OSOCA SKENARIO B BLOK XXI 2014

Learning Objective :

1. Definisi, Faktor riko gizi buruk pada anak

2. Klasifikasi status gizi pada anak (gizi baik, gizi buruk, gizi lebih)

3. Patofisiologi gizi buruk pada anak

4. penatalaksanaan gizi buruk pada anak

5. asuhan nutrisi pada anak

Ana, 10 months old girl, visited the outpatient clini RSMP with recurrent diarrhea
with her mother. She suffered from diarrhea almost once a month since she was 4 months
old. The length of diarrhea was 7 to 10 days. Her mother said that her daughter’s appetite
was like usual. Ana is not having fever, cough, cold and hard to breathe now.
Ana’s weight was never weighed (she was never taken to Public Health Center).
Highest weight was unknown. Ana was given exclusive breastfeeding just until 3 months
of age. Since her age was 3 months, she was given only regular formula milk 6 times a
day @90 cc until now. After her age was 4 months. She was given instant porridge as a
complementary feeding (MP ASI) 2 times a dat @1/2 sachet (1 sachet is 80 kcal). She
also was given cooked rice (tajin) 2-3 times a day @50 cc since her age was 4 months.

The mother’s pregnancy and childbirth history:

Ana is the first child from a 24 years old mother. During pregnancy, mother was
healthy and pre natal care to a midwife 4 times. Ana was delivered spontaneously at 37
weeks gestation. Immediately cried after birthed, APGAR score 1st minute is 9 and the 5th
minute is 10. Birth weight was 2800 grams. Birth length was 49 cm. Head circumference
was 33 cm.

Immunization History: BCG 1 time but DPT, polio, hepatitis dan measles vaccines were
never given.
Growth history: image attachment of ANA’s KMS
Development history: Ana can only sit with help
Medication history: Ana was never got treatment
Physical examination:
 General status: the child is not looking thin, round cheeks, pale, apathetic, whiny, weight
5.5 kg, length 60 cm, head circumference 43 cm, upper arm circumference 12 cm.
Vital Sign: HR 112x/minute, RR: 32x/minute, T: 36,5C
Spesific Status:
Head:
- No dismorphic face
- Round cheeks
- Easy revoked sheer yellowish red head hair
- Wistfull eyes
- Look and cry at the examiner
- Look towards when her name was called
Thorax: no ribs (piano sign)
Abdomen: bloated
Extremities:
- Edema in the four extremities
- No anatomy abnormalities to both legs and feet
- No baggy pants
Skin: there is skin skin abnormalities (dermatosis) in the buttocks and groin
Neurologicus status:
- normal movements, motoric muscle strenght 4
- Normal physiological reflexes
- Normal clonus and tone
- No uncontrollable movements
- No pathological reflexes
I. Identifikasi Masalah

1. Ana, 10 months old girl, visited the outpatient clini RSMP with recurrent diarrhea
with her mother. She suffered from diarrhea almost once a month since she was 4
months old. The length of diarrhea was 7 to 10 days.
2. Her mother said that her daughter’s appetite was like usual. Ana is not having fever,
cough, cold and hard to breathe now.
3. Ana’s weight was never weighed (she was never taken to Public Health Center).
Highest weight was unknown.
4. Ana was given exclusive breastfeeding just until 3 months of age. Since her age was
3 months, she was given only regular formula milk 6 times a day @90 cc until now.
5. After her age was 4 months. She was given instant porridge as a complementary
feeding (MP ASI) 2 times a dat @1/2 sachet (1 sachet is 80 kcal). She also was given
cooked rice (tajin) 2-3 times a day @50 cc since her age was 4 months.
6. The mother’s pregnancy and childbirth history:
Ana is the first child from a 24 years old mother. During pregnancy, mother was
healthy and pre natal care to a midwife 4 times. Ana was delivered spontaneously at
37 weeks gestation. Immediately cried after birthed, APGAR score 1st minute is 9
and the 5th minute is 10. Birth weight was 2800 grams. Birth length was 49 cm.
Head circumference was 33 cm.
7. Immunization History: BCG 1 time but DPT, polio, hepatitis dan measles vaccines
were never given.
8. Growth history: image attachment of ANA’s KMS
9. Development history: Ana can only sit with help
10. Medication history: Ana was never got treatment
11. Physical examination:
General status: the child is not looking thin, round cheeks, pale, apathetic, whiny,
weight 5.5 kg, length 60 cm, head circumference 43 cm, upper arm circumference
12 cm.
Vital Sign: HR 112x/minute, RR: 32x/minute, T: 36,5C
12. Spesific Status:
Head:
- No dismorphic face
- Round cheeks
- Easy revoked sheer yellowish red head hair
- Wistfull eyes
- Look and cry at the examiner
- Look towards when her name was called
Thorax: no ribs (piano sign)
Abdomen: bloated
Extremities:
- Edema in the four extremities
- No anatomy abnormalities to both legs and feet
 - No baggy pants
Skin: there is skin skin abnormalities (dermatosis) in the buttocks and groin
13. Neurologicus status:
- Normal movements, motoric muscle strenght 4
- Normal physiological reflexes
- Normal clonus and tone
- No uncontrollable movements
- No pathological reflexes

