Riwayat Hidup Singkat

Nama : Dr. Soedjatmiko, SpA(K), MSi

Dokter Spesialis Anak Konsultan Tumbuh Kembang - Pediatri Sosial,
Magister Sains Psikologi Perkembangan, no HP 08129040190
Jabatan
1. Pengurus Pusat Ikatan Dokter Anak Indonesia
2. Sekretaris Satgas Imunisasi PP IDAI
3. Ketua Divisi Tumbuh Kembang – Pediatri Sosial Dep. I KA FKUI – RSCM
4. Anggota Indonesia Technical Advisory Group for Immunization
5. Anggota Satgas Anemia Defisiensi Besi IDAI
6. Anggota Forum Pusat Pengembangan Anak Usia Dini (PAUD)
7. Konsultan Majalah Parents Guide, AyahBunda, Tabloid Nakita
Riwayat Singkat Pendidikan /Pelatihan:
1. 1992 : Dokter Spesialis Anak FKUI
2. 1997 : Surveilance & Epidemiology Course Kumamoto, Tokyo - Japan
3. 2000 : Growth & Nutrition Course, Santiago, Chile
4. 2002 : Magister Sains Psikologi Perkembangan. F Psi UI
5. 2002 : Konsultan Tumbuh Kembang – Pediatri Sosial
6. 2002 : Vaccinology Training Jakarta, Kinabalu, Singapore
7. 2006 : Bayley III Training Course, Kuala Lumpur
8. 2008 : Touch and Baby Massage Workshop, HoChiMinh, Vietrnam
 Iron Deficiency in Infancy and Childhood :
Impact on Child Cognitive
and Behavior

Soedjatmiko
Growth & Development
and Social Pediatrics
Division
Dept. of Child Health
MFUI & CMGH
Jakarta
Iron Deficiency Anemia and
Cognitive & Behavior problems
– sensory (auditory, visual)
– temperamen, emotion, affect
– attention,
• hiperactivity, inhibition
– Information processing,
• learning
• memory
– problem solving
• inteligency

 school performance
 behavior problems
» 2. Joyce C McCann JC, Ames BN. An overview of evidence for a causal relation between iron
deficiency during development and deficits in cognitive or behavioral function1 Am J Clin Nutr
2007;85:931– 45
» 3. Iannotti LL, Tielsch JM, Black MM, Black RE. Iron supplementation in early childhood : health benefit
and risks. Am J Clin Nutr 2006;84: 1261-76.
» 5. Grein J. The Cognitive Effect of Iron Deficiency in Non-Anemic Children. Nutrition Noteworthy 2001;
4(1).
» 6. Gordon N. Iron deficiency and the intelect. Brain & Development 2003 ; 25: 3 – 8.
» 7. Algarin C, Peirano P, Garrido M, Pizzaro F, Lozoff. Iron Deficiency Anemia in Infancy : Long-Lasting
Effects on Auditory and Visual System Functioniong. Pediatr Res 2003;53:217-223
Iron and
Brain Functions (1)

oxygen transportation
dendritic growth
Oligodendrocytes : myelination
enzymes activity : tryptophan & thyrosine hydroxilase
neurotransmitter : serotonin, dopamine, epinephrine
density and affinity of dopamine D2 receptors,
neural metabolites in the hippocampus
activity of proteins in energy metabolism (cytochrome C
oxidase and cytochrome c),
Gordon N. Iron deficiency and the intelect. Brain & Development 2003 ; 25: 3 – 8.
 Iron and Brain Functions (2)
 cofactor for enzymes that synthesize
neurotransmitters
 tryptophan hydroxylase (serotonin)
 tyrosine hydroxylase (norepinephrine,
dopamine)
 dopaminergic neurotransmitter systems
related to behavioral development
 inhibition,
 affect,
 attention processing,
 extraneous motor movements
Joyce C McCann JC, Ames BN. Am J Clin Nutr 2007;85:931
Lannotti LL, Tielsch JM, Black MM, and Black RE. Am J Clin Nutr 2006;84:1261–76
 Iron and Brain Functions (3)

 Iron in oligodendrocytes is required for

proper myelination of the neurons
 sensory systems (visual, auditory),
 learning
 interacting behaviors

