Case 1 The child is 7 months old. Complaints: poor weight and height gain, poor appetite, intermittent vomiting, unstable stool. From the anamnesis: The child from the first pregnancy, the pregnancy was uneventful. Childbirth at 39 weeks, without complications. Birth weight - 3300g, height - 53 cm. Until 3 months, he was breastfed, with 3 months on artificial feeding with an adapted and non-adapted mixture. On examination: Consciousness is clear. Annoying, restless sleep. There is general weakness, a decrease in interest in the environment. The skin is pale, jams in the corners of the mouth. The subcutaneous fat layer is absent on the abdomen, trunk, thinned on the extremities. The skin fold in the navel is 0.4-0.5 cm, the Chulitskaya index is -5 cm. Skin elasticity and tissue turgor are reduced. Actual weight - 6150g, Acting weight - 8200g. Height - 64.5 cm. Muscle tone is reduced. The abdomen is enlarged, swollen. Liver + 2.5 cm. Stool unstable, often liquefied. There is a lag in psychomotor development: does not sit, does not stand on its feet. General blood analysis: Hb -105 g/l, RBC - 3,5 g/l, ЦП-0,8, Ht- 38%, WBC –5,0*109/l, Eosinophil - 2% , NEUT - 58%, MON - 2%, LYMPH- 38%, ESR - 8 mm/h. Ultrasound of the abdominal organs - no structural changes. EchoCG -without features. 1. Formulate and justify the diagnosis 2.What are the exogenous and endogenous causes of this disease? 3. Give diet therapy to this child Case 2 A 5-month-old boy is admitted to the hospital with his mother's complaints of sudden anxiety, a shrill cry with stopping breathing for a few seconds. At the same time, the child turned pale, cold sweat appeared on the face and torso, cyanosis near the mouth. The attack lasted 1 minute, after which was a deep sonorous breath and the child's condition returned to normal. From the anamnesis: The child was born in November, at 36 weeks of gestation, an Apgar score of 6-7 points. It is known that the child is unwanted in the family, there are defects in care. At the age of 4 months, the boy was diagnosed with "Rickets of the II degree of severity, peak period, acute course" and prescribed treatment, but his mother did not follow the doctor's instructions. Objectively: The skin is pale, tissue turgor is reduced. The subcutaneous fat layer is moderately developed. The muscle tone is reduced, the abdomen is spread out, "froglike". The head is square, the frontal and parietal tubercles are pronounced. Baldness and flattening of the occiput, a large fontanel 2.5 * 2.3 cm, the edges of the fontanel are soft, pliable, palpation of the bones of the skull reveals soreness and softening of areas in the occipital bone. The ribcage is pliable, the lower aperture expands, a "Harrison's groove" is formed. Complete blood count: Hb - 102 g / l, RBC - 3.6x1012 / l, WBC - 7.5x109 / l, seg/neut.- 32%, eosis - 2%, lymph - 59%, mon - 7%, ESR - 9
protein energy malnutrition dystrophy infant diagnosis classification diet therapy
IFSO-WGO Obesity Guidelines
Page 210
rickets spasmophilia laryngospasm infant diagnosis treatment
Harrison's Principles of Internal Medicine, Twenty First Edition
Page 1459
Case 1 — 7-Month-Old with Failure to Thrive
1. Diagnosis and Justification
Justification by Criteria:
| Parameter | Finding | Significance |
|---|---|---|
| Actual weight | 6150 g | Expected (norm) ~8200 g |
| Weight deficit | (8200 - 6150) / 8200 × 100% = 25% | 20–30% deficit = Grade II |
| Height | 64.5 cm (norm ~67–68 cm) | Slight height lag |
| Skin fold (umbilicus) | 0.4–0.5 cm | Severely reduced (norm >1.5 cm) |
| Chulitskaya (nutritional) index | −5 cm | Normal is +20 to +25 cm; negative = Grade II–III |
| Subcutaneous fat | Absent on abdomen/trunk, thinned on limbs | Subcutaneous fat depleted in stages: abdomen first, then trunk, then limbs, then face (Grade II = absent on abdomen & trunk) |
