MALNUTRISI AKUT, GAGAL TUMBUH

DAN PEMERIKSAAN
ANTROPOMETRIK
Endy P. Prawirohartono
Divisi Nutrisi dan Penyakit Metabolik
Departemen Ilmu Kesehatan Anak
Fakultas Kedokteran UGM
Yogyakarta
 MALNUTRISI AKUT
(umur 5-59 bulan)

MALNUTRISI AKUT SEDANG MALNUTRISI AKUT BERAT

(Moderate acute malnutrition, (Severe acute malnutrition,
MAM) SAM)

- 3 SD WHZ < - 2 SD WHZ < - 3 SD

atau
atau Bilateral pitting edema
atau
11,5 cm LLA < 12,5 cm LLA < 11,5 cm
(GIZI KURANG) (GIZI BURUK)

UNESCO. EVALUATION OF COMMUNITY MANAGEMENT OF ACUTE MALNUTRITION (CMAM) , 2013

 Definisi: SAM Gizi buruk
Indikator <6 6-59 >59
bulan bulan bulan
BB/TB <- 3 SD*

LLA <115 mm

BMI/U <-3 SD*

Edema
bilateral

* WHO Child Growth Standard 2006

(WHO, 2013)
 Penampilan klinis lain?
Perlu dikenal pada pemeriksaan fisis
Penegakan diagnosis: tidak harus (simplifikasi)

Rambut tipis mudah dicabut, warna terang

Kulit kotor mudah mengelupas (crazy
pavement dermatosis)
Kulit keriput (baggy pants, monkey facies)
Bitots spot
dan lain-lain
ANTROPOMETRI
 UKURAN ANTROPOMETRI

BERAT BADAN PANJANG BADAN LINGKAR LENGAN ATAS

(< 2 tahun)
Satuan: TINGGI BADAN Satuan:
g (neonatus) ( 2 tahun) cm
kg (anak) Ketepatan:
Satuan: 0,1 cm
Ketepatan: cm
0,1 kg Ketepatan:
0,1 cm
 INDEKS* ANTROPOMETRI
BERAT BADAN PANJANG BADAN BERAT BADAN
MENURUT UMUR MENURUT UMUR MENURUT
(BB//U) (PB//U) PANJANG BADAN
atau (BB//PB)
WEIGHT FOR AGE TINGGI BADAN atau
(WFA) MENURUT UMUR BERAT BADAN
MENURUT
BODY MASS INDEX LENGTH FOR AGE TINGGI BADAN
MENURUT UMUR (LFA)
(BMI//U) atau WEIGHT FOR LENGTH
HEIGHT FOR AGE (WFL)
BODY MASS INDEX (HFA) atau
FOR AGE WEIGHT FOR HEIGHT
(BMIFA) (WFH)
* BUKAN INDIKATOR
 SATUAN INDEKS ANTROPOMETRI
Z-SCORE PERSENTIL PERSEN MEDIAN
(SD SCORE) (PERCENTILES)
Persentil ke:* Contoh:
WAZ 1 (1st)
LAZ/HAZ 3 (3rd) BB//U = 78% median
WHZ 5 (5th) TB//U = 86% median
BMIZ 15 (15th) BB//TB = 93% median
* BUKAN PERSENTIL 50,
25 (25th)
50 PERSENTIL 50 (50th)
50 PERSEN 75 (75th)
* PERSENTIL MAYOR:
85 (85th)
5th, 10th, 25th, 50th, 75th, 95 (95th)
90th, 95th (CDC 2000) 97 (97th)
(Olsen et al., Arch Dis Child
2007;92:109-14)
99 (99th)
KLASIFIKASI INDEKS ANTROPOMETRI

Z-score WAZ HAZ WHZ

<-3 SD Severe Severe stunting Severe wasting

underweight
- <2SD sd 3 SD Underweight Stunting wasting

- 2 SD sd + 2 SD Normal Normal normal

>+2 SD sd + 3 SD Tall Overweight

Overweight
>+ 3 SD Obese
Relation between the classifications low, normal and high for the indicators WHZ, WAZ and
HAZ with cut-offs at 2 standard deviations above and below the median

WHO. Measuring change in nutritional status. Guidelines for assessing the nutritional impact
of supplementary feeding programmes for vulnerable groups, 1983.
 INTERPRETASI KOMBINASI INDEKS
AREA WHZ WAZ HAZ INTERPRETATION
11 LOW LOW Normally fed with past history of malnutrition
9 NORMAL NORMAL NORMAL NORMAL
7 HIGH HIGH Tall, normally nourished
17 LOW HIGH Currently underfed ++
16 LOW LOW NORMAL Currently underfed +
14 NORMAL HIGH Currently underfed
2 HIGH LOW Obese +
1 HIGH NORMAL LOW Currently overfed with past history of
malnutrition
4 HIGH NORMAL Overfed but not necessarily obese
NORMAL = between 2SD to + 2SD LOW = < - 2 SD HIGH > + 2SD

