Divisi Nutrisi dan Penyakit Metabolik Dep. Ilmu Kesehatan Anak FKUI - RSCM

1. MASALAH MAKAN/FEEDING PROBLEM DivisiNutrisidan PenyakitMetabolik Dep. IlmuKesehatanAnak FKUI - RSCM dr. Soepardi Soedibyo, SpAK

2. Implikasi Kesulitan Makan EXCESS NUTRITION FEEDING PROBLEM SECONDARY PRIMARY DEFICIENCY TISSUE DEPLETION BIOCHEMICAL LESION CLINICAL SIGNS

3. Children who do develop feeding problem are at risk for weight loss, malnutrition, lethargy, impaired intellectual and social-emotional development, and growth retardation. In the most severe cases, children cease oral eating altogether, necessitating nasogastric or gastrostomy tube placement and feedings.

4. EPIDEMIOLOGY • Mild feeding problems: not always hungry/eating small amounts/picky eating/strong preferences • Healthy toddlers, early school age 25-40%

5. Epidemiology • Serious feeding problems: All children 3-10%, • Children developmental disability 33% (mental retardation, prematurity, organic dis)

6. Sources estimate that as many as 25% of children experience some type of feeding difficulties during infancy or early childhood. The incidence can be as high as 33% for children with developmental disabilities.

7. DEFINISI • Samsudin : masalah makan adalah bila anak hanya mampu menghabiskan kurang dari 2/3 dari jumlah makanannya sehingga kebutuhan nutrien tidak terpenuhi. • Palmer : masalah makan adalah ketidak mampuan untuk makan atau penolakan terhadap makanan tertentu sebagai akibat disfungsi neuromotorik, lesi obstruktif, atau faktor psikososial yang mempengaruhi makan, atau kombinasi dua atau lebih penyebab tersebut.

8. Definisi yang lain • Kekurangan dalam semua aspek mengkonsumsi makanan yang menyebabkan gizi kurang, pertumbuhan yang jelek, waktu makan yang menimbulkan stres baik untuk anak maupun yang momong

9. Most common feeding problems in young children (Kerwin 1999) • Inappropriate mealtime behaviours (e.g., temper tantrums, throwing food) • Lack of self-feeding • Food selectivity (eating only a few foods) • Failure to advance textures from puree to table food • Food refusal (not accepting any or only smell quantities of food) • Oral sensorimotor immaturity or dysfunction • Aspiration or swallowing problems • Frequent gagging or vomiting

10. Angka Kejadian • Laporan GUAPCD adalah sbb : • Hanya mau makanan lumat/cair 27.3% • Kesulitan menghisap, mengunyah, menelan 24.1% • Kebiasaan makan yang aneh/ganjil 23.4% • Tidak menyukai banyak macam makanan 11.1% • Keterlambatan makan mandiri 8.0% • Mealtime tantrums 6.1%

11. Angka Kejadian • Penelitian anak prasekolah usia 4 – 6 tahun di Jakarta, kesulitan makan sebesar 33.6% • 44.5% diantaranya menderita malnutrisi ringan- sedang • 79.2% telah berlangsung lebih dari 3 bulan.

12. Perkembangan keterampilan makan • Usia 4 bulan refleks ekstrusi menghilang • Usia 6 – 9 bulan merupakan periode kritis untuk membina keterampilan makan dan apabila tidak dimanfaatkan secara optimal dapat timbul masalah makan

13. Penyebab kesulitan makan (Samsudin) • Faktor organik • Faktor Nutrisi • Faktor psikologik • Faktor psikiatrik

14. Faktor organik • Kelainan pada rongga mulut • Kelainan bagian lain saluran cerna • Kelainan organ tubuh lain • Penyakit metabolik

15. Faktor Nutrisi : • Bayi konsumer pasif • Anak konsumer semi pasif/ semi aktif • Pemenuhan kebutuhan nutrisi masih bergantung pada orang lain. • Pada bayi & anak terjadi perubahan pola makan dari makanan bayi ke makanan dewasa, seringkali secara sinergis menimbulkan masalah makan yang dapat mengakibatkan terjadinya defisiensi nutrien dan malnutrisi, yang bisa menurunkan nafsu makan sehingga asupan makanan lebih berkurang lagi.

