severe malnutrition_ gizi print

SEVERE SEVERE MALNUTRITIOMALNUTRITIONN

Apa yang Anda Apa yang Anda pikirkan ?pikirkan ?

BAGAIMANA NASIB BAGAIMANA NASIB BANGSA ?BANGSA ?

DIAGNOSIS GIZI BURUKDIAGNOSIS GIZI BURUK

44

INDEKINDEKSS

STATUS GIZISTATUS GIZI Z- SCOREZ- SCORE

BB/UBB/U BB Lebih (Over weight)BB Lebih (Over weight) BB Normal (Normal weight)BB Normal (Normal weight) BB Rendah (Under weight)BB Rendah (Under weight) BB Sangat Rendah (Severe Under BB Sangat Rendah (Severe Under

weight) weight)

> +2 SD> +2 SD-2 SD s/d +2 -2 SD s/d +2 SDSD-3 SD s/d < -2 -3 SD s/d < -2 SDSD< -3 SD< -3 SD

TB/UTB/UPB/UPB/U

TB Jangkung (Tall)TB Jangkung (Tall) TB Normal (Normal height)TB Normal (Normal height) TB Pendek (Stunted)TB Pendek (Stunted) TB Sangat Pendek (Severe TB Sangat Pendek (Severe

stunted)stunted)

> +2 SD> +2 SD-2 SD s/d +2 -2 SD s/d +2 SDSD-3 SD s/d < -2 -3 SD s/d < -2 SDSD< -3 SD< -3 SD

BB/TBBB/TBBB/PBBB/PB

Gemuk (Fatty/obese)Gemuk (Fatty/obese) Normal (Normal)Normal (Normal) Kurus (Wasted)Kurus (Wasted) Sangat Kurus (Severe wasted)Sangat Kurus (Severe wasted)

> +2 SD> +2 SD-2 SD s/d +2 -2 SD s/d +2 SDSD-3 SD s/d < -2 -3 SD s/d < -2 SDSD< -3 SD< -3 SD

PENILAIAN STATUS GIZIPENILAIAN STATUS GIZI

(Sumber : WHO, 2000)(Sumber : WHO, 2000)

55

PENILAIAN STATUS GIZIPENILAIAN STATUS GIZI

KlasifikaKlasifikasisi

KlinisKlinis Antropometri Antropometri (BB/TB-PB)(BB/TB-PB)

Gizi BurukGizi Buruk Tampak sangat Tampak sangat kurus dan atau kurus dan atau edema edema

<-3 SD *)<-3 SD *)(bila ada edema (bila ada edema BB bisa lebih)BB bisa lebih)

Gizi Gizi KurangKurang

KurusKurus -3 SD ― -3 SD ― -2 SD -2 SD

Gizi BaikGizi Baik NormalNormal - 2 SD ― +2 SD- 2 SD ― +2 SDGizi LebihGizi Lebih GemukGemuk +2 SD+2 SD

(Buku I : Buku Bagan Tata Laksana Gizi Buruk, tahun 2005, (Buku I : Buku Bagan Tata Laksana Gizi Buruk, tahun 2005, hal. 2)hal. 2)

Recognize signs of severe Recognize signs of severe malnutritionmalnutrition

MarasmusMarasmus Visible severe wastingVisible severe wasting baggy pantsbaggy pants

KwashiorkorKwashiorkor oedemaoedema- mild (+) : both feet- mild (+) : both feet- moderate (++): both feet, lower legs, and lower - moderate (++): both feet, lower legs, and lower

armsarms- severe (+++) : generalized oedema including - severe (+++) : generalized oedema including

both feet, legs, hands, arms, and faceboth feet, legs, hands, arms, and face..

