08.09. GTK - Peran Zat Gizi & Stimulasi Pada Balita

Pertemuan VIII dan IX
PERAN ZAT GIZI DAN STIMULASI PADA MASA BALITA

TERHADAP PERTUMBUHAN DAN PERKEMBANGAN
Dr. Ir. Lilik Kustiyah, M.Si
MK GIZI PERTUMBUHAN DAN PERKEMBANGAN

PROGRAM STUDI ILMU GIZI
SEKOLAH PASCASARJANA
INSTITUT PERTANIAN BOGOR
2022
Topik bahasan:
1. Prinsip penentuan kebutuhan gizi pada

balita
2. Penilaian pemenuhan gizi dan status gizi
balita
3. Peran zat gizi dan stimulasi pada masa
balita dalam pertumbuhan fisik dan
perkembangan
4. Pertumbuhan dan perkembangan otak dan
pengaruhnya terhadap outcome kognitif
PRINSIP PENENTUAN KEBUTUHAN GIZI
PADA BALITA
Pemenuhan kebutuhan energi dan zat gizi anak balita
o Kebutuhan energi & zat gizi bertambah dg
bertambahnya usia
o Berasal dari:
• ASI (smp usia 2 thn)
• MPASI
o Usia balita bertambah:

• Kontribusi energi & zat gizi dr ASI berkurang
• Kualitas & kuantitas MPASI sangat penting
diperhatikan
Gap Persetase Pemenuhan Kebutuhan Energi dan
Zat Gizi Anak Baduta (ASI dan MP-ASI)
120,0
100,0
80,0
60,0
40,0
20,0
0,0
6-8 bulan
6-8 bulan
6-8 bulan
6-8 bulan
6-8 bulan
6-8 bulan
6-8 bulan
6-8 bulan
9-11 bulan
12-23 bulan
12-23 bulan
12-23 bulan
12-23 bulan
12-23 bulan
12-23 bulan
12-23 bulan
12-23 bulan
9-11 bulan
9-11 bulan
9-11 bulan
9-11 bulan
9-11 bulan
9-11 bulan
9-11 bulan
Energi (kkal) Protein (g) Folat (mcg) Vitamin C (mg) Vitamin D (mcg) Kalsium (mg) Zat besi (mg) Seng (mg)
% MP-ASI % ASI
Source: Dewey (2001);
Permenkes RI No. 28 ( 2019)
▪ Semakin meningkatnya usia anak maka terjadi penurunan kontribusi ASI sehingga tidak dapat memenuhi
kebutuhan anak.
▪ Oki, saat anak usia 6 bulan maka penting diberikan MP-ASI untuk memenuhi kebutuhan energi & zat gizi
dengan memperhatikan keragaman pangan; frekuensi, tekstur, dan variasi menu makanan yang disajikan.
Penentuan Kebutuhan Gizi pada Anak Baduta
Estimasi Kebutuhan Energi Anak
1. Energy
Energi
Usia Jenis Kelamin
▪ The average energy needs of infants in the first 6 months (kkal/hari)
of life is 108 cal per kg body weight, based on growth in Laki-laki 654-844
6-12 bulan
breastfed infants. Perempuan 593-768
▪ From 6 to 12 months of age, the average energy need is Laki-laki 844-1050
1-2 tahun
98 cal/kg body weight. Perempuan 768-997
▪ IOM (2002) → equation of total energy expenditure to Source: IOM, Food and Nutrition Board (2002)
generate energy demand for 6-12 months.
Angka Kecukupan Energi yang dianjurkan
[89xBB (kg)-100] + 175 kkal
▪ Energy needs in the first year based on EFSA (2013) and

WHO (2003) are 100-110 kcal/kgBW and every 3 years
the age deacreased by 10 kcal/kgBW.
Source: Permenkes RI No. 28 Tahun 2019
2. Protein
Angka Kecukupan Protein yang dianjurkan
▪ The recommended protein intake for infants from
birth to 6 months of age is 1.52 grams per kilogram
body weight, and 1.2 grams per kilogram from 7 to
12 months of age.
▪ Essential amino acids requirements for healthy

infants remain the same throughout the first year of
life. Source: Permenkes RI No. 28 Tahun 2019
▪ EFSA (2013) recommends protein requirements for

children aged 6-<36 months of 0.66 g/kgBW/day.
▪ Excessive or inadequate protein intake can result

with incorrect mixing of formula.
3. Lipid Kandungan Asam Lemak pada ASI dan Susu Formula
Susu Formula
▪ The Adequate Intake for fat is 30 grams for infants 7–12 Kandungan ASI (g/Liter)
(g/Liter)
months of age.
Asam Lioneat
5,6 3,3-8,6
(AL)
▪ Fat contributes approximately half of the calories in
breast milk and 40 to 50 percent of calories in infant Asam Alfa-
Linonenat (AAL) 0,63 0-0,67
formulas.
dan DHA
▪ Fat intake after the child reaches the age of 6 months is Source: Adriani dan Wirjatmadi (2012)
30-35% of energy needs. Angka Kecukupan Lemak yang dianjurkan
▪ The recommended intake of linoleic fat is 4.4 g/day,

omega-3 is 0.5 g/day, and omega-6 is 4.6 g/day.
▪ A low-fat diet can eliminate satiety, while a high-fat diet

can increase the risk of obesity.
4. Carbohydrate Angka Kecukupan Kaborhidrat yang

dianjurkan
▪ EFSA (2013), carbohydrate needs in 6-<12 months is 45-55%
of energy total and 12-<36 months is 45-60% of energy total.
▪ Some sources of sugar are limited and do not exceed 10% of

total energy such as sugary drinks, jams, cakes, sweets, and
chocolate.
▪ Some fruit juices such as apples and pears contain high

levels of sorbitol, fructose, and glucose so that only 10% can Source: Permenkes RI No. 28 Tahun 2019
be absorbed.
▪ Types of carbohydrates that can not be absorbed can cause

diarrhea, abdominal pain, and vomiting in children.
▪ The recommended consumption of fruit juice is about 4-6

tablespoons per day.
5. Vitamins Vitamin A
▪ Caregivers should not supplement their infants’ diets
▪ Vitamin A, a fat-soluble vitamin, refers to a group
with vitamins or minerals during the first year of life
unless they are prescribed by a health care provider. of compounds including preformed types of the
vitamin found in animal products and carotenes,
▪ Excessive amounts of certain vitamins and minerals, in precursors of vitamin A, found in plants.
the form of drops or pills, can be toxic or even fatal to ▪ International recommendations for vitamin A
infants. intake are remarkably consistent, and suggest that
intakes of around 350–400 RE per day should meet
the needs of all healthy infants and young children.
▪ Toxic effects, including bone and liver damage, may
arise following a single very large dose of retinol or
from the ingestion of excessive doses of vitamin A
supplements over a long period.
▪ Daily intakes of retinol should not exceed 900 RE in
infants and 1800 RE in children between 1 and 3
years of age
Source: WHO 2000, Update re-printed 2003

Vitamin D Vitamin E
▪ Infants receive vitamin E from breast milk and
▪ Vitamin D is manufactured in the skin by the infant formula.
action of ultraviolet light (from the sun) on ▪ Corn, soybean, and safflower oils are excellent
chemicals naturally present in the skin. sources of vitamin E → complementary feeding
▪ Routine vitamin E supplementation significantly
▪ The requirement for dietary vitamin D depends reduced the risk of intraventricular haemorrhage
on the amount of exposure an infant gets to but increased the risk of sepsis in preterm
sunlight. neonates.
▪ Breast milk contains a small amount of vitamin D.

