report pleno geriatry

8/12/2019 report pleno geriatry

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GERIATRIC SYSTEM

INTERNASIONAL CLASS 2010

REPORT PLENO MODULE 1:

IMPAIRMENT IN CHILDREN GROWTH &

DEVELOPMENT

GROUP 5

NAME NIM

FACULTY OF MEDICINE

HASSANUDDIN UNIVERSITY

2013


2/18

MODULE : IMPAIRMENT IN CHILDREN GROWTH AND DEVELOPMENT

SCENARIO :

A, a boywas taken to Puskesmas in Desember 5th 2009due to overnight fever. He

born in February the 25th, 2009; supported by a midwife, hardly breathingwhen he was

first delivered, with weak muscle tonus, birth weight (BW) 3000 grams, birth length (BL)

49 cm, head circumference (HC) 35 cm. The last 2 months consequtive weighin

records: 6100 grams dan 6300 grams, with HC 44 cms. For daily meal the baby was

fed with rice and vegetables, tofu, tempe, and sometimes egg. Starting from the age of

3 months, he consumed formula milk, bananas and baby porridgebecause he cried

most of the time.

He got BCG immunizationwhen he was 2 months old; 4 times polio vaccine; B Hepatitis

vaccine twice, in the age of 40 days and 3 months; DPTwhen he was 2 and 6 months

old.

The baby was able to crawl, but not yet sit and stand by him self. Sometimes mumbled,not able to hold jingling toyswith his hands. He responded to sound, and able to show

the direction of the sound source, can not feed him selfwith biscuits, and do not know

how to play peek-a-boo. His mother was elementary school graduate only. Toys

available at home: jingling toys, dolls, a three wheel bicycle. The mother never talked

much.

KEYWORDS/PATIENT STATUS:

A 9 months years old boy came with overnight fever

Weak muscle tonus and hardly breathing during delivery

A term baby with normal body weight

Last two months weight: BW:6100 and 6300 (low, it should be >8500g)

Daily meal variable

Breast milk only given in 3 months

Immunizations: polio 4x,BCG 1 x, Hep B 2x,DPT 2X

Able to crawl but not yet sit and stand, mumbled not able to hold jingling toys, good hearing,

cant feed himself cant play peek a boo

Mother has low education and not talkative

QUESTIONS:1. Why does he got fever?

2. What are the normal growth and development bases? Is this baby has normal growth and

development?

3. How does the nutritional status of the baby?

4. How does the immunization status of the baby?

5. How do we interpret the factor that influences the growth and development of the baby?

What is the disturbance that cause delay in baby growth and development? Is there any

relation between social interactions with impairment of development?

6. What is the relationship between birth status with the muscle tone and impairment of

development?


3/18

ANSWERS:

1. Why does he got fever?

Actually, both either bad nutritional status could cause fever and fever could cause bad nutrional

status and finally impaired the growth and development of the baby. But, we are more agree that

bad nutritional status causes the baby fever.

Malnutrition or undesirable physical or disease conditions related to nutrition can be caused by

eating too little, too much or an unbalanced diet that does not contain all nutrients necessary for

good nutritional status. In this book the term malnutrition is restricted to undernutrition, or lack of

adequate energy, protein and micronutrients to meet basic requirements for body maintenance,

growth and development.

Nutrition and infection, health and disease

The interaction or synergism of malnutrition and infection is the leading cause of morbidity and

mortality in children in most countries in Africa, Asia and Latin America. Viral, bacterial and parasiticinfections tend to be prevalent, and all can have a negative impact on the nutritional status of

children and adults. The situation was similar in North America and Europe from about 1900 to

1925; common infectious diseases had an impact on nutrition and produced high case fatality rates.

The synergistic relationship between malnutrition and infectious diseases is now well accepted and

has been conclusively demonstrated in animal experiments. The simultaneous presence of both

malnutrition and infection results in an interaction that has more serious consequences for the host

than the additive effect would be if the two worked independently. Infections make malnutrition

worse and poor nutrition increases the severity of infectious diseases.

