Treatment of hypotrophy

Treatment of hypotrophy in children of the first degree is usually carried out in outpatient conditions, and children with hypotrophy of the second and third degrees - in hospital. Treatment of hypotrophy in such children must be carried out comprehensively, that is, include balanced nutritional support and diet therapy, pharmacotherapy, adequate care and rehabilitation of the sick child.

In 2003, WHO experts developed and published recommendations for the management of children with malnutrition, which regulated all measures for nursing children with malnutrition. They identified 10 main steps:

• prevention/treatment of hypoglycemia;
• prevention/treatment of hypothermia;
• prevention/treatment of dehydration;
• correction of electrolyte imbalance;
• prevention/treatment of infection;
• correction of micronutrient deficiency;
• cautious start of feeding;
• ensuring weight gain and growth;
• providing sensory stimulation and emotional support;
• further rehabilitation.

The activities are carried out in stages, taking into account the severity of the sick child’s condition, starting with the correction and prevention of life-threatening conditions.

The first step is aimed at treating and preventing hypoglycemia and associated possible disturbances of consciousness in children with hypotrophy. If consciousness is not impaired, but the blood serum glucose level is below 3 mmol/l, then the child is shown a bolus administration of 50 ml of a 10% glucose or sucrose solution (1 teaspoon of sugar per 3.5 tablespoons of water) orally or through a nasogastric tube. Then such children are fed frequently - every 30 minutes for 2 hours in a volume of 25% of the volume of a regular single feeding, followed by a transfer to feeding every 2 hours without a night break. If the child is unconscious, lethargic, or has hypoglycemic convulsions, then he needs to be given a 10% glucose solution intravenously at a rate of 5 ml/kg. Then, glycemia is corrected by administering glucose solutions (50 ml of 10% solution) or sucrose through a nasogastric tube and switching to frequent feedings every 30 minutes for 2 hours, and then every 2 hours without a night break. All children with abnormal serum glucose levels are recommended to undergo antibacterial therapy with broad-spectrum drugs.

The second step is to prevent and treat hypothermia in children with BEM. If the child's rectal temperature is below 35.5 °C, he or she must be warmed up immediately: dressed in warm clothes and a hat, wrapped in a warm blanket, placed in a heated crib or under a radiant heat source. Such a child must be fed immediately, prescribed a broad-spectrum antibiotic, and regularly monitored for serum glycemia.

The third step is treatment and prevention of dehydration. Children with hypotrophy have pronounced disturbances of water-electrolyte metabolism, their BCC may be low even against the background of edema. Due to the risk of rapid decompensation of the condition and the development of acute heart failure in children with hypotrophy, the intravenous route should not be used for rehydration, except in cases of hypovolemic shock and conditions requiring intensive care. Standard saline solutions used for rehydration therapy for intestinal infections and, first of all, for cholera, are not used for children with hypotrophy due to their too high content of sodium ions (90 mmol / l Na ⁺ ) and an insufficient amount of potassium ions. In case of malnutrition, a special solution for rehydration of children with hypotrophy should be used - ReSoMal (Rehydratation Solution for Malnutrition), 1 liter of which contains 45 mmol of sodium ions, 40 mmol of potassium ions and 3 mmol of magnesium ions,

If a child with hypotrophy has clinically expressed signs of dehydration or watery diarrhea, then he is shown to undergo rehydration therapy orally or through a nasogastric tube with a ReSoMal solution at a rate of 5 ml/kg every 30 minutes for 2 hours. In the next 4-10 hours, the solution is administered at 5-10 ml/kg per hour, replacing the administration of the rehydration solution with feeding with formula or breast milk at 4, 6, 8 and 10 am. Such children also need to be fed every 2 hours without a night break. They should undergo constant monitoring of their condition. Every 30 minutes for 2 hours, and then every hour for 12 hours, the pulse and respiratory rate, frequency and volume of urination, stool and vomiting should be assessed.

The fourth step is aimed at correcting electrolyte imbalance in children with hypotrophy. As mentioned above, children with severe hypotrophy are characterized by excess sodium in the body, even if the serum sodium level is reduced. Deficiency of potassium and magnesium ions requires correction during the first 2 weeks. Edema in hypotrophy is also associated with electrolyte imbalance. Treatment of hypotrophy should not use diuretics, as this can only worsen existing disorders and cause hypovolemic shock. It is necessary to ensure regular intake of essential minerals in sufficient quantities into the child's body. It is recommended to use potassium in a dose of 3-4 mmol / kg per day, magnesium - 0.4-0.6 mmol / kg per day. Food for children with hypotrophy should be prepared without salt, only ReSoMal solution is used for rehydration. To correct electrolyte disturbances, a special electrolyte-mineral solution is used, containing (in 2.5 l) 224 g potassium chloride, 81 g potassium citrate, 76 g magnesium chloride, 8.2 g zinc acetate, 1.4 g copper sulfate, 0.028 g sodium selenate, 0.012 g potassium iodide, at a rate of 20 ml of this solution per 1 l of food.

