1

adreuli asakis bavSvis

fizikuri ganviTareba da misi

Sefaseba

klinikuri praqtikis erovnuli rekomendacia

(gaidlaini)

2

klinikuri praqtikis erovnuli rekomendacia (gaidlaini)

`adreuli asakis bavSvis fizikuri ganviTareba da misi

Sefaseba~ miRebulia klinikuri praqtikis erovnuli

rekomendaciebis (gaidlainebi) da daavadebaTa marTvis

saxelmwifo standartebis (protokolebi) SemuSavebis,

Sefasebis da danergvis erovnuli sabWos 2008 wlis 5

noembris #1 sxdomaze da damtkicebulia saqarTvelos

Sromis, janmrTelobisa da socialuri dacvis ministris

2009 wlis 14 aprilis # 155/o brZanebiT.

3

adreuli asakis bavSvis fizikuri ganviTareba da misi Sefaseba

definicia

fizikuri ganviTareba zrdis dinamikuri procesia, romelic

gulisxmobs sxeulis masis, sigrZis, Tavis da gulmkerdis

garSemowerilobebis matebas, sxeulis proporciis cvlilebas da

bavSvis orgnizmis biologiur momwifebas.

bavSvis zrdis procesze, gansakuTrebiT sicocxlis pirveli wlebis

ganmavlobaSi mravali faqtori axdens gavlenas, kerZod, genetika,

prenataluri periodis mimdinareoba, kveba, fizikuri aqtivobis

xarisxi, garemo faqtorebi da sxv.11,12.

bavSvis fizikuri ganviTarebis Sefaseba pediatriuli meTvalyureobis

erT-erTi ZiriTadi komponentia, vinaidan bavSvTa asakis nebismieri

problema (fsiqologiuri, interpersonaluri, socialuri) aisaxeba

zrdis procesze12.

bavSvis zrdis procesze meTvalyureobis mizania13,14:

• fizikuri ganviTarebis Sefaseba

• riskis jgufis gamoyofa;

• zrdis darRvevebis drouli identifikacia, adekvaturi

marTva da referali;

• zrdis Seferxebis prevencia;

• zrda-ganviTarebis xelSewyoba.

wonis, sigrZe/simaRlis, Tavis garSemowerilobis Sefaseba

pediatriuli pacientis gasinjvis mniSvnelovani komponentia

(rekomendacia C)56.

gaidlaini gankuTvnilia

⇒ samedicino personalisTvis, romelic muSaobs adreuli asakis

bavSvebTan samSobiaro saxlSi, jandacvis pirvelad rgolsa da

stacionarSi – neonatologebis, pediatrebis, ojaxis eqimebis,

axalSobilTa da patronaJis meddebisTvis.

gaidlainis samizne jgufi:

⇒ adreuli asakis bavSvebi.

epidemiologia

janmrTelobis msoflio organizaciis monacemebiT yovelwliurad

ibadeba 26 milioni mcire wonis axalSobili, rac ganpirobebulia

erTi mxriv orsulTa daavadebebiT, meore mxriv ki – orsulobis

periodSi kvebis deficitiT. ganviTarebad msoflioSi 230 milion

skolamdeli asakis bavSvs (43%) uvlindeba zrdis Seferxeba kvebis

C

4

deficitis an sxvadasxva daavadebebis gamo. savaraudod miaCniaT, rom

malnutriciis gamo weliwadSi SeiZleba daiRupos 7 milioni bavSvi,

sikvdilis mizezia uSualod wonis deficiti an mis fonze

ganviTarebuli paTologiebi1.

ukanasknel periodSi Tavi iCina simsuqnis problemam, rac

gansakuTrebiT TvalSi sacemia ganviTarebul qveynebSi. 1998 wels

janmrTelobis msoflio organizaciam simsuqne gamoacxada globalur

epidemiad2. 1981 wlidan kanadaSi Warbi wonisa da simsuqnis mqone 7-13

wlis bavSvTa raodenoba Sesabamisad gaormagda da gasammagda3.

aseTive tendencia SeimCneva did britaneTSi4. aSS-Si simsuqnes bavSvTa

da mozardTa nutriciul daavadebaTa Soris pirveli adgili

uWiravs5,6. msoflios masStabiT simsuqne iqca sazogadoebrivi

jandacvis pirveli rigis problemad, man Caanacvla wonis deficiti7.

es tendencia SemaSfoTebelia, radgan simsuqne Tavis mxriv zrdis

kardiovaskuluri daavadebebis, hipertoniis, II tipis Saqriani

daibetis ganviTarebis risks6,8-10.

fizikuri ganviTarebis gamokvlevisa da Sefasebis meTodebi

bavSvis fizikur ganviTarebas ikvleven SexedviT _ inspeqciiT anu somatoskopurad da gazomviT anu somatometrulad1,15:

• somatoskopia _ sxeulis aRnagobis, misi proporciebis, gulmker-

dis da kidurebis formis, kunTovani da cximovani

qsovilis ganviTarebis Sefaseba.

• somotometria anu anTropometria _ bavSvis wonis,

sigrZe/simaRlis, Tavis, kidurebis garSemowerilobis

da sigrZis gansazRvra.

bavSvis anTropometruli monacemebis erTjerad gamokvlevas erTmomen-

tiani, anu statikuri, erTi da igive parametris periodul Sefasebas

ki - dinamikuri kvleva ewodeba.

bavSvis zrda-ganviTarebaze meTvalyureoba unda warmoebdes

dinamikaSi, vinaidan erTjeradi Sefaseba SeiZleba gaxdes

anTropometruli maxasiaTeblebis araswori interpretaciis mizezi.

fizikuri ganviTarebis meTvalyureobis etapebia:

• anTropometria – sxeulis masis, sigrZe/simaRlis, Tavis da

mxris garSemowerilobis maCveneblis dadgena;

• monacemebis dafiqsireba bavSvis ganviTarebis istoriaSi;

• miRebuli monacemebis interpretacia;

• fizikuri ganviTarebis darRvevis SemTxvevaSi mizezis

identificireba, saWiroebisas damatebiTi gamokvleva,

saTanado mkurnaloba da referali;

• mSobelTa konsultireba bavSvis zrda-ganviTarebis

sakiTxebze.

5

fizikuri ganviTarebis ZiriTadi maxasiaTeblebis cvlileba bavSvTa asakSi

wonis dinamika12,15,16

axalSobili:

drouli axalSobilis wona meryeobs 2500-4000g Soris. dabadebis

wonis mixedviT janmrTelobis msoflio organizacia gamoyofs mcire

wonis axalSobilebs – dabadebis wona 1500-2500g da Zlier mcire

wonis axalSobilebs – dabadebis wona <1500g.

axalSobilis dabadebis wona misi saSvilosnosSiga ganviTarebis

indikatoria. igi erTi mxriv gansazRvravs, Tu ra tipis movla

esaWiroeba axalSobils, meore mxriv warmoadgens momavalSi bavSvis

janmrTelobis da ganviTarebis prognozul markers. dabadebis wonis

mixedviT gamoyofen gestaciuri asakis Sesabamisi, gestaciur asakTan

SedarebiT mcire da didi masis axalSobilebs. gestaciur asakTan

SedarebiT didi masis mqone axalSobilebSi maRalia samSobiaro

travmis, hipoglikemiis, perinataluri asfiqsiis ganviTarebis riski;

gestaciur asakTan SedarebiT mcire masis mqone axalSobilebSi ki

xSiria sxvadasxva organos morfofunqciuri umwifroba, dismetabo-

lizmi, asfiqsia/hipoqsia, respiratorul distres sindromi, Tanda-

yolili anomaliebi, saSvilosnosSiga infeqcia da sxva, ris gamoc

mocemul jgufSi peri- da neonataluri sikvdilianoba 3-4-jer metia

normaluri masis axalSobilebTan SedarebiT.

sicocxlis pirvel dReebSi axalSobilTa umravlesobas aReniSeba

wonis fiziologiuri kleba saSualod sxeulis masis 7%-iT

(mtkicebulebis done II).17-19 droul axalSobilebSi wonis danaklisi

ar unda aRematebodes 10%-s16, dRenaklulebSi 12%-s. wonis

fiziologiuri klebis ZiriTadi mizezia wylis dakargva kanis, fil-

tvebis, Tirkmlebisa da nawlavebis gziT, xolo misi intensivoba

damokidebulia axalSobilis masaze, sqesze, sameano da samSobiaro

paTologiaze, garemos temperaturasa da tenianobaze, axalSobilis

kvebis reJimze da sxv.

wonis dakleba 10%-ze metad saWiroebs damatebiT gamokvlevas

paTologiis gamosaricxad. wonis Warbi klebis uxSiresi mizezebia:

• kvebis darRveva;

• infeqcia;

• Tandayolili anomaliebi (mag.: gulis Tandayolili manki).

axalSobilTa masis Semcireba maqsimums aRwevs me-2-3 dRes, mesame

dRis Semdeg kleba wydeba da me-5 dRidan iwyeba masis mateba

(mtkicebulebis done II)17

, me-5 dRidan yoveldRiuri namati

daaxloebiT Seadgens 20-35 grams (mtkicebulebis done I)20.

axalSobilTa nawili me-10 dRes aRidgens dabadebis wonas, Tumca

SesaZlebelia wona aRdges SedarebiT mogvianebiT me-12-14 dReze.

(mtkicebulebis done II)17. Semdeg grZeldeba misi mateba. pirveli

Tvis ganmavlobaSi bavSvebi SedarebiT naklebs imateben wonaSi

II

II

I

II

6

(saSualod 600 g). pirveli Tvis ganmavlobaSi wonis namati ar unda

iyos 500 g-ze naklebi (mtkicebulebis done I, II)20,21.

