Prevention of malnutrition in children. Dystrophy in children (hypotrophy). The endogenous factors are

Dystrophy in children (hypotrophy) is a chronic eating disorder, one of the main manifestations of which is a gradually developing child. There are mild and severe forms of dystrophy. A clear boundary between these forms is often difficult to determine. A far advanced form of dystrophy is called atrophy.

Etiology and pathogenesis. The reasons for the development of dystrophy in children are very diverse. It can be caused by external and internal factors. The most common cause (external factor) is malnutrition, both quantitatively and qualitatively. A quantitative lack of food is often associated with malnutrition and can be from the first days of a child's life (lack of milk in the mother, the presence of tight or flat and inverted nipples, lethargy). Insufficiently active sucking is more often observed in, as well as those born in and with intracranial. Getting enough food can interfere with all sorts of congenital (non-closure of the upper and solid, etc.). Hypotrophy also develops as a result of a lack or absence of one of the important components of food (for example, protein, vitamins, salts), if their correct ratio is violated. Qualitative errors in nutrition are more common with mixed and artificial feeding. Of great importance are unfavorable environmental conditions (non-compliance with the sanitary and hygienic regime, lack of air, light, etc.), improper care. There are children in whom dystrophy has developed mainly as a result of a lack of appetite under the influence of improper introduction of complementary foods, drugs, and force-feeding. Infections and chronic diseases contribute to the development of dystrophy due to metabolic disorders and the activity of regulatory mechanisms. Under all these circumstances, the food that enters the body does not cover its needs; as a result, the child's own reserves are used up, which leads to depletion. During starvation, the activity of all body systems is perverted, a violation of all types of metabolism develops. Such children have reduced body resistance and they are prone to all kinds of diseases that are difficult for them and often cause death.

Clinic. The main manifestation of dystrophy (hypotrophy) is a decrease in the subcutaneous fat layer, first of all on the abdomen, then on the chest, back, limbs and later on the face. Happens. slowing down and even stopping weight gain, it becomes less than normal.

There are three degrees of malnutrition. Hypotrophy 1 degree characterized by a lag in weight by 10 - 15%, but the child has a normal. There is a decrease in the subcutaneous fat layer on the abdomen and partially on the limbs. The skin color remains normal or somewhat pale, the general condition is not disturbed.

At hypotrophy of the 2nd degree the weight of the child lags behind the norm by 20-30%, there is also a slight lag in growth (by 1-3 cm). The subcutaneous fat layer is reduced everywhere. The child is pale, the tissues are reduced, the skin is going into folds, the muscles are flabby. The general condition is disturbed, it decreases, the mood becomes unstable, the development of static and motor functions worsens or is delayed.

Hypotrophy 3 degrees characterized by a weight loss of more than 30%, severe wasting and stunting. The subcutaneous fat layer is absent, the eyes sink, wrinkles appear on the forehead, the chin is pointed, the face is senile. The muscles are flabby, retracted, the large fontanelle sinks, the conjunctiva and cornea of ​​the eyes are prone to drying out and ulceration, breathing is shallow, slow, weak, muffled. Appetite is reduced, but there is a tendency to diarrhea. Urination is reduced. Hypochromic anemia develops, with a sharp thickening of the blood, the amount also increases. Children are depressed, their voice is aphonic, the development of static and motor skills, speech is delayed.

The diagnosis of dystrophy in children (hypotrophy) is established on the basis of the anamnesis, appearance of the child, clinical examination data, weight, height.

Hypotrophy treatment- complex, taking into account the individual characteristics of the child, the conditions under which the disease developed. In severe forms - symptomatic, pathogenetic and stimulating therapy. It is especially important to properly prescribe nutrition. So, with hypotrophy of the 1st degree, it is necessary first of all to assign a child nutrition based on the weight that he should have according to his age. With a lack of breast milk, the mother is prescribed supplementary feeding with donor milk or mixtures. With artificial feeding, women's milk and mixtures are temporarily prescribed.

With malnutrition of the 2nd degree, women's milk or sour mixtures are prescribed at the rate of 2/3 or% of the amount required for the given age of the child (see). If the child's weight is reduced by 20%, then the total amount of food is calculated on the actual weight. If more than 20%, then the calculation is carried out on the average weight, that is, on the actual plus 20% of it. The lack of food volume is replenished with fruit and vegetable broths, 5% glucose solution,. The number of feedings increases to 7-8 times a day.

After 5-7 days, when the child's condition improves, the amount of food increases, but the calorie content should not exceed 130-150 calories per 1 kg of body weight. If necessary, carry out a correction with proteins, and (carefully) with fats.

Nutrition is especially carefully prescribed for malnutrition of the 3rd degree. The daily calculation of nutrition is carried out on an average weight between the due and actual. In the first days of treatment, regardless of age, only half of the required amount is prescribed and only women's milk. If it is impossible to provide the child with a sufficient amount of human milk, acid mixtures are given. The lack of food volume is replenished by liquid. An increase in the daily amount of food is carried out very carefully, even with a clear trend towards improvement. Caloric intake per actual weight should not exceed 180 calories per 1 kg of body weight. All children with malnutrition need vitamins and. To improve appetite, appoint 1 / 2-1 teaspoon 5 times a day or 1% solution diluted with before feeding, 0.2 g 2 times a day an hour after meals for 7-10 days. The appointment of anabolic hormones is shown (see). Measures to combat dehydration are carried out as in toxic dyspepsia (see Dyspepsia in children). In severe cases, plasma and blood transfusions are recommended.

Prevention. Proper organization of the general regimen and feeding.

Depends on the degree of the disease, reactivity and timeliness of treatment.

