Principles of managementChildren wi

Principles of management
Children with severe malnutrition are often seriously ill when they first present for
treatment. Wasting, anorexia and infections are common. Wherever possible, severely
malnourished children should be referred to hospital. Successful initial management
requires frequent, careful clinical evaluation and anticipation of common problems so
they can be prevented, or recognized and treated at an early stage. The physiology of
malnourished children is seriously abnormal; how this affects their management is
summarized in Appendix 3.
Recently admitted children should be kept in a special area where they can be
constantly monitored. Because they are very susceptible to infection, they should, if
possible, be isolated from other patients. The child should not be kept near a window or
in a draught, and windows should be closed at night. The child should be properly
covered with clothes, including a hat, and blankets. Washing should be kept to a minimum
and, if necessary, done during the day. When the child is washed he or she must be
dried immediately and properly. The room temperature should be kept at 25–30 °C (77–
86 °F). This will seem uncomfortably warm for active, fully clothed staff, but is necessary
for small, immobile children who easily become hypothermic.
Intravenous infusions should be avoided except when essential, as for severe dehydration
or septic shock. Intramuscular injections should be given with care in the
buttock, using the smallest possible gauge needle and volume of fluid.
Initial treatment begins with admission to hospital and lasts until the child’s condition
is stable and his or her appetite has returned, which is usually after 2–7 days. If
the initial phase takes longer than 10 days, the child is failing to respond and
additional measures are required (see section 7). The principal tasks during initial treatment
are:
— to treat or prevent hypoglycaemia and hypothermia;
— to treat or prevent dehydration and restore electrolyte balance;
— to treat incipient or developed septic shock, if present;
— to start to feed the child;
— to treat infection;
— to identify and treat any other problems, including vitamin deficiency, severe
anaemia and heart failure.
These tasks are described in detail below.
4.2 Hypoglycaemia
All severely malnourished children are at risk of developing hypoglycaemia (blood glucose

Hasil (Bahasa Indonesia) 1:

Prinsip-prinsip pengelolaan
anak-anak dengan malnutrisi berat sering sakit parah ketika mereka pertama kali hadir untuk
pengobatan. Membuang-buang, anoreksia dan infeksi yang umum. Sedapat mungkin, parah
kekurangan gizi anak harus dirujuk ke rumah sakit. Sukses manajemen awal
memerlukan sering, hati-hati evaluasi klinis dan antisipasi masalah umum jadi
mereka dapat dicegah, atau diakui dan diobati pada tahap awal. Fisiologi
anak-anak kekurangan gizi serius abnormal; Bagaimana ini mempengaruhi manajemen mereka adalah
diringkas dalam Apendiks 3.
baru-baru ini mengakui anak harus disimpan dalam area khusus dimana mereka dapat
terus-menerus dipantau. Karena mereka sangat rentan terhadap infeksi, mereka harus, jika
mungkin, terisolasi dari pasien lain. Anak tidak boleh disimpan di dekat jendela atau
di Dam, dan windows harus ditutup pada malam hari. Anak harus benar
ditutupi dengan pakaian, termasuk topi dan selimut. Cuci harus disimpan ke minimum
dan, jika perlu, dilakukan siang hari. Ketika anak dicuci dia harus
kering segera dan benar. Suhu kamar harus disimpan pada 25-30 ° C (77-
86 ° F). Ini akan tampak nyaman hangat untuk staf aktif, berpakaian lengkap, tetapi diperlukan
untuk anak-anak kecil, bergerak yang mudah menjadi hypothermic.
infus intravena harus dihindari kecuali ketika penting, untuk dehidrasi berat
atau mengalami septic shock. Injeksi intramuskular harus diberikan dengan perawatan di
pantat, menggunakan mungkin terkecil mengukur jarum dan volume cairan.
Pengobatan awal dimulai dengan masuk ke rumah sakit dan berlangsung sampai kondisi anak
stabil dan nafsu nya telah kembali, yang merupakan biasanya setelah 2-7 hari. Jika
fase awal mengambil lebih dari 10 hari, anak gagal untuk merespon dan
langkah-langkah tambahan yang diperlukan (Lihat bagian 7). Tugas utama selama pengobatan awal
adalah:
— untuk mengobati atau mencegah hypoglycaemia dan hipotermia;
— untuk mengobati atau mencegah dehidrasi dan mengembalikan keseimbangan elektrolit;
— untuk mengobati baru jadi atau maju mengalami septic shock, jika ada;
— untuk memulai untuk memberi makan anak;
— untuk mengobati infeksi;
— untuk mengidentifikasi dan mengobati masalah lain, termasuk kekurangan vitamin, parah
anemia dan gagal jantung.
tugas ini dijelaskan secara rinci di bawah.
