Évaluation de l'état nutritionnel et des besoins de l'enfant et de l'adolescent

Ten to fifteen percent of hospitalized children suffer from malnutrition. Children suffering from chronic diseases are at particularly high risk for malnutrition. A systematic screening for malnutrition and nutritional risk can improve nutritional care in this population. Simple measures (weight and height at admission) can be used to calculate nutritional indices (weight for height ratio or body mass index). Nutritional risk depends on: 1) the severety of the principal diagnosis, 2) the ability to feed oneself, and 3) the pain intensity. The oral or enteral route is preferred when the gut is functional. In all cases nutritional status must be followed throughout hospitalisation. Furthermore, it is preferable to begin nutritional care before malnutrition sets in. Nutritional care can improve the outcome and well-being of hospitalized children.     

Mécanismes de la dénutrition chez l'enfant et l'adolescent

Malnutrition in child and adolescent is observed in various situations where there is an imbalance between the food intakes and caloric and proteic needs. Child is particularly vulnerable because its reserves are weak and its high caloric and proteic needs because of its growth. Various mechanisms leading to malnutrition were brought back and correspond to distinct clinical entities. The situations of malnutrition by exclusive mechanism of intake deficiency meet primarily in third world where they can take the form of starvation, extreme adaptive situation with prolonged fast. During situations known as of aggression like severe sepsis, polytraumatism, extended burn, surgery, malnutrition can settle quickly. Mechanism brought back in situation of acute aggression is defined classically like related to hypermetabolism with hypercatabolism. Kwashiorkor, another type of caloric and proteic malnutrition concerning child in third world, cannot be regarded as a simple caloric and proteic deficiency. It currently seems that a deficiency at the same time in macronutriments and micronutriments plays a part in genesis of this pathology. The glutathion seems in particular, to play a fundamental part in the kwashiorkor's pathophysiology. The most documented hypothesis relates imbalance between production of free radicals and mechanisms of defence. Mechanisms of repair would be insufficient, and persistence of membrane deteriorations would cause anomalies observed in kwashiorkor like oedema, hepatic overload, neurological disorders and diarrhoea.     

Biodisponibilité de la glutamine et réponse du métabolisme protéique à l'apport de glutamine chez l'homme

Glutamine is synthetized in most tissue and accounts for two-thirds of the free amino acid pool in skeletal muscle. Glutamine is not only an interorgan nitrogen shuttle but a precursor of urinary ammonium, and a favorite fuel of the immune system and the gut (which uses ≠ 17 g of glutamine per day). Because they were designed at a time when glutamine was considered both unstable and non-essential, « tradtionalparenteral nutrition (PN) solutions are devoid of glutamine. Although « classicPN is able to maintain normal rates of glutamine turnover in healthy subjects or unstressed patients, classic PN solutions are unable to correct the precipitous depletion of glutamine pool that accompagnies catabolic illness. Glutamine becomes a « conditionally essentialamino acid in these situations. Replenishment of glutamine pool seems to stimulate protein synthesis, and improve nitrogen balance in catabolic patients. Supplementation of PN with glutamine-containing dipeptides or α-ketoglutarate (at doses of 15–50 g/d) is as effective as glutamine itself. The enteral route represents an attractive alternative for the supply of glutamine since : 1) glutamine is efficiently absorbed ; 2) nearly 50 % of enterally infused glutamine reaches systemic blood ; 3) glutamine residues present in a bound form in peptides seem to be bioavailable ; and 4) in addition to its protein anabolic effect, glutamine affects intestinal absorption and trophicity.     

