Malnutrition in children

Nutrition is not only physiology and biochemistry, not just the doctrine of metabolism. This includes the study of behavioral responses and mechanisms, socio-economic aspects of access to food, social security and equity, the organization of economic policy and food production at the regional, national or international levels. And here everything is not so simple as in the physiology and biochemistry of nutrition.

The world continues to be unsettled and unkind to many adults and children. Up to 30% of the inhabitants of the Earth simply starve, while about 10-15% suffer from excessive food consumption.

Hunger or a combination of hunger and infection are the main causes of death of children on our planet. Now we can confidently say that hunger is the main cause of mental and moral degeneration, the formation of aggressive behavior and intolerance. There is a vicious circle of poverty and hatred on our small planet. In this regard, the pediatrician, concerned with the problems of child nutrition, is always forced to take the position not only of a professional specialist, but also of a citizen, a politician, and an educator.

Hunger - insufficiency of food due to a forced reduction in the possibilities or sources of its production.

To recognize child hunger, preclinical methods are preferred that can diagnose not deep dystrophic processes with their very impressive symptoms, but a situation in which there is a likelihood of their occurrence. The above definition and the following questionnaire are borrowed from a number of social and medical programs conducted in the United States at the present time.

The SSNIR (1998) US questionnaire for recognizing starvation or the risk of starving children in the family

During the last 12 months:

1. Did it happen that the family did not have enough money to buy food?
2. Did you and other adult family members limit themselves to eating, knowing that there is not enough money to buy food?
3. did it happen that your children received less food than, in your opinion, they need, because of a lack of money for food?
4. Did the children ever tell you what they want to eat and that there is not enough food in the house?
5. Did your children go to bed hungry because the family did not have money to buy food?
6. have you ever reduced children's meals or missed some meals because of a lack of money for food?
7. have you or other adult members of your family limited their portions of food or missed meals due to lack of money for food?
8. did the family develop a practice of using a very limited set of food because of a shortage of cash?

Evaluation with three positive responses - the risk of starvation, with five - the apparent starvation of the child or all the children of the family.

The starting point or criterion for detecting the risk of hunger or lack of food safety in the family is a statement of the fact or, perhaps, the application of the child or adult member of the family about the lack of food in the home, the impossibility of satisfying hunger one or more times during the year due to lack of money to buy food products or the inability to receive it for other reasons.

At present, there is a tendency towards a broader understanding of fasting, the inclusion in it and all forms of malnutrition of a partial or qualitative nature, one or more food components (nutrients). In this interpretation, all cases of simply suboptimal nutrition should be referred to starvation. Then the frequency of fasting increases many times and for many age groups or social groups becomes close to 100%.

A more balanced use of the term "starvation" implies its use mainly for protein-energy insufficiency, which leads to a disruption in the rate of growth and development or creates the prerequisites for such violations. All other forms of non-optimal food supply should be referred to as "partial food insufficiency" or "unbalanced nutrition".

All forms of both protein-energy and partial qualitative starvation are widely spread in the world not only because people are poor and live in poverty, but for a variety of other reasons. One of these reasons are such secondary phenomena of civilization as a reduction in the variety of cultivated vegetables and cereals, berries and fruits, an increase in the number of technological methods for processing agricultural products and livestock products, with their natural micronutrients depleted. Often, the reason for the non-optimal food is cultural or family traditions, religious laws, own views and beliefs, both of the mother and the child.

The real "epidemics" of general and partial starvation are sometimes provoked by the mass media, creating a "fashion" for certain standards of physique. The most terrible example is massive long anorexia with imminent disruption of the growth of pelvic bones and reproductive organs in girls of older age groups and adolescents. This "epidemic" of anorexia became a reaction to such "standards" as the doll "Barbie", the winners of various beauty contests, fashion models and models.

Finally, the dominant cause of food imbalances and related health losses is simply ignorance or misunderstanding of simple nutritional laws, low level of medical education and culture in the general population.

Quite often, very significant nutritional disorders in children can be induced simply by a peculiar attitude towards nutrition or the eating behavior of children. This is primarily a violation of appetite, whose frequency in children 2-5 years of age reaches 35-40%. On the second place there are selective food negativisms with a definitive refusal of individual products, for example meat or milk, fish or vegetable oil, or just thick food, etc. Special preferences for sweet or salty, to fatty foods are always, besides the harm that comes from the excessively introduced product, accompanied by the negative consequences of the concomitant deficiency of some components of nutrition from relatively unused products. The formation of adequate eating behavior of the child is no less important task of preventive pediatrics than the organization of its nutrition.

