Trastornos alimentarios pediátricos con impacto nutricional severo / Pediatric feeding disorders with severe nutritional impact

Las dificultades en la alimentación tienen una prevalencia significativa en niños/as con desarrollo típico y aumentan, significativamente, cuando existen condiciones de salud comórbidas, siendo ésta una de las preocupaciones más frecuentes en la consulta pediátrica. La falta de una detección oportuna puede impactar de forma negativa en la salud integral de las niñeces. El objetivo de este trabajo es describir el abordaje que se realizó en niños/as que presentaron trastornos alimentarios pediátricos con impacto nutricional severo en el contexto de la "Clínica interdisciplinaria de deglución y conducta alimentaria" que funciona en un hospital público en la Ciudad Autónoma de Buenos Aires, Argentina. Se llevó a cabo un estudio de carácter descriptivo y retrospectivo. Se incluyeron en la muestra final a 16 familias. Los niños/as comprendían una franja etaria de 2 a 13 años. Los motivos de internación más prevalentes fueron impotencia funcional de miembros inferiores y alteraciones visuales. Un 93,75% de la población presentaba desafíos en su desarrollo. La edad promedio de aparición de las dificultades en la alimentación fue entre los 12 y 18 meses de edad. Un 56,25% había consultado, anteriormente, con algún profesional de la salud. El 56,25% no contaba con los apoyos terapéuticos adecuados. El 100% tenía dificultades en la conformación de rutinas. Los trastornos alimentarios pediátricos constituyen un fuerte desafío para el equipo de salud. La detección precoz, las intervenciones oportunas y el enfoque centrado en la familia son fundamentales para evitar complicaciones severas y propiciar un vínculo placentero a la hora de comer.

Pediatric feeding disorders (PFD) have a significant prevalence in typical development children and increase drastically when there are comorbilities health conditions. PFD are one of the most frequent concerns in pediatric consultant. The lack of accured detection can negatively impact the comprehensive health of children. The objective of this article is to describe the approach that was carried out in children and adolescents who presented pediatric feeding disorders with severe nutritional impact in the context of the "Interdisciplinary Swallowing and feeding team" that operates in a public hospital in the City from Buenos Aires, Argentina. A descriptive and retrospectivestudy was carried out. 16 families were included in the final sample. The children included an age range of 2 to 13 years. The most prevalentreasons for hospitalization were functional impotence of the lower limbs and visual alterations. 93.75% of the population presented challenges in their development. The average age of onset of feeding difficulties was between 12 and 18 months of age. 56.25% had previously consulted with a health professional. 56.25% did not have adequate therapeutic support. 100% had difficulties in forming routines. Pediatric Feeding Disorders (PFD) constitute a strong challenge for the health team, so awareness and training on this topic is essential. Early detection, timely interventions, and a family-centered approach are essential to avoid severe complications and promote a pleasant mealtime for all

Repercussões da Pandemia de COVID-19 no Tratamento de Pacientes com Anorexia/Bulimia: Revisão de Escopo / Repercussions of the COVID-19 Pandemic on the Treatment of Patients with Anorexia and Bulimia: Scoping Review

A emergência sanitária deflagrada pela pandemia de COVID-19 exigiu que os serviços de saúde especializados na assistência aos Transtornos Alimentares se adaptassem às novas circunstâncias impostas pela necessidade de distanciamento social. Considerando essa perspectiva, delineou-se uma revisão de escopo com objetivo de analisar as estratégias de cuidado adotadas por profissionais da saúde para garantirem a continuidade do atendimento interdisciplinar aos pacientes em tempos de COVID-19. Foram consultadas as bases Web of Science, Scopus, PubMed/MEDLINE, CINAHL, PsycINFO, Embase, LILACS e SciELO entre 2020 e 2022. Identificaram-se 387 registros nas bases de dados, dos quais 11 preencheram os critérios de elegibilidade e foram selecionados. Os resultados foram organizados em três categorias temáticas: (1) a "não escolha" da escolha do formato online: prós e contras; (2) foco na comunicação e acolhimento: ressignificando o uso do dispositivo online; (3) intervenções online: adaptações, inovações e recursos alternativos. As principais estratégias utilizadas durante a transição do tratamento para o ambiente online foram: teleatendimento e psicoterapia online. Apesar de terem sido bem avaliadas, foram percebidas barreiras para superar as limitações do cuidado online, como a desconfiança dos pacientes e seus potenciais efeitos na qualidade do vínculo terapêutico.

