Prise en charge nutritionnelle des troubles du comportement alimentaire chez l'adolescent

This review underlines the importance of a structured nutritional treatment in eating disorders particularly in anorexia nervosa, its physiopathological bases and influence on short and long term prognosis of the disease. Somatic and neuropsychological effects of undernutrition, their consequences in terms of morbidity, mortality and sequelae are underlined. The modalities of refeeding at home and during hospitalisation, the necessity of renutrition to a right target weight, and, after that, the importance to work for maintaining a good nutritional state are indicated. The frequency of relapses (around 50%) is underlined, as well as the importance of "therapeutic alliance" between physicians and families (and, as soon as possible, with anorectic adolescent) and the advantage of a good collaboration between psychiatric and pediatric teams. They discuss more briefly about nutritional aspects of bulimia management. Finally the authors state on their own results about 161 patients followed for more than 4 years of which 144 participate in an evaluation (68% of good, 23.3% of intermediary and 8.7% of bad results) attesting of progress versus an anterior evaluation and best results than 2 other studies, published in 1991 and 2001, with the same tests for evaluation.     

Nutrition et maladie d’Alzheimer

Deterioration of memory function and ultimately establishment of Alzheimer's disease (AD) severely debilitates the affected individual, uncompromisingly decreasing the quality of life of both patients and their caregivers. The global prevalence of cognitive impairment and dementia including Alzheimer's disease is expected to rise significantly in proportion to increased life expectancy. Weight loss is a common problem among patients with AD and is associated with mortality, morbidity, disease progression, and poor quality of life. The aim of this article is: (1) to emphasize the importance of malnutrition in Alzheimer's disease and (2) to review published evidences for the role of nutrition as a risk factor of the disease.     

Évaluation et prise en charge des troubles de la déglutition

Swallowing is a complex phenomenon, allowing per os feeding but with a protection of respiratory tract. Swallowing disorders are frequent, involve liquids, solids or theses two textures, and are mainly caused by neurological or otorhinolaryngological diseases. They may have severe consequences, like an alteration of quality of life for patients or their relatives, an increased risk of aspiration, of malnutrition or dehydration, and finally a possible decrease of survival. Assessment includes careful questioning and physical examination. The reference complementary investigation is videofluoroscopic evaluation. Nutritional assessment is mandatory. Taking care of swallowing disorders in a multidisciplinary manner is recommended, with interventions of physician, speech therapist, dietician, sometimes dentist or surgeon, and needs a strong contribution of the paramedical staff and the patient relatives. Enteral nutrition is recommended when repeated or severe respiratory complications occur, when the nutritional status is altered in spite of feeding enrichment, modulations of textures or use of oral nutritional supplements, or when the meals are too long.     

Stratégies de prise en charge nutritionnelle spécifiques : l'enfant et l'adulte jeune atteints d'un handicap

Handicapped children are at high risk for malnutrition. In this situation nutritional assessment becomes difficult to perform due to musculo-skeletal deformities, patient's collaboration. In any case nutritional indices require simple measures: weight and height. Nutritional care must be presented early to parents in order to start as soon as possible when oral intake does not meet nutritional needs. For the handicapped child, surgery is often a major stress that requires nutritional care before, during and after. Obesity often aggravates the burden of the handicap and does not provide protection against malnutrition. Like in non-handicapped persons nutritional care can improve the outcome and well being of handicapped children.     

Teignes du nourrisson en Tunisie

Objective

The aim of the study was to specify the epidemiological, clinical, and mycological particularities of tinea capitis in infants.

Design

We retrospectively collected data from the files of 245 infants presenting with tinea capitis, followed in the Hedi-Chaker hospital dermatology department and in two mycology laboratories of the Sfax hospital, between January 1995 and December 2006. We collected the epidemiological, clinical, and mycological data for each patient.

Results

We included 137 boys and 108 girls with trichophytic tinea in 62 % of cases and microsporic tinea in 34 % of cases. Trichophyton violaceum and Microsporum canis were identified by culture respectively in 51 and 37 % of cases.

Conclusion

Tinea capitis is frequent observed in our region, Trichophyton violaceum and Microsporum canis are the most frequent mycological agents.     

Nutrition artificielle : utilité ou futilité chez l'enfant en situation palliative

Palliative care are intended to children with life limiting conditions. In France, for the majority of pediatric team, the idea of continuity of cares is essential for the announcement of the diagnosis to the final state. The author describes here different situations according to the initial disease of these children. In all cases, the choices of artificial feeding depend of pluridisciplinary medical teams and their experience, and of family opinion. Ethical consideration must be present in this decision.     

