Malnutrition in children

Nutrition is not only physiology and biochemistry, not only the study of metabolism. It also includes the study of behavioral reactions and mechanisms, socio-economic aspects of food availability, problems of social security and justice, organization of economic policy and food production at regional, state or international levels. And here everything is far from being as 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 world's population is simply starving, while about 10-15% suffer from overconsumption of food.

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. A vicious circle of maintaining poverty and hatred is being formed on our small planet. In this regard, a pediatrician dealing with problems of children's nutrition is always forced to take the position of not only a professional specialist, but also a citizen, a politician, and an educator.

Hunger is a lack of food due to a forced reduction in the ability or sources of obtaining it.

Preclinical methods are preferable for recognizing childhood hunger, which are capable of diagnosing not deep dystrophic processes with their very impressive symptoms, but the situation in which the probability of their occurrence arises. The given definition and the following questionnaire are borrowed from a number of social and medical programs currently being conducted in the USA.

The 1998 US CHIP questionnaire for identifying hunger or risk of hunger in children in a family

Over the last 12 months:

1. Has it ever happened that your family didn't have enough money to buy food?
2. Have you and other adult family members ever found yourself restricting your food intake because you knew you didn't have enough money to buy groceries?
3. Have your children ever received less food than you thought they needed because you didn't have enough money to pay for food?
4. Have your children ever told you that they are hungry and that there is little food in the house?
5. Have your children ever gone to bed hungry because the family didn't have money to buy food?
6. Have you ever had to reduce your children's food portions or skip meals because you didn't have money for groceries?
7. Have you or other adult members of your family ever limited your food portions or skipped meals because you didn't have enough money to buy groceries?
8. Has the family developed a practice of using a very limited set of food products due to a lack of money?

An assessment of three positive answers indicates a risk of starvation; an assessment of five indicates obvious starvation of the child or all children in the family.

The starting point or criterion for establishing the risk of hunger or food insecurity in a family is a statement of fact or, possibly, a statement by a child or adult family member about the lack of food in the house, the inability to satisfy hunger one or more times during the year due to a lack of money to buy food or the inability to obtain it for other reasons.

At present, there is a tendency towards a broader understanding of starvation, including all forms of partial or qualitative nutritional deficiency in one or several food components (nutrients). In such an interpretation, all cases of simply suboptimal nutrition should be attributed to starvation. Then the frequency of starvation increases many times over and for many age or social groups of the population becomes close to 100%.

A more balanced use of the term "starvation" suggests its application mainly to protein-energy deficiency that leads to or creates the preconditions for growth and developmental disorders. All other forms of suboptimal nutrition should be referred to as "partial nutritional deficiency" or "unbalanced nutrition."

All forms of both protein-energy and partial quality starvation are becoming widespread in the world not only because people are poor and live in poverty, but also for a variety of other reasons. One of these reasons is such side phenomena of civilization as a reduction in the diversity (assortment) of cultivated vegetables and grains, berries and fruits, an increase in the number of technological methods for processing agricultural products and livestock products with the depletion of their natural micronutrients. Often the reason for non-optimal nutrition are cultural or family traditions, religious laws, personal views and beliefs of both the mother and the child.

Real "epidemics" of general and partial starvation are sometimes provoked by the mass media, creating a "fashion" for certain body standards. The most terrible example is mass long-term anorexia with inevitable disruption of the growth of the pelvic bones and reproductive organs in older girls and teenagers. This "epidemic" of anorexia became a reaction to such "standards" as the Barbie doll, winners of various beauty contests, photo models and mannequins.

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

Quite often, and quite significant, nutritional disorders in children can be induced simply by a peculiar attitude to nutrition or eating behavior of children. These are primarily appetite disorders, the frequency of which in children aged 2-5 years reaches 35-40%. In second place are selective food negativisms with a categorical refusal of certain products, such as meat or milk, fish or vegetable oil, or simply thick food, etc. Special addictions to sweet or salty, to fatty foods are always, in addition to the harm that comes from the excessively introduced product, accompanied by negative consequences of concomitant deficiency of some nutritional components from relatively little-used products. Formation of adequate eating behavior of a child is no less an important task of preventive pediatrics than the organization of his nutrition.

