Features of vegeto-vascular dystonia in children

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

Thus, the thesis about the "generalization - systemic - local" nature of changes in childhood has a very relative meaning and the allocation of individual forms of vegetative dystonia according to the leading syndrome is a forced measure, which rather presupposes the choice of a doctor (pediatrician, cardiologist, neurologist), to whose specialty the identified disorders are "closer". The indisputable fact is the participation of at least two systems: the nervous system and one of the somatovisceral systems (for example, the cardiovascular system).

The clinical severity of the symptoms of vegetative dystonia may vary, and often the doctor and patient are attracted by the prevalence of one symptom, but a detailed questioning and examination allow to detect other numerous vegetative manifestations. Until now, clinical analysis has taken the leading place in the diagnostics of vegetative dystonia, despite the importance of instrumental methods. According to the clinical course in children, as in adults, permanent and paroxysmal types of vegetative dystonia are noted.

Unlike adults, panic disorders in children have their own specifics, depending on the child's age. The prevalence of vegetative-somatic manifestations in the attack structure over panic and emotional experiences in younger children is noted. In older age groups, the vagal direction of reactions decreases, the sympathetic component in paroxysms increases, reflecting the general intensification of the humoral link of regulation. Naturally, as with any disease, childhood vegetative dystonia has a phased course. This is important to take into account, since with a paroxysmal type of course, the presence of crises clearly indicates an exacerbation phase, and with a permanent course, only dynamic observation and examination allow such a conclusion to be made.

It seems important for childhood to determine and reflect in the diagnosis the general characteristics of the autonomic nervous system: sympathicotonic, vagotonic (parasympathetic) or mixed type. Establishing these characteristics, which is quite simple, allows the pediatrician, neurologist to immediately choose the general line in the diagnostic process, link various clinical signs into a common pathophysiological concept, and navigate in the choice of therapy. It is important, in addition to the clinical examination, to pay great attention to a thorough questioning of the parents, especially the mother. This will allow identifying the child's personality traits and behavior, pathocharacteristic deviations that are not immediately noticeable.

During a clinical examination of a child, attention is primarily 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 early childhood and puberty, during periods of maximum participation of this system in autonomic reactions. In this case, vascular reactions of the skin and sweat glands may be expressed, especially in the distal parts of the hands. With vagotonia, a general tendency to reddening of the skin, the hands are cyanotic (acrocyanosis), moist and cold to the touch. On the body, marbling of the skin is noted ("vascular necklace"), sweating is increased (general hyperhidrosis), there is a tendency to acne (in puberty, more often ackne vulgaris); manifestations of neurodermatitis, various allergic reactions (such as urticaria, Quincke's edema, etc.) are common. This category of children with vegetative dystonia has a tendency to fluid retention and transient swelling of the face (under the eyes).

With the dominance of the sympathetic part of the autonomic nervous system, the skin of children is pale, dry, the vascular pattern is not expressed. The skin on the hands is dry, cold, sometimes eczematous manifestations and itching are noted. Features of the constitution are of great importance in the vegetology of childhood. For various variants of vegetative dystonia, there are their own, preferable constitutional types. Children with sympathicotonia are more often thin than plump, although they have an increased appetite. In the presence of vagotonia, children are prone to obesity, polylymphadenopathy, have enlarged tonsils, often adenoids. As the work of many researchers shows, a tendency to excess body weight is a genetically determined trait, which in 90% of cases is observed in one of the parents.

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Thermoregulation disorders

Thermoregulation disorders are a characteristic sign of permanent and paroxysmal vegetative disorders in childhood. Children tolerate even high temperatures well. Only at very high figures (39-40 °C) asthenic complaints are noted. In general, they remain active and participate in games. The temperature can remain at subfebrile figures (37.2-37.5 °C) for a very long time - months, which is often put in a causal relationship with some chronic somatic disease (rheumatism, chronic cholecystitis, etc.) or a previous infection, since "temperature tails" drag on for many weeks. Crisis increases in temperature (hyperthermic crises) occur against the background of emotional experiences, while children note "fever", mild headache. The temperature decreases spontaneously and does not change during the amidopyrine test.

The peculiarities of temperature disorders include the fact that they are usually absent during the summer holidays of children and resume with the beginning of the school year (the so-called "September 7 diseases"). When examining children with fever due to autonomic dysfunction, attention is drawn to the normal (cold) temperature of the skin of the forehead and extremities. In fact, elevated temperature is recorded only in the axillary cavity, and there may be thermal asymmetries. Signs of thermoregulation disorders in children with autonomic dystonia include chilliness (poor tolerance of low temperatures, drafts, damp weather), so such patients like to dress warmly, they easily develop chills.