It is extremely common to observe malnutrition in children, accompanied by a slight increase in body weight in relation to height and age. When this gap exceeds 10%, hypotrophy is diagnosed.

Hypotrophy (protein-energy malnutrition (PEM)) is a spectrum of conditions caused by various levels of protein and calorie deficiency and is characterized by insufficient body weight in relation to height.

Hypostatura is described as one of the variants of PEI, in which an interconnected deficit is established, both in body weight and in height.

The causes of malnutrition can be divided into two groups:

• exogenous (associated with external factors);
• endogenous (internal causes).

The mechanism of the onset of the disease and the development of its manifestations (pathogenesis)

In pathogenesis, the following pathophysiological phases are distinguished:

1. 1st phase - hungry excitement. The consumption of reserve reserves of carbohydrates provides the body's energy needs, the metabolism of amino acids weakens, and the excretion of nitrogen decreases.
2. 2nd phase - the phase in which the metabolism switches to the breakdown of fat, the main metabolism decreases, the synthesis of vital proteins is still preserved due to the breakdown of other body proteins.
3. The 3rd phase is irreversible: the splitting of the “internal” protein is carried out to cover energy goals, changes occur in the structure of mitochondria (organelles that are the energy base of cells) with a violation of their regulatory mechanisms.

Symptoms

Clinical manifestations of malnutrition are grouped into several syndromes.

Trophic disorder syndrome

Lack of tissue nutrition, which caused structural changes in tissues and cell death:

• flat or negative curve of body weight in dynamics;
• deficiency of body weight, to a lesser extent - body length;
• the proportionality of the physique is violated;
• trophic disorders of the skin and skin appendages: decreased elasticity, sagging, dryness, with cachexia (extreme exhaustion of the body) - a symptom of a "pouch" (a narrow mouth opening with deep wrinkles around it), dull nails and hair, alopecia (baldness);
• the subcutaneous fat layer is consistently thinning - on the body, abdomen, limbs, face;
• muscle hypotorphy and increasing;
• decrease in tissue elasticity.

Syndrome of digestive disorders and impaired food tolerance

• appetite decreases up to anorexia;
• increasing dyspeptic disorders - regurgitation, unstable stools, irregular defecation, alternating;
• enzymatic and secretory gastrointestinal tract are weakened.

CNS dysfunction syndrome

• disturbed emotional tone (scream, cry) and neuro-reflex excitability;
• involuntary muscle contraction;
• hyporeflexia (decreased reflexes);
• lag of psycho-emotional development;
• thermoregulation and sleep are disturbed.

Syndrome of impaired hematopoiesis and immunobiological reactivity

• deficiency of iron and other micro and macro elements, vitamins (iron deficiency anemia, rickets, etc.);
• frequent infectious and inflammatory diseases, their course is erased and atypical;
• develop toxic-septic conditions, dysbiocenosis of natural microbiological niches;
• signs of secondary immunodeficiency.

Weakened nonspecific resistance.

Depending on the lack of body weight, three degrees of malnutrition are distinguished: at degree 1, the insufficiency is 11–20% of the due value, at degree 2 - 21–30%, at degree 3 – a deficiency of more than 30% of the due body weight. In clinical practice, malnutrition of the 1st degree prevails, mainly associated with temporary alimentary disorders, the second degree is less often observed, the development of which is associated with a complex of etiological factors, mainly endogenous. III degree or cachexia with irreversible organ system consequences and subsequent death is a rare condition.

Fetal hypotraphy

Fetal hypotrophy is a delay in intrauterine development of the child.

There are three options for the development of pathology:

1. Hypotrophic. There is a malnutrition of all systems and organs, characterized by slow development of the fetus, which does not correspond to the gestational age.
2. Hypoplastic. It is characterized by a delay in the maturation of all organs in combination with a lag in the overall development of the fetus. This means that at birth, tissues and organs are not sufficiently formed and their functions are not fully performed.
3. Dysplastic. There is uneven development of some organs. For example, the liver, heart develop in accordance with the gestational age, and other organs have a lag in maturation.

Diagnosis of malnutrition in children

Diagnosis is based on anthropometric data (a method of measuring the human body and its parts): a lack of body weight and a slowdown in growth rates relative to proper values.

In the blood test, anemia is detected, with malnutrition of the 3rd degree - absolute lymphopenia (decrease in lymphocytes), slowing down the ESR.

Biochemical examination reveals:

• hypoalbuminemia (decrease in albumin, a substance that is an integral part of blood plasma);
• dysproteinemia (imbalance between blood protein fractions);
• hypoglycemia (decrease in glucose concentration);
• hypocholesterolemia (decrease in cholesterol);
• dyslipilemia (impaired lipid balance).

In the analysis of urine - leukocyturia, ketone bodies, an excess amount of ammonia. B - signs of impaired intestinal digestion.

How is the treatment carried out?

Children with grade 1 malnutrition are treated on an outpatient basis when the social environment is favorable. At the 2nd - 3rd degree, therapy is carried out only in a hospital (first in the intensive care unit, then in the general somatic unit).

All children need a therapeutic and protective regimen: sufficient sleep in calm conditions, regular ventilation of the room, access to sunlight, wet cleaning twice a day. The temperature in the room is maintained at 25 - 26 ° C. Walks, therapeutic exercises, massage, bathing - daily; skin and visible mucous membranes are carefully cared for (moisturizing creams, emulsions, vitamin masks).

Diet therapy is the basis of treatment, and is carried out in 3 stages. The basis is the rejuvenation of the diet (“step back”), that is, they use foods that are typical for an earlier age group.

When a child is breastfed, it is unacceptable to exclude a single drop of mother's milk from the diet of a patient with malnutrition.

