Malnutrition wasting in children
Introduction
Introduction to dystrophic weight loss in children Malnutrition in infants and young children, which is mainly caused by lack of heat, is called malnutrition, and malnutrition is caused by long-term food intake. The outstanding long-term energy is insufficient, or the food cannot be fully utilized, so that normal metabolism cannot be maintained. Your body tissue supplies energy to maintain the minimum life metabolism required. A chronic nutritional deficiency that occurs in which the body weight does not increase or decrease, growth and development are stagnant, and fat gradually disappears. It is a kind of extreme weight loss that is more common in infancy, also known as infantile atrophy (infantileatrophy, inanition, athrepsia). Muscle atrophy, lack of energy, easy to fatigue. At the same time, the systemic functions of the whole body are disordered and the immunity is low, which creates conditions for many diseases, especially infants with pneumonia and diarrhea. According to different clinical manifestations, it can be divided into: lean, edema and mixed; according to the degree of malnutrition, it is divided into mild, moderate and severe; according to the pathogenesis, it is divided into acute, subacute and chronic PEM. Acute onset is often accompanied by water and electrolyte imbalance; chronic patients are often accompanied by a variety of vitamins and trace elements, and about 3/4 of children are associated with zinc deficiency. basic knowledge The proportion of illness: 0.001% Susceptible people: children Mode of infection: non-infectious Complications: iron deficiency anemia rickets diarrhea pneumonia urinary tract infection hypoglycemia
Cause
Causes of dystrophic wasting in children
Feeding factors (25%):
Infants and young children grow rapidly and must supply enough nutrients, especially those with excellent bio-use value to meet the needs, such as insufficient breast milk products due to insufficient breast milk or improper feeding of artificial feeding, such as milk or milk powder. Or use cereals as the main food; or rush to eat dairy products after weaning, or improperly add food after weaning, eat with adults.
Disease factors (20%):
Diseases are often induced factors such as congenital lips, cleft palate affecting breastfeeding; diarrhea or gastroenteritis long-term restrictions on eating; chronic metabolic diseases affect digestion and absorption; various infectious diseases such as measles, whooping cough, dysentery, pneumonia, infant hepatitis, etc. In particular, chronic enteritis is the most important, and the latter suffers from malnutrition due to long-term digestion and absorption disorders, chronic consumption and insufficient intake.
Congenital nutritional basis is poor (15%):
More common in low birth weight infants caused by fetal malnutrition, full-term small samples and twins, multiple births and premature infants.
Heavier malnutrition is mostly caused by a variety of causes.
Pathogenesis
The pathological changes of mild dystrophy are reduced by subcutaneous fat, insufficient glycogen reserve and mild atrophy of the muscles. The severe intestinal dystrophy shows thinning of the intestinal wall, disappearance of mucosal folds, edema of myocardial fibers, hepatic fat infiltration, lymphoid tissue and thymus atrophy. As well as the reduction of various organs, the pathophysiological changes are as follows:
1. Tissue and organ function is low
(1) Digestive system changes: gastrointestinal mucosa shrinks and thins, wrinkles disappear, intestinal villi become shorter, mucosal epithelial cells become flat, cell number decreases, salivary glands, digestive glands of intestinal wall are severely atrophied, degenerated, pancreas becomes smaller, Vacuolar atrophy, reduced particle content, fatty degeneration, low digestive enzyme activity, significant digestive and absorption function, reduced intestinal peristalsis, lactose and sucrose in the stool, prone to hypertonic diarrhea, severe monosaccharide can not withstand Accepted.
(2) Central nervous system changes: the brain volume becomes smaller, the weight is reduced, the number of brain cells is not only reduced, the composition is also changed, and the amounts of lipidoids, lecithin, and cholesterol are all decreased, such as malnutrition occurring in the fetal period, newborns The critical period of brain development, such as period and infancy, can lead to irreversible changes and even affect future intelligence and behavior.