It is important to note that, unlike infectious fevers, any hyperthermic manifestations pass when falling asleep; at night, these children have a normal temperature. A rise in temperature is very frightening, first of all, to parents, whose behavior, at first being adequate (inviting a doctor, consultations, tests, treatment), becomes alarming as the expected therapeutic effect is insignificant or absent. Measuring the child's temperature is done more and more often and becomes obsessive, self-sufficient in nature, which has an extremely negative effect on children. Such behavior of parents leads to the child's fixation on his "defect", additionally forming psychogenic reactions of a phobic, depressive nature.

Respiratory organs

When examining children with vegetative dystonia, pathological manifestations are noted in 1/4 - 1/3 of cases, the spectrum of which is quite wide. The most common complaints are dissatisfaction with inhalation, a feeling of lack of air, constrained breathing, dyspnea. Respiratory disorders in most cases are accompanied by unpleasant affective disorders. Characteristic features of breathing in children with vegetative dystonia include deepening of inhalation with incomplete exhalation or rare forced inhalation with a long noisy exhalation. Often, children take deep noisy sighs against the background of normal breathing, which in some cases have an obsessive character. These complaints are most numerous in children with a parasympathetic orientation of vegetative dystonia. At the same time, sudden shortness of breath during moderate physical exertion, attacks of paroxysmal neurotic cough (spasmodic vagal cough) during emotional experiences confirm the psychogenic origin of these respiratory disorders.

Children with vegetative dystonia may have attacks of shortness of breath at night - pseudo-asthma, a feeling of lack of air ("suffocation") when worried; the latter manifestation often occurs in the structure of vegetative crises (with a paroxysmal type of vegetative dystonia) and is accompanied by an experience of vital fear. A feeling of lack of air and congestion in the chest occurs in sick children at certain hours (after waking up, when falling asleep, at night), is associated with mood swings, with the passage of atmospheric fronts. The inability to take a full deep breath, which sick children need from time to time, is difficult to bear, perceived as evidence of a severe lung disease; more often occurs with masked depression. A characteristic symptom is paroxysms of frequent shallow chest breathing with a quick change from inhalation to exhalation with the inability to hold the breath for a long time (shortened by 2-3 times against the norm of 5-60 s).

Attacks of psychogenic dyspnea are often combined with cardialgia, sensations of palpitations, which are accompanied by a feeling of anxiety, restlessness. All respiratory disorders in children are detected against the background of a depressed mood, anxiety, fear of death from suffocation. Attacks of imaginary asthma are accompanied by a specific noise pattern: moaning breathing, sighs, groans, whistling inhalation and noisy exhalation, while no wheezing is heard in the lungs. Respiratory movements during a pseudo-asthmatic attack increase to 50-60 per 1 min, while the immediate cause can be any excitement, an unpleasant conversation, etc. Hyperventilation disorders are combined with weakness and general malaise. Children complain of convulsive contractions in the fingers, calf muscles, unpleasant sensations (paresthesia) in various parts of the body. After an attack of pseudo-asthma, patients experience general weakness, drowsiness, attacks of hiccups and yawning.

When collecting anamnesis from children with respiratory disorders, it is quite often revealed that they had suffered from fear of death from suffocation (or they observed respiratory disorders in relatives, etc.), which contributed to neurotic fixation. Frequent yawning of an obsessive nature is often observed in children with vegetative dystonia, especially with asthenic features, but it is very difficult for the child to overcome this series of yawning movements, they end spontaneously. Children with respiratory disorders in the structure of the vegetative dystonia syndrome in the anamnesis often have asthmatic bronchitis, frequent respiratory viral infections.

Gastrointestinal system

The gastrointestinal system is the subject of complaints in children with vegetative dystonia. They are most typical for children with vagotonic orientation of vegetative tone. The most frequent complaints are nausea, abdominal pain, vomiting, heartburn, dyskinetic manifestations in the form of constipation or unexplained diarrhea. Common complaints that worry parents are appetite disorders.

Increased salivation is noticeable, less often it is decreased. Nausea and vomiting in children are frequent somatovegetative manifestations of emotional experiences. Having arisen once after acute psychogenia (fright), these symptoms are fixed and then persistently repeat in response to stress loads. In small children, frequent regurgitation and vomiting can be a manifestation of gastrointestinal dyskinesia, in particular pylorospasm, increased intestinal motility, at an older age - the result of cardiospasm. Pain in the abdomen in children with vegetative dystonia is a frequent and characteristic symptom, ranking second after headaches.