1. Ana, 10 months old girl, visited the outpatient clini RSMP with recurrent
diarrhea with her mother. She suffered from diarrhea almost once a month
since she was 4 months old. The length of diarrhea was 7 to 10 days.
a. What are the causes of recurrent diarrhea?
Answer:
Based on the causes agents;
1. Infectious agents:
a. Bacteria: Salmonella, Shigella, E. coli, Bacillus cereus
b. Virus: Rotavirus, Astrovirus, Koronavirus
c. Parasites: Cryptosporidium, Cyclospora sp, Giardial Lamblia
2. Noninfectious agents:
a. Food poisoning
 b. Anatomical defects (Hisprung Disease, Short Intestine, Striktura)
c. Malabsorption (Deficiency of Disaccharides)
d. Endocrinopathy (Tiroxicosis, Addison's disease)
e. Neoplasm
f. Other causes (milk allergy, chron disease, immune deficiency, water
laxative)

Based on other factors:

1. Infection Factor
a. Enteral Infections
Enteral infections are gastrointestinal infections that are the main
cause of diarrhea in children. These parenteral infections include;
1) Bacterial infections: E.coli, Salmonella, Shigella,
2) Viral infections: Enteroovirus, Adenovirus, Rotavirus.
3) Parasite infestation: Worm (Ascaris) fungi (candida albicans)
b. Parenteral infection
Parenteral infection is infection of other body parts outside the
digestive tool, such as acute otitis media (OMA), Tonsilofaringitis,
Bronkopneumonia, Encephalitis and so on.
2. Malabsorption Factors
a. Carbohydrate malabsorption:
disaccharides (lactose intolerance, maltose and sucrose),
monosaccharides (glucose intolerance, fructose and galactose).
b. Malabsorption of fat
c. Malabsorption of proteins
3. Food Factor: stale food, toxic.
In this case, diarrhea is caused by protein malabsorption.

Sumber:

(Subagyo dan Santoso, 2012)

b. What is the determinology of diarrhea almost once a month since she was 4
months old and the lengsht of diarrhea was 7 to 10 days?
Answer:
 Ana has a chronic diarrhea.
Based on the duration, diarrhea are divided into:
1) Acute diarrhea
Acute diarrhea is a bowel movement with increasing frequency and
consistency of soft or fluid stools and is suddenly coming and lasting in less
than 2 weeks.
2) Persistent diarrhea
Persistent diarrhea is diarrhea lasting 15-30 days, is a continuation of
acute diarrhea or a transition between acute and chronic diarrhea.
3) Chronic diarrhea
Chronic diarrhea is diarrhea that comes and goes, or lasts long with
non-infectious causes, such as gluten-sensitive disease or decreased
metabolic disorders. The duration of chronic diarrhea is more than 30 days.
According to (Suharyono, 2008), chronic diarrhea is diarrhea that is chronic
or persistent and lasts more than 2 weeks.
Source:
Suharyono, 2008
c. What is the pathophisiology of recurrent diarrhea in this case?
Answer:

Lactase enzyme deficiency in the small intestine brush border → lactose-

breaking disorder into glucose → impaired absorption of food or substances →

osmotic pressure in the intestine increases → water and electrolyte shifts in the

