Hypotrophy of muscle mass in a child. Causes and signs of protein-energy deficiency, malnutrition, in children. Essential fatty acid deficiency

In order to develop, he needs a complete one. If a growing organism receives few nutrients, then growth slows down.

The body directs nutrients to those systems that are vital. The rest either stop developing or develop very slowly. In infancy, developmental delays are a guarantee of disability in adulthood.

Dystrophy, or, as it is also called, hypotrophy, is the very condition that develops with insufficient. Now we will find out what malnutrition is, how it develops and whether it is possible to avoid the negative consequences of malnutrition in infants.

What is malnutrition and how often does it occur in children

Hypotrophy is a rare phenomenon in developed countries. According to the World Health Organization, for every hundred babies, there are seven to eight babies with malnutrition.

In developing countries, this figure is much higher - as many as twenty babies out of every hundred suffer from malnutrition. Hypotrophy can only be diagnosed in babies under two years of age; upon reaching this age, the body begins to develop differently.

In simple terms, malnutrition is the consequences of starvation. It doesn't matter who - the mother or the baby. Mother's milk is the only complete food for an infant, and if the mother eats poorly, the child will suffer more than her.

Hypotrophy is a condition that develops when there is a lack of nutrients in the body. There are quantitative and qualitative shortages. Quantitative - this is when food is scarce.

Qualitative develops in the case of improperly selected artificial. Mother's milk in sufficient quantities cannot lead to a quality shortage.

Classification and reasons

Hypotrophy is intrauterine and acquired. Intrauterine malnutrition develops when the baby's mother suffers severe toxicosis in the first and second trimesters. As for the degrees, there is a special classification that determines the severity of malnutrition in a baby.

Hypotrophy 1 (mild) degree can be diagnosed in children. At the same time, growth occurs normally, the baby does not gain up to 10% of the norm in weight.

Hypotrophy of the second (medium) degree- the condition is more severe. In this case, the weight deficit is already from 20 to 30%. The second degree poses a threat to the development of the baby, and if the lack of weight is not replenished within a month and a half, regressive processes will begin.

Third (severe) degree malnutrition is characterized by a serious deficiency of mass - from 30% and above, as well as an almost complete cessation of growth. The causes of malnutrition are varied - from malformations to the quality of child care.

If a mother eats poorly or has bad habits, all this will affect her child. The baby will be frail and underweight if the mother has serious chronic diseases, such as heart disease or endocrine disorders.

Did you know? No matter how small the arm of a newborn baby may seem, it is so strong that it can support the entire weight of his body. grasp reflex- one of the unconditional and very important reflexes both for a human child and for many young marsupials.

The physiological causes of a quantitative shortage are a sluggish sucking reflex, in which the child cannot drink enough milk, an irregular shape of the nipples and an increased density of the mammary glands.

In addition to the obvious lack of food, the causes of acquired malnutrition are infectious diseases accompanied by intestinal disorders, an environmentally unfavorable environment, and a lack of maternal care.

Maternal care refers to constant attention, physical contact, communication, frequent walks, and sincere affection. The stronger the stress, the higher will be the need for additional nutrition, which should compensate for energy losses.

Clinical manifestations

Congenital malnutrition is diagnosed immediately by external signs - lack of subcutaneous adipose tissue, weak turgor, large folds of skin on the neck, sides and buttocks, which do not straighten out for a long time.

The more the baby's ribs, joints stick out, the shoulder blades are visible under the skin, the more dystrophy is developed in him. Laboratory findings of a dystrophic baby usually show a lack of calcium and potassium in the plasma fluid, a reduced number and platelets, and low blood sugar.

Acquired malnutrition can be diagnosed only some time after the child stays at home with his parents.

As we have already found out, the causes of dystrophy can be not only the inattention of parents, but also physiological factors, therefore, the more often the child is examined by a pediatrician, the lower the possibility of starting malnutrition to a dangerous stage.

Important! In the second degree of malnutrition, the subcutaneous fat layer leaves the entire body, but remains on the face. As long as this fat layer remains, the child can be brought out of the state of exhaustion without consequences.

There are three stages of malnutrition. At first, the baby begins to show signs of anxiety. He becomes more nervous and capricious, begins to noticeably lose weight - the fat layer on the stomach becomes thinner.

Skin circulation at this stage is still stable, so skin color remains normal, but a decrease in appetite will alert any attentive parent. In this case, there is nothing to worry about, breastfeeding and good care will help the baby quickly gain normal weight.

The second stage of malnutrition is characterized by a violation of the activity of the baby. He becomes lethargic, drowsiness increases. Shortness of breath and tachycardia are possible, as well.

Another sign of hypotrophy of the second degree is a lag in growth of two to three centimeters from the norm. The skin of children begins to turn pale and peel off, muscle tone decreases and eating disorders become chronic.
The layer of adipose tissue begins to melt, this is especially noticeable on the abdomen and limbs. Hypotrophy of the third degree is characterized by thinning of the subcutaneous fat layer both on the face and on the whole body.

The color of the skin turns from pale to gray, the folds on the skin do not straighten out. Eyes sink, facial features, on the contrary, become sharper, the baby stops responding to stimuli.

At the last stage of malnutrition, the child develops inflammatory diseases.- , . It is possible, urination, on the contrary, becomes less frequent.

There are several diagnostic methods: instrumental, laboratory and general. With a general diagnosis, the pediatrician draws conclusions about the presence of symptoms of malnutrition based on observations.

He evaluates the baby's fatness (the presence of fat folds on the neck, sides and limbs) and its digestive function. The latter is characterized by the quality of feces - their color, smell and structure. In a child who suffers from dystrophy, feces have a fetid odor, often contain undigested food and even particles of muscle fibers.

At the end, the pediatrician checks the functioning of the central nervous system by observing the child's reaction to external stimuli.

Did you know? There are more bones in the body of a newborn baby than in the body of an adult, by as much as sixty pieces!

Laboratory studies are prescribed starting from the second stage of malnutrition, when the risk of pathological changes in the body increases.

The results of the analyzes differ at different stages of malnutrition, and the best way to show possible violations is a blood test - it gives an idea of ​​the protein balance, immunity stability and possible inflammatory processes.

Instrumental diagnostics is used when malfunctions in the work of internal organs and organ systems are suspected. First of all, the work of the heart is checked - the doctor conducts an electrocardiographic study.

Reinforced feeding will also not be a cure, as the whole body has already suffered. It requires a competent approach to nutrition, vitamin therapy and medical supervision.

Treatment of hypotrophy of the first degree can be carried out at home, after registering with a pediatrician. With the second and third degree of malnutrition, it is necessary to go to the hospital and strictly follow all medical recommendations that relate to the normalization of nutrition, daily routine, drug therapy and therapeutic massages.

Important! Frequent fractional feeding of a child speeds up his recovery, in contrast to plentiful but rare meals. The more severe the degree of exhaustion, the more often you need to feed the baby. For the first stage of the disease, six to seven times a day is enough, for the second- eight-ten and for the third- ten to twelve feedings per day.

This is the main method of treating malnutrition: without it, drug therapy and massages do not make sense. The higher the degree of exhaustion, the more sparing food the doctor will select and prescribe.

First, the degree of damage to the digestive and central nervous systems is checked, because the thinning of the subcutaneous fat layer is not the main indicator of the degree of damage to dystrophy.

Product resistance is tested empirically. If the child has reached the age at which complementary foods can be given, it is gradually introduced into the diet and monitored for bloating and disorders. For the treatment of breast-fed children, maternal nutrition is adjusted.

You can not give a lot of food to babies at once. The higher the degree of exhaustion, the smaller portions begin its recovery. At the second stage of diet therapy, special attention is paid to micro- and macroelements entering the body.
At the transitional stage, nutrition in young children should fill the body's need for calories and food volume for accelerated recovery from malnutrition. The child begins to feed less often, but more plentifully.

The last stage is characterized by enhanced feeding. The child is given plenty of food when the functionality of the digestive tract is fully restored.

It is necessary to limit the protein component of food, as the most difficult to digest, but to ensure nutrition - weight at this stage comes very intensively.

Frequent fecal analysis is a prerequisite for monitoring recovery. The amount of undigested dietary fiber and fatty elements show how to adjust the diet.

Did you know? For the first two years of life, the child sleeps unstably, and therefore his parents during this time lose about four and a half thousand hours of good sleep.- this is equal to almost half a year of life.

