CasePage 1Badu, an 10 month old boy visited RSHS, referred by PUSKESMAS to be hospitalized with chief complains thin and very weak child.Page 2The first week of his life, Badu got exclusive breast milk. But his mom got sore nipples at both side so he did not continue the breastfeeding and changed to bottle milk. When Badu was 1 month old, his mother started to work again, and he was taken care by his grandma. Grandma said that Badu did not like to eat and drink. At the age of 3 month old, he was introduced with home made semi solid food. Grandma realized that Badu looked smaller and thinner than other same old child. Badus body weight does not change for the last 2 month Page 3Badus parent is a couple with low socio-economic level. He is the 1st baby of the family. His delivery was help by traditional birth attendance (TBA), from a 9 months pregnancy mother. Badu was taken to POSYANDU for the first time when she was 6 month old. The cadre in POSYANDU said that Badus body weight was not good enough and concluded that grandma did not give the recommended infant feeding practice. The cadre also advised grandma to visit POSYANDU every months.When Badu was brought to POSYANDU for monthly visit at 10 month old, the cadre told grandma that his growth was bad according to Badus KMS. The last 2 measurement of Badus body weight did not gain, and the cadre recommended grandma to bring Badu to PUSKESMAS. Page 4Anthropometric dataBW / HT: 6.5 kg / 70 cmIndex Weight for age : < -3.22 SDHeight for age : between -1.7Weight for length : < -3.28Physical examPamela is irritable and weak. Vital sign : Pulse 96 bpm and temperature 36.5oCHEENT: No sign of vitamin A deficiency such as Bibots spot, scleral or cornea xerosis. Thorax: The cardio and respiratory examination are normal. Abdomen : Turgor examination in abdominal area: the skin went back slowly Baggy pant (+)Extremities : hypertrophy of muscle and no pretibial or dorsum pedis edema

Laboratory examHemoglobin: 10 g/dlWBC: 6000 cell/mm3Titer Albumin : 3 gr/dl

Page 5Badu is hospitalized with diagnosis of Marasmus, Acute Diarrhea with Dehydration and Lactose Pamela is treated with WHO Ten step Management of severe malnutrition in children. For nutritional status and dehydration correction, the doctor decided to use nasogastric tube to feed and give fluid therapy from route. The doctor explains to grandma about nutrient metabolism, response metabolism in starvation and stress condition, and also the consequences of malnutrition

EpilogueThree weeks later, Badu is sitting in bed, smiling, and eating vigorously. In the other room, the dietician is giving her mother training to prepare Pamelas nutritional care at home

Learning Objective 1. Explain the important of adequate infant nutrition for growth and the consequences of malnutrition2. Identify the type of malnutrition, under nutrition (protein energy malnutrition) and over nutrition (obesity)3. Explain the recommended infant feeding4. Explain about breastfeeding technique5. Give breast feeding counseling and supporting skills6. Explain about the anatomy of human breast, physiology of lactation, immunologic factor of human milk, and physiologic of bonding7. Explain the composition of human milk and infant formula8. Explain about weaning, feeding progression, and baby foods9. Explain about balanced nutrition10. Explain how to use and interpret KMS11. Analyze nutritional status in children using anthropometric indices12. Describe the nutrients (carbohydrate, protein, lipid) metabolism13. Describe the response metabolism of protein energy malnutrition14. Explain the effect of long time inadequate food intake to body cells, especially digestive tract cell15. Explain the pathophysiology of protein energy malnutrition16. Explain the WHO ten step for management severe protein energy malnutrition17. Describe the Pedoman Umum Gizi Seimbang18. Explain the current condition of PEM in Indonesia19. Explain the prevention of PEM20. Evaluate the issue of accessibility of health care21. Formulate research problem of case Case 8 Protein Energy Malnutrition27

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Concept Mapping

Basic Science Breast Breast are the most prominent superficial structure in the anterior thoracic wall, especially in womenConsist of glandular and supporting fibrous tissue embedded within a fatty matrix, together with blood vessels, lymphatic , and nervesThe mammary gland are in the subcutaneous tissue overlying the pectoralis major and minor muscle At the greatest prominence of the breast is the nipple, surrounded by pigmented area of skin (areola)AnatomyBreast lie from 2nd through 6th ribs, above pectorals muscle Between the breast and the pectoral fascia is a loose connective tissue plane or potential space, the retromammary space (bursa)A small part of the mammary gland may extended along the inferolateral edge of the pectoral fascia toward the axilla fossa (armpit), forming an axillary process or tail The mammary gland is firmly attached to the dermis of the overlying skin, especially by substantial skin ligament, the suspensory ligaments. These fibrous connective tissue particularly well developed in the suspensory part of the gland, help support the mammary gland lobuleThe lactiferous duct gives rise to bud that form 15-20 lobules of glandular tissue, which constitute the parenchyma of the mammary glandDeep to the areola, each duct has a dilated portion, the lactiferous sinus, in which a small droplet of milk accumulates or remains in the nursing mother. The areolae contain numerous sebaceous glands, which enlarge during pregnancy and secrete an oil substance that provides a protective lubricant for the areola and nipple, which are particularly subject to chaffing and irritation as mother begin nursingVasculature of the breastThe arterial supply of the breast derives from the:Medial mammary branches of perforating branches and anterior intercostals branches of the internal thoracic artery, originating from the subclavian arteryLateral thoracic and thoracoacromial arteries, branches of the axillary arteryPosterior intercostals arteries, branches of the thoracic aorta in the 2nd, 3rd, and 4th intercostals spacesVein: mainly to the axillary vein, but there is some drainage to the internal thoracic veinLymphatic: Skin of the breast drain into the ipsilateral axillary, inferior deep cervical, and infraclavicular lymph nodes, and also into the parasterna lymph nodes of both sideAxillary nodes drain into clavicular lymph nodes and from them into subclavian lymphatic trunk, which also drains lymph from the upper limbNerve of the breastThe nerves of the breast derive from anterior and lateral cutaneous branches of the 4th 6th intercostals nervesThe anterior primaryrami of T1 T11 are called intercostals nerves because they run within the intercostals spaceThe branches of the intercostals nerves pass through the deep fascia covering the pectoralis major to reach the skin, including the breast in the subcutaneous tissue overlying this muscleThe branches of the intercostal nerves thus convey sensory fiber to the skin of the breast and sympathetic fiber to the blood vessels in the breast and smooth muscle in the overlying skin and nipple

