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Dr Brain Gantoro, M.

Gizi, SpGK
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KALORI PROTEIN

• PERTUMBUHAN DAN • KEBUTUHAN SELAMA


PEMELIHARAAN JANIN KEHAMILAN 5-6 gram/hari.

• 80.000 Kal/ 280hari ~300 • Meningkat : Ornithine,


kal/hari Glycine, Taurin, Proline

• TRIMESTER I ~ • Menurun : Alanine , Glutamat


MENINGKAT MINIMAL
• Sumber protein hewani :
• TRIMESTER II , III ~ TERUS daging, telur, keju
MENINGKAT SAMPAI AKHIR
KEHAMILAN
Kebutuhan gizi pada ibu hamil

mineral vitamin

Fe, Kalsium, Zinc, Asam folat, vitamin A,


Iodine, Kalium, vitamin B12, Vitamin
Natrium B6, vitamin C, dll
REKOMENDASI DIET HARIAN
 Tergantung Indeks Massa Tubuh (Body Mass
Index/BMI) sebelum hamil

BMI = Berat Badan (kg)


Tinggi Badan
(cm)2
Berat Badan (kg)
BMI 
Tinggi Badan (m)2
Rekomendasi Terbaru
Peningkatan Berat Badan Ibu
Hamil
dari IOM 2009
Rekomendasi untuk kehamilan Ganda dari IOM
2009

Singleton Twins
BMI (lbs) (lbs)
Underweight < 18.5 28-40 Insufficient data
Normal 18.5-24.9 25-35 37-54
Overweight 25-29.9 15-25 31-50
Obese  30.0 11-20 25-42
Karbohidrat
Protein
MAKRO
lemak
NUTRIEN

Zat
Gizi
MIKRO
NUTRIEN
 Tumbuh-tumbuhan Fotosintesis
glukosa sederhana


1. Sumber energi

2. Pemberi rasa manis pada makanan

3. Penghemat protein

4. Pengatur metabolisme lemak

5. Membantu pengeluaran feses


Sumber : padi-padian, umbi-umbian,
kacang-kacangan, gula
 Kalori utama janin
 Dibagi :
- jenuh
- tak jenuh
 Kebutuhan :
-15-30% energi total
-kolesterol< 300 mg/hr
 1/5 bagian tubuh
 Molekul makro
 Rantai panjang asam amino
~ ikatan peptida
 Terdiri : C, H, O, N (utama)
 Sumber  P.Hewani
P. Nabati
 Pertumbuhan dan pemeliharaan
 Pembentukan ikatan-ikatan esensial
tubuh
 Mengatur keseimbangan air
 Memelihara netralitas tubuh
 pembentukan antibodi
 Mengangkut zat-zat gizi
 Sumber energi
Sumber protein
hewani  telur, susu, daging
nabati  kacang kedelai

Kebutuhan protein
penambahan 7 g per hr
trimester 1-2 : 6 g
trimester 3 : 10 g
Janin, plasenta

Vol darah
ibu, uterus, Trimester III
payudara,
lemak Trimester
II
300 kkal/hr :
Trimester I minimal 20% protein
30% lemak
50% karbohd.
ZAT GIZI
MIKRO
Zat gizi mikro adalah segala macam
vitamin dan mineral yang dibutuhkan oleh
tubuh dalam jumlah kecil, yang
kebutuhannya berbeda-beda dalam setiap
kondisi individu. (Budiyanto, 2001)
 Larut dalam lemak
(A,D,E,K)

 Larut dalam air (B,C)


 Vitamin A berfungsi dalam beberapa bentuk
ikatan kimia aktif, yaitu: retinol (bentuk
alkohol), retinal (aldehida), dan asam retinoat
(bentuk asam).
(Murray et al, 2003)
 Fungsi :
- Penglihatan
- Diferensiasi sel
- Sebagai pertahanan tubuh
 Sumber : hati, kuning telur, susu,
dan mentega
 Fungsi umum vitamin D adalah membantu
pembentukan dan pemeliharaan tulang bersama
dengan vitamin A dan C, hormon–hormon
paratiroid dan kalsitonin, protein kolagen serta
mineral–mineral kalsium, fosfor, magnesium dan
fluor. (Sediaoetama, 2008)