American Academy of Pediatric Dentistry (AAPD),
states: Infants who are breastfed but do not
receive supplemental vitamin D or adequate
sunlight exposure are at increased risk of
developing vitamin D deficiency or rickets.

Source: WHO 2000, Update re-printed 2003; Brion LP 2003.
Vitamin K
▪ Vitamin K is manufactured by bacteria normally
found in the intestine, this process is not fully
developed in the early stages of an infant’s life.
▪ Since breast milk is normally low in vitamin K,
exclusively breastfed infants are at risk of
developing a fatal brain hemorrhage due to
vitamin K deficiency > all infants be given an
intramuscular injection of vitamin K at birth,
regardless of the mothers’ plans to breast- or
formula-feed.
▪ Infants fed an adequate amount of infant formula
receive sufficient vitamin K.
▪ No requirement for vitamin K supplementation of
breastfed infants after hospital discharge has
been established, but some experts recommend
that mothers be supplemented while they are Source: WHO 2000, Update re-printed 2003
breastfeeding. Source: https://www.chla.org/sites/default/files/migrated/Chapter1_NutritionalNeeds.pdf
Vitamin B
▪ B vitamins will focus only on folic acid and vitamin B.
Deficiency of both of these vitamins can cause
megaloblastic anaemia.
▪ It is not known what proportion of anaemia can be
attributed to folic acid and/or vitamin B12 deficiency
in the Region.
▪ Both human milk and cow’s milk are good sources
(40–60 μg/l). Folic acid is heat-labile, however, and
megaloblastic anaemia responsive to folic acid
supplementation has been described in infants given
heat-treated home-made cow’s milk formula or
unfortified commercial infant formula.
▪ Children consuming a macrobiotic diet are at risk of
vitamin B12 deficiency, and infants breastfed by
strict vegan mothers are at risk of impaired
neurological development, anaemia and even
encephalopathy. Source: WHO 2000, Update re-printed 2003
Vitamin C
▪ Vitamin C is essential for the optimal functioning of
the immune system and for the synthesis of
collagen, and it has antioxidant properties.
▪ Vitamin C is particularly valuable in assisting the

absorption of non-haem iron from vegetables and
other non-haem sources.
▪ The enhancing effect of vitamin C on the absorption

of iron, and probably of zinc, from a meal depends
on the presence of adequate amounts of vitamin C.
▪ For example, consuming food containing 25 mg
ascorbic acid will approximately double the amount
of iron absorbed from cereals.
6. Minerals
Iron
▪ Iron is an essential component of haemoglobin,
found in red blood cells and requirements are high
in the under 5's. This is reflective of the rapid
growth and development seen in this age group.
Kebutuhan Zat Besi (AKG)

0-5 bulan = 1.1 mg/hari
6-11 bulan = 11 mg/hari
1-3 tahun = 7 mg/hari
Source: WHO
2000, Update re- Selisih 6,8-10.8 mg
printed 2003
Source: WHO 2000,

Update re-printed 2003
Calcium
▪ Breast-milk contains a high level of calcium and
is sufficient to meet the infant’s requirements
up to about 6 months.
▪ After this, breast-milk should continue to
provide most of the calcium needed by infants
and young children. Source: Permenkes RI No. 28 Tahun 2019
▪ Calcium absorption may be impaired through
binding with long-chain fatty acids present in
formula milks and unmodified cow’s milk.
▪ If infants and young children are fed a diet with
no breast-milk, cow’s milk or milk products
(after 9 months), it is almost impossible to
reach the RNI for calcium.
▪ As a result, it is common to recommend that
such infants and children receive a daily
calcium supplement. Source: WHO 2000, Update re-printed 2003
Zinc
▪ Requirements for dietary zinc markedly increased
during periods of “catch-up growth”, when
infants and young children are recovering from
malnutrition or infection.
▪ Infants absorb up to about 80% of the zinc in
breast-milk compared to 30% from cow’s milk Source: Permenkes RI No. 28 Tahun 2019
formula and about 15% from soya-based
formula.
▪ Estimates of infant zinc requirements between
the ages of 6 and 12 months, however, suggest
that the declining daily output of zinc in milk will
be insufficient if breast milk is the sole source.
▪ It is thus particularly desirable to select diets
with a high zinc bioavailability for infants after 6
months of age.

Penentuan Kebutuhan Gizi pada Anak Balita
EER for reference boys and girls at selected ages and
1. Energy varying PAL
▪ The Formula for Estimated Energi Requirements (EER)

for children ages 13–36 months is (89 × weight of
child [kg] – 100) + 20 (kcal for energy deposition).
▪ Beginning at age 3, the DRI equations for estimating

energy requirements are based on a child’s gender, Source: Data from National Academy of Sciences,
Institute of Medicine, Food and Nutritional Board.
age, height, weight, and physical activity level (PAL).
Angka Kecukupan Energi yang dianjurkan
▪ Energy needs of toddlers and preschool-age children
reflect the slowing growth velocity of children in this
age group.
▪ Based on Indonesian RDA 2019, Energy Adequacy

Rate for toddlers is 1200 kcal/person/day.
Dietary Reference Intakes for protein
2. Protein
▪ Adequate energy intake to meet an individual child’s needs
has a protein-sparing effect; that is, with adequate energy
intake, protein is used for growth and tissue repair rather
than for energy. Source: Data from National Academy of
Sciences, Institute of Medicine, Food and
Nutritional Board.
▪ Ingestion of high-quality protein, such as milk and other *RDA based on average weight for age
(reference individual).
animal products, lowers the amount of total protein needed
in the diet to provide the essential amino acids. Angka Kecukupan Protein yang dianjurkan

2. Protein
Source: Uauy R, Kurpad A, Tano-Debrah K, Otoo GE, Aaron GA, Toride Y, Ghosh S. Role of protein and amino acids in infant and young child nutrition:
protein and amino acid needs and relationship with child growth. Journal of nutritional science and vitaminology. 2015;61(Supplement):S192-4.
3. Lipid
▪ The fulfillment of lipid needs is obtained from 25-35% Angka Kecukupan Lemak yang dianjurkan
of children's energy needs.
▪ There are no current guidelines for the n-6/n-3 ratio,
but the current recommendations for n-6 and n-3
intake can be used to calculate what dietary n-6/n-3
ratio a person would have if they followed
recommendations. Source: Permenkes RI No. 28 Tahun 2019
▪ For instance, current recommendations for children
between 4 and 8 years old are to consume 10 g of
linoleic acid (LA, n-6) and 0.9 g of alpha-linolenic acid
(LNA, n-3) combined with either 0.1 g or 0.2 g of
docosahexaenoic acid (DHA, n-3) and eicospentaenoic
acid (EPA, n-3), producing an n-6/n-3 ratio of 9.1–10.1.
Source: Sheppard KW, Cheatham CL. 2018. Omega-6/omega-3 fatty
▪ Researchers have generally found ratios below 10 to acid intake of children and older adults in the US: dietary intake in
comparison to current dietary recommendations and the Healthy
be more optimal. Eating Index. Lipids in health and disease. 17(1):1-2.
4. Carbohydrate 5. Vitamins and Minerals

