Developmental amnesia in the premature infant

Mouron V, Hays S, Gonzalez-Monge S.

Service de néonatologie, hôpital de la Croix-Rousse, hospices civils de Lyon, 69317 Lyon cedex 04, France. virginie.mouron@chu-lyon.fr

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Monitoring and FollowUp of Prematurity Clinic Online

JL Taman Bendungan Asahan 5 Bendungan Hilir Jakarta Pusat Phone :62 (021) 70081995 – 5703646   

Clinical and Editor in Chief

r Widodo Judarwanto SpA, pediatrician

email : judarwanto@gmail.com,                                                                                                                 

 Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. You should not use the information on this web site for diagnosing or treating a medical or health condition. You should carefully read all product packaging. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider. 

Copyright © 2010, Clinic For Children Information Education Network. All rights

Patterned orocutaneous therapy improves sucking and oral feeding in preterm infants.

Poore M, Zimmerman E, Barlow SM, Wang J, Gu F.

Department of Speech-Language-Hearing: Sciences and Disorders, University of Kansas, Lawrence, KS 66045-7555, USA.

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Monitoring and FollowUp of Prematurity Clinic Online

JL Taman Bendungan Asahan 5 Bendungan Hilir Jakarta Pusat Phone :62 (021) 70081995 – 5703646   

Clinical and Editor in Chief

r Widodo Judarwanto SpA, pediatrician

email : judarwanto@gmail.com,                                                                                                                 

 Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. You should not use the information on this web site for diagnosing or treating a medical or health condition. You should carefully read all product packaging. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider. 

Copyright © 2010, Clinic For Children Information Education Network. All rights

Infant who are born born preterm are at increased risk for medical and developmental morbidity. Several decades of research have clearly identified premature infants, particularly those with low birth weight, as a group at risk for later cognitive and motor deficits. Developmental outcomes, however, have been variable in samples of these infants. Some premature infants develop normally from the first months; others whose initial development is delayed catch up; and still others continue to exhibit learning and behavioral difficulties throughout the school years. Over 60 years of research have not produced clear-cut conclusions about which of these infants are most likely to experience long-term problems. Advances in prenatal and neonatal care during the last few decades have made it possible for infants born extremely prematurely to survive. Concerns have been expressed about the long term outcome of these infants. In recent follow up surveys, the neurodevelopmental impairment rate of low birthweight infants has not changed significantly, and the disability rate of the most immature infants has remained considerable. Kitchen et al31 suggested that neurological findings at 2 years of age are too pessimistic, and that 33% of children had a poorer diagnosis at that age than at 5, and in only 4% was the outcome at 2 years of age better than at 5. However, in comparison with normal weight children, Halsey et al32 has shown that ELBW children classified as non-disabled at an early age show a significantly poorer performance on cognitive, verbal, perceptual, motor, and visual-motor measures at preschool age,

 Interviews with parents of preterm and full-term NIC 6.5 year old children indicated that NIC children were were older than control children when they reached certain stages in language development (short sentences, intelligible speech). Absence of babbling was more common in NIC children born at 23-27 wk and occurrence of stuttering was more commonly noticed in preterm NIC children born at 23-27 wk.

Preterm birth and associated hazards may constitute a significant risk factor for specific language impairment in a sizable minority of children.” Preterm children had lower scores for vocabulary, expressive language, phonological short-term memory, and general nonverbal ability. These lower scores were primarily based on results from 1/3 of the 26 preterm children who were identified as being “at risk” for persisting language difficulties.

Speech and language comprehension and production of 55 preterm children, 5 years old, were compared to children born full term of the same age. Mean performance for preterm children was significantly lower on most of the measures including the composite IQ scores. However, when nine children with major neurological disabilities were excluded statistically significant differences were found on only 4out of 12 of the speech and language measures. Preterm children were slower on rapid word retrieval and also had difficulties in comprehending relative concepts. This was believed to suggest ‘subtle dysnomia’ indicative of later reading problems.

Preterm children did not exhibit problems with global verbal measures or basic speech and language aspects. In fact, specific language impairment (defined as a discrepancy of > 1SD between Performance IQ and Verbal IQ scores) was more common in the control group. Boys were found to have a greater discrepancy between their Performance and Verbal IQ scores.

Children who had been in the NICU with respiratory disorders as newborns, either pre-term and or full-term newborns with asphyxia, were studied at preschool age. Newborns with hearing loss and mental retardation were excluded from this study. Complications of delivery, birthweight, hypoxia, persistent ductus arteriosus, duration of ventilation and complications of respiratory treatment were correlated with perception and comprehension issues. The intelligence level of pre-school children is found to be closely correlated to speech perception and comprehension

Reference :

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Monitoring and FollowUp of Prematurity Clinic Online

JL Taman Bendungan Asahan 5 Bendungan Hilir Jakarta Pusat Phone :62 (021) 70081995 – 5703646   

Clinical and Editor in Chief

r Widodo Judarwanto SpA, pediatrician

email : judarwanto@gmail.com,                                                                                                                 

 Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. You should not use the information on this web site for diagnosing or treating a medical or health condition. You should carefully read all product packaging. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider. 

Copyright © 2010, Clinic For Children Information Education Network. All rights

Kelahiran prematur merupakan salah satu penyebab utama kematian pada bayi baru lahir dan sangat beresiko terjadi gangguan neurodevelopment atau perkembangan dan perilaku di masa depan. Meski ilmu kedokteran sudah maju demikian pesat namun penyebab kelahiran prematur masih belum diketahui secara pasti. Kelahiran bayi prematur tampaknya sangat dipengaruhi oleh faktor genetik dan heriditer atau keturunan.

Fenomena tersebut ditunjukkan oleh penelitian faktor resiko pada saudara kandung. Perempuan yang lahir prematur atau yang memiliki saudara laki-laki dan perempuan yang juga lahir secara prematur, memiliki risiko 50-60 persen untuk mengalami persalinan lebih cepat dari waktunya.   Hasil tersebut ditunjukkan oleh  penelitian yang dilakukan tim peneliti dari The University of Aberdeen, Skotlandia, terhadap data 22.343 ibu dan anak perempuan di Skotlandia.

Studi pendahuluan ini bisa menjadi masukan bagi para ahli kebidanan untuk memasukkan faktor keturunan sebagai hal yang perlu diperhatikan untuk mencegah kelahiran prematur. Penelitian lebih lanjut akan dilakukan untuk mengidentifikasi pola gentiknya. Penelitian tersebut mengambil data dasar dari Aberdeen Maternity Neonatal Databank. Populasi penduduk di kota tersebut tidak fluktuatif dan mayoritas wanita melakukan persalinan di rumah sakit yang sama. Karena itu data ini dianggap cukup valid. Ibu hamil yang dulunya lahir secara prematur memiliki risiko 60 persen untuk mengalami persalinan kurang bulan, terutama jika itu merupakan kehamilan pertamanya.

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Clinic For Children Yudhasmara Foundation http://childrenclinic.wordpress.com/

Monitoring and FollowUp of Prematurity Clinic Online

JL Taman Bendungan Asahan 5 Bendungan Hilir Jakarta Pusat Phone :62 (021) 70081995 – 5703646   

Clinical and Editor in Chief :

Dr Widodo Judarwanto SpA, pediatrician

email : judarwanto@gmail.com,

Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. You should not use the information on this web site for diagnosing or treating a medical or health condition. You should carefully read all product packaging. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider. 

