Tatalaksana Gizi Buruk

Dr Brain Gantoro, M.Gizi, SpGK

 PEM.

Nutrition Problems in Indonesia

t Protein Energy Malnutrition (PEM)

t Iron Deficiency Anaemia

t Iodine Deficiency (=GAKI)
t Zinc Deficiency
t Vitamin A Deficiency
t Obesity
Theoretical framework of Nutrition Problems.
Nutrition problems

Food intake Infect Disease direct

causes

Food availability Mother & child Health indirect

in household caring service causes

POOR FAMILY & EDUCATION, main

FOOD STUFF & JOB OPPORTUNITY problem

ECONOMIC & POLITIC CRISIS core

problem
Types of Malnutrition
Overnutrition
Secondary malnutrition
Micronutrient malnutrition
Protein Calorie malnutrition
Overnutrition
Too many calories leading to obesity, diabetes, hypertension
and cardiovascular disease
Transition diets now a consideration of WHO due to
increase worldwide in chronic disease due to dietary change
On a global basis 79 % of all deaths attributable to chronic
disease are already occurring in developing countries
Public health implications are staggering
Overnutrition following fetal malnutrition has also been
linked to chronic disease risk in adulthood
Secondary Malnutrition
Condition that prevents proper digestion or absorption
Often accompanies and exacerbates other types of malnutrition

Causative conditions
Loss of appetite
Alteration of normal metabolism
during infection/fever
HIV/AIDS
Prevention of nutrient absorption
Diarrheal infection causing changes in GI epithelium
Diversion of nutrients to parasitic agents themselves
Hookworms, tapeworms, schistosome worm
Malaria
Children with Intestinal
Parasites
(courtesy of WHO)
Prevention of nutrient diversion
Sanitary waste disposal and clean water important
in reducing secondary malnutrition
Prevention of transmission of parasites and diarrheal
diseases
Hookworm acquired by walking barefoot over
contaminated soil
Other roundworm infections use oral-fecal route
Soap an important factor in nutritional status
Education of women extremely important in this regard
Micronutrient Malnutrition
Dietary Deficiencies of
Vitamin A
Iodine
Iron
Others: Zinc, vitamins D, C, and Bs
Protein Calorie Malnutrition
More food needed for normal growth,
health and activity
Rarely have protein deficiency without
caloric deficiency due to the nature of the
food supplies
exception seen with cassava and plantain as
staples
Role of calories
Involuntary use: breathing, blood
circulation, digestion, maintaining muscle
tone and body temperature
Physical activity
Mental activity
Fighting disease
Growth
Role of protein
For building cells that make up muscles,
membranes, cartilage and hair
Carrying oxygen
Nutrient transport
Antibodies
Enzymes needed for most chemical reactions
in the body
What happens to people when they
have inadequate amounts of food
and nutrients?
Metabolic changes
Physiologic changes
Psychological changes
Metabolic Response to Starvation
Hunger subsides after 2-3 days
Defecation ceases after 3-4 days
Urine output drops after 1 week in the majority of
people to 100-700 ml/day
Blood glucose levels drop to 35-65 mg/dL without
clinical signs of hypoglycemia
Nausea occurs in about 1/3 from ketone
production from body fat breakdown
Serum electrolytes do not change
Renal conservation occurs promptly
Rarely see low potassium in prolonged fast
Metabolic Response to Starvation
Negative nitrogen balance - 1st 5-7 days
12-15 grams of nitrogen per day is excreted in
the urine (based on 1800 kcal daily needs)
Skeletal muscle is catabolized to produce
glucose (gluconeogenesis), using about 75
grams per day of protein
This is equal to lb of wet tissue per day
About 160 gm/day of body fat is also used
Metabolic Response to Starvation
Negative nitrogen balance
Gradually slows so that at about 1 month
2-4 grams of nitrogen is loss per day
Skeletal muscle catabolism decrease
significantly
Only for cells that have to have glucose
Central nervous system
Red blood cells
White blood cells
Metabolic Response to Starvation
Gradual shift in metabolic fuels
First glucose is produced from protein
breakdown to provide energy
Then fat breakdown and metabolism provides
ketones for all tissues except CNS, RBC and
WBC
Brain will eventually use ketones but red blood cells
have no mitochondria, so must use glucose
Serum fatty acid levels increase
Serum albumin is normal until late in starvation
Production of Ketones
Metabolism
Metabolic Response to Starvation
Hormonal changes
Plasma insulin decreases
Plasma cortisol and growth hormone stay the
same and glucagon increases
These changes are responsible for the
mobilization and oxidation of fat stores
Changes in sympathetic nervous system and
metabolism of thyroid hormone lowers basal
metabolic rate
Metabolic Response to Starvation
Weight loss
1st week 0.7-1.3 kg/day, much of which is salt
& water loss
After 1st week 0.3-0.5 kg/day
Basal Metabolic Rate & Total Energy
Expenditure in prolonged starvation
See activity, sleep
body temperature
 Protein Energy Malnutrition

