ASI, MPASI, GIZI SEIMBANG

BALITA

Darmono SS
 Hasil Sensus Penduduk 2020

Generasi Z 27,94 % = 74.93 juta, gen Milenial 25.87 % =69.38 total = 134.31 juta jiwa, anak 90 juta
 Health, Nutrition Problems in Life Cycle 26,4 juta
Census (Indonesia) 2020 10 million IDA, 14 I, COPD,
Elderly people

5 million
Pregnant
- 3 mill IDA mothers
- 1,5 mill CEM
n Care ty
tri tio ilabili 118 million
l th , Nu od Ava sibility
Hea old Fo Acces 10 million
o useh ervice
H S
e a lt h
H
5 million Adolescent girls
& young women

New born
babies 31 million
- 5 mill stunting, obes
- 3,5 mill adolescent
- 8,1 million IDA
- 5 million VAD (15-19 yr) &
School age reprod. age IDA
600.000 LBW sub clinic
children - 30 million CEM
Every years

18 juta, Under five - 11 million stunting

children - 10 million IDA
- 3,4 million IDD risk
Jumlah anak sejak dalam kandungan sampai 18 tahun sebanyak 90 juta jiwa
Source: WHO MOD, 2020
 •Gizi ibu dan anak
•beyond intergenerational continuum
•Karena waktu tak akan kembali
•Chronicity gap to standard
•Gizi  long lasting impact
•Gizi  irreversible, point of no returned
What’s Wrong ?
Nutrition competition, among mother and
fetus

59.000 perkawinan anak per tahun, di Indonesia

World Health Assembly, Evaluation 2025

Post MDGs  SDGs agenda. General Assembly, 2014.

Kata kunci gizi janin dalam kandungan

• Gizi ibu sebelum hamil

• Konsepsi
• Celuler diferensiasi
• Proliferasi
• Maturasi
• Patologi
• Nature >< nurture
•Air Susu Ibu
Produksi ASI, Let Down Reflex

Human physiology, Sherwood, 2018.

 Amino acids ASI
• Alanine
• Arginine
• Aspartic acids
• Cystein
• Glutamines
• Glycine
• Histidine
• Isoleucin
 Amino acids ASI
• Isoleucine
• Lysine,
• Methionine
• Phenylalanine
• Proline
• Serine
• Taurin
• Threonine
• Tryptophan,
• Tyrosine
• valine
 Imunologis ASI
• Immuno modulating agents
• Interleukin : 1 beta, IL 6, IL 8, IL 10, TGF beta 2, TNF alpha,
• Leukocytes
• Macrophages
• Growth factors
• Granulocytes CSF
• Hormones
 Imunologis ASI
• Imunologis celuler, molekuler , gut epithelial maturity
•  gut integrity
• Colustrum  ? 3-5 hari
• ASI transisi 5 – 10 hari  matur milk
• Frekuensi 12 – 15 kali / hari
• 67 kcal / 100 ml
• Lipid 40 – 50 %
• Bifudus factor
 Imunologis ASI
• Linoleic acids
• Arachdonic acid
• Linolenic acids
• DHA, PUFA  cel otak dan retina
• Ig A
• Lactalbumin
• Lactolbuminm
• Casein, Lactoferin
• Lysozomes
 Imunologis ASI
• Anti inflammatory factors:
• TNF alpha receptor 1, II
• IL 1 receptor antagonist
• Protease inhibitors
• Enzyme degrading mediators
• Cytokines
• Prostaglandins
 Immunoglobuline specific ASI
• Ig A
• Ig G
• Ig M
• Ig D
• Ig E
• Nucleic acid
• nucleotides
 a-lactalbumin in human nutrition

Protein concentrations of whey and casein fractions in bovine and human milk. Bioactive peptides and essential amino
acids, including tryptophan, lysine, branched-chain amino acids, and sulfur-containing amino acids, all of which are
crucial for infant nutrition. a-Lactalbumin contributes to infant development 1,2 Abbreviations: Ig, immunoglobulin; ND,
a-lactalbumin in human nutrition
 a-lactalbumin in child nutrition

Serotonin synthesis and function in the neuron. Abbreviations: 5-HT, 5-hydroxytryptamine

(serotonin); MAO, monoamino oxidase; 5HIAA, 5-hydroxyindole acetic acid.
Epidemiology, Countries Have Stunting Rates of 40% or More

World General Assembly : 2014 : Timor Leste, Ghana, Gambia, Cad,

23 countries in Afrika. 16 countries in Asia, di Indonesia (160
kabupeten). Di 19 di kabupaten di Jawa Tengah.
 Indonesia Stunting epidemyology

