Features of vegetative-vascular dystonia in children

Vegetative disorders in children can be generalized or systemic, cutting - local. Since vegetative dystonia is a syndromic diagnosis, along with the leading syndrome it is necessary to indicate (if possible) a nosological affiliation (neurosis, residual-organic encephalopathy, hereditary-constitutional form, etc.). With the predominance of autonomic dysfunction in any visceral system (cardiovascular, gastrointestinal, etc.), there are almost always general shifts reflecting a decrease in the adaptation of the child's organism. In fact, with a sufficiently detailed examination of children with autonomic dystonia, it is not possible to find a system or organ that is not involved in general pathophysiological changes.

Thus, the thesis of "generalization - systemic - locality" of changes in childhood has a very relative significance and the isolation of individual forms of vegetative dystonia according to the leading syndrome is a compulsory measure, presupposing the choice of a doctor (pediatrician, cardiologist, neurologist), whose specialty is "closer" "There are revealed violations. An indisputable fact is the participation of at least two systems: nervous and one of somato-visceral (for example, cardiovascular).

The clinical severity of the symptoms of autonomic dystonia may be different, and often the attention of the doctor and the patient attracts the predominance of one symptom, but detailed inquiry and examination can reveal other numerous vegetative manifestations. To date, the clinical analysis is the leading place in the diagnosis of autonomic dystonia, despite the importance of instrumental methods. In the clinical course in children, as in adults, there are permanent and paroxysmal types of vegetative dystonia.

Unlike adults, panic disorders in children have their own specifics, depending on the age of the child. There is a predominance in the structure of the attack of vegetative-somatic manifestations over the panic, emotional experiences in the younger children. In older age groups, the vagal orientation of reactions decreases, the sympathetic component in paroxysms increases, reflecting the general intensification of the humoral regulating link. Naturally, as with any disease, the vegetative dystonia of childhood has phase flow. This is important to take into account, because with the paroxysmal type of flow, the presence of crises clearly indicates the phase of exacerbation, and in the case of permanent flow, only dynamic observation and examination make it possible to draw such a conclusion.

It is important to determine and reflect in the diagnosis the general characteristics of the autonomic nervous system: sympathicotonic, vagotonic (parasympathetic) or mixed type. The establishment of these characteristics, which is fairly straightforward, allows a pediatrician, a neurologist immediately to choose a general line in the diagnostic process, to link various clinical signs into a general pathophysiological concept, to orientate in the choice of therapy. It is important, in addition to clinical examination, to pay great attention to a thorough interview of parents, especially the mother. This will reveal the personality characteristics of the child and his behavior, not immediately apparent pathoharacteriological abnormalities.

At a clinical examination of the child, first of all, attention is paid to the condition of the skin. This is an important system of the body, a kind of representative organ of the autonomic nervous system, especially in the younger and pubertal ages, during periods of maximum participation of this system in vegetative reactions. In this case, the vascular reactions of the skin and sweat glands can be expressed, especially in the distal parts of the hands. With vagotonia, a general tendency to reddening the skin, hands are cyanotic (acrocyanosis), moist and cold to the touch. On the body, marbled skin ("vascular necklace"), sweating is increased (general hyperhidrosis), there is a tendency to acne (in puberty more often ackne vulgaris); There are often manifestations of neurodermatitis, various allergic reactions (such as hives, Quincke's edema, etc.). In this category of children with autonomic dystonia, a tendency to fluid retention is noted, transient edemas on the face (under the eyes).

With the dominance of the sympathetic part of the autonomic nervous system, the skin in children is pale, dry, and the vascular pattern is not expressed. The skin on the hands is dry, cold, sometimes there are eczematous manifestations, itching. Great importance in the vegetology of childhood have features of the constitution. For various variants of autonomic dystonia, there are their own, preferential constitutional types. Children with sympathicotonia are more often thin than full, although they have an increased appetite. In the presence of vagotonia, children are prone to fatness, poly-lymphadenopathy, have enlarged tonsils, often adenoids. As shown by the work of many researchers, the tendency to overweight is a genetically determined sign, which in 90% of cases is noted in one of the parents.

[1], [2], [3], [4],

Thermoregulatory disorders

Violations of thermoregulation are a characteristic feature of permanent and paroxysmal vegetative disorders in childhood. Children can tolerate even high temperatures. Only with very high figures (39-40 ° C) there are complaints of asthenic nature. In general, they remain active, participate in games. The temperature can hold on the low-grade figures (37.2-37.5 ° C) for a very long time - for months, which is often put in a causal relationship with some kind of chronic somatic disease (rheumatism, chronic cholecystitis, etc.) or a transmitted infection, because "Temperature tails" are delayed for many weeks. Creeping temperature rises (hyperthermic crises) occur against the background of emotional experiences, while children celebrate "fever", an easy headache. The temperature decreases spontaneously and does not change during the amidopyrine test.

