Malnutrisi adalah suatu keadaan di mana tubuh mengalami gangguan terhadap

absorbsi, pencernaan, dan penggunaan zat gizi untuk pertumbuhan, perkembangan dan
aktivitas.Malnutrisi merupakan kekurangan konsumsi pangan secara relatif atau absolute
untuk periode tertentu. (Bachyar Bakri, 2002)
Malnutrisi adalah keadaan dimana tubuh tidak mendapat asupan gizi yang cukup,
malnutrisi dapat juga disebut keadaaan yang disebabkan oleh ketidakseimbangan di
antara pengambilan makanan dengan kebutuhan gizi untuk mempertahankan kesehatan.
Ini bisa terjadi karena asupan makan terlalu sedikit ataupun pengambilan makanan yang
tidak seimbang. Selain itu, kekurangan gizi dalam tubuh juga berakibat terjadinya
malabsorpsi makanan atau kegagalan metabolik (Oxford medical dictionary, 2007).
WHO dalam Medscape (2014) mendefinisikan malnutrisi sebagai
ketidakseimbangan seluler antara suplai nutrisi dan energi dan kebutuhan tubuh untuk
pertumbuhan, pertahanan, dan fungsi-fungsi spesifik lainnya. Malnutrisi merupakan
faktor resiko yang paling utama untuk penyakit dan kematian pada anak, dengan
menyebabkan lebih dari setengah kematian anak di dunia. Jenis yang paling banyak
menyebabkan penyakit, khususnya di negara berkembang, adalah malnutrisi proteinenergi (PEM).
Menurut UNICEF (2004) malnutrisi berarti lebih dari sekedar perasaan lapar atau
tidak mempunyai cukup makanan untuk dimakan. Ketidakcukupan makanan ini meliputi
asupan protein (penting untuk mempertahankan kesehatan tubuh dan membentuk otot),
kalori (ukuran kebutuhan energi tubuh), besi (untuk fungsi sel darah), dan nutrien lain
yang menyebabkan berbagai tipe malnutrisi. Jika tubuh tidak menerima energi yang
dibutuhkan dalam makanan, maka kehilangan berat badan akan terjadi.
A. KLASIFIKASI
Kurang Energi Protein (KEP)
Penyebab KEP dapat dibagi kepada dua penyebab yaitu malnutrisi primer dan malnutrisi
sekunder. Malnutrisi primer adalah keadaan kurang gizi yang disebabkan oleh asupan
protein maupun energi yang tidak adekuat. Malnutrisi sekunder adalah malnutrisi yang
terjadi karena kebutuhan yang meningkat, menurunnya absorpsi dan/atau peningkatan
kehilangan protein maupun energi dari tubuh (Kleigmen et al, 2007).

Secara klinis, KEP dapat dibagikan kepada tiga tipe yaitu, kwashiorkor, marasmus, dan
marasmik-kwashiorkor. Marasmus terjadi karena pengambilan energi yang tidak cukup
sementara kwashiorkor terjadi terutamanya karena pengambilan protein yang tidak
cukup. Sementara tipe marasmik kwashiorkor yaitu gabungan diantara gejala marasmus
dan kwashiorkor (Kleigmen et al, 2007).
Klasifikasi KEP menurut Depkes RI (1999)
BB/U
Kategori

Status
(%Baku WHO-NCHS, 1983)

KEP I (KEP Ringan)

Gizi Sedang

70 % 79,9 % Median BB/U

KEP II (KEP Sedang)

Gizi Kurang

60 % 69,9 % Median BB/U

KEP III (KEP Berat)

Gizi Buruk

< 60 % Median BB/U

Klasifikasi KEP menurut WHO

Klasifikasi
Malnutrisi Sedang

Malnutrisi Berat

Edema

Tanpa edema

Dengan edema

BB/TB

-3SD s/d -2 SD

< -3 SD

TB/U

-3SD s/d -2 SD

< -3 SD

Secara klinis, KEP dapat dibagikan kepada tiga tipe yaitu, kwashiorkor, marasmus, dan
marasmik-kwashiorkor. (Kleigmen et al, 2007).
1. Marasmus (Atrofi infantile, kelemahan, insufisiensi nutrisi bayi (athrepesia))

Marasmus terjadi karena pengambilan energi yang tidak cukup

2. Malnutrisi protein (Malnutrisi protein-kalori (PCM), kwashiorkor)
Kwashiorkor merupakan sindroma klinis akibat dari malnutri protein berat (MEP
berat) dan masukan kalori tidak cukup. kwashiorkor terjadi terutamanya karena
pengambilan protein yang tidak cukup.
3. Marasmik-Kwashiorkor
Gambaran klinis merupakan campuran dari beberapa gejala klinik kwashiorkor dan
marasmus. Makanan sehari-hari tidak cukup mengandung protein dan juga energi
untuk pertumbuhan yang normal. Pada penderita demikian disamping menurunnya
berat badan < 60% dari normal memperlihatkan tanda-tanda kwashiorkor, seperti
edema, kelainan rambut, kelainan kulit, sedangkan kelainan biokimiawi terlihat pula
(Depkes RI, 2000)
Dalam FAO (2011) disebutkan bahwa ada 2 tipe malnutrisi :
1. Protein Energy Malnutrition (PEM) = malnutrisi yang disebabkan oleh defisiensi

beberapa atau semua nutrient baik makronutrien atau mikronutrien.

