蛋白質(zhì)能量營(yíng)養(yǎng)不良

蛋白質(zhì)——能量營(yíng)養(yǎng)不良

（Protein-EnergyMalnutrition,PEM）

AssProf.WangBinDeptofPediatricsZhujiangHospital,SMUe-mail:wangbin6556@126.com基本內(nèi)容基本概念

病因病理生理病理

臨床表現(xiàn)及分類：分類、度、型診斷

治療

basicconceptofPEMInabbreviation:malnutritionChronicdeficiencydiseasecausedbyshortageofenergyand/orproteinsupply.Usually<3y，character:BW→OR↓、wastingoredema、subcutaneousfat↓ORdisappear，accompanywithvariousdegreesoforganfailureandmetabolicdisorders.Termsanddefinition低體重（under-weight）：<meanBW-2SDofthesameage,samesex;OR<BWinthe3dpercentile消瘦（wasting）：<STATURALBW-2SDofthesameage,samesex;OR<STATURALBWinthe3dpercentile生長(zhǎng)遲緩（stunting)：<meanBL-2SDofthesameage,samesex;OR<BLinthe3dpercentile病因improperfeeding：breastmilkinsufficient、dietarybias、quantitynotsufficientdiseases

：diarrhea、intestinalabsorptiondisorder、infection、tumor、nephroticsyndromeCongenital：multiplets、prematurebirth、maternalmalnutriton，malformationofGI、harelip唇裂、cleftpalat腭裂pathophysiology

（一）metabolismdisorders

proteinmetabolismdisorders：ALB↓，globulin↓

、lowproteinedema.Glycometabolismdisorders：hypoglycemia/asymptomic，，glucogen↓，glucosetolerance↓

fatmetabolismdisorders：chol↓，甘油三酯積累→adiposishepaticawater-electrolytemetabolismdisorders：bodyfluid↑，hypotonic，Na+↓，K+↓、Ca↓，acidosis、Mg↓、2n↓、Fe↓

Thermoregulationdisorders：hypothermiaa.heatproduction↓b.heatradiation↑

pathophysiology

（二）organfailure

digestivefunction↓：digestiveenzyme↓、movement↓、dysbacteria菌群失調(diào)→digest↓tolerance↓→diarrheacirculationsystem↓：myocardialcontractility↓→cardiacoutput↓、BP↓、

glomerulus及renaltubule功能↓：creatinine

↑、diuresis多尿、低比重hypobaric尿

centralnervoussysteminhibition

immunity↓：非特異免疫↓—

皮膚屏障↓、WBC功能↓、補(bǔ)體↓、Ig↓、IgG2及IgG4缺陷、淋巴細(xì)胞↓、NK↓、APCC↓

特異免疫↓—

免疫反應(yīng)↓Pathology

mild：onlysubcutaneousfat↓、slightlyatrophiaofmusclesevere：organsdiminution，butliver,spleen,heart,kidneymayenlarge↑

PEM

manifestation

（一）overview

①nogainorloseofbodyweight：first②bodyheight↓：chronical③subcutaneousfatdecreaseordisappear：thesequenceabdoman→trunk→buttocks→extremities→cheeks

④wastingandedema

⑤disordersoforganfunctionandmetabolism:皮膚、肌肉、神經(jīng)、胃腸、體溫

SkinchangesDrypeelingskinwithrawexposedareasHyperpigmentedplaquesoverareasoftraumaNailchanges:Nailsbecomefissuredorridged.

Hairchanges:Hairisthin,sparse,brittle,easilypulledout,andturnsadullbrownorreddishcolor

OralchangesCheilosisAngularstomatitisPapillaratrophy

PEM

manifestation

(二）classification(<5yrs):typeanddegree低體重（under-weight）：<meanBW-2SDofthesameage,samesex;OR<BWinthe3dpercentile消瘦（wasting）：<STATURALBW-2SDofthesameage,samesex;OR<STATURALBWinthe3dpercentile生長(zhǎng)遲緩（stunting)：<meanBL-2SDofthesameage,samesex;OR<BLinthe3dpercentile<-3SD;-3SD<BW<-2SD;<-2SD

