klinikuri praqtikis erovnuli rekomendacia (gaidlaini) (mtkicebulebis done II)33,44; _ qalis wonaSi...

1

2 wlamde asakis bavSvis kveba

klinikuri praqtikis erovnuli rekomendacia

(gaidlaini)

2

klinikuri praqtikis erovnuli rekomendacia (gaidlaini) `2

wlamde asakis bavSvis kveba~ 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 # 153/o

brZanebiT.

3

2 wlamde asakis bavSvis kveba

definicia, sinonimebi, klasifikacia, terminologia

kveba mniSvnelovan gavlenas axdens bavSvis ganviTarebaze. adreul asakSi

aracionaluri kveba da araswori praqtika iwvevs iseT darRvevebs, romlebic

aisaxeba adamianis janmrTelobaze, ara mxolod bavSvobis, aramed

mozardobisa da mozrdilobis periodSic. kerZod, ferxdeba zrdis procesi, gonebrivi, inteleqtualuri da motoruli ganviTareba, izrdeba bavSvTa

avadobisa da sikvdilobis riski, mozrdilobis asakSi ki – qronikuli

daavadebebis ganviTarebis albaToba. Sesabamisad, 2 wlamde asakSi bunebrivi

kvebis principebis dacva, ZuZuTi kvebis xelSewyoba, damatebiTi sakvebis

drouli dawyeba da asakis Sesabamisi sakvebi ingredientebis gamoyeneba

bavSvis janmrTelobis erT erT mniSvnelovan safuZvels warmoadgens.

• eqskluziuri ZuZuTi kveba anu mxolod ZuZuTi kveba - Cvilis kveba qalis

(deda /donori) rZiT, xseniT, gamowvelili rZiT 6 Tvemde, sxva sakvebisa

da siTxeebis (maT Soris wylis) Sematebis gareSe (gamonakliss

warmoadgens medikamentebi, ORS, vitaminebi, mineraluri danamatebi)

• predominantuli ZuZuTi kveba anu upiratesad ZuZuTi kveba. _ dedis

(donoris) rZesTan erTad mcire raodenobis siTxeebis miReba (wyali, Cai,

wveni)

• komplementuri kveba - qalis rZesTan erTad naxevradmyari an myari

damatebiTi sakvebis miReba.

• ZuZuTi kveba _ kvebis wesi, rodesac bavSvi ikvebeba dedis rZiT da iRebs

nebismier sxva saxis sakvebs, maT Soris qalis rZis Semcvlelebs.

• prelaqtaciuri sakvebi – qalis rZis Semcvleli an nebismieri siTxe,

romelic gamoiyeneba ZuZuTi kvebis dawyebamde

• kani kanTan kontaqti – mSobiarobis Semdeg janmrTeli SiSveli

axalSobilis moTavseba dedis sxeulze.

gaidlaini gankuTvnilia

• samedicino personalisaTvis, romelic muSaobs 2 wlamde asakis bavSvebTan

samSobiaro saxlSi, stacionarSi da jandacvis pirvelad rgolSi –

neonatologebis, mean-ginekologebis, pediatrebis, ojaxis eqimebis, bebia-

qalebis, axalSobilTa da patronaJis meddebisTvis.

gaidlainis samizne jgufi:

• 2 wlamde asakis bavSvebi

gaidlaini ar moicavs:

• dRenakluli da mcire wonis axalSobilis kvebis principebs;

• xelovnuri kvebis principebs;

• 2 welze meti asakis bavSvis kvebas;

• avadmyofi bavSvis kvebas.

4

gamoyenebuli Semoklebebi:

ILKA _ laqtaciis konsultantTa saerTaSoriso asociacia;

IBFAN _ bavSvTa kvebis saerTaSoriso qseli;

WABA _ ZuZuTi kvebis msoflio aliansi;

Baby Milk Action - ZuZuTi kvebis qseli;

WHO _ janmrTelobis msoflio organizacia (janmo);

UNICEF – gaeros bavSvTa fondi;

IQ _ inteleqtualuri koeficienti;

aiv/Sidsi _ adamianis imunodeficitis virusi/SeZenili imunodeficitis

sindromi;

HTLV _ adamianis T-limfotropuli virusi.

epidemiologia

2005 wlis statistikuri monacemebis mixedviT samSobiaro saxlebSi ZuZuTi

kveba mSobiarobidan erT saaTSi iwyeba - 64,1%-Si, 1-8 saaTSi – 23%-Si,

samSobiarodan gamowerili axalSobilebis 90% imyofeba ZuZuTi kvebaze.

saxelmwifo satatikur monacemebis mixedviT 3 Tvemde asakis bavSvTaA 52,11%

ikvebeba ZuZuTi, gaeros bavSvTa fondis da ACTS Georgia-s mier 2005 wels

Catarebuli kvlevis SedegebiT eqskluziuri ZuZuTi kvebis maCvenebeli 36%-s

Seadgens.

2 wlamde asakis bavSvis kvebis ZiriTadi principebi

ZuZuTi kveba

qalis rZe cocxali biologiuri substanciaa, romelic mudmivad icvleba

bavSvis moTxovnilebis Sesabamasad da idealuri sakvebia axalSobili

da Cvili bavSvisTvis (mtkicebulebis done I, rekomendaciis xarisxi

B)1,12,25.

ZuZuTi kvebis upiratesoba

ZuZuTi kvebis upiratesoba bavSvisTvis

• qalis rZe srulad akmayofilebs Cvilis nutriciul moTxovnilebas

6 Tvis asakamde (mtkicebulebis done II)1,28, igi Seicavs bavSvis

optimaluri zrda-ganviTarebisTvis saWiro yvela sakveb ingredients

saukeTeso TanafardobiT: makro- da mikroelementebs (cila,

naxSirwylebi, cximi, vitaminebi, mineralebi, wyali,) (mtkicebulebis

done I; II) 1,2,3,4,5

B

II

I,II

5

• qalis rZe

_ advilad mosanelebelia;

_ steriluria;

_ mudmivad icvleba bavSvis moTxovnilebis da asakis Sesabamisad,

agreTve bavSvis avadmyofobis dros31.

_ xasiaTdeba tkivildamayuCebeli efeqtiT (mtkicebulebis done

I)6,7.

• ZuZuTi kveba amcirebs Semdegi daavadebebis ganviTarebis risks

(mtkicebulebis done I, II):

_ diarea6,11;

_ respiraciuli infeqcia6,10;

_ otiti6,11;

_ baqteriuli meningiti11;

_ mwvave nekrozuli enterokoliti153;

_ Cvilis uecari sikvdilis sindromi 8,12;

_ simsuqne pubertatul da mozrdil asakSi15,143;

_ alergiuli daavadebebi, maT Soris asTma da atopuri dermatiti154,155;

_ I da II tipis Saqriani diabeti11,155,156 - ZuZuTi kvebis xangrZlivobasa

da insulindamokidebuli diabetis gamovlinebas Soris aRiniSneba

ukuproporciuli damokidebuleba;

_ arsebobs kvlevebi, romelic miuTiTebs ZuZuTi kvebis SemTxvevaSi

bavSvTa asakSi leikozis da avTvisebiani simsivneebis riskis

Semcirebaze158,159.

• bunebrivi kveba xels uwyobs:

_ bavSvis optimalur fizikur ganviTarebas15;

_ gonebriv ganviTarebas (bunebriv kvebaze gazrdili bavSvebis

IQ testi mozrdilobis asakSi ufro maRalia, vidre xelovnur

kvebaze myofi bavSvebis) (mtkicebulebis done II) 11,18,19,48;

_ mxedvelobis srulfasovan ganviTarebas;

_ saxis Zvlebis da kunTovani sistemis ganviTarebasa da swori

Tankbilvis Camoyalibebas (mtkicebulebis done I)20;

_ deda–Svils Soris mWidro fsiqoemociuri kavSiris damyarebas,

bavSvTan usafrTxoebis grZnobis da ndobis Camoyalibebas

(mtkicebulebis done II)20,21,22,23,24.

ZuZuTi kvebis upiratesoba dedisTvis

ZuZuTi kveba mniSvnelovan gavlenas axdens dedis janmrTelobis

mdgomareobaze. kvebis adreuli dawyeba iwvevs saSvilosnos SekumSvas

da icavs qals mSobiarobis Semdgomi sisxldenisagan, ZuZuTi kveba

xels uwyobs saSvilosnos involucias (mtkicebulebis done II)11,20,32.

ZuZuTi kveba xels uwyobs:

_ sarZeve jirkvlisa da sakvercxeebis simsivnuri daavadebebis

ganviTarebis riskis Semcirebas (mtkicebulebis done II);

_ dedis xelaxali daorsulebisagan dacvas - laqtaciuri

amenorea (mtkicebulebis done II)33,44;

_ qalis wonaSi klebas (mtkicebulebis done II)34;

_ Zvlis mineralizaciis procesis gaumjobesebas, rac amcirebs

postklimaqsur periodSi motexilobebis sixSires160,161.

I

I,II

II

I

II

II

II

II

6

dadgenilia, rom ZuZuTi kvebis gagrZeloba bavSvis an dedis avadmyofobis

da hospitalizaciis dros aumjobesebs, maTi janmrTelobis xarisxs

(mtkicebulebis done II, III)35,36.

ZuZuTi kvebis upiratesoba ojaxisa da qveynisaTvis

ZuZuTi kveba ekonomiuria ojaxisa da qveynisTvis _ icavs ojaxs xelovnur

kvebasTan dakavSirebuli danaxarjisagan, amcirebs bavSvis mkurnalobisa da

hospitalizaciis xarjebs. aSS-Si Catarebuli kvleviT dadgenilia, rom igi

amcirebs jandacvaze moxmarebul xarjebs 3,6 bilioniT11, 37,38.

xelovnur kvebasTan dakavSirebuli risk-faqtorebi:

mravalricxovani kvlevebiT dadgenilia, rom xelovnuri kveba zrdis mravali

daavadebis ganviTarebis risks:

_ diarea, maT Soris persistiuli diarea da respiraciuli

infeqciebi165;

_ kvebis ukmarisoba da vitamin A-s deficiti78;

_ alergia da rZis autanloba78,165;

_ zogierT qronikuli daavadeba, maT Soris diabeti163;

_ simsuqne15,143;

_ anemia163,164.

qalis rZis Semadgenloba da misi mniSvneloba

dedis rZe axalSobili da Cvili bavSvis srulfasovani sakvebia (mtkicebulebis done I; II), masSi saukeTeso TanafardobiT aris

warmodgenili bavSvis optimaluri zrda-ganviTarebisTvis saWiro

yvela sacicxlo nivTiereba: wyali, cila, naxSirwyali, cximovani mJavebi,

vitaminebi da mineralebi. dedis rZe Secavs fermentebsa da damcvelobiT

nivTierebebs, ris gamoc igi advili mosanelebelia da mniSvnelovani

damcvelobiTi funqciac gaaCnia1,2,3,5,28,39,43,44.

I, II

II, III

7

cxrili 1

gansxvaveba xelovnur narevs, qalisa da cxovelur rZes Soris

qalis rZe cxoveluri rZe xelovnuri narevebi

baqteriuli

dabinZureba

ar aris SesaZlebelia SesaZlebelia

infeqciis

sawinaaRmdego

faqtorebi

arsebobs

ar arsebobs

ar arsebobs

zrdis

faqtorebi

arsebobs

ar arsebobs

ar arsebobs

cilebi saWiro raodenoba,

iolad asaTvisebeli

Warbi, Znelad

asaTvisebeli

nawilobriv

koregirebuli

Sratis cilebi 65-80 % 20 % nawilSi _ 40-60 %

kazeini 20-40 % 80 % 40-80 %

cximebi sakmarisi raodenoba,

ZiriTadad – ujeri

cximovani mJavebis

Semcveloba, romelic

ioli mosanelebelia

ujeri cximovani

mJavebis deficiti,

myari, aqroladi

mJavebis siWarbe

ujeri cximovani

mJavebis deficiti,

zogierT narevi

Seicavs ujer cximebs

omega6 /omega3

cximovani

mJavebi

Seicavs sakmarisi

raodenobiT

mcire raodenoba zogierT narevs

damatebuli aqvs

lipaza Seicavs ar Seicavs ar Seicavs

laqtoza sakmarisi raodenoba,

β laqtoza- uzrunvelyofs

bifidum baqteriis

zrdas nawlavSi

arasakmarisi

raodenoba,

α laqtoza-

uzrunvelyofs

Esherichia Coli-s zrdas nawlavSi

koregirebuli, ufro

xSirad iwvevs

Esherichia Coli-s zrdas nawlavSi, Tumca

SesaZlebelia

damatebuli hqondes

eubiotikebi

rkina mcire raodenoba,

kargad Seiwoveba

mcire raodenoba,

cudad Seiwoveba

xelovnurad

damatebuli, cudad

Seiwoveba

vitaminebi

sakmarisi

raodenobiT

A da C vitaminebis deficiti

xelovnurad

damatebuli

vitaminebis nakrebi

wyali sakmarisi

raodenobiT

Txoulobs

damatebas

SeiZleba saWiro

gaxdes damateba.

8

cila 1,2,3,5,28,39,43,44

cilis Semcveloba qalis rZeSi srulad Seesabameba bavSvis kvebiT

moTxovnilebas. cila aucilebeli komponentia bavSvis fizikuri da gonebrivi

ganviTarebisaTvis. D

• qalis rZis cila ZiriTadad warmodgenilia Sratis cilebiT

α�laqtalbuminiTa da laqtoferiniT, romlebic bavSvisTvis Seucvleli

aminomJaveebis wyaroa. qalis rZis 20 aminomJavidan 8 Seucvleleli

aminomJavaa, romlis sinTezi bavSvis organizms ar SeuZlia. maRalia

taurinis raodenoba, romelic organizmSi mxolod mcire raodenobiT

sinTezirdeba da aucilebelia nervuli qsovilis ganviTarebisa da

momwifebisTvis;

• qalis rZis cila advilad iSleba da aiTviseba. qalis rZeSi naklebia

kazeinis Semcveloba. Tanafardoba Sratis cilebsa da kazeins Soris

Seadgens 60-70/40-30. qalis rZis kazeini Zroxis rZis kazeinisgan

gansxvavdebiT SedarebiT advilad mosanelebelia;

• qalis rZis cilebis garkveuli nawili (imunoglobulinebi, laqtoferini,

lizocimi da sxv.) dauSlelad gadis kuW-nawlavis traqts da aqtiurad

monawileobs damcvelobiTi funqciis SesrulebaSi.

cximi 1,2,3,5,28,39,43,44

cximi bavSvis organizmisTvis energiis erT-erT ZiriTad wyaros warmoadgens.

• cximze modis qalis rZis kaloriulobis daaxloebiT naxevari;

• qalis rZis cximi advilad iSleba da aiTviseba bavSvis kuW-nawlavis

traqtSi. rZeSi Semavali fermenti lipaza xels uwyobs cximis monlebis

process;

• qalis rZe gamoirCeva ujeri cximovani mJavebis maRali SemcvelobiT. ujeri

cximovani mJavebi, maT Soris grZeli da saSualojaWvovani

trigliceridebi (araqidonis da linolenis, omega-3) aucilebelia bavSvis

nervuli qsovilis, gansakuTrebiT ki tvinis qerqis ganviTarebisa da

mxedvelobis normaluri funqciis CamoyalibebisTvis, ris gamoc maT

xSirad tvinis arqiteqtorebsac uwodeben;

• qalis rZe mdidaria qolesteriniT;

• sicocxlis pirveli Tveebis ganmavlobaSi bavSvs ar Seswevs unari najeri

cximovani mJavebi gardaqmnas ujer cximovan mJavebad. am nivTierebebis

wyaros mxolod dedis organizmi warmoadgens, romelic amaragebs ujeri

cximovani mJavebiT nayofs orsulobis periodSi, axalSobilsa da Cvils

ZuZuTi kvebis dros;

• cximis Semcveloba qalis rZeSi icvleba:

_ dRis ganmavlobaSi (diliT SedarebiT naklebia, saRamos meti);

_ bavSvis asakTan erTad;

_ uSualod kvebis procesSi (wina rZe Seicavs nakleb, xolo ukana rZe

meti raodneobiT cxims).

9

naxSirwyali 1,2,3,5,28,39,43,44

naxSirwylebi qalis rZeSi ZiriTadad laqtoziT (β) da oligosaqaridebiT

aris warmodgenili.

• naxSirwylebze modis qalis rZis kaloriulobis daaxloebiT 40%;

• qalis rZis naxSirwylebi advilad aiTviseba, qalis rZeSi Semavali

fermenti laqtaza gardaqmnis maT martiv Saqrebad;

• naxSirwylebi warmoadgens energiis erT-erT ZiriTad wyaros bavSvis

organizmisTvis;

• laqtoza Tavis tvinis ujredebis ZiriTadi energetikuli wyaroa da xels

uwyobs tvinis ganviTarebas;

• β laqtoza xels uwyobs nawlavis normaluri floris Camoyalibebas

(kerZod, ki Bifudm Bacteriae-s zrdas) da Sesabamisad kuW-nawlavis traqtis

normalur funqcionirebas.

vitaminebi da mineralebi

qalis rZeSi vitaminebisa da mikroelementebis Semcveloba mniSvnelovanwilad

damokidebulia dedis kvebaze28,43,44,45,46.

• Tu deda mravalferovani sakvebiT ikvebeba, rZe sakmarisi raodebiT Seicavs

aRniSnul nivTierebebs da 6 Tvis asakamde bavSvTan mikroelementebis

deficitis ganviTarebis riski dabalia;

• qalis rZeSi arsebuli vitaminebi da mikroelementebi advilad aiTviseba

bavSvis organizmis mier.

dedis rZeSi arsebuli mikroelementebi da vitaminebi or jgufad iyofa78:

I jgufi - mikroelementebi, romelTa Semadgenloba dedis rZeSi

damokidebulia dedis kvebasa da janmrTelobis mdgomareobaze.

II jgufi - mikroelementebi, romelTa Semadgenloba dedis rZeSi ar aris

damokidebuli dedis kvebasa da janmrTelobis mdgomareobaze (ix. cxrili 2.)

10

cxrili 2

dedis rZeSi arsebuli mikroelementebi da vitaminebi

I jgufi II-jgufi

• vit _ B1

• vit _ B2

• vit – B6

• vit – B12 • vit – D • vit – A • iodi

• seleniumi

daxasiaTeba

• dedis mier aRniSnuli

mikroelementebis moxmarebis dabali

done iwvevs maTi koncentraciis

daqveiTebas rZeSi, rac aisaxeba

bavSvis ganviTarebaze

• bavSvs aqvs aRniSnuli

mikroelementebis mcire maragi. maTi

saWiro donis SenarCuneba

damokidebulia miRebul sakvebze

• dedis racionaluri kveba advilad

aRadgens mikroelementebis

koncentracias dedis rZeSi.

• TuTia

• rkina

• foliumis mJava

• kalciumi

daxasiaTeba

• dedis mier am mikroelementebis

moxmarebis dabali done, an maTi

deficiti

_ naklebad aisaxeba maT

Semcvelobaze rZeSi, ar axdens

gavlenas mikroelementebis

koncentraciaze

_ bavSvi rZiT iRebs maT sakmaris

raodenobas

_ dedasTan maRalia mocemuli

mikroelementebis deficitis

ganviTarebis riski.

• rkina - qalis rZeSi rkina SedarebiT dabali koncentraciiT aris

warmodgenili, Tumca misi aTvisebis unari daaxloebiT oTxjer ufro

maRalia rkiniT gamdidrebul xelovnur sakvebTan SedarebiT. droul

axalSobils dabadebisas rkinis sakmarisi maragi aqvs da eqskluziuri

ZuZuTi kvebis SemTxvevaSi qalis rZe srulad akmayofilebs Cvilis

moTxovnilebas rkinaze 6 Tvis asakamde.

• kalciumi da fosfori - qalis rZeSi kalciumisa da fosforis

Tanafardoba saukeTesoa mocemuli mikroelementebis srulyofili

SewovisaTvis.

• TuTia - TuTiis Semcveloba qalis rZeSi dabalia, Tumca igi ufro kargad

aTviseba, vidre xelovnuri narevis an sxva sakvebi produqtis TuTia.

eqskluziur ZuZuTi kvebaze myof bavSvebs 6 Tvemde praqtikulad ar

uvlindebaT TuTiis deficiti.