Prevalence of stunting (%) in children 0–59 months. Source: Indonesia basic

Health Research survey (Lembaga Penerbitan Balitbangkes Kementerian
Kesehatan Republik Indonesia, Beal T, Matern Child Nutr, 2018, e12617.
Effect of Women’s Nutrition before and during Early Pregnancy
on Maternal and Infant Outcomes:
Poor Child
Maternal LBW Premature Growth & Maternal

Outcomes
Mortality Delivery Developmen Nutrition Status
immunization
, stimulation t

Adolescence, Subsequent
Early Points First Pregnancy
Nutrition specific Preconception Preconception Pregnancies

School Girls Newlyweds Interpregnancy

Out of School Girls Interval
Intervention

Food quality Micronutrient

Nutrition Education
& quantity Supplementation
Underlying Factor
Maternal

Nutrition Status , Age at first

BMI/ Fat Height Micronutrient Status
FP Pregnancy
Stores

Nutrition sensitive : safety net, FP, women empowerment, H &S. A Systematic Review .
Blackwell Publishing Ltd Paediatric and Perinatal Epidemiology, 2012, 26 (Suppl. 1), 285–301
 Kata Kunci, Tumbuh Kembang Anak
• Kata kunci pasca dilahirkan:
• ASI
• Vaksinasi
• MPASI
• Proteksi (prevensi, cegah inflamasi, infeksi,, cedera / jatuh, cacat)
• Stimulasi
• Evaluasi
• Koreksi
World Child Stunting (WHO, 1994 –
2007)
Child World Critical Window
Opportunity

www.thelancet.com vol 35, Februari 22, 2020

 • Gangguan pertumbuhan telah terjadi sejak usia 4-6 bulan pertama kehidupan bayi;
terjadi baik di desa maupun kota
• Mulai umur 6 bulan gangguan pertumbuhan makin nyata dan mencapai puncaknya
pada umur 11 bulan
• Kurva pertumbuhan masih tetap menurun hingga umur 23 bulan
• Sesudah 23 bulan kurva pertumbuhan relatif mendatar

1.5

1
K eadaan gizi m enurut B B/U

1999 2000 2002

0.5

0
0 4 8 12 16 20 24 28 32 36 40 44 48 52 56 60
-0.5

-1

-1.5

-2
Umur (bulan)
 GAMBARAN STATUS GIZI BALITA, RISKESDAS 2007 -
2018
40 36.8
35
30
Prevalensi (%)

25
20 18.4

15 13.6
12.2
10
5
0
GIZI KURANG PENDEK KURUS GEMUK

Stunting : Timor Leste, Chad. Indonesia, Nigeria, Gambia, Mali dan Chad .
Obesity : Turki, Vanuatu, negara pariwisata, berpenghasilan menengah keatas
Balita sangat Pendek & Pendek
 PREVALENCE OF UNDER-FIVE STUNTING AND OBESITY FOR HIGHEST
AND LOWEST WEALTH QUINTILES IN SELECTED COUNTRIES (%)

Note: Red circles are the lowest wealth quintiles; blue circles are the highest wealth quintiles. BAZ = body
mass index-for-age Z-score. HAZ = height-for-age Z-score. DHS = Demographic and Health Survey. MICS =
 Child Rearing Patern
Buat KIE, hindari semua kesalahan
Bayi baru lahir
Riskesdas 2013, Post Covid  back sliding
Let Down Reflex, welingness, baby
 •Gerakan lintas sector :
One ASI
•Satu aksi untuk negeri
Menyusui dan Involusi Uteri
 Hambatan ASI Eksklusif
• Kesadaran ?
• Breast care ?
• Pre lacteal ?
• Ibu bekerja di luar rumah (ASI dipompa)
• Pre term birth
• BBLR (12 – 27 %)
• Ibu yang anemi (> 70 %)
• Ibu yang KEK (23 %)
• Ibu yang obes (Gestational DM 10 -12 %)
 0
5
10
15
20
25
30

NAD
Sumut
Sumbar
Riau
Jambi
Sumsel
Bengkulu
Lampung
Babel
Kepri
DKI
Jabar
Jateng
Jogja
Jatim
Banten
Bali
NTB
NTT
Kalbar
Daya isap anak BBLR kurang
Kalteng
Kalsel
Kaltim
Sulut
Sulteng
Sulsel
Sulgar
Gorontalo
Sulbar
Maluku
Maltara
PapuaBar
Papua
Indonesia
Riskesdas, 2007
Low birth weight baby in Indonesia
 Produksi ASI Ibu Anemi

Mengancam Bayi Anemia, Partus macet, Perdarahan

melahirkan , kematian ibu IQ anak rendah,
Gizi ibu sebelum hamil KEK : Produksi ASI ?

