Principle

Management
of
Severe Malnutrition
Titis Prawitasari
Div. Nutrition & Metabolic Diseases
Faculty of Medicine University of Indonesia

What is Malnutrition?

Wt/Ht

MARASMIC

KWASHIORKOR

MARASMIC - KWASHIORKOR

Principle Management
of Severe Malnutrition
Initial treatment
identify life-threatening problems
treated in a hospital or a residential care facility

Rehabilitation
intensive feeding recover lost weight
emotional and physical stimulation
prepare for discharge, trained to continue care
at home

Follow-up
to prevent relapse and assure the continued
physical, mental and emotional development

Refeeding Syndrome

Dehydration

Sunken eyes

Dehydration

Turgor :

Oral rehydration salts (ORS)

solution
Severely malnourished children
deficient in potassium, high levels of
sodium
ReSoMal: less sodium, more
potassium; plus Mg, Zn and Cu to
correct deficiencies of these minerals
70-100 ml of ReSoMal per kg BW:
enough to restore normal hydration

How to make
ReSoMal
Ingredien
t

Amount

WHO-ORS

1 pack for 1L
or
5 sachet for
200ml

Composition of
ReSoMal
Componen Concentration
t
(mmol/L)
Glucose

125

Sodium

45

Potassium

40

Chloride

70

Citrate

20 ml

Magnesiu
m

2000 ml

Zinc

0.3

Copper

0.045

Sugar

50 g

Mineralmix
Water
upto

Osmolarit

300

How to use MM ?
Mineral-mix is used to make :
- Resomal
(Rehydration solution for
Malnutrition)

- Formula F75 and F100

20 ml of MM for each 1000 ml of
Resomal, F75 and F100

How to Feed ?
Initial treatment
Energy: 80-100 kal/kg/day
Protein: 1-1,5 gram/kg/day
Fluid: 130 ml/kg/day or 100 ml/kg/day (with
oedema)
Transition
Energy: 100-150 kal/kg/day
Protein: 2-3 gram/kg/day
Rehabilitation
Energy: 150-220 kal/kg/day
Protein: 3-4 gram/kg/day
Follow-up

A, laki-laki, 1 th, BB 6 kg, PB

73 cm
Fase inisial:
(80-100) kal x 6 kg = 480-600 kal
Fase transisi:
(100-150) kal x 6 kg = 600-900 kal
Fase rehabilitasi:
(150-220) kal x 6 kg = 900-1320 kal
Berdasarkan BB/TB atau BB ideal
(110-120) kal x 9,1 kg = 1001-1172 kal

TABEL PETUNJUK PEMBERIAN F-75

UNTUK
ANAK GIZI BURUK TANPA EDEMA
Volume F75/ 1 kali makan (ml)a)
Total
80% dari
BB anak
(kg)

total a)
Setiap 2 jam
b)
(12x mkn)

Setiap 3
jam c)
(8 x mkn)

Setiap 4
jam
(6 X mkn)

Sehari (130
ml/kg)

Sehari
(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

TABEL PETUNJUK PEMBERIAN F-75

UNTUK ANAK GIZI BURUK
YANG EDEMA BERAT
Volume F75/ 1 kali makan (ml)a)
BB anak
(kg)

Setiap 2 jam Setiap 3

b)
jam c)
(12 x mkn)
(8 x mkn)

Setiap 4
jam
(6 X mkn)

Total

80% dari
total a)

Sehari(100
ml/kg)

Sehari
(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

305

4.0

35

50

65

400

320

4.2

35

55

70

420

335

4.4

35

55

75

440

350

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

TABEL PETUNJUK PEMBERIAN F-100

UNTUK ANAK GIZI BURUK
Batas volume pemberian
makan F-100
BB anak Per 4 jam (6 kali sehari)
(kg)

Batas volume
pemberian F100
dalam sehari

Minimum
(ml)

Maksimum
(ml)

Minimum
150
ml/kg/hari

Maksimum
220
ml/kg/hari

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

Buku I : Buku Bagan Tata Laksana Anak Gizi Buruk, hal 21

Composition of F-75 and F-100

diets
Constituent
F-100
(per 100
ml) F-75
Ingredient
Dried
skimmed
milk

F-75

F-100

25

80

Sugar

g
70

g
Cereal flour

50
g

35

--

30

60

g
Vegetable
oil
Mineral mix
Vitamin mix

20
ml

20
ml

140
mg

140
mg

Energy

75 kcal

100 kcal

Protein

0.9 g

2.9 g

Lactose

1.3 g

4.2 g

Potassium

3.6
mmol

5.9 mmol

Sodium

0.6
mmol

1.9 mmol

Magnesium

0.43
mmol

0.73
mmol

Zinc

2.0 mg

2.3 mg

Copper

0.25 mg

0.25 mg

% energy from
: Protein
Fat

5%
32 %

12 %
53 %

Osmolarity

333

419

MODIFICATION of WHO FORMULA

FASE

STABILISASI

TRANSISI

REHABILITASI

Bahan Makanan

F75
I

F75
II

F75
III

F100

M1

M II

F135

M III

Susu skim bubuk (g)

25

100

100

100

Susu full cream (g)

35

110

25

120

Susu sapi segar (ml)

