TATALAKSANA TERBARU ANAK GIZI BURUK
USIA 6 – 59 BULAN DAN USIA < 6 BULAN
Julistio Djais
Nutrisi & Penyakit Metabolik
IDAI Jabar
MANAGEMENT OF SEVERE MALNUTRITION:
A MANUAL FOR PHYSICIANS AND
OTHERS SENIOR HEALTH WORKERS TRAINING COURSE ON
WHO 1999 THE MANAGEMENT OF SEVERE MALNUTRITION
WHO 2002
GUIDELINE UPDATES
ON THE MANAGEMENT OF
SEVERE ACUTE MALNUTRITION TRAINING COURSE ON
IN INFANTS AND CHILDREN THE MANAGEMENT OF SEVERE MALNUTRITION
WHO 2013 UPDATE 2009
TRAINING COURSE ON
WHO GUIDELINE
ON THE PREVENTION AND MANAGEMENT OF WASTING
THE INPATIENT MANAGEMENT OF
AND NUTRITION OEDEMA (ACUTE MALNUTRITION) SEVERE ACUTE MALNUTRITION
IN INFANTS AND CHILDREN UNDER 5 YEARS WHO 2022
WHO 2023
MODULE TRAINING
2002 & 2009 2022
Introduction Introduction
Principles of care Principles of care
Initial management Initial management
Feeding Feeding
Daily care Daily care
Monitoring and problem solving Monitoring and problem solving
Involving mothers in care Involving mothers in care
Outpatient management
of severe acute malnutrition
Severe acute malnutrition (SAM): very vulnerable and at high risk of death
Medical complication in SAM increases the risk of death
and requires specialized hospital care
SAM in children 6–59 months is defined by
the presence of bilateral pitting oedema
or severe wasting based on MUAC < 11.5 cm or WFH < −3 z-score
SAM in infants less than 6 months is defined by
the presence of bilateral pitting oedema
or severe wasting based on WFL < −3 z-score
Admission criteria for Inpatient care children aged 6 – 59 months
Bilateral pitting oedema +++
or marasmic kwashiorkor: any bilateral pitting oedema with severe wastinga
or bilateral pitting oedema + or ++ or severe wastinga with
any of the following danger signs or medical complications:
failed appetite test intractable vomiting
convulsions unconsciousness
inability to drink or breastfeed shock
severe dehydration hypoglycaemia
hypothermia high fever (> 39°C rectal or > 38.5°Caxillary)
acute diarrhoea severe malaria
severe anaemia lower respiratory tract infection
eye signs of vitamin A deficiency severe dermatosis
or referred from outpatient care according to outpatient care action protocol
Admission criteria for Outpatient care children aged 6 – 59 months
Bilateral pitting oedema + or ++ or Severe wasting
and
∎ passed appetite test
∎ clinically well
∎ alert
or transferred from inpatient care
after medical complications have been treated
Admission criteria for Inpatient care infant < 6 months
Any bilateral pitting oedema (+, ++, or +++)
or WFL < −3 z-score
with danger signs or medical complications
or with any of the following:
failure to gain weight
any loss of weight that crosses the infant’s growth line
ineffective breastfeeding directly observed for 15–20 minutes
disability that affects suckling or swallowing,
or a developmental problem affecting feeding
any social issue requiring detailed assessment or intensive support
(e.g. maternal depression)
Admission criteria for Outpatient care infant < 6 months
WFL < −3 z-score
and
no bilateral pitting oedema
clinically well and alert
gaining weight following the growth curve
(serial weight measurements follow consistently along a channel on
or between the same centiles)
adequate social circumstances and support
EMERGENCY TREATMENT FOR SAM
Emergency signs for airway and breathing, or coma or convulsions,
should receive standard emergency treatment.
SAM who have shock, WHO recommends a cautious approach to IV fluid resuscitation
Careful history should be taken, to properly manage shock in SAM
Severely malnourished children with signs of severe dehydration but not in shock
should not be rehydrated with IV fluids.