4.2 hypoglycaemia
semua gizi anak berada pada risiko mengembangkan hypoglycaemia (glukosa darah
< 54 mg/dl atau < 3 mmol/l), yang merupakan penyebab penting dari kematian selama pertama
2 hari perawatan. Hypoglycaemia dapat disebabkan oleh infeksi sistemik yang serius atau
dapat terjadi ketika seorang anak yang kurang gizi tidak telah diberi makan untuk 4-6 jam, seperti yang sering terjadi
selama perjalanan ke rumah sakit. Untuk mencegah hypoglycaemia anak harus diberi makan setidaknya setiap
2 atau 3 jam siang dan malam (Lihat bagian 4,5).
8 pengelolaan malnutrisi berat: manual untuk dokter dan pekerja kesehatan senior lain
tanda-tanda hypoglycaemia termasuk suhu tubuh rendah (< 36.5 ° C), kelesuan, limpness
dan penurunan kesadaran. Berkeringat dan pucat tidak biasanya terjadi di malnutrisi
anak-anak dengan hypoglycaemia. Sering, satu-satunya tanda sebelum kematian adalah kantuk.
jika hypoglycaemia diduga, pengobatan harus diberikan segera tanpa laboratorium
konfirmasi; dapat melakukan tidak membahayakan, bahkan jika diagnosis salah. Jika pasien
sadar atau dapat timbul dan mampu minum, memberikan 50 ml glukosa 10% atau Sukrosa, atau
memberikan F-75 diet oleh mulut (Lihat bagian 4,5), mana paling cepat tersedia. Jika hanya 50%
glukosa solusi tersedia, encer satu bagian empat bagian air steril. Tinggal dengan
anak sampai dia sepenuhnya waspada.
jika anak adalah kehilangan kesadaran, tidak dapat terangsang atau memiliki kejang-kejang, memberikan
5 ml/kg berat badan steril 10% glukosa intravena (IV), diikuti oleh 50 ml
glukosa 10% atau sukrosa oleh nasogastric (NG) tabung. Jika glukosa IV tidak boleh diberikan segera,
memberikan NG dosis pertama. Ketika anak mendapatkan kembali kesadaran, segera mulai
memberikan F-75 diet atau glukosa dalam air (60 g/l). Lanjutkan sering oral atau NG makan dengan
F-75 diet untuk mencegah terulangnya.
Semua anak-anak kekurangan gizi dengan dugaan hypoglycaemia juga dapat diobati
dengan antimikroba spektrum luas untuk infeksi sistemik yang serius (Lihat bagian
4,6).
4.3 hipotermia
bayi dibawah 12 bulan, dan orang-orang penderita marasmus, daerah besar kulit rusak atau
infeksi serius sangat rentan terhadap hipotermia. Jika suhu dubur
di bawah 35.5 ° C (95.9 ° F) atau suhu ketiak adalah di bawah 35.0 ° C (95.0 ° F), anak
harus dihangatkan. Entah menggunakan "teknik kanguru" dengan menempatkan anak di
ibu telanjang dada atau perut (kulit-kulit) dan meliputi keduanya, atau pakaian
anak baik (termasuk kepala), tutup dengan selimut yang hangat dan tempat pijar
lampu atas, tetapi tidak menyentuh, tubuh anak. Lampu neon yang ada penggunaan dan hotwater
botol berbahaya.
Suhu rektal harus diukur setiap 30 menit selama rewarming dengan
lampu, sebagai anak dapat dengan cepat menjadi hyperthermic. Suhu ketiak
tidak panduan yang bisa diandalkan untuk suhu tubuh selama rewarming.
Semua anak hypothermic harus juga diperlakukan untuk hypoglycaemia (Lihat bagian 4.2)
dan infeksi sistemik serius (Lihat bagian 4,6).