Cvili da adreuli asakis bavSvi:

wonis matebis intensivoba pirveli wlis ganmavlobaSi araTanabaria.

sicocxlis me-2-dan me-6 Tvis CaTvliT Cvili imatebs daaxloebiT 700-

800 grams TveSi. Tu bavSvi imyofeba ZuZuTi kvebaze wonis minimaluri

namati Tvis ganmavlobaSi unda iyos 500 g. 6 Tvidan 1 wlamde Cvili

yovelTviurad 400 grams imatebs15.

Cveulebriv drouli axalSobilis wona, romlis dabadebis masa

Seesabameboda gestaciur asaks, ormagdeba 4.5-5 Tvis da sammagdeba

erTi wlis asakSi. Semdeg wonis namati yovelwliurad daaxloebiT 2

kg-s Seadgens, wonaSi mateba gansakuTrebiT intensiuria pre- da

pubertul periodSi.

dabadebis mcire da Zlier mcire wonis bavSvTa anTropometruli

monacemebis dinamikis Tavisebureba

dabadebis mcire da Zlier mcire wonis axalSobilebis wonis dinamika

gansxvavebulia. maT axasiaTebT ganviTarebis SedarebiT swrafi tempi

(e.w. ”catch up growth”). maTi fizikuri ganviTarebis Sefasebisas saWiroa

asakis koreqtireba. amisaTvis faqtobriv (postnatalur) asaks akldeba

kvirebis is raodenoba (40 kvira _ bavSvis gestaciuri asaki), romelic

aklia axalSobils normalur gestaciur asakamde22,23. mag.: gestaciis

32 kviraze dabadebuli amJamad 5 Tvis (daaxloebiT 20 kviris) bavSvis

“koreqtirebuli” asaki Semdegnairad iTvleba: dabadebisas mas aklda

8 kvira (40-32=8). “koreqtirebuli” asaki = 20 kviras – 8 kvira = 12

kviras. anu am bavSvis anTropometruli maCveneblebi unda

Seesabamebodes 12 kviris (daaxloebiT 3 Tve) bavSvis maCveneblebs.

mas Semdeg rac anTropometruli maCveneblebi gautoldeba asakobriv

maCveneblebs (anu normas), asakis koreqtireba ar aris saWiro. Tavis

garSemoweriloba eweva normas daaxloebiT 18 Tvis asakSi, wona - 24

Tvis asakSi, simaRle 40 Tvis asakSi. zogierTi Zlier mcire wonis

axalSobili ver eweva normalur maCveneblebs skolis asakamde23.

sigrZe/simaRle 12,15

sicocxlis pirveli weli

pirveli wlis ganmavlobaSi axalSobilis sigrZis namati saSualod

25 sm-s Seadgens. wlis pirvel meoTxedSi sigrZeSi mateba

yovelTviurad 3 sm-ia, meore meoTxedSi – 2.5 sm, mesameSi – 2 sm,

meoTxeSi ki – 1 sm.

adreuli asakis bavSvebi

1 wlis Semdeg simaRleSi zrdis tempi neldeba. axalSobilTa

dabadebis sigrZe mxolod 4 wlis asakSi ormagdeba da saSualod 100

sm-s Seadgens, xolo 12 wlis asakSi sammagdeba. sicocxlis meore

I II

7

wlis ganmavlobaSi bavSvi imatebs 10-12 sm-s, mesame wels – 7-8 sm-s,

Semdeg yovelwliurad saSualo namati – 5-6 sm-s Seadgens. amasTan

erTad, vlindeba simaRlis 2 mkveTri e.w. maqsimaluri matebis periodi.

4-6 wlis asakSi da pubertatul periodSi.

bavSvis simaRleSi zrdis intensivoba da misi saboloo maCvenebeli Zi-

riTadad genetikuri faqtoriTaa ganpirobebuli, Tumca mniSvnelovania

garemo faqtorebis gavlenac. postnatalur periodSi zrdis process

aregulirebs endokrinuli sistema. gansakuTrebiT mniSvnelovania

hipofizis mier producirebuli somatotropuli anu zrdis hormoni,

farisebri jirkvlis hormonebi da insulini. 2 wlamde asakSi zrdis

procesi naklebad aris damokidebuli somatotropuli hormonis

Semcvelobaze62. garemo faqtorebi, kerZod, kvebis deficiti, misi

mniSvnelovani disbalansi, Seucvleli aminomJavebisa, vitaminebis (A, D) da mikroelementebis (kalciumi, rkina, TuTia, iodi),) nakleboba

iwvevs bavSvis zrdis SeCerebas. zrdis procesis, iseve rogorc

Zvlovani da kunTovani sistemis ganviTarebis umniSvnelovanes

mastimulirebel faqtors moZraobiTi aqtivoba warmoadgens12,15,56.

Tavis garSemoweriloba12,15,23

drouli axalSobilis Tavis garSemoweriloba 34-36 sm-ia. pirveli

wlis ganmavlobaSi Tavis garSemoweriloba 10-11 sm-iT imatebs.

Tavis garSemowerilobis gansazRvra gansakuTrebiT mniSvnelovania 2

wlamde asakis bavSvebSi, vinaidan misi garkveuli maCveneblebi da

matebis tempis darRveva miuTiTebs sxvadasxva paTologiis arsebobaze

(mikrocefalia, hidrocefalia da sxv).

sxeulis proporciebi12,15

mcire asakis bavSvis sxeulis proporciebi gansxvavdeba mozrdilis

sxeulis proporciebisagan, Tavi SedarebiT didia, kidurebi ki mokle.

bavSvis sxeulis calkeuli nawilis zrda araTanabarzomieria. qveda

kidurebi izrdeba 5-jer, zeda kidurebi – 4-jer, tani – 3-jer, xolo

Tavi 2-jer.

Tavis, tanisa da kidurebis araTanabarzomieri zrdis gamo sxeulis

Sua wertili qvemoT inacvlebs. dRenakluli axalSobilis sxeulis

Sua wertili Wipis zemoT, droulis – Wipis doneze, 6 wlis asakSi -

Wipsa da simfizs Soris, xolo 12-13 wlis asakisTvis simfizis doneze

mdebareobs.

kbilebis ganviTareba12,15

sarZeve kbilebis amoWra iwyeba 6-8 Tvis asakSi, pirvelad amoiWreba

qveda Sua saWreli kbilebi. kbilebis amoWris vadebi mocemulia

sqemaze. 2 wlis asakis bavSvs 20 sarZeve kbili aqvs. or wlamde

kbilebis raodenobis gamosaangariSeblad iyeneben formulas: n – 4, sadac n _ Tveebis ricxvia.

8

mudmivi kbilebis amoWra iwyeba 6 wlis asakSi.

anTropometria:

anTropometruli monacemebis gansazRvrisas metad mniSnvelovania

sizustis dacva, radgan am maCveneblebs xSir SemTxvevaSi efuZneba

klinikuri gadawyvetilebebi da intervencia.

9

anTropometruli monacemebis sizustes gansazRvravs 3 ZiriTadi

komponenti:

• gazomvis teqnika (unificirebuli meTodi)

• aRWurviloba (maRali sizustis)

• momzadebuli specialisti

samedicino personalma, romelic awarmoebs antropometrias unda

icodes, ramdenad mniSvnelovania aRWurvilobis kalibrireba yoveli

manipulaciis win, standartuli teqnikis gamoyeneba da monacemebis

sizuste, rac mniSvnelovania maxasiaTeblebis swori

interpretaciisTvis.

janmrTel bavSvze zedamxedvelobis aucilebel komponents

warmoadgens misi wonisa da sigrZe/simaRlis monitoringi da

miRebuli maCvneblebis dafiqsireba samedicino dokumentaciaSi.

(mtkicebulebis done IV) 24.

wonis gansazRvra25,26

awonvisaTvis gamoiyeneba meqanikuri da/an eleqtrosaswori. adreuli

asakis bavSvi iwoneba specialur horizontalur sasworze (suraTi 1,

2), romlis sizuste ±10 grams Seadgens, mozrdil bavSvi ki - Cve-

ulebriv samedicino sasworze, romlis sizustea +100 grami.

Cvili bavSvi mizanSewonilia aiwonos SiSveli, tansacmlis gareSe, an

ecvas mxolod sufTa erTjeradi safeni. tansacmliT an “Zveli”

safeniT Cvilis awonva masis araswori maCveneblis erT-erTi yvelaze

xSiri mizezia. mozrdili bavSvi unda aiwonos fexSiSveli da

tansacmlis gareSe (unda ecvas mxolod sacvali), awonva

mizanSewonilia dRis erTsa da imave monakveTSi, ufro xSirad diliT,

uzmoze, moSardvisa da defekaciis Semdeg.

bavSvi unda moTavsdes sasworis TefSis Sua nawilze, imisda

miuxedavad, Tu romeli sasworia gamoyenebuli. awonva mizanSewonilia

Catardes orjer. Cvilobis asakSi awonvis Sedegad miRebul or

maCvenebels Soris dasaSvebia sxvaoba 10, erTi wlis zemoT ki - 100

suraTi 1 suraTi 2

IV

10

gramamde. bavSvis masis dasadgenad gamoiyeneba 2 gazomviT miRebuli

maCveneblis saSualo ariTmetikuli. Tu 2 maCvenebels Soris sxvaoba

aRemateba dasaSveb asakobriv normas, mizanSewonilia awonva mesamed

Catardes. bavSvis zusti wonis dasadgenad 3 maCvenebels Soris unda

airCes 2 erTmaneTTan miaxlovebuli da ganisazRvros maTi saSualo

ariTmetikuli.