2. Micronutrient Deficiency Disease (MDDS) = malnutrisi yang terjadi sebagai hasil
dari defisiensi mikronutrien spesifik (vitamin atau mineral tertentu)

B. FAKTOR RESIKO
Secara garis besar sebab-sebab Marasmus ialah sebagaiberikut:
1. Masukan makanan yang kurang
Marasmus terjadi akibat masukan kalori yang sedikit,pemberian makanan yang tidak
sesuai dengan yang dianjurkanakibat dari ketidaktahuan orang tua si anak; misalnya
pemakaian secara luas susu kaleng yang terlalu encer.
2. Infeksi
Infeksi yang berat dan lama menyebabkan marasmus,terutama infeksi enteral misalnya
infantil gastroenteritis,bronkhopneumonia, pielonephritis dan sifilis kongenital.
3. Kelainan struktur bawaan
Misalnya: penyakit jantung bawaan, penyakit Hirschprung,deformitas palatum,
palatoschizis, micrognathia, stenosispilorus, hiatus hernia, hidrosefalus, cystic fibrosis
pancreas.
4. Prematuritas dan penyakit pada masa neonatus
Pada keadaan-keadaan tersebut pemberian ASI kurangakibat reflek mengisap yang
kurang kuat.
5. Pemberian ASI
Pemberian ASI yang terlalu lama tanpa pemberian makanan tambahan yang cukup.
6. Gangguan metabolik
Misalnya: renal asidosis, idiopathic hypercalcemia, galactosemia, lactose intolerance.
7. Tumor hypothalamus
Jarang dijumpai dan baru ditegakkan bila penyebab marasmus yang lain telah
disingkirkan.
8. Penyapihan
Penyapihan yang terlalu dini disertai dengan pemberianmakanan yang kurang akan
menimbulkan marasmus.
9. Urbanisasi
Urbanisasi mempengaruhi dan merupakan predisposisiuntuk timbulnya marasmus;
meningkatnya arus urbanisasidiikuti pula perubahan kebiasaan penyapihan dini dan
kemudian diikuti dengan pemberian susu manis dan susu yang terlaluencer akibat dari

tidak mampu membeli susu; dan bila disertaidengan infeksi berulang, terutama gastro
enteritis akanmenyebabkan anak jatuh dalam marasmus.
Kwashiorkor
Penyebab terjadinya kwashiorkor adalah inadekuatnya intake protein yang berlansung
kronis. Faktor yang dapat menyebabkan hal tersbut diatas antara lain :
1. Pola makan
Protein (dan asam amino) adalah zat yang sangat dibutuhkan anak untuk tumbuh dan
berkembang. Meskipun intake makanan mengandung kalori yang cukup, tidak semua
makanan mengandung protein/ asam amino yang memadai. Bayi yang masih
menyusui umumnya mendapatkan protein dari ASI yang diberikan ibunya, namun bagi
yang tidak memperoleh ASI protein adri sumber-sumber lain (susu, telur, keju, tahu
dan lain-lain) sangatlah dibutuhkan. Kurangnya pengetahuan ibu mengenai
keseimbangan nutrisi anak berperan penting terhadap terjadi kwashiorkhor, terutama
pada masa peralihan ASI ke makanan pengganti ASI.
2. Faktor sosial
Hidup di negara dengan tingkat kepadatan penduduk yang tinggi, keadaan sosial dan
politik tidak stabil, ataupun adanya pantangan untuk menggunakan makanan tertentu
dan sudah berlansung turun-turun dapat menjadi hal yang menyebabkan terjadinya
kwashiorkor.
3. Faktor ekonomi
Kemiskinan keluarga/ penghasilan yang rendah yang tidak dapat memenuhi kebutuhan
berakibat pada keseimbangan nutrisi anak tidak terpenuhi, saat dimana ibunya pun
tidak dapat mencukupi kebutuhan proteinnya.
4. Faktor infeksi dan penyakit lain

Telah lama diketahui bahwa adanya interaksi sinergis antara MEP dan infeksi. Infeksi
derajat apapun dapat memperburuk keadaan gizi. Dan sebaliknya MEP, walaupun
dalam derajat ringan akan menurunkan imunitas tubuh terhadap infeksi.

Faktor resiko lain

a. Pendidikan ibu yang rendah
Kurangnya pendidikan dan pengertian yang salah tentang kebutuhan pangan dan nilai
pangan adalah umum dijumpai setiap negara di dunia. Kemiskinan dan kekurangan
persediaan pangan yang bergizi merupakan faktor penting dalam masalah kurang
gizi.Salah satu faktor yang menyebabkan timbulnya kemiskinan adalah pendidikan
yang rendah. Adanya pendidikan yang rendah tersebut menyebabkan seseorang kurang
mempunyai keterampilan tertentu yang diperlukan dalam kehidupan.35 Rendahnya
pendidikan dapat mempengaruhi ketersediaan pangan dalam keluarga, yang
selanjutnya mempengaruhi kuantitas dan kualitas konsumsi pangan yang merupakan
penyebab langsung dari ekurangan gizi pada anak balita.Tingkat pendidikan terutama
tingkat pendidikan ibu dapat mempengaruhi derajat kesehatan karena pendidikan ibu
berpengaruh terhadap kualitas pengasuhan anak
b. Pengetahuan ibu
Ibu merupakan orang yang berperan penting dalam penentuan konsumsi makanan
dalam keluaga khususnya pada anak balita. Pengetahuan yang dimiliki ibu
berpengaruh terhadap pola konsumsi makanan keluarga. Kurangnya pengetahuan ibu
tentang gizi menyebabkan keanekaragaman makanan yang berkurang. Keluarga akan
lebih banyak membeli barang karena pengaruh kebiasaan, iklan, dan lingkungan.
Selain itu, gangguan gizi juga disebabkan karena kurangnya kemampuan ibu
menerapkan informasi tentang gizi dalam kehidupan sehari-hari.
c. Penyakit penyerta
Diare Persisten
Tuberkulosis
HIV AIDS
Penyakit tersebut di atas dapat memperjelek keadaan gizi melalui
gangguan masukan makanan dan meningkatnya kehilangan zat-zat gizi esensial tubuh.
Terdapat hubungan timbal balik antara kejadian penyakit dan gizi kurang maupun gizi