There are several levels of recognizing malnutrition or several different approaches to its diagnostics. Naturally, early or preventive assessments are most suitable for preventive pediatrics. This is no longer a diagnostic of the nutritional status, but of the adequacy of the diet used. There are methods for registering dishes or products prepared for children's meals, the extent to which they are actually used during feeding, accounting for products included in the menu for a given dish, and tables of the chemical composition of each food product. Based on all this and with the help of automated computer systems, the correspondence of the used and required quantities of various nutrients by a child, pregnant or nursing woman is processed. The consumption rate is taken as a rate individualized in relation to the nutritional status or some special level of energy expenditure (for example, child athletes). In St. Petersburg, AKDO-P programs are used for this. Examples of conclusions on such analyses (data obtained by M. I. Batyrev) are given below for several children whose parents sought advice.

Example of analysis of the provision of essential nutrients to consulted patients (% of recommended intake standards)

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	17
Vitamin A, mcg	69	94	64
Vitamin P, IU	12	25	34
Vitamin E, IU	53	73	62
Vitamin K, mcg	84	98	119
Vitamin C, mg	116	86	344
Vitamin B1, mcg	68	53	65
Vitamin B2, mcg	92	114	142
Vitamin PP, mcg	105	86	72
Vitamin B6, mcg	89	54	44
Folic acid, mcg	56	82	75
Vitamin B12, mcg	114	185	96
Biotin, mcg	18	46	24
Pantothenic acid, mcg	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	26
Molybdenum, mg	48	86	92
Zinc, mg	53	68	58
Copper, mcg	79	84	43
Iodine, mcg	32	43	25
Selenium, mcg	48	53	64
Manganese, mcg	54	65	84
Sodium, mcg	242	256	321
Potassium, mcg	103	94	108
Chlorine, mcg	141	84	163

Computer analysis involves selecting the necessary corrections to balance the diet. This is done with the participation of parents, who can indicate the availability or inaccessibility of certain food sources of nutrients for the family, as well as the range of taste preferences of the child.

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

Percentage of children of different age groups with nutrient intake below 2/3 of the daily age-sex norm

Nutrients	Children 1-3 years 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
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

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Clinical and anthropometric methods in assessing nutritional sufficiency or insufficiency in children

Changes in the main anthropometric indicators of body length and weight are the basis for establishing a wide range of adverse effects of both an external nature (inadequate nutrition and lifestyle) and an internal nature, in particular a wide variety of chronic diseases. In this case, the clinical picture of chronic nutritional disorders often develops against the background of a causal protracted or chronic disease. Some peculiarity of symptoms can also be determined by leading nutritional deficiencies. Thus, it is customary to distinguish a form of chronic nutritional disorder with predominantly protein deficiency. This form is called "kwashiorkor". In this case, the leading signs will be edema and hypoproteinemia, often in combination with dystrophic dermatosis, and the deficit in muscle mass can be expressed more clearly than the thinning of the subcutaneous fat layer. Edema in these cases seems to mask the deficit in body weight. In "marasmus" there is a combination of energy, protein and micronutrient deficiencies. In this case, exhaustion can be extremely pronounced, accompanied by bradycardia and a decrease in body temperature, but edema and hypoproteinemia are not typical. In a significant number of cases, it is deviations from the normal type of growth and body weight that are the first signs of these diseases, obliging the doctor to organize a comprehensive examination of the child.