(3) Circulatory system: Although the myocardial cells are not atrophy, the muscle fibers are turbid and swollen, the myocardial contractility is weakened, the cardiac output is small, the electrocardiogram shows low voltage, and the blood pressure is also low.
(4) Kidney: The renal tubules are turbid and swollen, and the steatosis causes the urine to decrease in specific gravity.
2. Metabolic disorders
(1) disorders of glucose metabolism: malnourished children have low appetite, low intake, insufficient glycogen or excessive consumption, often showing low blood sugar.
(2) disorders of fat metabolism: due to the large amount of body fat consumption in this disease, serum cholesterol decreased, body fat consumption is too much, more than the liver's metabolic capacity, can lead to liver fat infiltration and degeneration.
(3) Protein metabolism disorders: due to insufficient protein intake, protein is in a negative nitrogen balance, serum total protein and albumin are reduced, total protein is less than 40g / L, albumin is less than 20g / L, low protein edema can occur.
(4) Malfunction of water and salt metabolism: Since the reduction of ATP synthesis can affect the transport of sodium pump on the cell membrane, sodium is retained in the cells, so the total fluid volume of the whole body is relatively large when malnourished, and the extracellular fluid is generally hypotonic. Gastrointestinal dysfunction is prone to hypotonic dehydration acidosis, hypokalemia and hypoglycemia.
3. Impaired immune function
Thymic lymphoid tissue atrophy in moderate to severe dystrophy, spleen, lymph nodes, tonsils, intestinal and appendix lymphoid tissue atrophy, non-specific and specific immune function such as skin barrier function, leukocyte phagocytosis and complement function, cellular immune function and body fluids The immune function is reduced, lymphocyte proliferation and differentiation are low, lymphoid immune factors such as interleukin and tumor necrosis factor are decreased, IgG, IgM, and IgA are also decreased. Malnutrition may be reported to be associated with IgG subclass defects, mostly IgG2 and IgG4, which is easy to cause influenza B bacillus and Streptococcus pneumoniae infection, T lymphocyte reduction, often accompanied by changes in T cell subsets, CD4/CD8 ratio is significantly reduced, T cells produced by the antigen-stimulated interferon significantly reduced, due to recall The reaction and delayed-type hypersensitivity of the skin were weakened, showing an OT response and a significant reduction in induration.
Prevention
Pediatric dystrophic weight loss prevention
Reducing the incidence of malnutrition should focus on preventing the occurrence of this disease. The specific measures are:
1. Doing health care during pregnancy: More and more data indicate that malnutrition in childhood is the continuation of malnutrition in infants and young children, while the latter is mostly due to malnutrition during the fetal period. To this end, it should be done during pregnancy and strengthen Nutritional guidance for pregnant women, especially for pregnancy, advanced nutrition guidance, clarify the balance of diet during pregnancy and the importance of supplemental nutrition in the middle and late stages of fetal growth and development.
2. Strengthen nutrition guidance for infants and young children: encourage breastfeeding, such as breast milk shortage, timely supplement dairy products, and guide the deployment of artificially fed milk, for infants from April to June, during weaning ("milk change period") It should be emphasized that after breaking off breast milk, the staple food should still be dairy products, and the staple food should be dairy products throughout the infancy. The type of food is gradually changed to semi-liquid to soft food, baby food, so over-cultivating children chewing and swallowing function, guidance Mothers prepare a balanced diet and develop good eating habits that are not picky eaters and are not partial.
3. Make an infant growth monitoring: The growth monitoring chart is a good method to evaluate the growth and development of infants and early detection of malnutrition. For example, the growth curve of infants does not grow with age, and the weight curve should be flat or fall. Find out the reasons for correction.
4. Do a good job in disease prevention and treatment: regular vaccination to prevent infectious diseases, timely treatment of lesions to prevent the spread of disease, for some congenital malformations such as lips, cleft palate and hypertrophic pyloric stenosis, often affecting the digestion and absorption of food, should be timely Correction should be treated early for prolonged diarrhea and repeated respiratory infections.
