Ministry of health republic of uzbekistan tashkent medical akademy department of infections diseases and pediatrics

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Lection for the theme:

(for the students of treatment and medico-pedagogical faculties)

Taskent – 2012




Dean of medical-pedagogical


professor Zufarov P.S.

____ _____________ 2012

The lecturer: Khalmatova B.T.


Amount of students - 85-100

time – 2 hours

The form of educational employment

Lecture - visualisation

The lecture plan

1. To give concept about chronic frustration of a food

2. To tell the reasons of development of protein-power insufficiency

3. To give the characteristic of children with protein-power insufficiency

4. To show principles of the organisation of medical actions

5. To learn to make the plan of preventive actions

The purpose of educational employment: to acquaint students an aetiology, pathogenesis, diagnostics, principles of treatment and preventive maintenance of chronic forms of frustration of a food

Problems of the teacher: 1. To fix and deepen knowledge of students of kinds of chronic frustration of a food

2. To show the basic clinical signs

3. To develop at students skills of independent acceptance of the proved decisions at appointment of rehabilitation actions to children with protein-power insufficiency

4. To acquaint students principles of carrying out of preventive actions

Results of educational activity: the Student should:

1. To know concept about chronic frustration of a food at children

2. Classification chronic frustration of a food

3. Clinical displays of protein-power insufficiency on type paratrophy, hypotrophy depending on severity level

4. Treatment principles chronic frustration of a food

5. Rehabilitation actions

6. To carry out preventive actions

Methods and technics of training

Lecture - visualisation, technics: a blitz-interrogation, focusing questions, technics "yes-is not present"


Laser projector, visual materials, supply with information

Training forms

The collective

Training conditions

The audience adapted for work with means of training


Stages, time


The teacher

The teacher

1 stages


(5 min)

1. Informs the theme name, the purpose, planned results of lecture and the plan of its carrying out

1. Informs the theme name, the purpose, planned results of lecture and the plan of its carrying out

2 stages

Actualisation of knowledge

(20 min)

2.1. On purpose to staticize knowledge of students sets focusing questions:

1. What is the chronic frustration of a food?

2. What kinds of chronic frustration of a food meet is more often?

3. Principal causes of development of chronic frustration of a food?

Spends a blitz interrogation. 2.2. Displays and offers to familiarise with the lecture purpose. Makes comments on the slide maintenance. A slide ³1 2.3. Displays a slide №2

2.1. Answer questions

2.2. Study the mainte nance of a slide №1

2.3. Study the maintenan ce of a slide №2

3 stages

The information

(55 min)

3.1. Consistently states a floor-mat rial of lecture on plan questions, uses visual materials and system of focusing questions:

On 1 question of the plan: What kinds of chronic frustration of a food know?

On 2 question of the plan: Endogens the reasons of development of chronic frustration of a food?

On 3 question of the plan: the Basic clinical signs of a dystrophy of 2 degrees?

Focuses attention on the key moments of a theme, suggests them to write down.

3.1. Discuss the maintenance of the offered materials, specify, set questions.

Write down the main thing

4 stages

The final

(10 min)

4.1. Asks a question:

1. Children, what age are most subject to food frustration?

2. What is hypostature?

3. With what diseases it is necessary to spend the differential diagnosis?

4.2. Gives the task for independent work: Hypo- and polihypovitaminosis at children

4.1. Answer a question

4.2. Listen, write down

Dystrophy (protein-power insufficiency) - chronic frustration of a food and tropics the fabrics, breaking correct harmonious development of the child. In days of social shocks the dystrophy can develop at any age, but especially children of the first 3 years of a life are subject to it. Disease is accompanied by considerable infringement of exchange processes, immunity decrease, a delay physical, psychomotor, and further and intellectual development.


Allocate three kinds of a dystrophy.

Hypotrophya (deficiency of weight of a body in relation to growth).

Paratrophya (one of variants paratrophy - adiposity

o With prevalence of weight of a body over growth.

o With superfluous in weight of a body and growth.

o With normal in weight of a body and growth.

Hypostature (uniform backlog of weight of a body and growth from age norms).

Besides, dystrophies can be primary (mainly alimentary), caused by protein-power insufficiency, and secondary, accompanying other congenital and got diseases.