Medications

Drug therapy includes vitamin therapy, enzyme therapy and therapy that stimulates the body's metabolic processes. Vitamin therapy enriches the body with substances that are lacking more than others - C, B1 and B6.

First, subcutaneous and intramuscular administration of solutions is practiced. After the digestive function returns to normal and the vitamin complexes stop transiting, an enteral intake (through the mouth) is prescribed.

Stimulating therapy is carried out with drugs that enhance immunity (up to immunoglobulin at the most severe stages), increase blood circulation and stimulate oxygen transport to all tissues.

Massage and exercise therapy

Physical therapy is physiotherapy exercises. It, together with massage, is used to improve tissue metabolism, stimulate blood circulation, and accelerate lymph. Physical education strengthens muscles and ligaments and affects the baby's joints - they become flexible and mobile again.

In complex therapy, exercise therapy and massage play the role of a general tonic, normalize metabolic processes and, due to this, restore the excitability of the central nervous system, which begins to transmit normal food reflexes.

Important! Therapeutic exercise is active and passive. Active movements include movements that the baby performs on his own, reacting to stimuli. Passive exercise is performed by the hands of a qualified pediatrician or trained parents.

A woman should stop drinking alcohol, exclude, including passive, be in the fresh air and undergo regular check-ups with a gynecologist.

Did you know? At birth, babies do not have kneecap joints. They just don't need- at this age, children cannot support themselves in an upright position. Finally, the knee joints are formed only six months after birth.

After birth, you need to keep the baby in the best conditions - provide him with breastfeeding or purchase balanced ones if there is no milk. A nursing mother must watch her diet, because everything she eats will turn into food for the baby.

The pediatrician will tell you when you can introduce complementary foods to breast milk, and this should be done gradually, checking the reaction of the child to individual products. In addition to nutrition, you need to ensure that the baby is often exposed to sunlight and fresh air.
These natural factors cause strong young children. Hypotrophy is not a sentence, and with caring care, you can return the baby to normal in a short time. It is necessary to monitor the nutrition of a nursing mother and enrich her diet with vitamin complexes.

Complementary foods should be introduced in accordance with medical prescriptions and observing changes in the well-being of the baby. Knowing the symptoms and signs of malnutrition, you can understand when the baby began to have alarming symptoms and seek help from a pediatrician.

Only competent medical care will save the baby from progressive malnutrition and give him the opportunity to develop correctly.

Update: December 2018

Hypotrophy in children is starvation, quantitative or qualitative, as a result of which significant changes occur in the body. Qualitative starvation is possible with improper artificial feeding, lack of essential nutrients and vitamins, quantitative - with incorrect calculation of caloric content or lack of food resources.

Hypotrophy can be the result of acute diseases or the result of a chronic inflammatory process. Wrong actions of parents - lack of regimen, poor care, unsanitary conditions, lack of fresh air - also lead to this condition.

What does a normally developing baby look like?

Signs of normotrophic:

• healthy look
• The skin is pink, velvety, elastic
• A lively look, activity, studies the world around with interest
• Regular increase in weight and height
• Timely mental development
• Proper functioning of organs and systems
• High resistance to adverse environmental factors, including infectious ones
• Rarely cries

In medicine, this concept is used only in children under 2 years of age. According to WHO, malnutrition is not ubiquitous:

• in developed countries, its percentage is less than 10,
• and in developing countries - more than 20.

According to scientific studies, this deficiency condition occurs approximately equally in boys and girls. Severe cases of malnutrition are observed in 10-12 percent of cases, with rickets in a fifth of children, and anemia in a tenth. Half of the children with this pathology are born in the cold season.

Causes and development

The causes of malnutrition in children are diverse. The main factor causing intrauterine malnutrition is toxicosis of the first and second half of pregnancy. Other causes of congenital malnutrition are as follows:

• pregnancy before the age of 20 or after 40 years
• bad habits of the expectant mother, poor nutrition
• chronic diseases of the mother (endocrine pathologies, heart defects, and so on)
• chronic stress
• work of the mother during pregnancy in hazardous production (noise, vibration, chemistry)
• placental pathology (improper attachment, early aging, one umbilical artery instead of two, and other placental circulation disorders)
• multiple pregnancy
• metabolic disorders in the fetus of a hereditary nature
• genetic mutations and intrauterine anomalies

Causes of acquired malnutrition

Internal- caused by pathologies of the body that disrupt food intake and digestion, absorption of nutrients and metabolism:

• congenital malformations
• CNS lesions
• immunodeficiency
• endocrine diseases
• metabolic disorders

In the group of endogenous factors, food allergies and three hereditary diseases that occur with malabsorption syndrome, one of the common causes of malnutrition in children, should be singled out separately:

• cystic fibrosis - disruption of the external secretion glands, affected by the gastrointestinal tract, respiratory system
• , changes in the work of the intestines in a child begin from the moment gluten-containing foods are introduced into the diet - barley groats, semolina, wheat porridge, rye groats, oatmeal
• - the digestibility of milk is disturbed (lack of lactase).

According to scientific studies, malabsorption syndrome provokes malnutrition twice as often as nutritional deficiencies. This syndrome is characterized primarily by a violation of the chair: it becomes plentiful, watery, frequent, frothy.

External- due to the wrong actions of parents and an unfavorable environment:

All exogenous factors in the development of malnutrition cause stress in the child. It has been proven that light stress increases the need for energy by 20%, and for protein - by 50-80%, moderate - by 20-40% and 100-150%, strong - by 40-70 and 150-200%, respectively.

Symptoms

Signs and symptoms of intrauterine malnutrition in a child:

• body weight below the norm by 15% or more (see below the table of the dependence of weight on the height of the child)
• growth is less by 2-4 cm
• the child is lethargic, muscle tone is low
• congenital reflexes are weak
• thermoregulation is impaired - the child freezes or overheats faster and stronger than normal
• in the future, the initial weight is slowly restored
• umbilical wound does not heal well

Acquired malnutrition is characterized by common features in the form of clinical syndromes.

• Insufficient nutrition: the child is thin, but the proportions of the body are not violated.
• Trophic disorders(malnutrition of body tissues): the subcutaneous fat layer is thinned (first on the abdomen, then on the limbs, in severe cases and on the face), the mass is insufficient, the body proportions are disturbed, the skin is dry, elasticity is reduced.
• Changes in the functioning of the nervous system: depressed mood, decreased muscle tone, weakening of reflexes, psychomotor development is delayed, and in severe cases, acquired skills even disappear.
• Decreased food intake: appetite worsens up to its complete absence, frequent regurgitation, vomiting, stool disorders appear, the secretion of digestive enzymes is inhibited.
• Decreased immunity: the child begins to get sick often, chronic infectious and inflammatory diseases develop, possibly toxic and bacterial damage to the blood, the body suffers from general dysbacteriosis.

Degrees of malnutrition in children

Hypotrophy of the 1st degree is sometimes practically not noticeable. Only an attentive doctor on examination can identify it, and even then he will first conduct a differential diagnosis and find out if a body weight deficit of 11-20% is a feature of the child's physique. Thin and tall children are usually so due to hereditary characteristics. Therefore, a new mother should not be afraid if her active, cheerful, well-nourished child is not as plump as other children.

Hypotrophy 1 degree in children it is characterized by a slight decrease in appetite, anxiety, sleep disturbance. The surface of the skin is practically not changed, but its elasticity is reduced, the appearance may be pale. The child looks thin only in the abdomen. Muscle tone is normal or slightly reduced. Sometimes they show signs of rickets, anemia. Children get sick more often than their well-fed peers. Stool changes are insignificant: a tendency to constipation or vice versa.

Hypotrophy 2 degrees in children it is manifested by a weight deficit of 20-30% and growth retardation (about 2-4 cm). Mom can find cold hands and feet in a child, he can often spit up, refuse to eat, be lethargic, inactive, sad. Such children lag behind in mental and motor development, sleep poorly. Their skin is dry, pale, flaky, easily folded, inelastic. The child looks thin in the abdomen and limbs, and the contours of the ribs are visible. The stool fluctuates greatly from constipation to diarrhea. These kids get sick every quarter.

Sometimes doctors see malnutrition even in a healthy child who looks too thin. But if the growth corresponds to age, he is active, mobile and happy, then the lack of subcutaneous fat is explained by the individual characteristics and high mobility of the baby.