The peculiarities of temperature disturbances are that they are usually absent during the summer rest period of children and are renewed with the beginning of the school year (the so-called "September 7 diseases"). When examining children with an increase in temperature due to autonomic dysfunction, the normal (cold) temperature of the skin of the forehead, extremities attracts attention. In fact, the elevated temperature is recorded only in the axillary cavity, and there may be thermal asymmetry. Symptoms of thermoregulation disorders in children with vegetative dystonia include chilliness (poor tolerance of low temperatures, drafts, wet weather), so such patients like to dress warmly, they easily get chills.

It is important to note that, unlike infectious fevers, any hyperthermic manifestations occur when falling asleep; At night these children have normal temperature. The rise in temperature is very much frightening primarily for parents, whose behavior, at first, being adequate (doctor's invitation, consultations, tests, treatment), as the expected therapeutic effect or its absence is insignificant. The child's temperature is measured more and more often and becomes obtrusive, self-sufficient, which has a very negative effect on children. This behavior of the parents leads to the fixation of the child on his "defect", it forms additional psychogenic reactions of a phobic, depressive nature.

Respiratory system

When examining children with vegetative dystonia in 1/4 - 1/3 of cases, pathological manifestations are noted, the spectrum of which is quite wide. The most frequent complaints are dissatisfaction with inhalation, a feeling of lack of air, a stiffness of breathing, shortness of breath. Respiratory disorders in most cases are accompanied by unpleasant affective disorders. The characteristic features of the breathing of children with autonomic dystonia include a deepening of the inspiration with incomplete exhalation or a rare forced breath with a long noisy exhalation. Often, children on the background of normal breathing make deep noisy sighs, which in some cases are intrusive. The most numerous of these complaints in children with a parasympathetic focus of autonomic dystonia. At the same time, sudden shortness of breath during moderate physical exertion, paroxysmal neurotic coughing attacks (spasmodic vagal cough) in emotional experiences confirm the psychogenic origin of these respiratory disorders.

Children with autonomic dystonia may have shortness of breath at night - pseudo-asthma, a feeling of lack of air ("choking") with excitement; the latter manifestation often occurs in the structure of vegetative crises (with paroxysmal type of vegetative dystonia flow) and is accompanied by the experience of vital fear. The feeling of lack of air and zalozhennosti in the chest occurs in sick children at certain hours (after waking, when falling asleep, at night), is associated with mood swings, with the passage of atmospheric fronts. The inability to take a full deep breath, the need for which from time to time sick children, is hard to tolerate, is perceived as evidence of a severe lung disease; more common with masked depression. A characteristic feature is the paroxysms of frequent, superficial breathing of the thoracic type with a rapid change of inspiration with an exhalation, with the impossibility of prolonged respiratory arrest (shortened 2-3 times against the norm of 5-60 sec).

Attacks of psychogenic dyspnea are often combined with cardialgia, palpitation, which is accompanied by a sense of anxiety, anxiety. All respiratory disorders in children are detected against a background of depressed mood, anxiety, fear of death from suffocation. Attacks of imaginary asthma are accompanied by a specific noise formulation: breathing of groaning character, sighs, gasping, wheezing and noisy exhalation, at the same time in the lungs of any wheezing is not listened. Respiratory movements in a pseudo-asthmatic episode increase to 50-60 per 1 minute, with any excitement, an unpleasant conversation, etc., as a direct cause. Hyperventilation disorders are combined with weakness and general malaise. Children complain of convulsive information in the fingers, gastrocnemius muscles, unpleasant sensations (paresthesia) in various parts of the body. After an attack of pseudoasthemia, patients have general weakness, drowsiness, attacks of hiccough and yawn.

When collecting an anamnesis in children with respiratory disorders, it is quite often that the fear of death from suffocation is transferred (or they observed respiratory disorders in relatives, etc.), which contributed to a neurotic fixation. Often in children with autonomic dystonia, especially with asthenic traits, there is a rapid yawning, which is obtrusive, but it is very difficult to overcome this series of ghastly movements to the child, they end spontaneously. In children with respiratory disorders in the structure of the syndrome of vegetative dystonia in history, asthmatic bronchitis, frequent respiratory-viral infections are not uncommon.

Gastrointestinal system

Gastrointestinal system is the subject of complaints of children with vegetative dystonia. They are most characteristic for children with a vagotonic orientation of the vegetative tone. The most common complaints are nausea, abdominal pain, vomiting, heartburn, dyskinetic manifestations in the form of constipation or unexplained diarrhea. Common complaints that disturb parents are violations of appetite.

Attention is drawn to increased salivation, less often it is reduced. Nausea and vomiting in children are frequent somato-vegetative manifestations of emotional experiences. Having arisen once after acute psychogeny (fright), these symptoms are fixed and then persistently repeated in response to stressful stresses. In young children, frequent regurgitation and vomiting can be a manifestation of gastrointestinal dyskinesia, in particular pylorospasm, increased intestinal motility, in older age - the result of cardiopathy. Painful sensations in the abdominal region in children with autonomic dystonia are frequent and characteristic symptom, taking second place after headaches.