Copyright © 2010, Clinic For Children Information Education Network. All rights

• Currently 1 in 10 babies in the United States is born prematurely. Half of extremely premature infants who survive have mental or physical disabilities, a quarter of them severe. Boys are more likely than girls to have problems. Premature Babies: Half of Them Have Disabilities, New England Journal of Medicine 2000; Aug 10; 343 (6): 378-84.
• It has been more than 20 years since doctors began saving extremely premature infants and about a decade since advances in neonatology vastly improved the survival of babies with very low birth weight – those weighing less than 1,500 grams, or 3 lbs, 4 oz. The tiniest of these babies, micropreemies as they are called, are born as much as 14 weeks early and weigh less than 750 grams, or 1 lb., 1 oz. For the first time thousands of such children are now well into their school years. Conventional medical wisdom, based on previous studies, had been that premature children who were not seriously physically disabled, would catch up to other youngsters by age 5. Many do just fine, but as the first large group of tiny babies grows up, new research is showing that academic and behavioral problems often surface in the school years. As Premature Babies Grow, So Can Their Problems, Sheryl Gay Stolberg
• A study was done in Israel that measured the emotional and behavioral development of prematurely born children. It found that premature children had higher levels of anxiety, depression and aggression than full term children, and that they had a lower self concept. Premature children were found to have more disturbances at home and school. The smaller the birth weight, the less emotionally adjusted the child will be. Rachel Levy Shifft and Gili Einat, Journal of Clinical Child Psychology V 23 p 328-9
• Extremely low birth weight infants are at significant risk of neurologic abnormalities, developmental delays and functional delays at 18 to 22 months corrected age. Neurodevelopmental and Functional Outcomes of Extremely Low Birth Weight Infants in the National Institute of Child Health and Human Development Neonatal Research Network 1993-1994. Betty R. Vohr, Linda L. Wright, Anna M Dusick, Lisa Mele, Joel Verter, Jean J. Steichen, Neal P. Simon, Dee C. Wilson, Sue Brolyes, Charles R. Bauer, Virginia Delaney-Black, Kimberely A. Yolton, Barry E. Fleisher, Lu-Ann Papile, Michael D. Kaplan. Pediatrics Vol 105, No 6, June 2000, p 1216-1226.
• Changing patterns of neurologic and developmental functioning between 1 to 7 years of age were studied in very low birth weight infants. Children received a neurologic assessment at 1 year and were reexamined at age 7. The age 1 and age 7 neurologic assessments were significantly related. The findings of the study indicate that a neurologic classification at 1 year of age provides a guide for monitoring very low birth weight infants and can be helpful in alerting school personal to potential needs. Neurodevelopmental and School Performance of Very Low Birth Weight Infants: A Seven Year Longitudinal Study, BR Vohr and CT Garcia Coll, American Academy of Pediatrics, Volume 70, Issue 3, pp 345-350. 9/1/1985.
• Comparisons were made among 4 birth weight groups to examine the effect of birth weight on the classroom behavior of children entering elementary school. Extremely low birth weight children had lower attention and language skills, overall social competence, scholastic competence and athletic ability than all other birth weight groups as measured by classroom teachers, even when controlling for neonatal stay, child’s gender and ethnicity, and maternal education. All low birth weight children had lower attention and language skills and scholastic competence and higher daydreaming and hyperactivity scores then normal birth weight children. The classroom behavior of low birth weight children was rated by teachers as poor, even for children who had not failed a grade. Low birth weight children who are on grade level may still be at risk for problems. Classroom Behavior of Very Low Birth Weight Elementary School Children, Klebanov PK, Brooks-Gunn J, McCormick MC, Columbia University Teachers College, New York, NY, Pediatrics 1994, Volume 94, Issue 5, pages 700-708. 11/01/1994.
• Educational Status and School Related Abilities of Very Low Birth Weight Premature Children, Ross G, Lipper EG, Auld PA, Department of Pediatrics, Cornell University Medical College, New York, NY, Pediatrics December 1991, 88 (6): 1125-34.
• Eighty Eight premature children with birth weights less than or equal to 1,500 grams were evaluated at ages between 7 to 8 years old to determine their academic status in comparison with those of a matched full term group. Results showed that a much higher proportion of the premature children required special education interventions (48%) than either the full term (control group) children (15%), or the New York State elementary school population (10%). More than half of the premature children who received educational intervention were neurologically impaired or had below normal intelligence. The entire group of premature children differed significantly from the matched full term group on IQ score and on tests of verbal ability, school achievement and auditory memory. Six Year Neurodevleopmental Follow Up of Very Low Birthweight Children, Litt R, Joesph A, Gale R Department of Neonatalogy, Bikur Holim Hospital, Israel, Israel Journal of Medical Science, May 1995. 31 (5) 303-8
• Twenty Four children born preterm in 1985 with very low birthweights were followed until the age of 6. The mean verbal IQ of these children was significantly lower than the control group. Four of the children had major disabilities and minor neurological deficit was found in another 7. These findings point to possible future learning disabilities and point out the importance of long term follow up in order to identify and address these specific educational needs. Risk Factors for Major Neurodevelopmental Impairments and Need for Special Education Resources in Extremely Premature Infants. Msall ME, Buck GM, Rogers BT, Merke D, Catanzaro NL, Zorn WA. Journal of Pediatrics, October 1991, 119 (4) 606-14.
• A study comprised of 100 infants born between 24 to 28 weeks gestational age from 1983 to 1984, indicated that 25% of the children had major impairments, such as cerebral palsy, blindness and mental retardation. Another 9% required special education resources and 48% of the additional children would possibly need special education resources. Intellectual and Functional Status at School Entry of Children who Weighed 1,000 Grams or Less at Birth: A Regional Perspective of Births in the 1980’s. Saigal S, Szatmaria P, Rosenbaum P, Campbell D, King S. Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada, Journal of Pediatrics, March 1990. 116 (3) 409-16.
• A study was conducted on 90 children (average age at time of study 5 ½ years) who were born between 1980 to 1982 and weighing between 501 to 1,000 grams at birth. Of the children, 43% were shown to be at mild to high risk for future learning disabilities. Very Low Birthweight Boys at the Age of 19. Ericson A, Kallen B, Centre for Epidemiology, National Board of Health, Stockholm, Sweden, Arch Dis Child Fetal Neonat Ed, May 1998, 78 (3) 171-4.
• Long term follow-up (to 18-19 years of age) was made of 260 singleton boys whose birthweight was less than 1,500 grams. These boys had more visual and hearing impairments and were at much higher risk of cerebral palsy and other signs of mental impairment, evident as lower intelligence test scores and shorter schooling. School Performance at 9 Years of Age in Very Premature and Very Low Birth Weight Infants: Perinatal Risk Factors and Predictors at Five Years of Age.
• A study conducted by the Institute of Preventive Health Care in the Netherlands found that at the age of 9, 19% of very premature children were in special education. Of the children in mainstream education, 32% were in a grade below the appropriate level for age and 38% had special assistance. Collaborative Project on Preterm and Small for Gestational Age Infants in the Netherlands, Hille ET, Den Ouden Al, Bauer L, Van Den Oudenrijn C, Brand R, Verloove-Vanhorick SP. TON Institute of Preventative Health Care, Leiden, The Netherlands, Journal of Pediatrics, September 1994, 125 (3) 426-34.
• Two Hundred and eighty nine very low birthweight children born in New Zealand in 1986 were assessed at 7 to 8 years of age on measures of behavior, cognitive ability, school performance and the need for special education. The outcomes were compared with a sample group of over 1,000 children. The result was that the very low birthweight children had significantly higher rates of problems and poorer rates of functioning across all outcome measures than the general child sample. These differences persisted even after control for variability in social, family and other characteristics of the two samples and for the degree of sensineural disability. These findings are consistent with a growing body of research evidence which suggests that premature and very low birth weight infants are at increased risk of functional impairment in middle childhood. Cognitive, Educational and Behavioral Outcomes at 7 to 8 Years in a National Very Low BirthWeight Cohort. Horwood LJ, Mogridge N, Darlow BA, Christchurch Health and Development Study, Christchurch School of Medicine, New Zealand. Arch Dis Child Fetal Neonatal Ed, July 1998, 79 (1) F 12-20.
• A study was conducted of 243 prematurely born very low birthweight (less than 1501 grams) children with a normal birthweight, full term control group for comparison. The children were evaluated at 7 to 8 years of age and findings indicate that the children born preterm (both male and female) were rated by their teachers as expressing more behavior problems than their controls and were less well adjusted to the school environment. The deficits noted in the preterm children applied across social class. It is speculated that the problem behaviors reflect a failure in self regulatory functions.
  Behavioral Adjustment in School of Very Low BirthWeight Children, Sykes DH, Hoy EA, Bill JM, McClure BG, Halliday HL, Reid MM. School of Psychology, Queen’s University, Belfast, Northern Ireland, Journal of Child Psychology, Psychiatry, March 1997, 38 (3) 315-25.
• A study was conducted which categorized children into 4 birthweights grom extremely low to normal and then compared them on indicators of school achievement including: grade failure, placement in special classes, classification as handicapped and math and reading achievement scores. Results indicated that as birthweight decreased, the prevalence of grade failure, placement in special classes and classification as handicapped increased, even when controlling for maternal education and neonatal stay. Extremely low birthweight children scored lower than all other birthweight groups on math and reading achievement tests. School Achievement and Failure in Very Low Birth Weight Children. Klebanov PK, Brooks-Gunn J, McCormick MC. Colombia University, Teachers College, New York. Journal of Dev. Pediatrics, August 1994, 15 (4) 248-56.
• A study examined achievement, behavior and neuropsychological outcomes at early school age in a population of children born at less than 750 grams, and compared them to a full term birth control group. The preemie children performed more poorly than higher birth weight children on tests of math, in language, perceptual motor and attentional skills. Findings document specific weakness in achievement and neuropsychological skills in children less than 750 grams at birth weight and support the need for early identification and special education interventions. Achievement in Children with Birthweights less than 750 Grams with Normal Cognitive Abilities. Taylor HG, Hack M, Klein N, Schatschneider C. Dept of Pediatrics, Case Western Reserve University School of Medicine, Journal of Pediatric Psychology, Dec 1995, 20 (6) 703-19.
• Eight hundred and seventy three children in an entire school grade in a Swedish community were studied to show the effect of birth weight. Low birth weight children had lower school performance and IQ scores at age 13 than normal birth weight children irrespective of parental socio-economic status. School Performance and IQ Test Scores at Age 13 As Related to Birth Weight and Gestational Age. Lagerstrom M, Bremme K, Eneroth P, Magnusson D. Dept of Psychology, Stockholm, Sweden. Scandanavian Journal of Psychology 1991, 32 (4) 316-24.
• A study compared 65, 9 year old children born in 1976 who were very low birthweight and were free of neorological impairment with 65 “normal”, full term, children who were comparitive in background, etc. to the low birthweight group. Very low birth weight children scored significantly lower than controls on the WISC-R, Bender-Gestalt, Purdue Pegboard, subtests from the Woodcock Johnson Cognitive Abilities Battery and reading and mathematics achievement tests. Children Who Were Very Low Birthweight: Development and Academic Achievement at 9 Years of Age. Klein NK, Hack M, Breslau N. College of Education, Cleveland State University, Journal of Developmental Behavior Pediatrics, Feb 1989, 10 (1) 32-7.
• A nine year follow up of 116 children born in 1971 to 1974 with a birthweight of 1,500 grams or less found that 59 had died and 7 had extreme handicaps or blindness. The low birthweight children without extreme handicaps were found to have impaired motor function, speech defects and impaired school achievements more often than the controls. Nine Year Follow Up of Infants Weighing 1,500 grams or Less at Birth. Michelsson K, Lindahl E, Parre M, Helenius M. Acta Paediatr Scand. November 1984; 73 (6): 835-41.
•  Thirty five of 45 long term survivors with birth weights of 1,000 grams or less whor were cared for in the University of Washington, Seattle, Neonatal Intensive Care Unit, from 1960 to 1972 were examined at an average age of 10 ½ years. Twenty eight percent had one or more major neurological or sensory handicap, 64% have been or are presently in a special education program. Only 28% are currently rated by their teachers to be achieving at or above grade level. Arithmetic reasoning, mathematics achievement and reading comprehension were specific weaknesses. Fine and gross motor skills were impaired. Perceptual skills were impaired to a lesser degree. School Performance of Children with Birth Weights of 1,000 Grams or Less. Nickel RE, Bennett FC, Lamson FN. Am J Dis Child, Feb 1982; 136 (2): 105-10.
•  This study examined the relationship between very low birthweight children and possible developmental delay in the absence of frank developmental disability. Subjects were asymptomatic for disabling conditions but apparently well, very low birthweight, children were consistently at greater risk for both moderate and severe measures of delay across four functional areas. Relation Between Very Low Birth Weight and Developmental Delay Among Preschool Children Without Disabilities. Schendel DE, Stockbauer JW, Hoffman HJ, Herman AA, Berg CJ, Schramm WF. Developmental Disabilites Branch, Centers for Disease Control and Prevention, Chamblee GA, Usaam J. Epidemiol, November 1, 1997; 146 (9): 740-9.
• Fifty one children who were born at the same hospital in Liverpool, England, with weights of 1,250 grams or less were followed through age 8. The extremely low birth weight group of 8 year olds were compared with a control group of the same age, race, economic group and sex. The low birth weight children performed less well on basic math tests, spelling tests, and tests of motor impairment. Twenty three percent of very low birth weight children were having difficulty with one or more school subjects compared with 19% of controls and 26% had difficulties in 2 or more areas compared with 3% of the control group. Teachers identified characteristics typical of emotional disorders and overactivity more frequently among the very low birthweight group. The study concluded that children with birthweights of 1,250 grams or less and no major impairment have a high frequency of learning difficulties that become more apparent with advancing age. Outcome at 8 Years for Children with Birth Weights of 1,250 Grams or Less. Marlow N, Roberts L, Cooke R. Department of Child Health, Liverpool Maternity Hospital. Arch Dis Child, March 1993; 68 (3 Spec No): 286-90.