4.4 dehidrasi dan syok septik
Dehidrasi dan syok septik yang sulit untuk membedakan pada anak dengan malnutrisi berat.
tanda-tanda hipovolemia terlihat dalam kondisi baik, dan semakin memburuk jika
pengobatan tidak diberikan. Dehidrasi berlangsung dari "beberapa" untuk "parah", yang mencerminkan
5-10% dan mengatakan 10% berat badan, masing-masing, sedangkan mengalami septic shock berlangsung dari "baru jadi"
"dikembangkan", sebagai aliran darah ke organ-organ vital berkurang. Selain itu, dalam banyak
kasus syok septik sana adalah sejarah diare dan beberapa derajat dehidrasi,
memberikan campuran klinis gambar.
Diagnosis
banyak tanda-tanda yang biasanya digunakan untuk menilai dehidrasi dapat diandalkan di anak
dengan malnutrisi berat, membuatnya sulit atau mustahil untuk mendeteksi dehidrasi terpercaya
atau menentukan keparahan. Selain itu, banyak tanda-tanda dehidrasi juga dilihat dalam septic
shock. Ini memiliki dua hasil:
— dehidrasi cenderung menjadi overdiagnosed dan keparahan berlebihan; dan
— hal ini sering diperlukan untuk mengobati anak untuk kedua dehidrasi dan syok septik.
9 4. Awal treatment
(a) tanda-tanda dehidrasi dan/atau syok septik yang handal dalam anak dengan parah
malnutrisi meliputi:
Sejarah diare. Seorang anak dengan dehidrasi harus memiliki sejarah berair diare.
tinja berlendir kecil sering terlihat pada malnutrisi berat, tetapi tidak
menyebabkan dehidrasi. Seorang anak dengan tanda-tanda dehidrasi, tetapi tanpa diare berair,
harus diperlakukan sebagai mengalami septic shock.
kehausan. Minum bersemangat adalah tanda handal dehidrasi "beberapa". Pada bayi ini mungkin
dinyatakan sebagai kegelisahan. Haus bukanlah gejala septic shock.
hipotermia. Ketika hadir, ini adalah tanda infeksi serius, termasuk septik
shock. Ini bukanlah tanda dehidrasi.
mata cekung. Ini adalah tanda yang berguna dehidrasi, tetapi hanya bila ibu mengatakan
penampilan cekung hari.
lemah atau tidak ada Nadi radialis. Ini adalah tanda shock, dari dehidrasi berat baik atau
sepsis. Sebagai hipovolemia berkembang, denyut nadi meningkat dan denyut nadi menjadi
lemah. Jika pulsa dalam arteri karotid, femoralis atau brakialis lemah, anak adalah di
resiko kematian dan harus ditangani segera.
dingin tangan dan kaki. Ini adalah tanda dehidrasi berat dan mengalami septic shock. Itu
harus dinilai dengan punggung tangan.
aliran Urine. Aliran urine berkurang sebagai dehidrasi atau mengalami septic shock memburuk. Parah
dehidrasi atau syok septik sepenuhnya dikembangkan, urin tidak adalah formed.
(b) tanda-tanda dehidrasi yang tidak dapat diandalkan termasuk:
keadaan Mental. Gizi anak biasanya apatis ketika ditinggalkan sendirian
dan mudah marah ketika ditangani. Sebagai memperburuk dehidrasi, anak semakin kehilangan
kesadaran. Hypoglycaemia, hipotermia dan mengalami septic shock juga menyebabkan berkurang
kesadaran.
mulut, lidah, dan air mata. Kelenjar liur dan lacrimalis adalah berhenti tumbuh parah
malnutrisi, sehingga anak biasanya memiliki kering mulut dan absen air mata. Pernapasan
melalui mulut juga membuat mulut dry.
kekenyalan kulit. Hilangnya mendukung jaringan dan tidak adanya lemak subkutan membuat
kulit tipis dan longgar. Merata sangat lambat ketika mencubit, atau mungkin tidak meratakan pada semua
edema, jika ada, dapat menutupi berkurang elastisitas kulit.
klinis dehidrasi dan syok septik dibandingkan dalam tabel 5.