11

cxrili 3

vitaminebisa da mikroelementebis funqciebi

vitamini

minerali

wyaro funqcia deficitiT gamowveuli

mdgomareoba

vit A RviZli, rZis

produqtebi, Tevzis

qoni, mwvane da

narinjisferi

bostneuli

yvela organos (maT

Soris mxedvelobis)

funqcionirebasa da

zrdis procesSi

monawileoba

zrdaSi CamorCena,

mxedvelobis

daqveiTeba,

gansakuTrebiT RamiT

e.w. ”qaTmis sibrmave”.

xSiri avadoba imuni

tetis daqveiTebis gamo

vit D Tevzi, Tevzis qoni,

RviZli, kvercxis guli

Zvlebis formireba,

zrdaSi monawileoba

Zvlebis darbileba da

deformacia –“raqiti”

vit C citrusebi, bulgaruli

wiwaka, askili

pomidori, kombosto

yvela saxis ujredis

funqcionirebaSi

monawileoba.

suravandi, pirovnuli

Tvisebebis cvlileba,

reaqciis da aqtivobis

daqveiTeba, daRliloba

vit B2 mwvane foTlovani

bostneuli, xorci,

kvercxi, rZe

nervuli sistemis

moqmedebasa da

zrdaSi monawileoba

pirovnuli Tvisebebis

cvlileba, reaqciis

unaris da aqtivobis,

daqveiTeba, daRiloba

vit B1 marcvleuli, pur-

funTuSeuli, barda,

soio, lobio, Txili,

xorci

naxSirwylebis

aTvisebaSi

monawileoba

koncentraciis da

mexsierebis daqveiTeba,

gaRizianebadoba da

depresia. mozardebSi

agresiuli qceva

vit B12 xorci, Tevzi, kvercxi,

rZe

sisxlis warmoqmnasa

da nervuli sistemis

funqcionirebaSi

monawileoba

sisxlnakleboba -

anemia

folis

mJava

safuari, forToxali,

Tirkmeli, RviZli,

mwvane foTlovani

bostneuli

sisxlis warmoqmnaSi

monawileoba

sisxlnakleboba -

anemia

rkina RviZli, xorci, kvercxis

guli, Tevzi, marcvle-

uli, lobio, barda,

soio, ispanaxi, vaSli

sisxlis warmoqmna,

gonebrivi ganviTrebis

xelSewyoba

anemia, zrdaSi

CamorCena, gonebrivi

ganviTarebis Seferxeba,

Sromisunarianobis

daqveiTeba

kalciumi rZis produqti, Tevzi,

mwvane foTlovani

bostneuli

Zvlebis da kbilebis

Camoyalibeba, zrdis

processa da kunTebis

muSaobaSi

monawileoba

Zvlebis darbileba da

deformacia, krunCxva,

zrdis Seferxeba

12

iodi iodiani marili, zRvis

produqtebi

gonebrivi ganviTare

bis xelSewyoba

Ciyvi, gonebrivi

ganviTarebis mkveTri

Seferxeba (kretinizmi)

TuTia xorci, Tevzi, kvercxi,

marcvleuli, parkosnebi

fizikuri ganviTareba,

sasqeso organoebis

funqcionirebaSi

monawileoba,

Wrilobebis

Sexorceba

zrdaSi CamorCena,

sqesobrivi

ganviTarebis Seferxeba.

ftori ftorirebli wyali,

Cai,zRvis produqti

Zvlebisa da kbilebis

Camoyalibeba

Zvlebis deformacia da

kbilebis dazianeba

wyali

qalis rZe 80-90% wyals Seicavs da xSiri kvebis SemTxvevaSi dedis rZe

srulad akmayofilebs bavSvis moTxovnilebas siTxeebze. amitom

eqskluziuri ZuZuTi kvebis dros bavSvi ar saWiroebs damatebiT

siTxeebis miRebas (mtkicebulebis done II)41.

fermentebi28,43,44,47

qalis rZe, daaxloebiT, 20 ferments Seicavs (laqtaza, lipaza, amilaza,

ribonukleaza, peroqsidaza da sxv), romlebic xels uwyoben:

• qalis rZeSi Semavali sakvebi ingredientebis monelebas;

• mikroelementebis da vitaminebis aTvisebas.

mocemuli fermentebis nawili xasiTdeba baqteriociduli TvisebebiT.

zrdis faqtorebi

qalis rZe Sicavs sxvadasxva zrdis faqtors, mag. epidermuli, nervuli

qsovilis da sxv.

epidermuli zrdis faqtori xels uwyobs:

• kuW-nawlavis traqtis qsovilebis momwifebasa da diferenciacias;

• nawlavis barieruli funqciis Camoyalibebas, rac Tavis mxriv amcirebs

antigenebis Sewovas.

nervuli qsovlis zrdis faqtori xels uwyobs:

• nervuli qsovilebis momwifebasa da diferencirebas.

arsebobs mravali sxva zrdis faqtori, romelTa funqciac sakmarisad

Seswavlili ar aris.

hormonebi

qalis rZe Seicavs TxuTmetamde hormons, romlebic xels uwyoben bavSvis

organoTa da sistemebis momwifebas.

II

13

damcvelobiTi nivTierebebi

qalis rZe Seicavs mraval nivTierebas, romelic erTi mxriv icavs bavSvs

mravali infeqciuri, arainfeqciuri da alergiuli daavadebisagan, xolo

meore mxriv xels uwyobs bavSvis imunuri sistemis momwifebas.

cxrili 4

qalis rZis zogierTi damcvelobiTi nivTiereba da misi efeqti

faqtori funqcia sekretoruli A

imunoglobulini (SIg A)

icavs nawlavis kedels mis sanaTurSi

arsebuli antigenebis zemoqmedebisagan, axdens

axalSobilis imunuri sistemis stimulacias

laqtoferini konkurencias uwevs baqteriebs rkinis

aTvisebaSi da, aqedan gamomdinare, Trgunavs

maT zrdas

lizocimi antibaqteriuli fermenti: axorcielebs

mikrobis garsis liziss

bifidum–faqtori xels uwyobs bifidum baqteriebis zrdas

makrofagi STanTqavs baqteriebs

limfociti gamoimuSavebs imunoglobulinebs B

(limfocitebi) da limfokinebs

komplementi xels uwyobs baqteriebis liziss

interferoni antivirusuli faqtori

oligosaqaridi ainhibirebs baqteriis dafiqsirebas qsovilis

epiTelze

B12 da foliumis

damakavSirebeli cilebi

konkurencias uwevs baqteriebs am vitaminebis

aTvisebaSi da, aqedan gamomdinare, Trgunavs

maT zrdas

antistafilokokuri

faqtori

antistafilokokuri moqmedebis lipidi

antilambliuri faqtori antilambliuri moqmedebis lipidi

zrdis faqtorebi nawlavis momwifebis xelSewyoba

antioqsidanti icavs Tavisufali radikalebis

zemoqmedebisagan

imunoglobulinebi antibaqteriuli da antivirusuli moqmedeba

α2- makroglobulini antivirusuli moqmedeba

araqidonis mJava, omega 3,6

cximovani mJavebi

nervuli qsovilis da Tavis tvinis ujreduli

membranis Semadgeneli nawili

antioqsidantebi icaven qsovilebs Tavisufali radikalebiT

gamowveuli dazianebisagan

rZis produqcia

rZis produqcia da gamoyofa ZiriTadad hipofizis hormonebiT _

prolaqtiniTa da oqsitociniT regulirdeba. ZuZus wovis procesi

astimulirebs orive hormonis gamomuSavebas. Sesabamisad, rac ufro xSirad

wovs bavSvi, miT ufro maRalia hormonebis koncentracia dedis sisxlSi da

miT metia gamomuSavebuli rZis raodenoba.

14

• prolaqtini xels uwyobs rZis warmoqmnas. prolaqtinis produqcia

gansakuTrebiT maRalia Ramis saTebSi Aamdenad, Ramis kveba

erTerTi mniSvnelovani faqtoria rZis gamomuSavebis

regulirebisTvis (mtkicebulebis done II)14,21.

• oqsitocini ganapirobebs sarZeve jirkvlis kunTovani ujredebis

SekumSvas, rasac Tan sdevs rZis gamoyofa. oqsitocinis done

damokidebulia qalis fsiqologiur mdgomareobazec: bavSvTan

siaxlove, dedis survili ZuZuTi kvebos bavSvi, dadebiTi emociuri

ganwyoba, mSvidi da myudro garemo xels uwyobs oqsitocinis

gamomuSavebas da piriqiT, stresuli situacia, gaRizianeba aferxebs

mas. oqsitocini moqmedebs saSvilosnos kunTovan qsovilzec,

Sesabamisad misi maRali done mniSvnelovania saSvilosnos

SekumSvisTvis (mtkicebulebis done II)11,14,21,33.

• inhibitorebi aregulireben rZis sekreciis kontrols da icaven

sarZeve jirkvals Zlieri gadavsebisagan. aRniSnuli nivTierebebi

aqveiTeben rZis gamomuSavebis intensivobas, im SemTxvevaSi, Tu

ZuZuSi rZe didxans rCeba. rZis produqciisTvis gansakuTrebuli

mniSvneloba sarZeve jirkvlis bolomde daclas eniWeba

(mtkicebulebis done II) 51,52

• dedis mier Warbi siTxis miReba ar axdens gavlenas rZis

produqciaze (mtkicebulebis done I) 49

miuxedavad imisa, rom organizmis orive sarZeve jirkvali erTi da imave

hormonebis moqmedebas eqvemdebareba, rZis raodenoba SesaZlebelia maTSi

gansxvavebuli iyos, rac ganpirobebulia bavSvis mier TiToeuli sarZeve

jirkvlidan gamowovili rZis raodenobiT44,45,46,78.

optimaluri ZuZuTi kvebis principebi

janmos rekomendaciiT optimaluri ZuZuTi kvebis principebia44,45,46:

1. ZuZuTi kvebis adreuli dawyeba da kani kanTan kontaqti;

2. moTxovnilebiTi, xSiri ZuZuTi kveba (RamiT kveba, orive ZuZudan kveba);

3. eqskluziuri ZuZuTi kveba 6 Tvemde;

4. ZuZuTi kvebis gagrZeleba 2 wlamde.

1. ZuZuTi kvebis adreuli dawyeba da kani kanTan kontaqti

janmrTeli, drouli axalSobilis kani kanTan kontaqti dedasTan da ZuZuze pirveli moWideba unda ganxorcieldes dabadebidan pirveli 1

sT-is ganmavlobaSi. kani kanTan kontaqtis xangrZlivoba minimum 30

wuTi unda iyos da sasurvelia gagrZeldes 2 saaTi168,169. kani kanTan kontaqtis

procesSi unda ganxorcieldes pirveli moWideba, mas Semdeg, rac bavSvi

gamoxatavs kvebisTvis mzaobas (rekomendacia - D)44. sakeisro kveTis dros

rZis produqciis intensivoba da gamomuSavebuli rZis raodenoba

damokidebulia sarZeve jirkvlis daclis sixSireze da ara mxolod dedis

hormonebis doneze (mtkicebulebis done II)44,45,51,52,54.

D

II

II

II

I

15

kani kanTan kontaqti tardeba dedis narkozidan sruli gamofxizlebis

Semdeg5.

kani kanTan kontaqti da ZuZuTi kvebis adreuli dawyeba xels uwyobs:

• efeqturi woviTi refleqsebis Camoyalibebas (mtkicebulebis

done II)58,59;

• axalSobilis sxeulis normaluri temperaturis SenarCunebas

(mtkicebulebis done I)56,60,61;

• laqtaciis process (mtkicebulebis done II)14,24,55,62,64;

• oqsitocinis gamomuSavebas, saSvilosnos SekumSvas da qalis

dacvas mSobiarobis Semdgomi sisxldenisagan (mtkicebulebis

done II)21;

• dedasa da bavSvs Soris mWidro fsiqoemociuri kavSiris

damyarebas (mtkicebulebis done II)22,23,24,32,63.

ZuZuze pirveli moWidebis dros axalSobili iRebs pirvel rZes – xsens,

romelic maRalkaloriuli nivTierebaa. igi mcire raodenobiT gamoiyofa,

saSualod 30-100 ml pirvel 24 sT-Si, Tumca xSiri kvebis SemTxvevaSi

mTlianad akmayofilebs bavSvis moTxovnilebas sakvebsa da siTxeze. xsenis

moculoba Seesabameba axalSobilis kuWis mcire tevadobas

(mtkicebulebis done II)70. igi advilad mosanelebelia, mdidaria

Sratis cilebis identuri wvrildispersiuli cilebiT, Seicavs

natriumisa da magniumis marilebs rac xels uwyobs nawlavebis

peristaltikis gaZlierebas da mekoniumis gamoZevebas. xsenis miReba

amcirebs enterohepatul cirkulacias da Sesabamisad aqveiTebs

axalSobilTa siyviTlis ganviTarebis albaTobas (mtkicebulebis

done II)55,61,65,66. xsenis miReba xels uwyobs metabolur aqtivobas

(mtkicebulebis done I), aregulirebs Saqris dones (mtkicebulebis

done II)56,61,68,69.

xsenSi didi raodenobiT aris vitaminebi, gansakuTrebiT ki A vitamini da

karotini, rac xels uwyobs mxedvelobis formirebas. xseni mdidaria

bunebrivi antisxeulebiT, imunoglobulinebiT. damcvelobiTi nivTierebebis

maRali Semcvelobis gamo xsenis miRebas pirvel imunizaciasac uwodeben.

rekomendacia:

dabadebidan pirveli erTi saaTis ganmavlobaSi axalSobilisTvis

aucileblia xsenis miReba (rekomendacia B)71,72,73,74.

ar aris mizanSewonili prelaqtaciuri sakvebis gamoyeneba.

prelaqtaciuri sakvebi (formula, glukozis xsnari, wyali da sxv.)

xels uSlis laqtaciis Camoyalibebas da zrdis axalSobilis

inficirebis risks (rekomendacia B)71,72,73,74.

2. moTxovnilebiTi, xSiri ZuZuTi kveba

ZuZuTi kveba unda ganxorcieldes bavSvis moTxovnilebis mixedviT, dedam

bavSvs ZuZu unda miawodos maSinve, rogorc ki igi iwyebs SimSilis niSnebis

gamoxatvas. SimSilis niSnebia11, 43, 44, 45

:

• sxvadasxva saxis bgerebi,

B

II

I

II

II

II

II

B

II

16

• tuCebis cmacuni,

• woviTi moZraoba,

• tirili da sxv.

tirili bavSvis mier SimSilis grZnobis gamoxatvis ukiduresi

saSualebaa, sasurvelia bavSvs sakvebi SesTavazon manam, sanam tirils

daiwyebs ( rekomendacia - C)11, 43, 44, 45.

•

kvebis sixSire

axalSobilis kvebis sixSire dRe-Ramis ganmavlobaSi saSualod unda

Seadgendes 8-12-s (mtkicebulebis done I, II)50,53,54.

rZis gazrdili produqcia da bavSvis Segueba woviT procesebTan iwvevs

kvebis jeradobis Semcirebas. 1-1,5 Tvis asakSi Cvili gamoimuSavebs kvebis

sakuTar rutinul wess da ikvebeba daaxloebiT 7-10-jer dRe-RameSi. kvebaTa

Soris intervali am periodSi ar unda aRematebodes 3 sT-s. Tu bavSvi wonaSi

kargad imatebs da dedasTan ar aris gamoxatuli hipogalaqtiis niSnebi,

xangamoSvebiT, dasaSvebia mxolod erTi 6 sT-iani intervali (sasurvelia

Ramis periodSi).

zogierTi axalSobili SimSilis SemTxvevaSi axangrZlivebs Zilis periodebs,

Tu bavSvi Tavad ar iRviZebs 3 saaTis Semdeg, igi unda gaaRviZon da

kvebon ZuZuTi (mtkicebulebis done III)51,82,83. gaRviZebisTvis SeiZleba

Semdegi xerxebis gamoyeneba:

_ tansacmlis da safenebis gamocvla;

_ xelSi ayvana;

_ zurgis, muclis an kidurebis msubuqi masaJi.

kvebis xangrZlivoba da miRebuli sakvebis moculoba

Cvili Tavad aregulirebs erT jerze misaRebi sakvebis raodenobas. drouli,

janmrTeli axalSobili da Cvili saSualod wovs 15-30 wT. iSviaT SemTxvevaSi

40 wT81. ar aris mizanSewonili wovis xangrZlivobis SezRudva. kvebis

xangrZlivoba damokidebulia TiToeuli bavSvis individualur Tvisebebze da

mis aqtivobaze.

dadgenilia, rom Tu qalis rZe Seicavs naklebi raodnebiT cxims

Cvili moTxovnilebis dasakmayofileblad ufro didxans wovs

(mtkicebulebis done I, II)78,79.

kvebis dros bavSvma bolomde unda dacalos erTi sarZeve jirkvali, raTa man

miiRis rogorc wina, ise ukana rZe. Tu bavSvi ver clis bolomde ZuZus,

saWiroa darCenili rZis gamowvela da misi damateba kovziT.

Tu bavSvi mTlianad clis erT ZuZus da ar kmayofildeba, kveba unda

gagrZeldes meore sarZeve jirkvlidan. Semdegi kveba iwyeba im ZuZuTi,

romliTac damTavrda wina kveba (mtkicebulebis done II)78,79.

C

I, II

I, II

III

II

17

rekomendacia:

axalSobilma da Cvilma ZuZu unda wovos, sanam ar dakmayofildeba.

erT kvebaze bavSvi unda ikvebebodes orive ZuZudan.

Ramis kveba xels uwyobs laqtaciis process (rekomendacia D).

3. eqskluziuri ZuZuTi kveba 6 Tvemde

pirveli 6 Tvis ganmavlobaSi qalis rZe mTlianad akmayofilebs bavSvis

nutriciul moTxovnilebas30.

6 Tvemde bavSvs ar sWirdeba sakvebis, siTxis an wylis damateba.

dadgenilia, rom moTxovnilebiT ZuZuTi kvebaze myof Cvilebs ar

esaWiroebaT wylis damateba cxeli klimatis pirobebSic ki


6 Tvis Semdeg aucilebelia kvebis racionSi damatebiTi sakvebis Setana.

rekomendacia

pirveli 6 Tvis ganmavlobaSi Cvili unda ikvebebodes mxolod ZuZuTi (rekomendacia A)30,44,45,46.

• ar aris rekomendebuli mikroelementebis deficitis Sevsebis mizniT 6

Tvis asakamde damatebiTi sakvebis dawyeba. aucilebelia, dedis dietis

daregulireba da saWiroebis SemTxvevaSi mikroelementebis

medikamenturi formiT daniSvna28,82,86.

4. ZuZuTi kvebis gagrZeleba 2 wlamde

bunebrivi kvebis gagrZeleba rekomendebulia 2 wlis asakamde, 6 Tvidan

damatebiT sakvebTan erTad (rekomendacia D)44,45,46;

ZuZuTi kvebaze myofi bavSvebi 12-23 Tvis asakSi dedis rZidan iReben maTTvis

aucilebeli energiis 35-40%-s27;

2 wlamde ZuZuTi kveba xels uwyobs bavSvis gonebriv ganviTarebas11,18,19,48,

mozrdil asakSi qronikuli daavadebebisa da simsuqnis ganviTarebis riskis

Semcirebas15,45,46.

ZuZuTi kvebis gadaCveva mizanSewonilia daiwyos 2 wlis asakisTvis,

dedis rZis Canacvleba warmoebs TandaTanobiT, asakis Sesabamisi

sxvadasxva sakvebis gamoyenebiT (rekomendacia D).

ZuZuTi kvebis teqnika

ZuZuTi kvebis teqnikis dacva uzrunvelyofs laqtaciis normalur

mimdinareobas da zrdis mis xangrZlivobas (mtkicebulebis done II) 87,88,89.

ZuZuTi kveba wovisa da ylapvis mudmiv koordinacias moiTxovs. kvebis

efeqturoba ganisazRvreba swori moWidebiTa da kvebis poziciiT

(mtkicebulebis done III)89,90,91.

A

D

D

D

I, II

II

III

18

cxrili 5

swori da araswori moWidebisa da poziciis niSnebi

swori moWidebis da poziciis

niSnebi

araswori moWidebis da poziciis

niSnebi

bavSvi mTeli sxeuliT

Setrialebulia dedisaken da exeba

mis sxeuls

bavSvi Semotrialebulia dedisken,

magram ar exeba mis sxeuls

piri farTod aris gaRebuli, tuCis

lorwovani Cans

piri mokumulia ise, TiTqos

moWidebulia sawovaraze, tuCis

lorwovani ar Cans

loyebi gamoberilia da ar

monawileobs wovis aqtSi

loyebi Cavardnilia da monawileobs

wovis aqtSi

bavSvis nikapi mibjenilia ZuZuze

nikapi ar aris ZuZuze mibjenili

bavSvis piris RruSi dvrilTan

erTad moTavsebulia areolas 2,5 sm

bavSvis piris RruSi moTavsebulia

mxolod dvrili

bavSvis zeda tuCTan areolas ufro

meti nawili Cans, vidre qveda

tuCTan

areola kargad Cans orive tuCis gareT

1-2 woviT aqts moyveba ylapva ismis wklapuni. ylapva moyveba 10-12

woviT moZraobas

bavSvi kmayofilia, da mSvidi bavSvi ukmayofiloa, tiris

deda ar ganicdis tkivils deda grZnobs dvrilis tkivils

dedis xeliT fiqsirebulia bavSvis

kefa da kiseri

dedis xeliT fiqsirebulia Txemis

midamo

bavSvis Tavi, kiseri da sxeuli erT

xazzea

bavSvis Tavi da sxeuli ar aris erT

swor xazze, dedisken mitrialebulia

mxolod Tavi

19

rekomendacia:

samedicino personalma dedas unda aswavlos ZuZuze swori moWidebisa

da swori poziciis niSnebi: (rekomendacia D, mtkicebulebis done I,

II);

ZuZuze swori moWideba mkveTrad amcirebs dvrilebis dazianebis risks

(mtkicebulebis done I, II)88,91;

ZuZuTi kvebis poza ise unda SeirCes, rom qalic da bavSvic Tavs

komfortulad grZnobdnen81.

