In the name of Allah, the beneficent.

the merciful

BLOK TUMBUH KEMBANG
Beberapa hal dari bidang Ilmu Kesehatan Anak

Dr. Bambang Mulyawan SpA FK-UMM

Pendahuluan
• TUJUAN ILMU KESEHATAN ANAK :

“Tujuan utama IKA adalah membentuk seorang anak seutuhnya dg.kualitas sesuai potensi genetiknya melalui perawatan tumbuh kembang anak secara terus menerus dan terpadu sejak pembuahan sampai kematangan yang optimal “

Children = small adults

=
4 ©KHoppu 7.3.2007

Prof Sir Ian Kennedy The Report of the Public Health Inquiry into Children’s Heart Surgery at the Bristol Royal Infirmary 1984-1995 .‘Children are in a constant state of growth and development which creates particular needs and demands which are of a different order from those affecting adult patients’.

Tumbuh –Kembang normal • Growth and Development includes: – – – – – Physical Mental Psychological Social Spiritual .

• Pertumbuhan : bertambah besar dlm aspek fisik akibat multifikasi sel dan bertambahnya jumlah zat interseluler ( dpt diukur) • Perkembangan : bertambahnya ketrampilan dan fungsi yg kompleks = maturasi dan diferensiasi .

heredokonstitusional / gen / keturunan / endogen / dalam /bawaan /bakat • 2. lingkungan ( pranatal dan pascanatal ) : fisikobiopsikisosial • Lingkungan yang cukup baik akan memungkinkan dicapainya potensi genetik/ bawaan/ bakat anak .Faktor yang mempengaruhi pertumbuhan dan perkembangan • 1.

5 – 3.Bayi Baru Lahir (Clinical assessment Routine measurements) Measure: • Weight – normal 2.99kg • Length – normal 48 – 52cm • Occipitofrontal circumference (OFC) – normal 33 – 37cm Measurement of OFC using a nonstretchable tape measure .

Bayi Berat Badan Lahir Rendah • 75% neonatal deaths and 50% infant deaths occur among LBW infants • LBW babies are more prone to: – Malnutrition – Recurrent infections – Neuro developmental delay LBW babies have higher mortality and morbidity Teaching Aids: NNF LBW10 .

Intrauterine growth chart 4400 4000 LARGE FOR DATE 3600 90th percentile Birth weight (grams) 3200 2800 2400 2000 1600 1200 800 400 APPROPRIATE FOR DATE 10th percentile SMALL FOR DATE PRETERM 31 33 35 37 TERM 39 42 POST-TERM 44 45 Teaching Aids: NNF Gestation (weeks) LBW- 11 .

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Problem BBLR (SGA) • • • • • • • Asphyxia Meconium aspiration Pulmonary Hemorrhage Intracranial Hemorrhage Hypoglycemia Hypothermia Polycythemia .

Bayi Berat lahir Rendah 2. Bayi Lebih Bulan . Bayi Berat Lahir Berlebih • Masa gestasi / umur kehamilan : 1.Klasifikasi bayi menurut berat lahir dan masa gestasi • Berat lahir : 1. Bayi Berat Lahir Cukup/normal 3. Bayi Kurang Bulan 2. Bayi Cukup Bulan 3.

• BBLR : < 2500 gram tanpa memandang masa gestasi • Bayi Berat Lahir Cukup/ Normal : berat lahir >/= 2500 gram -4000 gram • Bayi Berat Lahir Lebih : > 4000 gram • Bayi Kurang Bulan (BKB) : masa gestasi < 37 minggu ( < 259 hari) • Bayi Cukup Bulan (BCB) : masa gestasi 37 – 42 mg (259-293 hari) • Bayi Lebih Bulan (BLB) : masa gestasi > 42 minggu (294 hari) • Bayi Kecil Untuk Masa Kehamilan :”Small for gestational age /SGA” berat lahir < 10 persentil grafik Lubchenko • Bayi Besar Untuk masa kehamilan: “ Large for gestational age/LGA” berat lahi > 10 persentil grafik Lubchenko .

