‫بسم ا الرحمن الرحيم‬

PROTEIN ENERGY
MALNUTRITION

Nutrition Department
Medical school
University of Sumatera Utara
Nutrition problems in Indonesia

 Protein energy malnutrition

 Iron deficiency anemia

 Iodine deficiency

 Vitamin A deficiency
 PEM results when the body’s need for protein
and energy fuels are not satisfied by the diet
 Accompanied by deficiency of several
micronutrients
 Its clinical manifestations depends on :
- Duration and degree of shortfall in dietary
intake
- The quality of the diet
- Host factors such as age
- Interplay with infection
 Origin

 Primary  inadequate food intake

 Secondary  other diseases that lead to :

- low food ingestion
- inadequate nutrient absorption
- increased nutritional requirements
- increased nutrient losses
 What are the Causes of Malnutrition?

Two Views

Economists Nutritionists
• Slow GDP • Not enough
calories or protein
growth • Poor nutrition
• Low incomes knowledge
• Micronutrient
deficiencies
• Infections
 MARASMUS
 Result from prolonged starvation
 Predominant energy deficit
 Because of chronic or recurring infections with
marginal food intake (secondary marasmus)
 Sign :
- severe wasting away of fat & muscle
- very thin with ‘old man’ face
- no edema
- ribs are very prominent
 most common form of PEM before 1 yr of age
 KWASHIORKOR

 Usually affect children after 18 mo of age

 Predominant protein deficiency and varying
degrees of energy deficit
 Main sign is edema so children look ‘fat’
 Others :
- hair changes : loss of pigmentation, easy
pluckability
- skin lesions and depigmentation
- apathetic
 MARASMIC KWASHIORKOR

 Mixed form of PEM

 Chronic energy deficiency and chronic or acute
protein deficit
 Main feature :
- edema of kwashiorkor
- with or without skin lesions
- muscle wasting & decrease subcutaneous
fat of marasmus
Phase I : examination & emergency
treatment

 Management of diarrhea & dehydration

 Intravenous therapy
 Parasites & gut flora
 Prevention of hypoglycemia
 Prevention of hypothermia
 Dietary management
 Dietary management

 WHO-recommended F75 & F100

 F75 for initial phase
 F100 for rehabilitation phase
 Diet to be used will depend on local diet, but
should have energy density 75 –100 kcal/100mL,
osmolarity < 350 – 400 mOsm/L, 6 – 12% come
from protein
 80 – 100 kcal / kg/day 
< 80 kcal/kg is insufficient to maintain
metabolic need, > 100 kcal/kg risk of refeeding
syndrome
 Preparation of F75 & F100

Energy
Ingredients 0,75 kcal/cc 1kcal/cc

Dried skim milk (g) 25 80

Sugar (g) 70 50
Cereal flour (g) 35 -
Vegetable oil (g) 27 60
Mineral mix (mL) 20 20
Vitamin mix (g) 140 140
Water to total vol (cc) 1000 1000
 Mineral & vitamin supplement

 Micronutrient deficiencies are common

 Retinol palmitate /o on admission 
50.000 IU for < 6 mo
100.000 IU for 6 – 12 mo
200.000 IU for older children
Repeat dose given the next day
3rd dose after 2 weeks or on discharge
 Folic acid single oral dose 5 mg on admission
followed by 1 mg daily
 Zinc 1 ml/kg/day
 Fe sulfate or fumarate 4 mg elemental Fe / kg
BW when rehabilitation start
 Phase 2 : rehabilitation

 Emphasis is on intensive feeding to restore lost

weight
 Dietary calorie intake should be increase
gradually
 Iron suppl should be started
 Phase 3 : Follow-up

 Recovered malnourished children often

relapse and children have >> mortality rate
after discharge
 Sustained recovery of nutritional status is
possible, although stunting usually remains
 Growth following rehabilitation depends on
the favorable home circumstances
 Should be follow up at least 6 mo
 ‫بسم ا الرحمن الرحيم‬

ANEMIA
DEFISIENSI BESI
 Prevalensi tertinggi :
- bayi
- anak
- remaja
- wanita usia subur
PENYEBAB ANEMIA DEFISIENSI BESI

 Masukan besi yang kurang / diet buruk

 Malabsorpsi :
- enteritis
- PEM
- Gastrectomy
- Celiac disease
 MANIFESTASI KLINIK

 Pucat
 Anemia ringan & sedang :
- Hb 6 – 10 mg%
- stomatitis angularis, koilonikia, disfagia
 Anemia berat :
- Hb < 5 mg %
- iritabilitas & anorexia, tachycardi
 PENATALAKSANAAN

1. Pengobatan terhadap faktor penyebab

2. Transfusi darah : biasanya tdk diperlukan

meskipun Hb sangat rendah, kecuali keadaan
umum buruk dan ditakutkan terjadi
decompensatio cordis, maka diberi infus
dalam bentuk PRC
3. Terapi besi oral :
- ferro sulfat, fumarat, glukonat, suksinat,
glutamat & laktat
- dilanjutkan selama 3 – 6 bulan untuk mengisi
kembali cadangan besi
 PENCEGAHAN

