Hypotrophy of the 3rd degree in newborns consequences. Hypotrophy in newborns and young children: symptoms, classification, treatment. Physiological weight loss in newborns

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

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

How to determine the degree of malnutrition?

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

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

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

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

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

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

4900 g - 100%

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

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

Signs of 1st degree of malnutrition

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

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

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

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

Signs of the 2nd degree of the disease

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

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

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

Signs of the 3rd degree of malnutrition in children

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

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

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

Hypotrophy (protein-energy deficiency) is a clinical syndrome that occurs in children against the background of serious illnesses or due to alimentary insufficiency (imbalance in nutrient intake, underfeeding). It is characterized by a reduced body weight in relation to the age norm, as well as a violation of tissue trophism, and, as a result, a violation of the development and functioning of internal organs.

In the treatment of malnutrition, properly organized therapeutic nutrition is of primary importance.

Hypotrophy is a common childhood pathology. According to medical statistics, in 5% of cases of visiting a pediatrician are associated with insufficient weight gain.

Source: serebryanskaya.com

Causes and risk factors

Hypotrophy can develop under the influence of a number of exogenous (external) and endogenous (internal) causes. Exogenous include:

• alimentary (nutrition that does not correspond to age, underfeeding);
• infectious (acute infectious diseases, sepsis);
• social (low social level of the family, defective upbringing).

The following diseases and pathological conditions become internal causes of malnutrition:

• anomalies of the constitution (diathesis);
• malformations of internal organs;
• neuroendocrine and endocrine disorders (pituitary dwarfism, adrenogenital syndrome, hypothyroidism, anomalies of the thymus gland);
• violation of the absorption process in the intestine (malabsorption syndrome, lactose deficiency, celiac disease);
• insufficient breakdown of nutrients (cystic fibrosis);
• primary metabolic disorders (fat, protein, carbohydrate);
• some chromosomal disorders.

Factors that increase the risk of malnutrition in children are:

• frequent respiratory viral infections;
• poor child care (insufficient sleep, infrequent bathing, lack of walks).

Kinds

Depending on the time of occurrence, the following types of malnutrition are distinguished:

• congenital (prenatal) Also called fetal hypotrophy. Its occurrence leads to a violation of the uteroplacental circulation, leading to intrauterine growth retardation. Prenatal malnutrition is always combined with fetal hypoxia;
• acquired (postnatal)- its development is based on protein-energy deficiency, resulting from insufficient intake of nutrients and energy into the child's body (i.e., the intake of nutrients in an amount that does not cover the costs of the body);
• mixed- caused by a combination of pre- and postnatal factors.

In the case of prenatal hypotrophy (fetal hypotrophy), the prognosis depends on the degree of hypoxic damage to the central nervous system.

Prenatal malnutrition, depending on the clinical manifestations, is divided into the following types:

• neuropathic- weight loss is insignificant, sleep and appetite disturbances are noted;
• neurodystrophic- characterized by a decrease in body weight, a lag in psychomotor development, persistent anorexia;
• neuroendocrine- characterized by a violation of the endocrine regulation of psychomotor development, as well as the functional state of internal organs;
• encephalopathic- is manifested by a pronounced neurological deficit, a severe lag in the child's mental and physical development, hypoplasia of the skeletal system.

Depending on the lack of body weight, the following degrees of malnutrition in children are distinguished:

1. Light. The deficit is 10-20%, body length corresponds to the age norm.
2. Average. Body weight is reduced by 20-30%, there is a growth delay of 2-3 cm.
3. Heavy. The deficit exceeds 30%, the child is significantly stunted.

With timely and complex treatment of malnutrition of I and II degrees, the prognosis is favorable.

Source: present5.com

signs

Clinical signs of malnutrition in children are determined by a lack of body weight.

With I degree of malnutrition, the general condition of the child remains satisfactory. There is a slight decrease in the thickness of the subcutaneous adipose tissue layer.

Signs of malnutrition II degree are:

• lability of the central nervous system (decreased emotional tone, lethargy, apathy, agitation);
• dryness, pallor, peeling of the skin;
• decrease in soft tissue turgor and skin elasticity;
• loss of subcutaneous tissue (remains only on the face);
• microcirculation disorders (cold extremities, marbling of the skin);
• dyspeptic disorders (constipation, vomiting, nausea);
• rapid breathing (tachypnea);
• tendency to tachycardia;
• muffled heart sounds.

