Hypotrophy. Dietary correction of malnutrition Calculation of nutrition for children with malnutrition

For children in the first months of life suffering from malnutrition, women's milk - the most optimal nutrition. Use in the absence of breast milk adapted milk formulas, better sour-milk options. During treatment children with malnutrition it is important not to delay the introduction of complementary foods, and in some cases some of its types should be given a little earlier than healthy ones.

To enrich the diet child high-grade protein is currently used by new dietary products, which are dry nutritional mixtures prepared on the basis of easily digestible milk proteins. These mixtures are enriched with fats, carbohydrates, a wide range of vitamins, essential minerals.

* - The composition depends on the method of preparation of the mixture.

** - When choosing a mixture, the genesis of malnutrition is necessarily taken into account.

Local pediatrician. Preventive medical care / N. L. Black

In Russia, for many years, the term malnutrition was generally accepted, which is synonymous with protein-energy insufficiency.

Protein-energy insufficiency (PEM) is a alimentary-dependent condition caused by protein and/or energy starvation of sufficient duration and/or intensity, manifested by a lack of body weight and/or growth and a complex disruption of the body's homeostasis in the form of a change in the main metabolic processes, water -electrolyte imbalance, changes in body composition, disorders of nervous regulation, endocrine imbalance, suppression of the immune system, dysfunction of the gastrointestinal tract and other organs and systems.

PEI may develop under the influence of endogenous or exogenous factors

Protein-energy deficiency is manifested not only by weight loss, but also by hypovitaminosis, deficiency of many essential microelements responsible for the implementation of immune functions, optimal growth, and brain development. Therefore, long-term malnutrition is often accompanied by a lag in psychomotor development, a delay in speech and cognitive skills and functions, a high infectious morbidity due to a decrease in immunity, which in turn exacerbates eating disorders.

There are 2 main forms: acute, manifested by a predominant loss of body weight and its deficiency in relation to the proper body weight for growth, and chronic, manifested not only by a lack of body weight, but also by a significant delay in physical development. Both forms have 3 degrees of severity: mild, moderate and severe.

Diagnostics

Clinical and laboratory methods are used to detect malnutrition in children.

Dietary correction of protein-energy malnutrition

Basic rules for the organization of clinical nutrition in PEU:

• Elimination of factors causing starvation;
• Treatment of the underlying disease;
• Optimal diet therapy: it is necessary to strive to meet the age-related needs of the child in basic nutrients, energy, macro- and micronutrients by gradually increasing the food load, taking into account the child's tolerance to food. In severe degrees of PEI (II-III stage), the principle of two-phase nutrition is applied: the period of clarification of food tolerance and the period of transitional and optimal nutrition. At the first stages, they resort to "rejuvenation" of the diet - they use women's milk or adapted milk mixtures, increase the frequency of feedings to 7-10 per day; in the most severe cases, continuous tube enteral nutrition is used in combination with partial parenteral nutrition. Unreasonable displacement of human milk or adapted milk formulas by complementary foods should be avoided; consistently introduce complementary foods, gradually increasing their volume; use industrial complementary foods;
• Organization of regimen, care, massage, exercise therapy;
• Stimulation of reduced body defenses;
• Treatment of concomitant diseases and complications.

With PEI of the 1st degree

it is necessary to establish a general regimen, care for the child, and eliminate feeding defects.

When prescribing nutrition, preference should be given to breast milk, and with mixed and artificial feeding - to adapted milk formulas enriched with probiotics, galacto- and fructo-oligosaccharides, which favorably affect the digestive processes and normalize the composition of the intestinal microflora; nucleotides that improve the absorption of nutrients and stimulate the child's immune system, as well as fermented milk mixtures and products in an amount of not more than 1/2 of the total feeding volume.

Non-adapted fermented milk products (kefir, etc.) should not be prescribed to children earlier than 8-9 months of age. To increase the energy value of the diet and increase the protein quota, it is possible to prescribe dishes and complementary foods (cereals, vegetable and meat purees, cottage cheese) 2 weeks earlier than healthy children. With PEI of the 1st degree, calculations and correction of nutrition are carried out on the due body weight, which consists of body weight at birth and the sum of its normal increases over the lived period.

With PEI II degree

dietary correction is conditionally divided into three periods: the adaptation period (determination of food tolerance), the reparation period (intermediate) and the period of enhanced nutrition.

During the adaptation period, which lasts 2-5 days, nutrition is calculated based on the actual body weight in accordance with the physiological needs of the child for basic nutrients and energy. The number of feedings is increased by 1-2 per day with a corresponding decrease in the volume of each feeding, additional liquid is introduced (5% glucose or saline solutions for oral rehydration). During this period, it is preferable to use women's milk, with its lack or absence - adapted infant formula enriched with probiotics, oligosaccharides and nucleotides. It is possible to use mixtures with a higher protein content, for example, specialized milk formulas for premature babies. If violations of the breakdown / absorption of food ingredients are detected, it is advisable to use therapeutic products (for example, low-lactose mixtures for lactase deficiency, mixtures with an increased quota of medium-chain triglycerides for malabsorption of fats). In the absence of effect, mixtures based on highly hydrolyzed milk protein should be prescribed.
With normal tolerance of the prescribed nutrition, gradually (within 5-7 days) increase the volume of feedings to the physiological norm. With sufficient rates of weight gain and the absence of dyspeptic phenomena, the calculation of nutrition can be carried out on the proper body weight, first carbohydrate and protein, and only lastly - the fat component of the diet.

