 Chronic
nutritional disorders (CND) are
characterized by delaying or stopping of
ponderal 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.
 Hypotrophy
– slowing or stagnating the
ponderal growth.
 Hypostature – stagnating uniformly ponderal
growth and stature.
 Paratrophy – excessive mass.
According to the origin, hypotrophy can be:
 Congenital, prenatal (intrauterine)
hypotrophy;
 Postnatal hypotrophy (acquired);
 Mixed hypotrophy (prenatal – postnatal).
 Neuropathic
form;
 Neurodystrofic form;
 Neuroendocrine form;
 Encephalopathic form.
Degree of severity:
 Mild malnutrition – degree I (10 – 20%)
 Medium malnutrition – degree II (20 – 30%)
 Severe malnutrition – degree III (more than
30%)
 Severe
protein – energy malnutrition
(marasmus)
 Severe protein malnutrition (kwashiorkor)
 Protein
deficit;
 Global energy deficit;
 Protein and energy deficit.
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.Exogenic factors
 2.Endogenous 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;
 c)less lipids in the foods etc.
- Infectious
 a)Repeated respiratory infections: pneumonia, urinary infections;
 b)Chronic gastrointestinal disorders, diarrhea;
 c)Long duration and excessive antibioticotherapy.
- Negligence, care and education.
 a)Negligence of physiological diet regime;
 b)Improper weaning foods.
-
Developmental anomalies of systemic
organs;
 - Hereditary metabolic disorders;
 - Congenital metabolic disorders;
 - Malabsorption disorders;
 - Endocrine disorders.

Pathogenesis is very complicated and still not
confirmed. It is difficult to explain all the factors and
the specific affection according to the age of
children. The chronic hypoxia of the maternal organs
and the modifications in the feto-placental
circulation with oxygen and nutrition transport
disturbances to the fetus play a major role in the
pathogenesis of intrauterine hypotrophy. Acquired
hypotrophy due to insufficient food uptakes the
organs of the child start using the storage:
carbohydrates, then lipids from the storage. As the
storage deplinishes, the protein breakdown starts. It
starts from muscle fibres, after that – from
parenchyma of the internal organs. In this ways
always it manifests with severe disorders involving
changes in the systemic organs (digestive, endocrine,
CNS, etc.) resulting in decreased immunity.
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1. Trophical disturbances syndrome: cellular – adipose layer
thinning, flattened growth curve, growth deficiency and
constitutional disturbances. Skin turgidity is diminished and
presents with symptoms of hypovitaminosis (A, B1, B2, B6, D, PP).
2. Digestive disorders syndrome: loss of appetite, anorexia, bowel
disturbances (constipation or dyspeptic stools), disturbances of the
intestinal flora, decrease of food tolerance, signs of maldigestion in
coprogram.
3. Central nervous system disturbances syndrome: emotional
disturbances, decreased motor activity, negative emotions, sleep
disturbances and thermal disturbances, psychomotor retardation,
muscular hypotony and dystony.
4. Hematopoietic and immunologic disturbances syndrome:
anemia, secondary immunodeficiency state, tendency of evolutions
without any manifestations, atypical manifestations of acute
inflammatory diseases, infections.
 Neurologic
mechanism is the basis of congenital
hypotrophy. It may manifest as severe anorexia and
disturbances in the digestive reflexes. The four
clinical forms mentioned above depend from 5
indices: weight, height, motor activity, psychic,
appetite.

Formula for calculating congenital hypotrophy
degree: birth weight/stature(length) at birth.
Normal children – more than 60. Degree I – 59-56;
degree II – 55-50; degree III – 49 and less.

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
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.
 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 ascending.
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.
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 hypotony. 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, low digestive tolerance. They may have
regurgitation, vomiting, swollen abdomen due to intestinal and
abdominal wall atony. There may be constipation, but frequently it
is hunger diarrhea. Reduced diuresis. The children are apatic,
adynamic, do not react to the surroundings and are hyporeflexic.
There are thermoregulatory and hypermetabolic disturbances.
 edematous
dystrophy and loss of the selective
proteins. The loss of the selective proteins is due to
disequilibrium of the nitrogen balance which is a
cause of insufficient protein diet and rarely due to
protein loss. It may develop after stopping the
breast feeding and transferring to protein less diet
(as a rule – vegetarian). The clinical signs set in
after 2 – 3 months after stopping the breast
feeding. The stagnation of the growth curve may be
noted. The generalized edema sometimes masks
the loss of weight in the child. The general
condition is altered, the child is apathic; fixed
vision, grimace, flaccid and dry skin are seen. Thin
and grey or red hair. Depigmentated hair. In serum –
hypoproteinemia and in blood – anemia.
the diagnosis is based on anthropometry,
clinical and lab findings. In anthropometry
the weight and the height are used. The
deviation from the normal weight is
calculated using Ponderal Index (PI) and
Nutritional Index (NI).

