Study guide growth and development 2007 2008

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Study Guide BlockGrowth and Development CURRICULUM Aims: • To assess growth and development in children and adolescents. • To diagnose, manage, and refer if required, common disorders of growth and development. • Awareness of the general means to assess fetal growth (intrauterine growth). • Awareness of the common health implications of normal and abnormal aging. Learning outcomes: • Assess physical growth of children and adolescents. • Diagnose and manage common nutritional problems in children and adolescents. • Investigate infant or child with suspect failure to thrive. • Identify common congenital anomalies in infants and children. • Assess fetal growth (intrauterine growth). • Assess development of children in specific domains. • Awareness of common developmental disorders in children. • Awareness of the normal sexual developmental sequence in children and adolescents. • Capability to evaluate critically the use of medicine in pregnancy, children, and elderly. • Detection of developmental deviation in children (Screening & Stimulation). • Awareness of the impacts of aging on the common health parameters of the elderly. • Awareness of the common clinical manifestations and disorders in the elderly. • Diagnose and manage common health problems and disorders in the elderly. Curriculum contents: • Normal growth patterns in children and adolescents. • Nutritional impacts on growth (and development) in infant, children and adolescents. • Clinical manifestations and diagnosis of failure to thrive. • Common congenital anomalies in infants and young children. • Clinical assessment of intrauterine growth (fetal growth). • Drug recommendation and toxicity on pregnancy and Children. • Assess development of children and adolescents in specific domains. • Methods of developmental deviation detection and stimulation. • Common developmental disorders in children and adolescents. • Diagnose common sexual developmental problems in children and adolescents. • Aging and physiologic changes in health parameters. • Common clinical manifestations and problems and management in the elderly. Udayana University Faculty of Medicine, MEU 1

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Study Guide BlockGrowth and Development PLANNERS TEAM NO NAME DEPARTMENT 1. dr. I G A Trisna Windiani, SpA (Head) Child Health 2. dr. I NG Wardana, S.Ked (Secretary) Anatomy 3. Prof. dr. Soetjiningsih, SpAK, IBCLC Child Health 4. dr. I N Mangku K, M.Repro Anatomy 5. dr. Eka Putra S, Sp.THT ENT 6. dr. I Komang Kari, SpA (K) Child Health 7. dr. I Made Kardana, SpA Child Health 8. dr. I KG Suandi, SpA Child Health 9. dr. AAN Prayoga, SpA Child Health 10. dr. W Bikin Suryawan, SpAK Child Health 11. dr. N. Sunerti, SpM Ophthalmology 12. dr. IGA Endah Ardjana, SpKJ Child Health 13. dr. R A Tuty Kuswardhani, SpPD Geriatri 14. dr. Nyoman Astika, SpPD Geriatri 15. dr. Tjok Gd Suardewa, SpOG Obstetri & Gynaecoogy ~ LECTURERS ~ NO NAME DEPARTMENT 1. dr. I G A Trisna Windiani, SpA (Head) Child Health 2. Prof. dr. Soetjiningsih, SpAK, IBCLC Child Health 3. dr. I N Mangku K, M.Repro Anatomy 4. dr. Eka Putra S, Sp.THT ENT 5. dr. I Komang Kari, SpA (K) Child Health 6. dr. I Made Kardana, SpA Child Health 7. dr. I KG Suandi, SpA Child Health 8. dr. AAN Prayoga, SpA Child Health 9. dr. W Bikin Suryawan, SpAK Child Health 10. dr. N. Sunerti, SpM Ophthalmology 11. dr. IGA Endah Ardjana, SpKJ Child Health 12. dr. R A Tuty Kuswardhani, SpPD Geriatri 13. dr. Nyoman Astika, SpPD Geriatri 14. dr. Tjok G A Suwardewa, SpOG Obstetri &Gynaecoogy 15. dr. Wayan Suwitra, Sp.HK Histology FACILITATORS Regular Class: No Name Department Phone Group Venue 1 dr. Nyoman Astika, Sp.PD Geriatri 08123974128 1 2nd floor: R.2.01 2 dr. Muliani, S.Ked Anatomy 08123900767 2 2nd floor: R.2.02 3 Ni Wyn Tianing, S.Si.,M.Kes Biochemistry 08123982504 3 2nd floor: R.2.03 4 dr. Ketut Ngurah Parasitology - 4 2nd floor: R.2.04 Udayana University Faculty of Medicine, MEU 2

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Study Guide BlockGrowth and Development 5 dr. Susi Purnawati Physiology 08123989891 5 2nd floor: R.2.05 6 dr. Wayan Suwitra Histology 08123803996 6 2nd floor: R.2.06 7 dr. Ratna Sundari Physiology 08123963634 7 2nd floor: R.2.07 8 dr. Wayan Sugiritama, M.Kes Histology 08164732743 8 2nd floor: R.2.08 9 dr. I G K Arijana Histology 08124665966 9 2nd floor: R.2.09 10 dr. I Nyoman Wartana Parasitology 081558119779 10 2nd floor: R.2.10 11 dr. I GA Sri Mahendra D, SpPA Phatologi Anatomy - 11 3rd floor: R.3.26 12 Drs. Made Rustika, Msi Physichology 08123958663 12 3rd floor: R.3.27 English Class: No Name Department Phone Group Room 1 dr. Hengky Forensic 08123988486 1 2nd floor: R.2.01 2 dr. I N Mangku K, M.Repro Anatomy 0811387105 2 2nd floor: R.2.02 3 dr. Ni Wayan Winarti Pathology Anatomy 08123997328 3 2nd floor: R.2.03 4 dr. A A Wiradewi Lestari, SpPA Phatologi Anatomy 08555237937 4 2nd floor: R.2.04 5 dr. I N G Wardana, S.Ked Anatomy 0361-7864957 5 2nd floor: R.2.05 6 dr. I B Putu Alit, SpF Forensic 081916361398 6 2nd floor: R.2.06 7 dr. Matinus Noerwidjaja Anatomy 08123803718 7 2nd floor: R.2.07 8 dr. Siany Herawati, SpPK Clinical Pathology 0818566411 8 2nd floor: R.2.08 9 dr. Dsk Md Wihandani, M.Kes Biochemistry 081338776244 9 2nd floor: R.2.09 10 dr. Yuliana, S.Ked Anatomy 0816555671 10 2nd floor: R.2.10 Reserve No Name Department Phone 1 dr. I GA Widianti Anatomy 08123921765 2 dr. Dwi Fatmawati Microbiology 0818557082 3 dr. Sri Widnyani Pathology Anatomy 081337115012 4 dr. I GN Swarba, SpA Child Health 08123994911 5 dr. Made Arimbawa, SpA Child Health 085237052159 Udayana University Faculty of Medicine, MEU 3

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Study Guide BlockGrowth and Development ~ TIME TABLE ~ Regular Class DAY/ DATE TIME ACTIVITY VENUE CONVEYER LEARNING OUTCOMES 1: ASSESS PHYSICAL GROWTH OF CHILDREN AND ADOLESCENTS 1 Friday 14 Dec 07 08.00 - 08.30 08.30 - 09.00 09.00 - 11.00 11.00 - 12.00 12.00 - 12.30 Intro: General Concepts of Growth and Development Lecture 1: Assessment Physical Growth of Children And Adolescents Individual learning Group discussion Plenary Class room Class room - Discussion room Class room Prof. Soetji Prof. Soetji Facilitator Prof. Soetji LEARNING OUTCOMES 2: ASSESS FETAL GROWTH (INTRAUTERINE GROWTH) 2 Monday 17 Dec 07 08.00 - 09.00 09.00 - 11.00 11.00 - 12.00 12.00 - 12.30 Lecture 2: The Stages of Prenatal Development Individual learning Group discussion Plenary Class room - Discussion room Class room Mangku K Facilitator Mangku K 3 Tuesday 18 Dec 07 08.00 - 08.30 08.30 - 09.00 09.00 - 11.00 11.00 - 12.00 12.00 - 12.30 Lecture 3: USG to Assess Fetal Anatomy Lecture 4: Assessment Growth and Development in Neonatus Individual learning Group discussion Plenary Class room Class room - Discussion room Class room Tjok Suardewa Kardana Facilitator Tjok S & Kardana LEARNING OUTCOMES 3: IDENTIFY COMMON CONGENITAL ANOMALIES IN INFANTS AND CHILDREN 4 Wednesday 19 Dec 07 08.00 - 09.00 09.00 - 11.00 11.00 - 12.00 12.00 - 12.30 Lecture 5: Prenatal Genetic Evaluation and Counseling Individual learning Group discussion Plenary Class room - Discussion room Class room Suwitra Facilitator Suwitra LEARNING OUTCOMES 4: CAPABILITY TO EVALUATE CRITICALLY THE USE OF MEDICINE IN PREGNANCY, CHILDREN, AND ELDERLY 5 Thursday 27 Dec 07 08.00 - 09.00 09.00 - 11.00 11.00 - 12.00 12.00 - 12.30 Lecture 6: Drugs in Pregnancy, Children, and Elderly Individual learning Group discussion Plenary Class room - Discussion room Class room Jawi Facilitator Jawi LEARNING OUTCOMES 5: DIAGNOSE AND MANAGE COMMON NUTRITIONAL PROBLEMS IN CHILDREN AND ADOLESCENTS 6 Friday 28 Dec 07 08.00 - 08.30 Lecture 7: Principles Breastfeeding for Infants With Normal Delivery Class room Prof. Soetji Udayana University Faculty of Medicine, MEU 4

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Study Guide BlockGrowth and Development 08.30 - 09.00 09.00 - 11.00 11.00 - 12.00 12.00 - 12.30 Lecture 8: Principles Feeding for Infants With Complicated Delivery Individual learning Group discussion Plenary - Discussion room Class room Kardana Facilitator Soetji & Kardana 7 Wednesday 2 Jan 08 08.00 - 08.30 08.30 - 09.00 09.00 - 11.00 11.00 - 12.00 12.00 - 12.30 Lecture 9: Vitamin A, Fe & Iodine Deficiencies Lecture 10: Protein Energy Malnutrition (PEM) & Obesity Individual learning Group discussion Plenary Class room - Discussion room Class room Prayoga Suandi Facilitator Prayoga&Suandi LEARNING OUTCOMES 6: INVESTIGATE INFANT OR CHILD WITH SUSPECT FAILURE TO THRIVE 8 Thursday 3 Jan 08 08.00 - 09.00 09.00 - 10.00 10.00 - 12.00 12.00 - 12.30 Lecture 11: Failure to Thrive Individual learning Group discussion Plenary Class room - Discussion room Class room Suandi Facilitator Suandi LEARNING OUTCOMES 7: ASSESS DEVELOPMENT OF CHILDREN IN SPECIFIC DOMAINS 9 Friday 4 Jan 08 08.00 - 08.30 08.30 - 09.00 09.00 - 11.00 11.00 - 12.00 12.00 - 12.30 Lecture 12: Assess Development in Motoric Domains Lecture 13: Assess Development in Language Domains Individual learning Group discussion Plenary Class room Class room Discussion room Class room Trisna Prof. Soetji - Facilitator Trisna & Soetji 10 Tuesday 8 Jan 08 08.00 - 08.30 08.30 - 09.00 09.00 - 11.00 11.00 - 12.00 12.00 - 12.30 Lecture 14: Cognitive Development Lecture 15: Psychosocial Development Individual learning Group discussion Plenary Class room Class room - Discussion room Class room Rustika Marheni - Facilitator Rustika&Marheni LEARNING OUTCOMES 8: DETECTION OF DEVELOPMENT DEVIATION IN CHILDREN (SCREENING AND STIMULATION) 11 Wednesday 09 Jan 08 08.00 - 09.00 09.00 - 11.00 11.00 - 12.00 12.00 - 12.30 Lecture 16: Detection of Developmental Deviation In Children (Screening & Stimulation) Individual learning Group discussion Plenary Class room - Discussion room Class room Prof. Soetji & Trisna - Facilitator Soetji & Trisna LEARNING OUTCOMES 9: AWARENESS OF THE NORMAL SEXUAL DEVELOPMENT SEQUENCE IN CHILDREN AND ADOLESCENT 12 Friday 11 Jan 08 08.00 - 09.00 09.00 - 11.00 11.00 - 12.00 Lecture 17: Sexual Developmental Sequence in Children and Adolescent Individual learning Class room - Discussion room Bikin S Facilitator Udayana University Faculty of Medicine, MEU 5

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Study Guide BlockGrowth and Development 12.00 - 12.30 Group discussion Plenary Class room Bikin S LEARNING OUTCOMES 10: AWARENESS OF COMMON DEVELOPMENTAL DISORDERS IN CHILDREN 13 Saturday 12 Jan 08 08.00 - 08.30 08.30 - 09.00 09.00 - 11.00 11.00 - 12.00 12.00 - 12.30 Lecture 18: Visual Impairment Lecture 19: Hearing Impairment Individual learning Group discussion Plenary Class room Class room - Discussion room Class room Sunerti Eka Putra - Facilitator Sunerti & Eka Putra 14 Monday 14 Jan 08 08.00 – 08.30 08.30 - 09.00 09.00 - 11.00 11.00 - 12.00 12.00 - 12.30 Lecturer 20: Learning Disorders Lecture 21: Down Syndrome and Mental Retardation Individual learning Group Discussion Plenary Class room - Discussion room Class room Endah Endah Facilitator Endah 15 Tuesday 15 Jan 08 08.00 - 09.00 09.00 - 11.00 11.00 - 12.00 12.00 - 12.30 Lecture 22: Attention Deficit/Hyperactivity Disorders Individual learning Group discussion Plenary Class room - Discussion room Class room Trisna/Endah Facilitator Trisna/Endah 16 Wednesday 16 Jan 08 08.30 - 08.30 08.30 - 09.00 09.00 - 11.00 11.00 - 12.00 12.00 - 12.30 Lecture 23: Autism Spectrum Disorders Lecture 24: Cerebral Palsy Individual learning Group discussion Plenary Class room Class room - Discussion room Class room Prof. Soetji K Kari - Facilitator Prof. Soetji & K Kari LEARNING OUTCOMES 11: AGING AND ITS CLINICAL IMPLICATIONS 17 Thursday 17 Jan 08 08.00 - 08.30 08.30 - 09.00 09.00 - 11.00 11.00 - 12.00 12.00 - 12.30 Lecture 25: Aging Process Lecture 26: Clinical Implication of Aging Process Individual learning Group Discussion Plenary Class room - Discussion room Class room R A Tuty K Astika Facilitator Tuty & Astika 18 Friday 18 Jan 08 Case Field Visit to day care centre (TPA), Playgroup, Kindergarten, Primary Health Care, Special Need School 19 Monday 21 Jan 08 08.00 - 10.20 Case Presentation Class room Team 20 Tuesday 22 Jan 08 Preparation for Examination 22 Friday 25 Jan 08 EXAMINATION ~ TIME TABLE ~ Udayana University Faculty of Medicine, MEU 6

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Study Guide BlockGrowth and Development English Class DAY/ DATE TIME ACTIVITY VENUE CONVEYER LEARNING OUTCOMES 1: ASSESS PHYSICAL GROWTH OF CHILDREN AND ADOLESCENTS 1 Friday 14 Dec 07 09.00 - 09.30 09.30 - 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Intro: General Concepts of Growth and Development Lecture 1: Assessment Physical Growth of Children And Adolescents Individual learning Group discussion Plenary Class room Class room - Discussion room Class room Prof. Soetji Prof. Soetji Facilitator Prof. Soetji LEARNING OUTCOMES 2: ASSESS FETAL GROWTH (INTRAUTERINE GROWTH) 2 Monday 17 Dec 07 09.00 - 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Lecture 2: The Stages of Prenatal Development Individual learning Group discussion Plenary Class room - Discussion room Class room Mangku K Facilitator Mangku K 3 Tuesday 18 Dec 07 09.00 - 09.30 09.30 - 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Lecture 3: USG to Assess Fetal Anatomy Lecture 4: Assessment Growth and Development in Neonatus Individual learning Group discussion Plenary Class room Class room - Discussion room Class room Tjok Suardewa Kardana Facilitator Tjok S & Kardana LEARNING OUTCOMES 3: IDENTIFY COMMON CONGENITAL ANOMALIES IN INFANTS AND CHILDREN 4 Wednesday 19 Dec 07 09.00 - 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Lecture 5: Prenatal Genetic Evaluation and Counseling Individual learning Group discussion Plenary Class room - Discussion room Class room Suwitra Facilitator Suwitra LEARNING OUTCOMES 4: CAPABILITY TO EVALUATE CRITICALLY THE USE OF MEDICINE IN PREGNANCY, CHILDREN, AND ELDERLY 5 Thursday 27 Dec 07 09.00 - 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Lecture 6: Drugs in Pregnancy, Children, and Elderly Individual learning Group discussion Plenary Class room - Discussion room Class room Jawi Facilitator Jawi LEARNING OUTCOMES 5: DIAGNOSE AND MANAGE COMMON NUTRITIONAL PROBLEMS IN CHILDREN AND ADOLESCENTS 6 Friday 28 Dec 07 09.00 - 09.30 09.30 - 10.00 Lecture 7: Principles Breastfeeding for Infants With Normal Delivery Lecture 8: Principles Class room Prof. Soetji Kardana Udayana University Faculty of Medicine, MEU 7

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Study Guide BlockGrowth and Development 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Feeding for Infants With Complicated Delivery Individual learning Group discussion Plenary - Discussion room Class room Facilitator Soetji & Kardana 7 Wednesday 2 Jan 08 09.00 - 09.30 09.30 - 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Lecture 9: Vitamin A, Fe & Iodine Deficiencies Lecture 10: Protein Energy Malnutrition (PEM) & Obesity Individual learning Group discussion Plenary Class room - Discussion room Class room Prayoga Suandi Facilitator Prayoga&Suandi LEARNING OUTCOMES 6: INVESTIGATE INFANT OR CHILD WITH SUSPECT FAILURE TO THRIVE 8 Thursday 3 Jan 08 09.00 - 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Lecture 11: Failure to Thrive Individual learning Group discussion Plenary Class room - Discussion room Class room Suandi Facilitator Suandi LEARNING OUTCOMES 7: ASSESS DEVELOPMENT OF CHILDREN IN SPECIFIC DOMAINS 9 Friday 4 Jan 08 09.0 - 09.30 09.30 – 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Lecture 12: Assess Development in Motoric Domains Lecture 13: Assess Development in Language Domains Individual learning Group discussion Plenary Class room Class room - Discussion room Class room Trisna Prof. Soetji - Facilitator Trisna & Soetji 10 Wednesday 9 Jan 08 09.00 - 09.30 09.30 - 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Lecture 14: Cognitive Development Lecture 15: Psychosocial Development Individual learning Group discussion Plenary Class room Class room - Discussion room Class room Rustika Marheni - Facilitator Rustika&Marheni LEARNING OUTCOMES 8: DETECTION OF DEVELOPMENT DEVIATION IN CHILDREN (SCREENING AND STIMULATION) 11 Thursday 10 Jan 08 09.00 - 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Lecture 16: Detection of Developmental Deviation In Children (Screening & Stimulation) Individual learning Group discussion Plenary Class room - Discussion room Class room Prof. Soetji & Trisna - Facilitator Soetji & Trisna LEARNING OUTCOMES 9: AWARENESS OF THE NORMAL SEXUAL DEVELOPMENT SEQUENCE IN CHILDREN AND ADOLESCENT 12 Friday 11 Jan 08 09.00 - 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Lecture 17: Sexual Developmental Sequence in Children and Adolescent Individual learning Group discussion Plenary Class room - Discussion room Class room Bikin S Facilitator Bikin S Udayana University Faculty of Medicine, MEU 8

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Study Guide BlockGrowth and Development LEARNING OUTCOMES 10: AWARENESS OF COMMON DEVELOPMENTAL DISORDERS IN CHILDREN 13 Saturday 12 Jan 08 09.00 - 09.30 09.30 - 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Lecture 18: Visual Impairment Lecture 19: Hearing Impairment Individual learning Group discussion Plenary Class room Class room - Discussion room Class room Sunerti Eka Putra - Facilitator Sunerti & Eka Putra 14 Monday 14 Jan 08 09.00 - 09.30 09.30 - 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Lecturer 20: Learning Disorders Lecture 21: Down Syndrome and Mental Retardation Individual learning Group Discussion Plenary Class room - Discussion room Class room Endah Endah Facilitator Endah 15 Tuesday 15 Jan 08 09.00 - 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Lecture 22: Attention Deficit/Hyperactivity Disorders Individual learning Group discussion Plenary Class room - Discussion room Class room Trisna/Endah Facilitator Trisna/Endah 16 Wednesday 16 Jan 08 09.00 - 09.30 09.30 - 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Lecture 23: Autism Spectrum Disorders Lecture 24: Cerebral Palsy Individual learning Group discussion Plenary Class room Class room - Discussion room Class room Prof. Soetji K Kari - Facilitator Prof. Soetji & K Kari LEARNING OUTCOMES 11: AGING AND ITS CLINICAL IMPLICATIONS 17 Thursday 17 Jan 08 09.00 - 09.30 09.30 - 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Lecture 25: Aging Process Lecture 26: Clinical Implication of Aging Process Individual learning Group Discussion Plenary Class room - Discussion room Class room R A Tuty K Astika Facilitator Tuty & Astika 18 Friday 18 Jan 08 Case Field Visit to day care centre (TPA), Playgroup, Kindergarten, Primary Health Care, Special Need School 19 Monday 21 Jan 08 10.20 – 12.40 Case Presentation Class room Team 20 Tuesday 22 Jan 08 Preparation for Examination 22 Friday 25 Jan 08 EXAMINATION Udayana University Faculty of Medicine, MEU 9

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Study Guide BlockGrowth and Development ~ MEETING ~ Meeting with the student representatives The meeting between block planners and student group representatives will be held on Saturday, 5 January 2008, at 09.00 until 11.00 at Class Room. In this meeting, all of the student group representatives are expected to give suggestions and inputs or complaints to the team planners for improvement. For this purpose, every student group should choose one student as their representative to attend the meeting. Meeting with the facilitators The meeting between block planners and facilitators will take place on Saturday, 5 January 2008, at 11.00 until 13.00 at Class Room. In this meeting the facilitators are expected to give suggestions and inputs to improve the study guide and the educational process. Because of its importances, all facilitators are expected to attend and participate in the meeting. ~ ASSESSMENT METHOD ~ Assessment will be carried out on Friday 25 January 2008. There will be 100 questions consisting mostly of Multiple Choice Questions (MCQ). The minimal passing score for the assessment is 70. Other than the examination score, your performance and attitude during group discussions will also be considered in the calculation of your final score. Udayana University Faculty of Medicine, MEU 10

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Study Guide BlockGrowth and Development ~ LEARNING PROGRAMS ~ LECTURE Prof. dr. Soetjiningsih, SpAK, IBCLC Learning outcomes - To describe the general concept of growth and development - To describe the stages in lifespan development - To understand the conceptual differences between growth and development - To describe the factors that may affect growth and development Abstract Lifespan development is a field of study that examines patterns of growth, change, and stability in behavior that occur throughout the entire life span. The life span is usually divided into broad age ranges: the prenatal period (the period from conception to birth); infancy and toddler hood (birth to age 3); the preschool period (ages 3 to 6); middle childhood (ages 6 to 12); adolescence (ages 12 to 20); young adulthood (ages 20 to 40); middle age (ages 40 to 60); and late adulthood (age 60 to death). Lifespan development specialists discuss development in several topics: physical development (development involving the body’s physical make up, including the brain, nervous system, muscles, senses, and the need for food, drink and sleep); cognitive development (development involving the ways that growth and change in intellectual capabilities influence a person’s behavior); personality development (development involving the ways that enduring characteristics that differentiate one person from another change over the life span); and social development ( the way in which individuals’ interactions with others and their social relationships grow, change, and remain stable over the course of life). Growth and development are an integral process. Growth refer to the metabolic change by which an organism increases in size and changes shape. Growth refers to quantitative changes. Changes in physical size and appearance are visible manifestations of the complex morphologic, biochemical and physiologic changes taking place during childhood. Child development is a process, a continuous series of purposeful changes, consisting of many aspects, moving together at differing paces. Development refers to qualitative and quantitative changes. There are 10 fundamental principles of development: 1. Development involves change 2. Early development is more critical than later development 3. Development is the product of maturation and learning 4. The developmental pattern is predictable 5. The developmental pattern has predictable characteristics 6. There are individual differences in development 7. There are periods in the developmental pattern 8. There are social expectations for every developmental period 9. Every area of development has potential hazards 10. Happiness varies at different periods in development Udayana University Faculty of Medicine, MEU Introductory lecture: General Concepts of Growth and Development 11

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Lecture 1: ~ AssessmentPhysical Growth of Children and Adolescents ~ Study Guide Block Growth and Development Environmental and genetic factors influence growth and development. In Bronfenbrenner’s ecological system theory, development is influenced at four levels: the microsystem, mesosystem, exosystem and macrosystem. Prof. dr. Soetjiningsih, SpAK, IBCLC Learning outcomes - Describe the clinical importance of study physical growth - Describe the normal patterns of the physical growth - Understand factors that affecting physical growth - Use of common growth parameter Abstract Physical growth usually refers to changes in size or mass. The most people usually think of growth at the level of the whole child, the cells and internal structures that make up the child, primarily by increasing in number or size. Growth assessment is essential because almost any problems within the physiologic, interpersonal and social domains can adversely affect growth. Anthropometry is an effective and frequently performed child health screening procedure. The value of physical growth data depends on their accuracy and reliability, how they are recorded and interpreted, and what follow- up efforts are made after identification of growth abnormality. The most powerful tool in growth assessment is the growth chart. Whenever possible, growth should be assessed by plotting accurate measurements on growth charts and comparing each set of measurements with previous measurements. The CDC Growth Charts 2000 are used to measure growth, consist of 16 charts including “Body mass index (BMI) for-age percentile” for boys and girls aged 2-20 years. Normal growth patterns have spurts and plateaus, but some shifting on the percentile graphs can be expected; however, large shifts warrant attention. Large discrepancies among height, weight, and head circumference percentiles also diserve attention. Deviation in growth patterns are nonspecific but important indicators of serious medical disorders. Deviations often provide the first clue that something is wrong, occasionally even when the parents do not suspect a problem. An accurate measurement of height, weight, and head circumference should be obtained at every health supervision visit. Serial measurements are much more useful than single measurements because they can help detect deviations from a particular child’s growth pattern even if the value remains within statistically defined normal limits. Factors affecting physical growth and health in infancy and toddlerhood continue to be influential in early childhood. Heredity affects physical growth by regulating the production of hormones. Extreme emotional deprivation can interfere with the production of growth hormone, thereby stunting children's growth. Sleep difficulties, in the form of night waking and nightmares, are common during the preschool years. Appetite decline is associated with a slower rate of physical growth. Disease can lead to malnutrition, seriously undermining children's growth, an effect that is especially common in developing countries. Udayana University Faculty of Medicine, MEU 12

