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PrinciplePrinciple

ManagementManagementofof

Severe MalnutritionSevere Malnutrition

Titis PrawitasariDiv. Nutrition & Metabolic DiseasesFaculty of Medicine University of Indonesia

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What is Malnutrition?What is Malnutrition?

Wt/Ht

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MARASMICMARASMIC

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KWASHIORKORKWASHIORKOR

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MARASMIC - KWASHIORKORMARASMIC - KWASHIORKOR

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Principle ManagementPrinciple Management

of Severe Malnutritionof Severe Malnutrition

Initial treatmentInitial treatment

identify life-threatenin !roble"s

treated in a hos!ital or a residential care facility

! Reha"ilitationReha"ilitation

intensive feedin recover lost weiht

e"otional and !hysical sti"ulation

!re!are for dischare# trained to continue careat ho"e

! #ollo$-up#ollo$-up

to !revent rela!se and assure the continued

!hysical# "ental and e"otional develo!"ent

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Refee%ing S&n%romeRefee%ing S&n%rome

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'eh&%ration'eh&%ration

Sun(en e&esSun(en e&es

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'eh&%ration'eh&%ration

)urgor *)urgor *

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Oral reh&%ration salts +ORS,Oral reh&%ration salts +ORS,

solutionsolution

Severel& malnourishe% chil%renSeverel& malnourishe% chil%ren

! de$cient in !otassiu"# hih levels ofde$cient in !otassiu"# hih levels of

sodiu"sodiu"! %eoMal' less sodiu"# "ore%eoMal' less sodiu"# "ore

!otassiu"( !lus M# )n and *u to!otassiu"( !lus M# )n and *u to

correct de$ciencies of these "ineralscorrect de$ciencies of these "inerals! +,-,, "l of %eoMal !er /0'+,-,, "l of %eoMal !er /0'

enouh to restore nor"al hydrationenouh to restore nor"al hydration

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Component

Concentration+mmol.,

/lucose 012

So%ium 32

Potassium 34

Chlori%e 54

Citrate 5

Magnesium

6

7inc 486

Copper 48432

Osmolarit 644

Composition ofComposition of

ReSoMalReSoMal

Ingre%ient

Amount

WHO-ORS 0 pac( for 0.or2 sachet for144ml

Sugar 24 g

Mineral-mi9

14 ml

Waterupto

1444 ml

Ho$ to ma(eHo$ to ma(e

ReSoMalReSoMal

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Ho$ to use MMHo$ to use MM??

! Mineral-mi9 is use% to ma(e *Mineral-mi9 is use% to ma(e *

- Resomal- Resomal+Reh&%ration solution for+Reh&%ration solution for

Malnutrition,Malnutrition,

- #ormula #52 an% #044- #ormula #52 an% #044

! 14 ml of MM for each 0444 ml of14 ml of MM for each 0444 ml of

Resomal: #52 an% #044Resomal: #52 an% #044

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Ho$ to #ee% ?Ho$ to #ee% ?! Initial treatmentInitial treatment

1nery' 2,-,, al33day

Protein' -#4 ra"33day

Fluid' 5, "l33day or ,, "l33day 6withoede"a7

! TransitionTransition

1nery' ,,-4, al33day

Protein' 8-5 ra"33day

! Reha"ilitationReha"ilitation

1nery' 4,-88, al33day

Protein' 5-9 ra"33day

! #ollo$-up#ollo$-up

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A: la(i-la(i: 0 th: ;; < (g: P;A: la(i-la(i: 0 th: ;; < (g: P;

56 cm56 cm

Fase inisial'62,-,,7 al : ; < 92,-;,, al

Fase transisi'

6,,-4,7 al : ; < ;,,-=,, al

Fase rehabilitasi'

64,-88,7 al : ; < =,,-58, al

/erdasaran //3T/ atau // ideal

6,-8,7 al : =# < ,,-+8 al

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)A;=. P=)>@>K P=M;=RIA #-52)A;=. P=)>@>K P=M;=RIA #-52

>)>K>)>K

AAK /I7I ;>R>K )APA ='=MAAAK /I7I ;>R>K )APA ='=MABB anak

(kg)

Volume F75/ 1 kali makan (ml)a) Total 80% daritotal a)

Setiap !amb)

(1" mkn)

Setiap #!am c)

(8 " mkn)