Organization of diet therapy

In the complex treatment of children, enzyme replacement therapy is used, taking into account the coprogram, as well as vitamin D3, iron preparations, vitamins of groups B, C, PP, A and E. Probiotic preparations based on bifido- and lactobacilli are prescribed to correct microbiocenosis disorders. At the 3rd degree of malnutrition, antimycotic agents are used to prevent candidal lesions of the intestine.

The use of anabolic drugs is carried out with caution, since, under the condition of a deficiency of nutrients, their use can lead to profound disorders of protein and other types of metabolism.

Conclusion

The prognosis is favorable for PEU of the 1st and 2nd degree. With the 3rd degree of malnutrition, despite the ongoing treatment, mortality is 20 - 50% of cases.

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Introduction

From birth, the child begins to significantly gain in body weight, all his organs grow, including the bones of the skeleton. If the baby is not properly fed and cared for, the first signs of malnutrition will immediately begin to appear in the form of a disruption in the functioning of various organs and systems. Most often, malnutrition develops due to a lack of protein and calories in the diet. With the initial lag in body weight, disturbances from the gastrointestinal tract begin, which leads to a violation of the absorption of nutrients. As a rule, children also suffer from a lack of vitamins and trace elements in their diet.

Causes of malnutrition

Internal factors include diseases of various internal organs involved in digestion, that is, nutrients, under the influence of any reasons, cannot be absorbed by the body. Here, for example, it is appropriate to say that the violation can be both at the level of the gastrointestinal tract, and at the tissue and cellular level. In this case, various metabolic disorders occur in the cell itself. Cellular energy reserves gradually decrease. In the case of their complete depletion, the natural process of cell death begins.

Internal causes of malnutrition

• Encephalopathy that occurs in the fetus during pregnancy. Here we are talking about the fact that during the period of intrauterine development in the fetus, the normal activity of the central nervous system is disturbed, with a secondary disruption of the work of all internal organs and systems.
• Underdevelopment of lung tissue. Insufficient oxygen enrichment of the blood leads to metabolic disorders in the body, and slows down the development of organs and systems.
• Congenital pathology of the gastrointestinal tract - when such phenomena as constipation or vomiting are constantly present (with Hirschsprung's disease, dolichosigma, impaired location of the pancreas).
• Frequent abdominal operations that lead to "short bowel" syndrome. The natural physiological process of food digestion is disrupted.
• Hereditary diseases of the immune system, leading to a decrease in the body's defenses, inability to fight infection.
• Some endocrine diseases. Hypothyroidism is a disease of the thyroid gland, in which growth and metabolic processes in the body slow down. Pituitary dwarfism is a disease of the central organ of the endocrine system, as a result of which a sufficient amount of growth hormone is not produced.
• Metabolic diseases that are inherited. For example, galactosemia (intolerance to milk and dairy products), fructosemia is a similar disease in which the child's body does not absorb the fructose contained in vegetables and fruits. Rarer hereditary pathologies related to metabolic disorders include: leucinosis, Niemann-Pick disease, Tay-Sachs and others.

External causes of malnutrition

• Firstly, the quantitative underfeeding of the baby occurs due to the underdevelopment of the female breast (flat nipple, inverted nipple) or lack of female milk. On the part of the child, the cause may be: an underdeveloped lower jaw, constant vomiting, a short frenulum at the lower edge of the tongue.
• Secondly, insufficient feeding with mother’s high-quality breast milk, or improper use of the nutrient mixture, late introduction of supplementary feeding or complementary foods to the child, insufficient intake of all necessary and useful ingredients in the baby’s diet also leads to chronic malnutrition and the development of malnutrition.

Clinical signs and symptoms of malnutrition by degree

With malnutrition, there are several main syndromes:
1. The first of these is a syndrome in which the trophic function of organs and tissues is disturbed. Here we are talking about the fact that metabolic processes in the organs and tissues of the body slow down, body weight drops, the subcutaneous fat layer becomes much thinner, the skin becomes lethargic and flabby.
2. Another important syndrome is a syndrome in which there is a violation of digestive functions. The entire digestive tract is affected. Less hydrochloric acid and pepsin are produced in the stomach, and there are not enough enzymes in the intestines to process the food bolus.
The main symptoms of the syndrome of digestive disorders are:

• stool disorder, which can manifest itself both in the form of constipation and diarrhea;
• the chair becomes unformed, shines;
• with a more detailed examination of the stool, I find in it undigested food residues.

In each individual case, more than one of the above syndromes may be expressed. The manifestations of malnutrition also depend on the predominance of the lack of any component of food. For example, during protein starvation, symptoms of hematopoiesis and a decrease in the body's defenses prevail.

There are three degrees of malnutrition. This separation is necessary for the convenience of assessing the general condition of the child and for planning the amount of treatment. But in reality, the degrees of malnutrition are stages of the same process, following one after another.

Hypotrophy of the first degree

Initially, fat reserves disappear in the abdomen, then in other places. The degree of depletion of the subcutaneous fat layer is assessed by different methods. The most practical, and at the same time informative method, is the Chulitskaya index. This method is based on measuring the circumference of the shoulder in two different places, then the hips and lower legs, and the child's height is subtracted from the resulting amount. The norm for a child up to a year is 20-25 cm. Another method is to measure the skin fold in four different places: on the abdomen to the left of the navel, on the shoulder, in the area of ​​​​the shoulder blades, and finally, on the thigh from the outside. With normal growth and development of the child, the skin fold is approximately 2-2.5 cm. In the first degree of malnutrition, the Chulitskaya index is 10-15 centimeters, and the skin fold slightly decreases.