Stratégies de prise en charge nutritionnelle spécifiques : l'enfant en cancérologie

In children with cancer, malnutrition may antedate the diagnosis or be a result of aggressive chemotherapeutic regimens. The prevalence of malnutrition at diagnosis is related to the type of tumour and the extent of the disease, ranging from < 10% in patients with standard-risk acute lymphoblastic leukaemia to 50% in children with advanced neuroblastoma. The pathogenis of the energy imbalance that underlies the development of malnutrition is complex, including increased breakdown of fat and protein as well as energy-consumptive changes in carbohydrate metabolism (Cori cycle). Despite several confounding factors (different definitions of nutritional status and the wide variety of measures used for its assessment), studies have shown decreased tolerance of chemotherapy associated with altered metabolism of antineoplastic drugs, increased infection rates, altered quality of life and possibly poor clinical outcome in malnourished patients. In this article, we review guidelines for the nutritional management of a child with cancer and we purpose an algorithm for nutritional support.     

Prise en charge nutritionnelle périopératoire du patient obèse

Recommendations for perioperative nutrition in obese subjects require considering the following evidences. Obesity has long been falsely considered a risk factor for poor outcomes from a variety of surgical procedures, yet recent studies of critically and chronically ill patients suggest that overweight and obese patients may paradoxically have better outcomes than normal weight patients. Preoperative weight loss should be considered as a risk factor of postoperative complications in obese subjects as in normal weight patients. Obese patients could be malnourished because of vitamin deficiencies and of sarcopenia. The prevalence of vitamin deficiencies in the morbidly obese population prior to surgery is high, especially for vitamins B1, B12, B9, A, C, D and E. Standard of care should include perioperative thiamine replacement, especially in case of prolonged vomiting. Vitamin B12 deficiency could appear fast after gastric or ileal surgery, and iron deficiency is more frequent. Low caloric diet is not recommended in obese subjects before surgery, especially for the elderly, because of the frequent sarcopenia in this population. Energy and protein recommendations are not easy to be determined in obese subjects. Recommended allowance for protein should be defined according of the fat free mass, which is not easy to evaluate in clinical practice. So it is recommended to use a normalized weigh for a theoretic BMI between 25 and 30 kg/m². The loss of muscle mass can be very fast in the postoperative period in these subjects. The nutritional objective of care is to preserve skeletal muscle mass and to enhance the protein balance.     

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.     

La nutrition artificielle en periopératoire chez le patient diabétique

The diabetic patients are at high risk of malnutrition. One recommends seeking specific deficiencies (zinc, selenium, vitamins C and E) for malnourished diabetic patients. For the perioperative cares, one recommends to cover their protein needs and their caloric needs and to accordingly optimize the antidiabetic treatment. One should probably use oral supplements or enteral nutrition products with a low glycemic index. The presence of diabetic gastroparesis can make it difficult or dissuade enteral nutrition. The incidence of gastroparesis justifies gastric residue control, the use of prokinetic, and nutrition in postpyloric site. An equivalent parenteral carbohydrate intake has a hyperglycaemic effect more important than with the oral or enteral way. It is recommended to use an infusion pump in diabetic patients to administer parenteral nutrition. Daily use of lipid emulsions is recommended in this context.     

Dénutrition périnatale : prise en charge nutritionnelle spécifique du nouveau-né

Malnutrition is quite rare in neonates. However perinatal malnutrition occurs in two situations. Fetal malnutrition leading to intra-uterine growth retardation with a birth weight below the lower limit for gestational age. On the other hand a postnatal relative malnutrition ("extra-uterine" growth retardation) which occurs mainly in preterm neonates. Both these situations need specific nutritional care after birth but also during the first years of life as there is probably a relationship between post-natal nutrition and health in adults (Barker hypothesis).     

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.     

Nutrition et vieillissement osseux: L’ostéoporose

Incidence of osteoporosis increases with ageing, and consequences to mortality, morbidity and quality of life are major. Increasing needs of calcium and decreasing « intakes » of vitamin D lead to osteopenia. Other micronutrients deficiences and decreasing proteic intakes participate to this phenomenon. Risk of fracture could be prevent by adapted dietary councelling.     