Tu bavSvi Zalian aqtiuria, awonva unda gadaidos, sanam igi ar

damSviddeba. Tu SeuZlebelia bavSvis marto awonva misi zedmeti

aqtiurobis gamo, mizanSewonilia awonvis alternatiuli meTodis

gamoyeneba:

• eleqtrosasworze xdeba mSoblis da bavSvis erTad, Semdeg

mSobelis marto awonva, wonaTa Soris sxvaoba aris bavSvis

wonis maCvenebeli.

monacemebis dafiqsireba bavSvis ganviTarebis istoriaSi – bavSvis

wonis maCvenebeli unda dafiqsirdes ganviTarebis istoriasa da wonis

diagramaze. Cvili bavSvis wona fiqsirdeba measedis (0,01 kg),

mozrdilis ki - meaTedis sizustiT (0,1 kg).

sigrZe/simaRlis gansazRvra25,26

bavSvis simaRle isazRvreba simaRlis

sazomiT, adreul asakSi (24-36 Tvemde)

gamoiyeneba horizontaluri (suraTi 3), 36

Tvis Semdeg ki vertikalur simaRlis sazomi.

Tu bavSvi axerxebs sazomTan sworad dgomas

24-36 Tvemde SesaZlebelia vertikaluri

sazomis gamoyeneba.

horizontaluri sazomi miaxlobiT 100 sm sigrZis dafaa, romelsac

erT boloSi uZravad mimagrebuli aqvs perpendikularuli 10-15 sm

simaRlis firfita, meore boloSi ki aqvs moZravi firfita, romelic

gadaadgildeba bavSvis sigrZis mixedviT (suraTi 4).

adreuli asakis bavSvis sigrZis zusti maCveneblis misaRebad

mizanSewonilia gazomva orma specialistma Caataros. bavSvs awvenen

TaviT simaRlis sazomis uZravi ficrisken, samedicino muSaki

afiqsirebs Tavs, ise, rom bavSvi vertikalurad zemoT iyurebodes.

nikapi ar unda exebodes gulmkerds da Tavi ar unda iyos ukan

gadaweuli. meore specialisti asworebs bavSvis tans ise, rom igi

beWiT da kudusuniT exebodes sazoms, qveda kidurebs afiqsirebs

muxlis saxsarSi maqsimalurad gaSlil mdgomareobaSi da simaRlis

sazomis qveda moZrav firfitas uaxlovebs bavSvis quslebs. or

firfitas Soris manZili (izomeba simaRlis sazomis Skalis mixedviT)

santimetrebiT Seesabameba bavSvis sigrZes.

suraTi 3

11

mozrdili asakis bavSvis simaRlis dasadgenad iyeneben vertikalur

simaRlis sazoms (suraTi 5).

bavSvs fexSiSvels ayeneben zurgiT simaRlis sazomTan, ise, rom igi

simaRlis sazomis svets exebodes quslebiT, beWebiT da kefiT, xelebi

CamoSvebuli hqondes qvemoT, Tavi ki sworad eWiros. Tu Tmaze bavSvs

aqvs samagri, saWiroa misi moxsna. bavSvs fexebi erTad unda hqondes

migdmuli. erTi specialisti awveba bavSvis (adreul asakSi) muxlis

da koW-wvivis saxsars sigrZis sazomisken. bavSvi unda iyurebodes win,

misi Tvalis Wrili da yuris zeda kide unda qmnides erT swor

horizontalur xazs. simaRlis sazomis moZrav ficars adeben bavSvs

Tavze da Skalaze aiTvlian bavSvis simaRles santimetrebiT25,26.

nebismier asakSi sigrZe/simaRlis gazomva mizanSewonilia Catardes 2

jer zedized. gazomvis Sedegad miRebul or maCvenebels Soris

sxvaoba ar unda aRematebodes 1 sm-s. bavSvis sigrZis dasadgenad

gamoiyeneba 2 gazomviT miRebuli maCveneblis saSualo ariTmetikuli.

Tu gazomvisas miRebuli sxvaoba aRemateba dasaSveb normas (1 sm),

mizanSewonilia gazomva Catardes mesamed. bavSvis zusti sigrZis

dasadgenad 3 maCvenebls Soris unda arCes 2 erTmaneTTan

miaxlovebuli da ganisazRvros maTi saSualo ariTmetikuli25.

monacemebis dafiqsireba bavSvis ganviTarebis istoriaSi – bavSvis

sigrZe/siimaRlis maCvenebeli unda dafiqsirdes ganviTarebis

istoriaSi da sigrZe/simaRlis diagramaze. bavSvis sigrZe/simaRle

fiqsirdeba meaTedis sizustiT (0,1 sm)

12

suraTi 4

13

suraTi 5

14

Tavis garSemowerilobis gansazRvra25,26

Tavis garSemowerilobas zomaven santimetriani zonriT, romelic

unda gadiodes kefis yvelaze gamodrekili adgilze, yurebis zemoT

da warbebs zemoT (ix. suraTi 6). zusti maCveneblis misaRebad tardeba

2-jer gazomva, maCvenebelTa Soris dasaSvebia sxvaoba 0,2 sm. Tu

sxvaoba aRemateba mocemul normas, mizanSewonilia gazomva Catardes

mesamed. bavSvis Tavis garSemowerilobis zustad dasadgenad 3

maCvenebels Soris unda airCes 2 erTmaneTTan miaxlovebuli da

ganisazrvros maTi saSualo ariTmetikuli25.

monacemebis dafiqsireba bavSvis

ganviTarebis istoriaSi – bavSvis

Tavis garSemowerilobis maCvenebeli

unda dafiqsirdes ganviTarebis

istoriaSi da Tavis garSemoweri-

loba/asakis diagramaze. bavSvis

Tavis garSemoweriloba fiqsirdeba

meaTedis sizustiT (0,1 sm)

mxris garSemowerilobis dadgena26

mxris gaSemowerilobis gansazRvra gamoiyeneba bavSvis kvebiTi

statusis SefasebisTvis 1 dan 5 wlamde asakSi. mxris garSemoweri-

loba mocemul asakSi umniSvnelod icvleba da normis SemTxvevaSi ar

unda iyos 13,5 sm-ze naklebi. mxris midamoSi cximovani qsovilis

ganleva kvebis darRvevis adreul stadiaze vlindeba, rac Sesabamisad

aisaxeba mxris garSemowerilobis Sefasebisas. amave dros,

gaTvaliswinebuli unda iyos, rom iSviaT SemTxvevaSi mxris garSemo-

werilobis daqveiTeba SesaZlebelia ganpirobebuli iyos mxris kunTis

atrofiiT.

mxris garSemoweriloba izomeba mxris Sua nawilSi (ix. suraTi 7). am

mizniT Tavdapirvelad unda ganisazRvros mxris sigrZe. bavSvs unda

moaxrevinon xeli idayvis saxsarSi marTi kuTxiT, izomeba manZili

mxris akromionis morCsa da idayvs Soris, dgindeba mxris Sua

wertili da mocemul areSi izomeba mxris garSemoweriloba. mxris

garSemowerilobis gansazRvra mizanSewonilia Catardes orjer.

miRebul monacemTa Soris sxvaoba ar unda aRematebodes 0.5 sm-s. Tu

sxvaoba aRemateba mocemul maCvenebels, mizanSewonilia gazomva

Catardes mesamed. bavSvis mxris garSemowerilobis zustad dasadgenad

3 maCvenebels Soris unda airCes 2 erTmaneTTan miaxlovebuli da

ganisazRvros maTi saSualo ariTmetikuli26. janmrTelobis msoflio organizaciis mier mowodebulia mxris

garSemowerilobis gansazRvra bavSvis kvebiTi statusis Sesa-

faseblad, roca misi zusti asaki ucnobia.

monacemebis dafiqsireba bavSvis ganviTarebis istoriaSi – bavSvis

mxris garSemowerilobis maCvenebeli unda dafiqsirdes ganviTarebis

istoriaSi. bavSvis mxris garSemoweriloba fiqsirdeba meaTedis

sizustiT (0,1 sm).

suraTi 6

15

suraTi 7

16

kanqveSa cximovani qsovilis sisqe 1,12

kanqveSa cximovani qsovilis sisqis gansazRvra farTod gamoiyeneba

mozrdilebSi simsuqnis dasadgenad. misi Sefaseba moiTxovs

gamocdilebas, specialur aparaturas, amave dros,

gasaTvaliswinebelia kanqveSa cximis sisqis individualuri variacia,

ris gamoc bavSvebSi misi gamoyeneba SezRudulia, garda im

SemTxvevebisa, rodesac Sefasebas atarebs kvalificiuri specialisti.

zrdis monitoringi

dReisaTvis ar arsebobs sakmarisi mtkicebuleba zrdis monitoringis

optimaluri sixSiris Sesaxeb. sigrZe/simaRlis, wonisa da Tavis

garSemowerilobis gansazRvra unda xdebodes janmrTel bavSvze

meTvalyureobis da imunizaciis vizitebis dros22,27-30.

wonis monitoringi1,12,15,16,31,62

bavSvis zrda-ganviTarebaze monitoringis pirveli aucilebeli

nabijia dabadebis wonis gansazRvra da misi gestaciur asakTan

Sesabamisobis dadgena.