 Neuronal metabolism in the

hippocampus and prefrontal
projections :  memory processing
 Joyce C McCann JC, Ames BN. Am J Clin Nutr 2007;85:931– 45

 Lannotti LL, Tielsch JM, Black MM, and Black RE. Am J Clin
Nutr 2006;84:1261–76
Iron Deficiency and Cognition
 Iron Deficiency and Behavior
Central nervous system 
– irritability,
– fatigue,
– decreased attentiveness
– shorter attention span,
– reduced cognitive performance,
– behavioural disturbances (eg. ADHD)

Bourre JM. J Nutr Health Aging 2006;10:377-85

Kane A. ADHD and iron deficiency. http://www.mental-health-
matters.com/articles/article.php?artID=751
Lanzkowsky P. Iron-deficiency anemia. In: Lanzkowsky P. Manual of pediatric
hematology and oncology, 2nd ed. p.35
Conrad ME. Iron deficiency anemia. http://www.emedicine.com
Iron Deficiency Anemia and
Cognitive & Behavior problems
– sensory (auditory, visual)
– temperamen, emotion, affect
– attention,
• hiperactivity, inhibition
– Information processing,
• learning
• memory
– problem solving
• inteligency

 school performance
 behavior problems
» 2. Joyce C McCann JC, Ames BN. An overview of evidence for a causal relation between iron
deficiency during development and deficits in cognitive or behavioral function1 Am J Clin Nutr
2007;85:931– 45
» 3. Iannotti LL, Tielsch JM, Black MM, Black RE. Iron supplementation in early childhood : health benefit
and risks. Am J Clin Nutr 2006;84: 1261-76.
» 5. Grein J. The Cognitive Effect of Iron Deficiency in Non-Anemic Children. Nutrition Noteworthy 2001;
4(1).
» 6. Gordon N. Iron deficiency and the intelect. Brain & Development 2003 ; 25: 3 – 8.
» 7. Algarin C, Peirano P, Garrido M, Pizzaro F, Lozoff. Iron Deficiency Anemia in Infancy : Long-Lasting
Effects on Auditory and Visual System Functioniong. Pediatr Res 2003;53:217-223
 Holly Qur’an : importancy of iron
for human life

• “ dan kami turunkan zat besi yang

padanya terdapat kekuatan yang
hebat dan berbagai manfaat bagi
manusia …
• (QS – Al Hadiid (57) : 25 )
Iron Storage in the Brain
High percentage of brain
iron is stored as
FERRITIN or is
associated with
hemosiderin or
transferrin

Functional brain deficits

before the depletion of
iron or a significant
brain iron not available
to all brain regions

• Joyce C McCann JC, Ames BN. Am J

Clin Nutr 2007;85:931– 45

Sachdev P. J Neuropsych Clin Neurosc 1993;5:18-29

Iron Deficiency without and with Anemia
Iron Depletion Iron Deficiency Iron Deficiency
(without anemia) (without anemia) (with anemia)
Stage I II III
Hb normal normal decreased
Serum Iron normal < 60 ug/dl < 40 ug/dl
TIBC 360-390 ug/dl > 390 ug/dl > 410 ug/dl
Transferin 20-30 % < 15 % < 10 %
saturation
Feritin < 20 ug/dl < 12 ug/dl < 12 ug / dl
MCV normal normal decreased

Modified from : Raspati H dkk. Anemia defisiensi besi. Dalam Permono B, dkk. Editor.
Buku Ajar Hemato-onkologi anak 2005. hal 30-431.
 Iron Deficiency Anemia 2001
Underfives Children in Indonesia

Age Prevalence (%)

(months)
0 – 5 mos 61,3
6 – 11 mos 64,8
12 – 23 mos 58,0
24 – 35 mos 54,4
36 – 47 mos 38,6
48 – 59 mos 32,1
Total 47,0
Household Survey, 2001

Untoro R. Peningkatan Kualitas Hidup Anak Melalui Pencegahan Anemia Gizi Besi. Disajikan pada Kampanye Anti Anemia 2006-
2008. Depkes, Jakarta, 1 Maret 2007.
Iron Deficiency Anemia in Indonesia 2001
women 15 – 49 years age
Age (years) Prevalensi (%)
15 – 19 26,5
20 – 29 25,3
30 – 39 25,9
40 – 49 28,7
total 26,4
married 26,9
unmarried 24,5
pregnant 40,1