Classification of malnutritionClassification of malnutrition Clinical findings :Clinical findings :

Visible severe wastingVisible severe wasting Symmetrical oedemaSymmetrical oedema

Weight for height Weight for height - SD score < - 3 SD- SD score < - 3 SD- < 70% percentil 50- < 70% percentil 50th th NCHS WHONCHS WHO

SD score = SD score = (observed value) – (median reference value)(observed value) – (median reference value)standard deviation of reference populationstandard deviation of reference population

KKlinis dan atau antropometrislinis dan atau antropometris

DIAGNOSIS GIZI BURUK DIAGNOSIS GIZI BURUK ::1. 1. Terlihat Terlihat sangat kurussangat kurus dan atau dan atau edemedemaa, ,

dan ataudan atau2.2. BB/PBBB/PB atau atau BB/TB <-3SDBB/TB <-3SD

PENILAIANPENILAIAN

Checklist of Medical HistoryChecklist of Medical History Usual diet before current episode of illnessUsual diet before current episode of illness Breasfeeding historyBreasfeeding history Food and fluids taken in past few daysFood and fluids taken in past few days Recent sinking of eyesRecent sinking of eyes Duration and frequency of vomiting or diarrhoea, Duration and frequency of vomiting or diarrhoea,

appearance of vomit or diarrhoeal stoolsappearance of vomit or diarrhoeal stools Time when urine was last passedTime when urine was last passed Contact with people with measles or tuberculosisContact with people with measles or tuberculosis Birth weightBirth weight Milestone reached (sitting up, standing, etc)Milestone reached (sitting up, standing, etc) ImmunizationsImmunizations

Checklist of physical examinationChecklist of physical examination Weight and length or heightWeight and length or height OedemaOedema Enlargement or tenderness of liver, jaundiceEnlargement or tenderness of liver, jaundice Abdominal distension, bowel sounds, “abdominal Abdominal distension, bowel sounds, “abdominal

splash” ( a splashing sound in the abdomen).splash” ( a splashing sound in the abdomen). Severe pallorSevere pallor Signs of circulatory collapse : cold hands and feet, Signs of circulatory collapse : cold hands and feet,

weak radial pulse, diminished consciousness.weak radial pulse, diminished consciousness. Temperature : hypothermia or feverTemperature : hypothermia or fever ThirstThirst Eyes : corneal lesions indicative or vit A deficiencyEyes : corneal lesions indicative or vit A deficiency Ears, mouth, throat : evidence of infectionEars, mouth, throat : evidence of infection Skin : evidence of infection or purpuraSkin : evidence of infection or purpura Respiratory rate and type of respiration : signs of Respiratory rate and type of respiration : signs of

pneumonia or heart failurepneumonia or heart failure Appearance of faeces.Appearance of faeces.

K A S U SK A S U SPada pemeriksaan antropometri didapatkan:

Nama Umur BB PB BB/PBKeterangan

Amir 25 bulan 7,5 kg 72,5 cm <-2 SD Kurus

Budi 25 bulan 7,5 kg 76 cm <-3 SD Kurus sekali

Kadir 25 bulan 7,5 kg 71 cm <-1 SD NormalKeterangan: tiga anak di atas umur dan berat badan sama BB/U sama,

BB/PB tidak sama, hanya Budi yang Gizi Buruk.

KUNCINYA :KUNCINYA :

DETEKSI DINI !DETEKSI DINI !

1414

GANGGUAN PERTUMBUHAN

Infeksi sering Pemberian makanKurang

GAGAL TUMBUH

MENINGGAL

Lingkaran setan malnutrisi dan infeksi

MarasmusKwashiorkor

Gizi kurang

Gizi makin kurang

Infeksi lebih sering

Penyembuhan lebih lambat

Penyakit lebih berat lagi

Infeksi: sering / lama

1515

GANGGUAN PERTUMBUHAN

Beberapa penyakit yang sering terjadi dan dapat menyebabkan kegagalan kenaikan BB pada anak:

Demam Batuk pilek (ISPA) Diare akut Gangguan telinga

(otitis media)

Lama: HIV TBC Diare kronik Cacat Bawaan

1616

HAMBATAN PERTUMBUHAN TERJADI:HAMBATAN PERTUMBUHAN TERJADI:

SEBELUM PENURUNAN STATUS GIZISEBELUM PENURUNAN STATUS GIZI SEBELUM TERJADI TANDA KLINIS GIZI SEBELUM TERJADI TANDA KLINIS GIZI

KURANG/BURUKKURANG/BURUK SAAT ANAK MASIH AKTIF, TIDAK SAAT ANAK MASIH AKTIF, TIDAK TERLIHAT TERLIHAT SAKIT/KURUSSAKIT/KURUS DAPAT TERJADI PADA SEMUA STATUS DAPAT TERJADI PADA SEMUA STATUS GIZI GIZI

GANGGUAN PERTUMBUHAN

Yang dinilai adalah arah garis Yang dinilai adalah arah garis pertumbuhan.pertumbuhan.

