Protein-energy deficiency. Protein-energy deficiency in children. Protein-energy malnutrition: classification Complications of treatment of protein-energy malnutrition

Protein-energy malnutrition, or protein-energy malnutrition, is an energy deficit due to a chronic deficiency of all macronutrients. It usually includes deficiencies in many micronutrients as well. Protein-energy deficiency can be sudden and total (starvation) or gradual. Severity ranges from subclinical manifestations to overt cachexia (with edema, hair loss, and skin atrophy), and multiple organ and multisystem failure. Laboratory tests, including assessment of serum albumin, are commonly used for diagnosis. Treatment includes correcting fluid and electrolyte deficiencies with intravenous fluids, followed by gradual oral nutrient replacement if possible.

In developed countries, protein-energy malnutrition is a common condition among nursing home residents (although often unaware of it) and among patients with disorders that reduce appetite or impair digestion, absorption, and metabolism of nutrients. In developing countries, protein-energy malnutrition is common among children who do not consume enough calories or protein.

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ICD-10 code

E46 Protein-energy malnutrition, unspecified

E64.0 Sequelae of protein-energy malnutrition

E45 Developmental delay due to protein-energy malnutrition

Classification and causes of protein-energy malnutrition

Protein-energy malnutrition can be mild, moderate, or severe. The stage is established by determining the difference in percentage of the patient's real and calculated (ideal) weight, corresponding to his height, using international standards (normal, 90-110%; mild protein-energy malnutrition, 85-90%; moderate, 75-85%; severe , less than 75%).

Protein-energy malnutrition can be primary or secondary. Primary protein-energy malnutrition is due to inadequate nutritional intake, and secondary protein-energy malnutrition is the result of various disorders or intake medicines that interfere with the use of nutrients.

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Symptoms of protein-energy malnutrition

Symptoms of moderate protein-energy malnutrition can be general (systemic) or affect certain organs and systems. Apathy and irritability are characteristic. The patient is weakened, working capacity is reduced. Violated cognitive abilities, and sometimes consciousness. Temporary lactose deficiency and achlorhydria develop. Diarrhea is common and is aggravated by a deficiency of intestinal disaccharidases, especially lactase. The tissues of the gonads are atrophic. PEU can cause amenorrhea in women and loss of libido in men and women.

Loss of fat and muscle mass is a common manifestation for all forms of PEU. In adult volunteers who fasted for 30-40 days, weight loss was clear (25% of initial weight). If fasting is more intense, weight loss can be as high as 50% in adults and possibly more in children.

Cachexia in adults is most evident in areas where there is normally visible fat deposits. Muscles decrease in volume, and bones protrude noticeably. The skin becomes thin, dry, inelastic, pale and cold. The hair is dry and falls out easily, becoming sparse. Weakened wound healing. In elderly patients, the risk of hip fractures, bedsores, and trophic ulcers increases.

In acute or chronic severe protein-energy malnutrition, heart size and cardiac output decrease; pulse slows down, blood pressure drops. The intensity of breathing and vital capacity of the lungs are reduced. Body temperature drops, sometimes leading to death. Edema, anemia, jaundice, and petechiae may develop. Liver, kidney or heart failure may occur.

Cellular immunity is weakened, susceptibility to infections increases. Bacterial infections (eg, pneumonia, gastroenteritis, otitis media, urogenital tract infections, sepsis) are common in all forms of protein-energy malnutrition. Infections lead to activation of the production of cytokines that exacerbate anorexia, leading to even greater loss of muscle mass and a significant decrease in serum albumin levels.

In infants, insanity causes hunger, weight loss, growth retardation, loss of subcutaneous fat and muscle mass. The ribs and facial bones protrude. Flabby, thin, "dangling" skin hangs in folds.

Kwashiorkor is characterized by peripheral edema. The abdomen protrudes, but there is no ascites. The skin is dry, thin and wrinkled; it becomes hyperpigmented, cracks, and then develops its hypopigmentation, friability and atrophy. The skin of different areas of the body may be affected at different times. Hair becomes thin, brown or gray. Head hair falls out easily, eventually becoming sparse, but eyelash hair may even grow excessively. The alternation of malnutrition and adequate nutrition results in the hair having a "striped flag" appearance. Sick children may be lethargic, but become irritable if they are stirred up.

Complete fasting is fatal if it lasts more than 8-12 weeks. Thus, the symptoms characteristic of protein-energy malnutrition do not have time to develop.

Primary protein-energy malnutrition

Worldwide, primary protein-energy malnutrition occurs mainly in children and the elderly, i.e. those who have limited ability to obtain food, although most common cause in old age - depression. It may also be due to fasting, fasting or anorexia. It can also be caused by mistreatment (abuse) of children or the elderly.

In children, chronic primary protein-energy deficiency has three forms: insanity, kwashiorkor, and a form that has characteristic features of both (marasmic kwashiorkor). The form of protein-energy deficiency depends on the ratio of non-protein and protein sources of energy in the diet. Starvation is an acute severe form of primary protein-energy insufficiency.

Marasmus (also called the dry form of protein-energy malnutrition) causes weight loss and wasting of muscle and fat stores. In developing countries, insanity is the most common form of protein-energy malnutrition in children.

Kwashiorkor (also called the wet, puffy, or edematous form) is associated with premature weaning of an older baby, which usually occurs when the baby is born. youngest child, "pushing" the older child from the chest. Thus, children with kwashiorkor are usually older than those with marasmus. Kwashiorkor can also result from an acute illness, often gastroenteritis or another infection (probably secondary to cytokine production) in children who already have protein-energy malnutrition. A diet that is more deficient in protein than in energy may be more likely to cause kwashiorkor than insanity. Less common than insanity, kwashiorkor tends to be restricted to certain regions of the world, such as rural regions of Africa, the Caribbean, and the Pacific Islands. In these areas, staple foods (eg cassava, sweet potatoes, green bananas) are poor in protein and rich in carbohydrates. In kwashiorkor, the permeability of cell membranes increases, causing extravasation of intravascular fluid and protein, leading to peripheral edema.

Marasmic kwashiorkor is characterized by the combined features of marasmus and kwashiorkor. Children affected by it are edematous and have more fat in the composition of the body than in insanity.

Starvation is a complete lack of nutrients. Sometimes fasting is voluntary (as during religious fasting or in anorexia nervosa), but usually it is due to external factors (for example, natural circumstances, being in the desert).