Indane-1,3-diones IX, synthèse et activité anti-inflammatoire de 2-polyaza-arylindane-1,3-diones et de leurs dérivés N- ou O-substitués

Les auteurs étudient les voies d'accès à des 2-polyaza-arylindane-1,3-diones et à leurs dérivés diversement substitués sur l'hétérocycle et l'homocycle ainsi que la pharmacomodulation de leur activité anti-inflammatoire. Ces β dicétoénamines fournissent en milieu alcalin des anions multidents conduisant en présence d'agents électrophiles à une C, N ou O-substitution; la mise en œuvre de la réaction de Mitsunobu a abouti à une N-(ω-amino-)-alkylation régiospécifique ou régiosélective. Parmi les diverses modifications structurales, la N-éthylation de la molécule de base, éventuellement couplée avec une méthoxylation en 5 sur l'homocycle s'est avérée efficace pour l'émergence d'une activité anti-inflammatoire en séries pyridazinyle, pyrimidinyle et tétrazolyle. Parmi les 3 molécules les plus actives 31, 43 et 50, la seconde a fait l'object d'une étude plus approfondie.     

Synthèse par SRN et évaluation de l'activité amoebicide de nouveaux dérivés quinoléiniques

Des dérivés quinoléiniques porteurs de chaînes carbonées, soufrées ou phosphorées, ainsi que des furoquinoléines sont obtenus à partir du Clioquinol (Vioforme) par des réactions de substitution nucléophile radicalaires en chaîne (S_RN¹) inédites dans cette famille d'hétérocycles. Une évaluation de leur activité in vitro est effectuée sur des cultures d'Entamoeba histolytica et de Trichomonas vaginalis.     

Stratégie de prise en charge nutritionnelle de l'enfant et de l'adolescent (Nutrition orale, entérale, parentérale)

Children are especially threatened by malnutrition, because of the high protein-energy cost of growth. Any nutritional deficiency is the source of protein energy malnutrition, which compounds the problems of underlying disease. The protein-energy cost of catch-up growth is particularly high, and should lead to a rigorous adjustment of nutritional supply to prevent metabolic disorders associated with refeeding syndrome (directly related to the homeostatic change secondary to severe protein energy malnutrition). If the gastrointestinal tract can be used for refeeding, it should be used (oral or enteral nutrition). When the gastrointestinal tract is unable to meet the protein and energy requirements, parenteral nutrition is required. Catch-up growth may be achieved by using appropriate nutritional support.     

Définition et évolution du statut nutritionnel au cours d'une greffe osseuse allogénique (15 malades): Rôle de la nutrition parentérale et de l'apport azoté

Our work concerned 15 patients (9 males, 6 females) with a mean age of 29.5 years, having a hematologic malignant disease and undergoing allogenic bone marrow transplantation.We studied :

1. The metabolic disorders induced by the conditioning regimen (chemotherapy and total body irradiation) pregraft accompanying cytolysis (day −7, −5, −2).

2. The corrective effect of a total parenteral nutrition introduced 2 days before the transplantation and pursued during 30 days post-graft (day −2 to day 30).

3. The interest of a high calorie intake (BEE × 2) and, after randomisation, of a variable nitrogen intake (24% of the total calorie intake for group A [8 patients] and 14% for group B [7 patients]). The patient characteristics of these two groups were closely comparable. Urinary parameters were studied daily (3-methylhistidine, cratinine, nitrogen) and blood parameters weekly (transferrin, pre-albumin, albumin, retinol binding protein).

We observed globally :

-- An excellent result of the nutritional support without significant weight loss;

-- protein catabolism stopped with a recovery of synthesis of RBP after day 7 and pre-albumin from day 7;

-- a decrease in muscle catabolism.

The randomized study showed :

-- a significant difference in nitrogen excretion between group A and group B;

-- earlier and better protein synthesis recovery in group A, particularly with regard to RBP and pre-albumin.

In conclusion, we recommend for the patients undergoing bone marrow transplantation :

-- nutritional support should be introduced before the conditioning regimen;

-- a high calorie intake (BEE × 2) with a nitrogen intake between 14% and 24% of the total calorie intake;

-- cyclic parenteral nutrition should be pursued during the second and third month post-graft.

