Biếng ăn ở trẻ em

Trẻ em biếng ăn1. Những nguyên nhân chính gây biếng ăn ở trẻ em:

1.1. Nguyên nhân tâm lý:
1.1.1 Chán ăn có nguồn gốc tâm lý ở trẻ nhỏ:

Hay xảy ra ở trẻ 6-9 tháng trong bối cảnh đang được thay đổi chế độ ăn. Trẻ có thái độ chống đối việc ép ăn của bố mẹ.

1.1.2 Chán ăn có nguồn gốc tâm lý ở trẻ lớn:  Xảy ra chủ yếu ở các trẻ gái ở tuổi thiếu niên.

1.2. Các bệnh nhiễm trùng và ký sinh trùng:
Biếng ăn là một triệu chứng xảy ra trong hầu hết mọi bệnh nhiễm trùng. Tình trạng này thường mất đi khi trẻ bắt đầu hồi phục. Nhiễm giun đũa cũng là một nguyên nhân gây biếng ăn phổ biến ở trẻ em nước ta.

1.3. Bệnh lý tiêu hoá và răng miệng:
Biếng ăn là một triệu chứng luôn có khi trẻ bị một số bệnh răng miệng:
     - Viêm miệng áp tơ
     - Herpangina
     - Viêm lưỡi bản đồ
     - Viêm loét họng-amiđan
     -Mọc răng

1.4. Bệnh mãn tính nặng:
     - Suy tim
     - Hen vừa và nặng

1.5. Các nguyên nhân khác:
1.5.1. Biếng ăn do sinh lý:

Trẻ thường biếng ăn khi trẻ biết lật biết ngồi biết đi v.v...

1.5.2. Biếng ăn do thuốc:
Các kháng sinh uống thường gây loạn khuẩn ruột giảm quá trình lên men thức ăn.

1.5.3. Biếng ăn do sai lầm trong chế độ ăn và cách chế biến thức ăn.

1.5.4. Biếng ăn bẩm sinh: khoảng 5% trẻ không bao giờ đòi bú hay đòi ăn.

2. Chẩn đoán biếng ăn:

2.1. Lâm sàng:
2.1.1. Biếng ăn do tâm lý ở trẻ nhỏ:
Đây là loại biếng ăn phổ biến nhất  ở trẻ em.
     - Thường xuất hiện khi trẻ trong khoảng 5-8 tháng thường có liên quan đến sự thay đổi chế độ ăn hay các đợt bị bệnh.
     - Thường liên quan đến một thái độ chống đối lại việc ép ăn của bố mẹ. Sự chống đối này có thể có tính chất chung nhưng thường chỉ nhắm vào mẹ.
     - Sự tăng cân và tầm vóc thường vẫn đảm bảo.
    
- Trẻ vẫn linh hoạt mạnh mẽ đôi khi còn trội hơn so với lứa tuổi. Chỉ biểu hiện sự chống đối trong các bữa ăn mà thôi.
     - Về phía gia đình mẹ của trẻ tường rất lo lắng và không chịu được sự chống đối của trẻ.Để chẩn đoán cần tìm hiểu về tình hình nuôi dưỡng của trẻ và khám để loại trừ các trường hợp biếng ăn có nguyên nhân thực thể nhiễm trùng rối loạn hấp thu.

2.1.2. Biếng ăn do nguyên nhân tâm lý ở trẻ thiếu niên:
Đây là loại biếng ăn xảy ra ở trẻ thiếu niên với hai đỉnh điểm là 14 5 tuổi và 18 tuổi. 25% xảy ra ở trẻ dưới 13 tuổi. Tình trạng này có yếu tố gia đình. Chẩn đoán dựa vào các tiêu chuẩn sau:
     (1) Rất sợ bị mập phì không giảm lo sợ khi đã gỉam cân;
     (2) Sự sợ tăng cân dựa trên những nhận xét chủ quan trong khi trên thực tế có thể là thiếu cân;
     (3) Không chịu duy trì cân nặng ở mức tối thiểu của cân nặng bình thường theo tuổi và chiều cao;
     (4) Không thấy kinh trong 3 chu kỳ liên tiếp trong lúc lẽ ra phải có.
Loại biếng ăn này kéo theo rối loạn ở nhiều cơ quan. Tỷ lệ tử vong khoảng 10% thường do rối loạn điện giải nặng loạn nhịp tim hoặc suy tim trong giai đoạn hồi phục. Nhịp tim chậm và hạ huyết áp tư thế cũng thường gặp. Tất cả đều hồi phục sau điều trị phục hồi dinh dưỡng. Điện tim có những biểu hiện như: điện thế thấp sóng T đảo ngược hoặc dẹt ST lõm rối loạn nhịp thất và trên thất v.v...Suy tim dẫn đến tử vong có thể xảy ra khi bồi phụ nước hoặc cho ăn lại quá nhanh (chế độ ăn không được gây tăng cân trên 0 4kg/ngày).

