malnutrition = too much/less nutrtion ⇒ undernutrition OR overnutrtion

WHO: malnutrition = energy-demand missmatch (of nutrients)

1. Primary (↓intake)

→ Behavioral factors (child+parent), social factors, environmental factors

‣
💬
1. “Incorrect preparation of formula (too diluted, too concentrated)
2. Unsuitable feeding habits (food fads, excessive juice)
3. Behavioral problems affecting eating
4. Poverty and food shortages
5. Neglect
6. Disturbed parent-child relationship
7. Mechanical feeding difficulties (or motor dysfunction, congenital anomalies, central nervous system damage, severe reflux)”

2. Secondary
• ↓Intake secondary (anorexia, oral intake restriction, cancer)
• ↑Losses (malabsorption)
‣
💬

• ↑Needs/metabolism (chronic disease (infection+cancer), trauma, hypoxemia)
‣
💬
hypoxemia:

• Defective utilization

(genetic (trisomies) , congenital infections, metabolic disorders (i.e. storage dis.))

Acute <3m ⇒ wasting = ↓weight / height

Chronic >3m ⇒ stuntung = ↓height / age

Acute + chronic ⇒ underweight = ↓weight / age

1. ↓🍗Protein reserveres

→ 💪 Muscle wasting → weakness + skeletal deformities

‣

💬



→ 🧊 Hypothermia (↓metabolic rate)

→ 💦 edema (Kwashiorkor)

‣

💬



→ 💫 ↓wound healing

→ 🧠 neurologic delay

→ 🍑 Hepatomegaly (↓lipoprotein production)

→ 🦷 enamel mottling, delayed eruption

2. ↓🫀CV-capacity
1. ↓❤️ Bradycardia + ↓BP
2. ↓circulation effects: (+ due to loss of micro nutrients i.e. iron + proteins):
• 🐻‍❄️ PALE skin (or hyper-/hypo-pigmented)
• DRYNESS
• 👁️ dry, pale conjunctiva
• 👄 angular stomatitis, cheilitis
3. ↓🫁 capacity
4. ↓🤏🏼Micronutrient:
• 👅 glossitis (b12, iron def.)
• 🥄 spoon-nail + dull sparse hair (iron def anemia, nutrtient, vitamin)

1. 🦠Infections (sepsis , pneumonia, gastroenteritis)
• 🧊Hypothermia (due to infection or ↓metabolic rate)
• ↓🍬 Hypoglycemia (due to sev. fasting or sepsis)
2. ❤️‍🔥 HF (due to bradycardia)
3. ⏰ Developmental (+cognititve) delay → 🧠  + 📈 
4. Kwashiorkor

1. Antropometric measures
1. wasting (weight/height) → acute
2. stunting (height/age) → chronic
3. less clinical significance: weight/age

⇒ SEVERITY for ACUTE malnutrition:

(weight/height = wasting)

z-score <(-3) = severe acute malnutrition

‣

💬

1. Identify Age and Sex:
• Determine the child's age group (0-23 months or 24-59 months) and gender (boy or girl).
• Measure children aged 0-23 months or less than 87 cm in length (lying down).
• Measure children aged 24-59 months or taller than 87 cm in height (standing up).
2. Locate Height/Length:
• Find the figure on the chart that corresponds to the child's length (0-23 months) or height (24-59 months). This is usually located in the left column.
3. Identify Weight Range:
• Move horizontally to the right from the figure you found to locate the weight range that includes the child's weight.
4. Determine Nutritional Status:
• The label at the top of the column containing the weight range will indicate the child's nutritional status.

z-score <(-2)📷 = moderate acute malnutrtion

z-score = (X*-m)/SD; *=height, weight or BMI (⇒ in this case: weight in graph for same age + same height)

2. Look for associated changes
1. ↓Albumin
2. ↓Micronutrients (Iron, zinc, Iodine, Vitamin A, folic acid)
3. ↓Lymphos (Immunodeficiencies)