In the period of reparation, it is possible to introduce complementary foods, starting with cereals of industrial production, followed by the introduction of meat, cottage cheese, and yolk. During this period, it is recommended to prescribe enzyme preparations, multivitamin complexes and agents that have a positive effect on metabolic processes.

Throughout the treatment of children with PEU, it is necessary to systematically record the actual nutrition with the calculation of the chemical composition of the daily diet for the main food nutrients.

With PEI III degree

all types of metabolism are sharply disturbed, the child's condition, as a rule, is very difficult, therefore, such children need intensive care, the use of enteral and parenteral nutrition, which requires inpatient treatment. PEI of the III degree, caused by an alimentary factor, occurs in Russia in exceptional cases, because. the main disorders in the child's nutrition are detected early and the necessary dietary correction of the diet of these children is carried out even with I-II degree of PEI.

Parenteral nutrition of the initial period should be carried out gradually, using only amino acid preparations and glucose solutions in the initial period. Fat emulsions in PEU are added to parenteral nutrition programs only 5-7 days after the start of therapy due to their insufficient absorption and high risk of side effects and complications. Parenteral nutrition in PEU should be balanced and minimal due to the risk of developing severe metabolic complications.

In parallel, parenteral correction of dehydration, violations of K.SchS (as a rule, acidosis) and electrolyte disorders is carried out.

The most justified type of enteral nutrition in severe forms of PEU is continuous enteral tube feeding, which consists in the continuous slow supply of nutrients to the gastrointestinal tract (stomach, duodenum, jejunum - drip, optimally - using an infusion pump). The constant slow introduction of specialized products is justified as much as possible, since the energy consumption for the digestion and absorption of nutrients under these conditions is much lower than with a bolus of the nutrient mixture. At the same time, abdominal digestion improves and the absorption capacity of the intestine gradually increases. Long-term enteral tube feeding normalizes the motility of the upper gastrointestinal tract. The protein component in such nutrition modulates the secretory and acid-forming function of the stomach, maintains adequate exocrine pancreatic function and secretion of cholecystokinin, ensures normal motility of the biliary system and prevents the development of complications such as biliary sludge and cholelithiasis. Protein entering the jejunum modulates the secretion of chemotrypsin and lipase.

The rate of entry of the nutrient mixture into the gastrointestinal tract should not exceed 3 ml / min, the caloric load should not exceed 1 kcal / ml, and the osmolarity should not exceed 350 mosmol / l. For enteral nutrition in young children, specialized products should be used. The most justified is the use of mixtures based on highly hydrolyzed milk protein, lactose-free, enriched with medium chain triglycerides (Alfare, Nutrilon Pepti TSC, Nutrilac Peptidi SCT, Pregestimil). They provide maximum absorption of nutrients in conditions of significant inhibition of the digestive and absorption capacity of the digestive canal (Table 28).

The increase in the concentration of the injected mixture is carried out slowly, increasing by 1% per day (Table 29).
Then gradually bring the concentration of the mixture to 13.5% (physiological), and with good tolerance - up to 15%. Missing calories, nutrients and electrolytes during the period of use of the formula in low concentration are compensated by parenteral nutrition.
When conducting permanent enteral tube feeding, all asepsis rules must be observed. Sterility of nutrient solutions is possible only when using ready-made liquid nutrient mixtures.

The duration of the period of constant enteral tube feeding varies from several days to several weeks, depending on the severity of impaired food tolerance (anorexia, vomiting, diarrhea). A gradual increase in calorie content and a change in the composition of food is carried out, a gradual transition to a bolus of the nutrient mixture is carried out at 7-10 daily feedings. With the improvement of the condition and appetite, the appearance of significant weight gain, a complete abolition of constant tube feeding is performed. Next, diet therapy is carried out, as in children with milder PEI, the main principles of which are food rejuvenation and phasing with the allocation of adaptive, reparative (intermediate) and enhanced stages of nutrition.

At this time, adaptation to the required volume is carried out and the correction of water-mineral and protein metabolism continues. At the same time, the child is given food often and in small portions, gradually increasing them (Table 30). The missing amount of food is replenished by ingestion of rehydration solutions.

During the reparation period, proteins, fats and carbohydrates are corrected, which leads to an increase in energy load (enhanced nutrition). The required daily amount of food for a child with PEU should eventually be about 200 ml/kg, or 1/5 of the actual weight. At the same time, the energy and protein load on the actual body weight is greater than in healthy children. This is due to a significant increase in energy expenditure in children during convalescence with PEU.

In the future, the child's diet approaches normal parameters due to the expansion of the range of products, the composition of the mixtures used changes. With good tolerance at the stage of enhanced nutrition, high-calorie nutrition (130-200 kcal / kg / day) is provided, with a high content of nutrients, but not more than: proteins - 5 g / kg / day, fats - 6.5 g / kg / day ., carbohydrates - 14-16 g / kg / day. The average duration of the stage of enhanced nutrition is 1.5-2 months.

The main indicator of the adequacy of diet therapy is weight gain. An increase is considered good if it exceeds 10 g / kg / day, average - 5-10 g / kg / day. and low - less than 5 g / kg / day.

Possible reasons for poor weight gain are: inadequate nutrition (incorrect nutrition calculation, restriction on the frequency or volume of nutrition, non-compliance with the rules for preparing nutrient mixtures, lack of nutrition correction, lack of child care), micronutrient deficiency, current infectious process, mental problems (rumination, inducing vomiting).

