Malnutrition in Children

mtsdarmawan

Background

Gizi (Nutrition)

Proses penggunaan makanan secara normal

12/29/2012

dr. Darmawan, SpA

Keadaan Gizi
Keseimbangan antara konsumsi, penyerapan & pemakaian.

12/29/2012

dr. Darmawan, SpA

Learning Obyektif
Mampu menjelaskan pengertian malnutrisi secara umum dan kondisi malnutrisi di Indonesia Mampu menjelaskan pengertian, ciri & penanganan kekurangan gizi Mampu menjelaskan pengertian, ciri dan penanganan kelebihan gizi Mampu menjelaskan pengertian malnutrisi mikronutrien dan pentingnya penanggulangan malnutrisi mikronutrien

Background
FR terpenting morbiditas & mortalitas 50% kematian sedunia; 54% kematian di negara berkembang pd 2001 PEM : 1st digambarkan pd 1920s :
Terbanyak di developing countries frequency pd pasien RS & chronically ill children in the USA.

Background
Two forms : kwashiorkor & marasmus Mixed type : Marasmic Kwashiorkor Perbedaan :
Kwashiorkor Marasmus : edema (+) : edema (-)

Background
Marasmus :
intake protein & calories, Adaptasi starvation (kelaparan)

Kwashiorkor :
Intake kalori fair-to-normal with protein
a dysadaptation to starvation.

Background
Two forms : kwashiorkor & marasmus Mixed type : Marasmic Kwashiorkor Perbedaan :
Kwashiorkor Marasmus : edema (+) : edema (-)

Kwashiorkor
BB & TB < baku Edema anasarka menyamarkan BB Massa otot mengecil. Kulit tipis, lembek & berbercak merah Rambut berwarna pirang, kasar dan kaku, serta mudah dicabut

Anak apatis, cengeng dan rewel

Marasmus
Anak kurus kering. Sering rewel, cengeng, penakut. Kulit keriput & wajah spt orang tua. Perut buncit, rambut merah & jarang Anak cengeng dan rewel

Marasmik ~ Kwashiorkor : gabungan keduanya

Prinsip penanganan kurang gizi

Asupan makanan dg banyak protein, tinggi kalori, cukup cairan, vitamin dan mineral. Makanan dalam bentuk mudah dicerna & diserap. Bertahap. Penyakit lain yg menyertai ditangani. Pemantauan & penyuluhan keluarga

Mengapa penting diatasi ?

Karena tidak akan capai tumb ~ bang sempurna. perkembangan otak juga buruk generasi yg Oon : tidak produktif dan tidak mampu hadapi tantangan

Frequency
USA < 1% : malnutrisi kronik. Incidence < 10%, bahkan pd kelompok risti 10% di poedalaman : secondary to inadequate nutrition Hospitalized children : 1/4 acute PEM (istilah lama) 27 % chronic PEM.

Frequency
International WHO : 2015 : prevalence to 17.6% Low weight for age :

113.4 million children < 5 years : 112.8 million in developing countries 70% of these in Asia : southcentral 26% in Africa.

165 million (30.0%) : stunted (pendek) length/height akibat poor nutrition.

Frequency
Sekarang, > 50% anak di Asia selatan : PEM, ~ 6.5 x prevalence dio Barat. Sub-Saharan Africa : 30% of children have PEM.

Definition
WHO : Cellular imbalance between : supply energi & nutrisi & kebutuhan tubuh for : tumbuh, maintenance & specific functions." Bisa oleh asupan kurang , ggn pencernaan or absorbsi. Kelebihan makanan Most : women & young children - of women of child-bearing age in Africa & South Asia : underweight Bayi BBLR

Definition
Tubuh tidak mendapatkan kecukupan
vitamins, minerals & other nutrients
maintain jaringan sehat & fungsi organ

