Diagnosis of hypotrophy

The diagnosis of hypotrophy in children is based on anamnesis data, clinical manifestations of the disease, assessment of anthropometric indicators and data from laboratory research methods.

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Indications for consultation with other specialists

Children with hypotrophy, especially with its chronic form, need a consultation with a medical geneticist and endocrinologist in order to exclude genetic syndromes, as well as hereditary and endocrine diseases that require specialized therapy. In case of disorders of the act of chewing and swallowing, a consultation with a neurologist is indicated, and in case of impaired eating behavior, neurogenic anorexia, a consultation with a medical psychologist and child psychiatrist is indicated. In examining a child with hypotrophy, it is necessary to involve a gastroenterologist in order to exclude primary gastroenterological pathology, and in case of an unusual epidemiological history and signs of an infectious or parasitic disease, a consultation with an infectious disease specialist is necessary.

When treating children with severe forms of malnutrition, especially with signs of multiple organ failure, the participation of doctors from the intensive care unit may be required to correct the infusion therapy and parenteral nutrition.

Diagnosis of hypotrophy based on anamnesis

When collecting anamnesis, it is important to assess:

• the nature of the patient's diet;
• consumption of unusual foods;
• a sudden change in diet;
• taking medications, vitamin and mineral supplements;
• the emergence of unusual taste preferences;
• choking when eating thick foods;
• episodes of regurgitation and vomiting.

It is also necessary to note other signs of gastrointestinal pathology, which are characterized by hypotrophy: bloating and abdominal pain, diarrhea, constipation or unstable stool, blood in the stool. It is necessary to find out whether general weakness, increased fatigue, decreased mental performance, impaired dim vision, bone pain, muscle pain, cramps and twitching, numbness, paresthesia in the limbs were observed. To diagnose hypotrophy, it is important to assess the dynamics of anthropometric indicators, especially changes in body weight over the past 6 months.

During a physical examination of children with suspected hypotrophy, it is necessary to assess the condition of the skin and its appendages:

• degree of skin dryness;
• presence of rash, petechiae;
• changes in hair color and quality, hair loss;
• condition of the visible mucous membranes (phenomena of cheilitis, glossitis, raspberry tongue, keratomalacia);
• condition of teeth.

When examining the patient, thinning or disappearance of the subcutaneous fat layer and loss of muscle mass are noted. Edema, hepatomegaly, and peripheral neuropathy may develop. These and other symptoms of hypotrophy in children not only reflect a deficiency of protein and energy, but also serve as signs of polynutrient deficiency.

Symptoms of macro- and micronutrient deficiency

	Symptoms	Nutrient deficiency
General.	Weakness, fatigue, weight loss, muscle weakness	Protein, calories
Leather	Pallor	Folacin, Fe, vitamin B ]2
	Follicular hyperkeratosis, thinning, dryness and roughness	Vitamin A, Vitamin C, Biotin
	Perifollicular petechiae	Vitamin C
	Dermatitis	Protein, calories, vitamin PP, vitamin B2, Zn, vitamin A, essential fatty acids
	Spontaneous hemorrhages, hemorrhages, petechiae	Vitamin C, Vitamin K, Polyphenols
Hair	Alopecia	Protein, Zn
	Thin, brittle	Biotin, pantothenic acid, vitamin C, vitamin A
Eyes	Hemeralopia, xerophthalmia, keratomalacia, photophobia, sand sensation, corneal conjunctival xerosis	Vitamin A
	Conjunctivitis	Vitamin A, vitamin B 2
Language	Glossitis	Vitamin B2 , vitamin PP, vitaminBt2
	Bleeding gums, erosions and ulcers of the mucous membranes	Folacin, protein, vitamin A, vitamin C, vitamin K
	Tingling and burning, soreness, enlargement and swelling of the papillae	Folacin, vitamin B12, vitamin C, vitamin PP
	Angular stomatitis, cheilosis	Folacin, Fe, vitamin B2, vitamin PP, vitamin B6
Nervous system	Tetany	Ca, Mg
	Paresthesia	Vitamin B1, vitamin B 6
	Decreased reflexes, ataxia, muscular dystrophy, hyperkinesis	Vitamin B 12, vitamin B2 ?, vitamin E
	Dementia, disorientation	Niacin, vitamin B 12
	Ophthalmoplegia	Vitamin E, vitamin B1
	Depression	Biotin, folacin, vitamin B 12

To date, the criteria for assessing the nutritional status of a healthy and sick person have not been sufficiently developed and scientifically substantiated. Large population studies of anthropometric indicators of the country's population are needed, taking into account gender, age, health status of the patient and social factors. Existing classifications of human nutritional status are usually based on an assessment of the deviation of actual body weight from its ideal (proper, normal, calculated) value. However, body weight depends on many factors: age, constitution, gender, previous nutrition, living conditions, nature of work, lifestyle, etc. According to the recommendations of FAO/WHO nutrition experts, the simplest, most generally accepted and highly informative criterion for assessing nutritional status is the so-called body mass index (BMI), or Quetelet index, calculated as the ratio of body weight (in kilograms) to height (in meters) squared. Many classifications of malnutrition are based on this indicator.