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Lecture 2: ~ TheStages of Prenatal Development ~ Lecture 3: ~ USG to Assess Fetal Anatomy ~ Study Guide Block Growth and Development I Nym Mangku Karmaya Learning outcomes Describe the main stages of embryonic development for use to estimate the gestational age of embryo. Abstract Early embryonic development is describe in stages because of the variable period it takes for embryos to develop certain morphological characteristics. Stage 1 of development begins at fertilization and embryonic development ends at stages 23, which occur on day 57 and ends when he fetus is completely outside the mother. The stages of embryonic development can be assessed by ultrasonography. In general the period of prenatal development is as follows:  1st week : zygote-blastomeres-morula-blastocyst.  2nd week : bilaminar germ disc  3rd week : trilaminar germ disc  3rd - 8th week : embryonic period/organogenesis  8th week-BIRTH : fetal period Tjokorda Gde Agung Suwardewa Learning outcomes Apply of USG to assess fetal anatomy: - Comprehend ultrasound waves generally - Comprehend compartments of ultrasonography unit (USG) - Comprehend how USG used for pregnant woman - Safety ultrasound waves to the fetus - Comprehend length, frequency, media of ultrasound waves Abstract Ultrasound is a sound waves with frequency more than 20,000 HZ. Normally we can hearing of sound waves by frequency between 16,000-20,000 cycle per second (Hertz) (1 Megahertz=1000,000 Hz). The sound waves length in ultrasound compartment (USG unit) role play to determine of resolution capacity that unit. The pictures displayed on the screen is produced by sound waves reflected back from the imaged structure. Alternating current is applied to a transducer containing piezoelectric crystals, which converts electric energy to high-frequency sound waves. A water soluble gel applied to the skin acts as coupling agent. Sound waves pass through layers of tissue, encounter an interface between tissues of deferent densities, and are reflected back to the transducer. Converted back into electrical energy, they are displayed on the screen. Dense tissue such as white on the screen. Fluid is anechoic and appearing black on the screen. Higher-frequency transducers yield better images resolution, whereas lower frequencies penetrate tissue more effectively. For examples, abdominal scanning is most commonly Udayana University Faculty of Medicine, MEU 13

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Study Guide BlockGrowth and Development performed with a 3-5 mHz transducer, but in early pregnancy, 7-10 mHz vaginal transducer may provide excellent resolution because the fetus is close to the transducer. Since the first obstetrical application of ultrasound imaging by Donald and co-worker (1958), this technique has become indispensable for evaluation of the fetus. Some indications for ultrasound examination are: confirm gestation location, fetal number, estimating gestational age, fetal morphology/anatomy, fetal abnormality, placenta, amniotic fluid volume. Kardana Learning outcomes - Apply the New Ballard Score to assess the gestational age of infant: the small for gestational age (SGA), appropriate for gestational age (AGA), or large for gestational age (LGA). Abstract Since the late 1960s, a variety of methods for assessing the gestational age of the newborn infant have been developed. Currently, the most widely use system for the postnatal assessment of gestational age is the New Ballard Score (NBS). This system includes both physical and neurologic characteristics. The score spans from 10 (correlating with 20 weeks’ gestation) to 50 (correlating with 44 weeks gestation). The examination consists of six neuromuscular criteria and six physical criteria. The neuromuscular criteria are based on the understanding that passive tone is more useful than active tone in indicating gestational age. The neuromuscular maturity includes: posture, square window, arm recoll, popliteal angel, scarf sign, and heal to ear. The physical maturity includes: skin, lanugo hair, plantar surface, breast, ear and ear, and genitalia. The examination of NBS is administered twice by two different examiners to ensure objective, and the data entered on the chart. Suwitra Abstract When Steele and Breg in 1966 demonstrated that amniotic fluid cells could be cultured to reveal fetal karyotype, prenatal diagnosis has become a mayor medical genetic service, in the context of prevention of specific genetic disorder The demand for genetic testing is sure to rise if a screening procedure is developed to identify pregnancies at risk of a chromosomal abnormality. In some minds prenatal diagnosis is equated with the issue of abortion. For families at risk having a child with condition that can be diagnosed prenatal, the option of monitoring pregnancies allow the parents to undertake pregnancies that they would otherwise forego. Only about 2% of all pregnancies in which there is prenatal diagnosis are terminated because of the fetus has genetic defect. Much more often, the fetus is found to be unaffected and the pregnancy continues. Indication of prenatal diagnosis: Udayana University Faculty of Medicine, MEU Lecture 4: ~ Assessment of Growth and Development in Neonatus 14 Lecture 5: ~ Prenatal Genetic Evaluation and Counseling ~

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Study Guide BlockGrowth and Development 1. Mother age of 35 years or more 2. Previous child with chromosomal abnormality 3. Present of structural chromosomal abnormality 4. Family history of neural rube defect. 5. X-linked disorder in family Techniques: amniocentesis, chorionic villous sampling, ultrasonography, fetoscopy, prenatal chromosome analysis, alpha-fetoprotein analysis, Prenatal diagnose require the combined skill of obstetricians, laboratory scientist, geneticists. The mayor concern in any prenatal diagnosis program is time or week of gestation for prenatal diagnosis and it should be provided as early in pregnancy as possible. Learning outcomes: after the lecture, the medical students have a knowledge obout: a. The history of prenatal diagnosis b. The aim of prenatal diagnose c. The indications and techniques of prenatal diagnosis d. The advantages and disadvantages of technique chosen Udayana University Faculty of Medicine, MEU 15

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Lecture 6: ~ Drugsin Pregnancy, Children, and Elderly ~ Study Guide Block Growth and Development Made Jawi Learning outcomes After completing this lecture, the students should be able to: - Describe the effect of drugs use in pregnancy. - To Choose the safe drugs for pregnant women, children, and elderly Abstract When a woman becomes pregnant, it is very important for her to lead a healthy life: to eat plenty of nourishing food, get plenty of rest, and exercise regularly. It is also vital that she avoid anything that might harm her or her baby-to-be. It is especially important to give up alcohol, cigarettes, and drugs. For a pregnant woman, drug abuse is doubly dangerous. First, drugs may harm her own health, interfering with her ability to support the pregnancy. Second, some drugs can directly impair prenatal development. Both prescription and over-the-counter drugs can be harmful, for her own health and the health of her baby-to-be. So a woman should avoid all of them as much as possible, from the time she first plans to become pregnant or learns that she is pregnant. Some drugs can be harmful when used at any time during pregnancy; others, however, are particularly damaging at specific stages. Most of the body organs and systems of the baby-to-be are formed within the first ten weeks or so of pregnancy (calculated from the date of the last menstrual period). During this stage, some drugs and alcohol in particular can cause malformations of such parts of the developing fetus as the heart, the limbs, and the facial features. After about the tenth week, the fetus should grow rapidly in weight and size. At this stage, certain drugs may damage organs that are still developing, such as the eyes, as well as the nervous system. Continuing drug use also increases the risk of miscarriage and premature delivery. But the greatest danger drugs pose at this stage is their potential to interfere with normal growth. Intrauterine growth retardation (IUGR) is likely to result in a low-birth weight baby a baby born too early, too small, or both. Low- birth weight babies require special care and run a much higher risk of severe health problems or even death. Current Categories for Drug Use in Pregnancy Category Description A Adequate, well-controlled studies in pregnant women have not shown an increased risk of fetal abnormalities. B Animal studies have revealed no evidence of harm to the fetus; however, there are no adequate and well-controlled studies in pregnant women. Or Animal studies have shown an adverse effect, but adequate and well- controlled studies in pregnant women have failed to demonstrate a risk to the fetus. C Animal studies have shown an adverse effect and there are no adequate and well-controlled studies in pregnant women. Or No animal studies have been conducted and there are no adequate and well-controlled studies in pregnant women. D Studies, adequate well-controlled or observational, in pregnant women have demonstrated a risk to the fetus. However, the benefits of therapy may outweigh the potential risk. X Studies, adequate well-controlled or observational, in animals or pregnant women have demonstrated positive evidence of fetal abnormalities. The use of the product is contraindicated in women who are or may become pregnant. Udayana University Faculty of Medicine, MEU 16

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Lecture 7: Apply thePrinciples of Breastfeeding for Infants with Normal Deliveries Study Guide Block Growth and Development Both prescription and over-the-counter drugs can be harmful, for children and elderly. There are a number of pharmacokinetic and pharmacodynamic differences between children or pediatric, elderly and adult patients. Neonates ( 0 to 1 month), infants (1 to 12 month) and children of increasing age are not simply small adult. The drugs used by the elderly are the same as those that a younger person might take-- yet they can have a far different effect. It doesn’t matter whether a person has heart disease or arthritis, osteoporosis, or high blood pressure, the story is the same: Because the organ systems tend to function less efficiently as we age, medications are handled differently by our bodies. Here are some of the most common changes affecting our health and our response to medicines: The stomachs may not absorb food and medication as well as they did before. The kidneys and livers don’t eliminate fluids and toxins in the same efficient manner. All of the above contribute to the potential harm that medications can cause in the aging body. If a kidney can’t eliminate a drug after it has done its work, it remains in the body longer, perhaps causing an overdose or an adverse effect. If someone forgets to take a medication that regulates the heart or blood pressure, a stroke or heart attack could be the result. Any person over the age of 65 who is taking medications in the following categories should be aware of the potential for increased side effects, overdose, and diminished efficacy: Antibiotics, Anti histamines, Anti hypertensives, Antiulcer medicines, Blood thinners, Bronchodilators, Calcium or potassium supplements, Cardiac medications, Corticosteroids, Estrogens, Over-the-counter drugs containing alcohol (cough and cold medications) or caffeine, Pain relievers, Psychiatric medications, Skin medications and creams In the lecture will be discuss the effects of drugs to the embryo and how to choose drugs for pregnant women, Children and Elderly Prof. dr. Soetjiningsih, SpAK, IBCLC Abstract Breast-feeding exclusively the recommended method for feeding normal infants during the first 6 months of life. Breastfeeding should continue with the addition of appropriate foods, for two years or more. Breastfeeding has advantages for infants, mothers, families, and society. These advantages include health, nutritional, immunologic, developmental, psychologic, social, economic, and environmental benefits. Breast milk contains the right balance of nutrients to help the infant grow into a strong and healthy toddler. Some of the nutrients in breast milk also help protect the infant against some common childhood illnesses and infections. While nutrients and antibodies pass to the baby, beneficial hormones are released from the mother's body. Colostrums, a high protein and low fat lactose product, are produced in small amounts during the first few postpartum days. It has some nutritional value but primarily has important immunologic and maturational properties. The bond between baby and mother can also be strengthened during breastfeeding. Breastfeeding doesn't always happen easily. Some new mums find it hard to get started, while others hit problems later on. Breast tenderness, engorgement, and cracked nipples are the most common problems encountered by mothers who are breast-feeding. Udayana University Faculty of Medicine, MEU 17

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Lecture 8: ~ ThePrinciples of Feeding for Infants with Complicated Deliveries ~ Lecture 9: ~ Vitamin A and Fe Deficiency ~ ~ Iodine Deficiency ~ Study Guide Block Growth and Development Kardana Learning outcomes - To know indication of enteral and parenteral nutrition - To know the type nutrition’s for enteral feeding - To know the routes of enteral feeding and feeding technique - To know the administration for parenteral nutrition - To know the contents of total parenteral nutrition Abstract Providing adequate nutrition support to newborns is an important to know and understanding the maturation, functional and physical disturbances to the baby. Optimal nutrition after birth enhances future neurodevelopmental outcome. For term healthy infants should be breast-fed as soon as possible within the first hour. Human milk is preferred for feeding term, preterm and sick infants. The following criteria should usually be met before initiating infant’s feedings: no history of excessive oral secretions, vomiting, or bilous-stained gastric aspirate, non-distended, soft abdomen with normal bowel sound, and no respiration distress. If the baby is small or complicated baby such as baby with the following associated conditions: perinatal asphyxia, hemodynamic instability, sepsis, frequent episodic apnea and bradycardia etc, initiation of enteral feeding is often precluded and parenteral nutrition can be initiation. Nutritional requirements in neonate includes: calories to maintain weight and to induce weight gain, carbohydrates, proteins, fats, vitamins and minerals and fluids. A A Ngr Prayoga ~ Vitamin A and Fe Deficiency ~ Learning outcomes - To understand the sign and symptom of patient with vitamin A and Fe deficiency - To built diagnosis of patient with vitamin A and Fe deficiency - To understand the treatment and prevention of patient with vitamin A and Fe deficiency Abstract Vitamin A is the generic term used to describe all retinoid having the biologic activity of all- trans retinol. Vitamin A, a light yellow crystalline alcohol, has been named retinol in reference to its specific function in the retina of the eye. The yellow-orange-red provitamin carotinoids, are describe in the term of beta-carotene A deficiency of Vitamin A is accompanied by keratinization of the mucous membranes that line the respiratory tract, the alimentary canal, and the urinary tract, and by keratinization of the body skin and epithelium of the eye, which lowers the barrier role played by these membranes in protection of the body against infections. Prolonged deficiency may produce skin changes, night blindness, and corneal ulceration. Primary deficiencies of vitamin A are the result of dietary inadequacies. Secondary can result from liver disease, protein-energy malnutrition, abetalipoproteinemia, or malabsorption due to bile acid Udayana University Faculty of Medicine, MEU 18

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Lecture 10: ~ ProteinEnergy Malnutrition (PEM) ~ ~ Obesity ~ Study Guide Block Growth and Development insufficiency. Acute deficiency is treated with large oral doses of vitamin A and correction of the usually concomitant protein-energy malnutrition. Massive intermittent dosing with 200,000 IU of vitamin A can reduced mortality by 35 to 70 %. Iron deficiency anemia is characterized by the production of small erythrocytes and diminished level of circulating hemoglobin. The three primary causes of iron deficiency anemia are chronic blood lose, faulty iron intake or absorption and increased iron requirement. The clinical findings are fatigue, anorexia, pica (pagophagia). Growth abnormalities, epithelial disorders, and reduction in gastric acidity are common. Defect in structure and function of epithelial tissue of tongue, nails, mouth, and stomach as deficiency becomes more severe. The chief treatment for iron deficiency consists of oral administration of inorganic iron in the ferrous form and nutritional care. ~ Iodine Deficiency ~ Learning outcomes - To understand the sign and symptom of patient with iodine deficiency. - To built diagnosis of patient with iodine deficiency. - To understand the treatment and prevention of patient with iodine deficiency. Abstract Iodine is absorbed easily in the form of iodide, in circulation it occurs both as free and protein-bound iodine. Iodine is stored in the thyroid, where it is used for synthesis of T3 and T4 when needed. Lack of iodine intake is associated with the development of endemic or simple goiter, which is an enlargement of thyroid gland. The deficiency may be absolute, especially in areas of subnormal iodine intake, or relative subsequent to increased need for thyroid hormones, such as in the female during adolescence, pregnancy, and lactation. Severe iodine deficiency during gestation and early postnatal growth results in cretinism, a syndrome characterized by mental deficiency, spastic diplegia, or quadriplegia, deaf mutism, dysarthria, a characteristic shuffling gait, shortened stature, and hypothyroidism. Early diagnosis and treatment are needed to prevent more severe of clinical sign and symptom. IKG Suandi ~ Protein Energy Malnutrition (PEM) ~ Learning outcomes - To understand the sign & symptom of patient with protein energy malnutrition (PEM) - To built diagnosis of patient with protein energy malnutrition (PEM) - To understand the treatment and prevention of the patient with protein energy malnutrition (PEM) Udayana University Faculty of Medicine, MEU 19

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Lecture 11: ~ Failureto Thrive ~ Study Guide Block Growth and Development Abstract Definition PEM is a spectrum of conditions caused by varying levels of protein and calorie deficiencies. The common form of primary PEM is marasmus and caused by severe caloric depletion. Kwashiorkor, presenting with pitting edema caused by inadequate protein intake in the presence of fair to good caloric intake. Secondary form of PEM is associated with other diseases. Clinical manifestation The clinical manifestation of marasmus: The body weight below 60% of expected for age or below 70% of the ideal weight for height and depleted body fat stores. Edema usually is absent. The head may appear large but generally proportional to the body length. The clinical manifestation of kwashiorkor: presenting pitting edema that starts in lower extremities and ascends with increasing severity, may be a complication of critical illness (acute and chronic infections, multiorgan system failure, anorexia nervosa, etc) Treatment and prevention Calories account of nutritional rehabilitation can be safety started at 20% above the child’s recent intake. The calorie intake can be increased 10-20% per day until appropriate re-growth is initiated. This may require 150% or more of the recommended calories for an age-matched, well nourished child. ~ Obesity ~ Learning outcomes - To understand the sign & symptom of patient with obesity - To built diagnosis of patient with obesity - To understand the treatment and prevention of the obesity Epidemiology The prevalence of obesity in children has increased in the last 2-3 decades, mainly in children as young as 4-5 years. Clinical manifestation In children BMI (body mass index) age and gender specific percentile curves allow an assessment of BMI percentile. In adolescent and adult BMI has been used in weight/height2 (kg/m2 ). The effects of obesity complication; such as psychosocial effect, growth (advanced bone age, increased height, early menarche), CNS (pseudo tumor cerebri, respiratory (sleep apnea, pickwickian syndrome), cardiovascular (hypertension, cardiac hypertrophy, ischemic heart disease, sudden death), orthopedic (slipped capital femoral epiphysis, Blount disease), metabolic (insulin resistance, type II diabetes mellitus, hypertriglyceridemia, hypercholesterolemia, gout, hepatic steatosis, ovary disease, cholelithiasis). Treatment and prevention The treatment and prevention of obesity includes a combination of education, behavior modification, exercise and diet. I KG Suandi Learning outcomes 1. To apply the diagnostic criteria of patient with failure to thrive (FTT). 2. To discuss the cause or path physiology of patient with FTT. 3. To evaluate and manage a child with FTT. Udayana University Faculty of Medicine, MEU 20

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Lecture 12 &13: ~Assess Development in the Motoric and Language Domains ~ Study Guide Block Growth and Development Definition The term ‘failure to thrive’ first was used to describe the malnutrition and depressed condition of many institutionalized infants in early 1900s. It remains a descriptive rather than a diagnostic label applied to children whose attained weight or rate of weight gain is significantly below that of other children of similar age and same sex. Table Definition of failure to thrive Attained growth 1. Weight < 3rd percentile on NCHS growth chart 2. Weight for height < 5th percentile on NCHS growth chart 3. Weight 20% or more below ideal weight for height 4. Triceps skin fold thickness < 5 mm Rate of growth 1. Depressed rate of weight gain < 20 g/d from 0-3 months of age < 15 g/d from 3-6 months of age 2. Fall-off from previously established growth curve Downward crossing of > 2 major percentiles on NCHS growth chart 3. Documented weight loss Patho physiology and clinical manifestation FTT can result from wide range of factors, including serious medical disease, dysfunctional child- caregiver interactions, poverty, parental misinformation, and child abuse. The physical examination of a child who is growing poorly should focus on identifying sign of underlying organic disease, severity of malnutrition, and important concomitant finding such as evident of physical abuse/neglect or the presence of deprivational behaviors. Treatment and prevention Management of the child with psychosocial failure to thrive must be individualized to the specific needs of the child and family. Nutritional rehabilitation, efforts are focused on correcting the dysfunctional child-parent interaction by addressing areas of parental misinformation, providing and helping to implement specific feeding guidelines, and addressing the larger psychosocial needs of the family. A multidisciplinary team approach involving the primary-care provider, nutritionist, social worker, child behavior specialist, and community-based outreach services is often most beneficial. I GA Trisna W ~ Assess Development in The Motoric Domain ~ Learning outcomes: - Describe gross and motor development - Determine factors affecting motor development Abstract Child developmental consist of several skills like: 1) Gross motor: using large groups of muscles to sit, stand, walk, run, etc., keeping balance, and changing positions; 2) Fine motor: using hands to be able to eat, draw, dress, play, write, and do many other things; 3) Language: speaking, using body language and gestures, communicating, and understanding what others Udayana University Faculty of Medicine, MEU 21

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Study Guide BlockGrowth and Development say; 4) Cognitive: Thinking skills: including learning, understanding, problem-solving, reasoning, and remembering; 5) Social: Interacting with others, having relationships with family, friends, and teachers, cooperating, and responding to the feelings of others. Developmental milestones are a set of functional skills or age-specific tasks that most children can do at a certain age range. Milestone can be described as what a child accomplishes throughout the different stages in their life. We can use milestones to help check how our child is developing. Although each milestone has an age level, the actual age when a normally developing child reaches that milestone can very quite a bit. Every child is unique. To determine whether a child has developmental delay, the physician must understand normal milestones The red flag age is the age at which you would expect almost every child to have already mastered a particular skill. For example walking, most children walk on their own, without holding on, around their first birthday. By 15 months--the red flag age for walking--a child who has not taken his first independent steps is certainly slower to walk than 90 percent of other children. Red flag milestones are helpful because they put a limit on when you, as a good, concerned parent, should worry. Motor development means the development of control over bodily movements through the coordinated activity of the nerve centers, the nerves and the muscles. This control comes from the development of the reflexes and mass activity present at birth. Until this development occurs, the child will remain helpless. From longitudinal studies of babies and young children, five general principles of motor development have emerged: 1) motor development depends on neural and muscular development; 2) learning skills cannot occur until the child is maturationally ready; 3) motor development follows a predictable pattern; 4) it is possible to establish norms for motor development; and 5) there are individual differences in rate of motor development. Motor development is divided into gross motor and fine motor development. Gross motor skills refer to the ability of children to carry out activities that require large muscles or groups of muscles. Muscles or groups of muscles should act in a coordinated fashion to accomplish a movement or a series of movements. Examples of gross motor tasks are walking, running, throwing something, jumping, standing on 1 leg, playing hopscotch, and swimming. Posture is an important element to consider in the assessment of gross motor skills. Adequate posture may make all the difference between being able or not able to execute a movement. Fine motor skills consist of movements of small muscles that act in an organized and subtle fashion, for instance, the hands, feet, and muscles of the head (as the tongue, lips, facial muscles), to accomplish more difficult and delicate tasks. Fine motor skills are the basis of coordination, which begins with transferring from hand to hand crossing the midline when aged 6 months. Examples of fine motor activities are writing, sewing, drawing, putting a puzzle together, imitating subtle facial gestures, pronouncing words (which involve coordination of the soft palate, tongue, and lips), blowing bubbles, and whistling. Many children who have difficulties in their fine motor skills also have difficulties in articulating sounds or words. The static and motor development of newborn into adult depends on the maturation process of the central nervous system. The process of this development is determined by genetically established patterns of behavior and stimulation from the environment. Some conditions that influence the rate of motor development. These factors include genetic constitution, prenatal condition, prematurity, nutrition, physical defects, stimulation, etc. They may contribute to poor abilities in motor functioning and coordination difficulties A decrease in movement during the process of motor development in the early stage of development and abnormal reactions on examination of primary reflexes may reflect early signs of motor handicaps. Udayana University Faculty of Medicine, MEU 22

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Study Guide BlockGrowth and Development Prof. dr. Soetjiningsih, SpAK, IBCLC ~ Assess Development in The Language Domain ~ Learning outcomes - Describe language development - Determine factors affecting language development Abstract Speech and language are tools that humans use to communicate or share thoughts, ideas, and emotions. Language is different from speech. Language is an elaborate system of communication that uses arbitrary and socially agreed on symbols to transmit and to receive messages from one human to another. Language is made up of socially shared rules that include the following: what words mean; how to make new words; how to put words together; and what word combinations are best in what situations. Speech is the verbal means of communicating. Speech consists of the following: articulation (how speech sounds are made); voice (use of the vocal folds and breathing to produce sound); and fluency (the rhythm of speech). There are many languages in the world, each includes its own set of rules for phonology (phonemes or speech sounds or, in the case of signed language, hand shapes), morphology (word formation), syntax (sentence formation), semantics (word and sentence meaning), prosody (intonation and rhythm of speech), and pragmatics (effective use of language). The most intensive period of speech and language development for humans is during the first three years of life, a period when the brain is developing and maturing. These skills appear to develop best in a world that is rich with sounds, sights, and consistent exposure to the speech and language of others. Children vary in their development of speech and language. There is, however, a natural progression or "timetable" for mastery of these skills for each language. The milestones are identifiable skills that can serve as a guide to normal development. Typically, simple skills need to be reached before the more complex skills can be learned. There is a general age and time when most children pass through these periods. These milestones help doctors and other health professionals determine when a child may need extra help to learn to speak or to use language. When a person has trouble understanding others (receptive language), or sharing thoughts, ideas, and feelings completely (expressive language), then he or she has a language disorder. Receptive language refers to the ability to understand, encompasses visual (reading, sign language comprehension) and auditory (listening comprehension) skills. Expressive language refers to the ability to produce symbolic communication, this output may be either visual (writing, signing) or auditory (speech) Delay in speech and language development in children can be defined as a “delay in speech and / or language development compared with controls matched for age, sex, cultural background, and intelligence”, or a discrepancy between a child’s potential ability to speak and the performance that is actually observed. Three common causes of speech delay are mental retardation, hearing loss and maturation delay. There are some conditions that contributing to variations in learning to speak i.e. health; intelligence; socioeconomic status; sex; desire communicate; stimulation; size of family; ordinal position; child-training methods; multiple birth; contact with peers; personality, etc. Udayana University Faculty of Medicine, MEU 23

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Lecture 14: ~ CognitiveDevelopment ~ Lecture 15: ~Psychosocial and Emotional Development~ Study Guide Block Growth and Development Rustika Learning outcomes: a. To understand the basic principles of cognitive process. b. To understand four stages of cognitive development Abstract: Most progressive change of human behavior related to cognitive development, so if someone wants to understand growth and development of human being comprehensively, they should learn about cognitive development. Piaget specifies four stages of cognitive development. The major cognitive achievement in the sensorimotor stage (which lasts from birth to about two years) is the development of the schema of object permanency. Thus, the attainment of this knowledge is indicative of representational ability. Such ability is involved in the major cognitive achievements in the preoperational stage (which lasts from about two through six years). Here, true systems of representation develop (e.g., as indexed by language, symbolic play, and delayed imitation). With the emergence of the concrete operational stage, however (which lasts from about six through twelve years), conservations are typically seen; thus, operational structures – internalized actions that are reversible – are evidence. The child cannot think counterfactually or hypothetically. Such ability characterizes the last stage of cognitive development, the formal operational stage (which lasts from about year twelve onward). Marheni Absract: Psychosocial development as propounded by Erik Erikson describes eight developmental stages through which a healthily developing human should pass from infancy to late adulthood. In each stage the person confronts, and hopefully masters, new challenges. Each stage builds on the successful completion of earlier stages. The challenges of stages not successfully completed may be expected to reappear as problems in the future. Erik Erikson developed the theory in the 1950s as an improvement on Sigmund Freud's psychosexual stages. Erikson accepted many of Freud's theories (including the id, ego, and superego, and Freud's infantile sexuality represented in psychosexual development), but rejected Freud's attempt to describe personality solely on the basis of sexuality. Also, Erikson criticized Freud for his concept of originology. This states that all mental illness can be traced to early experiences in childhood. According to Erikson, experience in early childhood is important, but the individual also develops within a social context. Erikson believed that childhood is very important in personality development and, unlike Freud, felt that personality continued to develop beyond five years of age. In his most influential work, Childhood and Society 1950, he divided the human life cycle into eight psychosocial stages of development. “ Human personality, in principle, develops according to steps predetermined in the growing person's readiness to be driven toward, to be aware of, and to interact with a widening social radius. ” —Erik Erikson Udayana University Faculty of Medicine, MEU 24

