1.adreuli asakis bavshvis fizikuri ganvitareba da misi shepaseba … · 2015-01-23 · 8 kvira...
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1
adreuli asakis bavSvis
fizikuri ganviTareba da misi
Sefaseba
klinikuri praqtikis erovnuli rekomendacia
(gaidlaini)
2
klinikuri praqtikis erovnuli rekomendacia (gaidlaini)
`adreuli asakis bavSvis fizikuri ganviTareba da misi
Sefaseba~ miRebulia klinikuri praqtikis erovnuli
rekomendaciebis (gaidlainebi) da daavadebaTa marTvis
saxelmwifo standartebis (protokolebi) SemuSavebis,
Sefasebis da danergvis erovnuli sabWos 2008 wlis 5
noembris #1 sxdomaze da damtkicebulia saqarTvelos
Sromis, janmrTelobisa da socialuri dacvis ministris
2009 wlis 14 aprilis # 155/o brZanebiT.
3
adreuli asakis bavSvis fizikuri ganviTareba da misi Sefaseba
definicia
fizikuri ganviTareba zrdis dinamikuri procesia, romelic
gulisxmobs sxeulis masis, sigrZis, Tavis da gulmkerdis
garSemowerilobebis matebas, sxeulis proporciis cvlilebas da
bavSvis orgnizmis biologiur momwifebas.
bavSvis zrdis procesze, gansakuTrebiT sicocxlis pirveli wlebis
ganmavlobaSi mravali faqtori axdens gavlenas, kerZod, genetika,
prenataluri periodis mimdinareoba, kveba, fizikuri aqtivobis
xarisxi, garemo faqtorebi da sxv.11,12.
bavSvis fizikuri ganviTarebis Sefaseba pediatriuli meTvalyureobis
erT-erTi ZiriTadi komponentia, vinaidan bavSvTa asakis nebismieri
problema (fsiqologiuri, interpersonaluri, socialuri) aisaxeba
zrdis procesze12.
bavSvis zrdis procesze meTvalyureobis mizania13,14:
• fizikuri ganviTarebis Sefaseba
• riskis jgufis gamoyofa;
• zrdis darRvevebis drouli identifikacia, adekvaturi
marTva da referali;
• zrdis Seferxebis prevencia;
• zrda-ganviTarebis xelSewyoba.
wonis, sigrZe/simaRlis, Tavis garSemowerilobis Sefaseba
pediatriuli pacientis gasinjvis mniSvnelovani komponentia
(rekomendacia C)56.
gaidlaini gankuTvnilia
⇒ samedicino personalisTvis, romelic muSaobs adreuli asakis
bavSvebTan samSobiaro saxlSi, jandacvis pirvelad rgolsa da
stacionarSi – neonatologebis, pediatrebis, ojaxis eqimebis,
axalSobilTa da patronaJis meddebisTvis.
gaidlainis samizne jgufi:
⇒ adreuli asakis bavSvebi.
epidemiologia
janmrTelobis msoflio organizaciis monacemebiT yovelwliurad
ibadeba 26 milioni mcire wonis axalSobili, rac ganpirobebulia
erTi mxriv orsulTa daavadebebiT, meore mxriv ki – orsulobis
periodSi kvebis deficitiT. ganviTarebad msoflioSi 230 milion
skolamdeli asakis bavSvs (43%) uvlindeba zrdis Seferxeba kvebis
C
4
deficitis an sxvadasxva daavadebebis gamo. savaraudod miaCniaT, rom
malnutriciis gamo weliwadSi SeiZleba daiRupos 7 milioni bavSvi,
sikvdilis mizezia uSualod wonis deficiti an mis fonze
ganviTarebuli paTologiebi1.
ukanasknel periodSi Tavi iCina simsuqnis problemam, rac
gansakuTrebiT TvalSi sacemia ganviTarebul qveynebSi. 1998 wels
janmrTelobis msoflio organizaciam simsuqne gamoacxada globalur
epidemiad2. 1981 wlidan kanadaSi Warbi wonisa da simsuqnis mqone 7-13
wlis bavSvTa raodenoba Sesabamisad gaormagda da gasammagda3.
aseTive tendencia SeimCneva did britaneTSi4. aSS-Si simsuqnes bavSvTa
da mozardTa nutriciul daavadebaTa Soris pirveli adgili
uWiravs5,6. msoflios masStabiT simsuqne iqca sazogadoebrivi
jandacvis pirveli rigis problemad, man Caanacvla wonis deficiti7.
es tendencia SemaSfoTebelia, radgan simsuqne Tavis mxriv zrdis
kardiovaskuluri daavadebebis, hipertoniis, II tipis Saqriani
daibetis ganviTarebis risks6,8-10.
fizikuri ganviTarebis gamokvlevisa da Sefasebis meTodebi
bavSvis fizikur ganviTarebas ikvleven SexedviT _ inspeqciiT anu somatoskopurad da gazomviT anu somatometrulad1,15:
• somatoskopia _ sxeulis aRnagobis, misi proporciebis, gulmker-
dis da kidurebis formis, kunTovani da cximovani
qsovilis ganviTarebis Sefaseba.
• somotometria anu anTropometria _ bavSvis wonis,
sigrZe/simaRlis, Tavis, kidurebis garSemowerilobis
da sigrZis gansazRvra.
bavSvis anTropometruli monacemebis erTjerad gamokvlevas erTmomen-
tiani, anu statikuri, erTi da igive parametris periodul Sefasebas
ki - dinamikuri kvleva ewodeba.
bavSvis zrda-ganviTarebaze meTvalyureoba unda warmoebdes
dinamikaSi, vinaidan erTjeradi Sefaseba SeiZleba gaxdes
anTropometruli maxasiaTeblebis araswori interpretaciis mizezi.
fizikuri ganviTarebis meTvalyureobis etapebia:
• anTropometria – sxeulis masis, sigrZe/simaRlis, Tavis da
mxris garSemowerilobis maCveneblis dadgena;
• monacemebis dafiqsireba bavSvis ganviTarebis istoriaSi;
• miRebuli monacemebis interpretacia;
• fizikuri ganviTarebis darRvevis SemTxvevaSi mizezis
identificireba, saWiroebisas damatebiTi gamokvleva,
saTanado mkurnaloba da referali;
• mSobelTa konsultireba bavSvis zrda-ganviTarebis
sakiTxebze.
5
fizikuri ganviTarebis ZiriTadi maxasiaTeblebis cvlileba bavSvTa asakSi
wonis dinamika12,15,16
axalSobili:
drouli axalSobilis wona meryeobs 2500-4000g Soris. dabadebis
wonis mixedviT janmrTelobis msoflio organizacia gamoyofs mcire
wonis axalSobilebs – dabadebis wona 1500-2500g da Zlier mcire
wonis axalSobilebs – dabadebis wona <1500g.
axalSobilis dabadebis wona misi saSvilosnosSiga ganviTarebis
indikatoria. igi erTi mxriv gansazRvravs, Tu ra tipis movla
esaWiroeba axalSobils, meore mxriv warmoadgens momavalSi bavSvis
janmrTelobis da ganviTarebis prognozul markers. dabadebis wonis
mixedviT gamoyofen gestaciuri asakis Sesabamisi, gestaciur asakTan
SedarebiT mcire da didi masis axalSobilebs. gestaciur asakTan
SedarebiT didi masis mqone axalSobilebSi maRalia samSobiaro
travmis, hipoglikemiis, perinataluri asfiqsiis ganviTarebis riski;
gestaciur asakTan SedarebiT mcire masis mqone axalSobilebSi ki
xSiria sxvadasxva organos morfofunqciuri umwifroba, dismetabo-
lizmi, asfiqsia/hipoqsia, respiratorul distres sindromi, Tanda-
yolili anomaliebi, saSvilosnosSiga infeqcia da sxva, ris gamoc
mocemul jgufSi peri- da neonataluri sikvdilianoba 3-4-jer metia
normaluri masis axalSobilebTan SedarebiT.
sicocxlis pirvel dReebSi axalSobilTa umravlesobas aReniSeba
wonis fiziologiuri kleba saSualod sxeulis masis 7%-iT
(mtkicebulebis done II).17-19 droul axalSobilebSi wonis danaklisi
ar unda aRematebodes 10%-s16, dRenaklulebSi 12%-s. wonis
fiziologiuri klebis ZiriTadi mizezia wylis dakargva kanis, fil-
tvebis, Tirkmlebisa da nawlavebis gziT, xolo misi intensivoba
damokidebulia axalSobilis masaze, sqesze, sameano da samSobiaro
paTologiaze, garemos temperaturasa da tenianobaze, axalSobilis
kvebis reJimze da sxv.
wonis dakleba 10%-ze metad saWiroebs damatebiT gamokvlevas
paTologiis gamosaricxad. wonis Warbi klebis uxSiresi mizezebia:
• kvebis darRveva;
• infeqcia;
• Tandayolili anomaliebi (mag.: gulis Tandayolili manki).
axalSobilTa masis Semcireba maqsimums aRwevs me-2-3 dRes, mesame
dRis Semdeg kleba wydeba da me-5 dRidan iwyeba masis mateba
(mtkicebulebis done II)17
, me-5 dRidan yoveldRiuri namati
daaxloebiT Seadgens 20-35 grams (mtkicebulebis done I)20.
axalSobilTa nawili me-10 dRes aRidgens dabadebis wonas, Tumca
SesaZlebelia wona aRdges SedarebiT mogvianebiT me-12-14 dReze.