- Diberikan untuk golongan risiko tinggi

- Diberikan senyawa besi dosis rendah
- Suplementasi
- Fortifikasi : tepung jagung, susu, gula pasir,
garam
 Anjuran :

 Pilih bahan makanan yang kaya zat besi

 Sertakan BM sumber vitamin C setiap makan
 Kalau mungkin konsumsi bahan makanan
sumber protein hewani setiap makan
 Hindari minum teh / kopi dalam jumlah besar
pada waktu makan
 H
Kurang Vitamin A

KVA
WHO
6-7 juta
xeroftalmia
kasus baru/thn

20%
kerusakan kornea

60% mati 25% 50-60%

dlm 1 thn BUTA ½ BUTA
Terjadinya KVA adalah akibat
 Cad Vit-A dlm tubuh anak
sewaktu lahir (-), ibu mdrt KVA
 Kadar Vit-A dlm ASI
 Kadar Vit-A dlm PASI
 Anak2 yg tdk suka bahan
makanan sumber Vit-A
 Gangguan Absorpsi Vit-A
ETIOLOGI
 makanan sehari2 kadar Vit-A/
Provit-A (jangka panjang)
 Gangguan Resorpsi Vit-A/Provit-A
 Kerusakan Hepar
 Kurang terbentuknya RBP
dan Pre-Albumin
Kelompok yg sering terkena
 Bayi, 6 bln, yg lahir dari ibu KVA
 Anak > 1 thn (mdrt Kwasiorkor)
 Anak BALITA (Prevalensi tertinggi)
 Klasifikasi Xeroftalmia
XN Buta Senja
X1A Xerosis Konyungtiva
X1B Bercak Bitot
X2 Xerosis Kornea
X3A Ulkus Kornea dg
X3B Xerosis
XS Keratomalasia
XF Parut Kornea
Xeroftalmia fundus
SUMBER: WHO Technical Report Series No. 672, 1982
 WHO

d i a g n o s i s
kr it e ri a A
m i a d a n K V
xer o f ta l
Masalah Kesehatan
 XN > 1%
X1B > 0,05%

X2-3A-3B >0,01%
XS >0,05%

Plasma Vit-A<0,35 µmol/l >5%

(10 µg/dl)
PENYULUHAN/SOSIAL MARKETING

Promosi
Himbauan
Pendidikan
PENYULUHAN/SOSIAL MARKETING

SUPLEMENTASI

Vit-A Dosis Tinggi

A + 4 0 I U v i t - E
0 . 0 0 0 IU v i t -
20 6 b u la n)
(set i a p
PENYULUHAN/SOSIAL MARKETING

SUPLEMENTASI

FORTIFIKASI

Susu
Mentega
Bumbu Penyedap
 H
gangguan
akibat GAKI
GAKI
kekurangan
yodium
 H
yodium

• 100-150 µgr/hari
Kebutuhan :
• Fungsi Hormon Tiroid
-Tiroksin (T4)
-Tri Iodo Tironin (T3)
 H
ETIOLOGI
PRIMER
Intake Iodium 

SEKUNDER
Zat Goitrogen
 H
Goitrogen

Natural
• Kubis/ Kol Tiosianat dan
Isotiosianat
• Singkong HCN

Sintetis
 H
KlasifikasiWHO
GRADE- 0 NORMAL
GRADE- 1 teraba

GRADE- 2

GRADE- 3
 H
KlasifikasiWHO

GRADE- 0

GRADE- 1

GRADE-
GRADE- 222
GRADE- dpt dilihat  kepala posisi normal

GRADE- 3
 H
KlasifikasiWHO

GRADE- 0

GRADE- 1

GRADE- 2

GRADE- 3 dpt dilihat  dari jarak 10 m

 H
Klasifikasi EKSRESI J
dlm Urin/24 jam

Tingkatan Prevalensi Median J urin

GAKI TGR (mg/L)

RINGAN 5,0 – 19,9 SEDANG

50 - 99
%
SEDANG 20-29,9 20 - 49
%
BERAT > 30 < 20
therapy

preventive
preventive
 H
preventive
GAKI

PANJANG
PANJANG
Jangka

PENDEK
PENDEK
Jangka
 H
Jangka Panjang
FORTIFIKASI
FORTIFIKASI
40
ppm
KJO3

GARAM
 H
Jangka
PENDEK
LIPIODOL
Golongan Umur Dosis (ml)
0 - 1 0,5
thn
1 - 5 1,0
thn
5 - 16 1,
thn
16 - 45 0
1,0
Lipiodol thn
: Yodium dlm minyak (480 mg/ml)
 H
Bahan Makanan Segar
… µgr /Kg bahan

Gandum 1 - 10
Kentang 30
Kacang- 8 - 60
Wortel
kacangan 30 - 90
Kol 130
Susu Sapi
(kubis) 70
M. Goreng
segar 30 -100
nabati
Bahan Makanan Segar
… µgr /Kg bahan

Udang, 200 -
Kepiting
Salmo 300
100 -
n
Minyak Ikan 500
3000 -
13000