1. Evaluation and classification
Taking weight/age, body length (height)/age and weight/body length (height) as evaluation indexes, protein-energy malnutrition was evaluated and classified by standard deviation method. The measured values below the median minus two standard deviations are low weight, growth retardation and emaciation.
The standard deviation method for evaluating the classification index of protein-energy malnutrition is used to evaluate the moderate low weight of weight/age m-3sd ~ m-2sd; M-3sd is severely underweight, length (height)/age m-3sd ~ m-2sd is moderately stunted; Weight/length (height) with severe developmental retardation
(1) Premature, low birth weight or small for gestational age.
(2) Improper feeding, such as insufficient milk intake, improper or appropriate food conversion, partial eclipse and picky eaters.
(3) Recurrent respiratory infection and diarrhea, digestive tract malformation, endocrine and genetic metabolic diseases and other chronic diseases that affect growth and development.
intervene
(1) Feeding guidance: feeding consultation and dietary investigation and analysis. According to the results of etiology, assessment and classification, and dietary analysis, parents are instructed to provide children with meals that meet their normal growth needs, so that the energy intake will gradually reach more than 85% of the recommended intake (RNI), and the intake of protein, minerals and vitamins will reach more than 80% of RNI.
(2) Management
1) Follow-up: nutritional monitoring, growth evaluation and guidance are conducted every month until normal growth is restored.
2) Referral: severely malnourished children, moderately malnourished children who have been treated for poor weight gain twice in a row, or children whose body length or height is still poor after 3-6 months of nutritional improvement need to be transferred to higher maternal and child health care institutions or specialized clinics for consultation or treatment in time. After referral, the prognosis of the children should be known regularly, and they should be included in the project management in time after discharge, and they should be assisted to resume treatment according to the treatment opinions of the maternal and child health care institutions at higher levels or specialized clinics until they return to normal growth.
3) Closing the case: Generally speaking, the case can be closed if the weight/age or body length (height)/age or weight/body length (height) ≥ m-2sd.
4. Prevention
(1) instruct premature/low birth weight infants to adopt special feeding methods, evaluate them regularly, and actively treat the serious congenital malformation that can be corrected.
(2) Analyze the medical history in time, ask the reasons of children's developmental retardation, and give personalized guidance according to the reasons; For children with feeding or eating behavior problems, guide parents to feed reasonably, correct behaviors, and let children's physical development return to normal speed.
(3) Children with recurrent digestive tract and respiratory tract infections and chronic diseases that affect their growth and development should be treated in time.
(2) nutritional iron deficiency anemia
1. Assessment and graduation
(1) evaluation index
1) Decreased hemoglobin (Hb): 6 months to 6 years old.
2) Peripheral red blood cells showed small cell hypopigmentation: mean red blood cell volume (MCV).
3) Conditional institutions can carry out further examinations such as iron metabolism to make a definite diagnosis.
(2) Judging the degree of anemia: Hb value of 90 ~ 109g/L is mild, and 60 ~ 89g/L is moderate.
Find the reason
(1) Premature delivery, twins or multiple births, fetal blood loss and maternal anemia lead to congenital iron deficiency.
(2) Iron-rich foods were not added in time, resulting in insufficient iron intake.
(3) Irrational diet and gastrointestinal diseases affect iron absorption.
(4) Rapid growth and development have increased the demand for iron.
(5) Long-term chronic blood loss leads to excessive iron loss.
intervene
(1) iron therapy
1) Dosage: Anemia children can be treated by oral iron supplementation. Calculate the iron supplement dose according to elemental iron, that is, supplement elemental iron 1 ~ 2 mg/kg daily, take it between meals and take it orally for 2 ~ 3 times, with the total daily dose not exceeding 30 mg. Vitamin C can be taken orally at the same time to promote the absorption of iron. Commonly used iron agents and their iron content, that is, every 1 mg of elemental iron is equivalent to: 5mg of ferrous sulfate, 8mg of ferrous gluconate, 5mg of ferrous lactate, 5mg of ammonium ferric citrate or 3mg of ferrous fumarate. Oral iron may cause side effects such as nausea, vomiting, stomachache, constipation, melena and diarrhea. When the above situation occurs, we can use the method of intermittent iron supplementation [supplementing elemental iron 1 ~ 2 mg/(kg times), l ~ 2 times a week or/kloc-0 times a day], and then gradually increase it to the usual amount after the side effects are alleviated. Taking iron between meals can reduce gastrointestinal side effects.