SAM with signs of severe dehydration but not in shock
should be rehydrated orally with ReSoMal
Manage hypoglycaemia
begin F75
Manage hypothermia
Manage a severely malnourished child who is in shock
Manage dehydration
giving ReSoMal
Manage very severe anaemia
Give emergency eye care
give vitamin A
Give a high dose of vitamin A to SAM and eye signs of vitamin A deficiency or
recent measles in inpatient care on Days 1, 2, and 15, irrespective of the type
of therapeutic food they are receiving
Give antibiotics
antibiotics for severely malnourished children
FEEDING
F-75 F-100 Ready-to-use therapeutic food (RUTF)
FEEDING SAM 6 – 59 months
DURING STABILIZATION FEED THE CHILD WITH F-75
On the first day, F-75 every 2 hours
130 ml/kg/day, It will give 100 kcal/kg/day and 1–1.5 g protein/kg/day.
This amount is appropriate until the child is stabilized.
If the child has severe (+++) oedema, should be given only 100 ml/kg/day
FEEDING THE CHILD IN TRANSITION
Once the child is stable, has increased appetite and has reduced oedema,
and is therefore ready to move into the rehabilitation phase,
the child should transition from F-75 to ready-to-use therapeutic food (RUTF).
The recommended energy intake during this period is 100–135 kcal/kg/day.
RUTF has higher energy and protein content and is used as a catch-up feed
The child will have to tolerate RUTF before being referred to outpatient care.
FEEDING SAM < 6 MONTHS
Provision of parenteral antibiotics
Promotion of breastfeeding where possible
SAM but no oedema, expressed breast milk should be given and,
where this is not possible, commercial infant formula or F-75 or diluted F-100
may be given, either alone or as the supplementary feed together with breast milk.
To make diluted F-100, add water to F-100 formula up to 1.5 litres instead of 1 litre.
Undiluted F-100 should never be given to infants aged less than 6 months
For infants with severe acute malnutrition and oedema, infant formula or F-75 should
be given as a supplement to breast milk.
Feeding infants without prospect of breastfeeding
SAM without oedema should be fed using infant formula or diluted F-100.
with oedema should be fed with F-75 until the oedema has resolved and
should then switch to infant formula or diluted F-100.
Feeding during stabilization
Give infant formula or diluted F-100 (or F-75 in case of oedema) at 130 ml/ kg/day,
distributed across 12 or 8 feeds per day (every 2–3 hours), providing 100 kcal/kg/day.
Two-hourly feeds are best for at least the first day.
Then, when the infant has little or no vomiting and modest diarrhoea, change to 3-hourly feeds.
After a day on 3-hourly feeds, and no vomiting and no diarrhoea, change to 4-hourly feeds.
Feed by NG tube when the infant is not taking sufficient milk by mouth.
The use of an NG tube should not exceed 3 days and should be used only in the stabilization phase.
Once there is a return of appetite and oedema starts resolving the infant can enter
a transition period before the rehabilitation phase.
Feeding during transition
Give infant formula or diluted F-100 at 150–170 ml/kg/day,
providing 110–130 kcal/ kg/day.
Criteria for discharge from hospital to outpatient care
Medical complication has resolved, and
Oedema has resolved, and
Weight gain of at least 20 g per day for 3 consecutive days has been achieved
Infant is clinically well and alert
Health worker is confident that the mother prepares infant formula well and gives it correctly
Access to adequate infant formula is secured
KESIMPULAN
SELURUH DUNIA BERKOMITMEN MENGIKUTI REKOMENDASI TATALAKSANA ANAK GIZI BURUK
DARI WHO
WHO TELAH MEMYEMPURNAKAN GUIDELINE NYA, SEHINGGA LEBIH MEMUNGKINKAN
KEBERHASILAN DALAM UPAYA MENANGANI KASUS ANAK GIZI BURUK
F75 DAN F100 TELAH DITAMBAH MINERAL MIX DAN MULTIVITAMIN MIX SEHINGGA KUALITAS
FORMULANYA MENJADI LEBIH BAIK
DIBAGIKAN READY TO USE THERAPEUTIC FOOD (RUTF) SEHINGGA KASUS ANAK GIZI BURUK
DAPAT LEBIH CEPAT DIPULANGKAN DAN DI RUMAH MENDAPATKAN MAKANAN DENGAN
JUMLAH KAL0RI YANG SESUAI UNTUK KEJAR TUMBUH
NAMUN DAERAH YANG TIDAK MENDAPATKAN PROGRAM INI, MASIH AKAN SULIT
MENJALANKAN TATALAKSANA GIZI BURUK WHO YANG SEMESTINYA