Setiap $!am

( & mkn)

Se'ari (1#0ml/kg)

Se'ari

(minimum)

2.0 20 30 45 260 210

2.2 25 35 50 286 230

2.4 25 40 55 312 250

2.6 30 45 55 338 265

2.8 30 45 60 364 290

3.0 35 50 65 390 310

3.2 35 55 70 416 335

3.6 40 60 80 468 375

Buku I : Buku Bagan Tata Laksana Anak Gizi Buruk, hal

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T>/1? P1TUN@UA P1M/1%I>N F-+4T>/1? P1TUN@UA P1M/1%I>N F-+4

UNTUA >N>A BI)I /U%UAUNTUA >N>A BI)I /U%UA

C>NB 1D1M> /1%>TC>NB 1D1M> /1%>T

BB anak

(kg)

Volume F75/ 1 kali makan (ml)a) Total 80% daritotal a)

Setiap !amb)

(1 " mkn)

Setiap #!am c)

(8 " mkn)

Setiap $!am

( & mkn)

Se'ari(100ml/kg)

Se'ari

(minimum)

3.0 25 40 50 300 240

3.2 25 40 55 320 255

3.4 30 45 60 340 270

3.6 30 45 60 360 290

3.8 30 50 65 380 3054.0 35 50 65 400 320

4.2 35 55 70 420 335

4.4 35 55 75 440 350

/uu I ' /uu /aan Tata ?asana >na Bii /uru# hal

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T>/1? P1TUN@UA P1M/1%I>N F-,,T>/1? P1TUN@UA P1M/1%I>N F-,,

UNTUA >N>A BI)I /U%UAUNTUA >N>A BI)I /U%UA

BB anak(kg)

Batas volume pemberianmakan !100

"er 4 #am (6 kali se$ari)

Batas volumepemberian 100%alam se$ari

&inimum

(ml)

&aksimum(ml)

&inimum

150ml'kg'$ari

&aksimum220

ml'kg'$ari

2.0 50 75 300 440

2.2 55 80 330 484

2.4 60 90 360 528

2.6 65 95 390 572

2.8 70 105 420 616

3.0 75 110 450 660

/uu I ' /uu /aan Tata ?asana >na Bii /uru# hal 8

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Constituent #-52 #-044=nerg& 52 (cal 044 (cal

Protein 48 g 18 g

.actose 086 g 381 g

Potassium 68.AMO'I#ICA)IO of WHO #ORM>.A

F>1 T>/I?I>I T%>NII %1E>/I?IT>I

Bahan Makanan F+4

I

F+4

II

F+4

III

M F,, M M II F54 M III

usu si" bubu 67 84 - - ,, - ,, ,, - -

usu full crea" 67 - 54 - - , - - 84 8,

usu sa!i sear 6"l7 - - 5,, - - - - - -

Bula !asir 67 +, +, +, 4, 4, 4, 4, +4 +4Te!un beras 67 54 54 54 - - - - 4, -

Te"!e 67 - - - - - - - 4, -

Minya sayur 67 8+ + + 84 5, 4, - ;, -

Mararin 67 - - - - - - 4, - 4,

?arutan eletrolit

6"l7

8, 8, 8, - 8, - - 8+ -

Ta"bahan air s3d6"l7

,,, ,,, ,,, ,,,

,,, ,,, ,,, ,,, ,,,

For Persistent diarrhea dan Disentri G7 M < Modiso

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Reha"ilitation PhaseReha"ilitation PhasePrinciples of managementPrinciples of management

to encourae to eat as "uch as !ossibleto encourae to eat as "uch as !ossible

to re-initiate3encourae /F as necessaryto re-initiate3encourae /F as necessary

to sti"ulate e"otional & !hysical devto sti"ulate e"otional & !hysical dev

to !re!are the "other or carerto !re!are the "other or carer

!The child should re"ain in hos!ital for theThe child should re"ain in hos!ital for the

$rst !art of the rehabilitation !hase$rst !art of the rehabilitation !hase

after that transfer to nutritionafter that transfer to nutrition

rehabilitation centrerehabilitation centre

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Reha"ilitation PhaseReha"ilitation Phase