▪ Fulfillment of carbohydrate needs in children ▪ Most children from birth to 5 years are
is obtained from 50-60% of children's energy meeting the targeted levels of consumption of
needs. most nutrients, except for iron, zinc, and
▪ EFSA (2013), carbohydrate needs in 12-<36 calcium.
months is 45-60% of energy total. Angka Kecukupan Vitamin dan Mineral yang dianjurkan
▪ Some sources of sugar are limited and do not
exceed 10% of total energy such as sugary
drinks, jams, cakes, sweets, and chocolate →
tooth decay and a high risk of obesity.
Angka Kecukupan Karbohidrat yang dianjurkan
Source: Permenkes RI No. 28 Tahun 2019 Source: Permenkes RI No. 28 Tahun 2019
5. Vitamins and Minerals Iron (continue)
▪ Iron plays a role in the process of oxidation-
Dietary Reference Intakes for key nutrients for toddlers reduction reactions, aerobic metabolism, and
oxygen carriers in the blood.
▪ Iron-deficiency anemia is more common among
low-income children and appears to cause long-
term delays in cognitive development and
Source: Data from National Academy of Sciences, Institute of Medicine,
behavioral disturbances.
Food and Nutritional Board.
Zinc
Iron ▪ In a longitudinal study of the nutrient and food
▪ A rapid growth rate coupled with frequently intakes of children ages 24–60 months, mean
inadequate intake of dietary iron places toddlers, intakes of zinc, folic acid, and vitamins D and E
especially 9- to 18-month-olds, at the highest risk were consistently below the recommended
for iron deficiency. levels.
▪ Based on Riskesdas 2013, the prevalence of Source: Prick, B. W., et al. Maternal phenylketonuria and hyperphenalainemia in pregnancy: pregnancy
complications and neonatal sequelae in untreated pregnancies. Am J Cln Nutr 2012; 95:374 –382.
anemia under five in rural and urban areas in Pellicano, R., et. al. Women and celiac disease: Association with unexplained infertility. Minerva Med 2007;
98:217–219.
Indonesia is 25.8% and 30.3%. Rapaport L. Celiac disease linked to miscarriages and preterm deliveries, Ann Gastroenterol 2015. Available
at: www.medscape
.com/viewarticle/843296?nlid=80164_2826&src=wnl_edit_medn_fmed&uac =61213SX&spon=34,
accessed 5/6/15.
Zinc (continue) Calcium (continue)

▪ Zinc plays an important role in growth; it has a ▪ Dairy products are good sources of calcium, as
recognized action on more than 300 enzymes by are canned fish with soft bones such as sardines,
participating in their structure or in their dark green leafy vegetables such as kale and bok
catalytic and regulatory actions. choy, tofu made with calcium, and calcium-
▪ Zinc is found in foods of animal origin. Plant fortified foods and beverages such as calcium-
sources of zinc include legumes, nuts, and fortified orange juice.
whole grains. ▪ Nonfat and low-fat dairy products are low in
saturated fat while still serving as a good source
Calcium of calcium.
▪ Adequate calcium intake in childhood affects
peak bone mass.
▪ An important aspect of adequate calcium intake
in toddlers is the development of eating patterns
that will lead to adequate calcium intake later in
childhood.
Fiber Adequate intake of total fiber for children

▪ High-fiber diets could also impact the
bioavailabilty of some minerals, such as iron and
calcium.
▪ Total fiber is the sum of dietary fiber and Source: Data from National Academy Press. Table
created by Nancy H. Wooldridge.
functional fiber.
▪ Earlier recommendations were based on dietary
fiber alone. Including fruits, vegetables, and 5. Vitamins and Minerals (continue)
whole-grain breads and cereal products in the At the age of toddlers, vitamin A, B,
diet can increase the dietary fiber intake of C deficiency is common. Intake of
children. vitamins such as vegetables by
Angka Kecukupan Serat yang dianjurkan 100-150 grams / day and fruits
such as yellow, orange, or sour
fruits by 100-200 grams / day.

Penentuan Kebutuhan Gizi pada Anak
KONSEP
MENU” 4
BINTANG”
PENILAIAN PEMENUHAN GIZI BALITA
Hal-hal yang harus diperhatikan dalam pemberian
makan pada anak terutama pada anak baduta
Framework dari Tools Dietary Assessment Child
1. Consider the “what, how and when” foods are provided to the child.
▪ Routinely feeding a diet very low or low in calories and or essential nutrients. [Vegan diet, macrobiotic
diet or other diet low in calories or nutrients.]
2. Consider the “what, how and when” of beverages, bottle use, sippy cup use, or pacifier use.
▪ Routinely feeding inappropriate beverages as the primary milk source. (NF or LF milk for children <2 yo;
▪ imitation/substitute milks including unfortified rice/soy.)
▪ Routinely feeding a child sugar-containing fluids.
▪ Routinely using nursing bottle, cups, or pacifiers improperly.
3. Consider feeding practices that may disregard the developmental stage of the child.
▪ Routinely using feeding practices that disregard the developmental needs or stages of the child.
▪ Routine ingestion of nonfood Items (pica).
4. Consider food safety
▪ Feeding foods that could be contaminated with harmful microorganisms.
5. Consider supplementation
▪ Feeding dietary supplements with potentially harmful consequences. 425.7
Routinely not providing dietary supplements recognized as essential by national public health
policy when a child’s diet alone cannot meet nutrient requirements. Fl-/Vit D
Source: https://www.dhhs.nh.gov/sites/g/files/ehbemt476/files/documents/2021-11/wic-child.pdf
Penilaian Pemenuhan Gizi Anak
Penilaian Pemenuhan Gizi Baduta
Konsumsi Pangan pada Anak Baduta
• Kuantitatif • Kualitatif
Energi dan Protein Frekuensi pemberian susu
Keragaman Pangan Minimal
(MMFF)
Kategori Interpretasi (MDD)
Defisit berat : <70% AKG
≥ 5/8 kelompok pangan Konsumsi susu dan/atau produk
Defisit sedang : 70-79% AKG olahannya → ≥2 kali/hari
Defisit ringan : 80-89% AKG
Normal : 90-119% AKG Frekuensi Makan Minimal (MMF) Diet Minimal yang dapat
diterima (MAD)
Kelebihan : ≥120% AKG
Sumber: Hardinsyah et al.(2002) ASI
Vitamin dan Mineral (Zat Gizi Mikro) 6-8 bulan → ≥2 kali/hari • ASI → MDD dan MMF harus
9-23 bulan → ≥3 kali/hari tercapai
Kategori Interpretasi • Non ASI → MDD, MMF,
Non ASI
Kurang : <77% AKG MMFF harus tercapai
6-23 bulan → ≥ 4 kali/hari
Cukup : ≥77% AKG
Sumber: WHO dan UNICEF (2021)
Sumber: Gibson (2005)
Penilaian Pemenuhan Gizi Balita
Konsumsi Pangan pada Anak Balita
• Kuantitatif • Kualitatif
Energi dan Protein Individual Dietary Diversity Score (IDDS)
❑ IDDS paling sering digunakan untuk anak-anak usia 24-59 bulan tetapi juga
Kategori Interpretasi dapat digunakan untuk orang dewasa.
Defisit berat : <70% AKG ❑ Indikator kecukupan mikronutrien dari segi kualitas dan tidak mengukur
asupan energi.
Defisit sedang : 70-79% AKG ❑ Diberi skor 1 atau dianggap mengonsumsi 1 klp pangan dimana berat
Defisit ringan : 80-89% AKG pangan yang dikonsumsi minimal 15 gram.
❑ Kategori Skor IDDS :
Normal : 90-119% AKG
Rendah (≤ 3 kelompok pangan); Sedang (4-5 kelompok pangan); Baik (≥ 6
Kelebihan : ≥120% AKG kelompok pangan).
Sumber: Hardinsyah et al.(2002)
Vitamin dan Mineral (Zat Gizi Mikro)
Kategori Interpretasi
Kurang : <77% AKG
Cukup : ≥77% AKG
Sumber: Gibson (2005)
Kondisi capaian konsumsi pangan anak baduta
PENILAIAN STATUS GIZI BALITA
Prevalence of children under 5 who are not growing
well (stunted, wasted or overweight), 2018
Indeks Standar Antropometri Anak
1. Indeks Berat Badan menurut Usia (BB/U)
• Indeks ini digunakan untuk menilai anak

dengan berat badan kurang (underweight) atau
sangat kurang (severely underweight), tetapi
tidak dapat digunakan untuk mengklasifi-
kasikan anak gemuk atau sangat gemuk.
• Anak dengan BB/U rendah, kemungkinan

mengalami masalah pertumbuhan, sehingga
perlu dikonfirmasi dengan indeks BB/PB atau
BB/TB atau IMT/U sebelum diintervensi.
Sumber: Peraturan Menteri Kesehatan Republik Indonesia Nomor 2 Tahun 2020 Tentang
Standar Antropometri Anak
2. Indeks Tinggi/Panjang Badan menurut Usia