- Pale skin, angular cheilitis (jams in corners of mouth) — nutritional deficiency
- Reduced skin elasticity and tissue turgor
- Muscle hypotonia, enlarged/distended abdomen
- Hepatomegaly (+2.5 cm) — reactive or fatty infiltration
- Psychomotor developmental delay (does not sit/stand at 7 months — norm is sitting at 6 months)
- Unstable/liquefied stool — impaired gut function
- Irritability, poor sleep, reduced environmental interest
- Hb 105 g/L (norm >110 g/L for age), RBC 3.5 × 10¹²/L, Color index 0.8 (hypochromic), Ht 38%
- Consistent with iron deficiency anemia secondary to nutritional deficiency and artificial feeding
2. Exogenous and Endogenous Causes
Exogenous Causes (External/Nutritional/Social)
- Quantitative underfeeding — insufficient caloric intake
- Qualitative underfeeding — use of non-adapted (unsuitable) formula from 3 months; non-adapted mixtures lack the correct protein/fat/carbohydrate balance for infants
- Early discontinuation of breastfeeding at 3 months
- Improper preparation of formula (incorrect dilution)
- Infectious causes — recurrent GI infections leading to malabsorption
- Defects in care and feeding regimen — irregular feeding, inadequate hygiene
Endogenous Causes (Child-side/Pathological)
- Malabsorption syndromes — celiac disease, cystic fibrosis (though abdominal ultrasound was normal, functional malabsorption is still possible)
- Congenital anomalies of the GI tract (pyloric stenosis, gastroesophageal reflux)
- Chronic infectious disease (recurrent infections in early life)
- Constitutional/metabolic factors — enzyme deficiencies, lactase deficiency
- CNS pathology — impaired swallowing or sucking reflex
- Premature birth / intrauterine growth restriction (though this child was born at term with normal weight, this is not primary here)
- Immunodeficiency states
3. Diet Therapy
Phase 1: Determination and Minimal Feeding (Days 1–3)
- Calculate required calories based on actual weight first
- Begin with 2/3 of the required volume, using only preferred foods (breast milk or adapted formula — switch immediately from non-adapted to adapted formula)
- Number of feedings: increase to 7–8 feedings/day (every 3 hours) with reduced volume per feed
- Volume on Day 1: ~2/3 of norm → ~560 mL/day
Norm caloric intake at 7 months: 110 kcal/kg/day × actual weight → 110 × 6.15 kg = 676 kcal/day
Phase 2: Cautious Increase (Days 4–7)
- Gradually increase volume daily by 20–30 mL per feeding
- Achieve full volume by day 5–7
- Continue on adapted formula (e.g., NAN, Nutrilon, Similac)
- Introduce complementary feeds appropriate for 7-month-old:
- Vegetable puree (zucchini, cauliflower, potato) — already due at 6 months
- Porridge (rice, buckwheat, corn, gluten-free) — on water or adapted formula
- Meat puree (turkey, rabbit) — begin after stabilization
Phase 3: Enhanced (Reparative) Nutrition
- Calculate calories based on due (proper) weight = 8200 g
- Protein: 3–3.5 g/kg/day (due weight) — use cottage cheese (tvorog), meat
- Calories: 120–130 kcal/kg of actual weight
- Continue vitamin supplementation: A, B-complex, C, D
- Iron supplementation for anemia: elemental iron 3–5 mg/kg/day (e.g., Sorbifer, Maltofer drops)
- Enzyme replacement if malabsorption present: Creon/Pancreatin with meals
- Probiotics to restore gut flora (Lactobacillus, Bifidumbacterin)
Sample Daily Diet at 7 Months (Repair Phase):
| Time | Feeding |
|---|---|
| 06:00 | Adapted formula 180 mL |
| 09:30 | Buckwheat/rice porridge 150 g + adapted formula 50 mL |
| 13:00 | Vegetable puree 150 g + meat puree 30 g + adapted formula |
| 16:30 | Fruit puree 60 g + adapted formula 100 mL |
| 20:00 | Adapted formula 180 mL |
| 23:00 | Adapted formula 180 mL |
Case 2 — 5-Month-Old Boy with Sudden Anxiety, Shrill Cry, Apnea, Cyanosis
1. Diagnosis and Justification
Justification:
- Born in November (winter — minimal UV exposure)
