Nutritional Support in Childhood Respiratory Rehabilitation

Introduction

Childhood respiratory disease has major medical and social significance because of its frequency, differential-diagnosis difficulties, recurrence and chronicity risk, and substantial economic burden. In Russian paediatrics, recurrent respiratory illness is often classified as frequently and persistently ill children, comprising 15–65% of the child population [1].

Frequent respiratory infections reduce immune resistance, disrupt compensatory-adaptive mechanisms and body function, particularly respiratory, gastrointestinal and autonomic systems, and promote early chronic disease. Recurrence, chronicity and limited effectiveness of conventional treatment/prevention largely reflect morphological and functional immune insufficiency that prevents optimal environmental adaptation [2]. Rational, balanced nutrition quantitatively and qualitatively meeting physiological needs is also important for health and immune reactivity [3]. High metabolic demands and immature organs make children sensitive to macro- and micronutrient deficiency, which creates adverse background conditions, immune failure and chronic disease. Inadequate nutrients, vitamins and minerals delay physical and mental development.

Studies support specialised nutritional products within comprehensive rehabilitation for recurrent respiratory disease [9–13].

The aim was to improve comprehensive rehabilitation of children with recurrent respiratory disease, considering nutritional status, health assessment and clinical/immunological measures.

Materials and methods

The study at Duslyk Children’s Sanatorium, Ufa, examined 182 children: the main group comprised 101 with recurrent respiratory disease; controls were 81 healthy children admitted for health improvement.

Inclusion criteria were age 5–9, recurrent respiratory disease with frequent historical relapses; no acute, hereditary/genetic or congenital respiratory disease, no exacerbated chronic digestive disease, and parental written voluntary informed consent.

Exclusions were acute respiratory disease, acute allergic reactions, hereditary/genetic respiratory disease, congenital respiratory malformations, exacerbated chronic digestive disease, primary immunodeficiency or no parental written informed consent.

Product effectiveness criteria included tolerance, subjective acceptance, appetite, allergic reactions, gastrointestinal disturbances, questionnaire-assessed tolerance/effectiveness, and anthropometric, somatometric, bioimpedance, biochemical and immunological assessments at baseline and study end. Table 1 presents participant distribution.

Health and physical-development characteristics and changes were assessed in both groups. Standardised anthropometry was classified by age- and sex-specific centile tables of M.V. Chichko, 1990. Harmony of physical development used accepted G.N. Serdyukovskaya methods, 1989.

Nutritional impairment was assessed by standard anthropometry: height with a Diakoms stadiometer, Russia, and weight with Massa-K electronic scales, Russia.

Nutritional disorders were diagnosed using BMI, the Quetelet index developed in 1869 by Belgian sociologist/statistician Adolphe Quetelet. It relates weight to height and is expressed in kg/m². CDC 2000 percentile tables classified BMI below the fifth percentile as underweight, above the 85th through the 95th as overweight, and above the 95th as obesity.

Triceps skinfold thickness was measured with an electronic calliper from Tulinovsky Instrument-Making Plant TVES, Russia.

Bioimpedance used the Diamant-AIST body-composition analyser, Diamant, Russia, with patients supine. Standard right-side measurements placed electrodes at wrist and ankle. Outcomes were fat mass, lean mass, active cell mass and total body water.

Nutritional biochemical markers were total protein, albumin and transferrin on Architectc 8000, Abbott Laboratories S.A., USA, and lymphocytes on Unicel DxH 800, Beckman Coulter, USA.

Statistical processing was performed under Windows XP using Statistica 6.0. Results are presented as mean values and the standard error of the mean, M±m. The significance of differences between mean values was assessed with Student’s t-test. Differences between parameters were considered statistically significant at p<0.05.

Rehabilitation effectiveness was evaluated through changes in clinical condition, physical development and nutritional status after six months.

Results and discussion

Family histories supported familial burden in recurrent respiratory disease. Chronic upper-airway disease, tonsillitis/sinusitis, affected 40 mothers, 39.6%, in the main group and 15, 18.5%, in controls (AR=33.77; p<0.01); fathers numbered 27, 26.7%, and eight, 9.9% (AR=34.64; p<0.01). Smoking occurred among 42.6% versus 23.5% of mothers (AR=17.35; p<0.05) and 71.3% versus 45.7% of fathers (AR=39.76; p<0.01), lower in controls.