Long-term pain is less characteristic of childhood than episodes of short-term, often quite severe abdominal crises, more often observed before the age of 10 years. During such an attack the child pales, stops playing or wakes up with weeping, as if to localize painful sensations, as a rule, can not. When the abdominal crises are combined with an increase in temperature (i.e., the clinic of an acute abdomen), an inflammatory shift in the blood formula, it is very difficult not to suspect a surgical pathology (appendicitis, mesadenitis, etc.), but also the possibility of "periodic disease "- Reiman's syndrome. Attacks abdominalgia have a bright vegetative color, mainly parasympathetic. This type of paroxysmal course of vegetative dystonia prevails in younger children and is less characteristic of older children and adolescents.

One should remember about "abdominal migraine", which proceeds in the form of paroxysmal pains in the abdomen, characteristic of which is a combination or alternation with a severe headache of migraineous nature. Attacks begin suddenly, last an average of several minutes and spontaneously end (often diarrhea). Children with recurrent abdominal pain should be included in the study complex EEG-study.

Out of the external manifestations of the temporal epileptic attack, abdominal pain is a characteristic feature. The abdominal aura can enter an integral part in a partial complex fit, proceeding without disturbance of consciousness.

Among other vegetative signs, one should note the sensation of a coma in the throat, the pain behind the sternum, associated with spasmodic contractions of the muscles of the pharynx and esophagus, which is often noted in the neurotic, egocentric children's warehouse. With age, you can trace a certain dynamics of complaints: in the first year of life - it is most often regurgitation, colic; in 1-3 years - constipation and diarrhea; in 3-8 years - episodic vomiting; in 6-12 years - a pain in the abdomen of a paroxysmal nature, dyskinesia of bile ducts, various manifestations of gastroduodenitis.

The cardiovascular system

The state of the cardiovascular system in children with autonomic dystonia is the most complex and important section of childhood vegetation. Cardiovascular manifestations are detected with various variants of autonomic dystonia. Actually, the syndrome of vegetative dysfunction is most distinctly represented by cardiovascular dysfunction. Depending on the leading symptom complex, disregulation (predominantly) in cardial (functional cardiopathy - PCF) or vascular type (arterial dystonia in hypertonic or hypotonic type) is distinguished. However, now, according to WHO recommendations, changes in blood pressure are usually called hypertension or hypotension, respectively. On the basis of this, it is more correct to call: autonomic dystonia with arterial hypertension or autonomic dystonia with arterial hypotension.

Why is this separation principle convenient? Firstly, due to the widespread prevalence of vegetative disorders in the children's population, the main burden of diagnosis and treatment lies with pediatricians, who can more easily characterize the patient in a therapeutic manner, without going into the complexity of psycho-vegeto-somatic relationships. Secondly, since psycho-vegetative syndrome of childhood is extremely polymorphic in the clinic (age and sex play an important role), the division used for these types of vegetative dystonia plays the role of a supporting feature supplementing it with data on the state of other systems, one can get a clear idea of the degree and the nature of autonomic dysfunction.

Autonomic dystonia according to the cardiac type (functional cardiopathies)

This section includes a large group of functional disorders in the activity of the heart due to impaired autonomic regulation. Disorders of heart rhythm and conduction are the most complex section of clinical pediatrics and vegetology. Unfortunately, there is still no unified understanding of the pathogenetic mechanisms responsible for the occurrence of cardiac arrhythmias. Currently, all causes of rhythm and conductivity disorders are divided into cardiac, extracardiac and combined. Any organic heart disease (myocarditis, vices, etc.) contributes to the occurrence of arrhythmias. Pathological effects cause electrical instability of the myocardium - a condition in which a stimulus not exceeding the threshold intensity can cause repeated electrical activity of the heart. In the development of this state, apart from organic, vegetative and humoral regulatory influences are of great importance. Extracardiac factors contributing to the development of arrhythmias include violations of the innervation of the heart due to functional insufficiency of the subsegmental and segmental parts of the child's nervous system that has been formed under the influence of perinatal trauma, as well as with hereditary inferiority of vegetative regulation. To extracardiac include humoral disorders, including endocrine-humoral perestroika pubertal period.

Thus, with many violations of the rhythm of the heart, great importance is attached to hypersympathicotonia. The wandering nerve exerts its effect on the electrical indices of the ventricles indirectly, through a decrease in the increased activity of the adrenergic apparatus. It is believed that the basis of cholinergic antagonism is muscarinic stimulation, which inhibits the release of noradrenaline from the end of sympathetic nerves and weakens the effect of catecholamines on receptors. Excess parasympathetic stimulation is also dangerous, it can manifest itself against a background of increased sympathetic activity in the form of compensatory bradycardia, hypotension in patients with a tendency to arterial hypertension, prolapse of the mitral valve,

By the nature of arrhythmias in childhood, one can not judge their extra- or cardiac genesis; only ventricular paroxysmal tachycardia, "threatened" ventricular extrasystoles, fibrillation and atrial and ventricular fibrillation, complete atrioventricular blockade are more characteristic of organic heart damage.

The functional nature of arrhythmias in children, their connection with the activity of vegetative supra-segmental regulatory systems was confirmed by introducing daily ECG monitoring (Holter's method). It turned out that in absolutely healthy children during a day, individual pathological ECG phenomena may appear without any connection with the organic interest of the heart. In holter monitoring conducted in 130 healthy children, it was found that the heart rate ranged from 45 to 200 in 1 min during the day, the I degree of atrioventricular blockade occurs in 8%, Mobits type II in 10% of children and more often at night, single atrial and ventricular extrasystoles are noted in 39% of the examined.