With hypotrophy of the 3rd degree growth retardation 7-10 cm, weight deficit ≥ 30%. The child is drowsy, indifferent, tearful, acquired skills are lost. The subcutaneous fat is thinned everywhere, pale gray, dry skin fits the baby's bones. There is muscle atrophy, cold extremities. Eyes and lips dry, cracks around the mouth. A child often has a chronic infection in the form of pneumonia, pyelonephritis.

Diagnostics

Differential Diagnosis

As mentioned above, the doctor first needs to figure out whether malnutrition is an individual feature of the body. In this case, no changes in the work of the body will be observed.
In other cases, it is necessary to conduct a differential diagnosis of the pathology that led to malnutrition: congenital malformations, diseases of the gastrointestinal tract or the endocrine system, lesions of the central nervous system, infections.

Treatment

The main directions of treatment of malnutrition in children are as follows:

• Identification of the cause of malnutrition, its elimination
• Proper care: daily routine, walks (3 hours daily, if outside ≥5˚), gymnastics and professional massage, bathing in warm baths (38 degrees) in the evening
• Organization of proper nutrition, balanced in proteins, fats and carbohydrates, as well as vitamins and microelements (diet therapy)
• Medical treatment

Treatment of congenital malnutrition consists in maintaining a constant body temperature in the child and establishing breastfeeding.

Nutrition for children with malnutrition

Diet therapy for malnutrition is divided into three stages.

The main directions of drug therapy

• Replacement therapy with pancreatic enzymes; drugs that increase the secretion of gastric enzymes
• The use of immunomodulators
• Treatment of intestinal dysbacteriosis
• vitamin therapy
• Symptomatic therapy: correction of individual disorders (iron deficiency, irritability, stimulant drugs)
• In severe forms of malnutrition - anabolic drugs - drugs that promote the formation of building protein in the body for muscles and internal organs.

Treatment of malnutrition requires an individual approach. It is more correct to say that children are nursed, not treated. Vaccinations for hypotrophy of the 1st degree are carried out according to the general schedule, for hypotrophy of the 2nd and 3rd degrees - on an individual basis.

Study of the causes and symptoms of malnutrition in children

In one of the somatic hospitals, 40 case histories of children diagnosed with hypertrophy (19 boys and 21 girls aged 1-3 years) were analyzed. The conclusions were obtained as a result of the analysis of specially designed questionnaires: most often, children with malnutrition were born from a pregnancy that proceeded with pathologies, with heredity for gastrointestinal pathologies and allergic diseases, with intrauterine growth retardation.

Prevention of malnutrition in children

Prevention of both intrauterine and acquired malnutrition begins with the struggle for the health of the woman and for the preservation of long-term breastfeeding.

The following areas of prevention are tracking the main anthropometric indicators (height, weight), monitoring the nutrition of children.

An important point is the timely detection and treatment of childhood diseases, congenital and hereditary pathologies, proper child care, and prevention of the influence of external factors in the development of malnutrition.

It should be remembered:

• Mother's milk is the best and irreplaceable food for a baby up to a year old.
• At 6 months, the menu should be expanded with plant foods (see). Also, do not transfer the child to adult food too early. Weaning from breastfeeding up to 6 months of the child is a crime against the baby, if any, you must first apply it to the breast and only then supplement it.
• Variety in nutrition is not different types of cereals and pasta throughout the day. A complete diet consists in a balanced combination of proteins (animal, vegetable), carbohydrates (complex and simple), fats (animal and vegetable), that is, vegetables, fruits, meat, dairy products must be included in the diet.
• As for meat - after a year it must be present in the child's diet - this is an indispensable product, there can be no talk of any vegetarianism, only meat contains the compounds necessary for growth, they are not produced in the body in the amount that is needed for full development and health.
• Important!!! There are no safe drugs "just" to reduce or increase a child's appetite.

Table of dependence of weight on height in children under 4 years old

Very strong deviations in the weight of the child are not due to reduced appetite or some individual characteristics of the body - this is usually due to an unrecognized disease or lack of good nutrition in the child. A monotonous diet, nutrition that does not meet age-related needs - leads to a painful lack of body weight. The weight of the child should be controlled not so much by age as by the growth of the baby. Below is a table of the dependence of the height and weight of the baby (girls and boys) from birth to 4 years:

• Norm is the interval between GREEN and BLUE weight value (25-75 centiles).
• Weight loss- between YELLOW and GREEN figure (10-25 centiles), however, it may be a variant of the norm or a slight tendency to reduce body weight in relation to height.
• Weight gain- between BLUE and YELLOW number (75-90 centiles) is both normal and indicates a trend towards weight gain.
• Increased or reduced body weight- between RED and YELLOW number indicates both low body weight (3-10th centile) and increased (90-97th centile). This may indicate both the presence of the disease and the characteristics of the child. Such indicators require a thorough diagnosis of the child.
• Painful weight loss or gain- per RED border (>97 or<3 центиля). Ребенок с таким весом нуждается в установлении причины гипотрофии или ожирения и корректировки питания и назначения лечения, массажа и пр. , поскольку это является проявлением какого-либо заболевания и опасно негармоничным развитием органов, систем организма, снижению сопротивляемости к инфекциям и негативным факторам окружающей среды.

Hypotrophy is a disease that is diagnosed in children from 0 to 2 years of age. Also, malnutrition can be congenital and manifest itself in a child during intrauterine life. The disease is characterized by an eating disorder, which leads to a lack of body weight of the baby. In this case, the diagnosis is made only if the weight of the child is below normal for his age by 10% or more.

You should not make a diagnosis on your own and try to supplement the child - this is the task of specialists

Causes of the disease

We have already found out that malnutrition in children can be congenital, as well as acquired. What are the main causes of this disease?

Congenital pathology is most often diagnosed in cases of malnutrition of a pregnant woman. Newfangled diets, on which future mothers sit, pose a danger to the fetus. In addition, the baby may suffer if a pregnant woman is diagnosed with placental insufficiency, somatic diseases, and toxicosis.

At risk are women who decide to bear a child at an advanced age or at a young age, as well as if the father and mother are in a related marriage. Often, congenital malnutrition accompanies the development of children with chromosomal mutations, for example, Down syndrome.

Acquired malnutrition can be provoked by several factors. Let's consider each of them separately:

• Underfeeding, and it can be both quantitative and qualitative. In the first case, the child does not receive the required amount of nutrition, in the second case, he is fed with a low-calorie mixture.
• Infectious diseases in young children, as well as their consequences. This is sepsis, constantly recurring diseases of the upper respiratory tract or gastrointestinal tract.
• Developmental defects. Atresia of the biliary tract, heart disease, kidney disease, central nervous system, and other diseases.
• Malabsorption syndrome is a chronic disorder of food digestion processes. As a rule, patients with cystic fibrosis, lactase deficiency, celiac disease or food allergies are at risk (we recommend reading:).

How is the disease diagnosed?

Hypotrophy in children is usually classified as mild, moderately severe, or critical. These three degrees of malnutrition can be diagnosed in newborns and older children.

Degree 1

At first glance, the baby feels satisfactory. If you examine it more closely, you can find a decrease in skin elasticity, a low subcutaneous fat layer on the abdomen. According to the parents, the child's appetite is reduced, weight is growing slowly. Objectively, the doctor notes that body weight is 10-20% lower than normal. A decrease in the level of digestive enzymes can be detected, while the body temperature is normal and the development of motor functions is within the normal range (we recommend reading:).

Degree 2

The child is depressed, his activity is reduced, his appetite is disturbed. The skin is pale, dry, inelastic, weak muscle tone. The subcutaneous fat layer is noticeably reduced on the abdomen, arms and legs, but on the face it is normal. The temperature fluctuates during the day within one degree, which indicates a disorder of thermoregulation. The baby almost does not grow weight (it is 20-30% less than the norm), tachycardia, muffled heart tones may be noted. These symptoms are not the only ones: the child begins to lag behind in development - he lacks the strength to catch up with his peers.

Grade 3

This is the most severe degree of malnutrition, it is diagnosed when the child's general condition is significantly impaired. The baby does not have a subcutaneous fat layer - on the stomach, arms and legs, on the face. The child resembles a skeleton covered with skin. His weight does not increase and may even decrease.

The mood of the baby changes - from lethargy and apathy, he goes into the stage of irritability and tearfulness. Body temperature drops, hands and feet are cold (see also:). Breathing is shallow, heart sounds are muffled, arrhythmia is manifested. The child is constantly spitting up, he has frequent loose stools, urination in small portions. Weight below normal by more than 30%.

