Diathesis Peel a hard-boiled chicken egg. Release the shell from the film, dry, grind into powder (in a mortar or coffee grinder). The resulting powder does not require precise dosage. If the child is small, take the powder on the tip of a knife. The older the child, the higher the dose.

Diathesis With this disease, the skin of the child is affected, but the cause of it is considered to be a violation of the digestive tract. Skin rashes usually appear after eating a particular food. Since the main food of the baby is mother's milk, she

Exudative-catarrhal (allergic) diathesis (ECD) - a condition, ha-
rasterized by polymorphic rashes on the skin, increased sensitivity and vulnerability of the mucous membranes, a decrease in resistance to infectious agents, and frequent allergic reactions.
Clinical symptoms of ECD appear early, sometimes from the first days of life, usually after some provoking effect, and disappear, as a rule, by 2-3 years (85-90%).
Etiology. ECD is caused by genetic factors (hereditary burden in 70-80% of children), age-related characteristics of enzyme formation and immunological protection, as well as environmental influences.
Among the risk factors are unfavorable conditions of intrauterine development (toxicoses, malnutrition of the mother), fetal hypoxia and damage to the central nervous system during childbirth, infection and massive drug therapy, and the nature of feeding. So, with early artificial feeding, ECD develops 5-7 times more often than with natural feeding.
Pathogenesis. It is customary to distinguish between immune (transient and true) and non-immune forms of diathesis. Transient and true variants of immune ECD have a common immunological phase - hyperproduction of immunoglobulins E (IgE) with a clear decrease in IgA, IgG and the level of T-lymphocytes. In the more common transient variant of immune ECD (85-90%), IgE overproduction is secondary and is usually due to a massive intake of cow's milk antigen into the blood. Antigenemia is caused by insufficient digestion of lactalbumin due to deficiency or low activity of specific enzymes, and also by increased permeability of the gastrointestinal tract to protein in a young child. In addition, in children of the first six months of life, the immunological barrier of the intestine is also reduced - little secretory immunoglobulin (SlgA) is produced in the mucous membrane. With natural feeding, this deficiency is completely or partially covered by the presence of SlgA in mother's milk. The antigen circulating in the blood irritates the child's imperfect immunocompetent organs, perverts their reactivity and leads to hyperproduction of IgE. Similar reactions can also be caused by other antigenic provoking factors: vaccinations, medications, chemicals, etc.
However, not all children have antigenemia accompanied by a clinical picture of diathesis. In the pathogenesis of ECD, an important place is also occupied by the failure of the child's tissue barriers, which can be congenital, genetically determined or acquired (for example, as a result of discorticism).

ma). In addition, a possible deficiency of blocking antibodies is important, in which free formation and fixation of haptens in the skin and mucous membranes occurs with the development of reaginic sensitization. Subsequently, local degranulation of mast cells, the release of biologically active substances that increase vascular permeability and cause exudative reactions are observed.
Much less often, only in 10-15% of cases, ECD is observed, which is based on a true immune genesis. Hyperproduction of IgE in this case is genetically determined, fixed even in the absence of clinical manifestations in the proband and his family members, and is realized in the clinic also in case of failure of tissue barriers and contact with the antigen. It is this form of diathesis that can later be transformed into so-called allergic diseases.
An important link in the pathogenesis are also neuroendocrine and metabolic disorders. The state of the nervous system in children with ECD has long attracted the attention of researchers. So, M. S. Maslov and A. F. Tur believed that it was the peculiar reactivity of the central and autonomic parts of the nervous system that underlies this condition. This position is confirmed by increased nervous excitability, distinct vegetative dystonia with a predominance of parasympathetic system activity, symmetry of skin changes, and more frequent development of the clinical picture of diathesis in children with posthypoxic encephalopathies. Hypoxic conditions, apparently, can also be the root cause of endocrine disorders, which are most often manifested by discorticism. The latter in this case may be due to posthypoxic damage to the adrenal cortex. In addition, dyscorticism can also develop against the background of morphological and functional immaturity of the liver and its enzyme systems and associated disorders of corticosteroid metabolism. The result is an increase in mineralocorticoid activity and easily occurring disorders of microcirculation and water-mineral metabolism. Insufficient differentiation and enzymatic dysfunction of the liver also lead to violations of protein and vitamin metabolism, especially vitamins of group B. The whole complex of metabolic disorders causes a decrease in redox processes and the development of acidosis, which is observed in all children with ECD.
clinical picture. Children with ECD are usually pale, pasty. Body weight increases unevenly, easily decreases with diseases. Subcutaneous tissue is loose, hydrophilic, often overdeveloped, tissue turgor and skin elasticity are reduced, and paratrophy is pronounced.
Skin manifestations occur early, in the first weeks and months of life, and reach a maximum in the second half of the year. Initially, it is "gneiss" on the scalp (increased formation of seborrheic scales, peeling), persistent diaper rash in the skin folds, especially in the perineum and buttocks. Then hyperemia, infiltration and peeling of the skin of the cheeks ("milky jet") (Fig. 31) and strophulus - an itchy nodular rash on exposed parts of the body, sometimes with a dotted vesicle in the center, join. Scratching causes pitting, weeping, yellowish crusting (weeping eczema) and easy secondary infection. In severe cases, eczema spreads to most of the trunk and limbs, causing constant itching, anxiety, sleep disturbance, and intoxication.
At an older age (after a year), urticarial, erythematous-papular and pruriginous rashes, dry eczema, neurodermatitis are more often observed.
Increased vulnerability of the mucous membranes is expressed in increased desquamation of the epithelium of the tongue (“geographic tongue” - whitish annular areas of swelling and peeling of the epithelium), changes in the oral mucosa (stomatitis), as well as in easily occurring inflammatory eye diseases (conjunctivitis, blepharitis) and upper respiratory tract (recurrent rhinitis, pharyngitis, sinusitis, bronchitis, sometimes with an asthmatic component, false croup). Diseases are often severe, with severe disorders of microcirculation, toxicosis and exSycosis. Such children often have changes in the urine (proteinuria, leukocyturia, squamous epithelial cells) and intestinal dysfunction (thinned, rapid mucous stools) for no apparent reason.
In children older than a year, the frequency of the “asthmatic component” increases, which often later turns into bronchial asthma, dyskinesias of the biliary tract and gastrointestinal tract are detected.
Hyperplasia of lymphadenoid tissue is a characteristic clinical manifestation of ECD. Increased adenoids and tonsils, lymph nodes (more often regionally in relation to the skin process and changes in the nasopharynx), liver and spleen. Hyperplasia of lymphadenoid tissue in ECD is considered to be secondary, a consequence of a defect in humoral immunity, discorticism, and repeated infectious effects of metabolic disorders.
Laboratory data. Laboratory studies indicate increasing allergization (eosinophilia), persistent disorders of protein (hypo- and dysproteinemia, a decrease in the level of albumins and y-globulins, an imbalance of amino acids), fat (hypocholesterolemia) and carbohydrate (high initial sugar level) metabolism, a shift in the balance of acids and bases towards acidosis.
The diagnosis is based on early developing characteristic changes in the skin and mucous membranes, hyperplasia of the lymphadenoid tissue; phenomena of paratrophy, distinct metabolic and immunological disorders, reduced resistance of the child's body to infectious influences.
Forecast. In most children, with a sparing regimen and the absence of additional antigenic stimuli, by the age of 2-3 years, the enzyme and immune systems differentiate, the barrier functions of the skin and mucous membranes increase, and metabolic processes stabilize. Only in some patients, usually with true immune ECD and unfavorable living conditions, there is a transformation into "allergic diseases" (bronchial asthma, neurodermatitis, eczema).

