Symptoms and treatment of stomatitis in the mouth in children: photo and prevention of the disease, opinion of Dr. Komarovsky. Inflammation due to allergies. General symptoms of the disease

Inflammatory disease mucous membrane oral cavity, usually infectious or allergic genesis. Stomatitis in children is manifested by local symptoms (hyperemia, edema, rashes, plaque, ulcers on the mucous membrane) and a violation general condition(fever, refusal to eat, weakness, adynamia, etc.). Recognition of stomatitis in children and its etiology is carried out by a pediatric dentist on the basis of an examination of the oral cavity, additional laboratory tests. Treatment of stomatitis in children includes local treatment of the oral cavity and systemic etiotropic therapy.

General information

Causes of stomatitis in children

The condition of the oral mucosa depends on the effects of external (infectious, mechanical, chemical, physical agents) and internal factors(genetic and age characteristics, the state of immunity, concomitant diseases).

In the first place in terms of frequency of distribution are viral stomatitis; of these, at least 80% of cases occur in herpetic stomatitis in children. Less often stomatitis viral etiology develop in children against the background of chickenpox, measles, influenza, rubella, infectious mononucleosis, adenovirus, human papillomavirus, enterovirus, HIV infection, etc.

Stomatitis of bacterial etiology in children can be caused by staphylococcus, streptococcus, as well as pathogens specific infections- diphtheria, gonorrhea, tuberculosis, syphilis. Symptomatic stomatitis in children develop against the background of diseases of the gastrointestinal tract (gastritis, duodenitis, enteritis, colitis, intestinal dysbiosis), blood system, endocrine, nervous system, helminthic invasions.

Traumatic stomatitis in children occurs due to mechanical trauma of the oral mucosa with a nipple, a toy; teething or biting teeth lips, cheeks, tongue; brushing teeth; burns of the oral cavity with hot food (tea, soup, jelly, milk), damage to the mucous membrane during dental procedures.

Allergic stomatitis in children can develop as a reaction to local exposure to an allergen (ingredients in toothpaste, lozenges or chewing gum with artificial colors and flavors, medicines, etc.).

Prematurity, poor oral hygiene, plaque accumulation, caries, wearing braces, frequent general morbidity, deficiency of vitamins and microelements (vitamins of group B, folic acid, zinc, selenium, etc.), the use of drugs that change the microflora of the oral cavity and intestines (antibiotics, hormones, chemotherapy drugs).

The mucous membrane of the oral cavity in children is thin and vulnerable, so it can be injured even with a slight impact on it. The microflora of the oral cavity is very heterogeneous and is subject to significant fluctuations depending on the characteristics of nutrition, the state of immunity and concomitant diseases. When weakened defensive forces even representatives normal microflora oral cavity (fusobacteria, bacteroids, streptococci, etc.) can cause inflammation. The barrier properties of saliva in children are poorly expressed due to the insufficient functioning of local immunity factors (enzymes, immunoglobulins, T-lymphocytes and other physiologically active substances). All these circumstances cause the frequent incidence of stomatitis in children.

Symptoms of stomatitis in children

Viral stomatitis in children

The course and features of herpetic stomatitis in children are discussed in detail in the corresponding article, so in this review we will focus on common signs viral infection oral cavity, characteristic of various infections.

main symptom viral stomatitis in children, the appearance of rapidly opening vesicles on the oral mucosa serves, in place of which small round or oval erosions are then formed, covered with a fibrinous coating. Vesicles and erosions can look like separate elements or have the character of defects that merge with each other.

They are extremely painful and, as a rule, are located against the background of a brightly hyperemic mucous membrane of the palate, tongue, cheeks, lips, and larynx. Local manifestations viral stomatitis in children are combined with other signs of infection caused by this virus (skin rash, fever, intoxication, lymphadenitis, conjunctivitis, runny nose, diarrhea, vomiting, etc.) Erosions are epithelialized without a scar.

Candidal stomatitis in children

Development of specific local symptoms candidal stomatitis in children, excessive dryness of the mucosa, a burning sensation and an unpleasant aftertaste in the mouth, and bad breath precede. Babies are naughty during meals, refuse breasts or bottles, behave restlessly, sleep poorly. Soon on inside small white dots appear on the cheeks, lips, tongue and gums, which, merging, form a plentiful white, cheesy consistency plaque.

In severe candidal stomatitis in children, plaque acquires a dirty gray tint, is poorly removed from the mucous membrane, exposing the edematous surface, which bleeds at the slightest touch.

In addition to the pseudomembranous candidal stomatitis described above, atrophic candidal stomatitis occurs in children. It usually develops in children wearing orthodontic appliances, and proceeds with poor symptoms: redness, burning, dryness of the mucous membrane. Plaque is found only in the folds of the cheeks and lips.

Repeated episodes of candidal stomatitis in children may indicate the presence of other serious illnesses- diabetes, leukemia, HIV. Complications fungal stomatitis children may have genital candidiasis (vulvitis in girls, balanoposthitis in boys), visceral candidiasis (esophagitis, enterocolitis, pneumonia, cystitis, arthritis, osteomyelitis, meningitis, ventriculitis, encephalitis, brain microabscesses), candidosepsis.

Bacterial stomatitis in children

Most frequent view bacterial stomatitis in childhood serves as impetiginous stomatitis. It is indicated by the combination of the following local and common features: dark red color of the oral mucosa with confluent superficial erosions; the formation of yellow crusts that stick together the lips; increased salivation; unpleasant putrid smell from mouth; subfebrile or febrile temperature.

With diphtheria stomatitis in children, fibrinous films are formed in the oral cavity, after the removal of which an inflamed, bleeding surface is exposed. With scarlet fever, the tongue is covered with a dense whitish coating; after its removal, the tongue becomes a bright crimson color.

Gonorrheal stomatitis in children is usually combined with gonorrheal conjunctivitis, in rare cases- with arthritis of the temporomandibular joint. Infection of the child occurs when passing through the infected genital tract of the mother during childbirth. The mucous membrane of the palate, back of the tongue, and lips is bright red, sometimes lilac-red, with limited erosions, from which a yellowish exudate is released.

Aphthous stomatitis in children

Prevention of stomatitis in children

Prevention of stomatitis in children consists in the exclusion of any microtrauma, careful hygiene care for the oral cavity, treatment concomitant pathology. To reduce the risk of stomatitis in children infancy it is important to regularly disinfect nipples, bottles, toys; to treat the mother's breast before each feeding. Adults should not lick a baby's nipple or spoon.