A

akvnis pozicia ragbis burTis pozicia

pirvel dReebSi deda ZuZus awovebs mwoliare mdgomareobaSi, ,,gverdze

wolis’’ pozicias xSirad mimarTaven epiziotomiebis, sakeisro kveTis Semdeg

an hipergalaqtiis dros. ZuZuTi kveba SesaZlebelia mjdomare mdgomareobaSic

_ ,,akvnis’’ an ,,ragbis burTis’’ pozicia, aseTi poziciis dros mosaxexebelia

baliSis gamoyeneba. ,,daTvis’’ pozicias iyeneben im SemTxvevaSi Tu bavSvs

xSirad aReniSneba wamoqafeba – kvebis dros dedas bavSvi vertikalurad

uWiravs, aseTi mdgomareoba xels uwyobs kuWis advilad daclas da

wamoqafebis sixSiris Semcirebas.

kvebis dros bavSvi mTeli sxeuliT unda ekvrodes dedas, mibrunebuli iyos

misken, ise rom xedavdes dedis saxes da Tvlebs. Dkvebis procesSi deda ar

unda daiRalos, ar unda daeZabos kunTebi, Sesabamisad iseTi pozicia unda

SearCios, romelSic maqsimalurad moxerxebulad igrZnobs Tavs.

G

gverdze wolis pozicia zurgze wolis pozicia

D

I, II

20

sawovara da boTli

ZuZuTi kvebis dros ar aris mizanSewonili sawovaras da boTlis gamoyeneba,

gansakuTrebiT sawyis etapze, vidre bavSvs kargad ar Camouyalibdeba swori

moWidebis Cveva. vinaidan boTlidan wovis procesSi bavSvi

gansxvavebulad eWideba sawovaras, misi xSiri gamoyenebis SemTxvevaSi

ki veRar axerxebs ZuZuze swori moWidebis ganxorcielebas (piris

aparatis Sesabamisi kunTebis ganviTarebis Seferexebis gamo), rac

seriozulad aferxebs ZuZuTi kvebis warmatebiT ganxorcielebas

(rekomendacia D)44,45,46.

• boTlidan kvebis gamoyeneba zrdis ZuZuze uaris Tqmis risks


• sawovaras da satyuaras sistematuri gamoyeneba zrdis ZuZuTi

kvebis problemebis risks (mtkicebulebis done I,

rekomendacia A )8,9. • satyuaras sistematuri gamoyeneba zrdis otitis ganviTarebis

risks (mtkicebulebis done II)8,9.

kvebis koreqcia

intensiuri zrdisa da ganviTarebis gamo bavSvs SesaZlebelia dasWirdes

zogierTi vitaminisa da mineraluri nivTierebis damateba. miuxedavad imisa,

rom qalis rZe saukeTeso sakvebia, sxva mikroelementebsa da vitaminebTan Se-

darebiT xSiria K, D vitaminebis, agreTve rkinis da fToris deficiti.

K vitaminis fiziologiuri deficiti viTardeba sicocxlis pirvel dReebSi,

rac ganpirobebulia qalis rZeSi misi dabali SemcvelobiT, xsenis mcire

rodenobiT da bavSvis organizmis uunarobiT moaxdinos mocemuli vitaminis

sinTezi. aqedan gamomdinare, yvela axalSobils samSobiaro saxlSi eniSneba

K vitamini. (ix. gaidlaini ,,axalSobilis movla samSobiaro saxlSi”), rac

amcirebs axalSobilTa hemoragiuli daavadebis ganviTarebis risks.

D vitaminis aTviseba qalis rZidan sakmaod maRalia, amitom avtorTa

umravlesoba, bunebrivi kvebis dros, D vitaminis deficitis ZiriTad mizezad

Tvlis insolaciis naklebobas.

• SedarebiT naklebi insolaciis pirobebSi, raqitis prevenciis mizniT,

mizanSewonilia 6 Tvis asakamde D vitaminis medikamenturi

formis saprofilaqtiko dozis (200-400 se) gamoyeneba


• rkinis deficiti Cvils SesaZlebelia gamouvlindes wlamde asakSi.

pirveli Tveebis ganmavlobaSi bavSvi moixmars orsulobis bolo

periodSi mis organizmSi deponirebuli rkinis marags. Cveulebriv,

aRniSnuli maragis utilizacia xdeba 4-6 Tvis, xolo paTologiuri

orsulobis da dRenaklulobis SemTxvevaSi 2-3 Tvis asakisTvis, rac

ganapirobebs e.w. fiziologiuri anemiis ganviTarebas. Tu

rkinadeficituri mdgomareoba gamoixateba 6 Tvemde, misi koreqcia

rekomendebulia rkinis preparatebiT da ara sakvebi danamatebiT. 6

Tvis Semdeg mizanSewonilia racionSi rkiniT mdidari produqtebis

gamoyeneba145.

D

A

I, II

II

III

21

ioddeficitis endemur kerebSi SesaZlebelia bavSvis, iseve, rogorc dedis

sakvebs dasWirdes iodis damateba.

fToris deficiti gansakuTrebiT xSiria iseT adgilebSi, sadac ar xdeba

sasmeli wylis fTorireba. mraval qveyanaSi rekomendebulia fToris

minimaluri doziT (0,25 mg/ dRe-RameSi) daniSvna 6 Tvis asakis Semdeg, Tu

sasmeli wyali Seicavs 0,3 mg/l-ze nakleb fTors. amave dros dauSvebelia

misi daniSvna profilaqtikis mizniT, Tu ar aris cnobili sasmel wyalSi

fToris Semcveloba.

kalciumis da fosforis deficitis SemTxvevaSi iniSneba maTi Semcveli

preparatebi.

ZuZuTi kvebis efeqturobis Sefaseba

ZuZuTi kvebis warmatebiT ganxorcielebis erTerT aucilebel pirobas

warmoadgens kvebis efeqturobis Sefaseba, rac aucileblad unda

ganaxorcielos rogorc samSobiaro saxlis, ise pirveladi jandacvis

rgolis samedicino personalma. Sefasebis Sedegebi unda aisaxos

samedicino istoriaSi (rekomendacia D, mtkicebulebis done II, III)92.

ZuZuTi kvebis efeqturobis Sefasebis meTodebi

• anamnezis Segroveba (diurezi, defekacia);

• kvebis teqnikis Sefaseba;

• wonis namatis Sefaseba;

• dedis sarZeve jirkvlisa da dvrilis mdgomarobis Sefaseba.

samSobiaro saxli – ZuZuTi kvebaze dakvirveba mizanSewonilia warmoebdes

dRis ganmavlobaSi 1-2-jer. fasdeba kvebis teqnika, bavSvis wona, Sardvis

sixSire, nawlavTa moqmedeba, dedis sarZeve jirkvlis mdgomareoba.

pirveladi jandacvis rgoli - Sefaseba unda ganxorcieldes patronaJis

vizitebis dros. gansakuTrebuli mniSvneloba aqvs pirvel vizits, romlis

drosac gamoiyeneba Sefasebis yvela meTodi. kvebasTan dakavSirebuli

problemebis gamovlenis SemTxvevaSi Sefaseba grZeldeba Semdeg vizitebzec.

Sefasebis Sedegebi unda dafiqsirdes bavSvis samedicino istoriaSi.

1.Aanamnezi

anamnezis Segrovebisas gansakuTrebuli yuradReba eqceva Semdeg maCveneblebs:

• kvebis sixSire (axalSobili unda ikvebebodes 8-12-jer, 6 Tvemde

Cvili minimimum 7-jer 24 saaTSi) (mtkicebulebis done II)1,150,53,54;

• diurezi – pirvel dReebSi SesaZlebelia gamovlindes Sardvis sixSiris

ufro dabali maCvenebeli fiziologiuri anuriis gamo. sicocxlis

mesame-meoTxe dRidan ki 24 saaTSi minimum 6-jer, rac miTiTebs imaze,

rom bavSvi iRebs sakmarisi raodenobiT rZes. (Tu iyeneben pampers,

Sardvis sixSiris gansazRvrisTvis rekomendeulia bavSvs gaxadon

pampersi da 24 saaTis ganmavlobaSi daiTvalon sveli safenebis

raodenoba)1,92;

D

II

22

• defekaciis sixSire da ganavlis konsistencia – pirveli 48 saaTis

Semdeg sixSire unda iyos 1-3 dRe-RameSi, me-4-5 dRisTvis ganavali xdeba

moyviTalo feris fafisebri konsistenciis1,92;

• axalSobilis qceva – kmayofili da mSvidi yvela kvebis Semdeg;

• kvebis saSualo xangrZlivoba xSirad ar unda aRematebodes 40 wT-s81.

2. kvebis teqnikis Sefaseba

kvebis teqnikis Sefaseba xorcieldeba kvebaze uSualo dakvirvebiT

(mtkicebulebis done I, II).

fasdeba:

• ZuZuze moWideba (swori moWidebis niSnebi);

• pozicia kvebis dros;

• rZis gadmodinebis refleqsi (rZis nakadis intensivobis Sefaseba

dedasTan da bavSvTan).

ZuZuze moWideba (swori moWidebis niSnebi):

_ farTod gaRebuli piri;

_ gadmobrunebuli tuCebi, romlis lorwovani garsi Cans;

_ nikapi ebjineba ZuZus;

_ areolas meti wili Cans bavSvis zeda tuCidan.

kvebis dros swori poziciis niSnebi:

_ bavSvis Tavi da sxeuli erT swor xazzea;

_ bavSvi mTeli sxeuliT mibrunebulia dedisken da ekvris mis sxeuls;

_ deda Tavs komfortulad grZnobs.

rZis gadmodinebis refleqsi (fasdeba rZis nakadis intensivoba)

rZis nakadis intensivobis Sefaseba dedasTan (rekomendacia D )92: _ rZis gadmosvlis SegrZneba, romelic ar aris mtkivneuli;

_ mSobiarobis Semdeg pirveli dReebis ganmavlobaSi muclis tkivili,

rac ganpirobebulia saSvilosnos SekumSviT;

_ kvebis dros rZis gadmodineba meore ZuZudan;

_ dedis wyurvilis SegrZneba bavSvis kvebis procesSi;

_ relaqsacia da Zilianoba kvebis Semdeg;

_ mkerdis darbileba kvebis Semdeg (mtkicebulebis done II);

rZis nakadis intensivobis Sefaseba bavSvTan (rekomendacia D)92

_ wovisa da ylapvis xma;

_ 1-2 woviT moZraobas moyveba ylapva;

_ sveli rZiani piri;

_ wovis dros moSvebuli sxuli.

3. wonis Sefaseba (rekomendacia D)92:

axalSobilisa da Cvilis normaluri wonis maCveneblebia:

• samSobiaro saxlSi wonis danakargi 7-10%-ze naklebi 25,94;

• wonaSi klebis SeCereba sicocxlis mesame dRidan;

• wonaSi matebis dawyeba sicocxlis mexuTe dRidan;

D

D

I, II

II

D

23

• dabadebis wonis aRdgena sicocxlis me-10-14 dRes;

• me-10-14 dRis Semdeg – wonis saSualo namati

_ minimum 500 g pirvel TveSi;

_ Semdeg 125-250g kviraSi (detaluri informaciisTvis ix.

gaidlaini bavSvis fizikuri ganviTareba).

4. sarZeve jirkvlisa da dvrilis mdgomareoba (rekomendacia D)92:

fasdeba:

_ naxeTqebis arseboba dvrilze;

_ herpesuli gamonayari dvrilze;

_ dvrilis kandidozuri infeqcia;

_ sarZeve jirkvlis gajirjveba;

_ gamkvrivebuli ubnis arseboba sarZeve jirkvalSi;

_ sarZeve jirkvlis hiperemia.

kvebis Sefaseba SesaZleblobas iZleva dadgindes ZuZuTi kvebis efeqturoba

da droulad moxdes ZuZuTi kvebis problemebis identificireba.

Tu kveba efeqturia, unda gagrZeldes dinamiuri dakvirveba da Catardes

Sesabamisi konsultireba gegmuri vizitis dros.

araefeqtur ZuZuTi kvebaze miuTiTebs Semdegi niSnebis arseboba

(rekomendacia D)92:

• sicocxlis pirveli 3-4 dRis Semdeg Sardvis sixSire naklebi 6-ze

24 saaTis ganmavlobaSi;

• ar ismis ylapvis xma wovis dros;

• bavSvi mudmivad mSieria da ver kmayofildeba;

• bavSvi iSviaTad tiris, ar iTxovs sakvebs 4-6 saaTis ganmavlobaSi;

• axlSobilebSi kvebaTa sixSire naklebi 8-ze, CvilebSi-7-ze;

• TiTqmis yvela kveba grZeldeba 45 wT-ze didxans;

• gamoxatuli yabzoba, mkvrivi konsistenciis, muqi feris ganavliT;

• wonis namatis SeCereba an normaze mcire namati (normaze mcire

namati SeiZleba gamowveuli iyo jvebis teqnikis darRveviT,

rodesac bavSvi ar clis ZuZus bolomde da iRebs mxolod wina

rZes).

araefeqturi ZuZuTi kvebis dros, saWiroa arsebuli problemis gamovlena,

dedis konsultireba da ganmeorebiTi vizitis dagegmva (2-3 dReSi).

Tu Cvili saerTod ver wovs ZuZus an aReniSneba xSiri Rebineba, aucilebelia

misi dauyovnebliv gadagzavna stacionarSi.

ZuZuTi kvebis ukuCvenebebi da dabrkolebebi ZuZuTi kvebis ukuCveneba – SeiZleba iyos dedismxrivi da bavSvismxrivi,

absoluturi da droebiTi.

D

D

24

ZuZuTi kvebis dedismxrivi ukuCveneba

absoluturi

• Sidsi - Aarsebobs SeZenili imunodeficitis virusis rZiT gadacemis

albaToba. SidsiT daavadebulma dedam ar unda kvebos bavSvi ZuZuTi,

Tu SesaZlebelia usafrTxo alternatiuli sakvebis gamoyeneba. Tu

aseTi SesaZlebloba ar arsebobs SidsiT daavadebuli dedis

rZis gamoyeneba SeiZleba pasterizaciis Semdeg (ix. Tavi ZuZuTi

kveba da aiv/Sidsi (mtkicebulebis done I,II,III)95,96.

• adamianis T-limfotropul (TLV-1) virusze seropozitiuri deda - aseT

SemTxvevaSi dasaSvebia dedis rZis gamoyeneba, mxolod misi

gayinva-galRobis Semdeg, vinaidan am procesiT xdeba HTLV-1 virusis gauvnebelyofa (mtkicebulebis done II)97,98.

droebiTi

• zogierTi medikamentis miReba - citostatikebiT, radiaqtiuri

preparatebiT Terapiis SemTxvevaSi kveba wydeba manam, sanam dedis

sxeulidan ar moxdeba medikamentis eliminacia


• dvrilebis herpesuli dazianeba _ droebiT unda Sewydes kveba

dazianebuli mkerdidan.

• sarZeve jirkvlis abscesi - droebiT unda Sewydes kveba dazianebuli

mkerdidan.

• narkomani deda (mtkicebulebis done III)104.

tuberkulozis Ria formis dros ukunaCvenebia kontaqti dedasa da bavSvs

Soris, vidre dedas ar Cautardeba mkurnalobis sruli kursi. axalSobils

unda Cautardes imunizacia da profilaqtikuri mkurnaloba. infeqcia

ar gadadis rZiT, amitom bavSvi unda ikvebebodes dedis gamowvelili

rZiT (mtkicebulebis done III)99.

dedis zogierTi mdgomareoba arasworad iTvleba ZuZuTi kvebis ukuCvenebad.

maT Soris:

• dedis cxeleba;

• B da C hepatiti, citomegalovirusuli infeqcia;

_ Tu deda C hepatitiTaa dainficirebuli, mizanSewonilia Tavi

Seikavos ZuZuTi kvebisagan, Tu aReniSneba dvrilis naxeTqebi da

sisxldena108;

_ Tu deda B hepatitiTaa inficirebuli, axalSobils dabadebidan 12

saaTSi ukeTdeba B hepatitis sawinaaRmdego imunoglobulini da

imunizacia da daculia infeqciisagan da Cveulebrivad

xorcieldeba ZuZuTi kveba.

• dedis virusuli an baqtriuli infeqci;

• Tambaqos moxmareba

_ Tambaqo iwvevs laqtaciis Semcirebas. mweveli qali unda ecados ar

mowios an Seamciros Tambaqos moxmareba orsulobisa da ZuZuTi

kvebis periodSi. magram Tu qali agrZelebs mowevas, misi rZe

mainc saukeTeso sakvebia bavSvisTvis. Ddedam ar mowios,

rodesac bavSvi xelSi uWiravs (mtkicebulebis done II)103,104;

I,II,

II

III

III

III

II

25

• alkoholis gamoyeneba dasaSvebia iSviTad, mcire raodenobiT

(mtkicebulebis done II)107.

ZuZuTi kvebis bavSvismxrivi ukuCveneba

bavSvis mxriv ZuZuTi kvebis absolutur ukunaCvenebas warmoadgens

sxvadasxva tipis fermentopaTia (mtkicebulebis done II, III) 109:

• fenilketonuria

• galaqtozemia

• leicinuria (nekerCxlis sirofis daavadeba)

rekomendacia:

samedicino personalma unda moaxdinos ZuZuTi kvebis ukuCvenebebis

identificireba, urCios mSoblebs ar ganaxorcielos ZuZuTi kveba da

SeurCios bavSvs alterantiuli, usafrTxo sakvebi. (rekomendaciis

xarisxi - D) 45

ZuZuTi kvebis dabrkolebas warmoadgens bavSvis zogirTi mdgomareoba

@(mtkicebulebis done II, III)25,110.

• Rrma dRenakluloba (wovisa da ylapvis refleqsebis ararseboba);

• enis lagami;

• tuCis defeqti – e.w “kurdRlis tuCi”;

• sasis naprali – e.w. “mglis xaxa”.

ZuZus wovis ukuCvenebaa:

• mZime nevrologiuri dazianeba (samSobiaro travma, qalasSiga

sisxlCaqceva);

• mkveTrad gamoxatuli respiraciuli distresi;

• gulis mZime Tandayolili manki.

am dros ukunaCvenebia wova da ara dedis rZe. amitom mizanSewonilia bavSvis

kveba gamowvelili rZiT. kveba Cvenebis mixedviT unda ganxorcieldes kovzis

an zondis saSualebiT (ar SeiZleba boTlidan kveba).

ZuZuTi kvebis marTva problemebis dros

samedicino personals unda SeeZlos ZuZuTi kvebis problemebis drouli

gamovlena da ZuZuTi kvebis swori marTva.

medpersonalis mier ZuZuTi kvebis problemebis dagvianebuli identificireba,

dedis informirebulobis dabali done da problemis marTvis

araswori meTodebis gamoyeneba xSirad ZuZuTi kvebis Sewyvetis mizezi

xdeba (mtkicebulebis done I, II)111,112.

D

I, II

II

II

II, III

26

brtyeli da Cabrunebuli dvrilebi

definicia

brtyeli dvrili – gadasworebulia da ar scildeba areolas zedapirs.

Cabrunebuli dvrili _ Cazneqilia areolas zedapiridan qvemoT. ganarCeven

araWeSmaritad da WeSmaritad Cabrunebul dvrils.

• araWeSmaritad Cabrunebuli dvrili wevadia, areolas gaRizianebiT da

dvrilis wevadobis varjiSiT igi advilad swordeba da areolas

zemoT amodis. Tu dvrili wevadia, igi ar warmoadgens dabrkolebas

ZuZuTi kvebis ganxorcielebisTvis;

• WeSmaritad Cabrunebuli dvrili ar aris wevadi, areolas gaRizianebiT

da wevadobis varjiSiT ar swordeba, warmoadgens seriozul

dabrkolebas ZuZuTi kvebis ganxorcielebisTvis.

marTva:

brtyeli da araWeSmaritad Cabrunebuli dvrili

aucilebelia

• daxmarebis aRmoCena mSobiarobidan 1 saaTis ganmavlobaSi pirveli

moWidebis dros91;

• dedis darwmuneba, rom igi SeZlebs ZuZuTi kvebis efeqturad

ganxorcielebas, Tu bavSvi sworad moeWideba ZuZus. bavSvi

eWideba areolas da ara dvrils (mtkicebulebis done I)91;

• ZuZuze moWidebis ganxorcielebamde dvrilis gaRizianeba da win

wamoweva (dvrilis damuSaveba ori an sami TiTiT). am mizniT

SesaZlebelia rZis gamosawveli saSualebebis gamoyeneba (ix. nax.1),

efeqturia wovis procesSi specialuri dvrilis safaris

gamoyeneba;

• bavSvis ZuZuze swori moWidebis uzrunvelyofa (mtkicebulebis

done II)111,112;

• dedisTvis konsultirebis gaweva da dvrilis wevadobis varjiSis

swavleba;

• dedisTvis bavSvis kvebis sxvadasxva poziciis SerCeva, mag. ”ragbis

burTis” pozicia102;

• saWiroebis SemTxvevaSi bavSvis kveba gamowvelili rZiT finjaniT an

kovziT.