Secondary protein-energy malnutrition

This type usually results from disorders that affect GI function, cachectic disorders, and conditions that increase metabolic demands (eg, infections, hyperthyroidism, Addison's disease, pheochromocytoma, other endocrine disorders, burns, trauma, surgery). In cachectic disorders (eg, AIDS, cancer) and kidney failure, catabolic processes lead to the formation of an excess of cytokines, which in turn leads to malnutrition. End-stage heart failure can cause cardiac cachexia, a severe form of malnutrition that has a particularly high mortality rate. Cachectic disorders can reduce appetite or impair nutrient metabolism. Disorders that affect GI function may impair digestion (eg, pancreatic insufficiency), absorption (eg, enteritis, enteropathy), or lymphatic transport of nutrients (eg, retroperitoneal fibrosis, Milroy's disease).

Pathophysiology

The initial metabolic reaction is a decrease in the intensity of metabolism. To provide energy, the body first "breaks down" adipose tissue. However, then the internal organs and muscles also begin to collapse, and their mass decreases. Most of all, the liver and intestines "lose" in weight, the heart and kidneys occupy an intermediate position, and the nervous system loses the least weight.

Diagnosis of protein-energy malnutrition

The diagnosis is based on the history of the disease, when clearly inadequate food intake is established. The cause of inadequate nutrition should be identified, especially in children. Children and adolescents must be aware of the possibility abuse and anorexia nervosa.

Physical examination findings can usually confirm the diagnosis. Laboratory studies are needed to identify the cause of secondary protein-energy malnutrition. Measurement of plasma albumin, total lymphocytes, CD4+ T-lymphocytes, and response to skin antigens help determine the severity of protein-energy malnutrition or confirm the diagnosis in borderline conditions. Measurement of C-reactive protein or soluble interleukin-2 receptor can help determine the cause of malnutrition if it is unclear and confirm a violation of cytokine production. Many additional indicators may differ from normal values: for example, reduced levels of hormones, vitamins, lipids, cholesterol, prealbumin, insulin-like growth factor-1, fibronectin, and retinol-binding protein are characteristic. Urinary creatinine and methylhistidine levels can be used as criteria for assessing the degree of muscle mass loss. As protein catabolism slows down, the level of urea in the urine also decreases. These data are rarely taken into account when choosing treatment tactics.

Other laboratory tests can also identify associated abnormalities that require treatment. Serum electrolytes, urea and creatinine, BUN, glucose, possibly Ca, Mg, phosphate, and Na should be measured. Blood glucose and electrolyte levels (especially K, Ca, Mg, phosphate, sometimes Na) are usually low. Indices of urea and creatinine, BUN in most cases remain at low values, until the development of renal failure. Metabolic acidosis is possible. A general blood test is carried out; normocytic anemia (mainly due to protein deficiency) or microcytic anemia (due to concurrent iron deficiency) is usually present.

Indicators used to assess the severity of protein-energy malnutrition

In the elderly, BMI

The Delayed Type Hypersensitivity Index indicates the amount of hardening detected by a skin test using a common antigen derived from Candida sp. or Trichophyton sp. Degree of induration 0 - 1.0 cm.

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Prevention and treatment of protein-energy malnutrition

Worldwide, the most important strategy for the prevention of protein and energy malnutrition is to reduce poverty, improve nutritional knowledge and improve health care delivery.

Mild to moderate protein-energy malnutrition, including intermittent fasting, is treated by using a balanced diet, preferably by mouth. Liquid oral nutritional supplements (usually lactose-free) may be used if solid foods cannot be adequately digested. Diarrhea often complicates oral feeding because fasting can make the gastrointestinal tract more sensitive and bacteria can enter Peyer's patches, contributing to infectious diarrhea. If diarrhea persists (presumably due to lactose intolerance), yogurt-based formulas are given rather than milk-based formulas because lactose intolerant people can tolerate yogurt and other fermented milk products. Patients also require multivitamin supplementation.

Severe protein-energy malnutrition or prolonged fasting requires inpatient treatment with a controlled diet. The main priorities are the correction of water and electrolyte imbalances and the treatment of infections. The next step is to supplement with macronutrients orally or, if necessary, through a tube: nasogastric (usually) or gastric. parenteral nutrition prescribed in case of severe malabsorption.

Other treatments may be needed to correct specific nutritional deficiencies that may appear with weight gain. To avoid micronutrient deficiencies, patients should continue to take micronutrients at doses approximately 2 times the recommended daily intake (RDA) until recovery occurs.

It is necessary to treat the disorders underlying the developed pathological condition. In children with diarrhea, feeding may be delayed by 24 to 48 hours to avoid worsening diarrhea. Feeding is frequent (6-12 times/day), but should be given in small amounts to avoid affecting the already limited intestinal absorption capacity (

The macronutrient energy distribution should be approximately: 16% protein, 50% fat, and 34% carbohydrate. As an example, we give a combination of skimmed cow's milk powder (110 g), sucrose (100 g), vegetable oil (70 g) and water (900 ml). Many others can be used milk formulas(e.g. full fat fresh milk plus corn oil and maltodextrin). Powdered milk used in milk mixtures is diluted with water.

Usually supplements are added to milk mixtures: MD 0.4 meq/kg/day intramuscularly for 7 days; B vitamins in a double RDA, given parenterally for the first 3 days, usually with vitamin A, phosphorus, zinc, manganese, copper, iodine, fluorine, molybdenum, and selenium. Since the absorption of dietary iron in children with protein-energy malnutrition is difficult, it is prescribed in supplements orally or intramuscularly. Parents are instructed on nutrient requirements.

In adults

It is necessary to eliminate the disorders associated with protein-energy malnutrition. For example, if AIDS or cancer leads to excessive production of cytokines, then megestrol acetate or hydroxyprogesterone may improve food intake. However, since these drugs drastically reduce testosterone production in men (possibly causing muscle loss), testosterone should also be used at the same time. Because these drugs can cause decreased adrenal function, they should only be used for a short time (

Medicines stimulants (hashish extract - dronabinol) should be given to patients with anorexia when none of the causes of their disease has been clarified, or to patients in their later years, when anorexia impairs their quality of life. Anabolic steroids have some positive effects (eg, increased lean body mass, possibly functional improvements) in patients with cachexia due to renal insufficiency and possibly in elderly patients.

