Tata

Laksana Anak Gizi Buruk

(severe wasting)

• Dr. Moretta Damayanti, M.Kes, SpA(K)

• Pengurus UKK Nutrisi dan Penyakit Metabolik
• Ikatan Dokter Anak Indonesia
• 2023

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 Outlines

• Memahami berbagai masalah gizi

• Memahami tanda dan gejala gizi buruk
• Memahami prinsip-prinsip tata laksana gizi buruk

@Moretta2023 2
 Malnutrition pathway

Pencegahan
sekunder
Intervensi dini Pencegahan tersier,
Pencegahan Manajemen penyakit,
progresifitas Meminimalkan sequele.

Gizi baik Weight Wasting Stunting

faltering
Pencegahan tersier
Populasi Sehat Manajemen penyakit
Promosis Pencegahan
Kesehatan dan progresifitas
pencegahan
primer
Akut (3 bulan) Kronis (3 bulan)
 Acute malnutrition affects
>2 million children in Indonesia
Definisi Wasting
Berat badan menurut panjang badan atau tinggi
7,7% badan yang <-2 SD pada kurva standard WHO
untuk anak <5 tahun.

SSGI 2022

Wasting prevalence in Indoneisa, 2018- 2022 (<5 years old)

*Total population: 275.773.800

SSGI, 2022. 4
WHO growth chart, 2006
Gizi buruk/SAM/Severe wasting

Menurut WHO (2013), gizi buruk dibedakan menurut

umur anak:
Usia kurang dari 6 bulan:
BB/PB kurang dari -3 SD (Z<-3 SD), atau edema
bilateral yang bersifat pitting (tidak kembali setelah
ditekan).
Usia 6-59 bulan:
BB/PB (atau BB/TB) kurang dari -3 SD (Z<-3 SD), atau
LiLA <11,5 cm, atau edema bilateral yang bersifat
pitting.
 The Guidelines

1999 (<5 years old, 2003 (<5 years old, 2013 guideline has included management <6 and 6-59 months old (evidence-based
inpatient treatment) inpatient treatment) update); inpatient à outpatient treatment.

2011 (<5 years old, 2013 (<5 years old,

inpatient treatment) inpatient treatment)
 Alur penapisan balita gizi buruk/kurang dan jenis layanan yang diperlukan

Kelompok
Khusus
Balita > 6
bulan dengan
berat badan <
4 kg
Referral systems

Type A hospitals

Type D àC àB
hospitals
Community
health center
Pustu? (Puskesmas)
Midwives?
Cadre?
The hospital(s): ITP and OTP
• Guidelines and SOPs
• Nutrition supply
• Non-infectious ward
• Standard anthropometric measuring
devices
• Good water supply
• Clean pantries
• etc
Patient flow: ITP
Personnel:
• Medical students and residents
• Pediatric Consultants
Outpatient • Pediatric Nutrition Care Team (Doctors,
clinic/ER Nurses, Dieticians, Pharmacists)

Inpatient wards
(non-infection)

NMD div +/-

other div
Case
Patient care:
AN, F, 24 m/o, weight 10 kgs, MUAC 9 cm
Diagnosis: Wilms tumour + SAM
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 Fase stabilisasi
Pada fase ini diprioritaskan penanganan kegawatdaruratan yang
mengancam jiwa:
1. Hipoglikemia =kadar gula darah < 3 mmol/L atau < 54 mg/dl
2. Hipotermia = suhu aksilar kurang dari 36oC. Jika hipotermi
bersamaan dgn hipoglikemiaà infeksi berat.
3. Dehidrasi dan gangguan keseimbangan elektrolit. Semua balita gizi
buruk dengan diare/penurunan jumlah urin dianggap mengalami
dehidrasi ringan. Hipovolemia dapat terjadi bersamaan dengan
adanya edema.
4. Infeksi. Balita gizi buruk seringkali menderita berbagai jenis infeksi,
namun sering tidak ditemukan tanda/gejala infeksi bakteri, seperti
demam. Karena itu, semua balita gizi buruk dianggap menderita
infeksi pada saat datang ke faskes dan segera diberi antibiotik.
 Routine medicines
Give routine medicines to all children admitted to OTP (at
health facility) even if the child appears well