buruk.Anak yang menderita gizi kurang dan gizi buruk akan mengalami penurunan
daya tahan, sehingga rentan terhadap penyakit.
d. BBLR
Gizi buruk dapat terjadi apabila BBLR jangka panjang.Pada BBLR zat anti kekebalan
kurang sempurna sehingga lebih mudah terkena penyakit terutama penyakit infeksi.
Penyakit ini menyebabkan balita kurang nafsu makan sehingga asupan makanan yang
masuk kedalam tubuh menjadi berkurang dan dapat menyebabkan gizi buruk.
e. Kelengkapan imunisasi
Sistem kekebalan tersebut yang menyebabkan balita menjadi tidak
terjangkit sakit. Apabila balita tidak melakukan imunisasi, maka kekebalan tubuh
balita akan berkurang dan akan rentan terkena penyakit. Hal ini mempunyai dampak
yang tidak langsung dengan kejadian gizi.

C. PEMERIKSAAN DIAGNOSTIK
A.

Malnutrisi Kwasiorkor
a. Anamnesis
a) Identitas pasien dan keluarga
b) Keluhan utama
1.
Berat badan yang kurang
c) Keluhan tambahan
1.
Anak tidak mau makan (anoreksia)
2.
Anak tampak lemas dan menjadi lebih pendiam
3.
Sering menderita sakit yang berulang
d) Riwayat makanan:
1. Nutrisi : pola kebiasaan makanan meliputi jenis makanan,
frekuensi, porsi/jumlah, dll
e) Riwayat keluarga
b.

Pemeriksaan fisik
Yang dapat dijumpai pada pemeriksaan fisik antara lain:
1. Inspeksi
a)
Edema
b)
Kurus
c)
Pucat
d)
Moo face
e)
Kelainan kulit (hiperpigmentasi)
f)
Crazy pavement dermatosis
2. Palpasi
a)
Hepatomegali
3. Pengukuran antoprometri (BB, TB, lingkaran kepala atas, dan lengan lipatan
kulit)
4. Pemeriksaan penunjang
5. Pemeriksaan laboratorium
a)
Tes darah(hb, glukosa, protein serum, albumin)
b)
Kadar enzim pencernaan
c)
Biopsy hati, biasanya ditemukan perlemakan ringan sampai
berat,finrosis,nekrosis. Pada perlemakan berat hamper semua sel
d)

B.

hati mengandung vakuol lemak besar

Pemeriksaan tinja dan urin

Malnutrisi Marasmus
a. Anamnesis
1. Keluhan utama
a. Kurus(perubahan BB)
b. Tampak seperti orang tua

2. Keluhan tambahan
3. Riwayat makanan
4. Kebiasaan makan
b.

Pemeriksaan fisik
1. Mengukur TB dan BB
2. Menghitung indeks masa tubuh, yaitu BB(dalam kg) dibagi dengan
TB(dalam meter)
3. Mengukur ketebalan kulit dilengan atas sebelah belakang (lipatan trisep)
ditarik menjauhi lengan, sehingga lapisan lemak dibawah kulitnyadapat
diukur, biasanya dengan menggunakan jangka lengkung (kapiler). Lemak
dibawah kulit banyaknya adalah 50% dari lemak tubuh. Lipatan lemak
normal sekitar 1,25 cm pada laki-laki dan sekitar 2,5 cm pada wanita.
4. Status gizi juga diperoleh dengan mengukur LLA untuk memperkirakan
jumlah oto rangka dalam tubuh (lead body massa)

c.

Pemeriksaan penunjang
1.
2.
3.
4.
5.

C.

Hb
Ht
Albumin
Serum ferritin
Elektrolit

Malnutrisi Marasmus Kwasiorkor

a. Anamnesis
1. Keluhan utama:
a. Berat badan berkurang
b. Kurus
c. Tampak seperti orang tua
2. Keluhan tambahan:
a. Rambut tipis, pirang dan mudah dicabut
b. Anak tampak lemas dan menjadi pendiam
c. Sering menderita sakit yang berulang
3. Riwayat keluarga :
a. Lingkunga rumah
b. Pendidikan dan pekerjaan anggota keluarga
c. Hubungan anggota keluarga
d. Perilaku yang dapat mempengaruhi kesehatan
b.

Pemeriksaan fisik
1. Pengukuran antoprometri (BB, TB, lingkaran kepala atas, dan lengan lipatan
kulit)

2.
3.
4.
5.
6.
7.
8.

