B GIO DC V O TO B Y T TRNG I HC Y H NI Lấ HONG HNH NGHI TìNH TRạNG DINH DƯỡNG Và THIếU VI CHấT TRẻ DƯớI TUổI BIếNG ĂN ĐếN KHáM TạI KHOA KHáM TƯ VấN DINH DƯỡNG Số VIệN DINH DƯỡNG, Hà NộI, NĂM 2015 LUN VN THC S Y HC H NI 2016 B GIO DC V O TO B Y T TRNG I HC Y H NI Lấ HONG HNH NGHI TìNH TRạNG DINH DƯỡNG Và THIếU VI CHấT TRẻ DƯớI TUổI BIếNG ĂN ĐếN KHáM TạI KHOA KHáM TƯ VấN DINH DƯỡNG Số VIệN DINH DƯỡNG, Hà NộI, NĂM 2015 Chuyờn ngnh: Dinh dng Mó s: 60720303 LUN VN THC S Y HC NGI HNG DN KHOA HC: PGS.TS TRN TH PHC NGUYT TS BS NGUYN TRNG HNG H NI 2016 LI CM N Tụi xin chõn thnh cm n Ban giỏm hiu, Phũng o to Sau i hc, Vin o to Y hc d phũng v Y t cụng cng, B mụn Dinh dng v An Ton Thc Phm, Th vin v cỏc phũng ban Trng i hc Y H Ni, Khoa khỏm t dinh dng s Vin Dinh Dng, B mụn Dinh Dng An Ton Thc Phm v Ban Giỏm Hiu Trng i Hc Y khoa Phm Ngc Thch ó to mi iu kin thun li cho tụi quỏ trỡnh hc tp, ó giỳp tụi tn tỡnh vic nghiờn cu v hon thnh lun Vi lũng bit n chõn thnh v tỡnh cm sõu sc, tụi xin chõn thnh cỏm n Thy Cụ hng dn Phú giỏo s, Tin s Trn Th Phỳc Nguyt v Tin s Nguyn Trng Hng l nhng ngi thy ó ht lũng hng dn nhng kin thc, phng phỏp lun quý bỏu, giỳp v to mi iu kin thun li cho tụi hon thnh lun Vi lũng kớnh trng v bit n sõu sc, tụi xin chõn thnh cỏm n cỏc Thy Cụ hi ng thụng qua cng v chm lun tt nghip Cỏc thy cụ ó cho tụi nhng úng gúp quý bỏu giỳp lun hon thin hn Tụi xin chõn thnh cỏm n Tin s Phm Th Thu Hng Trng khoa Dinh dng lõm sng Vin Dinh Dng Quc Gia v cỏc cng tỏc viờn ti Khoa khỏm t dinh dng ó giỳp nhit tỡnh, to mi iu kin thun li cho tụi quỏ trỡnh thc hin lun Tụi cú c kt qu nh ngy hụm nay, tụi xin by t lũng bit n ti cha m ó sinh thnh v nuụi dng Xin cỏm n nhng ngi thõn gia ỡnh cựng bn bố, ng nghip, ó dnh nhng tỡnh cm quý bỏu, thng xuyờn chia s ng viờn, khớch l tụi sut quỏ trỡnh hc v nghiờn cu Cỏm n cỏc em bnh nhi n khỏm ti Khoa khỏm t dinh dng s 2, nhng ngi ó tỡnh nguyn tham gia nghiờn cu gúp phn vụ cựng quan trng lun ny Tụi xin ghi nhn nhng tỡnh cm v cụng n y H Ni, ngy thỏng nm 2016 Hc viờn Lờ Hong Hnh Nghi LI CAM OAN Tụi l Lờ Hong Hnh Nghi, hc viờn cao hc khoỏ 23 Trng i hc Y H Ni, chuyờn ngnh Dinh dng, xin cam oan: Tụi xin cam oan õy l cụng trỡnh nghiờn cu chớnh tụi thc hin di s hng dn ca PGS TS Trn Th Phỳc Nguyt v TS BS Nguyn Trng Hng Cụng trỡnh ny khụng trựng lp vi bt kỡ nghiờn cu no khỏc ó c cụng b ti Vit Nam Cỏc s liu v thụng tin nghiờn cu l hon ton chớnh xỏc, trung thc v khỏch quan, ó c xỏc nhn v chp thun ca c s ni nghiờn cu Tụi xin hon ton chu trỏch nhim trc phỏp lut v nhng cam kt ny H Ni, ngy thỏng nm 2016 Hc viờn Lờ Hong Hnh Nghi DANH MC CH VIT TT Ch vit tt BMI CN/T CC/T CN/CC DSM í ngha ch vit tt/ Ngha ting Vit Body mass index/ Ch s c th Cõn nng theo tui Chiu cao theo tui Cõn nng theo chiu