Anthropometric criteria for recognizing growth retardation or weight gain can be divided into static (one-time) and dynamic, obtained on the basis of two or more measurements at different time intervals. The latter are much more sensitive. Therefore, in the practice of dispensary observation of young children, anthropometric data are recorded constantly 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 the impact of unfavorable factors than changes in growth. Therefore, during particularly critical periods in the life of a newborn or infant (illness, changes in nutrition), daily weighing is mandatory. A rapid drop in body weight observed in infancy is most often associated with the occurrence of digestive disorders accompanied by vomiting and loose stools, with insufficient fluid intake, with water loss through the skin and lungs with increased breathing and an increase in body temperature. A rapid, i.e. within one or two days, drop in body weight by 10-15% from the initial most often indicates acute dehydration of the child (acute dehydration) and is a definite indication for the use of intensive therapy, in particular rehydration, i.e. parenteral administration of fluids and salts.

Nutritional disorders and diseases that cause developmental disorders in children usually result in slower changes in their body weight. A probable delay in growth or weight gain can be considered if an insufficient amount of growth or body length or weight is detected over a certain period of time. Standard data are used for comparison. The time interval for body weight can be about 2 weeks or 1 month for a child in the first weeks of life, for body length the minimum time interval in the first year of life is 1 month, from 1 to 3 years - 2 months, later - 3-6 months. A reliable delay in growth or weight gain should be considered the absence of their dynamics over these periods or a lag in the rate of growth to the level of the 10th centile or less. A similar judgment can be expressed as approximate or probable if, during the next measurement, the characteristic of the length or body weight goes into the lower centile interval according to the static type tables.

The rate of increase in body weight changes earlier than others, then the increase in head circumference and body length (height). Accordingly, preference, especially for young children, should be given to the dynamics of body weight gain, then to the increase in body length; for young children, the increase in head circumference is also very indicative.

This can be called the first stage of anthropometric assessments or assessment of the dynamics of increments. Some of the normative tables provided are based on our own data, data obtained by V. N. Samarina, T. I. Ivanova, and data from the AKDO system bank. All tables by foreign authors have been tested on selective age-sex groups of children and have confirmed their adequacy for children in the North-West of Russia and other regions of the country.

The second stage of the anthropometric study of the nutritional status, and often the first stage in any medical contact with a child, is a static one-time study. The first step in such a study is an assessment of the subcutaneous fat layer, shoulder circumference, muscle relief, tone and strength. These assessments can be made directly physically, based on the professional experience of the doctor. Formulations of conclusions such as "norm", "decrease", "sharp decrease" are acceptable. A more rigorous system of assessments and conclusions is also possible, based on a standardized (using a caliper) study of the thickness of skin folds and subcutaneous fat layer, as well as an assessment of the results according to fold thickness standard tables. A decrease in skin fold thickness below the 25th centile indicates a probable decrease in nutrition, and below the 10th centile - a pronounced insufficiency of fat mass and nutrition.

A somewhat special position in the series of anthropometric assessments is occupied by the study of the circumference of the middle part of the upper arm in millimeters. These measurements are technically simpler, since only a centimeter tape can be used for them. The results of such measurements with high sensitivity, i.e. at relatively early stages, detect a decrease in fat deposition, but can also clearly react to muscle atrophy, leading to a decrease in the circumference of the upper arm. Thus, a decrease in the circumference of the upper arm, thigh and shin are very useful for screening diagnostics of both nutritional disorders and the state of the muscular system itself. Below are the standards for upper arm circumference for boys and girls. If the circumference decreases by more than 20%, a combined assessment of the skin fold and upper arm circumference can be used.

The algorithm for calculating the actual contribution of muscles to the reduction of arm circumference can be based on the calculation explained in Chapter 10. Using two measurements - arm circumference and the thickness of the skin fold above the triceps brachii - one can calculate the "muscle circumference at the middle of the arm" using the following formula:

C1 = C2 - πS,

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

The next stage of application of anthropometric studies of nutrition is the actual assessment of the static characteristics of the most important parameters of physical development - body length and weight. Changes in body weight in children are more sensitively detected in relatively short periods from the onset of nutritional deficiency already with the generally accepted orientation to age, but even more convincing in relation to possible nutritional deficiency is the assessment of body weight for the child's body length (height). This can be done based on the arithmetic mean values of growth indicators according to sigma-type assessment tables or relative to the median in centile-type standards. In the absence of special tables of body length standards, it is conditionally permissible to use tables of body weight by age, according to the age line to which the child's height indicator corresponds in the height-age table.