Nutrition périopératoire chez la personne âgée. Cas particulier de la fracture de l’extrémité supérieure du col du fémur

Emergency surgery is associated with an increase in the risk of malnutrition in the elderly. Thirty to fifty percent of elderly persons admitted to in surgery are malnourished. In patients for which nutritional status is threatened by both the aging process and comorbidities, the surgical intervention represents an additional stress that will induce or worsen malnutrition. Nutritional care must no be delayed. First choice is the oral route, including protein and energy rich nutritional supplements, and must be a part of multidimensional perioperative care It is recommended to reach 30 to 40 kcal tot/kg/day and 1.2 to 1.5 g of proteins/kg/day. It is recommended to prescribe, during the stay in rehabilitation wards after surgery, oral nutritional supplements. This oral supplementation has been shown to be efficacious in malnourished elderly patients: there is weight gain, a lower risk for complications and a lower mortality rate. However, compliance may be reduced in elderly patients with low appetite, especially in case of dementia, or early medical complications. In order to prevent other falls and fractures, it is recommended to look for vitamin D deficiency and to prescribe vitamin D 800–1200 UI/day.     

Conséquences de la dénutrition chez l'enfant et l'adolescent. Mortalité, morbidité, conséquences médicoéconomiques

In the developed countries, the sick children are at risk of protein-energy malnutrition (PEM). Marasmus is the most common form of severe PEM in such children. Its major characteristics are low muscle and fat masses with the presence of marked facial, axillary and inguinal skinfolds. Furthermore the marastic children are irritable and depressed. When the PEM is moderate, which is more frequent, the affected children present a failure to thrive. Severe and moderate PEM have multiple functional consequences on different systems and organs with an impact on mortality, morbidity and costs. In this paper, the functional consequences on the immune system, digestive tract, liver, lung, heart, kidney, skin, bone and brain are passed in review. To end, some comments are done about the particularities of PEM in mental anorexia and obesity.     

Nutrition périopératoire : protocoles de soins

Based on texts written by experts, the objective of this paper is to propose a practical approach to nutrition for clinicians, according to the nutritional status of patients and the evaluation of surgical risk. Any patient with a nutritional grade greater than or equal to 2 should benefit from nutritional support. Indeed, current data confirm that preoperative and early nutritional support in surgery at risk can reduce significantly postoperative morbidity for patients with non-malnourished (immunonutrition in cancer surgery GI), and the morbidity and mortality in malnourished patients (enteral nutrition when possible). A preoperative oral intake is recommended 2 to 3 hours before elective surgery for clear fluids and 6 hours for a light meal. Moreover, a preoperative oral intake of carbohydrates (maltodextrin 12.5%) is recommended (except in diabetic patients). Postoperatively, early oral feeding (within 24 hours) is recommended in the absence of cons to surgery. Glutamine is recommended in case of postoperative complications.     

Nutrition et accident vasculaire cérébral

Nutrition is an important factor to take into account in the management of stroke. Within the framework of primary and secondary prevention, different risk factors are now well known and designed as target, among them numerous nutritional factors like overweight or obesity, diabetes, dyslipidemia. At the opposite, stroke favours troubles of the glycoregulation and is a risk factor of malnutrition. Malnutrition has to be detected and treated because of its negative effects on morbidity and mortality. Dysphagia is one of the main causes of malnutrition, in particular if it do not regress rapidly. In this case, enteral nutrition is indicated and a gastrostomy is preferred if enteral nutrition has to be prolonged. In order to reduce morbidity and mortality, different nutritional interventions are yet to be evaluated.     

Éducation des familles et de l'enfant en nutrition artificielle à domicile

The techniques of artificial nutrition came of age since the seventies (1969 for enteral nutrition and 1973 for parenteral nutrition). Artificial nutrition has considerably modified the outcome of a great number of children with severe digestive tract pathologies or many other disorders making impossible or ineffective oral food administration. There are currently two techniques of artificial nutrition: enteral nutrition (the most physiological using the digestive tract) and parenteral nutrition (by central venous line, more demanding and more complications). Home parenteral and enteral nutrition emerged with new realities: increase in the number of children needing a nutritional assistance, increase in the number of indications and a constant need to make autonomous the child and the family leading to a better quality of life. The best care for these children needs a multidisciplinary approach (physicians, nurses, dieteticians, pharmacists, speech therapist, psychologists…) and a close relation between primary care and hospital. This also requires a significant investment of parents who are sometimes assisted by private nurses. Parents are thus educated with techniques of enteral nutrition and parenteral nutrition: use of the material, training with the care, learning the action to be taken in case of problem. They have thus a role of caregiver: heavy responsibility necessary to the return at home of their child. The educational role of the hospital team thus takes a paramount importance with the aim to provide an optimal home return and the most adequate care by the family.