Childhood Hypotrophy

CHILDHOOD HYPOTROPHY, the general name for those chronic nutritional disorders in children (mainly of early age) which manifest in poor weight gain and in the child's wasting. The concept of H. corresponds to the so-called "disorder of balance" according to the former classification of Finkelstein. The terminology is not fully established. French and some Russian authors use the term hypotrophy of the first or second degree in similar cases, depending on severity; Langstein and others use the term dystrophy (see), although in essence it has a broader meaning. -E T I O L O G Y. Childhood H. is not a disease, but a symptom complex that can develop under the influence of many endogenous and exogenous factors. Endogenous H. includes the so-called constitutional H. (hypotrophia e constitutione), which occurs in children with severe heredity (syphilis, alcoholism, blood relationship, etc.), with various congenital disorders (e.g., athyreosis) or developmental defects (e.g., congenital heart defect), as well as those developing in children with diatheses, premature infants, in short, in constitutionally abnormal children. Exogenous causes are even more diverse. Here, all sorts of diseases of the child play a role - both acute and chronic infections, especially syphilis, tuberculosis, diseases of the respiratory tract, purulent processes, etc. (h. e infectione), as well as non-infectious diseases (h. e morbo). A special role belongs to diseases accompanied by vomiting and diarrhea; the latter particularly often lead to H. No less numerous is the group of H. depending on various defects in feeding^, e alimentatione). This should include cases of complete or partial starvation 1) due to quantitative deficiency of food (for example, absence of milk in the mother, defects in the child preventing sucking, constant vomiting, refusal of the breast in neurotics, etc.) or 2) due to qualitative deficiency (mainly in artificial feeding), e.g., excessive dilution of milk, previously used for artificial feeding due to excessive fear of whole milk, which gave rise to calling this form p. e medico; further - deficiency of fats, carbohydrates, etc., or finally 3) due to unsuitable ratio (correlation) of food elements for a given child. Recently, deficiency of additional substances (vitamins) in food has been given importance, which occurs, for example, with excessive boiling of milk or with insufficient introduction of these substances to the mother or animal giving milk (scurvy). Similarly, other feeding defects can lead to H.: quantitative and qualitative overfeeding (especially with milk), prolonged monotonous diet, etc. The environment surrounding the child, unfavorable hygienic conditions (lack of sun, air, overheating, cooling, accumulation of infections), defects in care, further - drab surroundings, monotony of life, lack of educational influences - all those physical and psychological moments which in total are called hospitalism (see). These reasons play a major role in poorly organized closed institutions for infants. H. is most often caused not by any one of the mentioned reasons, but by their combination (e.g., constitutional anomaly and infection or defects in care and irrational feeding, etc.). H. does not develop equally easily in all children: the individuality of the child and the nature of his constitution (complete, incomplete), age (the hydro-lability characteristic of early age facilitates the development of H.), type of feeding (in artificially fed children, hypotrophy develops more easily) are of great importance here. The general picture of childhood H. can be very diverse, since the main factor causing it itself can give a whole series of symptoms (temperature, skin, nervous system, gastrointestinal tract, etc.). Generally speaking, for H. wasting, poor development of the child is characteristic. Weight increases poorly or even slowly decreases, so that a hypotrophic child always weighs less than normal. Body growth lags to a much lesser extent (mainly in h. e constitutione). The skin becomes pale and dry, loses its elasticity (poor turgor), subcutaneous fat gradually disappears, first on the abdomen, then on the trunk and limbs; on the cheeks and pubis it usually persists for a long time. Due to the reduction of the fat layer, the child loses normal roundness, seems excessively elongated, his skin forms folds on the shoulders and hips, as if it has become too wide. The mucous membranes are pale, in severe cases red and dry. Muscle tone decreases. Changes in internal organs are small. Temperature loses its normal monothermic character, often remains below normal. Appetite is sometimes good, sometimes sharply reduced; stool is sometimes delayed and consists of dry, dark lumps (hungry stool), sometimes abundant, crumbly, very light in color (soapy-fatty stool), or, conversely, liquid, but often quite normal. Vomiting is not characteristic of hypotrophy. The course of H. is very diverse and depends on the one hand on its form, degree and duration, and on the other - on the therapeutic measures applied. In the course of H., the tropholability of the hypotrophic child is usually sharply manifested, as a result of which the achieved weight gain is very easily lost. The child's tolerance to food normal in quantity and quality is reduced, and even to a cautious increase in food, the child may respond with diarrhea, weight stagnation, and in cases bordering on atrophy, even with its fall. On the other hand, hunger is also very harmful for the hypotrophic child, especially - frequent, repeated