MALNUTRITION

AS HEALTH PROBLEMS
AND
MANAGEMENT OF
SEVERE MALNUTRITION

M. NAZIR HZ
DEPARTEMENT OF CHILD HEALTH
FACULTY OF MEDICINE, SRIWIJAYA UNIVERSITY
NUTRITION PROBLEMS IN INDONESIA (2)

a. STUNTED < 5 YEAR 36.8% CHRONIC MALNUTR.

b. PREVALENCY OF ACUTE WASTED 13.6% ACUTE
MALNUTRITION
c. PREVALENCY OF LBW 11.7% PREGNANT WOMEN
MALNUTRITION
d. HIGH PREVALENT OF MICRONUT DEF: NUTRITIONAL
ANEMIA, JODIUM DEF AND DEFICIENCY OF VIT. A
e. INCREASED INCIDENCE OF OBESITY
f. RE-EMERGING OF INFECTION : TBC, HIV
NUTRITION PROBLEMS IN INDONESIA (1)

1. MACRONUTRIENT DEFICIENCY
1. PROTEIN ENERGY MALNUTRION

2. MICRONUTRIENT DEFICIENCY
2.1.VITAMIN A DEFICIENCY
2.2. NUTRITIONAL ANEMIA / IDA (IRON
DEFICIENCY ANEMIA)
2.3. JODIUM DEFICIENCY

3. OVER NUTRITION (OBESITY)

 MALNUTRITION
AS HEALTH PROBLEMS
AND
MANAGEMENT OF
SEVERE MALNUTRITION

M. NAZIR HZ
DEPARTEMENT OF CHILD HEALTH
FACULTY OF MEDICINE, SRIWIJAYA UNIVERSITY
PROTEIN ENERGY MALNUTRITION
 NUTRITIONAL DEFICIENCY
CAUSES OF PROBLEMS

NUT STATUS

INTAKE INFECTION directly

causes

Available/
behaviour/ careHealth services undirectly
Accesstability and
Mother and children causes
of food at home sanitation

POVERTY, LOW EDUCATED/ ILLITERATE, Main

NO (AVAILABILITY/ ACCESTABILITY) OF FOOD AND OCCUP. problem

ECONOMIC CRISIS, POLITIC AND The root of

SOCIAL problems
6
 NUTRITIONAL DEFICIENCY PROBLEMS IN
LIFE CYCLE
IMR, mental develop,
Risk of chronic
diseases in adult
Growth -
Adult nutritional developm
deficiency delayed

LBW
MEP < 5
CHILDREN

SCHOOL &
PUBERTY AGE

Nutrition Throughout The Growth disorder, low of

Life Cycle. 1999 MMR increased prestation & productions
 THE PREDISPOSSING FACTORS

1. SOCIAL, ECONOMIC AND CULTURAL

2. CHRONIC INFECTION
3. MALABSORPTION
4. PERSISTENT/ CHRONIC DIARRHEA
5. CONGENITAL DISORDER
6. MALIGNANCY
7. IMMUNITY DISORDER
Infection Nutitional deficincy
anorexia

intake <<

immunity Macro/Micronut. def

Nutritional deficiency

Reccurent infection
EFFECT OF MALNUTRITION

DECREASED OF IMMUNITY

INFECTION >>
SEVERE AND LONG DURATION OF ILLNESS
ALOS (AVERAGE LENGTH OF STAY) >>
POST OPERATIVE RECOVERY >>
POST OPERATIVE COMPLICATION >>
COST OF CARE >>

THE MOST COMMON CAUSES MORBIDITY AND MORTALITY

OF CHILDREN < 5 YEAR
 Malnutrition as a main cause of child mortality
(WHO, 2000)
HIV
4% Diarrhea
12%
others
Diarrhea others
29% 28%
malnutrition 28% malnutrition Malaria
8%
(underlying factor) (underlying factor)
>50% 60%
Malaria Perinatal
7% 22%
woughing
RTI cough RTI
15% 4% Tetanus
Neonatus 20%
Measles 6% measles
5%
11%
1990 2000
Protecting the World’s Children, A Call for Action, 1990;
Evidence and information for Policy/WHO, Child Adolescent Health and Development, 2001
WHO, Child and Adolescent Health and Development. On line www.who.int/child-adolescent-
health/inegr.htm 11
 SIGN - SYMPTOM

AND

MANAGEMENT OF
SEVERE MALNUTRITION
Diagnosis of severe malnutrition
based on :
1.Clinical symptom
very thin with or without edema

