Clinical Anatomy_ Applied Anatomy for Students and Junior Doct.pdf

Grant’s Dissector.pdf

ANESTHESIOLOGY
Barash Clinical Anesthesia 5th ed.pdf
Miller’s Anesthesia.pdf

BIOCHEMISTRY
Harper’s illustrated biochemistry 26ed.pdf
Harper’s illustrated biochemistry 27th edition.chm
Color Atlas of Biochemistry 2nd Ed J.Koolman K-H. Roehm Thieme 2005.pdf

CARDIOLOGY
ABC of Interventional Cardiology.pdf
Advanced Interventional Cardiology.pdf
Gulizia – Emerging Pathologies in Cardiology.pdf
Cannon – Critical Pathways in Cardiology 2001.pdb
Cardiology cd.exe
Wagner – Marriott’s Practical Electrocardiography 10th ed.pdb

CLINICAL EPIDEMIOLOGY
Basic Epidemiology – Beaglehole , Bonita.pdf
Clinical_Epidemiology__Robert_Fletcher.pdf
Pinciples of Epidemiology, An Introduction to Applied

evidence_base_of_clinical_diagnosis.pdf

Evidence-Based Imaging – Optimizing Imaging in Patient Care.pdf

Evidence-based Medicine Workbook.pdf

Evidence Based Practice in Primary Care [ILLUSTRATED].pdf

DERMATOLOGY
Atlas of Dermatology Schering Co USAss.pdf
Fitzpatrick – Dermatology 5th ed 2005.CHM
Fitzpatrick’s Dermatology In General Medicine 6th ed.pdb
Hall – Sauer’s Manual of Skin Diseases 8th ed.pdb

Handbook of Skin Diseases.pdf

EMERGENCY MEDICINE & ICU
Wolfson – The Clinical Practice of Emergency Medicine 3rd ed.pdb
Pediatric Emergency Medicine. (a comperhensive study guide). 2nd eition,2007.CHM
An Introduction to Clinical Emergency Medicine.pdf
Cline – Emergency Medicine – A Comprehensive Study
Intensive and Critical Care Medicine.pdf
Irwin and Rippe’s Intensive Care Medicine 5th ed.pdb
Noble – Textbook of Primary Care Medicine 3rd ed
Field Guide to Bedside Diagnosis, 2e 2006.CHM.part
Rosen’s Emergency Medicine.chm

ENDOCRINOLOGY
Williams Textbook of Endocrinology 10ed.pdf
Handbook of Diagnostic Endocrinology.pdf

FAMILY MEDICINE & GERIATRICS
CURRENT Diagnosis & Treatment in Family Medicine.chm
Evans – Oxford Textbook of Geriatric Medicine.pdb
Geriatric Medicine An Evidence-based Approach.pdf

HEMATOLOGY & IMMUNOLOGY
Modern Hematology Biology and Clinical Management 2nd ed.pdf
Oxford Handbook of Hematology.pdf
Color Atlas of Hematology.pdf
Wintrobe’s Clinical Hematology 11th.pdb
Adelman – Manual of Allergy and Immunology Diagnosis.pdb
World of Microbiology and Immunology.pdf
HISTOLOGY
Histology Image Review.CHM
Junqueira Carneiro – Basic Histology Text and Atlas 11ed.chm
Kuehnel – color atlas of cytology, histology and microscopic anatomy.pdf

INTERNAL MEDICINE

Harrison’s principles of internal medicine 17ed.chm
Harrison’s principles of internal medicine 16ed.pdf
Harrison_s_Manual_of_Medicine_16th_Edition.pdf
Cecil – Textbook of Medicine.pdf
Kelly’s Textbook of Medicine.pdb
Mayo Clinic Internal Medicine Concise Textbook.pdf
Lippincott.Wilkins.&.Williams.Yamada’s.Textbook.of.Gastroenterology.pdf
Schrier – Manual of Nephrology Diagnosis and Therapy 5th ed.pdb
Bates guide to physical examination+MCQs.pdf

Clinical Interviewing.pdf

Clinical Medicine – 6th edition.pdf

LR – Pocket Medicine 3rd Edition.pdf

Problem Solving in Clinical Medicine.pdf

MICROBIOLOGY
Jawetz, Melnick, & Adelberg’s Medical Microbiology, 24th Ed 2007 McGraw Hill.chm
Laboratory Exercises In Microbiology.pdf
Clinical Microbiology made simple.pdf
The Desk Encyclopedia Microbiology.pdf
Lippincott Illustrated Reviews_Microbiology
Essential Microbiology.pdf
Glazer Microbial Biotechnology – Fundamentals of Applied Microbiology 2nd ed.pdf

World of Microbiology and Immunology.pdf

NEUROANATOMY & NEUROLOGY
Snell’s clinical neuroanatomy
Neuroanatomy An Atlas of Structures, Sections, and Systems – Duane E. Haines.pdf
Adams and Victor’s Principles of Neurology 8th.pdf
Atlas of functional neuroanatomy 2nd ed.pdf

Cranial Nerves Functional Anatomy (2005).pdf

Differential Diagnosis in Neurology and Neurosurgery.pdf

Goetz textbook of neurology.pdb
The Clinical Science of Neurologic Rehabilitation (Contemporary Neurology Series, 66) (2003).pdf
Neuroanatomy – Atlas of Structures Sections Systems 6ed.pdf
Neuroscience – D.Purves, et al.pdf
Merritt – Merritt’s Neurology 10th Ed.pdb
Handbook of Neurology.CHM

Nervous System and Sensory Organs – Color Atlas and Textbook of Human Anatomy – Volume 3.pdf

OBSTETRICS-GYNECOLOGY
Benson Pernolls Handbook of Obstetrics-Gynecology.pdf
Williams Obstetrics 22nd Edition.pdf
Berek & Novak’s Gynecology 14th ed.pdf
Novak’s Gynecology 13ed.pdb
Obstetrics And Gynecology At A Glance.pdf
Stenchever – Comprehensive Gynecology 4th ed – Big Images.pdb
Havens – Manual of Outpatient Gynecology 4ed.pdb
The Johns Hopkins Manual of Gynecology and Obstetrics 2nd ed.pdb

Obstetrics and Gynecology An Illustrated Colour Text.pdf

ONCOLOGY

Weinstein Pediatric Oncology – Pediatric_Lymphomas.pdf

Manual of Pediatric Hematology and Oncology.pdf

Berek Practical Gynecologic Oncology 3ed.pdb

Rosenberg – Cancer – Principles and Practice of Oncology 6th.pdb

Pizzo – Principles and Practice of Pediatric Oncology 4th Ed.pdb

ORTHOPEDICS & RHEUMATOLOGY
MILLER’S_REVIEW_OF_ORTHOPEDICS.pdf
Manual of Rheumatology and Outpatient Orthopedic Disorders Diagnosis and Therapy 4th ed.pdb
Kelley’s Textbook of Rheumatology 6th Edition, 2-Volume Set – ISBN.pdb
DeLee and Drez’s – Orthopaedic Sports Medicine. Editor DeLee (2nd Ed. 2003).pdb
Current Diagnosis & Treatment in Orthopedics 3rd ed.pdb

Pediatric Orthopedics for Primary Care Physicians.pdf

Pediatric Orthopedics in Practice.pdf

PARASITOLOGY
Gillespie & Pearson – Principles and Practice of Clinical Parasitology 2001
Clinical Parasitology.pdf
Dictionary of Parasitology.pdf

PATHOLOGY
Robbins Pathologic Basis of Disease 7th ed 2005.pdf
stedmans Pathology&Lab medicine
Scott_Tietz’s Applied Laboratory Medicine 2nd ed.pdf
Ravel – Clinical Laboratory Medicine – Clinical Applications.pdb

PATHOPHYSIOLOGY OF DISEASE.pdf

PEDIATRICS
Nelson Textbook of Pediatrics 17th ed.pdf
Nelson Essentials of PEDIATRICS.CHM
Current Strategies in Pediatrics 2004.pdf

Pediatric.Musculoskeletal.Disease.pdf

Pediatric.Radiography.3HAXAP.pdf

Treatment.of.Pediatric.Neurologic.Disorders.3HAXAP.pdf

PHARMACOLOGY
Katzung basic clinical pharmacology 10ed.pdf
Katzung basic clinical pharmacology 9ed.pdf
Basic Clinical Pharmacology – 10th Ed.chm
Color Atlas of Pharmacology 3rdEd.pdf

Color Atlas of Pharmacology.pdf
Color Atlas Of Pharmacology,2Nd Ed (By H Lullmann Et Al ,Thieme 2000,Isbn 0865778434).pdf
Lippincott Illustrated Reviews_Pharmacology 2nd ed 2000
Edwards – Principles and Practice of Pharmaceutical Medicine 2nd ed.pdf
Goodman Gilman’s – The Pharmacological Basis of Therapeutics 11th Edition

PHYSIOLOGY
Review of Medical Physiology 21 Edition -William F. Ganong.chm
Physiology – Berne and Levy – 5th Edition.chm
physiology – Guyton.pdf

PSYCHIATRY
Kaplan & Sadock’s Comprehensive Textbook of Psychiatry (2 Volume Set) 7th Ed (Lippincott Williams & Wilkins).pdf
Lewis – Child and Adolescent Psychiatry A Comprehensive Textbook 4th Edition

RADIOLOGY
Dahnert – radiology review manual 4th ed.pdf
Getting Started in Clinical Radiology – from Image to Diagnosis.pdf
Emergency Radiology.pdf
WHO manuals of diagnostic imaging – Radiographic Anatomy and Interpretation of the Musculoskeletal System.pdf
Churchill Livingstone – 2001 – Grainger & Allison’s Diagnostic Radiology. A Textbook of Medical I.pdb