intestinal cavity → excessive intestinal contents of cavities → diarrhea

2. Her mother said that her daughter’s appetite was like usual. Ana is not having
fever, cough, cold and hard to breathe now.
a. What is the meaning of her daughter’s appetite was like usual?
Answer:
Her daughter’s appetite was like usual means that there is no problems with
her appetite. The problem may caused by other causes such as the lack ammount
of compsumption or the metabolism disorder.
b. How is the correlation between appetite like usual with the complaints?
 Answer:
The complaints is not caused by her appetite.
c. What is the meaning of ana is not having fever, cough, cold and hard to
breathe now?
Answer:
The meaning is the diarrhea that happened to Ana is not caused by infectious
factors.
3. Ana’s weight was never weighed (she was never taken to Public Health Center).
Highest height was unknown.
a. What is the meaning of Ana’s weight was never weighed and her height
was unknown?
Answer:
Ana’s family is not a KADARZI family. Keluarga Sadar Gizi (KADARZI) is
a family that is able to recognize, prevent and overcome the nutritional
problems of each member. A family is called KADARZI if it has a good
nutritional behavior that is characterized by at least:
1. Weigh the weight regularly.
2. Provide breast milk (breast milk) only to infants from birth to age 6
months (exclusive breastfeeding).
3. Eat the variaton food
4. Using iodized salt.
5. Drink nutritional supplements (TTD, high doses of Vitamin A capsules) as
recommended.
Source:
(DEPKES, 2012)
b. How about normal weight and height in infant aged 10 months?
Answer:
Based on Z-score growth chart;
Age:10 months
a. Weight : 8,2 kg
b. Lenght : 71,5 cm
c. Head circumference : 44,4 cm

Based on NCHS;
c. How is the normal growth and development of a 10-months-old baby?
Answer:
The normal growth and development of a 9-12 months baby;
1. Can stand alone without help
2. Can walk guided
3. Imitate sound
4. Repeat the sound he heard
5. Learn to declare one or two words
6. Understand simple command or prohibition
7. Show great interest in exploring the surroundings, eant to touch anything and put
things into his mounth
8. Participating and games
Some milestones of child development that must be know (developmental
milestone is the level of development that must be achieved by a child at a certain age) :
 child 9-10 month :

1. Pointing with the index finger

2. Holding objects with thumb and forefinger
3. crawl
4. sound dada…dada…
Source:
Soetjiningsih, 2012

Synthesis:
Age Rough Fine motor Personal- Language
motoric and adaptive Social
2 weeks Head shifted - Recognize Alert to the bell
to the right the face
ang left
2 months Shrugs on his Follow the Smile as a Cooing
stomach object past the response Looking for a sound
center line source using the eyes
4 months Raise hands Looking for See the Laughing and crying
stomach objects hand
not found Raking grasp
headlag if Start
pulled from playing
supine with toys
sleeping
position
6 months Sitting alone Move objects Can feed Babble
from hand to yourself
hand Holding
the bottle
9 months Start learing start pincer Can waved Say bye-bye and
to stand up grasp bye-bye Mama, but not
Can sit alone bring together 2 play pat-a- spesific
blocks cake Say 2 syllables
12 walk Insert the beam Drink from say mama and
monthhs rise up and in the cup a glass papa, spesific
stand up Imitating say 1-2
movement the other word
Other
people

d. How many times weight and body height checks are recommended at the
Public Health Center?
Answer:

According to the Decree of the health minister of the Indonesia Republic

number: 747 / menkes / sk / vi / 2007 on operational guidelines of nutritionally
conscious families in Desa Siaga, the recommendation to weigh baby weight are
the following;
4. Ana was given exclusive breastfeeding just until 3 months of age. Since her age
was 3 months, she was given only regular formula milk 6 times a day @90 cc
until now.
a. What are the contents and the benefits of breast milk?
Answer:
The composition of human milk is the biologic norm for infant nutrition. Human
milk also contains many hundreds to thousands of distinct bioactive molecules that
protect against infection and inflammation and contribute to immune maturation, organ
development, and healthy microbial colonization. Some of these molecules, e.g.,
lactoferrin, are being investigated as novel therapeutic agents.

Colostrum, produced in low quantities in the first few days postpartum, is rich in
immunologic components such as secretory IgA, lactoferrin, leukocytes, as well as
developmental factors such as epidermal growth factor. The macronutrient composition
of human milk varies within mothers and across lactation but is remarkably conserved
across populations despite variations in maternal nutritional status. The macronutrient
composition of mature, term milk is estimated to be approximately 0.9 to 1.2 g/dL for
protein, 3.2 to 3.6 g/dL for fat, and 6.7 to 7.8 g/dL for lactose (Ballard et al, 2013).

The most abundant proteins are casein, α-lactalbumin, lactoferrin, secretory

immunoglobulin IgA, lysozyme, and serum albumin.Non-protein nitrogen-containing
compounds, including urea, uric acid, creatine, creatinine, amino acids, and
nucleotides, comprise ~25% of human milk nitrogen. And many micronutrients vary in
human milk depending on maternal diet and body stores including vitamins A, B1, B2,
B6, B12, D, and iodine. Also, Human milk contains numerous growth factors that have
wide-ranging effects on the intestinal tract, vasculature, nervous system, and endocrine
system (Ballard et al, 2013).