I

II

Nnax. 1

27

WeSmaritad Cabrunebuli dvrili

• WeSmaritad Cabrunebuli dvrilis arsebobis dros aucilebelia bavSvis

kveba gamowvelili rZiT, vinaidan bavSvi ver eWideba areolas da ver

gamowovs rZis saWiro raodenobas;

• Tu rZis gamowvela ver xerxdeba bavSvs unda SesTavazon alternatiuli

sakvebi;

brtyeli da Cabrunebuli dvrilebis winaswar damuSaveba da dvrilis

wevadobis varjiSi antenatalur periodSi ar aris rekomendebuli. dvrilis

gaRizianeba iwvevs oqsitocinis gamomuSavebis gaZlierebas da

SesaZloa naadrevi mSobiarobis mizezi gaxdes. (mtkicebulebis done

II)25.

dvrilis wevadobis varjiSi

dvrilis wevadobis varjiSis ramdenime martivi meTodi arsebobs: varjiSis

dawyebamde TiTebis nazi moZraobiT areolas garSemo xdeba dvrilis

gaRizianeba. Ddeda dvrils kidebs xels saCvenebeli, cera da Sua TiTiT da

win gamoswevs, Semdeg uSvebs xels da dvrili ubrundeba sawyis mdgomareobas.

aseTi moZraoba daaxloebiT 8-10-jer mainc unda Sesruldes dRis

ganmavlobaSi. igive sixSiriT SesaZlebelia meore varjiSis Sesruleba. deda

TiTebs Soris aTavsebs dvrils, odnav win gamoswevs da asrulebs naxevrad

brunviT moZraobas morigeobiT – marjvniv da marcxniv, ise TiTqos fanqars

atrialebs xelSi. varjiSis Sesruleba SesaZlebelia orive sarZeve

jirkvalze erTdroulad an morigeobiT.

sarZeve jirkvlis gamkvriveba

definicia:

sarZeve jirkvlis gamkvriveba ZuZus gajirjveba da SeSupebaa, romlic

ganpirobebulia sarZeve jirkvlis rZiT gadavsebiT, uxSiresad vlindeba

mSobiarobidan pirveli kviris ganmavlobaSi.

mizezebi:

• rZis Warbi produqcia;

• ZuZuTi kvebis dagvianebuli dawyeba (mtkicebulebis done I)91;

• bavSvis araswori moWideba (mtkicebulebis done I)91;

• iSviaTi, saaTobrivi kveba;

• ZuZus arasruli dacla.

klinikuri simptomebi:

• tkivili, SeSupeba;

• gamkvriveba, simZimis SegrZneba;

• rZis nakadis intensivobis Semcireba;

• iSviaTad temperaturuli reaqcia.

I

I

II

28

marTva

samedicino personalma unda SeZlos:

• dedisTvis bavSvis kvebis swori poziciis SerCeva

(mtkicebulebis done I)91,93.

• bavSvis xSiri moTxovnilebiTi kvebis uzrunvelyofa

(mtkicebulebis done I)50,53,54,113;

• kvebis dawyebamde ZuZudan rZis mcire raodenobis gamowvela,

bavSvis ZuZuze ukeT moeWidebis uzrunvelsayofad

(mtkicebulebis done II)114,217;

• kvebis dawyebamde sarZeve jirkvalze Tbili safenis dadeba (10-15 wT),

kisris midamos da sarZeve jirkvlis msubuqi masaJi (zemodan qvemo

mimarTulebiT, ar aris rekomendebuli masaJis dros areolas

gaRizianeba); kvebis Semdeg sarZeve jirkvalze civi safenis

gamoyeneba 10-15 wT (mtkicebulebis done II)115,214;

• SesaZlebelia dazianebul sarZeve jirkvalze kombostos safenis

gamoyeneba (mtkicebulebis done I, II)115-117;

profilaqtika

sarZeve jirkvlis gamkvrivebis profilaqtikaa ZuZuTi kvebis adreuli dawyeba,

kvebis Tavisufali reJimi, ZuZus bolomde dacla da swori moWidebis

uzrunvelyofa.

mastiti

definicia

mastiti – sarZeve jirkvalis erTi an ramdenime alveolis da sadinaris

anTeba.

mizezebi:

dadasturebulia mastitis gamomwvevi 2 ZiriTadi mizezi88,118:

• rZis Segubeba

da

• inficireba

rZis Segubebas ganapirobebs:

• sarZeve jirkvlis arasruli dacla;

• iSviaTi, saaTobrivi kveba (mtkicebulebis done II)60,90,113;

• ZuZuze araswori moWideba da kvebis dros araswori pozicia

(mtkicebulebis done II)119;

• kvebis dros tansacmlis an TiTebis zewoliT gamowveuli

sadinris daxSoba;

• rZis nakadis intensivobis Seferxeba stresis, gadaWarbebuli fizikuri

da fsiqologiuri datvirTvis dros.

I

II

II

I,II

II

II

I

29

inficireba

dvrilze arsebuli naxeTqebi xSirad xdeba sarZeve jirkvalSi

infeqciis SeWris mizezi60,63. mastitis gamomwvev mikroorganizmebs

ZiriTadad miekuTvneba (mtkicebulebis done - II)120

• Staphylococcus aureus88,122,123,124,126; • Escherichia coli21; • Streptococcus 3,21,88,125,126.

klinikuri simptomebi

• sarZeve jirkvlis romelime ubnis gamkvriveba;

• tkivili;

• SewiTleba;

• dazianebuli ubnis kanis simxurvale;

• temperaturuli reaqcia;

• Semcivneba;

• zogadi sisuste;

• hipogalaqtia.

Semcivneba, temperaturis momateba, zogadi sisuste miuTiTebs infeqciuri

mastitis arsebobaze.

marTva

mkurnalobis ZiriTadi principebia:

• sarZeve jirkvlis dacla;

• saWiroebis SemTxvevaSi antibiotikoTerapia;

• simptomuri Terapia.

rZis SegubebiT gamowveuli mastitis marTva

• xSiri kveba, sarZeve jirkvlis bolomde dacla (mtkicebulebis

done I, II)50,113;

• kvebis swori poziciis SerCeva - sxvadasxva pozicia kvebis dros,

xels uwyobs ZuZus Tanabarzomier daclas32. mizanSewonilia

SeirCes iseTi pozicia, rom bavSvis nikapi da qveda yba moeqces

dazianebuli ubnis mxares (mtkicebulebis done I, II)91,119;

• kvebis dawyeba janmrTeli mkerdidan, gansakuTrebiT tkivilis

SemTxvevaSi;

• kvebis damTavrebis Semdeg ZuZus gamowvela (mtkicebulebis done

I,III)58.

infeqciuri mastitis marTva

antibiotikoTerapiis dawyeba rekomendebulia63,124,127,128, Tu gamoxatulia

• sarZeve jirkvlis mkveTri SewiTleba,

• tkivili (mtkicebulebis done II);

• dvrilze aRiniSneba naxeTqebi, saidanac SesaZlebelia infeqciis SeWra;

• temperaturuli reaqcia da Semcivneba;

II

I,II

I,II

I,III

II

30

• mZime zogadi mdgomareoba (mtkicebulebis done I, II, III)128,129.

antibiotikis SerCeva efuZneba ZiriTadi gamomwvevebis mgrZnobelobas

antibiotiki doza

eriTromicini5,23,36,163,130,132 250-500 mg 6 sT-Si erTxel

amoqsicilini 94,131 250-500 mg 8 sT-Si erTxel

cefaleqsini5,23,36,50,122,163,130,132,136 250-500 mg 6 sT-Si erTxel

antibiotikoTerapiis kursi grZeldeba 7-10 dRe, miuxedevad imisa, rom erT an

or dReSi mdgomareoba SeiZleba gaumjobesdes. Tu antibiotikoTerapia

tardeba moklevadiani kursiT maRalia mastitis klinikuri niSnebis

ganmeorebis riski32. Tu antibiotikebis miRebidan 2 dReSi mdgomareoba ar

gaumjobesda, unda gamoiricxos abscesis arseboba.

simptomuri mkurnaloba

• paracetamoli - yovel 6 sT-Si erTxel maRali temperaturisa

da tkivilis gayuCebis mizniT (mtkicebulebis done I, II)

• ibuprofeni, rogorc tkivilgamayuCebeli, ise anTebis saawinaRmdego

saSualeba (dauSvebelia sxva anTebis sawinaaRmdego preparatebis

gamoyeneba)

problemis efeqturi marTvis aucilebeli komponentebia:

• dedis Tavisufali tansacmlis gamoyeneba;

• kvebis an gamowvelis win ZuZus dazianebul ubanze Tbili

safenis dadeba 10-15 wT32,131,135. Tbili safenis gamoyeneba Aar aris

rekomendebuli, Tu rZe Tavisuflad modis (mtkicebulebis done

II)127;

• kvebis damTavrebis Semdeg grili safenis gamoyeneba tkivilis

Semcirebis mizniT. dazianebul sarZeve jirkvalze dasaSvebia

kombostos safenis dadeba (mtkicebulebis done I, II)117,127;

• kvebis dros dazianebuli ubnis msubuqi masaJi, zemodan qvemo

mimarTulebiT. ar aris rekomendebuli masaJis dros areolas

gaRizianeba130,135.

rekomendacia32,131:

aucilebelia infeqciuri mastitis diferencireba abscesisagan, romlis

klinikuri niSnebi infeqciuri mastitis identuria. abscesis damadasturebel

indikatorad gamoiyeneba bambis an saSrobi qaRaldis zedapirze darCenili

yviTeli laqa, gamowvelili rZis dawveTebis Semdeg. abscesi warmoadgens

ZuZuTi kvebis droebiT ukuCvenebas. abscesis SemTxvevaSi aucilebelia

referali qirurgTan abscesis drenireba da antibiotikoTerapia.

I,II

II

I,II

I,II

31

mastitis profilaqtika

• ZuZuTi kvebis adreuli dawyeba;

• kvebis Tavisufali reJimi;

• ZuZus bolomde dacla;

• swori moWidebis uzrunvelyofa.

dvrilis anTeba, naxeTqi

definicia

dvrilis naxeTqi areolas da dvrilis kanis zedapiris mTlianobis

darRvevaa, romelic uxSiresad vlindeba mSobiarobidan pirveli kviris

ganmavlobaSi da seriozul problemas qmnis ZuZuTi kvebis

ganxorcielebisTvis.

ZuZuTi kvebis dawyebis pirvel dReebSi dedebis umravlesobas

aReniSneba dvrilis susti tkivili, romelic ar aris dakavSirebuli

naxeTqis arsebobasTan (mtkicebulebis done II)91.

mizezebi:

• bavSvis ZuZuze araswori moWideba91 (mtkicebulebis done I);

• dedis mWidro tansacmeli sarZeve jirkvlis midamoSi;

• antiseptikuri xsnarebis da malamoebis gamoyeneba dvrilisa da

areolas damuSavebis mizniT;

• sapnis xSiri gamoyeneba dvrilisa da areolas damuSavebis mizniT

(yvela kvebis win);

• dvrilisa da bavSvis piris Rrus kandidozuri infeqcia

(mtkicebulebis done II)91,120.

klinikuri niSnebi

• dvrilisa da areolas zedapiris mTlianobis darRveva;

• sixldena naxeTqidan;

• tkivili.

marTva:

• ZuZuze swori moWidebis uzrunvelyofa (mtkicebulebis done II);

• bavSvis swor poziaciaSi kveba (mtkicebulebis done II)119;

• antiseptikuri xsnarebis, losionebis da malamoebis gamoyenebis

SezRudva (mtkicebulebis done II);

• sapnis gamoyeneba mxolod zogadi higienuri abazanis dros

(mtkicebulebis done III)137;

• galaqtoreis SemTxvevaSi rZis mimRebis (xufi) xmareba

(mtkicebulebis done II)137;

• kvebis Semdeg dvrilsa da areolaze gamowvelili rZis wasma da misi

haerze SeSroba;

• Tbili wylis an Cais kompresis gamoyeneba dvrilze tkivilis

Sesamcireblad (mtkicebulebis done II)137;

I

II

III

II

II

II

II

32

• profilaqtikis an mkurnalobis mizniT ar aris rekomendebuli sarZeve

jirkvalze malamoebis, sapnis, spirtis da sxva antiseptikuri

xsnarebis gamoyeneba (rekomdenacia D)25.

rZiana da dvrilis kandidozuri infeqcia

definicia

rZiana da dvrilis kandidozuri infeqcia gamowveulia candida-s mikrobiT da

Serwymulia bavSvis piris lorwovanis kandidozur infeqciasTan (rZiana).

simptomebi120

dedasTan dakavSirebuli

• dvrilisa da areolas kanis zedapiris SewiTleba, priali, mTlianobis

darRveva;

• dvrilis qavili, tkivili.

bavSvTan dakavSirebuli

• TeTri feris nadebi piris, loyebis, enis lorwovan garsebze;

• Wirveuloba;

• ZuZuze uaris Tqma.

marTva

dedis mkurnaloba

• dvrilebis damuSaveba gencianvioletis 0,5%-iani xsnariT, dReSi 2-jer

daavadebis niSnebis gaqrobamde;

• daavadebis siptomebis gaqrobis Semdeg dRegamoSvebiT 6-7 dRis

ganmavlobaSi;

• dvrilis damuSaveba nistatinis malamoTi 100.000/g dReSi oTxjer ZuZuTi

kvebis Semdeg. malamos gamoyeneba mizanSewonilia gagrZeldes

daavadebis niSnebis gaqrobidan kidev 7 dRis ganmavlobaSi44,45,46.

bavSvis mkurnaloba

• piris damuSaveba 0,25%-ian gencianvioletis xsnariT dReSi 2-jer 5 dRis

(aranakleb 3 dRis) ganmavlobaSi;

• 100.000/g nistatinis suspenziis pirSi CawveTeba 1 ml. odenobiT oTxjer

dReSi Wamis Semdeg 7-10 dRe.

rekomendacia:

profilaqtikis mizniT aucilebelia dedasTan da bavSvTan higienis wesebis

dacva, unda Sewydes satyuaras, sawovrebis da dvrilis xufebis

gamoyeneba44,45,46.

'

D

33

hipogalaqtia

definicia

hipogalaqtia rZis naklebobaa, ganarCeven “WeSmarit” da “cru” hipogalaqtias.

• “cru” hipogalaqtia uxSiresad vlindeba sicocxlis me-3-4 dRes, me-3-4

kviras da me-3-4 Tves, egreTwodebul “kritikuli periodebSi’’, rodesac

bavSvis moTxovnileba sakvebze izrdeba, rac ganpirobebulia misi

asakisa da wonis matebiT. am periodSi bavSvi iwyebs SedarebiT xSir

kvebas, rac dedas uqmnis rZis naklebobis STabeWdilebas. kritikul

periodebSi bavSvis xSiri kveba ZuZuTi kvebis gaxangrZlivebis

aucilebeli pirobaa (mtkicebulebis done II, III). am dros ar

aris rekomdenebuli sakvebis Semateba.

• ,,WeSmariti’’ hipogalaqtia - gamoxatulia rZis naklebobis sarwmuno

niSnebi.

WeSmariti hipogalaqtiis mizezebi (mtkicebulebis done I)91:

• kvebis dagvianebuli dawyeba;

• iSviaTi, xanmokle an saaTobrivi ZuZuTi kveba;

• ZuZuze araswori moWideba da araswori pozicia;

• boTlidan kveba;

• enis mokle lagami;

• dedis fsiqologiuri faqtori - rwmenis ukmarisoba, stresi, gadaRla;

• dedaze zogierTi mavne faqtoris gavlena – alkoholi, moweva, Casaxvis

sawinaaRmdego abebi, diuretikebi, Zlieri gamofitva.

klinikuri niSnebi

sarwmuno niSnebi

• mcire raodenobiT koncentrirebuli Sardis gamoyofa (Sardva 6-jer-ze

naklebi 24 sT);

• wonis mcire namati (500 g-ze naklebi TveSi, an 125 g-ze naklebi

kviraSi) (mtkicebulebis done I, II)68,135;

• gaiSviaTebuli nawlavTa moqmedeba, muqi feris, mkvrivi

konsistenciis ganavliT (mtkicebulebis done I, II)32.

arasarwmuno niSnebi

• bavSvi ver kmayofildeba kvebis Semdeg, xSirad iTxovs ZuZus da tiris;

• bavSvi uars ambobs ZuZuze;

• gamowvelisas rZe ar gamodis.

marTva

samedicino personalma problemis marTvamde unda daadginos hipogalaqtia

WeSmaritia, Tu araWeSmariti. gaarkvios rZis naklebobis SesaZlo mizezi.

rekomendebulia kvebis efeqturobis Sefasebis meTodebis gamoyeneba

gamoyeneba (ix. kvebis efeqturobis Sefaseba).

marTvis ZiriTadi principebi:

• xSiri ZuZuTi kvebis uzrunvelyofa (8-12 jer 24 sT-Si),

(mtkicebulebis done III)29,32:

I,II

III

II,III

I

I,II

34

• sarZeve jirkvlis bolomde dacla; sarZeve jirkvlis

gamowvela yvela kvebis Semdeg, gamowvelili rZiT bavSvis kveba

kovziT an WiqiT (mtkicebulebis done II, III)50; K

• periodulad (dReSi ramdenjerme) kani kanTan kontaqtis

ganxorcieleba (rekomendacia B ); • RamiT kvebis ZuZuTi kvebis uzrunvelyofa (rekomendacia B); • kvebis swori poziciis SerCeva (mtkicebulebis done I)91;

• dedis racionaluri kvebis uzrunvelyofa, siTxeebis miReba

moTxovnilebis Sesabamisad, gaZlierebuli wyurvilis grZnobis

dasakmayofileblad. siTxis miReba dasaSvebia bavSvis kvebis

procesSic (mtkicebulebis done I)49;

• dedisTvis stresuli situaciis Tavis arideba, xSiri dasveneba.

rZis “momyvani” saSualebebis gamoyenebas ar aqvs gavlena rZis produqciaze

(rekomendacia B). Tu deda darwmunebulia “rZis momyvani”

saSualebebis efeqturobaSi da mocemuli saSualeba usafrTxoa,

mizanSewonilia misi gamoyeneba dedis dadebiTi fsiqologiuri

ganwyobis Camosayalibeblad.

WeSmariti hipogalaqtiis SemTxvevaSi, SesaZlebelia saWiro gaxdes

alternatiuli sakvebis droebiT Semateba laqtaciis aRdgenamde. Tu marTvis

yvela meTodis gamoyenebis Sedegad ver xerxdeba laqtaciis aRdgena,

mizanSewonilia bavSvis Sereul kvebaze gadayvana.

Sesamatebeli sakvebi - donoris rZe da xelovnuri formula130,131

mtkicebulebaTa umetesobis mixedviT ar arsebobs mniSvnelovani gansxvaveba

dedis rZesa da donoris rZes Soris, Sesabamisad Sesamatebel sakvebad

saWiroebis SemTxvevaSi SeiZleba donoris rZis gamoyeneba

usafrTxoebis zomebis gaTvaliswinebis Semdeg (rekomendacia B)130,131.

donoris SerCevisas saWiroa Semdegi pincipebis dacva130,131

:

• daavadebaTa gadacemis Tavidan acilebis mizniT, donorma unda

gaiaros sisxlis testireba aiv da HTLV I da II virusebze

(rekomendacia B);

• rZis Cabarebisas donors ar unda hqondes miRebuli 150-200 ml

kofeinis Semcveli siTxe dRis ganmavlobaSi sam jerze metad

(rekomendacia D);

• Tu donoris rZe ar aris Semowmebuli, misi gamoyeneba SeiZleba

mxolod pasterizaciis Semdeg.

xelovnuri formula – rekomendebulia bavSvis asakis Sesabamisi

adaptirebuli narevis gamoyeneba.

sakvebis Sematebis teqnika

• yvela kvebis dros bavSvma unda dacalos orive sarZeve jirkvali da

mxolod amis Semdeg unda miiRos Sesamatebeli sakvebi kovziT an

WiqiT. Tavdapirvelad Sesamatebeli sakvebi eZleva mxolod erT

B

B

D

II,III

B

I

B

35

kvebaze mcire raodenoboT (30 ml), Semdeg TandaTanobiT xdeba

raodenobis gazrda da Semateba yvela kvebaze;

• Sesamatebeli sakvebis raodenobas gansazRvravs Tavad bavSvi;

• ar aris rekomendebuli erTi kvebis mTlianad Sesamatebeli sakvebiT

Canacvleba, radgan es amcirebs ZuZuTi kvebis sixSiresa da Sesabamisad

laqtacias.

ZuZuze Tavis danebeba

ZuZuTi kveba unda gagrZeldes 2 wlamde. ZuZuTi kvebaze Tavis danebeba

SeiZleba iyos103:

• bunebrivi – bavSvi Tavad anebebs Tavs ZuZus wovas, ZuZuTi kvebis

jeradobis TandaTan SemcirebiT, damatebiTi sakvebis

moculobisa da kvebis sixSiris matebis paralelurad (12-24 Tve)

(rekomendacia A, mtkicebulebis done III);

• dagegmili _ ZuZuTi kvebis Sewyveta xdeba dedis gadawyvetilebiT,

bavSvis survilisa da ZuZuze Tavis danebebis mzaobis gaTvaliswinebis

gareSe;

• uecari _ gansakuTrebuli mizezis gamo, romelic ar aris

dakavSirebuli dedis survilTan.