•  Neurodevelopmental, health and growth outcomes for 28 six year olds weight birthweights of less than 1,001 grams were compared with a control group of 26 full term birth children. Sixty one percent of the extremely low birth weight children had mild or moderate to severe neurological problems compared with the control group children (23%). A significant portion of extremely low birthweight children had no severe disabilities, but many had dysfunctions likely to affect learning and behavior in school. Neurodevelopmental, Health and Growth Status at Age 6 Years of Children with Birth Weights Less than 1,001 Grams. Teplin SW, Burchinal M, Johnson-Martin N, Humphry RA, Kraybill EN. Clinical Center for the Study of Development and Learning, Frank Porter Graham Child Development Center, University of North Carolina, J Pediatri, May 1991; 118 (5): 768-77.
• Thirty four long term survivors of a five year period (1977-1981) weighing 1,000 grams or less at birth were followed up at 8 to 11 years of age. Three (8.8%) of the children had severe functional handicap, seven (20.6%) had moderate impairments with the need for special schooling. Twenty four (70.6%) attended normal school but 7 (20.6%) needed special help. Infants Weighing 1,000 Grams or Less at Birth. Outcome at 8-11 Years of Age. Vekerdy-Lakatos Z, Lakatos L, Ittzes-Nagy-B. Department of Pediatrics, University Medical School, Debrecen, Hungary, Acta Paediatr Scand Suppl 1989; 360: 62-71.
• This study tested the hypothesis that very low birth weight children (less than 1.5 kg) whose head size is not normal by 8 months (adjusted age) have significantly poorer growth and neurocognitive abilities at school age than very low birth weight children with a normal head size at eight months. A group of 249 children born from 1977 to 1979 were evaluated at age 8 to 9 years; the 33 children with subnormal head sizes at the age of 8 months had significantly lower average birth weights and higher neonatal risk scores (71 versus 53) and at the age of eight years had a higher incidence of neurologic impairment (21% versus 8%) and lower IQ scores (average verbal 84 versus 98%). The conclusions of the study indicate that in very low birth weight infants, pernatal growth failure, as evidenced by a subnormal head circumference at 8 months of age, is associated with poor cognitive function, academic achievement and behavior at 8 years of age. Effect of Very Low Birth Weight and Subnormal Head Size on Cognitive Abilities at School Age. Hack M, Breslau N, Weissman B, Aram D, Klein N, Borawski E. Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland, OH. New England Journal of Medicine, July 25, 1991; 325 (4): 231-7.
• In 1990 to 1992 a study was conducted in which randomly selected and evaluated low birthweight and normal birthweight children from the 1983-1985 newborn lists of two major hospitals in Southeast Michigan. Low birth weight children scored significantly lower than normal birth weight children on tests measuring language, spatial., fine motor, tactile and attention abilities with appropriate controls for site, race, maternal IQ and education. Analysis revealed that test performance varied within birth weight levels and that performance continued to improve with increased birth weight well above 3,000 grams. Low Birth Weight and Neurocognitive Stauts at Six Years of Age. Breslau N, Chilcoat H, DelDotto J, Andreski P, Brown G. Department of Psychiatry, Henry Ford Health Sciences Center, Detroit, MI. Biol Psychiatry, Sept 1, 1996; 40 (5): 389-97.
•  Survival of extremely low birth weight infants, (less than 1,000 grams) has increased. From the period of 1943 to 1945 the survival rate of infants born weighing less than 800 grams was 0% but increased to 49% to 70% for the period 1994-1995. Rates of cerebral palsy. mental retardation, blindness and deafness have remained stable in the 1980’s and 1990’s. There is evidence. however, that the percent of functional limitations may be increasing as the requirement for special education resources among very low birthweight infants remains high at 44% to 56%. Neuropsychological and Functional Outcomes of Very Low Birth Weight Infants, Vohr BR, Msall ME. Women and Infants Hospital, Child Development Center of Rhode Island Hospital, Brown University School of Medicine, Providence, RI. Semin Perinatol, June 1997; 21 (3): 202-20.
• A study was conducted in which very low birth weight infants were compared with heavier low birth weight infants and normal birth weight children to assess the risk of behavior problems and school difficulty. Analysis revealed that 34% of very low birth weight children could be characterized as having school difficulty compared with 20% of heavier low birth weight children and 14% of normal birthweight children. Very low birthweight and hyperactivity scores contributed, independent or other sociodemographic factors, to the risk of academic problems. Very Low Birth Weight Children: Behavior Problems and School Difficulty in a National Sample. McCormick MC, Gortmaker SL, Sobol AM. Department of Behavioral Sciences, Harvard School of Public Health, Boston, Mass. J Pediatr, Nov 1990; 117 (5): 687-93.
• A review of 20 years experience with neonatal intensive care for very low birth weight infants indicates that an increasing proportion survive free of moderate to severe handicap. However, increasing literature suggests that early findings may be insufficient to characterize later outcomes, particularly problems encountered as children enter school. The study concludes that further definition of long term outcomes for very low birth weight children is critical to assess the utility of neonatal intensive care unit interventions and at the individual level for counseling families as to the health and educational needs of these children. Long Term Follow Up of Infants Discharged from Neonatal Intensive Care Units. McCormick MC. Joint Program in Neonatology, Harvard Medical School, Boston, Mass. JAMA, March 24-31, 1989; 261 (12): 1767-72.
• Children born about 3 months prematurely are 3 to 4 times more likely to struggle in school than children born full term. Compared with children born full term, students born prematurely were more likely to repeat a grade of school (33% versus 18%), receive special education (20% versus 5%) and require extra help with reading, spelling, math, handwriting, speech/language and occupational or physical therapy (16% versus 6%). Study conducted at University of Buffalo, reported in Paediatric & Perinatal Epidemiology, October 2000.
• Some studies have estimated that as many as 40 to 50% of children born prematurely will have some sort of learning disability. A study was conducted in which none of the premature children suffered from major “preemie” related health problems such as cerebral palsy, chromosonal abnormalities, hearing loss or mental retardation. According to one of the authors of the study: “In a sense, the children in our study represented a kind of sleeper phenomenon”, none had noticeable disabilities. There’s no way to pick up on some of these developmental problems in the first two years of life, so many of these children showed no outward signs of disabilities.” Predicting the Future of Premature Babies, Testing Previews Future Learning Problems, By Holly Wagner
• Almost half of children who survive extremely preterm birth have neurologic and developmental disabilities. Disability Risk for Extremely Premature Babies, Source: Yale University, (http://www.yale.edu/) Posted 10/18/2000.
• Brain scans of children born prematurely show key areas of the brain are much smaller than those of children born at full term. The study conducted by Yale researchers is the first to relate brain abnormalities in preemies to cognitive outcome and perinatal risk factors. The differences in brain volume on average were dramatic in all regions with reductions ranging from 11 to 35%. While not all preemies showed brain abnormalities, those born at a younger gestational age were most affected. The magnitudes of the abnormalities were directly proportional to how early the children were born and were strongly associated with the IQ of the children at age 8 years. “Premature birth at less than 1,000 grams birth weight (approximately 2 lbs) is a major cause of developmental disability. Infants in this birth weight range represent almost 1% of all births in our country, and the survival rate of these infants is well over 80%, but the incidence of handicap is high. By age 8 years, over 5% are in special education or receiving extensive resource room help. One fifth have already repeated a grade of school.” according to Dr. Laura Ment. “The study shows that when brains develop prematurely outside of the womb, they are vulnerable to developmental disturbances.” Dr. Bradley Peterson. Brain Size in Premature Infants Significantly Smaller than Full Term Babies; Source: Journal of American Medical Association 10/18/2000
• A quarter of a million babies a year are born prematurely in the United States and the ones doctors can save are getting smaller and smaller. But not getting the chance to finish their time in the womb may come back to haunt these children. A study conducted by British researchers showed that 52% of preemies had problems at age 2 ½, though many other prematurity related problems did not show up until age 5. University of Nottingham, published in New England Journal of Medicine, source EXN Staff, October 17, 2000.
• Children born extremely prematurely, weighing 2 lbs or less at birth, experience significant learning disabilities that persist into their teenage years. A study conducted at McMaster University in Hamilton, Ontario, Canada, followed 150 premature babies into their teens. Nearly half were receiving special education assistance, compared with just 10% of a control group of children who were not born prematurely but were similar in gender, age and social class. 25% of “preemies” had repeated a grade, compared with just 6% of the control group. Fewer than half of the smallest preemies (those born weighing 1 lb, 9 oz and under) scored in the normal range on most intelligence and achievement tests. Preemies Have Trouble Into Adolescence, Chicago AP
•  The outlook for children born extremely prematurely is precarious at best. Many parents do not know what to expect and their doctors do not know what to tell them. A new study from the United Kingdom suggests that extremely preterm babies who survive to leave the hospital have about a 50-50 chance of being free of disability at age 2 ½ years. Extremely Premature Babies at Risk of Severe Disability, New England Journal of Medicine 2000; 43. 378-384, 429-430.
• At the adjusted age of 5 years the development of 106 children born 5 or more weeks before term was compared with the development of 103 children born at term. No children with cerebral palsy were included and the groups were matched in terms of sex, age, birthplace, race and residential location. The results indicated a significant difference between the two groups including preterm children having small involuntary hand movements, less competent gross motor ability, poorer verbal performance and more variability in behavior postural response and balance. A higher than average incidence of minor motor, speech, behavior and learning problems in early school years is probable. Language and Motor Development in Pre Term Children: Some Questions. Le Normand MT, Vaivre-Douret L, Delfosse MJ. INSERM, Hospital de La Salpetriere, Paris, France. Child Care Health Dev, March 1995; 21 92) 119-33.
• A study conducted in a Southern Swedish population compared extremely preterm children to a control group of full term children at age 10. Health, cognitive development, school achievement and behavior were evaluated. Thirty eight percent of the extremely preterm children performed below grade level at school. Thirty two percent had general behavioral problems and 20% had attention deficit hyperactivity disorder compared with 10% and 8 % respectively in the full term group. The study concluded that extremely preterm children require intervention to support development and reduce behavioral problems. Ten Year Follow Up of Children Born Before 29 Gestational Weeks: Health, Cognitive Development, Behaviour and School Achievement. Stjernqvist K, Svenningsen NW. Department of Psychology, Lund University, Sweden. Acta Paediatr, May 1999; 88 (5): 557-62.
• Cognition, school performance and behavior were assessed at 8 years of age in 132 very low birth weight children who were otherwise free of major sensineural impairments and were compared with a control group of full term normal birthweight children. While the very low birth weight children were developing normally in many academic and social areas they were significantly inferior on tests of cognition, including tests of intelligence and visual memory and on teachers’ reports of motor skills and intelligence. Proportionally more very low birth weight children (20.5%) than normal birth weight children (5.9%) were reported by their parents to be not coping at school. Cognition, School Performance and Behavior in Very Low Birth Weight and Normal Birth Weight Children at 8 Years of Age: A Longitudinal Study. Rickards AL, Kitchen WH, Doyle LW, Ford GW, Kelly EA, Callanan C. Division of Pediatrics, Royal Women’s Hospital, Melbourne, Australia. J Dev Pediatr, December 1993; 14 (6): 363-8.
• The intellectual, psychoeducational and functional status of a group of 129 extremely low birth weight children born between 1977-1981 and weighing 501 to 1,800 grams at birth were compared with a matched control group. The children were tested at an average unadjusted age of 8 years. The average IQ was 91 for extremely low birth weight children and 104 for the control group. Between 8 to 12% scored in the abnormal IQ range compared with 1 to 2% of the control group. The low birth weight children did less well on reading, spelling and math tests and their motor performance and visual motor integration were poorer. Approximately 15% of the extremely low birth weight study participants perfomred in the abnormal range on the Vineland Adaptive Behavior Scales. Although about 2/3rds fo the low birth weight children performed in the normal range on intellectual measures they were significantly disadvantaged on every measure tested. Cognitive Abilities and School Performance of Extremely Low Birth Weight Children and Matched Term Control Children at Age 8 Years: A Regional Study. Saigal S, Szatmari P, Rosenbaum P, Campbell D, King S. Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada. J Pediatri, May 1991; 118 (5): 751-60.
• A study was conducted to examine developmental and educational outcomes in a group fo predominantly white, middle class, extremely low birth weight children (less than 1,000 grams birthweight). Fifty four extremely low birthweight children with an average age of 7 were compared to a children in a control group matched for gender, race and socioeconomic factors and were sorted to low and normal birthweight groups. Teachers’ reports, special education evaluations, and test of cognitive, motor, language and visual motor integration abilities were studied. Fifty percent of the extremely low birth weight children were in regular classrooms compared to 70% of low birth weight children and 93% of full term children. The extremely low birth weight children scored significantly lower than the comparison groups on all tests. While 79% of the extremely low birthweight children had average cognition scores, they average 14 to 17 points lower than the two comparison groups. Twenty percent of the extremely low birth weight children had significant disabilities including cerebral palsy, mental retardation, autism and low intelligence with severe learning problems. The study concluded that there is an increasing need for special services with decreasing birth weights. Even with optimal socioeconomic environments, 20% of extremely low birthweight children are significantly disabled and 1 out of every 2 extremely low birth weight children requires special educational services. Extremely Low Birth Weight Children and Their Peers, A Comparision of School-Age Outcomes, Halsey CL, Collin MF, Anderson CL. Loyola University Medical Center, Maywood, ILL, USA Arch Pediatric Adolesc Med August 1996; 150 (8): 790-4.
• Children with a birthweight of 2,000 grams or less born in Merseyside, England from 1980-1981 were assessed at age 8. The children and a matched control group were assessed using the Wechsler Intelligence Scale for Children (WISC) , the Neale analysis of Reading ability and the Stott-Moyes-Henderson test of Motor Impairment (TOMI). Children with low birth weight had a lower WISC IQ score, a lower reading age, and poorer motor performance. Clinical and Subclinical Deficits at 8 Years in a Geographically Defined Cohort of Low Birthweight Infants. Pharoah PO, Stevenson CJ, Cooke RW, Stevenson RC. Department of Public Health, University of Liverpool, Arch Dis Child, April 1994; 70 (4): 246-70.