(mtkicebulebis done II)17. Semdeg grZeldeba misi mateba. pirveli
Tvis ganmavlobaSi bavSvebi SedarebiT naklebs imateben wonaSi
II
II
I
II
6
(saSualod 600 g). pirveli Tvis ganmavlobaSi wonis namati ar unda
iyos 500 g-ze naklebi (mtkicebulebis done I, II)20,21.
Cvili da adreuli asakis bavSvi:
wonis matebis intensivoba pirveli wlis ganmavlobaSi araTanabaria.
sicocxlis me-2-dan me-6 Tvis CaTvliT Cvili imatebs daaxloebiT 700-
800 grams TveSi. Tu bavSvi imyofeba ZuZuTi kvebaze wonis minimaluri
namati Tvis ganmavlobaSi unda iyos 500 g. 6 Tvidan 1 wlamde Cvili
yovelTviurad 400 grams imatebs15.
Cveulebriv drouli axalSobilis wona, romlis dabadebis masa
Seesabameboda gestaciur asaks, ormagdeba 4.5-5 Tvis da sammagdeba
erTi wlis asakSi. Semdeg wonis namati yovelwliurad daaxloebiT 2
kg-s Seadgens, wonaSi mateba gansakuTrebiT intensiuria pre- da
pubertul periodSi.
dabadebis mcire da Zlier mcire wonis bavSvTa anTropometruli
monacemebis dinamikis Tavisebureba
dabadebis mcire da Zlier mcire wonis axalSobilebis wonis dinamika
gansxvavebulia. maT axasiaTebT ganviTarebis SedarebiT swrafi tempi
(e.w. ”catch up growth”). maTi fizikuri ganviTarebis Sefasebisas saWiroa
asakis koreqtireba. amisaTvis faqtobriv (postnatalur) asaks akldeba
kvirebis is raodenoba (40 kvira _ bavSvis gestaciuri asaki), romelic
aklia axalSobils normalur gestaciur asakamde22,23. mag.: gestaciis
32 kviraze dabadebuli amJamad 5 Tvis (daaxloebiT 20 kviris) bavSvis
“koreqtirebuli” asaki Semdegnairad iTvleba: dabadebisas mas aklda
8 kvira (40-32=8). “koreqtirebuli” asaki = 20 kviras – 8 kvira = 12
kviras. anu am bavSvis anTropometruli maCveneblebi unda
Seesabamebodes 12 kviris (daaxloebiT 3 Tve) bavSvis maCveneblebs.
mas Semdeg rac anTropometruli maCveneblebi gautoldeba asakobriv
maCveneblebs (anu normas), asakis koreqtireba ar aris saWiro. Tavis
garSemoweriloba eweva normas daaxloebiT 18 Tvis asakSi, wona - 24
Tvis asakSi, simaRle 40 Tvis asakSi. zogierTi Zlier mcire wonis
axalSobili ver eweva normalur maCveneblebs skolis asakamde23.
sigrZe/simaRle 12,15
sicocxlis pirveli weli
pirveli wlis ganmavlobaSi axalSobilis sigrZis namati saSualod
25 sm-s Seadgens. wlis pirvel meoTxedSi sigrZeSi mateba
yovelTviurad 3 sm-ia, meore meoTxedSi – 2.5 sm, mesameSi – 2 sm,
meoTxeSi ki – 1 sm.
adreuli asakis bavSvebi
1 wlis Semdeg simaRleSi zrdis tempi neldeba. axalSobilTa
dabadebis sigrZe mxolod 4 wlis asakSi ormagdeba da saSualod 100
sm-s Seadgens, xolo 12 wlis asakSi sammagdeba. sicocxlis meore
I II
7
wlis ganmavlobaSi bavSvi imatebs 10-12 sm-s, mesame wels – 7-8 sm-s,
Semdeg yovelwliurad saSualo namati – 5-6 sm-s Seadgens. amasTan
erTad, vlindeba simaRlis 2 mkveTri e.w. maqsimaluri matebis periodi.
4-6 wlis asakSi da pubertatul periodSi.
bavSvis simaRleSi zrdis intensivoba da misi saboloo maCvenebeli Zi-
riTadad genetikuri faqtoriTaa ganpirobebuli, Tumca mniSvnelovania
garemo faqtorebis gavlenac. postnatalur periodSi zrdis process
aregulirebs endokrinuli sistema. gansakuTrebiT mniSvnelovania
hipofizis mier producirebuli somatotropuli anu zrdis hormoni,
farisebri jirkvlis hormonebi da insulini. 2 wlamde asakSi zrdis
procesi naklebad aris damokidebuli somatotropuli hormonis
Semcvelobaze62. garemo faqtorebi, kerZod, kvebis deficiti, misi
mniSvnelovani disbalansi, Seucvleli aminomJavebisa, vitaminebis (A, D) da mikroelementebis (kalciumi, rkina, TuTia, iodi),) nakleboba
iwvevs bavSvis zrdis SeCerebas. zrdis procesis, iseve rogorc
Zvlovani da kunTovani sistemis ganviTarebis umniSvnelovanes
mastimulirebel faqtors moZraobiTi aqtivoba warmoadgens12,15,56.
Tavis garSemoweriloba12,15,23
drouli axalSobilis Tavis garSemoweriloba 34-36 sm-ia. pirveli
wlis ganmavlobaSi Tavis garSemoweriloba 10-11 sm-iT imatebs.
Tavis garSemowerilobis gansazRvra gansakuTrebiT mniSvnelovania 2
wlamde asakis bavSvebSi, vinaidan misi garkveuli maCveneblebi da
matebis tempis darRveva miuTiTebs sxvadasxva paTologiis arsebobaze
(mikrocefalia, hidrocefalia da sxv).
sxeulis proporciebi12,15
mcire asakis bavSvis sxeulis proporciebi gansxvavdeba mozrdilis
sxeulis proporciebisagan, Tavi SedarebiT didia, kidurebi ki mokle.
bavSvis sxeulis calkeuli nawilis zrda araTanabarzomieria. qveda
kidurebi izrdeba 5-jer, zeda kidurebi – 4-jer, tani – 3-jer, xolo
Tavi 2-jer.
Tavis, tanisa da kidurebis araTanabarzomieri zrdis gamo sxeulis
Sua wertili qvemoT inacvlebs. dRenakluli axalSobilis sxeulis
Sua wertili Wipis zemoT, droulis – Wipis doneze, 6 wlis asakSi -
Wipsa da simfizs Soris, xolo 12-13 wlis asakisTvis simfizis doneze
mdebareobs.
kbilebis ganviTareba12,15
sarZeve kbilebis amoWra iwyeba 6-8 Tvis asakSi, pirvelad amoiWreba
qveda Sua saWreli kbilebi. kbilebis amoWris vadebi mocemulia
sqemaze. 2 wlis asakis bavSvs 20 sarZeve kbili aqvs. or wlamde
kbilebis raodenobis gamosaangariSeblad iyeneben formulas: n – 4, sadac n _ Tveebis ricxvia.
8
mudmivi kbilebis amoWra iwyeba 6 wlis asakSi.
anTropometria:
anTropometruli monacemebis gansazRvrisas metad mniSnvelovania
sizustis dacva, radgan am maCveneblebs xSir SemTxvevaSi efuZneba
klinikuri gadawyvetilebebi da intervencia.
9
anTropometruli monacemebis sizustes gansazRvravs 3 ZiriTadi
komponenti:
• gazomvis teqnika (unificirebuli meTodi)
• aRWurviloba (maRali sizustis)
• momzadebuli specialisti
samedicino personalma, romelic awarmoebs antropometrias unda
icodes, ramdenad mniSvnelovania aRWurvilobis kalibrireba yoveli
manipulaciis win, standartuli teqnikis gamoyeneba da monacemebis
sizuste, rac mniSvnelovania maxasiaTeblebis swori
interpretaciisTvis.
janmrTel bavSvze zedamxedvelobis aucilebel komponents
warmoadgens misi wonisa da sigrZe/simaRlis monitoringi da
miRebuli maCvneblebis dafiqsireba samedicino dokumentaciaSi.
(mtkicebulebis done IV) 24.
wonis gansazRvra25,26
awonvisaTvis gamoiyeneba meqanikuri da/an eleqtrosaswori. adreuli
asakis bavSvi iwoneba specialur horizontalur sasworze (suraTi 1,
2), romlis sizuste ±10 grams Seadgens, mozrdil bavSvi ki - Cve-
ulebriv samedicino sasworze, romlis sizustea +100 grami.
Cvili bavSvi mizanSewonilia aiwonos SiSveli, tansacmlis gareSe, an
ecvas mxolod sufTa erTjeradi safeni. tansacmliT an “Zveli”
safeniT Cvilis awonva masis araswori maCveneblis erT-erTi yvelaze
xSiri mizezia. mozrdili bavSvi unda aiwonos fexSiSveli da
tansacmlis gareSe (unda ecvas mxolod sacvali), awonva
mizanSewonilia dRis erTsa da imave monakveTSi, ufro xSirad diliT,
uzmoze, moSardvisa da defekaciis Semdeg.
bavSvi unda moTavsdes sasworis TefSis Sua nawilze, imisda
miuxedavad, Tu romeli sasworia gamoyenebuli. awonva mizanSewonilia
Catardes orjer. Cvilobis asakSi awonvis Sedegad miRebul or
maCvenebels Soris dasaSvebia sxvaoba 10, erTi wlis zemoT ki - 100
suraTi 1 suraTi 2
IV
10
gramamde. bavSvis masis dasadgenad gamoiyeneba 2 gazomviT miRebuli
maCveneblis saSualo ariTmetikuli. Tu 2 maCvenebels Soris sxvaoba
aRemateba dasaSveb asakobriv normas, mizanSewonilia awonva mesamed
Catardes. bavSvis zusti wonis dasadgenad 3 maCvenebels Soris unda
airCes 2 erTmaneTTan miaxlovebuli da ganisazRvros maTi saSualo
ariTmetikuli.
