How to determine the degree of malnutrition in children. Instrumental diagnostic methods

Hypotrophy in children is a chronic underweight. Starting from stage prenatal 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 increasing the number of children with overweight is in the world medical practice very acute due to the fact that an increase in protein nutrition leads to speed dial weight in a child of the first year of life. In the future, they risk getting metabolic syndrome.

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

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

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 body length and head circumference corresponding to the gestational age, but the weight and circumference of the chest and abdomen are 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 degree 1, 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. normal mass body at 3 months this child should have 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.

Causes

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 during pregnancy, insulin-dependent diabetes mellitus, multiple pregnancy, infertility and a history of abortion, taking certain medicines, harmful production factors (vibration, ultrasound), chronic stress and other neuropsychic overloads, rubella, syphilis, suffered during pregnancy.
Placental causes associated with pathology of the placenta. Perhaps its underdevelopment, inflammation, low attachment, premature detachment, early aging. IN last years here they began to include antiphospholipid syndrome, that is, the formation of blood clots in the vessels of the placenta.

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 women living 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. varying degrees gravity.

Hypotrophy in young children is based on other causes:

Exogenous - direct lack of basic food ingredients, malnutrition and problems that interfere with 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 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 ongoing treatment, reaches 35%.

Children who have undergone IUGR have symptoms such as:

Lagging behind in physical development (60%);
Delayed psychomotor development (40%);
Children's cerebral paralysis;
(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 the early childhood especially up to a year.

Studying long-term effects congenital malnutrition of newborns revealed symptoms of decreased intelligence at school age, neurological disorders, propensity to develop hypertension, coronary heart disease, diabetes mellitus.

1 degree

With hypotrophy of the 1st degree, the child has minor symptoms, confirming that the diet has been disturbed. Removes the fat layer from the front abdominal wall, 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 the level of 2 degrees appear the following symptoms. 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, in feces undigested food. 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, sleep is disturbed, often naughty, restless.

3 degree

The 3rd degree of malnutrition in a child is the most severe, if it is not treated, the child 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 respiration, a decrease in pressure, stunting, delay mental development refusing 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 under one year old, the index is 25-30 cm. With hypotrophy of the 1st degree, it is reduced to 10-15 cm, with the 2nd degree it is 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 enough, 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, they will prescribe suitable breast milk substitutes, 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 diet 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 kid gets a complex infusion therapy and parenteral and enteral tube feeding.

Treatment of the 3rd degree of malnutrition is aimed at maintaining and correcting vital important functions 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 is adequate breastfeeding, the timely introduction of complementary foods and complementary foods and proper care for the baby.

Hypotrophy in newborns is one of the varieties of chronic malnutrition.

From the very moment of their birth, babies begin to actively gain weight. All their organs grow, all body systems continue to develop. If the child is not enough to feed and take care of the child incorrectly, then the first signs of a violation will appear quite quickly.

The described pathology is the most common and most significant variant of dystrophy. Babies of the first 3 years of life are especially susceptible to this disease. The prevalence of this condition among the child population depends on the level of socio-economic development of countries and ranges from 2-7 to 30%.

As a rule, about hypotrophy in question when there is a lag in body weight from age norm more than 10%. The disease in question is accompanied by profound disturbances in the process, suppression of immunity, and a lag in psychomotor and speech development.

Causes of malnutrition in newborns

The reasons as a result of which malnutrition may develop in newborns can be divided into internal factors and external.

The first includes encephalopathy, due to which the work of all organs is disrupted; underdevelopment lung tissue leading to an insufficient supply of oxygen to the body and, as a result, to a slowdown in the development of organs; congenital pathology digestive tract and other pathological conditions.

The latter include insufficient and improper feeding, late introduction of complementary foods, exposure to toxic substances, including drugs, and morbidity. various infections. All these negative external factors leading to hypotrophy of newborns, the photo of which is located below, are quite rare. However, they should not be underestimated.

Malnutrition in children can be of two types: congenital and acquired. The first develops while the baby is in the womb. The second occurs after the baby is born.

Manifestations of the described disease can be mild, moderate or severe, which corresponds to three degrees of the pathology in question.

Intrauterine malnutrition of the 1st degree in newborns

Hypotrophy of the newborn of the 1st degree is manifested by a slight change in appetite, which is usually accompanied by sleep disturbances and frequent anxiety. This degree considered the easiest. In this case, the lag in body weight is no more than 20%, and there are no deviations in growth. The integuments of the baby's skin, as a rule, do not undergo any changes, with the exception of the appearance of some pallor and reduced elasticity. Thinness is noted only in the tummy area. Muscle tone usually retained, sometimes slightly lowered.