Effects of malnutrition on infection

The immune system

The human body has the ability to resist almost all types of organisms or toxins that tend to damage

the tissues and organs. This capacity is called immunity. Much of the immunity is caused by a special

immune system that forms antibodies and sensitized lymphocytes which attack and destroy the

specific organisms or toxins. This type of immunity is called acquired immunity. An additional portion

of the immunity results from the general processes of the body; this is called innate immunity

Innate immunity is due to:

resistance of the skin to invasion by organisms;

phagocytosis of bacteria and other invaders by white blood cells and cells of the tissue macrophage

system;

destruction by the acid secretions of the stomach and by the digestive enzymes of organisms

swallowed into the stomach;

the presence in the blood of certain chemical compounds that attach to the foreign organisms or

toxins and destroy them.

There are two basic but closely allied types of acquired immunity. In one of these the body develops

circulating antibodies, which are globulin molecules that are capable of attacking the invading agents

and destroying them. This type of immunity is called humoral immunity. Antibodies circulate in the

blood and may remain there for a long time, so that a second infection with the same organism is

immediately controlled. This is the basis for some forms of immunization, which are designed to

stimulate antibody production.


4/18

The second type of acquired immunity is achieved through the formation of large numbers of highly

specialized lymphocytes which are specifically sensitized against the invading foreign agents. These

sensitized lymphocytes have the ability to attach to the foreign agents and to destroy them. This

type of immunity is called cellular immunity. It is a highly complex system involving many different

body organs (such as the spleen, thymus, lymph system and bone marrow) and also body fluids,

particularly blood and its constituents and lymph.

The study of the complex system of immunity is termed immunology.

Effects of malnutrition on resistance to infection

A considerable amount of literature, documenting studies both in experimental animals and in

people, demonstrates that dietary deficiency diseases may reduce the body's resistance to infections

and adversely affect the immune system.

Some of the normal defence mechanisms of the body are impaired and do not function properly in

the malnourished subject. For example, children with kwashiorkor were shown to be unable to form

antibodies to either typhoid vaccine or diphtheria toxoid; their capacity to do so was restored after

protein therapy. Similarly, children with protein malnutrition have an impaired antibody response toinoculation with yellow fever vaccine. An inhibition of the agglutinating response to cholera antigen

has been reported in children with kwashiorkor and nutritional marasmus. These studies provide a

fairly clear indication that the malnourished body has a reduced ability to defend itself against

infection.

Another defence mechanism that has been studied in relation to nutrition is that of leucocytosis

(increased production of white blood cells) and phagocytic activity (destruction of bacteria by white

corpuscles). Children with kwashiorkor show a lower than normal leucocyte response in the

presence of an infection. Perhaps of greater importance is the reduced phagocytic efficiency in

malnourished subjects of the polymorphonuclear leucocytes that are part of the fight against

invading bacteria. When malnutrition is present, these cells appear to have a defect in their

intracellular bactericidal (bacteria-destroying) capacity.

Although malnourished children frequently have increased immunoglobulin levels (presumably

related to concurrent infections), they also may have depressed cell-mediated immunity. In a recent

study, the extent of this depression was directly related to the severity of the protein-energy

malnutrition (PEM). Serum transferrin levels are also low in those with severe PEM, and they often

take considerable time to return to normal even after proper dietary treatment.

A quite different kind of interaction of nutrition and infection is seen in the effect of some deficiency

diseases on the integrity of the tissues. Reduction in the integrity of certain epithelial surfaces,

notably the skin and mucous membranes, decreases resistance to invasion and makes an easy

avenue of entry for pathogenic organisms. Examples of this effect are cheilosis and angular

stomatitis in riboflavin deficiency, bleeding gums and capillary fragility in vitamin C deficiency, flaky-

paint dermatosis and atrophic intestinal changes in severe protein deficiency and serious eye lesions

in vitamin A deficiency.

Why the boy has an overnight fever?

This is probably caused lack of necessary nutrition for which in turn cause defect in immunity

system for example:

-PUFA-consists of omega 3 and omega 6 which is vital for production of IgA and IgM

in blood plasma

-vitamin A-modulate 500 productions of gene which in turn the gene controlled production

of immune cells


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-vitamin D-regulates immune gene expression

-vitamin C-against oxidative agents produced by immune cells against the pathogen

So thats probably why this boy is vulnerable in infection thus causing this boy to have fever

Effects of infection on nutritional status

Infection affects nutritional status in several ways. Perhaps the most important of these is that

bacterial and some other infections lead to an increased loss of nitrogen from the body. This

repercussion was first demonstrated in serious infections such as typhoid fever, but it has

subsequently been shown in much milder infections such as otitis media, tonsillitis, chicken pox and

abscesses.

