Food for Energy

Do you know anything about this food pyramid? What does It show?

Many profesional sports teams have recently added a new member to their organization - a nutritionist. That's because athletes have become a ware that food affects performance. You don't have skipped breakfast and then tried to clean the house, you know that you need food for energy. Here are some tips about eating to increase your physical performance :

• Eat enough food. Your body needs a certain number of calories each day. If you're too thin, you'll often feel tired and you'll be more likely to get sick.
• Read the labels on food products. This information will tell you how nutritions the foods are.
• Avoid cating foods that are high in simple carbohydrates, that is, sugars. A chocolate bar will first give you energy, but then it will leave you feeling even more tired.
• Eat a balanced diet, one that includes complex carbohydrates, protein, and fat. Use food pyramid to help you decide how much to eat of each type of food. complex carbohydrates provide the body with "fuel". They are found in fruits and vegetables, and in bread, rice, pasta, and other foods to build muscles, and it uses fat to absorb the vitamins in food. Protein and fat are found in foods like milk, cheese, meat, fish, and eggs. Too much fat, however, can be harmful.

Source : www.healthnode.org,
http://experienceofadventure.blogspot.com

STROKE

Stroke is the name given to a "brain attack". It is a sudden loss of ability as a result of damage to the brain. The damage causes brain tissue to die (this is called an infarct).

What Causes Stroke?

A Stroke is caused by an interruption in the blood supply to the brain. This interruption is most often caused by the blood vessels getting blocked (an ischaemic stroke), or by the blood vessels bursting getting blocked (an ischaemic stroke), or by the blood vessels bursting (a hemorhagic stroke). Ischaemic strokes are the most common.
Blood carries essential nutrients and oxygen to the brain. Without a blood supply, brain cells can be damaged or destroyed and will not be able to function.
Because the brain controls almost everything the body does, damage to the brain can affect many functions of the body. The brain also controls how we think, learn, feel and communicate, so these prosseses can also be affected.
Stroke can cause many problems depending on which part of the brain is affected. These symtoms are usually very sudden. Common problems include ;

• Weakness or paralysis - often on one side of the body, of the leg, arm and face. This seakness on one side of the body is known as hemiplegia ;
• Altered Sensation - Usually a decrease in the sensation or numbness;
• Altered Speech - speech may be slurred, words unclear or the person completely unable to speak at all;
• Altered comprehension - the person may not be able to understand what is being said to them;
• Confusion or undeadiness;
• Unresponsiveness;
• Sudden blurred vision or loss of sight;
• A sevee headache (less common).

The effect of a stroke is very individual, and depends on the area of the brain affected, the extent of the damage and also the general health of the person at the time of the stroke.

Transient Ischeaemic Attack (TIA)
A TIA is sometimes called a mini-stroke. It is caused when very short time. The Symtoms are similar to a stroke but they resolve quickly. A TIA is a warning that there is a problem and there is a high risk that the person could have a more severe stroke. It should be taken seriously and preventative action taken rapidly.

Main Tupes of Stroke

1. Haemorrhagic (bleeding) stroke, blodd in artery, blood leaks out of artery wall which is damaged.
2. Ischaemic stroke, artery wall, patches of arheroma in lining of artery, blood cannot flow past blood clot from on atheroma on artery wall or comes from another part of the body and gets stuck.

Risk Factors
A stroke can happen to anyone, but some people are more at risk. Risk may be didided into those that can be reduced, and those that can not.

Modifiable risk factors :

• Smoking
• High blood pressure (hypertension)
• Diabetes
• Heart disease
• Abnormal blood lipid (fat) levels
• Too much salt in the diet
• Obesity and a sedentary lifestyle

Non-Modifiable risk factors :

• Previous stroke /TIA
• Age - the older you are the higher your risk
• Family history of stroke
• Ethnic background - people of Asian, African and African - Caribbean origin are more likely to have a stroke.

Can stroke be prevented?
There is no cure for stroke, once the damage to the brain has occured it cannot be completely reversed. Therefore prevention is very important. It is estimated that 90% of strokes can be prevented. Although this goal is difficult to achieve there are a few key things that can easily be done to decrease the risk of stroke.

Smoking doubles the risk of stroke because it damage ages the arteries (blood vessels), which increase the risk of the artery becoming blocked.

Healthy eating is essential for a healthy heart and bloodstream. Salt intake should be decreased as it raises blood pressure. Foods that contain a lot of fat should be reduced, including red meat and fried food. Body weight should be controlled to avoid obesity. Fresh fruit and vegetables (but not fried) should be eaten regularly.

Monitor medical conditions. It is very important that high blood pressure (hypertension), heart desease, high cholesterol, or diabetes are regularly monitored at the local health centre.

Doctors can prescribe medication to help keep these conditions under control. This medication can include medicine to lower blood pressure and cholesterol, to control diabetes, to keep the heart in a normal rhythm and to thin the blood.

People who have had a stroke of TIA at a higher risk of another stroke. After a first stroke all conditions should be closely monitored and appropriate medication and lifestyle changes made in order to prevent another stroke.

Sources : AMI, Health Massenger, www.nhlbi.nih.gov

ACCESSIBILITY

What is accessibility?

In the context of disablility,"accessibilty" refers to how easily, safely and independently an environment can be accessed by all people. It aims to create an environment free of barriers to to movement for everyone. For example, a person with disability who requeres a whellchair to move around cannot enter a building independently, freely and perhaps even safety if there are stairs at the entrance. If they have to be carried in this is not easy or independent, and may not be safe for them or their helpers.

An environment is said to be barrier free if every part of it is accessible, even for people with disability :

• Streets
• Public places
• Transportation
• Private buildings

A building is said to be accessible if everyone including people with disability can :

• Enter the building
• Move inside
• Use all the facilities
• Leave the building
  

Accessibility is a Human Right
A barrier free environment benefits everyone. It's a key factor in creating an inclusive society. But above this, accessibility has been declared a universal Human Right By the United Nations and this has been incorporeated into Indonesian law (UN resolution of 20th Desember 1993, art 19 of UN convention project and Indonesian law : no 4/1997 and no. 28/2002).

Why is accessibility improtant ?

• Better accessibility a significant part of the population that suffers from reduced mobility : according to the WHO, people with disability represent from 5% to 10% of the global population. If we add people "in situation of disability" (people with temporary disability, elderly pregnant women and children) this statistic reaches 50% of the whole population.
• Accessible places prevent accidents from happening.
  
• Incorporating accessibility into the original design of a building only the price slightly.
• But later modifications of the building are much more expensive.
• Taking accessibility into account in construction plans facilitates the practice of a sustainable development.

Obstacles or barriers in the environment become barriers for a person in achieving their rights.
What's up concerning accessibility?
Lauching of a 6 months Awareness Campaign "Access for all" June to december 2007 by the NGO HANDICAP INTERNATIONAL with the support of the Municipality of Banda Aceh (project financed by la chaine du bonheur, Swiss Solidarity).

For 6 months, public facilities of Banda Aceh are going to be audited in terms of accessibility. Following the audits, an accessibility map will be created showing accessible and non-accessible buildings as well as friendly areas. This map can be used as a guide by users of public facilities and policy makers. Accessibility awards will be offered to the most accessible buildings. There will be different categories of awards for : health facilities, commercial buildings, accommodations, schools, banks, markets and more.

Let's work for an accessible society for all
Sources : By Marjorie Unal, Inclusion Coordinator, Handicap International Banda Aceh, Health Massenger.

THE POST TRAUMATIC STREES DISORDER

Definition of the Post Traumatic Stress Disorder (PTSD)

At least 1/3 individuals who have been exposed to traumatic events develop long term problems. These problems (unexplained somatic complaints, anxiety, depeated consultations.