The health emergency triggered by the COVID-19 pandemic demanded that health services specialized in treating Eating Disorders adapt to the new circumstances imposed by social distancing. Considering this perspective, a scoping review was designed with the objective of analyzing the care strategies adopted by health professionals to maintain continuity of interdisciplinary care to patients in times of COVID-19. The Web of Science, Scopus, PubMed/MEDLINE, CINAHL, PsycINFO, Embase, LILACS, and SciELO databases were queried. A total of 387 records were identified in the databases, of which 11 met the eligibility criteria and were selected. The results were organized into three thematic categories: (1) the "non-choice" of choosing the online format: pros and cons; (2) focus on communication and welcoming: resignifying the use of the online device; (3) online interventions: adaptations, innovations and alternative resources. The main strategies used during the transition of the treatment to the online environment were: telehealth and online psychotherapy. Although well evaluated, barriers to overcome the limitations of online care were perceived, such as patients' distrust and its potential effects on the quality of the therapeutic bond.

Evolución y tratamiento de los trastornos de la conducta alimentaria en adolescentes: serie de casos / Treatment of eating disorders in adolescents: case series

Los trastornos de la conducta alimentaria son enfermedades de elevada prevalencia en la adolescencia y tienen repercusión en la salud integral. El objetivo fue describir su evolución y tratamiento en un grupo de adolescentes. Se estudiaron adolescentes menores de 18 años con al menos 6 meses de seguimiento y tratados por un equipo interdisciplinario. Se incluyeron 41 adolescentes: 23 presentaron anorexia nerviosa; 9, trastornos alimentarios no especificados; 7, bulimia nerviosa y 2, trastorno por atracones. El 35 % de pacientes con anorexia nerviosa requirió internación por complicaciones de la desnutrición. El 69 % de las pacientes con anorexia nerviosa, el 57 % de quienes tenían bulimia nerviosa y el 78 % de quienes tenían un trastorno alimentario no especificado presentaron remisión total o parcial, y no hubo pacientes fallecidos. La mayoría presentó una evolución favorable con el tratamiento.

Eating disorders are highly prevalent diseases in adolescence and have an impact on overall health. The objective was to describe the evolution and treatment of eating disorders in adolescents. Adolescents under 18 years of age with at least 6 months of follow-up and treated by an interdisciplinary team were studied. Forty one adolescents were included, 23 presented anorexia nervosa, 9 unspecified eating disorders, 7 bulimia nervosa and 2 binge eating disorders. Thirty five percent of patients with anorexia nervosa required hospitalization for complications of malnutrition. Sixty nine percent of the patients with anorexia nervosa, 57 % with bulimia nervosa, and 78 % with unspecified eating disorders had total or partial remission and there were no deceased patients. The majority presented a favorable evolution with the treatment.

El fonoaudiólogo en los trastornos de alimentación Más allá de la alimentación / The speech language pathologist in pediatric feeding disorders Beyond swallowing

Este articulo surge a partir de la necesidad de generar espacios de reflexión sobre el rol del fonoaudiólogo en las dificultades de alimentación infantil. Se debe tener en cuenta que la alimentación es un proceso natural que trasciende a la cultura. En el ámbito pediátrico son cada vez más frecuentes las consultas por dificultades de esta índole. La fonoaudiología, estudia e interviene las alteraciones de la deglución y alimentación en diferentes rangos etarios. Particularmente, en bebés y niños pequeños, estas problemáticas pueden deberse a múltiples condicionantes que alteren o dificulten la seguridad y eficacia deglutoria; como también el confort durante la alimentación. A lo largo del manuscrito se intentan revisar ejes centrales en estrecha relación a este tema que posee múltiples aristas y como parte final en la discusión se aborda la complejidad que plantean los desafíos de la alimentación con especial énfasis en la necesidad del trabajo interdisciplinario. Por lo que se busca como meta final dar a conocer el rol del fonoaudiólogo en los trastornos de alimentación a la comunidad científica a través de un artículo de reflexión