Tu bavSvi Zalian aqtiuria, awonva unda gadaidos, sanam igi ar
damSviddeba. Tu SeuZlebelia bavSvis marto awonva misi zedmeti
aqtiurobis gamo, mizanSewonilia awonvis alternatiuli meTodis
gamoyeneba:
• eleqtrosasworze xdeba mSoblis da bavSvis erTad, Semdeg
mSobelis marto awonva, wonaTa Soris sxvaoba aris bavSvis
wonis maCvenebeli.
monacemebis dafiqsireba bavSvis ganviTarebis istoriaSi – bavSvis
wonis maCvenebeli unda dafiqsirdes ganviTarebis istoriasa da wonis
diagramaze. Cvili bavSvis wona fiqsirdeba measedis (0,01 kg),
mozrdilis ki - meaTedis sizustiT (0,1 kg).
sigrZe/simaRlis gansazRvra25,26
bavSvis simaRle isazRvreba simaRlis
sazomiT, adreul asakSi (24-36 Tvemde)
gamoiyeneba horizontaluri (suraTi 3), 36
Tvis Semdeg ki vertikalur simaRlis sazomi.
Tu bavSvi axerxebs sazomTan sworad dgomas
24-36 Tvemde SesaZlebelia vertikaluri
sazomis gamoyeneba.
horizontaluri sazomi miaxlobiT 100 sm sigrZis dafaa, romelsac
erT boloSi uZravad mimagrebuli aqvs perpendikularuli 10-15 sm
simaRlis firfita, meore boloSi ki aqvs moZravi firfita, romelic
gadaadgildeba bavSvis sigrZis mixedviT (suraTi 4).
adreuli asakis bavSvis sigrZis zusti maCveneblis misaRebad
mizanSewonilia gazomva orma specialistma Caataros. bavSvs awvenen
TaviT simaRlis sazomis uZravi ficrisken, samedicino muSaki
afiqsirebs Tavs, ise, rom bavSvi vertikalurad zemoT iyurebodes.
nikapi ar unda exebodes gulmkerds da Tavi ar unda iyos ukan
gadaweuli. meore specialisti asworebs bavSvis tans ise, rom igi
beWiT da kudusuniT exebodes sazoms, qveda kidurebs afiqsirebs
muxlis saxsarSi maqsimalurad gaSlil mdgomareobaSi da simaRlis
sazomis qveda moZrav firfitas uaxlovebs bavSvis quslebs. or
firfitas Soris manZili (izomeba simaRlis sazomis Skalis mixedviT)
santimetrebiT Seesabameba bavSvis sigrZes.
suraTi 3
11
mozrdili asakis bavSvis simaRlis dasadgenad iyeneben vertikalur
simaRlis sazoms (suraTi 5).
bavSvs fexSiSvels ayeneben zurgiT simaRlis sazomTan, ise, rom igi
simaRlis sazomis svets exebodes quslebiT, beWebiT da kefiT, xelebi
CamoSvebuli hqondes qvemoT, Tavi ki sworad eWiros. Tu Tmaze bavSvs
aqvs samagri, saWiroa misi moxsna. bavSvs fexebi erTad unda hqondes
migdmuli. erTi specialisti awveba bavSvis (adreul asakSi) muxlis
da koW-wvivis saxsars sigrZis sazomisken. bavSvi unda iyurebodes win,
misi Tvalis Wrili da yuris zeda kide unda qmnides erT swor
horizontalur xazs. simaRlis sazomis moZrav ficars adeben bavSvs
Tavze da Skalaze aiTvlian bavSvis simaRles santimetrebiT25,26.
nebismier asakSi sigrZe/simaRlis gazomva mizanSewonilia Catardes 2
jer zedized. gazomvis Sedegad miRebul or maCvenebels Soris
sxvaoba ar unda aRematebodes 1 sm-s. bavSvis sigrZis dasadgenad
gamoiyeneba 2 gazomviT miRebuli maCveneblis saSualo ariTmetikuli.
Tu gazomvisas miRebuli sxvaoba aRemateba dasaSveb normas (1 sm),
mizanSewonilia gazomva Catardes mesamed. bavSvis zusti sigrZis
dasadgenad 3 maCvenebls Soris unda arCes 2 erTmaneTTan
miaxlovebuli da ganisazRvros maTi saSualo ariTmetikuli25.
monacemebis dafiqsireba bavSvis ganviTarebis istoriaSi – bavSvis
sigrZe/siimaRlis maCvenebeli unda dafiqsirdes ganviTarebis
istoriaSi da sigrZe/simaRlis diagramaze. bavSvis sigrZe/simaRle
fiqsirdeba meaTedis sizustiT (0,1 sm)
12
suraTi 4
13
suraTi 5
14
Tavis garSemowerilobis gansazRvra25,26
Tavis garSemowerilobas zomaven santimetriani zonriT, romelic
unda gadiodes kefis yvelaze gamodrekili adgilze, yurebis zemoT
da warbebs zemoT (ix. suraTi 6). zusti maCveneblis misaRebad tardeba
2-jer gazomva, maCvenebelTa Soris dasaSvebia sxvaoba 0,2 sm. Tu
sxvaoba aRemateba mocemul normas, mizanSewonilia gazomva Catardes
mesamed. bavSvis Tavis garSemowerilobis zustad dasadgenad 3
maCvenebels Soris unda airCes 2 erTmaneTTan miaxlovebuli da
ganisazrvros maTi saSualo ariTmetikuli25.
monacemebis dafiqsireba bavSvis
ganviTarebis istoriaSi – bavSvis
Tavis garSemowerilobis maCvenebeli
unda dafiqsirdes ganviTarebis
istoriaSi da Tavis garSemoweri-
loba/asakis diagramaze. bavSvis
Tavis garSemoweriloba fiqsirdeba
meaTedis sizustiT (0,1 sm)
mxris garSemowerilobis dadgena26
mxris gaSemowerilobis gansazRvra gamoiyeneba bavSvis kvebiTi
statusis SefasebisTvis 1 dan 5 wlamde asakSi. mxris garSemoweri-
loba mocemul asakSi umniSvnelod icvleba da normis SemTxvevaSi ar
unda iyos 13,5 sm-ze naklebi. mxris midamoSi cximovani qsovilis
ganleva kvebis darRvevis adreul stadiaze vlindeba, rac Sesabamisad
aisaxeba mxris garSemowerilobis Sefasebisas. amave dros,
gaTvaliswinebuli unda iyos, rom iSviaT SemTxvevaSi mxris garSemo-
werilobis daqveiTeba SesaZlebelia ganpirobebuli iyos mxris kunTis
atrofiiT.
mxris garSemoweriloba izomeba mxris Sua nawilSi (ix. suraTi 7). am
mizniT Tavdapirvelad unda ganisazRvros mxris sigrZe. bavSvs unda
moaxrevinon xeli idayvis saxsarSi marTi kuTxiT, izomeba manZili
mxris akromionis morCsa da idayvs Soris, dgindeba mxris Sua
wertili da mocemul areSi izomeba mxris garSemoweriloba. mxris
garSemowerilobis gansazRvra mizanSewonilia Catardes orjer.
miRebul monacemTa Soris sxvaoba ar unda aRematebodes 0.5 sm-s. Tu
sxvaoba aRemateba mocemul maCvenebels, mizanSewonilia gazomva
Catardes mesamed. bavSvis mxris garSemowerilobis zustad dasadgenad
3 maCvenebels Soris unda airCes 2 erTmaneTTan miaxlovebuli da
ganisazRvros maTi saSualo ariTmetikuli26. janmrTelobis msoflio organizaciis mier mowodebulia mxris
garSemowerilobis gansazRvra bavSvis kvebiTi statusis Sesa-
faseblad, roca misi zusti asaki ucnobia.
monacemebis dafiqsireba bavSvis ganviTarebis istoriaSi – bavSvis
mxris garSemowerilobis maCvenebeli unda dafiqsirdes ganviTarebis
istoriaSi. bavSvis mxris garSemoweriloba fiqsirdeba meaTedis
sizustiT (0,1 sm).
suraTi 6
15
suraTi 7
16
kanqveSa cximovani qsovilis sisqe 1,12
kanqveSa cximovani qsovilis sisqis gansazRvra farTod gamoiyeneba
mozrdilebSi simsuqnis dasadgenad. misi Sefaseba moiTxovs
gamocdilebas, specialur aparaturas, amave dros,
gasaTvaliswinebelia kanqveSa cximis sisqis individualuri variacia,
ris gamoc bavSvebSi misi gamoyeneba SezRudulia, garda im
SemTxvevebisa, rodesac Sefasebas atarebs kvalificiuri specialisti.
zrdis monitoringi
dReisaTvis ar arsebobs sakmarisi mtkicebuleba zrdis monitoringis
optimaluri sixSiris Sesaxeb. sigrZe/simaRlis, wonisa da Tavis
garSemowerilobis gansazRvra unda xdebodes janmrTel bavSvze
meTvalyureobis da imunizaciis vizitebis dros22,27-30.
wonis monitoringi1,12,15,16,31,62
bavSvis zrda-ganviTarebaze monitoringis pirveli aucilebeli
nabijia dabadebis wonis gansazRvra da misi gestaciur asakTan
Sesabamisobis dadgena.