A traumatic event could be natural disasters (earthquake, hurricane, or rape, war or armed conflict. A traumatic event breaks off a normal life. It is extremely powerful, potentially harmful and outside the scope of the normal life events. These events could be episodic of repetitive, those are so everwhelming that one's basic consepts of safety, security, and basic turst, moral, ethnics and future perspective are shattered. The prevalence of mass traumatisation is often associated with cycles of violence.

A normal reaction or coping prosess is necessary to integrate the traumatic experience. During the coping process both mental and physical traumatic stress symptoms are prevalent. Although these symptoms are a part of a normal reaction to abnormal events the victims perceived them as threatening. The healing (or coping) process is negatively influenced by the contex of disruption.

Intensity and Frequency
If healing or integration of the traumatic event fails (for example, in the case of repetition of the event), a post trumatic stress disorders or other psychopathology (mood, anxiety, behavioral disorders and psychosis) may develop.

PTSD includes both psychological and physical symptoms that persist more than 1 month after the traumatic event. Otherwise, it will be an acute stress disorder, relatively normal after a traumatic event.

Although a great similaity predominates between the signs of traumatic stress and PTSD there is an essential difference in intensity and frequency. People suffering from PTSD are stuck in their symptoms, while the signs of traumatic stress are still considered as a "normal reaction to abnormal circumstances".

The person's respone currently involved intense fea, helplessness or horror. In children, they may express that bay disorganized or agitated behavior.

The are three groups of Symptoms Intruction or recurent distressing recollection

• Intrusive images or thoughts linked to the traumatic event despite efforts to block them out. In young children, repetitive play may occur in which themes or aspects of the truma are expressed.
• Recurrent distressing dreams linked to the traumatic event or nightmares. In children, there may be frightening dreams without recognized content.
• Flashback episodes during which the patient feels as he relives part of the traumatic event. In young children, trauma-specific reenactment may occur.

Avoidance

• The patient tries to avoid everything that might be associated with the trauma (places, situations, people that arouse recollections of the trauma), avoidance of conversations, feelings or thoughts related to the trauma
• Inability to recall an improtant aspect of the trauma
  
• Having thoughts about the trauma : alcohol, psychotropic drugs or toxic drugs may be used for this purpose.

Increased arousal

• Anxiety
• Insomnia, difficulty falling or staying asleep (these symptoms are important because if the patient doest't sleep well, he will spend his time to think on the traumatic event and his thoughts won't help him to sleep, so it may risk to fall in an infernal circle, with a body and mind tiredness)
• Exaggerated startle response, panic attacks, hypervigilance
  
• Sometimes hypertension, sweating, trembling tachycardia, headache etc.

Other Symptoms Behavioral

• Avoidance of social and family relationships (feeling of detachment or estrangement from others).
• Markedly diminished interest and participation in ususal activities.
• Drugs and alcohol use.

Affective

• Sadness, hopelessness, apathy
• Irritability, difficulty controlling emotions, outbursts of anger.
• Restricted range of affect (unable to have loving feelings)
• Feelings of misunderstood
• Sense of foreshortened future.

Sources : WHO, Health Massenger, http://nlm.nih.gov, MsF-Holland guideline

TAKE CARE OF YOURSELF

For people suffering from stress, "Psychological first AID" can be provided to relieve the tension and there are various ways to do that.
Different activities can help people to relax : singing, listening to music, going for a walk, taking time to talk with friends with whom feelings and experiences can be shared.

There relaxation techniques can be very useful and effective for people suffering from stress, anxiety and psychosomatic disorders :

• Breathing exercises
• Muscular relaxation
• Meditation

These exercises should be done in a quiet place where nothing or nobody can be a disturbance, wearing loose clothes and, twice a day, for at least ten minutes, preferrably before meals. It is also important to be concentrated when doing the exercice and not think about other things.

The regular practice of these exercises can really help to find peace of mind, tanquility and calm in various tituations and hence, improve physical health.

Breathing Exercises
Learn to breathe, slowly and deeply, with you abdomen. Putting your hand on it, you can feel it expand, when you breathing you can count when you breathe in and out. For example you can count u to three, for example, for each breathing. With further practice you can incrase the counting during each breathing to help you to breathe more deeply and slowly.

Be careful not to become sleepy or dizzy. Do not exaggerate or accelerate your breathing.

To help you concentration, you can focus your attention on the airflow in your nose.

Muscular Relaxation
This is a very good exercise when, due to stress, muscles are continuously contracted, and / or the patient has headache, backache, neck pain, joint pains and feels weak and tired.

For this exercise, lie down on your back, on a bed or a mat. Lay your arms on each side close to your body with the palms upwards. Observe your breathing as mentioned above.

Starting from your toes, relax each part of your body. First you consentrate your thoughts on your feed and thing deeply "my feed are relaxed, very relaxed" and try to feel the relaxation spreading in your feet. Then move up step by step to your ankles, legs, thinhs, abdomen chest, arms, hands, soulders, neck and head. For each part of your body you should think "my is relaxed, very relaxed" In each part of your body you should feel the relaxation and tranquility spreading.

At the end of the exercise, the whole body should be deeply relaxed, almost "lifeless". Experience the feeling or relaxation in you whole body for a few minutes.

At the end of the exercise do not get up suddenly. Slowly move slightly some part of your body and then get up slowly.

Meditation
Meditation is practiced seated with the back straight. Legs may be crossed in the lotus position for those who are flexible enough and feel comfortable like this.

The simplest practice of meditation is to attentively observe your breathing and focus your mind on the airflow in the nostrils or on the movements of your abdomen. You may start by counting each breathing by series of 10 and then, when the mind is well enough concentrated, you just keep focusing on the air you inhale and exhale.

Another technique is to choose an object, an idea or a word, a symbol of peace or aword of wisdom.

The most important is to keep the concentration on the object of your meditation. if you feel that your mind becomes distracted, comes back to your object. If you feel that other ideas come to your mind, do not follow them and let them go away peacefully, just keep focusing on your object.

Sources : Health Massenger, http://www.activefitnessworld.com/articles/yoga/yoga_workout.php

CHILD MENTAL HEALTH

It is important to identify children who may have psychosocial or mental problems in the early hours. If it is detected soon enough, it would help their healthy and balanced growth.

In General, 10 to 15% of children of affected by mental problems. Around 3 to 4 % suffer from mental retardation and 1 % of epilepsy. A survey lead in August 2005 by the WHO shows that in 21 districts in Aceh Besar, Banda Aceh, Bireuen, Pidie, Aceh Utara, Aceh Barat, and Nagan Raya, there are 2,820 children under 5 years old who need a good and specific attention for their mental health.

Child mental health is an extremely important issue in order for him/her to have a balanced growth.

How to recognize children with mental health problems?
Children with mild mental problems may try to hide it through indifference and denial towards the others. They may also show indirectly their problems by poor school performance, antisocial, passive, or inhibited behaviors.

Any person involved in the well being of children can identify, with simple questions, wheter a child has or not psychological difficulties and perhaps mental health problems :

• Is the child's speaking in anyway abnormal?
• Does the child sleep badly?
• Did the child ever have a fit or fall on the ground without a reason?
• Did the child suffer from frequent headaches?
• Does the child run away from hom frequently?
• Does the child steal things?
• Does the child get scared or nervous without any reason?
• Does the child appear retarded in his/her development or slow to learn compared to other children of the same age?
• Is the child often reluctant to p;ay with other children?
• Does the child wet or soil him/herself beyond the normal age?
• Does the child show lack of attention at school?

Children need to be cared about, to be listend to and to be understood.