This article arises from the need to generate reflection spaces of the (SLP) speech and language pathology ́s role in pediatric feeding disorders. It should be taken into account that feeding is a natural process that transcends culture. In the pediatric field, consultations for difficulties of this nature are frequent increasingly. SLP assess and rehab feeding and swallowing disorders in all range age. Particularly in babies and young children, these problems may be due to multiple conditions that alter or hinder swallowing safety and efficacy, as well as comfort during feeding. Throughout the manuscript, an attempt is made to review central themes closely related to this topic, which has multiple edges, and as a final part of the discussion, the complexity posed by the challenges of nutrition is addressed with special emphasis on the need for interdisciplinary work. Therefore, the final goal is to make the role of the speech

Acompanhamento fonoaudiológico nas dificuldades alimentares no câncer infanto-juvenil: uma série de casos / Speech therapy follow-up for eating difficulties with juvenile child cancer: a series of cases / Seguimiento fonoaudiológico en las dificultades de alimentación en el cáncer infantojuvenil: una serie de casos

Objetivo: Este estudo teve como objetivo relatar o acompanhamento fonoaudiológico nas dificuldades alimentares no câncer infanto-juvenil. Métodos: O estudo de série de casos retrospectivo e descritivo-qualitativo teve amostra composta por 3 indivíduos com idade variando entre 8 e 14 anos, em acompanhamento com a equipe do Serviço de Oncologia Pediátrica do Hospital da Criança Santo Antônio - Irmandade Santa Casa de Misericórdia de Porto Alegre, com solicitação de avaliação fonoaudiológica para investigação de deglutição/alimentação. A coleta foi realizada por meio de dados extraídos de prontuário eletrônico da instituição, onde constavam as evoluções dos casos dos pacientes internados e atendidos em ambulatório, de março de 2018 a agosto de 2019. Resultados: Nos 3 casos relatados, os pacientes apresentaram deglutição normal, com indicação de via alternativa para alimentação pelo prejuízo na ingestão oral de alimentos durante e/ou após o tratamento oncológico. As queixas alimentares devido aos efeitos colaterais do tratamento foram inapetência, alteração de paladar, náusea e vômitos. Os casos foram acompanhados durante a internação e em ambulatório de fonoaudiologia. Dois dos pacientes permaneceram com a via alternativa por tempo prolongado e um deles reestabeleceu a alimentação por via oral exclusiva. Conclusão: O fonoaudiólogo inserido na equipe multidisciplinar de cuidados ao paciente com câncer infanto-juvenil é um dos responsáveis pelo acompanhamento das dificuldades alimentares provocadas pela doença e tratamentos, com olhar além da disfagia orofaríngea. A sua atuação deve envolver estratégias que promovam a nutrição adequada, seja por via alternativa ou via oral, visando segurança e conforto, com respeito à autonomia do paciente.

Objective: This study was aimed to report speech therapy follow-up for eating difficulties with childhood cancer. Methods: The retrospective and descriptive-qualitative case series study was sampled composed of patients aged between 8 and 14 years, under follow-up with the Pediatric Oncology Service of the Hospital da Criança Santo Antônio - Irmandade Santa Casa de Misericórdia de Porto Alegre, with a request for speech therapy evaluation for swallowing/feeding research. The collection was performed through data extracted from the institution's electronic medical records, with the evolution of the cases of patients hospitalized and attended in an outpatient clinic, from March 2018 to August 2019. Results: In the 3 reported cases, the patients presented normal swallowing, with indication of feeding tubes by impairment in oral food intake during and/or after cancer treatment. The dietary complaints due to the side effects of treatment were inapetence, taste change, nausea and vomiting. The cases were followed during hospitalization and in the speech therapy outpatient clinic. Two of the patients remained on a feeding tube for a long time and one of them reestablished exclusive oral feeding. Conclusion: The speech therapist inserted in the multidisciplinary team of care for patients with childhood cancer is one of those responsible for follow-up of eating difficulties caused by the disease and treatments, with a look beyond oropharyngeal dysphagia. Its performance should involve strategies that promote adequate nutrition, either alternatively or orally, aiming at safety and comfort, with respect to the patient's autonomy.