HistologyOne set of glands resembling highly modified apocrine sweat glands persists on each side of the chest.Consist of 15-205 lobes of compound tubule-alveolar type whose function is to secrete milk to nourish newborn.Each lobes, separated from the others by the dense connective tissue with much adipose tissue, is separate gland with its own excretory lactiferous ductThese duct emerge independently in the nipple Histologically, breasts are different on age, sex, and physiologic statusDuring pubertyBefore puberty, the mammary glands in both sexes are composed only with lactiferous sinuses near the nipple, with small, branching ducts emerging from these sinusUndergoing puberty, the breasts increase in size as a result of adipocyte accumulation in the connective tissue and increased growth and branching of the duct systemIn non-pregnant women, parenchymal structure of the gland consist of many lobules called terminal duct lobular units (TDLU)Each lobule has several small, branching ducts, but the attached secretory unit are small and rudimentary. The duct is embedded in loose, vascular connective tissue and a denser, less cellular connective tissue separates the lobes The lactiferous sinuses are lined with stratified cuboidal epithelium and the lining of the lactiferous duct and terminal ducts is simple cuboidal epithelium covered by closely packed myoepithelial cellsEpithelial cells of the duct become slightly more columnar at the time of peak estrogen levels around ovulation and in the premenstrual phase of the cycle connective tissue of the breast become somewhat edematous, making the breast largerSkin covering the nipple constituted the areola and is fairly typical thin skin sebaceous glands. Skin of nipple is supplied with sensory nerve ending. Connective tissue of the nipple is rich in smooth muscle fiber that run parallel to the lactiferous sinus and produce nipple erection when contractDuring pregnancy and lactationThe mammary glands undergo growth during pregnancy as a result of the synergistic action of several hormones, mainly estrogen, progesterone, prolactin, and human placental lactogenThe result is the proliferation of secretory alveoli at the ends of the intralobular ductAlveoli are composed of cuboidal epithelium, with stellate myoepithelial cells between the secretory cells and the basal laminaWhile alveoli and the system of ducts grow and develop during pregnancy in preparation for lactation, the stroma becomes less prominentThe loose connective tissue within lobules is infiltrated in lymphocytes and plasma cells, the latter becoming more numerous late in pregnancy when they begin to produce IgALate pregnancy, the alveoli and duct are dilated by accumulation of colostrums [rich of protein, vitamin A, and electrolytes that is produce under the influence of prolactin]Antibodies produce by plasma cells and transferred into colostrums [passive immunity]Following parturition level of circulating estrogen and progesterone decline and the glandular alveoli become active in milk production, influenced by prolatin from anterior pituitary.Epithelial cells of alveoli enlarge and engage actively in protein and lipid production for secretion. Physiology of lactationFollowing parturition levels of circulating estrogen-progesterone decline, the glandular alveoli of breast become very active in milk production due to the influence of prolactin. Large amount of protein are made on rough ER, processed through the golgi apparatus and packaged into secretory vesicles, which undergo exocytosis during merocrine secretion into the lumen. Spherical lipid droplets, containing primarily neutal triglycerides and cholesterol, form in the cytoplasm of the alveolar cells, grow greatly in size by accretion of more lipids and eventually pass out of the cells into the lumen by process of apocrine secretion, during which the droplets become enveloped with a portion of apical cell membrane. Although estrogen and progesterone are essential for the physical development of breast during pregnancy, these hormone inhibit milk secretionIn addition of prolactine secretion, the placenta secretes large quantities of human chorionic somatomammotropin, which probably has lactogenic properties, thus supporting the prolactine from mothers pituitary during pregnancyDue to estrogen and progesterone, the secretion of fluid is really minimum. No more than a few milliliters of fluid are secreted during the last few days before and the first few day after parturition (colostrum)After the baby is born, the sudden loss of both estrogen and progesterone secretion from the placenta allows the lactogenic effect of prolactin from the mothers pituitary gland to assume its natural milk promoting role, and the breast begin to secrete copious quantities of milk instead of colostrumsGrowth hormone, cortisol, parathyroid hormone, and insulin are necessary to provide the amino acids, fatty acids, glucose, and calcium required for milk formationMilk is secreted continuously into the alveoli of the breast, but milk does not flow easily from the alveoli into the ductal system and does not continually leak from the breast nippleFor ejaculation, ejection comes from the alveoli into the duct before the baby can obtain it and this is cause by a combined neurogenic and hormonal reflex that involves the posterior pituitary hormone oxytocinWhen the baby suckles, it receives virtually no milk for the first half minutes or so. Sensory impulses must first be transmitted through somatic nerves from the nipple to the mothers spinal cord and then to her hypothalamus, where they cause nerve signals that promote oxytocin and prolactin secretion tooNutrition: Breast milk vs Formula MilkBREAST MILK CONTAINSFORMULA CONTAINSCOWS MILKCOMMENT

FatsRich in brain-building omega 3s, namely DHA and AA-Automatically adjusts to infant's needs; levels decline as baby gets older-Rich in cholesterol-Nearly completely absorbed-Contains fat-digesting enzyme, lipase-No DHA-Doesn't adjust to infant's needs-No cholesterol-Not completely absorbed-No lipaseBaby cannot absorb cows milk fat easilyFat is the most important nutrient in breastmilk; the absence of cholesterol and DHA, vital nutrients for growing brains and bodies, may predispose a child to adult heart and central nervous system diseases. Leftover, unabsorbed fat accounts for unpleasant smelling stools in formula-fed babies.

Protein-Soft, easily-digestible whey-More completely absorbed; higher in the milk of mothers who deliver preterm-Lactoferrin for intestinal health-Lysozyme, an antimicrobial-Rich in brain-and-body- building protein components-Rich in growth factors-Contains sleep-inducing proteins-Harder-to-digest casein curds-Not completely absorbed, more waste, harder on kidneys-No lactoferrin, or only a trace-No lysozyme-Deficient or low in some brain-and body-building proteins-Deficient in growth factors-Does not contain as many sleep-inducing proteins.Contain high amount of casein, hard to digest. The amount of protein in cows milk is at least double the amount in breast milk. Infants aren't allergic to human milk protein.

Carbohydrates-Rich in lactose-Rich in oligosaccharides, which promote intestinal health-No lactose in some formulas-Deficient in oligosaccharidesLess carbohydrate compared to breast milk.Lactose is considered an important carbohydrate for brain development. Studies show the level of lactose in the milk of a species correlates with the size of the brain of that species.

Immune Boosters-Rich in living white blood cells, millions per feeding-Rich in immunoglobulins-No live white blood cells-or any other cells. Dead food has less immunological benefit.-Few immunoglobulins and most are the wrong kindIt do not have any antibody that are produced naturally in mothers milk.When mother is exposed to a germ, she makes antibodies to that germ and gives these antibodies to her infant via her milk.

Vitamins and Minerals-Better absorbed, especially iron, zinc, and calcium-Iron is 50 to 75 percent absorbed.-Contains more selenium (an antioxidant)-Not absorbed as well-Iron is 5 to 10 percent absorbed-Contains less selenium (an antioxidant)Cows milk has more some of the vitamins and minerals but it not the right amount for infantVitamins and minerals in breast milk enjoy a higher bioavailability-that is, a greater percentage is absorbed. To compensate, more is added to formula, which makes it harder to digest.

Enzymes and Hormones-Rich in digestive enzymes, such as lipase and amylase-Rich in many hormones: thyroid, prolactin, oxytocin, and more than fifteen others-Varies with mother's diet-Processing kills digestive enzymes-Processing kills hormones, which are not human to begin with-Always tastes the sameIt do not contain enzymes or hormones needed by the infantDigestive enzymes promote intestinal health. Hormones contribute to the overall biochemical balance and well- being of baby.By taking on the flavor of mother's diet, breast milk shapes the tastes of the child to family foods.

