CHAPTER 1

INTRODUCTION

Malnutrition is the result of deficiency of protein, energy, minerals as well

as vitamins leading to loss of body fats and muscle tissues. Malnutrition is a
significant public health problem which is often neglected.(2). The World Health
Organization estimates that by the year 2015, the prevalence of malnutrition will
have decreased to 17.6% globally, with 113.4 million children younger than 5
years affected as measured by low weight for age. The overwhelming majority of
these children, 112.8 million, will live in developing countries with 70% of these
children in Asia, particularly the southcentral region, and 26% in Africa. An
additional 165 million (29.0%) children will have stunted length/height secondary
to poor nutrition.

(3)

Malnutrition is directly responsible for 300,000 deaths per

year in children younger than 5 years in developing countries and contributes

indirectly to more than half of all deaths in children worldwide. (6) Protein-energy
Malnutrition (PEM) in children is still a problem of nutrition and public health in
Indonesia. Based Health Research in 2010, as many as 13.0% less nutritional
status, of which 4.9% severe malnutrition. The same data showed 13.3% of
children underweight, of which 6.0% was emaciated children and 17.1% of
children have a very short category. Riskesdas 2013 there is an increased
prevalence of malnutrition-less, namely 19.6%, of which 5.7% severe malnutrition
and 13.9% less nutritional status.
Protein-energy undernutrition (PEU), previously called protein-energy
malnutrition, is an energy deficit due to deficiency of all macronutrients. It
commonly includes deficiencies of many micronutrients. In children, chronic
primary PEU has 2 common forms: marasmus and kwashiorkor. The form
depends on the balance of nonprotein and protein sources of energy. (7)
Marasmus is one of the serious forms of PEM. Marasmus is almost never
seen in the developed world.

CHAPTER II
LITERATURE REVIEW
2.1 Marasmus www.unicef.org type of undernutrition
A rapid deterioration in nutritional status in a short time can lead to
marasmus, one form of acute malnutrition. Marasmus is the most common form of acute
malnutrition in nutritional emergencies and, in its severe form, can very quickly lead to
death if untreated.
It is characterised by severe wasting of fat and muscle which the body breaks down to
make energy. Wasting can affect both children and adults.
The body of a wasted child tries to conserve energy as much as possible by
reducing physical activity and growth, reducing internal body processes and shutting
down the bodys response to infection. This reduced activity results in limited function of
the liver, kidney, heart and gut putting the child at risk for:

Low blood sugar (hypoglicemia)

Low body temperature (hypotermia)

Fluid overload/heart failures

Infection

2.2. Etiologi Marasmus

The immediate cause of PEM is a deficiency of calories and protein with various
symptoms. While the cause is not immediately KEP very much, so the disease is often
called a multifactorial causes. One reason is the relationship with time breastfeeding or
breast milk and supplementary food after weaning (Khurnaidi, 1989).
Jellife (1998) states that the nutritional state of a person is the interaction of all
aspects of the environment including the physical environment, biological and cultural
factors. Broadly speaking, the factors that determine the nutritional state of the public,
especially the children is the parents' education level, economic conditions, the
availability of sufficient food, as well as health aspects.
PEM is basically determined by two factors. Factors that can directly affect the
occurrence of PEM in children under five is the food and the presence or absence of
infectious diseases. Both of these factors are influenced by the quality and quantity of
food eaten on a child, among others, determined by some indirect factor, namely a) the
nutrients contained in the food, b) the purchasing power of families, including income,

the price of materials food, and family expenditures for other needs besides food, c)
beliefs about food and health of the mother, d) the presence or absence of health care,
including cleanliness (Levinson, 1979 in Lismartina, 2000).