Drug therapy for PEU III degree

In addition to drug (parenteral) correction of dehydration and electrolyte disorders, in the acute period, it is necessary to remember the need for timely diagnosis of possible adrenal insufficiency.

Starting from the period of adaptation, enzyme replacement therapy with pancreatic preparations is advisable. Preference is given to microencapsulated preparations (Creon). With intestinal dysbacteriosis, repeated courses of antibiotic therapy, biological preparations are used.

The use of anabolic drugs in PEU is carried out with caution, because in conditions of nutrient deficiency, their use can cause profound disorders of protein and other types of metabolism, inhibition of parietal digestion enzymes. The use of vitamin therapy with a stimulating and replacement purpose is shown. In severe forms of PEU, vitamins are prescribed parenterally.

Treatment of rickets, iron deficiency anemia is carried out starting from the period of reparation.

Indications for stimulating and immunotherapy are determined individually. During the height of PEU, preference should be given to passive immunotherapy - native plasma and immunoglobulins. During the period of convalescence, non-specific immunostimulants diabazol, methyluracil, and biostimulants such as apilac, adaptagens can be prescribed.

Tactics of management of patients with PEU III degree

In 2003, WHO experts developed and published recommendations for the management of children with PEU, which regulate the main activities for nursing children with severe malnutrition. These recommendations should be used in the treatment of children with severe forms of alimentary PEU.

10 main steps have been identified:

1. prevention/treatment of hypoglycemia,
2. prevention/treatment of hypothermia,
3. prevention/treatment of dehydration,
4. correction of electrolyte imbalance,
5. prevention/treatment of infection,
6. correction of micronutrient deficiencies,
7. careful start of feeding,
8. providing weight gain and growth,
9. providing sensory stimulation and emotional support,
10. further rehabilitation.

Activities are carried out in stages (Fig. 4), taking into account the severity of the condition of a sick child and begin with the correction and prevention of life-threatening conditions.

The first step is aimed at the treatment and prevention of hypoglycemia and associated possible impairment of consciousness. If the child’s consciousness is not disturbed, but the blood glucose level has decreased to less than 3 mmol / l, then the child is shown a bolus injection of 50 ml of a 10% glucose or sucrose solution (1 teaspoon of sugar per 3.5 tablespoons of water) through the mouth or nasogastric tube. Further, such children are given frequent feeding, every 30 minutes, for 2 hours in the amount of 25% of the volume of the usual one-time feeding, followed by transfer to feeding every 2 hours without a night break. If the child is unconscious, lethargic, or has hypoglycemic convulsions, then such a child should be injected intravenously with a 10% glucose solution at a rate of 5 ml / kg, and then correct glycemia by introducing glucose solutions through a nasogastric tube (10% 50 ml ) or sucrose and transfer to frequent feedings every 30 minutes for 2 hours, and then every 2 hours without a night break. All children with PEU who have impaired serum glucose levels are shown to be given antibiotic therapy with broad-spectrum drugs.

The second step is to prevent and treat hypothermia in children with PEU. If the child's rectal temperature is lower than 35.5 C, then it must be urgently warmed up: dressed in warm clothes and a hat, wrapped in a warm blanket, laid in a heated bed or under a source of radiant heat. Such a child needs to be fed urgently, prescribe a broad-spectrum antibiotic and regularly monitor the level of serum glycemia.

The third step is the treatment and prevention of dehydration. Children with PEU have pronounced disturbances in water and electrolyte metabolism; they may have a low volume of circulating blood even against the background of edema. Due to the risk of rapid decompensation of the condition and the development of acute heart failure in children with PEU, intravenous rehydration should not be used, except in cases of hypovolemic shock and conditions requiring intensive care. The standard saline solution used for rehydration therapy for intestinal infections, and primarily for cholera, cannot be used in children with PEU because of their too high content of sodium ions (90 mmol Na + / n) and insufficient amount of potassium ions . In case of malnutrition, a special solution for rehydration of children with PEU should be used, 1 liter of which contains 45 mmol sodium ions, 40 mmol potassium ions and 3 mmol magnesium ions.

If a child with PEU has clinical signs of dehydration or watery diarrhea, then rehydration therapy is indicated by mouth or nasogastric tube with a similar solution at the rate of 5 ml / kg every 30 minutes for 2 hours, and then 5-10 ml / kg / h in the next 4-10 hours with a replacement at 4, 6, 8 and 10 hours the introduction of a rehydration solution for feeding with formula or mother's milk. Such children should also be fed every 2 hours without a night break. They should be constantly monitored. Every 30 minutes for 2 hours, and then every hour for 12 hours, the frequency of pulse and respiration, the frequency and volume of urination, the frequency and volume of stool and vomiting should be assessed.

The fourth step is aimed at correcting the electrolyte imbalance that children with PEU have. As mentioned above, children with severe PEU have an excess of sodium in the body, even if their serum levels are low. There is a deficiency of potassium and magnesium ions, which requires correction during the first 2 weeks. The edema present in PEU is also associated with an electrolyte imbalance. For their correction, diuretics should not be used, as this can only aggravate existing disorders and cause hypovolemic shock. It is necessary to ensure the regular intake of essential minerals in the body of the child in sufficient quantities. It is recommended to use potassium at a dose of 3-4 mmol / kg / day, magnesium - 0.4-0.6 mmol / kg / day.

The fifth step is the timely treatment and prevention of infectious complications in children with PEU who have secondary combined immunodeficiency.