Classification of newborn by weight and gestational age • Help in predict potential problems – LBW: <2500gm – VLBW: <1500gm – ELBW: <1000gm • Term :completed 37 weeks gestation till 42 week • Premature. less than 37 weeks gestation .

LOW BIRTH WEIGHT BABIES Low birth weight • Definition • Incidence : < 2500 g : 30% neonates 17 .

. . • LBW babies are more prone to : .recurrent infections.malnutrition. .Importance • LBW babies account for 25% neonatal deaths and 50% infant deaths.neurodevelopmental delay.

Two types of LBW neonates • Preterm ( 1/3 ) • Small for dates ( 2/3) 19 .

LBW (Preterm) : Problems • Birth asphyxia • • • Respiratory distress Hypothermia • Apneic spells Feeding difficulties • Intraventricular hemorrhage Infections • Hypoglycemia Hyperbilirubinemia • Metabolic acidosis 20 • • .

LBW (SFD) : Problems • • • • • • Birth asphyxia Meconium aspiration syndrome Hypothermia Hypoglycemia Infections Polycythermia 21 .

anemia.Causation : IUGR / SFD • • • • • Poor nutritional status of mother. Tobacco use. chronic illness. . Chronic malaria. Multiple pregnancy. toxemia. postmaturity. Hypertension.

cervical incompetence. • Induced premature delivery. • Previous preterm baby. multiple pregnancy. • Antepartum hemorrhage.Causation : Prematurity • Low maternal weight. teenage pregnancy. • Majority unknown. . acute systemic disease.

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breast nodule. . genitalia.Identification of preterm LBW • Date of LMP • Physical features . ear cartilage / recoil. sole creases.

Identification: Preterm LBW Breast nodule Preterm Term Preterm Teaching Aids: NNF LBW- Term 26 .

Identification: Preterm LBW Male genitalia Preterm Preterm Term Term Teaching Aids: NNF LBW- 27 .

Identification: Preterm LBW Female genitalia Preterm Term Teaching Aids: NNF LBW- 28 .

Identification: Preterm LBW Sole creases Preterm Term Teaching Aids: NNF LBW- 29 .

Identification: Preterm LBW Ear Cartilage Preterm Teaching Aids: NNF LBW- Term 30 .

Hipotermia pada neonatus .

Pendahuluan All gestational age newborns at risk of losing heat soon after birth .

. progressing to death .Pendahuluan . . . leading to O2 consumption – Caloric consumption and glycogen stores – Development of acidosis due to pulmonary vasoconstriction – Thermal shock and DIC (in the more serious cases). • Neonatal hypothermia induced cold stress and result in: – Metabolic rate.

. . LBW (~65%). • Hypothermia significantly occurred in the vulnerable group of newborns on neonatal admission. suffering hypoglycaemia since birth or birth asphyxia. • The vulnerable group of babies with C/S birth in OT were more easily prone to hypothermia. . • The vulnerable group of sick babies included premature (~38%).Fakta .

• In general. without any special equipment. • Both are dangerous and may cause the death of the baby. newborns need a warmer environment than adults. • All health care providers need to be alert to the risk of hypothermia and hyperthermia. by simple procedures. but are easily prevented. .

4˚c  36˚c 35.9˚c  32˚c Below 32˚c Mild hypothermia Moderate hypothermia Severe hypothermia WHO.WHO: Definition of hypothermia (°C) 36. 1997 .

Operative Definition of Hypothermia in Delivery Suite

Hypothermia = Temp below 36ºC

Moderate hypothermia =Temp at 35-35.9

Profound hypothermia =Temp less than 35º

Optimal temp. range:36.8–37.2 °C

Kehilangan panas pada neonatus

Four ways a newborn may lose heat to the environment. Most cooling of the newborn occurs during the first minutes after birth.

