Hasanuddin University

Medicine Faculty
Nutritional Department Document Code
Clinical Nutrition Specialist Programme
Course Profile
Course Code Class of Subject Credit 2 Semester Compiled on
Nutritional Management of 20C17530203 T= P= 2
Metabolic-Endocrine Diseases

Academic Senat Authorization Course Profile Developer Course Coordinator Head of School

DR. dr. Andi Makbul Amin, Sp.PD- Prof. Dr. dr. Nurpudji A. Taslim, MPH, Sp.GK (K)
KEMD

Expected Learning Outcome EXPECTED LEARNING OUTCOMES attributed to this course 

LO 1 Have devotion to God Almighty, religious, civilized, upholds human values, ethical values, independent, and
contribute to improving the quality of life in the community in the fields of medicine and health.
LO 2 Basic nutritional medical aspects
LO 3 Aspects of clinical specialization and hospital nutrition service management
LO 4 Able to develop and compile logical, critical, systematic, and creative thinking through scientific research and
arguments, subsequently published according to scientific principles, procedures, and ethics as a specific design in
media or in an accredited scientific journal

LO 5 Able to manage, develop, and maintain networks with colleagues and peers within the wider research institution and
community
LO 6 Able to perform and assess nutritional and metabolic status through nutritional screening methods, anamnesis,
assessment of energy and nutrient intake, physical examination, anthropometric examination, laboratory
examination, examination of body composition and examination of functional capacity
LO 7 Able to perform and record medical nutrition therapy, monitoring, and evaluation of various nutritional status
disorders as well as organ function and metabolism disorders according to national and international standards
LO 8 Able to carry out, monitor, and evaluate oral, enteral, and parenteral nutritional therapy in various
1

Short Description MK
Study Materials / Materials
lesson
conditions/diseases
LO 9 Able to apply International Patient Safety Goals (IPSG) principles in every action of clinical nutrition service which
includes effective communication with patients, patients' families, and work partners regarding medical nutrition
therapy according to the patient's condition, procedures undertaken, risk of complications, and nutritional
management, as well as building and carrying out good nutritional therapy team work oriented to the patient's
interests
Subject Learning Outcomes (CPMK)
To examine the nutritional management of PEM for infants, children and adolescents
Sub Subject Learning Outcomes (Sub CPMK)
1 Perform management ofof malnourished children
2 Detect growth disorders and follow-up
3 Assess the clinical signs and symptoms of malnourished children
4 Implementing a 10 (ten) step management plan for malnourished children in accordance with 5 (five) clinical
conditions
5 Applying nutritional therapy and how to make formulas and foods for malnourished children
This course will lead lecture participants to be able to diagnose malnutrition in infants, children and adolescents and provide nutritional
therapy
NUTRITION MANAGEMENT IN MACRO NUTRITION DEFICIENCY (PEM)
A.Definition of Growth
GROWTH:
Increase in physical size over time
Example: the child gets taller and gets bigger
DEVELOPMENT:
Development of mental, psychomotor and social functions
Example: a child from lying down is able to sit, stand, walk, talk, play and socialize
B. Monitor growth using Kartu Menuju Sehat(KMS)
Able to assess growth, it is necessary to measure body weight (BW), height / length (H / L) regularly.
- Every month: BW&H/L (<1 year)
- Every 3 months: H/L (1 to 5 years)
- Every 6 months: H/L (≥ 5 years)
2
Growth assessment is carried out by drawing a line that connects two points of weighing results on the Card Towards Health (KMS).
Growth is said to be good: if BB under five increases (N) in KMS
Growth is said to be not good: if BB under five does not increase (T) in KMS

3
 Body weight is increases (N): If the BB increases compared to last month, faster than the
standard line or the graph / growth line moves to the higher band on KMS "N1" (chasing
growth)

If BB increases compared to last month according to the standard line or graph / growth
line following the same color band on KMS "N2" (normal growth)

For children with BGM and weight gain: If the graph is close to the red
“N1” line (chasing growth) If the graph is parallel to the red line
"N2" (grows normally) If the graph moves away from the red line
"T1" (grows inadequately)
Berat Badan disebut naik (N): Jika BB naik dibanding bulan lalu lebih cepat dari garis

A. TO DETERMINE NUTRITION STATUS

 ANTHROPOMETRY:
BW / age, height / age, weight / height, BMI / age,
MUAC, Thick fat
 CLINIC:
Skin, muscles, fat jars, eyes, tongue, lips
Thin, edema (+/-), muscle atrophy, fatty tissue, pale, beetroot spots, dermatitis
 LABORATORY:
Biochemistry of blood, urine
 DIET / FOOD ANALYSIS:
Food frequency, amount of food, type of food,