source : http://www.prematurity.org

Supported by

Clinic For Children Yudhasmara Foundation http://childrenclinic.wordpress.com/

Monitoring and FollowUp of Prematurity Clinic Online

JL Taman Bendungan Asahan 5 Bendungan Hilir Jakarta Pusat Phone :62 (021) 70081995 – 5703646   

Clinical and Editor in Chief :

Dr Widodo Judarwanto SpA, pediatrician

email : judarwanto@gmail.com,

Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. You should not use the information on this web site for diagnosing or treating a medical or health condition. You should carefully read all product packaging. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider. 

Copyright © 2010, Clinic For Children Information Education Network. All rights

Bayi prematur terutama dengan gangguan hipersensitif saluran cerna (khususnya yang sering muntah dan mual) sering mengalami gangguan pergerakan motorik otot mulut (gangguan oral motor). Berbagai gangguan yang dialami adalah gangguan bicara, keterlambatan bicara, gangguan mengunyah dan menelan. Berbagai gangguan tersebut dapat dilakkan penangnan dengan pendekatan intervensi diet hipersensitif makanan. Intervensi lain yang dapat dilakukan adalah dengan menggunakana terapi oral motor.

“Motor Oral” telah didefinisikan dalam berbagai cara dalam literatur ilmiah.  Berbagai strategi dan tehnik telah dilakukan dalam teknik stimulasi terutama, seperti menyikat (pijat tekanan), icing (stimulasi termal), peregangan cepat (penyadapan), dan getaran (manual dan mekanis). Strategi ini telah digunakan untuk mempersiapkan area otot untuk gerakan.  Strategi ini tidak dapat mengubah rentang pergerakan otot atau kekuatan otot tanpa gerakan otot tambahan.  Teknik oral motor yang lainnya memerlukan kerjasama individu untuk mengikuti perintah untuk menyelesaikan gerakan. 