The fifth step is timely treatment and prevention of infectious complications in children with malnutrition and secondary combined immunodeficiency.

The sixth step is used to correct micronutrient deficiency, which is typical for any form of hypotrophy. This step requires a very balanced approach. Despite the fairly high incidence of anemia, the treatment of hypotrophy does not require the use of iron preparations in the early stages of nursing. Sideropenia is corrected only after the condition has stabilized, in the absence of signs of an infectious process, after the restoration of the main functions of the gastrointestinal tract, appetite and stable weight gain, that is, not earlier than 2 weeks after the start of therapy. Otherwise, this therapy can significantly increase the severity of the condition and worsen the prognosis when an infection is superimposed. To correct micronutrient deficiency, it is necessary to ensure the intake of iron at a dose of 3 mg / kg per day, zinc - 2 mg / kg per day, copper - 0.3 mg / kg per day, folic acid (on the first day - 5 mg, and then - 1 mg / day) with subsequent prescription of multivitamin preparations, taking into account individual tolerance. It is possible to prescribe individual vitamin preparations:

• ascorbic acid in the form of a 5% solution intravenously or intramuscularly 1-2 ml (50-100 mg) 5-7 times a day during the adaptation phase for grades II-III hypotrophy or orally 50-100 mg 1-2 times a day for 3-4 weeks during the reparation phase;
• vitamin E - orally 5 mg/kg per day in 2 doses in the afternoon for 3-4 weeks during the adaptation and reparation phase;
• calcium pantothenate - orally 0.05-0.1 g 2 times a day for 3-4 weeks during the phase of reparation and enhanced nutrition;
• pyridoxine - orally 10-20 mg once a day before 8 am for 3-4 weeks during the adaptation and reparation phase;
• retinol - orally 1000-5000 IU in 2 doses in the afternoon for 3-4 weeks during the phase of reparation and enhanced nutrition.

The seventh and eighth steps include balanced diet therapy taking into account the severity of the condition, impaired gastrointestinal function and food tolerance. Treatment of severe hypotrophy often requires intensive therapy, the degree of impairment of their metabolic processes and digestive system functions is so great that conventional diet therapy is not able to significantly improve their condition. That is why, in severe forms of hypotrophy, complex nutritional support is indicated using both enteral and parenteral nutrition.

Parenteral nutrition of the initial period should be carried out gradually using only amino acid preparations and concentrated glucose solutions. Fat emulsions in hypotrophy are added to parenteral nutrition programs only after 5-7 days from the start of therapy due to their insufficient absorption and a high risk of developing side effects and complications. In order to avoid the risk of developing severe metabolic complications, such as hyperalimentation syndrome and "refeeding syndrome" , in case of PEM, balanced and minimal parenteral nutrition is necessary. "Refeeding syndrome" is a complex of pathophysiological and metabolic disorders caused by successive depletion, oversaturation, shift and disrupted interaction of phosphorus, potassium, magnesium, water-sodium and carbohydrate metabolism, as well as polyhypovitaminosis. The consequences of this syndrome are sometimes fatal.