Disease / clinical conditions caused by energy &

protein deficiency, usually accompanied by
deficiency of other nutrients.

Primary:
nutrition intake <<

quality / quantity of nutrition <<

Secondary : - nutr needs/output >>

Energy balance: negative
INPUT:
Infection
Poverty
Organic dis.
etc.

OUTPUT:
Infection
Chronic diarrhea/
Malabsorption
Hypermetabolism
etc.
 Protein Energy Malnutrition

T Nutr.status = spectrum :

Wt/Ht

undernutrition normal overnutrition

70 80 90 110 120 %
-3SD -2SD +2SD +3SD

PEM severe moderate mild overweight obese

-Kwashiorkor mild
-Marasmus moderate
-M-K severe
super
Classification PEM
1 GOMEZ (195..) W/A
2 MacLarren (196..) Clinical + laboratory
3 The Wellcome Trust Clinical + anthropometric
Party (1970) (W/A)
4 Waterlow (1973) W/H
5 WHO (1999) Clinical + anthropometric
(Z-score)
Classification (WHO, 1999) MEP
Moderate PEM Severe PEM
Symmetrical -- +
oedema (oedematous malnutrition)
W/H -3< Z-score <-2 < -3 Z-score
(70-79%) (<70%)
(severe wasting)
H/A -3< Z-score <-2 < -3 Z-score
(85-89%) (<85%)
(severe stunting)
 PEM.

DIAGNOSIS :

1. Anamnesis

2. Physical examination

3. others : - laboratory
- anthropometry
- dietary analysis
 PEM.

Checklist : anamnesis
Usual diet before current episode of
illness
Breastfeeding history
Food & fluids taken in past few days
Recent sunken eyes
Duration & freq. of vomiting / diarrhoea,
appearance of vomit / diarrhoeal stools
 PEM.

Checklist : anamnesis
Time when urine was last passed
Any deaths of siblings
Birth weight?
Milestones reached (sitting up, standing,etc)
Contact with people with measles or
tuberculosis
Immunizations
 PEM.

Checklist: Physical examination

Weight, Length/Height
Signs of circulatory collapse : cold hands &
feet, weak pulse, consciousness <<
Temperature : hypothermic / fever
Respiratory rate and type of respiration :
signs of pneumonia or heart failure.
Severe pallor anaemia gravis
Eyes : - corneal lesion vit.A deficiency
- sunken dehydration
Anaemia
 PEM.

Checklist: physical examination

Thirst, dryness of lips & mouth
ENT : evidence of infection?
Abdominal distension, bowel sounds?
Enlargement or tenderness of liver, jaundice
Skin : infection, purpura, fat tissue?
Oedema, muscles atrophy
Apperance of faeces
 Severe PEM : Kwashiorkor
hair
face

Puffy

Oedema
 Severe PEM : Kwashiorkor

Hepatomegaly
Crazy pavement oedema
dermatosis
 Severe PEM : Marasmus
face

hair

Muscles atrophy
SC fat <<
Ribs
Severe PEM : Marasmus + KP

lymphadenopathy
 Severe PEM : Marasmus + KP
Caverne

Destroyed lung 6 weeks after th/

 PEM.