Objetivo: Este estudio tenía como objetivo de relatar el seguimiento fonoaudiológico en las dificultades de alimentación en el cáncer infantil. Métodos: El estudio retrospectivo y descriptivo-cualitativo de la serie de casos estaba compuesto por 3 individuos de entre 8 y 14 años, bajo seguimiento con el equipo de Servicio de Oncología Pediátrica del Hospital da Criança Santo Antônio - Irmandade Santa Casa de Misericórdia de Porto Alegre, con solicitud de evaluación fonoaudiológica para la investigación de la deglutición/alimentación. La recopilación se realizó a través de datos extraídos de la historia clínica digitalizada institucional con la evolución de los casos de pacientes hospitalizados y atendidos en un servicio de consulta externa, de marzo de 2018 a agosto de 2019. Resultados: En los 3 casos reportados, los pacientes presentaron deglución normal, con indicación de vía alterna de alimentación por presentar dificultad en la ingesta oral de alimentos durante y/o después del tratamiento oncológico. Las quejas alimenticias asociadas a los efectos secundarios del tratamiento fueron la pérdida del apetito, alteración en el sentido del gusto, náuseas y vómito. Los casos fueron acompañados por el fonoaudiólogo durante la hospitalización y el servicio de consulta externa. Dos de los pacientes permanecieron con via alterna de alimentación durante un tiempo prolongado y uno de ellos restableció la alimentación por vía oral por completo. Conclusión: El fonoaudiólogo como parte del equipo multidisciplinario de atención en pacientes con cáncer infantil, es uno de los responsables del seguimiento de las dificultades de alimentación causadas por la enfermedad y los tratamientos, con una mirada más allá de la disfagia orofaríngea. Su actuación debe incluir estrategias que promuevan una nutrición adecuada, ya sea por vía alterna o vía oral, con el objetivo de garantizar la seguridad y comodidad del paciente y respetando su autonomía.

Effects of intervention based on internet platform for feeding disorders of infants with low birth weight / 上海预防医学

Objective To evaluate the effects of intervention based on internet platform for feeding disorders of infants with low birth weight (LBW), and to provide evidence for spreading and conducting intervention in communities. Methods A total of 994 infants aged 1 month born between January 2016 and February 2017 with LBW consulted in Department of Child Health Care of Minhang Maternal and Children Health Hospital were selected in this study.The participants were randomly divided into intervention group (499 cases) and control group (495 cases).The intervention group received health education in the assistance of a communication platform founded on internet, and the control group received health education by common pattern.After 12 months of intervention, a self-developed and normalized Chinese Infant Feeding Scale was used to assess the infants feeding disorder and feeding behaviors of caregivers were also investigated by filling out a specially designed questionnaire, to understand the occurrence of feeding disorders in the intervention group and the control group and the changes of feeding behavior of the parents. Results The score of feeding behavior questionnaire based on internet platform intervention was significantly higher than that of the control group (P < 0.05), and the parental feeding behavior was significantly improved in five aspects:food preparation, nutrition knowledge, feeding methods, feeding concept and feeding environment (P < 0.01).The incidence of feeding disorders in the intervention group was lower than that in the control group, and the difference was statistically significant (P < 0.05). Conclusion Interventions based on the internet platform for feeding disorders in LBW infants can reduce the incidence of feeding disorders and improve parental feeding behavior.

Effects of intervention based on internet platform for feeding disorders of infants with low birth weight / 上海预防医学

Objective To evaluate the effects of intervention based on internet platform for feeding disorders of infants with low birth weight (LBW), and to provide evidence for spreading and conducting intervention in communities. Methods A total of 994 infants aged 1 month born between January 2016 and February 2017 with LBW consulted in Department of Child Health Care of Minhang Maternal and Children Health Hospital were selected in this study.The participants were randomly divided into intervention group (499 cases) and control group (495 cases).The intervention group received health education in the assistance of a communication platform founded on internet, and the control group received health education by common pattern.After 12 months of intervention, a self-developed and normalized Chinese Infant Feeding Scale was used to assess the infants feeding disorder and feeding behaviors of caregivers were also investigated by filling out a specially designed questionnaire, to understand the occurrence of feeding disorders in the intervention group and the control group and the changes of feeding behavior of the parents. Results The score of feeding behavior questionnaire based on internet platform intervention was significantly higher than that of the control group (P < 0.05), and the parental feeding behavior was significantly improved in five aspects:food preparation, nutrition knowledge, feeding methods, feeding concept and feeding environment (P < 0.01).The incidence of feeding disorders in the intervention group was lower than that in the control group, and the difference was statistically significant (P < 0.05). Conclusion Interventions based on the internet platform for feeding disorders in LBW infants can reduce the incidence of feeding disorders and improve parental feeding behavior.