The sixth step is necessary to correct the micronutrient deficiencies that are present in any form of PEU. This step requires a very balanced approach. Although the incidence of anemia in PEU is quite high, iron supplements are not used in early nursing. Correction of sideropenia is carried out only after stabilization of the condition, the absence of signs of an infectious process, the restoration of the main functions of the gastrointestinal tract, appetite and the presence of a stable weight gain, that is, not earlier than 2 weeks after the start of therapy. Otherwise, this therapy can significantly increase the severity of the condition and worsen the prognosis when the infection is layered. In order to correct the deficiency of micronutrients, it is necessary to ensure the intake of iron at a dose of 3 mg/kg/day, zinc - 2 mg/kg/day, copper - 0.3 mg/kg/day, folic acid - on the first day 5 mg, and then 1 mg / day, followed by the appointment of multivitamin preparations, taking into account individual tolerance.

The seventh and eighth steps involve administering a balanced diet based on the severity of the condition, impaired gastrointestinal function, and food tolerance. Children with severe PEU often require intensive care, the degree of impairment of their metabolic processes and the function of the digestive system is so great that the use of conventional diet therapy is not able to significantly improve their condition. Therefore, in these cases, complex nutritional support is indicated using both enteral and parenteral nutrition.

The ninth step provides for sensory stimulation and emotional support. Children with PEI need good care, affectionate communication between parents and the child, massage, therapeutic exercises, regular water procedures and outdoor walks.

The tenth step provides for a long-term rehabilitation, which includes sufficient nutrition in terms of frequency, volume, content of basic nutrients and energy value, regular medical examinations, adequate immunoprophylaxis, vitamin and mineral correction.

Hypotrophy, especially in young children, most often develops as a result of malnutrition, when the child systematically receives less of any nutrients he needs (most often protein and vitamins). Such malnutrition usually occurs with irrational artificial feeding of children in the first year of life.

In this regard, dystrophic changes occur in the child's body, and they, in turn, lead to disruption of the digestive system: the production of digestive juices decreases, their activity decreases, the digestion and absorption of nutrients are disturbed, the so-called dysbacteriosis (violation of the intestinal microflora) develops. As a result, the child has a stop or even loss of body weight.

Hypotrophy can also develop in a child as a result of previous diseases, especially after acute, pneumonia, and in older children - as a result of chronic diseases of the gastrointestinal tract, bronchopulmonary system and others.

In some cases, malnutrition develops due to malnutrition of the fetus during its intrauterine development (this is the so-called intrauterine malnutrition). And also as a result of birth trauma. Such malnutrition are persistent in nature and their treatment is carried out in stationary conditions.

With malnutrition, proper nutrition is one of the main means of complex treatment. It is built in such a way that the diet of a sick child provides not only his physiological need for basic nutrients, but also corresponds to the individual capabilities of the child's body. After all, with a significant lag in development, the child has the most significant violations in the activity of the digestive organs and he cannot always “cope” with the food load offered to him.

Depending on the degree of body weight deficiency, there are three degrees of malnutrition. With hypotrophy of the I degree, the body weight deficit ranges from 10 to 20 percent. For example, if the body weight of a child aged 11 months is only 8.5 kg at a rate of 10 kg (deficit - 15 percent), then a diagnosis of hypotrophy of the 1st degree is made.

With hypotrophy of the II degree, the body weight deficit is already from 20 to 30 percent (in our example, such a child will weigh only 8 or 7 kg). If the body weight deficit exceeds 30 percent, then this is already degree III hypotrophy.

What are the basic principles of diet therapy for malnutrition?

With hypotrophy of the first degree, which most often occurs as a result of diseases or disorders in the organization of feeding, it is enough to simply establish proper nutrition for the child, streamline the feeding regimen, and make sure that his diet includes a sufficient amount of protein foods and foods rich in vitamins. After such therapy, there is a rapid normalization of the patient's condition and a good rate of weight gain.

Treatment of malnutrition II and III degree (the latter, as a rule, is treated in a hospital) requires much more effort. Here it is especially important to observe an individual approach to the patient, take into account his condition and ability to endure the necessary nutritional load.

With such severe forms of malnutrition, diet therapy is carried out in two stages: at the first stage, the child is prescribed fractional feeding, in which food volumes can be from 1/2 to 2/3 of the volume due to age. But at the same time, be sure to ensure that the child receives a sufficient amount of liquid. At the second stage, a gradual increase in the amount of food to the age-appropriate norm is performed.

Carrying out therapeutic nutrition, the doctor calculates the main nutrients of the patient's diet per 1 kg of his body weight. At the same time, the amount of proteins and carbohydrates is calculated on the basis of age-related physiological norms for the body weight that a child should have by age. If the degree of body weight behind the norm in a child is very large (hypotrophy of the III degree), then these calculations are carried out on an approximately due weight, which is the actual weight + 20 percent. In the example above, if an 11-month-old baby should have a normal (should) body weight of 10 kg, and in fact it is 7 kg, then the approximate weight should be 8.4 kg (7 + 1.4).

Fats in the diet of a child suffering from malnutrition are always calculated only on the real body weight, since their tolerance in such children is sharply reduced.

As the child's condition improves, body weight begins to steadily increase, its deficiency decreases, nutrition gradually approaches the physiological one, which fully meets the age-related need for basic nutrients and energy.

What products are better to use for a child with malnutrition?