SURGERY
Schwartz Manual of Surgery 8ed.pdf
Oxford Textbook of Surgery (2ed).pdf
Clinical Surgery in General R.M.Kirk 4th Ed 2004.pdf
Wilmore – ACS Surgery – Principles and Practice 2nd ed.zip
Morris – Oxford Textbook of Surgery 2nd ed.pdb
Sabiston Textbook of Surgery, 16th Edition.pdf

Current Surgical Diagnosis and Treatment 11ed With images.pdb
MANUALS, DICTIONARIES, ATLAS
Current Clinical Strategies. Physicians’ Drug Manual. Side Effects, Drug Interactions, and Newly Approved Drugs. 2003 Ed.pdf
Dale – Infectious Diseases The Clinician’s Guide to Diagnosis, Treatment, and Prevention – Big Images.pdb
Bennett and Brachman’s Hospital Infections (Lippincott, 2007).chm
LR – Pocket Medicine 3rd Edition.pdf
Lippincott Williams Wilkins 2003 Medical Terminology An Illustrated Guide 4th Ed.pdf
Merck Manual 17th.Ed.pdb
Pocket Atlas of Radiographic Anatomy 2nd ed, 2000.pdf
Pocket Guide to Diagnostic Tests-0838581358.pdf
Pocket.Guide.to.Musculoskeletal.Diagnosis.3HAXAP.pdf
Oxford Textbook Of Rheumatology, 2nd ed (1998).pdb
Oxford_textbook_of_public_health_4th_ed.pdb
Manual of Clinical Problems In Pediatrics 5th Edition (2000).pdb
Manual of Family Practice 2nd ed.pdb
Ferri’s Clinical Advisor 2004 – Instant Diagnosis and Treatment. 6th edition.pdb
Pocket Atlas of Echocardiography.pdf
Pocket Atlas Of Radiographic Anatomy 2d ed – Torsten B. Moller, Emil Reif.pdf
Pocket_Atlas_of_Human_Anatomy__H._Feneis__W._Dauber._4th_Ed._2000_.pdf
Pocket guide to diagnostic tests.chm
Stedman’s Electronic Medical Dictionary 6th Edition.pdf
Colour Atlas of Anatomical Pathology.pdf
Glossary of Biotechnology Terms, Third Edition.pdf
Clinical Neuropathology Text and Color Atlas.pdf
An Atlas Of Back Pain.pdf
An Atlas of Headache.maxiwarez.pdf
Atlas of Clinical Diagnosis 2nd Ed (2003).pdf
Henry Clinical Diagnosis and Management by Laboratory Methods 21st ed.chm

FLASH CARDS
- ANATOMY (NETTER)
- ANATOMY (ROHEN’S)
- PATHOLOGY
- PHARMACOLOGY

ABC SERIES

ABC of AIDS.pdf
ABC of Antenatal Care.pdf
ABC of Antithrombotic Therapy.pdf
ABC of Arterial and Venous Disease.pdf
ABC of Burns.pdf
ABC of Clinical Electrocardiography.pdf
ABC of Clinical Genetics.pdf
ABC of Clinical Haematology.pdf
ABC of Colorectal Cancer.pdf
ABC of Conflict and Disaster.pdf
ABC of Dermatology.pdf
ABC of Diabetes.pdf
ABC of Eyes.pdf
ABC of First Year.pdf
ABC of Heart failure.pdf
ABC of Intensive Care.pdf
ABC of Interventiona Cardiology 2004.pdf
ABC of Learning Teaching Medicine.pdf
ABC of Nutrition, 4th Edition.pdf
ABC of Occupational and Environmental Medicine.pdf
ABC of Preterm Birth.pdf
ABC of Psychological Medicine.pdf
ABC of Resuscitation.pdf
ABC of Sexually Transmitted Infections.pdf
ABC of Spinal Cord Injury 4th Ed.pdf
ABC of Subfertility.pdf
ABC of the Liver Pancreas and Gall Bladder.pdf
ABC of the Upper Gastrointestinal.pdf

—————————————————————
US MLE REVIEW SERIES

anatomy.pdf
basic epidemiology -beaglehole,bonita.pdf
behavioral sciences.pdf
beyond basic resp.pdf
biochemistry.pdf
clinical anatomy 11ed.pdf
clinical epidimiology -robert fletcher.pdf
kaplan lecture notes.pdf
lecture on visuals.pdf
microbiology,immunology.pdf
pathology.pdf
pharmacology.pdf
physiology.pdf
principles of epidemiology.pdf
Qbook.pdf
upper extremities cadaver pics.pdf
kaplan medical timeline.pdf

OTHERS:

1. Journal Medical Passwords 2003.pdf
——————————————————
1. Anatomy.tv – Anatomy Study Guides.chm
2. Cranial_Nerves_Functional_Anatomy.pdf
3. Outline of Biology – Fried, George H..pdf
——————————————————
1. Gray’s Anatomy for Students.chm
2. Chest Radiology The Essentials, 2nd Edition.CHM
3. Clinical Anatomy by Regions – 8th Ed.CHM
4. Grant’s Dissector.pdf
5. Clinical Radiology Made Ridiculously Simple (MedMaster Series 2003 Ed
6. Clinical Anatomy_ Applied Anatomy for Students and Junior Doct.pdf
7. The Medical Student’s Guide to the Plain Chest Film.pdf
——————————————————
1. Clinical Interviewing 3rd edition.pdf
2. What They Didnt Teach You at Medical School.pdf
3. Medical English.pdf
4. Medical Law and Moral Rights (Springer, 2005).pdf
5. Neuroethics.pdf
——————————————————
1. Ferri’s Clinical Advisor 2008_ Instant Diagnosis and Treatment.CHM
2. Current Medical Diagnosis & Treatment 2007, 46th Ed.chm
3. Handbook of Neurology.CHM
4. Professional Guide to Signs and Symptoms – 5th Ed.chm
5. Colour Atlas of Anatomical Pathology.pdf
6. Glossary of Biotechnology Terms, Third Edition.pdf
7. Clinical Neuropathology Text and Color Atlas.pdf
8. An Atlas Of Back Pain.pdf
9. An Atlas of Headache.maxiwarez.pdf
10. Atlas of Clinical Diagnosis 2nd Ed (2003).pdf
11. Atlas of functional neuroanatomy 2nd ed.pdf
12. Kahle, Color Atlas of Human Anatomy, vol 3 (2003).pdf
13. Neuroanatomy An Atlas of Structures, Sections, and Systems – Duane E. Haines.pdf
14. Pocket Atlas of Echocardiography.pdf
15. Pocket Atlas Of Radiographic Anatomy 2d ed – Torsten B. Moller, Emil Reif.pdf
16. Pocket_Atlas_of_Human_Anatomy__H._Feneis__W._Dauber._4th_Ed._2000_.pdf
17. Stedman’s Electronic Medical Dictionary 6th Edition.pdf
——————————————————
1. Skill 01[1].Temperature..pdf
2. Skill 02[1]..Pulse.pdf
3. Skill 03[1]..Respiration.pdf
4. Skill 04[1]..Blood Pressure.pdf
5. Skill 05[1]..Pulse Oximetry.pdf
6. Skill 06[1]..Capillary Blood Draw.pdf
7. Skill 07[1]..Venipuncture.pdf
8. Skill 08[1]..Blood Draw from a Central Venous Catheter.pdf
9. Skill 09[1]..Nasopharyngeal Swab.pdf
10. Skill 10[1]..Throat Culture.pdf
11. Skill 11[1]..Collection of Stool Specimen.pdf
12. Skill 12[1]..Collection of Urine Specimen.pdf
13. Skill 13[1]..Collection of a Midstream.pdf
14. Skill 14[1]..Assisting with Child during Bone Marrow.pdf
15. Skill 15[1]..Assisting with Child during Lumbar Puncture.pdf
16. Skill 16[1]..Assisting with Collection of Cerebrospinal.pdf
17. Skill 17[1]..Sponge Bath.pdf
18. Skill 18[1]..Insertion of a Peripheral IV Line.pdf
19. Skill 19[1]..Dressing Change Central Venous Line.pdf
20. Skill 20[1]..Insertion of a Nasogastric Tube.pdf
21. Skill 21[1]..Management of Gastrointestinal Suction.pdf
22. Skill 22[1]..Nasogastric Tube Irrigation.pdf
23. Skill 23[1]..Nasogastric Tube Lavage.pdf
24. Skill 24[1]..Administration of a Bolus Feeding.pdf
25. Skill 25[1]..Administration of NG, NJ, Gastrostomy and.pdf
26. Skill 26[1]..Changing a Fecal Ostomy Appliance.pdf
27. Skill 27[1]..Emptying an Ostomy Pouch.pdf
28. Skill 28[1]..Administration of Enemas.pdf
29. Skill 29[1]..Urinary Catheterization.pdf
30. Skill 30[1]..Petaling a Cast.pdf
31. Skill 31[1]..Pin Site Care.pdf
32. Skill 32[1]..Care of the Child in an External Fixation.pdf
33. Skill 33[1]..Pin Care, External Fixation Device.pdf
34. Skill 34[1]..EVD Maintaining System at Correct Level and Functioning.pdf
35. Skill 35[1]..EVD Client Assessment.pdf
36. Skill 36[1]..EVD Monitoring Cerebrospinal Fluid (CSF).pdf
37. Skill 37[1]..EVD Changing the Drainage Bag.pdf
38. Skill 38[1]..EVD General Nursing Care and Safety.pdf
39. Skill 39[1]..Assisting with Chest Tube Insertion.pdf
40. Skill 40[1]..Preparing the Chest Tube Drainage System.pdf
41. Skill 41[1]..Care of the Child with a Chest Tube.pdf
42. Skill 42[1]..Assisting with Removal of Chest Tube.pdf
43. Skill 43[1]..Oxygen Administration.pdf
44. Skill 44[1]..Bulb Suctioning.pdf
45. Skill 45[1]..Nasotracheal Suctioning.pdf
46. Skill 46[1]..Tracheostomy Monitoring.pdf
47. Skill 47[1]..Tracheostomy Tube Change.pdf
48. Skill 48[1]..Tracheostomy Tube.pdf
49. Skill 49[1]..Tracheostomy Suctioning.pdf
50. Skill 50[1]..Endotracheal Tube Monitoring (ETT).pdf
——————————————————