The content of the article

In the doctrine of exudative-catarrhal diathesis, there are many unresolved issues; there is still no clear definition of this concept. A. A. Valentinovich (1972), O. A. Sinyavskaya (1978) consider the term " exudative diathesis” is not entirely correct and suggest replacing it with “allergic diathesis”, since children with this anomaly of the constitution have allergic altered reactivity, against which allergic dermatitis, true and seborrheic eczema, neurodermatitis, as well as combined lesions most often occur at an early age. skin and mucous membranes of the respiratory tract and alimentary canal.

M. S. Maslov pointed out that exudative-catarrhal diathesis is not a disease, but only a hereditary readiness, a predisposition to the disease. In the vast majority of cases, it is possible to single out the factor of heredity in the transmission of this readiness. According to M.S. Maslov, 43.7% of parents of children suffering from exudative diathesis also had manifestations of diathesis in childhood. A. F. Smyshlyaeva, A. A. Prikhodchenko (1973) found allergic diseases in the families of 71% of children suffering from exudative diathesis.

However, recognizing the importance of the constitutional factor in the genesis of exudative diathesis, it is also necessary to take into account that in the process of the formation of the child's phenotype, various environmental factors that cause sensitization of the body both in the prenatal period and in the process of childbirth and extrauterine development have a great influence. Readiness for sensitization can develop in children in utero. Possible passive and active sensitization of the fetus, especially in the last months of pregnancy. Factors contributing to the formation of fetal allergic reactivity can be toxicosis of pregnant women, errors in the diet of the expectant mother, diseases, intoxications, medications and other causes that lead to changes in the mother-placenta-fetus system with an increase in the permeability of the placental barrier for allergens.

Significantly more often, sensitization of the child occurs after birth. This is facilitated by the ability of the intestinal wall of children in the first months of life to pass substances containing allergens into the blood. Especially often such conditions are created in diseases of the intestines or an increase in the permeability of the vascular wall in various pathological conditions.

Increased permeability of vascular membranes, lability of vascular reactions, increased excitability of bulbar centers cause more frequent and rapid sensitization of the organism of children.

Causes of exudative-catarrhal diathesis

During the period of milk teeth and at school age, the number of factors that can cause allergies increases: a variety of food substances, local physical and chemical irritants, pustular skin infections, climatic and meteorological factors, etc.

M. I. Olevsky objects to the main role of food as an allergic factor in the pathogenesis of skin lesions in children suffering from exudative catarrhal diathesis, and believes that the process of autosensitization plays a leading role. The role of autoantigens, in his opinion, can be played by damaged skin cells that cause the production of autoantibodies.

The symmetry of the lesion, its dynamics, often rapid involvement in the process of significant surfaces, the dynamics of itching indicate the involvement of the nervous system in the development of pathological changes in the skin with exudative diathesis. Dysfunctions of other systems and organs are secondary and primarily reflect the disorder of neurohumoral regulation. In children with exudative-catarrhal diathesis, regardless of the ways and conditions of its development, there is a completely different reaction to various environmental influences compared to healthy children: a tendency to catarrhal processes, slight vulnerability and irritability of the skin, low resistance to infections, a protracted course of the disease , frequent complications and relapses.

Pathogenesis of exudative-catarrhal diathesis

At children suffering from exudative diathesis, there is a disimmunoglobulinemia of the main classes of immunoglobulins and a genetically determined feature of the synthesis of IgE. Children with a hereditary predisposition to allergic reactions have excessive production of IgE and insufficient secretion of secretory IgA. Reagins that are fixed in tissues cause significant changes in them - a violation of microcirculation, cell proliferation (AD Ado, 1970).

Thus, the leading role in the pathogenesis of exudative-catarrhal diathesis is played by a violation of immunological reactivity, a defect in the immune system; special importance is attached to secretory and serum IgA. Allergic process, according to O. A. Sinyavskaya (1978), is "launching" and affects the overall biological processes in the body. Exudative-catarrhal diathesis is characterized by hyperplasia of the lymphoid tissue, thymus gland, i.e., cells involved in the immune response.

Of great importance in the genesis of exudative-catarrhal diathesis is the peculiarity of the activity of the central and autonomic nervous system. It can be assumed that against the background of the innate functional characteristics of the nervous system, sensitization to alimentary, medicinal, infectious and other allergens easily develops.

Significant role in the pathogenesis of exudative-catarrhal diathesis have metabolic disorders: protein, lipid, carbohydrate, water-electrolyte. There is an increased water content in the tissues, especially in the skin, a slow excretion of sodium chloride from the body with a delay of chlorine and sodium in the tissues, which leads to their increased hydrophilicity (with the intradermal McCoupure-Aldrich test, the time for resorption of the blister with the introduction of isotonic sodium chloride solution decreases to 6 - 15 minutes, at the norm - 45 minutes). The lability of water metabolism explains the peculiar fluctuations in the curve of body weight in children suffering from exudative-catarrhal diathesis. The content of potassium in the blood serum is increased to 5.5 - 6.2 mmol / l (normally 3.8 - 4.6 mmol / l), the calcium level is within the normal range (2 - 2.6 mmol / l), the ratio potassium to calcium increases. Dysproteinemia (a decrease in the content of albumins and an increase in globulin fractions) is noted mainly due to a2- and y-globulins. There are significant deviations in the acid-base balance, impaired liver function, biosynthesis processes in the adrenal cortex (the predominance of the synthesis of 17-deoxycorticosteroids-promineralocorticoids).

