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26МЕДИЦИНСКИЕ НАУКИ
INFANTILE CEREBRAL PALSY: PROTEIN-ENERGY INSUFFICIENCY AND ITS DIAGNOSIS Mavlyanova Z.F.
Mavlyanova Zilola Farkhadovna - Candidate of Medical Sciences, Associate Professor, DEPARTMENT OF PHYSICAL REHABILITATION AND SPORTS MEDICINE, SAMARKAND STATE MEDICAL INSTITUTE, SAMARKAND, REPUBLIC OF UZBEKISTAN
Abstract: the article presents data on a complex assessment of the degree of protein-energy malnutrition (PEM) of 50 patients with cerebral palsy, taking into account clinical and laboratory parameters based on the Bilbreri-Cohen method, which includes the determination of the following indicators: subjective global assessment, determination of body mass index, skin and fat thickness folds over the triceps, circumference of the muscles of the shoulder, the concentration of blood serum albumin, the absolute number of lymphocytes in the peripheral blood.
Keywords: children, infantile cerebral palsy, protein-energy malnutrition, anthropometric parameters.
Relevance. Infantile cerebral palsy develops with a frequency of 2-3.6 per 1000 alive newborns and is the main cause of children neurological disability in the world. Among premature infants, the frequency of cerebral palsy is 1% [1, 2, 4].
Children with cerebral palsy have muscle spasticity or severe atony, hyperkinesis, problems with chewing and food swallowing, pseudobulbar syndrome and bulbar disorders, gastroesophageal reflux disease, reduced physical activity, concomitant diseases lead to the rapid progression of macro- and micronutrient insufficiency. In addition, children with cerebral palsy are characterized by an increase in energy expenditure associated with energy exchange defect and insufficient regulation of the functions of the autonomic nervous system [5,6,7,8,10].
As K. L. Bell and P. S. Davies (2003) indicate, children with cerebral palsy are more likely to have changes in body composition, they turn out to be lower in height and have less body weight than their healthy peers. Evident disorders of nutritional status (malnutirition) in the absence of their appropriate adequate correction can cause disorders by immune and endocrine systems, lead to neuromuscular dysfunction and cognitive disorders.
Taking into account a number of facts:
1) an adequate method of assessing the patient 's body composition is to measure the thickness of the skin-fat fold above the triceps, the circumference of the shoulder and the circumference of the shoulder muscles. These indicators correlate with sufficient accuracy with total peripheral protein reserves and body fat reserves [9];
2) the main markers of patient 's protein status are transport proteins synthesized by liver, including albumin [3];
3) the state of immunity directly and directly depends on its protein-energy capabilities [3], and the calculation of the absolute number of lymphocytes (ANL) of blood is the simplest method of assessing the state of the immune system, allowing to carry out a complex assessment of trophic disorders, etc., our cohort of patients with cerebral palsy, the technique of Bilbreri-Cohen ball assessment was used.
The aim of the study: Assess the extent of protein-energy malnutrition (PEM) in patients with infantile cerebral palsy.
Material and methods of research. On the basis of the Department of Children's Neurology of 1st Clinic of Samarkand State Medical Institute and the Department of Children's Neurology of Samarkand Regional Children's Multidisciplinary Medical Center
from 2015 till 2019 50 children were examined with cerebral palsy diagnosis between the ages of 3 to 15 who made up the main group. The control group included 20 healthy children between the ages of 3 to 15 examined in Samarkand family polyclinic No. 3. Clinical observation groups were comparable in age and gender.
The degree of expression of protein-energy malnutrition (PEM) was determined on the basis of the study of clinical, anthropometric (body weight and length, shoulder circumference, thickness of skin-fat fold above triceps) and laboratory indicators (absolute number of blood lymphocytes and albumin content) results. Children were examined regularly, once every 3 months for 5 years
Results and discussion. For objective assessment of protein-energy status, Bilbreri-Cohen method was used, which includes determination of the following parameters: subjective global assessment, determination of body weight index, thickness of skin-fat fold above triceps, circumference of shoulder muscles, concentration of blood serum albumin, absolute number of lymphocytes in peripheral blood. In the absence of deviations from the age norm, the indicator from the given set was estimated to be 0 points, in light, medium and severe changes the indicator was assigned from 1 to 3 points. The total rating by six parameters in 0-1 point was interpreted as normal state of power supply, 2-6 points - light degree of PEM, 7-12 points - medium degree of PEM, 13-18 points - heavy degree of PEM (Figure 1).