• samSobiaro blokSi axalSobili unda aiwonos dabadebidan 2
sT-is Semdeg, vinaidan axalSobilis ufro adre awonva zrdis
hipoTermiis ganviTarebis risks;
• samSobiaro saxlSi axalSobilis awonva rekomendebulia
yoveldRe, mizanSewonilia wonis cvlilebis yoveldRiuri
kontroli da maCveneblis fiqsireba bavSvis istoriaSi;
• pirveli Tvis ganmavlobaSi bavSvi unda aiwonos 2 kviraSi
erTxel;
• axalSobilobis periodis Semdeg mizanSewonilia bavSvis
awonva TveSi erTxel, Tu bavSvs uvlindeba wonis darRveva
SesaZlebelia awonva warmoebdes ufro xSirad (saSualod 2
kviraSi erTxel);
• 1-idan 3 wlamde asakSi wonis kontroli saWiroa 3 TveSi
erTxel, 3-6 wlamde 6 Tvis intervaliT, xolo 6 wlis Semdeg
yovelwliurad;
• wonis kontroli da misi fiqsacia ganviTarebis istoriaSi
yoveli vizitis dros bavSvis zrda – ganviTarebaze
monitoringis aucilebelia pirobaa.
sigrZe/simaRle, Tavis garSemoweriloba12,15,16,31,62
• axalSobilis sigrZe da Tavis garSemoweriloba unda
ganisazRvros dabadebidan 2 sT-is Semdeg;
• Tavisa garSemowerilobis gansazRvra mizanSewonilia 2 wlamde
asakSi 1-3 Tvis intervaliT. Tu aRiniSneba darRveva saWiroa
yovelTviuri kontroli;
17
• 1 wlamde asakSi mizanSewonilia sigrZis Sefaseba
meTvalyureobis vizitebis dros (kvartalSi erTxel);
• sigrZe/simaRlis monitorireba gansakuTrebiT mniSvnelovania 2
wlis asakis Semdeg iseTive sixSiriT rogorc wonis
monitoringi;
• aucilebelia bavSvis fizikuri ganviTarebis Sefaseba skolaSi
wasvlis win.
Tu bavSvs aReniSneba zrdis darRveva monitoringi ufro
xSirad unda warmoebdes. Tu mSobels ar miyavs bavSvi
meTvalyureobis dagegmil vizitebze fizikuri ganviTarebis
Sefaseba unda moxdes avadmyofobis vizitebis dros (rekomendacia D)22.
bavSvis zrdis procesis Sefasebisas aucileblia mSoblebis
anTropometruli monacemebis gaTvaliswineba (rekomednacia B)22.
kbilebis ganviTarebis Sefaseba
janmrTel bavSvze meTvalyureobis vizitebis dros fasdeba:
• sarZeve da mudmivi kbilebis amoWris vadebi da Tanmimdevroba;
• kbilebis mdgomareoba (Tankblivis darRveva, kariesi, emalis
defeqti).
anTropometruli monacemebis Sefasebis meTodebi
bavSvis fizikuri ganviTarebis Sefasebis Sedegebi unda Sedardes
standartul maCveneblebs. am mizniT gamoiyeneba standartuli
cxrilebi (Sedgenili centilebis da standartuli gadaxris SD - Z qulis mixedviT) da zrdis diagramebi. upiratesoba eniWeba diagramebs,
radgan maTi gamoyeneba SedarebiT martivia da zrdis procesis
dinamikuri Sefasebis SesaZleblobas iZleva.
fizikuri ganviTarebis SefasebisaTvis gamoiyeneba Semdegi saxis
diagramebi:
• gestaciuri asaki/dabadebis wonis diagrama
• wona-asakis diagrama
• sigrZe/simaRle-asakis diagrama
• Tavis garSemoweriloba-asakis diagrama
• wona-sigrZe/simaRlis diagrama
• sxeulis masis indeqsi (smi)-asakis diagrama.
nebismieri anTropometruli maCveneblis mrudebi Sedgenilia
centilebis an Z qulebis mixedviT.
D
B
18
centiluri diagrama1,12,15,28,32
centiluri diagrama Sedgeba standartuli mrudebisgan. TiToeuli
mrudi Seesabameba garkveuli centilis (3-97) maCvenebels. centili
gviCvenebs, konkretuli asakis bavSvTa ramden procents aReniSneba
mocemuli anTropometruli maCvenebeli. saSualo normad anu medianad
miCneulia 50 centili. 50-ze naklebi centili - 3, 10, 25 - miuTiTebs,
rom aRniSnuli maCvenebeli uvlindeba am asakis bavSvTa Sesabamisad -
3, 10, 25 procents. 50-ze meti centili - 75, 90, 97 - miuTiTebs, rom
aRniSnuli maCvenebeli uvlindeba am asakis bavSvTa raodenoba,
romlis procentic gamoiTvleba Semdegnairad “100 – centili”. mag. 75
centili niSnavs, rom es maCvenebeli aReniSneba am asakis bavSvebis
100-75=25 %-s.
normad miRebulia maCveneblebi, romlebic 3-97 centilis farglebSia.
Tu romelime parametri 3 centilze naklebia, gamoxatulia deficiti,
Tu 97 centilze metia – siWarbe, es paTologiaze miuTiTebs da
specialuri gamokvlevebis Catarebas saWiroebs.
standartuli gadaxra SD - Z qulis diagrama 1,12,15,28
TiToeuli diagrama Sedgeba ramdenime mrudisgan, romlebic gviCvenebs
anTropometruli monacemebis ganawilebas.
saSualo normad anu medianad miCneulia nulovani mrudi. danarCeni
mrudebi gviCveneben standartul gadaxras saSualo maCveneblidan.
normad miRebulia maCveneblebi, romlebic ±2Z qulis farglebSia.
Tu romelime parametri _2Z qulaze naklebia, gamoxatulia deficiti,
Tu +2Z qulaze metia - siWarbe, es paTologiaze miuTiTebs da
specialuri gamokvlevebis Catarebas saWiroebs.
janmrTelobis msoflio organizacia upiratesobas aniWebs Z qulis
diagramebs, radgan misi gamoyeneba monacemebis ufro zusti
interpretaciis saSualebas iZleva.
fizikuri ganviTarebis Sefasebis individualuri mrudis agebis principebi da interpretacia
samSobiaro saxlSi axalSobilis dabadebis wonisa da gestaciuri
asakis Sesabamisobis dasadgenad sargebloben wona-gestaciuri asakis
diagramiT.
janmrTel bavSvze meTvalyuroebis vizitebis dros xdeba wona-asakis,
sigrZe/simaRle-asakis da Tavis garSemoweriloba–asakis mrudis ageba.
wona – gestaciuri asakis diagrama
diagramis horizontalur anu abscisTa RerZze Cveulebriv ga-
dazomilia bavSvis gestaciuri asaki, xolo vertikalur anu
19
ordinatTa RerZze Sesabamisad _ wonis maCvenebeli da agebulia
standartuli Z qulis mrudebi.
pacientis wonis da gestaciuri asakis Sesabamisobis gansazRvrisTvis
unda moiZebnos misi gestaciuri asakis da dabadebis masis Sesabamisi
xazebis gadakveTis wertili. am wertilis diagramaze ganTavsebis
mixedviT gamoiyofa16:
• gestaciur asakTan SedarebiT didi masis mqone axalSobilebi -
gestaciuri asakis da dabadebis masis xazebis gadakveTis wertili
xvdeba diagramaze aRniSnul or standartul mruds zemoT (> +2 Z qulze).
• gestaciur asakTan Sesabamisi masis mqone axalSobilebi -
gestaciuri asakis da dabadebis masis xazebis gadakveTis wertili
xvdeba or standartul mruds Soris (dabadebis masa +2 Z qulis
farglebSia).
• gestaciur asakTan SedarebiT mcire masis mqone axalSobilebi -
gestaciuri asakis da dabadebis masis xazebis gadakveTis wertili
xvdeba or standartul mruds qvemoT (< -2 Z qulaze). es miuTiTebs
saSvilosnosSiga ganviTarebis Seferxebaze.
maCvenebeli (wona, sigrZe/simaRle, Tavis garSemoweriloba) asakis
diagrama1,3,12,21,35,37
diagramis horizontalur anu abscisTa RerZze Cveulebriv ga-
dazomilia bavSvis asaki, xolo vertikalur anu ordinatTa RerZze
Sesabamisad anTropometruli parametri - wona, an sigrZe/simaRle, an
Tavis garSemoweriloba da agebulia standartuli centiluri an Z qulis mrudebi. bavSvis sqesis mixedviT mowodebulia gansxvavebuli
diagramebi.
pacientis nebismieri parametris
individualuri mrudis aigeba
Semdegnairad: miRebul maCvenebelze
ivleba horizontaluri, xolo asakze
vertikaluri xazi, maTi gadakveTis
adgili aRiniSneba wertiliT (ix
suraTi 8). Semdgomi gamokvlevisas
(mag: 1 Tvis Semdeg) meordeba
procedura da sqemaze arsebuli
wertilebis SeerTebiT miiReba bavSvis maCveneblis (masa,
sigrZe/simaRle, Tavis da gulmkedris garSemoweriloba)
individualuri mrudi.
janmrTeli bavSvis mrudi unda moTavsdes standartuli mrudebis
normul maCveneblebs Soris (-2 da +2 Z qula; 3-97 centili). metad
mniSvnelovania bavSvis individualuri mrudi iyos standartuli
mrudebis paraleluri, rac miuTiTebs zrdis normalur intensiobaze.
suraTi 8
20
amrigad, mniSvneloba eqceva:
• mrudis mimarTulebas
da
• mrudis pozicias.
mrudis agebamde unda ganisazRvros pacientis zusti asaki.
wona_asakis diagrama1,32,38,39
wona_asakis diagrama gansazRvravs wonis asakTan Sesabamisobas, rac
saSualebas iZleva gamovlindes wonis deficiti an siWarbe.