WHO. Measuring change in nutritional status. Guidelines for assessing the nutritional impact
of supplementary feeding programmes for vulnerable groups, 1983.
 LLA vs INDEKS
INDEX SHORT TERM LONGTERM SIMPLICITY COST
CHANGE CHANGE
WHZ +++ ++ + ++
WAZ ++ ++ + ++
HAZ ++ +++ + ++
MUAC +++ ++ +++ +++
INDEX ACCEPTABILITY INDEPENDENCE RELIABILITY AND
OF AGE ACCURACY
WHZ +++ ++ +
WAZ +++ +++ +
HAZ +++ +++ +
MUAC +++ ++ ++
+++ = good ++ = fair + = poor Frison et al. BMC Nutr. 2016;2:76 .
TATA LAKSANA GIZI BURUK
 Time frame for the management of the child with
severe malnutrition

Stabilization Transition Rehabilitation

10 STEPS
Days 1-2 D Days 3-7 Weeks 2-6

1. Hypoglycemia
2. Hypothermia
3. Dehydration
4. Electrolytes
5. Infection
6. Micronutrients no iron with iron
7. Initial feeding
8. Catch-up growth
9. Sensory stimulation
10. Prepare for follow-up
STEP 1 HYPOGLYCEMIA

Is quick blood glucose test (e.g. Dextrostix) available?

YES NO

Blood glucose normal Hypoglycemia* Assume that the child

has hypoglycemia

* < 3 mmol/l
Is the child conscious?
or < 54 mg/dl
** 1 teaspoon of
sugar in YES NO (unconscious)
31/2 tablespoons Give: Give:
water First feed of F-75 i.v. 10% glucose 5ml/kg
or: 50 ml of 10% glucose orally or: 50 ml of 10% glucose
or: 50 ml of sucrose solution** by NGT
or: 50 ml of sucrose
REPEAT TEST AFTER 30 MINUTES solution by NGT
STEP 2
HYPOTHERMIA
Is thermometer available?

YES NO

NORMAL HYPOTHERMIA* Assume the child

has hypothermia

* Axillar temperature Child clothed (including head) - Warm blanket -

< 35C Place a heater or lamp nearby
or: or:
Rectal temperature Put the child on bare chest or abdomen of the mother
< 35,5C (skin-to-skin) cover them with warm blanket and/or
warm clothing
Monitor temperature every 2 hour until it increases
more than 36.5C
or:
Every hour if a heater is being used
 It is difficult to estimate
STEP 3 DEHYDRATION dehydration status accurately
in a severely malnourished child

Is the child suffering from watery diarrhea?

YES NO

Assume the child may has some dehydration

Give: ReSoMal by oral or NGT

- 5 ml/kg/30 minutes for first 2 hours
- 5-10 ml/kg/hour for the next 4-10 hours
Rehydration is still occurring at 6 and 10 hours

Give: F-75 instead of ReSoMal use the same volume of F-75

as for ReSoMal
NOTE: Do not use i.v. route for rehydration EXCEPT in cases of shock
Overhydration may lead to heart failure check:
- respiratory rate increases by 5/minute
- pulse rate increases by 15/minute
Stop ReSoMal immediately and reasses after 1 hour
STEP 4 ELECTROLYTES

All severely malnourished children have deficiencies

of potassium and magnesium takes 2 weeks
or more to correct
Do not treat edema with a diuretics
Excess body sodium exists even though the plasma
sodium may be low
GIVING HIGH SODIUM LOADS
COULD KILL THE CHILD!

Give:
-Extra potassium (3-4 mmol/kg/daily)
-Extra magnesium (0.4-0.6 mmol/kg/daily)
The extra potassium and magnesium should be added to the
feeds during their preparation
 All severely malnourished
STEP 5 children should be assumed
INFECTION have infection during their
arrival in hospital

Are there complications (hypoglycemia, hypothermia or the child

looks lethargic or sickly)?