18 % TB ibu hamil <

150 Cm
9,4 % TB ibu hamil <
145 Cm
BMI < 18,5
30 % ibu hamil KEK ( <
23,5 Cm)

The most common organs and tissues of the female human body in which PlGF is produced. J
Maternal Fetal Neonatal Med, 2013; 26(10): 995–1002 ! 2013 Informa UK Ltd. DOI:
10.3109/14767058.2013.766694
Status Gizi Ibu,  gagal menyusui
 Balita Gizi seimbang
• Cegah IUGR,
• ibu hamil gizi normal(jangan anemi, KEK, Overweight, obes)
• Lahir BB 3000 gram
• Panjang Badan 49 Cm
• ASI eksklusif MP ASI adequate
• BB umue 1 tahun 9,5 Kg
• PB 75 Cm
• TB anak umur 5 tahun 105 Cm
 A new conceptual framework for
maternal health

Maternal morbidity measurement (MMM) framework. Veronique Filippi1 Int J Gynecol

Obstet 2018; 141 (Suppl. 1): 4–9
 A future for the world’s children? A WHO–
UNICEF–Lancet Commission. Intergenerational
continum

Sustainable Development Goals measuring protective and risk factors for child wellbeing across the life
course ICT=information communication technology. SRH=sexual and reproductive health.
Nutrition and life cycle, Intergenerational continuum
di asuh satu persatu

Maternal height < 145 Cm  9,4 %  BBLR, stunting (< 49 Cm)

Ibu KEK < LLA < 23,5 Cm  30 %,  BBLR  11,5 % - 27 %
 Screening Gizi Ibu Hamil
Algoritma, Pregnancy & Nutrition
Women who report at clinics within the first trimester of pregnancy
< 50 kg
Weight Specialised nutritional care
50 kg+
Asses dietary intake
Height < 145 cm Assess physical activity
Review food security
145 cm+ Asses nutrition knowledge
Calculate BMI Encourage HIV testing if not done yet
Assess socio economic situation
27+ 20 – 25.9 <20
Provide nutrition and lifestyle education
Energy and nutrient supplementation
Arragne for support from social services and feeding
schemes
Monitor weekly weight gain (0.5 kg/weeks)

Specialised nutritional care

Routine prenatal care
Assess dietary intake
Assess nutrition knowledge

Provide nutrition and lifestyle education

Monitor blood pressure and urine glucose at each visit
Test Urine for signs of urinary tract infections
Monitor weekly weight gain (0.3 kg/weeks)

Women who report at clinics after 20 weeks gestation:

Weight: apperantly underweight Measure mid-upper circumference: <22 cm
Obviously overweight 22 cm+
Not obviously over-under weight
< 145 cm
Height 145 cm+ Insufficient weight gain (IOM Guidelines)
Monitor weekly weight gain: Adequate weight gain
(0,4 kg/week) Excessive weight gain
Routine care
 Kebutuhan Protein Anak (based PDCAA)
Age Media n body Recommended Amino acid Requirement(mg/kg body weight)
weight, kg intake(average Histidine Isoleuc Leucine Lysine Sulfur- Aromatic-AA Threni Tryptophan Valin
requirement+2 in AA ne
SD),g/d

0,5 y 7,6 10,0 22 36 73 64 31 59 34 9,5 49

1y 9,3 10,5 15 27 54 45 22 40 23 6,4 36
1,5 y 10,6 10,9 12 23 44 35 17 30 18 4,8 29
2y 11,9 11,5 Scoring pattern(mg/g protein requirement)
3y 14,1 12,7 20 32 66 57 27 52 31 8,5 43
4y 16,2 13,9 18 31 63 52 25 46 27 7,4 41
5y 18,3 15,5 16 31 61 48 23 41 25 6,6 40
Institute of Medicine
7-12 mo 9 11

1-3 y 12 13
4-8 y 20 19
 Perbedaan Tinggi Badan rata-rata Anak 15-19 thn
(Riskesdas 2007) dg Standar WHO 2005

200.0 200.0
Perempuan
Laki-laki
190.0
Lebih pendek 13,6 cm 190.0 Lebih pendek 10,4 cm
180.0
pd usia dewasa 180.0 pada usia dewasa
Tinggi Badan rata-rata

