LACK OF PROTEIN ENERGY IN

CHILDREN

1
 FLOW OF SERVICE
MALNOURISHED CHILDREN

3
EXAMINATION PROCEDURES
MALNOURISHED CHILDREN

5
 PROCEDURES FOR EXAMINATION
MALNOURISHED CHILDREN

Establishing the Diagnosis:

- Anamnesis (disease & nutrition)
- Physical examination (clinical and
anthropometry)
- Laboratory/radiological examination
- Dietary and food analysis

6
 PROCEDURES FOR EXAMINATION
MALNOURISHED CHILDREN (continued....)

Early anamnesis:
to be aware of any red flags and
Important signs:
- shock/blasphemy
- lethargical (declining consciousness)
- vomiting and or diarrhea or dehydration

7
 PROCEDURES FOR EXAMINATION
MALNOURISHED CHILDREN (continued....)
Advanced anamnesis:
To find out the factors that cause
the occurrence of malnutrition:
- history of pregnancy & birth (premature, BBLR)
- Feeding history (BREAST MILK, MP-ASI)
- history of immunization & administration of high
doses of vit A
- history of comorbidities/complicating diseases
(diarrhea, worms,TB,malaria, ISPA/pneumonia,
HIV/AIDS)
- Growth and Development History (Motoric, Routine
weighing in posyandu, have KMS)
- cause of death in siblings
- social, economic and cultural status of the family 8
 PROCEDURES FOR EXAMINATION OF
MALNOURISHED CHILDREN (continued.....)

Physical examination:
- Signs of circulatory disorders
(Tension, Pulse, Frequency of breathing)
- Signs of dehydration
(sunken eyes/mata cekung, thirst, dry on lips
& mouth, turgor down, last pee/kencing
terakhir)
- Signs of hypoglycemy & hypothermy
- Signs of infection (fever ?)

9
 PROCEDURES FOR EXAMINATION OF
MALNOURISHED CHILDREN (continued.....)

Physical examination (CONT’....):

- Signs of anemia (Very pale)
- Other organs of the body (head, eyes,
ears, nose, throat, neck, chest,
abdomen, extremities, skin) and the
whole body.
- Anthropometry: BB, PB or TB, compare
with the standard table of Book I
references,
pp 22-24. 10
 PROCEDURES FOR EXAMINATION OF
MALNOURISHED CHILDREN (continued.....)
Laboratory/radiological examination:
- Hemoglobin
- Blood sugar
- routine urine
- Albumin, electrolyte (K, Na, cl)
- zinc serum etc.
- thorax photo, ultrasound/USG etc.
Dietary analysis:
- Quantity of food intake (Food recall)
- quality of food intake (Food frequency)
11
 4 (FOUR) PHASES ON THE CARING AND
TREATMENT OF MALNOURISHED CHILDREN

12
 4 (FOUR) PHASES ON THE CARING AND
TREATMENT OF MALNOURISHED CHILDREN

• Stabilization Phase:
The initial phase→ immediate action (overcome and
prevent hypoglycemia, hypothermia and dehydration),
delay will result in death

The administration of fluids, energy & proteins is

gradually increased to avoid "overload“→ heart failure.

1 – 2 days and can continue up to 1

weeks (according to the child's clinical condition)

13
 4 (FOUR) PHASES ON THE CARING AND
TREATMENT OF MALNOURISHED CHILDREN (cont’)

• Transition Phase:
Transition period (from stabilization to rehabilitation)
An increase in the amount of fluid and the consistency
of the formula is carried out slowly in order for
intestinal cells adaptation.
1 week (generally)

14
 4 (EMPAT) FASE PADA PERAWATAN DAN
PENGOBATAN ANAK GIZI BURUK (Lanjutan ….)