Undernourished or overnourished

Klasifikasi Traditional
Malnutrisi Akut

Malnutrisi Akut Berat

Malnutrisi Akut Moderat

Rawat inap

Rawat jalan

Perbedaan Malnutrisi Akut & Kronis

Etiologi berbeda Indikator diagnostik berbeda Malnutrisi kronis :
stunting (TB/U) Underweight & stunting (BB/U)

Perbedaan Malnutrisi Akut & Kronis

Etiologi berbeda Indikator diagnostik berbeda Malnutrisi Akut :
wasting (kurus) LLA atau BB/TB)

HIV

Perbedaan Malnutrisi Akut & Kronis

Perbedaan pendekatan terapi Tipe program
Malnutrisi kronis preventif : supplemen nutrisi Malnutrisi Akut terapi : diet terapi komplet

Durasi program
Malnutrisi kronis - bertahun Malnutrisi Akut 1-2 bulan

Malnutrisi akut
Fokus pada underweight (BB/U)
Lancet : tidak menggunakan

WHO masih gunakan

Malnutrisi akut
IMCI ( Integrated Management Child Ill = MTBS ~ tidak memakai indikator antropometrik
Hanya berdasar tanda klinis Malnutrisi akut tidak sensitif dan non-specific

Jenis malnutrisi ?
a. Malnutrisi mikronutrien, terpenting : kekurangan vit A, yodium & Fe b. Kekurangan gizi c. Kelebihan gizi (overweight & obesitas)

Undernutrition
Kekurangan intake nutrien esensial or penggunaan or ekskresi berlebihan. Bisa berupa : Malnutrisi Sekunder Malnutri Mikronutrien Malnutrisi Protein Energi (PEM)
Most important

Malnutrisi Sekunder
Diet normal Makanan TIDAK dicerna atai diabsorpsi
Diarea Parasit

Tapeworm

Undernutrition
Bayi, anak kecil, belasan tahun, wanita hamil or buteki : perlu additional nutrients. Nutrient loss : accelerated by diarrhea, keringat berlebih, perdarahan masif, or gagal ginjal. Intake can be restricted by Saat sakit, diet ketat, food allergies, trauma berat, peny serius a lengthy hospitalization, or substance abuse.

Malnutrisi Sekunder

Undernutrition
Chronic malnutrition :
1% in the USA vs to 50% Southeast Asia.

+ 2/3 malnourished : Asia + 1/4 : in Africa

Undernutrition
PEM : penyebab kematian di neg berkembang Akibat intake kalori inadequate : proteins, vitamins & minerals. Undernourished child mjd PEM bila :
Kecepatan pertumbuhan >, infeksi or Sakit yg sebabkan kebutuhan protein & mineral esensial

Protein & mineral disebut micronutrients or

trace elements.

Overnutrition
In USA, akibat dietary imbalances. Results from eating too much, eating too many of wrong things, not exercising enough, or taking too many vitamins or other dietary replacements.

Overnutrition
Risk : by being > 20% overweight, consuming a diet high in fat and salt, and taking high doses of:
Nicotinic acid (niacin) to lower elevated cholesterol levels Vit B6 to relieve premenstrual syndrome Vit A to clear up skin problems Iron or other trace minerals tidak diresepkan oleh doctor.

Overnutrition
Kurang gizi pengaruhi system & the senses of sight, taste, and smell. anxiety, perubahan mood psychiatric symptoms Dimulai dg perub level nutrient darah & jaringan perub level enzyme, abnormalitas jaringan, & malfungsi organ sakit mati

Over weight & Obesitas

BB/TB or BMI > 85%ile : overweight & > 95%ile : obese. Masukan energi > kebutuhan Berhub dg obesitas ortu & inactivity (berjamjam membaca, TV) prevalensi pd anak & dewasa. Prevensi LEBIH MUDAH > terapi. Edukasi healthy eating

Over weight & Obesitas

BB & TB > anak seusia.