Chair with hypotrophy

The classification of stool in malnutrition serves as an additional way to diagnose this disease. The changes are quite pronounced, so we will talk about them separately. The most characteristic types of stool:

• Hungry. Very scanty, dense, dry, almost colorless. In some children, the "hungry" stool becomes green, patches of mucus are noticeable in it, and the smell is putrid, unpleasant. Such a chair often occurs against the background of the development of dysbacteriosis.
• Mealy. This type of stool is usually thin, greenish, with mucus impurities. During a coprological examination, a lot of fiber, starch, neutral fat, mucus and leukocytes are found.
• Protein. The stool is hard, dry, crumbly. The study revealed lime and magnesium salts.

Complications

Hypotrophy is a dangerous condition for a baby. If this disease is not treated, lack of body weight can provoke the development of concomitant serious diseases. The second and third stages often give complications and are accompanied by:

• inflammation of the lungs;
• developmental delay, including mental;
• inflammation of the large and small intestines;
• rickets;

• anemia
• inflammation of the middle ear;
• the development of dysbacteriosis;
• violation of the enzymatic activity of the body.

Treatment

Treatment of malnutrition can be divided into four components. Each of them is important, but the effectiveness will be low if not used in combination:

• The first thing to do is to identify the cause of the disease and eliminate it.
• The next step is to establish proper care for the child. It is important to walk with him at least three hours a day (however, at a temperature not lower than 5˚C), regularly massage, baths with warm water (about 38˚C).
• Optimize the nutrition of a small patient. It is important that the baby receives the necessary amount of proteins, fats, carbohydrates.
• If necessary, use drug therapy.

Also, treatment can be conditionally divided into stages. Each of them requires a thoughtful approach and careful adherence to the doctor's advice:

• stage of adaptation;
• interim period;
• stage of enhanced nutrition.

Child care during recovery

Children with 1 and 2 degrees of malnutrition should be massaged regularly. All exercises must be performed by laying the child on his back, then turning over on his stomach. One of the conditions for the massage is the preparation of the room: a recognized expert in pediatrics, Dr. Komarovsky, notes that the room must be ventilated, and the air temperature is about 22˚С.

The simplest massage techniques:

• stroking hands and feet;
• spreading the arms to the sides and crossing them on the chest;
• massage of the abdomen with circular movements;
• flexion and extension of arms and legs;
• turning over on the stomach;
• the child should reflexively try to crawl, for this you need to put your palm under his heels and lightly press;
• foot massage.

There are other massage techniques that can be used depending on the condition of the child, as well as his age. With caution, massage is performed for those children who have been diagnosed with the 3rd degree of the disease. Stroking should be the main elements of such a massage.

Food

Diet therapy is the main method of treating malnutrition in both newborns and older children. It is necessary to organize a diet in compliance with the recommendations of a doctor. If you feed the baby immediately with the amount of food that is shown to him at this age, you can aggravate the condition, cause vomiting, indigestion, and weakness. We will outline the basic principles for calculating the number of feedings and the daily amount of food - they are unchanged for each stage of the disease.

This period is intended for a smooth transition from a critical state to the process of normalizing weight and setting appetite. Its duration and principles may vary and depend on factors such as the degree of the disease.

With 1 degree of malnutrition, the adaptation period is usually 1-3 days. On the first day, the child can eat 2/3 of the total diet. The number of feedings should not exceed 6-7 times a day. Regardless of the age of the baby, it should be fed only with mother's milk or a mixture.

The second degree of malnutrition implies a longer period of adaptation - up to seven days. The first day is very important - the total amount of the mixture on this day should be within ½ - 2/3 of the norm. In this case, you need to use a mixture intended for children younger than the patient by 2 months. The entire period of adaptation is necessary to gradually increase the number of feedings per day - by one or two. Since it is desirable to treat a baby with 2 degrees of malnutrition in a hospital, the child should receive a 5% glucose solution or glucose-salt preparations through a gastric tube. At the moment of reaching the calculated daily amount of nutrition, the patient proceeds to the next stage - intermediate or reparative.

During the treatment of the third degree of malnutrition, the adaptation period should be even longer - from 10 days to 2 weeks. On the first day, the volume of food eaten should be half the norm, and the number of feedings should be ten. Every day you need to increase the amount of food per day by 100 ml. During the adaptation period, it is necessary to gradually switch to 8 meals a day. This stage can be considered passed when the amount of food eaten per day will be equal to 1/5 of the child's body weight.

Stage 2 and 3 of therapeutic nutrition

At the second (reparation) stage, the amount of daily food is finally brought to the required norm, according to the weight and age of the child. In addition, special therapeutic mixtures are introduced into the diet.

The third stage involves enhanced high-calorie nutrition. At a rate of 100-120 kilocalories per day, the baby should receive 200. In order to achieve this goal, you can use high-protein mixtures, as well as add cereals from buckwheat, rice and corn to the diet.

Medical therapy

Drug treatment includes vitamin therapy - vitamins C, B12, B6, B1, A, folic acid are prescribed. To improve digestion, enzymes are prescribed: pancreatin, festal, creon, mexase (see also:). Also, the doctor may recommend hormonal and non-hormonal drugs with an anabolic effect. Of particular note are medicines containing L-carnitine, for example, Elkar (more in the article:). This drug is indicated for children with underweight, malnutrition - it stimulates appetite, increases overall tone.

If the baby has a severe form of malnutrition, he will be given a dropper with albumin, glucose, and special nutrition. Also, such patients are infused with blood, plasma, and hormonal preparations are prescribed.

Often this disease is accompanied by intestinal dysbacteriosis, then the doctor will recommend special preparations with beneficial bacteria that will help improve the functioning of the intestine. In addition, it is required to correct the functional disorders of the nervous system, so children are prescribed soothing herbal preparations, valerian, motherwort. Herbs in the form of tincture are given orally, and also added to bath water.

Forecast

The first and second stages of the disease respond well to treatment if the cause that led to the deficiency of body weight is identified. Proper nutrition, adequate child care will allow you to get the first results in a month. The prognosis for children diagnosed with the third stage of malnutrition is not so rosy. A lethal outcome is observed in 30-50% of cases, while the rest of the patients with the third stage of malnutrition may well have a history of quite serious diseases.

Prevention

Prevention of malnutrition is to eliminate the possible causes that can lead to such a condition. A pregnant woman should eat right, undergo examinations in a timely manner and give up bad habits. After the baby is born, you should follow the doctor's standard recommendations - breastfeed the newborn or formula if breastfeeding is not possible. It is also important to go outside with the baby every day, treat possible foci of infection in a timely manner, and keep chronic diseases under control.

Nutrition should be balanced: from six months, vegetable food is introduced into the baby's menu, closer to a year - meat, fish, eggs. It is important to observe the drinking regimen and make sure that the child drinks not only formula or breast milk, but also water, various teas, compotes. An infant should be shown to the pediatrician every month and control weighings and measurements of physical indicators should be carried out. At the first sign of a lag in weight or height, the cause of such deviations should be found and eliminated. Subject to all these recommendations, the likelihood of developing malnutrition will be minimized.

Hypotrophy(Greek hypo - under, below; trophe - nutrition) - a chronic eating disorder with a lack of body weight. In Anglo-American literature, the term malnutrition is used instead of the term malnutrition - malnutrition. The main most common type of malnutrition is protein-energy malnutrition (PKI). As a rule, such children also have a deficiency in the intake of vitamins (hypovitaminosis), as well as microelements. According to

Etiology

There are two groups of malnutrition according to etiology - exogenous and endogenous, although mixed variants are also possible. It is important to remember that weight loss up to the development of malnutrition is a non-specific reaction of a growing organism to a long-term effect of any damaging factor. With any disease, children develop: stagnation in the stomach, inhibition of the activity of enzymes of the gastrointestinal tract, constipation, and sometimes vomiting. This is associated, in particular, with an almost 10-fold increase in the level of somatostatin in sick children, which inhibits anabolic processes. With alimentary reasons, primary malnutrition is diagnosed, with endogenous - secondary (symptomatic).

Exogenous causes of malnutrition

Nutritional factors - quantitative underfeeding in case of hypogalactia in the mother or difficulties in feeding on the part of the mother (flat, inverted nipple, "tight" mammary gland, etc.), the child (regurgitation, vomiting, small lower jaw, "short frenulum" of the tongue and etc.) or high-quality underfeeding (use of an age-inappropriate mixture, late introduction of complementary foods, poverty of the daily ration of animal proteins, fats, vitamins, iron, microelements).