2.3 Pathophysiology

Protein-energy malnutrition will occur when the body's need for calories,
protein, or both are not fulfilled by diet. (Arisman, 2004: 92). In a state of lack of
food, the body is always trying to preserve life by meeting basic needs or energy.
The ability of the body to use carbohydrates, proteins and fats is very essential to
maintain life, carbohydrates (glucose) can be used by all body tissues as fuel,
unfortunately the body's ability to store carbohydrates very little, so that after 25
hours was possible shortage. As a result, protein catabolism occurs after a few
hours to produce amino acids are immediately converted into carbohydrates in the
liver and kidneys. Diving fasting fat tissue are broken down into fatty acids,
glycerol and ketone bodies. Muscles can use fatty acids and ketone bodies as an
energy source that is running a chronic food shortage. The body will defend itself
not to break down proteins again after losing roughly half of the body.
2.4 Clinical Signs of Marasmus www.fao.org.human nutrition in a developing
world
Poor growth. In all cases the child fails to grow properly. If the age is known, the weight
will be found to be extremely low by normal standards (below 60 percent or -3 SD of the
standard). In severe cases the loss of flesh is obvious: the ribs are prominent; the belly, in
contrast to the rest of the body, may be protuberant; the face has a characteristic simian
(monkey-like) appearance; and the limbs are very emaciated. The child appears to be skin
and bones. An advanced case of the disease is unmistakable, and once seen is never
forgotten.
Wasting. The muscles are always extremely wasted. There is little if any subcutaneous fat
left. The skin hangs in wrinkles, especially around the buttocks and thighs. When the skin
is taken between forefinger and thumb, the usual layer of adipose tissue is found to be
absent.

Alertness. Children with marasmus are quite often not disinterested like those with
kwashiorkor. Instead the deep sunken eyes have a rather wide-awake appearance.
Similarly, the child may be less miserable and less irritable.
Appetite. The child often has a good appetite. In fact, like any starving being, the child
may be ravenous. Children with marasmus often violently suck their hands or clothing or
anything else available. Sometimes they make sucking noises.
Anorexia. Some children are anorexic.
Diarrhoea. Stools may be loose, but this is not a constant feature of the disease.
Diarrhoea of an infective nature, as mentioned above, may commonly have been a
precipitating factor.
Anaemia. Anaemia is usually present.
Skin sores. There may be pressure sores, but these are usually over bony prominences,
not in areas of friction. In contrast to kwashiorkor, there is no oedema and no flaky-paint
dermatosis in marasmus.
Hair changes. Changes similar to those in kwashiorkor can occur. There is more
frequently a change of texture than of colour.
Dehydration. Although not a feature of the disease itself, dehydration is a frequent
accompaniment of the disease; it results from severe diarrhoea (and sometimes vomiting)

F. Diagnosis
In malnourished patients, the most common complain is no increase of body
weight, poor feeding, frequently ill, or bilateral ankle edema, and the whole body.
In patients with kwashiorkor, children look letargis, apatis, and or irritable. The
apparently manifestation of kwashiorkor are swelling of the abdominal wall,
making the body weight undecreased in thr first time of kwashiorkor.

Diagnosis of malnutrition is made based on nutritional status of the patient.

Nutritional status is defined by physical examination and anthropometric
(BW/BL, AC). Clinical manifestations of children with kwashiorkor are:
alterations of consciousness to apatis, anemia, alterations or colour and texture of
hairs, easy to peel of, disturbaances of gastrointestinal system, hepatomegaly,
dermatosis, athrophy of muscles, bilateral ankle pitting edema to the whole body.
Based on physical examination and anthropometric (BW/BL), nutritional
status is categorized to be severe malnutrition, mild-moderate malnutrition, health,
and obesity.

Anthropometry

Clinical Presentation
Severe malnutrition

(BW/BL)

Looked very thin and or bilateral < -3 SD **)

ankle edema and the whole
body.

Mild-moderate malnutrition

Looked thin

- 3 SD < - 2 SD

Health

Looked health

- 2 SD 2 SD

Obesity

Looked fat

> 2 SD

**) BW/BL can be > -3 SD if there is severe edema (the whole body).
Malnutrition is categorized to severe malnutrition with complications,
severe malnutrition without complications and mild-moderate malnutrition.
Physical Examination, BW/BL, AC
Severe malnutrition Severe malnutrition without