In Russia, malnutrition in children in the first year of life is usually called hypotrophy. Depending on the degree of body weight deficit, they speak of malnutrition of degree I, II or III. The benchmarks are the degrees of difference in body weight or length indicators as a percentage of the norm or standard. Most current international classifications have adopted the use of the degree of difference of a specific body weight or length indicator from the median (50th centile, or arithmetic mean) as a percentage.

In a very large group of children with malnutrition, the discrepancy between the child's age-appropriate length (height) comes to the fore, while the body weight relative to height appears to be close to the norm. This condition is called "hypostature" or "alimentary dwarfism" for children in their first year of life and "alimentary subnanism" for older children. Only stunting can be determined by the level of the child's height deviation from the median of the corresponding age and sex group. Modern classifications by Waterlow require that only 5% of the median be classified as stunting. In the absence of endocrine and chronic somatic diseases, mild or moderate growth deficiency may be evidence of malnutrition, possibly several or many years ago. It is the prevalence and persistence of alimentary hypostature that underlies the existing diversity in adult height characteristics in most countries and regions of the world.

Hypostatura and other forms of pathological short stature must be distinguished from the form of short stature that has a constitutional, usually hereditary, nature.

The etiological and chronological features of development and the very duration of existing eating disorders suggest a great variety of their manifestations both in the clinical picture and in changes in the parameters of physical development of children. This entire range of changes is most fully presented in the domestic classification of chronic eating disorders by G. I. Zaitseva and L. A. Stroganova, which has gone through a long path of various modifications.

Modern classifications common in foreign pediatrics do not have a clinical focus, but are of interest in relation to the accepted criteria for assessing different degrees of chronic nutritional disorders.

Combined Classification of Malnutrition

Power status	Weight loss (weight for age)	Growth retardation (height for 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 degrees of protein-energy malnutrition

Only A - exhaustion (relatively acute and recent).

Only B - stunting as a manifestation of past malnutrition.

A + B - chronic ongoing malnutrition.

Indicator	Percentage of standard median
A. By weight per body length
Norm	90-110
BKN light	80-89
BKN moderate	70-79
BKN is severe	69 and less

Norm	95-105
BKN light	90-94
BKN moderate	85-89
BKN is severe	84 and less

Classification of nutritional disorders in children (according to I. M. Vorontsov, 2002)

Indicators	Beginner (easy)	Medium-heavy	Severe (severe)	Very heavy
Body length, % of median for age	95-90%	89-85%	Less than 85%	Less than 85%
Mass, % median for age	90-81%	80-70%	Less than 70%	Less than 70%
Weight, % of median Quetelet-2 index by age	90-81%	80-71%	Less than 70%	Less than 70%
Clinical features	Borderline malnutrition syndrome	Anemia, osteopenia, recurrent infections, symptoms of qualitative nutritional disorders	Localized infection, cachexia syndrome, decreased tolerance, decreased renal, hepatic, and cardiac function	Generalization of infection, brady-arrhythmia, dermatosis, edema, paresis, hypotension or shock
Restorative nutrition	Oral physiological with moderate forcing	Oral forced with enteral according to indications	Parenteral for several days and enteral forced long-term	Parenteral for long periods, combination with increasing enteral

To judge the violations of the child's nutritional status and growth, it is advisable to use standard scales for body length and weight, which directly provide the boundary criteria (percentage of the median). Such scales can be called "criterial". A set of tables with such criterion boundaries is given below (Tables 25.51 - 25.54). The basis of the given tables is the data of the AKDO bank. Unlike the tables for assessing physical development, the criterion tables do not contain distribution centiles, but the average value of the feature and the boundaries of the parameter (height, weight, circumference), which are included in the above-mentioned accepted criteria or definitions. The boundary of 70% of the median of body length and 60% for body weight are introduced to judge extremely severe violations within the framework of the Gomez classification, which retains its significance.