Symptoms of hypotrophy of the first degree:

• Fat folds are flabby, muscle tone is reduced, elasticity and firmness of the skin is lost.
• The growth of the child initially corresponds to age norms.
• Body weight is reduced from approximately 11% to 20% of the original.
• General health is normal. There is rapid fatigue.
• There are no disorders of the central nervous system. Sleep disturbing, intermittent.
• The child is a little irritable, may spit up the food he has eaten.

Hypotrophy of the second degree

Signs of malnutrition of the second degree:

• The subcutaneous fat layer is very thin on the legs, arms, and may be absent on the abdomen or chest.
• The Chulitskaya index decreases, and varies from one to ten centimeters.
• The skin is pale, dry.
• The skin is flabby, easily shifts into folds.
• Hair and nails become brittle.
• Muscle mass on the limbs decreases, body weight decreases by about twenty to thirty percent, and stunting is also noted.
• Thermoregulation is disturbed, such children quickly freeze, or also quickly overheat.
• There is a high risk of exacerbation of chronic infections (pyelonephritis, otitis media, pneumonia).
• Violation of resistance to the food taken. In connection with trophic disorders of the villi and the intestinal mucosa, digestion is disturbed, in particular the absorption of nutrients. Dysbacteriosis appears, that is, pathogenic bacterial flora predominates. Children appear: increased gas formation, bloating and discomfort in the abdomen. Frequent constipation or diarrhea, often alternating one after another.
• Decreased muscle tone. Due to the significantly reduced muscle tone, the abdomen protrudes outward, and the impression of a frog's abdomen is created.
• The lack of vitamin D and calcium in the body leads to additional development of muscle weakness, the development of symptoms of osteoporosis (washing out of calcium from the bones). At the same time, the bones of the skull become soft, the large and small fontanelles remain open for quite a long time.
• On the part of the central nervous system, a number of pathological disorders similar to those in the first degree of malnutrition are also revealed. Children are restless, cannot fall asleep, often act up. Then the characteristic symptoms of overexcitation of the central nervous system are gradually replaced by lethargy and apathy towards the outside world.

Hypotrophy of the third degree

Characteristic signs and symptoms of hypotrophy of the third degree:

• By appearance, you can immediately determine that there is a chronic lack of nutrition. The subcutaneous fat layer is absent in almost all places, including the face. The skin is dry, pale and so thin that the child looks like a mummy.
• When you try to form a skin fold with your fingers, there is practically no resistance of healthy skin. The elasticity of the skin is so reduced that the fold does not straighten out for a long time after releasing the fingers. Deep wrinkles form all over the body.
• Muscle mass and body weight as a whole are so small that the fatness index according to Chulitskaya is not determined, or is negative. The overall weight loss is 30% or more of normal values.
• On the face, the retraction of the cheeks is visible, the cheekbones protrude forward, the sharpening of the chin is pronounced.
• Manifestations of lack of vital trace elements and vitamins are clearly expressed.
• Lack of iron affects the appearance of cracks in the corners of the mouth (jamming), as well as anemia.
• The lack of vitamins A and C manifests itself in the form of appearance on the mucous membranes: bleeding and atrophy (death, reduction in size) of the gums, stomatitis in the form of small whitish rashes.
• The abdomen is greatly distended due to the weakness of the muscles that support it.
• Body temperature often jumps up and down due to the fact that the thermoregulation center in the brain does not work.
• Immunity is sharply reduced. You can detect signs of sluggish chronic infections. Inflammation of the middle ear - otitis, inflammation of the kidneys - pyelonephritis, pneumonia - pneumonia.
• The child's growth lags behind the average.

Options for the course of malnutrition

Depending on the period of development of hypotrophic manifestations, there are four variants of the course of hypotrophy:

• intrauterine malnutrition;
• hypostatura;
• alimentary insanity.

Intrauterine malnutrition

There are several options for the development of intrauterine malnutrition:
1. Hypotrophic- when the nutrition of all organs and systems is disturbed, the fetus develops very slowly, and does not correspond to the gestational age.
2. Hypoplastic- this variant of development means that along with insufficient general development of the fetal organism, there is also some lag in the maturation and development of all organs. Here we are talking about the fact that organs and tissues at birth are not sufficiently formed, and do not fully perform their functions.
3. Dysplastic the variant of the course of malnutrition is characterized by uneven development of individual organs. Some, such as the heart, liver, develop normally, corresponding to the gestational age, while others, on the contrary, lag behind in their development, or develop asymmetrically.

Hypostatura

The only difference from true malnutrition is that the skin and subcutaneous fat layer do not undergo strong changes.

Hypostatura, as one of the variants of the course of malnutrition, occurs secondarily in chronic diseases of some internal organs. The development of hypostature is usually associated with transitional periods of growth and development of the child. One of these periods falls on the first six months of a child's life. At the same time, they begin to gradually add food products, milk formulas to mother's milk - in other words, to supplement the child. The appearance of this pathology in the second year of life is associated primarily with congenital chronic diseases. Here are the most common ones:

• Congenital malformations of the cardiovascular system. Violation of blood circulation leads to insufficient flow of oxygen and nutrients to organs and tissues.
• Encephalopathies in combination with endocrine disorders also have an extremely adverse effect on the metabolism in the body, delaying development and growth.
• Bronchopulmonary dysplasia is a disturbed development of the lung tissue during the period of intrauterine development of the fetus. In this case, there are serious complications associated with breathing and the delivery of oxygen to the blood.

Kwashiorkor

In addition, there are specific disorders in which the body receives less, does not synthesize or does not absorb protein foods at all.