Human milk immunologic and nutritional content Energy Nutrients The energy-nutrient composition of breast milk differs dramatically from that recommended for adult diets. Yet for infants, breast milk is natures most nearly perfect foodThe main carbohydrate in breast milk (and infant formula) is the disaccharide lactose. In addition to being easily digested, lactose enhances calcium absorption. The carbohydrate component of breast milk also contains abundant oligosaccharides, which are present only in trace amounts in cows milk and infant formula made from cows milk. Human milk oligosaccharides help protects the infant from infection by preventing the binding of pathogens to the infants intestinal cells. The amount of protein in breast milk is less than in cows milk, but this quantity is actually beneficial It places less stress on the infants immature kidneys to excrete the major end product of protein metabolism, urea. Much of the protein in breast milk is alpha-lactalbumin (efficiently digested and absorbed)Breast milk contains a generous proportion of the essential fatty acids linoleic acid and linolenic acid, as well as their longer-chain derivatives arachidonic acid and DHA (docosahexaenoic acid). DHA is the most abundant fatty acid in the brain and is also present in the retina of the eye. DHA accumulation in the brain is greatest during fetal development and early infancy. Research has focused on the mental and visual development of breastfed infants and infants fed standard formula with and without DHA added. Most studies, however, show no beneficial effect of DHA supplementation of formula for term infants. Adding DHA to standard infant formulas has no adverse effects, however, and most standard formulas are currently fortified with both DHA and arachidonic acid.Vitamins With the exception of vitamin D, the vitamins in breast milk are ample to support infant growth. The vitamin D in breast milk is low, and vitamin D deficiency impairs bone mineralization. Vitamin D deficiency is most likely in infants who are not exposed to sunlight daily, have darkly pigmented skin, and receive breast milk without vitamin D supplementation.The AAP currently recommends a vitamin D supplement for all infants who are breastfed exclusively, and for any infants who do not receive at least one liter of vitamin Dfortified formula daily.

Minerals The calcium content of breast milk is ideal for infant bone growth, and the calcium is well absorbed. Breast milk contains relatively small amounts of iron, but the iron has a high bioavailability. Zinc also has a high bioavailability, thanks to the presence of a zinc-binding protein. Breast milk is low in sodium, another benefit for immature kidneys. Fluoride promotes the development of strong teeth, but breast milk is not a good source.Supplements Pediatricians may routinely prescribe liquid supplements containing vitamin D, iron, and fluoride. The AAP recommends giving a single dose of vitamin K to infants at birth to protect them from bleeding to death. Immunological Protection In addition to its nutritional benefits, breast milk offers immunological protection. Not only is breast milk sterile, but it actively fights disease and protects infants from illnesses. Such protection is most valuable during the first year, when the infants immune system is not fully prepared to mount a response against infections. During the first two or three days after delivery, the breasts produce colostrum, a premilk substance containing mostly serum with antibodies and white blood cells. Colostrum (like breast milk) helps protect the newborn from infections against which the mother has developed immunity. The maternal antibodies in the breast milk inactivate disease-causing bacteria within the infants digestive tract before they can start infections. This explain breastfed infants have fewer intestinal infections than formula-fed infants. Colostrum and breast milk provide other powerful agents that help to fight against bacterial infection. Other substance in colostrumOligosaccharides that prevent pathogens from binding to intestinal cells Bifidus factors favor the growth of the friendly bacterium Lactobacillus bifidus in the infants digestive tract, harmful bacteria cannot become established. Lactoferrin An iron-binding protein in breast milk that keeps bacteria from getting the iron they need to grow, helps absorb iron into the infants intestinal cells, and kills some bacteria directly. The protein lactadherin binds to, and inhibits replication of, the virus that causes most infant diarrhea. Breastfeeding also protects against other common illnesses of infancy such as middle ear infection and respiratory illness. A growth factor that is present in breast milk stimulates the development and maintenance of the infants digestive tract and its protective factors. Several breast milk enzymes such as lipase also help protect the infant against infection. Clearly, breast milk is a very special substance.Allergy and Disease Protection Breast milk may offer protection against the development of allergies. Compared with formula-fed infants, breastfed infants have a lower incidence of allergic reactions, such as recurrent wheezing and skin rashes. This protection is especially noticeable among infants with a family history of allergies. Similarly, breast milk may offer protection against the development of cardiovascular disease. Compared with formula-fed infants, breastfed infants have lower blood pressure and lower blood cholesterol as adultsFormula milk Infant Formula Composition Formula manufacturers attempt to copy the nutrient composition of breast milk as closely as possible. The AAP recommends that all formula-fed infants receive iron-fortified infant formulasThe increasing use of iron-fortified formulas during the past few decades is a major reason for the decline in iron deficiency anemia among infantsRisks of Formula Feeding Infant formulas contain no protective antibodies for infants, but in general, vaccinations, purified water, and clean environments in developed countries help protect infants from infections. Formulas can be prepared safely by following the rules of proper food handling and by using water that is free of contamination. Contaminated formulas (eg. using contaminated water) often cause infections, leading to diarrhea, dehydration, and malabsorption. Without sterilization and refrigeration, formula is an ideal breeding ground for bacteria. Whenever such risks are present, breastfeeding can be a life-saving option: breast milk is sterile, and its antibodies enhance an infants resistance to infections.Infant Formula Standards National and international standards have been set for the nutrient contents of infant formulas. The standard developed by the AAP reflects human milk taken from well-nourished mothers during the first or second month of lactation, when the infants growth rate is high. The Food and Drug Administration (FDA) mandates the safety and nutritional quality of infant formulas. Formulas meeting these standards have similar nutrient compositions. Small differences among formulas are sometimes confusing, but they are usually unimportant.Special Formulas Standard formulas are inappropriate for some infants. Special formulas have been designed to meet the dietary needs of infants with specific conditions such as prematurity or inherited diseases. Most infants allergic to milk protein can drink formulas based on soy protein. Soy formulas also use cornstarch and sucrose instead of lactose and so are recommended for infants with lactose intolerance as well. They are also useful as an alternative to milk-based formulas for vegan families. Despite these limited uses, soy formulas account for one-fourth of the infant formulas sold today. Although soy formulas support the normal growth and development of infants, for infants who dont need them, they offer no advantage over milk formulas. Some infants who are allergic to cows milk protein may also be allergic to soy protein. For these infants, special formulas based on hydrolyzed protein are available.Nutritional requirement for lactation Lactating is nutritionally demanding, especially for women nurses infant exclusively for monthsMilk production is most affected by the frequency of suckling and maternal hydration but the composition varies according to the mothers dietBreast milk of malnourished mother has been shown to have lower level of nutrient (marginal vitamin A status 54% infant and 18% mother in Indonesia)EnergyMilk production is 80% efficient: production of 10ml milk (75kcal) require 85kcal expenditure and during the first 6 months, average production of breast milk is 750 ml/day with a range of 550 to 1200 ml/daySince production is function of frequency, duration, and intensity of infant suckling good feeding infant produce larger volume of milk The DRI for energy during lactating is 330 kcal greater during 6 months and 400 kcal greater during 2nd 6 months of lactation and fat that storage during pregnancy is about 100 150 kcal to support early month lactation Health breast feeding women usually can lose as much as 1 lb/wk and supply adequate milk to maintain infants growth should reminded of energy expenditure required to produce milk with no reduction in calories intake to support the loss of body fat It is generally advisable for lactating mother to maintain an energy intake > 1800 kcal/dayProtein DRI suggest additional 25gr to protein a day for lactation or 71 gr/dayWomen with surgical delivery and those who enter pregnancy in poor nutritional shape need additional protein Carbohydrate: The requirement of carbohydrate in lactation is 160 - 210 gr/day provide enough calories in diet for adequate volume of milk and prevent ketonemia and maintain appropriate blood glucose during lactation Lipid There is no DRI for total lipids during lactation since it depends on amount of energy required by mother to maintain milk production, but fatty acid (long chain PUFA) in human milk are crucial for fetal and infant brain developmentHuman milk contain 10 to 20 mg/dl cholesterol, resulting in approximately consumption of 100 mg/day by infant Amount of cholesterol in milk does not reflect the mothers diet so the cholesterol content decrease over time as lactation progressVitamin and mineral Vitamin D is related to maternal vitamin D intake and degree of sun exposure Calcium content of breast milk is not related to maternal intake and there is no convincing evidence that maternal change in bone mineral density is influenced by calcium and maternal bone loss during lactation is about 3 7% which regained after waning Iodine in breast milk reflect the intake The requirement of zinc is greater in lactation than pregnancy because in process of lactation, zinc content of breast milk decrease dramatically from 2 3 mg/day Weaning, feeding progression, and baby foodWeaning The introduction of solids into an infant's diet begins the weaning process in which the infant transitions from a diet of only breast milk or formula to a more varied one. Weaning should proceed gradually and be based on the infant's rate of growth and developmental skills. Weaning foods should be carefully chosen to complement the nutrient needs of the infant, promote appropriate nutrient intake, and maintain growth.Many infants begin the process of weaning with the introduction of the cup at about 6 to 9 months of age and complete the process when they are able to ingest an adequate amount of milk from a cup at 18 to 24 months of age. Parents of infants who are breast-fed may choose to transition the infant directly to a cup or have an intermittent transition to a bottle before the cup is introduced.Food progressionAge (month)PresentationRecommended food Oral motor skillOther skill

