suplementasi besi secara rasional pada anak

7/25/2019 Suplementasi Besi Secara Rasional Pada Anak

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Prof. Dr. dr. DASRIL DAUD,

Sp.A(K)

CURRICULUM

VITAE

EDUCATION

General Practitioner FK.UNHAS 1978

Pediatrician FK.UNHAS 1981Hemato-Oncology of

Pediatric Consultant FKUI/RSCM 1992

Doctoral FK.UNHAS 201

ORGANIZATION

Head of Pediatric Dept, FK.UNHAS/RSWS Makassar

Head of Hemato-Oncology Division, Pediatrics Dept, FK.UNHAS/RSWSMakassar

Head of Combine Degree Program, FK.UNHAS

Head of Ethic Commision, RSWS MakassarProfessor of Pediatric, Medical Faculty University of Hasannudin, Makassar


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Dasril Daud

MPU, Makassar, 1-2 Nov emb er 2014


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More than 100 chemical elements known

Only 24 different elements are

essential to the human body:

- The largest elemental components of the body:

Oxygen (65%), hydrogen (10%) and nitrogen (3%)

- The Other elements in the body:

calcium, phosphorus, iron and copper:

mineral elements and trace elements

Iron comprises only 0,008% of the bodys mass

We cannnot live without this important element

The Importance of Iron in the Body


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Iron is essential element for electron transport and is required for

the functioning of numerous proteins

Oxygen transport Hemoglobin

Myoglobin

Oxydative energy production Cytochrome

CatalasePeroxidase

Mitochondrial respiration Succinate dehydrogenase

DNA synthesis Cell division) Ribonucleotide reductase

The Crucial Role of Iron in the Body

Function Compound


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ZAT BESI:

Proliferasi, diferensiasi, tumbuh & kembang

Zat besi sangat esensial:

- Hemoglobin

- Mioglobin

- Sitokrom

- Bagian integral dari berbagai enzim

- Sintesis DNA :

Proliferation and activation of sel B and T

Multifungsi


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DEFISIENSI ZAT BESI: Gangguan Pertumbuhan

Defisiensi besi:- gangguan pertumbuhan mukosa


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Defisiensi besi:Imunitas seluler & humoral menurunFagositosis terganggu

Mudah Infeksi


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DEFISIENSI ZAT BESI:

Gangguan Perkembangan Fungsi Kognitif

Fungsi Kognitif:

- mengambil- menyimpan

- menyajikan kembali

berbagai

bentuk ingatan

Zat besi: komponen esensial untukpertumbuhan dan perkembanganotak & fungsi SSP


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Area otak untuk fungsi kognitif membutuhkan

zat besi lebih banyak

Pertumbuhan otak sangat sensitive thdp perubahanstatus besi krn tumbuh & kembang otak sgt cepat& terjadi dlm kurun waktu singkat.

Gangguan fgs kognitif


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Tiga proses utama pd defisiensi besi dasar ggn fungsi kognitif:

1. Ggn pembentukan mielin

2. Ggn metabolisme neurotransmitter

3. Ggn metabolisme sel otak:

- perolehan 02 dan energi menurun

Area otak yang paling terpengaruh def. besi fungsi kognitif tinggi: hipokampus


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Myelin

Mielinisasi:oligodendrosit sel predominan dg zat besi

Def. besi transmisi lambat

Makin dini & makin lama

def. besi

makin sulitmemulihkan fgs kognitif


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Defisiensi besi gangguan

perkembangan psikomotor


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Defisiensi besi:- proliferasi sel otot menurun- mioglobin berkurang

Otot atrofi

& lemah


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Proliferation

Differentiation

Maturation

Enzymes

CytochromNeurotransmitter

Hemoglobin

GrowthDevelopmentIron


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WHO 39% penduduk dunia < usia 5 tahun48% usia 5 -14 tahun

Indonesia :

40 45%

SKRT (2001) prevalensi ADB pada bayi 0-6 bulan61,3%

Prevalensi tertinggi: usia tahun kedua

asupan besi rendah

pertumbuhan yg cepat pd tahun pertama

ADB masalah serius:gangguan pertumbuhan & perkembangan kualitas SDM

Anemia def. besi (ADB/IDA):


