It is an incredible pleasure for any parent to watch the growth and development of their baby. He changes every day, learns something new and learns everything alive! And the only thing left for parents is to have time to celebrate important milestones in his development: here he smiled for the first time, now he confidently holds his head, but the baby is already sitting. And also - the first word, the first tooth, the first independent step.

Each child is individual and develops in the rhythm as intended by nature. But still, in this exciting business, monitoring the development of the baby, some kind of benchmark is important for parents, with which they can compare and understand whether everything is going well. To do this, pediatricians have scales for assessing physical and psychomotor development. For example, in Ukraine, to assess the development of healthy children, specialists use Order No. 149 dated 03/20/2008 "Clinical protocol for medical supervision of a healthy child up to 3 years old", which presents the development charts and rating scales recommended by the World Health Organization.

But, if the baby was born before 37 weeks, it is more difficult to make such an assessment, since the development of premature babies differs from that of children born at term. Mainly due to immaturity nervous system At the time of birth, premature babies grow and develop at their own pace, which lags behind those of full-term babies. For example, if full-term babies at 4 months already reach for toys and roll over from their stomach to their backs, then a four-month-old baby born at 30 weeks will not be able to do this, since in fact he is only 1.5 months old. Therefore, to assess the conformity of the physical and psychomotor development of a premature baby with true maturity, doctors use the definition of corrected age.

Adjusted age is the difference between the baby's actual age in weeks and the baby's age in weeks. For example, a baby is 4 months old (16 weeks) and was born at 30 weeks of gestation. His adjusted age will be 6 weeks. This means that he will be 10 weeks behind in his development from his peers, but born on time.
But this does not mean that the lag will be observed throughout life. Don't worry, the kid will catch up with his peers and learn everything, only a little later.

Someone a little earlier, someone a little later, but, as a rule, by the age of two, almost all premature babies catch up with their peers who were born on time. And you no longer have to calculate the corrected age to find out if your baby is developing normally or not.

However, it is important to remember that if a child has been on a ventilator or has undergone surgery, if he has bronchopulmonary dysplasia or other serious health problems, this can affect his growth and development. In addition, children born with extremely low birth weight will have a more pronounced growth retardation. This category of children also has a higher risk of developmental disorders.

Physical development (body weight, height, head circumference)

Experts distinguish the following conditional periods of development of a premature baby after birth:

І-th period: transitional - lasts from the birth of a child to 7 days of life

During this period, the child can lose from 10% (if birth weight is 1500-2500 g) to 15% (if birth weight is less than 1500 g) of body weight in the early neonatal period. Therefore, the task of this period is to provide the child with nutrients and calories.

II-nd period: stabilization - lasts from 7 days of life until the child is discharged from the maternity hospital

In utero, a fetus with a gestational age of 24-36 weeks on average daily gains 15 g / day, so the task of this period is to ensure the same increase in body weight in a child. This means that during this period, on average, a child:

• with gestational age<32 недель должен за неделю набирать от 150 до 200 граммов (15-20 г в сутки);
• with a gestational age of 33-36 weeks should gain from 200 to 250 g per week (25 g per day);
• with a gestational age of 37-40 weeks should gain from 250 to 300 g per week (30 g per day).

Such dynamics of body weight is ensured when a child consumes at least 120-140 kcal / g / day due to breast milk.

III period: normalization - continues from the moment of discharge from the maternity hospital / hospital until 1 year of life or more

The task of this period is to achieve growth and development indicators of a full-term baby.

To assess the dynamics of changes in body weight, height and head circumference of a premature baby, doctors use special graphs or curves. The most commonly used Fenton growth curves.

psychomotor development

At each visit, the doctor evaluates not only the physical, but also the psychomotor development of your baby. As we have already said, this always takes into account the corrected age of the child. But remember that the main stages of development are only a guideline, and the timing of the appearance of certain skills in children can vary greatly. For example, about half of all full-term babies take their first independent steps at 1 year old, but there are perfectly healthy babies who do not start walking until they are 18 months old.