PI (Ponderal Index) = actual weight/ideal
weight for that age.

NI (Nutritional Index) = actual
weight/weight for the height (but not age).
 Infants
with PI of 0.9 – 1.1 and NI of 1.0 – 0.9
are considered eutrophic. Infants with PI and
NI less than 0.9 denote malnutrition.

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Clinical criteria include past history and clinical signs.
In the history it is necessary to determine prenatal
and obstetrical history. The history of infections at
mother and child is important. Clinical examination
depicts signs of weight loss, loss of adipose tissue,
fall of growth curve, change in muscular tone and
modifications in the systemic organs.
Metabolic changes: hypothermia, bradycardia,
decreased intestinal tolerance, paradoxical reaction
to hunger, decreased resistance for infections.
Delayed neuropsychic development.
The laboratory findings: decreased serum protein
and serum albumin, hyponatremia. The stools pH
control and d – xylose test performing if necessary.
Immunologic tests and analysis if necessary.
The treatment of hypotrophy is complex and
includes:
1. finding the cause and treating the cause of
hypotrophy;
2. daily regime, care, education, massage,
gymnastics;
3. diet therapy;
4. vitamin therapy, ferment therapy, symptomatic
treatment;
5. treating the foci of infection;
6. treating the associated diseases.

In degree I of prenatal hypotrophy the children at birth
have satisfactory general condition and the weight gain
is normal if the child is under medical supervision. The
children with II – III degree of congenital hypotrophy and
prematures require care in special centers. The diet in
children with hypotrophy is fixed taking into
consideration the etiology and the metabolic disorders.
In the case of celiac disease the gluten containing diet
is restricted like wheat flour. The children with lactase
insufficiency should be restricted from the milk
containing diet. These are fed with lactic acid products
(mixture containing acidophilic bacteria) or soya
formulas. In cystic fibrosis limited lipids and rich
protein diet is indicated. The necessary lipid is got from
vegetable oils.
 Level
I - rest and minimum diet;
 Level II – increase in the caloric input
(intermediary);
 Level III – returning to normal regime.
 The
diet therapy is given according to the degrees
of hypotrophy. Before starting the diet therapy the
daily required diet is calculated 170 – 200 ml/kg
body weight or 1/5 of the body mass, but not more
than 1 litre/day. At the level I at the severity of
hypotrophy by I degree is 2/3, II degree – 1/2, and
III degree – 1/3 from 1/5 of the body weight.

In the following days if the appetite is good then
the digestive tract tolerance is considered as
satisfactory and the volume of the food is raised
from 1/3 to ½ or 2/3. If the tolerance is good in the
time of 3 – 5 days, then the volume of the food is
raised to 2/3 from 1/5 of the real body mass. In the
loss of appetite and less tolerance the volume
previously consumed is indicated.
In the I level of diet therapy the required liquid can be
given in the form of carrot soup, 5% glucose solution,
rice porridge, tea, fruit juice and vegetable soup. In
children with II – III degree hypotrophy i/v 5-10% glucose
solution, Ringer’s solution can be administered.
In the stage of minimum diet the food for 1 kg of body
weight should contain:

Protein - 0.7 – 1.5 – 2.0 g;

Lipids - 2.0 – 4.0 g;

Carbohydrates - 8.0 – 11.0 g;

Calories - 60 – 70 – 100.
The protein is slowly raised daily until it reaches 3 – 4
g/kg/day.
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Increased calories intake. The child receives the necessary food
per day (2/3 or ½ of the basic mixture). In this level the following
may be consumed: mother’s milk, milk from the donator, industrial
milk formulas. From the seventh month – yoghurt, curds, biolact,
rich carbohydrates and lipids foods can be used.
The correction mixture is distributed in small portion, 10-20-3050-60 ml, before each alimentation with the basic mixture.
In the intermediary stage the lipid quantity in the natural
alimentation is raised up to 3 g/kg, in the mixed alimentation – 3,5
g/kg, and in artificial alimentation – up to 4 g/kg.
The fat quantity remains low - 4 - 4,5 g/kg and the
carbohydrates touch the lower limits of normal quantity.
In the adaptation stage in 5th and 7th day of II level, pure mixture
(without fat or decreased fat) is mixed step by step with mixture
rich in protein and fat, curds, biolact and Enpit lipid. In this level
the lipids are increased up to 5 – 6 g/kg body mass.
Carbohydrates up to 13 – 15 g/kg in the intermediary stage are
done ultimately by introducing lactate mixture, juices, fruit mash
in the food in the first months of life. After 6 months mashed
vegetables and gruel are added.