300

Gula pasir (g)

70

70

70

50

50

50

50

75

75

Tepung beras (g)

35

35

35

50

150

27

17

17

25

30

50

60

50

50

Larutan elektrolit
(ml)

20

20

20

20

27

Tambahan air s/d

(ml)

1000

1000

1000

100
0

1000

1000

1000

1000

1000

Tempe (g)
Minyak sayur (g)
Margarin (g)

For Persistent diarrhea dan Disentri

*) M = Modisko

Rehabilitation Phase
Principles of management
to encourage to eat as much as possible
to re-initiate/encourage BF as necessary
to stimulate emotional & physical dev
to prepare the mother or carer
The child should remain in hospital for the
first part of the rehabilitation phase
after that transfer to nutrition
rehabilitation centre

Rehabilitation Phase
During the first few days of rehabilitation
children with oedema may not gain
weight, despite an adequate intake
Progress is seen as decreased oedema
rather than rapid weight gain
F-100 should be continued until -1 SD
(90%) of the median reference values for
W/H

Emotional & Physical

Stimulation
Delayed development occurred
if not treated, can become the most
serious long-term result of malnutrition

Stimulation through play programs

start during rehabilitation & continue
after discharge
can substantially reduce the risk of
permanent mental retardation &
emotional impairment

Assessing progress
Weighed daily & plotted on a graph
Weight gain: 1015 g/kg per day
Failing to respond to treatment:
does not gain at least 5 g/kg per day for 3
consecutive days

With high-energy feeding, most severely

malnourished children reach their target
weight for discharge after 24 weeks

Learning from failure

Accurate records should be kept
age, sex, date of admission, weight, height, W/H, principal
diagnoses, treatment, date and time of death, and
apparent cause of death

Criteria for discharge

When W/H has reached -1 SD (90%) of the
median reference values or
Recently: at least 15% weight gain

It is essential that the child receives as

many meals as possible per day
In some instances, a child may be
discharged before they reached the target:
they need continuing care

Follow Up
After discharge, the child should be seen
after 1 week, 2 weeks, then 1, 3, 6 months
W/H is no less than -1 SD (90%)
progress is considered satisfactory

If a problem is found, visits should be more

frequent until it is resolved:
after 6 mo, visits 2x/year until the child is at
least 3 years old.

Children with frequent problems

should remain under supervision longer

Older Children
It is appropriate to introduce solid food,
especially for those who want a mixed diet
most traditional mixed diets: lower energy
content
relatively deficient in minerals (K, Mg, Zn, Cu,
Fe) and vitamin

Oil and mineral, vitamin mixes should be

added to increase the energy content,
The energy content of mixed diets should
be at least 1 kcal or 4.2 kJ/g

Older Children
F-100 should be given between feeds of the
mixed diet. For example:
If mixed diet is given three times daily, F-100
should also be given three times daily, making
six feeds a day

Water intake is not usually a problem

At the beginning of rehabilitation, fed every
4 hours, day and night
When they are growing well making five feeds
per 24 hours

Problems
Infection

Persistent diarrhoea
Dysentery
Otitis media
Pneumonia
Urinary tract infections
Skin infections
Tuberculosis
Helminthiasis
Malaria
HIV infection and AIDS
Serious underlying disease

Adolescents and
Adults
Malnutrition in adolescents and adults
Commonly associated with other illnesses
Chronic infections, malabsorption, alcohol &
drug dependence, liver disease, endocrine and
autoimmune diseases, cancer and AIDS

Both the malnutrition and the

underlying illness must be treated

Adolescents and
Adults
The principles of management:
the general guidelines should be followed

There are some differences

in the amount of food required & drug dosages

Except in famine conditions, rarely associate

with wasting or oedema
The most common problem:
often reluctant to take formula feeds, except
traditional foods

ALUR PELAYANAN ANAK GIZI BURUK DI

RUMAH SAKIT/PUSKEMAS PERAWATAN
ANAK

Datang
Sendiri
Dirujuk
MTBS
Non
MTBS

Gizi
Buruk
Penyaki
t
Ringan
/ Berat

RAWAT INAP
Penerapan 10
langkah dan
5 kondisi
Tatalaksana Anak
Gizi Buruk

RAWAT INAP

YANKES
RUJUKAN

Periksa
klinis
dan
antropometri.
BB & TB
anak

Penyaki
t Berat
Gizi
Kurang

Obati
Penyakit
Penambahan
Energi dan
Protein 2025% di atas
AKG

RAWAT JALAN
Penyaki
t
Ringan
Gizi
kurang

PULANG

P
U
S
K
E
S
M
A
S

POSYANDU
/ Pos
Pemulihan
Gizi (PPG)

RUMAH
TANGGA

Obati Penyakit
Penambahan
Energi dan
Protein 20-25%
di atas AKG

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

On
admission:
Sh, girl, 2
yrs,
W : 3.875 g
H : 67 cm
W/H : < -4SD

2 weeks later:
W : 4.750 g
H : 67.4 cm
W/H : < -3 SD

4 weeks later:
W : 5.310 g
H : 67.7 cm
W/H : + -3 SD

5 weeks later:
W : 6.280 g
H : 67.8 cm
W/H : - 2 SD