5. Others: Measures such as reasonable living arrangements, adequate sleep, regular meals, and physical exercise enhancements are important to prevent malnutrition.
Complication
Pediatric dystrophic weight loss complications Complications iron deficiency anemia diarrhea diarrhea pneumonia urinary tract infection hypoglycemia
1. Nutritional small cell anemia: the raw materials for children's hematopoiesis such as protein, iron, vitamin B12 are easy to lack, it is easy to suffer from anemia, common iron deficiency anemia.
2. Vitamin and trace element deficiency: lack of various vitamins and trace elements, especially vitamin A, B and C deficiency are more common, due to growth retardation, calcium, phosphorus need less, because of the serious vitamin D deficiency is relatively rare However, if the patient suffers from rickets and malnutrition, both can exist at the same time. In recent years, severe malnutrition has been found to be accompanied by iron, zinc, copper, and selenium deficiency, especially zinc deficiency. Zeng Baijin et al reported severe malnutrition 73.2%. With low blood zinc.
3. Infection: The most common are diarrhea, pneumonia and various infections, easy to secondary bronchial pneumonia, diarrhea, tuberculosis, otitis media, urinary tract infections and sepsis and other infections, especially infantile diarrhea can be prolonged, often accompanied by electrolytes Disorders, thus forming a vicious circle, more serious malnutrition.
4. Spontaneous hypoglycemia: Children with prolonged unhealed sometimes have spontaneous hypoglycemia, manifested as hypothermia, pale complexion, unconsciousness, slow pulse and even apnea, but no convulsions, if not timely intravenous injection A glucose solution that can die from apnea.
Symptom
Pediatric dystrophy weight loss symptoms common symptoms weight loss muscle dysplasia weakness pale pale diarrhea appetite drop blood pressure low irritability restless night horror mucus
Weight loss is not the first symptom of malnutrition. When the course is long, the body length (high) will be lower than normal. The subcutaneous fat layer will not be fully or completely disappeared. The order of reduction is abdominal, followed by chest, back and waist. Then the upper limbs, the lower limbs, the buttocks, the last forehead, the neck, the ankles and the cheeks. Therefore, in the early stage of malnutrition, if you only look at the face and do not have a whole body examination, it is not easy to find the weight loss. When the subcutaneous fat disappears a lot, the skin becomes dry. Pale, wrinkles and relaxation, loss of elasticity, intestinal type visible, muscle dysplasia, low muscle tone, sometimes increased, motor function development retardation, mental retardation, hypothermia, low heart sound, irregular rhythm, low blood pressure, respiratory table Shallow, often crying and irritating at the beginning, then become dull, not interested in the surrounding environment, sleep disorders, or alternating depression and irritability, early appetite is good, followed by low or even disappear, often vomiting and diarrhea, can also Stools with frequent frequency band mucus, so-called hunger diarrhea, children with chronic feeding may also be constipated often, accompanied by various life-giving Insufficient symptoms can occur, such as dry eye caused by vitamin A deficiency, B vitamin deficiency keratitis, iron deficiency, folic acid and vitamin B12 deficiency anemia, due to low immunity, susceptible to concurrent Symptoms, most commonly diarrhea, pneumonia and various infections.
1. Prenatal malnutrition: John Dobbingl proposed in 1968 that if malnutrition occurs in the second trimester, it is at the peak of brain development (developing brain), which is also a period of vulnerable brain cells. Poority can significantly affect the development of the brain, which may lead to brain dysfunction caused by the development of nerves and mental movements, and then cause cognitive and intelligent defects in children. Malnutrition in the third trimester affects the development of skeletal muscle and adipose tissue, caused by intrauterine malnutrition. Immune damage is both serious and long-lasting, and it is not easy to be corrected by post-natal nutritional supplementation. Recently, there are many epidemiological data showing that stunting can cause short stature in children, and it also reports fetal malnutrition and cardiovascular disease in adults. Such as hypertension, coronary heart disease and diabetes, intrauterine malnutrition often cause low birth weight children.