The most important thing is to be sure that your child is moving forward in his development. For example, from learning to sit without support, your child should learn to stand and then walk. Remember that children reach new milestones at different times. You know your child better than anyone else. If you carefully monitor the development of your baby, you will be able to understand in time if he needs additional help. A doctor, nurse, neurologist, rehabilitation specialist and other specialists are always there for you and ready to provide you with help, support and information.

UDC 616-053.32

Ivanova I.E., 2014

Received on February 12, 2014

I.E. IVANOV

Physical development premature CHILDREN

(Lecture)

Institute for Postgraduate Medical Education, Cheboksary

The main regularities of the physical development of premature babies born at different gestational ages are presented, the dynamics of an increase in height, body weight, head and chest circumferences, as well as the forecast of "catching up" growth up to 17 years of age are shown.

Keywords: physical development, prematurity, catch-up growth

Prematurely born children account for 3-16% of all newborns. According to the State Statistics Committee of the Russian Federation (2009), the frequency of birth of children with low body weight in Russia is 4.0-7.3% in relation to the number of all births. According to the data of the Population Health Monitoring Department, in 2008-2010. the frequency of birth of children with extremely low birth weight (ELBW) in Moscow was 0.1-0.3%, with very low birth weight (VLBW) - 0.8-0.9%. In the USA (2006), low birth weight was noted in 8.3% of newborns, VLBW - in 1.48% of newborns. In European countries (2008) from 1.1 to 1.6% of children are born very preterm (<33 недель гестации).

Over the past years, the number of premature births in the Chuvash Republic has remained constant and amounts to 5.1-5.4% of all births. Children with ENMT account for 0.9-1.2% of the number of all births (in the Russian Federation - 0.35%) and 6.6% of the number of premature births (in the Russian Federation 5%).

Back in the 60s. of the last century, it was believed that premature babies with a birth weight of less than 1500 g are not viable. Since 2012, in Russia, in accordance with the WHO criteria, the registration standards for infants born at a gestational age of 22 weeks or more and weighing 500 g or more have changed, and conditions for their care have been created in the leading perinatal centers of the country. Thanks to the development of intensive care technologies, optimization of perinatal care in last years the survival rates of children with VLBW and ELBW improved (Table 1), which made the problem of further nursing of these children relevant not only for neonatologists, but also for the primary pediatric link - the district service.

Table 1

Survival of children with ENMT in weight groups according to

obstetric hospitals in 2009 (per 1000 live births weighing 500-999 g)

It should be taken into account that very premature babies do not adapt well to extrauterine conditions of existence, almost half of them have damage to the central nervous system (CNS) in the form of intraventricular hemorrhages of varying severity, ischemic foci, periventricular leukomalacia. Their treatment and nursing require large material costs and moral stress from the staff. At the same time, literature data show that only in 10-15% of children, neurological pathology is so serious already in the neonatal period that an unfavorable outcome of its development and disability can be established at this age. The rest of the children after somatic adaptation can and should be at home, although for almost the entire first year of life they may have changes in the bronchopulmonary system, the consequences of perinatal damage to the central nervous system, hemodynamic instability with the functioning of fetal communications, problems with vision and hearing, a tendency to to viral and bacterial infections, a high incidence of rickets, anemia, dysfunction of the gastrointestinal tract, fermentopathy. Thus, very preterm infants have a number of specific problems associated, on the one hand, with immaturity and underlying pathology, and, on the other hand, with the consequences of ongoing intensive care (in particular, mechanical ventilation).

Premature babies have a number of anatomical and physiological features, which, along with the above pathological conditions, cannot but affect the features of their physical and morphofunctional development. The physical development (PD) of a premature baby cannot be assessed according to the criteria of their full-term peers, since this will always lead to an underestimation of its parameters and an artificial aggravation of the child's condition. In world and domestic pediatrics, sufficient experience has already been accumulated in assessing the growth and development of children born prematurely, which we used in preparing this lecture.

