Feeding Problem pada Anak:

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• Latar Belakang Masalah

• Pediatric Feeding Disorder
• Rekomendasi tata laksana

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 Rekomendasi Kriteria Diagnostik Pediatric Feeding Disorder
A. A disturbance in oral intake of nutrients, inappropriate for age, lasting at B. Absence of the cognitive processes consistent with eating disorders
least 2 weeks and associated with 1 or more of the following: and
1. Medical dysfunction, as evidenced by any of the following: pattern of oral intake is not due to a lack of food or congruent with
a. Cardiorespiratory compromise during oral feeding cultural
b. Aspiration or recurrent aspiration pneumonitis norms.
2. Nutritional dysfunction, as evidenced by any of the following:
a. Malnutrition
b. Specific nutrient deficiency or significantly restricted intake of one or
more nutrients resulting from decreased dietary diversity
c. Reliance on enteral feeds or oral supplements to sustain nutrition and/
or hydration
3. Feeding skill dysfunction, as evidenced by any of the following:
a. Need for texture modification of liquid or food
b. Use of modified feeding position or equipment
c. Use of modified feeding strategies The following International Classification of Functioning, Disability and
Health (ICF) categories apply to each of the criteria above and can be used to
4. Psychosocial dysfunction, as evidenced by any of the following: describe the functional profile of affected patients.
Medical dysfunction: impaired functions of the cardiovascular and
a. Active or passive avoidance behaviors by child when feeding or respiratory systems.
being fed Nutritional dysfunction: any impaired body functions and structures,
environmental factors (products and substances for personal consumption).
b. Inappropriate caregiver management of child’s feeding and/or Feeding skill dysfunction: limitations in activities/participation related to
eating.
nutrition needs Psychosocial dysfunction: limitations in activities/participation related
to interpersonal interactions and relationships.
c. Disruption of social functioning within a feeding context
d. Disruption of caregiver-child relationship associated with feeding
Pediatric Feeding Disorder: Consensus Definition and Conceptual Framework

Goday, Praveen S.; Huh, Susanna Y.; Silverman, Alan; Lukens, Colleen T.; Dodrill, Pamela; Cohen, Sherri S.; Delaney, Amy L.; Feuling, Mary B.; Noel, Richard J.; Gisel, Erika; Kenzer, Amy; Kessler,
Daniel B.; Kraus de Camargo, Olaf; Browne, Joy; Phalen, James A. Journal of Pediatric Gastroenterology and Nutrition68(1):124-129, January 2019. doi: 10.1097/MPG.0000000000002188

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 4 Domain utama dalam Pediatric Feeding
Disorder

Impaired structure/function of the Faktor a restricted quality, quantity,

GI, cardiorespiratory, and Faktor and/or variety of beverages
Kondisi
neurological systems Nutrisi and foods consumed
Medis

Altered feeding experiences due to

Faktor Faktor
Factors within the child, caregiver,
illness, injury, or developmental delay Feeding Psikososia and the feeding environment
may lead to impairment of feeding Skill l (psychosocial impairments)
skills.

Pediatric Feeding Disorder: Consensus Definition and Conceptual Framework

Goday, Praveen S.; Huh, Susanna Y.; Silverman, Alan; Lukens, Colleen T.; Dodrill, Pamela; Cohen, Sherri S.; Delaney, Amy L.; Feuling, Mary B.; Noel, Richard J.; Gisel, Erika; Kenzer, Amy; Kessler,
Daniel B.; Kraus de Camargo, Olaf; Browne, Joy; Phalen, James A. Journal of Pediatric Gastroenterology and Nutrition68(1):124-129, January 2019. doi: 10.1097/MPG.0000000000002188