NO YES

Amoxycillin oral: Ampicillin 50 mg/kg/i.m./i.v. 6 hourly 2 days

15 mg/kg/8 hr, + gentamicin 7.5 mg/kg/i.m./i.iv. once daily 2 days
OR
Ampicillin oral: Improvement?
50 mg/kg/6 hr
5 days YES NO Continue ampicillin and
Gentamicin until 7 days
NOTE Add: Chloramphenicol:
Check for meningitis, malaria, tuberculosis 25 mg/kg/i.m./i.v. 8 hourly 5 days
pneumonia, dysentery, skin infection
 Terapi diet gizi buruk
Resintesis enzim
Gangguan organ-organ (hati, usus,
ginjal) Metabolisme membaik
Infeksi, bakteri tumbuh lampau di Edema menghilang
usus Proses fisiologis mulai normal
Anoreksia Nafsu makan membaik

Makanan dengan kandungan

Energi dan protein lebih padat
protein, besi, dan natrium rendah
Mudah dicerna Fortifikasi vitamin dan mineral
Kaya kalium dan magnesium Promosi pertumbuhan
Bukan untuk pertumbuhan

F-75 F-100
Golden MH. Evolution of nutritional management of acute malnutrition. Indian Pediatr 2010;47:667-78.
 Terapi diet gizi buruk
Sebenarnya ada masalah fungsi tubuh
yang tidak disadari oleh dokter:
F-100 Kemampuan ginjal belum baik
Intoleransi glukose
Sekresi insulin belum normal
Berat badan bertambah Fungsi imunitas masih jelek
Panjang/ tinggi badan Pompa natrium belum baik
bertambah Konsentrasi elektrolit intraselular
belum terkoreksi
Komposisi tubuh masih belum
ideal terutama pertumbuhan otot
Dokter puas

Zinc
Golden MH. Evolution of nutritional management of acute malnutrition. Indian Pediatr 2010;47:667-78.
STEP 6 MICRONUTRIENTS
INITIAL FEEDING

Give daily for at least two weeks:

a multivitamin supplement
folic acid 5 mg on day 1, then 1 mg/day
zinc 2 mg Zn/kg/day
copper 0.3 mg/kg/day
once gaining weight, ferrous sulfate 3 mg/kg/day
vitamin A orally (aged < 6 mo: 50000 IU, aged 6 mo 12 months:
100.000 IU, older children 200.000 UI 20,.000 daily) on day 1
OR
Vitamin A 5000 IU daily up to stop the ten steps
 All severely malnourished
STEP 7 INITIAL FEEDING children have vitamin and
mineral deficiencies

Essential features of initial feeding are:

1. Frequent small feeds
2. Oral or nasogastric tube (never parenteral preparation )
3. 100 kcal/kg/day
4. Protein 1-1.5 g/kg/day
5. Liquid: 130 ml/kg/day (100 ml/kg/day if the child has severe edema)
6. If the child is breastfed, continue with this, but make sure the
prescribed amounts of starter formula are given

Days Frequency Vol/kg/feed Vol/kg/day

1-2 2-hourly 11 ml 130 ml

3-5 3-hourly 16 ml 130 ml
6 onwards 4-hourly 22 ml 130 ml
 Signs that a child has
STEP 8 reached this phase are:
CATCH-UP GROWTH return of appetite
most/all of the edema
has gone

Replace F-75 with an equal amount of catch-up F-100 for 2 days

The increase each successive feed by 10 ml until some feed remains
uneaten

After a gradual transition give:

frequent feeds, unlimited amounts
150-220 kcal/kg/day
4-6 g of protein/kg/day
Assess progress:
poor: < 5 g/kg/day requires a full re-assessment
moderate: 5-10 g/kg/day check whether the intake targets are
being met, or infection has been overlooked
good: > 10 g/kg/day
STEP 9 SENSORY STIMULATION

Provide:
tender loving care
a cheerful stimulating environment
structured play therapy for 15-30 minutes a day
physical activity as soon as the child is well enough
maternal involvement as much as possible
(e.g. comforting, feeding, bathing, play)
STEP 10 PREPARE FOR FOLLOW-UP

A child who is 90% weight for length (equivalent to 1 SD)

can be considered to have recovered
The child is still likely to have a low weight for age because of stunting

Show the parents how to:

feed frequently with energy-rich and nutrient-dense
foods
give structured play therapy
ask the parents to bring the child back for regular
follow-up (at 1, 2 and 4 weeks, then monthly for
6 months) and make sure the child receives
booster immunizations and 6-monthly vitamin A
GAGAL TUMBUH
(FAILURE TO THRIVE)
 GRAFIK BERAT BADAN ANAK

masih biasa
(normal)

5,5 kg
4,9 kg
4,1 kg
3,5 kg
 FENOMENA KAMAR PRAKTEK

Seorang anak laki-laki, 3 bulan, BB = 5,5 kg, PB

= 60,0 cm
Dibawa ibu ke dokter, karena kenaikan BB
kurang (melihat grafik BB anak cenderung turun)
BB lahir = 3,5 kg, PB lahir = 49,0 cm

APAKAH BENAR KENAIKAN BB ANAK

KURANG?
 GRAFIK BERAT BADAN ANAK

STATUS GIZI

normal
PERTUMBUHAN

5,5 kg

3,5 kg

3 BULAN

Apakah benar ada kesan BB turun? BENAR!

