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REFERAT PROTEIN ENERGY MALNUTRITIONARLHA APORIA DEBINTA 07120100068
Fakultas K!"kt#a$ U$%&#s%tas Pl%ta Ha#a'a$K'a$%t#aa$ Kl%$%k Il(u Ks)ata$ A$ak
R* B)a+a$,ka#a Tk-I R-*- *uka$t"./aka#taP#%"! N"& 201 3 11 /a$ua#% 201
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Defnition
Malnutrition as "the cellular imbalancebetween the supply o nutrients and
energy and the body's demand or themto ensure growth, maintenance, andspecifc unctions." (WH!
ormerly #nown as $rotein %nergy
Malnutrition ($%M!, now is used todescribe a group o related disorders thatinclude marasmus, #washior#or, andintermediate states o marasmus&
#washior#or.
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%pidemiology
t any time approimately )** millionchildren su+er rom the moderate or
seere orms o $%M. ccording to Riset Kesehatan Dasar
(-is#esdas! in **/, 0ndonesia1s childnutrition problem has slightly showed an
improement, rom 2,34 in **/ to 3,54in *)*.
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%tiology
%tiology o $%M may be diided into6
0llness&related
7on&illness -elated
0llness&related comprise o6
8astrointestinal disorders
%.g $ancreatic insu9ciency, enteritis,retroperitoneal fbrosis.
Wasting disorders
0D:, ;ancer, ;$D
;ondition that increases metabolic demands
%ndocrine disorders e.g $heochromocytoma
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%tiology
N"$.Ill$ss #lat! %$4lu!
:ocio&economic actor
inancial restrain causing amilies
not to be able to buy proper oodcontaining nutrients re
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8rowth :tatus
0t is important to #now a growth status o a child beorema#ing a diagnosis o $%M.
0mportant data includes height, weight, age.
Weight
>hose children who weigh less than the mean weights ochildren in their age group are thus called "wasted1.
cute orms o malnutrition chie?y a+ect body weight morethan height.
Height
>hose children whose heights are less than the meanheights o children in their age group are called 'stunted1.
;hronic orm both height and weight are a+ected
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:eeral method o classifcation is usedsuch as
). 8ome@ classifcation
. Waterlow classifcation
A. WH classifcation
3. Mc=arens scoring suystem or proteinenergy malnutrition
2. Wellcome >rust $arty system
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8ome@ classifcation
>he 8ome@ classifcation does not ta#e
height into consideration thereore it isotenly critici@ed or being inaccurate.
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Waterlow classifcation
Waterlow combines weight&or&height
(indicating acute episodes o malnutrition!with height&or&age to show the stuntingthat results rom chronic malnutrition.
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WH ;lassifcation
>he World Health rgani@ation (WH!
defnes seere acute malnutrition as6 a mid upper arm circumerence (MB;!
C )).2 cm,
a weight&or&height z-score (WHE!below FA, or
the presence o bilateral pedal oedema inchildren with #washior#or.
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;lassifcation o 7utritional :tatus based onweightGage (W! indicator6
Malnutrition 6 E score C&A
=ess 7utrition 6 * Escore I &A.* s G dEscore C&
8ood 7utrition 6 * Escore I &.* s G dEscore CI
More 7utrition 6 * Escore .*
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;lassifcation o 7utritional :tatus based onheightGage (H! indicators6
Jery :hort 6 Escore C&A.*
:hort 6 Escore I & A.* s G d Escore C&.*
7ormal 6 Escore I &.*
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;lassifcation o 7utritional :tatus based onweight G height indicator6
Jery :#inny6 Escore C&A
:#inny 6 * Escore I &A.* s G dEscore C&
7ormal 6 * Escore I &.* s G dEscore CI
;hubby 6 * Escore .*
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;lassifcation o 7utritional :tatus based on combinedheightGage (H! and weightGheight (WH! indicators6
:hort&:#inny 6 Escore >K G B C&.* and E:core weight G
height C&.*
:hort&7ormal 6 Escore >K G B C&.* and Escore weight Gheight between &.* s G d .*
:hort&at 6 Escore >K G B C&.* and Escore KK G >K .*
7ormal&>hin >K6 >K Escore G B I &.* and Escore weight Gheight C&.*
7ormal&7ormal >K6 >K Escore G B I &.* and Escore weight Gheight between &.* s G d .* >K
7ormal&at 6 Escore >K G B I &.* and Escore KK G >K .*
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Wellcome >rust Wor#ing $arty system, as shown inthe table below 6 3
Lwashior#or 6 Kody weight *4 rom normalN edema
Marasmus 6 Kody weight C *4 rom normalwithout edema
MarasmicOLwashior#or 6 Kody weight *4 romnormal N edema
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;lassifcation
irstly malnutrition can be diided into6
$rimary malnutrition which means
malnutrition resulting rom inade
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>wo distinct clinical syndromes hae beendescribed, #washior#or and marasmus,
and represent the seere orms o $%M.