At the III degree of malnutrition, a pronounced developmental delay is observed. The general condition of the child is severe. There is a loss of previously acquired skills, signs of anorexia, weakness, lethargy are expressed. The skin is pale and dry, with a grayish tinge, gathering into folds (the so-called senile skin). Subcutaneous tissue is completely absent, the face becomes sunken, as Bish's lumps disappear, giving roundness to children's cheeks. Muscle hypotrophy develops up to their complete atrophy. The child looks like a skin-covered skeleton. Often there are symptoms of dehydration:

• dry mucous membranes;
• retraction of a large fontanel;
• shallow breathing;
• muffled heart tones;
• a significant decrease in blood pressure;
• violation of thermoregulation.

Diagnostics

Diagnosis of malnutrition begins with an examination and careful collection of obstetric and postnatal history (features of the course of pregnancy, maternal illness, toxicosis, the course of childbirth, the use of obstetric benefits, the duration of the anhydrous period, the monthly weight gain of the child, past diseases). They also find out the social (socio-economic situation of the family, living conditions) and hereditary (endocrine, metabolic diseases, enzymopathies in family members) anamnesis.

Against the background of malnutrition I and II degree, children often develop intercurrent diseases (pyelonephritis, pneumonia, otitis media).

Laboratory diagnosis of malnutrition in children includes the following types of tests:

• complete blood count (hypochromic anemia, increased hematocrit and ESR, thrombocytopenia, leukopenia);
• general and biochemical analysis of urine;
• determination of the acid-base composition of the blood;
• determination of serum concentrations of electrolytes (sodium, calcium, potassium);
• immunogram (performed during infectious processes);
• endocrine profile (hormones of the adrenal glands, thyroid gland) - if indicated;
• study of sweat for the content of chlorides (if cystic fibrosis is suspected);
• virological and bacteriological studies - if infectious processes are suspected.

If necessary, the child is referred for a consultation with an endocrinologist, ophthalmologist, gastroenterologist, etc.

To exclude a specific pulmonary process (tuberculosis, cystic fibrosis), an X-ray examination of the chest organs is performed.

Treatment

With I and II degrees of malnutrition with satisfactory tolerance to food loads, treatment is carried out on an outpatient basis. Indications for hospitalization are:

• age less than one year;
• the presence of infectious or somatic concomitant diseases;
• low tolerance to food loads;
• III degree of malnutrition.

In the treatment of malnutrition, properly organized therapeutic nutrition is of primary importance. It has three phases:

1. Preparatory.
2. Enhanced nutrition.
3. Recovery.

The purpose of the preparatory phase is to determine the child's tolerance to the food load and its increase, correction of violations of the water-salt balance. With malnutrition of the I degree, food loads are reduced compared to the norm to 2/3 of the required volume of food, and with II and III degrees of malnutrition, to 1/3-1/2. When breastfeeding, a child with malnutrition of I and II degrees is prescribed 100 ml of breast milk per kilogram of body weight per day.

With poor tolerance of food loads, there is a need for parenteral nutrition. For this purpose, solutions of colloids and crystalloids are administered intravenously in a ratio of 1:1.

The goals of the enhanced nutrition phase are to restore all types of metabolism and energy, as well as the transition to complete intestinal nutrition. The calorie content of the diet is 150-180 kcal per kilogram of the child's actual body weight. The diet is gradually expanded, introducing all macro- and micronutrients into it in age proportions.

General principles of diet therapy for malnutrition:

According to medical statistics, in 5% of cases of visiting a pediatrician are associated with insufficient weight gain.

The recovery phase of therapeutic nutrition is aimed at organizing the normal intake of nutrients in terms of the body weight due to the age of the child.

Hypotrophy in children is a chronic underweight. Starting from the stage of intrauterine development, for each age of the child there are standards for height and weight, deviations from which in one direction or another indicate a change in nutrition. Overweight in children - paratrophy is no better than malnutrition. The issue of an increase in the number of overweight children is very acute in world medical practice due to the fact that an increase in protein nutrition leads to rapid weight gain in a child of the first year of life. In the future, they risk getting metabolic syndrome.

If the causes of overweight lie in overeating (alimentary factor), then underweight is more often associated not with the fact that the child does not eat enough, but with absorption problems.