Starting from the moment of eruption of the first teeth, regular visits to the dentist are necessary for preventive measures. For cleaning children's teeth, it is recommended to use special toothpastes that increase local immunity of the oral mucosa.

Diseases of the oral cavity in children are associated with pathological processes occurring in the internal organs, weakened immunity, adverse impact external factors. The causes are pathologies of the teeth, lack of oral hygiene, unsystematic medication, trauma to the mucosa due to the use of acute or too hot food, dehydration.

Hormonal disorders, deficiency of vitamins and minerals, infections of upper respiratory tract (whooping cough, scarlet fever, influenza, whooping cough, sinusitis), various viruses, fungi can also provoke the disease.

Types of inflammation of the oral mucosa in children

Diseases of the oral cavity, depending on the causes that caused their development, are divided into:

1. infectious;
2. viral or bacterial;
3. traumatic;
4. allergic;
5. fungal;
6. caused comorbidities Gastrointestinal tract, ENT organs, cardiovascular and endocrine systems;
7. hereditary.

Stomatitis

Stomatitis of the oral mucosa in children is common. The disease is accompanied by reddening of the oral cavity, a whitish coating on the tongue, inner surface cheeks, gums, bad smell mouth, fever. The child experiences pain and discomfort, refuses to eat, becomes capricious and whiny.

General symptoms of diseases:

• bleeding sores of yellow-white color on the mucous tissues of the tongue, lips, cheeks, gums;
• swelling and bleeding of the gums;
• increased secretion of salivary fluid;
• dry tongue;
• enlarged lymph nodes in the neck;
• painful sensations;
• loss of appetite;
• capriciousness and tearfulness.

To relieve the inflammatory process and disinfect the affected areas, you need to rinse your mouth with antiseptic agents - a warm decoction of chamomile or sage, a solution of furacilin, soda or hydrogen peroxide.

Herpetic stomatitis

The most common type of stomatitis is caused by the herpes virus. Acute form of herpetic stomatitis - contagious disease. The disease is especially susceptible to babies from 6 months to 3 years with weak immunity. With age, the protective functions of the body are strengthened and the likelihood of infection decreases.

Symptoms of the disease in acute form:

1. body temperature often rises to 41ºС;
2. signs general malaise- impotence, fatigue, headaches, pallor, increased painful sensitivity of muscles and skin;
3. lack of appetite;
4. nausea and vomiting;
5. swollen lymph nodes under the jaws and on the neck;
6. severe swelling and redness of the mucous tissues in the oral cavity;
7. a large number of sores on the inside of the lips, cheeks, gums and tongue;
8. with a moderate and severe form of the disease, rashes affect the outer skin around the mouth, ear lobes and eyelids;
9. increased salivation;
10. bad breath;
11. bleeding gums;
12. dry and chapped lips;
13. in rare cases - nosebleeds due to a violation of blood clotting by herpesvirus.

For treatment, medication and local therapy are prescribed. Recommended medications to increase immunity (gamma globulin injections, Lysozyme, Prodigiosan, herpetic immunoglobulin, etc.); general therapy - Diphenhydramine, Suprastin, Pipolfen, calcium gluconate, etc.

Local therapy of the disease consists in treating the oral cavity with agents that relieve pain, prevent the spread of rashes, and stimulate the processes of regeneration of damaged tissues.

For the destruction of viruses are prescribed various ointments(Oxolinic, Florenal, Heliomycin, Interferon, etc.). For antiseptic treatment, solutions of furacilin, Ethonia, Etakridine, rosehip oil, Karatolin, Solcoseryl are used.

All meals for feeding a child should be liquid or mushy (soups, broths, mashed potatoes). Recommended for detoxification plentiful drink. Before eating, the oral cavity must be treated with an anesthetic (5% anesthetic emulsion), after eating, the mouth is rinsed.

Aphthous stomatitis

Aphthous stomatitis is of an allergic or infectious nature, alternating with periods of remission and exacerbation. The first symptoms of the disease are fever (+39 ... + 40ºС), restlessness and capriciousness of the child, lethargy, dry mouth.

Gradually, the oral mucosa swells, turns red, hyperemia of the mucous tissues increases. Aphthae appear on the 3-4th day in the form of round or oval erosive formations ranging in size from 1 to 5 mm with yellow or gray bloom surrounded by a red border. They affect the tongue, lips, cheeks, are single or multiple. The disease is accompanied by pain in the mouth, migraine, loss of appetite, impaired stool, increased lymph nodes. The duration of the course of the disease is 2-3 weeks.

Candidal stomatitis

Candidal stomatitis is an inflammation of the oral mucosa caused by Candida fungi. The disease begins with redness and swelling of the tongue, then a white curdled coating appears on the mucous surface of the cheeks and lips. Under the plaque, ulcers and erosions form, which bleed and hurt.

The reason is the weakening of the immune system, and provoke the development of the disease and the spread of fungi milk nutrition babies. For treatment, immunomodulatory drugs are prescribed, and the mouth is regularly treated with soda solution. A 2% solution of boric acid is well suited for removing Candida fungi, which is used to treat the oral mucosa 3 times a day.

Gingivitis or gingivostomatitis

Gingivitis is a disease associated with inflammation in the gums. It is a consequence of damage to the teeth (caries, plaque or calculus). Often the factors provoking gingivitis can be vitamin deficiency, weakened immunity, hormonal imbalance, infections (herpes).

The disease is accompanied by pain, aggravated during eating, brushing teeth. The gums turn red, swell, become loose and bleed. If the nature of the disease is infectious, then ulcerative or erosive formations on the gums may appear. Characteristic features – bad smell from mouth, copious excretion salivary secretion. In the absence of proper treatment, the disease can be complicated by the development of periodontitis and tooth loss.

To prevent the disease, it is necessary to carefully care for the oral cavity (teeth, gums) - regular hygiene, timely removal of tartar. For treatment, irrigation of the mouth with infusions is prescribed. medicinal herbs- chamomile, sage, plantain. To exclude various pathologies internal organs should be examined by a pediatrician.

Thrush in children

Thrush is caused by pathogenic reproduction of fungi of the genus Candida, caused by weakened immunity due to various diseases, dysbacteriosis due to prolonged use of antibiotics. The disease is most common in infants and toddlers under 1 year of age. Pathology manifests itself in the form of a white cheesy plaque in the mouth and throat.