MODERATE

⇒ ↑ by 25 kcal/kg/day more than daily recommended for age

⇒ food rich in micro-nutrients (iron, zinc, VitA, essential fatty acids)

SEVERE

PHASE 1 - STABILIZATION phase (week 1)

CORRECTION of:

• 🌊 dehydration + acid-base

‣

💬

• 🧂electrolytes (Ca, Mg, K)
• 🦠 infection

PHASE 2 - REHABILITATION phase (week 2-6)

⇒ 🥗 ORAL FEEDINIG: 100kcal/kg/day

→ if <80 kcal/kg/day ⇒ nasogastric tube

‣

💬

⇒ start 🔗 IRON TX

‣

💬

PHASE 3- FOLLOW-UP phase (after week 6)

⇒ 🥗 FEEDING (ad libitum) → to catch up growth

‣

💬

⇒ ⚡ stimulation: emotional + sensory

1. follow up during pregnancy + supplements if needed
2. monitor growth of children
3. promote breastfeeding + adequate feeding
1. timly complementary
2. hygiene
4. correct micronutrtients

→ i.e. give Vitamin A + iron supplements (also to young children)

5. endemic areas: parasites tx + rehydration (if high diarrhea region)

1. 🥇Primary obesity (≥95%)
‣
Whats the ETIOLOGY of primary obesity?
1. Genetic: Parental obesity
2. Hypercaloric diet
3. ↓Physical acitivty → ↑Sedentary behaviour
4. other (Socioeconomic status, maternal factors, infection, sleep deprivation, environment
‣
💬
maternal factors:

2. 2️⃣Secondary obesity (<5%)
1. 🎡 Endocrine
• hypothalamic-pituitary lesion
• Hypothyroidism
• Cushings
• GH deficiency
• hyperinsulinism
2. 💊 Drugs
• steroids
• insulin
• contraceptives
• anti-epiletics + anti-psychotics
3. 🧬 Genetic
• Single gene disorder (i.e. leptin defic.)
• syndromes
• genetic obesity syndromes ⇒ prader-willi
• chromosomal abnormalities ⇒ Down, turner, klinefelter

1. Clinical picture? (fat child)

↓

2. History?

(FH, growth + development, diet, activity, drugs)

↓

3. Anthropometric measurements ⇒ severity? (overweight, obese) (if <2y ⇒ use weight/lenght; >2y ⇒ use BMI / age)

Age Group	Normal	Overweight	Obese	Grades of Obesity
0-2 years (weigh-for length)		≥97th percentile	>99.9th percentile	Risk of overweight: >85th percentile
2-18 years (BMI, percentile)	5 – 84.9th percentile	85 – 94.9th percentile	≥95th percentile	Severe obesity: ≥99th percentile
Adults (BMI, kg/m2)	18.5 – 24.9 BMI	25 – 29.9 BMI	≥30 BMI	Class I: 30 – 34.9, Class II: 35 – 39.9, Class III: ≥40

↓

4. Abdominal vs. generalized obesity? ⇒ risk of complications? (+ etiological hints) (waist + hip circumference & height)

Measurement	Abdominal (Android) Obesity	Generalized (Gynoid) Obesity
Waist Circumference	≥90th percentile	<90th percentile
Waist/Hip Circumference Ratio	≥1.0 in boys, ≥0.8 in girls	<1.0 in boys, <0.8 in girls
Waist/Height Ratio	≥0.5	<0.5
Complications	More common	Less common

↓

1. Etiological workup:
1. primary vs. secondary?

Characteristic	Primary Obesity	Secondary Obesity
Prevalence	≥95% of cases	<5% of cases
Family History of Obesity	Common	Uncommon
Mental Function	Normal	Often mentally impaired
Stature	Tall (usually >50th percentile)	Short (usually <5th percentile)
Physical Examination	Otherwise normal	Associated stigmata
Bone Age	Normal or advanced	Often delayed

*mentally impaired → genetic syndrome?, **stigmata → dysmorphism, hirsutism, abdominal obesity, sexual development, etc.