! Durin the $rst few days of rehabilitationDurin the $rst few days of rehabilitation

children with oede"a "ay not ainchildren with oede"a "ay not ain

weiht# des!ite an adeHuate intaeweiht# des!ite an adeHuate intae Proress is seen as decreased oede"aProress is seen as decreased oede"a

rather than ra!id weiht ainrather than ra!id weiht ain

! F-,, should be continued until - DF-,, should be continued until - D

6=,7 of the "edian reference values for6=,7 of the "edian reference values for

03E03E

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=motional F Ph&sical=motional F Ph&sical

StimulationStimulation

! Delayed develo!"ent occurredDelayed develo!"ent occurred

if not treated# can beco"e the "ostif not treated# can beco"e the "ost

serious lon-ter" result of "alnutritionserious lon-ter" result of "alnutrition

! ti"ulation throuh !lay !rora"sti"ulation throuh !lay !rora"s

start durin rehabilitation & continuestart durin rehabilitation & continue

after dischareafter dischare

can substantially reduce the ris ofcan substantially reduce the ris of

!er"anent "ental retardation &!er"anent "ental retardation &

e"otional i"!air"ente"otional i"!air"ent

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Assessing progressAssessing progress

! 0eihed daily & !lotted on a ra!h0eihed daily & !lotted on a ra!h

! 0eiht ain' ,J4 3 !er day0eiht ain' ,J4 3 !er day

! Failin to res!ond to treat"ent'Failin to res!ond to treat"ent' does not ain at leastdoes not ain at least4 3 !er day for 54 3 !er day for 5

consecutive daysconsecutive days

! 0ith hih-enery feedin# "ost severely0ith hih-enery feedin# "ost severely"alnourished children reach their taret"alnourished children reach their taret

weiht for dischare after 8J9 weesweiht for dischare after 8J9 wees

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.earning from failure.earning from failure

! >ccurate records should be e!t>ccurate records should be e!t ae# se:# date of ad"ission# weiht# heiht# 03E# !rinci!alae# se:# date of ad"ission# weiht# heiht# 03E# !rinci!al

dianoses# treat"ent# date and ti"e of death# anddianoses# treat"ent# date and ti"e of death# and

a!!arent cause of deatha!!arent cause of death

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Criteria for %ischargeCriteria for %ischarge

! 0hen 03E has reached - D 6=,7 of the0hen 03E has reached - D 6=,7 of the

"edian reference values or"edian reference values or

%ecently' at least 4 weiht ain%ecently' at least 4 weiht ain

! It is essential that the child receives asIt is essential that the child receives as

"any "eals as !ossible !er day"any "eals as !ossible !er day

! In so"e instances# a child "ay beIn so"e instances# a child "ay bedischared before they reached the taret'dischared before they reached the taret'

they need continuin carethey need continuin care

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#ollo$ >p#ollo$ >p

! >fter dischare# the child should be seen>fter dischare# the child should be seen

after wee# 8 wees# then # 5# ; "onthsafter wee# 8 wees# then # 5# ; "onths

! 03E is no less than - D 6=,703E is no less than - D 6=,7

!roress is considered satisfactory!roress is considered satisfactory

! If a !roble" is found# visits should be "oreIf a !roble" is found# visits should be "ore

freHuent until it is resolved'freHuent until it is resolved'

after ; "o# visits 8:3year until the child is atafter ; "o# visits 8:3year until the child is at

least 5 years old.least 5 years old.

! *hildren with freHuent !roble"s*hildren with freHuent !roble"s

should re"ain under su!ervision lonershould re"ain under su!ervision loner

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Ol%er Chil%renOl%er Chil%ren

! It is a!!ro!riate to introduce solid food#It is a!!ro!riate to introduce solid food#

es!ecially for those who want a "i:ed dietes!ecially for those who want a "i:ed diet

"ost traditional "i:ed diets' lower enery"ost traditional "i:ed diets' lower enery

contentcontent relatively de$cient in "inerals 6A# M# )n# *u#relatively de$cient in "inerals 6A# M# )n# *u#

Fe7 and vita"inFe7 and vita"in

! Kil and "ineral# vita"in "i:es should beKil and "ineral# vita"in "i:es should be

added to increase the enery content#added to increase the enery content#!The enery content of "i:ed diets shouldThe enery content of "i:ed diets should

be at least cal or 9.8 @3be at least cal or 9.8 @3

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! F-,, should be iven between feeds of theF-,, should be iven between feeds of the

"i:ed diet. For e:a"!le'"i:ed diet. For e:a"!le'