Épidémiologie et facteurs de risque psychosociaux dans l’anorexie mentale

The prevalence for anorexia nervosa is estimated at 0.5% in the young girls and the highest incidence was found between ten to 19 years. Among women, the prevalence for anorexia nervosa is estimated between 0 to 1.5%. The lifetime prevalence varies between 0.6 and 4%. The methodological limitations relate to the variety of the instruments to diagnose an eating disorder and the lack of definition approved for eating disorders not otherwise specified. The empirical models of the pathogenesis of eating disorders continue to stress the role of social pressure to thinness, this one being transmitted by the media, the family environment and the peers. The methodological limitations continue to pose a challenge in the interpretation of the modulation by the sociocultural factors of the etiologic ways for anorexia nervosa. A complex multifactor aetiology is considered, implying the interaction of genetic predisposition and certain specific environmental risk factors, in particular social factors.     

Thérapies comportementales et cognitives de l’anorexie mentale

To lead a behavioral and cognitive therapy supposes that the patient wishes to change his behavior and that he asks to the therapist to help him by an information, a support and instructions there. This initiative is rarely voluntary at the patient's suffering from anorexia nervosa. These therapies were thus adapted to this pathology. The practice of aspirational interviews is also lawful on an extrapolation from investigations concerning the other pathologies, a priori close. The clinical impression shared by the practitioners formed in these methods is the one of a facilitation of the behavior of the treatment and an intensification of what we call the therapeutic alliance. Problems posed by the particularities of the anorexia nervosa however have the effect of stimulating the evolution of the behavioral therapies. This pathology confronts the therapists with the firm reality of the contradictions and the irrational logics, which are inherent in fact to the human thought.     

Outils et procédures de dépistage de la dénutrition et de son risque en milieu hospitalierTools and procedures for screening for malnutrition and its associated in risks in hospital

Malnutrition affects on average 20–50% of hospital inpatients and its negative repercussions in terms of morbi-mortality have been fully documented. Although this state of affairs is well known, there is little screening for malnutrition in hospitals. There is no single parameter indicating malnutrition, which instead has to be diagnosed based on anthropometric and biological data, and by multi-factorial indices of nutritional risk. Screening adapted to each of the four main classes of hospital care, acute medicine and surgery, intensive care, geriatrics and paediatrics needs to be systematically performed for every inpatient. To make malnutrition screening a natural part of the practice of care, we need to design training courses, which highlight the benefits in terms of length of stay, morbi-mortality and cost.     

Asthme du petit enfant : facteurs prédictifs de sévérité et de persistance Analyse de 180 observations

Background : Asthma is the most common chronic disease in infants. In young children, asthma still raises many questions and many points are still being debated. Aim : The aim of this study is to identifies, in asthmatic children, factors predictors of severity and persistence of symptoms. Methods: A retrospective study of asthmatic infants<3 years enrolled in the pediatric department of Sfax over a period of 5 years (2007-2011). We were interested to social and environmental factors, the allergic background, clinical severity of the disease, results of allergic skin tests, treatment and respiratory outcome.Results: We collected 180 children with a sex ratio of 2.2. Family history of atopy and exposition to passive tobacco were noted in 45 % and 52% of cases respectively. The mean age of onset of wheezing was 6.6 months. Skin tests were positives in 32% of cases. At the time of diagnosis, asthma was classified intermittent (21%), mild to moderate (55.6%) and severe (22.2%). Inhaled corticosteroids was initiated in 142 infants (78.8%). Skin tests performed in 84 patients, were positive in 32%. Factors associated with severe asthma were passive smoking, early age of onset, number of hospitalizations for exacerbation and existence of an aggravating factor.Factors predictors of persistence were an early age of onset, caesarean delivery, passive smoking and positive skin tests. Conclusion : Factors associated with persistence of asthma at the individual level remains uncertain. However, atopy and passive smoking are major indicators.     

Synthèse et étude préliminaire de l'activité psychotrope d'alkylamino et iminopyrrolo[1,2-a]indoles

La synthèse de nouveaux pyrrolo[1,2-a]indoles est décrite. Le test d'habituation révèle in vivo pour certains dérivés une activité psychostimulante non amphétaminique.