Long-term pain is less typical for childhood than episodes of short-term, often quite severe abdominal crises, which are more often observed at the age of up to 10 years. During such an attack, the child turns pale, stops playing or wakes up crying, and usually cannot localize the pain. When abdominal crises are combined with an increase in temperature (i.e., acute abdomen), an inflammatory shift in the blood formula, it is very difficult not to suspect surgical pathology (appendicitis, mesadenitis, etc.), but one should also remember the possibility of a "periodic disease" - Reimann's syndrome. Attacks of abdominalgia have a bright vegetative coloring, mainly parasympathetic orientation. This type of paroxysmal course of vegetative dystonia prevails in younger children and is less typical for older children and adolescents.

It is important to remember about "abdominal migraine", which occurs in the form of paroxysmal abdominal pain, the characteristic feature of which is a combination or alternation with a severe headache of a migraine nature. Attacks begin suddenly, last on average several minutes and end spontaneously (often with diarrhea). For children with recurrent abdominal pain, an EEG study should be included in the examination complex.

Of the external manifestations of a temporal lobe epileptic seizure, abdominal pain is a characteristic sign. Abdominal aura may be a component of a partial complex seizure that occurs without impairment of consciousness.

Among other vegetative symptoms, it is necessary to note the sensation of a lump in the throat, pain behind the breastbone, associated with spastic contractions of the muscles of the pharynx and esophagus, which is often observed in neurotic, egocentric children. With age, a certain dynamics of complaints can be traced: in the first year of life - most often regurgitation, colic; at 1-3 years - constipation and diarrhea; at 3-8 years - episodic vomiting; at 6-12 years - paroxysmal abdominal pain, biliary dyskinesia, various manifestations of gastroduodenitis.

Cardiovascular system

The state of the cardiovascular system in children with vegetative dystonia is the most complex and important section of childhood vegetology. Cardiovascular manifestations are detected in various variants of vegetative dystonia. The syndrome of vegetative dysfunctions is most clearly represented by cardiovascular dysfunction. Depending on the leading symptom complex, dysregulation is distinguished (mainly) by the cardiac (functional cardiopathies - FCP) or vascular type (arterial dystonia by hypertensive or hypotensive type). However, now, according to WHO recommendations, changes in blood pressure are usually called hypertension or hypotension, respectively. Based on this, it is more correct to call: vegetative dystonia with arterial hypertension or vegetative dystonia with arterial hypotension.

What is the advantage of such a division principle? Firstly, due to the widespread prevalence of autonomic disorders in the child population, the main burden of diagnosis and treatment falls on pediatricians, who find it easier to characterize the patient in a therapeutic vein, without delving into the complexities of psycho-vegetative-somatic relationships. Secondly, since the psycho-vegetative syndrome of childhood is extremely polymorphic in its clinical presentation (age and gender play a major role), the division used into the specified types of autonomic dystonia plays the role of a supporting feature, supplementing which with data on the state of other systems, one can obtain a clear idea of the degree and nature of autonomic dysfunction.

Vegetative dystonia of the cardiac type (functional cardiopathies)

This section includes a large group of functional disorders in the activity of the heart due to impaired vegetative regulation. Heart rhythm and conduction disorders 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 conduction disorders are divided into cardiac, extracardiac and combined. Any organic heart disease (myocarditis, defects, etc.) contributes to the occurrence of arrhythmias. Pathological influences cause electrical instability of the myocardium - a condition in which a stimulus that does not exceed the threshold intensity is capable of causing repetitive electrical activity of the heart. In the development of this condition, in addition to organic ones, vegetative and humoral regulatory influences are of great importance. Extracardiac factors that contribute to the development of arrhythmias include disturbances in the innervation of the heart due to functional insufficiency of the suprasegmental and segmental parts of the child's nervous system, formed under the influence of perinatal trauma, as well as hereditary conditioned inadequacy of vegetative regulation. Extracardiac factors also include humoral disturbances, including endocrine-humoral changes during puberty.

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

The nature of arrhythmias in childhood cannot be used to judge their extra- or cardiac genesis; only ventricular paroxysmal tachycardia, “threatened” ventricular extrasystoles, fibrillation and fibrillation of the atria and ventricles, complete atrioventricular block are more characteristic of organic heart disease.