The principles of correction of protein-energy deficiency in adults are generally similar to those in children. For most adults, feeding should not be delayed; small amounts of food with frequent intake are recommended. A commercial oral formula may be used. Nutrients are given at the rate of 60 kcal/kg and 1.2-2 g protein/kg. If liquid oral supplements are used with solid food, then they should be taken at least 1 hour before ingestion so that the amount of solid food eaten is not reduced.

Treatment of patients with protein-energy malnutrition placed in a nursing home requires compliance with many conditions, including changes in the environment (eg, make the dining area more inviting); assistance in feeding; changes in diet (for example, increased nutrition and calorie supplements between meals); treatment of depression and other underlying disorders; use of appetite stimulants, anabolic steroids, or a combination thereof. For patients with severe dysphagia, prolonged use of a gastrostomy for feeding is indispensable; although its use in patients with dementia is controversial. Avoiding unpalatable therapeutic diets (eg, low-salt, diabetic, low-cholesterol diets) also has measurable benefits, as these diets reduce food intake and can cause severe protein-energy malnutrition.

Complications of the treatment of protein-energy malnutrition

Treatment of protein-energy malnutrition can cause complications (refeeding syndrome), including fluid overload, electrolyte deficiencies, hyperglycemia, cardiac arrhythmias, and diarrhea. Diarrhea is usually mild and resolves on its own; however, diarrhea in patients with severe PEU sometimes causes severe dehydration or death. Causes of diarrhea, such as sorbitol used in tube feeding, or Clostridiumdifficile, if the patient received antibiotic therapy, can be eliminated by special interventions. Osmotic diarrhea due to excess calorie intake is rare in adults and should only be considered as a cause when other causes of protein-energy malnutrition have been ruled out.

Because protein-energy malnutrition can impair cardiac and renal function, hydration can cause an increase in intravascular fluid volume. Treatment also reduces the concentration of extracellular K and Mg. A decrease in K or Mg can cause arrhythmias. Activation of carbohydrate metabolism during treatment stimulates the release of insulin, which leads to the entry of phosphate into the cells. Hypophosphatemia can cause muscle weakness, paresthesia, paralysis, arrhythmias, coma. Blood phosphate levels during parenteral nutrition should be measured regularly.

Prognosis of protein-energy malnutrition

In children, mortality varies from 5 to 40%. Mortality rates are lower in children with mild protein-energy malnutrition and in those who received intensive care. Death in the first days of treatment is usually due to electrolyte deficiency, sepsis, hypothermia, or heart failure. Impaired consciousness, jaundice, petechiae, hyponatremia, and persistent diarrhea are ominous prognostic symptoms. The cessation of apathy, edema and anorexia are favorable symptoms. A faster recovery is noted with kwashiorkor than with insanity.

To date, it has not been fully established what causes long-term protein-energy deficiency in children. Some children develop chronic malabsorption syndrome and pancreatic insufficiency. In children younger age the development of moderate oligophrenia is possible, which can persist until school age. Permanent cognitive impairment may be observed, depending on the duration, severity, and age at which protein-energy malnutrition began.

In adults, protein-energy malnutrition can lead to morbidity and mortality (eg, progressive weight loss increases mortality by 10% in elderly people in nursing homes). Except in cases where organ or system failure develops, the treatment of protein-energy malnutrition is almost always successful. In elderly patients, protein-energy malnutrition increases the risk of complications and mortality in surgical interventions, infections or other disorders.

Eating disorders are pathological conditions that develop as a result of insufficient or excessive intake and / or absorption of nutrients. Eating disorders are characterized by physical development, metabolism, immunity, morphofunctional state of internal organs and body systems.

According to ICD-10, the following headings are included in the group of eating disorders.

E40-46 - protein-energy deficiency.

E50-64 - other malnutrition (deficiency of vitamins and trace elements).

E65-68 - obesity and other types of malnutrition.

PROTEIN AND ENERGY INSUFFICIENCY

Synonyms:

Hypotrophy type dystrophy;

Hypotrophy;

malnutrition syndrome;

malnutrition syndrome;

Hypostatura;

Malnutrition.

The malnutrition syndrome is a universal concept that reflects the processes occurring in the body with a deficiency of any of the essential nutrients (proteins and other energy sources, vitamins, macro- and microelements). Malnutrition can be primary, due to inadequate intake of nutrients, and secondary, associated with impaired intake, assimilation or metabolism of nutrients due to disease or injury. A narrower concept of "protein-energy malnutrition" reflects changes in the body associated with a deficiency of predominantly protein.

and/or other energy substrate.

Protein-energy insufficiency (PEN) is a alimentary-dependent condition caused by predominant protein and / or energy starvation of sufficient duration

and/or intensity. PEU manifests itself as a complex violation of homeostasis in the form of changes in the main metabolic processes, water and electrolyte imbalance, changes in body composition, nervous regulation disorders, endocrine imbalance, suppression of the immune system, dysfunction of the gastrointestinal tract and other organs and their systems.

The impact of PEI on an actively growing and developing child's body is especially unfavorable. PEU causes a significant delay in the physical and neuropsychic development of the child, resulting in impaired immunological reactivity and food tolerance.

ICD-10 CODES

In ICD-10, PEW is included in class IV "Diseases of the endocrine system, eating disorders and metabolic disorders".

E40-E46. Nutritional deficiencies.

E40. Kwashiorkor.

E41. Alimentary insanity.

Protein-energy malnutrition(PEN) or alimentary dystrophy, substrate-energy insufficiency - a condition characterized by the development of symptoms of protein and energy deficiency, as well as other nutrients (fats, carbohydrates, vitamins, minerals) as a result of their relative or absolute insufficiency, which develops as a result of partial or complete starvation.

Protein-energy insufficiency can also be caused by insufficient intake of proteins and energy in the human body, as well as increased protein catabolism processes in the body, for example, in case of burn disease, severe trauma, purulent-septic diseases.

With insufficient intake of proteins and energy, body weight and the amount of adipose tissue decrease, and one of these changes may be more pronounced.

The main manifestations of severe PEU include edema, baldness, and skin atrophy. The function of all organs and systems is impaired. Patients with PEU are more likely to experience prolonged wound healing, suture failure, increased hospitalization and recovery time, and infectious complications.

The diagnosis is based on the data of anamnesis, assessment of clinical symptoms, results of anthropometric and laboratory studies.

Treatment consists in correcting water and electrolyte deficiency, prescribing artificial (enteral or parenteral) nutrition.