You can talk about several levels of recognition of malnutrition or several different approaches to its diagnosis. Naturally, early or precautionary assessments are suitable for preventive pediatrics. This is already a diagnosis not of the state of nutrition, but the adequacy of the diet used. There are methods for registering dishes or products prepared for a children's table, the extent to which they are actually used during feeding, taking into account the products included in the menu for this dish, and the table of the chemical composition of each food. Based on all this and with the help of automated computer systems, the correspondence of the used and required amounts of various nutrients to a child, a pregnant woman or a nursing woman is processed. For the rate of consumption, a norm is adopted that is individualized relative to the state of nutrition or some special level of energy expenditure (for example, children-athletes). In St. Petersburg, AKDO-P programs are used for this. Examples of conclusions from such analyzes (data obtained by MI Batyrev) are given below for several children whose parents applied for advice.

An example of analysis of the supply of essential nutrients to counseled patients (% of recommended consumption rates)

Nutrients, nutritional value	Alexander K., 2.5 years old	Marina A., 9 years old	Alena V., 14 years old
Energy, kcal	72	94	63
Protein, g	139	121	92
Linoleic acid, g	46	54	59
ω-Linolenic acid	16	34	17th
Vitamin A, μg	69	94	64
Vitamin R, ME	12	25	34
Vitamin E, ME	53	73	62
Vitamin K, μg	84	98	119
Vitamin C, mg	116	86	344
Vitamin B1, μg	68	53	65
Vitamin B2, μg	92	114	142
Vitamin PP, μg	105	86	72
Vitamin B6, μg	89	54	44
Folic acid, μg	56	82	75
Vitamin B12, μg	114	185	96
Biotin, μg	18	46	24
Pantothenic acid, μg	67	84	89
Calcium, mg	88	65	41
Phosphorus, mg	102	94	75
Magnesium, mg	67	75	49
Iron, mg	89	73	36
Fluorine, mg	15	34	26th
Molybdenum, mg	48	86	92
Zinc, mg	53	68	58
Copper, μg	79	84	43
Iodine, μg	32	43	25
Selenium, μg	48	53	64
Manganese, μg	54	65	84
Sodium, μg	242	256	321
Potassium, μg	103	94	108
Chlorine, μg	141	84	163

Computer analysis involves selecting the necessary adjustments to equalize the diet. This is done with the participation of parents who can point out the availability or inaccessibility for the family of some nutritional sources of nutrients, as well as the range of taste preferences of the child.

Screening group nutritional assessments for children of different age groups are important for the healthcare system and municipalities.

The percentage of children of different age groups with nutritional intake below 2/3 of the daily age-sex ratio

Nutrients	Children 1-3 years old n = 35	Children 11-14 years old n = 49	Girls 19-21 years old n = 42
Energy	9.3	22.4	14.3
Vitamin A	1.9	40.8	47.6
Vitamin 0	92.6	42.8	28.6
Vitamin K	18.5	37.5	11.4
Vitamin E	3.7	0	0
Vitamin B1	30.0	55.1	42.8
Vitamin B2	9.3	46.9	28.6
Pantothenic acid	9.3	85.7	85.7
Biotin	16.7	67.3	90.4
Folacin	5.7	61.2	71.4
A nicotinic acid	20.4	42.8	28.6
Ascorbic acid	3.7	8.2	19.0
Iron	24.1	30.6	28.6
Potassium	-	30.6	28.6
Sodium	1.9	-	14.3
Calcium	24.1	81.6	61.9
Chlorine	2.9	40.8	38.1
Zinc	5.6	36.7	52.4
Iodine	24.1	79.6	95.6
Molybdenum	2.9	12.5	52.4
Selenium	5.7	68.8	90.4
Chromium	17.0	62.5	28.6
Magnesium	-	26.5	14.3
Manganese	1.9	26.5	19.0

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

Clinical and anthropometric methods in assessing the sufficiency or malnutrition in children

Changes in the basic anthropometric parameters of length and body weight are the basis for ascertaining a wide range of adverse effects as an external plan (inadequate nutrition and a regime of life) and internal character, in particular a wide variety of chronic diseases. In this case, the clinical picture of chronic eating disorders often develops against the background of a causal lingering or chronic illness. Some peculiarity of the symptomatology can be determined by the leading food deficiencies. So, it is customary to isolate the form of a chronic eating disorder with predominantly protein deficiency. This form is called "kwashiorkor". With it, leading signs are swelling and hypoproteinemia, often in combination with dystrophic dermatosis, and muscle mass deficit may be more pronounced than thinning of the subcutaneous fat layer. Edemas in these cases, as it were, mask and deficiency of body weight. At "marasmus" there is a combination of energy, protein and micronutrient deficiency. At the same time, exhaustion can be extremely pronounced, accompanied by bradycardia and a decrease in body temperature, but edema and hypoproteinemia are not characteristic. In a large part of cases it is the deviations from the normal type of growth supplements and body weight that are the first signs of these diseases, which oblige the doctor to organize a comprehensive examination of the child.