B. TO DETERMINE NUTRITIONAL STATUS USING ANTHROPOMETRY

INDEX

 BW/age: body weightfor age, cannot describe the presence or absence of malnutrition
(undernutrition/overnutrition)“underweight”
 H/age: Height for age, describe the presence or absence chronic malnutrition 
“stunted”

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  BW/H:body weight for height,mdescribe presence or absence acute malnutrition
“wasted”

(Reference : WHO2006)

INDEX NUTRITIONAL STATUS Z- SCORE

Over weight > +2 SD

BW/AGE Normal weight -2 SD s/d +2 SD
Under weight -3 SD s/d < -2 SD
Severe Under weight < -3 SD

H/AGE Tall > +2 SD

L/AGE Normal height -2 SD s/d +2 SD
Stunted -3 SD s/d < -2 SD
Severe stunted < -3 SD
Fatty/obese
BW/H > +2 SD
Normal
BW/H -2 SD s/d +2 SD
Wasted -3 SD s/d < -2 SD
Severe wasted
< -3 SD

DEFINITION OF MALNUTRITION
Clinical and or anthropometry

DIAGNOSIS OF MALNUTRITION :
1. Looks very thin and or oedema,
2. BW/Heightor BW/Length : <-3 SD
Clinical Anthropometry
(BW/H -L)

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 Severe Looks very thin and / or <-3 SD *)
malnutrition edema in both dorsum pedis to (If there is oedema BW can be
the whole body increased)

Mild thin -3 SD ―  -2 SD

malnutrition
Normal Normal - 2 SD ― +2 SD

overnutrition overweight  +2 SD

Types, signs and clinical symptoms of malnourished children

1.Kwashiorkor type
2. Marasmic type
3. Marasmic-kwashiorkor type

EXAMINATION PROCEDURES FOR MALNOURISHED CHILDREN

a. Making the enegakkanDiagnosis:
- Anamnesis (diseases&nutrition)
- Physical examination (clinical and anthropometry)
- Laboratory/radiology examinations
- Diet analysis
b.A Initial anamnesis:
to detect any danger signs and important signs:
- shock / shock
- lethargy
- vomiting and / or diarrhea or dehydration
c. Follow up Anamnesis:
To find out the factors that cause malnutrition:
- history of pregnancy & birth (premature, LBW)
- history of feeding (ASI, MP-ASI)
- history of immunization & administration of high doses of vitamin
 - A history of comorbidities / complications (diarrhea, worms, TB, malaria, ARI / pneumonia, HIV / AIDS)
- history of growth and development (motor skills, do you weigh regularly at posyandu, have KMS)
- the cause of death of the sibling
- family social, economic and cultural status

Physical examination:
- Signs of circulatory disorders (tension, pulse, respiratory rate)
- Signs of dehydration
(sunken eyes !, thirst !, dry lips & mouth, decreased turgor, last pee!)
- Signs of hypoglycemia & hypothermia
- Signs of infection (fever?)
- Signs of anemia (Very pale)
Other organs (head, eyes, ears, nose, throat, neck, chest, abdomen,
extremities, skin) and the whole body.
Anthropometry: BW, height atau length, compared with table in reference book 1, page 22-24.
Laboratory?radiologi examination:
Hemoglobin
blood
glucoseroutine
urine
Albumin, electrolyte (P,
sodium, cl) zinc serum dll
thorax foto, USG dll

Diet Analysis :
- Quantity of food intake (Foodrecall)
- Quality of food intake (Foodfrequency)

4 (FOUR) PHASE ON CARE AND TREATMENT OF MALNOURISHED CHILDREN

• Stabilization Phase:
Early phase  immediate action (overcome and prevent hypoglycemia, hypothermia and dehydration), delay will result in death
 Administration of fluids, energy & protein is increased gradually to avoid "overload"  heart failure. Lasts 1 - 2
days and can continue up to 1 week (according to the child's clinic conditions)
• Transition:
Transition period (from stabilization to rehabilitation)
Increasing the amount of fluid and consistency of the formula is done slowly so that the intestinal cells adapt.
Lasts 1 week (generally)
• Rehabilitasition Phase:
Feeding to grow catch up
Energy and protein are increased according to ability.
Lasts 2 - 4 weeks (generally)
• Follow up phase:
After the child is discharged from the hospital / health center / nursing
home, nutrition food grows catch up (family food and PMT-recovery

10 STEPS OF BAD NUTRITION ADMINISTRATION

1. Prevent and treat hypoglycemia
2. Prevent and overcome hypothermia
3. Prevent and overcome dehydration
4. Improve electrolyte balance disorders
5. Treating infection
6. Improve micronutrient deficiencies
7. Provide weeks for stabilization and transition
8. Provide food to grow up to catch up
9. Give stimulation for growth and development

THE PURPOSE AND BASIC PRINCIPLES OF NUTRITION THERAPY

1. The purpose of nutritional therapy in malnourished children is to provide energy & nutrients to prevent and overcome:

Hypoglicemia
Hypothermia
Dehydration
Deficiency of micronutrient, vitamin mineral dan electrolyte (K, Mg, Cl, Zn, Cu), Restoring health conditions
 2. The basic principles of nutritional therapy in malnourished:
Long-term damage to the intestinal mucosa & enzymes results in a weakened digestive system
in children with persistent diarrhea.