An infant can become infected with a fungus during childbirth, if the mother has vaginal candidiasis or due to poor hygiene during subsequent care, if the intestinal microflora is disturbed, which is often found in babies in the first six months of life.

Treatment of the disease consists in treating the oral cavity with a solution of baking soda. With the antibacterial nature of thrush, Nystatin or Levorin is prescribed. To increase the level of immunity and normalization intestinal flora the child is assigned good nutrition With great content vitamins (groups B, C, A, nicotinic acid).

Treatment and causes of cheilitis in children

Cheilitis is an inflammation of the lips caused by infection of a wound on the lips resulting from injury (cut, burn, mechanical damage upon impact, fall, etc.). Also, the causative agents of the pathology can be herpes viruses, erysipelas or eczema. The cause of the disease of the oral cavity may be vitamin B2 deficiency.

The disease is accompanied by swelling of the lips and a violation of its mobility, the mucous membrane of the oral cavity becomes red, painfully sensitive. Sometimes there are symptoms general intoxication- Weakness, headaches and muscle pain.

Zayeda or angular cheilitis is a subspecies of cheilitis. The causative agents of the disease are streptococci or fungi. When driving, the corners of the mouth are affected by small, but painful erosions, which crack and bleed when the mouth is opened, then crust over.

Antibiotics are prescribed to clear the infection. In case of formation of an abscess, it must be opened and treated with an antiseptic. With inflammation of the labial glands, opening, drainage and cleaning of infected areas is also shown.

For the treatment of fungal seizures, nystatin ointment is used, and the viral one is treated with an emulsion of synthomycin or penicillin ointment. Vitamin B2 deficiency is replenished by the use of riboflavin. It is necessary to carry out regular processing of the mouth, utensils and children's toys, use individual means hygiene (towel, washcloth, Toothbrush, tableware).

Traumatic lesions of the oral mucosa

Traumatic stomatitis can be caused by various one-time injuries or constant mechanical irritation of the mucous tissues of the mouth. In children, injury occurs due to toys, when falling or biting the tongue or cheek, due to wearing braces; in infants, gum disease can be caused by tooth growth. As a result, pustules, abscesses, sores or erosions form at the site of violation of the integrity of the mucosa. If an external infection has not entered the wound, it heals quickly without side effects.

Treatment consists in eliminating the cause of injury (a tooth fragment is removed or polished, tartar is removed, incorrect braces or dentures are corrected); wounds are treated with an antiseptic. If an infection is present, anti-inflammatory drugs are additionally prescribed.

Glossitis or inflammation of the tongue

Glossitis is an inflammatory lesion of the tongue, expressed in peeling of the skin layer and the formation of a whitish thickening in the form of a narrow strip. The affected surfaces are in the form of rings or semi-rings of a light red hue, sometimes merge into larger spots. This condition is called "geographical" language because of the loss of homogeneity of the surface of the organ and the similarity with a geographical map. Other symptoms such as pain or discomfort, redness and swelling are not observed, in rare cases, a slight burning sensation of the tongue is felt.

The causes of the disease are unknown, treatment is not prescribed. It is recommended to rinse the mouth with soda solution or Citral.

Other types of diseases

There are many diseases of the oral cavity, the most common of them are discussed above. Also in medicine, such pathologies of the oral mucosa are described as Infectious mononucleosis and viral warts.

Infectious mononucleosis is viral disease. Manifested by an increase (up to size walnut) and soreness of the lymph nodes on the neck and under the jaw, the development of tonsillitis, stomatitis and changes in the composition of the blood.

Infection occurs through the pharynx or nasopharynx, spreads rapidly through lymphatic system and blood. The disease is accompanied by fever, headaches, drowsiness, lethargy and fatigue, nausea and vomiting. In young children, there may be an increase in the size of the liver, spleen. The analysis shows an increase in leukocytes, lymphocytes and monocytes, appear in the blood and atypical mononuclear cells (15-30%).

Treatment of mononucleosis is aimed at relieving symptoms - the appointment of painkillers and antipyretics, NSAIDs, vitamin and mineral complexes to boost immunity. As a local therapy for the disease, it is recommended to rinse the oral cavity with a solution of furacilin. The patient is prescribed bed rest, isolation, high-calorie food and plentiful drink.

Viral warts in the oral cavity are neoplasms of benign etiology. There are flat and pointed. Most often, they affect the inner corners of the mouth and the side walls of the tongue, less often they can appear on the gums, lips, or the outside of the mouth. In most cases, they are associated with wart formations on the hands or genitals.

Treatment viral warts carried out with Oxolinic ointment (3%), Bonafton (0.5%), Florenal (0.5%) and others antiviral ointments. Before applying the product, it is necessary to thoroughly rinse the mouth and brush the teeth.

Prevention of oral diseases

In order to avoid the development of various diseases of the oral cavity, a child should be taught from early childhood to follow the rules of care and hygiene - brush your teeth regularly, limit the consumption of sweets. Subsequently, children can be taught to use dental floss and rinse it after each meal.

It is necessary to visit the dentist regularly, at least 2 times a year, together with the child, treat caries in time, remove plaque and stones. Should be strengthened children's immunity hardening, exercise, swimming.

The child needs to provide good nutrition, rich in various vitamins and minerals. AT winter time according to the pediatrician's prescription, various vitamins should be given to the baby. It is important to remember that it is always easier to prevent the development of a disease than to treat its consequences.

Oral diseases in children are quite common and common ailments that occur as a result of non-compliance with hygiene rules, reduced immunity or injuries.

The most common diseases of the oral mucosa in children are: stomatitis, thrush, pyoderma. It is also not uncommon when ailments develop due to damage to the mucous membranes due to injuries.

Stomatitis, which cause a lot of anxiety to the child, are divided into several types: acute aphthous stomatitis, chronic aphthous stomatitis and herpetic.

Acute and chronic aphthous stomatitis can be attributed to the most common ailments arising from allergies or infections that affect the oral mucosa. The symptoms of these ailments are pronounced: aphthae (mucosal defects), have round shape, are covered with a whitish coating and red rims can be seen along the edges of the lesions.

At chronic course aphthae diseases can affect the mucosa in mild form, and can cause significant damage to the condition of the child. At severe course disease, many deep scarring aphthae are formed, which do not disappear for a long time. This disease of the oral cavity is often accompanied by fever, pain.