Infectious factors - intrauterine generalized infections (etc.), intranatal infections, toxic-septic conditions, and urinary tract infections, intestinal infections, etc. Especially often the cause of malnutrition is infectious lesions of the gastrointestinal tract, causing morphological changes in the intestinal mucosa (up to atrophy of the villi), inhibition of the activity of disaccharidases (usually lactase), immunopathological damage to the intestinal wall, dysbacteriosis, contributing to prolonged diarrhea, maldigestion, malabsorption. It is believed that for any mild infectious diseases, energy and other nutritional needs increase by 10%, moderate - by 50% of the needs under normal conditions.
ness (BKN). As a rule, such children also have a deficiency in the intake of vitamins (hypovitaminosis), as well as microelements. According to , in developing countries, up to 20-30% or more of young children have protein-calorie or other types of malnutrition.

Toxic factors - the use of expired or low-quality milk formulas during artificial feeding, hypervitaminosis D and A, poisoning, including medicinal ones, etc.

Anorexia as a result of psychogenic and other deprivation, when the child does not receive enough attention, affection, psychogenic stimulation of development, walks, massage and gymnastics.

Endogenous causes of malnutrition

Perinatal encephalopathies of various origins

Congenital malformations of the gastrointestinal tract with complete or partial obstruction and persistent vomiting (pyloric stenosis, annular pancreas, dolichosigma, Hirschsprung's disease, etc.), as well as the cardiovascular system.

Syndrome of "short bowel" after extensive bowel resections.

Hereditary (primary) immunodeficiency states (mainly T-systems) or.

Primary malabsorption and maldigestion (intolerance to lactose, sucrose, glucose, fructose, celiac disease, exudative enteropathy), as well as secondary malabsorption (allergic intolerance to cow or soy milk proteins, enteropathic acrodermatitis, etc.).

Hereditary metabolic anomalies (fructosemia, leucinosis, xanthomatosis, Niemann-Pick and Tay-Sachs diseases, etc.).

Endocrine diseases (adrenogenital syndrome, pituitary dwarfism, etc.).

All clinical symptoms of BKN are divided into the following groups of disorders:

1. Syndrome of trophic disorders - thinning of the subcutaneous fat layer, a flat growth curve and a lack of body weight and a violation of the proportionality of the physique (the indices of L. I. Chulitskaya and F. F. Erisman are reduced), a decrease in tissue turgor and signs of polyhypovitaminosis (A, B, B2 , B6, D, P, PP).

2. Syndrome of digestive disorders - loss of appetite up to anorexia, unstable stool with a tendency to both constipation and dyspepsia, dysbacteriosis, decreased food tolerance, signs of maldigestion in the coprogram.
3. Syndrome of dysfunction of the central nervous system - disorders of emotional tone and behavior, low activity, dominance of negative emotions, sleep disturbances and thermoregulation, lag in the pace of psychomotor development, muscle hypo-, dystonia.

4. Syndrome of impaired hematopoiesis and decreased immunobiological reactivity - anemia, secondary immunodeficiency states, a tendency to an erased, atypical course of frequent infectious and inflammatory diseases. The main reason for the suppression of immunological reactivity in malnutrition is protein metabolism disorders.

Classification

According to the severity, there are three degrees of malnutrition: I, I, III. The diagnosis should indicate the most likely etiology of malnutrition, concomitant diseases, complications. It is necessary to distinguish between primary and secondary
nye (symptomatic) malnutrition. malnutrition can be the main or concomitant diagnosis and is usually the result of undernutrition. Secondary malnutrition is a complication of the underlying disease that must be identified and treated.

Clinical picture

Hypotrophy I degree

characterized by thinning of the subcutaneous fat layer in all parts of the body and especially on the abdomen. The fatness index of Chulitskaya is 10-15. The fat fold is flabby, and muscle tone is reduced. There is some pallor of the skin and mucous membranes, a decrease in firmness and elasticity of the skin. The growth of the child does not lag behind the norm, and body weight is 11-20% below the norm. The weight gain curve is flattened. The general health of the child is satisfactory. Psychomotor development corresponds to age, but he is irritable, restless, easily tired, sleep is disturbed. Has a tendency to vomit.

Hypotrophy II degree

The subcutaneous fat layer is absent on the abdomen, sometimes on the chest, sharply thinned on the limbs, preserved on the face. The fatness index of Chulitskaya is 1-10. The skin is pale with a grayish tinge, dry, easily folds. The transverse folds typical of healthy children on the inner surface of the thighs disappear and flabby longitudinal folds appear, hanging like a bag. The skin is pale, flabby, as if redundant on the buttocks, thighs, although sometimes there are swelling.

As a rule, there are signs of polyhypovitaminosis (marbling, peeling and hyperpigmentation in the folds, fragility of nails and hair, brightness of mucous membranes, seizures in the corners of the mouth, etc.). reduced. Typically, a decrease in the mass of the muscles of the limbs. A decrease in muscle tone leads, in particular, to an increase in the abdomen due to hypotension of the muscles of the anterior abdominal wall, intestinal atony and flatulence.

Body weight is reduced compared to the norm by 20-30% (in relation to length), there is a lag in growth. The body weight gain curve is flat. Appetite is reduced. Food tolerance is reduced. Characterized by weakness and irritability, the child is restless, noisy, whiny or lethargic, indifferent to the environment. The face takes on a worried, adult expression.
zhenie. Sleep is restless. Thermoregulation is impaired and the child quickly cools or overheats, depending on the ambient temperature. Fluctuations in body temperature during the day exceed 1°C.

Many sick children have otitis media, pneumonia, and other infectious processes that are asymptomatic. In particular, the clinical picture of pneumonia is dominated by respiratory failure, intoxication with mild catarrhal phenomena or in their absence and the presence of only a shortened tympanitis in the interscapular regions. Otitis is manifested by some anxiety, sluggish sucking, while even with an otoscopic examination of the tympanic membrane it is weakly expressed. The stool in patients with malnutrition is unstable: constipation is replaced by dyspeptic stool.

Hypotrophy III degree (marasmus, atrophy)

Hypotrophy of the III degree is characterized by an extreme degree of exhaustion: the appearance of the child resembles a skeleton covered with skin. The subcutaneous fat layer is absent on the abdomen, trunk and limbs, sharply thinned or absent on the face. The skin is pale gray, dry, sometimes purple-blue, the limbs are cold. The skin fold does not straighten out, since there is practically no elasticity of the skin (an abundance of wrinkles). The fatness index of Chulitskaya is negative. On the skin and mucous membranes there are manifestations of hypovitaminosis C, A, group B. Thrush, stomatitis are detected. The mouth looks bright, large, with cracks in the corners of the mouth ("sparrow's mouth").
Sometimes there is weeping erythema of the skin. The forehead is covered with wrinkles. The nasolabial fold is deep, the jaws and cheekbones protrude, the chin is pointed, the teeth are thin. Cheeks sink in as Bish's lumps disappear. The child's face resembles the face of an old man ("Voltaire's face"). The abdomen is distended, distended, or bowel loops are contoured. The stool is unstable: more often constipation, alternating with soapy-calcareous stools.

Body temperature is often lowered. There is no difference in temperature in the armpit and in the rectum. The patient quickly cools on examination, easily overheats. The temperature periodically "for no reason" rises to numbers. Due to a sharp decrease in immunological reactivity, otitis media and other foci of infection (, , colienteritis, etc.) are often found, which, as in stage II malnutrition, are asymptomatic. There are hypoplastic and osteomalacia signs of rickets. With severe flatulence, the muscles of the limbs are rigid. There is a sharp decrease in muscle mass.

The curve of weight gain is negative, the patient is losing weight every day. Body weight is 30% or more less than the average in children of the corresponding height. The child sharply lags behind in growth. With secondary malnutrition of the III degree, the clinical picture is less severe than with primary ones, they are easier to treat if the underlying disease is identified and there is an opportunity to actively influence it.
Options for the course of malnutrition

Intrauterine malnutrition - currently, according to the International Classification of Diseases, this term has been replaced by intrauterine growth retardation (). There are hypotrophic, hypoplastic and dysplastic variants. In the English literature, instead of the term "hypotrophic variant of IUGR", the term "asymmetric" is used, and the hypoplastic and dysplastic variants are combined with the term "symmetrical IUGR".