2. Neonatal malnutrition: Neonatal malnutrition may be the continuation of fetal malnutrition, but it can also occur within 1 month after birth. The cause is often related to improper feeding, congenital malformation of the digestive system such as lip and cleft palate, and clinical manifestations are physiological. After the weight loss, it is not easy to rise again, the weight continues to decrease, the subcutaneous fat is lost a lot, the forehead is wrinkled, the humerus is raised, and the appearance of "small old man" is good, crying, irritability, loss of appetite or refusal of milk, immune function is low, easy Infection, often associated with anemia, vitamin deficiency and edema, combined with diarrhea acidosis, due to poor respiratory function compensation, clinical manifestations of typical acidosis, should be vigilant.
Malnutrition in children over 3.3 years old: malnutrition in this period can be due to: the continuation of malnutrition in infancy; insufficient heat and protein intake; poor eating habits affecting eating; heavy homework affecting appetite or due to various causes such as systemic diseases, early It is manifested as burnout, irritability, loss of appetite and digestive disorder. Constipation is quite common, or even hunger mucus, poor fat tolerance, such as excessive supply, vomiting, diarrhea, muscle relaxation A tired posture such as a round shoulder, a flat chest and abdomen protruding, often showing burnout, pale, dark complexion and lack of eyes, most children have neurological symptoms such as sleep, night terror, sometimes developed into Various neuropsychiatric symptoms, such as enuresis, bite nails and facial convulsions, common hypoalbuminemia, prolonged cases, delayed bone development, irregular teeth, puberty can be delayed, patients' resistance is reduced, and various infections are easily associated .
Examine
Pediatric dystrophic weight loss check
1. Plasma insulin growth factor 1 (IGF-1) reduction: insulin growth factor 1 plays an important role in regulating substance metabolism and promoting growth and development. Patients with malnutrition have not changed their body length (high), body weight and other physical development indicators. Decreased, and is not affected by liver function, is considered to be a sensitive and reliable indicator for early diagnosis of protein malnutrition. Huang Yonglan et al recently reported that serum IGF-1 levels in children with dystrophic growth retardation are significantly reduced, the degree of reduction and physical development The degree of abnormality of the indicator is related.
2. Amino acid-related ratio: the ratio of plasma essential amino acids to non-essential amino acids decreased, amino acid urinary acid, plasma taurine content decreased significantly, and can also be used as an early diagnostic indicator.
3. Decreased serum enzyme activity: various serum enzyme activities are reduced, such as amylase, cholinesterase, transaminase, alkaline phosphatase, trypsin and xanthine oxidase, and the activity is reduced, and soon returns to normal after treatment.
4. Reduced blood glucose levels: a diabetic tolerance curve.
5. Serum cholesterol: serum cholesterol levels are reduced.
6. Decreased trace element content: such as serum iron, zinc, selenium, copper, magnesium, etc., especially blood zinc decreased significantly in severe malnutrition. It has been reported that serum zinc reduction is significantly positively correlated with serum IGF-1 decrease.
7. Anthropometric measurements: measuring height, weight, upper arm circumference, upper arm circumference, head circumference, chest circumference, abdominal circumference; measuring the thickness of skin folds at specific sites to determine the growth and development of children, significantly lower than their peers.
8. Creatinine/Height Index: Creatinine is a breakdown product of whole body muscles. When normal, the daily discharge is relatively constant. When protein storage decreases, muscle atrophy leads to a decrease in creatinine production. Therefore, the creatinine/height index decreases, and 24 hours of urine can be used for evaluation. The creatinine discharge is divided by the ideal creatinine discharge of the medium-sized body corresponding to the height, and the actual discharge is calculated as the percentage of the ideal discharge. The diagnostic criteria are: >90% normal; 80%-90% is mild nutritional deficiency; 60 % to 80% are moderate nutritional deficiencies; <60% are severe nutritional deficiencies.