Unlike aphthous stomatitis, herpetic stomatitis is caused simple virus herpes. This is a rather dangerous disease, which indicates that the child's immunity is very weakened. This disease is highly contagious and airborne. by drip. Unfortunately, herpetic stomatitis is not curable. With the help of immunomodulators and antiviral drugs, it is possible to suppress the spread of virus cells, but it will not work to get rid of them for good.

This disease can occur in three forms: mild, moderate and severe. Unlike aphthous stomatitis, this disease has a rather long incubation period - more than two weeks from the moment of infection. The weaker the child's immunity, the shorter the incubation period. In newborns, this disease can develop in a few days. How older child, topics less likely infection with this virus due to acquired immunity.

Symptoms of acute herpetic stomatitis are manifested as follows: fever (the more severe the form of the disease, the higher the temperature). The mucous membrane of the mouth swells, becomes sensitive. The child experiences itching and pain. Further, small ulcers form on the tongue, gums or oral mucosa. If the form mild disease there are not many bubbles. AT severe cases almost the entire mucosa is affected, ulcers can spread to the lips and skin around the mouth. With this disease, it is not uncommon for the gums to bleed and become inflamed, which requires immediate treatment with antiviral drugs. In order to avoid relapses, it is necessary to strengthen the immunity of the child.

Another disease that is often diagnosed in infants- milkmaid. This disease is caused by a fungal infection that affects the oral mucosa. The symptoms of thrush are quite easy to recognize: a white curdled coating on the tongue, gums, and mucous membranes of the mouth. This infection develops against the background of low immunity and because of the very thin epithelium of the oral cavity. Basically, this disease can begin due to poor hygiene when feeding and caring for a child. It is also not uncommon for babies to become infected with thrush during childbirth by passing through infected birth canal mother.

Thrush must be treated. Candida fungus tends to grow uncontrollably, affecting the mucous membranes of the mouth. Under a white coating, the epithelium becomes vulnerable to other infections.

There are diseases of the oral cavity, which are characterized by streptostaphylococcal lesions of the mucous membrane. This infection - pyoderma, can spread not only on the mucous membranes, but also capture the lips, perioral area. This ailment most often diagnosed in children who have a weakened immune system. It is also not uncommon when pyoderma occurs due to an unbalanced diet or in violation of the digestive tract.

This type of oral disease in severe form occurs in children who are sick diabetes. Metabolic disorder creates favorable environment for breeding pathogenic bacteria. Symptoms this disease have a pronounced form: an increase in body temperature, a rash on the mucous membranes and skin in the form of small pustular vesicles. At severe forms many bubbles form a dense crust, under which pus can accumulate. If this disease is not treated, it easily spreads throughout the body.

Also, do not ignore the diseases of the oral cavity resulting from injuries and injuries. With wounds and abrasions on the oral mucosa, which can occur when brushing your teeth, eating solid foods, medical intervention, the risk of infection with dangerous microorganisms increases. Also beware of infection. dangerous infection due to non-compliance with the rules of hygiene when caring for an infant.

Almost all diseases of the oral cavity are accompanied by pain and an increase in body temperature. Parents should be aware that most children who suffer from such ailments have a weakened immune system.

Methodical development

FOR PEDIATRIC DENTISTRY

AND PREVENTION OF DENTAL DISEASES

(For 5th year students of the Faculty of DentistryIX semester)

Discussed at the meeting of the department

Protocol No. _______

Introductory test control. Anatomical and physiological age-related features of the oral mucosa in children. Elements of defeat SOPR. Methods for examining OM in children

Total class time – 6.0

academic hours

PURPOSE OF THE LESSON:

To identify the level of preparation of students for the topics of the semester in related disciplines, to assess the degree of assimilation of the material obtained in related dental departments and in the study of the previous sections of propaedeutics of pediatric therapeutic dentistry and outpatient pediatric dentistry. The previously acquired knowledge will provide students with a full understanding and assimilation of the material of the current semester.

To learn to understand the relationship between the structural features of the oral mucosa in children with clinical manifestations of pathological conditions in the oral cavity in various age periods. To master the methods of examination of the oral mucosa. Learn to diagnose traumatic injuries of the oral mucosa in children, differentiate them from similar diseases, master methods of treatment and prevention.

MATERIAL EQUIPMENT:

Tables, dummies, slides, radiographs, samples.

OBJECTIVES OF THE LESSON:

REQUIREMENTS FOR THE INITIAL LEVEL OF KNOWLEDGE

To master the material offered in the study of the semester, the student must repeat:

From normal anatomy - the structure of oral mucosa and periodontal tissues.

From histology and embryology - the histological structure of oral mucosa and periodontal tissues, their functions.

From pathological physiology - inflammation (signs, stages, chemical reactions).

From microbiology - the composition of the microflora of the oral cavity and dental plaque.

From pediatrics - clinical manifestations Gastrointestinal tract, kidneys, CCC, blood.

From therapeutic dentistry - clinical manifestations and pathogenesis of gingival inflammation.

From prevention dental diseases- dental examination of the patient, the state of oral hygiene, methods and means of individual prevention.

From the nursery therapeutic dentistry- caries of temporary and permanent teeth with incomplete root formation, non-carious lesions of hard tissues of the tooth, pulpitis and apical periodontitis of temporary and permanent teeth with incomplete root formation.

TEST QUESTIONS

IN RELATED DISCIPLINES

1. The structure of the oral mucosa in adults.

2. Methods of examination for diseases of the oral mucosa.

3. Elements of damage in diseases of the oral mucosa in adults (primary, secondary).

4. Signs and stages of inflammation.

Control questions from related disciplines and previously studied sections of propaedeutics of pediatric therapeutic dentistry are offered to students in the form of a test control of the initial level of knowledge.

At the practical part of the lesson, after writing the test control, students discuss with the teacher the questions that caused difficulty or misunderstanding.

CONTROL QUESTIONS ON THE TOPIC OF THE LESSON

1. Features of the structure of the oral mucosa in children:

a) up to a year;

b) at the age of 1 - 3 years, 4 - 12 years.

2. Methods of examination for diseases of the oral mucosa in children.

EDUCATIONAL MATERIAL

ANATOMICAL AND PHYSIOLOGICAL AGE FEATURES OF THE ORAL MUCOSA IN CHILDREN. ELEMENTS OF DEFEAT RESIST. METHODS OF EXAMINATION OF CORP IN CHILDREN.