Birth 4 Nipple Breast milk / formulaSuckling become sucking Turns head toward any object that brushes cheek. Initially swallows using back of tongue; gradually begins to swallow using front of tongue as well. Strong reflex (extrusion) to push food out during first 2 to 3 months.

4 6 Nipple or spoonBreast milk / formula; iron-fortified cereal mixed with breast milk or formula Mature sucking pattern, sucking from spoon Extrusion reflex diminishes, and the ability to swallow non liquid foods develops. Indicates desire for food by opening mouth and leaning forward. Indicates satiety or disinterest by turning away and leaning back.Sits erect with support at 6 months. Begins chewing action. Brings hand to mouth. Grasps objects with palm of hand.

6 8 Nipple, spoon, cup introduced (8 months)Breast milk or formula, commercial purred baby food or purred table foods (no sugar or salt added), new grain introduced Primitive reflexes are diminishing (rooting, biting), munching / chewing solidsAble to self-feed finger foods. Develops pincer (finger to thumb) grasp. Begins to drink from cup.

8 12 Nipple, spoon, cup, self-feeding without utensilsBreast milk or formula, nonacidic juice (apple, pear, grape), finger foods (crackers, bread, pasta, cereal), meat and other finely chopped protein introduced (ground meat, cheese, legumes, egg yolks)Upper lip used to clean spoon, tongue lateralization begins biting on object 8 10Begins to hold own bottle.Reaches for and grabs food and spoon.Sits unsupported.10 12Begins to master spoon, but still spills some.

12 15 Nipple (weaning), cup, spoon, self-feeding without utensil Liquids, purred chopped fine solids, coarsely chopped table food (15 months)Tongue lateralization, rotary chew emerges

15 24 Cup, self-feeding with utensils (fork / spoon)Table food Rotary chew, increased jaw stability in cup drinking

Hall, Kelly Dailey. Pediatric Dysphagia: Resource Guide. Clifton Park, NY: Delmar,2001

Early baby food / complementary food By approximately 6 months, complementary feeding of semisolid foods is suggested. By this age, an exclusively breastfed infant requires additional sources of several nutrients, including protein, iron, and zinc. General signs of readiness include the ability to hold the head up and sit unassisted, bringing objects to the mouth, showing interest in foods, and the ability to track a spoon and open the mouth. A relatively high-fat and calorically dense diet (human milk or formula) is needed to deliver adequate calories. The choice of foods to meet micronutrient needs is less critical for formula-fed infants because of the nutrient fortification of formula. The exposure to different textures and the process of self-feeding are important developmental experiences for formula-fed infants.Commercially prepared or homemade foods help meet the nutritional needs of the infant. Because infant foods are usually less energy dense than human milk and formula, they generally should not be used in young infants to compensate for inadequate intake from breastfeeding or formula. Oropharyngeal coordination is immature before 3 months, making feeding with solid foods difficult. Vitamin-fortified and iron-fortified dry cereals are often used as a source of calories and micronutrients (particularly iron) to supplement the diet of infants whose needs for these nutrients are not met by human milk after about 6 months of age. Cereals commonly are mixed with breast milk, formula, or water and later with fruits. To help identify possible allergies or food intolerances that may arise when new foods are added to the diet, single-grain cereals (rice, oatmeal, barley) are recommended as starting cereals. Pured fruits, vegetables, and meats are available in containers that provide an appropriate serving size for infants. By approximately 6 months, the infant's gastrointestinal tract is mature, and the order of introducing complementary foods is not critical. Introduction of single-ingredient meats as an early complementary food provides an excellent source of bioavailable iron and zinc, both of which are important for the older breastfed infant. Parents who prefer to make homemade infant foods using a food processor or food mill should be encouraged to practice safe food handling techniques and avoid flavor additives such as salt. If juice is given, it should be started only after 6 months of age, be given in a cup, and limited to 4 oz daily. An infant should never be put to sleep with a bottle or sippy cup filled with milk, formula, or juice, because this can result in infant bottle tooth decay. Foods with high allergic potential that should be avoided during infancy, especially for infants with a strong family history of food allergy, include fish, peanuts, tree nuts, dairy products, and eggs. Hot dogs, grapes, popcorn, and nuts present a risk of aspiration and airway obstruction. All foods with the potential to obstruct the young infant's airway should be cut into sizes smaller than an infant's main airway. In general, such foods should be avoided until 4 years of age or older. Honey (risk of infant botulism) should not be given before 1 year of age

