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02/04/2016

MALNUTRITION

Sri S Nasar
UKK Nutrisi dan Peny.Metabolik
IDAI

The top priorities of the action to prevent


malnutrition are to:

 Focus on the window of opportunity from


preconception to around 24 months of age, the
critical period when the foundation for life long
health is set. 1000 days early life

 Build awareness, institutional capacity and


leadership at national, sub-national, community
and global levels for accelerating action on
nutrition.

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Pediatric Nutrition Care


and IFP

Current Approach
‘’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’

115mm

350 kcal +
170-200 kcal /kg 15 g protein

OTP SFP

<115mm

SC/TFC/ITP
Valid International 2006
The 10 steps

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Treatment Option for Moderate and Severe


Acute Malnutrition
Treatment Options
Moderate and Severe Acute
Malnutrition WITH INPATIENT Facility
COMPLICATION(s) (Inpatient Therapeutic
SAM in babies <6 months Programme = ITP)
with/without complication(s)
or BW<4 kg
SAM without complication OUTPATIENT Therapeutic
Programme (=OTP)
MAM without complication Supplementary Feeding
Programme (=SFP)

Inpatient care : GENERAL TREATMENT


“The 10 steps” (WHO,2000)
No Intervention Stabilization Transition Rehabilitation Follow-up
d.1-2+ d.3-7+ wk 2-6 wk 7-26
1. Treat/prevent
hypoglycemia
2. Treat/prevent
hypothermia
3. Treat/prevent
dehydration
4. Correct electr.
imbalance
5. Treat infection
6. Correct micro- without Fe + Fe
nutrients defic.
7. Begin feeding F-75
8. Increase feeding F75F100
F100
9. Stimulation
10. Prepare for
discharge

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FEEDING
STABILIZATION TRANSITION REHABILITATION

F75 F100

F100+solid food
F75 OR:
F100 /
RUTF F100+ RUTF
E: 80-100 kkal/kgbb/h
P: 1-1.5 g/kgbb/h E: 100-150 kkal/kgbb/h E:150-220 kkal/kgbb/h
Cairan : 130 ml/kgbb/h P: 2-3 g/kgbb/h P: 4-6 g/kgbb/h
Cairan : 150 ml/kgbb/h Cairan : bebas

INPATIENT CARE (ITP) OUTPATIENT CARE (OTP)

WHO vs PNC

♀, 22bln, 6.000 g, 73 cm  BB/TB: 68.2%, <-3SD,


H-A : 11 bln, BBi : 8.800 g

WHO 2000 PNC


Target : 8.0 kg (-1 SD) Target : 8.8 x (110-120) kkal=
Stab: 80-100 kkal/kgbb/h 968-1056 kkal
 6x80-100 kkal= 480-600 kkal Awal : 50-75% =
Transisi: 100-150 kkal/kgbb/h (484-528) kkal
 6x100-150kkal= 600-900 kkal (726-792) kkal
Rehab: 150-220 kkal/kgbb/h Final : 8.8 x (110-120) kkal=
6x150-220kkal= 900-1320 kkal 968-1056 kkal

BB aktual BB ideal

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F75 /starter F100/catch-up RUTF


Dried skimmed milk (g)* 25 80 90
Sugar (g) 100 50 65
Vegetable oil (g) 30 (=35 ml) 60 (=70 ml) 85 (= 95ml)
Electr/mineral sol.(ml) 20 20 20
Water: make up to 1000 ml 1000 ml ---
Contents per 100 ml 100 ml 100 g
Energy (kcal) 75 100 520-550
Protein (g) 0.9 2.9 12.5-15
Lactose (g) 1.3 4.2 ….
Potassium (mmol) 4.0 6.3 300-600 mg
Sodium (mmol) 0.6 1.9 290 mg max
Iron (-SO4, mg) - - 10-14 mg
Zinc (mg) 2.0 2.3 11-14
Magnesium (mmol) 0.43 0.73 80-140 mg
Copper (mg) 0.25 0.25 ….
% energy from protein 5 12 +10-12
% energy from fat 36 53 +45-60
Osmolarity (mOsmol/L) 333 419 ….

Example : A, girl, 2 yrs, BW : 6 kg

Stab req F75 F100 RUTF*


Energy,kkal 100/kg ~ 600 585 600 780 1.2 sachet

Protein,g 1-1.5/kg ~ 6-9 7 17.4 22.6 15-18

Fluid,ml 130ml/kg ~ 780 780 600 780 --


(2.5%~3ml)
Zn, mg 2 mg/kg ~ 12 15.6 13.8 18 13.2-16.8

Fe, mg --- --- --- --- 12 - 16.8

K+, mg 160mg/kg ~ 960 1120 1440 1840 1320-1680

* : 1 sachet = 500 kcal


Most suitable for
stabilization phase

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Composition F75 F100 Pediasu Nutren Pepta F.Prem Infatrini Nutrini


re 1.0 Jr men 1.0 SGM 1.0
Energy/Kcal 750 1000 1000 1027 1000 810 1010 1000
Protein/g 9 29 30 30.6 30 25 26 28
Fats /g 20/30 55.5 50 40.3 38.4 43 54 44
CHO/g 133.5 99 107 136.8 136 8 103 123
Vitamin
Vit A/mcg 1500 1710 2580 iu 1540iu 3320 iu 270 810 410
Vit D/mcg 30 30.4 320 iu 418 iu 600 iu 636 17 10
Vit E/mg 22 38 23 iu 15.4 iu 28 iu 12 12 13
Vit B1/mg 0.7 1.1 2.7 0.62 2.4 1,03 1,5 1.5
Vit B2/mg 2 3.2 2.1 0.81 2 1,70 1,5 1.6
Vit B3/mg 10 17 6.2 9.6 9 12 11
Panthot.ac/mg 3 5.8 7 3.1 10 5 4,5 3.3
Vit B6/mg 0.7 1.1 2.6 0.81 2.4 1,02 0,6 1.2
Vit B12mcg 1 3.4 3 1.5 6 2 4,1 2.5
Folic acid/mcg 350 399 220 205 289.60 80 150 150
Biotin/mcg 100 123.5 37 15 200 127 23 40
Vit C/mg 70? 100 100 81 100 30 120 100
Vit K/mcg 40 40 38 42 60 84 67 40