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 Faktor Kondisi Medis
1. Disfungsi saluran cerna: gangguan saluran cerna bagian atas primer (anomali atau penyakit)
maupun sekunder (patologi di saluran nafas atau respirasi), anomali orofaring dan laring
(mengganggu mekanis dalam pemberian makan normal), inflamasi saluran cerna atas, gangguan
motilitas dan fungsional saluran cerna, intoleransi terhadap volume makanan
2. Penyakit saluran nafas dan paru-paru: gangguan koordinasi ‘suck-swallow breathe’ pada anak
dengan takipnea kronis, gangguan menelan dan feeding skill pada prematuritas, aspirasi yang
menyebabkan infeksi saluran nafas bawah
3. Penyakit Jantung Bawaan: rawat inap lama, intervensi penyakit kritis (menunda dan merusak
kemampuan makan). Bedah jantung dapat menyebabkan paralisis saraf laring dengan paralisis
pita suara kiri dan mengganggu proteksi jalan nafas. Intoleransi makan dan muntah pada anak
anak dengan hipoksia kronis dan cedera vagal
4. Gangguan neurologis: saat kebutuhan melampaui feeding skill, gangguan motorik dan
keterlambatan kognitif, disfagia neurogenik, gangguan perkembangan saraf pada ASD, gangguan
mekanisme sinyal nafsu makan

Pediatric Feeding Disorder: Consensus Definition and Conceptual Framework

Goday, Praveen S.; Huh, Susanna Y.; Silverman, Alan; Lukens, Colleen T.; Dodrill, Pamela; Cohen, Sherri S.; Delaney, Amy L.; Feuling, Mary B.; Noel, Richard J.; Gisel, Erika; Kenzer, Amy; Kessler,
Daniel B.; Kraus de Camargo, Olaf; Browne, Joy; Phalen, James A. Journal of Pediatric Gastroenterology and Nutrition68(1):124-129, January 2019. doi: 10.1097/MPG.0000000000002188
 Contoh Kondisi Medis yang Diasosiasikan dengan Feeding
Disorder
Impairment (Body structure/function*) Dysfunction (Activity Limitations*)
Disorders that affect oral, nasal, or pharyngeal function   Malnutrition and its sequelae
Macroglossia, Extensive dental disease , Labial or palatal clefts , Velopharyngeal insufficiency , Choanal  Aspiration, recurrent aspiration
pneumonias, chronic lung disease
atresia, Tonsillar hypertrophy  
Aerodigestive disease 
Airway : Laryngeal clefts, Vocal fold paralysis or injury, Airway malacia (laryngo-, tracheo-, or
bronchomalacia) , Subglottic stenosis 
Pulmonary
Bronchopulmonary dysplasia, Any process resulting in chronic tachypnea
Gastrointestinal 
Eosinophilic esophagitis, Esophageal motility disorder (post-esophageal atresia or achalasia) , Gastric or
duodenal ulcers
Other gastrointestinal disorders
Feeding/volume intolerance of any cause, Gastroparesis 
Congenital and other heart disease 
Any form of congenital heart disease (esp. hypoplastic left heart syndrome) and other conditions that
result in staged single ventricle repair , Associated pulmonary hypertension , Myocarditis and other causes
of heart failure 
Neurologic, developmental, and psychiatric disorders 
Autism spectrum disorder, Disorders of motor control with hyper- or hypotonia, Cerebral palsy, Muscular
dystrophies, Attention-deficit/hyperactivity disorder 
Iatrogenic
Prolonged hospitalization with critical care support , Invasive operative procedures affecting vital
systems, Aversive feeding 

Pediatric Feeding Disorder: Consensus Definition and Conceptual Framework

Goday, Praveen S.; Huh, Susanna Y.; Silverman, Alan; Lukens, Colleen T.; Dodrill, Pamela; Cohen, Sherri S.; Delaney, Amy L.; Feuling, Mary B.; Noel, Richard J.; Gisel, Erika; Kenzer, Amy; Kessler, Daniel B.; Kraus de Camargo, Olaf; Browne, Joy; Phalen, James A. Journal of Pediatric
Gastroenterology and Nutrition68(1):124-129, January 2019. doi: 10.1097/MPG.0000000000002188