Churchill Livingstone – 2001 – Grainger & Allison’s Diagnostic Radiology. A Textbook of Medical I.pdb
Classifications and Scores of the Shoulder – Habermeyer.pdf
Clinical Examination of Musculoskeletal System – Assessing Rheumatic Conditions.pdf
Clinical Interviewing.pdf
Clinical Orthopaedic Examination, Fifth Edition (2004).pdf
Clinical Tests for the Musculoskeletal System.pdf
Clinical.Anatomy.11ed.1405138041.Oct.2006.pdf
Clinical.Knowledge.Management.Opportunities.and.Challenges.pdf
clinical_evidence_vol_10.pdb
clinical_evidence_vol_9.pdb
clinical_laboratory_medicine_-_clinical_applications.pdb
Clinician’s Pocket Reference_0838515525.pdf
Color Atlas of Pharmacology.pdf
Color Atlas of Physiology.pdf
Common Symptom Answer Guide.pdf
Complementary Therapies in Neurology.pdf
Comprehensive Management of Chronic Obstructive Pulmonary Disease (2002) – COPD.iso
Core Topics in Pain.pdf
Cranial Nerves Functional Anatomy (2005).pdf
Current Diagnosis & Treatment in Orthopedics 3rd ed.pdb
Current Medical Diagnosis & Treatment, 2005 full pic.pdb
DeLee and Drez’s – Orthopaedic Sports Medicine. Editor DeLee (2nd Ed. 2003).pdb
Differential Diagnosis in Neurology and Neurosurgery.pdf
Drawing the Line. Art Therapy with the Difficult Client.pdf
Dynamics_of_Human_Gait.pdf
Electrodiagnosis in Diseases of Nerve and Muscle – Principles and Practice.chm
Elsevier’s Medical Terminology for the Practicing Nurse (1998).pdf
Encyclopedia of Infectious Diseases.pdf
Essentials of Complementary and Alternative Medicine.pdf
Essentials_of_Physical_Medicine_and_Rehabilitation.pdb
Evaluation of the Low Back Pain Practice Guideline Implementation in the Army.pdf
Evidence Based Practice in Primary Care [ILLUSTRATED].pdf
Evidence-Based Imaging – Optimizing Imaging in Patient Care.pdf
Evidence-based Medicine Workbook.pdf
evidence_base_of_clinical_diagnosis.pdf
Exercise Leadership in Cardiac Rehabilitation – An Evidence-based Approach – 0470019719.pdf
Ferri’s Clinical Advisor 2004 – Instant Diagnosis and Treatment. 6th edition.pdb
Foundations of Sport-Related Brain Injuries.pdf
Fractures_Classification_in_Clinical_Practice__2006_.pdf
Fractures_in_children_5ed.pdb
Functional Neuroanatomy of Pain.pdf
General Practice, 3rd Edition (J. Murtagh).pdb
Geriatric Medicine An Evidence-based Approach.pdf
Hand Bone Age.pdf
Handbook of couples therapy.pdf
Healing or Stealing. Medical Charlatans in the New Age.pdf
Healing_Back_Pain_The_Mind.pdf
How to Present at Meetings 2001.pdf
How to Read a Paper.pdf
Human Biology_0071218068.pdf
Human Body Dynamics – classical mechanics and human movement – A.Tozeren.pdf
Image-guided spine interventions.pdf
Information Technologies in Medicine – Volume I.pdf
Instant Pain Control – Using the Body’s Trigger Points.djvu
Interpretation of Diagnostic Tests 7th ed.pdb
Interviewing And Diagnostic Exercises For Clinical And Counseling Skills Building – ISBN 08058464.pdf
Kelley’s Textbook of Rheumatology 6th Edition, 2-Volume Set – ISBN.pdb
Lab Notes Guide to Lab and Diagnostic Tests (2005).pdf
Learning_Medicine_An_Informal_Guide_to_a_Career_in_Medicine.pdf
Living well with Parkinson’s.pdf
Lovell_and_winter_s_pediatric_orthopaedics_3rd_ed.pdb
Managing the symptoms of multiple sclerosis.pdf
Managing Your Multiple Sclerosis.pdf
Manual of Clinical Problems In Pediatrics 5th Edition (2000).pdb
Manual of Family Practice 2nd ed.pdb
Manual of Rheumatology and Outpatient Orthopedic Disorders Diagnosis and Therapy 4th ed.pdb
Marketing health services.pdf
Massage For Dummies.pdf
MCQ.Companion.to.Applied.Radiological.Anatomy.3HAXAP.pdf
Means Ends and Medical Care.pdf
Medical and Psychosocial Aspects of Chronic Illness and Disability, Third Edition (2005).pdf
Medical Malpractice – A Physician’s Sourcebook.pdf
Medical_Physiol_2nd_Ed.pdf
Merritt – Merritt’s Neurology 10th Ed.pdb
MILLER’S_REVIEW_OF_ORTHOPEDICS.pdf
Modern Neuromuscular Techniques (Modern Neuromuscular Techniques (WCD)) (2003).ISO
MP Van De Graaff Human Anatomy.pdf
Musculoskeletal.Diseases.DIAGNOSTIC IMAGING AND INTERVENTIONAL TECHNIQUES.pdf
Nelson.Textbook.of.Pediatrics.17th.ed – Behrman.pdb
Nervous System and Sensory Organs – Color Atlas and Textbook of Human Anatomy – Volume 3.pdf
Neuroanatomy – Atlas of Structures Sections Systems 6ed.pdf
Neuroscience – D.Purves, et al.pdf
Neurotransmitters, Drugs and Brain Function Wiley (2001).pdf
Nurses manual of laboratory and diagnostic tests 4th Ed 2003.pdf
Nursing practice in multiple sclerosis – a core curriculum.pdf
Occupational Health Practice – Arnold.Publishers.Fourth.EditionISBN0750627204.pdf
Opportunities in Physician Careers_0071438483.pdf
Outpatient and Primary Care Medicine, 2005 Edition (2004).pdf
Oxford Textbook Of Rheumatology, 2nd ed (1998).pdb
Oxford_Dictionary_of_Medical_Quotations.pdf
Oxford_textbook_of_public_health_4th_ed.pdb
Pediatric Musculoskeletal Diseases.pdf
Pediatric Radiography.pdf
Pain and Depression – An Interdisciplinary Patient-centered Approach.pdf
Pain.Medicine.and.Management.Just.the.Facts.pdf
Pain.Psychological.Perspectives.eBook-DDU.pdf
PATHOPHYSIOLOGY OF DISEASE.pdf
Pediatric Orthopedics for Primary Care Physicians.pdf
Pediatric Orthopedics in Practice.pdf
Physical Medicine and Rehabilitation Board Review.pdf
Pocket Atlas of Radiographic Anatomy 2nd ed, 2000.pdf
Pocket Guide to Diagnostic Tests-0838581358.pdf
Pocket.Guide.to.Musculoskeletal.Diagnosis.3HAXAP.pdf
Primary_care_medicine_office_evaluation_and_managem.pdb
Principles.and.Practice.of.Burn.Surgery.3HAXAP.pdf
Quick reference dictionary for massage therapy and bodywork.pdf
Robbins Pathologic Basis of Disease (with pictures).pdb
Rosen’s Emergency Medicine.chm
Scientific Writing Easy When You Know How (2002).pdf
Screening Notes Rehabilitation Specialists Pocket Guide (Davis Notes S) ISBN0803615736.pdf
Soft Tissue Rheumatology.CHM
Sports Injuries – Mechanisms, Prevention, Treatment. 2nd edition.pdb
SPORTS MEDICINE Just the Facts.pdf
strength training anatomy.pdf
Stretching – anderson bob.pdf
Super Joints Russian Longevity Secrets for Pain-Free Movement, Maximum Mobility & Flexible Strength (2001).pdf
Symptoms of Unknown Origin.pdf
T’Ai Chi for Seniors. How to Gain Flexibility, Strength, and Inner Peace .pdf
Textbook of Clinical Trials Wiley (2004).pdf
Textbook of Medical Physiology.pdf
Textbook Of Physical Diagnosis History – Examination Swartz.djvu
The Aging Spine.pdf
The A-Z Medical Writing.pdf
The Circuitry of the Human Spinal Cord_Its Role in Motor Control and Movement Disorders_0521825814.pdf
The Clinical Drug Therapy Rationales for Nursing Practice (Field Guide Series) (2006).pdf
The Clinical Science of Neurologic Rehabilitation (Contemporary Neurology Series, 66) (2003).pdf
The Coiled Spring.pdf
The Handbook of Brain Theory and Neural Networks – ISBN 0262511029.pdf
The healthcare quality book- vision, strategy, and tools.pdf
The Massage connection – ANATOMY AND PHYSIOLOGY.pdf
The Trigger Point Therapy Workbook – Your Self-Treatment Guide for Pain Relief – Clair Davies.pdf
The.Ultimate.New.York.Body.Plan.eBook-TLFeBOOK.pdf
TMJ Disorders and Orofacial.doc
Toward.Replacement.Parts.for.the.Brain.Implantable.Biomimetic.Electronics.PDF.eBook-YYePG.pdf
Trauma.E.Moore, et al – 5th edition.pdb
Treating Pediatric Bed-wetting With Acupuncture & Chinese Medicine.pdf
Treatment of Osteoarthritic Change in the Hip – Joint Preservation or Joint Replacement.pdf
Treatment.of.Pediatric.Neurologic.Disorders.3HAXAP.pdf
Tyranny of Health Doctors and the Regulation of Lifestyle.pdf
Understanding Human Anatomy and Physiology 5th edition.pdf
Using Alternative Therapies – A Qualitative Analysis.pdf
Visions of the Future. Chemistry and Life Science.pdf
Weight Training Basics.pdf
What They Didn’t Teach You at Medical School.pdf
What’s Wrong With Me – The Frustrated Patients’ Guide to Getting an Accurate Diagnosis.pdf
When.Walking.Fails.eBook-DDU.pdf
WHO manuals of diagnostic imaging – Radiographic Anatomy and Interpretation of the Musculoskeletal System.pdf
Who s who in orthopedics.pdf
World of Microbiology and Immunology.pdf
Writing Skills in Practice (Health Professionals).pdf