Fig. 1. Degrees of protein-energy malnutrition
Loss of weight; anorexia; loss of subcutaneous cellulose; loss of muscle mass - the main parameters of subjective global assessment, estimated from 0 to 7 points. The arithmetic addition of 4 numbers was eventually the index of the subjective global estimate. On the basis of the SGA index, the assessment of protein-energy malnutrition (PEM) was carried out: absence of malnutrition (1-6) - 0 points; mild malnutrition (7-13) - 1 point; moderate reduction of nutrition (14-20) - 2 points; an evident reduction of nutrition (21 and more) - 3 points.
Since the relation of body weight to height is a more accurate indicator of the risk of developing PEM, the body mass index (BMI) was estimated by Quetelet (Yuryeva V.V., 2009): I = mass (kg) / [height (m)] 2. At BMI of less than 18.5 kg / m2 revealed malnutrition. The total score for malnutrition was as follows: absence of malnutrition (26th - 75th percentile) - 0 points; mild malnutrition (25th - 10th percentile) - 1 point, a moderate decrease in nutrition (9th - 5th percentile) - 2 points, evident nutrition decrease (below the 5th percentile) - 3 points
Measurement of the skin-fat fold thickness above the triceps (SFFTh, mm) was carried out at the level of the middle third of the shoulder by an electronic caliper. The results were then evaluated by percentile tables: no malnutrition (26th - 75th percentile) - 0 points; mild
malnutrition (25th - 10th percentile) - 1 point; moderate nutritional reduction (9th - 5th percentile) - 2 points; evident nutrition reduction (below 5 percentile) - 3 points.
Measurement of the circumference of the shoulder (CSh, mm) was carried out with a standard centimeter tape at the level of the middle third of the shoulder. The index of the circumference of the shoulder muscles (CShM, mm) was calculated by the formula: CShM = CSh - 0.314 x ThSF, where CSh is the circumference of the muscles of the shoulder (mm), ThSF is the thickness of the skin-fat fold over the triceps (mm). Then the CShM indicator was also interpreted according to percentile tables as follows: absence of malnutrition (26th - 75th percentile) - 0 points; mild malnutrition (25th - 10th percentile) - 1 point; moderate decrease in nutrition (9th - 5th percentile) - 2 points; marked reduction in nutrition (below the 5th percentile) - 3 points.
The calculation of ANL was carried out according to the formula ANL = lymphocytes (%) x the number of leukocytes (109 / L) / 100. The results were interpreted as follows: the absence of malnutrition (1.8 x 109 / L) - 0 points; mild malnutrition (1.79-1.5 x 109 / l) - 1 point; moderate reduction in nutrition (1.49-0.9 x 109 / l) - 2 points; evident decrease in nutrition (below 0.9 x 109 / l) - 3 points.
Serum blood albumin was evaluated as follows: mild malnutrition (35-30 g / l) -1 point; moderate reduction in nutrition (30-25 g / l) - 2 points; evident reduction in nutrition (below 25 g / l) -3 points.
As a result of the systematization of indicators reflecting the main positions of the protein-energy status: subjective data on the nutritional status (nutrition diary, SGA), anthropometric indicators (BMI, CShM, SFFTh), blood albumin assessment, the presence of immunodeficiency (ANL), the optimal variant of assessing the degree of protein-energetic malnutrition of children with cerebral palsy is formed, which directly depends on the form and severity of the main disease (Figure 2).
diplegia hemiplegia form form Astatic
U PEM is abs. L11 degree U II degree Hill degree
Fig. 2. Relationship between the severity ofprotein-energy malnutrition and the form of cerebral palsy
Due to the fact that the evidence of oral-motor dysfunction correlates with the severity of the disease and delayed motor development during the study, it was found that severe forms of protein-energy malnutrition are characteristic of children with severe motor impairment.
Conclusions. In general, assessing of protein-energy malnutrition is not an easy task for children with cerebral palsy. Growth disorder and development of this category of children has a multifactorial genesis, and therefore, the solution of the issues of the protein-energy assessing status in these patients should be comprehensive. Only a complex solution, taking into account clinical-neurological and anthropometric indicators, laboratory markers, as well as knowledge of the characteristics of physical development, actual nutrition, body composition of children with cerebral palsy will help reflect the real state of the nutritional status of the patient.
The study revealed that 82% of the examined children with infantile cerebral palsy had more or less degree of protein-energy malnutrition resulting from problems with feeding. Almost all children were diagnosed with oral-motor and oral-sensory dysfunctions,
problems of sucking, swallowing were characterized; due to the developmental delay, more
than half of the children constantly needed help from their parents while eating.
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