FR- a set of morphological and functional properties of the organism, characterizing the process of its growth and maturation. The RF of children is of great social and medical importance. Experts World Organization health care define the indicators of the RF as one of the fundamental criteria in a comprehensive assessment of the child's health. In addition, the harmonious PR of the child is a measure of the child's capacity and endurance. Numerous modern studies show that the long-term cognitive development of a child is directly dependent on growth rates in the early neonatal period and after discharge from the perinatal center. FR parameters are of different clinical and diagnostic value. Body length characterizes the growth processes of the child's body, weight indicates the development of the musculoskeletal system, subcutaneous fat, and internal organs. The increase in head circumference in the first months of life, reflecting the active growth of the brain, has an important prognostic value for the further mental development of preschool and adolescence. If the child does not grow skeletal, does not add mass according to the genetic development program laid down, then during this period there is no increase in the mass of the brain, like any other organ. A developmental delay may turn out to be unrehabilitated in terms of intelligence in the future.

When assessing RF in preterm infants, such concepts as gestational, postnatal, postconception, and corrected age should be taken into account. Gestational age is usually understood as the number of complete weeks that have elapsed between the first day of the last menstruation and the date of birth. Postnatal age is the actual (calendar) age, i.e. the number of months since the birth of the child. Postconceptional (postmenstrual) age is calculated as the sum of the gestational age and the postnatal age of the child. To calculate the corrected age, it is necessary to subtract from the calendar age those weeks for which ahead of schedule was born prematurely. The risk factors for preterm infants should only be assessed by corrected age. This is especially important for children born before 32-33 weeks of gestation and weighing less than 1500 g. For children born at 32-33 weeks or later, gestational age correction may be completed at the age of 1 year. Corrected age in preterm infants should be calculated in the first two years of life. Some authors suggest correcting up to 3 or 7 years. The moment of completion of the age adjustment must be recorded.

To assess growth in neonatology, growth curves of the fetus and premature baby are used. Growth curves are a graphical display of the dynamics of anthropometric indicators depending on the gestational age. Growth curves usually contain 3 measurements: mass, height and head circumference. Weight measurement, according to experts from the World Health Organization, is an accurate measurement, since electronic scales are used for this. Head circumference can also be measured with a high degree of accuracy. A child's height, according to experts, may be measured less accurately due to positioning issues.

Modern growth curves of Fenton (2013) can be used to monitor the growth of the fetus and premature baby (Fig. 1 and 2).

Rice. 1. Centile curves of girls' developmental parameters depending on gestational age (Fenton T.R., 2013)

Rice. 2. Centile curves of male developmental parameters depending on gestational age (Fenton T.R., 2013)

Fenton's curves include the 3rd, 10th, 50th, 90th, and 97th percentiles of weight, height, and head circumference, which are plotted on a grid. In the zone from the 10th to the 90th percentile, there are average indicators of RF, characteristic of 80% of premature babies. In the zones from the 10th to the 3rd and from the 90th to the 97th percentile there are values ​​indicating the level of development below or above the average, characteristic of only 7% of apparently healthy preterm infants. Values ​​below the 3rd and above the 97th percentile are areas of very low and very high rates that occur in healthy preterm infants no more than 3% of cases. The Fenton Growth Plot is on a large scale for high accuracy. The step of the child's weight is 100 g, the step of growth and head circumference is 1 cm. The time interval is 1 week. The graph allows you to compare the growth of a premature baby with the growth of the fetus, starting at 22 weeks of gestation and up to 10 weeks of postnatal age. The chart is deliberately extended to 50 weeks, since most premature babies are discharged home at this age. A space is made at the bottom of the diagram for marking measurement data.

After stabilization of the condition and discharge from the hospital, premature infants show an acceleration of growth, the so-called catch-up growth (catch-upgrowth), which requires appropriate nutritional support at the outpatient stage of nursing. Children who “catch up” with their centile corridor by 6–9 months of corrected age have a better prognosis for neuropsychic development than those who have not reached the required weight and height indicators. A significantly better neurological prognosis is observed in children who “catch up” with the corresponding normative indicators of RF by 2–3 months of corrected age. The most beneficial for further development is a growth spurt in the first 2 months of corrected age.

