Hypotrophy 1 2 degrees in newborns. What is malnutrition in children. What does a normally developing baby look like?

Update: December 2018

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

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

What does a normally developing baby look like?

Signs of normotrophic:

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

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

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

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

Causes and development

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

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

Causes of acquired malnutrition

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

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

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

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

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

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

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

Symptoms

Signs and symptoms of intrauterine malnutrition in a child:

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

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

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

Degrees of malnutrition in children

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

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

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

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

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

Diagnostics

Differential Diagnosis

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

Treatment

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

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

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

Nutrition for children with malnutrition

Diet therapy for malnutrition is divided into three stages.

The main directions of drug therapy

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

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

Study of the causes and symptoms of malnutrition in children

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

Prevention of malnutrition in children

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

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

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

It should be remembered:

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

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

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

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

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

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

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

The causes of malnutrition can be divided into two groups:

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

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

In pathogenesis, the following pathophysiological phases are distinguished:

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

Symptoms

Clinical manifestations of malnutrition are grouped into several syndromes.

Trophic disorder syndrome

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

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

Syndrome of digestive disorders and impaired food tolerance

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

CNS dysfunction syndrome

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

Syndrome of impaired hematopoiesis and immunobiological reactivity

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

Weakened nonspecific resistance.

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

Fetal hypotraphy

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

There are three options for the development of pathology:

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

Diagnosis of malnutrition in children

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

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

Biochemical examination reveals:

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

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

How is the treatment carried out?

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

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

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

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

Organization of diet therapy

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

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

Conclusion

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

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.

Dystrophy(Greek dys - disorder, trophe - nutrition) develops mainly in young children and is characterized by impaired absorption of nutrients by body tissues. There are the following types of dystrophies: 1) dystrophy with a lack of body weight (hypotrophy); 2) dystrophy with body weight corresponding to height or some excess of mass over length (paratrophy); 3) dystrophy with overweight (obesity) (Table 1).

Hypotrophy(Greek hypo - under, below trophe - nutrition) - a chronic eating disorder with a lack of body weight. This is a pathophysiological reaction of a young child, accompanied by a violation of the metabolic and trophic functions of the body and characterized by a decrease in food tolerance and immunobiological reactivity. According to WHO, malnutrition (malnutrition) is diagnosed in 20-30% or more of young children.

Etiology: According to the time of occurrence, congenital (prenatal) and acquired (postnatal) malnutrition are distinguished (Table 1). The causes, clinic and treatment of intrauterine growth retardation are discussed above in the section "Antenatal malnutrition".

There are 2 groups of acquired malnutrition according to etiology - exogenous and endogenous (Table 1). With careful collection of anamnesis data, a mixed etiology of malnutrition in a child is often established. With exogenous causes, primary malnutrition is diagnosed, with endogenous causes - secondary (symptomatic).

Exogenous causes of malnutrition:

1. Nutritional factors- Quantitative underfeeding in case of hypogalactia in the mother or feeding difficulties on the part of the mother or child, or qualitative underfeeding (use of an age-inappropriate mixture, late introduction of complementary foods).

2. Infectious factors- intrauterine infections, infectious diseases of the gastrointestinal tract, repeated acute respiratory viral infections, sepsis.

3. Toxic factors- the use of low-quality milk mixtures with an expired shelf life, hypervitaminosis A and D, drug poisoning.

4. Disadvantages of care, regime, education.

Endogenous causes of malnutrition:

1. Perinatal encephalopathy of various origins.

2. Bronchopulmonary dysplasia.

3. Congenital malformations of the gastrointestinal tract, cardiovascular system, kidneys, liver, brain and spinal cord.

4. Primary malabsorption syndrome (deficiency of lactase, sucrose, maltase, cystic fibrosis, exudative enteropathy) or secondary (intolerance to cow's milk proteins, "short gut" syndrome after extensive bowel resections, secondary disaccharidase deficiency).

5. Hereditary immunodeficiency states.

6. Hereditary metabolic disorders.

7. Endocrine diseases (hypothyroidism, adrenogenital syndrome).

8. Anomalies of the constitution.

Pathogenesis:

With malnutrition, the utilization of nutrients (primarily proteins) is impaired both in the intestine and in tissues. In all patients, the excretion of nitrogenous products in the urine increases with a violation of the ratio between urea nitrogen and total urine nitrogen. A decrease in the enzymatic activity of the stomach, intestines, pancreas is characteristic, and the level of deficiency corresponds to the severity of malnutrition. Therefore, a nutritional load that is adequate for a healthy child can cause acute indigestion in a patient with II-III degree malnutrition. With malnutrition, the functions of the liver, heart, kidneys, lungs, immune, endocrine, and central nervous systems are disrupted.