The functional nature of arrhythmias in children, their connection with the activity of the autonomic suprasegmental regulatory systems were confirmed by the introduction of daily ECG monitoring (Holter method). It turned out that in absolutely healthy children, individual pathological ECG phenomena may appear throughout the day without any connection with the organic involvement of the heart. During Holter monitoring, conducted in 130 healthy children, it was established that the heart rate during the day fluctuates from 45 to 200 per 1 min, atrioventricular blocks of the first degree occur in 8%, of the second degree of the Mobitz type - in 10% of children and more often at night, isolated atrial and ventricular extrasystoles are noted in 39% of those examined.

For the occurrence of the above types of functional heart pathology, the basic indicators of vegetative regulation, in particular tone and reactivity, are of great importance. The following are distinguished in the group of functional cardiopathies.

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

Atrioventricular block (AVB) of the first degree is most often observed in children with vagotonic vegetative tone. To confirm the functional nature of the shifts, the following is carried out:

• ECG examination of the parents, in which case the detection of prolongation of the PR interval in them indicates a hereditary origin of AVB in the child;
• ECGs are recorded in orthostasis - in 1/3 - 1/2 of children the PR interval is normalized in the vertical position;
• When atropine is administered subcutaneously or intravenously, AVB is removed.

Syndrome of premature ventricular excitation (Wolff-Parkinson-White syndrome) occurs most often in children with vagotonic initial vegetative tone in the cardiovascular system. It should be said that the listed syndromes are diagnosed by ECG examination, 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 attacks of paroxysmal tachycardia, inclusion in the group of risk factors for sudden death (WHO nomenclature), make it necessary to know these syndromes.

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Wolff-Parkinson-White syndrome (WPW)

Wolff-Parkinson-White syndrome is observed in 60-70% of cases in children without organic heart disease. The true frequency of the syndrome in the population is unknown due to its transient nature. WPW syndrome is associated with the circulation of impulses along the Kent bundle. Evidence that the conduction of impulses along additional pathways has an auxiliary, compensatory value is the presence of a sigma wave on the ECG in 60% of healthy children. In the genesis of WPW syndrome, the main role (in 85% of patients) is played by impaired vegetative regulation, clinically manifested by SVD.

The ECG criteria for WPW syndrome are as follows:

• shortening (less than 0.10 s) of the PR interval;
• widening of the QRS complex by more than 0.10-0.12 s;
• presence of the 5th 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 burden for diseases of the trophotropic circle (peptic ulcer, neurodermatitis, etc.). In 1/2 of cases, their parents have similar changes on the ECG. The occurrence of vegetative dysfunction in children with WPW syndrome is always facilitated by an unfavorable course of pregnancy and childbirth. In most cases, the clinical picture of vegetative dysfunction in these children was accompanied by complaints of headache, sweating, dizziness, fainting episodes, pain "in the heart area", in the abdomen, in the legs, more often at night. Arterial hypotension and bradycardia are noted in the status.

Neurological symptoms are limited to individual micro-signs; compensated intracranial hypertension syndrome is registered in 2/3 of cases. In the 1 emotional and personal plan, children with WPW are distinguished by a high level of neuroticism, sensitivity, anxiety, the presence of phobic disorders, and often a pronounced asthenic symptom complex. Vagotonic tone is a characteristic sign. Elimination of WPW syndrome with the help of stress and drug tests allows us to exclude its organic nature. When using an atropine test (0.02 mg/kg), WPW syndrome disappears in 30-40%, and when using ajmaline (1 mg/kg), in 75% of children. The persistence of the WPW phenomenon after the drug test necessitates restrictions on playing big-time sports. In particular, children in whom ajmaline does not relieve WPW have a short effective refractory period, i.e. they are at risk for sudden death. Attacks of atrial paroxysmal tachycardia, observed in 40% of children with WPW syndrome, are manifestations of a vegetative paroxysm of sympathetic tension against a vagotonic background.

In general, the prognosis for WPW syndrome is favorable. Treatment of the main clinical manifestations with vegetotropic and psychotropic drugs is necessary.

Clerk-Levi-Cristesco syndrome (CLC) - short PR interval syndrome - is a type of premature ventricular excitation syndrome due to the circulation of impulses through accessory 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, attacks of paroxysmal tachycardia are characteristic. Drug tests (for example, with hilurythmal) eliminate this phenomenon, but vegetative dystonia remains.

Mahaim syndrome occurs much more frequently. The clinical and pathophysiological features are similar to those of WPW syndrome. Treatment is the same as for the above syndromes.