Insufficiency of a number of vitamins (ascorbic acid, retinol, tocopherol and group B) is also of great importance in the pathogenesis of exudative-catarrhal diathesis.

There is an increased permeability of capillaries, a violation of tissue redox processes, histamine metabolism, a decrease in the histamine-pectic activity of blood serum, ATP deficiency, a violation of tryptophan metabolism, pyridoxine biosynthesis, the enzymatic status of blood neutrophils, and a decrease in nonspecific immunity.

Clinic of exudative-catarrhal diathesis

• Eretic is more often observed in children with a strong unbalanced, unrestrained type of mental activity (type III - according to N. I. Krasnogorsky). These children are easily excitable, irritable, tearful, their sleep is not deep, their appetite is reduced, the subcutaneous fat layer is poorly developed.
• The pasty type of diathesis is observed mainly in children with a weak hypoergic type of mental activity (type IV - according to N. I. Krasnogorsky). Children are lethargic, inactive, phlegmatic, characterized by reduced excitability of nervous processes and their rapid exhaustion, slow development of conditioned reflexes. They have overweight and reduced tissue turgor.

The main clinical symptoms of exudative-catarrhal diathesis are various skin rashes, the most common are erythema, diaper rash, gneiss, milk scab, strophulus, pruritus, eczema.

• Skin erythema- redness of the skin in the area of ​​​​natural folds and on the trunk.
• diaper rash- weeping irritation of the skin of adjacent folds (on the neck, in the inguinal folds, perineum, behind the ears, in the armpit, elbows, etc.).
• Gneiss- the appearance of oily scales (dandruff) often with a weeping surface under them on the head around a large fontanelle, on the forehead, superciliary arches. Gneiss refers to the early manifestations of exudative-catarrhal diathesis.
• milk scab- hyperemic infiltrate of the skin of the cheeks, sharply delimited from normal skin. In the future, due to persistent itching and scratching, an exudate appears, drying into crusts and scabs.
• Strofulus- in children aged 6-8 months, sometimes older, itchy vesicles filled with a clear liquid appear on the skin of the trunk and extremities, and denser, papular rashes of 2-3 mm in size, surrounded by a halo of hyperemia. Severe itching, aggravated especially in the evenings and at night, disturbs the sleep of children, excoriations appear as a result of scratching, and pyodermatitis develops with a secondary pyogenic infection. The course of strophulus is long, remissions are replaced by frequent exacerbations.
• Scabies characterized by localization of the rash on the extensor surfaces of the limbs, especially the lower ones. Abundant rashes are observed on the shins and forearms. The elements of the rash have a peculiar appearance: pruriginous nodules - papules ranging in size from 1 - 3 to 5 - 7 mm, very dense in consistency, slightly different in color from normal skin (they are easier to feel than to see). Severe itching, especially at night, leads to scratching of the nodules with the formation of excoriations, covered with a blackish-brown crust. The rashes last for several days and leave behind either age spots or, with deep excoriations, a small white scar.
• eczema seborrheic may appear as early as 2-3 weeks of a child's life. The process begins with the scalp, quickly spreads to the face, and then all over the skin. The skin in the lesions is hyperemic, slightly infiltrated with grayish-white scales on the surface. Unlike true childhood eczema, with seborrheic, moderate itching is observed, very rarely weeping. It usually develops in children with dry skin and poor weight gain from birth.
• True eczema more often observed in pastose children with overweight. On the 3rd - 5th month of life, small itchy, symmetrically located vesicles with transparent contents appear on the erythematous skin of the cheeks. Bubbles have a sluggish top, quickly open, turning into microerosions, which merge with each other, forming widespread weeping surfaces. After the exudate dries up, yellow or brown crusts form. The process ends with the rejection of the crusts, after which the skin of the cheeks becomes smooth, bright pink. Despite the recurrent course of the disease, after treatment, the skin of the face remains thin and tender.
• microbial eczema characterized by asymmetric appearance of foci, clear boundaries, often pronounced polymorphism of rashes, the absence or mild infiltration of the skin. More often localized on the lower extremities, less often - on the skin of the trunk, head. The skin in the lesions is brightly hyperemic, edematous, often with weeping or serous-bloody, purulent crusts on the surface. Around the main foci are scattered pustules. This form of eczema often develops in children with chronic intoxication, in the presence of foci of infection (tonsillitis, otitis, cholecystitis, urinary tract infection, etc.) and ends, as a rule, with recovery after sanitation of the foci and rational treatment.
• Neurodermatitis. The favorite localization of rashes in neurodermatitis is the skin of the rear of the hands, elbow and popliteal folds, neck, around the wrist and ankle joints. The skin of the affected areas acquires a brown-pink color, sometimes with a cyanotic tint; papules merge with each other, the skin is infiltrated, lichenized, cracks, excoriations, and crusts are often observed. During periods of exacerbation, the skin of the affected areas becomes brightly hyperemic, edematous, weeping is observed. Characteristically, itching precedes the rash.

• In the neonatal period - erythema, persistent diaper rash, gneiss, small papular rash on the face.
• In infancy - skin erythema, diaper rash, gneiss, milk scab, strophulus, pruritus.
• In the second half of life, persistent diaper rash disappears, the manifestations of seborrhea are noticeably reduced. The milk scab gradually transforms into an eczematous lesion of the face. The transformation of exudative diathesis into childhood eczema is facilitated by irrational feeding, the introduction of a new food product (cow's milk, eggs, citrus fruits, etc.), repeated illnesses, long-term antibiotic therapy, and in some cases preventive vaccinations (often the second and third DTP).
• On the 2nd - 3rd year of life, against the background of exudative-catarrhal diathesis, true allergic diseases often form.
• In older children, eczema and neurodermatitis are often combined with other allergies (bronchial asthma, urticaria, angioedema).

In children with exudative-catarrhal diathesis, as a rule, regional lymph nodes are enlarged: occipital, cervical, parotid, submandibular: less often - axillary and inguinal. Often there is an enlargement of the spleen. Indicators of nonspecific resistance (complement titer, phagocytosis, lysozyme content, properdin level, bactericidal activity of blood serum) are reduced.