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Prevalence of IDA in Indonesia

Study Year -place Incidence (%)

Dirjen Kesmas RI 2000 < 5 year : 40.5

School- age : 47.2

Adolescence (female) : 57.1

SKRT 2001 < 5 y.o : 48.1 %

< 1 y.o : 55%,0-6 m.o : 61,3 %

Pusponegor HD, IDAI 2004 (1000 school-age in

11 province )

20-25 %

Susilowaty(Puslitbangkes)

2004 in Bogor, Buleleng:2-4 mo (317 infants)

56,5 %

Nelly R, Bidasari L

at.al

2008 in Medan 52 % (9-12 y.o )

Every age group of children are a susceptible for anemia


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Hasil: sampel terdiri dari 55 bayi, 63,6% laki-laki, 58,2% berumur 8-

12 bulan, dan 87,3% berasal dari keluarga dengan pendapatan per

kapita per bulan rendah. Sebagian besar berstatus gizi kurang (60%),

96,4% lahir cukup bulan, 3,6% bayi lahir dengan berat badan rendah

pemberian ASI ekslusif 94,5%. Diantara 55 bayi 38,2% mengalami

anemia dan 71,4% bayi anemia tersebut menderita anemia defisiensi

besi. Prevalensi anemia defisiensi besi lebih besar pada bayi 8-12

bulan daripada bayi yang lebih muda, yaitu 73,3%.

38,2% mengalami anemia dan 71,4% bayi anemiatersebut menderita anemia defisiensi besi. Prevalensi

anemia defisiensi besi lebih besar pada bayi 8-12 bulan

daripada bayi yang lebih muda, yaitu 73,3%.


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The prevalence of Hb


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Risk factors of iron deficiency Decrease of storage : preterm, LBW, growth,

breastfed > 6 mo

without iron supllementation, milk formula with

low iron contain

Below 1 y.o

Inadequate Iron intake , only milk formula, rapidgrowth

Increase requirement due to recurrent infection,malabsorption

1 2 y.o

2 5 y.o

> 5 y.o

Menstruation >>adolescence

Decrease iron intake (especially heme iron ).Increase requirement due to recurrent infection, blood

lost

Blood lost due to parasit infection, polyposis


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Smith et al. 1989

Parenteral iron treatment is associated with exacerbation of certaininfections in particular malaria and respiratory diseases in infants in

popu lations where malaria is endemic.

Oppenheimer, 1989

Parenteral iron is also associated with increased risk of serious

Esche richia coli sepsis in neonates

Brunser et al. 1993

Daily feeding of iron-enriched milk for 6 mo was associated with an

increased frequency of watery diarrhea and persistent diarrhea

Free iron is essential for the multiplication of bacteria includingspecies of Candida, Escherichia, Mycobacterium, Pasteurella,

Shigella and Staphylococcus.

Weinberg 1974


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Consequences of Iron Excess: Preterm Infants

Providing excess iron might be particularly harmful to preterm infants, who are at increased

risk for oxidative injury for several reasons, including immature antioxidant defense systems.

(39) Neonates tend to have low TIBC; high saturation of circulating transferrin; and low

concentrations of ceruloplasmin, unbound transferrin, and albumin, all of which bind free

iron. (40) Although no direct link has been shown between iron excess and disease in

preterm infants, concerns have been raised about the potential for iron to cause increased

oxidative stress, which may contribute to complications of prematurity such as retinopathy of

prematurity (41) or bronchopulmonary dysplasia. (42) Short-term studies indicate that iron

does not induce oxidative stress, as measured by isoprostanes and antioxidant status, whenprovided to stable, growing low-birthweight infants at doses ranging from 2 to 12 mg/kg per

day or at a twice-daily dose of 9 mg per day. (43)(44)

Iron Balance in the NeonateCarissa Cheng and Sandra Juul

Neoreviews 2011;12;e148

Short-term studies indicate that iron does not induce oxidative stress,

as measured by isoprostanes and antioxidant status, when provided

to stable, growing low-birthweight infants at doses ranging from 2 to

12 mg/kg per day or at a twice-daily dose of 9 mg per day.