Children with vegetative dystonia may experience cardiac arrhythmias that are the result of a disruption of neurohumoral rhythm regulation (in the absence of signs of organic heart pathology): supraventricular and right ventricular extrasystole at rest, attacks of paroxysmal tachycardia, non-paroxysmal heterotropic supraventricular tachycardia, chronic sinus tachy- and bradycardia.

Vegetative arterial dystonia

For correct diagnosis of arterial dystonia, it is necessary to remember the WHO recommendations for determining blood pressure figures, taking into account the complexity of distinguishing between the norm and pathology. The very fact of correctly measuring the child's pressure is of great importance. After measuring blood pressure, the average values and cutoff points of the percentile distribution of systolic blood pressure (SBP) and diastolic blood pressure (DBP) in schoolchildren are determined according to the existing blood pressure tables for schoolchildren aged 7-17, which should be on the desk of every pediatrician. The group of people with high blood pressure includes children with SBP and DBP exceeding the values of 95% of the cutoff points of the distribution, the group with low blood pressure - 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 blood pressure norm in children: 7-9 years old - 125/75 mm Hg, 10-13 years old - 130/80 mm Hg. Art., 14-17 years - 135/85 mm Hg. Art. Often, high blood pressure in children is recorded accidentally - during a medical examination, in a sports section, etc., but confirmation of the detected high blood pressure values in children requires systematic (with an interval of several days) measurements due to the lability of the indicators and the large role of the emotional factor.

Vegetative dystonia with arterial hypertension

Vegetative dystonia with arterial hypertension (neurocirculatory dystonia of the hypertensive type) is observed in children with arterial pressure values exceeding the 95th percentile; they are characterized by a labile increase in arterial pressure without signs of persistent organ involvement. This form of vegetative-vascular dysregulation is more common in middle-aged and older schoolchildren, i.e., in adolescence. It is widespread in the child population. Elevated arterial pressure values are detected in 4.8-14.3% of children, and in school-age children - in 6.5%.

High blood pressure is twice as common among urban schoolchildren as among rural ones. With age, young men outstrip girls in the frequency of this form of vegetative dystonia (14.3 and 9.55%, respectively), although girls dominate in the younger groups. This form of vegetative dystonia can transform into hypertension, so every doctor should pay special attention to the implementation of medical examinations.

In the clinical picture of vegetative dystonia with arterial hypertension, the set of complaints is usually small. Most often, these are headaches, cardialgia, irritability, fatigue, complaints of memory loss, and less often, non-systemic dizziness. Usually, there is no connection between the level of arterial pressure and the presentation of complaints; here, the general emotional state of the child and his fixation on his own health are more likely to have an effect. In hospital settings, such children may have normal arterial pressure, although functional tests confirm the diagnosis.

Depending on the severity and persistence of symptoms, three stages of the disease are distinguished: transient arterial hypertension, labile and stable. The first two varieties cover at least 90% of all children with fluctuations in blood pressure. The division into stages allows for differentiated solutions to therapy issues, avoiding unnecessary early administration of adrenergic blockers and other powerful hypotensive agents.

The hereditary burden of children in 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 observation once a year and preventive measures). From the anamnestic data, it should be noted that these children have an unfavorable perinatal period (rapid labor, early rupture of membranes, etc.).

Clinical examination reveals normal or accelerated sexual development, manifestation of vegetative-vascular dysfunction. Obesity is an important concomitant factor related to predictors of hypertension in this category of children. Various methods can be used to determine excess body weight, such as the Quetelet index.

Quetelet index = 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 insufficient; it has been shown that it is 5-6 times lower than usual for the corresponding age. In girls, blood pressure figures often increase on certain days of the menstrual cycle, which should be taken into account during examination.

Headache with vegetative dystonia with high blood pressure has its own characteristics, among which its localization should be highlighted - mainly in the occipital, parietal-occipital region. The pain is dull, pressing, monotonous, appears in the morning soon after waking up or during the day, intensifies with physical exertion. Sometimes it acquires a pulsating character with an accent on one side (resembles migraine). Nausea is noted at the height of the pain, but vomiting is rare. Mood and performance in children at the time of headache are reduced.

The nature of objective experiences in children and adolescents with vegetative dystonia and increased blood pressure is related to age and gender. The greatest number of complaints are presented by girls in puberty: tearfulness, fatigue, irritability, mood swings, headache; boys more often report headaches, memory loss, fatigue.

In some 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, reddening of the skin, dizziness, ringing in the ears, abdominal pain, polyuria. This group of children is characterized by increased emotional lability, the possibility of developing attacks against the background of anxiety.