Anthropometric criteria for recognizing growth delays or weight gain can be divided into static (one-stage) and dynamic, obtained on the basis of two or more measurements in different time intervals. The latter are much more sensitive. Therefore, in the practice of dispensary observation of young children, anthropometric data is recorded continuously at intervals of 1 month in the first year of life and at least once a quarter in the interval from 1 to 3 years of life. Changes in body weight are more responsive and more sensitive to adverse factors than changes in growth. Therefore, during the most critical periods of life of a newborn or an infant (disease, changes in nutrition), daily weighing is mandatory. Rapid weight loss, observed in infancy, is most often associated with the occurrence of digestive disorders accompanied by vomiting and loose stool, with unpaired baby, with water loss through the skin and lungs with increased respiration and increased body temperature. Fast, i.e., within one or two days, a 10-15% drop in body weight from the baseline indicates the acute dehydration of the child (acute dehydration) and is a definite indication of the use of intensive therapy, in particular rehydration, i.e., e. Parenteral administration of fluid and salts.

Nutritional disorders and diseases that cause developmental disorders in children usually lead to slower changes in their body weight. The probable delay in growth or increase in body weight can be said in the event that an insufficient amount of growth or length of the body or its mass is detected over a period of time. For comparison, these standards are used. The time interval for body weight may be in a child of the first weeks of life about 2 weeks or 1 month, for the length of the body the minimum time interval in the first year of life is 1 month, from 1 to 3 years 2 months, and later 3-6 months. A reliable delay in growth or increase in weight should be considered the absence of their dynamics over these periods or the lag in the speed of growth to the level of the 10th centile or less. A similar judgment can be expressed as tentative or probable if, in the next measurement, the characteristic of the length or mass of the body passes to the underlying cantilever interval from the static type tables.

Before others, the speed characteristics of the increase in body weight change, then the growth of the head circumference and the length of the body (growth). Accordingly, preference, especially for young children, should be given to the dynamics of weight gain, then to body length increments; for children of early age are very indicative and head circumference increases.

This can be called the first stage of anthropometric assessments or an estimate of the growth dynamics. Some of the above normative tables are constructed from their own data, the data obtained by VN Samarina, TI Ivanova, and the bank data of the AKDO system. All tables of foreign authors have passed tests on selective age-sex fuppam of children and have confirmed the adequacy for children of the Northwest of Russia and other regions of the country.

The second stage of anthropometric research of a status of a delivery, and at any medical contact to the child quite often also the first stage - static one-stage research. The first step in this study is to assess the subcutaneous fat layer, shoulder circumference, relief, tone and muscle strength. These estimates can be made directly physically, focusing on the professional experience of the doctor. The wording of conclusions like "norm", "reduction", "sharp decrease" is admissible. A more rigorous system of estimates and conclusions is possible, based on a standardized (with the aid of a caliper instrument) study of the thickness of the folds of the skin and the subcutaneous fat layer, as well as the evaluation of the results from the standards of thickness of folds. Reducing the thickness of the fold of the skin below the 25th centile suggests a possible reduction in nutrition, and below the 10th centile - a pronounced lack of fat mass and nutrition.

A special position in the series of anthropometric estimates is occupied by the study of the circumference of the middle part of the shoulder in millimeters. These measurements are technically simpler, since only a centimeter tape can be used for them. The results of such measurements with a high sensitivity, ie, at relatively early times, detect a decrease in fat deposition, but also can clearly react to muscle atrophy, which leads to a decrease in the circumference of the shoulder. Thus, reducing the circumference of the shoulder, hip, and shin is very useful for screening the diagnosis of both eating disorders and the condition of the muscular system proper. Below are the shoulder circumference standards for boys and girls. When the circumference is reduced by more than 20%, a combined evaluation of the skin fold and shoulder circumference can be applied.

The algorithm for calculating the actual involvement of muscles in reducing the circumference of the shoulder can be based on the calculation explained in Chapter 10. Using two dimensions-the shoulder circumference and the thickness of the skin fold above the triceps muscle of the shoulder-you can calculate the "circumference of the muscles in the middle of the shoulder" according to the following formula:

C1 = C2-πS,

Where is the circumference of the muscles, mm; C2 - shoulder circumference, mm; S - thickness of subcutaneous fat (skin folds), mm; π = 3.14.

