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Definition:
Chronic nutritional disorders (CND) are characterized by delaying or stopping of
ponderal (weight) growth, stature or both for a period of more than a month with a
difference more than 10% of normal values corresponding to the age.
There are three forms of CND:
1. Hypotrophy – slowing or stagnating the ponderal growth.
2. Hypostature – stagnating uniformly ponderal growth and stature.
3. Paratrophy – excessive mass.
Classification of hypotrophy:
According to the origin, hypotrophy can be:
1. Congenital, prenatal (intrauterine) hypotrophy;
2. Postnatal hypotrophy (acquired);
3. Mixed hypotrophy (prenatal – postnatal).
I. Congenital hypotrophy: prenatal nutritional disorders.
1. Neuropathic form;
2. Neurodystrofic form;
3. Neuroendocrine form;
4. Encephalopathic form.
II. Acquired hypotrophy: Gomes classification (WHO)
Degree of severity:
1. Mild malnutrition – degree I (10 – 20%)
2. Medium malnutrition – degree II (20 – 30%)
3. Severe malnutrition – degree III (more than 30%)
Clinical forms:
1. Severe protein – energy malnutrition (marasmus)
2. Severe protein malnutrition (kwashiorkor)
Modality of evaluation:
1. Protein deficit;
2. Global energy deficit;
3. Protein and energy deficit.
Etiology:
Congenital hypotrophy is a consequence of different factors:
- Noxious profession of mother during pregnancy;
- Precocious pregnancy;
- Placental anomalies;
- Deficiency in alimentation;
- Hereditary factors – chromosomal mutations (Down’s syndrome,
Klinefelter’s, Turner’s syndromes etc.
- Genetic disorders: cystic fibrosis, celiac disease, galactosemia etc.
Acquired hypotrophy – provoking factors are diverse: they are conventionally
divided into two groups:
1. Exogenous factors:
- Alimentary
a) Maternal hypogalactesia;
b) Milk dilution;
c) Chronic vomiting – leading to insufficiency;
d) Anorexic children;
e) Neuropsychic disorders of sucking and deglutition.
- Less quality
a) Less proteins in the foods;
b) excessive flour quantity in foods;
c) low lipids quantity in foods etc.
- Infectious:
a) Repeated respiratory infections: pneumonia, urinary tract infections;
b) Chronic gastrointestinal disorders, diarrhea;
c) Long duration and excessive antibacterial therapy.
- Negligence, care and education.
a) Negligence of physiological diet regime;
b) Improper weaning foods.
2. Endogenous factors:
- Developmental anomalies of systemic organs;
- Hereditary metabolic disorders;
- Congenital metabolic disorders;
- Malabsorption disorders;
- Endocrine disorders.
Pathogenesis:
1. Neuropathic form. Children with this form usually have birth weight and height
normal at term. Hypotrophy appears after birth, length in most of the children is
normal. The psychomotor and neurological developments are not modified.
Compartmental behavioral changes, motor excitations, negative emotions, sleep
disturbances, loss of appetite and disturbances of gastric reflexes appear in the first
place of clinical picture.
2. Neurodystrophic form. These children present with changes in the CNS,
delayed psychomotor development. The basic symptom is the presence of severe
insidious dystrophy in mostly congenital cases. The deviation of the weight in the
infant may reach up to 50% and more. Growth retardation is a mild manifestation
but weakness, irritability and anorexia are severe.
3. Neuroendocrine form. These children present with changes in CNS and
endocrine function. The psychomotor development is delayed. Body mass deficit
and retardation of height are predominant manifestations. Almost all the children
with this form or born with signs of hypotrophy and short length. On inspection
they have dwarfism, microthoracocephaly, hemiassymetry. Gastric reflexes are
modified. Endocrine abnormalities, more likely hypophyseal dwarfism, absence of
ossification centers. Thyroid and parathyroid function abnormalities are usually
found.
4. Encephalopathic form. These children present with insignificant retardation in
psychomotor development. Height is normal.
Acquired hypotrophy.
Degree I. It is characterizing by body mass deficit of 10 – 20% or 10 – 24%
according to WHO. Ponderal index = 0.90 – 0.76; nutritional index = 0.9 – 0.81.
Height remains normal. Subcutaneous fat tissue is thin on abdomen and thorax,
skin fold is less than 1,5 cm. Skin turgidity is moderately reduced. Growth curve is
stationary or slightly descending. The child appears weak, otherwise he is healthy.
Motor activity is normal or slightly reduced. Appetite is normal or slightly reduced.
The children are irritable. The metabolic aspects are low absorption of lipids,
increase in the level of free fat acids, hyponatremia and moderate hypokalemia.
Immunity is normal or slightly reduced.
Degree II. Pale or grey colored, dry skin. Body weight deficit – 20-30% or 25-
39% according to WHO. Ponderal index = 0.76 – 0.61; nutritional index = 0.8 –
0.71. Height remains normal, subcutaneous fat tissue disappears on abdomen and
thorax (the ribs are seen) and slightly reduced on the extremities and face.
Hypotonia, loss of appetite, increased incidence of viral infections. Growth curve
falls slowly. Skin turgidity is reduced. The gastric, pancreatic and intestinal
secretions are reduced. Stools are unstable. SNC manifestations are anxiety and
hyperexcitability. Crying without any reason may suggest apathy. The child’s
motor development stops: delayed milestones like sitting, crawling. In some cases
the child loses the motor activity. Thermoregulation is affected. The first
manifestations of less food intake appear. The body easily warms up and cools due
to circulatory insufficiency. Low cardiac beats. Liver is enlarged. Immunity is
reduced. Hypoproteinemia, decrease of phospholipids in serum, hypoglycemia,
hyponatremia, hypocalcemia and hypovitaminosis may be seen.
Degree III. This is the most severe form of malnutrition which may set in usually
between 3 and 12 months. In this we have 2 forms of malnutrition: protein –
energy and protein.
Protein-energy malnutrition (Marasmus): body weight deficit more than 30% or
40% according to WHO. Ponderal index less than 0.60. Nutritional index less than
0.7. Growth stagnation. Pale, grey colored, flaccid skin. Skin folds in medial
surfaces of thighs and gluteal region. Ulcers and bed sores, erythema. Triangular
face with deep nasolabial grooves, maxillary prominence, sharp chin, thin cheeks
and frontal skin wrinkles (“old man face”) may be seen. Absence of buccal fat pad.
Atrophy and muscular hypotonia. Sudden fall of growth curve, arrhythmic
respiration with long expiration and periodic apnoea. Pneumonia with atypical
evolution may set in. Low cardiac beats, bradycardia (60 – 80 b/min). Low blood
pressure, cold extremities, loss of appetite until anorexia and low digestive
tolerance are observed. They may have regurgitation, vomiting, swollen abdomen
due to intestinal and abdominal wall atonia. There may be constipation, but
frequently it is hunger diarrhea. Reduced diuresis. The children are apathic,
adynamic, do not react to the surroundings and are hyporeflexic. There are
thermoregulatory and hypermetabolic disturbances.
Treatment
Hypostature
Paratrophy
Literature:
1. Lection: “Chronic nutritional disorders” – Department of pediatrics.
2. Kliegman: Nelson Textbook of Pediatrics, 18th edition. ISBN-13; 978-1-
4160-2450-7.
3. Marcu Rudi Curs de pediatrie Vol.I. Chişinău, 1999. P.55-70.
4. Alexandru Voloc, Valentin Ţurea. Dezvoltarea copilului şi conduita în
maladiile nutriţionale. Chişinău, 2007. P. 112-136.