Rationale:
Children with SAM have weak immune systems and may not
show symptoms of infection until they begin to recover from
SAM
Routine medicines:
• Antibiotics on admission
• Deworming at 2nd OTP visit
 Antibiotics
• A course of antibiotics is given to the child at
admission.
• The first dose should be given at the OTP, and
treatment continues at home.
• The caregiver should be advised how to give the
antibiotic to the child.
• First line antibiotic is Amoxicillin.
• If signs and symptoms of infection continue beyond
the initial treatment, refer to ITP

Amoxicillin: 40-45 mg/kg orally every 12 hours – for 7 days

(guideline says 15mg/kg every 8 hours for 5 days)
 Infection Treatment
Severe wasting with complications (hypoglycemia,
hypothermia or the child looks lethargic or sickly) or
any other medical complication:

Ampicillin (50 mg/kg IM or IV every 6 h) for 2 days,

then oral Amoxicillin (25–40 mg/kg every 8 h for 5 days)

Gentamicin (7.5 mg/kg IM or IV) once a day for 7 days.

Consider newer regimens:
• ampicillin plus gentamicin for 7 days if no symptoms of infection
• ceftriaxone for 7 days if symptoms of infection
• can change to oral amoxicillin to finish 7 days if recovers quickly
 Dehydration Treatment
• Whenever possible, rehydration for severely malnourished
children should be attempted by mouth.
• Do not use the IV route for rehydration except in cases of shock.
Give fluid orally or by NGT, much more slowly than you would
when rehydrating a well-nourished child.
• Severely malnourished children are deficient in potassium and
have abnormally high levels of sodium, so the standard WHO
ORS should generally not be used.
• Give ReSoMal (Rehydration Solution for Malnutrition). Where
ReSoMal is not available, a modified, half-strength standard
WHO ORS may be used with added potassium and glucose.

Assume all children with watery diarrhea or reduced urine have

some dehydration.
 Ingredients for ReSoMal
(Rehydration Solution for Malnutrition)
Ingredient Amount
Standard WHO ORS 1 small sachet
(normally for 200 mL water)
Sugar 10 g
Mineral Mix solution** 8 mL
Added water up to 400 mL
** 1 sachet (8g): 1.792g KCl; 0.648g trisodium citrate dihydrate;
0.608g MgCl; 0.066g Zn acetate; 0.011g CuSO4.

Mineral mix solution: dissolve 1 sachet mineral mix with boiled

water up to 20 mL

If mineral mix is not available, another recipe:

2 liters water, 5 small packets (or 1 large packet) ORS, 50 g sugar, 50mL of 7.4% KCl
 Electrolyte imbalance treatment
All severely malnourished children have electrolyte imbalance:
Relatively low potassium and magnesium and high sodium
which may take two weeks or more to correct.
Oedema is partly a result of electrolyte imbalance. Do not
treat oedema with a diuretic.
Give mineral mix solution (which give extra potassium 3-
4mmol/kg per day and extra magnesium 0.4-0.6mmol/kg per
day)à added to F75 or F100 and ReSoMal

Properly made F75/F100/ReSoMal will have corrections for electrolyte issues.

 Correcting Micronutrient
Deficiencies
Severely malnourished children have vitamin and mineral
deficiencies.

Give vitamin and mineral supplementation to provide the

daily requirement, unless standard WHO therapeutic
foods (fortified with vitamin and mineral) are given.

Do not give iron during stabilization phase. Wait until the

child has a good appetite and starts gaining weight
(usually after 2-3 days in rehabilitation phase). Iron can
make infections worse.
Properly made F75/F100/ReSoMal will have corrections for micronutrients.
 Deworming
• Pyrantel Pamoate, albendazole, or mebendazole is provided
at the second visit

• Only given to children aged one year and above

• If child was dewormed in the last 6 months (National

Campaign February and August), do not have to give again but
is a good idea to give again so as to maximize benefit and
keep program simple

• If the caregiver cannot remember if the child was dewormed

in the last six months, give a single dose at the second visit
 Vitamin A, Zinc, Iron, Folic Acid
Vitamin A:
• Children receiving RUTF do not need a vitamin A supplement as RUTF
contains enough vitamin A.
• Vitamin A is only during emergencies or measles outbreaks or if the
child has eye findings or recent measles infection (children with signs
of severe vitamin A deficiency should be referred to ITP)
Zinc
• Children receiving RUTF do not need a zinc supplement, even if the
child has diarrhea, as RUTF contains enough zinc.