 Sumber : Minyak hati ikan, mentega, kuning telur,


ragi, hati
 Fungsi vitamin E adalah sebagai
antioksidan, fungsi struktural dalam
memelihara integritas membran sel,
sintesis DNA, merangsang reaksi
kekebalan, mencegah keguguran dan
sterilisasi

 Sumber : Minyak tumbuh–tumbuhan,


kecambah, gandum dan biji-bijian. Selain
itu, daging, unggas, ikan, kacang–
kacangan, dan buah.
 Fungsi vitamin K berperan dalam proses
sintesis protrombin yang diperlukan dalam
pembekuan darah.
 Sumber : hati, sayuran hijau, kuning telur,
minyak kedelai, kacang- kacangan, kol, buncis,
dan brokoli
Fungsi dalam metabolisme, antara lain:
 Sintesis Kolagen

 Absorpsi dan Metabolisme Besi

 Absorpsi Kalsium

 Mencegah Infeksi

Hal ini disebabkan oleh pengaruh vitamin C


terhadap mukosa dan itulah yang berpengaruh
terhadap kekebalan
Sumber : sayur dan buah terutama yang asam
 Terutama : Asam Folat (vitamin B-9)
 Kebutuhan yang dianjurkan :
 400 g/hari : Wanita Usia Subur
 1 mg/hari : Wanita hamil
 4mg/hari :Wanita dengan riwayat
melahirkan bayi dengan neural tube
defect, dianjurkan mengkonsumsi 1
bulan sebelum konsepsi dan pada awal
trimester pertama kehamilan
MINERAL
KALSIUM (Ca)

Kalsium dalam kehamilan memberikan


efek menguatkan tulang, memperbaiki
kontraksi otot, dan juga untuk kesehatan
gigi.
BESI (Fe)

Dosis yang direkomendasikan : 60 mg (kombinasi


dengan 5mcg asam folat). Pemberian ini
diharapkan dapat mencegah anemia.

IODIUM (I)

Suplementasi Iodium diharapkan dapat


mencegah gangguan mental (efektif diberikan
pada saat prekonsepsi sampai trimester
kedua)
Zinc (Zn)

 Nutrisi penting di masa kehamilan


 Berperan dalam proses fertilisasi
 Defisiensi Zn dapat menyebabkan :
- abortus spontan
- kelahiran prematur
- persalinan lewat waktu
- abnormalitas pada janin
Apabila konsumsi melebihi 50 mg

Absorbsi Cu <<<
(menurun)
Selenium (Se) :
Selenium diyakini berfungsi untuk proteksi jaringan
tubuh melawan stress oksidatif, memberi
pertahanan dalam melawan infeksi, serta
pengaturan pertumbuhan dan perkembangan.
 Kebutuhan nutrien meningkat selama hamil 
sesuai umur kehamilan  pertumbuhan dan
perkembangan janin (programming )
 Malnutrisi  ketidakseimbangan antara
kebutuhan tubuh dan asupan zat gizi esensial.

kekurangan gizi (undernutrisi)


kelebihan gizi (overnutrisi)
 kurangnya asupan makanan dan adanya
penyakit
 gizi kurang (IMT < 19,8) dengan peningkatan
berat badan selama hamil yang tidak adekuat
 Malnutrisi  kelainan vaskuler plasenta (DNA
dan protein yang kurang ) kemampuan
transpor oleh plasenta  (permukaan villus  )
 BBLR + penyulit persalinan
 katabolisme protein (kehilangan separuh dari
tubuh)  albumin oleh hepar   edema
 Fetus normal adalah penerima pasif glukosa dari ibu
 kadar glukosa janin mencapai puncak pada 8-9 mmol/l

 kadar glukosa ibu tinggihiperglikemia pada fetus


(kadar insulin ibu tidak dapat mencapai fetus)  Sel
beta pancreas fetus menyesuaikan  Hiperinsulinemia
fetus  lemak  makrosomia
 wanita gemuk :

masa kehamilan yang lebih panjang


membutuhkan induksi persalinan buatan
memerlukan operasi caesar
memiliki tingkat komplikasi yang lebih besar
First trimester Second trimester Third Trimester