Tidak memandang letak / posisi BB atau Tidak memandang letak / posisi BB atau PPB B dalam KMS / grafik pertumbuhan.dalam KMS / grafik pertumbuhan.

Tidak dapat digunakan untuk Tidak dapat digunakan untuk menentukan status gizi.menentukan status gizi.

Penilaian pertumbuhanPenilaian pertumbuhan

A

C

A

B

Penilaian Pertumbuhan

•Anak ditimbang tiap bulan, BB anak dicatat Bagaimana pertumbuhan anak ini ?•Pertumbuhan anak ini tidak dapat dinilai gunakan grafik pertumbuhan

•Apakah dapat menilai pertumbuhan dengan catatan ini ?

Penilaian Pertumbuhan

Apa yg terjadi pada anakdg gizi buruk ?

Schema showing the changes that occurs inSchema showing the changes that occurs insevere malnutritionsevere malnutrition

AnorexiaAnorexia InfectionInfection Starvation Starvation MalabsorptionMalabsorption NeoplasmNeoplasm

LossLoss Reduced intakeReduced intake DeficiencyDeficiency

Reduced massReduced mass Reduced requirementReduced requirement

Reduced workReduced work Efficient useEfficient use

Body compositionBody composition Physiological and metabolicPhysiological and metabolic changedchanged responses changed responses changed

InfectionInfection Loss of reserve tissue Loss of reserve tissue Spesific Spesific

deficiencydeficiency

and functional capacityand functional capacitySmall bowel Small bowel LossesLossesOvergrowthOvergrowth

LOSS OF HOMEOSTASISLOSS OF HOMEOSTASIS

Sumber : GoldenSumber : Golden

Pathogenesis of oedemaPathogenesis of oedema1. A 1. A low protein low protein intake leads to a reduction of intake leads to a reduction of

plasma albumin synthesis in the liverplasma albumin synthesis in the liverThe mechanism by which hypoalbuminemia The mechanism by which hypoalbuminemia leads to oedema leads to oedema Starling’s lawStarling’s law, according to a , according to a reduced plasma reduced plasma oncotic pressureoncotic pressure favours favours extravasation of fluid from the capillaries into the extravasation of fluid from the capillaries into the extracellular spaceextracellular space..

2.2. The The depleted of potassium may cause oedema depleted of potassium may cause oedema (JC. Waterlow)(JC. Waterlow)

Pathogenesis of oedema (cont. 3)Pathogenesis of oedema (cont. 3)

3. The fatty liver : the accumulation of drops of fat 3. The fatty liver : the accumulation of drops of fat that fills the cells of the peripheral part of the liver that fills the cells of the peripheral part of the liver lobule.lobule.The most promising theory for the cause of the The most promising theory for the cause of the intense infiltration of kwashiorkor is decreased intense infiltration of kwashiorkor is decreased hepatic synthesis of the apoprotein responsible for hepatic synthesis of the apoprotein responsible for removing fat from the liverremoving fat from the liver, parallel to the , parallel to the decrease in decrease in synthesis albuminsynthesis albumin..Unpublished experiment in Jamaica : showed that Unpublished experiment in Jamaica : showed that the uptake of labelled methionine into lipoprotein the uptake of labelled methionine into lipoprotein was even more reduced than the uptake of was even more reduced than the uptake of albumin.albumin.

Pathogenesis of oedema (cont. 4)Pathogenesis of oedema (cont. 4)4. Golden :The actions of 4. Golden :The actions of free radical produces free radical produces by by

infections or toxins, that producing infections or toxins, that producing peroxidation of peroxidation of lipidslipids, particularly the unsaturated lipids of cell , particularly the unsaturated lipids of cell membranes. membranes.

- Iron (both Fe - Iron (both Fe 2+2+ and and 3+3+ ) are potent ) are potent generators of free radicals. generators of free radicals. - Antioxidant (- Antioxidant ( carotene, vit C and E) carotene, vit C and E) are loware low

- SOD and GPX which play a particularly - SOD and GPX which play a particularly important role in important role in scavengingscavenging free radical free radical are low.are low.