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Marasmus (non&edematous :;B withseere wasting!
7on&edematous :;B was belieed toresult primarily rom inade
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Lwashior#or (edematous :;B!
%dematous :;B was belieed to result
primarily rom inade
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Marasmic & Lwashior#or, has eatures oboth disorders (wasting and edema!.
Marasmic & Lwashior#or is a miture oboth conditions. :ometimes a child canswitch rom one to the other.
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$athophysiology
Dietary defcit is the biggest contributor causingmalnutrition.
0n the case o Marasmus6
=ean body mass utili@ed causing wasting
urther brea#down and ammonia synthesis
Muscle brea#down
$roduce #etone bodies
:upressed insulin production
;atabolic hormones starts to act
0nsu9cient energy inta#e
Kody uses it own stores
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0n the case o #washior#or6
0nsu9cient protein inta#e
Hypoproteinemia and edema
Kody unable to produce lipoprotein
ats accumulate in lier (atty lier!
0mmune proteins are not synthesi@ed
+ect all organ system
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;linical Maniestation
Marasmus 5Ol! (a$ a4 *%(%a$ M"$k+ l%k9
a''a#a$4 " a4 s%$4 t) 4)%l!a''a#a$4 "$l+ 4"('#%s " sk%$ a$!
:"$s-
Fa%lu# t" t)#%& ;)%l!#$ sk%$ )a$,%$, %s s'4%all+ s$ a#"u$!:utt"4ks a$! t)%,)s> $a(l+ 5:a,,+
'a$ts a''a#a$4-
Lss %#%ta:l ;"('a#! t" k(a#as(%4 4)%l!#$ )a& !' su$k$ +sa$! #at)# lss %##%ta:l-
Ha%# 4)a$,s %$ t?tu# ("# t)a$ 4"l"#-
Lwashior#or E!(a !u t" )+'"'#"t%$(%a
la!%$, t" @u%! #t$t%"$- T)
!(a %s '%tt%$, a$! (a+ &a#+#"( (%l! '%tt%$, t" a$asa#4a-
M$tal 4)a$,s t) 4)%l! (%,)t: a'at)t%4 a$! lt)a#,%4-
*k%$ 4)a$,s s)"
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ther eatures occuring in both Marasmus andLwashior#or6
Jomiting and diarrhoea leading to dehydration.
nemia due to reduced dietary inta#e ohematopoietic actors li#e preotein and olic acid. Mostcommon type o anemia is iron defciency anemia.
0nection such as respiratory inection
ther nutritional defciency such as6
Perophtalmia (lac# o Jitamin !
Jitamin K comple defciency
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Diagnosis
Bsed oten to diagnose malnutrition in0ndonesia is a guideline proided by WH
that states6 Weight or height C &A:D or C/*4 rom
2*th percentile
%dema on dorsal part o the eet to allparts o the body or
Lwashior#or weight or height &A :D
Marasmic&Lwashior#or C &A :D
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0nitial history ta#ing should includeinormation regarding6
s#ing whether there is sudden deepsun#en eyes
Diarrhea and omitting inormation
Brination
Whether etremities eel cold
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urther inormation regarding this inormation should also beobtained6
Dietary habit beore sic#ness
Kreasteeding inormation
eeding inta#e
Whether or not there is a decline in appetite
;ontact with patient diagnosed with tuberculosis Whether within the last three months, patient su+er rom
measles
;hronic cough
0normation regarding (death o! siblings
Kirth weight ;hild deelopmental milestones
0mmuni@ation history
Whether there is monthly documentation o weight increment
%nironmental inormation (including amily and socialbac#ground!
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$hysical eamination should include6
Whether edema is present ssess nutritional status
:ign o dehydration (thirst, sun#en eyes, poor s#in turgor!
$resence o shoc# signs (cold etremities, poor capilarry reflltime!
eer
-espiratory rate
$allor
ssess hepatosplenomegaly
Distended abdomen (loo# or bowel sound!
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>reatment >he usual approach to the treatment o the child with seeremalnutrition is diided into three phases (>able 3A&2!. >hese are6
0nitial treatment (days )&/!6
lie&threatening problems are identifed and treated in ahospital or a residential care acility,
specifc defciencies are corrected, metabolicabnormalities are reersed and eeding is begun.
-ehabilitation (wee#s &!6
intensie eeding is gien to recoer most o the lostweight, emotional and physical stimulation are increased,
the mother or carer is trained to con tinue care at home,
preparations are made or discharge o the child.
ollow&up (wee#s /&!6 ater discharge,
the child and the child1s amily are ollowed to preentrelapse and assure the continued physical, mental and
emotional deelopment o the child.