In some cases, intrauterine hypotrophy of the 1st degree in newborns occurs with anemia or rickets. The activity of the immune system as a whole is reduced. Children from this often get sick, outwardly they do not seem as well-fed as their peers. Some babies may experience digestive disorders such as diarrhea or constipation.

Often, hypotrophy of the 1st degree in newborns is not noticed at all by parents. The disease can only be detected by an experienced specialist during a thorough examination with diagnostics.

At the same time, the doctor will definitely find out if the thinness of the child does not belong to his physiological characteristics. The fact is that high growth and thinness could be inherited by the baby. And it is quite possible that you should not worry at all about the fact that the child does not look so well-fed, if at the same time the baby remains active, he is cheerful enough and eats quite well.

2nd degree of malnutrition in a newborn child

The second degree of the described pathology in terms of severity is medium. It includes lagging behind the norm both in weight and in body length. At the same time, weight is reduced by an average of 20-30%, growth by 30-40 mm, which, unlike the first degree of the disease, does not go unnoticed by parents.

This degree of malnutrition of newborns may be accompanied by frequent regurgitation, the baby is lethargic, he is reluctant to eat food or refuses it altogether, moves little, feels sad, his hands and feet are cold.

With the described variant of pathological changes in infants, developmental delay occurs not only physically, but also mentally. Sleep impairments are observed. The skin becomes dry and pale, often flaky, loses its elasticity and folds easily.

Thinness is more pronounced and affects not only the stomach, but also the limbs. With hypotrophy of the second degree, the contours of the ribs are clearly visible in the baby. Babies with a similar form of violation are very often exposed to various kinds of diseases. The chair of such kids is characterized by instability.

Hypotrophy of the 3rd degree in newborns

Hypotrophy of the newborn of the 3rd degree is the most severe of the described options. Deviations in body weight in this case reach more than 30%. The growth deficit is significant, on average it is about 10 cm. The child is weak, drowsy and tearful, indifferent to almost everything. Many acquired skills in the baby are lost.

The thinning of the subcutaneous fat layer is largely expressed throughout the body. On the part of the muscles, severe atrophy is noted. The baby's hands and feet are cold. The skin is dry, the color is pale with a grayish tinge. The eyes and lips of the baby are dry, cracks form around the mouth.

Often, children with a similar variant of the pathology develop various infectious lesions certain organs, in particular, kidneys (pyelonephritis), lungs (), etc.

Treatment of malnutrition in newborns

The diagnosis of the described pathology is established not only according to the medical examination.

In order to objectively assess the severity of hypotrophy of the newborn, the baby's body weight is determined and the baby's body length is measured. In addition, the thickness of the skin fold is determined, and the circumference of the shoulders and hips is determined.

Therapy under consideration pathological condition always depends on the cause that led to its development, on the severity of the disease, as well as on the nature and type of disorders in the functioning of internal organs formed as a result of the disease.

To save the baby from malnutrition, it is necessary not only to take vitamin medications or start heavy feeding. Treatment of this disease usually involves a whole range of measures aimed at eliminating the cause of the disease, maintaining optimal age-appropriate nutrition, and also aimed at combating complications.

With pathology of the 1st degree, the baby can be treated at home. Hypotrophy of the 2nd degree in newborns, and even more so, the 3rd degree of the disease is necessarily treated in a hospital.

The fundamental therapeutic method for this disease is diet. The first step is to test stability. At the same time, the doctor monitors how the child digests food, whether there is diarrhea, bloating, etc.

The second stage includes the gradual compensation of the missing nutrients, including trace elements and . The number of meals decreases, the volume and calorie content increases.

At the third stage of diet therapy, the food load increases. This is done only after the full restoration of the function of the stomach and intestines. At the same time, protein intake is limited. The criteria for the effectiveness of treatment are daily weight gain of 25-30 grams, restoration of appetite and general condition of the baby, normalization of the skin condition.

With hypotrophy of the 3rd degree in newborns self-administration food often becomes impossible. Plus, the baby's digestive tract is severely damaged and unable to process food. Based on this, such children are transferred to intravenous nutrition, which is used as various solutions that replenish the volume of fluid and regulate metabolism.

An obligatory component of the therapy of the described pathology is intramuscular or intravenous administration vitamins. The most basic in this case are vitamins C, B1 and B6. Subsequently, multivitamin complexes are prescribed.