For the appearance of these types of functional pathology of the heart, the basic indices of vegetative regulation, in particular tonus, reactivity, are of great importance. In the group of functional cardiopathies, the following are distinguished.

Violation of repolarization processes (nonspecific changes in ST-T) is associated with an absolute increase in the level of endogenous catecholamines or with an increase in the sensitivity of myocardial receptors to catecholamines. At children in rest and in orthostasis on the ECG, there are smoothed or negative ST, aVF, V5, 6 teeth, possibly a shift of 1-3 mm below the isoline of the ST segment. The functional nature of the shifts is confirmed by the normalization of the ECG during samples with potassium chloride (0.05-0.1 g / kg), obzidan (0.5-1 mg / kg), and combined potassium-obzidan test (0.05 g / kg potassium chloride and 0.3 mg / kg obzidan).

Atrioventricular blockade (AVB) of the 1st degree is most often observed in children with a vagotonic vegetative tone. To confirm the functional nature of the shifts, carry out:

• ECG-study of parents, while the detection of their lengthening PR interval indicates the hereditary origin of AVB in the child;
• ECG is recorded in orthostasis - in 1/3 - 1/2 children the PR interval is normalized in an upright position;
• when subcutaneous or intravenous atropine, AVB is removed.

Syndrome of premature excitation of the ventricles (Wolff-Parkinson-White syndrome) occurs most often in children with vagotonic initial vegetative tone in the cardiovascular system. It should be noted that these syndromes are diagnosed in the ECG study, but their close connection with the functional state of the cardiovascular system, an important role in the genesis of a number of clinical manifestations such as paroxysmal tachycardia, entering into a group of risk factors for sudden death WHO nomenclature), make knowledge of these syndromes necessary.

[5], [6], [7], [8], [9]

Wolff-Parkinson-White Syndrome (WPW)

Wolff-Parkinson-White syndrome in 60-70% of cases is noted in children who do not have organic heart damage. The true frequency of the syndrome in the population is unknown because of its transient nature. The syndrome of WPW is associated with the circulation of the pulse along the bundle of Kent. Proof of the fact that carrying out pulses along additional paths has an auxiliary, compensatory value, is finding a sigma wave on the ECG in 60% of healthy children. In the genesis of WPW syndrome, the main significance (in 85% of patients) is the disturbed vegetative regulation, clinically manifested by SVD.

The criteria for WPW syndrome on ECG are as follows:

• shortening (less than 0.10 s) of the PR interval;
• the QRS complex broadening is more than 0.10-0.12 s;
• the presence of a 5-wave (on the ascending QRS complex);
• secondary ST-T changes;
• frequent combination with paroxysmal tachycardia and extrasystole.

60 % of children with WPW syndrome come from families with psychosomatic heredity of heredity for diseases of the trophotropic circle (peptic ulcer, neurodermatitis, etc.). Their parents in 1/2 cases have similar changes on the ECG. The emergence of autonomic dysfunction in children with WPW syndrome is always favored by the unfavorable course of the period of pregnancy and childbirth. In most cases, the clinical picture of autonomic dysfunction in these children was accompanied by complaints of headache, sweating, dizziness, fainting episodes, pain "in the region of the heart," in the abdomen, in the first legs more often at night. In the status of arterial hypotension, bradycardia.

Neurological symptoms are limited to individual micro-signs, in 2/3 cases compensated syndrome of intracranial hypertension is registered. In 1 emotional-personal plan, children with WPW are distinguished by a high level of neuroticism, impressionability, anxiety, the presence of phobic disorders, often a pronounced asthenic symptom complex. Vagotonic tenderness is a characteristic feature. Elimination of WPW syndrome with the help of stress and medicinal samples allows to exclude its organic nature. With the use of atropine sample (0.02 mg / kg), WPW syndrome disappears in 30-40%, while using Aymalin (1 mg / kg) - in 75% of children. Preservation of the phenomenon of WPW after a drug test causes the need for restrictions in the exercise of great sport. In particular, children whose Aymalin does not withdraw WPW have a short effective refractory period, i.e., they constitute a risk group for sudden death. Attacks of atrial paroxysmal tachycardia, noted in 40% of children with WPW syndrome, are manifestations of vegetative paroxysm of sympathetic tension on the vagotonic background.

In general, the forecast for WPW syndrome is favorable. It is necessary to treat the main clinical manifestations with vegetotrophic and psychotropic agents.

Clerk-Levi-Cristesco syndrome (CLC) - a syndrome of the truncated interval PR - is a kind of premature ventricular excitation syndrome in connection with the circulation of impulses along additional bundles. CLC syndrome is characterized by a combination with attacks of atrial paroxysmal tachycardia, it is more often observed in girls. This syndrome can occur in children with initial vagotonia; in this case, paroxysmal tachycardia attacks are characteristic. Drug samples (for example, with giluritmalom) eliminate this phenomenon, but vegetative dystonia remains.

