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ASESMEN DAN DIAGNOSIS

GIZI PADA BALITA


MALNUTRISI

TANGGERANG SELATAN, 7 SEPTEMBER 2019


Hello!
I Am Gunarti Yahya

I am here because I love to


Presentation : Awareness of
Malnutrition in Pediatrics

My contact : 0812-9937083

“A person who never made a mistake never
tried anything new.”
Topik Pembahasan
1.Pendahuluan
2.Model Proses NCP
3. Asesmen Gizi: Malnutrisi
4. Diagnosis Gizi : Malnutrisi
Permasalahan Gizi Balita Di Indonesia
1000 HPK (Hari Pertama Kehdupan)
• Pertumbuhan pesat terjadi pada 2 tahun pertama kehidupan,
meliputi pertumbuhan otak dan pertumbuhan linear
• Teori Thrifty Phenotype (Barker dan Hales) menyatakan bahwa, bayi
yang mengalami kekurangan gizi di dalam kandungan dan telah
melakukan adaptasi metabolik dan endokrin secara permanen, akan
mengalami kesulitan untuk beradaptasi pada lingkungan kaya gizi
pasca lahir.
• Kita masih bisa melakukan optimalisasi pertumbuhan bayi di periode
emas 0-24 bulan, masih bisa diperbaiki. Tetapi bila gangguan
pertumbuhan berlanjut, tidak dikoreksi sampai anak usia 2 tahun,
kondisi ini tidak bisa dikoreksi

Ir. Doddy Izwardi, Kualitas manusia ditentukan pada 1000 Hari Pertama
Kehidupannya, publikasi 20 Januari 2017. www.depkes.go.id
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3 Cara Untuk terhindar masalah Gizi Pada Bayi dan
Balita
1. 1 jam pertama Inisiasi menyusui Dini
2. Pemberian ASI eksklusif 0 – 6 bulan
3. Fase diatas 6 bulan pemberian Makanan Pendamping ASI
(WHO 2003 merekomendasikan 4 syarat pemberian MP-
ASI, Tepat waktu, Adekuat, Aman, Diberikan secara benar),
perhatikan aspek-aspek Pemberian Makanan Bayi dan
Balita).
Ir. Doddy Izwardi, Kualitas manusia ditentukan pada 1000 Hari Pertama Kehidupannya,
publikasi 20 Januari 2017. www.depkes.go.id

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Sifat alat skrining:
Sederhana Malnutrisi ???
Mudah
Sebagai data rutin Skrining Gizi : Suatu proses
Murah mengidentifikasi individu yang
Efektif mengidentifikasi
berisiko / mengalami malnutrisi
malnutrisi
Reliable dan valid agar mendapatkan pengkajian
gizi sesuai indikasi (ASPEN,
2011)
Tools Skrining untuk Anak
• Strong-Kids dari Belanda
• PYMS dari Inggris
• STAMP dari Inggris
ADAPTASI STRONG KIDS
NO Parameter Skor
1 Apakah Pasien tampak kurus? a. Tidak 0
b. Ya 1
2 Apakah terdapat penurunan berat badan selama 1 bulan a. Tidak 0
terakhir? berdasarkan data penurunan BB objektif bila b. Ya 1
ada/penilaian subjektif dari orang tua ATAU untuk Bayi
<1tahun: BB tidak naik dalam 3 bulan terakhir)
3 Apakah ada salah satu dari kondisi berikut? Diare >5 kali per a. Tidak 0
hari dan atau muntah >3x per hari dalam seminggu terakhir b. Ya 1
4 Asupan makan berkurang selama 1 minggu terakhir a. Tidak 0
b. Ya 1
5 Apakah konsisi penyakit yang menyebabkan beresiko malnutrisi a. Tidak 0
seperti penyakit di bawah ini? b. Ya 1
Interpretasi skor Strong-Kids
•Skor 0: Beresiko malnutrisi
ringan
•Skor 1-3: Beresiko malnutrisi
sedang
•Skor 4-5: Beresiko malnutrisi
tinggi

10
Here you can write more
More about your project.

Content itself is what the end-user derives


value from also can refer.
PENGKAJIAN GIZI
• Antropometri

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Standar Referensi / Pembanding
• Indeks antropometri:
•BB/U
•PB/U, TB/U
•BB/TB, BB/PB
•LK/U
•LLA/U
•IMT/U