Diagnosis of exudative-catarrhal diathesis

In the conditions of an allergological office and a hospital, skin tests with a set of food, household and bacterial allergens, passive hemagglutination reaction (PHA), complement fixation reaction (RCC), indirect reaction of mast cell degranulation, Shelley test, reaction of blast transformation of lymphocytes are used as additional diagnostic tests ( RBTL), rosette formation (E-ROK).

Of great importance for the diagnosis of exudative-catarrhal diathesis, the identification of individual intolerance to certain allergens, is keeping a food diary, in which the time of eating, its composition, quantity, quality of the food product, the method of cooking, the child's well-being, changes in the general condition, and itching are recorded daily. , nausea, vomiting, diarrhea, skin rashes.

The course of exudative-catarrhal diathesis is undulating. OA Sinyavskaya (1980) distinguishes 4 phases in the clinic of exudative diathesis: latent, manifest, remission and relapse.

Latent phase - the period before the first clinical manifestations of diathesis in the presence of a hereditary predisposition. The exacerbation of the process can be caused by nutritional errors, the introduction of vaccine preparations, y-globulins, the use of antibiotics, sulfanilamide preparations.

Rapid manifestations of diathesis from the skin and mucous membranes are usually observed in infants. At the end of the second year of life, the manifestations of diathesis in most children noticeably decrease, and later go into a remission phase. During this period, various tests can reveal increased irritability of the skin and mucous membranes, the originality of the reactions of the autonomic nervous system and metabolism. Allergic tests remain positive for a long time.

Forecast of exudative-catarrhal diathesis

Treatment of exudative-catarrhal diathesis

In complex treatment it is necessary to provide for rational nutrition, elimination of identified and suspected allergens, normalization of the general regimen of the child, sanitation of foci of chronic infection, followed by dispensary observation.

• The use of antihistamine and antiallergic drugs is pathogenetically justified. In severe forms of exudative-catarrhal diathesis, histaglobulin (hystaglobin) is used.
  Before starting treatment, an intradermal test with 0.1 ml of histoglobulin is performed. In the absence of a reaction, treatment is carried out. The drug is administered subcutaneously, gradually increasing the dose from 0.5 ml to 1 - 2 ml; the interval between injections is 3-4 days. The course of treatment consists of 4 - 6 injections. If necessary, the treatment can be repeated after 1-2 months. Histaglobulin is especially effective for eczema and neurodermatitis. The undoubted advantage of the drug is a pronounced antipruritic effect, a significant lengthening of the remission period.
• Vitamins that mainly affect tissue metabolism are widely used: retinol acetate, thiamine chloride and bromide, riboflavin, calcium pantothenate, pyridoxine hydrochloride, calcium pangamate, ascorbic acid, rutin. It should be remembered that the use of thiamine and pyridoxine during the period of pronounced clinical manifestations of exudative-catarrhal diathesis is contraindicated, as it can exacerbate allergic reactions, especially with eczema.
• To reduce itching and improve sleep, a variety of sedatives and hypnotics are used: phenobarbital (0.005 - 0.075 g); barbamil (0.01 - 0.15 g); bromisoval (00.3 - 0.1 - 0.25 g); sodium bromide (children under 1 year - 0.05 - 0.1 g; up to 2 years - 0.15 g; 3 - 4 years - 0.2 g); infusion of valerian root (at the rate of 2 g per 100 ml of water, 1 teaspoon 3-4 times a day); chlordiazepoxide (0.005 g per day); chlorpromazine at the rate of 1 mg / kg / day for 2 - 3 doses.
• From non-narcotic analgesics, derivatives of salicylic acid are prescribed: sodium salicylate, acetylsalicylic acid.
• For the treatment of exudative-catarrhal diathesis, calcium salts are widely used: calcium chloride, gluconate, lactate.
• In lethargic, passive, pasty children, the administration of thyroidin (0.003-0.01 g 2-3 times a day) has a positive effect. The duration of treatment with thyroidin is 2-3 weeks.
• If children with exudative-catarrhal diathesis have staphylococcal skin lesions, it is effective to prescribe broad-spectrum antibiotics (oxacillin, ampiox, gentamicin, lincomycin, tseporin) and specific anti-staphylococcal therapy (administration of anti-staphylococcal y-globulin and toxoid according to the scheme).
• M. D. Nemtseva with exudative-catarrhal diathesis recommends prescribing magnesium sulfate inside, which has a laxative effect. Children under the age of 6 months are prescribed 1 teaspoon of a 1% solution 4 times a day 15 minutes before meals for 3 days; from 6 months to 1 year - 1 teaspoon of a 2% solution 4 times a day; 1 - 3 years - dessert spoon of 2% solution 4 times a day; after 3 years - 1 tablespoon 4 times a day. If the rash does not decrease, take a break for 1-2 days, after which another course of treatment is carried out.
• With a tendency to constipation, the appointment of a 10-15% solution of sorbitol, 30-50 ml 3 times a day for 3-4 weeks, is indicated.

Diet for exudative-catarrhal diathesis

A child of the first year of life should receive protein 3 - 3.5 g / kg, fat - 5 - 6 g / kg, carbohydrates - 12 - 13 g / kg per day. It is advisable to introduce part of the fat at the expense of vegetable fats rich in unsaturated fatty acids.

Children who are on artificial and mixed feeding need to reduce the amount of cow's milk. Instead of milk, it is desirable to give fermented milk mixtures (kefir and its dilutions, acidophilic milk, biolact), which are better tolerated. Complementary foods should be introduced earlier - at 3.5 - 4 months, and it is better to prescribe vegetable puree, and not porridge.

American authors recommend that children with manifestations of exudative-catarrhal diathesis with natural feeding introduce complementary foods later than healthy children. Each new type of food should be introduced very carefully, in small doses and traced in a food diary for at least two weeks.

Freshly prepared juices (apple, plum, lingonberry, blueberry, currant), rich in mineral salts, which have a beneficial effect on hematopoiesis and capillary resistance, should be introduced into the diet. Orange juices (from oranges, tangerines, carrots) for children with exudative catarrhal diathesis are prescribed later than usual, with caution and in limited quantities.

Egg yolk is prescribed at the age of 3.5 - 4 months very carefully, starting with the V8 part, always boiled and only at a time when the child does not have clinical manifestations of diathesis.

