Types of fat distribution. Method for studying the subcutaneous fat layer Subcutaneous fat layer is developed

The development of the subcutaneous fat layer, the presence of edema

Page 1

The development of the subcutaneous fat layer can be normal, increased or decreased. The fat layer can be distributed evenly or its deposition occurs only in certain areas. The thickness of the subcutaneous fat layer (degree of fatness) can be judged by palpation. For these purposes, with two fingers, take a fold of skin with subcutaneous tissue along the outer edge of the rectus abdominis muscle at the level of the navel, the lateral surface of the shoulder or at the angle of the shoulder blade and measure its thickness with a caliper. normal thickness skin fold should be within 2 cm, a thickness of less than 1 cm is regarded as a decrease, and more than 2 cm as an increase in the development of the subcutaneous fat layer. The latter is noted in various forms of obesity (alimentary exogenous, pituitary, adiposogenital, etc.). Insufficient development of subcutaneous fat is due to the constitutional features of the body (asthenic type), malnutrition, dysfunction of the digestive system. Extreme exhaustion is called cachexia

It is observed in advanced forms of tuberculosis, malignant tumors. In modern conditions, a more accurate idea of the degree of fatness of a person gives the definition of such an indicator as body mass index.

Body mass index (BMI) is calculated as the ratio of body weight (in kg) to the square of height (in m2). BMI standards, as well as the classification of overweight are presented in Table 1.

Table 1.

Classification of overweight and obesity by body mass index

Body mass types		Risk of comorbidities
underweight		Risk of other diseases
normal body weight
Overweight		Moderate
Obesity 1st degree		elevated
Obesity 2nd degree
Obesity 3rd degree		Very tall

Previously, a variety of proportionality indices were widely used: Pignet, Bouchard, Quetelet (height-weight). Currently, great importance is given to the measurement of the waist circumference (OT). The relationship between OT and the risk of developing diabetes type 2, coronary heart disease (see table 2).

Table 2.

Increased Risk	high risk

Waist circumference and risk of metabolic complications

Edema is an abnormal accumulation of fluid in soft tissues, organs and cavities. According to their origin, they are:

) general

edema: cardiac, renal, hepatic, cachexic (hungry);

) local: -

inflammatory, angioedema, with local compression of the vein by a tumor, lymph nodes.

According to the predominant mechanism of occurrence (pathogenesis), they are divided into hydrostatic,

or congestive (with heart failure, impaired local venous outflow with thrombophlebitis, compression of the vein by a tumor, lymph nodes, etc.);

hypooncotic

Due to a decrease in oncotic blood pressure with large protein losses (renal, cachexic, partially hepatic edema);

membranogenic

Due to increased permeability of cell membranes (inflammatory, angioedema); mixed.

More on the subcutaneous fat layer:

Practical recommendations for the study of the subcutaneous fat layer.
Anatomy and physiology of subcutaneous adipose tissue - study of the relationship between cellulite and sex in vivo by magnetic resonance

A general idea of the quantity and distribution of the subcutaneous fat layer can be obtained by examining the child, however, the final judgment on the state of the subcutaneous fat layer is made only after palpation.

To assess the subcutaneous fat layer, a somewhat deeper palpation is required than when examining the skin: with the thumb and forefinger of the right hand, not only the skin, but also the subcutaneous tissue is captured in the fold. The thickness of the subcutaneous fat layer should not be determined in one area, since in a number of diseases the deposition of fat in different places is not the same. Depending on the thickness of the subcutaneous fat layer, one speaks of normal, excessive and insufficient fat deposition. Attention is drawn to the uniform (throughout the body) or uneven distribution of the subcutaneous fat layer. It is recommended to determine the thickness of the subcutaneous fat layer in the following sequence: first on the abdomen - at the level of the navel and outward from it, then on the chest - at the edge of the sternum, on the back - under the shoulder blades, on the extremities - on the inner back surface of the thigh and shoulder, and, finally, on face - in the area of the cheeks.

More objectively, the thickness of the subcutaneous fat layer is determined by the caliper by the sum of the thickness of 4 skin folds above the biceps, triceps, under the scapula, above ilium. For in-depth assessments of physical development, special tables and nomograms are used, which allow, by the sum of the thickness of skin folds, to accurately calculate the total fat content and active (fat-free) body weight of the body.

On palpation, attention should also be paid to the consistency of the subcutaneous fat layer. In some cases, the subcutaneous fat layer becomes dense, and in separate small areas or all or almost all of the subcutaneous tissue (sclerema). Along with the compaction, swelling of the subcutaneous fat layer - scleredema - can also be observed. Puffiness differs from compaction in that in the first case, when pressed, a depression is formed, which gradually disappears, in the second case, a hole is not formed when pressed. Attention should be paid to the presence of edema and their prevalence (on the face, eyelids, limbs, general edema - anasarca or localized). Edema can be easily seen on examination if they are well expressed or localized on the face. To determine the presence of edema in the lower extremities, it is necessary to press the index finger of the right hand in the shin area above the tibia. If, when pressed, a hole is obtained that disappears gradually, then this is a true edema. If the fossa does not disappear, then this indicates mucous edema. In a healthy child, a fossa does not form.

Determination of soft tissue turgor. It is carried out by squeezing the skin and all soft tissues on the inner surface of the thigh and shoulder with the thumb and forefinger of the right hand. At the same time, resistance or elasticity, called turgor, is felt. If in young children the turgor of tissues is reduced, then when they are squeezed, a feeling of lethargy or flabbiness is determined.

To assess the subcutaneous fat layer, it is necessary to capture not only the skin, but also the subcutaneous tissue in the fold with the thumb and forefinger of the right hand. The thickness of the subcutaneous fat layer should be determined in various places and, depending on the thickness of the subcutaneous fat layer, judge normal, excessive and insufficient fat deposition. Pay attention to the uniform or uneven distribution of the subcutaneous fat layer.

The thickness of the subcutaneous fat layer is determined in the sequence:

On the abdomen - the level of the navel

On the chest - at the edge of the chest, along the anterior axillary line

On the back - under the shoulder blades

on the limbs - on the inner back of the thigh and shoulder

More objectively, the thickness of the subcutaneous fat layer is determined by the caliper by the sum of the thickness of 4 skin folds: over the biceps, triceps, under the scapula, over the ilium.

The sum of the thickness of 4 skin folds in children 3-6 years old.

Age in years

boys	girls	boys	girls	boys	girls	boys	girls

The sum of the thickness of 4 skin folds in boys 7-15 years old.

Centili	Age in years
Centili

The sum of the thickness of 4 skin folds in girls 7-14 years old.

Centili	Age in years
Centili

For in-depth assessments of physical development, special tables and nomograms are used, which allow, by the sum of the thickness of skin folds, to accurately calculate the total fat content and active (fat-free) body weight

Currently, the assessment of the thickness of the subcutaneous fat layer is carried out according to centile tables.

When fasting, the child loses weight by reducing body fat. Stable overfeeding leads to excessive development of the subcutaneous fat layer - to obesity. A 20% excess of body weight in relation to the median of body weight at a given height speaks of excess nutrition, sometimes obesity is accompanied by an increase in growth (macrosomia). Congenital general lipodystrophy is characterized by the complete inability of the child to form fat deposits, the complete absence of the subcutaneous fat layer, despite the presence of fat cells. Partial lipodystrophy - the ability to accumulate adipose tissue - is lost, for example, only on the face, and persists in other parts of the body. Obstructive sleep apnea in obese children (during inhalation, negative pressure is created in the pharynx, during sleep, the muscles relax, which contributes to airflow turbulence and snoring). With constitutional hereditary obesity, girls develop polycystic ovaries (an increase in androgen production in the ovaries and adrenal glands).

Literature:

Propaedeutics of childhood diseases //T.V. Captain // M, 2004

Propaedeutics of childhood diseases //A.V. Mazurin, I.M. Vorontsov // M, 1985.\

teaching aid for students, Ulyanovsk, 2003.

Reviewer: Associate Professor A.P. Cherdantsev

Subcutaneous adipose tissue is detected in the fetus at the 3rd month of intrauterine life in the form of fat droplets in mesenchymal cells. But the accumulation of the subcutaneous fat layer in the fetus is especially intensive in the last 1.5-2 months of intrauterine development (from 34 weeks of pregnancy). In a full-term baby, by the time of birth, the subcutaneous fat layer is well expressed on the face, trunk, abdomen and limbs; in a premature baby, the subcutaneous fat layer is poorly expressed, and the greater the degree of prematurity, the greater the lack of subcutaneous fat. Therefore, the skin of a premature baby looks wrinkled.

In postnatal life, the accumulation of the subcutaneous fat layer is intensive up to 9-12 months, sometimes up to 1.5 years, then the intensity of fat accumulation decreases and becomes minimal by 6-8 years. Then a repeated period of intense fat accumulation begins, which differs both in the composition of fat and in its localization from the primary one.

In primary fat deposition, fat is dense (this determines the elasticity of tissues) due to the predominance of dense fat in it. fatty acids: palmitic (29%) and stearic (3%). This circumstance in newborns sometimes leads to the occurrence of sclerema and scleredema (hardening of the skin and subcutaneous tissue, sometimes with swelling) on the legs, thighs, buttocks. Sclerema and scleredema usually occur in immature and premature babies during cooling, accompanied by a violation of the general condition. In well-fed children, especially when they are removed with forceps, in the first days after birth, infiltrates appear on the buttocks, dense, red or cyanotic. These are foci of necrosis of fatty tissue resulting from trauma during childbirth.

Baby fat includes a lot of brown (hormonal) adipose tissue). From the point of view of evolution, this is bear adipose tissue, it makes up 1/5 of all fat and is located on the lateral surfaces of the body, on the chest, under the shoulder blades. It participates in heat generation due to the esterification reaction of unsaturated fatty acids. Heat generation due to the metabolism of carbohydrates is the second "reserve" mechanism.

With secondary fat deposition, the composition of fat approaches that of an adult, with different localization in boys and girls.

The tendency to deposition of a fatty layer is genetically determined (the number of fat cells is coded), although the nutritional factor is also of great importance. Adipose tissue is an energy depot, and proteins, fats, and carbohydrates are transformed into fat.

The expenditure of fat is determined by the tone of the sympathetic nervous system, so sympathicotonic children are rarely overweight. When fasting in the human body formed "hormones of hunger", which regulate the consumption of fat.

The subcutaneous fat layer is examined almost simultaneously with the skin. The degree of development of fatty tissue is often in accordance with body weight and is determined by the size of the skin fold on the abdomen in the navel; with a sharp decrease in it, it is easier to take the skin into a fold; with a significant deposition of fat, this often cannot be done.

Of great clinical importance is the identification of edema.

Edema

Edema (fluid retention) occurs primarily in the subcutaneous tissue due to its porous structure, especially where the fiber is looser. Hydrostatic and hydrodynamic factors explain the appearance of edema in low-lying areas of the body (lower limbs). The latter factor plays an important role in the development of edema in heart disease accompanied by congestive heart failure. Edema appears more often by the end of the day, with a long stay of the patient in an upright position. At the same time, in diseases of the kidneys, small swellings often appear primarily on the face (in the eyelids) and usually in the morning. In this regard, the patient may be asked if he feels heaviness, swelling of the eyelids in the morning. For the first time, the relatives of the patient may pay attention to the appearance of such swelling.

With diseases of the heart, kidneys, liver, intestines, endocrine glands, edema can be common. In violation of the venous and lymphatic outflow, allergic reactions edema is often asymmetrical. In rare cases, in older people, they can appear with a long stay in an upright position, which (like edema in women during the hot season) is of little clinical importance.

Patients may consult a doctor with complaints of swelling of the joints, swelling of the face, legs, rapid weight gain, shortness of breath. With a general fluid retention, edema occurs primarily, as already mentioned, in low-lying parts of the body: in the lumbo-sacral region, which is especially noticeable in persons occupying a vertical or semi-lying position. This situation is typical for congestive heart failure. If the patient can lie in bed, edema occurs primarily on the face, hands, as happens in young people with kidney disease. An increase in venous pressure in any area leads to fluid retention, for example, with pulmonary edema due to left ventricular failure when ascites occurs in patients with increased pressure in the portal vein system (portal hypertension).

Usually, the development of edema is accompanied by an increase in body weight, but even the initial edema in the legs and lower back is easily detected by palpation. It is most convenient to press the tissue against the dense surface of the tibia with two or three fingers, and after 2-3 seconds, in the presence of edema, pits are found in the subcutaneous fatty tissue. Weak degree puffiness is sometimes referred to as "pasty". The pits on the lower leg are formed with pressure only if the body weight has increased by at least 10-15%. With chronic lymphoid edema, myxedema (hypothyroidism), the edema is more dense, and when pressed, the fossa is not formed.

Both with general and local edema, factors involved in the formation of interstitial fluid at the capillary level play an important role in their development. Interstitial fluid is formed as a result of its filtration through the capillary wall - a kind of semi-permeable membrane. Some of it returns back to the vascular bed due to the drainage of the interstitial space through the lymphatic vessels. In addition to hydrostatic pressure inside the vessels, the osmotic pressure of proteins in the interstitial fluid affects the fluid filtration rate, which is important in the formation of inflammatory, allergic and lymphatic edema. Hydrostatic pressure in capillaries varies in different parts of the body. So, the average pressure in the pulmonary capillaries is about 10 mm Hg. Art., while in the renal capillaries about 75 mm Hg. Art. When the body is upright, as a result of gravity, the pressure in the capillaries of the legs is higher than in the capillaries of the head, which creates the conditions for the appearance of slight swelling of the legs by the end of the day in some people. The pressure in the capillaries of the legs in a person of average height in a standing position reaches 110 mm Hg. Art.