Hypostatura (Greek hypo - under, below; statura - growth, size)

More or less uniform lag of the child in height and body weight with a slightly reduced state of fatness and skin turgor. Both indices of L.I. Chulitskaya (fatness and axial) are slightly reduced. This form of chronic eating disorder is typical for children with congenital heart defects, brain malformations, encephalopathies, endocrine pathology, and bronchopulmonary dysplasia (BPD). That this is a form of chronic eating disorder is confirmed by the fact that PBP is reduced, and after active treatment of the underlying disease, for example, surgery for congenital heart disease, the physical development of children is normal. As a rule, children with hypostature have other signs of chronic malnutrition that are characteristic of grade II malnutrition (trophic disorders and moderate signs of polyhypovitaminosis on the skin, dysproteinemia, deterioration in fat absorption in the intestine, low levels of phospholipids, chylomicrons and a-lipoproteins in the blood, aminoaciduria).

It is important to emphasize that the biological age of the child (bone, etc.) corresponds to its length and body weight. Unlike children with hypostature, children with hypoplasty (with constitutional growth retardation) do not have trophic disorders: they have pink velvety skin, there are no symptoms of hypovitaminosis, they have good muscle tone, their neuropsychic development corresponds to age, food tolerance and not violated. After eliminating the cause of hypostatura, children catch up with their peers in terms of physical development. The same situation is with hypoplastics, that is, the phenomenon of “canalization” of growth or homeoresis according to Waddington sets in. These terms denote the ability of an organism to return to a given genetic development program in cases where the traditional dynamics of child growth was disturbed under the influence of either damaging environmental factors or diseases.

Hypostatura is usually a pathology of children in the second half of the year or the second year of life, but, unfortunately, now there are children with hypostature already in the first months of life. These are children with bronchopulmonary dysplasia, severe brain damage due to intrauterine infections, alcoholic fetopathy, "industrial syndrome" of the fetus. Such children are very resistant to therapy and they do not have the phenomenon of "canalization". On the other hand, hypostature must be differentiated from primordial dwarfism (birth weight and length are very low), as well as other forms of growth retardation, which should be read about in the chapter "Endocrine Diseases".

Kwashiorkor

A peculiar variant of the course of malnutrition in young children in tropical countries, due to eating mainly plant foods, with a deficiency of animal proteins. The term is thought to mean "weaned" (usually due to the mother's next pregnancy). At the same time, protein deficiency can also contribute to (or even cause it):

1) a decrease in protein absorption in conditions accompanied by prolonged diarrhea;

2) excessive loss of protein during (), infectious diseases and helminthiases, burns, large blood loss;

3) decreased protein synthesis in chronic liver diseases.

Symptoms

Common symptoms of kwashiorkor are:

1) neuropsychiatric disorders (apathy, lethargy, drowsiness, lethargy, tearfulness, lack of appetite, psychomotor development lag);

2) edema (at the beginning, due to hypoproteinemia, the internal organs “swell”, then edema may appear on the limbs, face, which creates a false impression of the child’s fatness);

3) a decrease in muscle mass, up to muscle atrophy, and a decrease in tissue trophism;

4) lag of physical development (to a greater extent of growth than body weight).

These symptoms are called D. B. Jelliff's tetrad.

Common symptoms: hair changes (lightening, softening - silkiness, straightening, thinning, weakening of the roots, leading to hair loss, hair becomes sparse), (darkening of the skin appears in areas of irritation, but unlike pellagra, in areas not exposed to sunlight, then desquamation of the epithelium occurs in these areas and foci of depigmentation remain, which can be generalized) and signs of hypovitaminosis on the skin, anorexia, moon face, anemia, diarrhea. In older children, the manifestation of kwashiorkor may be a gray strand of hair or
vanishing of normal hair color and discolored ("flag symptom"), changes in nails.

Rare symptoms: layered-pigmented dermatosis (red-brown patches of skin of a rounded shape), hepatomegaly (due to fatty infiltration of the liver), eczematous lesions and skin cracks, ecchymoses and petechiae. All children with kwashiorkor have signs of polyhypovitaminosis (A, B, B2, Bc, D, etc.), kidney function (both filtration and reabsorption) is reduced, hypoproteinemia in blood serum (due to hypoalbuminemia), hypoglycemia ( but the glucose tolerance test has a diabetic type), aminoaciduria, but with a decrease in the excretion of hydroxyproline in relation to creatinine, low activity of liver and pancreatic enzymes.

Characteristic in the analysis of blood is not only anemia, but also lymphocytopenia, increased ESR. In all sick children, it is significantly reduced, which leads to a severe course of infectious diseases. It is especially difficult for them, therefore, in the complex therapy of measles, the expert committee recommends that such children be prescribed vitamin A, which leads to a decrease in mortality. They often have subcutaneous septic ulcers, leading to the formation of deep necrotic ulcers. All patients also have intermittent diarrhea with foul-smelling stools and severe steatorrhea. Often in such children and (for example, ankylostomiasis, etc.).

In conclusion, we emphasize that protein-calorie malnutrition, that is, can also exist in Russia - for example, we observed it in a teenager with chronic active hepatitis.

Insanity alimentary (exhaustion)

It occurs in children of preschool and school age - balanced starvation with a deficit in the daily diet of both protein and calories. The constant symptoms of insanity are a lack of mass (below 60% of the standard body weight for age), wasting of muscles and subcutaneous fat, which makes the hands of patients very thin, and the face "senile". Rare symptoms of marasmus are hair changes, concomitant vitamin deficiency (often a deficiency of vitamins A, group B), zinc deficiency, thrush, diarrhea, recurrent infections.

Trophic status assessment

To assess the trophic status of schoolchildren, you can use the criteria (with some reductions) proposed for adults [Rudman D., 1993]:

Anamnesis. Previous dynamics of body weight.

Typical dietary intake based on retrospective data.

Socio-economic status of the family.

Anorexia, vomiting, diarrhea.
In adolescents, assessment of puberty, in particular in adolescent girls, assessment of menstrual status.

Drug therapy with an assessment of the possible impact on nutritional status (in particular, diuretics, anorexants).

Social adaptation among peers, family, possible signs of psychogenic stress, anorexia, drug addiction and substance abuse, etc.

physical data.

Skin: pallor, scaly, xerosis, follicular hyperkeratosis, pellagrozny, petechiae, ecchymosis, perifollicular hemorrhages.

Hair: dispigmentation, thinning, straightening, weakening of the hair roots, sparse hair.

Head: rapid emaciation of the face (specify from photographs), enlargement of the parotid glands.

Eyes: Bitot's plaques, angular inflammation of the eyelids, xerosis of the conjunctiva and sclera, keratomalacia, corneal vascularization.

Oral cavity: cheilosis, angular stomatitis, glossitis, hunter's glossitis, atrophy of the papillae of the tongue, ulceration of the tongue, loosening of the gums, dentition of the teeth.

Heart: cardiomegaly, signs of energy-dynamic or congestive heart failure.

Abdominal cavity: protruding abdomen, hepatomegaly.

Extremities: obvious decrease in muscle mass, peripheral edema, koilonychia.

Neurological status: weakness, irritability, tearfulness, muscle weakness, calf tenderness, loss of deep tendon reflexes.

Functional indicators: reduced cognitive ability and performance.

Adaptation of vision to the dark, sharpness of taste (reduced).

Fragility of capillaries (increased).

In the presence of the above symptoms and a weight deficit of 20-35% (along the body length), a moderate degree of protein-calorie deficiency, alimentary depletion is diagnosed.

In the etiology of moderate forms of malnutrition in children and adolescents, chronic stress, excessive neuropsychic stress, neuroses leading to excessive emotional arousal, and insufficient sleep can be of decisive importance. In adolescence, girls often limit their diet for aesthetic reasons. Malnutrition is also possible due to family poverty. According to radio and television reports, every fifth conscript to the Russian army
in 1996-1997 had a body mass deficit in length exceeding 20%. Common symptoms of mild protein malnutrition are lethargy, fatigue, weakness, restlessness, irritability, constipation, or loose stools. Undernourished children have a shortened attention span and do poorly in school. Characteristic for such young men and women are pallor of the skin and mucous membranes (deficiency anemia), muscle weakness - the shoulders are lowered, the chest is flattened, but the stomach protrudes (the so-called “tired posture”), “sluggish posture”, frequent respiratory and other infections, some delayed puberty, caries. In the treatment of such children, in addition to the normalization of the diet and a long course of vitamin therapy, an individual approach is required in the recommendations on the daily routine and lifestyle in general.