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Lecture 16: ~ Detectionof Developmental Deviation in Children (Screening & Stimulation) ~ Study Guide Block Growth and Development Prof. dr. Soetjiningsih, SpAK, IBCLC dr. I GA Trisna Windiani, SpA Learning outcomes - Describe the aims of detection developmental deviation - Recognize the methods of detection developmental deviation - Apply methods of detection developmental deviation (Denver test, Pediatric Symptom Checklist / PSC test) - Describe the aims of stimulation developmental deviation - Understand the principles of early stimulation - Recognize the methods of stimulation developmental deviation Abstract Developmental screening is a brief evaluation of developmental skills that is applied to a total population of children to identify children with suspected delays who require further diagnostic assessment. Developmental screening involves the use of standardized screening tests. Screening tests can be categorized as general screening tests that cover all behavioral domains or as targeted screens that focus on one area of developmental. They can administer in the office setting by professionals or completed at home by parents. The Pediatric Symptom Checklist is a psychosocial screen designed to facilitate the recognition of cognitive, emotional, and behavioral problems so that appropriate interventions can be initiated as early as possible. Included here are two versions, the parent-completed version (PSC) and the youth self-report (Y-PSC). PSC can be administered to 4-18 years old while Y- PSC can be administered to adolescents ages 11 and up. The Denver II is design to be used with apparently well children between birth and six years of age and is administered by assessing a child’s performance on various age appropriate tasks. The test is valuable in screening asymptomatic children for possible problem, in continuing intuitive suspicious with an objective measure, and in monitoring children at risk for developmental problems, such as those who have experienced perinatal difficulties. The Denver II consist of 125 tasks, or items which arranged on the test form in four sectors to screen areas of function: 1) personal social; 2) Fine motor adaptive; 3) Language; and 4) gross motor Early intervention or stimulation is necessary and effective because development is malleable and readily affected by the environment. In large part, early intervention works by systematically removing external risk factors. Early intervention programs place children in developmentally enriching settings; train parents in responsiveness and effectiveness, and provide continuous positive redirection and focused building of skills. The benefits of early intervention clearly depend on early detection, which requires that clinicians know how to identify accurately patients who have disabilities. Because time and reimbursement are limited, clinicians also should know how to identify patients quickly. Appropriate stimulation in childhood ranks as one of the most important factors that influence childhood development. Udayana University Faculty of Medicine, MEU 25

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Lecture 17: ~ SexualDevelopmental Sequence in Children and Adolescents ~ Study Guide Block Growth and Development W Bikin Suryawan Learning outcomes - To interpret maturation of the hypothalamic-pituitary-gonadal axis and connecting with the onset of puberty starts. - To explain positive feedback and negative feedback in puberty regulation. - To interpret kind of the factors affecting for sexual developmental. - To explain the pubertal staging in boys and girls. - To interpret the ovarian development and testicular development. - To explain the process of adrenarche and gonarche in puberty starts. Introduction Puberty can be defined as maturation of the hypothalamic-pituitary-gonadal axis that results in growth and development of the genital organs, and leads to the capacity to reproduce. Puberty is characterized by a number of physical and psychological changes. The onset of puberty starts with slow, frequent releases of gonadotropin releasing hormone (GnRH). GnRH is transported via the portal system to gonadotropic cells at the pituitary level, where it stimulates the production and release of the gonadotropins luteinizing hormone (LH) and follicle stimulating hormone (FSH). LH and FSH then stimulate growth and production of hormones and other factors in the ovaries and the testes, respectively. These secreted products are inhibitory (via negative feedback) at the pituitary and hypothalamic levels. During maturation in females, positive feedback occurs, leading to the mid-cycle LH surge. Hormonal regulation The release of the hypothalamic neurotransmitter GnRH is regulated by many factors, and is subject to negative and positive feedback at the pituitary and hypothalamic levels. During gestation, GnRH plasma levels increase; maximum levels are attained at 22-25 weeks of gestation in female fetuses and at 34-38 weeks of gestation in male fetuses. In primate studies, gamma-amino butyric acid (GABA) and other substances have been associated with decreased GnRH release, although stimulating effects of GABA have been observed as well. In primates, disinhibition of GnRH neurons by GABA is critical for the onset of puberty. In humans, low gonadotropin levels during childhood may in fact be due to tonic inhibition of GnRH by GABA. GnRH stimulates the production and release of both LH and FSH. GnRH levels are difficult to measure directly, since GnRH is secreted into the portal circulation and transported directly to the pituitary. GnRH is secreted in a pulsatile pattern. Simultaneous episodic fluctuations of GnRH in the portal blood and LH in the peripheral blood have been observed in sheep. A pulsatile pattern of LH release has been observed in humans as well, and it can be assumed that this pattern reflects pulsatile GnRH release. Fluctuations in FSH levels are not as marked as those in LH levels in humans, and are not always synchronized with LH pulses. As puberty progresses, LH secretion gradually increases, and occurs both during the day and during the night. This increase in LH secretion can be attributed to both enhanced LH pulse frequency and enhanced LH pulse amplitude. During puberty, the day-night rhythm is maintained; however, this with the progression of puberty in girls, the response to a challenge of exogenous GnRH increases as well. During prepuberty (pubertal stage B1), when endogenous GnRH stimulation is low, there is little or no increase in gonadotropins following such a challenge. From pubertal stages B2 to B5, a GnRH Udayana University Faculty of Medicine, MEU 26

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Study Guide BlockGrowth and Development challenge leads to increases in LH and FSH in girls (see also the subchapter entitled ‘Pubertal staging’). In girls, there is a remarkable exception for FSH in stage B2. High GnRH-stimulated levels of FSH alone characterize this stage. The FSH response is much lower in stage B3. In their study, they observed that the mean weight of 48 kg at menarche remained constant with increasing menarcheal age, while mean height increased significantly with increasing menarcheal age. Later studies in both female rats and humans showed that a particular ratio of fat to lean body mass is necessary for puberty to begin and for maintainance of reproductive capacity. Pubertal staging In girls, puberty, which begins following increased release of GnRH, can best be defined as the estrogen-dependent onset of breast development (thelarche), as increased estrogen levels are the result of an active hypothalamic-pituitary-gonadal axis. Growth of pubic hair (pubarche) begins following secretion of adrenal and ovarian androgens. In general, pubic hair appears a few months after the onset of breast development. However, pubic hair development can occur in the absence of breast development, as the result of an early adrenarche. Below are the 5 stages of breast development described by Marshall and Tanner. B1: In this pre-pubertal stage, which persists until puberty begins, only the nipple is raised above the level of the skin. B2: In this budding stage, a bud-shaped elevation of the areola and papilla becomes noticeable. On palpation, a fairly hard “button” can be felt, and may be painful to the touch. The areola increases in diameter and the surrounding area can be elevated. These changes may occur earlier in one breast than in the other. B3: Further elevation of the breasts occurs. The diameter of the areola increases further. The shape of small adult mammary glands, with continuous contours, is apparent. B4: Fat deposits increase. The areola and papilla enlarge further. The areola forms a secondary elevation above that of the breast. This secondary mound is apparent in roughly half of girls and may persist into adulthood. B5: In this adult stage, the areola is usually recessed to the general contour of the breast. Pubic hair grows as a result of exposure to androgens. In girls, these androgens, including DHEA-S, are of adrenal origin. The ovaries also produce androgens such as 4-androstenedione. Below are the 6 stages of pubic hair development in girls. P1: In this pre-pubertal stage, there is no growth of pubic hair. P2: A few lightly pigmented hairs, usually straight or only slightly curled, appear, chiefly along the labia. P3: Pubic hair is still sparse, yet there is definite pigmented, curly hair on the labia that also spreads onto pubic mons. P4: Pubic hair is “adult” in type, but the area covered is still considerably smaller than in adults. There has been no spread of pubic hair up to inguinal fold. P5: Pubic hair has an adult distribution in an inverse triangle, with horizontal lining on the pubic mons and lateral spreading up to the inguinal fold. P6: This stage is reached after adolescence in only in a minority of women. There is a further extension of pubic hair laterally onto the thighs or upward onto the abdominal wall. In boys, the first sign of pubertal development is testicular growth. A testicular volume greater than or equal to 4 mL indicates that the gonadal axis is active. Marshall and Tanner have described different Udayana University Faculty of Medicine, MEU 27

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Study Guide BlockGrowth and Development stages of testicular and penile growth. Below are the 5 stages of genital development described by Marshall and Tanner. G1: In this pre-pubertal state, the testes, scrotum, and penis are the same size and shape as in a young child. G2: The testes and scrotum become larger, with testicular volume greater than or equal to 4 mL. The skin of the scrotum becomes redder, thinner, and wrinkled. The size of the penis is similar to that in G1. G3: The penis becomes larger, particularly in length. The testes and scrotum become even larger, and the scrotum descends. G4: The testes and scrotum become even larger, and the scrotal skin shows increased pigmentation. This stage is “not quite adult”. G5: In this stage, the external genitalia are adult in size and shape. The scrotum is ample, and the penis and bottom of the scrotum reach to about the same level. Below are the 6 stages of pubic hair development in boys. P1: In this pre-pubertal stage, there has been no growth of pubic hair. There may be fine hair over the pubes, but this growth is not different from that on the rest of the abdomen. P2: A few lightly pigmented, longer, straight hairs, often still downy, appear at base of the penis and sometimes on the scrotum. P3: Hair that is still sparse, yet definitely pigmented, coarser, and curlier appears around the base of the penis. P4: Hair is “adult” in type, but the area covered by hair is still considerably smaller than in adults, not going further than in the inguinal fold. P5: Hair is adult in quantity and type and spreads up to the medial surface of the thighs, but not up the linea alba. P6: Further extension occurs laterally and up the linea alba after adolescence. The majority of adult men reach this stage. Ovarian development Menarche, which usually occurs about 2.4 years after the start of breast development, does not necessarily indicate that there is full interaction among the hypothalamus, the pituitary, and the ovaries. In fact, during the first years after menarche, anovulatory cycles occur. Following this stage, ovulation occurs after an LH surge as a result of positive feedback to estrogens. During menstruation, gonadotropin levels (primarily levels of FSH) increase. FSH levels then decrease, with gradual increases in estradiol. Testicular development In young, developing, 6- to 7-week-old embryos, gonadal tissue is undifferentiated. The presence of the sex-determining region of the Y chromosome (SRY) triggers the tissue to differentiate to become testes. In the absence of this SRY, the tissue would differentiate to become ovaries. Undifferentiated gonadal tissue consists of 4 major cell lines: 1. Supporting cells develop into Sertoli cells, which have a paracrine function in spermatogenesis. Their number is a limiting factor in spermatogenesis. Anti-Mullerian hormone, a hormone secreted by Sertoli cells, is necessary for regression of the Mullerian duct and influences gonadal differentiation. Udayana University Faculty of Medicine, MEU 28

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Lecture 18: ~ VisualImpairment ~ Study Guide Block Growth and Development 2. Leydig cells, which are steroidogenic, produce androgens, which induce development of secondary sex characteristics. In the human fetus, Leydig cells are present after 8 weeks of gestation. During gestation and shortly after birth, these cells are functionally active, secreting testosterone. Fetal Leydig cells eventually develop into adult-type Leydig cells, which are responsible for pubertal development. 3. Connective cells give rise to peritubular myoid cells. These cells function along with Sertoli cells to produce the basal lamina of testicular tissue. This basal lamina serves as a base for testis cord formation. 4. Germ cells develop through several stages into spermatozoa. Testicular volume increases 3-fold between birth and 9 years of age, but remains at a prepubertal volume (i.e., <4 mL). Gonadarche versus adrenarche Androgens of adrenal origin, particularly dehydroepiandrosterone (DHEA) and its sulfate (DHEA- S), are responsible for sexual hair development in girls. The point at which the adrenals increase production of DHEA is known as adrenarche. In girls, pubic hair development occurs around the same mean age as breast development (11 years). Premature adrenarche is characterized by an early development of pubic hair, with little or no increase in height velocity and without progressive bone maturation. Early pubic hair growth may be an isolated event or may be accompanied by increased sweat and body odor, acne, axillary hair, and/or fatty skin. In general, premature adrenarche does not require treatment. In boys, pubic hair development is caused by adrenal and testicular androgens. Premature adrenarche may occur in boys, but is diagnosed more often in girls. When early growth of pubic hair occurs along with an increase in height velocity and progression of bone development, one should be aware of diagnoses associated with an excess of sex steroids. In such cases, a late- onset adrenal hyperplasia caused by a partial enzyme deficiency can often be diagnosed. Maturation of the gonadal axis and the adrenal axis occur separately, which means that in cases of adrenal insufficiency, gonadarche will occur appropriately. In cases of gonadal failure, the adrenals will contribute to adrenarche. It is well known that delayed and early-onset puberty are related, although specific genes contributing to these phenomena have not yet been recognized. To date, several gene mutations and polymorphisms of GnRH and its receptor, and of the gonadotropins LH and FSH and their receptors, have been identified. Sunerti Abstract Many people have some type of visual problem at some point in their lives. Some can no longer see objects far away. Others have problems reading small print. These types of conditions are often easily treated with eyeglasses or contact lenses. But when one or more parts of the eye or brain that are needed to process images become diseased or damaged, severe or total loss of vision can occur. In these cases, vision can't be fully restored with medical treatment, surgery, or corrective lenses like glasses or contacts. Blindness. They haven't lost their sight completely but have lost enough vision that they'd have to stand 20 feet from an object to see it as well as someone with perfect vision could from 200 feet away. What Causes Visual Impairment? Udayana University Faculty of Medicine, MEU 29

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Study Guide BlockGrowth and Development People rarely lose their eyesight during their teen years. When they do, it's usually caused by an injury like getting hit in the eye or head with a baseball or having an automobile or motorcycle accident. Some babies have congenital blindness, which means they are visually impaired at birth. Congenital blindness can be caused by a number of things — it can be inherited, for instance, or caused by an infection (like German measles) that's transmitted from the mother to the developing fetus during pregnancy. Conditions that may cause vision loss after birth include: amblyopia, strabismus, cataracts, diabetic retinopathy, glaucoma, macular degeneration, trachoma Udayana University Faculty of Medicine, MEU 30

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Lecture 19: ~ HearingImpairment ~ Lecture 20: ~ Learning Disorders ~ Study Guide Block Growth and Development Eka Putra S -------------- I GA Endah Ardjana Learning outcomes Learning disorders are diagnosed when standardized est. achievement in reading, math, or written expression are substantially lower than expected for a particular age, school level, or intelligence. These disorders involve academic deficits and impairments in specific areas of reading, math, spelling, and writing. About 5 percent of students in public schools in the United States are estimated to have a learning disorder, and up o 40 percent of these students drop out of school. Reading Disorders: a. Reading achievement, as measured by individually administered standardized tests of reading accuracy or comprehension, is substantially below that expected given the person’s chronological age, measured intelligence, and age-appropriate education. b. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living ha require reading skills. c. If a sensory deficit is present, the reading difficulties are in excess of those usually associated with it. Mathematic Disorders a. Mathematical ability, as measured by individually administered standardized tests, is substantially below that expected given the person’s chronological age, measured intelligence, and age appropriated education. b. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require mathematical ability. c. If sensory deficit is present, the difficulties in mathematical ability are in excess of hose usually associated with it. Disorders of Written Expression a. Writing skills, as measured by individually administered standardized tests (or functional assessments writing skills), are substantially below those expected given the person’s chronological age, measured intelligence, and age-appropriate education. b. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require the composition of written text (e.g., writing grammatically correct sentences and organized paragraphs). c. If a sensory deficit is present, the difficulties in writing skills are in excess of those usually associated with it. Udayana University Faculty of Medicine, MEU 31

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Study Guide BlockGrowth and Development Udayana University Faculty of Medicine, MEU 32

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Lecture 21: ~ MentalRetardation and Down Syndrome ~ Study Guide Block Growth and Development I GA Endah Ardjana ~ Mental Retardation ~ Abstract: For a definite diagnosis, there should be a reduced level of intellectual functioning resulting in diminished ability to adapt to the daily demands of the normal social environment. Associated mental or physical disorders have a major influence on the clinical picture and the use made of any skills. The diagnostic category chosen should therefore be based on global assessments of ability and not on any single area of specific impairment or skill. The IQ levels given are provided as a guide and should not be applied rigidity in view of the problems of cross-cultural validity. The categories are given below are arbitrary divisions of complex continuum, and cannot be defined with absolute precision. The IQ should be determined from standardized, individual’s level of functioning and additional spesific handicapping conditions, e.g. expressive language problem, hearing impairment, physical involvement. Scales of social maturity and adaptation, again locally standardized, should be completed if at all possible by interviewing a parent or care provider whi is familiar with the individual’s skills in everyday life. Without the use of standardized procedures, the diagnosis must be regarded as a provisional estimete only. According to Diagnosis and Statistical Manual of Mental Disorders (DSM-IV-TR), mental retardation is defined as, a. Significantly subaverage general intellectual functioning: an IQ of approximately 70 or below on an individually administered IQ test (for infants, a clinical judgment of significantly subaverage intellectual functioning). b. Concurrent deficits or impairments in present adaptive functioning (i.e., the person’s effectiveness in meeting the standards expected for his or her age by his or her cultural group) in at least two of the following areas: communication, self-care, home living, social/interpersonal skills, use of community resources, self-direction, functional academic skills, work, leisure, health and safety. c. The onset before age 18 years. Degree of Mental Retardation: - Mild Mental Retardation : IQ level 50 to 69. - Moderate Mental Retardation : IQ level 35 to 49. - Severe Mental Retardation : IQ level 20 to 34. - Profound Mental Retardation : IQ is under 20. ~ Down Syndrome ~ Learning outcomes: - Understand the genetic aspect of Down Syndrome. - Understand the screening test of Down Syndrome. - Understand the clinical aspect of Down Syndrome. - Understand the diagnosis and therapy of Dwon Syndrome. - Understand the genetic counselling of Down Syndrome. Abstract: Dwon Syndrome, also known as trisomy 21, is a disorder caused by a chromosomal abnormality, and the most common cause of birth defect including mental child is born. Women over the age of 35 are in the most risk. The incidence of Down Syndrome is estimated 1 in every 800 to 1000 babies born. They don’t appear to be associated with paternal age. Udayana University Faculty of Medicine, MEU 33

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Lecture 22: ~ AttentionDeficit / Hyperactivity Disorder (ADHD) ~ Study Guide Block Growth and Development Down Syndrome is a chromosomal abnormalty characyerized by extra copy of genetic maternal on the 21st chromosome, either in whole (trisomy 21) or due to translocation (Robertsonian translocation or familial Down Syndrome), mosaicism or duplication of portion of chromosome 21. Patient with Down Syndrome chare certain physical features such as a flat facial profile, an upward slant to the eyes, small ear, a single crease across the centre of the palms, and an enlarge tongue. Down Syndrome affect cognitive abilities in different ways, but most have mild to moderete mental retardation. Diagnostic test are about 99% accurate in detecting Down Syndrome. They are generally recommended only for women age 35 or older, and those with a familial history of genetic defect. Screening test include nuchal translucency testing, alpha fetoprotein, ultrasound, amniocentesis, chorionic villus sampling, and percutaneus umbilical blood sampling, now widely available for early detection. Prof. dr. Soetjiningsih, SpAK, IBCLC Learning outcomes: Awarness of common developmental disorders in children: - Suspect children with ADHD - Refer children with ADHD Abstract: Attention Deficit Hyperactivity Disorders (ADHD) is the most common neurobehavioral disorders of childhood. ADHD is also among the most prevalent chronic health conditions affecting school-aged children. Recorded prevalence rates for ADHD vary substantially, partly because of changing diagnostic criteria over time, partly because of variations in ascertainment in different settings and the frequent use of referred samples to estimate rate. Prevalence rates also vary significantly depending on whether they reflect school samples 6.9% (5.5%-8.5%) versus community samples 10.3% (8.2%-12.7%). The core symptoms of ADHD include inattention, hyperactivity and impulsivity. Children with ADHD may experience significant functional problems, such as school difficulties, academic underachievement, troublesome interpersonal relationships with family members and peers, and low self-esteem. Individuals with ADHD present in childhood and may continue to show symptoms as they enter adolescence and adult life. Early recognition, assessment and management of this condition can redirect the educational and psychosocial development of most children with ADHD. The American Academy of Pediatrics (AAP) recommended that the primary care physicians should initiate an evaluation for ADHD. The clinician during routine health supervision may assist in early recognition of ADHD. So, knowledge, skill for screening, diagnosis and manage children with ADHD is mandatory understood by primary care physician Udayana University Faculty of Medicine, MEU 34

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Lecture 23: ~ AutismSpectrum Disorders ~ Study Guide Block Growth and Development Prof. dr. Soetjiningsih, SpAK, IBCLC Learning outcomes Awareness of common developmental disorders in children: - Suspect children with Autism - Refer children with Autism Abstract Autism describes a spectrum of clinical conditions of neurobiological origin that are characterized by: (1) qualitative dysfunctions of social interaction, (2) qualitative impairments in communication abilities, and (3) unusual or restricted ranges of play and interests. The totality of these impairments, though quite variable from person to person, is usually a lifelong condition that results in some degree of social isolation and varying amounts of unusual behavior. Despite extensive investigation, no consistent pattern of the cause of autism has emerged. In fact, more than 60 different disease entities have been shown to be likely causes of autism, including genetic, infectious, endocrine, toxic, and space-occupying etiologies. This suggests that autism is a final common clinical presentation of a variety of underlying neurobiological and genetic processes. The prevalence of autism appears to have increased during the past decade, perhaps due to (1) greater awareness about autism and its symptoms, (2) more-inclusive recent definitions, and (3) possibly a true increase in incidence. Overall, the ratio of males to females is about 3:1 to 4:1. Prevalence estimates range from 2 to 6 per 1,000 children. This wide range of prevalence points to a need for earlier and more accurate screening for autism. Many instruments can used to screen for autism. The brief instruments such as the Checklist for Autism in Toddlers (CHAT), designed to screen for autism in 18-months old. Screening instruments do not provide individual diagnosis but serve to assess the need for referral for possible diagnosis of Autism. Criteria for the diagnosis of autism are included in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). The earlier the disorder is diagnosed, the sooner the child can be helped through treatment interventions. For most children who have a disorder within the autistic spectrum, results of the physical and neurology examinations will entirely normal. No routine laboratory tests seem necessary. When autistic disorders are associated with general medical condition, laboratory findings consistent with general condition will be observed. Although no definitive treatments are yet available, remarkable progress in the area of intervention has occurred. Primary modalities include (1) educational programs, including early intervention, school-based programs, and prevocational services; (2) behavioral techniques; (3) speech and language therapy programs; (4) family support services; and (5) adjunctive psychopharmacologic management of specific symptoms. Early intensive intervention may dramatically improve outcome. Udayana University Faculty of Medicine, MEU 35

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Lecture 25: ~ AgingProcess ~ Lecture 24: ~ Cerebral Palsy Syndrome ~ Study Guide Block Growth and Development K Kari Abstract Cerebral palsy (CP) is an umbrella term encompassing a group of non-progressive, non- contagious diseases that cause physical disability in human development. The incidence in developed countries is approximately 2.12–2.45 per 1000 live births. Incidence has not declined over the last 60 years despite medical advances (such as electro-fetal monitoring) because these advances allow extremely low birth weight and premature babies to survive. Cerebral refers to the affected area of the brain, the cerebrum (however the centres have not been perfectly localised and the disease most likely involves connections between the cortex and other parts of the brain such as the cerebellum) and palsy refers to disorder of movement. CP is caused by damage to the motor control centers of the young developing brain and can occur during pregnancy (about 75 percent), during childbirth (about 5 percent) or after birth (about 15 percent) up to about age three. Eighty percent of causes are unknown; for the small number where cause is known this can include infection, malnutrition, and/or head trauma in very early childhood. R A Tuty Kuswardhani S Abstract Aging is a process of the loosing of ability the tissue slowly to develop itself and to maintain the structure and the normal function; so it cannot stand towards the trauma to develop the damage. The human being progressively will lose his defense against the infection it will pile the more metabolic and structural distortion. Aging process theory, according to this theory aging has been programmed genetically for some certain species. Different of aging process theories which support the process of aging i.e.: 1. Genetic clock theory 2. The damaged of body immune system. 3. Metabolic theory. 4. The shortening of telomere theory. 5. The damaged by free radical. Udayana University Faculty of Medicine, MEU 36

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Lecture 26: ~ ClinicalImplication of Aging Process ~ Study Guide Block Growth and Development Nym Astika Learning outcomes - To describe the changes associated with aging - To know common problem of Geriatrics (a series of I’s) - To knows components of assessment of older patients Abstract The care of older patients differs from that of younger patients for number of reasons. Some of these can be traced to the change that occur in the process of aging, some are caused by the plethora of diseases and disruptions that accompany seniority, and still other result from the way old people are treated We have already noted the critical and difficult distinction a clinician must make to attribute a finding to either the expected course of aging or the result of pathology changes. Many of the changes associated with aging result from gradual loss, most organ systems seem loss function at about 1 percent a year beginning around age 30 year. Other data suggest that the changes in people followed longitudinally are much less dramatic and certainly begin well after age 70 years Comprehensive evaluation of an older individual’s health status is one of the most challenging aspects of clinical geriatrics. Udayana University Faculty of Medicine, MEU 37

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DAY 1 Study Guide BlockGrowth and Development ~LEARNING TASKS~ Case 1 A mother came to the physician to consult about her child development. Her child is a boy 10 months old. His mother complained that he cannot crawl and cannot stand up alone. When he was 8 months old, he has sir alone. He was born at midwife, spontaneously; his birth weight was 2700 gram. Assignment: a. Please describe, is it a normal child development? b. Please describe, was the child had sequential normal development? c. As a physician, what kind information that you give to his mother? Self Assessment a. Describe the lifespan developing stages b. What is the differentiate between growth and development c. Describe factors that affecting growth and development Case 2: A 15 months old girl was brought by her mother to the Growth and Development Clinic to know whether her child’s growth normal or not. On the physical examination revealed that her weight was 9 kg; her length was 75 cm; her head circumference was 47 cm. Her father’s height was 176 cm; her mother’s height was 157 cm. Assignment: a. Please plot all of the data to the CDC 2000 curve, and interpret it b. Please calculate the potential genetic height of the child c. Please plot the head circumference measurement to the Nellhauss curve and interpret it Case 3: An infant, girl, was brought by her mother to the Growth and Development Clinic for immunization, on September 22, 2007. She was born on December 9, 2006. The following are the data of her weight based on measurement at Primary Health Care. Birth weight 2900 grams 1 month 3800 gram 2 months 5600 grams 3 months 6000 grams 5 months 6500 grams 6 months 6700 grams 8 months 7000 grams Assignment: a. Please calculate the chronological age b. Please plot the data into KMS (Road to Health Chart) c. Please interpret the result of the measurement Self Assessment a. Please differentiate physical growth patterns between boy and girl b. Describe the factors that affecting physical growth c. Describe the normal pattern of the body system growth Udayana University Faculty of Medicine, MEU 38