Intervensi ini khusus yang memberikan bantuan gerakan untuk mengaktifkan kontraksi otot dan untuk memberikan gerakan terhadap perlawanan untuk membangun kekuatan. Fokus intervensi ini adalah untuk meningkatkan respons fungsional terhadap tekanan dan gerakan, jangkauan, kekuatan, dan pengendalian berbagai gerakan bibir, pipi, rahang dan lidah.  Intervensi yang diperlukan ditentukan oleh penilaian kemampuan oral motor. Perangkat yang dilakukan adalah dengan menggunakan gerakan dibantu dan refleks peregangan untuk mengukur respon terhadap tekanan dan gerakan, jangkauan, kekuatan, dan kontrol berbagai gerakan untuk pipi bibir, rahang, lidah dan langit-langit lunak. Penilaian ini didasarkan pada parameter fungsional didefinisikan secara klinis kompetensi minimal dan tidak memerlukan partisipasi kognitif individu.Karena komponen-komponen gerakan yang fungsional, bukan usia tertentu, protokol berguna dengan berbagai usia dan kategori diagnostik. 

 Keterampilan motorik oral sangat penting untuk fungsi-fungsi dasar yang terjadi bahkan ketika kita tidur, seperti mengendalikan sekresi, menelan, dan menjaga keselarasan struktur oral sehingga pernapasan yang tidak terganggu.. oral motor ketrampilan dasar kelangsungan hidup dampak seperti mengisap dan menelan dengan bayi yang mulai dengan bulan ketiga kehamilan. Pengembangan keterampilan ini meningkatkan perkembangan dari ASI atau susu formula, lalu ke makanan bubur, dan pada meja makanan, serta keterampilan yang diperlukan untuk kemajuan dari mengisap puting, untuk menggunakan berbagai peralatan, termasuk sedotan, cangkir, sendok, dan garpu. keterampilan oral juga berdampak pada kontrol yang diperlukan untuk perkembangan bicara, dari memproduksi berdekut suara sebagai bayi, untuk mengartikulasikan kata-kata kompleks dalam pidato percakapan.  oral keterampilan motorik yang buruk dapat mengakibatkan berkurangnya pengembangan keterampilan atau tertunda untuk daerah yang tercantum di atas. 

Keterampilan motorik oral dipengaruhi oleh banyak hal yang berbeda di bagian luar dan di bagian dalam tubuh.  Posisi dan penyelarasan tubuh mempengaruhi gerakan lisan. Bagaimana peringatan individu juga mempengaruhi keterampilan oral.  Karena itu, banyak profesional berperan dalam meningkatkan keterampilan motorik oral.  Pendekatan terapi oral motor adalah berbagai rangkaian intervensi mulai dari menilai kemampuan motorik oral, rencana intervensi oral motor dibutuhkan dan bekerja sama dengan anggota tim lainnya: pemberi perawatan, terapi okupasi, terapi fisik, ahli diet, guru, psikolog, dokter, perawat, apoteker dan lainnya sesuai kebutuhan. 

GANGGUAN ORAL MOTOR YANG SERING DIALAMI BAYI PREMATUR

• Bicara terburu-buru, cadel, gagap.
• Keterlambatan bicara.
• Sering timbul ngeces atau drooling (keliar air liur berlebihan)
• Picky Eater (pemilih makanan) terjadi akibat gangguan GANGGUAN MENELAN DAN MENGUNYAH, tidak bisa  makan makanan berserat tertentusapi, sayur  nasi) . Biasanya yang lebih disukai adalah telor, mi, nugget dan makanan yang crispy seperti krupuk atau makanan yang renyah lainnya. Tidak suka makanan yang lengket atau berbau tajam.
• Pada bayi anak sulit minum atau minum hanya sedikit atau memakai sendok sulit memakai dot.
• Pada anak tampak dengan gejala makan yang sangat cepat tanpa dikunyah.
• Sulit untuk menggosok gigi.
• Gangguan meniup
• Disertai keterlambatan pertumbuhan gigi.
  

Supported by

Clinic For Children Yudhasmara Foundation http://childrenclinic.wordpress.com/

Monitoring and FollowUp of Prematurity Clinic Online http://prematureclinic.wordpress.com

JL Taman Bendungan Asahan 5 Bendungan Hilir Jakarta Pusat Phone :62 (021) 70081995 – 5703646   

Clinical and Editor in Chief :

Dr Widodo Judarwanto SpA, pediatrician

email : judarwanto@gmail.com,

Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. You should not use the information on this web site for diagnosing or treating a medical or health condition. You should carefully read all product packaging. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider. 

Copyright © 2010, Clinic For Children Information Education Network. All rights

Bayi dengan kelahiran prematur sering menimbulkan dampak kesehatan di kemudian hari, yang berakibat terjadi berbagai gangguan pertumbuhan dan perkembangan. Sebagian besar bayi dengan kelahiran prematur mengalami alergi dan hipersensitifitas saluran cerna. Gangguan ini sering berkaitan dengan alergi makanan dan hipersensitifitas makanan.

Penelitian yang telah dilakukan Judarwanto W menunjukkan bahwa hampir sebagian besar bayi atau sekitar 89% mengalami gangguan alergi dan hipersensitifitas saluran cerna. Ternyata gangguan ini sering berakibat dan berdampak pada berbagai organ dan sistem tubuh tanpa disadari. Telah dilakukan peneletian prospektif terhadap 225 bayi dengan kel;ahiran prematur yang di amati dalam 12 tahun kehidupannya.

Gangguan alergi dan hipersensitifitas saluran cerna adalah gangguan fungsional saluran cerna yang tidak mengalami gangguan organ dengan mengekslusi kelainan kongenital atai kelainan infeksi kongenital lainnya. Ganngguan saluran cerna tersebut berkaitan dengan gangguan alergi makanan dan hipersensitifitas makanan.

Tanda dan Gejala gangguan Alergi dan Hipersensitif Saluran Cerna Bayi prematur di kemudian hari

• Pada Bayi  : GASTROOESEPHAGEAL REFLUKS ATAU GER, Sering MUNTAH/gumoh, kembung,“cegukan”, buang angin keras dan sering, sering rewel gelisah (kolik) terutama malam hari, BAB > 3 kali perhari, BAB tidak tiap hari. Feses warna hijau,hitam dan berbau.  Sering “ngeden & beresiko Hernia Umbilikalis (pusar), Scrotalis, inguinalis. Air liur berlebihan. Lidah/mulut sering timbul putih, bibir kering, sebagian bibir bagian dalam berwarna kehitaman.
• Pada anak yang lebih besar :

1. Mudah MUNTAH bila menangis, berlari atau makan banyak. MUAL pagi hari.
2. Sering Buang Air Besar (BAB)  3 kali/hari atau lebih, sulit BAB sering ngeden kesakitan saat BAB (obstipasi). Kotoran bulat kecil hitam seperti kotoran kambing, keras, warna hitam, hijau dan bau tajam. sering buang angin, berak di celana. Sering KEMBUNG, sering buang angin dan bau tajam. Sering NYERI PERUT, tidur malam nungging (biasanya karena perut tidak nyaman)
3. Nyeri gigi, gigi berwarna kuning kecoklatan, gigi rusak, gusi mudah bengkak/berdarah. Bibir kering dan mudah berdarah, sering SARIAWAN, lidah putih & berpulau, mulut berbau, air liur berlebihan.

• KULIT : sering timbul bintik kemerahan terutama di pipi, telinga dan daerah yang tertutup popok. Kerak di daerah rambut. Timbul bekas hitam seperti tergigit nyamuk. Kotoran telinga berlebihan & berbau. Bekas suntikan BCG bengkak dan bernanah. Timbul bisul.
• SALURAN NAPAS : Napas grok-grok, kadang disertai batuk ringan. Sesak pada bayi baru lahir disertai kelenjar thimus membesar (TRDN/TTNB)
• HIDUNG : Bersin, hidung berbunyi, kotoran hidung banyak, kepala sering miring ke salah satu sisi karena salah satu sisi hidung buntu, sehingga beresiko ”KEPALA PEYANG”.
• MATA : Mata berair atau timbul kotoran mata (belekan) salah satu sisi.
• KELENJAR : Pembesaran kelenjar di leher dan kepala belakang bawah.
• PEMBULUH DARAH :  telapak tangan dan kaki seperti pucat, sering terba dingin
• GANGGUAN HORMONAL : keputihan/keluar darah dari vagina, timbul bintil merah bernanah, pembesaran payudara, rambut rontok.
• PERSARAFAN : Mudah kaget bila ada suara keras. Saat menangis : tangan, kaki dan bibir sering gemetar atau napas tertahan/berhenti sesaat (breath holding spells)
• PROBLEM MINUM ASI : minum berlebihan, berat berlebihan krn bayi sering menangis dianggap haus (haus palsu : sering menangis belum tentu karena haus atau bukan karena ASI kurang.). Sering menggigit puting sehingga luka. Minum ASI sering tersedak, karena hidung buntu & napas dengan mulut. Minum ASI lebih sebentar pada satu sisi,`karena satu sisi hidung buntu, jangka panjang bisa berakibat payudara besar sebelah.