Disorders that contribute to the development of kwashiorkor include:

• Long-term indigestion, manifested by persistent unstable stools - in other words, the child has chronic diarrhea.
• In diseases of the liver, its protein-forming function is disrupted.
• Kidney disease, accompanied by increased loss of protein along with urine.
• Burns, excessive blood loss, infectious diseases.

In addition to the constant symptoms, children with kwashiorkor have other signs of the disease that occur with varying frequency.

Common symptoms are:
1. Color change, softening of thinning and, eventually, hair loss on the head. Hair becomes lighter, and in later manifestations of the disease, or in older children, discolored or even gray strands of hair are found.
2. Dermatitis is an inflammation of the superficial layers of the skin. Redness, itching, cracks appear on the skin. Subsequently, the skin in the affected areas exfoliates, and traces remain in this place in the form of light spots.

Rare symptoms include:
1. Dermatosis - red-brown spots of a rounded shape.
2. Hepatomegaly is an abnormal enlargement of the liver. The liver tissue is replaced by adipose and connective tissue. The liver is not able to form enzymes and other active substances necessary for the normal function of the whole organism.
3. Kidney dysfunction. The filtration capacity is reduced. In the blood, harmful metabolic products accumulate.
4. Stool disorders are permanent. The child has persistent diarrhea. The feces are shiny and smell unpleasant.

Summing up the material presented, we can say with confidence that kwashiorkor is a disease that is extremely rare in countries with a temperate climate. Countries located in this geographic latitude have a developed social status and standard of living, so the possibility of malnutrition and a deficiency in the diet of proteins and calories is practically excluded.

Alimentary insanity

To establish the cause and make an accurate diagnosis, find out:

• From the history of the onset of the disease, they learn what the body weight of the child was even before the first signs of malnutrition appeared.
• The socio-economic situation in which the child's family is located.
• If possible, find out the daily diet.
• Whether there is vomiting or chronic diarrhea, and how often it occurs.
• Is this child taking any medications? For example, anorexigenic, which suppress appetite, or diuretics, which remove many useful nutrients from the body, including protein.
• Are there any disorders of the central nervous system: stressful situations, alcohol or drug addiction.
• In adolescence, in particular in girls, starting from the age of 12, they find out the presence and evaluate the regularity, frequency and duration of the menstrual cycle.

Among all the symptoms that appear with alimentary insanity, permanent and rare symptoms are distinguished.

Permanent symptoms include:

• weight loss reaches up to 60% of normal, age-appropriate;
• decrease in the thickness of the subcutaneous fat layer;
• reduction in the mass of muscle fibers;
• the limbs of the patient become very thin;
• many wrinkles appear on the face, the skin fits all the facial bones and it seems as if this is the face of an old man.

• Diarrhea is chronic. The chair is liquid, shines, with an unpleasant smell.
• Thinning and clarification of hair, which eventually begin to fall out.
• Exacerbation of chronic infections is a very frequent companion of an organism weakened by malnutrition.
• Thrush is a fungal disease that affects the mucous membranes of the mouth, vagina and urethra. They are manifested by whitish discharge, itching and discomfort in these places.
• Symptoms of multivitamin deficiency, depending on the lack of certain vitamins and minerals.

• Eye changes are manifested by inflammation of the eyelids, the formation of new small vessels on the cornea. Grayish plaques appear in the inner corners of the eyes (lack of vitamin A).
• In the oral cavity, inflammatory changes in the mucous membrane and gums are observed. The tongue increases in size (due to a lack of vitamin B 12).
• The heart is enlarged. Insufficient strength of cardiac impulses leads to stagnation of blood in the veins, swelling of the lower extremities appears.
• Weakness of the muscles of the anterior abdominal wall causes a sagging, protruding abdomen. The liver protrudes beyond the lower edge of the right hypochondrium.
• Explicit neurological disorders are manifested in nervousness, increased irritability, muscle weakness, and a decrease in tendon reflexes.

• Memory worsens, mental and cognitive abilities, including working capacity, decrease.
• Decreased visual acuity. A lack of vitamin A causes a decrease in vision at dusk.
• The sharpness of taste sensations is also reduced.
• A lack of vitamin C leads to increased capillary fragility. Small punctate hemorrhages can be seen on the skin after a slight pinch.

Lack of essential fatty acids

In most cases, this variant of malnutrition appears in infants who lack the nutrition of mother's milk. Cow's milk and other milk mixtures do not contain essential fatty acids in the amount necessary for the energy and plastic costs of a young organism. Depending on the deficiency of one or another fatty acid, the symptoms of the disease will differ slightly from each other.

With a lack of linoleic acid, the following symptoms appear:

• Dryness of the skin with exfoliation of the superficial stratum corneum.
• Wound healing continues for a long period.
• Thrombocytopenia - a reduced number of platelets (blood cells responsible for its clotting) in the blood. The lack of platelets leads to increased fragility of small vessels, with accidental minor domestic injuries of the skin, bleeding lengthens. Insignificant tweaks cause the appearance of many small-point hemorrhages.
• Prolonged loose stools (diarrhea).
• Periodic exacerbations of infectious diseases (for example, skin or lungs).

• numbness and paresthesia (tingling sensation) of the lower and upper extremities;
• general muscle weakness;
• visual impairment.

Diagnosis of malnutrition

Key points

Detection of important clinical signs in all major systems involved in the pathological process. This includes the following violations:

• fatness disorders - manifested in the form of thinning of the subcutaneous fat layer and trophic changes;
• digestive disorders - include changes in food resistance;
• metabolic disorders: protein, fat, carbohydrate, mineral, vitamin;
• functional disorders of the central nervous system.