Balance nutritionA balanced diet means getting the right types and amounts of foods and drinks to supply nutrition and energy for maintaining body cells, tissues, and organs, and for supporting normal growth and developmentBreast milk counselling and child growth Counselling and techniqueCoba baca di Module Skill labPreparationThe advantages of breast-feeding should be presented throughout the childbearing years. The process of lactation (milk secretion) and the benefits of breast-feeding should be a part of school health curricula. Women should be encouraged to express and discuss their opinions and feelings so that any misinformation can be corrected. During the last months of pregnancy, counseling on the process of lactation should be made available to women who have decided to breast-feed. Fathers should be encouraged to participate in counseling sessions because the emotional support they provide contributes to the success of lactation. Resources for breast-feeding support after hospital discharge should be made available at that time.The Technique The baby should be put to breast after birth and remain in direct skin-to-skin contact until the first feed is accomplished. Colostrum, the first milk available after birth, is higher in protein and lower in fat and carbohydrate than mature milk. Breast-feeding is a learned skill for both mother and her infant. Allow the mother to choose a comfortable position so that her baby is well supported with her hand holding the lower portion of the baby's head, neck, and shoulders. With the baby close to her body, the mother aligns the nipple opposite the nose. When the mouth opens wide, the mother brings the baby's body to the breast, aiming the nipple to the back of the babys mouth. The chin should indent the breast, and the nose may touch the breast. The baby should be allowed to nurse on the first breast until satiated and then be offered the second. Length of time at the breast should not be limited since this can prevent the establishment of successful lactation. Lactating women may experience tingling sensation in the breast signaling the let-down reflex. This is often accompanied by milk dripping from the other breast and occasionally in the early days after birth, by uterine cramps' thirst, and drowsiness. Some women never feel let-down, but swallowing by the baby is a definite sign that it has occurred. Rest or a hot shower before nursing may facilitate the let-down reflex. If the mother has too much milk, the baby may only need to nurse on one side at a feeding. Allow the baby to feed on the other breast t the next feeding if the mother experiences discomfort from a tooTo remove the baby from the breast, a finger is placed in the corner of the baby's mouth until the suction is broken. This allows the mother to prevent nipple trauma if she needs to end a feed. Because breast milk is more easily digested, breastfeeding infants may wish to feed more often, and 8 to 12 feeds per day are common. Breast-feeding whenever the baby shows sign of feeding readiness (lip smacking, rooting, sucking movements) helps contribute to a mother's confidence in the care of her baby. During growth spurts babies often feed more often for a few days to increase the mother's supply. Feeding time is perfectly suited for establishing and maintaining close mother-child interactions. When she needs to be away at the usual time of a feeding, a bottle of breast milk that has been expressed earlier can be given. It is best to avoid supplemental bottles until the milk supply is established, usually around 3 to 4 weeks' after birth. The sucking action required to empty a bottle is different from that needed to nurse at the breast, and the flow of milk is faster and easier to obtain. Some infants may then refuse the breast, leading to lactation difficulties. In the early week, sit is important to minimize mother-baby separation. There is no need to offer breast-fed babies additional water since 87% of breast milk is water. Exercise and Breast Feeding The breast-feeding mother should be encouraged to get back to exercise a few weeks' after delivery after lactation is well established. Aerobic exercise at 60%o to 70% of maximum heart rate has no adverse effect on lactation; infants gain weight at the same rate, and the mother's cardiovascular fitness improves. Exercise also improves plasma lipids and insulin response in lactating women without negating maternal or infant immune statusRecommended infant nutritionInitially, the infant drinks only breast milk or formula but later begins to eat some foods, as appropriate. Common sense in the selection of infant foods along with a nurturing, relaxed environment support an infants health and well-being.Energy and Nutrient Needs An infant grows fast during the first year. Growth directly reflects nutrient intake and is an important parameter in assessing the nutrition status of infants and children. Health-care professionals measure the heights and weights of infants and children at intervals and compare the measurements with standard growth curves for gender and age and with previous measures of each child. Energy Intake and Activity A healthy infants birth weight doubles by about 5 months of age and triples by 1 year, typically reaching 20 to 25 pounds. The infants length changes more slowly than weight, increasing about 10 inches from birth to 1 year. By the end of the first year, infant growth slows considerably; during the second year, an infant typically gains less than 10 pounds and grows about 5 inches in length. A newborn baby requires about 450 kcalories per day, whereas most adults require about 2000 kcalories per day. If an infants energy needs were applied to an adult, a 170-pound adult would require more than 7000 kcalories a day. After 6 months, the infants energy needs decline as the growth rate slows, but some of the energy saved by slower growth is spent in increased activity. Energy Nutrients Recommendations for the energy nutrients [carbohydrate, fat, and protein] during the first six months of life are based on the average intakes of healthy, full-term infants fed breast milk. During the second six months of life, recommendations reflect typical intakes from solid foods as well as breast milk. Carbohydrates provide energy to all the cells of the body, especially those in the brain, which depend primarily on glucose to fuel activities. Relative to the size of the body, the size of an infants brain is greater than that of an adults. Thus, an infants brain uses relatively more glucoseabout 60 percent of the days total energy intake. Fat provides most of the energy in breast milk and standard infant formula. Its high energy density supports the rapid growth of early infancy. No single nutrient is more essential to growth than protein. All of the bodys cells and most of its fluids contain protein; it is the basic building material of the bodys tissues. Excess dietary protein can cause problems, too, especially in a small infant. Too much protein stresses the liver and kidneys, which have to metabolize and excrete the excess nitrogen. Signs of protein overload include acidosis, dehydration, diarrhea, elevated blood ammonia, elevated blood urea, and fever. Such problems are not common, but they have been observed in infants fed inappropriate foods, such as fat-free milk or concentrated formula.Vitamins and Minerals An infants needs for most nutrients, in proportion to body weight, are more than double those of an adult. Some of the differences are extraordinary. Infant recommendations are based on the average amount of nutrients consumed by thriving infants breastfed by well-nourished mothers.Water One of the most essential nutrients for infants, as for everyone, is water. The younger the infant, the greater the percentage of body weight is water. During early infancy, breast milk or infant formula normally provides enough water to replace fluid losses in a healthy infant. If the environmental temperature is extremely high, however, infants need supplemental water. Because much of the fluid in an infants body is located outside the cellsbetween the cells and in the blood vesselsrapid fluid losses and the resulting dehydration can be life-threatening. Conditions that cause rapid fluid loss, such as diarrhea or vomiting, require treatment with an electrolyte solution designed for infants.Nutritional status Measuring nutritional adequacy There are several important and often complementary methods by which to assess nutritional adequacy. Growth according to expected trends can be tracked using the 2000 Centers for Disease Control and Prevention (CDC) and 2006 World Health Organization (WHO) growth charts. The WHO growth charts are derived from longitudinal and cross-sectional data obtained from a sample of healthy breast-fed infants and children (0-5 yr) receiving adequate nutritional intake and medical care. The WHO growth charts are therefore not only descriptive of population average and distribution but also prescriptive regarding how adequately nourished healthy children should grow. Other biomarkers can be used to assess the status of specific nutrients. For infants and children with specific dietary or health concerns, consultation with lactation consultants, registered dieticians, and/or physician nutrition specialists may also be indicated.Anthropometric component

Height for age reflect achieved linear growth and its deficits indicate long term, cumulative inadequacies of nutrition Wight for height reflect body weight relative to height Weight for age reflect body mass relative to chronological age and is influenced by both height of child (Height for age) and weight (BMI) and its composite nature makes interpretation complex Mid-upper arm circumference (MUAC) in emergency situation if 3 above are relative impossible to check / measured BMISkinfold assess thickness of subcutaneous tissue and widely used for assessing obesity Head circumference to assess potential developmental or neurological disability in children Interpretation Z-score or standard deviation value system using X score and standard deviation if below or above the reference mean of median value Percentile system percentile refers to the position of individual on given reference distribution (more commonly used). Light Medium Severe

BB/U70 80%60 70%< 60%

TB/U90 95%85 89%< 85%

BB/TB80 90%70 90%< 70%

Percent of median system express as percentage of median value of expected reference but the system is a lack of exact correspondence with a fixed point of distribution across age or height status. KMSPendahuluanKartu Menuju Sehat (KMS) adalah kartu yang memuat kurva pertumbuhan normal anak berdasarkan indeks antropometri berat badan menurut umur. Dengan KMS gangguan pertumbuhan atau risiko kelebihan gizi dapat diketahuilebih dini, sehingga dapat dilakukan tindakan pencegahan secara lebih cepat dan tepat sebelum masalahnya lebih berat