cao The Diagnostic and Statistical Manual of Mental Disorders/ Cm FTT ICD IMFeD nang thng kờ v chn oỏn cỏc ri lon tõm thn Failure to thrive/ Khụng tng trng International Classification of Disease/ Phõn loi bnh quc t Identification and Management of Feeding Difficulties/ MDI SD SDD TPHCM WHO Xỏc nh v x trớ bing n Mental Development Index/ Ch s phỏt trin tõm thn Standard deviation/ lch chun Suy dinh dng Thnh ph H Chớ Minh World Health Organization/ T chc Y t Th gii MC LC T VN CHNG TNG QUAN 1.1 TNG QUAN V BING N 1.1.1 Khỏi nim v bing n .4 1.1.2 Phõn loi v bing n 1.2 TèNH TRNG DINH DNG CA TR BING N 11 1.2.1 Tỡnh trng dinh dng ca tr bing n trờn th gii v Vit Nam 11 1.2.2 Mt s yu t liờn quan n tỡnh trng dinh dng ca tr bing n 12 1.3 TèNH TRNG THIU VI CHT CA TR BING N .14 1.3.1 Tỡnh trng thiu vi cht ca tr bing n trờn th gii v Vit Nam .14 1.3.2 Mt s yu t liờn quan n tỡnh trng thiu vi cht ca tr bing n 16 CHNG 18 I TNG V PHNG PHP NGHIấN CU .18 2.1 A IM NGHIấN CU THI GIAN NGHIấN CU .18 2.2 I TNG NGHIấN CU 18 2.2.1 Tiờu chun la chn 18 2.2.2 Tiờu chun loi tr 18 Tr nm ngoi tui nghiờn cu 18 2.3 PHNG PHP NGHIấN CU 18 2.3.1 Thit k nghiờn cu 18 2.3.2 C mu Cỏch chn mu 18 2.3.3 Cỏc bin s v ch s nghiờn cu 20 2.3.4 Cỏc tiờu ỏnh giỏ 21 2.3.5 Cụng c v k thut thu thp thụng tin 23 2.3.6 Sai s v cỏc bin phỏp khng ch sai s 25 2.3.7 Nhp v x lý s liu 26 2.4 O C TRONG NGHIấN CU 26 CHNG 28 KT QU NGHIấN CU 28 3.1 C IM CA I TNG NGHIấN CU 28 3.1.1 Phõn b i tng nghiờn cu theo nhúm tui 28 Nhn xột: 28 Trong tng s 466 tr tui t < 60 thỏng c chn oỏn l bing n n khỏm ti Khoa khỏm t dinh dng s 2, Vin Dinh Dng, ch yu l nhúm tr cú tui t 12 - < 24 thỏng l 166 tr, chim 35,6%, tip theo l nhúm tr t - < 12 thỏng l 140 tr, chim 30% Nhúm tr t 24 - < 36 thỏng, nhúm tr 36 - 12 thỏng tui cú t l bing n cao hn nhúm tr < 12 thỏng tui Kt qu ny cng tng ng vi nghiờn cu ca tỏc gi Lờ Th Kim Dung (2013) [8], nghiờn cu trờn 366 tr t 12 36 thỏng tui, ú hai nhúm tui chim t l cao nht l nhúm 12 < 18 thỏng v 18 - < 24 thỏng (41% + 26% = 67%) Nghiờn cu ca tỏc gi o Th Yn Phi 602 tr di 15 tui bing n (2006) [7] thỡ nhúm tui t - 24 thỏng chim t l cao nht l 57,14% Nhúm tui ny bao gm nhúm tui t - < 12 thỏng v t 12 - < 24 thỏng nghiờn cu ca chỳng tụi (35,6% + 30% = 65,6%) Nghiờn cu ca tỏc gi Nguyn Thanh Danh v cng s (1999) [50] 132 tr t 48 thỏng tui bing n thỡ cao nht l la tui 12 - < 24 thỏng (39,4%) cng tng ng vi kt qu ca chỳng tụi .42 T thỏng tui tr lờn, tr c n dm Tr c lm quen vi cỏc loi thc n mi ngoi sa m Giai on t 12 thỏng tui tr lờn l giai on khỏ quan trng i vi tr, õy l giai on tr chuyn t n thc n mn sang thc n thụ, ln cn, tr phi bit nhai thc n Hai giai on chuyn tip ny rt quan trng i vi tr, nu tr khụng c cho n ỳng cỏch, thc n khụng phự hp vi giai on phỏt trin