(c) tanda tambahan mengalami septic shock:
baru jadi mengalami septic shock. Anak biasanya lemas, apatis dan mendalam, anoreksia
tetapi Haus maupun gelisah.
dikembangkan mengalami septic shock. Vena-vena superficial, seperti eksternal jugularis dan kulit kepala
urat, melebar bukan dibatasi. Vena paru mungkin juga menjadi
penelan, membuat paru-paru kaku dari normal. Untuk alasan ini anak dapat mengerang,
mendengus, memiliki batuk yang dangkal dan tampaknya memiliki kesulitan bernapas. Sebagai memperburuk shock,
gagal ginjal, hati, usus atau jantung dapat terjadi. Ada mungkin muntah dari
darah yang dicampur dengan isi perut ("kopi-tanah muntah"), darah dalam tinja, dan
perut distension dengan "perut splash"; usus cairan dapat terlihat pada Xray.
ketika seorang anak mencapai tahap ini, kelangsungan hidup tidak mungkin.

Hasil (Bahasa Indonesia) 2:

Principles of management
Children with severe malnutrition are often seriously ill when they first present for
treatment. Wasting, anorexia and infections are common. Wherever possible, severely
malnourished children should be referred to hospital. Successful initial management
requires frequent, careful clinical evaluation and anticipation of common problems so
they can be prevented, or recognized and treated at an early stage. The physiology of
malnourished children is seriously abnormal; how this affects their management is
summarized in Appendix 3.
Recently admitted children should be kept in a special area where they can be
constantly monitored. Because they are very susceptible to infection, they should, if
possible, be isolated from other patients. The child should not be kept near a window or
in a draught, and windows should be closed at night. The child should be properly
covered with clothes, including a hat, and blankets. Washing should be kept to a minimum
and, if necessary, done during the day. When the child is washed he or she must be
dried immediately and properly. The room temperature should be kept at 25–30 °C (77–
86 °F). This will seem uncomfortably warm for active, fully clothed staff, but is necessary
for small, immobile children who easily become hypothermic.
Intravenous infusions should be avoided except when essential, as for severe dehydration
or septic shock. Intramuscular injections should be given with care in the
buttock, using the smallest possible gauge needle and volume of fluid.
Initial treatment begins with admission to hospital and lasts until the child’s condition
is stable and his or her appetite has returned, which is usually after 2–7 days. If
the initial phase takes longer than 10 days, the child is failing to respond and
additional measures are required (see section 7). The principal tasks during initial treatment
are:
— to treat or prevent hypoglycaemia and hypothermia;
— to treat or prevent dehydration and restore electrolyte balance;
— to treat incipient or developed septic shock, if present;
— to start to feed the child;
— to treat infection;
— to identify and treat any other problems, including vitamin deficiency, severe
anaemia and heart failure.
These tasks are described in detail below.
4.2 Hypoglycaemia
All severely malnourished children are at risk of developing hypoglycaemia (blood glucose
<54 mg/dl or <3 mmol/l), which is an important cause of death during the first
2 days of treatment. Hypoglycaemia may be caused by a serious systemic infection or
can occur when a malnourished child has not been fed for 4–6 hours, as often happens
during travel to hospital. To prevent hypoglycaemia the child should be fed at least every
2 or 3 hours day and night (see section 4.5).
8 Management of severe malnutrition: a manual for physicians and other senior health workers
Signs of hypoglycaemia include low body temperature (<36.5 °C), lethargy, limpness
and loss of consciousness. Sweating and pallor do not usually occur in malnourished
children with hypoglycaemia. Often, the only sign before death is drowsiness.
If hypoglycaemia is suspected, treatment should be given immediately without laboratory
confirmation; it can do no harm, even if the diagnosis is incorrect. If the patient is
conscious or can be roused and is able to drink, give 50 ml of 10% glucose or sucrose, or
give F-75 diet by mouth (see section 4.5), whichever is available most quickly. If only 50%
glucose solution is available, dilute one part to four parts of sterile water. Stay with the
child until he or she is fully alert.
If the child is losing consciousness, cannot be aroused or has convulsions, give
5 ml/kg of body weight of sterile 10% glucose intravenously (IV), followed by 50 ml of
10% glucose or sucrose by nasogastric (NG) tube. If IV glucose cannot be given immediately,
give the NG dose first. When the child regains consciousness, immediately begin
giving F-75 diet or glucose in water (60 g/l). Continue frequent oral or NG feeding with
F-75 diet to prevent a recurrence.
All malnourished children with suspected hypoglycaemia should also be treated
with broad-spectrum antimicrobials for serious systemic infection (see section
4.6).