Composition F75 F100 Pedia Nutren Pepta- F.Prem Infatri ni Nutrini


sure 1.0 Jr men 1.0 SGM 1.0
Minerals
Ca/mg 320 912 980 917 1120 1030 800 600
P/mg 240 760 610 612 840 652 400 500
K/mg 1270 2090 1300 1100 1320 843 930 1100
Na/mg <130 456 460 488 460 398 250 600
Mg 100 122 200 117 200 103 80 110
Fe <0.3 0.6max 14 10.3 14 8 10 10
Zn/mg 20.5 22.4 10 10.3 10.8 6 9 10
Cu/mg 2.8 2.6 1.020 0.81 1 0,75 O,60 0.810
Se/mcg 47 47 30 26 30 8 20 30
I/mcg 77 152 96 130 100 207 150 100
Osmolarity 154 360 (Ped1.5: 350 260 -- 350 235
dil 238 370)

LSRO : PRSL max for normal children : 223 mOsm/L


Formula lain tidak dapat digunakan pd fase stabilisasi dan transisi 
dan RUTF fase rehabilitasi dengan suplementasi 10 mg Zn dan
+ 1000mg K per 1000 ml formula

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SAM < 6 months

• Stabilization phase : F75.


Diluted F100 : inappropriate due to :
- marginal PRSL (238 mOsm/L)
- higher protein, Na, lactose
• Rehabilitation phase : F100 should not be used due to
high PRSL (360 mOsm/L)  alternatives : expressed
breastmilk, infant formula or diluted F100
• Breastfeeding : unsuccessful deaths.
Recommendation : therapeutic feeding + relactation.

SAM Adolescents (10 – 18 yrs)


• Criteria : - BMI < P5 or nutritional oedema +
- Stunting : BMI < P3 or <-2SD (NCHS)
• Initial treatment :
– Same formula F75, F100 (+ mineral + vitamin)
– Energy : Age, yrs Daily Energy Volume, ml/kg/h
kcal/kg F75 F100
7 - 10 75 4,2 3,0
11 - 14 60 3,5 2,5
15 - 18 50 2.8 2,0

• Rehabilitation : - appetite +
- F100  Regular diet + F100
• Discharge : - appetite ++, BW , medical problem resolves
- give suppl  BMI > P5

WHO 2000; Management of severe malnutrition: a manual for ........

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Summary of suggested criteria for admission for SAM used


in children five years or older, adolescents and adults

Age group Criteria for therapeutic admission


yrs
5 -9 MUAC < 129 mm, and / or BMI for age < -3 z-score,
and /or Bilateral pitting oedema
10 -18 MUAC < 160 mm, and / or BMI for age < -3 z-score,
and /or Bilateral pitting oedema
> 18 BMI < 16 (kg/m) and / or MUAC < 185 mm‡ and / or
Bilateral pitting oedema

Note: ‡ There is no international agreement on the MUAC cut-off for adolescents and
adults. Available published data for adults suggests < 160 mm but this is currently
considered too low in non-famine contexts (including in the context of HIV/AIDS) and
cut-offs of < 180 mm or < 185 mm are most widely used by agencies

Sumber : UNICEF Programme Guidance Document ; Management of Severe Acute Malnutrition


in children: Working towards results at scale, 2015

Anthropometric criteria to identify SAM


Indicator SAM
Infants less than 6 months
W/L < - 3 Z-Score
Oedema Present
Other signs Too weak to suckle or feed
6 months to 10 yrs
W/H Z-Scores < -3 Z-Score
MUAC (6 - 59 months only) < 11.5 cm
Oedema Present
Adolescent (10 - 18 yrs)
MUAC < 16 cm
Oedema present
*Anthropometric criteria based on WHO Child Growth Standards (2006)
Sumber : National Guideline for Integrated Management of Acute Malnutrition, Version 1: June 2009.
MINISTRY OF PUBLIC HEALTH & SANITATION, Kenya

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Weight gain : - < 5 g/kg/d : poor


- 5-10 g/kg/d : good / sufficient
- > 10 g/kg/d : excellent/satisfactory

• ♀, 22bln, 6.000 g, 73 cm, target BB : 8.000 g (- 1SD) d : 2.000 g


• Golden : utk replesi 1 gram jaringan tubuh dibutuhkan 5 kkal*
• Bila kenaikan BB 10 g/kgbb/h : 6 x 10 g = 60 g/h  Dibutuhkan
waktu utk mencapai -1SD : 2000/60 x 1 hari = 33 hari

• Tambahan Energi yg dibutuhkan : 60 g x 5 kkal = 300 kkal/h (di luar


utk infeksi, malabsorpsi, dll)
• Bila kebutuhan Energi dihitung spt anak normal (100 kkal/kgbb/h)
 perlu 6 kg x 100 kkal = 600 kkal/hari Minimum
 total energi : 600 + 300 kkal = 900 kkal/hari = 150 kkal/kgbb/h

*Golden MH, Briend A, Grellety Y. Supplementary feeding programmes with


particular reference to refugee populations. Eur J Clin Nutr 1995;49:137-45.