16. Faktor Psikologik : • Mekanisme beban sosiokultural serta aturan makan yang ketat/berlebihan • Sikap ibu yang obsesif dan memaksa akibat overproteksi • Respons infantil terhadap sikap ibu

17. Faktor psikiatrik • Infancy/early childhood • Pica • Rumination disorder

18. Infancy/early childhood • Persistent failure to eat • Failure to thrive (> 1 month) • No gastrointestinal/medical cause • No lack of food supply • Before 6 years

19. Pica • Persistence eating nonnutritive substances (> 2 months) • Inappropriate for development level • No part of culturally sanctioned practice • Can be during course of mental retardation, pervasive, developmental disorder, but needs independent attention

20. Rumination disorder • Repeated regurgitation, rechewing food (> 1 month) • No gastrointestinal/medical course • Not confined to the course of anourexia of bulimia • Can be during course of mental retardation, pervasive developmental disorder but need independent attention

21. Masalah makan tahun pertama • Kurang makan, bayi gelisah, menangis dan BB kurang • Kelebihan makan baik kualitatif/kuantitatif • Regurgitasi dan muntah, 6 bln pertama wajar • Diare/tinja lembek. Tinja ASI lebih lembek • Konstipasi, bisa karena cairan/ makanan kurang • Kolik,biasa terjadi sampai usia 3 bulan

22. Faktor risiko terjadinya masalah makan • Bayi/anak dengan GER • Bayi kurang bulan dan berat lahir rendah terutama dg intubasi lama • Bayi dg komplikasi pada masa neonatal mis intubasi lama yang mengakibatkan reflex muntah berlebihan, bahkan tidak bisa makan sama sekali • Bayi dengan displasia brokopulmuner, CHD, nerologik dll

23. Masalah makan masa anak • Kecepatan tumbuh rata - rata melambat • Nafsu makan bervariasi • Suka/ tidak suka makan cepat berubah • Lambung masih kecil • Anak tidak pernah membuat dirinya kelaparan • Anak tidak boleh dipaksa makan • Suplementasi vitamin/ mineral tak perlu

24. Tatalaksana masalah makan Mencakup 3 aspek yaitu : • Identifikasi faktor penyebab • Evaluasi tentang dampak yang telah terjadi • Upaya perbaikan : a. nutrisi b. faktor penyebab

25. The Feeding Disorders Program team involves the following disciplines: Medicine Psychology Occupational Therapy Nursing Nutrition Speech/language therapy

26. Upaya yang dilakukan adalah : • Atasi faktor penyebab (organik, infeksi, psikologik, dll) • Atasi dampak yang telah terjadi (malnutrisi, defisiensi nutrien tertentu, dll) • Upaya nutrisi : perbaiki/ tingkatkan asupan makanan • ‘Re-edukasi’ tentang perilaku makan • Fisioterapi bagi anak yang mengalami kesulitan mengunyah/ menelan

27. Meningkatkan komposisi kalor pada formula bayi • Formula disajikan dalam konsentrasi yang lebih tinggi yi dg air kurang dari yang dianjurka • Tambahkan glukosa polimer 23 kcal/sendok teh, minyak jagung 8,4 kcal/ml

28. Pada anak lebih dari 1 tahun • Gunakan formula tinggi kalori yi 1 kcal/ml • Tambahkan suplemen bubuk pada susu

29. Behavioural interventions • Parents should first know the basic food rules that apply to all young children • Parents should control what, when and where children are being fed. • Children should control how much they eat in order to learn internal regulation of eating in accordance with physiologic signals of hunger and fullness.

30. Behavioural interventions • In the feeding disorder termed “state regulation” mothers should be helped to modulate the amount of stimulation during feeding (level III evidence) • Infants should be fed promptly before prolonged crying (not more than 30 minutes) and should not be unnecessarily aroused, burped, or wiped. • mother’s anxiety, fatique, or depression should be addressed.