Physiological basis for treatment Physiological basis for treatment of severe malnutritionof severe malnutrition

1. Cardiovascular system :1. Cardiovascular system :COP COP , SV , SV , BP , BP , renal perfusion and , renal perfusion and circulation time circulation time , plasma vol N, plasma vol NRBC RBC restrict blood transfusion to 10 ml/kg restrict blood transfusion to 10 ml/kg and and

give diuretic.give diuretic.

2. Liver :2. Liver : Synthesis protein Synthesis protein , abnormal metabolites aa , abnormal metabolites aa Metab. CH Metab. CH , gluconeogenesis , gluconeogenesis HypoglycemiaHypoglycemia Capacity to metabolize and excrete toxin Capacity to metabolize and excrete toxin Bile secretion reducedBile secretion reduced

frequent feeding, small mealsfrequent feeding, small meals Ensure that amount of CH and protein is Ensure that amount of CH and protein is

sufficientsufficient Reduce the dosage of drugsReduce the dosage of drugs Do not given iron supplements, because Do not given iron supplements, because

transferrin levels are reducedtransferrin levels are reduced

3. Genitourinary system3. Genitourinary system Glomerular filtration Glomerular filtration capacity to excrete excess acid / water capacity to excrete excess acid / water urinary phosphate output urinary phosphate output , sodium excretion , sodium excretion UTI is commonUTI is common

Prevent tissue breakdown by adequate Prevent tissue breakdown by adequate energy, energy, Sufficient high quality protein,Sufficient high quality protein,Avoid acid load ( e.g MgClAvoid acid load ( e.g MgCl2 2 ))Restrict sodiumRestrict sodium

4. Gastrointestinal system4. Gastrointestinal system Gastric acid Gastric acid , intestinal motility , intestinal motility , , pancreas atrophy, small intestinal mucosa pancreas atrophy, small intestinal mucosa

digestive enzyme digestive enzyme ,, absorption of nutrients is reduced when large absorption of nutrients is reduced when large

amounts of food are eaten.amounts of food are eaten.

give the child small, frequent feedsgive the child small, frequent feeds malabsorption of fat malabsorption of fat treatment with treatment withpancreatic enzyme.pancreatic enzyme.

5. Immune system5. Immune system Lymph glands, tonsils, thymus Lymph glands, tonsils, thymus atrophy atrophy T-cell, SIgA, complement, Acute phase T-cell, SIgA, complement, Acute phase immune immune

respons, TLC respons, TLC Hypoglycaemia & hypothermia Hypoglycaemia & hypothermia

Broad-spectrum antimicrobialBroad-spectrum antimicrobial IsolatedIsolated

6. Endocrine system6. Endocrine system Insulin level Insulin level Insulin Growth Factors 1 (IGF-1) Insulin Growth Factors 1 (IGF-1) , , cortisol level usually cortisol level usually

give the child small, frequent feedsgive the child small, frequent feeds do not give steroiddo not give steroid

7. Circulatory system7. Circulatory system Basic metabolic rate (BMR) Basic metabolic rate (BMR) 30% 30% Energy expenditure due to activity is very Energy expenditure due to activity is very lowlow Heat regulator is impairedHeat regulator is impaired

keep warm !!keep warm !! keep the temperature 25 – 30keep the temperature 25 – 30oo C, C, don’t use cold water and alcohol if don’t use cold water and alcohol if a child has fever.a child has fever.

8. Cellular function8. Cellular function Sodium pump activity Sodium pump activity Na intracellular Na intracellular , , K and Mg intracellular K and Mg intracellular Protein synthesis Protein synthesis

Give K and Mg, restricted NaGive K and Mg, restricted Na

9. Skin, muscles and glands9. Skin, muscles and glands The skin and subcutaneous fat The skin and subcutaneous fat Signs of dehydration are reliableSigns of dehydration are reliable Many glands are atrophied Many glands are atrophied dryness dryness Respiratory muscles are easily fatiguedRespiratory muscles are easily fatigued

Rehydrate the child with ReSoMal Rehydrate the child with ReSoMal oror

F-75 diet.F-75 diet.