ca tr thỡ cú th dn n tỡnh trng bing n tr Tr s khụng thớch ng c, tr d nụn, nụn úi, sc dn n tr s s n, ỏc cm vi thc n, tr t chi n .42 4.1.2 Gii tớnh 43 Trong nghiờn cu ca chỳng tụi t l tr nam v tr n tng ng nhau, phõn b tng i ng u ú tr trai cú 222 tr, chim 47,6%, tr n cú 244 tr, chim 52,4%, t l gia hai gii l nam : n l : 1,1, ghi nhn bing n xut hin c hai gii 43 Kt qu ny ca chỳng tụi ging vi kt qu ca tỏc gi Lờ Th Kim Dung (2013) [8] (t l nam : n = 1,14 :1) v kt qu ca tỏc gi o Th Yn Phi (2006) [7] (t l nam : n = 1,1 : 1) Kt qu ny cng tng ng vi kt qu ca tỏc gi Nguyn Thanh Danh (1999) [50] (t l nam : n = 1,2 : 1) Nghiờn cu ca tỏc gi Caruth v cng s (2004) [2], nghiờn cu v tỡnh trng n ung ca 3022 tr t 24 thỏng tui trờn ton nc M ghi nhn rng tỡnh trng bing n xut hin c hai gii .43 4.1.3 Ni c trỳ 43 Trong nghiờn cu ca chỳng tụi, tr c ng ti H Ni chim a s, 83,1% So sỏnh vi kt qa nghiờn cu ca tỏc gi o Th Yn Phi v tr bing n n khỏm ti phũng khỏm Trung tõm Dinh dng [7] v nghiờn cu ca tỏc gi Nguyn Thanh Danh ti Trung tõm Phc hi Tr m cụi Suy dinh dng v Trung tõm Dinh dng Tr em [50] phõn b khu vc cú th 54 nguyờn nhõn thng gp l m khụng sa cho tr, hoc tr chm tng cõn, hoc cho tr n trc phũng m i lm Dự vỡ nguyờn nhõn no thỡ vic cho tr n dm sm cng l mt nguyờn nhõn gúp phn lm tng nguy c suy dinh dng, nguy c thiu mỏu thiu km cho tr, vỡ cỏc nghiờn cu ó ch rng: cho tr n dm sm, cho tr n dm trc thỏng tui s lm tng nguy c d ng thc phm tr, tng nguy c ri lon tiờu húa tr v tr s khụng nhn lng sa m theo khuyn ngh Cn cú cỏc gii phỏp truyn thụng giỏo dc dinh dng cho cỏc nhõn viờn y t, cỏc bc cha m v ngi chm súc tr cú s quan tõm ỳng mc v cỏc thiu ht vi cht dinh dng tr bing n ch n ung cng nh cỏc nguyờn nhõn khỏc cú th gõy tỡnh trng thiu vi cht tr Ngoi cng cn cú cỏc chng trỡnh can thip dinh dng cho tr bing n, ci thin tỡnh trng thiu vi cht dinh dng cho tr bing n kp thi tr khụng b ht tng trng, thiu ht phỏt trin chiu cao, cú nh vy mi ci thin c tm vúc ca niờn Vit Nam sau ny, ỏp ng mong mun ca cỏc bc cha m gia ỡnh Nng km huyt thp nht nhúm tr bing n kộn chn thc n l 10,6 3,0 àmol/L Hin nay, thiu km c bit l sc khe cng ng nhiu nc nhng Vit Nam cũn ớt nghiờn cu v tỡnh trng dinh dng ca tr bing n v cha cú nghiờn cu no v tỡnh trng thiu vi cht ca tr bing n Do ú cn cú nhiu nghiờn cu i sõu hn na v tỡnh trng dinh dng v tỡnh trng thiu vi cht tr bing n KT LUN Tỡnh trng dinh dng ca tr bing n di tui ti Khoa khỏm t dinh dng s 2-Vin Dinh Dng nm 2015 - T l suy dinh dng chung tr bing n di tui l 44,2% - Trong tng s 466 tr bing n di tui n khỏm, cú tr tha cõn chim t l l 0,9% 55 - T l suy dinh dng tr n cao hn tr nam c th nh cõn,thp cũi, gy cũm, nhng s khỏc bit khụng cú ý ngha thng kờ - tr bing n di tui, t l suy dinh dng th nh cõn l 18%, t l suy dinh dng th thp