Household Survey, 2001

Untoro R. Peningkatan Kualitas Hidup Anak Melalui Pencegahan Anemia Gizi Besi. Disajikan pada Kampanye
Anti Anemia 2006-2008. Depkes, Jakarta, 1 Maret 2007.
Anemia among infants in Jakarta
• Sekartini et al (2005) Utan Kayu, East Jakarta
• 55 fullterm infants aged 4 – 12 mos
– Exclusively breast feeding 94.5 %
– No chronic disease
• Low and midle social economic status
– 38 % anemia,
– 73,3 % at 8 -12 mo of age
– the youngest 4 mo of age
– Hb 8,9 g/dl,
– feritin serum 3,2 ug.
Sekartini R, Soedjatmiko, Wawolumaya C, Yuniar I, Dewi R. Prevalensi Anemia Defisiensi Besi
pada Bayi Usia 4-12 Bulan di Kecamatan Matraman dan Sekitarnya, Jakarta Timur. Sari
Pediatri 2005 ; 7(1):2-8
 Indonesia Anemia Prevalence
Riskesdas 2007 (n = 8.700)

• 1 - 4 year 27,7 %
• 5 - 14 9,4 %
• 15 - 24 6,9 %
• 25 - 34 5,5 %
• 35 - 44 6,2 %
• 45 - 54 6,6 %
• 55 - 64 7,7 %
• 65 – 74 10,4 %
Anemia and Iron Deficiency
at Banjarbaru (Ringoringo, 2008)
– Anemia 0 – 6 mo : 40,8%,
• highest : 0 - 2 mo

– Iron depletion : 28,0 %,

– Iron deficiency : 27 % (0 - 6 bulan)

• highest at 0 mo : 14,2 %
 PREVALENSI ANEMIA
DI 17 SEKOLAH DASAR DKI JAKARTA TH 2007

60.0%

50.0%

40.0%

30.0%

20.0%

10.0%

0.0%
UTKU KBBW PSBR PDKL UTKU PSBR UTKS UTKS KBMG KBMG CPBS PDKP PDBB PDKL PDKL PDKL DRS
RATA2
07 01 05 01 11 07 13 20 08 09 03 06 05 11 12 02 W 10
Series1 36.9% 31.3% 29.3% 16.9% 11.1% 20.6% 22.6% 31.3% 37.5% 50.9% 14.4% 16.4% 25.1% 14.3% 15.3% 18.7% 27.0% 23.2%

Sasongko A. Prevalensi Anemia pada 17 Sekolah Dasar di Jakarta. Disajikan pada Kampanye Anti Anemia 2006-2008.
Depkes, Jakarta, 1 Maret 2007
Human Development Index 2005

• Singapura 25
• Malaysia 61
• Thailand 73
• Filipina 84
• China 85
• Palestina 102
• Vietnam 108
• Indonesia 110
(UNDP Report 2006)
 Alif Ahmad
Maulana
Anak pintar dan
jujur ?
 WHO recommendation
for iron suplementation (1998)
Prevalence Daily dosage Birthweight Duration
of Anemia category
in Children
6 – 24 mo
< 40 % 12,5 mg iron + Normal 6 – 12 mo
50 ug folic acid
LBW (< 2,500g) 2 – 24 mo

> 40 % 12,5 mg iron + Normal 6 – 24 mo

50 ug folic acid

LBW (<2,500g) 2 – 24 mo
Indication for Routine Iron Supplementation
Children <5 y old
Lannotti LL, Tielsch JM, Black MM, and Black RE,
Am J Clin Nutr 2006;84:1261–76
 Rekomendasi Ikatan Dokter Anak Indonesia (IDAI)
Pemberian Besi mulai Bayi sampai Remaja

Umur Dosis Lama Pemberian

Bayi BBLR (<2500 g) 3 mg /kgbb / hari Umur 1 bulan sd 2 tahun, tiap hari
sampai umur 2 thn (maks. 15 mg/hari/x)

Bayi cukup bulan 2 mg /kgbb / hari Umur 4 bulan sd 2 tahun, tiap hari
sampai umur 2 thn (maks. 15 mg/hari/x)