If a "yes" is answered to any of these questions, it indicates that the child needs help.
Family, relatives or an elder in the community can give assistance or advices to the child and his/her parents. In case of long term or serious mental health issues, talk about it to a teacher, a health worker, and child to counselor or psychologist.

1. Domestic violance can explain the child's poor performance at school
2. War, social conflicts, any violent event is potentially traumatic for children.

Poor School Performance
many reasons can be behind the poor school performance of a child. The problems can be linked to :
Disease : for example a chronic or a brain-related illness
Family : alcoholism, domestic violence, quarrels between family members
School : overcrowded schools, conflicts with teachers or other students
Environment : war, social conflicts, traumatic events
To help the child, it is important to understand why he/she does not have good results.
Parents and teachers should not blame him/her for being lazy. Unless it is advised by an health worker, he/she should not be removed from school: this would enhance his/her problems.

Sources : WHO, Health Massenger, www.cartoonstock.com

IMPORTANT TREATMENT DURING PREGNANCY

According to a July survey (ASHO), There were, in july 2005, 28 pregnant women in Banda Aceh, 54 in Aceh Besar, 52 in Bireun, 100 Aceh Pidie, 119 in Aceh Utara, 15 in Aceh Barat, and 7 in Nagan Raya : 375 women needing to know the basics for a good treatment during pregnancy.

Goot To Remember

• Women with risk conditions need to be cared in a health facility which is staffed and equipped to provide essential obstetrical and neonatal services, including surgery.
• Do not delay anymore! Have you health routinely checked-up starting labor, and during puerperal period by the doctor, nurse or midwife, in the nearest health center or hospital!

What are ante-natal basic cares?
Improved nutrition and address anemia

• Promote good and balanced diet iron and folic acid for all
• Provide target protein-energy supplementation as appropriate
• Identify and treat sever and moderate anemia.

Prevention and treatment of infections in pregnant women

• Identify and treat STIs, especially syphilis, gonorrheal and non-gonorheal urethritis, always aware of possible trnsmission of HIV/AIDS.
• Institute prevention of malaria in endemic areas.
• Ensure tetanus, toxoid immunization coverage of all pregnant women

Get eady to delivery

• Enable women to choose a skilled midwifes/doctors and to ensure clean materials for delivery.
• Encourage mothers, fathers, and families to prepare for potential complications during delivery.
• Address transport difficulties wiht use of community paticipatory metheods

Health promotion for community

• Educate women/communities about the danger signs for the mother during pregnancy and delivery.

Warning!
what are the risks situations during pregnancy?

• Very young (less than 20 years) or over 40 years old women.
• Very frequent period of pregnancies (less than 2 years).
• Woman with medical problem (such as very short in height or malnourish woman)
• Woman who had more than four previous pregnancies.
• Woman who had experienced difficulties during previous deliveries.
• Woman who had caesarean section in the past.
• Woman who had baby born dead or miscarriage in the past.
• Woman who had premature or very small baby in the past
• Woman who is pregnant twins babies
• Woman who is bleeding abnormally
• Woman with high blood pressure
• Woman with abdomen size over than normal.

Sources : Health massenger, WHO, Special Issue On Mental Health.

DRUGS DONATIONS : WHAT TO DO?

On the 26th of Desember 2004, the news of the Tsunami caused a huge shock all around the world. Everyone felt concerned by the disaster and wanted to help the population in Aceh, who had lost so much.

In a rush of generosity, people gave materials, clothes, food, medicines and medical equipments, through mor or less experinced NGOs. At that moment nobody knew the real needs of the country, and a large part of those donations were completely inappropriate, particulary drugs.

Moreover, on arrival in the country, many of the donations containing perishable products had been dispersed in different places, regerdless of the lack of space, and lots of boxes were stored in poor conditions, exposed to elements.

What are inappropriate drugs?
All around the world, usual medicines are more or less the same, and they have an interntional non proprietary name or "generic name". But each country has drawn up a list of authorized drugs that can be used on its territory. Moreover, WHO (World Health Organization) has established a list of "essential drugs" and guidelines for drug donations, which give recomendations to donors.

However, these standars are not always followed by donors and a lot donated drugs are inappropriate. It means that they cannot be used in the country for several reasons :

• Labelling : how difficult for Indonesia pharmacists, assistants, doctor or nurses to read a label in French, German or Chinese..
• Poor Condition of storage due to the massive arrival of drugs. It is not possible to guarrantee their quality. Indeed, the warehouses are designed to offer storage space for nomal use and regular comsumption.
• Expiry date : many drugs or sterile material have no expeiry date, and for others, the given date is too short or has already expired.
• Unused in the country and not on the official list of authorized drugs in puskesmas or hospitals. A different molecules, strength, presentation or way of administration can crate changes in prescription habits.

How to solve the problem?
The management of medicines and medical material has of course been deeply disturbed in every health facility and warehouse. Lack of space, lack of staff, so numerous boxes arriving at the same time and too often without packing lists and inventories, produced a critical situation : boxes were piled up in rooms to protect them from elements. Hence, the medicines were inaccessible and many of them with short expiry dates are now outdated, and have to be destroyed.

The best way to solve the problem is to take the time to sort out and to make inventories of all the donated drugs as soon as possible, particularly at the entry points (airport, harbors) in order to redistribute the appropriated medicines in the health system.

The non appropriated medicines should be centralized - as explained on the diagram - by the district warehouse which will organise the bringing back to the provincial warehouse.

The problem of inappropriate medicines is not yet solved, and many specialists are working to develop national guidelines for correct sorting and destroying disposals.

Sources : Pharmaciens Sans Frontiers - Comite International (PSF-CI) Indonesia, Directorate General of Pharmaceutical service and medical device, Ministry of Health

HYGIENE PROTECTS YOU AGAINST DISEASES

Good hygiene is the first step towards good health, in the health centre, the house and for people. In hard working or living situations it is important to fit to simple hygiene principles and to remind the patient about it.

What is good hygiene? to have good hygiene means to keep yourself, your house, your garden, your village, and your work environment clean to prevent infection. An infection is a desease caused by bacteria or virus, which can be extremely harmful to people, especially the weak one: children, pregnant women, sick persons and elders.

Why prevention is so important ?

• Not all infectious diseases can be traated and some of them are fatal
• Prevention is less expensive than treatment.

What is an infectious disease?
Infectious diseases are the result of an attack of the body by a bacterium, a virus, a superior parasite or a fungus. The symptoms of an infeciton depend on the balance between of an infection depend on the balanace between the demaga done by the germ and the immune defences of the body and the localization of the infection.

Glossary
Virus : Very small and simple orgnisms which cannot live without the help of the body the infected. The live and reproduce themselves within the body cells and meanwhile they can be infecting them. Them are not necessarily harmful.
Bacteria : Bigger then a virus but still not a complete cell. Bacteria can live without the help of an external organism, on the skin, in the digestive tract or the vagina. They are not necessarily harmful for people. High temperature kills bacteria.
Germ : Small animal, peresnt in the air but only visible with the help of a microscope. It can transmit infection to the human body.
Superior Parasites : Organisms with one (Plasmodium Falciparum) or many cells (worms). They cannot live without the help of a host.
Fungus : Kind of vegetal organism that needs exchange of food with another body. Funguses only generate pain and infaction when body's immunity is destroyed.

Health Education
As a health worker you also have to give health educaion to your patients. These are some of the advices that you can give them:

Personal Hygiene

• Wash your body with soap every day
• Keep your fingernalis short and clean
• Brush your teeth twice a day
• Wear shoes when you are outside
• Wash your hands with soap before and after cooking, eating, drinking, using latrines, etc.
• Wash small wounds with boiled water, protect them with a clean and dry cloth, and go to the pustus as soon as possible.