The main group more often had prematurity, 11 children/10.9%, intrauterine growth restriction, 11/10.9%, and fetal hypoxia, 62/48.5%, versus 2.5%, 2.5% and 18.5% in controls (p<0.05). Pregnancy pathology, 35/34.6% versus 12/14.8%, and childbirth pathology, 36/35.6% versus 12/14.8%, differed significantly (p<0.01): gestosis, threatened miscarriage, exacerbated chronic somatic disease, adnexitis, prolonged or precipitous labour, premature membrane rupture, prolonged anhydrous period, primary/secondary uterine inertia and asphyxia. Previous perinatal CNS injury was more common: 92/91.1% versus 41/50.6%, p<0.05.

Main-group children had lower physical-development measures throughout life. One third with recurrent respiratory disease, 36/35.6%, had acute respiratory infection before age one (p<0.01).

Table 2 presents clinical characteristics. Comorbidities were more frequent in children with recurrent respiratory disease.

Questionnaires showed daily food volume below age recommendations in 91 main-group children, 90.1%. Home diets were usually unbalanced and monotonous. Frequent sweet, bun and fast-food snacks occurred in 97, 96.0%. Sausages, flour products, pasta, sweets, canned foods and soft drinks dominated in 95, 94.1%. Almost all ate products unsuitable for a children’s assortment daily: ketchup, mayonnaise, convenience pizza, dumplings and crisps. In 85, 84.1%, major food groups—dairy, meat, vegetables, juice and fruit—were insufficient and consumed only two or three times weekly.

Clinical examination identified reduced tissue turgor and muscle tone and vitamin/mineral deficiency, significantly more often in the main group (Table 3).

Anthropometry showed harmonious development 1.7 times less often in the main group (Table 4). Morphofunctional status was harmonious in 45 main-group children, 44.6%, and 76 controls, 93.8%; disharmonious in 30, 29.7%, and five, 6.2%; and markedly disharmonious in 26 main-group children, 25.7% (p<0.05). Main-group abnormalities were chiefly underweight, 34/33.6%, and overweight, 22/21.8%. Parents associated overweight with inactivity, carbohydrate-heavy diets, frequent sweets, buns, fast food, crisps and sugary drinks.

BMI results confirmed anthropometry (Table 5). The Quetelet index showed significantly more disharmonious development in the main group. Normal harmonious development was 1.6 times less frequent: 45/44.6% versus 74/91.3%. Insufficient development with underweight occurred in 36/35.6% versus five/6.2%; excessive development with overweight in 20/19.8% versus two/2.5%.

Bioimpedance-assessed physical development is shown in Table 6. Age-average development was 1.6 times lower in the main group: 47/46.5% versus 76/93.8%. Insufficient development occurred in 39/38.6% versus four/5%, excessive in 15/14.9% versus one/1.2%. These disharmonious bioimpedance findings indicate significant nutritional disturbances expressed as deficient or excessive weight.

Bioimpedance monitoring of fat, muscle, active cell mass and water identified significant group differences (Table 7). Main-group composition was imbalanced toward total fluid, with lower fat, lean and active cell masses. Nutritional impairment mainly involved reduced lean mass, a reduced somatic protein pool, potentially indicating induced metabolic processes and endogenous protein breakdown in recurrent respiratory illness. Active cell and lean mass are major protein-tissue stores. Reduced muscle tone in 71 children, 70.3%, indirectly suggested reduced cellular mass with increased fluid. Reduced tissue turgor in 67, 66.3%, and thinner subcutaneous skinfold accompanied increased tissue hydrophilicity on bioimpedance.

Correlation analysis showed a significant direct association between tissue turgor and total fluid, r=−0.20, p<0.05, and muscle tone and active cell mass, r=0.21, p<0.05. Greater fluid accompanied lower turgor; greater active-cell deficit accompanied lower muscle tone.

Metabolic nutritional-status parameters differed significantly (Table 8). The main group had lower BMI, triceps skinfold, absolute lymphocytes, total protein, albumin and transferrin, characteristic of protein–energy malnutrition.

Findings established predominantly catabolic metabolism in the main group from recurrent respiratory disease, leading to malnutrition. Short-lived proteins such as transferrin, albumin and total protein were lower. Protein deficiency may reduce immunity and antioxidant activity, cause intracellular energy deficiency and disturb micronutrient transport.

