Protein-energy malnutrition
Protein-energy malnutrition, referred to as malnutrition, is a kind of malnutrition caused by lack of energy and/or protein, which is mainly seen in infants under 3 years old. Its clinical characteristics are weight loss, progressive emaciation or edema, subcutaneous fat reduction, and often accompanied by different degrees of organ dysfunction. There are three common types in clinic: emaciation type with insufficient energy supply; Edema and emaciation, which are in short supply in protein-edema in between.
(1) etiology
1. Improper feeding or eating often includes long-term improper feeding or long-term partial eclipse and insufficient intake. If the intake of energy and protein is insufficient, it will lead to diseases.
2. The most common diseases are digestive system diseases (such as persistent diarrhea, allergic enteritis, intestinal malabsorption syndrome, etc. (Common reasons! ); Congenital malformation (cleft lip, cleft palate, pyloric obstruction, etc.). ); The recovery period of acute and chronic infectious diseases (such as measles, typhoid fever, hepatitis, tuberculosis and dysentery); Intestinal parasitic diseases; Diabetes, massive proteinuria, febrile diseases, hyperthyroidism and malignant tumor diseases increase the consumption of nutrients; Congenital defects (such as premature delivery and twins) and other needs to be increased to catch up with growth can cause malnutrition.
(2) Clinical manifestations
1. Clinical manifestations: No weight gain as the first symptom (the first one! ), followed by weight loss, subcutaneous fat gradually reduced or disappeared, and the height of patients with chronic illness was lower than normal. Subcutaneous fat gradually decreases or disappears, first in the abdomen, then in the trunk, buttocks, limbs, and finally in the cheeks (the order is very important! )。 The thickness of abdominal subcutaneous fat layer is one of the important indexes to judge the degree of malnutrition. With the aggravation of malnutrition, systemic symptoms and biochemical metabolic changes gradually appear. Often accompanied by decreased activity, fatigue, loss of appetite, irritability, dry hair and other manifestations. In severe malnutrition, subcutaneous fat disappears completely, and looks like an old man, with poor and slow response, muscle atrophy, low muscle tension, low body temperature and slow pulse, low ECG voltage and low T wave.
2. Current classification and grading standards (applicable to children under 5 years old) (change! )
(1) Low body weight: the body weight is lower than the average of the reference population of the same age and sex minus 2SD. If it is lower than the average value of reference population of the same age and sex, the reduction of 2SD~3SD is moderate; Less than 3SD is severe. This index mainly reflects chronic or acute malnutrition.
(2) Growth retardation: Growth retardation is defined as the average body length less than the reference population of the same age and gender minus 2SD. If it is lower than the average value of reference population of the same age and sex, the reduction of 2SD~3SD is moderate; Less than 3SD is severe. This index mainly reflects chronic malnutrition.
(3) emaciation: weight less than the average of reference population of the same sex and height minus 2SD is emaciation. If it is lower than the average value of the reference population of the same sex and height, the reduction of 2SD~3SD is moderate; Less than 3SD is severe. This index mainly reflects recent and acute malnutrition.
(3) Diagnose the history and clinical manifestations of tuberculosis, make relevant physical measurements and relevant auxiliary examinations, and then the disease can be diagnosed.
complication
1. Nutritional anemia is mostly nutritional iron deficiency anemia (common), nutritional megaloblastic anemia or both.
2. Vitamin A and D deficiency, vitamin B and vitamin C deficiency are common. When malnutrition occurs, the symptoms of vitamin D deficiency are not obvious, but when the growth rate is accelerated in the recovery period, the symptoms are more prominent.
3. Infection is easy to be infected by various bacteria, viruses and fungi, such as respiratory tract infection, intestinal infection, urinary tract infection, septicemia, etc., due to low nonspecific and specific immune function. Diarrhea, in particular, will prolong malnutrition and form a vicious circle.
4. Spontaneous hypoglycemia can occur suddenly, manifested as pallor, unconsciousness, slow pulse, apnea, no increase in body temperature, but generally no convulsions. If not treated in time, he can die of respiratory paralysis (a very important complication).
(5) The principle of treatment is to actively deal with all kinds of life-threatening complications, eliminate the causes, adjust diet and promote digestive function.