• samSobiaro blokSi axalSobili unda aiwonos dabadebidan 2

sT-is Semdeg, vinaidan axalSobilis ufro adre awonva zrdis

hipoTermiis ganviTarebis risks;

• samSobiaro saxlSi axalSobilis awonva rekomendebulia

yoveldRe, mizanSewonilia wonis cvlilebis yoveldRiuri

kontroli da maCveneblis fiqsireba bavSvis istoriaSi;

• pirveli Tvis ganmavlobaSi bavSvi unda aiwonos 2 kviraSi

erTxel;

• axalSobilobis periodis Semdeg mizanSewonilia bavSvis

awonva TveSi erTxel, Tu bavSvs uvlindeba wonis darRveva

SesaZlebelia awonva warmoebdes ufro xSirad (saSualod 2

kviraSi erTxel);

• 1-idan 3 wlamde asakSi wonis kontroli saWiroa 3 TveSi

erTxel, 3-6 wlamde 6 Tvis intervaliT, xolo 6 wlis Semdeg

yovelwliurad;

• wonis kontroli da misi fiqsacia ganviTarebis istoriaSi

yoveli vizitis dros bavSvis zrda – ganviTarebaze

monitoringis aucilebelia pirobaa.

sigrZe/simaRle, Tavis garSemoweriloba12,15,16,31,62

• axalSobilis sigrZe da Tavis garSemoweriloba unda

ganisazRvros dabadebidan 2 sT-is Semdeg;

• Tavisa garSemowerilobis gansazRvra mizanSewonilia 2 wlamde

asakSi 1-3 Tvis intervaliT. Tu aRiniSneba darRveva saWiroa

yovelTviuri kontroli;

17

• 1 wlamde asakSi mizanSewonilia sigrZis Sefaseba

meTvalyureobis vizitebis dros (kvartalSi erTxel);

• sigrZe/simaRlis monitorireba gansakuTrebiT mniSvnelovania 2

wlis asakis Semdeg iseTive sixSiriT rogorc wonis

monitoringi;

• aucilebelia bavSvis fizikuri ganviTarebis Sefaseba skolaSi

wasvlis win.

Tu bavSvs aReniSneba zrdis darRveva monitoringi ufro

xSirad unda warmoebdes. Tu mSobels ar miyavs bavSvi

meTvalyureobis dagegmil vizitebze fizikuri ganviTarebis

Sefaseba unda moxdes avadmyofobis vizitebis dros (rekomendacia D)22.

bavSvis zrdis procesis Sefasebisas aucileblia mSoblebis

anTropometruli monacemebis gaTvaliswineba (rekomednacia B)22.

kbilebis ganviTarebis Sefaseba

janmrTel bavSvze meTvalyureobis vizitebis dros fasdeba:

• sarZeve da mudmivi kbilebis amoWris vadebi da Tanmimdevroba;

• kbilebis mdgomareoba (Tankblivis darRveva, kariesi, emalis

defeqti).

anTropometruli monacemebis Sefasebis meTodebi

bavSvis fizikuri ganviTarebis Sefasebis Sedegebi unda Sedardes

standartul maCveneblebs. am mizniT gamoiyeneba standartuli

cxrilebi (Sedgenili centilebis da standartuli gadaxris SD - Z qulis mixedviT) da zrdis diagramebi. upiratesoba eniWeba diagramebs,

radgan maTi gamoyeneba SedarebiT martivia da zrdis procesis

dinamikuri Sefasebis SesaZleblobas iZleva.

fizikuri ganviTarebis SefasebisaTvis gamoiyeneba Semdegi saxis

diagramebi:

• gestaciuri asaki/dabadebis wonis diagrama

• wona-asakis diagrama

• sigrZe/simaRle-asakis diagrama

• Tavis garSemoweriloba-asakis diagrama

• wona-sigrZe/simaRlis diagrama

• sxeulis masis indeqsi (smi)-asakis diagrama.

nebismieri anTropometruli maCveneblis mrudebi Sedgenilia

centilebis an Z qulebis mixedviT.

D

B

18

centiluri diagrama1,12,15,28,32

centiluri diagrama Sedgeba standartuli mrudebisgan. TiToeuli

mrudi Seesabameba garkveuli centilis (3-97) maCvenebels. centili

gviCvenebs, konkretuli asakis bavSvTa ramden procents aReniSneba

mocemuli anTropometruli maCvenebeli. saSualo normad anu medianad

miCneulia 50 centili. 50-ze naklebi centili - 3, 10, 25 - miuTiTebs,

rom aRniSnuli maCvenebeli uvlindeba am asakis bavSvTa Sesabamisad -

3, 10, 25 procents. 50-ze meti centili - 75, 90, 97 - miuTiTebs, rom

aRniSnuli maCvenebeli uvlindeba am asakis bavSvTa raodenoba,

romlis procentic gamoiTvleba Semdegnairad “100 – centili”. mag. 75

centili niSnavs, rom es maCvenebeli aReniSneba am asakis bavSvebis

100-75=25 %-s.

normad miRebulia maCveneblebi, romlebic 3-97 centilis farglebSia.

Tu romelime parametri 3 centilze naklebia, gamoxatulia deficiti,

Tu 97 centilze metia – siWarbe, es paTologiaze miuTiTebs da

specialuri gamokvlevebis Catarebas saWiroebs.

standartuli gadaxra SD - Z qulis diagrama 1,12,15,28

TiToeuli diagrama Sedgeba ramdenime mrudisgan, romlebic gviCvenebs

anTropometruli monacemebis ganawilebas.

saSualo normad anu medianad miCneulia nulovani mrudi. danarCeni

mrudebi gviCveneben standartul gadaxras saSualo maCveneblidan.

normad miRebulia maCveneblebi, romlebic ±2Z qulis farglebSia.

Tu romelime parametri _2Z qulaze naklebia, gamoxatulia deficiti,

Tu +2Z qulaze metia - siWarbe, es paTologiaze miuTiTebs da

specialuri gamokvlevebis Catarebas saWiroebs.

janmrTelobis msoflio organizacia upiratesobas aniWebs Z qulis

diagramebs, radgan misi gamoyeneba monacemebis ufro zusti

interpretaciis saSualebas iZleva.

fizikuri ganviTarebis Sefasebis individualuri mrudis agebis principebi da interpretacia

samSobiaro saxlSi axalSobilis dabadebis wonisa da gestaciuri

asakis Sesabamisobis dasadgenad sargebloben wona-gestaciuri asakis

diagramiT.

janmrTel bavSvze meTvalyuroebis vizitebis dros xdeba wona-asakis,

sigrZe/simaRle-asakis da Tavis garSemoweriloba–asakis mrudis ageba.

wona – gestaciuri asakis diagrama

diagramis horizontalur anu abscisTa RerZze Cveulebriv ga-

dazomilia bavSvis gestaciuri asaki, xolo vertikalur anu

19

ordinatTa RerZze Sesabamisad _ wonis maCvenebeli da agebulia

standartuli Z qulis mrudebi.

pacientis wonis da gestaciuri asakis Sesabamisobis gansazRvrisTvis

unda moiZebnos misi gestaciuri asakis da dabadebis masis Sesabamisi

xazebis gadakveTis wertili. am wertilis diagramaze ganTavsebis

mixedviT gamoiyofa16:

• gestaciur asakTan SedarebiT didi masis mqone axalSobilebi -

gestaciuri asakis da dabadebis masis xazebis gadakveTis wertili

xvdeba diagramaze aRniSnul or standartul mruds zemoT (> +2 Z qulze).

• gestaciur asakTan Sesabamisi masis mqone axalSobilebi -

gestaciuri asakis da dabadebis masis xazebis gadakveTis wertili

xvdeba or standartul mruds Soris (dabadebis masa +2 Z qulis

farglebSia).

• gestaciur asakTan SedarebiT mcire masis mqone axalSobilebi -

gestaciuri asakis da dabadebis masis xazebis gadakveTis wertili

xvdeba or standartul mruds qvemoT (< -2 Z qulaze). es miuTiTebs

saSvilosnosSiga ganviTarebis Seferxebaze.

maCvenebeli (wona, sigrZe/simaRle, Tavis garSemoweriloba) asakis

diagrama1,3,12,21,35,37

diagramis horizontalur anu abscisTa RerZze Cveulebriv ga-

dazomilia bavSvis asaki, xolo vertikalur anu ordinatTa RerZze

Sesabamisad anTropometruli parametri - wona, an sigrZe/simaRle, an

Tavis garSemoweriloba da agebulia standartuli centiluri an Z qulis mrudebi. bavSvis sqesis mixedviT mowodebulia gansxvavebuli

diagramebi.

pacientis nebismieri parametris

individualuri mrudis aigeba

Semdegnairad: miRebul maCvenebelze

ivleba horizontaluri, xolo asakze

vertikaluri xazi, maTi gadakveTis

adgili aRiniSneba wertiliT (ix

suraTi 8). Semdgomi gamokvlevisas

(mag: 1 Tvis Semdeg) meordeba

procedura da sqemaze arsebuli

wertilebis SeerTebiT miiReba bavSvis maCveneblis (masa,

sigrZe/simaRle, Tavis da gulmkedris garSemoweriloba)

individualuri mrudi.

janmrTeli bavSvis mrudi unda moTavsdes standartuli mrudebis

normul maCveneblebs Soris (-2 da +2 Z qula; 3-97 centili). metad

mniSvnelovania bavSvis individualuri mrudi iyos standartuli

mrudebis paraleluri, rac miuTiTebs zrdis normalur intensiobaze.

suraTi 8

20

amrigad, mniSvneloba eqceva:

• mrudis mimarTulebas

da

• mrudis pozicias.

mrudis agebamde unda ganisazRvros pacientis zusti asaki.

wona_asakis diagrama1,32,38,39

wona_asakis diagrama gansazRvravs wonis asakTan Sesabamisobas, rac

saSualebas iZleva gamovlindes wonis deficiti an siWarbe.