Hypotrophya - the most widespread and significant kind of a dystrophy. On time of occurrence it divide into three forms:

prenatal, developed till a birth of the child;

postnatal, arisen after a birth;

mixed, generated under the influence of the reasons operating on an organism of the child intra-and oututerina.

The reasons of dystrophies

Pre-natal (prenatal) the dystrophy is caused by adverse conditions and the various factors breaking correct development of a fruit.

Young (till 20 years) or elderly (after 40 years) age of the pregnant woman.

Infectious and somatic diseases of the pregnant woman.

Gestosis in any trimester of pregnancy.

Adverse social conditions, nervous stresses, an irrational food and bad habits.

Professional harm at both parents.

a placenta Pathology (reveal in most cases if all factors set forth above are excluded, and the dystrophy is diagnosed for the child prenatal).

Out uterine (postnatal) the dystrophy can be connected both with exogenous influences and with endogens the factors causing a secondary dystrophy.

the Basic exogenous factors postnatal dystrophies:

o the alimentary: the protein-power insufficiency caused quantitatively or qualitatively unbalanced food, deficiency of microcells (zinc, copper, selenium, etc.);

o the infectious: intestinal infections, repeated ARVI, especially complicated recedive an otitis;

o the social.

To endogens etiologic to factors postnatal dystrophies carry:

o developmental anomalies and chromosomal diseases;

o enzimophthy and malabsorbsion (both primary, and secondary);

o anomalies of the constitution;

o immunodefisients conditions.


In development prenatal dystrophies a leading role-play infringement of uterine-placenta blood circulation and pre-natal hypoxia a fruit, leading to frustration of tropic functions SNS. Pathogenesis postnatal hypotrophy irrespective of its origin and the form can be presented as uniform pathophisiological process in which basis infringement of digestion and decrease in excitability of a bark of a brain lay. In the simplified kind, it is possible to present this process in the form of the scheme.

Paratrophy connect with excessively high caloric content of food and the superfluous maintenance in it of fats and carbohydrates. To development paratrophy contribute limfatiko-hypoplastic and ekssudativ-cataral a diathesis.

Hypostature, apparently, it is caused by deep defeat neuroendocrine systems (more often pre-natal).

Symptoms of dystrophies

The clinical picture depends on the form of a dystrophy and disease severity level.

Clinical variants prenatal dystrophies

Depending on weight hypoxi defeats of a brain and clinical displays allocate following forms prenatal dystrophies (on E.M.Fateevoj).

the Nevropatichesky form: the weight of a body at a birth is normal or moderately lowered, growth without features. Psychomotor development corresponds to age. Attract attention excitation and negativism of the child, dream infringement, a distortion and appetite decrease.

the Nejrodistrofichesky form: are characteristic decrease as weights, and bodies are (to a lesser degree long at a birth, prevalence of processes of braking in SNS, moderate backlog in psychomotor development, a persistent anorexia

 Neuroendocrine the form: mark considerable (usually proportional) decrease in weight and length of a body since a birth, the expressed backlog in physical and psychomotor development; often observe congenital stigmas dysembriogenesis

the Entsefalopatichesky form is accompanied by deep backlog of the child in physical and psychomotor development, microsephali, signs local brain defeats, hyperplasia bone system, an anorexia and development polyhypovitaminosis.


Distinguish easy (I degree), midle (II degree) and heavy (III degree) hypotrophya

Hypotrophya I degrees it is appreciable only at attentive inspection of the child. Usually its condition satisfactory, appetite is lowered moderately, a skin smooth, elastic, pale, internal bodies and physiological departures without visible deviations. Turgor fabrics it is lowered, the thickness hypodermic fatty cellular tissue on a stomach is much less than norm, but on the person and finitenesses is kept. Deficiency of weight of a body makes 10-20 % on comparison with average indexes. At inspection mark dysproteinemia and decrease in activity of digestive enzymes.

