Treatment of hypotrophy

Treatment of hypotrophy in children of the I degree is usually performed in outpatient settings, and children with grade II and III hypotrophy are hospitalized. Treatment of hypotrophy in these children should be carried out in a complex way, that is, include balanced nutritional support and diet therapy, pharmacotherapy, adequate care and rehabilitation of a sick child.

In 2003, WHO experts developed and published recommendations on the management of children with hypotrophy, which regulate all activities for nursing children with malnutrition. They identified 10 basic 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;
• careful beginning of feeding;
• providing weight gain and growth;
• providing sensory stimulation and emotional support;
• further rehabilitation.

Activities are carried out in stages, taking into account the severity of the condition of the sick child, beginning with the correction and prevention of life-threatening conditions.

The first step is aimed at treating and preventing hypoglycemia and associated possible disorders of consciousness in children with hypotrophy. If the consciousness is not disturbed, but the serum glucose level is below 3 mmol / l, the child is shown a bolus injection of 50 ml of a 10% solution of glucose or sucrose (1 tsp sugar per 3.5 tbs water) through the mouth or nasogastric probe. Then these children are fed often - every 30 minutes for 2 hours in a volume of 25% of the volume of the usual single-time feeding, followed by transfer to feeding every 2 hours without a night break. If the child is unconscious, in lethargy, or has hypoglycemic convulsions, then he needs to inject 10% glucose solution from the calculation of 5 ml / kg intravenously. Then, correction of glycemia is performed by injecting glucose solutions (50 ml of 10% solution) or sucrose through a nasogastric tube and transferring to frequent feeding every 30 minutes for 2 hours, and then every 2 hours without a night break. All children with impaired serum glucose levels are shown to carry out antibacterial therapy with broad-spectrum drugs.

The second step is the prevention and treatment of hypothermia in children with PEN. If the child's rectal temperature is below 35.5 ° C, then it must be urgently warmed: put on warm clothes and a hat, wrap it in a warm blanket, put it in a heated bed or under a radiant heat source. Such a child should be urgently fed, a broad-spectrum antibiotic prescribed and regular monitoring of serum glycemia.

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

If a child with hypotrophy has clinical signs of dehydration or watery diarrhea, then he is shown to perform rehydration therapy through the mouth or nasogastric tube with a solution of ReSoMal from the calculation of 5 ml / kg every 30 minutes for 2 hours. For the next 4-10 hours, the solution is administered at 5 -10 ml / kg per hour, replacing the introduction of rehydration solution for feeding with a mixture or mother's milk at 4, 6, 8 and 10 hours. These children also need to be fed every 2 hours without a night break. They should conduct continuous monitoring of the condition. Every 30 minutes for 2 hours, and then every hour for 12 hours, you should evaluate the pulse and respiration rate, frequency and volume of urination, stool and vomiting.

The fourth step is aimed at correcting electrolyte imbalance in children with hypotrophy. As mentioned above, for children with severe hypotrophy, an excess of sodium in the body is characteristic, even if the serum sodium level is lowered. 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, since this can only aggravate existing disorders and cause hypovolemic shock. It is necessary to provide regular intake of essential minerals in the body of the child in sufficient quantities. 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, for rehydration use only ReSoMal solution. To correct electrolyte disturbances, a special electrolyte-mineral solution containing (in 2.5 liters) 224 g of potassium chloride, 81 g of potassium citrate, 76 g of magnesium chloride, 8.2 g of zinc acetate, 1.4 g of copper sulfate, 0.028 g sodium selenate, 0.012 g of potassium iodide, based on 20 ml of this solution per 1 liter of food.

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

The sixth step is used to correct the micronutrient deficiency characteristic of any form of hypotrophy. At this step, an extremely balanced approach is needed. Despite the high enough frequency of anemia, the treatment of hypotrophy does not require the use of iron preparations in the early stages of nursing. Correction of sideropenia is carried out only after stabilization of the state, in the absence of signs of an infectious process, after restoration of the main functions of the gastrointestinal tract, appetite and persistent weight gain, that is, not earlier than 2 weeks from the start of therapy. Otherwise, this therapy can significantly increase the severity of the condition and worsen the prognosis when the infection stratifies. To correct the deficiency of micronutrients it is necessary to ensure the intake of iron in 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, 1 mg / day) with the subsequent appointment 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 in the adaptation phase at II-III degree of hypotrophy or inside 50-100 mg 1-2 times per day in during 3-4 weeks in the phase of repair;
• vitamin E - inside 5 mg / kg per day in 2 doses in the afternoon for 3-4 weeks in the phase of adaptation and repair;
• calcium pantothenate - inside by 0,05-0,1 g 2 times a day for 3-4 weeks in the phase of repair and enhanced nutrition;
• pyridoxine - inside by 10-20 mg 1 time per day until 8 am for 3-4 weeks in the phase of adaptation and repair;
• retinol - inside for 1000-5000 units in 2 receptions in the afternoon for 3-4 weeks in the phase of repair and enhanced nutrition.