• PENENTUAN STATUS GIZI ANAK


1. CARA PERSENTIL (PERSEN TERHADAP
MEDIAN)
untuk Umur diatas 5th Grafik CDC 2000
2. CARA SIMPANGAN BAKU TERHADAP
MEDIAN (Z SCORE)
Untuk Umur 0-5th Grafik WHO 2006

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Penentuan Status Gizi (Z-Score)
Indikator malnutrisi pada pediatrik
1. Velositas kenaikan berat badan
2. Adekuasi asupan makanan/zat gizi dan utilisasi
3. Lingkar lengan atas (5 –59 bulan )
4. Kekuatan genggam ( handgrip strength )usia +6 tahun
5. Tanner Stage
 Bisa digunakan sebagai marker gizi usia (<5tahun)
 Sebaiknya dideteksi sebelum usia remaja

(sumber : AND/ASPEN,2015)

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Indikator malnutrisi pada pediatric (1 Indikator)
Indikator Ringan Sedang Berat
(Z-Score)
BB/PB atau -2SD<Z<-1SD -3SD<Z<-2SD <-3SD
BB/TB
IMT/U - 2SD<Z<-1SD 3SD<Z<-2SD <-3SD
PB/U atau N/A N/A -3SD
TB/U
LLA/U -2SD<Z<-1SD 3SD<Z<-2SD <-3SD

Sumber : AND/ASPEN,2015 16
Indikator Malnutrisi pada pediatric
(2 indikator atau lebih)
Indikator Ringan Sedang Berat
Velositas kenaikan BB <75% standar <50% standar <25% standar
(usia <2tahun)
Penurunan BB/minggu 5%BB 7.5 % BB 10% BB
(usia 2-20tahun)
Penurunan BB/PB atau Penurunan 1SD Penurunan 2SD Penurunan 3SD
BB/TB
Asupan energi/protein 51-75% estimasi 26-50% estimasi ≤-25% estimasi
tidak adekuat kebutuhan kebutuhan kebutuhan

Sumber : AND/ASPEN,2015 17
Kriteria Gizi Buruk Bayi & Anak
• Gizi buruk pada anak usia 6 - 59 bulan ditandai oleh adanya
edema pitting bilateral atau sangat kurus berdasarkan LILA
< 11,5 cm atau BB/TB < -3 z-score.

• Gizi buruk pada bayi < 6 bulan ditandai oleh edema pitting
bilateral atau sangat kurus berdasarkan BB/PB < -3 z-score
KWASHIORKOR
• Asupan protein tidak cukup untuk
mempertahankan “visceral stores”
• Albumin < 3,0 g/dl dan serum tranferin menurun
• Triceps skinfold (TSF) dan BB/TB  normal
• Rendahnya BUN, kreatinin dan TLC
• Pitting edema dan perlemakan hati biasanya
terjadi.
• Terjadi dalam waktu beberapa minggu  bulan
Pemeriksaan fisik terkait gizi Kwasiorkor
1. Kurus (pada lengan dan
kaki)
2. Perut membesar
(asites/hepatomegali)
3. Edema perifer
4. Penurunan massa otot
5. Wajah tampak bulat
‘moonface’
6. Apatis
7. Rambut kemerahan 20
Ringan ( + ) Sedang ( ++ ) Berat ( +++ )
Edema kedua kaki Edema kedua tungkai Edem anasarka,
dan tanga termasuk tungkai,
tangan dan muka
MARASMUS

• Asupan kalori yang tidak adekuat dalam


beberapa bulan sampai tahun (kronik)
• Penurunan nilai antropometri (LILA, TSF, BB/TB)
• Nilai Albumin dan transferin  normal
Pemeriksaan Fisik terkait gizi pada MARASMUS

• Kurus (tulang terbungkus kulit)


• Iga gambang
• Kehilangan massa lemak
• Atrofi massa otot
• Wajah tampak seperti orang tua
• Rewel
• Rambut mudah dicabut
• Diare kronik
• Pada anak sangat kurus tampak kulit di daerah bokong dan paha melipat-lipat
menyerupai baggy pant.
• Karena anak kurus kehilangan jaringan lemak dan otot, LILA akan berkurang, dan
berat badannya lebih rendah dari anak sehat yang mempunyai tinggi yang sama, jadi
BB/TB defisit.
• LILA dan BB/TB digunakan untuk mengkonfirmasi kondisi sangat kurus
MARASMIC KWASHIORKOR