fasts prescribed for diarrhea. Immunity in H. is reduced, as a result of which infections easily develop, especially purulent (pyoderma, otitis, pyelitis); the development of pneumonia is especially dangerous, as well as diarrhea, which can easily arise from the most insignificant cause. The hypotrophic child is also very sensitive to other harmful factors - poor hygienic conditions, overheating, excessive cooling, etc. Thus, the pathological processes that in some cases are the cause of H., in other cases become its complications, in turn worsening H.; a vicious circle is created. - The prognosis in H. is always doubtful, especially in cases where H., gradually worsening, leads to atrophy. Death usually occurs from complications. However, with timely and appropriate intervention, even severe degrees of H. can be cured. - The pathogenesis of all forms of H. apparently essentially comes down to cellular starvation, resulting from pathologically altered intermediate metabolism, processes of assimilation and dissimilation: in some cases - on the basis of congenital deficiency of metabolic functions (h. e constitutione), in others - on the basis of its perversion under the influence of toxins (h. e infectione) or pathological metabolic products (h. e alimentatione). The mechanism of development of H. under the influence of hospitalism is still insufficiently elucidated. Some authors recently see in the basis of some H. an alimentary-anaphylactic factor (Mouriquand, Weill, Rocaz). As for the particulars of metabolism, its character in H. may also depend on the type of feeding and the cause that caused H. The alimentary form due to overfeeding with milk has been studied in most detail. In these cases, protein metabolism is apparently not disturbed, while fat metabolism somewhat suffers: only 85% of the introduced fat is assimilated (Bahrdt). The salt exchange is more significantly disturbed: the balance of alkalis and alkaline earths is reduced due to increased excretion of the latter through the intestines. It should also be noted the decrease in the strength of digestive juices (reduction of enzymes, also HCl in gastric juice) in H. - P A T H O L O G I C A L - A N A T O M I C A L data almost entirely depend on the cause that led to H.; cases of pure, uncomplicated H. rarely come to the autopsy table. - The diagnosis of hypotrophy often presents great difficulties, often and is impossible if one wants to establish etiology. Here the study of the child's and parents' history and careful observation of the clinical features of the case, supported by appropriate laboratory research, can clarify the matter. Prevention of H. Correct feeding, rational care, observance of hygiene requirements, as well as the fight against hereditary influences (tuberculosis, syphilis, alcoholism, etc.) - these are the foundations of prevention of H. In this respect, open institutions for the protection of motherhood and infancy - nurseries, consultations, playgrounds - play a huge role. Prevention of constitutional H. can be carried out only by carrying out eugenic measures. - T R E A T M E N T. First place is given to attempts to eliminate the causes that led to the development of H.: treatment of infections, elimination of hospitalism influences, etc. With such etiological treatment, the greatest success can be achieved in alimentary H. by rationalizing the child's feeding; for example ' in H. from starvation due to lack of milk in the mother, the number of breast feedings is increased or feeding with both breasts, expressed breast milk, etc. is established, or supplementary food is added; in cases of refusal of the breast in neurotics, it is sometimes necessary to transfer the child to artificial feeding.

In cases of qualitative defects in food, the latter is changed rationally (carbohydrates, fats, vitamins are introduced), and in case of overfeeding with milk-its amount is reduced (by introducing carbohydrates, etc.). Dietotherapy gives success not only in alimentary H., but also in other types. The implementation of dietotherapy for H. is sometimes difficult, since on the one hand, the hypotrophic patient usually needs food of higher caloric value (sometimes up to 200 calories per kg of weight), and on the other hand, his tolerance for large amounts of food is reduced. Here, concentrated mixtures (see) that contain high caloric value in a small volume can be of some benefit. Among them, Schick's double food (lac duplex bovinum), concentrated protein milk, and especially the fatty-flour mixtures of Czerny, Kleinschmidt, and Niemann have proven themselves. Sometimes early introduction of porridge, jelly is useful. Concentrated food is dosed very carefully, starting with small doses and gradually increasing them. In all cases of H., the most beneficial food is breast milk (exclusively or with the addition of milk mixtures, preferably sour), especially in H. with dyspeptic phenomena; in severe cases of H., it is often irreplaceable by anything. Another difficulty in dietotherapy is the very easy occurrence of diarrhea in the hypotrophic patient; here one should be cautious about prescribing repeated hunger pauses (danger of atrophy). In general, in all cases it is necessary to take into account the individual characteristics of the case, avoiding stereotypes. In addition to dietotherapy, great importance is attached to the general hygiene of the child (ventilation of the room, being taken out into the air); in recent years, heliotherapy (Medovikov) and protein therapy (Epstein and others) have begun to be applied.