The seventh and eighth steps include a balanced diet, 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 disruption of their metabolic processes and the functions of the digestive system are so great that conventional diet therapy can not significantly improve their condition. That is why, in severe forms of malnutrition, complex nutritional support with both enteral and parenteral nutrition is indicated.

Parenteral nutrition of the initial period should be carried out gradually using exclusively amino acid preparations and concentrated solutions of glucose. Fatty emulsions with hypotrophy are added to parenteral nutrition programs only after 5-7 days from the start of therapy because of their inadequate digestion and a high risk of side effects and complications. To avoid the risk of developing severe metabolic complications, such as hyperalimentation syndrome and the "refeeding syndrome" syndrome, with PEN, balanced and minimal parenteral nutrition is necessary. The syndrome of "renewed nutrition" is a complex of pathophysiological and metabolic disorders caused by sequential depletion, supersaturation, shift and disturbed interaction of phosphoric, potassium, magnesium, sodium-water and carbohydrate metabolism, as well as polyhypovitaminosis. The consequences of this syndrome are sometimes fatal.

Treatment of severe form of severe hypotrophy is performed with the use of constant enteral feeding: continuous slow intake of nutrients in the digestive tract (stomach, duodenum, jejunum) with their optimal utilization, despite the pathological process. The rate of intake of the nutritional formula in the digestive tract should not exceed 3 ml / min, the caloric load - no more than 1 kcal / ml, and the osmolarity - not more than 350 mosmol / l. It is necessary to use specialized products. The most justified use of mixtures based on deep hydrolyzate of milk protein, ensuring maximum absorption of nutrients in conditions of significant inhibition of the digestive and absorption capacity of the digestive canal. Another requirement for mixtures for children with severe forms of hypotrophy is the lack or low content of lactose, since these children are noted for a marked disaccharidase insufficiency. When carrying out a permanent enteral feed, all aseptic rules should be followed, and if necessary, ensure sterility of the nutrient mixture, which is possible only with the use of ready-made liquid nutrient mixtures. Since energy consumption for digestion and assimilation of nutrients is much lower than with bolus administration of the nutritional formula, this kind of nutrition is maximally justified. This kind of diet therapy improves the cavity digestion and gradually increases the absorption capacity of the gut. Constant enteral probe feeding normalizes the motor function of the upper gastrointestinal tract. The protein component (independently semi-elemental or polymeric diet) at such nutrition modulates the secretory and acid-forming function of the stomach, supports adequate exocrine pancreatic function and cholycysticinin secretion, provides normal motor function 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 chemotripsin and lipase. The duration of the constant enteral feeding period varies from several days to several weeks, depending on the severity of the disturbed food tolerance (anorexia and vomiting). Gradually increasing the calorie content of food and changing its composition, the transition to bolus feeding of the nutrient mixture is carried out with 5-7-day feeding with constant probe feeding at night. When the volume of daily feeding reaches 50-70%, the constant probe feeding is completely canceled.

Treatment of moderate and mild to moderate 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:

• the stage of adaptive, cautious, minimal nutrition;
• the stage of reparation (intermediate) nutrition;
• phase of optimal or enhanced nutrition.

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

The recommended feeding regimen for hypotrophy in the "Careful Nutrition" phase (WHO, 2003)

Day	Frequency	Single volume, ml / kg	Daily volume, ml / kg daily
1-2	After 2 hours	Eleven	130
3-5	After 3 hours	16	130
6-7 +	After 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 amount of food is prescribed. In the period of finding out the tolerance to food, its volume is gradually increased. When the necessary daily volume of food is prescribed, enhanced nutrition. At the same time, the number of proteins, fats and carbohydrates is calculated on the body's weight (we can calculate the amount of fat per average body weight between the actual weight and the amount of fat required). At the II degree of hypotrophy, on the first day, 1 / 2-2 / 3 of the required daily volume of food is prescribed. The missing volume of food is replenished by the intake of rehydration solutions. The adaptation period ends when the required daily volume of food is reached.