ZuZuTi kvebis uecari Sewyveta

ZuZuTi kvebis uecarma Sewyvetam SeiZleba gamoiwvios garkveuli problemebi

da diskomforti, rogorc dedasTan, ise bavSvTan. problemebis gamovlenis

albaToba miT ufro maRalia, rac ufo mcire asakisaa bavSvi da aqtiuria

laqtacia.

ZiriTadi problemebia:D

• dedis sarZeve jirkvlis gamkvriveba

• dedis mastiti an sarZeve jirkvlis abscesi

• dedis da bavSvis fsiqologiuri problemebi

marTva

rekomendebulia103

• rZis gamowvela sarZeve jirkvlis gadavsebis SemTxvevaSi;

• sarZeve jirkvalze civi safenis da kombostos furclis dadeba

gamowvelis Semdeg;

• sarZeve jirkvlis masaJi;

• tkivilgamayuCebeli saSualebebis gamoyeneba;

• Tavisufali konfortuli tansacmlis gamoyeneba.

ar aris rekomendebuli sarZeve jirkvlis gakvra, vinaidan arsebobs sadinaris

daxSobisa da momavalSi sarZeve jirkvlis paTologiebis ganviTarebis

albaToba103.

A

36

ZuZuTi kvebis Ddagegmili Sewyveta103

rekomendebulia

• kvebis dros bavSvTan urTierTobis minimumamde Semcireba;

• kvebaTa SorisD bavSvis damSvideba da xSiri mofereba;

• ZuZuTi kveba Rrma Zilis periodSi, an roca bavSvi axali gaRviZebulia;

• kvebis poziciis xSiri cvla da bavSvis kvebisTvis sxvadasxva adgilis,

maT Soris sxvadasxva oTaxis SerCeva, kvebasTan dakavSirebuli

refleqsebis SesustebisaTvis;

• ZuZuTi kvebis alternatiuli sakvebiT TandaTan Canacvleba.

ZuZuze Tavis danebebis mizniT ar aris rekomendebuli bavSvis ,,SimSili” da

dedis da bavSvis erTmaneTisgan daSoreba.

rekomendacia:

samedicino personalma unda gamoarkvios ZuZus Sewyvetis mizezi, Tu

arsebobs ZuZuTi kvebis SenarCunebis realuri SesaZlebloba dedas

gauwios Sesabamisi konsultacia ZuZuTi kvebis or wlamde

gaxangrZlivebis da ZuZuTi kvebis bunebrivi gziT Sewyvetis Taobaze

(rekomendacia A).

gamowvelili rZis Senaxva

usafrTxoebis mizniT aucilebelia gamowvelili rZis Senaxvis principebis

dacva:

• rZe inaxeba 25 0C-ze 3-4 saaTis ganmavlobaSi.

• rZe inaxeba 4 0C-ze macivarSi 48 saaTis ganmavlobaSi.

rZis gaTboba SeiZleba Tbil wylian WurWelSi. dauSvebelia rZis gaTboba

mikrotalRovan RumelSi an misi aduReba (rekomendacia D). dauSvebelia narCeni rZis kvlav macivarSi Senaxva da gamoyeneba.

meZuZuri dedis kveba

bunebrivi kvebis efeqturoba damokidebulia meZuZuri qalis janmrTelobis

mdgomareobaze da kvebiT statusze. dedis kveba mniSvnelovan gavlenas ar

axdens rZis ZiriTadi ingredientebis (cila, cximi, naxSirwyali)

Semcvelobaze, Tumca moqmedebs garkveuli vitaminebisa da mikroelementebis

koncentraciaze47 (ix. cxrili 2). dedis kvebis deficiti pirvel rigSi

aisaxeba mis janmrTelobis mdgomareobaze.

meZuZuri dedis dRiuri energetikuli moTxovnileba 500 kkal-iT metia (mag.:

damatebiT 2 Wiqa mawoni) orsulobamdel periodTan SedarebiT.

meZuZurma qalma unda miiRos mravalferovani sakvebi da siTxeebi

moTxovnilebis mixedviT (rekomendacia A). dedis mier Warbi siTxis

miReba ar axdens gavlenas rZis produqciaze (mtkicebulebis done II)28,49;

dedam yoveldRiurad unda miiRos sakvebis erTi saxeoba mainc sakvebi

produqtis yvela jgufidan43,44,45:

_ naxSirwylebiT mdidari - puri da marcvleuli,

A

A

D

37

_ vitaminebiT mdidari - xili da bostneuli,

_ ciliT, rkiniT da kalciumiT mdidari - xorci da rZis produqti,

_ cximebi – mcenareuli da cxoveluri, upiratesoba eniWeba

mcenareul cxims.

ioddeficitis zonaSi rekomendebulia sakvebSi iodiani marilis gamoyeneba.

meZuZuri dedisTvis ar aris rekomendebuli:

• alkoholuri sasmeli (maT Soris ludi) _ advilad gadadis rZeSi. ar

aris sabolood gansazRvruli minimaluri raodenoba, romelic ar

iwvevs bavSvis janmrTelobis problemebs (mtkicebulebis done

III)32,107;

• didi raodenobiT kofeinis Semcveli (muqi Cai, yava, koka-kola) da ga-

ziani sasmelebi;

• zedmetad mlaSe da cxare sakvebi, umi xaxvi da niori, saneleblebi _

cvlis rZis suns da gemos, rac xSir SemTxvevaSi ZuZuze uaris Tqmis

mizezia;

• Tambaqo _ iwvevs laqtaciis Semcirebas103,104.

• Sebolili sakvebi.

iSviaT SemTxvevaSi saWiro xdeba dedis kvebis racionidan im sakvebis

droebiT amoReba, romelic Cvils problemebs uqmnis (kolika, alergia

da sxv) (rekomendacia B, mtkicebulebis done II, III). Tu bavSvs

uvlindeba alergia, mizanSewonilia dedam Tavi Seikavos Semdegi

produqtis gamoyenebisagan: Txili, nigozi, miwis Txili, kvercxi, Zroxis rZe,

Tevzi, citrusebi11,12.

samedicino personalma unda gaiTvaliswinos, rom im SemTxvevaSic, ki roca

qalis kveba ar aris racionaluri, dedis rZis Semadgenloba mniSvnelovnad

ar icvleba da igi mainc saukeTesi sakvebia bavSvisTvis. kvebis deficitis

SemTxvevaSi dedasTan rekomendebulia vitaminebis da sakvebi danamatebis

gamoyeneba.

medikamenturi Terapia da laqtacia166,167

ZuZuTi kvebis dros dedis mier miRebuli samkurnalo preparatebis

umravlesoba xvdeba qalis rZeSi da zogierTma maTganma SeiZleba gverdiTi

movlenebi gamoiwvios. Sesabamisad medikamentis daniSvnamde aucilebelia

wamlis moqmedebis meqanizmis gacnoba. Tu medikamenti ukunaCvenebia laqtaciis

dros, saWiroa alternatiuli preparatis SerCeva. gamonaklis SemTxvevebSi

SesaZlebelia saWiro gaxdes ZuZuTi kvebis Sewyveta. prepatatebi laqtaciis

periodSi gamoyenebis mixedviT SesaZlebelia daiyos 4 jgufad: I - usafrTxo,

II - SesaZlebelia gamoyeneba, Tumca iSviaTad aRiniSneba gverdiTi efeqti, III

- potenciurad saSiSi; IV - winaaRmdegnaCvenebi.

laqtaciis periodSi medikamentis gamoyenebisas aucilebelia:

• medikamentis usafrTxoebaSi darwmuneba;

• misi daniSvna mxolod aucilebelobis SemTxvevaSi;

• medikamentis SeZlebisdagvarad mcire doziT da xanmokle kursiT

gamoyeneba;

• gaxangrZlivebuli moqmedebis preparatebis gamoyenebisagan Tavis arideba;

B

III

38

• medkamentis miReba bavSvis kvebaTa Soris yvelaze xangrZlivi intervalis,

an uSualod kvebis dros;

• preparatis Secvla, Tu igi bavSvTan iwvevs gverdiT efeqts;

• ZuZuTi kvebis Sewyveta, Tu dedasTan aucilebelia im preparatis daniSvna,

romelic ukunaCvenebia laqtaciis periodSi.

minimumamde unda iyos dayvanili iseTi medikamentebis daniSvna, romlebic

laqtacias amcireben (mag.: estrogenebis Semcveli kontraceptivebi, Tiazidis

Semcveli diuretikebi).

cxrili 6

medikamentebi da laqtacia

IV jgufi - laqtaciis periodSi winaaRmdegnaCvenebi medikamentebi _ mocemuli

medikamentebis gamoyenebis aucileblobis SemTxvevaSi saWiroa ZuZuTi kvebis

Sewyveta

• citostatikebi

• radioaqtiuri nivTierebebi

• bromidebi

• qloramfenikoli; tetraciklini,

qinolonis rigis antibiotikebi

(ciprofloqsacini)

• oqros marilebi

• salicilatebi (maRali doziT)

• metronidazoli

• iodidebi (topikuri moxmarebis

CaTvliT)

III jgufi - potenciurad saSiSi medikamentebi, romelTa gamoyenebis dros

SesaZlebelia gamovlindes gverdiTi efeqti

• antihistaminurisa da dekongestantis kombinacia *

• atenololi

• benzodiazepinebi

• klindamicini

• rezerpini

• nitrofuranebi

• sulfanilamidebi

• estrogenis Semcveli

kontraceptivebi *

• etosuqsimidi

• narkotiuli saSualebebi

• nikotini (moweva) *

• Tiazidis jgufis diuretikebi

(gaxangrZlivebuli moqmedebis an

maRali doziT) *

• piroqsikami

• fenobarbitali (antikonvulsiuri

doza)

II jgufi - medikamentebi, romelTa gamoyeneba SesaZlebelia, iSviaTad

aRiniSneba gverdiTi efeqti

• aminoglikozidebi

• antiqolinerguli preparatebi

• antikonvulsantebi

(fenobarbitalis da etosuqsimidis

garda)

• butirofenonebi (mag.

haloperidoli)

• oraluri dekongestantebi*

• flukonazoli

• H2 histaminoblokatorebi

39

• antihistaminebi

• antituberkulozuri

• azaTioprini

• barbituratebi (fenobarbitalis

garda)

• verapamili

• tricikluri antidepresantebi

• tetraciklini

• arasteroiduli

anTebissawinaaRmdego saSualebebi

(umjobesia ibuprofeni)

• metoklopramidi

• salicilatebi

• terfenadini

• spironolaqtoni

• Tiaziduri diuretikebi, xanmokle

moqmedebis (dabali doza)

I jgufi - medikamentebi, romelTa gamoyeneba usafrTxoa Cveulebrivi

dozirebiT

• paracetamoli

• antacidebi

• cefalosporinebi eriTromicini

• penicilinebi

• vankomicini

• kortikosteroidebi

• nazaluri dekongestantebi

• heparini

• sainhalacio steroidebi da

bronqodilatatorebi

• magnezia

• lidokaini

• digoqsini

• Teofilini

• prpranooli

• mikonazoli, klotrimazoli

* es medikamentebi damatebiT iwvevs laqtaciis Semcirebas

ZuZuTi kveba da aiv/Sidsi

bolo 15 wlis ganmavlobaSi mTel msofloiSi SidsiT dainficrebulia 3

milionamde bavSvi, maT Soris 90% SemTxvevaSi dainficireba aRiniSneba

vertikaluri transmiiT dedidan bavSvze.

ZuZuTi kveba da dedidan bavSvze Sidsis gadacemis riski

• bavSvis SidsiT dainficireba SesaZlebelia orsulobis dros,

mSobiarobis procesSi da ZuZuTi kvebis dros140.

• Tu bavSvi imyofeba ZuZuTi kvebaze dedidan bavSvze Sidsis virusis

transmisia Seadgens daaxloebiT 5-20%-s (mtkicebulebis done I,

II)35,124,138,139;

• dedidan bavSvze Sidsis virusis transmiis riski mcirdeba

dedasTan antiretrovirusuli mkurnalobiT, mSobiarobis sakeisro

kveTis meTodis gamoyenebiT da ZuZuTi kvebisgan Tavis SekavebiT.

(rekomednacia - A)138,139; • dedis rZiT virusis transmisiis riski ufro maRalia im

SemTxvevaSi, Tu dedis inficireba xdeba laqtaciis periodSi.

A

I, II

40

dedidan bavSvze Sidsis virusis gadacemis riskis Semcireba

• samedicino personalma unda urCios aiv dadebiT dedebs ar

kvebon bavSvi ZuZuTi (rekomednacia – A), Tu SesaZlebelia

usafrTxo alternatiuli sakvebis miwodeba. ZuZuTi kveba ar

unda ganxorcieldes, miuxedavad imisa utardeba dedas

specifiuri mkurnaloba Tu ara (mtkicebulebis done - II)

• avtorTa nawili Tvlis, rom im SemTxvevaSi Tu adekvaturi da usafrTxo

sakvebi ar aris xelmisawvdomi, bavSvi unda ikvebebodes mxolod dedis

rZiT 4-6 Tve damatebiTi sakvebis miRebamde. inficirebis riski naklebia

eqskluziuri ZuZuTi kvebis dros predominantul da parcialur ZuZuTi

kvebasTan SedarebiT. ganviTarebul qveynebSi Sidsi iTvleba ZuZuTi

kvebis absolutur ukuCvenebad.

• Tu deda aiv inficirebulia da ar aqvs usafrTxo da adekvaturi

xelovnuri sakvebis gamoyenebis SesaZlebloba, rekomendebulia dedis

rZis pasterizeba141.142. stacionaris pirobebSi pasterizacia tardeba

62,50C 30 wuTis ganmavlobaSi. Tu ar aris pasterizaciis SesaZlebloba,

saxlis pirobebSi mizanSewonilia dedis rZis wamoduReba, Semdeg

gagrileba da bavSvisTvis miwodeba139.

• saWiroa dedisgan informirebuli Tanxmoba bavSvis kvebis meTodze,

risTvisac mas unda miewodos srulyofili informacia, rogorc ZuZuTi

kvebis sargeblianobis, aseve bunebrivi kvebis dros aiv infeqciis

gadacemis SesaZlo riskis Taobaze.

damatebiTi kveba

pirveli 6 Tvis ganmavlobaSi qalis rZe mTlianad akmayofilebs Cvilis

moTxovnilebas sakvebsa da siTxeze. bavSvis intensiur zrdasTan erTad

izrdeba misi kvebiTi da energetikuli moTxovnileba, ris gamoc aucilebeli

xdeba dedis rZesTan erTad damatebiTi sakvebis miwodeba kvebiTi racionis

ciliT, cximiT, naxSirwyliT, mikroelementebiTa da vitaminebiT Sesavsebad.

definicia

damatebiTi kveba - 6 Tvis Semdeg dedis rZesTan (xelovnur narevTan) erTad

naxevradmyari damatebiTi sakvebis miReba.

damatebiTi sakvebi _ produqti da siTxe, romelic gamoiyeneba Cvili bavSvis

sakvebad 6 Tvidan.

damatebiT sakvebi iyofa or jgufad:

• I jgufi – gardamavali periodis sakvebi, romelic gamoyeneba 6 Tvidan

1 wlamde78,145. misi saSualebiT xdeba asakobrivi kvebiTi

moTxovnilebebis dakmayofileba, ZuZuTi kvebis TandaTanobiT

Canacvleba da bavSvis ojaxis sakvebTan Segueba.

II

A

41

• II jgufi - sakvebi saerTo (ojaxis) magididan, romelic gamoiyeneba 1

welze meti asakis bavSvis kvebiTi moTxovnilebis

dasakmayofileblad78,145.

damatebiTi kvebis vadebi

damatebiTi sakvebis dawyebis vadebis gansazRvra emyareba bavSvis mzaobas

miiRos naxevradmyari sakvebi, rac Tavis mxriv dakavSirebulia nerv-kunTovani,

saWmlis momnelebli, Sard-gamomyofi sistemebis momwifebasTan.

nerv-kunTovani sitema47,78,145

4-5 TvisTvis viTardeba ,,ReWvis refleqsi”, bavSvs SeuZlia lukmis

formireba, gadaadgileba da gadaylapva, rac ganpirorbebulia Semdegi

asakobivi TaviseburebebiT (rekomednacia D)78:

• qreba sakvebis gadmogdebis refleqsi;

• Cndeba pirveli ReWviTi moZraobebi, izrdeba wovis Zala;

• bavSvs Tavisuflad uWiravs Tavi da amoZravebs kisers;

• iwevs sakvebisken da aRebs pirs, roca Sia.

cxrili 7

kvebasTan dakavSirebuli refleqsebi

asaki/Tve refleqsebi da unarCvevebi

0-6 wova da ylapva

4-7 pirveli ReWviTi moZraobis gaCena, wovis Zalis gazrda.

7-12 tuCebiT kovzis molokva, ReWva, kbeCa, enis gverdiTi moZraoba da

sakvebis kbilebTan gadaadgileba

12-24 brunviTi ReWviTi moZraobebi

saWmlis momnelebeli sistema78,145

sekretoruli funqcia _ 4-5 Tvidan saWmlis momnelebeli fermentebis

sekreciis srulyofa ganapirobebs cilebis, cximebis da naxSirwylebis

srulfasovan monelebasa da Sewovas.

kuWis tevadoba sakmaod mcirea, daaxleoebiT 30 ml/kg, ris gamoc ar aris

mizanSewonili didi moculobis da dabali energetikuli Rirebulebis

sakvebis miwodeba.

kuW-nawlavis barieruli funqcia 6 Tvis asakisTvis srulyofas ganicdis.

kerZod imatebs kuWis mJavianoba, izrdeba lorwovani garsis damcvelobiTi

unari, iwyeba sekretoruli imunoglobulinis (sIgA) gamomuSaveba, Zlierdeba

peristaltika, yalibdeba nawilavis flora. Sesabamisad bavSvis kuW-nawlavis

sistema momwifebulia da mzad aris axali sakvebis misaRebad

D

42

Sard-gamomyofi sistema

6 TvisTvis bavSvis Tirkmeli momwifebulia, srulfasovnad SeuZlia wylis

SenarCuneba da nivTierebaTa cvlis Sedgad warmoqmnili narCenebis eqskrecia,

amitom 6 Tvemde ar aris mizanSewonili damatebiTi kvebis dawyeba. damatebiTi

kvebis adreuli dawyebisas Cvilis moumwifebeli TirkmelebiT gaZnelebulia

Warbi cxoveluri cilis daSlis produqtebis gamoyofa.

amrigad, bavSvis mzardi kvebiTi moTxovnilebebisa da ganviTarebis

fiziologiuri Taviseburebis gaTvaliswinebiT damatebiTi sakvebis daniSvnis

saukeTeso periodad 6 Tvis asakia miCneuli78,45,46,145.

• janmrTelobis msoflio organizaciis rekomendaciiT bavSvebi

eqskluziur ZuZuTi kvebaze unda imyofebodnen 6 Tvis asakamde

(mtkicebulebis done I)78,145,155. mkacri samedicino Cvenebebis

arsebobisas, damatebiTi kveba individualurad SesaZlebelia dai-

niSnos 4 Tvidan (araviTar SemTxvevaSi _ 4 Tvemde). damatebiTi kvebis

adreuli dawyebis Cvenebaa: janmrTeli bavSvis masis matebis SeCereba,

bavSvis mudmivi daukmayofilebloba da SimSili ZuZuTi SeuzRudavi

kvebis fonze.

damatebiTi sakvebis naadrevi dawyeba amcirebs laqtacias da zrdis dispef-

siuri movlenebis, diareis, alergiuli daavadebebis, Saqriani diabetis

ganviTarebis da dedis xelaxali daorsulebis risks45,146, 155;

damatebiTi sakvebis dagvianebuli dawyeba xels uSlis saReWi

kunTebis srulfasovan Camoyalibebas da iwvevs: makro da

mikronutrientebis deficitis ganviTarebas, sakvebis gemos da

struqturis aRqmis unaris Seferxebas (rekomendacia C)55, 78,145,148.

damatebiTi kvebis etapebi78,145

ZuZuTi kvebidan ojaxis sakvebze gadasvla xorcieldeba etapobrivad. bavSvis

sakvebis moculoba da energetikuli Rirebuleba yvela etapze unda

Seesabamebodes mis fiziologiur moTxovnilebas.

I etapi - bavSvi eCveva sakvebis kovzidan miRebas da swavlobs tuCebis

gamoyenebas, piris RruSi sakvebis gadaadgilebas da gadaylapvas. pirveli

damatebiTi sakvebi unda iyos rbili konsistenciis da Seicavdes mxolod erT

ingredients. damatebiTi sakvebi bavSvma unda miiRos mcire raodenobiT erTi-

orjer dRis ganmavlobaSi, ZuZuTi kvebis damTavrebis Semdeg. am periodSi ar

aris rekomendebuli ZuZuTi kvebis mTlianad Canacvleba damatebiTi sakvebiT.

bavSvma aucileblad unda gaagrZelos ZuZuTi kveba igive sixSiriT, rogorc

eqskluziuri ZuZuTi kvebis dros.