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DAY 2 DAY 3 DAY 4 Study Guide BlockGrowth and Development Assigment: 1. Describe the embryonic development phases and its morphological characteristic. 2. Explain the main phenomena during human development on the 1st week, 2nd week, 3rd week, 3rd -8th week and 8h week to birth. 3. Explain the clinical correlation in each phase. 4. Predict the time of birth based on the LNMP. Case You are called to attend the delivery of baby boy G at uncertain gestational, who is to be delivered by spontaneously labor. The delivery, there was no meconium, and the baby need only towel drying, clearing of the airway. After the baby stable (about 10 hours) the New Ballard Score was examination, with the score are: neuromuscular maturity score are 19, and the physical maturity score are: 21. The baby weight is 3500 gram, length is 51 cm, and head circumference is 35 cm. Assignment 1: 1. What is your assessment of his gestational age? 2. What is your assessment of his classification? Self assessment: 1. Describe the methods of determining postnatal gestational age 2. Describe and explain the classification of the infants based on Lubchenco chart. 3. Describe the physical appearance the preterm, term and post term infant. 4. Describe and explain the risk factors the baby born preterm, or post term. Assignment 2: 1. What does the definition of ultrasound waves? 2. Explains that ultrasound waves length and its associate with images resoluition. 3. What does the function of gel was applied on the skin? 4. What kinds of ultrasonic media/tissue in pregnant woman? 5. Indication of ultrasound scanning is? 6. When did the USG used firstly in Obstetrics? 7. Explains about RADIUS means! 1. ???? Udayana University Faculty of Medicine, MEU 39

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DAY 5 DAY 6 Study Guide BlockGrowth and Development Assignment: Many medications have side effects that are potentially harmful during pregnancy, but their benefits may outweigh their risks. A woman should consult her doctor or midwife before taking any drug, even one sold over the counter. If you to be a medical doctor can you explain to a pregnant women if she want to take medicine like: 1. Anticonvulsants, such as phenytoin (Dilantin) and carbamazepine (Tegretol), to prevent epileptic seizures? 2. Aspirin, ibuprofen, and other non-steroidal anti-inflammatory drugs (NSAIDs)? 3. Could you explain to her about the effect of drugs at different stages of pregnancy? 4. Paracetamol is a drugs that A category. Could you explain it? How about B category, C category and X category? Case 1 A mother came to the clinic with lactation problem. During the first week she found that her breasts were very swollen, tender, throbbing, lumpy, and uncomfortably full. Sometimes the swelling extends all the way to the armpit. She panicked, thinking that her milk ducts were blocked, even though she had been through exactly the same experience with her first child. Assignment a. What kind of the mother lactation problem? a. How can the mother treat it (What should the mother do?) b. How long does it last? c. Can the mother still breastfeed? d. Will the conditions affect her baby? Self Assessment a. Describe the composition of human milk b. Describe the benefits of breastfeeding c. Describe the most common problems encountered by mothers who are breast-feeding and management of the breastfeeding problems Case 2 A male neonate was born at 40 weeks gestation with severe asphyxia. After resuscitation about 10 minutes, the baby was spontaneously breathing and crying loudly. The body weight was 3500 gram. You want to give nutrition on the first day of life. Assignment 1. What type nutrition you will give? Why? 2. How many fluids will you give? 3. When will you start the oral feeding? What is the best oral feeding will you chose? Self assessment 1. Describe the benefits of breastfeeding 2. Describe the general principles of feeds small babies 3. Describe feed and fluid volume for small babies 4. Explain about feeding intolerance and complications Udayana University Faculty of Medicine, MEU 40

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DAY 7 Study Guide BlockGrowth and Development 5. Explain about complication of parenteral nutrition Case 1 Armani, two years old boy, with body weight of 7.7 kg and length of 70 cm came with the main complains of spot on his left eyes since 1 month ago and cannot seeing object in the evening before night. He suffered edema on his feet (dorsum pedis), looked pale and often suffered infection. Assignment: 1. What is the diagnosis of this case? 2. What are the reasons? 3. Formulate the management of vitamin A and Fe deficiency. Self Assessment: 1. Describe the definition of the vitamin A and iron deficiency. 2. Describe the etiology and pathogenesis of the vitamin A and iron deficiency. 3. Describe the prognosis and prevention of the vitamin A and iron deficiency. Case 2 Doni is 6-month old infant came with main complain of mental deficiency, spastic diplegia, or quadriplegia, deaf mutism, dysarthria, a characteristic shuffling gait, shortened stature, and hypothyroidism. Assignment 1. What is the diagnosis of this case? 2. What are the reasons? 3. Formulate the management of iodine deficiency Self assessment 1. Describe the definition of the iodine deficiency. 2. Describe the etiology and pathogenesis of the iodine deficiency. 3. Describe the prognosis and prevention of the iodine deficiency. Case 3 A 3 years old adolescent with body weight 11 kg and height 95 cm; he looks pale, with pitting edema in the lower extremities and scrotum. He comes to the pediatrics clinic with acute respiratory problems. He is belonging to poor family; the food intake is always low compare with other children. Assignment 1. What is the diagnosis of the patient above? 2. Formulate the management of protein energy malnutrition! Self assessment 1. Describe differentiation of primary PEM and secondary PEM. 2. Describe differentiation of clinical manifestations between marasmus and kwashiorkor. 3. Explain the path physiology of pitting edema of patient with kwashiorkor. Case 4 A 14 years old adolescent with body weight 132 kg and height 200 cm; he looks likes ‘sumo player’, a popular traditional sport in Japan. He usually comes to the pediatrics clinic because of respiratory problems. His father and mother are overweight. Assignment 1. Calculate the BMI of the patient; is he overweight or obesity! Udayana University Faculty of Medicine, MEU 41

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DAY 8 DAY 9 Study Guide BlockGrowth and Development 2. Formulate the management of obesity in childhood! Self assessment 1. Describe the risk factors of obesity. 2. Describe the clinical manifestations and complications of obesity. 3. Describe the diseases associate with childhood obesity. Case Because the weight gains of a 3 months old infant (the body weight 4050 g and length 50 cm) was poorly since 3 month, the parents brought him to hospital. Breast milk intake is always low compared with others healthy infant; and the infant often suffered from respiratory tract problems. Normal weight gain in healthy infant < 3 months is 750-1000 g/month. Assignment 1. What is the ‘diagnoses’ of the patient above? 2. Formulate the management of patient above! Self assessment 1. Describe definition/criteria of patient with FTT. 2. What kind of multidisciplinary approach in Indonesia could be organized as a team work to solve the problem (FTT)? 3. List the risk factors could cause FTT and focus to the factors of patient who need refer to the hospital! Case 1 An infant, boy, 7 months old consulted by his mother to the Growth and Development clinic for immunization. He was born at Sanglah Hospital, spontaneously, asphyxia, and birth weight was 2300 g, gestational age 37 weeks. There is no congenital anomaly. She had antenatal care at midwife. On the physical examination always found fist right hand. His mother did not know about this. Assignment: a. Describe the motor developmental milestones in 7 months infant b. Describe the risk factors that influence the motor development deviation in infant c. What kind examination that necessary for motor development deviation? Self Assessment a. Please differentiate between gross and fine motor development b. Describe the factors that affect motor development c. Describe the primitive and postural reflexes; when these reflexes present or absent? Case 2 TR, girl, 24 months old consulted to the Growth and Development clinic, by her mother with chief complaint cannot compose 2 word combinations yet. She just only says 1 word like “mama”; “papa”. She was born at Sanglah Hospital by caesarean section, helped by obstetrician, cried spontaneously, and birth weight was 2700 g, gestational age was 38 weeks. There is no congenital anomaly. She has febrile convulsion when she was 10 months old. Five months ago she got febrile convulsion but never hospitalized. Udayana University Faculty of Medicine, MEU 42

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DAY 10 Study Guide BlockGrowth and Development Assignment: a. Describe the language developmental milestone in 24 months old b. Describe the red flag of the language developmental milestone in 24 months old c. Describe the risk factors that influence the language development deviation toward that girl d. What should we suggest to her mother? Self Assessment a. Please differentiate between speech and language b. Please differentiate expressive and receptive language c. Describe the factors that affecting language development Case 3 SI, girl, 19 months came with her mother to the Growth and Development clinic with complaint cannot walk well yet. She can stand alone 2 months ago. She can speak mama/papa specific. She was born at midwife, spontaneously, asphyxia, and birth weight was 2800 g, gestational age 38 weeks. There is no congenital anomaly. Assignment: a. Has the child in the normal development? b. Describe the developmental milestones in 19 months child c. Describe the red flag of the developmental milestone in 19 months old a. What should we suggest to her mother? Self Assessment a. Describe the development milestone from birth until 5 years old b. Describe the red flag of development from birth until 5 years old Assignments 1 a. Describe about organization and adaptation in biological systems and cognitive development! b. Describe about assimilation! (Demonstrate some examples) c. Describe about accommodation! (Demonstrate some examples) d. Explain about equilibration in cognitive development! e. Explain the role of reproductive assimilation in cognitive development! f. Describe about schema! g. Compare The Sensorimotor Stage and The Preoperational Stage! h. Describe about conservation! (Demonstrate some examples) i. Compare The Concrete Operational Stage and The Formal Operational Stage! Assignments 2 a. Differentiate between Erikson and Freud’s Development Theory. b. Discuss the ego implication in social life. c. Why does every Erkson’s phase in Psychosocial Development is critical period. d. Identify eight phases in psychosocial development and their psychosocial needs. e. Diferentiate the adult mature personality and immature personality. f. Discuss this case: Sanjaya familiy is the obedient familiy in religion and very diligent goes to the churc and pray to god. Although Mr and Mrs. Sanjaya are very busy, they never forget to remain their children to pray. One day Mr. Sanjaya feel upset when he heard and Udayana University Faculty of Medicine, MEU 43

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DAY 11 Study Guide BlockGrowth and Development saw from TV news, that his child name John (17 years old) was capture by the cop in drug’s party. Case 1 A mother brought her child to Growth and Development clinic at December 9, 2005 with chief complaint her child was still unable to walk. He was born at January 24, 2003, with gestational age 37 weeks. The following were his history of development: 1. Gross motor: - Walk well (-) - Pull to stand (+) - Sit, no support (+) 2. Language: - Can speak 3 words (+) - Papa/mama specific (+) - Point 2 body part (+) - Name 1 picture (+) 3. Fine motor: - Put block in cup (+) - Scribbles (+) - Takes 2 cubes (+) - Tower of cubes 4 (+) - Initiate vertical line (-) 4. Personal social: - Play pat-a-cake (+) - Wave bye-bye (+) - Drink from cup (+) - Remove garment (-) - Put on clothing (-) - Wash and dry hands (-) Assignment: a. Complete the Denver test and the interpretation Case 2 A Mother brought her son to general physician. He is 5 years old with asthma since he was 2 years old. The asthma relapses almost every month. Now he is in kindergarten. According to his mother and his teacher report, his complained were: - Often absent from school - Often distracted easily - Irritable and often angry - Has trouble concentrating - Less interested in friends, often fights with other children - Sometimes takes things that do not belong to him - Often does not listen to rules Assignment: a. Scoring these symptoms, fill the Pediatric Symptom Checklist and the interpretation! b. As a general physician, what is your planning after PSC screening? Case 3 A 5 months old infant, boy, brought by his mother to the Growth and Development Clinic. On the developmental examination found that he could not roll over and he was has head leg Assignment: Udayana University Faculty of Medicine, MEU 44

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DAY 12 Study Guide BlockGrowth and Development a. Please describe is it normal development? b. Please describe the method of stimulation in this child? c. If you are a general physician, when will you refer the child who has developmental deviation? Case 4 A 2 years old girl, consulted to the Growth and Development Clinic with chief complained that she cannot speak 4-5 syllables Assignment: a. Please describe is she has normal development? b. How to give stimulation to this child? Self Assessment a. What is the aim of early detection and stimulation; describe the benefit of early detection and stimulation. b. Describe the principles of early stimulation Case 1 A girl with a painful nipple An 11-year-old girl attends your outpatient clinic because her left nipple is painful to the touch. She has been healthy and has had no complaints until now. Her height is 150 cm (0 SD), and her weight is 35 kg (-1 SD). Physical examination reveals no abnormalities. There is a small, pea-like lump, which is painful to the touch, below her left nipple. Which diagnosis do you consider? (Choose 1 answer.) a. The start of puberty b. A breast tumor c. A breast cyst Case 2 A 6-year-old girl with pubic hair At the outpatient clinic, you see a 6-year-old girl who has had pubic hair since the age of 6 months. For the past few weeks, she has also had some body odor. Her mother is very worried about her pubertal development, particularly about the timing of menarche. She knows that after menarche, her daughter will not grow very much. Other than these complaints, the girl is healthy. Physical examination reveals a healthy-looking girl with a height within the target range (-1 SD). She has no breast development, but does have some pubic and axillary hair. What would your diagnosis be? (Choose 1 answer.) a. Presence of an androgen-producing tumor b. Central precocious puberty c. Premature adrenarche d. Hirsutism Udayana University Faculty of Medicine, MEU 45

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DAY 13 Study Guide BlockGrowth and Development Self Assessment: 1. Describe the onset of puberty starts in boys and girls. 2. Describe the factors to influence release of the hypothalamic neurotransmitter GnRH. 3. Describe changes of FSH/LH secretion from the fetal stage to adulthood. 4. Describe difference GnRH release in fetal period, prepuberty period and adult period. 5. Describe factors to block release GnRH from hypothalamus in puberty starts. 6. Describe stages of breast development in girls. 7. Describe stages of pubic hair development in boys and girls. 8. Describe stages of genital development in boys. 9. Describe of ovarian development in puberty girls. 10. Describe of testicular development in puberty boys. 11. Describe difference of adrenarche and gonarche in puberty. 12. Describe the process of spermatogenesis. Case 1 Young mother came to Eye Clinic with complain that her baby has white pupil in the both eye. The age of baby is 3 month old. The age of gestation and birth weight of the baby are normal. At external examination we found opacity on both lens. Assignment: a. Describe ocular examination of infants and young children b. How to distinguish differential diagnosis of leucocorea c. Describe about the complication congenital cataract if we late starting therapy Case 2 A 6-year old boy, still unable to speak, with a history of fall from his bed during infancy, was sent by his parents to attend a school for the handicapped. This decision was made following the advice of several friends and relatives. A hearing-aid device was prescribe and the boy was trained some techniques of communication such as reading verbal and lip signs, etc and various vocational skills needed to function as member in the society. Case 3 A 6-year old boy with a hearing-aid device and being able to speak, entered a normal primary school with special attention from the teacher. During pregnancy, his mother was suspected to have contracted a viral infection. His mother noted that at age 18 months, the boy couldn’t speak like other children of comparable age. Following the administration of various hearing tests, the boy was found several deaf. A hearing-aid device was fitted and the boy has then been intensely trained in verbal communication. Udayana University Faculty of Medicine, MEU 46

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Study Guide BlockGrowth and Development Assignment 1. Describe the influence of delayed detection and rehabilitation of the boys. 2. Will there be any difference in the outcomes of rehabilitation started early (2 years of age) and years later (6 years of age)? 3. Describe the social impacts of delayed rehabilitattion on the boys future. 4. Desbribe the prospects for obtaining a decent education and job for the boys. Udayana University Faculty of Medicine, MEU 47

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DAY 14 Study Guide BlockGrowth and Development Case 1 Janet, 13 years old, had a long history of school problems. She failed first grade, supposedly because her teacher was “mean”, and was removed from special classroom because she kept getting into fights with the other children. Currently in a normal sixth-grade classroom, she is failing reading, barely passing English and spelling, and doing satisfactory work in art and sports. Her teacher describes Janet as a ”slow learner with a poor memory”, and states and requires a great deal of individual attention. Janet’s medical history was unremarkable except for a tonsillectomy at age 5 years and an early history of chronic otitis. She sat up at 6 months, walked at 12 months, and began taking at 18 months. An examination revealed an open and friendly girl who was nonetheless touchy about her academic problems. She stated that she was “bossed around” at school but had good friends in the neighborhood. Intelligence testing revealed a full-scale intelligence quotient of 97. Wide- range achievement testing produced grade-level scores of 4.8 for reading, 5.3 for spelling, and 6.3 for arithmetic. The most likely diagnosed is: a. Disorder of written expression. b. Expressive language disorder. c. Phonological disorder. d. Reading disorder. e. None of the above. Disorder of written expression is often associated with: a. Reading disorder. b. Mixed expressive-receptive language disorder. c. Developmental coordination disorder. d. Mathematics disorder. e. All of the above. Assignment: a. Explain the criteria diagnostic for mental retardation. b. Explain four degree of mental retardation and developmental characteristics of Mentally Retarded Persons. c. Explain the etiology and pathophysiology Mental Retardation. d. Explain what is the differential diagnosis for Mental Retardation. e. Explain the strategy of holistic therapy for Mental Retardation. Self assessment: Select the one that is the best in each case. 1. DSM-IV-TR lists the prevalence of mental retardation in the United States as: a. 1 percent. b. 3 percent. c. 5 percent. d. 6 percent. e. 10 percent. 2. Mental Retardation should be diagnosed when the intelligence Quotion (IQ) is below: a. 100. b. 85. c. 70. d. 65. e. 60. Udayana University Faculty of Medicine, MEU 48

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DAY 15 Study Guide BlockGrowth and Development 3. A decline in IQ begins at approximately 10 to 15 years in which of the following disorders? a. Down’s syndrome. b. Fragile X syndrome. c. Cerebral palsy. d. Nonspecific mental retardation. e. None of the above. Self assessment: Select the one that is the best in each case: 1. All of the following chromosomal aberrations associated with Down’s syndrome lead to a phenotypic expression of the disorder except: a. Patient have 45 chromosomes. b. Patient have three of chromosome 21. c. Patient have 47 chromosomes with an extra chromosome 21. d. Patient have 46 chromosomes, but two, usually 21 and 15, are fused. e. Patient have mosaicism, with normal and trisomic cells in various tissues. 2. The genetic finding linked most closely to advancing maternal age is: a. Translocation between chromosome 14 and chromosome 21. b. Mitotic nondisjunction of chromosome 21. c. Partially trisomic karyotipe. d. Meiotic nondisjunction of chromosome 21. e. All of the above. Case GD, 5 years old boy came to Growth and Development Clinic, Sanglah Hospital accompanied by his mother. His mother complained about her son which is hyperactive and lack of communication. He is constantly running around and climbing tables and chairs. He can’t sit still for long, except while watching television. He gets bored easily with new toys. Now GD is a kindergarten student. His teacher complained GD cannot pay attention in class. He is very hard to control because he is always wants to run around and he is restless most of the time. He always grabs toys from other children and hits other children. His mother also said that there is no history of serious illness. His mother had normal pregnancy period, birth weight was 3.000 gram, spontaneous delivery in midwife, the baby cried spontaneously. Assignment: a. What is the differential diagnosed of this case? b. Please examine this child using Conners Parent Rating Scales (CPRS). What are the points that necessary to fill observation item in the CPRS? c. According to DSM IV-TR criteria, is he an ADHD? Why? Self Assessment a. Describe how to diagnose the ADHD b. Describe the etiology of the ADHD c. Describe the patophysiology of ADHD d. Describe the treatment of ADHD e. Describe the prognosis of ADHD Udayana University Faculty of Medicine, MEU 49

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DAY 17 DAY 16 Study Guide BlockGrowth and Development Case A 2 years old boy, came to the Growth and Development Clinic with chief complaint deficient verbal and non verbal communication; unusual use of language and echolalia. He spent more time alone; he cannot join with another child, and lack of eye contact. He always arranges something everyday and repetitive. He cannot play peek-a- boo. Assignment: a. Please examine this child using CHAT. What are the points that necessary to fill observation item in the CHAT? b. According to DSM IV criteria, is he suffering from autism? Why? c. Please differentiate between autism and delayed speech development? Self Assessment a. Describe how to diagnose the autism b. Describe the cause of the autism c. Describe the interventions of the autism Case A boy was brought to the ambulatory service of the Central General Hospital of Denpasar on February 13, 2006, for being unable to walk. The boy was born on January 12, 2004 in the same Hospital following a seemingly normal delivery with a weight of 1450 gram, spontaneous cry after birth and appeared robust. Gestation age is 36 weeks Assignment a. To estabilish accurate diagnosis, what other additional information is required? b. When the child is lifted up by the axilla, one of the legs appers shorter. What additional investigation is required to determine the location of abnormality, and what would be result? c. CT scan of the head revealed periventricular leucomalacea. Based on the findings so far, what do you think about the diagnosis? d. When for the first time, do you suspect the boy may have had some neurological abnormalities? e. What other consultations are required? f. How World you manage the child? Assignment: a. What is “aging”? b. Describe the various theories of aging c. Explain in more detail the genetic clock theory d. What do you know about the connection between caloric metabolism and aging? e. Why free radicals are thought into influence the process of aging? f. How does the shortening of telomere cause the death of cell? g. Explain what is meant by lengthening of telomere theory Udayana University Faculty of Medicine, MEU 50

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DAY 18 Study Guide BlockGrowth and Development Case Mrs. L, a 75-year-old widow, came to your office after being discharged from the hospital, where she underwent surgery for a fracture of her right shoulder. Mrs. L has been under your care for several years and has been treated for hypertension, osteoarthritis of both knees, and obesity. She had a stroke 4 years ago but the deficit resolved. She has no history of diabetes or glaucoma. Her hypertension had been well controlled with daily hydrochlorothiazide 25 mg and atenonol 50 mg. Because she does not tolerate nonsteroidal anti-inflammatory agents, she acetaminophen for her knee pain but still has pain when she walks and sometimes uses a cane. Other medications include enteric-coated aspirin and a multivitamin. Mrs. L explains that, on the night of the fracture, she woke up to urinate around midnight, and then fell the broke her shoulder. She related her fall to drinking wine that night with a friend, which had made her a little drowsier than usual when she got up at midnight. She drinks alcohol only occasionally, and has not had trouble before. The conversation reminded Mrs. L that she experienced frequent nocturnal urination during the hospitalization and on several occasions was unable to get to the toilet on time and became incontinent. When questioned, she admits that she has had urinary frequency for several years but managed it by avoiding beverages before sleep or before leaving her house. She also avoids going out for long periods during the day, and, whenever she returns from her brief excursions, she develops urinary urgency “as soon as the key goes into the lock.” She has occasionally experienced leakage when sneezing, standing, or coughing, but this most commonly occurs when she is trying to hold her urine during one of her “urgent” episodes. Still, she did not view her urinary pattern as a big problem until her recent hospitalization. Mrs. L last visited her gynecologist 1 year ago. She has no cystocele, rectocele, or uterine prolapse. She denies dysuria, fever, or constipation. Assignment: Evaluating this geriatric patient: a. Physical assessment. b. Functional assessment. c. Nutritional Assessment. Self assessment: 1. Describe the changes associated with “normal” aging. 2. Explain of classifying geriatric problems. 3. Describe the components of assessment of older patients. Please see study guide for case field Udayana University Faculty of Medicine, MEU 51

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Study Guide BlockGrowth and Development ~ CURRICULUM STRUCTURE ~ Udayana University Faculty of Medicine Semester Program or curriculum blocks 10 Senior Clerkship 9 Senior Clerkship 8 Senior clerkship 7 Critical care (2 weeks) The skin & disorders (2 weeks) Special topics (5 weeks) Special study 3 (4 weeks) Basic Clinical Skill 6 (3 weeks) 6 Musculoskeletal system & connective tissue disorders (4 weeks) Neuroscience and neurological disorders (4 weeks) Behavior and disorders (4 weeks) Basic Clinical Skill 5 (4 weeks) 5 Alimentary & hepato- biliary systems & disorders (4 Weeks) The endocrine & metabolic disorders (4 weeks) Clinical nutrition & disorders (2 weeks) Special study 2 (4 weeks) Basic Clinical Skill 4 (2 weeks) 4 Respiratory system & disorders (4 weeks) Cardiovascular system & disorders (4 weeks) Urinary system & disorders (3 weeks) The genital system & disorders (3 weeks) Basic Clinical Skill 3 (2 weeks) 3 Hematologic system & disorders & clinical oncology (4 weeks) Immune system & disorders (3 weeks) Infection & infectious diseases (5 weeks) The visual system & disorders (2 weeks) Basic Clinical Skill 2 (2 weeks) 2 Community- based practice (4 weeks) Health system- based practice (3 weeks) Information management (2 weeks) Basic clinical skills 1 (3 weeks) Special Study 1 (4 weeks) 1 Studium generale (3 weeks) Medical professionalism (3 weeks) Medical communication (3 weeks) The cell as biochemical machinery (3 weeks) Growth & development (4 weeks) Udayana University Faculty of Medicine, MEU 52

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Study Guide BlockGrowth and Development REFERENCES Basic References: 1. Behrman RE, Kliegman RM. Nellson Textbook of Pediatrics. 17th ed. Philadelphia, WB Saunders. 2004. 2. Sadler TW: Langman’s Medical Embryology, 10th ed. Philadelphia, Lippincott Williams and Wilkins. 2006. 3. Soetjiningsih. Tumbuh Kembang Anak. EGC. 1995. 4. Thompson JS and Thompson MW.Genetics in Medicine. 4th ed. Philadelphia, WB Saunders. 1986. 5. Ultrasound and Doppler. In Cunningham F G et al, in Williams Obstetrics, 21st ed. 1997; 1111-1139. Additional References: 1. Ballantyne J, Groves J. Scott-Brown’s Diseases of the ear, Nose, and Throat. 4th ed, Boston, Butterworths. 2. Elizabeth B. Hurlock. Child Development. 6th ed. Mc Graw Hill. 1984. 3. Eva PR, Whitcher JP. Vaughan & Asbury’s General Ophthalmology. 16th ed. Lange Medical Book. 4. Hazzard WR, Blass JP, Ettinger WH, Halter JB, Ouslander JG. Principles of Geriatric Medicine and Gerontology. 4th ed. McGraw-Hill Co. 5. Jeremy KH, Jan Maarten W, Alan D Rogol. Pediaric Endocrinology and Growth. 2nd ed. Saunders Co, Philadelphia. 2003. 6. Kane RL, Ouslander JG, Abrass IT, Essentials of Clinical Geriatrics. 5th ed. McGraw-Hill Co. 2004. 7. Klaus MH, Fanacroff AA. Care of the High-Risk Neonate. 5th ed. Philadelphia, WB Saunders Co. 2001. 8. Koren G, Pastuszak A, Ito S. Drugs in Pregnancy. New Engl J Med. 1998. 338; (16). 1128-1137. 9. L Kathleen M, Marian TA. Nutritional care in anemia in Krause’s Food nutrition & diet therapy. W B Saunders Co, Philadelphia, 5th Ed, 1992. pp 558-563. 10. Lawrence RA, Lawrence RM. Breast feeding a Guide for the Medical Profession. 5th ed. Philadelphia, Mosby. 1999. 11. Lerner RM. Concepts and Theories of Human Development. 12. Mahan KL, Escott-Stump: Krause’s Food, Nutrition, & Diet Therapy, 11th ed. Philadelphia, WB Saunders, 2004. 13. Soetjiningsih, Moersintowarti, Sudiyanto, Titi Sularyo. Pedoman Deteksi Dini Penyimpangan Tumbuh Kembang Balita bagi Keluarga. Komie Tumbuh Kembang Anak Indonesia. 1996. 14. Soetjiningsih. Pentingnya Stimulasi Dini Untuk mengoptimalkan Kecerdasan Otak. SMF Ilmu Kesehatan Anak K UNUD/RS Sanglah Denpasar. 15. Tricia LG, Cunningham MD, Fabien GE, Karin EZ. Neonatology: Management, Procedures, On-Call Problems, Disease, and Drugs. 5th ed. McGraw-Hill Co. 2004. 16. Wijayanegara Hidayat et al. Kursus Dasar Ultrasonografi dan Kardiotokografi, 2000, hal 11-14. Udayana University Faculty of Medicine, MEU 53