• Rehabilitation Phase:
Feeding to grow chase (tumbuh kejar)
Energy and protein are increased according to ability.
Lasts 2 – 4 weeks (generally)

• Follow-up Phase:
After the child is discharged from the hospital / puskesmas /
nutrition recovery house
Food grow chase (Family food and PMT- Recovery)
Lasts up to 4 - 5 months

15
10 MANAGEMENT STEPS FOR
MALNOURISHED CHILDREN

DIREKTORAT BINA GIZI MASYARAKAT

DEPARTEMEN KESEHATAN RI

16
"10 main steps" Management of Severe Malnutrition
No Action Stabilisasi Transisi Rehabilitasi Tindak lanjut
H 1-2 H 3-7 H 8-14 mg 3-6 mg 7-26
1. Prevent and
overcoming hypoglycemia
2. Prevent and
Overcoming hypothermia
3. Prevent and
overcoming dehydration
4. Fixing electrolyte balance

5. Treating infections

6. Fixing micronutrient Defici- tanpa Fe + Fe

ency
7. Giving food
for stab & trans

8. Giving food to Grow up

after (tumb kejar)

9. Giving stimulation for

Growth and development

10. Preparing for Next Action

at home 17
(Buku I : Buku Bagan Tata Laksana Gizi Buruk, tahun 2006, hal. 3)
 STEP 1

PREVENTING AND
OVERCOMING HYPOGLYCEMIA

18
 HYPOGLYCEMIA

• Very low blood glucose levels (< 3 mmol/liter or <

54 mg/dl)
• It usually occurs simultaneously with
hypothermia
• Other signs: lethargic (loss of consciousness),
pulse weak, loss of consciousness
• Symptoms of hypoglycemia in the form of
sweating and pallor (pucat) are very rarely found
in malnourished children
(Petunjuk Teknis Tata Laksana Gizi Buruk, Buku II,
hal. 3)
19
 HIPOGLIKEMIA (continued...)

• Death from hypoglycemia, sometimes

only preceded (didahului) by a sign such
as drowsiness (mengantuk)
• If there is no blood glucose level
examination facility, every malnourished
child who comes must be considered to have
hypoglycemia → immediately treat / handle
according to the management of
hypoglycemia
(Petunjuk Teknis Tata Laksana Gizi Buruk, Buku II, hal. 3)

20
 HOW TO OVERCOME HYPOGLYCEMIA

SIGN HOW TO OVERCOME

AWARE  Give 10% Glucose solution or solution

(NOT LETHARGICAL) granulated sugar 10%*) orally/NGT (bolus) as
much as 50 ml
UNCONSCIOUS  Give 10% iv Glucose Solution (bolus) 5 ml/kgBB
(LETHARGICAL)  Next give Glucose solution 10% or 10%
granulated sugar solution oral or NGT (bolus) of
50 ml

RENJATAN (SYOK)  Give iv liquid in the form of Ringer Lactate and

Dextrose/Glucose 10% with 1:1 ratio (=RLG
5%) of 15 ml/KgBB for the first 1 hour or 5
drops/min/KgBB.
 Next give 10% iv Glucose solution (bolus) as
much as 5 ml/KgBB.

*) 5 gram gula pasir (= 1 sendok teh munjung) + air matang s/d 50 ml

(Petunjuk Teknis Tata Laksana Gizi Buruk, Buku II, hal. 3) 21
 STEP 2

PREVENTING AND OVERCOMING

HYPOTHERMIA

22
 HYPOTHERMIA

• Axillary temperature < 36.5 OC (measure for 5 minutes)

• It usually occurs together with hypoglycemia
• Hypothermia + hypoglycemia: is a sign of the
presence of serious systemic infections → therapy for
all three (hypothermia + hypoglycemia + infection)
• The energy reserves of malnourished children are very
limited → not capable of producing heat for
maintaining body temperature

(Petunjuk Teknis Tata Laksana Gizi Buruk, Buku II, hal. 4) 23

 HYPOTHERMIA (continued....)

• Maintain the body temperature of

malnourished children by covering his
body
• The act of warming the body = effort of
savings usage reserve energy.