2. Anthropometry measurement
BW/ L-Ht: NCHS < 70%
z score <-3SD
 NUTRITIONAL STATUS BASED ON BW/ H, SEX
AND AGE 0 - 24 MONTHS
BOY HEIGHT GIRLS

14
 NUTRITIONAL STATUS BASED ON BW/ H, SEX
AND AGE 24 – 60 MONTHS
B
BOY HEIGHT GIRLS

15
 Waterloo:
Status Gizi:
BB terukur/ BB
utk TB/PB Terukur
X 100 % ---
6/8,9 X 100% =
0,67% -- <70%
Gizi Buruk

Status Gizi :LK/ 12 bl/ 6 kg/ PB 70 cm

Dari titik PB 70 cm, buat grs kekanan sd memotong p50 kurva PB/U. Dari titik ini buat
grs kebawah sd memotong p50 kurva BB/U. dari titik potong ini buat grs kekanan
memotong grs BB. Titik potong ini adalah BB ideal utk PB tsb diatas.
LK PB 85 cm, BB 8,0 Kg

Status Gizi: Buruk,

< p3

BB ideal utk TB 85 CM 12,5 Kg

Status gizi 8,0/ 12,5 X 100

= 64 %
< 70%
Gizi buruk
TB 85 cm, BB 8,0 kg
Status Gizi < -3 SD
Gizi Buruk
18
 Diagnosis of severe malnutrition
Clinical appearence Anthropometry
(BW/H-L)
Severe Very thin with or <-3 SD *)
Malnutrion without edema: (if edema the Z
-Dorsum manus/ score more then
pedis -3 SD
-Limbs
-All of body/

Mild - anasarca
thin -3 SD -  -2SD
moderate
Undernutrition
Normal Normal - 2 SD ― +2 SD
Over nutrition Fatty  +2 SD
Clinical Symptom:

Clacification of severe malnutrion:

1.Kwashiorkor
2.Marasmus
3.Marasmic kwashiorkor
Kwashiorkor:

1. Mental status: lethargy, apathy and irritability

2. Hair: thin, sparse and coarse; reddish/ greyish
3. Loss of muscle tissue (atrophy)
4. Flabby subcutaneous tissue, edema (internal organ
before face and limbs.
5. Infection, diarrhea, pnemonia, TBC, UTI etc
6. Hepatomegaly
7. Dermatitis: not exposure sun light, iritation,
desquamation, depigmentation, infection
(CPD= carzy pavement dermatosis)
8. Micronutrient deficiency (Anemia, Xerophthelmia etc)
 KWASHIORKOR

SIGN
KWASHIORKOR

 Hair: sparse, coarse, reddish,

greyish,
 Face Edema
 hypo actif, irritable
 Muscle atrophy
 CPD (crazy pavement dermatosis)
Flag sign
 Kwashiorkor after measles infection

edema

edema
Edema:
+ Dorsum manus and pedis
++ Limb
+++ all

Pitting edema
Crazy pavement dermatosis (CPD)
- specific clinical finding for kwashiorkor
- micronutrients deficiency
- blood flow
- tissue hypoxia
- wet, pressure, infection
- often: bottocks, thigh

27
 hepatomegaly

Normal liver
Marasmus:

1. Very skinny (bone covered by skin), face (like old man)

2. lethargy, apathy and irritability
3. Skin: fat subcutaneous losses, wrinkled, elasticity
4. Loss of muscle tissue (atrophy)
5. Infection: diarrhea, pnemonia, TBC, UTI etc
6. Micronutrient deficiency (iron, vitamin etc)
7. Abdomen: destended/ flat, the intestinal pattern
readly visible
8. The temperature usually subnormal
 Marasmus

Fat subcutaneus (-), muscle atrophy, very skinny (bone cover by skin),
not able to stand
Marasmus Like old man/woman face
Very skinny
Subcutaneus fat (-)
Muscle atrophy
Amin 2 6/12 th, L 78 cm, BW 7,1 kg,
 Marasmus

Subcutaneus fat (-)

Muscle atrophy
Skin elasticity (turgor)

Baggy pants diarrhea

 Marasmic Kwashiorkor

Clinical findings:
- marasmus – kwashiorkor
- antrophometry
BW/L – Ht :< 70% NCHS standart
< -3 SD Z score
- slight edema, dermatosis
- very skinny, muscle atrophy, skin
elasticity
- face: old man/ woman
Marasmic Kwashiorkor with noma

Noma

Muscle
atrophy

Dorsum
pedis edema

Noma
Nutritional status this children ?