2.1.3. Biếng ăn do các bệnh nhiễm trùng bệnh lý răng miệng bệnh mãn tính nặng:
     - Biếng ăn do bệnh nhiễm trùng và ký sinh trùng:
          + Biếng ăn là một triệu chứng xuyên suốt từ khi khởi bệnh cho đến khi bệnh hồi phục của hầu hết các bệnh nhiễm khuẩn và virus. Trẻ bắt đầu thèm ăn trở lại là dấu hiệu của sự lui bệnh.
          + Nhiễm giun: Trẻ chán ăn xanh xao hay đau bụng rối loạn tiêu hoá nôn mửa.
     - Các bệnh lý tiêu hoá răng miệng:
          + Viêm miệng áp tơ herpangina: Là tình trạng viêm loét niêm mạc miệng do virus herpes. Trẻ không chịu ăn vì thức ăn làm trẻ đau. Đi đôi với chán ăn trẻ đùn nhiều nước bọt và miệng có mùi hôi. Khám niêm mạc miệng lưỡi hoặc vòm khẩu cái mềm thấy có những vết loét có kích thước đa dạng từ 1-5 mm phủ lớp bựa vàng nhạt đường viền chung quanh chỗ loét có màu đỏ.
          + Viêm lợi: Lợi sưng đỏ và dễ chảy máu ở chân răng. Trẻ cũng chán ăn và đùn nhiều nước bọt.
          + Nấm miệng (nhiễm Candida albican): Niêm mạc miệng phủ một lớp bựa trắng mỏng và dễ chùi sạch. Thấy nhiều nhất là vùng mặt trong má hai bên lưỡi vòm khẩu cái mềm.
          + Viêm họng do liên cầu khuẩn hay virus: Trẻ sốt đau họng tự nhiên hay khi nuốt. Họng đỏ đôi khi có lớp xuất tiết trắng. Amiđan thường sưng đỏ và có thể có lớp xuất tiết phủ bên trên. Do đau họng và tình trạng nhiễm trùng làm trẻ chán ăn.
     - Bệnh mãn tính nặng: Biếng ăn đi đôi với mức độ khó thở.
          + Suy tim nặng: Trẻ khó thở tím tái nhịp tim nhanh gan lớn và đau tiểu ít nghe tim thấy nhịp tim nhanh có tiếng ngựa phi.
          + Hen vừa và nặng: Khó thở chủ yếu kỳ thở ra sò sè vã mồ hôi tím tái phổi nhiều ran ngáy rít lồng ngực căng dãn và có thể bị biến dạng.

2.2. Cận lâm sàng:

2.2.1. Các bệnh nhiễm trùng và ký sinh trùng:
Tuỳ theo bệnh mà có những xét nghiệm thích hợp. Chung nhất có thể làm các xét nghiệm để xác minh một tình trạng nhiễm trùng và đánh giá mức độ tiến triển: Công thức máu tốc độ lắng máu CRP v.v.... Đối với ký sinh trùng đường ruột có thể làm xét nghiệm soi phân tìm trứng giun.

2.2.2. Các bệnh lý tiêu hoá và răng miệng:
Các bệnh lý răng miệng thường có thể chẩn đoán dựa vào khám lâm sàng.

2.2.3. Các bệnh mãn tính nặng:
     - Suy tim: Cần làm một số xét nghiệm giúp chẩn đoán và đánh giá mức độ nặng của suy tim: X quang tim-phổi siêu âm tim điện tim v.v...
     - Hen vừa và nặng: Cần làm các xét nghiệm:
          + Xác định bệnh nguyên: IgE đặc hiệu test lẫy da test gây hen thử.
          + Đánh giá độ nặng: Đo chức năng hô hấp bằng máy phế dung kế (FEV1) hay máy đo lưu lượng đỉnh (PEFR).