24
(Petunjuk Teknis Tata Laksana Gizi Buruk, Buku II, hal. 4)
The way to maintain and restore the child's body
temperature to prevent hypothermia.
Body temperature 36.5 – 37.0 ºC
Hypothermia easy to occurs → maintain temperature :

1. Cover the child's body including the head

2 . Avoid gusts of wind (hembusan angin)
3. Maintain a room temperature of 25–30 oC
4. Keep blankets at night
5. Do not leave without clothes for too long during inspection
& weighing
6. Caring hands should be warm
7. Immediately change clothes or wet sleeping utensils
8. Dry immediately after bathing
9. Do not use a hot water bottle to warm the child
→ sunburn (kulit terbakar)

25
(Petunjuk Teknis Tata Laksana Gizi Buruk, Buku II, hal. 4)
The way to maintain and restore the child's body
temperature to prevent hypothermia (cont’)

Body temperature < 36.5 ºC (hypothermia)

Action→ warm the body :
1. “Kangaroo“ way: direct contact of the mother's
skin and child skin
2. Lamp: laid (diletakkan) 50 cm from the child's
body
3. Monitor temperature every 30 minutes
- the temperature is normal?
- the temperature is not too high?
4. Stop heating when body temperature is already
reaches 37C

26
(Petunjuk Teknis Tata Laksana Gizi Buruk, Buku II, hal. 4)
 STEP 3

PREVENTING AND
OVERCOMING DEHYDRATION

27
 SIGNS OF DEHYDRATION
No SIGN HOW TO VIEW AND DETERMINE

1 Letargical Limp (lemas), unwary (tdk waspada),

disinterested to surrounding events
2 Restless terutama bila disentuh/dilakukan
(gelisah) and tindakan
cranky child
3 No tears No tears when the child cries

4 Sunken eyes Sunken eyes are usually or have only been

(mata cekung) for a while

5 Dry mouth and Fingering (raba) with a dry finger and

tongue clean to determine if the tongue
and the mouth is dry
28
(Petunjuk Teknis Tata Laksana Gizi Buruk, Buku II, hal. 5)
 SIGNS OF DEHYDRATION (continued...)
No SIGN HOW TO VIEW AND DETERMINE
6 Thirsty Does the child want to reach for the cup
when given ReSoMal. When the cup was
removed, does the child still want to
drink again?
7 The return of Gently pull the skin layer and the underlying
slow skin tissue of the skin. Pinch (cubit) for 1 second
pinching/tur and release. If the skin is still folded (has
gor not flipped flat for > 2 seconds)→ slow skin
turgor. (Note: pinching of the skin is usually
slow in "wasting" children)
8 Last When more than 6 hours dehydration is
pee(kencing suspected
terakhir)
29
(Petunjuk Teknis Tata Laksana Gizi Buruk, Buku II, hal. 5)
 STEP 4

FIXING ELECTROLYTE BALANCE

DISTURBANCES

30
 Fixing electrolyte balance
disturbances

◼ In children with severe malnutrition occurs

electrolyte imbalance in the body
◼ Need to be given mineral mix/electrolyte solution
in the form of ReSoMal (when diarrhea) and WHO
formula according to its phases

31
 Fixed electrolyte balance disturbances
(continued.....)
ReSoMal : Rehidration Solution for
Malnutrition
◼ Oralit:
diluted (encerkan) 2 x to lower Na levels → to prevent
hipervolemia (Conditions due to deficiency volume of
extracellular fluid), pulmonary edema, heart failure
◼ Sugar:
adds energy and prevents hypoglycemia
◼ Mineral Mix/Electrolyte Solution:
increase electrolyte deficiency (K, Mg, Cu, zinc)

32
 STEP 5

TREATING INFECTIONS

33
 INSTRUCTIONS FOR
ADMINISTERING ANTIBIOTICS
• No obvious complications/infections (Tidak ada
komplikasi/infeksi yang jelas)
→ kotrimoksasol/oral/12 jam selama 5 hari

• There are complications

→ Gentamicin IV (intravenous) or IM
(intramuscular) for 7 days, plus Ampicillin IV or
IM/6 hours for 2 days, followed by amoxicillin/8
hours for 5 days
34
 INSTRUCTIONS FOR
ADMINISTRATION OF
ANTIBIOTICS (continued.....)

