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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

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.
Prof Sir Ian Kennedy

The Report of the Public Health Inquiry into Childrens Heart Surgery at the Bristol Royal Infirmary 1984-1995

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

Faktor yang mempengaruhi pertumbuhan dan perkembangan


1. 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

Bayi Baru Lahir (Clinical assessment Routine measurements)

Measure: Weight
normal 2.5 3.99kg

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

Problem BBLR (SGA)


Asphyxia Meconium aspiration Pulmonary Hemorrhage Intracranial Hemorrhage Hypoglycemia Hypothermia Polycythemia

Klasifikasi bayi menurut berat lahir dan masa gestasi


Berat lahir : 1. Bayi Berat lahir Rendah 2. Bayi Berat Lahir Cukup/normal 3. Bayi Berat Lahir Berlebih Masa gestasi / umur kehamilan : 1. Bayi Kurang Bulan 2. Bayi Cukup Bulan 3. Bayi Lebih Bulan

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

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

Two types of LBW neonates


Preterm ( 1/3 ) Small for dates ( 2/3)

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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

Causation : IUGR / SFD


Poor nutritional status of mother. Hypertension, toxemia, anemia. Multiple pregnancy, postmaturity. Chronic malaria, chronic illness. Tobacco use.

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

Identification of preterm LBW


Date of LMP Physical features - breast nodule, genitalia, sole creases, ear cartilage / recoil.

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

Pendahuluan . . . .
Neonatal hypothermia induced cold stress and result in:
Metabolic rate, 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), progressing to death

Fakta . . .
Hypothermia significantly occurred in the vulnerable group of newborns on neonatal admission. The vulnerable group of sick babies included premature (~38%), LBW (~65%), suffering hypoglycaemia since birth or birth asphyxia.

The vulnerable group of babies with C/S birth in OT were more easily prone to hypothermia.

In general, newborns need a warmer environment


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

WHO:
Definition of hypothermia (C)
36.4c 36c
35.9c 32c Below 32c

Mild hypothermia
Moderate hypothermia Severe hypothermia WHO, 1997

Operative Definition of Hypothermia in Delivery Suite

Hypothermia = Temp below 36C

Moderate hypothermia =Temp at 35-35.9

Profound hypothermia =Temp less than 35

Optimal temp. range:36.837.2 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

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

Hipoglikemia pada neonatus

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

Incidence of Hypoglycemia
Overall Incidence = 1- 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, 1999 as cited by Verklan & Walden

Why is hypoglycemia a problem?


Glucose is the primary fuel for the brain. The brain needs a steady supply of glucose to function normally. Glucose is the fetuss only source of carbohydrate.

Karlsen, 2006

Why is hypoglycemia a problem?


Compared with adults, infants have a higher brain to body weight ratio, resulting in higher glucose demand in relation to glucose production capacity. Cerebral glucose utilization accounts for 90% of the neonates glucose consumption.
Verklan & Walden, 2004

Preparation for Birth


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

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. When the infant is born, the cord is cut and so is the major supply of glucose!

Haney, 2005

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.
Haney, 2005

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, 2006

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

Karlsen, 2006

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.

Increased Utilization of Glucose


Sick/Stressed infants
Causes increase in metabolic demand Uses up glucose quickly. These include all sick, premature and SGA infants.

Karlsen, 2006

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

Signs & Symptoms of Hypoglycemia


Jitteriness Irritability Hypotonia Lethargy High-pitched cry Hypothermia Poor suck Tachypnea Cyanosis Apnea Seizures Cardiac arrest

Verklan & Walden, 2004

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

What Medical Students Expect from Medical Ethics Classes


HATTORI Kenji, MD DMSc MA (Japan, Gunma University)

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. 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, however, has been paid for what medical students expect from medical ethics classes yet.

Methods
We used an 8-item structured, 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.

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, 84.7%) in fiscal year 2000 and 47 of the 85 first-year students (response rate, 55.3%) in fiscal year 2001 participated in this survey. Below, the set of first-year students in fiscal year 2000 is designated as 'Student-2000', and the other set as 'Student-2001'.

Recognition of the importance of a medical ethics class


Totally unnecessary More necessary than not Necessary Definitely necessary Values are n (%). Student-2000 0 (0.0) 2 (2.8) 41 (56.9) 29 (40.3) Student-2001 1 (2.1) 0 (0.0) 27 (57.5) 19 (40.4)

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 (%). 24 (34.3) 31 (44.2) 9 (12.9) 6 (8.6) Student-2001 9 (20.4) 31 (70.5) 4 (9.1) 0 (0.0)

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

17

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 (%). 3 (4.3) 10 (12.6) 35 (50.7) 21 (30.4) Student-2001 3 (7.1) 2 (4.8) 22 (52.4) 15 (35.7)

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.

Session styles
Student-2000
Primarily Lectures 6 (8.5) Primarily Discussions 15 (21.1) Lectures + Discussions 50 (70.4)

Student-2001
1 (2.5) 11 (26.8) 29 (70.7)

Values are n (%).

Recognition of a suitable method


of course evaluation

Multiple-choice test Essay test Values are n (%).

Student-2000 17 (25.0) 51 (75.0)

Student-2001 9 (22.0) 32 (78.0)

When to hold the course


Grade 1 2 3 4 5 6 Student-2000 50 (70.4) 1 4 3 6 8 Student-2001 35 (77.8) 2 4 0 0 4

Values are n (%).

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, cloning humans, assisted reproduction, or dying with dignity), no inquiry into the fundamental nature of these courses was actually executed. Before selecting themes for lectures, we tried to discover the attitudes and needs of the students from a fundamental viewpoint of course construction as a whole.

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

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.

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, 3) what decisions they make, 4) what actions they take with regard to their decisions, and 5) how they can acquire the ability to see things from a number of different perspectives.

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

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

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

Thank you for your attention!

In conclusion
Students who are weak in communication skills are not hard to find. 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, to make sure that these students are fully aware of their own ethical positions, and to urge reviews that include serious self-examination.