mts malnutrition 2011
Post on 16-Apr-2015
67 Views
Preview:
TRANSCRIPT
Malnutrition in Children
mtsdarmawan
Background
04/11/23 dr. Darmawan, SpA 3
Gizi (Nutrition)
• Proses penggunaan makanan secara normal
04/11/23 dr. Darmawan, SpA 4
Keadaan Gizi
• Keseimbangan antara konsumsi, penyerapan & pemakaian.
Learning Obyektif
• Mampu menjelaskan pengertian malnutrisi secara umum dan kondisi malnutrisi di Indonesia
• Mampu menjelaskan pengertian, ciri & penanganan kekurangan gizi
• Mampu menjelaskan pengertian, ciri dan penanganan kelebihan gizi
• Mampu menjelaskan pengertian malnutrisi mikronutrien dan pentingnya penanggulangan malnutrisi mikronutrien
Background
• → FR terpenting morbiditas & mortalitas50% kematian sedunia; 54% kematian di negara berkembang pd
2001
• PEM : 1st digambarkan pd 1920s : – Terbanyak di developing countries – ↑ frequency pd pasien RS & chronically ill
children in the USA.
Background
• Two forms : kwashiorkor & marasmus• Mixed type : Marasmic Kwashiorkor • Perbedaan :
– Kwashiorkor : edema (+)– Marasmus : edema (-)
Background
• Marasmus : – ↓ intake protein & calories, – Adaptasi starvation (kelaparan)
• Kwashiorkor : – Intake kalori fair-to-normal with ↓
protein – a dysadaptation to starvation.
Background
• Two forms : kwashiorkor & marasmus• Mixed type : Marasmic Kwashiorkor • Perbedaan :
– Kwashiorkor : edema (+)– Marasmus : edema (-)
Kwashiorkor
• BB & TB < baku• Edema anasarka → menyamarkan ↓ BB • Massa otot mengecil.• Kulit tipis, lembek & berbercak merah• Rambut berwarna pirang, kasar dan kaku,
serta mudah dicabut
• Anak apatis, cengeng dan rewel
Marasmus
• Anak kurus kering.• Sering rewel, cengeng, penakut.• Kulit keriput & wajah spt orang tua.• Perut buncit, rambut merah & jarang• Anak cengeng dan rewel
• Marasmik ~ Kwashiorkor : gabungan keduanya
Prinsip penanganan kurang gizi
• Asupan makanan dg banyak protein, tinggi kalori, cukup cairan, vitamin dan mineral.
• Makanan dalam bentuk mudah dicerna & diserap.
• Bertahap.• Penyakit lain yg menyertai ditangani.• Pemantauan & penyuluhan keluarga
Mengapa penting diatasi ?
• Karena tidak akan capai tumb ~ bang sempurna. → perkembangan otak juga buruk → generasi yg ‘Oon’ : tidak produktif dan tidak mampu hadapi tantangan
Frequency
USA• < 1% : malnutrisi kronik. • Incidence < 10%, bahkan pd kelompok
risti • 10% di poedalaman : secondary to
inadequate nutrition • Hospitalized children :
– 1/4 acute PEM (istilah lama)– 27 % chronic PEM.
Frequency
InternationalWHO :
• 2015 : prevalence ↓ to 17.6%• Low weight for age :
– 113.4 million children < 5 years :• 112.8 million in developing countries
– 70% of these in Asia : southcentral – 26% in Africa.
• 165 million (30.0%) : stunted (pendek) length/height akibat poor nutrition.
Frequency
• Sekarang, > 50% anak di Asia selatan : PEM, ~ 6.5 x prevalence dio Barat.
• Sub-Saharan Africa : 30% of children have PEM.
Definition
WHO : • “Cellular imbalance between :
– supply energi & nutrisi & kebutuhan tubuh for :• tumbuh, maintenance & specific functions."
– Bisa oleh asupan kurang , ggn pencernaan or absorbsi.
