Gizi Buruk

Bag.I.kesehatan AnakFakultas Kedokteran Universitas YARSI

Dr.Wan Nedra K. Sp.A

PENANGANAN PASIEN GIZI ANAK:

1. mengerjakan ANAMNESIS2. mengerjakan PEM.FISIK3. menentukan PEM.PENUNJANG4. menegakkan DIAGNOSIS5. memberikan TERAPI6. mempertimbangkan PROGNOSIS7. mengusahakan PREVENSI

1. Anamnesis :Riwayat makanan : - jangka pendek : sblm

sakit - jangka panjang: sejak bayi

Nafsu makan : baik / kurang / buruk ?

Masukan makanan : jumlah dan jenis mak. yang

dikonsumsi --> dapat utk menilai / kesan ttg :

kwalitas : baik / kurang, berdasarkan :

- jenis mak.- komposisi nutrien- distribusi kalori

kwantitas : cukup / kurang / lebih --.> thd. RDA - energi / protein / vitamin / mineral dll.

2. Pemeriksaan fisik 2.1. Tanda / gejala penyakit gizi :

- MEP : wajah, rambut, otot, jar.lemak subkutis, edema, dsb.

- KVA ( Xerophthalmia ) : bercak Bitot, xerosis konyungtiva, ulkus kornea, dst.

- Anemia defisiensi : pucat ( organomegali - )- GAKI : kel.tiroid >, kretin, dll.- def.vit B1 : beri-beri / edema, polineuritis,

refleks fisiol. <- def.vit B2 : stomatitis angularis

- def.vit C : skorbut- dll.

2. Pemeriksaan fisik 2.2. Membuat KESAN KLINIS tentang status gizi :

- gizi lebih ( overweight --> obesitas )- gizi baik ( wellnourished )- gizi kurang ( undernourished )- gizi buruk ( severe malnutrition)

Kesan klinis dibuat berdasarkan tanda / gejala klinis.

2.3. Menentukan status gizi secara ANTROPOMETRIS :

- BB/U - BB/TB- TB/U - LILA, dsb.

Status Gizi anak laki2, 2 thn

• BB: 7 kg

• TB: 60 cm

• Status Gizi:

• BB/U: 7/ 12,8: x 100%: 54 % (G.Buruk)

• BB/TB: 7/ 6 x 100%: 116%

• TB/U: 60/ 87 x 100: 69%

Defisiensi vit A (Xerophthalmia)

Bitot’spot Ulcuscornea

Xerosis conyunctiva & cornea Keratomalacea

2. Pemeriksaan fisik 2.2. Membuat KESAN KLINIS tentang status gizi :

- gizi lebih ( overweight --> obesitas )- gizi baik ( wellnourished )- gizi kurang ( undernourished )- gizi buruk ( severe malnutrition)

Kesan klinis dibuat berdasarkan tanda / gejala klinis.

2.3. Menentukan status gizi secara ANTROPOMETRIS :

- BB/U - BB/TB- TB/U - LILA, dsb.

Kwashiorkor & Marasmus

Iga gambang

Rambut

Hepar >>

Edema

Atrofi otot

Lemak SC <<

Marasmic-Kwashiorkor

Baggy pants

Edema

Iga gambang

Atrofi ototJar.lemak SC <<

3. Pem. Penunjang :

3.1. Pem. Laboratoris :- Hb

- protein serum, albumin, globulin- profil lipid ( lipid total, triglserida,

kolesterol, LDL, HDL)

- BUN, dll

3.2. Pem.radiologis : - usia tulang

- osteoporosis/osteomalasia

3.3. Pem.antropometris: - BB, TB/PB, LILA, LK, TLK.

4. Diagnosis :

4.1. Sehat : - status gizi baik

- T-K normal / optimal - + kriteria sehat lain

4.2. Penyakit gizi :- defisiensi : MEP, Vit - Min.

- kelebihan : Obesitas, intoksikasi vit-min.

