Marasmus ABSTRACT Marasmus is one form of malnutrition that is often encountered in Childhood. Multifactorial causes, among others, the less input of food, disease factors and environmental factors as well as ignorance to choose nutritious foods and the adverse economic circumstances. Diagnosis based on clinical picture; to determine the cause anamnesis need food and other diseases. Aimed at the prevention of marasmus causes and require health services and counseling is good. Treatment of marasmus is the provision of a diet high in calories and high in protein and treatment at the hospital which consists of: initial stage, the stage of adjustment and rehabilitation. INTRODUCTION Less calories of protein is one of the main nutrition problems in Indonesia. Efforts to improve the nutritional state of society have been implemented through various programs to improve nutrition by the Ministry of Health in collaboration with the community. According to the 1986 Health Survey of the incidence of malnutrition among children under 1.72% and poor nutrition as much as 11.4 (2). Unlike the field survey, the incidence of malnutrition and malnutrition among children under the care of stay in hospitals is still high. Rani in Dr. Medan Pirngadi received 935 (38%) patients with malnutrition of children under five who were treated in 2453 (3). They consist of 67% and 33% malnutrition malnutrition. Patients with severe malnutrition is the most common type of marasmus. Arif in hospital. Dr.Sutomo Surabaya get a 47% (4) and Barus in Dr. Medan Pirngadi much as 42% (5). This is understandable because the state of marasmus is often associated with population density and poor hygiene in urban areas who are building (6) and as well as the economic crisis in ludonesia. This paper aims to discuss the causes of marasmus, pathophysiology, diagnosis, prevention and treatment during the anakbalita. INCIDENCE OF Based on health statistics in 2005 the Ministry of Health of Indonesia 241 973 879 residents, six percent, or approximately 14.5 million people suffer from malnutrition. Patients in general malnutrition of children under five years old (toddlers). MOH has also conducted a mapping and the results showed that patients with malnutrition was found in 72% of districts in Indonesia. 2-4 of 10 toddlers indications menderitagizikurang. Marasmus is a condition in which a child has both protein and energy deficiencies. Generally this condition experienced by people who suffer from hunger. Marasmus is a serious problem that occurred in developing countries. According to WHO data approximately 49% of the 10.4 million deaths that occur in children under age five in developing countries related to the deficiency energidanproteinsekaligus. Patients with severe malnutrition is the most common type of marasmus. Arif in RS. Dr. Sutomo Surabaya get a 47% and the Barus in Dr. Medan Pirngadi much as 42%. This is understandable because the state of marasmus is often associated with population density and poor hygiene in urban areas that are membangundan and economic crisis in lndonesia. CAUSE marasmus Marasmus is a form of calorie-protein is less severe. This situation is the outcome of the interaction between infectious disease and food shortages. In addition to environmental factors, there are several other factors on their own children are taken from birth, is presumed to influence the occurrence of marasmus (6). Outline the causes of marasmus is as follows: 1. Enter the food that is less (7,8,9) Marasmus results from caloric intake a bit, giving foods that do not conform with the recommended result of ignorance of the child's parents; for example the use of widely milk cans are too thin. 2. Infection (8,9,10) Infection causes severe and long marasmus, especially infections such as enteral Infantile gastroenteritis, bronkhopneumonia, pielonephritis and congenital syphilis. 3. Innate structural abnormalities (7.9) For example: congenital heart disease, hirschprung disease, deformity palate, palatoschizis, micrognathia, pylorus stenosis, hiatal hernias, hydrocephalus, cystic pancreatic fibrosis. 4. Prematurity and disease in neonatal period (7.11) In these circumstances breast feeding is less due to the lack of a strong sucking reflex. 5. Breastfeeding (7.11) Prolonged breast feeding without supplementary feeding enough. 6. Metabolic disorders (7.11) For example: renal acidosis, idiopathic hypercalcemia, galactosemia, lactose intolerance. 7. Hypothalamic tumors (7) Rare and only enforced when other causes of marasmus have been removed. 8. Weaning (12) Premature weaning accompanied by a less-feeding will cause marasmus. 9.Urbanisasi (11.12) Urbanization affects and is a predisposition to the emergence of marasmus; the increasing urbanization also followed the changes of early weaning habits and then followed with sweet milk and milk that is too dilute result of not being able to buy milk, and when accompanied by recurrent infections, particularly gastro enteritis will cause the child fall in marasmus. Pathophysiology Actually, malnutrition is a syndrome that occurs due to many factors. These factors can be classified into three important factors are: the body's own (host), agent (germ causes), environment (the environment). Indeed dietary factors (food) plays an important role but other factors that also determine (10.13). Gopalan mention malnutrition marasmus are compensated. In the state of food shortage, the body is always trying to preserve life by meeting basic needs or energy. Body's ability to use carbohydrates, proteins and fats is a is essential to sustain life; carbohydrates (glucose) can be used by all tissues of the body as fuel, unfortunately the body's ability to store very little carbohydrate, so that after 25 hours can already occur shortage. As a result of protein catabolism occurs after several hours with a yield of amino acids which immediately converted into carbohydrates in the liver and the kidneys. During fasting fat tissue is split into fatty acids, glycerol and ketone bodies. Muscles can utilize fatty acids and ketone bodies as an energy source when it runs a chronic food shortage. The body will defend itself not to break down the protein again after losing roughly half of the body. OVERVIEW: Clinical (7,9,11,14) Marasmus is common at age 0-2 years. The situation that looks striking is the loss of subcutaneous fat, especially in the face. Consequently, the child's oval face, wrinkles and looked older (old man face). Weak muscles and atrophy, together with the loss of subcutaneous fat limbs look like skin to bone. More clearly visible ribs. Hipotonus abdominal wall and the skin is loose. Weight down to less than 60% weight loss by age. Low body temperature could be due to the heat retaining layer is missing. DIAGNOSIS Marasmus diagnosis is made based on clinical picture, but to find the cause to be done anamnesis food and eating habits as well as past medical history. PREVENTION Precautions against marasmus can be performed well if the cause is known. (7,14,15) such efforts require health facilities and infrastructure is good for health services and nutritional counseling. 