Malise
Kulit keriput
Asites
Edema
Pucat
Moon face
hiperpigmentasi

c. Pemeriksaan penunjang
1. Pada pemeriksaan laboraturium, anemia selalu ditemukan karena asupan zat
besi yang kurang dalam makanan, kerusakan hati dan absorbs.
2. Pemeriksaan radiologis dilakukan untuk menemukan adanya kelainan pada
paru
Beberapa parameter biokimia perlu dinilai:
1) Serum albumin, mempunyai waktu paruh yang panjang yaitu 21 hari. Kadar
albumin < 3.5 g/dL menunjukkan pasien mempunyai risiko malnutrisi.
2) Bila Total lymphocyte count, < 1,500 cells per milimeter kubik juga dapat sebagai
indikator mempunyai risiko malnutrisi.
3) Serum transferrin, waktu paruh 7 hari. Pada beberapa pasien mempunyai kadar
transferin < 140 mg/dL, pasien dapat dinyatakan berrisiko malnutrisi.
4) Serum pre-albumin (transthyretin), waktu paruh 3 hari. Dikatakan berrisiko malnutrisi
bila kadarnya <17 mg/dL.
5) Total iron-binding capacity (TIBC) dikatakan normal bila kadarnya antara 250 and
450 mcg/dL.
6) Kadar Kolesterol juga dapat digunakan untuk menilai status gizi, bila kadarnya < 150
mg/dL, menunjukkan ada peningkatan risiko gangguan status gizi.
Oleh karena tidak ada parameter tunggal untuk Diagnosis status gizi:
Saat ini > 90 % diagnosis malnutrisi dapat ditegakkan melalui anamnesis dan
pemeriksaan fisik yang dikenal sebagai Subjective Global Assessment (SGA).
Penilaian status gizi secara SGA merupakan cara yang sederhana. Sepanjang
penilai telah terlatih, SGA dapat merupakan diagnosis gizi yang reliable dan merupakan
prediktor akurat untuk menilai adanya peningkatan risiko komplikasi seperti infeksi dan
penymbuhan luka yang terhambat.

Pada SGA akan diperoleh informasi tentang:

1)
2)
3)
4)
5)
6)

Perubahan berat badan

Perubahan asupan makanan
Gejala-gejala gastrointestinal
Kapasitas fungsional
Hubungan antar penyakit dengan kebutuhan nutrisi.
Pemeriksaan fisik yang difokuskan aspek gizi

Pemeriksaan Diagnostik antropometri:

Dalam WHO (2014) :

Keterangan :
MUAC : mid-upper arm circumference
WFH/L : weight for height/ length
RUTF : ready-to-use therapeutic foods

D. KOMPLIKASI
Bahaya komplikasi pada pasien malnutrisi energi protein sangat mudah mendapat infeksi
karena daya tahan tubuhnya rendah terutama sistem kekebalan tubuh. Infeksi yang paling
sering ialah bronkopneumonia dan tuberkulosis. Adanya atrofivili usus menyebabkan
penyerapan terganggu mengakibatkan pasien sering diare. Melihat komplikasi tersebut
sukar untuk dicegah yang perlu diperhatikan adalah kebersihan mulut, kulit, diare dan
hipotermia. (Ngastiyah, 264:2005)
Adapula komplikasi yang lain, yaitu
- Hipotermi
- Hipoglikemi.
- Infeksi
- Diare dan Dehidrasi
- Syok
Penyebab Hipotermi
- Tidak/kurang/jarang diberi makan
- Menderita Infeksi
- Paparan angin :
a. Genting bocor
b. Dinding berlubang
c. Tidur dekat pintu
d. Selimut dan topi kurang rapat
- Menempel benda yang dingin:
a. Tidur dilantai
b. Mandi terlalu lama
c. Popok basah tidak segera diganti(ngompol,Diare)
Penyebab Hipoglikemi
- Tidak dapat/kurang/jarang dapat makan
- Penyakit Infeksi
Gejala : - Hipotermi (<35c)
- Lemah
- Penurunan kesadaran
E. PENCEGAHAN
Pencegahan Tingkat Pertama (Primary Prevention)
Pencegahan tingkat pertama mencakup promosi kesehatan dan perlindungan khusus
dapat dilakukan dengan cara memberikan penyuluhan kepada masyarakat terhadap halhal yang dapat mencegah terjadinya kekurangan gizi. Tindakan yang termasuk dalam
pencegahan tingkat pertama :

a. Hanya memberikan ASI saja kepada bayi sejak lahir sampai umur 6
b.
c.
d.
e.

bulan.
Memberikan MP-ASI setelah umur 6 bulan.
Menyusui diteruskan sampai umur 2 tahun.
Menggunakan garam beryodium
Memberikan suplemen gizi (kapsul vitamin A, tablet Fe) kepada anak