• Classification of protein-energy malnutrition

• Epidemiology of protein-energy malnutrition

  According to the WHO, in 2000 there were 191.9 million malnourished children in the world in developing countries. In South Asia and East Africa, about half of the children living there are stunted due to this problem.

  According to WHO estimates, by 2015 the frequency of PEU will decrease to 17.6%, which will amount to 113.4 million children under the age of 5 years. Currently, PEU is diagnosed in more than half of children living in North African countries and in 30% of children from the South African region.

  Each year, approximately 50% of the 10 million deaths that are reported in developing countries and the main cause of which is malnutrition, occur in children under 5 years of age.

  In developing countries, primary PEI is most often observed (accounting for 25%), in developed countries - secondary PEI. Kwashiorkor is common in Africa, the Caribbean and the Pacific.

  In the United States, approximately 55% of hospitalized elderly patients have some degree of malnutrition. Approximately 40% of children show signs of acute PEU on admission, and 27% show symptoms of a chronic illness.

  In Russia, in the course of selective studies of the nutrition of the population, it was found that about 25% of the surveyed are malnourished, and 80% have a deficiency of vitamins and microelements.

  PEU is one of the main problems of patients in therapeutic and surgical hospitals. More than 50% of patients admitted for treatment suffer from PEU and severe hypovitaminosis (especially deficiency of folic acid, vitamins B 2 and C).

  According to the clinics of the All-Union Scientific Center of the Russian Academy of Medical Sciences, among oncological patients who are in the hospital, malnutrition is 30%. Among patients receiving outpatient treatment for chronic and oncological diseases, about 10% have signs of malnutrition.

• ICD-10 code

  E. 46 - Protein-energy malnutrition.

Clinic and complications

With a pronounced deficiency in nutrient intake, a long phase of compensation is initially observed, when endocrine-metabolic mechanisms protect the visceral protein pool and mobilize fats and proteins of the somatic pool (adipose tissue and skeletal muscles) for energy needs.

In conditions of predominantly energy deficiency, insanity develops.

If protein deficiency develops at a faster pace (against the background of providing the energy value of malnutrition with the help of carbohydrates), then compensation may from the very beginning be insufficient in relation to the preservation of visceral protein. In these cases, kwashiorkor develops. In this case, decompensation occurs earlier, the survival rates of patients are reduced.

• Main Clinical signs malnutrition
  • Syndrome of progressive weight loss.
  • Asthenovegetative syndrome.
  • Persistent decline in professional performance.
  • Morphological and functional changes in the digestive organs (atrophy of the mucous membrane of the stomach and small intestine, suppression of gastric and intestinal juice secretion, disorders of digestion and absorption, dysbacteriosis).
  • circulatory lability.
  • Immunodeficiencies.
  • Polyhypovitaminosis.
  • Syndrome of polyglandular endocrine insufficiency.
  • In children with PEI, in addition to a decrease in weight and height indicators, there is increased excitability, attention deficit, anxiety, and impaired social contacts. In adult patients with PEU, there is a decrease in body weight, which may be masked by edema. They become lethargic, get tired quickly, they have increased sensitivity to cold, and prolonged wound healing is observed.

• Clinical symptoms of insanity
  • progressive weight loss.
  • Depletion and atrophy of the subcutaneous fat layer and muscles.
  • Stunted growth, retracted abdomen.
  • Apathy and irritability.
  • Dry, pale, cold skin with brown patches of pigmentation.
  • Dry, dull, thin hair.
  • Bone fractures may occur.
  • Achlorhydria and diarrhea.

• Clinical symptoms of kwashiorkor
  • Widespread edema (anasarca), ascites.
  • Patients have a moon-shaped face, swollen abdomen.
  • Apathy and irritability.
  • Lack of appetite.
  • Spotted areas of skin depigmentation ("enamel or scaly dermatosis"), erythema.
  • Thinning and discoloration of hair. Stripes of discoloration are found on the hair and nails (flag symptom). Hair brightens and acquires a reddish tint, becomes brittle, falls out easily.
  • Hepatomegaly.
  • Loss of libido in men, amenorrhea in women.

• Complications of protein-energy malnutrition
  • Infections.

    The main complications of PEU, which determine high mortality and treatment costs, are infectious processes. The frequent development of infections in patients with PEU is associated with a number of factors, among which the most important are disorders of the adaptive response and secondary immunodeficiency.

  • Immunological disorders.

    Immunological disorders in PEU are characterized primarily by a violation of the T-cell link: the absolute number of T-lymphocytes decreases, their function and differentiation are impaired.

    Changes in the function of immunoglobulins. The content of IgG often increases, but can be reduced. There is a decrease in IgA and, accordingly, a weakening of the induction of the immune response of the mucous membranes to the presence of the antigen. This is due to a decrease in the number of IgA-producing cells, a violation of the synthesis of secreted components and the function of T-lymphocytes.

  • Signs of multivitamin deficiency. Read more: Importance of vitamins in human nutrition.

    As a rule, PEI is accompanied by a deficiency of vitamins A, B 1 , B 2 , B 6 , folic and nicotinic acids.

    • Signs of hypovitaminosis of vitamins B 2 , B 6 are manifested by changes in the skin, its appendages, tongue and mucous membranes. Dryness and flaking are found skin, cheilitis, glossitis, stomatitis. May appear dark spots on the face, neck, hands, legs and feet. Read more: Vitamin B2 and vitamin B6 deficiency.
    • Vitamin B6 deficiency is also characterized by: irritability, insomnia or drowsiness, epileptimorphic convulsions, depression, peripheral polyneuritis, microcytic hypochromic anemia, leukopenia.
    • Deficiency of vitamins B 1 and E leads to paresthesias and neuropathies. Read more: Vitamin B1 and vitamin E deficiency.
    • Vitamin B12 deficiency leads to megaloblastic anemia. Read more: Vitamin B12 deficiency.
    • Clinical symptoms of folic acid deficiency are: hyperchromic megaloblastic anemia, thrombocytopenia, leukopenia, cheilosis, glossitis, esophagitis, conjunctivitis; atrophic or erosive gastritis, enteritis with achlorhydria and diarrhea, steatorrhea; growth retardation, deterioration of wound healing, exacerbation of chronic infections, subfebrile condition. Read more: Folic acid deficiency.
    • With vitamin A deficiency, patients develop disorders of twilight vision. Read more: Vitamin A deficiency.
  • Mineral metabolism disorders.