• Tu bavSvis individualuri mrudi an erTjeradi gazomvis

Sedegad miRebuli maCvenebeli ganTavsda -2 da -3Z qulovan

mrudebs Soris (an 3 centils qvemoT), saxezea wonaSi CamorCena _

dabali wona.

• Tu bavSvis individualuri mrudi an erTjeradi gazomvis

Sedegad miRebuli maCvenebeli ganTavsda –3Z qulovani mrudis

qvemoT saxezea wonaSi mkveTri CamorCena _ Zlier dabali wona.

• Tu bavSvis individualuri mrudi an erTjeradi gazomvis

Sedegad miRebuli maCvenebeli ganTavsda +2Z qulovan mruds (an

97 centilis) zemoT, es miuTiTebdes wonis siWarbeze.

individualuri mrudis standartulis zemoT an qvemoT ganTavseba

yovelTvis ar niSnavs, rom saxezea simsuqne an wonis deficiti,

vinaidan bavSvi SeiZleba iyos maRali/dabali da misi wona

Seesabamebodes simaRles. aseT SemTxvevaSi mizanSewonilia aigos

wona_sigrZe/simaRlis an smi-asakis (2 wlidan) mrudi da misi

SefasebiT gadawydes, vlindeba Tu ara wonis problema75,76.

sadReisod iTvleba, rom wonis deficitis dros ufro

informatiulia wona-simaRlis diagrama, xolo Warbi wonis dros –

smi-asakis diagrama.

nebismieri mwvave daavadebis an kvebis reJimis darRvevis dros bavSvis

individualurma mrudma SeiZleba miiRos horizontaluri

mimarTuleba (wonis namatis SeCereba), rac 2 kviraze metad ar unda

gaxangrZlivdes. Tu wonis SeCereba gagrZelda bavSvi saWiroebs

gamokvlevas.

Tu mrudi iRebs daRmaval an mkveTrad aRmaval mimarTulebas,

miuxedavad imisa, rom bavSvis individualuri mrudi SeiZleba

moTavsebuli iyos standartul mrudebs Soris, bavSvs esaWiroeba

gamokvleva mizezis dasadgenad.

sigrZe/simaRle_asakis diagrama1,32,38,39,40

diagrama gansazRvravs sigrZe/simaRlis asakTan Sesabamisobas, rac

saSualebas iZleva gamovlindes hipostatura da Warbi simaRle.

21

• Tu bavSvis individualuri mrudi an erTjeradi gazomvis Sedegad

miRebuli maCvenebeli ganTavsda –2Z qulovan (an 3 centilis) mruds

qvemoT, es miuTiTebs, rom saxezea simaRleSi CamorCena

(rekomendacia D)22.

• Tu bavSvis individualuri mrudi an erTjeradi gazomvis Sedegad

miRebuli maCvenebeli ganTavsda +2Z qulovan (an 97 centilis)

mruds zemoT, es SeiZleba miuTiTebdes Warb simaRleze.

Tu mrudi iRebs daRmaval an mkveTrad aRmaval mimarTulebas,

miuxedevad imisa, rom bavSvis individualuri mrudi SeiZleba

moTavsebuli iyos standartul mrudebs Soris, bavSvs esaWiroeba

gamokvleva paTologiis gamosavlenad.

Tavis garSemoweriloba_asakis diagrama23

diagrama gansazRvravs Tavis garSemowerilobis asakTan Sesabamisobas,

rac saSualebas iZleva gamovlindes mikro da makrocefalia.

• Tu bavSvis individualuri mrudi an erTjeradi gazomvis

Sedegad miRebuli maCvenebeli ganTavsda –2Z qulovan (an 3

centilis) mruds qvemoT, savaraudoa mikrocefaliis arseboba,

saWiroa nevropaTologis konsultacia da damatebiTi

gamokvlevebis Catareba.

• Tu bavSvis individualuri mrudi an erTjeradi gazomvis

Sedegad miRebuli maCvenebeli ganTavsda +2Z qulovan (an 97

centilis) mruds zemoT, savaraudoa makrocefaliis arseboba,

saWiroa nevropaTologis konsultacia da damatebiTi

gamokvlevebis Catareba.

bavSvis fizikuri ganviTarebis globaluri SefasebisaTvis saWiroa

individualuri mrudebis kompleqsuri Sefaseba. sxvadasxva mrudis

ganawilebis mixedviT SesaZlebelia gamovlindes gansxvavebuli

problemebis arseboba. Tu bavSvis wona, sigrZe da Tavis

garSemoweriloba CamorCeba normas savarudoa genetikuri an

konstituciuri anomaliis arseboba. konstituciuri darRvevebis

dros, bavSvis mSoblebis anTropometruli monacemebic normaze

dabalia an normis qveda sazRvrebSia, bavSvis individualuri mrudi

ganTavsebulia standartuli mrudebis qvemoT, Tumca maTi

paraleluria.

mwvave kvebis deficitis dros Tavdapirvelad vlindeba masis

deficiti, xolo sigrZe/simaRlis da Tavis garSemowerilobis mrudi

rCeba normis farglebSi. qronikuli kvebis deficitis SemTxvevaSi

wonasTan erTad vlindeba simaRleSi zrdis Seferxebac. aseT dros

wona asakis da sigrZe/simaRle asakis individualuri mrudi

standartul mrudebze qveviT mdebareobs, xolo wona-sigrZe/simaRlis

mrudi xSir SemTxvevaSi normis farglebSia.

simaRleSi CamorCena SesaZlebelia agreTve ganpirobebuli iyos

Tandayolili anomaliebiT, endokrinuli an konstituciuri

darRvevebiT.

D

22

wona sigrZe/simaRlis diagrama1,32,38,39,40

diagrama gansazRvravs bavSvis wonis Sesabamisobas mis

sigrZe/simaRlesTan.

diagramis horizontalur anu abscisTa RerZze mocemulia bavSvis sig-

rZe/simaRle, xolo vertikalur anu ordinatTa RerZze Sesabamisad

wona da agebulia standartuli centiluri an Z qulis mrudebi.

bavSvis individualuri mrudis ageba xdeba zemoT aRwerili meTodiT.

• Tu bavSvis individualuri mrudi an erTjeradi gazomvis

Sedegad miRebuli maCvenebeli ganTavsda –2Z qulovan (an 3

centilis) mruds qvemoT, es miuTiTebs, rom saxezea wonis

deficiti sigrZe/simaRlesTan SedarebiT (rekomendacia D)22. • Tu bavSvis individualuri mrudi an erTjeradi gazomvis

Sedegad miRebuli maCvenebeli ganTavsda +2Z qulovan (an 97

centilis) mruds zemoT, es SeiZleba miuTiTebdes wonis

siWarbeze.

Tu mrudi iRebs daRmaval an mkveTrad aRmaval mimarTulebas,

miuxedevad imisa, rom bavSvis individualuri mrudi SeiZleba

moTavsebuli iyos standartul mrudebs Soris, bavSvs esaWiroeba

gamokvleva paTologiis gamosavlenad. meTvalyureoba esaWiroebaT,

agreTve bavSvebs romelTa anTropometruli maCveneblis Sesabamisi

mrudi ganTavsda standartuli mrudis normuli sazRvris qvemoT an

zemoT.

D

23

qronikuli malnutriciis dros wona sigrZe/simaRlis individualuri

mrudi SeiZleba moTavsdes standartul mrudebs Soris da imeorebdes

mis mimarTulebas, radgan bavSvi CamorCeba rogorc simaRleSi, aseve

wonaSi12. Tumca mocemuli maCveneblebis asakTan Sesabamisi

individualuri mrudebi normaze dabalia.

sxeulis masis indeqsi-asakis diagrama1,22,32

saerTaSoriso rekomendaciebiT sxeulis masis indeqsi (smi) bavSvis

kvebiTi statusis Sefasebis erT-erTi saukeTeso indikatoria33-35,

vinaidan igi gviCvenebs ramdenad Seesabameba bavSvis wona mis simaRles

asakisa da sqesis gaTvaliswinebiT. smi gamoiyeneba 2 wlis asakidan.

sxeulis masis indeqsis gamoTvla xdeba Semdegnairad:

sxeulis masa (kg)

smi =

simaRle (m)2

diagramis horizontalur anu abscisTa RerZze Cveulebriv

aRniSnulia bavSvis asaki, xolo vertikalur anu ordinatTa RerZze

Sesabamisad sxeulis masis indeqsis maCvenebeli da agebulia stan-

dartuli centiluri an Z qulis mrudebi. pacientis sxeulis masis

indeqsis mrudis asagebad, Sesabamisad bavSvis asakisa da smi-s

maCveneblebze gavlebuli xazebis gadakveTa aRiniSneba wertiliT,

Semdgomi gamokvlevisas (mag: 1 Tvis Semdeg) meordeba procedura da

sqemaze arsebuli wertilebis SeerTebiT miiReba bavSvis smi-asakis

Sesabamisi mrudi.

normad miCneulia maCvenebeli, romelic 3-85 centils an _2 da +1Z qulas Soris mdebareobs.

• wonis deficiti - maCvenebeli 3 centilze an _2Z qulis

qvemoT mdebareobs (rekomendacia D)22;

• Warbi wonis riski - maCvenebeli 85-97 centilebs an +1 da +2Z qulas Sorisaa (rekomendacia D)22;

• simsuqne – maCvenebeli aRemateba 97 centils an +2Z qulas

(rekomendacia D)22.

wonisa da sigrZe/simaRlis araTanabari zrdis gamo sxeulis masis

indeqsi mudmivad icvleba, ris gamoc smi-asakis mruds aqvs

araTanabarzomieri forma36.

sxeulis masis indeqsis diagrama ZiriTadad 2 wlis zemoT asakSi

gamoiyeneba, raTa droulad dadgindes is daavadebebi da

paTologiuri mdgomareobebi, romlebic iwvevs wonis darRvevas.