II etapi - mas Semdeg, rac bavSvi mieCveva kovzidan kvebas, bavSvs unda

SesTavazon mravalferovani SedarebiT sqeli konsistenciis sakvebi (sqeli

piure da fafa). ZuZuTi kveba kvlav grZeldeba moTxovnilebis mixedviT,

magram misi sixSire ufro naklebia, vidre eqskluziuri ZuZuTi kvebis dros.

bavSvma damatebiTi sakvebi (xili, bostneuli, parkosnebi, xorci) unda miiRos

2-3-jer dReSi.

C

I

43

III etapi - bavSvs SeuZlia miiRos ufro sqeli konsistenciis dakepili da

daWyletili sakvebi, rac xels uwyobs ReWvis ganviTarebas. ZuZuTi kveba

grZeldeba moTxovnilebis mixedviT, Tumca igi aRar aris makronutrientebis

ZiriTadi wyaro. 9 Tvis Semdeg bavSvs unda miscen jer damatebiTi sakvebi,

Semdeg ZuZu. unda SesTavazon iseTi sakvebi, romelic SeuZlia xeliT aiRos.

damatebiTi sakvebi eZleva 2-3 jer dReSi, kvebaTa Soris mizanSewonilia

waxemseba (orcxobila, xili da sxva.).

IV etapi - erTi wlis Sedeg bavSvs SeuZlia miiRos sakvebi saerTo magididan.

sakvebi unda iyos kargad gaqnili da dakepili. mozrdilma xeli unda

Seuwyos damoukidebeli kvebis Cvevebis Camoyalibebas. Tumca bavSvi kvebis

dros marto ar unda darCes. ZuZuTi kveba unda gagrZeledes 2 wlamde.

damatebiTi sakvebis Semadgenloba da kvebis teqnika145,146

bavSvi unda ikvebebodes mravalferovani sakvebiT. asakis gaTvaliswinebiT man

yoveldRe unda miiRos produqti sakvebis yvela jgufidan78,145

• xili da bostneuli;

• burRuleuli;

• xorci da rZis produqti;

• cximebi (mcenareuli da cxoveluri) .

kvebiTi moTxovnilebis dakmayofilebas ganapirobebs Semdegi faqtorebi:

• sakvebis energetikuli Rirebuleba - damatebiTi sakvebis daniSvnisas

gaTvaliswinebuli unda iyos misi Semadgenloba da kaloriuloba145.

rekomendebulia sakvebis gamdidreba cximiT;

• sakvebis konsistencia;

• kvebis sixSire.

damatebiTi sakvebis konsistencia145,148

• asakis matebasTan erTad didi mniSvneloba eniWeba SedarebiT mkvrivi

konsistenciis sakvebis miwodebas swori artikulaciisa da metyve-

lebis CamoyalibebisaTvis, kuW-nawlavis traqtis, saReWi

muskulaturis, fermentuli procesebisa da nawlavis motorikis

gaaqtivebisa da stimulaciisTvis (rekomednacia D)78.

• 6 Tvidan 8 Tvemde Cvils SeuZlia miiRos piures tipis, gatarebuli

sakvebi. sakvebi unda iyos homogenuri, 8 Tvidan bavSvma unda miiRos

naxevrad myari da myari sakvebi, 12 Tvis Semdeg bavSvi ukve unda

ikvebebodes ojaxis sakvebiT.

• Tu myari sakvebis gamoyeneba iwyeba 10 Tvis Semdeg an ufro

gvian es zrdis mogvianebiT kvebiTi problemebis ganviTarebis

risks (rekomendacia C)78,145,148.

•

D

C

44

cxrili 8

sxvadasxva tipis sakvebis daniSvnis vadebi refleqsebsa da unar-CvevebTan

mimarTebaSi

asaki TveebSi refleqsebi-Cvevebi Pproduqtis tipi

0-6 wova da ylapva siTxeebi

4-7 pirveli ReWviTi moZraobis

gamoCena, wovis Zalis gazrda

siTxeebi-6 Tvemde, piures tipis

sakvebi - 6 Tvidan

7-12 tuCebiT kovzis molokva, ReWva,

kbeCa, enis gverdiTi moZraoba da

sakvebis kbilebTan gadaadgileba

gaxexili da dakepili

produqti, 8-9 Tvidan myari

sakvebi

12-24 brunviTi ReWviTi moZraobebi sakvebi saerTo magididan

damatebiTiKkvebis sixSire145

janmrTelma ZuZuTi kvebaze myofma bavSvma damatebiTi sakvebi unda miiRos

dReSi saSualod:

• 6-8 Tvis asakSi - 2-3 jer;

• 9-11 Tvis asakSi - 3-4 jer;

• 12-24 Tvis asakSi - 4 jer.

damatebiT kvebaTa Soris aucilebelia saaTobrivi reJimis mkacri dacva,

aranakleb 3,5-4 saaTisa. kvebaTa Soris dasaSvebia waxemseba (mag: xil-fafis

miwodeba) 1-2 jer dReSi.

damatebiTi sakvebis daniSvnis vadebi 46,144,149

produqti asaki TveebSi

6 7 8 9-12

xilfafa

bostneulis piure /sufi

marcvleulis fafa

mawoni

kvercxis guli

xorcis piure

yveli (umarilo)

naduRi

puri, orcxobila

mcenareuli zeTi/ karaqi

Tevzi

xaWo

xorcis naxarSi

45

wlamde ar SeiZleba cximis SezRudva, radgan is energiis ZiriTad wyaros

warmoadgens (rekomendacia A)168.

• damatebiTi kvebis teqnika47,162:

• bavSvisTvis sakvebi unda momzaddes yoveli kvebis win;

• sakvebis momzadebisas aucilebelia higienuri normebis dacva;

• bavSvis Segueba axal sakvebTan unda moxdes TandaTanobiT. sasurvelia

axali sakvebis pirveli ulufa dRis ganmavlobaSi Seadgendes

saSualod 5-10g (1-2 Cais kovzi) daNNTandaTan gaizardos. damatebiTi

sakvebis minimalur raodenobad miCneulia 4 sufris kovzi (saSualod

80-100g) sakvebi, romelic 9 Tvemde asakis bavSvs eZleva ZuZuTi kvebis

Semdeg, 9 Tvis asakis Semdeg ki ZuZuTi kvebis win;

• marcvleulis fafis damateba iwyeba ugluteno marcvleuliT (wiwbura,

brinji, simindi);

• xilfafis da bostneulis piures dawyebisas Tavdapirvelad iyeneben

erTi saxeobis produqts, romelsac TandaTan emateba gansxvavebuli

xili da bostneuli 1-2 dRiani intervaliT;

• bavSvis kveba unda ganxorcieldes kovziT, romelic xels uwyobs

bavSvis saReWi kunTovani aparatis ganviTarebas.

ar aris rekomendebuli

• bavSvisTvis ori an meti axali sakvebis erTdroulad micema. Semdgomi

axali produqtis gamoyeneba, umjobesia, ramdenime dRiani intervalis

dacviT, mas Semdeg, rac bavSvi iRebs wina damatebiT sakvebis srul

ulufas;

• damatebiTi sakvebis miwodeba boTliT da sawovaraTi;

• bavSvis sakvebisTvis marilis an Saqris damateba;

• 12 Tvis asakamde Zroxis rZis gamoyeneba, radgan igi iwvevs rkinis

Sewovis Seferxebas da anemias46,144,149;

• citrusis da kvercxis cilis 12 Tvis asakamde miwodeba alergiis

ganviTarebis riskis Semcirebis mizniT145;

• Taflis gamoyeneba - wlamde asakSi asocirdeba alergiis,

konservirebuli ki botulizmis ganviTarebis riskTan92.

• Cai - Seicavs didi raodenobiT taninebs da amcirebs rkinisa da sxva

mikroelementebis Sewovas92,143.

erTidan or wlamde asakis bavSvis kveba

1 wlis Semdeg bavSvi agrZelebs intensiur zrda-ganviTarebas, iwyebs aqtiur

moZraobas, siaruls, TamaSs da Sesabamisad meore wlis ganmavlobaSi misi

moTxovnileba energiasa da ZiriTad sakveb nivTierebebze ufro metia, vidre

pirveli wlis bolos47,162.

janmos rekomendaciiT 2 wlis asakamde ojaxis sakvebTan erTad bavSvi unda

iRebdes dedis rZes44,46,145. qalis rZe am periodSi mniSvnelovani kvebiTi

RirebulebiT aRar gamoirCeva, magram 1 wlis Semdeg mis SemadgenlobaSi

izrdeba damcvelobiTi faqtorebis raodenoba. 1-dan 2 wlamde periodSi

A

46

izrdeba bavSvis garemosTan urTierTobis areali, patara aqtiurad daxoxavs,

xSirad ecema siarulis dros, TamaSobs qviSaSi, pirSi idebs sxvadasxva

sagnebs da saTamaSoebs, rac zrdis bavSvis inficirebis risks. dedis rZis

miReba ki uzrunvelyofs mas damcvelobiTi nivTierebebiT.

aucilebelia cilebze bavSvis asakobrivi moTxovnilebis

dakmayofileba (rekomendacia B)168.

naxSirwylebi unda Seadgendes sakvebis kaloraJis 40-50%-s

(rekomendacia C)168.

1-2 wlamde asakis bavSvis energetikuli da nutriciuli moTxovnilebis

uzrunvelsayofad mis dRiur racionSi unda Sediodes sakvebi qvemoT

moyvanili produqtis yvela jgufidan iseTi TanafardobiT, rogorc amas

janmos mier mowodebuli ,,sakvebis piramida’’ warmoadgens. misaRebi sakvebis

raodenoba regulirdeba ulufebis mixedviT.

puri, marcvleuli, brinji da makaroni – 6 ulufa dReSi

erT ulufas Seadgens:

• 1 naWeri puri (30-40 gr) • 4 patara krekeri

• 1/2 Wiqa fafa (marcvleulis)

• 1/2 Wiqa moxarSuli makaroni

an brinji

bostneuli – 3 ulufa dReSi


• 1/2 Cais Wiqa moxarSuli bostneuli

• 1/2 Cais Wiqa umi bostneuli

• 1/2 Cais Wiqa bostneulis wveni

xili – 2 ulufa dReSi


• 1/2 cocxali vaSli an atami

• 1 cali qliavi

• 1/2 Cais Wiqa xilis wveni (arakonservirebuli)

• 1/2 Cais Wiqa daWrili cocxali xili.

rZe da rZis produqti – 4 ulufa dReSi


• 1/2 Cais Wiqa rZe

• 1 naWeri yveli

• 1/2 Cais Wiqa mawoni

• 1/4-1/3 Cais Wiqa xaWo, naduRi.

xorci, kvercxi da parkosnebi – 2 ulufa dReSi


• 70 g xorci (qaTami, saqoneli, Tevzi)

C

B

47

• 1/2 Cais Wiqa moxarSuli parkosnebi

• 1 kvercxi.

cximebi (karaqi, erbo, mcenareuli zeTi), tkbileuli da marili

2 wlamde bavSvebSi ar SeiZleba cximis raodenobis SezRudva

(rekomendacia B)168. umjobesia bavSvma meti mcenareuli cximi miiRos,

vidre cxoveluri. tkbileuli da marili unda miewodos SezRuduli

raodenobiT.

siTxeebi

• Zroxis rZis miRebuli raodenoba ar unda aRematebodes 2 Wiqas

dReSi;

• xilis wveni – ar unda aRematebodes 1/2 Wiqas;

• wyali –kvebaTa Soris survilis mixedviT.

1-dan 2 wlamde asakis bavSvis kvebis sixSire saSualod 4-5 jeradia,

SeiZleba gamoyenebuli iyos samjeradi ZiriTadi sakvebi 2 waxemsebiT. ZuZuTi

kveba sakmarisia dReSi 1-2-jer, aseTi sixSire srulad uzrunvelyofs bavSvs

damcvelobiTi niTierebebis saWiro raodenobiT.

2 wlamde ar aris rekomendebuli Semdegi sakvebis gamoyeneba:

• tkbili siTxeebi da didi raodebiT xilis wvenebi maTi dabali

energitikuli da nutriciuli Rirebulebis gamo. amave dros isini

aqveiTeben bavSvis madas142,143,145;

• Cai (xSiri gamoyeneba) - Seicavs didi raodenobiT taninebs da amcirebs

rkinisa da sxva mikroelementebis Sewovas92,143;

• am asakSi bavSvs ar unda miawodon iseTi sakvebi, romelic SeiZleba

gadacdes (kenkra, Txili, yurZnis marcvali da a.S.) 78.145.

bavSvze zrunva kvebis dros

bavSvze zrunva kvebis dros miekuTvneba fsiqo-socialuri zrunvis

principebs145,151.

mecnierebi miiCneven, rom damatebiTi kvebis optimaluroba ganisazRvreba ara

mxolod imiT, Tu ras Wams bavSvi, aramed imiTac, Tu sad, rodis, rogor da

vin aWmevs mas145.

• bavSvis kvebis dros ufrosi unda ijdes mis pirispir;

• kvebis dros bavSvis yuradReba ar unda iyos gafantuli, bavSvis kveba

sasurvelia mimdinareobdes mSvidad da auCqareblad, ar aris

mizanSewonili sakvebis daZaleba;

• wlis Semdeg bavSvs esaWiroeba ufrosis daxmareba, roca is cdilobs

damoukideblad Wamas;

• Tu bavSvi xSirad ambobs uars sakvebze, rekomendebulia SesaTavazon

mas sxvadasxva sakvebi;

B

48

• erTidan or wlamde asakSi mizanSewonilia bavSvi mieCvios sisufTavis

wesebis dacvas (xelebis dabana kvebis win, kbilebis gawmenda);

• kvebis procesi aris bavSvis swavlis, masTan Tbili urTierTobis da

pirispir kontaqtis damyarebis saukeTeso periodi.

avadmyofi bavSvis kveba

bavSvis avadmyofobis dros didi mniSvneloba aqvs racionaluri kvebis

principebis dacvas, avadmyofi bavSvis fiziologiuri moTxovnilebebis

gaTvaliswinebiT. uxSiresad avadmyofobis dros organizmis moTxovnileba

siTxeebze ufro metia. Sesabamisad, am periodSi rekomendebulia

bavSvis siTxeebiT datvirTva, Tu bavSvi ZuZuzea, mas ZuZu ufro

xSirad unda SesTavazon (rekomendacia A). A

avadmyofobis dros bavSvisTvis damaxasiaTebelia madis daqveiTeba. Tu bavSvi

ZuZusTan erTad damatebiT sakvebs iRebs an ojaxis sakvebiT ikvebeba, ar aris

rekomendebuli sakvebis daZaleba, sasurvelia damatebiTi sakvebis xSirad da

mcire ulufebiT SeTavazeba. mizanSewonilia bavSvis kvebis sixSire erTi

kvebiT gaizardos.

bavSvma unda miiRos mikroelementebis Semcveli, mravalferovani da advilad

mosanelebeli sakvebi, rac xels uwyobs gamojanmrTelebis process.

avadmyofobis dros ufrosi unda Seecados moamzados iseTi sakvebi, romelic

bavSvs uyvars, an romelsac is xSirad iTxovs27,145.

avadmyofobis Semdeg aucilebelia kvebis sixSiris gazrda,

mikroelementebiTa da energiiT mdidari mravalferovani sakvebis gamoyeneba,

imisTvis, rom bavSvma droulad aRidginos, rogorc wonis, ise kvebiTi

(nutriciuli) danakargi. Sesabamisad ufrosma xeli unda Seuwyos

gamojanmrTebul bavSvs, rom 2 kviris ganmavlobaSi man dReSi erTi kvebiT

meti mainc miiRos, vidre avadmyofobis periodamde iRebda145.

kvebis Sefaseba

kvebis Sefaseba unda ganxorcieldes individualurad (rekomendacia

C)169. Ffasdeba:

• kvebiTi anamnezi;

• kvebiTi unar-Cvevebi;

• dieta (kvebis racioni);

• medikamentebis gamoyeneba;

• fizikuri ganviTarebis maCveneblebi - anTropometria;

• laboratoriul kvlevis Sedegebi.

kvebis Sefasebis sixSire ganisazRvreba individualurad da efuZneba

pacientis mdgomareobas, nutriciuli problemis simZimes

(rekomendacia C)169

konsultireba bavSvis kvebis dros

bavSvis racionaluri kvebis danergvisa da farTod gavrcelebisaTvis

yvelaze efeqtur saSualebas konsultireba warmoadgens. mSobelTa

konsultireba adreuli asakis bavSvis kvebis Sesaxeb unda moicavdes Semdeg

A

C

C

49

sakiTxebs: ZuZuTi kvebis ZiriTadi principebi, damatebiTi kvebis mniSvneloba

da misi daniSvnis vadebi, bavSvis kveba 1 wlis Semdeg.

dadgenilia, rom mSobelTa konsultireba ZuZuTi kvebis sakiTxebze

da konsultirebasTan erTad maTi uzrunvelyofa nabeWdi sainfarmacio

masaliT, xels uwyobs ZuZuTi kvebis sixSiris 5-10%-iT zrdas

(mtkicebulebis done - I)92, ojaxis sxva wevrebis CarTva ganaTlebis procesSi

xels uwyobs ZuZuTi kvebis xangrZlivobis gazrdas (mtkicebulebis

done - II)145. konsultireba ZuZuTi kvebis sakiTxebze unda daiwyos

antenatalur periodSi, gagrZeldes samSobiaro saxlSi da patronaJis

vizitebis dros92.

patronaJis vizitebis dros dedas konsultireba unda gaewios aseve

damatebiTi sakvebis mniSvnelobaze da daniSvnis vadebze.

antenatalur periodSi konsultirebis ZiriTad mizans warmoadgens dedis

motivireba, bavSvis kvebis Sesaxeb swori gadawyvetilebis misaRebad.

gansakuTrebuli yuradReba unda daeTmos Semdeg sakiTxebs:

• ZuZuTi kvebis upiratesoba dedisa da bavSvisTvis;

• kani kanTan kontaqti da ZuZuTi kvebis adreuli dawyebis mniSvneloba;

• samSobiaro saxlSi dedisa da bavSvis erTad yofnis mniSvneloba;

• dedis kveba orsulobis periodSi.

konsultaciis sakvanZo rekomendaciebi:

• qalis rZe Cvilis saukeTeso sakvebia, romelic mudmivad icvleba

bavSvis moTxovnilebis Sesabamasad da xels uwyobs mis srulfasovan

ganviTarebas;

• ZuZuTi kveba amcirebs bavSvTa avadobisa da sikvdilobis risks;

• ZuZuTi kveba icavs bavSvs mravali infeqciuri Tu alergiuli

daavadebisagan;

• ZuZuTi kveba amcirebs dedasTan sarZeve jirkvlisa da sakvercxeebis

simsivnuri daavadebebis ganviTarebis risks da icavs qals xelaxali

daorsulebisagan;

• janmrTeli, drouli axalSobilis kani kanTan kontaqti dedasTan da

ZuZuze pirveli moWideba dabadebidan pirveli 1 sT-is ganmavlobaSi

unda ganxorcieldes. kani kanTan kontaqtis xangrZlivoba minimum 30

wuTia, sasurvelia 2 sT gagsZeldes;

• ZuZuTi kvebis adreuli dawyeba (sicocxlis pirvel saaTSi) xels

uwyobs saSvilosnos SekumSvas da icavs qals mSobiarobis Semdgomi

sisxldenisagan. xsenis (pirveli rZe) miReba icavs bavSvs mravali

daavadebisagan. xseni axalSobilis pirvel imunizacias warmoadgens;

• samSobiaro saxlSi dedisa da bavSvis erTad yofna mniSvnelovnad

amcirebs daavadebebis ganviTarebis risks, xels uwyobs

moTxovnilebiTi kvebis, maT Soris Ramis kvebis ganxorcielebas,

dedisa da bavSvis fsiqoemuciur kavSirs;

• dedis racionalur kvebas orsulobis periodSi didi mniSvneloba aqvs

nayofis ganviTarebis xelSewyobisTvis.