(TB/U atau PB/U)
• Indeks ini dapat mengidentifikasi anak-anak

yang pendek (stunted) atau sangat pendek
(severely stunted), yang disebabkan oleh gizi
kurang dalam waktu lama atau sering sakit.
• Anak-anak dengan tinggi badan di atas normal

(tinggi sekali) biasanya disebabkan oleh
gangguan endokrin, namun hal ini jarang
terjadi di Indonesia.
3. Indeks Berat Badan Badan menurut

Tinggi/Panjang (BB/TB atau BB/PB)
• Indeks ini menggambarkan apakah berat badan

anak sesuai terhadap pertumbuhan
panjang/tinggi badannya.
• Digunakan untuk mengidentifikasi anak gizi

kurang (wasted), gizi buruk (severely wasted)
serta anak yang memiliki risiko gizi lebih
(possible risk of overweight).
• Kondisi gizi buruk biasanya disebabkan oleh

penyakit dan kekurangan asupan gizi akut
maupun kronis.
4. Indeks Indeks Massa Tubuh menurut Umur
(IMT/U)
• Indeks ini dapat menentukan kategori gizi

buruk, gizi kurang, gizi baik, berisiko gizi lebih,
gizi lebih dan obesitas.
• Grafik IMT/U dan grafik BB/PB atau BB/TB

cenderung menunjukkan hasil yang sama.
Namun indeks IMT/U lebih sensitif untuk
penapisan anak gizi lebih dan obesitas.
• Anak dengan ambang batas IMT/U >+1SD

berisiko gizi lebih sehingga perlu ditangani lebih
lanjut untuk mencegah gizi lebih dan obesitas.
4. Head Circumference atau Lingkar Kepala
• Head circumference measurement is an important

screening procedure to detect abnormalities of
head and brain growth, especially in the first year
of life.
• Head circumference increases rapidly during the first 12
months of life but, by 36 months, growth is much slower.
• Head circumference- for-age can be evaluated using a suitable

pediatric growth chart.
• If weight growth can be maintained normally, then body length

and head circumference will also be normal.
Source: Lee RD, Nieman DC. 2013. . Nutritional assessment sixth edition. New York (US): McGraw-Hill.
Peraturan Menteri Kesehatan Republik Indonesia Nomor 2 Tahun 2020 Tentang Standar Antropometri Anak
4. Head Circumference atau Lingkar Kepala

Interpretasi dari hasil pengukuran lingkar kepala:
a. Jika ukuran lingkaran kepala anak berada di dalam “jalur
hijau” maka lingkaran kepala anak normal.
b. Bila ukuran lingkaran kepala anak berada di luar “jalur hijau”
maka lngkaran kepala anak tidak normal.
c. Lingkaran kepala anak tidak normal ada 2 (dua), yaitu
makrosefal bila berada diatas “jalur hijau” dan mikrosefal bila
berada dibawah “jalur hijau”
Intervensi:
Bila ditemukan makrosefal maupun mikrosefal segera dirujuk ke
rumah sakit.
Source: Kemenkes RI. 2016. Pedoman Pelaksanaan Stimulasi, Deteksi dan Intervensi Dini Tumbuh Kembang Anak. Jakarta (ID): Kemenkes RI
Pemantauan Berat Badan Anak Balita
SANGAT PENTING UNTUK

DIPERHATIKAN DAN SELALU DIPANTAU
Source: Kartu Menuju Sehat

Kerangka Konsep Pembinaan Tumbuh Kembang Balita Dan Anak Pra Sekolah
Source: Kemenkes RI. 2016. Pedoman Pelaksanaan

Stimulasi, Deteksi dan Intervensi Dini Tumbuh
Kembang Anak. Jakarta (ID): Kemenkes RI.
PERAN ZAT GIZI PADA MASA BALITA
DALAM PERTUMBUHAN FISIK DAN
PERKEMBANGAN
Percentage of children under 5 with hidden hunger
Characteristics of children's dietary needs, intake patterns,
and determinants that explain their nutrition behaviors
Peran Zat Gizi dalam Pertumbuhan Fisik dan Perkembangan
1. Energy
▪ Children have to ingest large amounts of energy, a key
determinant of energy intake is the energy density of
complementary foods.
▪ Too low an energy density may result in an energy deficit and
consequently poor growth.
▪ Children need energy for growth, development and activity.
The energy needs of each child are different and intake should
be tailored to each child to ensure optimal growth and
development whilst avoiding overweight and obesity.
▪ Energy requirements of young children are obviously less
than those of adults but they do double (approximately)
between the ages of 1 and 5 years.
▪ Getting energy balance right involves offering the right
balance of foods in the right quantities (or portion sizes) as
well as appropriate physical activity.
1. Energy
If the diet supplies adequate energy and

essential nutrients, there is no convincing
evidence that a dietary fat intake of 30% of
energy adversely affects the growth and
development of healthy children living in a
clean environment.
Dietary energy density, nutrient density and