For children in the first two months of life, breast milk is the optimal nutrition. In the absence of milk from the mother, one should try to get donor milk at least for the first 2-3 months of the child's life. If there is no donor milk, artificial milk mixtures have to be used. But at the same time, you need to choose only adapted mixtures intended for artificial feeding. These include domestic milk formulas "Baby", "Detolact", "Ladushka", "Aistenok", "Sunshine", as well as imported ones - "Similak" (USA), "Piltti", "Bona" (Finland), "Robolakt "," Linolak "(Hungary),

"Impress" (Germany), "Snow-Brand" (Japan) and others. Diluted milk and mixtures such as B-rice, B-kefir, which, unfortunately, are still quite often prepared in our dairy kitchens, cannot be used to feed children with malnutrition, since these products are very poor in protein and practically devoid of vitamins . With malnutrition in young children, disorders of the gastrointestinal tract are often observed. Therefore, these children are very useful sour-milk products. They improve digestion processes, are well absorbed, and normalize the composition of the intestinal microflora. For children of the first year of life, fermented milk products should be given in the form of adapted mixtures, such as the acidophilic mixture "Baby", "Bifilin", "Bifilakt" and others. Older children can be given kefir, acidophilus, curdled milk, fermented baked milk.

It is very important not to delay the deadlines. In some cases, children with malnutrition are prescribed complementary foods even earlier than healthy ones. It is recommended to start giving vegetable puree from 3.5 months, meat (in the form of double-turned boiled minced meat) - from 5-5.5 months. Cottage cheese can be introduced from the first weeks of life, including during breastfeeding, in order to correct the amount of protein in the child's diet, especially if he suffers from poor appetite and does not suck out the entire norm of milk or mixture. However, the amount of cottage cheese required is determined by the doctor, taking into account the total daily amount of protein that the child receives, his needs for this ingredient and the nutritional capabilities of the patient.

To correct the protein component in the diet of older children, protein-rich foods are widely used: meat, eggs, fish, cottage cheese, cheese, dairy products, as well as various offal (liver, heart, brains, tongue, and others), which are also rich in protein. iron and other minerals, as well as vitamins.

To enrich the child's diet with protein, you can also use new dietary specialized high-protein products - enpits (protein enpit, fat-free enpit). They are a dry milk mixture enriched with biologically valuable milk proteins, vegetable oil, vitamins, iron preparations. The advantage of these products is that they can be used to introduce a significant amount of protein to the child in a small amount of the mixture. Enpitas can be used both as drinks (usually in the form of a 15 or 20 percent solution) and as additives to any dish (porridge, soup, mixture). The amount of protein needed is determined based on its content in the powder, which is indicated on the label.

Usually in children suffering from malnutrition, there is a pronounced decrease in appetite. Most often this is due to a violation of the food stereotype.

According to the norm, a person's appetite occurs when the stomach is freed from the next portion of food. In young children, this happens 3-4 hours after feeding. With malnutrition, which is often accompanied by indigestion and a decrease in the production of digestive juices, the usual portion of food does not have time to be digested for the next feeding, so the child does not feel hungry. If in this case the child is forced to eat a certain amount of food (with persuasion, with entertainment, sometimes by force), he has vomiting as a protective reflex from overfeeding. With frequent repetitions of this situation, habitual vomiting may occur not only during feeding, but even with one type of food. In this case, not only the work of the digestive organs suffers, but sometimes the mental state of the child.

If the child refuses to eat, in no case should you force feed him. It is better to skip one feeding or push it to a later time, and then feed the child in small portions, but more often, distributing the food he is entitled to for 5-6 or more meals. And yet, the intervals between individual feedings should be at least 3 hours.

It is very important at the beginning of feeding to give the child some product or dish that has the ability to enhance the separation of digestive juices and thereby increase appetite. It can be sour fruit or berry juice, a piece of herring, sauerkraut, pickled cucumber, raw vegetable salad. A strong meat broth has a good juice-making effect. By the way, some pediatricians recommend meat broth even to very young children if their appetite drops sharply. In this case, the broth can be given 1-2 teaspoons before feeding, starting from 2-3 months of age. However, it is very important to pay attention to the possibility of allergic reactions (rash, redness of the skin of the cheeks). In this case, the broth has to be abandoned.

For children with reduced appetite, it is very important to strictly observe the feeding regime - do not give anything to eat in the intervals between separate meals, and also do not give a lot to drink, then he will be more willing to start eating with liquid dishes. At the same time, when feeding a child, he can be allowed to drink solid food with water, juice or vegetable broth and, of course, not limit drinking immediately after feeding.

Of great importance for improving appetite is the correct, calm and patient attitude of adults to the nutrition of a child with reduced appetite. It is necessary to strive in every possible way to diversify his diet as much as possible, to give the dishes an attractive, appetizing look, to set the table beautifully. For some time, you can apply the method of "free feeding", that is, feed the child as he wants. They cook their favorite dishes more often than others, but at the same time change the recipe somewhat, adding the necessary protein-rich foods (meat, cottage cheese, and others).

Some children are more willing to eat at a common table, in the family circle, in the company of other children. Such facts are known when, when a child was sent to a preschool institution, his appetite improved, habitual vomiting stopped. In general, it may be necessary to exercise some ingenuity in organizing the nutrition of a child with poor appetite.

Sometimes the child does not eat well due to the fact that by the beginning of feeding he is in an excited state, too passionate about the game, some activities. In this case, you can slightly push back (for 20-30 minutes) the meal, give time for the child to be able to rebuild, calm down. If he is overexcited, take a break from work and switch to food.