Assessment of nutritional status in children over 12 years of age using body mass index

Type of eating disorder	Degree	Body mass index
Obesity	III	>40
	II	30-40
	I	27.5-29.9
Increased nutrition		23.0-27.4
Norm	19.5
Low nutrition		18.5-19.4
Protein-energy malnutrition	I	17-18.4
	II	15-16.9
	III	<15

When assessing the nutritional status of children, most criteria and classifications of malnutrition are difficult or even impossible to use. It is necessary to take into account the age and rapid growth rate of the child's body. Calculating BMI for young children is uninformative and can only be used for children over 12 years old; in children under 12 years old, the percentage of deviation from the expected weight is used as a criterion for hypotrophy. The classification of J. Waterlow is widely used in the world to determine the severity of hypotrophy in young children.

The expected (ideal) body weight of children is determined using tables of centile or percentage distributions of body weight depending on the child’s height and age.

In addition to body length and weight, when studying anthropometric indicators in children, the circumference of the head, chest, abdomen, shoulder, hip, as well as the thickness of the skin-fat folds at standard points are assessed. In young children, great importance is attached to the indicators of head circumference, the number of teeth and the size of the fontanelles.

Laboratory test results in children with hypotrophy show significant changes in biochemical markers of protein metabolism: marasmus is characterized by a moderate decrease in the content of total protein and albumin in the blood serum, a decrease in the absolute number of peripheral blood lymphocytes; with kwashiorkor, the level of albumin and other transport proteins is significantly reduced. The level of urea in children with hypotrophy is sharply reduced or is at the lower limit of the norm, while the level of creatinine remains virtually unchanged. The level of creatinine in urine may increase, total nitrogen in urine is usually reduced.

Serum proteins are more indicative markers of protein starvation than muscle mass, but their sensitivity to changes in the internal environment depends on their half-life. Short-lived proteins are better for monitoring the effectiveness of treatment.

Protein markers of nutritional status (Cynober L, 2000)

Protein	Half-life, days	Concentration in blood
Albumen	20	42±2 g/l
Transferrin	8	2.8+0.3 g/l
Transthyretin	2	310±35 mg/l
Retinol binding protein	0.5	62±7 mg/l

In addition to protein metabolism disorders, children with hypotrophy often experience:

• polycythemia and increased blood viscosity;
• tendency to hypoglycemia;
• hypokalemia;
• hypocalcemia;
• hypomagnesemia and a tendency to hypernatremia;
• significant hormonal changes.

The immunogram parameters indicate secondary immunodeficiency with suppression of cellular immunity (reduction in the number of T-lymphocytes) and impaired phagocytic activity of neutrophils; the level of immunoglobulins of class M, G and A may remain at a normal level. Changes in the coprogram are variable and depend on the type of nutritional disorder:

• for "milk feeding disorder":
  • alkaline reaction of feces;
  • increased content of lime and magnesium salts;
• acidic stool;
  • increased content of extracellular starch, digestible fiber, fatty acids, mucus and leukocytes.

Instrumental examination reveals rapid exhaustion when performing functional tests. When performing dynamometry and respiratory tests, a significant drop in certain indicators is noted, indicating muscle weakness. When performing an ECG, signs of metabolic changes in the ventricular myocardium are detected; with cardiointervalography - signs of sympathicotonia in grades I and II hypotrophy, signs of vagotonia - in grade III; with echocardiography (EchoCG) - a hyperdynamic reaction of the myocardium in grades I and II hypotrophy, a hypodynamic reaction - in grade III.

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Differential diagnostics of hypotrophy

When examining a child with hypotrophy, the disease that caused hypotrophy is first determined. In this regard, hypotrophy must be differentiated from the following diseases:

• infectious;
• chronic gastrointestinal diseases;
• hereditary and congenital enzymopathies;
• endocrine diseases;
• organic diseases of the central nervous system, etc.

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