2) Course of treatment: After the Hb value is normal, iron supplementation should be continued for 2 months to restore the body's iron storage level.
3) Treatment standard: Hb value began to rise after 2 weeks of iron supplementation, and Hb value should rise 10 ~ 20 g/L and above after 4 weeks.
(2) Other treatments
1) general treatment: feed foods rich in iron reasonably; Folic acid, vitamin B 12(VitB 12) and other micronutrients can also be supplemented; Prevent infectious diseases.
2) Etiological treatment: Take corresponding measures according to possible etiologies and basic diseases.
(3) Management
1) Follow-up: Hb was reexamined 2-4 weeks after iron supplementation in children with mild and moderate anemia to understand the compliance of iron supplementation and observe the curative effect.
2) Referral: Children with severe anemia, children with mild and moderate anemia who have not improved or gradually worsened after 1 month of routine iron treatment, should be promptly transferred to higher maternal and child health care institutions or specialized outpatient clinics for consultation or referral.
2) Closing the case: After the whole course of treatment, the case can be closed when the Hb value reaches normal.
4. Prevention
(1) Diet adjustment and iron supplementation
1) Pregnant women: Strengthen nutrition and eat more foods rich in iron. From the third month of pregnancy, take oral iron supplementation according to elemental iron 60 mg/d, which can last until postpartum if necessary; At the same time, small doses of folic acid (400 mg/d) and other vitamins and minerals were supplemented. Delaying the ligation of umbilical cord for 2 ~ 3 minutes during delivery can increase the iron reserve of infants.
2) Infants: Premature/low birth weight infants should be supplemented with iron from 4 weeks old, with a daily dose of 2 mg/kg elemental iron until 1 year. Full-term infants who are exclusively breast-fed or mainly breast-fed begin to supplement iron at the age of 4 months, and the dose is 1 mg/kg elemental iron per day; Artificial feeding of infants should adopt iron fortified formula.
3) Children: Pay attention to the balance and nutrition of food, provide more foods rich in iron, encourage eating more vegetables and fruits, promote the absorption of iron in the intestines, and correct children's bad habits such as anorexia and partial eclipse.
(2) Prevention and treatment of parasitic infection: In areas with high incidence of parasitic infection, while preventing anemia, it is necessary to carry out anthelmintic treatment.
Vitamin d deficiency rickets
1. Assessment and preparation
(1) Early stage: It is more common in infants within 6 months, especially within 3 months. There may be nonspecific neuropsychiatric symptoms, such as hyperhidrosis, irritability and night terrors. And there are often no bone diseases during this period. Blood calcium and phosphorus are normal or slightly lower, alkaline phosphatase (AKP) is normal or slightly higher, and blood 25-(OH)D is decreased. There is no abnormality in X-ray film of bone or the temporary calcified zone at metaphysis of long shaft is blurred.
(2) Activity cycle
1) Skeletal signs: Infants under 6 months may have skull softening; Babies over 6 months old can see square cranium, hand (foot) bracelet, rib bead, costal cartilage groove, chicken breast, O-leg and X-leg.
2) Blood biochemistry: Blood calcium is normally low or decreased, blood phosphorus is obviously decreased, blood AKP is increased, and blood 25-(OH)D is obviously decreased.
3) Bone X-ray film: The temporary calcified zone at the metaphyseal end of the long shaft disappeared, the metaphyseal end widened into a brush or cup shape, and the epiphyseal cartilage disc widened by > 2 mm 。
(3) recovery period
1) Symptoms and signs: Children in early or active stage can gradually relieve or disappear after sunlight irradiation or treatment.
2) Blood biochemistry: Blood calcium, blood phosphorus, AKP and 25-(OH)D gradually returned to normal.