 Status gizi versus pertumbuhan

Status gizi Pertumbuhan

Data cross-sectional Data longitudinal
Skala ordinal lebih Skala rasio lebih sering
sering dipakai dibanding dipakai dibanding skala
skala rasio ordinal
Tidak dapat menilai Dapat menilai trend
trend
Mengenal perubahan Mengenal perubahan
(abnormalitas) lebih (abnormalitas) lebih dini
lambat
 Apakah keadaan ini disebut failure to thrive?

Konsep failure to thrive pertama kali dijelaskan oleh

Holt (1879)

Anak tidak naik berat badannya sesuai dengan

seharusnya

Indikator failure to thrive menggunakan BB bukan TB

BB yang pertama kali dipengaruhi, TB baru pada tahap
berikutnya (hanya sedikit mempengaruhi LK)
Apa yang dimaksud dengan seharusnya?
 Indikator failure to thrive
Indikator untuk mendeteksi failure to thrive
adalah weight increment atau weight velocity
Weight increment ialah:
Perubahan BB (g) dalam periode waktu tertentu
Weight velocity ialah:
Perubahan BB (g) menurut waktu (bulan)
atau g/bulan dibandingkan dengan populasi
sesuai dengan umurnya
Perubahan <persentil ke-5 menunjukkan failure
to thrive
Kunci menentukan weight velocity
1. Berapa bulan intervalnya?
2. Mulai umur berapa bulan sampai dengan berapa
bulan?

Dalam contoh di atas:

1. Interval = 3 bulan
2. Mulai umur 0 bulan (lahir) sampai dengan 3 bulan

Lihat dalam tabel WHO Growth Standard 2007

 Persentil ke 5
Interval
3 bulan

Antara umur
0-3 bulan Simplified field tables

3-month weight increments (g) BOYS

Birth to 24 months (percentiles)

Interval 1st 3rd 5th 15th 25th 50th 75th 85th 95th 97th 99th
0-3 mo 1733 1960 2083 2409 2608 2989 3383 3600 3972 4119 4401
2083 g 1-4 mo
2-5 mo
1415
1011
1621
1187
1733
1284
2031
1542
2214
1702
2565
2012
2931
2337
3132
2518
3480
2833
3618
2958
3882
3199
3-6 mo 704 856 940 1166 1307 1582 1874 2038 2323 2438 2659
4-7 mo 496 632 707 910 1038 1289 1558 1709 1975 2082 2289
5-8 mo 355 480 550 739 859 1096 1350 1494 1748 1850 2049
6-9 mo 249 369 436 618 733 962 1208 1348 1595 1694 1888
Kenaikan BB 7-10 mo 162 280 346 526 639 865 1108 1246 1489 1587 1778
minimal selama
8-11 mo 86 205 271 452 567 793 1036 1173 1414 1511 1700
9-12 mo 21 142 210 393 509 738 982 1120 1360 1457 1644
3 bulan (antara
10-13 mo -35 90 159 347 465 696 942 1080 1320 1416 1602
lahir sd 3 bulan)
11-14 mo -80 48 119 310 430 665 913 1051 1291 1387 1571
12-15 mo -115 16 88 283 404 641 891 1029 1269 1364 1547
13-16 mo -141 -8 65 263 385 624 874 1012 1252 1347 1529
14-17 mo -159 -25 49 248 372 611 861 1000 1239 1334 1515
 Weight velocity

Berat badan lahir = 3,5 kg

Berat badan 3 bulan = 5,5 kg

Kenaikan BB 3 bulan (persentil ke 5) = 2083 g

Kenaikan BB aktual (dari 0-3 bulan) = 2000 g

Kenaikan BB aktual <kenaikan BB 3 bulan

(persentil ke 5) FAILURE TO THRIVE
GROWTH FALTERING: 54 COUNTRIES
Global Database on Child Growth and Malnutrition

Victora CG et al. Pediatrics 2010;125:e473-e480.

 KEWAJIBAN TENAGA KESEHATAN
Mengukur BB, PB atau TB dan lingkar kepala
Menentukan status pertumbuhan (adakah
failure to thrive?)
Menentukan status nutrisi (adakah MAM atau
SAM)

Setiap bulan atau bila ditentukan waktu lain

TERIMA KASIH