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AND
MANAGEMENT OF
SEVERE MALNUTRITION
NUTRITION PROBLEMS IN INDONESIA
NUT STATUS
Available/
behaviour/ careHealth services undirectly
Accesstability and
Mother and children causes
of food at home sanitation
LBW
MEP < 5
CHILDREN
SCHOOL &
PUBERTY AGE
intake <<
PEM
Reccurent infection
Chronic starvation catabolism
ORGAN ATROPHY
DECREASED
ORGAN DISFUNCTION
INTAKE
DECREASED IMMUNITY HOSPITALIZED
PNEUMONIA
PREDISPOSSING SYMPTOM S OF DIARRHEA
FACTORS
ORGAN DIFUNCTION/ SYMPTOMS
INFECTION OF DEF. MACRO/
MICRO NUTR
COMPLEXS
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 >>
2. Anthropometry measurement
BW/ L-Ht: NCHS < 70%
z score <-3SD
BB ideal utk PB 70 Cm
= 8,9 kg
Status Gizi:
BB terukur X 100%
BB ideal
6/8,9 X 100%=67,3%
Status Gizi: BURUK
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Diagnosis of severe malnutrition
Clinical appearence Anthropometry
(BW/H-L)
1.Kwashiorkor
2.Marasmus
3.Marasmic kwashiorkor
Kwashiorkor:
SIGN
KWASHIORKOR
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
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hepatomegaly
Normal liver
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
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
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Predispotition Food intake
factors BW decreased Immunity
Accompanying diseases Admitted to hospital
Duration of illness
complexity sign
1. Accompanying diseases with complication
2. Sign of organ disfunction
3. Sign of diseases as predispotition factors
diseases
Normal intestinevillous
Atrophy of intestine epithelial cell
Atrophy
disfunction of organ
Lactase deficiency
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
Sunken eyes
Sign of breathing difficulties Pneumonia
Nasal flare
Chest indrawing
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VITAMIN A DEFICIENCY
XN (Xerophthalmia):
X1 B Bitot’ spot
-Foam-like’ substance, Hyperpigmentation
& wrinkle
- Cornea: clear, clean, no sign of infection
- 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)
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
51
Treatment scheme of severe malnourished children
Severe malnutrition
condition
0 24
2. Transition :
0 24
3. Rehabilitation
4. Follow - up
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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
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TEN STEPS IN THE MANAGEMENT OF
SEVERELY MALNOURISHED CHILDREN
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First 2 hours in The Initial stabilization phase
Condition I II III
O2 + - -
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First 2 hours in The Initial stabilization phase
Condition IV V
Hypothermia + +
Antibiotic Cotrimoksazole +
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Second 10 hours in The Initial stabilization phase
Condition I II III IV V
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Continued stabilization phase
Condition I II III IV V
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Transition phase
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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
60
Follow up
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
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THANK YOU
ASSALAMU’ALAIKUM
WAROHMATULLAH
WABAROKAATUH
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