(rekomendacia B)22.

D

D

B

24

fizikuri ganviTarebis Sefaseba sxva maCveneblebiT

mxris garSemoweriloba1,26

mxris garSemowerilobis mixedviT fasdeba 1-dan 5 wlamde asakis

bavSvis kvebiTi statusi:

• kargi kvebiTi satusi - mxris garSemoweriloba metia 13,5 sm-

ze;

• msubuqi xarisxis kvebis deficiti - mxris garSemoweriloba 12,5

da 13,5 sm-s Sorisaa;

• kvebis mZime deficiti - mxris garSemoweriloba < 12,5sm-ze.

aRniSnuli meTodi gamoiyeneba bavSvTa didi populaciis swrafi

SefasebisTvis. meTodis nakli imaSi mdgomareobs, rom ver xerxdeba

wonis siWarbis Sefaseba.

bavSvis tanis proporciebi12,15

fizikuri ganviTarebis maCveneblebidan yvelaze informaciulia masa

da simaRle, magram zrdis kriteriumad, masisa da simaRlis garda,

tanis sxvadasxva nawilis sigrZe da maTi urTierTproporciaa

miCneuli.

sxeulis zeda da qveda nawils Soris Tanafardoba dabadebisas 1,7-ia,

3 wlis asakSi – 1,3, 7 wlis Semdeg _ 1,0.

sxeulis qveda segmenti - manZili simfizidan qvemo kiduris bolomde,

zeda segmenti – sxeulis sigrZe/simaRles gamoklebuli qveda

segmentis zoma.

Tu sxeulis zeda da qveda nawils Soris Tanafardoba aRemateba

asakobriv normas SesaZlebelia vlindebodes araproporciuli

qondriskacoba, an Zvlovani sistemis iseT paTologia, rogoricaa

raqiti.

zrdis darRvevis problemebi

wonis darRveva

malnutricia1,16,37-41

definicia _ malnutricia wonis deficitia, romelic uxSiresad

gamowveulia arasakmarisi da/an arabalansirebuli kvebiT, monelebisa

da Sewovis darRveviT.

malnutriciis adreuli diagnostika da prevencia jandacvis

yvela dawesebulebaSi unda warmoebdes (rekomendacia B)56. B

25

malnutriciis uxSiresi mizezebi:

• arasakmarisi kveba - xelovnuri sakvebis araswori momzadeba

(nakleb koncentrirebuli an koncentrirebuli), araswori

kvebis reJimi, anoreqsia, siRaribe, bavSvis ugulebelyofa,

kvebis gaZneleba (mZime refluqsi, Tandayolili anomaliebi)

da sxva;

• sakvebis monelebis da Sewovis darRveva (celiakia, pankreasis

kistofibrozi, Zroxis rZeze alergia, biliaruli atrezia

an RviZlis daavadebebi da sxv);

• metabolizmis gaZlierebiT mimdinare paTologia

(hiperTireoidizmi, bavSvTa asakis avTvisebiani daavadebebi,

Tirkmlis qronikuli ukmarisoba, Tandayolili gulis

mankebi da sxv.).

diagnostika

kvebis deficitis – malnutriciis dadgena xorcieldeba wona/asakis

da wona/simaRlis standartuli diagramebis meSveobiT. mocemuli

diagramebi mixedviT gamoyofen:

• kvebis darRvevas anu dabal wonas _ bavSvis wonis maCvenebli

moTavsebulia -2 da -3 Z qulis Sesabamis diagramebs Soris.

• kvebis mZime darRvevas anu Zlier dabal wonas _ bavSvis wonis

maCvenebli moTavsebulia -3 Z qulis Sesabamis diagramis qvemoT.

wonis darRvevis dros mniSvnelovania:

1. anamnezis Segroveba

• bavSvis dietis Sefaseba (fasdeba 24 sT-s ganmavlobaSi

miRebuli sakvebis raodenoba, jeradoba da kaloriuloba,

sakvebis tipebi, vin kvebavs bavSvs da sxv);

• samedicino anamnezi - dRenakluloba, gestaciur asakTan

SedarebiT dabali wona, qronikuli daavadebebis arseboba (asTma,

gulis Tandayolili manki), Rebinebis arseboba, refluqsi,

gastroenteraluri problemebi;

• ojaxuri anamnezi – ojaxis wevrebis janmrTelobis mdgomareoba,

memkvidruli daavadebebi, ojaxSi stersuli situaciis arseboba

da sxv.

2. obieqturi Sefaseba, romlis mizania disembriogenezuli stigmebis

dafiqsireba, rac SesaZlebeli miuTiTebdes genetikur

paTologiaze; Tanmxlebi daavadebebis diagnostika, romelic

SesaZlebelia iwvevdes malnutricias, bavSvis ugulebelyofis an

masze Zaladobis niSnebis dadgena.

26

marTva _ dabali da Zlier dabali wona

referali stacionarSi saWiroa, Tu gamoxatulia:

⇒ Zlier dabali wona an

⇒ dabali wona, romelic gamowveulia qronikuli daavadebebiT,

sakvebis Sewovis an monelebis darRveviT.

marTva binaze

binaze xorcieldeba im pacientebis marTva, romelTac aReniSnebaT

araswori kvebiT gamowveuli dabali wona.

binaze marTvis meTodebi:

• maRalkaloriuli dieta – gaTvlili ara faqtiur, aramed asakis

Sesabamis standartul wonaze. kaloriulobis gazrda 6 Tvis

Semdeg ZiriTadad cximis xarjze xdeba (ix. malnutriciis

protokoli);

• mizanSewonilia multivitaminebis kompleqsis damateba

asakobrivi dozebiT;

• dedis konsultireba bavSvis kvebis da saSiSroebis niSnebis

Sesaxeb (Tu bavSvi ver iRebs sakvebs da siTxes, dauyovnebliv

unda ganxorcieldes viziti ambulatoriaSi);

• ganmeorebiTi viziti da wonis Sefaseba xdeba 2 kviraSi. Tu

bavSvs aReniSneboda kvebiTi problemebi (mag: araswori moWideba

ZuZuTi kvebis dros, kvebis reJimis darRveva da sxv)

ganmeorebiTi viziti tardeba 5 dReSi;

• Tu ganmeorebiTi vizitis dros ar aRiniSneba wonis namati, unda

dadgindes ramdenad adekvaturad Seasrula dedam

rekomendaciebi:

_ Tu dedam sworad ver/ar Seasrula rekomendacia, saWiroa

rekomendaciis da detaluri axsna-ganmartebebis

ganmeorebiT micema da vizitis ganxircieleba 2 kviraSi.

_ Tu dedam Seasrula rekomendacia da miuxedavad amis ar

aris wonis namati saWiroa referali stacionarSi.

malnutriciis marTvis Sesaxeb detaluri informacia ixileT

Sesabamis gaidlainsa da protokolSi

Warbi wona/simsuqne10,22,40,42-52

definicia

simsuqne organizmSi cximovani qsovilis Warbi dagrovebaa. simsuqne

zrdis Semdegi daavadebebis ganviTarebis risks:

• gul-sisxlZarRvTa daavadebebi - hipertonia, hiperinsulinemia,

marcxena parkuWis hipertrofia, hiperlipidemia

(mtkicebulebis done II) 43-48

• bronquli asTma (mtkicebulebis done II)10,49-50; II

II

27

• II tipis Saqriani diabetis ganviTarebis riski (mtkicebulebis

done II) 10,43,49-50.

simsuqnis dros, gansakuTrebiT gogonebSi, mkveTrad aris gamoxatuli

fsiqosocialuri distresi da qceviTi darRvevebi (mtkicebulebis

done II)50.

simsuqnis uxSiresi mizezebi:

• Warbi kveba;

• hipodinamia;

• genetikuri daavadebebi (daunis sindromi, terneris sindromi da

sxva);

• endokrinuli darRvevebi (zrdis hormonis deficiti,

hipoTireozi da sxva);

• zogierTi medikamentis gamoyeneba (steroidebi, tricikluri

antidepresantebi da sxva).

diagnostika

Warbi wonis/simsuqnis zusti identifikaciisaTvis gamoyenebuli

unda iyos wona sigrZe/simaRlis (2 wlamde) da smi asakis (2

wlidan) diagrama. uknasknel periodSi rekomendebulia smi asakis

mrudis gamoyeneba (mtkicebulebis done III, reomendacia B)52.

• Tu bavSvis wona sigrZe/simaRlis individualuri mrudi an

erTjeradi gazomvis Sedegad miRebuli maCvenebeli ganTavsda

+2Z qulovan (an 97 centilis) mruds zemoT, miuTiTebs simsuqneze.

• smi asakis mrudi:

⇒ Tu smi maCvenebeli 85-97 centilebs an +1 da +2Z qulas

Sorisaa gamoxatulia Warbi wonis riski; (rekomendacia D)22.

⇒ Tu maCvenebeli aRemateba 97 centils an +2Z qulas

gamoxatulia simsuqne (rekomendacia D)22.

Sefasebis dros gaTvaliswinebuli unda iyos ojaxuri riskis

faqtorebi (mtkicebulebis done IV)24 da meoradi sismuqnis mizezebi. sam wlamde simsuqne ar miuTiTebs, rom Semdgom asakSi gamovlindeba

Warbi wona. Tumca, Tu aseT SemTxvevaSi mSoblebs aReniSnebaT Warbi

wona, SesaZlebelia simsuqne aRiniSnos mozrdilobis asakSic

(rekomendacia C)50.