balita.
f. Pemberian imunisasi dasar lengkap.
Pencegahan Tingkat Kedua (Secondary Prevention)
Pencegahan tingkat kedua lebih ditujukan pada kegiatan skrining kesehatan dan deteksi
dini untuk menemukan kasus gizi kurang di dalam populasi. Pencegahan tingkat kedua
bertujuan untuk menghentikan perkembangan kasus gizi kurang menuju suatu
perkembangan ke arah kerusakan atau ketidakmampuan. Tindakan yang termasuk dalam
pencegahan tingkat kedua:
a. Pemberian makanan tambahan pemulihan (MP-ASI) kepada balita gakin
yang berat badannya tidak naik atau gizi kurang.
b. Deteksi dini (penemuan kasus baru gizi kurang) melalui bulan
penimbangan balita di posyandu.
c. Pelaksanaan pemantauan wilayah setempat gizi (PWS-Gizi).
d. Pelaksanaan sistem kewaspadaan dini kejadian luar biasa gizi buruk.
e. Pemantauan Status Gizi (PSG)
Pencegahan Tingkat Ketiga (Tertiary Prevention)
Pencegahan tingkat ketiga ditujukan untuk membatasi atau menghalangi
ketidakmampuan, kondisi atau gangguan sehingga tidak berkembang ke arah lanjut yang
membutuhkan perawatan intensif. Pencegahan tingkat ketiga juga mencakup pembatasan
terhadap segala ketidakmampuan dengan menyediakan rehabilitasi saat masalah gizi
sudah terjadi dan menimbulkan kerusakan. Tindakan yang termasuk dalam pencegahan
tingkat ketiga :
a. Konseling kepada ibu-ibu yang anaknya mempunyai gangguan pertumbuhan.
b. Meningkatkan pengetahuan dan keterampilan ibu dalam memberikan asuhan
gizi kepada anak.
c. Menangani kasus gizi buruk dengan perawatan puskesmas dan rumah sakit.
Pemberdayaan keluarga untuk menerapkan perilaku sadar gizi

RISK FACTORS
Broadly speaking, the causes Marasmus is sebagaiberikut:
1. Put the food which is less
Marasmus occur as a result of caloric intake slightly, feeding is not in accordance with the
dianjurkanakibat of ignorance of the child's parents; for example the use of widely milk cans
were too thin.
2. Infection
Severe infection and long lead marasmus, especially infections enteral example of infantile
gastroenteritis, bronkhopneumonia, pielonephritis and congenital syphilis.
3. congenital structural abnormalities
For example: congenital heart disease, Hirschsprung's disease, deformities of the palate,
palatoschizis, micrognathia, stenosispilorus, hiatus hernia, hydrocephalus, cystic fibrosis of the
pancreas.
4. Prematurity and illness in the newborn period
In those circumstances breastfeeding kurangakibat less powerful sucking reflex.
5. Breastfeeding
Breastfeeding is too long without sufficient supplementary feeding.
6. Metabolic Disorders
For example: renal acidosis, idiopathic hypercalcemia, galactosemia, lactose intolerance.
7. Tumors hypothalamus
Rare and only made when other causes have been ruled marasmus.
8. Weaning
Weaning too early accompanied by pemberianmakanan less will lead to marasmus.
9. urbanization

Urbanization affects and is predisposisiuntuk onset of marasmus; urbanisasidiikuti increasing

flow also changes the habits of early weaning and then followed by administration of sweet milk
and milk terlaluencer a result of not being able to buy milk; and when disertaidengan recurrent
infections, particularly gastroenteritis akanmenyebabkan child falls into marasmus.
kwashiorkor
The cause of kwashiorkor is inadekuatnya chronic intake of protein occurred. Factors that could
cause tersbut above include:
1. Diet
Protein (and amino acids) is a substance that is needed children to grow and develop. Although
the intake of food containing enough calories, not all foods contain protein / amino acids are
sufficient. Babies who are breast-feeding generally get protein from milk given her, but for those
who are not breast fed protein adri other sources (milk, eggs, cheese, tofu, etc.) is required. Lack
of knowledge of mothers on children's nutritional balance is vital to happen kwashiorkhor,
especially in the transitional period the milk to breast-milk substitutes.
2. Social factors
Living in a country with a high population density, social and political situation is not stable, nor
any restrictions on use of certain foods and already occurred down and down can be the cause
kwashiorkor.
3. The economic factor
Family poverty / low income who can not meet the needs of children result in nutritional balance
is not met, the time when his mother was not able to meet their protein requirements.
4. Factors other infections and diseases
It has long been known that the existence of a synergistic interaction between the MEP and
infection. Any grade infection may worsen malnutrition. MEP and vice versa, although in mild
degrees will decrease the body's immunity to infection.

Other risk factors

a. Low maternal education

Lack of education and misconceptions about food security and food values are common every
country in the world. Poverty and lack of nutritious food supply is an important factor in the
issue is less gizi.Salah of the factors that cause poverty is education. Their low educational
causes a person lacked the specific skills needed in kehidupan.35 Lack of education can affect
the availability of food in the family, which in turn affects the quantity and quality of food
consumption is a direct cause of Malnutrition in children balita.Tingkat education, especially
education level the mother can affect the degree of health for the mother's education affects the
quality of childcare