– Kelebihan makanan
• Most : women & young children • ¼ - ½ of women of child-bearing age in Africa &
South Asia : underweight
Bayi BBLR
Definition
• Tubuh tidak mendapatkan kecukupan – vitamins, minerals & other nutrients → maintain jaringan sehat & fungsi organ
• Undernourished or overnourished
Malnutrisi Akut
Malnutrisi Akut Berat
Malnutrisi Akut Moderat
Rawat inap Rawat jalan
Klasifikasi Traditional
Perbedaan Malnutrisi Akut & Kronis
• Etiologi berbeda• Indikator diagnostik berbeda
– Malnutrisi kronis :• stunting (TB/U)• Underweight & stunting (BB/U)
Perbedaan Malnutrisi Akut & Kronis
• Etiologi berbeda• Indikator diagnostik
berbeda– Malnutrisi Akut :
• wasting (kurus) LLA atau BB/TB)
HIV
Perbedaan Malnutrisi Akut & Kronis
• Perbedaan pendekatan terapi– Tipe program
•Malnutrisi kronis – preventif : supplemen nutrisi
•Malnutrisi Akut – terapi : diet terapi komplet
– Durasi program•Malnutrisi kronis - bertahun•Malnutrisi Akut – 1-2 bulan
Malnutrisi akut
• Fokus pada underweight (BB/U)– Lancet : tidak menggunakan
• WHO masih gunakan
Malnutrisi akut
• IMCI ( Integrated Management Child Ill = MTBS ~ tidak memakai indikator antropometrik
– Hanya berdasar tanda klinis
– Malnutrisi akut tidak sensitif dan non-specific
Jenis malnutrisi ?
a. Malnutrisi mikronutrien, terpenting : kekurangan vit A, yodium & Fe
b. Kekurangan gizic. Kelebihan gizi (overweight &
obesitas)
Undernutrition
• Kekurangan intake nutrien esensial or penggunaan or ekskresi berlebihan.
• Bisa berupa :– Malnutrisi Sekunder– Malnutri Mikronutrien– Malnutrisi Protein Energi (PEM)
• Most important
Malnutrisi Sekunder
• Diet normal• Makanan TIDAK
dicerna atai diabsorpsi– Diarea– Parasit
Tapeworm
Undernutrition
• Bayi, anak kecil, belasan tahun, wanita hamil or buteki : perlu additional nutrients.
• Nutrient loss : accelerated by diarrhea, keringat berlebih, perdarahan masif, or gagal ginjal.
• Intake can be restricted by – Saat sakit, diet ketat, food allergies,
trauma berat, peny serius – a lengthy hospitalization, or substance
abuse.
Malnutrisi Sekunder
Undernutrition
• Chronic malnutrition :– 1% in the USA vs to 50% Southeast Asia.
• + 2/3 malnourished : Asia • + 1/4 : in Africa
Undernutrition• PEM : penyebab kematian di neg
berkembang• Akibat intake kalori inadequate : proteins,
vitamins & minerals. • Undernourished child → mjd PEM bila :
– Kecepatan pertumbuhan >, infeksi or – Sakit yg sebabkan kebutuhan protein & mineral
esensial ↑
• Protein & mineral disebut micronutrients or
trace elements.
Overnutrition
• In USA, akibat dietary imbalances. • Results from
– eating too much, – eating too many of wrong things, – not exercising enough, or – taking too many vitamins or other
dietary replacements.
Overnutrition
• Risk : ↑ by being > 20% overweight, consuming a diet high in fat and salt, and taking high doses of:– Nicotinic acid (niacin) to lower elevated
cholesterol levels– Vit B6 to relieve premenstrual syndrome– Vit A to clear up skin problems– Iron or other trace minerals tidak diresepkan
oleh doctor.
Overnutrition
• Kurang gizi → pengaruhi system & the senses of sight, taste, and smell. → anxiety, perubahan mood psychiatric symptoms
• Dimulai dg perub level nutrient darah & jaringan → perub level enzyme, abnormalitas jaringan, & malfungsi organ → sakit → mati
Over weight & Obesitas
• BB/TB or BMI > 85%ile : overweight & > 95%ile : obese.
• Masukan energi > kebutuhan • Berhub dg obesitas ortu & inactivity
(berjam-jam membaca, TV)• ↑ prevalensi pd anak & dewasa.• Prevensi LEBIH MUDAH > terapi.• Edukasi healthy eating
Over weight & Obesitas
• BB & TB > anak seusia.