Adult avoidant/restrictive food intake disorder: a case report / Transtorno alimentar evitativo/restritivo em uma adulta: um relato de caso

ABSTRACT The aim this report is to present an adult case of avoidant/restrictive food intake disorder (ARFID) in a patient with atypical development. To emphasize the diagnostic and behavioral characteristics of this new nosological category included in the Feeding and Eating Disorders (FED) section of DSM-5. A woman with Down Syndrome in early adulthood who developed restriction and avoidance symptoms of food until the total eating refusal with weight loss, malnutrition and dependence exclusively on enteral feeding by gastrostomy tube. This case exemplified how ARFID may remain a hidden diagnosis and even be misdiagnosed as other eating disorders, such as anorexia nervosa. The increase in diagnostic suspicion for this nosological entity with neurobiological/behavioral mechanisms involved in its clinical presentations in mind, might increase knowledge about this serious eating disorder, aiming the development of evidence-based interventions.

RESUMO O objetivo deste relato é apresentar um caso de transtorno alimentar evitativo/restritivo (TARE) em uma paciente adulta com desenvolvimento atípico e salientar as características diagnósticas e comportamentais dessa nova categoria nosológica incluída na seção de Transtornos Alimentares da DSM-5. Mulher com síndrome de Down que, no início da vida adulta, evoluiu com sintomas de restrição e evitação alimentar até a recusa total da alimentação, com perda de peso, desnutrição e dependência total de alimentação enteral por gastrostomia. Este caso elucida como o diagnóstico de TARE pode permanecer oculto e ser confundindo com outras condições patológicas alimentares, como a anorexia nervosa. O aumento da suspeição diagnóstica para essa entidade nosológica, tendo em mente os mecanismos neurobiológicos/comportamentais envolvidos em suas apresentações clínicas, possibilitará o aumento do conhecimento sobre esse grave transtorno alimentar, visando ao desenvolvimento de intervenções eficazes baseadas em evidências.

Evaluación y manejo de dificultades de succión-deglución en recién nacidos y lactantes sin compromiso neuromuscular / Assessment and management of sucking-swallowing difficulties in newborns and infants without neuromuscular disease

The difficulties of sucking, swallowing and feeding have been extensively studied in pediatric population with congenital or acquired condition. The severity and variety of signs and symptoms guide the evaluation and treatment with relatively low complexity, if the necessary specialists and equipment are available. The confrontation of swallowing and feeding disorders in newborns and infants who do not have neurological, genetic or metabolic conditions becomes a major challenge. Difficulties are related to failures in the safety, efficiency and behavior of the child when feeding. This article reviews the development of feeding, the relationship with the digestive air tract and the impact on speech acquisition. Assessment and treatment criteria are also detailed, with emphasis on the management of multidisciplinary teams and active family incorporation.

Las dificultades de succión, deglución y alimentación han sido ampliamente estudiadas en población pediátrica portadora de alguna condición congénita o adquirida. La severidad y variedad de signos y síntomas, orientan a la evaluación y tratamiento con relativa baja complejidad, si se cuenta con los especialistas y equipamiento necesario. Se transforma en un desafío mayor el enfrentamiento de alteraciones de deglución y alimentación en recién nacidos y lactantes que no presentan condiciones neurológicas, genéticas o metabólicas. Las dificultades se relacionan con fallas en la seguridad, eficiencia y la conducta del niño al alimentarse. En este artículo se revisa el desarrollo de la alimentación, su relación con el tracto aéreo digestivo y el impacto en la adquisición del habla. También se detallan criterios de evaluación e intervención, con énfasis en el manejo de equipos multidisciplinarios e incorporación activa de la familia.

Narratives of mothers of children with autism spectrum disorders: focus on eating behavior / Narrativa de mães de crianças com transtorno do espectro do autismo: foco no comportamento alimentar

Abstract Objective To investigate the eating behavior of individuals with autism through their mothers' narratives. Methods The study of narratives was used to report on the narrators' experiences. Data on the eating habits of individuals with autism were collected using semi-structured interviews held individually with the mothers. The interviews were recorded, transcribed and codified using the NVivo software program. Results Eighteen mothers of boys/young men with autism participated in the study. Analysis yielded three major categories: eating patterns, the family's attitudes to the child's eating habits, and food-related behavior. Conclusion Results show that autism-related factors may affect the child's food choices. Environmental factors, particularly the parents' behavior, may also play a decisive role, both in reinforcing the child's food choices and in encouraging a healthier and more diversified diet. Professionals should instruct parents regarding their decisive role in reinforcing or discouraging inappropriate mealtime behavior in children with autism.