Malnutrition is a condition in which the body is impaired to the absorption, digestion and use of
nutrients for growth, development and aktivitas.Malnutrisi is a shortage of food consumption
relative or absolute for a certain period. (Bachyar Bakri, 2002)
Malnutrition is a condition where the body does not get adequate nutrition, malnutrition can also
be referred to circumstances caused by the imbalance between taking meals with nutritional
needs to maintain health. This could occur due to the intake eat too little or taking an unbalanced
diet. In addition, malnutrition in the body also results in malabsorption of food or metabolic
failure (Oxford medical dictionary, 2007).
WHO in Medscape (2014) defines malnutrition as a cellular imbalance between supply of
nutrients and energy and the body's need for growth, defense, and other specific functions.
Malnutrition is a major risk factor for the disease and death in children, with more than half of
child deaths in the world. The kind that most causes of disease, particularly in developing
countries, is a protein-energy malnutrition (PEM).
According to UNICEF (2004) malnutrition means more than just feeling hungry or do not have
enough food to eat. Insufficiency of these foods include protein intake (important to maintain a
healthy body and build muscle), calories (the size of the body's energy needs), iron (for blood
cell function), and other nutrients that cause various types of malnutrition. If the body does not
receive the required energy in the diet, the weight loss will occur.
A. CLASSIFICATION
Protein Energy Malnutrition (PEM)
The cause of PEM can be divided to two causes are malnutrition primary and secondary
malnutrition. The primary malnutrition is malnutrition caused by the intake of protein and energy
is inadequate. Secondary malnutrition is malnutrition that occurs due to an increasing necessity,
decreased absorption and / or an increase in loss of protein and energy of the body (Kleigmen et
al, 2007).
Clinically, PEM can be distributed to the three types, namely, kwashiorkor, marasmus and
kwashiorkor-marasmik. Marasmus happens because energy capture is not quite as kwashiorkor
occur mainly due to taking protein that is not enough. While this type of marasmik kwashiorkor

which is a combination between the symptoms of marasmus and kwashiorkor (Kleigmen et al,
2007).
KEP classification according to MOH (1999)
Category Status BB / U
(% Baku WHO-NCHS, 1983)
KEP I (KEP Light) Nutrient Medium 70% - 79.9% Median BB / U
KEP II (KEP Average) Nutrition Less 60% - 69.9% Median BB / U
KEP III (KEP weight) Malnutrition <60% Median BB / U
KEP according to WHO classification
Classification
Malnutrition Moderate Malnutrition Weight
Edema No edema By edema
BB / TB -3SD s / d -2 SD <-3 SD
TB / U -3SD s / d -2 SD <-3 SD
Clinically, PEM can be distributed to the three types, namely, kwashiorkor, marasmus and
kwashiorkor-marasmik. (Kleigmen et al, 2007).
1. Marasmus (infantile atrophy, weakness, insufficiency of infant nutrition (athrepesia))
Marasmus happens because energy capture is not enough
2. Malnutrition protein (protein-calorie malnutrition (PCM), kwashiorkor)
Kwashiorkor is a clinical syndrome resulting from malnutri weight protein (MEP weight) and
caloric intake is not enough. kwashiorkor occurs mainly due to the protein-making that is not
enough.
3. Marasmik-Kwashiorkor

The clinical picture is a mixture of several clinical symptoms of kwashiorkor and marasmus. The
daily diet does not contain enough protein and energy for normal growth. In such patients
besides weight loss <60% of normal show signs of kwashiorkor, such as edema, hair disorders,
skin disorders, while the biochemical abnormalities seen also (MOH, 2000)
In FAO (2011) mentioned that there are two types of malnutrition:
1. Protein Energy Malnutrition (PEM) = malnutrition caused by a nutrient deficiency of some or
all of either macronutrients or micronutrients.
2. Micronutrient Deficiency Disease (MDD'S) = malnutrition that occurs as a result of specific
micronutrient deficiencies (vitamins or certain minerals)

B. RISK FACTORS
Broadly speaking, the causes Marasmus is sebagaiberikut:
1. Put the food which is less
Marasmus occur as a result of caloric intake slightly, feeding is not in accordance with the
dianjurkanakibat of ignorance of the child's parents; for example the use of widely milk cans
were too thin.
2. Infection
Severe infection and long lead marasmus, especially infections enteral example of infantile
gastroenteritis, bronkhopneumonia, pielonephritis and congenital syphilis.
3. congenital structural abnormalities
For example: congenital heart disease, Hirschsprung's disease, deformities of the palate,
palatoschizis, micrognathia, stenosispilorus, hiatus hernia, hydrocephalus, cystic fibrosis of the
pancreas.
4. Prematurity and illness in the newborn period
In those circumstances breastfeeding kurangakibat less powerful sucking reflex.

5. Breastfeeding
Breastfeeding is too long without sufficient supplementary feeding.
6. Metabolic Disorders
For example: renal acidosis, idiopathic hypercalcemia, galactosemia, lactose intolerance.
7. Tumors hypothalamus
Rare and only made when other causes have been ruled marasmus.
8. Weaning
Weaning too early accompanied by pemberianmakanan less will lead to marasmus.
9. urbanization
Urbanization affects and is predisposisiuntuk onset of marasmus; urbanisasidiikuti increasing
flow also changes the habits of early weaning and then followed by administration of sweet milk
and milk terlaluencer a result of not being able to buy milk; and when disertaidengan recurrent
infections, particularly gastroenteritis akanmenyebabkan child falls into marasmus.
kwashiorkor
The cause of kwashiorkor is inadekuatnya chronic intake of protein occurred. Factors that could
cause tersbut above include:
1. Diet
Protein (and amino acids) is a substance that is needed children to grow and develop. Although
the intake of food containing enough calories, not all foods contain protein / amino acids are
sufficient. Babies who are breast-feeding generally get protein from milk given her, but for those
who are not breast fed protein adri other sources (milk, eggs, cheese, tofu, etc.) is required. Lack
of knowledge of mothers on children's nutritional balance is vital to happen kwashiorkhor,
especially in the transitional period the milk to breast-milk substitutes.
2. Social factors

Living in a country with a high population density, social and political situation is not stable, nor
any restrictions on use of certain foods and already occurred down and down can be the cause
kwashiorkor.
3. The economic factor
Family poverty / low income who can not meet the needs of children result in nutritional balance
is not met, the time when his mother was not able to meet their protein requirements.
4. Factors other infections and diseases
It has long been known that the existence of a synergistic interaction between the MEP and
infection. Any grade infection may worsen malnutrition. MEP and vice versa, although in mild
degrees will decrease the body's immunity to infection.