Since 1961, WHO has introduced the term "protein-energy malnutrition", but in Russia the lack of physical development, especially in newborns and young children, is referred to as malnutrition. The problem is aggravated by the fact that a long-term deficiency of a number of nutritional components, such as proteins, polyunsaturated fats, iron, microelements, leads to a violation of the child's mental abilities.

Depending on the time of occurrence, malnutrition is divided into prenatal and postnatal. Prenatal (prenatal) or congenital malnutrition is nothing more than intrauterine growth retardation syndrome (IUGR). It develops when there is a violation of the blood supply to the fetus through the uterus and placenta (fetoplacental insufficiency).

If the indicators of fetal development lag behind the standards by 14 days, they speak of 1 degree of developmental delay, 3-4 weeks - 2 degree and more than a month - 3 degree.

There are 3 options for expressing delayed fetal development:

• The hypotrophic variant is characterized by the body length corresponding to the gestational age and the circumference of the head, chest and abdomen below normal;
• The hypoplastic variant reflects the proportional, but reduced parameters of the child;
• With a dysplastic variant, malformations and deformities of the fetus are observed.

Postnatal (postpartum) malnutrition is divided into degrees in accordance with the lack of body weight. At 1 degree, the lack of body weight is 10-20%;

• At 2 degrees - 20-30%;
• At 3 degrees over 30%.

The actual weight of the child is compared with the weight, the calculation of which is carried out according to the tables of normal monthly weight gain. For example, body weight at birth 3700g, at the age of 3 months 5300g. According to the table, the child should gain 600 g + 800 g + 800 g in 3 months, a total of 2200 g. The normal body weight at 3 months for this child should be 5900 g.

The mass deficit is 5900–5300, that is, 600 g, which corresponds to 10% according to the proportion formula:

• 5900 – 100%;
• 600 - 10%, therefore, the child has hypotrophy of the 1st degree.

The reasons

The causes of prenatal and postnatal malnutrition are different. The following causes are characteristic of the fetal IUGR syndrome:

• maternal factor- diseases of the cardiovascular, broncho-pulmonary, urinary systems, smoking, alcoholism, drug use, malnutrition, insulin-dependent diabetes mellitus, multiple pregnancy, history of infertility and abortion, taking certain medications, chronic stress and other neuropsychic overload, transferred rubella, syphilis,.
• Placental causes associated with pathology of the placenta. Perhaps its underdevelopment, inflammation, low attachment, premature detachment, early aging. In recent years, antiphospholipid syndrome, that is, the formation of blood clots in the vessels of the placenta, has been attributed here.

• Socio-biological factors are also considered as the causes of congenital malnutrition. Occurs in young primiparous aged 15-17 years, in single women who give birth without a husband, in those who live in the highlands;
• Hereditary causes are associated with chromosomal and gene abnormalities.

All these reasons directly or indirectly impair uteroplacental blood flow, which disrupts the nutrition of the fetus and hypotrophy of newborns of varying severity.

Hypotrophy in young children is based on other causes:

• Exogenous - direct lack of basic food ingredients, malnutrition and problems that disrupt eating. For example, swallowing problems due to disorders of the nervous system or malformations of the face and jaws;
• Endogenous - there are 3 groups:
• Problems with digestion, absorption and retention of food eaten;
• A child’s disease when he needs increased nutrition (prematurity, chronic diseases of the pulmonary system, microbial and viral infections;
• Received from birth problems in metabolism.

With malnutrition in children, metabolism progressively worsens, which ultimately leads to stress, due to acidosis, and cell destruction.

Liver function suffers, humoral immunity decreases. The breakdown of adipose tissue destabilizes the cell membrane. The body rebuilds metabolic processes in order to direct energy to the brain. The entire digestive system suffers, the mucosa atrophies, the production of enzymes decreases, motility changes, local immunity decreases.

Symptoms

Symptoms of malnutrition in newborns depend on the variant of IUGR. It should be noted that even in modernly equipped perinatal centers, the mortality of newborns in the first 7 days of life in the case of a pronounced syndrome, despite the treatment, reaches 35%.

Children who have undergone IUGR have symptoms such as:

• Lagging behind in physical development (60%);
• Delayed psychomotor development (40%);
• Cerebral palsy;
• (12%).