Severe general edema (anasarca) can occur with hypoproteinemia, in which the oncotic pressure falls, mainly associated with the content of albumin in the plasma, and the fluid is retained in the interstitial tissue without entering the vascular bed (often there is a decrease in the amount of circulating blood - oligemia, or hypovolemia).

The causes of hypoproteinemia can be the most various states united clinically by the development of edematous syndrome. These include the following:

insufficient protein intake (starvation, poor nutrition);
indigestion (impaired secretion of enzymes by the pancreas, for example, in chronic pancreatitis, other digestive enzymes);
malabsorption of food products, primarily proteins (resection of a significant part of the small intestine, damage to the wall of the small intestine, celiac enteropathy, etc.);
violation of the synthesis of albumin (liver disease);
significant loss of proteins in the urine with nephrotic syndrome;
loss of protein through the intestines (exudative enteropathy).

A decrease in intravascular blood volume associated with hypoproteinemia can cause secondary hyperaldosteronism through the renin-angiotensin system, which contributes to sodium retention and the formation of edema.

Heart failure causes edema due to the following reasons:

violation of venous pressure, which can be detected by the expansion of the veins in the neck;
effect of hyperaldosteronism;
violation of the renal blood flow;
increased secretion of antidiuretic hormone;
a decrease in oncotic pressure due to stagnation of blood in the liver, a decrease in albumin synthesis, a decrease in protein intake due to anorexia, loss of protein in the urine.

Renal edema most clearly manifested in nephrotic syndrome, when, due to severe proteinuria, a significant amount of protein (primarily albumin) is lost, which leads to hypoproteinemia and hypooncotic fluid retention. The latter is exacerbated by developing hyperaldosteronism with increased sodium reabsorption by the kidneys. The mechanism for the development of edema in acute nephritic syndrome is more complex (for example, in the midst of a typical acute glomerulonephritis), when, apparently, a more significant role is played by the vascular factor (increased permeability vascular wall), in addition, sodium retention is important, leading to an increase in the volume of circulating blood, “blood edema” (hypervolemia, or plethora). As with heart failure, edema is accompanied by a decrease in diuresis (oliguria) and an increase in the patient's body weight.

local edema may be due to causes associated with venous, lymphatic or allergic factors, as well as a local inflammatory process. With compression of the veins from the outside, vein thrombosis, insufficiency of venous valves, varicose veins capillary pressure rises in the corresponding area, which leads to stagnation of blood and the appearance of edema. Most often, thrombosis of the veins of the legs develops in diseases that require prolonged bed rest, including conditions after surgery, as well as during pregnancy.

With a delay in the outflow of lymph, water and electrolytes are reabsorbed back into the capillaries from the interstitial tissue, however, proteins filtered from the capillary into the interstitial fluid remain in the interstitium, which is accompanied by water retention. Lymphatic edema also occurs as a result of obstruction of the lymphatic tract by filariae (- tropical disease). In this case, both legs, external genitalia can be affected. The skin in the affected area becomes rough, thickened, elephantiasis develops.

With a local inflammatory process as a result of tissue damage (infection, ischemia, exposure to certain chemical substances such as uric acid) releases histamine, bradykinin and other factors that cause vasodilation and increased capillary permeability. Inflammatory exudate contains a large amount of protein, as a result, the mechanism for moving tissue fluid is disrupted. Often, classic signs of inflammation are simultaneously noted, such as redness, pain, and local fever.

An increase in capillary permeability is also observed in allergic conditions, however, unlike inflammation, there is no pain and no redness. With Quincke's edema - a special form of allergic edema (often on the face and lips) - the symptoms usually develop so quickly that a threat to life is created due to swelling of the tongue, larynx, neck (asphyxia).

Violation of the development of subcutaneous fat

In the study of subcutaneous adipose tissue, attention is usually paid to its increased development. With obesity, excess fat is deposited in the subcutaneous tissue fairly evenly, but to a greater extent in the abdomen. Uneven deposition of excess fat is also possible. The most typical example is Cushing's syndrome (observed with excessive secretion of corticosteroid hormones by the adrenal cortex), often there is a cushingoid syndrome associated with long-term treatment with corticosteroid hormones. Excess fat in these cases is deposited mainly on the neck, face, and also the upper body, the face usually looks rounded, and the neck is full (the so-called moon-shaped face).

The skin of the abdomen is often significantly stretched, which is manifested by the formation of areas of atrophy and scars of a purple-cyanotic color, in contrast to whitish areas of skin atrophy from stretching after pregnancy or large edema.

Progressive lipodystrophy and significant loss of the subcutaneous fat layer (as well as fatty tissue of the mesenteric region) are possible, which is observed in a number of serious diseases, after major surgical interventions, especially on the gastrointestinal tract, during fasting. Local atrophy of subcutaneous fat is observed in patients

The thickness of the various layers of the skin in children under three years of age is 1.5-3 times less than in adults, and only by the age of 7 does it reach the parameters of an adult.

The cells of the epidermis in children are relatively far apart from each other, its structure is loose. The stratum corneum in newborns is thin and consists of 2-3 layers of easily listening cells. The granular layer is poorly developed, which determines the significant transparency of the skin of newborns and its pink color. The basal layer is well developed, however, in the first months of life, due to the low function of melanocytes, the skin background is lighter.

A distinctive feature of the skin of children, especially newborns, is the weak connection of the epidermis with the dermis, which is primarily caused by the lack of quantity and poor development of anchor fibers. In various diseases, the epidermis easily exfoliates from the dermis, which leads to the formation of blisters.

The surface of the skin of a newborn is covered with a secret with weak bactericidal activity, since its pH is close to neutral, but by the end of the first month of life, the pH decreases significantly.

In the skin of newborns and children of the first year of life, a network of wide capillaries is well developed. In the future, the number of wide capillaries gradually decreases, while the number of long and narrow ones increases.

Nerve endings of the skin by the time of birth are underdeveloped, but functionally consistent and determine pain, tactile and temperature sensitivity.

The skin of a child of the first year of life, due to its structural features, biochemical composition and good vascularization, is distinguished by tenderness, velvety and elasticity. In general, it is thin, smooth, its surface is drier than in adults, and prone to peeling. The entire surface of the skin and hair is covered with a water-lipid layer, or mantle, which protects the skin from adverse factors. environment, slows down and prevents the absorption and effects of chemicals, serves as a site for the formation of provitamin D, and has antibacterial properties.

Sebaceous glands

The sebaceous glands begin to function even in the prenatal period, their secret forms a curdled lubricant that covers the surface of the skin of the fetus. The lubricant protects the skin from amniotic fluid and makes it easier for the fetus to pass through the birth canal.

The sebaceous glands are actively functioning in the first year of life, then their secretion decreases, but again increases in the puberty period. In adolescents, they are often clogged with horny plugs, which leads to the development of acne.

sweat glands

By the time of birth, the eccrine sweat glands are not fully formed, their excretory ducts are underdeveloped and covered by epithelial cells. Sweating begins at the age of 3-4 weeks. During the first 3-4 months, the glands do not function fully. In children of early (up to 3 years) age, sweating appears at a higher temperature than in older children. As the sweat glands, the autonomic nervous system, and the thermoregulation center in the brain mature, the sweating process improves, and its threshold decreases. By the age of 5-7 years, the glands are fully formed, and adequate sweating occurs at 7-8 years.

Apocrine sweat glands begin to function only with the onset of puberty.

Primary hair before birth or shortly after it is replaced by vellus (with the exception of eyebrows, eyelashes and scalp). Hair in full-term newborns does not have a core, and the hair follicle is underdeveloped, which does not allow the formation of a boil with a purulent shaft. The skin, especially on the shoulders and back, is covered with vellus hair (lanugo), which is much more noticeable in premature babies.

Eyebrows and eyelashes are poorly developed, in the future their growth increases. Hair development ends during puberty.

Nails in term newborns are well developed and reach to the fingertips. In the first days of life, nail growth is temporarily delayed and a so-called physiological trait is formed on the nail plate. At the 3rd month of life, it reaches the free edge of the nail.

SKIN EXAMINATION METHOD

To assess the condition of the skin, questioning, examination, palpation and special tests are carried out.

INQUIRY AND INSPECTION

Examination of the child, if possible, is carried out in natural daylight. The skin is examined sequentially from top to bottom: hairy part head, neck, natural folds, inguinal and gluteal areas, palms, soles, interdigital spaces. On examination, evaluate:

Skin color and its uniformity;

Humidity;

Cleanliness (absence of rashes or other pathological elements, such as peeling, scratching, hemorrhages);

The state of the vascular system of the skin, in particular the localization and severity of the venous pattern;

The integrity of the skin;

The condition of the skin appendages (hair and nails).

Skin rashes

Skin rashes (morphological elements) can affect different layers of the skin, as well as its appendages (sweat and sebaceous glands, hair follicles).

Primary morphological elements appear on intact skin. They are divided into cavitary (spot, papule, node, etc.) and cavitary with serous, hemorrhagic or purulent contents (blister, bladder, abscess) (Table 5-3, Fig. 5-2-5-P).

The color of the skin depends on its neck and transparency, the amount of normal and pathological pigments contained in it, the degree of development, the depth of occurrence and plethora of skin vessels, the content of lib and the volume unit of the crop, and the degree of saturation of lib with oxygen. Depending on race and ethnicity, a child's normal skin color may be pale pink or varying shades of yellow, red, brown, and black. Pathological and changes in skin color in children include pallor, flushing, nianosis. jaundice and pigmentation

The moisture of the skin is predicted by its luster: normally, the surface of the skin is moderately shiny, with increased humidity, the skin is very shiny, i.e. often covered with drops of sweat: excessively dry skin is matte, rough

If pathological elements are found on the skin, it is necessary to clarify;

The time of their appearance;

connection with any factors (food, medicinal, chemical, etc.):

The existence of similar symptoms in the past, their evolution (and the change in skin color, the nature of the rash):

Morphological type (see below):

Size (in millimeters or centimeters):

The number of elements (single elements s, not abundant rash, the elements of which can be counted on examination, abundant - multiple elements that cannot be counted):

Shape (round, oval, irregular, stellate, annular, etc.):

Color (for example, with inflammation, ischemia occurs);

Localization and prevalence (indicate pseudo-parts of the body that have a rash, predominantly subcutaneous - head, trunk, flexion or extensor surfaces of the extremities, skin folds, etc.):

Background of the skin in the area of the rash (for example, hyperemic):

The stages and dynamics of the development of the elements of the rash: - features of the secondary elements remaining after

Skin purity

fading of the rash (peeling, hyper- or gyno-pigmentation, crusts and etc.)

Secondary morphological elements appear as a result of the evolution of primary ones (Tables 5-4).

The condition of the skin appendages

When examining hair, pay attention to the uniformity of growth, I determine! correspondence of the degree of development of the hairline and its distribution on the body to the age and sex of the child. Evaluate the appearance of the hair (they should be shiny with even ends) and the condition of the skin of the scalp.

When examining nails, pay attention to the shape, color, transparency, thickness and integrity of the nail plates. Healthy nails are pink in color, smooth surfaces and edges, fit snugly to the nail bed. The periungual ridge should not be hyperemic and painful.

PALPATION

Palpation of the skin is carried out sequentially from top to bottom, and in areas of damage - with extreme caution. Assess the moisture, temperature and elasticity of the skin.

Humidity is determined by stroking the skin of symmetrical areas of the body, including the skin of the palms, feet, axillary and inguinal regions.

5.2. SUBCUTANEOUS FAT FIBER

Adipose tissue consists predominantly of white fat, found in many tissues, and a small amount of brown fat (located in the mediastinum, along the aorta and under the skin in the interscapular region in adults). In brown fat cells, a natural mechanism for uncoupling oxidative phosphorylation functions: the energy released during the hydrolysis of triglycerides and the metabolism of fatty acids is not used for the synthesis of adenosine triphosphate, but is converted into heat.

ANAT0M0-PHYSIOLOGICAL CHARACTERISTICS OF SUBCUTANEOUS FATTY FIBER

At the end of the prenatal period and in the first year of life, the mass of adipose tissue increases as a result of an increase in both the number and size of fat cells (by 9 months of life, the mass of one cell increases 5 times). The thickness of the subcutaneous adipose tissue increases markedly in the period from birth to 9 months, and then gradually decreases (by the age of 5, it decreases by an average of 2 times). The smallest thickness is noted at 6-9 years.

In puberty, the thickness of the subcutaneous fat layer increases again. In adolescent girls, up to 70% of fat is located in the subcutaneous tissue (which gives them roundness), while in boys, only 50% of the total fat is in the subcutaneous layer.

METHOD FOR THE STUDY OF SUBCUTANEOUS FATTY FIBER

The condition of the subcutaneous adipose tissue is assessed during examination and palpation.

DEGREE OF DEVELOPMENT

The degree of development of subcutaneous adipose tissue is assessed by the thickness of the skin fold, measured in different parts of the body (Fig. 5-40):

On the stomach;

On the chest (at the edge of the sternum);

On the back (under the shoulder blades);

On the limbs.

For an approximate practical assessment, you can limit yourself to examining 1-2 folds.