• Deplesi cadangan protein somatic dan visceral


• Penurunan nilai antropometri, muscle mass dan serum
protein
• Dapat terjadi setelah beberapa minggu
• Dapat terjadi edema
KODE MALNUTRISI PADA ICD-10
Kode Malnutrisi Keterangan

E40 Kwasiorkor Malnutrisi berat disertai edema denagn


dispigmentasi kulit dan rambut
E41 Marasmus Malnutirsi Marsmus
E42 Marasmik Kwasiorkor Malnutrisi energi-protein berat dengan
tanda klinis marasmus dan
Malnutrisi energi-protein Wasting pada anak dan dewasa kenaikan
E43 berat tidak spesifik BB yang kurang menyebabkan BB/PB atau
BB/TB <-3SD
Edema starvasi

Sumber : ICD-10 Second Edition, 2005


Non Illness Related Pediatric Malnutrition (undernutrition) (NC-4.1.4)
• Definition
Inadequate nutrient intake due to environmental or behavioral factors which may
negatively affect growth, development, and/or other outcomes. Indicators for
identifying Mild, Moderate, and Severe non illness related pediatric malnutrition are
included here.
• Etiology (Cause/Contributing Risk Factors)
Factors gathered during the nutrition assessment process that contribute to the
existence or the maintenance of pathophysiological, psychosocial, situational,
developmental, cultural, and/or environmental problems:
Lack of or limited access to food, e.g., economic constraints, restricting
food/feedings given to children, neglect or abuse, adoption/immigration/refugee
from or in poorly resourced or war-torn countries
Interruptions of or intolerance to feedings
Social, economic, behavioral, cultural or religious practices that affect the ability
to access food 27
Non Illness Related Pediatric Malnutrition (undernutrition) (NC-4.1.4)
• Definition
Inadequate nutrient intake due to environmental or behavioral factors which may
negatively affect growth, development, and/or other outcomes. Indicators for
identifying Mild, Moderate, and Severe non illness related pediatric malnutrition are
included here.
• Etiology (Cause/Contributing Risk Factors)
Factors gathered during the nutrition assessment process that contribute to the
existence or the maintenance of pathophysiological, psychosocial, situational,
developmental, cultural, and/or environmental problems:
Lack of or limited access to food, e.g., economic constraints, restricting
food/feedings given to children, neglect or abuse, adoption/immigration/refugee
from or in poorly resourced or war-torn countries
Interruptions of or intolerance to feedings
Social, economic, behavioral, cultural or religious practices that affect the ability
to access food 28
Non Illness Related Pediatric Malnutrition (undernutrition) (NC-4.1.4)
Nutrition
Assessment Potential Indicators of This Nutrition Diagnosis (one or more must be present)
Category
When a single data point is available When two or more data points are
Mild malnutrition available the following additional indicators
-1 to -1.9 weight for length z score may then be assessed
-1 to -1.9 body mass index for age z score • Mild malnutrition
-1 to -1.9 mid upper arm circumference z score
<75% of the norm for expected weight
Moderate malnutrition
gain velocity (< 2 y of age)
-2 to -2.9 weight for length z score
5% usual body weight loss (2-20 y of
-2 to -2.9 body mass index for age z score
-2 to -2.9 mid-upper arm circumference z score age)
Severe malnutrition Decline of 1 z score in weight for
-3 weight for length z score or below length or BMI for age z score
-3 body mass index for age z score or below • Moderate malnutrition
-3 length/height for age z score or below <50 % of the norm for expected weight
Anthropometric Measurements gain velocity (< 2 y of age)
-3 mid-upper arm circumference z score or
below 7.5% usual body weight loss (2-20 y of
age)
Decline of 2 z score in weight for
length or BMI for age z score 29
• Severe malnutrition
Non Illness Related Pediatric Malnutrition (undernutrition) (NC-4.1.4)
Nutrition Assessment Potential Indicators of This Nutrition Diagnosis (one or more must be
Category present)
Nutrition-Focused Physical • Stagnation in Tanner staging
Findings • Moderate malnutrition
 Mild loss of subcutaneous fat, e.g., orbital, triceps, fat overlying the ribs
 Mild muscle loss, e.g., wasting of the temples (temporalis muscle), clavicles
(pectoralis & deltoids), shoulders (deltoids), interosseous muscles, scapula
(latissimus dorsi, trapezious, deltoids), thigh (quadriceps) and calf
(gastrocnemius)
 Mild localized or generalized fluid accumulation (extremities, vulvar/scrotal,
ascites)
• Severe malnutrition
 Severe loss of subcutaneous fat, e.g., orbital, triceps, fat overlying the ribs
 Severe muscle loss, e.g., wasting of the temples (temporalis muscle), clavicles
(pectoralis & deltoids), shoulders (deltoids), interosseous muscles, scapula
(latissimus dorsi, trapezious, deltoids), thigh (quadriceps) and calf
(gastrocnemius)
 Severe localized or generalized fluid accumulation (extremities, vulvar/scrotal,
ascites)
30
Non Illness Related Pediatric Malnutrition (undernutrition) (NC-4.1.4)
Nutrition Assessment Potential Indicators of This Nutrition Diagnosis (one or more must be
Category present)
Food/Nutrition-Related History Reports or observations of:
Change in functional indicators, e.g., handgrip strength or other measures of physical
activity and/or strength
• Mild malnutrition When two or more data points are available
Inadequate nutrient intake of 51% to 75% estimated energy/protein need
• Moderate malnutrition
Inadequate nutrient intake 26% to 50% estimated energy/protein need
• Severe malnutrition
Inadequate nutrient intake of ≤25% estimated energy/protein need
Reports or observations of the following, for example:

 Anorexia nervosa, abuse, neglect, poverty, frailty, and anything that results in limited access to food
Client History
(associated with malnutrition in the context of environmental and social circumstances)

 Existing medical diagnosis of malnutrition

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Illness Related Pediatric Malnutrition (undernutrition) (NC-4.1.5)
• Definition
Nutrient deficit or imbalance due to disease or injury which may negatively affect growth,
development, and/or other outcomes. Indicators for identifying Mild, Moderate, and
Severe illness related pediatric malnutrition are included here.
• Etiology (Cause/Contributing Risk Factors)
Factors gathered during the nutrition assessment process that contribute to the existence
or the maintenance of pathophysiological, psychosocial, situational, developmental,
cultural, and/or environmental problems:
Physiological causes increasing nutrient needs due to prematurity, genetic/congenital
disorders, illness, injury, or trauma
Inadequate intake related to anorexia or feeding intolerance
Alteration in gastrointestinal tract structure and/or function
Altered utilization of nutrients
Food- and nutrition-related knowledge deficit concerning amount of energy and
amount and type of dietary protein
Psychological causes, e.g., depression or eating disorders 32
Illness Related Pediatric Malnutrition (undernutrition) (NC-4.1.5)
Nutrition
Assessment Potential Indicators of This Nutrition Diagnosis (one or more must be present)
Category
Reports or observations of the following, for example:
 Organ failure, malignancies, rheumatoid diseases, gastrointestinal diseases, growth
failure, malabsorptive syndromes, and other etiologies including but not limited to
congenital birth defects, genetic anomalies such as spinal muscular atrophy
 Sepsis, pneumonia, peritonitis, and wound infections, burns, trauma, closed head injury,
acute lung injury, respiratory distress syndrome, and surgeries
Client History
 Existing medical diagnosis of malnutrition
 History of prematurity, congenital birth defects
(cardiac/renal/gastrointestinal/neurological/pulmonary)
 Genetic or acquired conditions: Cerebral Palsy, cystic fibrosis, seizure disorders,
metabolic disease, irritable bowel syndrome
 Feeding difficulty, food allergy, eosinophilic enteritis 33
REFERENSI

Modul Pelatihan Tata AND/ASPEN, 2015. Identification


International Dietetics
Laksana Balita Gizi Buruk, and Documentation of adult and
& Nutrition
Kemkes-PERSAGI-UNICEF, Pediatric Malnutrition: The
Terminology, 2018
2019 Academy / ASPEN Collaboration

ICD-10, 2005. Endocrine, Hasil Riskesdas 2018


Nutritional and www.depkes.go.id
Metabolic Disease.ICD-
10 Second Edition
Thanks!
Any questions?
You can find me at:

gyahya66@gmail.com