Modern scientists distinguish 3 types of mucous membrane: integumentary (mucosa of the lips, cheeks, transitional folds, floor of the mouth, soft palate), chewing (mucosa of the gums and hard palate) and specialized (back surface of the tongue).

Throughout the oral mucosa (OM) is lined with stratified squamous epithelium, consisting of several layers of cells. Under it are the basement membrane, the mucous membrane itself and under slime layer. The ratio of these layers in different parts of the oral cavity is not the same. The hard palate, tongue, gums, which are subjected to the most severe pressure during meals, have a more powerful epithelium. Lips, cheeks have a well-defined lamina propria, and the floor of the mouth and transitional folds have a predominantly developed submucosa.

Epithelium directly facing the oral cavity and due to the desquamation of the upper layer is subject to constant renewal. In some areas, the epithelium is able to keratinize as a result of mechanical, physical and chemical influences. The keratinization is most pronounced on the hard palate, tongue and gums, where several rows of non-nuclear cells can be observed. A granular layer adjoins the layer of non-nucleated cells, the cells of which are elongated and contain keratohyalin grains in their cytoplasm. This layer occurs only where the process of keratinization is expressed. in the cheeks, lips, floor of the mouth, transitional folds, in the gingival sulcus and on bottom surface language in the norm of keratinization is not observed. Here the surface is formed by flattened cells. They are adjoined by several rows of i-like cells of a polygonal shape, tightly connected to each other.

The deepest layer of the epithelium is the germ layer, formed by cylindrical cells. They are located in one row on the basal membrane, therefore they are called the basal layer. Basal cells contain a rounded nucleus with a nucleolus and cytoplasm with numerous mitochondria. In addition to cylindrical cells in the basal layer, there are stellate cells with long processes - Langerhans cells. They are only revealed by silver impregnation. The regeneration of the epithelium occurs due to the growth layer.

basement membrane It is formed by a dense plexus of thin argyrophilic fibers and is the link between the epithelium and the lamina propria.

The actual mucosa consists of connective tissue, represented by the main substance, fibrous structures and cellular elements. This layer in the form of papillae undulates into the epithelium. This is where the capillaries are located. nerve plexuses and lymphatic vessels. The protective function of the connective tissue is to create a mechanical barrier. In this regard, for the normal state of the connective tissue, the substrate-enzyme system is of great importance: hyaluronic acid of the main substance - hyaluronidase. With an increase in the amount of tissue or microbial hyaluronidase, depolymerization of hyaluronic acid occurs, resulting in an increase in the permeability of the connective tissue.

Fibrous structures are represented by collagen and argyrophilic fibers. The greatest number of collagen fibers is located in the mucous membrane of the gums and hard palate.

The cellular elements of the mucosal lamina propria are represented mainly by fibroblasts, macrophages, mast and plasma cells, histiocytes (sedentary macrophages).

Fibroblasts are the main cellular form of connective tissue. They secrete precollagen, proelastin, etc.

Macrophages perform protective function. They phagocytize foreign particles of bacteria, dead cells, actively participate in inflammatory and immune reactions. During inflammation, histiocytes turn into macrophages, and after inflammation they return to dormant cell forms.

Mast cells - functional cells of connective tissue - are characterized by the presence of granules in the protoplasm. More often they are localized along the vessels. There are more of these cells in the area of ​​the mucous membrane of the lips and cheeks, less in the area of ​​the tongue, hard palate, gums, i.e. where the epithelium becomes keratinized. Mast cells serve as carriers of biologically active substances that are triggers for inflammation; heparin and histamine. They regulate vascular permeability, participate in the process of allergic reactions.

Plasma cells carry out protective, immunological processes of the mucous membrane, contain a large amount of RNA. Formed by antigen from lymphocytes. They produce immunoglobulins.

When pathological processes occur, segmented leukocytes and lymphocytes appear in the oral mucosa. Histiocytes can transform into epithelioid cells, which in turn can form giant cells. Epithelioid cells are found in specific mucosal diseases and candidiasis.

Submucosal layer represented by loose connective tissue. In the mucous membrane of the tongue, gums and partially hard palate, the submucosa is absent, and in the region of the floor of the mouth, transitional folds of the lips, cheeks, it is well expressed. This layer contains a large number of small vessels, minor salivary glands and Fordyce's sebaceous glands.

The mobility of the oral mucosa depends on the degree of expression of the submucosal layer (except for the tongue, where the mobility is due to the muscles).

The tissues of the oral cavity, lips, teeth and anterior 2/3 of the tongue are innervated by the trigeminal nerve (peripheral processes of the nerve cells of the Gasser ganglion). From the anterior 2/3 of the tongue, taste sensitivity perceives facial nerve(7th pair). The sensory nerve of the posterior 1/3 of the tongue is the glossopharyngeal nerve (9th pair). Sympathetic fibers penetrate along the arteries from the upper cervical ganglion. They affect mucosal blood supply and secretion salivary glands.

Features of the structure of the oral mucosa in children

In children, there are 3 age periods for the development of oral mucosa (Mergembaeva Kh.S., 1972):

I - neonatal period (from 1 to 10 days) and chest (from 10 days to 1 year).

II ~ early childhood period (1-3 years).

III - primary (4-7 years) and secondary (8-12 years) children's periods.

In newborns, epithelial the cover of the mucous membrane is thin and consists of 2 layers - basal and spiny. The papillary layer is not developed. The basement membrane is very thin and delicate. The epithelium contains a large amount of glycogen and RNA.

The connective tissue in its own layer of OM is loose and unformed. Fibrous structures are poorly differentiated, but their sharp fuchsinophilia is revealed, which indicates the presence of mature protein structures in the tissues. This fact can be regarded as the result of the placental transfer of protein structures to the fetus from the mother. In the chest period, the immune properties of the tissue acquired in the antenatal period begin to be lost.

The submucosal layer contains a significant amount cellular elements, mainly fibroblasts. There is a small number of histiocytes, lymphocytes and young mast inactive cells.

Such structural features of the oral mucosa in newborns determine its slight vulnerability and high ability to regenerate, as well as high resistance to viral and bacterial stomatitis.

In infancy the epithelium thickens, parakeratosis appears in the masticatory mucosa and on the tops of the filiform papillae, the amount of glycogen in these areas decreases. The basement membrane remains thin, the connective tissue of its own layer of the OM is poorly differentiated.