Tu bavSvi imyofeba Warbi wonis riskis qveS unda gatardes

prevenciuli RonisZiebebi (mtkicebulebis done I)40,50-51:

• samedicino personalma unda Seafasos bavSvis dieta da

fizikuri aqtivoba (mtkicebulebis done IV)24 • dieta - rekomendebulia upiratesad xilis da bostneulis

miReba, cximis da tkbileulis SezRudva, Tumca bavSvebSi ar

aris sasurveli mkacri dietis dacva (mtkicebulebis done III,

reomendacia B)52

II

D

B

D

IV

C

I

B

II

IV

28

• mjdomare aqtivobis Semcireba - televizoris yureba,

kompiuterTan muSaoba unda SeizRudos dReSi 2 sT an kviraSi

14 sT-mde (rekomendacia D)50

• fizikuri aqtivobis gazrda – mag. siaruli minimum 30 wT

dReSi, Tu bavSvi janmrTelia dReSi rekomendebulia 60 wT

varjiSi (rekomendacia D)50 6 wlamde asakSi mizanSewonilia

aqtiuri TamaSebis waxaliseba (sirbili, daWerobana, burTiT

TamaSi da sxv.), 6 wlis Semdeg SeiZleba bavSvis CarTva

organizebul sportul TamaSebSi (fexburTi, kalaTburTi da

sxva), Tumca gaTvaliswinebuli unda iyos, rom 9 wlamde ar

aris rekomendebuli Zlieri fizikuri datvirTva54.

Warbi wonis riskis zonaSi myof bavSebSi mTavaria ar moxdes wonis

mateba, risTvisac saWiroa mudmivi monitoringi (rekomendacia D)50.

marTva

• Warbi wonisa da sismuqnis prevencia da mkurnaloba unda daiwyos

bavSvobis asakidan (rekomendacia C)50.

• simsuqnis mkurnaloba tardeba im SemTxvevaSi, Tu bavSvs da

mSobels aqvT survili Secvalon cxovrebis stili

(rekomendacia D)50.

• wonis SenarCuneba da kleba miiRweva mxolod qcevis cvlilebiT

(rekomendacia D)50, (mtkicebulebis done III, reomendacia B)52. • metad mniSvnelovania jansaRi kvebis damkvidreba (rekomendacia

D)50.

referali stacionarSi unda ganxorcieldes Tu:

⇒ saeWvoa endokrinuli paTologiis arseboba

⇒ vlindeba simsuqniT gamowveuli daavadebebi – hipertenzia, apnoe

Zilis dros, simsuqnismieri hipoventilacia, orTopediuli

problemebi, fsiqosocialuri problemebi, (rekomendacia D)50.

marTva binaze

binaze xorcieldeba im pacientebis marTva, romelTac aReniSnebaT

araswori kvebiT gamowveuli Warbi wona/simsuqne.

• 7 wlamde kveba ise unda SeirCes, rom SenarCundes arsebuli wona,

• 7 wlis Semdeg bavSvs, romelic garkveuli periodis ganmavlobaSi

inarCunebda arsebul wonas, SesaZlebelia daeniSnos dieta wonis

daklebis mizniT (TveSi wonis klebis maCvenebeli ar unda

aRematebodes 0,5 kg). dieta unda SeirCes endokrinologTan

konsultaciiT (rekomendacia D)50.

D

D

D

D

B

D

C

D

D

29

simaRlis darRveva

simaRleSi CamorCena - hipostatura1,12,22,38,58,59,60

diagnostika

• sigrZe/simaRle asakis diagramaze bavSvis individualuri mrudis

an erTjeradi gazomvis Sedegad miRebuli maCveneblis –2 Z qulovan (an 3 centilis) mruds qvemoT ganTavseba miuTiTebs,

simaRleSi CamorCenaze (rekomendacia D)22,59.

mizezebi

• endokrinuli darRvevebi _ zrdis hormonis deficiti,

hipoTireoidizmi (Zvlovani asaki CamorCeba qronologiur asaks);

• kvebis qronikuli deficiti _ vlindeba rogorc wonaSi, ise

simaRleSi CamorCena. wona_sigrZe/simaRlis mrudi normis

farglebSia;

• ojaxuri an genetikuri hipostatura – dabali simaRle,

sigrZe/simaRle-asakis diagramaze bavSvis individualuri mrudi –2 Z qulovan mruds qvemoT aris ganTavsebuli, Tumca standartuli

mrudis paraleluria, rac miuTiTebs, rom zrdis tempi

normaluria. Zvlovani asaki Seesabameba qronologiur asaks.

dabali simaRle aRiniSneba mSoblebTanac;

• konstituciuri simaRleSi CamorCena - Zvlovani asaki CamorCeba

qronologiur asaks, dagvianebulia sqesobrivi momwifeba, 3

wlidan pubertul periodamde aRiniSneba zrdis matebis dabali

tempi (mrudi ar aris standatrtuli mrudebis paraleluri),

Tumca zrdasrul asakSi simaRle normis farglebSia;

• terneris sindromi gogonebSi.

Zvlovani asaki ganisazRvreba majis Zvlebis rentgenografiuli

kvleviT, fasdeba gaZvalebis wertilebis arseboba.

marTva

• genetikuri hipostaturis gamoricxvis mizniT saWiroa mSoblebis

simaRlis Sefaseba;

• hipostaturis dros saWiroa endokrinologis konsultacia,

damatebiTi gamokvleva (hormonebis Seswavla, Zvlovani asakis

dadgena da sxv).

Warbi simaRle - gigantizmi12,60-61

diagnostika

bavSvis individualuri mrudis an erTjeradi gazomvis Sedegad

miRebuli maCveneblia ganTavseba +2Z qulovan (an 97 centilis) mruds

zemoT miuTiTebs simaRlis siWarbeze.

D

30

mizezebi

• endokrinuli paTologia (insulinis msgavsi zrdis faqtor-I-is

moqmedebiT ganpirobebuli zrdis hormonis pirveladi da meoradi

siWarbe);

• genetikuri paTologia (marfanis sindromi, klainfelteris

sindromi da sxv.).

marTva

• endokrinologis konsultacia, damatebiTi gamokvleva

(hormonebis Seswavla, Zvlovani asakis dadgena da sxv);

• genetikosis konsultacia.

kbilebis dagvianebuli amoWra

kbilebis dagvianebul amoWraze saubroben im SemTxvevaSi, Tu bavSvs

13 Tvis asakSi arc erTi kbili ar aqvs.

mizezebi: kvebiTi daRvevebi, vitaminebisa da mikroelementebis

deficiti, hipoTireozi, hipoparaTireoidizmi, xSiria ojaxuri

“kbilebis dagvianebuli amoWra”.

marTva: stomatologis da endokrinologis konsultacia. kvebis

darRvevebis dros _ kvebis koreqcia, mikroelementebisa da

vitaminebis daniSvna (kalciumi, D vitamini asakobrivi dozebiT).

kariesi da emalis defeqtebi.

mizezebi: kvebis (tkbili siTxeebis da tkbileulis Warbi miReba) da

metaboluri darRvevebi, mikroelementebis deficiti (kalciumi da

ftori) qronikuli daavadebebi, zogierTi medikamentis gamoyeneba,

satyuaras xSiri da xangrZlivi gamoyeneba da boTlidan

xangrZlivi kveba (rekomendacia C)63.

marTva: stomatologis konsultacia; oraluri higiena pirveli

kbilis amoWrisTanave (rbili qsoviliT an asakis Sesabamisi

jagrisiT, 3 wlidan sabavSvo kbilis pastis gamoyeneba);

tkbileulis, boTlis da sawovaras gamoyenebis SezRudva

(rekomendacia C)63. saWiroebis SemTxvevaSi mikroelementebis

damateba asakobrivi doziT (kalciumi, ftori).

gaidlainis gadasinjvisa da ganaxlebis vada – 2 weli

C

C

31

gaidlainis miRebis xerxi/wyaro

gaidlainis SemuSavebis meTodologia

• adreuli asakis bavSvTa fizikuri ganviTarebis Sefasebis

Sesaxeb arsebobs samecniero mtkicebulebis safuZvelze

Seqmnili rekomendaciebi. mocemuli gaidlainis Semqmnis

procesSi samuSao jgufis gadawyvetilebiT moZiebuli da

Sefasebuli iqna ukve arsebuli praqtikuli

rekomendaciebi. moxda arsebuli rekomendaciebis

adaptirebuli variantis SemuSaveba, romelic erTis mxriv

pasuxebs saerTaSoriso moTxovnebs, xolo meore mxriv

iTvaliswinebs saqarTvelos samedicino dawesebulebaTa

rogorc adamianur, ise teqnikur resursebs.

• rekomendaciaTa moZieba xorcieldeboda eleqtronuli

monacemTa bazis gamoyenebiT.

qveyana da resursis

dasaxeleba

internet-misamarTi

US National Guideline Clearinghouse (NGC)

http://www.guideline.gov

Centers for Disease Control and Prevention (CDC)

http://www.phppo.cdc.gov/CDCRecommends/AdvSearchV.asp

Health Canada – Population and Public Health Branch (PPHB)

http://www.hc-sc.gc.ca/pphb-dgspsp/dpg_e.html

Scottish Intercollegiate Guidelines Network (SIGN)

http://www.sign.ac.uk

German Guideline Information Service (GERGIS)

http://www.leitlinien.de/english/english/view;

Australian National Health and Medical Research Council (NHMRC)

http://www.health.gov.au/hfs/nhmrc/publicat/cp-home.htm

New Zealand Guidelines Group (NZGG)

http://www.nzgg.org.nz/library.cfm

CDC http://www.cdc.gov/growthcharts/

Canadian Paediatric Society http://www.cps.ca

WHO – World Health Organization

http://www.who.int/

klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi

wyaroebi da meTodebi

• koxreinis biblioTeka - The Cochrane Library 2006, Issue 2; • amerikis samedicino biblioTekis mier Seqmnil eleqtronul

bibliografiul monacemTa baza - medlaini – MEDLINE.