Washing

• Wash your clothes, mats and blankets regularly.
• Hang or spread blankets in the sun after washing.

In the house

• Use the latrines; do not pass stool or urine on the ground or in the river.
• Teach your children to use latrines early
• Do not let anmals come into the house
• Do not spit on the floor
• Clean the house often (floors, walls, furniture).

Cleanliness in eating and drinking

• Boil the water during 10 minutes before drinking.
• Keep boiled water inside clean and covered containers
• Do not let filies and other insects land or crawl on food
• Protect food by keeping it covered.
• Before eating fruits or vegetables, wash it with clean water.
• Only eat meat that is well cooked. Do not eat food that it still or smells bad. It may be poisonous. If it is necessary, re-cooked again the food or makes it warm before eating it.

Sanitation

• Do not let the children drink water directly from the tap or the well
• Put the garbage into a deep hole far away form the houses
• Burn all the garbage that can be burnt
• Build latrines far away from the houses, from the river and from where the people bathe or get drinking water.
• Avoid stagnant water

Sources : WHO, Healt Massenger.

MALNUTRITION

Malnutrition is a condition that develops when the body does not get the proper amount of protein, enery (calories), vitamins, and other nutrients it needs to maintain healthy tissues and organ function: unbalanced or insufficent diet or defective assimilation or utilization of foods.

Although malnutrition occurs in children who are either undernourished or overnoureished, in Indonesia child malnutrition, as measured by the proportion of children who are either undersnourished or overnourished, in Indonesia child malnutrition, as measured bay the proportion of children under five years of age, who are moderately or severely underweigh, reaches 28 % in 2003; meanwhile seer malnutrition equals 8 % in 2002. This last figure would even be one in eight children in tsunami-affected areas of Indonesia, according to a nutrition assessment conducted by UNICEF in January 2005.

As protein and energy are indispensable for growth and development, children are more likely to suffer form consequences of malnutrition due to poor eating habits or lack of available food, and thus are more vulnerable to have other diseases.

Symptoms and diagnosis :
The child nutrition status can be measured with :

1. Body weight (BB), body height (TB), and BB/TB to becompared with standard tables.
2. Circle a child's mid-upper arm and measure tha thick of fat triceps fold or sub scapular.

Most sever cases of maltuntrition :
Marasmus: a form of protin-energy malntrition predominatly due to prolonged severe caloric deficit, chiefly occurring the firs year of life, characterized by : growth reterdation and progressive wasting of subcutaneous fat and muscle, but usually with retention of the appetite and mental alertness. often comes with darrhea or constipation and infectious diseases may be procipitating factors. Also called infantile atrophy, athrepsia, and pedatrophia.

Kwashiorkor : a form of protein-energy malnutrition produced by severe protein deficiency; caloric intake may be adequate but is ususally also deficient. it is charactrize by:

• Retarded growth
• Changes in skin and hair pigment
• Edema
• Enlarged abdomen
• Immunodeficiency
• Pathologic changes in the liver, including fatty infiltration, necrosis and fibrosis
• Mental apathy
• Atrophy of the pancreas
• Gastrointestinal disorders
• Anemia
• Low serum albumin
• Dermatoses

Marasmic Kwashiorkor : condidition in which there is deficiency both calories and protein with :

• Severe tissue wasting
• Loss of subcutaneous fat,
• Dehydration (usually)

How to treat it ?

• Slight and moderate malnutrition treatment consists in giving nutritional food, balance menu, a large amount of carbohydrate and protein. Neverheless other disease linked with malnutrition which could cause growt disturbance to the child (such as intestinal worm infection, diarrhea, etc) also need to be diagnosed and treated.
• Severe cases of malntrition represent an emergency situation. Hospitalization and appropriate treatment is required.

How to Prevent it?

• A good nutritive diet during pregnancy
• Exclusive brastfeeding (ASI) during the firts 6 months of life and breastfeeding up to 2 years of life.
• Regular check of the baby's growth and development
  
• Immunization of the child to prevent from communicable diseases
• Accurate knowladge about malnutrition symptoms for early diagnosis and complications prevention.

Sources : Health Massenger, WHO, Mawarny Halijah, Project coordinator,

THE BENEFITS OF BREASTFEEDING

Appropriate feeding practices are of fundamental importance for infants' health in the first two years of life. Fie essential messages of breastfeeding had been issued by WHO/UNICEF/USAID in 1999 as part of international recomendations, applied in the majority of the world, including Indonesia.

As health workers, we should comunicate theses messages to every woman by the las trimester of fregnancy until the first hours and months of the child's life, in order to help mothers avoid inadequate prectices and ensure children's proper growth and development:

Initiate breastfeeding within the first hour of life.
For the mother the benerits include reduced bleeding and infections after birth; the mani benefit for the child is that the sucking reflex helps to stimulate the mother's milk flow and ensure suffuicient milk immediately after and on of the delivery.

In Indonesia, less than one sixth of mothers do so with some three quarter initiating only after xix hours after delivery thus deleying the formation of sucking riflex and the production of milk.

Exclusively feed all colostrum (first breast milk, yellow in color)
Colostrum contains increased amount of antibodies and proteins essential to baby's early life and immunity. Do not give anything (water, teas, etc) before breastfeeding is started.

Colostrum is often considered harmful in some parts of Indonesia, and for which significant proportion of mothers discards part of it and up to one third do not give any of it.

Exclusive breastfeeding during the first 6 months of life reinforce the immunity system preventing the newborn baby form communicable desease infection.

Breastfeed exclusively for the first 6 months of life.
Breast milk contains all nutriens the baby needs and is also rich in antibodies to help fighting infections. Early introduction of tother foods (water, teas, bananas, coconut, or other solid foods) is harmful because the baby,s digestive system is not at all prepared to consume them.

Currently in Indonesia, Exclusive breastfeeding is very low and practiced by less than one sixth of women with one third of babies being fed with solid foods as early as one month. In addintion, very few babies are exclusively breastfeeding up to 6 months (less than 10%).

Introduce nutrition complementary food at the age of 6 months.
After 6 months breast milk no longer meets nutrition needs of the infant. Most apprppriate products to ensure the baby's growth are varied and nutritious foods, properly and freshly cooked: fresh and thick creamy porridge made from cereals, rice or millets in water/milk or mixture (do not water down the porridge to preserve energy content). Moreover, to give fruit purees and juices, thick vegetable soups or boiled pureed meats/eggs will contribute greatly to the baby's weight gain and health. On contrary to above, in Indonesia, up to half (!) of mothers consider that most appropriate first solid food for babies are commercial instant baby food, followed by fruits.

Continue breastfeeding up to 2 years of life.
Infants need breast milk for at least two years for optimal growth, health and development. In Indonesia, up to half of all children are weaned between first and second birthday.

Good To Remember : for the baby, there is no better, natural or healthier food than his mother's milk, which is produced to satisfy all his needs! Do not accept or Encourage mothers to give formula milk.


Sources : Nutrition specialis ; Lilia Turcan adn Rufina Pardosi, UNICEF Banda Aceh, Health Massenger, WHO.

DIARRHEA AND DEHYDRATION

Diarrhea is an infectious disease characteriszed by an abnormal liquidity and frequency (3 times or mor in a day) of fecal discharges, causing 18% of the deaths that occurred among under-fives in Indonesia in 2005.

Causes
Diarrhea is caused by infections of illnesses that either lead to excess production of fluids or prevent absorption of fluids, due to bacteria (E. coli, Shigella, Salmonella, Vibrio virus, Adenovirus) or parasite (Ameba, Giardia lambli). It can also be caused by :

• Lactose intolerance,
• Carbohydrate intolerance,
• Carbohydrate, fat, and protein malabsorpstion,
• Food poisoning by chemistry substances poison, toxin microorganism, Clostridium perfringens, Staphylococcus,
• Immunedericiency.