The syndrome of mahayima is much sharper. Clinical and pathophysiological features are similar to those in WPW syndrome. Treatment is the same as with the above syndromes.

Children with autonomic dystonia may experience cardiac arrhythmias resulting from a violation of the neurohumoral regulation of the rhythm (in the absence of signs of an organic pathology of the heart): supraventricular and right ventricular restlessness, paroxysmal tachycardia, non-paroxysmal heterotrophic supranventicular tachycardias, chronic sinus tachycardia, and bradycardias.

Vegetative arterial dystonia

For correct diagnosis of arterial dystonia, it is necessary to remember WHO recommendations for determining blood pressure figures, given the difficulty in distinguishing between norm and pathology. The very fact of the correct measurement of the pressure of the child is of great importance. After measuring blood pressure, the mean values and cut points of the percentile distribution of systolic blood pressure (SBP) and diastolic blood pressure (DBP) in schoolchildren are determined from existing blood pressure tables for schoolchildren 7-17 years old, which should be on the table of each pediatrician. The group of people with elevated blood pressure includes children with SBP and DBP exceeding 95% of cut-off points of distribution, in a group with a lower BP - with SBP, the values of which are below 5% of the distribution curve. In fact, for convenience, the following values can be taken as the upper limits of the norm of blood pressure in children: 7-9 years - 125/75 mm. Gt; st., 10-13 years - 130/80 mm. Gt; st, 14-17 years - 135/85 mm. Gt; Art. Often, high blood pressure in children is recorded accidentally - during a clinical examination, in a sports section, etc., but confirmation of the revealed elevated blood pressure values in children requires systematic (with an interval of several days) measurements due to the lability of the indicators and the great role of the emotional factor .

Vegetative dystonia with arterial hypertension

Vegetative dystonia with arterial hypertension (neurocirculatory dystonia according to the hypertonic type) is noted in children with blood pressure figures exceeding the 95th percentile; for them, there is a labile increase in blood pressure without signs of persistent organ involvement. This form of vegetative-vascular dysregulation is more common in schoolchildren of middle and older age, i.e. In the adolescent period. It is widely distributed in the children's population. Elevated blood pressure figures are detected in 4.8-14.3% of children, and at school age - in 6.5%.

Urban schoolchildren have high blood pressure 2 times more often than in rural areas. With age, young men are overtaken by girls in the frequency of this form of vegetative dystonia (14.3 and 9.55%, respectively), although the younger groups are dominated by girls. This form of autonomic dystonia can be transformed into hypertensive disease, so every doctor should pay special attention to the implementation of medical examinations.

In the clinical picture of autonomic dystonia with arterial hypertension, the set of complaints is usually small. More often it is a headache, cardialgias, irritability, fatigue, complaints of memory loss, less often - to nonsystemic dizziness. There is usually no connection between the level of blood pressure and the presentation of complaints; here the overall emotional state of the child, its fixation on the state of its own health, is more likely to affect. In a hospital in these children, normal blood pressure can be recorded, although functional tests confirm the diagnosis.

Depending on the severity and persistence of the symptoms, three stages of the course of the disease are distinguished: transient arterial hypertension, labile and stable. The first two species cover at least 90% of all children with fluctuations in blood pressure. Division at the stage allows differentiating treatment issues, avoiding unnecessary adrenoblockers, other powerful antihypertensive drugs at early stages.

Hereditary complication of children of this group for hypertension (the presence of this disease in one or both parents) is a condition for classifying them as a risk group (with supervision once a year and carrying out preventive measures). From the anamnestic data it is necessary to note an unfavorable perinatal period in these children (rapid delivery, early discharge of water, etc.).

Clinical examination reveals normal or accelerated sexual development, manifestation of vegetative-vascular dysfunction. Obesity is an important concomitant factor attributable to the predictors of hypertension in this category of children. To determine the excess body weight, you can use various methods, for example, the Quetelet index.

Index of Quetelet = Body weight, kg / Height 2, m2

The following values of the Quetelet index correspond to the presence of excess body weight: at the age of 7-8 years -> 20, at 10-14 years -> 23, 15-17 years -> 25. The level of physical activity of children in this group is not enough; It is shown that it is 5-6 times lower than usual for the corresponding age. In girls, blood pressure figures are often increased on certain days of the menstrual cycle, which must be taken into account when examining.

Headache with vegetative dystonia with high blood pressure has features, among which it is necessary to isolate its localization - mainly in the occipital, parieto-occipital region. The pain is dull, pressing, monotonous, appears in the morning soon after waking up or in the afternoon, increases with physical exertion. Sometimes it takes on a pulsating character with an accent on one side (resembles migraine). Nausea is noted at the height of pain, but vomiting is infrequent. The mood and performance in children in the moment of headache are reduced.

The nature of objective experiences in children and adolescents with vegetative dystonia and elevations of blood pressure is associated with age and gender. The greatest number of complaints are made by girls of the pubertal period: tearfulness, fatigue, irritability, mood swings, headache; boys often notice headache, memory loss, fatigue.

In a number of patients, vegetative dystonia may have a crisis course, especially in the pubertal period. The attack is accompanied by pronounced vegetative symptoms: sweating, tachycardia, increased blood pressure, redness of the skin, dizziness, ringing in the ears, abdominal pain, polyuria. For this group of children are characterized by increased emotional lability, the possibility of developing attacks against the background of excitement.