Mild-moderate

with complications

malnutrition

complications

Children with one

Children with

Children with

AC>11.5cm<12.5cm

or more signs:

one or more

one or more

(children 6-59

-Looked very thin

signs:

signs:

months) (BW/BL<-2

-Edema the whole

-Looked very

body

thin

very thin -

- BW/BL<-3SD

-Minimal

BW/BL<-3SD

And

-AC<11,5cm

edema, bilateral

Goodly feeding

(children 6-59

palm/ankle

-Looked

to -3 SD)
No edema

AC<11,5cm

No clinical

months) and one or edema

(children 6-59

abnormality

more medical

- BW/BL<-3SD

months)

complications

-AC<11,5cm

signs:

(children 6-59

-goodly feeding

-Anorexia

months)

-without any

-Severe pneumonia

and

-Severe anemia

-goodly feeding

-Severe

-without any

dehydration

medical

-High grade fever

complications

And

medical
complications

-level of
consciousness
Some laboratories examination we should do for patients with kwashiorkor
are blood glucose, peripheral blood smear, urinalysis, stool examination,
electrolyte, protein, and ferittin. Maantoux test, chest x-ray, and ECG to exclude
differential diagnosis should be consider.
G. Management
Children with malnutrition should be treated with four phases, they are:
stabilization,

transition,

rehabilitation,

and

further

management

Medical
N
Steps

Stabilization

Transition Rehabilita- Further

tion
H 1-2

H 3-7

Preventing
1
and

nd

management
th

2 -6

th

th

7 -66

ome

weeks

weeks

importa

treating

nt

---

things

hypoglycemia

we must

Preventing
2
and

attend

treating

hypothermia

are:

---

Preventing
3
and

on't

treating

dehydration

give Fe

---

before
2nd

Treating
4
electrolyte

----

week

imbalance

(Fe

Treating
5

given in

infection

-------------------

stabiliza

Stabilized
6

tion

micronutrient

Without Fe

deficiencies

-------------------------

With Fe

phase).
Don't

-----Feeding
7
for

give
intraven

stabilization and

ous

transition

fluid

Feeding
8
for

drip
unless

growth

the

Stimulating
9
for

patient

development
Preparation
1
for
0

is

further
management at
home

is

in
shock
or
severe

dehydration.
Don't give high protein diet in stabilization phase.
Don't give diuretics to patients with kwashiorkor.

Preventing and treating hypoglycemia

Hypoglycemia is defined with blood glucose < 40mg% in children and blood glucose
<50mg% in infant. Treat hypoglycemia with rapid injection of 50cc glucose 10% or sucrose
10% per oral/NGT.

Preventing and treating hypothermia

Hypothermia is defined with axilla temperature < 36.5o C. Treat hypothermia with
kangaroo method, hold the child in the chest, a blanket to the head.

Preventing and treating dehydration

Classification of dehydration (min 2 signs + 1 *)
Without dehydration

Mild-moderate

Severe dehydration

dehydration
Presentation*

Alert

Irritable

Letargis

Tears

Eyes

Sunken

Very sunken

Lips mucosa

Dry

Very dry

Thirsty*

Want to drink

Thirsty

Cannot drink

Turgor *

Good

<

Poor

To treat dehydration, give Resomal (Rehydration Solution for Malnutrition)

5cc/kgBW/30' for 2 hours orally/NGT.

Antibiotic for Infection

No complications

Cotrimoxazole (25mg sulfametoksasol+5mg

trimethoprim/kg)/12 hours for 5 days

Complications (shock,

Gentamicin iv or im (7.5mg/kg)/day for 7 day,

hypoglycemia, hypothermia,

plus

dermatosis, URI,UTI, or

Ampicillin iv or im

Followed by

letargis, ill looking)

(50mg/kg)/6 hours for

amoxicillin orally

2 days

(15mg/kg)/8 hours for

5 days

No improvement of any

Chloramphenicol iv or im (25mg/kg)/8 hours

symptoms within 48 hours, add:

for 5 days (every 6 hours if suspected for

meningitis)