The introduction of liquid and salt should be somewhat limited. With dysfunction of the intestines, it is necessary to limit the content of fat in food to 5-4 g / kg. Meat broth should be excluded from the diet. From 7 - 8 months of age, boiled meat (beef, rabbit) can be introduced, starting with one teaspoon (5 g).

The amount of sugar in the diet should not exceed 5%, and during the period of exacerbation of diathesis, it is advisable to replace it with sorbitol or xylitol, which have a lipotropic effect and improve fat resorption.
Diet in children older than 1 year should be observed as strictly as in infancy. It is very important to avoid overfeeding. The child should receive no more than 400 ml of milk per day, preferably in the form of kefir, yogurt, acidophilus milk. It is necessary to exclude meat broths, fats, fatty meats; meat is better to give boiled.
Obligate allergens are also excluded:
citrus fruits, strawberries, wild strawberries, tomatoes, bananas, honey, nuts, cocoa, chocolate, smoked meats, etc. The food of children of any age should be rich in vitamins. Additionally, ascorbic acid is prescribed at 200-300 mg/day, thiamine chloride at 10-15 mg, riboflavin at 2-6 mg, rutin at 40-60 mg/day.

local treatment.
The child should be washed with infusion of chamomile or 2% solution of boric acid. Abundant crusts on the head and face are removed after repeated application (for several hours) of bandages soaked in boiled vegetable oil. Then lotions are made on the weeping surface from a 0.25% solution of silver nitrate. In the absence of wetting, it is recommended to use a sulfur color. After reducing wetting, infiltration and hyperemia of the skin, you can use indifferent talkers with talc, zinc, less often with anesthesin, and then Lassar paste. Good results are obtained by alternating Lassar paste (after lotions) with 1% synthomycin liniment. In the future, ointments are used: nafgalan, sulfur-naphthalan, 2% yellow mercury, etc. Dry skin with cracks should be treated with retinol.

In case of infection of the affected areas of the skin, it is necessary to use antimicrobial agents: 1-2% solution of brilliant green, methylene blue, Castellani's paint.
With infected eczema, heliominin ointment (4% on a vaseline-lanolin basis) can be used.
Ointments with steroid hormones (prednisolone, oxycort, fluorocort, dermozolon, locacorten, flucinar, sinalar forte, sinalar-N, etc.) are prescribed in exceptional cases, mainly for eczema and neurodermatitis, accompanied by severe itching, with the ineffectiveness of other methods of treatment, only for short term (no more than 7 - 10 days) and on separate skin areas.

During the period of pronounced skin manifestations of diathesis, baths with infusion of chamomile, thyme herb, decoction of string, tricolor violet, oak bark, etc. are shown. The choice of bath depends on the nature of the rashes on the skin. With diaper rash, strophulus, pruritus, true and seborrheic eczema, tannin baths, with a decoction of string, oak bark, which have a tanning effect, or starch baths are more often used. With neurodermatitis, baths with chamomile infusion, coniferous extract, and wheat bran are shown. In the presence of a secondary infection, baths with the addition of potassium permanganate (0.3 g per bucket of water) are recommended.

After the bath, the child's skin should be thoroughly dried with blotting movements and powdered with "sour" powder, consisting of lanolin - 5 g, sulfuric ester - 25 g, boric acid - 10 g, talc - 85 g or salicylic acid - 1 g, boric acid - 20 g, talc - 79 g. "Acid" powder provides a slightly acid reaction of the skin, which prevents the introduction of pyococcal infection.

With a protracted, recurrent course of exudative-catarrhal diathesis, stimulating therapy is used - ultraviolet irradiation (15 - 20 sessions), aloe extract (0.1 - 0.2 ml) subcutaneously, for a course of treatment - 10 - 15 injections.

Children of early age, but after a year, stay by the sea is shown (Anapa, Berdyansk, Evpatoria, Riga seashore). Balneological and resort treatment (Sochi, Matsesta) is recommended for older children. If skin rashes intensify in summer, then ultraviolet irradiation, sunbathing, and staying by the sea are contraindicated for children.
The duration of treatment for exudative-catarrhal diathesis is different and depends on the duration and severity of skin manifestations.
In each individual case, treatment should be complex, highly individual and always combined with rational diet therapy.
In the complex of therapeutic measures, the correct organization of the regimen, a long stay in the fresh air, careful hardening, and careful care of the child are of great importance.
It is necessary to strictly monitor the frequent change of linen and bedding.

Prevention of exudative-catarrhal diathesis

• Antenatal prevention of exudative-catarrhal diathesis carried out by obstetricians and gynecologists. During pregnancy, a woman should eat rationally: avoid one-sided and excessive nutrition, eating food-trophallergens. Under the special control of the antenatal clinic should be women with complicated pregnancy (early and late toxicosis), with various extragenital diseases. Their timely detection and treatment is an important measure for the prevention of intrauterine fetal sensitization.
• Postnatal prevention of exudative diathesis carried out by pediatricians. Of great importance is the promotion of natural feeding, since diathesis is more often observed in children who are on artificial and mixed feeding. Obligate trophallergens must be excluded from the child's diet. With mixed and early artificial feeding, it is advisable to prescribe fermented milk mixtures. An excess of protein, fat, carbohydrates, salt should not be allowed in the diet, dishes and foods rich in extractive substances should be excluded, and overfeeding should be avoided. If a child is prone to excessive weight gain, an appropriate nutritional correction is necessary, since paratrophy contributes to the development of allergic diseases.

Children with exudative-catarrhal diathesis should be registered in the dispensary. The question of carrying out prophylactic vaccinations should be decided strictly individually, with great care and not earlier than 6 months after the last relapse. Antihistamines, calcium gluconate, ascorbic acid, rutin are prescribed 3 days before vaccination and within 10 days after it.

Early prevention of exudative-catarrhal diathesis, timely treatment of its exacerbations is the basis for the prevention of severe allergic and infectious-allergic diseases in children.

The concept of the constitution. constitutional anomalies. Types of diathesis.

Atopic dermatitis.

Nursing process with anomalies of the constitution.

Lecture #7

Lecture plan:

1. The concept of the constitution. constitutional anomalies. Types of diathesis.

2. Atopic dermatitis. The incidence rate. Causes and risk factors of atopic dermatitis.

Clinical manifestations of atopic dermatitis in young children, complications. Diagnosis and principles of treatment. Nursing process in atopic dermatitis.