Nitrogen is lost by several mechanisms. The principal one is probably increased breakdown of tissue

protein and mobilization of amino acids, especially from the muscles. The nitrogen is excreted in the

urine and is evidence of a depletion of body protein from muscles.

Full recovery is dependent upon the restoration of these amino acids to the tissues once the

infection is overcome. This requires increased intake of protein, above maintenance levels, in thepost-infection period. In children whose diet is marginal in protein content, or those who are already

protein depleted, growth will be retarded during and after infections. In developing countries,

children from poor families suffer from many infections in quick succession during the post-weaning

period, and they often have multiple infections.

Anorexia or loss of appetite is another factor in the relationship between infection and nutrition.

Infections, especially if accompanied by a fever, often lead to loss of appetite and therefore to

reduced food intake. Some infectious diseases commonly cause vomiting, with the same result. In

many societies mothers and often medical attendants as well consider it desirable to withhold food

or to place the child with an infection on a liquid diet. Such a diet may consist of rice water, very

dilute soups, water alone or some other fluid with a low calorie density and usually deficient in

protein and other essential nutrients. The old adage of "starve a fever" is of doubtful validity, and

this practice may have serious consequences for the child whose nutritional status is already

precarious.

The traditional treatment of diarrhoea in some communities is to prescribe a purgative or enema.

The gastro-enteritis may already have resulted in reduced absorption of nutrients from food, and

the treatment may further aggravate this situation.

These are all examples of how illnesses such as measles, upper respiratory infections and gastro-

intestinal infections may contribute to the development of malnutrition. The relationship of

intestinal parasites, diarrhoea and measles to nutrition is discussed below.Parasitic infections

Parasitic infections, particularly intestinal helminthic infections, are extremely prevalent and are

increasingly being shown to have an adverse effect on nutritional status, especially in those heavily

infected. Hookworms(Ancylostoma duodenale and Necator americanus) infect over 00 million

people, mainly the poor in tropical and subtropical countries. They used to cause a prevalent

debilitating disease in the southern United States. Hookworms cause intestinal blood loss, and

although it appears that most of the protein in the lost blood is absorbed lower down in the

intestinal tract, there is considerable loss of iron.

Hookworm disease is a major cause of iron deficiency anaemia in many countries. The extent of the

loss of blood and iron in hookworm infections has been studied (Layrisse and Roche, 1966): daily

faecal blood loss per hookworm (N. americanus) was reported to be 0.031 0.015 ml. It was


6/18

estimated that about 350 hookworms in the intestine cause a daily loss of 10 ml of blood, or 2 mg of

iron. Infection densities much higher than this are not uncommon. In Venezuela, where much of this

work was done, iron losses greater than 3 mg per day often resulted in anaemia in adult males, and

losses of half this amount frequently produced anaemia in women of child-bearing age and in young

children.

Worldwide, roundworm (Ascaris lumbricoides) is among the most prevalent of intestinal parasites. It

is estimated that 1 200 million people in the world (one-quarter of the world's population) harbour

roundworms. The roundworm is large (15 to 30 cm long), so its own metabolic needs must be

considerable. High parasite densities, particularly in children, are common in environments where

sanitation is poor. Complications of ascariasis can develop, including intestinal obstruction or the

presence of worms in aberrant sites such as the common bile duct. In some countries ascarids are a

cause of surgical emergencies in children, and many with obstruction die. In the majority of children,

however, when malnutrition is prevalent, deworming improves child growth.

Trichuris trichiura or whipworm inhabits the large intestine and infects about 600 million people

worldwide. The worms are small and, in heavily infected children, may cause diarrhoea andabdominal pain.

Many children living in poor sanitary conditions are infected with several parasitic infections at the

same time. In areas where infection with these three parasites is common and where malnutrition is

prevalent, deworming of children leads to an improvement in growth, a reduction in the extent of

malnutrition and an increase in appetite. It also positively influences physical fitness and perhaps

psychological development.

Bilharzia or schistosomiasis infections are prevalent in some countries. They also contribute to poor

nutrition, poor appetite and poor growth. The three organisms that cause

schistosomiasis (Schistosoma haematobium, Schistosoma mansoni and Schistosoma japonicum) are

flukes, rather than ordinary worms.