INPUT OUTPUT

KEP BERAT

CADANGANMIKRO

NUTRIENT (-)CADANGAN ENERGI (-)

ATROFI USUS

KEKEBALAN(-)

ATROPI OTOT

DEF MIKRONUTR

HIPO-TERMI

HIPO-GLIKEMI

DIAREDEHIDRASI

INFEKSI JANTUNG

TERSEDAK

BESI VIT A K Zn GANGGUAN ELEKTROLIT

PENGELOLAAN GIZI PENGELOLAAN GIZI BURUKBURUK

Time-frame for the management of a child with severe malnutrition

ActivityActivity Initial treatment : Initial treatment : Rehabilitation Rehabilitation Follow-up:Follow-up: days 1-2 days 3-7days 1-2 days 3-7 weeks 2-6 weeks 2-6 weeks 7-26weeks 7-26

Treat of prevent:Treat of prevent: hypoglycemia ---------hypoglycemia --------- hypothermiahypothermia --------- --------- dehydrationdehydration --------- ---------Correct electrolyte ------------------------------------------Correct electrolyte ------------------------------------------ imbalanceimbalanceTreat infectionTreat infection --------------------- ---------------------Correct micronutrient Correct micronutrient deficienciesdeficienciesBegin feedingBegin feeding --------------------- ---------------------Increase feeding toIncrease feeding to -------------------------------------------- -------------------------------------------- recover lost weightrecover lost weight (“catch-up growth”)(“catch-up growth”)Stimulate emotional ----------------------------------------------------------------------Stimulate emotional ---------------------------------------------------------------------- and sensorialand sensorial developmentdevelopmentPrepare for dischargePrepare for discharge ----------------- -----------------

Without iron With iron

INITIAL TREATMENTINITIAL TREATMENT1.1. HypoglycaemiaHypoglycaemia

- Blood Glucose < 54 mg/dl or < 3 mmol/l- Blood Glucose < 54 mg/dl or < 3 mmol/l- Signs: Hypothermia (<36,5- Signs: Hypothermia (<36,5°C), lethargy, °C), lethargy, limpness, loss of conscious.limpness, loss of conscious.- caused by a serious systemic infection or - caused by a serious systemic infection or fasting for 4-6 hoursfasting for 4-6 hours- Treatment : 50 ml of 10% glucose / - Treatment : 50 ml of 10% glucose / sucrose / F-75 diet oral / NGT, sucrose / F-75 diet oral / NGT, except losing conciousness 5 except losing conciousness 5 ml/kgBW of ml/kgBW of 10% glucose iv10% glucose iv

2. 2. HypothermiaHypothermia- < 35.5°C rectal / < 35.0°C axiller- < 35.5°C rectal / < 35.0°C axiller- Treatment :- Treatment :- Kangaroo technique- Kangaroo technique- clothe the child well (icluding the head)- clothe the child well (icluding the head)- cover with a warmed blanket- cover with a warmed blanket- place an incandescent lamp over (but not - place an incandescent lamp over (but not touching), hindering the windtouching), hindering the wind

Cara KanguruCara Kanguru

3. Dehydration and septic shock3. Dehydration and septic shockDiarrhoeaDiarrhoea

- History of watery - History of watery diarrhoeadiarrhoea

- Thirst- Thirst- Recently sunken eyes- Recently sunken eyes- Weak / absent radial - Weak / absent radial

pulse (shock)pulse (shock)- Cold hands and feet - Cold hands and feet - Low of urine flow- Low of urine flow

Septic shockSeptic shock

- Hypothermia- Hypothermia- Weak / absent - Weak / absent

radialradial pulse (shock)pulse (shock)- Cold hands and feet- Cold hands and feet- Low of urine flow- Low of urine flow

Treatment of Treatment of dehydrationdehydration

DON’T GIVE ORALIT (ORS) !!DON’T GIVE ORALIT (ORS) !!

Contents of ReSoMal Contents of ReSoMal WaterWater 2 litres2 litresWHO ORSWHO ORS one litre packetone litre packetsugarsugar 50 g50 gmineral mix solutionmineral mix solution 40 ml40 ml

Give ReSoMal in the following Give ReSoMal in the following frequency, frequency, in amounts based on the child’s weightin amounts based on the child’s weight

How often to give How often to give ReSoMalReSoMal

Amount to giveAmount to give

Every 30 minutes for Every 30 minutes for first 2 hoursfirst 2 hours

5 ml/kg body weight5 ml/kg body weight

Alternate hours for up to Alternate hours for up to 10 hours10 hours

5-10 ml/kg*5-10 ml/kg*

The amount offered in this range should be based on the child’s willingness to drink and the amount of ongoing losses in the Stool. F-75 is given in alternate hours during this period until theChild is rehydrated.