5. Terapi :

5.1. Terapi nutrisi : - oral / enteral / parenteral

- dukungan thd. penyakit utama : ginjal, sal.cerna, DM, IEM, dsb.

5.2. Menentukan dosis obat

5.3. Pemantauan respons th/ keseluruhan

6. Prognosis :6.1. Perbaikan / kemunduran :

- perbaikan --> penyembuhan :- nafsu makan >- BB >

- kemunduran --> perburukan :- nafsu makan <

- BB <

6.2. Memperkirakan ( berdasarkan status gizi ) :

- daya tahan tubuh

- kemungkinan komplikasi / penyembuhan

7. Prevensi :

7.1. Keadaan defisiensi

7.2. Penyakit gizi iatrogenik

Anaemia

Severe PEM : Kwashiorkor hair face

Oedema

‘Puffy’

Severe PEM : Kwashiorkor

Crazy pavementdermatosis

oedema

Hepatomegaly

Severe PEM : Marasmus

face

hair

Ribs

Muscles atrophySC fat <<

Severe PEM : Marasmus + KP

lymphadenopathy

Severe PEM : Marasmus + KP

‘Caverne’

6 weeks after th/‘Destroyed lung’

PEM.

Laboratory tests:• Tests that may be useful :

Blood glucose : < 54 mg/dl = hypoglycaemia Blood smear : parasit malaria Hb or Ht : < 4 g/dl or < 12% = severe anaemia Urine exam/culture: bacteria + or > 10 lekosit/HPF

infection Faeces : blood + disentri Giardia + / parasit lain

infeksi X-ray : - thorax : Pneumonia

Heart failure - bone : rickets, fracture

Tes tuberkulin : often negative

• Tests that are little ot no value : serum protein, HIV, electrolytes

PEM.

Therapy:

Mild-moderate PEM (Gizi kurang) : - no specific clinical signs : thin,

hypotrophic- not necessary to hospitalize- looking for the probable causes- nutr. education & supplementation

Severe PEM : should be hospitalized

PEM.

Other criteria :

Very low BW : - W/H < 70%- W/A < 60%(- W/A > 60% + oedema)

+ clinical signs & symptoms : - oedema (M-K)- severe dehydration- persistent diarrhoea and / or

vomiting- severe pallor, hypothermia, shock- signs of systemic/local infection, URI- severe anaemia ( Hb < 5 g/dl)- jaundice- anorexia- < 1 yr of age

PEM.

Signs & symptoms of dehydration :

- history of diarrhoea or no/diminished intake

- weak, apathetic unconscious

- weak to absent radial pulse

- thirst, dry mouth and absent of tears

- sunken eyes and fontanel

- hypothermia

- cold hands and feet

- Urine flow << / -

Dehydration

Sunken eyes

Dehydration

Turgor :

PEM.

Therapy:

Mild-moderate PEM (Gizi kurang) : - no specific clinical signs : thin,

hypotrophic- not necessary to hospitalize- looking for the probable causes- nutr. education & supplementation

Severe PEM : should be hospitalized

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. Stimulation10. 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 admissionPrimary failure to respond:- failure to regain appetite Day 4- Failure to start to lose oedema Day 4- Oedema 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

Emergency :

Shock :

N2 or RLG5%15 ml/kg, 1 hr

Repeat 1 hr more

Resomal 10 ml/kg, 10 hrs

Special formula

sepsis

Maintenance, 4 ml/kg/hrFresh blood, 10 ml/kg

Improvement+

_

Emergency :

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 :Sh, girl, 2 yrs,W : 3.875 gH : 67 cmW/H : < -4SD

2 weeks later : W : 4.750 g H : 67.4 cm W/H : < -3 SD

4 weeks later : W : 5.310 g H : 67.7 cm W/H : + -3 SD

5 weeks later :W : 6.280 g H : 67.8 cmW/H : - 2 SD

7 yrs,10 kg

Recovery : 16 kg