Malnutrition in Children

mtsdarmawan

Background

04/11/23 dr. Darmawan, SpA 3

Gizi (Nutrition)

• Proses penggunaan makanan secara normal

04/11/23 dr. Darmawan, SpA 4

Keadaan Gizi

• Keseimbangan antara konsumsi, penyerapan & pemakaian.

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 & mortalitas50% 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 : edema (+)– Marasmus : 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 : edema (+)– Marasmus : 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

InternationalWHO :

• 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 • ¼ - ½ 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

Malnutrisi Akut

Malnutrisi Akut Berat

Malnutrisi Akut Moderat

Rawat inap Rawat jalan

Klasifikasi Traditional

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 gizic. 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

(berjam-jam 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– Lahir mati– Miscarriages– Retardasi Mental

• Sumber terbaik yodium alami– Sea weed / rumput laut– Sea food

Goiter

(pembesaran tiroid)

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 Mengurangi :

survivalVitamin A

PEMLBW

productivity

IronintelligenceIodine

Mortalitas Balita Akibat Underweight

•

6,000

8,000

2006200720082009201020112012201320142015

6,000

8,000

2006200720082009201020112012201320142015

Deaths

Over 375,000 child deaths

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 dicegah2. 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.

TreatmentTube 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

• Dermatologis : eksema, atopi, urtikaria, angioedema, gatal, rash

• Sistemic : anafilaksis, nyeri kepala, perubahan kebiasaan/ behavioral

Food Allergy Symptoms

Hidup is Pilihan

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