    With the progression of PEI and the utilization of cellular proteins, there is a loss of potassium, phosphorus, magnesium, and calcium. Therefore, symptoms of deficiency of these substances may appear.

    • Calcium deficiency can cause paresthesia, cramps, muscle and bone pain. In severe cases, calcium deficiency can contribute to osteoporosis of the long bones, spine and pelvis. Read more: Calcium deficiency.
    • In patients with hypocalcemia and hypomagnesemia, Chvostek's and Trousseau's symptoms become positive. Read more: Magnesium deficiency.
    • Due to the increased neuromuscular excitability characteristic of hypokalemia, a symptom of a “muscle roller” is detected; patients are also worried about lethargy, muscle weakness. Read more: Potassium deficiency.
    • In patients with a deficiency of zinc, copper and iron, a skin rash develops, iron deficiency anemia develops, and body temperature rises. Read more: Deficiency of zinc, copper, iron.
  • Violations of adaptive functions.

    Violations of adaptive systems are a limiting factor in the treatment of patients.

    • In patients with PEU, the lability of the conduction system of the heart is reduced.
    • Decreased ability of the kidneys to concentrate urine.
    • Decreased peristalsis of the gastrointestinal tract.
    • Patients develop disorders of respiratory and thermoregulatory functions.
    • Skin lesions are not painful, proceed without edema and hyperemia.
    • The rate of wound healing is slowed down, the frequency of postoperative complications increases.
    • In infections of the urinary system pyuria, pyuria is not observed.

In Russia, for many years, the generally accepted term was hypotrophy, That is synonymous with protein-energy malnutrition.

Protein-energy malnutrition (PEM) - alimentary-dependent state caused by protein and/or energy starvation sufficient in duration and/or intensity, manifested by a lack of body weight and/or growth and a complex violation of the body's homeostasis in the form of changes in basic metabolic processes, water-electrolyte imbalance, changes in body composition , disorders of nervous regulation, endocrine imbalance, suppression of the immune system, dysfunction of the gastrointestinal tract and other organs and systems.

PEI can develop under the influence of endogenous or exogenous factors (Table 24).

The pathogenesis of PEU is determined by the disease that caused it, but in all cases it includes profound metabolic disorders with depletion of fat and carbohydrate reserves, increased protein catabolism and a decrease in its synthesis.

Protein-energy deficiency is manifested not only by weight loss, but also hypovitaminosis, deficiency of many essential microelements responsible for the implementation of immune functions, optimal growth, and brain development. Therefore, long-term malnutrition is often accompanied by a lag in psychomotor development, a delay in speech and cognitive skills and functions, a high infectious morbidity due to a decrease in immunity, which in turn exacerbates eating disorders.

Until now, in our country there is no generally recognized and approved at the congresses of pediatricians classification of PEI in children. In the world literature and pediatric practice, the classification proposed by Waterlow is most widely used. In its latest modification (Table 25), 2 main forms are distinguished: acute, manifested by a predominant loss of body weight and its deficiency in relation to the due body weight for growth, and chronic, manifested not only by a deficiency in body weight, but also by a significant delay in physical development. Both forms have 3 degrees of severity: mild, moderate and severe.

Diagnostics

Clinical and laboratory methods are used to detect malnutrition in children (Table 26).

Somatometric methods are a key way to assess a child's nutritional status. A necessary element of anthropometry is the availability of tables for comparing weight-height and age indicators and / or maps of the centile distribution of weight and height indicators. In 2006 year World Organization Healthcare has proposed "Standard Growth Charts" of children of all age groups for use in wide pediatric practice. These maps contain the distribution of children by weight and age, height and age, weight and height indicators, as well as by the value of the body mass index.

Since the most objective indicators of the state of the child's physical development are not only body weight, but also height, it is advisable to use centile tables. Combined deficiency of body weight and height develops not only with long-term malnutrition, but also with severe chronic diseases of the child.

In epidemiological studies of the prevalence of malnutrition in children, the Z-score is used, which is the deviation of the values ​​of an individual indicator (body weight, height, BMI) from the average value for a given population, divided by the standard deviation of the average value.

In a standard population, the mean Z-score is zero with a standard deviation of 1.0. Positive Z-score values ​​indicate an increase in the anthropometric index compared to the standard, and negative values ​​indicate a decrease in parameters compared to the standard value. Based on these indicators, we can assess the severity of PEU (Table 27).

In accordance with the formula, his Z-score is -2, which indicates a significant lag in physical development.

Dietary correction of protein-energy malnutrition

Basic rules for the organization of clinical nutrition in PEU:

Elimination of factors causing starvation;

Treatment of the underlying disease;

Optimal diet therapy: it is necessary to strive to meet the age-related needs of the child in basic nutrients, energy, macro- and micronutrients by gradually increasing the food load, taking into account the child's tolerance to food. At severe degrees PEN (II-III st.) The principle of two-phase nutrition is applied: the period of clarification of food tolerance and the period of transitional and optimal nutrition. At the first stages, they resort to "rejuvenation" of the diet - they use women's milk or adapted milk mixtures, increase the frequency of feedings to 7-10 per day; in the most severe cases, continuous tube enteral nutrition is used in combination with partial parenteral nutrition. Unreasonable displacement of human milk or adapted milk formulas by complementary foods should be avoided; consistently introduce complementary foods, gradually increasing their volume; use industrial complementary foods;

Organization of regimen, care, massage, exercise therapy;

Stimulation of reduced body defenses;

Treatment of concomitant diseases and complications. With PEN I degree, it is necessary to establish a general

mode, child care, eliminate feeding defects. When prescribing nutrition, preference should be given to breast milk, and with mixed and artificial feeding - to adapted milk formulas enriched with probiotics, galacto- and fructo-oligosaccharides, which favorably affect the digestive processes and normalize the composition of the intestinal microflora; nucleotides that improve the absorption of nutrients and stimulate the child's immune system, as well as fermented milk mixtures and products in an amount of not more than 1/2 of the total feeding volume. Non-adapted fermented milk products (kefir, etc.) should not be prescribed to children earlier than 8-9 months of age. To increase the energy value of the diet and increase the protein quota, it is possible to prescribe dishes and complementary foods (cereals, vegetable and meat purees, cottage cheese) 2 weeks earlier than healthy children. With PEI of the 1st degree, calculations and correction of nutrition are carried out for the required body weight, which consists of body weight at birth and the sum of its normal increases over the lived period.