Laboratory tests:
Tests that may be useful :
Blood glucose : < 54 mg/dl = hypoglycaemia
Blood smear : parasit malaria
Hb or Ht : < 4 g/dl / < 12% = severe anaemia
Urine exam/culture: bacteria (+) / > 10 lekosit/HPF
infection
Faeces : blood (+) disentri
Giardia (+) / parasit lain infeksi
X-ray : - thorax : l Pneumonia
l Heart failure

- bone : rickets, fracture

Tes tuberkulin : often negative
Tests that are little ot no value :serum protein, HIV,
electrolytes
 PEM.

MANAGEMENT :

l Mild-moderate PEM :
- no specific clinical signs : thin, hypotrophic
- not necessary to hospitalize
- looking for the probable causes
- nutrition education & supplementation

l Severe PEM : should be hospitalized

 PEM.

Other criteria :
Very low BW:
W/H < 70%
W/A < 60%
W/A > 60% + edema
+ clinical signs & symptoms :
edema (M-K)
severe dehydration
persistent diarrhea & / vomiting
severe pallor, hypothermia, shock
signs of systemic / local infection, URI
severe anemia ( Hb < 5 g/dl)
jaundice
anorexia
< 1 yr of age
 PEM.
Signs & symptoms of dehydration :
history of diarrhea or no/diminished intake
weak, apathetic unconscious
weak to absent of radial pulse
thirst, dry mouth & absent of tears
sunken eyes & fontanel
hypothermia
cold hands & feet
urine flow << / -
Dehydration

Sunken eyes
 Dehydration

Turgor :
 PEM.

5 ASPECTS in the MANAGEMENT of Severe PEM :

A. 10 main steps

B. Treatment of underlying diseases

C. Failure to respond to treatment

D. Discharge before recover

E. Emergency
 PEM.
A : 10 main steps
No Interven- Stabilization Transition Rehabilitation Follow-up
tion d.1-2 d.3-7 wk-2 wk 3-6 wk 7-26
1. Treat/prevent
hypoglycaemia
2. Treat/prevent
hypothermia
3. Treat/prevent
dehydration
4. Correct electr.
imbalance
5. Treat infection
6. Correct micro- without Fe + Fe
nutrients defic.
7. Begin feeding
8. Increase feeding
9. Stimulation
10. Prepare for
discharge
 PEM.

B. Treatment of underlying diseases / infection :

Bacterial infection :
- no apparent signs of infection/no complication:
cotrimoxazole ( 5 mg TMP/kg, 2x/d, 5 days )

- signs of infection / complications / sepsis :

- ampicilline 50 mg/kg/6 hrs, IM/IV,
for 2 days oral (ampi / amoxy)
- gentamycin 7.5 mg/kg, IM/IV, 7 days
- KP (+) anti-TB drugs

Viral infection : no specific th/

- all PEM should receive measles vaccine
 PEM.

C. Failure to respond to treatment :

Frequent causes of failure to respond :

a. Problems with the treatment facility :

- poor environment for malnourished children
- insufficient or inadequately trained staff
- inaccurate weighing machine
- food prepared or given incorrectly
 PEM.

C. Failure to respond to treatment :

Frequent causes of failure to respond :

b. Problems of individual children :

- insufficient food given
- vitamin-mineral deficiency
- malabsorption of nutrients
- rumination
- infections
- serious underlying disease
 PEM.

C. Failure to respond to treatment :

Criteria Time of admission

Primary failure to respond:
- Failure to regain appetite Day 4
- Failure to start to lose oedema Day 4
- Edema still present Day 10
- Failure to gain at least 5 g/kg/d Day 10

Secondary failure to respond :

- Failure to gain at least 5 g/kg/d During rehabilitation
for 3 consecutive days
 PEM.