Filed by A.F. Tura, on average, the thickness of the fold on the abdomen is:

In newborns - 0.6 cm;

At 6 months - 1.3 cm;

At 1 year - 1.5 cm;

At 2-3 years old - 0.8 cm;

At 4-9 years old - 0.7 cm;

At 10-15 years old - 0.8 cm.

Lymph nodes - oval-shaped and of various sizes, located in groups at the confluence of large lymphatic vessels

Axillary lymph nodes are located in the armpits, collect lymph from the skin of the upper limb (with the exception of 111. IV and V fingers and the inner surface of the hand).

The thoracic lymph nodes are located medially from the anterior axillary line under the lower edge of the pectoralis major muscle, they collect lymph from the skin of the chest, from the parietal pleura, partly from the lungs and from the mammary glands.

The ulnar (cubital) lymph nodes are located in the groove of the biceps mouse. Collect lymph from II I. IV. V fingers and the inner surface of the hand.

Inguinal lymph nodes are located along the inguinal ligament, collect lymph from the skin of the lower extremities, lower part and abdomen, buttocks, perineum, from the genitals and anus.

The popliteal lymph nodes are located in the popliteal fossae and collect lymph from the skin of the foot.

Research methodology

The survey reveals:

Enlargement lymph nodes;

The appearance of soreness and redness in the area of lymph nodes;

Prescription of the occurrence of these complaints;

Possible reasons preceding the appearance of these complaints (infections and other provoking factors);

Concomitant conditions (presence of fever, weight loss, symptoms of intoxication, etc.).

Inspection reveals:

Significantly enlarged lymph nodes;

Signs of inflammation are hyperemia of the skin and swelling of the subcutaneous fatty tissue over the lymph node.

Palpation allows you to assess the characteristic changes in the lymph nodes.

* The size of the lymph nodes. Normally, the diameter of the lymph node is 0.3-0.5 cm (pea size). There are six degrees of enlarged lymph nodes:

Grade I - a lymph node the size of a millet grain;

ANAMNESIS

Pathological conditions of the subcutaneous fat layer, associated with its insufficient or excessive development, are most often caused by a nutritional factor. In this case, there may be complaints associated with insufficient or excessive development of the subcutaneous fat layer.

When fasting the child loses weight due to the predominant decrease in the amount of fat in the body, but in the future, a decrease in the growth rate, disturbances in the functioning of internal organs, muscle atrophy, deterioration of the teeth and gums, skin appendages, etc. will begin.

Permanent overfeeding child leads to excessive development of the subcutaneous fat layer, and then to obesity. Negative consequences with excess nutrition at an early age, they are associated with an increase in the number and size of adipocytes. Subsequently, at an older age, two types of obesity are formed:

. peripheral, or female, type(the accumulation of fat is carried out mainly in the subcutaneous tissue):

. visceral, or male, type(fat accumulation occurs during internal organs and abdominal cavity).

Parents may sometimes pay attention to swelling - accumulation of fluid in the subcutaneous tissue.

INSPECTION

When examining the subcutaneous fat layer determine:

The degree of development of the subcutaneous fat layer;

The uniformity of its distribution;

Be sure to emphasize gender difference, since in boys and girls the subcutaneous fat layer is distributed differently: in boys, the distribution is uniform, in girls from 5-7 years old, and especially during puberty, fat accumulates in the thighs, abdomen, buttocks, and chest in front.

Attention should be paid not only to the presence of edema, but also their distribution (on the face, eyelids, limbs, general edema - anasarca or localized). Edema is easy to notice on examination if they are well expressed and localized on the face. Often, deep impressions of the skin from diapers, elastic bands of clothes, belts, belts, and tight shoes testify to the pastosity of the fabric. In a healthy child, such phenomena are absent.

PALPATION

The following pathological abnormalities are determined by palpation:

The thickness of the subcutaneous fat layer;

Visible swelling;

Soft tissue turgor.

Table 5.1. The thickness of the subcutaneous fat layer in children, cm

Determine thickness subcutaneous fat layer in the following sequence:

On the stomach - at the level of the navel and outward from it (Fig. 5.1, a);

On the chest - at the edge of the sternum in the second intercostal space (Fig. 5.1, b);

On the back - under the shoulder blades (Fig. 5.1, c);

On the limbs - upper (shoulder in front and behind - Fig. 5.1, d, e) and lower on the inner surface of the thigh (Fig. 5.1, f);

On the face - in the area of the cheeks.

To determine the thickness of the subcutaneous fat layer, you can use a caliper (see Fig. 5.1, e, f).

On palpation of the skin fold, attention should be paid to consistency subcutaneous fat layer. It can be flabby, dense and resilient. In some cases, the subcutaneous fat layer becomes dense. Violation of the consistency of adipose tissue can manifest itself in the form of thickening of the skin and subcutaneous fatty tissue, sometimes accompanied by edema (Table 5.2).

Table 5.2. Changes in the consistency of the subcutaneous fat layer

Puffiness differs from compaction in that in the first case, when pressed, a depression forms, which gradually disappears, in the second case, a hole does not form when pressed.

The skin of children of the earliest age in its morphological and physiological features is distinguished by significant originality.

The stratum corneum is thin and consists of 2-3 rows of weakly interconnected and constantly sloughing cells; the main layer is strongly developed; one can always prove energetic division in it epithelial cells.

The main membrane separating the epidermis and dermis is underdeveloped in newborns, very tender and loose. The result of this morphological underdevelopment of the main membrane is a weak connection between the epidermis and the skin proper; in the latter, it should also be noted the insufficient amount of elastic, connective tissue and muscle elements. Children's skin is especially characterized by good blood supply, which depends on a well-developed network of capillaries.

The sebaceous glands function well even in newborns. They very often have yellowish-white dots (milia) on the skin of the tip and wings of the nose, and sometimes on the adjacent areas of the skin of the cheeks - an excessive accumulation of secretion in the skin sebaceous glands. sweat glands during the first
3-4 months reveal some functional insufficiency.

The specified morphological immaturity of the skin, combined with the insufficiency of local immunity and the known imperfection of local thermoregulation, explain the slight vulnerability of the skin, the tendency to maceration, easy infection and the peculiarity of the course of skin diseases in children, especially at an early age.

The water-rich skin of newborns appears luscious, somewhat edematous, pale or pale cyanotic. At birth, it is covered with a rather thick layer of a grayish-white cheesy lubricant, the so-called vernix caseosa. Curd grease consists of fat, exfoliating elements of the epidermis, contains a lot of cholesterol, glycogen and eleidin.

After removal of the lubricant, the skin shows reactive redness, sometimes with a cyanotic tint. This kind of inflammatory condition of the skin is called the physiological catarrh of the skin of newborns (erythema neonatorum). In premature babies, this redness is especially pronounced and lasts much longer than in full-term babies. After a few days, the redness begins to gradually disappear and is replaced by small pityriasis peeling.

Around the 2-3rd day of life, less often - by the end of the 1st day or on the 4th-6th day (and, as an exception, later), almost 80% of all newborns develop icteric staining of the skin, mucous membranes and sclera - physiological jaundice of newborns (icterus neonatorum). The color intensity is very different - from a barely perceptible subictric shade to a bright yellow color. Physiological catarrh of the skin makes it difficult to detect early light degrees of icteric coloration of the skin. The icteric phenomena, having reached the greatest intensity within 2-3 days, begin to weaken and completely disappear by the 7-10th day. Light forms pass within 2-3 days; much less often, the color lasts 3-4 weeks (icterus prolongatus). In premature babies, as a rule, jaundice is more pronounced and often drags on for up to 6-8 weeks. The general condition of newborns is not disturbed, although sometimes they show some lethargy.

Newborn jaundice is characterized by the absence of acholic stools and intense coloration of urine. The pathogenesis of this peculiar condition is based on hemolysis of erythrocytes and, as a result, physiological bilirubinemia in children of the neonatal period, a slightly increased permeability of the capillary wall and, apparently, some functional low value of the liver.

To the touch, the skin of newborns is velvety soft, with good turgor and over the entire surface, especially on the shoulders and back, is covered with a soft fluff (lanugo); its abundance is characteristic of premature babies and to a certain extent gives the right to judge the degree of maturity of the child. However, in some full-term and strong newborns, one sometimes also has to observe abundant downy vegetation.

The hair on the head of newborns is mostly dark. In quantitative terms, they are developed in individual children very differently: some newborns have an almost bald head at birth, while others, on the contrary, have dense and long vegetation. Very abundant or, on the contrary, extremely insufficient vegetation of the scalp in newborns, as well as the initial coloring of the hair, do not prejudge the characteristics of the latter in the child in subsequent years of his life.

Eyebrows and eyelashes in newborns are relatively poorly developed. In the future, their growth increases significantly, and in children 3-5 years old they reach almost the same length as in adults.

The nails are usually well defined and reach the fingertips, not only in full-term, but often in rather severely premature babies.

These properties of the skin persist throughout early childhood and only gradually change with the age of the child.

It is necessary to point out some peculiar conditions of the skin and its derivatives bordering on pathology, often observed in children during the first days of life. Many newborns on the back of the head and on the forehead, less often in the eyebrow area, have irregularly shaped red spots due to local vasodilation. These spots bear some resemblance to naevi vasculosi, but unlike the latter, they usually disappear without any treatment, while vascular birthmarks show an increasing trend.

Very often, even after perfectly normal childbirth, children have pinpoint hemorrhages on the skin and conjunctiva, resulting from capillary damage due to stagnation during eruption of the head during childbirth. The so-called generic tumor (caput succedaneum) is of the same origin - swelling of the soft integument of the presenting part of the child. Most often, the birth tumor is located on the head, in the region of the crown or occiput (Fig. 36). The birth tumor immediately after the birth of the child begins to decrease rapidly and disappears after 2-3 days; hemorrhages last 8-10 days.

Rice. 36. Generic tumor (scheme).
1 - dura mater; 2 - bone; 3-periosteum; 4 - galea aponeurotica; 6 - skin; 6 - swelling of the fiber.

During the first days of a child's life, regardless of sex, the mammary glands enlarge, reaching a maximum between the 5th and 10th days (physiological swelling mammary glands newborns). The skin over the glands, reaching various sizes - from a pea to a hazelnut, is mostly unchanged and only sometimes slightly hyperemic. With pressure from the enlarged mammary glands, you can squeeze out a secret that resembles and appearance and the composition of human milk in the first days of the postpartum period.

From the 2-3rd week, the glands begin to decrease and by the end of the 1st month of life they return to their original size (a normal piece of iron is barely palpable in the form of a grain). In premature babies, swelling of the mammary glands is very weakly expressed.

Breast swelling in newborns is a physiological phenomenon and does not require any treatment; squeezing out the secret is definitely contraindicated.

The influence of the endocrine glands is largely reflected in the pubertal period on the characteristics of vegetation on the pubis, in the armpits, upper lip etc. In normal children, secondary hair growth occurs in the following order: pubic region, axillary cavities, then mustache and beard in boys. Vellus hair on the body and limbs are replaced by stiffer, permanent ones. Hair growth in girls occurs in the same order, but the general hairiness is much less pronounced. The time of the final detection of secondary vegetation can vary over a very wide range.

The skin is primarily a protective organ that protects deeper tissues from accidental harmful mechanical and chemical influences. This function of the skin in children is much less pronounced than in adults.

The thermoregulatory function of children's skin with its characteristic thinness and tenderness, an abundance of blood vessels, some insufficiency of the function of the sweat glands and a special lability of vasomotors is relatively imperfect and makes the child prone to both hypothermia and overheating.

The skin is to some extent an excretory organ and a respiratory organ, as it takes part in water-mineral and gas exchange.

The skin is the site of the formation of enzymes, immune bodies and specific beginnings of growth - witasterins, which acquire activity under the influence of ultraviolet rays. The skin releases histamine into the blood and lymph. This humoral connection of the skin with the whole body in children has not yet been studied at all. Much more important is the effect of the skin on the body not by the humoral, but by the neuroreflex way.

The skin contains numerous and diverse receptors that perceive irritations that fall on it from the external environment surrounding the child. The skin is one of the five sense organs (p. 174) that ensure the adaptation of the child from the first days of his life to the environment. From the skin, the impulses perceived by the nerve endings go along centripetal (afferent) paths to the central nervous system, from where they reach the skin through centrifugal (efferent) conductors. There is a constant mutual influence between the skin and the central and autonomic nervous system.

Irritation of the skin undoubtedly affects the balance of the tone of the autonomic nervous system, the morphological features of the blood, its physico-chemical properties, the function of the abdominal organs, etc.

The ability of children's skin to form and accumulate pigments is subject to wide fluctuations. Some children tan quickly and well under the influence of sunlight or a quartz lamp, while others under the same conditions give poor pigmentation; this difference, apparently, does not depend on the age of the child, but on his individual characteristics.

The subcutaneous fat layer in the fetus accumulates mainly during the last 1.5-2 months of intrauterine life and is well expressed in normal full-term newborns. In the extrauterine life of a child, it intensively grows during the first 6 months, mainly on the face, more slowly - on the stomach. In girls, especially starting from the prepubertal period, the subcutaneous fat layer is more pronounced than in boys.

The chemical composition of subcutaneous fat in children of different ages is different: in young children there are relatively more solid fatty acids - palmitic and stearic, which causes a greater density of fat and a higher melting point.

Apparently, subcutaneous fat in different parts of the body has a different composition, which explains the well-known regular sequence in the accumulation and disappearance of fat with weight gain and fall. Fat disappears most easily from the walls of the abdomen, then from the trunk, then from the limbs, and last of all from the face in the cheek area. With the accumulation of fat, its deposition occurs in the reverse order.