II

I

50

samSobiaro saxlSi da patronaJis vizitebis dros konsultirebis ZiriTadi

mizania meZuZuri dedis daxmareba, raTa man efeqturad ganaxorcielos

axalSobili da Cvili bavSvis ZuZuTi kveba.Aam periodSi gansakuTrebuli

yuradReba unda daeTmos Semdeg sakiTxebs:

• rZis produqcia;

• optimaluri ZuZuTi kvebis principebi;

• ZuZuTi kvebis teqnika;

• ZuZuTi kvebis problemaTa prevencia;

• meZuZuri dedis kveba;

• bavSvze zrunva kvebis dros;

• kvebis principebi bavSvis avadmyofobis dros.

konsultaciis sakvanZo rekomendaciebi:

• moTxovnilebiTi xSiri ZuZuTi kveba 8-12-jer dRe-RameSi. rZis

produqcia damokidebulia ZuZus wovis sixSireze. rac ufro xSirad

wovs bavSvi da clis ZuZus, miT meti rZe gamomuSavdeba. es moTxovnisa

da miwodebis erTiani sistemaa;

• eqskluziuri ZuZuTi kveba 6 Tvemde, 6 Tvis Semdeg damatebiTi sakvebi;

• ZuZuTi kvebis gagrZeleba 2 wlamde;

• damatebiT sakvebad mravalferovani, axalad momzadebuli

naxevradmyari sakvebis gamoyeneba. mniSvnelovania kvebis racionSi

rkinis da A vitaminis Semcveli sakvebis damateba. 1 wlis Semdeg

saWiroa ojaxis sakvebis miwodeba. sakvebis momzadebisas higienis

wesebis dacva; • kvebis procesi aris bavSvis swavlis, masTan Tbili urTierTobis da

pirispir kontaqtis damyarebis saukeTeso periodi;

• ZuZuTi kvebis gagrZeleba da sixSiris gazrda bavSvis avadmyofobis

dros. Tu bavSvi 6 Tveze meti asakisaa ZuZusTan erTad saWiroa

damatebiTi siTxeebis miwodeba. avadmyofobis Semdeg aucilebelia 1

damatebiTi kvebis gamoyeneba 2 kviris ganmavlobaSi.

51

danarTi 1

saqarTvelos kanoni “bavSvTa bunebrivi kvebis dacvisa da xelSewyobis, xelovnuri sakvebis kontrolirebadi moxmarebis Sesaxeb”

metad mniSvnelovania, samedicino personali icnobdes saqarTvelos kanons

“bavSvTa bunebrivi kvebis dacvisa da xelSewyobis, xelovnuri sakvebis

kontrolirebadi moxmarebis Sesaxeb”, gansakuTrebiT ki mis im nawils,

romelic samedicino dawesebulebebis da personalis ufleba movaleobebs

asaxavs.

T a v i III

samedicino saqmianobis samarTalsubieqtebi muxli 17.

samedicino saqmianobis samarTalsubieqti movalea daicvas da xeli

Seuwyos Cvili da adreuli asakis bavSvTa bunebriv kvebas.

muxli 18.

orsuli da meZuZuri qalebis, Cvili da adreuli asakis bavSvebis

kvebasTan dakavSirebuli samedicino sakiTxebis mowesrigebis ufleba aqvs

mxolod janmrTelobis dacvis saministros mier dadgenili wesiT

registrirebul, akreditebul da licenzirebul samedicino saqmianobis

samarTalsubieqts.

muxli 19.

samedicino saqmianobis samarTalsubieqts ekrZaleba bavSvTa xelovnuri

kvebisa da sakvebis, sawovriani boTlebisa da satyuarebis nebismieri formiT

reklamireba da propaganda an aseTi qmedebisaTvis xelSewyoba.

muxli 20.

samedicino saqmianobis samarTalsubieqts bavSvTa xelovnuri sakvebi

ufasod an fasdaklebiT samedicino dawesebulebaSi gamosayeneblad an

gasavrceleblad SeiZleba gadaeces mxolod janmrTelobis saministros

werilobiTi TxovniT da werilobiTi nebarTviT, romelSic aRniSnulia

gadasacemi produqtis raodenoba. gamonaklisi daiSveba 21-e muxlSi aRniSnul

SemTxvevebSi.

muxli 21.

oboli da mSoblebis zrunvas moklebul bavSvebis samedicino

dawesebulebas xelovnuri sakvebi ufasod an fasdaklebiT SeiZleba gadaeces

nebismieri raodenobiT janmrTelobis dacvis saministros werilobiTi

Txovnisa da werilobiTi nebarTvis gareSe.

muxli 22.

samedicino saqmianobis samarTalsubieqti, romelic ufasod an

fasdaklebiT gaavrcelebs bavSvTa xelovnur sakvebs me-7 muxlSi aRniSnuli

pirobis Sesabamisad, valdebulia uzrunvelyos SerCeuli kontingentisaTvis

igive pirobebiT xelovnuri sakvebis miwodebis uwyvetoba am ukanasknelis

saWiroebis mTeli drois ganmavlobaSi.

muxli 23.

samedicino saqmianobis samarTalsubieqts ekrZaleba:

52

1. bavSvTa xelovnuri sakvebis mwarmoeblisagan an gasaRebis agentisagan

xelovnuri sakvebis nimuSis, partiis, sxva raime nebismieri sagnis, nivTis an

Tanxis saCuqrad miReba.

2. bavSvTa xelovnuri sakvebis mwarmoeblis da/an gasaRebis agentisaTvis

orsuli qalebis da Cvili da adreuli asakis bavSvebis dedebis vinaobisa

da misamarTis gadacema.

muxli 24.

samedicino dawesebulebaSi dauSvebelia bavSvTa xelovnuri sakvebis,

sawovriani boTlebis, satyuarebis Sesaxeb sareklamo, sainformacio,

saswavlo masalebis gamokvra, xelovnuri sakvebis mwarmoeblebis an gasaRebis

agentebis safirmo an sxva raime niSnebiT, maTi saxelwodebiT,

gamosaxulebebiT Tanxlebuli nivTis an sagnis xmareba an ganTavseba.

muxli 25.

dauSvebelia bavSvTa xelovnuri sakvebis mwarmoeblebis an gasaRebis

agentebis mier samedicino-biologiuri kvlevebis dafinanseba, samedicino

personalis samecniero da praqtikuli (yriloba, konferencia, sesia,

simpoziumi da sxv.) an nebismieri sxva saxis Sexvedris, mivlinebebis,

staJirebis, uwyveti samedicino ganaTlebis, agreTve samedicino asociaciebis

saqmianobis sponsoroba.

gaidlainis gadasinjvisa da ganaxlebis vada – 4 weli

gaidlainis miRebis xerxi/wyaro

gaidlainis SemuSavebis meTodologia

• 2 wlamde asakis bavSvTa bunebrivi kvebis Sesaxeb arsebobs

samecniero mtkicebulebis safuZvelze Seqmnil rekomendaciaTa

sakmarisi raodenoba. mocemuli gaidlainis Seqmnis 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.

cxrili 2

qveyana da resursis

dasaxeleba

internet-misamarTi

aSS

US National Guideline Clearinghouse (NGC)

http://www.guideline.gov

Centers for Disease Control and Prevention (CDC)

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

Agency for Healthcare Research and Quality (AHRQ)

http://www.ahrq.gov/clinic/cpgsix.htm

53

Health Services Technology Assessment Text (HSTAT) and National Library of Medicine (NLM)

http://hstat.nlm.nih.gov

Institute of Clinical Systems Improvement (ICSI)

http://www.icsi.org

American Medical Association http://www.ama-assn.org

Canadian Medical Association (CMA)

http://mdm.ca/cpgsnew/cpgs/index.asp

Health Canada – Population and Public Health Branch (PPHB)

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

didi britaneTi National Institute for Clinical Excellence (NICE)

http://www.nice.org.uk

Sheffield Evidence for Effectiveness and Knowledge (SEEK)

http://www.shef.ac.uk/seek/guidelines.htm

National electronic Library for Health (NeLH)

http://www.nelh.nhs.uk/guidelinesfinder

PRODIGY Clinical Guidance http://www.prodigy.nhs.uk/ClinicalGuidance

Scottish Intercollegiate Guidelines Network (SIGN)

http://www.sign.ac.uk

German Guideline Information Service (GERGIS)

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

avstralia Australian National Health and Medical Research Council (NHMRC)

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

axali zelandia

New Zealand Guidelines Group (NZGG)

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

mtkicebiTi medicinis

specialistTa

regionTaSorisi

sazogadoeba

http://www.osdm.org

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

54

publikaciebis CarTvis/gamoricxvis kriteriumebi

• arCeul iqna kvlevebi Semdegi dizainiT: randomizebuli,

kontrolilerabadi, 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 axalSobilTa axalSobilTa bunebrivi kvebis

marTvis 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:

⇒ janmrTelobismsoflo organizacia

⇒ amerikis pediatrTa akademia

⇒ kanadis pediatrTa sazogadoeba

⇒ laqtaciis konsultantTa saerTaSoriso asocia (ILKA)

gaTvaliswinebuli iyo bavSvTa kvebis saerTaSoriso qseli (IBFAN) ZuZuTi kvebis msoflio aliansi (WABA), Baby Milk Action ZuZuTi kvebis

qselis masalebi

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.

55

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

swori dizainis mqone

randomizebul

kontrolirebad kvleva

B eyrdnoba II donis

mtkicebulebas da

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

klinikuri rekomendaciebis piloturi gamocda

samedicino personali, romelic uSualod muSaobs axalSobilTan (SaraSiZis

samedicino centri, axalSobilTa reanimaciis da gadaudebeli daxmarebis

ganyofilebebi, samSobiaro saxli „bibida“, saerTaSoriso organisazacia

IBFAN-is saqarTvelos jgufi arasamTavrobo organizacia „klaritasi“) gaecno

klinikur gaidlains. gaidlainis SemuSavebis procesSi gaTvaliswinebuli iyo

maTi SeniSvnebi da praqtikuli rekomendaciebi.

bunebrivi kvebis xelSewyobis programa saqarTvelos Sromis janmrTelobisa

da socialuri dacvis saministros mier aRiarebulia saxelmwifo programad

da saerTaSoriso organizaciebis - gaeros bavSvTa fondi „UNICEF“, „UMCOR“ WABA, ACTS Georgia finansuri xelSewyobiT inergeba 1996 wlidan. mocemuli

periodis ganmavlobaSi gaumjobesda ZuZuTi kvebis maCveneblebi:

samSobiarodan gamowerili axalSobilTa 90 % imyofeba ZuZuTi kvebaze,

dainerga eqskluziuri ZuZuTi kvebis praqtika, romlis maCvenebelmac gaerosa

bavSvTa fondis da ACTS is mier Catarebuli kvlevis SedegebiT 2005w.

Seadgina 36 %. 1999 wels saqarTvelos parlamentis mier damtkicda

saqarTvelos kanoni “bavSvTa bunebrivi kvebis dacvisa da xelSewyobis,

xelovnuri sakvebis kontrolirebadi moxmarebis Sesaxeb”.

56

alternatiuli gaidlani ar arsebobs gamoyenebuli literatura:

1. International Lactation consultant association (ILCA).Clinical Guidelines for the establishment of exclusive breastfeeding June 2005 Overfield M.L.

2. Kramer MS, Guo T, Platt RW, Sevkovskaya Z, Dzikovich I, Collet JP, et al. Infant growth and health outcomes associated with 3 compared with 6 month of exclusive breastfeeding. Am J Clin Nutr2003;78(2):291-5.

3. Kramer MS, Kakuma R. The optimal duration of exclusive breastfeeding: a systematic review. Adv Exp Med Biol 2004;554:63-77.

4. Marasco L, Marmet C, Shell E. Polycystic ovary syndrome: a connection to insufficient milk supply? J Hum Lact 2000;16(2):143-8.

5. van’t Hof MA. The Influence of Breastfeeding and Complementary Foods on Growth Until Three Years of Age in the Euro-Growth Study. Pediatrics 2000;106(5):1281.

6. Canadian Paediatric Society Nutrition Committee, Dietitians of Canada, Health Canada. Nutrition for Healthy Term Infants; 1998.

7. Gray L, Miller LW, Philipp BL, Blass EM. Breastfeeding is analgesic in healthy newborns. Pediatric 2002; 109(4):590-3.

8. Fleming PJ, Blair PS, Pollard K, et al. Confidential Enquiry Canada into Stillbirths and Deaths in Infancy/Sudden Unexpected Deaths in Infancy Research Team. Pacifier use and sudden infant death syndrome: Results from the Confidential Enquiry into Stillbirths and Deaths in Infancy/Sudden Unexpected Deaths in Infancy case control study. Arch Dis Child 1999;81:112-6.

9. L’Hoir MP, Engelberts AC, van Well GTJ, et al. Risk and preventive kanada factors for cot death in The Netherlands, a low incidence country. Eur J Pediatr 1998;157:681-8.

10. Canadian Paediatric Society Nutrition Committee, Canada Dietitians of Canada, Health Canada. Nutrition for Healthy Term Infants 07.23.2006

11. American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 2005;115(2):496-506.

12. World Health Organization. (2002) Infant and Young Child Nutrition: Global Strategy on Infant and YoungChild Feeding. WHO, Fifty-fifth World Health Assembly. April.

13. Chandra RK. Food allergy and nutrition in early life: implications for later health. Proc Nutr Soc 2000;59(2):273-7.

14. Ф.Сэведж Кинг. Помощь Матерям в кормлении Грудью1995 15. Butte NF, Garza C, Smith EO, Nichols BL. Human milk intake and growth in exclusively breast-fed

infants. J Pediatr 1984;104(2):187-95. 16. Dewey KG. Maternal and fetal stress are associated with impaired lactogenesis in humans. J Nutr

2001;131(11): 17. 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. 18. Dewey KG, Peerson JM, Brown KH, Krebs NF, Michaelsen KF, Persson LA, et al. Growth of breastfed

infants deviates from current reference data: a pooled analysis of US, Canadian, and European data sets. World Health Organization Working Group on Infant Growth. Pediatrics 1995;96(3 Pt 1):495-503.

19. Dewey KG, Nommsen-Rivers LA, Heinig MJ, Cohen RJ. Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatalweight loss. Pediatrics 2003;112(3 Pt 1):607-19.

20. Ferber SG, Makhoul IR. The effect of skin-to-skin contact (kangaroo care) shortly after birth on the neurobehavioral responses of the term newborn: arandomized, controlled trial. Pediatrics 2004; 113(4):858-65.

21. Matthiesen AS, Ransjo-Arvidson AB, Nissen E, Uvnas-Moberg K. Postpartum maternal oxytocin release by newborns: effects of infant hand massage and sucking. Birth 2001;28(1):13-9.

22. Prodromidis M, Field T, Arendt R, Singer L, Yando R, Bendell D. Mothers touching newborns: a comparison of rooming-in versus minimal contact. Birth 1995;22(4):196-200; discussion 201-3.

23. Renfrew MJ, Lang S, Woolridge MW. Early versus delayed initiation of breastfeeding. Cochrane Database Syst Rev 2000(2):CD000043.

24. Wiberg B, Humble K, de Chateau P. Long-term effect on mother-infant behaviour of extra contact during the first hour post partum. V. Follow-up at three years. Scand J Soc Med 1989;17(2):181-91.

57

25. Lawrence RA, Lawrence RM. Breastfeeding: A Guide for the Medical Profession, 5th ed. St. Louis: Mosby, 1999.

26. 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):F472-76.

27. Brown KH. (2000) WHO/UNICEF Review on complementary feeding and suggestions for future research: WHO/UNICEF guidelines on complementary feeding. Pediatrics 106(5):1290

28. Dewey KG, Cohen RJ, Brown KH, Rivera LL. (2001) Effects of exclusive breastfeeding for four versus six months on maternal nutritional status and infant motor development: results of two randomized trials in Honduras. J Nutrition 131:262-267.

29. Kramer MS, Kakuma R. (2003) Optimal duration of exclusive breastfeeding (Cochrane Review). In: TheCochrane Library, Issue 1. Oxford: Update Software.

30. Kramer MS, Chalmers B, Hodnett E, Sevkovskaya, Z, Dzikovich I, Shapiro, S et al. (2001) Promotion of the breastfeeding intervention trial (PROBIT): A randomized trial in the Republic of Belarus. JAMA 285(4):413

31. Brown KH, et al. Effects of common illnesses on infants’ energy intakes from breast milk and other foods during longitudinal community-based studies in Huascar (Lima), Peru. Am J Clin Nutr 1990;52:1005-13.

32. Metaj M, Laroia N, Lawrence RA, Ryan RM. Comparison of breast- and formula-fed normal newborns in time to first stool and urine. J Perinatol 2003;23(8):624-8.

33. Labbok MH, Hight-Laukaran V, Peterson AE, Fletcher V, von Hertzen H, Van Look PF. Multicenter study of the Lactational Amenorrhea Method (LAM): I. Efficacy, duration, and implications for clinical application. Contraception 1997;55(6):327-36.

34. Taveras EM, Capra AM, Braveman PA, Jensvold NG, Escobar GJ, Lieu TA. Clinician support and psychosocial risk factors associated with breastfeeding discontinuation. Pediatrics 2003;112(1 Pt 1):108-15.

35. American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 2005;115(2):496-506.

36. Howard CR, Howard FM. Management of breastfeeding when the mother s ill. Clin Obstet Gynecol 2004;47(3):683-95.

37. Hall RT, Mercer AM, Teasley SL, McPherson DM, Simon SD, Santos SR, et al. A breast-feeding assessment score to evaluate the risk for cessation of breast-feeding by 7 to 10 days of age. J Pediatr 2002;141(5):659-64.

38. Hamprecht K, Maschmann J, Muller D, Dietz K, Besenthal I, Goelz R, et al. Cytomegalovirus (CMV) inactivation in breast milk: reassessment of pasteurization and freeze-thawing. Pediatr Res 2004; 56(4):529-35.

39. Marques RF, Lopez FA, Braga JA. [Growth of exclusively breastfed infants in the first 6 months of life]. J Pediatr (Rio J) 2004;80(2):99-105.

40. Gray L, Watt L, Blass EM. Skin-to-skin contact is analgesic in healthy newborns. Pediatrics 2000; 105(1):e14.

41. Ashraf RN, Jalil F, Aperia A, Lindblad BS. Additional water is not needed for healthy breast-fed babies in a hot climate. Acta Paediartr Scan 1993;82:1007-1011.

42. World Health Assembly. International Code of Marketing of Breast-milk Substitutes. Geneva: World Health Organization; 1981.

43. World Health Organization. Evidence for the Ten Steps to Successful Breastfeeding, Revised Ed. In: WHO/CHD/98.9; 1998.

44. World Health Organization. The World Health Organization multinational study of breast-feeding and lactational amenorrhea. III. Pregnancy during breast-feeding. World Health Organization Task Force on Methods for the Natural Regulation of Fertility. Fertil Steril 1999;72(3):431-40.

45. World Health Organization. Global strategy for infant and young child feeding. Geneva: 2003. 46. World Health Organization. Global strategy: breastfeeding critical for child survival—UNICEF and WHO

call for increased commitment to appropriate feeding practices for all infants and young children. Indian J Med Sci 2004;58(3):138-9.

47. n. xerxeuliZe “bavSvTa daavadebaTa propedevtika”

48. James W Anderson,bryan m Johnstone, and Daniel T Remley breast-feeding and cognitive development: a meta-analysis Am. J Clin Nutr 1999 70-525-35

49. Dusdieker LB, Stumbo PJ, Booth BM, Wilmoth RN.Prolonged maternal fluid supplementation in breastfeeding. Pediatrics 1990;86(5):737-40.

50. Cregan MD, Mitoulas LR, Hartmann PE. Milk prolactin, feed volume and duration between feeds in women breastfeeding their full-term infants over a 24 h period. Exp Physiol 2002;87(2):207-14.

58

51. Daly SE, Hartmann PE. Infant demand and milk supply.Part 2: The short-term control of milk synthesis in lactating women. J Hum Lact 1995;11(1):27-37.

52. Daly SE, Hartmann PE. Infant demand and milk supply.Part 1: Infant demand and milk production in lactating women. J Hum Lact 1995;11(1):21-6.

53. Daly SE, Kent JC, Owens RA, Hartmann PE. Frequency and degree of milk removal and the shortterm control of human milk synthesis. Exp Physiol1996;81(5):861-75.

54. Peaker M, Wilde CJ. Feedback control of milk secretion from milk. J Mammary Gland Biol Neoplasia 1996;1(3):307-15.

55. Yamauchi Y, Yamanouchi I. Breast-feeding frequency during the first 24 hours after birth in full-term neonates. Pediatrics 1990;86(2):171-5.

56. Bergman NJ, Linley LL, Fawcus SR. Randomized controlled trial of skin-to-skin contact from birth versus conventional incubator for physiological stabilization in 1200- to 2199-gram newborns. Acta Paediatr 2004;93(6):779-85.

57. Zetterstrom R. Breastfeeding and infant-motherinteraction. Acta Paediatr Suppl 1999;88(430):1-6. 58. Righard L, Alade MO. Effect of delivery room routines on success of first breast-feed. Lancet

1990;336(8723):1105-7. 59. Bystrova K, Widstrom AM, Matthiesen AS, Ransjo- Arvidson AB, Welles-Nystrom B, Wassberg C, et al.

Skin-to-skin contact may reduce negative consequences of “the stress of being born”: a study on temperature in newborn infants, subjected to different ward routines in St. Petersburg. Acta Paediatr 2003;92(3):320-6.

60. Inch S. Fisher C. Mastitis: infeqtion or inflammation? Practitioner., 1995, 239 (1553): 472-476 61. Christensson K, Siles C, Moreno L, Belaustequi A, De La Fuente P, Lagercrantz H, et al. Temperature,

metabolic adaptation and crying in healthy full-term newborns cared for skin-to-skin or in a cot. Acta Paediatr 1992;81(6-7):488-93.

62. Mikiel-Kostyra K, Mazur J, Boltruszko I. Effect of early skin-to-skin contact after delivery on duration of breastfeeding: a prospective cohort study. Acta Paediatr 2002;91(12):1301-6.

63. Academy of Breastfeeding Medicine Protocol Committee. Clinical Protocol #3: Hospital Guidelines for the Use of Supplemental Feedings in the Healthy Term Breastfed Neonate; 2003.