Hypotrophya II degrees it is accompanied by decrease in an emotional tone and activity of the child, apathy, slackness, adinamy, an arrest of development of psychomotor functions and speeches, bad appetite. A skin pale, dry, shelled. Elasticity and turgor fabrics are lowered, as well as a muscular tone. Hypodermic fatty cellular tissue it is kept on the person, but it is considerably reduced or is absent on a stomach and finitenesses. Deficiency of weight of a body in relation to growth makes 20-30 % against backlog in growth on 2-4 the Curve of increase of weight of a body-flattening see. Fluctuations of a body temperature within days (to 1 °С) and constantly cold finiteness’s testify to thermoregulation frustration. Often mark taxipnoe, arrhythmic rigid breath, warm tones, propensity to a tachycardia and an arterial hypotension. At violent feeding there is a vomiting, quite often there are locks. Often join intercurrent diseases (for example, an otitis, a pyelonephritis, a pneumonia). At laboratory researches find out hypochrom an anaemia, hypo-and dysproteinemia, considerable decrease in activity of digestive enzymes.

Hypotrophya III degrees (the atrophy, alimentary marasmus) causes considerable infringements of the general condition of the child: drowsiness, indifference, irritability, the negativism, the expressed delay in development, loss of already got skills and abilities, anorexia. Outwardly, the child reminds a skeleton fitted by a dry skin of is pale-grey colour, hanging down folds on buttocks and hips. The person senile, wrinkled, the triangular form. Hypodermic fatty cellular tissue is absent everywhere, including cheeks as lumps Bisha peculiar to children disappear. Fabrics completely lose turgor, muscles atrophic, but their tone is usually raised in connection with frustration electrolyte balance and neurologic infringements. Deficiency of weight of a body is made more than 30 %, by a curve of its increase absolutely flat or decreasing. Growth less than age norm see on 7-10 dehydration signs Are expressed: Thirst, falling big fontanels and eyeballs, afonia, dryness conjunctive and corneas, bright colouring of a mucous membrane of lips, cracks in mouth corners («a mouth of a sparrow»). The Body temperature is usually lowered and fluctuates depending on an ambient temperature; sometimes there are unmotivated lifting’s to subfebril values. Finitenesses constantly cold. Breath superficial and arrhythmic. Often reveal asymptomatic atelektasis and a hypostatic pneumonia. Pulse rare, weak, arterial pressure low, tones of heart are muffled. A stomach will involve or it is blown up and strained. The liver and a spleen are reduced in sizes. Almost always mark dyskinetic frustration GIT: regurgitation, the vomiting, the speeded up liquid chair. Urine way rare, small portions.

Laboratory data testify to a blood condensation (concentration of haemoglobin and the maintenance erythrocytes within norm or are raised, SSE it is slowed down). In urine reveal a considerable quantity of chlorides, phosphates and urea, sometimes find out acetone and ketons bodies.

Kwashiorkor - a variant of a dystrophy at children of 2-4th year of a life in the tropical and subtropical countries. Arises after an excommunication from a breast at a food by mainly vegetative food (albuminous starvation), accompanying infectious diseases and other adverse factors. The basic symptoms: a considerable delay in physical and psychomotor development, diffuse depigmentation skin and hair, loss of hair, the crescent-shaped person, pastose and hypostases of fabrics, a muscular atrophy at partially remained hypodermic fatty layer, heavy degree of an anaemia, rickets display.


Hypostature - an arrest of development caused by protein-power insufficiency, a variant of a dystrophy with more or мене uniform backlog of the child in growth and weight of a body at satisfactory fatness.

Hypostature usually happens a stage of deducing from heavy primary hypotrophy. At a reparation from hypotrophy the hypodermically-fatty layer is restored quickly enough, growth accrues much more slowly. It is possible hypostature at an unbalanced food, for example, at mainly carbohydrate feeding with deficiency of other components.

The child more or less proportionally lags behind in growth, weight, psychomotor development, intelligence, teething terms. The biological age of the child lags behind from calendar and corresponds to its growth and weight of a body. The patient on all parametres of development makes impression of the child of smaller age. Signs of chronic frustration of a food, characteristic for hypotrophy II degrees are thus obvious.

The diagnosis establish because of clinical-anthropometrical data.