Complications and prevention
Complications to diarrhea may occur : dehydration, disturbance of bases acid balances, disturbance of electrolyte balance, nutrition disorder, and anemia.

Proper hygiene and food handling techniques can prevent many cases of diarrhea. the most important action is to prevent the complications of dehydration, a loss of water and salts that are essential for normal body function.

Therapy A : Diarrhea without dehydration (to treat the diarrhea at home)

1. Give the child more liquid than usual to prevent dehydration: use recommeded home's liquid such as Oral Rehydration Solution (ORS), liquid food (soup, thick water) until the child's diarrhea stpos. For the baby under 6 months is better to give ORS and cooked water than liquefy food.
2. Feed the child to prevent under nutrition: continue breastfeeding (breastfeeding) or milk as usual. For children over 6 months give adequate feeding: Porridge or other flours mixture, if possible mixed with vegetables, meet or fish. Sore fresh fruit or soft banana to increase kalium. Fresh food, cook and soft it. Encourage the child to eat at least 6 times/day. Give the same food after the diarrhea stopped, and give additional food every day for 2 weeks.
3. Bring the child to the health facility if the child do not get better in 3 days or suffer: Pass stool is diluted and frequently. Repeated Vomitig. Very thirsty, Eat or drink a little. Fever. Bloody stools

Therapy B : diarrhea with mild to medium dehydration
The amount of ORS given in the first 3 hours = patient's weight (kgs) x 75 mL or if the weight is unknown : Age (year) <> 5 give ORS (mL) 1200, Adult give ORS (mL) 2400.

• Give more ORS if the child wants to. Show the ways to give it : one tea spoon in every 1 - 2 minutes to the children <2>
• Encourage the mother to continue breastfeeding.
  
• For the baby <6>
• Check time to time if there is a problem.
• If the children vomit, wait until 10 minutes and than continue to give ORS, but slowly example one spoon in every 3-4 minutes.
• If child's eyelid is swollen, stop to give the ORS and give the cooked water or breast milk. Give ORS accordance to plan therapy A if the swollen done.

After 3 - 4 hours, rexam the children by using examination draft, then choose plan therapy A, B, or C to continue therapy. If the signs still show mild/medium dehydration, repeat the plan therapy B but offer food, milk, and sore fruit as plan therapy A.

Glossary
Acute diarrhea : less than 2 weeks
Persistent d : diarrhea lasting more than 2 weeks.
Dysenteric d : diarrhea with muccous and bloddy stools
Choleraic d : acute diarrhea with serous stools, acampained by circulatory.
Collapse d : thus resembling cholera.

Good To Know
Gelatin water may be subtituted for electrolyte replacement solutions if an ORS is unavailable it is made by diluting a 3 oz package in a quart of water or by adding one-fourth teaspoon of salt and a tablespoon of sugar to a print of water.

Therapy C : diarrhea with severe dehydration
Start to give IV liquid soon. If the patient can drink give ORS when IV liquid is started. Give 100 mL/kg RL/NaCl, divides as follows : Age : Baby<1>

Exam again the patient in every 1 -2 hours. if no sign of rehydration make fast IV drops.

Also give ORS (5mL/kg/hour) if the patient can drink, usually after 3 - 4 hours (baby) or 1 - 2 hours (child), after 6 hours (baby) or 3 hours (child). Exam again the patient by using examination table. then plan therapy as necessary.

Send the patient for the IV therapy

If the patient can drink, provide ORS to the mother and show how to give it during travel

Start rehydration per oral with ORS. Give 20 mL/kgbb/hours for 6 hours (total 120 mL/kgbb)

Exam the patient every 1 -2 hours

If vomiting or the stomach puffing give the liquid slowly

If no sign of rehydration within 3 hours, refer the patinet to IV therapy

Afer 6 hours exam again the patient and give a plan.

Sources : General Coordinator, Zul habibi, Atjeh Student's Of health Orgnization ASHO, Health Massenger

HYPOSPADIAS

Hypospadias is a development anomaly in the male in which the urinary tract opening, or urethral meatus, opens the underside of the penis or on the perineum.

Etiology

The development of the penis place in early stages of pregnacy by the formation of the urinary channel and foeskin thanks to the stimulation of male hormones, various problems with hormone action may result in the congenital condition called hypospadias. in few cases, the cause of hypospadia in genetic.

Symptoms

Hypospadias is diagnosed most often during the initial newborn physical examination observing the urethral opening in a wrong position, combined in some cases with other symptoms :

• Foreskin incompletely developed resulting in a dorsal hood (tip of the penis exposed)
• penis curvature (chordee)
• undescended tested

If left untreated, hypospadias can lead to an abnormal direction of the urine stream, abnormal appearance of the penis, infertility if the defect is located far enough away from the tip of the penis, and an inability to have sexual intercourse in cases involving chordee.

Diagnosis
Hypospadias is classified based on where tha urethral meatus is located

Therapy

The degree of hypospaidias and the extend of penile curvature will determine the necessity of a surgical intervention.

The surgery aims to create a normal straight penis with a urinary channel that ends at the tip of the head of the penis. the operation usually involves four steps : straightenig the shaft; creating the channel; positioning the urethral opening in the head and either circumcising or reconstructing the foreskin

Occasionally, when the opening is proximal, tratment with the male hormone testoterone previous to surgery may be recommended. Males who have hypospadias located within or near the scrotum should also have a procedure called a voiding cystogram to rule out additional urinary tract anomalies.

The recommended age of surgical repair is between four and 12 months. this age is ideal for many reasons including the size of the penis and the slow rate of growth of the penis.

Children should not be circumsiced because the foreskin if often essential in hypospadias repair surgery.

Prognosis
After hypospadias repair the penis appears normal and functions normally, very few children experience postoperative complications (woud infections, unexpected opening near the repair site)

Possible forms of hypospadias :

1. Glandular / Distal
2. Midle penile
3. Pen scrotal
4. Perinea/proximal

Sources : RSU Zainoel Abidin, Dr. Dahril SpU. Health Massenger

IMMUNIZATION

In 2002, WHO estimed that 1.4 million of deaths among children under 5 years were due to diseases that could have been prevented by routine vaccination. This represents 14% of global total mortality in children under 5 years of age.

Definition

Immunization is the process whereby a person acquires immunity (resistance) to an infectious disease, typically by the administration of a vaccine/antigen. vaccine stimulate the body's own immune system (antibody) to protect the person against subsequent infection or disease (WHO definition)
The number of doses in the immunization scedudule corresponds to the number of doses required to fully protect a child against the corresponding disease.

Immunization Scedules by antigen in Indonesia

1. BCG : Bacille Calmette Guering Vaccine, Number of dosis; 1, scedule ; 1 mounth
2. DT : Tetanus and Diphtheria toxoid children's dose, Number of dosis; 1, scedule 6 years
3. DTwp : Diphtheria and tetanus toxoid with whole cell pertussis vaccine, Number of dosis; 3, scedule ; 2,3,4 months
4. DTwPHep : Diphtheria and tetanus toxoid with whole cell pertussis and HepB vaccine, Number of Dosis ; 3, scedule ; 2,3,4 months; part of country
5. HepB ; Hepatitis B vaccine, Number of Dosis; 3, scedule ; birth 2 months; 3,2 months
6. Measles : Measles Vaccine, Number of dosis; 2, scedule; 9 months; 6 years
7. OPV : Oral Polio Vaccine, Number of dosis; 4, secudule; birth 1, 2, 3, 4 months
8. TT : Tetanus toxoid, Number of dosis; 2, scedule; 7,8 years
9. Vitamin A : Vitamin A supplementation, number of dosis; 2, scedule 6 - 11, 12 - 59 months

Immunization Contraindications
Each vaccine has specific contraindications, so it is in dispensable to always read the notice carefully before practicing immunization. nevertheless, some contraindications are common to all vaccines;

• In case of immunodeficiency and immunosuppressive treatment, except in special conditions.
• Using a long term corticosteroid treatment and healthy children treated with corticosteroid in common dose for more than 2 weeks, or in high dose (dose>2mg/kgBB or 20mg/day).