More objectively, the thickness of the subcutaneous fat layer is determined by the caliper by the sum of the thickness of 4 skin folds over the biceps, triceps, under the scapula, over the ilium. For in-depth assessments of physical development, special tables and nomograms are used, which allow, by the sum of the thickness of skin folds, to accurately calculate the total fat content and active (fat-free) body weight of the body.

The thickness of the subcutaneous fat layer is determined in the sequence:

On the abdomen - the level of the navel

On the chest - at the edge of the chest, along the anterior axillary line

On the back - under the shoulder blades

on the limbs - on the inner back of the thigh and shoulder

More objectively, the thickness of the subcutaneous fat layer is determined by the caliper by the sum of the thickness of 4 skin folds: over the biceps, triceps, under the scapula, over the ilium.

The sum of the thickness of 4 skin folds in children 3-6 years old.

Age in years

boys	girls	boys	girls	boys	girls	boys	girls

The sum of the thickness of 4 skin folds in boys 7-15 years old.

Centili	Age in years
Centili

The sum of the thickness of 4 skin folds in girls 7-14 years old.

Centili	Age in years
Centili

Currently, the assessment of the thickness of the subcutaneous fat layer is carried out according to centile tables.

Literature:

Propaedeutics of childhood diseases //T.V. Captain // M, 2004

Propaedeutics of childhood diseases //A.V. Mazurin, I.M. Vorontsov // M, 1985.\

teaching aid for students, Ulyanovsk, 2003.

Reviewer: Associate Professor A.P. Cherdantsev

CHAPTER 9

SUBCUTANEOUS FAT FIBER
ANATOMO - PHYSIOLOGICAL FEATURES

The subcutaneous tissue is composed of individual fat cells - adipocytes, located in the form of fat accumulations (deposits). The thickness of body fat is not the same in all places. In the forehead and nose, the fat layer is weakly expressed, and on the eyelids and skin of the scrotum it is completely absent. The fat layer is especially well developed on the buttocks and soles. Here it performs a mechanical function, being an elastic bedding. The degree of fat deposition depends on age, body type, fatness. Adipose tissue is a good thermal insulator.

Subcutaneous fatty tissue begins to form at the 5th month of intrauterine life and is deposited in the fetus mainly during the last 1.5 - 2 months of pregnancy. In young children, solid fatty acids with a higher melting point (palmitic, stearic) predominate in subcutaneous fat, which makes it easier to solidify with a significant decrease in temperature.

By birth, subcutaneous fatty tissue is more developed on the face (fatty bodies of the cheeks - lumps of Bit), limbs, chest, back; weaker on the stomach. In the case of a disease, the disappearance of subcutaneous fatty tissue occurs in the reverse order, i.e., first on the abdomen, then on the limbs and torso, last of all on the face, which is associated with the composition of fatty acids: mainly solid acids (stearic acid) are located in the fatty cells of the cheeks. ), the stomach is dominated by liquid (oleic acid).

The subcutaneous fat layer is better expressed in full-term newborns. In premature babies, it is the less, the greater the degree of prematurity.

A feature of the subcutaneous adipose tissue of the fetus and newborn is brown adipose tissue. Its differentiation occurs from the 13th week of intrauterine development. Histologically, brown adipose tissue cells differ from white cells in the abundance of fat vacuoles and their small size. Its largest accumulations are in the posterior cervical, axillary regions, around the thyroid and goiter glands, in the supraileocecal zone and around the kidneys. The main function of brown adipose tissue is the so-called non-shivering thermogenesis, i.e. heat production not associated with muscle contraction. Brown adipose tissue has the maximum capacity for heat production in the first days of life: in a full-term baby, it provides protection from moderate cooling for 1–2 days. With age, the ability of brown adipose tissue to produce heat decreases. In children exposed to prolonged cooling, it may disappear completely. During starvation, white adipose tissue first disappears, and only with long periods and the degree of starvation - brown. Therefore, children with dystrophy freeze easily. In severely preterm infants, a low supply of brown adipose tissue is one of the factors leading to rapid cooling. Children "do not keep warm", therefore they require a higher ambient temperature (physical methods of warming, incubator, etc.).

Common edema observed in the edematous form of hemolytic disease of the newborn.

General edema quite often occurs in acute and chronic kidney diseases, with heart failure. The development of general edema in case of heart failure in children is preceded by swelling of the lower extremities and an enlarged liver. With decompensation, edema becomes more common, combined with the accumulation of fluid in the serous cavities - the pleura, pericardium, and abdominal cavity. Cardiac edema increases in the evening and primarily on the legs, creating a "syndrome of tight shoes."

With kidney disease, edema appears first in the morning on the face (periorbitally). Massive edema occurs with nephrotic syndrome.

There are general edemas of alimentary origin, appearing in case of insufficiency of protein-containing food (preferential nutrition of flour, carbohydrate foods), with general dystrophy.

Localized edema due to angioedema, typical manifestation which is Quincke's edema. This swelling can appear anywhere, but most often occurs on the lips, eyelids, auricles, tongue, and external genitalia. Localized edema is characteristic of serum sickness, hemorrhagic vasculitis (on the extremities, anterior abdominal wall, face) before the appearance of a hemorrhagic rash.

Local edema, sometimes very massive, is observed after the bites of insects, spiders, snakes, especially in cases where the child has an allergic predisposition.

Very dense swelling of skin areas occurs at the beginning of the development of dermatomyositis and systemic scleroderma.

Often, osteomyelitis or phlegmon is accompanied by massive edema over the site of the lesion.

Some infectious diseases are also accompanied by localized edema. So, with toxic diphtheria, there is swelling of the skin and subcutaneous fatty tissue on the neck up to the collarbones, in rare cases - on the chest wall. With mumps, a massive test-like edema is found in the region of the parotid salivary glands.

Moderate swelling of the face is possible due to severe cough paroxysms with whooping cough.

A kind of dense swelling of the skin and subcutaneous adipose tissue develops with hypothyroidism. The skin in this disease becomes dry and thickened, mucinous edema is located in the supraclavicular fossae in the form of “pads”, a fossa does not form on the anterior surface of the lower leg when pressed.

Possible and seals subcutaneous adipose tissue associated with its diseases - necrosis in acute panniculitis, nodules with multiple lipomatosis, followed by the formation of depressions, scars and the disappearance of the fiber itself - lipodystrophy.

On palpation of the subcutaneous adipose tissue, nodules that are practically unrelated to it can be detected: infiltrates at the injection and vaccine sites, vascular nodules in rheumatism and rheumatoid arthritis, specific dense formations in sarcoidosis and xanthomatosis.

Question 2. What fatty acids predominate in adipose tissue in newborns compared to adults?

Palmitic.

Oleic.

Stearic.

None of the above.

Answer by code

Question 3. What diseases are common edema?

Hemolytic disease of the newborn.

Dermatomyositis.

nephrotic syndrome.

Hypotrophy.

Answer by code

Question 4. What is the main function of brown adipose tissue?

Protective.

excretory.

Heat transfer.

Heat production.

Answer by code

Question 5. A mother with a 3-year-old child came to the clinic. Complaints - poor appetite, rapid fatigue of the child. On examination, attention is drawn to the pallor and dryness of the skin, periorbital cyanosis, the absence of a subcutaneous fat layer on the abdomen, chest and lower extremities. The child's body weight is 10 kg, body length is 82 cm.

What is the most likely diagnosis?

constitutional feature.

Hypotrophy I degree.

Hypotrophy II degree.

Hypotrophy III degree.

Dystrophy II degree.

Answer by code
ANSWERS
To question 1-E.

To question 2-B.

To question 3 - B.

To question 4-D.

To question 5-E.

Morphological features of the skin, their clinical characteristics.

Features of the development and functioning of the appendages of the skin.

This section of the lecture is fully and consistently described in the textbook "Propaedeutics of childhood diseases" (M., Medicine, 1985, pp. 71-73). Below is a commentary on the material of the textbook.

Skin develops from ectodermal and mesodermal germ layers. Already by the 5th week of intrauterine life, the epidermis is represented by 2 layers of epithelial cells, with the lower germinal layer further developing the remaining layers of the epidermis, and the upper (periderm) is separated by 6 months and takes part in the formation of the skin lubricant of the fetus - "vernix caseosae ". At 6-8 weeks of fetal development, epithelial rudiments are introduced into the dermis, from which hair, sebaceous and sweat glands develop from the 3rd month. The germ layer of cells of the eccrine sweat glands is found only at 5-6 months of intrauterine life. The basement membrane is formed on the 2nd month of intrauterine development.

By the time of birth, the main differentiation of the skin layers has already occurred and it is possible to distinguish the epidermis, dermis, and hypodermis in it.

The epidermis is made up of:

1) the stratum corneum of nuclear-free cells-plates containing keratin. The stratum corneum is especially developed on the soles and palms;

2) vitreous shiny layer, also consisting of flat nuclear-free cells that contain the protein substance eleidin;

3) granular keratohyalin layer, consisting of 1-2 rows

4) powerful prickly layer (4-6 rows of cells);

5) a germinal basal layer, consisting of 1 row of polysade-like cells. Here there is a continuous reproduction of cells going to the formation of the overlying layers.

The epidermis does not contain blood vessels. Between the cells in the basal and spinous layers there are intercellular bridges formed by the protoplasmic processes of the cells; in the intervals between them, lymph circulates, feeding the epidermis.

The skin itself - the dermis consists of a superficial layer (papillary) and a deeper one (reticular or reticular). The dermis contains:

a) connective tissue (bundles of collagen, elastin, reticulin);

b) cellular elements (fibroblasts, histiocytes, plasmocytes, pigment cells, mast cells);

c) structureless intermediate (or basic) substance.

The dermis increases in size until the age of 16-30 due to the growth and thickening of collagen and elastin fibers. From the age of 60-70, the skin begins to thin.

The skin of children is characterized by abundant blood supply, which is due to a well-developed network of capillaries. There are 1.5 times more capillaries per unit of skin surface in a child than in an adult. Blood vessels form a superficial network in the skin located in the subpapillary dermis and a deep network at the border of the mesoderm with the hypodermis. In addition, the superficial vessels in a child (especially a newborn) are large and wide; arterial and venous capillaries have the same diameter, are located horizontally. From 2 to 15 years of age, differentiation of skin capillaries occurs: the number of wide capillaries decreases from 38 to 7.2%, and the number of narrow ones increases from 15 to 28.7%.

The vessels of the skin of an infant also differ in their response to thermal and cold stimuli. To both those and other stimuli, they respond with an extension with a long latent period and a longer duration. That is why in a cold room the child does not retain heat well (there is no vasoconstriction) and is easily supercooled. With age, along with the reaction of expansion, the reaction of vasoconstriction appears. By the age of 7-12, a two-phase reaction is fixed: first, narrowing, and then expanding.

The skin is richly supplied with nerves of the cerebrospinal (sensory) and autonomic (vasomotor and supplying the smooth muscles of the hair follicles and sweat glands) nervous system. Skin receptors are tactile Merkel cells located in the epidermis, Meissner bodies, Golgi-Mazzoni, Vater-Paccini, Ruffini, Krause flasks.

In the skin there are smooth muscle fibers located either in the form of bundles (muscles of the hair) or in the form of layers (muscles of the nipples, areola, penis, scrotum). But the younger the child, the less developed the muscles in the skin are.

The sebaceous glands located in the skin belong to the alveolar group. Each gland consists of lobules, its secret is formed due to the destruction of cells and is the result of degeneration of the epithelium; consists of water, fatty acids, soaps, cholesterol, protein bodies. Part of the sebaceous glands opens directly to the surface of the skin, part - to the upper section of the hair follicle. The sebaceous glands begin to function in utero immediately before birth, their secretion increases and their secret, together with particles of fatty degeneration of the surface layer of the epidermis, forms a lubricant. After birth, the function of the sebaceous glands decreases somewhat, but during the first year of life it remains quite high. A new increase in the function of the sebaceous glands is noted with the onset of sexual development and reaches a maximum by 20-25 years. This period is also characterized by increased "follicular keratinization" (achne vulgaris).

It should be noted that in the postnatal period there is no laying of new sebaceous glands, therefore, with age, their number decreases (per unit area) both due to an increase in the skin surface and due to the degeneration of some of them. At 1 cm. The surface of the skin of the nose accounts for 1360-1530 sebaceous glands in a newborn, 232-380 in 18-year-olds, and 112-128 in 57-76-year-olds.

The laying of the sweat glands occurs in the embryo, and by the time of birth, many sweat glands are already able to function. Structurally, the sweat glands take shape by the age of 5 months (before that, instead of the central hole there is a continuous mass of cells) and reaches full development by 5-7 years of age.

There are primitive (apocrine) sweat glands in the axillary and pubic regions and eccrine glands on the palms, soles and on the entire surface of the body. Moreover, only humans have eccrine glands on the body, while animals also have primitive glands. The eccrine apparatus of the body has exclusively thermoregulatory significance. The eccrine glands of the palms and soles, according to physiologists, reflect the emotional and intellectual activity of a person. In the process of evolution, these glands had an adaptive value (grasping, repulsion, for which it was necessary to wet the paws). Apocrine primitive sweat glands begin to function at pre- and pubertal age.

Sweating begins most often at the end of the 3rd-4th week, but is most pronounced by the 3rd month. With age, the total number of functioning sweat glands increases from 1.5 million at the age of 1 month to 2.5 million in boys 17-19 years old.