In early childhood(1-3 years) the regional differences in the SOPR are clearly defined. In the epithelium of the tongue, lips, cheeks, a relatively low amount of glycogen is detected. The basement membrane of the specialized and integumentary mucosa still tends to loosen.

A large number of cellular elements in the own layer of the mucous membrane, as well as around the blood vessels in the specialized and integumentary mucosa contributes to high permeability vascular wall in these areas. This can serve as one of the reasons for the frequent defeat of these particular areas in acute herpetic stomatitis.

The epithelial cover of the masticatory mucosa thickens. It reveals the processes of keratinization and parakeratosis.

During the primary period(4-7 years old) the intensity of metabolic processes decreases, the number of blood vessels and cellular elements in the proper layer of the OM decreases. The epithelium thickens, and the content of glycogen and RNA in it slightly increases, which is explained by a decrease in their consumption during this period.

In secondary childhood(8-12 years) there is a decrease in the amount of glycogen and an increase in the number of protein structures in the epithelium. The basement membrane becomes dense, the number of reticulin, elastic and collagen fibers increases in its own layer.

The number of lymphoid-histiocytic infiltrates around the vessels increases, which indicates the presence of sensitization in the child's body and the formation of protective mechanisms (antibody production). During this period, the tendency to diffuse reactions in the oral cavity decreases and oral diseases associated with allergies appear. There are quantitative and qualitative changes in mast cells- their number decreases, and their activity increases due to the accumulation of heparin monosulfate in their cytoplasm, which acts as non-specific factor protection, blocks proteolytic and mucolytic enzymes of blood and tissues, normalizes capillary permeability.

Morphological features of the oral mucosa, indicating a decrease in its permeability during this period, create prerequisites for a protracted chronic process in the oral cavity.

At the age of 12-14 years, under the influence of hormonal changes in the oral cavity, diseases such as juvenile gingivitis and mild leukoplakia predominate.

Separate parts of the oral mucosa (gingiva, hard and soft palate, etc.) in children may have a number of structural features, but in general they differ little from those in adults.

Desna - part of the mucous membrane immediately surrounding the lips. It isolates the periodontium from the external environment and is involved in the fixation of the tooth. The gum is subdivided into 3 elements: the interdental papillae, the marginal part, freely adjacent to the neck of the tooth, and the attached part, which is firmly fused with the periosteum of the alveolar process. Between the marginal gum and the neck of the tooth there is a gingival groove lined with non-keratinized stratified squamous epithelium and filled with gingival fluid. At the bottom of the gingival groove is an epithelial attachment to the tooth.

The gums in children are characterized by a number of signs:

1. More vascularized, the epithelium has a thinner layer of keratinized cells (up to 2.5-3 years old keratinized layer

absent or weakly expressed), and therefore the color of the gums is brighter.

2. Has a less pronounced granular surface due to a slight deepening of the epithelial papillae (papillary layer).

3. Differs in a low density of connective tissue.

4. It is characterized by a greater depth of gingival grooves than in adults.

5. During teething, the gingival margin has rounded edges with edema and hyperemia.

6. The basement membrane is thinner and has a delicate structure.

7. In children up to 2.5-3 years old, oral mucosa, including gums, contains a lot of glycogen. By the end of the formation of a temporary bite, the appearance of glycogen in the gum indicates inflammation of this area. This is the basis of diagnostics using the Schiller-Pisarev test.

8. Collagen fibers of the proper layer of the gingival mucosa are located loosely, insufficiently oriented, elastic fibers are absent.

9. During the period of mixed dentition, the layer of the epithelium of the gums thickens, its surface layer becomes keratinized, collagen matures and the tendency to diffuse reactions decreases. The permeability of histohematic barriers also decreases due to the appearance of perivascular accumulations of lymphocytes and histiocytes, which creates the preconditions for a chronic course. pathological process in the gum

10. During the period of permanent occlusion, the gums in children have a mature differentiated structure. Its surface layer becomes keratinized, with the exception of the epithelium lining the gingival sulcus, which is a weak point in the event of gingivitis.

Solid sky covered with stratified squamous keratinized epithelium and fixedly fused with the periosteum of the palatine bones. There are 4 zones of the mucous membrane of the palate:

1. Fat zone - located in the anterior third of the hard palate, its submucosa contains adipose tissue. In this zone, at right angles to the palatine suture, palatine folds diverge, which are based on thick bundles of collagen fibers. These folds are most pronounced in the fetus and smooth out significantly after birth.

2. Glandular zone - located in the middle and posterior thirds of the hard palate and contains end sections mucous palatine salivary glands. The submucosa is poorly expressed.

3. Zone of the palatine suture - stretches in the form of a narrow strip along the center of the hard palate from front to back. There is no submucosal layer in this area. A characteristic feature of the mucous membrane of the hard palate in the suture area is the presence in the lamina propria of rounded accumulations of epithelial cells (epithelial pearls), which are the remnants of the epithelium from the embryonic period during the fusion of the palatine processes.

4. Lateral (marginal) zone - corresponds to the areas of transition of the hard palate into the gum. There is no submucosa in this zone.

At the core lips lies the circular muscle of the mouth. The lip consists of 3 sections:

1. Skin section - has the structure of the skin, covered with stratified squamous keratinized epithelium, contains hair, sweat sebaceous glands, muscle fibers.

2. Red border - covered with stratified squamous keratinized epithelium, contains single sebaceous glands. The papillary layer is well defined with capillary loops that give the lip a red color. There are a large number nerve endings. There are no salivary glands in this area, which can cause dry lips. The zone of transition of the red border into the mucous membrane is called the Klein line. The epithelium of this zone undergoes parakeratosis, and in newborns it is covered with epithelial outgrowths (villi), which are considered a sucking device.

3. Mucous section - lined with non-keratinized stratified squamous epithelium, which contains a significant amount of glycogen. The lamina propria is composed of fibrous connective tissue and capillaries. The submucosa adjoins the muscles and contains more vessels, adipose tissue and terminal sections of the mixed salivary glands, excretory ducts which open in front of the oral cavity.

Cheek limits the lateral wall of the oral cavity; it is based on the buccal muscle. In the dermis and submucosal layer there is a large amount of adipose tissue and elastic fibers. The epithelium of the buccal mucosa is multi-layered, flat, non-keratinizing. Along the line of closing of the teeth, the epithelium can become keratinized and have more pale color. Epithelial cells contain large amounts of glycogen.