C. Failure to respond to treatment :

1. Death
= within first 24 hrs :
- hypoglycemia
- hypothermia
- dehydration
- sepsis

= within 24 72 hrs :
- volume of formula >>
- caloric density >>
 PEM.

C. Failure to respond to treatment :

2. Inadequate gaining weight :

- infection
- diet
- psychologic

Weight gain :
= satisfactory: > 10 g/kg/d good =
= sufficient : 5-10 g/kg/d > 50 g/kg/wk
= poor : < 5 g/kg/d or < 50 g/kg/wk
 PEM.

D. Discharge before fully recover:

= Dietary advice :
- high protein and calorie
- frequent feeding ( 5x/d )
- finish all meals given
- vit-min supplementation & electrolytes
- continue BF
= frequent controle ( 1x/wk )
= Immunization
 5. Emergency :

5.1. Shock :
N2 or RLG5%
15 ml/kg, 1 hr

Improvement
_
+

Repeat 1 hr more sepsis

Resomal 10 ml/kg, 10 hrs Maintenance, 4 ml/kg/hr

Fresh blood, 10 ml/kg

Special formula
 5. Emergency :

5.2. Severe anaemia.

Hb ?

Hb < 4 g/dl Hb 4-6 g/dl

Resp.distress/heart failure?
Fresh blood 10 ml/kg* _
+

PRC 10 ml/kg* Observation

* : give furosemid 1 mg/kg, iv, before transfusion

 PEM.

Prepare for discharge :

- W/H : - 1 SD or severe PEM moderate/mild

- Education for mother :
- hygiene & sanitation
- healthy foods
- immunization
- stimulation
- regular controle

- to continue the th/ of chronic diseases

- to completing immunization
On admission : 2 weeks later :
Sh, girl, 2 yrs, W : 4.750 g
W : 3.875 g H : 67.4 cm
H : 67 cm W/H : < -3 SD
W/H : < -4SD

4 weeks later : 5 weeks later :

W : 5.310 g W : 6.280 g
H : 67.7 cm H : 67.8 cm
W/H : + -3 SD W/H : - 2 SD
7 yrs,
10 kg

Recovery : 16 kg
Protein energy malnutrition
1- Marasmus
Definition:
A clinical syndrome & a form of under nutrition
characterized by failure to gain weight due
to inadequate caloric intake.
Incidence:
Commonly in infants between the age of 6mo -
2years (Infantile atrophy).
 Etiology
1. Dietary errors
2. Infection: (acute / chronic) TB, Otitis media, Pyelonephritis
3. Gastroenteritis: acute / chronic
4. Parasitic infestations: Ascaris, Ankylostoma, Giardia
5. Congenital anomalies: Cardiac (PDA, VSD, F4), Renal (renal
agenesis, obstructive uropathy), GIT (Pyloric stenosis, Cleft lip or
palate)
6. Metabolic diseases: Galactosemia, Fructose intolerance, Idiopathic
hypocalcaemia
7. Prematurity
8. Some cases of mental retardation
9. Low socio-economic status
10. Endocrine causes (DM, Hyperthyroidism)
 Assessment of Marasmic
Child/Infant
Failure to thrive, loss of weight (weight < 60% of expected)
Loss of subcutaneous fat: (measured at many parts of the
body according to the degrees)
o 1 st degree: abd. wall
o 2 nd degree: abd. wall & limbs
o 3 rd degree: abd. Wall, limbs & face
 Assessment of Marasmic
Child/Infant (Cont.)
Muscle wasting (thin muscles & prominence of
bony surfaces)
GIT disturbances: anorexia in advanced cases,
hungry, constipation / diarrhea / starvation diarrhea
Liability to infection
Hypovolemia
Weak feeble pulse, subnormal temp, pulse rate
Senile face & pallor
 Complications of Marasmus