The main importance of the sweat glands in a child is thermoregulation. In a child of the first month of life per 1 kg. weight per day evaporates through the skin 30-35 g of water, and in a one-year-old - 40-45 g. The amount of sweat per unit area of skin in children is 2 times greater than in adults. Heat transfer through evaporation from 1 m of body surface per day at 1 month of age is 260 kcal, and by the year - 570 kcal. (respectively 40 and 57% of all heat losses). With excessive sweating, the child loses a lot of water and may become dehydrated.

Hair develops from the integumentary epithelium. They appear by the end of the 3rd month of intrauterine life and initially cover all the skin except for the palms and soles. This is fluffy, soft colorless hair. In the interval from 4 to 8 months of intrauterine development, long hair on the head and bristly hair on the eyebrows and eyelashes. A healthy full-term baby is born with moderate downy vegetation on the body (in premature babies, it is plentiful - lanugo). The rate of hair growth in newborns is 0.2 mm. per day. Hair growth is stimulated thyroid gland, therefore, there is insufficient hair growth (dry, brittle) with hypothyroidism and thick hair and eyebrows with hyperthyroidism. By the time of puberty, tertiary hair growth begins - the growth of pubic hair, in the armpits - this is sexual hair growth, depending on the androgenic function of the adrenal glands. Therefore, with hyperfunction of the adrenal glands, there may be phenomena of hirsutism (hypertrichosis).

Skin functions

The main features of the skin, on which the quality of its function depends, are: thinness of the stratum corneum, neutral reaction, good blood supply, looseness of the basement membrane, weak functional activity of the sweat glands in the first months and years of life, a gradual increase in the number of collagen and elastic fibers in the dermis.

1. The protective function of the skin.

The skin protects the deeper tissues and the child's body as a whole from mechanical, physical, chemical, radiation and infectious factors. However, the protective function of the skin in relation to mechanical influences is extremely imperfect, especially in newborns and children of the first year of life. This is due to the thinness of the stratum corneum (2-3 rows of cells), low tensile strength. The skin of a child is very sensitive to chemical irritants. This is due not only to the thinness of the stratum corneum, but also to the absence of the so-called acid mantle. The fact is that the pH of the skin of an adult is 3-3.5 (that is, the reaction is sharply acidic), and that of a child is 7 (neutral). The absence or weakness of the acid mantle of the skin predetermines its increased sensitivity of the child to water and alkaline solutions, so children do not tolerate ordinary soap and alkaline ointments (skin irritation occurs). The baby's skin also has weak buffering properties. In an adult, the pH of the skin is restored 15 minutes after washing, and in a child after a few hours. The same factors provide, along with a well-developed vascular network of the skin, good absorption of drugs when applied externally, on the skin. Therefore, with diaper rash, exudative diathesis, it is necessary to use ointments containing potent substances, hormones, antibiotics with great care and according to strict indications.

Its low bactericidal activity is also associated with the neutral reaction of the skin. The skin of a child is easily and quickly infected, and the presence of a wide network of skin capillaries contributes to the rapid generalization of the infection, its penetration into the bloodstream, that is, to sepsis. Local inflammatory reactions on the skin of a child are also peculiar.

Due to the friability of the main membrane located between the epidermis and the dermis, the infected epidermis is exfoliated with the formation of extensive blisters filled with serous-purulent contents (pemphigus - pemphigus). With abundant desquamation of the epidermis, exfoliative dermatitis (dermatitis exfoliafiva) develops in large areas. In adults, skin infection with staphylococcus occurs in the form of limited foci of suppuration (impetigo).

As for exposure to sunlight, the skin of an adult is protected from burns by a thick stratum corneum and the formation of a protective pigment - melanin. A child very easily gets thermal burns if the sun's rays are not properly used.

2. The respiratory function of the skin in infants is of great importance due to the thinness of the stratum corneum and rich blood supply. That is why it is especially important to monitor the condition of the skin with respiratory diseases and pneumonia. Children are prescribed hot therapeutic baths to expand the blood vessels of the skin and increase its respiratory function. In adults, this function is very insignificant, since the skin absorbs oxygen 800 times less than the lungs.

3. The function of thermoregulation in children is imperfect, which is associated with the thinness and tenderness of the skin, the abundance of blood capillaries, insufficiency of sweat glands, and underdevelopment of the central mechanisms of thermoregulation. Heat production occurs due to the release of energy in the process of metabolism and during muscle activity. Heat transfer is carried out by conduction of heat (convection) and by sweating. On the one hand, the child easily gives off heat due to thin skin and wide blood vessels. It has already been said above that the vessels of the skin react with expansion even to cooling. Therefore, it is easy to cool down. And this should be taken into account when controlling the temperature regime of the premises (+ 20-22.5 ° C) and organizing walks (clothing "according to the weather"). On the other hand, when high temperatures environment, heat transfer by conduction is practically unimportant. And sweating in the first weeks and months of life is not enough. Therefore, the child easily and overheats ("heat stroke"). To maintain body temperature, a child must generate 2-2.5 times more heat than an adult.

4. Vitamin formation function of the skin. Under the influence of ultraviolet rays, active anti-rachitic vitamin D 43 0 is formed from provitamin.

5. Histamine-forming function of the skin. Under the action of ultraviolet rays, histamine is also formed, which is absorbed into the blood. This property of the skin is used in the treatment of certain allergic diseases (for example, bronchial asthma, in which desensitization is carried out by irradiating individual areas of the skin).

6. Skin is a sense organ. It contains receptors for tactile, pain, temperature sensitivity.

Anatomical and physiological features

subcutaneous fat

Subcutaneous fat is detected in the fetus at the 3rd month of intrauterine life in the form of fat droplets in mesenchymal cells. But the accumulation of the subcutaneous fat layer in the fetus is especially intensive in the last 1.5-2 months of intrauterine development (from 34 weeks of pregnancy). In a full-term baby, by the time of birth, the subcutaneous fat layer is well expressed on the face, trunk, abdomen and limbs; in a premature baby, the subcutaneous fat layer is poorly expressed, and the greater the degree of prematurity, the greater the lack of subcutaneous fat. Therefore, the skin of a premature baby looks wrinkled.

With primary fat deposition, fat is dense (this is due to tissue elasticity) due to the predominance of dense fatty acids in it: palmitic (29%) and stearic (3%). This circumstance in newborns sometimes leads to the occurrence of sclerema and scleredema (hardening of the skin and subcutaneous tissue, sometimes with swelling) on the legs, thighs, buttocks. Sclerema and scleredema usually occur in immature and premature babies during cooling, accompanied by a violation of the general condition. In well-fed children, especially when they are removed with forceps, in the first days after birth, infiltrates appear on the buttocks, dense, red or cyanotic. These are foci of necrosis of fatty tissue resulting from trauma during childbirth.

With secondary fat deposition, the composition of fat approaches that of an adult, with different localization in boys and girls.

The expenditure of fat is determined by the tone of the sympathetic nervous system, so sympathicotonic children are rarely full. When fasting in the human body formed "hormones of hunger", which regulate the consumption of fat.

In more detail with the material of this section of the lecture

Plan and methodology for skin examination and

subcutaneous adipose tissue

I. The questioning includes an analysis of complaints, an anamnesis of the disease and life.

The most characteristic complaints in skin lesions are a change in its color (pallor, hyperemia, jaundice, cyanosis), the appearance of rashes of various nature, changes in skin moisture (dryness, sweating), itching. Lesions of the subcutaneous adipose tissue are characterized by complaints of weight loss, weight gain, the appearance of focal seals, and edema.

In order to clearly present the priority moments of the anamnesis of the life of patients with lesions of the skin and subcutaneous tissue, it is necessary to keep in mind the optimal list of the most common diseases and syndromes that have clinical symptoms from the skin and subcutaneous adipose tissue. AT pediatric practice this is:

allergic diseases (exudative-catarrhal and atopic diathesis, allergic dermatitis, neurodermatitis, eczema),

manifested by dry skin, weeping, itching, rash;

exanthemic infections (measles, measles and scarlatinal rubella, chickenpox, scarlet fever) and other infectious diseases (meningococcemia, abdominal and typhus, syphilis, scabies, infectious hepatitis), manifested by a rash, discoloration of the skin;
purulent-septic diseases, manifested by pyoderma, phlegmon, omphalitis, etc.;
diseases of the blood system (anemia, hemorrhagic diathesis, leukemia), manifested by pallor or yellowness of the skin and hemorrhagic rash;
congenital and acquired diseases of cardio-vascular system(carditis, heart defects), manifested by pallor, cyanosis, edema.

So, a typical plan for studying anamnesis in this case is implemented as follows:

1. Genealogical data revealed a family hereditary predisposition to allergic diseases, increased bleeding, obesity, cardiovascular pathology. Examples are eczema, hemophilia, congenital heart disease.

2. Information about the state of health of parents, their age, professional affiliation, social orientation will help to identify the factors that implement the genetic predisposition to certain diseases, or the causes of acquired diseases. Examples are occupational hazards that provoke allergic reactions.

3. Obstetric history of the mother - information about previous pregnancies, miscarriages, abortions, stillbirths suggests incompatibility between the mother and fetus for Rh- and other blood factors, intrauterine infection of the fetus of a woman who persists in the body of a cytomegalovirus, herpetic infection, syphilis, with hemolytic disease of the newborn or intrauterine hepatitis with icteric or anemic syndrome.

4. The course of pregnancy with this child, complicated by toxicosis, acute infections, exacerbation of chronic diseases, anemia in pregnancy can also reveal the alleged causes of anemia (pallor), jaundice, cyanosis, rashes in a child, since the fetus, infected, has undergone chronic hypoxia, intoxication can be born premature, immature, sick with anemia, heart disease, hepatitis, intrauterine infection, etc.

5. A complicated course of childbirth in the fetus can be clinically manifested by pallor (anemia) due to large blood loss in the mother, jaundice due to resorption of cephalohematoma or intraventricular hemorrhage, cyanosis, due to respiratory and cardiovascular disorders due to birth trauma of the central nervous system.

6. Violation of the sanitary and hygienic regimen when caring for a newborn child can cause prickly heat, diaper rash, pustular rash, pemphigus, omphalitis, phlegmon, pseudofurunculosis.

7. In postnatal life, irrational feeding and care, unfavorable material and living conditions as a reason deficiency anemia accompanied by pallor of the skin and contacts with patients with exanthemic and other infections accompanied by a rash.

Medical history provides an analysis of the dynamics skin manifestations, finding out their connection with previous diseases and contacts, with the nature of food, the effectiveness of previously used treatment.

II. Objective research:

Inspection skin should be carried out in a warm, bright (natural lighting is better) room, in side transmitted light. Infants and young children are undressed completely, and older children are gradually undressed as they are examined. Inspection is carried out in the direction from top to bottom. Particular attention is paid to the examination of skin folds (for auricles, in the armpits, inguinal regions, in the interdigital spaces, between the buttocks). The skin of the scalp, palms, soles, and the anus area is inspected. On examination, the following is assessed:

1. Skin color. Normally, in children, the color of the skin depends on the amount of skin pigment (melanin), the thickness of the stratum corneum, the degree of blood supply, that is, the number and condition of the skin capillaries, the composition of the blood (the content of erythrocytes and hemoglobin in it), the season and climatic conditions (the degree of skin irradiation ultraviolet rays), nationality. In healthy children, the skin color is usually uniformly pale pink, sometimes swarthy. In pathological conditions, there may be pallor of the skin, cyanosis, hyperemia, jaundice, a bronze hue of color.

2. In newborns, it is especially necessary to carefully examine the area of the umbilical ring and the umbilical wound. Up to 5-7 days, the remainder of the umbilical cord takes place in varying degrees of mummification (drying). Then it disappears and within 2 weeks the umbilical wound epithelializes. Until the moment of complete epithelialization from the umbilical wound, there may be a slight serous discharge (humidity). Under pathological conditions, there may be abundant serous-purulent discharge, hyperemia of the umbilical ring and abdominal wall, a pronounced venous vascular network in the umbilical region, which usually indicates infection of the umbilical wound (omfamitis, fungus, phlebitis of the umbilical veins, phlegmon of the navel and anterior abdominal wall).

3. When examining newborns, it is important to correctly assess the physiological changes in the skin: primordial lubrication, physiological catarrh (hyperemia), physiological jaundice, milia, physiological hyperkeratosis, physiological engorgement of the mammary glands.

4. In children, especially infants and young children, it is very important to identify skin changes that are characteristic of constitutional anomalies - diathesis. Distinguish:

seborrheic predisposition, characterized by dry skin, a tendency to peel (desquamation). Such skin is easily irritated by water and soap, but rarely becomes infected;
exudative (lymphophilic) predisposition, characterized by pallor, pastosity, moisture of the skin, which creates a false impression of the fullness of the child. These children often have weeping and skin infections;
angioedema predisposition, characteristic of older children. Such children are prone to goosebumps, urticaria, Quincke's edema, itching. The general neuropathic disposition of children is noted.

5. The degree of development of the venous vascular network. In healthy children, veins may only be visible on the upper chest in pubertal girls and in boys who play sports. In pathological conditions, the venous is clearly visible on the abdominal wall with cirrhosis of the liver (jellyfish head), on the head with hydrocephalus and rickets, on the upper back with an increase in bronchopulmonary nodes. At chronic diseases lungs, liver, may be " spider veins"(bugs, spiders) on the upper chest and back. It is necessary to distinguish from them angiomas - vascular tumors that can range in size from a few millimeters to several tens of centimeters and grow into the underlying tissues.