Malformations Hypertrophic cardiomyopathy Hypoglycemia


Growth retardation Polyhydramnion Hypocalcemia
Fetal wastage Erythremia Hyperbilirubinemia
Placental insufficiency Respi distr.syndrome
Preeclampsia Macrosomia
Fetal loss Hypomagnesia
Low IQ Intrauterine death
 Ibu hamil dengan status gizi overweight dan
obesitas, lebih banyak yang mengalami
preeklampsia (2:1) dibandingkan dengan yang
tidak mengalami preeklampsia
 Berat badan sebelum hamil juga berpengaruh
terhadap perkembangan janin
 Bila BMI sebelum hamil termasuk kategori
underweight ( < 18.5 kg/m2) maka resiko
terjadinya berat badan lahir rendah akan
meningkat. Begitu juga dengan keadaan
obesitas, akan meningkatkan kemungkinan
janin makrosomia
 Arrowsmith : kehamilan lewat waktu lebih
banyak dialami ibu hamil yang pada trimester
pertama memiliki indeks massa tubuh (BMI)
lebih tinggi maupun mereka yang berat
badannya melonjak tinggi saat hamil.
 BMI dan hiperkolesterol sudah lama diketahui
mempunyai hubungan yang positif membran
sel (~kolesterol) kontraktilitas otot polos
efektifitas kontraksi uterus
 Mikronutrisi defisiensi
 Folic Acid defek neural tube
 Iron anemia, perdarahan.
 Iodine Kretinisme.
 Kalsium hipertensi, pre-eklampsia.
 Zinc anemia, defek neural tube, berat
badan lahir rendah, anencephali.
 Vitamin A Transmisi HIV secara vertikal,
Ketahanan hidup bayi, anemia
pada ibu, Infeksi, Kematian ibu.
 Mikronutrisi defisiensi
 Vitamin D hipokalsemia neonatal.
 Vitamin K perdarahan.
 Copper anemia, anensefali, bayi
berat lahir rendah.
 Selenium defek neural tube, disfungsi
otak, dan sistem kardiovaskular, aborsi.
 Magnesium peningkatan koagulasi,
toksemia, persalinan prematur.
 Mencegah preconceptionally recurrent and first
occurent neural tube defects
 Mengurangi resiko beberapa birth defects
 Dosis
 400 g/day : laktasi
 1 mg/day : wanita hamil
 4 mg/day : Riwayat neural tube defect deliveries
folic acid 1 month prekonsepsi dan trimester pertama
 Kebutuhan
 Wanita dewasa :
 800 g iron lost/day
 + 500 g iron lost/day during menses
 Wanita hamil
 Peningkatan volome darah
 Fetal and placental requirements
 Blood loss selama persalinan
 Suplementasi besi :
 Pencegahan anemia nutrisional
 Dosis : 60 mg besi + 500 g asam folat
 Pencegahan mental impairment
 Supplementasi efektif pada prekonsepsi sampai
mid trimester
 Zinc – mengandung 300 enzim,
nucleoprotein, DNA and protein
synthesis, cell division.
 Kadar Serum zinc wanita
normal, normal 7-10 mol/l
 Berhubungan dengan berat
lahir, Pertumbuhan janin
terhambat, prematur, kongenital
anomali,
atonia uterin
 Dosis selama kehamilan :-10 000IU perhari
atau 25 000IU perminggu
 Indikasi suplementasi vitamin A :
 Vertical transmisi HIV
 Infant survival
 Maternal anemia: positive interaction with iron in
reducing anemia
 Infeksi
 Maternal mortality
 Potential adverse effects of vitamin A
 Total dosis harian > 10,000 IU sebelum 7 week of
gestation associated with birth defects: craniofacial,
central nervous system, thymic cardiac
 Vitamin D.
 Absorbsi calcium, Neonatal hypocalcaemia.
 No study.
 Routinely Administered.

 Vitamin K.
 Deficiency associated with haemorrhage?
 No study
 Fungsi - Cu-proenzymes, Cytochrome-c -
oxidase, angiogenesis, connective tissue
synthesis.
 Kebutuhan : - 110 to 210 micro gm/dl.
 Peak value- 220-300 micro gm/dl.
 Pattern of rise- First/Second trimester.
 Postpartum levels- 2 / 4 / 8-12 weeks.
 Tidak ada hubungan aborsi, berat, preterm
delivery or other adverse pregnancy outcomes.
 Inverse relationship with birth weight.
 Fungsi - antioxidant, co-factor for enzyme
glutathione peroxidase, prevents free radical
formation, DNA changes.
 Results of four prospective studies: -
 Fall in serum selenium during pregnancy
 Levels in pregnancy - 35-70 ng/ml
 Neural tube defects
 First trimester miscarriage
 Preterm delivery
 Defisiensi: - meningkatkan
kekentalan darah,
preeclampsia, persalinan
preterm?
 Studi prospektif
 Kadar wanita normal -
1.55-.92mg/dl
 Berat lahir
 Pertumbuhan janin terhambat
TERIMA KASIH
Poor maternal and child health and malnutrition
as a cause for structural damage of the brain and
cognitive development

Prepared and delivered by Leena Rammah

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 Evidence shows - good health, nutrition of pregnant
women and young children, along with an appropriate
stimulation during the early years have an important
positive effect on cognitive development.