Treatment of severe hypotrophy is carried out using continuous enteral tube feeding: continuous slow flow of nutrients into the gastrointestinal tract (stomach, duodenum, jejunum) with their optimal utilization, despite the pathological process. The rate of flow of the nutrient mixture into the gastrointestinal tract should not exceed 3 ml/min, the caloric load - no more than 1 kcal/ml, and the osmolarity - no more than 350 mosmol/l. It is necessary to use specialized products. The most justified is the use of mixtures based on deep hydrolysate of milk protein, which ensure maximum absorption of nutrients under conditions of significant inhibition of the digestive and absorption capacity of the digestive tract. Another requirement for mixtures for children with severe hypotrophy is the absence or low content of lactose, since these children have severe disaccharidase deficiency. When performing continuous enteral tube feeding, it is necessary to observe all the rules of asepsis, and if necessary, to ensure the sterility of the nutritional mixture, which is possible only when using ready-made liquid nutritional mixtures. Since the energy expenditure on digestion and assimilation of nutrients is much lower than with bolus administration of the nutritional mixture, this type of nutrition is most justified. This type of diet therapy improves cavity digestion and gradually increases the absorption capacity of the intestine. Continuous enteral tube feeding normalizes the motility of the upper gastrointestinal tract. The protein component (regardless of the semi-elemental or polymer diet) in such nutrition modulates the secretory and acid-forming function of the stomach, maintains adequate exocrine function of the pancreas and secretion of cholecystokinin, ensures normal motility of the biliary system and prevents the development of complications such as biliary sludge and cholelithiasis. The protein entering the jejunum modulates the secretion of chymotrypsin and lipase. The duration of the period of continuous enteral tube feeding varies from several days to several weeks depending on the severity of impaired food tolerance (anorexia and vomiting). By gradually increasing the caloric content of food and changing its composition, a transition is made to bolus administration of the nutritional mixture with 5-7 times a day feeding with continuous tube feeding at night. When the volume of daytime feedings reaches 50-70%, continuous tube feeding is completely discontinued.

Treatment of moderate and mild hypotrophy is carried out using traditional diet therapy based on the principle of food rejuvenation and a gradual change in diet with the allocation of:

• stage of adaptation, cautious, minimal nutrition;
• stage of reparative (intermediate) nutrition;
• stage of optimal or enhanced nutrition.

During the period of determining tolerance to food, the child is adapted to its required volume and water-mineral and protein metabolism is corrected. During the reparation period, protein, fat and carbohydrate metabolism is corrected, and during the period of enhanced nutrition, the energy load is increased. If there is hypotrophy, then in the initial periods of treatment, the volume is reduced and the frequency of feeding is increased. The required daily volume of food for a child with hypotrophy is 200 ml / kg, or 1/5 of his actual body weight. The volume of liquid is limited to 130 ml / kg per day, and in case of severe edema - 100 ml / kg per day.

Recommended feeding regimen for malnutrition at the stage of “Cautious feeding” (WHO, 2003)

Day	Frequency	Single volume, ml/kg	Daily volume, ml/kg per day
1-2	In 2 hours	11	130
3-5	In 3 hours	16	130
6-7+	In 4 hours	22	130

At the first degree of hypotrophy, the adaptation period usually lasts 2-3 days. On the first day, 2/3 of the required daily food volume is prescribed. During the period of determining food tolerance, its volume is gradually increased. Upon reaching the required daily food volume, enhanced nutrition is prescribed. In this case, the amount of proteins, fats and carbohydrates is calculated based on the required body weight (let's assume that the amount of fat is calculated based on the average body weight between the actual and required weight). At the second degree of hypotrophy, on the first day, 1/2-2/3 of the required daily food volume is prescribed. The missing food volume is replenished by taking rehydration solutions orally. The adaptation period ends when the required daily food volume is reached.

In the first week of the transition period, the amount of proteins and carbohydrates is calculated based on the weight corresponding to the patient's actual body weight plus 5% of it, and fats - on the actual weight. In the second week, the amount of proteins and carbohydrates is calculated based on the actual weight plus 10% of it, and fats - on the actual weight. In the third week, the frequency of feedings corresponds to the age, the amount of proteins and carbohydrates is calculated based on the actual weight plus 15% of it, and fats - on the actual weight. In the fourth week, the amount of proteins and carbohydrates is calculated approximately based on the expected body weight, and fats - on the actual weight.

During the period of enhanced nutrition, the content of proteins and carbohydrates is gradually increased, their amount is calculated on the expected weight, the amount of fats - on the average weight between the actual and expected. In this case, the energy and protein load on the actual body weight exceeds the load in healthy children. This is due to a significant increase in energy costs in children during the convalescence period with hypotrophy. In the future, the child's diet is brought closer to normal parameters by expanding the range of products, increasing the daily volume of food consumed and reducing the number of feedings. The composition of the mixtures used is changed, the caloric content and content of essential nutrients are increased. During the period of enhanced nutrition, hypercaloric nutritional mixtures are used. Protein consumption is corrected with cottage cheese, protein modules; fat consumption - with fat module mixtures, cream, vegetable or butter; carbohydrate consumption - with sugar syrup, porridges (by age).