Immunizations in Specific Situations

• HIV patients a giving vaccine of OPV (oral polio vaccine), measles, MMR and BCG are contraindicated. Giving vaccine of DPT, infuenza, H. Influenzae, IPV (inactivated polio vaccin), and pneumonia may be allowed.
• In High incidence TB areas, WHO recomend to give BCG for asymtomatic HIV cases.
• The patients of Clinic HIV always in contact with their family is not allowed to receive OPV, but IPV.
• The child without HIV manifestation can receive imunization routinely. Premature baby; The immunization is according to age chronology. under weight baby at birth can receive the same immunization schedule but following points should be taken into consider:

• Passive immunity their titer through maternal trnsmission is lower than on non premature baby. if the baby's weight is under <1000>
• If the baby is still hospitalized after 2 months age, the polio vaccine to be given is IPV injection.

What is AEFI?
In addition to the desired reaction, all vaccines produce some degree of unwanted reaction. The vast majority of these are trivial and harmless. some are more noticeable and annoying. A very small number are serious and potentially life threatening.
AEFI (Adverse Events Following Immunization) can happen within one month after the immunizaiton. In specific situations, the duration of AEFI observation might take 42 days.

Some symptoms of AEFI are :

• Local reaction a abscess on injecton space of lymphadenitis, cellulite, and BCG itis
• SSP a acute parlyze, encephalopthy, encephalitis, meningitis, stiffness.
• Other a allergy reaction (nettle rash, dermatitis, edema), anaphylaxis reaction, anaphylaxis shock, arthralgia, high fever > 38,5oC, septic shock, continuing shout crying (>3 hours) osteomyelitis.

Causes Of AEFI?
Etiology factors based on WHO field clasification of Western Pacific (1999) :

1. Programmic Errors: high doses, wrong injection area, not sterile needle and syringe, vaccine and diluents has been contaminated, vaccine is not stored in the right place or in opotimal conditions (temperature/cold chain and light), Ignorance of the CI, Using an expired vaccine, ignored procedure's instructions
2. Injection Reacion : All clinical symptoms occurring because of needle stick trauma directly (feeling pain, swollen, and reddish on the injection space) or indirectly (feeling fear, dizzy, nausea, and syncope)
3. Vaccine Reaction : When the vaccine is no properly administered (obsolete or non appropriate vaccine toolls)
4. Coincident Factor : An illness or death occurring after immunization, but not linked with the vaccine itself or the orther factors cited above.

WHO recomendations on minimizing AEFIs

• Measles, BCG and yellow fever vaccines should be reconstituted only with the diluents supplied by the manufacturer.
• Reconstitured vaccines should be discarded no longer than six hours after reconstitution or at the end of each immunization session.
• In the refrigeraor , no other drugs and substances shourl be stored beside vaccines.
• Labels should be carefully read before a vaccine is prepared for administration. if the leable cannot be clearly read and there is doubt about the contents of a vial or ampoule it should not be used
• Immunization workers should be trained and closely supervised to ensure that proper proceures are being follwed.

Sources : Melisa Lilisari, Medical Editor, Health Messenger

CHILDREN'S RIGHT TO ACCESS HEALTH SERVICE

The first effective effort in defending children's right was the Declaration of Children's right made in 1924 by Eglantyne Jebb, followed in 1989 by the United Nations Convention on the Rights of the Child (UNHCR)

The United Nation Convention on the Rights of the Child (UNHCR) is an international rights treaty that grants all children and young people (aged 17 and under) a comprehensive set of rights, including :

• Special protection measures and assistance
• Acces to services such as education and health care.
• Develop their personalities, abilities and telents to the fullent potential
• Grow up in an environment of happiness, love and understanding
• Be informed about and participate in achieving theri rights in an accessible and active manner.

The four core principles of the convention are nondiscrimination; devotion to the best interests of the child ; the right to life, survival and development; and respect for the views of the child.

The Indonesian goverment celbrates the national children's day in Indonesia the 23rd of July and had also ratified the UN Convention on the Rights of the Child through Presidential Decree No. 36, Year 1990, that articulates the State's responsibility to provide services and programmers for the welfare of children in fulfillment of its obligations as a State Party to the UNCRC

Since 1954, the Children's world day is celebrated the 20th of November.

Extract Of The UNCRC
Article 24: Health

1. States Parties recognize the right of the child to enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. states Parties shall strive to ensure that no child is deprived of his or her right of access to such health care services.
2. States Parties shall pursue full implementation of this right and, in particular, shall take appropriate measures ;
   

• To diminish infant and child mortality;
• To ensure the provision of necessariy medical asistance and health to all children whith emphasis on the development of primary health care;
• To combat desease and malnutrition, including within the framework of primary health care, through, interalia, the application of readily available technology and through the provision of adequate nutritious foods and clean drinking-water, taking into consideration the dangers and risks of environmental pollution;
• To ensure appropriate pre-natal and post-natal health care for mothers;
• To ensure that all segments of seciety, in particular parents and children, are informed, have acces to eductions and are supported in the use of basic knowledge of child health and nutrition, the advantage of breastfeeding, hygiene and environmental sanitation and the prevention of accidents ;
• To develop preventive health care, guidence for parents and family planning education and services.

3. States Parties shall take all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children.
4. States Parties undertake to promote and encourage international cooperation with a view to achieving progressively the full realization of the right recognized in the present article. In this regard, particular account shall be taken of the needs of developing countries.

Sources : Dr. Melisa Lilisari, Medical Editor, Health Messenger.

INDONESIA : CHILD HEALTH PROFILE

Demographics and information system
Under five population (2005) = 22000000
Annual number of births (2005) = 4000000
Birth registration coverage =55%
Coverage of vital registration of deaths (2002) = <25% style="color: rgb(0, 0, 153); font-weight: bold;">Health Status Indicators
Neonatal, infant and under five mortality
Neonatal mortality rate per 1000 live birth (2004) = 17
Annual number of neonatal deaths (2004) = 61000
Infant mortality rate per 1000 live births (2005) = 28
Annual number of infatn deaths (2005) = 126000
Under five mortality rate (2005) = 36
Annual number of under five deaths (2005) = 161000
Neonatal causes as a proportion
of all under five deaths (2000) = 38%

Distribution of under five deaths by age groups

Based on mortality estimates from the IACMEG for 2005 78% of all under five deaths in Indonesia occur during the first year of life : 38 % in net neonatal period and another 40% between the first and the eleventh month. the remaining 22% occur the second and the fifth years of age.
Infectious diseases such as diarrhea (18%), pneumonia (14%), and measles (5%) account for more 37% of the 161000 deaths the occured among under five in indonesia in 2005.
Among the 61000 neonatal deaths that the estimated to have occured in 2004-2005.

• About 22% were due to infections (severe infections including pneumonia, neonatal tetanus, and diarrhea),
• Another 69% were due to birth asphyxia (30%), preterm birth (32%), and congenital anomalies (7%)

Trends In Neonatal Mortality Rates
DHS has reperted a NNMRs for the following years/periods : 1987, 1991, 1994,1997, and 2002 - 2003. these were 27, 32, 30, 22, and 20 per 1000 live births, respectively. WHO estimated NNMRs were 18 and 17 per 10000 live births in the years 2000 and 2004, respectively.