 Deeper analysis shows maternal health and nutrition


affects child’s health right from fetus brain
development till later stages.

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A concept that includes:

 Family planning
 Prenatal, and postnatal care
 Education provision
 Health promotion

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Let us look at Health, Nutrition and Cognitive
Development during two major phases:

1. Prenatal phase
2. Postnatal phase

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 Studies prove women with proper prenatal care have
better health results than women who miss PNC during
pregnancy.

 The health and the well being of women and their


children are inter-linked. This process requires a
substantial strengthening of the health system (DFID)

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Factors that affect mother’s and child’s health
and can damage brain development (prenatal)

 Early or late age pregnancies


 Premature delivery

 Contact with potentially toxic substances (e.g. alcohol


tobacco, and drug abuse, etc.
 Existence of certain diseases (maternal measles,

toxoplasmosis,..)

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Factors that affect mother’s and child’s health
and can damage brain development (prenatal)

 Exposure to Radiation
 Maternal attitudes and behaviors
 Absence of skilled health personnel during delivery
 High blood pressure (pre-eclampsia)
 Intake of certain medication due to illness
 Poor education

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Factors that affect mother’s and child’s health
and can damage brain development (perinatal)

 Intrauterine position
 Obstructed labor and asphyxia
 Prolonged labor
 Obstetrical trauma
 Pelvic fetus incompatibility

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 The younger the age at pregnancy, the greater the health risks for
mother and child and the higher risk of infant mortality (60%)
 Children who survive are more likely to suffer from low
birth weight, under nutrition and delayed cognitive
development. (Lawn et al., 2006;UNICEF, 2008b; WHO, 2005).

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Factors that affect child’s health and can damage
brain development (postnatal)

Postnatal care is likewise important and includes:


 Child birth
 Newborn’s care
 ECD’s education

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Factors that affect child’s health and can damage
brain development (postnatal)

 Poor disease prevention and vaccination


 Exposure to accidents
 Lack of physical activity
 Improper stimulation

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Factors that affect child’s health and can damage
brain development (postnatal)

 Lack of early education


 Lack of psychological and social care
 Lack of love and parents’ care, (bonding)
 Existence of Infectious diseases (Meningitis,..)

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Maternal nutrition deficiency that affect brain
and cognitive development (prenatal)

 Folic Acid deficiency


 Iron deficiency anemia (IDA)
 Iodine deficiency
 Omega 3 deficiency

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Child’s nutrition deficiency that affect brain and
cognitive development (postnatal)

 Iron deficiency and its effect upon brain and cognitive


development.
 Iodine deficiency and its affects
 Vitamin A deficiency.
 Lack of exclusive breastfeeding till the age of six
months.
 Insufficient supplementary food and of micronutrients
introduced after the age of six with continuation of
breast feeding well into the second year.

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How do poor maternal and child’s malnutrition
affect cognitive development? (Postnatal)

Iron deficiency has been clearly linked to cognitive deficits


in young children. Iron is critical for maintaining an adequate
number of oxygen-carrying red blood cells, which in turn are
necessary to fuel brain growth. (http://www.zerotothree.org/brainwonders).

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Children who are malnourished usually:
 are fussy eaters
 are deprived of adequate calories
 are deprived of protein in their diet
 experience insufficient growth in early years
 suffer from lasting behavioral and cognitive deficits,
including slower language and fine motor
development, lower
IQ, and poorer school performance.
(www.zerotothree.org/brainwonders)
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How do poor maternal and child’s malnutrition affect
cognitive development? (Postnatal)

Breast milk contains all the amino and fatty acids needed
for brain development. Research has shown that babies
who are breast-fed as compared to babies who are formula
fed score higher on IQ tests.

