Pediatric Protein-Energy Malnutrition
Introduction
Introduction to Pediatric Protein-Energy Malnutrition Protein-energymal-trition (PEM) is a malnutrition caused by insufficient protein and/or energy supply in food or due to certain diseases, and occurs all over the world. Mainly manifested as progressive weight loss, subcutaneous fat reduction, edema and dysfunction of various organs, severe PEM can directly cause death, light chronic PEM is often ignored, but has a great impact on children's growth and disease recovery, so PEM is an important issue in clinical nutrition. basic knowledge The proportion of illness: 0.005% Susceptible people: children Mode of infection: non-infectious Complications: anemia, fatty liver, hypoglycemia
Cause
Pediatric protein-energy malnutrition
(1) Causes of the disease
According to the cause of the lack of protein and energy, it is divided into primary and secondary:
1. Primary protein-energy malnutrition: Primary protein-energy malnutrition occurs because the intake of protein and/or energy in food does not meet the physiological needs of the body, mainly due to improper diet and Insufficient intake, such as insufficient breast milk in infancy, but not timely and correct mixed feeding; if the milk powder is too diluted, suddenly weaned, the baby can not adapt or reject new foods, the older children often have bad eating habits, partial eclipse or vegetarian diet, Eat more candy, anorexia milk, meat, eggs, long-term use of amyloid foods (such as milk cakes, porridge), improper long-term food ingredients, insufficient heat or too little protein, the above reasons can cause insufficient intake Thermal energy - insufficient protein.
2. Secondary protein-energy malnutrition: Secondary protein-energy malnutrition is associated with disease, mainly due to loss of appetite, malabsorption, hyperbolism, increased consumption, dysplasia, and more common in digestive tract infections. (such as persistent diarrhea, chronic diarrhea, severe parasitic infections, etc.), intestinal malabsorption syndrome, congenital malformations of the digestive tract (such as cleft lip, cleft palate, congenital hypertrophic pyloric stenosis, etc.), chronic wasting diseases (such as tuberculosis, Hepatitis, long-term fever, malignant tumors, etc.).
(two) pathogenesis
Due to the lack of heat and protein supply, the body first uses stored glycogen, followed by the use of fat, fat reduction, and finally causes protein oxidation and energy supply, so that the body protein consumption, the formation of negative nitrogen balance, with the consumption of systemic fat and plasma protein Low, the total amount of fluid in the body is relatively increased, making the extracellular fluid hypotonic, such as vomiting, diarrhea, prone to hypotonic dehydration and acidosis, low sodium, low potassium, low magnesium and hypocalcemia.
Severe malnutrition has an impact on the digestive system, heart, kidney function, and central nervous system.
1. Digestive system gastrointestinal mucosa thinning or even atrophy, epithelial cells are deformed, intestinal villi lose normal morphology, gastric acid is reduced, disaccharidase is reduced, pancreas is reduced, pancreatic secretion enzyme activity is decreased, intestinal peristalsis is slowed, digestion and absorption function is decreased, The flora is dysfunctional and can cause diarrhea.
2. Severe cases of cardiac function cause a decrease in cardiac output, slow heart rate, prolonged circulation time, decreased peripheral blood flow, electrocardiogram often no specific change, X-ray shows heart shrinkage.
3. In patients with severe renal function, renal tubular cells are turbid and swollen, fat infiltration, glomerular filtration rate and renal blood flow are reduced, concentration function is reduced, and urine specific gravity is decreased.
4. Central nervous system malnutrition has a great impact on brain and mental development. Malnutrition, such as occurs at the peak of brain development, will affect the volume and chemical composition of the brain, reduce the weight of the brain, reduce phospholipids, and express imagination. , perception, language and movement ability lag behind normal children, IQ is low.
Prevention
Pediatric protein-energy malnutrition prevention
Prevention of malnutrition is essential, and prevention should focus on strengthening child health, providing nutrition guidance, promoting reasonable feeding knowledge, paying attention to hygiene, and preventing disease.
1. Reasonable feeding to encourage breastfeeding, complete breastfeeding within 4 months after birth, and gradually add as needed in 4-6 months.
2. Prevention and treatment of diseases to improve personal and environmental hygiene, prevention of acute and chronic infectious diseases, attention to disinfection of food utensils, prevention of gastrointestinal diseases, vaccination on schedule, cleft lip, cleft palate, congenital hypertrophic pyloric stenosis Handle in time.
3. Growth and development monitoring application of growth and development monitoring map, regular weight measurement and marked on the growth and development monitoring map, the measurement results are connected into a curve, if the weight gain is found to be slow, do not increase or fall, should be promptly looking for reasons to deal with.
4. Reasonably arrange the living system to ensure sleep, proper outdoor exercise and physical exercise, so that children's life has regularity.
Complication
Pediatric protein-energy malnutrition complications Complications, anemia, fatty liver, hypoglycemia
1. Anemia: Nutritional small cell anemia is most common, and is associated with the lack of iron, folic acid, vitamin B12, protein and other hematopoietic materials.
2. Vitamin deficiency: Common vitamins, especially vitamin A, B, C, D deficiency.
3. Growth and development disorders: Short stature, mental retardation, imagination, perception, language and motor skills lag behind normal children, IQ is low.
4. Fatty liver: Fatty liver often occurs.
5. Infection: The body's immunity is reduced, and various infectious diseases are prone to occur. The above feelings, thrush, otitis media, pneumonia, dermatitis, especially diarrhea, often prolonged unhealed, aggravating malnutrition and forming a vicious circle.