On hot summer days or when the air temperature in the room is high, the child's body loses a lot of fluid. This leads to a decrease in the production of digestive juices and a decrease in appetite. In such cases, before starting feeding, it is recommended to give the child some cool boiled water or unsweetened juice, you can start feeding with a fermented milk drink (kefir, yogurt). You can change the feeding regimen: in the hottest midday time, give the child a second light breakfast (kefir, bun, fruit), and take lunch to a later time, say, after daytime sleep. Then a well-rested and hungry child after a light breakfast can easily cope with a fairly high-calorie lunch.

And one more thing should be taken into account when organizing the nutrition of children suffering from malnutrition. With all types of malnutrition, even with a slight deficiency in body weight, the phenomena of hypovitaminosis are noted in children. Therefore, the maximum amount of fresh vegetables, fruits, berries should be introduced into the diet of such children, and if they are deficient, vitamin preparations should be introduced. First of all, vitamin C, which has a beneficial effect on overall vitality, improves metabolic processes, and increases resistance to infections. Vitamin C preparation can be given to children throughout the year, but it is especially important to do this in the winter-spring period, when there is very little of this vitamin in natural products. It is also useful to conduct repeated courses of taking multivitamin preparations (as prescribed by a doctor).

Treatment of malnutrition should be comprehensive and includes:

• 1) identification of the causes of malnutrition and an attempt to eliminate or correct 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.

The basis of rational treatment of patients with primary malnutrition is diet therapy. The fundamental principle of diet therapy for malnutrition is three-phase nutrition:

• 1) the period of clarification of tolerance to food;
• 2) transitional period;
• 3) a period of enhanced (optimal) nutrition.

Important points of diet therapy in patients with malnutrition are:

• Use at the initial stages of treatment only easily digestible food (women's milk, and in its absence, adapted low-lactose fermented milk mixtures, such as lactofidus);
• 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);
• 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, salts, etc .; regular (1 time in 7 days) calculation of the food load for proteins, fats, carbohydrates; twice a week - coprogram.

Diet therapy starts with testing food tolerance. Complementary foods are excluded from the diet and the child is transferred to feeding with mixtures (optimally - breast milk), the volume of which is part of the due according to the actual body weight of the child. The missing part of the volume is filled with rehydration solutions (rehydron, oralit, citroglucosolan, vegetable decoctions, raisin drink).

Starting diet therapy for malnutrition at the beginning of the period of clarification of food tolerance

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 g per day. In severe forms of malnutrition, parenteral nutrition is prescribed - glucose, amino acid solutions, albumin, saline solutions are administered. It is also advisable to correct solutions with potassium preparations (up to 4 mmol / kg / day), calcium, phosphorus, magnesium.

During the period of clarification of food tolerance, gradually (about 10-20 ml per feeding daily) increase the amount of the main mixture, bringing it to the proper level at the end of the period (in the first year of life up to 1/5 of the actual weight, but not more than 1 liter).

AT transition period continue a gradual increase in the volume of the mixture, trying to achieve the amount of nutrition calculated for the weight that the child should have at this age (proper weight), reduce the number of feedings, and begin the consistent introduction of complementary foods necessary for age.

Carbohydrate loading in the transitional period is adjusted to 14-16 g/kg/day. and after that they begin to increase the load of proteins and fats. An increase in the amount of proteins is achieved by adding protein mixtures and products (protein enpit); carbohydrates (including sugar syrup, cereals). To increase fat in the diet, bifilin, fatty enpit, egg yolk are used.

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 (fatness), restoration of lost and acquisition of new skills of psychomotor development, improvement of food digestion (according to the coprogram). In the event of signs of a decrease in food tolerance, the food load is temporarily reduced, followed by its gradual increase.

AT period of enhanced nutrition the child receives approximately the same nutrition as his peers who do not have malnutrition. At the same time, the energy supply and protein load on the actual body weight is greater than in healthy children (Table 3.26).

Larger amounts of protein are not absorbed, and therefore useless, moreover, they can contribute to the development of metabolic acidosis.

For each sick child, an individual approach to the diet and its expansion is necessary, which is carried out under the obligatory control of the dynamics of body weight, coprogram.

Diet therapy of malnutrition in the period of enhanced nutrition

The organization of care is of great importance, a child with malnutrition is not so much treated as nursed. It is very important to create a positive emotional tone in a child - it is necessary to take him in your arms more often (prevention of hypostatic pneumonia), talk to him, walk.

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 degrees must be placed in a hospital with their mother. Attention should be paid to the prevention of cross-infection (the patient should be placed in isolated boxes), the identification and sanitation of foci of infection. Mandatory in the treatment of children with malnutrition are massage and gymnastics.