170.0 170.0

Tinggi Badan rata-rata

160.0 WHO 160.0
2005
150.0 150.0 WHO
2005
140.0 140.0

130.0 Anak laki-laki In- 130.0

donesia Anak perempuan
Indonesia
120.0 120.0

110.0 110.0

100.0 100.0
5 6 7 8 9 10111213141516171819

13
11

15

17

19
Umur (thn)
Umur (thn)

Sumber: Atmarita. MOH, 2007

 Integrated Gaps
1 Integration of child development intervention with health services
2 Evaluation of integrated intervention at scale
3 Long term follow-up of intervention with modest initial impacts
4 Studies designed to show individual and combined effects
5 Evaluation of different approaches to reach children 1 – 3 years of age
6 Evaluation of effect of program quality
7 Evaluation of ways to improve quality of center based strategies for children 3 – 6 year of ages
8 Evaluation of sustainability of benefits from integrated intervention using cohorts
9 Id effects of nutrition intervention on both growth and development entification of the essential
components of child development interventions for maximum effect
10 Techniques to enhance
Annals of US Academy of Sciences, 2016
 Untuk Mencapai Indonesia Emas, 2045
• Aksi : to morrow is to day
•  kita selesaikan masalah anak sekarang juga
• Koordinasi
• Kolaborasi
• Sinergi
• Motivasi
• Standardisasi
• Evaluasi
 Rangking kesejahteraan anak
di berbagai negara di dunia 186 negara

Malaysia 76, Thailand 93, Vietnam 103, Indonesia 107

Sumber : worldsavethechildren.org 2021,
 • Layanan per individu, by name, by address
• Gizi diurus oleh 17 Menteri, termasuk Menteri Desa dan Daerah
tertinggal
• Gunakan NIK, kolaborasi dengan Dukcapil
• Per Pres 39 tahun 2019 satu data  tata kelola penduduk
• UU No 16 tahun 1997 tentang Statistik
•Untuk Mencapai Indonesia Emas,
2045

• Beyond expectation
• Beyond imagination
 Pantun

• Beli sayur di pasar pagi

• Jangan lupa cabai keriting & ikan gabus
• Berikan bayi ASI dan MPASI
• Agar terbebas dari stunting & obes
 kalau ada jarum yang patah, jangan disimpan dalam almari
kalau ada kata yang salah, maafkan kami

07/04/2018
Terima DJOKO W 57
Rekomendasi Lokakarya ke Menko PMK

1 Cuti hamil 6 bulan

2 MPASI cabut
3 Penyerderhanaan Ortala terpadu
4 Penggunaan data tunggal Dukcapil
5 Keluarga hamil & anak bebas rokok
6 Kampanye Nasional menyeluruh ttg ASI Eksklusif
7 MPASI berkualitas
8 Aktivasi tenaga kesehatan
9 TOT di lapangan, kabupaten ke desa dan keluarga
10 PMTAS SD desa tertinggal
11 Sertifikat Catin : komprehensif, koreksi sbl nikah
12 PKJA lintas sektor
13 Remaja putri, Tablet Fe plus heme iron
14 Hasil laut untuk SDM unggul
 A global view of severe maternal morbidity:
moving beyond maternal mortality
• Effects of SMM on delivery outcomes and infants: Severe maternal morbidity not only
puts the woman’s life at risk, her fetus/neonate may suffer consequences of morbidity
and mortality as well. Adverse delivery outcomes occur at a higher frequency among
women with SMM. Reducing preventable severe maternal morbidity not only reduces
the potential for maternal mortality but also improves the health and well-being of the
newborn.
• Conclusion: Increasing global maternal morbidity is a failure to achieve broad public
health goals of improved women’s and infants’ health. It is incumbent upon all countries
to implement surveillance initiatives to understand the burden of severe morbidity and
to implement review processes for assessing potential preventability. Stacie E.
Geller1,2*, Abigail R. Koch2, Caitlin E. Garland2, E. Jane MacDonald3, Francesca Storey3
and Beverley Lawton3. Geller et al. Reproductive Health 2018, 15(Suppl 1):98
• https://doi.org/10.1186/s12978-018-0527-2
Countries Falling Above and Below Expectations Based on
GDP