If "i:ed diet is iven three ti"es daily# F-,,If "i:ed diet is iven three ti"es daily# F-,,

should also be iven three ti"es daily# "ainshould also be iven three ti"es daily# "ainsi: feeds a daysi: feeds a day

! 0ater intae is not usually a !roble"0ater intae is not usually a !roble"

! >t the beinnin of rehabilitation# fed every>t the beinnin of rehabilitation# fed every9 hours# day and niht9 hours# day and niht

0hen they are rowin well "ain $ve feeds0hen they are rowin well "ain $ve feeds

!er 89 hours!er 89 hours

Ol%er Chil%renOl%er Chil%ren

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Pro"lemsPro"lems

InfectionInfection! Persistent diarrhoeaPersistent diarrhoea

! DysenteryDysentery

! Ktitis "ediaKtitis "edia! Pneu"oniaPneu"onia

! Urinary tract infectionsUrinary tract infections

! in infectionsin infections

! TuberculosisTuberculosis! Eel"inthiasisEel"inthiasis

! MalariaMalaria

! EIL infection and >IDEIL infection and >ID

!erious underlyin diseaseerious underlyin disease

% l %A% l t %

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A%olescents an%A%olescents an%

A%ultsA%ults! Malnutrition in adolescents and adultsMalnutrition in adolescents and adults *o""only associated with other illnesses*o""only associated with other illnesses

!*hronic infections# "alabsor!tion# alcohol &*hronic infections# "alabsor!tion# alcohol &dru de!endence# liver disease# endocrine anddru de!endence# liver disease# endocrine and

autoi""une diseases# cancer and >IDautoi""une diseases# cancer and >ID

! /oth the "alnutrition and the/oth the "alnutrition and theunderlyin illness "ust be treatedunderlyin illness "ust be treated

A% l t %A% l t %

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!The !rinci!les of "anae"ent'The !rinci!les of "anae"ent'

the eneral uidelines should be followedthe eneral uidelines should be followed

!There are so"e dierencesThere are so"e dierences in the a"ount of food reHuired & dru dosaesin the a"ount of food reHuired & dru dosaes

! 1:ce!t in fa"ine conditions# rarely associate1:ce!t in fa"ine conditions# rarely associate

with wastin or oede"awith wastin or oede"a

!The "ost co""on !roble"'The "ost co""on !roble"'

often reluctant to tae for"ula feeds# e:ce!toften reluctant to tae for"ula feeds# e:ce!t

traditional foodstraditional foods

A%olescents an%A%olescents an%

A%ultsA%ults

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A.>R P=.AGAA AAK /I7I ;>R>K 'IA.>R P=.AGAA AAK /I7I ;>R>K 'I

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A.>R P=.AGAA AAK /I7I ;>R>K 'IA.>R P=.AGAA AAK /I7I ;>R>K 'I

R>MAH SAKI)P>SK=MAS P=RAWA)AR>MAH SAKI)P>SK=MAS P=RAWA)A

Datanendiri

Diruu MT/ Non

MT/

Periksaklinisdanantropo-metri

BB ! TB

anak

/ii

;uru( Pen&a(i

tRingan ;erat

Pen&a(itRingan

/ii(urang

Pen&a(it ;erat

/iiKurang

RAWA) IAP

Penera!an ,lanah dan4 ondisi

Tatalasana >naBii /uru

RAWA) IAP Kbati

Penyait Pena"bahan

1neri danProtein 8,-84 di atas>AB

RAWA) @A.A Kbati Penyait Pena"bahan

1neri danProtein 8,-84di atas >AB

P > . A /

POSGA'> Pos

Pemulihan/ii +PP/,

R>MAH)A//A

GAK=SR>@>KA

AAK

P>SK=SMAS

(Buku I : Buku Bagan Tata Laksana Gizi Buruk, tahun 2006,(Buku I : Buku Bagan Tata Laksana Gizi Buruk, tahun 2006,

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Knad"ission'h# irl# 8

yrs#0 ' 5.2+4 E ' ;+ c"03E ' O -9D

8 wees later'0 ' 9.+4, E ' ;+.9 c"

03E ' O -5 D

9 wees later'0 ' 4.5,

E ' ;+.+ c"03E ' -5 D

4 wees later'0 ' ;.82,

E ' ;+.2 c"03E ' - 8 D