Supported  by
CLINICAL PEDIATRIC ONLINE

Yudhasmara Foundation

JL Taman Bendungan Asahan 5 Jakarta Indonesia 102010

phone : 62(021) 70081995 – 5703646

email : judarwanto@gmail.com,

http://clinicalpediatric.wordpress.com/

Clinical and Editor in Chief :

DR WIDODO JUDARWANTO

Copyright © 2009, Clinical Pediatric Online Information Education Network. All rights reserved.

Supported  by
CLINICAL PEDIATRIC ONLINE

Yudhasmara Foundation

JL Taman Bendungan Asahan 5 Jakarta Indonesia 102010

phone : 62(021) 70081995 – 5703646

email : judarwanto@gmail.com,

http://clinicalpediatric.wordpress.com/

Clinical and Editor in Chief :

DR WIDODO JUDARWANTO

Copyright © 2009, Clinical Pediatric Online Information Education Network. All rights reserved.

Consequences of disturbed nutrition during a vulnerable period

Adolescents must be adequately nourished to ensure their growth and development progresses normally and continuously.  Monitoring and modifying the wide swings in nutritional status during the course of eating disorders in order to maintain normal growth and development requires specific knowledge. The most sophisticated techniques available to the physical health and social sciences today must be applied to help teenagers change disturbed eating behaviors that impair their nutritional health;  behaviors not included in diagnosable syndromes as well as those which are included.  Knowledge and expertise regarding treatment for these complicated problems is expanding.  Principal nutritional aspects of anorexia nervosa and bulimia nervosa, documented through research and practitioner consensus, are reviewed here. 

Eating Disorders:  Prevalence 

The number of adolescents with diagnosed anorexia nervosa or bulimia nervosa is growing and many adolescents with various eating disorders and disordered eating behaviors remain undiagnosed and untreated.  Uncounted teenagers preparing to be models, entertainers, dancers, gymnasts, jockeys and other athletes who manipulate their weight also suffer from long-term effects of chronic malnutrition, whether they do or do not meet the criteria for anorexia nervosa or bulimia nervosa.  They may be categorized as having an “Eating disorder not otherwise specified” when they have combinations of symptoms that do not fit the exact criteria of the other described eating disorders.

Eating Disorders:  Characteristics

Spectrum of physical characteristics seen among adolescents with eating disorders.  Those with acute anorexia nervosa are usually among the thinnest and the developmentally obese* among the heaviest.  Adolescents across the spectrum are affected by various underlying psychosocial disturbances.  While the physical aspects may obviously require treatment, interventions should be directed to all aspects of these complex conditions, not solely the physical symptoms.
(Modified from Rees JM: Eating disorders.  Copyright Mahan LK, Rees JM Seattle, Wash, 1989. Originally published in Mahan LK, Rees JM: Nutrition in Adolescence, St. Louis, 1984, Times Mirror/Mosby.)
*Note:  The developmental obesity referred to develops through specific family interaction from birth (described by Hilde Bruch in 1973 – Eating Disorders: New York, Basic Books).  It is one of the many types of obesity, a condition with many etiologies.

Physically, adolescents with eating disorders form a spectrum, from the extremely thin to the extremely heavy, as the drawing above illustrates.  Between the extremes are various types of  physiques.  Along the spectrum, adolescents with disordered eating behaviors have underlying problems interfering with normal nourishment; they use food inappropriately.  Food related behaviors and associated deviation in body weight are two obvious characteristics of these disorders.  These outward symptoms are obvious to the affected adolescent, the public, and  health professionals. Understanding the underlying neuro-physical and psycho-developmental issues is essential to dealing adequately with the disorders.

Background:  Physical growth and development. 

Rapid physical growth and development in adolescence constitute the unique background for development of eating disorders at this stage of life. Self-esteem problems intensify in many normal young women in the process of doubling their body weight, increasing the percent of body fat, gaining about 4 inches in height, developing breasts and acquiring other features of the mature female body, as well as experiencing menarche.  Given that this development occurs within a 6-8 year period, the rapidity of change contributes to the difficulty of the task of acceptance.

The intensity of physical growth and development also accounts for the vulnerability of any adolescent to long-term consequences if they experience semi-starvation.  All organisms are subject to the greatest harm from food deprivation at periods when they are synthesizing tissue;  they need nutrients to build into tissues and food energy to fuel the process.  Human teenagers are no exception to this basic biological rule.

Background:  Body image and psychosocial development

Adapting a mental image of one’s unique body (the body image) is a basic feature of adolescent development.  Body image distortion is a core characteristic of anorexia nervosa and bulimia nervosa.  Thus, these disorders are commonly seen in adolescence, the period when young people are vulnerable to body image problems. Whether as cause or effects, progress in adopting adult body image is interrupted for the teenager with an eating disorder. 

Teenagers with severe eating disorders also fail in varying degrees to accomplish other psychosocial developmental tasks of adolescence. The most striking of the developmental problems first described by Hilde Bruch in 1973 (Eating Disorders.  New York, Basic Books) is a struggle to develop autonomy.
 

• Inability to develop and use formal operational thought processes, especially in reference to themselves.
• Inability to experience bodily sensations originating within themselves as “normal” and “valid”.
• Unrealistic perceptions of body size.
• Preoccupation with weight and food, reflecting dependence on social opinion and judgment.
• Failure to normalize eating and exercise patterns.
• Unrealistic expectations for themselves.
• Failure to develop autonomy.
• Difficulty in accomplishing the normal psychosocial tasks of adolescence.

Background:  Etiology 

For many adolescents disturbed eating has developed slowly throughout earlier life, though seeming to appear suddenly in adolescence.  The origin of eating disorders is very complex. Individual and familial, biological and psychological characteristics contribute.  Cultural values combined with eating habits common in modern societies create a milieu that is said to foster eating problems.  To reflect the multiple influencing factors, eating disorders are said to have a multi-factorial etiology.

Anorexia Nervosa: Symptoms

The term anorexia nervosa is actually a misnomer.  Affected adolescents ignore and even lose their hunger sensations.  The motivation to be thin apparently keeps these adolescents from eating.  Since an early description (in 1689), a combination of symptoms has come to be regarded as characteristic of anorexia nervosa, although certain of these symptoms may be seen in other disorders.  The unique combination of symptoms in anorexia nervosa has been defined by the American Psychiatric Association (APA)
A description appears below, including considerations suggested by adolescent eating disorder specialists (in brackets and capital letters), making it applicable to most adolescents.
 

• Refusal to maintain body weight at or above minimal normal weight for age and height
• Loss or failure to gain weight with maintenance weight 15% below expected [FOR AGE APPROPRIATE DEVELOPMENTAL STAGE]
• Fear of gaining weight or becoming fat, although underweight [OR APPARENTLY NORMAL WEIGHT WITHOUT SUFFICIENT BODY FAT STORES FOR AGE APPROPRIATE DEVELOPMENT STAGE]
• Disturbed experience or evaluation of body weight, size, or shape 
• Feeling fat [OR THAT BODY PARTS ARE FAT], although underweight [OR AT UNHEALTHY WEIGHT FOR AGE APPROPRIATE DEVELOPMENT STAGE]
• Absence of three consecutive menstrual* cycles not relying on estrogen in post-menarcheal females [OR FAILURE TO ACHIEVE MENARCHE* AND ESTABLISH MENSES* AT AN APPROPRIATE AGE]
  * In all cases females are considered amenorrheic when menses do not occur unless induced by estrogen replacement.

“A relentless pursuit of thinness” and “a misuse of the eating function in efforts to solve or camouflage problems that otherwise would appear insolvable” underlies these symptoms as pointed out by Hilde Bruch in her classic description in 1973 (Eating Disorders.  New York, Basic Books).  In summary, the adolescent with a severe eating disorder suffers from arrested physical and psychological growth and development. (Because most patients are females, the feminine pronoun will be used in this discussion.)

Anorexia Nervosa:  Overall prevalence

Although recent precise figures are not available, as many as 1% of American teenaged females, 15 – 19 years of age, are said to suffer from anorexia nervosa.  The majority of persons with anorexia nervosa are adolescents, although the disease affects young adults and other age groups.  The disorder is supported by a cultural paradox:  food is abundant and used lavishly for purposes other than survival and on the other hand slimness is highly valued.  These cultural values are strong internal messages for many in the modern world.  The impact is great on a young adolescent who has not developed autonomy.