• Tu bavSvis individualuri mrudi an erTjeradi gazomvis
Sedegad miRebuli maCvenebeli ganTavsda -2 da -3Z qulovan
mrudebs Soris (an 3 centils qvemoT), saxezea wonaSi CamorCena _
dabali wona.
• Tu bavSvis individualuri mrudi an erTjeradi gazomvis
Sedegad miRebuli maCvenebeli ganTavsda –3Z qulovani mrudis
qvemoT saxezea wonaSi mkveTri CamorCena _ Zlier dabali wona.
• Tu bavSvis individualuri mrudi an erTjeradi gazomvis
Sedegad miRebuli maCvenebeli ganTavsda +2Z qulovan mruds (an
97 centilis) zemoT, es miuTiTebdes wonis siWarbeze.
individualuri mrudis standartulis zemoT an qvemoT ganTavseba
yovelTvis ar niSnavs, rom saxezea simsuqne an wonis deficiti,
vinaidan bavSvi SeiZleba iyos maRali/dabali da misi wona
Seesabamebodes simaRles. aseT SemTxvevaSi mizanSewonilia aigos
wona_sigrZe/simaRlis an smi-asakis (2 wlidan) mrudi da misi
SefasebiT gadawydes, vlindeba Tu ara wonis problema75,76.
sadReisod iTvleba, rom wonis deficitis dros ufro
informatiulia wona-simaRlis diagrama, xolo Warbi wonis dros –
smi-asakis diagrama.
nebismieri mwvave daavadebis an kvebis reJimis darRvevis dros bavSvis
individualurma mrudma SeiZleba miiRos horizontaluri
mimarTuleba (wonis namatis SeCereba), rac 2 kviraze metad ar unda
gaxangrZlivdes. Tu wonis SeCereba gagrZelda bavSvi saWiroebs
gamokvlevas.
Tu mrudi iRebs daRmaval an mkveTrad aRmaval mimarTulebas,
miuxedavad imisa, rom bavSvis individualuri mrudi SeiZleba
moTavsebuli iyos standartul mrudebs Soris, bavSvs esaWiroeba
gamokvleva mizezis dasadgenad.
sigrZe/simaRle_asakis diagrama1,32,38,39,40
diagrama gansazRvravs sigrZe/simaRlis asakTan Sesabamisobas, rac
saSualebas iZleva gamovlindes hipostatura da Warbi simaRle.
21
• Tu bavSvis individualuri mrudi an erTjeradi gazomvis Sedegad
miRebuli maCvenebeli ganTavsda –2Z qulovan (an 3 centilis) mruds
qvemoT, es miuTiTebs, rom saxezea simaRleSi CamorCena
(rekomendacia D)22.
• Tu bavSvis individualuri mrudi an erTjeradi gazomvis Sedegad
miRebuli maCvenebeli ganTavsda +2Z qulovan (an 97 centilis)
mruds zemoT, es SeiZleba miuTiTebdes Warb simaRleze.
Tu mrudi iRebs daRmaval an mkveTrad aRmaval mimarTulebas,
miuxedevad imisa, rom bavSvis individualuri mrudi SeiZleba
moTavsebuli iyos standartul mrudebs Soris, bavSvs esaWiroeba
gamokvleva paTologiis gamosavlenad.
Tavis garSemoweriloba_asakis diagrama23
diagrama gansazRvravs Tavis garSemowerilobis asakTan Sesabamisobas,
rac saSualebas iZleva gamovlindes mikro da makrocefalia.
• Tu bavSvis individualuri mrudi an erTjeradi gazomvis
Sedegad miRebuli maCvenebeli ganTavsda –2Z qulovan (an 3
centilis) mruds qvemoT, savaraudoa mikrocefaliis arseboba,
saWiroa nevropaTologis konsultacia da damatebiTi
gamokvlevebis Catareba.
• Tu bavSvis individualuri mrudi an erTjeradi gazomvis
Sedegad miRebuli maCvenebeli ganTavsda +2Z qulovan (an 97
centilis) mruds zemoT, savaraudoa makrocefaliis arseboba,
saWiroa nevropaTologis konsultacia da damatebiTi
gamokvlevebis Catareba.
bavSvis fizikuri ganviTarebis globaluri SefasebisaTvis saWiroa
individualuri mrudebis kompleqsuri Sefaseba. sxvadasxva mrudis
ganawilebis mixedviT SesaZlebelia gamovlindes gansxvavebuli
problemebis arseboba. Tu bavSvis wona, sigrZe da Tavis
garSemoweriloba CamorCeba normas savarudoa genetikuri an
konstituciuri anomaliis arseboba. konstituciuri darRvevebis
dros, bavSvis mSoblebis anTropometruli monacemebic normaze
dabalia an normis qveda sazRvrebSia, bavSvis individualuri mrudi
ganTavsebulia standartuli mrudebis qvemoT, Tumca maTi
paraleluria.
mwvave kvebis deficitis dros Tavdapirvelad vlindeba masis
deficiti, xolo sigrZe/simaRlis da Tavis garSemowerilobis mrudi
rCeba normis farglebSi. qronikuli kvebis deficitis SemTxvevaSi
wonasTan erTad vlindeba simaRleSi zrdis Seferxebac. aseT dros
wona asakis da sigrZe/simaRle asakis individualuri mrudi
standartul mrudebze qveviT mdebareobs, xolo wona-sigrZe/simaRlis
mrudi xSir SemTxvevaSi normis farglebSia.
simaRleSi CamorCena SesaZlebelia agreTve ganpirobebuli iyos
Tandayolili anomaliebiT, endokrinuli an konstituciuri
darRvevebiT.
D
22
wona sigrZe/simaRlis diagrama1,32,38,39,40
diagrama gansazRvravs bavSvis wonis Sesabamisobas mis
sigrZe/simaRlesTan.
diagramis horizontalur anu abscisTa RerZze mocemulia bavSvis sig-
rZe/simaRle, xolo vertikalur anu ordinatTa RerZze Sesabamisad
wona da agebulia standartuli centiluri an Z qulis mrudebi.
bavSvis individualuri mrudis ageba xdeba zemoT aRwerili meTodiT.
• Tu bavSvis individualuri mrudi an erTjeradi gazomvis
Sedegad miRebuli maCvenebeli ganTavsda –2Z qulovan (an 3
centilis) mruds qvemoT, es miuTiTebs, rom saxezea wonis
deficiti sigrZe/simaRlesTan SedarebiT (rekomendacia D)22. • Tu bavSvis individualuri mrudi an erTjeradi gazomvis
Sedegad miRebuli maCvenebeli ganTavsda +2Z qulovan (an 97
centilis) mruds zemoT, es SeiZleba miuTiTebdes wonis
siWarbeze.
Tu mrudi iRebs daRmaval an mkveTrad aRmaval mimarTulebas,
miuxedevad imisa, rom bavSvis individualuri mrudi SeiZleba
moTavsebuli iyos standartul mrudebs Soris, bavSvs esaWiroeba
gamokvleva paTologiis gamosavlenad. meTvalyureoba esaWiroebaT,
agreTve bavSvebs romelTa anTropometruli maCveneblis Sesabamisi
mrudi ganTavsda standartuli mrudis normuli sazRvris qvemoT an
zemoT.
D
23
qronikuli malnutriciis dros wona sigrZe/simaRlis individualuri
mrudi SeiZleba moTavsdes standartul mrudebs Soris da imeorebdes
mis mimarTulebas, radgan bavSvi CamorCeba rogorc simaRleSi, aseve
wonaSi12. Tumca mocemuli maCveneblebis asakTan Sesabamisi
individualuri mrudebi normaze dabalia.
sxeulis masis indeqsi-asakis diagrama1,22,32
saerTaSoriso rekomendaciebiT sxeulis masis indeqsi (smi) bavSvis
kvebiTi statusis Sefasebis erT-erTi saukeTeso indikatoria33-35,
vinaidan igi gviCvenebs ramdenad Seesabameba bavSvis wona mis simaRles
asakisa da sqesis gaTvaliswinebiT. smi gamoiyeneba 2 wlis asakidan.
sxeulis masis indeqsis gamoTvla xdeba Semdegnairad:
sxeulis masa (kg)
smi =
simaRle (m)2
diagramis horizontalur anu abscisTa RerZze Cveulebriv
aRniSnulia bavSvis asaki, xolo vertikalur anu ordinatTa RerZze
Sesabamisad sxeulis masis indeqsis maCvenebeli da agebulia stan-
dartuli centiluri an Z qulis mrudebi. pacientis sxeulis masis
indeqsis mrudis asagebad, Sesabamisad bavSvis asakisa da smi-s
maCveneblebze gavlebuli xazebis gadakveTa aRiniSneba wertiliT,
Semdgomi gamokvlevisas (mag: 1 Tvis Semdeg) meordeba procedura da
sqemaze arsebuli wertilebis SeerTebiT miiReba bavSvis smi-asakis
Sesabamisi mrudi.
normad miCneulia maCvenebeli, romelic 3-85 centils an _2 da +1Z qulas Soris mdebareobs.