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

During the period of enhanced nutrition, the content of proteins and carbohydrates is gradually increased, their number begins to count on the weight, the amount of fats - on the average mass between the actual and the required. At the same time, 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 consumption in children during convalescence in hypotrophy. In the future, the child's diet is brought closer to normal parameters by expanding the range of products, increasing the daily intake of food and reducing the number of feedings. Change the composition of the mixtures used, increase the caloric content and the content of basic nutrients. During the period of intensive nutrition, hypercaloric nutrient mixtures are used. Correction of protein intake is carried out by cottage cheese, protein modules; consumption of fat - fatty modular mixtures, cream, vegetable or butter; consumption of carbohydrates - sugar syrup, porridge (by age).

Approximate composition of milk formulas * (WHO, 2003)

	F-75 (starting)	F-100 (later)	F-135 (later)
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
Mg, mmol / 100 mL	0.43	0.73	0.8
Zn, mg / 100 ml	2.0	2.3	3.0
Cu, mg / 100 ml	0.25	0.25	0.34
Proportion of protein energy,%	5	12	10
Fat energy percentage,%	36	53	57
Osmolarity, MOSMOL / L	413	419	508

* For poor developing countries.

The amount of feeding should be increased gradually under strict control of the child's condition (pulse and respiration rate). If during 2 consecutive 4-hour feeding the respiratory rate increases by 5 per min, and the pulse rate increases by 25 or more per minute, the feeding volume is reduced, and the subsequent increase in the volume of single feeding is slowed down (16 ml / kg for feeding - 24 h , then 19 ml / kg for feeding - 24 hours, then 22 ml / kg for feeding - 48 hours, then increasing each subsequent feeding by 10 ml). With good tolerability, high-calorie nutrition (150-220 kcal / kg per day) with an increased nutrient content is provided at the stage of enhanced nutrition, however, 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 diet is 1.5-2 months.

The main indicator of the adequacy of diet therapy is weight gain. A good increase is considered to be more than 10 g / kg per day, medium - 5-10 g / kg per day and low - less than 5 g / kg per day. Possible causes of a bad weight gain:

• inadequate nutrition (lack of night feeding, improper calculation of nutrition or without weight gain, restriction of frequency or volume of nutrition, failure to comply with the rules for preparing nutritional formulas, lack of correction for breast or normal nutrition, lack of care for the child);
• deficiency of specific nutrients, vitamins;
• the current infectious process;
• mental problems (rumination, vomiting, lack of motivation, mental illness).

The ninth step provides sensory stimulation and emotional support. Children with hypotrophy need a gentle, loving care, affectionate communication of parents with the child, carrying out a massage, therapeutic gymnastics, regular water procedures and walking outdoors. Children should be played for at least 15-30 minutes a day. The most optimal air temperature for children with hypotrophy is 24-26 ° C with a relative humidity of 60-70%.

The tenth step provides for a long-term rehabilitation, including:

• food sufficient in frequency and volume, adequate for caloric content 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. Substitution therapy is prescribed for all children with hypotrophy. The composition of this therapy includes enzymes, the most optimal microspherical and microencapsulated forms of pancreatin. Enzyme preparations are prescribed for a long time from the calculation of 1000 U / kg per day lipase in 3 meals during meals or in basic meals. A prerequisite for the treatment of hypotrophy is the appointment of vitamin and microelement preparations (step 6). In the adaptation phase, as well as in other phases with a low tolerance to food or in the absence of weight gain, it is justified to prescribe insulin from the calculation of 1 ED per 5 g in combination with intravenous administration of concentrated glucose solutions. In the phase of the restoration of metabolism, with a constant increase in body weight for its fixation and some stimulation, the appointment of other drugs with an anabolic effect is indicated:

• inosine - inside before meals at 10 mg / kg per day in 2 doses in the afternoon for 3-5 weeks;
• orotova acid, potassium salt - inside before meals at 10 mg / kg per day in 2 receptions in the afternoon for 3-5 weeks in the phase of enhanced nutrition with a satisfactory tolerance to food (or against the background of taking enzyme preparations), with a bad increase body weight;
• Levokarnitina - 20% solution inside for 30 minutes before meals 5 drops (premature infants), 10 drops (for children up to one year), 14 drops (children from 1 year to 6 years) 3 times a day for 4 weeks;
• or cyproheptadine by inside at 0.4 mg / kg 1 time per day at 20-21 hours for 2 weeks.

Treatment of hypotrophy in the presence of severe body weight and growth deficiency in the background of substitution (basic) therapy with vitamins and enzymes (in case of a delay in the bone age from the passport) should be accompanied by the appointment of nandrolone intramuscularly at 0.5 mg / kg 1 time per month for 3-6 months .