Human milk is a dynamic, multi-faceted fluid containing nutrients and bioactive

factors needed for infant health and development. Its composition varies by stage of
lactation and between term and preterm infants. While many studies of human milk
composition have been conducted, components of human milk are still being identified.
Standardized, multi-population studies of human milk composition are sorely needed to
create a rigorous, comprehensive reference inclusive of nutrients and bioactive factors.
Nevertheless, knowledge of human milk composition is increasing, leading to greater
understanding of the role of human milk in infant health and development (Ballard et
al, 2013).
Benefits:

1. Lactose
As an energy-producing source, as a major carbohydrate, it increases the
absorption of calcium in the body, stimulating the growth of lactobacilli
bifidus.
2. Protein
Has a function for the regulator and builder of the baby's body.
3. Fat
Serves as a major heat / energy hazard, decrease the risk of heart disease at
a young age.
4. Vitamin A
Vitamins are very useful for the development of infant vision.
5. Iron
Substances that help the formation of blood to prevent the baby from less
blood or anemia.
6. Taurine
Neotransmitters are good for brain development of children.
7. Lactoferrin
Inhibits the development of candida and bacterial staphylococcal fungi that
harm the health of the baby.
8. Lisozyme
Very useful to reduce dentis caries and malocclusion and can break down
the walls of harmful bacteria.
 9. Colostrum
10. Important substances that contain many nutrients and substances of the
baby's body from disease attack.
11. AA and DHA
Substances obtained from changes in omega-3 and omega-6 that work for
fetal and infant brain development.

b. How long exclusive breastfeeding was given to a baby?

Answer:
Exclusive breastfeeding should given to a baby for 6 months long. Review of
evidence has shown that, on a population basis, exclusive breastfeeding for 6 months is
the optimal way of feeding infants. Thereafter infants should receive complementary
foods with continued breastfeeding up to 2 years of age or beyond.

Source: WHO,2017

c. What are the effects of breastfeeding not given exclusively?

Answer:

1. Short-term Infant Health Outcomes

a. Infection
Not breastfeeding significantly increases an infant’s risk of illness from
infectious diseases. For every additional month of full breast- feeding,
30.1% of hospitalizations resulting from infection could have been
prevented. An estimated 53% of diarrhea hospitaliza- tions and 27% of
lower respiratory tract infections could have been prevented monthly by
exclusive breastfeeding and 31% and 27% respectively by partial
breastfeeding.
b. Sudden infants Death syndrome
Not breastfeeding increases the chance of an infant dying from sudden
infant death syndrome (SIDS). In a 2009 German study, exclusive
breastfeeding at one month of age halved the risk of SIDS, and partial
breastfeeding at one month of age also reduced the risk. Being exclusively
breastfed in the last month of life fur- ther reduced the risk of SIDS, as did
being partially breastfed
c. Mortality
Not breastfeeding significantly increases a child’s risk of dying in
infancy. In both developed and developing countries, breastfeed- ing and

human milk protects against post-neonatal death.
 In developing countries

infants who are not breastfed have higher rates of diarrhea and respiratory
diseases, both of which are main causes of infant death. A cohort case study
in Ghana found a marked dose response of increasing risk of neonatal

mortality with increasing delay in initiation of breastfeeding from 1 hour


to day 7.

d. Weight
Not breastfeeding increases a child’s risk of being both overweight and
obese. The estimated percentage of 6-11 year old U.S. chil- dren
considered to be obese has more than quadrupled to 19% since 1960.
Infants who have never been breastfed are at higher risk for later
childhood obesity than infants who have ever been breastfed.
e. Temperature and Respiratory Regulation

Bottle feeding puts an infant at risk for physiological instabil-
 ity.

Oxygen saturation and body temperature were found to be significantly

lower in preterm infants who were bottle fed versus those who were
directly breastfed.
f. Necrotizing Enterocolitis
Not breastfeeding significantly increases an infant’s risk of nec-
rotizing enterocolitis (NEC). NEC occurs in 3-10% of VLBW infants
and rarely in compromised term infants. It is associated with an
increased morbidity and mortality, including growth and
neurodevelopmental impairment, infection and increased need for
central line placement.
g. Pain
Not breastfeeding increases the infant’s response to pain. An analysis
of eleven studies demonstrates that both breastfeeding and human milk
are pain relieving. Neonates who were swaddled or received a pacifier
 exhibited more crying times (proportion and duration) and increased
heart rates when compared to breastfeed- ing infants. Pain scores were
significantly worse (more pain) for infants who were not breastfeeding.