The second point that should not escape the attention of doctors is the differentiation of pathological changes that occur during malnutrition, with other similar diseases, with a decrease in height, body weight, and overall physical development of children.

Symptoms of children with hypostatura are very similar to a disease such as nanism. This is a pathology of the central endocrine organs (hypothalamus and pituitary gland), in which growth hormone, somatotropin, is not produced. With this disease, unlike hypostatura, there are no pathological changes in the form of thinning of the subcutaneous fat layer and other trophic disorders. All organs develop evenly, although they are reduced in size.

Assessment of the child's condition and determination of the degree of pathological changes is also determined by the nature of the feces. Initially, with malnutrition, the stool is scanty, colorless, with a characteristic fetid odor. In the future, violations of the functional ability to process food through the gastrointestinal tract lead to the fact that the stool becomes plentiful, shiny, it contains the remains of undigested food, muscle fibers. Infection with pathogenic bacteria of the intestinal mucosa entails dysbacteriosis (diarrhea, bloating and discomfort in the abdomen).

Due to insufficient intake of protein, the body uses internal reserves (from muscles, adipose tissue), the metabolic products of which are excreted by the kidneys in the form of ammonia. The urine of such patients has the smell of ammonia.

Laboratory research

In biochemical analyzes, signs of impaired liver function, lack of vitamins and trace elements can be detected.

Instrumental diagnostic methods

Ultrasound is used when the borders of the heart are enlarged, the liver is enlarged, or there are other pathological changes in the abdominal cavity.
If necessary, or in doubtful cases, the attending physician prescribes the appropriate instrumental diagnostic method at his discretion.
Diagnosis of malnutrition and the degree of pathological changes is not an easy task, and requires a lot of patience, care and experience from the doctor.

Hypotrophy treatment

Complex therapy includes:

• Determination of the cause that caused malnutrition, simultaneously with an attempt to regulate and eliminate it.
• Diet therapy, which is selected individually in each specific case, and also depends on the degree of pathological disorders in the body.
• Detection of chronic foci of infection that contribute to the development of malnutrition, as well as their active treatment.
• Symptomatic treatment, which includes the use of multivitamin and enzyme preparations.
• Appropriate regimen with proper care and educational activities.
• Periodic courses of massage and therapeutic exercises.

diet therapy

• 2/3 for hypotrophics of the first degree.
• 1/2 for hypotrophics of the second degree.
• 1/3 for hypotrophics of the third degree.

3. The third period in diet therapy is the stage of enhanced food intake. Only after complete restoration of the functional activity of the gastrointestinal tract, the patient can increase the load of food.
In the third period, intensive feeding is continued, however, with a restriction of protein intake, since the increased intake of protein products is not fully absorbed by the body.
During each stage of diet therapy, the stool is periodically checked for the content of residual dietary fiber and fat (coprogram).

Other, no less important conditions when prescribing a diet are:
1. Reducing the periods between feedings. And the frequency of feeding itself increases several times a day, and is:

• with hypotrophy of the first degree - seven times a day;
• in the second degree - eight times a day;
• in the third degree - ten times a day.

3. Maintaining adequate periodic nutritional control. For this purpose, special diaries are kept, where the amount of food eaten is noted. Systematic control is simultaneously performed for stool, diuresis (number and frequency of urination). If nutrient mixtures are administered intravenously, then their amount is also recorded in the diary.

4. Fecal samples are taken several times a week for the presence of undigested dietary fiber and fatty inclusions.

5. Every week, the child is weighed, and additional calculations are made to calculate the required amount of nutrients (proteins, fats and carbohydrates).

The criteria for the effectiveness of dietary therapy are:

• normalization of the condition and elasticity of the skin;
• improving the appetite and emotional state of the child;
• daily weight gain, an average of 25-30 grams.

Care of patients with malnutrition

• The conditions for staying in the wards should be as comfortable as possible, and are as follows: the lighting complied with all regulatory standards, ventilation was carried out twice a day, the air temperature was optimal, within 24-25 degrees Celsius.
• Daily walks in the fresh air serve both as hardening and as a prevention of upper respiratory tract infections (congestive pneumonia).
• Periodic gymnastic exercises and massage courses will help restore reduced muscle tone, and will have a beneficial effect on the general condition of the body.

Enzyme therapy

vitamin therapy

Stimulant Therapy

Symptomatic treatment

• With anemia, iron preparations (sorbifer, totem) are prescribed. If a child has a very low hemoglobin value (below 70 g/l), he is prescribed a red blood cell transfusion.
• With rickets, vitamin D is prescribed, as well as preventive courses of physiotherapy. For this purpose, irradiation with ultraviolet rays using a special quartz lamp is used.

Prevention of the development of malnutrition

• The child must be completely healthy.
• Eat food according to the age of the child.
• Complementary foods are introduced gradually, and before breastfeeding. The child eats with a small spoon.
• The change of one type of feeding is replaced by one type of complementary foods.
• The food you eat should be rich in vitamins and essential minerals.

Summing up the above material, it should be noted that the prognosis for the development of malnutrition depends primarily on the causes that participated in the occurrence of this pathological condition. The conditions of the external and internal environment, the nature of feeding, as well as the age of the patient - all this plays a big role in the development of malnutrition. With alimentary insufficiency, the outcome of the disease is usually favorable.

Hypotrophy is a malnutrition that refers to dystrophy and is characterized by a decrease in tissue trophism, growth and body weight of the child. With malnutrition, metabolic processes are disturbed, which lead to a lag in the physical development of children.

Depending on the time of occurrence, congenital and acquired forms of malnutrition are distinguished, and the overall frequency of occurrence varies between 3–5% of all childhood diseases.