feeding frequency may be more important
than dietary fat content in determining
intake and growth of young children.
Source: Uauy R, Castillo C. Lipid requirements of infants: implications for nutrient composition of Source: WHO 2000, Update re-printed 2003
fortified complementary foods. The Journal of nutrition. 2003 Sep 1;133(9):2962S-72S.
2. Protein
▪ Protein-energy malnutrition hampers brain, immune system and
High protein intakes are
intestinal mucosal functions.
reported in European
▪ Protein requirement is necessary for infants and growing children
children during the
than for adults.
complementary feeding
▪ For children who are vegetarians a variety of food sources,
period and are indicative
including legumes and corn, must be incorporated to meet the
of having a growth-
requirement of essential amino acids.
stimulating role
▪ Protein intake is particularly important in infancy and childhood,
(especially that of linear
when rapid growth requires amino acids from which to build new
growth) through effects
tissue (particularly the organs and muscle).
on insulin-like growth
▪ All amino acids provide nitrogen for synthesis of human proteins,
factor (IGF-1).
but some essential (indispensable) amino acids cannot be
synthesized by the body and must therefore be supplied in the
diet.
Source: Michaelsen K, Hoppe C, Mølgaard C. 2003. Effect of early
Source: protein intake on linear growth velocity and development of
https://hindrise.org/resources/nutrition-for-children/ adiposity. Monatsschrift Kinderheilkunde 151(0): S78–S83. doi:
WHO 2000, Update re-printed 2003 10.1007/s00112-003-0805-z
2. Protein
An analysis of dietary and anthropometric
Research by Pollitt et al demonstrated the
data collected on Ghanaian children aged 2–
importance of macronutrients, specifically
13 y, found an association between protein
protein, during the prenatal period and early
quality and risk of being stunted irrespective
childhood in achievement of full
of energy. Total energy, total protein and
developmental trajectory.
total utilizable protein availability estimates
• Linear growth rate before, but not after
have been independently significantly and
12 months of age, and infant weight
negatively associated with prevalence of
before four months of age significantly
stunting in analyses of 200 countries
predicts child intelligence quotient (IQ) at
(p<0.001).
age 9 years.
• Neither child linear growth nor weight
after 12 months is associated with child
Source: Ghosh S, Suri D, Vuvor F, Armah SM, Scrimshaw NS, Uauy R. 2010.
IQ nine years later. Dietary protein quality is associated with risk of being stunted in peri-urban
children in Greater Accra. 2nd World Public Health Congress on Nutrition,
Source: Pollitt E, Gorman KS, Engle PL, Riveras JA, Martorell R. Nutrition in Early Life and Porto, Portugal.
the Fulfillment of Intellectual Potential. J Nutr. 1995; 125:1111S–1118S.
3. Fats
▪ In addition to being energy-dense, fats provide
essential fatty acids and have important 60% of the brain is
structural and functional roles. comprised of the long-
▪ Fatty acids are needed for the development of chain omega fatty acids
nervous system myelination in younger children DHA and EPA, which are
less than two years of age. essential to the
▪ Fats also facilitate absorption of fat-soluble formation of gray
vitamins. matter, the central
▪ The functions of fats are important for nervous system, and
neurological and ocular development. cognitive performance
▪ For children younger than two years, 25% to (Benton 2010; Nyaradi et
40% of total calories will come from fat, and for al. 2013).
older children, 10% to 35% calories will come
from fat.
Source: Benton, D. (2010). The plausibility of sugar addiction and its role in obesity and eating disorders. Clinical Nutrition, 29(3), 288–303.
Nyaradi, A., Li, J., Hickling, S., Foster, J., & Oddy, W. H. (2013). The role of nutrition in children’s neurocognitive development, from pregnancy through childhood.
Frontiers in Human Neuroscience, 7.
3. Fats
A review of studies from Europe and
North America found little evidence of
adverse effects of low dietary fat on
Stonehouse et al. (2013) concluded that DHA
growth of young children 6 –36 mo of
supplementation over a 6-month time span
age. Percentage of dietary fat was not
improved overall memory and reaction
correlated with energy intake, growth
times in adults between the ages of 18-45
velocity or energy density of the diet
years with low DHA.
between ages 6 and 12 mo whereas
energy density was positively
Source: Stonehouse, W., Conlon, C. A., Podd, J., Hill, S. R., Minihane, A. M., Haskell, C., & Kennedy, D.
(2013). DHA supplementation improved both memory and reaction time in healthy young adults: a
randomized controlled trial. The American Journal of Clinical Nutrition, 97(5), 1134–1143.
associated with energy intake and
weight gain.
Source: Fjeld, C. R., Schoeller, D. A. & Brown, K. H. (1989) A new model for predicting energy requirements of children during catch-up growth developed using doubly labeled water. Pediatr. Res. 25: 503–508.
Butte, N. F. (1996) Energy requirements of infants. Eur. J. Clin. Nutr. 50: S24 –S36.
Torun, B., Davies, P.S.W., Livingstone, M.B.E., Paolisso, M., Sackett, R. & Spurr, G. B. (1996) Energy requirements and dietary energy recommendations for children and adolescents 1 to 18 years old. Eur. J. Clin. Nutr.
50(Suppl.1): S37–S81.
McDowell, M. A., Briefel, R. R. & Alaimo, K. (1994) Energy and macronutrient intakes of persons ages 2 months and over in the United States: Third National Health and Nutrition Examination Survey, phase 1, 1988 –91.
Hyattsville, MD: DHHS, pp. 1–24.
Mun ̃ oz, K. A., Krebs-Smith, S. M., Ballard-Barbash, R. & Cleveland, L. E. (1997) Food intakes of US children and adolescents compared with recommendations. Pediatrics 100: 323–329.
Nicklas, T. A., Webber, L. S., Koschak, M. L. & Berenson, G. S. (1992) Nutrient adequacy of low fat intakes for children: the Bogalusa Heart Study. Pediatrics 89: 221–228.
Shea, S., Basch, C. E., Stein, A. D., Contento, I. R., Irigoyen, M. & Zybert, P. (1993) Is there a relationship between dietary fat and stature or growth in children three to five years of age? Pediatrics 92: 579 –586.
4. Carbohydrates
▪ Carbohydrates are either simple or complex, and are major sources of energy in all human
diets. They provide energy of 4 Kcal/g.
▪ Starchy carbohydrate food should be given at each meal and at least one snack during the
day for children aged 1 to 5 years. They are a good source of calories, provide B vitamins
essential for growth and some fibre.
Few studies have reported the impact of the type of carbohydrates such as lactose,
sucrose or glucose polymer, on whole body metabolism in infants and children.
Although lactose has been shown to enhance calcium absorption, and glucose
polymers can impact gastric emptying, the effect of these carbohydrates on
physiological processes such as fatty acid synthesis and nitrogen accretion have not
been determined (Ziegler & Fomon, 1983; Stathos et al, 1996; Wirth et al, 1990;
DeCurtis et al, 1986; Southgate, 1995)
Source: Ziegler EE & Fomon SJ (1983): Lactose enhances mineral absorption in infancy. J. Pediatr. Gastroent. Nutr. 2, 288 ± 294
Stathos TH, Shulman RJ, Schanler RJ & Abrams SA (1996): Effect of carbohydrates on calcium absorption in premature infants. Pediatr. Res. 39, 666 ± 670.
Wirth FH Jr, Numerof B, Pleban P & Neylan MJ (1990): Effect of lactose on mineral absorption in preterm infants. J. Pediatr. 117, 283 ± 297.
DeCurtis M, Senterre J, Rigo J & Putet G (1986): Carbohydrate derived energy and gross energy absorption in preterm infants fed human milk or formula. Arch. Dis. Child. 61, 867 ± 870.
Southgate DAT (1995): Digestion and metabolism of sugars. Am. J. Clin. Nutr. 62, 203S ± 211S.
5. Micronutrients
Micronutrient supplementation, including supplementation with multiple micronutrients, zinc, and

vitamin A, is linked to improved child growth in height and length.
Zinc Vitamin A
A large study of children aged 2-10 in Taiwan On its own or combined with zinc,
showed improvements in height, weight, BMI vitamin A supplementation has also been
and appetite ratings among supplemented shown to improve linear growth in
children who had low initial serum zinc levels children suffering from vitamin A
(<75 mg/dL). These effects of zinc on linear deficiency. Vitamin A plays an important
growth and BMI likely stem from its wide- role in immune function, and the
ranging roles in cellular growth, improvement in linear growth in
differentiation, and metabolism, including its supplemented children may be
promotion of growth hormone production, attributed to a reduction in diarrheal and
chondrogenesis, osteoblast function and bone respiratory infection morbidity.
calcification. (Page 85) (Page 85)
Iodine Iron
Iodine is an essential substrate in the synthesis Pollitt et al. (1989) and Beasley et al. (2000) also
of the thyroid hormones, which are among the observed that although iron supplements
key regulators of metabolism. The thyroid hor- improve the cognition and growth of deficient
mones are required for normal growth and children, they could be harmful as microbial
development, for oxygen consumption in cells, proliferation is influenced by the iron concentra-
and for the maintenance of metabolic rate. tion of the culture medium (Kochan, 1997) and
Thyroid hormones are also important in mental iron supplements can produce oxidative stress
development and mental retardation, and (Kadiiska et al., 1995).
congenital deafness can be due to
hypothyroidism induced by
Source: Ekweagwu E, Agwu AE, Madukwe E. The role of
iodine deficiency in utero. It is therefore
micronutrients in child health: A review of the literature.
important that both maternal stores and the African journal of Biotechnology. 2008;7(21).
maternal diet during pregnancy contain
adequate quantities of iodine.
Source: Cusick SE, Georgieff MK. 2016. The role of nutrition in brain development: the golden opportunity of the
“first 1000 days”. The Journal of pediatrics. 175: 16-21.