Sources : World Population Prospects - the 2006 revision, UN population Division, New York, 2007, UNICEF, The State of The Wourld Childrend 2007, WHO, World Health Statistic 2007, UNDP, World Bank,

ACEH HEALTHY SCHOOLS PROGRAM

Mercy Corps' Aceh Healthy School Program is addressing the health and nutrition needs of school aged children in two districts in Aceh through an intergrated strategy designed to reduce anemia levels adn improve hygiene.

Initially, the program will reach 10,000 children with plans to scale up doubling that figure over two years. The program aims to reduce anemia levels by providing micronutrient supplementation, supporting initiatives in parasite elimination, promoting basic hygiene and improving nutrition practices.

Anemia Status in Aceh

While great strides have been made in Aceh since the december 2004 tsunami, children's helath status remains disturbing, with indications of chronic under nutrition and high prevalence of anemia.

In october 2007, Mercy corps conducted a preliminary assessment to more clearly understand anmia patterns in Aceh Province with plans to replicate, as appropriate, its long established Sumatra Healthy Schools Program. That Program succesfully reduced anemia rates and worm infestation throughout five provinces of Sumatra.
The results of the Aceh preliminary assessment show alarmingly high anemia and worm infection rates. intestinal worms contrubute to anemia and overll poor nutrition status and are associated with poor sanitary conditions. in Aceh Besar, anemia rates were 68.5% of 4 - 5 years old and in Nagan Raya, 56% of 6 - 7 years old were effected. worm infection rates in Aceh Besar were 32.2% and in Nagan Raya they were 64.2%. these finding reinforce the need for an anemia prevention project through focused interventions addressing the root couses of anemia.

What is anemia and why is it important?
Iron deficiency affecs a sgnificant part, and often a majority of the population in nearly every country in the world. Risk for iron deficiency varies with each stage of the life cycle due to changes in iron stores, level of intake and needs relating to growth or iron loss. for example, before six months iron stores are usually adequate from the perinatal period, however, iron storage levels in children begin to decline during the second year of life due to low iron content in the diet and rapid growth spurts. In areas with a high prevalence of hook worm infestation, school aged children as well as adults can also develop significant iron deficiency.
Iron deficiency is defined as a condition in which there are insufficient iron stores and in which there is compromised supply of iron to tissues. the more severe stages of iron deficiency are associated with anemia which is clinically determined if hemoglobin levels drop to less than 11 g/dL(6 months -<5 years old) or 11.5 g/dL (5 -< 11 years old). However, even mild to moderate forms of iron deficiency which may not clinically be qualified as anemia, tussues still are functionally impaired causing children to be tired, slow motor activity and inhibit a child's ability to learn. moreover, the affects of iron deficiency in childhood, a time of significant growth spurts, can be irreversible leading to leower functioning adults.

Sources : Paula miller, Aceh Healthy Schools Project Manager, Health Messenger

UNICEF Report, September 2005,

AVIAN INFLUENZA

Avian Influenza : Getting the disease under control

With a death toll from the virulent H5N1 strain of bird flu of 55, Indonesia has the world's higherst number of human deaths. The country has become the focus of the fight against the virus. Most of the infections have been contracted from domestic fowl. The World Health Organization fears the virus could mutate a form that easily spreads among humans, sparking a global epidemic.

Prevention of Avian Influenza Infection Costumer of chicken and chicken products :

• Chicken meats and eggs in the market are safe but they be throughly cooked. Meat should be throughly cooked untill it is no longer pink.
• Do not eat half cooked meat (chicken, duck etc)
• Do not eat raw eggs or soft-boiled eggs.

Food handlers and people who prepare food for household comsumtion:

• Don't buy chicken meat that has dark, bruised or hemorrhagic spots.
• Don't buy unusually cheap chicken meat ( as this may suggest that the animal was sick before slaughter)
• Don't buy eggs that have cracked shells or have dirt, feces or feathers on them. wash eggs thoroughly before cooking.
• Don't use dirty hand to touch the nouse, eyes, or mouth. Wash hands frequently, especially after handling chicken meat, duck meat, offal and eggs.
• Use separate chopping boards for meats, vegetable, cooked and raw food.

Sources : Avian Influenza Team, WHO Indonesia, Health Massenger,

DOWN SYNDROME

Down Syndrome, or trisomy 21, is a common genetic variation characterized by the presence of one or part of an extra chromosome 21 in an individual's genetic identify or karyotipe.

This chromosomal rearrangement usually causes variation in mental abilities and delays in behavioural and physical development and is one of the leading clinical causes of cognitive delay. the women's age appears to be the most important risk factor responsible for this genetic disorder.

Symptoms And Development
Though being a chromosomal disorder, a set of physical characteristics are usually identified on babies with down syndrome at birth: overly quiet, less responsive, with weak and floppy muscles.

Main Symptoms of Down Syndrome
While develoving, some physical features may be observed on children with trisomy 21:

• flat appearing face and small head
• slanting eyelids
• depressed nasal bridge
• small ears
• small skin folds at the inner corner or the eyes
• small mouth
• decreased muscle tone
• loose ligaments
• short wide hands with small fingers and a line across the palm (50%), often with a gap between the first and second toes
• small feed

The physical features observe in children with Down Syndrome (and there are many more than described above) generally do not couse ani disability. nevertheless, children with down syndrome ususally present severe mental retardation and their motor development is slow instead of walking by 12 to 14 months as other children do, they might learn to walk between 15 to 36 months and language development is also maredly delayed

Health Conserns usually oberserved in individuals with Down Syndrome
Children with Down Syndrome need the same medical care as any other children. The paediatrician or family physician should provide general health mainenance, immunizations; attend to medical emergencies, and offer support and couselling to the family. but as other types of defects often accompany Down Syndrome, there are nevertherless situations when special attention and appropriate tratment is necessary.

1. A significant propotion of children with Down Syndrome have Hearing Deficits. therefore, audiologic assessments at an early age and follow-up hearing tests are indicated. if there is a significant hearing loss, the child should be seen by an otorhinolaryngologist (nose, ear and throat specialist).
2. Children with Down Syndrome may have congenital heart disease. Many of these children will have to undergo cardiac surgery and often will need long term care by a paediatric cardiologist.
3. Intestinal abnomalities also occur at a higher frequency in children with Down Syndrome. For example, a blockage of the esophagus (food pipe), duodenum (small bowel), and at the anus are not uncommon. these may need to be surgically corectd at once in order to have a normal functioning intestinal tract.
4. Children with Down Syndrome often have more eye problems then other children who do not have this chromosome disorder. For example, some infants with trisomy 21 have cataracts. They need to be removed surgically. Other eye proglems such as trabismus (cross eye), near-sightedness, far-sightedness and other eye conditions are also frequently observed
5. Another concern related to nutritional aspects. Some children with Down syndrome, in particular those with severe heart disease often fail to thrive in infancy. on the other hand, obesity is often noted during adolescence and early adulthood. these conditions can be prevented by providing appropriate nutritional counseling and anticipatory dietary guidance.
6. Thyroid dysfunctions are more common in children with Down syndrome. Hypothyroidism for example is important to identify early since it may comprpmise normal central nervous system functioning.
7. Skeletal problems have also been noted at a higher frequency in children with Down syndrome, including kneecap subluxation (incomplete or partial dislocation), hip dislocation, and atlantoaxial instability. the latter condition occurs when the first two bones are not well aligned because of the presence of loose ligaments.
8. Other important medical aspects in Down syndrome, including immunlogic concerns, leukemia, Alzheimer disease, seizure disorders, sleep apnea and skin disorders, may require the attention of specialists in their respective fields.