2. Long-term Infant Health Outcomes

a. Atopic Dermatitis
b. Asthma
c. Cognitive and Development disorder, etc

Source: (Spatz and Lessen, 2011)

d. How is the correlation between breastfeeding was given until 3 months of

age with complaints?
Answer:
Exclusive breastfeeding for up to 6 months will provide immunity to infants
against various diseases. Asi contains sIgA, T lymphocytes, B lymphocytes, and
lactoferrin which can improve immune status in infants. Infants who are not exclusively
breastfed for 6 months will be susceptible to infections and metabolism disorder that
cause diarrhea.

e. What are the effects of the infant was given formula milk?
Answer:
We must restrict the formula milk feeding because it will bring the Jellife
triage that are diarrhea due to infection, moniliasis in the mouth and marasmus.
The situation is caused because the bottle is less hygiene cleaned up, bottle milk
tends to dilute, thus reducing the nutritional value.

5. After her age was 4 months. She was given instant porridge as a
complementary feeding (MP ASI) 2 times a dat @1/2 sachet (1 sachet is 80
kcal). She also was given cooked rice (tajin) 2-3 times a day @50 cc since her
age was 4 months.
a. What is the meaning of she was given instant porridge as a complementary
feeding when she was 4 months?
Answer:
It means that breastfeeding was not given exclusively.
b. How to feed children by age?
Answer:
Pattern of giving the breast milk and complementary feeding;

Frequency and the amount of giving MP-ASI;

Example of Daily Menu;

 Source: (Kemenkes, 2011)

c. How is the caloric needs based on age?

Answer:
Ideal weight: 8,5 kg
Caloric Needs:
Ideal Weight x RDA cased on height age= caloric needs
8,5x 100 =850 kkal
 d. How are the compositions of instant porridge and cooked rice?
Answer:
Instant porridge composition

The nutrient content and quality of instant porridge that has been qualified is
energy (minimum 80 kcal / 100 g), ash (maximum 3.5%), protein (8-22%), zinc
(minimum 2.5 mg / 100 g), Fe (at least 5 mg / 100 g), and protein digestibility
(at least 70%). Meanwhile, the content and quality of nutrients that have not
fulfilled SNI are water content (maximum 4%), fat content (6-15%), total
dietary fiber (maximum 5%), calcium (minimum 200 mg / 100 g), and total
plate number (maximum of 104 colonies / gram). The instant serving quantity of
instant porridge is 27 g which contains 22.25% protein, 55.25% iron, 27.63%
zinc based on nutritional label (ALG) of children aged 7-24 months so it can be
claimed as food source of protein and zinc and high in iron.
(Yustiani, 2013)

Cooked rice water composition

It contains 7-10% protein, low calcium, glucose and other minerals.

(Silvia, 2010)

6. The mother’s pregnancy and childbirth history:

Ana is the first child from a 24 years old mother. During pregnancy, mother was
healthy and pre natal care to a midwife 4 times. Ana was delivered spontaneously at
37 weeks gestation. Immediately cried after birthed, APGAR score 1st minute is 9
and the 5th minute is 10. Birth weight was 2800 grams. Birth length was 49 cm.
Head circumference was 33 cm.
a. How is the interpretation and abnormal mechanism of mother’s pregnancy
and childbirth history?
Answer:
- Normal age of pregnant women: 20 – 30 years old
 In this case, her mother is 24 years old when she was pregnant with Ana
 normal
- Normal gestasional age : 37 – 42 weeks
In this case, gestasional age was 37 weeks, cried after birth : normal
APGAR score :

1st minute = 9  normal

5th minute = 10  normal

- Normal weight of newborn baby : 2500 – 4000 gram

In this case : 2800 gram  normal
- Normal Lenght of newborn baby: 48 – 52 cm
In this case : 49 gram  normal
- Normal head circumference of newborn baby:33 – 35 cm
In this case : 33 cm  normal

b. How to assess APGAR Score on newborns?