The lack of gastric juice is replaced enzyme preparations, of which Festal or Panzinorm is most often prescribed. To improve metabolic processes resort to stimulating therapy. Assign Pentoxifylline or ginseng preparations. In severe cases, resort to the help of immunoglobulin.

With the development of rickets, physiotherapy and vitamin D are used. In case of anemia, iron preparations are prescribed.

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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, utilization is impaired nutrients(primarily proteins) both in the intestines and in the 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, the nutritional load, adequate healthy child in a patient with malnutrition II-III degree can cause severe indigestion. 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 weight gain curve, trophic skin changes, muscle thinning, decreased tissue turgor, signs of polyhypovitaminosis.

2. Syndrome of reduced food tolerance- loss of appetite up to anorexia, the development of dyspeptic disorders (regurgitation, vomiting, unstable chair), a decrease in the 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. On the background sharp decline 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.

Hardly considered rare today. This condition is accompanied by chronic eating disorders, in which the weight of the baby lags behind the norm by more than 10%. Hypotrophy can be both intrauterine and develop after the birth of a child. So what are the causes and symptoms of this pathology?

Causes of intrauterine malnutrition in a child

In some cases, a violation of normal nutrition appears even during the fetus. Such a child is born already with noticeable symptoms - he weighs much less than normal. Sick children are feeble with poorly developed fatty layer and flaky skin.

To begin with, it is worth noting that the mother's nutrition plays a significant role in the development of the fetus, and it is worth taking into account not only the quantity, but also the quality of the food consumed. The diet of a pregnant woman should be varied and contain the main groups of nutrients.

On the other hand, malnutrition may also be associated with metabolic disorders in the placenta. To include insufficient blood circulation, early and late severe toxicosis. Sometimes the reasons lie in adverse environmental conditions. The risk of developing malnutrition increases with constant stress.

Causes of malnutrition in a child after birth

Often children are born quite healthy, but in the next few weeks you can notice a sharp weight loss. Quite often, malnutrition in infants is associated with malnutrition. For example, a deficit subcutaneous tissue sometimes the result of too little breast milk (or formula). Do not forget that a nursing mother should also eat right, as the quality and satiety of milk depends on this.

On the other hand, the cause of malnutrition may be a disorder in work. digestive system. Intestinal infections, dysbacteriosis and some other diseases are often accompanied by vomiting and diarrhea, which, accordingly, creates a lack of nutrients. Risk factors include damage to the nervous system or heart muscle, as well as trauma or congenital anatomical anomalies in the structure. oral cavity because it prevents the child from eating normally.

Symptoms and forms of malnutrition in a child

Of course, the signs of this pathology directly depend on its severity.

Hypotrophy of the 1st degree in children is accompanied by a lag in weight gain by about 10-15%. The amount of fatty subcutaneous tissue decreases mainly on the hips and abdomen.
The second degree of malnutrition is characterized by a decrease in the layer of subcutaneous fat not only on the trunk, but also on the limbs. The delay in mass in this case is 15-30%.
If the baby's body weight is more than 30% below normal, then doctors talk about the third, severe degree of malnutrition. The fat layer disappears on the trunk, limbs and face.

Treatment of malnutrition in children

Of course, similar condition requires medical attention. First of all, the doctor must determine what is the cause of such an eating disorder. Medical treatment necessary in cases where malnutrition is the result of certain malformations, infectious or chronic diseases. If the reasons lie in malnutrition, then you need to adjust the diet of the baby or the nursing mother. But the diet should be compiled individually by the attending physician - an additional amount of food should be introduced gradually. An additional intake of mineral-vitamin complexes, walks on fresh air and regular therapeutic exercises.

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 bridle language, 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 (and others), intranatal infections, toxic-septic conditions, and infection urinary tract, intestinal infections, etc. Especially often the cause of hypotrophy 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 in any mild infectious diseases, energy and other nutritional requirements 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 the data in developing countries up to 20-30% or more of young children have protein-calorie or other types of malnutrition.

Toxic factors - use in artificial feeding milk mixtures with an expired shelf life or poor quality, hypervitaminosis D and A, poisoning, including drugs, 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 bovine or soy milk, 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 BKN is divided into following groups violations:

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 concerned, adult expression.
zhenie. Sleep is restless. Thermoregulation is impaired and the child quickly cools or overheats depending on the temperature environment. 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 otoscopic examination eardrum weakly expressed. The stool in patients with malnutrition is unstable: constipation is replaced by dyspeptic stool.

