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8/9/2019 Referat Arlha Pem

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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

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