Answer:

Interpretation:
7-10 = Normal
4-6 = Mild
0-3 = Severe
7. Immunization History: BCG 1 time but DPT, polio, hepatitis dan measles vaccines
were never given.
a. How is the interpretation of immuunization history?
Answer:
Ana immuunization history is incomplete
b. What immunization should be given to a child?
Answer:

IDAI, 2017
8. Growth history: image attachment of ANA’s KMS
 a. How is the interpretation of growth history?
Answer:
At the age of 0-2 months the growth rate pattern follows the normal

growth curve (SD 0), on month 3 to month 9 growth rate deviate → Failure to

thrive
b. What is the ideal pattern of normal child growth from KMS drawing?
Child growth is said to be normal if it follows the normal percentile curve
of the KMS chart.
9. Development history: Ana can only sit with help
a. How is the interpretation of development history?
Answer:

Can only sit but with the help → rough motoric development disorder

10. Medication history: Ana was never got treatment

a. How is the interpretation of medication hisory?
Answer:
Ana’s parent never take ana to take a treatment may caused by many factors;
knowledge factor, socioeconomic factor and caring factor.
11. Physical Examination
General status: the child is not looking thin, round cheeks, pale, apathetic, whiny,
weight 5.5 kg, length 60 cm, head circumference 43 cm, upper arm circumference
12 cm.
Vital Sign: HR 112x/minute, RR: 32x/minute, T: 36,5C
a. How is the interpretation of physical examination?
Answer:
Physical Examination Normal Interpretation

Not looking thin Not looking thin Normal

Round Cheeks Abnormal, Edema

Pale Abnormal

Apatis Compos mentis Loss of

consciousness

Whiny Not Whiny Abnormal, more

often in
malnourished
children

Weight 5,5 kg 8,5 kg >-3 SD Malnutrition

under percentil -3

Length 71 cm Failed to grow

Head Circumference 45 45-48 cm Normal

cm

HR 112 x/menit 120-160 x/menit Normal

RR 32 x/menit 20-60 x/menit Normal

37,50C 36,5-37,2oC Normal

b. How is the abnormal mechanism of physical examination?

Answer:
 (Rabinowitz dkk, 2016)
12. Spesific Status
Head:
- No dismorphic face
- Round cheeks
- Easy revoked sheer yellowish red head hair
- Wistfull eyes
- Look and cry at the examiner
- Look towards when her name was called
Thorax: no ribs (piano sign)
Abdomen: bloated
Extremities:
- Edema in the four extremities
- No anatomy abnormalities to both legs and feet
- No baggy pants
Skin: there is skin skin abnormalities (dermatosis) in the buttocks and groin
a. How is the interpretation of spesific status?
Answer:
Spesific Status Normal Interpretation

Round cheeks, easy recoked sheer Tidak ada Clinic manifestation in Kwashiokor
yellowish red head hair, wistfull patient
eyes, look and cry at the examiner,
abdomen bloated, edema in four
extremities and dermatosis in the
buttocks and groin

No ribs (piano sign), no baggy pants Tidak ada edema Normal, Usually in marasmus

b. How is the abnormal mechanism of spesific status?

Answer:
13. Neurologicus status
- Normal movements, motoric muscle strenght 4
- Normal physiological reflexes
- Normal clonus and tone
- No uncontrollable movements
- No pathological reflexes
a. How is the interpretation of neurologicus status?
Answer:
- Normal movements, motoric muscle strenght 4: normal, parese
- Normal physiological reflexes: normal
- Normal clonus and tone: normal
- No uncontrollable movements: normal
- No pathological reflexes: normal

14. How to Diagnose?

Answer:
Anamnesis
Complaints are often found is less growth, thin children, or less weight. In addition
there are complaints of children less / do not want to eat, often suffering from
recurrent pain or swelling on both feet, sometimes until the whole body.
Physical examination
1. Mental changes to apathy
2. Anemia
3. Changes in color and texture of hair, easily revoked / fall
4. Gastrointestinal system disorders
5. Enlarged heart
6. Skin changes (dermatosis)
7. Muscle atrophy
8. Symmetrical edema on both backs of the foot, can be up to the whole body
Source:
(Pudjiadji et al, 2010) (Puone et al, 2001)
15. How is the differential diagnosis in this case?
Answer:

Marasmus-
Gejala Kasus Kwashiorkor Marasmus
kwashiorkor

Tampak kurus + - + -
Rambut tipis mudah
+ + + +
di lepas
Infeksi berulang + + + +
Iga gambang
+ - + +
Dan edema
Abdomen cekung + - + -
Baggy pants + - + -
Penurunan BB + + + -