Pemantauan pertumbuhan adalah serangkaian kegiatan yang terdiri dari Penilaian pertumbuhan anak secara teratur melalui penimbangan berat badan setiap bulan, pengisian KMS, menentukan status pertumbuhan berdasarkan hasil penimbangan berat badan;Menindaklanjuti setiap kasus gangguan pertumbuhan. Tindak lanjut hasil pemantauan pertumbuhan biasanya berupa konseling, pemberian makanan tambahan, pemberian suplementasi gizi dan rujukanBentuk dan pengembangan KMS ditentukan oleh rujukan atau standar antropometri yang dipakai, tujuan pengembangan KMS serta sasaran pengguna Pada tahun 2008, KMS balita direvisi berdasarkan Standar Antropometri WHO 2005Fungsi KMS Sebagai alat untuk memantau pertumbuhan anak. Pada KMS dicantumkan grafik pertumbuhan normal anak, yang dapat digunakan untuk menentukan apakah seorang anak tumbuh normal, atau mengalami gangguan pertumbuhan. Bila grafik berat badan anak mengikuti grafik pertumbuhan pada KMS, artinya anak tumbuh normal, kecil risiko anak untuk mengalami gangguan pertumbuhan. Bila grafik berat badan tidak sesuai dengan grafik pertumbuhan, anak kemungkinan berisiko mengalami gangguan pertumbuhan.Sebagai catatan pelayanan kesehatan anak Dicatat riwayat pelayanan kesehatan dasar anak terutama berat badan anak, pemberian kapsul vitamin A, pemberian ASI pada bayi 0-6 bulan dan imunisasi.Sebagai alat edukasi Dicantumkan pesan-pesan dasar perawatan anak seperti pemberian makanan anak, perawatan anak bila menderita diare.Manfaat KMNBagi orang tua balitaOrang tua dapat mengetahui status pertumbuhan anaknya. Apabila ada indikasi gangguan pertumbuan (berat badan tidak naik) atau kelebihan gizi, orang tua balita dapat melakukan tindakan perbaikan, seperti memberikan makan lebih banyak atau membawa anak ke fasilitas kesehatan untuk berobat. Orang tua balita juga dapat mengetahui apakah anaknya telah mendapat imunisasi tepat waktu dan lengkap dan mendapatkan kapsul vitamin A secara rutin sesuai dengan dosis yang dianjurkan.Bagi kaderKMS digunakan untuk mencatat berat badan anak dan pemberian kapsul vitamin A serta menilai hasil penimbangan. Bila berat badan tidak naik 1 kali kader dapat memberikan penyuluhan tentang asuhan dan pemberian makanan anak. Bila tidak naik 2 kali atau berat badan berada di bawah garis merah kader perlu merujuk ke petugas kesehatan terdekat, agar anak mendapatkan pemerikasaan lebih lanjut. KMS juga digunakan kader untuk memberikan pujian kepada ibu bila berat badan anaknya naik serta mengingatkan ibu untuk menimbangkan anaknya di posyandu pada bulan berikutnya. Bagi petugas kesehatanPetugas dapat menggunakan KMS untuk mengetahui jenis pelayanan kesehatan yang telah diterima anak, seperti imunisasi dan kapsul vitamin A. Bila anak belum menerima pelayanan maka petugas harus memberikan imunisasi dan kapsul vitamin A sesuai dengan jadwalnya. Petugas kesehatan juga dapat menggerakkan tokoh masyarakat dalam kegiatan pemantauan pertumbuhan. KMS juga dapat digunakan sebagai alat edukasi kepada para orang tua balita tentang pertumbuhan anak, manfaat imunisasi dan pemberian kapsul vitamin A, cara pemberian makan, pentingnya ASI eksklusif dan pengasuhan anak. Tindak lanjut berdasarkan hasil penilaian pertumbuhan balita adalah sebagai berikut:Berat badan naik (N): Berikan pujian kepada ibu yang telah membawa balita ke PosyanduBerikan umpan balik dengan cara menjelaskan arti grafik pertumbuhan anaknya yang tertera pada KMS secara sederhanaAnjurkan kepada ibu untuk mempertahankan kondisi anak dan berikan nasihat tentang pemberian makan anak sesuai golongan umurnya.Anjurkan untuk datang pada penimbangan berikutnya.Berat badan tidak naik 1 kaliBerikan pujian kepada ibu yang telah membawa balita ke PosyanduBerikan umpan balik dengan cara menjelaskan arti grafik pertumbuhan anaknya yang tertera pada KMS secara sederhanaTanyakan dan catat keadaan anak bila ada keluhan (batuk, diare, panas, rewel, dll) dan kebiasaan makan anakBerikan penjelasan tentang kemungkinan penyebab berat badan tidak naik tanpa menyalahkan ibu.Berikan nasehat kepada ibu tentang anjuran pemberian makan anak sesuai golongan umurnyaAnjurkan untuk datang pada penimbangan berikutnyaBerat badan tidak naik 2 kali atau berada di Bawah Garis Merah (BGM)Berikan pujian kepada ibu yang telah membawa balita ke Posyandu dan anjurkan untuk datang kembali bulan berikutnya.Berikan umpan balik dengan cara menjelaskan arti grafik pertumbuhan anaknya yang tertera pada KMS secara sederhana Tanyakan dan catat keadaan anak bila ada keluhan (batuk, diare, panas, rewel, dll) dan kebiasaan makan anakBerikan penjelasan tentang kemungkinan penyebab berat badan tidak naik tanpa menyalahkan ibu.Cara pengisian

1. A child in this range is very tall. Tanness is rarely a problem, unless it is so excessive that it may indicate endocrine such as a growth-hormone-producing tumor. Refer a child in this range for assessment if you suspect an endocrine disorder

2. A Child whose weight-for-age falls in this range may have a growth problem, but this is better assessed from weight-length/heoght or BMI-for Age.

3. A plotted point above 1 shows possible risk. A trent toward the 2 z-score line show definite risk

4. It is possibke for a stunded or severely stunded child to become overweight

MalnutritionOver nutritionEtiology and epidemiologyObesity runs in families; this could be related to genetic influences or the influence of a common, shared environment. Eighty percent of the variance in weight for height or skin-fold thickness in adopted twin pairs may be explained on the basis of genetics. A strong relationship exists between the BMI of adoptees and that of their biologic parents; a weaker relationship exists between the BMI of adoptees and that of their adoptive parents. The association between obesity and television watching and dietary intake, the different rates of obesity observed in urban versus rural areas, and changes in obesity with seasons support the important influence of environment.Diagnosis Complications of obesity in children and adolescents can affect virtually every major organ system. The history and physical examination should screen for many potential complications noted among obese patients in addition to specific diseases associated with obesity (Table 29-2). Medical complications usually are related to the degree of obesity and usually decrease in severity or resolve with weight reductionThe diagnosis of obesity depends on the measurement of excess body fat. Actual measurement of body composition is not practical in most clinical situations. BMI is a convenient screening tool that correlates fairly strongly with body fatness in children and adults. BMI age-specific and gender-specific percentile curves (for 2- to 20-year-olds) allow an assessment of BMI percentile. For children younger than 2 years of age, weight-for-length measurements greater than 95th percentile may indicate overweight and warrant further assessment. A BMI for age and gender above the 99th percentile is strongly associated with excessive body fat and is associated with multiple cardiovascular disease risk factors