The presence of 3-4 or more neurological microsigns (usually convergence insufficiency, grin asymmetry, nystagmus in the absence of vestibular disorders, etc.) indicates a certain organic insufficiency of the brain in children of this group compared to healthy children. These symptoms are often detected against the background of general tendon hyperreflexia, dissociation of the expression of reflexes along the body axis, symptoms of increased neuromuscular excitability (Chvostek's symptom). Hypertensive-hydrocephalic syndrome in children with high blood pressure is observed in 78% of cases and, unlike that with ongoing organic processes in the central nervous system, is not severe. Echoencephaloscopy often reveals dilation of the third or lateral ventricles of the brain, increased amplitude of signal pulsation. A typical ophthalmological sign in children of this group is narrowing of the retinal arteries.

Unfavorable signs that worsen the possibility of therapy and prognosis are pronounced vagotonic initial vegetative tone, hypersympathetic-tonic vegetative reactivity. Activity support may be normal, but hyperdiastolic and hypersympathetic-tonic variants are often recorded during orthoclinoprobes; with a persistent increase in blood pressure, an asympathetic-tonic variant of the test is noted. Valuable information is provided by bicycle ergometry using the FWCi70 method, assessing the vegetative support of activity, allowing to detect vascular hyperreactivity, the degree of involvement of sympathoadrenal mechanisms in the load. Children with a tendency to increased blood pressure are recommended to have increasing dosed physical activity, starting with 0.5-1 W/kg. The risk of developing hypertension in the future is higher in children with a significant increase in blood pressure in response to exercise (more than 180/100 mmHg with PWC170) than in children with normal values, regardless of the level of blood pressure at rest.

According to bicycle ergometry data, children with a hypertensive reaction should be assessed as at risk for arterial hypertension, especially in the presence of hereditary burden and obesity. The type of hemodynamics distinguishes children of this group from healthy ones; thus, a decrease in the representation of the eukinetic variant is noted due to the prevalence 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 (TPVR). The hypokinetic variant is more common in girls.

The most unfavorable in terms of prognosis and transition to hypertension are hypo- and eukinetic hemodynamic variants with increased OPSS. In the cerebral vascular basin, especially against the background of headache, heaviness in the occipital region, according to REG data, lability of the curve shape, interhemispheric asymmetry, decrease or noticeable asymmetry of blood filling in the vertebrobasilar basin, worsening during a test with a head turn, are detected. Difficulty in venous outflow is a frequent REG sign of these children. During an attack of headache, REG indicates an increase in the tone of small arteries, which indicates the need to prescribe this category of patients drugs that affect microcirculation, improve venous outflow (trental, troxevasin, etc.).

EEG, as a rule, does not reveal gross violations, mainly non-specific changes are noted. The most important feature of the bioelectrical activity of the brain in children with a tendency to high 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 loads. Mild dysrhythmias, bilaterally synchronous bursts of slow rhythms are more typical of children under 11 years of age; in this they differ little from healthy children.

Emotional, personal and behavioral characteristics are essential in the development of arterial hypertension. At present, attempts to link the development of hypertension with a certain personality structure have not been successful, which indicates the heterogeneity of mental factors and their different contributions to the pathogenetic mechanisms of the disease. Emotional lability, asthenia, sensitivity are important personality traits of a teenager prone to high blood pressure.

The psychological characteristics of boys with this form of vegetative dystonia significantly distinguish them from girls. Boys are characterized by high anxiety with a tendency to unpleasant somatovisceral sensations, which complicates their adaptation, deepens introversion, and contributes to the emergence of internal tension. Girls also have a tendency to anxious affects, mild hypochondriacal fixation, but they are more active, egocentric, and hysterical manifestations are clearly visible in their behavior. This category of adolescents is characterized by an increased representation of accentuated personalities.

Unfavorable features are inflated self-esteem, prolonged affective processing of stressful situations - this contributes to the maintenance of pressor reactions in the cardiovascular system. In the formation of vegetative dystonia with a tendency to increase blood pressure, the conditions of the child's upbringing and relationships within the family are of great importance. In such families, as a rule, a contradictory (contrasting) style of upbringing is noted, fathers distance themselves from the problems of upbringing, and mothers experience insecurity and anxiety. Such relationships are stressful, contribute to the emergence of dissatisfaction in the child with the attitude of the mother, father with an unconscious feeling of protest, aggression. This is manifested by a tendency to leadership in the group, conflicts with classmates, comrades, which is reflected in the reactions of the cardiovascular system.

A psychological assessment allows for a more correct approach to treatment, and the appropriate selection of doses of psychotropic drugs and psychotherapy methods.