Resumo Objetivo Investigar o comportamento alimentar de indivíduos com transtorno do espectro do autismo (TEA) através das narrativas de suas mães. Métodos Os dados sobre os hábitos alimentares dos indivíduos com TEA foram coletados utilizando entrevistas semiestruturadas realizadas individualmente com as mães. As entrevistas foram gravadas, transcritas e codificadas usando o programa NVivo. Resultados Dezoito mães de meninos/jovens homens com autismo participaram do estudo. A análise produziu três categorias principais: padrões alimentares, a atitude da família em relação aos hábitos alimentares da criança e comportamentos relacionados à alimentação. Conclusão Os resultados mostram que os fatores relacionados ao autismo podem afetar as escolhas alimentares da criança. Os fatores ambientais, particularmente o comportamento dos pais, também podem desempenhar um papel decisivo, tanto no reforço das escolhas alimentares da criança quanto no incentivo a uma dieta mais saudável e diversificada. Os profissionais devem instruir os pais sobre o seu papel decisivo no reforço ou desencorajamento do comportamento inapropriado nas refeições em crianças com TEA.

The efficacy of individualized swallowing training for premature infants with feeding disorders: A randomized controlled trial / 中华物理医学与康复杂志

Objective To observe the effect of individualized swallowing training in the neonatal intensive care unit on the swallowing function of premature infants with feeding disorders.Methods Sixty-two preterm (28 to 32 weeks) infants with feeding disorders were randomly divided into a treatment group (n=34) and a control group (n =28).Both groups were given routine gastric tube feeding,but the treatment group was additionally provided with individualized swallowing training twice a day for 2 weeks,including oral sensory and motor stimulation,milking,family participation,a better environment and a selection of feeding tools.The subjects' daily milk consumption and weight were recorded,along with the age when the gastric tube was removed and the total length of the hospital stay.Results The treatment group showed significantly greater improvement than the control group in their daily milk consumption and weight gain,though both groups showed significant improvements.The average time to removing the gastric tube and the average hospital stay were both significantly shorter for the treatment group than for the control group.Conclusion Individualized swallowing training can effectively improve sucking and swallowing skills and shorten the period of using a gastric tube and the total hospital stay for premature infants.

Obesidad y síndrome metabólico en niños y adolescentes / Obesity and metabolic syndrome in children and adolescents

La obesidad y el síndrome metabólico se encuentran íntimamente relacionados con los casos de enfermedad cardiovascular; son considerados habitualmente como propios de la población adulta aunque se observan con una frecuencia creciente en niños y adolescentes. Existe evidencia de que las lesiones ateroescleróticas se presentan con más frecuencia en jóvenes obesos. Los factores involucrados en esta pandemia son múltiples e incluyen desde variables genético-biológicas hasta cambios culturales. La familia y el entorno en el que el niño se desarrolla juegan un papel fundamental en la adopción de los hábitos relacionados con la alimentación y la actividad física. Esta problemática no respeta fronteras ni culturas sino que todos los países están siendo afectados, más aún aquellos de ingresos medios. El papel que le cabe al Estado y a la sociedad en su conjunto se orienta a modificar este medio ambiente. La restricción en las ventas de alimentos poco saludables y la lucha contra el sedentarismo son políticas que urgen ser aplicadas. El impacto que estos trastornos tendrán en términos de enfermedad cardiovascular, no ha cobrado aún su verdadera dimensión.

Obesity and the metabolic syndrome are closely related to the cases of cardiovascular disease; they are usually regarded as belonging to the adult population but are seen with increasing frequency in children and adolescents. There is evidence that atherosclerotic lesions occur most often in young people with obesity. The factors involved in this pandemic are manifold and range from genetic-biological to cultural changes. The family and the environment in which the child develops play a key role in the adoption of habits related to diet and physical activity. This problem does not respect borders and cultures but all countries are being affected, even more those of middle-income. State and Society as a whole can play a role oriented to modify this environment. The restriction on sales of unhealthy food and the fight against the sedentary lifestyle are urgently needed to be applied. The impact that these disorders will have in terms of cardiovascular disease, has not yet reached its true dimension.