PEM

臨床表現(xiàn)

（三）嬰幼兒PEM的Gomer分度

Ⅰ度（輕）Ⅱ度（中）Ⅲ度（重）體重↓15-25%25-40%40%以上身長(zhǎng)尚正常稍↓明顯↓腹部皮下脂肪0.8-0.4cm0.4cm以下消失消瘦不明顯明顯皮包骨樣，老人貌皮膚尚正常稍蒼白、干燥蒼白、干皺、彈性消失肌張力基本正常↓，肌肉松馳明顯↓，肌肉萎縮神經(jīng)精神欠活潑易疲勞，多哭鬧、萎靡呆滯、反應(yīng)↓、抑制與煩躁交替食欲稍↓↓無(wú)PEMcomplicationnutritionalanemia：Hb↓、Fe↓、B12↓，vitamindeficiency：VitA(mostcommon)

InfectionTraceelementsdeficiency:Zn↓

spontaneoushypoglycemiaDiagnosis

highlight：①age+history②manifestation+measurement

③Lab：ALB↓

、RBP視黃醇結(jié)合蛋白↓、前白蛋白↓、TBP甲狀腺素結(jié)合蛋白↓、transferrin轉(zhuǎn)鐵蛋白↓、IGF-1↓、immunization↓、Chol↓、enzymes↓（diastase淀粉酶、lipidase脂肪酶、transaminase轉(zhuǎn)氨酶、alkalinephosphatase）④etiologicaldiagnosis⑤degree

notice：①NOTallunderweightorwastingsarePEM②PEMwithedemabutwithoutkidneypblisofseveredegreeTreatmentLiferiskyfactors：supportingandbalanceinternalenvironment–acidosis,shock,hypoglycemiaOriginaldiseasestreatment

RegulatedietNutritionsupplementDigestivefunctionaids

調(diào)整飲食原則①根據(jù)程度、消化能力、耐受性逐步調(diào)整②以實(shí)際體重或現(xiàn)有身高的標(biāo)準(zhǔn)體重計(jì)算熱量與營(yíng)養(yǎng)素③食物應(yīng)富含高熱量、優(yōu)質(zhì)蛋白、并補(bǔ)充補(bǔ)生素及微量元素④重度營(yíng)養(yǎng)不良定時(shí)喂糖水，以防發(fā)生低血糖⑤注意避免誘發(fā)腹瀉、感染→惡性循環(huán)

調(diào)整飲食方法Ⅰ°PEM：開始100-120Kcal/kg/d、蛋白3.0g/k/d→逐步增加→140-150Kcal/kg/d→蛋白3.4-4.5g/kg/d、脂肪1.8g/kg/d→正常水平

Ⅱ°PEM：開始60-80Kcal/kg/d、蛋白2.0g/kg/d脂肪1.8g/kg/d→以后按I°PEM給

III°PEM：開始40-60Kcal/kg.d、蛋白1.3-1.5g/kg.d、脂肪0.4g/kg/d→基礎(chǔ)代謝→增至60-80Kcal/kg/d后按II°PEM給

預(yù)防宣傳合理喂養(yǎng)及營(yíng)養(yǎng)知識(shí)培養(yǎng)良好的飲食習(xí)慣及生活習(xí)慣推廣生長(zhǎng)發(fā)育監(jiān)測(cè)，盡早發(fā)現(xiàn)輕癥病人積極治療各種原發(fā)的急、慢性疾病

及時(shí)矯正先天性消化道畸形

預(yù)后時(shí)間越長(zhǎng)，影響越大，生長(zhǎng)發(fā)育↓

→智力↓，可能永久性

輕-中預(yù)后好，重度病死率也↓，但致殘率仍高發(fā)生時(shí)間越早，遠(yuǎn)期影響越大

思考題？一

.營(yíng)養(yǎng)不良的最初癥狀是：

A消瘦

B體重不增或體重下降

C面部皮下脂肪減少

D蒼白

E煩躁不安二.營(yíng)養(yǎng)不良患兒皮下脂肪消減的順序是：

A軀干、臀部、四肢→腹部→面頰