• SALURAN NAPAS DAN HIDUNG : Batuk / pilek lama (>2 minggu), ASMA, bersin, hidung buntu, terutama malam dan pagi hari. MIMISAN, suara serak, SINUSITIS, sering menarik napas dalam.
• KULIT : Kulit timbul BISUL, kemerahan, bercak putih dan bekas hitam seperti tergigit nyamuk. Warna putih pada kulit seperti ”panu”. Sering menggosok mata, hidung, telinga, sering menarik atau memegang alat kelamin karena gatal. Kotoran telinga berlebihan, sedikit berbau, sakit telinga bila ditekan (otitis eksterna).
• SALURAN CERNA : Mudah MUNTAH bila menangis, berlari atau makan banyak. MUAL pagi hari. Sering Buang Air Besar (BAB)  3 kali/hari atau lebih, sulit BAB (obstipasi), kotoran bulat kecil hitam seperti kotoran kambing, keras, sering buang angin, berak di celana. Sering KEMBUNG, sering buang angin dan bau tajam. Sering NYERI PERUT.
• GIGI DAN MULUT : Nyeri gigi, gigi berwarna kuning kecoklatan, gigi rusak, gusi mudah bengkak/berdarah. Bibir kering dan mudah berdarah, sering SARIAWAN, lidah putih & berpulau, mulut berbau, air liur berlebihan.
• PEMBULUH DARAH Vaskulitis (pembuluh darah kecil pecah) : sering LEBAM KEBIRUAN pada tulang kering kaki atau pipi atas seperti bekas terbentur. Berdebar-debar, mudah pingsan, tekanan darah rendah.
• OTOT DAN TULANG : nyeri kaki atau kadang  tangan, sering minta dipijat terutama saat malam hari. Kadang nyeri dada
• SALURAN KENCING : Sering minta kencing, BED WETTING (semalam  ngompol 2-3 kali)
• MATA : Mata gatal, timbul bintil di kelopak mata (hordeolum). Kulit hitam di area bawah kelopak mata. memakai kaca mata (silindris) sejak usia 6-12 tahun.
• HORMONAL : rambut berlebihan di kaki atau tangan, keputihan, gangguan pertumbuhan tinggi badan.
• Kepala,telapak kaki/tangan sering teraba hangat. Berkeringat berlebihan meski dingin (malam/ac). Keringat  berbau.
• FATIQUE :  mudah lelah, sering minta gendong

• SUSUNAN SARAF PUSAT : sakit kepala, MIGRAIN, TICS (gerakan mata sering berkedip), , KEJANG NONSPESIFIK (kejang tanpa demam & EEG normal).
• GERAKAN MOTORIK BERLEBIHAN Mata bayi sering melihat ke atas. Tangan dan kaki bergerak terus tidak bisa dibedong/diselimuti. Senang posisi berdiri bila digendong, sering minta turun atau sering menggerakkan kepala ke belakang, membentur benturkan kepala. Sering bergulung-gulung di kasur, menjatuhkan badan di kasur (“smackdown”}. ”Tomboy” pada anak perempuan : main bola, memanjat dll.
• AGRESIF MENINGKAT sering memukul kepala sendiri, orang lain. Sering menggigit, menjilat, mencubit, menjambak (spt “gemes”)
• GANGGUAN KONSENTRASI: cepat bosan sesuatu aktifitas kecuali menonton televisi,main game, baca komik, belajar. Mengerjakan sesuatu  tidak bisa lama, tidak teliti, sering kehilangan barang, tidak mau antri, pelupa, suka “bengong”, TAPI ANAK TAMPAK CERDAS
• EMOSI TINGGI (mudah marah, sering berteriak /mengamuk/tantrum), keras kepala, negatifisme
• GANGGUAN KESEIMBANGAN KOORDINASI DAN MOTORIK : Terlambat bolak-balik, duduk, merangkak dan berjalan. Jalan terburu-buru, mudah terjatuh/ menabrak, duduk leter ”W”. 
• GANGGUAN SENSORIS : sensitif terhadap suara (frekuensi tinggi) , cahaya (mudah silau), perabaan telapak kaki dan tangan sensitif  (jalan jinjit, flat foot, mudah geli, mudah jijik, tidak suka memegang bulu, boneka dan bianatang berbulu)
• GANGGUAN ORAL MOTOR : TERLAMBAT BICARA, bicara terburu-buru, cadel, gagap. GANGGUAN MENELAN DAN MENGUNYAH, tidak bisa  makan makanan berserat (daging sapi, sayur, nasi) Disertai keterlambatan pertumbuhan gigi.
• IMPULSIF : banyak bicara,tertawa berlebihan, sering memotong pembicaraan orang lain
• Memperberat gejala AUTIS dan ADHD (Alergi dan hipersensititas makanan bukan penyebab Autis atau ADHD tetapi hanya memperberat gejalanya)

• Daya tahan menurun sering sakit demam, batuk, pilek setiap bulan bahkan sebulan 2 kali. (normal sakit seharusnya 2-3 bulan sekali)
• Karena sering sakit berakibat Tonsilitis kronis (AMANDEL MEMBESAR) hindari operasi amandel yang tidak perlu  atau mengalami Infeksi Telinga
• Waspadai dan hindari efek samping PEMAKAIAN OBAT TERLALU SERING. 
• Mudah mengalami INFEKSI SALURAN KENCING.  Kulit di sekitar kelamin sering kemerahan 
• SERING TERJADI OVERDIAGNOSIS TBC  (MINUM OBAT JANGKA PANJANG PADAHAL BELUM TENTU MENDERITA TBC / ”FLEK ”)  KARENA GEJALA ALERGI MIRIP PENYAKIT TBC. BATUK LAMA BUKAN GEJALA TBC PADA ANAK BILA DIAGNOSIS TBC MERAGUKAN SEBAIKNYA ”SECOND OPINION” DENGAN DOKTER LAINNYA  
• MENGALAMI RESIKO GIZI GANDA : Pada sebagian kelompok mengalami kesulitan makan dan gangguan kenaikkan berat badan sebagian kecil lainnya mengalami ganmgguan MAKAN BERLEBIHAN KEGEMUKAN atau OBESITAS
• INFEKSI JAMUR (HIPERSENSITIF CANDIDIASIS) di lidah, selangkangan, di leher, perut atau dada, KEPUTIHAN

• Diagnosis gangguan alergi makanan dan hipersensitifitas saluran cerna pada bayi prematur disebabkan  alergi atau hipersensitif makanan dibuat bukan dengan tes alergi tetapi berdasarkan diagnosis klinis, yaitu anamnesa (mengetahui riwayat penyakit penderita) dan pemeriksaan yang cermat tentang riwayat keluarga, riwayat pemberian makanan, tanda dan gejala alergi makanan sejak bayi dan dengan eliminasi dan provokasi.
• Untuk memastikan makanan penyebab alergi dan hipersensitifitas makanan harus menggunakan Provokasi makanan secara buta (Double Blind Placebo Control Food Chalenge = DBPCFC). DBPCFC adalah gold standard atau baku emas untuk mencari penyebab secara pasti alergi makanan. Cara DBPCFC tersebut sangat rumit dan membutuhkan waktu, tidak praktis dan biaya yang tidak sedikit.
• Beberapa pusat layanan alergi anak melakukan modifikasi terhadap cara itu. Children Allergy clinic Jakarta melakukan modifikasi dengan cara yang lebih sederhana, murah dan cukup efektif. Modifikasi DBPCFC tersebut dengan melakukan “Eliminasi Provokasi Makanan Terbuka Sederhana”. Bila setelah dilakukan eliminasi beberapa penyebab alergi makanan selama 3 minggu didapatkan perbaikan dalam gangguan muntah tersebut, maka dapat dipastikan penyebabnya adalah alergi makanan.
• Pemeriksaan standar yang dipakai oleh para ahli alergi untuk mengetahui penyebab alergi adalah dengan tes kulit. Tes kulit ini bisa terdari tes gores, tes tusuk atau tes suntik. PEMERIKSAAN INI HANYA MEMASTIKAN ADANYA ALERGI ATAU TIDAK, BUKAN UNTUK MEMASTIKAN PENYEBAB ALERGI. Pemeriksaan ini mempunyai sensitifitas yang cukup baik, tetapi sayangnya spesifitasnya rendah. Sehingga seringkali terdapat false negatif, artinya hasil negatif belum tentu bukan penyebab alergi. Karena hal inilah maka sebaiknya tidak membolehkan makan makanan penyebab alergi hanya berdasarkan tes kulit ini.  
• Dalam waktu terakhir ini sering dipakai alat diagnosis yang masih sangat kontroversial atau ”unproven diagnosis”. Terdapat berbagai pemeriksaan dan tes untuk mengetahui penyebab alergi dengan akurasi yang sangat bervariasi. Secara ilmiah pemeriksaan ini masih tidak terbukti baik sebagai alat diagnosis. Pada umumnya pemeriksaan tersebut mempunyai spesifitas dan sensitifitas yang sangat rendah. Bahkan beberapa organisasi profesi alergi dunia tidak merekomendasikan penggunaan alat tersebut. Yang menjadi perhatian oraganisasi profesi tersebut bukan hanya karena masalah mahalnya harga alat diagnostik tersebut tetapi ternyata juga sering menyesatkan penderita alergi yang sering memperberat permasalahan alergi yang ada
• Namun pemeriksaan ini masih banyak dipakai oleh praktisi kesehatan atau dokter. Di bidang kedokteran pemeriksaan tersebut belum terbukti secara klinis sebagai alat diagnosis karena sensitifitas dan spesifitasnya tidak terlalu baik. Beberapa pemeriksaan diagnosis yang kontroversial tersebut adalah Applied Kinesiology, VEGA Testing (Electrodermal Test, BIORESONANSI), Hair Analysis Testing in Allergy, Auriculo-cardiac reflex, Provocation-Neutralisation Tests, Nampudripad’s Allergy Elimination Technique (NAET), Beware of anecdotal and unsubstantiated allergy tests.