Stimulation services and vocational opportunities
Researched have shown that early intervention, environmental enrichment, and assistance to teh families will result in progress that is usually not archieved by those infants who have not by such educational and stimulating experiences.

Children with Down syndrome, like all children, can benefit from sensory stimulation, specific exercises involving gross and fine motor activities, and instruction in cognitive development. Also, preschool plys and important role in the young child's life since exploring the environment beyond the home enables the child to participate in a broader world.

Experiences provided in school assist the child in obtaining a feeling of self-respect and enjoyment and give an opporunity to engage him in sharing relationships with others.
Health and educational services have an important role in stimulating development and preventing secondary effects. Doctors, physioterapists, occupational therapist, speech therapists, psychologists, nurses and educators should work alongside with the family and the child in order tob able to maximize the capacities of the child.


Sources : Dr. Andrew Carroll, University of Alabama at Birmingham, Health Messenger.

INTESTINAL WORMS INFECTONS

Intestinal worm infection is a tropical and sub tropical disease caused by a lack of hygiene and healthy behavior, most of the time transmitted by touching contaminated or eating uncooked food grown in contaminated soil or irragated with inadequately trated wastewater.

Definition
The WHO defines the Ascarisasis, the most common human parasitic infections, as "an infection of the small intestine caused by Ascaris lumbricoides, a large roundworm. The eggs of the worm are found in soil contaminated by human feaces or in uncooked food contaminated by soil containing eggs of the worm. A person (and especially a child) becames in fected after accindentally swallowing the eggs. The eggs hatch into larvae within the person's intestine. The larvae pentrate the intestine wall and reach the lungs through the blood stream. in the intestines, the larvae develop into adult worms. the female adult worm which can grow to over 30 cm in length, lays eggs that are then passed into the feaces. if soil is polluted with human or animal feaces containing eggs the cycle begins again. eggs develop in the soil and become infective after 2-3 weeks, but can remain infective for several months or years.

Kind Of Disease :

1. Ascaris lumbricoides (roundworm), high prevalence, especially among children, frequency 60 - 70%, worm size 10 - 35 cm, the worm can produce roe around 100000 - 200000/day, a big worm in the kidney sucks 0.14 g carbohydrate/day and disturb absorption of vitamin A.
2. Necator Americanus and Ancylostoma deudenale (hookworm), high prevalence especially in planantation area, land loose. Relate to the using of the faeces as fertilizer and the habit of not using slipper/shoes, size around 1 cm, giving roe 10.000 granules/day. A big worm sucks 0,1-0,2 mL blood/day.
3. Trichuris trichiura(whipworm), frequency around 30-90%, the spreading is related to contamination between the soil and faeces, size 4 - 5 cm, a worm can produce 3000-10000 roes/day. do not pass lung cycle, big worm live especially in the ascending colon, sucking food subsance and 0.005 mL blood/day
4. Enterobius Vermicularis (pincourm), Transmission can occur in a family or a group staying in the same environment (dormitory house), size 2 - 13 mm. worm produce 11.000-15.000 roes/day in perianal area.

Symptoms
Several symptoms can be noticed :

• Degestive symptoms ; stomach ache, nausea, vomit, low weight, fever, darrrhea, or constipation. Diarrhea can sometimes be combined with dysentery syndrome and ractum polactus. The pinworm can give pruritus ani especially at night, enuresis, and irritability. A chronic infection can also contrubute to food allergy. a worum living in the kidney can also cause a reduction of nutritive substances (macronutrient and micronutrient) leading to malnutrition problems, less appetite, absropstion difficulties.
• Respiratory symptoms; cough, wheezing and difficulty in breathing, or fever.
• Urinary tract symptoms: kidney obstruction (roundworm)
• Metabolic symptoms: blood artery wall iritation (whipworm). iron deficiency (leading to anaemia)
• Immunological suppression
• Genarally lagging development (but mostly physical)

Interventions
Health education providing the following massages reduces the number of infected people :

• Avoid contact with soil that may be contaminated with human faeces;
• Wash hands with soap and water before handling food;
• Wash, peel or cook all raw vegetables and fruits;
• Protect food from soil and wash or reheat any food that falls on the floor.

Treatment
The tratment can be conducted publicly or personally, with pyrantel pamoat, membendazol, or albendazole. Infected individuals should be treated to reduce total of 1,913 (93%) of children aged 2 - 5 years in two districts of Aceh were given OPV + albendazole (400mg)

Sources : WHO, Medical Editor,

CLEFT LIP AND PALATE

A cleft lip and or palate is a birth defect (congenital) generally of the upper part of the mouth. A cleft lip creates an opening in the upper lip between the mouth and nose and a cleft palate occurs when the roof of the mouth has not joined completely.
In sumatra, 1 of 300 children is born with cleft lip and or palate. children of Sumatra, a NGO created in 2002, has coordinated until now 60 operations in hospital and rehabilitation units in Medan, beneficiating from the special intervention of a western plastic surgeon for most severe cleft lip and or palate cases. In September 2007, 42 operations have been realized.

Causes
Causes of cleft lip and or palate are not well identified; nevertherless a combination of genetic and environmental factors may favor appearance of this congenital defect:

• Family history of facial clefts
• Alcohol and drugs abuse during first weeks of pregnancy.
• Vitamins lack (especially folic acid) during the first week of pregnancy
• Mothers with diabetes

Diagnosis
Because clefting causes specific physical manifestastions, it is to diagnose. for an accurate diagnosis and classification, check :

• The harelip localis status in detail,
• The nature of the clefting; lip, palate or both
• Cleft extensivities; complete (a cleft extended through the entire affected mouth structure), gnatho (gums), or incomplete (limited disruption, ususally the gnatho is still complete),
• Cleft location: unilateral (one side) or bilateral (both side),
• Alveolar and gums segment; is there a gap or not? is the gap wide or narrow? Does it collapse or not?

Clefts may occur alone or with other abnormalities (hidden or obvious) in the saliva glands, genital area, fingers and extremitas and may be combined with mental retardation, or hearth and other facial anomalies, so newborns with clefts should be carefully examined by a specialized physician soon after birth.

Cleft palate's patient normally also have tuba Eustachian function disorder and are more likely to suffer from otitis media which can have repercussions on earring functions and speaking learning process. In such case, a consultation with THT specialit (otolaryngologist) is needed.

Treatment
Due to the physical appearence modification, untreated cleft lip (in most cases because of treatment costs) can have repercussion on children self-esteem increased by social acceptance dificulties, generating educational problems.

A cleft lip and or palate can be repaired with corrective surgery :
Labioplasty or cheiloplasty is the plastic surgery of the lip. The recomended age for the surgery follow the 10 s rule :

• Age > 10 weeks (3 months)
• Weight > 10 pounds (5 kg)
• Hb > 10 g/dl

Process :
The edges of the cleft between the lip and nose are cut. The bottom of the nostril is formed with suture. The upper part of the lip tissue is closed and the stitches are extended down to close entirely.

Palatoplaty (platic reconstruction of the palate) is ideally practiced between 18-24 months on healthy children and before speech abilities are developed. to prevent speech dysfunction it is recommended to consult a speech therapist 3 to 6 months after palatoplaty.

Sources : WHO, Young, Greg, M. D (1998). Cleft Lip and Palate January 28 1998, UTMB Dept. of Otolaryngology Grand Rounds, RSU Zainoel Abidin, Plastic surgery specialist, Dr. BJ. Bismedi.