MALNUTRITION OF ENERGY

PROTEIN
SCENARIO
A baby girl, age 9 months, brought by her mother to the health center
with complaints of frequent diarrhea since last 1 month. A history of
feeding: breastfeeding is given up to three months, then given starch
water until now. Birth history: BBL 2800 g, PB 47 cm. On physical
examination found: BB 3.4 kg, PB 56 cm. Palms looked pale. Found
bitot spot on the eye, edema dorsum of the foot and edema pretibial.
Also it appears the wasting and baggy pants. Dehydration score 13 and
hemoglobin 5 g / dl.
Keywords
• A baby girl, age 9 months
• Diarrhea since last 1 month
• History of feeding: -
• breastfeeding up to three months
• then given starch water until now
• Birth history: Birth weight = 2800 g,
Lenght = 47 cm
• Physical examination found:
• Weight =3.4 kg, Length = 56 cm
• Palms looked pale
• bitot spot on the eye
• edema dorsum of the foot and
edema pretibial
• appears the wasting and baggy
pants
• Dehydration score 13
• Hemoglobin 5 g / dl
QUESTIONS
1. How to asses the nutrition status of the baby in scenario?
2. Pathomecanism of : Bitot spot, diarrhea, dehydration, anemia, edema dorsum pedis
and pretibial, wasting and baggy pants.
3. What are the compositions of starch water?
4. What are the vitamin suplement that can be given to the baby?
5. What are the immunization giving to the baby ( 9 months
6. What are the pedisposition factors?
7. Definition of malnutrition, teraphy, complication and penyakit penyerta
8. Explain PEM (Clssification, pemfis, etiology)
9. Penatalaksanaan setiap patomekanisme sesuai usia bayi
10. Menguraikan tata laksanan Malnutrisi
11. The islamic perspective of scenario
 How to assessment
nutritional status of the
baby in scenario?
The standard weight for age ( W / A)
Boys aged 0-60 months

Based on the table ,

9-month old baby which weight
is 3.4 Kg were in < - 3 SD , which
means the baby is suffering from
severely underweight.

Keputusan Menteri Kesehatan Republik Indonesia (Nomor:1995/MENKES/SK/XII/2010). Tentang Standar Antropometri Penilaian Status Gizi Anak.
Standard body length by age ( L / A )
Boys aged 0-24 months

Based on the table , 9-month old

baby which lenght is 56 cm
were in < - 3 SD , which means
the baby is suffering from
severely stunted.

Keputusan Menteri Kesehatan Republik Indonesia (Nomor:1995/MENKES/SK/XII/2010). Tentang Standar Antropometri Penilaian Status Gizi Anak.
The standard weight for length ( W / L )
Boys aged 0-24 months

Based on the table , a boy

weight 3.4 kg and body length
56 cm were in < - 3 SD , which
means that the baby is severely
wasted.

Keputusan Menteri Kesehatan Republik Indonesia (Nomor:1995/MENKES/SK/XII/2010). Tentang Standar Antropometri Penilaian Status Gizi Anak.
Standard body mass index for age ( BMI / A )
Boys 0-24 months

• BMI = weight(kg) / height(m)2

• BMI (9-month old baby)
= 3,4 / (0,56)2 = 10,84 kg/m2

Based on the table , a boy weight

3.4 kg and body length 56 cm
which the body mass index (BMI)
is 10,84 kg/m2 were in < - 3 SD ,
which means that the baby is
severely wasted.
Keputusan Menteri Kesehatan Republik Indonesia (Nomor:1995/MENKES/SK/XII/2010). Tentang Standar Antropometri Penilaian Status Gizi Anak.
 breastmilk

A water content of starch

 Energy (kal) 43.20 Kandungan Kolostrum Transisi Asi Matur

 Water (g) 91.21 Energy (Kg kla) 57,0 63,0 65,0

Laktosa (gr/100ml) 6,5 6,7 7,0
 Protein (g) 0.66 Lemak (gr/100ml) 2,9 3,6 3,8

 Fat (g) 1.92 Protein (gr/100ml)

Mineral (gr/100ml)
1,195
0,3
0,965
0,3
1,324
0,2

 Carbohydrate (g) 5.82 Immunoglobulin :

 IgA (mg/100ml) 335,9 - 119,6
 Abu (g) 0.38 

Ig G (mg/100ml)
IgM (mg/100ml)
5,9
17,1
-
-
2,9
2,9
 Vitamin b1 (mg) 0.0046 

Lisosim (mg/100ml)
Laktoferin
14,2-16,4
420-520
-
-
24,3-27,5
250-270

 Fe (mg) 0.086
Vitamin After Fat
Vitamin A (Retinol) The function of vitamin A is to meet the needs component in the formation of
pigment rhodopsin (vision purple), establishing and maintaining epithelial tissue,
helps the growth and development of bones and teeth, help the growth of
spermatogenesis, helping the formation of thyroxine, and as an antioxidant. Sources
of vitamin A can be formed naturally, such as the liver, kidneys, liver oil, milk, and
egg yolks. Another source is formed of provitamin A (carotene), such as carrots,
potatoes, spinach, cabbage, broccoli, pumpkin, apricot, and others.