Somewhat less is known about the relationship between intestinal protozoa! diseases and nutrition,

but amoebas, causing serious dysentery and liver abscess, are highly pathogenic organisms, and

infection with Giardia lamblia may cause malabsorption and abdominal pain.

The fish tapeworm (Diphyllobothrium latum) has an avidity for vitamin B12and can deprive its host of

this vitamin, with megaloblastic anaemia resulting. The fish tapeworm is common in people in only

limited geographic areas, mainly in temperate areas and where undercooked fish is frequently

consumed.

In many northern industrialized countries, farm animals and domestic pets such as dogs and cats are

dewormed routinely. Much evidence suggests that pigs grow better when they regularly receive

anthelmintics. Now that highly effective, relatively inexpensive and safe broad-spectrum

anthelmintics such as albendazole and mebendazole are available, routine mass deworming should

be introduced where parasitic infections are prevalent in humans and where PEM and anaemia are

common. Similarly, routine efforts to treat children with schistosomiasis using metrifonate or

praziquantel seem highly desirable both to rid children of potential serious pathology and to

improve their nutritional status. More attention needs to be given to population-based

chemotherapy for these infections along with intensification of public health and other measures to

reduce their transmission, including improved sanitation and water supplies. Such efforts would

improve the health and nutritional status of millions of the world's children.


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Effects of diarrhoea

Many studies have indicated that gastrointestinal infections, and especially diarrhoea, are very

important in precipitating serious PEM. Diarrhoea is common in, and often lethal to, the young child.

In breastfed infants there is often some protection during the first months of life, so diarrhoea is

often a feature of the weaning process. Weanling diarrhoea is extraordinarily prevalent in poor

communities throughout the world, both in tropical and temperate zones. The organism responsible

varies and often cannot be identified. Diarrhoea was a major cause of mortality in children in

industrialized countries up to the beginning of the twentieth century.

Several studies have shown that admissions of cases of malnutrition are greatly increased during the

season when diarrhoea is most common. For example, in a report from the Islamic Republic of Iran,

more than twice as many cases of PEM were admitted in the warm summer than in the cold winter.

The incidence of diarrhoeal disease followed the same pattern.

Hospital and community studies indicate that cases of xerophthalmia and keratomalacia are

frequently precipitated by gastro-enteritis, as well as by other infectious diseases such as measles

and chicken pox. Xerophthalmia is the major cause of blindness in several Asian countries; it is alsoprevalent in certain parts of Africa, Latin America and the Near East.

Intestinal parasites may contribute to diarrhoea and to poor vitamin A status. The exact mechanism

of this relationship has not been proved, but it is likely that many infections reduce vitamin A

absorption and that some result in decreased consumption of foods containing vitamin A and

carotene.

Diarrhoea can be fatal, usually because it can lead to severe dehydration (see Chapter 37).

Diarrhoea, and the complication of dehydration, may be said to be a form of malnutrition.

Dehydration is a "deficiency" in the body of water and mineral electrolytes, and providing adequate

quantities of these cures the deficiency. The term "fluid electrolyte malnutrition" (FEM) has been

coined for this condition. Provision of water and adequate minerals in home-prepared food,

breastfeeding or administration of oral rehydration fluids is now the accepted treatment. Although

these are forms of therapy or treatment, they are really refeeding and replenishment. However,

prevention requires measures and interventions to reduce infections, poverty and malnutrition.

These are essential if countries are to reduce the incidence of diarrhoea.

Fatality rates for measles and other infectious diseases

A dramatic illustration of the effect of malnutrition on infection is seen in the fatality rates for

common childhood diseases such as measles. Measles is a severe disease with a case fatality rate of

about 15 percent in many poor countries because the young children who develop it have poor

nutritional status, lowered resistance and poor health. In Mexico the fatality rate for measles has

been reported to be 180 times higher than that in the United States; in Guatemala, 268 times higher;

and in Ecuador, 480 times higher. The decline in case fatality rates of measles in North America,

Europe and other industrialized countries has been dramatic over the last century.

Differences in the clinical severity and the fatality rates of measles in developed and developing

countries are due not to differences in virus virulence but to differences in the hosts' nutritional

status. For example, during a measles epidemic in the United Republic of Tanzania that was causing

considerable mortality among the children of poorer families, it was observed that fatalities from the

disease were extremely uncommon in the children of families of moderate income, such as those of

hospital employees. Measles is also related to vitamin A deficiency. It has been shown that providing

vitamin A supplements to children with measles who have poor vitamin A status greatly reducescase fatality rates.