A B C
Accompanying diseases

37
THE PATHOGENESIS AND THEIR HEALTH IMPACT
CATABOLISM
INFECTION

ORGAN ATROPHY
DECREASED
ORGAN DISFUNCTION
INTAKE HOSPITALIZED
DECREASED IMMUNITY

1. PNEUMONIA
PREDISPOSSING SYMPTOM S OF DIARRHEA
FACTORS
ORGAN DIFUNCTION/ 2. SYMPTOMS
INFECTION OF ORGAN
DYSFUNCTION
3. DEF. MACRO/
MICRO NUTR
-- . COMPLEXS
 Prolong satrvation continous catabolic condition

Normal intestinevillous
Atrophy of intestine epithelial cell
Atrophy

Structural changes of organs

disfunction of organ

Lactase deficiency

organ atrofi ---- organ dysfunction

2 yr, L 74 Cm, BW 8,4 kg 7 months/BW 3 kg/ L 57 cm
BW/A BW/A: 44%,
L/A L/A: 82,61%,
BW/L BW/L: 60%
Nutritional status Z Score: -3SD to -4SD
Clinical findings Nutritional status
Clinical findings

Persistent diarrhea Pneumonia, Lung TBC

Persistent diarrhea
HIV
Sign of dehydration Skin elasticity (turgor )

Sunken eyes
Sign of breathing difficulties Pneumonia

Nasal flare
Chest indrawing
43
 VITAMIN A DEFICIENCY

XN (Xerophthalmia):

The child couldn’t saw (blind) when

light intensity is low:
- sun set time
- room with light dim
X1A : conjunctival Xerosis c

Cornea: clear, clean

no infection

X1 B Bitot’ spot
-Foam-like’ substance, Hyperpigmentation
& wrinkle
- Cornea: clear, clean, no sign of infection

X2: Corneal Xerosis

- Dry, rough, dark
- infection :
* ciliary/ conjungtival injection
(vascularitation >>)
* inflamation
X3 : Corneal ulcer

X3A: ulcer < 1/3 diameter of cornea

X3B: unlecer > 1/3 diameter of cornea

- ulcer
- Dry, rough, dark
- infection :
* ciliary/ conjungtival injection
(vascularitation increase)
* inflamation

Phthysis bulbi
Cornea to be soften
and destroyed
blind

XS : Corneal scar
Scar after corneal
ulcer has cured
 NUTRITIONAL ANEMIA
Nutritional anemia
- iron deficiency
- Folic acid/ vitamin B12 deficiency
Caused by :
- quantity and quality of food intake <<
- infection
Easy method How to
pale Reddish pale know the child has
suffered anemia

compare your
palm with palm of child

Laboratory examination
 Vitamin C deficiency
gum bleeding

bleeding

Scorbutic rosary
 Zinc deficiency

Crazy pavemement
dermatosis (CPD)

Zn is needed to form RBP Cornea ulcer caused

(Retinol Binding Protein) by vit A deficiency
by liver

Vit A deficiecy this child

caused by Zn deficiency Dermatosis caused by
Zn deficiency
Helminthiasis ascariasis
 MANAGEMENT OF
SEVERE MALNUTRITION
CHILDREN
Clinical finding
Antrophomery z score <-3SD
Severe malnutrition

Shock (1)
Lethargic (2) Condition
Dehydration (3)

I II III IV V
(1,2,3) (2,3) (3) (2) (-)

Stabilization phase
Initial Stab.
Continued Stab. TEN STEPS IN THE MANAGEMENT
Transtition phase OF SEVERELY MALNOURISHED
Rehabilitation phase CHILDREN
Follow-up

52
 Treatment scheme of severe malnourished children
Severe malnutrition

condition

1. Stabilization : 1.1. Initial stabilization phase (12 hours)

0 2 12
1.2. Continued stabilization phase

2. Transition : 0 24

0 24
3. Rehabilitation

4. Follow - up

53
SHOCK: Lethargic/ Unconcious
Cold hands
Weak or fast pulse
Slow capillary refill
(longer than 3 seconds)
caused by diarrhea with severe dehydration
haemorrhage
burn
sepsis