6. Only in pathological conditions a child can have rashes, ulcers, scars, cracks, diaper rash. When these elements are found, it is necessary to find out the time of their appearance, the dynamics of development.

Palpation the skin should be superficial, careful, and the doctor's hands should be warm, clean and dry. With the help of palpation, the thickness and elasticity of the skin, its moisture content, temperature are determined, endothelial tests are performed, and dermographism is examined.

To determine the thickness and elasticity of the skin, it is necessary to grab the skin (without subcutaneous fat) with the forefinger and thumb into a small fold in places where there is little subcutaneous fat layer - on the back of the hand, on the front surface of the chest above the ribs, in the elbow bend, then fingers must be removed. If the skin fold straightens immediately after the removal of the fingers, the elasticity of the skin is considered normal. If the smoothing of the skin fold occurs gradually, the elasticity of the skin is reduced.

Skin moisture is determined by stroking the skin with the back of the doctor's hand on symmetrical areas of the body. Determination of moisture on the palms and soles of prepubertal children is especially important; the appearance of increased moisture in these areas of the skin is called distal hyperhidrosis. Determination of skin moisture at the back of the head is of particular diagnostic importance in infants. Normally, the skin of a child has moderate moisture. In diseases, there may be dry skin, increased humidity and increased sweating.

To determine the condition of the blood vessels, especially their increased fragility, several symptoms are used: tourniquet, pinch, malleus. To carry out a pinch symptom, it is necessary to grab a skin fold (without a subcutaneous fat layer), preferably on the front or lateral surface of the chest, with the thumb and forefinger of both hands (the distance between the fingers of the right and left hands should be about 2-3 mm.) And shift its parts across the length of the fold in the opposite direction. The appearance of hemorrhages at the site of the pinch is a positive symptom.

Dermographism study is performed by passing from top to bottom with the tip of the index finger of the right hand or the handle of the hammer over the skin of the chest and abdomen. After some time, a white (white dermographism), pink (normal dermographism) or red (red dermographism) band appears at the site of mechanical irritation of the skin. The type of dermographism (white, red, pink), the speed of its appearance and disappearance, the size (spilled or unspilled) are noted.

When examining subcutaneous fat pay attention to:

development and distribution of subcutaneous adipose tissue;
indicators of physical development (normotrophy, underweight, overweight);
the presence of visual deformations, swelling, edema.

Palpation of subcutaneous fat involves the definition:

a) the thickness of the skin-subcutaneous fold (on the abdomen, chest, back, on the inner-back surface of the shoulder and thigh, on the face). But the guidelines are the following indicators: in infants on the stomach (in newborns 0.6 cm, at 6 months - 0.8 cm, by 1 year - 1.5-2 cm - up to 2.5 cm - according to A.F.Turu, in older children - at the level of the angle of the scapula 0.8-1.2 cm;

b) tissue turgor, which is determined by feeling (squeezing with the thumb and forefinger) a fold consisting of skin, subcutaneous fat and muscle on the inner surface of the thigh and shoulder;

c) the consistency of the subcutaneous fat layer. Premature and immature newborns may have scleroma (hardening of the subcutaneous fat) and scleredema (seal with swelling of the subcutaneous fat);

d) edema and its prevalence (on the face, eyelids, limbs. Edema can be general (anasarca) or localized). To determine edema in the lower extremities, it is necessary to press the index and middle fingers of the right hand in the shin area above the tibia. If, when pressed, a hole is obtained that disappears gradually, then this is a true edema. If the fossa does not disappear, then this indicates a "mucous" edema in hypothyroidism. In a healthy child, a fossa does not form.

Semiotics of skin color change

1. Paleness of the skin is a very characteristic symptom of many diseases. There are 10-12 shades of pallor. But healthy children can also be pale ("false pallor") due to the deep location of the skin capillaries. Such children are always pale both in the cold and when the temperature rises. In addition, in healthy people, pallor can be a manifestation of pronounced emotional reactions (fear, fright, anxiety) due to spasm of peripheral vessels. True pallor is most often associated with anemia, but even with a significant decrease in the number of red blood cells and hemoglobin, children turn pink when the temperature rises and in the cold. Other causes of pallor are: - spasm of peripheral vessels in kidney disease, hypertension; - exudative-lymphatic constitution, characterized by excessive hydrophilicity of tissues. At the same time, pallor has a matte tint, as well as with renal edema; - shock, collapse and other conditions with a sharp drop blood pressure, acute heart failure. In this case, pallor is accompanied by cold sweat and has a grayish tint; - acquired and congenital heart defects and a decrease in BCC in big circle circulatory failure mitral valve, stenosis of the left atrioventricular orifice, stenosis of the aortic orifice VSD, PDA, ASD. The decrease in the volume of circulating blood in these diseases is compensated by spasm of peripheral vessels; - acute and chronic intoxications (tonsillogenic, tuberculosis, helminthic, in diseases of the gastrointestinal tract, and others); - newborns immediately after birth may be pale as a result of deep ("white") asphyxia; - pallor is observed in blood diseases (leukemia, hemophilia, thrombocytopenia), oncological and collagen diseases due to anemia and intoxication.

2. Hyperemia (redness) of the skin. In addition to the physiological erythema of newborns, reddening of the skin in children occurs in inflammatory processes (erysipelas), some infectious diseases (scarlet fever), burns (solar, thermal), diaper rash, erythroderma, psycho-emotional arousal, fever.

3. Icteric staining of the skin is due to hyperbilirubinemia. It manifests itself when the level of bilirubin in the blood serum is above 160-200 mmol / l (the norm is up to 20 μmol / l). Jaundice is assessed in natural light and when pressure is applied to the skin with a glass.

Hyperbilirubinemia and impaired metabolism of bile pigments can be caused by: hemolysis of erythrocytes (hemolytic jaundice), damage to the liver parenchyma (parenchymal "hepatic" jaundice), impaired discharge of bile through the biliary tract when they are blocked (obstructive jaundice). The pathogenesis of hyperbilirubinemia in different variants of jaundice, of course, is different. During hemolysis of erythrocytes, a large amount of free hemoglobin is formed, then its porphyrin ring breaks up in the RES with the release of verdoglobin, from which iron is cleaved off and globin-bilirubin or indirect bilirubin is formed. In the liver, with the help of glucuronyl transferase, globin is cleaved off and indirect bilirubin is converted (conjugated) into direct bilirubin. Under normal conditions, healthy person during physiological hemolysis of erythrocytes, indirect bilirubin is formed a little, and with sufficient activity of glucuronyl transferase, it is completely conjugated. Direct bilirubin in the composition of bile through the biliary tract is excreted into the intestine, where it is converted into urobilinogen and stercobilin. With massive hemolysis, indirect bilirubin is not completely conjugated, therefore, in the patient's blood with laboratory research indirect bilirubin is detected. It is toxic, affects the reticuloendothelial and nervous systems (due to fat solubility) and primarily the nuclear substances of the brain with the development of hemolytic encephalopathy ("nuclear jaundice"). Part of the indirect bilirubin is still conjugated in the liver with the formation of direct bilirubin and the usual content of urobilinogen and stercobilin. Therefore, urine and feces during hemolysis have the usual color.

With lesions of the liver cells (hepatitis), the amount of direct bilirubin and urobilinogen bodies in the blood increases. Urine acquires an intense color (the color of "beer"). The stool may be discolored due to a deficiency in the formation of stercobilin.

With blockage of the biliary tract in the blood, the content of direct bilirubin is increased and the content of urobilinogen is reduced. Reduced content of bile pigments in the urine (light urine). The chair is also discolored.

From true jaundice, it is necessary to distinguish carotene pigmentation of the skin when drinking large amounts of carrot juice, pumpkin, oranges. The condition of the child does not suffer. The mucous membranes and sclera have the usual color. Jaundice of the skin can be when taking quinacrine, poisoning with picric acid ("false jaundice").

Causes of parenchymal jaundice:

acute and chronic infectious and inflammatory congenital and acquired liver diseases (hepatitis);
hepatodystrophy in case of poisoning and intoxication;
infectious diseases with toxic liver damage (sepsis, mononucleosis);
galactosemia.

Causes of obstructive jaundice:

4. Cyanotic staining of the skin. The appearance of cyanosis is associated with the accumulation in the blood of significant amounts of underoxidized hemoglobin or its pathological forms.

Normal pink skin tone in a healthy child depends on sufficient blood oxygenation and good cardiovascular activity. Therefore, cyanosis can occur with respiratory disorders of central and pulmonary origin, with cardiovascular diseases, as well as with the transition of hemoglobin to some pathological forms (methemoglobin, sulfhemoglobin) or with the accumulation of a large amount of hemoglobin associated with carbon dioxide.

The following pathogenetic groups of causes of cyanosis can be distinguished:

Cyanosis of "central" origin as a result of depression or paralysis of the respiratory center and paralysis of the respiratory muscles, resulting in hypoventilation of the lungs and hypercapnia. Such phenomena can be observed with ante- and intranatal asphyxia, with intracranial hemorrhage in newborns, with cerebral edema (infectious toxicosis, meningoencephalitis), craniocerebral trauma, and tumors.
Cyanosis of "respiratory" origin appears either as a result of a violation of the passage of air through the respiratory tract or as a result of a violation of the diffusion of gases in the alveolar membranes. Examples are aspiration of a foreign body, food, obstructive bronchitis and bronchiolitis, pneumonia, pulmonary edema, stenosing laryngotracheitis (croup), hydrothorax, pleural empyema, pneumothorax, exudative pleurisy.
Cyanosis of "cardiovascular" origin can arise from shunting of venous blood into the arterial bed in some congenital heart defects (2 or 3 chambered heart, transposition of the great vessels, common arterial trunk, tetralogy of Fallot). These are the so-called "blue" heart defects. With them, general cyanosis is expressed in a child from birth. In addition, cyanosis can occur with the development of cardiovascular decompensation and with other heart defects: mitral valve insufficiency, aortic stenosis, VDM and others, which are accompanied only by pallor during the compensation period. In these cases, it has acrocyanosis of a "stagnant" character.
Cyanosis of "blood" origin as a result of the formation of methemoglobin in case of poisoning carbon monoxide, some dyes.

More rare causes of cyanosis due to difficulty in breathing are spasmophilia, affective-respiratory attacks, volumetric processes in the mediastinum, diaphragmatic hernia, rib fracture, pharyngeal abscess.

Semiotics of rashes

Rashes can be primary (spot, papule, tubercle, nodule, nodule, blister, vesicle, bladder, abscess) and secondary, appearing as a result of the evolution of primary elements (scale, hyperpigmentation, depigmentation, crust, ulcer, scar, lichenization, lichenification, atrophy ). Primary elements can be cavitary, that is, having a cavity with serous, hemorrhagic or purulent contents (bladder, vesicle, abscess) and noncavitary (spot, papule, node, blister, tubercle).

The primary elements of the rash (see also textbook pp. 77-79):

1. Spot (macula) - a change in skin color in a limited area that does not rise above the surface of the skin and does not differ in density from healthy areas of the skin. Depending on the size, the following elements of a spotted rash are distinguished:

roseola - spotty rash up to 5 mm in size., roseola 1-2 mm in size. called punctate rash;
multiple spotty elements 5-10 mm in size. form small-spotted, and 10-20 mm in size. - large-spotted rash;
spots of 20 mm. and more is called erythema.

The listed elements are based on inflammatory changes in the skin and are due to the expansion of the vessels of the skin, therefore, when pressed, they disappear. Spotted rash is typical for measles, rubella, scarlet fever. But there may be spots caused by hemorrhages in the skin. Hemorrhagic rash is characteristic of hemorrhagic diathesis(hemorrhagic vasculitis, thrombocytopenia, hemophilia), meningococcemia, leukemia, sepsis. When pressed with glass, the elements of the rash do not disappear. These include:

petechiae - point hemorrhages with a diameter of 1-2 mm;
purpura - multiple hemorrhages 2-5 mm in size;
ecchymosis - hemorrhages with a diameter of more than 5 mm;
hematomas - large hemorrhages with a diameter of 20-30 mm. up to several centimeters, penetrating into the subcutaneous tissue.

2. Papule (papula) - an element that rises above the surface of the skin, ranging in size from 1 to 20 mm. Large papules are called plaques.

3. Tubercle (tubercullum) - a limited dense, cavityless element protruding above the surface of the skin, 5-10 mm in diameter, which is usually based on the formation of an inflammatory granuloma in the dermis. It is clinically similar to a papule, but is a denser formation and, with reverse development, often necrotic with an outcome in an ulcer or scar. These elements are characteristic of tuberculosis, leprosy, fungal skin lesions.

4. Knot (nodus) - dense, protruding above the surface of the skin and extending into its thickness, formation with a diameter of more than 10 mm. It can be both inflammatory and non-inflammatory in nature. In the process of evolution, it often ulcerates and scars. An example of nodes of an inflammatory nature is erythema nodosum (blue-red nodes, more often on the legs, painful on palpation), and non-inflammatory - fibroma, myoma.

5. Blister (urtica) - an acute inflammatory element, which is based on a limited swelling of the papillary layer of the skin, rising above the surface of the skin, with a diameter of 20 mm. and more. It is prone to rapid and reverse development, while leaving no traces (secondary elements). Urticarial rash is especially characteristic for allergic dermatoses, in particular, its most typical representative is urticaria.