Hanya untuk kalangan medis

 FAKTOR NUTRISI: Dampak bila tidak
adekuat
Goal Dysfunction Examples of Health Conditions
Macronutrient consumption Inadequate Energy • Undernutrition
Energy Excessive Energy# • Overweight#
Protein Inadequate Protein • Stunting
Fat Inadequate Fat • Impaired neurodevelopment
• Essential fatty acid deficiency
• Need for tube feeding
• Need for texture modification
Micronutrient consumption Inadequate Micronutrient • Rickets
Key micronutrients^ - calcium, Excessive Micronutrient# • Iron deficiency anemia
vitamin D, iron, zinc, vitamin C, • Impaired immune function
vitamin A, beta-carotene • Loss of appetite
• Scurvy
• Toxicity of vitamin A/beta-carotene#
• Other nutritional anemias
Consumption of other critical non- Inadequate water/fluid • Dehydration
nutritive elements Inadequate fiber • Constipation
Dietary diversity Inadequate dietary • Impaired social functioning
Normal dietary diversity for social diversity • Micronutrient deficiency
functioning^ • Macronutrient deficiency

Pediatric Feeding Disorder: Consensus Definition and Conceptual Framework

Legend: ^ will vary depending on sociocultural and nutritional beliefs and practices; # these are less common

Goday, Praveen S.; Huh, Susanna Y.; Silverman, Alan; Lukens, Colleen T.; Dodrill, Pamela; Cohen, Sherri S.; Delaney, Amy L.; Feuling, Mary B.; Noel, Richard J.; Gisel, Erika; Kenzer, Amy; Kessler, Daniel B.; Kraus de Camargo, Olaf; Browne, Joy; Phalen, James A. Journal of Pediatric
Gastroenterology and Nutrition68(1):124-129, January 2019. doi: 10.1097/MPG.0000000000002188

Hanya untuk kalangan medis

 MALNUTRISI pada PFD
• Definisi: asupan zat gizi tidak adekuat untuk memenuhi kebutuhan
nutrisi, menyebabkan defisit kumulatif energi, protein, atau nutrisi
mikro, yang dapat berdampak buruk terhadap pertumbuhan,
perkembangan dan kesehatan1
• Malnutrisi mempengaruhi 25% hingga 50% anak-anak dengan PFD2,3 dan
meningkat pada penyakit kronis atau gangguan perkembangan saraf 4
• Restriksi terhadap keanekaragaman pangan/dietary diversity yang
umum terjadi pada PFD memberikan konsekuensi nutrisi buruk lainnya.
Eksklusi keseluruhan kelompok makanan (seperti buah dan sayuran)
menyebabkan defisiensi mikronutrisi, bahkan dengan asupan
makronutrient yang cukup.

1. Mehta NM, Corkins MR, Lyman B, et al. Defining pediatric malnutrition: a paradigm shift toward etiology-related definitions. JPEN J Parenter Enteral Nutr 2013;37:460–81.
2. Ammaniti M, Lucarelli L, Cimino S, et al. Feeding disorders of infancy: a longitudinal study to middle childhood. Int J Eat Disord 2012;45:272–280.
3. Rommel N, De Meyer AM, Feenstra L, et al. The complexity of feeding problems in 700 infants and young children presenting to a tertiary care institution. J Pediatr Gastroenterol Nutr 2003;37:75–84
4 Becker P, Carney LN, Corkins MR, et al. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: indicators recommended for the identification and documentation of pediatric malnutrition
(undernutrition). Nutr Clin Pract 2015;30:147–61.

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 Faktor Feeding Skill
Altered feeding experiences due to illness, injury, or
developmental delay may lead to impairment of feeding skills.
Impairment (Body functions and impairments *) Dysfunction (Activities and participation/limitations and restrictions*)
Oral sensory functioning Limitation in oral feeding skills
 Under- or over-response to sensory aspects of liquids  Unable to consume age-appropriate liquid and food textures
and food textures inhibiting acceptance and/or  Unable to use age-appropriate feeding utensils and devices
tolerance  Unable to self-feed at age-appropriate expectations
Oral motor function  Unable to use age-appropriate mealtime seating
 Reduced strength, coordination, range of motion,  Requires more assistance or requires special strategies relative to other
timing inhibiting oral movements required for children of same age
acceptance, control, manipulation and/or oral transit  Prolonged mealtime duration
of liquids and food textures  Insufficient oral intake
Pharyngeal sensory processing and/or motor function Restrictions in mealtime participation due to safety concerns:
 Under- or over-response to bolus during pharyngeal  Adverse mealtime events (e.g. coughing, choking, gagging, vomiting,
transit or residue remaining post-swallow discomfort, stress, fatigue, refusal)
 Reduced strength, coordination, range of motion,  Adverse cardio-respiratory events (e.g. apnea, bradycardia, increased
timing impacting pharyngeal transit of liquids and work of breathing)
food textures  Aspiration
 Inhibiting efficient swallowing and/or airway
protection