With PEN II The degree of dietary correction is conditionally divided into three periods: the adaptation period (determination of food tolerance), the reparation period (intermediate) and the period of increased nutrition.

During the adaptation period, which lasts 2-5 days, nutrition is calculated based on the actual body weight in accordance with the physiological needs of the child for basic nutrients and energy. The number of feedings is increased by 1-2 per day with a corresponding decrease in the volume of each feeding, additional liquid is introduced (5% glucose or saline solutions for oral rehydration). During this period, it is preferable to use women's milk, with its lack or absence - adapted infant formula enriched with probiotics, oligosaccharides and nucleotides. It is possible to use mixtures with a higher protein content, for example, specialized milk formulas for premature babies. If violations of the breakdown / absorption of food ingredients are detected, it is advisable to use therapeutic products (for example, low-lactose mixtures for lactase deficiency, mixtures with an increased quota of medium-chain triglycerides for malabsorption of fats). In the absence of effect, mixtures based on highly hydrolyzed milk protein should be prescribed.

With normal tolerance of the prescribed nutrition, gradually (within 5-7 days) increase the volume of feedings to the physiological norm. With sufficient rates of weight gain and the absence of dyspeptic phenomena, the calculation of nutrition can be carried out on the proper body weight, first carbohydrate and protein, and only lastly - the fat component of the diet.

In the period of reparation, it is possible to introduce complementary foods, starting with cereals of industrial production, followed by the introduction of meat, cottage cheese, and yolk. During this period, it is recommended to prescribe enzyme preparations, multivitamin complexes and agents that have a positive effect on metabolic processes.

Throughout the treatment of children with PEU, it is necessary to systematically record the actual nutrition with the calculation of the chemical composition of the daily diet for the main food nutrients.

With PEN III degrees, all types of metabolism are sharply violated, the child's condition, as a rule, is very difficult, therefore, such children need intensive care, the use of enteral and parenteral nutrition, which requires inpatient treatment. PEI of the III degree, caused by an alimentary factor, occurs in Russia in exceptional cases, because. the main disorders in the child's nutrition are detected early and the necessary dietary correction of the diet of these children is carried out even with I-II degree of PEI.

The cause of grade III PEI in children in our country, as a rule, is a severe somatic pathology, therefore, timely diagnosis and treatment of a causally significant disease is a fundamental factor in the prevention and treatment of this condition.

parenteral nutrition the initial period should be carried out gradually, using only amino acid preparations and glucose solutions in the initial period. Fat emulsions in PEU are added to parenteral nutrition programs only after 5-7 days from the start of therapy due to their insufficient absorption and high risk of developing side effects and complications. Parenteral nutrition in PEU should be balanced and minimal due to the risk of developing severe metabolic complications.

In parallel, parenteral correction of dehydration, violations of K.SchS (as a rule, acidosis) and electrolyte disorders is carried out.

The most justified type of enteral nutrition in severe forms of PEU is permanent enteral tube feeding, which consists in a continuous slow supply of nutrients to the gastrointestinal tract (stomach, duodenum, jejunum - drip, optimally - using an infusion pump). The constant slow introduction of specialized products is justified as much as possible, since the energy consumption for the digestion and absorption of nutrients under these conditions is much lower than with a bolus of the nutrient mixture. At the same time, abdominal digestion improves and the absorption capacity of the intestine gradually increases. Long-term enteral tube feeding normalizes the motility of the upper gastrointestinal tract. The protein component in such nutrition modulates the secretory and acid-forming function of the stomach, maintains adequate exocrine pancreatic function and secretion of cholecystokinin, ensures normal motility of the biliary system and prevents the development of complications such as biliary sludge and cholelithiasis. Protein entering the jejunum modulates the secretion of chemotrypsin and lipase.

The rate of entry of the nutrient mixture into the gastrointestinal tract should not exceed 3 ml / min, the caloric load should not exceed 1 kcal / ml, and the osmolarity should not exceed 350 mosmol / l. For enteral nutrition in young children, specialized products should be used. The most justified is the use of mixtures based on highly hydrolyzed milk protein, lactose-free, enriched with medium chain triglycerides (Alfare, Nutrilon Pepti TSC, Nutrilac Peptidi SCT, Pregestimil). They provide maximum absorption of nutrients in conditions of significant inhibition of the digestive and absorption capacity of the digestive canal (Table 28).

The increase in the concentration of the injected mixture is carried out slowly, increasing by 1% per day (Table 29).

D then gradually bring the concentration of the mixture to 13.5% (physiological), and with good tolerance - up to 15%. Missing calories, nutrients and electrolytes during the period of use of the formula in low concentration are compensated by parenteral nutrition.

When conducting permanent enteral tube feeding, all asepsis rules must be observed. Sterility of nutrient solutions is possible only when using ready-made liquid nutrient mixtures.

The duration of the period of constant enteral tube feeding varies from several days to several weeks, depending on the severity of impaired food tolerance (anorexia, vomiting, diarrhea). A gradual increase in calorie content and a change in the composition of food is carried out, a gradual transition to a bolus of the nutrient mixture is carried out at 7-10 daily feedings. With the improvement of the condition and appetite, the appearance of significant weight gain, a complete abolition of constant tube feeding is performed. Next, diet therapy is carried out, as in children with milder PEI, the main principles of which are food rejuvenation and phasing with the allocation of adaptive, reparative (intermediate) and enhanced stages of nutrition.

At this time, adaptation to the required volume is carried out and the correction of water-mineral and protein metabolism continues. At the same time, the child is given food often and in small portions, gradually increasing them (Table 30). The missing amount of food is replenished by ingestion of rehydration solutions.

During the reparation period, proteins, fats and carbohydrates are corrected, which leads to an increase in energy load (enhanced nutrition). The required daily amount of food for a child with PEU should eventually be about 200 ml/kg, or 1/5 of the actual weight. At the same time, the energy and protein load on the actual body weight is greater than in healthy children. This is due to a significant increase in energy expenditure in children during convalescence with PEU.

In the future, the child's diet approaches normal parameters due to the expansion of the range of products, the composition of the mixtures used changes. With good tolerance at the stage of enhanced nutrition, high-calorie nutrition (130-200 kcal / kg / day) is provided, with a high content of nutrients, but not more than: proteins - 5 g / kg / day, fats - 6.5 g / kg / day ., carbohydrates - 14-16 g / kg / day. The average duration of the stage of enhanced nutrition is 1.5-2 months.