2 – 12 thn 1 mg /kgbb / hari 2x /minggu, selama 3 bulan berturut-

turut, tiap tahun

12 – 18 thn 60 mg /hari idem

Laki-laki

12 – 18 thn 60 mg/hari idem

Perempuan + asam folat 400 ug
Review of 40 studies : Cognitive or behavioral
performance of children with iron deficiency
Joyce C McCann JC, Ames BN. Am J Clin Nutr 2007;85:931– 45

40 studies of various experimental designs

cognitive or behavioral
ID + Anemia,
60% <2 y of age

consistent association between

ID + Anemia and poor performance
Review of 40 studies : Cognitive or behavioral
performance of children with iron deficiency
Joyce C McCann JC, Ames BN. Am J Clin Nutr 2007;85:931– 45

20 iron-treatment trials children with ID+Anemia,

mostly double blind randomized clinical trial
poorer performance
• improve with iron treatment in children > 2 y of
age
• more resistant to improvement in children <2 y of
age
 Review of 26 RCT Iron Supplementation in
Early Childhood
Lora L Iannotti, James M Tielsch, Maureen M Black, and Robert E Black
Am J Clin Nutr 2006;84:1261–76

• 26 randomized controlled trials.

– 0–59 mo, developing countries.

• Improved in cognitive and motor development deficits

– iron-deficient or anemic children,
– longer-duration, lower-dose regimens.

• No effect on morbidity,.

• in Nepal, no effects on mortality in young children

• Iron supplementation in preventive programs to be targeted
of iron-deficient children.
Screening and Routine iron supplementation
 Benefit of Iron Supplementation in
Iron Deficiency or Anemia Early Childhood
Lannotti LL, Tielsch JM, Black MM, and Black RE .Am J Clin Nutr 2006;84:1261–76

 Iron supplementation have some positive effects on

developmental among preschool-aged children
 reducing preexisting deficits
 preventing losses cognitive and motor skill
development

 Treatment at lower doses for 2–12 mo more beneficial

than very short courses of supplementation

• Two studies found a positive effect on height

increases in iron-deficient children,
 Cognitive or behavioral outcomes in
formerly anemic children

Auditory evoked potentials

• Joyce C McCann JC, Ames BN Am J Clin Nutr 2007;85:931– 45

Lozoff et al : conduction times measured over a 4-y period in

Chilean children with ID+A and control subjects  children at 5–
6 mo of age,
received iron supplements for 1.5 y 
the formerly ID+A group was gradually catching up to control
subjects,

• Shankar et al observed a significant correlation

between the severity of anemia and conduction
time in a group of children with ID+A ranging in age
from 3 to 11 y
 Mean Mental Development Score Before and
After Treatment with Ferrous Sulfate in 12 to
18 Month Infants

Before Iron
120
109 Treatment
108 108
105
102
After Iron
100 Treatment
89
Mental Development Score

80

60

40

20

0
Iron Deficiency Anemic Iron Deficiency Nonanemic Iron Sufficiency

Idjradinata P, Pollitt E. Reversal of developmental delays in iron-deficient anaemic infants treated with iron. Lancet 1993;
341: 1-4.
Supplementation for hematologically normal
children (1)
Joyce C McCann JC, Ames BN
Am J Clin Nutr 2007;85:931– 45

A non randomized trial (n = 1000),

examined normal children at 1y of
age after 6 mo of iron
supplementation,
longer looking times (P <0.01)
and other evidence of developmental
behavioral deficits
Suplementation in normal children (2)
Joyce C McCann JC, Ames BN
Am J Clin Nutr 2007;85:931– 45

Preventive trials in hematologically normal children if

they are supplemented with iron

Friel et al DBRCT (n=77) of a group of breastfed

children supplemented with iron or placebo from ages 1
to 6 mo
 At 12–18 mo of age,
higher visual acuity scores
and improved performance on the Bayley Psychomotor
Development Index
 Review of 8 RCT iron supplementation
Lannotti LL, Tielsch JM, Black MM, and Black RE . Am J Clin Nutr 2006;84:1261–76
• 8 RCTs iron supplementation reviewed for developmental outcomes,
5 found some possible benefits of iron supplementation (11, 13, 16–18),

Bangladesh : a weekly dose of 20 mg ferrous sulfate over 6 mo significantly

reduced developmental losses in orientation engagement (exploration)
Black MM, Baqui AH, Zaman K, et al. Iron and zinc supplementation promote motor development
and exploratory behavior among Bangladeshiinfants. Am J Clin Nutr 2004;80:903–10.