Thus, vegetative dystonia with arterial hypertension, being a characteristic form of neurohumoral dysregulation in childhood and adolescence, requires a comprehensive approach to diagnosis and treatment, and early implementation of dispensary measures.

Vegetative dystonia with arterial hypotension

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

Currently, this form of arterial dyskinesia is considered an independent nosological unit, which is reflected in the International Classification of Diseases (1981). In childhood, vegetative dystonia with arterial hypotension is a common disease that can be more or less severe in different patients. This form is detected early, most 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 with arterial pressure within the 5-25th percentile of the distribution curve. Hypotension can be systolic, systolic-diastolic, and less often diastolic. It is characterized by low pulse pressure, not exceeding 30-35 mm Hg. When diagnosing this form of vegetative dystonia, it is necessary to remember that arterial hypotension is only one component of a single symptom complex of a peculiar psycho-vegetative syndrome of childhood.

For correct diagnosis, it is necessary to know the criteria of physiological arterial hypotension, which is understood as an isolated decrease in blood pressure without complaints or decreased performance; physiological hypotension is observed in people who arrived from the Far North, from high-mountain areas, in trained athletes as a constitutional feature that manifested itself during adaptation to unusual conditions. All other types of arterial hypotension (pathological) are divided into primary (which is what we are talking about) and symptomatic hypotension, which develops in the structure of a somatic disease or as a result of infection, intoxication (with myocarditis, hypothyroidism, etc.).

The generally accepted point of view is that arterial hypotension is a polyetiological disease, the occurrence of which requires a combination of a complex of exogenous and endogenous causes. Among the endogenous factors, the first to stand out is a hereditary predisposition to arterial hypotension, which can be traced in two generations in a row, with trophotropic diseases making up the family fund mainly on the mother's side. The occurrence of this form of pathology is greatly influenced by the pathology of the period of pregnancy and childbirth. It has been established that in mothers suffering from arterial hypotension, this important period of life is overshadowed by numerous complications, especially during childbirth (premature birth, labor weakness, asphyxia, frequent intrauterine hypoxia of the fetus, miscarriages, etc.). It is believed that this is due to uteroplacental and fetoplacental hemodynamic disorders due to low blood pressure in the mother.

Among the most important exogenous factors, it is necessary to note first of all the influence of mental stresses, which are of exceptional importance as predispositional and triggering factors. Children with arterial hypotension are the least favorable group among other forms of vegetative dystonia in terms of saturation with stressful circumstances. The percentage of single-parent families is high, when the mother's parents are engaged in raising an only child. Alcoholism of parents has an ambiguous effect on the development of vegetative dystonia in children. If the mother suffers from alcoholism even before the birth of the child, then the child is destined for pronounced vegetative dysfunction, often with sympathicotonia, gross psychopathological manifestations. Usually, a child encounters the pathogenic influence of alcoholism in pre-school, primary school age, i.e., during the period of greatest vulnerability to stress. It is among children, whose parents' drunkenness and alcoholism debuted in the family at this age, that the percentage of patients with arterial hypotension is highest (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 pain sensations, among which headache is in first place (76%). Headache usually appears in the afternoon, during lessons, has a pressing, squeezing, aching character, localized mainly in the frontal-parietal and parietal-occipital areas. Less often, headache is noted in the temporal-frontal region with a pulsating shade. The time of occurrence, intensity and nature of headache depend on the emotional state of the child, the load he performs, the time of day and other factors. Often, a break in classes, walks in the fresh air, switching attention stop or reduce cephalgia.

Common complaints include dizziness (32%), which occurs shortly after sleep, often with a sharp change in body position, standing up, and also with long breaks between meals. Dizziness is more common in children aged 10-12 years; in older children and adolescents, it occurs in the morning. Cardialgia is observed in 37.5% of children, more often in girls; its appearance is accompanied by an increase in anxiety.

The most numerous group of complaints is related to emotional and personal disorders; this is primarily emotional lability with a tendency to depressive states (accompanied by tearfulness, irascibility, mood swings), which is observed in 73% of patients.