Anorexia Nervosa:  Prevalence in females 

About 1% of average high school aged girls in the US and England are thought to be affected.  It must be recognized, however, that accurate data are difficult to obtain because of the secretive nature of the disorder and the fact that many do not seek treatment. 

Anorexia Nervosa:  Prevalence in males 

The disorder is not common among males, with only about 5% to 10% of diagnosed cases being males less than 14 years.  Of cases diagnosed in older adolescents, 19% to 30% are in males.  Males with anorexia nervosa seem to have the same sort of disorder as females. The traditional lack of value on extreme slimness in males adolescents probably puts them at a somewhat lower risk for the disorder.  Celebrities with excessively thin and/or muscular bodies are beginning to influence the ideals of young males, however.  Obsessive muscle building and exercise to the point of harming their bodies, may be the equivalent of anorexia nervosa in vulnerable male

The physical manifestation of anorexia nervosa may be sudden, although unrecognized underlying characteristics may have been present prior to manifestation of an identifiable disorder.  Intervention strategies should simultaneously address the psychological and physical issues of the adolescent.
 

Onset: Progressive development 

From the family’s point of view, the teenager with anorexia nervosa has traditionally been a “model child”.  She fits into the family and meets her parents’ high expectations, working extremely hard at school and being satisfied only with excellent grades.  Suddenly she displays a compulsive attitude about her weight and food consumption.  The family erupts in crisis as response to her extreme eating behavior.

Onset: Psychological characteristics 

The teenager with anorexia nervosa is troubled about her life. She finds it difficult to  mature psycho-socially and clings to the rigid patterns of childhood. She is unable to sustain peer friendships and isolates herself.  Life appears to be out of her control. She is conflicted about living as her parents direct, is hurt by their critical comments and begins to realize that she must assert herself but finds that difficult. She feels too fat and thinks she has to be slim to be a worthy person. She takes an uncompromising stand about her eating and exercise habits.  Increasingly preoccupied and angry when her family interferes, she denies her illness.

Onset: Distorted perceptions 

A range of distorted perceptions has been noted, often related to body size and shape, hunger, satiety, physical endurance and the need for rest.  Distorted perceptions characteristic of anorexia nervosa may be exacerbated during episodes of crisis level starvation and will vary from time to time as well as adolescent to adolescent.  Anorexia nervosa should not be ruled out on the basis of lack of specific distortions if other symptoms are present.

Onset: Motivation 

The adolescent with anorexia nervosa has been described as wishing to stave off adulthood.  The question is whether she tries to avoid maturation or whether maturation eludes her.

Onset: Family characteristics

Many families of adolescents with anorexia nervosa list no problems until the manifestation of the disorder.  They need assistance from family specialists on the health care team to deal with the unexpected crisis of an eating disorder.  As treatment progresses they require guidance while developing a family system to support their adolescent as she learns to regain her healths.

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CLINICAL PEDIATRIC ONLINE 

Yudhasmara Foundation

JL Taman Bendungan Asahan 5 Jakarta Indonesia 102010

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Clinical and Editor in Chief :

DR WIDODO JUDARWANTO

Copyright © 2009, Clinical Pediatric Online Information Education Network. All rights reserved.

Initial Stage: Common physical symptoms 

In the initial stage of anorexia nervosa, physical symptoms are linked to body weight loss, food restriction, excessive exercise, interrupted menses, and inadequate nutritional status.

Initial Stage: Weight preoccupation 

Females are typically hypersensitive to developing breasts and hips.  Appearance of these adult female sexual characteristics causes panic among vulnerable adolescents.  In some cases adolescents with anorexia nervosa  are overweight when the disorder begins. They may recall a chance statement about their weight by a relative or close friend, or a suggestion about a weight reduction plan by a health professional, as the trigger for their initial food restricting behavior.

Initial Stage: Dietary behaviors

The adolescent with anorexia nervosa usually develops a personal philosophy about her diet, limiting herself by eating food only from certain categories and in certain ways. She especially limits total food energy and fat consumption, and may manipulate the fiber, fluid or sodium content of her diet. In addition, she may force herself to vomit or misuse laxatives and/or diuretics to rid herself of ingested food energy and body fluids.  Vomiting may follow episodes of binge eating, and be followed in turn by fasting.

Initial Stage: Exercise habits 

The type and amount of activity they engage in also varies but teenagers with anorexia nervosa ritually perform excessive calisthenics and other strenuous activities. They are drawn to high risk and solitary activities rather than team sports  (They often deny fatigue and may limit rest and use stimulants).  They are so frequently involved in junior and senior high school athletics and dancing that coaches and teachers should be educated about the disorder.  Knowledgeable adults, teachers and coaches recognize an eating disorder is developing when a student exercises to her/his detriment, training compulsively beyond reasonable endurance while rapidly losing or maintaining an unhealthy weight.

Initial Stage: Menses

It is well known that adolescents (as well as older women) in a state of starvation are amenorrheic.  Psychological changes and physical stress interfere with endocrine regulation of the menstrual cycle.  Cessation of menses occurs in about one third of adolescents with anorexia nervosa before they have lost sufficient weight and body fat to cause the interruption, however.  Further, amenorrhea often lasts beyond the point when they have regained close to normal weight and body fat.  This indicates both physical and psychological aspects of the disorder contribute to the complicated mechanisms underlying amenorrhea.  It is also clear that malnourished young women will not experience menarche.  When energy is inadequate to fuel all body processes both males and females shunt the scarce resource to life-supporting, as opposed to reproductive, functions.

Initial Stage: Nutritional status

In the initial phase of anorexia nervosa, semi-starvation does not appear to effect the body measurably other than through weight loss.  Stored fat and muscle components as well as the total body register the loss. The short-term nature of the starvation apparently does not lead to the same synergism between malnutrition and infection seen in populations chronically in semi-starving conditions.  Deficiencies in specific nutrients have not been reported, possibly because the catabolic state decreases requirements.  The increased demand for nutrients (especially minerals) in adolescence is reason to be concerned about sub-clinical and long-term deficiencies, however.  Symptoms of severe starvation may become apparent if weight loss continues unchecked.  Nutritional problems listed in the Crisis section undermine basic health, indicating a life-threatening crisis.

Initial Stage: Intervention strategies

When anorexia nervosa first appears, a team of experts will need to assess the situation and determine the most appropriate treatment.  Initial actions will be planned to avert a serious threat to health.  All members of the family will need to work with the therapeutic team to accomplish this goal.

Initial Stage: Timely recognition of symptoms

Recognizing the symptoms of anorexia is the most important early intervention strategy.  Friends, school personnel, family and health professionals who are alerted by developing problems can take steps to initiate treatment.  Younger people do not always fulfill all the diagnostic criteria of an eating disorder.  The possibility of a disorder should not be dismissed if all symptoms do not perfectly fit. Symptoms, attitudes and behaviors that are detrimental to health should be treated whenever they are identified. See Eating Disorders not Otherwise Specified described in Prevalence, Chapter 1.

Initial Stage: Psychotherapy

Individual and family psychotherapy by experienced mental health care providers will enable both the affected adolescent and her family to adopt more appropriate attitudes and behaviors.  In therapy, families learn to support the physical and psychological development of their children.  With support the adolescent can give up harmful habits as she matures.

Initial Stage: Medical nutritional therapy

Initially, the nutritionist on the health care team will assess and monitor the adolescent’s nutritional status, helping to determine her overall state of health in order to establish a diagnosis and therapeutic goals.  The nutritionist will also begin to correct the adolescent’s misunderstandings about nutrition and help her modify her eating habits to meet her physical needs.  Nutritional counseling should take advantage of the adolescent’s ability to change rather than impose a rigid system of dietary planning by a professional.  A strong and more directive stance will need to be taken if no readiness for change can be identified. 
The disorder should not be defined as solely a nutritional problem, although nutritional counseling is an important component of comprehensive therapy. Refocusing, through psychotherapy, on primary emotional and interactional problems rather than the power struggle over food and exercise patterns will often enable the adolescent to gradually abandon her compulsive striving for thinness. She can begin to devote her energy to recovery.

Initial Stage: Progressing from initial to crisis stage

Avoidance of intervention or lack of progress during initial therapy usually leads to physical and mental deterioration.  With this crisis stage of anorexia nervosa, intervention must be directed toward both the psychological and physiological symptoms, which are severe.

Crisis Stage Anorexia Nervosa in Adolescence

Crisis Stage: Psychological effects of starvation 

A crisis associated with anorexia nervosa can cause great distress among family, friends, and professionals.  The family may believe the adolescent’s abnormal eating behaviors are the sole problem, failing to understand the underlying multifaceted disturbance.  They may seek treatment that does not require them to be involved in psycho-therapy.  As she becomes truly cachectic, specific characteristics of starvation are superimposed on the already disturbed psychological state of an adolescent with anorexia nervosa.  Unhealthful behaviors, distorted perceptions, and weight phobia become more pronounced. The symptoms below, termed starvation neurosis, and documented in a classic study by Ancel Keys et al (in The Biology of Human Starvation, U of Minn. Press, 1950, vol. II)  of volunteers who underwent starvation designed to mimic conditions in Europe during World War II, are clearly seen in the syndrome of anorexia nervosa.
 

• Cognitive processes center on food. Thoughts of food intrude constantly; the major part of the waking hours are spent in contemplating it.
• Behavior includes toying with food and hoarding it, especially during re-nourishment.
• Coherent, creative thinking is impaired.
• Mental function is characterized by apathy, dullness, exhaustion, and depression.
• Interest in sex wanes.

