Nutritional Disorders in Children

Patient Story

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An 18-month-old female was brought in for evaluation of a pale appearance. She was described as an active toddler with no recent fatigue, melena, or hematochezia. She was described as a picky eater and has averaged 30 to 40 ounces of milk intake per day for the past 6 months. Family history and past medical histories were noncontributory. On exam, height and weight were at the 50th percentile. Examination was normal except for a pale appearance, spooning of her nails (Figure 63-1), mild tachycardia, and a grade II/VI systolic ejection murmur heard best over the left lower sternal border. Labs were significant for the following: Hgb 7.0 g/dl, Hct 21.0 percent, MCV 52 fL, RDW 18 percent, reticulocyte count 1.9 percent, total iron 10 ug/dL (30 to 140 ug/dL), transferrin saturation 9 percent (11 to 46%), and ferritin 16 ng/mL (18–300 ng/mL). Peripheral smear showed microcytosis, hypochromia, mild anisocytosis, and polychromasia.

FIGURE 63-1

Koilonychia due to iron deficiency. (Used with permission from Rudolph CD, Rudolph AM, Lister GE, First LR, Gershon AA: Rudolph’s Pediatrics, 22nd edition: www.accesspediatrics.com.)

She was diagnosed with iron deficiency anemia and started on oral iron with concomitant reductions in her daily consumption of milk to no more than 18 to 20 ounces a day. At follow-up appointment one month later, she looked well and her appetite had improved with consumption of a wider variety of foods. Repeat Hgb was 9.5 g/dL and her MCV 69 fL. Three months later, her hemoglobin had completely normalized.

Introduction

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Nutritional disorders in children include both deficiency and excess states. Protein energy malnutrition remains one of the leading causes of death in children in underdeveloped countries. Obesity has emerged as one of the most common nutritional disorders in children worldwide. Children who have a body mass index (BMI) in the 85th to 94th sex- and age-specific percentile are considered overweight. Those with a BMI at or above the 95th percentile are considered obese.

Epidemiology

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  • Severe protein-energy malnutrition is uncommon in the US and other developed countries.

  • Childhood obesity rates have risen steadily, with current global estimates at approximately 17 percent, disproportionately affecting minority youth. Overweight and obesity are now on the rise in low- and middle-income countries, particularly in urban settings. Almost 35 million overweight children live in developing countries and 8 million in developed countries.

  • Overweight and obesity are linked to more deaths worldwide than malnutrition.

Etiology and Pathophysiology

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  • Nutritional deficiency states may occur as a result of poor dietary intake, increased nutrient loss, or increased nutrient and energy requirements as seen in patients with chronic illness.

  • The small intestine is the predominant site of absorption of nutrients from the gastrointestinal tract. Any disease that interrupts bile flow, digestive enzyme excretion, or small bowel mucosal integrity, may result in a variety of nutritional deficiencies (Table 63-1).

  • Deficiencies in fat soluble vitamins (A, D, E, and K) can be seen in patients with poor oral intake and diseases that cause malabsorption including pancreatic disorders and cholestatic liver disease. Vitamin D deficiency can also result from lack of sun exposure.1

  • Iron deficiency is the most common nutritional deficiency in childhood. It can be seen secondary to poor oral intake, poor absorption, and in cases of chronic blood loss.

  • Vitamin B1 (thiamin) is found in milk, meats, eggs, legumes, and fruits. Deficiency results from inadequate intake or poor absorption due to intestinal or liver disease.

  • Vitamin B2 (riboflavin) deficiency is seen in patients on long term barbiturates, disorders of intestinal malabsorption, and in patients who avoid dairy products which are a good source of this vitamin.

  • Vitamin B3 (niacin) deficiency is seen in patients with carcinoid syndrome and Hartnup disease (autosomal recessive disorder of tryptophan metabolism). It is also seen with prolonged use of certain medications such as isoniazid, azathioprine, and phenobarbital.2

  • Vitamin B6 (pyridoxine) deficiency is uncommon. Low levels of pyridoxal phosphate can be seen in patients with chronic illnesses such as diabetes, asthma, and sickle cell anemia.