FR indicators and their dynamics include length, mass, and circumference of the head and chest. One of the practically significant features in assessing the physical status of a premature baby is the deviation from the synchronism of the increase in various physical parameters, the uneven growth processes of different structures in further periods of development. The RF of prematurely born children depends on the initial data, weight and length of the body "at the start". Although most preterm infants catch up with full-term infants in the FR during the first year of life, some infants with LBW at birth and infants with severe chronic lung disease may remain small forever. Slow head growth may be an early sign of abnormal neuropsychic development.

The RF of premature babies is characterized by higher rates of weight gain and body length in the first year of life (except for the first month). By 2-3 months, they double the initial body weight, by 3-5 - triple, by the year - increase by 4-7 times. At the same time, extremely immature children are significantly behind in terms of absolute indicators of height and body weight (“miniature” children) - the 1st-3rd corridor of centile tables. In subsequent years of life, very preterm infants may retain a kind of harmonic delay in RF.

Most children born weighing less than 2000 g double it by 2.5-3.5 months, triple by 5-6 months. Basically, premature babies catch up with their full-term peers in terms of weight and height indicators by 2-3 years of age, and children weighing less than 1000 g - only by 6-7 years. Children with intrauterine growth retardation (IUGR) and congenital short stature syndromes are also stunted in subsequent age periods.

Initial weight loss in preterm infants is 4-12%. The maximum decrease is noted on the 4-7th day, then it does not change for several days (a 2-3-day plateau) and subsequently begins to slowly increase. Permissible transient weight loss after birth in preterm infants:

body weight at birth> 1500 g - 7-9%;

body weight at birth from 1500 to 1000 g - 10-12%;

birth weight< 1000 г - 14-15%.

After frequent and profuse regurgitation, with severe illness and a decrease in edema, a pathological loss of body weight (more than 15%) is noted, which develops faster than the initial loss of body weight. Restoration of body weight in preterm infants (average 15 g/kg/day) depends on the degree of prematurity and occurs faster, the lower the body weight at birth. The initial body weight is restored by the 2-3rd week of life. Children with higher birth weight and longer gestational age also have higher weight gain. A flat weight curve is often observed in preterm patients, as well as in children with VLBW at birth and low gestational age (later, CNS damage is detected in some of them). Children with a body weight of up to 1000-1200 g and a gestational age of up to 28 weeks restore their original weight by 1 month.

Normal weight gain for the 1st month of life in children of I degree of prematurity will fluctuate within 300-450 g, II degree - 450-675 g, III - 600-900 g. th month of life. In the future, when assessing the state of the risk factor of premature babies, one can roughly focus on the average monthly weight gain of a full-term baby, which is 800 g at the 3rd month of life, 750 g at the 4th month, 700 g at the 5th month, etc. . (Table 2).

The growth rate in children with birth weight > 1000 g in the first 6 months of life is 2.5-5.5 cm per month, in the second half of the year - 0.5-3 cm per month. During the first year of life, body length increases by 26.6-38 cm. Very premature babies grow faster. Average length the body of a premature baby reaches 70.2-77.5 cm by the age of 1 year.

table 2

Physical development of premature babies in the first year of life

The daily increase in head circumference in premature babies in the first 3 months is 0.07-0.13 cm (measurement is carried out every 5 days). On average, the increase in head circumference in the 1st half of the year is 3.2-1 cm, in the 2nd half of the year - 1-0.5 cm per month. By the end of the 1st year of life, the head circumference increases by 15-19 cm and reaches 44.5-46.5 cm. The "cross" of head and chest circumference indicators in healthy preterm infants occurs between the 3rd and 5th months after birth ( Tables 3, 4).

Table 3

Head circumference in premature babies in the first 3 months of life, cm

Table 4

Head circumference growth in preterm infants with birth weight

less than 1500 g

The rate of increase in chest circumference in premature babies is approximately 1.5-2 cm per month.

The eruption of the first teeth in premature babies begins:

1. with a birth weight of 800-1200 g - at 8-12 months;
2. with a birth weight of 1000-1500 g - at 10-11 months;
3. with a birth weight of 1501-2000 g - at 7-9 months;
4. with a birth weight of 2001-2500 g - at 6-7 months.