Crisis Stage: Behavior pattern

Most adolescents with anorexia nervosa resist what they see as intrusions by professionals or others seeking to intervene.  They are secretive and hide their rituals.  They may appear apathetic but have sudden flashes of bad temper, as starving people of all ages usually do.  Adolescents with anorexia nervosa may obsessively plan menus, read recipes, cook and serve food to others, manipulate food before eating it, and record all that they eat.  They frequently recite “calorie” and fat content of food, but have distorted views and knowledge of nutrition.  Pretending to eat, they may hide and dispose of food.  These behaviors are driven by the disturbed adolescent’s fear of gaining weight which intensifies in a crisis.

Crisis Stage: Overall physical state 

In the crisis stage of anorexia nervosa, the adolescent’s physical state deteriorates. Electrolyte and cardiac abnormalities are among the signs that starvation is approaching a life threatening stage. 

Crisis Stage: Physical signs of starvation

As the crisis stage develops, the individual is unable to take care of herself.  The physical symptoms of human starvation are now superimposed on the other problems inherent in the disorder.  Physical signs of starvation commonly seen in adolescents with severe anorexia nervosa include:
 

• Fat store depletion
• Muscle wasting
• Skeletal appearance (cachexia)
• Amenorrhea/delayed menarche 
• Fainting (postural hypotension)
• Irregular pulse/heart beat (cardiac arrhythmia)
• Fissures at corners of mouth (cheilosis)
• Yellowed skin (carotonemia)
• Dry, scaly skin
• Fine downy hair (lanugo) growing over body (hirsutism)
• Thin, dry, brittle hair
• Loss of hair from head (alopecia)
• Degradation of fingernails
• Bluish tips of fingers and ear lobes (acrocyanosis)
• Feeling extremely cold or hot (inability to regulate body temperature)
• Frequent night urination (inability to concentrate urine)
• Constipation

Crisis Stage: Currently studied nutritional problems

In acute and severe human malnutrition, all body tissues are affected.  Recent research has focused on bone demineralization, growth failure, and structural changes in the brain of severely malnourished adolescents.  Intra-cranial cerebrospinal fluid spaces enlarge in adolescents with anorexia nervosa, meanwhile brain tissues change.  Adolescents with anorexia also suffer reduced bone mass, delayed pubertal development and fail to reach their potential height.  Studies relate these detrimental symptoms specifically to lower than normal body weight-for-height and document improvement with re-nourishment.  The possibility that certain of the brain, bone and growth abnormalities are, however, irreversible is of special concern and dictates ongoing monitoring and aggressive early treatment.  The seriousness of damage to the brain and bone documented to the present indicates that the effects of semi-starvation during adolescence on all body tissues should be studied.

Crisis Stage: Endocrine abnormalities

Adaptations to starvation by the hypothalamus result in extensive alterations in the body functions it controls in, a pre-pubertal state in adolescents with anorexia nervosa. The adolescent with anorexia is amenorrheic, is unable to adapt to heat and cold, suffers sleep disturbances, and is unable to conserve body water.  The inability to maintain adult levels of sexual hormones could account for the lack of interest in sex described in anorexia nervosa since the earliest recorded cases.

Crisis Stage: Terminal starvation signs

During a crisis when basic life is threatened, professionals monitor the adolescent’s vital signs and take remedial action .  The most outstanding signs that starvation has reached a life threatening stage depend upon the specific type of starvation include now identified:
 

• Fluid and electrolyte imbalance, with dehydration and edema, indicating the body cannot maintain homeostasis
• Severe cardiac arythmias in the absence of electrolyte imbalances, indicating a wasted myocardium
• Absence of ketone bodies in the urine, indicating a lack of fat used for metabolic fuel, when normal sources are restricted and therefore absence of fuel
• Bloody diarrhea, indicating intestinal tissue damage

Crisis Stage: Intervention strategies

When the adolescent’s condition reaches the crisis stage, health care team must intervene.  Hospitalization provides the protection and comprehensive care needed.  Intensive interventions are necessary when outpatient treatment has failed or when there is evidence of medical or psychiatric deterioration.  The goal will be to treat life threatening symptoms, and nutritionally rehabilitate the adolescent. Psychotherapy supports nutritional and medical stabilization during hospitalization.  Following rehabilitation adolescents make even greater psychological gains without the effects of semi-starvation neurosis.

Crisis Stage: Hospitalization

Young people require hospitalization to obtain intensive monitoring and care in order to avoid suffering long-term damage caused when semi-starvation is severe and prolonged.  The health care team specializing in treating adolescents with eating disorders will need to work with a trained inpatient staff to achieve the best results from inpatient treatment.  The augmented team, experienced in dealing with adolescents, will understand the developmental issues as well as the physiological needs of adolescents.  Goals of hospitalization will be to: 

• medically and nutritionally stabilize adolescents

• eleminate starvation neurosis so adolescents can progress in outpatient psychotherapy and other treatment following discharge

• help adolescents internaliz the need to regain health by eating sufficient food to meet body needs

An intensive program will guide the adolescent initially, providing incentives within a safe environment for her to assume as much responsibility as she is able.  The clear documentation of altered brain and bone stucture, as well as potential retardation of overall growth and develoment constitute an imparative for early specialized intervention.

Crisis Stage: Specialized Day-Treatment facilities

In some situations health care providers may decide a day-treatment intervention is appropriate for an adolescent who can be medically and nutritionally stabilized in a slightly less intensive therapeutic setting.  These programs incorporate treatment methods developed in hospital settings and allow adolescents to experience moderating their behaviors in a real world setting.  At reduced cost, these programs monitor and guide adolescents while they participate in psychotherapeutic and educational groups as well as attending school.  Adolescents are thus supervised during nutritional rehabilitation, yet able to live at home with their families. 

Crisis Stage: In-Home Care

Health care providers may determine outpatient care programs are appropriate for affected adolescents and their families in some situations.  The treatment team is multidisciplinary as in other settings.  Monitoring and treatment sessions at clinics will be frequent.  Parents have a major responsibility for carrying out the program at home with the guidance of professionals.  The treatment team will support the family in offering food, maintaining prescribed energy expenditure limits, and developing appropriate inter-personal interactions.  Parents must also be taught to recognize sudden downturns in the adolescent’s physical status and how to access emergency care.  Weight restoration will be prolonged in these circumstances, as the family learns what is necessary to promote recovery.

Crisis Stage: Comprehensive treatment

In a crisis it is essential that care be comprehensive and provided by an experienced multidisciplinary team.  All professionals and family who have contact with the adolescent will need to understand and support the treatment plan.  Physicians will manage overall care, monitoring symptoms and progress.  Nutritional components of therapeutic regimens for anorexia nervosa adolescents in the crisis stage are intertwined with the psychological aspects of the treatment.  Nutritional rehabilitation principles apply regardless of the treatment setting.  Treatment teams often use a behavioral contract to establish the core relationship between state of wellness and allowable adolescent activities.  Professionals, parents and the adolescent will sign the contract, confirming the weight gain required to justify energy expenditure in unnecessary activities.  At this stage, speaking with family and friends, using the telephone, and getting out of bed for the bathroom are included as part of the controlled energy expenditure.  Even these basic activities may have to be limited to building up the body energy supply.  Therefore, adolescents who do not eat will be kept at bed rest at this stage, and monitored, whether in a hospital or other setting. 

Crisis Stage: Medical nutritional therapy

Nutritional therapy is based on classic principles of nutritional rehabilitation for starving humans.  Re-nourishment obviously will begin with a gradual increase in energy intake.  In some programs the adolescent will be allowed to choose anything available to other adolescents (or family at home).  Other programs impose rules, make additions to what is ordered, or serve a set menu.  If a diet is prescribed, following established dietary principles, it should have adequate protein to meet basic needs.  Additional energy will be made up of complex carbohydrates and a small amount of fat.  Sodium and sugars should be moderated as they may enhance fluid retention.  Fibrous foods should be included to achieve bowel regularity, with the added caution that adolescents may experiment in using excessive amounts of fibrous foods as laxatives.  The overall diet should be rich in micro-nutrients, especially calcium and iron.  Supplemental vitamins and minerals can be given in amounts recommended for daily intake, though these are not routinely prescribed.  It should be clear that taking vitamin supplements does not substitute for eating regular food.

Crisis Stage: Nutritionally complete liquid formula

If an adolescent refuses to eat normal food, a nutritionally-complete-liquid formulated for adults, prescribed and dispensed as a medicine, may be used.  If the adolescent refuses all oral feedings it may be necessary to use nasogastric or parenteral methods.  Invasive methods will be presented as lifesaving procedures, not as punishment for refusing to eat.  Nourishment by mouth is the preferred route and is possible in most cases.

Crisis Stage: Body responses to re-nourishment

People being rehabilitated after starvation, as well as those reaching a starving state, generally develop edema. Because anorexia nervosa adolescents fear gaining weight, swelling with fluid increases their anxiety.  The edema seems to an adolescent to be proof that she will “expand” as she feared.  Anticipatory guidance can help her accept edema and other temporary body changes during refeeding. Assurance that professionals will guide her in gaining strength without adding excess fat can desensitize her to an increase in body size.  The intervention team will reinterpret nutrition misconceptions that have supported a adolescent’s life threatening behaviors.  Thus, adolescents can be reminded that: 

• Storing calcium in bones and replenishing nutrients in the brain will increase weight but not body size. 
• Nutrients filling up shrunken cells maintain normal life, they are not “fat”. 
• A person must have stored energy to keep him/herself strong enough to live.

Long-Term Recovery Stage Anorexia Nervosa in Adolescence

Long-Term Recovery: Role of the clinical nutritionist 

The clinical nutritionist/dietitian on the therapeutic team provides nutritional care while working within the framework of mutually established psychotherapeutic goals.  The focus of the adolescent’s energy is directed away from food phobias toward recovery.  Techniques developed by the social sciences and experience in modifying the disordered eating behaviors and attitudes help accomplish this.  The nutritionist’s knowledge of energy balance applied to an individual adolescent’s needs is required to establish dietary intake and nutritional rehabilitation goals throughout therapy. 