  • Vitamin B9 (folic acid) is essential to numerous bodily functions including DNA synthesis and repair as well as to act as a cofactor in certain biological reactions. It is especially important in aiding rapid cell division and growth, and is required to produce healthy red blood cells and prevent anemia. Lack of adequate intake leads to folate deficiency, which is now uncommon.

  • Vitamin B12 is bound to intrinsic factor in the stomach and is absorbed primarily in the terminal ileum. Deficiency typically results from inadequate intake (vegan mothers and in their breast fed infants), surgery involving the stomach or terminal ileum, or lack of excretion of intrinsic factor in the stomach (pernicious anemia).

  • Vitamin C (ascorbic acid) deficiency occurs in severely malnourished patients and in those who consume a diet devoid of fruits and vegetables. Deficiency leads to impaired collagen and chondroitin sulfate formation. The tendency to hemorrhage, presence of defective tooth dentin, and loosening of teeth caused by deficient collagen is known as scurvy.

  • Copper deficiency can be seen in patients after gastric bypass surgery and also in those with malabsorption such as patients with untreated celiac disease. Premature infants receiving milk without adequate copper supplementation and those on long-term total parenteral nutrition (TPN) can also develop copper deficiency.

  • Zinc deficiency can occur in patients with pancreatic insufficiency (pancreatic enzymes are needed for the release of dietary zinc), chronic inflammatory diseases and those on long term total parenteral nutrition (TPN). Acrodermatitis enteropathica results in zinc deficiency due to malabsorption.3

  • Selenium deficiency is rare, but can occur in patients receiving long-term parenteral nutrition without supplementation.4

  • Nutrient toxicity states are more commonly seen with fat soluble vitamins as well as minerals and are due to excess ingestion or administration.

  • The causes of obesity can be attributed to both genetic and environmental factors.5 The most common cause is overconsumption of calories as compared to amount of calories used.

TABLE 63-1Possible Nutritional Deficiencies in Gastrointestinal Disease

Risk Factors For Nutritional Deficiency States

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  • Poor nutritional intake.

  • Low socioeconomic status.

  • Patients on long-term TPN.

  • Malabsorption syndromes and chronic disorders (Table 63-1).

Risk Factors For Nutritional Toxicity States and Obesity

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  • Excessive intake.

  • Sedentary lifestyle.

Diagnosis

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Clinical Features
  • The clinical manifestations of malnutrition and overweight/obesity can be assessed using anthropometric measurements (standardized growth charts), specific physical examination findings, and confirmatory laboratory measurements.

  • Common clinical features of nutrient deficiency and excess states are listed in Tables 63-2 and 63-3.

  • Iron deficiency leading to anemia is the most prevalent mineral deficiency in children. Chronic deficiency may lead to spooning and pallor of the nail beds (Figure 63-1).

  • Vitamin A deficiency presents with night blindness (earliest symptom), xerosis (dry eyes), and the development of Bitot’s spot—triangular areas of abnormal squamous cell proliferation and keratinization of the conjunctiva (Figure 63-2).6

  • Vitamin B1 (Thiamin) is classically associated with symptoms of cardiac dysfunction (cardiomyopathy) along with neurological symptoms, which may include polyneuropathy and seizures. Wernicke-Korsakoff syndrome (characterized by a triad of nystagmus, ophthalmoplegia, and ataxia) is only rarely seen in the pediatric age group.

  • Vitamin B2 (Riboflavin) deficiency is characterized by angular stomatitis, glossitis and seborrheic dermatitis (Figure 63-3).

  • Zinc deficiency is characterized by perioral and perianal dermatitis (Figure 63-4). Other clinical manifestations include an increased susceptibility to infections, diarrhea, and growth failure.

  • Obese children should be carefully evaluated for hypertension. Other commonly associated signs include hepatomegaly from fatty liver disease and acanthosis nigricans (associated with insulin resistance). Signs of possible reversible causes of obesity should also be sought including deep purple striae and the “buffalo hump” of Cushing’s syndrome (a rare secondary cause of obesity).

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Dec 31, 2018 | Posted by in PEDIATRICS | Comments Off on Nutritional Disorders in Children

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