How to determine the degree of malnutrition?

The degrees of malnutrition mean how severe the symptoms are and how much weight loss there is in relation to the height of the child. So, for example, a born child is diagnosed with "hypotrophy of the 1st degree" in newborns if he was born at a gestational age of more than 38 weeks, has a body weight of 2800 g or less, and a body length of less than 50 cm. If the child has an acquired form of malnutrition , then they calculate the so-called "weight loss index" or fatness index according to Chulitskaya (Professor of the Department of the University of Physical Culture, St. Petersburg).

ICH (Chulitskaya fatness index) is the sum of the circumference of the shoulder, thigh and lower leg, from which the length of the child's body is taken away. Calculations are carried out in centimeters, and in normal children under the age of one year, this figure is 25-30 cm. If children develop malnutrition, then this index decreases to 10-15 cm, which indicates the presence of malnutrition 1 degree.

The body weight deficit is also calculated using a formula that all pediatricians have. The table contains weight indicators, which should be added monthly:

• 1 month after birth - 600 g.
• 2 and 3 months - 800 g each.
• 4 month - 750 g.

The calculation of the fifth and all subsequent months is equal to the previous weight minus 50 g.

When measuring the degree of malnutrition, the actual weight of the child is compared and the one that is calculated according to the table according to age. For example, a baby was born with a weight of 3500 g, and at the age of 2 months it weighs 4000 g. The actual weight should be 3500 + 600 + 800 = 4900 g. The deficit is 900 g, which is 18% as a percentage:

4900 g - 100%

X \u003d (900 x 100) / 4900 \u003d 18%

• Hypotrophy of the 1st degree - is placed with a weight deficit of 10% to 20%.
• Hypotrophy of the 2nd degree - is placed with a weight deficit of 20% to 30%.
• Hypotrophy of the 3rd degree - is placed with a weight deficit of 30% or more.

Signs of 1st degree of malnutrition

Each degree of malnutrition has its own clinical picture, signs and characteristic symptoms, by which it is also possible to determine the stage of development of the disease.

Signs characteristic of hypotrophy of the 1st degree are as follows:

• IUCH is 10-15 cm.
• The subcutaneous fat layer disappears on the abdomen.
• Skin folds are flabby and straighten out slowly.
• The elasticity of soft tissues is reduced.
• Muscles become sluggish.
• Body weight below normal weight by 10-20%.
• There is no stunting.
• The child's well-being does not suffer and the psyche is not disturbed.
• The child often suffers from infectious and other diseases.
• There is a slight indigestion (regurgitation).
• Irritability and sleep disturbance appear.
• The child becomes restless and gets tired quickly.

Treatment of this degree of malnutrition is not difficult, and weight can be normalized when the regime is restored (the entire amount of food is divided into 7-8 meals) and the diet. The diet is dominated by carbohydrates, cereals, fruits, vegetables.

Signs of the 2nd degree of the disease

Hypotrophy of the 2nd degree is characterized by the following symptoms and signs:

• HI becomes less than 10 and goes to zero.
• The fat layer is absent on almost the entire area of ​​the body.
• Sagging and sagging appear on the skin.
• Joints and bones are clearly visible.
• There is a decrease or lack of appetite.
• Vomiting, nausea and frequent regurgitation of food.
• Irregular and unstable stools, and there are remnants of undigested food in the stool.
• Signs of beriberi are dry hair, brittle and thinning nails, cracks in the corners of the mouth.
• The weight deficit reaches 20-30%.
• Growth is retarded.
• Symptoms of the nervous system - lethargy, anxiety, fatigue, loudness, irritability, sleep disturbance.
• Violation of the process of thermoregulation (the child quickly overheats and cools).
• Infectious diseases the baby gets sick often and for a long time.

Treatment of this degree of malnutrition can be carried out both at home and in a hospital. For treatment, increase the number of feedings and reduce portions of food. Of the drugs prescribed biostimulants, vitamins, minerals, enzymes.

Signs of the 3rd degree of malnutrition in children

This degree is considered severe, since all the symptoms only worsen, and without timely treatment lead to death in children. To all the above signs, signs of a violation of the activity of all organs and systems are added:

• The weight deficit is 30% or more.
• Growth retardation.
• Absence of subcutaneous fat.
• There are violations of the heart rhythm and work of the heart.
• Respiratory failure.
• Mental retardation.
• Muscle atrophy and wrinkling of the skin.
• Anorexia symptoms.
• Violation of thermoregulation and decrease in pressure.

Treatment of this degree of malnutrition should be carried out only in a hospital, since the work of metabolic processes and the activity of all organs and systems are disrupted. Drug treatment includes intravenous transfusion of blood, plasma, glucose solution, hormones, as well as treatment with enzymes, vitamins, microelement compounds.

Very often in children there is a pathological malnutrition, which is accompanied by a small increase in body weight compared to the norm in relation to age and height. If this gap is more than 10%, malnutrition is diagnosed, which most often manifests itself before 3 years.

In pediatrics, this disease is considered as an independent type of dystrophy. Since malnutrition in young children is accompanied by very serious disorders in the body (failure of metabolic processes, decreased immunity, lag in speech and psychomotor development), it is important to identify the disease in a timely manner and begin treatment.

Correctly identified causes of malnutrition will help doctors prescribe the best treatment in each case. Factors of the prenatal or postnatal period can lead to a pathological malnutrition of a child.

Intrauterine malnutrition:

• unfavorable conditions for the normal development of the fetus during its gestation (bad habits of a woman, malnutrition, non-compliance with the daily regimen, environmental and industrial hazards);
• somatic diseases of the expectant mother (diabetes mellitus, nephropathy, heart disease, hypertension) and her nervous breakdowns, constant depression;
• pregnancy pathologies (, toxicosis, premature birth, placental insufficiency);
• intrauterine infection of the fetus, its hypoxia.