Feeding disorders of infancy or early chilhood: A review / Trastornos de la ingestión alimentaria de la infancia o la niñez: Una revisión

Feeding disorders of infancy or early childhood are a common presenting problem at health clinics. However, they are often mistaken with eating disorders, such as Anorexia Nervosa or Bulimia Nervosa, in spite of remaining as different diagnostic categories in both the DSM-IV-TR and the ICD-10. Children's feeding disorders are also understudied in comparison with eating disorders. The lack of a clear definition of feeding disorders, the diversity in prevalence figures and the challenges in the classification of these disorders affects the identification of feeding disorders in the clinical practice. This article aims to review the available literature in order to contribute to a better understanding of feeding disorders of infancy or early childhood.

Los Trastornos de la Ingestión Alimentaria de la Infancia o la niñez (TIAI) son de común presentación en las consultas de profesionales de la salud. Sin embargo, a menudo son confundidos con los Trastornos de la Conducta Alimentaria (TCA), Anorexia Nerviosa y Bulimia Nervosa, aunque estos permanecen como entidades diagnósticas separadas tanto en el DSM-IV-TR como en el ICD-10. En comparación con los TCA y con otros trastornos del comportamiento infanto-juvenil, los TIAI están escasamente investigados. Los términos utilizados para su descripción, la diversidad en la prevalencia, y las dificultades en la clasificación, afectan la identificación de estos problemas en la práctica clínica. Por ello, este artículo tiene como objetivo el repasar la literatura disponible sobre estos trastornos para así contribuir a una mejora en el entendimiento de los TIAIs.

La neurocirugía en los trastornos de la alimentación: ¿una alternativa posible?