Paratrophya develops at a reforage of the child chest milk, dry dairy mixes, sweet juice is more often, and also at an unbalanced food it is a lot of carbohydrates and deficiency of fiber (for example, at excessive feeding by porridges), especially at inactive children with ekssudative-cataral or a limfatiko-hypoplastic diathesis. The long reforage or a constant hypodynamia can lead to adiposity development. Clinical displays paratrophya are similar to those at hypotrophy, but there is no deficiency of weight of a body. At the child mark instability of an emotional tone, anxiety or slackness, adynami. Senior children complain of a short wind, fatigue, headaches. Appetite selective, often lowered. Integuments pale, quite often pastose, their elasticity can be lowered. Turgor fabrics and a muscular tone are insufficient, despite good or superfluous development of a hypodermic fatty layer. Cellular tissue it is often distributed non-uniformly and more expressed on hips and a stomach. The weight of a body and growth correspond to age parametres or exceed them, a constitution often disproportional. As well as at hypotrophy, infringements albuminous, water-salt, vitamin and other kinds of an exchange are expressed. It is possible acidosis. Functional and morphological changes of internal bodies, decrease immunologic protection (frequent diseases of respiratory ways, otitises, infections of uric ways) are frequent. The plentiful liquid foamy chair with a sour smell is possible.

Diagnostics of dystrophies

The dystrophy diagnosis is based on the characteristic clinical symptoms including decrease turgor of fabrics, consecutive disappearance or reduction of a thickness hypodermic fatty cellular tissue on a stomach, finitenesses and the person (or superfluous and its non-uniform adjournment), backlog of weight of a body from growth, resistibility decrease to infectious diseases and various influences of an environment. In the diagnosis specify a kind of a dystrophy and time of its occurrence in relation to the birth moment (prenatal, postnatal). At hypotrophy specify its degree, an aetiology and the development period (initial, progressing, reconvalesentia).

Differential diagnostics

The primary dystrophy should be differentiated from secondary, caused by developmental anomalies GIT and other bodies, a hereditary pathology, organic defeat SNS, endocrine diseases. In cases heavy hypotrophy, not giving in usual therapy, and also at paratrophy and the adiposity, especially combined with considerable backlog in psychomotor development, the dystrophy happens secondary is more often.

Disproportionate nanism, caused chondrodystrophia, congenital fragility of bones or tubulophathy, differs from hypostatura a rough pathology of a skeleton which it is impossible to explain a rickets quite often accompanying dystrophies. Roentgenograms of bones and indicators phosphor-caltsie an exchange allow to exclude these diseases.

Proportional nanism it is caused by hypophysis defeat (гипофизарный нанизм) or a heavy congenital pathology of cardiovascular and respiratory systems. It is seldom shown at a birth, usually develops later. Difficulties arise at differential diagnostics from nanism, caused by tolerance of fabrics of an organism to STH. At this disease, children at a birth have low indicators of weight and length of a body, and further the increase in growth and weight of a body is extremely insignificant. However clinical and laboratory signs of a dystrophy are absent.

Treatment of dystrophies

Medical actions depend on a kind of a dystrophy and degree of its weight. First they include elimination etiologic factors, the organisation of a mode and optimum for the child of conditions of environment. Paramount value has diet treatment. Sanitation of the centres of a chronic infection, treatment of accompanying diseases, the prevention of secondary infections, struggle with hypodynamic are necessary also.

The leaving organisation

Children with hypotrophy I degrees treat houses under supervision of the local pediatrist without change of the usual mode corresponding to their age. Treatment of children with hypotrophy II and III degrees spend in the conditions of a hospital with the obligatory organisation of a sparing mode: the child should be protected from all superfluous раздражителей (light, sound, etc.). The maintenance of the child in boxing with creation of an optimum microclimate (temperature of air 27-30 °С, humidity of 60-70 %, frequent airing) Is desirable; mother hospitalise together with the child. During walks of the child it is necessary to hold on hands, to watch that brushes and stops were warm (use hot-water bottles, socks). Increases of an emotional tone should achieve the tender reference with the patient, massage and gymnastics application. At hypotrophy III degrees, especially at a muscular hypertone, massage spend with the big care and only the stroking.

Diet treatment

The diet makes a basis of rational treatment of a dystrophy (first of all hypotrophy). Diet treatment it is possible to divide into two stages:

finding-out of shipping of various food;

gradual increase in volume of food and correction of its quality before achievement of physiological age norm.

The first stage proceeds from 3-4 till 10-12 days, the second - before recover.