3. Nguyên tắc xử trí:

3.1. Biếng ăn do nguyên nhân tâm lý:

3.1.1. Ở trẻ nhỏ:
Đa số các trường hợp biếng ăn ở trẻ em là loại này. Trẻ mất sự thèm ăn là trẻ có cảm giác bị ép buộc bị bỏ rơi hay bị đánh lừa. Do đó để xử trí loại biếng ăn này bố mẹ cần:
     - Hết sức bình tĩnh kiên nhẫn tìm hiểu lý do trẻ không chịu ăn.
    
- Cần tránh những hành vi ép buộc trẻ.
     - Cố gắng thay đổi hành vi thái độ: Mẹ dành nhiều thời gian chơi với trẻ tạo không khí vui vẻ thoải mái khi trẻ ăn cho trẻ tự do chọn thức ăn.
     - Đừng bao giờ lén pha thuốc vào thức ăn của trẻ.

3.1.2.Ở trẻ thiếu niên:
Cách điều trị hiện nay là:
    
- Tâm lý liệu pháp các kỹ thuật thay đổi thái độ.
    
- Phục hồi dinh dưỡng.
     -  Các thuốc chống trầm cảm rất có ích đối với những bệnh nhân bị trầm cảm kết hợp biếng ăn do tâm lý. Tử vong có thể xảy ra trong giai đoạn cấp hay trong  quá trình phục hồi dinh dưỡng.

3.2. Biếng ăn do bệnh nhiễm trùng ký sinh trùng bệnh lý tiêu hoá răng miệng:
     - Chẩn đoán và điều trị sớm các bệnh nhiễm trùng ( đặc biệt là các bệnh do vi khuẩn).
     - Bổ sung các vi chất dinh dưỡng mà trẻ thiếu (các vitamin nhóm B các acid amin đặc biệt là lysin kẽm v.v...)
     - Xổ giun định lý mỗi 6 tháng.
     - Giữ gìn vệ sinh răng miệng tốt. Điều trị sớm các bệnh lý ở răng miệng bằng các biện pháp thích hợp.
     - Bổ sung các vi khuẩn lactobacillus để tái lập thế quân bình của khuẩn giới ở ruột bị rối loạn sau điều trị kháng sinh.

3.3. Biếng ăn do bệnh lý mãn tính nặng:
     - Điều trị sớm và tích cực các bệnh lý mãn tính.
     - Bổ sung các vi chất giúp trẻ thèm ăn: Các vitamin nhóm B các acid amin tối cần đặc biệt là lysin kẽm v.v...

3.4. Biếng ăn do các nguyên nhân khác:
3.4.1. Biếng ăn do sinh lý (khi trẻ biết ngồi biết lật biết đi v.v...):
Hãy cho trẻ ăn từng bữa nhỏ làm các món ăn lạ và hấp dẫn. Giai đoạn này sẽ qua đi một cách tự nhiên.

3.4.2. Biếng ăn do sai lầm trong chế độ ăn và cách chế biến thức ăn:
Cần tránh những sai lầm sau:
     - Chỉ cho trẻ ăn nước rau nước thịt không ăn xác. Lâu ngày gây thiếu dưỡng chất.
     - Pha bột vào sữa pha sữa quá đặc pha sữa bằng nước cháo nước hầm xương làm trẻ khó tiêu hoá. Pha bột quá đặc khi trẻ mới tập ăn dặm.
     - Chất và lượng thực phẩm trong chén cháo hoặc bột không đủ.
     - Thức ăn đơn điệu làm cho trẻ chán ăn.
     - Bữa ăn qua nghèo nàn (chỉ có bột và thịt hoặc cá) làm trẻ bị thiếu một số acid amin tối cần và các vitamin. Sự thiếu hụt này có thể dẫn đến tình trạng chán ăn.

Tài liệu tham khảo:
1. Harrison’s principles of internal medicine 15th  edition (2000).
2. Pédiatrie ELLIPSES/AUPELF. 1998.
3. Nelson Textbook of pediatrics 16th edition (2000)

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