• Hidung & mulut relatif kecil, dagu berbentuk ganda, perut buncit
• Sering malas bergaul karena malu
• → risiko penyakit berat saat dewasa – kardiovaskuler : stroke,
hipertensi, – metabolik : DM
Prinsip Tatalaksana
• Atasi faktor penyebab, fisik or psikis.• Motivasi OT & anak diet seimbang • OR teratur dg frekuensi, jenis dan lama
latihan sesuai
Malnutrisi Mikornutrien
• Asupan nutrien spt vit A, Fe & yodium tidak cukup.
• Secara fisik sering tak terdeteksi tapi mempengaruhi kesehatan lebih dari 2 milyar orang di seluruh dunia.
Sebelum terapi & 2 tahun setelah Tx kalsium
Sebelum terapi & 2 tahun setelah Tx kalsium
Defisiensi Vitamin A • Penyebab utama : << konsumsi• Sumber :
· daun singkong, bayam, tomat, kangkung· daun pepaya, daun katuk· pepaya, wortel, telur, ikan, hati
Akibat Defisiensi Vitamin A
• ↓ imunitas → mudah infeksi.• Rabun senja → dapat berakhir dg
kebutaan
Bercak Bitot
Xerosis
Xerosis
Prevensi
• Konsumsi harian : – Sayuran hijau & buah berwarna,
sayur ditumis or dimasak dg santan, agar vit A larut
• Kapsul vit A dosis tinggi diberikan tiap 6 bulan (Februari & Agustus), juga diberikan pada ibu melahirkan
Defisiensi Fe
Akibat :• Tersering : anemia def besi
(Adebe). • ↑ risiko prematur, BBLR• ↑ risiko kematian ibu hamil• ↓ kemampuan kerja fisik
(letoy)• ↓ kemampuan belajar
Anemia Defisiensi Besi ~ ADeBe
• Menyerang 2 juta org, • 90% di negara berkembang
– 39% anak pra sekolah, 52% bumil
• Berkurang dengan : – Aktivitas fisik & mental
• Meningkat karena : – Mortalitas bayi lahir– Cacing, Malaria, HIV
• Beras tinggi besi dapat menolong
Pellagra = defisiensi B3
(Niacin)
Defisiensi Yodium
• Penyebab :Makanan & air kurang mengandung yodium.
• Tidak gunakan garam yodium dlm makanan, khususnya kelg yg tinggal di daerah gondok endemik.
Akibat GAKY
• IQ rendah• Ggn perkembangan fisik : TB terhambat,
ggn saraf motorik → gerakan lamban, ggn pendengaran → tuli.
• Defisiensi tingkat → kretinisme. • Dewasa : pembesaran kelejar gondok • Wanita usia subur sering : infertilitas • Jika terjadi pd ibu hamil → aborsi atau
IUFD
Hipotiroidisme kongenital
2. Deficiensi Yodium
• Defisiensi Yodium– Menyerang 740 juta org di
seluruh dunia– Penyebab tunggal kerusakan
otak pada bayi yg dapat dicegah
– Goiter– Lahir mati– Miscarriages– Retardasi Mental
• Sumber terbaik yodium alami– Sea weed / rumput laut– Sea food
Goiter
(pembesaran tiroid)
Prevensi
• Selalu gunakan garam yodium di RT.• Untuk endemik → anak 1-5 tahun
diberi kapsul yodium selama 1 tahun
Defisiensi Mikronutrien Lain
• Zinc– Retardasi pertumbuhan– Maturasi seksual terlambat– Lesi kulit & mata– 48% penduduk dunia berisiko
berisiko defisiensi zinc
• Kalsium– Osteoporosis: kerapuhan
tulang
• Vitamin D– Rickets: malformasi tulang
Other Deficiencies
• Vitamin C– Sebabkan Scurvy: problem in
kamp pengungsian
• Niacin– Sebabkan Pellagra: dermatitis,
diarea, dementia– Akibat diet tinggi maizena
(rendah tryptophan)
• Thiamin– sebabkan beriberi– Akibat diet tinggi beras ‘kilat’
• Folate– Defek saat lahir : Anansefali &
Spina Bifida
Cheilosis = def vit B2
Akibat Malnutrisi
Defisiensi Mengurangi :
survivalVitamin A
PEMLBW
productivity
IronintelligenceIodine
Mortalitas Balita Akibat Underweight
•
6,000
8,000
2006200720082009201020112012201320142015
6,000
8,000
2006200720082009201020112012201320142015
Deaths
Over 375,000 child deaths
Year
Causes and Symptoms
Causes
USA : • Primary reasons : kemiskinan & kurang
makan.• 10% saja: • PEM occurs in
– 50% pasien bedah – in 48% pasien rawat inap
Causes
• ↑ risk chronic diseases, especially pd intestinal tract, kidneys, and liver :
• Cancer, AIDS, intestinal parasites, and other gastric disorders may lose weight rapidly → rentan undernourishment karena tak dapat absorbsi vitamins, calories & iron.