 PENATALAKSANAAN 

• Penanganan permasalahan gangguan alergi makanan dan hipersensitifitas makanan pada bayi prematur dikemudian hari  haruslah dilakukan secara benar, paripurna dan berkesinambungan. Pemberian obat terus menerus bukanlah jalan terbaik dalam penanganan gangguan tersebut tetapi yang paling ideal adalah menghindari penyebab yang bisa menimbulkan keluhan alergi tersebut.    
• Penghindaran makanan penyebab alergi dan hipersensitifitas makanan pada anak harus dicermati secara benar, karena beresiko untuk terjadi gangguan gizi. Sehingga orang tua penderita harus diberitahu tentang makanan pengganti yang tak kalah kandungan gizinya dibandingklan dengan makanan penyebab alergi. Penghindaran terhadap susu sapi dapat diganti dengan susu soya, formula hidrolisat kasein atau hidrolisat whey., meskipun anak alergi terhadap susu sapi 30% diantaranya alergi terhadap susu soya. Sayur dapat dipakai sebagai pengganti buah. Tahu, tempe, daging sapi atau daging kambing dapat dipakai sebagai pengganti telur, ayam atau ikan. Pemberian makanan jadi atau di rumah makan harus dibiasakan mengetahui kandungan isi makanan atau membaca label makanan.  
• Obat-obatan simtomatis seperti pencahar, anti histamine (AH1 dan AH2), ketotifen, ketotofen, kortikosteroid, serta inhibitor sintesaseprostaglandin hanya dapat mengurangi gejala sementara bahkan dlamkeadaan tertentu seringkali tidak bermanfaat, umumnya mempunyai efisiensi rendah. Sedangkan penggunaan imunoterapi dan natrium kromogilat peroral masih menjadi kontroversi hingga sekarang.  

Obat

• Penanganan permasalahan gangguan alergi makanan dan hipersensitifitas makanan pada bayi prematur dikemudian hari yang baik adalah dengan menanggulangi penyebabnya. Bila gangguan sulit makan yang dialami disebabkan karena gangguan alergi dan hipersensitifitas makanan, penanganan terbaik adalah menunda atau menghindari makanan sebagai penyebab tersebut.    
• Konsumsi obat-obatan saluran cerna atau pencahar, pola makan serat, buah dan air putih banyak, terapi tradisional ataupun beberapa cara dan strategi untuk menangani Gangguan Buang Air Besar (Konstipasi) Pada Anak tidak akan berhasil selama penyebab utama  alergi dan hipersensitifitas makanan tidak diperbaiki.

Daftar Pustaka :

• Liem JJ, Kozyrskyj AL, Huq SI, Becker AB. The risk of developing food allergy in premature or low-birth-weight children.J Allergy Clin Immunol. 2007 May;119(5):1203-9. Epub 2007 Mar 26.
• Judarwanto W. Follow Up of developing allergy and hypersensitivity gastrointestinal in premature or low-birth-weight children. (unpublished)
• Torpy JM, et al. Premature infants. Journal of the American Medical Association. 2005;294:390.
• Hass DM, et al. Tocolytic therapy: A meta-analysis and decision analysis. Obstetrics & Gynecology. 2009;113:585.
• Pregnancy: Frequently asked questions. American Dental Association. http://www.ada.org/public/topics/pregnancy_faq.asp. Accessed Oct. 7, 2009.
• Coping with the NICU experience: The NICU roller coaster. March of Dimes. http://www.marchofdimes.com/prematurity/21292_11191.asp. Accessed Oct. 16, 2009.
• Parenting in the NICU: Feeding your baby. March of Dimes. http://www.marchofdimes.com/prematurity/21295_6091.asp. Accessed Oct. 16, 2009.
• Hovi P, et al. Glucose regulation in young adults with very low birth weight. The New England Journal of Medicine. 2007;356:2053.
• Stephens BE, et al. Neurodevelopmental outcome of the premature infant. Pediatric Clinics of North America. 2009;56:631.
• Lockwood CJ. Overview of preterm labor and delivery. http://www.uptodate.com/home/index.html. Accessed Oct. 5, 2009.
• Behrman RE, et al. Preterm Birth: Causes, Consequences, and Prevention. Washington, D.C.: The National Academies Press; 2007.
• Robinson JN, et al. Risk factors for preterm labor and delivery. http://www.uptodate.com/home/index.html. Accessed Oct. 5, 2009.
• Preterm labor. March of Dimes. http://www.marchofdimes.com/pnhec/188_1080.asp. Accessed Oct. 15, 2009.
• American College of Obstetricians and Gynecologists. Management of preterm labor. International Journal of Gynecology & Obstetrics. 2003;82:127.
• Preterm labor. American College of Obstetricians and Gynecologists. http://www.acog.org/publications/patient_education/bp087.cfm. Accessed Oct. 7, 2009.
• Johnson JR, et al. Cervical insufficiency. http://www.uptodate.com/home/index.html. Accessed Oct. 16, 2009.
• Rotteveel J, et al. Infant and childhood growth patterns, insulin sensitivity, and blood pressure in prematurely born young adults. Pediatrics. 2008;122:313.
• McLenan D. Care of the high-risk neonate. In: Rakel RE, et al. Conn’s Current Therapy 2009. Philadelphia, Pa.: Saunders Elsevier; 2009. http://www.mdconsult.com/das/book/body/165165325-12/0/2159/511.html?tocnode=58019811&fromURL=511.html#4-u1.0-B978-1-4160-5974-5..00259-8_4198. Accessed Oct. 16, 2009.

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Monitoring and FollowUp of Prematurity Clinic Online http://prematureclinic.wordpress.com

JL Taman Bendungan Asahan 5 Bendungan Hilir Jakarta Pusat Phone :62 (021) 70081995 – 5703646   

Clinical and Editor in Chief :

Dr Widodo Judarwanto SpA, pediatrician

email : judarwanto@gmail.com,

Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. You should not use the information on this web site for diagnosing or treating a medical or health condition. You should carefully read all product packaging. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider. 

Copyright © 2010, Clinic For Children Information Education Network. All rights

Kelahiran prematur mempunya dampak dan resiko gangguan tumbuh dan berkembang di kemudian hari. Berbagai penelitian telah dilakukan untuk mengetahui dampak akibat kelahiran prematur. Salah satu dampak yang terjadi pada penderita bayi prematur adalah masalah gangguan belajar.

Hampir dari setengah bayi yang dilahirkan secara prematur akan menghadapi masalah seperti ketidakmampuan dan kesulitan belajar dikemudian hari. Sebuah penelitian dilakukan terhadap 1.200 bayi yang dilahirkan sebelum 26 pekan dari 38 pekan yang seharusnya dilalui oleh seorang ibu dalam masa kehamilan.  Selain itu  bayi dengan kelahiran prematur beresiko memakai  kacamata lebih didni. Saat sang bayi prematur ini tumbuh dewasa, maka pada usia 6 tahun resiko ini akan mengalami kenaikan dua kali lipat.

Studi The Epicure didasari atas monitoring bayi yang dilahirkan di Inggris dan Irlandia pada tahun 1995 khususnya bayi yang dilahirkan sebelum kehamilan memasuki pekan ke-26. The Epicure menyatakan bahwa publikasi yang mereka berikan dengan tujuan agar para orangtua bisa mengerti masalah yang akan dihadapi oleh anak mereka yang dilahirkan secara prematur.

Untuk bayi laki-laki resiko terkena sejumlah masalah itu akan 2.4 kali lebih tinggi ketimbang bayi perempuan. Namun peneliti tidak bisa menjelaskan penyebab ketidakmampuan dari resiko yang diterima oleh sang bayi prematur itu.

Gangguan belajar adalah defisiensi pada kemampuan belajar sepesifik dalam konteks

Tipe-tipe Gangguan Belajar

• Gangguan pemusatan perhatian atau Gangguan Konsentrasi
• Gangguan Matematika  Gangguan Metematika menggambarkan anak-anak dengan kekurangan kemampuan aritmatika.
• Gangguan Menulis Gangguan Menulis mengacu pada anak-anak dengan keterbatasan kemampaun menulis
• Gangguan Membaca ( disleksia ) Gangguan Membaca –disleksia- mengacu pada anak-anak yang memiliki perkembangan ketrampilan yang buruk dalam mengenali kata-kata dan memahami bacaan.

sumber : http://insciences.org/article.php?article_id=3242

Supported by

Clinic For Children Yudhasmara Foundation http://childrenclinic.wordpress.com/

Monitoring and FollowUp of Prematurity Clinic Online http://prematureclinic.wordpress.com

JL Taman Bendungan Asahan 5 Bendungan Hilir Jakarta Pusat Phone :62 (021) 70081995 – 5703646   

Clinical and Editor in Chief :

Dr Widodo Judarwanto SpA, pediatrician

email : judarwanto@gmail.com,

Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. You should not use the information on this web site for diagnosing or treating a medical or health condition. You should carefully read all product packaging. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider. 

Copyright © 2010, Clinic For Children Information Education Network. All rights

Penelitian terkini meunjukkan bahwa seorang ibu yang lahir prematur atau memiliki saudara yang lahir prematur 60 persen berisiko melahirkan bayi prematur pada kehamilan pertama. Kehamilan berikutnya, potensi kelahiran prematur menurun menjadi 50 persen.