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- to make use of iron as efficiently as adequate iron status.

- to pacify (rander safe) iron meticulously

prevent iron free

IRON REGULATION

The body regulates iron:


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Hepatocyte

Fe2+Enterocyte

FPN

FPNFPN

PFe2+

Macrophage

P PHepcidin

Absorption Recycling

Fe2+

Hepcidin (LEAP-1):

Powerful negative regulator of ironInhibits:

Dietary iron absorption

The efflux of recycled iron (macrophage)

Release of iron from stroge in hepatocyte

Hepcidin controls the entry of iron into plasma by regulating ferroportin

IRON REGULATION


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The regulation of iron

metabolism involves the

interaction of a number of

specific proteins.

Hepcidin controls

dietary iron absorption.

IRON REGULATION

Mucosal block"Mucosal intelligence


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In man the normal diet should contain 1318 mg of iron per day of whichonly 1 mg is absorbed. Even in iron deficiency, absorption is only 24 mg

and in iron overload it is reduced to 0.5 mg.

PHYSIOLOGY AND MOLECULAR BIOLOGY OFDIETARY IRON ABSORPTION.

Silvia Miret, Robert J. Simpson, and Andrew T. McKie

Annu. Rev. Nutr. 2003. 23:283301


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We reviewed 26 randomized controlled trials of preventive, oral iron supplementation

in young children (aged 059 mo) living in developing countries to ascertain the associated

health benefits and risks. The outcomes investigated were anemia, development, growth,

morbidity, and mortality. Initial hemoglobin concentrations and iron status were considered

as effect modifiers, although few studies included such subgroup analyses. Among iron-

deficient or anemic children, hemoglobin concentrations were improved with iron

supplementation. Reductions in cognitive and motor development deficits were observed in

iron-deficient or anemic children, particularly with longer-duration, lower-dose regimens.

With iron supplementation, weight gains were adversely affected in iron-replete children; the

effects on height were inconclusive. Most studies found no effect on morbidity, although few

had sample sizes or study designs that were adequate for drawing conclusions. In a

malaria-endemic population of Zanzibar, significant increases in serious adverse eventswere associated with iron supplementation, whereas, in Nepal, no effects on mortality in

young children were found. More research is needed in populations affected by HIV and

tuberculosis. Iron supplementation in preventive programs may need to be targeted through

identification of iron-deficient children. Am J Cl in Nutr 2006;84:126176.

Review Articles

Iron supplementation in early childhood: health

benefits and risksLora L Iannotti, James M Tielsch, Maureen M Black, and Robert E Black

Most studies found no effect on morbidity, although few had sample

sizes or study designs that were adequate for drawing conclusions


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ABSTRACT The effect of long-term oral iron supplementation on morbidity due to diarrhea, dysentery and

respiratory infections in 349 children, aged 248 mo, living in a poor community of Bangladesh, was

evaluated in this double-blind study. The treatment group received 125 mg of ferrous gluconate (15 mg

elemental iron) plus multivitamins and the controls received only multivitamins, daily for 15 mo. House-to-

house visits were made onalternate days by trained community health workers for recording symptoms

and duration of illnesses and for monitoring medicine intake. Seventy-six percent of the children continued

the syrup for over 1 y. No untoward effects were noticed in either treatment group. The attack rates for

diarrhea, dysentery and acute respiratory tract infections (ARI) were 3, 3 and 5 episodes per child per

year, respectively. Each episode of diarrhea lasted a mean of 3 d, and those of dysentery and ARI, 5 d.

The two treatment groups did not differ in the number of episodes, mean duration of each episode, or total

days of illnesses due to diarrhea, dysentery and ARI. However, a 49% greater number of episodes of

dysentery was observed with iron supplementation in a subset of the study children who were less than12 mo old (P 0.03). The results of this study suggest that long-term oral iron supplementation is not

harmful for older children in a poor community. Further studies are needed to demonstrate the safety and

efficacy of iron administration in young infants. J. Nutr. 127: 14511455, 1997.