- Premature at 36 weeks (higher risk)
- Apgar 6–7 (perinatal compromise)
- Non-compliant with prescribed treatment
- Unwanted child, defects in care (poor nutrition, likely vitamin D deficiency)
| Finding | Significance |
|---|---|
| Square head, prominent frontal/parietal tubercles | Craniotabes + frontal/parietal bossing = active rickets |
| Large fontanel 2.5 × 2.3 cm, soft/pliable edges | Delayed fontanel closure, bone softening |
| Occipital bone softening and soreness | Craniotabes — classic Grade II rickets |
| Baldness of occiput (alopecia) | Sweating from autonomic dysfunction in rickets |
| "Harrison's groove" | Horizontal depression along costal insertions of diaphragm |
| Flared lower chest aperture | Chest deformity from softened ribs |
| "Frog abdomen" | Muscle hypotonia |
| Reduced tissue turgor, muscle hypotonia | Systemic effect of vitamin D deficiency |
- Sudden onset of anxiety + shrill (crowing) cry
- Apnea for seconds (inspiratory spasm of glottis)
- Pallor, cold sweat
- Perioral cyanosis
- Resolved with a deep sonorous breath — pathognomonic of laryngospasm (inspiratory stridor as spasm breaks)
- Duration ~1 minute, full recovery afterward
- Chvostek's sign — twitching of facial muscles on tapping facial nerve
- Trousseau's sign — carpopedal spasm on arm compression
- Eclampsia (generalized seizures) — most severe form
- Hb 102 g/L — mild anemia (common in rickets due to nutritional deficiency)
- Lymphocytosis (59%) — physiological for age
- No signs of bacterial infection (WBC 7.5 × 10⁹/L, ESR implied normal)
- Serum Ca²⁺ (expected ↓, <1.7–1.8 mmol/L during attack)
- Serum phosphate (↓ in rickets)
- Serum alkaline phosphatase (markedly ↑)
- 25-OH Vitamin D level (↓)
- PTH (↑ secondary hyperparathyroidism)
- Wrist X-ray — "fraying," "cupping," widened metaphyses
- Blood pH/bicarbonate — alkalosis
2. Treatment
Acute Management of Laryngospasm:
- Calm the child, lay on flat surface, ensure airway patency
- Stimulate breathing: irritate mucous membranes (ammonia/cold water to face), press on root of tongue, flick sole of foot
- Calcium gluconate 10% — 0.5–1 mL/kg IV slowly (over 5–10 min) diluted 1:1 with 5% glucose — first-line to terminate spasm (as per Harrison's, p. 1459)
- Oxygen via mask if cyanosis persists
- If laryngospasm does not break: sedation with diazepam 0.5 mg/kg IV/rectal, or phenobarbital
After Attack Stabilizes:
| Treatment | Detail |
|---|---|
| Oral calcium | Calcium gluconate 5% solution, 1 teaspoon 3×/day for 2–3 weeks |
| Vitamin D | After 3–5 days of calcium loading begin Vitamin D₃: 2000–4000 IU/day for rickets Grade II |
| Anticonvulsants | Phenobarbital 5 mg/kg/day if seizures recur, short course |
| Diet correction | Adequate calcium intake, sun exposure |
| Parental education | Compliance with treatment, proper care, nutrition |
Vitamin D Dosing for Rickets Grade II (Acute Course):
- Therapeutic dose: 2000–4000 IU/day × 30–45 days
- Then maintenance: 500–1000 IU/day
- Reassess alkaline phosphatase and 25-OH-D at 1 month
Monitoring:
- Serum Ca²⁺ every 3–5 days during acute phase
- Avoid hypercalcemia (do not exceed 4000 IU/day without monitoring)
- Urine calcium:creatinine ratio to detect hypercalciuria
Summary Table
| Case 1 | Case 2 | |
|---|---|---|
| Diagnosis | Hypotrophia Grade II (PEM), Iron deficiency anemia | Rickets Grade II, peak/acute + Spasmophilia (laryngospasm) |
| Key mechanism | Caloric/protein deficit from non-adapted formula | Vitamin D deficiency → hypocalcemia → neuromuscular hyperexcitability |
| Critical finding | Chulitskaya index −5, weight deficit 25%, absent subcutaneous fat | Laryngospasm = apnea + crowing cry + perioral cyanosis → spontaneous recovery |
| Priority treatment | Switch to adapted formula, phased refeeding, iron supplementation | IV calcium gluconate (acute) → oral Ca²⁺ + Vitamin D₃ (maintenance) |