8/18

Immunization against measles is proving very effective, and in many countries measles incidence has

been markedly reduced.

Other common infectious diseases such as whooping cough, diarrhoea and upper respiratory

infections also have much more serious consequences in malnourished children than in those who

are well nourished. Mortality statistics from most developing countries show that such

communicable diseases are the major causes of death. It was observed in several African countries

at the end of the Sahel famine that very few children were dying of starvation or malnutrition, but

that deaths from measles, respiratory infections and other infectious diseases were still very much

above pre-famine levels. It is clear that many, perhaps the majority, of these deaths were due to

malnutrition. This may seem a moot point for a grieving parent, but for the policy planner and the

public health official it is important to know to what extent morbidity and mortality rates are due to

or related to undernutrition.

An inter-American investigation of mortality in childhood showed that of 35 000 deaths of children

under five years of age in ten countries, in 57 percent of the cases malnutrition was either the

underlying or an associated cause of death. Nutritional deficiency was the most serious healthproblem uncovered, and it was frequently associated with common infectious diseases

Source:Human nutritionin the developing world

http://www.fao.org/docrep/W0073E/w0073e03.htm#P316_22106

2. What are the normal growth and development bases? Is this baby has normal growth and

development?

What is the growth and development of the baby?

Growth

The change of large, amount, measures or dimension of the cell stage, organ and individual.

Example : body weight, body length, bone age, circumference head, and circumference of the arm.

Stages of growth-development

Postnatal period (after birth)

neonatal

periods

(0-28 days)

Baby periods (1mo-2 yr) preschool

periods(2-6

yr)

School

periods (6-10 yr,8-12 yr)

adolescent

periods (10-18 yr,12-20yr)

Early baby

(1mo-1yr)

final baby

(1-2 years)

adaption to

environment,

the change of

blood

circulation,

start to the

function of

body organ

Rapid

growth,

maturation

process

take place.

continue

the

increasing

of nerve

system

function

Speed of

growth

start

decrease,

progress of

growth of

motor &

function of

excretion

stable of the

growth,

corporeal

activity

increase & the

increasing of

skilled &

process of

thinking

rapid

growth,

skill and

intelectual

more

expand,

like to play

in the team

the transition

of period of

child to adult,

acceleration

growth,

marking of

secondary sex
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9/18

Based on our case, the age of the baby is 9 months. Thus, the baby is in early baby periods. In this

period, rapid growth, maturation process take place continue and the increasing of nerve system

function is occurred.

The characteristic of growth1. Change of measure physical ; increasing of the body organ improvement of

requirement of body increased

2. Change of proportion head of the newborn baby relative have the bigger proportion

than age furthermore. Center body in umbilicus, adult as high as pubis symphisis

3. The vanish of old marking growth process disappearing of the thymus gland, fall out

of the milkteeth, the vanish of primitive reflects

4. Appear of the new marking the maturation effect of organ function permanet tooth,

the marking of secondary sex

Growth Assessment

1. Body Weight(BW)

Normal = 25004000g

Birth BW: 3000g

Interpretation: Normal

Addition of BW:

Trimester I 700-1000 g/month

Trimester II 500-600 g/monthTrimester III 350-450 g/month

Trimester IV 250-350 g/month

Calculation:

Minimum BW: 3000g + 3(700)g + 3(500)g + 3(350)g = 7650g

Maximum BW: 3000g + 3(1000)g + 3(600)g + 3(450)g = 9150g

Normal BW Estimation: 7650g-9150g

BW(9 m/o): 6500g

Interpretation: Underweight


10/18

2. Body Length(BL)

Normal = 48-53cm

Birth BL: 49cm


3. Head Circumference(HC)

Normal = 33-38 cm

Birth HC: 35cm


Normal HC Estimation: 42.5cm

HC (7-9 m/o): 44cm

Addition of HC for first 2y/o:

0-6 months 1.0cm/month

7-12 months 0.5cm/month

1-2 years 2.0cm/year

Calculation:

35 cm + 6(1.0) cm +3(0.5)cm = 42.5cm


BW Birth:3000g

7m/o:6100g

8m/o:6300g

9m/o:6500g

Interpretation of

growth pattern:

< 3th percentile

Failure of thrive


11/18

Interpretation: Normal in range (-2SD +2SD) but cannot evaluate HC growth pattern due to only

2 data is available.

