MALNUTRITION

Present by
Rini Widowati 10700045
Faculty of medicine
Wijaya Kusuma Surabaya University
November 2015

DEFINITION

Malnutrition is a state of
deficiency,
excess
or
imbalance
of
energy
protein
and
other
nutrients that can cause
dysfunction in the body. 1

MALNUTRISION

UNDER NUTRITION

MARASMUS

KWASHIORKOR

MARASMUS-KWASHIORKOR

OVER NUTRITION

OBESITY

EPIDEMIOLOGY
National prevalence Toddler Nutrition in
2007 by
Weight / Age
Malnutrition 5,4%

Under nutrition 13,0%.

Malnutrition and undernutrition 18,4%.

nutrition improvement program achievement target 2015
MTD
PO
20%

The target was exceeded

MDG
18,5
%

Marasmus
The cause of
marasmus:
1. Revenue calories
are not enough.
2. improper eating
habits.
3. metabolic
disorders. For
example: renal
acidosis, idiopathic
hypercalcemia,
galactosemia,
lactose intolerance.
4. Congenital
malformations. For
example:
congenital heart
disease, cleft
deformity,

ETIOLOGY
Kwashiork
or
The cause
of
kwashiork
or:
1. Diet
2. Social
factors
3.
Economic
factors
4. Factors
infections
and other
diseases

obesity
Marasmic - Causes of
kwashiorkor obesity:
Causes
marasmic
1. Genetic
2.
kwashiorkor environme
:
nt such as
1. Primary
physical
Malnutrition activity,
2.
nutritional
Secondary
factors,
Malnutrition socioecono
mic factors

Pathophysiology
Less intake

Infection

Mobilitation
reserve various
foods

Sterss
katabolic

Establish of
calories

lack of food
suplement
weaning too
early

Protein
needs
relative
protein
deficiency

congenital
structural
abnormalities
prematurity and
neonatal disease

Kwasiorkor
( acute
malnutrition)

Still adapt
Marasmus ( cronic
malnutrition)

metabolic
disorders

urbaniza
tion

deficiency of
vitamin A, C, E
lipolysis, less
protein
(collagen)

Marasmus

whiny and fussy

mobilization of
carbohydrates, protein
and fat for calories
formation

Very thin
subcutaneous fat
tissue minimal / no
concave stomach,
ribs xylophone
Baggy pants

less energy and

protein

the immune
system is
inadequate

often
accompanied by
infection and
diarrhea

dehydration, whiny,
fussy, sunken eyes,
turgor slow,
apathetic

oncotic pressure
decreases,
extravasation of
fluid into the
interstitial
tissue
edema
face puffy and
rounded
<< protein,
lipoprotein <<
formation, HDL and
LDL accumulate in
the liver

hepatomegaly

Kwasiorkor
<< protein

anemia
<< imun system
infection
hipotrofi muscle

<<<
Vitamin A, C,
E, Minerals
thin hair, reddish
hair like corn,
easily removed,
and loss
bitot't spot
(vitamin A
deficiency)
crazy pavement
dermatosis (redbrown spots in
the skin and easy
to peel

DIAGNOSIS
1. Clinical signs and

symptoms
2. Anthropometric
measurements

Marasmus

Clinical
Kwashiorkor
manifestations

Obesity

Growth is reduced or stopped

Mental changes to apathy

Looks very thin

Anemia

and double chin

Facial appearance such as the elderly

Changes in color and texture of the hair,

relatively short neck

mental changes

easily removed / fall

chest swelled with enlarged breasts

maudlin

Gastrointestinal system disorders

belly bulge and abdominal striae

Skin dry, cool, relaxes, wrinkles

enlargement of the liver

the boys: Buried penis,

Subcutaneous fat disappear until

changes porters

gynaecomastia

reduced skin turgor

muscle atrophy

early puberty

Muscle atrophy so that the contours of

Edema symmetrical on both back legs,

genu valgum (X-shaped leg) with

the bone is clearly visible

can be up to the entire body.