3) Bone X-ray film: The temporary calcified zone at the metaphyseal end of the long shaft reappeared, widened and increased in density, with epiphyseal cartilage disc.
(4) Sequela period: After severe rickets were cured, skeletal deformities of different degrees were left behind.
Find the reason
(1) Insufficient perinatal reserve: insufficient vitamin D(VitD) in pregnant women and nursing mothers, premature delivery, twins or multiple births.
(2) Insufficient sunlight exposure: less outdoor activities, high-rise shelter, air pollution (such as smoke and dust), winter and high latitude (north of the Yellow River) areas.
(3) Overgrowth: Infants with overgrowth and development have relatively insufficient VitD.
(4) Diseases: Recurrent respiratory infections, chronic digestive tract diseases, liver and kidney diseases.
intervene
(1)VitD treatment: it is recommended that children with active rickets take VitD orally, with the dosage of 800 iu/d (20μ g/d) for 3-4 months or 2000-4000 iu/d (50-100μ g/d)1month. When oral administration is difficult or diarrhea affects absorption, high-dose shock therapy can be used, and Vitd1.5 ~ 300,000 IU (3.75 ~ 7.5 mg) can be injected into muscle at one time. If the above indications are improved after treatment, 400 iu/d (10μ g/d) of Vitd should be taken orally after13 months. Blood biochemical indexes should be monitored during high-dose treatment to avoid hypercalcemia and hypercalciuria.
(2) Other treatments
1) Outdoor activities: Exercise 1 ~ 2 hours a day under the condition of sufficient sunshine and suitable temperature to fully expose the skin.
2) Calcium supplementation: Milk is a high-quality source of calcium nutrition for infants, and full-term infants with sufficient milk may not need calcium supplementation. Those who have insufficient calcium intake in the diet can supplement calcium appropriately.
3) Strengthen nutrition: We should pay attention to the supplement of various nutrients.
(3) Management
1) Follow-up: Recheck rickets in active period 1 time, and Rickets in convalescence 1 time, lasting for 2 months until it is cured.
2) Referral: If the symptoms, signs and laboratory tests of active rickets are still not improved after treatment with VitD for 1 month, other non-VitD deficiency rickets (such as renal osteodystrophy, renal tubular acidosis, hypophosphatemia against VitD rickets, Fanconi syndrome), endocrine and bone metabolic diseases (such as hypothyroidism, achondroplasia and mucopolysaccharide storage) should be considered.
3) Closing the case: In the active stage, the symptoms of rickets disappear for 65,438+0 ~ 3 months, and the signs are relieved or returned to normal, and the case can be closed after 2 ~ 3 months without change.
4. Prevention
(1) Mother: Pregnant women should often go outdoors and eat foods rich in calcium and phosphorus. In order to prevent the occurrence of congenital rickets, women in the third trimester of pregnancy in winter and spring should be properly supplemented with VitD 400 ~1000 iu/d (10 ~ 25 μ g/d). Vitamin preparations should be used to avoid vitamin poisoning and vitamin intake
(2) Babies
1) outdoor activities: infants and young children should engage in outdoor activities, receive sunlight every day 1 ~ 2 hours, and try to expose their body parts.
2) VitD supplement: VitD 400 IU/d( 10 μg/d) will be supplemented for infants (especially those who are exclusively breastfed) a few days after birth.
3) Supplement for high-risk groups: Premature infants and twins should be supplemented with VitD 800IU/d(20μg/d) immediately after birth, and changed to 400I U/d( 10 μg/d) three months later. If conditions permit, we can monitor blood biochemical indexes and adjust the dosage appropriately according to the results.
(4) Overweight/obesity
1. Assessment and graduation
(1) Overweight: weight/length (height) ≥M+ 1SD, or body mass index/age (body mass index/age) ≥M+ 1SD.
(2) Obesity: weight/length (height) ≥M+2SD, or body mass index/age ≥M+2SD.
Find out why
(1) overfeeding, unreasonable dietary structure.
(2) lack of exercise and behavioral deviation.