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>he guidelines or the treatment oseere malnutrition are diided infe sections6
. 8eneral principles or routine care(the1)* steps1!
K. %mergency treatment o shoc#and seere anaemia
;. >reatment o associated conditions
D. ailure to respond to treatment
%. Discharge beore recoery iscomplete
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T)# a# t$ ss$t%al st's).>reatGpreent hypoglycaemia. >reatGpreent hypothermiaA. >reatGpreent dehydration3. ;orrect electrolyte imbalance2. >reatGpreent inection. ;orrect micronutrient defciencies/. :tart cautious eedingQ.chiee catch&up growth
5.$roide sensory stimulation andemotional support)*. $repare or ollow&up ater recoery
A- GENERAL PRIN;IPLE* FORROUTINE ;ARE
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).$reent hypoglycemia
;riteria
Detrosti C23gGdl
$reention
)*4 o glucose, rereatment
2*ml )*4 glucose or sucrose () teaspoon sugar in three tablespoonwater!
/2 therapeutic mil# eery hour or the frst 3 hour, continueeery or A hour.
0 the child is unconcious, treat with )*4 glucose ia 78>
Monitor
Monitor blood glucose, i ound to be low, repeat measurement A*mins aterwards.
Watch or unconciousness, rectal temperature C A2.2*;, repeat test.
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.$reent hypothermia
Watch i aillarytempertture CA2o;, ta#erectal temperature. 0rectal temperatureCA2o;6
eed straightaway (orstart rehydration ineeded!
rewarm the child6 eitherclothe the child(including head!, coerwith a warmed blan#etand place a heater orlamp nearby (do not usea hot water bottle!, or
put the child on themother1s bare chest s#in
M"$%t"#
:"!+ t('#atu# !u#%$,#
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A.$reent dehydration
T#at($t
>he standard oral
rehydration salts solution(5* mmol sodiumGl!contains too muchsodium and too littlepotassium or seerely
malnourished children.0nstead gie specialRhydration *"lution orMalnutrition (-e:oMal!.
R*"Mal (lk, &#+ 0(%$- "# t "#all+ "#:+ $as",ast#%4 tu:> t)$
.10 (lk,) "# $?t .10)"u#s t) ?a4t a("u$t t": ,%&$ s)"ul! :!t#(%$! :+ )"< (u4) t)4)%l! a$! st""l l"ssa$! &"(%t%$,- R'la4 t)R*"Mal !"ss at > 6> 8 a$!10 )"u#s t)$
4"$t%$u !%$, sta#t# F.7
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3.;orrect electrolyte
imbalance ll seerely malnourished
children hae ecess bodysodium een though
plasma leel may be low.8ie6
etra potassium A&3mmolG#gGd
etra magnesium *.3&*.mmolG#gGd
when rehydrating, gielow sodium rehydration?uid (e.g. -e:oMal!
prepare ood without salt
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2. $reent 0nection
0n seere acute malnutrition, theusual signs o bacterial inection,such as eer, are oten absent,yet multiple inections are
common.
T#at($t
8ie all seerely malnourishedchildren6
broad&spectrum antibiotic
measles accine i the child is R months and not accinated orwas accinated beore 5 monthsage. Delay accination i thechild is in shoc#.
;)"%4 " a$t%:%"t%4s
Bncomplicated acutemalnutrition, gie a("?4%ll%$"# !a+s-
Ken@ylpenicillin (2*.*** 0BG#g0M or 0J eery h!orampicillin (2* mgG#g 0M or
0J eery h! or days, thenoral amoicillin (2O3* mgG#geery Q h or 2 days! .
8entamicin /.2 mgG#g 0M or0J! once a day or / days.
>reat other inection as
appropriate (e.g meningitis,respiratory inection!
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. ;orrect micronutrient
defciencyT#at($t
8ie itamin on day ) and repeaton days and )3 only i child hasany signs o itamin defciencyli#e corneal uleration or history omeasles.
Dosage is 2*.*** 0B or Cmonths, **.*** 0B or &)months and **.*** or )months.
:tart iron at A mgG#gGday or dayson &)** catch up ormula. gie theollowing micronutrients daily or atleast wee#s6
olic acid 2mg on day ) and
)mg daily
Mult%&%ta(%$s %$4lu!%$,&%ta(%$ A a$! "l%4 a4%!> %$4a$! 4"''# a# al#a!+'#s$t %$ F.7> F.100 a$!