Indonesia: iron supplementation for 4 mo resulted in higher motor and mental

development scores on the Bayley Scales for Infant Development II (BSID)
in children with iron deficiency anemia,
but not in children who were iron deficient without anemia or who were iron replete
(11).
• Idjradinata P, Pollitt E. Reversal of developmental delays in irondeficient anaemic infants treated
with iron. Lancet 1993;34:1– 4.
•
Positive effect of iron supplementation
Lannotti LL, Tielsch JM, Black MM, and Black RE . Am J Clin Nutr 2006;84:1261–76

• Indonesian studies : with longer supplementation periods (6 & 2 mo,

respectively) indicated positive development outcomes:
– motor development as assessed by BSID in all children (18),
– visual attention and concept acquisition only inchildren with iron
deficiency anemia (13)
Effect of iron supplementation on cognition in
Greek preschoolers
E Metallinos-Katsaras1*, E Valassi-Adam2, KG Dewey3, B Lo nnerdal3, A Stamoulakatou4 and
E Pollitt3
European Journal of Clinical Nutrition (2004) 58, 1532–1542.

• Subjects: In all, 49 of 3–4-y olds (21 anemic, 28 good iron status)

with birth weight not less than 2500 g, currently healthy; benign past
medical history,I
• Intervention: The intervention consisted of a 2–month
supplementation of 15mg iron (and MV) vs placebo (MV alone).

• Results: After iron treatment, the anemic subjects made

significantly
– fewer errors of commission (14% higher specificity,P<0.05),
– exhibited 8% higher accuracy (P<0.05)
– significantly more efficient (mean difference¼1.09, Po0.05)
– These effects of iron were not found among preschoolers with good
iron status.
– No effects of iron treatment were found on the Oddity Learning task.
• Conclusions:
– iron supplementation of iron-deficient anemic preschoolers results in an
improvement in discrimination, specifically selective attention.
 WHO recommendation for
iron suplementation (1998)
Prevalence Daily dosage Birthweight Duration
of Anemia category
in Children
6 – 24 mo
< 40 % 12,5 mg iron + Normal 6 – 12 mo
50 ug folic acid
LBW (< 2,500g) 2 – 24 mo

> 40 % 12,5 mg iron + Normal 6 – 24 mo

50 ug folic acid

LBW (<2,500g) 2 – 24 mo
 Rekomendasi Ikatan Dokter Anak Indonesia (IDAI)
Pemberian Besi mulai Bayi sampai Remaja

Umur Dosis Lama Pemberian

Bayi BBLR (<2500 g) 3 mg /kgbb / hari Umur 1 bulan sd 2 tahun, tiap hari
sampai umur 2 thn (maks. 15 mg/hari/x)

Bayi cukup bulan 2 mg /kgbb / hari Umur 4 bulan sd 2 tahun, tiap hari
sampai umur 2 thn (maks. 15 mg/hari/x)

2 – 12 thn 1 mg /kgbb / hari 2x /minggu, selama 3 bulan berturut-

turut, tiap tahun

12 – 18 thn 60 mg /hari idem

Laki-laki

12 – 18 thn 60 mg/hari idem

Perempuan + asam folat 400 ug
 Summary :
Iron Deficiency without and with Anemia
Iron Depletion Iron Deficiency Iron Deficiency
(without anemia) (without anemia) (with anemia)
Stage I II III
Hb normal normal decreased
Serum Iron normal < 60 ug/dl < 40 ug/dl
TIBC 360-390 ug/dl > 390 ug/dl > 410 ug/dl
Transferin 20-30 % < 15 % < 10 %
saturation
Feritin < 20 ug/dl < 12 ug/dl < 12 ug / dl
MCV normal normal decreased

Modified from : Raspati H dkk. Anemia defisiensi besi. Dalam Permono B, dkk. Editor.
Buku Ajar Hemato-onkologi anak 2005. hal 30-431.
 Iron Deficiency Anemia 2001
Underfives Children in Indonesia

Age Prevalence (%)