Other risk factors

a. Low maternal education
Lack of education and misconceptions about food security and food values are common every
country in the world. Poverty and lack of nutritious food supply is an important factor in the
issue is less gizi.Salah of the factors that cause poverty is education. Their low educational
causes a person lacked the specific skills needed in kehidupan.35 Lack of education can affect
the availability of food in the family, which in turn affects the quantity and quality of food
consumption is a direct cause of Malnutrition in children balita.Tingkat education, especially
education level the mother can affect the degree of health for the mother's education affects the
quality of childcare
b. knowledge mother
Mother is a person who plays an important role in determining the keluaga food consumption
among children. The knowledge of the mother affect the food consumption patterns of families.
Lack of knowledge of mothers about nutrition in the diversification of food is reduced. Families
will be more to buy goods because of the influence of habit, ads, and environments. In addition,

nutritional disorders are also caused due to the lack of a mother's ability to apply information on
nutrition in everyday life.
c. morbidities
Persistent Diarrhea
Tuberculosis
HIV AIDS
The above diseases can memperjelek nutritional state through
food intake disorders and increasing loss of essential nutrients in the body. There is a reciprocal
relationship between the incidence of disease and malnutrition and nutritional buruk.Anak
suffering from malnutrition and malnutrition will be decreased endurance, making it susceptible
to disease.
d. LBW
Malnutrition can occur if panjang.Pada term LBW LBW less than perfect immune antibodies
that are more susceptible to diseases, especially infectious diseases. The disease causes a toddler
less appetite, so the intake of food taken into the body to be reduced and can lead to malnutrition.
e. completeness of immunization
The immune system that causes a toddler becomes
contracted the illness. If toddlers do not do immunizations, then sends the immune decreases and
thus prone to diseases. This has an indirect impact with the incidence of malnutrition.

C. DIAGNOSTIC
A. Malnutrition kwashiorkor
a. anamnesis
a) The identity of the patient and family

b) The main complaint

1. Weight loss less
c) an additional complaint
1. Kids will not eat (anorexia)
2. Children looked limp and become more reticent
3. Often suffering from recurring
d) History of food:
1. Nutrition: food habit patterns include the type of food, the frequency, the portion / number, etc.
e) Family history
b. Physical examination
Which can be found on physical examination include:
1. Inspection
a) Edema
b) Skinny
c) Pale
d) Moo face
e) Abnormalities of the skin (hyperpigmentation)
f) Crazy pavement dermatosis
2. palpation
a) Hepatomegali
3. Measurement antoprometri (BB, TB, circle above the head, and arm skin folds)
4. Investigation
5. Laboratory tests

a) Blood tests (hb, glucose, serum protein, albumin)

b) levels of digestive enzymes
c) Biopsy liver, fatty liver is usually found mild to severe, finrosis, necrosis. In severe fatty liver
almost all cells containing fat vacuoles large
d) Examination of feces and urine

B. Malnutrition Marasmus
a. anamnesis
1. The main complaint
a. Petite (changes BB)
b. Looks like an old man
2. Additional Complaints
3. History of Food
4. Eating habits
b. Physical examination
1. Measure TB and BB
2. Calculate body mass index, the weight (in kilograms) divided by TB (in meters)
3. Measure the thickness of the skin on the back dilengan (folds triceps) is pulled away from the
arm, so that the fat layer under kulitnyadapat measured, typically by using calipers (capillaries).
The amount of fat under the skin is 50% of body fat. Normal fat folds about 1.25 cm in men and
about 2.5 cm in women.
4. The nutritional status were also obtained by measuring the LLA to estimate the number of auto
body frame (lead body mass)
c. Supporting investigation

1. Hb
2. Ht
3. Albumin
4. Serum ferritin
5. electrolytes

Malnutrition C. Marasmus kwashiorkor

a. anamnesis
1. The main complaint:
a. Reduced weight
b. Thin
c. Looks like an old man
2. Additional Complaints:
a. Thin hair, blonde and easily removed
b. Children looked limp and be quiet
c. Often suffer from recurrent pain
3. Family history:
a. an environmental home
b. Education and employment of family members
c. Relationship of family members
d. Behaviors that can affect health
b. Physical examination
1. Measurement antoprometri (BB, TB, circle above the head, and arm skin folds)

2. Malise
3. Skin Wrinkles
4. Ascites
5. edema
6. Pale
7. Moon face
8. hyperpigmentation
c. Supporting investigation
1. On laboratory examination, anemia always found because less iron intake in the diet, liver
damage and absorbs.
2. Radiological examination is made to find abnormalities in the lung

Some biochemical parameters need to be assessed:

1) Serum albumin, has a long half-life is 21 days. Levels of albumin <3.5 g / dL indicate
patients at risk of malnutrition.
2) If the total lymphocyte count, <1,500 cells per cubic millimeter can also be an indicator of risk
for malnutrition.
3) Serum transferrin, a half-life of 7 days. In some patients have transferrin levels <140 mg / dL,
the patient can be declared at risk of malnutrition.
4) Serum pre-albumin (transthyretin), the half-life of 3 days. Is said to be at risk of malnutrition
if the level is <17 mg / dL.
5) The total iron-binding capacity (TIBC) is said to be normal if the level is between 250 and 450
mcg / dL.
6) Cholesterol can also be used to assess the nutritional status, when the level is <150 mg / dL,
showed no increased risk of interference nutritional status.