The main directions of drug therapy:

• 1. Substitutive enzyme therapy is carried out mainly with pancreatic preparations, with preference given to preparations of the combined composition panzinorm, festal. To stimulate the processes of digestion, gastric juice, acidin pepsin, hydrochloric acid with pepsin are used. With intestinal dysbacteriosis, biological preparations - bifidumbacterin, bifikol, bactisubtil in long courses (3 weeks).
• 2. Parenteral nutrition is carried out in severe forms of malnutrition accompanied by malabsorption phenomena. Assign protein preparations for parenteral nutrition - Alvezin, Levamine, protein hydrolysates. If indicated, fat
• 3. Correction of water and electrolyte disturbances and acidosis. Infusions of glucose-salt solutions, a polarizing mixture are prescribed.
• 4. Anabolic drugs and vitamins. The use of anabolic drugs for malnutrition is carried out with caution, since in conditions of nutrient deficiency, their use can cause profound disorders of protein and other types of metabolism. Retabolil is usually prescribed at 1 mg/kg body weight once every 2-3 weeks. Carnitine chloride has anabolic properties. Vitamin therapy is carried out with a stimulating and replacement purpose - Vit. B1, B6, A, PP, B15, B5, E, etc. In severe forms of malnutrition, vitamins are prescribed parenterally.
• 5. Stimulant and immunotherapy. During the height of malnutrition, preference should be given to passive immunotherapy - native plasma, plasma enriched with specific antibodies (antistaphylococcal, antipseudomonal, etc.). immunoglobulins. During the period of convalescence, non-specific immunostimulants are diabazol, methyluracil. Biostimulants such as apilac, adaptagens.

Vitamins of group B, tocopherol, aevit are prescribed. With pluriglandular hormonal deficiency - prephysone. Rickets, iron deficiency anemia are being treated.

The first question that is usually of interest to parents and relatives of a newborn child is what is the weight of the baby whether it is normal.

This question constantly arises, and in the future, especially in the first year of life child. And this is understandable. After all, weight, or rather body weight, is one of the most important indicators that reflect physical development, so each visit to a children's clinic invariably begins with weighing the baby.

Pediatricians have developed special standards for the physical development of children of all ages (they are periodically updated and updated), where body weight comes first, then height, and then many other anthropometric indicators. Comparing the baby's data with age standards, the pediatrician draws a conclusion about his physical development.

About malnutrition they say when the body weight of an infant is less than the normative and lags behind growth.
At the same time, congenital and acquired hypotrophy is distinguished.

Congenital malnutrition of newborns is a consequence of a violation of the development of the fetus as a result of various complications of pregnancy (toxicosis, nephropathy, the threat of miscarriage, polyhydramnios, acute diseases and exacerbations of chronic during pregnancy, etc.), pathological changes in the placenta and umbilical cord, intrauterine infection.

An important role in the occurrence of the disease is played by the malnutrition of a pregnant woman, her non-compliance with a rational daily regimen, physical and neuropsychic overload, alcohol consumption, smoking, and some harmful factors at work. This disrupts the delivery of oxygen and nutrients to the fetus from the mother's body, which leads to the development of the disease.

Acquired malnutrition occurs most often with improper feeding of the child, due to acute and chronic diseases of the gastrointestinal tract, primarily infectious, as a result of defects in care, regimen and education.
All this leads not only to insufficient intake of proteins, fats, carbohydrates, energy substances into the baby's body, but also to their poor absorption.

As a result, the child is starving, he has a slow formation of organs and tissues, their functional activity decreases. Various disorders of the gastrointestinal tract, nervous and endocrine systems aggravate the severity of the disease and lead to disruption of almost all types of metabolism in the body.
Against such an unfavorable background, a secondary infection often develops, significantly worsening the course of the underlying disease. This is how a complex pathological complex develops, the clinical picture of which is not limited to insufficient body weight.

A special role in the treatment of malnutrition is played by properly organized diet therapy. It should be strictly individual and depend on the severity of the disease. The difficulty of feeding a child with malnutrition lies in the fact that for a successful cure, the baby needs an increased amount of essential nutrients.

At the same time, the resistance of the gastrointestinal tract of a sick child to nutritional stress is reduced, and with increased nutrition, complete indigestion can easily occur, which will further aggravate the severity of the disease.
Therefore, diet therapy should be prescribed only by a pediatrician. The task of the parents is to strictly fulfill all his appointments.

Nutrition for malnutrition

Treatment of hypotrophy of a newborn is an individual and rather lengthy process, in severe cases requiring hospitalization. It is based on proper nutrition, not only for the child, but also for the mother. Indeed, for a breastfed baby, mother's milk is the most important (and in the first months of life - almost the only) source of nutrients and energy. Therefore, rational nutrition of a nursing mother is a necessary condition for the successful removal of a baby from malnutrition. It implies not only a sufficient quantity of food consumption, but also their high quality composition.

Depending on the severity of the disease, there are:
hypotrophy of the 1st degree (the weight of the child is 10-20% below the norm),
2 degrees (weight 20-40% below normal),
3 degrees (mass more than 40% below normal).
The latter is an extreme degree of exhaustion of the child, which is often complicated by various infectious and inflammatory diseases, which further aggravates the severity of the baby's condition.

With hypotrophy of the 1st degree diet therapy is usually carried out on an outpatient basis, i.e. at home. The doctor determines the deficiency of certain essential nutrients and makes the necessary correction of the diet.

To make up for the protein deficiency, cottage cheese, kefir or protein enpit are prescribed - a special dietary health food product. If cottage cheese or kefir have been used for this purpose for a long time, then protein enpit is a relatively new product, its industrial production has been established quite recently. Compared with cottage cheese and kefir, it has a high biological value due to the high content of complete milk proteins, balanced mineral composition, enrichment, B1, B2, B6, PP, C.

The daily amount of enpit needed by the child is prescribed by the doctor. He also determines a single dose of the product, the number of doses, the duration of use, teaches parents how to obtain a liquid product from a dry one, and the rules for including it in the child's diet.