1. Breastfeeding (breast milk) until age two years is the best energy source for infants. (7,15,16) 2. Coupled with the additional provision of nutritious foods at the age of 6 years and older. (7.9) 3. Prevention of infectious diseases, by improving environmental cleanliness and personal hygiene. (9.12) 4. Immunization. (7.12) 5. Follow the family planning programs to prevent pregnancy too often. (7.15) 6. Guidance / nutrition education about adequate feeding is a long-term prevention efforts. (12.14) 7. Monitoring (surveillance), which regularly on infants and children in areas with endemic malnutrition, with the way their body weight each month. (9.12) TREATMENT The goal of treatment in patients with marasmus is the provision of a diet high in calories and high in protein and preventing relapse (14). Marasmus patients without complications can be treated the way home were given counseling about providing good food, while patients who experienced complications as well as dehydration, shock, acidosis and others need to get treatment in hospital. Management of patients who were treated in hospitals are divided into several stages (13.17). The initial phase of the first 24-48 hours is a critical period, ie actions to save lives, among other things to correct dehydration or acidosis with intravenous fluids. The liquid solution is given Darrow-Ringer Lactat Glucosa or Dextrose 5%. Fluids are given as much as 200 ml / kg bw / day. Initially given 60 ml / kg BW in the first 4-8 hours. Then 140 ml of the remainder is given in the next 16-20 hours. The second phase of adjustment. Most patients do not require correction of fluid and electrolytes, so it can immediately begin with adjustments to the provision of food (13,18,19). In the first days given the amount of calories as much as 30-60 calories / kg / day or an average of 50 calories / kg / day, with 1 to 1.5 g protein / kg BW / day. This amount was increased gradually every 1-2 days so as to achieve 150-175 calories / kg / day with protein 3-5 g / kg bw / day. Time needed to achieve high-calorie high-protein diet is approximately 7-10 days. Fluids are given as much as 150 ml / kg bw / day. The provision of vitamins and minerals are Vitamin A is given as 200,000. peroral or 100 000 iu iu im the first day and then at day two provided 200 000 iu oral. Vitamin A is given regardless of the existence of deficiency symptoms of Vitamin A. Minerals that need to be added is K, a total of 1-2 mEq / kg / day / IV or oral preparations in the form of 75-100 mg / kg bw / day and Mg, in the form of MgS04 50% 0.25 ml / kg / day or megnesium oral 30 mg / kg bw / day. Can be given one ml of vitamin Bc and 1 ml vit. C im, followed by preparations given orally or by diet. What kind of food which are eligible to severe malnutrition sufferer is milk. In the selection of foods should be noted weight loss patients. It is advisable to use the guidelines of less than 7 kg of body weight given food for infants with a major food or milk formula is a modified, gradually add mashed food and soft food. Patients with the BB on top of 7 kg of food given to children over one year, in the form of liquid food and soft food and solid food. Antibiotics should be given, because patients with marasmus is often accompanied by infection. Choice of drug used is penicillin or a combination procain penicilin and streptomycin. Other things to note: a) The possibility was examined by dextrostix hypoglycemia. When blood sugar levels less than 40% provided therapy 40% glucose 1-2 ml / kg / IV (13,17,19) b) hipotermy (17.19) Overcome by the use of blankets or sleeping with his mother. Can be given a hot water bottle or feeding is often every two hours. Monitoring can be done with carapenimbangan patient weight, height and thickness measurement of subcutaneous fat. In the first few weeks are often not seen because the body weight. After adjustment is achieved then found the body weight. Patients may be discharged if there is an increase up to approximately 90% of normal body weight according to age, if his appetite has returned and infectious diseases have been resolved. Patients who had returned to his appetite gets accustomed to regular food as that eaten daily. Normal caloric needs to be returned because the body has to adjust itself again. Meanwhile, parents are given training on the provision of food, especially regarding food selection, processing, according to its purchasing power. Given the difficulties caring for patients with malnutrition, the prevention efforts need to be improved. Antibiotics Severe malnutrition who have a high mortality, death is often caused by infection; often unable to distinguish between deaths due to infection or due to malnutrition alone. Prognosis depends on the stage when treatment began to be implemented. In some cases, although seemingly adequate treatment, progressive disease when death is inevitable, probably due to irreversible changes of sets of body cells due under Nutrition. SUMMARY Marasmus is one form of malnutrition is most common in infants, especially in urban areas. The causes are multifactorial, among others, the less input of food, disease factors and environmental factors. Diagnosis based on clinical features and to determine the cause of food needed and disease anamnesis ago. Aimed at the prevention of marasmus causes and require health services and good counseling. Treatment of marasmus is the provision of diet, high in calories and high in protein, and treatment in hospital were divided into early stage, phase adjustment, and rehabilitation.