Hidung & mulut relatif kecil, dagu berbentuk ganda, perut buncit Sering malas bergaul karena malu risiko penyakit berat saat dewasa kardiovaskuler : stroke, hipertensi, metabolik : DM

Prinsip Tatalaksana
Atasi faktor penyebab, fisik or psikis. Motivasi OT & anak diet seimbang OR teratur dg frekuensi, jenis dan lama latihan sesuai

Malnutrisi Mikornutrien
Asupan nutrien spt vit A, Fe & yodium tidak cukup. Secara fisik sering tak terdeteksi tapi mempengaruhi kesehatan lebih dari 2 milyar orang di seluruh dunia.

Sebelum terapi & 2 tahun setelah Tx kalsium

Sebelum terapi & 2 tahun setelah Tx kalsium

Defisiensi Vitamin A
Penyebab utama : << konsumsi Sumber : daun singkong, bayam, tomat, kangkung daun pepaya, daun katuk pepaya, wortel, telur, ikan, hati

Akibat Defisiensi Vitamin A

imunitas mudah infeksi. Rabun senja dapat berakhir dg kebutaan

Bercak Bitot

Xerosis

Xerosis

Prevensi
Konsumsi harian : Sayuran hijau & buah berwarna, sayur ditumis or dimasak dg santan, agar vit A larut Kapsul vit A dosis tinggi diberikan tiap 6 bulan (Februari & Agustus), juga diberikan pada ibu melahirkan

Defisiensi Fe
Akibat : Tersering : anemia def besi (Adebe). risiko prematur, BBLR risiko kematian ibu hamil kemampuan kerja fisik (letoy) kemampuan belajar

Anemia Defisiensi Besi ~ ADeBe

Menyerang 2 juta org, 90% di negara berkembang
39% anak pra sekolah, 52% bumil

Berkurang dengan :
Aktivitas fisik & mental

Meningkat karena :
Mortalitas bayi lahir Cacing, Malaria, HIV

Beras tinggi besi dapat menolong

Pellagra = defisiensi B3 (Niacin)

Defisiensi Yodium
Penyebab : Makanan & air kurang mengandung yodium. Tidak gunakan garam yodium dlm makanan, khususnya kelg yg tinggal di daerah gondok endemik.

Akibat GAKY
IQ rendah Ggn perkembangan fisik : TB terhambat, ggn saraf motorik gerakan lamban, ggn pendengaran tuli. Defisiensi tingkat kretinisme. Dewasa : pembesaran kelejar gondok Wanita usia subur sering : infertilitas Jika terjadi pd ibu hamil aborsi atau IUFD

Hipotiroidisme kongenital

2. Deficiensi Yodium
Defisiensi Yodium
Menyerang 740 juta org di seluruh dunia Penyebab tunggal kerusakan otak pada bayi yg dapat dicegah

Goiter (pembesaran tiroid)

Goiter Lahir mati Miscarriages Retardasi Mental

Sumber terbaik yodium alami Sea weed / rumput laut Sea food

Prevensi
Selalu gunakan garam yodium di RT. Untuk endemik anak 1-5 tahun diberi kapsul yodium selama 1 tahun

Defisiensi Mikronutrien Lain

Zinc
Retardasi pertumbuhan Maturasi seksual terlambat Lesi kulit & mata 48% penduduk dunia berisiko berisiko defisiensi zinc

Kalsium
Osteoporosis: kerapuhan tulang

Vitamin D
Rickets: malformasi tulang

Other Deficiencies
Vitamin C
Sebabkan Scurvy: problem in kamp pengungsian

Niacin
Sebabkan Pellagra: dermatitis, diarea, dementia Akibat diet tinggi maizena (rendah tryptophan)

Thiamin
sebabkan beriberi Akibat diet tinggi beras kilat

Folate
Defek saat lahir : Anansefali & Spina Bifida

Cheilosis = def vit B2

Akibat Malnutrisi
Defisiensi
Vitamin A
PEM LBW

Mengurangi :

survival productivity intelligence

Iron Iodine

Mortalitas Balita Akibat Underweight

8,000

Deaths

Over 375,000 child deaths

6,000 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Year

Causes and Symptoms

Causes
USA : Primary reasons : kemiskinan & kurang makan. 10% saja: PEM occurs in 50% pasien bedah in 48% pasien rawat inap

Causes
risk chronic diseases, especially pd intestinal tract, kidneys, and liver : Cancer, AIDS, intestinal parasites, and other gastric disorders may lose weight rapidly rentan undernourishment karena tak dapat absorbsi vitamins, calories & iron.