3. Prevention of atopic dermatitis.

body constitution(constitutio - composition, structure) is a complex of hereditary, functional and morphological features of the body that determine its response to various environmental influences.

Anomalies of the constitution - diathesis(diathesis - predisposition, inclination to something). Diathesis is an anomaly of the constitution, which is manifested by an inadequate response to common external factors and determines the body's predisposition to the development of certain pathological processes and diseases.

There are four types of diathesis:

Exudative-catarrhal

Allergic

Lymphatic-hypoplastic

neuro-arthritic

Family-hereditary predisposition to allergic diseases, disorders of the gastrointestinal tract, chronic inflammatory diseases.

Irrational nutrition of the mother during pregnancy, abuse of obligate allergens (citrus fruits, chocolate, strawberries, fish, chicken, honey, eggs).

Severe toxicosis of pregnancy, infectious diseases of the mother during pregnancy.

Early artificial feeding of the child. The main role in the occurrence of diathesis is assigned to cow's milk protein, then egg white, etc.

The use of drugs, both during pregnancy and in the postnatal period (antibiotics, vitamins, gamma globulins, vaccines, sera, etc.)

The use of household allergens in child care: washing powders, fragrances, creams, oils, etc.

Impact of non-specific factors: overheating, hypothermia, solar insolation, etc.

Exudative catarrhal diathesis (ECD) - a special condition of the body, characterized by increased sensitivity of the skin and mucous membranes to inflammation, a predisposition to allergic reactions and a protracted course of inflammatory diseases. ECD is observed in 50-60% of young children.

Etiology:

Hereditary predisposition to allergic diseases.

The development of sensitization and allergies.

Risk factors for developing the disease:

· Family and hereditary predisposition to allergic diseases, disorders of the gastrointestinal tract, chronic inflammatory diseases.

Improper nutrition of the mother during pregnancy, abuse of obligate allergens (citrus fruits, chocolate, strawberries, fish, chicken, honey, eggs).

Severe toxicosis of pregnancy, infectious diseases of the mother during pregnancy.

· Early artificial feeding of the child. The main role in the occurrence of diathesis is assigned to cow's milk protein, then egg white, etc.

The use of drugs, both during pregnancy and in the postnatal period (antibiotics, vitamins, gamma globulins, vaccines, sera, etc.)

· The use of household allergens in child care: washing powders, fragrances, creams, oils, etc.

· Impact of non-specific factors: overheating, hypothermia, solar insolation, etc.

The mechanism of the pathological process:

There is a hereditary-conditioned change in the immunological reactivity of the child's body, a decrease in Ig A and an increase in Ig E. Biologically active substances (histamine, serotonin, etc.) accumulate in tissues and liquid media, which, being released from connective tissue mast cells, platelets and basophils cause allergic reactions.

In addition, there is a hereditary metabolic disorder: protein metabolism (dysproteinemia), fat metabolism (hypercholesterolemia, hyperlipidemia), carbohydrate metabolism (hyperglycemia), acid-base state (acidosis), vitamin metabolism (hypovitaminosis A, C).

Violation of the function of the adrenal glands causes an increased delay in the body of sodium, chlorine, potassium and water.

Dysfunction of the gastrointestinal tract leads to a decrease in the activity of digestive enzymes and an increase in the permeability of the mucous membrane of the digestive tract.

clinical picture.

The first symptoms may appear already in the first weeks of a child's life, after the repeated intake of the allergen into the body, the production of a sufficient amount of antibodies and the interaction of antibodies with antigens:

Persistent diaper rash in the natural folds of the skin with good care, difficult to treat.

Brownish fatty scales on the scalp and superciliary arches (gneiss, seborrhea).

Hyperemia, infiltration, peeling on the skin of the cheeks (milk scab), sometimes bubbles and small scales form.

Dryness and pallor of the skin.

Recurrent thrush on the oral mucosa, "geographical" tongue.

Weeping and cracks behind the ears.

The general condition of the child is disturbed: restless sleep, irritability, mood instability.

From 2-3 months may appear:

Erythematous-papular weeping spots on the cheeks, which can spread to the entire face, neck, wrists, hands, extensor surfaces of the limbs, causing severe itching (dry or weeping eczema).

Rashes in the form of vesicles filled with serous contents (strophulus), which quickly open and form erosions; at the same time, damaged skin surfaces often become infected.

Sometimes small, dense, itchy nodules (pruritus) appear on the limbs with severe dryness and flaking of the skin.

· Unstable stools may appear.

The course of the disease is undulating, periods of exacerbation are replaced by periods of remission. Exacerbation of ECD often coincides with the transfer of a child to artificial feeding or the introduction of new food allergens into food.

Complications:

Layering of secondary infection.

Transition to an allergic disease.

Symptoms of diathesis usually subside by the age of 3-5 years, however, children suffering from ECD may subsequently be predisposed to the development of the following diseases and allergic processes:

Infectious and inflammatory diseases: blepharitis, conjunctivitis, pharyngitis, laryngitis, bronchitis, acute respiratory viral infections, pneumonia with obstructive syndrome, urinary tract infections (there is a tendency to their recurrent course).

· Allergic diseases: respiratory allergy, bronchial asthma, neurodermatitis.

· Chronic eating disorders.

Rickets, anemia.

Formation of chronic foci of infection: tonsillitis, sinusitis, adenoiditis.

Basic principles of diathesis treatment:

1. Organization of rational nutrition (hypoallergenic diet):

The maximum duration of breastfeeding (up to 3-4 months).

· Obligate allergens and histamine liberators (chocolate, fish, mushrooms, smoked meats, citrus fruits, etc.) should be excluded from the diet of a nursing mother, cow's milk, eggs should be limited, vegetables and fruits of red, black and orange color should be excluded.

In the absence of breast milk, sour-milk mixtures are prescribed, in case of intolerance to cow's milk - mixtures prepared with soy or almond milk or milk of other animals (goat).

The first complementary foods are introduced from 4 months in the form of dairy-free vegetable puree from zucchini, white cabbage, potatoes.

The second complementary foods - cereals (buckwheat, rice, corn, oatmeal) on a vegetable broth or soy-based, introduced a month after the appointment of the first complementary foods.

The third complementary food is again vegetable puree from 6 months.

· Meat is introduced from 6-7 months (rabbit, turkey, lean beef, lean pork) in boiled form.