cũi l 16,7%, t l suy dinh dng th gy cũm l 9,5% - T l suy dinh dng cao nht nhúm tui t - < 12 thỏng tui, cú 72 tr chim 35% Nhúm tui t 24 - < 36 thỏng tui cú t l suy dinh dng thp nht, t l 10,7%, cú 22 tr - Tỡnh trng tr suy dinh dng th nh cõn, th thp cũi, th gy cũm cao nht nhúm bing n khụng rừ nguyờn nhõn, th nh cõn chim 57,1%, th thp cũi chim 61,5%, th gy cũm chim 63,6%, tng ng cú 48 tr suy dinh dng th nh cõn, 48 tr suy dinh dng th thp cũi v 28 tr suy dinh dng th gy cũm Tỡnh trng thiu vi cht ca tr bing n di tui ti Khoa khỏm t dinh dng s 2-Vin Dinh Dng nm 2015 - T l thiu mỏu ca tr bing n di tui l 47%, t l thiu mỏu hai nhúm tui t - < 12 thỏng v nhúm tui t 12 - < 24 thỏng l cao nht, tng cng chim 63,9% v t l thiu mỏu gim dn theo tui - T l thiu mỏu tr nam l 43,8% v tr n l 56,2% - T l thiu mỏu nhúm phõn loi bing n khụng rừ nguyờn nhõn l cao nht, 56,5% Phõn b thiu mỏu ch yu mc nh, nng hemoglobin trung bỡnh ca cỏc nhúm phõn loi bing n khụng cú s khỏc bit cú ý ngha thng kờ - Tỡnh trng thiu km ca tr bing n di tui l 43,8%, t l thiu km cao nht tr cng hai nhúm tui t - < 12 thỏng tui v t 12 - < 24 thỏng tui, chim 65,6% T l thiu km tr gim dn theo tui - T l thiu km tng ng c hai gii 56 - T l thiu km nhúm phõn loi bing n khụng rừ nguyờn nhõn l ch yu, 57,8% Khụng cú s khỏc bit cú ý ngha thng kờ v nng km huyt gia cỏc nhúm phõn loi bing n 57 KHUYN NGH Tỡnh trng bing n tr em cũn ph bin v cú nh hng n tỡnh trng dinh dng v s tng trng ca tr Do ú, cn cú nhng gii phỏp iu tr bing n phự hp h tr ci thin tỡnh trng dinh dng cho tr, giỳp tr bt kp tng trng, h thp t l suy dinh dng nh cõn, thp cũi, gy cũm y mnh cụng tỏc truyn thụng dinh dng chỳ trng n chm súc n ung cho ph n mang thai, cho tr bỳ m hon ton thỏng u, tip tc cho tr bỳ ti tr c 18 24 thỏng tui, cho tr n b sung hp lý, phỏt trin kinh t h gia ỡnh, gi gỡn v sinh cỏ nhõn v v sinh mụi trng, v sinh an ton thc phm Tip tc thỳc y cỏc chng trỡnh truyn thụng giỏo dc sc khe cỏc bc ph huynh a tr n khỏm bing n sm nhm trỏnh nguy c tr b suy dinh dng, nguy c thiu vi cht dinh dng tr Tỡnh trng bing n gõy nờn tỡnh trng thiu mỏu, thiu km tr T l thiu mỏu, thiu km nhúm tui < 24 thỏng l khỏ cao Do thiu st l nguyờn nhõn ch yu ca thiu mỏu, phũng chng thiu mỏu, thiu km, cn cho tr n cỏc thc phm giu st, giu km, s dng cỏc thc phm tng cng st, km, hoc dựng cỏc ch phm b sung st, km Tip tc thit k cỏc nghiờn cu i sõu hn na v tr bing n, nht l cỏc liờn quan n tõm lý n ung, thiu vi cht, cú th kt hp vi nhiu chuyờn ngnh khỏc nh tõm lý, xột nghim Cn tip tc theo dừi v so sỏnh nng hemoglobin v km huyt cng nh t l thiu mỏu, thiu km gia cỏc nhúm tr cú tỡnh trng dinh dng khỏc TI LIU THAM KHO Chatoor I (2009) Diagnosis and Treatment of Feeding disorders in Infants, Toddlers, and Young Children , ZERO TO