Development

Child development refers to the biological and psychological changes that occur in human beings

between birth and the end of adolescence, as the individual progresses from dependency to

increasing autonomy. In general development also described as:

1. Increase in the complexity of function and skill progression.

2. It is the capacity and skill of a person to adapt to the environment.

3. Development is the behavioural aspect of growth

Developmental change may occur as a result of genetically-controlled processes known as

maturation, or as a result of environmental factors and learning, but most commonly involves an

interaction between the two, it may also occur as a result of human nature and our ability to learn

from our environment. Human beings have a keen sense to adapt to their surroundings and this is

what child development encompasses.

The characteristic of development

There are several characteristic of development; first, it is associated with changes. This is also

means that, every growth accompanied by change of function, example development of the

reproduction system accompanied by change of organ sexual. The second is that early

development determining the growth for the next level. This is means one cannot pass one

development phase before going through the previous level. Third, developmental pattern has a

fixed pattern which is from head to caudal area (cephalocudal) or from proximal to distal

(proximodistal). It is in a regular and according to the sequence pattern. It has a different rate

speed and always correlated to the growth also.

Aspect of children development

There are four main aspect of development in children:

1. Gross motor - Gross motor skills are the abilities required in order to control the large

muscles of the body for walking, running, sitting,crawling,and other activities.

2. Fine motor and vision - Fine motor skills generally refer to the small movements of the

hands, wrists, fingers, feet, toes, lips, and tongue.

3. Speech, language and hearing.

4. Social, emotional, behavioural.
http://www.healthofchildren.com/C/Crawling.htmlhttp://www.healthofchildren.com/C/Crawling.htmlhttp://www.healthofchildren.com/C/Crawling.htmlhttp://www.healthofchildren.com/C/Crawling.html


12/18

Monitoring and early detection of the developmental problem:

Developmental problems are all associated with the four main aspects as being mentioned above.

There are four method of screening that we can do to detect early developmental problem inchildren, they are:

1. DENVER II Developmental Screening Test

2. Pediatric Symptom Checklist (PSC)

3. CHAT (Checklist for Autism in Toddlers)

4. Bayley-III

The interpretation according to the Denver II is listed in the table below:

Aspect of

development

Normal for a 9 months

old boy

According to the

scenario

interpretation

Gross motoric

development

Stand holding on

Pull to stand Getting to sit

Bear weight on leg

Able to craw

Cannot sit andstand by himself

Delayed in gross

motoric development

Fine motoric

development

Take two cubes

Thumb finger

grasp

Not able to hold

jingling toys with

his hand

Delayed in fine

motoric development

Speech and language Dada-mama non

specific

Combine syllabus

Jabbers

Turn to voice and

rattling sound

Able to respond

sound able to

show direction of

the sound source

Sometimes

mumbled

Normal speech and

language development

Social behaviour Play peek a boo

Feed self

Wave bye bye

Not able to feed

himself

Not knowing how

to play peek a boo

Delayed in social

behavioural

development

Below is also the example of Danver II assessment sheet to evaluate the development of the

children:


13/18


14/18

3. How does the nutritional status of the baby?

Nutritional status cannot be determined since in we cannot plot the graph in CDC.Since the length

of the baby cannot be determined we cannot use the waterlow formula to count the nutritional

status

Nutrition in our case:

1) For daily meal the baby was fed with rice and vegetables, tofu, tempe, and sometimes egg.

2) Starting from the age of 3 months, he consumed formula milk, bananas and baby porridge

because he cried most of the time.

Ideal nutrition:

o ASI exclusive for 6 month!

o By 9 months, babies are usually eating two solid meals in a day

Nutrition Status

Instrument: Rumus waterlow & Growth

Status Percentage

Obesity >120%

Overweight 110% - 120%

Mild malnutrition 90% - 110%

Moderate malnutrition 70% - 90%

Severe malnutrition >70%

This case:

BW/A= 6.5/9.2= 70.65% (moderate malnutrition)

BL/A= 70/72= 97.2% (normal)

BW/BL= 6.5/8.8= 73.86% (moderate malnutrition)

According to the scenario given:

Age 9 months old babyCurrent BW is 6.5kg (normal 9.2kg)

Current BH is 70cm (normal 72cm)

Nutritional status

BW/A= 6.5/9.2= 70.65% (moderate mulnutrition)

BL/A= 70/72= 97.2% (normal)

BW/BL= 6.5/8.8= 73.86% (moderate malnutrition)

BL is suitable for 8 months baby


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4. How does the immunization status of the baby?