Causes
Ketergantungan drug or alcohol kemampuan absorbsi nutrients rusak Eating disorders : anorexia or bulimia : restrict food intake

Symptoms
Ketidaksengajaan losing > 10 pounds : sign of malnutrition. Skinny or bloated (kembung/bengkak):
pale, thick, dry, and bruises easily.

Rashes and changes in pigmentation Joints ache & bones : soft & tender. Gums bleed easily. Tongue swollen or kerut & pecah2. Ggn visual : night blindness & sensitivity to light & silau.

Other symptoms include

Anemia, diarrhea, disorientation night blindness, irritability, anxiety, & attention deficits, goiter, loss of reflexes and lack of muscular coordination muscle twitches, amenorrhea scaling and cracking of the lips and mouth. Malnourished children may be short for their age, thin, listless, and have weakened immune systems.

Causes
Food allergies. difficult to obtain food need additional calorie intake Failure to absorb nutrients in food following bariatric (weight loss) surgery. Bariatric surgery : techniques as stomach stapling (gastroplasty) and various intestinal bypass procedures to help people eat less and lose weight malnutrition is a possible side effect of bariatric surgery

Clinical

History
Clinical signs and symptoms of PEM include:
Poor weight gain Slowing of linear growth Behavioral changes irritability, apathy, social responsiveness, anxiety, and attention deficits

History
Clinical signs and symptoms of micronutrient deficiencies :
may closely resemble those observed in PEM.

History
The most common and clinically significant deficiencies : Iron - Fatigue, anemia, cognitive function, headache, glossitis & nail changes Iodine - Goiter, developmental delay & MR Vit D - Poor growth, rickets, and hypocalcemia Vit A - Night blindness, xerophthalmia, poor growth, and hair changes Folate - Glossitis, anemia (megaloblastic) & neural tube defects (in fetuses of women without folate supplementation) Zinc - Anemia, dwarfism, hepatosplenomegaly, hyperpigmentation and hypogonadism, acrodermatitis enteropathica, diminished immune response, poor wound healing

Physical of PEM
subcutaneous tissue : most affected : legs, arms, buttocks & face. Edema: most affected : distal extremities & anasarca (generalized edema) Oral changes : Cheilosis Angular stomatitis Papillar atrophy

Physical of PEM
Abdominal findings
Abdominal distension secondary to poor abdominal musculature Hepatomegaly secondary to fatty infiltration

Skin changes
Dry peeling skin with raw exposed areas Hyperpigmented plaques over areas of trauma

Nail changes: fissured or ridged. Hair changes: thin, sparse, brittle, easily pulled out, and turns a dull brown or reddish color.

Causes
Most common cause : inadequate food intake. Developing countries :
Secondary to insufficient or inappropriate food supplies or early cessation of breastfeeding. In some areas, cultural and religious food customs may play a role. Inadequate sanitation further endangers children by the risk of infectious diseases that nutritional losses & alters metabolic demands

Causes
Instead, diseases and, in particular, chronic illnesses play an important role in the etiology of malnutrition. Children with chronic illness : risk for nutritional problems :
Frequently have anorexia inadequate food intake. inflammatory burden and metabolic demands can caloric need. Any chronic illness that involves the liver or small bowel affects nutrition adversely by impairing digestive and absorptive functions.