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 Child illness / malnutrition reduce cognitive development and
intellectual performance, school enrolment and attendance.
 Intrauterine growth retardation and malnutrition during early
childhood have long term effects on body size and strength
with implication on productivity in adulthood (WHO 2006)

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 Micronutrient deficiencies can severely affect early cognitive
development, including a loss of up to fifteen points on IQ test
even in moderate forms.
 Children are also affected by Vitamin A deficiency which

causes blindness, poor health and concentration (Victoria et al., 2008).

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Intervention with stunted children
IQ
110 non-stunted
Both
105
stimulated
100 supplemented

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control
90

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Baseline 6 mo 12 mo 18 mo 24 mo

Grantham-McGregor et al, 1991 78


What is brain development in prenatal phase?

Average Brain Weights at


Different Times of
Development:

AGE BRAIN WEIGHT


(grams)

20 weeks of gestation 100


Birth 400
18 months old 800
3 years old 1100
Adult 1300-1400
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Brain development in prenatal phase

The brain grows at an amazing rate during this period.


From the 3rd week of Intrauterine life 250,000 neurons
proliferate every minute.
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Neurons which are continuously firing or activated, through
stimulation will consolidate and strengthen over time.

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The child has by birth 100 Billion Neurons. For the brain to function in
proper way, these neurons have to be connected by synapses.
These synapses can be developed by:
1. Appropriate nutrition, especially breast feeding, that helps to form
myelin that cover the synapses and can allow the impulse to pass.
2. Early stimulation for the brain through interaction with the child.

Through ECD, a child may form and reinforce over 1 trillion connections
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Combination between nutrition and stimulation
that can affect cognitive development
115

110

105
Adopted before the
100 age of 2
95 Adopted after the
age of 2
90

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Severe Moderate Well
malnutrtion malntrtion nourished

Study on level of intelligence among orphaned Vietnamese girls


according to the level of nutrition.

American Journal of clinical nutrition 1977, 30

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Poor maternal health is associated with poverty

Poverty reduction

Intergenerational transmission of poverty


preschool child
low IQ, behaviour problems

school
poor stimulation, poor school achievement
nutrition & health behaviour problems

adult
low education
National low skilled / no work
economy high fertility
depressed/stressed

Lancet Paper 1, S Grantham-McGregor 2007

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Why invest in maternal health, newborn and
child health?

1. The value of women and children’s health.


2. Inexpensive ways to save lives of women and children
3. The economic soundness.
4. The political soundness, including social stability and
human security
5. The improvement of the health system.

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A key to beat poverty
Integration of disease prevention and care for mothers
newborns and children makes economic sense as it
maximizes benefits and minimizes costs for mothers,
newborns and children. Indeed high under 5 mortality and
morbidity and high level of malnutrition have a serious
economic and development cost. (DFID)

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Short-term distress in the form of rising malnutrition will
have negative long-term consequences for education.

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Situation analysis of health, education

Many countries lack programs addressing health, nutrition,


care, and education of children under 3, a critical period in life.

World

Arab States
Central/East. Europe
Sub-Saharan Africa
East Asia/Pacific
South/West Asia
L. America/Carib.
Central Asia
N. America/W. Europe

0% 50% 100%

Countries with at least one formal program for children under 3 in 2005 (%)

Source: EFA Global Monitoring Report 2007. 88


 10% of worldwide disease is caused by under nutrition
(WHO 2005)

 According to 2007 MDG report, 84% of women who


have completed secondary or higher education are
attended by skilled personnel during child birth, more
than twice the rate of mothers with no formal
education (UNICEF 2008)

 Childrenof educated mothers are 50% more likely to


survive until the age of 5 and beyond than those
whose mothers who didn’t receive or complete
schooling (UNICEF 2008)

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To advocate for services that should include:
 Education on safe motherhood.
 Promotion of maternal nutrition.
 Supplementation of micronutrient and tetanus toxoid,
where appropriate.
 Prenatal care and counseling.
 Delivery assistance in all cases by a skilled professional

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 Care for obstetric emergencies, including referral for
pregnancy, childbirth, and abortion complications.
 Postnatal care.
 Promotion of longer intervals between births through
family counseling.

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Recommendations

Postnatal care, including exclusive breast-feeding.


Early stimulation for the brain of the child through interaction
ECD as Holistic approach on policy level

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 Mrs. Lara Hussain
 Dr. Mahendra Sheth
 Dr. Malak Zalouk
 Mr. Moncef Moalla

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Thank you

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