PERAN STIMULASI PADA MASA BALITA
DALAM PERTUMBUHAN FISIK DAN
PERKEMBANGAN
Peran Stimulasi pada Masa Balita dalam Pertumbuhan Fisik dan Perkembangan
1. Angka keterlambatan pertumbuhan dan perkembangan masih cukup
tinggiyaitu sekitar 5-10% mengalami keterlambatan perkembangan
umum.
2. 0,4 juta (16%) balita di Indonesia mengalami gangguan perkembangan
3. Dua dari 1.000 bayi mengalami gangguan perkembangan motorik dan 3
sampai 6 dari 1.000 bayi juga mengalami gangguan pendengaran serta
satu dari 100 anak mempunyai kecerdasan kurang dan keterlambatan
bicara sekitar 33% dari total populasi dan setiap tahun akan meningkat
24,4
4. 21,7
18 17 17
14 14,9
12,5 12
9,5
7,1 7
Stunting (%) Wasting (%) Underweight (%)

PSG 2016 Target 2019 SSGI 2021 Target 2024
Peran Stimulasi pada Masa Balita dalam Pertumbuhan
Fisik dan Perkembangan
1
Angka keterlambatan pertumbuhan dan 2
perkembangan masih cukup tinggi yaitu sekitar 0,4 juta (16%) balita di Indonesia mengalami
5-10% mengalami keterlambatan perkembangan gangguan perkembangan, baik perkembangan
umum. motorik halus dan kasar, gangguan pendengaran,
kecerdasan kurang dan keterlambatan bicara.
3
Dua dari 1.000 bayi mengalami gangguan
perkembangan motorik dan 3 sampai 6 dari
4
1.000 bayi juga mengalami gangguan 21,7 18 24,4
14 17 14,99,5 17 12
pendengaran serta satu dari 100 anak 12,5 7,1 7
mempunyai kecerdasan kurang dan
keterlambatan bicara sekitar 33% dari total Stunting (%) Wasting (%) Underweight (%)
populasi dan setiap tahun akan meningkat. PSG 2016 Target 2019 SSGI 2021 Target 2024
Source: Sugeng HM. 2019. Gambaran Tumbuh Kembang Anak pada Periode Emas Usia 0-24 Bulan di Posyandu Wilayah Kecamatan Jatinangor. Jurnal Sistem Kesehatan, 4(2), 96-101.
[Kemenkes RI] Kementerian Kesehatan Republik Indonesia. 2017. Hasil Pemantauan Status Gizi (PSG) Balita Tahun 2016. Jakarta (ID): Kementerian Kesehatan Republik Indonesia.
[Kemenkes RI]. 2021. Hasil Studi Status Gizi Kabupaten/ Kota Tahun 2021. Jakarta (ID): Kementerian Kesehatan Republik Indonesia.
Prastiwi MH. 2019 Pertumbuhan dan Perkembangan Anak Usia 3-6 Tahun. Jurnal Ilmiah Kesehatan Sandi Husada. 10(2):242-249.
Stimulasi adalah perangsangan

yang datang dari lingkungan luar Pembagian peran ayah
Tujuan stimulasi adalah dan ibu yang spesifik
anak yang sangat penting dalam
meningkatkan kualitas dan sesuai kodrat dan
pertumbuhan dan perkembangan
kuantitas sel-sel otak agar gender. Pengasuhan
anak. Anak mendapat stimulasi
dapat bekerja dan berfungsi yang dilakukan ayah
yang terarah akan lebih cepat
optimal sejak anak berusia dengan anak lebih
berkembang dibandingkan
dini. Pemberian stimulasi banyak melibatkan
dengan anak yang kurang atau
secara rutin sesuai usia aktifitas fisik, sedangkan
bahkan tidak mendapatkan
anak tidak hanya ibu cenderung
stimulasi. Stimulasi berfungsi
mengoptimalkan tumbuh melibatkan aktifitas
sebagai penguat yang
kembang, namun juga verbal.
bermanfaat bagi perkembangan
dipercaya dapat
anak.
meningkatkan
kecerdasannya.
Source: Soetjiningsih. 1995. Tumbuh Kembang Anak. Jakarta: EGC.
▪ Optimalisasi perkembangan diperlukan adanya interaksi antara anak dan orangtua,
terutama peranan ibu sangat bermanfaat bagi proses perkembangan anak secara
keseluruhan → mengenali kelainan proses perkembangan anaknya sedini mungkin
dan memberikan stimulus tumbuh kembang anak yang menyeluruh dalam aspek
fisik, mental, dan sosial.
▪ 4 faktor risiko yang mempengaruhi perkembangan anak di negara berkembang yaitu

malnutrisi kronis berat, stimulasi dini yang tidak adekuat, defisiensi yodium dan
anemia defisiensi besi.
▪ Salah satu faktor resiko yang penting dan berhubungan dengan interaksi ibu dan
anak adalah pemberian stimulasi dini.
▪ Salah satu perkembangan anak yang penting untuk dipantau pada periode ini adalah
perkembangan motorik karena banyak kinerja kognitif yang berakar pada
keberhasilan perkembangan motorik.
▪ Gabungan antara interaksi ibu dan anak yang positif, latihan fisik dan stimulasi dini
akan meningkatkan perkembangan motorik anak.
Source: Hati FS, Lestari P. Pengaruh pemberian stimulasi pada perkembangan anak usia 12-36 bulan di Kecamatan Sedayu, Bantul. JNKI (Jurnal Ners dan
Kebidanan Indonesia) (Indonesian Journal of Nursing and Midwifery). 2016 Mar 1;4(1):44-8.
Pertumbuhan dan
perkembangan saling Status gizi kurang akan
mendukung satu sama lain. memengaruhi perkembangan
Perkembangan seorang anak mental maupun sosial anak.
tidak dapat maksimal tanpa Oleh karena itu, keduanya
dukungan. Seorang anak harus mendapat perhatian,
memerlukan perhatian khusus baik dari pemerintah,
untuk optimalisasi tumbuh masyarakat maupun orang tua.
kembangnya.
Source: Departemen Kesehatan RI. 2009. Pedoman

pelaksanaan stimulasi. Deteksi dan intervensi dini
Salah satu indikator untuk melihat
tumbuh kembang anak di tingkat pelayanan kesehatan
dasar. Jakarta: Depkes RI.
pertumbuhan fisik anak adalah
Kementrian Kesehatan RI. 2013. Laporan hasil riset dengan melihat status gizi
kesehatan dasar Tahun 2013. Jakarta: Kemenkes RI.
Hairunis MN, Salimo H, Dewi YL. 2018. Hubungan anak→perkembangan seorang
status gizi dan stimulasi tumbuh kembang dengan
perkembangan balita. Sari Pediatri.20(3):146-151. anak dengan menggunakan KMS
Hasil penelitian menunjukkan