(3) Endocrine and genetic metabolic diseases.
Step 3 intervene
(1) infancy
1) Reasonable nutrition during pregnancy, maintaining normal weight gain during pregnancy, and avoiding overweight or low birth weight at birth.
2) Advocate exclusive breastfeeding within 6 months, and continue breastfeeding until 2 years old on the basis of timely and reasonable addition of food.
3) Control the weight growth rate of overweight/obese babies, and do not take measures to lose weight.
4) Monitor the growth and development of body weight and length, emphasize reasonable diet and avoid overfeeding.
5) Avoid excessive catch-up growth of low birth weight infants.
(2) Early childhood
1) Measure your weight once a month and your body length once every three months, monitor your physical growth, avoid overeating and overeating, properly control your weight growth rate, and do not use weight loss measures that affect children's health, such as hunger and drugs.
2) Use behavioral therapy to change bad eating behaviors and cultivate healthy eating habits.
3) Develop good exercise habits and lifestyles, do more outdoor activities and try not to watch TV or electronic media.
(3) Preschool period
1) Carry out health education activities to prevent children from being overweight/obese, including a balanced diet, avoiding overeating, cultivating healthy eating habits and lifestyles, and watching TV or electronic media as little as possible.
2) Evaluate the physical development once every quarter, analyze the diet and lifestyle of overweight/obese children, and correct the bad diet and lifestyle.
4. Medical expertise
(1) Risk factors: After excluding pathological obesity, children screened as obese need to be assessed for risk factors. Any of the following indicators are positive for high-risk obese children.
Family history: overeating, obesity, diabetes, coronary heart disease, hyperlipidemia, hypertension, etc.
2) Diet history: history of overeating or overeating.
3) Birth history: low birth weight or macrosomia.
4) Rapid increase of body mass index: The body mass index has increased by ≥2.0 in the past 1 year.
(2) Complications: According to the severity, medical history and signs of childhood obesity, select relevant tests as appropriate to determine whether there are complications such as hypertension, fatty liver, hypercholesterolemia, insulin resistance and abnormal glucose tolerance.
manage
(1) All screened obese children were monitored by weight/length (height) curve or body mass index curve.
(2) On the basis of routine health examination, the weight of obese children with risk factors is monitored every month, and relevant auxiliary examinations are carried out as appropriate.
(3) Intervene according to the age of obese children.
(4) Obese children who are suspected of pathological factors, have complications or the degree of obesity continues to increase after intervention are referred to higher maternal and child health care institutions or specialist clinics for further diagnosis and treatment. (A) management methods
1. Registration management
Children with low weight, growth retardation, emaciation, obesity, nutritional iron deficiency anemia and vitamin D deficiency rickets were registered and managed (table 1), and timely intervention was made to record the outcome.
2. Project management
Children with moderate and severe malnutrition, children with moderate and severe nutritional iron deficiency anemia and children with active rickets should be specially managed (Table 2-4).
3. Counseling and referral
Difficult cases should be promptly transferred to higher maternal and child health care institutions or specialist outpatient consultation, follow-up and record.
(2) Qualification of project management personnel
Project managers must have the qualifications of clinical practitioners and have received basic knowledge of nutrition and training in nutritional diseases. Energy malnutrition in protein
Project management rate of moderately and severely malnourished children = (number of moderately and severely malnourished children in the jurisdiction/number of moderately and severely malnourished children in the jurisdiction) × 100%.
(2) nutritional iron deficiency anemia
1. The registration and management rate of children with mild anemia = (number of children with mild anemia registered and managed in the jurisdiction/number of children with mild anemia in the jurisdiction) × 100%.
2. The project management rate of children with moderate and severe anemia = (number of children with moderate and severe anemia in the jurisdiction/number of children with moderate and severe anemia in the jurisdiction) × 100%.
Vitamin d deficiency rickets
Project management rate of children with active rickets = (number of children with active rickets/number of children with active rickets) × 100%.
fat
The registration management rate of obese children aged 0-6 = (number of obese children registered and managed in the jurisdiction/number of obese children aged 0-6 in the jurisdiction) × 100%.