LETHARGIC: Not allert

Apathic, Somnolent, Soporous, Coma

DEHYDRATION: to have lost body water caused by diarrhea/

haemorrhage

54
 TEN STEPS IN THE MANAGEMENT OF
SEVERELY MALNOURISHED CHILDREN

1. Treat or prevent hypoglycemia

2. Treat or prevent hypothermia
3. Treat or prevent dehydration
4. Correct electrolyte imbalance
5. Treat infection
6. Correct micronutrient deficiency
7. Begin feeding formula 75
8. Increase feeding to recover lost weight
(catch up growth)
9. Stimulate emotional and sensorial development
10. Prepare for discharge

55
 First 2 hours in The Initial stabilization phase

Condition I II III

O2 + - -

Hypoglycemia Bolus IV Bolus IV D10% sugar sol 10 %

D10% 50 ml / NGT D10%
Hypothermia + + +

Dehydration IVFD RLG 5% NGT Resomal Resomal 5 ml/kg

1:1 15 ml/kg 5 ml/kg every p.o every 30’
/1 hr 30’
NGT Resomal
5 ml/kg every
30’
Antibiotic Broad spectrum + +

Micronutrient Vit . A, Folic Acid, + +

Bcompl/ C

56
First 2 hours in The Initial stabilization phase
Condition IV V

Hypoglycemia Bolus IV D10% sugar sol. 10% p.o

5 ml/kg

Hypothermia + +

Antibiotic Cotrimoksazole +
Micronutrient Vit . A, Folic Acid, +
Bcompl/ C

Begin Feeding gives ¼ of the 2 hourly gives ¼ of the 2 hourly

amount every 30’ amount every 30’

57
 FORMULA - 75
ON SEVERE MALNUTRION WITHOUT EDEMA
F-75/ MEAL TOTAL/D TOTAL/D

BW (KG) 2 HOURS 3 HOURS 4 HOURS 130 ML/KG MINIMAL

58
 FORMULA - 75
ON SEVERE MALNUTRION WITH EDEMA
F-75/ MEAL TOTAL/D TOTAL/D

BW (KG) 2 HOURS 3 HOURS 4 HOURS 100 ML/KG MINIMAL

59
Second 10 hours in The Initial stabilization phase
Condition I II III IV V

F75 and resomal

Intermittent
Every 1 hour + + + F75 F75
( every 2 hours
No Resomal )

60
Continued stabilization phase
Condition I II III IV V

F75 12 feeds/day + + + F75 F75

Resomal every
diarrhea

F75 8 feeds/day + + + F75 F75

Resomal every
diarrhea

F75 6 feeds/day + + + F75 F75

Resomal every
diarrhea

No diarrhea Resomal (-)

61
 Transition phase

The first 2 days

Give F100 6 feeds/day in the same amount as you last gave F75

F100 6 feeds/ day

Increased 10 ml each feeding until he/ she doesn’t
finished the formula.

If he/ she could finished F100 6 X 150 ml 2 – 4 weeks

If the child breastfeeding encourage the mother to breastfeed

Water : 150 ml/kg

Calori : 100 – 150 Kcal/kg
Protein : 2 – 3 g /kg

62
 FORMULA - 100

BW (kg) F-100/ 4 hours (ml) Total/ day (ml) Total/ day (ml)
BW
(Kg)
Minimal Maximal Minimal Maximal

63
 Rehabilitation phase
Water : 150 – 200 ml/kg Nutritional status
Calori : 150 - 220 kcal/kg + 2 SD
Protein : 3 – 4 g/kg

Menu

1. F100 3 X

2. Porridge
2.1. BW < 7 kg powder porridge
2.2. BW > 7 kg soft porridge

3. Fruit
3.1. BW < 7 kg Juice
3.2. BW > 7 kg slice fruit

64
 CONTOH PENGGANTIAN F75 DAN F100 SESUAI FASE
BB 5 Kg PB 75 Cm TANPA EDEMA

STABILISASI TRANSISI REHABILITASI

F75 F75 F75 F100

6 x 55 ML 8 X 80 ML 6 X 110 ML 6 X 110 ML

HARI KE 1 2 3 4 5 6
F100 DINAIKKAN
10-15 ML/HR S/D
ANAK TDK MAMPU
MENGHABISKAN

F100 SESUAI BB 65
(TABEL F100)
Follow up
1. More freq. feeding

2. Regular check
2.1. First month every week
2.2. second month every 2 weeks
2.3. third month every month

3.Vaccination
3.1. measles vaccination after rehabilitation phase
3.2. Booster basic immunization (BCG, Polio, DPT, Hepatitis B)
3.2. Vitamin A every 6 month

66