Long-Term Recovery: Psychosocial issues

The adolescent with anorexia who has recovered from a starvation crisis will still have to overcome the developmental arrest that brought her to the crisis. Several years are usually required for recovery. The adolescent will need to solve problems concerning choice and preparation for a vocation, financial support, and relationships with peers (including the opposite sex), along with maintaining adequate nourishment and accepting her inherited physique.

Long-Term Recovery: Physical issues

Before fully recovering from anorexia, adolescents will often experience wide swings in weight from extreme thinness to obesity, and some may develop bulimia.  An adolescent may see herself as somewhat detached from her body and experiment with extreme food habits before adopting a more reasonable perspective. By restricting food and experiencing stress she may not regain her menses as soon as expected. She may feel bloated and have bouts of edema as physical responses to starvation and refeeding.  Until she is fully nourished her skin may be yellow from time to time as result of carotenemia.

Long-Term Recovery: Intervention strategies

During recovery the psychotherapeutic goal will be to facilitate normal physical and psychological development, preparing the adolescent for a full healthy adult role in society.  True psychological maturation will enable her to function without depending on unhealthy eating and exercise habits. Nutritional counseling will provide her with needed information and retraining about food and the physical aspects of life; education regarding healthy weight management techniques will also be useful. Issues such as the level of nourishment necessary to maintain the menstrual cycle will resurface from time to time, as cognitive and emotional development proceeds. Returning to such issues will enable her to deal more capably with them as she matures. Guided experiences in eating out, grocery shopping, cooking, and entertaining, prepare adolescents to manage food in the environment without overfocusing on it. A team of psychological, nutritional and medical specialists will provide necessary care, and monitor her progress toward recovery.

Long-Term Recovery: Final outcome

Strong resistance to treatment and a high incidence of relapse and partial recovery are common outcomes of anorexia nervosa in adolescents. Many will retain symptoms into adulthood. Results of outcome studies reported to date indicate that although weight-for-height-for-age proportion improved in a majority of the adolescents, menstrual cycles were often unsatisfactorily maintained, ideas about food and weight remained disturbed, and psychosocial maladjustment was common.  The relationship of depressed body weight to depressive symptoms, as well as to sex role and body image distortions, and the observation that fewer than the expected number of children are born to adolescents formerly diagnosed with anorexia nervosa, are equally disturbing.

Supported  by
CLINICAL PEDIATRIC ONLINE 

Yudhasmara Foundation 

JL Taman Bendungan Asahan 5 Jakarta Indonesia 102010

phone : 62(021) 70081995 – 5703646

email : judarwanto@gmail.com,

http://clinicalpediatric.wordpress.com/

Clinical and Editor in Chief :

DR WIDODO JUDARWANTO

Copyright © 2009, Clinical Pediatric Online Information Education Network. All rights reserved.

First called bulimarexia, bulimia nervosa is a more recently recognized eating disorder than anorexia nervosa. Bulimia nervosa is characterized by gorging on food followed by one of several extreme behaviors in attempts to rid the body of food and weight.  These symptoms may also be associated with starvation in anorexia nervosa but do not occur exclusively in that disorder. 

Bulimia Nervosa: Behavior and onset in adolescence

The adolescent suffering from bulimia nervosa often maintains close-to-normal weight-for-height-for-age, meanwhile eating abnormally large amounts of food, (known as binge eating) and regularly forcing her bowels to empty by taking laxatives (called purging) or voluntarily vomiting.  They may also resort to fasting or extreme forms of exercise rather than vomiting and/or purging.  These behaviors, designed to rid the body of food, weight and bulk, may be referred to collectively as purging.  Professionals must inquire carefully to determine what practices are described as “purging” in a specific situation.  Adolescents with bulimia nervosa may have somewhat less severely distorted perceptions of their body shape and size and less restrictive weight goals compared with those suffering from anorexia nervosa. Adolescents with bulimia nervosa are often older at age of onset.

Bulimia Nervosa: Diagnostic criteria

American Psychiatric Association (APA) criteria may be found at their web site.  The diagnostic criteria established by the APA includes the following behaviors:
 

• Recurrent episodes of binge eating, rapid consumption of abnormally large amounts of food in a discrete period
• Sense of inability to control binges and eating
• Regular self-induced vomiting, misuse of laxatives, diuretics, enemas or other medications, fasting, or excessive exercise (inappropriate compensatory behaviors)
• Occurrence of binge-eating episodes and compensatory behaviors on average at least twice a week for 3 months
• Self evaluation inappropriately based on body shape and weight

Further two specific TYPES are described:

PURGING has regularly and is currently engaged in:

self induced vomiting, or misuse of laxatives, diuretics or enemas

NON-PURGING has regularly and is currently engaged in:

fasting or excessive exercise and nor other compensatory behaviors

Note that specific compensatory behaviors are listed in the criteria.  While some are categorized under PURGING TYPE and others NON-PURGING TYPE, each has specific detrimental effects and all should not be referred  to non-descriptively together as purging (as many adolescents will do) but specifically identified and treated.

Bulimia Nervosa: Prevalence

The syndrome of bulimia nervosa should be differentiated from the recent behavior of many normal adolescent females who try to control their weight and shape by occasionally causing themselves to vomit.  These young women may also use laxatives or diuretics to rid themselves of body fluids and the products of digestion. By college age as many as 20% of females may engage in these inappropriate behaviors.  Only about 2-4% of college age women have serious disorders that meet the diagnostic criteria for bulimia nervosa.  The effected population is more diverse than with anorexia nervosa;  more are women of color, older at onset, male and from a broad economic spectrum. 

A serious condition is one that is uncontrollable, and includes psychological features that impair normal functioning.  Bulimia nervosa sometimes develops in obese adolescents or following episodes of anorexia nervosa. The disorder may also arise in adolescents with less fashionable hereditary shapes, e.g. large or unusually shaped leg muscles.  The adolescent with bulimia is more likely to be fertile than the individual with anorexia nervosa.  Therefore, certain young women will have bulimia during pregnancy

Bulimia Nervosa: Common psychosocial characteristics

Bulimia nervosa, a serious eating disorder, indicates important psychological disturbances in the adolescent.  Her self-esteem is often extremely low and tied to her feelings about certain characteristics of her body that are genetically controlled. She usually thinks of herself as physically unattractive, although others may observe that she is well groomed and has normal, even attractive, physical features.  Normal weight adolescents with bulimia obviously will not have the seriously compromised nutritional status of those starving with anorexia nervosa.  Thus, unlike adolescents with anorexia nervosa, they will not experience the mental dysfunction and distorted perception resulting from starvation neurosis (described by Keys et al in The Biology of Human Starvation, U of Minn. Press, 1950, vol. II). See section on Crisis Stage: Psychological effects of starvation

Superficially, the adolescent with bulimia nervosa may keep a heavy social schedule, but in reality she may have few close friends. In contrast to the more rigid adolescent with anorexia nervosa, young women with bulimia nervosa often demonstrate poor impulse control. By all accounts, gorging, vomiting, and purging serve to release tension for the sufferers.  They often describe feeling “numbed out” during a binge.  However, the residual guilt and feelings of inadequacy bring renewed tension that helps perpetuate an uncontrolled cycle.  Social isolation is also perpetuated because they fear their secret will be found out. 

Bulimia Nervosa: Food related behavior

The teenager with bulimia nervosa periodically eats large amounts of food and then voluntarily vomits, purges or exercises excessively.  Each person with bulimia nervosa defines a binge for herself.  Because of distortions in thinking about food, as little as one doughnut may be thought of as a binge by one person while as much as an entire package of doughnuts may constitute a binge for another. As the habits continue, it becomes easier for adolescents to vomit.  Eventually, the vomiting is a nearly automatic response.  In addition, an adolescent may abuse laxatives to purge herself of the food she has ingested or use diuretics to remove body fluid.

Bulimia Nervosa: Common physical symptoms

Physical symptoms of the adolescent with bulimia nervosa will include:
 

• Cracked, damaged lips 
• Tooth damage
• Throat irritation
• Esophageal inflammation (all of the above symptoms are caused by exposure of unprotected tissues to acidic vomitus)
• Callused hands (from contact with teeth when used to stimulate vomiting)
• Swollen salivary glands (caused by acidic reflux or constant stimulation)
• Broken blood vessels in face (from force of vomiting)
• Rectal bleeding (caused by overuse of laxatives)
• Fluctuations in body weight

Life-threatening situations are rarer in adolescents with bulimia nervosa than with anorexia nervosa. They are:
 

• Dehydration and electrolyte imbalance 
• Ruptures in the upper gastrointestinal tract 
• Kidney disorders

Bulimia Nervosa: Dental destruction

Adolescents who regularly vomit due to an eating disorder will sustain severe damage to dental enamel, most prominently on the lingual surface of the teeth.  A specific pattern of erosion of enamel, and even of dentin, has been identified in frequent vomiters and described in detail.  Previously applied fillings will be left standing above the surface of teeth that have been eroded.  Dentists, may be the first health care professionals in position to recognize an eating disorder if an adolescent seeks improved dental esthetics.  Dental specialists have developed a protocol for prevention of further erosion, meanwhile referring adolescents for eating disorder treatment.  The strategy includes neutralizing oral fluids following vomiting episodes and avoiding abrasion of the teeth.  Thus, adolescents are taught to use bicarbonate of soda washes and to refrain from brushing after vomiting.  Dentists supply fluoride as a preventive.  Meanwhile, to insure the restoration will be effective, restorative procedures are delayed until adolescents are in treatment and have ceased vomiting. 