The main indicator of the adequacy of diet therapy is weight gain. An increase is considered good if it exceeds 10 g / kg / day, average - 5-10 g / kg / day. and low - less than 5 g / kg / day.

Possible reasons for poor weight gain are: inadequate nutrition (incorrect nutrition calculation, restriction on the frequency or volume of nutrition, non-compliance with the rules for preparing nutrient mixtures, lack of nutrition correction, lack of child care), micronutrient deficiency, current infectious process, mental problems (rumination, inducing vomiting).

Medical Therapy for PEU III degree

In addition to drug (parenteral) correction of dehydration and electrolyte disorders, in the acute period, it is necessary to remember the need for timely diagnosis of possible adrenal insufficiency.

Starting from the period of adaptation, enzyme replacement therapy with pancreatic preparations is advisable. Preference is given to microencapsulated preparations (Creon). With intestinal dysbacteriosis, repeated courses of antibiotic therapy, biological preparations are used.

The use of anabolic drugs in PEU is carried out with caution, because in conditions of nutrient deficiency, their use can cause profound disorders of protein and other types of metabolism, inhibition of parietal digestion enzymes. The use of vitamin therapy with a stimulating and replacement purpose is shown. In severe forms of PEU, vitamins are prescribed parenterally.

Treatment of rickets, iron deficiency anemia is carried out starting from the period of reparation.

Indications for stimulating and immunotherapy are determined individually. During the height of PEU, preference should be given to passive immunotherapy - native plasma and immunoglobulins. During the period of convalescence, non-specific immunostimulants diabazol, methyluracil, and biostimulants such as apilac, adaptagens can be prescribed.

Management of patients with PEUIIIdegree

In 2003, WHO experts developed and published recommendations for the management of children with PEU, which regulate the main activities for nursing children with severe malnutrition. These recommendations should be used in the treatment of children with severe forms of alimentary PEU.

10 main steps have been identified:

prevention/treatment of hypoglycemia,

prevention/treatment of hypothermia,

prevention/treatment of dehydration,

correction of electrolyte imbalance,

prevention/treatment of infection,

correction of micronutrient deficiencies,

careful start of feeding,

providing weight gain and growth,

providing sensory stimulation and emotional support,

further rehabilitation.

Activities are carried out in stages (Fig. 4), taking into account the severity of the condition of a sick child and begin with the correction and prevention of life-threatening conditions.

First step It is aimed at the treatment and prevention of hypoglycemia and possible disorders of consciousness associated with it. If the child’s consciousness is not disturbed, but the blood glucose level has decreased to less than 3 mmol / l, then the child is shown a bolus injection of 50 ml of a 10% glucose or sucrose solution (1 teaspoon of sugar per 3.5 tablespoons of water) through the mouth or nasogastric tube. Further, such children are given frequent feeding, every 30 minutes, for 2 hours in the amount of 25% of the volume of the usual one-time feeding, followed by transfer to feeding every 2 hours without a night break. If the child is unconscious, lethargic, or has hypoglycemic convulsions, then such a child should be injected intravenously with a 10% glucose solution at a rate of 5 ml / kg, and then correct glycemia by introducing glucose solutions through a nasogastric tube (10% 50 ml ) or

sucrose and transfer to frequent feedings every 30 minutes for 2 hours, and then every 2 hours without a night break. All children with PEU who have impaired serum glucose levels are shown to be given antibiotic therapy with broad-spectrum drugs.

Second step is to prevent and treat hypothermia in children with PEU. If the child's rectal temperature is lower than 35.5 C, then it must be urgently warmed up: dressed in warm clothes and a hat, wrapped in a warm blanket, laid in a heated bed or under a source of radiant heat. Such a child needs to be fed urgently, prescribe a broad-spectrum antibiotic and regularly monitor the level of serum glycemia.

Third step - It is the treatment and prevention of dehydration. Children with PEU have pronounced disturbances in water and electrolyte metabolism; they may have a low volume of circulating blood 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 PEU, intravenous rehydration should not be used, except in cases of hypovolemic shock and conditions requiring intensive care. The standard saline solution used for rehydration therapy for intestinal infections, and primarily for cholera, cannot be used in children with PEU because of their too high content of sodium ions (90 mmol Na + / n) and insufficient amount of potassium ions . In case of malnutrition, a special solution for rehydration of children with PEU should be used, 1 liter of which contains 45 mmol sodium ions, 40 mmol potassium ions and 3 mmol magnesium ions.

If a child with PEU has clinical signs of dehydration or watery diarrhea, then rehydration therapy is indicated by mouth or nasogastric tube with a similar solution at the rate of 5 ml / kg every 30 minutes for 2 hours, and then 5-10 ml / kg / h in the next 4-10 hours with a replacement at 4, 6, 8 and 10 hours the introduction of a rehydration solution for feeding with formula or mother's milk. Such children should also be fed every 2 hours without a night break. They should be constantly monitored. Every 30 minutes for 2 hours, and then every hour for 12 hours, the frequency of pulse and respiration, the frequency and volume of urination, the frequency and volume of stool and vomiting should be assessed.

Fourth step is aimed at correcting the electrolyte imbalance that exists in children with PEU. As mentioned above, children with severe PEU have an excess of sodium in the body, even if their serum levels are low. There is a deficiency of potassium and magnesium ions, which requires correction during the first 2 weeks. The edema present in PEU is also associated with an electrolyte imbalance. For their correction, diuretics should not be used, as this can only aggravate existing disorders and cause hypovolemic shock. It is necessary to ensure the regular intake of essential minerals in the body of the child in sufficient quantities. It is recommended to use potassium at a dose of 3-4 mmol / kg / day, magnesium - 0.4-0.6 mmol / kg / day.

Fifth step consists in timely treatment and prevention of infectious complications in children with PEU who have secondary combined immunodeficiency.

sixth step necessary to correct micronutrient deficiencies present in any form of PEU. This step requires a very balanced approach. Although the incidence of anemia in PEU is quite high, iron supplements in early dates care is not applied. Correction of sideropenia is carried out only after stabilization of the condition, the absence of signs of an infectious process, the restoration of the main functions of the gastrointestinal tract, appetite and the presence of a 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 the infection is layered. In order to correct the deficiency of micronutrients, it is necessary to ensure the intake of iron at a dose of 3 mg/kg/day, zinc - 2 mg/kg/day, copper - 0.3 mg/kg/day, folic acid - on the first day 5 mg, and then 1 mg / day, followed by the appointment of multivitamin preparations, taking into account individual tolerance.