TERAPI GIZI PDTERAPI GIZI PDANAK GIZI BURUKANAK GIZI BURUK

4444

TUJUAN TERAPI GIZI TUJUAN TERAPI GIZI ANAK GIZI BURUK :ANAK GIZI BURUK :

Hipoglikemia Hipoglikemia HipotermiaHipotermiaDehidrasi Dehidrasi Infeksi Infeksi Kurang elektrolit (K, Mg, Cl, Zn, Cu)Kurang elektrolit (K, Mg, Cl, Zn, Cu)Kelebihan NatriumKelebihan Natrium

MAKANAN YANG DIBERIKAN : Tinggi energi Tinggi protein STATUS GIZI NORMALCukup vitamin

4545

PRINSIP DASARPRINSIP DASAR

SISTIM PENCERNAAN LEMAH :SISTIM PENCERNAAN LEMAH : Kerusakan mukosa usus & enzim Kerusakan mukosa usus & enzim

PEMBERIAN MAKANAN :PEMBERIAN MAKANAN : Secara teratur (selama 24 jam)Secara teratur (selama 24 jam) Bertahap (cair, lembik, padat)Bertahap (cair, lembik, padat) Porsi kecil & sering Porsi kecil & sering Melalui fase stabilisasi, transisi & rehabilitasiMelalui fase stabilisasi, transisi & rehabilitasi Tidak boleh tergesa2 menaikkan berat badanTidak boleh tergesa2 menaikkan berat badan Selalu dipantau dan dievaluasiSelalu dipantau dan dievaluasi

4646

TERAPI GIZI FASE STABILISASI, TRANSISI DAN

REHABILITASI SERTA MAKANAN FORMULA YANG DIPERLUKAN

4747

A. FASE A. FASE STABILISASISTABILISASI

MEMBERIKAN MAKANAN AWAL : MEMBERIKAN MAKANAN AWAL : Agar kondisi anak stabil Agar kondisi anak stabil

TANPA EDEMA :TANPA EDEMA : Cairan : 130 ml/kg BB Cairan : 130 ml/kg BB Energi : 80 – 100 Kkal/kg BB Energi : 80 – 100 Kkal/kg BB Protein : 1 – 1,5 g /kg BBProtein : 1 – 1,5 g /kg BB

DENGAN EDEMA :DENGAN EDEMA : Cairan : 100 ml/kg BBCairan : 100 ml/kg BB Energi : 80 – 100 Kkal/kg BBEnergi : 80 – 100 Kkal/kg BB Protein : 1 – 1,5 g/kg BBProtein : 1 – 1,5 g/kg BB

(Buku II: Bagan Tatalaksana Anak Gizi Buruk, tahun (Buku II: Bagan Tatalaksana Anak Gizi Buruk, tahun 2006, hal. 13)2006, hal. 13)

4848

A. FASE STABILISASI A. FASE STABILISASI (LANJUTAN (LANJUTAN ..)..)

F75/MODIFIKASI F75/MODISCO ½ F75/MODIFIKASI F75/MODISCO ½

Cukup energi Cukup energi Cukup Protein Cukup Protein Cukup cairanCukup cairanCukup elektrolit Cukup elektrolit

4949

TABEL PETUNJUK PEMBERIAN F-75 UNTUK TABEL PETUNJUK PEMBERIAN F-75 UNTUK ANAK GIZI BURUK TANPA EDEMAANAK GIZI BURUK TANPA EDEMA

BB BB anakanak(kg)(kg)

Volume F75/ 1 kali makan Volume F75/ 1 kali makan (ml)(ml)aa))

TotalTotal 80% dari 80% dari total total aa))

Setiap 2 Setiap 2 jam jam bb ) )(12x mkn)(12x mkn)

Setiap 3 Setiap 3 jam jam cc))(8 x (8 x mkn)mkn)

Setiap 4 Setiap 4 jamjam(6 X (6 X mkn)mkn)

Sehari Sehari (130 (130

ml/kg)ml/kg)

Sehari Sehari (minimum(minimum

))