Therefore there is no single parameter for diagnosis of nutritional status:

Currently> 90% diagnosis of malnutrition can be enforced through history and physical
examination known as the Subjective Global Assessment (SGA).
Assessment of nutritional status in SGA is a simple way. Throughout the assessors have been
trained, SGA can be a reliable nutritional diagnosis and an accurate predictor for assessing the
increased risk of complications such as wound infection and curative obstructed.

At the SGA will be obtained information about:

1) Changes in body weight
2) Changes in food intake
3) gastrointestinal symptoms
4) Functional Capacity
5) The relationship between the disease with nutritional needs.
6) physical examination focused on nutritional aspects

Diagnostic anthropometry:
In the WHO (2014):

D. COMPLICATIONS

Danger of complications in patients with protein-energy malnutrition is very easy to get

infections because the body resistance is low, especially the immune system. Is the most
common infectious bronchopneumonia and tuberculosis. Atrofivili their intestine causing
impaired absorption resulting in frequent diarrhea patients. Seeing such complications is difficult
to be prevented to note is the cleanliness of the mouth, skin, diarrhea and hypothermia.
(Ngastiyah, 264: 2005)
There is also another complication, namely
- Hypothermia
- Hypoglycemia.
- Infection
- Diarrhoea and Dehydration
- Shock
Causes of Hypothermia
- No / less / rarely fed
- Suffers Infection
- Exposure to the wind:
a. Genting leak
b. perforated wall
c. Bed near the door
d. Blankets and hats to be less dense
- Stick to cold objects:
a. sleeping on the floor
b. Bath too long
c. No wet diapers promptly replaced (bedwetting, diarrhea)

 Cause Hypoglycemia
- Unable to / less / rarely can eat
- Infectious Diseases
Symptoms: - Hypothermia (<35C)
- Weak
- Loss of consciousness
E. PREVENTION
Prevention of First Instance (Primary Prevention)
Prevention of the first level include the promotion of health and special protection can be done in
a way to educate more people to the things that can prevent malnutrition. Measures included in
the first-level prevention:
a. Just give breast milk to infants from birth to age 6 months.
b. Providing complementary feeding after 6 months of age.
c. Breastfeeding is continued until the age of 2 years.
d. Use of iodized salt
e. Provide nutritional supplements (vitamin A capsules, tablets Fe) to toddlers.
f. Complete basic immunization.
Second Level Prevention (Secondary Prevention)
The second level of prevention activities aimed more at the health screening and early detection
to find cases of malnutrition in the population. The second-level prevention aims to stop the
progress of cases of malnutrition towards a development in the direction of damage or disability.
Measures included in the second-level prevention:
a. Recovery supplementary feeding (MP-ASI) to toddlers gakin whose weight does not rise or
malnutrition.
b. Early detection (discovery of new cases of malnutrition) through months of a child's weight in
Posyandu.
c. Monitoring the implementation of the local area of nutrition (PWS-Nutrition).

d. The implementation of early warning systems of outbreaks of malnutrition.

e. Nutritional Status Monitoring (PSG)
Third Level Prevention (Tertiary Prevention)
The third level of prevention is intended to limit or impede disability, condition or disorder that
does not develop in the direction of requiring more intensive care. Prevention of the third level
also includes restrictions on any current inability to provide rehabilitation nutritional problems
have occurred and caused damage. Measures included in the third-level prevention:
a. Counseling to mothers whose children have stunted growth.
b. Improving knowledge and skills of mothers in providing nutritional care to the child.
c. Tackling malnutrition with care health centers and hospitals.
Empowering families to apply nutrition conscious behavior

b. knowledge mother
Mother is a person who plays an important role in determining the keluaga food consumption
among children. The knowledge of the mother affect the food consumption patterns of families.
Lack of knowledge of mothers about nutrition in the diversification of food is reduced. Families
will be more to buy goods because of the influence of habit, ads, and environments. In addition,
nutritional disorders are also caused due to the lack of a mother's ability to apply information on
nutrition in everyday life.
c. morbidities
Persistent Diarrhea
Tuberculosis
HIV AIDS
The above diseases can memperjelek nutritional state through
food intake disorders and increasing loss of essential nutrients in the body. There is a reciprocal
relationship between the incidence of disease and malnutrition and nutritional buruk.Anak
suffering from malnutrition and malnutrition will be decreased endurance, making it susceptible
to disease.

d. LBW
Malnutrition can occur if panjang.Pada term LBW LBW less than perfect immune antibodies
that are more susceptible to diseases, especially infectious diseases. The disease causes a toddler
less appetite, so the intake of food taken into the body to be reduced and can lead to malnutrition.
e. completeness of immunization
The immune system that causes a toddler becomes
contracted the illness. If toddlers do not do immunizations, then sends the immune decreases and
thus prone to diseases. This has an indirect impact with the incidence of malnutrition.