both the inner groin sticking

a round face with chubby cheeks

Superficial veins apparent

together and rubbing can cause

Large sunken fontanelle

skin laceration

Cheekbones and chin appear to be

prominent
Eyes look large and in
Sometimes there is bradycardia
Lower blood pressure than children the
same age

MEASUREMENT
ANTHROPOMETRY
AGE
Calculation of age is in full months, meaning
that the rest of the age in days not counted
(Depkes, 2004).
WEIGHT
Body weight is expressed in index form W / A
(Weight by Age)
HEIGHT
Height expressed in index form of H / A
(height for age), or index also W/ H (Weight
by Height)

Raw Score measurement (Z-score)

Z-score (or SD-score) =

(observed value - median
value of the reference
population) / standard
deviation value of reference
population

Nutritional Status Assessment based index W / A, H / A, W / H Standard

Standard Antropometeri WHO-NCHS 2005

No
1

Index
W/A

H/A

W/H

Nutritional Status

(Z-Score)
< -3 SD

Malnutrition

- 3 s/d <-2 SD

Undernutrition

- 2 s/d +2 SD

Good nutrition

> +2 SD

Obesity

< -3 SD

Very short

- 3 s/d <-2 SD

Short

- 2 s/d +2 SD

Normal

> +2 SD

Tall

< -3 SD

Very thin

- 3 s/d <-2 SD

Thin

- 2 s/d +2 SD

Normal

Example
a boy at the age of 11 months with a body length of 68 cm and

weight 5 kg.
Distribution standard deviations Weight by Age
Raw intersection
Age

11
months

-3 SD

-2 SD

-1 SD

Median

+1 SD

+2 SD

+3 SD

6,8

7,6

8,4

9,4

10,5

11,7

13

in the case of infants 11 months, weight (5 kg) is smaller than the median
value (9.4), and therefore the value of the reference standard deviations
become 9,4-8,4 = 1
So the calculation z score :
(5-9,4) / (9,4-8,4)
z score = - 4,4
Because the value has reached -4.4 z scores mean relatively poor
nutritional status.

Example
A boy aged 26 months with a height of 90 cm and weight 15 kg

Distribution standard deviations W/A :

Raw intersection
Age
26
Months

-3 SD

-2 SD

-1 SD

Median

+1 SD

+2 SD

+3 SD

8,9

10,0

11,2

12,5

14,1

15,8

17,8

Because the weight (15 kg) is greater than the median value of standard
deviations (12.5), then the standard deviations from the reference value is
obtained by subtracting the value of standard deviations + 1SD the median
value, 14.1 - 12.5 = 1, 6
So the calculation z score :
(15 12,5) / (14,1 12,5)
z score = 1,56
because the value of its z-score of 1.56, the relatively good
nutritional status.

MEASUREMENT BY THE DIRECTORATE

OF NUTRITION SOCIETY 2002
INTERPRETATION

Normal: - 2 SD to 2 SD or good nutrition

Thin : <- 2 SD to - 3 SD or undernutrition
Skinny: <- 3 SD or malnutrition
Obesity:> 2 SD or more nutrients

Example
A girl with a body length of 70.0 cm and a

weight of 7.5 kg. In the column body length

of 70.0 cm daughter, when drawn straight
line to the right turned out to weigh 7.5 kg
lies in columns 6.6 to 11.1 kg: -2 SD column
to 2 SD. Interpretation: the child is said to
be normal.

TREATMENT UNDERNUTRISION

Treatment Hypoglycemia
Immediately give the first F75 or modification
When the first F75 can not be provided quickly, give 50

ml of 10% glucose or sugar (1 teaspoon sugar in 50 ml

of water) orally or via NGT.
Continue giving F-75 every 2-3 hours, day and night
for at least two days.
If still breastfed continue breastfeeding beyond the
schedule of the F-75.
If the child is unconscious (letargis), give 10% glucose
solution intravenously (bolus) of 5 ml / kg body weight,
or a solution of glucose / sugar solution 50 ml with
NGT.
Give antibiotics.

treatment hypothermia
Immediate feed F-75 (if necessary, do

rehydration first).
Make sure that children dress (including the
head).
Cover with a warm blanket and place a heater
(not leading directly to the child) or lamp nearby,
or place it directly on the child's mother's chest
or abdomen (skin-to-skin: kangaroo method).
When using electric lights, put a 60 W
incandescent lamp with a distance of 60 cm from
the child's body.
Give appropriate antibiotic guidelines.