Extrauterine malnutrition:

• congenital malformations up to chromosomal abnormalities;
• fermentopathy (, lactase deficiency);
• immunodeficiency;
• constitutional anomaly;
• protein-energy deficiency due to poor or unbalanced nutrition (underfeeding, sucking difficulties with flat or inverted nipples in the mother, hypogalactia, insufficient amount of milk formula, abundant regurgitation, micronutrient deficiency);
• poor nutrition of a nursing mother;
• some diseases of the newborn do not allow him to actively suckle, which means - to eat fully: cleft palate, congenital heart disease, cleft lip, birth trauma, perinatal encephalopathy, cerebral palsy, pyloric stenosis, alcohol syndrome;
• frequent SARS, intestinal infections, tuberculosis;
• unfavorable sanitary and hygienic conditions: poor child care, rare exposure to the air, rare bathing, insufficient sleep.

All these causes of childhood malnutrition are closely interrelated, have a direct impact on each other, thus forming a vicious circle that accelerates the progression of the disease.

For example, due to malnutrition, malnutrition begins to develop, while frequent infectious diseases contribute to its strengthening, which, in turn, leads to malnutrition and weight loss by the child.

Classification

There is a special classification of malnutrition in children, depending on the lack of body weight:

1. Hypotrophy of the 1st degree is usually detected in newborns (in 20% of all infants), which is diagnosed if the child's lag in weight is 10–20% less than the age norm, but growth rates are absolutely normal. Parents should not worry about such a diagnosis: with timely care and treatment, the baby recovers in weight, especially when breastfeeding.
2. Hypotrophy of the 2nd degree (average) is a decrease in weight by 20–30%, as well as a noticeable lag in growth (by about 2–3 cm).
3. Hypotrophy of the 3rd degree (severe) is characterized by a lack of mass, exceeding 30% of the age norm, and a significant lag in growth.

The above three degrees of malnutrition suggest different symptoms and treatments.

Symptoms of childhood malnutrition

Usually, the symptoms of malnutrition in newborns are determined already in the hospital. If the disease is acquired, and not congenital, attentive parents, according to some signs, even at home will be able to understand that their child is sick. Symptoms depend on the form of the disease.

I degree

• satisfactory state of health;
• neuropsychic development is quite consistent with age;
• loss of appetite, but within moderate limits;
• pale skin;
• reduced tissue turgor;
• thinning of the subcutaneous fat layer (this process begins with the abdomen).

II degree

• impaired activity of the child (excitation, lethargy, lag in motor development);
• poor appetite;
• pallor, peeling, flabbiness of the skin;
• decreased muscle tone;
• loss of tissue turgor and elasticity;
• disappearance of the subcutaneous fat layer on the abdomen and limbs;
• dyspnea;
• tachycardia;
• frequent otitis, pneumonia, pyelonephritis.

III degree

• severe exhaustion;
• atrophy of the subcutaneous fat layer on the entire body of the child;
• lethargy;
• lack of response to banal stimuli in the form of sound, light and even pain;
• a sharp lag in growth;
• neuropsychic underdevelopment;
• pale gray skin;
• dryness and pallor of the mucous membranes;
• muscles atrophy;
• loss of tissue turgor;
• retraction of the fontanel, eyeballs;
• sharpening of facial features;
• cracks in the corners of the mouth;
• violation of thermoregulation;
• frequent regurgitation, vomiting, diarrhea, candidal stomatitis (thrush);
• alopecia (baldness);
• hypothermia, hypoglycemia or may develop;
• infrequent urination.

If malnutrition is detected in a child, an in-depth examination is carried out to clarify the causes of the disease and appropriate treatment. For this, consultations of children's specialists are appointed - a neurologist, a cardiologist, a gastroenterologist, a geneticist, an infectious disease specialist.

Various diagnostic studies are carried out (ECG, ultrasound, EchoCG, EEG, coprogram, biochemical blood test). Based on the data obtained, therapy is already prescribed.

Treatment of the disease

On an outpatient basis, treatment of malnutrition of the I degree in young children is carried out, inpatient - II and III degrees. The main activities are aimed at:

• normalization of nutrition;
• diet therapy (gradual increase in calorie content and volume of food consumed by the child + fractional, frequent feeding);
• compliance with the regime of the day;
• organization of proper child care;
• correction of metabolic disorders;
• drug therapy (enzymes, vitamins, adaptogens, anabolic hormones);
• in the presence of a severe form of the disease, intravenous administration of glucose, protein hydrolysates, vitamins, saline solutions is prescribed;
• massage with elements of exercise therapy.

With timely treatment of the disease of I and II degrees, the prognosis is favorable, but with hypotrophy of the III degree, a lethal outcome is noted in 50% of cases.

Prevention methods

Prevention of malnutrition in children involves a weekly examination by a pediatrician, constant anthropometry and nutritional correction. You need to think about the prevention of such a terrible disease even while carrying a baby:

• observe the daily routine;
• eat on time;
• correct pathologies;
• exclude all adverse factors.

After the birth of the crumbs, an important role is played by:

• high quality and balanced;
• timely and correct introduction of complementary foods;
• body weight control;
• rational, competent care of the newborn;
• treatment of any, even spontaneously occurring concomitant diseases.

Having heard such a diagnosis as malnutrition, parents should not give up. If the child is provided with normal conditions for the regimen, care and nutrition, quick and effective treatment of possible infections, severe forms can be avoided.