Vitamin D2 Vitamin D has a function to absorb calcium and phosphorus, and decrease the
(ergocalciferol) and phosphorus excretion in the kidney. Sources of vitamin D is sunlight, cod liver oil,
vitamin D3 mackerel, salmon, tuna, and sardines. Other sources of vitamin D-fortified foods,
(cholecalciferol) such as milk, dairy products, cereals fortified vitamin D, and some drinks for
breakfast.
Vitamin E Vitamin E in the body has a function to help produce red blood cells and protects
from hemolysis, maintaining the integrity of the muscle and liver, as a coenzyme
factor in respiratory tissues, minimizing poliunsaturasi oxidation of fatty acids and
vitamins A and C in the channel and intestinal tissue. The source of vitamin E are
vegetable oils, wheat germ oil, milk, egg yolks, fish, rice, beans, peas, spinach, and
broccoli.

Vitamin K The function of vitamin K in the body as a catalyst for the production of prothrombin
and blood coagulation factors II, VII, IX, and X in the liver. Sources of vitamin K is
pork, greens, cabbage, tomato, egg yolk and cheese. This vitamin deficiency in
children is characterized by bleeding. While the advantages of this vitamin can result
in hemolytic anemia in individuals deficient in glucose 6-phosphate dehydrogenase.
 Water Soluble Vitamins
Vitamin B complex consists of vitamins Thiamin (B1), riboflavin (B2), niacin
(B3) Pantothenic Acid (B5), Pyridoxine (B6), biotin (B7) and Folic Acid (B9) and
Cyanocobalamin (B12, Jathar, R. , 2010). Each type of these vitamins have
varied benefits and functions of the human body. The imbalance of vitamin
intake can lead to impaired function of human organs.
Cont …

Vitamin C Vitamin C sourced from some foods, such as citrus fruits, strawberries,
tomatoes, potatoes, cabbage, broccoli, cauliflower, green peppers,
spinach, papaya, mango, cantaloupe, watermelon, fruit juices fortified.
• Age 0 months : Hepatitis B-1, Polio-0, BCG
• 1 month of age : Hepatitis B-2
• Age 2 months : Polio-1, DPT-1, PCV-1, Hib-1, Rotavirus-1
• The age of 4 months : Polio-2, DPT-2, PCV-2, 2-Hib, Rotavirus-2
• Ages 6 months : Polio-3, DPT-3, 3-PCV, Hib-3, Rotavirus-3. For rotavirus vaccine is given 3x if RotaTeq vaccine used
for the brand, if the brand Rotarix 2x enough.
• Age 9 months : Measles-1
• 12 months of age : PCV-4, Varicella
• Age 15 months : 4th Hib, MMR-1
• Age 18 months : Polio-4, DPT-4
• Age 24 months : Measles-2
• 2 years of age : Hepatitis A (given interval of 6-12 months 2x), Typhoid (repeats every 3 years)
• Ages 5 years : DPT-5, 5-Polio, MMR-2
• Age 10 years : Td, HPV (administered 3 times)
• Age 18 years : Td
Protein Energy Malnutrition
(PEM)
Protein Energy Malnutrition (PEM)
PEM: invariably reflect combined deficiencies in..
• Protein: deficit in amino acids needed for cell stucture, function
• Energy: calories derived from macronutrients: protein, carhohydrate
and fat
• Micronutrients: vitamin A, B-complex, iron, zinc, calcium, others.
 Diet

Role of free Social and

Radicals and Economic
Aflatoxins
Etiology factors

of PEM
Biological Environmental
factors Factors
Clasification of PEM
Marasmus
• Severely wasted (emaciated) &
stunted
• Very low WAZ
• “Balanced”starvation
• “Old Man”face, wrinkled appearance,
sparse hair
• No edema, fatty liver, skin
changes•Too little breast milk or
complementary foods
• < 2 yrs of age
Kwasiorkor
• Edema
• Mental changes
• Hair changes
• Fatty liver
• Dermatosis (skin lesions)
• Infection
• Mod low WAZ, wasting
• High case fatality
• Low prevalence
• 1st to 3rd yrs of life
Marasmic Kwashiorkor
• There is varying degree of muscle
wasting, oedema along with hair and
skin changes.
• There is the presence of moderate
anemia, and along with it more than
one vitamin deficiencies are also found.
• Vitamin A deficiency is associated with
severe malnutrition and may cause
blindness.
“10 steps” management of a child with severe malnutrition
No Tindakan stabilitation Transition Rehabilitation Tindak lanjut
H 1-2 H 3-7 H 8-14 2-6 mg 7-26mg

1. treat hypoglicemia

2. treat hypothermia

3. treat dehydration

4. treat decrease
electrolyte

5. treat infection

6. treat decrease of whithout Fe + Fe

mikronutrien

7. cautious feeding

8. catch-up growth

9. stimulation

10. Prepare for follow up

Perspektif islam tentang ASI

Mothers shall suckle their children for two full years, that is for those who want to enhance
breastfeeding. And obligations of a father feeding and clothing the ma'ruf mother’s manner.
Someone not burdened but according to levels of ability. No mother suffered misery for her son
and a father for his son, and heir shall be chargeable as .if both want wean (before two years)
with both willingness and consent, there is no blame on either of them. And if you want your
son feeded by others, then there is no sin on you if you make the payment according to the
worth. Your fear Allah and know that allah is seer of what ye do. (qs. Al-baqarah: 233)

And we were inspired to the mother of moses; "give the babys

milk, and if you fear against the throw him to the river (nil). And do
not worry and do not (also) grieve, for we will return it to you, and
make (one) of Rasul. (surah al-qasas: 7 )