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Study Guide BlockGrowth and Development CURRICULUM Aims: • To assess growth and development in children and adolescents. • To diagnose, manage, and refer if required, common disorders of growth and development. • Awareness of the general means to assess fetal growth (intrauterine growth). • Awareness of the common health implications of normal and abnormal aging. Learning outcomes: • Assess physical growth of children and adolescents. • Diagnose and manage common nutritional problems in children and adolescents. • Investigate infant or child with suspect failure to thrive. • Identify common congenital anomalies in infants and children. • Assess fetal growth (intrauterine growth). • Assess development of children in specific domains. • Awareness of common developmental disorders in children. • Awareness of the normal sexual developmental sequence in children and adolescents. • Capability to evaluate critically the use of medicine in pregnancy, children, and elderly. • Detection of developmental deviation in children (Screening & Stimulation). • Awareness of the impacts of aging on the common health parameters of the elderly. • Awareness of the common clinical manifestations and disorders in the elderly. • Diagnose and manage common health problems and disorders in the elderly. Curriculum contents: • Normal growth patterns in children and adolescents. • Nutritional impacts on growth (and development) in infant, children and adolescents. • Clinical manifestations and diagnosis of failure to thrive. • Common congenital anomalies in infants and young children. • Clinical assessment of intrauterine growth (fetal growth). • Drug recommendation and toxicity on pregnancy and Children. • Assess development of children and adolescents in specific domains. • Methods of developmental deviation detection and stimulation. • Common developmental disorders in children and adolescents. • Diagnose common sexual developmental problems in children and adolescents. • Aging and physiologic changes in health parameters. • Common clinical manifestations and problems and management in the elderly. Udayana University Faculty of Medicine, MEU 1

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Study Guide BlockGrowth and Development PLANNERS TEAM NO NAME DEPARTMENT 1. dr. I G A Trisna Windiani, SpA (Head) Child Health 2. dr. I NG Wardana, S.Ked (Secretary) Anatomy 3. Prof. dr. Soetjiningsih, SpAK, IBCLC Child Health 4. dr. I N Mangku K, M.Repro Anatomy 5. dr. Eka Putra S, Sp.THT ENT 6. dr. I Komang Kari, SpA (K) Child Health 7. dr. I Made Kardana, SpA Child Health 8. dr. I KG Suandi, SpA Child Health 9. dr. AAN Prayoga, SpA Child Health 10. dr. W Bikin Suryawan, SpAK Child Health 11. dr. N. Sunerti, SpM Ophthalmology 12. dr. IGA Endah Ardjana, SpKJ Child Health 13. dr. R A Tuty Kuswardhani, SpPD Geriatri 14. dr. Nyoman Astika, SpPD Geriatri 15. dr. Tjok Gd Suardewa, SpOG Obstetri & Gynaecoogy ~ LECTURERS ~ NO NAME DEPARTMENT 1. dr. I G A Trisna Windiani, SpA (Head) Child Health 2. Prof. dr. Soetjiningsih, SpAK, IBCLC Child Health 3. dr. I N Mangku K, M.Repro Anatomy 4. dr. Eka Putra S, Sp.THT ENT 5. dr. I Komang Kari, SpA (K) Child Health 6. dr. I Made Kardana, SpA Child Health 7. dr. I KG Suandi, SpA Child Health 8. dr. AAN Prayoga, SpA Child Health 9. dr. W Bikin Suryawan, SpAK Child Health 10. dr. N. Sunerti, SpM Ophthalmology 11. dr. IGA Endah Ardjana, SpKJ Child Health 12. dr. R A Tuty Kuswardhani, SpPD Geriatri 13. dr. Nyoman Astika, SpPD Geriatri 14. dr. Tjok G A Suwardewa, SpOG Obstetri &Gynaecoogy 15. dr. Wayan Suwitra, Sp.HK Histology FACILITATORS Regular Class: No Name Department Phone Group Venue 1 dr. Nyoman Astika, Sp.PD Geriatri 08123974128 1 2nd floor: R.2.01 2 dr. Muliani, S.Ked Anatomy 08123900767 2 2nd floor: R.2.02 3 Ni Wyn Tianing, S.Si.,M.Kes Biochemistry 08123982504 3 2nd floor: R.2.03 4 dr. Ketut Ngurah Parasitology - 4 2nd floor: R.2.04 Udayana University Faculty of Medicine, MEU 2

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Study Guide BlockGrowth and Development 5 dr. Susi Purnawati Physiology 08123989891 5 2nd floor: R.2.05 6 dr. Wayan Suwitra Histology 08123803996 6 2nd floor: R.2.06 7 dr. Ratna Sundari Physiology 08123963634 7 2nd floor: R.2.07 8 dr. Wayan Sugiritama, M.Kes Histology 08164732743 8 2nd floor: R.2.08 9 dr. I G K Arijana Histology 08124665966 9 2nd floor: R.2.09 10 dr. I Nyoman Wartana Parasitology 081558119779 10 2nd floor: R.2.10 11 dr. I GA Sri Mahendra D, SpPA Phatologi Anatomy - 11 3rd floor: R.3.26 12 Drs. Made Rustika, Msi Physichology 08123958663 12 3rd floor: R.3.27 English Class: No Name Department Phone Group Room 1 dr. Hengky Forensic 08123988486 1 2nd floor: R.2.01 2 dr. I N Mangku K, M.Repro Anatomy 0811387105 2 2nd floor: R.2.02 3 dr. Ni Wayan Winarti Pathology Anatomy 08123997328 3 2nd floor: R.2.03 4 dr. A A Wiradewi Lestari, SpPA Phatologi Anatomy 08555237937 4 2nd floor: R.2.04 5 dr. I N G Wardana, S.Ked Anatomy 0361-7864957 5 2nd floor: R.2.05 6 dr. I B Putu Alit, SpF Forensic 081916361398 6 2nd floor: R.2.06 7 dr. Matinus Noerwidjaja Anatomy 08123803718 7 2nd floor: R.2.07 8 dr. Siany Herawati, SpPK Clinical Pathology 0818566411 8 2nd floor: R.2.08 9 dr. Dsk Md Wihandani, M.Kes Biochemistry 081338776244 9 2nd floor: R.2.09 10 dr. Yuliana, S.Ked Anatomy 0816555671 10 2nd floor: R.2.10 Reserve No Name Department Phone 1 dr. I GA Widianti Anatomy 08123921765 2 dr. Dwi Fatmawati Microbiology 0818557082 3 dr. Sri Widnyani Pathology Anatomy 081337115012 4 dr. I GN Swarba, SpA Child Health 08123994911 5 dr. Made Arimbawa, SpA Child Health 085237052159 Udayana University Faculty of Medicine, MEU 3

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Study Guide BlockGrowth and Development ~ TIME TABLE ~ Regular Class DAY/ DATE TIME ACTIVITY VENUE CONVEYER LEARNING OUTCOMES 1: ASSESS PHYSICAL GROWTH OF CHILDREN AND ADOLESCENTS 1 Friday 14 Dec 07 08.00 - 08.30 08.30 - 09.00 09.00 - 11.00 11.00 - 12.00 12.00 - 12.30 Intro: General Concepts of Growth and Development Lecture 1: Assessment Physical Growth of Children And Adolescents Individual learning Group discussion Plenary Class room Class room - Discussion room Class room Prof. Soetji Prof. Soetji Facilitator Prof. Soetji LEARNING OUTCOMES 2: ASSESS FETAL GROWTH (INTRAUTERINE GROWTH) 2 Monday 17 Dec 07 08.00 - 09.00 09.00 - 11.00 11.00 - 12.00 12.00 - 12.30 Lecture 2: The Stages of Prenatal Development Individual learning Group discussion Plenary Class room - Discussion room Class room Mangku K Facilitator Mangku K 3 Tuesday 18 Dec 07 08.00 - 08.30 08.30 - 09.00 09.00 - 11.00 11.00 - 12.00 12.00 - 12.30 Lecture 3: USG to Assess Fetal Anatomy Lecture 4: Assessment Growth and Development in Neonatus Individual learning Group discussion Plenary Class room Class room - Discussion room Class room Tjok Suardewa Kardana Facilitator Tjok S & Kardana LEARNING OUTCOMES 3: IDENTIFY COMMON CONGENITAL ANOMALIES IN INFANTS AND CHILDREN 4 Wednesday 19 Dec 07 08.00 - 09.00 09.00 - 11.00 11.00 - 12.00 12.00 - 12.30 Lecture 5: Prenatal Genetic Evaluation and Counseling Individual learning Group discussion Plenary Class room - Discussion room Class room Suwitra Facilitator Suwitra LEARNING OUTCOMES 4: CAPABILITY TO EVALUATE CRITICALLY THE USE OF MEDICINE IN PREGNANCY, CHILDREN, AND ELDERLY 5 Thursday 27 Dec 07 08.00 - 09.00 09.00 - 11.00 11.00 - 12.00 12.00 - 12.30 Lecture 6: Drugs in Pregnancy, Children, and Elderly Individual learning Group discussion Plenary Class room - Discussion room Class room Jawi Facilitator Jawi LEARNING OUTCOMES 5: DIAGNOSE AND MANAGE COMMON NUTRITIONAL PROBLEMS IN CHILDREN AND ADOLESCENTS 6 Friday 28 Dec 07 08.00 - 08.30 Lecture 7: Principles Breastfeeding for Infants With Normal Delivery Class room Prof. Soetji Udayana University Faculty of Medicine, MEU 4

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Study Guide BlockGrowth and Development 08.30 - 09.00 09.00 - 11.00 11.00 - 12.00 12.00 - 12.30 Lecture 8: Principles Feeding for Infants With Complicated Delivery Individual learning Group discussion Plenary - Discussion room Class room Kardana Facilitator Soetji & Kardana 7 Wednesday 2 Jan 08 08.00 - 08.30 08.30 - 09.00 09.00 - 11.00 11.00 - 12.00 12.00 - 12.30 Lecture 9: Vitamin A, Fe & Iodine Deficiencies Lecture 10: Protein Energy Malnutrition (PEM) & Obesity Individual learning Group discussion Plenary Class room - Discussion room Class room Prayoga Suandi Facilitator Prayoga&Suandi LEARNING OUTCOMES 6: INVESTIGATE INFANT OR CHILD WITH SUSPECT FAILURE TO THRIVE 8 Thursday 3 Jan 08 08.00 - 09.00 09.00 - 10.00 10.00 - 12.00 12.00 - 12.30 Lecture 11: Failure to Thrive Individual learning Group discussion Plenary Class room - Discussion room Class room Suandi Facilitator Suandi LEARNING OUTCOMES 7: ASSESS DEVELOPMENT OF CHILDREN IN SPECIFIC DOMAINS 9 Friday 4 Jan 08 08.00 - 08.30 08.30 - 09.00 09.00 - 11.00 11.00 - 12.00 12.00 - 12.30 Lecture 12: Assess Development in Motoric Domains Lecture 13: Assess Development in Language Domains Individual learning Group discussion Plenary Class room Class room Discussion room Class room Trisna Prof. Soetji - Facilitator Trisna & Soetji 10 Tuesday 8 Jan 08 08.00 - 08.30 08.30 - 09.00 09.00 - 11.00 11.00 - 12.00 12.00 - 12.30 Lecture 14: Cognitive Development Lecture 15: Psychosocial Development Individual learning Group discussion Plenary Class room Class room - Discussion room Class room Rustika Marheni - Facilitator Rustika&Marheni LEARNING OUTCOMES 8: DETECTION OF DEVELOPMENT DEVIATION IN CHILDREN (SCREENING AND STIMULATION) 11 Wednesday 09 Jan 08 08.00 - 09.00 09.00 - 11.00 11.00 - 12.00 12.00 - 12.30 Lecture 16: Detection of Developmental Deviation In Children (Screening & Stimulation) Individual learning Group discussion Plenary Class room - Discussion room Class room Prof. Soetji & Trisna - Facilitator Soetji & Trisna LEARNING OUTCOMES 9: AWARENESS OF THE NORMAL SEXUAL DEVELOPMENT SEQUENCE IN CHILDREN AND ADOLESCENT 12 Friday 11 Jan 08 08.00 - 09.00 09.00 - 11.00 11.00 - 12.00 Lecture 17: Sexual Developmental Sequence in Children and Adolescent Individual learning Class room - Discussion room Bikin S Facilitator Udayana University Faculty of Medicine, MEU 5

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Study Guide BlockGrowth and Development 12.00 - 12.30 Group discussion Plenary Class room Bikin S LEARNING OUTCOMES 10: AWARENESS OF COMMON DEVELOPMENTAL DISORDERS IN CHILDREN 13 Saturday 12 Jan 08 08.00 - 08.30 08.30 - 09.00 09.00 - 11.00 11.00 - 12.00 12.00 - 12.30 Lecture 18: Visual Impairment Lecture 19: Hearing Impairment Individual learning Group discussion Plenary Class room Class room - Discussion room Class room Sunerti Eka Putra - Facilitator Sunerti & Eka Putra 14 Monday 14 Jan 08 08.00 – 08.30 08.30 - 09.00 09.00 - 11.00 11.00 - 12.00 12.00 - 12.30 Lecturer 20: Learning Disorders Lecture 21: Down Syndrome and Mental Retardation Individual learning Group Discussion Plenary Class room - Discussion room Class room Endah Endah Facilitator Endah 15 Tuesday 15 Jan 08 08.00 - 09.00 09.00 - 11.00 11.00 - 12.00 12.00 - 12.30 Lecture 22: Attention Deficit/Hyperactivity Disorders Individual learning Group discussion Plenary Class room - Discussion room Class room Trisna/Endah Facilitator Trisna/Endah 16 Wednesday 16 Jan 08 08.30 - 08.30 08.30 - 09.00 09.00 - 11.00 11.00 - 12.00 12.00 - 12.30 Lecture 23: Autism Spectrum Disorders Lecture 24: Cerebral Palsy Individual learning Group discussion Plenary Class room Class room - Discussion room Class room Prof. Soetji K Kari - Facilitator Prof. Soetji & K Kari LEARNING OUTCOMES 11: AGING AND ITS CLINICAL IMPLICATIONS 17 Thursday 17 Jan 08 08.00 - 08.30 08.30 - 09.00 09.00 - 11.00 11.00 - 12.00 12.00 - 12.30 Lecture 25: Aging Process Lecture 26: Clinical Implication of Aging Process Individual learning Group Discussion Plenary Class room - Discussion room Class room R A Tuty K Astika Facilitator Tuty & Astika 18 Friday 18 Jan 08 Case Field Visit to day care centre (TPA), Playgroup, Kindergarten, Primary Health Care, Special Need School 19 Monday 21 Jan 08 08.00 - 10.20 Case Presentation Class room Team 20 Tuesday 22 Jan 08 Preparation for Examination 22 Friday 25 Jan 08 EXAMINATION ~ TIME TABLE ~ Udayana University Faculty of Medicine, MEU 6

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Study Guide BlockGrowth and Development English Class DAY/ DATE TIME ACTIVITY VENUE CONVEYER LEARNING OUTCOMES 1: ASSESS PHYSICAL GROWTH OF CHILDREN AND ADOLESCENTS 1 Friday 14 Dec 07 09.00 - 09.30 09.30 - 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Intro: General Concepts of Growth and Development Lecture 1: Assessment Physical Growth of Children And Adolescents Individual learning Group discussion Plenary Class room Class room - Discussion room Class room Prof. Soetji Prof. Soetji Facilitator Prof. Soetji LEARNING OUTCOMES 2: ASSESS FETAL GROWTH (INTRAUTERINE GROWTH) 2 Monday 17 Dec 07 09.00 - 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Lecture 2: The Stages of Prenatal Development Individual learning Group discussion Plenary Class room - Discussion room Class room Mangku K Facilitator Mangku K 3 Tuesday 18 Dec 07 09.00 - 09.30 09.30 - 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Lecture 3: USG to Assess Fetal Anatomy Lecture 4: Assessment Growth and Development in Neonatus Individual learning Group discussion Plenary Class room Class room - Discussion room Class room Tjok Suardewa Kardana Facilitator Tjok S & Kardana LEARNING OUTCOMES 3: IDENTIFY COMMON CONGENITAL ANOMALIES IN INFANTS AND CHILDREN 4 Wednesday 19 Dec 07 09.00 - 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Lecture 5: Prenatal Genetic Evaluation and Counseling Individual learning Group discussion Plenary Class room - Discussion room Class room Suwitra Facilitator Suwitra LEARNING OUTCOMES 4: CAPABILITY TO EVALUATE CRITICALLY THE USE OF MEDICINE IN PREGNANCY, CHILDREN, AND ELDERLY 5 Thursday 27 Dec 07 09.00 - 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Lecture 6: Drugs in Pregnancy, Children, and Elderly Individual learning Group discussion Plenary Class room - Discussion room Class room Jawi Facilitator Jawi LEARNING OUTCOMES 5: DIAGNOSE AND MANAGE COMMON NUTRITIONAL PROBLEMS IN CHILDREN AND ADOLESCENTS 6 Friday 28 Dec 07 09.00 - 09.30 09.30 - 10.00 Lecture 7: Principles Breastfeeding for Infants With Normal Delivery Lecture 8: Principles Class room Prof. Soetji Kardana Udayana University Faculty of Medicine, MEU 7

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Study Guide BlockGrowth and Development 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Feeding for Infants With Complicated Delivery Individual learning Group discussion Plenary - Discussion room Class room Facilitator Soetji & Kardana 7 Wednesday 2 Jan 08 09.00 - 09.30 09.30 - 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Lecture 9: Vitamin A, Fe & Iodine Deficiencies Lecture 10: Protein Energy Malnutrition (PEM) & Obesity Individual learning Group discussion Plenary Class room - Discussion room Class room Prayoga Suandi Facilitator Prayoga&Suandi LEARNING OUTCOMES 6: INVESTIGATE INFANT OR CHILD WITH SUSPECT FAILURE TO THRIVE 8 Thursday 3 Jan 08 09.00 - 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Lecture 11: Failure to Thrive Individual learning Group discussion Plenary Class room - Discussion room Class room Suandi Facilitator Suandi LEARNING OUTCOMES 7: ASSESS DEVELOPMENT OF CHILDREN IN SPECIFIC DOMAINS 9 Friday 4 Jan 08 09.0 - 09.30 09.30 – 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Lecture 12: Assess Development in Motoric Domains Lecture 13: Assess Development in Language Domains Individual learning Group discussion Plenary Class room Class room - Discussion room Class room Trisna Prof. Soetji - Facilitator Trisna & Soetji 10 Wednesday 9 Jan 08 09.00 - 09.30 09.30 - 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Lecture 14: Cognitive Development Lecture 15: Psychosocial Development Individual learning Group discussion Plenary Class room Class room - Discussion room Class room Rustika Marheni - Facilitator Rustika&Marheni LEARNING OUTCOMES 8: DETECTION OF DEVELOPMENT DEVIATION IN CHILDREN (SCREENING AND STIMULATION) 11 Thursday 10 Jan 08 09.00 - 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Lecture 16: Detection of Developmental Deviation In Children (Screening & Stimulation) Individual learning Group discussion Plenary Class room - Discussion room Class room Prof. Soetji & Trisna - Facilitator Soetji & Trisna LEARNING OUTCOMES 9: AWARENESS OF THE NORMAL SEXUAL DEVELOPMENT SEQUENCE IN CHILDREN AND ADOLESCENT 12 Friday 11 Jan 08 09.00 - 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Lecture 17: Sexual Developmental Sequence in Children and Adolescent Individual learning Group discussion Plenary Class room - Discussion room Class room Bikin S Facilitator Bikin S Udayana University Faculty of Medicine, MEU 8

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Study Guide BlockGrowth and Development LEARNING OUTCOMES 10: AWARENESS OF COMMON DEVELOPMENTAL DISORDERS IN CHILDREN 13 Saturday 12 Jan 08 09.00 - 09.30 09.30 - 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Lecture 18: Visual Impairment Lecture 19: Hearing Impairment Individual learning Group discussion Plenary Class room Class room - Discussion room Class room Sunerti Eka Putra - Facilitator Sunerti & Eka Putra 14 Monday 14 Jan 08 09.00 - 09.30 09.30 - 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Lecturer 20: Learning Disorders Lecture 21: Down Syndrome and Mental Retardation Individual learning Group Discussion Plenary Class room - Discussion room Class room Endah Endah Facilitator Endah 15 Tuesday 15 Jan 08 09.00 - 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Lecture 22: Attention Deficit/Hyperactivity Disorders Individual learning Group discussion Plenary Class room - Discussion room Class room Trisna/Endah Facilitator Trisna/Endah 16 Wednesday 16 Jan 08 09.00 - 09.30 09.30 - 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Lecture 23: Autism Spectrum Disorders Lecture 24: Cerebral Palsy Individual learning Group discussion Plenary Class room Class room - Discussion room Class room Prof. Soetji K Kari - Facilitator Prof. Soetji & K Kari LEARNING OUTCOMES 11: AGING AND ITS CLINICAL IMPLICATIONS 17 Thursday 17 Jan 08 09.00 - 09.30 09.30 - 10.00 10.00 - 12.00 12.00 - 13.00 13.00 - 13.30 Lecture 25: Aging Process Lecture 26: Clinical Implication of Aging Process Individual learning Group Discussion Plenary Class room - Discussion room Class room R A Tuty K Astika Facilitator Tuty & Astika 18 Friday 18 Jan 08 Case Field Visit to day care centre (TPA), Playgroup, Kindergarten, Primary Health Care, Special Need School 19 Monday 21 Jan 08 10.20 – 12.40 Case Presentation Class room Team 20 Tuesday 22 Jan 08 Preparation for Examination 22 Friday 25 Jan 08 EXAMINATION Udayana University Faculty of Medicine, MEU 9

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Study Guide BlockGrowth and Development ~ MEETING ~ Meeting with the student representatives The meeting between block planners and student group representatives will be held on Saturday, 5 January 2008, at 09.00 until 11.00 at Class Room. In this meeting, all of the student group representatives are expected to give suggestions and inputs or complaints to the team planners for improvement. For this purpose, every student group should choose one student as their representative to attend the meeting. Meeting with the facilitators The meeting between block planners and facilitators will take place on Saturday, 5 January 2008, at 11.00 until 13.00 at Class Room. In this meeting the facilitators are expected to give suggestions and inputs to improve the study guide and the educational process. Because of its importances, all facilitators are expected to attend and participate in the meeting. ~ ASSESSMENT METHOD ~ Assessment will be carried out on Friday 25 January 2008. There will be 100 questions consisting mostly of Multiple Choice Questions (MCQ). The minimal passing score for the assessment is 70. Other than the examination score, your performance and attitude during group discussions will also be considered in the calculation of your final score. Udayana University Faculty of Medicine, MEU 10

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Study Guide BlockGrowth and Development ~ LEARNING PROGRAMS ~ LECTURE Prof. dr. Soetjiningsih, SpAK, IBCLC Learning outcomes - To describe the general concept of growth and development - To describe the stages in lifespan development - To understand the conceptual differences between growth and development - To describe the factors that may affect growth and development Abstract Lifespan development is a field of study that examines patterns of growth, change, and stability in behavior that occur throughout the entire life span. The life span is usually divided into broad age ranges: the prenatal period (the period from conception to birth); infancy and toddler hood (birth to age 3); the preschool period (ages 3 to 6); middle childhood (ages 6 to 12); adolescence (ages 12 to 20); young adulthood (ages 20 to 40); middle age (ages 40 to 60); and late adulthood (age 60 to death). Lifespan development specialists discuss development in several topics: physical development (development involving the body’s physical make up, including the brain, nervous system, muscles, senses, and the need for food, drink and sleep); cognitive development (development involving the ways that growth and change in intellectual capabilities influence a person’s behavior); personality development (development involving the ways that enduring characteristics that differentiate one person from another change over the life span); and social development ( the way in which individuals’ interactions with others and their social relationships grow, change, and remain stable over the course of life). Growth and development are an integral process. Growth refer to the metabolic change by which an organism increases in size and changes shape. Growth refers to quantitative changes. Changes in physical size and appearance are visible manifestations of the complex morphologic, biochemical and physiologic changes taking place during childhood. Child development is a process, a continuous series of purposeful changes, consisting of many aspects, moving together at differing paces. Development refers to qualitative and quantitative changes. There are 10 fundamental principles of development: 1. Development involves change 2. Early development is more critical than later development 3. Development is the product of maturation and learning 4. The developmental pattern is predictable 5. The developmental pattern has predictable characteristics 6. There are individual differences in development 7. There are periods in the developmental pattern 8. There are social expectations for every developmental period 9. Every area of development has potential hazards 10. Happiness varies at different periods in development Udayana University Faculty of Medicine, MEU Introductory lecture: General Concepts of Growth and Development 11

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Lecture 1: ~ AssessmentPhysical Growth of Children and Adolescents ~ Study Guide Block Growth and Development Environmental and genetic factors influence growth and development. In Bronfenbrenner’s ecological system theory, development is influenced at four levels: the microsystem, mesosystem, exosystem and macrosystem. Prof. dr. Soetjiningsih, SpAK, IBCLC Learning outcomes - Describe the clinical importance of study physical growth - Describe the normal patterns of the physical growth - Understand factors that affecting physical growth - Use of common growth parameter Abstract Physical growth usually refers to changes in size or mass. The most people usually think of growth at the level of the whole child, the cells and internal structures that make up the child, primarily by increasing in number or size. Growth assessment is essential because almost any problems within the physiologic, interpersonal and social domains can adversely affect growth. Anthropometry is an effective and frequently performed child health screening procedure. The value of physical growth data depends on their accuracy and reliability, how they are recorded and interpreted, and what follow- up efforts are made after identification of growth abnormality. The most powerful tool in growth assessment is the growth chart. Whenever possible, growth should be assessed by plotting accurate measurements on growth charts and comparing each set of measurements with previous measurements. The CDC Growth Charts 2000 are used to measure growth, consist of 16 charts including “Body mass index (BMI) for-age percentile” for boys and girls aged 2-20 years. Normal growth patterns have spurts and plateaus, but some shifting on the percentile graphs can be expected; however, large shifts warrant attention. Large discrepancies among height, weight, and head circumference percentiles also diserve attention. Deviation in growth patterns are nonspecific but important indicators of serious medical disorders. Deviations often provide the first clue that something is wrong, occasionally even when the parents do not suspect a problem. An accurate measurement of height, weight, and head circumference should be obtained at every health supervision visit. Serial measurements are much more useful than single measurements because they can help detect deviations from a particular child’s growth pattern even if the value remains within statistically defined normal limits. Factors affecting physical growth and health in infancy and toddlerhood continue to be influential in early childhood. Heredity affects physical growth by regulating the production of hormones. Extreme emotional deprivation can interfere with the production of growth hormone, thereby stunting children's growth. Sleep difficulties, in the form of night waking and nightmares, are common during the preschool years. Appetite decline is associated with a slower rate of physical growth. Disease can lead to malnutrition, seriously undermining children's growth, an effect that is especially common in developing countries. Udayana University Faculty of Medicine, MEU 12