Seventh and eighth steps include a balanced diet therapy taking into account the severity of the condition, impaired function of the gastrointestinal tract and food tolerance. Children with severe PEU often require intensive care, the degree of impairment of their metabolic processes and the function of the digestive system is so great that the use of conventional diet therapy is not able to significantly improve their condition. Therefore, in these cases, complex nutritional support is indicated using both enteral and parenteral nutrition.

Ninth step Provides sensory stimulation and emotional support. Children with PEI need good care, affectionate communication between parents and the child, massage, therapeutic exercises, regular water procedures and outdoor walks.

The tenth step provides for a long-term rehabilitation, which includes sufficient nutrition in terms of frequency, volume, content of basic nutrients and energy value, regular medical examinations, adequate immunoprophylaxis, vitamin and mineral correction.

Materials for this chapter were provided by: Ph.D. Bushueva T.V. (Moscow), Ph.D. Shumilov P.V. (Moscow), Ph.D. Roslavtseva E.A. (Moscow), Ph.D. Rybakova E.P. (Moscow), Ph.D. Stepanova T.N. (Moscow), Ukrainian SE. (Moscow).

It will not be a secret to anyone that proper nutrition is of great importance in the life of every person. The same applies to children. In this article, I would like to talk in detail about such a problem as protein-energy malnutrition.

What it is?

At the very beginning, you need to decide on the concepts that will be used in the article. What is protein-energy deficiency is probably clear to everyone. This is a lack of protein in the child's body. It is also worth clarifying that this condition is pathological. To be more precise, too little or no protein in any form enters the human body. It can also be caused by too rapid decay of the substance. In this case, burns, purulent-septic diseases, or severe injuries can become the cause of this phenomenon.

Main reasons

Why can protein-energy malnutrition occur? It is worth saying that this problem is very common among residents of developing countries. During periods of hunger strikes, the percentage of people with this disease reaches 25%. In this case, the cause is insufficient quantity or poor quality of food. The problem is aggravated by the lack of energy supply. And all because the amino acids from food in this case are not used for They are oxidized for energy.

Secondary protein-energy malnutrition in children can occur for the following reasons:

1. Violation of the processes of digestion (absorption of nutrients decreases).
2. Protein loss may occur due to neuroendocrine regulation.

Forms

1. Marasmus. In this case, the growth of the child is retarded, and subcutaneous fat is also observed.
2. Kwashiorkor. This is just an isolated protein deficiency. In addition to growth retardation, the child may have swelling and, however, in this case, the subcutaneous fat is preserved.

Severity

If we are talking about such a problem as protein-energy malnutrition, degrees - that's what you also need to talk about. There are only three of them:

1. Easy (first, I).
2. Moderate (second, II).
3. Heavy (third, III).

Light degree

If we are talking about a mild degree of protein deficiency, the child's body is only weakened. In this case, its resistance to various viruses and infections decreases. The main symptoms that will be present in this case:

1. Growing weakness.
2. Lethargy of the child, his low ability to work.
3. Fast not only physical, but also psychological fatigue.
4. Chilliness, feeling cold.
5. Thirst and hunger. There may be frequent urination.
6. Possible dizziness.
7. There is numbness of the lower extremities.

At this stage, growth retardation of the child may also occur.

moderate degree

We further consider such a problem as protein-energy insufficiency. 2 degrees of the disease (first) most often occur in residents of precisely developing countries. In this case, as mentioned above, there is a growth retardation of children. However, the second degree is also characterized by biochemical changes in the body. So, there is a significant cellular weakening of immunity. And this leads to increased sensitivity to various kinds of viruses and infections.

Severe form

There is also a deep or severe protein-energy deficiency (i.e. cachexia). However, it is more typical for people with cancer. In this case, the child can lose weight very quickly, diarrhea occurs. The musculature of the patient also suffers, the limbs seem to be sticks covered with skin. Hair becomes dull, brittle, fall out. There may be water retention in the tissues, often this is fraught with edema. There are also irreversible changes in internal organs sick. However, all this is individual (the doctor can tell about this after certain studies). Other symptoms characteristic of such a problem as severe protein-energy malnutrition in children:

1. Apathy, fatigue.
2. Constant feeling of cold.
3. Depigmentation of skin and hair.
4. The skin becomes dry, covered with cracks. The child's face takes on an aged look.
5. Blood pressure, pulse, temperature decrease.

isolated form

Quite rarely, however, an isolated form of protein deficiency can still occur. Most often, it is accompanied by a lack of components such as vitamins B1, B2, B6, folic and nicotinic acid, vitamin A. If we talk about children, in this case, vitamin A deficiency is dangerous for babies. As the disease progresses, intracellular loss of potassium occurs , phosphorus and magnesium.

Treatment

If we talk about such a problem as protein-energy malnutrition, treatment is what you also need to focus on. So, if a child has one of the first two forms of the disease, you can still cope with the problem by adjusting the diet. In this case, it is very important to increase the daily dose of protein intake. For babies different ages it will vary:

1. If the child is from one to seven, the daily dose will be approximately 3-4 grams of protein per 1 kg of weight.
2. In schoolchildren, the need for protein is slightly lower: 2-3 grams per 1 kg of weight.

The child will definitely be prescribed multivitamin complexes. After all, only one food in this case will not be enough. The regulation of water and electrolyte balance can also be carried out.

If the child has a severe protein-energy deficiency, in this case the baby will be sent to the hospital. It is impossible to cope with this problem on your own at home. What will be relevant in this case:

1. controlled diet.
2. Correction of water-electrolyte balance with the help of infusion therapy.
3. Supplementary nutrition with mixtures that are rich in nutrients will also be prescribed.
4. If digestibility is impaired, the child will be prescribed (infusion of nutrients).
5. Vitamin therapy. However, in this case, it will be special. Such people need twice as many vitamins as a healthy person. And this is until the moment of recovery.
6. Patients with anorexia may be prescribed drugs that increase appetite. If you need to increase muscle mass, doctors may prescribe anabolic steroids.

Prevention

To avoid protein-energy malnutrition in children, you need to carefully monitor their diet. The following foods will help saturate food with protein:

1. Chicken meat.
2. Fish.
3. Beef.
4. Eggs.
5. Dairy.

It is also important to remember about other useful trace elements. Together with the protein, the child must receive sufficient carbohydrates and fats from food.