The symptoms are less pronounced in the hypotrophic variant, the prognosis is more favorable, but the susceptibility to infectious diseases and pneumonia remains high in early childhood, especially up to a year.

The study of the long-term consequences of congenital malnutrition of newborns revealed symptoms of a decrease in intelligence at school age, neurological disorders, a tendency to develop hypertension, coronary heart disease, and diabetes mellitus.

1 degree

With hypotrophy of the 1st degree, the child has minor symptoms, confirming that the diet has been disturbed. The fat layer from the anterior abdominal wall disappears, skin turgor and muscle elasticity decrease, regurgitation is observed, sleep is disturbed, anxiety and fatigue are noted. At the same time, there is no lag in growth and deviations in mental development. The child is prone to frequent colds.

2 degree

When nutrition is disturbed at level 2, the following symptoms appear. Fat disappears from the whole body, except for the cheeks, skin and muscles are flabby, joints and bones are visible, the child has reduced or no appetite, irregular stools, undigested food in the feces. Due to beriberi, the growth of hair, nails, seizures in the corners of the mouth are disturbed, the child quickly overheats or cools down, frequent and prolonged colds, often naughty, restless.

3 degree

The 3rd degree of malnutrition in a child is the most severe, if it is not treated, he will die. The main symptoms include the disappearance of fat from the cheeks of the child, atrophy of the skin and muscles, disruption of the heart and breathing, decreased pressure, stunting, mental retardation, refusal to eat.

Pediatricians in practice use the calculation of the fatness index for newborns and children under one year old. Such a calculation is easy to do yourself. Measure the circumference of the shoulder, thigh and lower leg, find the sum, subtract the height of the child from it. Normally, in a child up to a year old, the index is 25–30 cm. With hypotrophy of the 1st degree, it is reduced to 10–15 cm, with the 2nd - below 10 cm.

Treatment

Fetal IUGR should be treated during pregnancy. The goal of treatment is to improve uteroplacental blood flow. For this, Curantil, Actovegin, vitamin and mineral complexes, including vitamins - antioxidants, are used. Treatment includes proper nutrition, fresh fruits and vegetables in sufficient quantities, protein diet, dairy products.

In some cases, depending on the severity of the condition of the fetus and the prognosis, the question of the advisability of maintaining pregnancy is decided.

It is not difficult to restore nutrition with 1 degree of malnutrition. In the children's clinic, they will make the necessary calculation of the amount of breast milk per day and one feeding. In case of hypogalactia, suitable breast milk substitutes will be prescribed, they will recommend the introduction of juices, cottage cheese. The frequency of feeding in such children should be increased to 7-8 per day.

Babies over one year old include cereals, fruits and vegetables in the diet. The appointment of drugs with 1 degree of malnutrition is not required.

Grade 2 requires the need to adjust diet and feeding, balance nutrition, prescribe medication that can be performed both at home and in the hospital.

Diet and nutrition should be age appropriate, the regime changes. Portions are reduced, but the frequency of eating becomes more frequent. Treatment is carried out with biological stimulants, digestive enzymes, vitamin and mineral complexes.

Just adjusting your diet is not enough. The baby receives complex infusion therapy and parenteral and enteral feeding through a tube.

Treatment of the 3rd degree of malnutrition is aimed at maintaining and correcting the vital functions of the body and includes transfusion of blood, plasma, glucose, the introduction of enzymes and hormones.

There is a fight against dehydration, electrolyte imbalance, acid-base balance. The tube feeding diet includes a specially designed milk-protein mixture, devoid of lactose, but with the addition of fats, including PUFAs (Alfare). When removed from a serious condition, rickets and anemia begin to be treated. In the future, a diet appropriate for age is drawn up. During the period of convalescence, treatment with non-specific immunomodulators is carried out.

Prevention

Prevention has always been and remains preferable and more economical than cure. Prevention of malnutrition in children consists in adequate breastfeeding, the timely introduction of supplementary feeding and complementary foods, and proper care of the baby.

Oddly enough, but prevention should begin from the childhood of future parents. A balanced diet, physical education and sports, work and rest regimen, sleep, avoidance of stress, rejection of bad habits, timely sanitation of foci of infection, personal and intimate hygiene, planned pregnancy and conducting it under the supervision of a specialist in compliance with all recommendations - effective prevention of complications and the birth of a healthy child.