Causes• Ketergantungan drug or alcohol
→ kemampuan absorbsi nutrients rusak • Eating disorders :
→ anorexia or bulimia : restrict food intake
Symptoms
• Ketidaksengajaan losing > 10 pounds : sign of malnutrition.
• Skinny or bloated (kembung/bengkak): – pale, thick, dry, and bruises easily.
• Rashes and changes in pigmentation • Joints ache & bones : soft & tender. • Gums bleed easily. • Tongue swollen or kerut & pecah2. • Ggn visual : night blindness & ↑ sensitivity
to light & silau.
Other symptoms include
• Anemia, diarrhea, disorientation• night blindness, irritability, anxiety, &
attention deficits, goiter, loss of reflexes and lack of muscular coordination
• muscle twitches, amenorrhea • scaling and cracking of the lips and
mouth.• Malnourished children may be short for
their age, thin, listless, and have weakened immune systems.
Causes
• Food allergies. → difficult to obtain food → need additional calorie intake
• Failure to absorb nutrients in food following bariatric (weight loss) surgery.
• Bariatric surgery : techniques as stomach stapling (gastroplasty) and various intestinal bypass procedures to help people eat less and lose weight → malnutrition is a possible side effect of bariatric surgery
Clinical
History
• Clinical signs and symptoms of PEM include:– Poor weight gain– Slowing of linear growth– Behavioral changes –
•irritability, apathy, ↓ social responsiveness, anxiety, and attention deficits
History
• Clinical signs and symptoms of micronutrient deficiencies : – may closely resemble those observed in
PEM.
History• The most common and clinically significant
deficiencies :– Iron - Fatigue, anemia, ↓ cognitive function,
headache, glossitis & nail changes– Iodine - Goiter, developmental delay & MR– Vit D - Poor growth, rickets, and hypocalcemia – Vit A - Night blindness, xerophthalmia, poor
growth, and hair changes– Folate - Glossitis, anemia (megaloblastic) &
neural tube defects (in fetuses of women without folate supplementation)
– Zinc - Anemia, dwarfism, hepatosplenomegaly, hyperpigmentation and hypogonadism, acrodermatitis enteropathica, diminished immune response, poor wound healing
Physical of PEM
• ↓ subcutaneous tissue : most affected : legs, arms, buttocks & face.
• Edema: most affected : distal extremities & anasarca (generalized edema)
• Oral changes :– Cheilosis– Angular stomatitis– Papillar atrophy
Physical of PEM
• Abdominal findings– Abdominal distension secondary to poor
abdominal musculature– Hepatomegaly secondary to fatty infiltration
• Skin changes– Dry peeling skin with raw exposed areas– Hyperpigmented plaques over areas of trauma
• Nail changes: fissured or ridged.• Hair changes: thin, sparse, brittle, easily
pulled out, and turns a dull brown or reddish color.
Causes
• Most common cause : inadequate food intake.
• Developing countries :– Secondary to insufficient or inappropriate
food supplies or early cessation of breastfeeding.
– In some areas, cultural and religious food customs may play a role.
– Inadequate sanitation further endangers children by ↑ the risk of infectious diseases that ↑ nutritional losses & alters metabolic demands
Causes
• Instead, diseases and, in particular, chronic illnesses play an important role in the etiology of malnutrition.
• Children with chronic illness : risk for nutritional problems :– Frequently have anorexia → inadequate food
intake.– ↑ inflammatory burden and ↑ metabolic
demands can ↑ caloric need.– Any chronic illness that involves the liver or
small bowel affects nutrition adversely by impairing digestive and absorptive functions.