The presence of 3-4 or more neurological micro-signs (more often, the lack of convergence, the asymmetry of a grin, nystagmus in the absence of vestibular disorders, etc.) testifies to a certain organic insufficiency of the brain of children of this group in comparison with healthy ones. These symptoms are more often detected on the background of general tendon hyperreflexia, dissociation of the expressiveness of reflexes along the body axis, symptoms of increased neuromuscular excitability (Khvostek's symptom). Hypertensive hydrocephalic syndrome in children with high blood pressure is noted in 78% of cases and, in contrast to that in current organic processes in the central nervous system, is non-rugged. Echoencephaloscopy often reveals an expansion of the III or lateral ventricles of the brain, amplification of the signal pulsation amplitude. A typical ophthalmologic sign in children of this group is the narrowing of the retinal arteries.

Adverse symptoms that worsen the possibility of therapy and prognosis are pronounced vagotonic initial vegetative tone, hypersympathic-tonic vegetative reactivity. The provision of activities may be normal, but hyperdiastolic and hypersympathic-tonic variants are frequently recorded during orthoclinic testing; with a persistent increase in blood pressure, there is an asymptotic-tonic variant of the sample. Valuable information is provided by veloergometry using the FWCi70 method, which evaluates the vegetative support of the activity, which allows to detect vascular hyperreactivity, the degree of connection of sympathoadrenal mechanisms to the load. Children with a tendency to increase blood pressure are encouraged to increase their measured physical load, starting from 0.5-1 W / kg. The risk of developing hypertension in the future in children with a significant increase in blood pressure in response to the load (more than 180/100 mm Hg with PWC170) is higher than in children with normal indices, regardless of the level of arterial pressure at rest.

According to veloergometry, children with hypertensive reaction should be evaluated as threatened by hypertension, especially if there is hereditary complication and obesity. The type of hemodynamics distinguishes children of this group from healthy ones; Thus, there is a decrease in the representation of the eukinetic variant due to the predominance of hyper- and hypokinetic. The hyperkinetic variant is more common in boys and is due to a hemodynamic shock or a relative increase in total peripheral vascular resistance (OPSS). The hypokinetic variant is more often in girls.

The most unfavorable for the prognosis and the transition to hypertensive disease are hypo- and eukinetic variants of hemodynamics with an increase in OPSS. In the cerebral vascular basin, especially against the background of headache, gravity in the occipital region, the lability of the shape of the curves, interhemispheric asymmetry, a decrease or a noticeable asymmetry of the blood filling in the vertebrobasilar basin deteriorating in the sample with a turn of the head are revealed according to the REG. Difficulty of venous outflow is a frequent sign of REG of these children. During an attack of headache, the REG indicates an increase in the tone of small arteries, which indicates the need to designate this category of sick drugs that affect microcirculation, improving venous outflow (trental, troxevasin, etc.).

EEG, as a rule, does not reveal gross violations, mainly changes of non-specific nature are noted. The most important feature of the brain's bioelectric activity in children with a tendency to increase blood pressure is the presence of signs of increased activity of the mesencephalic reticular formation, manifested by an increased frequency of "flattened" EEG, a decrease in the alpha-index on the load. Negrible dysrhythmia, bilateral-synchronous outbreaks of slow rhythms are more common in children under 11 years of age; in this they differ little from the healthy.

In the emergence of hypertension, emotional-personal and behavioral characteristics are essential. At present, attempts to connect the emergence of hypertension with a specific personality structure have not been successful, which indicates the heterogeneity of mental factors and their different contribution to the pathogenetic mechanisms of the disease. Emotional lability, asthenic, sensitiveness are important personality traits of a teenager prone to increased blood pressure.

The psychological characteristics of boys with this form of autonomic dystonia significantly distinguish them from girls. For boys, there is a high anxiety with a tendency to unpleasant somato-visceral sensations, which complicates their adaptation, deepens introversion, promotes the appearance of internal tension. Girls also have a tendency for anxious affects, a loose hypochondriacal fixation, but they are more active, self-centered, their behavior clearly traces hysterical manifestations. For this category of teenagers is characterized by an increased representation of accentuated personalities.

Unfavorable features are overestimated self-esteem, long-term affective processing of stressful situations - this helps maintain pressor reactions in the cardiovascular system. In the formation of autonomic dystonia with a tendency to increase blood pressure, the conditions of child upbringing, relationships within the family are of great importance. In such families, as a rule, there is a contradictory (contrasting) style of upbringing, fathers are removed from the problems of upbringing, and mothers are uncertain and anxious. Such relationships are stressful, contribute to the emergence of a child's dissatisfaction with the relationship of the mother, the father with an unconscious sense of protest, aggression. This manifests itself as a tendency to leadership in the group, conflicts with fellow practitioners, comrades, which affects the reactions of the cardiovascular system.

Psychological evaluation allows you to correctly approach treatment, adequately choose the dose of psychotropic drugs, the method of psychotherapy.