Causes
Chronic illnesses that commonly are associated with nutritional deficiencies include the following:
Cystic fibrosis Chronic renal failure Childhood malignancies Congenital heart disease Neuromuscular diseases Chronic inflammatory bowel diseases

Causes
Significant risk :
Prematurity Developmental delay In utero toxin exposure (ie, fetal alcohol exposure)

Multiple food allergies special nutritional challenge because of severe dietary restrictions. Patients with active allergic symptoms may have calorie and protein needs.

Gizi buruk
Bentuk terparah kurang gizi menahun Indonesia kehilangan 220 juta IQ poin Dampak lain : produktivitas 20-30% Anak pendek Ggn tumbuh kembang otak IQ rendah

Gizi buruk
Tumbuh kembang otak 80 % saat dlm kandungan s/d 2-5 tahun. WHO : 54% kematian bayi & balita didasari gizi anak yang jelek.

KEP berat : risiko kematian 55%.

6,7 juta balita / 27.3% Indonesia kurang gizi akibat ASI MPASI 1,5 juta gizi buruk. KEP ringan pada anak 9 bulan - 2 tahun,

Gizi buruk
1. Dapat dicegah 2. Bukan hanya karena kemiskinan, tapi pola asuh tidak tercapainya gizi memadai (masalah keluarga). 3. Risiko meninggal gizi buruk 13 x >>

KLB Gizi
Ditemukannya balita : BB/U di bawah standar atau Tanda-tanda marasmus atau kwasiorkor

Diagnosis
Overall :
appearance, behavior, body-fat distribution, and organ function

Record what they eat during a specific period. X rays : determine bone density and reveal GI disturbances & heart and lung damage.

Diagnosis
Blood & urine : measure vitamins & minerals levels & waste products.

Treatment
Normalizing nutritional status starts with a nutritional assessment. This process enables :
a nutritionist or dietician confirm the malnutrition assess the effects of the disorder formulate diets that will restore adequate nutrition.

If cannot or will not eat or unable to absorb nutrients taken by mouth

parenteral nutrition or NGT / enteral nutrition

Treatment
Tube feeding (NGT) : provide nutrients to burns patients or inflammatory bowel disease. Long-term : placed directly into the stomach or small intestine through an incision in the abdomen.

Treatment

Tube feeding cannot always deliver adequate nutrients to patients who: Severely malnourished, require surgery Undergoing chemotherapy or radiation Tx Seriously burned Persistent diarrhea or vomiting Whose GI tract is paralyzed.

iv feeding

Prognosis
< 10% body weight lost : without side effects, > 40% : almost always fatal. Death results from : heart failure, electrolyte imbalance, or hypothermia Poorer prognosis : semiconsciousness, persistent diarrhea, jaundice, or low blood Na levels

Prognosis
Some PEM childrens recover completely Others : problems throughout life, including MR & inability to absorb nutrients Dependent on age, length & severity Young children and the elderly : highest rate of long-term complications and death.

Prevention
ASI exclusive
All Americans > 2 y : Consume plenty of fruits, grains, and vegetables Variety of low fats foods, cholesterols & contain only moderate amounts of salt, sugars & sodium Engage in moderate physical activity, for at least 30 minutes/day, at least several times a week Achieve or maintain their ideal weight Avoid alcohol

Prevention
Screening for every admitted patient If > average risk :
closely assessed and reevaluated often during long-term hospitalization or nursing-home care.

Food Intolerance & Allergy

Alergi : reaksi imunologis terhadap makanan Intoleransi : non-immunologis Klinis :
sistem respirasi, GI, dermatologis or gejala sistemik

Tes challenge

Food Allergy Symptoms

GI : nyeri abdomen, kembung, diare, malabsorpsi, nausea, muntah, konstipasi Respiratory: asma, batuk kronik berulang (BKB), hidung buntu atau meler, wheezing

Food Allergy Symptoms Food Allergy Symptoms

Dermatologis : eksema, atopi, urtikaria, angioedema, gatal, rash Sistemic : anafilaksis, nyeri kepala, perubahan kebiasaan/ behavioral

Hidup is Pilihan

terima kasih