64. de Chateau P, Wiberg B. Long-term effect on motherinfant behaviour of extra contact during the first hour post partum. III. Follow-up at one year. Scand J. Soc Med 1984;12(2):91-103.

65. Bertini G, Dani C, Tronchin M, Rubaltelli FF. Is breastfeeding really favoring early neonatal jaundice? Pediatrics 2001;107(3):E41.

66. Blair PS, Ball HL. The prevalence and characteristics associated with parent-infant bed-sharing in England. Arch Dis Child 2004;89(12):1106-10.

67. Semmekrot BA, de Vries MC, Gerrits GP, van Wieringen PM. [Optimal breastfeeding to prevent hyperbilirubinaemia in healthy, term newborns]Ned Tijdschr Geneeskd 2004;148(41):2016-9.

68. Yamauchi Y. Hypoglycemia in healthy, full-term, breast-fed neonates during the early days of life: preliminary observation. Acta Paediatr Jpn 1997;39 Suppl 1:S44-7.

69. Williams A. Hypoglycemia of the newborn: Review of the literature. Geneva: World Health Organization;1997. p. 1-56.

70. Humenick S. The clinical significance of breastmilk maturation rates. Birth 1987;14(4):174-81. 71. Barros FC, Victora CG, Semer TC, et al. Use of pacifiers is associated with decreased

breastfeedingduration.Pediatrics 1995;95:497-499. 72. Casiday RE, Wright CM, Panter-Brick C, Parkinson KN. Do early infant feeding patterns relate to

breastfeeding continuation and weight gain? Data from alongitudinal cohort study. Eur J Clin Nutr 2004;58(9):1290-6.

73. Hill PD, Humenick SS, Brennan ML, Woolley D. Does early supplementation affect long-term breastfeeding? Clin Pediatr (Phila) 1997;36(6):345-50.

74. Blomquist HK, Jonsbo F, Serenius F, Persson LA. Supplementary feeding in the maternity ward shortens the duration of breast feeding. Acta Paediatr 1994;83(11):1122-6.

75. Tyson J, Burchfield J, Sentance F, Mize C, Uauy R, Eastburn J. Adaptation of feeding to a low fat yield in breast milk. Pediatrics 1992;89(2):215-20.

76. Woolridge MW, Ingram JC, Baum JD. Do changes in pattern of breast usage alter the baby’s nutrient intake? Lancet 1990;336(8712):395-7.

77. ВОЗ. Методические рекомендации для европейского региона.Кормление ипитание грудных детей раннего возраста. Европейская серия № 87, 2003

59

78. Tison J, Burchfield J, Sentance F, Mize C, Uauy R, Eastburn J. Adaptation of feeding to a low fat yield in breast milk. Pediatrics 1992;89(2):215-20.

79. Sachdev HP, Krishna J, Puri RK, Satyanarayana L, Kumar S. Water supplementation in exclusively breastfed infants during summer in the tropics. Lancet 1991;337(8747):929-33.

80. Brandt KA, Andrews CM, Kvale J. Mother-infant interaction and breastfeeding outcome 6 weeks after birth. J Obstet Gynecol Neonatal Nurs 1998;27(2):169-74.

81. Brazelton TB. Neonatal Behavioral Assessment Scale, 2nd ed. Philadelphia: JB Lippencott; 1984. 82. Cohen R, Mrtek MB. The impact of two corporate lactation programs on the incidence and duration of

breast-feeding by employed mothers. Am J Health Promot 1994;8(6):436-41. 83. Dewey KG, Peerson JM, Brown KH, Krebs NF Michaelsen KF, Persson LA, et al. Growth of breastfed

infants deviates from current reference data: a pooled analysis of US, Canadian, and European data sets. World Health Organization Working Group on Infant Growth. Pediatrics 1995;96(3 Pt 1):495-503.

84. Cernadas JM, Noceda G, Barrera L, Martinez AM, Garsd A. Maternal and perinatal factors influencing the duration of exclusive breastfeeding during the first 6 months of life. J Hum Lact 2003;19(2):136-

85. Ingram J, Johnson D, Greenwood R. Breastfeeding in Bristol: teaching good positioning, and support from fathers and families. Midwifery 2002;18(2):87-101.

86. Righard L, Alade MO. Sucking technique and its effect on success of breastfeeding. Birth 1992;19(4): 185-9.

87. Morton JA. Ineffective suckling: a possible consequence of obstructive positioning. J Hum Lact 1992;8(2):83-5.

88. Henderson A, Stamp G, Pincombe J. Postpartum positioning and attachment education for increasing breastfeeding: a randomized trial. Birth 2001;

89. Righard L, Alade MO. Sucking technique and its effect on success of breastfeeding. Birth 1992;19(4):1859. 90. Singapur Ministry of Health. Management of breastfeeding for healthy full term infants. 2002. ec1.89.p.97

(references) 91. American Dietetic Association. Breaking the barriers to breastfeeding - Position of ADA. J Am Diet Assoc

2001;101:1213. 92. Avoa A, Fischer PR. The influence of perinatal education about breast-feeding on neonatal weight loss.

Pediatrics 1990;86(11):313-5. 93. Bertolli J, Hu DJ, Nieburg P, Macalalad A, Simonds RJ Decision analysis to guide choice of interventions

to reduce mother-to-child transmission of HIV. Aids 2003;17(14):2089-98. 94. Coutsoudis A, Pillay K, Spooner E, Coovadia HM, Pembrey L, Newell ML. Morbidity in children born to

women infected with human immunodeficiency 95. Carles G, Tortevoye P, Tuppin P, Ureta-Vidal A, Peneau C, El Guindi W, et al. [HTLV1 infection and

pregnancy]. J Gynecol Obstet Biol Reprod (Paris) 2004;33(1 Pt 1):14-20. 96. Ando Y, Ekuni Y, Matsumoto Y, Nakano S, Saito K, Kakimoto K, et al. Long-term serological outcome

of infants who received frozen-thawed milk from human T-lymphotropic virus type-I positive mothers. J Obstet Gynaecol Res 2004;30(6):436-8.

97. Chaves RG, Lamounier JA. [Breastfeeding and maternal medications]. J Pediatr (Rio J) 2004;80 (5 Suppl):S189-98.

98. Hale T. Medications and Mothers’ Milk. ninth ed. Amarillo: Pharmasoft Publishing; 2004. 99. Eskott R. Positioning, attachment and infections. Emergensy Medical Cliniks of North Amerika, 1985,

3(10: 87-115 100. Horta BL, Victora CG, Menezes AM, Barros FC. Environmental tobacco smoke and breastfeeding

duration. Am J Epidemiol 1997;146(2):128-33. 101. Community Paediatric Committee, Canadian paediatric Society ( CPS). Weaning from breast. Paediatrics

& Child health 2004; 9(4), 249-253 102. Grandjean P, Budtz-Jorgensen E, Steuerwald U, Heinzow B, Needham LL, Jorgensen PJ, et al.

Attenuated growth of breast-fed children exposed to increased concentrations of methylmercury and polychlorinated biphenyls. Faseb J 2003;17(6):699-701.de Araujo Burgos MG, Bion FM, Campos F. [Lactation and alcohol: clinical and nutritional effects]. Arch Latinoam Nutr 2004;54(1):25-35.

103. Yasuda A, Kimura H, Hayakawa M, Ohshiro M, Kato Y, Matsuura O, et al. Evaluation of cytomegalovirus infections transmitted via breast milk in preterm infants with a real-time polymerase chain reaction assay. Pediatrics 2003;111(6 Pt 1):1333-6.

104. Blyth RJ, Creedy DK, Dennis CL, Moyle W, Pratt J, De Vries SM. Effect of maternal confidence on breastfeeding duration: an application of breastfeeding self-efficacy theory. Birth 2002; 29(4):278-84.

60

105. Blyth RJ, Creedy DK, Dennis CL, Moyle W, Pratt J, De Vries SM, et al. Breastfeeding duration in an Australian population: the influence of modifiable antenatal factors. J Hum Lact 2004;20(1):30-8.

106. Giugliani ER. [Common problems during lactation and their management]. J Pediatr (Rio J) 2004;80 (5 Suppl):S147-54.

107. Hill PD, Humenick SS. The occurrence of breast engorgement. J Hum Lact 1994;10(2):79-86. 108. Stockle U, Hoffmann R, Schutz M, von Fournier C,Sudkamp NP, Haas N. Fastest reduction of

Sttraumatic edema: continuous cryotherapy or intermittent impulse compression? Foot Ankle Int 997;18(7):432-8.

109. Snowden HM, Renfrew MJ, Woolridge MW. Treatments for breast engorgement during lactation. Cochrane Database Syst Rev 2001(2):CD000046.

110. Roberts KL, Reiter M, Schuster D. Effects of cabbage leaf extract on breast engorgement. J Hum Lact 1998;14(3):231-6.

111. Nikodem VC, Danziger D, Gebka N, Gulmezoglu AM, Hofmeyr GJ. Do cabbage leaves prevent breast engorgement? A randomized, controlled study. Birth 1993;20(2):61-4.

112. Dewey KG, Heinig MJ, Nommsen LA, Lonnerdal B. Adequacy of energy intake among breast-fed infants in the DARLING study: relationships to growth velocity, morbidity, and activity levels. Davis Area Research on Lactation, Infant Nutrition and Growth. J Pediatr 1991;119(4):538-47.

113. Ziemer MM, Pigeon JG. Skin changes and pain in the nipple during the 1st week of lactation. J Obstet Gynecol Neonatal Nurs 1993;22(3):247-56.

114. Morrill JF, Heinig MJ, Pappagianis D, Dewey KG. Risk factors for mammary candidosis among lactating women. J Obstet Gynecol Neonatal Nurs 2005; 34(1):37-45.

115. Donnelly A, Renfrew MJ, Woolridge MW. Commercial hospital discharge packs for breastfeeding women (Cochrane Review). The Cochrane Library 2001;Update Software(1).

116. Hanson LA, Korotkova M, Telemo E. Breast-feeding, infant formulas, and the immune system. Ann Allergy Asthma Immunol 2003;90(6 Suppl 3):59-63.

117. Hellings P, Howe C. Breastfeeding knowledge and practice of pediatric nurse practitioners. J Pediatr Health Care 2004;18(1):8-14.

118. Ferreira CS, Martinho PC, Amato Neto V, Cruz RR. Pasteurization of human milk to prevent transmission of Chagas disease. Rev Inst Med Trop Sao Paulo 2001;43(3):161-2.

119. Ingram J, Woolridge M, Greenwood R. Breastfeeding: it is worth trying with the second baby. Lancet 2001;358(9286):986-7.

120. American Academy of Family Physicians. Breastfeeding Policy and Position Statement. Leawood, KS: American Academy of Family Physicians; 2001.

121. Snowden HM, Renfrew MJ, Woolridge MW. Treatments for breast engorgement during lactation. Cochrane Database Syst Rev 2001(2):CD000046.

122. Stockle U, Hoffmann R, Schutz M, von Fournier C, Sudkamp NP, Haas N. Fastest reduction of posttraumatic edema: continuous cryotherapy or intermittent impulse compression? Foot Ankle Int 1997;18(7):432-8.

123. Guise JM, Palda V, Westhoff C, Chan BK, Helfand M, Lieu TA. The effectiveness of primary care-based Interventions to promote breastfeeding: systematic evidence review and meta-analysis for the US Preventive Services Task Force. Ann Fam Med 2003;1(2):70-8.

124. Bittencourt AL. Possible risk factors for vertical transmission of Chagas’ disease. Rev Inst Med Trop Sao Paulo 1992;34(5):403-8.

125. Menzies D. Effect of treatment on contagiousness of patients with active pulmonary tuberculosis. Infect Control Hosp Epidemiol 1997;18(8):582-6.

126. Menzies D. Effect of treatment on contagiousness of patients with active pulmonary tuberculosis. Infect Control Hosp Epidemiol 1997;18(8):582-6.

127. Page T., Lokwood E., Guest K. NMMDC 1999 Institute of Medicine. Nutrition During Lactation. Washington, DC: National Academy Press; 1991.

128. HIV and infant feeding. Guidelines for decision-makers. WHO 2003 129. American Academy of Pediatics Committee on Infectious Disease. Transmission of infectious agents via

human milk. In: LK P, editor. Red Book 2003 Report of the Committee on Infectious Diseases. Elk Grove Village: American Academy of Pediatrics; 2003.

130. Jeffery BS, Mercer KG. Pretoria pasteurisation: a potential method for the reduction of postnatal mother to child transmission of the human immunodeficiency virus. J Trop Pediatr 2000;46(4):219-23.

131. Jeffery BS, Soma-Pillay P, Makin J, Moolman G. The effect of Pretoria Pasteurization on bacterial contamination of hand-expressed human breastmilk. J Trop Pediatr 2003;49(4):240-4.

61

132. UNICEF. Breastfeeding and complementary feeding; 1990-2000. 133. Naylor AJ, Morrow AL. Developmental readiness of normal full term infants to progress from exclusive

breastfeeding to the introduction of complementary foods. Linkages/Wellstart International, 2001. 134. WHO/UNICEF. Complementary feeding of young children in developing countries: a review of current

scientific knowledge. Geneva: World Health Organization, WHO/NUT/98.1, 1998. 135. Dewey KG, Brown KH. Update on technical issues concerning complementary feeding of young

children in developing countries and implications for intervention programs. Food Nutr Bull, in press 2002

136. Cohen RJ, et al. Effects of age of introduction of complementary foods on infant breast milk intake, total energy intake, and growth: a randomized intervention study in Honduras. Lancet 1994;344:288-93.

137. Dewey KG, et al. Age of introduction of complementary food and growth of term, low birth weight breastfed infants: a randomized intervention study in Honduras. Am J Clin Nutr 1999;69: 679-86.

138. Allen LH, Ahluwalia N. Improving iron status through diet. John Snow, Inc./OMNI Project,1997. 139. Gibson RS, Ferguson EL, Lehrfeld J.Complementary foods for infant feeding in developing countries:

their nutrient adequacy and improvement. Europ J Clin Nutr 1998;52:764-70. 140. Skinner JD, Carruth BR, Moran J, Houck K, ColettaF. Fruit juice intake is not related to children’s

growth. Pediatrics 1999;103:58-64. 141. Dennison BA, Rockwell HL, Baker SL. Excess fruit juice consumption by preschool-aged children is

associated with short stature and obesity. Pediatrics 1997;99:15-22. 142. Ziegler EE, Fomon SJ, Nelson SE, et al. Cow milk feeding in infancy: further observations on blood loss

from the gastrointestinal tract. J Pediatr 1990;116:11-8. 143. Guiding Principles for Complementary Feeding of the Breastfeed Child. WHO Global Consultation on

Complementary Feeding, December 10-13, 2001. 144. Huffman SL, Baker J, Shumann J, Zehner ER. The case for promoting multiple vitamin/mineral

supplements for women of reproductive age in developing countries. LINKAGES Project, Academy for Educational Development, Washington DC, 1998.

145. Domellof M, Cohen RJ, Dewey KG, Hernell O,Landa Rivera L, Lonnerdal B. Iron supplementation of Honduras and Swedish breastfed infantsfrom 4 to 9 months of age: effects on hemoglobinand other indices of iron status. J Pediatr 2001;138:679-87.

146. Northstone K, Emmett P, Nethersole F, and the ALSPAC Study Team. The effect of age of introduction to lumpy solids on foods eaten and reported feeding difficulties at 6 and 15 months.J Hum Nutr Diet 2001;14:43-54.

147. Griffin IJ, Abrams SA. Iron and breastfeeding.Pediatr Clin N Amer 2001;48:401-14. 148. Engle PL, Bentley M, Pelto G. The role of care in nutrition programmes: current research and a research

agenda. Proc Nutr Soc 2000;59:25-35. 149. Pelto G, Levitt E, Thairu L. Improving feeding practices: current patterns, common constraints, and the

design of interventions. Food Nutr Bull,in press. 150. Anderson P, Pochop S, Manoguerra A. Adverse drug reactions in breastfed infants: less than

imagined.Clin Pediatr (Phila) 2003;42(4):325-40. 151. Lucas A & Cole TJ (1990). Breast milk and neonatal necrotising enterocolitis. Lancet 336: 1519-1522. 152. Oddy WH et al. (1999) Association between breastfeeding and asthma in 6 year old children: findings of

a prospective birth cohort study. BMJ 319: 815-819 153. Oddy WH et al (2002). Maternal asthma, infant feeding, and the risk of asthma in childhood. J Allergy

Clin Immunol 110: 65-7. 154. Paronen J et al (2000) Effect of cow's milk exposure and maternal type 1 diabetes on cellular and humoral

immunization to dietary insulin in infants at genetic risk for type 1 diabetes. Finnish Trial to Reduce IDDM in the Genetically at Risk Study Group. Diabetes 49: 1657-65

155. Young TK et al (2002). Type 2 Diabetes Mellitus in Children: Prenatal and Early Infancy Risk Factors Among Native Canadians. Arch Pediatr Adolesc Med 156: 651-655

156. Shu XO et al (1999) Breast-feeding and risk of childhood acute leukemia. J Natl Cancer Inst 91: 1765-72 157. Mathur GP et al (1993) Breastfeeding and childhood cancer. Indian Pediatr 30: 651-7 158. Paton LM et al (2003). Pregnancy and lactation have no long-term deleterious effect on measures of bone

mineral in healthy women: a twin study. Am J Clin Nut 77: 707-14 159. Polatti F et al (1999). Bone mineral changes during and after lactation. Obstet Gynecol 94: 52-6 160. Infant Feeding Guideline – East Tennessee Children Hospital 2005

62

161. Working Group on Cow's Milk Protein and Diabetes Mellitus of the American Academy of Pediatrics. Infant feeding practices and their possible relationship to the etiology of diabetes mellitus. Pediatrics 1994;94:752-4

162. UNICEF UK statement on mother-infant bed sharing, 16 February 2004 163. World Health Organization (WHO), Food and Argriculture Organization (FAO), FAO/WHO workshop

on E sakazakii and other micro-organisms, The Sesiion (2003) of the Codex committee on food Hygiene (CCFH), IBFAN-GIFA)

164. Sharon Gardiner, Drug Information Pharmacist, Christchurch Hospital and Evan Begg, Clinical Pharmacologist, Christchurch School of Medicine. Drug Safety in Lactation Website: May 2001 Prescriber Update No.21:10-23

165. Berlin CM, Briggs GG. Drugs and chemicals in human milk. Semin Fetal Neonatal Med 2005;10(2): 149-59.

166. Normal requirements - pediatrics. JPEN J Parenter Enteral Nutr 2002 Jan-Feb;26(1 Suppl):25SA-32SA 167. Nutrition assessment - pediatrics. JPEN J Parenter Enteral Nutr 2002 Jan-Feb;26(1 Suppl):13SA-17SA. 168. WHO - Integrated Management of Pregnancy and Childbirth Pregnancy, Childbirth, Postpartum and

Newborn Care: A guide for essential practice. – 2006 169. WHO - Managing newborn problems: A guide for doctors, nurses and midwives 2003

avtorTa jgufi

pediatrTa da neontologTa kavSiri àlternativa~

samuSao jgufi:

• Tamar manjaviZe – medicinis doqtori, baksis eqsperti-gare

Semfasebeli, saqarTvelos kanoni “bavSvTa bunebrivi kvebis dacvisa

da xelSewyobis, xelovnuri sakvebis kontrolirebadi moxmarebis

Sesaxeb” – avtori. pediatrTa da neontologTa kavSiri

àlternativa~-s wevri;

• maia xerxeuliZe – medicinis doqtori. Tbilisis saxelmwifo

samedicino universitetis zogadi pediatriis departamentis asistent-

profesori. pediatrTa da neontologTa kavSiri àlternativa~-s

wevri;

• nani yavlaSvili - medicinis doqtori. Tbilisis saxelmwifo

samedicino universitetis zogadi pediatriis departamentis asistent-

profesori. pediatrTa da neontologTa kavSiri àlternativa~-s

wevri;

• eka kandelaki _medicinis doqtori, Tbilisis saxelmwifo samedicino

universitetis zogadi pediatriis departamentis asistent-profesori.

pediatrTa da neontologTa kavSiri àlternativa~-s wevri.

eqsperti:

• qeTevan nemsaZe – medicinis doqtori, profesori, Tbilisis saxelmwifo

samedicino universitetis zogadi pediatriis departamentis ufrosi,


xelovnuri sakvebis kontrolirebadi moxmarebis Sesaxeb” – avtori

63

• medea beleSaZe _ medicinis doqtori, baksis eqsperti-gare Semfasebeli,


xelovnuri sakvebis kontrolirebadi moxmarebis Sesaxeb” – avtori

• lela woworia _ saqarTvelos Sromis, janmrTelobisa da socialuri

dacvis saministros jandacvis departamenti;

• Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa da socialuri

dacvis saministros jandacvis departamenti.

klinikuri praqtikis erovnuli rekomendacia (gaidlaini) (mtkicebulebis done II)33,44; _ qalis wonaSi...

Documents

Transcript of klinikuri praqtikis erovnuli rekomendacia (gaidlaini) (mtkicebulebis done II)33,44; _ qalis wonaSi...