Of the metabolic disorders, the most typical are: hypoproteinemia, hypoalbuminemia, aminoaciduria, a tendency to hypoglycemia, acidosis, hypokalemia and hypokalemia, hypocalcemia and hypophosphamenia.

Classification:

According to the severity, three degrees of malnutrition are distinguished: I, II, W: (Table 1). The diagnosis indicates the etiology, time of onset, period of the disease, comorbidity, complications. It is necessary to distinguish between primary and secondary (symptomatic) malnutrition. Primary malnutrition can be the main or concomitant diagnosis and is usually the result of undernutrition.

Secondary malnutrition- complication of the underlying disease. Diagnosis

malnutrition is competent in children up to 2-3 years of age.

Clinical picture:

All clinical symptoms of malnutrition in children for the following groups of syndromes:

1. Trophic_disorder syndrome- thinning of the subcutaneous fat layer, lack of body weight and disproportionate physique (Chulitskaya and Erisman indices are reduced), a flat curve of weight gain, trophic skin changes, muscle thinning, decreased tissue turgor, signs of polyhypovitaminosis.

2. Syndrome of reduced food tolerance- loss of appetite up to anorexia, development of dyspeptic disorders (regurgitation, vomiting, unstable stool), decrease in secretory and enzymatic functions of the gastrointestinal tract.

3. CNS dysfunction syndrome- violation of emotional tone and behavior; low activity, the predominance of negative emotions, sleep disturbance and thermoregulation, delayed psychomotor development, muscle hypo-, dystonia.

4. Syndrome of decreased immunobiological reactivity- a tendency to frequent infections - inflammatory diseases, their erased and atypical course, the development of toxic-septic conditions, dysbiocenoses, secondary immunodeficiency states, a decrease in nonspecific resistance.

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 reduced to 10-15. Tissue turgor and muscle tone are reduced, the fat fold is flabby. Characterized by pallor of the bones and mucous membranes, a decrease in firmness and elasticity of the skin. The growth of the child does not lag behind the norm. The body weight deficit is 10-20%. The weight gain curve is flattened. The child's health is not disturbed. Psychomotor development corresponds to age. The child is restless, does not sleep well. Immunological reactivity is not broken.

Hypotrophy II degree. The subcutaneous fat layer is absent on the abdomen, chest, sharply thinned on the limbs, preserved on the face. Severe pallor, dryness, decreased elasticity of the skin. The fatness index of Chulitskaya is 0-10. Reduced tissue turgor (a skin fold hangs down on the inner surface of the thighs) and muscle tone. Active rickets in children is manifested by muscle hypotension, symptoms of osteoporosis, osteomalacia and hypoplasia. The body weight deficit is 20-30% (in relation to height), there is a lag in growth. The body weight gain curve is flat. Appetite is reduced. Food tolerance is reduced. Often regurgitation and vomiting are observed. Characterized by weakness and irritability, the child is indifferent to the environment. Sleep is restless. The child loses already acquired motor skills and abilities. Thermoregulation is impaired, and the child quickly cools or overheats.

Most children develop various diseases (otitis media, pneumonia, pyelonephritis), which are asymptomatic and long-term.

The chair is unstable (often liquefied, undigested, rarely constipation). Significantly reduced acidity of gastric juice, secretion and activity of enzymes of the stomach, pancreas and intestines. Subcompensated intestinal dysbacteriosis develops.

Hypotrophy III degree(marasmus, atrophy). Primary malnutrition of the III degree is characterized by an extreme degree of exhaustion: the external child resembles a skeleton covered with skin. The subcutaneous fat layer is absent. The skin is pale gray, dry. Extremities are cold. Skin folds do not straighten out, as there is no elasticity of the skin. Characterized by thrush, stomatitis. The forehead is covered with wrinkles, the chin is pointed, the cheeks are sunken. The abdomen is distended, distended, or bowel loops are contoured. The chair is unstable.

Body temperature is often lowered. The patient quickly cools on examination, easily overheats. Against the background of a sharp decrease in immunological reactivity, various

foci of infection that are asymptomatic. Significantly reduced muscle mass. The weight gain curve is negative. The body weight deficit exceeds 30% in children of appropriate height. The Chulitskaya index is negative. The child is severely retarded. 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.

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 a 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 nutritional 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 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 hypotrophy 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.