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Lecture 2: ~ TheStages of Prenatal Development ~ Lecture 3: ~ USG to Assess Fetal Anatomy ~ Study Guide Block Growth and Development I Nym Mangku Karmaya Learning outcomes Describe the main stages of embryonic development for use to estimate the gestational age of embryo. Abstract Early embryonic development is describe in stages because of the variable period it takes for embryos to develop certain morphological characteristics. Stage 1 of development begins at fertilization and embryonic development ends at stages 23, which occur on day 57 and ends when he fetus is completely outside the mother. The stages of embryonic development can be assessed by ultrasonography. In general the period of prenatal development is as follows:  1st week : zygote-blastomeres-morula-blastocyst.  2nd week : bilaminar germ disc  3rd week : trilaminar germ disc  3rd - 8th week : embryonic period/organogenesis  8th week-BIRTH : fetal period Tjokorda Gde Agung Suwardewa Learning outcomes Apply of USG to assess fetal anatomy: - Comprehend ultrasound waves generally - Comprehend compartments of ultrasonography unit (USG) - Comprehend how USG used for pregnant woman - Safety ultrasound waves to the fetus - Comprehend length, frequency, media of ultrasound waves Abstract Ultrasound is a sound waves with frequency more than 20,000 HZ. Normally we can hearing of sound waves by frequency between 16,000-20,000 cycle per second (Hertz) (1 Megahertz=1000,000 Hz). The sound waves length in ultrasound compartment (USG unit) role play to determine of resolution capacity that unit. The pictures displayed on the screen is produced by sound waves reflected back from the imaged structure. Alternating current is applied to a transducer containing piezoelectric crystals, which converts electric energy to high-frequency sound waves. A water soluble gel applied to the skin acts as coupling agent. Sound waves pass through layers of tissue, encounter an interface between tissues of deferent densities, and are reflected back to the transducer. Converted back into electrical energy, they are displayed on the screen. Dense tissue such as white on the screen. Fluid is anechoic and appearing black on the screen. Higher-frequency transducers yield better images resolution, whereas lower frequencies penetrate tissue more effectively. For examples, abdominal scanning is most commonly Udayana University Faculty of Medicine, MEU 13

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Study Guide BlockGrowth and Development performed with a 3-5 mHz transducer, but in early pregnancy, 7-10 mHz vaginal transducer may provide excellent resolution because the fetus is close to the transducer. Since the first obstetrical application of ultrasound imaging by Donald and co-worker (1958), this technique has become indispensable for evaluation of the fetus. Some indications for ultrasound examination are: confirm gestation location, fetal number, estimating gestational age, fetal morphology/anatomy, fetal abnormality, placenta, amniotic fluid volume. Kardana Learning outcomes - Apply the New Ballard Score to assess the gestational age of infant: the small for gestational age (SGA), appropriate for gestational age (AGA), or large for gestational age (LGA). Abstract Since the late 1960s, a variety of methods for assessing the gestational age of the newborn infant have been developed. Currently, the most widely use system for the postnatal assessment of gestational age is the New Ballard Score (NBS). This system includes both physical and neurologic characteristics. The score spans from 10 (correlating with 20 weeks’ gestation) to 50 (correlating with 44 weeks gestation). The examination consists of six neuromuscular criteria and six physical criteria. The neuromuscular criteria are based on the understanding that passive tone is more useful than active tone in indicating gestational age. The neuromuscular maturity includes: posture, square window, arm recoll, popliteal angel, scarf sign, and heal to ear. The physical maturity includes: skin, lanugo hair, plantar surface, breast, ear and ear, and genitalia. The examination of NBS is administered twice by two different examiners to ensure objective, and the data entered on the chart. Suwitra Abstract When Steele and Breg in 1966 demonstrated that amniotic fluid cells could be cultured to reveal fetal karyotype, prenatal diagnosis has become a mayor medical genetic service, in the context of prevention of specific genetic disorder The demand for genetic testing is sure to rise if a screening procedure is developed to identify pregnancies at risk of a chromosomal abnormality. In some minds prenatal diagnosis is equated with the issue of abortion. For families at risk having a child with condition that can be diagnosed prenatal, the option of monitoring pregnancies allow the parents to undertake pregnancies that they would otherwise forego. Only about 2% of all pregnancies in which there is prenatal diagnosis are terminated because of the fetus has genetic defect. Much more often, the fetus is found to be unaffected and the pregnancy continues. Indication of prenatal diagnosis: Udayana University Faculty of Medicine, MEU Lecture 4: ~ Assessment of Growth and Development in Neonatus 14 Lecture 5: ~ Prenatal Genetic Evaluation and Counseling ~

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Study Guide BlockGrowth and Development 1. Mother age of 35 years or more 2. Previous child with chromosomal abnormality 3. Present of structural chromosomal abnormality 4. Family history of neural rube defect. 5. X-linked disorder in family Techniques: amniocentesis, chorionic villous sampling, ultrasonography, fetoscopy, prenatal chromosome analysis, alpha-fetoprotein analysis, Prenatal diagnose require the combined skill of obstetricians, laboratory scientist, geneticists. The mayor concern in any prenatal diagnosis program is time or week of gestation for prenatal diagnosis and it should be provided as early in pregnancy as possible. Learning outcomes: after the lecture, the medical students have a knowledge obout: a. The history of prenatal diagnosis b. The aim of prenatal diagnose c. The indications and techniques of prenatal diagnosis d. The advantages and disadvantages of technique chosen Udayana University Faculty of Medicine, MEU 15

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Lecture 6: ~ Drugsin Pregnancy, Children, and Elderly ~ Study Guide Block Growth and Development Made Jawi Learning outcomes After completing this lecture, the students should be able to: - Describe the effect of drugs use in pregnancy. - To Choose the safe drugs for pregnant women, children, and elderly Abstract When a woman becomes pregnant, it is very important for her to lead a healthy life: to eat plenty of nourishing food, get plenty of rest, and exercise regularly. It is also vital that she avoid anything that might harm her or her baby-to-be. It is especially important to give up alcohol, cigarettes, and drugs. For a pregnant woman, drug abuse is doubly dangerous. First, drugs may harm her own health, interfering with her ability to support the pregnancy. Second, some drugs can directly impair prenatal development. Both prescription and over-the-counter drugs can be harmful, for her own health and the health of her baby-to-be. So a woman should avoid all of them as much as possible, from the time she first plans to become pregnant or learns that she is pregnant. Some drugs can be harmful when used at any time during pregnancy; others, however, are particularly damaging at specific stages. Most of the body organs and systems of the baby-to-be are formed within the first ten weeks or so of pregnancy (calculated from the date of the last menstrual period). During this stage, some drugs and alcohol in particular can cause malformations of such parts of the developing fetus as the heart, the limbs, and the facial features. After about the tenth week, the fetus should grow rapidly in weight and size. At this stage, certain drugs may damage organs that are still developing, such as the eyes, as well as the nervous system. Continuing drug use also increases the risk of miscarriage and premature delivery. But the greatest danger drugs pose at this stage is their potential to interfere with normal growth. Intrauterine growth retardation (IUGR) is likely to result in a low-birth weight baby a baby born too early, too small, or both. Low- birth weight babies require special care and run a much higher risk of severe health problems or even death. Current Categories for Drug Use in Pregnancy Category Description A Adequate, well-controlled studies in pregnant women have not shown an increased risk of fetal abnormalities. B Animal studies have revealed no evidence of harm to the fetus; however, there are no adequate and well-controlled studies in pregnant women. Or Animal studies have shown an adverse effect, but adequate and well- controlled studies in pregnant women have failed to demonstrate a risk to the fetus. C Animal studies have shown an adverse effect and there are no adequate and well-controlled studies in pregnant women. Or No animal studies have been conducted and there are no adequate and well-controlled studies in pregnant women. D Studies, adequate well-controlled or observational, in pregnant women have demonstrated a risk to the fetus. However, the benefits of therapy may outweigh the potential risk. X Studies, adequate well-controlled or observational, in animals or pregnant women have demonstrated positive evidence of fetal abnormalities. The use of the product is contraindicated in women who are or may become pregnant. Udayana University Faculty of Medicine, MEU 16

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Lecture 7: Apply thePrinciples of Breastfeeding for Infants with Normal Deliveries Study Guide Block Growth and Development Both prescription and over-the-counter drugs can be harmful, for children and elderly. There are a number of pharmacokinetic and pharmacodynamic differences between children or pediatric, elderly and adult patients. Neonates ( 0 to 1 month), infants (1 to 12 month) and children of increasing age are not simply small adult. The drugs used by the elderly are the same as those that a younger person might take-- yet they can have a far different effect. It doesn’t matter whether a person has heart disease or arthritis, osteoporosis, or high blood pressure, the story is the same: Because the organ systems tend to function less efficiently as we age, medications are handled differently by our bodies. Here are some of the most common changes affecting our health and our response to medicines: The stomachs may not absorb food and medication as well as they did before. The kidneys and livers don’t eliminate fluids and toxins in the same efficient manner. All of the above contribute to the potential harm that medications can cause in the aging body. If a kidney can’t eliminate a drug after it has done its work, it remains in the body longer, perhaps causing an overdose or an adverse effect. If someone forgets to take a medication that regulates the heart or blood pressure, a stroke or heart attack could be the result. Any person over the age of 65 who is taking medications in the following categories should be aware of the potential for increased side effects, overdose, and diminished efficacy: Antibiotics, Anti histamines, Anti hypertensives, Antiulcer medicines, Blood thinners, Bronchodilators, Calcium or potassium supplements, Cardiac medications, Corticosteroids, Estrogens, Over-the-counter drugs containing alcohol (cough and cold medications) or caffeine, Pain relievers, Psychiatric medications, Skin medications and creams In the lecture will be discuss the effects of drugs to the embryo and how to choose drugs for pregnant women, Children and Elderly Prof. dr. Soetjiningsih, SpAK, IBCLC Abstract Breast-feeding exclusively the recommended method for feeding normal infants during the first 6 months of life. Breastfeeding should continue with the addition of appropriate foods, for two years or more. Breastfeeding has advantages for infants, mothers, families, and society. These advantages include health, nutritional, immunologic, developmental, psychologic, social, economic, and environmental benefits. Breast milk contains the right balance of nutrients to help the infant grow into a strong and healthy toddler. Some of the nutrients in breast milk also help protect the infant against some common childhood illnesses and infections. While nutrients and antibodies pass to the baby, beneficial hormones are released from the mother's body. Colostrums, a high protein and low fat lactose product, are produced in small amounts during the first few postpartum days. It has some nutritional value but primarily has important immunologic and maturational properties. The bond between baby and mother can also be strengthened during breastfeeding. Breastfeeding doesn't always happen easily. Some new mums find it hard to get started, while others hit problems later on. Breast tenderness, engorgement, and cracked nipples are the most common problems encountered by mothers who are breast-feeding. Udayana University Faculty of Medicine, MEU 17

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Lecture 8: ~ ThePrinciples of Feeding for Infants with Complicated Deliveries ~ Lecture 9: ~ Vitamin A and Fe Deficiency ~ ~ Iodine Deficiency ~ Study Guide Block Growth and Development Kardana Learning outcomes - To know indication of enteral and parenteral nutrition - To know the type nutrition’s for enteral feeding - To know the routes of enteral feeding and feeding technique - To know the administration for parenteral nutrition - To know the contents of total parenteral nutrition Abstract Providing adequate nutrition support to newborns is an important to know and understanding the maturation, functional and physical disturbances to the baby. Optimal nutrition after birth enhances future neurodevelopmental outcome. For term healthy infants should be breast-fed as soon as possible within the first hour. Human milk is preferred for feeding term, preterm and sick infants. The following criteria should usually be met before initiating infant’s feedings: no history of excessive oral secretions, vomiting, or bilous-stained gastric aspirate, non-distended, soft abdomen with normal bowel sound, and no respiration distress. If the baby is small or complicated baby such as baby with the following associated conditions: perinatal asphyxia, hemodynamic instability, sepsis, frequent episodic apnea and bradycardia etc, initiation of enteral feeding is often precluded and parenteral nutrition can be initiation. Nutritional requirements in neonate includes: calories to maintain weight and to induce weight gain, carbohydrates, proteins, fats, vitamins and minerals and fluids. A A Ngr Prayoga ~ Vitamin A and Fe Deficiency ~ Learning outcomes - To understand the sign and symptom of patient with vitamin A and Fe deficiency - To built diagnosis of patient with vitamin A and Fe deficiency - To understand the treatment and prevention of patient with vitamin A and Fe deficiency Abstract Vitamin A is the generic term used to describe all retinoid having the biologic activity of all- trans retinol. Vitamin A, a light yellow crystalline alcohol, has been named retinol in reference to its specific function in the retina of the eye. The yellow-orange-red provitamin carotinoids, are describe in the term of beta-carotene A deficiency of Vitamin A is accompanied by keratinization of the mucous membranes that line the respiratory tract, the alimentary canal, and the urinary tract, and by keratinization of the body skin and epithelium of the eye, which lowers the barrier role played by these membranes in protection of the body against infections. Prolonged deficiency may produce skin changes, night blindness, and corneal ulceration. Primary deficiencies of vitamin A are the result of dietary inadequacies. Secondary can result from liver disease, protein-energy malnutrition, abetalipoproteinemia, or malabsorption due to bile acid Udayana University Faculty of Medicine, MEU 18

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Lecture 10: ~ ProteinEnergy Malnutrition (PEM) ~ ~ Obesity ~ Study Guide Block Growth and Development insufficiency. Acute deficiency is treated with large oral doses of vitamin A and correction of the usually concomitant protein-energy malnutrition. Massive intermittent dosing with 200,000 IU of vitamin A can reduced mortality by 35 to 70 %. Iron deficiency anemia is characterized by the production of small erythrocytes and diminished level of circulating hemoglobin. The three primary causes of iron deficiency anemia are chronic blood lose, faulty iron intake or absorption and increased iron requirement. The clinical findings are fatigue, anorexia, pica (pagophagia). Growth abnormalities, epithelial disorders, and reduction in gastric acidity are common. Defect in structure and function of epithelial tissue of tongue, nails, mouth, and stomach as deficiency becomes more severe. The chief treatment for iron deficiency consists of oral administration of inorganic iron in the ferrous form and nutritional care. ~ Iodine Deficiency ~ Learning outcomes - To understand the sign and symptom of patient with iodine deficiency. - To built diagnosis of patient with iodine deficiency. - To understand the treatment and prevention of patient with iodine deficiency. Abstract Iodine is absorbed easily in the form of iodide, in circulation it occurs both as free and protein-bound iodine. Iodine is stored in the thyroid, where it is used for synthesis of T3 and T4 when needed. Lack of iodine intake is associated with the development of endemic or simple goiter, which is an enlargement of thyroid gland. The deficiency may be absolute, especially in areas of subnormal iodine intake, or relative subsequent to increased need for thyroid hormones, such as in the female during adolescence, pregnancy, and lactation. Severe iodine deficiency during gestation and early postnatal growth results in cretinism, a syndrome characterized by mental deficiency, spastic diplegia, or quadriplegia, deaf mutism, dysarthria, a characteristic shuffling gait, shortened stature, and hypothyroidism. Early diagnosis and treatment are needed to prevent more severe of clinical sign and symptom. IKG Suandi ~ Protein Energy Malnutrition (PEM) ~ Learning outcomes - To understand the sign & symptom of patient with protein energy malnutrition (PEM) - To built diagnosis of patient with protein energy malnutrition (PEM) - To understand the treatment and prevention of the patient with protein energy malnutrition (PEM) Udayana University Faculty of Medicine, MEU 19

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Lecture 11: ~ Failureto Thrive ~ Study Guide Block Growth and Development Abstract Definition PEM is a spectrum of conditions caused by varying levels of protein and calorie deficiencies. The common form of primary PEM is marasmus and caused by severe caloric depletion. Kwashiorkor, presenting with pitting edema caused by inadequate protein intake in the presence of fair to good caloric intake. Secondary form of PEM is associated with other diseases. Clinical manifestation The clinical manifestation of marasmus: The body weight below 60% of expected for age or below 70% of the ideal weight for height and depleted body fat stores. Edema usually is absent. The head may appear large but generally proportional to the body length. The clinical manifestation of kwashiorkor: presenting pitting edema that starts in lower extremities and ascends with increasing severity, may be a complication of critical illness (acute and chronic infections, multiorgan system failure, anorexia nervosa, etc) Treatment and prevention Calories account of nutritional rehabilitation can be safety started at 20% above the child’s recent intake. The calorie intake can be increased 10-20% per day until appropriate re-growth is initiated. This may require 150% or more of the recommended calories for an age-matched, well nourished child. ~ Obesity ~ Learning outcomes - To understand the sign & symptom of patient with obesity - To built diagnosis of patient with obesity - To understand the treatment and prevention of the obesity Epidemiology The prevalence of obesity in children has increased in the last 2-3 decades, mainly in children as young as 4-5 years. Clinical manifestation In children BMI (body mass index) age and gender specific percentile curves allow an assessment of BMI percentile. In adolescent and adult BMI has been used in weight/height2 (kg/m2 ). The effects of obesity complication; such as psychosocial effect, growth (advanced bone age, increased height, early menarche), CNS (pseudo tumor cerebri, respiratory (sleep apnea, pickwickian syndrome), cardiovascular (hypertension, cardiac hypertrophy, ischemic heart disease, sudden death), orthopedic (slipped capital femoral epiphysis, Blount disease), metabolic (insulin resistance, type II diabetes mellitus, hypertriglyceridemia, hypercholesterolemia, gout, hepatic steatosis, ovary disease, cholelithiasis). Treatment and prevention The treatment and prevention of obesity includes a combination of education, behavior modification, exercise and diet. I KG Suandi Learning outcomes 1. To apply the diagnostic criteria of patient with failure to thrive (FTT). 2. To discuss the cause or path physiology of patient with FTT. 3. To evaluate and manage a child with FTT. Udayana University Faculty of Medicine, MEU 20

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Lecture 12 &13: ~Assess Development in the Motoric and Language Domains ~ Study Guide Block Growth and Development Definition The term ‘failure to thrive’ first was used to describe the malnutrition and depressed condition of many institutionalized infants in early 1900s. It remains a descriptive rather than a diagnostic label applied to children whose attained weight or rate of weight gain is significantly below that of other children of similar age and same sex. Table Definition of failure to thrive Attained growth 1. Weight < 3rd percentile on NCHS growth chart 2. Weight for height < 5th percentile on NCHS growth chart 3. Weight 20% or more below ideal weight for height 4. Triceps skin fold thickness < 5 mm Rate of growth 1. Depressed rate of weight gain < 20 g/d from 0-3 months of age < 15 g/d from 3-6 months of age 2. Fall-off from previously established growth curve Downward crossing of > 2 major percentiles on NCHS growth chart 3. Documented weight loss Patho physiology and clinical manifestation FTT can result from wide range of factors, including serious medical disease, dysfunctional child- caregiver interactions, poverty, parental misinformation, and child abuse. The physical examination of a child who is growing poorly should focus on identifying sign of underlying organic disease, severity of malnutrition, and important concomitant finding such as evident of physical abuse/neglect or the presence of deprivational behaviors. Treatment and prevention Management of the child with psychosocial failure to thrive must be individualized to the specific needs of the child and family. Nutritional rehabilitation, efforts are focused on correcting the dysfunctional child-parent interaction by addressing areas of parental misinformation, providing and helping to implement specific feeding guidelines, and addressing the larger psychosocial needs of the family. A multidisciplinary team approach involving the primary-care provider, nutritionist, social worker, child behavior specialist, and community-based outreach services is often most beneficial. I GA Trisna W ~ Assess Development in The Motoric Domain ~ Learning outcomes: - Describe gross and motor development - Determine factors affecting motor development Abstract Child developmental consist of several skills like: 1) Gross motor: using large groups of muscles to sit, stand, walk, run, etc., keeping balance, and changing positions; 2) Fine motor: using hands to be able to eat, draw, dress, play, write, and do many other things; 3) Language: speaking, using body language and gestures, communicating, and understanding what others Udayana University Faculty of Medicine, MEU 21

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Study Guide BlockGrowth and Development say; 4) Cognitive: Thinking skills: including learning, understanding, problem-solving, reasoning, and remembering; 5) Social: Interacting with others, having relationships with family, friends, and teachers, cooperating, and responding to the feelings of others. Developmental milestones are a set of functional skills or age-specific tasks that most children can do at a certain age range. Milestone can be described as what a child accomplishes throughout the different stages in their life. We can use milestones to help check how our child is developing. Although each milestone has an age level, the actual age when a normally developing child reaches that milestone can very quite a bit. Every child is unique. To determine whether a child has developmental delay, the physician must understand normal milestones The red flag age is the age at which you would expect almost every child to have already mastered a particular skill. For example walking, most children walk on their own, without holding on, around their first birthday. By 15 months--the red flag age for walking--a child who has not taken his first independent steps is certainly slower to walk than 90 percent of other children. Red flag milestones are helpful because they put a limit on when you, as a good, concerned parent, should worry. Motor development means the development of control over bodily movements through the coordinated activity of the nerve centers, the nerves and the muscles. This control comes from the development of the reflexes and mass activity present at birth. Until this development occurs, the child will remain helpless. From longitudinal studies of babies and young children, five general principles of motor development have emerged: 1) motor development depends on neural and muscular development; 2) learning skills cannot occur until the child is maturationally ready; 3) motor development follows a predictable pattern; 4) it is possible to establish norms for motor development; and 5) there are individual differences in rate of motor development. Motor development is divided into gross motor and fine motor development. Gross motor skills refer to the ability of children to carry out activities that require large muscles or groups of muscles. Muscles or groups of muscles should act in a coordinated fashion to accomplish a movement or a series of movements. Examples of gross motor tasks are walking, running, throwing something, jumping, standing on 1 leg, playing hopscotch, and swimming. Posture is an important element to consider in the assessment of gross motor skills. Adequate posture may make all the difference between being able or not able to execute a movement. Fine motor skills consist of movements of small muscles that act in an organized and subtle fashion, for instance, the hands, feet, and muscles of the head (as the tongue, lips, facial muscles), to accomplish more difficult and delicate tasks. Fine motor skills are the basis of coordination, which begins with transferring from hand to hand crossing the midline when aged 6 months. Examples of fine motor activities are writing, sewing, drawing, putting a puzzle together, imitating subtle facial gestures, pronouncing words (which involve coordination of the soft palate, tongue, and lips), blowing bubbles, and whistling. Many children who have difficulties in their fine motor skills also have difficulties in articulating sounds or words. The static and motor development of newborn into adult depends on the maturation process of the central nervous system. The process of this development is determined by genetically established patterns of behavior and stimulation from the environment. Some conditions that influence the rate of motor development. These factors include genetic constitution, prenatal condition, prematurity, nutrition, physical defects, stimulation, etc. They may contribute to poor abilities in motor functioning and coordination difficulties A decrease in movement during the process of motor development in the early stage of development and abnormal reactions on examination of primary reflexes may reflect early signs of motor handicaps. Udayana University Faculty of Medicine, MEU 22

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Study Guide BlockGrowth and Development Prof. dr. Soetjiningsih, SpAK, IBCLC ~ Assess Development in The Language Domain ~ Learning outcomes - Describe language development - Determine factors affecting language development Abstract Speech and language are tools that humans use to communicate or share thoughts, ideas, and emotions. Language is different from speech. Language is an elaborate system of communication that uses arbitrary and socially agreed on symbols to transmit and to receive messages from one human to another. Language is made up of socially shared rules that include the following: what words mean; how to make new words; how to put words together; and what word combinations are best in what situations. Speech is the verbal means of communicating. Speech consists of the following: articulation (how speech sounds are made); voice (use of the vocal folds and breathing to produce sound); and fluency (the rhythm of speech). There are many languages in the world, each includes its own set of rules for phonology (phonemes or speech sounds or, in the case of signed language, hand shapes), morphology (word formation), syntax (sentence formation), semantics (word and sentence meaning), prosody (intonation and rhythm of speech), and pragmatics (effective use of language). The most intensive period of speech and language development for humans is during the first three years of life, a period when the brain is developing and maturing. These skills appear to develop best in a world that is rich with sounds, sights, and consistent exposure to the speech and language of others. Children vary in their development of speech and language. There is, however, a natural progression or "timetable" for mastery of these skills for each language. The milestones are identifiable skills that can serve as a guide to normal development. Typically, simple skills need to be reached before the more complex skills can be learned. There is a general age and time when most children pass through these periods. These milestones help doctors and other health professionals determine when a child may need extra help to learn to speak or to use language. When a person has trouble understanding others (receptive language), or sharing thoughts, ideas, and feelings completely (expressive language), then he or she has a language disorder. Receptive language refers to the ability to understand, encompasses visual (reading, sign language comprehension) and auditory (listening comprehension) skills. Expressive language refers to the ability to produce symbolic communication, this output may be either visual (writing, signing) or auditory (speech) Delay in speech and language development in children can be defined as a “delay in speech and / or language development compared with controls matched for age, sex, cultural background, and intelligence”, or a discrepancy between a child’s potential ability to speak and the performance that is actually observed. Three common causes of speech delay are mental retardation, hearing loss and maturation delay. There are some conditions that contributing to variations in learning to speak i.e. health; intelligence; socioeconomic status; sex; desire communicate; stimulation; size of family; ordinal position; child-training methods; multiple birth; contact with peers; personality, etc. Udayana University Faculty of Medicine, MEU 23

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Lecture 14: ~ CognitiveDevelopment ~ Lecture 15: ~Psychosocial and Emotional Development~ Study Guide Block Growth and Development Rustika Learning outcomes: a. To understand the basic principles of cognitive process. b. To understand four stages of cognitive development Abstract: Most progressive change of human behavior related to cognitive development, so if someone wants to understand growth and development of human being comprehensively, they should learn about cognitive development. Piaget specifies four stages of cognitive development. The major cognitive achievement in the sensorimotor stage (which lasts from birth to about two years) is the development of the schema of object permanency. Thus, the attainment of this knowledge is indicative of representational ability. Such ability is involved in the major cognitive achievements in the preoperational stage (which lasts from about two through six years). Here, true systems of representation develop (e.g., as indexed by language, symbolic play, and delayed imitation). With the emergence of the concrete operational stage, however (which lasts from about six through twelve years), conservations are typically seen; thus, operational structures – internalized actions that are reversible – are evidence. The child cannot think counterfactually or hypothetically. Such ability characterizes the last stage of cognitive development, the formal operational stage (which lasts from about year twelve onward). Marheni Absract: Psychosocial development as propounded by Erik Erikson describes eight developmental stages through which a healthily developing human should pass from infancy to late adulthood. In each stage the person confronts, and hopefully masters, new challenges. Each stage builds on the successful completion of earlier stages. The challenges of stages not successfully completed may be expected to reappear as problems in the future. Erik Erikson developed the theory in the 1950s as an improvement on Sigmund Freud's psychosexual stages. Erikson accepted many of Freud's theories (including the id, ego, and superego, and Freud's infantile sexuality represented in psychosexual development), but rejected Freud's attempt to describe personality solely on the basis of sexuality. Also, Erikson criticized Freud for his concept of originology. This states that all mental illness can be traced to early experiences in childhood. According to Erikson, experience in early childhood is important, but the individual also develops within a social context. Erikson believed that childhood is very important in personality development and, unlike Freud, felt that personality continued to develop beyond five years of age. In his most influential work, Childhood and Society 1950, he divided the human life cycle into eight psychosocial stages of development. “ Human personality, in principle, develops according to steps predetermined in the growing person's readiness to be driven toward, to be aware of, and to interact with a widening social radius. ” —Erik Erikson Udayana University Faculty of Medicine, MEU 24