• wonis deficiti - maCvenebeli 3 centilze an _2Z qulis
qvemoT mdebareobs (rekomendacia D)22;
• Warbi wonis riski - maCvenebeli 85-97 centilebs an +1 da +2Z qulas Sorisaa (rekomendacia D)22;
• simsuqne – maCvenebeli aRemateba 97 centils an +2Z qulas
(rekomendacia D)22.
wonisa da sigrZe/simaRlis araTanabari zrdis gamo sxeulis masis
indeqsi mudmivad icvleba, ris gamoc smi-asakis mruds aqvs
araTanabarzomieri forma36.
sxeulis masis indeqsis diagrama ZiriTadad 2 wlis zemoT asakSi
gamoiyeneba, raTa droulad dadgindes is daavadebebi da
paTologiuri mdgomareobebi, romlebic iwvevs wonis darRvevas.
(rekomendacia B)22.
D
D
B
24
fizikuri ganviTarebis Sefaseba sxva maCveneblebiT
mxris garSemoweriloba1,26
mxris garSemowerilobis mixedviT fasdeba 1-dan 5 wlamde asakis
bavSvis kvebiTi statusi:
• kargi kvebiTi satusi - mxris garSemoweriloba metia 13,5 sm-
ze;
• msubuqi xarisxis kvebis deficiti - mxris garSemoweriloba 12,5
da 13,5 sm-s Sorisaa;
• kvebis mZime deficiti - mxris garSemoweriloba < 12,5sm-ze.
aRniSnuli meTodi gamoiyeneba bavSvTa didi populaciis swrafi
SefasebisTvis. meTodis nakli imaSi mdgomareobs, rom ver xerxdeba
wonis siWarbis Sefaseba.
bavSvis tanis proporciebi12,15
fizikuri ganviTarebis maCveneblebidan yvelaze informaciulia masa
da simaRle, magram zrdis kriteriumad, masisa da simaRlis garda,
tanis sxvadasxva nawilis sigrZe da maTi urTierTproporciaa
miCneuli.
sxeulis zeda da qveda nawils Soris Tanafardoba dabadebisas 1,7-ia,
3 wlis asakSi – 1,3, 7 wlis Semdeg _ 1,0.
sxeulis qveda segmenti - manZili simfizidan qvemo kiduris bolomde,
zeda segmenti – sxeulis sigrZe/simaRles gamoklebuli qveda
segmentis zoma.
Tu sxeulis zeda da qveda nawils Soris Tanafardoba aRemateba
asakobriv normas SesaZlebelia vlindebodes araproporciuli
qondriskacoba, an Zvlovani sistemis iseT paTologia, rogoricaa
raqiti.
zrdis darRvevis problemebi
wonis darRveva
malnutricia1,16,37-41
definicia _ malnutricia wonis deficitia, romelic uxSiresad
gamowveulia arasakmarisi da/an arabalansirebuli kvebiT, monelebisa
da Sewovis darRveviT.
malnutriciis adreuli diagnostika da prevencia jandacvis
yvela dawesebulebaSi unda warmoebdes (rekomendacia B)56. B
25
malnutriciis uxSiresi mizezebi:
• arasakmarisi kveba - xelovnuri sakvebis araswori momzadeba
(nakleb koncentrirebuli an koncentrirebuli), araswori
kvebis reJimi, anoreqsia, siRaribe, bavSvis ugulebelyofa,
kvebis gaZneleba (mZime refluqsi, Tandayolili anomaliebi)
da sxva;
• sakvebis monelebis da Sewovis darRveva (celiakia, pankreasis
kistofibrozi, Zroxis rZeze alergia, biliaruli atrezia
an RviZlis daavadebebi da sxv);
• metabolizmis gaZlierebiT mimdinare paTologia
(hiperTireoidizmi, bavSvTa asakis avTvisebiani daavadebebi,
Tirkmlis qronikuli ukmarisoba, Tandayolili gulis
mankebi da sxv.).
diagnostika
kvebis deficitis – malnutriciis dadgena xorcieldeba wona/asakis
da wona/simaRlis standartuli diagramebis meSveobiT. mocemuli
diagramebi mixedviT gamoyofen:
• kvebis darRvevas anu dabal wonas _ bavSvis wonis maCvenebli
moTavsebulia -2 da -3 Z qulis Sesabamis diagramebs Soris.
• kvebis mZime darRvevas anu Zlier dabal wonas _ bavSvis wonis
maCvenebli moTavsebulia -3 Z qulis Sesabamis diagramis qvemoT.
wonis darRvevis dros mniSvnelovania:
1. anamnezis Segroveba
• bavSvis dietis Sefaseba (fasdeba 24 sT-s ganmavlobaSi
miRebuli sakvebis raodenoba, jeradoba da kaloriuloba,
sakvebis tipebi, vin kvebavs bavSvs da sxv);
• samedicino anamnezi - dRenakluloba, gestaciur asakTan
SedarebiT dabali wona, qronikuli daavadebebis arseboba (asTma,
gulis Tandayolili manki), Rebinebis arseboba, refluqsi,
gastroenteraluri problemebi;
• ojaxuri anamnezi – ojaxis wevrebis janmrTelobis mdgomareoba,
memkvidruli daavadebebi, ojaxSi stersuli situaciis arseboba
da sxv.
2. obieqturi Sefaseba, romlis mizania disembriogenezuli stigmebis
dafiqsireba, rac SesaZlebeli miuTiTebdes genetikur
paTologiaze; Tanmxlebi daavadebebis diagnostika, romelic
SesaZlebelia iwvevdes malnutricias, bavSvis ugulebelyofis an
masze Zaladobis niSnebis dadgena.
26
marTva _ dabali da Zlier dabali wona
referali stacionarSi saWiroa, Tu gamoxatulia:
⇒ Zlier dabali wona an
⇒ dabali wona, romelic gamowveulia qronikuli daavadebebiT,
sakvebis Sewovis an monelebis darRveviT.
marTva binaze
binaze xorcieldeba im pacientebis marTva, romelTac aReniSnebaT
araswori kvebiT gamowveuli dabali wona.
binaze marTvis meTodebi:
• maRalkaloriuli dieta – gaTvlili ara faqtiur, aramed asakis
Sesabamis standartul wonaze. kaloriulobis gazrda 6 Tvis
Semdeg ZiriTadad cximis xarjze xdeba (ix. malnutriciis
protokoli);
• mizanSewonilia multivitaminebis kompleqsis damateba
asakobrivi dozebiT;
• dedis konsultireba bavSvis kvebis da saSiSroebis niSnebis
Sesaxeb (Tu bavSvi ver iRebs sakvebs da siTxes, dauyovnebliv
unda ganxorcieldes viziti ambulatoriaSi);
• ganmeorebiTi viziti da wonis Sefaseba xdeba 2 kviraSi. Tu
bavSvs aReniSneboda kvebiTi problemebi (mag: araswori moWideba
ZuZuTi kvebis dros, kvebis reJimis darRveva da sxv)
ganmeorebiTi viziti tardeba 5 dReSi;
• Tu ganmeorebiTi vizitis dros ar aRiniSneba wonis namati, unda
dadgindes ramdenad adekvaturad Seasrula dedam
rekomendaciebi:
_ Tu dedam sworad ver/ar Seasrula rekomendacia, saWiroa
rekomendaciis da detaluri axsna-ganmartebebis
ganmeorebiT micema da vizitis ganxircieleba 2 kviraSi.
_ Tu dedam Seasrula rekomendacia da miuxedavad amis ar
aris wonis namati saWiroa referali stacionarSi.
malnutriciis marTvis Sesaxeb detaluri informacia ixileT
Sesabamis gaidlainsa da protokolSi
Warbi wona/simsuqne10,22,40,42-52
definicia
simsuqne organizmSi cximovani qsovilis Warbi dagrovebaa. simsuqne
zrdis Semdegi daavadebebis ganviTarebis risks:
• gul-sisxlZarRvTa daavadebebi - hipertonia, hiperinsulinemia,
marcxena parkuWis hipertrofia, hiperlipidemia
(mtkicebulebis done II) 43-48
• bronquli asTma (mtkicebulebis done II)10,49-50; II
II
27
• II tipis Saqriani diabetis ganviTarebis riski (mtkicebulebis
done II) 10,43,49-50.
simsuqnis dros, gansakuTrebiT gogonebSi, mkveTrad aris gamoxatuli
fsiqosocialuri distresi da qceviTi darRvevebi (mtkicebulebis
done II)50.
simsuqnis uxSiresi mizezebi:
• Warbi kveba;
• hipodinamia;
• genetikuri daavadebebi (daunis sindromi, terneris sindromi da
sxva);
• endokrinuli darRvevebi (zrdis hormonis deficiti,
hipoTireozi da sxva);
• zogierTi medikamentis gamoyeneba (steroidebi, tricikluri
antidepresantebi da sxva).
diagnostika
Warbi wonis/simsuqnis zusti identifikaciisaTvis gamoyenebuli
unda iyos wona sigrZe/simaRlis (2 wlamde) da smi asakis (2
wlidan) diagrama. uknasknel periodSi rekomendebulia smi asakis
mrudis gamoyeneba (mtkicebulebis done III, reomendacia B)52.
• Tu bavSvis wona sigrZe/simaRlis individualuri mrudi an
erTjeradi gazomvis Sedegad miRebuli maCvenebeli ganTavsda
+2Z qulovan (an 97 centilis) mruds zemoT, miuTiTebs simsuqneze.
• smi asakis mrudi:
⇒ Tu smi maCvenebeli 85-97 centilebs an +1 da +2Z qulas
Sorisaa gamoxatulia Warbi wonis riski; (rekomendacia D)22.
⇒ Tu maCvenebeli aRemateba 97 centils an +2Z qulas
gamoxatulia simsuqne (rekomendacia D)22.