• Within 48 hours it does not improve

→ Chloramphenicol IV or IM/8 hours for 5 days

• When there is a special infection

→ special antibiotics according to Disease

Dosis dan jenis obat pada Bagan Tata Laksana Gizi Buruk, Buku I, hal.
14 - 15)

35
 STEP 6

CORRECTING MICRONUTRIENT
DEFICIENCIES

36
 DOSAGE OF IRON TABLETS AND IRON SYRUP
FOR CHILDREN AGED 6 MONTHS TO 5 YEARS

FORM OF FORMULA Fe DOSIS

IRON/FOLATE TABLETS Bayi usia 6 – < 12 bln → 1 x sehari ¼ tab

(sulfas ferosus 200 mg atau 60
mg besi elemental + Anak usia 1–5thn→ 1 x sehari ½ tablet
0,25 mg as folat)

IRON SYRUP Bayi 6 – < 12 bulan → 1 x sehari 2 ,5 ml

(sulfas ferosus 150 ml), (½ sendok teh)
setiap 5 ml mengandung 30 mg
besi elemental Anak usia 1–5 thn → 1 x sehari 5 ml
10 mg ferosulfat setara dengan (1 sendok teh)
3 mg besi elemental

Catatan:
• Fe diberikan setelah minggu ke2 (pada fase rehabilitasi)
• Zat Besi atau Fe diberikan setiap hari selama 4 minggu atau lebih
• Dosis Fe : 1 – 3 mg Fe elemental/kg berat badan/hari
(Bagan Tata Laksana Gizi Buruk, Buku I, hal. 15) 37
 HIGH DOSE OF VITAMIN A CAPSULES DOSAGE
FOR CHILDREN AGED 6 MONTHS TO 5 YEARS

Age Dose
< 6 months 50.000 SI ( ½ kapsul biru )
6 – 11months 100.000 SI ( 1 kapsul biru )
1 – 5 years 200.000 SI ( 1 kapsul merah )

38
 DOSAGE OF VITAMINS AND MINERALS
FOR CHILDREN AGED 6 MONTHS TO 5 YEARS

Dose
Vitamin C BB < 5 kg: 50 mg/hari (1
tablet)
BB > 5 kg: 100 mg/hari (2
tablet)
Asam Folat Hari I: 5 mg/hari,
selanjutnya 1 mg/hari
Vitamin B 1 tablet/hari
compleks
Mineral Mix Zn, K, Mg, Cu (dalam Mineral
Mix/larutan elektrolit)
39
 STEP 7

PROVIDING FOOD FOR

STABILIZATION AND TRANSITION

40
 NUTRITIONAL NEEDS ACCORDING TO THE
FEEDING PHASE IN MALNOURISHED
CHILDREN

A. Stabilization Phase
◼ Energy : 80 – 100 Kkal/kgBB/hari
◼ Protein : 1 – 1,5 g/kgBB/hari
◼ Liquid : 130 ml/kgBB/hari atau
100 ml/kgBB/hari (bila edema berat +++)
◼ Formula 75/modifikasi/modisco ½

Jumlah dan frekwensi cairan yang diberikan sesuai dengan:

-Tabel Pedoman F-75 (buku I, hal.19 – 20) dan
- Jadwal pemberian makanan anak gizi buruk sesuai fase (buku II, hal 12)

41
 NUTRITIONAL NEEDS ACCORDING TO THE
PHASE OF FEEDING IN MALNOURISHED
CHILDREN (Continued ....)

B. Transition Phase
◼ Energy: 100 – 150 Kkal/kgBB/hari
◼ Protein: 2 – 3 g/kgBB/hari
◼ Liquid: 150 ml/kgBB/hari
◼ Formula 100/modifikasi/modisco I/II

Jumlah dan frekwensi cairan yang diberikan sesuai dengan:

-Tabel Pedoman F-75 (buku I, hal.21) dan
- Jadwal pemberian makanan anak gizi buruk sesuai fase (buku II, hal 12)

42
 STEP 8

GIVING FOOD
TO GROW CHASE (TUMBUH KEJAR)