The general principles diet treatment, recommended at treatment of dystrophies:

diet "rejuvenation" - application of the foodstuff intended for children of more younger age (chest milk, the sour-milk adapted mixes on a basis hydrolyzed the squirrel);

a fractional food - frequent feeding (for example, to 10 times a day at hypotrophy III degrees) with reduction of quantity of food by one reception;

weekly calculation of food loading by quantity of fibers, fats and carbohydrates with correction according to increase in weight of a body;

the regular control of a correctness of treatment (conducting a food diary with instructions of quantity of the food, the drunk liquid, diuresis and chair characteristics; drawing up of "a weight curve», coprology research, etc.).

Food calculation at hypotrophy I degrees carry out on forced (corresponding to age) weight of a body of the child with full satisfaction of its requirements for the basic components of food, microcells and vitamins. At hypotrophy II and III degrees in the first 2-3 days food volume limit to 1/3-1/2 for forced weight of a body. In the subsequent it gradually increase to 2/3-3/5 daily diets of the healthy child. Missing volume of a food fill with a liquid - vegetable and fruit juice, 5 % a glucose solution. On reaching the volume of food put on age the quantity of fibbers’ and carbohydrates count on forced weight of a body, and fats - on actual. If at the child in the course of increase in quantity of food is not present dyspepsia, and the weight of a body increases (usually it occurs through 1 - 12 days from the treatment beginning), gradually spend qualitative correction of the food, all components count on forced weight of a body (fibers and fats - 4-4,5 g/kg, carbohydrates - 13-16 g/kg).

Medicinal therapy

Enzymes necessarily appoint at any degree hypotrophy as because of increase in food loading at treatment, and in connection with decrease in activity of own enzymes GIT of the patient. Enzimotreatment spend it is long, replacing preparations: enzymes (abomine), at a considerable quantity of neutral fat and fat acids in coprogramme - pancreatine, panzinorm. Pathogenetic application of vitamins, first of all ascorbic acid, pyridoxine and thyamine is proved also. Stimulating therapy includes alternating courses uterine milk (apilac), a ginseng and other means. At infectious disease, development enters Ig.

Preventive maintenance of dystrophies

Preventive maintenance is expedient for dividing on antenatal and postnatal.

Antenatal preventive maintenance includes family planning, sanitary education of parents, struggle against abortions, treatment of diseases of future mother, especially illnesses of sexual sphere, health protection of the pregnant woman [a balanced diet, observance of a mode of day, walk on fresh air, transfer into easy work (at adverse working conditions), an exception of smoking and other bad habits].

Postnatal preventive maintenance includes natural feeding with its timely correction, observance of a mode and rules of care of the child, correct education, the prevention and treatment infectious and intercurrent diseases, dispensers supervision with monthly (till 1 year) weighing and measurement of length of a body.

The forecast

The forecast depends first on possibility of elimination of the reason which have led to development of a dystrophy, and also from presence of accompanying diseases. At a primary alimentary and alimentary-infectious dystrophy the forecast quite favourable.

Marasmus - exhaustion at children of the preschool and school age, caused by the starvation, proceeding with deficiency of weight of a body more than 60 % from the age standard.

The marasmus reason - the starvation caused by the social and economic reasons or diseases, proceeding with a long anorexia, vomiting. All kinds of a metabolism are broken, physical and mental development sharply is late.

Allocate primary and secondary forms of marasmus, specify weight and the period.

For marasmus clinic pallor and dryness of a skin with follicular hyperkeratosis, depigmentation, non-uniform colouring («a flag symptom») and the hair, the grown thin "senile" person with inflamed eyelids and helloes, an exhaustion of muscles and a hypodermically-fatty layer are characteristic. At survey it is possible to note cardiomegali, hepatomegali, hemorrhagic displays. Growth is late, children are irritable, whining, lag behind in mental development, in them informative activity, memory and working capacity is lowered.

The diagnosis is established on a basis clinikal-anamnesticks and anthopometrical data.

The differential diagnosis spends with the diseases accompanied by exhaustion: organic pathology SNS, hereditary anomalies of a metabolism, etc.

In heavy cases marasmus treatment begin in a somatic hospital - parenteral a food and replaceable therapy. In less heavy cases treatment is probably out-patient: a diet, replaceable therapy (vitamins, minerals, digestive enzymes), stimulating treatment, psychotherapy. At secondary forms of marasmus spend treatment of the basic disease. Normalisation of the social and economic environment, psychology-pedagogical work with children has the important preventive value.

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