Any specific infection

Specific antibiotics

Stabilization Phase
Fluid and feeding allowance in stabilization phase to a malnourished patient without
any warning signs (shock, unconscious, and vomiting/diarrhea/dehydration). Give 50ml of
glucose 10% orally rapidly, monitor heart rate, respiratory and alertness every 30 minutes in
the first 2 hours, and every 1 hour in the next 10 hours.
In the first 2 hour, give F-75 every 30 minutes, doses for 2 hours based on body
weight (with or without edema). Monitor heart rate, respiratory, alertness and provision of
F75 every 30 minutes. In the next 10 hours, continue the provision of F75 in children every 2
hours. Monitor heart rate, respiratory and provision of F75. If the child is still breastfeeding,
give ASI between the provisions of F75. If the child can consume almost of F75, change the
time of provision to be every 3 hours or every 4 hours if the child can consume the whole of
F75. You'd better give F75 orally as much as you can. Consider NGT if the child cannot
consume the whole F75.
Reduce to give F75 based on minimal calories requirements in stabilization phase (with
or without edema) if you find any warning signs; heart rate and respiratory rate increased,
jugular vein blocked, or edema increased (e.g.: markedly periorbital edema).
Transition and Rehabilitation Phase (4)
If every doses of F75 given per 4 hours could be finished by children, change F75 to
be F100 as much as the volume of F75 for 2 day. Monitor heart rate, respiratory and
provision of F100 every 4 hours. If the child is stable, continue F100 based on body weight in

the third day. Increase 10 ml every 4 hours until the child couldnt finish the formula, but not
to exceed the maximal doses of F100.
In the fourth day of transition phase, give F100 every 4 hours based on body weight
between minimal and maximal doses. Continue F100 for next 14 days (last day of transition
phase).
In rehabilitation phase, give F100 and solid food based on body weight. If the BW <
7kgs, give F100 plus soft food and fruits extract. If the BW>7kgs, give F100 plus soft food
and fruits. Continue giving the food until BW/BL>-2 SD standard WHO 2005.
Reduce to give F100 if you find any warning signs; heart rate and respiratory rate
increased, jugular vein blocked, or edema increased (e.g.: markedly periorbital edema).
Evaluate for 1 hour.

Giving sensory and emotional stimulation

A child with malnutrition is usually accompanied by delayed of mental and behavior,
so the parents should give love, happy environmental, structured playing treatment for 15-30
minutes/day, daily activities as soon as the child recover with mother's involvement.

Preparation for further management at home

Children with malnutrition is said to be recovered if BW/BL > -2SD. Instruct the
parents how to make a meal based on the childs BW. Control the growth and development of
children once per week in the first month, once every 2 weeks in the second month, and once
every month in the next 4 months. Remember to give immunizations and booster, and highdose vitamin A every 6 months (based on age).

H. Prognosis (12)
Getting treatment early generally leads to good results. Treating kwashiorkor in its
late stages will improve the child's general health. However, the child may be left with
permanent physical and mental problems. If treatment is not given or comes too late, this
condition is life-threat

