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.     

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.     

Aspects métaboliques de la dénutrition au cours de la maladie VIH

The Wasting Syndrome (WS) is one of the major aspects of the acquired immunodeficiency syndrome (AIDS). Fat free mass, the amount of functionnal protoplasm in non adipose tissue is an independent predictor of death in AIDS patients.The deficit of the energy balance could be the result of decreased caloric intake and/or increased energy expenditure. Elevated Resting Energy Expenditure (REE) has been reported in the early stage of the HIV infection. Patients with AIDS who had active secondary infection had a striking average weight loss resulting of the combination of anorexia and dramatic elevated REE. The role of cytokines in the WS was proposed in reason of the in vitro and in vivo metabolic disturbances induced by these cytokines. The difference studies suggest that synergistic interactions between cytokines may be necessary for developping the WS.     

Stratégies de dépistage de la dénutrition chez l''enfant hospitalisé

Metabolic stress modifies homeostasis, therefore nutrient's metabolism and nutritional needs. Stress is a risk factor of malnutrition, which increases morbidity and short-term mortality, and, in the child, can threaten long-term growth. Nutritional assessment is difficult in critically ill children. Nutritional support must be undertaken early as possible, especially in malnourished children and with severe agression. Enteral nutrition must be privileged. Parenteral nutrition is indicated when enteral nutrition is impossible, badly supported or insufficient to satisfy needs. Monitoring must be rigorous because aggression increases the risk of metabolic complications.     

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.     

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.     

Place de l'impédancemétrie dans le dépistage de la dénutrition à l'hôpitalBio-impedance analysis: Screening of denutrition in hospitalized patients

The prevalence of malnutrition is high in patients and tends to worsen during the hospital stay. In the absence of one reliable method to evaluate patients, the assessment of nutritional status is based on a global approach. Body composition measurement by bio-impedance analysis (BIA) is one of these approaches. Body composition measurements can detect malnutrition or abnormal hydration. Fat free mass, fat mass, and total body water are the main body compartments that are evaluated. Determination of abnormal body composition can then guide nutritional support. The reliability of BIA depends on the equation used to predict body composition and the parameters included in the formula (weight, height, sex, age, race, etc.). These parameters allow to minimize measurement errors. Thus, formula developed for specific populations allow to evaluate the nutritional status with reasonable error rates. BIA has been found to be inaccurate with abnormal distribution of body compartments (ascites, dialysis, lypodystrophy, etc.) or extreme weights (cachexia, obesity). Multi-frequency or segmental BIA was developed to overcome hydration abnormalities and variations in body geometry. However, these techniques require further validation. The BIA seems to have some limitations. This review aims to assess the reliability of BIA to detect protein-calorie malnutrition at hospital admission or during nutritional follow-up of patients.     

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.     

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.     

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.     

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.     

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.     

Prévalence et conséquences de la dénutrition dans l'insuffisance respiratoire chronique

From large series of patients with COPD, the prevalence of malnutrition can be estimated at 25% taking a cut-off value for Body Mass Index (BMI) less than 20 kg/m², and 35% for a body weight less than 90% of the ideal body weight. Data are very scarce for the other causes of respiratory failure. Malnutrition is a feature of emphysema. There is a well established correlation between height related body weight and FEV1, and TCO: it is not possible to assert that malnutrition is lither a cause or a consequence of the altered respiratory function. Nutritional status is a predictor for the capacity of exercise, independently of the alteration of respiratory function. There is probably a link between malnutrition and the performance of respiratory muscles. The prognostic influence of malnutrition in chronic respiratory failure is well established, with the best survival rates for overweight patients.     

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.     

Manifestations digestives et nutritionnelles des déficits immunitaires congénitaux et acquis chez l'enfant

The gastrointestinal and nutritional impact of congenital immunodeficiencies is varied and non-specific (serious refractory diarrhea, exsudative enteropathy, enterocolitis and chronic infections by Cryptosporidium, Giardia, rotavirus, Candida, etc.). Ulcerative colitis and autoimmune diseases are less frequent. Available therapeutic tools (immunoglobulins, implantable venous accesses and BMT) are reasonably effective. AIDS in children can be either rapidly or slowly progressive, and is usually due to maternofetal transmission. Gastrointestinal lesions are non-specific (candidiasis, chronic malabsorptive diarrhea, hepatitis, cryptosporidiosis, CMV, giardiasis, herpes) and cause overall malnutrition. Early nutritional support is indicated, but the modalities and results remain to be determined.     

Complications hépatiques de la nutrition artificielle chez l'enfant : stratégies thérapeutiques

Parenteral nutrition-associated complications in children can result in the deterioration of hepatic structure and function which ultimately leads to cirrhosis. The frequency and prevalence of these complications are difficult to clarify; moreover, their presentation is polymorphous (lithiasis, steatosis, cholestasis, fibrosis) and nonspecific. Patients at risk need to be clearly identified, since preventive intervention and treatment can slow down the disease's progression. However, when intestinal functions become severely impaired with absolute dependency on parenteral nutrition, intestinal transplantation becomes the sole treatment.