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