—Note: All 127 countries with available data were included in this analysis. Stunting rates are for the latest available year 2000- 2010. Data
sources: WHO Global Database on Child Growth and Malnutrition (who.int/nutgrowthdb/); UNICE F Global Databases (childinfo.org); recent
DHS and MIC S (as of March 2012) and The World Bank, World Development Indicators (data.worldbank.org/indicator). State of the World’s
Mothers 2012
Maternal Chronic Energy Malnutrition
Women Reproductive Age
 Algoritma, Pregnancy & Nutrition
Women who report at clinics within the first trimester of pregnancy
< 50 kg
Weight Specialised nutritional care
50 kg+
Asses dietary intake
Height < 145 cm Assess physical activity
Review food security
145 cm+ Asses nutrition knowledge
Calculate BMI Encourage HIV testing if not done yet
Assess socio economic situation
27+ 20 – 25.9 <20
Provide nutrition and lifestyle education
Energy and nutrient supplementation
Arragne for support from social services and feeding
schemes
Monitor weekly weight gain (0.5 kg/weeks)

Specialised nutritional care

Routine prenatal care
Assess dietary intake
Assess nutrition knowledge

Provide nutrition and lifestyle education

Monitor blood pressure and urine glucose at each visit
Test Urine for signs of urinary tract infections
Monitor weekly weight gain (0.3 kg/weeks)

Women who report at clinics after 20 weeks gestation:

Weight: apperantly underweight Measure mid-upper circumference: <22 cm
Obviously overweight 22 cm+
Not obviously over-under weight
< 145 cm
Height 145 cm+ Insufficient weight gain (IOM Guidelines)
Monitor weekly weight gain: Adequate weight gain
(0,4 kg/week) Excessive weight gain
Routine care
What is the cause of stunting ?

1. Low density 
Need LARGE
volume to meet
energy requirement
2. Limit stomach
volume capacity
GROWTH
 Increase 1 cm in Height 
weight gain about 210
gram
 Nutrient potentially needed
in higher amount for
skeletal than lean tissue
include:
 Sulfur, phosphorus,
calcium, magnesium,
vitamin D, vitamin K,
vitamin C and copper
 To gain 5 gr/kgBW/day 
need calories 200
kkal/kgBW
 Integrated Gaps
1 Integration of child development intervention with health services
2 Evaluation of integrated intervention at scale
3 Long term follow-up of intervention with modest initial impacts
4 Studies designed to show individual and combined effects
5 Evaluation of different approaches to reach children 1 – 3 years of age
6 Evaluation of effect of program quality
7 Evaluation of ways to improve quality of center based strategies for children 3 – 6 year of ages
8 Evaluation of sustainability of benefits from integrated intervention using cohorts
9 Id effects of nutrition intervention on both growth and development entification of the essential
components of child development interventions for maximum effect
10 Techniques to enhance
Annals of US Academy of Sciences, 2016
Rangking kesejahteraan anak
di 186 negara di dunia

Sumber : worldsavethechildren.org 2021,

Kebutuhan Nutrisi Usia 6-23 bulan
6-8 bulan 9-11 bulan 12-23 bulan

Kebutuhan 600 kkal 800 kkal 1100 kkal

Energi
Kebutuhan 200 kkal 300 kkal 550 kkal
Energi
MPASI
Densitas 0,74 0,88 kkal/gr 0,99 kkal/gr
Energi kkal/gr
Kebutuhan 9,1 gr/dl 9,6 gr/dl 10,9 gr/dl
Protein
Kebutuhan 1,9 gr/d 4,0 gr/dl 6,2 gr/dl PE Ratio
Protein 8-15 %
MPASI
Lemak 30-45 % 30-45 % 30-45 %
ANAK BUKANLAH DEWASA KECIL
First 1000 days (1000 HPK)

Age
conception Birth 6 mo 12 mo 24 mo

1st 500 days 2nd 500 days

Complementary feeding
Body Length

0 cm 50 cm 67.5 cm 74 cm 86 cm

Body Weight 4 mo

0 3 Kg 2x 3x BBL 4x BBL
BBL

Head Circumference
0 cm 34.5 cm 43 cm 46.1 cm 48.3 cm
Tinggi Rata Rata Laki Laki, Tahun Kelahiran
• More than 50% of pregnancy-related deaths in the United States occur after the birth of thechild, or post partum. Any
death within 1 year of the end of pregnancy due to a pregnancycomplication or a death during pregnancy is classi􀂦ed as
a pregnancy-related death. Deathsthat occur within 1 week post partum (19% of all maternal deaths) are largely
attributed tosevere bleeding, high blood pressure, and infection.

• Gianna Melillo, https://www.ajmc.com/ 2020