1. Intercurrent infection:
Bronchopneumonia is the cause of death
2. Gastroenteritis
3. Hemorrhagic tendency, purpura
4. Hypothermia
5. Hypoglycemia
6. Edema (marasmic kwashiorkor)
 Investigations for Marasmic
Infant
1. Blood analysis: WBC, Electrolytes,
Glucose, Ketones, Plasma proteins
2. Urine analysis: Culture, Glucose,
Ketones, Ca, Phosphate, Protein
3. Stool analysis: parasites
4. X-ray: chest
5. Tuberculin test: TB
6. ENT examination: Otitis media
 Treatment
1. Prevention:
Balanced nutritional diet
Encourage breast feeding up to weaning
Proper weaning
Vaccination (measles, TB, whooping cough)
Education regarding the cheap sources of balanced
diet, family planning.
Proper follow up of the growth rate
Early treatment of defects or associated diseases
 Treatment (Cont.)
2 Curative treatment:
A. Proper dietary management:
Adequate balanced feeding; teaching: nutritional needs, preparation
of diet, technique of administration of food
If there is vomiting or anorexia, give IV fluids / naso gastric tube
feeding.
Gradual increase the amount and concentration of formula (total
calories is 120-200 cal/kg/d)
B. Treatment of the cause
C. Emergency treatment for complications
D. Blood transfusion
E. Vitamins and minerals supplementation
 2-Kwashiorkor
Definition
A clinical syndrome & a form of malnutrition
characterized by slow rate of growth due to
deficient of protein intake, high CHO diet
and vitamins & minerals deficiency
(adequate supply of calories).
Incidence
Commonly in toddlers between the age 1-
3years, following or with weaning
 Etiology

1. Unbalanced diet (protein, CHO)

2. Improper weaning (during & post weaning
period)
3. Faulty management of marasmic baby
4. Ignorance poverty due to lack of basic
health education
5. Precipitating factors: acute infection with
measles, diarrhea & malaria, parasitic
infestations
 Assessment
1. Essential features
(cardinal manifestation):
Growth retardation:
Weight is diminished (60-80%) of
expected
Edema:
Due to hypoproteinemia, starts in the
feet & lower parts of the legs, then
becomes generalized edema.
The cheeks become bulky, pale,
waxy in appearance (doll-like-
cheeks)
 Assessment..
1. Essential features:..
Diminished muscle fat ratio:
Generalized (muscle wasting) with subcutaneous fat
Fatty liver:
Detected by liver biopsy
Mental changes:
Apathy, never smile, looks sad & cry weak
 Assessment..
2. Early features (usual
manifestation):
Hair changes:
sparse, dyspigmentation (reddish or
grayish), atrophic, easily pick able.
GIT Manifestations:
anorexia, vomiting in severe cases,
diarrhea
 Assessment..
3. Occasional / variable features
Vitamins (A, C, D) & minerals defection (Fe, Zn & Mg)
Hepatomegaly.
Skin changes (dermatitis in areas due to pigmentation, napkin
dermatitis, petechiae over the abdomen, fissures, ulceration)
Poor resistance & liability to infections
 Complication of kwashiorkor
1. Secondary infection, fungal & bacterial
2. Hemorrhagic tendency, purpura
3. Gastroenteritis
4. Hypoglycemia
5. Hypothermia
6. Heart failure due to anemia & infection.
Investigations for kwashiorkor
1. Blood analysis: (Albumin < 2.5 mg/dL), total
protein, Enzymes (amylase, lipase, alkaline
phosphate), Glucose (hypoglycemia), K
(hypokalemia)
2. Low pancreatic & intestinal enzymes
3. Urine analysis, culture for infection
4. Stool analysis for parasites
5. Chest x-ray
6. Tuberculin test
 3-Marasmic Kwashiorkor
Definition
A combination of caloric deficiency (marasmus) &
protein deficiency (Kwashiorkor) .
Clinical picture
The clinical picture of this disease represents
manifestations from both diseases as:
loss of subcutaneous fat as in marasmus
edema, hair & skin changes as in kwashiorkor but
there is no moon face.
Thank You