Essential fatty acid deficiency

Feeding formulas from cow's milk that are not adapted for baby food, malabsorption of fats can lead to a syndrome of insufficiency of linoleic and linolenic acid: dryness and flaking of the skin, alopecia, small gains in body weight and length, poor wound healing, thrombocytopenia, diarrhea, recurrent skin infections, lungs; linolenic acid: numbness, paresthesia, weakness, blurred vision. Treatment: adding vegetable oils to the diet (up to 30% of the need for fat), nucleotides, which are abundant in women's milk and few in cow's milk.

Carnitine deficiency can be hereditary (9 known hereditary anomalies with a violation of its metabolism) or acquired (deep prematurity and prolonged parenteral nutrition, prolonged hypoxia with myocardial damage). Clinically manifested, in addition to malnutrition, repeated vomiting, enlargement of the heart and liver, myopathy, attacks of hypoglycemia, stupor, coma. This disease in the family is often preceded by the sudden death of previous children or their death after episodes of acute encephalopathy, vomiting with the development of a coma. A typical symptom is a specific smell emanating from the child (the smell of sweaty feet, cheese, rancid butter). Treatment with riboflavin (10 mg every 6 hours intravenously) and carnitine chloride (100 mg/kg orally in 4 doses) leads to the normalization of the condition of children.

Deficiencies of vitamins and trace elements are described in other sections of the chapter.

Diagnosis and differential diagnosis

The main criterion for diagnosing malnutrition and establishing its degree is the thickness of the subcutaneous fat layer. The criteria for diagnosis are detailed in Table. 29. The body weight of the child must also be taken into account,
but not in the first place, since with the simultaneous lag of the child in growth (hyposomia, hypostatura), it is rather difficult to establish the true deficiency of body weight.

The chair in a child with malnutrition is more often "hungry"

Hungry stools are scanty, dry, discolored, lumpy, with a putrid, offensive odor. Urine smells like ammonia. A hungry stool quickly turns into a dyspeptic one, which is characterized by a green color, an abundance of mucus, leukocytes, extracellular starch, digestible fiber, fatty acids, neutral fat, and sometimes muscle fibers. At the same time, dyspeptic phenomena are often caused by the ascent of Escherichia coli into the upper intestines and an increase in its motility or infection with its pathogenic strains, dysbacteriosis.

In the differential diagnosis of malnutrition, one must keep in mind all those diseases that can be complicated by chronic malnutrition and are listed in the "Etiology" section.

In a patient with hypostatura, it is necessary to exclude various types of dwarfism - disproportionate (chondrodystrophy, congenital fragility of bones, vitamin D-resistant forms of rickets, severe vitamin D-dependent) and proportional (primordial, pituitary, thyroid, cerebral, cardiac, etc.). We must not forget about constitutional hyposomia (hypoplasty).

In some families, due to various hereditary characteristics of the endocrine system, there is a tendency towards lower growth rates. Such children are proportional: with some lag in growth and body weight, the thickness of the subcutaneous fat layer is normal everywhere, tissue turgor is good, the skin is pink, velvety, without signs of hypovitaminosis. Muscle tone and psychomotor development of children are age appropriate.

It is believed that in a healthy child, the body length can vary within 1.5 s from the arithmetic mean body length of healthy children of the corresponding age. If the length of the child's body goes beyond the specified limits, then they speak of hyper- or hyposomy. Hyposomia within 1.5-2.5 s can be both a variant of the norm and a consequence of a pathological condition. With a child's body length less than the average value minus 3 s, nanism is diagnosed.

Hypotrophy can develop in a child both with normosomy and with hyper- and hyposomia. Therefore, permissible fluctuations in body length in children of the first six months of life are considered 4-5 cm, and later up to 3 years - 5-6 cm; permissible fluctuations in body weight in the first half of the year - 0.8 kg, and later up to 3 years - 1.5 kg (in relation to the arithmetic mean body length of the child).

Treatment

In patients with malnutrition, therapy should be complex and include:

1) identification of the causes of malnutrition and attempts to correct or eliminate them;

2) diet therapy;

3) organization of a rational regimen, care, education, massage and gymnastics;

4) detection and treatment of foci of infection, rickets, anemia and other complications and concomitant diseases;

5) enzyme and vitamin therapy, stimulating and symptomatic treatment.

diet therapy

The basis of rational treatment of patients with malnutrition. The degree of reduction in body weight and appetite does not always correspond to the severity of malnutrition due to damage to the gastrointestinal tract and central nervous system.

Therefore, the fundamental principles of diet therapy for malnutrition are three-phase nutrition:

1) the period of clarification of tolerance to food;

2) transitional period;

3) a period of enhanced (optimal) nutrition.

A large food load, introduced early and abruptly, can cause a breakdown in the patient, dyspepsia due to insufficient capacity of the gastrointestinal tract to utilize nutrients (in the intestine, the total pool of epithelial cells and the rate of restorative proliferation are reduced, the rate of migration of epithelial cells from crypts to the villus is slowed down , reduced activity of intestinal enzymes and absorption rate).

Sometimes a patient with malnutrition, exhaustion with excess nutrition does not have an increase in the weight gain curve, and a decrease in calorie content leads to its increase. During all periods of diet therapy, an increase in the food load should be carried out gradually under the regular control of the coprogram.

The following important principles of diet therapy in patients with malnutrition are:

1) the use of only easily digestible food at the initial stages of treatment (women's milk, and in the absence of its hydrolyzed mixtures (Alfare, Pepti-Junior, etc.) - adapted mixtures, preferably fermented milk: acidophilic "Baby", "Kid", "Lactofidus" , "Biolakt", "Bifilin", etc.), since in patients with malnutrition often
there is intestinal dysbacteriosis, insufficiency of intestinal lactase;

2) more frequent feedings (7 - with hypotrophy of the I degree, 8 - with hypotrophy of the II degree, 10 feedings with hypotrophy of the III degree);

3) adequate systematic monitoring of nutrition (keeping a diary with notes on the amount of food eaten at each feeding), stool, diuresis, the amount of fluid drunk and administered parenterally, salt, etc .; regular, every 5-7 days, calculation of the food load for proteins, fats, carbohydrates; twice a week - coprogram).

The period for determining food tolerance in malnutrition of I degree is usually 1-2 days, II degree - about 3-7 days and III degree - 10-14 days. Sometimes a child does not tolerate lactose or cow's milk proteins well. In these cases, you have to resort to lactose-free mixtures or "vegetable" types of milk.

It is important to remember that from the very first day of treatment, the child should receive the amount of fluid corresponding to the actual weight of his body (see Table 27). The daily volume of the milk mixture used on the first day of treatment is usually given: with malnutrition of the I degree, approximately 2/3, malnutrition of the II degree - '/2 and hypotrophy of the III degree - '/3 of the proper body weight. In this case, the calorie content is: with malnutrition of the I degree - 100-105 kcal / kg per day; II degree - 75-80 kcal / kg per day; III degree - 60 kcal / kg per day, and the amount of protein, respectively - 2 g / kg per day; 1.5 g/kg per day; 0.6-0.7 g / kg per day. It is necessary that from the very first day of treatment the child does not lose body weight, and from the 3-4th day, even with severe degrees of malnutrition, he begins to add 10-20 or more grams per day. The missing amount of fluid is administered enterally in the form of glucose-salt solutions (oralite, rehydron, citroglucosolan, worse - vegetable decoctions, raisin drink, etc.). In the absence of commercial preparations for rehydration, a mixture of 400 ml of 5% glucose solution, 400 ml of isotonic solution, 20 ml of 7% potassium chloride solution, 50 ml of 5% sodium bicarbonate solution can be used. To increase the effectiveness of such a mixture, 100 ml of an amino acid mixture for parenteral nutrition (10% aminone or aminoven, alvesin) can be added to it.

Especially if the child has diarrhea, it must be remembered that all mixtures and solutions given orally have a low osmolarity (approximately 300-340 mOsm / l). Rarely (with severe diarrhea, vomiting, obstruction of the gastrointestinal tract), it is necessary to use parenteral nutrition. At the same time, it must be remembered that the daily amount of potassium (both with enteral and parenteral nutrition) should be 4 mmol / kg (that is, 1-1.5 times higher than normal), and sodium should not be more
more than 2-2.5 mmol / kg, because patients easily retain sodium, and they always have a potassium deficiency. Potassium "additives" give about 2 weeks. Correction of solutions with preparations of calcium, phosphorus, magnesium is also advisable.