Kelahiran prematur mempunya dampak dan resiko gangguan ppertumbuhan dan perkembangan di kemudian hari. Berbagai penelitian telah dilakukan untuk mengetahui permasalahan dan pencegahan kelahiran prematur. Secara pasti masih belum diketahui penyebab kelahiran prematur pada bayi tertentu. Dari berbagai penelitian telah didapatkan berbagai faktor resiko mengapat terjadi kelahiran bayi prematur.

Penelitian  di Universitas Aberdeen didapatkan dari data ibu dan anak perempuan yang melahirkan di Aberdeen antara September 1948 dan Maret 2008. Peneliti menggunakan data catatan bersalin 22.343 pasangan ibu-anak untuk mengeksplorasi kemungkinan penyebab genetik kelahiran prematur spontan.

Kelahiran prematur adalah penyebab utama kematian pada bayi baru lahir dan salah satu faktor resiko gangguan tumbuh kembang pada anak.  
Dr Sohinee Bhattacharya, Di Bagian Kebidanan Epidemiologi di University of Aberdeen mengatakan, hubungan antara ibu yang lahir prematur dan menyebabkan kelahiran prematur pada bayi mereka digunakan untuk memprediksi dan mencegah kelahiran prematur pada kehamilan berisiko tinggi. “Penelitian kami mendukung adanya kecenderungan genetik pada janin untuk lahir prematur. Penelitian lebih lanjut harus berfokus pada identifikasi gen yang menyebabkan kondisi tersebut.

 sumber : http://www.telegraph.co.uk/health/healthnews/7760711/Women-born-prematurely-more-likely-to-have-premature-babies.html

Supported by

Clinic For Children Yudhasmara Foundation http://childrenclinic.wordpress.com/

Monitoring and FollowUp of Prematurity Clinic Online

JL Taman Bendungan Asahan 5 Bendungan Hilir Jakarta Pusat Phone :62 (021) 70081995 – 5703646   

Clinical and Editor in Chief :

Dr Widodo Judarwanto SpA, pediatrician

email : judarwanto@gmail.com,

Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. You should not use the information on this web site for diagnosing or treating a medical or health condition. You should carefully read all product packaging. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider. 

Copyright © 2010, Clinic For Children Information Education Network. All rights

Berbagai permasalahan yang beresiko mengganggu perkembangan bayi prematur diperlukan rangsangan yang terus menerus melalui berbagai sistem dan fungsi tubuh agar keterlambatan dan resiko gangguan pertumbuhan dan perkembangan yang ada dapat dioptimalkan. Intervensi yang dilakukan sejak dini, dilakukan secara berkesinambungan dan berlangsung lebih lama akan memberikan manfaat lebih besar di bandingkan dengan intervensi yang terlambat atau dilakukan dalam waktu singkat. 

Stimulasi psikososial
Bayi dengan kelahiran prematur adalah bayi dengan resiko tinggi yang secara klinis belum menunjukkan hambatan perkembangan, tetapi berpotensi untuk mengalami gangguan perkembangan akibat faktor-faktor resiko biomedik ataupun lingkungan psikososial atau ekonomi, yang dialami sejak masa konsepsi sampai masa neonatal. Prematuritas termasuk salah satu resiko biomedik yang tersering ditemukan dan berpotensi untuk menghambat tumbuh kembang. Umumnya gangguan perkembangan bersumber pada gangguan perkembangan otak.
Plastisitas otak adalah kemampuan susunan syaraf untuk menyesuaikan diri terhadap perubahan atau kerusakan yang disebabkan oleh faktor eksternal dan internal. Pada bayi, kemampuan plastisitas ini tinggi karena jumlah neuron, percabangan akson, dendrit serta jumlah sinaps jauh lebih banyak dibandingkan dengan dewasa. Struktur yang dimanfaatkan akan menetap bahkan berkembang menjadi rangkaian fungsional, tetapi bila tidak dimanfaatkan maka struktur tersebut akan mengalami eliminasi.

Stimulasi bayi prematur yang harus dilakukan adalah  

1. Stimulasi Rangsang Taktil (pijat, fleksi, ekstensi, posisi)
2. Stimulasi Vestibular kinestetik (menggoyang, mengayun)
3. Stimulas Pendengaran (menanyi, musik, rekaman suara ibu, irama jantung ibu)
4. Stimulasi Visual (gerakan, warna, bentuk)

Stimulasi Dini Yang Bisa Dilakukan Pada Bayi Prfematur Sesuai Usia perkembangan

Stimulasi sebaiknya dilakukan secara teratur dan berlkesinambungan dalam janghka panjang. Stimulasi dapat dilakukan dalam kehidupoan sehari-hari saat  menjelang tidur,  memandikan, mengganti popok, menyusui, menyuapi makanan, menggendong, mengajak berjalan-jalan, bermain, menonton TV, di dalam kendaraan.

• Stimulasi untuk bayi 0 – 3 bulan. Stimulasi untuk bayi 0 – 3 bulan dapat dilakukan dengan cara : mengusahakan rasa nyaman, aman dan menyenangkan, memeluk, menggendong, menatap mata bayi, mengajak tersenyum, berbicara, membunyikan berbagai suara atau musik bergantian, menggantung dan menggerakkan benda berwarna mencolok (lingkaran atau kotak-kotak hitam-putih), benda-benda berbunyi, mengulingkan bayi kekanan-kekiri, tengkurap-telentang, dirangsang untuk meraih dan memegang mainan
• Stimulasi untuk bayi 3 – 6 bulan. Stimulasi untuk bayi umur 3 – 6 bulan dapat dilakukan dengan cara dengan bermain ‘cilukba’, melihat wajah bayi dan pengasuh di cermin, dirangsang untuk tengkurap, telentang bolak-balik, duduk.
• Stimulasi untuk bayi 3 – 6 bulan.   Stimulasi untuk umur 6 – 9 bulan dapat dilakukan dengan cara memanggil namanya, mengajak bersalaman, tepuk tangan, membacakan dongeng, merangsang duduk, dilatih berdiri berpegangan.
• Stimulasi untuk bayi 9 – 12 bulan. Stimulasi untuk umur 9 – 12 bulan dapat dilakukan dengan cara mengulang-ulang menyebutkan mama-papa, kakak, memasukkan mainan ke dalam wadah, minum dari gelas, menggelindingkan bola, dilatih berdiri, berjalan dengan berpegangan.
• Stimulasi untuk bayi 12 – 18 bulan. Stimulasi untuk umur 12 – 18 bulan dapat dilakukan dengan cara latihan mencoret-coret menggunakan pensil warna, menyusun kubus, balok-balok, potongan gambar sederhana (puzzle) memasukkan dan mengeluarkan benda-benda kecil dari wadahnya, bermain dengan boneka, sendok, piring, gelas, teko, sapu, lap. Latihlah berjalan tanpa berpegangan, berjalan mundur, memanjat tangga, menendang bola, melepas celana, mengerti dan melakukan perintah-perintah sederhana (mana bola, pegang ini, masukan itu, ambil itu), menyebutkan nama atau menunjukkan benda-benda.
• Stimulasi untuk bayi 18 – 24 bulan. Stimulasi untuk umur  18 – 24 bulan dapat dilakukan dengan cara menanyakan, menyebutkan dan menunjukkan bagian-bagian tubuh (mana mata ? hidung?, telinga?, mulut ? dll), menanyakan gambar atau menyebutkan nama binatang & benda-benda di sekitar rumah, mengajak bicara tentang kegiatan sehari-hari (makan, minum mandi, main, minta dll), latihan menggambar garis-garis, mencuci tangan, memakai celana – baju, bermain melempar bola, melompat.
• Stimulasi untuk bayi 2 – 3 tahun. Stimulasi umur 2 – 3 tahun dapat dilakukan dengan cara mengenal dan menyebutkan warna, menggunakan kata sifat (besar-kecil, panas-dingin, tinggi-rendah, banyak-sedikit dll), menyebutkan nama-nama teman, menghitung benda-benda, memakai baju, menyikat gigi, bermain kartu, boneka, masak-masakan, menggambar garis, lingkaran, manusia, latihan berdiri di satu kaki, buang air kecil / besar di toilet.
• Setelah umur 3 tahun selain mengembangkan kemampuan-kemampuan umur sebelumnya, stimulasi juga di arahkan untuk kesiapan bersekolah antara lain : memegang pensil dengan baik, menulis, mengenal huruf dan angka, berhitung sederhana, mengerti perintah sederhana (buang air kecil / besar di toilet), dan kemandirian (ditinggalkan di sekolah), berbagi dengan teman dll. Perangsangan dapat dilakukan di rumah (oleh pengasuh dan keluarga) namun dapat pula di Kelompok Bermain, Taman Kanak-Kanak atau sejenisnya.

Supported by

Clinic For Children Yudhasmara Foundation http://childrenclinic.wordpress.com/

JL Taman Bendungan Asahan 5 Bendungan Hilir Jakarta Pusat Phone :62 (021) 70081995 – 5703646   

Clinical and Editor in Chief :

Dr Widodo Judarwanto SpA, pediatrician

email : judarwanto@gmail.com,

Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. You should not use the information on this web site for diagnosing or treating a medical or health condition. You should carefully read all product packaging. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider. 

Copyright © 2010, Clinic For Children Information Education Network. All rights