Pencegahan
Warm Chain: Is a set of ten interlinked procedures carried out at birth and during the following hours and days which will minimize the likelihood of hypothermia in all newborns.

Pencegahan hipotermi neonatal

Warm resuscitation. 3. 4. 9. Mother and baby together. 2. Skin-to-skin contact. Training/awareness raising. Bathing and weighing postponed. Warm delivery room. 7.Pencegahan THE WARM CHAIN 1. 6. 10. Breast-feeding. Warm transportation. . 8. Appropriate clothing and bedding. Immediate drying. 5.

Hipoglikemia pada neonatus .

as cited by Barnes-Powell. > 20 preterm (Kenner & Lott. 2006) > 40 mg/dl (Verklan & Walden. 2007) . R. 2004) > 30 term. 2004) > 45 mg/dl (Cowett.What is Normal? • Defining a normal glucose level remains controversial – – – – 50 – 110 mg/dl (Karlsen.

Incidence of Hypoglycemia • Overall Incidence = 1. 1999 as cited by Verklan & Walden .5/1000 live births – Normal newborns – 10% if feeding is delayed for 3-6 hours after birth – At-Risk Infants – 30% • • • • LGA – 8% Preterm – 15% SGA – 15% IDM – 20% McGowan.

2006 .Why is hypoglycemia a problem? • Glucose is the primary fuel for the brain. • Glucose is the fetus’s only source of carbohydrate. Karlsen. • The brain needs a steady supply of glucose to function normally.

Verklan & Walden. infants have a higher brain to body weight ratio. 2004 .Why is hypoglycemia a problem? “Compared with adults. “Cerebral glucose utilization accounts for 90% of the neonate’s glucose consumption”. resulting in higher glucose demand in relation to glucose production capacity”.

Preparation for Birth • Fetal plasma glucose is 60 – 80% of the maternal glucose level. heart. • Most of the glycogen is made and stored in the last month of the 3rd trimester. Karlsen. lung. • The fetus stores glucose in the form of glycogen (liver. and skeletal muscle). 2006 .

2005 . • When the infant is born. the cord is cut and so is the major supply of glucose! Haney.Preparation for Birth • The fetus has limited ability to convert glycogen to glucose and must rely upon placental transfer of glucose to meet energy needs.

Preparation for Birth • The transition from fetus to newborn creates a significant energy drain on the newborn. • The newborn is now required to meet increased metabolic demands while changing the energy source from a placenta-supplied source to an external food source. 2005 . Haney.

2006 .Infants at Highest Risk • • • • • • < 37 weeks gestation Infant of a diabetic mother Small for gestational age Large for gestational age Stressed/ill infants Exposure to certain medications – – – – – Treatment of preterm labor Treatment of hypertension Treatment of type 2 diabetes Benzothiazide diuretics Tricyclic antidepressants in the 3rd trimester Karlsen.

2006 .Factors that negatively affect glucose availability after birth • Inadequate Glycogen • Increased Utilization of Glucose • Excessive Insulin Karlsen.

Inadequate Glycogen • Glycogen stores increase rapidly in the last month of the 3rd trimester • Preterm infants are born before this occurs. Karlsen. 2006 . What little glycogen is available is used up rapidly and their supply is depleted.

Inadequate Glycogen • SGA – birth weight < 10 percentile. . Chronically stressed infants have higher metabolic demands and use up available glucose for growth and survival. • Markedly post-mature infants are at increased risk due to increased metabolic demand.

– These include all sick. Karlsen. premature and SGA infants. 2006 .Increased Utilization of Glucose • Sick/Stressed infants – Causes increase in metabolic demand – Uses up glucose quickly.

Excessive Insulin .IDM • Infants of Diabetic Mothers – Many consequences for the neonate – Single most important factor in determining the outcome for the infant is maternal glucose control .