· Meat broth is contraindicated, only vegetarian soups are prepared.

· Hard-boiled egg yolk is allowed in the diet no earlier than 12 months. The introduction of cottage cheese, fish, whole eggs is not shown.

Easily digestible carbohydrates are limited, part of the sugar is replaced by sweeteners.

· Juices are given according to age, freshly prepared, from green apples and white currants. You can not enter canned food in any form.

2. Organization of hypoallergenic life:

Wet cleaning in the room where the child is, 2 times a day.

· Avoid contact of the child with pets, fish food, household allergens, remove feather and down pillows, blankets, duvets.

Remove carpets and potted flowers from the child's environment.

· Avoid woolen, synthetic clothing.

3. Medications:

Antihistamines: tavegil, suprastin, pipolfen, fenkarol, claritin, ketotifen.

Vitamin therapy: vitamins A, B, E, calcium pantothenate, lipoic acid.

Biological products: bifidumbacterin, lactobacterin (with unstable stool).

Enzyme therapy: abomin, pancreatin, panzinorm.

Immunocorrective therapy: histaglobulin, allergoglobulin.

Immunity enhancers: dibazol, eleutherococcus, ginseng, lemongrass.

Sedative preparations (for skin itching): valerian, motherwort.

4. Local therapy:

Zinc paste with anestezin, ointments with naftalan, lanolin, zinc oxide, 3% sulfur-salicylic ointment - to relieve itching and inflammation. In the absence of effect - ointments with the addition of glucocorticoids (prednisolone, flucinar).

· Talkers with talc and zinc oxide, solcoseryl (ointment, gel).

Lotions with 1% resorcinol solution or 0.25% silver nitrate solution, with peach or olive oil - when wet.

· Therapeutic baths with decoctions of succession, viburnum, chamomile, with starch (during exacerbation, carry out daily).

· In case of gneiss, 2 hours before bathing, lubricate the crusts with vaseline or vegetable oil, remove them with a comb during bathing.

5. Phytotherapy: a decoction of the collection of herbs - licorice, burdock root, nettle, sage, birch - for 2-4 weeks, repeat the course 3 times a year

Prevention.

1. Antenatal:

Detect pregnant women with a aggravated allergic history when performing patronage

Rational nutrition of a pregnant woman, do not abuse the intake of drugs.

Avoid stressful situations during pregnancy, give up bad habits.

Timely detection and treatment of toxicosis and diseases in a pregnant woman.

2. Postnatal:

The maximum duration of breastfeeding.

Rational nutrition of a nursing mother and child with the exception of food allergens.

Avoid contact with possible allergens.

· Carry out hardening of the child, long walks in the fresh air.

· Take medication only as directed by your doctor.

Create a hypoallergenic life in the house.

Keeping a "food diary" on a regular basis to identify significant allergens and eliminate them.

Regularly sanitize foci of chronic infection.

Timely treatment of dysbacteriosis.

Dispensary observation carried out by a pediatrician for at least 2 years from the moment of exacerbation, if necessary, an immunologist, an allergist, a dermatologist consult.

Possible patient problems:

· Malnutrition.

Violation of the integrity of the skin, mucous membranes.

Discomfort due to itching.

· Sleep disturbance.

High risk of secondary infection.

Psycho-emotional lability.

High risk of developing allergic diseases.

Possible problems for parents:

· Lack of information about the disease.

Difficulty in creating and maintaining a hypoallergenic household

Organization and provision of a child with a hypoallergenic diet.

Feelings of powerlessness and guilt.

· Fear for the child, uncertainty about the successful outcome of the disease.

Mistakes of upbringing (indulgent overprotection).

Nursing interventions:

1. To help parents see the prospects for the development of a healthy child, to fill the gap in knowledge about the disease and prognosis.

2. Explain the need to create a hypoallergenic environment in the house, remove house dust accumulators.

3. Convince parents to use drugs with caution in any child's illness.

4. During local treatment, avoid exposure of the child to adverse environmental factors and contact with possible allergens.

5. Distract the child from scratching the skin, take him in your arms more often, play games with him, select toys according to age.

6. Teach parents to apply ointments, soak off seborrheic crusts.

8. Be careful when using detergents, washing powders, lotions, creams.

9. Advise parents to wash baby clothes without using SMS.

10. Teach parents the basic principles of a hypoallergenic diet, cooking technology, and the rules for keeping a "food diary":

Approximate scheme for filling out a "food diary" .

Advise parents to periodically prevent dysbacteriosis with fermented milk mixtures or eubiotics for 3-4 weeks.

Protect the child from sudden fluctuations in temperature and high humidity. Carry out hardening activities, massage, gymnastics, long walks in the fresh air, recommend carefully introducing sun and sea baths.

Timely sanitize foci of chronic infection for all family members.

Explain to parents the need for timely vaccination according to an individual calendar with preliminary preparation of the child (before and after vaccination for 10 days, strictly follow a hypoallergenic diet and take courses of antihistamines). Do not plan vaccination during the hot season, take into account biorhythms, i.e. get vaccinated in the morning.

Exudative catarrhal diathesis (ECD) in children is considered a fairly common type of pathology of an allergic nature. According to various sources, the disease occurs in 20-50% of young children.

The first signs of the disease can appear already in the neonatal period. The disease mainly affects children. under the age of 3 years.

The main cause of the development of the disease is considered to be a hereditary factor that determines the predisposition of the child to the occurrence of allergic reactions, however, no less external negative factors are also important that increase the sensitivity of the child's body to various kinds of irritants.

Characteristics of the disease

Exudative catarrhal diathesis is developmental anomaly, in which the child has an increased sensitivity of the body to various kinds of allergic reactions, a tendency to changes in the skin when exposed to irritating substances.

Rashes, redness appear on the skin of the child, localized mainly on the cheeks. Changes in the skin occur mainly after the use of certain.

Pathology is hereditary, is a certain changes in the functioning of the immune system when the amount of immunoglobulin A decreases, and immunoglobulin E, on the contrary, increases.

This leads to the accumulation of special elements in the tissues (for example, histamine), which provokes the development of an allergic reaction.

In addition to pronounced skin changes in the child's body disturbed water-salt balance, as well as metabolic processes (carbohydrate, protein, fat). Many children develop along with ECD, that is, insufficient content of vitamins A and C in the body.

Internal organs and systems (adrenal glands, organs of the gastrointestinal tract) are also affected, which provokes the development of edema, a violation of the digestive processes.