32

publikaciebis CarTvis/gamoricxvis kriteriumebi

• arCeul iqna kvlevebi Semdegi dizainiT: randomizebuli,

kontrolirebadi, sistemuri mimoxilvebi da meta-analizi,

erTmomentiani, kohortuli kvlevebi.

• rekomendaciis momzadebisas ZiriTadad dadgenili iyo drois

12 wliani SezRudva. Tumca zogjer gamoyenebuli iyo ufro

adreuli publikaciebi, romlebic dResac aqtualuria da

safuZvlad udevs sxva Tanamedrove mtkicebulebebs.

• dadgenili iyo enobrivi SezRudvebi, radganac samuSao jgufs

SesaZlebloba hqonda literaturis wyaroebi Seeswavla

mxolod inglisur da rusul enebze.

moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi

• samuSao jgufis mier tardeboda moZiebuli wyaroebis analizi.

Catarebuli Ziebis Sedegad miRebuli iyo ramdenime klinikuri

meToduri rekomendacia adreuli asakis bavSvTa fizikuri

ganviTarebis Sefasebis sakiTxebze, romlebic Seicavda jgufis

miznis Sesaferis saWiro informacias. am rekomendaciebis

Sefasebisas gamoyenebuli iyo rekomendaciaTa atestaciisa da

eqspertizis kiTxvari - AGREE (94,96-98). Sefasebis Sedegad

amorCeuli iyo qvemoT CamoTvlili organizaciebis gaidlainebi:

⇒ janmrTelobis msoflo organizacia

⇒ amerikis pediatrTa akademia

⇒ kanadis pediatrTa sazogadoeba

⇒ Sotlandiis gaidlainebis qseli

samuSao jgufi xelmZRvanelobda saqarTvelos Sromis,

janmrTelobisa da socialuri dacvis saministros mier SemuSavebuli

nacionaluri gaidlainebis gzamkvleviT.

• rekomendaciebis mtkicebulebaTa doneebis gansazRvrisas

gamoyenebuli iyo saqarTvelos Sromis janmrTelobisa da

socialuri dacvis saministros mier mowodebuli

mtkicebulebebis donisa da rekomendaciebis xarisxis sqema.

mtkicebulebaTa doneebisa da rekomendaciebis xarisxis sqema

done mtkicebulebis siZlieris done

(Muir Gray)

xarisxi rekomendaciis xarisxi

(Cook et al)

I Zlieri mtkicebuleba,

eyrdnoba minimum erT

sistemur mimoxilvas,

romelic efuZneba swori

dizainis mqone

randomizebul

kontrolirebad kvleva

A eyrdnoba I donis

mtkicebulebas da

Sesabamisad mtkiced

rekomendebulia

II Zlieri mtkicebuleba,

eyrdnoba minimum erTi

B eyrdnoba II donis

mtkicebulebas da

33

swori dizainis mqone

randomizebul

kontrolirebad kvleva

Sesabamisad mtkiced

rekomendebulia

III klinikuri kvleva

randomizaciis gareSe,

kohortuli da SemTxveva-

kontrolis kvlevebi

C eyrdnoba III donis

mtkicebulebas SeiZleba

CaiTvalos Sesabamisad

IV araeqsperimentuli

multicentruli kvlevebi

D eyrdnoba IV da V donis

mtkicebulebas saWiroebs

konsesuss

Va avtoritetul

profesionalTa

mosazreba

Vb klinikuri gamocdileba,

aRwerilobiTi kvlevebi

an eqspertTa angariSi

alternatiuli gaidlaini ar arsebobs

gamoyenebuli literatura:

1. WHO Library Cataloguing-in-Publication Data WHO child growth standards: length/height-for-age, weight-for-age, weight-for-length, weight-forheight and body mass index-for-age: methods and development. 2006

2. World Health Organization. Obesity: preventing and managing the global epidemic. Geneva: WHO, 1998 (63)

3. Tremblay MS, Willms JD. Correction. CMAJ. 2001;164(7):970. (65) 4. Reilly J. Epidemic of obesity in UK children. Lancet. 1999;354:1874-1875. (66) 5. Freedman DS, Srinivasan SR, Valdez RA, Williamson DF, Berenson GS. Secular

increases in relative weight and adiposity among children over two decades: The Bogalusa Heart Study. Pediatrics. 1997;99:420-426. (67)

6. Dietz WH. Health consequences of obesity in youth: childhood predictors of adult disease. Pediatrics. 1998;101:518-525. (68)

7. Tremblay MS, Willms JD. Secular trends in the body mass index of Canadian children. CMAJ. 2000;163(11):1429-1433. (63)

8. Freedman DS, Dietz WH, Srinivasan SR, Berenson GS. The relation of overweight to cardiovascular risk factors among children and adolescents: The Bogalusa Heart Study. Pediatrics. 1999;103:1175-1182. (69)

9. Whitaker RC, Wright JA, Pepe MS, Seider KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med. 1997;337(13):869-873. (70)

10. Guo SS, Chumlea WC. Tracking of BMI in children in relation to overweight in adulthood. Am J Clin Nutr. 1999;70 (suppl):145S-148S. (71)

11. Scudder L.E. – Evaluating Pediatric Growth and Nutrition: Guidelines for Primary Care Clinician - Copyright © 2000 Medscape Portals, Inc http://www.medscape.com

12. Behrman, Kleigman, Jenson. Nelson Test Book of Pediatrics 17-th edition.2004 13. Garner P., Pnpanich R., Logan S. – Is Routine Growth Monitoring Effective? A

systematic Review of Trails – Arch Dis Childhood 2000, 82 (3); 121-3

34

14. Sachs M. – Routine Weighing babies: does it improve feeding and care? J Child Health Care 2006, 10 (2); 90-95

15. xerxeuliZe n. – bavSvTa daavadebaTa propedevtika 2004

16. World Health Organization. Managing newborn problems: a guide for doctors, nurses, and midwives (Integrated management of pregnancy and childbirth) - 2003

17. Macdonald PD, Ross SR, Grant L, Young D. Neonatal weight loss in breast and formula fed infants. Arch Dis Child Fetal Neonatal Ed 2003;88(6):F472-6. (152)

18. Marchini G, Fried G, Ostlund E, Hagenas L. Plasma leptin in infants: relations to birth weight and weight loss. Pediatrics 1998;101(3 Pt 1):429-32. (153)

19. Rodriguez G, Ventura P, Samper MP, Moreno L, Sarria A, Perez-Gonzalez JM. Changes in body composition during the initial hours of life in breast-fed healthy term newborns. Biol Neonate 2000;77(1): 12-6 (201)

20. Kramer MS, Guo T, Platt RW, Shapiro S, Collet JP, Chalmers B, et al. Breastfeeding and infant growth: biology or bias? Pediatrics 2002;110(2 Pt 1):343-7. (135)

21. Dewey KG, Heinig MJ, Nommsen LA, Peerson JM, Lonnerdal B. Breast-fed infants are leaner than formula-fed infants at 1 y of age: the DARLING study. Am J Clin Nutr 1993;57(2):140-5. (68)

22. Co-signatories: Dietitians of Canada, Canadian Paediatric Society, The College of Family Physicians of Canada, and Community Health Nurses Association of Canada Nutrition Committee, Canadian Paediatric Society (CPS) - The use of growth charts for assessing and monitoring growth in Canadian infants and children - Paediatrics & Child Health 2004;9(3):171-180 Reference No. CPS04-01

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avtorTa jgufi

pediatrTa da neontologTa kavSiri `alternativa~

samuSao jgufi:

⇒ nani yavlaSvili – medicinis doqtori, Tbilisis

saxelmwifo samedicino universitetis zogadi pediatriis

departamentis asistent-profesori. saqarTvelos Sromis,

janmrTelobisa da socialuri dacvis saministros

eqsperti. pediatrTa da neontologTa kavSiri

`alternativa~-s wevri;

⇒ maia xerxeuliZe – medicinis doqtori, Tbilisis

saxelmwifo samedicino universitetis zogadi pediatriis

departamentis asistent-profesori. saqarTvelos Sromis,

janmrTelobisa da socialuri dacvis saministros

eqsperti. pediatrTa da neontologTa kavSiri

`alternativa~-s wevri;

⇒ eka kandelaki – medicinis doqtori, Tbilisis

saxelmwifo samedicino universitetis zogadi pediatriis

departamentis asistent-profesori. pediatrTa da

neontologTa kavSiri `alternativa~-s wevri;

⇒ Tamar manjaviZe – medicinis doqtori, saqarTvelos

Sromis, janmrTelobisa da socialuri dacvis

saministro. pediatrTa da neontologTa kavSiri

`alternativa~-s wevri.

eqsperti:

⇒ nino manjaviZe - medicinis mecnierebaTa doqtori,

profesori, Tsu pediatriis departamentis kerZo pediatriis

mimarTulebis sruli profesori;

⇒ aleqsandra xitaliSvili - saqarTvelos Sromis,

janmrTelobisa da socialuri dacvis saministro;

37

⇒ lela woworia _ saqarTvelos Sromis, janmrTelobisa da

socialuri dacvis saministros jandacvis departamenti;

⇒ Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa da

socialuri dacvis saministros jandacvis departamenti.