The next stage in the application of anthropometric nutrition research is actually the evaluation of the static characteristics of the most important parameters of physical development - length and body weight. Changes in body weight in children with greater sensitivity are detected in relatively close periods from the onset of nutritional insufficiency, even with the generally accepted age orientation, but even more convincing as to possible malnutrition is the body weight estimate for the body's length (growth). This can be done on the basis of the average arithmetic values of growth indicators on the estimated tables of the sigma type or relative to the median in the standards of the centile type. In the absence of special tables of mass standards along the length of the body, it is conventionally permissible to use the body mass tables by age, by the line of age corresponding to the growth rate of the child in the growth-age table.

In Russia, malnutrition in children of the first year of life is usually called hypotrophy. Depending on the degree of deficiency of body weight, they speak about malnutrition of I, II or III degrees. Orientations are the degree of difference in weight or body length as a percentage of the norm, or standard. In most of the current international classifications, it was accepted to use the degree of difference of a specific weight or body length indicator from the median (the 50th centile, or the arithmetic mean) in percent.

In a very large group of children with malnutrition, the child's disparity with the age-specific body length (growth) standards comes to the forefront, while the body weight relative to growth appears close to normal. This condition is called a "hypostructure" or "alimentary nannism" for children of the first year of life and "alimentary subnannism" for older children. Only the lag in growth (stan- ding) can be ascertained by the level of distance of the growth of the child from the median of the corresponding age-and-sex group. Modern classification. Waterlow) oblige to attribute to the delay of growth the backlog from the median by only 5%. In the absence of endocrine and chronic somatic diseases, a mild to moderate degree of growth deficiency may be evidence of malnutrition, possibly several years ago. It is the prevalence and persistence of an alimentary hypostructure that underlies the existing diversity in the characteristics of adult growth in most countries and regions of the world.

Hypostatura and other forms of pathological low growth should be distinguished from the form of short stature, which has a constitutional, usually hereditary, nature.

Etiological and chronological features of development and the duration of existing eating disorders assume a wide variety of their manifestations both in the clinical picture and in the changes in the parameters of the physical development of children. Most fully this whole range of changes is presented in the national classification of chronic eating disorders GI Zaitseva and LA Stroganova, who have traveled a long way of various modifications.

The modern classifications in foreign pediatrics are not clinically oriented, but are of interest in relation to the accepted criterial limits of assessing the different degrees of chronic eating disorders.

Unified classification of malnutrition

Power state	Weight loss (weight per age)	Growth retardation (growth by age)	Weight per body length
Normal	More than 90%	More than 95%	More than 90%
Mild malnutrition	75-90%	90-95%	81-90%
Moderate malnutrition	69-74%	85-89%	70-80%
Severe malnutrition	Less than 60%	Up to 85%	Less than 70%

Classification of the degrees of protein-energy deficiency

Only A is depletion (relatively acute and recent).

Only B - lag in growth (stanting) as a manifestation of malnutrition in the past.

A + B - chronic current malnutrition.

Index	Percent of median standard
A. By mass per length of body
Norm	90-110
BKN lung	80-89
BKN moderate	70-79
BKN heavy	69 and less

Norm	95-105
BKN lung	90-94
BKN moderate	85-89
BKN heavy	84 and less

Classification of malnutrition in children (according to IM Vorontsov, 2002)

Indicators	Initial (easy)	Medium Heavy	Expressed (severe)	Very heavy
Body length,% median for age	95-90%	89-85%	Less than 85%	Less than 85%
Weight,% median for age	90-81%	80-70%	Less than 70%	Less than 70%
Mass,% of the median of the Quetelet-2 index for age	90-81%	80-71%	Less than 70%	Less than 70%
Clinical Features	Syndrome Border insufficient-precision power supply	Anemia, osteopenia, repeated infections, symptoms of high-quality violations supply	Localized infection, cachexia syndrome, reduced tolerance, decreased kidney, liver, heart function	Generalization of infection, brady-arrhythmia, dermatosis, edema, paresis, hypotension or shock
Restorative food	Oral physiological with moderate forcing	Oral forcing with enteral according to indications	Parenteral several days and enteral forced long-term	Parenteral for long periods, a combination with increasing enteral

To judge about the violations of fatness and growth of the child, it is advisable to use normative scales for length and body weight, in which the boundary criteria (percent from the median) are directly given. Such scales can be called "criterial". A set of tables with such criterial boundaries is given below (Tables 25.51 - 25.54). The basis of the tables is the AKDO bank data. Unlike the physical development evaluation tables, the criterial tables contain not the values of the distribution, but the average value of the characteristic and the parameter boundaries (growth, mass, circle) that are included in the above accepted criteria or definitions. The boundary of 70% of the median length of the body and 60% of the body weight are introduced to judge the extremely serious violations within the framework of the Gomez classification, which retains its importance.