terdapat hubungan
positif dengan kekuatan yang kuat Parent’s stimulation has a
dan secara statistik signifikan significant relationship with the
antara stimulasi tumbuh gross motor development of Compared with no intervention,
kembang dengan perkembangan stunted toddlers (p=0.02, however, stimulation resulted in higher
anak usia 1-3 tahun di Kecamatan r=0.237), and parent’s full scale IQ scores (coefficient 0·38,
Sedayu (p=0,001; CI 95% stimulation has a significant 95% CI 0·06–0·71, p=0·019) and higher
;OR=3,37). relationship with the fine motor scores on the verbal subscale (0·37,
Source: Hati FS, Lestari P. Pengaruh pemberian development of stunted toddlers 0·07–0·68, p=0·018), Peabody picture
stimulasi pada perkembangan anak usia 12-36 bulan (p=0.002, r= 0.314). vocabulary test (7·84, 0·73–14·95,
di Kecamatan Sedayu, Bantul. JNKI (Jurnal Ners dan
Kebidanan Indonesia) (Indonesian Journal of Nursing
p=0·031), verbal analogies (0·26, 0·03–
and Midwifery). 2016 Mar 1;4(1):44-8. 0·49, p=0·028), and reading tests (4·73,
Source: Santoso YD, Efendi F, Kurnia ID, Susanti 1·31–8·14, p=0·007, and 2·7, 1·12–4·37,
IA, Pramono AP, Habibie AN. The Correlation
Between Parental Stimulation and Motor
p=0·001).
Development in Stunted Toddlers. International
Journal of Psychosocial Rehabilitation. Source: Walker SP, Chang SM, Powell CA, Grantham-McGregor
2020;24(7). SM. Effects of early childhood psychosocial stimulation and
nutritional supplementation on cognition and education in
growth-retarded Jamaican children: prospective cohort study.
Peran Stimulasi pada Masa Balita dalam Pertumbuhan Fisik dan
Perkembangan
Motor Development
▪ Motor development reflects an infant’s ability to
control voluntary muscle movement.
▪ The development of muscle control and
coordination progresses from top down; initiating
with head control and ending with lower leg
coordination and walking.
▪ Muscle development also progresses centrally to
peripherally; meaning that the infant learns to
control the shoulder and arm muscles before
muscles in the hands.
▪ Motor development influences both the ability of
the infant to feed and the amount of energy
expended in the activity.
▪ As motor skills continue to progress, daily energy
needs increase because of higher energy
expenditure.
Cognitive Development
▪ Undernourished infants may frequently be ill and
▪ Risk factors for poor cognitive, motor, and socio- subsequently irritable, fussy, tired, and withdrawn.
emotional development include: severe, acute
malnutrition, chronic undernutrition, iron deficiency ▪ Caregivers may experience more difficulty when
anemia, and iodine deficiency. feeding these infants.
▪ The baby’s interactions with the environment stimulate ▪ A decrease in their activity level may occur and alter
the developing brain, which is now seen as structuring their ability to explore their environment and interact
the nervous system in the long term. with their caregivers, and poor brain development may
result.
▪ Research has shown that access to adequate energy and
protein alone may not be sufficient for maximizing brain
maturation without simultaneously providing psycho-
social stimulation.
▪ Improving the nutritional status of infants can positively

affect their environment-related experiences and
stimulation.
1. Development of children aged 1-18 months
https://www.healthline.com/health/childrens-health/stages-of-child-development#birth-18-months
2. Development of children aged 18-24 months
3. Development of children aged 3-5 years
3. Development of children aged 3-5 years (continue)
Source: Parten MB. 1932. Social Participation among Preschool

Children. Journal of Abnormal and Social Psychology. 27 (3): 243–
269.
Source: Nelson CA. 2020. Adversity in childhood is linked to mental and physical health throughout life. BMJ. 371: 1-9.
The brain is developed over time, from the bottom up. The basic
structure of the brain is built through a continuous process that
begins before birth and persists into adulthood. This
development of the brain is influenced by many factors, including
a child’s relationships, experiences and environment.
Model Ekologi Bronfenbrenner
Source: Berk L, Roberts W. 2009. Child development (3rd Canadian

ed.) Toronto (ON): Pearson Allyn and Bacon.
Program Stimulasi Deteksi dan Intervensi Dini Tumbuh
Kembang Anak
❑ Pelaksaan program SDIDTK disuatu wilayah

disebut berhasil, bila semua balita dan anak
prasekolah mendapatkan pelayanan DDTK,
ditindaklanjuti oleh keluarga dengan menstimulasi
anak dan dirujuk bilamana memerlukan rujukan.
❑ Penerapan SDIDTK dapat dilakukan di dalam
maupun di luar gedung.
✓ Penerapan SDIDTK di dalam gedung dilakukan
di Puskesmas, dan di Pustu.
✓ Penerapan SDIDTK di luar gedung dapat
dilakukan di Posyandu, Kelas Ibu Balita dan
PAUD seperti di TK/RA, Kelompok Bermain,
tempat pengasuhan anak dan satuan PAUD
sejenis.
Source: Kemenkes RI. 2016. Pedoman Pelaksanaan

Stimulasi, Deteksi dan Intervensi Dini Tumbuh Kembang
Anak. Jakarta (ID): Kemenkes RI.
Deteksi Dini Penyimpangan Perkembangan melalui
Kusioner Pra Skrining Perkembangan (KPSP)
Source: Kemenkes RI. 2016. Pedoman Pelaksanaan Stimulasi, Deteksi

dan Intervensi Dini Tumbuh Kembang Anak. Jakarta (ID): Kemenkes RI.
PERTUMBUHAN DAN PERKEMBANGAN
OTAK DAN PENGARUHNYA TERHADAP
OUTCOME KOGNITIF
Pertumbuhan dan Perkembangan Otak dan Pengaruhnya
Terhadap Outcome Kognitif
Source: Pollitt E. 1993. Early supplementary feeding and cognition: effects over two decades. Monogr Soc Res Child
Source: Walker SP, Wachs, TD, Grantham-McGregor, S, Black, MM, Nelson, CA, Huffman, Dev. 58:1–99.
SL, Richter L. 2011. Inequality in early childhood: Risk and protective factors for early Levitsky DA, Barnes RH. 1972. Nutrition and environmental interactions in the behavioural development of the rat:
child development. The Lancet. 378: 1325–1313. long-term effects. Science. 176:68–71.
Prado EL, Dewey KG. 2014. Nutrition and brain development in early life. Nutrition reviews. 72(4): 267-284.
Piaget Theory (Cognitive Development)
▪ Jean Piaget made a landmark contribution to

psychology’s understanding of cognitive
development, asserting that interaction with the
environment and maturation gradually alter the way
children think.
▪ This progression in thinking occurs through the

complementary processes of assimilation
(interpreting new experiences in terms of existing
mental structures without changing them) and
accommodation (changing existing mental
structures to explain new experiences).
▪ Piaget proposed that children’s thought processes go

through a series of four major stages. Within each Source: Piaget J. 1929. The child’s conception of the
world. London (UK): Routledge.
stage there are characteristic thinking and reasoning
Piaget J. 1950. The psychology of intelligence. London
patterns, as well as milestones in development. (UK): Routledge
1 2
Understanding human brain
development from the fetal life to Plasticity of the brain refers to
adulthood is of great clinical the brain’s ability to reorganize
importance as many neurological and recover from injury or alter 3 Mechanisms known to provide
and neurobehavioral disorders its gestalt by adaptive plasticity include deletion of
have their origin in early structural mechanisms induced by neurons through apoptosis,
and functional cerebral environmental factors. proliferation and pruning of
maturation. synapses, activity-dependent
modelling of synaptic
5 4 connections and for certain
Despite marked improvements Increases in white matter (WM), growing areas persistence of
in perinatal practice, perinatal complexity of neuronal networks neurogenesis and alteration of
brain injury remains one of the suggested by gray matter and WM developing glia cells.
most common complications changes, and environmentally sensitive
causing life-long handicapping plasticity are all essential aspects in a
conditions. child’s ability to think and maintain the
adaptive flexibility necessary for
achieving high sociocognitive functioning.
Source: Huppi PS. 2010. Growth and development of the brain and impact on cognitive outcomes. Importance of Growth for Health and Development. 65: 137-151.
Intelligence and cognition can be
Intelligence comprises a
regarded as functions of the brain set of abilities to
→ Head Circumference. understand, learn and
apply knowledge and can
be expressed in terms of
an intelligence quotient
(IQ).
Cognition is the knowl-

