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
MTDP
O
20%

MDG

18,5%

The target was exceeded

ETIOLOGY
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,
palatoschizis, micrognathia

Kwashiorkor
The cause of
kwashiorkor:
1. Diet
2. Social
factors
3. Economic
factors
4. Factors
infections and
other diseases

Marasmic kwashiorkor
Causes marasmic
- kwashiorkor:
1. Primary
Malnutrition
2. Secondary
Malnutrition

obesity
Causes of
obesity:

1. Genetic
2. environment
such as physical
activity,
nutritional
factors,
socioeconomic
factors

Pathophysiology
Less intake

Infection

Mobilitation reserve
various foods

Sterss katabolic

Establish of calories

Protein needs

lack of food
suplement
weaning too early

congenital structural
abnormalities

relative protein
deficiency
Kwasiorkor ( acute
malnutrition)

Still adapt
Marasmus ( cronic
malnutrition)

prematurity and neonatal

disease
metabolic disorders

urbanization

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

Marasmus

mobilization of carbohydrates,
protein and fat for calories
formation

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

whiny and fussy

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 (red-brown
spots in the skin and
easy to peel

DIAGNOSIS
1. Clinical signs and symptoms

2. Anthropometric measurements

Clinical manifestations
Marasmus

Kwashiorkor

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 skin

Large sunken fontanelle

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 WHONCHS 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

F-75

F-100

ReSoMaL

skimmed milk
(g)

25

85

sugar (g)

100

50

25

Vegetable oil (g) 30

60

Oralit (sachet)

2,5

Mineral mix
(ml)

20

20

20

water s/d
phase

1000 ml
Stabilisation

Transition dan
rehabilitation

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...