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Lecture 16: ~ Detectionof Developmental Deviation in Children (Screening & Stimulation) ~ Study Guide Block Growth and Development Prof. dr. Soetjiningsih, SpAK, IBCLC dr. I GA Trisna Windiani, SpA Learning outcomes - Describe the aims of detection developmental deviation - Recognize the methods of detection developmental deviation - Apply methods of detection developmental deviation (Denver test, Pediatric Symptom Checklist / PSC test) - Describe the aims of stimulation developmental deviation - Understand the principles of early stimulation - Recognize the methods of stimulation developmental deviation Abstract Developmental screening is a brief evaluation of developmental skills that is applied to a total population of children to identify children with suspected delays who require further diagnostic assessment. Developmental screening involves the use of standardized screening tests. Screening tests can be categorized as general screening tests that cover all behavioral domains or as targeted screens that focus on one area of developmental. They can administer in the office setting by professionals or completed at home by parents. The Pediatric Symptom Checklist is a psychosocial screen designed to facilitate the recognition of cognitive, emotional, and behavioral problems so that appropriate interventions can be initiated as early as possible. Included here are two versions, the parent-completed version (PSC) and the youth self-report (Y-PSC). PSC can be administered to 4-18 years old while Y- PSC can be administered to adolescents ages 11 and up. The Denver II is design to be used with apparently well children between birth and six years of age and is administered by assessing a child’s performance on various age appropriate tasks. The test is valuable in screening asymptomatic children for possible problem, in continuing intuitive suspicious with an objective measure, and in monitoring children at risk for developmental problems, such as those who have experienced perinatal difficulties. The Denver II consist of 125 tasks, or items which arranged on the test form in four sectors to screen areas of function: 1) personal social; 2) Fine motor adaptive; 3) Language; and 4) gross motor Early intervention or stimulation is necessary and effective because development is malleable and readily affected by the environment. In large part, early intervention works by systematically removing external risk factors. Early intervention programs place children in developmentally enriching settings; train parents in responsiveness and effectiveness, and provide continuous positive redirection and focused building of skills. The benefits of early intervention clearly depend on early detection, which requires that clinicians know how to identify accurately patients who have disabilities. Because time and reimbursement are limited, clinicians also should know how to identify patients quickly. Appropriate stimulation in childhood ranks as one of the most important factors that influence childhood development. Udayana University Faculty of Medicine, MEU 25

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Lecture 17: ~ SexualDevelopmental Sequence in Children and Adolescents ~ Study Guide Block Growth and Development W Bikin Suryawan Learning outcomes - To interpret maturation of the hypothalamic-pituitary-gonadal axis and connecting with the onset of puberty starts. - To explain positive feedback and negative feedback in puberty regulation. - To interpret kind of the factors affecting for sexual developmental. - To explain the pubertal staging in boys and girls. - To interpret the ovarian development and testicular development. - To explain the process of adrenarche and gonarche in puberty starts. Introduction Puberty can be defined as maturation of the hypothalamic-pituitary-gonadal axis that results in growth and development of the genital organs, and leads to the capacity to reproduce. Puberty is characterized by a number of physical and psychological changes. The onset of puberty starts with slow, frequent releases of gonadotropin releasing hormone (GnRH). GnRH is transported via the portal system to gonadotropic cells at the pituitary level, where it stimulates the production and release of the gonadotropins luteinizing hormone (LH) and follicle stimulating hormone (FSH). LH and FSH then stimulate growth and production of hormones and other factors in the ovaries and the testes, respectively. These secreted products are inhibitory (via negative feedback) at the pituitary and hypothalamic levels. During maturation in females, positive feedback occurs, leading to the mid-cycle LH surge. Hormonal regulation The release of the hypothalamic neurotransmitter GnRH is regulated by many factors, and is subject to negative and positive feedback at the pituitary and hypothalamic levels. During gestation, GnRH plasma levels increase; maximum levels are attained at 22-25 weeks of gestation in female fetuses and at 34-38 weeks of gestation in male fetuses. In primate studies, gamma-amino butyric acid (GABA) and other substances have been associated with decreased GnRH release, although stimulating effects of GABA have been observed as well. In primates, disinhibition of GnRH neurons by GABA is critical for the onset of puberty. In humans, low gonadotropin levels during childhood may in fact be due to tonic inhibition of GnRH by GABA. GnRH stimulates the production and release of both LH and FSH. GnRH levels are difficult to measure directly, since GnRH is secreted into the portal circulation and transported directly to the pituitary. GnRH is secreted in a pulsatile pattern. Simultaneous episodic fluctuations of GnRH in the portal blood and LH in the peripheral blood have been observed in sheep. A pulsatile pattern of LH release has been observed in humans as well, and it can be assumed that this pattern reflects pulsatile GnRH release. Fluctuations in FSH levels are not as marked as those in LH levels in humans, and are not always synchronized with LH pulses. As puberty progresses, LH secretion gradually increases, and occurs both during the day and during the night. This increase in LH secretion can be attributed to both enhanced LH pulse frequency and enhanced LH pulse amplitude. During puberty, the day-night rhythm is maintained; however, this with the progression of puberty in girls, the response to a challenge of exogenous GnRH increases as well. During prepuberty (pubertal stage B1), when endogenous GnRH stimulation is low, there is little or no increase in gonadotropins following such a challenge. From pubertal stages B2 to B5, a GnRH Udayana University Faculty of Medicine, MEU 26

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Study Guide BlockGrowth and Development challenge leads to increases in LH and FSH in girls (see also the subchapter entitled ‘Pubertal staging’). In girls, there is a remarkable exception for FSH in stage B2. High GnRH-stimulated levels of FSH alone characterize this stage. The FSH response is much lower in stage B3. In their study, they observed that the mean weight of 48 kg at menarche remained constant with increasing menarcheal age, while mean height increased significantly with increasing menarcheal age. Later studies in both female rats and humans showed that a particular ratio of fat to lean body mass is necessary for puberty to begin and for maintainance of reproductive capacity. Pubertal staging In girls, puberty, which begins following increased release of GnRH, can best be defined as the estrogen-dependent onset of breast development (thelarche), as increased estrogen levels are the result of an active hypothalamic-pituitary-gonadal axis. Growth of pubic hair (pubarche) begins following secretion of adrenal and ovarian androgens. In general, pubic hair appears a few months after the onset of breast development. However, pubic hair development can occur in the absence of breast development, as the result of an early adrenarche. Below are the 5 stages of breast development described by Marshall and Tanner. B1: In this pre-pubertal stage, which persists until puberty begins, only the nipple is raised above the level of the skin. B2: In this budding stage, a bud-shaped elevation of the areola and papilla becomes noticeable. On palpation, a fairly hard “button” can be felt, and may be painful to the touch. The areola increases in diameter and the surrounding area can be elevated. These changes may occur earlier in one breast than in the other. B3: Further elevation of the breasts occurs. The diameter of the areola increases further. The shape of small adult mammary glands, with continuous contours, is apparent. B4: Fat deposits increase. The areola and papilla enlarge further. The areola forms a secondary elevation above that of the breast. This secondary mound is apparent in roughly half of girls and may persist into adulthood. B5: In this adult stage, the areola is usually recessed to the general contour of the breast. Pubic hair grows as a result of exposure to androgens. In girls, these androgens, including DHEA-S, are of adrenal origin. The ovaries also produce androgens such as 4-androstenedione. Below are the 6 stages of pubic hair development in girls. P1: In this pre-pubertal stage, there is no growth of pubic hair. P2: A few lightly pigmented hairs, usually straight or only slightly curled, appear, chiefly along the labia. P3: Pubic hair is still sparse, yet there is definite pigmented, curly hair on the labia that also spreads onto pubic mons. P4: Pubic hair is “adult” in type, but the area covered is still considerably smaller than in adults. There has been no spread of pubic hair up to inguinal fold. P5: Pubic hair has an adult distribution in an inverse triangle, with horizontal lining on the pubic mons and lateral spreading up to the inguinal fold. P6: This stage is reached after adolescence in only in a minority of women. There is a further extension of pubic hair laterally onto the thighs or upward onto the abdominal wall. In boys, the first sign of pubertal development is testicular growth. A testicular volume greater than or equal to 4 mL indicates that the gonadal axis is active. Marshall and Tanner have described different Udayana University Faculty of Medicine, MEU 27

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Study Guide BlockGrowth and Development stages of testicular and penile growth. Below are the 5 stages of genital development described by Marshall and Tanner. G1: In this pre-pubertal state, the testes, scrotum, and penis are the same size and shape as in a young child. G2: The testes and scrotum become larger, with testicular volume greater than or equal to 4 mL. The skin of the scrotum becomes redder, thinner, and wrinkled. The size of the penis is similar to that in G1. G3: The penis becomes larger, particularly in length. The testes and scrotum become even larger, and the scrotum descends. G4: The testes and scrotum become even larger, and the scrotal skin shows increased pigmentation. This stage is “not quite adult”. G5: In this stage, the external genitalia are adult in size and shape. The scrotum is ample, and the penis and bottom of the scrotum reach to about the same level. Below are the 6 stages of pubic hair development in boys. P1: In this pre-pubertal stage, there has been no growth of pubic hair. There may be fine hair over the pubes, but this growth is not different from that on the rest of the abdomen. P2: A few lightly pigmented, longer, straight hairs, often still downy, appear at base of the penis and sometimes on the scrotum. P3: Hair that is still sparse, yet definitely pigmented, coarser, and curlier appears around the base of the penis. P4: Hair is “adult” in type, but the area covered by hair is still considerably smaller than in adults, not going further than in the inguinal fold. P5: Hair is adult in quantity and type and spreads up to the medial surface of the thighs, but not up the linea alba. P6: Further extension occurs laterally and up the linea alba after adolescence. The majority of adult men reach this stage. Ovarian development Menarche, which usually occurs about 2.4 years after the start of breast development, does not necessarily indicate that there is full interaction among the hypothalamus, the pituitary, and the ovaries. In fact, during the first years after menarche, anovulatory cycles occur. Following this stage, ovulation occurs after an LH surge as a result of positive feedback to estrogens. During menstruation, gonadotropin levels (primarily levels of FSH) increase. FSH levels then decrease, with gradual increases in estradiol. Testicular development In young, developing, 6- to 7-week-old embryos, gonadal tissue is undifferentiated. The presence of the sex-determining region of the Y chromosome (SRY) triggers the tissue to differentiate to become testes. In the absence of this SRY, the tissue would differentiate to become ovaries. Undifferentiated gonadal tissue consists of 4 major cell lines: 1. Supporting cells develop into Sertoli cells, which have a paracrine function in spermatogenesis. Their number is a limiting factor in spermatogenesis. Anti-Mullerian hormone, a hormone secreted by Sertoli cells, is necessary for regression of the Mullerian duct and influences gonadal differentiation. Udayana University Faculty of Medicine, MEU 28

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Lecture 18: ~ VisualImpairment ~ Study Guide Block Growth and Development 2. Leydig cells, which are steroidogenic, produce androgens, which induce development of secondary sex characteristics. In the human fetus, Leydig cells are present after 8 weeks of gestation. During gestation and shortly after birth, these cells are functionally active, secreting testosterone. Fetal Leydig cells eventually develop into adult-type Leydig cells, which are responsible for pubertal development. 3. Connective cells give rise to peritubular myoid cells. These cells function along with Sertoli cells to produce the basal lamina of testicular tissue. This basal lamina serves as a base for testis cord formation. 4. Germ cells develop through several stages into spermatozoa. Testicular volume increases 3-fold between birth and 9 years of age, but remains at a prepubertal volume (i.e., <4 mL). Gonadarche versus adrenarche Androgens of adrenal origin, particularly dehydroepiandrosterone (DHEA) and its sulfate (DHEA- S), are responsible for sexual hair development in girls. The point at which the adrenals increase production of DHEA is known as adrenarche. In girls, pubic hair development occurs around the same mean age as breast development (11 years). Premature adrenarche is characterized by an early development of pubic hair, with little or no increase in height velocity and without progressive bone maturation. Early pubic hair growth may be an isolated event or may be accompanied by increased sweat and body odor, acne, axillary hair, and/or fatty skin. In general, premature adrenarche does not require treatment. In boys, pubic hair development is caused by adrenal and testicular androgens. Premature adrenarche may occur in boys, but is diagnosed more often in girls. When early growth of pubic hair occurs along with an increase in height velocity and progression of bone development, one should be aware of diagnoses associated with an excess of sex steroids. In such cases, a late- onset adrenal hyperplasia caused by a partial enzyme deficiency can often be diagnosed. Maturation of the gonadal axis and the adrenal axis occur separately, which means that in cases of adrenal insufficiency, gonadarche will occur appropriately. In cases of gonadal failure, the adrenals will contribute to adrenarche. It is well known that delayed and early-onset puberty are related, although specific genes contributing to these phenomena have not yet been recognized. To date, several gene mutations and polymorphisms of GnRH and its receptor, and of the gonadotropins LH and FSH and their receptors, have been identified. Sunerti Abstract Many people have some type of visual problem at some point in their lives. Some can no longer see objects far away. Others have problems reading small print. These types of conditions are often easily treated with eyeglasses or contact lenses. But when one or more parts of the eye or brain that are needed to process images become diseased or damaged, severe or total loss of vision can occur. In these cases, vision can't be fully restored with medical treatment, surgery, or corrective lenses like glasses or contacts. Blindness. They haven't lost their sight completely but have lost enough vision that they'd have to stand 20 feet from an object to see it as well as someone with perfect vision could from 200 feet away. What Causes Visual Impairment? Udayana University Faculty of Medicine, MEU 29

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Study Guide BlockGrowth and Development People rarely lose their eyesight during their teen years. When they do, it's usually caused by an injury like getting hit in the eye or head with a baseball or having an automobile or motorcycle accident. Some babies have congenital blindness, which means they are visually impaired at birth. Congenital blindness can be caused by a number of things — it can be inherited, for instance, or caused by an infection (like German measles) that's transmitted from the mother to the developing fetus during pregnancy. Conditions that may cause vision loss after birth include: amblyopia, strabismus, cataracts, diabetic retinopathy, glaucoma, macular degeneration, trachoma Udayana University Faculty of Medicine, MEU 30

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Lecture 19: ~ HearingImpairment ~ Lecture 20: ~ Learning Disorders ~ Study Guide Block Growth and Development Eka Putra S -------------- I GA Endah Ardjana Learning outcomes Learning disorders are diagnosed when standardized est. achievement in reading, math, or written expression are substantially lower than expected for a particular age, school level, or intelligence. These disorders involve academic deficits and impairments in specific areas of reading, math, spelling, and writing. About 5 percent of students in public schools in the United States are estimated to have a learning disorder, and up o 40 percent of these students drop out of school. Reading Disorders: a. Reading achievement, as measured by individually administered standardized tests of reading accuracy or comprehension, is substantially below that expected given the person’s chronological age, measured intelligence, and age-appropriate education. b. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living ha require reading skills. c. If a sensory deficit is present, the reading difficulties are in excess of those usually associated with it. Mathematic Disorders a. Mathematical ability, as measured by individually administered standardized tests, is substantially below that expected given the person’s chronological age, measured intelligence, and age appropriated education. b. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require mathematical ability. c. If sensory deficit is present, the difficulties in mathematical ability are in excess of hose usually associated with it. Disorders of Written Expression a. Writing skills, as measured by individually administered standardized tests (or functional assessments writing skills), are substantially below those expected given the person’s chronological age, measured intelligence, and age-appropriate education. b. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require the composition of written text (e.g., writing grammatically correct sentences and organized paragraphs). c. If a sensory deficit is present, the difficulties in writing skills are in excess of those usually associated with it. Udayana University Faculty of Medicine, MEU 31

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Study Guide BlockGrowth and Development Udayana University Faculty of Medicine, MEU 32

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Lecture 21: ~ MentalRetardation and Down Syndrome ~ Study Guide Block Growth and Development I GA Endah Ardjana ~ Mental Retardation ~ Abstract: For a definite diagnosis, there should be a reduced level of intellectual functioning resulting in diminished ability to adapt to the daily demands of the normal social environment. Associated mental or physical disorders have a major influence on the clinical picture and the use made of any skills. The diagnostic category chosen should therefore be based on global assessments of ability and not on any single area of specific impairment or skill. The IQ levels given are provided as a guide and should not be applied rigidity in view of the problems of cross-cultural validity. The categories are given below are arbitrary divisions of complex continuum, and cannot be defined with absolute precision. The IQ should be determined from standardized, individual’s level of functioning and additional spesific handicapping conditions, e.g. expressive language problem, hearing impairment, physical involvement. Scales of social maturity and adaptation, again locally standardized, should be completed if at all possible by interviewing a parent or care provider whi is familiar with the individual’s skills in everyday life. Without the use of standardized procedures, the diagnosis must be regarded as a provisional estimete only. According to Diagnosis and Statistical Manual of Mental Disorders (DSM-IV-TR), mental retardation is defined as, a. Significantly subaverage general intellectual functioning: an IQ of approximately 70 or below on an individually administered IQ test (for infants, a clinical judgment of significantly subaverage intellectual functioning). b. Concurrent deficits or impairments in present adaptive functioning (i.e., the person’s effectiveness in meeting the standards expected for his or her age by his or her cultural group) in at least two of the following areas: communication, self-care, home living, social/interpersonal skills, use of community resources, self-direction, functional academic skills, work, leisure, health and safety. c. The onset before age 18 years. Degree of Mental Retardation: - Mild Mental Retardation : IQ level 50 to 69. - Moderate Mental Retardation : IQ level 35 to 49. - Severe Mental Retardation : IQ level 20 to 34. - Profound Mental Retardation : IQ is under 20. ~ Down Syndrome ~ Learning outcomes: - Understand the genetic aspect of Down Syndrome. - Understand the screening test of Down Syndrome. - Understand the clinical aspect of Down Syndrome. - Understand the diagnosis and therapy of Dwon Syndrome. - Understand the genetic counselling of Down Syndrome. Abstract: Dwon Syndrome, also known as trisomy 21, is a disorder caused by a chromosomal abnormality, and the most common cause of birth defect including mental child is born. Women over the age of 35 are in the most risk. The incidence of Down Syndrome is estimated 1 in every 800 to 1000 babies born. They don’t appear to be associated with paternal age. Udayana University Faculty of Medicine, MEU 33

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Lecture 22: ~ AttentionDeficit / Hyperactivity Disorder (ADHD) ~ Study Guide Block Growth and Development Down Syndrome is a chromosomal abnormalty characyerized by extra copy of genetic maternal on the 21st chromosome, either in whole (trisomy 21) or due to translocation (Robertsonian translocation or familial Down Syndrome), mosaicism or duplication of portion of chromosome 21. Patient with Down Syndrome chare certain physical features such as a flat facial profile, an upward slant to the eyes, small ear, a single crease across the centre of the palms, and an enlarge tongue. Down Syndrome affect cognitive abilities in different ways, but most have mild to moderete mental retardation. Diagnostic test are about 99% accurate in detecting Down Syndrome. They are generally recommended only for women age 35 or older, and those with a familial history of genetic defect. Screening test include nuchal translucency testing, alpha fetoprotein, ultrasound, amniocentesis, chorionic villus sampling, and percutaneus umbilical blood sampling, now widely available for early detection. Prof. dr. Soetjiningsih, SpAK, IBCLC Learning outcomes: Awarness of common developmental disorders in children: - Suspect children with ADHD - Refer children with ADHD Abstract: Attention Deficit Hyperactivity Disorders (ADHD) is the most common neurobehavioral disorders of childhood. ADHD is also among the most prevalent chronic health conditions affecting school-aged children. Recorded prevalence rates for ADHD vary substantially, partly because of changing diagnostic criteria over time, partly because of variations in ascertainment in different settings and the frequent use of referred samples to estimate rate. Prevalence rates also vary significantly depending on whether they reflect school samples 6.9% (5.5%-8.5%) versus community samples 10.3% (8.2%-12.7%). The core symptoms of ADHD include inattention, hyperactivity and impulsivity. Children with ADHD may experience significant functional problems, such as school difficulties, academic underachievement, troublesome interpersonal relationships with family members and peers, and low self-esteem. Individuals with ADHD present in childhood and may continue to show symptoms as they enter adolescence and adult life. Early recognition, assessment and management of this condition can redirect the educational and psychosocial development of most children with ADHD. The American Academy of Pediatrics (AAP) recommended that the primary care physicians should initiate an evaluation for ADHD. The clinician during routine health supervision may assist in early recognition of ADHD. So, knowledge, skill for screening, diagnosis and manage children with ADHD is mandatory understood by primary care physician Udayana University Faculty of Medicine, MEU 34

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Lecture 23: ~ AutismSpectrum Disorders ~ Study Guide Block Growth and Development Prof. dr. Soetjiningsih, SpAK, IBCLC Learning outcomes Awareness of common developmental disorders in children: - Suspect children with Autism - Refer children with Autism Abstract Autism describes a spectrum of clinical conditions of neurobiological origin that are characterized by: (1) qualitative dysfunctions of social interaction, (2) qualitative impairments in communication abilities, and (3) unusual or restricted ranges of play and interests. The totality of these impairments, though quite variable from person to person, is usually a lifelong condition that results in some degree of social isolation and varying amounts of unusual behavior. Despite extensive investigation, no consistent pattern of the cause of autism has emerged. In fact, more than 60 different disease entities have been shown to be likely causes of autism, including genetic, infectious, endocrine, toxic, and space-occupying etiologies. This suggests that autism is a final common clinical presentation of a variety of underlying neurobiological and genetic processes. The prevalence of autism appears to have increased during the past decade, perhaps due to (1) greater awareness about autism and its symptoms, (2) more-inclusive recent definitions, and (3) possibly a true increase in incidence. Overall, the ratio of males to females is about 3:1 to 4:1. Prevalence estimates range from 2 to 6 per 1,000 children. This wide range of prevalence points to a need for earlier and more accurate screening for autism. Many instruments can used to screen for autism. The brief instruments such as the Checklist for Autism in Toddlers (CHAT), designed to screen for autism in 18-months old. Screening instruments do not provide individual diagnosis but serve to assess the need for referral for possible diagnosis of Autism. Criteria for the diagnosis of autism are included in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). The earlier the disorder is diagnosed, the sooner the child can be helped through treatment interventions. For most children who have a disorder within the autistic spectrum, results of the physical and neurology examinations will entirely normal. No routine laboratory tests seem necessary. When autistic disorders are associated with general medical condition, laboratory findings consistent with general condition will be observed. Although no definitive treatments are yet available, remarkable progress in the area of intervention has occurred. Primary modalities include (1) educational programs, including early intervention, school-based programs, and prevocational services; (2) behavioral techniques; (3) speech and language therapy programs; (4) family support services; and (5) adjunctive psychopharmacologic management of specific symptoms. Early intensive intervention may dramatically improve outcome. Udayana University Faculty of Medicine, MEU 35

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Lecture 25: ~ AgingProcess ~ Lecture 24: ~ Cerebral Palsy Syndrome ~ Study Guide Block Growth and Development K Kari Abstract Cerebral palsy (CP) is an umbrella term encompassing a group of non-progressive, non- contagious diseases that cause physical disability in human development. The incidence in developed countries is approximately 2.12–2.45 per 1000 live births. Incidence has not declined over the last 60 years despite medical advances (such as electro-fetal monitoring) because these advances allow extremely low birth weight and premature babies to survive. Cerebral refers to the affected area of the brain, the cerebrum (however the centres have not been perfectly localised and the disease most likely involves connections between the cortex and other parts of the brain such as the cerebellum) and palsy refers to disorder of movement. CP is caused by damage to the motor control centers of the young developing brain and can occur during pregnancy (about 75 percent), during childbirth (about 5 percent) or after birth (about 15 percent) up to about age three. Eighty percent of causes are unknown; for the small number where cause is known this can include infection, malnutrition, and/or head trauma in very early childhood. R A Tuty Kuswardhani S Abstract Aging is a process of the loosing of ability the tissue slowly to develop itself and to maintain the structure and the normal function; so it cannot stand towards the trauma to develop the damage. The human being progressively will lose his defense against the infection it will pile the more metabolic and structural distortion. Aging process theory, according to this theory aging has been programmed genetically for some certain species. Different of aging process theories which support the process of aging i.e.: 1. Genetic clock theory 2. The damaged of body immune system. 3. Metabolic theory. 4. The shortening of telomere theory. 5. The damaged by free radical. Udayana University Faculty of Medicine, MEU 36

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Lecture 26: ~ ClinicalImplication of Aging Process ~ Study Guide Block Growth and Development Nym Astika Learning outcomes - To describe the changes associated with aging - To know common problem of Geriatrics (a series of I’s) - To knows components of assessment of older patients Abstract The care of older patients differs from that of younger patients for number of reasons. Some of these can be traced to the change that occur in the process of aging, some are caused by the plethora of diseases and disruptions that accompany seniority, and still other result from the way old people are treated We have already noted the critical and difficult distinction a clinician must make to attribute a finding to either the expected course of aging or the result of pathology changes. Many of the changes associated with aging result from gradual loss, most organ systems seem loss function at about 1 percent a year beginning around age 30 year. Other data suggest that the changes in people followed longitudinally are much less dramatic and certainly begin well after age 70 years Comprehensive evaluation of an older individual’s health status is one of the most challenging aspects of clinical geriatrics. Udayana University Faculty of Medicine, MEU 37

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DAY 1 Study Guide BlockGrowth and Development ~LEARNING TASKS~ Case 1 A mother came to the physician to consult about her child development. Her child is a boy 10 months old. His mother complained that he cannot crawl and cannot stand up alone. When he was 8 months old, he has sir alone. He was born at midwife, spontaneously; his birth weight was 2700 gram. Assignment: a. Please describe, is it a normal child development? b. Please describe, was the child had sequential normal development? c. As a physician, what kind information that you give to his mother? Self Assessment a. Describe the lifespan developing stages b. What is the differentiate between growth and development c. Describe factors that affecting growth and development Case 2: A 15 months old girl was brought by her mother to the Growth and Development Clinic to know whether her child’s growth normal or not. On the physical examination revealed that her weight was 9 kg; her length was 75 cm; her head circumference was 47 cm. Her father’s height was 176 cm; her mother’s height was 157 cm. Assignment: a. Please plot all of the data to the CDC 2000 curve, and interpret it b. Please calculate the potential genetic height of the child c. Please plot the head circumference measurement to the Nellhauss curve and interpret it Case 3: An infant, girl, was brought by her mother to the Growth and Development Clinic for immunization, on September 22, 2007. She was born on December 9, 2006. The following are the data of her weight based on measurement at Primary Health Care. Birth weight 2900 grams 1 month 3800 gram 2 months 5600 grams 3 months 6000 grams 5 months 6500 grams 6 months 6700 grams 8 months 7000 grams Assignment: a. Please calculate the chronological age b. Please plot the data into KMS (Road to Health Chart) c. Please interpret the result of the measurement Self Assessment a. Please differentiate physical growth patterns between boy and girl b. Describe the factors that affecting physical growth c. Describe the normal pattern of the body system growth Udayana University Faculty of Medicine, MEU 38