Nursing Management • Complete evaluation and review of systems • Early breast or bottle feeding within 30 minutes • Glucose monitoring within 1 hour • Monitor pre-feeding levels thereafter .

Monitoring • Serum glucose level is the gold standard • Bedside glucose levels are for screening • Monitor at least hourly until glucose level has stabilized • Know your hospital policy for monitoring infants at risk for hypoglycemia Kenner. 1998 .

2004 .Signs & Symptoms of Hypoglycemia • • • • • • Jitteriness Irritability Hypotonia Lethargy High-pitched cry Hypothermia • • • • • • Poor suck Tachypnea Cyanosis Apnea Seizures Cardiac arrest Verklan & Walden.

Treatment • Oral feedings as tolerated • If glucose is very low or the infant is not able to feed orally: – – – – 2ml/kg of D10W IV bolus Follow up screenings within 30 minutes Repeat bolus if glucose is < 50 mg/dl If unable to stabilize glucose consider increasing IV rate or glucose concentration Karlsen. 2006 .

Prevention • Increase awareness of conditions that predispose an infant to hypoglycemia • Early screening of at-risk infants • Early and frequent feedings • Maintain temperature .

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What Medical Students Expect from Medical Ethics Classes HATTORI Kenji. Gunma University) . MD DMSc MA (Japan.

however. • Most of them focus on the present variety of styles how to teach in practice and the attitudes of teachers toward their classes. • Little attention. has been paid for what medical students expect from medical ethics classes yet.Background & Aims • Most medical schools have acknowledged the importance of medical ethics education. There are many surveys concerning to the methodology of medical ethics classes. .

anonymitytype questionnaire to survey the needs and expectations of medical students with their medical ethics class. . • The survey population consisted of firstyear students in a medical school who had been taking a medical ethics course for approximately three months.Methods • We used an 8-item structured.

The Questionnaire 1 * How much value does the medical ethics class have? * How much time should be spared for this subject? * What kind of person would be fit to teach a course on medical ethics? * Should the class be conscious of the National Examination for Physicians or not? .

The Questionnaire 2 * What are purposes expected of the class? * What is a suitable form of the class? * What is a suitable form of the evaluation examination? * In which grade should the class be offered? .

Results Seventy-two of the 85 first-year students (response rate. the set of first-year students in fiscal year 2000 is designated as 'Student-2000'. 55. . and the other set as 'Student-2001'.3%) in fiscal year 2001 participated in this survey.7%) in fiscal year 2000 and 47 of the 85 first-year students (response rate. 84. Below.

3) Student-2001 1 (2.8) 41 (56.0) 2 (2.1) 0 (0.Recognition of the importance of a medical ethics class Totally unnecessary More necessary than not Necessary Definitely necessary Values are n (%).4) .9) 29 (40.5) 19 (40.0) 27 (57. Student-2000 0 (0.

24 (34.2) 9 (12.Recognition regarding appropriate semester hours Student-2000 23 hours half a year 45 hours for a year 90 hours for a year More credit hours Values are n (%).4) 31 (70.9) 6 (8.1) 0 (0.6) Student-2001 9 (20.3) 31 (44.0) .5) 4 (9.

Recognition regarding who should be the teacher in charge Student-2000 Best Better Student-2001 Best Better 13 1 0 0 0 12 0 10 3 1 0 5 4 0 Philosophers/ethicist who is interested in medical issues Medical legal professional Priest/theologian Welfare professional Nurse 16 0 0 1 2 24 1 11 6 0 2 11 16 0 Clinician Biomedical researcher Medical Profession who has undergone a philosophy or ethics education NGO/NPO activist Values are n. 23 7 17 5 1 4 0 1 .