It should be stressed that the above formalized mathematical-statistical approach to estimating the state of nutrition and the degree of its violation is not the only one. In particular, the International Classification of Diseases and Causes of Death (ICD-10), adopted today in Russia, classifies the assessment of nutritional deficiencies by deviations from the arithmetic mean of the standards in the values of the quotient of the difference divided by the standard deviation in the standard system. This is the so-called "z-sour" method. A careful study of this approach by specialists in Russia and in other countries is necessary. It seems that the transition to this method is only a tribute to formal mathematization and is unlikely to benefit clinical practice and children's health statistics.

The most important information about the significance, timing of the debut and the duration of malnutrition can be obtained from the ratio of body weight and length. This indicator and the criterion are included in different classification of degrees or severity of eating disorders. At the same time, it is proved that the use of mass distributions along the length of the body for children of middle and senior school age is not justified because the diversity of biological age and constitutional types of physique in older children is extremely large, and it is possible to meet perfectly healthy children who do not suffer deficiencies in nutrition, with a wide range of body mass indexes for the same growth rate. The tables of standards, taking into account the types of build and the level of maturity achieved, have not yet been created. The attempts to simplify this problem through accounting for the size of the breast circumference were not justified. Therefore, the evaluation of body weight along the length is eligible only up to body lengths of about 140 cm.

For children with a height above 140-150 cm, the simple proportions of length and body weight given below were found to be poorly solitary, and therefore they can not be recommended for practical purposes.

In the world practice (Europe and the USA) for large children and adolescents it is recognized that it is advisable to carry out a weight-for-length assessment through the "Quetelet Index", or "Body Mass Index".

A comparison of the American and domestic indicators of child nutrition reveals some difference. It is possible that it is due to a decrease in the food security of our children in recent years. Another interpretation is also possible: a higher prevalence of over-nutrition in US children. Therefore, for practical diagnosis of malnutrition (or its redundancy), one can rely on domestic body mass index standards, but a parallel assessment according to the American standard may also be of interest.

Clinical assessments of malnutrition can be based on the analysis of anthropometric data, primarily speed characteristics of growth, then the already achieved growth or body weight. This was discussed in detail in the chapter on the study of the physical development of children. Qualitative signs of eating disorders include behavioral and clinical. The earliest of these are lethargy, decreased appetite, irritability, asthenia. The next stage is usually pallor and more frequent intercurrent infections, pain in the bones and points of attachment of muscles. In recent years, the alimentary condition of one of the variants of the syndrome of chronic fatigue, not associated with infection, is widely discussed. The basis may lie both protein-energy deficiency and associated deficiencies of nutrients: polyunsaturated fatty acids, carnitine, inositol, nicotinic acid, biotin, iron, chromium, selenium, zinc.

Syndrome of chronic energy and poly nutrient deficiency in schoolchildren:

• decreased appetite;
• lethargy of behavior, exhaustion in the game and initiative;
• desire to "lie down" in the middle of the day or immediately after school;
• the appearance of negativism, hysteroid reactions;
• memory and attention impairment;
• deterioration in school performance and school admissions;
• repeated complaints of headache;
• repeated complaints of abdominal pain, an objective clinical and endoscopic picture of gastroduodenitis and reflux;
• repeated complaints of pain in the bones and muscles;
• instability of the cervical spine;
• listlessness of posture;
• decrease muscle strength and reduce the muscular circumference of the shoulder;
• tendency to arterial hypotension and late postural dizziness;
• pain in bones and joints after walking or running;
• palpation sensitivity at points of attachment of tendons with change of points;
• the instability of thermoregulation (psychogenic subfebrile conditions);
• unstable stool;
• lagging of the tongue, smoothness of the papillae;
• cheilitis or cheilosis, angular stomatitis;
• follicular hyperkeratosis of the 1st type;
• dryness of the conjunctiva, often with vascularization.

Polysymptomatic or syndrome combinations of signs of various organ lesions may indicate the presence of partial food deficiencies. The procedure for examining the patient, focused on identifying such partial deficiencies of nutrition, is given below.

When analyzing nutrition problems in the main course of pediatrics, special attention is paid to clinical recognition of protein-energy malnutrition and predominantly protein, as well as various syndromes of vitamin or mineral deficiency.

[6], [7], [8], [9], [10],