#a!+.t".us t)#a'ut%4 ""!'a4kts-
=)$ '#(%?! 'a4kts a#us!> t)# %s $" $! "#a!!%t%"$al !"ss-I$ a!!%t%"$>
% t)# a# $" + s%,$s "#)%st"#+ " (asls> t)$ !" $"t,%& a )%,) !"s " &%ta(%$ A:4aus t) a("u$ts al#a!+'#s$t %$ t)#a'ut%4 ""!sa# $"u,)-
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/. ;autious eeding
0nitial eeding
S re
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Q. chiee catch up growth
>arget gain )*ggainG#gGday
I
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5. :ensory stimulation and emotional support
$roide6
tender loing care
a cheerul, stimulating enironment
structured play therapy )2&A* minGd
physical actiity as soon as the child is well
enough maternal inolement when possible
(e.g. comorting, eeding, bathing, play!
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)*. ollow up ater recoery
child who is 5*4 weight&or&length(e
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B- E(#,$4+ t#at($t " s)"4k a$! s&# a$a(%a
I$ t) 4as " s)"4k
gie oygen
gie sterile )*4 glucose (2 mlG#g! by 0J
gie 0J ?uid at )2 mlG#g oer ) hour. Bse -inger1s lactatewith 24
detroseU or hal&normal saline with 24 detroseU or hal&strength Darrow1s solution with 24 detroseU or i these are
unaailable, -inger1s lactate measure and record pulse and respiration rates eery )*
minutes
gie antibiotics
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I t)# a# s%,$s " %('#"&($t'uls a$! #s'%#at%"$ #ats all9
repeat 0J )2 mlG#g oer ) hourU thenswitch to oral or nasogastric rehydrationwith -e:oMal, )* mlG#gGh or up to )*hours.
8ie -e:oMal in alternate hours withstarter &/2, then
continue eeding with starter &/2
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I t) 4)%l! a%ls t" %('#"& ater the frst hour o treatment
()2 mlG#g!, assume that the child has septic shoc#. 0n this case6
gie maintenance 0J ?uids (3 mlG#gGh! while waiting or blood,
when blood is aailable transuse resh whole blood at )*mlG#g slowly oer A hoursU then
begin eeding with starter &/2 (step /!
I t) 4)%l! ,ts
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I$ t) 4as " s&# a$(%a
blood transusion is re
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;- T#at($t " ass"4%at! 4"$!%t%"$s
). Jitamin defciency
0 the child shows a$+ + s%,$s o defciency, gie orally6
itamin on days ), and )3 (or age ) months, gie
**,*** 0BU or age &) months, gie )**,*** 0BU or age *&2 months, gie 2*,*** 0B!. 0 frst dose has been gien in the
reerring centre, treat on days ) and )3 only
0 there is 4"#$al 4l"u!%$, "# ul4#at%"$, gieadditional eye care to preent etrusion o the lens6
instil chloramphenicol or tetracycline eye drops ()4! &Ahourly as re
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$arasitic worms
gie mebenda@ole )** mg orally, twice daily or A days
Diarrhea Mucosal damage
8ie metronida@ole (/.2 mgG#g Q&hourly or / days!
=actose intolerance
:ubstitute mil# eeds with yoghurt or a lactose&ree
inant ormula smotic diarrhea
Bse isotonic /2
0ntroduce )** orally
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2. >uberculosis (>K!
0 >K is strongly suspected (contacts with adult
>K patient, poor growth despite good inta#e,chronic cough, chest inection not responding toantibiotics!6
perorm Mantou test (alse negaties arereK, treat according to national >K guidelines.
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D. ailure to respond to
treatment ailure is indicated i6
High mortality
=ow weight gain during rehabilitationphase
0mportant to chec# on6
0nade
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;omplication
ON MALNUTRITION
atty lier may be result as it is oten seen in Lwashior#or. at
content may be up as high as 2*4, due to increase in ?u@ o
atty acids rom adipose tissue or production o energy anddecreased hepatic synthesis o $&lipoporetein that normalytransport triglycerides rom the lier.
$ancreas shows mar#ed atrophy o acinar cells.
Heart muscles atrophy leads to reduced cardiac output,
resulting to congestie cardiac ailure. Hemopoietic system results in anemia
Muscle shows glycogen depletion and disorgani@ation o thesarcomere
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ON REFEEDING
-eeeding syndrome6
:eere hypophosphatemia (:erumphosphate leels o T*.2 mmolG= ! during)st wee# o reeeding.
;ausing wea#ness, rhabdomyolisis,
cardiorespiratory ailure, arryhtmias,sudden death
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$rognosis
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Malnutrition a+ects many organs andsystem in the body.
0n acute state, $%M cause hypothermia,hypoglycemia, dehydration andelectrolyte imbalance.
0n long term, it cause speech and growthretardation that leads to decreasecognitie unction