Jenis Vaksin Bulan

BCG 2 - 3

Polio Lahir 2 4 6

Hepatitis B Lahir 1 6

DPT 2 4 6

Campak 9

5. How do we interpret the factor that influences the growth and development of the baby?

What is the disturbance that cause delay in baby growth and development? Is there any

relation between social interactions with impairment of development?

A. INTRINSIC risk factors

birthweight

Apgar score

Asphyxia

Hyperbilirubinemia

Infection

congenital abnormality

temperament


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APGAR Scoring

B. EXTRINSIC risks factors (environment)

1. MICROenvironment (quality of mother, care-giver)

2. MINI environment (quality of father, siblings housing, toys, faciliities, rule, norm, reward)

3. MESOenvironment (neighbour, health & educational services, sanitation)

4. MACROenvironment (WHO, Unicef, proffesionprogram and services)1. MICRO Environment (quality of mother):

age, height, health status during pregnany and delivery (anemia, nutritional status, therapy),

smoking, drugs, alcohol, educational status, occupacy), family planning (number of children,

spacing,) infectious diseases, knowledge and behavior, marietal status (single parent,

diforce, unwanted child etc)

2. MINI environment (father, siblings, caregiver, facilities etc) :

Father : age, height, educational status, occupancy, salary, knowledge / skill/ behavior,

diseases, marietal status, family planning

Siblings : number, spacing, ages, health status (nutrition, immunisation, congenital

abnormality, delayed development),

Caregiver:education, knowledge/skill/behavior, norm, value, rule,reward, punishment,

Facilities: toys, housing sanitation (water, air, illumination).

3. MESO environment :

neighbour (economic status, behavior), playtmatch, play fasilities, health and educational

services, sanitation, environmenmtal ststus, socio-culture

4. MACRO environment:

awarness of health staff, officials, profesionals WHO, Unicef, governmnet programme etc


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6. What is the relationship between birth status with the muscle tone and impairment of

development?

Perinatal asphyxia or neonatal asphyxia is the medical condition resulting fromdeprivation of oxygen to a

newborn infant that lasts long enough during the birth process to cause physical harm, usually to the brain.

Hypoxic damage can occur to most of the infant's organs (heart,lungs,liver,gut,kidneys), butbrain damage is

of most concern and perhaps the least likely to quickly or completely heal. In the more pronounced cases, an

infant will survive, but with damage to the brain manifested as either mental, such asdevelopmental

delay orintellectual disability,or physical, such asspasticity in fact,spastic diplegia and the other forms

ofcerebral palsy almost always feature asphyxiation during the birth process as a major, if not defining, factor.

It results most commonly from a drop in maternalblood pressure or some other substantial interference

with blood flow to the infant'sbrain duringdelivery.This can occur due to inadequatecirculation orperfusion,

impaired respiratory effort, or inadequateventilation.Perinatal asphyxia happens in 2 to 10 per 1000

newborns that are born at term, and more for those that are born prematurely.

An infant suffering severe perinatal asphyxia usually has poor color (cyanosis), perfusion, responsiveness,

muscle tone, and respiratory effort, as reflected in a low 5 minuteApgar score.Extreme degrees of asphyxiacan causecardiac arrest and death. If resuscitation is successful, the infant is usually transferred to aneonatal

intensive care unit.

Signs and symptoms of Perinatal asphyxia :

Each baby may experience symptoms of birth asphyxia differently. However, the following are the

most common symptoms.

Before delivery, symptoms may include:

Abnormal heart rate or rhythm

An increased acid level in a baby's blood

At birth, symptoms may include:

Bluish or pale skin color

Low heart rate

Weak muscle tone and reflexes ******

Weak cry ******

Gasping or weak breathing ******

Meconium the first stool passed by the baby in the amniotic fluid, which can block

small airways and interfere with breathing

The complications of neonatal asphyxia?