ComplicationEffects

PsychosocialPeer discrimination, teasing, reduced college acceptance, isolation, reduced job promotion*

GrowthAdvance bone age, increased height, early menarche

Central nervous systemPseudotumor cerebri

RespiratorySleep apnea, pickwickian syndrome

CardiovascularHypertension, cardiac hypertrophy, ischemic heart disease,* sudden death*

OrthopedicSlipped capital femoral epiphysis, Blount disease

MetabolicInsulin resistance, type 2 diabetes mellitus, hypertriglyceridemia, hypercholesterolemia, gout,* hepatic steatosis, polycystic ovary disease, cholelithiasis

Assessment Anthropometric data, including weight, height, and calculation of BMI. Data should be plotted on age-appropriate and gender-appropriate growth charts and assessed for weight gain trends and upward crossing of percentiles. Dietary and physical activity history Assess patterns and potential targets for behavioral change. Physical examination Assess blood pressure, adiposity distribution (central versus generalized), markers of comorbidities (acanthosis nigricans, hirsutism, hepatomegaly, orthopedic abnormalities), and physical stigmata of genetic syndrome (Prader-Willi syndrome). Laboratory studies These are generally reserved for children who are obese, who have evidence of comorbidities or both. Useful laboratory tests may include a fasting lipid profile, fasting glucose levels, liver function tests, and thyroid function tests (if evidence of plateau in linear growth). DIETACTIVITY

Consume five or more servings of fruits and vegetables per dayLimit screen time to 2 hours per day

Minimize consumption of sugar-sweetened beveragesBe physically active 1 hour per day; engage in both unstructured and structured activities

Prepare more meals at home rather than purchasing restaurant food

Eat at table, as a family, at least five to six times per week

Consume a healthy breakfast every day

Allow child to self-regulate his or her meals and avoid overly restrictive feeding behaviors

Management (4 stage)Prevention plus The goal is improved BMI status. Problem areas identified by dietary and physical activity history should be provided, and emphasis should be placed on healthy eating and physical activity patterns. This is especially appropriate for preventing further weight gain and for overweight and mildly obese children. Structured weight management: The approach may include planned diet, structured daily meals, and planned snacks; additional reduction in screen time; planned, supervised activity; self-monitoring of behaviors, including logs; and planned reinforcement for achievement of targeted behavior change. This may be done in the primary care setting but generally requires a registered dietitian or a clinician who has specialized training and monthly follow-up visits are recommended. Comprehensive multidisciplinary intervention: This level of treatment increases the intensity of behavior change, frequency of visits, and the specialists involved. Programs at this level are presumed to be beyond the capacity of most primary care office settings. Typical components of a program include structured behavior modification, food monitoring, diet and physical activity goal setting, and contingency management. A multidisciplinary team with expertise in childhood obesity typically includes a behavior counselor, registered dietitian, exercise specialist, and primary care provider to monitor ongoing medical issues. Tertiary care intervention: This more intensive approach should be considered for severely obese children. Approaches include medications, very low calorie diets, and weight control surgery, in addition to the attainment of behavior changes to improve diet and activity patterns. This level of intervention also includes a multidisciplinary team with expertise in obesity and its comorbidities and takes place in a pediatric weight management centerUnder nutritionMarasmus is the term used for severe PEM and wasting (low wt/ht). Many secondary forms of marasmic PEM are associated with chronic diseases (cystic fibrosis, tuberculosis, cancer, acquired immunodeficiency virus, celiac disease). The principal clinical manifestation in a child with severe malnutrition is emaciation with a body weight less than 60% of the median (50th percentile) for age or less than 70% of the ideal weight for height and depleted body fat stores. Loss of muscle mass and subcutaneous fat stores are confirmed by inspection or palpation and quantified by anthropometric measurements. The head may appear large but generally is proportional to the body length. Edema usually is absent. The skin is dry and thin, and the hair may be thin, sparse, and easily pulled out. Marasmic children may be apathetic and weak. Bradycardia and hypothermia signify severe and life-threatening malnutrition. Atrophy of the filiform papillae of the tongue is common, and monilial stomatitis is frequent. Inappropriate or inadequate weaning practices and chronic diarrhea are common findings in developing countries. Stunting (impaired linear growth (Table 30-1)) results from a combination of malnutrition, especially micronutrients, and recurrent infections. Stunting is more prevalent than wasting

Protein Energy MalnutritionNutrient metabolism Baca case T2DM / GDM di draft EMSMetabolisme: Seluruh reaksi kimia pada tubuh baik katabolisme (degreadasi molekul menghasilkan ATP) ataupun anabolisme (sintesis molekul dengan ATP)3 tahap katabolisme Tahap I: Hidrolisis yaitu pemecahan molekul komplek menjadi unit pembangun Tahap II: Konversi yaitu pembentukan ACoA dari unit pembangun tadiTahap III: Oksidasi yaitu pembentukan ATP melalui rantai fosforilasi oksidatif Penggunaan nutrisi dalam tubuh akan dipengaruhi adanya 3 faktor utamaKetersediaan nutrient (keseimbangan energi intake dan expenditure)Hormonal Respon inflamasi (proses konversi akan dihambat jika terjadi inflamasi Metabolsime pada keadaan fasting Glikogen di liver dan otot Glukosa energi untuk otak dan sel Lemak di tubuh akan dipecah menjadi asam lemak untuk energi sel dengan keton sebagai hasilnyaProtein tubuh akan dipecah menjadi badan keton, glukosa untuk otak, dan urea Definition: Deficiency in single nutrient can cause deficiency in other nutrient PEM, manifested primarily by inadequate dietary intakes of protein and energy, either because the dietary intakes of these 2 nutrients are less than required for normal growth or the needs for growth are greater that can supplied PEM is almost always accompanied by deficiency of other nutrient

EtiologyPrimary: low protein intake / consumption from daily dietSecondary: due to other disease such as infection, renal failure, cancer cachexia, etcClassification Grading / degree of deficiency (Gomez classification)Protein energy malnutrition grade IPEM moderate grade IIPEM severe grade IIIType of the severe Marasmus (non edematous malnutrition with severe wasting) deficiency in calories intake Kwashiorkor (edematous malnutrition) protein malnutrition predominantTypeBB in KMSBW/AgeWeight / Height