31. Behavioural interventions • In the feeding disorder termed “reciprocity” the focus should be on training parents in sensitivity and responsiveness to infant’s feeding cues (level III evidence). • Complicated cases need a multidisciplinary approach where family physicians can play a key role in coordinating services.

32. Behavioural interventions • In cases of infantile anorexia, the mother-child dyad becomes involved in conflicting interactions, with a struggle for control and food being the battleground. • Therapy, consists of helping parents understand their children’s special temperaments, set limits and structure mealtimes to facilitate the internal regulation of eating and to counteract the external regulation produced by emotional interactions within the caregiving environment. • Food rules are strongly encouraged, and ‘time out” should be used in response to children’s inappropriate behaviour (level II evidence)

33. Behavioural interventions • Prevention of sensory food oversions starts with introducing various foods at 4 to 6 months of age. • New foods should be introduced singly and not during illnesses, such as colds and diarrhea, and parents should persevere and present the new food day after day until children get used to it. • Toddlers more easily accept a new food if they see their parents eating it • Withholding favourite food to get toddlers to eat “healthy” food seems to have a negative effect. • Treatment of food aversions Is based on increasing appropriate behaviour through positive reinforcement and decreasing maladaptive behaviour by extinction (removing what reinforces a response) and time out (level II evidence).

34. Behavioural interventions • Feeding problems associated with concurrent medical conditions might result from an interaction between intrinsic oral motor dysfunction, oral hypersensitivity, adynophagia and learned aversive behaviour. • Parents should be tought management skills, such as • setting clear time limits for meals, • ignoring non-eating behaviour, and • using contingencies (active praising, positive reinforcement) to motivate children to meet the food-intake goals that have been set (level I evidence).

35. Behavioural interventions • Infants with posttraumatic feeding disorder are generally receiving enteral tube feeding that interferes with their experience of hunger and development of oropharyngeal coordination. • Treatment is aimed at eliminating tube feeding and overcoming the resistance to oral feeding, either through • The behavioural technique of extinction, which was shown to be successful in 1 controlled study (level I evidence) or • By gradual desensitization (level II evidence)

36. SYMPTOMS DIAGNOSIS SELF - CARE BEGIN HERE • Always • Hungry? NO Go to Question 5 YES • Mother drinks enough • fluids • If sores or white patches • in baby’s mouth, see doctor Breast milk insufficient or sore mouth 2. Breastfed? YES NO 3. Bottle fed or sore mouth? Bottle nipple CLOGGED or too small or mouth sore YES Correct the nipple problem See above if mouth sore 4. Fall asleep after feel from breast or bottle? Common for younger infants, but must decrease as baby grows See doctor to check baby’s growth and weight gain YES NO Next Page

37. SYMPTOMS DIAGNOSIS SELF - CARE NO 5. Cry after Feeding? NO Go to question 9 YES 6. Throwing up with forceful vomiting? YES PYLORIC STENOSIS Contact doctor NO 7. Lot of gas and stomach discomfort? LACTOSE INTOLERANCE YES Switch to a non-cow’s-milk? NO See doctor 8. Severe crying after meal? YES COLIC? NO Next Page

38. SYMPTOMS DIAGNOSIS SELF - CARE NO 9. Little interest in food Or slow weight gain? DEVELOPMENTAL PROBLEM? YES See your doctor NO Allergy or more severe intolerance (LACTOSE INTOL or CELIAC DIS) 10. Bowel movements loose/ Feel-smelling after the feedings YES See your doctor NO For more information, please consult your doctor. If you think the problem is serious, call right away

39. Preventing feeding problems • Teach to feed him self as early as possible • Provide with healthy choices • Allow experimentation • As long as your child is growing normally, probably little to worry about • Avoid giving large amount which have little nutritional value • Meal time should be enjoyable and pleasant

40. SEKIANTERIMA KASIH