16. How is the additional examination in this case?

Answer:
Required additional examination:
1. Laboratory examination: blood glucose, complete peripheral blood, complete
feces, serum electrolytes, serum protein (albumin, globulin), ferritin. On
laboratory examination, anemia is always found primarily normocytic normocytic
types due to eritropoesis system disorders due to chronic bone marrow
hypothlasia in addition to poor dietary intake of iron, liver damage and impaired
absorption. In addition can be found decreased serum albumin levels 4.
2. Radiological examination (chest, AP and lateral) is also necessary to find any
abnormalities in the lung.
3. The mantoux test
4. EKG (Hidajat et al, 2011)
17. What is the working diagnosis in this case?
Answer:
Malnutrition (type Kwashiokor) + failed to thrive
18. What treatment should be given in this case?
Answer:

These steps are accomplished in two phases: an initial stabilisation phase where the acute
medical conditions are managed; and a longer rehabilitation phase. Note that treatment
procedures are similar for marasmus and kwashiorkor. The approximate time-scale is given
in the box below:

1. Step 1 : Treat/prevent hypoglycaemia

Hypoglycaemia and hypothermia usually occur together and are signs of infection.
Check for hypoglycaemia whenever hypothermia (axillary<35.0oC; rectal<35.5oC) is
found. Frequent feeding is important in preventing both conditions.

Treatment:

If the child is conscious and dextrostix shows <3mmol/l or 54mg/dl give:

a. 50 ml bolus of 10% glucose or 10% sucrose solution (1 rounded teaspoon

of sugar in 3.5 tablespoons water), orally or by nasogastric (NG) tube. Then
feed starter F-75 (see step 7) every 30 min. for two 
 hours (giving one
quarter of the two-hourly feed each time) 

 b. antibiotics (see step 5) 

c. two-hourly feeds, day and night (see step 7)

 If the child is unconscious, lethargic or convulsing give: 

a. IV sterile 10% glucose (5ml/kg), followed by 50ml of 10% glucose 
 or
sucrose by Ng tube. Then give starter F-75 as above 

b. antibiotics 

c. two-hourly feeds, day and night 


Monitor:

blood glucose, rectal temperature and level of consciousness: if this deteriorates, repeat
dextrostix 


2. Step 2: Treat/ prevent hypothermia

Treatment:
If the axillary temperature is <35.0oC, take the rectal temperature using a low
reading thermometer.
If the rectal temperature is <35.5oC (<95.9oF):

a. Feed straightaway (or start rehydration if needed) 


b. Rewarm the child: either clothe the child (including head), cover with a 


warmed blanket and place a heater or lamp nearby (do not use a hot water
bottle), or put the child on the mother’s bare chest (skin to skin) and cover

them 


c. Give antibiotics (see step 5) 


Monitor:
a. body temperature: during rewarming take rectal temperature two- hourly

until it rises to >36.5oC (take half-hourly if heater is used)


b. ensure the child is covered at all times, especially at night
 • feel for

warmth 


c. blood glucose level: check for hypoglycaemia whenever hypothermia is

found 

3. Step 3: Treatment/ Prevent dehydration
Treatment:
It is difficult to estimate dehydration status in a severely malnourished child using
clinical signs alone. So assume all children with watery diarrhoea may have
dehydration and give:
a. ReSoMal 5 ml/kg every 30 min. for two hours, orally or by nasogastric tube,

then 


b. 5-10 ml/kg/h for next 4-10 hours: the exact amount to be given should be
determined by how much the child wants, and stool loss and vomiting.
Replace the ReSoMal doses at 4, 6, 8 and 10 hours with F-75 if rehydration

is continuing at these times, then 


c. continue feeding starter F-75 (see step 7) 
 During treatment, rapid

respiration and pulse rates should slow down and the child should begin to

pass urine. 


Monitor progress of rehydration:
 Observe half-hourly for two hours, then hourly for

the next 6-12 hours, recording: 
 pulse rate, respiratory rate 
 ,urine frequency

,stool/vomit frequency 


4. Step 4: Corect Electrolite imbalance

Give: 


a. Extra potassium 3-4 mmol/kg/d 


b. Extra magnesium 0.4-0.6 mmol/kg/d 


c. When rehydrating, give low sodium rehydration fluid (e.g. Resomal) 


d. Prepare food without salt 


5. Step 5:Treat/prevent infection

 In severe malnutrition the usual signs of infection, such as fever, are often absent, and

infections are often hidden.
 Therefore give routinely on admission:

a. broad-spectrum antibiotic(s) AND 


b. measles vaccine if child is > 6m and not immunised 
 (delay if the child is in shock)

6. Step 6: Correct micronutrient deficiencies

Give:


Vitamin A orally on Day 1 (for age >12 months, give 200,000 IU; for age 6-12
months, give 100,000 IU; for age 0-5 months, give 50,000 IU) unless there is
definite evidence that a dose has been given in the last month

Give daily for at least 2 weeks:

a. Multivitamin supplement 


b. Folic acid 1 mg/d (give 5 mg on Day 1) 


c. Zinc 2 mg/kg/d 


d. Copper 0.3 mg/kg/d 


e. Iron 3 mg/kg/d but only when gaining weight 


7. Step 7: Start caution feeding

The essential features of feeding in the stabilisation phase are:

a. small, frequent feeds of low osmolarity and low lactose 


b. oral or nasogastric (NG) feeds (never parenteral preparations) 


c. 100 kcal/kg/d 


d. 1-1.5 g protein/kg/d 


e. 130 ml/kg/d of fluid (100 ml/kg/d if the child has severe oedema) 

 f. if the child is breastfed, encourage to continue breastfeeding but 
 give the

prescribed amounts of starter formula to make sure the child’s needs are met.

8. Step 8: Achieve catch-up growth 


9. Step 9 : Provide sensory stimulation and emotional support

severe malnutrition there is delayed mental and behavioural development.
Provide:

a. tender loving care 


b. a cheerful, stimulating environment 


c. structured play therapy 15-30 min/d (Appendix 10 provides examples) 


d. physical activity as soon as the child is well enough 


e. maternal involvement when possible (e.g. comforting, feeding, bathing, 


play) 


10. Step 10: Prepare for follow-up after recovery 


Good feeding practices and sensory stimulation should be continued at home.

Show parent or carer how to:

a. feed frequently with energy- and nutrient-dense foods 


b. give structured play therapy 


Advise parent or carer to: 


a. bring child back for regular follow-up checks 


b. ensure booster immunizations are given 


c. ensure vitamin A is given every six months 


Source: (Ashworth et al, 2003)

19. What is the complication in this case?

 Answer:
Children with kwashiorkor will be more susceptible to infection due to
weakness of the immune system. The maximum height and potential growth will
never be achieved by a child with a history of kwashiorkor. The statistical evidence
suggests that kwashiorkor that occurs early in life (infants and children) can decrease
IQ permanently. Another complication that can be generated from kwashiorkor is :
1. Iron deficiency
2. Hyperpigmentation of the skin
3. Anacaral edema
4. Immunity decreases so easily infection
5. Diarrhea due to atrophy of the intestinal epithelium
6. Hypoglycemia, hypomagnesemia

Refeeding syndrome is one of the metabolic complications of nutritional support

in severe malnourished patients characterized by hypophosphatemia, hypokalemia,
and hypomagnesemia. This occurs as a result of changes in the main energy source
of the body's metabolism, from fat at the time of starvation to carbonhydrate given
as part of nutritional support, resulting in an increase in insulin levels and the
electrolyte displacement required for intracellular metabolism. Clinically patients
may develop dysrhythmias, heart failure, acute respiratory failure, coma paralysis,
nephropathy, and liver dysfunction. Therefore, in the provision of nutritional support
in patients with severe malnutrition needs to be given gradually
(Pudjiadi et al, 2010)
20. What is the medical doctor compentences in this case?
Answer:
4A
Ability level 4. Doctor graduates are able to make a clinical diagnosis and manage
the disease independently and thoroughly.
21. What is the prognosis in this case?
Answer:
Quo ad vitam: dubia ad bonam
Quo ad functionam: Dubia ad malam
22. NNI
Right to get breastfeeding exclusively
  Al-Baqarah: 233

Mothers may breastfeed their children two complete years for whoever
wishes to complete the nursing [period]. Upon the father is the mothers'
provision and their clothing according to what is acceptable. No person is
charged with more than his capacity. No mother should be harmed through
her child, and no father through his child. And upon the [father's] heir is [a
duty] like that [of the father]. And if they both desire weaning through
mutual consent from both of them and consultation, there is no blame upon
either of them. And if you wish to have your children nursed by a substitute,
there is no blame upon you as long as you give payment according to what is
acceptable. And fear Allah and know that Allah is Seeing of what you do.

2.3 Hypothesis
Ana, a 10 months old girl, experiencing malnutrition type kwashiokor+ failure to thrive
et causa Breastfeeding is not given exclusively dan recurrent diarrhea.

2.4 Conceptual framework

Breastfeeding is not given exclusively

Lactosa intolerance

Recurrent diarrhea

Malnutrition (Kwashiokor)
growth + development disrupted

failure to thrive