Approximate composition of infant formulas* (WHO, 2003)

	F-75 (launch)	F-100 (subsequent)	F-135 (follow-on)
Energy, kcal/100 ml	75	100	135
Protein, g/100 ml	0.9	2.9	3.3
Lactose, g/100 ml	1.3	4.2	4.8
K, mmol/100 ml	4.0	6.3	7.7
Na, mmol/100 ml	0.6	1.9	2,2
Md, mmol/100 ml	0.43	0.73	0.8
Zn, mg/100 ml	2.0	2,3	3.0
Si, mg/100 ml	0.25	0.25	0.34
Protein energy content, %	5	12	10
Share of energy from fats, %	36	53	57
Osmolarity, mosmol/l	413	419	508

* For poor developing countries.

The feeding volume should be increased gradually under strict monitoring of the child's condition (pulse and respiratory rate). If during the next 2 4-hour feedings the respiratory rate increases by 5 per minute, and the pulse rate increases by 25 or more per minute, then the feeding volume is reduced, and the subsequent increase in the volume of a single feeding is slowed (16 ml / kg per feeding - 24 hours, then 19 ml / kg per feeding - 24 hours, then 22 ml / kg per feeding - 48 hours, then increasing each subsequent feeding by 10 ml). If well tolerated, at the stage of enhanced nutrition, high-calorie nutrition is provided (150-220 kcal / kg per day) with an increased nutrient content, but the amount of proteins does not exceed 5 g / kg per day, fats - 6.5 g / kg per day, carbohydrates - 14-16 g / kg per day. The average duration of the enhanced nutrition stage is 1.5-2 months.

The main indicator of the adequacy of diet therapy is weight gain. A good gain is one exceeding 10 g/kg per day, an average gain is 5-10 g/kg per day, and a low gain is less than 5 g/kg per day. Possible reasons for poor weight gain:

• inadequate nutrition (lack of night feedings, incorrect calculation of nutrition or without taking into account weight gain, limiting the frequency or volume of feeding, failure to comply with the rules for preparing nutritional mixtures, lack of correction during breastfeeding or regular feeding, insufficient care of the child);
• deficiency of specific nutrients, vitamins;
• current infectious process;
• mental problems (rumination, vomiting, lack of motivation, mental illness).

The ninth step involves sensory stimulation and emotional support. Children with hypotrophy need tender, loving care, affectionate communication between parents and the child, massage, therapeutic exercises, regular water procedures and walks in the fresh air. Children need to be played with for at least 15-30 minutes per day. The most optimal air temperature for children with hypotrophy is 24-26 °C with a relative humidity of 60-70%.

The tenth step involves long-term rehabilitation, including:

• nutrition that is sufficient in frequency and volume, adequate in calories and content of essential nutrients;
• good care, sensory and emotional support;
• regular medical examinations;
• adequate immunoprophylaxis;
• vitamin and mineral correction.

Pharmacotherapy is closely related to dietary correction. Replacement therapy is prescribed to all children with hypotrophy. This therapy includes enzymes, the most optimal are microspherical and microencapsulated forms of pancreatin. Enzyme preparations are prescribed for a long time at the rate of 1000 U/kg per day of lipase in 3 doses during meals or during main meals. A mandatory condition for the treatment of hypotrophy is the prescription of vitamin and microelement preparations (step 6). In the adaptation phase, as well as in other phases with low food tolerance or in the absence of weight gain, it is justified to prescribe insulin at the rate of 1 U per 5 g in combination with intravenous administration of concentrated glucose solutions. In the phase of metabolic restoration, with a constant increase in body weight, for its consolidation and some stimulation, the prescription of other drugs with anabolic effect is indicated:

• inosine - orally before meals, 10 mg/kg per day in 2 doses in the afternoon for 3-5 weeks;
• orotic acid, potassium salt - orally before meals, 10 mg/kg per day in 2 doses in the afternoon for 3-5 weeks during the enhanced nutrition phase with satisfactory food tolerance (or while taking enzyme preparations), with poor weight gain;
• levocarnitine - 20% solution orally 30 minutes before meals, 5 drops (for premature babies), 10 drops (for children under one year old), 14 drops (for children from 1 year to 6 years old) 3 times a day for 4 weeks;
• or cyproheptadine orally at 0.4 mg/kg once a day at 8-9 p.m. for 2 weeks.

Treatment of hypotrophy with a pronounced deficit in body weight and height against the background of replacement (basic) therapy with vitamins and enzymes (in case of a lag in bone age from the passport age) should be accompanied by the administration of nandrolone intramuscularly at 0.5 mg/kg once a month for 3-6 months.