All this negatively affects the general well-being of a small patient and can lead to serious problems with health.

Causes and risk factors

The root cause of the development of ECD is considered hereditary factor, that is, the genetically determined predisposition of the body to the development of an allergic reaction upon contact with an irritating substance.

In addition, pathology can develop as a result of an allergoic reaction - that is, the reaction of the child's body to external stimuli, proceeding like an allergy, but having other development mechanisms.

This reaction is due to the peculiarities of the development of the child's body at a young age, its manifestations. disappear as the child grows(which is not observed with ordinary allergies).

Other reasons that contribute to the development of ECD include:

Classification: types and forms of pathology

It is currently accepted to distinguish pasty and eretic appearance ECD.

Depending on the age of the child, skin manifestations of ECD are of a different nature. So, in newborn children, such rash elements like erythema, diaper rash, rash on the face in the form of small bubbles.

At the age of 1-5 months. to the above elements, skin manifestations such as milk scab, strophulus. After 6 months of age, the nature of the rash changes, all the elements that were present earlier may disappear, in their place the child develops eczema.

In older children, eczema is often combined with other negative pathologies, such as bronchial asthma, urticaria.

Clinical picture: symptoms and signs

ECD in a child is manifested not only in the form of rashes on the skin, there is also a number of other symptoms, such as:

Skin manifestations ECD can be different:

1. Rash on the body.
2. Dry skin, the appearance of flaky areas.
3. Paleness of the skin.
4. Milky scab (when the skin first turns red and then begins to peel). This phenomenon occurs mainly after exposure to frosty air.
5. The appearance of itchy spots.
6. Strofulus (rash in the form of nodules).

Possible complications and consequences

ECD most often resolves after the child reaches 3 years of age, and during subsequent years of life pathology does not manifest itself. In this case, no consequences and complications arise.

If the ECD does not disappear as the baby grows, its manifestations will disturb the patient throughout life.

However, dealing with them is quite simple, the main thing is to know which substances are irritants. can provoke an allergic reaction and avoid contact with them.

In this case, there will be no complications either. In some cases, a patient develops diseases such as allergic rhinitis or bronchitis against the background of ECD. It is necessary to follow the instructions of the doctor, as these pathologies can cause significant harm to health.

Diagnostics

To make a diagnosis, a doctor needs examine the patient to determine the intensity and nature of the rash, and to interview him (or his parents).

For a complete history of pathology, parents need to keep a food diary, which records the time of feeding, the foods that the child consumed, the body's reaction to the consumption of certain foods.

The data of such a diary must be provided to the doctor. This will facilitate the detection of pathology. In addition, the child will need take a stool test for dysbacteriosis.

Differential diagnosis is important to distinguish ECD from other pathologies with a similar clinical picture (lichen rosea, immunodeficiency diseases, scabies, seborrheic dermatitis).

To exclude these diseases, the child is prescribed special allergy tests to identify the main allergen. In some cases, a blood test is prescribed to determine the ratio and amount of immunoglobulin groups A and E.

Treatment Methods

ECD is a disease characterized by various manifestations, so any one there is no specific treatment regimen.

Therapy is selected for each patient individually, depending on the severity of the pathology, the age of the patient, the nature of the manifestations of the disease.

Most often used complex treatment, which includes such methods as taking medications, using external agents, traditional medicine recipes.

The daily regimen and nutrition of the child, the proper organization of hygiene procedures are important.

Medical

1. To eliminate allergic reactions prescribed antihistamines funds (Suprastin, Desal).
2. Phenobarbital is prescribed to eliminate itching.
3. If the disease is severe, prescribe hormonal therapy (eg, prednisolone).
4. In the presence of extensive inflammatory processes, an appointment is prescribed antibiotics.
5. As topical agents, such preparations as Lassar paste, zinc ointment, fish oil are used.

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Dieting

A child suffering from ECD need to follow a special diet, which means that certain restrictions will have to be introduced. So, it is necessary to reduce the consumption of such products as:

Children under 1 year old breastfeeding is recommended and this means that the diet of a young mother must also comply with the specified standards, that is, a nursing woman should not consume those products that are contraindicated for the child.

Traditional medicine and herbal medicine

Traditional medicine recipes successfully help to cope with the manifestations of ECD, however, it is not recommended to use them without the approval of the attending physician, especially when it comes to an infant.

1. Fir oil mixed with baby cream in equal proportions, the mixture is applied to the skin of the child for 10 minutes, after which it is removed with warm water. Instead of baby cream, you can take olive oil. It is recommended to add a small amount of Vit. FROM.
2. AT sulfuric ointment add an equal amount of fir oil and baby cream. The mixture is applied to the affected areas of the skin. The tool allows you to eliminate itching, soothe and disinfect the skin.
3. Widely used for internal use in EKD herbal decoctions based on string, yarrow, elecampane, wheatgrass root. To prepare a decoction, you need 1-2 tablespoons. pour a glass of boiling water, insist, strain. Give the child 2-3 times a day (the amount depends on the age of the baby).

How to do therapeutic baths?

To prepare such a bath, you need to add a small amount of the selected product to warm water (it is recommended to use special baby baths for bathing), the duration of the procedure should not exceed 10-20 minutes depending on the age of the child.

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Forecast

Prognosis for ECD favorable. In most cases, the pathology goes away on its own as the child grows up.

However, the disease still needs specialized therapy, since a violation of the integrity of the skin can contribute to the attachment of a secondary infection.

Prevention

It is possible to prevent the development of ECD, following the rules of nutrition.

So, a woman during pregnancy and breastfeeding is recommended to limit the consumption of foods with a high degree of allergenicity (especially if she herself is prone to developing an allergic reaction).

In addition, a child under 1 year old needs breast-feeding(if this is not possible, it is necessary to choose an adapted mixture that is closest in composition to human milk).

Complementary foods must be introduced with extreme caution, using hypoallergenic products. It is important to provide the child with complete care (regular bathing and hygiene procedures, clean clothes and bed linen, sufficient exposure to fresh air).

ECD is a disease that manifests itself in young children. Pathology is characterized by damage to the skin, the appearance of rashes, internal disorders of the body.

In addition to the hereditary factor, other unfavorable causes can also lead to the development of the disease, mainly associated with unhealthy diet and lifestyle.

Pathology most often disappears when the child reaches 3 years of age, however, the disease still needs to be treated.

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