Sefasebis dros gaTvaliswinebuli unda iyos ojaxuri riskis
faqtorebi (mtkicebulebis done IV)24 da meoradi sismuqnis mizezebi. sam wlamde simsuqne ar miuTiTebs, rom Semdgom asakSi gamovlindeba
Warbi wona. Tumca, Tu aseT SemTxvevaSi mSoblebs aReniSnebaT Warbi
wona, SesaZlebelia simsuqne aRiniSnos mozrdilobis asakSic
(rekomendacia C)50.
Tu bavSvi imyofeba Warbi wonis riskis qveS unda gatardes
prevenciuli RonisZiebebi (mtkicebulebis done I)40,50-51:
• samedicino personalma unda Seafasos bavSvis dieta da
fizikuri aqtivoba (mtkicebulebis done IV)24 • dieta - rekomendebulia upiratesad xilis da bostneulis
miReba, cximis da tkbileulis SezRudva, Tumca bavSvebSi ar
aris sasurveli mkacri dietis dacva (mtkicebulebis done III,
reomendacia B)52
II
D
B
D
IV
C
I
B
II
IV
28
• mjdomare aqtivobis Semcireba - televizoris yureba,
kompiuterTan muSaoba unda SeizRudos dReSi 2 sT an kviraSi
14 sT-mde (rekomendacia D)50
• fizikuri aqtivobis gazrda – mag. siaruli minimum 30 wT
dReSi, Tu bavSvi janmrTelia dReSi rekomendebulia 60 wT
varjiSi (rekomendacia D)50 6 wlamde asakSi mizanSewonilia
aqtiuri TamaSebis waxaliseba (sirbili, daWerobana, burTiT
TamaSi da sxv.), 6 wlis Semdeg SeiZleba bavSvis CarTva
organizebul sportul TamaSebSi (fexburTi, kalaTburTi da
sxva), Tumca gaTvaliswinebuli unda iyos, rom 9 wlamde ar
aris rekomendebuli Zlieri fizikuri datvirTva54.
Warbi wonis riskis zonaSi myof bavSebSi mTavaria ar moxdes wonis
mateba, risTvisac saWiroa mudmivi monitoringi (rekomendacia D)50.
marTva
• Warbi wonisa da sismuqnis prevencia da mkurnaloba unda daiwyos
bavSvobis asakidan (rekomendacia C)50.
• simsuqnis mkurnaloba tardeba im SemTxvevaSi, Tu bavSvs da
mSobels aqvT survili Secvalon cxovrebis stili
(rekomendacia D)50.
• wonis SenarCuneba da kleba miiRweva mxolod qcevis cvlilebiT
(rekomendacia D)50, (mtkicebulebis done III, reomendacia B)52. • metad mniSvnelovania jansaRi kvebis damkvidreba (rekomendacia
D)50.
referali stacionarSi unda ganxorcieldes Tu:
⇒ saeWvoa endokrinuli paTologiis arseboba
⇒ vlindeba simsuqniT gamowveuli daavadebebi – hipertenzia, apnoe
Zilis dros, simsuqnismieri hipoventilacia, orTopediuli
problemebi, fsiqosocialuri problemebi, (rekomendacia D)50.
marTva binaze
binaze xorcieldeba im pacientebis marTva, romelTac aReniSnebaT
araswori kvebiT gamowveuli Warbi wona/simsuqne.
• 7 wlamde kveba ise unda SeirCes, rom SenarCundes arsebuli wona,
• 7 wlis Semdeg bavSvs, romelic garkveuli periodis ganmavlobaSi
inarCunebda arsebul wonas, SesaZlebelia daeniSnos dieta wonis
daklebis mizniT (TveSi wonis klebis maCvenebeli ar unda
aRematebodes 0,5 kg). dieta unda SeirCes endokrinologTan
konsultaciiT (rekomendacia D)50.
D
D
D
D
B
D
C
D
D
29
simaRlis darRveva
simaRleSi CamorCena - hipostatura1,12,22,38,58,59,60
diagnostika
• sigrZe/simaRle asakis diagramaze bavSvis individualuri mrudis
an erTjeradi gazomvis Sedegad miRebuli maCveneblis –2 Z qulovan (an 3 centilis) mruds qvemoT ganTavseba miuTiTebs,
simaRleSi CamorCenaze (rekomendacia D)22,59.
mizezebi
• endokrinuli darRvevebi _ zrdis hormonis deficiti,
hipoTireoidizmi (Zvlovani asaki CamorCeba qronologiur asaks);
• kvebis qronikuli deficiti _ vlindeba rogorc wonaSi, ise
simaRleSi CamorCena. wona_sigrZe/simaRlis mrudi normis
farglebSia;
• ojaxuri an genetikuri hipostatura – dabali simaRle,
sigrZe/simaRle-asakis diagramaze bavSvis individualuri mrudi –2 Z qulovan mruds qvemoT aris ganTavsebuli, Tumca standartuli
mrudis paraleluria, rac miuTiTebs, rom zrdis tempi
normaluria. Zvlovani asaki Seesabameba qronologiur asaks.
dabali simaRle aRiniSneba mSoblebTanac;
• konstituciuri simaRleSi CamorCena - Zvlovani asaki CamorCeba
qronologiur asaks, dagvianebulia sqesobrivi momwifeba, 3
wlidan pubertul periodamde aRiniSneba zrdis matebis dabali
tempi (mrudi ar aris standatrtuli mrudebis paraleluri),
Tumca zrdasrul asakSi simaRle normis farglebSia;
• terneris sindromi gogonebSi.
Zvlovani asaki ganisazRvreba majis Zvlebis rentgenografiuli
kvleviT, fasdeba gaZvalebis wertilebis arseboba.
marTva
• genetikuri hipostaturis gamoricxvis mizniT saWiroa mSoblebis
simaRlis Sefaseba;
• hipostaturis dros saWiroa endokrinologis konsultacia,
damatebiTi gamokvleva (hormonebis Seswavla, Zvlovani asakis
dadgena da sxv).
Warbi simaRle - gigantizmi12,60-61
diagnostika
bavSvis individualuri mrudis an erTjeradi gazomvis Sedegad
miRebuli maCveneblia ganTavseba +2Z qulovan (an 97 centilis) mruds
zemoT miuTiTebs simaRlis siWarbeze.
D
30
mizezebi
• endokrinuli paTologia (insulinis msgavsi zrdis faqtor-I-is
moqmedebiT ganpirobebuli zrdis hormonis pirveladi da meoradi
siWarbe);
• genetikuri paTologia (marfanis sindromi, klainfelteris
sindromi da sxv.).
marTva
• endokrinologis konsultacia, damatebiTi gamokvleva
(hormonebis Seswavla, Zvlovani asakis dadgena da sxv);
• genetikosis konsultacia.
kbilebis dagvianebuli amoWra
kbilebis dagvianebul amoWraze saubroben im SemTxvevaSi, Tu bavSvs
13 Tvis asakSi arc erTi kbili ar aqvs.
mizezebi: kvebiTi daRvevebi, vitaminebisa da mikroelementebis
deficiti, hipoTireozi, hipoparaTireoidizmi, xSiria ojaxuri
“kbilebis dagvianebuli amoWra”.
marTva: stomatologis da endokrinologis konsultacia. kvebis
darRvevebis dros _ kvebis koreqcia, mikroelementebisa da
vitaminebis daniSvna (kalciumi, D vitamini asakobrivi dozebiT).
kariesi da emalis defeqtebi.
mizezebi: kvebis (tkbili siTxeebis da tkbileulis Warbi miReba) da
metaboluri darRvevebi, mikroelementebis deficiti (kalciumi da
ftori) qronikuli daavadebebi, zogierTi medikamentis gamoyeneba,
satyuaras xSiri da xangrZlivi gamoyeneba da boTlidan
xangrZlivi kveba (rekomendacia C)63.
marTva: stomatologis konsultacia; oraluri higiena pirveli
kbilis amoWrisTanave (rbili qsoviliT an asakis Sesabamisi
jagrisiT, 3 wlidan sabavSvo kbilis pastis gamoyeneba);
tkbileulis, boTlis da sawovaras gamoyenebis SezRudva
(rekomendacia C)63. saWiroebis SemTxvevaSi mikroelementebis
damateba asakobrivi doziT (kalciumi, ftori).
gaidlainis gadasinjvisa da ganaxlebis vada – 2 weli
C
C
31
gaidlainis miRebis xerxi/wyaro
gaidlainis SemuSavebis meTodologia
• adreuli asakis bavSvTa fizikuri ganviTarebis Sefasebis
Sesaxeb arsebobs samecniero mtkicebulebis safuZvelze
Seqmnili rekomendaciebi. mocemuli gaidlainis Semqmnis
procesSi samuSao jgufis gadawyvetilebiT moZiebuli da
Sefasebuli iqna ukve arsebuli praqtikuli
rekomendaciebi. moxda arsebuli rekomendaciebis
adaptirebuli variantis SemuSaveba, romelic erTis mxriv
pasuxebs saerTaSoriso moTxovnebs, xolo meore mxriv
iTvaliswinebs saqarTvelos samedicino dawesebulebaTa
rogorc adamianur, ise teqnikur resursebs.