THREE, Washington, DC, USA, pp 1-3 Carrruth B.R.,Ziegler P.J., 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3(54)- ph bn), tr 114- 117 PH LC PHIU IU TRA BING N Tụi ó c thụng tin y v nguy c cú th cú v li ớch ca nghiờn cu ny, v ng ý cho tham gia cuc nghiờn cu H tờn thõn nhõn : _Ký tờn : Quan h vi : I Hnh chớnh : Ngy n khỏm: /./ 20 Ln khỏm th: (Nu khỏm li: ghi ngy khỏm ln gn nht, cõn nng, chiu cao ln gn nht: Ngy khỏm ln trc: Cõn nng ln trc (kg): Chiu cao ln trc (cm):) H v tờn tr: Gii: 1.Nam/ 2.N Ngy thỏng nm sinh (dng lch): Cõn nng sinh (kg): Bộ l th my: H v tờn m (hoc ngi trc tip chm súc tr): a ch: in thoi: Ngh nghip ca m: 1.Cỏn b viờn chc 2.Ni tr 3.Nụng nghip 4.Cụng nhõn 5.Kinh doanh 6.Khỏc (ghi rừ): Trỡnh hc ca m:1.Tiu hc 2.Trung hc c s 3.Trung hc ph thụng 0.Bit c,vit/mự ch 4.Trung cp/Cao ng 5.i hc/sau i hc Ngi chm súc tr chớnh nh: 1.M/b 2.ễng b 3.Ngi giỳp vic 4.Khỏc (ghi rừ): Lý a tr n khỏm: Bing n Lý khỏc (ghi rừ) Nu ch lo lng ch bing n thỡ ch cú cỏc du hiu sau khụng? (khoanh hoc nhiu du hiu m ch ang cú): Cõu 1: Cú 1.Bộ t chi n giai on n dm Cõu 2: 1.Bộ n ớt hoc t chi n ang mc bnh Cõu 3: 1.Bộ s hói bit sp phi n 2.Bộ khúc, co ngi hoc t chi m ming c cho n Bộ ó tri qua trc ú mt s c ỏng s kiờn quan n n ung Cõu 4: 1.Bộ kiờn quyt khụng n mt s mún n 2.Bộ khụng n hoc n rt ớt th mún n mi Khụng Cõu 5: 1.Bộ khụng tnh tỏo/ bun ng n 2.Bộ khụng t c cõn nng phự hp vi la tui/ st cõn Bộ khụng mc cỏc bnh lý thc th Cõu 6: Con ch cú bt k triu chng no sau õy khụng? Cú Khụng 1.Bộ cú khú khn hoc au nut 2.B nụn tr 3.B tiờu chy 4.B tỏo bún 5.B au bng 6.St cõn 7.D ng thc n hoc khụng dung np (nờu c th, nu cú): II Tỡnh trng dinh dng Ch s Ngy thỏng nm Cõn nng (kg) Chiu cao (cm) III.Cỏc du hiu lõm sng : Tr bing n ó c bao lõu cha (my tun)? Trc bing n, cú biu hin gỡ khụng? 1.Bỡnh thng 2.Ly/bũ 3.Mc rng 4.Bnh/m 5.Viờm li bn 6.Khỏc (ghi rừ): A.Vit s vo loi Bing n sau õy: 1.Bing n chuyn dng thc n 1.Cú 2.Khụng Tr t chi n thng xut hin vo giai on n dm ca tr, in hỡnh t thỏng n tui Tr t chi n giai on t n mt mỡnh 2.Bing n bnh lý 1.Cú 2.Khụng Tr ớt thy ngon ming (n ớt) hoc t chi n ung liờn quan n vic ang mc bnh hoc sau mc bnh Bing n s n 1.Cú 2.Khụng Tr cú biu hin s hói bit sp phi n, tr chng li vic cho n bng cỏch khúc, co ngi hoc t chi m ming Cú th ó tri qua trc ú mt s c ỏng s liờn quan n n ung 4.Bing n kộn chn thc n 1.Cú 2.Khụng Tr kiờn quyt t chi mt s mún n vỡ mựi v, mn mng, hỡnh thc, thnh phn mún n Tr cú th tr nờn lo lng nu b ộp n cỏc thc phm khụng thớch 5.Bing n khụng rừ nguyờn nhõn 1.Cú 2.Khụng Tr khụng tnh tỏo, n nh lỳc n, tr hoc quỏ bun ng hoc l quỏ kớch ng hoc rt khú chu n Tr khụng t c cõn nng phự hp vi la tui hoc st cõn Khú khn n ung ca tr khụng th gii thớch c bnh lý thc th B.Xột nghim: Km huyt (mcg/l) Hb mỏu (g/L)