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

Returning to the optimum diet regime corresponding to the
biologic age. Egg yolk, vegetable oil, butter, cheese of cow’s milk
and meat are added accordingly to the age limits. In this period
optimum diet for 1 kg of real mass should contain:
Protein - 4 – 4,5 g;
Lipids
- 6 – 6,5 g;
Carbohydrates - 15 – 16 g;
Calories - 130 – 150/kg
In the case of destruction of the intestinal flora biologically active
substances are added like: Bifidum-bacterin and bificol. In severe
malnutrition there is hypovitaminosis. To regulate this parenteral
hydrosoluble vitamins are administered in the early stage of the
treatment like: vitamin B1, B2, C and cocarboxylase. In the
intermediary stage vitamin B5, B6, B12, B15, nicotinic acid and
liposoluble vitamins A and E are administered.
Pepsin with hydrochloric acid, pepsin, gastric juice, pancreatic
ferments may be administered to help digestion. The ferments are
prescribed at the end of the period of the minimal diet when the
volume of the diet corresponds with 1/5 of the real weight in the
duration of 3 – 4 weeks.
Concomitantly or after the correction of anemia
are done by administering iron preparations.
Rickets is treated by vitamin D administration.

In the level II the treatment includes manage and
gymnastics.

Antibiotics are indicated if there exist a foci of
infection or associated infection diseases.

The treatment for hypotrophy is complicated and
for a long duration.

Prognosis
 The prognosis of mild and moderate forms is
satisfactory. In the severe form the prognosis is
reserved.
Prophylaxis
 1. Early diagnosis and correction of the diet.
 2. Maintaining of natural diet.
 3. Calculated mixed or artificial diets with
corrected mixtures.
 4. Diversification of the corrected diet.
 5. Early diagnosis and correct treatment of
infections.
Hypostature is proportional retardation of the ponderal
growth and the height. This is characteristic for children
with congenital heart defects, with developmental
anomalies of the brain, children with encephalopathy
and endocrine disorders. These children have trophic
changes and nonevident signs of polyhypovitaminosis,
hypoproteinemia, intestinal lipid absorption
disturbances. Low levels of phospholipids and alfalipoproteins and aminoaciduria are observed.

The hypostature children who are hypoplastic
(constitutional height retardation) does not show
trophic changes. Skin is red, absence of signs of
hypovitaminosis. Normal muscular tone and skin
turgidity and normal neuropsychic development which
corresponds to the age. Digestive tolerance is normal
and resistance to infections is adequate. Hypostature is
found in children older than 6 months.


Paratrophy is a chronic disorder of nutrition with
excessive body mass.
 Incorrect
diet with wrong proportions of the
principal ingredients of alimentation and
high carbohydrate (surplus of sweet tea,
juices, gruel, biscuits), high protein
(condensed cow milk, cheese, Enpit).
Lymphatico – hypoplastic disorders, allergic
disorders, and anemia contribute for
paratrophy. Surplus of breast milk never
leads to paratrophy.
 The
excessive carbohydrate and protein intake
leads to intestinal dysfunction, digestive
disturbances, disturbances in the intestinal flora,
anemia, endogenous intoxication, acidosis and
hypovitaminosis. Excessive carbohydrates
contribute to vitamin B1 deficiency (marble skin,
decreased muscle tone). Hypovitaminosis A
manifests as dry skin, purulent eruptions over skin,
repeated infections, anorexia, hypertension. The
children with paratrophy have a predisposition to
rickets and anemia.
Basic symptoms of paratrophy are neuropsychic
disturbances. Children are adynamic, emotionally
labile, apathic, insomnolent and have selective appetite
for diet. Skin is pale, soft, dry and sometimes the skin is
cream colored (due to excessive protein intake).
Excessive adipose tissue and decreased muscular tonus
are present. In the serum the level of phospholipids is
low and cholesterol is high. Due to decreased immunity
the children are prone to viral infections, otitis and
urinary tract infections. Various intestinal disturbances
are met in children with paratrophy.

The stools are pasty. In the case of excessive
carbohydrates the stools are loose, with acidic pH,
yellow color, with mucus and positive iodine test (blue
in the case of starch presence). Microscopic the starch
is in high quantity; cells, fatty acids and leukocytes are
present.

Diagnosis

The diagnosis in paratrophy is based on the
clinical manifestations. In the peripheral blood –
iron deficient anemia, folic acid deficiency anemia
and vitamin B6 and B12 deficiency is found.
Treatment

Regulation of diet. Introducing of vegetable
components in the diet. Feeding in the intervals
between the meals is strictly prohibited. Acidic diet
mixture with less lipids is preferable. In general
physical exercise, massage, walking and cold water
baths are indicated.