PEM I (light)Yellow ribbon 70 80%80 90%

PEM II (medium)Below Red Line 60 70%70 80%

PEM III (severe)< 60%< 70%

Marasmic kwashiorkor marked protein deficiency and marked calorie insufficiency signs present, sometimes referred to as the most severe form of malnutritionEpidemiologyMarasmus can occur at any age, but it is common in children younger than 1 year. In marasmus, starvation is attributable to lack of protein and carbohydrates. One third of the worlds children suffer from PEM, with the highest concentrations in, Asia, Africa, Latin America, and the Carribbean. The mortality risk for children in developing countries has been found to be inversely related to anthropometric indicators There is elevated risk even in the mild to moderate range of malnutrition.Poor sanitation, early weaning of breast-fed infants, use of overdiluted commercial formulas, and infection (measles, malaria, pneumonia, HIV, and diarrheal disease) are major risk factors for PEMPathogenesis It also has been proposed that giving excess carbohydrate to a child with nonedematous malnutrition reverses the adaptive responses to low protein intake, resulting in mobilization of body protein stores. Eventually, albumin synthesis decreases, resulting in hypoalbuminemia with edema. Fatty liver also develops secondary, perhaps, to lipogenesis from the excess carbohydrate intake and reduced apolipoprotein synthesis. Other causes of edematous malnutrition are aflatoxin poisoning as well as diarrhea, impaired renal function and decreased Na+/K+-ATPase activity. Free radical damage has been proposed as an important factor in the development of edematous malnutrition. This proposal is supported by low plasma concentrations of methionine, a dietary precursor of cysteine, which is needed for synthesis of the major antioxidant factor, glutathione. This possibility also is supported by lower rates of glutathione synthesis in children with edematous compared with nonedematous malnutrition.PathophysiologyKwashiorkorIn kwashiorkor, the deficit of dietary amino acids reduces protein synthesis in all tissues. Physical growth and mental growth are stunted, and maintenance of minimal life processes is in jeopardy. The lack of sufficient plasma proteins, particularly albumin, causes systemic pressure changes that result in generalized edema. The volume of total body water and extracellular fluid increases, causing a substantial loss of potassium. The liver swells with stored fat because no hepatic proteins are synthesized to form and release lipoproteins and pancreatic atrophy and fibrosis may be present. Kwashiorkor also causes malabsorption, reduced bone density, and impaired renal function. If the condition is not reversed, the prognosis is very poorMarasmus Because the intake of all dietary nutrients is reduced to a minimum in marasmus, metabolic processes, including liver function, are preserved but growth is severely retarded. Caloric intake is too low to support protein synthesis for growth or the storage of fat. If more protein is needed than is ingested, muscle wasting occurs. Fat wasting and anemia are common and can be severe and the volume of total body water is high. Serum triglyceride and phospholipid levels increase with increasing severity of malnutrition, but other serum values, such as cholesterol, are normal or slightly reduced. Severe vitamin A deficiency contributes to blindness.Diagnosis and clinical picture Nonedematous malnutrition (marasmus) Characterized by failure to gain weight and irritability, followed by weight loss and listlessness until emaciation results. The skin loses turgor and becomes wrinkled and loose as subcutaneous fat disappears. Loss of fat from the sucking pads of the cheeks often occurs late in the course of the disease; thus, the infants face may retain a relatively normal appearance compared with the rest of the body, but this, too, eventually becomes shrunken and wizened. Infants are often constipated, but they can have starvation diarrhea, with frequent small stools containing mucus. The abdomen may be distended or flat, with the intestinal pattern readily visible. There is muscle atrophy and resultant hypotonia. As the condition progresses, the temperature usually becomes subnormal and the pulse slowsEdematous malnutrition (kwashiorkor) Can occur initially as vague manifestations that include lethargy, apathy, and/or irritability. When kwashiorkor is advanced, there is lack of growth, lack of stamina, loss of muscle tissue, increased susceptibility to infections, vomiting, diarrhea, anorexia, flabby subcutaneous tissues, and edema. The edema usually develops early and can mask the failure to gain weight. It is often present in internal organs before it is recognized in the face and limbs. Liver enlargement can occur early or late in the course of disease. Dermatitis is common, with darkening of the skin in irritated areas, but in contrast to pellagra not in areas exposed to sunlight. Depigmentation can occur after desquamation in these areas, or it may be generalized. The hair is sparse and thin, and in dark-haired children, it can become streaky red or gray. Eventually, there is stupor, coma, and death.Therapy Grade I Penyuluhan gizi, ASI eklusif, dan penyesuaian makananGrade II Rawat jalan (penyuluhan gizi dan ASI sampai 2 tahun) dan rawat inap (makan tinggi protein)Grade III 10 General principle of WHO Mencegah dan mengatasi hipoglikemia ==> berikan dekstrose 10% baik intravena maupun oral.Mencegah dan mengatasi hipotermia ==> pertahankan suhu tubuh.Mencegah dan mengatasi dehidrasi ==> berikan resomalMemperbaiki gangguan elektrolit ==> berikan mineral mixMengobati infeksi ==> dengan atau tanpa demam berikan antibiotik.Tanpa komplikasi : kotrimoksasol.Dengan komplikasi : gentamisin +ampisilin diikuti amoksisilin oral.Memperbaiki kekurangan zat gizi mikro==> AGB : berikan tablet besi setelah 2 minggu (setelah fase stabilisasi)==> KVA : Tidak ada gejala (hari ke-1 : 1 kapsul); ada gejala : hari ke 1,2 dan 15 @ 1 kapsul sesuai dosis usia.Memberikan makanan untuk stabilisasi dan transisi. stabilisasi: F 75 : mencegah hipoglikemia resomal : mencegah dehidrasi transisi : Bertahap dari F 75 F 100.Memberikan makanan untuk tumbuh kejar.Energi : 150-220 kkal/kg BBProtein : 3-4 gr/kg BB/hrBB < 7 kg : makanan bayiBB > 7 kg : makanan anak.Stimulasi sensorik dan dukungan emosional pada anak gizi buruk.Tindak lanjut dirumah

BHPEthical obligations to guide reform of the current system:Every member of society must have an adequate array of core health care benefits.The contents and limits of health care benefits must be established through anethical process.The health care system must be sustainable.The health care system must ensure that its stakeholders have clear responsibilities for which they are accountable.Dalam lingkungan masyarakat, POSYANDU menjadi salah satu komponen pelayanan kesehatan yang penting. Pelayanan POSYANDU harus dapat dijangkau oleh masyarakat dari segala kalangan serta para kader yang bertanggung jawab harus dapat memperhatikan masyarakat / penduduk disekirat POSYANDU tersebut. Dalam melakukan konseling, gunakan kata - kata dengan bijak, jangan sampai menyinggung atau membuat minder pasien PHOPLakukan penyuluhan tentang pentingnya dan cara menyusui yang benarAnjurkan masyarakat untuk menimbang bayi di POSYANDU teratur setiap bulan dan ajarkan cara membaca KMS untuk menilai kondisi bayi merekaJalankan fungsi POSYANDU dengan tepatMempercepat penurunan angka kematian bayi, balita, dan naonatusPercepat penerimaan NKKBSTingkatkan kemampuan masyarakat dalam mengembangkan kegiatan kesehaan serta kegiatan lain yang menunjang, sesuai dengan kebutuhan CRPPada umumnya masyarakat indonesia telah mampu mengkonsumsi makanan yang cukup secara kuantitatif. Namun dari segi kualitatif masih cukup banyak yang belum mampu mencukupi kebutuhan gizi minimum. Departemen Kesehatan juga telah melakukan pemetaan, dan hasilnya menunjukan bahwa penderita gizi kurang ditemukan di 72% kabupatendi Indonesia. Indikasinya 2 4 dari 10 balita di Indonesia menderita gizi kurang. Sesuai dengan survai di lapangan, insiden gizi buruk dan gizi kurang pada anak balita yang dirawat mondok di rumah sakit masih tinggi.