Legend: * International Classification of Functioning, Disability, and Health (ICF) terminology

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 Faktor Psikososial
Psychosocial Restriction (Health Conditions and Problems*) Impact on Feeding Behaviors

Developmental (child and/or caregiver) • Learned aversion (child and/or caregiver)

• Delay • Stress/distress (child and/or caregiver)
• Disorder • Caregiver disengagement
Mental/Behavioral Health (child and/or caregiver) • Caregiver over-engagement
• Diagnosed disorder • Disruptive behavior
• Undiagnosed signs/symptoms of disorder • Food refusal (passive & active resistance)
• Deregulated temperament/personality characteristics • Gagging/vomiting
Social • Elopement/attempts to disengage or flee from meal
• Caregiver-child interaction problems • Food over-selectivity
• Cultural expectations are not commensurate with AAP • Failure to advance to age-appropriate diet or feeding habit
nutrition guidelines despite adequate skill
Environmental • Reliance on formula beyond expected chronological
• Disorganized/distracting feeding environment age
• Disorganized or poorly timed schedule of feedings • Failure to consume age-typical texture
• Access to food or other necessary resources • Not feeding self at age-typical level
• Inadvertent reinforcement of food refusal behavior • Grazing behavior
• Caregiver use of compensatory strategies to feed child

Legend: * International Classification of Functioning, Disability, and Health (ICF) terminology; AAP: American Academy of Pediatrics

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 Dampak negative feeding problem terhadap kesehatan anak

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 Manajemen masalah makan

• Evaluasi:
• Orang Tua : coping, bonding, kesehatan mental
• Pertumbuhan: Grafik tinggi, berat badan, rasio, laju pertumbuhan
• Riwayat Prenatal, Kelahiran, Faktor Risiko

Phalen. Pediatrics in Review, 2013

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 Algoritma pendekatan diagnosis dan tata
laksana masalah makan

Masalah
Red flags?
makan?

Gizi kurang Gizi baik

Feeding rules Feeding rules Feeding rules Feeding rules

benar salah salah benar

Inappropriate Inappropriate
Small eater feeding feeding Mispersepsi
practice practice

Sjarif et al. Pendekatan Diagnosis dan Tata Laksana Masalah Makan pada Batita di Indonesia. IDAI. 2014

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 Red flags
Kelainan struktural Masalah neurodevelopmental Masalah perilaku makan
• Kelainan rongga hidung & • Palsi serebral • Muntah/regurgitasi berulang
mulut • Malformasi Arnold-Chiari • Posisi Sandifer (back
• Kelainan laring & trakea • Meningomielokel arching)
• Kelainan esofagus • Disautonomia familial • Diare berulang / diare kronik
• Distrofi muskular / diare berdarah
• Miastenia gravis • Batuk > 2 minggu atau batuk
• Distrofi okulofaringeal >3 episode dalam 3 bulan
• Tampak
kesakitan/menangis/
menjengking saat diberi
makan
• Pucat
• Demam >2 minggu tanpa
penyebab jelas
• Pembesaran kelenjar getah
bening leher/inguinal/aksila
• Sesak saat minum

Chatoor I. Textbook of child and adolescent psychiatry.; 2004. p. 639-52.

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 Menentukan status gizi pada anak

WAZ, LAZ,
BMI
WHZ

0-5 tahun: 0-2 tahun:

WHO 2006 WHO 2006

5-18 tahun: 2-18 tahun:

CDC 2000 CDC 2000

UKK Nutrisi dan Penyakit Metabolik, 2011

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 WHO Anthro

Bisa dipilih bila

terdapat lebih dari 1
pengukuran untuk
melihat trend
masing-masing anak

https://www.who.int/childgrowth/software/en/

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 Sjarif et al. Pendekatan Diagnosis dan Tata Laksana Masalah Makan pada Batita di Indonesia. IDAI. 2014

Hanya untuk kalangan medis

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 Developmental Progression of Food Selectivity Based on Motor Skills