6. Hypoglycemia: Spontaneous hypoglycemia often occurs, and even death is caused.
Symptom
Pediatric protein-energy malnutrition symptoms Common symptoms Indifferent cheeks and depressions are monkey-like irritations, edema, hypotension, dry skin, slow pulse, full moon face, easy to cry, thin
Clinically, according to body weight, the degree of subcutaneous fat reduction and the severity of systemic symptoms, infants and young children malnutrition are classified as mild, moderate and severe. Severe malnutrition is clinically divided into marasmus and edema (kwashiorkor). ) and weight loss - edema type (marasmus-kwashiorkor).
1. Weight loss type: It is characterized by weight loss. Children's weight is significantly reduced, skinny and lean, growth retardation, subcutaneous fat reduction, dry and slack skin, loss of elasticity and luster, hair thinning, loss of inherent luster, face , weak, slow pulse, low blood pressure, low body temperature, easy to cry and so on.
2. Edema type: It is characterized by edema of the whole body. The light is seen in the lower limbs, the back of the foot, the heavy one is seen in the lower back, the external genitals and the face are also seen edema, the height of the child can be normal, the body fat is not reduced, the muscle is slack, like Full moon face, eyelid edema, easy peeling off of the skin-like skin disease, nails are fragile and have a horizontal groove, expression is indifferent, easy to irritate and willful, often fatty liver.
Simple protein or energy malnutrition is rare, and in most cases, protein and energy are simultaneously absent, manifesting as mixed protein-energy malnutrition.
Examine
Pediatric protein-energy malnutrition examination
1. The normal value of plasma albumin is >35g/L, 30~34g/L when the nutritional status is low, and 25~25g/L when the nutrition is low; when the plasma albumin is <25g/L, the pathological changes have been obvious in the body. .
2. The half-life of transferrin serum transferrin in vivo is 8-10 days, which is shorter than albumin (about 20 days), so the nutritional status is more sensitive than albumin. The normal value is 1.7-2.5g/L, moderate. Malnutrition was 1.0 to 1.5 g/L, and severe malnutrition was <1.0 g/L.
3. The pre-albumin prealbumin has a half-life of only 2 days in vivo, so it is more sensitive to evaluate the nutritional status. The normal value is 280-350 mg/L, and the protein-energy malnutrition is significantly decreased.
4. Serum amino acid determination The ratio of non-essential amino acids in the serum to essential amino acids was changed. In the early stage of nutrient deficiency, it was more sensitive than plasma protein and albumin. The normal value was 2-3.
Serum amino acid ratio = glycine serine glutamate taurine / leucine isoleucine valine methionine.
Its ratio > 3 has diagnostic reference value.
5. Urea and creatinine ratio When the low-protein diet is ingested, the urea excretion in urine is reduced, so the ratio is decreased.
6. The discharge of hydroxyproline in urine is related to the growth rate. The amount of urinary excretion in children with malnutrition is reduced. The amount of hydroxyproline and creatinine in urine can be determined to find hydroxyproline. index.
Hydroxyproline index = hydroxyproline (mol/ml) / creatinine [mol / (ml · kg)].
This index is relatively constant within 3 years of age, and preschool children are 2.0 to 5.0, < 2 means slow growth.
Electrocardiogram examination showed sinus bradycardia and QRS wave low voltage, ST-T abnormality, visible U wave.
Two-dimensional echocardiography shows that the heart is shrinking, a small number of visible heart chambers are enlarged, and cardiac output is decreased.
Chest X-ray examination: the heart is reduced, a small number of patients with mild heart enlargement, chest wall and spinal osteoporosis.
Diagnosis
Diagnosis and identification of protein-energy malnutrition in children
diagnosis
PEM is a complex clinical syndrome. There is no simple and reliable method for the diagnosis of various types, especially subclinical types. Most of them need to be comprehensively evaluated according to the main clinical symptoms and anthropometric parameters.
1. The medical history should be asked in detail about feeding and diet. The retrospective method is used to understand the relationship between the patient's morbidity and diet, and to estimate the intake of protein and heat for one day, which is of great value for diagnosis.
2. Clinical manifestations of protein-energy malnutrition clinically have weight loss, subcutaneous fat reduction, symptoms and signs of systemic dysfunction.
3. Physical Measurement In 1995, the National Conference on Improving the Quality of Life of Children decided that China also refers to the WTO evaluation criteria for physical measurement of child malnutrition:
(1) Underweight: According to the age and sex, compared with the same age, the normal reference value of the same sex, the median minus 2 standard deviations, but higher than or equal to the median minus 3 standard deviations Moderate weight loss; lower than the median minus 3 standard deviations for severe weight loss, this indicator reflects children's past and / or now have chronic and / or acute malnutrition, but this can not be distinguished Acute or chronic malnutrition.
(2) Stunting: According to the age and gender height, compared with the normal reference value of the same age and the same sex, the median is reduced by 2 standard deviations, but higher than or equal to the median minus 3 standard deviations. Moderate growth retardation; lower than the median minus 3 standard deviations for severe growth retardation, this indicator mainly reflects chronic malnutrition in the past or long-term.
(3) marasmus: according to height and sex, compared with the same age, normal reference value of the same sex, below the median minus 2 standard deviations, but higher than or equal to the median minus 3 standard deviations For moderate weight loss; those who are below the median minus 3 standard deviations are severely wasted. This indicator reflects the recent acute malnutrition in children.
Differential diagnosis
Children with edema due to the apparent lack of protein should be differentiated from heart, kidney edema, tuberculous peritonitis, ascites due to cirrhosis, and allergic edema.
