PROBLEM BASED LEARNING REPORT

MALNUTRITION ENERGY PROTEIN MODUL

PEDIATRIC AND GERIATRIC SYSTEM

Created by :
GROUP 14
Tutor : dr. Hasta Handayani Idrus,
M. Kes

GROUP 14

Nur Aini Pido 110 213 0018

Andi Tenriawaru Parenrengi

A.Nadiah Nurul Fadilah

Erwin Wijaya 110 213 0060

Andi Nurul Fasty Batari

Dian Eka Saputri

110 213 0090

Ahmad Gifari Raya

110 213 0102

Nur Fatima Zulkaidani110 213 0107

Nurainun Darwis 110 213 0149

Adhe Ikhmaniar Puteri

110 213 0032

110 213 0048

110 213 0136

110 213 0145

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.

Difficult Words

Bitot spot :

whiteorgraytriangulardepositsonthebulbarconjunctivaadjacenttothelatera
lmarginofthecornea,aclinicalsignofvitaminAdeficiency.

Wasting and baggy pants:

Muscle wasting is present and there is severe loss of fat in subcutanous

tissues.

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. a. How to assess the nutrition status of the baby in scenario?
b.How the interpretation of dehydration score and hemoglobin of the baby in scenario?
2. How is the normal feeding to the 9 months baby?
3. What are the compositions of starch water and breastmilk?
4. How is the phatomechanism of all symptomps in scenario?
5. How to diagnose according to the problem of the baby in scenario?
6. Explain about Malnutrition :
7. How is the treatment steps for malnutrition according to WHO?
8. How is the treatment for the baby in scenario?
9. How is the islamic perspective of scenario?

1. a) How to assessment
nutritional status of the
baby in scenario?

The standard weight for age ( W / A)

Girls 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 )

Girls 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 )

Girls aged 0-24 months

Based on the table , a girl

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 )

Girls 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 girl 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.

b) How the interpretation of dehydration score and

hemoglobin of the baby in scenario?
Interpretation of dehydration score

Based on the scenario, the dehydration score of the

baby is 13. It means the baby is severe
dehydration

Interpretation of Hemoglobin value

Based on secenario, the hemoglobin of the

baby is 5gr/dl. It means the baby has low
hemoglobin or anemia

2. How is the normal feeding to the 9 months baby?

Normal feeding according to Age

Age

Kind and Frequency

0-6 months

Breastmilk

6-10 months

Breastmilk, Fruit 1-2x , soft food 1-2x, creamed food 1-2x

10-12 months

Breastmilk, formula milk, Fruit 1-2x, soft food 1-2x, creamed

food 1-2x, egg 1x

In the scenario, the baby only have breastfeeding up to three months, then
given starch water until now. The baby didnt get the normal feeding according to
her age.

Slide Kuliah Prof. Dr.dr. R. Satriono, M.Sc, Sp.A(K), Sp. GK(K) , Infant and Children Feeding

3. What are the compositions of starch

water and breastmilk?
starch water

Energy (kal) 43.20

Water (g) 91.21

Protein (g) 0.66

Fat (g) 1.92

Carbohydrate (g) 5.82

Vitamin b1 (mg) 0.0046

Fe (mg) 0.086

breastmilk
Composition
Energy (Kg kla)

Kolostrum
57,0

Transisi
63,0

Asi Matur
65,0

Laktosa (gr/100ml)

6,5

6,7

7,0

Lemak (gr/100ml)

2,9

3,6

3,8

Protein (gr/100ml)

1,195

0,965

1,324

Mineral (gr/100ml)

0,3

0,3

0,2

335,9
5,9
17,1
14,2-16,4
420-520

119,6
2,9
2,9
24,3-27,5
250-270

Immunoglobulin :
IgA (mg/100ml)

Ig G (mg/100ml)

IgM (mg/100ml)

Lisosim (mg/100ml)

Laktoferin

4. How is the phatomechanism of all

symptomps in scenario?
Edema
protein
hipoalbuminemia
Osmotic Pressure Plasma
Plasma Volume
ADH
WATER RETENTION

ANP N/

Renin Angiotensin System

Na RETENTION

RETENTION

EDEMA

Referensi :
Sudoyo, Aru W, dkk. 2009. Buku Ajar Ilmu Penyakit Dalam jilid II. Edisi V. Jakarta : Interna Publishing. Hal 148.

Bitots Spot
Vitamin A (Retinoal)

The growth and

differentiation of
epithelial cells
Vitamin A
deficiency
If continued

ulceration,
necrosis,
keratomalasia,
and permanent
corneal scarring

metaplasia
conjunctival
epithelial cells
xeroftalmia

gland does not

produce liquid

xerosis conjunctival
& cornea

Bitots Spot

Referensi :
Marcdante, Karen, Dkk. 2014. Nelson Ilmu Kesehatan Anak Esensial. Edisi 6. Singapore : Saunders Elsevier. Hal 132-133

Dry eyes

Diarrhea
Malabsorption
in the
intestines

Water was
drawn to the
intestinal
lumen

DIARRHEA

Intake lots of
sweet drinks
(carbohydrate)

Exceeds the
absorption
capacity of
the intestine

Referensi :
Marcdante, Karen, Dkk. 2014. Nelson Ilmu Kesehatan Anak Esensial. Edisi 6. Singapore : Saunders Elsevier. Hal 459

Wasting & Baggy Pants

Inadequate intake of nutrients
(low carb, etc.)

Low blood glucose levels

Muscle atrophy (Baggy Pants)

Reduced insulin hormone

synthesis

Reduced muscle protein

Glukoneogenesis

cortisol increases

Increased muscle protein

metabolism

Referensi :
Guyton and Hall. 2006. Buku ajar fisiologi kedokteran. edisi 9. Jakarta : EGC

5. How to diagnose according to the problem of the

baby in scenario?