Thus, vegetative dystonia with arterial hypertension, being a characteristic form of neurohumoral disregulation of childhood and adolescence, requires an integrated approach to diagnosis and treatment, early dispensary measures.

Vegetative dystonia with arterial hypotension

Primary arterial hypotension of neurocirculatory dystonia by hypotonic type, hypotonic disease, essential hypotension.

At present, this form of arterial dyskinesia is considered to be an independent nosological unit, which is reflected in the International Classification of Diseases (1981). In childhood, autonomic dystonia with arterial hypotension is a common disease that can occur more or less severely in different patients. This form is revealed early, more often it begins at the age of 8-9 years. Statistical data on the prevalence of vegetative dystonia with arterial hypotension are contradictory - from 4 to 18%.

Arterial hypotension in children can be diagnosed at arterial pressure within the 5-25th percentile of the distribution curve. Hypotension can be systolic, systolic-diastolic, less often diastolic. It is characterized by a low pulse pressure, not exceeding 30-35 mm Hg. Art. When diagnosing this form of autonomic dystonia, it must be remembered that arterial hypotension is only one of the components of a single symptom complex of a kind of psycho-vegetative syndrome of childhood.

For proper diagnosis it is necessary to know the criteria of physiological arterial hypotension, which is understood as an isolated decrease in blood pressure without complaints and reduced efficiency; physiological hypotension is noted in persons arriving from the Far North, from the highlands, from trained athletes as a constitutional feature, manifested when adapting to unusual conditions. All other types of arterial hypotension (pathological) are divided into primary (about which we are talking) and symptomatic hypotension, which develops in the structure of a physical illness or due to infection, intoxication (with myocarditis, hypothyroidism, etc.).

A common view on arterial hypotension as a polyethological disease, for the emergence of which requires a combination of a complex of exogenous and endogenous causes. Among the endogenous factors, the hereditary predisposition to arterial hypotension, which is traced in two generations in a row, is primarily distinguished, with trophotropic diseases constituting the family fund mainly along the mother's line. On the emergence of this form of pathology, great importance is the pathology of the period of pregnancy and childbirth. It has been established that in mothers suffering from arterial hypotension, this critical period of life is overshadowed by numerous complications, especially in the period of labor (premature birth, obstetrical weakness, asphyxia, frequent intrauterine fetal hypoxia, miscarriages, etc.). It is believed that this is due to utero-placental and fetoplacental hemodynamic disorders due to low blood pressure in the mother.

Among the most important exogenous factors, first of all, it is necessary to note the influence of mental stresses, which are of exceptional importance as pre-disposition, and also trigger ones. Children with arterial hypotension are the least well-off group among other forms of autonomic dystonia in terms of saturation with stressful circumstances. The percentage of single-parent families is high, when the parents of the mother are engaged in the upbringing of the only child. Alcoholism of parents has an ambiguous impact on the development of autonomic dystonia in children. If alcoholism suffers mother even before the birth of a child, then he is expected to have expressed autonomic dysfunction more often with sympathicotonia, gross psychopathological manifestations. Usually the child faces the pathogenic influence of alcoholism in pre-school, junior school age, i.e., during the period of greatest vulnerability to stress. It is among the children whose drunkenness and alcoholism of parents that debuted in the family at this age of the child, the highest percentage of patients with arterial hypotension (35%).

Complaints of children with arterial hypotension are numerous and varied. As a rule, already at the age of 7-8 years, children complain of various painful feelings, among which the first place is the headache (76%). The headache appears, as a rule, in the second half of the day, during lessons, it is pressing, compressive, aching, localized mainly in the fronto-parietal and parieto-occipital areas. Less often the headache is noted in the temporomandibular region with a pulsating hue. The time of occurrence, intensity and nature of the headache depends on the emotional state of the child, the load that he performs, the time of the day and other factors. Often, a break in classes, walking in the fresh air, switching attention to stop or reduce cephalgia.

Common complaints are dizziness (32%), which occurs soon after a dream, often with a sudden change in body position, rising, and also with large breaks between meals. Vertigo is more common in children 10-12 years of age; in older children and adolescents, it occurs on a voyage. Cardialgia is noted in 37.5% of children, more often in girls; their occurrence is accompanied by an increase in the level of anxiety.

The most numerous group of complaints is associated with emotional and personal disorders; it is primarily emotional lability with a tendency to depressive states (accompanied by tearfulness, hot flashes, mood swings), which is noted in 73% of patients.

An important sign of autonomic dystonia with arterial hypotension is poor tolerance of physical exertion: 45% of children report increased fatigue. A characteristic feature of the patients of this group is also complaints about memory loss, distraction, absent-mindedness, worsening of working capacity (41%). Complaints of a gastroenterological nature are characteristic of V3 children of this group: usually this is a decrease in appetite, abdominalgia outside the connection with food intake, dyspeptic disorders. A variety of crisis states can be considered an important feature of patients with arterial hypotension: vegetative attacks occur in the form of panic attacks - with pronounced vital fear, tachycardia, osteoponotic hyperkinesis, increased blood pressure, respiratory discomfort, polyuria - in 30% of children, more often in adolescence. Syncope (syncope) - in 17% of children. In severe arterial hypotension, frequent (1-2 times a month) vegetative seizures are usually difficult to tolerate by children, especially if there are distinct hyperventilation disorders in combination with vestibular and gastrointestinal discomfort (dizziness, nausea, rumbling in the abdomen, pain, diarrhea, etc.) ). The night sleep of these children is disturbing, with unpleasant dreams, in the morning they feel lethargic, shabby.