CNS: hypoxic-ischemic encephalopathy(HIE), intracranial hemorrhage(ICH)

RS: meconium asphyration syndrome(MAS), respiratory distress syndrome(RDS), pulmonary

hemorrhage

CVS: heart failure, cardiac shock

GIS: necrotising enterocolitis(NEC), stress gastric ulcer

Others: hypoglycemia, hypocalcemia, hyponatremia

ClassificationClinical features of HIA:

Mild(stage I): hyperalert, irritable, normal muscular tone & reflex, no seizure, normal EEG

Moderate(stage II): lethargy, hypotonia, weak sucking & Moro response, often seizure,

EEG+Severe(stage III): coma, absent muscular tone & reflex,persistent seizure, EEG++
http://en.wikipedia.org/wiki/Hypoxia_(medical)http://en.wikipedia.org/wiki/Hearthttp://en.wikipedia.org/wiki/Lunghttp://en.wikipedia.org/wiki/Liverhttp://en.wikipedia.org/wiki/Gut_(zoology)http://en.wikipedia.org/wiki/Kidneyshttp://en.wikipedia.org/wiki/Brain_damagehttp://en.wikipedia.org/wiki/Developmental_delayhttp://en.wikipedia.org/wiki/Developmental_delayhttp://en.wikipedia.org/wiki/Intellectual_disabilityhttp://en.wikipedia.org/wiki/Spasticityhttp://en.wikipedia.org/wiki/Spastic_diplegiahttp://en.wikipedia.org/wiki/Cerebral_palsyhttp://en.wikipedia.org/wiki/Blood_pressurehttp://en.wikipedia.org/wiki/Brainhttp://en.wikipedia.org/wiki/Childbirthhttp://en.wikipedia.org/wiki/Circulatory_systemhttp://en.wikipedia.org/wiki/Perfusionhttp://en.wikipedia.org/wiki/Ventilation_(physiology)http://en.wikipedia.org/wiki/Cyanosishttp://en.wikipedia.org/wiki/Apgar_scorehttp://en.wikipedia.org/wiki/Cardiac_arresthttp://en.wikipedia.org/wiki/Neonatal_intensive_care_unithttp://en.wikipedia.org/wiki/Neonatal_intensive_care_unithttp://www.ucsfbenioffchildrens.org/conditions/meconium_aspiration_syndrome/index.htmlhttp://www.ucsfbenioffchildrens.org/conditions/meconium_aspiration_syndrome/index.htmlhttp://en.wikipedia.org/wiki/Neonatal_intensive_care_unithttp://en.wikipedia.org/wiki/Neonatal_intensive_care_unithttp://en.wikipedia.org/wiki/Cardiac_arresthttp://en.wikipedia.org/wiki/Apgar_scorehttp://en.wikipedia.org/wiki/Cyanosishttp://en.wikipedia.org/wiki/Ventilation_(physiology)http://en.wikipedia.org/wiki/Perfusionhttp://en.wikipedia.org/wiki/Circulatory_systemhttp://en.wikipedia.org/wiki/Childbirthhttp://en.wikipedia.org/wiki/Brainhttp://en.wikipedia.org/wiki/Blood_pressurehttp://en.wikipedia.org/wiki/Cerebral_palsyhttp://en.wikipedia.org/wiki/Spastic_diplegiahttp://en.wikipedia.org/wiki/Spasticityhttp://en.wikipedia.org/wiki/Intellectual_disabilityhttp://en.wikipedia.org/wiki/Developmental_delayhttp://en.wikipedia.org/wiki/Developmental_delayhttp://en.wikipedia.org/wiki/Brain_damagehttp://en.wikipedia.org/wiki/Kidneyshttp://en.wikipedia.org/wiki/Gut_(zoology)http://en.wikipedia.org/wiki/Liverhttp://en.wikipedia.org/wiki/Lunghttp://en.wikipedia.org/wiki/Hearthttp://en.wikipedia.org/wiki/Hypoxia_(medical)


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Conclusion

Early management

Improving nutrition status by giving the appropriates nutrition.

Give the enough immunization and on time.

Optimalize of parents responsibility in stimulation of infant in order to development of

infant achieving the appropriates ASUH, ASIH and ASAH.

Controls the fever and give appropriate treatment based on diagnosis if need

Monitoring is very important and helpful!

report pleno geriatry

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