Restoring the normal volume of circulating blood, maintaining and correcting disturbed electrolyte metabolism, and stimulating protein synthesis are the tasks of the first two days of therapy for severe malnutrition. With parenteral nutrition, solutions of amino acids (aminoven, etc.) must also be added. During the period of clarification of tolerance to food, gradually (about 10-20 ml per feeding daily) increase the amount of the main mixture, bringing it at the end of the period to the proper amount for the actual body weight (in the first year of life, about 1/5 of the actual weight, but no more 1 l).

Interim period.

At this time, therapeutic formulas are added to the main mixture (up to 1/3 of the total volume), that is, those mixtures in which there are more food ingredients compared to breast milk or adapted mixtures, reduce the number of feedings, bring the volume and ingredients of the food to , which the child would receive for the due body weight. An increase in the food load with proteins, carbohydrates and, last but not least, fats, should be carried out under the control of its calculation (the amount of proteins, fats and carbohydrates per 1 kg of body weight per day in the food eaten) and under the control of coprograms (1 time in 3-4 days ). An increase in the amount of proteins is achieved by adding protein mixtures and products (protein enpit, fat-free kefir, kefir 5, cottage cheese, yolk, etc.); carbohydrates (including sugar syrup, cereals); fat (fat enpit, cream). 100 g of dry protein enpit contains 47.2 g of protein, 13.5 g of fat, 27.9 g of carbohydrates and 415 kcal.

After its correct dilution (15 g per 100 g of water), 100 g of the liquid mixture will respectively contain 7.08 g of proteins, 2.03 g of fats, 4.19 g of carbohydrates and 62.2 kcal. Diluted in the same way, 15% fat enpit will contain in 100 g: proteins - 2.94 g, fats - 5.85 g, carbohydrates - 4.97 g and 83.1 kcal. The criterion for the effectiveness of dietary treatment are: improvement in emotional tone, normalization of appetite, improvement in the condition of the skin and tissue turgor, daily weight gain by 25-30 g, normalization of the L. I. Chulitskaya index (fatness) and restoration of lost psychomotor development skills along with the acquisition of new ones. , improved digestion of food (according to the co-program).

It should be borne in mind that the optimal ratio between food protein and energy for protein utilization at the initial stage is: 1 g of protein per 150 non-protein kilocalories, and therefore, simultaneously with the protein load, it is necessary to increase the amount of carbohydrates, because patients with eating disorders increase the fat load endure badly.

Already in the transitional period, children begin to introduce complementary foods (if it is necessary for their age and they received them before the start of treatment), but cereals and vegetable purees are prepared not on whole, but on half cow's milk or even on vegetable broth to reduce the load of lactose and fats. The load of carbohydrates during the transitional period reaches 14-16 g/kg per day, and after that they begin to increase the load of fats, using whole kefir, bifilin, porridge additives of yolk, vegetable oil, fatty enpit.

During the period of enhanced nutrition, the child receives about 140-160 kcal/kg per day with hypotrophy of the I degree, about 160-180-200 kcal/kg per day for the P-III degree. At the same time, proteins make up 10-15% of calories (in healthy people 7-9%), that is, about 3.5-4 g / kg of body weight. Large amounts of protein are not absorbed, and therefore useless, in addition, they can contribute to metabolic acidosis, hepatomegaly. In the initial period of enhanced protein nutrition, a child may experience transient tubular distal acidosis (in children with constipation, Litwood's syndrome increases), sweating. In this case, a sodium bicarbonate solution is prescribed at a dose of 2-3 mmol / kg per day orally, although it is necessary to think about reducing the protein load.

The main criterion for the effectiveness of diet therapy are: improvement of psychomotor and nutritional status and metabolic indicators, achievement of regular weight gain of 25-30 g / day, and not calculated diet indicators

The above is a scheme for the treatment of patients with malnutrition with the help of a diet. However, for each sick child, an individual approach to diet and its expansion is required, which is carried out under the mandatory control of the coprogram, body weight curves and sugar curves. The body weight curve during the treatment of a patient with malnutrition can be stepped: the rise corresponds to the deposition of nutrients in the tissues (deposition curve), the flat part corresponds to their assimilation (assimilation curve).

Care organization.

Patients with malnutrition I degree in the absence of severe concomitant diseases and complications can be treated at home. Children with malnutrition II and III degree must be placed in a hospital with their mother. The patient should be in a bright, spacious, regularly ventilated room. The air temperature in the ward should not be lower than 24-25 °C, but not higher than 26-27 °C, as the child easily cools down and overheats. In the absence of contraindications to walking (high temperature, otitis media), you should walk several times a day at an air temperature of at least -5 ° C. At lower air temperatures, a walk on the veranda is organized. In autumn and winter, when walking, they put a heating pad at their feet. It is very important to create a positive tone in the child - to take him in your arms more often (prevention of hypostatic pneumonia). Attention should be paid to the prevention of cross-infection - place
the patient in isolated boxes, regularly irradiate the ward or box with a bactericidal lamp. A positive effect on the course of malnutrition is provided by warm baths (water temperature 38 ° C), which, in the absence of contraindications, should be carried out daily. Mandatory in the treatment of children with malnutrition are massage and gymnastics.

Identification of foci of infection and their sanitation is a necessary condition for the successful treatment of patients with malnutrition. To fight the infection, they prescribe (do not use nephro-, hepato- and ototoxic!), physiotherapy, and, if necessary, surgical treatment.

Correction of dysbacteriosis.

Given that almost all patients with malnutrition have dysbacteriosis, it is advisable to provide a course of bifidumbacterin or bificol within 3 weeks in the complex of therapeutic measures.

Enzyme therapy is widely used as a temporary substitution in the treatment of patients with malnutrition, especially during the period of clarification of food tolerance. For this purpose, abomin, gastric juice diluted with water, festal, mezim, etc. are used. If the coprogram shows an abundance of neutral fat and fatty acids, then additionally creon, panzinorm, pancitrate, etc. are prescribed.

Vitamin therapy is an integral part of the treatment of a patient with malnutrition, and vitamins are first administered parenterally, and later - per os. In the first days, vitamins C, B, B6 are used. The initial dose of vitamin B6 is 50 mg per day. The dose and duration of treatment with vitamin B6 is best determined by the reaction of urine to xanthurenic acid (with ferric chloride). A positive reaction indicates a deficiency in the body of vitamin B6. In the 2nd-3rd periods of malnutrition treatment, alternating courses of vitamins A, PP, B15, B5, E, folic acid, B12 are carried out.

Stimulating therapy consists in prescribing alternating courses of apilac, dibazol, pentoxyl, metacil, ginseng, pantocrine and other agents. In severe malnutrition with layering of infection, intravenous immunoglobulin is administered. As a stimulating therapy, you can also use a 20% solution of carnitine chloride, 1 drop per 1 kg of body weight 3 times a day inside (dilute with boiled water). For this purpose, blood and plasma transfusions should not be used, anabolic steroids (Nerobol, Retabolil, etc.), glucocorticoids should not be prescribed.

Symptomatic therapy depends on the clinical picture of malnutrition. In the treatment of anemia, it is advisable to use folic acid, iron preparations (if they are poorly tolerated, iron preparations are administered parenterally), and with hemoglobin less than 70 g / l, erythrocyte mass is transfused or washed. With malnutrition of the first degree in excited children, mild sedatives are prescribed.
All children with malnutrition pathogenetically have and, which manifests itself as symptoms of osteoid tissue hyperplasia only during a period of enhanced nutrition and an increase in body weight gain, therefore, after the end of the period of clarification of food tolerance, UVR is prescribed. Therapy of symptomatic malnutrition, along with diet therapy and other types of treatment, should first of all be directed to the underlying disease.

Treatment of malnutrition in different children should be differentiated. The doctor requires perseverance, an integrated approach to the patient, taking into account his individual characteristics. It is rightly said that patients with malnutrition are not cured, but nursed.

Forecast

It depends primarily on the cause that led to malnutrition, the possibilities of its elimination, the presence of concomitant and complicating diseases, the age of the patient, the nature, care and environmental conditions, the degree of malnutrition. With alimentary and alimentary-infectious malnutrition, the prognosis is usually favorable.

Prevention

Natural, early detection and rational treatment of hypogalactia, proper nutrition with its expansion in accordance with age, sufficient fortification of food, organization of age-appropriate care and regimen, and prevention of rickets are important. Early diagnosis and proper treatment of rickets, anemia, infectious diseases of the respiratory system, gastrointestinal tract, kidneys, and endocrine diseases are of great importance. An important element in the prevention of malnutrition are also measures aimed at antenatal protection of the health of the fetus.

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.