(months)
0 – 5 mos 61,3
6 – 11 mos 64,8
12 – 23 mos 58,0
24 – 35 mos 54,4
36 – 47 mos 38,6
48 – 59 mos 32,1
Total 47,0
Household Survey, 2001

Untoro R. Peningkatan Kualitas Hidup Anak Melalui Pencegahan Anemia Gizi Besi. Disajikan pada Kampanye Anti Anemia 2006-
2008. Depkes, Jakarta, 1 Maret 2007.
 Indonesia Anemia Prevalence
Riskesdas 2007 (n = 8.700)

• 1 - 4 year 27,7 %
• 5 - 14 9,4 %
• 15 - 24 6,9 %
• 25 - 34 5,5 %
• 35 - 44 6,2 %
• 45 - 54 6,6 %
• 55 - 64 7,7 %
• 65 – 74 10,4 %
Iron Deficiency Anemia and
Cognitive & Behavior problems
– sensory (auditory, visual)
– temperamen, emotion, affect
– attention,
• hiperactivity, inhibition
– Information processing,
• learning
• memory
– problem solving
• inteligency

 school performance
 behavior problems
» 2. Joyce C McCann JC, Ames BN. An overview of evidence for a causal relation between iron
deficiency during development and deficits in cognitive or behavioral function1 Am J Clin Nutr
2007;85:931– 45
» 3. Iannotti LL, Tielsch JM, Black MM, Black RE. Iron supplementation in early childhood : health benefit
and risks. Am J Clin Nutr 2006;84: 1261-76.
» 5. Grein J. The Cognitive Effect of Iron Deficiency in Non-Anemic Children. Nutrition Noteworthy 2001;
4(1).
» 6. Gordon N. Iron deficiency and the intelect. Brain & Development 2003 ; 25: 3 – 8.
» 7. Algarin C, Peirano P, Garrido M, Pizzaro F, Lozoff. Iron Deficiency Anemia in Infancy : Long-Lasting
Effects on Auditory and Visual System Functioniong. Pediatr Res 2003;53:217-223
 WHO recommendation for
iron suplementation (1998)
Prevalence Daily dosage Birthweight Duration
of Anemia category
in Children
6 – 24 mo
< 40 % 12,5 mg iron + Normal 6 – 12 mo
50 ug folic acid
LBW (< 2,500g) 2 – 24 mo

> 40 % 12,5 mg iron + Normal 6 – 24 mo

50 ug folic acid

LBW (<2,500g) 2 – 24 mo
 Rekomendasi Ikatan Dokter Anak Indonesia (IDAI)
Pemberian Besi mulai Bayi sampai Remaja

Umur Dosis Lama Pemberian

Bayi BBLR (<2500 g) 3 mg /kgbb / hari Umur 1 bulan sd 2 tahun, tiap hari
sampai umur 2 thn (maks. 15 mg/hari/x)

Bayi cukup bulan 2 mg /kgbb / hari Umur 4 bulan sd 2 tahun, tiap hari
sampai umur 2 thn (maks. 15 mg/hari/x)

2 – 12 thn 1 mg /kgbb / hari 2x /minggu, selama 3 bulan berturut-

turut, tiap tahun

12 – 18 thn 60 mg /hari idem

Laki-laki

12 – 18 thn 60 mg/hari idem

Perempuan + asam folat 400 ug
 MD ?
( setelah disita semua
hasil kejahatannya)
 Rekomendasi Ikatan Dokter Anak Indonesia (IDAI)
Pemberian Besi mulai Bayi sampai Remaja

Umur Dosis Lama Pemberian

Bayi BBLR (<2500 g) 3 mg /kgbb / hari Umur 1 bulan sd 2 tahun, tiap hari
sampai umur 2 thn (maks. 15 mg/hari/x)

Bayi cukup bulan 2 mg /kgbb / hari Umur 4 bulan sd 2 tahun, tiap hari
sampai umur 2 thn (maks. 15 mg/hari/x)

2 – 12 thn 1 mg /kgbb / hari 2x /minggu, selama 3 bulan berturut-

turut, tiap tahun

12 – 18 thn 60 mg /hari idem

Laki-laki

12 – 18 thn 60 mg/hari idem

Perempuan + asam folat 400 ug
 Thank You
Mama Papa !