Long-Term Oral Supplementation with Iron Is

Not Harmful for Young Children in a Poor

Community of Bangladesh.Amal K. Mitra, Syed M. Akramuzzaman, George J. Fuchs, Mohammad

M. Rahman and Dilip Mahalanabis.

The results of this study suggest that long-term oral

iron supplementation is not harmful for older childrenin a poor community.


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Conclusion:

- iron supplementation increases the levels of hematologic indicators

- reduces the prevalence of IDA/ID in low birth weight/premature infants.

- There is insufficient evidence to make a definitive statement regardingthe effects of Iron supplementation on growth,neurodevelopment, or

the occurrence of adverse effects in low birth weight/premature infants.


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BBLR, perlu suplementasi besi

ANEMIA

Sedikitcadangan besi

saat lahir

Kebutuhanbesi sesuaimassa sdmdibanding

aterm

Hemolisis,

Rendahnyakadar EPO


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Extensive studies and review

have looked at oxidative

damage to DNA protein, and

lipid .(Kadiiska et al, 1995,

Aust SD 1985 )

Excess iron may be

detrimental to cognitive, motor,

and behavioral development (

limited to case of genetically

susceptible) .Hayflick SJ et al, 2003

Potential neurologic

dysfunction associated with

dietary iron overload early in

life (animal study ) in human is

less clear. Srigiridhar,1998

Iron supplementation can

result in generation of free

radicals.

Kadiiska et all, 1995

RATIONAL IRON SUPPLEMENTATION

Timing, dosis, duration, and monitoring

Risk of iron supplementation in early childhood


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We need Iron supplementationin Early Childhood

Iron def is

thought to be

commonenst

cause

More than 1.6

billion people

worldwide are

anemic

before

anemia ID

iassociated

with many

adveerse effect

The cognitive

performance,

behaviour, and

physical growth of

infants, preschooland school-aged

children

The immune

status andmorbidity

from

infections of

all age

groups

The use of energy

source by muscle

,,,,the physical

capacity and work

performance

Blood sampling,

blood loss with

medical procedure

- smaller iron store

- greater iron req

- increase hemolysis

- low EPO level

In adequate iron store

Low birthweight and

prematurity

Iron deficiency generally develops

slowly and is not clinically apparentuntil anemia is severe even though

functional consequences already

exist


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We need Iron supplementationin Early Childhood

Iron def is

thought to be

commonenst

cause

More than 1.6

billion people

worldwide are

anemic

ID generallydevelops slowly

and is not clinically

apparent until

anemia eventhough

functional

consequencies

aleeady exist

The cognitive

performance,

behaviour, and

physical growth of

infants, preschooland school-aged

children

The immune

status andmorbidity

from

infections of

all age

groups

The use of energy

source by muscle

,,,,the physical

capacity and work

performance

Blood sampling,

blood loss with

medical procedure

- smaller iron store

- greater iron req

- increase hemolysis

- low EPO level

In adequate iron store

Low birthweight and

prematurity

Iron deficiency generally develops

slowly and is not clinically apparentuntil anemia is severe even though

functional consequences already

exist

Need

Iron

supplemen

tation


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Rationale

Tepat Diagnosis

Tepat Terapi

Tepat dosis Tepat Indikasi

Waspada efek samping

Iron supplementation for anemia control

recommendations must balance safety and efficacy


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Kesimpulan

Bayi yang mendapat supplementasi besi :

- terjadi peningkatan kadar Hb- Peningkatkan cadangan besi , menurunkan risiko akan ADB

- Belum jelas ada hub antara suplementasi besi pada preterm dan BBLR

terhadap neurodevelopmental , dan pertumbuhan dikemudian hari .