The lamina propria forms a low papillary layer, which is embedded in the epithelium by 1/4 of its thickness and contains collagen fibers.

In the submucosal layer there are mixed buccal salivary glands, which are more numerous in the posterior sections. In the buccal mucosa, subepithelially, sebaceous glands (Fordyce's glands) can occur, which look like yellowish grains on the surface of the mucous membrane, more often in the distal sections.

Soft sky is a fold of the mucous membrane with a muscular-fibrous basis. It has a brighter color compared to the hard palate, as it is covered relatively thin layer stratified squamous epithelium through which the capillary network is visible. Has its own mucous membrane. In the anterior part of the soft palate there is a submucosal layer, in which the terminal sections of the mucous salivary glands are located.

The posterior (nasal) surface of the soft palate is covered with a single-layer multi-row prismatic ciliated epithelium. In the lamina propria there are lymphatic nodules and ducts of small salivary glands.

The mucous membrane of the floor of the mouth covered with a thin stratified squamous non-keratinized epithelium, under which is its own plate, penetrated large quantity blood and lymph vessels. The submucosal layer is well defined, contains lobules of adipose tissue and small salivary glands.

Inferior surface of the tongue covered with thin stratified squamous non-keratinized epithelium. It has its own mucosal and submucosal layers. In the anterior section are mixed salivary glands.

Upper surface of the tongue (specialized mucosa) covered with a single layer of keratinized squamous epithelium. The submucosal layer is absent. There is an accumulation of lymphoid tissue in the posterior third of the tongue Pink colour or with a bluish tint. This is the lingual tonsil, which is part of the lymphoepithelial pharyngeal ring and performs a protective function. The lingual tonsil reaches its greatest development in childhood and undergoes involution after puberty. Under the mucous membrane, especially in back section, small salivary glands are located, the excretory ducts of which open to the surface. By the nature of the secret, serous, mucous and mixed glands are distinguished.

The epithelium and the mucous membrane proper on the back of the tongue form papillae: filiform, foliate, fungiform and grooved.

The filiform papillae cover the entire surface of the tongue, do not contain taste buds, and form a strong abrasive surface with which the tongue presses the food bolus against the hard palate. The epithelium in the region of the tops of the papillae undergoes keratinization and desquamation. When desquamation slows down, the tongue becomes furred. With the acceleration of desquamation of the epithelium, desquamative areas of pink color are formed.

Foliate papillae are well developed in children, located in the form of 8-15 folds on the lateral surfaces of the tongue in the distal sections and contain taste buds.

Fungiform papillae are located among the filiform papillae in the region of the tip of the tongue in the form of red dots and contain taste buds. They are covered with a thin layer of non-keratinizing multilayer squamous epithelium. The blood in the vessels is visible through a thin layer of the epithelium, giving these papillae a red color.

Grooved papillae (surrounded by a shaft) - the largest papillae of the tongue - are located in the form of a V closer to the root and are surrounded by a roller and a groove. In their walls there are a large number of taste buds.

On the border of the body of the tongue and the root, behind the grooved papillae, there is a blind hole - a consequence of the overgrown thyroid duct.

Pathological processes

Pathological processes in the OM can be divided into 2 groups: inflammatory lesions and tumors.

Inflammation is a protective vascular-tissue reaction of the body to the action of an irritant. According to morphology, they are distinguished 3 phases of inflammation: alterative, exudative and proliferative. Inflammation can be acute, subacute, and chronic. At acute course alterative and exudative changes predominate, and in chronic - proliferative ones.

Alternative the inflammation phase is characterized by the predominance of dystrophic and necrotic processes in cells, fibrous structures and in the interstitial substance of the mucosa.

Exudative the phase of inflammation is characterized by the predominance of hyperemia, edema and infiltration. Following a short-term reflex narrowing of the lumen of the capillaries, their persistent expansion occurs. Slowing of the blood flow leads to stasis and thrombosis of the mucosal vessels. The tone of the vessels decreases, and the permeability of their walls is disturbed. Blood plasma (exudation) and blood cells (emigration) go beyond the vessels.

Violation of vascular permeability is caused by the release of a large amount of biologically active substances (acetylcholine, histamine, serotonin, kinins) as a result of cell lysis. At the same time, edema and infiltration of the walls of blood vessels and connective tissue of the SO PR are observed. The infiltrate can be leukocyte, lymphoid, from plasma cells and with a predominance of erythrocytes.

proliferative the phase of inflammation is characterized by the processes of reproduction and transformation of cells. Reproduction of connective tissue cells underlies the formation of granulation tissue. In the process of fibroblastic proliferation, a new formation of connective fibers occurs. Such is the outcome of the acute process.

Chronic inflammation of the mucous membrane is characterized by the multiplication of connective tissue cells (lymphocytes, plasma cells, fibroblasts, etc.). Then a young, cell-rich granulation tissue is formed. The outcome of productive inflammation is the formation of mature connective tissue, i.e. development of sclerosis and fibrosis.

As a result of neurovascular disorders, focal necrosis often appears in the connective tissue structures of the mucosa. Surface defects - erosion - are formed when the integrity of only the surface layers of the epithelium is violated. If the connective tissue layer is damaged, then a scar is formed as a result of healing.

Diseases of the oral mucosa in a child

Chronic recurrent aphthous stomatitis (CRAS)- one of the most common diseases, which can be classified as infectious-allergic. CRAS is characterized by periods of remission and exacerbation and manifests itself in the form of aphthae - superficial painful defects of the mucous membrane. The aphthae are round or oval in shape, covered with a fibrinous coating, red hyperemic rims are visible around the aphthae. The appearance of aphthae is not preceded by the formation of bubbles. HRAS can occur in a mild form (1-2 aphthae) and in a severe form, when recurrent deep scarring aphthae are formed, the period of epithelization of which is delayed up to 2-3 weeks. At the same time, relapses of the disease are very frequent (may occur monthly).
The treatment regimen includes a diet with the exclusion of irritating foods, the appointment of immunocorrectors and immunomodulators (after consultation with an immunologist), vitamins B and C, desensitizing therapy. Local treatment of the oral cavity of the child antiseptic solutions, apply applications of proteolytic enzymes, lubricate with oil solutions of vitamins.