Pain and discomfort in the oral cavity may interfere with normal eating patterns adolescents need to adopt in order to recover from bulimia or anorexia nervosa.  Thus, the permanent teeth of adolescents need to be protected by attentive clinicians of all disciplines who can refer them to dentists familiar with the complexities of serving adolescents with eating disorder syndromes.

Bulimia Nervosa: Intervention strategies

The techniques most frequently reported in treating adolescents with bulimia nervosa are similar to those employed to promote recovery of anorexia nervosa adolescents, including psychotherapy, nutritional therapy, medical monitoring and health education.  Pharmicotherapy may be included with other modalities when providers determine it will improve overall treatment.  An experienced, well trained treatment team will be needed for greatest success.

Bulimia Nervosa: Psychotherapy

The emphasis of this component of psychotherapy is freeing the person from guilt, facilitating gains in self-esteem, and helping her deal with anxiety.  Distorted goal setting linked to perfection or changing inherent body characteristics is challenged. Ideally the adolescent’s family or partner will be included in certain aspects of psychotherapy, though not as routinely as for anorexia nervosa since adolescents are generally older.

Bulimia Nervosa: Nutritional therapy

While she deals with the psychological problem, the adolescent with bulimia nervosa will need reeducation to nourish herself properly.  Physical and nutritional education can fill gaps in the knowledge of these teenagers about their body functions. Over time, myths about weight management can be dispelled and more normal eating habits developed. Because of distorted feelings about food, the adolescent with bulimia may feel guilty every time she eats, despite the fact that food is necessary to sustain life.  The family often reinforces her guilt with a misguided overfocus on food, thinness and physical appearance.  An adolescent with bulimia usually attempts to restrict her food intake to match the “ideal” (generally restrictive) plan she conceives for herself.  Binges may thus arise from the natural physical and psychological urge to end hunger, with an over compensation for the deprivation earlier in the day.

Bulimia Nervosa: Role of the clinical nutritionist

The clinical nutritionist on the interdisciplinary treatment team will help a young person with bulimia nervosa understand the role of food in life and accept a more realistic weight. Helping her understand energy balance and nutrient functions as well as the effects or gorging, vomiting, and purging is especially useful.  Education must be done in a counseling mode, allowing for gradual alteration of the adolescent’s rigid set of beliefs.  Psycho-therapists will provide concurrent family and individual psychotherapy, dealing with underlying causes of obsessional food behavior.  They may determine group therapy will be most effective at some stages of recovery.  Physicians will manage the physical care, monitoring symptoms and progress.

Bulimia Nervosa: Coincident with pregnancy

If pregnant, the teenager with bulimia may be committed to protecting her unborn child but retain ideas that inhibit normal nourishment of herself, her fetus, and the child after birth. Physical concerns during pregnancy are the adverse bio-chemical- chemical environment for the mother and fetus, the mother’s abnormal weight gain pattern and the mother’s unrealistic ideas about infant feeding.  Weight loss, lack of weight gain or inordinate gain during gestation, indicate adverse nutritional status.  During recovery, care of any pregnancy that may occur must be included.

Bulimia Nervosa: Pregnancy care 

The teenager with bulimia nervosa who is pregnant can be helped to accept the idea that the baby she wants must be adequately nourished. She is then supported in retaining foods that the fetus needs. If she cannot give up bingeing and vomiting, or purging, totally, she must be taught to delay it until nourishing foods have been digested.  Delaying detrimental bulimic behavior is analogous to making sure an oral contraceptive is not vomited out of the system, which sexually active adolescents who wish to avoid pregnancy learn to do.  All aspects of gestational progress should be carefully monitored.  The pregnant adolescent with bulimia should also be helped to learn to recognize natural hunger signals from her baby after it is born.  Intensive therapy for an eating disorder, building on skills the young woman developed to maintain health during gestation, can begin post partum.

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CLINICAL PEDIATRIC ONLINE 

Yudhasmara Foundation 

JL Taman Bendungan Asahan 5 Jakarta Indonesia 102010

phone : 62(021) 70081995 – 5703646

email : judarwanto@gmail.com,

http://clinicalpediatric.wordpress.com/

Clinical and Editor in Chief :

DR WIDODO JUDARWANTO

Copyright © 2009, Clinical Pediatric Online Information Education Network. All rights reserved.

Nutritional Care Summarized* (* Schebendach 1999, Schebendach & Nussbaum 1992, Fisher et al. 1995, Golden et al. 1997, Kreipe et al. 1995 [ Society of Adolescent Medicine, Position Paper on Adolescent Eating Disorders 

Assess and monitor   

• body size – Compare to reference data in percentiles by age and sex :1) CDC Growth charts (Adobe Acrobat .pdf file):
  

  Girls	Boys
  height-for-age	height-for-age
  weight-for-age	weight-for-age
  BMI-for-age	BMI-for-age
  weight-for-height	weight-for-height

Notes:
 a) Validation studies are needed to determine cut-off points for underweight in BMI-for-age data.
 b) 5th percentile cut-off suggested by WHO was not based on current data
 c) Symptoms of eating disorders are often seen at BMI’s above the 5th percentile of current BMI-for-age charts

2)  weight-for-height-for-age and sex table (Cromer et al, 1992), 

• body composition (estimate fat stores and muscle mass)  – Use nomogram to estimate muscle mass from midarm circumference and triceps skinfold measures (Gurney & Jelliffe 1973)
• skin folds (Compare to reference data in percentiles by race, age, sex, (Frisancho 1993))
• muscle mass  (Compare to reference data in percentiles by race, age, sex, (Frisancho 1993))
• fluid retention (edema)  – Assess edema (Seidel, HM et al. 1991)
• weight gain/loss and height gain history (compare to normal for sexual maturity rating, age, sex, and hereditary potential).  At least 25th percentile of reference data should be maintained for lower range of normal healthy weights.  Normality of growth status and progress for pubertal stage requires additional judgment of clinician trained to evaluate pubertal growth
• nutrient intake (adequacy of amount and balance for size, sex, age, energy stores and activity)
• fluid intake and output (out-patient, report; in-patient, measure and assess for normalcy)
• metabolic rate — measure or calculate to guide dietary prescription  Caloric prescription — weight gain:
         1.3 X measured resting energy expenditure (REE) for sedentary male or female
            or
         1.3 X adjusted Harris-Benedict equation (HB), for predicted REE in females as follows:
             a) Calculate HB Equation:
                         Calculated REE = 655 + (9.6 X wt in kg) + (1.85 X ht in cm) – (4.7 X age in yr)
             b) Adjust for hypometabolic rate:
                         Adjusted HB, for initial hypometabolism = (1.84 X calculated REE) – 1435
             c) Caloric prescription = 1.3 X Adjusted HB
           (Schebendach 1999, Schebendach & Nussbaum 1992)
   
• food and weight related behaviors, beliefs and knowledge (are they compatible with health, reality and factual information?)
• sensations of hunger and satiety (perceived need to eat and stop eating)Note: No single measure will provide an accurate nutritional status evaluation.

Prescribe a diet during crises

• about 1200 – 1400 kcal energy daily when admitted to hospital for malnutrition, based on measured or calculated energy needs
• 100 kcal daily increase* in acute phase
• 200 kcal daily increase* in refeeding phase until normal intake for individual is reached
• nutrients balanced and adequate

(* Increases in both cases above are based on the adolescents pattern of weight gain)

Set limits

• regulate energy expenditure to allow repletion and maintenance of energy stores 

Establish weight-for-height-for-age goals 

• 1-3 lb per week gain during life-threatening phase of malnutrition 
• ½-1 lb per week gain in acute outpatient phase of malnutrition 
• intermediary goals (10th,15th, 25th percentile) weight-for-height-for-age until normal  (25-75th percentile) is reached, with normal menstrual status for pubertal stage

Plan treatment with patient

• include patient in planning treatment to the extent possible to encourage autonomy

Supported  by
CLINICAL PEDIATRIC ONLINE 

Yudhasmara Foundation 

JL Taman Bendungan Asahan 5 Jakarta Indonesia 102010

phone : 62(021) 70081995 – 5703646

email : judarwanto@gmail.com,

http://clinicalpediatric.wordpress.com/

Clinical and Editor in Chief :

DR WIDODO JUDARWANTO

Copyright © 2009, Clinical Pediatric Online Information Education Network. All rights reserved.

Supported  by
CLINICAL PEDIATRIC ONLINE 

Yudhasmara Foundation 

JL Taman Bendungan Asahan 5 Jakarta Indonesia 102010

phone : 62(021) 70081995 – 5703646

email : judarwanto@gmail.com,

http://clinicalpediatric.wordpress.com/

Clinical and Editor in Chief :

DR WIDODO JUDARWANTO

Copyright © 2009, Clinical Pediatric Online Information Education Network. All rights reserved.

0-1 years:

• Developmental and genetic conditions that were present at birth
• Sudden infant death syndrome (SIDS)
• All conditions associated with prematurity and low birth weight

1-4 years:

• Accidents
• Developmental and genetic conditions that were present at birth
• Cancer

5-14 years:

• Accidents
• Cancer
• Homicide

15-24 years:

• Accidents
• Homicide
• Suicide

Supported  by
CLINICAL PEDIATRIC ONLINE 

Yudhasmara Foundation 

JL Taman Bendungan Asahan 5 Jakarta Indonesia 102010

phone : 62(021) 70081995 – 5703646

email : judarwanto@gmail.com,

http://clinicalpediatric.wordpress.com/

Clinical and Editor in Chief :

DR WIDODO JUDARWANTO

Copyright © 2009, Clinical Pediatric Online Information Education Network. All rights reserved.