2. Assoc. symptoms of secondary causes: hypothyroidism, cushing, hyperglycemia
3. Lab:
1. Metabolic profile: lipid, gluc, insulin, liver function
2. depending on etiology:
1. thyroid
2. cortisol levels
3. others

1. 🫀 CV →HT, heart hypertrophy, arrythmias, Ischemia
2. 🧈 metabolic → DM, ↑blood fats
3. 🎡 endocrine → precocious puberty, irregular menses, gynecomastia
4. 🫁 respiratory → obstructive sleep apnea, asthma
5. 💩 GI → GERD
6. 🍑  & 🎋  & 🍤 liver + biliary + pancreas → fatty liver, bile stones, pancreatits
7. 💪 skin → yeast infection
8. 🧠 neuro + psychosocial → HT (pseudotumor cerebri+migraine) + psychological problems

#🥇 NON-PHARMA

1. Diet modifications → Stop light diet plan
‣

💬

Quality	Green Light Foods	Yellow Light Foods	Red Light Foods
Calories	↓	↑	↑↑
Fiber	↑
Fat	↓	↑	↑
Nutrient	↑	↑	↑
Sugar			↑

	Green Light Foods	Yellow Light Foods	Red Light Foods
Types	Fruits, Vegetables	Lean meats, Dairy, Starches, Grains	Fatty meats, Fried foods, Sugar, Sugar-sweetened beverages

	Green Light Foods	Yellow Light Foods	Red Light Foods
Quantity	Unlimited	Limited	Infrequent or Avoided

2. Eating habit modification
‣

💬

“b. Do not eat due to boredom, anger or frustration. c. Do not eat directly from the tray. d. Do not eat fast. e. Do not skip meals. f. Do not eat at fast food restaurants (McDonalds,...).

Recommended: a. The child should eat in a room devoid of amusement. b. The child/adolescent should pay attention to hunger and fullness during a meal. c. Food will be served in small plates (to limit the portion size) and will be cut into small pieces. d. Food will be eaten only at meal times. e. Meals will be served along with other family members. f. All family members should adopt the same healthy eating habits.”

3. Exercise

↓

#🥈: PHARMA → 💊 Orlistat (if >12y !)

‣

💬

OR

BARITRIC SURGERY:

→ if ≥13y + BMI >40 + complications + failed #1 for 6month

1. 👀 early recognition
2. 🥗 Promoting healthy eating pattern
‣
💬
1. “Promotion of breastfeeding for at least the first 6 months of life.
2. Regularly scheduled meals and snacks.
3. Age-appropriate portion sizes for meals and snacks.
4. Healthy food choices (foods with low energy density).
5. Children should never be forced to eat when they are not willing.
6. Children should not be punished during mealtimes with regard to eating.
7. Foods should not be used as rewards.
8. Interactions during meals should be pleasant and happy.”
3. 🏃🏽‍♂️ ↑Physical acitivty

Notes:

• * FGF-23 = fibroblast growth factor-23; effects include ↓ tubular reabsorption of HPO₄²⁻ and ↓ formation of 1,25(OH)₂D.
• ** Effects with pharmacological doses.

