severe migraines;
  • cardiopsychoneurosis;
  • impotence;
  • hypertension;
  • scoliosis;
  • attention deficit disorder;
  • hyperactivity;
  • vision problems;
  • fine motor disorders.

The disease itself and its severe consequences are a real tragedy for parents. However, such dysfunctions of the brain and central nervous system are not a sentence, many manifestations are curable. Especially since modern development medical technologies is rapidly progressing. Medicines and treatments are getting better. Perhaps, in the very near future, a cure for encephalopathy will also be found.

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