• rekomendaciaTa moZieba xorcieldeboda eleqtronuli
monacemTa bazis gamoyenebiT.
qveyana da resursis
dasaxeleba
internet-misamarTi
US National Guideline Clearinghouse (NGC)
http://www.guideline.gov
Centers for Disease Control and Prevention (CDC)
http://www.phppo.cdc.gov/CDCRecommends/AdvSearchV.asp
Health Canada – Population and Public Health Branch (PPHB)
http://www.hc-sc.gc.ca/pphb-dgspsp/dpg_e.html
Scottish Intercollegiate Guidelines Network (SIGN)
http://www.sign.ac.uk
German Guideline Information Service (GERGIS)
http://www.leitlinien.de/english/english/view;
Australian National Health and Medical Research Council (NHMRC)
http://www.health.gov.au/hfs/nhmrc/publicat/cp-home.htm
New Zealand Guidelines Group (NZGG)
http://www.nzgg.org.nz/library.cfm
CDC http://www.cdc.gov/growthcharts/
Canadian Paediatric Society http://www.cps.ca
WHO – World Health Organization
http://www.who.int/
klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi
wyaroebi da meTodebi
• koxreinis biblioTeka - The Cochrane Library 2006, Issue 2; • amerikis samedicino biblioTekis mier Seqmnil eleqtronul
bibliografiul monacemTa baza - medlaini – MEDLINE.
32
publikaciebis CarTvis/gamoricxvis kriteriumebi
• arCeul iqna kvlevebi Semdegi dizainiT: randomizebuli,
kontrolirebadi, sistemuri mimoxilvebi da meta-analizi,
erTmomentiani, kohortuli kvlevebi.
• rekomendaciis momzadebisas ZiriTadad dadgenili iyo drois
12 wliani SezRudva. Tumca zogjer gamoyenebuli iyo ufro
adreuli publikaciebi, romlebic dResac aqtualuria da
safuZvlad udevs sxva Tanamedrove mtkicebulebebs.
• dadgenili iyo enobrivi SezRudvebi, radganac samuSao jgufs
SesaZlebloba hqonda literaturis wyaroebi Seeswavla
mxolod inglisur da rusul enebze.
moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi
• samuSao jgufis mier tardeboda moZiebuli wyaroebis analizi.
Catarebuli Ziebis Sedegad miRebuli iyo ramdenime klinikuri
meToduri rekomendacia adreuli asakis bavSvTa fizikuri
ganviTarebis Sefasebis sakiTxebze, romlebic Seicavda jgufis
miznis Sesaferis saWiro informacias. am rekomendaciebis
Sefasebisas gamoyenebuli iyo rekomendaciaTa atestaciisa da
eqspertizis kiTxvari - AGREE (94,96-98). Sefasebis Sedegad
amorCeuli iyo qvemoT CamoTvlili organizaciebis gaidlainebi:
⇒ janmrTelobis msoflo organizacia
⇒ amerikis pediatrTa akademia
⇒ kanadis pediatrTa sazogadoeba
⇒ Sotlandiis gaidlainebis qseli
samuSao jgufi xelmZRvanelobda saqarTvelos Sromis,
janmrTelobisa da socialuri dacvis saministros mier SemuSavebuli
nacionaluri gaidlainebis gzamkvleviT.
• rekomendaciebis mtkicebulebaTa doneebis gansazRvrisas
gamoyenebuli iyo saqarTvelos Sromis janmrTelobisa da
socialuri dacvis saministros mier mowodebuli
mtkicebulebebis donisa da rekomendaciebis xarisxis sqema.
mtkicebulebaTa doneebisa da rekomendaciebis xarisxis sqema
done mtkicebulebis siZlieris done
(Muir Gray)
xarisxi rekomendaciis xarisxi
(Cook et al)
I Zlieri mtkicebuleba,
eyrdnoba minimum erT
sistemur mimoxilvas,
romelic efuZneba swori
dizainis mqone
randomizebul
kontrolirebad kvleva
A eyrdnoba I donis
mtkicebulebas da
Sesabamisad mtkiced
rekomendebulia
II Zlieri mtkicebuleba,
eyrdnoba minimum erTi
B eyrdnoba II donis
mtkicebulebas da
33
swori dizainis mqone
randomizebul
kontrolirebad kvleva
Sesabamisad mtkiced
rekomendebulia
III klinikuri kvleva
randomizaciis gareSe,
kohortuli da SemTxveva-
kontrolis kvlevebi
C eyrdnoba III donis
mtkicebulebas SeiZleba
CaiTvalos Sesabamisad
IV araeqsperimentuli
multicentruli kvlevebi
D eyrdnoba IV da V donis
mtkicebulebas saWiroebs
konsesuss
Va avtoritetul
profesionalTa
mosazreba
Vb klinikuri gamocdileba,
aRwerilobiTi kvlevebi
an eqspertTa angariSi
alternatiuli gaidlaini ar arsebobs
gamoyenebuli literatura:
1. WHO Library Cataloguing-in-Publication Data WHO child growth standards: length/height-for-age, weight-for-age, weight-for-length, weight-forheight and body mass index-for-age: methods and development. 2006
2. World Health Organization. Obesity: preventing and managing the global epidemic. Geneva: WHO, 1998 (63)
3. Tremblay MS, Willms JD. Correction. CMAJ. 2001;164(7):970. (65) 4. Reilly J. Epidemic of obesity in UK children. Lancet. 1999;354:1874-1875. (66) 5. Freedman DS, Srinivasan SR, Valdez RA, Williamson DF, Berenson GS. Secular
increases in relative weight and adiposity among children over two decades: The Bogalusa Heart Study. Pediatrics. 1997;99:420-426. (67)
6. Dietz WH. Health consequences of obesity in youth: childhood predictors of adult disease. Pediatrics. 1998;101:518-525. (68)
7. Tremblay MS, Willms JD. Secular trends in the body mass index of Canadian children. CMAJ. 2000;163(11):1429-1433. (63)
8. Freedman DS, Dietz WH, Srinivasan SR, Berenson GS. The relation of overweight to cardiovascular risk factors among children and adolescents: The Bogalusa Heart Study. Pediatrics. 1999;103:1175-1182. (69)
9. Whitaker RC, Wright JA, Pepe MS, Seider KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med. 1997;337(13):869-873. (70)
10. Guo SS, Chumlea WC. Tracking of BMI in children in relation to overweight in adulthood. Am J Clin Nutr. 1999;70 (suppl):145S-148S. (71)
11. Scudder L.E. – Evaluating Pediatric Growth and Nutrition: Guidelines for Primary Care Clinician - Copyright © 2000 Medscape Portals, Inc http://www.medscape.com
12. Behrman, Kleigman, Jenson. Nelson Test Book of Pediatrics 17-th edition.2004 13. Garner P., Pnpanich R., Logan S. – Is Routine Growth Monitoring Effective? A
systematic Review of Trails – Arch Dis Childhood 2000, 82 (3); 121-3
34
14. Sachs M. – Routine Weighing babies: does it improve feeding and care? J Child Health Care 2006, 10 (2); 90-95
15. xerxeuliZe n. – bavSvTa daavadebaTa propedevtika 2004
16. World Health Organization. Managing newborn problems: a guide for doctors, nurses, and midwives (Integrated management of pregnancy and childbirth) - 2003
17. Macdonald PD, Ross SR, Grant L, Young D. Neonatal weight loss in breast and formula fed infants. Arch Dis Child Fetal Neonatal Ed 2003;88(6):F472-6. (152)
18. Marchini G, Fried G, Ostlund E, Hagenas L. Plasma leptin in infants: relations to birth weight and weight loss. Pediatrics 1998;101(3 Pt 1):429-32. (153)
19. Rodriguez G, Ventura P, Samper MP, Moreno L, Sarria A, Perez-Gonzalez JM. Changes in body composition during the initial hours of life in breast-fed healthy term newborns. Biol Neonate 2000;77(1): 12-6 (201)
20. Kramer MS, Guo T, Platt RW, Shapiro S, Collet JP, Chalmers B, et al. Breastfeeding and infant growth: biology or bias? Pediatrics 2002;110(2 Pt 1):343-7. (135)
21. Dewey KG, Heinig MJ, Nommsen LA, Peerson JM, Lonnerdal B. Breast-fed infants are leaner than formula-fed infants at 1 y of age: the DARLING study. Am J Clin Nutr 1993;57(2):140-5. (68)
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avtorTa jgufi
pediatrTa da neontologTa kavSiri `alternativa~
samuSao jgufi:
⇒ nani yavlaSvili – medicinis doqtori, Tbilisis
saxelmwifo samedicino universitetis zogadi pediatriis
departamentis asistent-profesori. saqarTvelos Sromis,
janmrTelobisa da socialuri dacvis saministros
eqsperti. pediatrTa da neontologTa kavSiri
`alternativa~-s wevri;
⇒ maia xerxeuliZe – medicinis doqtori, Tbilisis
saxelmwifo samedicino universitetis zogadi pediatriis
departamentis asistent-profesori. saqarTvelos Sromis,
janmrTelobisa da socialuri dacvis saministros
eqsperti. pediatrTa da neontologTa kavSiri
`alternativa~-s wevri;
⇒ eka kandelaki – medicinis doqtori, Tbilisis
saxelmwifo samedicino universitetis zogadi pediatriis
departamentis asistent-profesori. pediatrTa da
neontologTa kavSiri `alternativa~-s wevri;
⇒ Tamar manjaviZe – medicinis doqtori, saqarTvelos
Sromis, janmrTelobisa da socialuri dacvis
saministro. pediatrTa da neontologTa kavSiri
`alternativa~-s wevri.
eqsperti:
⇒ nino manjaviZe - medicinis mecnierebaTa doqtori,
profesori, Tsu pediatriis departamentis kerZo pediatriis
mimarTulebis sruli profesori;
⇒ aleqsandra xitaliSvili - saqarTvelos Sromis,
janmrTelobisa da socialuri dacvis saministro;
37
⇒ lela woworia _ saqarTvelos Sromis, janmrTelobisa da
socialuri dacvis saministros jandacvis departamenti;
⇒ Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa da
socialuri dacvis saministros jandacvis departamenti.