2.02.0 2020 3030 4545 260260 2102102.22.2 2525 3535 5050 286286 2302302.42.4 2525 4040 5555 312312 2502502.62.6 3030 4545 5555 338338 2652652.82.8 3030 4545 6060 364364 2902903.03.0 3535 5050 6565 390390 3103103.23.2 3535 5555 7070 416416 3353353.63.6 4400 6060 8800 446688 375375

Buku I : Buku Bagan Tata Laksana Anak Gizi Buruk, hal 19

5050

TABEL PETUNJUK PEMBERIAN F-75 TABEL PETUNJUK PEMBERIAN F-75 UNTUK ANAK GIZI BURUKUNTUK ANAK GIZI BURUK

YANG EDEMA BERAT YANG EDEMA BERAT

BB BB anakanak(kg)(kg)

Volume F75/ 1 kali makan Volume F75/ 1 kali makan (ml)(ml)aa))

TotalTotal 80% dari 80% dari total total aa))

Setiap 2 Setiap 2 jam jam bb ) )(12 x (12 x mkn)mkn)

Setiap 3 Setiap 3 jam jam cc))(8 x mkn)(8 x mkn)

Setiap 4 Setiap 4 jamjam(6 X (6 X mkn)mkn)

Sehari(10Sehari(100 ml/kg)0 ml/kg)

Sehari Sehari (minimum)(minimum)

3.03.0 2525 4040 5050 300300 2402403.23.2 2525 4040 5555 320320 2552553.43.4 3030 4545 6060 340340 2702703.63.6 3030 4545 6060 360360 2902903.83.8 3030 5050 6565 380380 3053054.04.0 3535 5050 6565 400400 3203204.24.2 3535 5555 7070 420420 3353354.44.4 3355 5555 7755 444400 353500

Buku I : Buku Bagan Tata Laksana Anak Gizi Buruk, hal 20

5151

B. FASE TRANSISI B. FASE TRANSISI FASE TRANSISI FASE TRANSISI (F100/Modifikasi/Modisco): (F100/Modifikasi/Modisco):

Mempersiapkan anak untuk menerima Mempersiapkan anak untuk menerima cairan cairan

dan energi lebih besar dan energi lebih besar Cairan : 150 ml/kg BB Cairan : 150 ml/kg BB Energi : 100 – 150 Kkal/kg BB Energi : 100 – 150 Kkal/kg BB Protein : 2 – 3 g /kg BBProtein : 2 – 3 g /kg BB

(Buku II: Bagan Tatalaksana Anak Gizi Buruk, tahun (Buku II: Bagan Tatalaksana Anak Gizi Buruk, tahun 2006, hal. 13)2006, hal. 13)

5252

TABEL PETUNJUK PEMBERIAN F-100 TABEL PETUNJUK PEMBERIAN F-100 UNTUK ANAK GIZI BURUKUNTUK ANAK GIZI BURUK

BB anak BB anak (kg)(kg)

Batas volume Batas volume pemberian makan F-pemberian makan F-

100100Per 4 jam (6 kali Per 4 jam (6 kali

sehari)sehari)

Batas volume Batas volume pemberian F100 pemberian F100

dalam seharidalam sehari

Minimum Minimum (ml)(ml)

MaksimuMaksimum (ml)m (ml)

MinimumMinimum150 150

ml/kg/hariml/kg/hari

MaksimuMaksimum 220 m 220

ml/kg/hariml/kg/hari

2.02.0 5050 7575 300300 4404402.22.2 5555 8080 330330 4844842.42.4 6060 9090 360360 5285282.62.6 6565 9595 390390 5725722.82.8 7070 105105 420420 6166163.03.0 7755 111010 445500 666060

Buku I : Buku Bagan Tata Laksana Anak Gizi Buruk, hal 21

5353

TAHAP AKHIR STABILISASI :TAHAP AKHIR STABILISASI : F 75 interval 4 jam (dpt dihabiskan) F 75 interval 4 jam (dpt dihabiskan) diganti diganti F100 setiap 4 jam dg dosis sesuai BB F100 setiap 4 jam dg dosis sesuai BB

tabel F 75 selama 2 haritabel F 75 selama 2 hari PADA HARI KE 3 :PADA HARI KE 3 :