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DAY 2 DAY 3 DAY 4 Study Guide BlockGrowth and Development Assigment: 1. Describe the embryonic development phases and its morphological characteristic. 2. Explain the main phenomena during human development on the 1st week, 2nd week, 3rd week, 3rd -8th week and 8h week to birth. 3. Explain the clinical correlation in each phase. 4. Predict the time of birth based on the LNMP. Case You are called to attend the delivery of baby boy G at uncertain gestational, who is to be delivered by spontaneously labor. The delivery, there was no meconium, and the baby need only towel drying, clearing of the airway. After the baby stable (about 10 hours) the New Ballard Score was examination, with the score are: neuromuscular maturity score are 19, and the physical maturity score are: 21. The baby weight is 3500 gram, length is 51 cm, and head circumference is 35 cm. Assignment 1: 1. What is your assessment of his gestational age? 2. What is your assessment of his classification? Self assessment: 1. Describe the methods of determining postnatal gestational age 2. Describe and explain the classification of the infants based on Lubchenco chart. 3. Describe the physical appearance the preterm, term and post term infant. 4. Describe and explain the risk factors the baby born preterm, or post term. Assignment 2: 1. What does the definition of ultrasound waves? 2. Explains that ultrasound waves length and its associate with images resoluition. 3. What does the function of gel was applied on the skin? 4. What kinds of ultrasonic media/tissue in pregnant woman? 5. Indication of ultrasound scanning is? 6. When did the USG used firstly in Obstetrics? 7. Explains about RADIUS means! 1. ???? Udayana University Faculty of Medicine, MEU 39

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DAY 5 DAY 6 Study Guide BlockGrowth and Development Assignment: Many medications have side effects that are potentially harmful during pregnancy, but their benefits may outweigh their risks. A woman should consult her doctor or midwife before taking any drug, even one sold over the counter. If you to be a medical doctor can you explain to a pregnant women if she want to take medicine like: 1. Anticonvulsants, such as phenytoin (Dilantin) and carbamazepine (Tegretol), to prevent epileptic seizures? 2. Aspirin, ibuprofen, and other non-steroidal anti-inflammatory drugs (NSAIDs)? 3. Could you explain to her about the effect of drugs at different stages of pregnancy? 4. Paracetamol is a drugs that A category. Could you explain it? How about B category, C category and X category? Case 1 A mother came to the clinic with lactation problem. During the first week she found that her breasts were very swollen, tender, throbbing, lumpy, and uncomfortably full. Sometimes the swelling extends all the way to the armpit. She panicked, thinking that her milk ducts were blocked, even though she had been through exactly the same experience with her first child. Assignment a. What kind of the mother lactation problem? a. How can the mother treat it (What should the mother do?) b. How long does it last? c. Can the mother still breastfeed? d. Will the conditions affect her baby? Self Assessment a. Describe the composition of human milk b. Describe the benefits of breastfeeding c. Describe the most common problems encountered by mothers who are breast-feeding and management of the breastfeeding problems Case 2 A male neonate was born at 40 weeks gestation with severe asphyxia. After resuscitation about 10 minutes, the baby was spontaneously breathing and crying loudly. The body weight was 3500 gram. You want to give nutrition on the first day of life. Assignment 1. What type nutrition you will give? Why? 2. How many fluids will you give? 3. When will you start the oral feeding? What is the best oral feeding will you chose? Self assessment 1. Describe the benefits of breastfeeding 2. Describe the general principles of feeds small babies 3. Describe feed and fluid volume for small babies 4. Explain about feeding intolerance and complications Udayana University Faculty of Medicine, MEU 40

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DAY 7 Study Guide BlockGrowth and Development 5. Explain about complication of parenteral nutrition Case 1 Armani, two years old boy, with body weight of 7.7 kg and length of 70 cm came with the main complains of spot on his left eyes since 1 month ago and cannot seeing object in the evening before night. He suffered edema on his feet (dorsum pedis), looked pale and often suffered infection. Assignment: 1. What is the diagnosis of this case? 2. What are the reasons? 3. Formulate the management of vitamin A and Fe deficiency. Self Assessment: 1. Describe the definition of the vitamin A and iron deficiency. 2. Describe the etiology and pathogenesis of the vitamin A and iron deficiency. 3. Describe the prognosis and prevention of the vitamin A and iron deficiency. Case 2 Doni is 6-month old infant came with main complain of mental deficiency, spastic diplegia, or quadriplegia, deaf mutism, dysarthria, a characteristic shuffling gait, shortened stature, and hypothyroidism. Assignment 1. What is the diagnosis of this case? 2. What are the reasons? 3. Formulate the management of iodine deficiency Self assessment 1. Describe the definition of the iodine deficiency. 2. Describe the etiology and pathogenesis of the iodine deficiency. 3. Describe the prognosis and prevention of the iodine deficiency. Case 3 A 3 years old adolescent with body weight 11 kg and height 95 cm; he looks pale, with pitting edema in the lower extremities and scrotum. He comes to the pediatrics clinic with acute respiratory problems. He is belonging to poor family; the food intake is always low compare with other children. Assignment 1. What is the diagnosis of the patient above? 2. Formulate the management of protein energy malnutrition! Self assessment 1. Describe differentiation of primary PEM and secondary PEM. 2. Describe differentiation of clinical manifestations between marasmus and kwashiorkor. 3. Explain the path physiology of pitting edema of patient with kwashiorkor. Case 4 A 14 years old adolescent with body weight 132 kg and height 200 cm; he looks likes ‘sumo player’, a popular traditional sport in Japan. He usually comes to the pediatrics clinic because of respiratory problems. His father and mother are overweight. Assignment 1. Calculate the BMI of the patient; is he overweight or obesity! Udayana University Faculty of Medicine, MEU 41

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DAY 8 DAY 9 Study Guide BlockGrowth and Development 2. Formulate the management of obesity in childhood! Self assessment 1. Describe the risk factors of obesity. 2. Describe the clinical manifestations and complications of obesity. 3. Describe the diseases associate with childhood obesity. Case Because the weight gains of a 3 months old infant (the body weight 4050 g and length 50 cm) was poorly since 3 month, the parents brought him to hospital. Breast milk intake is always low compared with others healthy infant; and the infant often suffered from respiratory tract problems. Normal weight gain in healthy infant < 3 months is 750-1000 g/month. Assignment 1. What is the ‘diagnoses’ of the patient above? 2. Formulate the management of patient above! Self assessment 1. Describe definition/criteria of patient with FTT. 2. What kind of multidisciplinary approach in Indonesia could be organized as a team work to solve the problem (FTT)? 3. List the risk factors could cause FTT and focus to the factors of patient who need refer to the hospital! Case 1 An infant, boy, 7 months old consulted by his mother to the Growth and Development clinic for immunization. He was born at Sanglah Hospital, spontaneously, asphyxia, and birth weight was 2300 g, gestational age 37 weeks. There is no congenital anomaly. She had antenatal care at midwife. On the physical examination always found fist right hand. His mother did not know about this. Assignment: a. Describe the motor developmental milestones in 7 months infant b. Describe the risk factors that influence the motor development deviation in infant c. What kind examination that necessary for motor development deviation? Self Assessment a. Please differentiate between gross and fine motor development b. Describe the factors that affect motor development c. Describe the primitive and postural reflexes; when these reflexes present or absent? Case 2 TR, girl, 24 months old consulted to the Growth and Development clinic, by her mother with chief complaint cannot compose 2 word combinations yet. She just only says 1 word like “mama”; “papa”. She was born at Sanglah Hospital by caesarean section, helped by obstetrician, cried spontaneously, and birth weight was 2700 g, gestational age was 38 weeks. There is no congenital anomaly. She has febrile convulsion when she was 10 months old. Five months ago she got febrile convulsion but never hospitalized. Udayana University Faculty of Medicine, MEU 42

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DAY 10 Study Guide BlockGrowth and Development Assignment: a. Describe the language developmental milestone in 24 months old b. Describe the red flag of the language developmental milestone in 24 months old c. Describe the risk factors that influence the language development deviation toward that girl d. What should we suggest to her mother? Self Assessment a. Please differentiate between speech and language b. Please differentiate expressive and receptive language c. Describe the factors that affecting language development Case 3 SI, girl, 19 months came with her mother to the Growth and Development clinic with complaint cannot walk well yet. She can stand alone 2 months ago. She can speak mama/papa specific. She was born at midwife, spontaneously, asphyxia, and birth weight was 2800 g, gestational age 38 weeks. There is no congenital anomaly. Assignment: a. Has the child in the normal development? b. Describe the developmental milestones in 19 months child c. Describe the red flag of the developmental milestone in 19 months old a. What should we suggest to her mother? Self Assessment a. Describe the development milestone from birth until 5 years old b. Describe the red flag of development from birth until 5 years old Assignments 1 a. Describe about organization and adaptation in biological systems and cognitive development! b. Describe about assimilation! (Demonstrate some examples) c. Describe about accommodation! (Demonstrate some examples) d. Explain about equilibration in cognitive development! e. Explain the role of reproductive assimilation in cognitive development! f. Describe about schema! g. Compare The Sensorimotor Stage and The Preoperational Stage! h. Describe about conservation! (Demonstrate some examples) i. Compare The Concrete Operational Stage and The Formal Operational Stage! Assignments 2 a. Differentiate between Erikson and Freud’s Development Theory. b. Discuss the ego implication in social life. c. Why does every Erkson’s phase in Psychosocial Development is critical period. d. Identify eight phases in psychosocial development and their psychosocial needs. e. Diferentiate the adult mature personality and immature personality. f. Discuss this case: Sanjaya familiy is the obedient familiy in religion and very diligent goes to the churc and pray to god. Although Mr and Mrs. Sanjaya are very busy, they never forget to remain their children to pray. One day Mr. Sanjaya feel upset when he heard and Udayana University Faculty of Medicine, MEU 43

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DAY 11 Study Guide BlockGrowth and Development saw from TV news, that his child name John (17 years old) was capture by the cop in drug’s party. Case 1 A mother brought her child to Growth and Development clinic at December 9, 2005 with chief complaint her child was still unable to walk. He was born at January 24, 2003, with gestational age 37 weeks. The following were his history of development: 1. Gross motor: - Walk well (-) - Pull to stand (+) - Sit, no support (+) 2. Language: - Can speak 3 words (+) - Papa/mama specific (+) - Point 2 body part (+) - Name 1 picture (+) 3. Fine motor: - Put block in cup (+) - Scribbles (+) - Takes 2 cubes (+) - Tower of cubes 4 (+) - Initiate vertical line (-) 4. Personal social: - Play pat-a-cake (+) - Wave bye-bye (+) - Drink from cup (+) - Remove garment (-) - Put on clothing (-) - Wash and dry hands (-) Assignment: a. Complete the Denver test and the interpretation Case 2 A Mother brought her son to general physician. He is 5 years old with asthma since he was 2 years old. The asthma relapses almost every month. Now he is in kindergarten. According to his mother and his teacher report, his complained were: - Often absent from school - Often distracted easily - Irritable and often angry - Has trouble concentrating - Less interested in friends, often fights with other children - Sometimes takes things that do not belong to him - Often does not listen to rules Assignment: a. Scoring these symptoms, fill the Pediatric Symptom Checklist and the interpretation! b. As a general physician, what is your planning after PSC screening? Case 3 A 5 months old infant, boy, brought by his mother to the Growth and Development Clinic. On the developmental examination found that he could not roll over and he was has head leg Assignment: Udayana University Faculty of Medicine, MEU 44

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DAY 12 Study Guide BlockGrowth and Development a. Please describe is it normal development? b. Please describe the method of stimulation in this child? c. If you are a general physician, when will you refer the child who has developmental deviation? Case 4 A 2 years old girl, consulted to the Growth and Development Clinic with chief complained that she cannot speak 4-5 syllables Assignment: a. Please describe is she has normal development? b. How to give stimulation to this child? Self Assessment a. What is the aim of early detection and stimulation; describe the benefit of early detection and stimulation. b. Describe the principles of early stimulation Case 1 A girl with a painful nipple An 11-year-old girl attends your outpatient clinic because her left nipple is painful to the touch. She has been healthy and has had no complaints until now. Her height is 150 cm (0 SD), and her weight is 35 kg (-1 SD). Physical examination reveals no abnormalities. There is a small, pea-like lump, which is painful to the touch, below her left nipple. Which diagnosis do you consider? (Choose 1 answer.) a. The start of puberty b. A breast tumor c. A breast cyst Case 2 A 6-year-old girl with pubic hair At the outpatient clinic, you see a 6-year-old girl who has had pubic hair since the age of 6 months. For the past few weeks, she has also had some body odor. Her mother is very worried about her pubertal development, particularly about the timing of menarche. She knows that after menarche, her daughter will not grow very much. Other than these complaints, the girl is healthy. Physical examination reveals a healthy-looking girl with a height within the target range (-1 SD). She has no breast development, but does have some pubic and axillary hair. What would your diagnosis be? (Choose 1 answer.) a. Presence of an androgen-producing tumor b. Central precocious puberty c. Premature adrenarche d. Hirsutism Udayana University Faculty of Medicine, MEU 45

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DAY 13 Study Guide BlockGrowth and Development Self Assessment: 1. Describe the onset of puberty starts in boys and girls. 2. Describe the factors to influence release of the hypothalamic neurotransmitter GnRH. 3. Describe changes of FSH/LH secretion from the fetal stage to adulthood. 4. Describe difference GnRH release in fetal period, prepuberty period and adult period. 5. Describe factors to block release GnRH from hypothalamus in puberty starts. 6. Describe stages of breast development in girls. 7. Describe stages of pubic hair development in boys and girls. 8. Describe stages of genital development in boys. 9. Describe of ovarian development in puberty girls. 10. Describe of testicular development in puberty boys. 11. Describe difference of adrenarche and gonarche in puberty. 12. Describe the process of spermatogenesis. Case 1 Young mother came to Eye Clinic with complain that her baby has white pupil in the both eye. The age of baby is 3 month old. The age of gestation and birth weight of the baby are normal. At external examination we found opacity on both lens. Assignment: a. Describe ocular examination of infants and young children b. How to distinguish differential diagnosis of leucocorea c. Describe about the complication congenital cataract if we late starting therapy Case 2 A 6-year old boy, still unable to speak, with a history of fall from his bed during infancy, was sent by his parents to attend a school for the handicapped. This decision was made following the advice of several friends and relatives. A hearing-aid device was prescribe and the boy was trained some techniques of communication such as reading verbal and lip signs, etc and various vocational skills needed to function as member in the society. Case 3 A 6-year old boy with a hearing-aid device and being able to speak, entered a normal primary school with special attention from the teacher. During pregnancy, his mother was suspected to have contracted a viral infection. His mother noted that at age 18 months, the boy couldn’t speak like other children of comparable age. Following the administration of various hearing tests, the boy was found several deaf. A hearing-aid device was fitted and the boy has then been intensely trained in verbal communication. Udayana University Faculty of Medicine, MEU 46

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Study Guide BlockGrowth and Development Assignment 1. Describe the influence of delayed detection and rehabilitation of the boys. 2. Will there be any difference in the outcomes of rehabilitation started early (2 years of age) and years later (6 years of age)? 3. Describe the social impacts of delayed rehabilitattion on the boys future. 4. Desbribe the prospects for obtaining a decent education and job for the boys. Udayana University Faculty of Medicine, MEU 47

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DAY 14 Study Guide BlockGrowth and Development Case 1 Janet, 13 years old, had a long history of school problems. She failed first grade, supposedly because her teacher was “mean”, and was removed from special classroom because she kept getting into fights with the other children. Currently in a normal sixth-grade classroom, she is failing reading, barely passing English and spelling, and doing satisfactory work in art and sports. Her teacher describes Janet as a ”slow learner with a poor memory”, and states and requires a great deal of individual attention. Janet’s medical history was unremarkable except for a tonsillectomy at age 5 years and an early history of chronic otitis. She sat up at 6 months, walked at 12 months, and began taking at 18 months. An examination revealed an open and friendly girl who was nonetheless touchy about her academic problems. She stated that she was “bossed around” at school but had good friends in the neighborhood. Intelligence testing revealed a full-scale intelligence quotient of 97. Wide- range achievement testing produced grade-level scores of 4.8 for reading, 5.3 for spelling, and 6.3 for arithmetic. The most likely diagnosed is: a. Disorder of written expression. b. Expressive language disorder. c. Phonological disorder. d. Reading disorder. e. None of the above. Disorder of written expression is often associated with: a. Reading disorder. b. Mixed expressive-receptive language disorder. c. Developmental coordination disorder. d. Mathematics disorder. e. All of the above. Assignment: a. Explain the criteria diagnostic for mental retardation. b. Explain four degree of mental retardation and developmental characteristics of Mentally Retarded Persons. c. Explain the etiology and pathophysiology Mental Retardation. d. Explain what is the differential diagnosis for Mental Retardation. e. Explain the strategy of holistic therapy for Mental Retardation. Self assessment: Select the one that is the best in each case. 1. DSM-IV-TR lists the prevalence of mental retardation in the United States as: a. 1 percent. b. 3 percent. c. 5 percent. d. 6 percent. e. 10 percent. 2. Mental Retardation should be diagnosed when the intelligence Quotion (IQ) is below: a. 100. b. 85. c. 70. d. 65. e. 60. Udayana University Faculty of Medicine, MEU 48

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DAY 15 Study Guide BlockGrowth and Development 3. A decline in IQ begins at approximately 10 to 15 years in which of the following disorders? a. Down’s syndrome. b. Fragile X syndrome. c. Cerebral palsy. d. Nonspecific mental retardation. e. None of the above. Self assessment: Select the one that is the best in each case: 1. All of the following chromosomal aberrations associated with Down’s syndrome lead to a phenotypic expression of the disorder except: a. Patient have 45 chromosomes. b. Patient have three of chromosome 21. c. Patient have 47 chromosomes with an extra chromosome 21. d. Patient have 46 chromosomes, but two, usually 21 and 15, are fused. e. Patient have mosaicism, with normal and trisomic cells in various tissues. 2. The genetic finding linked most closely to advancing maternal age is: a. Translocation between chromosome 14 and chromosome 21. b. Mitotic nondisjunction of chromosome 21. c. Partially trisomic karyotipe. d. Meiotic nondisjunction of chromosome 21. e. All of the above. Case GD, 5 years old boy came to Growth and Development Clinic, Sanglah Hospital accompanied by his mother. His mother complained about her son which is hyperactive and lack of communication. He is constantly running around and climbing tables and chairs. He can’t sit still for long, except while watching television. He gets bored easily with new toys. Now GD is a kindergarten student. His teacher complained GD cannot pay attention in class. He is very hard to control because he is always wants to run around and he is restless most of the time. He always grabs toys from other children and hits other children. His mother also said that there is no history of serious illness. His mother had normal pregnancy period, birth weight was 3.000 gram, spontaneous delivery in midwife, the baby cried spontaneously. Assignment: a. What is the differential diagnosed of this case? b. Please examine this child using Conners Parent Rating Scales (CPRS). What are the points that necessary to fill observation item in the CPRS? c. According to DSM IV-TR criteria, is he an ADHD? Why? Self Assessment a. Describe how to diagnose the ADHD b. Describe the etiology of the ADHD c. Describe the patophysiology of ADHD d. Describe the treatment of ADHD e. Describe the prognosis of ADHD Udayana University Faculty of Medicine, MEU 49

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DAY 17 DAY 16 Study Guide BlockGrowth and Development Case A 2 years old boy, came to the Growth and Development Clinic with chief complaint deficient verbal and non verbal communication; unusual use of language and echolalia. He spent more time alone; he cannot join with another child, and lack of eye contact. He always arranges something everyday and repetitive. He cannot play peek-a- boo. Assignment: a. Please examine this child using CHAT. What are the points that necessary to fill observation item in the CHAT? b. According to DSM IV criteria, is he suffering from autism? Why? c. Please differentiate between autism and delayed speech development? Self Assessment a. Describe how to diagnose the autism b. Describe the cause of the autism c. Describe the interventions of the autism Case A boy was brought to the ambulatory service of the Central General Hospital of Denpasar on February 13, 2006, for being unable to walk. The boy was born on January 12, 2004 in the same Hospital following a seemingly normal delivery with a weight of 1450 gram, spontaneous cry after birth and appeared robust. Gestation age is 36 weeks Assignment a. To estabilish accurate diagnosis, what other additional information is required? b. When the child is lifted up by the axilla, one of the legs appers shorter. What additional investigation is required to determine the location of abnormality, and what would be result? c. CT scan of the head revealed periventricular leucomalacea. Based on the findings so far, what do you think about the diagnosis? d. When for the first time, do you suspect the boy may have had some neurological abnormalities? e. What other consultations are required? f. How World you manage the child? Assignment: a. What is “aging”? b. Describe the various theories of aging c. Explain in more detail the genetic clock theory d. What do you know about the connection between caloric metabolism and aging? e. Why free radicals are thought into influence the process of aging? f. How does the shortening of telomere cause the death of cell? g. Explain what is meant by lengthening of telomere theory Udayana University Faculty of Medicine, MEU 50

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DAY 18 Study Guide BlockGrowth and Development Case Mrs. L, a 75-year-old widow, came to your office after being discharged from the hospital, where she underwent surgery for a fracture of her right shoulder. Mrs. L has been under your care for several years and has been treated for hypertension, osteoarthritis of both knees, and obesity. She had a stroke 4 years ago but the deficit resolved. She has no history of diabetes or glaucoma. Her hypertension had been well controlled with daily hydrochlorothiazide 25 mg and atenonol 50 mg. Because she does not tolerate nonsteroidal anti-inflammatory agents, she acetaminophen for her knee pain but still has pain when she walks and sometimes uses a cane. Other medications include enteric-coated aspirin and a multivitamin. Mrs. L explains that, on the night of the fracture, she woke up to urinate around midnight, and then fell the broke her shoulder. She related her fall to drinking wine that night with a friend, which had made her a little drowsier than usual when she got up at midnight. She drinks alcohol only occasionally, and has not had trouble before. The conversation reminded Mrs. L that she experienced frequent nocturnal urination during the hospitalization and on several occasions was unable to get to the toilet on time and became incontinent. When questioned, she admits that she has had urinary frequency for several years but managed it by avoiding beverages before sleep or before leaving her house. She also avoids going out for long periods during the day, and, whenever she returns from her brief excursions, she develops urinary urgency “as soon as the key goes into the lock.” She has occasionally experienced leakage when sneezing, standing, or coughing, but this most commonly occurs when she is trying to hold her urine during one of her “urgent” episodes. Still, she did not view her urinary pattern as a big problem until her recent hospitalization. Mrs. L last visited her gynecologist 1 year ago. She has no cystocele, rectocele, or uterine prolapse. She denies dysuria, fever, or constipation. Assignment: Evaluating this geriatric patient: a. Physical assessment. b. Functional assessment. c. Nutritional Assessment. Self assessment: 1. Describe the changes associated with “normal” aging. 2. Explain of classifying geriatric problems. 3. Describe the components of assessment of older patients. Please see study guide for case field Udayana University Faculty of Medicine, MEU 51

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Study Guide BlockGrowth and Development ~ CURRICULUM STRUCTURE ~ Udayana University Faculty of Medicine Semester Program or curriculum blocks 10 Senior Clerkship 9 Senior Clerkship 8 Senior clerkship 7 Critical care (2 weeks) The skin & disorders (2 weeks) Special topics (5 weeks) Special study 3 (4 weeks) Basic Clinical Skill 6 (3 weeks) 6 Musculoskeletal system & connective tissue disorders (4 weeks) Neuroscience and neurological disorders (4 weeks) Behavior and disorders (4 weeks) Basic Clinical Skill 5 (4 weeks) 5 Alimentary & hepato- biliary systems & disorders (4 Weeks) The endocrine & metabolic disorders (4 weeks) Clinical nutrition & disorders (2 weeks) Special study 2 (4 weeks) Basic Clinical Skill 4 (2 weeks) 4 Respiratory system & disorders (4 weeks) Cardiovascular system & disorders (4 weeks) Urinary system & disorders (3 weeks) The genital system & disorders (3 weeks) Basic Clinical Skill 3 (2 weeks) 3 Hematologic system & disorders & clinical oncology (4 weeks) Immune system & disorders (3 weeks) Infection & infectious diseases (5 weeks) The visual system & disorders (2 weeks) Basic Clinical Skill 2 (2 weeks) 2 Community- based practice (4 weeks) Health system- based practice (3 weeks) Information management (2 weeks) Basic clinical skills 1 (3 weeks) Special Study 1 (4 weeks) 1 Studium generale (3 weeks) Medical professionalism (3 weeks) Medical communication (3 weeks) The cell as biochemical machinery (3 weeks) Growth & development (4 weeks) Udayana University Faculty of Medicine, MEU 52

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Study Guide BlockGrowth and Development REFERENCES Basic References: 1. Behrman RE, Kliegman RM. Nellson Textbook of Pediatrics. 17th ed. Philadelphia, WB Saunders. 2004. 2. Sadler TW: Langman’s Medical Embryology, 10th ed. Philadelphia, Lippincott Williams and Wilkins. 2006. 3. Soetjiningsih. Tumbuh Kembang Anak. EGC. 1995. 4. Thompson JS and Thompson MW.Genetics in Medicine. 4th ed. Philadelphia, WB Saunders. 1986. 5. Ultrasound and Doppler. In Cunningham F G et al, in Williams Obstetrics, 21st ed. 1997; 1111-1139. Additional References: 1. Ballantyne J, Groves J. Scott-Brown’s Diseases of the ear, Nose, and Throat. 4th ed, Boston, Butterworths. 2. Elizabeth B. Hurlock. Child Development. 6th ed. Mc Graw Hill. 1984. 3. Eva PR, Whitcher JP. Vaughan & Asbury’s General Ophthalmology. 16th ed. Lange Medical Book. 4. Hazzard WR, Blass JP, Ettinger WH, Halter JB, Ouslander JG. Principles of Geriatric Medicine and Gerontology. 4th ed. McGraw-Hill Co. 5. Jeremy KH, Jan Maarten W, Alan D Rogol. Pediaric Endocrinology and Growth. 2nd ed. Saunders Co, Philadelphia. 2003. 6. Kane RL, Ouslander JG, Abrass IT, Essentials of Clinical Geriatrics. 5th ed. McGraw-Hill Co. 2004. 7. Klaus MH, Fanacroff AA. Care of the High-Risk Neonate. 5th ed. Philadelphia, WB Saunders Co. 2001. 8. Koren G, Pastuszak A, Ito S. Drugs in Pregnancy. New Engl J Med. 1998. 338; (16). 1128-1137. 9. L Kathleen M, Marian TA. Nutritional care in anemia in Krause’s Food nutrition & diet therapy. W B Saunders Co, Philadelphia, 5th Ed, 1992. pp 558-563. 10. Lawrence RA, Lawrence RM. Breast feeding a Guide for the Medical Profession. 5th ed. Philadelphia, Mosby. 1999. 11. Lerner RM. Concepts and Theories of Human Development. 12. Mahan KL, Escott-Stump: Krause’s Food, Nutrition, & Diet Therapy, 11th ed. Philadelphia, WB Saunders, 2004. 13. Soetjiningsih, Moersintowarti, Sudiyanto, Titi Sularyo. Pedoman Deteksi Dini Penyimpangan Tumbuh Kembang Balita bagi Keluarga. Komie Tumbuh Kembang Anak Indonesia. 1996. 14. Soetjiningsih. Pentingnya Stimulasi Dini Untuk mengoptimalkan Kecerdasan Otak. SMF Ilmu Kesehatan Anak K UNUD/RS Sanglah Denpasar. 15. Tricia LG, Cunningham MD, Fabien GE, Karin EZ. Neonatology: Management, Procedures, On-Call Problems, Disease, and Drugs. 5th ed. McGraw-Hill Co. 2004. 16. Wijayanegara Hidayat et al. Kursus Dasar Ultrasonografi dan Kardiotokografi, 2000, hal 11-14. Udayana University Faculty of Medicine, MEU 53

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