Acute herpetic stomatitis
Much more dangerous and, unfortunately, widespread is another form - acute herpetic stomatitis Infection of children with a virus herpes simplex is 60% under the age of 5, and 90% by the age of 15. In addition, acute herpetic stomatitis in immunocompromised children is highly contagious. The disease is spread by airborne droplets and by contact-household. The older the child, the lower the chance of getting sharp shape herpetic stomatitis due to acquired immunity.
The disease occurs in mild, moderate and severe forms. Incubation period is up to 17 days (in newborns - up to 3 days). In a child with acute herpetic stomatitis, the temperature may rise (up to 37-39o C, depending on the severity of the disease). The mucous membrane of the oral cavity is hyperemic, then single or grouped elements of the lesion appear. In more severe forms, rashes can appear both in the oral cavity and on the skin in the oral region. The disease is accompanied by symptoms of catarrhal gingivitis (inflammation and bleeding of the gums
The most reliable method for diagnosing a herpes infection is the polymerase chain reaction method (PCR diagnostics)

Treatment of acute herpetic stomatitis.
The treatment is complex. First of all, it is necessary to provide the child with good nutrition, however, excluding all traumatic factors from food (food should not be hard, spicy, salty, hot, etc.). It is important to ensure plenty of fluids. Before each feeding of the child, his mucous membrane must be anesthetized (2-5% anesthesin oil solution or lidochlor-gel). Antiviral therapy involves taking special antiviral drugs (as prescribed by a doctor. For epithelialization of affected areas, ointments based on proteolytic enzymes of animal origin are used, as well as oil solutions vitamins. Antivirals must be combined with immunomodulators (as prescribed by a doctor). When using a laser, aphthae are cleansed of fibrinous plaque, healing processes are accelerated.
To prevent relapse, it is necessary to strengthen the child's immunity naturally: hardening, swimming, good nutrition, etc. Careful sanitation of the oral cavity is also important: removal of dental deposits, treatment of caries and its complications.

pyoderma
Treatment of pyoderma in children
Pyoderma is streptostaphylococcal lesions of the oral mucosa, lips (cracks), skin perioral region. They occur in weakened children, with low immunity, as well as in children who do not receive balanced nutrition. Children with diabetes are extremely susceptible to pyoderma, which creates a good breeding ground for bacteria. Provoking factors are: hypothermia, overwork, overheating of the body, systemic diseases other organs.
With pyoderma, body temperature can rise to 38-39 degrees. C, lymphadenitis is observed. Bubbles-pustules form on the surface of the mucosa, the surface around which is hyperemic, and with rashes, purulent pustules and crusts appear on the skin. If left untreated, the infection can easily spread to other parts of the body (eyes, hands, etc.).
Treatment of pyoderma is determined by the nature of the pathogen. Therefore, it is necessary to bacteriological culture to determine the causative agent of the infection and its sensitivity to certain antibacterial drugs, and only after that the doctor can prescribe adequate treatment. Self-medication without tests can only blur the picture without destroying the pathogen.

Catarrhal stomatitis in children
Lesions of the oral mucosa caused by taking medicines. When taking many drugs (antibiotics, serums, vaccines, sulfonamides, novocaine, iodine, phenol, etc.), lesions of the oral mucosa may occur, which can be combined under the general name "catarrhal stomatitis".
An allergic reaction to medications also belongs to the same group of diseases of the oral mucosa in children. The mucous membrane is hyperemic, edematous, covered with multiple vesicles, after opening of which erosion may remain. The tongue and lips are also swollen. At the same time, the child may develop urticaria, muscle and joint pain, dyspepsia, and even anaphylactic shock.
Treatment is aimed primarily at identifying the cause of stomatitis. If taking, for example, antibiotics is necessary in the future, it must be combined with antifungal treatment and with antihistamines. Locally used rinses, painkillers, ointments that promote healing and epithelialization of the mucosa.

Diseases of traumatic origin

AT special group diseases of the oral mucosa in children of traumatic origin should be distinguished. The mucous membrane, due to its physiological features, has a high regenerative capacity. However, if it is mechanically damaged, dangerous pathogens can easily enter the wound, which will lead to its inflammation. A child can get injuries of the oral mucosa when brushing his teeth, when taking solid food, and during dental interventions. This may be an injury from sharp destroyed teeth, orthodontic appliances in the oral cavity. The child can bite the tongue, lips, cheek. A newborn, with careless wiping of the mouth, can be injured, which causes the so-called aphthae of newborns.
Treatment traumatic lesions The oral mucosa begins with the elimination of the causes of injury. Then locally prescribed antiseptic agents that relieve inflammation, and agents that promote healing (oils, solcoseryl-gel, etc.).
At chemical damage oral mucosa in a child (accidental ingestion of potent chemical substances) it is necessary to immediately rinse the child's mouth with plenty of water and a neutralizing solution (for example, alkaline - for acid burns). In the future, painkillers, antidotes, and agents that stimulate epithelialization are used. The nature of diseases of the oral mucosa in children is largely determined by age characteristics mucosal structure.

Thrush (acute candidiasis)
In infancy, the epithelium of the oral mucosa is very thin, so a fungal infection, with a decrease in saliva immunity, is very easily fixed on the surface of the mucosa. Thrush symptoms
At the first stage of the disease, red spots appear. They can be found on the tongue, buccal mucosa, lips and gums. A few days later, white cheesy rashes appear in place of the red areas. They look like the remains of cottage cheese or kefir in a child's mouth.
White plaque is separated with difficulty, and the wounds opened at the same time begin to bleed, bacteria in the oral cavity enter them, which can lead to various complications. Thrush in the mouth is painful. Because of this, children refuse to eat, cannot swallow saliva, and become restless. If you find a manifestation of the disease, then you need to see a doctor and only after that start treating thrush in children in the mouth.
In a severe form of the disease, the temperature rises, the baby becomes lethargic, symptoms of intestinal diseases join.
Treatment depends on the degree of the disease. It is necessary to treat the cavity of the baby regularly. Even if there are visible improvements, it is necessary to continue treatment according to the doctor's prescription. Since this is - fungal disease, then it may appear again and again. Treatment of thrush in children takes place until the infection disappears completely, as evidenced by repeated laboratory tests.
If thrush is found in the mother, then it will definitely be in the child.

Prevention of thrush
Follow the hygiene rules for children: bathe your baby regularly, boil nipples, bottles, toys. Strengthen your child's immunity with walks on fresh air, vitamins from fresh vegetables and fruits, therapeutic massage and, of course, love your baby, give him enough time and attention, and then he will grow up healthy.