Diagnosis of hypotrophy

The diagnosis of hypotrophy in children is based on history, clinical manifestations of the disease, evaluation of anthropometric indicators and laboratory data.

[1], [2], [3], [4], [5], [6]

Indications for consultation of other specialists

Children with hypotrophy, especially with its chronic form, need advice from the medical genetics and endocrinologist in order to exclude genetic syndromes, as well as hereditary and endocrine diseases requiring specialized therapy. In case of violations of the act of chewing and swallowing, the consultation of the neurologist is shown, and in the case of disturbed eating behavior, neurogenic anorexia, a consultation of a medical psychologist and a child psychiatrist is shown. In the examination of a child with hypotrophy, a gastroenterologist should be involved in order to exclude primary gastroenterological pathology, and with an unusual epidemiological history and signs of an infectious or parasitic disease, a consultation of an infectious disease specialist is necessary.

In the treatment of children with severe forms of hypotrophy, especially with signs of multiple organ failure, to correct the infusion therapy and parenteral nutrition may require the participation of doctors of the intensive care unit.

Diagnosis of anamnesis-based hypotrophy

When collecting anamnesis, it is important to assess:

• the nature of the patient's diet;
• the use of unusual products;
• a sharp change in diet;
• taking medicines, vitamin and mineral supplements;
• the appearance of unusual taste preferences;
• shaking at the use of thick food;
• episodes of regurgitation and vomiting.

It is necessary to note other signs of gastrointestinal pathology, which are characterized by hypotrophy: bloating and abdominal pain, diarrhea, constipation or unstable stool, an admixture of blood in the stool. It is necessary to find out whether general weakness, increased fatigue, decreased mental performance, impaired vision, bone pain, muscle pain, convulsions and twitching, numbness, paresthesia in the extremities were noted. For the diagnosis of hypotrophy, it is important to evaluate the dynamics of anthropometric indicators, especially changes in body weight over the last 6 months.

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

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

When examining the patient, thinning or disappearing of the subcutaneous fat layer is noted, loss of muscle mass. Perhaps the development of edema, hepatomegaly, peripheral neuropathy. These and other symptoms of hypotrophy in children not only reflect deficiency of protein and energy, but also serve as signs of poly-nutrient deficiency.

Symptoms of a deficiency of macro- and micronutrients

	Symptoms	Nutrient deficiency
Are common .	Weakness, fatigue, weight loss, muscle weakness	Protein, calorie
Leather	Pallor	Folacin, Fe, Vitamin B ] 2
	Follicular hyperkeratosis, thinning, dryness and roughness	Vitamin A, vitamin C, biotin
	Perifollicular petechiae	Vitamin C
	Dermatitis	Protein, calorie, vitamin PP, vitamin B 2, Zn, vitamin A, essential fatty acids
	Spontaneous hemorrhages, hemorrhages, petechiae	Vitamin C, vitamin K, polyphenols
Hair	Allopecia	Protein, Zn
	Thin, brittle	Biotin, pantothenic acid, vitamin C, vitamin A
Eyes	Hemerolopia, xerophthalmia, keratomalacia, photophobia, sensation of sand, xerosis of the conjunctiva of the cornea	Vitamin A
	Conjunctivitis	Vitamin A, vitamin B 2
Language	Glossitis	Vitamin B 2, vitamin PP, vitamin B t 2
	Bleeding gums, erosion and sores of mucous membranes	Folacin, protein, vitamin A, vitamin C, vitamin K
	Tingling and burning, soreness, enlargement and swelling of the papillae	Folacin, vitamin B 12, vitamin C, vitamin PP
	Angular stomatitis, Hailosis	Folacin, Fe, vitamin B 2, vitamin PP, vitamin B 6
Nervous system	Tetany	Ca, Mg
	Paresthesia	Vitamin B1, vitamin B 6
	Decreased reflexes,, ataxia, muscular dystrophy, hyperkinesia	Vitamin B 12, vitamin B2 ? , vitamin E
	Dementia, disorientation	Niacin, vitamin B 12
	Ophthalmoplegia	Vitamin E, vitamin B1
	Depression	Biotin, folicin, vitamin B 12

Until now, 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 the anthropometric indicators of the country's population are needed, taking into account the gender, age, patient's health and social factors. The existing classifications of the state of human nutrition, as a rule, are based on an estimate of the deviation of the actual body weight from its ideal (due, normal, calculated) value. However, the amount of body weight depends on many factors: age, constitution, sex, previous nutrition, living conditions, the nature of work, lifestyle, etc. According to the recommendations of FAO / WHO nutrition experts, the most simple, generally accepted and highly informative criterion for assessing nutritional status is the so-called body mass index (BMI) or the Quetelet index, calculated as the ratio of body weight (in kilograms) to growth (in meters) squared. Based on this indicator, many classifications of malnutrition have been constructed.

Assessment of the nutritional status of children over 12 years of age by body mass index

Type of eating disorder	Power	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 insufficiency	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 to use or even impossible to use. It is necessary to take into account the age and rapid growth rates of the child's body. Calculation of BMI for young children is not very informative, and it can be used only in children over 12 years of age; in children under 12 years as a criterion of malnutrition, the percentage of deviation from the weight is used. To determine the severity of hypotrophy in young children, the classification of J. Waterlaw is widely used in the world.

The corresponding (ideal) body weight in children is determined using tables of centile or higher body mass distributions depending on the growth and age of the child.

In addition to body length and body weight, the head, chest, abdomen, shoulder, hip circumference, as well as the thickness of the skin-fat folds at standard points are estimated in children in the study of anthropometric indices. In children of early age, great importance is attached to the indices of the head circumference, the number of teeth and the size of the fontanelles.

The results of laboratory studies in children with hypotrophy show significant changes in the biochemical markers of protein metabolism: when marasmus is characterized by a moderate decrease in the total protein and albumin content of blood serum, a decrease in the absolute number of peripheral blood lymphocytes; at 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 practically does not change. Urine may increase the level of creatinine, the total urine nitrogen is usually lower.

Proteins of blood serum are more indicative markers of protein starvation than the volume of muscle mass, but their sensitivity to changes in the internal environment depends on their half-life. To monitor the effectiveness of treatment, it is better to use short-lived proteins.

Protein markers of nutritional status (Cynober L, 2000)

Protein	Half-life, days	Concentration in the 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 the violation of protein metabolism in children with hypotrophy, it is often noted:

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

Immunogram records indicate secondary immunodeficiency with inhibition of cellular immunity (decrease in the number of T-lymphocytes) and impaired phagocytic activity of neutrophils; the level of immunoglobulins of class M, G and A can be maintained at a normal level. Changes in the coprogram are variable and depend on the type of food disturbance:

• for "milk-eating disorder":
  • alkaline reaction of feces;
  • increased content of calcareous and magnesium salts;
• acid reaction of stool;
  • increased content of extracellular starch, digested fiber, fatty acids, mucus and leukocytes.

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

[7], [8], [9], [10], [11],

Differential diagnosis of hypotrophy

When examining a child with hypotrophy, the disease that causes him is hypotrophic. In connection with this, hypotrophy is differentiated with the following diseases:

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

[12], [13], [14]