1. Actively deal with various life-threatening complications, such as severe dehydration and electrolyte disorder during diarrhea, acidosis, shock, renal failure, spontaneous hypoglycemia, secondary infection, eye injury caused by vitamin A deficiency, etc.
2. Remove the etiology and actively treat the primary disease, such as correcting digestive tract malformation, controlling infectious diseases, radically curing various consumptive diseases and improving feeding methods.
3. Diet adjustment should be based on the degree of malnutrition, digestive ability and food tolerance, and should not be rushed. Especially for moderate and severe children, the supply of calories and nutrients should be gradually increased from low to high, otherwise digestive system disorder will aggravate the condition. When choosing a diet, children should choose foods that are easy to digest and absorb, high in calories and high in protein. In addition, there are milk, eggs, fish, liver and lean meat. Can be used. When the heat energy is not enough, you can add a little vegetable oil to the food. In addition, vitamins and trace elements should be supplemented at the same time (general principle).
(1) Mild malnutrition: caloric restriction is 80 ~100 kca1(334.72 ~ 418.4 kj)/(kg? D), protein 3g/(kg? D) gradually increase to 150 ~ 470 kcal (627.6 ~ 711.28kj)/(kg? D), protein 3.5 ~ 4.5g/(kg? D) When the body weight is close to normal, it will return to the calorie100 ~120kca1(418.4 ~ 502.08kJ)/(kg? D), protein 3.0g/(kg? D) test.
(2) Moderate malnutrition: the calorie is limited to 60-80 kilocalories (251.04-334.72 kilojoules)/(kg? D), protein 2g/(kg? D), fat 1g/(kg? D) gradually increased at first, about 1 week later, and increased to 12 kcal(502.08 kj)/(kg? D), protein 3g/(kg? D), fat 1.8g/(kg? D), and then adjust according to the same steps of mild malnutrition.
(3) Severe malnutrition: the calorie intake range is 40 ~ 60 kcal (167.36 ~ 251.04 kj)/(kg? D), protein 1.5 ~ 2g/(kg? D) fat 1g/(kg? D) First meet the basic metabolic needs of children, and then gradually increase, and adjust according to the same steps as moderate malnutrition.
4. Promote digestion and give various digestive enzymes (pepsin, pancreatin, etc.). ) to help digestion. Supplement vitamins and trace elements (such as a, b, c, zinc, iron, etc.). ), patients with decreased blood zinc were given oral 1% zinc sulfate syrup from 0.5ml/(kg? D) Start and gradually increase to 2ml (kg? D) Supplementing zinc intake can promote appetite and improve metabolism. If necessary, protein anabolic steroid preparations such as norbornyl propionate can be injected intramuscularly, 10 ~ 25mg each time and 1 ~ 2 times a week for 2 ~ 3 weeks, so as to promote the body to synthesize protein and stimulate appetite (promote synthesis! )。 For those who eat less or refuse to eat, insulin and glucose therapy can be tried. Routine insulin was injected subcutaneously for 2 ~ 3U/ time, once a day 1 ~ 2 times. Intravenous injection of 20 ~ 30g glucose or 40 ~ 60ml 25% glucose before injection to prevent hypoglycemia. Every 1 ~ 2 weeks is a course of treatment.
Acupuncture, massage, touching, chiropractic and other therapies treated by traditional Chinese medicine can promote appetite. Traditional Chinese medicine can take Qin Shen Baizhu Powder and other drugs to strengthen the spleen and replenish qi, help digestion and promote absorption.
6. Other treatments For patients with severe illness accompanied by obvious hypoproteinemia or severe anemia, component blood transfusion or albumin infusion may be considered. At the same time, elemental diet or intravenous high nutrition can be given, and glucose, amino acids, fat milk and albumin can be dripped intravenously as appropriate.
Simple obesity
Simple obesity is caused by long-term energy intake exceeding consumption, which leads to excessive fat accumulation in the body and makes the weight exceed 20% of the average of children of the same sex and height. It can occur at any age, but it is most common in infancy, preschool and adolescence (numerical and age control! )。
(1) The causes are genetic factors, overnutrition, too little activity, eating habits and psychological factors.