resumen está disponible en el texto completo

Abstract: Composition and quantity of food in-taken varies considerably between one meal and another, or between one day and the following. Non biological factors -such as emotional, social, day time, feasibility in the type of food, and cost- are, among others, factors that in some way affect the degree of energy in-take by food, which generally is not related with daily energy expenditure. These phenomena represent an active process of regulation that is characterized by the balance between signs that stimulate hunger, called orexigenics and those that produce satiation to stop in-take, called anorexigenics, that promotes the stability in the quantity of corporal energy manifested as fat. In this feeding regulatory process there are many molecular signs that participate and regulate the in-take of behaviour food for homeostasis. There are two hypothalamic centers related with the food in-take control: the hunger centre in the lateral hypothalamus and the satiation centre in the ventromedial nucleus. In this control many impulses participate, regulated by substances called neurotransmitters, such as: neuropeptide Y, galanine, orexines for the hunger centre and nor epinephrine, serotonin, and dopamine for the satiation centre. Insulin reaches the brain through circulation and acts reducing the contribution of energy, it was the first hormonal sign that was implicated in weight control by CNS. The second identified hormone, secreted by the adiposity, was leptin. Both hormones circulate in levels proportional to the corporal fat and get to the CNS in proportion to its plasmatic concentrations. Receptors as leptin and insulin are expressed by brain neurons involved in the contribution of energy, and the administration of any of both peptides directly to the brain, reduce the in-take of food. The lack of any of these hormones produces the opposite. Leptin has a more important role than insulin in the control of the energetic homeostasis in the CNS. For example, the lack of leptin causes severe obesity with hyperfagia that persists regardless the levels of elevated insulin. In contrast, obesity isn't induced by the lack of insulin. Insulin has a critic role to promote the storage of fat and the synthesis of leptin through the fat cellule. The neuropeptide Y, produced in the arcuate nucleus of the hypothalamus has an anabolic effect. The gene of expression and secretion of this peptide in the hypothalamus increases during depletion, in the storage of corporal fat and/or when the signs of leptin/insulin are decreased in the brain. Leptin inhibits the gene of expression of the neuropeptide Y in the arcuate nucleus and the genetic "knockout" of the NPY reduces hyperfagia and obesity in mice ob/ob, indicating that the total response to the lack of leptin requires the signs of the NPY. Other substances like the Agouti protein (AGRP), the orexines (hypocretines A and B) and the concentrations of the melancortin hormone have been added to the molecule candidate list with anabolic effects. Also in the adjoining neurons of the arcuate nucleus, are originated anorexigenic peptides like alfa-MSH (a derivated of the pro-opiomelancortin, POMC) and CART (transcript protein related with cocaine and amphetamine). Both types of neurons (NPY/AGRP and POMC/CART) coexpress the leptin receptors. In those situations in which the levels of leptin or insulin are low, the NPY/AGRP neurons activate and the POMC/CART are inhibited. This suggests that the main site of adiposity signs transformation is a neuronal response in the arched nucleus. The link between the lateral hypothalamus and the elevated centers of the brain that regulate hunger and satiation is a very important aspect of the regulation system. There have been typified two types of neuropeptides linked to neurons, that appear to be exclusively of the lateral hypothalamus area: the concentrated melanin hormone (MCH) and the orexines. At the lateral zone, there have been specified two types of hypothalamic neuropeptides, the orexines A and B, also known as hypocretines 1 and 2, which are cellular bodies of the hypothalamus, especially at the lateral hypothalamus and the perifornical area, which stimulate the appetite in an independent way to other neuropeptides known. On the other hand, the orexines A and B derive (by proteolysis) of a common precursor, and are capable of activating their two respective receptors that work in conjunction with proteins G. The central administration of orexines stimulates the in-take and production of orexines' increase with fasting. These neuropeptides match with the hypocretines described by other authors, with expression in late ral hypothalamus, arched nucleus, septal nucleus and forebrain. Monoaminergic neurotransmitters. Noradrenalin Noradrenalin is synthesized in different areas of the brain such as the dorsal nucleus of the vague and the locus coeruleus.Noradrenalin shares the same place with NPY and the injection of both inside the preventricular nucleus increase the in-take of food. The repeated injection can result in weight increase; leptin can inhibit noradrenalin secretion. Dopamine Critic dependence of the in-take of food in the CNS is given by the dopamine sign, which is implicated in the voluntary lack of the food in-take. Motor alterations associated with the lack of dopamine affect also the alimentary behavior. The dopamine effect over the alimentary behavior varies depending of the studyied area. For example the routes of dopamine in the mesolimbic area contribute to the reward of the in-take of savory food. SerotoninThe 5HT2c receptor of serotonin is implicated in the decrease of the in-take of food and the weight increase, due to its effect in the impulse of the satiation centre. To maintain the homeostasis of normal energy it is necessary that the serotonin sign be intact. New alternative hypothesis. On one hand, the knowledge of regulation of the appetite-satiety neuroendocrine cycle, and on the other, the new techniques of neuromodulation through stereotaxic surgery, allow to offer an extraordinarily interesting field of research in certain patients with feeding disorders of difficult control and with an increase in the mortality risk. The alternative of controlling specific centers of hunger/satiation regulation, is still a hypothesis, though there are some data that allow us to assume that it could be feasible and we will mention them after. Current experience. Stereotaxic (Latin: stereo, three-dimensional; taxis, positioning) is a modern technique of neurosurgery that allows the localization and precise access to intra-cerebral structures, through a small orifice in the skull. If we have identified the places that regulate the intake of food or satiety, it is feasible that through this technique we can stimulate or inhibit this function and offer the patient an alternative that in theory could be feasible. Some of its possible advantages will be that we are talking about a minimum invasive surgery, generally performed using local anesthesia; patients need a minimum hospitalization stay and surgical risks are minimized. This allows us to predict in the majority of the patients a satisfactory evolution of weight decrease. The current experience of stereotaxic used in eating disorders is null; everything about it is hypothetic. However, the use of this proceeding for other accepted indications where there is previous experience, has allowed us to obtain interesting data of the evolution of these patients that shows indirectly, that the procedure has influenced in the corporal weight. We present these indirect results, which motivate us to continue considering its possible use in patients that show the approved profile according to an ethic committee properly authorized. In depression or bipolar disorder cases, the use of the stereotaxic surgery applying electrodes in the bottom pedunculo thalamic region (ITP), independently that they show an improve in their basal alteration, the patients show a weight increase, inferring a relationship of this area and the one of the hypothalamus for the appetite/satiation control, situation that hypothetically could benefit patients with anorexia nervosa or bulimia. In the cases with Parkinson Disease, the stereotaxic procedure has been made in the pre-lemniscal (RAPRL) or the subtalamic region (STN) in a unilateral or bilateral way, and although the response hasn't been uniform, the weight changes showed a decrease, making this a possible alternative to be used in some patients with morbid obesity according to the inclusion criteria. Final comments. The expectative of stereotaxic surgery in handling patients with difficult to control feeding disorders or with high risk of morbid-mortality, is shown as an hypothesis, that should consider the specific rules of good clinical practices and adjust to the rules of an approved ethics committee, for these procedures.