Provision of liquids and foods:

1. Regularly (for 24 hours)
2. Gradually, starting from the form of liquid, crushed & solid (easily absorbed)
3. Small portions & frequent, do not be in a hurry
4. oing through the stabilization, transition & rehabilitation phases
5. Always monitored and evaluated (prevent excess fluid and food intake)

STABILISATION PHASE
The purpose of feeding:
Make the child's condition is stable
Given F75/ F75 modification/MODISCO ½
Enough Energy
EnoughProtein
Enoughfluid
Enough Elektrolyte
If there is severe edema (+++):
fluids : 100 ml/kg BW
Energy : 80 – 100 Kkal/kgBW
Protein: 1 – 1,5 g /kgBW
If there is not edema or edema (+, ++):
fluid : 130 ml/kg BW
Energy : 80 – 100 Kkal/kg BW
Protein: 1 – 1,5 g/kg BW
(Chart of Management of Children with Malnutrition, book II, p. 19-20)

STABILIZATION TRANSITION
 The final stage of stabilization
F 75 interval 4 hours (can be spent) reflaced
 F100 every 4 hours with the amount of liquidaccording to BW (tabelF75) given during 2days
 On day 3:
F100 with the amount of fluid according to body weight (table F100), the following 4 hours the fluid is increased by 10 ml
 followed by F 100 according to the table but not exceeding the max amount
 On day 4:
F100 with the amount of fluids according to BW +7-14 days, proceed to the rehabilitation phase

TRANSITION PHASE
The purpose of feeding:
Prepares children to receive more fluids and energy

Given (F100/Modification/Modisco I & II):

 Fluid : 150 ml/kgBW
 Energy : 100 – 150 Kkal/kgBW
 Protein: 2 – 3 g /kgBW

REHABILITATION
The purpose of feeding
To pursue growth, Given after the child can eat
Given (F135 / Modisco III plus baby / child food):
Fluid : 150 – 200 ml/kgBW
Energy : 150 – 220 kkal/kg BW
Protein : 3 – 4 gr/kg BW
Form of solid food, given according to BW:
BB < 7 kg , given baby food/crushed
BB > 7 kg , given child food /softfood

NUTRITIONAL THERAPY IN THE FOLLOW UP PHASE

HOUSEHOLD
Eat a variety of food, small portion, and
often feed your toddlers patiently
Give ASI  2year
Use oil, coconut milk, fat
Give fruits
POSYANDU (Pos Pemulihan Gizi)
Give PMT- P: 350 Kkal energy& 15 g protein, for 3 months, given every day.
Use local food ingredients (rice flour, milk, sugar, oil, nuts, vegetables, eggs, and other side dishes (family food).

Every week do a cooking demonstration, provide groceries to take home.

Use KMS for monitor children’s weight every month

HOW TO MAKE RESOMAL, FORMULA AND FOOD FOR

MALNOURISHED CHILDREN

RESOMAL (Rehydration Solution for Malnutrition)

Bahan membuat ReSoMal

Bubuk WHO-ORS (oralit )utk 1liter(*) : 1 pak (5 sachet @ 200 ml

sugar : 50 gram
Lar.Elektrolit/MineralMix: 40 ml
add boiled water until the solution : 2liter

Every 1 literReSoMal solution : Na = 37,5mEq,

(*) WHO-ORS powder/1 liter : Nacl 2,6 gram, trisodium citrat dihidrat 2,9 gram, KCl = 1,5 g and glucose 13,5 gram

Electrolyte solution / mineral mix compotition

KCl : 224gram
Tripotasiumcitrat : 81gram
MgCl2.6H2) : 76gram
Zn acetat2H2O : 8,2gram
CuSO4.5H2O : 1,4gram
Add water : 2.5 liter

RESOMAL MODIFICATION (Rehydration Solution for Malnutrition)

If mineral mix is not available, KCl can use as follows
Ingradient For2000ml for 400ml
 WHO-ORS powder 1 pak @1000 ml 1 sachet @ 200ml
Sugar 50gr 10gr
KCl powder 4 gr 0,8gr
Add water to 2liter 400ml
Because it does not contain Mg, Zn and Cu,
Given fruit juice that contains lots of minerals, or given MgSO4 50% i.m single dose of 0.3 ml / kgBW maximum 2 ml