(2) Clinical manifestations
1. The child has a big appetite and likes sweets and fatty foods.
2. Obese, but the subcutaneous fat is evenly distributed throughout the body, especially in the abdomen, shoulders, cheeks, breasts and other places. Because of too much fat, white or purple lines appear on the skin of abdomen, buttocks and thighs. Boys are misdiagnosed as penile dysplasia because of excessive fat accumulation in the perineum of thighs and penis buried in perineum, or as breast dysplasia because of rich breast fat.
Children who are obviously obese often feel tired, short of breath or leg pain when exerting strength.
4. Obesity: Excessive accumulation of fat restricts the movement of the thorax and diaphragm, leading to insufficient lung ventilation, shallow breathing, decreased alveolar ventilation, hypoxemia, shortness of breath, cyanosis, erythrocytosis, enlarged heart or congestive heart failure, which is called obesity-poor ventilation syndrome ().
Because they are afraid of being laughed at and unwilling to associate with other children, they often have psychological obstacles (such as inferiority, loneliness and timidity). ).
(3) Diagnosis and differential diagnosis
1. Combined with medical history, clinical manifestations and related auxiliary examinations, it is not difficult to diagnose simple obesity. 10% ~ 19% is overweight and 20% ~ 29% is slightly obese. Weight over 30% ~ 49% is moderately obese; Weight over 50% is severe obesity. Body mass index (BMI) is another index to evaluate obesity, which refers to the weight per unit area. BMI = weight (kg)/ height square (m2). Body mass index & gt the 95th percentile of the same age and sex can diagnose obesity. Auxiliary examination items: ① blood triglyceride and cholesterol are increased, and β lipoprotein may be increased in severe cases; ② There may be abnormal glucose tolerance curve and hyperinsulinemia; ③ The serum growth hormone level decreased, and the peak value of growth hormone provocation test was lower than that of normal children; ④ Liver ultrasound examination often has fatty liver (grading and auxiliary examination).
2. Differential diagnosis
(1) Hereditary diseases with obesity: ① Prader-Willi syndrome: peripheral obesity. Short stature, mental retardation, small hands and feet, low muscle tension and hypoplasia of external genitalia; ②Laurenc-Moon-Biedl syndrome: peripheral obesity, mild mental retardation, retinitis pigmentosa, polydactyly and sexual dysfunction; ③Alstrom syndrome: centripetal obesity, retinitis pigmentosa, blindness, nervous deafness and diabetes.
(2) Endocrine diseases related to obesity: ① Frohlic syndrome: the disease is secondary to hypothalamic and pituitary lesions, and its body fat is mainly distributed in the neck, chin, breast, lower limbs, perineum and buttocks, with slender fingers and toes, short stature and delayed or missing secondary sexual characteristics; ② Other endocrine diseases, such as hypercortisolism, hypothyroidism and growth hormone deficiency, have their own characteristics, so it is not difficult to distinguish them.
(4) treatment
1. Control calorie restriction, recommend recipes with high protein, low fat and low carbohydrate, and encourage eating more vegetables with large volume and low energy. Avoid overeating at dinner, do not eat late-night snacks and snacks, and try to avoid high-calorie foods such as chocolate, cream and candy. We should develop good eating habits, such as eating less and eating more, eating slowly, chewing slowly and so on.
2. Increase the amount of exercise and keep exercising for 30 minutes every day. The amount of activity is based on the principle of being relaxed and happy after exercise and not feeling overtired.
3. Psychotherapy encourages children to consciously control their food intake, build confidence and persist in exercise.
(5) Prevention
1. Strengthen education and correct the misconception that obesity is healthier. In the third trimester, the mother should start prevention, properly control the diet, and prevent the fetus from being overweight.
2. Emphasize that breastfeeding should reduce the addition of high-sugar and high-fat complementary food and moderate diet. If the baby of 6 ~ 8 months is obese, the milk quantity should be limited and the refined rice flour food should be reduced to control the intake of excessive energy.
3. Develop good living habits and don't prefer high-sugar and high-fat foods; Avoid watching TV and playing video games for a long time.
4. Carry out regular weight monitoring to find obesity tendency early. (Simple understanding of treatment and prevention)