4.3 Hypothermia
Infants under 12 months, and those with marasmus, large areas of damaged skin or
serious infections are highly susceptible to hypothermia. If the rectal temperature is
below 35.5 °C (95.9 °F) or the underarm temperature is below 35.0 °C (95.0 °F), the child
should be warmed. Either use the “kangaroo technique” by placing the child on the
mother’s bare chest or abdomen (skin-to-skin) and covering both of them, or clothe the
child well (including the head), cover with a warmed blanket and place an incandescent
lamp over, but not touching, the child’s body. Fluorescent lamps are of no use and hotwater
bottles are dangerous.
The rectal temperature must be measured every 30 minutes during rewarming with
a lamp, as the child may rapidly become hyperthermic. The underarm temperature is
not a reliable guide to body temperature during rewarming.
All hypothermic children must also be treated for hypoglycaemia (see section 4.2)
and for serious systemic infection (see section 4.6).
4.4 Dehydration and septic shock
Dehydration and septic shock are difficult to differentiate in a child with severe malnutrition.
Signs of hypovolaemia are seen in both conditions, and progressively worsen if
treatment is not given. Dehydration progresses from “some” to “severe”, reflecting
5–10% and >10% weight loss, respectively, whereas septic shock progresses from “incipient”
to “developed”, as blood flow to the vital organs decreases. Moreover, in many
cases of septic shock there is a history of diarrhoea and some degree of dehydration,
giving a mixed clinical picture.
Diagnosis
Many of the signs that are normally used to assess dehydration are unreliable in a child
with severe malnutrition, making it difficult or impossible to detect dehydration reliably
or determine its severity. Moreover, many signs of dehydration are also seen in septic
shock. This has two results:
— dehydration tends to be overdiagnosed and its severity overestimated; and
— it is often necessary to treat the child for both dehydration and septic shock.
9 4. Initial treatment
(a) Signs of dehydration and/or septic shock that are reliable in a child with severe
malnutrition include:
History of diarrhoea. A child with dehydration should have a history of watery diarrhoea.
Small mucoid stools are commonly seen in severe malnutrition, but do not
cause dehydration. A child with signs of dehydration, but without watery diarrhoea,
should be treated as having septic shock.
Thirst. Drinking eagerly is a reliable sign of “some” dehydration. In infants this may
be expressed as restlessness. Thirst is not a symptom of septic shock.
Hypothermia. When present, this is a sign of serious infection, including septic
shock. It is not a sign of dehydration.
Sunken eyes. These are a helpful sign of dehydration, but only when the mother says
the sunken appearance is recent.
Weak or absent radial pulse. This is a sign of shock, from either severe dehydration or
sepsis. As hypovolaemia develops, the pulse rate increases and the pulse becomes
weaker. If the pulse in the carotid, femoral or brachial artery is weak, the child is at
risk of dying and must be treated urgently.
Cold hands and feet. This is a sign of both severe dehydration and septic shock. It
should be assessed with the back of the hand.
Urine flow. Urine flow diminishes as dehydration or septic shock worsens. In severe
dehydration or fully developed septic shock, no urine is formed.
(b) Signs of dehydration that are not reliable include:
Mental state. A severely malnourished child is usually apathetic when left alone
and irritable when handled. As dehydration worsens, the child progressively loses
consciousness. Hypoglycaemia, hypothermia and septic shock also cause reduced
consciousness.
Mouth, tongue and tears. The salivary and lacrimal glands are atrophied in severe
malnutrition, so the child usually has a dry mouth and absent tears. Breathing
through the mouth also makes the mouth dry.
Skin elasticity. The loss of supporting tissues and absence of subcutaneous fat make
the skin thin and loose. It flattens very slowly when pinched, or may not flatten at all.
Oedema, if present, may mask diminished elasticity of the skin.
The clinical features of dehydration and septic shock are compared in Table 5.
(c) Additional signs of septic shock:
Incipient septic shock. The child is usually limp, apathetic and profoundly anorexic,
but is neither thirsty nor restless.
Developed septic shock. The superficial veins, such as the external jugular and scalp
veins, are dilated rather than constricted. The veins in the lungs may also become
engorged, making the lungs stiffer than normal. For this reason the child may groan,
grunt, have a shallow cough and appear to have difficulty breathing. As shock worsens,
kidney, liver, intestinal or cardiac failure may occur. There may be vomiting of
blood mixed with stomach contents (“coffee-ground vomit”), blood in the stool, and
abdominal distension with “abdominal splash”; intestinal fluid may be visible on Xray.
When a child reaches this stage, survival is unlikely.