↓Ca AND/OR ↓Phosphorus

⇒ deficient mineralization of cartilage including growth plates (rickets) / osteoid (osteomalacia)

1. Calciopenic rickets (secondary ↓Phosphate)
1. Primary calcium deficiency (↓intake)
2. ↓ Vitamin D-related
1. Deficiency (↓intake / ↓sun)
1. Malabsorption (i.e. CF, biliary, celiac)
2. Enzymes (liver + renal)
‣
💬
liver:

kidney:

3. End-organ resistance
2. Phosphopenic ricket (primary ↓Phosphate)
1. Renal loss of phosphate

(i.e. due to genetic, Fanconi, tumor-induced, renal tubular acidosis)

bone biopsy ⇒ but not really used!

genetic + environmental trigger → autoimmune response → production specific antibodies → destruction of pancreatic beta cells → absolute insulin deficiency

HLA-DR3 + -DR4

childhood onset <20y (technically at any age)

bimodal peak: 4-6y and 10-14y

1. acute (infants) - days 🚨 ⇒ severe dehydration!
2. intermediate (#1) - weeks
3. slow (children+teens) - months

T

⇒ 📷

T

Prognosis

1. Treatment within 14d of life → normal intellectual development
2. Treatment after 14d of life → progressive loss of IQ points

1. TSH newborn-screening (before day 14) ⇒ ↑TSH?
2. Genetic counseling in genetic forms

Persistent:

1. Primary: Thyroid patho ⇒ ↑TSH + ↓ T4
1. dysgenesis (ectopia, aplasia, hypoplasia)
2. dyhormogenesis (defective genes for thyroid-proteins involv. in biosynthesis)
2. Secondary: TSH, TRH deficiency/resistance ⇒ ↓TSH + ↓T4

Transient:

1. Maternal cause:
1. Iodine def.
2. Antithyroid-drugs
‣
💬

3. Antibodies (i.e. anti-TSH-Receptor)
2. Idiopathic

male external genital + female internal genital (UTERUS + OVARIES)

⇒ 📷

GH → IGF-1 synth. by liver

• IGF-1 binds to IGF + insulin receptors → cell growth + proliferation, inhibit apoptosis

→ bone, cartilage, skeletal muscles, skin, ST, organs incr. in size

→ impaired glucose tolerance (due to action on Insulin-R)

• incr. secretion of Somatostatin → inhibit [neg. feedback]
• lipolysis

Kidney:

• incr. reabsorption Phosphorus + inc. excretion Ca
• incr. Na + Water reabsorption

1. ❓Idiopathic (congenital or acquired) ⇒ 🥇
2. 🧠CNS
1. congenital malformation
2. acquired: secondary CNS lesions
‣
💬

3. others:
• functional
‣
💬

• Amphetamine Tx
‣
💬

1. ↓Height parameters
• Height <3rd percentile = short stature
• Height velocity/bone age <3rd (if still normal height)/25th(if short) percentile = failure to grow
• ↓Target height
2. Consider DDx: Etiological Dg-workup for short stature

GH def = proportial + ↓height+velocity + ↓bone age

3. Additional clinical findings suggestive for GH deficiency:
• Neonate:
• 🍬↓ - Gluc
• 💀↓ - microcephalus
• 🌼 hepatitis + prolonged jaundice
‣
💬

• Child:
• 🧠 - CNS history (PMH or FH)
‣

💬

“In a child: cranial irradiation, head trauma, central nervous system infection, consanguinity or an affected family member, craniofacial midline abnorma- lities, signs indicative of an intracranial lesion, signs of multiple pituitary hormone deficiencies.”

• 🧄  - multiple pituitary hormone deficiency (Adenoma)
‣

💬

GH deficiency → growth retardation (during childhood) Prolactin deficiency → Ø lactation after delivery FSH/LH deficiency → hypogonadism (hypogonadotropic hypogonadism) TSH deficiency → hypothyroidism ACTH deficiency → adrenal insufficiency

4. Paraclinical workup:
1. Xray → ↓ bone age
2. Lab: ↓IGF (IGF-1 + IGF-BP3)
3. GH stimulation test (2 positive tests)

‣

💬

Two different positive GH stimulatory tests; positive test = GH <10 ng/mL post- stimulation; stimuli: sleep, exercise, clonidine, arginine, insulin, glucagon, L-dopa, propranolol, glucagon, GHRH.