Hypotrophy III degree (marasmus, atrophy)

Hypotrophy III degree is characterized extreme 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, bronchopulmonary dysplasia (BPD). That this is a form of chronic eating disorder is supported by the fact that PBP is reduced, and after active treatment of the underlying disease, for example, surgery for congenital defect heart, the physical development of children is normalized. As a rule, children with hypostatura also have other signs of chronic eating disorders that are characteristic of grade II malnutrition (trophic disorders and moderate pronounced signs polyhypovitaminosis on the skin, dysproteinemia, deterioration of fat absorption in the intestine, low levels phospholipids, chylomicrons and blood a-lipoproteins, aminoaciduria).

It is important to emphasize that biological age child (bone, etc.) corresponds to its length and body weight. Unlike children with hypostatura, 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 age-appropriate, food tolerance and not broken. 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 in intrauterine infections, with 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 mainly to nutrition plant food, 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 protein loss with (), 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) reduction 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: stratified pigmented dermatosis (red-brown patches of skin round 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 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 are also characterized by intermittent diarrhea with stools with bad smell 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)

Occurs in preschool children 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 evaluation possible influence on nutritional status (in particular, diuretics, anorexants).

Social adaptation among peers, family, possible signs, 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, sore calves, 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, there may be crucial: chronic stress, excessive neuropsychic stress, neurosis, leading to excessive emotional arousal, insufficient sleep. 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%. Frequent symptoms 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, rib cage flattened but protruding belly (so-called "tired posture"), "flaccid posture", frequent respiratory and other infections, some delay in puberty, caries. In the treatment of such children, in addition to the normalization of the diet and a long course of vitamin therapy, it is necessary individual approach in recommendations on the regime of the day and in general on the way of life.

Essential fatty acid deficiency

Feeding unadapted for baby food mixtures from cow's milk, malabsorption of fats can lead to a syndrome of insufficiency of linoleic and linolenic acid: dryness and peeling of the skin, alopecia, small gains in body weight and length, poor wound healing, thrombocytopenia, diarrhea, recurrent infections of the skin, 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 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 disorder in the family is often preceded by sudden death 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 sweaty feet, cheese, rancid butter). Treatment with riboflavin (10 mg intravenously every 6 hours) and carnitine chloride (100 mg/kg orally in 4 doses) leads to the normalization of the children's condition.

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, sometimes muscle fibers. However, often dyspeptic phenomena are due to the ascent coli V upper divisions intestines and an increase in its motility or infection with its pathogenic strains, dysbacteriosis.

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

In a patient with hypostatura, it is necessary to exclude different kinds dwarfism - disproportionate (chondrodystrophy, congenital bone fragility, 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 endocrine system there is a downward trend. 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 in the future 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.

That's why fundamental principles diet therapy for malnutrition is a three-phase diet:

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.

Next important principles 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 first day of treatment the child does not lose body weight, and from the 3-4th day even with severe degrees hypotrophy began 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 with parenteral nutrition) should be 4 mmol / kg (that is, 1-1.5 times higher than normal), and sodium should not exceed
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 amount due to 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, add to the main mixture medicinal mixtures(up to '/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 that which the child would receive for the proper body weight. Increasing the dietary load of proteins, carbohydrates and, in last turn, fats, should be made 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 (inclusion sugar syrup, porridge); 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 increases weight by 25-30 g, normalization of the L. I. Chulitskaya index (fatness) and restoration of lost skills of psychomotor development along with the acquisition of new ones, improvement of food digestion (according to the co-program).

It should be borne in mind that the optimal ratio between food protein and energy for protein utilization on initial stage is: 1 g of protein per 150 non-protein kilocalories, and therefore, simultaneously with the protein load, it is imperative to increase the amount of carbohydrates, because patients with eating disorders do not tolerate an increase in fat load.

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 transition period reaches 14-16 g/kg per day, and after that they begin to increase the load of fats, using whole kefir, bifilin, yolk porridge additives, 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 quantities proteins are not absorbed, and therefore are useless, in addition, they can contribute to metabolic acidosis, hepatomegaly. IN initial period increased protein nutrition in a child, transient tubular distal acidosis may occur (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 hypotrophy of the 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. positive impact warm baths (water temperature 38 ° C) exert on the course of malnutrition, 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 - necessary condition successful treatment 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 in the complex medical measures a course of bifidumbacterin or bificol for 3 weeks.

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 is used, gastric juice diluted with water, festal, mezim, etc. 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). Blood and plasma transfusions should not be used for this purpose, prescribe anabolic steroid(Nerobol, Retabolil, etc.), glucocorticoids.

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 when hemoglobin is 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 various children should be differentiated. Persistence is required from the doctor, A complex 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

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