Iron and Folic Acid

• Children receiving RUTF do not need iron and folic acid supplement.
 Vaccination
• The child’s vaccination status is checked on
admission
.. and recorded on the OTP Admission Card

• If the child’s vaccinations are incomplete, refer to EPI

to complete them

• If the child has not been vaccinated for measles

(child age ≥ 9 month), the vaccination is given to the
child on the immunization day at the Posyandu or
Puskesmas after the fourth OTP visit
 Pemberian diet
Segera diberikan bila tidak ada kegawatdaruratan
Dilakukan secara bertahap mulai dari F-75 (rendah protein, rendah laktosa)
à F-100 / RUTF
 Fase transisi
• Transisi ke layanan rawat jalan (bila
tersedia)
• F-100/RUTF dalam jumlah cukup untuk meningkatkan BB dan
kesembuhan
• Pemulihan bisa lebih lambat
• Stimulasi tumbuh kembang

• Transisi ke layanan rawat inap fase

rehabilitasi (bila layanan rawat jalan tidak
tersedia), jika:
• Jika ≥90% jatah F-100 dapat dihabiskan
• Tidak ada masalah pada pemantauan
 Fase rehabilitasi
• Hindari terjadinya gagal jantung
• Gejala dini gagal jantung: nadi cepat, nafas cepat.
• Tanda bahaya: bila pernafasan meningkat 5x/menit dan
nadi naik 25x/menit yang menetap selama 2x
pemeriksaan interval 4 jam berturut-turut
• Bila terjadi gagal jantung, maka:
• Volume makan dikurangi (100 ml/kgBB/hari tiap 2 jam
• Volume makan ditingkatkan perlahan (115 ml/kgBB/hari selama
24 jam berikutnya, lalu 130 ml/kgBB/hari selama 48 jam
berikutnya, selanjutnya naik 10 ml/kali.
• Telusuri dan atasi penyebab
 Penilaian Kemajuan
à kecepatan kenaikan BB setelah fase transisi dan mendapat F-
100/RUTF

• Timbang BB setiap pagi sebelum makan. Hitung dan catat

kenaikan BB setiap 3 hari (g/kgBB/hari)
• Kenaikan BB:
• Kurang, bila <5 g/kgBB/hari à penilaian ulang lengkap
• Sedang, 5-10 g/kgBB/hari à periksa target asupan
terpenuhi/tidak, mungkin ada infeksi yang tidak terdeteksi
• Baik, bila >10 g/kgBB/hari
• Atau kurang jika kenaikan BB <50 g/kgBB/minggu (penilaian
ulang) dan baik jika ≥50 g/kgBB/minggu.
Tata Laksana Kelompok Khusus

1. Fase stabiliisasi
2. SF (tanpa edema) 130
ml/kgBB/hari, dinaikkan
bertahap.
3. Fase transisi: menaikkan
ASI/SF sesuai ketersediaan
ASI
4. Fase rehabilitasi: kenaikan
BB absolut 20 g/hari
selama 5 hari berturut-
turut. Dengan ASI saja/SF.

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Management
• F-75 + mineral mix
• F-100 + mineral mix
• Pemberian antibiotika dan mikronutrien
• LOS: 3 weeks
• Discharged with oral nutrition supplement (1 Kcal/ml)
• Readmission due to chemotherapy
After 2 months treatment
In brief…
• Pedoman tata laksana anak gizi buruk terus disempurnakan menurut
evidence-based medicine
• Prinsip utama TAGB meliputi 4 fase (rawat jalan dan rawat inap)
mencakup 10 Langkah yang simultan
• Perlu penguatan sistem temuan kasus berbasis masyarakat dan sistem
rujukan mulai dari posyandu hingga ke RS
• Perlu penguatan sistem rujuk balik dan pemantauan lanjutan setelah
pasien-pasien menyelesaikan perawatan di RS

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