Rehabilitation programme

Given marked dietary deficiency—daily intake one third below age norms, lower calories and altered protein/fat/carbohydrate ratios—micronutrient symptoms and nutritional impairment, 49 main-group children, 48.1%, received rehabilitation including enteral nutrition. In the sanatorium, traditional six-meal nutrition was adjusted for principal nutrients, with an additional balanced specialised PediaSure product, Abbot Nutrithion, Netherlands, 200 mL once at dinner by sipping. Alongside nutritional support, rehabilitation included 12–15 intermittent normobaric hypoxic sessions, 8–10 mechanical-massage sessions, hardening procedures and therapeutic exercise.

Intermittent normobaric hypoxic therapy used Bio-Nova, Mountain Air. Sessions activate urgent adaptation, cellular/tissue respiration, normalise metabolism and improve resistance to adverse factors. Massage used the Raduga combined system to stimulate circulation and normalise metabolism.

The sanatorium rehabilitation course lasted 21 days. At home, specialised nutrition continued at 200 mL daily for six months. Enteral nutrition was well tolerated, without unwanted effects or individual intolerance. Its six-month cost did not impose a major family-budget burden. Controls received the same volume of kefir, a fermented milk product.

Rehabilitation outcomes

Outcomes were reassessed at six months. After specialised nutrition, significant main-group improvements were tissue turgor in 77 children, 76.2%, muscle tone in 70, 69.3%, and reduced multiple-vitamin/micronutrient deficiency signs in 30, 29.7%; all p<0.01.

Anthropometry improved: harmonious morphofunctional status increased 1.3-fold from 44.6% to 58.4%, p<0.05; weight rose from 22.17 to 23.65 kg, and reduced/low weight prevalence fell 1.7-fold from 33.6% to 19.8%.

BMI showed normal development increasing 1.4-fold, from 45 children/44.6% to 64/63.4%, p<0.05, while reduced/low weight decreased 2.1-fold, from 36/35.6% to 17/16.8%.

Bioimpedance showed insufficient development decreasing 2.4-fold, 39/38.6% to 16/15.8%, and age-appropriate nutritional status increasing 1.4-fold, 47/46.5% to 70/69.3%, p<0.05.

Main-group fat mass increased 1.03-fold, 12.80% to 13.24%; lean mass 1.1-fold, 78.11% to 86.76%; total fluid 1.03-fold, 61.23% to 63.51%; and active cell mass 1.1-fold, 47.66% to 53.17%, all p<0.05, indicating improved metabolism during combined treatment. Controls increased less: fat 13.1% to 13.12%, lean 85.34% to 85.53%, fluid 61.01% to 61.13%, active cells 51.1% to 51.75%, all p>0.05.

Main-group laboratory results showed total protein increasing 1.02-fold, 64.12 to 65.62 g/L; albumin 1.03-fold, 41.34 to 42.54 g/L; transferrin 2.54 to 2.63 g/L; and lymphocytes 2.80 to 2.91 × 10^9/L, all p<0.05. Control changes were minor.

Improved nutritional parameters support the effectiveness of combined health measures for correcting metabolic and immunological disturbances and meeting energy and tissue-building needs in children with recurrent respiratory disease.

At 12-month follow-up in the main group, mean acute respiratory infection episodes decreased 2.5-fold and mean illness duration 1.7-fold.

Conclusion

Comprehensive sanatorium rehabilitation with nutritional support improves physical development and nutritional status and reduces acute respiratory infection frequency 2.5-fold and average duration 1.7-fold in children with recurrent respiratory disease.

Table 4. Anthropometry before rehabilitation

Baseline data. Dashes are retained from the original.

Table 5. Physical development by BMI

Baseline data. Dashes are retained from the original.

Table 6. Physical development by bioimpedance

Baseline data. Dashes are retained from the original.

Table 7. Body composition before rehabilitation (M±m)

Baseline data. Dashes are retained from the original.

Full table 1 — PDF, 2

Full table 2 — PDF, 3

Full table 3 — PDF, 4

Full table 8 — PDF, 5

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Full main-text translation of: Насибуллина Л.М., Дружинина Н.А., Бакиева Ч.Р. Совершенствование реабилитации детей с рецидивирующей респираторной патологией с учетом нутритивного статуса. Медицинский вестник Башкортостана. 2015;10(5/59):35–41.

Насибуллина Л.М., Дружинина Н.А., Бакиева Ч.Р. Совершенствование реабилитации детей с рецидивирующей респираторной патологией с учетом нутритивного статуса. Медицинский вестник Башкортостана. 2015;10(5/59):35–41. — PDF

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