F100 dgn dosis sesuai BB dgn tabel F100,F100 dgn dosis sesuai BB dgn tabel F100, 4 jam berikut dosis naik 10 ml 4 jam berikut dosis naik 10 ml dilanjutkan dilanjutkan

tetapi tak melebihi dosis maxtetapi tak melebihi dosis max PADA Hari ke 4 :PADA Hari ke 4 :

F100 dosis sesuai BB berkisar min-max sampaiF100 dosis sesuai BB berkisar min-max sampai 7-14 hr, dilanjutkan rehabilitasi 7-14 hr, dilanjutkan rehabilitasi

FASE STABILISASI & TRANSISI FASE STABILISASI & TRANSISI ((lanjutan)lanjutan)

C. FASE REHABILITASIC. FASE REHABILITASI FASE REHABILITASI FASE REHABILITASI

(F135/Makanan bayi/anak):(F135/Makanan bayi/anak): - - Mengejar pertumbuhan Mengejar pertumbuhan Cairan : 150 – 200 ml/kg BBCairan : 150 – 200 ml/kg BB Energi : 150 – 220Energi : 150 – 220 Kkal/kg BBKkal/kg BB Protein : 3– 4 g/kg BB Protein : 3– 4 g/kg BB : Diberikan setelah anak sudah bisa makan Makanan padat yang diberikan dibedakan menurut

BB anak : BB < 7 kg, diberikan makanan bayi (lumat)

BB > 7 kg, diberikan makanan Anak (lunak)- Pada fase ini anak dapat dirawat di rumah dan

pemantauan di posyandu.

FASE REHABILITASI FASE REHABILITASI (lanjutan ...)(lanjutan ...)

CONTOH : Kebutuhan energi seorang balita dgn berat badan 6 kg pada fase rehabilitasi adalah : “6 kg x 200 kkal/kgBB/hr = 1200 kkal/hr”

Kebutuhan energi tersebut dapat dipenuhi :

F-135 : 3 x 100 cc 3 x 135 kkal = 405 kkal

Makanan lumat/lembik 3 x 250 kkal = 750 kkal

Sari buah 1 x 100 cc 1 x 45 kkal = 45 kkal + Total = 1.200 kkal

Buatlah :Buatlah :

Grafik Grafik Pemantauan Pemantauan Berat BadanBerat Badan

Formulir Formulir Pemantauan Pemantauan Berat BadanBerat Badan

SAMPAI KAPAN MERAWAT GIZI SAMPAI KAPAN MERAWAT GIZI BURUK ?BURUK ?

Jawab : Sampai sembuh !Kriteria sembuh:

anak menjadi gizi baik !(BB/PB > -1 SD WHO 1999)(bukan masuk KEP sedang)

Waktu yang dialokasikan: 26 minggu = 6 bulan

Criteria for transfer to a Criteria for transfer to a nutrition rehabilitation centrenutrition rehabilitation centre Eating wellEating well Mental state has improved : smiles, responds Mental state has improved : smiles, responds

to stimuli, interested in surroundingsto stimuli, interested in surroundings Sits, crawls, stands or walks (depending on Sits, crawls, stands or walks (depending on

age)age) Normal temperature (36,5 – 37,5 C)Normal temperature (36,5 – 37,5 C) No vomiting or diarrhoeaNo vomiting or diarrhoea No oedemaNo oedema Gaining weight : > 5 g/kg of body weight per Gaining weight : > 5 g/kg of body weight per

day for 3 successive days.day for 3 successive days.

KRITERIA SEMBUHKRITERIA SEMBUH1.1. ANAKANAK

a. BB/PB > -1 SDa. BB/PB > -1 SDb. Nafsu makan membaikb. Nafsu makan membaikc. Tidak ada penyakit infeksic. Tidak ada penyakit infeksi

2.2. IBU/ORTUIBU/ORTUa. Tahu merawat anaknyaa. Tahu merawat anaknyab. Tahu menyiapkan makananb. Tahu menyiapkan makananc. Tahu memberi stimulasic. Tahu memberi stimulasid. Tahu memberi obatd. Tahu memberi obat

3.3. PETUGASPETUGASMampu melakukan Mampu melakukan follow-upfollow-up

Andaikan aku dulu spt dia.., Saat ini aku tdk spt ini…

Help me please …

Thank youSelamat belajar,Engkaulah harapanku….

qodrisantosa@gmail.comqodrisantosa@gmail.com