Causes
• Chronic illnesses that commonly are associated with nutritional deficiencies include the following:– Cystic fibrosis– Chronic renal failure– Childhood malignancies– Congenital heart disease– Neuromuscular diseases– Chronic inflammatory bowel diseases
Causes
• Significant risk :– Prematurity– Developmental delay– In utero toxin exposure (ie, fetal alcohol
exposure)• Multiple food allergies → special
nutritional challenge because of severe dietary restrictions.
• Patients with active allergic symptoms may have ↑ calorie and protein needs.
Gizi buruk
• Bentuk terparah kurang gizi menahun • Indonesia kehilangan 220 juta IQ poin • Dampak lain :↓ produktivitas 20-30%• Anak pendek• Ggn tumbuh kembang otak → IQ
rendah
Gizi buruk
• Tumbuh kembang otak 80 % saat dlm kandungan s/d 2-5 tahun.
• WHO : 54% kematian bayi & balita didasari gizi anak yang jelek.
• KEP berat : risiko kematian 55%. • 6,7 juta balita / 27.3% Indonesia kurang
gizi akibat ASI MPASI• 1,5 juta gizi buruk.• KEP ringan pada anak 9 bulan - 2 tahun,
Gizi buruk
1. Dapat dicegah2. Bukan hanya karena kemiskinan,
tapi pola asuh → tidak tercapainya gizi memadai (masalah keluarga).
3. Risiko meninggal gizi buruk 13 x >>
KLB Gizi
• Ditemukannya balita : BB/U di bawah standar atau
• Tanda-tanda marasmus atau kwasiorkor
Diagnosis
Overall :– appearance, behavior, body-fat
distribution, and organ function
• Record what they eat during a specific period.
• X rays : determine bone density and reveal GI disturbances & heart and lung damage.
Diagnosis
• Blood & urine : measure vitamins & minerals levels & waste products.
Treatment
• Normalizing nutritional status starts with a nutritional assessment. This process enables :– a nutritionist or dietician → confirm the
malnutrition – assess the effects of the disorder – formulate diets that will restore adequate
nutrition.
• If cannot or will not eat or unable to absorb nutrients taken by mouth → – parenteral nutrition or – NGT / enteral nutrition
Treatment
• Tube feeding (NGT) : provide nutrients to burns patients or inflammatory bowel disease.
• Long-term : placed directly into the stomach or small intestine through an incision in the abdomen.
TreatmentTube feeding cannot always deliver adequate nutrients to patients who:
• Severely malnourished, require surgery• Undergoing chemotherapy or radiation Tx• Seriously burned• Persistent diarrhea or vomiting• Whose GI tract is paralyzed.
iv feeding
Prognosis
• < 10% body weight lost : without side effects,
• > 40% : almost always fatal. • Death results from :
– heart failure, electrolyte imbalance, or – hypothermia
• Poorer prognosis : – semiconsciousness, persistent diarrhea,
jaundice, or – low blood Na levels
Prognosis
• Some PEM childrens recover completely• Others : problems throughout life,
including MR & inability to absorb nutrients
• Dependent on age, length & severity • Young children and the elderly : highest
rate of long-term complications and death.
Prevention
• ASI exclusive• All Americans > 2 y :
– Consume plenty of fruits, grains, and vegetables
– Variety of low fats foods, cholesterols & contain only moderate amounts of salt, sugars & sodium
– Engage in moderate physical activity, for at least 30 minutes/day, at least several times a week
– Achieve or maintain their ideal weight– Avoid alcohol
Prevention
• Screening for every admitted patient
• If > average risk : – closely assessed and – reevaluated often during long-term
hospitalization or nursing-home care.
Food Intolerance & Allergy
• Alergi : reaksi imunologis terhadap makanan
• Intoleransi : non-immunologis• Klinis :
– sistem respirasi, GI, dermatologis or gejala sistemik
• Tes challenge
Food Allergy Symptoms
• GI : nyeri abdomen, kembung, diare, malabsorpsi, nausea, muntah, konstipasi
• Respiratory: asma, batuk kronik berulang (BKB), hidung buntu atau meler, wheezing
Food Allergy Symptoms
• Dermatologis : eksema, atopi, urtikaria, angioedema, gatal, rash
• Sistemic : anafilaksis, nyeri kepala, perubahan kebiasaan/ behavioral
Food Allergy Symptoms
Hidup is Pilihan
terima kasih
top related