- Dosis standar Fe : 2-3 mg/kgbb/hari

- Supplementasi dimulai usia 2 bulan dilajutkan hingga usia 12 bulan

The Cochrane Library2012, Issue 5


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39

Age groups Indication for supplementation Dosage schedule Duration

Low birth-weight infants Universal supplementation Iron : 2mg/kg body weight/day From 2 months of age up to 23

months of age

Children from 6 to 23 months of

age

Where the diet does not include

food foertified with iron or where

anaemia prevalence is above 40%

Iron : 2mg/kg body weight/day From 6 months of age up to 23

months of age

Children from 24 to 59 months of

age

Where anaemia prevalence is

above 40%

Iron : 2mg/kg body weight/day up

to 30 mg

3 months

School-aged children (above 60

months)

Where anaemia prevalence is

above 40%

Iron : 30 mg/day

Folic acid: 250 g/day

3 months

Women of childbearing age Where anaemia prevalence is

above 40%

Iron : 60 mg/day


3 months

Pregnant women Universal supplementation Iron : 60 mg/day


AS soon as posible after gestation

starts- no later than the 3rd month-

and continuing for the rest of

pregnancy

Lactating woman Where anaemia prevalence is

above 40%

Iron : 60 mg/day


3 months post partum

Dose and schedu les of iron supp lementat ion to p revent ADB

(WHO, 2001


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Dose and Duration o f Iron supplementation , IDAI, 2011

Usia (tahun) Dosis besi elemental Lama pemberian

Bayi* : BBLR (< 2.500g)

Cukup bulan

3 mg/kgBB/hari

2 mg/kgBB/hari

Usia 1 bulan sampai 2 tahun

Usia 4 bulan sampai 2 tahun

2-5 (balita) 1 mg/kgBB/hari 2x/ minggu selama 3 bulan berturut-turut

setiap tahun

>5-12 (usia sekolah) 1 mg/kgBB/hari 2x/ minggu selama 3 bulan berturut-turut

setiap tahun

12-18 (remaja) 60 mg/hari* 2x/ minggu selama 3 bulan berturut-turut

setiap tahun

Keterangan :* Dosis maksimum untuk bayi: 15 mg/hari, dosis tunggal

*Khusus remaja perempuan ditambah 400 g asam folat


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Percentage and amount of elemental iron

International Nutritional Anemia Consultative Group (INACG). Guidelines for the use of iron supplements to prevent and treat iron

deficiency anemia. Washington, D. C.: ILSI PRESS; 1998.

Iron supplementat ion

Preparation Iron

compound

(mg) per tablet

Percent

(%)

Of Iron

Elemental Iron (mg)

per tablet

Ferrous fumarate 200 33 66

Ferrous glukonat 300 12 36

Ferrous sulfate (7H2O) 300 20 60

Ferrous sulfate anhydrous 200 37 74

Ferrous sulfate, exsiccated

(1H2O)

200 30 60


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Suplementasi besi 2 mg/KgBB/hari : usia 6 minggu-6 bulan :menurunkan resiko secara efektif tanpa efek yang

merugikan pada morbiditas dan pertumbuhan


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RCT : Ferro sulfat dosis tunggal dan 3 kali/hari pada bayi

usia 6-24 bulan :

- feritin dan efek samping minimal terjadi sama pada

kedua kelompok

- Memperbaiki pertumbuhan dan perkembanganpsikomotor secara signifikan


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efek pemberian suplementasi besi pada anak sekolah dasar usia5-12 tahun : - Aman efek hematologi dan non hematologi

CMAJ 2013. DOI:10.1503


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Kesimpulan. Insidens deplesi besi, defisiensi besi, ADB paling tinggi

pada bayi berusia 0 bulan. Suplementasi zat besi elemental dengan

dosis 1 mg/kg/hari hendaknya diberikan pada semua bayi aterm

sejak lahir. (Sari Pediatri 2008;10(3):163-70).


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ositive Response to Therapy

- 3-5days: 1.Reticulocyteincrease

2.Increasedappetite

- 5-10days 3.Decreasedirritability

4.Improvedwellbeing

5.IncreaseinHBlevel>0,1gr/dl

perdayfrom5thday

- 60days :Hb concentrationvirtuallybecomesnormal

- 90-180days:Repletionofironstates


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K SIMPUL N

Setiap kelompok umur pada anak

rentan mengalami anemia ADB

Suplementasi zat besi hendaknya diberikan

pada semua bayi dan anak secara rasional.

Suplementasi zat besi pada bayi dan anak

diperlukan untuk mencapai pertumbuhan dan

perkembangan optimal.

suplementasi besi secara rasional pada anak

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