Arterial hypotension can proceed more or less heavily, severely disadapting the patient. For severe form, stable arterial hypotension is characteristic with a level of blood pressure lower than 5% of the distribution curve. At the age of 8-9 years, this blood pressure is below 90/50 mm Hg. At 11-12 years - below 80/40 (boys) and 90/45 mm Hg. Art. (girls), at the age of 14-15 years - 90/40 (boys) and 95/50 mm Hg. Art. (girls). These children have a long, often recurring morning headache, sharply reducing the child's efficiency and overall adaptation, worsening academic achievement.

Vegetative crises occur very often - from once a week to 2 times a month, often with vegetative-vestibular manifestations, pre-syncopal sensations. There is pronounced meteotropism and vestibulopathy, orthostatic syncopes. For the moderate form of arterial hypotension, the blood pressure level is within 5-10% of the distribution curve, vegetative paroxysms are marked much less often (1-2 times per year); characteristic features common to the first group are poor tolerance of heat and stuffiness, vestibulopathy, a tendency to dizziness and orthostatic presyncopal states. The intensity and duration of headaches in this group of children was less.

With a decrease in blood pressure within 10-25% of the distribution curve, its labile nature is indicated by the mild form of arterial hypotension. The clinical picture is dominated by asthenoneurotic manifestations, episodic cephalalgia. In the clinical picture of autonomic dystonia with arterial hypotension, the slight delay in the physical development of these children, noted by us in 40%, attracts attention. Body weight in half of children is reduced, rarely excessive. So, the share of low physical development accounts for 15%, below the average - 25%. A direct correlation was established between the degree of lag in physical development and the severity of the course of arterial hypotension. Sexual development in 12% of children also slightly lags behind the age standard. The indicated deviations are not found in children with physiological arterial hypotension.

As a rule, children with arterial hypotension differ paleness with a pronounced vascular pattern of the skin, a red spilled dermographism is determined. On examination, signs of a "vagus" heart are noted (easy widening of the border to the left, muffled I tone and III tone at the apex) with a tendency to bradycardia. ECG - bradyarrhythmia, incomplete blockade of the right leg of the bundle, a syndrome of early repolarization, an increase in the T wave in the left thoracic leads.

Vegetative homeostasis in children with arterial hypotension is characterized by a parasympathetic orientation of the initial vegetative tone in 70% of cases, while at the same time, with physiological arterial hypotension, a mixed tone is noted in 69% of cases. In the remaining patients with hypotension, autonomic lability with a parasympathetic orientation is determined. Vegetative reactivity is increased, manifested in the form of hypersympatic-tonic reactions in the cardiovascular system in 80% of children. The vegetative maintenance of activity in children with primary arterial hypotension is inadequate, and the most disadaptive variants are registered during an orthoclinostatic test - hyperdiastolic, tachycardic. Conducting an orthostatic test in almost 10% of children is accompanied by pallor, unpleasant sensations, dizziness, nausea and a drop in blood pressure until the development of syncope, which is more often observed in children with severe arterial hypotension. The majority of children with arterial hypotension have a slight increase in SBP and DBP on exercise, and those children who have this significant increase tend to have hereditary hypertension and need regular follow-up.

For all children with arterial hypotension, a non-rigid residual-organic cerebral insufficiency is characteristic. In the status it manifests itself in the form of neurological micro-signs that do not reach the degree of outlined organic syndromes, in combination with signs of a non-structured hypertensive-hydrocephalic syndrome. In comparison with other forms of vegetative dystonia in arterial hypotension, the greatest degree of scarring of the cerebral structures is observed, apparently acquired in the early stages of ontogeny. The state of nonspecific, integrative systems of the brain in autonomic dystonia with arterial hypotension is characterized by severe dysfunction of the structures of the limbic-reticular complex. On EEG it is reflected in the form of signs of functional insufficiency of diencephalic structures associated with the generation of beta activity. The severity of EEG changes, as a rule, correlates with the severity of the course of arterial hypotension.

Psychologically, patients with autonomic dystonia with arterial hypotension are characterized by high anxiety, emotional tension, conflict, pessimistic assessment of their own perspective. With the use of experimental psychological methods (MIL, Rosenzweig test), a low level of activity, an asthenic type of response, a hypochondriacal fixation on one's own experiences were revealed. Violation of free self-actualization in 2/3 of adolescents, characterized as neurotic overcontrol, promoted withdrawal into the disease, a depressive background of mood.

In general, pathoharakterologicheskie features of children of this group were closely correlated with the severity of arterial hypotension, age (in puberty, impairment was noted), tension in the psychosocial environment of the child. Therefore, when prescribing therapy, it is necessary to take into account all the above-mentioned features of the clinical picture; except for psychotropic drugs, it is necessary to include psychocorrecting measures.