edge-handling aspect of
behavior and can be
discerned in the
following cognitive
domains: speech and
language, visuospatial
Source: Nicolau L et al. 2020. Factors and visuoconstructive
associated with head circumference skills, motor skills,
and indices of cognitive development in learning and memory,
early childhood. BMJ Global Health. attention and executive
5(e): 1-10 functions such as
Kinsbourne M, Graf WD. 2000. planning, problem
Disorders of mental development; in solving and self
Menkes JH, Sarnat HB (eds): Child monitoring
Neurology. Philadelphia, Lippincott
Williams & Wilkins.
Head circumference with Intelligence Quotient and IQ
• HC correlated directly with IQ at age 4

yeard of age. Outcome at 4 years of age
was also influenced by the educational
achievements ot the mother and the
child’s height.
• HC of <-2 SD had “very low predictive
• Socio economic status best value” for mental retardation for an
predicted psychometric test inidividual child. How ever, two thirds of
scores, but Head children with HC<-3 SD had IQs <80. As
Circumference (HC) was the in other studies, short stature was also
second best predictor. associated with worse mental outcome.
Stunting in early childhood has been consistently linked to
Compared to children with HC z-scores ≥ − 2 SD, those poorer cognitive performance and lower school
with measurements < − 3 SD had a lower cognition achievement during childhood, including a reduction in
scores by − 2.21 [95% CI: − 3.87 - -0.56] at 2 years. years of completed schooling, an older age at school
Also, children with HC < − 3 SD at two years scored enrollment, and a greater likelihood of failing a grade.
significantly lower scores in cognitive domains of
Source: Grantham-McGregor S, Cheung YB, Cueto S, Glewwe P, Richter L, Strupp B, International Child
verbal, − 7.35 [95% CI: − 11.78 - -2.92] and Development Steering Group. The Lancet2007. Developmental potential in the first 5 years for children in
performance, − 7.07 [95% CI: − 11.77 - -2.36] developing countries.. 369(9555):60e70.
Martorell R, Melgar P, Maluccio JA, Stein AD, Rivera JA. 2010. The nutrition intervention improved adult
intelligence at five years. human capital and economic productivity. J Nutr. 140(2):411e414.
Source: Koshy B et al. 2021. Association between head circumference at two years and second and fifth Stunting children who experience catch-up growth
year cognition. BMC Pediatrics. 21(1): 1-8.
have higher cognitive abilities than non-catch-up
stunting children. In addition, the most influential
Growth faltering and cognitive development both factors on cognitive ability were catch-up growth,
stem from deficient environmental conditions, stunting status of children at an early age, duration of
including suboptimal nutrition, inadequate care breastfeeding, number of parity, father’s education,
and repeated infections, which may underlie father’s occupation, and father’s smoking habit.
poorer outcomes seen in stunted children.
Source: Marjan AQ, Sartika R. 2022. Correlation between Catch-up Growth in Early Childhood with
Source: Leroy JL, Frongillo EA. 2019. Perspective: what does stunting really mean? A critical review of the Cognitive Ability among School-Aged Children (10–12 Years): A Longitudinal Study. Open Access
evidence. Adv Nutr. 10(2):196e204. Macedonian Journal of Medical Sciences. 10.T8: 23-29.
De Onis M, Branca F. 2016. Childhood stunting: a global perspective. Matern Child Nutr. 12:12e26.
Being born
SGA places a
child at risk for
impairments in
intelligence
and cognition,
but, as stated
earlier, the
overall
outcome of
each individual
is the result of
a complex
interaction
between
several factors
(Fig 1)
Note: Small for Gestational Age (SGA)

Appropriate for Gestational Age (AGA) Source: Debie HMA. 2010. Brain development, intelligence and cognitive outcome in children
born small for gestational age. Hormone research in paediatrics,.73.(1): 6-14.
Mapping of UNICEF-supported sectoral interventions
(Programme Interventions Life course approach)
Source: WHO 2017

Mapping of UNICEF-supported sectoral interventions
(Programme Interventions Life course approach)
Source: WHO 2017

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Pertemuan VIII dan IX

PERAN ZAT GIZI DAN STIMULASI PADA MASA BALITA

Dr. Ir. Lilik Kustiyah, M.Si

MK GIZI PERTUMBUHAN DAN PERKEMBANGAN

1. Prinsip penentuan kebutuhan gizi pada

o Usia balita bertambah:

▪ Energy needs in the first year based on EFSA (2013) and

▪ Essential amino acids requirements for healthy

▪ EFSA (2013) recommends protein requirements for

▪ Excessive or inadequate protein intake can result

▪ The recommended intake of linoleic fat is 4.4 g/day,

▪ A low-fat diet can eliminate satiety, while a high-fat diet

4. Carbohydrate Angka Kecukupan Kaborhidrat yang

▪ Some sources of sugar are limited and do not exceed 10% of

▪ Some fruit juices such as apples and pears contain high

▪ Types of carbohydrates that can not be absorbed can cause

▪ The recommended consumption of fruit juice is about 4-6

Source: WHO 2000, Update re-printed 2003

▪ Breast milk contains a small amount of vitamin D.

Source: WHO 2000, Update re-printed 2003

▪ Vitamin C is particularly valuable in assisting the

▪ The enhancing effect of vitamin C on the absorption

Kebutuhan Zat Besi (AKG)

Source: WHO 2000,

Source: WHO 2000, Update re-printed 2003

▪ The Formula for Estimated Energi Requirements (EER)

▪ Beginning at age 3, the DRI equations for estimating

▪ Based on Indonesian RDA 2019, Energy Adequacy

Source: Permenkes RI No. 28 Tahun 2019

4. Carbohydrate 5. Vitamins and Minerals

Zinc (continue) Calcium (continue)

Fiber Adequate intake of total fiber for children

Source: Permenkes RI No. 28 Tahun 2019

1. Indeks Berat Badan menurut Usia (BB/U)

• Indeks ini digunakan untuk menilai anak

• Anak dengan BB/U rendah, kemungkinan

2. Indeks Tinggi/Panjang Badan menurut Usia

• Indeks ini dapat mengidentifikasi anak-anak

• Anak-anak dengan tinggi badan di atas normal

3. Indeks Berat Badan Badan menurut

• Indeks ini menggambarkan apakah berat badan

• Digunakan untuk mengidentifikasi anak gizi

• Kondisi gizi buruk biasanya disebabkan oleh

• Indeks ini dapat menentukan kategori gizi

• Grafik IMT/U dan grafik BB/PB atau BB/TB

• Anak dengan ambang batas IMT/U >+1SD

• Head circumference measurement is an important

• Head circumference- for-age can be evaluated using a suitable

• If weight growth can be maintained normally, then body length

4. Head Circumference atau Lingkar Kepala

SANGAT PENTING UNTUK

Source: Kartu Menuju Sehat

Source: Kemenkes RI. 2016. Pedoman Pelaksanaan

If the diet supplies adequate energy and

Dietary energy density, nutrient density and

Micronutrient supplementation, including supplementation with multiple micronutrients, zinc, and

Source: WHO 2000, Update re-printed 2003

Source: WHO 2000, Update re-printed 2003

Stunting (%) Wasting (%) Underweight (%)

Stimulasi adalah perangsangan

▪ 4 faktor risiko yang mempengaruhi perkembangan anak di negara berkembang yaitu

Source: Departemen Kesehatan RI. 2009. Pedoman

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