A significant symptom of vegetative dystonia with arterial hypotension is poor tolerance of physical activity: increased fatigue is noted by 45% of children. A characteristic feature of patients in this group is also complaints of memory loss, distractibility, absent-mindedness, deterioration in performance (41%). Gastroenterological complaints are typical of V3 children in this group: usually this is a decrease in appetite, abdominalgia unrelated to food intake, dyspeptic disorders. Various crisis conditions 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, chill-like hyperkinesis, increased blood pressure, respiratory discomfort, polyuria - in 30% of children, more often in adolescence. Syncopal states (syncopes) - in 17% of children. In case of severe arterial hypotension, frequent (1-2 times a month) vegetative attacks are usually hard for children to bear, especially if there are distinct hyperventilation disorders in combination with vestibular and gastrointestinal discomfort (dizziness, nausea, rumbling in the stomach, pain, diarrhea, etc.). The night sleep of these children is restless, with unpleasant dreams, in the morning they feel lethargic and exhausted.

Arterial hypotension can be more or less severe, greatly disadapting the patient. The severe form is characterized by stable arterial hypotension with the level of blood pressure decrease below 5% of the distribution curve. At the age of 8-9 years, this is BP below 90/50 mm Hg, at 11-12 years - below 80/40 (boys) and 90/45 mm Hg (girls), at the age of 14-15 years - 90/40 (boys) and 95/50 mm Hg (girls). These children have long-term, frequently recurring morning headaches, which sharply reduce the child's performance and general adaptation, worsening academic performance.

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

When the blood pressure decreases within 10-25% of the distribution curve, its labile nature indicates a mild form of arterial hypotension. Asthenoneurotic manifestations and episodic cephalgias predominate in the clinical picture. In the clinical picture of vegetative dystonia with arterial hypotension, a slight delay in the physical development of these children, noted by us in 40%, attracts attention. The body weight of half of the children is reduced, rarely excessive. Thus, the share of low physical development accounts for 15%, below average - 25%. A direct correlation has been established between the degree of retardation in physical development and the severity of arterial hypotension. Sexual development in 12% of children also lags slightly behind the age standard. The indicated deviations do not occur in children with physiological arterial hypotension.

As a rule, children with arterial hypotension are pale with a pronounced vascular pattern of the skin, and red diffuse dermographism is determined. During examination, signs of a "vagal" heart are noted (slight expansion of the border to the left, muffled 1st tone and 3rd tone at the apex) with a tendency to bradycardia. On the ECG - bradyarrhythmia, possible incomplete block of the right leg of the bundle of His, early repolarization syndrome, increased T waves in the left chest leads.

Vegetative homeostasis in children with arterial hypotension is characterized by parasympathetic orientation of the initial vegetative tone in 70% of cases, while with physiological arterial hypotension, mixed tone is observed in 69% of cases. In other patients with hypotension, vegetative lability with a parasympathetic orientation is determined. Vegetative reactivity is increased, manifested in the form of hypersympathetic-tonic reactions in the cardiovascular system in 80% of children. Vegetative support of activity in children with primary arterial hypotension is insufficient, and when conducting an orthoclinostatic test, the most maladaptive variants are recorded - hyperdiastolic, tachycardic. Conducting an orthostatic test in almost 10% of children is accompanied by pallor, discomfort, dizziness, nausea and a drop in blood pressure up to the development of a fainting state, which is more often observed in children with severe arterial hypotension. Most children with arterial hypotension show a slight increase in SBP and DBP during exercise, and those children who have a significant increase usually have a hereditary burden of hypertension and require outpatient observation.

All children with arterial hypotension are characterized by mild residual organic cerebral insufficiency. In the status, it is manifested in the form of neurological microsigns that do not reach the degree of outlined organic syndromes, in combination with signs of mild hypertensive-hydrocephalic syndrome. Compared with other forms of vegetative dystonia, arterial hypotension is characterized by the highest degree of deficiency of cerebral structures, acquired, apparently, at the early stages of ontogenesis. The state of nonspecific, integrative systems of the brain in vegetative dystonia with arterial hypotension is characterized by pronounced dysfunction of the structures of the limbic-reticular complex. On the EEG, this 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 arterial hypotension.

In psychological terms, patients with vegetative dystonia with arterial hypotension are characterized by high anxiety, emotional tension, conflict, and a pessimistic assessment of their own prospects. Using experimental psychological methods (MIL, Rosenzweig test), a low level of activity, an asthenic type of response, and a hypochondriacal fixation on their own experiences were revealed. Violation of free self-actualization in 2/3 of adolescents, characterized as neurotic overcontrol, contributed to withdrawal into illness and a depressive mood background.

In general, the pathocharacterological features of children in this group closely correlated with the severity of arterial hypotension, age (deterioration was noted during puberty), and tension in the child's psychosocial environment. Therefore, when prescribing therapy, it is necessary to take into account all the above-mentioned features of the clinical picture; in addition to psychotropic drugs, it is imperative to include psychocorrective measures.