Treatment dehydration
Give ReSoMal, orally or by NGT, perform more slowly

than if it did rehydration in children with good nutrition.

Give 5 ml / kg every 30 minutes for the first 2 hours
After 2 hours, give ReSoMal 5-10 ml / kg / hour
alternating with F-75 by the same amount, every hour
for 10 hours.
The exact amount depends on how much the child
wants, volume of stool output and whether the child
vomit.
Furthermore, given the F-75 on a regular basis every 2
hours
If still diarrhea, give ReSoMal whenever diarrhea. For
ages <1 yr: 50-100ml each defecation, age 1 year:
100-200 ml every bowel movement.

Treatment imbalance electrolyte

To cope with given electrolyte disturbances

Potassium and Magnesium, which are

already contained in the solution
Mineral-Mix were added to the F-75, F-100
or ReSoMal
Use ReSoMal solution for rehydration
Prepare food without adding salt (NaCl).

treatment infections
Broad-spectrum antibiotics
Measles vaccine if child aged 6 months

and had never get it, or if a child aged> 9

months and has never been vaccinated
before the age of 9 months.
Delay immunization if the child is in shock.

Treatment micronutrient deficiency

Multivitamin
Folic acid (5 mg on day 1, and then 1 mg /

day)
Zinc (Zn elemental 2 mg / kg / day)
Copper (0.3 mg Cu / kg / day)
Ferosulfat 3 mg / kg / day after a weight
gain (start the rehabilitation phase)
Vitamin A: given orally on days 1 (unless it
has been given before referral)

Provide food for stabilization and

transition
The food in small amounts but often, low

osmolarity and low lactose

Give orally or by NGT, avoid using
parenteral
Energy: 100 kcal / kg / day
Protein: 1-1.5 g / kg / day
Liquid: 130 ml / kg / day (when there is
severe edema give 100 ml / kg / day)
If the child is breastfed, continue

Provide food for catch-up growth

Change F75 to F100. Give F100 amount equal to the F-75

for 2 consecutive days.

Furthermore, raising the number of F-100 10 ml each
time giving up the child is not able to spend or a little left.
Usually this happens when giving formula to reach 200 ml
/ kg / day.
Can also be used porridge or complementary foods are
modified so that the energy and protein content is
comparable to the F-100.
After gradual transition, give the child:
feeding often with an unlimited number
(sesuaikemampuan children) Energy: 150-220 kcal / kg /
day of protein: 4-6 g / kg / day.
If the child is breastfed, continue breastfeeding

Preparing for follow-up at home

Menu and how to make energy-rich foods

and nutrient dense and frequency of

feeding often.
Suggest a structured play therapy:
Completing basic immunizations and / or
replay
Following a program of vitamin A (February
and August)

componen
skimmed
milk (g)
sugar (g)
Vegetable
oil (g)
Oralit
(sachet)
Mineral
mix (ml)
water s/d
phase

F-75
25

F-100
85

ReSoMaL
-

100
30

50
60

25
-

2,5

20

20

20

Stabilisatio
n

1000 ml
Transition
dan
rehabilitatio
n

malnutrition
with
diarrhea or
dehydration

Management Overnutrition
1. Set target weight loss
2. Dietary
3. Setting physical activity
4. Changing lifestyles / behaviors
5. The participation of parents, family members,
friends and teachers
6. Counseling psychosocial problems, especially to
increase confidence
7. Intensive Therapy

complication

In children with severe malnutrition can be

found comorbidities, among others:

Problems in the eye
severe anemia
Skin lesions in kwashiorkor
Persistent diarrhea (giardiasis and intestinal
mucosal damage, lactose intolerance,
osmotic diarrhea)

PROGNOSIS

Death is often caused by an infection, often

can not distinguish between deaths due to

infection or due to malnutrition alone.
Prognosis depends on the stage when
treatment is commenced.

THANKYOU...