HOW TO MAKE A RESOMAL

Combine ORS + sugar + mineral mix,
Add boiled water until it becomes 1000 ml
This solution can be drunk immediately

1. WHO Formula 75/100/135

Combine sugar and vegetable oil, stir until blended
Add e le c t r ol yt e / M i ne r al Mi x s ol uti on ,
Add skim milk little by little, stirring until blended
Dilute with warm water little by little, while stirring until homogeneous until it becomes 1000 ml
Thi s s ol ut i on c a n be dr unk i mm e di a t el y. Cook f or 4 m inut e s, for toddl er s wit h pe r s is t e nt
dys e nte r y or di a rr he a
2. Modified Formula 75 /100/135formula:
Combine, sugar, oil, mix all
Add flour, skim milk / full cream / fresh milk
Add wa t e r s o t hat it re a c hes 1 l it e r
Bring to a boil while stirring until dissolved for 5-7 minutes
References Main :
Buku acuan standar Tatalaksana anak gizi buruk. Departemen Kesehatan RI, Jakarta. 2003
Supporting :
1. Mahan LK, Raymond JL. Krause’s Food & The Nutrition Care Process, 14 th Edition. St Louis, Missouri, Elsevier,2017.
2. Mahan LK dan Escott-Stump S. Krause’s Food Nutrtion & Diet Therapy, 12 th ed. Philadelphia, Saunders,2008
3. WildmanREC,MedeirosDM.AdvancedhumannutritionChap.16.CardiovascularDiseaseandNutrition.CRCPress,
Washington D.C.2000
4. GrodnerM,LongS,DeYoungS.Foundationsandclinicalapplicationsofnutrition.Anursingapproach.Chap20.Nutrition for
cardiovascular disease. Ed.ke-3.Mosby,USA.2006
5. Nelms M, Long S. Nutrition therapy and pathophysiology,USA. Thomson Brooks/ Cole.2016
 6. Ross, A. C., Caballero, B. H., Cousins, R. J., Tucker, K. L., & Ziegler, T. R. (2012). Modern nutrition in health and disease:
Eleventh edition. Wolters Kluwer Health Adis (ESP).

Supporting 1. Dr. dr. Aida Juliyati A.Baso,Sp.A(K),

lecturer 2. dr. Ema Alasiry,Sp.A,
3. 3.dr.Nur Ainun Rani, M.Kes,Sp.GK
Courses 1. Nutritional Physiology and Nutritional Metabolism 2. Life Cycle Nutrition Science 3. Basic Clinical Nutrition
precondition
Sub Cp-MK Assessment Learning Forms;
Learning methods;
(Final ability of Assignment Learning Rating Weight
Week each stage of College student; Materials (%)
learning) Estimated time (Library)
Indicator Criteria and Form offline (onlin
e
)
1 2 3 4 5 6 7 8
1 Perform  Explain the  Form: Test or Face to face Book 10
management of management of non-test (30%) 1,2,3.4.5.6,7
children with children with Case
malnutrition malnutrition Criteria:
discussion
10 = Detail 1
of 2 points (30%)
Independent
study (30%)
Clinical
Practice (10%)
2  Detect growth  Form: Test Face to face book 20
from the graph or non-test (30%) 1,2,3.4.5.6,7
 Follow up on Case
growth disorders Criteria:
discussion
Detect growth 20 = Specify 2
disorders and of 2 points (30%)
follow-up 10 = Detail 1 Independent
of 2 points study (30%)
Clinical
Practice (10%)

3  Determine nutritional  Form: Test or Face to face Book 20

status non-test (30%) 1,2,3.4.5.6,7
 Diagnose Case
malnutrition Criteria:
discussion
20 = Specify 2
Assess the (30%)
of 2 points
clinical signs Independent
10 = Detail 1
and symptoms study (30%)
of 2 points
of malnourished
children Clinical
Practice (10%)

4  Describe the phase  Form: Test or Face to face Book 20

Implementing a in the care of non-test (30%) 1,2,3.4.5.6,7
10 (ten) step malnourished Case
management plan children Criteria:
discussion
for malnourished  Prescribes 10 steps 20 = Specify 2
of 2 points (30%)
children in to manage children
with malnutrition 10 = Detail 1 Independent
accordance with 5
(five) clinical of 2 points study (30%)
conditions Clinical
Practice (10%)

254
5  Prescribe nutritional  Form: Test Face to face Book 30
therapy in or non-test (30%) 1,2,3.4.5.6,7
malnourished
Apply Criteria: Case discussion
children
nutritional  Prescribes how to 20 = Specify 2 (30%)
therapy and make formulas and of 2 points
how to foods for 10 = Detail 1
manufacture of 2 points
malnourished
formulas as well Learn
children
food for independent
malnourished (30%)
children
Clinical
Practice
(10%)

255
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