- chronic malnutrition, accompanied by an insufficient increase in body weight of the child in relation to his height and age. Hypotrophy in children is expressed by a child's lag in weight, growth retardation, lag in psychomotor development, underdevelopment of the subcutaneous fat layer, and a decrease in skin turgor. Diagnosis of malnutrition in children is based on examination data and analysis of anthropometric indicators of the child's physical development. Treatment of malnutrition in children involves changing the regimen, diet and caloric intake of the child and the nursing mother; if necessary, parenteral correction of metabolic disorders.

General information

Hypotrophy in children is a lack of body weight due to a violation of assimilation or insufficient intake of nutrients in the child's body. In pediatrics, malnutrition, paratrophy and hypostatura are considered as independent types of chronic eating disorders in children - dystrophy. Hypotrophy is the most common and significant variant of dystrophy, to which children of the first 3 years of life are especially susceptible. The prevalence of malnutrition in children in different countries of the world, depending on the level of their socio-economic development, ranges from 2-7 to 30%.

Hypotrophy in a child is said to be when the body weight lags by more than 10% compared to the age norm. Hypotrophy in children is accompanied by serious disturbances in metabolic processes, decreased immunity, and a lag in psychomotor and speech development.

Causes of malnutrition in children

A variety of prenatal and postnatal factors can lead to chronic malnutrition.

Intrauterine malnutrition in children is associated with adverse conditions that disrupt the normal development of the fetus. In the prenatal period, pathology of pregnancy (toxicosis, preeclampsia, fetoplacental insufficiency, premature birth), somatic diseases of the pregnant woman (diabetes mellitus, nephropathy, pyelonephritis, heart defects, hypertension, etc.), nervous stress, bad habits, malnutrition of women, industrial and environmental hazards, intrauterine infection and fetal hypoxia.

Extrauterine malnutrition in young children may be due to endogenous and exogenous causes. The causes of the endogenous order include chromosomal abnormalities and congenital malformations, fermentopathy (celiac disease, disaccharidase lactase deficiency, malabsorption syndrome, etc.), immunodeficiency states, constitutional abnormalities (diathesis).

Exogenous factors leading to malnutrition in children are divided into alimentary, infectious and social. Alimentary influences are associated with protein-energy deficiency due to insufficient or unbalanced nutrition. Hypotrophy in a child may be the result of constant underfeeding associated with difficulty sucking with an irregular shape of the mother's nipples (flat or inverted nipples), hypogalactia, insufficient amount of milk formula, profuse regurgitation, qualitatively malnutrition (microelement deficiency), poor nutrition of a nursing mother, etc. The same group of reasons should include diseases of the newborn itself, which do not allow him to actively suckle and receive the necessary amount of food: cleft lip and palate (cleft lip, cleft palate), congenital heart defects, birth trauma, perinatal encephalopathy, pyloric stenosis, cerebral palsy, alcohol fetal syndrome etc.

Children suffering from frequent acute respiratory viral infections, intestinal infections, pneumonia, tuberculosis, etc. are prone to the development of acquired malnutrition. An important role in the occurrence of malnutrition in children belongs to unfavorable sanitary and hygienic conditions - poor child care, insufficient exposure to fresh air, rare bathing, insufficient sleep .

Classification of malnutrition in children

Thus, according to the time of occurrence, intrauterine (prenatal, congenital), postnatal (acquired) and mixed malnutrition in children are distinguished. The development of congenital malnutrition is based on a violation of the uteroplacental circulation, fetal hypoxia and, as a result, a violation of trophic processes leading to intrauterine growth retardation. In the pathogenesis of acquired malnutrition in children, the leading role belongs to protein-energy deficiency due to malnutrition, disturbances in the processes of food digestion or absorption of nutrients. At the same time, the energy costs of a growing organism are not compensated by food coming from outside. With a mixed form of malnutrition in children, alimentary, infectious or social influences join the adverse factors that acted in the prenatal period after birth.

According to the severity of underweight in children, hypotrophy of I (mild), II (medium) and III (severe) degrees is distinguished. Hypotrophy of the 1st degree is said when a child lags behind in weight by 10-20% of the age norm with normal growth. Hypotrophy of the II degree in children is characterized by a decrease in weight by 20-30% and a growth lag of 2-3 cm. With hypotrophy of the III degree, the body weight deficit exceeds 30% of the due age, there is a significant lag in growth.