9. Radiological examination: routinely not required, but X-ray examination is necessary if rickets, osteomalacia, infantile scurvy or protein thermal malnutrition are found.
10. ECG examination: beriberi, potassium deficiency, selenium deficiency (Keshan disease) involve the heart, ECG examination is helpful for diagnosis and treatment.
11. Dark adaptation test: When accompanied by vitamin A deficiency, the adaptation time is prolonged.
12. Nutritional index (Nutritional: assessment: index, NAI): Mortality can also be predicted. When NAI 60, the prognosis is good, 40 complications and mortality are high, and 60 to 40 are moderate.
Calculation formula:
NAI=2.64(AC): 0.6(PA): 3.76(RBP): 0.017(PPD)-53.8
Where AC is the arm circumference (cm), PA is the prealbumin (mg·L-1), RBP is the retinol binding protein (mg·L-1) and PPD is the purified protein derivative intradermal reaction circle (long Trail × short diameter, cm2).
Diagnosis
Diagnosis and diagnosis of dystrophic wasting in children
1. History and physical examination: According to the child's birth history, age, feeding, weight loss, subcutaneous fat reduction, systemic dysfunction and other nutrient deficiency symptoms and signs, typical case diagnosis is not difficult, for mild cases Children need to be discovered through longitudinal growth monitoring.
2. Physical measurement
(1) Commonly used indicators: age-specific body weight, age-specific body length (height) and body length (height)-specific weight, the base layer can also use the abdominal wall skinfold thickness, generally mild malnutrition, and the abdominal wall skinfold thickness <0.8cm, moderate <0.4cm, the severity is basically disappeared, and the head circumference can be measured under 3 years old. Generally, moderate malnutrition has a head circumference of <2SD and a severity <3SD.
(2) Evaluation method:
Median reduction standard deviation method:
1 underweight: the child's age is lower than the same age, the same sex reference population value (US National Health Statistics Center, NCHS) variation range, below the median minus 2 standard deviation; higher than or equal to The median was reduced by 3 standard deviations to moderate; below the median minus 3 standard deviations was severe. This indicator mainly reflected children's past and/or now chronic and/or acute malnutrition.
2 stunting: the child's age-specific length (height) is lower than the normal age range of the same-age peer-to-sex reference population (NCHS), less than the median minus 2 standard deviations; higher or equal to the median reduction The three standard deviations were moderate; below the median minus 3 standard deviations were severe, this indicator mainly reflected malnutrition in the past or long-term.
3 wasting: The child's body length (height) is less than the normal range of the same-sex-height reference population (NCHS), less than the median minus 2 standard deviations, but higher than or equal to the median The reduction of 3 standard deviations is moderate; below the median minus 3 standard deviations is severe, this indicator mainly reflects children's recent acute malnutrition.
(3) Early diagnosis indicators: the ratio of plasma essential amino acids to non-essential amino acids decreased, amino acid urine appeared, and plasma taurine content decreased significantly, which was an early diagnostic indicator.
(4) Reduced serum activity of various enzymes: decreased activity of various enzymes, such as amylase, cholinesterase, transaminase, alkaline phosphatase, trypsin and xanthine oxidase, and decreased quickly after treatment normal.
(5) Decreased blood glucose level: a diabetic tolerance curve and a decrease in serum cholesterol levels.
(6) Decreased trace element content: such as serum iron, zinc, selenium, copper, magnesium, etc., especially blood zinc decreased significantly in severe malnutrition. Recently, it has been reported that serum zinc reduction is significantly positively correlated with serum IGF-1 decrease. .
Pay attention to the difference between zinc deficiency and other nutrient deficiency caused by weight loss; identify with chronic diseases such as tuberculosis infection, intestinal parasitic disease, intestinal malabsorption syndrome.