The study of the level of risk factors in prematurely born children in the remote periods of life is extremely important and relevant due to the fact that this is one of the most important indicators of a child's health. Some children (especially those born prematurely with IUGR) may experience manifestations of growth heterochrony deviations from a given program, when some parts of the body or organs grow faster than others or, on the contrary, are characterized by slow growth, while the consistency and synchronism of the growth of different structures are disturbed. Studies in Russia confirmed this fact, showing that almost every third premature baby with IUGR (27.0%) had short stature further. When assessing the FR of very preterm infants, it was found that only 24.0-44.7% of those examined had normal by the year.

As a rule, children with ELMT do not grow well in early childhood, and often this problem persists in the future. By the age of 5, 30% of children born before the 30th week of gestation may have a weight deficit, and 50% of growth - 50%. By the age of 8-9, about 20% are still lagging behind in growth. The periods of "stretching" in this group of children begin 1-2 years later. In children born weighing less than 800 g, by the age of 3, body length and head circumference are below the 5th percentile, and body weight is about the 10th percentile. Most often, growth disorders (growth retardation) are detected in children with cardiorespiratory problems, gastroesophageal reflux disease, CNS pathology (swallowing disorder), anemia, short bowel syndrome, and other chronic diseases.

At the same time, a decrease in the size of the head circumference (less than the third percentile) is associated with impaired cognitive function in school age(compared to children with normal growth heads in the first two years of life, children with a slow increase in head circumference had a significantly lower mental development index).

However, it must be emphasized that, taking into account even the most pessimistic forecasts of some studies, with a favorable medical and social environment for the child FR indicators in premature babies by the age of 17 almost always reach the norm. With age in prematurely born children, there is a decrease in the dependence of physical parameters on the impact of biological factors.

Until the end of age correction, when formulating a conclusion about the RF in the individual history of the development of a premature baby, the following expressions are used: "Physical development corresponds to the gestational age" or "Physical development does not correspond to the gestational age" indicating the excess or deficiency of any parameter (weight, height, circumference head and chest).

Growth disorder (short stature) and its correction in premature infants with IUGR

In the majority of children born with IUGR, in the first 6-24 months of life, there is a period of rapid growth and an increase in height and weight indicators. In the literature, this phenomenon is called "postnatal growth spurt", or "catch-up growth rates". The growth spurt allows children to return to their genetic trajectory after a period of intrauterine growth retardation. Nevertheless, approximately 10-15% (6 thousand in Russia annually) of children with IUGR retain low growth rates in the postnatal period. As a result of inadequate rates of postnatal growth, these children are already stunted by the age of 2 years. Growth deficit is observed throughout childhood and adolescence which ultimately leads to short stature in adults. The more IUGR a child had, the more chances he had to remain a short adult. In the absence of spontaneous growth acceleration, children remain stunted, making up 14-22% of adults whose height is less than 150 cm in women and less than 160 cm in men. Small children are 5 to 7 times more likely to become short adults compared to children with normal sizes body at birth. This significantly affects their social status.

Determining the level of hormones in newborns or children with IUGR is not shown in everyday clinical practice, since neither the concentration of somatotropic hormone (STH), nor the values ​​of IGF-I or IGF-binding protein-3 in the circulating blood in children of the first year of life are predictors of subsequent growth. Current recommendations boil down to the fact that in a child born with low weight / height, it is necessary to measure height, body weight and head circumference every 3 months during the 1st year of life and every 6 months thereafter. In those children who do not show significant and significant catch-up growth during the first 6 months of life, or who remain stunted (less than -2SD for age) by 2 years of age, the causes of growth limitation should be identified and appropriate treatment instituted.

In connection with the existing anomalies in the secretion of GH, IGF-I, attempts are being made in various countries of the world to treat undersized children with a history of IUGR with recombinant growth hormone (rGH) preparations. The effectiveness of this treatment has been actively studied for more than 15 years. Data from large multicenter studies indicate a dose-dependent effect of rGH therapy in this category of patients. With long-term continuous treatment (average duration 6 years), most children (about 85%) achieve final height that is within normal limits for a healthy population or within the boundaries of the target growth (average 95%), i.e. comparable to their biological parents. Therefore, it is recommended to early detection undersized children born with low weight / height, and in order to establish an accurate diagnosis, refer them for a consultation with an endocrinologist. Factors influencing the effectiveness of rGH therapy during the first 2-3 years include the following: age and height SDS at the time of initiation of therapy, average parental height, and rGH dose. The average increase in height after 3 years of treatment with rGH varies from 1.2 to 2 SD at a dose of rGH 0.035-0.070 mg/kg/day.