Anamnesis

Identity
Main complaint : onset, duration
Additional complaint
Food History : food habit, include the kind of food, the frequency, the
portion / number, vitamin suplemen, etc.
Birth History :Birth weight, lenght
Immunization history
Growth and development history
Family history

Physical
Examination

Antropometri data : measure LLA, weight, length/ height, calculate BMI

Vital sign : temperature, blood pressure, pulse, respiratory rate
Inspeksi
Palpasi
Perkusi
Auskultation

Pemeriksaan
Penunjang

Laboratorium examination
Electrolyte
Radiology

asnjoer A, dkk. Kapita Selekta Kedokteran. Edisi III. Jilid II. FKUI. Jakarta. 2000; 514-18.

6. Explain about Malnutrition !

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.

Classification

In FAO (2011) mentioned that there are two types of malnutrition:

Protein Energy Malnutrition (PEM)
malnutrition caused by a nutrient
deficiency of some or all of either
macronutrients or micronutrients.

Micronutrient Deficiency Disease (MDD'S)

malnutrition that occurs as a result of
specific micronutrient deficiencies
(vitamins or certain minerals)

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.

Keith P. West, Jr. 2006. Protein-Energy Malnutrition (PEM) and Undernutrition. The John Hopkins University.

Diet
Diet

Role
Role of
of free
free
Radicals
Radicals and
and
Aflatoxins
Aflatoxins

Etiology
of PEM

Biological
Biological
factors
factors

Social
Social and
and
Economic
Economic
factors
factors

Environmental
Environmental
Factors
Factors

Keith P. West, Jr. 2006. Protein-Energy Malnutrition (PEM) and Undernutrition. The John Hopkins University.

Clasification of PEM
Marasmus
Severely wasted (emaciated) & stunted
Very low WAZ
Balancedstarvation
Old Manface, wrinkled appearance, sparse
hair
No edema, fatty liver, skin changes
Too little breast milk or complementary foods
< 2 yrs of age

Keith P. West, Jr. 2006. Protein-Energy Malnutrition (PEM) and Undernutrition. The John Hopkins University.

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

Keith P. West, Jr. 2006. Protein-Energy Malnutrition (PEM) and Undernutrition. The John Hopkins University.

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.

Keith P. West, Jr. 2006. Protein-Energy Malnutrition (PEM) and Undernutrition. The John Hopkins University.

Marasmus

Kwashiorkor

Marasmic
Kwashiorkor

Severely
underweight

Severely stunted

Severely wasting

Edema dorsum of
foot and pretibial

Wasting and baggy

pants

+/-

Bitot spot

+/-

Diarrhea

+/-

+/-

+/-

Dehydration

+/-

+/-

+/-

Anemia

7. How is the treatment steps

for malnutrition according to
WHO?

management of a child with severe

malnutrition
10 steps
No

Tindakan

H 1-2

stabilitation
Transition Rehabilitation Tindak lanjut
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
mikronutrien
7. cautious feeding
8. catch-up growth
9. stimulation
10. Prepare for follow up

whithout Fe

+ Fe

8. How is the treatment for the baby in scenario?

Treat the diarrhea and dehydration

Bagan Tata Laksana Anak Gizi Buruk. 2011. Kementrian Kesehatan Republik Indonesia Direktorat Jenderal Bina Gizi dan
Kesehatan Ibu Dan Anak.

Nutrition treatment according to needs in each phase

Bagan Tata Laksana Anak Gizi Buruk. 2011. Kementrian Kesehatan Republik Indonesia Direktorat Jenderal Bina Gizi dan
Kesehatan Ibu Dan Anak.

Vitamin A suplemen to treat deficiency of vitamin A

Bagan Tata Laksana Anak Gizi Buruk. 2011. Kementrian Kesehatan Republik Indonesia Direktorat Jenderal Bina Gizi dan
Kesehatan Ibu Dan Anak.

9. 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 mothers 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)

REFERENCE

Keputusan Menteri Kesehatan Republik Indonesia (Nomor:1995/MENKES/SK/XII/2010). Tentang Standar

Antropometri Penilaian Status Gizi Anak. Kementrian Kesehatan RI. Direktorat Jenderal Bina Gizi dan
Kesehatan Ibu dan Anak. Direktorat Bina Gizi. Jakarta: 2011.

Slide Kuliah Prof. Dr.dr. R. Satriono, M.Sc, Sp.A(K), Sp. GK , Infant and Children Feeding

The Benefit of Starch Water for Human. Teofilus. 2016

Marcdante, Karen, Dkk. 2014. Nelson Ilmu Kesehatan Anak Esensial. Edisi 6. Singapore : Saunders Elsevier.
Hal 132-133

Marcdante, Karen, Dkk. 2014. Nelson Ilmu Kesehatan Anak Esensial. Edisi 6. Singapore : Saunders Elsevier.
Hal 459

Guyton and Hall. 2006. Buku ajar fisiologi kedokteran. edisi 9. Jakarta : EGC

Masnjoer A, et al. Capita Selecta Medicine. Edition III. Volume II. FKUI. Jakarta. 2000; 514-18.

Ngastiyah. Perawatan Anak Sakit edisi 2. Jakarta: EGC. 2005

Keith P. West, Jr. 2006. Protein-Energy Malnutrition (PEM) and Undernutrition. The John Hopkins University.

Bagan Tata Laksana Anak Gizi Buruk. 2011. Kementrian Kesehatan Republik Indonesia Direktorat Jenderal
Bina Gizi dan Kesehatan Ibu Dan Anak.