During malnutrition in children, the initial period, the stages of progression, stabilization and convalescence are distinguished.

Symptoms of malnutrition in children

With malnutrition of the first degree, the condition of the children is satisfactory; neuropsychic development corresponds to age; there may be a mild decrease in appetite. A close examination reveals pallor of the skin, a decrease in tissue turgor, thinning of the thickness of the subcutaneous fat layer on the abdomen.

Hypotrophy of the II degree in children is accompanied by a violation of the child's activity (excitation or lethargy, lag in motor development), poor appetite. The skin is pale, scaly, flabby. There is a decrease in muscle tone, elasticity and tissue turgor. The skin easily gathers into folds, which are then poorly straightened. The subcutaneous fat layer disappears on the abdomen, trunk and limbs; on the face - saved. Children often present with shortness of breath, hypotension, and tachycardia. Children with II degree malnutrition often suffer from intercurrent diseases - otitis media, pneumonia, pyelonephritis.

Hypotrophy III degree in children is characterized by a sharp depletion: the subcutaneous fat layer atrophies throughout the body and on the face. The child is lethargic, adynamic; practically does not react to stimuli (sound, light, pain); sharply lags behind in growth and neuropsychic development. The skin is pale gray, the mucous membranes are dry and pale; the muscle is atrophic, tissue turgor is completely lost. Exhaustion and dehydration lead to retraction of the eyeballs and fontanel, sharpening of facial features, the formation of cracks in the corners of the mouth, and impaired thermoregulation. Children are prone to regurgitation, vomiting, diarrhea, decreased urination. In children with hypotrophy of the III degree, conjunctivitis, candidal stomatitis (thrush), glossitis, alopecia, atelectasis in the lungs, congestive pneumonia, rickets, anemia are often noted. In the terminal stage of malnutrition, children develop hypothermia, bradycardia, and hypoglycemia.

Diagnosis of malnutrition in children

Intrauterine fetal malnutrition, as a rule, is detected during ultrasound screening of pregnant women. In the process of obstetric ultrasound, the dimensions of the head, length and estimated weight of the fetus are determined. With a delay in intrauterine development of the fetus, the obstetrician-gynecologist sends the pregnant woman to the hospital to clarify the causes of malnutrition.

In newborns, the presence of malnutrition can be detected by a neonatologist immediately after birth. Acquired malnutrition is detected, a study of the coprogram and feces for dysbacteriosis, a biochemical blood test, etc.).

Treatment of malnutrition in children

Treatment of postnatal malnutrition of the 1st degree in children is carried out on an outpatient basis, malnutrition of the II and III degrees - in a hospital. The main measures include the elimination of the causes of malnutrition, diet therapy, the organization of proper care, and the correction of metabolic disorders.

Diet therapy for malnutrition in children is implemented in 2 stages: clarification of food tolerance (from 3-4 to 10-12 days) and a gradual increase in the volume and calorie content of food to the physiological age norm. The implementation of diet therapy for malnutrition in children is based on fractional frequent feeding of the child, weekly calculation of the food load, regular monitoring and correction of treatment. Feeding children with weakened sucking or swallowing reflexes is carried out through a probe.

Drug therapy for malnutrition in children includes the appointment of enzymes, vitamins, adaptogens, anabolic hormones. With severe malnutrition, children are given intravenous administration of protein hydrolysates, glucose, saline solutions, and vitamins. With malnutrition in children, massage with elements of exercise therapy, UVI is useful.

Forecast and prevention of malnutrition in children

With timely treatment of hypotrophy of I and II degrees, the prognosis for the life of children is favorable; with malnutrition III degree mortality reaches 30-50%. To prevent the progression of malnutrition and possible complications, children should be examined weekly by a pediatrician with anthropometry and nutrition correction.

Prevention of prenatal fetal malnutrition should include adherence to the regimen of the day and nutrition of the expectant mother, correction of the pathology of pregnancy, exclusion of the impact on the fetus of various adverse factors. After the birth of a child, the quality of nutrition of a nursing mother, the timely introduction of complementary foods, the control of the dynamics of an increase in the body weight of a child, the organization of rational care for a newborn, and the elimination of concomitant diseases in children become important.

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.