Currently, recommendations have been developed for the treatment of rGH in this category of children. rGH therapy can be administered to short children with a history of IUGR at the age of 2-6 years, with growth below -2.5 SD. During the first years of rGH therapy, most children experience a rapid catch-up increase in growth and its normalization (growth rates reach a genetically determined curve). In the future, against the background of treatment, the normal growth rate is maintained until the final growth is reached. The maintenance phase of rGH therapy is less dose dependent. During the first years of rGH therapy, most children experience a rapid catch-up increase in growth and its normalization (growth rates reach a genetically determined curve). In the future, against the background of treatment, the normal growth rate is maintained until the final growth is reached. The maintenance phase of rGH therapy is less dose dependent.

A positive response to rGH treatment is considered to be a change in height SDS of more than +0.5 in the first year of therapy. If the response to therapy is inadequate, an additional examination is necessary to identify factors affecting the effect of treatment, assess compliance, and dose of rGH. In the majority of short children with IUGR who received rGH in childhood, pubertal development began in a timely manner and proceeded normally.

BIBLIOGRAPHY

1. Alyamovskaya G.A. Features of the physical development of very premature children in the first year of life / G.A. Alyamovskaya, E.S. Keshishyan, E.S. Sakharova // Bulletin of modern clinical medicine. - 2013. - V. 6, issue 6. - S. 6-14.
2. Vinogradova I.V. Modern technologies for the treatment of premature newborns / I.V. Vinogradova // Fundamental research. - 2013. - No. 9 (part 3). - S. 330-334.
3. Hypotrophy and intrauterine growth retardation in children: textbook. allowance / comp. I.E. Ivanova, V.A. Rodionov, T.V. Zolnikov. - Cheboksary, 2011. - 100 p.
4. Children's diseases: textbook / ed. N.N. Volodina, Yu.G. Mukhina. - M.: Dynasty, 2011.- Vol.1. Neonatology. - 512 p.
5. Observation of very premature children in the first year of life / T.G. Demyanova [i dr.]. - M.: Medpraktika, 2006. - 148 p.
6. Monitoring of premature babies in a children's clinic: textbook / ed. I.E. Ivanova. - Cheboksary: ​​AU Chuvashia "IUV", 2014. - 650 p.
7. Neonatology: national guide / ed. N.I. Volodin. - M.: GEOTAR-Media, 2013. - 886 p.
8. Rendering Features medical care children born at 22-27 weeks gestation / D.O. Ivanov [i dr.]. - St. Petersburg: Inform-Navigator, 2013. - 132 p.
9. Principles of staged nursing of premature babies / Union of Pediatricians of Russia, FGBU “Nauch. children's health center" RAMS; ed. L.S. Namazova-Baranova. - M.: Pediatr, 2013. - 240 p.
10. Timoshenko V.N. Premature newborns: textbook. allowance / V.N. Timoshenko. - Rostov n / a.: Phoenix; Krasnoyarsk: Publishing projects, 2007. - 192 p.
11. Physiology of growth and development of children and adolescents (theoretical and clinical issues) / ed. A.A. Baranova, L.A. Scheplyagina. - M., 2000. - 584 p.
12. Shabalov N.P. Neonatology: textbook. allowance: in 2 vols. T.1 / N.P. Shabalov. - 4th ed., Rev. and additional - M.: MEDpress-inform, 2006. - 656 p.
13. Fenton T.R. / T.R. Fenton, J.H. Kim // A systematic review and meta-analysis to revise the Fenton growth chart for preterm infants. - BMC Pediatrics, 2013. - URL: http://www.biomedcentral.com/1471-2431/13/59.