6) 35 (50.8) 22 (52.3) 10 (12.Awareness of the National Examination for Physicians and Medical Ethics Class Student-2000 The course should concentrate on the NEP Much weight should be devoted to the NEP Little weight should be devoted to the NEP The NEP should be of no concern Values are n (%).7) .1) 2 (4. 3 (4.4) 15 (35.7) 21 (30.4) Student-2001 3 (7.

Role anticipation for teachers Student-2000 most important more important Introductions of actual situations in a clinical setting 23 11 Explanations of research and theoretical trends 1 3 Instigating arguments and dealing with problems 13 7 Scholarship in medicine 2 3 Scholarship in medical law 0 3 Scholarship in philosophy and ethics 3 1 Scholarship in medical policy 0 0 Responsive to the opinions of students 7 11 Offerings of most appropriate moral judgements 1 1 Proper manners and etiquette 1 5 Presentation of personal opinions and experiences 1 4 Thoughts from divergent perspectives 15 16 Values are n. .

5) Primarily Discussions 15 (21.Session styles Student-2000 Primarily Lectures 6 (8.4) Student-2001 1 (2.1) Lectures + Discussions 50 (70. .8) 29 (70.7) Values are n (%).5) 11 (26.

0) 32 (78.0) .0) Student-2001 9 (22. Student-2000 17 (25.Recognition of a suitable method of course evaluation Multiple-choice test Essay test Values are n (%).0) 51 (75.

.When to hold the course Grade 1 2 3 4 5 6 Student-2000 50 (70.8) 2 4 0 0 4 Values are n (%).4) 1 4 3 6 8 Student-2001 35 (77.

or dying with dignity). . we tried to discover the attitudes and needs of the students from a fundamental viewpoint of course construction as a whole. cloning humans. assisted reproduction. Before selecting themes for lectures. no inquiry into the fundamental nature of these courses was actually executed.Discussion 1 Some previous researches included surveys on students’ attitudes. Although the authors asked the students what lecture themes they preferred (issues of brain death and organ transplants.

the students from two different school years gave considerably similar responses . however.Discussion 2 It is impossible to assume that all medical students could possibly share a single opinion. and the form and nature of the previous courses they have taken. school year. As far as this survey is concerned. We can assume that their responses may vary widely depending on circumstances such as the university.

Discussion 3 Many of the students who participated in the survey seem to be in favor of starting a medical ethics course from the first year. This probably indicates they are aware that a lack of detailed knowledge in medicine as a natural science would not be a major obstacle to taking a medical ethics course. .

.Discussion 4 Many medical students do not seem to wish to be given (at least not by a teacher) knowledge that can be answered in yes-orno questions.

4) what actions they take with regard to their decisions. 3) what decisions they make.Discussion 5-1 What underclassmen in medical schools really want to know seems to be 1) the reality of a clinical setting. . 2) what ethical issues physicians face. and 5) how they can acquire the ability to see things from a number of different perspectives.

They seems to have intuition that clinicians’ talk and belief can be close to simple dogmatism.Discussion 5-2 This is not to imply that they necessarily want to swallow whatever experienced doctors judge and practice. it seems that they want to review and examine what they are told and what is considered to be “medical ethics”. Rather. .

Medical ethics teachers are here to show the way. . to be able to accept different values as they are.Discussion 6 A patient and a medical worker seldom share the exact same values or views of life. and to carry out a continuous and thorough consideration at all times. It is very important for students to learn to be more receptive to divergent views and values that other people may have.

Second. thirdly. the professors should maintain an attitude of acceptance in order to ensure the expression of divergent perspectives. . such a course should be offered in an introspective format with lively discussions. And.It seems appropriate to remark that the cooperation between clinicians and philosophers and ethicists is a basic necessity for a medical ethics classes.

Thank you for your attention! .

to make sure that these students are fully aware of their own ethical positions. The essential task for a medical ethics teacher is to provide a relative evaluation of the opinions and values of each of his/her students. .In conclusion Students who are weak in communication skills are not hard to find. and to urge reviews that include serious self-examination.

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