CHAPTER III
CASE REPORT
3.1 Objective

The objective of this paper is to report a case of 2 years and 3 months old girl with a diagnosis of
Bronchopneumonia.
3.2 Case
K, a 2 years and 3 months girl, with 7 kg of BW and 79 cm of BH, is a new patient of infection
unit in Pediatric Department in Central Public Hospital Haji Adam Malik Medan on September
2nd 2015 at 14.55. Her chief complaint was dyspnea.
History of disease:
K ,a girl, 2 years and 3 months old, came to Haji Adam Malik Hospital at September 2 nd 2015
with dyspnea as the chief complaint. The patient have been experienced this since morning.
Patient looks weak since a day before. Dyspnea (+) since 2 days ago. Dyspnea doesnt caused by
activity or weather. Cough (+) been experienced for 2 weeks. At first was dry, but then became
productive. History of recur cough since this past 2 months. Her grandmother also had productive
cough for a month. History of fever was 2 months ago, lasted for this two weeks, up and down.
Diarrhea was experienced for a day, without losing weight. Vomitting was denied. No history of
family having the same condition.
History of previous illness: The patient is a new patient
History of medication:History of family: No family history of DM and other diseases
History of parents medication: unclear
History of pregnancy: Patients mother was 27 years old during pregnancy. The gestation age
was 36 weeks. No history of complication neonate and maternal problem.
History of birth: Birth assisted by GP. The baby was born paravaginal and she cried
spontaneously. Bluish was not found. Body weight 2700 gram, body length 46 cm, and head
circumference was not measured.
History of feeding: 6 months of exclusive breast feeding, additional food since 7 months old and
family food was given from 19th week onward.
History of immunization: BCG, Polio 4 times, Hepatitis B 3 times, DPT 3 times, and Measles.
History of growth and development: Face down: 4 months old, Sit down: 6 months old, Crawl:
8 months old, Stand up: 10 months old, Walk: 13 months old, Talk: 12 months old.
Physical Examination:
Present status: Level of consciousness: Conscious, Body temperature: 38C, HR: 100 bpm,
RR: 48 bpm, BW: 7 kg, BH: 79 cm, BW/A: -3 < SD BL/A: -3 < SD < -2, BW/BL: -3 < SD ,
anemic (-), icteric (-), dyspnea (+), cyanosis (-), edema (-).
Localized status:
Face edema (-), Eyes: superior and inferior palpebral edema (-), Light reflex +/+,
isochoric pupil, pale wasnt found in inferior conjunctiva palpebral.
Ears: within normal range
Nose: within normal range
Mouth: within normal range
-)
Symmetrical fusiform, suprasternal, intercostal and substrenal retraction (+), Cor
S1,S2 (+), HR: 100 bpm, regular, murmur (-), RR: 48 bpm, regular, rhonchi (+/+) wheezing (-/-),
rales (-/-)
Symmetric, supple, normal peristaltic, liver and spleen: unpalpable.
00 bpm regular, p/v adequate, warm acral, CRT < 3, clubbing finger(-),
pretibial oedema (-).

Laboratory finding
Complete blood analysis (September 2nd , 2015)
Test
Hemoglobin
Erythrocyte
Leucocyte
Thrombocyte
Hematocrite
Eosinophil
Basophil
Neutrophil
Lymphocyte
Monocyte
Neutrophil absolute
Lymphocyte absolute
Monocyte absolute
Eosinophyl absolute
Basophyl absolute
MCV
MCH
MCHC
RDW

Result
10.40
3.77
18.13
332
32.30
1.00
0.900
62.90
27.50
7.70
11.41
4.99
1.39
0.18
0.16
85.70
27.60
32.20
12.60

Unit
g%
106/mm3
103/mm3
103/mm3
%
%
%
%
%
%
103/L
103/L
103/L
103/L
103/L
fL
Pg
g%
%

Morphology: Erythrocyte: normochromic normosite

Leukocyte: leukocytosis
Thrombocyte: thrombocytosis
Clinical Chemistry Test
Result
Unit
Carbohydrate Metabolism
Blood Glucose
151.00
mg/dL
Electrolite
Natrium
138
mEq/L
Kalium
4.3
mEq/L
Chloride
104
mEq/L
Blood Arterial Gas
Analyse
pH
7.320
pCO2
21.0
mmHg
pO2
183.0
mmHg
Bicarbonate (HCO3)
10.8
mmol/L
Total CO2
11.4
mmol/L
Base Excess(BE)
-14.0
mmol/L
O2 Saturation
100.0
mmol/L

Referral
12.0-14.4
4.40-4.48
4.5-13.5
150-450
37-41
1-6
0-1
37-80
20-40
2-8
2.4-7.3
1.7-5.1
0.2-0.6
0.10-0.30
0-0.1
81-95
25-29
29-31
11.6-14.8

Referral
< 200
135-155
3.6-5.5
96-106

7.35-7.45
38-42
85-100
22-26
19-25
(-2) (+4)
95-100

Working diagnosis : Bronchopneumonia + Mild Malnutrition

Therapy :
1. O2 nasal canule 1 liter/i
2. Inj Meropenem 140 mg/8 hour /iv
3. Salbutamol 3x0,5 mg
4. Ambroxol 3x5 mg

5. As. Folat 1x1 mg

6. Vit. C 1x100 mg
7. Vit. B Complex 1x1
8. Diet F 75 100cc/3hour+ mineral mix 2cc
Planning Assement
1. Blood gas saturation, electrolytes, /3 hour
2. Balance fluid / 6 hour
3. Observe vital sign/ 30 minutes