It should be emphasized that the given formalized mathematical-statistical approach to assessing 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 provides a classification of assessing nutritional disorders by deviations from the arithmetic mean indicators of standards in the values of the quotient of the difference divided by the value of the standard mean square deviation. This is the so-called "z-score" method. This approach needs to be carefully studied by specialists both in Russia and in other countries. It seems that the transition to this method is only a tribute to formal mathematization and is unlikely to be of benefit to clinical practice and statistics of children's health.

The most important information about the significance, timing of onset and duration of malnutrition can be obtained from the ratio of body weight and length. This indicator and criterion are included in various classifications of the degrees or severity of nutritional disorders. At the same time, it has been proven that the use of weight distributions by body length for children of middle and senior school age is not justified due to the fact that the diversity of biological age and constitutional body types in older children is extremely large, and it is possible to meet completely healthy children who do not suffer from nutritional deficiencies with a wide range of body weight indicators for the same height indicator. Standard tables taking into account body types and the achieved level of maturity have not yet been created. The attempts to simplify the solution of this problem by taking into account the chest circumference have not been justified. Therefore, the assessment of body weight by length is valid only up to body length indicators of about 140 cm.

For children taller than 140-150 cm, the simple length-weight relationships given below have proven to be inconsistent and therefore cannot be recommended for practical purposes.

In world practice (Europe and the USA) for tall children and adolescents it is considered appropriate to assess the mass for body length using the “Quetelet Index” or “Body Mass Index”.

A comparison of American and domestic indicators of children's nutrition shows some difference. It is possible that it is due to a decrease in the nutritional security of our children in recent years. Another interpretation is also possible - a higher prevalence of overnutrition in US children. Therefore, for practical diagnostics of nutritional deficiency (or overnutrition), one can rely on domestic standards of the body mass index, 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 growth rates, then the values of achieved height or body weight. This was discussed in detail in the chapter on the study of physical development of children. Qualitative signs of malnutrition include behavioral and clinical. The earliest of these are lethargy, loss of appetite, irritability, asthenia. The next stage is usually pallor and increased frequency of intercurrent infections, pain in bones and muscle attachment points. In recent years, the alimentary determinacy of one of the variants of chronic fatigue syndrome not associated with infection has been widely discussed. It can be based on both protein-energy deficiency and combined nutrient deficiencies: polyunsaturated fatty acids, carnitine, inositol, nicotinic acid, biotin, iron, chromium, selenium, zinc.

Syndrome of chronic energy and polynutrient malnutrition in schoolchildren:

• loss of appetite;
• lethargy of behavior, exhaustion in play and initiative;
• the desire to "lie down" in the middle of the day or right after school;
• the emergence of negativism, hysterical reactions;
• deterioration of memory and attention;
• deterioration in academic performance and absence from school;
• repeated complaints of headache;
• repeated complaints of abdominal pain, objective clinical and endoscopic picture of gastroduodenitis and reflux;
• repeated complaints of pain in bones and muscles;
• instability of the cervical spine;
• laxity of posture;
• decreased muscle strength and a decrease in muscle circumference of the shoulder;
• tendency to arterial hypotension and late postural dizziness;
• pain in bones and joints after walking or running;
• palpation sensitivity at the points of tendon attachment with a change of points;
• instability of thermoregulation (psychogenic subfebrile conditions);
• instability of stool;
• coated tongue, smoothed papillae;
• cheilitis or cheilosis, angular stomatitis;
• follicular hyperkeratosis type 1;
• dryness of the conjunctiva, often with vascularization.

Polysymptomatic or syndromic combinations of signs of various organ lesions may indicate the presence of partial nutritional deficiencies. The procedure for examining a patient, aimed at identifying such partial nutritional deficiencies, is given below.

When examining nutritional diseases in the basic course of pediatrics, special attention is paid to the clinical recognition of protein-energy nutritional deficiency and predominantly protein, as well as various syndromes of vitamin or mineral deficiency.

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