43
 NUTRITIONAL NEEDS ACCORDING TO THE
PHASE OF FEEDING IN MALNOURISHED
CHILDREN (Continued ....)

A. Rehabilitation Phase
◼ Energy : 200 – 220 Kkal/kgBB/hari
◼ Protein : 3 – 4 g/kgBB/hari
◼ Liquid : 150 – 200 ml/kgBB/hari
◼ Formula 100/135/modifikasi/modisco III
◼ Plus food:
- BB < 7 kg → baby food/soft
- BB ≥ 7 kg → Child food/soft

Jumlah dan frekwensi cairan yang diberikan sesuai dengan:

- Jadwal pemberian makanan anak gizi buruk sesuai fase (buku II, hal 12)
44
 NUTRITIONAL NEEDS ACCORDING TO THE
FEEDING PHASE IN MALNOURISHED
CHILDREN (continued.....)
FASE STABILISASI

RENCANA I RENCANA II RENCANA III RENCANA IV RENCANA V

FASE TRANSISI

FASE REHABILITASI

Pemberian makanan berdasarkan rencana I, II, III, IV, V

45
akan dijelaskan lebih lanjut pada materi inti IV dan V
 NUTRITIONAL NEEDS ACCORDING TO THE
PHASE OF FEEDING IN MALNOURISHED
CHILDREN (Continued ....)

A. Follow-up Phase

Energy and protein needs according to Weight and child's

age.

◼ PMT- Recovery: Energy 350 Kkal/hr & prot. 15 g/hr

◼ Plus family meals

Jumlah dan cara pemberian makanan sesuai dengan:

- Jadwal pemberian makanan anak gizi buruk sesuai fase (buku II, hal 14)
46
 STEP 9

Provides stimulation for

growth and development

47
 Provides stimulation for
Growth and development

Malnourished children:
Delay in mental and behavioral development
→ give:

• Affection (kasih sayang)

• Cheerful environment
• Structured play therapy for 15 – 30 minutes/
day (For example: the game ci luk ba or
using Educational Game Tools)
• Physical activity immediately after recovery
• Involvement of the mother (feeding, bathing,
• play and so on)
48
 IMPORTANT THINGS
WHAT TO LOOK FOR

1. Do not give Fe before week 2

(Fe is given in the rehabilitation phase)

2. Do not give intravenous fluid, except for shock

or severe dehydration

3. Do not give too high protein

4. Do not give diuretics to sufferers

Kwashiorkor

49
 STEP 10

Preparing for
Follow-up at Home

50
 PREPARING FOR FOLLOW-
UP AT HOME
When clinical symptoms are no longer present and
Weight/Height (BB/TB-PB) > - 2 SD→"child healed"

Good feeding and stimulation pattern

must continue at home

Give an example to Parents:

a. Menu and how to make food with high energy
content and nutrient dense accordingly to age and
weight of the child.
(lihat buku II, lampiran 4, hal. 53)
b. Structured play therapy
51
 PREPARING FOR FOLLOW-UP AT HOME
(continued....)

Recommend:
• food with small portions and often, appropriate with the
age of the child
• Control Regularly:
Month I : 1 x / week
Month II : 1 x / 2 weeks
Month III - VI : 1 x / month
Basic injections/immunizations of BCG, Polio, DPT,
Measles (campak), Hepatitis B and replays (boosters)
(Malnourished children are not recommended to measles
immunization, but in all malnourished children should be immunized
measles before the child goes home, after the rehabilitation phase)
Vit.A high dose every 6 months (age-appropriate dosage)
52
 CRITERIA FOR RETURN OF MALNOURISHED
CHILDREN

Child:

1. Good appetite, food given is eaten all

2. There is an improvement in mental state
3. Already smiling, sitting, crawling, standing, walking, according to
his age
4. Body temperature ranges from 36.5 – 37.5 C
5. No vomiting or diarrhea
6. No edema
7. Weight gain > 5 g/kgBB/hari, 3 hari berturut-turut
or increased of 50 g/kgBB/minggu, 2 minggu berturut-turut
8. Already in a state of BB/TB-PB > - 3 SD (and no longer
there are clinical signs and symptoms of malnutrition)
53
 RETURN CRITERIA OF
MALNOURISHED CHILDREN
(continued.....)
Mother/caregiver:

1. Already able to make the necessary food to grow

chase at home
2. Have been able to care for and provide food right to
the child

Field institutions:

Puskesmas/Nutrition Recovery Post/Posyandu is ready

to receive post-treatment referrals (rujukan pasca
perawatan)
54
 Jadual Pemberian Imunisasi Pada Bayi
Dengan Menggunakan Vaksin DPT dan HB1
Dalam Bentuk Terpisah, Menurut Tempat Lahir Bayi

UMUR VAKSIN TEMPAT

Bayi lahir di rumah:
0 bulan HB1 Rumah
1 bulan BCG, Polio1 Posyandu atau tempat
pelayanan lain
2 bulan DPT1, HB2, Polio2 Posyandu atau tempat
pelayanan lain
3 bulan DPT2, HB3, Polio3 Posyandu atau tempat
pelayanan lain
4 bulan DPT3, Polio4 Posyandu atau tempat
pelayanan lain
9 bulan Campak Posyandu atau tempat
pelayanan lain
Sumber: Departemen Kesehatan RI, Jakarta, 2005, Keputusan Menkes RI No. 1611/ 55
MENKES/ SK/ XI/ 2005 tentang Pedoman Penyelenggaraan imunisasi.
 Jadual Pemberian Imunisasi Pada Bayi
Dengan Menggunakan Vaksin DPT dan HB1
Dalam Bentuk Terpisah, Menurut Tempat Lahir Bayi

UMUR VAKSIN TEMPAT

Bayi lahir di RS/ RB/ Bidan Praktek:

0 bulan HB1, Polio1, BCG RS/ RB/ Bidan

2 bulan DPT1, HB2, Polio2 RS/ RB/ Bidan atau Posyandu
3 bulan DPT2, HB3, Polio3 RS/ RB/ Bidan atau Posyandu
4 bulan DPT3, Polio4 RS/ RB/ Bidan atau Posyandu
9 bulan Campak RS/ RB/ Bidan atau Posyandu

Sumber: Departemen Kesehatan RI, Jakarta, 2005, Keputusan Menkes RI No. 1611/
MENKES/ SK/ XI/ 2005 tentang Pedoman Penyelenggaraan imunisasi.
56
 Jadual Pemberian Imunisasi Pada Bayi Dengan
Menggunakan Vaksin DPT dan HB Dalam Bentuk Terpisah
Menurut Frekuensi dan Selang Waktu dan Umur Pemberian

VAKSIN PEMBERIAN SELANG UMUR KETERANGAN

IMUNISASI WAKTU
PEMBERIAN
MINIMAL
BCG 1x - 0-11 bulan
DPT 3x 4 minggu 2-11 bulan
(DPT 1, 2, 3)
Polio 4x 4 minggu 0-11 bulan
(Polio 1, 2, 3, 4)
Campak 1x - 9-11 bulan
HB 3x 4 minggu 0-11 bulan Untuk bayi lahir di RS/
(HB 1, 2, 3) puskesmas oleh tenaga
kesehatan pelaksana HB
segera diberikan dalam 24
jam pertama kelahiran,
vaksin BCG dan Polio
diberikan sebelum bayi
pulang ke rumah.
57
Sumber: Departemen Kesehatan RI, Jakarta, 2005, Keputusan Menkes RI No. 1611/ MENKES/ SK/ XI/ 2005
tentang Pedoman Penyelenggaraan imunisasi.
 THE ROLE OF THE NUTRITION
SUPPORT TEAM

prevent

treat

Severe
Good
Malnutrition
nutrition
The Role of the Nutrition Support Team:

• Doctor : determine the diagnosis, perform actions,

treatment and follow-up
• Nurse/midwife: nursing care
• Nutritionist : providing food, conducting nutrition counseling
(in hospitals and in health centers)
58
59