6. Vesicle (vesicula) - a superficial cavity formation protruding above the surface of the skin, with serous or serous-hemorrhagic contents, 1-5 mm in diameter; in the process of evolution, it is successively replaced by a crust, after which a weeping surface of the skin remains, followed by its temporary depigmentation. Scars usually do not remain or they are shallow and disappear over time. If the vesicle becomes infected, then an abscess is formed - a pustule (pustulae). This is a deeper element and after it there is a scar.

Vesicular and pustular rashes are characteristic of chickenpox and smallpox, lichen lichen, eczema, staphylococcal pyoderma, herpetic infection.

7. Bubble (bulla) - cavity element 3-15 mm in size. and more. It is located in the upper layers of the epidermis and is filled with serous, hemorrhagic or purulent contents. After opening the bubble, crusts and unstable pigmentation form. Occurs with burns, acute dermatitis, Dühring's dermatitis herpetiformis, Ritter's exfoliative dermatitis.

Secondary elements of the rash:

1. Scale (sguama) - torn off horny plates of the epidermis larger than 5 mm. (leaf-like peeling), from 1 to 5 mm. (lamellar peeling) and the smallest (pityriasis peeling). Peeling is characteristic of the convergence of scarlet fever and measles rash, psoriasis, seborrhoea.

2. Crust (crusta) - is formed as a result of drying of the exudate of the bubbles. blisters and pustules. The crusts can be serous, purulent, bloody. In particular, crusts on the cheeks of a child with exudative-catarrhal diathesis are called milk scabs.

3. Ulcer (ulcus) - a deep skin defect, sometimes reaching the underlying organs. It occurs as a result of the collapse of the primary elements of the rash, with violations of blood and lymph circulation, injuries.

4. Scar (cicatrix) - coarse fibrous connective tissue that performs a deep skin defect, fresh scars are red, but then they turn pale.

Rashes in children can be at any age, they often have a decisive diagnostic value in many non-communicable and infectious diseases.

Semiotics of rashes in infectious diseases

Typhoid fever is characterized by a roseolous rash, pale pink in color with a favorite localization on the anterior abdominal wall.

With scarlet fever, the rash is small-pointed against a general hyperemic background of the skin, disappearing with pressure, located on the chest, trunk, buttocks, limbs, the most dense on the flexion surfaces of the limbs and in natural skin folds. There is no rash on the face, a pale nasolabial triangle and a bright blush of the cheeks stand out. After the disappearance of the rash, there is a large peeling of the feet and hands ("like gloves"). Other symptoms of scarlet fever are "flaming throat" (tonsillitis), "crimson" tongue, white dermographism.

With measles, the rash is spotted, polymorphic, differs in stages of the rash (face, trunk, limbs), disappears in the same order, leaving brown pigmentation and small pityriasis peeling. On the oral mucosa there is an enanthema and spots of Filatov-Belsky. Rashes are accompanied by severe catarrhal phenomena from the upper respiratory tract, conjunctivitis, photophobia.

For chickenpox a vesicular rash is characteristic, passing in its development a number of stages: papule-vesicle-crust-scar. The elements of chickenpox are different from the elements of smallpox. They are superficial (occupying only the epidermis), single-chamber vesicles, with serous contents, scars are shallow, 3-4 weeks after the disease they disappear due to the desquamation of the epidermis. With natural smallpox, the elements are located deep, they are multi-chamber with purulent contents, the scars are deep, remain for life.

With measles rubella, the rash is spotted, but smaller than with measles, located on the buttocks and extensor surfaces of the limbs, there is no clear staging of the rash, subsequent pigmentation and

peeling. The occipital lymph nodes are often enlarged.

The rash is also observed with scabies, syphilis, toxoplasmosis, psoriasis and others. skin diseases. You will get acquainted with them when studying the course of dermatovenereology.

Semiotics of rash in hemorrhagic diathesis

Hemorrhagic diathesis - diseases combined common symptom- bleeding. These include, in particular, hemophilia, thrombocytopenic purpura (Werlhof disease), hemorrhagic vasculitis (Schonlein-Genoch disease). Hemophilia (blood clotting disorder) is characterized by the appearance of large ecchymosis and hematomas at the slightest injury (hematoma type of bleeding). Thrombocytopenia is characterized by polymorphic hemorrhages - purpura and ecchymosis on the limbs, trunk, buttocks in combination with spontaneous nasal, uterine and other bleeding (petechial-spotted or microcirculatory type of bleeding). Hemorrhagic vasculitis is characterized by punctate hemorrhagic rash, mainly on the extremities in the joints, symmetrical, often with swelling and pain in the joints. Often there is an abdominal and renal syndrome due to a violation of the permeability of the vessels of the gastrointestinal tract and kidneys (vasculitic-purple type of bleeding).

Semiotics of rashes in allergic dermatitis

In children of the first year of life with exudative-catarrhal diathesis, dermatitis is manifested by the following symptoms:

persistent diaper rash in the natural folds of the skin, even with good care;
hyperemia and dryness of the skin of the cheeks, buttocks;
the presence of papular or vesicular-pustular rash on the cheeks and buttocks;
crusts formed as a result of drying of the exudate of the abdominal elements ("milk scab");
"gneiss" - dry skin and desquamation of the epithelium on the scalp;
pastosity of tissues.

In older children with allergic dermatitis, urticaria, urticaria, dry skin, white dermographism, itching, scratching are more often observed.

Semiotics of changes in humidity, temperature,

sensitivity, skin pigmentation, dermographism

Dry skin often accompanied by peeling and is characteristic of ichthyosis, hypovitaminosis A, B, hypothyroidism (myxedema), diabetes, scarlet fever.

high humidity occurs with rickets, chronic tuberculous intoxication, vegetative-vascular dystonia of the vagotonic type, neuropathy, a period of convalescence after infectious diseases and pneumonia (vagus-phase of the disease).

Skin temperature increased with overheating, infectious diseases, local inflammatory processes, mechanical injuries (abrasion), and reduced in children with dystrophy, exsicosis, with shock and collapse, after prolonged illness, with hypothermia.

Skin hyperesthesia characteristic of diseases of the central nervous system with increased intracranial pressure Key words: neurotoxicosis, hydrocephalus, meningitis, brain tumors, intracranial hemorrhages. Cutaneous hypoesthesia is characteristic of damage to the peripheral nervous system.

hyperpigmentation skin is characteristic of chronic adrenal insufficiency (Addison's disease), xanthomatosis, collagenosis, urticaria pigmentosa, measles.

Depigmentation skin is characteristic for vitiligo, leukoderma, striae. In addition, telangiectasias, nevi, angiomas, "Mongolian spots", birthmarks can be detected on the skin.

White dermographism characteristic of scarlet fever, hypertension, neuropathy, vegetovascular dystonia of the sympathicotonic type, meningitis.

Semiotics of hair change

Dry brittle hair is characteristic of hypothyroidism.

Sparse hair and general alopecia (alopecia) may be a congenital defect, but often develops secondarily under the influence of cytostatic and radiotherapy, after severe infectious (typhoid) and somatic diseases (lupus). In addition, hair loss is characteristic of trichophytosis, rickets (baldness of the back of the head). Focal alopecia, alopecia areata develops with fungal infections of the hair, tillium poisoning, neurosis, celiac disease.

Excessive hair growth (hypertrichosis) can be familial-constitutional or develop with hypercortisolism (including iatrogenic - with long-term treatment with corticosteroid drugs), mucopolysaccharidosis. Early secondary hair growth indicates endocrine pathology, premature puberty.

Semiotics of changes in subcutaneous fat

I. Hypotrophy - a disease clinically characterized by a decrease in the thickness of the subcutaneous fat layer (at I degree - on the abdomen, at II degree - on the abdomen and limbs, at III degree - on the trunk, limbs and face), varying degrees of decrease in skin elasticity and turgor fabrics. Hypotrophy of II and III degrees is characterized by a deterioration in appetite and emotional tone, a decrease in natural immunity, a tendency to infectious diseases and their long course. Depending on the severity of the disease, hypotrophy of the I degree with a mass deficit of 10-19%, hypotrophy of the II degree with a mass deficit of 20-29% and hypotrophy of the III degree with a mass deficit of more than 30% are distinguished.

II. Disorders (lack) of fat deposition are often caused by endocrine diseases:

1) hormonal dystrophy or paratrophy;

2) pituitary cachexia (insufficiency of the pituitary gland);

3) weight loss in hyperthyroidism and adrenal insufficiency.

III. Alimentary obesity:

1) fat is deposited evenly on the trunk and limbs;

2) a good state of muscle tone (although with obesity of the II degree there may be a decrease in muscle tone).

According to the percentage of excess weight from age standards, 4 degrees of obesity are distinguished: I degree - the weight exceeds the normal values for a given age and gender by 15-25%, II degree - by 26-50%, III degree - by 51-100%, IV degree - 100% or more.

IV. Diencephalic and endocrine obesity.

It develops with hypothyroidism, excessive function of the adrenal cortex. In this case, fat is deposited unevenly, mainly on the face, abdominal wall; limbs become thin.

Clinically, emaciation is expressed by thinning of the skin fold, and obesity by its thickening. The thickness of the skin fold at the level of the navel is as follows: by 3 months - 6-7 mm., by the year - 10-12 mm., at 7-10 years old - 7 mm., 11-16 years old - 8 mm. in boys and 12-15 mm. in girls.

Physiological features of the skin of a newborn baby

1. Primordial grease (vernix caseosae) - protects the skin from injury, reduces heat loss, has immune properties.

2. Milia - accumulation of secretion in the skin sebaceous glands(whitish-yellowish formations the size of millet grains on the wings and the tip of the nose).

3. Physiological catarrh of the skin of newborns - appears 1-2 days after birth and lasts 1-2 weeks, and in premature babies - much longer.

4. Physiological peeling (hyperkeratosis).

5. Physiological jaundice of the skin of a newborn as a result of physiological hemolysis of erythrocytes and insufficiency of the enzymatic activity of the liver (insufficiency of glucuronyltransferase).

Physiological jaundice appears on the 2nd day of life, increases until the 4th day and disappears by the 7th day. In premature babies, jaundice lasts up to 3-4 weeks. Newborn jaundice is characterized by the absence of acholic stools and intense staining of urine. Physiological jaundice occurs in 80% of newborns.

Skin changes in a newborn baby

1. Congenital changes:

a) telangiectasias - reddish-bluish vascular spots, localized on the back of the nose, on upper eyelids, on the border of the scalp and the back of the neck. Disappear without treatment by 1-1.5 years;

b) "Mongolian spots" - bluish spots in the area of the sacrum and buttocks in children of the Mongoloid race. Disappear by 3-5 years;

c) birthmarks - brown or bluish-brown, of any localization. They remain for life as a cosmetic defect.

2. Birth damage to the skin and subcutaneous tissue - abrasions, scratches, ecchymosis and more.

3. Acquired changes in the skin of a non-infectious nature (due to defects in care):

a) prickly heat - small dotted red rash, localized most often in the area of \u200b\u200bnatural folds on the skin of the body or

limbs. The appearance of prickly heat may be associated with insufficient

skin care or overheating of the newborn;

b) scuffs - occur more often in hyperexcitable newborns or with improper swaddling. Localized on the inner ankle, less often - on the neck. Manifested by limited hyperemia or weeping;

c) diaper rash - localized in the buttocks, inner thighs, natural folds and behind the ears. The cause of their occurrence may be defects in care or exudative-catarrhal diathesis. There are 3 degrees of diaper rash: I - moderate reddening of the skin without a visible violation of its integrity; II - bright redness with large erosions; III - bright redness of the skin and weeping as a result of merged erosions, the formation of ulcers is possible.