Protein enpit It is a fine white powder, taste and smell reminiscent of milk powder. To prepare 100 ml of a liquid product, pour 30-40 ml of hot boiled water (50-60 °) into a clean dish, dissolve 15 g of dry powder in it, stir thoroughly until the lumps disappear, add water to 100 ml and heat to a boil with continuous stirring . After cooling to 36-38° the liquid mixture is ready for use.
If necessary, it can be stored in the refrigerator for a day, heated before use in a water bath to 36-38 °.

Liquid enpit, on the recommendation of a doctor, is given to the child once or several times a day in its pure form or mixed with breast milk (infant formula). Like any new product, enpit is gradually introduced into the baby's diet, starting with 10-20 ml, increasing this amount daily in order to reach the volume determined by the doctor within a week. br>
The lack of fat in the baby's diet is replenished with cream, as well as vegetable or butter, which is added to complementary foods.
Enpit, called fat, is also used to correct the fat component of the diet. It contains a large amount of fat, balanced in fatty acid composition due to the addition of biologically active polyunsaturated fatty acids, and is enriched with water- and fat-soluble vitamins. In dry form, it is a slightly creamy powder, which also tastes and smells like powdered milk. The method for restoring a liquid product from a dry powder is the same as for protein enpit. The rules for its use are similar.

Least of all, a carbohydrate deficiency is found in a child's diet. It is replenished with fruit juices, mashed potatoes, sugar syrup.
To prepare a syrup, 100 g of sugar is poured into 40-50 ml of water, brought to a boil, stirring, so that the sugar is completely dissolved, and filtered through 2 layers of gauze with a cotton pad. Boiled water is added to the resulting filtrate to a volume of 100 ml, brought to a boil again, mixed thoroughly, poured into a boiled bottle and closed with a cork. Ready syrup can be stored in the refrigerator for no more than a day, warming up to 36-38 ° before use.

Correction of the diet of a child with hypotrophy of the 1st degree usually leads to a gradual increase in weight and a complete cure.

Much harder to carry out diet therapy for malnutrition 2 and especially 3 degrees, the full treatment of which is possible only in a hospital setting.

Such children need to significantly increase the food load, but, as we have already noted, this often leads to a complete indigestion: vomiting and diarrhea appear. Therefore, diet therapy for malnutrition 2 and 3 degrees is carried out in stages, and at the first stage the daily amount of food can be from 1/3 to 3/5 of the required.

The duration of this stage of unloading is individual and depends on the degree of indigestion, the presence of complications or concomitant diseases. It is at this stage that it is especially important to follow the recommendations of the doctor. Often, the mother, delighted by the fact that with the beginning of unloading, the child has an appetite, vomiting and diarrhea have disappeared, independently begins to increase the amount of food. As a rule, this leads to an exacerbation of the disease and nullifies the first successes of treatment. And everything has to start over.

At the first stage of diet therapy (the stage of unloading), the child is usually given only breast milk or a formula replacing it, even if the baby's diet can be much more varied. In the absence of breast milk, adapted formulas should be used. It is very important that the child's diet contains acidophilic adapted mixtures and other fermented milk products.
Taking into account the reduced adaptation of the child to food, in some cases the frequency of feedings is increased, respectively, reducing the volume of one feeding. Gradually, a single amount of milk or mixture is increased, and the number of feedings is reduced to the norm corresponding to age.

When a good adaptation to food is established at the first stage of diet therapy, they proceed to its second stage. The volume of the diet is gradually increasing, expanding its range. At the same stage, the doctor, on the basis of calculations, makes the necessary correction of the diet, which should be carefully observed.

Since vitamin deficiency develops early in malnutrition, special attention should be paid to fruit, berry and vegetable juices and purees.

In addition to being a source of vitamins, juices and purees increase appetite, promote the release of digestive juices, stimulate the motor function of the intestine, the development of beneficial microflora in it, and therefore represent one of the important components of the complex treatment of malnutrition.

Great importance is attached to other corrective additives (cottage cheese, egg yolk, meat puree), as well as complementary foods (vegetable puree, milk porridge).
If cottage cheese appears in the diet of healthy children of the first year of life only with the introduction of the first complementary foods, that is, at the fifth month of life, then with malnutrition it can be started if the doctor detects a protein deficiency in the diet.
A hard boiled egg yolk containing complete proteins, fats, mineral salts, vitamins A, D, B1, B2, PP can be given from the age of three months.

An important source of animal protein, the deficiency of which develops during malnutrition, is meat. It also contains fats, mineral salts, extractives, vitamins and is well absorbed in the child's body.
Unlike healthy children, in whose diet meat appears at the end of the seventh month of life, children with malnutrition can begin to give it earlier - from the age of five months. It is advisable to use special canned meat for baby food, which have a high nutritional value and are well absorbed.

All complementary foods are introduced at the same time as for healthy children.

With malnutrition, especially with its congenital form, the child often has perversions of food reactions: a complete refusal to eat or eating only liquid food, preference for sweet or, conversely, sour-milk products; refusal to eat from a spoon, etc.

Some children may not be able to feed when they are awake, but it is relatively easy to do so while they are sleeping. This, by the way, is what many parents do, striving in any way to prevent the exhaustion of the child.
But if you follow the baby's lead, then the manifestations of malnutrition will not only not decrease, but will worsen even more.

Of course, in the acute period of the disease, especially when the child is in a serious condition, in order to spare his overexcited nervous system, it is permissible to make some concessions without drastically changing his eating habits. However, as the condition normalizes, you should gradually switch to a diet appropriate for the age of the baby.

Only with properly organized diet therapy, following all the advice of a doctor, a complete cure for malnutrition is possible.