Phalen. Pediatrics in Review, 2013

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 Feeding Rules untuk Batita dan
Anak-anak

Phalen. Pediatrics in Review, 2013

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 Metode Pemberian Makanan

Phalen. Pediatrics in Review, 2013

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 Kebutuhan Kalori
Usia tinggi (tahun) Energi (kkal/kg/hari)

• Berdasarkan perhitungan target 0-1 0 – 6 bulan: 120

BB ideal 6 – 12 bulan: 110

1-3 100

4-6 90

BB ideal x RDA 7-9 Lelaki: 80-90

Perempuan: 60-80
menurut usia tinggi
10-14 Lelaki: 50-70
Perempuan: 40-65

15-18 Lelaki: 40-50

Perempuan: 40

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 70%
MPASI

30%
Susu

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 Suplementasi Nutrisi Oral

• Suplementasi oral sebagai tambahan makanan

normal
• Dikelompokkan sebagai nutrisi enteral
• Komposisi : energi 0,9-1.2 kcal/ml (energi
standard) atau > 1.2 kcal/ml (energi tinggi), dan PKMK untuk Gagal Tumbuh, Gizi
protein 15-20% Kurang dan Gizi Buruk berupa oral
• Dapat berbentuk cair, bubuk, makanan penutup nutrition supplement dengan kandungan
atau batang/bars energi lebih besar dari 0,9 kkal/mL.

UKK Nutrisi dan Penyakit Metabolik, 2014

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Hanya untuk kalangan medis
 https://apps.who.int/iris/bitstream/handle/10665/43411/WHO_TRS_935_eng.pdf?ua=1

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 Clinical Evidence of ONS

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 Penambahan tinggi badan lebih banyak pada periode 3 bulan
terakhir pasca intervensi (median perubahan 4.43 cm pada 6
bulan; range 3.9–6.2 cm) dibandingkan dengan 3 bulan
petama (median perubahan 1.62 cm pada 3 bulan; range
1.52–2.25 cm)

Peningkatan tinggi badan signifikan (p<0.0001)

dari baseline ke bulan ketiga dan keenam

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 Berat badan meningkat secara stabil dari baseline ke bulan ke 3
(median perubahan 1.11 kg; range 0.91–1.40 kg) dan ke 6 (median
perubahan 1.81 kg; range 1.41–2.21 kg)

Peningkatan berat badan signifikan dari baseline (p<0.0001)

ke bulan ketiga dan keenam

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 Perubahan indicator antropometrik seiring waktu

Peningkatan Z Peningkatan Z
Peningkatan Z skor median skor median
skor median WAZ 0.65 unit WHZ 0.72 unit
HAZ 0.25 (range
0.09 hingga
0.623)

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 Prevalensi Status Stunted, Underweight, dan Wasting

40% anak pulih

dari stunted
berdasarkan HAZ
(p<0.0001)

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 ONS TERBUKTI KLINIS DUKUNG IMUNITAS DAN
PERTUMBUHAN

Pertambahan
Jumlah hari sakit tinggi (cm)

+ 50%
- 64% pertamba
hari han tinggi
sakit lebih
cepat

*Bila dikombinasikan dengan konseling diet pada anak anak *Bila dikombinasikan dengan konseling diet pada anak anak picky eater usia 3-5
Filipina usia 3-4 tahun dengan risiko malnutrisi tahun dengan risiko malnutrisi, dibandingkan dengan kontrol yang hanya
mendapat konseling gizi. Perbaikan tampak dalam 90 hari

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 Pemberian ONS: memperbaiki keragaman pangan
(peningkatan diversity score)

a
p<0.0001, b p=0.0680, Signed rank test  and controlled for multiple
comparisons using Stepdown Bonferroni adjustment
After excluding milk, milk product and oral nutritional supplement
Huynh et al., J Hum Nutr Diet. 2015 Epub

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 Rangkuman
• Masalah makan meningkatkan risiko perlambatan pertumbuhan
pada anak
• Small eater memiliki proporsi besar dalam masalah makan pada anak
• Rekomendasi tata laksana untuk small eater: feeding rules dan
suplementasi nutrisi oral
• Pemberian suplementasi nutrisi oral terbukti klinis memperbaiki
status pertumbuhan pada anak

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