4. Infectious skin lesions:

a) Vesiculopustulosis is a disease of staphylococcal etiology, manifested by inflammation in the eccrine sweat glands. On the skin of the buttocks, thighs, head and in natural folds, small superficial vesicles with a diameter of up to several millimeters appear, filled at the beginning with a transparent, and then cloudy content. The flow is benign. Bubbles spontaneously open after 2-3 days, small erosions form, then dry crusts, after which there are no scars or pigmentation left.

b) Pemphigus of newborns (pemphigus) - has two forms - benign and malignant. With a benign form, erythematous spots appear on the skin, then vesicles and blisters 0.5-1 cm in diameter with serous-purulent contents. They are localized more often on the skin of the abdomen, near the navel, on the limbs and in natural folds. Bubbles spontaneously open without the formation of crusts. The body temperature of the newborn may be subfebrile, intoxication is insignificant in the form of anxiety or lethargy with a slowdown in weight gain. With active antibacterial and local therapy recovery occurs in 2-3 weeks. The malignant course is characterized by more pronounced intoxication, febrile temperature, neutrophilic leukocytosis with a shift of the formula to the left, an increase in ESR. Blisters on the skin are sluggish, 2-3 cm in diameter. The disease can result in sepsis.

c) Ritter's exfoliative dermatitis is the most severe form of staphylococcal pyoderma. It is clinically characterized by extensive erythematous spots and flaccid blisters, after the opening of which erosion and cracks remain. Expressed hyperthermia, intoxication, exsicosis, concomitant staphylococcal diseases (otitis media, omphalitis, conjunctivitis, pneumonia). The disease ends with sepsis.

d) Figner's pseudofurunculosis - damage to the sweat glands with the development of inflammatory infiltrates with purulent contents. Localized on the skin of the scalp, neck, back, buttocks. May be accompanied by hyperthermia, intoxication, reaction of regional lymph nodes and characteristic changes in the blood.

e) Mastitis of newborns - develops against the background of physiological engorgement of the mammary glands. It is clinically manifested by infiltration of the gland, hyperemia of the skin, soreness, intoxication. From the excretory ducts of the gland, when pressed or spontaneously, purulent contents are released. Possible metastatic purulent-septic complications.

f) Necrotic phlegmon of newborns - begins with the appearance of a red spot dense to the touch, then the spot increases in size, the inflammatory process passes to the subcutaneous tissue with its melting and subsequent rejection of dead skin and tissue. Healing proceeds through granulation and epithelialization with scarring. The disease is accompanied by intoxication, fever, metastasis of foci of infection.

g) Damage to the umbilical wound during infection is manifested by catarrhal and catarrhal-purulent omphalitis, navel ulcer, thrombophlebitis of the umbilical veins, gangrene of the umbilical cord (umbilical cord remnant). Catarrhal omphalitis is characterized by a serous discharge of the umbilical wound and a slowdown in its epithelization, the condition of the newborn is not disturbed. With catarrhal-purulent omphalitis, the lesion is more common (umbilical ring, subcutaneous fat, blood vessels), purulent discharge; there may be fever and symptoms of intoxication. An umbilical ulcer is a complication of omphalitis. Thrombophlebitis of the umbilical veins usually accompanies omphalitis or may be independent and is diagnosed by palpation of the elastic cord above the umbilicus. Gangrene of the umbilical cord begins in the first days of life and is caused by an anaerobic bacillus. The mummification of the umbilical cord residue stops, it becomes moist, acquires a dirty brown hue and exudes an unpleasant putrefactive odor. The falling off of the umbilical cord residue is late, a purulent discharge immediately appears in the umbilical wound. The condition of the patients is disturbed, hyperthermia, symptoms of intoxication, changes in blood tests are characteristic. Sepsis usually develops.

h) Streptoderma is manifested by the development of erysipelas, paronychia, intertriginous and papuloerosive streptoderma, vulgar ecthyma. The primary lesion in erysipelas is more often localized on the skin of the face or in the navel and quickly spreads to other areas of the skin; the disease begins with febrile temperature, chills, the appearance of local hyperemia and infiltration of the skin and subcutaneous fat. The edges of the lesion are scalloped, irregularly shaped, there is no delimiting ridge, the altered skin is warm to the touch, hyperesthesia is possible. The course of the disease is severe, the condition of children is rapidly deteriorating, the child becomes lethargic, refuses to breastfeed, dyspeptic disorders appear, myocarditis, meningitis and kidney damage appear. Paronychia is an infection of the nail folds caused by streptococci with stratification staph infection. Against the background of hyperemia and edema, blisters appear in the area of the nail folds, followed by the development of erosions. Possible regional lymphadenitis.

i) Mycosis of the skin - the causative agents are most often yeast-like fungi Candida albicans, causing the development of candidiasis of the oral cavity and tongue (thrush). Small islands of white color appear on the mucous membranes, loose, well removed with a swab. Subsequently, white raids are formed, then taking on a grayish, and sometimes a yellowish tint. Plaque can turn into a solid gray-white film. The condition of the newborn is not disturbed, however, with abundant thrush, there is often a deterioration in sucking and a decrease in weight gain, sometimes irritability appears.

Sanitary and epidemiological regime of the maternity hospital is carried out according to the Order of the Ministry of Health of the USSR N 55 of January 9, 1986 "On the organization of the work of maternity hospitals (departments)" and involves:

medical control over the state of health of staff (initial examination upon admission to work, scheduled examinations and daily inspections).
compliance with the sanitary and hygienic requirements for the premises of the maternity hospital (general cleaning, current and complete disinfection);
control over the implementation of sanitary and hygienic standards for the care of a newborn child (primary toilet for a newborn, care for a newborn in the wards of the department).

Primary toilet of the newborn

After the birth of the baby's head, mucus is aspirated from the upper respiratory tract of the newborn using an electric suction or a rubber balloon. The midwife puts the born child on a tray covered with a sterile diaper, placed at the feet of the mother. Before separating the child from the mother, he takes a pipette from the expanded package for the primary treatment of the newborn and, using cotton swabs (for each eye separately), holding the eyelids of the child, instills in the eyes, and for girls on the external genitalia, 2-3 drops of sulfacyl-sodium solution 30 %. The midwife then places one Kocher clamp on the umbilical cord at a distance of 10 cm from the umbilical ring and a second Kocher clamp at a distance of 8 cm from the umbilical ring. The section of the umbilical cord between the first and second Kocher clamps is treated by the midwife with a ball of 95% ethyl alcohol and crossed with scissors. A section of a child's umbilical cord stump is lubricated with a 1% iodonate solution. This is the primary treatment of the umbilical cord. The secondary processing of the umbilical cord is carried out by the Rogovin method: using a sterile gauze wipe, the umbilical cord residue is squeezed from the base to the periphery and wiped with a gauze ball with 95% ethyl alcohol. Then, an open clamp with a bracket previously inserted into it is pushed onto the umbilical cord residue so that the edge of the bracket is at a distance of 3-4 mm. from the skin edge of the umbilical ring. Next, the clamp is closed until it snaps into place, opening again, and removed. With sterile scissors, the umbilical cord is cut off at a distance of 3-5 mm. from the top edge of the bracket. The cut surface, the base of the umbilical cord and the skin around the umbilical residue are treated with a cotton swab moistened with a 5% potassium permanganate solution. After that, a sterile gauze bandage - a triangle - is applied to the umbilical residue. Then they move on to primary processing skin: with a sterile cotton swab moistened with sterile vegetable or vaseline oil from an individual bottle opened before treating the child, the midwife removes blood, primordial lubricant, mucus, meconium from the head and body of the child with light movements. After treatment, the skin is dried with a sterile diaper. Then the child, wrapped in another sterile diaper, is weighed on a tray scale. The weight of the diaper is subtracted. The measurement of the child is carried out using a sterile tape.

The degree of development of subcutaneous fat is determined by the method of palpation (palpation) and consists in measuring the thickness of the skin fold, which is formed when the skin is captured with the thumb and forefinger.

In the region of the lower third of the shoulder along the back surface;

On the anterior abdominal wall at the level of the navel along the edge of the rectus abdominis muscles;

At the level of the angles of the shoulder blades;

At the level of costal arches;

On the front of the thigh.

With a skin fold thickness of 1-2 cm, the development of the subcutaneous fat layer is considered normal, less than 1 cm - reduced, more than 2 cm - increased.

Attention is also drawn to the nature of the distribution of the subcutaneous fat layer. Normally, it is distributed evenly (the thickness of the skin fold is almost the same in different parts of the body). With uneven distribution of the subcutaneous fat layer, it is necessary to indicate the places of increased fat deposition.

9. Edema: varieties by origin and mechanism of development. Characteristics of cardiac and renal edema. Methods for detecting edema.

Edema is an excessive accumulation of fluid in the tissues of the body and serous cavities, manifested by an increase in the volume of tissues or a decrease in the capacity of serous cavities and a disorder in the function of edematous tissues and organs.

Edema can be local (local) and general (common).

There are several degrees of edema:

Latent edema: not detected during examination and palpation, but are detected by weighing the patient, monitoring his diuresis and McClure-Aldrich test.

Pastosity: when pressing with a finger on the inner surface of the lower leg, a small hole remains, which is caught mainly by touch.

Explicit (pronounced) edema: the defiguration of the joints and tissues is clearly visible, and when pressed with a finger, a clearly visible fossa remains.

Massive, widespread edema (anasarca): accumulation of fluid not only in the subcutaneous fat of the trunk and extremities, but also in the serous cavities (hydrotorox, ascites, hydropericardium).

The main reasons for the development of edematous syndrome:

1) an increase in venous (hydrostatic) pressure - hydrodynamic edema;

2) decrease in oncotic (colloid-osmotic) pressure - hypoproteinemic edema;

3) violation of electrolyte metabolism;

4) damage to the walls of capillaries;

5) violation of lymphatic drainage;

6) drug-induced edema (minerocorticoids, sex hormones, non-steroidal anti-inflammatory drugs);

7) endocrine edema (hypothyroidism).

Edema of cardiac origin. At in a patient with heart failure, edema is always localized symmetrically. Initially, swelling of the feet and ankles is formed, which after a night's rest can completely disappear. The swelling gets worse towards the end of the day. As heart failure progresses, the legs swell, then the thighs. In bedridden patients, edema of the lumbosacral region appears. The skin over the edema is tense, cold, cyanotic. Edema is dense, when pressed with a finger, a hole remains. In the process of progression of heart failure, ascites, hydrotorox may appear. Trophic changes in the skin in the area of the legs are often detected in the form of increased pigmentation, exhaustion, cracking, and the appearance of ulcers.

Edema of renal origin.

Renal edema is of two types:

1) nephritic edema - formed quickly and localized mainly on the face, less often on the upper and lower extremities; first of all, tissues rich in blood vessels and loose fiber swell;

2) nephrotic edema - one of the manifestations of nephrotic syndrome, which is characterized by hypoproteinemia, dysproteinemia, hypoalbuminemia, hyperlipidemia, massive proteinuria (more than 3 g / day); nephrotic edema develops gradually, at first the face swells after a night's rest, then the legs, lower back, anterior abdominal wall swell, ascites, hydrothorax, anasarca may occur.

Renal edema is pale, soft, pasty, sometimes shiny, easily mobile.

Methods for detecting edema:

1) inspection;

2) palpation;

3) daily determination of body weight, measurement of diuresis and its comparison with the volume of fluid consumed;

4) a test for the hydrophilicity of McClure-Aldrich fabrics.

Technique and normal parameters of the test for tissue hydrophilicity: 0.2 ml of physiological NaCl solution is injected intradermally into the region of the inner surface of the forearm. With a pronounced tendency to edema, the resorption of the blister occurs within 30-40 minutes instead of 60-90 minutes in the norm.

SUBCUTANEOUS ADIPOSE FIBER - loose connective tissue with fatty deposits that connects the skin to deeper tissues. It forms subcutaneous cellular spaces, in which there are end sections of sweat glands, vessels, lymph nodes, skin nerves.

Anatomy and histology

The basis of the PZhK is made up of connective tissue fibrous cords formed by bundles of collagen fibers mixed with elastic fibers (see Connective tissue), originating in the reticular layer and going to the superficial fascia, which delimits the PZhK from the underlying tissues (proper fascia, periosteum, tendons). According to the thickness, fibrous cords of the 1st, 2nd and 3rd order are distinguished. Between the strands of the 1st order there are thinner strands of the 2nd and 3rd order. The cells, bounded by fibrous cords of various orders, are completely filled with lobules of adipose tissue that form fatty deposits (panniculus adiposus). The structure of PLC determines its mechanical properties - elasticity and tensile strength. In places subject to pressure (palm, sole, lower third buttocks), thick fibrous strands predominate, penetrating the subcutaneous tissue perpendicular to the surface of the body and forming skin retainers (retinacula cutis), which tightly fix the skin to the underlying tissues, limiting its mobility. Similarly, the skin of the scalp is connected to the tendon helmet. Where the skin is mobile, fibrous bands are located obliquely or parallel to the surface of the body, forming lamellar structures.

In the body of an adult, they average approx. 80% of the total mass of pancreas (the percentage varies greatly depending on age and gender and body type). Adipose tissue is absent only under the skin of the eyelids, penis, scrotum, clitoris and labia minora. Its content is insignificant in the subcutaneous base of the forehead, nose, outer ear, lips. On the flexor surfaces of the limbs, the content of adipose tissue is greater than on the extensor ones. The largest fat deposits are formed on the abdomen, buttocks, in women also on the chest. There is a close correlation between the thickness of the SFA in various segments of the limbs and on the trunk. The ratio of the thickness of the pancreas in a man and a woman is on average 1: 1.89; its total weight in an adult man reaches 7.5 kg, in a woman 13 kg (respectively 14 and 24% of body weight). In old age, the total mass of adipose tissue under the skin decreases and its distribution becomes disproportionate.

In some parts of the body, muscles are located in the pancreas, during the contraction of which the skin in these places gathers into folds. Striated muscles are located in the subcutaneous tissue of the face [facial muscles (facial muscles, T.)] and neck (subcutaneous muscle of the neck), smooth muscles - in the subcutaneous base of the external genital organs (especially in the fleshy membrane of the scrotum), anus, nipple and areola mammary gland.

The pancreas is rich in blood vessels. Arteries, penetrating into it from the underlying tissues, form a dense network on the border with the dermis. From here, their branches go in fibrous cords and divide into capillaries surrounding each fatty lobule. In the pancreas, venous plexuses are formed, in which large saphenous veins are formed. Limf, PZhK vessels originate in deep limf, networks of skin and go to regional limf, nodes. The nerves form a wide-loop plexus in the deep layer of the pancreas. Sensitive nerve endings are represented in the subcutaneous tissue by lamellar bodies - bodies of Vater - Pa-chini.

Physiological significance

Functions of PZhK are diverse. The external shape of the body, turgor and skin mobility, the severity of skin furrows and folds largely depend on it. PZhK is the energy depot of the body and is actively involved in fat metabolism; it plays the role of a thermal insulator of the body, and brown fat, found in fetuses and newborns, is an organ of heat production. Due to its elasticity, the PZHK performs the function of a shock absorber of external mechanical influences.